6606 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221963 03/12/2026 (a) Basis. The Texas Department of Human Services, hereinafter referred to as TDHS, the Texas Department of Health, hereinafter referred to as TDH, and the Texas Department of Mental Health and Mental Retardation, hereinafter referred to as TDMHMR, are required under the provisions of Human Resources Code, § 22.014, to enter into a memorandum of understanding regarding responsibilities, procedures, and standards involved in the provision, regulation, and/or funding of services in hospitals or long term care institutions. However, this agreement does not apply to state hospitals or to any TDMHMR service not funded under Title XIX of the Social Security Act.(b) Provision of services.(1) Hospital and long term care services are provided by facilities under contract to TDHS as the Title XIX designated single state agency. TDHS contracts for intermediate care provided by facilities for the mentally retarded (ICF-MR) in community-based settings and in state schools and state centers, and for intermediate care (ICF) and skilled nursing facility (SNF) care in nursing homes.(2) TDHS is also responsible for reimbursing Title XIX participating hospitals and long term care facilities for covered Title XIX services provided to Title XIX eligible individuals. Reimbursement is subject to the specifications, conditions, limitations, and requirements established by the department or its designee.(c) Regulation of service/standards and procedures of operations.(1) TDHS promulgates standards and policies, appropriate to complement and support federal regulations, to govern the participation of acute care hospitals and the operation of intermediate care and skilled nursing facility care in nursing homes. TDMHMR develops, with the approval of TDHS, standards and policies, appropriate to complement and support federal regulations, to govern the operation of community-based IFC-MR facilities and state schools for the mentally retarded.(2) TDH, under contract to TDHS, surveys, certifies, and monitors facilities providing services to ICF-MR clients and to ICF-SNF clients. TDH develops and publishes licensure requirements for all facilities providing health care. Consonant with federal regulations, TDH develops and publishes the certification procedures which govern the certification of facilities desiring to enter into contracts with TDHS as providers of ICF/SNF service. TDH has administrative penalties which provide sanctions for nursing home facilities who fail to provide acceptable care and to maintain compliance with state licensure requirements. TDHS' standards for participation contain sanctions requirements for facilities who fail to carry out their contractual responsibilities.(3) TDHS and TDH entered into contracts in 1972, whereby TDH agreed to survey and certify as meeting state and federal standards, all nursing facilities wishing to contract or continue to contract with TDHS as ICFs and SNFs under Title XIX. These contracts have been in force continuously since 1972. In 1977, pursuant to State Bill 9, 65th Legislature, 1st Called Session 1977, TDHS and TDH entered into a contract whereby TDH agreed to be responsible for monitoring and evaluating the quality of care provided by ICF, SNF, and ICF-MR facilities.(4) TDHS and TDMHMR, pursuant to House Bill 656, 67th Legislature, 1981, agreed that TDMHMR would develop and recommend policy and standards, and that TDMHMR would assume the responsibility for monitoring TDH's activities regarding quality of care review in community-based ICF-MR facilities and state schools.(d) Funding of services.(1) TDHS requests state funds and matching federal funds in support of the Medicaid program in Title XIX participating hospitals and long term care facilities. TDHS also requests federal matching funds for expenditures made by TDH and TDMHMR on behalf of Medicaid.(2) TDMHMR requests state funds for its activities and certifies expenditures to TDHS for the purpose of drawing down federal matching funds under Title XIX. TDH requests state funds for its activities and certifies expenditures to TDHS for the purpose of drawing down federal matching funds as they relate to survey and certification of nursing facilities for Title XIX participation and quality of care in such facilities.(e) Promulgation of rules.(1) TDHS, TDH, and TDMHMR agree that no new rules or regulations that would increase the cost of providing the required services or increase the number of personnel in hospitals or long term care facilities will be promulgated by the agencies unless:(A) the commissioner of health certifies that the new rules or regulations are urgent and necessary to protect the health or safety of recipients of hospital or long term care services; or(B) TDHS provides written verification that funds are available to adequately reimburse hospital or long term care service providers for any increased costs resulting from the rule or regulation and establishes reimbursement rates that are sufficient to cover the increased costs; or(C) the rules are required by state or federal law or federal regulations.(2) TDHS, TDH, and TDMHMR agree that any rules or regulations proposed by the agencies which would increase the costs of providing the required services or increase the number of personnel in hospital or long term care facilities will be accompanied by a preliminary fiscal note prepared for the agency promulgating the rules. The fiscal note will be submitted to TDHS and will state the expected impact on the cost of providing the required service and the anticipated impact on the number of personnel in hospital or long term care facilities. For a rule to be finally adopted, TDHS must provide written verification that funds are available to adequately reimburse hospital or long term care service providers for any increased costs resulting from the rule or regulation. Written verification is not required if the commissioner of health certifies that the new rule or regulation is urgent and necessary to protect the health or safety of recipients of hospital or long term care services. The provisions of this paragraph do not apply if the rules are required by state or federal law or federal regulations.(f) Termination. In the event that federal and/or state laws or other requirements should be amended or judicially interpreted so as to render continued fulfillment of this agreement substantially unreasonable or impossible, or if the parties should be unable to agree upon any amendment which would therefore be needed to enable the substantial continuation of services contemplated herein, then, and in that event, the parties shall be discharged from any further obligation created under the terms of this agreement, except for the equitable settlement of the respective accrued interests or obligations incurred up to the date of termination.(g) Annual review. TDHS, TDH, and TDMHMR shall review and, if necessary, update this memorandum of understanding prior to the close of each fiscal year.(h) Effective date. For the faithful performance of this agreement, this agreement is executed by the commissioners of TDHS, TDMHMR, and TDH, to be effective January 1, 1988. Source Note: The provisions of this §3.1 adopted to be effective August 22, 1988, 13 TexReg 3829; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES A MEMORANDA OF UNDERSTANDING FOR LONG-TERM CARE §3.1 Services in Hospitals and Long-term Care Institutions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221964 03/12/2026 (a) Basis. The Texas Department of Human Services, hereinafter referred to as DHS, the Texas Office of the Attorney General, hereinafter referred to as OAG, and the Texas Department of Protective and Regulatory Services, hereinafter referred to as TDPRS are required under the provisions of Health and Safety Code §§247.046 and 247.062 to enter into a memorandum of understanding (MOU) regarding their respective responsibilities, procedures, enforcement needs, and plans for correcting violations or deficiencies in assisted living facilities. This MOU implements those requirements.(b) DHS responsibilities.(1) DHS accepts applications and issues licenses in accordance with the requirements of Chapter 247, and DHS rules and standards adopted to implement the law.(2) If DHS finds a licensed assisted living facility operating in violation of minimum standards or licensing requirements and the violation creates an immediate threat to the health and safety of a resident in the facility, DHS may suspend the license or order the immediate closing of all or part of the facility. DHS shall retain primary responsibility for assisting families in finding new placements for individuals displaced when facilities licensed by or subject to licensure by DHS are closed. DHS will inquire whether a resident is receiving services from a mental health authority (MHA) and will contact the MHA accordingly to ensure continuation of service and placement assistance.(3) DHS shall investigate each allegation of abuse, exploitation, or neglect of a resident of a assisted living facility in accordance with Chapter 247 of the Health and Safety Code, Chapter 48 of the Human Resources Code, and DHS rules. If the investigation reveals abuse, exploitation, or neglect, DHS shall implement enforcement measures, including closing the facility, revoking the facility's license, relocating residents, and making referrals to law enforcement agencies (including the OAG) as appropriate.(4) DHS may refer a facility to the OAG or a local prosecuting attorney for the purpose of petitioning a district court for a temporary restraining order to restrain a continuing violation of standards or licensing requirements for assisted living facilities. If DHS finds that the violation creates an immediate threat to the health and safety of the assisted living facility residents, the referral is made to the OAG along with all affidavits necessary to prosecute the case. If the violation does not create an immediate threat to the health and safety of assisted living facility residents, the referral is to a local prosecuting attorney. DHS, through the OAG or a local prosecuting attorney, may petition a district court for a restraining order to inspect a facility that is operating without a license when admission to the facility cannot be obtained. In these inspection situations, DHS shall first contact the local prosecuting attorney for assistance.(5) DHS shall cooperate with the OAG and/or the local prosecuting attorney in the preparation and prosecution of injunctive actions against assisted living facilities against which DHS has requested legal proceedings.(6) DHS may refer persons who do not possess a license, or assisted living facilities that violate the Personal Care Facility Licensing Act (Chapter 247 of the Health and Safety Code) or a rule adopted under that act, whose violation threatens the health and safety of a resident of a assisted living facility, to the OAG for the purpose of petitioning a district court for civil penalties under section 247.045 of the Health and Safety Code. DHS will refer civil penalty cases to the local district attorney, county attorney, or city attorney if the OAG does not take action within 30 days of the referral. DHS shall cooperate with the OAG and the local prosecuting attorneys in the preparation for and prosecution of civil penalty actions.(c) TDPRS responsibilities. TDPRS will assist DHS, upon request, in finding suitable placement for incapacitated individuals who have no family willing to assist and who must be relocated due to the closing of a assisted living facility licensed or subject to licensure by DHS.(d) OAG responsibilities.(1) The OAG will work in close cooperation with DHS throughout any legal proceeding requested by DHS under Chapter 247 of the Health and Safety Code.(2) The OAG will keep DHS informed of the status of all cases referred to the OAG under Chapter 247 of the Health and Safety Code upon the request of DHS.(3) The OAG will represent DHS to the full extent of the law in Chapter 247 actions.(4) When the OAG chooses not to prosecute a Chapter 247 case referred by DHS, it will immediately inform DHS so that alternative action can be taken.(e) Complaint investigations and opportunities for corrective action.(1) When a complaint is received about a licensed or a unlicensed assisted living facility, DHS will do a complaint investigation of the facility. If the owner of an unlicensed facility denies DHS investigators access to a facility, DHS may, through the OAG or a local prosecutor's office, petition a district court for a temporary restraining order to inspect the facility.(2) If the investigation indicates that there is a violation of minimum standards and the violation creates an immediate threat to the health and safety of a facility resident, DHS will suspend the license and order closing of the facility for a ten day period.(3) If the investigation indicates that there is a violation of minimum standards or licensing requirements and the violation is a threat to resident health and safety, DHS immediately makes a referral to the Attorney General's office to enjoin the facility's operation, enjoin the facility from violating standards or licensing requirements, and/or for assessment of civil monetary penalties.(4) If the OAG does not take action on a civil penalty referral within 30 days of the referral, DHS will refer the case to the local prosecuting attorney.(5) If the investigation indicates a violation of minimum standards or licensing requirements but the violation is not a threat to resident health and safety, DHS may notify the owner that he is in violation and make a referral to the local prosecuting attorney or the OAG only after the facility owner is given an opportunity to take appropriate action to come into compliance within a reasonable time.(6) If the local prosecuting attorney refuses to prosecute a case, DHS may seek the assistance of the OAG.(7) DHS may deny, suspend, or revoke the license of a licensed facility for violating the Personal Care Facility Licensing Act or rules adopted under that act.(8) If further investigation or monitoring of a facility that has previously indicated that it will come into compliance, indicates that violations have continued, DHS may immediately seek injunctive or other appropriate relief in coordination and cooperation with the OAG or the local prosecuting attorney. Source Note: The provisions of this §3.3 adopted to be effective August 18, 1999, 24 TexReg 6315; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES A MEMORANDA OF UNDERSTANDING FOR LONG-TERM CARE §3.3 Assisted Living Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221965 03/12/2026 (a) The Texas Department of Human Services, the Texas Department of Health, the Texas Department of Mental Health and Mental Retardation, the Texas Rehabilitation Commission, the Texas Commission for the Blind, the Texas Commission for the Deaf, the Texas Education Agency, the Texas Department of Protective and Regulatory Services, and the Texas Interagency Council on Early Childhood Intervention are required under the provisions of the Human Resources Code, §22.011, to adopt a joint memorandum of understanding to facilitate the coordination of services to persons with disabilities.(b) This memorandum of understanding will clarify the financial and service responsibilities of each agency in relation to persons with disabilities and address how each agency will share data relating to services delivered to persons with disabilities. Each agency will adopt this memorandum of understanding and all revisions to the memorandum by rule. Consultation and input from advocacy and consumer groups will be obtained during the public comment period for proposed rule publication. Appropriate revisions to this memorandum of understanding will be made based on public comment. Source Note: The provisions of this §3.51 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.51 Basis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221966 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) Health care services.(A) One of the most important Medicaid benefits provided to low-income individuals is comprehensive health care services. In Texas, Medicaid services are funded by a combination of approximately 40% state funds and 60% federal funds. The federal matching rate is based upon the state's average per capita income.(B) Medicaid eligibility is linked by federal law to eligibility for supplemental security income (SSI), the financial assistance program for low-income aged and blind persons, and persons with disabilities; aid to families with dependent children (AFDC), the financial assistance program for low-income families; and Medicaid for low-income children and pregnant women. Eligibility for AFDC and Medicaid (low-income families) is determined by client self-support services (CSS) eligibility staff. Eligibility for SSI benefits is determined by the Social Security Administration (SSA) based on income and resource requirements and a determination of disability. The SSA contracts with the Texas Rehabilitation Commission (TRC) to perform the disability determinations. Of the three million Texans living in poverty, the Texas Medicaid program covers about 790,000 individuals. Of that number, more than 128,000 are persons with disabilities under age 65.(C) Federal regulations specify which Medicaid services states must provide as well as a range of optional services states may elect to cover.(i) Mandatory Medicaid services. The mandatory Medicaid services are long-term institutional care services in nursing facilities.(ii) Optional Medicaid services. Optional Medicaid services include: day activity and health services and long-term institutional care services in intermediate care facilities (ICF); intermediate care facilities for the mentally retarded (ICF-MR); and skilled nursing facilities (SNF) for children under age 21.(iii) Medicaid waiver services. Under the provisions of the Social Security Act, §1915(c), states have the option to provide certain home and community-based services to individuals who would otherwise require long-term institutional care. Pending approval of the waiver requests by the Health Care Financing Administration (HCFA), states may define the home and community-based services and make them available to a limited number of individuals on less than a statewide basis. The cost of these additional home and community-based services must be no greater than the cost of Medicaid services without a waiver. Texas currently has four 1915(c) Medicaid waiver programs which serve persons with disabilities.(I) The waiver program for medically dependent children provides Medicaid benefits and in-home skilled nursing services to children under age 18 who would otherwise require nursing home care in an ICF or an SNF. Currently, this waiver program serves 517 children statewide. Eligible children are served on a first-come, first-served basis.(II) The 1915(c) waiver program for mentally retarded individuals is designed to provide 11 different home and community-based services to individuals living in their own home or with family members, as alternatives to institutional care in an ICF-MR. Eligible clients use their SSI to pay room and board costs. Home and community-based services are delivered based on an individual plan of care. This waiver program is in its 11th year of operation and can serve a maximum of 1,350 clients located in 31 geographic catchment areas. This waiver program is administered through an inter-agency contract between DHS and the Texas Department of Mental Health and Mental Retardation (TXMHMR). The state matching funds are provided by TXMHMR.(2) Office on Services to Persons with Disabilities (OSPD).(A) In January 1991, the Texas Board of Human Services adopted a proactive position statement on community-based services to persons with disabilities. The philosophy of DHS became "... people with disabilities of all ages can live in the community when provided appropriate services and supports." DHS committed itself to take all appropriate and necessary actions to ensure the development of a system of community-based services and supports for persons with disabilities, and committed itself to the development of specific plans and policies whereby this philosophy would be implemented in all areas of DHS. The OSPD is responsible for coordination of this effort.(B) To specify how OSPD would facilitate the implementation of this philosophy organization-wide, an OSPD strategic plan with specific goals, objectives, timeframes, and products was developed. Although it is located in the Health Care Services Division, which is one major program area of DHS, the OSPD's scope is within all DHS programs and services for persons with disabilities.(C) OSPD staff have five major roles:(i) advocating for persons with disabilities within DHS and externally;(ii) advocating for the implementation of the DHS position statement organization-wide;(iii) facilitating and coordinating the development of community-based programs and supports for persons with disabilities;(iv) serving as a focal point for DHS staff, consumers, providers, advocates, and other agencies to raise issues and concerns; and(v) providing technical assistance and education on disability-related issues.(3) Client self-support services. Client self-support services is a group of DHS programs that provides basic maintenance services such as food stamps, AFDC, Medicaid coverage, nutrition, and energy assistance for eligible individuals, as well as services aimed at making clients self-sufficient, such as education, job training, child care, and transportation.(4) Community care services for aged and disabled persons. Community care services are provided to low-income, elderly persons; persons with disabilities; and persons with chronic health conditions, to help these persons remain at home or in community settings. These services also provide a support system to families caring for their elderly or disabled members. Eligibility for community care services is based on age; income; financial resources; the degree of functional impairment; and, in some cases, medical need. The income eligibility ceiling for community care services is $1,302 per month and the resource limit is $5,000.(A) In-home community care services.(i) Primary home care (PHC) provides medically necessary personal care or supportive care, supervised by a registered nurse, in the client's home. DHS contracts with licensed home health agencies to provide these services to individuals for up to 50 hours per week.(ii) Family care (FC) provides personal care, housekeeping, escort service, and meal preparation in the client's own home. These services are provided through contracts with home health agencies for up to 50 hours per week.(iii) Congregate and home-delivered meals provide nutritious meals in a central location or a client's home through community-based provider agencies. All menus are approved by a registered dietitian or nutritionist.(iv) The Emergency Response System (ERS) is a 24-hour electronic monitoring service that permits quick response to emergencies using a network of volunteers and remote telephone-calling capability to a base station. Services are available to functionally impaired elderly or disabled adults who live alone or who are physically isolated from the community.(v) The In-home and Family Support Program (IHFSP) provides direct grant benefits to people with physical disabilities and their families who choose and purchase services which enable the person with the disability to remain in the community. Allowable services include pre-approved items and services that are directly related to the person's disability, such as special equipment; architectural modification of a home to improve access or facilitate the care of a person with a disability; medical services; counseling and training programs which help provide proper care for a person with a disability; attendant care; respite care; and transportation.(vi) Respite services up to 336 hours per year of short-term care to elderly or disabled adults whose caregivers need temporary relief.(B) Out-of-home community care services.(i) Adult foster care (AFC) provides supervision and assistance with daily living to eligible adults in 24-hour living arrangements provided in enrolled foster homes, for up to four clients, and licensed group homes, for four to eight clients. Clients pay their own room and board costs, and DHS pays the caregiver for personal care and supervision.(ii) Day activity and health services (DAHS) provide personal care, nursing services, physical rehabilitation, and nutrition and supportive services in adult day-care facilities licensed by the Texas Department of Health (TDH) and certified by DHS. These services are available at least 10 hours per weekday and can provide respite for families.(iii) Special services for persons with disabilities provide counseling, personal care, help with independent living skills, and transportation.(iv) Residential care services are provided to eligible adults who require access to personal care services on a 24-hour basis, but not daily nursing intervention. Services may include board, protective supervision, personal care, social and recreational services, housekeeping, laundry, and transportation.(C) Client Managed Attendant Services Program. The Client Managed Attendant Services Program is targeted to the needs of younger persons with physical disabilities who need personal care services to continue living in the community. It allows clients to hire and supervise their own attendants and schedule care according to their daily routines. This project serves approximately 690 clients in nine sites throughout the state. The fiscal year 1993 budget is $5.5 million.(5) Long-Term Care Program.(A) The purpose of the statewide Long-term Care Program of DHS is to assure that quality care is provided to persons in long-term care and related facilities and that these facilities are properly utilized. DHS inspects and licenses nursing homes, custodial care homes, personal care homes, certain facilities for the mentally retarded, and certain adult day care and adult health care facilities. DHS surveys and certifies nursing homes and facilities for the mentally retarded that participate in Medicaid, and surveys and recommends certification of nursing home's participation in Medicare. DHS performs inspection of care visits relating to care and services provided to each Medicaid recipient in nursing homes and facilities for the mentally retarded and determines the appropriate level of care needed for each recipient.(B) The contact for program information is the associate commissioner for long-term care, (512) 450-4971.(C) DHS will continue the following memoranda of understanding with:(i) the Texas Department on Aging (TDoA) regarding that agency's ombudsman program and the responsibilities of both agencies in complaint investigations; and implementing the state long-term care plan for the elderly;(ii) the Texas Board of Licensure for Nursing Home Administrators for training of nursing home administrators; and(iii) TDoA to train ombudsmen and TDoA representatives on nursing facility standards and complaint investigation procedures.(D) In addition, DHS has entered into an inter-agency contract with the Texas Department of Corrections (TDC) to microfiche old records.(6) Other DHS services. All DHS services are available to low-income persons with disabilities based on the eligibility criteria associated with the various funding sources.(b) Service delivery data. DHS has a variety of data identifying the type of services, the number of clients receiving services, and expenditure data for all programs. The most comprehensive DHS documents that contain service delivery and expenditure data are:(1) Legislative appropriations request (LAR). The LAR is a document prepared and submitted to the Legislative Budget Board and the governor's Budget Office prior to each legislative session. It contains DHS's request for appropriations for the next biennium based on four levels of funding for each program and activity. It also provides a summary of DHS's request. Specifically, it provides the objective and a description of each program and activity as well as data for need indicators, performance measures, object of expense, and method of finance for a five-year period. This period includes two years of the appropriations request and the three previous years.(2) Fiscal year operating plan. The fiscal year operating plan is the budget for DHS based on appropriations received. It contains a breakdown of budgeted dollars by program area and activity at the state level. For each program, the document states the need, the description of program activities, the budget allocation for each activity, the performance measures or units of service, and the method of finance. The allocation covers a three-year period consisting of the current fiscal year and two previous years.(3) Annual report. The annual report is a fiscal-year description of DHS services, a review of the services, and an accounting of DHS's expenditures. The report contains a section of statistics that depicts estimated expenditures by method of finance; benefit expenditures by region; a summary by county of agency information; aged and disabled benefits, and families and children benefits; and data concerning the regulation of child care facilities.(A) In addition to client data, DHS has demographic data from the 1990 United States Census, the 1989 Special Texas Census, and population estimates and projections from the state comptroller's office and Texas A&M University. The 1989 Special Texas Census was a mailout survey to the general population of Texas. It was a data-collection effort comprising a sample of 44,000 Texas households to identify human service needs in support of the DHS budget and planning process. With an adjusted response rate of about 66% of the valid sample, data was collected for more than 23,000 households. The data collected for each person concentrated on money; income; demographics (age, sex, race/ethnicity, marital status, language, and education); employment status; medical insurance coverage; medical utilization; disability; functional impairment; help available for persons with disabilities; child care; child support payment; knowledge about runaways; child abuse and/or neglect; and family violence shelters. Based on the response rate and the selection of data variables, data may provide adequate representation for the state and for DHS regions. DHS service delivery and demographic data may be requested from the Budget Management Services Department.(B) The OSPD also develops an annual report containing the yearly activities of implementing the DHS position statement and recommendation of the task force on services to persons with disabilities and DHS advisory committee for the aged and disabled (ADAC). It describes the accomplishments toward achieving goals, objectives, and products detailed in the OSPD strategic plan. Source Note: The provisions of this §3.53 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.53 Texas Department of Human Services (DHS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221967 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) Chronically Ill and Disabled Children's Services Bureau.(A) The Chronically Ill and Disabled Children's Services Bureau provides diagnosis and evaluation; restorative and corrective medical treatment; speech, occupational, and physical therapy; transportation; meals and lodging; and case management through purchased services for children below the age of 21 years who meet medical, financial, and residency requirements. Persons with the diagnosis of cystic fibrosis are eligible regardless of age.(B) The Chronically Ill and Disabled Children's Services Bureau also administers:(i) the Hemophilia Assistance Program, which provides assistance to adult hemophilia patients (over age 21) for the purchase of blood products;(ii) the Epilepsy Assistance Program, which provides diagnosis, treatment, and support services for persons with epilepsy, through contracts with private organizations; and(iii) the Children's Outreach Heart Program, which provides pre-diagnostic and follow-up evaluation services for cardiovascular disorders for children in south Texas who meet financial eligibility requirements, through a contract with the Children's Heart Institute of Texas.(C) The Chronically Ill and Disabled Children's Services Bureau also administers the Supplemental Security Income Disabled Children's Services Program (SSI-DCP).(D) The contact for program information is the manager for field and provider relations, Chronically Ill and Disabled Children's Services Bureau, (512) 458-7355.(E) The Chronically Ill and Disabled Children's Services Bureau has written agreements with the Texas Commission for the Blind (TCB), the Texas Rehabilitation Commission (TRC), the Texas Education Agency (TEA), the Texas Youth Council, and the Texas Department of Human Services (DHS). These agreements specify that the Chronically Ill and Disabled Children's Services Bureau and the other agency which is party to the agreement must:(i) coordinate service delivery; and(ii) provide services only to persons who have been determined eligible for services by both parties.(2) Supplemental Security Income Disabled Children's Program (SSI-DCP)(A) The SSI-DCP provides case management services for all children with disabilities who are below the age of 16 and receiving SSI benefits. Services provided directly include diagnostic, counseling, and referral services; inter-agency liaison; follow-up through case management provided by medical social workers; and the purchase of services and adaptive equipment, if these services are not available through any other resource.(B) The contact for program information is the manager for field and provider relations, Chronically Ill and Disabled Children's Services Bureau, (512) 458-7355.(C) As the SSI-DCP program is administered by the Chronically Ill and Disabled Children's Services Bureau, inter-agency agreements are described in paragraph (1) of this subsection.(3) Kidney Health Program.(A) The Kidney Health Program provides assistance to Texas residents with end-stage renal disease (ESRD), as certified by a licensed nephrologist, with assistance in paying for drugs, hospitalization, medical services and supplies, and transportation. Clients are reimbursed directly for drugs and travel; reimbursement is made directly to the provider for medical services and supplies. The Kidney Health Program does not pay for services covered by Medicare, Medicaid, or private insurance.(B) The contact for program information is the director of the Kidney Health Program, (512) 458-7796.(4) Vision, hearing, and speech services (VHSS).(A) VHSS has legal authority to establish standards and regulate screening for special senses and communication disorders, primarily vision and hearing problems, and to assure standardized performance of audiometric testing devices statewide. Legislation permits VHSS to provide services to identify individuals in need if services are not otherwise available. VHSS provides hearing aids and attendant services to medically indigent children, ages 0 through 20.(B) The contact for VHSS program information is the director for Vision, Hearing, and Speech Services, Division of Maternal and Child Health, (512) 458-7420.(C) VHSS and the DHS have entered into a contract for reimbursement of hearing aid services to Medicaid clients age 0 through 20. In order to carry out DHS's memorandum of understanding with the Commission for the Deaf, the VHSS developed and maintains a contract with DHS for the acquisition of interpreter services for Texas Department of Health's (TDH's) deaf and hearing-impaired patients, clients, and staff.(5) Mandatory Medicaid services. Mandatory Medicaid services include: physician services; inpatient and outpatient hospital; laboratory and X-ray; home health care; ambulance; rural health clinic; nurse midwife; early and periodic screening, diagnosis, and treatment (EPSDT) services for children up to age 21; certified pediatric nurse practitioners; certified family nurse practitioners; dentist's services; family planning; federally qualified health centers; ICF-MR dental; medical transportation; and renal dialysis services.(6) Optional Medicaid services. Optional Medicaid services include: eyeglasses, optometric, podiatric, and chiropractic services; ambulatory surgical centers; hearing aid services; limited oral surgery; post-surgical lenses; vendor drug services; primary home care; emergency hospital services; birthing center services; certified registered nurse anesthetist's services; diagnostic and evaluation services (MR); hospice care; in-home total parenteral hyperalimentation services; in-home respiratory care services; maternity clinic services; outpatient counseling for chemical dependency; physical therapist; psychologist services; targeted case management services; mental health rehabilitation services; and services provided by Christian Science sanitoriums.(b) Service delivery data.(1) TDH produces several documents and reports on a department-wide basis either annually or biennially. These are:(A) Legislative appropriations request (LAR). The LAR is published biennially and includes program needs indicators for each TDH program, program objectives, descriptions of program performance measures, the TDH budget and expenditures, and activity profiles.(B) Texas hospital data inventory. Hospital data is collected annually, and routine and special reports are developed from the data.(C) Bureau of Health Data and Policy Analysis: Population Projection to the year 2000. Data is available by age, sex, and race/ethnicity for each year.(D) Bureau of Disease Control and Epidemiology: Epidemiology in Texas. This report is published annually.(E) Texas Vital Statistics. This report is published annually.(2) To examine these documents, contact the TDH Library, (512) 458-7559.(3) In addition, bureaus and programs of TDH generate annual reports for their programs specifically tailored to their program needs. Additional information may be requested by contacting the Office of the Commissioner, Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756, (512) 458-7375. Source Note: The provisions of this §3.55 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.55 Texas Department of Health (TDH) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221968 03/12/2026 (a) Mission. The mission of the Texas Department of Mental Health and Mental Retardation (TXMHMR) is to offer an array of services which respond to the needs of people with mental illness and mental retardation and which enable them to make choices that result in lives of dignity and increased independence. Our vision is that the TXMHMR service system will become one that is permeated with a commitment to continuous quality improvement (CQI) that is truly customer-driven. It embraces the belief that large public systems even with their inherent regulatory roles and resource limitations can become highly personalized, highly responsive, and highly innovative.(b) Financial and service responsibilities to persons with disabilities. The Texas MHMR Act requires that TXMHMR identify its priority populations and the minimum array of services necessary to address the needs of persons within these priority populations. This legislation also requires that services be offered first to those most in need and that state dollars be used only for services provided to the priority population.(1) Mental retardation services.(A) Mental retardation priority population.(i) The priority population for mental retardation services consists of the 70,840 persons considered to be the most in need. That is approximately 15% of the 480,000 Texans with mental retardation. TXMHMR estimates that there are approximately 26,000 persons with mental retardation in the priority population who currently require our agency's services and are not receiving them.(ii) TXMHMR's priority population for mental retardation services includes those persons who request and need services and possess one or more of the following conditions:(I) mental retardation, as defined by the Health and Safety Code, Title 7, §591.003(13);(II) autism, as defined in the current edition of the Diagnostic and Statistical Manual (DSM);(III) eligibility for Early Childhood Intervention services; or(IV) eligibility for Omnibus Budget Reconciliation Act of 1987-mandated services for mental retardation or a related condition as per specific legislation.(iii) The presence of mental retardation must be determined through a recognized diagnosis and evaluation process or through the use of assessments performed by qualified professionals as per interagency memoranda of understanding. Results of evaluations by appropriately credentialed professionals can be used to determine the presence of autism. For persons with mental retardation or autism, the priority population includes only those individuals whose needs for services can be most appropriately met through programs currently or potentially offered by TXMHMR rather than some other service system. Services are to be offered in coordination with efforts of other agencies to ensure that all services are provided by agencies as required by laws, rules, and regulations. The priority population does not include persons whose service needs may be most appropriately met through other means, as determined by TXMHMR.(iv) Persons who are members of the priority population are eligible to receive services from TXMHMR. Since resources are insufficient to meet all the service needs of all the members of the priority population, services should be provided to meet the most intense needs first.(v) Service participant groups include only members of the priority populations. The purpose of grouping service participants is to provide a structure for gathering data about members of the priority population who have specific characteristics which seem to influence the type and intensity of services required to meet their needs. These groups are mutually exclusive. If an individual has characteristics of more than one group, assignment should be made to the group that most accurately characterizes the person's most intense service needs. No one group has priority over any other group.(vi) Service participant groups are comprised of members of the priority population who:(I) have a challenging behavior (CB) (with or without a mental illness diagnosis) or which requires frequent intervention or regular monitoring. The severity of the behavior is such that it interferes significantly with daily living or learning activities;(II) have a severely challenging behavior (SB) (with or without a mental illness diagnosis). The severity of the behavior is such that it seriously threatens the health and safety of this person or others. The management of the behavior is a primary consideration in planning the individual's activities;(III) have a severe physical disability (PD) as evidenced by a need for an ongoing program designed and monitored by a professionally qualified habilitation therapist or specialist. Such programs are designed to alleviate the primary condition and decrease the effects of any secondary disability. These disabilities may include, but are not limited to, eating problems, ambulation problems, severe sensory (tactile, visual, or auditory) impairments, and other major physical disabilities;(IV) have a health care (HC) need so severe that its treatment and monitoring are the foremost considerations in planning the individual's activities. Immediate 24-hour response from nursing staff, weekly physician intervention, and monitoring of a health care plan by a professional nurse is often needed;(V) need either training or support (TS) to enable or maintain their community arrangements for living, working, or training;(VI) are eligible to receive early childhood intervention (ECI) services according to the following criteria.(-a-) A child is eligible for ECI services if the child is under three years of age, including those children authorized for services as visually or auditory impaired children under the Texas Education Code.(-b-) A child is eligible for ECI services if the child is documented as developmentally delayed or has a medically diagnosed physical or mental condition that has a high probability of resulting in developmental delay.(B) Community center services.(i) TXMHMR contracts with community MHMR centers to provide mental retardation services. Community MHMR centers are locally staffed and governed by a local board of trustees. The centers are usually designated as the mental retardation authority (MRA) for their local service area and are responsible for the provision of a wide range of services as a condition for receiving state funds. These services include case management, emergency services, medical treatment, and respite care. Other services that may be provided are work-related activities including vocational training, vocational assessments, sheltered workshops, supported work programs, and job placements. Short and long-term residential care and developmental programs may also be a part of services.(ii) Eligible individuals receive care at 31 of the 35 community MHMR centers across the state. The four centers that provide care only to persons with mental illness are the Life Resource Center, Texas Panhandle Mental Health Authority, Navarro County MHMR Center, and Riceland Regional Mental Health Authority. Priority is given to clients who are most in need of treatment and support services from the TXMHMR system.(C) State center services.(i) Community services. State centers provide community-based services to persons with mental retardation in areas of the state not served by state schools or community MHMR centers. Services include in-home support services, respite services, family support, case management services, diagnosis and screening, and training and treatment to enhance the individual's ability to function as independently as possible. Individuals may request services by contacting state centers located in Amarillo, Beaumont, El Paso, Harlingen, and Laredo.(ii) Campus-based services. Four of the five state centers provide short and/or long-term residential care and nonresidential service in areas of the state not served by state schools or community MHMR centers. The range of services includes vocational, medical and dental services, and physical, occupational, and recreational therapy. Also included are support services such as maintenance, food services, and laundry. Individuals have the opportunity to participate in activities occurring in the local community. Persons with special needs are served by qualified professionals with consultation from specialists in the medical, dental, and habilitation fields. The five state centers delivering inpatient services are located in Amarillo, Beaumont, El Paso, Harlingen, and Laredo. All of these centers except Beaumont have facilities that are certified as intermediate care facilities for the mentally retarded (ICF/MR).(D) State school services.(i) Community services.(I) Community services provided by state schools are designed to meet the needs of persons who have returned to the community from institutional placement and/or to prevent eligible persons from requiring institutionalization. These services include in-home support services, respite services, family support services, case management services, and diagnostic and evaluation services designed to help the individual live independently. Vocational programs also offered include work adjustment training, pre-vocational services, sheltered workshops, support work, and independent employment. Services are both residential and nonresidential.(II) TXMHMR provides these services directly through 13 state schools located throughout Texas. The 13 state schools are certified as intermediate care facilities for the mentally retarded (ICF-MR). Persons' needs are assessed by interdisciplinary teams, then the services are provided which best meet their individual needs.(ii) Campus-based services.(I) Campus-based services include residential services, therapeutic care and treatment, meals, education, medical care, and recreation for persons with mental retardation. Because many individuals have visual and hearing problems, muscular and/or skeletal anomalies or metabolic and nervous disorders, the facility also helps them cope with or correct their physical disabilities.(II) Under the Social Security Act (Medicaid), the federal government reimburses the state for a significant portion of the costs of providing ICF-MR services to eligible persons at a matching rate of approximately 36% state and 64% federal. The Texas State Legislature appropriates general revenue funds to TXMHMR to cover the costs of operating the schools. The reimbursement obtained from the federal government is returned to the state treasury and is not reflected in TXMHMR's budget.(2) Mental health services.(A) Mental health priority population.(i) There are an estimated 2.6 million persons with mental illness in Texas. TXMHMR's priority population consists of approximately 15% of these persons. It is estimated that in 1993, 347,248 of those were persons with a major diagnosis of mental illness and functional impairment. TXMHMR's estimates suggest that there are approximately 90,000 persons in the priority population who currently need our agency's services but are not receiving them.(ii) The department's priority population for mental health services consist of:(I) children and adolescents under age 18 who have a diagnosis of mental illness, exhibit severe emotional or social disabilities which are life-threatening, or require prolonged intervention; and(II) adults who have severe and persistent mental illnesses, such as schizophrenia, major depression, manic depressive disorders, or other severely disabling mental disorders which require crisis resolution or ongoing and long-term support and treatment.(iii) In targeting services to the priority populations, the choice of and admission to services is determined jointly by the person seeking service and the provider. Factors used to make these determinations are the level of functioning of the individual, the need of the individual, and the availability of resources. TXMHMR funding is directed to provide the identified core services which are designed to meet the needs of these priority populations. Providers who wish to offer services to people other than those in the priority populations may do so using non-department funds.(iv) The agency's strategic plan also identifies groups within the priority population with special needs. These include:(I) children and adolescents;(II) older adults;(III) minorities; and(IV) persons with mental illness in the criminal justice system.(B) Campus-based services.(i) Campus-based services include residential, therapeutic care and treatment; meals; medical care; and recreation for persons with mental illness. These services are provided at eight state hospitals, two state centers, and one state center for youth. The average daily census in these state facilities is approximately 3,300. Nearly 18,000 persons receive residential services annually.(ii) All state hospitals are accredited by the Joint Commission on Accreditation of Hospitals (JCAH). Certain units providing services for elderly patients are also certified to receive Medicare funds.(C) Community services.(i) Community mental health services are provided by 63 mental health authorities. Included in these authorities are 35 community mental health and mental retardation centers which provide mental health services under contract with TXMHMR. The remaining mental health authorities are state hospital or state center programs provided through community service centers which are located in the local service areas of the hospitals or state centers. These programs currently provide services to over 150,000 individuals annually.(ii) Other programs include 24-hour emergency screening and assessment; community and state hospital liaison; family support programs; medication related services; psychosocial rehabilitation programs; day treatment; and case management services.(iii) Services provided by the local mental health authorities consist of individual support services; family support services; psychosocial rehabilitation services; service coordination; and residential services and housing, which may include supervised living arrangements. The crisis stabilization component of the residential services must be available to the residents of a mental health authority.(D) Legislative mandates.(i) The Texas State Legislature and TXMHMR require the provision of core services aimed at meeting individual needs and enhancing personal skills for optimum community living.(ii) The Texas Mental Health and Mental Retardation Act specifies the core services as:(I) 24-hour emergency screening and rapid crisis stabilization services;(II) community-based crisis residential service or hospitalization;(III) community-based assessments, including the development of interdisciplinary treatment plans and diagnosis and evaluation;(IV) medication-related services, including medication clinics, laboratory monitoring, medication education, mental health maintenance education, and the provision of medication;(V) family support services, including respite care;(VI) psychosocial rehabilitation services, including social support activities, independent living skills, and vocational training; and(VII) case management services.(c) Service delivery data. The following data may be obtained by contacting the administrative head of the section or by contacting the director of planning and policy development, at (512) 465-4698 or STS 824-4698.(1) Public Information Office. This office produces the annual report and a directory of TXMHMR services. Telephone: (512) 465-4540.(2) Strategic planning. This office is responsible for demographic data and long-range planning. Telephone: (512) 465-4620.(3) Financial services. This area publishes the TXMHMR Annual Operating Budget and the Biennial Legislative Appropriations Request. Telephone: (512) 465-4550.(4) Information services. This office processes client data information from client assignment and registration system (CARE). Telephone: (512) 465- 4570.(5) Mental health services. Questions regarding mental health services program and/or policy issues can be directed to this section. Telephone: adults (512) 465-4511 and adolescents and children (512) 465-4832.(6) Mental retardation services. This section responds to inquiries about Mental Retardation Services Program and/or policy issues. Telephone: (512) 465-4521.(7) Consumer services and rights protection services. This area is responsible for information regarding issues or statistics regarding client rights. Telephone: (512) 323-3242. Source Note: The provisions of this §3.57 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.57 Texas Department of Mental Health and Mental Retardation (TXMHMR) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221969 03/12/2026 (a) Direct service responsibilities to persons with disabilities.(1) Vocational Rehabilitation Program.(A) This program prepares eligible individuals with disabilities for employment. Services include evaluations to determine vocational, educational, medical, and psychological abilities and needs; limited vocationally necessary medical treatment; training in trade schools, business colleges, rehabilitation centers, halfway houses, colleges, and universities; interpreter services for the deaf; job placement and assistance to employers in modifying jobs for persons with disabilities; and assistive technology devices such as wheelchairs, artificial limbs, and braces to improve functioning on the job.(B) Individuals served must have a physical or mental disability which results in substantial problems in getting and keeping a job; and vocational rehabilitation services are required by that person to prepare for, get, or keep a job.(2) Extended Rehabilitation Services Program (ERS).(A) This program provides long-term employment support services. Other support services available are independent living skills training, transportation, and mobility training.(B) To be eligible, the individual must have a physical or mental disability that results in a substantial barrier to employment. This disability must require some type of ongoing support service in order for the client to obtain and maintain employment. The individual must be at least age 16. Eligible ERS clients, at the conclusion of employment training and placement, must be able to earn 15% of minimum wage.(3) Independent Living (IL) Program.(A) Independent living centers.(i) Nonresidential centers help persons with disabilities live in the community as independently as possible. IL centers are directed and staffed by a majority of persons with disabilities. Core services, mandated by the Rehabilitation Act of 1992, as amended, are information and referral, advocacy, peer counseling, and independent living skills training. Services are either provided directly, or through referral, and may include attendant services, housing referral, transportation, recreational activities, and interpreter services.(ii) Services are available to persons with disabilities as well as individuals who are interested in disability-related issues.(iii) IL centers funded through the Texas Rehabilitation Commission (TRC) with state general revenue funds, are located in Austin, Dallas, El Paso, Houston, San Antonio, Amarillo, Crockett, Fort Worth, Lubbock, and Pharr. An eleventh center in Odessa receives only direct federal funding.(B) Independent living services.(i) Ten IL counselors statewide deliver IL services directly to clients in their immediate areas. IL services are available in the same cities where TRC-funded IL centers are located.(ii) IL services include adaptive equipment such as wheelchairs and environmental control systems, communication aids, modification of vehicles, and sponsorship of medical rehabilitation services.(iii) Eligible individuals must have a severe physical or mental disability which interferes with their ability to function independently, and there must be a reasonable expectation that IL services will substantially improve the individual's ability to function independently. Also, the individuals must have an economic need and cannot be eligible for either the Vocational Rehabilitation or Extended Rehabilitation Services Programs of the Texas Rehabilitation Commission (TRC).(4) Comprehensive rehabilitation services.(A) This program provides inpatient medical rehabilitation services for persons with spinal cord injuries. It also provides inpatient and outpatient medical rehabilitation services for persons with traumatic brain injuries. It is designed to assist patients to achieve higher levels of independence and self-care.(B) Individuals served must have recently sustained a traumatic spinal cord or traumatic brain injury, not be eligible for services through other resources, have an economic need, and be reasonably expected to improve their independent functioning.(5) Services for persons who are deaf-blind and have multiple disabilities. Services include a residential program, a summer camp program, and parent training/counseling, in conjunction with the Texas School for the Blind. Residential services are for adults (age 18 and older) who are deaf-blind, have multiple disabilities, and who need 24-hour support for their daily living. Camp participants must be deaf-blind, have multiple disabilities, and be age six or older. Camp is provided in two locations and during various weeks throughout the summer. Parent training is provided through an annual conference held in conjunction with the Texas School for the Blind and the Deaf-Blind Multihandicapped Association of Texas. Participants are parents of people who are deaf-blind and have multiple disabilities. Respite is provided for all siblings during this weekend conference.(6) Personal attendant services. Personal attendant services is a state-funded program designed to provide assistance on a sliding scale to persons who are severely disabled and have a job that is at risk, or for whom employment is unlikely without support. It is a pilot project that is only available in 19 counties. The program is a client-managed program that stresses independence and responsibility of the person with the disability. The program is limited to a maximum of 35 hours per week.(b) Service delivery data. For information on TRC programs call Special Services at (512) 483-4060. Source Note: The provisions of this §3.59 adopted to be effective September 1, 1993, 18 TexReg 5595; amended to be effective February 15, 1994, 19 TexReg 513; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.59 Texas Rehabilitation Commission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221970 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) The Texas Commission for the Blind has primary responsibility for providing services to persons who are visually disabled, except welfare services and services for children provided by regularly established educational agencies and state authorities as provided in the Human Resources Code, Chapter 91.021(a).(2) The Texas Commission for the Blind offers a continuum of services for persons of all ages who are blind or visually impaired. These service programs include:(A) Blind and Visually Impaired Children's Program.(i) State funding is used to provide services which will prevent blindness, restore vision, reduce dependency for children who have permanent visual problems, and prepare the child for enhanced vocational success. Services include counseling and guidance for the child and the family, adaptive aids, educational support services, resource development and utilization, pre-vocational information, and information and referral services. The target population includes children ages 0 through 16 who are blind, blind multidisabled, deaf-blind, or severely visually impaired.(ii) Youths between the ages 16 and 22 may receive transition services from either the Blind and Visually Impaired Children's Program or the Vocational Rehabilitation Program.(B) Vocational Rehabilitation Program. This program is funded by both the state and federal governments. All services are provided with the ultimate goal of employment for persons who are blind or visually impaired. The target population for this program includes individuals desiring employment who are blind, blind multi-disabled, deaf-blind, or severely visually impaired.(i) Services include vocational counseling; vocational training; rehabilitation teacher services; orientation and mobility training; physical restoration; employment assistance in sheltered, supported, or competitive employment; personal and social adjustment training; and rehabilitation engineering.(ii) To be eligible for vocational rehabilitation services, a person must:(I) have a physical or mental disability (including a visual condition);(II) have a disability that constitutes a barrier to employment; and(III) be reasonably expected to benefit from vocational rehabilitation services, in terms of employment.(C) Independent living rehabilitation. This program is designed to help persons who are blind or visually impaired to live as independently as possible.(i) Services in this program include counseling, evaluation and skills training, referral, advocacy, and assistance with eye medical problems. Independent living services are for individuals for whom employment is not plausible and, although most of the clients receiving services under this program are elderly, there are no age restrictions.(ii) Funding for this program comes from the Vocational Rehabilitation Act of 1973, as amended, under Title VII, Parts A, B, and C, and from state appropriations for serving older clients who are blind or visually impaired.(D) Deaf-blind services.(i) Services for persons who are deaf-blind are provided on a statewide basis through the Blind and Visually Impaired Children's Program, the Vocational Rehabilitation Program, and the Independent Living Program.(ii) Specific services include rehabilitation center training, adaptive skills training, career guidance, job readiness counseling, and employment assistance. Federal funding is provided under the Vocational Rehabilitation Act of 1973, as amended, and a three-year grant for services to persons who are deaf-blind.(b) Service delivery data.(1) The Texas Commission for the Blind's biennial report for fiscal years 1989-1990 contains a brief description of each program, the services that are provided, and a summary about individuals receiving agency services and funding expenditures.(2) Legislative requests for funding are submitted to the commissioner of the Health and Human Services Commission pursuant to Texas Civil Statutes, Article 4413(502), §13. The legislative appropriations request (LAR) details the description and objectives of each of the Texas Commission for the Blind's programs and lists specific budget details and need indicators.(3) The Texas Commission for the Blind has detailed and general information regarding the types of services provided in each program in the UNISYS A4 computer database. General information is currently available, and special computer runs may be provided for more specific information upon request.(4) Additional information regarding agency programs and services is available by contacting: Deputy Director for Programs, Texas Commission for the Blind, P.O. Box 12866, Austin, Texas 78711, Voice or TDD: (512) 459-2602 or 1-800-252-5204. Source Note: The provisions of this §3.61 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.61 Texas Commission for the Blind https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221971 03/12/2026 (a) Financial and service responsibilities to disabled persons.(1) The Texas Commission for the Deaf and Hearing Impaired (TCDHI) is authorized to provide direct delivery services to persons who are deaf or hearing impaired. These services are rendered through annual contracts with local service providers. TCDHI currently has contracts with service providers located in 16 cities: Abilene, Amarillo, Austin, Beaumont, Big Spring, Corpus Christi, Dallas, El Paso, Fort Worth, Houston, Lubbock, McAllen, San Antonio, Sherman, Tyler, and Waco.(2) The number of staff, types of direct services, and number of clients at each service provider vary considerably. Many provide other direct services in addition to those authorized and subsidized by the state through TCDHI. The range of TCDHI-contracted services include:(A) Interpreter services. Interpreters are provided for clients who are deaf or hearing impaired to assist them in obtaining, medical, legal, governmental, and economic services. Interpreters are also available through the local service providers for state agencies, courts, and businesses; however, these entities must reimburse the service provider. Payment for interpreters is reimbursed monthly by TCDHI on an hourly basis for services provided. The rate of payment is determined by the fee schedule recommended for interpreters by TCDHI.(B) Information and referral services. Service providers disseminate information regarding general and specialized community services to persons who are deaf or hearing impaired, as well as information about deafness to the general public.(C) Services to older hearing impaired Texans (SOHIT). Clients who are age 60 or older and deaf or hearing impaired are assisted in obtaining information and/or services from agencies such as the Texas Department on Aging, local agencies on aging, social security offices, and local parks and recreation departments. Services provided may include case management, transportation assistance, nutrition, social interaction, and communication. This program reduces the need for long-term care, provides information to concerned individuals, and provides training to other personnel serving the elderly. These programs are referred to as Services to Older Hearing Impaired Texans (SOHIT). Currently, 11 local service providers offer SOHIT services.(D) Other services. In addition to the services described in subparagraphs (A)-(D) of this paragraph, TCDHI has service and financial responsibilities to:(i) develop and implement a statewide advocacy and education program to ensure the continuity of services to Texans who are deaf or hearing impaired;(ii) ensure more effective coordination/cooperation among public and nonprofit entities that serve persons who are deaf or hearing impaired;(iii) establish a board for the evaluation of interpreters which commission approval, conducts interpreter exams, prescribes qualifications, evaluates, and certifies interpreters at varying levels of skill. TCDHI is required to charge fees for these services. In addition, statutes require that the Board for Evaluation of Interpreters work with the Texas Rehabilitation Commission to develop a communication competency evaluation for TRC's vocational rehabilitation counselors and other staff who work with clients who are deaf or hearing impaired. Commission (TRC) a communication competency evaluation for vocational rehabilitation counselors who work at TRC with clients who are deaf or hearing impaired;(iv) establish a system to approve courses and workshops for the instruction and continuing education of interpreters;(v) annually review fees recommended by TCDHI for the payment of interpreters and adopt a schedule of reasonable fees for interpreters at varying levels of skill. This schedule of fees must be made available to and recommended for adoption by other state agencies;(vi) prescribe the qualifications for, and compile a list of, qualified interpreters available for assignment by state agencies, courts, and political subdivisions. This list is to be disseminated to these entities and the general public;(vii) adopt a schedule of reasonable fees recommended for the payment of interpreters required by law to be provided in proceedings of state agencies, courts, and political subdivisions;(viii) adopt a sliding fee scale for persons who are deaf or hearing impaired who receive interpreter services in nongovernmental settings which are reimbursed by TCDHI. The fee scale is based on the requestor's financial ability to pay; however, a client may not be denied this service because of his/her inability to pay;(ix) design and provide a decal to be attached to motor vehicles regularly operated by persons who are deaf or hearing impaired with a cost of not more than $2.00 per decal;(x) offer a one-week summer camp session for children and youth who are deaf or hearing impaired to participate in barrier-free recreational and instructional activities. TCDHI annually contracts with a private facility for this program. Eligibility requirements are that students must be deaf or hearing impaired, ages 8 through 17;(xi) charge reasonable fees for TCDHI publications. Fees for publications may be waived for a client who is deaf or hearing impaired if he/she is unable to pay; and(xii) publish an annual Directory of Services and an agency newsletter (based on available funding) and make available a Registry of Interpreters.(E) Interagency contracts. Currently, TCD has interagency contracts primarily concerning interpreter services with the Texas Employment Commission, Texas Commission on Alcohol and Drug Abuse, Texas Department of Criminal Justice, Texas Department of Mental Health and Mental Retardation, and the Texas Department of Health.(F) Memorandum of understanding. House Bill 550, passed by the 70th Legislature, required TCDHI to write (and adopt by rule) memoranda of understanding to coordinate the delivery of services to persons who are deaf and hearing impaired and to reduce duplication of services with each of the following agencies: Texas Department of Human Services, Texas Department of Mental Health and Mental Retardation, Texas Employment Commission, Texas Department of Health, Texas Higher Education Coordinating Board, Texas Education Agency, Texas Department on Aging, Texas School for the Deaf, Texas Rehabilitation Commission, and the institutional division of the Texas Department of Criminal Justice, and other state agencies that provide services to persons who are deaf or hearing impaired. TCDHI also participates in two multi-agency memoranda of understanding which facilitate the coordination of services to persons with disabilities and to inmates of the Texas prison system who have disabilities.(b) Service delivery data.(1) The contact person for TCD may be reached at (512) 444-3323 (voice/TDD) and (512) 326-9639 (fax machine).(2) Information regarding councils for the deaf is provided in:(A) the TCDHI Contracted Services Listing that provides lists of services provided by each service provider;(B) the Registry of Interpreters that makes available, on request, the names, locations, phone numbers, and interpreting skill levels of TCDHI-certified (or National Registry of Interpreters for the Deaf-certified) interpreters in Texas;(C) the legislative appropriations request (LAR) which is the agency's request for biennium funding (and information about its program activities, goals, and objectives). The LAR is prepared and submitted to the Legislative Budget Office;(D) Resource Handbook on Interpreting, Interpreter Certification, and Principles of Ethical Behavior explains the interpreter certification procedure, the use of interpreters, and the laws relating to the use of interpreters. Source Note: The provisions of this §3.63 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.63 Texas Commission for the Deaf and Hearing Impaired https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221972 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) TEA is authorized to serve children and youth with disabilities who:(A) are ages three through 21 and are:(i) orthopedically impaired;(ii) other health impaired;(iii) mentally retarded;(iv) emotionally disturbed;(v) learning disabled;(vi) speech impaired;(vii) autistic;(viii) multiply disabled; or(ix) pregnant students;(B) are ages 0 through 21 and are:(i) auditorially impaired;(ii) visually impaired; or(iii) deaf-blind;(C) students, including:(i) bilingual students, limited English proficient;(ii) educationally and economically disadvantaged students;(iii) children of migrant workers;(iv) gifted and talented students;(v) prekindergarten, four-year-old, limited English proficient, and economically disadvantaged;(vi) refugee children needing transition services;(vii) delinquent, neglected, and those in correctional facilities;(viii) educationally disadvantaged and limited-English-speaking adults; and(ix) dropouts and students at risk of dropping out.(2) TEA administers services relating to the needs of children and youth, including:(A) Special education for students with disabilities, involving:(i) comprehensive individualized student assessment which includes identification and referral and determination of physical, mental, emotional, general educational, and vocational education needs;(ii) individualized instruction provided by the district in a variety of classroom arrangements within the school and also in home, hospital, and residential facility-based arrangements;(iii) related services when needed to enable a student with disabilities to benefit from the specialized instruction which includes:(I) orientation and mobility training;(II) adaptive equipment;(III) audiological services;(IV) corrective therapy;(V) counseling services;(VI) medical diagnostic services;(VII) psychological services;(VIII) occupational therapy;(IX) art therapy;(X) music therapy;(XI) recreation therapy;(XII) school health services;(XIII) social work services;(XIV) transportation; and(XV) vision training;(iv) other support services including special instructional equipment and materials, consultative services, and staff development services.(B) Vocational Education Program.(i) Vocational training and job placement programs at high school and college levels includes special provisions for children with disabilities and children who are educationally disadvantaged.(ii) The Job Training and Partnership Act (JTPA) Program operated by school districts provides job-specific training, counseling, remedial education, and vocational exploration opportunities.(b) Sources of funds.(1) Foundation School Program funds.(A) Service description. State funds generated by students with disabilities may be used to employ or contract with special education personnel to provide special education instruction and related services as stipulated by each student's individual education plan. A maximum of 15% of state special education funds may be used by a school district for general administrative costs. These funds are also used to purchase instructional supplies, materials, and specialized equipment.(B) Delivery method.(i) State special education funds are distributed on the basis of full-time equivalents of students with disabilities served during the school district's best four-of-eight weeks of overall average daily attendance (ADA). For the purposes of special education funding, "full-time equivalent student" means 30 hours of contact a week between a special education student and special education program personnel.(ii) School districts count ADA and receive credit for contact hours for serving eligible students with disabilities who reside in intermediate care facilities for the mentally retarded (ICF-MRs), or who are in care and treatment facilities approved by the Texas Department of Human Services (DHS) or the Texas Department of Mental Health and Mental Retardation (TXMHMR), if these facilities are located within the district's boundaries. However, no local taxes are generated for these particular students since their parents/guardians reside in school districts other than the ones where the facilities are located. Children in the conservatorship of the state also do not generate local taxes.(C) Eligibility requirements. Students who are at least age three and not over age 22 on September 1 and who meet the eligibility criteria for the conditions stated in the Texas Administrative Code, Title 19, §89.211 (concerning Students with Disabilities) are eligible.(D) Delivery method. Students with disabilities receive special education instructions and related services in their local schools based upon the recommendations of the admission, review, and dismissal committee for placement in the least restrictive environment.(2) Education of the Handicapped Act, Part B, Texas Education Agency (TEA).(A) Service description.(i) Funds are used to pay for salary costs of special education personnel, special materials and equipment, related services, consultant services, student evaluation services, staff travel and related services, and residential care costs for residential placements of students with severe disabilities in nonpublic schools approved by TEA.(ii) These funds supplement state and local funds in the provision of special education instruction and related services for all students with disabilities; special services for three-, four-, and five-year-olds; and special education teacher training.(iii) Public Law 99-457 amended this act to provide for inter-agency coordination, to allow split funding, and to prevent duplication of services.(B) Delivery method. TEA allocates federal funds primarily through local school districts and special education cooperatives supplemented by services from the regional education service centers. Funding is allocated on a per-child basis through a count of students taken each year on December 1.(C) Eligibility requirements. Students served are those with disabilities, ages three through 21 who meet the criteria established in the Texas Administrative Code, Title 19, §89.211 (concerning Students with Disabilities).(3) Education of the Handicapped Act, Part C--Deaf/Blind.(A) Service description. Services include technical assistance in transition services from education programs to future living and work settings, sheltered living experiences, vocational training, and related services; consultative/counseling services to families and service providers; inservice training for staff working with deaf-blind persons; and coordination of activities with other agencies.(B) Delivery method. Children receive this aid in their local schools. TEA provides technical assistance in local schools or residential facilities on an as-needed basis.(C) Eligibility criteria. Deaf-blind children ages 0 through 21 are eligible.(4) Regional services for the deaf.(A) Service description. Eligible deaf students receive a basic instructional program suitable to their educational needs and are provided with the opportunity for achievement at a level more equivalent to their peers with normal hearing. Funding provides supplemental instructional services; parent counseling and training; special diagnostics; special media, materials, and equipment; and staff development.(B) Delivery method. Local school districts apply to TEA for funds to meet identified priorities of the local programs, based on standards established by TEA. Applications are then negotiated and become contracts.(C) Eligibility requirements. Students are eligible if they are deaf or hearing impaired and meet other specific criteria outlined in the Texas Administrative Code, Title 19, §89.211(c) (concerning Students with Disabilities).(5) Services for students with visual impairments.(A) Service description. Services include:;(i) review of applications for state funding by school districts and regional education service centers to ensure that education services will be provided that are adapted for students with visual impairments;(ii) evaluation of special education services;(iii) maintenance of a system of registration and development of standards and guidelines for special education services;(iv) provision of consultation and technical assistance to programs; and(v) maintenance of effective liaison with other agencies and service providers involved with services to students with visual impairments.(B) Delivery method.(i) Students receive services described in subparagraph (A) of this paragraph in their local schools. TEA staff work directly with local school districts in evaluating programs, developing standards and guidelines, providing technical assistance, and keeping a registry of students with visual impairments. Funding is based on the needs of the districts' programs.(ii) TEA's Division of Special Education Funding (Services for the Visually Impaired) is primarily responsible for the ongoing development and administration of comprehensive statewide services for the education of students with visual impairments, as assigned by law.(C) Eligibility requirements. Students must be legally blind and age 0 through 21.(6) Services for students with visual impairments--education service centers.(A) Service description.(i) Funding supports:(I) existing programs, to expand direct and supportive services for students with visual impairments which are not available through use of other funds;(II) development of special cooperatives formed specifically to meet the educational and related service needs;(III) programs for infants with visual impairments; and(IV) minimum components of services in each education service center to provide direct services and technical assistance as needed.(ii) Specific types of activities include:(I) supplemental instructional services;(II) orientation and mobility training;(III) parent counseling and training;(IV) special diagnostics;(V) other special related services;(VI) special media, materials, and equipment; and(VII) staff development and other supplemental services.(B) Delivery method. Students receive services in their local schools. Local school districts and regional education service centers may apply for state supplemental funding aid for special services to students with visual impairments. Funding does not supplant other existing funds or programs and is allocated by TEA.(C) Eligibility requirements. Students served must be students with visual impairments ages 0 through 21, who meet eligibility criteria for the visually impaired as outlined in the Texas Administrative Code, Title 19, §89.211(d) (concerning Students with Disabilities). Funding to districts is on a need/application basis rather than formal allocation.(c) Service delivery data.(1) Types of data collected on children and youth include:(A) number of students with disabilities by district, age, disabling condition, and services provided including residential contract care;(B) number of different student populations residing in each district apart from parent or guardian;(C) number of economically disadvantaged students by district;(D) number of special student populations by district (example: migrant, bilingual, and limited English proficient; refugees; legal; and undocumented immigrants); and(E) number of students with disabilities and number of students without disabilities in correctional facilities and other state-operated residential facilities.(2) The contact person for the interagency coordination for the student with disabilities may be reached at (512) 463-9283. Source Note: The provisions of this §3.65 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.65 Texas Education Agency (TEA) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221973 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) Protective services for children and adults.(A) Child Protective Services (CPS) is the branch of the Texas Department of Protective and Regulatory Services (PRS) that provides services to children at risk of abuse or neglect and to their families. These services include: intake/investigation of abuse/neglect referrals, in-home services, truant and runaway services, removal services, substitute care, family reunification, and adoption. Child protective services are provided without regard to income. If the court orders removal of a child from the child's home and places the child in the conservatorship of the state, foster care maintenance payments are made to the substitute care provider. Children in foster care are also eligible for Medicaid.(B) The Adult Protective Services (APS) Program of PRS investigates reports of abuse, neglect, or exploitation of elderly adults and adults with disabilities. When a report is validated, APS provides or arranges for services to remedy the situation in the least restrictive manner possible. Ongoing APS services provided include direct casework, specialized support services, and guardianship services. All services provided are voluntary, except in cases in which a client:(i) requires services to alleviate a threat to life;(ii) the client is refusing services; and(iii) the client does not appear to have the capacity to understand the situation.(C) PRS also has the responsibility of overseeing investigations of abuse, neglect, or exploitation conducted by other state agencies which operate, license, certify, or register facilities for persons with disabilities. PRS receives and reviews complaints about these investigations. Of the 30,235 clients served in fiscal year (FY) 1992, 34% (10,171) were nonelderly persons with disabilities. PRS expects to provide APS services to approximately 11,518 nonelderly persons with disabilities in FY 1993.(2) Licensing.(A) The Licensing Department of PRS regulates facilities that provide out-of-home care for children and regulates child-placing agencies that place children for foster care, residential child care, and adoption. The Child Day Care Licensing Program is responsible for regulating day care centers, kindergartens, and nursery schools; schools, grades kindergarten and above; drop-in care centers; group day care homes; and registered family homes.(B) The Residential Child Care Licensing Program is responsible for regulating institutions providing basic child care, residential treatment centers, halfway houses, therapeutic camps, institutions serving mentally retarded children, emergency shelters, foster group homes, foster family homes, child-placing agencies, and maternity homes.(C) The Licensing Program develops minimum standards, evaluates applications for licensure, certification, and registration, and monitors regulated facilities on an ongoing basis for compliance with minimum standards. Licensing staff investigate complaints and serious incidents in regulated facilities and allegations of illegal operation. Specialized staff investigate allegations of abuse and neglect in regulated child care facilities and allegations of illegal child-placing activities.(b) Service delivery data.(1) PRS has a variety of data identifying the type of services, the number of clients receiving services, and expenditure data for all programs. The most comprehensive PRS documents that contain service delivery and expenditure data are:(A) the legislative appropriations request (LAR), a document prepared and submitted to the Legislative Budget Board and the governor's Budget Office prior to each legislative session. It contains PRS's request for appropriations for the next biennium based on four levels of funding for each program and activity. It also provides a summary of PRS's request. Specifically, it provides the objective and a description of each program and activity as well as data for need indicators, performance measures, object of expense, and method of finance for a five-year period. This period includes two years of the appropriations request and the three previous years;(B) the fiscal year operating plan is the budget for PRS based on appropriations received. It contains a breakdown of budgeted dollars by program area and activity at the state level. For each program, the document states the need, the description of program activities, the budget allocation for each activity, the performance measures or units of service, and the method of finance. The allocation covers the current fiscal year and the two previous years;(C) the annual report is a fiscal-year description of PRS services, a review of the services, and an accounting of PRS expenditures. The report contains a section of statistics that depicts estimated expenditures by method of finance, benefit expenditures by region, a summary of agency information by county, aged and disabled benefits by county, families and children benefits by county, and data concerning the regulation of child care facilities. In addition to client data, PRS has demographic data from the 1985 Special Texas Census and population estimates and projections from the Texas Department of Health. The 1985 Special Texas Census was a mailout survey to the general population of Texas. It was a data collection effort comprising a sample of 22,000 Texas households to identify human service needs in support of the Texas Department of Human Services' (DHS's) budget and planning process. With a response rate of over 64% of the valid sample, data was collected for more than 12,300 households or over 33,000 individuals. The data collected for each person concentrated on money income; demographics (age, sex, race/ethnicity, marital status, language, and education); employment status; medical insurance coverage; medical utilization; disability; functional impairment; help available for persons with disabilities; child care; child support payment; knowledge about runaways; child abuse and/or neglect; and family violence shelters. Based on the response rate and the selection of data variables, data may provide adequate representation for the state and for DHS regions.(2) PRS service delivery and demographic data may be requested from the Office of Public Information, (512) 450-3645. Source Note: The provisions of this §3.67 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.67 Texas Department of Protective and Regulatory Services (PRS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221974 03/12/2026 (a) Financial and service responsibilities to persons with disabilities.(1) ECI was established by the Texas State Legislature to provide services to infants and toddlers with developmental delays and their families. ECI contracts with 75 local community organizations and agencies. The ECI programs are affiliates of local school districts, educational service centers, state centers, state schools, Texas Department of Mental Health and Mental Retardation (TXMHMR) community centers, private rehabilitation centers, and universities. Children under age three with a significant delay in one or more areas of development, or with established medical conditions known to lead to developmental delays (such as Down's syndrome), and children diagnosed as having atypical behaviors are eligible for services. The contact for program information is the executive director, Texas Early Childhood Intervention Program, (512) 502-4900.(2) Agreements with state agencies. The Texas ECI Program represents an inter-agency effort of the Texas Department of Health, Texas Department of Mental Health and Mental Retardation, Texas Department of Human Services, Texas Commission on Alcohol and Drug Abuse, Texas Department of Protective and Regulatory Services, and the Texas Education Agency. The Texas ECI Program is governed by an inter-agency council with a representative from each of the departments listed in this paragraph, plus three public representatives appointed by the Office of the Governor.(b) Service delivery data.(1) The legislative appropriations request (LAR) is a document prepared and submitted to the Legislative Budget Board and the governor's Budget Office, prior to each legislative session, that contains the agency's request for appropriations for the next biennium based upon ECI's strategic plan.(2) The fiscal year operation plan is the budget for ECI based on appropriations received. It contains a breakdown of budgeted dollars by strategy at the state level.(3) The annual performance report to the legislature contains a summary of performance measures and funding as annually projected and as actually reported. Data collected from local providers and from administrative sources are reported. Source Note: The provisions of this §3.69 adopted to be effective September 1, 1993, 18 TexReg 5595; amended to be effective December 15, 1993, 18 TexReg 8704; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.69 The Texas Interagency Council on Early Childhood Intervention (ECI) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221975 03/12/2026 Texas Department of Human Services, Texas Department of Health, Texas Department of Mental Health and Mental Retardation, Texas Rehabilitation Commission, Texas Commission for the Blind, Texas Commission for the Deaf, Texas Education Agency, Texas Department of Protective and Regulatory Services, and the Early Childhood Intervention Program agree to:(1) share all pertinent client information at the local level that is deemed appropriate to any agency involved in service planning or service delivery. Client information shared between agencies involved in service delivery is not open to public inspection and will not be disclosed in any manner that will identify an individual, unless ordered by the court. Any transfer of client information would be made pursuant to the rules and regulations of the transferring agency and only for the purposes of providing treatment or service;(2) share the service delivery data identified in this memorandum of understanding upon request through the designated contact person for each state agency;(3) review and, if necessary, update this memorandum of understanding prior to the end of each state fiscal year;(4) adopt this memorandum of understanding and all revisions to this memorandum by rule;(5) consult with and solicit input from advocacy and consumer groups in the formulation of this memorandum of understanding through the public comment process for proposed rule publication; and(6) adhere to all applicable federal and state requirements for program accessibility for persons with disabilities. Source Note: The provisions of this §3.71 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.71 Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221976 03/12/2026 This agreement is effective September 1, 1993. Source Note: The provisions of this §3.73 adopted to be effective September 1, 1993, 18 TexReg 5595; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES B MEMORANDUM OF UNDERSTANDING CONCERNING COORDINATION OF SERVICES TO PERSONS WITH DISABILITIES §3.73 Effective Date https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221977 03/12/2026 (a) This memorandum of understanding (MOU) between Texas Rehabilitation Commission (TRC), Texas Department of Human Resources (DHS), Texas Department of Health (TDH), and Texas Department of Mental Health and Mental Retardation (TDMHMR) is to implement and coordinate the exchange and distribution of public awareness information among the agencies. This agreement is intended to satisfy the requirements of Senate Bill 298, of the 70th Legislature, 1987.(1) The TRC is the state authority for the delivery of vocational rehabilitation services, Texas Codes Annotated, the Human Resources Code, Title 7, leading to:(A) employment for persons with disabilities;(B) the determination of social security disability benefits;(C) licensing of occupational therapists;(D) promoting employer acceptance of workers with disabilities; and(E) developing programs to serve persons with developmental disabilities.(2) DHS provides services to two major groups of needy people: families and children, and aged and disabled adults.(A) Eligible families and children receive cash grants from the aid to families with dependent children program, health care, family self-support services, and food stamps.(B) Services to aged and disabled individuals who are poor include health care, institutional care, community care, and food stamps.(C) Services available to all Texans regardless of financial need, include protective services for children, protective services for aged and disabled persons, disaster assistance, and childcare licensing.(3) TDH is an agency of the state of Texas created by Texas Civil Statutes, Article 4414b, to better protect and promote the health of the people of Texas.(4) TDMHMR is the state agency that provides a system of services for the conservation and restoration of mental health among Texas citizens and to provide, coordinate, develop, and improve services for the mentally retarded citizens of this state so that they will be afforded the opportunity to develop their respective mental capacities to the fullest practicable extent and to live as useful and productive lives as possible. To accomplish this, the department provides a network of eight state hospitals for the mentally ill, 13 state schools for the mentally retarded, seven special centers, and 34 community centers.(b) Each state agency designs, writes, publishes, and distributes information to the public about the programs and services available from that agency. For the purpose of this MOU, each agency agrees to:(1) provide a current list of publications designed for public awareness to the other agencies; and(2) provide a copy of each publication designed for public awareness to the other agencies. As publications are updated they will be distributed to the other agencies.(c) Each agency adopts this memorandum of understanding and agrees to review and update the memorandum no later than the last month of each state fiscal year. Each agency by rule shall adopt the memorandum of understanding and all revisions to the memorandum. Source Note: The provisions of this §3.101 adopted to be effective July 1, 1988, 13 TexReg 2974; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES C MEMORANDUM OF UNDERSTANDING FOR EXCHANGE AND DISTRIBUTION OF PUBLIC AWARENESS INFORMATION §3.101 Authorization and Requirement To Exchange and Distribute Public Awareness Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221978 03/12/2026 The Texas Department of Human Services (DHS) adopts by reference Texas Administrative Code, Title 37, Public Safety and Corrections, Part VI, Texas Department of Criminal Justice, Chapter 159, Special Programs, §159.5 and §159.7 (concerning Continuity of Care System for Offenders with Physical Disabilities and Continuity of Care System of Elderly Offenders) as adopted effective May 31, 1995. This memorandum of understanding between the Texas Department of Criminal Justice and DHS provides for continuity of care system for offenders with physical disabilities and elderly offenders. Source Note: The provisions of this §3.151 adopted to be effective September 5, 1995, 20 TexReg 6455; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES D MEMORANDUM OF UNDERSTANDING WITH THE TEXAS DEPARTMENT OF CRIMINAL JUSTICE §3.151 Memorandum of Understanding with the Texas Department of Criminal Justice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221979 03/12/2026 (a) Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts by reference a rule of the Texas Education Agency (TEA) in 19 TAC §89.1115 (relating to Memorandum of Understanding Concerning Interagency Coordination of Special Education Services to Students with Disabilities in Residential Facilities).(b) The TEA rule contains the text of an MOU between the following state agencies:(1) TDMHMR;(2) TEA;(3) Texas Department of Human Services;(4) Texas Department of Health;(5) Texas Department of Protective and Regulatory Services;(6) Texas Interagency Council on Early Childhood Intervention;(7) Texas Commission on Alcohol and Drug Abuse;(8) Texas Juvenile Probation Commission; and(9) Texas Youth Commission.(c) The MOU concerns the provision of a free and appropriate education for school-age residents of residential facilities and is required by the Texas Education Code, §29.012(d).(d) Copies of the MOU are filed in the Office of Policy Development, TDMHMR, 909 West 45th Street, Austin, Texas 78756, and may be reviewed during regular business hours. Source Note: The provisions of this §3.251 adopted to be effective November 15, 1999, 24 TexReg 10091; amended to be effective February 18, 2003, 28 TexReg 1392; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9027. 1 HEALTH AND HUMAN SERVICES COMMISSION 3 MEMORANDUM OF UNDERSTANDING WITH OTHER STATE AGENCIES E MOU--COORDINATION OF SPECIAL EDUCATION SERVICES TO STUDENTS WITH DISABILITIES IN RESIDENTIAL FACILITIES §3.251 Interagency Coordination of Special Education Services to Students with Disabilities in Residential Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198170 03/12/2026 Authority is granted to the Texas Health and Human Services Commission (HHSC) under Texas Health and Safety Code §467.001 to establish minimum criteria for peer assistance programs. Source Note: The provisions of this §8.101 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.101 Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198171 03/12/2026 This chapter applies to any peer assistance program organized and operated under authority of Texas Health and Safety Code, Chapter 467. This chapter does not apply to peer assistance programs established for licensed physicians or pharmacists or for any other profession that is authorized by other law to establish a peer assistance program. The peer assistance program for pharmacists is required to establish and comply with rules that are at least as strict as those contained in this chapter. Source Note: The provisions of this §8.103 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.103 Applicability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198172 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Approved peer assistance program--A program designed to help an impaired professional which is:(A) established or approved by a licensing or disciplinary authority;(B) meets the criteria established by HHSC in this chapter; and(C) meets any additional criteria established by the licensing or disciplinary authority.(2) HHSC--The Texas Health and Human Services Commission.(3) Impaired professional--An individual whose ability to perform professional services is impaired by a mental health or substance use condition.(4) Impaired student--A student whose ability to perform the services of the profession for which the student is preparing for licensure would be, or would reasonably be expected to be, impaired by a mental health or substance use condition.(5) Licensing or disciplinary authority--A state agency or board that licenses or has disciplinary authority over professionals.(6) Mental health condition--A condition (excluding intellectual or developmental disability or a substance use condition) that substantially impairs an individual's:(A) thought, perception of reality, emotional process, or judgment;(B) behavior; or(C) ability to participate in daily routines.(7) Mental health professional--An individual licensed by the state as a:(A) licensed chemical dependency counselor;(B) licensed clinical social worker;(C) licensed marriage and family therapist;(D) licensed professional counselor;(E) psychologist; or(F) nurse, with at least a master's degree in nursing and national certification in substance use or psychiatric nursing.(8) Peer assistance program--Identifies, assists, and monitors individuals experiencing mental health or substance use conditions that are, or are likely to be, job-impairing, so that the individuals may return to safe practice. Peer assistance programs offer support and assistance and have a rehabilitative emphasis rather than a disciplinary emphasis.(9) Professional--An individual who may incorporate under The Texas Professional Corporation Law as described by Section 1.008(m), Business Organizations Code, or who is licensed, registered, certified, or otherwise authorized by the state to practice as a licensed vocational nurse, social worker, chemical dependency counselor, occupational therapist, speech-language pathologist, audiologist, licensed dietitian, or dental or dental hygiene school faculty member.(10) Professional association--A national or statewide association of professionals, including any committee of a professional association and any nonprofit organization controlled by or operated in support of a professional association.(11) Staff--All persons responsible for implementing a peer assistance program, whether employed, under contract, paid, or volunteer.(12) Student--An individual enrolled in an educational program or course of study leading to initial licensure as a professional as such program or course of study is defined by the appropriate licensing or disciplinary authority.(13) Substance use condition--A recurrent use of alcohol or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Source Note: The provisions of this §8.105 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198173 03/12/2026 (a) A professional association or licensing or disciplinary authority may establish a peer assistance program to identify and assist impaired professionals in accordance with the minimum criteria established by HHSC in this chapter and any additional criteria established by the appropriate licensing or disciplinary authority.(b) Peer assistance programs must be certified by HHSC under this chapter.(1) A peer assistance program must submit all documentation required by HHSC to verify that the program meets the minimum standards described in this chapter.(2) Once HHSC is satisfied that a peer assistance program meets minimum standards, the program receives a document confirming certification.(3) A peer assistance program is recertified periodically as determined by HHSC.(4) A peer assistance program must notify HHSC within 30 days of any change in status, including change of address or telephone number.(c) A peer assistance program established by a professional association must submit evidence to the appropriate licensing or disciplinary authority showing that the association's program meets the minimum criteria established by HHSC in this chapter and any additional criteria established by that authority.(1) If a licensing or disciplinary authority receives evidence showing that a peer assistance program established by a professional association meets the minimum criteria established by HHSC in this chapter and any additional criteria established by that authority, the authority must approve the program.(2) A licensing or disciplinary authority may revoke its approval of a program established by a professional association if the authority determines that:(A) the program does not comply with the criteria established by HHSC or by that authority; and(B) the professional association does not bring the program into compliance within a reasonable time, as determined by that authority. Source Note: The provisions of this §8.107 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.107 Peer Assistance Program Certification and Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198174 03/12/2026 (a) A peer assistance program's governing body is legally responsible for the management, services, and operations of the program. No member of the governing body may have the potential for direct financial gain from these activities.(b) A peer assistance program's governing body must designate or employ an administrator for the peer assistance program. The administrator is responsible for the day-to-day operations of the program.(c) A peer assistance program must maintain adequate financial records according to generally accepted accounting principles. Financial records must include an annual budget and records of income and expenditures. Source Note: The provisions of this §8.109 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.109 Organization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198175 03/12/2026 (a) A peer assistance program must maintain an adequate number of staff to effectively administer the program and provide the services identified in the program description.(b) Each staff position must have a written job description that specifies:(1) duties and responsibilities; and(2) minimum qualifications, including the level of education, training, and related work experience required.(c) An application or resume for each staff member must document education, training, and related work experience that meets or exceeds the minimum qualifications in that person's job description.(d) The organization must provide adequate supervision for staff.(e) All staff must receive training regarding program and participant confidentiality requirements. Staff who will coordinate intervention or participation or will consult with or monitor a participant must complete eight hours of training before working with program participants. At least five hours of the training must be conducted by a mental health professional and include:(1) mental health and substance use conditions;(2) appropriate treatment for mental health and substance use conditions; and(3) intervention and advocacy skills, as applicable.(f) The program must maintain documentation of required training.(g) Each personnel file must be kept for at least two years after the individual stops working with the program. Source Note: The provisions of this §8.111 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.111 Staffing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198176 03/12/2026 (a) A peer assistance program must have a written description of the program that includes:(1) target population;(2) the plan for ensuring services are available throughout the state;(3) how the following areas are to be addressed:(A) identification of and intervention with impaired professionals and, if served, impaired students;(B) assistance with accessing treatment;(C) monitoring and support of participants;(D) intervention in crises, including relapses; and(E) support during the reentry by participants to professional practice or academic role;(4) the plan for program evaluation; and(5) the methods used to promote and encourage use of the program.(b) A peer assistance program must operate according to the program description required by subsection (a) of this section. Source Note: The provisions of this §8.113 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.113 Program Description https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198177 03/12/2026 (a) A peer assistance program must operate according to written policies and procedures designed to support the implementation of the program description.(b) The policies and procedures for a peer assistance program must comply with:(1) this chapter;(2) any requirements of the licensing or disciplinary authority that established or approved the program; and(3) all applicable state or federal laws or rules.(c) There must be at least one professional in recovery from a substance use condition and one professional in recovery from a mental health condition involved in program and policy development. These individuals may be members of the governing board, staff, or members of an advisory committee for the program.(d) The written policies and procedures must state philosophy and methods for program operation, including:(1) the licensing or disciplinary authority's role in the process and the program's relationship to the authority;(2) procedures for maintaining confidentiality;(3) compliance with applicable state and federal legal authority and regulations;(4) eligibility criteria for participants;(5) the circumstances under which an individual will be accepted as a participant in the program;(6) all formal agreements (including consents for disclosure) required of participants;(7) a description of the following processes, including, where applicable, how they apply to self-referrals and participants:(A) referral;(B) assessment;(C) intervention;(D) drug testing;(E) treatment;(F) return to work;(G) crisis and relapse;(H) participant noncompliance with intervention, drug testing, or treatment;(I) participant dismissal from the program;(J) participant who moves out of state; and(K) participant program completion;(8) the program's role in the accessing of treatment by the participant;(9) participant records and related documentation;(10) program's relationship to reporting third parties; and(11) the criteria to be used for selection of assessment and treatment referral resources.(e) The policies and procedures must be current, and staff must have access to applicable information. Source Note: The provisions of this §8.115 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.115 Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198178 03/12/2026 (a) A person who knows or suspects that a professional is impaired by a substance use or mental health condition may report the professional's name and any relevant information to an approved peer assistance program.(b) A person who is required by law to report an impaired professional to a licensing or disciplinary authority satisfies that requirement if the person reports the professional to an approved peer assistance program.(c) An approved peer assistance program may report in writing to the appropriate licensing or disciplinary authority the name of a professional who the program knows or suspects is impaired and any relevant information concerning that professional. Source Note: The provisions of this §8.117 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.117 Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198179 03/12/2026 (a) Neither the peer assistance program nor any individual associated with it may accept compensation for referrals. Compensation includes:(1) pay;(2) anything of value; and(3) any other form of benefit or consideration.(b) If the peer assistance program has a relationship with a licensed treatment facility that involves ownership, operation, management, or control, then the program must comply with the requirements of Texas Health and Safety Code §164.007 and §164.008 regarding referrals for treatment.(c) If the peer assistance program is not subject to Texas Health and Safety Code §164.007 and §164.008, the program must:(1) implement an objective process for selecting assessment and treatment resources to be provided as referrals to participants; and(2) maintain documentation including:(A) the method for establishing selection criteria;(B) the relevance of the criteria to the services to be provided;(C) the process used to apply the criteria to potential resources; and(D) the justification for the selection of those assessment and treatment resources chosen. Source Note: The provisions of this §8.119 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.119 Referrals to Assessment and Treatment Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198180 03/12/2026 (a) An impaired professional who is referred to a peer assistance program must, as a condition of participation in the program, give consent to the program that authorizes the program to disclose the impaired professional's success or failure to complete the program to the appropriate licensing or disciplinary authority.(b) A peer assistance program must notify the appropriate licensing or disciplinary authority if a person succeeds or fails to complete the program, as required by the appropriate licensing or disciplinary authority.(c) A peer assistance program must notify a person who made a report under §8.117 of this chapter (relating to Reports) if the professional who was reported fails to participate in the program as required by the appropriate licensing or disciplinary authority. Source Note: The provisions of this §8.121 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.121 Program Completion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198181 03/12/2026 (a) Any information, report, or record that an approved peer assistance program or a licensing or disciplinary authority receives, gathers, or maintains under Chapter 467 of the Texas Health and Safety Code is confidential. Except as prescribed in Chapter 467 of the Texas Health and Safety Code, a person may not disclose that information, report, or record without written approval of the impaired professional or other interested person. An order entered by a licensing or disciplinary authority may be confidential only if the licensee subject to the order agrees to the order and there is no previous or pending action, complaint, or investigation concerning the licensee involving malpractice, injury, or harm to any member of the public.(b) Information that is confidential under subsection (a) of this section may be disclosed:(1) at a disciplinary hearing before a licensing or disciplinary authority in which the authority considers taking disciplinary action against an impaired professional whom the authority has referred to a peer assistance program under Texas Health and Safety Code §467.006(a) or (b);(2) at an appeal from a disciplinary action or order imposed by a licensing or disciplinary authority;(3) to qualified personnel for bona fide research or educational purposes only after information that would identify a person is removed;(4) to health care personnel to whom an approved peer assistance program or a licensing or disciplinary authority has referred an impaired professional; or(5) to other health care personnel to the extent necessary to meet a health care emergency. Source Note: The provisions of this §8.123 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.123 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198182 03/12/2026 (a) A peer assistance program may provide services to impaired students.(b) A peer assistance program that elects to provide services to impaired students is not required to provide the same services to those students that it provides to impaired professionals.(c) A peer assistance program that provides services to students must comply with any criteria for those services that are adopted by the appropriate licensing or disciplinary authority. Source Note: The provisions of this §8.125 adopted to be effective January 27, 2020, 45 TexReg 579. 1 HEALTH AND HUMAN SERVICES COMMISSION 8 PEER ASSISTANCE PROGRAMS FOR IMPAIRED PROFESSIONALS §8.125 Provision of Services to Students https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224522 03/12/2026 (a) Except as provided in subsections (b) - (e) of this section, all of the sections of this chapter apply to an applicant or contractor for one or more of the following programs and services: (1) Medicaid waiver programs and services under Title XIX, §1915(c) of the Social Security Act as follows: (A) the Community Living Assistance and Support Services (CLASS) Program: (i) CLASS-case management agency (CMA); (ii) CLASS-continued family services (CFS); (iii) CLASS-direct service agency (DSA); and (iv) CLASS-support family services (SFS); (B) the Deaf Blind with Multiple Disabilities (DBMD) Program; (C) the Home and Community-based Services (HCS) Program; (D) the Texas Home Living (TxHmL) Program; and (E) transition assistance services (TAS); (2) Medicaid state plan programs or services under Title XIX, §1902(a)(10)(A) of the Social Security Act as follows: (A) hospice; (B) the Primary Home Care (PHC) Program; (C) the Community Attendant Services (CAS) Program; and (D) day activity and health services (DAHS); (3) services and programs under Title XX, Subtitle A of the Social Security Act as follows: (A) adult foster care (AFC); (B) emergency response services; (C) the Home-Delivered Meals (HDM) Program; (D) residential care (RC); (E) DAHS; (F) the Family Care (FC) Program; (G) the Consumer Managed Personal Attendant Services (CMPAS) Program; (H) special services to persons with disabilities (SSPD); and (I) SSPD - 24-hour shared attendant care; and (4) financial management services under the consumer directed services option authorized under Texas Government Code Chapter 546, Subchapter C as follows: (A) financial management services agency (FMSA)--CLASS; (B) FMSA-DBMD; (C) FMSA-HCS; (D) FMSA-PHC/CAS/FC; and (E) FMSA-TxHmL. (b) Section 49.310 of this chapter (relating to Abuse, Neglect, and Exploitation Allegations), Subchapter D of this chapter (relating to Monitoring and Investigation of a Contractor), and Subchapter E, Divisions 2 and 3 of this chapter (relating to Immediate Protection; and Actions) do not apply to a contractor that has a contract for: (1) the HCS Program; or (2) the TxHmL Program. (c) Subchapter D of this chapter and §49.523 of this chapter (relating to Referral Hold) do not apply to a contractor that has a contract for hospice. (d) Sections 49.202 - 49.205 and §§49.207 - 49.211 of this chapter (relating to Provisional Contract; Provisional Contract Application Process; Additional Provisional Contract Application Requirements; License, Certification, Accreditation, and Other Requirements; Provisional Contract Application Denial; Provisional Contract Application Approval; Standard Contract; Contractor Change of Ownership or Legal Entity; and Religious Organization Applicants) and Subchapter G of this chapter (relating to Application Denial Period) do not apply to a contractor that has a contract for: (1) the CMPAS Program; (2) SSPD; or (3) SSPD - 24-hour shared attendant care. (e) Section 49.310 of this chapter does not apply to a contractor that has a contract for one or more of the following programs or services: (1) a CLASS-CMA; (2) a CLASS-DSA; (3) the CMPAS Program; (4) the DBMD Program; (5) an FMSA-CLASS; (6) an FMSA-DBMD; (7) an FMSA-HCS; (8) an FMSA-PHC/CAS/FC; (9) an FMSA-TxHmL; (10) the PHC Program; (11) the CAS Program; and (12) the FC Program. Source Note: The provisions of this §52.1 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091; amended to be effective April 1, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES A APPLICATION AND DEFINITIONS §52.1 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219131 03/12/2026 The following words and terms have the following meanings when used in this chapter, unless the context clearly indicates otherwise:(1) AA--Adaptive aids.(2) Abuse--"Abuse" as defined by the statute or rule that governs the investigation of alleged abuse of an individual.(3) AFC--Adult foster care.(4) Applicant--A person seeking to obtain a contract.(5) Application denial period--A period of time during which HHSC denies a contract application submitted to HHSC.(6) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(7) CAS Program--Community Attendant Services Program.(8) CFC PAS/HAB--A Medicaid state plan service provided through the Community First Choice (CFC) Option, described in 1 Texas Administrative Code Chapter 354, Subchapter A, Division 27 (relating to Community First Choice), under a contract for:(A) the HCS Program;(B) the TxHmL Program;(C) a DSA in the CLASS Program; or(D) the DBMD Program.(9) CFS--Continued family services.(10) Change of legal entity--An event that occurs when a contractor is required to obtain a new federal tax identification number.(11) Change of ownership--An event that occurs when:(A) as a result of a transfer or sale, at least 50 percent of the ownership of a contractor is held by one or more persons who owned less than 5 percent of the contractor before the transfer or sale; and(B) the contractor is not required to obtain a new federal tax identification number.(12) Choice list--A list of contracts under which an individual or LAR may choose to receive services.(13) CLASS Program--Community Living Assistance and Support Services Program.(14) Clean claim--In accordance with Code of Federal Regulations, Title 42, §447.45(b), a claim for services submitted by a contractor that can be processed without obtaining additional information from the contractor or a party other than HHSC, including a claim with errors originating in the Texas claims management system, but not including a claim from a contractor under investigation for fraud or abuse, or a claim under review for medical necessity.(15) CMA--Case management agency.(16) CMPAS Program--Consumer Managed Personal Attendant Services Program.(17) Contract--A written agreement between HHSC and another person that obligates the other person to provide a service to an individual in exchange for payment from HHSC. The term includes standard and provisional contracts.(18) Contractor--The person other than HHSC who is a party to a contract.(19) Contractual agreement--A written, legally binding agreement that is not a contract as defined in this section.(20) Controlling ownership interest--A direct ownership interest, an indirect ownership interest, or a combination of direct and indirect ownership interests, of 5 percent or more in an applicant or contractor.(21) Controlling person--A person who:(A) has a controlling ownership interest;(B) is a managing employee;(C) has been delegated the authority to obligate or act on behalf of an applicant or contractor;(D) is an officer or director of a corporation that is an applicant or contractor;(E) is a partner in a partnership that is an applicant or contractor;(F) is a member or manager in a limited liability company that is an applicant or contractor;(G) is a trustee or trust manager of a trust that is an applicant or contractor;(H) is a spouse of a person who is an applicant or contractor; or(I) because of a personal, familial, or other relationship with an applicant or contractor, is in a position of actual control or authority with respect to the applicant or contractor, regardless of the person's title.(22) Conviction--A determination of being found or proved guilty that:(A) is any of the following:(i) a judgment of conviction that has been entered by a federal, state or local court, regardless of whether:(I) there is a post-trial motion or an appeal pending; or(II) the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;(ii) a finding of guilt made by a federal, state, or local court; or(iii) an acceptance of a plea of guilty or nolo contendere by a federal, state, or local court; and(B) does not include successful completion of a period of deferred adjudication community supervision and receipt of a dismissal and discharge in accordance with Texas Code of Criminal Procedure, Article 42.12, Section 5(c).(23) DADS--The Department of Aging and Disability Services.(24) DAHS--Day activity and health services.(25) Day--A calendar day, including weekends and holidays.(26) DBMD Program--Deaf Blind with Multiple Disabilities Program.(27) Desk review--A review by HHSC of a contractor's service delivery or business operation that takes place away from the contractor's administrative and service delivery sites, using records provided to HHSC by the contractor. The scope of the review is at the discretion of HHSC.(28) DFPS--The Department of Family and Protective Services.(29) Direct ownership interest--An interest in the ownership of an applicant or contractor as described in subparagraphs (A) and (B) of this paragraph.(A) Direct ownership interest is:(i) ownership of equity in the capital, stock, or profits of an applicant or contractor; or(ii) ownership in a mortgage, deed of trust, note, or other obligation secured by property of an applicant or contractor.(B) The percentage of direct ownership interest of an applicant or contractor, based on ownership of a mortgage, deed of trust, note, or other obligation, is determined by multiplying the percentage of ownership in the obligation by the percentage of the applicant's or contractor's assets used to secure the obligation. For example, ownership of 10 percent of a note secured by 60 percent of a contractor's or applicant's assets equals 6 percent direct ownership interest in the applicant or contractor (that is, 0.1 x 0.6 = 0.06).(30) DSA--Direct service agency.(31) Electronic record--Information that is stored in a medium having electrical, digital, magnetic, wireless, optical, electromagnetic, or similar capabilities, and is retrievable in perceivable form.(32) Emergency response plan--A written plan that describes the actions that will be taken to protect individuals, including evacuation or sheltering-in-place, in the event of an emergency such as a fire or other man-made or natural disaster.(33) Exploitation--"Exploitation" as defined by the statute or rule that governs the investigation of alleged exploitation of an individual.(34) FC Program--Family Care Program.(35) FMSA--Financial management services agency. An entity that contracts with HHSC to provide financial management services, as defined in §41.103 of this title (relating to Definitions).(36) Governmental entity--An agency or other entity of federal, state, or local government.(37) HCS Program--Home and Community-based Services Program.(38) HCSSA--Home and community support services agency.(39) HDM Program--Home-Delivered Meals (HDM) Program.(40) HHS list of exclusions--A list made before September 1, 2014, of individuals and entities prohibited from conducting business with DADS in any capacity for a specified period.(41) HHSC--The Texas Health and Human Services Commission.(42) Indirect ownership interest--An interest in the ownership of an applicant or contractor as described in subparagraphs (A) and (B) of this paragraph.(A) Indirect ownership interest is an ownership interest in a person that has a direct or indirect ownership interest in an applicant or contractor.(B) The percentage of indirect ownership interest is determined by multiplying the percentage of ownership interest in the person that has a direct ownership interest in the applicant or contractor by the percentage of direct ownership that the person has in the applicant or contractor. For example:(i) ownership of 10 percent of the stock of a corporation that owns 80 percent of the stock of an applicant or contractor equals 8 percent indirect ownership of the applicant or contractor (that is, 0.1 x 0.8 = 0.08); and(ii) ownership of 50 percent of the stock of a corporation that owns 10 percent of the stock of a corporation that owns 80 percent of the stock of an applicant or contractor equals 4 percent indirect ownership of the applicant or contractor (that is, 0.5 x 0.1 x 0.8 = 0.04).(43) Individual--A person who is enrolled in a program or service described in §49.101(a) of this subchapter (relating to Application).(44) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a particular matter. The term may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(45) LEIE--List of excluded individuals and entities. In this context, "individual" does not have the meaning as defined in this section.(46) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC in accordance with Texas Health and Safety Code, §533A.035.(47) Managing employee--A person who exercises operational or managerial control over, or who conducts the day-to-day operation of, an applicant or contractor.(48) Neglect--"Neglect" as defined by the statute or rule that governs the investigation of alleged neglect of an individual.(49) OHR--Out of home respite.(50) Paper record--Information that is stored on paper.(51) Person--A corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, natural person, or any other legal entity that can function legally, sue or be sued, and make decisions through agents.(52) PHC Program--Primary Home Care Program.(53) Provisional contract--A contract that HHSC enters into in accordance with §49.208 of this chapter (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §49.208(e) of this chapter.(54) RC--Residential care.(55) Records--Paper records and electronic records.(56) Recoup--To reduce payments that are due to a contractor under a contract to satisfy a debt the contractor owes to HHSC but does not include making routine adjustments for prior overpayments to the contractor.(57) Referral hold--An action in which HHSC prohibits a contractor from, for a period of time determined by HHSC, providing services to an individual not receiving services from the contractor at the time the referral hold was imposed.(58) SFS--Support family services.(59) Signature authority--A person authorized to negotiate and execute a contract on behalf of a contractor as identified on the HHSC "Governing Authority Resolution" form.(60) SSPD--Special Services to Persons with Disabilities (SSPD) Program.(61) Standard contract--A contract that HHSC enters into in accordance with §49.209 of this chapter (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with §49.209(d) of this chapter.(62) Subcontract--An agreement, other than a contract, between a contractor and another person that obligates the other person to provide all or part of the goods, services, work, or materials required of the contractor in a contract.(63) Subcontractor--The person other than a contractor who is a party to a subcontract.(64) TAS--Transition assistance services.(65) TxHmL Program--Texas Home Living Program.(66) Vendor hold--A temporary suspension of payments that are due to a contractor under a contract.(67) Volunteer--A person who works for a contractor without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §52.3 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective March 20, 2016, 41 TexReg 1970; amended to be effective September 28, 2016, 41 TexReg 7514; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective October 1, 2019, 44 TexReg 5149; amended to be effective May 10, 2020, 45 TexReg 2890; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES A APPLICATION AND DEFINITIONS §52.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219132 03/12/2026 Sections 49.202 - 49.205 and §§49.207 - 49.211 of this subchapter (relating to Provisional Contract; Provisional Contract Application Process; Additional Provisional Contract Application Requirements; License, Certification, Accreditation, and Other Requirements; Provisional Contract Application Denial; Provisional Contract Application Approval; Standard Contract; Contractor Change of Ownership or Legal Entity; and Religious Organization Applicants) do not apply to a contractor that has a contract for:(1) the CMPAS Program;(2) SSPD; or(3) SSPD - 24-hour shared attendant care. Source Note: The provisions of this §52.25 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.25 Contractors Not Subject to Certain Portions of Subchapter B https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219133 03/12/2026 (a) To obtain a contract for a service or program for which a person does not have a contract, or a contract in a service or catchment area in which the person does not have a contract, the person must apply for a provisional contract in accordance with §49.203 of this subchapter (relating to Provisional Contract Application Process) and §49.204 of this subchapter (relating to Additional Provisional Contract Application Requirements).(b) HHSC may require that a contract be limited to a single facility or single service or catchment area. Source Note: The provisions of this §52.27 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.27 Provisional Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219135 03/12/2026 (a) To apply for a provisional contract, an applicant must:(1) if required by HHSC as stated on the HHSC website, complete HHSC pre-application orientation (PAO) and training in accordance with the instructions on the HHSC website before submitting an application packet to HHSC as described in paragraph (3) of this subsection;(2) if applying for a Title XX HDM contract, obtain written approval from HHSC staff in the region in which the applicant is seeking to provide services regarding budgetary issues and health inspections before submitting an application packet to HHSC as described in paragraph (3) of this subsection; and(3) submit an application packet that contains:(A) an HHSC provisional contract application completed in accordance with the application instructions;(B) other documents required by the application instructions including:(i) if required to complete PAO or training, a certificate of completion of the PAO or training issued by HHSC;(ii) if the applicant is applying not because of a change of ownership as described in §49.210 of this subchapter (relating to Contractor Change of Ownership or Legal Entity), a copy of any document required to be a contractor as described in §49.205 of this subchapter (relating to License, Certification, Accreditation, and Other Requirements);(iii) if the applicant is applying because of a change of ownership or because of a change of legal entity as described in §49.210 of this subchapter, a copy of the application for change of ownership of any license required to be a contractor as described in §49.205 of this subchapter; and(iv) if the applicant is not required to have a license issued by HHSC under §49.205 of this subchapter, a written acknowledgement from the Texas Department of Public Safety that the applicant has requested, in accordance with the application instructions, a criminal history record be sent to HHSC for each controlling person of the applicant.(b) An applicant must submit the completed application packet to HHSC in a timely manner as described in this subsection.(1) An application packet must be delivered to HHSC, in accordance with the application instructions, by:(A) the United States Postal Service, with a postmark bearing a date no later than 60 days after the applicant completed the PAO;(B) a commercial carrier, with a receipt by the carrier showing it was given to the carrier no later than 60 days after the applicant completed the PAO; or(C) hand delivery, no later than 60 days after the applicant completed the PAO.(2) For purposes of paragraph (1)(B) and (C) of this subsection, if the 60th day is a day on which the HHSC office receiving the application packet is closed, the period extends through the end of the next day the office is open.(c) If the applicant timely submits an incomplete or incorrect application packet, including failing to submit a required document, HHSC:(1) requests, in writing, that the applicant submit a missing document; or(2) returns a document to the applicant for correction or completion.(d) HHSC gives an applicant only one opportunity to submit a missing document or to complete or correct a document in accordance with this subsection. An applicant must submit a missing, completed, or corrected document to HHSC in a timely manner as described in this subsection.(1) A missing document must be delivered to HHSC, in accordance with HHSC instructions, by:(A) the United States Postal Service, with a postmark bearing a date no later than 30 days after the date of HHSC's written request for a missing document;(B) a commercial carrier, with a receipt by the carrier showing it was given to the carrier no later than 30 days after the date of HHSC's written request for a missing document; or(C) hand delivery, fax, or e-mail no later than 30 days after HHSC's written request for a missing document.(2) A properly completed or corrected document must be delivered to HHSC, in accordance with HHSC instructions, by:(A) the United States Postal Service, with a postmark bearing a date no later than 30 days after the date of the letter from HHSC returning the incomplete or incorrect document;(B) a commercial carrier, with a receipt by the carrier showing it was given to the carrier no later than 30 days after the date of the letter from HHSC returning the incomplete or incorrect document; or(C) hand delivery, fax, or e-mail no later than 30 days after the date of the letter from HHSC returning the incomplete or incorrect document.(3) For purposes of paragraphs (1)(B) and (C) and (2)(B) and (C) of this subsection, if the 30th day is a day on which the HHSC office receiving the missing, completed, or corrected document is closed, the period extends through the end of the next day the office is open. Source Note: The provisions of this §52.29 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.29 Provisional Contract Application Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219136 03/12/2026 (a) An applicant that is licensed as an assisted living facility, applies for a Title XX RC contract, and otherwise meets application requirements must meet the requirements in §46.13 of this title (relating to Housing Options), as determined by HHSC based on an on-site visit.(b) An applicant that applies for a Title XX AFC contract and otherwise meets application requirements must meet the requirements in Chapter 48, Subchapter K of this title (relating to Minimum Standards for Adult Foster Care).(c) Except as provided in subsections (d) and (e) of this section, an applicant that applies for an HCS or TxHmL contract and otherwise meets application requirements must complete provider applicant training and receive a score of at least 85 percent on the provider competency examination.(d) An applicant that applies for an HCS contract does not have to complete provider applicant training or take the provider competency examination if the applicant otherwise meets application requirements and has a standard contract for the HCS Program in another service area.(e) An applicant that applies for a TxHmL contract does not have to complete provider applicant training or take the provider competency examination if the applicant otherwise meets application requirements and has a standard contract for the HCS Program or TxHmL Program in another service area.(f) An applicant that applies for an FMSA contract and otherwise meets application requirements must complete HHSC training in accordance with the instructions on the HHSC website and receive a score of at least 85 percent on the HHSC financial management services test. Source Note: The provisions of this §52.31 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.31 Additional Provisional Contract Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219137 03/12/2026 (a) To be a contractor, an applicant must have a license, certification, accreditation, or other document as follows:(1) CLASS-CFS and CLASS-SFS require:(A) a permit to operate a child-placing agency issued by HHSC in accordance with Chapter 745 of this title (relating to Licensing); or(B) a HCSSA license issued by HHSC in accordance with 26 TAC Chapter 558 (relating to Licensing Standards for Home and Community Support Services Agencies) with:(i) the licensed home health services (LHHS) category; or(ii) the licensed and certified home health services (L&CHHS) category;(2) CLASS-DSA requires a HCSSA license issued by HHSC in accordance with 26 TAC Chapter 558 with:(A) the LHHS category; or(B) the L&CHHS category;(3) the DBMD Program requires:(A) a HCSSA license issued by HHSC in accordance with 26 TAC Chapter 558 with:(i) the LHHS category; or(ii) the L&CHHS category; and(B) for a contractor that provides residential services to four to six individuals, an assisted living facility license Type A or Type B issued by HHSC in accordance with 26 TAC Chapter 553 (relating to Licensing Standards for Assisted Living Facilities);(4) TAS requires:(A) written documentation from HHSC or the Administration for Community Living of the United States Department of Health and Human Services that the applicant is a center for independent living, as defined by 29 United States Code §796a;(B) a contract other than the TAS contract; or(C) written designation by HHSC as an area agency on aging;(5) Medicaid hospice requires:(A) a HCSSA license for hospice issued by HHSC in accordance with 26 TAC Chapter 558; and(B) a written notification from the Centers for Medicare & Medicaid Services that the applicant is certified to participate as a hospice agency in the Medicare Program;(6) the PHC Program, CAS Program, and FC Program require a HCSSA license issued by HHSC in accordance with 26 TAC Chapter 558 with:(A) the LHHS category;(B) the L&CHHS category; or(C) the PAS category;(7) DAHS requires a DAHS facility license issued by HHSC in accordance with Chapter 98 of this title (relating to Day Activity and Health Services Requirements);(8) Title XX AFC requires for an AFC home serving four to eight individuals, an assisted living facility license Type A or Type B issued by HHSC in accordance with 26 TAC Chapter 553; and(9) Title XX RC requires an assisted living facility license Type A or Type B issued by HHSC in accordance with 26 TAC Chapter 553.(b) The license, certification, accreditation, or other document required by subsection (a) of this section must be valid in the service or catchment area:(1) in which the applicant is seeking to provide services; or(2) covered under the contractor's contract. Source Note: The provisions of this §52.33 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 28, 2016, 41 TexReg 7514; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.33 License, Certification, Accreditation, and Other Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219138 03/12/2026 (a) HHSC may determine an applicant or contractor is ineligible to contract with HHSC if the applicant, contractor, or a controlling person of the applicant or contractor has a conviction of any of the following misdemeanor or felony offenses, regardless of the date of conviction:(1) an offense listed in §99.2(a) of this title (relating to Convictions Barring Licensure);(2) an offense related to the person's involvement in any program under Medicare, Medicaid, or Title XX, Subtitle A of the Social Security Act;(3) an offense described in Texas Occupations Code, §102.001 or §102.006 (relating to Solicitation, Offense; and Failure to Disclose, Offense); or(4) an offense of aiding, abetting, or conspiring to commit an offense described in paragraphs (1) - (3) of this subsection.(b) HHSC considers a conviction of an offense under the laws of another state, federal law, or the Uniform Code of Military Justice containing elements that are substantially similar to the elements of an offense listed in subsection (a) of this section as if it is a conviction of one of the listed offenses.(c) If an applicant, contractor or a controlling person of an applicant or contractor has a conviction of an offense listed in subsection (a) or (b) of this section, HHSC considers the following information when determining if the applicant or contractor is eligible to contract with HHSC:(1) the nature and seriousness of the offense;(2) the relationship of the offense to the applicant's, contractor's, or controlling person's duties under the contract;(3) the extent to which a contract might offer an opportunity for the applicant, contractor, or controlling person to engage in activity similar to the offense;(4) the age of the applicant, contractor, or controlling person at the time of the offense;(5) the amount of time since the offense;(6) whether the applicant, contractor, or controlling person has been convicted of other offenses; and(7) any other information provided by the applicant, contractor, or controlling person to explain the circumstances of the offense or to evidence the applicant's, contractor's, or controlling person's conduct since the offense. Source Note: The provisions of this §52.35 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.35 Ineligibility Due to Criminal History https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219139 03/12/2026 (a) HHSC denies a provisional contract application if:(1) HHSC has not approved the applicant or contractor for enrollment in accordance with 1 TAC Chapter 352 (relating to Medicaid and Children's Health Insurance Program Provider Enrollment) and 1 TAC Chapter 371, Subchapter E (relating to Provider Disclosure and Screening);(2) HHSC has denied the enrollment application of the applicant or contractor, or has disenrolled the applicant or contractor, in accordance with 1 TAC Chapter 352 or Chapter 371, Subchapter E;(3) the applicant or a controlling person of the applicant is under an application denial period as described in §49.702 of this chapter (relating to Application Denial Period);(4) the applicant or a controlling person of the applicant is under a period of exclusion in accordance with §§1128, 1128A, 1136, 1156, or 1842(j)(2) of the Social Security Act;(5) the applicant or a controlling person of the applicant is listed on:(A) the HHSC employee misconduct registry as unemployable;(B) the HHSC nurse aide registry as revoked or suspended;(C) the United States System for Award Management maintained by the General Services Administration;(D) the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General;(E) the LEIE maintained by the HHSC Office of Inspector General;(F) the Debarred Vendor List maintained by the Texas Comptroller of Public Accounts and the period of debarment has not expired; or(G) the HHS list of exclusions;(6) the applicant has not submitted a completed application packet as required by §49.203 of this subchapter (relating to Provisional Contract Application Process);(7) the applicant does not have a license, certification, accreditation, or other document required by §49.205 of this subchapter (relating to License, Certification, Accreditation, and Other Requirements);(8) the applicant is applying because of a change of ownership or a change of legal entity and HHSC has denied the application for change of ownership of any license required to be a contractor as described in §49.205 of this subchapter;(9) the applicant or a controlling person of the applicant is ineligible to contract with HHSC in accordance with §49.206 of this subchapter (relating to Ineligibility Due to Criminal History);(10) the applicant or a controlling person of the applicant is prohibited from contracting with HHSC in accordance with Chapter 79, Subchapter S, of this title (relating to Contracting Ethics);(11) the applicant does not meet a requirement described in §49.204 of this subchapter (relating to Additional Provisional Contract Application Requirements);(12) a DSA in the CLASS Program is applying to be a CMA in the CLASS Program in the same catchment area in which the applicant is a DSA;(13) a CMA in the CLASS Program is applying to be a DSA in the CLASS Program in the same catchment area in which the applicant is a CMA;(14) the applicant is applying to be a DSA and CMA in the CLASS Program in the same catchment area;(15) the applicant is required to register with the Texas Secretary of State and the applicant's status with the Texas Secretary of State is not "in existence"; or(16) the applicant is required to pay Texas franchise tax and the applicant's right to transact business status with the Texas Comptroller of Public Accounts is not "active."(b) HHSC may deny a provisional contract application for good cause, including that:(1) the application packet contains incorrect information;(2) the applicant or a controlling person of the applicant terminated a contractual agreement with a governmental entity in a federal health care program, as defined in §1128B(f) of the Social Security Act, while an adverse action or sanction was proposed or in effect;(3) the applicant or a controlling person of the applicant terminated a contract while an action or sanction by DADS or HHSC, as described in §49.521 or §49.531 of this chapter (relating to Action by HHSC; Sanction by HHSC) was proposed or in effect;(4) DADS or HHSC proposed or imposed an action or sanction, as described in §49.521 or §49.531 of this chapter, against:(A) a contract of the applicant, contractor or a controlling person of the applicant; or(B) a contract of a person for whom the applicant or a controlling person of the applicant was a controlling person;(5) HHSC, another governmental entity, or a managed care organization contracting with a governmental entity, proposed or imposed a termination, suspension, recoupment, or penalty against:(A) a contractual agreement of the applicant or a controlling person of the applicant; or(B) a contract of a person for whom the applicant or a controlling person of the applicant was a controlling person;(6) HHSC or another governmental entity proposed or imposed a penalty, revocation, denial, termination, or suspension against a license, certification, or registration held by the applicant or a controlling person of the applicant;(7) the applicant or a controlling person of the applicant has an unresolved financial liability with HHSC or another governmental entity; or(8) the applicant or a controlling person of the applicant has been confirmed by DFPS or HHSC as having committed abuse, neglect, or exploitation.(c) If HHSC denies a provisional contract application, HHSC provides written notification to the applicant. If the applicant wants to be a contractor, the applicant must repeat the application process described in §49.203 and §49.204 of this subchapter. Source Note: The provisions of this §52.37 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.37 Provisional Contract Application Denial https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219140 03/12/2026 (a) HHSC approves a provisional contract application if it is not denied in accordance with §49.207 of this subchapter (relating to Provisional Contract Application Denial).(b) If HHSC approves a provisional contract application, HHSC:(1) provides written notification to the applicant;(2) enters into a provisional contract with the applicant; and(3) except as provided in §49.302(b) of this chapter (relating to General Requirements), places the contract on the choice list for the program or service covered by the provisional contract.(c) HHSC may subject a provisional contract to conditions in accordance with 1 TAC Chapter 352 (relating to Medicaid and the Children's Health Insurance Program Provider Enrollment) and 1 TAC Chapter 371, Subchapter E (relating to Provider Disclosure and Screening).(d) The effective date of a provisional contract is as follows:(1) if the applicant applied for the contract in accordance with §49.210(a)(2) of this subchapter (relating to Contractor Change of Ownership or Legal Entity), the effective date is the effective date of the change of ownership or legal entity of the contractor; or(2) for an applicant other than one described in paragraph (1) of this subsection, the effective date is determined by HHSC.(e) HHSC and a contractor may agree, in writing, to extend the term of a provisional contract. A provisional contract may be extended only once and for no more than one year. The extension of a provisional contract is not a decision by HHSC that it will offer the contractor a standard contract. Source Note: The provisions of this §52.39 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.39 Provisional Contract Application Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219141 03/12/2026 (a) During the term of a provisional or standard contract, HHSC may offer the contractor a standard contract that will be effective the day after the existing contract ends. HHSC offers a standard contract that is for the same program, service, or facility, in the same service, catchment, or waiver contract area as the existing contract, but other terms of the contract offered may be different than the terms of the existing contract.(b) HHSC may subject a standard contract to conditions in accordance with 1 TAC Chapter 352 (relating to Medicaid and the Children's Health Insurance Program Provider Enrollment) and 1 TAC Chapter 371, Subchapter E (relating to Provider Disclosure and Screening).(c) If HHSC offers a standard contract to a contractor and the contractor does not enter into the standard contract in accordance with HHSC's instructions, HHSC notifies the contractor and any controlling person of the contractor, in writing, of the application denial period set in accordance with §49.702(c) of this chapter (relating to Application Denial Period).(d) HHSC and a contractor may agree, in writing, to extend the term of a standard contract. A standard contract may be extended only once and for no more than one year. The extension of a standard contract is not a decision by HHSC that it will offer the contractor another standard contract. Source Note: The provisions of this §52.41 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective April 28, 2020, 45 TexReg 2725; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.41 Standard Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219142 03/12/2026 (a) If a contractor intends to undergo a change of ownership or change of legal entity, the following action must be taken to obtain a new provisional contract:(1) at least 60 days before the proposed date of the change of ownership or change of legal entity, the contractor must notify HHSC in accordance with §49.551 of this chapter (relating to Contractor Terminating Contract or Not Entering into a Standard Contract) that it intends to terminate the contract;(2) the contractor (for a change of ownership) or new legal entity (for a change of legal entity) must apply for a provisional contract in accordance with §49.203 of this subchapter (relating to Provisional Contract Application Process) at least 60 days before the proposed date of the change of ownership or change of legal entity;(3) the contractor or new legal entity must receive approval from HHSC of the provisional contract application before the date of the change of ownership or change of legal entity in accordance with §49.208 of this subchapter (relating to Provisional Contract Application Approval); and(4) if required to have a license under §49.205 of this subchapter (relating to License, Certification, Accreditation, and Other Requirements) to be a contractor, the contractor or new legal entity must ensure that the date of the change of ownership or change of legal entity is the same as the date of the change of ownership or change of legal entity for the new license.(b) If a contractor undergoes a change of ownership or change of legal entity and the requirements in subsection (a)(1) - (4) of this section are met, HHSC:(1) notifies individuals receiving services or LARs in accordance with §49.551(c)(2)(A) of this chapter; and(2) enters into a new provisional contract with the contractor or new legal entity.(c) If a contractor undergoes a change of ownership or change of legal entity and the requirements in subsection (a)(1) - (4) of this section are not met, HHSC:(1) proposes to terminate the contractor's contract in accordance with §49.534(a)(2)(C) of this chapter;(2) notifies individuals receiving services or LARs in accordance with §49.534(c)(1) and (2) of this chapter; and(3) does not enter into a new provisional contract with the contractor or new legal entity with an effective date the same as the date of the change.(d) If a contractor or new legal entity does not receive approval in accordance with subsection (a)(3) of this section, HHSC does not enter into a contract with the contractor or new legal entity. Source Note: The provisions of this §52.43 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.43 Contractor Change of Ownership or Legal Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219143 03/12/2026 (a) The provisions in this section are based on Code of Federal Regulations, Title 45, Part 87.(b) An applicant that is a religious organization is eligible to become a contractor on the same basis as any other applicant.(c) HHSC does not discriminate against an applicant based on the applicant's religious character or affiliation, in approving or denying an applicant's application. Source Note: The provisions of this §52.45 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES B CONTRACTOR ENROLLMENT §52.45 Religious Organization Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219144 03/12/2026 Section 49.310 of this subchapter (relating to Abuse, Neglect, and Exploitation Allegations) does not apply to a contractor for one or more of the following programs and services:(1) CLASS-CMA;(2) CLASS-DSA;(3) the CMPAS Program;(4) the DBMD Program;(5) FMSA-CLASS;(6) FMSA-DBMD;(7) FMSA-HCS;(8) FMSA-PHC/CAS/FC;(9) FMSA-TxHmL;(10) the HCS Program;(11) the PHC Program;(12) the CAS Program;(13) the FC Program; and(14) the TxHmL Program. Source Note: The provisions of this §52.101 adopted to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.101 Contractors Not Subject to Certain Portions of Subchapter C https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219145 03/12/2026 (a) A contractor must have and maintain a license, certification, accreditation, or other documentation required of an applicant in §49.205 of this chapter (relating to License, Certification, Accreditation, and Other Requirements), except:(1) a contractor that has had a contract for the DBMD Program continuously since September 1, 1999, and that does not provide home health or personal assistance services is not required to have a HCSSA license issued in accordance with Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies) for a contract in effect on September 1, 2014; and(2) a contractor that has had a contract for AFC services in a four-bed home continuously since January 15, 2009, and that has an assisted living facility Type C license issued in accordance with Chapter 92 of this title (relating to Licensing Standards for Assisted Living Facilities) is not required to have an assisted living facility Type A or Type B license issued in accordance with Chapter 92 of this title.(b) A contractor must complete any training required by HHSC as stated on the HHSC website before HHSC places a contract of the contractor on a choice list.(c) A contractor must ensure that an employee, subcontractor, or volunteer can effectively communicate with an individual or LAR concerning service planning and the provision of services, which may require the contractor to provide an interpreter for the individual.(d) Except as provided in HHSC rules governing services provided under the contract, a contractor must not allow an individual to perform services under the contract or perform other work that benefits the contractor.(e) A contractor must comply with the terms of its contract, which requires compliance with applicable federal and state laws, rules, and regulations, including this chapter, rules governing services provided under the contract, and applicable reimbursement rules in 1 TAC Chapter 355 (relating to Reimbursement Rates).(f) A contractor:(1) must accept the reimbursement rate for a service in effect at the time the service is provided as payment in full for performance under the contract; and(2) must not make an additional charge to the individual, any member of the individual's family, or any other source for supplementation for performance under the contract, unless specifically allowed by federal or state law, rule, or regulation.(g) A contractor must:(1) subscribe to receive HHSC e-mail updates, using the link provided at the HHSC website and, for its contract, select the following categories:(A) information letters; and(B) provider alerts; and(2) be informed of the content of the e-mail updates.(h) A contractor must notify HHSC of a change of ownership or change in legal entity in accordance with §49.210(a)(1) of this chapter (relating to Contractor Change of Ownership or Legal Entity).(i) If there is a change to a contractor's physical, mailing, or e-mail address, as stated on the contractor's contract application packet or on a prior written notice of change to the information, the contractor must notify HHSC of the change and provide the new physical, mailing, or e-mail address:(1) at least 30 days before the address changes; or(2) if a natural or unforeseen disaster prevents compliance with paragraph (1) of this subsection, within three days after the change.(j) If there is a change to the name of the signature authority, the contractor must notify HHSC of the change within 30 days after the change by submitting a new, fully executed HHSC "Governing Authority Resolution" form.(k) If there is a change to the information regarding the applicant or a controlling person of the applicant being confirmed by DFPS or HHSC as having committed abuse, neglect, or exploitation, as stated on the contractor's contract application packet or on a prior written notice of change to the information, the contractor must notify HHSC of the change within three business days after the contractor or controlling person becomes aware of the change.(l) If a controlling person of a contractor is convicted of any crime listed in §49.206 of this chapter (relating to Ineligibility Due to Criminal History), the contractor must notify HHSC within three business days after the contractor or controlling person becomes aware of the conviction.(m) If a contractor files for bankruptcy, the contractor must notify HHSC within 14 days after filing.(n) If a contractor or controlling person of a contractor is excluded in accordance with §§1128, 1128A, 1136, 1156, or 1842(j)(2) of the Social Security Act, the contractor must notify HHSC of the exclusion change within three business days after the contractor or controlling person becomes aware of the exclusion.(o) If a contractor or a controlling person of a contractor becomes aware the contractor or controlling person is listed on any of the following, the contractor must notify HHSC within three business days after the contractor becomes aware of the listing:(1) the HHSC employee misconduct registry as unemployable;(2) the HHSC nurse aide registry as revoked or suspended;(3) the United States System for Award Management maintained by the General Services Administration;(4) the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General;(5) the LEIE maintained by the HHSC Office of Inspector General; or(6) the Debarred Vendor List maintained by the Texas Comptroller of Public Accounts.(p) If there is a change to any of the information on the contractor's contract application packet or on a prior written notice of change to the information, other than the information referenced in subsections (i) - (o) of this section, a contractor must notify HHSC of the change and provide the new information within 14 days after the information changes.(q) For a notice that a contractor is required to send to HHSC in accordance with this chapter, the contractor must ensure that the notice is:(1) in writing;(2) signed by the signature authority; and(3) sent to the HHSC mailing address or email address identified on the form "Contract Approval Letter" issued to the contractor when the contract was awarded.(r) A contractor must allow HHSC and any authorized federal or state agency access to:(1) individuals;(2) employees, subcontractors, or volunteers of the contractor; and(3) any premises controlled by the contractor.(s) A contractor must not pay for any item or service furnished, ordered, or prescribed by an individual listed on either LEIE described in §49.304(f)(1) of this subchapter (relating to Background Checks). Source Note: The provisions of this §52.103 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.103 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219146 03/12/2026 (a) A contractor must comply with applicable federal and state laws regarding confidentiality of information regarding an individual.(b) A contractor may use confidential information, including the names and contact information of an individual receiving services from another contractor, only for the authorized purpose for which the confidential information was legally obtained. Source Note: The provisions of this §52.105 adopted to be effective September 1, 2014, 39 TexReg 6637; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.105 Confidentiality of Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219147 03/12/2026 (a) A contractor that is required to have a license, as described in §49.302(a) of this subchapter (relating to General Requirements), must comply with licensure requirements regarding criminal history record checks, the HHSC employee misconduct registry and the HHSC nurse aide registry for employees, subcontractors, and volunteers.(b) A contractor that is not required to have a license, as described in §49.302(a) of this subchapter, must:(1) before offering employment to an unlicensed applicant for employment or contracting with an unlicensed potential subcontractor, obtain directly or through a private agency the criminal history record of the applicant or potential subcontractor from the Department of Public Safety (DPS);(2) before accepting an unlicensed volunteer applicant for a volunteer position that directly interacts with an individual, obtain directly or through a private agency the criminal history record of the applicant from DPS;(3) review the criminal history record of the unlicensed applicant or potential subcontractor;(4) not employ an unlicensed applicant for employment, contract with an unlicensed potential subcontractor, or accept an unlicensed applicant for a volunteer position, for the time periods set forth in Texas Health and Safety Code, §250.006, if the applicant or potential subcontractor has been convicted of an offense listed in Texas Health and Safety Code, §250.006; and(5) not employ an unlicensed applicant for employment, contract with an unlicensed potential subcontractor, or accept an unlicensed applicant for a volunteer position if the applicant or potential subcontractor has been convicted of an offense that the contractor determines is a contraindication to the applicant's employment, contracting, or volunteering.(c) A contractor that is not required to have a license, as described in §49.302(a) of this subchapter, must:(1) before offering employment to an unlicensed applicant for employment or contracting with an unlicensed potential subcontractor, search the HHSC employee misconduct registry and the HHSC nurse aide registry for the name of the applicant or potential subcontractor;(2) before accepting an unlicensed volunteer applicant for a volunteer position that directly interacts with an individual, search the HHSC employee misconduct registry and the HHSC nurse aide registry for the name of the applicant;(3) not employ an unlicensed applicant for employment, contract with a unlicensed potential subcontractor, or accept an unlicensed applicant for a volunteer position that directly interacts with an individual if the applicant or potential subcontractor is listed on:(A) the HHSC employee misconduct registry as unemployable; or(B) the HHSC nurse aide registry as revoked or suspended;(4) within five business days after hiring an unlicensed employee, contracting with an unlicensed subcontractor, or accepting an unlicensed volunteer for a position that directly interacts with an individual, provide written information to the employee, subcontractor, or volunteer that a person listed on the HHSC employee misconduct registry is not permitted to be employed by, contract with, or volunteer for the contractor;(5) at least once every twelve months after hiring an unlicensed employee, contracting with an unlicensed subcontractor, or accepting an unlicensed volunteer for a position that directly interacts with an individual, search the HHSC employment misconduct registry and the HHSC nurse aide registry for the name of the employee, subcontractor, or volunteer; and(6) not continue to employ an unlicensed employee, contract with an unlicensed subcontractor, or use an unlicensed volunteer for a position that directly interacts with an individual if the employee, subcontractor, or volunteer is listed on:(A) the HHSC employee misconduct registry as unemployable; or(B) the HHSC nurse aide registry as revoked or suspended.(d) A contractor must:(1) before contracting with a potential subcontractor or offering employment to an applicant for employment, search the Debarred Vendor List maintained by the Texas Comptroller of Public Accounts; and(2) not contract with the potential subcontractor or employ the applicant if the potential subcontractor or applicant is listed on the Debarred Vendor List and the period of debarment has not expired.(e) A contractor must develop and implement a policy that requires an employee, volunteer, or subcontractor to report to the contractor if any of the information obtained in accordance with subsection (b)(1), (c)(1), or (d)(1) of this section has changed. If a contractor becomes aware that information the contractor obtained in accordance with subsection (b)(1), (c)(1), or (d)(1) of this section was erroneous or has subsequently changed so the contractor would not be allowed to employ the person, contract with the person, or accept the person for volunteer status in accordance with subsection (b)(3) or (4), (c)(2), or (d)(2) of this section, the contractor must terminate the person's employment, volunteer status, or contract.(f) A contractor must:(1) review the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General, and the LEIE maintained by the HHSC Office of Inspector General:(A) before hiring an applicant for employment or contracting with a potential subcontractor; and(B) at least monthly, for each employee and subcontractor;(2) not employ an applicant for employment or contract with a potential subcontractor to perform any duties that may be paid for directly or indirectly through a contract if the applicant or potential subcontractor is listed on either LEIE described in paragraph (1) of this subsection;(3) prohibit an employee or subcontractor listed on either LEIE described in paragraph (1) of this subsection from performing any duties that may be paid for directly or indirectly through a contract; and(4) if an employee or subcontractor is listed on either LEIE described in paragraph (1) of this subsection, immediately report to the HHSC Office of Inspector General, in accordance with the self-reporting protocol of the HHSC Office of Inspector General:(A) the identity of an excluded employee or subcontractor; and(B) the amount paid by the contractor to the employee or subcontractor for services provided under a contract. Source Note: The provisions of this §52.107 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.107 Background Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219148 03/12/2026 (a) A contractor must develop and maintain records in accordance with its contract, this subchapter, and HHSC rules governing services provided under the contract.(b) A contractor must:(1) use forms required by HHSC or, if a specific form is not required by HHSC, develop records that include elements required by HHSC; and(2) ensure that:(A) a beginning time for a service is not documented until after the service being documented has been initiated; and(B) an ending time or a time period for a service is not documented until after the service has been provided.(c) Before a contractor submits a claim for services under its contract, the contractor's records must support the claim.(d) A contractor's records must be maintained in accordance with generally accepted accounting principles, referred to as GAAP, established by the Financial Accounting Standards Board.(e) A contractor must develop and maintain records that:(1) document the extent of services provided;(2) document compliance with this chapter; and(3) include records required by rules governing services provided under its contract.(f) A contractor must develop and maintain records for an employee, subcontractor, or volunteer that include:(1) a description of the employee, subcontractor, or volunteer's responsibilities;(2) the employee's completed application;(3) records that the employee, subcontractor, or volunteer is qualified for the position for which the person is employed, contracting, or volunteering, in accordance with rules governing services provided under the contract;(4) records that the contractor conducted the reviews described in §49.304 of this subchapter (relating to Background Checks);(5) records that the employee, subcontractor, or volunteer received any training required by rules governing services provided under the contract; and(6) records of any disciplinary action.(g) For purposes of subsection (f)(4) of this section, records maintained to show compliance with §49.304(f) of this subchapter must include:(1) documentation of the first and last name, date of birth, and social security or employer identification number of an employee or subcontractor required to be the subject of a review described in §49.304(f)(1) of this subchapter;(2) the printed first and last name and signature of the person conducting the review;(3) documentation of the date the review was conducted;(4) documentation of whether the employee and subcontractor who was the subject of the review was listed on either of the LEIEs described in §49.304(f)(1) of this subchapter; and(5) a copy of the report made in accordance with §49.304(f)(4) of this subchapter.(h) A contractor must develop and implement written procedures to:(1) prevent falsification or unauthorized access, disclosure, modification, or destruction of records and data;(2) ensure the availability, integrity, authenticity, completeness, and confidentiality of records and data; and(3) ensure that appropriate audit trails and sufficiently complete transaction histories are maintained to identify the person or position that makes an entry, modification, or correction to records or data that supports a claim for services under its contract.(i) If a contractor uses paper records described in this section, the contractor must:(1) ensure records are completed in ink;(2) retain the original records;(3) except as provided in HHSC rules governing services provided under the contract, ensure records are signed and dated by the person making the entry;(4) ensure a stamped signature is used only by a person with a disability as an accommodation for the disability; and(5) ensure that if a correction to records is necessary, the correction is made by:(A) marking a single line through the error;(B) adding the date the correction was made and the initials of the person who made the correction; and(C) not using correction fluid or tape or otherwise obliterating the original entry.(j) If a contractor uses electronic records described in this section, the contractor must:(1) develop and implement written procedures, which must include maintaining current virus protection software, to prevent the loss or corruption of data due to malicious code;(2) develop and implement written procedures governing the use of electronic signatures that:(A) ensure authenticity of an electronic signature;(B) describe the method of authentication used, such as password, personal identification number, digital signature, or other unique identifier, by document type;(C) identify the person or position who is authorized to sign electronically by document type; and(D) describe security measures used to prevent unauthorized use of electronic signatures; and(3) use an electronic record system that:(A) documents any change in content that was made to the electronic record;(B) documents the date the change was made;(C) documents the name and employee number or other unique identifier of the person who made the change; and(D) allows a record to be retrievable as a paper record.(k) A contractor must:(1) ensure records are available for review in accordance with the contract; and(2) as requested by HHSC or any federal or state agency authorized to have access to records:(A) provide, at no charge, a copy of any records to HHSC and the federal or state agency in the form requested by HHSC or the federal or state agency; or(B) allow HHSC and the federal or state agency to make a copy of any records, at no charge. Source Note: The provisions of this §52.109 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.109 Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219149 03/12/2026 A contractor using an electronic visit verification system must comply with Chapter 68 of this title (relating to Electronic Visit Verification (EVV) System). Source Note: The provisions of this §52.111 adopted to be effective September 1, 2014, 39 TexReg 6637; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.111 Electronic Visit Verification System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219150 03/12/2026 (a) Except as provided in subsections (c) and (d), a contractor must retain a record in the form in which it was created as follows:(1) a record developed and maintained in accordance with §49.305 of this subchapter (relating to Records) until the latest of the following:(A) seven years after the contractor submits a claim for the service about which the record relates;(B) seven years after all issues that arise from any litigation, claim, negotiation, audit, open records request, administrative review, or other action involving the record are resolved; or(C) the individual about whom the record relates becomes 21 years of age.(2) its contract and any contract solicitation documents until the later of the following:(A) seven years after the contract expires or is terminated; or(B) seven years after all issues that arise from any litigation, claim, negotiation, audit, open records request, administrative review, or other action involving the contract are resolved.(b) If a contractor destroys records containing confidential information, the records must be destroyed in a manner that makes the confidential information unusable, as follows:(1) for paper, film, and other hard copy records, shredding, pulping, or burning; and(2) for electronic records, disintegration, degaussing, digital shredding, or using specialized software to copy over the data.(c) If applicable law, the contract, or rules governing services provided under the contract require a contractor to retain records for a longer period than described in subsection (a) of this section, the contractor must retain the records for the longer period.(d) A contractor is not required to comply with subsection (a) of this section for a record not required by applicable law, rule, or the contract to be in the contractor's possession on September 1, 2018. Source Note: The provisions of this §52.113 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.113 Record Retention and Disposition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219151 03/12/2026 If a contractor uses a subcontractor to provide a service to an individual, the contractor must:(1) have a written agreement with the subcontractor that requires the subcontractor and any of its subcontractors to comply with applicable provisions of the contract, this subchapter, and HHSC rules governing services provided under the contract, as if the subcontractor and its subcontractors were the contractor;(2) monitor the subcontractor to ensure that the subcontractor is in compliance with the written agreement referenced in paragraph (1) of this section; and(3) maintain records of its monitoring of the subcontractor. Source Note: The provisions of this §52.115 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.115 Subcontracts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219152 03/12/2026 (a) A contractor must develop and implement written procedures for investigating and resolving a complaint about services provided under a contract, other than an allegation of abuse, neglect, or exploitation, that:(1) allow a complaint to be submitted to the contractor:(A) either orally or in writing; and(B) anonymously; and(2) require the contractor to:(A) request, but not require disclosure of, the name, mailing address, and telephone number of a complainant;(B) investigate and resolve a complaint within 30 days after the complaint is received by the contractor;(C) document the name of the person who conducted the investigation;(D) document the name of persons contacted during an investigation;(E) obtain written statements from persons contacted during an investigation or document conversations with those persons; and(F) provide the following information to the complainant within 30 days after a complaint is received by the contractor, unless the complainant did not provide a mailing address or phone number:(i) the findings of the investigation;(ii) the contractor's resolution of the complaint;(iii) the telephone number of:(I) HHSC Complaint and Incident Intake (1-800-458-9858), if the contractor has a contract for:(-a-) CLASS-CFS;(-b-) CLASS-DSA;(-c-) CLASS-SFS;(-d-) the DBMD Program;(-e-) the HCS Program;(-f-) the TxHmL Program;(-g-) hospice;(-h-) the PHC Program;(-i-) the CAS Program;(-j-) DAHS;(-k-) Title XX AFC and services are provided in an AFC home serving four to eight people;(-l-) Title XX RC;(-m-) the CMPAS Program;(-n-) the FC Program;(-o-) SSPD and services are provided in a DAHS facility; or(-p-) SSPD-24-hour shared attendant care; or(II) the HHSC Office of the Ombudsman (1-877-787-8999), if the contractor has a contract for:(-a-) CLASS-CMA;(-b-) TAS;(-c-) Title XX AFC and services are provided in an AFC home serving fewer than four people;(-d-) emergency response services;(-e-) the HDM Program;(-f-) SSPD and services are not provided in a DAHS facility;(-g-) FMSA-CLASS;(-h-) FMSA-DBMD;(-i-) FMSA-HCS;(-j-) FMSA-PHC/CAS/FC; or(-k-) FMSA-TxHmL; and(iv) an explanation that the telephone number may be used if the complainant is not satisfied with the contractor's resolution of the complaint.(b) The contractor must give the information described in subsection (a)(2)(F) of this section as follows:(1) in person, if the complainant is the individual receiving services; or(2) if the complainant is not the individual receiving services:(A) by mail, if the contractor knows the complainant's mailing address; or(B) by telephone, if the contractor does not know the complainant's mailing address, but knows the complainant's telephone number.(c) A contractor must maintain a written log that contains the following information:(1) the date the contractor received a complaint;(2) a description of the complaint;(3) the findings of the investigation;(4) the contractor's resolution of the complaint and the date of resolution; and(5) the date the contractor provided information to the complainant in accordance with subsection (b) of this section.(d) A contractor must provide the following information to an individual and LAR:(1) a description of the contractor's complaint process;(2) the telephone number of:(A) HHSC Complaint and Incident Intake (1-800-458-9858), if the contractor has a contract for:(i) CLASS-CFS;(ii) CLASS-DSA;(iii) CLASS-SFS;(iv) the DBMD Program;(v) the HCS Program;(vi) the TxHmL Program;(vii) hospice;(viii) the PHC Program;(ix) the CAS Program;(x) DAHS;(xi) Title XX AFC and services are provided in an AFC home serving four to eight people;(xii) Title XX RC;(xiii) the CMPAS Program;(xiv) the FC Program;(xv) SSPD and services are provided in a DAHS facility; or(xvi) SSPD-24-hour shared attendant care; or(B) the HHSC Office of the Ombudsman (1-877-787-8999), if the contractor has a contract for:(i) CLASS-CMA;(ii) TAS;(iii) Title XX AFC and services are provided in an AFC home serving fewer than four people;(iv) emergency response services;(v) the HDM Program;(vi) SSPD and services are not provided in a DAHS facility;(vii) FMSA-CLASS;(viii) FMSA-DBMD;(ix) FMSA-HCS;(x) FMSA-PHC/CAS/FC; or(xi) FMSA-TxHmL; and(3) an explanation that the telephone number may be used to file a complaint with HHSC.(e) A contractor must provide the information described in subsection (d) of this section orally and in writing, as follows:(1) before or at the time the individual begins receiving program services from the contractor; and(2) at least once every 12 months thereafter. Source Note: The provisions of this §52.117 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.117 Complaint Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219153 03/12/2026 A contractor must develop and implement written procedures for reporting and investigating an allegation of abuse, neglect or exploitation regarding an individual that:(1) comply with applicable laws and rules governing services provided under the contract;(2) require the contractor to report an allegation of abuse, neglect, or exploitation to the appropriate investigative authority;(3) ensure that the contractor's employees, subcontractors, and volunteers:(A) are knowledgeable of:(i) acts that constitute abuse, neglect, or exploitation of an individual;(ii) the requirement to report acts of abuse, neglect, or exploitation, or suspicion of such acts to the appropriate investigative authority;(iii) how to report allegations of abuse, neglect, or exploitation to the appropriate investigative authority; and(iv) methods to prevent the occurrence of abuse, neglect, and exploitation; and(B) report suspected abuse, neglect, or exploitation as instructed by the contractor;(4) ensure that individuals and LARs are informed, orally and in writing, of how to report allegations of abuse, neglect, or exploitation:(A) before or at the time the individual begins receiving program services from the contractor; and(B) at least once every 12 months thereafter;(5) if the contractor suspects an individual has been or is being abused, neglected, or exploited or is notified of an allegation of abuse, neglect, or exploitation, require the contractor to:(A) take necessary actions to secure the safety of the individual; and(B) notify, as soon as possible but no later than 24 hours after the contractor reports or is notified of an allegation, the individual, or the individual's LAR of the allegation report and the actions that have been or will be taken;(6) if abuse, neglect, or exploitation is confirmed by the investigative authority and the contractor is notified of the confirmation, require the contractor to take appropriate action to prevent the reoccurrence of abuse, neglect or exploitation, including, when warranted, disciplinary action against the employee, subcontractor, or volunteer confirmed to have committed abuse, neglect, and exploitation;(7) at least annually, require the contractor to review incidents of confirmed abuse, neglect, or exploitation of which the contractor is notified and identify program process improvements that will prevent the reoccurrence of such incidents and improve service delivery; and(8) prohibit the contractor from discharging or otherwise retaliating against:(A) an employee, subcontractor, volunteer, individual, or other person because the employee, subcontractor, volunteer, individual, or other person files a complaint, presents a grievance, or otherwise provides good faith information relating to possible abuse, neglect, or exploitation of an individual; or(B) an individual because someone on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to possible abuse, neglect, or exploitation of the individual. Source Note: The provisions of this §52.119 adopted to be effective September 1, 2014, 39 TexReg 6637; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.119 Abuse, Neglect, and Exploitation Allegations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219154 03/12/2026 (a) HHSC pays a contractor for a claim for services that meets the requirements described in subsection (b) of this section.(b) A contractor must ensure a claim for services is:(1) for a service that has been provided by a contractor;(2) a clean claim;(3) complete and accurate;(4) submitted within 12 months after one of the following, whichever is later:(A) the last day of the month in which the service was provided, the adaptive aid or medical supply delivered, or the minor home modification completed; or(B) the date the individual's eligibility for the service was determined;(5) for a type and amount of service that is authorized by HHSC;(6) for a service provided to an individual who is eligible for the service;(7) except as provided in HHSC rules governing services provided under the contract, for a service provided to an individual whose authorization for services has not been suspended or terminated by HHSC;(8) for a service provided during a time period authorized by HHSC;(9) for a service provided during the term of, and in accordance with, the contract, this subchapter, and HHSC rules governing services provided under the contract;(10) supported by records required by the contract and HHSC rules governing services provided under the contract;(11) for a service provided by a qualified service provider in accordance with HHSC rules governing services provided under the contract;(12) for a service ordered by a qualified practitioner, if required by the contract or HHSC rules governing services provided under the contract;(13) submitted in accordance with procedures required by HHSC rules governing services provided under the contract and by the claims administrator; and(14) not for a service that a source other than HHSC would have paid for if the contractor had submitted a proper, complete, and timely request for payment to the other source.(c) As used in subsection (b)(11) and (12) of this section, the terms "qualified service provider" and "qualified practitioner" do not include a person whose health-related license has been suspended or revoked or who has been excluded from participation in a program administered under Title V, XVIII, XIX, or XX of the Social Security Act.(d) HHSC denies a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract. If HHSC denies a claim for services, a contractor may request and receive an administrative hearing.(e) If a contractor or HHSC determines that the contractor received payment for a claim for services that does not meet the requirements in subsection (b) of this section and HHSC rules governing services provided under the contract:(1) the contractor may submit a corrected claim for services to allow HHSC to adjust amounts paid to a contractor, even if it is after the 12-month period described in subsection (b)(4) of this section; or(2) HHSC recoups funds paid to the contractor in accordance with §49.533 of this chapter (relating to Recoupment).(f) If a claim for services is denied by HHSC, the contractor that submitted the claim may submit a corrected claim within the 12-month period described in subsection (b)(4) of this section.(g) HHSC may adjust amounts paid to a contractor after the 12-month period described in subsection (b)(4) of this section. Source Note: The provisions of this §52.121 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.121 Claims Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219155 03/12/2026 (a) A contractor must comply with requirements regarding payment of a base wage to a personal attendant as described in 1 TAC §355.7051 (relating to Base Wage for a Personal Attendant).(b) A contractor, other than a contractor that has an FMSA contract listed in §49.101(a)(4) of this chapter (relating to Application), must notify a person who becomes employed or contracts with the contractor as a personal attendant that the contractor must pay at least the wage required by 1 TAC §355.7051. The contractor must make this notification within three days after the person accepts employment or enters into a contract with the contractor. For purposes of this subsection, a personal attendant has the meaning set forth in 1 TAC §355.7051(a). Source Note: The provisions of this §52.123 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2015, 40 TexReg 5466; amended to be effective May 10, 2020, 45 TexReg 2890; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.123 Personal Attendants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219156 03/12/2026 (a) A contractor that has a contract for the HCS Program, the TxHmL Program, the CLASS Program, or the DBMD Program must:(1) in a building or a portion of a building that is owned or leased by the contractor and in which the contractor provides day habilitation in the HCS Program, the TxHmL Program, or the DBMD Program or provides prevocational services in the CLASS Program:(A) conduct, at least once every 90 days, a fire drill during which individuals evacuate the building; and(B) prominently post, in an area of the building that is readily accessible to individuals, employees, subcontractors, volunteers, and visitors, a notice of the requirement to report an allegation of abuse, neglect, or exploitation of an individual and how to report such an allegation to the DFPS toll free telephone number at 1-800-647-7418; and(2) have an emergency response plan for individuals while receiving day habilitation or prevocational services in the building.(b) If a contractor described in subsection (a) of this section has a written agreement required by §49.308 of this subchapter (relating to Subcontracts) with a subcontractor to provide day habilitation in the HCS Program, the TxHmL Program, or the DBMD Program or provide prevocational services in the CLASS Program and the day habilitation or prevocational services are provided in a building or a portion of a building the subcontractor owns or leases, the written agreement must include the following provisions:(1) that the subcontractor must conduct, at least once every 90 days, a fire drill during which individuals evacuate the building;(2) that the subcontractor must have an emergency response plan for individuals while receiving day habilitation or prevocational services in the building;(3) that the subcontractor must prominently post, in an area of the building that is readily accessible to individuals, employees, subcontractors, volunteers, and visitors, a notice of the requirement to report an allegation of abuse, neglect, or exploitation of an individual and how to report such an allegation to the DFPS toll free telephone number at 1-800-647-7418;(4) that the subcontractor, in accordance with §49.304 of this subchapter (relating to Background Checks), must conduct background checks on the subcontractor's employees, subcontractors, and volunteers who provide day habilitation or prevocational services; and(5) that the subcontractor must:(A) for an individual in the HCS Program, provide day habilitation in accordance with the individual's implementation plan as defined in §9.153 of this title (relating to Definitions) and keep a copy of the plan in the building;(B) for an individual in the TxHmL Program, provide day habilitation in accordance with the individual's implementation plan as defined in §9.553 of this title (relating to Definitions) and keep a copy of the plan in the building;(C) for an individual in the CLASS Program, provide prevocational services in accordance with the individual's IPP as defined in §45.103 of this title (relating to Definitions) and keep a copy of the IPP in the building; and(D) for an individual in the DBMD Program, provide day habilitation in accordance with the individual's IPP as defined in §42.103 of this title (relating to Definitions) and keep a copy of the IPP in the building. Source Note: The provisions of this §52.125 adopted to be effective September 28, 2016, 41 TexReg 7514; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES C REQUIREMENTS OF A CONTRACTOR §52.125 Day Habilitation Requirements in the HCS Program, the TxHmL Program, and the DBMD Program and Prevocational Services Requirements in the CLASS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219157 03/12/2026 This subchapter does not apply to a contractor that has a contract for the HCS Program, TxHmL Program, or hospice. Source Note: The provisions of this §52.201 adopted to be effective September 1, 2014, 39 TexReg 6637; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES D MONITORING AND INVESTIGATION OF A CONTRACTOR §52.201 Contractors Not Subject to Subchapter D https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219158 03/12/2026 (a) HHSC conducts contract and fiscal monitoring on site or by desk review:(1) to determine if:(A) a contractor is in compliance with its contract, which requires compliance with applicable federal and state laws, rules, and regulations, provider manuals and handbooks, billing guidelines, and communications promulgated by HHSC including information letters; or(B) a contractor is in compliance with a corrective action plan as described in §49.522 of this chapter (relating to Corrective Action Plan) or an immediate protection plan as described in §49.511 of this chapter (relating to Immediate Protection and Immediate Protection Plan);(2) for purposes described in paragraph (1)(A) of this subsection, at least once during the term of a provisional contract and periodically after the effective date of a standard contract, on a schedule determined by HHSC;(3) by evaluating standards in accordance with:(A) for all contractors, a program-specific HHSC contract and fiscal compliance monitoring tool; and(B) for contractors that have an FMSA contract listed in §49.101(a)(5) of this chapter (relating to Application), a CDS tax monitoring tool; and(4) at a location identified by HHSC, which may include a location where the contractor conducts business or provides contracted services.(b) To conduct contract and fiscal monitoring, HHSC:(1) sends a written notice to a contractor that includes the date the monitoring will begin and lists the records the contractor must provide at the entrance conference described in paragraph (2) of this subsection;(2) conducts an entrance conference with the contractor;(3) performs other activities, which may include:(A) reviewing the contractor's records;(B) reviewing the contractor's policies and procedures;(C) reviewing consumer satisfaction surveys;(D) interviewing a person with knowledge relevant to the contract, including an individual receiving services or the contractor's employee; and(E) observing an individual receiving services;(4) conducts an exit conference with the contractor, at which HHSC reports the compliance score for each standard reviewed and an overall compliance score; and(5) notifies the contractor, in writing, of the results of the monitoring.(c) A contractor must provide records listed in the notice described in subsection (b)(1) of this section to HHSC at the entrance conference described in subsection (b)(2) of this section. If a contractor does not provide records in accordance with this subsection, HHSC conducts contract monitoring with any records provided.(d) If HHSC determines that a contractor's compliance score for a standard on a monitoring tool described in subsection (a)(3) of this section is less than 90 percent, HHSC requires the contractor to submit an acceptable corrective action plan to HHSC in accordance with §49.522 of this chapter.(e) If HHSC determines that a contractor's overall compliance score on a monitoring tool described in subsection (a)(3) of this section is less than 90 percent, HHSC considers the contractor out of substantial compliance with the contract and may:(1) determine that a contractor does not qualify for a standard contract;(2) impose an action or sanction in accordance with Subchapter E of this chapter (relating to Enforcement by HHSC and Termination by Contractor);(3) conduct additional monitoring in accordance with this section; or(4) take a combination of the actions described in paragraphs (1) - (3) of this subsection.(f) If, during a contract and fiscal monitoring, HHSC determines that the contractor is not protecting an individual's health and safety, HHSC may require the contractor to:(1) immediately protect the individual's health and safety; and(2) submit an immediate protection plan in accordance with §49.511 of this chapter. Source Note: The provisions of this §52.211 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES D MONITORING AND INVESTIGATION OF A CONTRACTOR §52.211 Contract and Fiscal Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219159 03/12/2026 (a) If HHSC receives an oral or written allegation that indicates a contractor may have violated a contract or program requirement, HHSC conducts an unannounced investigation of the contractor. The investigation is conducted on-site or by a desk review.(b) To conduct an investigation, HHSC:(1) conducts an entrance conference with the contractor if the investigation is conducted on-site;(2) performs other activities, which may include:(A) reviewing the contractor's records;(B) reviewing the contractor's policies and procedures;(C) reviewing consumer satisfaction surveys;(D) interviewing a person with knowledge relevant to the contract, including an individual receiving services or the contractor's employee; and(E) observing an individual receiving services.(c) A contractor must provide records requested by HHSC as follows:(1) for an investigation conducted on-site, the contractor must provide the records to HHSC within one hour after the entrance conference described in subsection (b)(1) of this section, unless another time period is agreed to by HHSC in writing for an EVV report; and(2) for an investigation conducted by a desk review, the contractor must provide the records to HHSC within one business day after HHSC's request.(d) HHSC notifies the contractor, in writing, of the results of the investigation.(e) If, based on an investigation, HHSC determines that the contractor is out of compliance with the contract, HHSC may:(1) impose an action or sanction in accordance with Subchapter E of this chapter (relating to Enforcement by HHSC and Termination by Contractor);(2) conduct additional monitoring in accordance with §49.411 of this division (relating to Contract and Fiscal Monitoring); or(3) take a combination of the actions described in paragraphs (1) and (2) of this subsection.(f) If, during an investigation, HHSC determines that the contractor is not protecting an individual's health and safety, HHSC may require the contractor to:(1) immediately protect the individual's health and safety; and(2) submit an immediate protection plan in accordance with §49.511 of this chapter (relating to Immediate Protection and Immediate Protection Plan). Source Note: The provisions of this §52.213 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES D MONITORING AND INVESTIGATION OF A CONTRACTOR §52.213 Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219160 03/12/2026 (a) HHSC may conduct a financial review, including an audit, of a contractor at any time. The review is conducted on-site or by a desk review.(b) To conduct a financial review, HHSC.(1) conducts an entrance conference with the contractor; and(2) performs other activities, which may include:(A) reviewing the contractor's records;(B) reviewing the contractor's policies and procedures; or(C) interviewing a person with knowledge relevant to the contract.(c) If, based on a financial review, HHSC determines that the contractor is out of compliance with the contract, HHSC may impose an action or sanction in accordance with Subchapter E of this chapter (relating to Enforcement by HHSC and Termination by Contractor). Source Note: The provisions of this §52.215 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES D MONITORING AND INVESTIGATION OF A CONTRACTOR §52.215 Financial Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219161 03/12/2026 (a) Divisions 2 and 3 of this subchapter (relating to Immediate Protection; and Actions) do not apply to a contractor that has a contract for the HCS Program or the TxHmL Program.(b) Section 49.523 of this subchapter (relating to Referral Hold) does not apply to a contractor that has a contract for hospice. Source Note: The provisions of this §52.231 adopted to be effective September 1, 2014, 39 TexReg 6637; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.231 Contractors Not Subject to Certain Portions of Subchapter E https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219164 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219164 03/12/2026 (a) HHSC requires a contractor to immediately protect an individual's health and safety if HHSC determines that:(1) the contractor is not complying with its contract; and(2) the contractor's failure to comply with its contract jeopardizes the health and safety of the individual.(b) If HHSC requires immediate protection in accordance with subsection (a) of this section, HHSC notifies the contractor:(1) orally or in writing, that the contractor must immediately protect the individual's health and safety; and(2) in writing, that the contractor must submit and implement a written immediate protection plan.(c) If HHSC notifies the contractor in accordance with subsection (b) of this section, the contractor must:(1) immediately protect the individual's health and safety; and(2) submit a written immediate protection plan to HHSC within three business days after the date of the notice from HHSC.(d) An immediate protection plan submitted in accordance with subsection (c)(2) of this section must:(1) describe the non-compliance that jeopardized the health and safety of the individual;(2) describe the immediate protection taken by the contractor;(3) describe the activities the contractor will perform to prevent the non-compliance described in paragraph (1) of this subsection from reoccurring;(4) include a schedule for performing the activities described in paragraph (3) of this subsection; and(5) include:(A) the title of the person who ensured completion of the immediate protection; and(B) the title of the person responsible for completion of the activities described in paragraph (3) of this subsection. Source Note: The provisions of this §52.251 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.251 Immediate Protection and Immediate Protection Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219163 03/12/2026 (a) HHSC may take one or more of the following actions against a contractor in accordance with §49.522 and §49.523 of this division (relating to Corrective Action Plan and Referral Hold):(1) require the development of and compliance with a corrective action plan; and(2) impose a referral hold.(b) HHSC may consider the following factors in determining the action to be taken:(1) the extent and seriousness of the contractor's non-compliance with the contract that is the subject of the action;(2) the contractor's history of previous non-compliance with:(A) the contract that is the subject of the action;(B) a contract other than the one that is the subject of the action;(C) a contractual agreement with HHSC; and(D) a contractual agreement with a governmental entity other than HHSC;(3) previous action taken or sanctions imposed against the contractor by DADS or HHSC; and(4) the contractor's written response to HHSC's finding that the contractor is not in compliance with the contract. Source Note: The provisions of this §52.271 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.271 Action by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219162 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219162 03/12/2026 (a) HHSC requires corrective action if the contractor's compliance score for a standard is less than 90 percent as described in §49.411(d) of this chapter (relating to Contract and Fiscal Monitoring).(b) HHSC may require corrective action if HHSC determines the contractor has not complied with its contract, including a determination of non-compliance described in §49.411(e) of this chapter or §49.413(e) of this chapter (relating to Investigation). Corrective action may include the contractor paying or ensuring payment to a personal attendant who was not paid the wage required by §49.312 of this chapter (relating to Personal Attendants) the difference between the amount required and the amount paid to the personal attendant.(c) If HHSC requires corrective action in accordance with subsection (a) or (b) of this section, HHSC notifies the contractor in writing that the contractor must submit and implement a written corrective action plan.(d) If HHSC notifies the contractor in accordance with subsection (c) of this section, the contractor must submit a written corrective action plan to HHSC within 10 business days after the date of the notice from HHSC.(e) A corrective action plan submitted in accordance with subsection (c) of this section must:(1) describe the non-compliance that HHSC identified from the monitoring or investigation resulting in the corrective action plan;(2) describe the activities the contractor will perform to correct or prevent the non-compliance described in paragraph (1) of this subsection from reoccurring;(3) include the title of the person responsible for performing the activities described in paragraph (2) of this subsection; and(4) include a schedule for performing the activities described in paragraph (2) of this subsection. Source Note: The provisions of this §52.273 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.273 Corrective Action Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219165 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219165 03/12/2026 (a) HHSC may place a contractor on a referral hold if:(1) HHSC has proposed to terminate the contract;(2) HHSC determines the contractor has not complied with the contract, including a determination of non-compliance described in §49.411(e) of this chapter (relating to Contract and Fiscal Monitoring) or §49.413(e) of this chapter (relating to Investigation);(3) the contractor has not submitted or has not complied with an immediate protection plan as described in §49.511(d) of this subchapter (relating to Immediate Protection and Immediate Protection Plan);(4) the contractor has not submitted or has not complied with a corrective action plan as described in §49.522(d) of this division (relating to Corrective Action Plan); or(5) the contractor's application packet:(A) contained incorrect information; or(B) contains information that has become incorrect and the contractor has not notified HHSC in accordance with §49.302(i) - (q) of this chapter (relating to General Requirements).(b) If HHSC places a contractor on a referral hold in accordance with subsection (a) of this section, HHSC notifies the contractor of the referral hold in writing.(c) A contractor may request that HHSC conduct an informal review of a referral hold. The request must be in writing and received by HHSC within 20 days after the date of the notice of the referral hold from HHSC. The contractor must include in the written request:(1) the reasons the contractor believes the referral hold was improper;(2) documentation to support the reasons; and(3) a copy of the notice from HHSC of the referral hold.(d) HHSC releases a referral hold:(1) imposed in accordance with subsection (a)(1) of this section if:(A) HHSC withdraws the proposed contract termination;(B) the contractor appeals the proposed contract termination and the final decision from the administrative hearing is favorable to the contractor; or(C) the contractor requests an informal review in accordance with subsection (c) of this section and, as a result of the review, HHSC determines that the referral hold was improper;(2) imposed in accordance with subsection (a)(2) - (5) of this section if:(A) a period of time determined by HHSC has elapsed; or(B) the contractor requests an informal review in accordance with subsection (c) of this section and, as a result of the review, HHSC determines that the referral hold was improper. Source Note: The provisions of this §52.275 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.275 Referral Hold https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219166 03/12/2026 (a) HHSC may take one or more of the following sanctions:(1) for any contractor, impose a vendor hold in accordance with §49.532 of this division (relating to Vendor Hold);(2) for any contractor, recoup funds in accordance with §49.533 of this division (relating to Recoupment);(3) for any contractor, terminate the contract in accordance with §49.534 of this division (relating to Termination of Contract by HHSC); and(4) for a contractor that has a contract for the HCS Program or TxHmL Program, impose an administrative penalty in accordance with §49.535 of this division (relating to Administrative Penalties in HCS and TxHmL Programs).(b) For a sanction described in subsection (a)(1) or (3) of this section, HHSC may consider factors in determining the sanction to be taken, including:(1) the extent and seriousness of the contractor's non-compliance with the contract that is the subject of the sanction;(2) the contractor's history of previous non-compliance with:(A) the contract that is the subject of the sanction;(B) a contract other than the one that is the subject of the sanction;(C) a contractual agreement with HHSC; and(D) a contractual agreement with a governmental entity other than HHSC;(3) previous action taken or sanctions imposed against the contractor by DADS or HHSC; and(4) the contractor's written response to HHSC's finding that the contractor is not in compliance with the contract. Source Note: The provisions of this §52.301 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective April 28, 2020, 45 TexReg 2725; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.301 Sanction by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219169 03/12/2026 (a) HHSC imposes a vendor hold on a contractor if:(1) HHSC has proposed to terminate the contract and the contractor participates in attendant compensation rate enhancement as described in 1 TAC §355.112 (relating to Attendant Compensation Rate Enhancement); or(2) The HHSC Office of Inspector General determines that a vendor hold must be imposed in accordance with 42 CFR §455.23(a) due to a credible allegation of fraud for which an investigation is pending under the Medicaid Program.(b) HHSC may impose a vendor hold on a contractor:(1) if HHSC has proposed to terminate the contract and the contractor does not participate in attendant compensation rate enhancement as described in 1 TAC §355.112;(2) if HHSC does not offer the contractor a standard contract when its contract expires;(3) if the contractor does not enter into a standard contract when its contract expires;(4) if the contractor terminates the contract;(5) if HHSC determines the contractor has not complied with the contract, including a determination of non-compliance described in §49.411(e) of this chapter (relating to Contract and Fiscal Monitoring) or §49.413(e) of this chapter (relating to Investigation);(6) if the contractor has not submitted or has not complied with an immediate protection plan as described in §49.511(d) of this subchapter (relating to Immediate Protection and Immediate Protection Plan);(7) if the contractor has not submitted or has not complied with a corrective action plan as described in §49.522(d) of this subchapter (relating to Corrective Action Plan); or(8) if the contractor's application packet described in §49.203(a)(3) of this chapter (relating to Provisional Contract Application Process):(A) contained incorrect information; or(B) contains information that has become incorrect and the contractor has not notified HHSC in accordance with §49.302(i) - (q) of this chapter (relating to General Requirements);(9) for a contractor that has a contract for the HCS Program, in accordance with §9.183 of this title (relating to Program Provider Compliance and Corrective Action); or(10) for a contractor that has a contract for the TxHmL Program, in accordance with §9.587 of this title (relating to Program Provider Compliance and Corrective Action).(c) If HHSC imposes a vendor hold on a contractor in accordance with subsection (a) or (b) of this section, HHSC notifies the contractor of the vendor hold in writing. HHSC may impose a vendor hold pending an administrative hearing appealing the vendor hold.(d) HHSC releases a vendor hold less any amounts being recouped by HHSC:(1) imposed in accordance with subsections (a)(1) and (b)(1) - (4) of this section if:(A) the contract has been terminated or expires and any amounts owed to individuals and LARs have been paid by the contractor;(B) HHSC withdraws the proposed contract termination; or(C) the contractor appeals the proposed contract termination and the final decision from the administrative hearing is favorable to the contractor;(2) imposed in accordance with subsection (a)(2) of this section, if the HHSC Office of Inspector General determines that HHSC must resume payment under the contract;(3) imposed in accordance with subsection (b)(5) - (8) of this section, if HHSC determines the contractor has resolved the reason for the vendor hold; or(4) imposed in accordance with subsection (b)(9) - (10) of this section if HHSC determines it may be released as described in §9.183 or §9.587 of this title. Source Note: The provisions of this §52.311 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective April 28, 2020, 45 TexReg 2725; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.311 Vendor Hold https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219168 03/12/2026 (a) A contractor is liable to HHSC for amounts paid to the contractor for a service if the contractor has not complied with contract requirements regarding a service claim or payment for a service, including §49.305 of this chapter (relating to Records), §49.311 of this chapter (relating to Claims Payment), and other HHSC rules governing services provided under the contract.(b) If a contractor is liable to HHSC in accordance with subsection (a) of this section, HHSC may propose to recoup funds for the amount due to HHSC.(c) If HHSC proposes to recoup funds paid to a contractor in accordance with subsection (b) of this section, HHSC notifies the contractor of the proposed recoupment in writing before the effective date of recoupment.(d) HHSC recoups funds paid to contractor on the date given in HHSC's notice of proposed recoupment if:(1) the contractor does not appeal the proposed recoupment; or(2) the contractor appeals the proposed recoupment and the final decision from the administrative hearing is favorable to HHSC. Source Note: The provisions of this §52.313 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.313 Recoupment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219167 03/12/2026 (a) HHSC may propose to terminate a contract:(1) without cause by giving at least 60 days written notice to the contractor as provided by the contract; or(2) for good cause as determined by HHSC, including if:(A) the contractor has not provided any services under the contract during a period of 12 consecutive months;(B) the contractor has not complied with the terms of the contract, including:(i) the contractor's overall compliance score from a contract monitoring is less than 90 percent, as described in §49.411(e) of this chapter (relating to Contract and Fiscal Monitoring);(ii) the contractor has not submitted or complied with a corrective action plan as described in §49.522(d) of this subchapter (relating to Corrective Action Plan);(iii) the contractor has not submitted or complied with an immediate protection plan as described in §49.511(d) of this subchapter (relating to Immediate Protection and Immediate Protection Plan); or(iv) DADS or HHSC has imposed repeated actions or sanctions against the contractor that, when considered cumulatively, constitute significant non-compliance with the contract;(C) the contractor undergoes a change of ownership or change of legal entity and the requirements in §49.210 (a)(1) - (4) of this chapter (relating to Contractor Change of Ownership or Legal Entity) are not met, as described in §49.210(c)(1) of this chapter;(D) the contractor's application packet described in §49.203(a)(3) of this chapter (relating to Provisional Contract Application Process):(i) contained incorrect information; or(ii) contains information that has become incorrect and the contractor has not notified HHSC in accordance with §49.302(i) - (q) of this chapter (relating to General Requirements);(E) the contractor or a controlling person of the contractor is under a period of exclusion in accordance with §§1128, 1128A, 1136, 1156, or 1842(j)(2) of the Social Security Act;(F) the contractor or a controlling person of the contractor is ineligible to contract with HHSC in accordance with §49.206 of this chapter (relating to Ineligibility Due to Criminal History);(G) the contractor or a controlling person of the contractor is prohibited from contracting with HHSC in accordance with Chapter 79, Subchapter S of this title (relating to Contracting Ethics);(H) the contractor is required to register with the Texas Secretary of State and contractor's status with the Texas Secretary of State is not "in existence";(I) the contractor is required to pay Texas franchise tax and the contractor's right to transact business status with the Texas Comptroller of Public Accounts is not "active";(J) HHSC or another governmental entity proposed or imposed a penalty, revocation, denial, termination, or suspension against a license, certification, or registration held by the contractor;(K) the contractor no longer has a license, certification, accreditation or other document required by §49.302(a) of this chapter;(L) the contractor or a controlling person of the contractor is listed on:(i) the HHSC employee misconduct registry as unemployable;(ii) the HHSC nurse aide registry as revoked or suspended;(iii) the United States System for Award Management maintained by the General Services Administration;(iv) the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General;(v) the LEIE maintained by the HHSC Office of Inspector General;(vi) the Debarred Vendor List maintained by the Texas Comptroller of Public Accounts and the period of debarment has not expired; or(vii) the HHS list of exclusions;(M) the contractor or a controlling person of the contractor has been confirmed by DFPS or HHSC as having committed abuse, neglect, or exploitation;(N) HHSC proposed or imposed an action or sanction against:(i) another contract of the contractor or a controlling person of the contractor; or(ii) a contract of a person for whom the contractor or a controlling person of the contractor was a controlling person;(O) a governmental entity other than HHSC or a managed care organization contracting with a governmental entity proposed or imposed an action or sanction against:(i) a contractual agreement of the contractor or a controlling person of the contractor; or(ii) a contractual agreement of a person for whom the contractor or a controlling person of the contractor was a controlling person;(P) the contractor or a controlling person of the contractor terminated a contractual agreement with a governmental entity in a federal health care program, as defined in §1128B(f) of the Social Security Act, while an adverse action or sanction was proposed or in effect;(Q) the contractor or a controlling person of the contractor terminated another contract while an action or sanction was proposed or in effect;(R) the contractor or a controlling person of the contractor has an unresolved financial liability with HHSC or another governmental entity;(S) HHSC denies or terminates certification of a contractor that has a contract for the HCS or TxHmL Program, in accordance with §9.183 of this title (relating to Program Provider Compliance and Corrective Action) or §9.587 of this title (relating to Program Provider Compliance and Corrective Action); or(T) for a contractor that has a contract for Title XIX DAHS, Title XX AFC, RC, or DAHS, the contractor does not have a legal right to occupy the facility under the contract.(b) If HHSC proposes to terminate a contract:(1) in accordance with subsection (a)(1) of this section, HHSC notifies the contractor of the proposed termination in writing at least 60 days before the effective date of termination; or(2) in accordance with subsection (a)(2) of this section, HHSC notifies the contractor of the proposed termination in writing, which may be less than 60 days before the effective date of termination.(c) If HHSC proposes to terminate a contract, HHSC notifies individuals receiving services from the contractor and the individual's LARs that:(1) HHSC has proposed to terminate the contract and has placed the contractor's payments on a vendor hold; and(2) an individual or LAR may choose to receive services under a contract listed on the choice list, subject to program-specific requirements.(d) HHSC terminates a contract on the date given in HHSC's notice of proposed termination if:(1) the contractor does not appeal the proposed contract termination; or(2) the contractor appeals the proposed contract termination and the final decision from the administrative hearing is favorable to HHSC.(e) HHSC does not pay a contractor for services provided after the effective date of contract termination.(f) If HHSC terminates a contract, HHSC notifies the contractor and any controlling person of the contractor, in writing, of the application denial period set in accordance with §49.702(c) or (d) of this chapter (relating to Application Denial Period). Source Note: The provisions of this §52.315 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective April 28, 2020, 45 TexReg 2725; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.315 Termination of Contract by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219170 03/12/2026 (a) HHSC may impose an administrative penalty:(1) for a contractor that has a contract for the HCS Program, in accordance with §9.181 of this title (relating to Administrative Penalties); or(2) for a contractor that has a contract for the TxHmL Program, in accordance with §9.581 of this title (relating to Administrative Penalties).(b) HHSC sends a contractor written notice if HHSC is imposing an administrative penalty. The notice includes:(1) for a violation described in §9.181(a)(1) or §9.581(a)(1) of this title:(A) the date the administrative penalty begins to accrue, as described in §9.181(e) or §9.581(e) of this title; and(B) the amount of the administrative penalty that will accrue each day; or(2) for an action described in §9.181(a)(2) or §9.581(a)(2) of this title:(A) the amount of the administrative penalty, as described in §9.181(b) or §9.581(b) of this title; and(B) the date HHSC will require the contractor to pay HHSC the amount of the administrative penalty.(c) For a violation described in §9.181(a)(1) or §9.581(a)(1) of this title, HHSC gives a contractor written notice after the administrative penalty stops accruing and any informal dispute resolution related to the violation is completed. The notice includes:(1) the date the administrative penalty stopped accruing, as described in §9.181(f) or §9.581(f) of this title;(2) the total amount of the administrative penalty;(3) the date HHSC will require the contractor to pay HHSC the amount of the administrative penalty; and(4) if the violation is not an immediate threat as defined in §9.153 or §9.553 of this title (relating to Definitions), a statement that:(A) the contractor may choose amelioration as described in §9.182 or §9.586 of this title (relating to Amelioration);(B) to choose amelioration, the contractor must notify HHSC of this choice, in writing, within 10 business days after the date of HHSC's notice that the administrative penalty has stopped accruing; and(C) if the contractor does not notify HHSC that the contractor is choosing amelioration within the required 10-day period the contractor forfeits the opportunity to choose amelioration.(d) If HHSC imposes an administrative penalty and the contractor chooses amelioration, HHSC requires the contractor to pay HHSC the amount of the administrative penalty only if:(1) the contractor does not submit a plan for amelioration as described in §9.182(d) or §9.586(d) of this title, and the contractor:(A) does not appeal the administrative penalty; or(B) appeals the administrative penalty and the final decision from the administrative hearing is favorable to HHSC;(2) HHSC denies the plan for amelioration as described in §9.182(h)(2) or §9.586(h)(2) of this title, and the contractor:(A) does not appeal the administrative penalty; or(B) appeals the administrative penalty and the final decision from the administrative hearing is favorable to HHSC; or(3) the contractor does not implement an approved plan for amelioration as described in §9.182(i) or §9.586(i) of this title and the contractor:(A) does not appeal the issue of whether the plan was implemented; or(B) appeals the issue of whether the plan was implemented and the final decision from the administrative hearing is favorable to HHSC.(e) If HHSC approves the plan of amelioration and the cost of the proposed changes is less than the amount of the administrative penalty, HHSC requires the contractor to pay HHSC the difference between the cost of the proposed changes and the administrative penalty.(f) If HHSC imposes an administrative penalty and the contractor does not notify HHSC that the contractor chooses amelioration within the required 10-day period, HHSC requires the contractor to pay HHSC the amount of the administrative penalty:(1) if the contractor does not appeal the administrative penalty; or(2) if the contractor appeals the administrative penalty and the final decision from the administrative hearing is favorable to HHSC. Source Note: The provisions of this §52.317 adopted to be effective April 28, 2020, 45 TexReg 2725; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.317 Administrative Penalties in the HCS and TxHmL Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219171 03/12/2026 (a) A contractor may appeal a sanction, as described in §49.531(a) of this subchapter (relating to Sanction by HHSC), proposed or imposed by HHSC.(b) To appeal a sanction proposed or imposed by HHSC, a contractor must request an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing). Source Note: The provisions of this §52.351 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.351 Contractor's Right to Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219172 03/12/2026 (a) A contractor must notify HHSC if the contractor intends to:(1) terminate its contract; or(2) not enter into a standard contract when its contract expires.(b) The notification required by subsection (a) of this section must be given in accordance with §49.302(q) of this chapter (relating to General Requirements) and must:(1) include:(A) the contract number;(B) the type of program or service;(C) the proposed date of contract termination or the date of contract expiration;(D) the reason for terminating the contract or not entering into a standard contract; and(E) if it is notification of termination and the reason for terminating the contract is a change of ownership or change of legal entity, the proposed date of the change; and(2) be received by HHSC at least 60 days before the proposed date of the termination or the date of expiration.(c) If a contractor terminates its contract or does not enter into a standard contract when its contract expires:(1) the contractor must:(A) cooperate fully with HHSC, the LIDDA if applicable, and other contractors to transfer individuals receiving services from the contractor; and(B) submit documentation or take other action as directed by HHSC; and(2) HHSC:(A) notifies individuals receiving services from the contractor or LARs that:(i) the contractor is terminating the contract or not entering into a standard contract when its contract expires and that HHSC has placed or will place the contractor's payments on a vendor hold; and(ii) that the individuals or LARs may choose to receive services under a contract listed on the choice list, subject to program-specific requirements; and(B) removes the contract to be terminated or the expired contract from the appropriate choice list; and(C) notifies the contractor and any controlling person, in writing, of the application denial period set in accordance with §49.702(d) or (e) of this chapter (relating to Application Denial Period). Source Note: The provisions of this §52.371 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective March 20, 2016, 41 TexReg 1970; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.371 Contractor Terminating Contract or Not Entering into a Standard Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219173 03/12/2026 (a) HHSC may decide not to offer a standard contract to a contractor:(1) for any reason for which HHSC may deny a provisional contract application, as described in §49.207 of this chapter (relating to Provisional Contract Application Denial);(2) for any reason for which HHSC may terminate a contract, as described in §49.534 of this subchapter (relating to Termination of Contract by HHSC); or(3) if the contractor has a provisional contract for the HCS or TxHmL Program and HHSC imposed a vendor hold on the contractor in accordance with §9.183 (relating to Program Provider Compliance and Corrective Action) or §9.587 of this title (relating to Program Provider Compliance and Corrective Action) during the term of the provisional contract.(b) If HHSC decides not to offer a contractor a standard contract when its contract expires:(1) the contractor must:(A) cooperate fully with HHSC, the LIDDA if applicable, and other contractors to transfer individuals receiving services from the contractor; and(B) submit documentation or take other action as directed by HHSC; and(2) HHSC:(A) notifies individuals receiving services from the contractor or LARs that:(i) the contractor's contract is ending and HHSC has placed or will place the contractor's payments on a vendor hold; and(ii) the individuals or LARs may choose to receive services under a contract listed on the choice list, subject to program-specific requirements;(B) removes the expiring contract from the appropriate choice list; and(C) notifies:(i) the contractor of the decision, in writing, and includes in the notification the application denial period set in accordance with §49.702(a) of this chapter (relating to Application Denial Period); and(ii) any controlling person of the contractor, in writing, of the application denial period set in accordance with §49.702(a) of this chapter. Source Note: The provisions of this §52.391 adopted to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES E ENFORCEMENT BY HHSC, TERMINATION BY CONTRACTOR, AND NO OFFER OF STANDARD CONTRACT BY HHSC §52.391 HHSC Does Not Offer a Standard Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219174 03/12/2026 (a) HHSC may review a contractor's records to evaluate billing standards in accordance with program-specific requirements if:(1) HHSC proposes to terminate the contractor's contract;(2) HHSC does not offer the contractor a standard contract when its contract expires;(3) the contractor does not enter into a standard contract when its contract expires; or(4) the contractor terminates its contract.(b) If one of the events described in subsection (a)(1) - (4) of this section occurs, a contractor must provide the following information to HHSC:(1) the location of records related to the contract expiring or being terminated; and(2) the name, address, phone number, and e-mail address of a person HHSC may contact to arrange access to records.(c) HHSC may recoup funds in accordance with §49.533 of this chapter (relating to Recoupment) based on the results of a review described in subsection (a) of this section. Source Note: The provisions of this §52.601 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES F REVIEW BY HHSC OF EXPIRING OR TERMINATED CONTRACT §52.601 HHSC Review and Contractor Requirements Related to Expiring or Terminated Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219175 03/12/2026 This subchapter does not apply to a contractor that has a contract for:(1) the CMPAS Program;(2) SSPD; or(3) SSPD - 24-hour shared attendant care. Source Note: The provisions of this §52.701 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective October 1, 2019, 44 TexReg 5149; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES G APPLICATION DENIAL PERIOD §52.701 Contractors Not Subject to Subchapter G https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219176 03/12/2026 (a) If HHSC decides not to offer a standard contract to a contractor, as described in §49.561 of this chapter (relating to HHSC Does Not Offer a Standard Contract), HHSC sets an application denial period for the contractor or controlling person of the contractor that applies:(1) to all programs and services; and(2) for a period of time determined by HHSC, but no less than 12 months after the date the previous contract expires.(b) If HHSC terminates a contract for the contractor's failure to provide services for 12 consecutive months, as required by §49.534(a)(2)(A) of this chapter (relating to Termination of Contract by HHSC), HHSC sets an application denial period for the contractor or controlling person of the contractor that applies:(1) to the same program or service as the terminated contract; and(2) for 12 months after the date of termination.(c) If HHSC terminates a contract for a reason other than the contractor's death or the contractor's failure to provide services for 12 consecutive months, HHSC sets an application denial period for the contractor or controlling person of the contractor that applies:(1) to all programs and services; and(2) for a period of time determined by HHSC, but no less than 12 months after the date of termination.(d) If a contractor does not enter into a standard contract or terminates its contract in accordance with the contract, including §49.551 of this chapter (relating to Contractor Terminating Contract or Not Entering into a Standard Contract), for a reason other than a change of ownership or change of legal entity, HHSC sets an application denial period for the contractor or controlling person of the contractor that applies:(1) to the same service or program as the terminated or expired contract; and(2) for a period of time determined by HHSC, but no less than 12 months after the date the contract terminated or expired.(e) If a contractor does not enter into a standard contract or terminates a contract not in accordance with the contract, including §49.551 of this chapter, HHSC sets an application denial period for the contractor or controlling person of the contractor that applies:(1) to all programs and services; and(2) for a period of time determined by HHSC, but no less than 12 months after the date the contract terminated or expired.(f) If a contractor submits a provisional contract application to HHSC after the expiration of an application denial period described in subsections (a) - (e) of this section, HHSC may deny the contract application for a reason described in §49.207 of this chapter (relating to Provisional Contract Application Denial). Source Note: The provisions of this §52.702 adopted to be effective September 1, 2014, 39 TexReg 6637; amended to be effective September 1, 2018, 43 TexReg 5230; amended to be effective December 22, 2020, 45 TexReg 9234; transferred effective April 29, 2024, as published in the March 29, 2024, issue of the Texas Register, 49 TexReg 2091. 1 HEALTH AND HUMAN SERVICES COMMISSION 52 CONTRACTING FOR COMMUNITY SERVICES G APPLICATION DENIAL PERIOD §52.702 Application Denial Period https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224553 03/12/2026 The purpose of this chapter is to implement HHSC ombudsman programs, as established by Texas Government Code, Title 4, Chapter 531, Subchapter Y. Source Note: The provisions of this §87.1 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES A PURPOSE, DEFINITIONS, AND ESTABLISHMENT OF OMBUDSMAN PROGRAMS §87.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224554 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise. (1) AMH--Adult Mental Health program. The home and community-based services adult mental health program, operated under a Texas Medicaid state plan amendment and 26 Texas Administrative Code Chapter 307, Subchapter B (relating to Home and Community-Based Services--Adult Mental Health Program). (2) Compact with Texans--A document that describes the Texas Health and Human Services Commission's services, principles, and process for filing complaints and requesting information. (3) Complaint--Any expression of dissatisfaction by a consumer of an HHS program or service about HHS benefits or services. Complaints do not include the following, which are handled through other processes: (A) allegations of abuse, neglect, or exploitation; (B) allegations of discrimination or other civil rights violations; (C) allegations of fraud, waste, or abuse; (D) requests for Fair Hearings or administrative appeals; or (E) concerns about regulated individuals and entities. (4) Consumer--An applicant or a client of HHS programs, as well as a member of the public seeking information about HHS programs. (5) Contact--A written or oral inquiry or complaint from a consumer, individual, or LAR about HHS programs or services. (6) DFPS--Texas Department of Family and Protective Services. The state agency established by Texas Human Resources Code Chapter 40 and responsible for administration of Child Protective Services.(7) Dispute resolution services--An independent and impartial review of a program's actions regarding an HHS consumer complaint that has not been resolved to the consumer's satisfaction. (8) FCO--Foster Care Ombudsman. The Ombudsman for Children and Youth in Foster Care. (9) HCS--The Home and Community-based Services Program. A program operated by HHSC in accordance with §1915(c) of the Social Security Act.(10) Health care provider--A physician, pharmacist, or other licensed provider who is authorized under state law to provide health care services, or a credentialed professional who provides behavioral health, mental health, or substance use disorder services. (11) HHS--Texas Health and Human Services. The system for providing or otherwise administering health and human services in this state established in Texas Government Code Chapter 521, comprised of HHSC and the Texas Department of State Health Services. (12) HHSC--Texas Health and Human Services Commission. The agency established by Texas Government Code Chapter 523. (13) IDD--Intellectual or developmental disability. (14) IDDO--The Ombudsman for individuals with an intellectual or developmental disability.(15) Individual--A person seeking or receiving IDD services. (16) Inquiry--A request by a consumer, individual, or LAR for information about HHS programs or services. (17) LAR--Legally authorized representative. A person legally authorized to act on behalf of an individual with regard to a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (18) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority in accordance with Texas Health and Safety Code §533.0356(a). (19) LIDDA--Local intellectual and developmental disability authority. An entity designated as the local intellectual and developmental disability authority in accordance with Texas Health and Safety Code §533A.035(a). (20) LMHA--Local mental health authority. An entity designated as the local mental health authority in accordance with Texas Health and Safety Code §533.035(a). (21) MCO--Managed care organization. An entity contracted with HHSC to provide health care services in a Medicaid managed care program. (22) OBH--Ombudsman for Behavioral Health Access to Care. (23) OO--Office of the Ombudsman. The HHSC office with authority and responsibility over the HHS system in performing ombudsman functions. (24) Ombudsman program--An ombudsman program administered by HHSC as established by Texas Government Code §531.9912. (25) OMCAT--Ombudsman Managed Care Assistance Team. (26) Parity--The requirement outlined in Texas Insurance Code, Chapter 1355, Subchapter F that a health benefit plan provide benefits and coverage for mental health conditions and substance use disorders under the same terms and conditions applicable to the plan's medical and surgical benefits and coverage. (27) Program provider--A person who has a contract with HHSC to provide HCS or TxHmL services. (28) Retaliation--A harmful action taken because of, or substantially motivated by, reprisal or revenge in response to a legally protected activity, such as making a good faith complaint.(29) State hospital--A state mental health facility operated by HHSC. (30) Substantiated complaint--A complaint for which research clearly indicates HHS policy was violated or HHS expectations were not met. (31) TxHmL--The Texas Home Living Program. A program operated by HHSC in accordance with §1915(c) of the Social Security Act.(32) Unable to substantiate a complaint--A complaint for which research does not clearly indicate if HHS policy was violated or HHS expectations were met or not met. (33) Unsubstantiated complaint--A complaint for which research clearly indicates HHS policy was not violated or HHS expectations were met. (34) Youth--Children and youth in the conservatorship of DFPS, which ends at age 18. Source Note: The provisions of this §87.3 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES A PURPOSE, DEFINITIONS, AND ESTABLISHMENT OF OMBUDSMAN PROGRAMS §87.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224555 03/12/2026 (a) Texas Government Code §531.9912 requires the following programs to be established by the HHSC executive commissioner: (1) the HHS office of the ombudsman in accordance with Texas Government Code §531.9915; (2) the ombudsman for children and youth in foster care in accordance with Texas Government Code §531.9931;(3) the ombudsman for managed care assistance in accordance with Texas Government Code §531.9932;(4) the ombudsman for behavioral health access to care in accordance with Texas Government Code §531.9933; and(5) the ombudsman for individuals with an intellectual or developmental disability in accordance with Texas Government Code §531.9934. (b) The HHSC executive commissioner appoints an ombudsman for each ombudsman program to serve at the will of the HHSC executive commissioner. Source Note: The provisions of this §87.5 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES A PURPOSE, DEFINITIONS, AND ESTABLISHMENT OF OMBUDSMAN PROGRAMS §87.5 Establishment of Ombudsman Programs and Appointment of Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224556 03/12/2026 A person is prohibited from serving as ombudsman in an ombudsman program if the person or the person's spouse has a conflict as defined by Texas Government Code §531.9921. Source Note: The provisions of this §87.7 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES A PURPOSE, DEFINITIONS, AND ESTABLISHMENT OF OMBUDSMAN PROGRAMS §87.7 Conflict of Interest https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224557 03/12/2026 (a) OO is established by Texas Government Code §531.9912 in accordance with Texas Government Code §531.9915. (1) OO has authority and responsibility over the HHS system in: (A) providing dispute resolution services; (B) performing consumer protection and advocacy functions; and (C) collecting inquiry and complaint data related to the HHS system.(2) OO is responsible for a standard process for tracking and reporting consumer and individual contacts within the HHS system, including centralized tracking of consumer and individual contacts submitted to field, regional, or other local offices. (b) HHSC Compact with Texans outlines customer service principles and standards, including a complaint process for consumers and individuals. As part of that process, a consumer is directed to first contact the HHS program for which they have an inquiry or a complaint. If the concern is not resolved to the consumer's satisfaction, the consumer is directed to contact OO. In accordance with HHSC Compact with Texans, OO is committed to providing high quality services in a professional and ethical manner. (c) In accordance with Texas Government Code §531.9915(b), OO does not have authority to process case actions or overturn HHS program decisions. OO staff also cannot give legal advice. (d) OO strives to adhere to the United States Ombudsman Association's government ombudsman standards by: (1) maintaining independence from HHS programs through an organizational structure that has OO report to the HHSC executive commissioner through a separate chain of command from program staff; (2) remaining impartial by receiving and reviewing each contact in an objective and fair manner, free from bias, and treating all parties without favor or prejudice; (3) maintaining discretion to keep confidential or release information related to a contact or a complaint investigation, if authorized by a consumer, individual, or LAR to do so; and (4) providing a credible review process by performing responsibilities in a manner that engenders respect, confidence, and accessibility to all consumers, individuals, and LARs.(e) The Office of the State Long-term Care Ombudsman is affiliated with the OO. This office is authorized by Texas Human Resources Code Chapter 101a, Subchapter F; 42 United States Code 3058f and 3058g; and 45 Code of Federal Regulations Part 1324. Its purpose is to protect the health, safety, welfare, and rights of people living in nursing facilities and assisted living facilities. Administrative rules for this program can be found in 26 Texas Administrative Code Chapter 88 (relating to State Long-term Care Ombudsman Program). The rules in this chapter do not apply to the State Long-term Care Ombudsman program. Source Note: The provisions of this §87.15 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.15 Creation of the Office and Ombudsman Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224558 03/12/2026 (a) Data.(1) OO staff maintain records of inquiries and complaints in the OO primary recordkeeping system. (2) In accordance with Texas Government Code §531.995, HHSC and DFPS must provide an ombudsman access to the records that relate to a complaint the ombudsman is reviewing or investigating. (b) Agency Monthly Contact Report (AMCR). In accordance with Texas Government Code §531.9915(d), OO staff compile a monthly report of consumer, individual, and LAR contacts received by HHS programs, including those received by vendors contracted to provide services on behalf of an HHS program. OO submits this report to the HHSC executive commissioner and designated program management staff across the HHS agencies on a periodic basis. OO staff may also provide reporting of program-specific contact data to management teams of HHS programs. (c) Annual Report.(1) Each ombudsman must prepare an annual report in accordance with Texas Government Code §531.998. (2) No later than December 1 of each year the report must be submitted to the governor, the lieutenant governor, the relevant standing committees of the legislature, each member of the legislature, and the HHSC executive commissioner. (3) The report must be publicly available on the HHSC website. Source Note: The provisions of this §87.17 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.17 Data and Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224559 03/12/2026 (a) An ombudsman serves as an impartial party in assisting persons, including children and youth in DFPS conservatorship, with complaints regarding issues or case-specific activities within the authority and programs of HHSC and DFPS. Each ombudsman has the same duties and procedures. (b) Statewide procedures. Texas Government Code §531.993(b) requires an ombudsman to develop and implement procedures to:(1) receive and review complaints and take appropriate action, including:(A) investigate individual complaints that allege violations of HHSC or DFPS procedures or policies or other violations; and(B) refer any trends or systemic issues identified in complaints to HHSC or DFPS for resolution; (2) assist persons, including children and youth in DFPS conservatorship, in making complaints and reporting allegations of abuse, neglect, or exploitation under Texas Human Resources Code Chapter 48;(3) maintain the confidentiality of an ombudsman's communications and records, records of another person that have been provided to an ombudsman, and communications of another person with an ombudsman; and(4) inform a person who files a complaint of the results of the ombudsman's investigation of the complaint, including whether the complaint was substantiated, and any corrective action recommended. (c) Duties performed in collaboration with HHSC or DFPS. Texas Government Code §531.993(b) requires an ombudsman to:(1) collaborate with HHSC to develop and implement an annual outreach plan to promote awareness of ombudsman programs; the plan must include how an ombudsman may be contacted, the purpose of an ombudsman, and the services an ombudsman provides; and(2) collaborate with HHSC or DFPS to identify consequences for any retaliatory action related to a complaint filed with an ombudsman, in accordance with Texas Government Code §531.997.(d) Final determination report; corrective action. An ombudsman, HHSC, and DFPS have the following duties related to the final determination of a complaint and recommended corrective actions: (1) an ombudsman, in accordance with Texas Government Code §531.993(b) and (c), must: (A) issue and file with HHSC or DFPS, a report containing an ombudsman's final determination regarding a complaint and any recommended corrective actions; (B) include a determination in the report of whether there was wrongdoing or negligence by HHSC or DFPS or the complaint was frivolous or without merit; and(C) monitor and evaluate the corrective actions taken in response to an ombudsman's recommendation.(2) HHSC and DFPS, in accordance with Texas Government Code §531.993(c-1), are required to provide written notice to an ombudsman on whether a recommended corrective action was adopted or rejected. If rejected, HHSC or DFPS must include in the notice the reason for the rejection. (e) Additional duties. In accordance with Texas Government Code §531.993:(1) an ombudsman must establish a secure form of communication with any person who files a complaint; and(2) an ombudsman may attend any judicial proceeding related to a complaint filed with the ombudsman program. Source Note: The provisions of this §87.19 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.19 Duties and Statewide Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224560 03/12/2026 In accordance with Texas Government Code §531.994, if an ombudsman discovers unreported violations of HHSC or DFPS rules and policies during the investigation of a complaint, the ombudsman must open a new investigation for each unreported violation. Source Note: The provisions of this §87.21 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.21 Investigation of Unreported Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224561 03/12/2026 (a) Confidentiality Requirements. In accordance with Texas Government Code §531.996, and §87.19(b)(3) and (e)(1) of this chapter (relating to Duties and Statewide Procedures):(1) a person may communicate with an ombudsman relating to a complaint by telephone, mail, electronic mail, or any other means the ombudsman determines to be feasible, secure, and accessible;(2) the records of an ombudsman relating to a complaint are confidential; (3) communications with an ombudsman are confidential both during and after an investigation or review of a complaint; (4) the disclosure of confidential information to an ombudsman does not constitute a waiver of confidentiality; any information disclosed remains confidential and privileged following disclosure; (5) an ombudsman may communicate with HHSC or DFPS regarding confidential information disclosed to the ombudsman; and(6) an ombudsman may make reports relating to an investigation of a complaint public after the complaint is resolved; a report may not include information that identifies an individual complainant, client, parent, employee, or any other person involved in the complaint.(b) Complaint Communications Process. (1) Except as noted in paragraph (3) of this subsection, before sharing complaint-related information, OO staff verify the identity of the person receiving the information and only share the information with the consumer or individual applying for or receiving services, their LAR, and staff within HHS and DFPS involved in the review of the complaint. With the consent of the consumer or individual or their LAR, OO staff may share complaint information with other appropriate parties who can assist with the issue. (2) OO staff follow the HHSC policies relating to transmission of complaint data, including use of secure email to encrypt messages that contain an individual's confidential information or protected health information. (3) In certain instances, state and federal laws and rules and regulations may authorize or require OO staff to contact vendors contracted to provide services on behalf of an agency program and share complaint information with them to address a complaint, without obtaining explicit permission of the individual or their LAR. This is especially relevant for individuals who may be unable to communicate. Source Note: The provisions of this §87.23 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.23 Confidentiality and Communications Related to Complaints. https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224562 03/12/2026 (a) The OO maintains a public website with information on how to contact the office via phone, online, fax, and mail. The OO develops brochures and other materials that can be distributed to consumers and healthcare providers. Contact information and materials for distribution are also maintained for each ombudsman program listed in §87.3 of this chapter (relating to Definitions). (b) Each HHS office that provides direct service delivery of programs or services offers a process to a consumer or individual to submit complaints and advises the consumer or individual how to contact OO staff if that office does not resolve the complaint to the consumer's satisfaction. These HHS programs ensure OO contact information is provided on appropriate web pages and in written materials and is available upon request in local offices. This includes communications made to a consumer by a vendor contracted to provide services on behalf of an HHS program.(c) All residential child-care facilities in which foster youth are placed must display FCO contact information in a location that is easily accessible and offers maximum privacy to the youth. A youth may also contact an FCO in person when FCO staff present to youth in events organized by DFPS or when visiting a residential treatment center or hospital where a youth is placed.(d) The OBH toll-free number is published in consumer rights handbooks made available at all service locations at state hospitals or LBHAs or LMHAs. Consumers at these facilities also have a right to have all their rights explained verbally--including the right to complain to OBH--within 24 hours of admission. (e) A LIDDA must post the IDDO toll-free number conspicuously in every program area. IDDO publishes handbooks describing the rights of individuals with IDD, including the right to contact IDDO. HCS and TxHmL program providers, and LIDDAs must inform individuals of their right to complain to IDDO and provide the IDDO toll-free number.(f) Each MCO must include OMCAT contact information on its member website and in member handbooks. Source Note: The provisions of this §87.25 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.25 Contact Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224563 03/12/2026 (a) OO staff may refer a consumer to the appropriate program area within HHS or DFPS or the appropriate contractor for HHS services if the consumer has not yet attempted to resolve their issue with that HHS or DFPS program or contractor before contacting the OO.(b) OO staff may refer a consumer or individual to a resource outside the HHS system if the consumer's or individual's issue does not fall within the jurisdiction of HHS. (c) If a person, other than a youth in foster care or the court-appointed attorney for a youth who is not able to verbalize their concerns, contacts FCO, that person will be referred to the appropriate area for assistance. (d) If a youth contacts FCO with a complaint that is outside of the scope of FCO's ability to assist, the FCO will offer resources to assist with the issue. (e) Residents of state supported living centers (SSLCs) or their LARs are referred to the Office of the Independent Ombudsman for SSLCs established by Texas Health and Safety Code, Chapter 555, Subchapter C.(f) OO staff may refer a consumer, or the consumer's LAR, in the child health plan with a grievance related to health plan providers to the Texas Department of Insurance in accordance with Texas Health and Safety Code, Chapter 62.(g) All allegations of abuse, neglect, or exploitation are immediately referred to the appropriate entity. OO will always inform a complainant who makes allegations of abuse or neglect that the referral is being made. Source Note: The provisions of this §87.27 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.27 Referrals to Other HHS Offices or Other Entities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224564 03/12/2026 (a) An ombudsman must give emphasis to assisting a person with an urgent or immediate medical or support need.(b) A contact received through an online submission is automatically and immediately loaded in the OO primary recordkeeping system and assigned to appropriate OO staff for action. (c) A contact received by postal mail, fax, or email is uploaded to the primary recordkeeping system and assigned to appropriate OO staff for action within one business day of receipt. (d) A call received by OO staff is immediately entered in the primary recordkeeping system. (e) OO publishes on its website a list of commitments OO staff makes to ensure cases are dealt with fairly, efficiently, and effectively. The list also includes commitments OO asks of consumers and LARs to ensure the same objective. Consumers and LARs may hear a verbal summary of the list or receive a written copy. (f) OO staff use HHSC contracted vendors to provide language interpretation services, when necessary.(g) When FCO meet a youth in person who has an inquiry or a complaint, they enter the contact in the primary recordkeeping system on the first business day after they return to the FCO office.(h) When FCO receive calls that include information that give FCO staff reason to suspect abuse or neglect, calls are transferred to the Texas Abuse Hotline operated by DFPS Statewide Intake (SWI). FCO staff assist the youth in making a report. Online reports can be made when hold times warrant. (i) When FCO receive written submissions that include information that gives FCO reason to suspect abuse or neglect, FCO staff attempt to communicate with the youth by phone. If FCO staff are not able to speak with the youth by phone within one business day, FCO staff report the suspected abuse or neglect by calling SWI. Online reports can be made when hold times warrant. Source Note: The provisions of this §87.29 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.29 Intake of Contacts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224565 03/12/2026 (a) OO staff review all relevant information through inquiry into agency program systems.(b) Each complaint is investigated to determine if agency policy was followed by program staff and vendors contracted to provide services on behalf of an agency program. Applicable policies include federal and state law, administrative rules, program handbooks, contracts, and internal program policies and procedures. (c) When investigating a complaint, OO staff may also consider: (1) legal authority, by examining the basis of the agency program's decision, and assessing if the decision was made within the scope of that authority; (2) procedural fairness and rights, by examining if the consumer or individual was given a full understanding of the situation, offered all applicable opportunities to appeal, and given sufficient time to respond when information was requested; and (3) agreed expectations, by reviewing if the agency program followed through after agreeing to take particular actions, and if the program provided an adequate explanation of decisions. Source Note: The provisions of this §87.31 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.31 Investigation of Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224566 03/12/2026 (a) Once OO staff have determined all pertinent information has been gathered and their investigation of a complaint is complete, they inform the consumer or individual of the outcome and whether they have determined the complaint to be substantiated, unsubstantiated, or unable to be substantiated.(b) For substantiated complaints, OO staff document any recommended corrective actions to be taken as a result of the complaint. (c) A written response will be provided to the consumer or individual if requested. Source Note: The provisions of this §87.33 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.33 Substantiating and Closing Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224567 03/12/2026 (a) For any contact in which OO staff does not have a real-time interaction with a consumer, individual, or LAR, the OO staff will follow up within one business day of the date of receipt of the contact. OO staff will follow up with the consumer, individual, or LAR at least every 10 business days thereafter, until the contact is closed.(b) OO staff may establish a more structured communication plan if the conduct of a consumer, individual, or LAR hinders the effective investigation and resolution of a case. (1) To determine what actions may be appropriate to structure future communication, the case and all communication between OO staff and the consumer, individual, or LAR will be reviewed by an OO supervisor. (2) If the supervisor determines more structured communication would achieve effective investigation and resolution of the case, a written communication will be shared with the consumer, individual, or LAR outlining what OO finds has hindered complaint resolution. (3) If the conduct of a consumer, individual, or LAR continues to hinder the investigation or resolution, the HHS Ombudsman will communicate with the consumer, individual, or LAR in writing to outline how future communication with OO staff will be structured. The conduct of the consumer, individual, or LAR will continue to be monitored to determine if communication has improved to the point that the structured communication can be discontinued.(c) The process outlined in subsection (b) of this section will never result in a consumer, individual, or LAR being left without a way to contact OO staff. Source Note: The provisions of this §87.35 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES B PROVISIONS COMMON TO ALL OMBUDSMAN PROGRAMS §87.35 Contact Follow-up https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224568 03/12/2026 Texas Government Code §531.995 requires HHSC and DFPS to provide an ombudsman access to records that relate to a complaint the ombudsman is reviewing or investigating. Source Note: The provisions of this §87.41 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES C PROVISIONS DIRECTING HHS AND DFPS §87.41 Access to Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224569 03/12/2026 (a) Texas Government Code §531.997 prohibits HHSC or DFPS from retaliating against an employee of either agency, as applicable, or any other person who in good faith makes a complaint to an ombudsman or against any person who cooperates with the ombudsman in an investigation. (b) As referenced in §87.19(c)(2) of this chapter (relating to Duties and Statewide Procedures), the ombudsman will collaborate with HHSC or DFPS to identify consequences for any retaliatory action related to a complaint filed with an ombudsman. Source Note: The provisions of this §87.43 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES C PROVISIONS DIRECTING HHS AND DFPS §87.43 Retaliation Prohibited. https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224570 03/12/2026 (a) OMCAT is established by Texas Government Code §531.9912 in accordance with Texas Government Code §531.9932.(b) OMCAT is responsible for assisting persons who are experiencing barriers in the Medicaid application and enrollment process and educating them so that they understand the concept of managed care; understand their rights under Medicaid, including grievance and appeal procedures; MCOs, health care providers, and any other appropriate entity on and can advocate for themselves. OMCAT intervenes promptly with HHSC Medicaid program staff, behalf of a person who has an urgent need for medical services.(c) As a part of the support and information services, OMCAT is responsible for operating a statewide toll-free assistance telephone number. (d) In accordance with Texas Government Code §531.9932(e), OMCAT is sufficiently independent from other aspects of Medicaid managed care to represent the best interests of consumers in complaint resolution. (e) OMCAT coordinates a network of entities to provide support and information services to persons enrolled in or applying for Medicaid who experience barriers to receiving health care services. Source Note: The provisions of this §87.51 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES D OMBUDSMAN FOR MANAGED CARE ASSISTANCE §87.51 Creation of the Program and Populations Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224571 03/12/2026 (a) FCO is established by Texas Government Code §531.9912 in accordance with Texas Government Code §531.9931. (b) FCO serves as an impartial party in assisting children and youth in the conservatorship of DFPS with complaints regarding issues within the authority of DFPS or an HHS agency. (c) While individuals aged 18 and older may continue to receive DFPS services, they are not considered part of the population served by FCO because they are no longer "in the conservatorship" of DFPS. However, if FCO receives a complaint from a youth who turns 18 during the course of an FCO investigation, the complaint will be completed. (d) FCO is responsible for receiving and investigating inquiries and complaints from youth in the conservatorship of DFPS, including youth placed by contract as part of the community-based care model established by Texas Family Code, Chapter 264, Subchapter B-1, including single source continuum contractors that provide placement and case management services. For cases involving youth in foster care, or a court-appointed attorney for a youth unable to verbalize their concerns, FCO investigates and maintains communication with either the youth or the attorney. FCO is required to inform complainants of the result of an investigation.(e) FCO may refer youth to any DFPS or HHS program or service that can assist with the youth's inquiry. With permission from the youth, FCO may work with staff in any DFPS or HHS program to resolve a complaint. Source Note: The provisions of this §87.61 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES E OMBUDSMAN FOR CHILDREN AND YOUTH IN FOSTER CARE §87.61 Creation of Program and Population Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224572 03/12/2026 (a) OBH is established by Texas Government Code §531.9912 in accordance with Texas Government Code §531.9933.(b) OBH serves as an impartial party to help consumers, including consumers who are uninsured or have public or private health benefit coverage, and behavioral health care providers navigate and resolve issues related to consumer access to behavioral health care, including care for mental health conditions and substance use disorders. OBH identifies, tracks, and helps report potential parity violations of Texas Insurance Code, Chapter 1355, Subchapter F. (c) OBH assists consumers who have questions, concerns, or complaints regarding services provided by a state hospital, an LBHA, an LMHA, or through a contract with HHSC as part of the AMH program. Specific rights of these consumers are outlined in 25 Texas Administrative Code Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services). Source Note: The provisions of this §87.71 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES F OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO CARE §87.71 Creation of the Program and Populations Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224573 03/12/2026 In accordance with Texas Insurance Code §1355.2572(b), OBH collaborates with the Texas Department of Insurance on an annual report on the status of rights and responsibilities for mental health condition and substance use disorder benefits and resolved and unresolved parity complaints. Source Note: The provisions of this §87.73 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES F OMBUDSMAN FOR BEHAVIORAL HEALTH ACCESS TO CARE §87.73 Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224574 03/12/2026 (a) The IDDO program is established by Texas Government Code §531.9912 in accordance with Texas Government Code §531.9934. (b) IDDO serves as an impartial party to assist individuals with IDD, their LARs, their program providers, and LIDDAs as they navigate and resolve complaints or grievances regarding infringement of the rights of a person with an intellectual disability or delivery of intellectual disability services. This in accordance with Texas Health and Safety Code §592.039. Source Note: The provisions of this §87.81 adopted to be effective April 3, 2025, 50 TexReg 2203. 1 HEALTH AND HUMAN SERVICES COMMISSION 87 OMBUDSMAN SERVICES G OMBUDSMAN FOR INDIVIDUALS WITH AN INTELLECTUAL OR DEVELOPMENTAL DISABILITY §87.81 Creation of the Program and Populations Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190355 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190355 03/12/2026 The purpose of this chapter is to implement the State Long-Term Care Ombudsman Program, as established by:(1) the Older Americans Act, §711 and §712 (United States Code, Title 42, §3058f and §3058g);(2) CFR, Title 45, Parts 1321 and 1324; and(3) Texas Human Resources Code, Title 6, Chapter 101A, Subchapter F. Source Note: The provisions of this §88.1 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM A PURPOSE AND DEFINITIONS §88.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218302 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code, §662.021.(2) Certified ombudsman--A staff ombudsman or a volunteer ombudsman.(3) CFR--Code of Federal Regulations.(4) Complainant--A person who makes a complaint.(5) Complaint--A statement of dissatisfaction or concern made by or on behalf of a resident, that relates to action, inaction, or a decision by any of the following entities or persons, that may adversely affect the health, safety, welfare, or rights of the resident:(A) a long-term care (LTC) facility or LTC facility staff;(B) a governmental entity, including a health and human services agency; or(C) any other person who provides care or makes decisions related to a resident.(6) DAHS facility--A day activity and health services facility. A facility licensed in accordance with Texas Human Resources Code, Chapter 103.(7) Day--A calendar day.(8) Federal fiscal year--A 12-month period of time from October 1 through September 30.(9) Governmental entity--An entity that is:(A) a state agency;(B) a district, authority, county, municipality, regional planning commission, or other political subdivision of the state; or(C) an institution of higher education, as defined in Texas Education Code, §61.003.(10) Grievance--A statement of dissatisfaction or concern regarding a representative of the Office of the State Long-Term Care Ombudsman (Office) or the State Ombudsman and the performance of their functions, responsibilities, and duties described in 45 CFR §1324.13, 45 CFR §1324.19, and this chapter.(11) Grievant--A person who makes a grievance.(12) HCSSA--Home and community support services agency. An entity licensed in accordance with Texas Health and Safety Code Chapter 142.(13) HHSC--The Texas Health and Human Services Commission or its designee.(14) Host agency--A governmental entity or nonprofit organization that contracts with HHSC to ensure that the local ombudsman entity implements the State Long-Term Care Ombudsman Program (Ombudsman Program) in an ombudsman service area.(15) Incident report--A document created by an LTC facility about an abnormal event involving a resident, including an accident or injury.(16) Immediate family member--A member of the same household or a relative with whom there is a close personal or significant financial relationship.(17) Informed consent--Consent from a resident or legally authorized representative after the State Ombudsman or a representative of the Office explains the options for ombudsman action and possible outcomes of such options in a manner and language in which the resident or legally authorized representative understands, as determined by the State Ombudsman or a representative of the Office. Informed consent may be communicated in writing, orally, visually, or through the use of auxiliary aids and services.(18) Individual conflict of interest--A situation in which a person is involved in multiple interests, financial or otherwise, that could affect the effectiveness and credibility of the Ombudsman Program and includes a person:(A) having direct involvement in the licensing, surveying, or certification of an LTC facility, a HCSSA, a DAHS facility, a nursing facility administrator, or a nurse aide;(B) having ownership or investment interest (represented by equity, debt, or other financial relationship) in an LTC facility, a HCSSA, a DAHS facility, or an association of LTC facilities, HCSSAs, or DAHS facilities;(C) managing or being employed in an LTC facility, a HCSSA, a DAHS facility, or an association of LTC facilities, HCSSAs, or DAHS facilities;(D) being employed by an LTC facility within the 12 months before performing functions of the Ombudsman Program;(E) accepting gifts, gratuities, or other consideration from an LTC facility or from a resident of such an LTC facility or the resident's family;(F) accepting money or any other consideration from anyone other than the local ombudsman entity or host agency for performing functions of the Ombudsman Program;(G) receiving or having the right to receive, directly or indirectly, remuneration (in cash or in kind) under a compensation arrangement with an owner or operator of an LTC facility, a HCSSA, or a DAHS facility;(H) being involved in PASRR screenings for LTC facility placements other than responding to a complaint made to the Ombudsman Program;(I) determining eligibility regarding Medicaid or other public benefits for residents;(J) being employed by a managed care organization that provides services to residents;(K) serving as a representative of the Office for an LTC facility in the ombudsman service area and in which a relative of the representative resides or works;(L) acting as a decision-maker or legally authorized representative for a resident in the ombudsman service area;(M) having management responsibility for, or operating under the supervision of, a person with management responsibility for adult protective services as described in Texas Human Resources Code, Chapter 48;(N) being a resident;(O) being a member of a board or council that represents the interests of an LTC facility; or(P) having an immediate family member who meets any of the descriptions in subparagraphs (A) - (O) of this paragraph.(19) Legally authorized representative--A person authorized by law to act on behalf of another person with regard to a matter described in this chapter, including:(A) a parent, guardian, or managing conservator of a minor;(B) the guardian of an adult;(C) an agent to whom authority to make health care decisions is delegated under a medical power of attorney or durable power of attorney in accordance with state law; or(D) the representative of a deceased person.(20) Local ombudsman entity--One of the following:(A) an identifiable unit of a host agency that:(i) consists of representatives of the Office who are employees, independent contractors, or volunteers of the host agency; and(ii) implements the Ombudsman Program in an ombudsman service area; or(B) an identifiable unit of a governmental entity or nonprofit organization that:(i) consists of representatives of the Office who are employees, independent contractors, or volunteers of the governmental entity or nonprofit organization; and(ii) contracts with a host agency to implement the Ombudsman Program in an ombudsman service area.(21) LTC facility--Long-term care facility. A nursing facility licensed or required to be licensed in accordance with Texas Health and Safety Code, Chapter 242, and or an assisted living facility licensed or required to be licensed in accordance with Texas Health and Safety Code, Chapter 247.(22) Managing local ombudsman--A person who:(A) is certified as a staff ombudsman to serve as a managing local ombudsman in accordance with §88.102 of this chapter (relating to Certification of an Ombudsman); and(B) works with a host agency and the Office to oversee the implementation of the Ombudsman Program in an ombudsman service area.(23) Office--The Office of the State Long-Term Care Ombudsman. An organizational unit within HHSC that:(A) is headed by the State Ombudsman;(B) consists of representatives of the Office who are employees of HHSC; and(C) oversees the statewide implementation of the Ombudsman Program.(24) Older Americans Act--A federal law (Title 42, United States Code, §3011 et seq.) that establishes and funds a comprehensive service system for persons 60 years of age or older and certain caregivers and family members of persons 60 years of age or older.(25) Ombudsman database--The statewide reporting system required by §712(c) of the Older Americans Act that is a web-based application in which Ombudsman Program data is entered, stored, maintained, and analyzed.(26) Ombudsman intern--A person who is being trained to be a volunteer ombudsman in accordance with the Ombudsman Certification Training Manual but has not been certified as a volunteer ombudsman.(27) Ombudsman Program--The State Long-Term Care Ombudsman Program as defined in 45 CFR §1324.1. The program through which the functions of the Office are carried out by the State Ombudsman and representatives of the Office.(28) Ombudsman Program records--The files, records, and other information created or maintained by the State Ombudsman or a representative of the Office in the performance of functions of the Ombudsman Program, including:(A) information relating to complaint investigations;(B) emails and documentation of phone conversations;(C) documentation related to the budget and expenditures for the Ombudsman Program; and(D) information contained in the ombudsman database.(29) Ombudsman service area--The county or counties, specified in the contract between HHSC and a host agency, in which the local ombudsman entity performs functions of the Ombudsman Program.(30) Organizational conflict of interest--A situation in which an organization is involved in multiple interests, financial or otherwise, that could affect the effectiveness and credibility of the Ombudsman Program and includes an organization:(A) having any ownership, operational, or investment interest in, or receiving grants or donations from, an LTC facility;(B) being an association of LTC facilities or an affiliate of such an association;(C) having responsibility for licensing, surveying, or certifying LTC facilities;(D) having a governing board member with an ownership, investment, or employment interest in an LTC facility;(E) providing long-term care to residents of LTC facilities, including the provision of personnel for LTC facilities or the operation of programs that control access to, or services of, LTC facilities;(F) providing long-term care coordination or case management for residents of LTC facilities;(G) setting reimbursement rates for LTC facilities;(H) providing adult protective services, as described in Texas Human Resources Code, Chapter 48;(I) determining eligibility regarding Medicaid or other public benefits for residents of LTC facilities;(J) conducting PASRR screening for LTC facility placements;(K) making decisions regarding admission of residents to, or discharge of residents from, LTC facilities; or(L) providing guardianship, conservatorship, or other fiduciary or surrogate decision-making services for residents of LTC facilities.(31) PASRR--Preadmission Screening and Resident Review. A review performed in accordance with 42 CFR Part 483, Subpart C.(32) Private and unimpeded access--Has the following meanings:(A) as used in §88.201(a)(1) of this chapter (relating to Access to Facilities, Residents, and Resident Records), access to enter an LTC facility without interference or obstruction from facility employees, volunteers, or contractors; and(B) as used in §88.201(a)(2) of this chapter, access to communicate with a resident outside of the hearing and view of other persons without interference or obstruction from facility employees, volunteers, or contractors.(33) Representative of the Office--A staff ombudsman, volunteer ombudsman, or ombudsman intern.(34) Resident--A person of any age who resides in an LTC facility.(35) Resident representative--A person chosen by a resident, through formal or informal means, to act on behalf of the resident to:(A) support the resident in decision-making;(B) access medical, social, or other personal information of the resident;(C) manage financial matters; or(D) receive notifications.(36) Staff ombudsman--A person who meets the following criteria, including a managing local ombudsman:(A) is certified as a staff ombudsman in accordance with §88.102 of this chapter;(B) performs functions of the Ombudsman Program; and(C) is an employee or independent contractor of:(i) a host agency;(ii) a governmental entity or nonprofit organization that contracts with a host agency, as described in paragraph (16)(B) of this section; or(iii) HHSC.(37) State Ombudsman--The State Long-term Care Ombudsman, as defined in 45 CFR §1324.1. The person who heads the Office and performs the functions, responsibilities, and duties described in §88.101 of this chapter (relating to Responsibilities of the State Ombudsman and the Office).(38) Volunteer ombudsman--A person who:(A) is certified as a volunteer ombudsman in accordance with §88.102 of this chapter;(B) performs functions of the Ombudsman Program; and(C) is not an employee or independent contractor of:(i) HHSC;(ii) a host agency; or(iii) a governmental entity or nonprofit organization that contracts with a host agency, as described in paragraph (16)(B) of this section.(39) Willfully interfere--To act or not act to intentionally prevent, interfere with, or impede or to attempt to intentionally prevent, interfere with, or impede. Source Note: The provisions of this §88.2 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM A PURPOSE AND DEFINITIONS §88.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218303 03/12/2026 (a) The Office is headed by the State Ombudsman.(b) The State Ombudsman, directly or through a designee:(1) may designate a local ombudsman entity to perform the functions of the Ombudsman Program in an ombudsman service area;(2) certifies ombudsmen as described in §88.102 of this subchapter (relating to Certification of an Ombudsman), and refuses, suspends, and terminates certification, as described in §88.103 of this subchapter (relating to Refusal, Suspension, and Termination of Certification of an Ombudsman);(3) designates local ombudsman entities, and refuses, suspends, or terminates designation in accordance with §88.104 of this subchapter (relating to Designation of a Local Ombudsman Entity);(4) approves the allocation of federal and state funds provided to a host agency for the local ombudsman entity and determines that program budgets and expenditures of the Office, host agency, and local ombudsman entities are consistent with laws, rules, policies, and procedures governing the Ombudsman Program;(5) is responsible for the programmatic oversight of a representative of the Office, which includes:(A) screening a representative of the Office who is employed by HHSC for individual conflicts of interest as described in subsection (d) of this section;(B) screening a host agency for organizational conflicts of interest, as described in §88.403 of this chapter (relating to Conflicts of Interest Regarding a Host Agency) at least once a year;(C) directing a representative of the Office to investigate a complaint or take other action related to a complaint; and(D) providing advice and consultation to a representative of the Office in the performance of functions of the Ombudsman Program;(6) identifies, investigates, and resolves complaints, made by or on behalf of residents, that relate to action, inaction, or decisions that may adversely affect the health, safety, welfare, and rights of residents;(7) represents the interests of residents before governmental agencies and pursues administrative, legal, and other remedies to protect residents;(8) provides administrative and technical assistance to representatives of the Office, local ombudsman entities, and host agencies regarding performance of the functions of the Ombudsman Program;(9) consults with host agencies and representatives of the Office in the establishment of Ombudsman Program policies and procedures;(10) monitors the performance of local ombudsman entities, including providing information to a host agency regarding the performance of a staff ombudsman;(11) investigates grievances made against a representative of the Office regarding the performance of the functions of the Ombudsman Program, as described in Subchapter G of this chapter (relating to Grievances);(12) coordinates with a local ombudsman entity and, if appropriate, a host agency about concerns the State Ombudsman has regarding a representative of the Office, as described in §88.103(e) of this subchapter (relating to Refusal, Suspension, and Termination of Certification of an Ombudsman); and(13) publishes an annual report in accordance with 45 CFR §1324.13(g).(c) For purposes of determining if a representative of the Office has an individual conflict of interest in accordance with this section, the state of Texas is the ombudsman service area.(d) The State Ombudsman:(1) requires an applicant for a position within the Office to complete HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" to identify an individual conflict of interest of the applicant;(2) requires a representative of the Office employed by HHSC to complete HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" at least once a year and if the representative of the Office identifies an individual conflict of interest; and(3) reviews a form required by paragraphs (1) and (2) of this subsection to determine if an identified conflict of interest can be removed or remedied.(e) The Office makes decisions independent of HHSC, including decisions about:(1) the disclosure of confidential information maintained by the Ombudsman Program;(2) recommendations to changes in federal, state, and local laws, rules, regulations, and other governmental policies and actions that relate to the health, safety, welfare, and rights of residents; and(3) the provision of information to public and private agencies, legislators, the media, and other persons regarding problems and concerns about residents and recommendations related to the problems and concerns.(f) In accordance with the Older Americans Act, §712(a)(3), 45 CFR §1324.11(e)(5), and §1324.13(a)(7) - (9), the Office is responsible for:(1) analyzing, commenting on, and monitoring the development and implementation of federal, state, and local laws, regulations, and other governmental policies and actions that pertain to LTC facilities and services and to the health, safety, welfare, and rights of residents;(2) recommending any changes in such laws, rules, regulations, policies, and actions as the Office determines to be appropriate;(3) providing information to public and private agencies, legislators, the media, and other persons regarding problems and concerns about residents and providing recommendations related to the problems and concerns;(4) overseeing activities described in paragraphs (1) - (3) of this subsection, including coordination of such activities carried out by representatives of the Office, as described in §88.302(a)(2)(A) of this chapter (relating to Requirement to Ensure a Representative of the Office Performs Functions of the Ombudsman Program);(5) coordinating with and promoting the development of citizen organizations that have a purpose consistent with the interests of residents;(6) promoting and providing technical support for the development of resident and family councils; and(7) providing ongoing support as requested by resident and family councils to protect the well-being and rights of residents. Source Note: The provisions of this §88.101 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.101 Responsibilities of the State Ombudsman and the Office https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218304 03/12/2026 (a) The State Ombudsman initially certifies a person described in §88.2(36)(C)(i) or (ii) of this chapter (relating to Definitions) as a staff ombudsman, other than a managing local ombudsman, if:(1) the person has one of the following:(A) a bachelor's or advanced degree from an accredited college or university; or(B) a high school diploma or a certificate recognized by the state in which it was issued as the equivalent of a high school diploma and at least four years of one, or a combination, of the following:(i) paid experience in a social, behavioral, health, or human service field; or(ii) experience as a certified ombudsman;(2) the person has not been convicted of an offense listed under Texas Health and Safety Code §250.006 during the time periods set forth in Texas Health and Safety Code §250.006, according to a criminal history record of the person obtained by the Office from the Texas Department of Public Safety;(3) the person:(A) does not have an individual conflict of interest according to HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" completed by the person; or(B) has an individual conflict of interest that has been remedied, as described in §88.303 of this chapter (relating to Individual Conflicts of Interest Regarding a Local Ombudsman Entity);(4) the person successfully completes the certification training provided by the local ombudsman entity in accordance with the Ombudsman Policies and Procedures Manual; and(5) the local ombudsman entity recommends to the Office, using HHSC form "Certified Ombudsman Application," that the person be approved as a certified ombudsman in accordance with §88.301(a) of this chapter (relating to Requirements to Recommend Certification as an Ombudsman).(b) The State Ombudsman initially certifies a person as a staff ombudsman to serve as the managing local ombudsman if:(1) the person meets the criteria in subsection (a)(1) - (3) of this section;(2) the person successfully completes certification training provided by the Office; and(3) the person demonstrates competency to serve as a managing local ombudsman.(c) The State Ombudsman initially certifies a person as a volunteer ombudsman if:(1) the person meets the criteria in subsection (a)(2) - (4) of this section;(2) the local ombudsman entity recommends to the Office, using HHSC form "Certified Ombudsman Application," that the person be approved as a certified ombudsman in accordance with §88.301(b) of this chapter; and(3) the person successfully completes an internship in accordance with the Ombudsman Policies and Procedures Manual.(d) The State Ombudsman initially certifies a person to be a staff ombudsman or volunteer ombudsman by signing HHSC form "Certified Ombudsman Application."(e) The State Ombudsman certifies a person to be a staff ombudsman or volunteer ombudsman for a period of two years. After initial certification, the Office renews the certification of a staff ombudsman or volunteer ombudsman if:(1) for a staff ombudsman, the staff ombudsman:(A) meets the requirements in subsection (a)(1) - (3) of this section;(B) completes continuing education provided by the Office; and(C) demonstrates compliance with the Ombudsman Certification Training Manual and the Ombudsman Policies and Procedures Manual; and(2) for a volunteer ombudsman, the volunteer ombudsman:(A) meets the requirements in subsection (a)(2) and (3) of this section;(B) completes continuing education provided by the local ombudsman entity in accordance with the Ombudsman Policies and Procedures Manual; and(C) demonstrates compliance with the Ombudsman Certification Training Manual and the Ombudsman Policies and Procedures Manual.(f) The State Ombudsman certifies a person described in §88.2(36)(C)(iii) of this chapter as a staff ombudsman if the person:(1) has not been convicted of an offense listed under Texas Health and Safety Code §250.006 during the time periods set forth in Texas Health and Safety Code §250.006, according to a criminal history record of the person obtained by the Office from the Texas Department of Public Safety;(2) meets one of the following;(A) does not have an individual conflict of interest according to HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" completed by the person; or(B) has an individual conflict of interest that has been remedied by the State Ombudsman; and(3) successfully completes the certification training provided by the Office. Source Note: The provisions of this §88.102 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.102 Certification of an Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190358 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190358 03/12/2026 (a) The State Ombudsman refuses to initially certify:(1) a staff ombudsman, other than a managing local ombudsman, if the requirements in §88.102(a) of this subchapter (relating to Certification of an Ombudsman) are not met;(2) a managing local ombudsman if the requirements in §88.102(b) of this subchapter are not met; and(3) a volunteer ombudsman if the requirements in §88.102(c) of this subchapter are not met.(b) The State Ombudsman refuses to renew certification of:(1) a staff ombudsman if the requirements in §88.102(e)(1) of this subchapter are not met; and(2) a volunteer ombudsman if the requirements in §88.102(e)(2) of this subchapter are not met.(c) The State Ombudsman may suspend certification of a certified ombudsman for good cause, as determined by the State Ombudsman, including if:(1) the certified ombudsman is not adequately performing the functions of the Ombudsman Program;(2) the certified ombudsman fails to complete continuing education in accordance with the Ombudsman Policies and Procedures Manual;(3) an individual conflict of interest regarding the certified ombudsman is identified; or(4) the State Ombudsman is in the process of deciding whether to terminate the certified ombudsman's certification.(d) The State Ombudsman may terminate certification of a certified ombudsman for good cause, as determined by the State Ombudsman, including if:(1) the certified ombudsman is not adequately performing the functions of the Ombudsman Program;(2) the certified ombudsman fails to complete continuing education in accordance with the Ombudsman Policies and Procedures Manual;(3) the certified ombudsman does not disclose an individual conflict of interest regarding the certified ombudsman to the local ombudsman entity or host agency;(4) an individual conflict of interest regarding the certified ombudsman is not removed or remedied, as described in §88.303 of this chapter (relating to Individual Conflicts of Interest Regarding a Local Ombudsman Entity) and §88.403 of this chapter (relating to Conflicts of Interest Regarding a Host Agency);(5) the certified ombudsman has been convicted of an offense listed under Texas Health and Safety Code §250.006 during the time periods set forth in Texas Health and Safety Code §250.006;(6) the certified ombudsman acts in a manner that threatens the health, safety, welfare, or rights of residents or undermines the integrity of the Ombudsman Program; or(7) the certified ombudsman is no longer an employee or volunteer of the local ombudsman entity or host agency.(e) If the State Ombudsman has a concern about a representative of the Office, the State Ombudsman informs the local ombudsman entity and, if appropriate, the host agency about the concern and may:(1) work with the local ombudsman entity and the host agency to address the concern; and(2) develop a corrective action plan and request comments on the plan from the local ombudsman entity and the host agency.(f) The State Ombudsman immediately notifies the managing local ombudsman and, if appropriate, the host agency of a decision to refuse, suspend, or terminate certification of a certified ombudsman. Source Note: The provisions of this §88.103 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.103 Refusal, Suspension, and Termination of Certification of an Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218305 03/12/2026 (a) The State Ombudsman may designate a local ombudsman entity to perform the functions of the Ombudsman Program in an ombudsman service area.(b) The State Ombudsman does not designate a local ombudsman entity if the host agency or a governmental entity or nonprofit organization contracting with the host agency, as described in §88.2(20)(B) of this chapter (relating to Definitions):(1) has an organizational conflict of interest described in §88.2(30)(A) - (C) of this chapter; or(2) has an organizational conflict of interest described in §88.2(30)(D) - (L) of this chapter that has not been removed or remedied as approved by the State Ombudsman in accordance with §88.403(d) of this chapter (relating to Conflicts of Interest Regarding a Host Agency).(c) The State Ombudsman may remove the designation of a local ombudsman entity if:(1) the host agency or local ombudsman entity has policies, procedures, or practices that the State Ombudsman determines to be in conflict with the laws, rules, policies, or procedures governing the Ombudsman Program; or(2) the host agency or local ombudsman entity fails to comply with the requirements of this chapter including:(A) not removing or remedying an organizational or individual conflict of interest as described in §88.303 of this chapter (relating to Individual Conflicts of Interest Regarding a Local Ombudsman Entity) and §88.403 of this chapter;(B) not submitting:(i) a written plan of correction required by:(I) §88.106(d) of this subchapter (relating to Onsite Monitoring of a Local Ombudsman Entity and a Host Agency);(II) §88.107(d) of this subchapter (relating to Desk Review Monitoring of a Local Ombudsman Entity); and(III) 88.409(b) of this chapter (relating to Noncompliance by a Host Agency); or(ii) a modified written plan of correction required by:(I) §88.106(e) of this subchapter;(II) §88.107(e) of this subchapter; and(III) §88.409(c) of this chapter; or(C) not completing actions in accordance with an approved plan of correction or an approved modified plan of correction as required by:(i) §88.106(d) of this subchapter;(ii) §88.107(d) of this subchapter; and(iii) §88.409(b) of this chapter.(d) If the State Ombudsman removes the designation of a local ombudsman entity, the Office notifies the local ombudsman entity and host agency, in writing, of the decision to remove the designation and includes the reasons for the decision in the notification.(e) A host agency may request reconsideration of the State Ombudsman's decision to remove the designation of the local ombudsman entity. To request a reconsideration of the decision, the host agency must, within 10 days after receiving the notification of removal of the designation, submit a written request for reconsideration and additional information supporting the request to the State Ombudsman.(f) If the removal of designation of a local ombudsman entity results in termination of the contract between HHSC and the host agency, the host agency may appeal the termination in accordance with §213.7 of this title (relating to Appeal Procedures for Area Agency on Aging Contractors). Source Note: The provisions of this §88.104 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.104 Designation of a Local Ombudsman Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218306 03/12/2026 (a) The State Ombudsman:(1) determines the use of the federal and state funds appropriated for the operation of the Office;(2) approves the allocation of federal and state funds to a host agency for the operation of the Ombudsman Program in accordance with subsection (b) of this section; and(3) determines that Ombudsman Program budgets and expenditures are for an appropriate amount and relate to functions of the Ombudsman Program.(b) The State Ombudsman distributes funds through the HHSC Office of the Area Agencies on Aging to a host agency for the operation of the Ombudsman Program in accordance with the Older Americans Act, §712(a)(2). Annually, a host agency is allocated:(1) a base amount of $3,000 from federal funds appropriated or otherwise available for the Ombudsman Program;(2) additional federal funds:(A) 75 percent of which is based on the licensed capacity of nursing facilities in the ombudsman service area; and(B) 25 percent of which is based on the number of certified ombudsmen in the ombudsman service area who actively performed functions of the Ombudsman Program during the previous federal fiscal year; and(3) state general revenue funds for the performance of Ombudsman Program functions based on the following factors:(A) the number of assisted living facilities and nursing facilities in the ombudsman service area on or about July 1 of each year;(B) the number of assisted living facilities and nursing facilities in the ombudsman service area located in a rural area, as determined by the State Ombudsman, on or about July 1 of each year; and(C) the type and licensed capacity of assisted living facilities in the ombudsman service area on or about July 1 of each year. Source Note: The provisions of this §88.105 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.105 Fiscal Management of a Local Ombudsman Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218307 03/12/2026 (a) The Office conducts an onsite visit of a local ombudsman entity and a host agency to monitor:(1) the performance of functions of the Ombudsman Program by a representative of the Office;(2) the compliance by a local ombudsman entity with Subchapter D of this chapter (relating to Requirements of a Local Ombudsman Entity);(3) the compliance by a host agency with Subchapter E of this chapter (relating to Requirements of a Host Agency); and(4) the compliance by a local ombudsman entity and a host agency with Subchapter G of this chapter (relating to Grievances).(b) The Office conducts at least one onsite visit every three years. An onsite visit includes:(1) observing and evaluating a visit of a managing local ombudsman to an LTC facility; and(2) reviewing information regarding a local ombudsman entity's compliance with Subchapter D of this chapter, including documentation regarding:(A) the training of representatives of the Office;(B) identification of individual conflicts of interest; and(C) expenditures for the Ombudsman Program, such as timesheets and evidence supporting mileage reimbursement for representatives of the Office.(c) The Office:(1) selects a date for an onsite visit in consultation with the managing local ombudsman;(2) notifies the host agency of a scheduled onsite visit at least 30 days before the visit; and(3) within 45 days after the Office completes an onsite visit, provides to the local ombudsman entity and the host agency a written report that may contain findings and recommendations from the visit.(d) The host agency must, within 45 days after receipt of the written report described in subsection (c)(3) of this section that contains one or more findings, submit a written plan of correction to the Office that describes:(1) the action that will be taken to correct each finding; and(2) the date by which each action will be completed.(e) Within 45 days after the date the Office receives the plan of correction required by subsection (d) of this section, the Office notifies the local ombudsman entity and host agency of whether the plan is approved or requires modification. If the Office approves the plan, the local ombudsman entity must complete the actions contained in the plan of correction by the dates in the plan. If the Office determines that the plan requires modification, the host agency must submit a modified written plan of correction within a time period determined by the Office for approval by the Office.(f) To determine if the local ombudsman entity or host agency has completed the actions in accordance with an approved plan of correction or approved modified plan of correction, the Office takes one or more of the following actions:(1) reviews information in the ombudsman database;(2) requests that the local ombudsman entity or host agency submit evidence of correction to the Office; and(3) visits the local ombudsman entity.(g) If the Office determines that the local ombudsman entity or host agency did not complete an action in accordance with an approved plan of correction or an approved modified plan of correction:(1) the Office may allow the local ombudsman entity or host agency additional time to complete the action;(2) HHSC may impose a Level Two sanction in accordance with §213.5 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Sanctions); or(3) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this subchapter (relating to Designation of a Local Ombudsman Entity).(h) If the Office allows a local ombudsman entity additional time to complete an action as described in subsection (g)(1) of this section and the Office determines that the local ombudsman entity or host agency did not complete the action within the time allowed:(1) HHSC may impose a Level Two sanction in accordance with §213.5 of this title; or(2) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this subchapter.(i) Upon request by a local ombudsman entity or host agency, the Office provides technical assistance to a local ombudsman entity or host agency regarding developing a plan of correction. Source Note: The provisions of this §88.106 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.106 Onsite Monitoring of a Local Ombudsman Entity and a Host Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218308 03/12/2026 (a) The Office conducts a desk review of a local ombudsman entity to determine if the local ombudsman entity:(1) is in compliance with §88.305(a)(3) and (c)(2) of this chapter (relating to Complaints) and §88.307(a) of this chapter (relating to Requirements Regarding LTC Facility Visits and Submitting Information to the Office);(2) is making progress toward meeting:(A) performance measures required by §88.405(a)(3) - (6) of this chapter (relating to Performance Measures); and(B) performance measure projections required by §88.405(b) of this chapter; and(3) has conducted at least one visit to each LTC facility in the ombudsman service area each quarter of a federal fiscal year as required by the Ombudsman Policies and Procedures Manual.(b) The Office:(1) conducts at least one desk review of a local ombudsman entity every three months; and(2) may conduct a desk review of a local ombudsman entity at any time.(c) If the Office identifies a finding from a desk review, the Office provides to the local ombudsman entity and the host agency a written report that contains the finding and may include recommendations.(d) If a local ombudsman entity or host agency receives a written report described in subsection (c) of this section, the host agency, within 14 days after receipt of the report, must submit a written plan of correction to the Office that describes:(1) the action that will be taken to correct each finding in the report; and(2) the date by which each action will be completed.(e) Within 14 days after the date the Office receives the plan of correction required by subsection (d) of this section, the Office notifies the local ombudsman entity and host agency of whether the plan is approved or requires modification. If the Office approves the plan, the local ombudsman entity must complete the actions contained in the plan of correction by the dates in the plan. If the Office determines that the plan requires modification, the host agency must submit a modified written plan of correction within a time period determined by the Office for approval by the Office.(f) To determine if the local ombudsman entity has completed the actions in accordance with an approved plan of correction or approved modified plan of correction, the Office takes one or more of the following actions:(1) reviews information in the ombudsman database;(2) requests that the local ombudsman entity submit evidence of correction to the Office; and(3) visits the local ombudsman entity.(g) If the Office determines that the local ombudsman entity did not complete an action in accordance with an approved plan of correction or a modified plan of correction:(1) the Office may allow the local ombudsman entity additional time to complete the action;(2) HHSC may impose a Level Two sanction in accordance with §213.5 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Sanctions); or(3) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this subchapter (relating to Designation of a Local Ombudsman Entity).(h) If the Office allows a local ombudsman entity additional time to complete an action as described in subsection (g)(1) of this section and the Office determines that the local ombudsman entity did not complete the action within the time allowed:(1) HHSC may impose a Level Two sanction in accordance with §213.5 of this title; or(2) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this subchapter.(i) Upon request by a local ombudsman entity or host agency, the Office provides technical assistance to a local ombudsman entity or host agency regarding developing a plan of correction. Source Note: The provisions of this §88.107 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM B ESTABLISHMENT OF THE OFFICE §88.107 Desk Review Monitoring of a Local Ombudsman Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218309 03/12/2026 (a) The State Ombudsman and a representative of the Office have:(1) immediate, private, and unimpeded access to enter an LTC facility, in accordance with the Older Americans Act, §712(b)(1)(A) and 45 CFR §1324.11(e)(2)(i):(A) at any time during a facility's regular business hours or regular visiting hours; and(B) at a time other than regular business hours or visiting hours, if the State Ombudsman or a certified ombudsman determines access may be required by the circumstances to be investigated;(2) immediate, private, and unimpeded access to a resident, in accordance with the Older Americans Act, §712(b)(1)(A) and 45 CFR §1324.11(e)(2)(ii); and(3) access to the name and contact information of a resident representative, if any, when the State Ombudsman or representative of the Office determines the information is needed to perform functions of the Ombudsman Program, in accordance with 45 CFR §1324.11(e)(2)(iii).(b) Disclosure of information by the State Ombudsman or a representative of the Office related to any complaint, including a description of the circumstances to be investigated, is subject to requirements in the Ombudsman Policies and Procedures Manual related to disclosure of confidential information.(c) The State Ombudsman and a certified ombudsman have immediate access:(1) in accordance with the Older Americans Act, §712(b)(1)(B) and 45 CFR §1324.11(e)(2), to all medical, social, and other records relating to a resident regardless of format, including an incident report involving the resident, if:(A) in accordance with 45 CFR §1324.11(e)(2)(iv)(A) or (B), the State Ombudsman or certified ombudsman has the informed consent of the resident or legally authorized representative;(B) in accordance with the Older Americans Act, §712(b)(1)(B)(i)(II), the resident is unable to communicate informed consent to access and has no legally authorized representative; or(C) in accordance with 45 CFR §1324.11(e)(2)(iv)(C), such access is necessary to investigate a complaint and the following occurs:(i) the resident's legally authorized representative refuses to give consent to access the medical, social, and other records;(ii) the State Ombudsman or certified ombudsman has reasonable cause to believe that the legally authorized representative is not acting in the best interests of the resident; and(iii) if it is the certified ombudsman seeking access to the medical, social, and other records the certified ombudsman obtains the approval of the State Ombudsman to access the medical, social, and other records, without the legally authorized representative's consent; and(2) in accordance with 45 CFR §1324.11(e)(2)(v), to the administrative records, policies, and documents of an LTC facility to which the residents or general public have access.(d) In accordance with 45 CFR §1324.11(e)(2), access by the State Ombudsman and a certified ombudsman to a record, as described in subsection (c) of this section, includes obtaining a copy of the record upon request.(e) In accordance with the Ombudsman Policies and Procedures Manual, a certified ombudsman must document one of the following in the ombudsman database:(1) whether a resident who is able to communicate informed consent communicated informed consent for the ombudsman to access a record described in subsection (c)(1) of this section;(2) whether the legally authorized representative communicated informed consent to access a record described in subsection (c)(1) of this section;(3) whether the certified ombudsman has authority to access a record described in subsection (c)(1) of this section without consent because the resident is unable to communicate informed consent and does not have a legally authorized representative; or(4) whether the State Ombudsman has given approval to access a record described in subsection (c)(1) of this section accordance with subsection (c)(1)(C) of this section.(f) The rules adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and 45 CFR Part 164, subparts A and E, do not preclude an LTC facility from releasing protected health information or other identifying information regarding a resident to the State Ombudsman or a certified ombudsman if the requirements of subsections (a)(3) and (c) of this section are otherwise met. The State Ombudsman and a certified ombudsman are each a "health oversight agency" as that phrase is defined in 45 CFR §164.501. Source Note: The provisions of this §88.201 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM C ACCESS BY THE STATE OMBUDSMAN AND REPRESENTATIVES OF THE OFFICE §88.201 Access to Facilities, Residents, and Resident Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218310 03/12/2026 A certified ombudsman must, at the request of an LTC facility, provide a completed HHSC form "Acknowledgement of Ombudsman Access to Confidential Record" to the facility at the time the certified ombudsman is requesting access to a confidential record concerning a resident from the facility as described in §88.201(c) of this subchapter (relating to Access to Facilities, Residents, and Resident Records). Source Note: The provisions of this §88.202 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM C ACCESS BY THE STATE OMBUDSMAN AND REPRESENTATIVES OF THE OFFICE §88.202 Notification to LTC Facility of Authorization to Access Resident Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190363 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190363 03/12/2026 (a) For a person to be certified as a staff ombudsman, other than a managing local ombudsman, in accordance with §88.102 of this chapter (relating to Certification of an Ombudsman), the local ombudsman entity must recommend to the Office that the person be certified, using HHSC form "Certified Ombudsman Application." The local ombudsman entity may make a recommendation only if:(1) the person has not been convicted of an offense listed under Texas Health and Safety Code §250.006 during the time periods set forth in Texas Health and Safety Code §250.006;(2) the person does not have an individual conflict of interest or has an individual conflict of interest that has been remedied, as described in §88.303 of this subchapter (relating to Individual Conflicts of Interest Regarding a Local Ombudsman Entity); and(3) the person successfully completes the certification training provided by the local ombudsman entity in accordance with the Ombudsman Policies and Procedures Manual.(b) For a person to be certified as a volunteer ombudsman in accordance with §88.102 of this chapter, the local ombudsman entity must recommend to the Office that the person be certified, using HHSC form "Certified Ombudsman Application." The local ombudsman entity may make a recommendation only if:(1) the person meets the criteria in subsection (a)(1) - (3) of this section; and(2) the person successfully completes an internship in accordance with the Ombudsman Policies and Procedures Manual. Source Note: The provisions of this §88.301 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.301 Requirements to Recommend Certification as an Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190364 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190364 03/12/2026 (a) A local ombudsman entity must ensure that:(1) a certified ombudsman performs the functions described in the Older Americans Act, §712(a)(3) and (5) and 45 CFR §1324.19(a), including:(A) identifying, investigating, and resolving complaints, made by or on behalf of residents, that relate to action, inaction, or decisions that may adversely affect the health, safety, welfare, or rights of residents;(B) providing services to protect the health safety, welfare, and rights of residents;(C) providing residents with information about the Ombudsman Program;(D) making regular visits to residents in LTC facilities, as well as promptly responding to requests received by telephone, mail, and electronic means;(E) representing the interests of residents before governmental agencies, and pursuing administrative, legal, and other remedies to protect residents;(F) analyzing, commenting on, making recommendations, and monitoring the development and implementation of laws, rules, regulations, and other policies and actions that pertain to the health, safety, welfare, and rights of residents, with respect to the adequacy of LTC facilities and services; and(G) coordinating with and promoting the development of citizen organizations, including resident and family councils;(2) a representative of the Office:(A) consults with and obtains approval from the Office before:(i) commenting on or recommending changes to a public official or governmental entity regarding the development and implementation of laws, rules, regulations, and other policies and actions that pertain to the health, safety, welfare, and rights of residents, with respect to the adequacy of LTC facilities and services; or(ii) providing information to a legislator or the media regarding a problem or concern about a resident or a recommendation related to the problem or concern;(B) when providing comments or recommended changes to a public official or governmental entity or information to a legislator or the media as described in subparagraph (A)(i) or (ii) of this paragraph, must include a statement that the comments, recommended changes, or information is made as a representative of the Office and does not represent the position or views of the host agency with whom the representative is affiliated;(C) promptly responds to a request from the Office regarding a request for information from a legislator or the media; and(D) complies with the following:(i) the Ombudsman Policies and Procedures Manual available on the HHSC website;(ii) the Ombudsman Program Protocols available on the HHSC website; and(iii) the Ombudsman Certification Training Manual available on the HHSC website;(3) a staff ombudsman:(A) completes continuing education provided by the Office as required by §88.102(e)(1)(B) of this chapter (relating to Certification of an Ombudsman); and(B) is evaluated annually to determine if the staff ombudsman demonstrates compliance with the Ombudsman Certification Training Manual and the Ombudsman Policies and Procedures Manual; and(4) a volunteer ombudsman:(A) completes continuing education provided by the local ombudsman entity in accordance with the Ombudsman Policies and Procedures Manual; and(B) is evaluated annually to determine if the volunteer ombudsman demonstrates compliance with the Ombudsman Certification Training Manual and the Ombudsman Policies and Procedures Manual.(b) In accordance with 45 CFR §1324.11(e)(5)(i), Texas Government Code §556.006 and Texas Local Government Code §391.0116, which prohibit lobbying and other advocacy activities by employees of the state, a council of governments, or regional planning commission, do not apply to a certified ombudsman performing the functions described in subsection (a)(1)(F) of this section.(c) If a local ombudsman entity determines that a certified ombudsman is not demonstrating compliance with the Ombudsman Certification Training Manual or the Ombudsman Policies and Procedures Manual or identifies a concern with a certified ombudsman's performance, the local ombudsman entity:(1) must address the performance concern or resolve the failure to demonstrate compliance; and(2) may request technical assistance from the Office in complying with paragraph (1) of this subsection.(d) A local ombudsman entity may recommend to the State Ombudsman that a certified ombudsman's certification be suspended or terminated. Source Note: The provisions of this §88.302 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.302 Requirement to Ensure a Representative of the Office Performs Functions of the Ombudsman Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190365 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190365 03/12/2026 (a) A local ombudsman entity must ensure that HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" is completed by:(1) an applicant for a volunteer ombudsman position before performing functions of the Ombudsman Program; and(2) a certified ombudsman, other than a managing local ombudsman:(A) at least once a year; and(B) if the local ombudsman entity identifies an individual conflict of interest involving the certified ombudsman.(b) A local ombudsman entity must require a representative of the Office to immediately notify the local ombudsman entity of an individual conflict of interest regarding a representative of the Office.(c) If a local ombudsman entity identifies an individual conflict of interest:(1) regarding a representative of the Office other than the managing local ombudsman, within 30 days after identifying the conflict, the local ombudsman entity must:(A) complete HHSC form "Conflict of Interest Identification, Removal, and Remedy," including a recommended action to remove or remedy the conflict of interest, if possible; and(B) submit the completed form to the Office; and(2) regarding the managing local ombudsman, the local ombudsman entity must immediately notify the host agency so the host agency can comply with §88.403(c) of this chapter (relating to Conflicts of Interest Regarding a Host Agency).(d) If the Office receives a completed form as described in subsection (c)(1) of this section, the State Ombudsman reviews the form and:(1) approves, modifies, or rejects the recommended action to remove or remedy the conflict of interest; or(2) if it is not possible to remove or remedy the conflict of interest, refuses or terminates certification of the person with the individual conflict of interest. Source Note: The provisions of this §88.303 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.303 Individual Conflicts of Interest Regarding a Local Ombudsman Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190366 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190366 03/12/2026 (a) Information identifying a resident or complainant is confidential. Such information includes:(1) the name of the resident or complainant;(2) information about the resident's medical condition;(3) the resident's medical history;(4) the resident's social history, which includes occupation, residences, and information about a resident's family;(5) the resident's source of payment;(6) information about the resident's personal life; and(7) information from a communication between a resident and a representative of the Office.(b) A local ombudsman entity must ensure that a disclosure of confidential information that is not written information complies with the Older Americans Act, §712(d), 45 CFR §1324.11(e)(3), and the Ombudsman Policies and Procedures Manual.(c) A response to a request to disclose written confidential information must be in accordance with this subsection.(1) If a representative of the Office receives a request to disclose written confidential information as described in subsection (a) of this section, including a subpoena, the representative must immediately:(A) notify the State Ombudsman of the request; and(B) provide the State Ombudsman with any communication from the requestor.(2) If the State Ombudsman receives a request to disclose written confidential information, the State Ombudsman:(A) sends written acknowledgement of receipt of the request to the representative of the Office;(B) reviews the request and responds to the requestor within a time frame required by applicable state or federal law; and(C) sends a copy of the response to the local ombudsman entity.(d) In accordance with 45 CFR §1324.11(e)(3)(iv), a representative of the Office must not, except as provided in §1324.19(b)(5) - (8), report allegations of abuse, neglect, or exploitation under state law, including Texas Human Resources Code, Chapter 48, without appropriate consent or court order. This prohibition applies:(1) regardless of whether a representative of the Office is required to report allegations of abuse, neglect, or exploitation under professional licensure standards; and(2) to a representative of the Office only in the performance of functions of the Ombudsman Program.(e) A local ombudsman entity must, at the request of the Office, immediately provide Ombudsman Program records to the Office. Source Note: The provisions of this §88.304 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.304 Disclosure of Confidential Information; Exclusion from Reporting Requirements Regarding Abuse, Neglect, or Exploitation; and Provision of Records to the Office https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218311 03/12/2026 (a) A local ombudsman entity must:(1) ensure that a person is allowed to make a complaint as follows:(A) in writing, including by email;(B) in person; and(C) by telephone;(2) initiate a complaint if the local ombudsman entity becomes aware of circumstances that may adversely affect the health, safety, welfare, or rights of a resident;(3) respond to the complainant within two business days after receipt of the complaint, except as provided in subsection (c)(2) of this section regarding a complaint that is an allegation of abuse, neglect, or exploitation of a resident; and(4) ensure that a certified ombudsman initiates an investigation of a complaint as soon as practicable after receipt of the complaint.(b) A local ombudsman entity must ensure that a certified ombudsman investigates complaints in accordance with this subsection.(1) If a certified ombudsman receives a complaint, the certified ombudsman must:(A) document the nature of the complaint;(B) determine:(i) whether the complaint is appropriate for the certified ombudsman to investigate;(ii) if any attempts have been made to resolve the complaint; and(iii) the outcome sought by the complainant;(C) if the complainant is not the resident, inform the complainant that the complaint will be investigated only if:(i) the resident or legally authorized representative communicates informed consent to the investigation;(ii) in accordance with 45 CFR §1324.19(b)(2)(iii), the resident is unable to communicate informed consent and has no legally authorized representative; or(iii) in accordance with 45 CFR §1324.19(b)(7), the resident is unable to communicate informed consent to investigate the complaint, has a legally authorized representative, and:(I) the complaint relates to an action, inaction, or decision of the legally authorized representative that may adversely affect the health, safety, welfare, or rights of the resident;(II) the certified ombudsman does not have evidence that the resident would object to the complaint being investigated;(III) the certified ombudsman has reasonable cause to believe that it is in the best interest of the resident to investigate the complaint; and(IV) the State Ombudsman approves the request of the certified ombudsman to investigate the complaint; and(D) in accordance with the Ombudsman Policies and Procedures Manual:(i) seek the informed consent of the resident or legally authorized representative to investigate the complaint;(ii) determine if authority exists to investigate the complaint because, in accordance with 45 CFR §1324.19(b)(2)(iii), the resident is unable to communicate informed consent and has no legally authorized representative;(iii) request approval from the State Ombudsman for the certified ombudsman to investigate the complaint by making a referral to the appropriate agency for investigation in accordance with 45 CFR §1324.19(b)(7), if:(I) the resident has a legally authorized representative;(II) based on the reasonable belief of the certified ombudsman, the complaint relates to an action, inaction or decision by the legally authorized representative that may adversely affect the health, safety, welfare, or rights of the resident;(III) the resident is unable to communicate informed consent to investigate the complaint;(IV) the certified ombudsman does not have evidence that the resident would object to the complaint being investigated; and(V) the certified ombudsman has reasonable cause to believe that it is in the best interest of the resident to investigate the complaint; and(iv) document one of the following in the ombudsman database:(I) whether a resident who is able to communicate informed consent communicated informed consent to investigate the complaint;(II) whether the legally authorized representative communicated informed consent to investigate the complaint;(III) whether the certified ombudsman has authority to investigate the complaint without consent because the resident is unable to communicate informed consent and does not have a legally authorized representative; or(IV) whether the State Ombudsman has given approval to investigate the complaint in accordance with clause (iii) of this subparagraph.(2) If the complainant is the resident and the certified ombudsman has determined the complaint is appropriate for ombudsman investigation and has obtained informed consent to investigate the complaint or has authority to investigate the complaint in accordance with 45 CFR §1324.19(b)(2)(iii), the certified ombudsman must:(A) determine what, if any, federal or state law or rule applies to the complaint;(B) observe the environment of the resident and situations in the LTC facility related to the complaint;(C) interview relevant witnesses;(D) review relevant records, if necessary, including confidential information if consent or other authority is obtained in accordance with the Ombudsman Policies and Procedures Manual;(E) determine if disclosure of confidential information is necessary to effectively investigate the complaint and if such disclosure is necessary:(i) identify the specific confidential information that needs to be disclosed;(ii) seek informed consent from the resident to disclose the confidential information; and(iii) if consent is given, only disclose the specific information for which consent was obtained; or(iv) if consent to disclose the confidential information is not given(I) explain to the resident or LAR that without disclosing the confidential information, the effectiveness of the investigation may be limited; and(II) attempt to investigate the complaint without disclosing the confidential information;(v) document in the ombudsman database whether the resident consented to the disclosure of confidential information.(F) if the complaint relates to a regulatory violation, inform the resident of the option to report the complaint to the appropriate regulatory or law enforcement authority;(G) work with the resident to develop a plan of action for resolution of the complaint;(H) encourage the resident to participate in the process to resolve the complaint; and(I) determine the resident's satisfaction with the outcome of the investigation.(3) If the complainant is not the resident and the certified ombudsman has determined the complaint is appropriate for ombudsman investigation and has obtained consent to investigate the complaint, the certified ombudsman must:(A) communicate with the resident about the complaint and obtain the resident's perspective about the complaint, if the resident is able to communicate;(B) determine what, if any, federal or state law or rule applies to the complaint;(C) inform the resident or legally authorized representative of the residents' rights and other law related to the complaint;(D) observe the environment of the resident and situations in the LTC facility related to the complaint;(E) interview relevant witnesses;(F) review relevant records, if necessary, including confidential records if consent or other authority is obtained in accordance with the Ombudsman Policies and Procedures Manual;(G) determine if disclosure of confidential information is necessary to effectively investigate the complaint and if such disclosure is necessary:(i) identify the specific confidential information that needs to be disclosed;(ii) seek informed consent from the resident or LAR to disclose the confidential information; and(iii) if informed consent is given, only disclosing the specific information for which consent was obtained; or(iv) if consent to disclose the confidential information is not given(I) explain to the resident or LAR that without disclosing the confidential information, the effectiveness of the investigation may be limited; and(II) attempt to investigate the complaint without disclosing the confidential information;(v) document in the ombudsman database whether the resident provide informed consent to the disclosure of confidential information;(H) if the complaint relates to a regulatory violation, inform the resident or the legally authorized representative of the option to report the complaint to the appropriate regulatory or law enforcement authority;(I) work with the resident or legally authorized representative to develop a plan of action for resolution of the complaint;(J) encourage the resident or legally authorized representative to participate in the process to resolve the complaint; and(K) determine the resident's or legally authorized representative's satisfaction with the outcome.(4) If the complainant is not the resident and the certified ombudsman has determined the complaint is appropriate for ombudsman investigation and has authority to investigate the complaint in accordance with 45 CFR §1324.19(b)(2)(iii), the certified ombudsman must:(A) determine what, if any, federal or state law, regulation, or rule applies to the complaint;(B) determine how many residents are potentially affected by the complaint;(C) observe the environment of the resident and situations in the LTC facility related to the complaint;(D) interview relevant witnesses;(E) review relevant records, if necessary, including confidential records if consent or other authority is obtained in accordance with the Ombudsman Policies and Procedures Manual; and(F) determine whether the complaint is satisfactorily resolved.(5) As described in paragraph (1)(D)(iii) of this subsection, if the complainant is not the resident and the certified ombudsman requests approval to investigate the complaint by making a referral to the appropriate agency for investigation in accordance with 45 CFR §1324.19(b)(7), the certified ombudsman must:(A) if the State Ombudsman approves the request:(i) make the referral to the appropriate agency; and(ii) determine whether the complaint is satisfactorily resolved; or(B) if the State Ombudsman does not approve the request, follow the instruction of the State Ombudsman.(6) If the resident or legally authorized representative declines to consent to have the complaint investigated, the certified ombudsman must:(A) not investigate the complaint;(B) inform the complainant that the complaint will not be investigated because the resident or legally authorized representative declined to consent; and(C) advise the complainant of his or her options to pursue resolution.(7) If a certified ombudsman identifies a complaint that affects a substantial number of residents in an LTC facility, the certified ombudsman may investigate and work to resolve the complaint without obtaining consent from each resident to investigate the complaint. In investigating the complaint, a certified ombudsman may review confidential records only if consent or other authority is obtained in accordance with the Ombudsman Policies and Procedures Manual.(8) A certified ombudsman must document the complaint investigation in the ombudsman database in accordance with the Ombudsman Policies and Procedures Manual.(c) If a complaint is an allegation of abuse, neglect, or exploitation of a resident, a certified ombudsman:(1) must not investigate whether abuse, neglect, or exploitation of a resident has occurred;(2) within one business day after receipt of the complaint, inform the complainant of the appropriate investigative authority to report the allegation; and(3) comply with the Ombudsman Policies and Procedures Manual.(d) In accordance with 45 CFR §1324.11(e)(3)(iv), a representative of the Office must not, except as provided in §1324.19(b)(5) - (8), report allegations of abuse, neglect, or exploitation under state law, including Texas Human Resources Code, Chapter 48, without appropriate consent or court order.(e) Confidential information described in §88.304(a) of this subchapter (relating to Disclosure of Confidential Information; Exclusion from Reporting Requirements Regarding Abuse, Neglect, or Exploitation; and Provision of Records to the Office) may only be disclosed in accordance with §88.304 of this subchapter. Source Note: The provisions of this §88.305 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.305 Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190368 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190368 03/12/2026 A local ombudsman entity must comply with:(1) the Ombudsman Policies and Procedures Manual available on the HHSC website;(2) the Ombudsman Program Protocols available on the HHSC website; and(3) the Ombudsman Certification Training Manual available on the HHSC website. Source Note: The provisions of this §88.306 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.306 Compliance with Documents of the Office https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218312 03/12/2026 (a) A local ombudsman entity must ensure each LTC facility in the ombudsman service area is visited by a certified ombudsman in accordance with the Ombudsman Policies and Procedures Manual during each federal fiscal year to:(1) monitor residents' health, safety, welfare, and rights; and(2) receive, investigate, and resolve complaints on behalf of residents.(b) A local ombudsman entity must submit activities and casework, as described in the Ombudsman Policies and Procedures Manual, to the Office by entering information into the ombudsman database within 14 days after completion of the activity or receipt of a complaint. Source Note: The provisions of this §88.307 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.307 Requirements Regarding LTC Facility Visits and Submitting Information to the Office https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190370 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190370 03/12/2026 (a) The local ombudsman entity must obtain approval by the Office of materials to be distributed to persons other than representatives of the Office, before the materials are distributed.(b) If a local ombudsman entity uses a logo on printed materials created by the local ombudsman entity, the local ombudsman entity must use the logo approved by the Office. A host agency may use its logo on printed materials in addition to the logo approved by the Office.(c) A local ombudsman entity must ensure that an outgoing message for the telephone of a staff ombudsman includes:(1) a statement that the staff ombudsman works in the Ombudsman Program; and(2) that a message left by the caller will be confidential.(d) A local ombudsman entity may request technical assistance from the Office regarding website content related to the Ombudsman Program. Source Note: The provisions of this §88.308 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.308 Ombudsman Program Logo and Communications to the Public https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190371 03/12/2026 A local ombudsman entity must not:(1) willfully interfere with the State Ombudsman or a representative of the Office performing any of the functions of the Ombudsman Program;(2) retaliate against the State Ombudsman or a representative of the Office:(A) with respect to a resident, employee of an LTC facility, or other person filing a complaint with, providing information to, or otherwise cooperating with a representative of the Office; or(B) for performance of the functions, responsibilities, or duties described in 45 CFR §1324.13 and §1324.19 and this chapter, including prohibiting a representative of the Office from commenting or recommending changes as described in §88.302(a)(1)(F) of this subchapter (relating to Requirement to Ensure a Representative of the Office Performs Functions of the Ombudsman Program); or(3) have personnel policies or practices that prohibit a representative of the Office from performing the functions of the Ombudsman Program or from adhering to the requirements of the Older Americans Act, §712. Source Note: The provisions of this §88.310 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM D REQUIREMENTS OF A LOCAL OMBUDSMAN ENTITY §88.310 Prohibition of Interference and Retaliation by a Local Ombudsman Entity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190373 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190373 03/12/2026 (a) In accordance with 45 CFR §1324.11(e)(1)(iv), a host agency must coordinate with the Office about the hiring and termination of a staff ombudsman.(b) Before a person is hired to serve as a staff ombudsman, including the hiring or promotion of a person to serve as a managing local ombudsman, the host agency must ensure that the following documentation is submitted to the Office:(1) the applicant's resume or job application;(2) HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" as evidence of screening for an individual conflict of interest and, if a conflict is identified, a proposed removal or remedy plan for the conflict, using HHSC form "Conflict of Interest Identification, Removal, and Remedy"; and(3) one of the following:(A) consent by the applicant for a criminal history check, using HHSC form "Consent for Criminal History Check"; or(B) the criminal history record of the applicant from the Texas Department of Public Safety obtained directly by the host agency or through a private agency.(c) Within two business days after receiving the documentation described in subsection (b) of this section, the State Ombudsman reviews the documentation and notifies the requestor of whether any issues exist that may prevent the State Ombudsman from certifying the applicant as an ombudsman as described in §88.102 of this chapter (relating to Certification of an Ombudsman).(d) A host agency may request technical assistance from the Office for the purpose of hiring and terminating a staff ombudsman.(e) A host agency must ensure that, if an employee who is a representative of the Office is terminated, the Office is notified of the termination, in writing, within one business day after the effective date of termination. Source Note: The provisions of this §88.401 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.401 Coordination with the State Ombudsman in Hiring and Terminating a Staff Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190374 03/12/2026 (a) In accordance with 45 CFR §1324.17(a), a host agency is responsible for the personnel management, but not the programmatic oversight, of a representative of the Office who works for the host agency. Personnel management includes:(1) hiring and terminating a staff ombudsman as described in §88.401 of this subchapter (relating to Coordination with the State Ombudsman in Hiring and Terminating a Staff Ombudsman) and subsection (c)(2) of this section;(2) overseeing compliance with host agency policies by a representative of the Office;(3) collecting timesheets from a staff ombudsman to demonstrate work performance;(4) determining salary and benefits for a staff ombudsman;(5) evaluating job performance of a staff ombudsman;(6) assigning work space and equipment for a staff ombudsman; and(7) performing payroll and accounting activities regarding the local ombudsman entity.(b) A host agency must ensure that a local ombudsman entity has a managing local ombudsman.(c) A host agency must ensure that a managing local ombudsman:(1) is the primary contact for the local ombudsman entity;(2) participates in making the decision to hire and terminate a staff ombudsman;(3) decides whether the local ombudsman entity recommends to the Office that a person be approved as a certified ombudsman in accordance with §88.301 of this chapter (relating to Requirements to Recommend Certification as an Ombudsman); and(4) except as permitted by subsection (d) of this section, serves on a full-time basis in performing duties of the managing local ombudsman.(d) A host agency may request that the State Ombudsman waive the requirement for the managing local ombudsman to serve on a full-time basis.(1) To make a request to waive the requirement, the host agency must:(A) complete HHSC form "Waiver Request for Full-Time Requirement of a Managing Local Ombudsman"; and(B) submit the form to the State Ombudsman before the beginning of the federal fiscal year that the host agency is requesting the requirement be waived.(2) Within two business days after receiving a completed form as described in paragraph (1) of this subsection, the State Ombudsman reviews the request and notifies the host agency of whether the request is approved.(3) The State Ombudsman approves a request only if the host agency demonstrates that:(A) funding is not available for a full-time staff ombudsman position; and(B) if the managing local ombudsman position is combined with another function within the host agency, any conflict of interest is removed or remedied as required by §88.403 of this subchapter (relating to Conflicts of Interest Regarding a Host Agency).(4) Any approval of a request to waive the requirement for the managing local ombudsman to serve on a full-time basis is only for the fiscal year for which the request was submitted.(e) A host agency must ensure that, in its personnel management of representatives of the Office, a local ombudsman entity complies with Subchapter D of this chapter (relating to Requirements of a Local Ombudsman Entity).(f) A host agency may request technical assistance from the Office for the purpose of evaluating the job performance of a staff ombudsman. Source Note: The provisions of this §88.402 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.402 Personnel Management of Representatives of the Office https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218321 03/12/2026 (a) If a host agency, or a governmental entity or nonprofit organization contracting with a host agency, as described in §88.2(20)(B) of this chapter (relating to Definitions), has an organizational conflict of interest, the host agency must, within 30 days after identifying the conflict of interest:(1) complete HHSC form "Conflict of Interest Identification, Removal, and Remedy," including a recommended action to:(A) remove a conflict of interest described in §88.2(30)(A) - (C) of this chapter (relating to Definitions); and(B) remove or remedy a conflict of interest described in §88.2(30)(D) - (L) of this chapter; and(2) submit the completed form to the Office.(b) A host agency must ensure that HHSC form "Individual Conflict of Interest Screening of a Representative of the Office," is completed by a managing local ombudsman:(1) at least once a year; and(2) if the host agency identifies an individual conflict of interest involving the managing local ombudsman.(c) Within five business days after identifying an individual conflict of interest regarding a managing local ombudsman, the host agency must:(1) complete HHSC form "Conflict of Interest Identification, Removal, and Remedy," including a recommended action to remove or remedy the conflict of interest; and(2) submit the completed form to the Office.(d) If the Office receives a completed form described in subsection (a) or (c) of this section, the State Ombudsman reviews the form and approves, modifies, or rejects the recommended action to remove or remedy the conflict of interest.(1) If it is not possible to remove or remedy an organizational conflict of interest of the host agency, the State Ombudsman removes the designation of the local ombudsman entity, as described in §88.104(c)(2)(A) of this chapter (relating to Designation of a Local Ombudsman Entity).(2) If it is not possible to remove or remedy an individual conflict of interest of the managing local ombudsman, the State Ombudsman refuses to initially certify or terminates certification of the managing local ombudsman as described in §88.103(a)(2) and (d)(4) of this chapter (relating to Refusal, Suspension, and Termination of Certification of an Ombudsman). Source Note: The provisions of this §88.403 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.403 Conflicts of Interest Regarding a Host Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218322 03/12/2026 (a) In accordance with the Older Americans Act, §712(d)(2)(A) and 45 CFR §1324.13(e)(1), the State Ombudsman has the sole authority to make determinations concerning the disclosure of confidential information, as described in §88.304(a) of this chapter (relating to Disclosure of Confidential Information, Exclusion from Reporting Requirements Regarding Abuse, Neglect, and Exploitation, and Provision of Records to the Office).(b) A request to disclose written confidential information is responded to in accordance with this subsection.(1) If a person who is not a representative of the Office but works for a host agency or governmental entity or nonprofit organization contracting with a host agency, as described in §88.2(20)(B) of this chapter (relating to Definitions), receives a request to disclose written confidential information, as described in §88.304(a) of this chapter, the host agency must ensure that the State Ombudsman is immediately:(A) notified of the request; and(B) provided any communication from the requestor.(2) If the State Ombudsman receives a request to disclose written confidential information, the State Ombudsman:(A) sends written acknowledgement of receipt of the request to the host agency;(B) reviews the request and responds to the requestor within a time frame required by applicable state or federal law; and(C) sends a copy of the response to the host agency.(c) A host agency must ensure that, except as provided in 45 CFR §1324.19(b)(5) - (8), a representative of the Office is not required to report allegations of abuse, neglect, or exploitation under state law, including Texas Human Resources Code, Chapter 48, without appropriate consent or court order.(d) A host agency must, at the request of the Office, immediately provide Ombudsman Program records that do not contain confidential information, such as timesheets and evidence supporting mileage reimbursement for representatives of the Office, to the Office. Source Note: The provisions of this §88.404 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.404 Provision of Records to the Office, Disclosure of Confidential Information, and Allegations of Abuse, Neglect, or Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218323 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218323 03/12/2026 (a) The performance measures of a local ombudsman entity are described in this subsection.(1) The number of certified ombudsmen who will, during a federal fiscal year:(A) conduct visits at LTC facilities; and(B) identify and investigate complaints.(2) The percentage of complaints that will be resolved or partially resolved in a federal fiscal year.(3) The number of visits to assisted living facilities by certified ombudsmen that will occur during a federal fiscal year, as required by the Ombudsman Policies and Procedures Manual.(4) The number of visits to nursing facilities by certified ombudsmen that will occur during a federal fiscal year, as required by the Ombudsman Policies and Procedures Manual.(5) Compliance with the complaint response requirements described in §88.305(a)(3) and §88.305(c)(2) of this chapter (relating to Complaints).(6) Compliance with the requirement described in §88.307(b) of this chapter (relating to Requirements Regarding LTC Facility Visits and Submitting Information to the Office).(7) Compliance with the minimum expenditure requirement described in §88.406(a) of this subchapter (relating to Requirements Regarding Expenditures for the Ombudsman Program).(b) A host agency must work with the local ombudsman entity to develop projections for the performance measures described in subsection (a)(1) - (2) of this section for a federal fiscal year and submit the projections to the Office by July 31st of each year using the HHSC form "Ombudsman Performance Measure Projections." The Office reviews a form submitted by the host agency and approves the form or recommends modifications to the form. If the Office recommends modifications to the form, the host agency must submit a revised form to the Office for approval within a time period determined by the Office.(c) A host agency must ensure that a local ombudsman entity, by the end of each federal fiscal year, meets the performance measure projections approved by the Office as described in subsection (b) of this section by:(1) being within a variance of minus ten percent of the projections; or(2) exceeding the projections.(d) A host agency must ensure that a local ombudsman entity, by the end of each federal fiscal year, meets the performance measures required by subsection (a)(3) - (6) of this section by:(1) being within a variance of minus ten percent of the measures; or(2) exceeding the measures.(e) A host agency must ensure that a local ombudsman entity, by the end of each federal fiscal year, meets or exceeds the performance measure required by subsection (a)(7) of this section. Source Note: The provisions of this §88.405 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.405 Performance Measures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218324 03/12/2026 (a) A host agency must, for the Ombudsman Program implemented by a local ombudsman entity, expend for a federal fiscal year at least the amount of federal funds expended as required by the Older Americans Act, §306(a)(9). In determining the amount of funds expended, the host agency may include all funds except, in the discretion of the State Ombudsman, an amount of state general revenue funds allocated to the host agency described in §88.105(b)(3) of this chapter (relating to Fiscal Management of a Local Ombudsman Entity). The State Ombudsman will notify host agencies of the specific amount of state general revenue funds to be excepted from the determination of funds expended by a communication published on the Long-Term Care Ombudsman website.(b) A function of the Ombudsman Program performed by a local ombudsman entity that is paid for with funds allocated by HHSC must be an allowable activity in accordance with the Ombudsman Policies and Procedures Manual.(c) A purchase of a service, material, equipment, or good by a host agency for the Ombudsman Program implemented by a local ombudsman entity with funds allocated by HHSC must meet the criteria described in 45 CFR Part 75. Source Note: The provisions of this §88.406 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.406 Requirements Regarding Expenditures for the Ombudsman Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218325 03/12/2026 (a) The Office sends a host agency an Ombudsman Staffing Plan form on or about July 31st of each year.(b) A host agency must complete and submit the Ombudsman Staffing Plan form sent to the host agency by the Office as specified in the form.(c) The Office reviews a completed Ombudsman Staffing Plan form submitted by the host agency and notifies the host agency in writing of whether the form is approved. If the form is not approved by the Office, a host agency may submit a revised form to the Office.(d) The Office will not reimburse a host agency for expenditures made by the host agency for Ombudsman Program functions until the Office approves an Ombudsman Staffing Plan form submitted by the host agency. Source Note: The provisions of this §88.407 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.407 Requirement for Approval of Ombudsman Staffing Plan Form https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218326 03/12/2026 (a) A host agency must not:(1) willfully interfere with the State Ombudsman or a representative of the Office performing any of the functions of the Ombudsman Program, which includes:(A) prohibiting a representative of the Office from:(i) commenting or recommending changes, as described in §88.302(a)(1)(F) of this chapter (relating to Requirement to Ensure a Representative of the Office Performs Functions of the Ombudsman Program);(ii) submitting comments to the Office regarding proposed legislation; or(iii) responding to a question from a legislator or the media regarding a problem that pertains to an LTC facility or service, or to the health, safety, welfare, and rights of residents; and(B) requiring a representative of the Office to obtain approval from the host agency before submitting testimony at a legislative hearing;(2) retaliate against the State Ombudsman or a representative of the Office:(A) with respect to a resident, employee of an LTC facility, or other person filing a complaint with, providing information to, or otherwise cooperating with, a representative of the Office; or(B) for performance of the functions, responsibilities, or duties described in 45 CFR §1324.13 and §1324.19 and this chapter; or(3) have personnel policies or practices that prohibit a representative of the Office from performing the functions of the Ombudsman Program or from adhering to the requirements of the Older Americans Act, §712.(b) A host agency must ensure that a governmental entity or nonprofit organization contracting with a host agency, as described in §88.2(20)(B) of this chapter (relating to Definitions), complies with subsection (a) of this section as if the entity or organization is a host agency.(c) A host agency may require a representative of the Office to notify the host agency of:(1) comments or recommendations made in accordance with §88.302(a)(1)(F) of this chapter; and(2) subject to disclosure requirements in §88.304 of this chapter (relating to Disclosure of Confidential Information; Exclusion from Reporting Requirements Regarding Abuse, Neglect, or Exploitation; and Provision of Records to the Office):(A) information being sent to a legislator or the media regarding a problem or concern about a resident or a recommendation related to the problem or concern, as described in §88.302(a)(2)(A)(ii) of this chapter; and(B) a response to a request for information from a legislator or the media, as described in §88.302(a)(2)(C) of this chapter. Source Note: The provisions of this §88.408 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.408 Prohibition of Interference and Retaliation by a Host Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218327 03/12/2026 (a) If the Office determines that a host agency is not in compliance with this subchapter and the determination is not based on onsite monitoring or a desk review, the Office sends the local ombudsman entity and host agency a written notice describing the determination of non-compliance.(b) If a local ombudsman entity or host agency receives a written notice described in subsection (a) of this section, the host agency, within 14 days after the date of the receipt of the notice, must submit a written plan of correction to the Office that describes:(1) the action that will be taken to correct the noncompliance described in the notice; and(2) the date by which each action will be completed.(c) Within 14 days after the date the Office receives the plan of correction required by subsection (b) of this section, the Office notifies the local ombudsman entity and host agency of whether the plan is approved or requires modification. If the Office approves the plan, the host agency must complete the actions contained in the plan of correction by the dates in the plan. If the Office determines that the plan requires modification, the host agency must submit a modified written plan of correction within a time period determined by the Office for approval by the Office.(d) To determine if the host agency has completed the actions in accordance with an approved plan of correction or approved modified plan of correction, the Office takes one or more of the following actions:(1) reviews information in the ombudsman database;(2) requests that the host agency submit evidence of correction to the Office; and(3) visits the host agency or local ombudsman entity.(e) If the Office determines that the host agency did not complete an action in accordance with an approved plan of correction or a modified plan of correction:(1) the Office may allow the host agency additional time to complete the action;(2) HHSC may impose a Level Two sanction in accordance with §213.5 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Sanctions);(3) HHSC may impose a Level Three sanction in accordance with §213.5 of this title; or(4) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this chapter (relating to Designation of a Local Ombudsman Entity).(f) If the Office allows a host agency additional time to complete an action as described in subsection (e)(1) of this section and the Office determines that the host agency did not complete the action within the time allowed, HHSC may:(1) impose a Level Two sanction in accordance with §213.5 of this title;(2) impose a Level Three sanction in accordance with §213.5 of this title; or(3) the State Ombudsman may remove the designation of the local ombudsman entity as described in §88.104(c)(2)(B) of this chapter.(g) Upon request by a local ombudsman entity or host agency, the Office provides technical assistance to a local ombudsman entity or host agency regarding developing a plan of correction. Source Note: The provisions of this §88.409 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM E REQUIREMENTS OF A HOST AGENCY §88.409 Noncompliance by a Host Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218320 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218320 03/12/2026 (a) For purposes of determining if the State Ombudsman or a representative of the Office has an individual conflict of interest, the state of Texas is the ombudsman service area.(b) HHSC requires an applicant for the position of State Ombudsman to complete HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" to identify an individual conflict of interest of the applicant.(c) HHSC requires the State Ombudsman to complete HHSC form "Individual Conflict of Interest Screening of a Representative of the Office" on or about January 15th of each year and if the State Ombudsman identifies an individual conflict of interest.(d) The Executive Commissioner or designee reviews a form completed by an applicant or the State Ombudsman as described in subsection (b) or (c) of this section to determine if an identified conflict of interest can be removed or remedied.(e) Except as provided in subsection (f) of this section, HHSC does not employ the State Ombudsman or a representative of the Office who has an individual conflict of interest.(f) HHSC may employ the State Ombudsman or a representative of the Office who has an individual conflict of interest described in §88.2(17)(K), (L), or (O) of this chapter (relating to Definitions) if:(1) the Executive Commissioner or designee approves a remedy for the conflict of interest of the State Ombudsman; or(2) the State Ombudsman approves a remedy for the conflict of interest of a representative of the Office.(g) HHSC ensures that no person involved in selecting or terminating the State Ombudsman has an individual conflict of interest. Source Note: The provisions of this §88.501 adopted to be effective April 5, 2018, 43 TexReg 2007; amended to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM F REQUIREMENTS OF HHSC §88.501 HHSC Responsibilities Regarding Individual Conflicts Of Interest https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190381 03/12/2026 (a) HHSC takes reasonable steps to avoid organizational conflicts of interest between the Office and HHSC.(b) HHSC requires the State Ombudsman to complete HHSC form "Conflict of Interest Identification, Removal, and Remedy," to identify an organizational conflict of interest between the Office and HHSC and propose a remedy for an identified conflict of interest:(1) no later than 30 days after the date the State Ombudsman assumes responsibilities;(2) on or about January 15th of each year; and(3) if the State Ombudsman identifies an organizational conflict of interest.(c) The Executive Commissioner or designee reviews a form completed by the State Ombudsman as described in subsection (b) of this section and removes or remedies an identified conflict of interest.(d) HHSC ensures that the State Ombudsman includes identified organizational conflicts of interest between the Office and HHSC and the steps taken to remove or remedy the conflicts in the annual report submitted to the federal Administration for Community Living through the National Ombudsman Reporting System. Source Note: The provisions of this §88.502 adopted to be effective April 5, 2018, 43 TexReg 2007. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM F REQUIREMENTS OF HHSC §88.502 HHSC Responsibilities Regarding Organizational Conflicts of Interest Between the Office and HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218328 03/12/2026 (a) A grievance regarding the performance of functions of the Ombudsman Program by a representative of the Office, other than a grievance about the managing local ombudsman, is addressed in accordance with this subsection. A host agency must ensure that a local ombudsman entity complies with this section.(1) The local ombudsman entity must:(A) ensure that a grievance may be submitted:(i) in writing, in person, or by telephone; and(ii) anonymously;(B) request, but not require disclosure of, the name and contact information of a grievant;(C) document the nature of the grievance in detail;(D) document the name of the person who conducted the investigation required by subparagraph (F)(ii) of this paragraph;(E) document the name of persons contacted during the investigation; and(F) within 30 days after receiving the grievance:(i) notify the representative of the Office who is the subject of the grievance that a grievance was submitted;(ii) investigate the grievance;(iii) develop a proposed response to the grievant, including actions to be taken, if any; and(iv) submit the following information to the Office:(I) the information described in subparagraphs (C) - (E) of this paragraph;(II) a description of the activities conducted during the investigation; and(III) the proposed response to the grievant as required by clause (iii) of this subparagraph.(2) If the Office receives the information regarding a grievance described in paragraph (1)(F)(iv) of this subsection, the State Ombudsman:(A) reviews the information; and(B) approves or modifies the proposed response to the grievant developed by the local ombudsman entity.(3) The local ombudsman entity must send a response to the grievant as approved or modified by the State Ombudsman.(b) A grievance regarding the performance of functions of the Ombudsman Program by a managing local ombudsman is addressed in accordance with this subsection.(1) A grievance about the managing local ombudsman must be submitted to the Office.(2) If the Office receives a grievance about a managing local ombudsman, the Office, within 90 days after receiving the grievance:(A) investigates the grievance;(B) informs the host agency of the actions to be taken, if any; and(C) sends a response to the grievant. Source Note: The provisions of this §88.601 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM G GRIEVANCES §88.601 Grievances Regarding Performance of a Representative of the Office Who is an Employee, Independent Contractor, or Volunteer of a Host Agency, Including a Managing Local Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218329 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218329 03/12/2026 (a) A grievance regarding the performance of functions of the Ombudsman Program by the State Ombudsman is addressed in accordance with this subsection.(1) A grievance about the State Ombudsman that is not related to fraud, waste, or abuse must be submitted to the Director of the Office of the Ombudsman.(2) A grievance about the State Ombudsman related to fraud, waste, or abuse must be submitted to the Office of the Inspector General.(b) A grievance regarding the performance of functions of the Ombudsman Program by a representative of the Office who is an employee or volunteer of HHSC is addressed in accordance with this subsection.(1) The State Ombudsman:(A) ensures that a grievance may be submitted:(i) in writing, in person, or by telephone; and(ii) anonymously;(B) requests, but does not require disclosure of, the name and contact information of a grievant;(C) documents the nature of the grievance in detail;(D) documents the name of persons contacted during the investigation; and(E) within 30 days after receiving the grievance:(i) notifies the representative of the Office who is the subject of the grievance that a grievance was submitted;(ii) investigates the grievance; and(iii) develops and submits a response to the grievant, including actions to be taken, if any.(2) The State Ombudsman submits a grievance about a representative of the Office who is an employee or volunteer of HHSC related to fraud, waste, or abuse to the Office of the Inspector General. Source Note: The provisions of this §88.602 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM G GRIEVANCES §88.602 Grievances Regarding the Performance of the State Ombudsman or a Representative of the Office Who is an Employee or Volunteer of HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218330 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218330 03/12/2026 If the State Ombudsman refuses, suspends, or terminates certification of a representative of the Office, the person whose certification was refused, suspended, or terminated may file a grievance to request that the State Ombudsman reconsider the decision to refuse, suspend, or terminate certification in accordance with this section.(1) To request a grievance under this section, the grievant must complete HHSC form "Grievance Regarding Ombudsman Certification Decision" and submit the completed form to the Office within 30 days of a decision.(2) If the Office receives a completed form described in paragraph (1) of this section, the State Ombudsman:(A) reviews the form;(B) determines whether the decision to refuse, suspend, or terminate certification is affirmed, modified, or reversed;(C) sends a response to the grievant which includes a description of the State Ombudsman's determination; and(D) takes any necessary action in accordance with the determination.(3) In accordance with 45 CFR §1324.11(e)(7), the State Ombudsman makes the final determination regarding the refusal, suspension, or termination of certification of a representative of the Office. Source Note: The provisions of this §88.603 adopted to be effective May 22, 2024, 49 TexReg 3566. 1 HEALTH AND HUMAN SERVICES COMMISSION 88 STATE LONG-TERM CARE OMBUDSMAN PROGRAM G GRIEVANCES §88.603 Grievances Regarding Certification Decisions by the State Ombudsman https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226544 03/12/2026 The purpose of this subchapter is to describe fair and equitable process and procedures for conducting administrative hearings requested under the Persons with Mental Retardation Act, Texas Health and Safety Code, Title 7, Subtitle D, to contest:(1) the conclusion of a determination of mental retardation conducted by a state MR facility or mental retardation authority;(2) the denial of an individual's or LAR's request to transfer or discharge the individual; and(3) a state MR facility's proposed transfer or discharge of an individual. Source Note: The provisions of this §100.501 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.501 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226545 03/12/2026 The provisions of this subchapter apply to:(1) state MR facilities;(2) mental retardation authorities; and(3) TDMHMR Central Office. Source Note: The provisions of this §100.503 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.503 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226546 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) CEO or chief executive officer--The superintendent of a state MR facility or the executive director of a mental retardation authority.(2) Discharge--The release by TDMHMR of an individual committed or voluntarily admitted for residential mental retardation services from the custody and care of a state MR facility and the termination of the individual's assignment to the state MR facility in the Client Assignment and Registration System (CARE).(3) Hearing officer--An attorney designated to conduct and preside over an administrative hearing held under this subchapter.(4) Individual--A person who is seeking or receiving residential mental retardation services from a state MR facility or mental retardation services from a mental retardation authority.(5) LAR or legally authorized representative--A person authorized by law to act on behalf of an individual with regard to a matter in this subchapter, and who may include a parent, guardian, or managing conservator of a minor individual; a guardian of an adult.(6) Mental retardation authority--An entity designated by the commissioner to which the Texas Mental Health and Mental Retardation Board delegates its authority and responsibility for planning, policy development, coordination, and resource allocation, and resource development for and oversight of mental retardation services and supports in one or more local service areas.(7) Party--Each person and the state MR facility or mental retardation authority named or admitted as a party in an administrative hearing held under this subchapter.(8) Preponderance of evidence--Evidence which is of greater weight or more convincing than the evidence which is offered in opposition to it.(9) State MR facility--A facility operated by TDMHMR that provides residential mental retardation services to individuals with mental retardation.(10) Transfer--The reassignment of an individual from one state MR facility to another state MR facility.(11) Trial de novo--A new trial, which is held as if no administrative hearing had been held. Source Note: The provisions of this §100.505 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.505 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226547 03/12/2026 (a) An individual or LAR is entitled to request an administrative hearing to contest:(1) the conclusion of a determination of mental retardation conducted by a state MR facility or mental retardation authority, as provided by the Texas Health and Safety Code, §592.019;(2) the denial of an individual's or LAR's request to transfer or discharge the individual, as provided by the Texas Health and Safety Code, §594.012; or(3) a state MR facility's proposed transfer or discharge of an individual, as provided by the Texas Health and Safety Code, §594.014.(b) An administrative hearing held under this subchapter is not a "contested case" under the Administrative Procedures Act, Texas Government Code, Chapter 2001.(c) If the last day of a time period referenced in this subchapter is a Saturday, Sunday, or day on which TDMHMR's Central Office is closed, then the period extends through the end of the next day which is not a Saturday, Sunday, or day on which TDMHMR's Central Office is closed. Source Note: The provisions of this §100.507 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.507 General Principles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226548 03/12/2026 (a) Written notice to the individual or LAR of the right to request an administrative hearing must be provided by:(1) the state MR facility or mental retardation authority, as applicable, at the time the report, as referenced in §415.755(h) of this title (relating to Determination of Mental Retardation (DMR)), is provided to the individual or LAR who requested the determination of mental retardation;(2) a state MR facility, upon its denial of a request by the individual or LAR for a transfer or discharge; or(3) a state MR facility, at least 31 calendar days before the date of the state MR facility's proposed transfer or discharge of the individual.(b) The notice must contain:(1) the conclusion of the determination of mental retardation as to whether or not the individual has mental retardation, for the notice referenced in subsection (a)(1) of this section;(2) the decision to deny a requested transfer or discharge and the reasons for such decision, for the notice referenced in subsection (a)(2) of this section;(3) the decision to propose a transfer or discharge, the reasons for such proposal, and the date of the proposed transfer or discharge, for the notice referenced in subsection (a)(3) of this section;(4) an explanation of the individual's or LAR's right to request an administrative hearing and the procedure for requesting such;(5) the timeframe for requesting a hearing;(6) a statement that the individual or LAR may represent himself or herself or use another person as a representative; and(7) the name, address, and phone number of the person designated by the state MR facility or mental retardation authority to receive the request for an administrative hearing. Source Note: The provisions of this §100.509 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.509 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226549 03/12/2026 (a) A request for an administrative hearing must be received by the state MR facility or mental retardation authority within 30 calendar days after the individual's or LAR's receipt of notice referenced in §414.155(a) of this title (relating to Notice).(b) The request for administrative hearing must be submitted in accordance with the instructions provided in the notice referenced in §414.155(a) of this title (relating to Notice).(c) The request for an administrative hearing may be oral or in writing.(d) The state MR facility or mental retardation authority, as appropriate, must document in writing an oral request for an administrative hearing.(e) The state MR facility or mental retardation authority, as appropriate, must forward the request for an administrative hearing to the TDMHMR's Office of Legal Services within one working day after receipt of the request.(f) A party may not take action to transfer or discharge an individual if an administrative hearing is requested under subsection (a)(2) or (a)(3) of §414.154 of this title (relating to General Principles). Source Note: The provisions of this §100.511 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.511 Request for an Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226550 03/12/2026 (a) The hearing officer must contact the person who requested a hearing within five working days after the receipt of the request by the Office of Legal Services.(b) The hearing officer must set a date, time, and location convenient for the parties for the administrative hearing. The hearing officer may conduct the hearing by telephone for appropriate reasons, including the location of the person who requested the hearing and other persons who will be participating in the hearing(c) The administrative hearing must be held no later than 30 calendar days after the date the hearing was requested, unless a continuance beyond 30 calendar days is agreed to by the person who requested the hearing.(d) The hearing officer must, at least 20 calendar days prior to the date of the hearing, send a written notice of the hearing to the person who requested the hearing and the CEO.(e) The notice must contain:(1) the time, date, and location of the hearing;(2) the issue being contested at the hearing;(3) a statement that the individual or LAR may represent himself or herself or choose another person as a representative;(4) a statement that each party must, upon request, provide the other parties with the opportunity to examine and copy any records concerning the individual and relevant to the contested issue at least 14 calendar days prior to the hearing;(5) a statement that requests for reasonable accommodations or for interpreters at the hearing must be made to the hearing officer, in writing, at least five calendar days prior to the hearing; and(6) a copy of this subchapter. Source Note: The provisions of this §100.513 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.513 Preliminary Matters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226551 03/12/2026 (a) For hearings held under the Texas Health and Safety Code, §593.008, the state MR facility or mental retardation authority, as appropriate, has the burden of proof by a preponderance of the evidence to demonstrate that the conclusion of the determination of mental retardation as to whether or not the individual has mental retardation is accurate.(b) For hearings held for actions described under the Texas Health and Safety Code, §594.012, the state MR facility has the burden of proof by a preponderance of the evidence to demonstrate that the criteria for transfer or discharge have not been met, as set forth in:(1) the Texas Health and Safety Code, §594.011;(2) §412.271(b) of this title (relating to Transfer of an Individual Between State MR Facilities);(3) §412.279 of this title (relating to Discharge from a State MR Facility of an Individual Who Moves to an Alternate Living Arrangement); or(4) §412.282 of this title (relating to Review by Local MRA of Individual in a Community Living Arrangement).(c) For hearings held for actions described under the Texas Health and Safety Code, §594.014, the state MR facility has the burden of proof by a preponderance of the evidence to demonstrate that the criteria for transfer or discharge have been met, as set forth in:(1) the Texas Health and Safety Code, §594.011;(2) §412.271(b) of this title (relating to Transfer of an Individual Between State MR Facilities);(3) §412.279 of this title (relating to Discharge from a State MR Facility of an Individual Who Moves to an Alternate Living Arrangement);(4) §412.280 of this title (relating to Administrative Discharges Initiated by a State MR Facility); or(5) §412.282 of this title (relating to Review by Local MRA of Individual in a Community Living Arrangement). Source Note: The provisions of this §100.515 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.515 Burden of Proof https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226552 03/12/2026 (a) The person requesting the hearing has the option of having the hearing open or closed to the public.(b) The individual, LAR, and CEO have the right to:(1) be present at the hearing and represent themselves or have another person represent them;(2) examine witnesses;(3) present oral and written testimony and evidence;(c) Any interested person may appear at the hearing and give oral or written testimony.(d) In a hearing held under the Texas Health and Safety Code, §593.008, the individual, LAR, or representative may introduce the results of an independent determination of mental retardation.(e) The hearing shall be tape recorded and the state MR facility or mental retardation authority, as appropriate, shall provide the equipment for such recording.(f) The hearing officer must notify the parties, in writing, of any requests or orders made by the hearing officer, including that for submission of documents. If the hearing officer requests the submission of documents, then the notification must include a statement that each party must provide a copy of all documents submitted to the hearing officer to the other parties within a time period specified by the hearing officer.(g) The hearing officer may not orally announce the decision of the hearing on the date of the hearing unless the hearing officer intends to issue a written decision on that day. Source Note: The provisions of this §100.517 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.517 The Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226553 03/12/2026 (a) Within 10 working days after the hearing, the hearing officer must send a written decision to all parties that includes:(1) findings of fact, the reasons for those findings, and conclusions of law;(2) a statement that to appeal the decision, a party must file an appeal with the county court of Travis County or county in which the individual resides within 30 calendar days of the date of the written decision; and(3) a statement that the decision is final on the 31st calendar day after the date of the written decision, unless an appeal is timely filed.(b) A party may appeal the hearing officer's decision without filing a motion for rehearing with the hearing officer.(c) An appeal is by trial de novo.(d) A party may not take action on the hearing officer's decision if an appeal is filed. Source Note: The provisions of this §100.519 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.519 Hearing Officer's Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226554 03/12/2026 Reference is made to the following statutes and TDMHMR rules:(1) Texas Health and Safety Code, Title 7, Subtitle D; Title 7, Chapter 534, Subchapter A; §592.019; §593.005; §593.008; §594.011; §594.012; and §594.014;(2) Texas Government Code, Chapter 2001;(3) §415.755(h) of this title (relating to Determination of Mental Retardation (DMR);(4) §412.271(b) of this title (relating to Transfer of an Individual Between State MR Facilities);(5) §412.279 of this title (relating to Discharge from a State MR Facility of an Individual Who Moves to an Alternate Living Arrangement);(6) §412.280 of this title (relating to Administrative Discharges Initiated by a State MR Facility); and(7) §412.282 of this title (relating to Review by Local MRA of Individual in a Community Living Arrangement). Source Note: The provisions of this §100.521 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.521 References https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226555 03/12/2026 This subchapter shall be distributed to:(1) members of the Texas MHMR Board;(2) executive, management, and program staff at Central Office;(3) superintendents/directors of all state MR facilities;(4) executive directors of all mental retardation authorities; and(5) advocacy organizations. Source Note: The provisions of this §100.523 adopted to be effective December 27, 2000, 25 TexReg 12785; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS N HEARINGS FOR INDIVIDUALS SEEKING OR RECEIVING INTELLECTUAL DISABILITY SERVICES §100.523 Distribution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226556 03/12/2026 This subchapter applies to all Medicaid programs administered by the Texas Department of Mental Health and Mental Retardation. Source Note: The provisions of this §100.531 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS O ADVERSE ACTIONS PERTAINING TO INTELLECTUAL DISABILITY SERVICES §100.531 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226557 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Administrative law judge--The attorney designated or appointed by the commissioner to conduct and preside over the administrative hearing.(2) Adverse action--Any action taken or proposed by the department against a provider in which the provider may request an administrative hearing under Chapter 406 of this title (relating to ICF/MR Programs) or this chapter, concerning Medicaid Programs.(3) Commissioner--The commissioner of the Texas Department of Mental Health and Mental Retardation.(4) Days--Calendar days, unless otherwise specified.(5) Department--The Texas Department of Mental Health and Mental Retardation (TXMHMR) or its designee.(6) Person--An individual, partnership, corporation, association, governmental subdivision or agency, or a public or private organization of any character.(7) Provider--Any person with whom the department has a provider agreement.(8) Provider agreement--Any written agreement that obligates the department to pay money to a person for goods or services under the Title XIX Medical Assistance Program. Source Note: The provisions of this §100.533 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS O ADVERSE ACTIONS PERTAINING TO INTELLECTUAL DISABILITY SERVICES §100.533 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226558 03/12/2026 (a) The commissioner or designee is authorized to make decisions concerning adverse action.(b) The commissioner or designee must send a provider a notice advising the provider of any adverse action. The notice is sent by certified mail, return receipt requested, unless the department determines that a more immediate form of notice is required. The notice includes a description of the basis for the adverse action, including citation of the specific rule section(s) or portion of the provider agreement with which the provider in is noncompliance and informs the provider of the provider's right to an administrative hearing to contest the adverse action. If the adverse action proposed by the department is termination of the provider agreement, then the notice must also specify the dates that the department intends to begin withholding payment and to terminate the provider agreement in accordance with §409.35 of this title (relating to Withholding Provider Agreement Payments).(c) The department does not have to give a notice of adverse action with each billing transaction for areas of the department that have a large volume of bills or which routinely post debit and credit entries. The department must give a provider a notice of appeal rights any time the provider informs the department in writing of the provider's dissatisfaction with a claim transaction which is an adverse action. Source Note: The provisions of this §100.535 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS O ADVERSE ACTIONS PERTAINING TO INTELLECTUAL DISABILITY SERVICES §100.535 Notice of Adverse Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226559 03/12/2026 (a) A provider must send to the department a written request for an administrative hearing within 15 days after receiving the department's official notice of adverse action. The request for an administrative hearing:(1) may be in the form of a petition or a letter;(2) must state the reasons the provider considers it is not subject to the adverse action; and(3) must be addressed to: Hearings Office, TXMHMR, P.O. Box 12668, Austin, Texas 78911-2668.(b) After the department receives the written request for an administrative hearing, the matter shall be referred to an administrative law judge for disposition according to Chapter 403, Subchapter O of this title (relating to Administrative Hearings of the Department in Contested Cases). Source Note: The provisions of this §100.537 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS O ADVERSE ACTIONS PERTAINING TO INTELLECTUAL DISABILITY SERVICES §100.537 Request for an Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226560 03/12/2026 If the department proposes to terminate a provider agreement and the provider requests an administrative hearing in accordance with §409.34 of this title (relating to Request for an Administrative Hearing), then the department may not terminate the provider agreement before the completion of the administrative hearing. If the department intends to terminate a provider agreement, then payments to the provider may be withheld by the department pending an administrative hearing appealing the proposed termination of the provider agreement. If the final decision of the administrative hearing is favorable to the department or the provider does not make a timely request for an administrative hearing, then payments withheld will not be made by the department to the provider. If the final decision is favorable to the provider, then payments withheld will be made by the department to the provider and provider agreement payments will be resumed by the department. Source Note: The provisions of this §100.539 adopted to be effective June 13, 1995, 20 TexReg 3987; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6881. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS O ADVERSE ACTIONS PERTAINING TO INTELLECTUAL DISABILITY SERVICES §100.539 Withholding Provider Agreement Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226561 03/12/2026 (a) This subchapter establishes procedures:(1) in Division 1 of this subchapter (relating to General Rules) that govern generally all administrative hearings and appeals;(2) in Division 2 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services) that govern appeals concerning the vocational rehabilitation, independent living, and comprehensive rehabilitation programs of the Division for Blind Services and Division for Rehabilitation Services;(3) in Division 3 of this subchapter (relating to Division for Early Childhood Intervention Services) that govern hearings concerning the provision of appropriate early intervention services to a child or child's family; and(4) in Division 4 of this subchapter (relating to Office for Deaf and Hard of Hearing Services) that govern hearings concerning the suspension, revocation, or probation of a certificate holder's certificate granted under the provisions of Chapter 81, Human Resources Code and Chapter 57, Government Code.(b) The provisions of this subchapter shall not be construed so as to enlarge, diminish, modify, or alter the jurisdiction, powers, or authority of DARS or the substantive rights of any person.(c) A person's decision to seek an informal resolution, under Divisions 2 and 4 of this subchapter, of matters about which the person is dissatisfied shall not prevent, compromise, or delay the person's access to formal resolution procedures in this subchapter. Source Note: The provisions of this §100.551 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.551 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226562 03/12/2026 The following statutes and regulations authorize the procedures established by this subchapter:(1) The Rehabilitation Act of 1973, as amended, 29 U.S.C. §701 et seq., and regulations of the Department of Education, 34 C.F.R. Parts 361, 363, 364, 365, and 367 as amended;(2) Texas Human Resources Code, Chapter 91, Subchapter D (concerning vocational rehabilitation services of the blind);(3) Texas Human Resources Code, Chapter 111, Subchapter D (concerning vocational rehabilitation services);(4) The Individuals with Disabilities Education Act, as amended, 20 U.S.C. §1400 et seq., and 34 C.F.R. §303.1 et seq., as amended (concerning early intervention services for children with disabilities and developmental delays);(5) Texas Administrative Procedure Act, Texas Government Code, Chapter 2001, as amended;(6) Texas Human Resources Code, Chapters 81 and 82 (concerning services for people who are deaf); and(7) Texas Government Code, Chapter 57 (concerning court interpreter certification program for interpreters for people who are hearing-impaired). Source Note: The provisions of this §100.553 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.553 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226563 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. The use of the singular or plural case is not meant to be limiting unless the context clearly indicates otherwise.(1) Act--The Rehabilitation Act of 1973 as amended, 29 U.S.C. §701, et seq.(2) Appellant--An applicant, eligible individual, authorized representative, or parent who has initiated formal procedures under this subchapter.(3) Applicant--A person who has applied for services but for whom an eligibility determination has not been made.(4) Authorized representative--An attorney authorized to practice law in the State of Texas, or a person designated by a party to represent the party in hearing procedures. The term includes a parent or a person made legally responsible for the child by a court of competent jurisdiction.(5) Commissioner--The chief executive officer of the Department of Assistive and Rehabilitative Services.(6) Consumer--The term "consumer" refers to and includes a person who:(A) under Division 2 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services), has been determined eligible for and is receiving services from DARS;(B) under Division 3 of this subchapter (relating to Division for Early Childhood Intervention Services), is a parent, child, or the child's family; or(C) under Division 4 of this subchapter (relating to Office for Deaf and Hard of Hearing Services), not only has been determined eligible for and is receiving services from DARS, but also is an individual defined by §101.1205(e) of this subchapter (relating to Definitions).(7) DARS--The Texas Department of Assistive and Rehabilitative Services, its officers, employees, and agents.(8) Discovery--The process by which a party, before any final hearing on the merits, may obtain evidence and other information that is relevant to a claim or defense in the appeal.(9) Eligible individual--Any individual person whom DARS has determined to be eligible to receive vocational rehabilitation services.(10) Hearing--A formal review conducted under this chapter. This term includes prehearing conferences.(11) Impartial hearing officer (IHO)--A person who is appointed to conduct a hearing under this chapter.(12) Parent--(A) Under Division 2 of this subchapter, the term "parent" whether in the singular or plural means a minor child's natural or adoptive parent, the spouse of the minor child's natural or adoptive parent, the minor child's surrogate or foster parent, the spouse of the surrogate or foster parent, or other person made legally responsible for the minor child by a court.(B) Under Division 3 of this subchapter, the meaning of the term "parent" is as defined in §108.103 of this title (relating to Definitions).(13) Party--A person or agency named or admitted to participate in a formal hearing.(14) Person--Any individual; representative; corporation; or other entity, including any public or nonprofit corporation, or agency or instrumentality of federal, state, or local government.(15) Record--The official record of a hearing, including all arguments, briefs, pleadings, motions, intermediate rulings, orders, evidence received or considered, statements of matters officially noticed, questions and offers of proof, objections and rulings on objections, proposed findings of fact, conclusions of law, and hearing officer decision; any other decision, opinion, or report by the hearing officer or commissioner; and all DARS memoranda or data, including consumer and applicant files, submitted to or considered by the impartial hearing officer. Source Note: The provisions of this §100.555 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.555 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226564 03/12/2026 (a) Persons who may file a Request for Review.(1) Under Division 2 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services), an applicant or eligible individual who is dissatisfied with a DARS determination made by staff of DARS that affects the provision of vocational rehabilitation services may request a review of the determination. (2) Under Division 3 of this subchapter (relating to Division for Early Childhood Intervention Services), a parent may initiate a hearing involving the identification, evaluation, placement, or provision of appropriate early intervention services to a child or child's family.(3) Under Division 4 of this subchapter (relating to Office for Deaf and Hard of Hearing Services), a certificate holder may request a review of a proposal by DARS to revoke or suspend a certificate or place a certificate holder on probation.(b) A request for a review brought:(1) under Division 2 of this subchapter, shall be filed, as provided in §101.1009 of this subchapter (relating to Filings) with the hearings coordinator, DARS Legal Services;(2) under Division 3 of this subchapter, is filed, as provided in §101.1107 of this subchapter (relating to Administrative Hearings Concerning Individual Child Rights) with the assistant commissioner for ECI or, with the hearings coordinator, DARS Legal Services, if that assistant commissioner so delegates; and(3) under Division 4 of this subchapter, is filed as provided in §101.1215 and §101.1217 of this subchapter (relating to Filing a Request for Hearing and Filings). Source Note: The provisions of this §100.557 adopted to be effective March 12, 2012, 37 TexReg 1706; amended to be effective December 31, 2012, 37 TexReg 9785; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.557 Filing a Request for Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226565 03/12/2026 A hearing conducted under Division 2 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services), by an impartial hearing officer selected in accordance with this division, will be held within 60 days of an applicant's or eligible individual's request for review of a DARS determination that affects the provision of vocational rehabilitation services to the individual, unless informal resolution or a mediation agreement is achieved before the 60th day or the parties agree to a specific extension of time. Source Note: The provisions of this §100.559 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.559 Time for Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226566 03/12/2026 (a) The hearings coordinator as described in §101.1215 and §101.1217 of this subchapter (relating to Filing a Request for Hearing and Filings) shall select, on a random basis, or by agreement between DARS' authorized representative and the appellant, or if appropriate, the appellant's authorized representative or a parent.(b) The impartial hearing officer shall be an individual who:(1) is not an employee of a public agency (other than an administrative law judge, hearing examiner, or employee of an institution of higher education);(2) has knowledge of the delivery of vocational rehabilitation services, the state plan, and the federal and state regulations governing appeals under Division 2 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services);(3) has received training specified by DARS with respect to the performance of official duties; and(4) has no personal, professional, or financial interest that would conflict with his or her objectivity in the hearing.(c) An individual is not considered to be an employee of a public agency for the purposes of subsection (b) of this section solely because the individual is paid by the agency to serve as a hearing officer.(d) In addition to those qualifications in subsections (a) - (c) of this section, an impartial hearing officer who conducts hearings under Division 3 of this subchapter (relating to Division for Early Childhood Intervention Services) must have knowledge about the provisions of the Individuals with Disabilities Education Act; the rules promulgated under that act; and services available for eligible children and their families.(e) Despite the provisions in subsection (a) of this section, if in a subsequent appeal, the appellant raises factual issues or claims that either were previously adjudicated or could have been adjudicated in a prior appeal:(1) the hearings coordinator may appoint the same IHO that heard the prior appeal to hear a subsequent appeal; or(2) the IHO, on DARS' motion, reassigns the appeal to the IHO who heard the prior appeal. Source Note: The provisions of this §100.561 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.561 Assignment of Impartial Hearing Officer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226567 03/12/2026 (a) The impartial hearing officer has the authority and duty to:(1) conduct a full and impartial hearing;(2) take action to avoid unnecessary delay in the disposition of the proceeding; and(3) maintain order.(b) The impartial hearing officer has the power to regulate the course of the hearing, including the power to:(1) administer oaths;(2) take testimony;(3) rule on questions of evidence;(4) rule on discovery issues;(5) issue orders relating to hearing and prehearing matters, including orders granting motions to subpoena witnesses and imposing nonmonetary sanctions regarding discovery;(6) admit or deny party status;(7) limit irrelevant, immaterial, and unduly repetitious testimony and reasonably limit the time for presentations;(8) grant continuance(s);(9) request parties to submit legal memoranda, proposed findings of fact, and conclusions of law; and(10) issue decisions based on findings of fact and conclusions of law.(c) Unless required for the disposition of ex parte matters authorized by law, the impartial hearing officer may not directly or indirectly communicate in connection with any issue of fact or law with the commissioner or any party or a party's authorized representative, except on notice and opportunity for each party to participate.(d) The authority of the impartial hearing officer concerning any discovery under subsection (b) of this section is subject to the authority granted by these rules or the Texas Administrative Procedure Act, Texas Government Code, Chapter 2001. Source Note: The provisions of this §100.563 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.563 Powers and Duties of Impartial Hearing Officer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226568 03/12/2026 (a) If for any reason an impartial hearing officer is unable to continue presiding over a pending hearing, or issue a decision after the conclusion of the hearing, another impartial hearing officer shall be designated as a substitute to complete the hearing and render a decision in accordance with these rules.(b) The substitute impartial hearing officer may use the existing record and may conduct further proceedings as are necessary and proper to conclude the hearing and render a decision. Source Note: The provisions of this §100.565 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.565 Substitution of Impartial Hearing Officer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226569 03/12/2026 (a) Any hearing or proceedings conducted under this subchapter shall be held, whenever feasible, by telephone (directly or by relay), but at a time and place reasonably accessible either to the appellant or the certificate holder and any witnesses, and convenient for parties. In considering the physical location of a hearing or proceeding, the impartial hearing officer considers, among other factors:(1) the suitability of any proposed facilities for a hearing, including such accommodations as the ability either of the appellant or the certificate holder and any witnesses to gain physical to the proceedings and facilities; and(2) the comparative distances and times required to travel from places of work or residence to a proposed hearing location by parties and witnesses.(b) DARS shall, upon reasonable notice, provide the appellant with readers or interpreters. Reasonable notice shall be considered to be no fewer than five working days prior to the proceeding unless good cause for a shorter period shall exist in the judgment of the impartial hearing officer.(c) A copy of a transcript prepared during hearing proceedings and all notices and documents are provided to the appellant in an accessible format upon request. Source Note: The provisions of this §100.567 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.567 Reasonable Accommodations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226570 03/12/2026 (a) An individual may represent himself or herself.(b) A party may be represented by an attorney authorized to practice law in Texas or by any other representative authorized by the party to represent him or her.(c) A party's authorized representative shall be copied on all notices, pleadings, and other correspondence.(d) A party's authorized representative remains the representative of record in absence of a formal request to withdraw and an order approving such withdrawal issued by the impartial hearing officer.(e) DARS is not responsible for expenses incurred by appellants seeking remedy through this subchapter, and representation and attorney fees and related expenses are the responsibility of the individual parties. Source Note: The provisions of this §100.569 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.569 Appearance of Parties at Hearings; Representation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226571 03/12/2026 If, after receiving a notice of a hearing, a party or the party's authorized representative fails to attend the hearing, the impartial hearing officer may proceed and, where appropriate, may issue a default decision against the absent party. Source Note: The provisions of this §100.571 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.571 Failure to Attend Hearing and Default https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226572 03/12/2026 (a) Any witness or deponent who is not a party to and who is subpoenaed or otherwise appears at any hearing or proceeding at the request of DARS is entitled to receive reimbursement as provided in the Texas Government Code, §2001.103.(b) DARS is not responsible for expenses incurred by any witness or deponent who is not a party to and who is subpoenaed or otherwise appears at any hearing or proceeding at the request of the appellant.(c) The party calling or deposing an expert witness is responsible for all fees and expenses charged by the expert witness. Source Note: The provisions of this §100.573 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.573 Witness Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226573 03/12/2026 (a) The impartial hearing officer may hold a prehearing conference to resolve matters preliminary to the hearing. At the discretion of the impartial hearing officer, a prehearing conference may be held by telephone (directly or by relay). A prehearing conference may be convened to address any or all of the following matters:(1) notice of jurisdiction or the impartial hearing officer's authority;(2) scope or party status;(3) the date and location of the final hearing;(4) factual and legal issues;(5) motions;(6) issuance of subpoenas;(7) discovery disputes;(8) scheduling;(9) stipulations;(10) settlement conferences;(11) requests for official notice;(12) identification and exchange of documentary evidence;(13) admissibility of evidence;(14) identification and qualification of witnesses;(15) order of presentation; and(16) other matters that promote the orderly and prompt conduct of the hearing.(b) Within five business days of the date on which the IHO receives the appellant's petition or request for review, the impartial hearing officer shall notify the appellant in writing of any other matters the impartial hearing officer considers expedient for an orderly conduct of the prehearing, including the following:(1) the final or merits hearing will be held within 60 days after the date when the hearings coordinator received the petition or request for review;(2) the appellant's right to request mediation;(3) the reasons for the prehearing conference;(4) the way the appellant might request a continuance of the prehearing conference;(5) the effect of failing to participate in a prehearing conference; and(6) the appellant's right to be represented. Source Note: The provisions of this §100.575 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.575 Prehearing Conferences https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226574 03/12/2026 (a) The impartial hearing officer may entertain motions for dismissal without a hearing for the following reasons:(1) failure to pursue the hearing;(2) unnecessary duplication of proceedings, res judicata, or collateral estoppel;(3) withdrawal of the request for hearing;(4) moot questions;(5) lack of jurisdiction;(6) failure to raise a material issue in the pleading;(7) failure of a party or authorized representative to appear at a scheduled hearing;(8) failure to respond to a discovery request; and(9) failure to respond to any order by the impartial hearing officer including an order to disclose the identities of witnesses and exhibits.(b) If the impartial hearing officer finds that a motion for dismissal should be granted, the impartial hearing officer may enter a final order of dismissal. Source Note: The provisions of this §100.577 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.577 Dismissal Without Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226575 03/12/2026 (a) On a genuine issue in a contested case, each party or authorized representative is entitled to:(1) call witnesses, including parties;(2) offer evidence;(3) cross-examine any witness called by another party; and(4) make opening and closing statements.(b) Once the hearing is begun, the parties and authorized representatives may be off the record only when the impartial hearing officer permits. If the discussion off the record is pertinent, then the impartial hearing officer summarizes the discussion for the record.(c) Objections shall be timely noted in the record.(d) The impartial hearing officer may continue a hearing from time to time and from place to place. If the time and place for the hearing to reconvene are not announced at the hearing, a notice is mailed stating the time and place of the hearing.(e) The impartial hearing officer may question witnesses and parties and/or direct the submission of supplemental evidence. Source Note: The provisions of this §100.579 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.579 Conduct of Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226576 03/12/2026 (a) A case shall be called to order by the impartial hearing officer.(b) Proceedings under Divisions 2 and 3 of this subchapter (relating to Division for Blind Services and Division for Rehabilitation Services and Division for Early Childhood Intervention Services) are conducted according to the following:(1) The appellant may state briefly the nature of the claim or defense, what the appellant expects to prove, and the relief sought. Immediately thereafter, DARS may make a similar statement, and any other parties are afforded similar rights as determined by the impartial hearing officer. The impartial hearing officer may limit the time available for each party or authorized representative with respect to such statement.(2) Evidence is then introduced by the appellant. DARS, or its authorized representative, and any other parties may cross-examine each of the appellant's witnesses.(3) Cross-examination is not limited solely to matters raised on direct examination. Parties or authorized representatives are entitled to redirect and recross-examination.(4) Unless the statement has already been made, the DARS or its authorized representative may briefly state the nature of the claim or defense, what DARS expects to prove, and the relief sought.(5) Evidence, if any, is introduced by DARS. The appellant and any other parties may cross-examine each of DARS' witnesses.(6) Any other parties may make statements and introduce evidence. The appellant and DARS may cross-examine the other parties' witnesses.(7) The parties may present rebuttal evidence.(8) The parties may be allowed to make either oral or written closing statements at the discretion of the impartial hearing officer.(9) The impartial hearing officer may examine any witness and party.(c) The order of proceedings set out in subsection (b) of this section applies to proceedings under Division 4 of this subchapter (relating to Office for Deaf and Hard of Hearing Services), except that DARS bears the burden of proof and is entitled to present its case first subject to cross-examination by the certificate holder and any other parties. Once DARS rests, the certificate holder may present his or her case.(d) The impartial hearing officer may permit deviations from this order of procedure in the interest of justice or to expedite the proceedings.(e) Parties shall provide four copies of each exhibit offered.(f) Burden of proof. The party seeking affirmative relief, either on the case as a whole or on an issue, bears the burden of proof to prove the affirmative of the issue, or the party's case as a whole, by a preponderance of the evidence. In cases brought under Division 4 of this subchapter, DARS bears the burden of proof. Source Note: The provisions of this §100.581 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.581 Order of Proceedings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226577 03/12/2026 (a) The rules of evidence as applied in nonjury civil cases by the district courts of the state of Texas apply to a hearing under this subchapter.(b) Exceptions: evidence inadmissible under the rules of evidence applied in nonjury civil cases by the district courts of the state of Texas may be admitted:(1) if it consists of any documents contained in any file of DARS related to the appellant; or(2) if it is:(A) necessary to ascertain the facts not reasonably susceptible of proof under those rules;(B) not precluded by statute; and(C) of a type on which reasonably prudent persons commonly rely in the conduct of their affairs.(c) Irrelevant, immaterial, or unduly repetitious evidence shall be excluded. Source Note: The provisions of this §100.583 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.583 Rules of Evidence https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226578 03/12/2026 (a) Unless precluded by law, the hearing shall be recorded electronically by tape recorder or similar device either by the IHO or by someone designated by the IHO. The tape recording is the official record of the testimony offered as evidence during the hearing. Any party, however, may request, at the party's expense, that the hearing be recorded by a court reporter if the request is made within ten days of the date for the hearing.(b) In lieu either of a recording of the testimony electronically or of the reporting of testimony by a court reporter, the parties to a hearing may agree upon a statement of the evidence, agree to use taped transcriptions as a statement of the testimonial evidence, or agree to the summarization of testimony before the impartial hearing officer; provided, however, that proceedings or any part of them must be transcribed on written request of any party.(c) Unless otherwise provided in this subchapter, the party requesting a transcription of any electronic recording of the proceedings shall bear the cost for transcribing any such electronically recorded testimony. Nothing provided for in this section limits DARS to a stenographic record of the proceedings. Source Note: The provisions of this §100.585 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.585 Transcription of Proceedings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226579 03/12/2026 In all proceedings and after all parties of record have been given copies, the prepared testimony of a witness upon direct examination may be incorporated in the record as if read or received as an exhibit. The prepared testimony may be either in narrative or question and answer form. The witness must be sworn and must identify the testimony. The witness is subject to cross-examination, and the prepared testimony is subject to a motion to strike in whole or in part. Source Note: The provisions of this §100.587 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.587 Prepared Testimony https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226580 03/12/2026 (a) In a formal appeal, all pleadings, for which no other form is prescribed, shall contain:(1) the name of the party making the pleading;(2) the names of all other known parties;(3) a concise statement of the facts alleged and relied upon;(4) a request stating the type of relief, action, or order desired;(5) any other matter required by law;(6) a certificate of service, as required by these rules; and(7) the signature of the party or the party's authorized representative making the pleading.(b) Any pleading filed in a formal appeal may be amended up to 14 days before the date of the hearing. Amendments filed after that time may be accepted at the discretion of the impartial hearing officer.(c) Any pleading may adopt and incorporate, by specific reference, any part of any document or entry in the official files and records of DARS.(d) All pleadings relating to any matter pending before DARS shall be filed with the impartial hearing officer and all parties.(e) All pleadings must be in a format and medium reasonably calculated to provide the required information and must be clear and legible.(f) Pleadings shall contain the name, address, and telephone number of the party filing the document or the name, telephone number, and business address of the authorized representative.(g) The party or the party's authorized representative filing the pleading shall include a signed certification that a true and correct copy of the pleading has been served on every other party. Source Note: The provisions of this §100.589 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.589 Pleadings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226581 03/12/2026 (a) The impartial hearing officer, at his or her discretion, may grant a continuance to further the interests of justice. No motion for continuance shall be granted, unless it is made in writing or stated in the record, and the motion shall set forth the specific grounds upon which the party seeks the continuance.(b) Unless made during a prehearing or hearing, a party seeking a continuance, cancellation of a scheduled proceeding, or extension of an established deadline must file such motion no later than 10 days before the date or deadline in question. A motion filed fewer than 10 days before the date or deadline in question must contain a certification that the movant contacted the other party or party's authorized representative and whether it is opposed by the party or party's authorized representative. Further, if a continuance to a certain date is sought, the motion must include a proposed date or dates and must indicate whether the other party or party's authorized representative contacted agrees on the proposed new date or dates. Source Note: The provisions of this §100.591 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.591 Continuance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226582 03/12/2026 (a) Any party to a hearing, except as provided in Division 3 of this chapter (relating to Division for Early Childhood Intervention Services), may file a motion for reconsideration within 20 days after the party is notified of the issuance of the decision of the impartial hearing officer. The motion shall be filed with the hearings coordinator, DARS Legal Services.(b) The motion for reconsideration must specify the matters in the decision of the impartial hearing officer that the party considers to be erroneous. Any response to the motion for reconsideration must be filed no later than 30 days after a party, or a party's attorney or representative, is notified of the impartial hearing officer's issuance of the decision.(c) The impartial hearing officer shall rule on the motion for reconsideration no later than 15 days after receipt of the motion, or after receipt of the response to the motion for reconsideration, whichever comes later. If the motion is granted, the IHO issues a decision upon reconsideration within an additional 15 days. If the impartial hearing officer fails to rule on the motion for reconsideration within 15 days, the motion is denied as a matter of law.(d) Service. Service of the impartial hearing officer's decision or of a motion or response under this section shall be made by any of the following means to a party, a party's attorney, or representative:(1) hand-delivery;(2) courier-receipted delivery;(3) regular first-class mail, certified, or registered mail;(4) email or facsimile transmission before 5:00 p.m. on a business day to the recipient's current email address or telecopier number; or(5) such other means as the impartial hearing officer may direct.(e) Date of service. The date of service is the date of hand-delivery, of delivery by courier, of mailing, of emailing, or of facsimile transmission, unless otherwise required by law. Unless the contrary is shown, a decision, motion, or response that is sent by regular first-class mail is presumed to have been received within three days of the date of postmarking, if enclosed in a wrapper addressed to the recipient's last known address with return address to the sender, stamped with the appropriate first-class postage, and deposited with the U.S. Postal Service on the date postmarked. Source Note: The provisions of this §100.593 adopted to be effective March 12, 2012, 37 TexReg 1706; amended to be effective December 31, 2012, 37 TexReg 9785; amended to be effective June 1, 2013, 38 TexReg 3355; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.593 Motion for Reconsideration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226583 03/12/2026 (a) Any party who disagrees with the findings and decision of an impartial hearing officer has a right to bring a civil action in any court of competent jurisdiction without regard to the amount in controversy.(b) A person must initiate a civil action for review of an impartial hearing officer's decision by filing a petition not later than the 30th day after the date on which the decision that is the subject of complaint is final and appealable. Source Note: The provisions of this §100.595 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.595 Civil Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226584 03/12/2026 (a) An applicant, eligible individual, or parent who has initiated a proceeding under this subchapter may request mediation to resolve the dispute. DARS, with the consent of the applicant, eligible individual, or parent, may also originate the request for mediation.(b) Mediation is voluntary on the part of the parties; must not be used to deny or delay the right of an individual to a hearing under this subchapter, or to deny any other right afforded by the Rehabilitation Act; and shall be conducted by a qualified and impartial mediator who is trained in effective mediation techniques. (c) DARS shall bear all costs related to the mediation process.(d) Upon receiving a request for mediation from the parties, the hearings coordinator shall select an individual from a list of qualified mediators who are knowledgeable in laws and regulations relating to the provision of vocational rehabilitation, independent living services, comprehensive rehabilitation services, or the provision of services by Early Childhood Intervention Services, whichever may apply to the dispute.(e) Sessions in the mediation process shall be coordinated by the mediator in a timely manner at a location convenient to both parties in the dispute.(f) All discussions that occur during the mediation sessions are confidential and may not be used as evidence in any subsequent due process hearing or civil proceeding. The mediator may require the parties to sign a confidentiality pledge before the start of the mediation process.(g) Any agreement reached through the mediation process is documented in a written mediation agreement and signed by the parties to the dispute. The agreement then becomes a part of the consumer record. Source Note: The provisions of this §100.597 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.597 Mediation Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226585 03/12/2026 (a) In computing any period of time prescribed or allowed by the rules in this subchapter, by order of an IHO, or by any applicable statute, the day of the act, event, or default after which the designated period of time begins to run is not included.(b) Unless otherwise provided by the rules in this subchapter, the last day of the period so computed is included, unless it is a Saturday, Sunday, or legal holiday, in which event the period runs until the end of the next day that is not a Saturday, Sunday, or legal holiday. Saturdays, Sundays, and legal holidays are not counted for any purpose in any time period of five days or less in the rules under this subchapter.(c) In computing the time periods required for filing a motion for reconsideration (§101.943 of this subchapter (relating to Motion for Reconsideration)) and for appealing a final decision of an IHO to a court (§101.945 of this subchapter (relating to Civil Action)), Saturdays, Sundays, and legal holidays are included. Source Note: The provisions of this §100.599 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.599 Computation of Time https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226586 03/12/2026 (a) This division establishes procedures under which an applicant or eligible person may appeal a determination made either by the Division for Blind Services or by the Division for Rehabilitation Services that affects the provision of vocational rehabilitation services, independent living services, and comprehensive rehabilitation services for that applicant or eligible person.(b) The provisions of this subchapter shall not be construed so as to enlarge, diminish, modify, or alter the jurisdiction, powers, or authority of DARS or the substantive rights of any person. Source Note: The provisions of this §100.651 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.651 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226587 03/12/2026 (a) The following statutes and regulations authorize the procedures established by this chapter:(1) The Rehabilitation Act of 1973, as amended, 29 U.S.C. §701 et seq. and regulations of the Department of Education, Rehabilitation Services Administration, 34 C.F.R. §361.57 et seq., as amended;(2) Texas Human Resources Code, Chapter 91 (concerning vocational rehabilitation services for the people who are blind and visually impaired);(3) Texas Human Resources Code, Chapter 111 (concerning vocational rehabilitation services for people with disabilities); and(4) Texas Administrative Procedure Act, Texas Government Code, Chapter 2001, as amended.(b) The procedures in this division apply to those determinations made by DARS' personnel that affect the provision of vocational rehabilitation services, independent living services, or comprehensive rehabilitation services by DARS.(1) Unless the determination concerns the denial, reduction, suspension or termination of vocational rehabilitation services, independent living or comprehensive rehabilitation services by the Department, it is not subject to review under the procedures of this subchapter.(2) The following decisions or determinations are not subject to review under this subchapter:(A) administrative decisions that are made by DARS' supervisors or managers without reference to any specific applicant or consumer and that apply generally to the provision of vocational rehabilitation services to applicants or consumers, including to those concerning the assignment of personnel;(B) decisions, diagnoses, or judgments made by, or actions or omissions of third-party vendors or service providers;(C) decisions concerning the content of an applicant's or consumer's record of service for which remedies are provided under 34 C.F.R. §361.38(c)(4) and §361.47(a)(12); and(D) decisions allegedly violating any state or federal antidiscrimination or civil rights statute (as amended), including the provisions of Texas Labor Code, Chapter 21; Rehabilitation Act of 1973; Section 504, the Americans with Disabilities Act; or Age Discrimination in Employment Act.(c) Ineligibility. The following may challenge a determination of ineligibility through the procedures of this division:(1) applicants who are found not to be eligible for vocational rehabilitation services; and(2) previously eligible individuals who have been determined no longer eligible for vocational rehabilitation services under 34 C.F.R. §361.43.(d) A person's decision to seek an informal resolution to matters about which the person is dissatisfied shall not prevent, compromise, or delay the person's access to formal resolution procedures in this division.(e) DARS shall not suspend, reduce, or terminate vocational rehabilitation services being provided to an applicant or consumer, including evaluation and assessment services and the development of an Individualized Plan for Employment, pending a resolution of the applicant's or consumer's appeal by mediation or hearing unless:(1) the applicant or consumer requests a suspension, reduction, or termination of services; or(2) DARS has evidence that the applicant or consumer obtained the services through misrepresentation, fraud, collusion, or criminal conduct. Source Note: The provisions of this §100.653 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.653 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226588 03/12/2026 The words and terms defined in §101.905 of this subchapter (relating to Definitions), when used in this division, have the same meanings unless the context clearly indicates otherwise. The use of the singular or plural is not meant to be limiting unless the context clearly indicates otherwise. Source Note: The provisions of this §100.655 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.655 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226589 03/12/2026 (a) Any applicant or eligible individual who is dissatisfied with a determination, as described in §101.1003 of this subchapter (relating to Legal Authority), made either by the Division for Blind Services or the Division for Rehabilitation Services may request a review of the determination. Although no prescribed form is required to file a request, preprinted forms for this purpose are maintained in every DARS office and are available upon request.(b) The request for a review shall be filed in writing with the hearings coordinator, DARS Legal Services.(1) A request shall be considered filed on the day that it is received by the hearings coordinator.(2) Preprinted forms for this purpose are available upon request either from the hearings coordinator, DARS Legal Services, or from any DARS office.(c) Upon receiving a request for review, the hearings coordinator, DARS Legal Services, shall, within five working days, mail the appellant:(1) the name, address, and phone number of the Client Assistance Program established under federal law;(2) the name of the impartial hearing officer appointed to hear the appeal, and the date, time, and place of any prehearing;(3) a copy of applicable hearing procedures; and(4) notice that the appellant has the right to request mediation procedures.(d) Timeliness of a request for review. A request is considered timely if it is received by DARS no later than 180 days from the date of the determination that is the subject of an applicant's or eligible individual's request for review. Source Note: The provisions of this §100.657 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.657 Filing a Request for Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226590 03/12/2026 (a) All filings shall be sent to DARS, 4800 North Lamar, Suite 300, Austin, Texas 78756, with the notation "Attention: Hearings Coordinator," or delivered to DARS at that address.(b) A copy of all filings shall be sent by mail or otherwise delivered to all parties.(c) A certificate of service shall be contained in or attached to all filings. The certificate must be signed by the person making the filing, show the manner of service, state that the filing has been served on all other parties, and identify those parties. The certificate is prima facie evidence of service. Source Note: The provisions of this §100.659 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.659 Filings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226591 03/12/2026 (a) Written Discovery. Requests for disclosure of information shall be the only form of written discovery that the parties are entitled to make. Unless a party is ordered by the IHO during a pretrial conference to disclose other information in addition to the items in this section, a party may request in writing that the other party disclose or produce the following:(1) the names, addresses, and phone numbers of persons having knowledge of relevant facts, including those who might be called as witnesses and any expert who might be called to testify;(2) for any testifying expert:(A) the subject matter on which the expert will testify;(B) the expert's summary; and(C) a brief summary of the substance of the expert's mental impressions and opinions and the basis for them; and all documents and tangible things reflecting such information;(3) the issues and in general the factual basis for a party's claims and defenses in the appeal; and(4) information concerning the appellant's employment, including the appellant's job application with the appellant's current employer and any personnel evaluations.(b) Subject to the provisions in this section, parties may obtain discovery regarding any matter that is relevant to a claim or defense in the appeal.(c) All discovery requests should be directed to the party from which discovery is being sought.(d) All disputes with respect to any discovery matter shall be filed with and resolved by the impartial hearing officer.(e) All parties shall be afforded a reasonable opportunity to file objections and motions to compel with the impartial hearing officer regarding any discovery requests.(f) Copies of discovery requests and documents filed in response thereto shall be filed on all parties, but should not be filed with the impartial hearing officer or the hearings coordinator unless directed to do so by the impartial hearing officer or when in support of objections, motions to compel, motions for protective order, or motions to quash.(g) Any documents contained in any file of DARS related to the appellant are considered to be admissible. DARS must, without awaiting either an order or a discovery request under subsection (a) of this section, provide to the appellant a complete copy of the appellant's record of services, as described in 34 C.F.R. §361.47, including any electronically stored or preserved records. Source Note: The provisions of this §100.661 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.661 Discovery and Mandatory Disclosures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226592 03/12/2026 (a) Documentary evidence may be received in the form of copies or excerpts if the original is not readily available. On request, parties shall be given an opportunity to compare the original and the copy or excerpt.(b) When numerous similar documents that are otherwise admissible are offered into evidence, the impartial hearing officer may limit the documents received to those that are typical and representative. The impartial hearing officer may also require that an abstract of relevant data from the documents be presented in the form of an exhibit, provided that all parties be given the right to examine the documents from which such abstracts were made.(c) The following laws, rules, regulations, and policies are officially noticed:(1) The Rehabilitation Act of 1973, as amended, 29 U.S.C. §701, et seq.;(2) Department of Education regulations, 34 C.F.R. Parts 361, 363, 364, 365, and 367;(3) Texas Human Resources Code, Chapter 91 and Chapter 111;(4) Department of Assistive and Rehabilitative Services, Division for Blind Services' and Division for Rehabilitation Services' State Plan for Vocational Rehabilitation Services;(5) Department of Assistive and Rehabilitative Services, Division for Blind Services, Vocational Rehabilitation and Independent Living Manuals; and Division for Rehabilitation Services, Rehabilitation Policy Manual;(6) Texas Administrative Code, Title 40, Part 2, Department of Assistive and Rehabilitative Services.(d) Official notice also may be taken of:(1) all facts that are judicially cognizable; and(2) generally recognized facts within the area of DARS' specialized knowledge. Source Note: The provisions of this §100.663 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.663 Documentary Evidence and Official Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226593 03/12/2026 (a) Within 30 days of the hearing completion date, the impartial hearing officer shall issue a decision that is based on the evidence and which is consistent with the provisions of the approved state plan; the Rehabilitation Act of 1973, as amended; federal vocational rehabilitation regulations and state regulations and policies that are consistent with federal requirements, and shall provide to the appellant or, if appropriate, the appellant's authorized representative, and DARS' authorized representative or DARS Legal Services, as appropriate, a full written report of the findings of fact, conclusions of law, and any other grounds for the decision.(b) The hearing completion date is the date upon which the impartial hearing officer receives the transcript, if any was prepared, of the oral hearing, or, if no transcript was prepared, the date of the adjournment of the hearing.(c) The decision shall address each issue considered by the impartial hearing officer.(d) The impartial hearing officer may prescribe such remedies as are appropriate within the scope of, and permitted by, the Human Resources Code, Chapters 91 and 111; Rehabilitation Act; the regulations of Rehabilitation Services Administration of the Department of Education; and DARS' policies and rules.(1) The impartial hearing officer may not award restitutionary, compensatory, or monetary relief, including monetary damages to any party.(2) The impartial hearing officer may not prescribe an action affecting the employment of a DARS employee. Source Note: The provisions of this §100.665 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.665 Impartial Hearing Officer Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226594 03/12/2026 The decision of the impartial hearing officer is the final decision of DARS, and, if no timely motion for reconsideration is filed, becomes the final decision of DARS. Source Note: The provisions of this §100.677 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.667 Finality of the Hearing Officer's Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226817 03/12/2026 If a party brings a civil action to challenge a final decision of an impartial hearing officer, the final decision involved shall be implemented pending review by the court. Source Note: The provisions of this §100.669 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.669 Implementation of Final Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226596 03/12/2026 Either party to a hearing may file a motion for reconsideration with the hearings coordinator, DARS Legal Services, as provided in §101.943 of this subchapter (relating to Motion for Reconsideration). Source Note: The provisions of this §100.671 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.671 Motion for Reconsideration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226598 03/12/2026 A party aggrieved by a final decision may bring an action for judicial review as provided in §101.945 of this subchapter (relating to Civil Action). Source Note: The provisions of this §100.673 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.673 Appeal of Final Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226619 03/12/2026 This division is intended to bring DARS procedures for hearings into compliance with Part C of the Individuals with Disabilities Education Act, and the applicable federal regulations, 34 C.F.R. §303.1 et seq. This division supplements existing DARS rules governing hearings and is intended to be applied together except where a conflict exists, in which case this division shall prevail. Source Note: The provisions of this §100.691 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.691 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226620 03/12/2026 (a) Applicability. This division applies only to hearings which involve the identification, evaluation, placement, or provision of appropriate early intervention services to a child and the child's family under Early Childhood Intervention. This process is also referred to as the due process complaint process or due process hearing process.(b) Request for hearing.(1) A parent may initiate a hearing on any matter described in subsection (a) of this section and in §101.907 of this subchapter (relating to Filing a Request for Review).(2) The request for hearing must be in writing and filed as provided in §101.907 of this subchapter with the ECI assistant commissioner. The request for hearing is considered filed when actually received by the ECI assistant commissioner.(c) Impartial hearing officer.(1) Hearings shall be conducted by an impartial hearing officer appointed and selected as provided in §101.911 of this subchapter (relating to Assignment of Impartial Hearing Officer) and §101.915 of this subchapter (relating to Substitution of Impartial Hearing Officer). The impartial hearing officer must be a person who in addition to the qualifications listed in §101.911 of this subchapter:(A) is knowledgeable about the provision of ECI comprehensive services;(B) is knowledgeable about the provisions for ECI due process hearings, the needs of children and families, and the services available to the child and family;(C) will listen to viewpoints about the due process complaint, examine information relevant to the issues, and seek to reach timely resolution of the due process complaint; and(D) will provide a record of the proceedings, including a written decision.(2) The person must not be an employee of DARS or any program involved in the provision of services or care to the child or the child's family, or have a personal or professional interest that would conflict with his or her objectivity in the hearing.(3) A person is not an employee of an agency solely because the person is paid to implement the complaint resolution or hearing process.(d) Hearing rights. In addition to those rights provided parties to a hearing under Division 1 of this subchapter (relating to General Rules), a party to a hearing shall have a right to:(1) be accompanied and advised by counsel and by individuals with special knowledge or training with respect to early childhood intervention comprehensive services;(2) prohibit the introduction of any evidence at the hearing that has not been disclosed to that party at least five days before the hearing;(3) obtain a written or electronic verbatim record of the hearing; and(4) obtain written findings of fact, conclusions of law, and decision.(e) Hearing procedures. In addition to the procedures provided in Division 1 of this subchapter:(1) The impartial hearing officer shall afford the parties an opportunity for hearing after reasonable notice of not less than 10 days, unless the parties have agreed otherwise.(2) The impartial hearing officer may issue subpoenas and commissions to take depositions under the Government Code, Chapter 2001. Subpoenas and commissions to take depositions shall be issued in the name of DARS.(3) The impartial hearing officer shall issue a final decision no later than 30 days after a request for hearing is filed. A final decision must be in writing and shall include findings of fact and conclusions of law, separately stated. Findings of fact must be based exclusively on the evidence and on matters officially noticed under the Government Code, Chapter 2001. The final decision shall be transmitted to each party by the hearing officer.(4) A hearing officer may grant specific extensions of time beyond the period set out in paragraph (3) of this subsection at the request of a party.(5) Hearings conducted under these sections are closed to the public unless the parent requests that the hearing be open.(f) Child's status during proceedings.(1) During the pendency of any administrative proceeding regarding a due process complaint, unless the parties agree otherwise, the child involved in the complaint must continue to receive appropriate comprehensive services previously agreed upon.(2) If the complaint involves an application for initial admission to a program, the child must receive those comprehensive services not in dispute. Source Note: The provisions of this §100.693 adopted to be effective March 12, 2012, 37 TexReg 1706; amended to be effective December 31, 2012, 37 TexReg 9785; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.693 Administrative Hearings Concerning Individual Child Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226621 03/12/2026 A party aggrieved by a final decision may bring an action for judicial review as provided in §101.945 of this subchapter (relating to Civil Action). Source Note: The provisions of this §100.695 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.695 Appeal of Final Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226622 03/12/2026 In all cases, as applied to this Division, days means calendar days. Even when the last day is on a weekend, holiday or non-business day, the time expires on that day. Source Note: The provisions of this §100.697 adopted to be effective December 31, 2012, 37 TexReg 9785; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.697 Computation of Time https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226603 03/12/2026 This division establishes rules and procedures for hearings conducted under Texas Human Resources Code, Chapter 81, and Texas Government Code, Chapter 57, whenever DARS proposes to suspend or revoke a certificate or place a certificate holder on probation. Source Note: The provisions of this §100.725 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.725 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226604 03/12/2026 (a) The provisions of Texas Human Resources Code, Chapters 81 and 82; Texas Occupations Code, Chapter 53; and Texas Government Code, Chapters 57 and 2001, authorize these rules and procedures.(b) Except as otherwise noted in this division, the rules and procedures of this division apply to all certificate holders, including certified court interpreters. Source Note: The provisions of this §100.727 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.727 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226605 03/12/2026 (a) The words and terms defined in §101.905 of this subchapter (relating to Definitions), when used in this division, have the same meanings unless the context clearly indicates otherwise. The use of the singular or plural is not meant to be limiting unless the context clearly indicates otherwise.(b) Board for Evaluation of Interpreters--Refers to the DARS certification programs for interpreters for persons who are deaf and hard of hearing created under Texas Human Resources Code §81.007.(c) Board for Evaluation of Interpreters Advisory Board--Refers to the advisory board appointed by the Executive Commissioner of the Health and Human Services Commission, or the Executive Commissioner's designee, to assist DARS in administering DARS' interpreter certification programs, and authorized under Texas Human Resources Code §81.007.(d) Certificate holder--An interpreter who was issued a certificate by DARS under Texas Human Resources Code, Chapter 81, or Texas Government Code, Chapter 57. Unless otherwise noted, certificate holder and interpreter have the same meaning.(e) Consumer--Includes any individual, whether deaf, hearing impaired, or hearing, who is part of an interpreted conversation. (f) Director--The director of the Office for Deaf and Hard of Hearing Services, Division for Rehabilitation Services, Department of Assistive and Rehabilitative Services.(g) DHHS--The Office for Deaf and Hard of Hearing Services, which is part of the Department of Assistive and Rehabilitative Services, Division for Rehabilitation Services. Source Note: The provisions of this §100.729 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.729 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226606 03/12/2026 Unless otherwise provided in this division, the rules and procedures in Division 1 of this subchapter (relating to General Rules), shall govern hearings conducted under this division. Source Note: The provisions of this §100.731 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.731 Rules and Procedures Governing Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226607 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226607 03/12/2026 (a) DHHS, on its own determination or based on the recommendation of the Advisory Board to the Board for Evaluation of Interpreters, may revoke or suspend a certificate or place a certification holder on probation for a violation of a statute, rule, or policy of DARS. If a certificate holder is placed on probation, DHHS may require the practitioner:(1) to report regularly to DHHS on matters that are the basis of the probation;(2) to limit practice to those areas prescribed by DHHS; or(3) to continue or renew professional education until a satisfactory degree of skill has been attained in those areas that are the basis of the probation.(b) Emergency Suspension. DHHS, through its director, may issue an emergency suspension order to any BEI certificate holder, except for BEI certified court interpreters, if the director has reasonable cause to believe that the conduct of the certified interpreter creates an imminent danger to public health or safety.(1) An emergency suspension issued by the DHHS is effective immediately without a hearing or notice to the certificate holder. Notice to the certificate holder shall be presumed established on the date that a copy of the signed emergency suspension order is sent to the certificate holder at the address shown in the current records of DARS.(2) A copy of the emergency suspension order is sent to all government entities, institutions, or facilities with which the certificate holder is known to be associated.(3) If a written request for a hearing is received from the suspended certificate holder within 15 days of the date of the emergency suspension notice, DARS shall conduct a hearing not later than the 30th day after the date on which a hearing request is received to determine if the emergency suspension will be continued, modified, or rescinded. Any written request for a hearing received after 15 days from the date of the emergency suspension notice is governed by §101.1215 of this subchapter (relating to Filing a Request for Hearing).(c) Revocation or suspension of certification of a certified court interpreter. DARS may revoke or suspend a court interpreter certification under this subchapter only after a hearing. DARS may reissue a court interpreter certificate to a person whose court interpreter certificate has been revoked if the person applies in writing to DARS and shows good cause to justify reissuance of the certificate. Copies of procedures for submitting applications for reissuance after revocation of a court interpreter certificate may be obtained from DHHS. Source Note: The provisions of this §100.733 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.733 Revocation and Suspension of a Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226608 03/12/2026 DHHS may deny application; suspend or revoke certification; or otherwise discipline, reprimand, or place on probation a certificate holder for any of the following causes:(1) violations of federal or state laws that are substantiated by credible evidence, whether or not there is a complaint, indictment, or conviction, such violations include, but are not limited to, the following:(A) any felony, including homicide, rape, sexual abuse of a child, indecency with a child, injury to a child, aggravated assault, robbery, burglary, theft, forgery, bribery, and perjury;(B) any Class A or Class B misdemeanor involving moral turpitude that involves dishonesty, fraud, deceit, misrepresentation, or deliberate violence, or that reflects adversely on the certificate holder's honesty, trustworthiness, or fitness to interpret under the scope of the person's certificate; or(C) any offense, excluding an offense punishable as a Class C misdemeanor, involving theft or controlled substances;(2) engaging in sexually inappropriate behavior with or comments directed at a consumer, including individuals who are part of the interpreted situation;(3) using or being under the influence of drugs, whether or not controlled, or intoxicating liquors to an extent that affects the interpreter's professional competence;(4) impersonating another person who holds an interpreter certification from DARS;(5) allowing another person to use the certificate holder's certificate or five-year certificate renewal documents;(6) misrepresenting oneself or another interpreter as having a certification awarded by DARS or as having a certification level different from the actual level of certification awarded by DARS;(7) using fraud; deception, which includes cheating; or misrepresentation on an application for certification during the certification examination, or in the annual certificate maintenance or five-year certificate renewal process;(8) violating or aiding in the violation of the Code of Professional Conduct described in §101.1213(a)(1) of this subchapter (relating to Codes of Professional Conduct and Ethics) or, with respect to certified court interpreters only, of the Code of Ethics and Professional Responsibility of Certified Court Interpreters described in §101.1213(a)(2) of this subchapter;(9) being grossly incompetent or grossly negligent in performing the duties as an interpreter; or having demonstrated repeated and/or continuous negligence or irresponsibility in the performance of the duties;(10) being adjudicated mentally incompetent by a court of competent jurisdiction;(11) intentionally harassing, abusing, or intimidating, either physically or verbally, a consumer, including individuals who are part of the interpreted situation; a board member; a rater; or any staff member of DARS;(12) intentionally divulging or using inappropriately any aspect of confidential information relating to the certification examination including content, topic, vocabulary, identity of individuals involved in the tests, skills, written test questions, and any other testing materials considered confidential;(13) failure to meet requirements for annual certificate maintenance or five-year certificate renewal;(14) engaging in the practice of interpreting while identified as a certified interpreter even though certification is suspended;(15) falsifying or providing false documents in support of five-year certificate renewal, by altering original letters, certificates issued through continuing education, or attendance verification;(16) failure to disclose a criminal conviction or providing false or misleading information concerning a criminal conviction;(17) failure to provide information or documentation requested by DARS for any purpose related to certification or the certification program, including information or documentation requested: (A) in consideration of an application for certification, annual certificate maintenance, or five-year certificate renewal; or(B) concerning criminal conviction records.(18) violation of a statute, rule, order, or policy of DARS or the terms or conditions of a probation, suspension, or revocation imposed by DARS. Source Note: The provisions of this §100.735 adopted to be effective March 12, 2012, 37 TexReg 1706; amended to be effective May 1, 2014, 39 TexReg 3445; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.735 Grounds for Denying, Revoking, or Suspending an Interpreter's Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226609 03/12/2026 (a) Applicable Codes of Conduct and Ethics.(1) The Code of Professional Conduct of the National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf, Inc. (RID) shall govern the professional conduct of interpreters/transliterators certified by the Office.(2) The Code of Ethics and Professional Responsibility of Certified Court Interpreters of the Office shall govern the professional conduct of court interpreters certified under Texas Government Code, Chapter 57.(A) The Code of Professional Conduct of the National Association of the Deaf (NAD) and the Registry of Interpreters for the Deaf, Inc., (RID) govern the professional conduct of interpreters and transliterators certified by DHHS.(B) The Code of Ethics and Professional Responsibility of Certified Court Interpreters of DHHS governs the professional conduct of court interpreters certified under Texas Government Code, Chapter 57.(b) Willful violation of either the NAD-RID Code of Professional Conduct or the Code of Ethics and Professional Responsibility of Certified Court Interpreters is grounds for suspension or revocation of certification under §101.1211 of this subchapter (relating to Grounds for Denying, Revoking, or Suspending an Interpreter's Certificate).(c) Copies of the Codes.(1) Copies of the NAD-RID Code of Professional Conduct may be obtained from the National Association of the Deaf, from the Registry of Interpreters for the Deaf, Inc., or from DHHS.(2) Copies of the Code of Ethics and Professional Responsibility of Certified Court Interpreters may be obtained from DHHS. Source Note: The provisions of this §10.737 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.737 Codes of Professional Conduct and Ethics https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226610 03/12/2026 (a) A certificate holder, other than a certified court interpreter, whose certificate DARS proposes to suspend, revoke, or place on probation, may request a hearing. A certified court interpreter's certificate may be suspended or revoked by DARS only after a hearing.(b) Although no prescribed form is required to file a request, preprinted forms for this purpose are maintained by DHHS and are available upon request.(c) The request for hearing shall be filed in writing with the hearings coordinator, DARS Legal Services. A request is considered filed on the day that it is received by the hearings coordinator. (d) Upon receiving a request for review, the hearings coordinator, DARS Legal Services, within five business days, shall notify the certificate holder of the name of the impartial hearing officer appointed to hear the appeal, and the date, time, and place of any prehearing.(e) Timeliness of a request for hearing. Except as prescribed in §101.1209(b) of this subchapter (relating to Revocation and Suspension of a Certificate), relating to a hearing request on an emergency suspension, unless good cause is shown, a request shall be considered timely if it is received by DARS' hearings coordinator no later than 60 days from the date the certificate holder is served according to Government Code, §2001.054(c) with written notice of DARS' proposal to revoke or suspend the certificate holder's certificate or place the certificate holder on probation. Source Note: The provisions of this §100.739 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.739 Filing a Request for Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226611 03/12/2026 (a) All filings shall be sent to DARS, 4800 North Lamar, Suite 300, Austin, Texas 78756 with the notation "Attention: Hearings Coordinator," or delivered to DARS at that address.(b) A copy of all filings shall be sent by mail or otherwise delivered to all parties.(c) A certificate of service shall be contained in or attached to all filings. The certificate must be signed by the person making the filing, show the manner of service, state that the filing has been served on all other parties, and identify those parties. The certificate is prima facie evidence of service. Source Note: The provisions of this §100.741 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.741 Filings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226612 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226612 03/12/2026 (a) The Texas Government Code, Chapter 2001, governs discovery and the admissibility of evidence.(b) All discovery requests should be directed to the party from which discovery is being sought.(c) All disputes with respect to any discovery matter shall be filed with and resolved by the impartial hearing officer.(d) All parties shall be afforded a reasonable opportunity to file objections and motions to compel with the impartial hearing officer regarding any and all discovery requests.(e) Copies of discovery requests and documents filed in response thereto shall be filed on all parties, but should not be filed with the impartial hearing officer or the hearings coordinator unless directed to do so by the impartial hearing officer or when in support of objections, motions to compel, motions for protective order, or motions to quash. Source Note: The provisions of this §100.743 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.743 Discovery and Evidence https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226613 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226613 03/12/2026 (a) Documentary evidence may be received in the form of copies or excerpts if the original is not readily available. On request, parties shall be given an opportunity to compare the original and the copy or excerpt.(b) When numerous similar documents that are otherwise admissible are offered into evidence, the impartial hearing officer may limit the documents received to those that are typical and representative. The impartial hearing officer may also require that an abstract of relevant data from the documents be presented in the form of an exhibit, provided that all parties be given the right to examine the documents from which such abstracts were made.(c) The following laws, rules, regulations, and policies are officially noticed:(1) Texas Human Resources Code, Chapters 81 and 82;(2) Texas Occupations Code, Chapter 53;(3) Texas Administrative Code, Title 40, Part 2, Chapter 109, Office for Deaf and Hard of Hearing Services, Division for Rehabilitation Services, Department of Assistive and Rehabilitative Services; and(4) where applicable, Texas Government Code, Chapter 57.(d) Official notice also may be taken of:(1) all facts that are judicially cognizable; and(2) generally recognized facts within the area of DARS' specialized knowledge. Source Note: The provisions of this §100.745 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.745 Documentary Evidence and Official Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226614 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226614 03/12/2026 (a) Within 30 days of the hearing completion date, the impartial hearing officer shall issue a decision and shall provide to the appellant or, if appropriate, the appellant's authorized representative, the director, and DARS' authorized representative a full written report of the findings of fact, conclusions of law, and any other grounds for the decision.(b) The hearing completion date shall be that date upon which the impartial hearing officer receives the transcript, if any was prepared, of the oral hearing, or, if no transcript was prepared, the date of the adjournment of the hearing.(c) The decision shall address each issue considered by the impartial hearing officer.(d) The impartial hearing officer may prescribe such remedies as are appropriate within the scope of Texas Human Resources Code, Chapters 81 and 82, and Texas Occupations Code, Chapter 53. Source Note: The provisions of this §100.747 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.747 Impartial Hearing Officer Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226615 03/12/2026 The decision of the impartial hearing officer is the final decision of DARS, and, if no timely motion for reconsideration is filed, becomes the final decision of DARS. Source Note: The provisions of this §100.749 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.749 Finality of the Hearing Officer's Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226616 03/12/2026 If a party brings a civil action to challenge a final decision of an impartial hearing officer, the final decision involved shall be implemented pending review by the court. Source Note: The provisions of this §100.751 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.751 Implementation of Final Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226617 03/12/2026 Either party to a hearing may file a motion for reconsideration with the hearings coordinator, DARS Legal Services, as provided in §101.943 of this subchapter (relating to Motion for Reconsideration). Source Note: The provisions of this §100.753 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.753 Motion for Reconsideration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226618 03/12/2026 A party aggrieved by a final decision may bring an action for judicial review as provided in §101.945 of this subchapter (relating to Civil Action). Source Note: The provisions of this §100.755 adopted to be effective March 12, 2012, 37 TexReg 1706; transferred effective October 31, 2025, as published in the October 17, 2025, issue of the Texas Register, 50 TexReg 6883. 1 HEALTH AND HUMAN SERVICES COMMISSION 100 APPEALS AND HEARINGS P APPEALS AND HEARING PROCEDURES §100.755 Appeal of Final Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211642 03/12/2026 The purpose of this chapter is to describe procedures for hearings under the Administrative Procedure Act, Texas Government Code, Chapter 2001 (relating to Administrative Procedure). Source Note: The provisions of this §110.1 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211643 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context indicates otherwise.(1) Administrative law judge (ALJ)--Unless otherwise specified, ALJ means both a SOAH ALJ and an HHSC ALJ.(2) Commissioner--The Executive Commissioner of HHSC.(3) Contested case--A contested case, as defined in Texas Government Code, §2001.003, to which HHSC is a party.(4) HHSC--The Texas Health and Human Services Commission.(5) Party--HHSC or another person named or admitted to participate in a contested case.(6) PFD--Proposal for decision.(7) SOAH--The State Office of Administrative Hearings.(8) TAC--Texas Administrative Code. Source Note: The provisions of this §110.3 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211636 03/12/2026 (a) The State Office of Administrative Hearings (SOAH) hears a contested case arising from the following Texas Health and Human Services Commission (HHSC) programs, services, or activities:(1) primary home care services;(2) community attendant services;(3) day activity and health services;(4) the Community Living Assistance and Support Services Program;(5) the Home and Community-based Services Program;(6) the Texas Home Living Program;(7) the Deaf-Blind Multiple Disabilities Program;(8) the Medically Dependent Children Program;(9) social services authorized by Title XX of the Social Security Act (42 United States Code §§1397 - 1397f);(10) In-Home and Family Support services for a person without a diagnosis of an intellectual disability;(11) the Program of All-Inclusive Care for the Elderly;(12) licensure, certification, or contracting of a nursing facility, including a determination related to the Resource Utilization Group Classification System or other utilization review;(13) hospice services;(14) licensure or certification of an intermediate care facility for persons with an intellectual disability or related condition;(15) licensure of a nursing facility administrator;(16) licensure of an assisted living facility;(17) licensure of a day activity and health services facility;(18) licensure of a home and community support services agency;(19) the nurse aide registry;(20) the nurse aide training and competency evaluation program;(21) the long-term care regulation and provider investigation employee misconduct registry; and(22) the medication aide program.(b) Before a contested case described in subsection (a) of this section is transferred to SOAH:(1) the HHSC Appeals Division has exclusive jurisdiction over the case;(2) Texas Administrative Code (TAC), Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and this chapter govern the case; and(3) the parties may conduct discovery in accordance with 1 TAC Chapter 357, Subchapter I.(c) SOAH conducts hearings in accordance with 1 TAC Chapter 155 (relating to Rules of Procedure) and this chapter.(d) A SOAH administrative law judge issues a proposal for decision (PFD) in accordance with 1 TAC Chapter 155.(e) If a party files PFD exceptions, or a reply to exceptions, the party must comply with 1 TAC Chapter 155. Source Note: The provisions of this §110.5 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.5 Contested Case Heard by SOAH https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211637 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) Appeals Division hears a contested case other than one described in §110.5(a) of this chapter (relating to Contested Case Heard by SOAH).(b) The HHSC Appeals Division conducts a hearing in accordance with Texas Administrative Code (TAC), Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and this chapter.(c) An HHSC administrative law judge (ALJ) schedules a hearing upon request for a hearing date by either party.(d) An HHSC ALJ issues a final order in accordance with 1 TAC §357.498 (relating to Final Orders and Rehearings).(e) If a party files a request for a rehearing, the party must comply with 1 TAC §357.498. Source Note: The provisions of this §110.7 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.7 Contested Case Heard by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211638 03/12/2026 The Texas Health and Human Services Commission (HHSC) Executive Commissioner, or the Executive Commissioner's designee, reviews the proposal for decision (PFD), issued by a SOAH administrative law judge (ALJ). The HHSC Executive Commissioner or the Executive Commissioner's designee may submit exceptions to the PFD in accordance with 1 TAC §155.507. Source Note: The provisions of this §110.9 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.9 Review of SOAH Proposal for Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211639 03/12/2026 After reviewing a proposal for decision (PFD), the Texas Health and Human Services Commission (HHSC) Executive Commissioner or the Executive Commissioner's designee issues a final order in accordance with 1 TAC Chapter 357. Source Note: The provisions of this §110.11 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.11 Issuance and Finality of SOAH Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211640 03/12/2026 (a) A party may file a motion for rehearing in accordance with Texas Government Code 2001 §146(a).(b) A party must file a reply to a motion for rehearing in accordance with Texas Government Code 2001 §146(b).(c) The Texas Health and Human Services Commission (HHSC) Executive Commissioner or the Executive Commissioner's designee shall act on a motion for rehearing not later than the 55th day after the date the decision that is the subject of the motion is signed or the motion for rehearing is overruled by operation of law in accordance with Texas Government Code 2001 §146(c). Source Note: The provisions of this §110.13 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.13 Motion for Rehearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211641 03/12/2026 (a) In accordance with Texas Government Code §2001.145, a decision that is final under this chapter is appealable; however, a timely motion for rehearing is a prerequisite to appeal a decision that is final in accordance with Texas Government Code §146.(b) In accordance with Texas Government Code §2001.171, a person who has exhausted all administrative remedies at the Texas Health and Human Services Commission and who is aggrieved by a final decision in a contested case is entitled to judicial review under Texas Government Code, Chapter 2001.(c) In accordance with Texas Government Code §2001.176(b)(3), filing a petition to initiate judicial review of a contested case does not affect the enforcement of a final decision for which the manner of review authorized by law is other than trial de novo. Source Note: The provisions of this §110.15 adopted to be effective January 1, 2023, 47 TexReg 8679. 1 HEALTH AND HUMAN SERVICES COMMISSION 110 HEARINGS UNDER THE ADMINISTRATIVE PROCEDURE ACT §110.15 Judicial Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219990 03/12/2026 Subchapter H of this chapter applies only to a DAHS facility that contracts with DADS to provide DAHS under Title XIX or Title XX of the Social Security Act. Source Note: The provisions of this §211.200 adopted to be effective December 1, 2016, 41 TexReg 9327; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.200 Applicability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219991 03/12/2026 The client must meet eligibility requirements described in §48.2915 of this title (relating to Day Activity and Health Services). The physician providing the physician's order cannot be the facility owner or have a significant financial or contractual relationship with the facility. Source Note: The provisions of this §211.201 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective August 31, 2004, 29 TexReg 8382; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.201 Eligibility Requirements for Participation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219992 03/12/2026 A DAHS facility must:(1) contract with DADS to provide DAHS;(2) provide services at least 10 continuous hours each day, five days a week (Monday through Friday), except for published holidays;(3) serve eligible clients, unless a DAHS facility is at licensed capacity;(4) participate in the Child and Adult Care Food Program (CACFP);(5) submit documentation of participation in the CACFP to DADS consisting of a copy of the CACFP agreement or a copy of the approval letter for participation in the CACFP, or both;(6) advise the individual of the individual's rights in a language the individual understands, provide the individual with a signed copy, and maintain the original in the record; and(7) comply with Chapter 49 of this title (relating to Contracting for Community Services). Source Note: The provisions of this §211.202 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective October 1, 2000, 25 TexReg 9644; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective September 1, 2014, 39 TexReg 6679; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.202 Program Overview https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219995 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219995 03/12/2026 (a) DAHS facilities receive written referrals from caseworkers based on the following priorities:(1) client's choice;(2) physician's choice, if stated; and(3) rotation of eligible providers.(b) When a DAHS facility receives a referral from the caseworker, the DAHS facility nurse must make every effort to request prior approval for the client within 14 days after the referral date on DADS' authorization for community care services form.(c) If the DAHS facility cannot request prior approval within 14 days, the DAHS facility must notify the caseworker about the reason for delay. This notification must be sent on DADS' Case Information form within 14 days after the referral date.(d) Within the same 14 days after receipt of DADS' authorization for community care services form from the caseworker and before requesting prior approval, the nurse must conduct a health assessment/plan of care with the client, using DADS' Client Health Assessment/Plan of Care form. If the client is unable to participate due to cognitive impairment, the client's responsible party should participate.(e) If the nurse cannot conduct the health assessment within 14 days after the referral date, the DAHS facility must notify the caseworker about the reason for delay on DADS' Case Information form within the 14-day period.(f) Within the same 14 days after receipt of DADS' authorization for community care services form from the caseworker, the nurse must obtain a physician's order for the client by sending DADS' Physician's Order for Day Activity and Health Services form to the client's physician. The nurse sends a copy of DADS' Client Health Assessment/Plan of Care form to the physician.(g) If the DAHS facility cannot obtain physician's orders within 14 days after the referral date, the DAHS facility must notify the caseworker about the reason for delay. The notification must be sent on DADS' Case Information form within the 14-day period. DADS' Case Information form must include the date of the health assessment/plan of care and must be dated after the health assessment/plan of care date, if one has been conducted.(h) If the physician fails to date DADS' Physician's Order for Day Activity and Health Services form or if the signature date is illegible, the DAHS facility stamp-in date will be considered the date of the physician's order. The date stamp must include the day, month, year, and the name of the DAHS facility. An abbreviated name or initials are acceptable. Source Note: The provisions of this §211.203 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective October 1, 2000, 25 TexReg 9644; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.203 Written Referrals for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219993 03/12/2026 (a) The applicant may be admitted to a day activity and health services DAHS facility as soon as verbal physician's orders are obtained if he appears to:(1) be Medicaid eligible; and(2) meet the medical/functional need criteria based on the information collected on DADS' Client Health Assessment/Plan of Care form.(b) When a DAHS facility initiates a referral:(1) the DAHS facility interviews the applicant to determine whether he appears to be Medicaid eligible. The DAHS facility determines Medicaid eligibility by reviewing the information on the applicant's Medical Care Identification Card;(2) the nurse:(A) conducts a health assessment/plan of care to determine whether the applicant appears to have a medical need for the service. The nurse determines medical need by completing DADS' Client Health Assessment/Plan of Care form; and(B) obtains verbal or written physician orders, if the applicant appears to meet the medical/functional need criteria;(3) the DAHS facility verbally notifies the DADS caseworker or intake unit of the placement the day the applicant contacts the DAHS facility. The DAHS facility follows up the notification in writing within seven days using DADS' Case Information form. This verbal notification is a request for community services and supports.(c) The DAHS facility must request written prior approval for the applicant from the regional nurse within 30 days after the date of the physician orders.(d) If the DAHS facility fails to submit prior approval forms or additional documentation within required time frames, if the additional documentation is not adequate, or if the applicant is determined ineligible by the DADS caseworker, the regional nurse cancels the DAHS facility-initiated prior approval and the DAHS facility is not reimbursed for services.(e) If DADS' Client Health Assessment/Plan of Care form or Physician's Order for Day Activity and Health Services form is missing, or if any of the critical omissions or errors stated in paragraphs (1) - (9) of this subsection have occurred in the required documentation, the DAHS facility cannot obtain prior approval.(1) The nurse fails to sign or date DADS' Client Health Assessment/Plan of Care form or omits the registered nurse/licensed vocational nurse credentials that should follow his signature.(2) Documentation on DADS' Client Health Assessment/Plan of Care form does not support the medical eligibility criteria specified in §98.201 of this title (relating to Eligibility Requirements for Participation).(3) Items A, B, in Sections II and III of DADS' Client Health Assessment/Plan of Care form are not completed or completed incorrectly and medical need cannot be determined.(4) DADS' Physician's Order for Day Activity and Health Services form does not include the MD or DO credential of the physician who signed the form.(5) DADS' Physician's Order for Day Activity and Health Services form does not include the license number of the physician who signed it.(6) The physician who signed the order is excluded from participation in Medicare or Medicaid.(7) The physician's signature is not on DADS' Physician's Order for Day Activity and Health Services form.(8) The physician's signature date is missing or illegible and the DAHS facility's stamped date is missing from DADS' Physician's Order for Day Activity and Health Services form.(9) The DAHS facility's stamped date used instead of the physician's date on DADS' Physician's Order for Day Activity and Health Services form does not include the provider agency's name, abbreviated name, or initials. Source Note: The provisions of this §211.204 adopted to be effective May 1, 1999, 24 TexReg 3100 amended to be effective August 31, 2004, 29 TexReg 8382; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.204 DAHS Facility-Initiated Referrals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219994 03/12/2026 (a) The DAHS facility must initiate services within seven days after the beginning date of coverage in Item 4 of DADS' Authorization for Community Care Services.(b) If the DAHS facility does not initiate services within the seven-day period, the DAHS facility must notify the caseworker, using DADS' Case Information form, by the eighth day after the beginning date of coverage in Item 4 of DADS' Authorization for Community Care Services. DADS' Case Information form must include the reasons for the delay and the date when services are scheduled to begin.(c) The DAHS facility must complete and return DADS' authorization for community services form to the caseworker within 14 days after the beginning date of coverage in Item 4 of DADS' authorization for community care services form. The DAHS facility must indicate the date services were initiated, the schedule for delivering services, and the total units authorized for the client. Source Note: The provisions of this §211.205 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2000, 25 TexReg 2403; amended to be effective October 1, 2000, 25 TexReg 9644; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.205 Initiation of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219996 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219996 03/12/2026 The DAHS facility must provide services that include the following:(1) Nursing services. Nursing services must include:(A) assessing, observing, evaluation, and documenting an individual's health condition, and instituting appropriate nursing intervention to stabilize or improve an individual's condition or prevent complications;(B) ensuring that the individual plan of care appropriately reflects the physician's orders;(C) assisting the individual to order, maintain, or administer prescribed medications or treatments, as indicated by physician's orders;(D) counseling the individual on his health need and illness and involving significant others in the discussions of his immediate and long-term health goals; and(E) providing or supervising personal care services to enable the individual to restore, maintain, or improve his ability to perform personal care tasks. For purposes of this requirement, personal care is defined as assistance with dressing, feeding, grooming, bathing, toileting, transferring/ambulation, or assistance with self-administering medication.(2) Physical rehabilitative services. Physical rehabilitative services must include:(A) restorative nursing; and(B) group and individual exercises, including range of motion exercises.(3) Nutrition/food service. Nutrition/food service in DAHS facilities is provided under 4 TAC Chapter 25, Subchapter A, concerning the Child and Adult Care Food Program (CACFP) and must include:(A) one hot noon meal served between the hours of 11:00 a.m. and 1:00 p.m. The meal must:(i) be suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of an individual with special needs. The CACFP staff monitor the adequacy of a meal by totaling the amount of food produced and cooked by the number of adults fed to determine if the average amount of food meet the following food components: two ounces of meat, 1/2 cup of fruit/vegetables, one cup of milk, and two servings of bread; and(ii) supply 1/3 of the recommended daily allowance for adults as recommended by the United States Department of Agriculture;(B) special diets as required by the individual's plan of care;(C) a supplementary mid-morning and mid-afternoon snack;(D) dietary counseling and nutrition education for the individual and family; and(E) assisting the individual with his meals if necessary. This includes:(i) food texture modification, including grinding meats and mashing vegetables for an individual having trouble chewing; and(ii) food management, including spoon feeding, bread buttering, and milk opening for an individual with hand deformities, paralysis, or hand tremors.(4) Other supportive services. Other supportive services must include:(A) community interaction, cultural enrichment, educational or recreational activities, and other social activities on site or in the community in a planned program to meet an individual's social needs and interests;(B) providing at least three social activities per day; and(C) posting a monthly activity calendar at least one week in advance.(5) Transportation services.(A) Transportation services must include:(i) transportation to and from the DAHS facility; and(ii) transportation to and from a DAHS facility approved to provide therapies, if an individual requires specialized services on days of attendance at the day activity and health services DAHS facility.(B) If the DAHS facility provides transportation for an individual to a non-therapy medical DAHS facility, the DAHS facility can claim the time spent in transport as part of the unit of services.(C) If the DAHS facility does not provide transportation, the DAHS facility must coordinate transportation with other resources.(D) Vehicles used for transportation services must:(i) be properly operated and maintained in accordance with state law;(ii) have current inspection and registration;(iii) have proper heating and cooling systems to maintain reasonable temperature levels inside the vehicle;(iv) have working seatbelts for each individual unless the vehicle was manufactured without seatbelts;(v) have a method to secure a wheelchair to ensure an individual's safety during transit; and(vi) if equipped with a wheelchair lift, have a properly operated and maintained lift. Source Note: The provisions of this §211.206 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective November 20, 2012, 37 TexReg 9117; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.206 Program Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219997 03/12/2026 (a) The DAHS facility must suspend services before the end of the prior approval period if one or more of the circumstances specified in paragraphs (1) - (10) of this subsection occur:(1) the client leaves the state or moves outside the geographic area served by the DAHS facility;(2) the client dies;(3) the client is admitted to a hospital, nursing home, state school, or state hospital;(4) the client requests that services end;(5) the physician requests that services end;(6) the Health and Human Services Commission (HHSC) denies the client's Medicaid/Title XX eligibility;(7) DADS enforces sanctions against the DAHS facility by terminating the contract;(8) the client threatens the health and safety of himself or others;(9) the client is absent from the DAHS facility for 15 consecutive days;(10) the client becomes ineligible for Medicaid. Each month the DAHS facility must verify that a client has a current HHSC Medical Care Identification Card.(b) No later than the first DADS workday after services are suspended, the DAHS facility must verbally notify the caseworker or staff in the caseworker's office about the reason the DAHS facility suspended services. Written notification on DADS' Case Information form must be sent to the caseworker within seven workdays after the incident that was reported verbally. Source Note: The provisions of this §211.207 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.207 Suspension of Day Activity and Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219998 03/12/2026 (a) If a client becomes ill or injured at the DAHS facility, the director/nurse must notify a relative or other responsible person the same day of the occurrence. Clients with communicable diseases cannot attend the DAHS facility until the physician has released the client. Examples of communicable disease are lice and scabies.(b) No later than the first DADS workday after becoming aware of changes in the client's status or condition, the DAHS facility must verbally notify the caseworker or staff in the caseworker's office about any change that may require a change in the client's plan of care, units, or service termination. The DAHS facility must follow up this verbal notification in writing, to the caseworker, using DADS' Case Information form. Written notification must occur within seven days after verbal notification.(c) If a client is absent from a regularly scheduled program, DAHS facility staff must contact the client or someone knowledgeable about his condition the same day that the absence occurs. If DAHS facility staff are unable to contact the client or someone knowledgeable about his condition, staff document this in the client's record.(d) The DAHS facility must verbally notify DADS by the next DADS workday and in writing within seven days after verbal notification of the following changes in DAHS facility operations:(1) change in operation, telephone number, and location of administrative office;(2) change in hours of operation; and(3) change in director, activities director, nurse, or membership of governing board. Source Note: The provisions of this §211.208 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.208 Notifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219999 03/12/2026 (a) Personnel records. The DAHS facility must keep personnel records in a central location in the DAHS facility. Personnel records include staff qualifications, performance reports, attendance, and staff development records. The DAHS facility must maintain these documents and records according to the retention requirements. The DAHS facility must document staff coverage for days when regular staff are away from the DAHS facility on sick or vacation leave.(b) Attendance records. The DAHS facility must use DADS forms to maintain a daily record of attendance and transportation to and from the DAHS facility, including the time each client began receiving services and the time he left the DAHS facility's care. If transportation is provided by the DAHS facility, driver's transportation records must be used. Arrival and departure times must be documented for clients not using DAHS facility-provided transportation.(c) Transportation records. The DAHS facility driver must maintain accurate daily transportation and mileage records, and records of expenses for purchase of gas and oil. Source Note: The provisions of this §211.209 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.209 Record Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220000 03/12/2026 (a) In the absence of acceptable secondary documentation, financial errors include the errors described in this section.(1) The DAHS facility is reimbursed for services, but DADS Daily Attendance and Daily Transportation Record form is missing for the period for which services are reimbursed. DADS applies the error to the total number of units reimbursed for the billing period.(2) The DAHS facility is reimbursed for units that exceed the units recorded on DADS Daily Attendance and Daily Transportation Record form. DADS applies the error to the total number of units reimbursed in excess of the units recorded.(3) The DAHS facility is reimbursed for units of service and the client did not receive services or was Medicaid ineligible (not applicable to Title XX clients). DADS applies the error to the total number of units reimbursed for the days the client did not receive services or was Medicaid ineligible.(b) Corrections of critical omissions or errors in DAHS facility documentation must be postmarked or date stamped as received by DADS within 14 days after the regional nurse mails DADS Notification of Critical Omissions/Errors in Required Documentation form to the DAHS facility. If the DAHS facility fails to meet this time frame:(1) the date of prior approval can be no earlier than the postmark or DADS-stamped date on the corrected documentation; or(2) DADS may refer the individual to another DAHS facility of the individual's choice.(A) If there is space in another DAHS facility, the regional nurse notifies the case manager by the next workday to give the individual or individual's family/representative the option to be referred to another DAHS facility.(B) The case manager will contact the individual within three workdays after being notified by the regional nurse and refer the individual to another DAHS facility, if the individual or the individual's family/representative prefers this option. Source Note: The provisions of this §211.210 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective September 1, 2014, 39 TexReg 6679; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.210 Financial Errors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220001 03/12/2026 (a) The method of payment is a unit of authorized service and is defined as half a day. One unit of service constitutes three hours but less than six hours of covered services provided by the DAHS facility. Six hours or more of service constitutes two units of service. Time spent in approved transportation provided by the DAHS facility shall be counted in the unit of service.(b) The DAHS facility is not entitled to payment if:(1) the DAHS facility fails to submit prior approval forms or supporting documentation to the regional nurse within the required time frames for DAHS facility initiated referrals;(2) the DAHS facility did not maintain the staff-client ratio for one or more days;(3) the DAHS facility exceeded its license capacity; or(4) the DAHS facility's monthly claims do not correspond to the DAHS facility's service authorizations and DADS' Daily Attendance/Daily Transportation Record form. Source Note: The provisions of this §211.211 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.211 Billing and Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220002 03/12/2026 DADS may deny and recoup funds from a DAHS facility for the days it exceeded its licensed capacity. The amount denied or recouped is two units of service (regardless of the number of units actually provided) for every individual (client, applicant, private pay, etc.) that exceeded the DAHS facility license capacity. Source Note: The provisions of this §211.212 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective September 1, 2014, 39 TexReg 6679; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4935. 1 HEALTH AND HUMAN SERVICES COMMISSION 211 DAY ACTIVITY AND HEALTH SERVICES (DAHS) CONTRACTUAL REQUIREMENTS §211.212 Sanctions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205206 03/12/2026 The Texas Department on Aging develops and maintains the aging services network by designation of planning and service areas and area agencies on aging.(1) Application for designation to become a planning and service area. The Department provides an opportunity to any unit of general-purpose local government or Indian reservation to apply to be designated as a PSA. The State may designate as a planning and service area any unit of general-purpose local government which has a population of 100,000 or more. In any case in which a unit of general-purpose local government makes application to the State agency under this part to be designated a planning and service area, the State agency shall, upon request, provide an opportunity for a public hearing on such application to such unit of general-purpose local government. Public agencies of units of general-purpose local government shall have the right of first refusal for new area agency on aging designation, where the boundaries of the unit of general-purpose local government and the boundaries of the planning and service area are reasonably contiguous.(2) Submission requirements. Applicants for PSA designation shall submit a written application to the Department no later than October 1 of the year preceding development of the State Plan. The application will include the following:(A) the distribution of persons age 60 and older within the proposed PSA in relation to those other counties within the State regional planning area involved delineating those persons age 60 and older with the greatest economic need and greatest social need;(B) a narrative and statistical description of the incidence of need for services supported by the Older Americans Act in the proposed PSA;(C) a list of agencies providing services supported by the Older Americans Act in the proposed PSA;(D) written evidence of approval by resolution of 75% of the general-purpose local government unit and other pictorial information depicting, at a minimum, the state-delineated regional planning areas, Indian reservations, existing economic development district boundaries and areas, boundaries of the state-delineated health services area, and the Department of Human Resources district area;(E) if the proposed PSA's boundaries are not contiguous with an existing designated state regional planning area, but is either a subdivision of or a combination of such areas, a narrative and statistical description shall address, as well, the basis of need for a PSA other than the regional planning areas involved;(F) an applicant that is submitting an application for designation as an interstate PSA shall include the following:(i) written indication of local interstate governmental agency support;(ii) information as required in paragraph (2) of this subsection;(iii) a list and description of those agencies providing aging services within the interstate area involved; and(iv) description of particular local conditions that may affect the written conditions agreed upon by each State as required by federal regulations.(3) Designation of planning and service area (PSA).(A) A proposed PSA shall be coterminous with, a combination of, or a subdivision of State planning regions as delineated by the governor and authorized by Local Government Code, Chapter 391. A proposed PSA should not split an existing PSA.(B) Existing PSAs shall continue to be designated unless the designation of another PSA is necessary for the assurance of the efficient and effective administration of the programs authorized by the Older Americans Act.(C) The Texas Department on Aging (state agency) shall document the basis for its designation of each PSA.(D) State procedures to provide due process to affected parties:(i) the state agency shall provide notice of an action or proceeding to the affected area agencies on aging, grantee organizations and citizens advisory councils by certified mail;(ii) the state agency shall provide in the notice the documentation for the need of the action or proceedings. The documentation will include:(I) statutory authority for the action; and(II) summary of projected impact of action on clients within service areas affected, and the anticipated improvements in service that will result from said action.(iii) the state agency shall conduct a public hearing for the action or proceedings. The state agency shall:(I) register participants at the hearing and tape record oral testimony presented; and(II) receive a report consisting of a summary of all oral testimony received at the hearing, copies of all written testimony, and a list of names of all persons attending. The report on the hearing will be presented in a public meeting of the Board within 30 calendar days of the completion of the hearing.(iv) the state agency shall request written comment from area agencies on aging, service providers, and older individuals on the action or proceedings;(v) the state agency shall allow an appeal to the Assistant Secretary on Aging of the decision of the state agency on the action or proceedings; and(vi) the state agency shall provide a plan for an orderly transition to ensure continuity in the provision of services to older persons in the PSA.(E) Adversely affected parties involved in an action or proceeding described in subparagraph (D) of this paragraph may bring an appeal as provided in subparagraph (F) of this paragraph, relating to appeals to the Assistant Secretary on the basis of the following:(i) the facts and merits of the matter that is the subject of the action or proceeding; or(ii) procedural grounds.(F) Appeals to the assistant secretary. The assistant secretary's decision on the appeal described in subparagraph (E) of this paragraph may affirm or set aside the decision of the State agency. If the Assistant Secretary on Aging sets aside the decision, the state agency shall nullify its action.(4) Hearing procedures for applicants for Planning and Service Area designation.(A) Right to a hearing. Any applicant for designation as a PSA whose application is denied by Department has a right to a hearing to appeal such denial.(B) Request for hearing. A request for hearing must be in writing and must state with specificity the grounds upon which the Department's decision is appealed and all grounds upon which petitioner refutes the basis of Department's decision.(i) The request must include:(I) the dates of all relevant actions;(II) the names of individuals or organizations involved in the action;(III) a specific statement of any section of the Act or regulations believed to have been violated; and(IV) a certified copy of the minutes or resolution in which the applicant's governing body requests a hearing and authorizes a person or persons to act in behalf of the agency or organization. The minutes or resolution shall indicate adoption by a majority of a quorum of the governing body of the agency or organization.(ii) The request for hearing must be filed with the Department within 30 calendar days following petitioner's receipt of the notice of Department's decision.(iii) The petitioner may submit written amendments to the request for hearing which must be received by the Department not less then ten calendar days prior to the hearing date.(iv) The Department may require that additional information as to the basis for appeal be provided to the Department at any time prior to the hearing.(C) Notice of Hearing.(i) Upon receipt of a request for hearing, the Executive Director shall, within ten working days, set a date for the hearing.(ii) The Department shall issue a written notice to the petitioner, which shall include:(I) a statement of time, date, location, and nature of the hearing;(II) a statement of the legal authority and nature of the hearing;(III) a reference to the particular section of statutes, regulations and rules involved; and(IV) a short and plain statement of the reasons for the decision that is being appealed and the evidence on which the decision was based.(iii) If the Department is unable to state in detail the evidence and reasons for the decision at the time the notice is served, the initial notice may be limited to a statement of the issues involved. Thereafter, a more definite and detailed statement shall be furnished not less than three working days prior to the date set for the hearing.(iv) Petitioner shall be given no less than ten working days notice of the scheduled hearing. Notice shall be sent by registered or certified mail, return receipt requested.(D) Hearing examiner. The executive director shall select an impartial hearing examiner to preside at the hearing. The hearing examiner may not be an employee of Department, and the hearing examiner may be but is not required to be an attorney at law. The hearing examiner shall conduct the hearing in an orderly fashion and in accordance with the procedures outlined herein. It is the responsibility of the hearing examiner to fully consider information relevant to the complaint and to draft a fair proposed decision based on such information.(E) Conduct of Hearing. The proceedings and conduct of the hearing shall follow the rules promulgated in 1 TAC Chapter 155, State Office of Administrative Hearing, Chapter 155, Rules of Procedure, et seq.(F) Appeal to the Assistant Secretary, Administration on Aging, U.S. Department of Health and Human Services. Any petitioner whose appeal is denied by the Department may appeal to the Assistant Secretary on Aging. Such appeal shall be governed by the procedures outlined in the current 45 Code of Federal Regulations, Part 1321.(5) Designated Planning and Service Areas. The following are the currently designated planning and service areas in which the Texas Department on Aging operates aging programs for the elderly.(A) PSA 1: Armstrong, Briscoe, Carson, Castro, Childress, Collingsworth, Dallam, Deaf Smith, Donely, Gray, Hall, Hansford, Hartley, Hemphill, Hutchinson, Limpscomb, Moore, Ochiltree, Oldham, Parmer, Potter, Randall, Roberts, Sherman, Swisher, and Wheeler counties.(B) PSA 2: Bailey, Cochran, Crosby, Dickens, Floyd, Garza, Hale, Hockley, King, Lamb, Lubbock, Lynn, Motley, Terry, and Yoakum counties.(C) PSA 3: Archer, Baylor, Clay, Cottle, Foard, Hardeman, Jack, Montague, Wichita, Wilbarger, and Young counties.(D) PSA 4a: Collin, Denton, Ellis, Erath, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, and Wise counties.(E) PSA 4b: Dallas County.(F) PSA 4c: Tarrant County.(G) PSA 5: Bowie, Cass, Delta, Franklin, Hopkins, Lamar, Morris, Red River, and Titus counties.(H) PSA 6: Anderson, Camp, Cherokee, Gregg, Harrison, Henderson, Marion, Panola, Rains, Rusk, Smith, Upshur, Van Zandt, and Wood counties.(I) PSA 7: Brown, Callahan, Coleman, Comanche, Eastland, Fisher, Haskell, Jones, Kent, Knox, Mitchell, Nolan, Runnels, Scurry, Shackelford, Stephens, Stonewall, Taylor, and Throckmorton counties.(J) PSA 8: Brewster, Culberson, El Paso, Hudspeth, Jeff Davis, and Presidio counties.(K) PSA 9: Andrews, Borden, Crane, Dawson, Ector, Gaines, Glasscock, Howard, Loving, Martin, Midland, Pecos, Reeves, Terrell, Upton, Ward, and Winkler counties.(L) PSA 10: Coke, Concho, Crockett, Irion, Kimble, Mason, McCulloch, Menard, Reagan, Schleicher, Sterling, Sutton, and Tom Green counties.(M) PSA 11: Bosque, Falls, Freestone, Hill, Limestone, and McLennan counties.(N) PSA 12: Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, Travis, and Williamson counties.(O) PSA 13: Brazos, Burleson, Grimes, Leon, Madison, Robertson and Washington counties.(P) PSA 14: Angelina, Houston, Jasper, Nacogdoches, Newton, Polk, Sabine, San Augustine, San Jacinto, Shelby, Trinity, and Tyler counties.(Q) PSA 15: Hardin, Jefferson, and Orange counties.(R) PSA 16a: Austin, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Liberty, Matagorda, Montgomery, Walker, Waller, and Wharton counties.(S) PSA 16b: Harris County.(T) PSA 17: Calhoun, Dewitt, Goliad, Gonzales, Jackson, Lavaca, and Victoria counties.(U) PSA 18a: Atascosa, Bandera, Comal, Frio, Gillespie, Guadalupe, Karnes, Kendall, Kerr, Medina, and Wilson counties.(V) PSA 18b: Bexar County.(W) PSA 19: Jim Hogg, Starr, Webb, and Zapata counties.(X) PSA 20: Aransas, Bee, Brooks, Duval, Jim Wells, Kenedy, Kleberg, Live Oak, McMullen, Nueces, Refugio, and San Patricio counties.(Y) PSA 21: Cameron, Hidalgo, and Willacy counties.(Z) PSA 22: Cooke, Fannin, and Grayson counties.(AA) PSA 23: Bell, Coryell, Hamilton, Lampasas, Milam, Mills, and San Saba counties.(BB) PSA 24: Dimmit, Edwards, Kinney, La Salle, Maverick, Real, Uvalde, Val Verde, and Zavala counties. Source Note: The provisions of this §213.1 adopted to be effective August 10, 1994, 19 TexReg 5851; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.1 Designation of Planning and Service Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205207 03/12/2026 The following procedures shall be used to select and designate area agencies on aging.(1) Eligible Entities. The Department shall provide opportunity for the following types of agencies to be designated as an area agency on aging;(A) an established office on aging which operates within a PSA;(B) any office or agency of a unit of general-purpose local government that is proposed by the chief elected official of the unit;(C) any office or agency proposed by the chief elected officials of a combination of units of general-purpose local government; or(D) any other public or private nonprofit agency, except any regional or local agency of the state.(2) Application Procedures. Applicants for area agency designation shall submit a written application to the Department no later than February 1 of the year of development of the state plan. The application shall include:(A) a description of the legal basis upon which the agency is organized;(B) an organizational description and chart of the agency;(C) a list of members serving on the governing board of the agency and the entities they represent;(D) job descriptions of those positions which the agency intends to staff;(E) a copy of the most current agency audit;(F) a copy of the agency's current approved financial plan; and(G) a narrative description of the agency's past relationships with agencies which are providing services to the elderly in their planning and service area.(3) Competing Applications. Any application for area agency designation which, if approved, would result in the replacement of an existing area agency or substantially impact upon the aging network within the PSA involved shall include:(A) written indication by resolution of 75% of the governing bodies of city and counties with the PSA involved;(B) documentation that existing services can be substantially improved through the proposed change in designation; and(C) assurance that no staff or board member of the agency has served on the staff or board of the existing area agency within the affected PSA, Department, or the Administration on Aging for a period of not less than two years prior to the date of notification of application.(4) On-Site Reviews. The local agency being considered for area agency designation shall provide an opportunity for on-site review and assessment by the Department to ensure that said agency has the capacity to perform the functions of an area agency. The on-site assessment shall include but not be limited to:(A) a review of the agency's administrative and fiscal management capability to conform with §254.3 of this title (relating to Support Documents);(B) a review of the agency's capability, through employment and retention of appropriate staff, to develop and administer an area plan for a comprehensive and coordinated system of services;(C) a review of the agency's capability to serve as the advocate and focal point for older Americans in the designated PSA involved; and,(D) a review of the agency's capability to furnish local financial resources and support as required by state and federal law.(5) Effective Dates of Designation. The Department shall designate an area agency in each PSA in which the Department decides to allocate funds under the Older Americans Act no later than March 31 of the year involved in the development of the state plan. Preference will be given to established area agencies and shall take into consideration the historical experience applicant agencies have had in coordinating, planning, and delivering services to the elderly.(6) Designated Area Agencies on Aging. The following is a listing, in alphabetical order, of area agencies which are currently designated in the State. Planning and service area number is indicated as follows:(A) Alamo Area Agency on Aging (18A);(B) Ark-Tex Area Agency on Aging (05);(C) Bexar Area Agency on Aging (18B);(D) Brazos Valley Area Agency on Aging (13);(E) Capital Area Agency on Aging (12);(F) Central Texas Area Agency on Aging (23);(G) Coastal Bend Area Agency on Aging (20);(H) Concho Valley Area Agency on Aging (10);(I) Dallas County Area Agency on Aging (04B);(J) Deep East Texas Area Agency on Aging (14);(K) East Texas Area Agency on Aging (06);(L) Golden Crescent Area Agency on Aging (17);(M) Harris County Area Agency on Aging (16B);(N) Heart of Texas Area Agency on Aging (11);(O) Houston-Galveston Area Agency on Aging (16A);(P) Lower Rio Grande Valley Area Agency on Aging (21);(Q) Middle Rio Grande Area Agency on Aging (24);(R) North Central Texas Area Agency on Aging (04A);(S) North Texas Area Agency on Aging (03);(T) Panhandle Area Agency on Aging (01);(U) Permian Basin Area Agency on Aging (09);(V) Rio Grande Area Agency on Aging (08);(W) South East Texas Area Agency on Aging (15);(X) South Plains Area Agency on Aging (02);(Y) South Texas Area Agency on Aging (19);(Z) Tarrant County Area Agency on Aging (04C);(AA) Texoma Area Agency on Aging (22); and(BB) West Central Texas Area Agency on Aging (07). Source Note: The provisions of this §213.3 adopted to be effective August 10, 1994, 19 TexReg 5851; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.3 Designation of Area Agencies on Aging https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205208 03/12/2026 (a) Background. To the extent feasible, and subject to the availability of funds and other resources, the Department will give rewards to those area agencies on aging which the Department finds have demonstrated exceptional performance. When a contractor has failed to comply with the terms of a contract which governs the use of monies appropriated under that contract, the Texas Department on Aging may take actions, described in this section, as may be legally available and appropriate to the circumstance. It is the intent of this rule to outline the rewards available for compliance with a contract and the sanctions available for non-compliance with contract terms and conditions.(b) Definitions. Definitions for the terms used in this section are located in §254.1 of this title (relating to the Operation of the Texas Department on Aging) and the definitions for words and terms specific to this chapter shall have the following meanings, unless the context clearly indicates otherwise.(1) Level One Sanction - The sanction that the Texas Department on Aging may impose as a response to a contractual breach and/or failure to comply with agency rules and specific state and federal requirements.(2) Level Two Sanction - The sanction that the Texas Department on Aging may impose as a response to a severe problem and the potential negative impact such a problem may have on a Contractor's region or the state.(3) Level Three Sanction - The sanction that the Texas Department on Aging may impose where a severe and/or continued failure to comply with contractual requirements, agency rules, and/or state and/or federal laws may affect service delivery and/or Contractor financial stability.(4) Level Four Sanction - The sanction that the Texas Department on Aging may impose where a severe and/or continued failure to comply with contractual requirements, agency rules, and/or state and/or federal laws continues to go uncorrected.(5) Acceptable corrective action plan - Identification of actions to be taken, including a time line, that are acceptable to the Department to correct an identified issue of contractual or legal non- compliance.(6) Administrative payments - Payments for general administration of an Area Agency on Aging, including any indirect costs recovery.(7) Certified - When used in conjunction with performance measure testing it describes having obtained acceptable results, within tolerances allowed by the State Auditor's Office, for data tested.(8) Discretionary funds - Any funds issued by the Department that are not awarded based on a general funding formula or not awarded to all Area Agencies on Aging by action of the Texas Board on Aging.(9) Extension - An approved request, which is submitted to the Department on or before the original due date, to submit required reports or other required information later than the established original due date. No more than 2 extensions shall be granted in any one federal fiscal year.(c) Preventive Maintenance. Preventive maintenance measures, developed to ensure program outcome and provide fiscal accountability, include technical assistance, Program Instructions, timely and effective program and fiscal monitoring, performance measure testing, and quality initiative reviews.(1) Technical assistance is performance-driven and outcome-based, stressing the sharing of information and best practice models. Assistance is provided for both fiscal and program issues.(2) Program Instructions provide clarification and interpretation of rule and are performance- driven and outcome-based. Program Instructions may be provided for both fiscal and program issues.(3) Program and Fiscal Monitoring assistance may include site visits, desk reviews, and analysis of both financial and program outcomes to help identify potential weaknesses before such weaknesses result in sub-standard performance or questioned costs. Monitoring may result in recommendations that provide practical solutions that can be used to take immediate corrective action.(4) Performance measure testing is conducted to determine the accuracy of data submitted to the Department and to assess the quality of the controls in place to ensure the consistency of accurate and well-documented data. Certification of performance measure testing should be by design of the controls in place within the system.(5) Quality Initiative assistance includes routine evaluation of essential quality indicators and certification systems and will be enhanced with timely and relevant professional training and technical assistance to help develop and maintain the knowledge, skills, and abilities required across program lines.(d) Contractor Responsibilities. A contractor is responsible for compliance with the terms of the contract and shall:(1) comply, as applicable, with all governing documents set forth in §254.3 of this title (relating to Governing Documents);(2) comply with the requirements of approved contracts or plans;(3) meet the administrative and service requirements as published by the Department, including, but no limited to, all budget documents and required reporting in a timely, complete, and accurate manner, consistent with §260.1 of this title (relating to Area Agency on Aging Administrative Requirements), and §260.2 of this title (relating to Area Agency on Aging Fiscal Responsibilities);(4) respond to requests by the Department for specific correction as a result of:(A) the area plan or area plan amendment review;(B) program and fiscal reviews, monitoring and assessments;(C) investigation and response to complaints; or(D) erroneous or incomplete information on program performance or financial reports.(e) Rewards. Rewards for exceptional performance will be determined by the Department based on the results of annual monitoring of an Area Agency on Aging by the Department. Actual rewards are not limited to, but may include, any one or a combination of: notification of outstanding performance to the public in the Area Agency's region and the Board on Aging; funding awards for conferences or leadership workshops including in-state travel; funding awards for the purchase of computer equipment; and decreased frequency of monitoring and other review processes.(f) Level One Sanctions. Level one sanctions may result in one or more of the following actions:(1) require the development, submission, and implementation of an acceptable corrective action plan to address identified weaknesses and/or non-compliance;(2) submission of additional and/or more detailed financial and/or performance reports;(3) designation as a high-risk contractor requiring additional monitoring visits; and(4) repayment of disallowed costs.(g) Level Two Sanctions. Level two sanctions may result in one or more of the following actions:(1) imposition of one or more level one sanctions;(2) restrictions on ability to draw down contractor/Area Agency on Aging administrative funds with notice of such action to the Area Agency on Aging Director, the Area Agency on Aging Director's superior, and the contractor's Chairman of the Board or comparable agency official;(3) prohibit participation in discretionary funds application or carryover pool redistribution; and(4) provision of appropriate technical assistance.(h) Level Three Sanctions. Level three sanctions may result in one or more of the following actions:(1) imposition of one or more level one sanctions;(2) imposition of one or more level two sanctions;(3) prohibit or limit provision of direct services by contractor/Area Agency on Aging;(4) prohibit or limit the use of specific service providers/vendors; and(5) imposition of the requirement that reimbursement payments made to contractor/Area Agency on Aging for the remainder of the fiscal year shall be made only following submission of bills paid or other documentation to show that bills for which reimbursement is sought have been paid.(i) Level Four Sanctions. Level four sanctions may result in one or more of the following actions:(1) imposition of one or more level one sanctions;(2) imposition of one or more level two sanctions;(3) imposition of one or more level three sanctions;(4) require directed amendment to current area plan; and(5) recommend dedesignation and/or cancellation of the contract of the Area Agency on Aging to the Texas Board on Aging.(j) Administrative Violations. Administrative violations shall result in disciplinary actions as specified in this section, unless the violation was due to an act of God or action by the Department. Violations will be documented and greater levels of administrative sanctions will be applied for non-compliance issues deemed most serious and for continued non-compliance of less serious offenses.(k) Violations Subject to Level One Sanctions. Violations which may result in the imposition of level one sanctions include the following:(1) failure to submit a required report by the due date or approved extension. For purposes of this violation, a Form 269 and CIS/MIS submission for a single month shall be considered one report submission;(2) failure to submit required reports accurately and completely, if identified by the Department (not to exceed two instances in one fiscal year), and not corrected within five workdays following notification;(3) failure, on the third occurrence, to submit required reports accurately and completely, if identified by the Department, whether or not a violation notice was previously issued;(4) failure to submit timely an acceptable corrective action plan for findings of program and fiscal monitoring within 45 days;(5) failure to conduct an appropriate audit review process for required provider audits;(6) failure to resolve deficiencies noted in an audit review within timeframes established by contract;(7) failure to comply with the Department's requirements related to the Agreement Between the State of Texas and the Secretary of the Treasury, the United States Department of the Treasury in Accordance With the Cash Management Improvement Act of 1990 (CMIA), and its attendant regulations as set forth in 31 Code of Federal Regulations (CFR), Part 205, for the first time within a budget period; and(l) Violations Subject to Level Two Sanctions. Violations which may result in the imposition of level two sanctions include the following:(1) failure to rectify any level one sanction within the timeframe established for corrective action;(2) failure to timely complete corrective actions provided in any corrective action plan;(3) failure to timely submit a Single Audit, in accordance with OMB Circular A-133, to the Department;(4) failure to be certified as having had accurate data following performance measure testing;(5) commits a second violation, within a budget period, of the Department's requirements related to the Agreement Between the State of Texas and the Secretary of the Treasury, the United States Department of the Treasury in Accordance With the Cash Management Improvement Act of 1990 (CMIA), and its attendant regulations as set forth in 31 Code of Federal Regulations (CFR), Part 205;(6) failure to conduct on-site monitoring of providers as required;(7) failure to issue letter of findings within 30 days following on-site monitoring or quality assurance review (QAR) of service providers; and(8) failure to assure contractor's resolution of deficiencies found during service provider's monitoring/quality assurance review within the timeframes established in the corrective action plan.(m) Violations Subject to Level Three Sanctions. Violations which may result in the imposition of level three sanctions include the following:(1) failure to rectify any level 1 sanction within 90 days following the timeframe established for corrective action;(2) failure to rectify any level 2 sanction within the timeframe established for corrective action;(3) failure to appropriately act upon reported or identified threats to the health and safety of program participants within 72 hours of notice/identification;(4) failure to appropriately report and respond to allegations of abuse, neglect, and/or exploitation, and/or allegations of fraud or ethics code violations;(5) failure to have tested data certified as accurate 2 times out of any 4 consecutive performance measure tests; and(6) commits four or more level one violations or three or more level two violations within the same fiscal year.(n) Violations Subject to Level Four Sanctions. Violations which may result in the imposition of level four sanctions include the following:(1) failure to rectify any level 1 sanction within 180 days following the timeframe established for corrective action;(2) failure to rectify any level 2 sanction within 90 days following the timeframe established for corrective action; and(3) failure to rectify any level 3 sanction within the timeframe established for corrective action.(o) Notice.(1) The date of notice shall be the date the notice is sent to the contractor via facsimile transmission (FAX), if transmitted or recorded as delivered by 12:00 Noon on a regular business day. If transmitted after 12:00 Noon, the next business day will be considered the date of notice.(2) All notices of violations will be sent by the following methods:(A) facsimile (FAX) transmission for all notices; and(B) letter by regular mail for violations subject to a level one and level two sanction or, for violations subject to a level three and level four sanction, by regular mail, return receipt requested.(3) All notices will be addressed to:(A) the contractor's Executive Director or designated representative;(B) the Director of the Area Agency on Aging; and(C) the contractor's Chairman of the Board or comparable agency official.(p) Fraud. All allegations of fraud will be investigated by the Department. Complaints will be referred to the appropriate agency for action. Since payments to contractors are made from both State and Federal funds, submission of false or fraudulent claims, statements, documents, or the concealment of a material fact may be prosecuted as a felony in either Federal or State Court.(1) The Department will inform the contractor of the exact nature of the complaint and may require the contractor to conduct its own internal investigation.(2) The Department will document its investigation's findings and conclusions and inform the contractor and the complainant of the results. If an investigation indicates there is a substantiated situation in which there is a question of fraud, the Department will require the contractor to take corrective action and/or refer the complaint to the Texas Attorney General's Office, the United States Attorney General's Office and other appropriate law enforcement agencies.(q) Ethics Code Violations. Violations of the Ethics Code requirements, Texas Government Code 572, related to ethics, as specified in the contract, will be investigated by the Department and referred by the Department to the appropriate law enforcement agency. Ethics violations may result in criminal prosecution and may be pursued based on the provisions of the Texas Government Code, the Election Code, the Penal Code, or other pertinent laws and regulations.(1) The Department will inform the contractor of the exact nature of the complaint and may require the contractor to conduct its own internal investigation.(2) The Department will document its investigation's findings and conclusions and inform the contractor and the complainant of the results. If an investigation indicates there is a substantiated situation in which there is a question of ethics code violations, the Department will require the contractor to take corrective action and/or refer the complaint to appropriate law enforcement agencies.(r) Abuse, Neglect, and Exploitation. Abuse, neglect, exploitation and other violations of client rights will be reported by the Department to the appropriate authorities.(s) Other Remedies. The Department may take and/or impose other remedies that are legally available based on the circumstances involved.(t) Procedures for the Withdrawal of Area Agency on Aging Designation.(1) If the Department proceeds to withdraw Area Agency on Aging designation, action shall be taken to assure that appropriate individuals and agencies are informed in advance of the reasons which make it necessary. Correspondence shall be prepared summarizing the basis for the action. This correspondence shall be mailed by certified mail, return receipt requested, to the contractor and other interested parties, including subcontractors or vendors for the contract involved. Such notification will be sent at least ten working days prior to the effective date of the dedesignation as an area agency on aging. Such notification shall explain the right of the contractor to appeal such decisions as outlined in 254.15 of this title (relating to Appeal Procedures for Area Agencies on Aging Contractors).(2) Procedures following withdrawal of designation. If the Department withdraws an area agency's designation, the Department shall take the following action:(A) Notify Appropriate Entities. The Department shall notify by certified mail, return receipt requested, the Assistant Secretary on Aging, Department of Health and Human Services, and those individuals and agencies specified in paragraph (1) of this subsection;(B) Continue Services. The Department shall provide a plan for the continuity of services in the affected planning and service area and will:(i) discontinue reimbursement to the contractors concerned;(ii) notify service providers to submit requests for reimbursement directly to the Texas Department on Aging or to the designated contractor;(C) place a notice in local and regional newspapers advising that claims against the contractor related to Older Americans Act programs shall be referred to the Texas Department on Aging; and(D) designate an interim or new area agency in the planning and service area within 180 calendar days, or extension of time approved by the Administration on Aging.(3) Administration by the Department. If necessary to ensure continuity of services in a PSA, the Department may, for a period of up to 180 calendar days after withdrawing designation of an area agency:(A) perform the area agency responsibilities;(B) assign the responsibilities of the area agency to another agency in the planning and service area;(C) assign the responsibility to an area agency on aging in a contiguous planning and service area; or(D) if necessary, may request an extension of the 180 day limit from the Assistant Secretary. The Assistant Secretary may extend the period an additional 180 calendar days if the need for the extension is demonstrated.(u) Appeals. Appeals will be provided as specified in §254.15 of this title (relating to Appeal Procedures for Area Agency on Aging Contractors). Source Note: The provisions of this §213.5 adopted to be effective March 10, 1999, 24 TexReg 1638; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.5 Compliance with Contractor Responsibilities, Rewards and Sanctions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205209 03/12/2026 (a) Definitions. Definitions for the words and terms used this section are located in §254.1 of this title (relating to the Operation of the Texas Department on Aging).(b) Purpose. The purpose of this section is to establish procedures for any area agency on aging contractor who is aggrieved in connection with penalties imposed by the Department, as described in §254.13 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Penalties). All notifications sent from the Department to a contractor during the proposed imposition of a penalty shall contain information informing the contractor of the right to appeal, as well as the level of appeal appropriate for the matter, as described in this section.(c) Appeal to the Executive Director. The imposition of a level one penalty may be appealed by presenting a formal protest to the executive director of the Texas Department on Aging.(1) The protest shall follow the format described in subsection (f) of this section.(2) The contractor shall submit three copies of the protest to the Executive Director.(3) The Executive Director shall investigate the protest and issue a written determination within 30 calendar days upon receipt of the protest. The decision of the Executive Director is final.(d) Dispute Resolution Committee. The imposition of a level two or level three penalty may be appealed by the contractor by presenting a formal protest, as described in subsections (f)-(h) of this section, to the Dispute Resolution Committee of the Texas Department on Aging. When two Department division managers not connected with the matter cannot be identified, the Department may choose to refer the protest to a Dispute Resolution Center in Austin, Texas.(e) Exception. In the event of the level two and level three penalties relating to the temporary withholding of funds, as described in §254.13(g)(2)(B) and §254.13(g)(3)(C) of this title (relating to Compliance with Contractor Responsibilities, Rewards and Penalties) and/or relating to the disallowance of costs as described in §260.2(a)(3) of this title (relating to Area Agency on Aging Fiscal Responsibilities), and prior to presenting a formal protest to the Dispute Resolution Committee, a contractor may choose to request a public hearing from the Department, in accordance with the Older Americans Act, §306(e)(1)-(3).(f) Formal Protest. A formal protest must contain:(1) a specified identification of the statutory or regulatory provision or the contract provision that the contractor is alleged to have violated;(2) a specific description of the violation or violations;(3) a precise statement of the relevant facts;(4) an identification of the issue or issues to be resolved; and(5) arguments and authorities in support of the protest.(g) Copies. In making a formal protest to the Dispute Resolution Committee, the contractor shall send five copies of the protest to the Department. Copies of the protest shall also be sent by the protesting contractor to other interested parties, i.e., subcontractors or vendors for the contract(s) involved.(h) Settlement/Resolution. The Dispute Resolution Committee shall have the authority to settle and resolve the dispute. The committee may solicit written responses to the protest from other interested parties. If the protest/dispute is not resolved by mutual agreement during the meeting between the contractor and the Dispute Resolution Committee, the committee will issue a determination which shall be final. The committee will issue a written determination on the protest within 30 calendar days following the dispute resolution meeting.(i) Request for a Hearing before an Administrative Law Judge. The imposition of a level four penalty may be appealed by a request from the contractor for a hearing before an administrative law judge. The request shall be in writing and must state with specificity the grounds upon which the proposed penalty is appealed and all grounds upon which the contractor refutes the basis of the proposed penalty. The request must include:(1) the dates of all relevant actions;(2) the names of individuals or organizations involved in the proposed penalty;(3) specific statements and documentation which disprove the findings made by the Department, and/or that the sections of the Older Americans Act, state law or any rules or regulations cited in the letter of notification have not been violated; and(4) A certified copy of the minutes or resolution which indicates adoption by a majority of the quorum of the contractor's governing body a request for a hearing before an administrative law judge.(j) Conduct of a Hearing before an Administrative Law Judge. The person or persons so designated in the contract between the Department and the contractor shall act on behalf of the contractor. The proceedings and conduct of the hearing shall follow the rules promulgated in Title 1, Part VII, State Office of Administrative Hearings, Chapter 155, Rules of Procedure, et seq. The hearing examiner shall issue a final decision on behalf of the Department.(k) Time Limitations. A request to appeal any level of penalties as described in this subsection must be received by the Department within 30 calendar days following the contractor's receipt of notification of proposed action by the Department.(1) In the event that a request for an appeal is not timely, the appeal will not be considered and the protesting contractor will be notified in writing.(2) The contractor may submit written amendments to a request for an appeal, which must be received by the Department not less than ten working days prior to the date set for the appeal.(l) Department responses to a request for an appeal. Upon receipt of a request for an appeal, the Department shall, within ten working days:(1) set a date for the appeal consideration, and/or hearing, if a hearing is applicable; and(2) issue a written notice to the contractor by registered or certified mail, return receipt requested, which shall provide:(A) a statement of time, date and location of the appeal consideration or hearing, if a hearing is applicable;(B) a statement of the legal authority and jurisdiction under which the appeal is to be held;(C) a reference to the particular sections of statutes, regulations and rules involved; and(D) a summary of the reasons for the proposed penalty that is being appealed and the evidence on which the proposed penalty is based.(m) Effective Date of Penalties. In the event of a timely appeal under this section, the Department may not make a final determination regarding its proposed penalties until a requested appeal and hearing, if applicable, has been granted.(1) During the appeal process, the Department shall not proceed with the next levels of penalties, unless it makes the written determination that by delaying the next levels of penalties, service interruptions or poor service quality will occur, and/or that the health and safety of older people will be at risk, and/or an emergency exists.(2) If the appeal process results in a final determination in support of the department's imposition of the penalties, the penalties will be effective upon the original date of the notification of deficiency sent by the Department to the contractor.(n) Appeal to the Assistant Secretary on Aging, United States Department of Health and Human Services. In accordance with §305(b)(5)(C) of the Older Americans Act, and 45 CFR, Part 1321, a contractor may make an appeal to the Assistant Secretary, and the Department shall conduct a public hearing, when the Department has made a final determination to:(1) withdraw the designation of an area agency on aging;(2) designate an additional planning and service area; or(3) divide the state into different planning and service areas, or otherwise affect the boundaries of the current planning and service areas. Source Note: The provisions of this §213.7 adopted to be effective September 24, 1996, 21 TexReg 8744; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.7 Appeal Procedures for Area Agency on Aging Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205210 03/12/2026 (a) Right to Submit a Grievance. Participants in Older Americans Act Programs may submit grievances regarding specific actions or activities affecting their personal participation in the program or the conduct of the program as it relates to all participants at that site or location.(1) Grievances may be in writing or may be made orally.(2) A grievance may be presented by an individual on behalf of the participant. If the participant elects this option, he or she shall accompany that spokesperson to every meeting at which the appeal is discussed.(3) A grievance should be resolved at the lowest level of authority to avoid undue paperwork or loss of time. Grievances shall be directed as indicated to the following authorities in the order indicated:(A) site director;(B) project director;(C) area agency on aging director;(D) grantee director;(E) executive director of the Texas Department on Aging.(4) Grievances may be made at any time. The site manager, however, should be advised within ten days of the event which created the basis for the grievance of the intent to appeal.(b) Grievance procedures.(1) An oral grievance must state in detail the basis for the appeal and the reasons the participant objects to the action or circumstances in question. To facilitate this statement, a written outline should be prepared for the oral grievance which outlines the reasons for the grievance. This outline should contain or refer to the following:(A) the notice, document, policy or situation upon which a grievance is being made;(B) the dates that are significant which pertain to the grievance;(C) the names of individuals and organizations involved in the grievance;(D) a reference to any provision of the Older Americans Act or regulations believed to have been violated by site management, grantee, area agency or the Department.(2) A written grievance may also be made. A written grievance must contain all the elements specified for the oral grievance, as stated in paragraph (1) of this subsection.(c) Disposition of Grievances.(1) If the facts support the grievance, the site manager or service provider director shall, within 30 working days of the receipt of the written grievance, make the changes necessary to resolve the issue.(2) If the site manager's or service provider's director's decision is not acceptable to the participant, the participant may, within ten working days, appeal to the next higher authority as specified in subsection (a)(3) of this section relating to resolving issues at the lowest possible level of authority. The site manager or service provider director, and each level of authority at which the grievance has been unresolved, shall within ten working days following receipt of a request for continuing grievance action, develop a memorandum detailing the circumstances of the grievance, attach all pertinent documentation regarding the findings and actions taken at that level of authority, and forward it to the next level with a request for a meeting of the parties concerned with the issue.(3) If the grievance is resolved, parties to the grievance shall jointly notify each level of authority involved in the grievance of this fact in writing.(d) Referral to the Texas Department on Aging. If the grievance cannot be informally or formally resolved and it becomes necessary to refer it to the Texas Department on Aging, the Executive Director shall issue a decision on behalf of the Department.(e) Rights of Appellant. A copy of this rule will be made available to participants in Older Americans Act programs. Source Note: The provisions of this §213.9 adopted to be effective January 12, 1995, 19 TexReg 10555; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.9 Grievance Procedures for Participants in Older Americans Act Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205211 03/12/2026 The Department shall consult with the Office of Emergency Management, Department of Public Safety, the Federal Emergency Management Agency (FEMA), the Administration on Aging, grantees, area agencies on aging, other state, county and local government entities, service providers and other activities which have an interest in or role in meeting the needs of the elderly in planning for, during, and after natural, civil defense, and/or man-made disasters. To facilitate this responsibility, the Department shall identify an individual as the Emergency Management specialist for the Department who shall:(1) represent the Department at meetings and functions pertinent to emergency management and communicate and coordinate with representatives of other agencies and activities concerned with emergency management;(2) develop all reports resulting from disaster recovery operations;(3) develop procedures for reimbursement of Title III funds for use by area agencies on aging in disaster recovery operations, including the acquisition of certificates of non-duplication of services from the FEMA on-site director, review such requests for accuracy and validity, and forward these requests to the Administration on Aging for payment;(4) provide technical assistance to area agencies engaged in planning for services to the elderly prior to disasters and following any natural, man-made or civil defense disaster which impacts the elderly within their PSA; and(5) assist area agencies in disaster recovery operations. Source Note: The provisions of this §213.11 adopted to be effective January 12, 1995, 19 TexReg 10555; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3421. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING A OPERATION OF THE AREA AGENCIES ON AGING §213.11 Emergency Management Responsibilities of the Texas Department on Aging https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205203 03/12/2026 (a) Purpose and Goals. This rule establishes the requirements for implementation by area agencies on aging of the system of access and assistance. Each area agency on aging shall establish and maintain a system of access and assistance. The program shall incorporate necessary strategies and activities to meet the following goals:(1) to provide persons age 60 years and older efficient access to needed services;(2) to conduct effective screening and assessment of individual needs and preferences;(3) to efficiently and effectively target resources so that persons most in need receive assistance; and(4) to establish a strong local role and clear identity of the area agency on aging as a source of access and assistance for eligible persons and/or their family members or other caregivers.(b) Outcomes.(1) The area agency on aging shall achieve the following system outcomes.(A) The area agency on aging will conduct outreach and marketing efforts to inform eligible persons and/or their family members or other caregivers of available services.(B) The area agency on aging shall serve as a source of connection to comprehensive information on services, benefits and opportunities.(C) The area agency on aging system of access and assistance shall meet specific local needs and take advantage of specific local strengths and resources including volunteers.(D) Access and assistance services are accessible, flexible, coordinated and designed to support an individual's highest level of functioning in the least restrictive environment.(E) Access and assistance services are available to persons age 60 years and older and/or his/her family member or other caregiver regardless of income.(F) The area agency on aging system of access and assistance shall have the capability to respond to racially, culturally and ethnically diverse groups.(2) The area agency on aging shall achieve the following client outcomes.(A) Eligible persons and/or their family members or other caregivers served are provided sufficient information to make informed decisions about services.(B) People in need are connected with existing benefits and services.(C) Clients are provided an opportunity to express their level of satisfaction with access and assistance services received.(D) Services are provided so that clients maintain hope, dignity, respect and independence.(c) The area agency on aging system of access and assistance shall include:(1) Information, Referral and Assistance;(2) Benefits Counseling;(3) Care Coordination; and(4) Ombudsman Services.(d) Professional Staffing. The area agency on aging shall strive to maintain an adequate level of professional access and assistance staff who possess necessary general and specialized knowledge. Where applicable, access and assistance staff must complete the training and certification requirements set forth by the Department.(e) System Integration.(1) The system of access and assistance shall strive to develop cooperative working relationships with local service providers to build an integrated service delivery system which ensures broad access to and information about community services, maximizes the utilization of existing resources, avoids duplication of effort and gaps in services and facilitates the ability of people who need services to easily find the most appropriate provider.(2) Coordination with the Texas Department of Human Services. Area agency on aging access and assistance staff shall work with the local Texas Department of Human Services (TDHS) staff to ensure any person who may be eligible for TDHS services will be referred to that agency. The area agency on aging may provide services to persons who are eligible for TDHS services in the following instances:(A) the person is on an interest list for TDHS services;(B) the person is in need of immediate service provision and awaiting determination of eligibility for TDHS services; or(C) the person is in need of immediate service provision and awaiting location and placement of a TDHS family care or primary home care service provider.(f) Client Eligibility. Eligible clients include any person age 60 years and older and/or his/her family member or other caregiver .(g) Client Intake. The intake process varies with the type of service indicated. For all clients, access and assistance staff will determine client needs and preferences. If clients have multiple or complex needs, access and assistance staff will gather identifying information to determine eligibility for services funded by the area agency on aging or other agencies.(h) Prohibited Service Activities. Access and assistance staff will not perform or participate in any of the following activities:(1) accepting gifts from a client;(2) lending or borrowing money or articles to or from a client;(3) transporting a client in an access and assistance staff person's automobile unless appropriate liability insurance is in force; and(4) driving or riding in a client's automobile.(i) Confidentiality of Client Records. Area agency on aging access and assistance staff shall comply with the requirements described in 40 TAC §270.1(d), regarding confidentiality of client records.(j) Release of Client Information. When referrals are made, access and assistance staff must obtain and clearly document the consent of the client for release of confidential information to other service provider agency(ies). This consent may be obtained from the client verbally or in writing.(k) Client Contributions.(1) Area agency on aging access and assistance staff must comply with the requirements described in 40 TAC §270.1(j), regarding client contributions.(2) Care management clients who meet the criteria identified in Human Resources Code 101, Subchapter C relating to Options for Independent Living shall be encouraged to contribute towards the cost of their care through a suggested contribution schedule.(l) Conflicts of Interest. The area agency on aging shall ensure that any conflicts of interest between the function of access and assistance and the provision of direct client services are disclosed to the Department. The intent is to separate the function of access and assistance from the provision of other client services.(m) Reporting. The area agency on aging must comply with the reporting requirements identified in §260.1(c)(2) of this title (relating to programmatic reports).(n) Information, Referral and Assistance. The information, referral and assistance process consists of activities such as assessing the needs of the inquirer, evaluating appropriate resources, assessing appropriate response modes, identifying organizations capable of meeting those needs, providing enough information about each organization to help inquirers make an informed choice, helping inquirers for whom services are unavailable by locating alternative resources, when necessary, actively participating in linking the inquirer to needed services and following up on referrals to ensure the service was received or provided.(1) Target Population.(A) Information, referral and assistance services shall be provided to any person age 60 years and older and/or his/her family member or other caregiver.(B) Information, referral and assistance services shall be provided to Medicare beneficiaries of any age under the provisions of funds received from the Centers for Medicare and Medicaid Services.(2) Access and assistance staff shall provide telephone, electronic or walk-in information, referral and assistance services in which the inquirer has one-to-one contact with an information, referral and assistance specialist. In accordance with §260.1 of this title, the published phone number will be answered "Area Agency on Aging" when the call is received.(3) Service providers shall coordinate with emergency response organizations, such as local law enforcement agencies or other existing agencies/activities as appropriate to provide the necessary coverage.(4) The area agency on aging telephone messaging system will provide callers with appropriate emergency phone numbers when calls are received after hours.(5) Resource Information.(A) Access and assistance staff shall develop criteria for the inclusion or exclusion of agencies and programs in the resource database or use criteria developed by other information, referral and assistance entities. These criteria shall be uniformly applied and published so that staff and the public will be aware of the scope and limitations of the database.(B) A standardized profile shall be developed for each organization that is part of the community service delivery system.(C) Information in the resource database shall be indexed and accessible in ways that support the information, referral and assistance process.(D) Access and assistance staff shall use the AIRS/Infoline Taxonomy to facilitate retrieval of community resource information and to promote the reliability and consistency of information across the service region and across the state.(E) The resource database shall be updated through continuous revision or at intervals sufficiently frequent to ensure accuracy of information and comprehensiveness of its content.(6) Information, Referral and Assistance Log.(A) Access and assistance staff shall maintain a system for collecting and organizing inquirer information that facilitates appropriate referrals and provides a basis for describing requests.(B) A unit of service is a client's initial request for information or assistance. The area agency on aging shall have a system for recording both initial inquiries and follow-up contacts made by either the client or the agency.(C) The area agency on aging shall use information it records to identify service gaps and overlaps, assist with needs assessments, support the development of products, identify issues for staff training, facilitate the development of the resource information system.(7) Cooperation with Local Information and Referral (I&R) Providers.(A) In communities with comprehensive and/or specialized information and referral (I&R) providers, including Area Information Centers, when applicable, the area agency on aging shall develop cooperative working relationships to build an integrated system of information, referral and assistance which ensures broad access to services, maximizes the utilization of existing resources, avoids duplication of effort and encourages seamless access to community resource information.(B) If the area agency on aging is designated by the Texas Information and Referral Network as an Area Information Center, the area agency on aging must meet the expectations of the designation.(8) Professional Conduct.(A) Access and assistance staff providing information, referral and assistance services shall adhere to the standards of conduct set forth by the Alliance of Information and Referral Systems which are adopted by reference.(B) Area agencies on aging are encouraged to seek and maintain agency accreditation with the Alliance of Information and Referral Systems.(o) Care Coordination. The purpose of care coordination is to assess the needs of a client and effectively plan, arrange, coordinate and follow-up on services which most appropriately meet the identified needs as mutually defined by access and assistance staff, the client, and where appropriate, a family member(s) or other caregiver.(1) Program Design. The operational design of care coordination is dictated by the needs of the area agency on aging service area and includes a combination of levels of care. These levels of care coordination include:(A) Service Authorization without an assessment;(B) Service Authorization requiring an assessment; and(C) Care Management, which includes the model of case management as defined by the program entitled, Options for Independent Living, as required by in Human Resources Code Chapter 101, Subchapter C.(2) Service Authorization. A process which identifies a need for a service(s) and uses the direct purchase of service procedures to obtain and initiate one or more services. There are two types of service authorization. They include service authorization without an assessment and service authorization requiring an assessment.(A) Service Authorization Without an Assessment.(i) Service authorization without an assessment may be used to procure all services except home delivered meals, homemaker, personal assistance, residential repair and respite services .(ii) Service authorization without an assessment may be performed by any area agency on aging-approved access and assistance staff member either by phone or in person.(iii) Service authorization without an assessment must be based on a client intake completed by area agency on aging access and assistance staff or by a qualified source. When authorizing congregate meals a nutritional risk assessment must also be completed.(B) Service Authorization Requiring an Assessment.(i) Service authorization requiring an assessment may be used to procure home delivered meals, homemaker, personal assistance, residential repair and respite services .(ii) Service authorization requiring an assessment may be performed by any area agency on aging-approved access and assistance staff member either by phone or in person.(iii) In addition to completing the client intake and nutritional risk assessment (home delivered meals), a modified assessment must be conducted which may include:(I) TDHS Form 2060; or(II) Service appropriate assessment.(III) Area agency on aging access and assistance staff may conduct the assessment, procure it or accept it from a qualified source.(C) Care Management. Care management is a process that assists clients with multiple needs by developing and implementing comprehensive plans of care.(i) Care management services may be provided only to persons age 60 years and older and/or his/her family member or other caregiver, with priority given to those:(I) who have recently suffered a major illness or health care crisis or have recently been hospitalized and need additional attention during the recuperation period in accordance with Human Resource Code, Chapter 101, Subchapter C, relating to Options for Independent Living;(II) who live in a rural area;(III) who are moderately to severely impaired in activities of daily living and instrumental activities of daily living;(IV) have insufficient caregiver support; or(V) who are in great economic or social need, particularly low-income, minority older persons.(ii) Care management must include the following:(I) Comprehensive Client Assessment: A needs assessment may be provided, procured or accepted from a qualified source and must include the following components:(-a-) cognitive status (if applicable);(-b-) emotional status (if applicable);(-c-) physical environment (requires on-site evaluation);(-d-) social environment, including informal or family support;(-e-) physical status;(-f-) economic status;(-g-) self-care capacity; and(-h-) services presently received.(II) Care Plan. Care Managers shall develop a written plan that is based upon the client's preferences, as supported by identified priority needs and within available public/private resources. The care plan must specify the amount, frequency and duration of each service to be provided and identify the outcomes to be achieved.(III) Service Arrangement. Care managers shall arrange for services identified in the care plan to begin at the earliest possible date, consistent with the capacity of the provider and may include, but is not limited to:(-a-) exploring the availability and quality of services, eligibility criteria and accessibility of a service to the client;(-b-) making and documenting referrals to community service agencies;(-c-) working with volunteers to provide services;(-d-) working with family and friends of the client to help achieve specific service goals; and(-e-) authorizing services deemed appropriate by the area agency on aging using direct purchase of service procedures.(IV) Monitoring/Follow-up Activities. Care managers shall conduct monitoring and follow-up activities which include verifying service delivery, determining the extent to which services meet the needs and expectations of the client, and where necessary, advocating for improvements in service delivery. Monitoring shall include at least monthly contacts with the client and a home visit not less than every six months.(V) Reassessment. Reassessments shall be conducted and the care plan shall be amended as needed based on changes in client status and provider effectiveness and may be conducted by phone or in person.(VI) Client Case Records. A confidential client case record shall be maintained on each client served and shall be protected from damage, theft and unauthorized inspection and shall contain at least:(-a-) the client needs assessment, including initial referral date and date of completion of assessment; re-assessment(s), if applicable;(-b-) the care plan including amount, frequency and duration of each service to be provided;(-c-) names of service providers and informal caregivers who render services to the client;(-d-) a notation explaining any lapse in service;(-e-) notation of hospital admission and/or discharge, with dates;(-f-) date and signature for each notation;(-g-) record of all care manager contacts and visits;(-h-) record of any client complaints and action taken;(-i-) record of termination or closure; and(-j-) list of names and phone numbers for notification in event of an emergency.(VII) Care management may not be provided by any entity with a vested interest in the delivery of services purchased by the area agency on aging without an approved waiver from the Department.(VIII) Professional Conduct. Care managers must adhere to the pledge of ethics and the standards of practice for professional geriatric care managers as set forth by the National Association of Professional Geriatric Care Managers and adopted by reference.(p) Other key components of the area agency on aging system of access and assistance include Benefits Counseling and Ombudsman Services. The requirements for the Ombudsman Program are identified in §260.11 of this title (relating to Ombudsman Services).(1) Benefits Counseling. Benefits counseling includes both legal assistance and legal awareness services.(A) Legal Assistance. Legal assistance includes the provision of client-specific advice, counseling and representation on matters involving insurance issues, public/private benefits, consumer problems and other legal issues.(B) Legal Awareness. Legal awareness includes general education and outreach on matters involving insurance issues, public/private benefits, consumer problems and other legal issues.(2) Targeting.(A) Benefits counseling services shall be provided to persons age 60 years and older and/or their family members or other caregivers.(B) Benefits counseling services shall be provided to Medicare beneficiaries of any age under the provisions of funds received from the Centers for Medicare and Medicaid Services.(3) The area agency on aging shall focus its benefits counseling services on the following priority issue areas:(A) Income Maintenance/Public Benefit. Food Stamps, Social Security, Social Security Disability, Supplemental Security Income, veterans benefits, pensions, railroad retirement, child support, unemployment compensation, general assistance and other income benefits.(B) Medical Entitlements. Medicare, Medicaid, QMB/SLMB, Veterans Administration Medical, indigent health and other medical entitlements.(C) Insurance. Medicare Supplement, HMO, long-term care policies, individual health policies, group health policies/COBRA and non-health insurance.(D) Surrogate Decision Making. Advanced directives, durable/general powers of attorney, money management, guardianship, custody and other probate matters.(E) Individual Rights. Age discrimination, disability discrimination, abuse, neglect, exploitation and dispute resolution.(F) Housing. Landlord/tenant issues, repair/modification, utilities, rent subsidy, alternative housing, home equity lending/reverse mortgage, homestead tax credit, weatherization, property tax, housing relocation and general property.(G) Institutional Care. Acute care, nursing facility care, assisted living facility care and mental health care.(H) Consumer Issues. Bankruptcy, collections, financial counseling, bill reductions, solicitation and unfair sales practices/fraud.(4) Benefits counseling services shall be provided according to the following:(A) If a request for assistance involving any of the priority issue areas identified in paragraph (3) of this subsection requires intervention by an attorney or paralegal, the benefits counselor shall refer the client shall be referred to an appropriate provider in the area.(B) For the purpose of handling requests or referrals which originate from sources other than the area agency on aging, the benefits counselor, in consultation with the local legal provider(s), shall develop an appropriate and timely referral process.(C) Regardless of the referral source, the benefits counselor shall determine whether or not the client may be assisted with other resources, such as the Legal Hotline for Older Texans, pro-bono or reduced-fee providers or through services funded by the Legal Services Corporation.(5) Relationship with Providers. The area agency on aging shall establish the following procedures when working with providers of benefits counseling and related legal services:(A) To accomplish paragraph (4), subparagraph (A) of this subsection, the area agency on aging shall coordinate with the Legal Hotline for Older Texans, Texas Young Lawyers Association, the private bar and local legal programs (such as law clinics or student law programs), Legal Services Corporation grantees, the Ombudsman Program or other programs.(B) The area agency on aging shall utilize the Legal Hotline for Older Texans to provide legal consultation and back-up to access and assistance staff, as needed.(C) If consultation/back-up is needed for access and assistance staff in addition to paragraph (5), subparagraph (B) of this subsection, such assistance may be obtained through agreements with programs such as pro-bono or reduced-fee attorneys, law school students, local legal programs or Legal Services Corporation grantees.(6) Education and Outreach.(A) Education and outreach activities include the dissemination of accurate, timely and relevant information regarding any issue identified under the priority areas in paragraph (3) of this subsection to persons identified under paragraph (2) of this subsection.(B) Education and outreach may be provided to individuals or through a group setting such as forums, workshops, seminars and training sessions and other public venues, and shall be reported as legal awareness.(7) Classification of Activities.(A) The provision of activities described in paragraph (6) of this subsection to eligible persons in a one-on-one setting or by telephone where detailed information is provided but no client intake is necessary shall be reported as legal awareness.(B) The provision of advice, counseling and/or representation on matters involving insurance issues, public/private benefits, consumer problems and other legal issues shall be reported as legal assistance if a client intake is completed.(C) If a client has a simple request for information on any topic including those identified under paragraph (3) of this subsection, it shall be reported as information, referral and assistance.(D) While education and outreach initiatives that include the dissemination of information through mass media may be budgeted as associated costs under legal awareness, the activities may not be reported as units of service.(E) Presentations or other activities that describe the services of the area agency on aging in general including the benefits counseling program may not be reported as units of service.(8) The area agency on aging shall collaborate with local, state and federal entities to provide education and outreach. Such entities may include but are not limited to the Texas Department of Insurance, Texas Legal Services Center, Texas Medical Foundation, the Centers for Medicare and Medicaid Services and the Social Security Administration.(9) Benefits counselors shall complete the training and certification requirements as set forth in the benefits counseling certification manual issued by the Department. Source Note: The provisions of this 213.51 adopted to be effective September 3, 2000, 25 TexReg 8438; amended to be effective June 8, 2003, 28 TexReg 4318; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3422. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING B AREA AGENCY ON AGING ADMINISTRATION §213.51 System of Access and Assistance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205204 03/12/2026 (a) To be certified to provide services pursuant to Texas Government Code §81.1011, a benefits counselor must meet the following requirements:(1) Be an employee or volunteer of an area agency on aging affiliated with the Texas Department on Aging who provides benefits counseling services through an area agency on aging system of access and assistance to persons age 60 years and older and/or their family members or other caregivers, and(2) Have received the training in providing technical advice, consultation, and assistance, described in subsection (b) of this section.(b) The training referred to in subsection (a)(2) of this section must:(1) Be approved by the Texas Department on Aging; and(2) Include the following components:(A) statutory, regulatory, and policy provisions applicable to advance directives in Texas;(B) the use of letters, questionnaires, and checklists for gathering information to provide technical advice, consultation and document preparation for clients;(C) conducting the client interview (including confidentiality and conflict of interest considerations);(D) how to complete, sign, and witness, the Advance Directives provided for in the Texas Health and Safety Code, Chapter 166, and how to complete, sign, and witness, the Designation of Guardian Before Need Arises provided for in the Texas Probate Code §679;(E) how revocation of the documents referred to in subparagraph (D) of this paragraph is accomplished; and(F) proper procedures for filing and informing health care personnel about the documents referred to in subparagraph (D) of this paragraph.(3) Include an assessment tool approved by the Texas Department on Aging that verifies that the employee or volunteer providing benefits counseling through an area agency on aging system of access and assistance has sufficient knowledge after the training described in paragraphs (1) and (2) of this subsection, to provide high quality services that meet the needs of clients for technical advice, consultation, and document preparation in regard to the Advance Directives in Texas Health and Safety Code, Chapter 166, and in regard to the Designation of Guardian Before Need Arises provided for in the Texas Probate Code §679. The assessment tool shall require a score of 70% correct answers as the minimum passing grade.(c) The Texas Department on Aging shall certify an employee or volunteer providing benefits counseling through an area agency on aging system of access and assistance who has completed the training described in subsection (b)(1) and (2) of this section and who has completed the assessment tool with a score of 70% or higher to provide services under Texas Government Code §81.1011. Each area agency on aging has the discretion to decide whether the services authorized under Texas Government Code §81.1011, shall be offered by the area agency on aging. Source Note: The provisions of this §213.53 adopted to be effective December 3, 2001, 26 TexReg 9914; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3422. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING B AREA AGENCY ON AGING ADMINISTRATION §213.53 Certification of Benefits Counselors Regarding the Preparation of Advanced Directives https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205205 03/12/2026 (a) Purpose. Direct Purchase of Service (DPS) is a procurement method that provides flexibility and effective management of resources by purchasing services on a client-by-client basis as determined by an assessment of the individual's service needs.(b) The DPS procurement method is used:(1) to facilitate an individual's access to services;(2) to target limited resources;(3) to encourage broad participation of service providers in Title III programs;(4) to promote accuracy in reporting; and(5) to assist the area agency on aging in meeting key performance measures projection targets .(c) DPS System Structure.(1) Vendor Pool. A vendor pool shall be developed and maintained by the area agency on aging using:(A) Open Enrollment. Open enrollment allows eligible service providers to enroll at any time in the program year; or(B) Closed Enrollment. Closed enrollment allows eligible service providers to enroll only during the enrollment period established by the area agency on aging; or(C) A combination of open and closed enrollment.(2) Vendor Agreement. A vendor agreement shall be developed by the area agency on aging in accordance with the standards and criteria established by the area agency on aging and TDoA to ensure service providers meet all applicable certifications, standards and criteria established by state law.(3) Service Authorization.(A) Service authorization may be provided by an area agency on aging approved access and assistance staff member either by phone or in person.(B) If the following factors are identifiable or measurable, the area agency on aging must include them in the service authorizations: the number of units authorized, frequency and duration of the service to be purchased.(C) The vendor list from which a service is authorized shall be regularly reviewed and approved by the area agency on aging.(d) Match. Match shall be obtained in accordance with §260.2 of this title (relating to Area Agency on Aging Fiscal Responsibilities).(e) Program Income. Program income shall be accounted for in accordance §260.2 of this title.(f) Quality Assurance. Quality assurance of services provided by vendors shall be determined through reassessment and other follow-up activities with the client conducted by the area agency on aging. The area agency on aging shall require monthly reports from active vendors. A quality assurance review is conducted to ensure a satisfactory performance in the following areas to determine whether a vendor has met the service criteria established in the vendor agreement and whether :(1) the vendor is meeting the performance criteria and frequency of the service as authorized for the client;(2) the vendor is performing those duties specified when the service was authorized;(3) the client indicated that the services provided are satisfactory; and(4) services met or exceeded all applicable state and federal guidelines. Source Note: The provisions of this §213.55 adopted to be effective June 15, 2000, 25 TexReg 5663; amended to be effective June 8, 2003, 28 TexReg 4318; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3422. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING B AREA AGENCY ON AGING ADMINISTRATION §213.55 Direct Purchase of Service (DPS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205187 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) AAA--An area agency on aging (commonly referred to as a "triple A"). A public or private nonprofit agency or organization, designated by HHSC in accordance with the Older Americans Act §305(a)(2)(A) (42 U.S.C. §3025(a)(1)(A)) that develops and implements an area plan.(2) Adult--A person who is 18 years of age or older.(3) Alarm call--A signal transmitted from an electronic monitoring system to a service provider's response center indicating a program participant needs immediate assistance.(4) Area plan--A plan developed and implemented by a AAA for its planning and service area that establishes a comprehensive and coordinated system of services in accordance with the Older Americans Act §306(a) (42 U.S.C. §3026(a)).(5) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021.(6) Contract--A binding agreement between a AAA and a subcontractor obligating the subcontractor to take responsibility for the complete implementation and administration of a service described in this chapter, including determining which individuals are eligible to receive such a service and providing the service to such individuals.(7) Child--A person who is under 18 years of age.(8) Cost reimbursement--Payment of actual costs incurred for goods or services.(9) DADS--Texas Department of Aging and Disability Services. As a result of the reorganization of health and human services delivery in Texas, DADS was abolished, and its functions transferred to the Texas Health and Human Services Commission (HHSC).(10) Day--A calendar day, unless otherwise specified.(11) Direct purchase--When items or services are obtained from a vendor.(12) Disability (except when such term is used in the phrase "severe disability")--A disability attributable to mental or physical impairment, or a combination of mental and physical impairments, that results in substantial functional limitations in one or more of the following areas of major life activity:(A) self-care;(B) receptive and expressive language;(C) learning;(D) mobility;(E) self-direction;(F) capacity for independent living;(G) economic self-sufficiency;(H) cognitive functioning; and(I) emotional adjustment.(13) Electric monitoring system--The equipment used to allow a program participant to call an ERS vendor for assistance in the event of an emergency. Such equipment includes an alert bracelet or necklace that can be activated by the program participant and the signal box to receive the call from the program participant.(14) ERS--Emergency response services.(15) Federal fiscal year--A 12-month period beginning October 1 and ending September 30.(16) Fixed unit rate--A negotiated cost for a service, cost per program participant, or cost per event set forth in a contract or vendor agreement, that remains the same until the contract or vendor agreement is renegotiated, regardless of the amount of services provided, the number of program participants served, or the number of events that occur.(17) HHSC--Health and Human Services Commission. HHSC is the sole state agency (also referred to as the "state unit on aging") designated in accordance with the Older Americans Act §305(a)(1) (42 U.S.C. §3025(a)(1)).(18) Meal provider--A service provider that provides a congregate or home delivered meal.(19) Means testing--Using a person's income and resource data.(20) Older Americans Act--A federal law enacted to establish and fund a comprehensive service system for people 60 years of age or older, which can be found at 42 U.S.C. §§3001-3058ff.(21) Planning and service area--A geographical area, consisting of one or more counties, for which HHSC designates one AAA to develop and implement an area plan.(22) Program participant--A person receiving a service described in this chapter.(23) Responder--A person identified by the program participant or designated by the AAA who will respond to an alarm call by a program participant.(24) Service provider--A subcontractor or a vendor.(25) Severe disability--A severe, chronic disability attributable to mental or physical impairment, or a combination of mental and physical impairments, that:(A) is likely to continue indefinitely; and(B) results in substantial functional limitation in three or more of the major life activities specified in paragraph (12)(A) - (I) of this section.(26) Staff person--Personnel, including a full-time and part-time employee or contractor, and intern but excluding a volunteer.(27) Statewide carryover pool--An account established and managed by HHSC that contains award funds not spent by a AAA at the end of a federal fiscal year as described in §213.303(c)(1)(B) of this chapter (relating to Unspent Award Funds).(28) Subcontractor--The party with whom a AAA enters into a contract.(29) System check--Activating the call button of an electronic monitoring system to test the system.(30) Variable unit rate--A negotiated cost for a service, cost per program participant, or cost per event set forth in a contract or vendor agreement that may change depending on the criteria and conditions set forth in the contract or vendor agreement.(31) Vendor agreement--A binding agreement between a AAA and a vendor obligating the vendor to provide goods or services to individuals determined eligible by the AAA for such goods or services as part of the AAA's implementation and administration of a service described in this chapter.(32) Vendor--The party with whom a AAA enters into a vendor agreement. Source Note: The provisions of this §213.101 adopted to be effective September 1, 2008, 33 TexReg 7293; amended to be effective September 1, 2011; 36 TexReg 4811; amended to be effective April 5, 2018, 43 TexReg 2027; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721; amended to be effective June 3, 2021, 46 TexReg 3415. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.101 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201609 03/12/2026 (a) Purpose. This section:(1) establishes the responsibilities of a AAA in developing and maintaining an organized and efficient system of administration that demonstrates accountability and compliance with state and federal law and with all terms and conditions of the contract it enters into with HHSC; and(2) applies to a service under the Older Americans Act provided to a program participant that is funded, in whole or in part, by HHSC.(b) Structure of a AAA.(1) A AAA must:(A) reflect its organizational structure through job descriptions, staffing plans, area plans, and organizational charts that demonstrate its ability to effectively administer Older Americans Act programs and other programs funded by HHSC;(B) identify a person as a director or manager of the AAA;(C) if a director or manager position becomes vacant, ensure that a qualified staff person is assigned to perform the duties of the director or manager until the position is filled;(D) budget all positions based on the projected percentage of time to be spent performing the duties of an identified service;(E) maintain documentation to support the actual time spent performing the duties of an identified service; and(F) comply with the Service Definitions for Area Agencies on Aging available on the HHSC website for all services funded by HHSC.(2) In accordance with the Older Americans Act, §306(a)(6)(D), a AAA must establish an advisory council that:(A) continually advises the AAA on all matters relating to the development and administration of and operations conducted under the area plan; and(B) consists of persons who are 60 years of age or older (including minority persons and persons residing in rural areas) who are program participants or who are eligible to participate in programs under the Older Americans Act, family caregivers of such individuals, representatives of persons 60 years of age or older, service providers, representatives of the business community, local elected officials, providers of veterans' health care, if appropriate, and the general public.(3) A AAA must ensure that its board members, employees, advisory committee members, and volunteers are not subject to a conflict of interest, as described in subparagraph (A) of this paragraph, in fact or perception, and notify HHSC in accordance with HHSC Program Instruction AAA - PI 500 Conflicts of Interest, when potential conflicts of interest occur.(A) A conflict of interest includes:(i) having a substantial financial interest, directly or indirectly, in the profits of any entity from which services or goods are contracted or otherwise procured by the AAA; and(ii) deriving a personal profit, directly or indirectly, from any entity that would conflict in any manner or degree with the performance of responsibilities of the board member, employee, advisory committee member, or volunteer.(B) If a AAA is part of a host agency as defined in 26 TAC §88.2 (relating to Definitions), the AAA must comply with Title 26, Part 1, Chapter 88 (relating to State Long-Term Care Ombudsman Program).(C) A AAA must include a requirement in a request for proposal (RFP) for services for older persons and requests for vendor enrollment that any potential conflicts of interest be identified in the RFP or vendor enrollment response. The notification of potential conflicts of interest must include:(i) the person and the nature for which a potential conflict of interest exists; and(ii) the relationship to any current or former board member, current or former aging advisory committee member, or current or former employee.(c) Compliance with laws, rules, regulations, and other requirements. A AAA must comply with applicable federal and state laws, rules, and regulations, standards, and instructions, including:(1) the Older Americans Act of 1965;(2) state laws regarding the financial operation of a AAA; (3) 45 Code of Federal Regulations (CFR) §1321.67;(4) 45 CFR §92.25;(5) Uniform Grant Management Standards;(6) Office of Management and Budget Circulars; and(7) HHSC Program Instructions.(d) Accountability.(1) A AAA must:(A) maintain financial and programmatic systems capable of producing expenditure reports, cost center analyses, budgets, and state and federal reports;(B) develop and implement written policies and procedures to back up automated information systems and continually update virus protection software to prevent the loss or corruption of program and financial data;(C) meet programmatic and fiscal performance targets as outlined in the approved budget, as amended, within a five percent variance; and(D) submit fiscal and programmatic reports required by HHSC in a timely, complete, and accurate manner.(2) A request for an extension to submit fiscal and programmatic reports must be submitted in writing to the AAA Help Desk at HHSC on or before the date and time the reports are due.(3) HHSC may grant up to two requests for an extension per report per federal fiscal year. A AAA may be granted no more than a total of eight extensions per federal fiscal year. The length of an extension is negotiated, as much as possible, but HHSC makes the final decision regarding extensions.(4) A AAA must comply with the terms of all applicable interagency agreements, including those agreements legislatively mandated or to which HHSC and the AAA are parties.(e) Review of subcontractors.(1) A AAA must review a subcontractor's programs and fiscal activities on a regular and systematic basis. Reviews must be conducted through a desk audit or by on-site review. A AAA must conduct a risk assessment annually to determine the necessity of an on-site review if it conducts an on-site review less than annually for all subcontractors.(2) A AAA must conduct an annual customer satisfaction survey of program participants utilizing the process furnished by HHSC.(3) A AAA must comply with the requirements specified in §81.13 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Sanctions) when imposing sanctions against a subcontractor for noncompliance with a contract.(4) A AAA may develop requirements for a subcontractor in addition to those listed in paragraphs (1) - (3) of this subsection.(f) Targeting. A AAA must ensure, in providing a service described in Subchapter D of this chapter (relating to Older Americans Act Services), that priority is given to persons:(1) described in the Older Americans Act, §306(a)(4)(B)(i); and(2) who have an unmet need for such a service.(g) Means testing. A AAA must not use means testing for purposes of determining a person's eligibility to receive services, in accordance with the Older Americans Act, §315(b)(3).(h) Confidentiality.(1) A AAA must comply with all applicable state and federal laws, rules, and regulations related to the confidentiality of program participant information, including 45 CFR §1321.51 and §85.401(k) of this chapter.(2) A AAA must:(A) keep the records of a program participant in a secure, locked facility when not in use by authorized personnel; and(B) limit access to program participant records maintained in computer information systems through acceptable computer security practices, including password protection.(i) Satisfaction with services. A AAA must, at least annually, give a program participant an opportunity to express his or her level of satisfaction with the services provided.(j) Grievances. A AAA must:(1) implement grievance procedures in accordance with §81.19 of this title (relating to Grievance Procedures for Participants in Older Americans Act Programs); and(2) inform a program participant of the grievance procedures. (k) Service participation. A AAA must not require a program participant to be a member in a specific private organization, group, association, or fraternal organization as a condition of receiving services, which includes permitting services to be provided in an organization's facility to which admission is limited to members of the organization.(l) Contributions. A AAA:(1) must provide a program participant with an opportunity to contribute toward the cost of the services the program participant receives;(2) must not require a program participant to contribute toward the cost of services the program participant receives;(3) may provide a program participant with a contribution schedule that suggests a contribution amount based on the income ranges of the program participant population, but may not determine a program participant's income using a means test;(4) must protect the privacy of a program participant with respect to the program participant's contribution;(5) must establish appropriate procedures to safeguard and account for all contributions made; and(6) must use all program participant contributions to support or expand services for which the program participant contributed, in accordance with applicable state and federal laws, rules, and regulations. (m) Facilities. A AAA must ensure that facilities in which services are provided are in compliance with applicable local building codes and ordinances and applicable state and federal laws, rules, and regulations.(n) Tobacco policy. A AAA must prohibit the use of tobacco during the hours of operation of and in areas designated for Older Americans Act programs.(o) Insurance. A AAA must maintain insurance that protects the health and safety of its employees and of program participants and complies with all applicable state and federal laws, rules, and regulations.(p) Records. A AAA:(1) must develop, maintain, and retain records in accordance with the Uniform Grant Management Standards, Subpart C;(2) must establish written procedures to adequately ensure proper development, maintenance and retention of all financial records, supporting documents, statistical records and all other records relating to its performance;(3) must maintain all records for a minimum of five years following the end of the federal fiscal year to which the record pertains and until any pending litigation, claim or audit findings, issuance or proposed disallowed costs or other disputes have been resolved;(4) must maintain all records at a designated central location regardless of whether the AAA has one or multiple locations; and(5) must give HHSC, the Comptroller General of the United States, and the State of Texas, through any authorized representatives, access to its records, including:(A) financial records such as contracts, general ledgers, invoices, accounts payable, and accounts receivable;(B) program participant records unless specifically prohibited by law;(C) other documents related to HHSC funded programs; and(D) any other records not directly related to the AAA if the purpose of such access is to review charges to any indirect costs pool.(q) Service provider compliance. A AAA must ensure that a service provider complies with requirements described in subsections (f) - (p) of this section.(r) Contingency plan. A AAA must have a written plan ensuring continuity of services to a program participant in the event a service provider is unable to provide a service.(s) Designation of focal points. A AAA must comply with the Older Americans Act, §306(a)(3)(A) and (B) regarding designation of focal points.(t) Visibility.(1) A AAA must use the logo designed by HHSC (illustrated in paragraph (2) of this subsection) to ensure a uniform, statewide symbol for AAAs.(2) A AAA must use the logo on all printed material it develops.Attached Graphic(u) AAA contact information.(1) A AAA must publicize its contact information through a variety of media such as telephone directories, resource directories, the Internet, and other outreach tools for persons who reside in any geographical area that lies in whole or in part in the planning and service area served by the AAA.(2) Contact information must begin with the words "area agency on aging" and must include the host agency, as applicable. A AAA must ensure that a telephone call to the AAA is answered "area agency on aging."(v) Phrase for printed material. A AAA must cite HHSC as the primary funding source using the phrase "Funded by the Texas Health and Human Services Commission" or "Funded in part by Texas Health and Human Services Commission" on all printed material.(w) Identification of a AAA facility. A AAA must prominently display a sign outside its primary place of business that:(1) adheres to local ordinances concerning signs; and(2) conforms to the requirements in subsection (t) of this section.(x) Emergency management.(1) When a disaster occurs, a AAA must notify HHSC of its need to provide for emergency management activities, provide information to HHSC regarding the impact of the disaster on the older population in its service area, provide emergency management services in accordance with current Administration on Aging disaster relief guidelines, and collect pertinent data necessary to submit reimbursement requests for disaster services.(2) A AAA must consult with the appropriate agencies that have an interest or role in meeting the needs of persons 60 years of age or older to plan for the occurrence and aftermath of natural, civil defense, or man-made disasters. To accomplish this, a AAA must:(A) develop an emergency disaster plan in accordance with HHSC requirements;(B) require by contract or vendor agreement that a service provider develop plans for emergency management; and(C) provide technical assistance as necessary to service provider staff persons regarding emergency management activities.(y) Reporting abuse, neglect, or exploitation.(1) A AAA must instruct its staff persons and representatives, other than a representative of the Office as defined in 26 TAC §88.2, to report allegations of abuse, neglect, or exploitation of a program participant to the Department of Family and Protective Services (DFPS) in accordance with Texas Human Resources Code, Chapter 48. A report must be made by calling 1-800-252-5400 or by following the instructions available at www.txabusehotline.org.(2) The AAA must take appropriate corrective action if:(A) a staff person, other than a representative of the Office as defined in 26 TAC §88.2, does not report an allegation of abuse, neglect, or exploitation of a program participant in accordance with Texas Human Resources Code, Chapter 48; or(B) DFPS confirms abuse, neglect, or exploitation of a program participant by a staff person of the AAA.(z) Emergency services. A AAA must instruct all of its staff persons to call 911 or another local emergency hotline for fire-fighting, police, medical, or other emergency services, as appropriate, in the event of an emergency involving a program participant. (aa) Reporting waste, abuse, or fraud.(1) A AAA must instruct its staff persons and representatives to report allegations of waste, abuse, or fraud, as defined in 1 TAC §371.1601 (relating to Definitions), regarding a service described in subsection (a)(2) of this section. A report must be made to:(A) the Texas Health and Human Services Commission (HHSC), Office of the Inspector General, in accordance with the HHSC instructions available at www.hhs.state.tx.us; and(B) HHSC by calling 1-800-436-6184.(2) The Office of the Inspector General investigates reports of waste, abuse, or fraud in accordance with 1 TAC, Chapter 371, Subchapter G.(bb) Ethical conduct.(1) A AAA must ensure that its staff persons and representatives conduct themselves in an ethical manner.(2) A AAA staff person may not: (A) engage in inappropriate treatment of a program participant or person seeking services;(B) withhold or suppress a complaint or report against the AAA or HHSC;(C) retain or distribute program participant information for personal gain;(D) obtain a certification by fraud or deceit; or(E) knowingly participate in the preparation of false or misleading program participant information.(3) A AAA must instruct all staff persons and representatives to report allegations of unethical conduct, as described in paragraph (2) of this subsection, to HHSC's AAA Section Manager.(cc) Service provider compliance. A AAA must ensure that a service provider complies with the requirements described in subsections (y), (z), (aa)(1)(A), and (bb) of this section.(dd) Complaints. A AAA must ensure that a service provider: (1) on or before initiation of a service described in Subchapter D of this chapter, informs a program participant, in writing, of the procedure by which the program participant may file a complaint regarding such service;(2) obtains and maintains documentation of receipt of the complaint procedure by the program participant;(3) date stamps receipt of a written complaint;(4) documents receipt of an oral complaint, with the date of receipt and a narrative of the allegations;(5) investigates each complaint and responds, in writing, to the program participant regarding the results of the investigation in a timely manner; and(6) maintains a written log of complaints filed by program participants that is accessible to the AAA and contains the following information:(A) the date of the service provider's receipt of the complaint;(B) the name of the person who filed the complaint;(C) a description of the nature of the complaint;(D) the name of the staff person who conducted the investigation of the complaint;(E) the names of persons who were contacted during the investigation of the complaint;(F) the outcome of the complaint; and(G) the date final action was taken by the service provider in response to the complaint. Source Note: The provisions of this §213.151 adopted to be effective September 1, 2008, 33 TexReg 7293; amended to be effective April 5, 2018, 43 TexReg 2027; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.151 AAA Administrative Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201610 03/12/2026 (a) Purpose. This section establishes the fiscal responsibilities of a AAA, including responsibilities related to purchases of goods and services, audits, costs allocation plans, and service and administrative match. (b) Purchases of goods and services. (1) A AAA is permitted to enter into contracts and vendor agreements for the purchase of goods and services. (2) Except as provided in paragraph (3) of this subsection, a AAA must comply with competitive bidding procedures in selecting a subcontractor through the use of formal bidding, informal bidding, or competitive proposals, as appropriate. A AAA must document its compliance with the competitive bidding procedures. (3) A AAA may select a subcontractor using sole source procurement in accordance with 45 Code of Federal Regulations (CFR) §92.36(d)(4) if the award of a contract is not feasible using competitive bidding. (4) When purchasing goods and services from a service provider, a AAA must use one of the following cost determination methodologies in accordance with DADS requirements: (A) cost reimbursement; (B) fixed unit rate; or (C) variable unit rate. (5) A AAA may make a direct purchase of a service for a program participant on an individual basis in accordance with §83.19 of this title (relating to Direct Purchase of Services (DPS)). (6) A AAA must reference in a contract and vendor agreement the state rules relating to the services being provided by the subcontractor or the vendor. (7) A AAA must include in a contract a requirement that subcontractors have an accounting system that identifies all costs for each specific service being purchased or provided and that complies with 45 CFR, Part 1321. (8) All purchases of services, materials, equipment, and goods made by a AAA with grant funds must meet the criteria of allowability as set forth in, as applicable, the Uniform Grant Management Standards, as adopted by the Governor's Office of Budget and Planning, including the Office of Management and Budget (OMB) Circulars A-87 and A-122 and 45 CFR, Chapter 92. (9) All purchases made by a AAA must be evidenced by receipt of the service or merchandise or issuance of a purchase contract, voucher, or other legal document that binds both parties to the transaction, no later than the last day of the grant period for which funds have been budgeted and encumbered. (10) If the service or merchandise has not been received by the last day of the grant period as described in paragraph (9) of this subsection, a AAA must have received the service or merchandise and made payment for such before the due date of the closeout report for the grant period for which funds have been budgeted and encumbered. (11) A AAA must ensure that a service provider complies with the requirements described in paragraphs (8) - (10) of this subsection. (c) Independent audit. (1) A AAA must ensure that an independent certified public accounting firm performs an audit in accordance with: (A) the standards for financial and compliance audits contained in the Standards for Audit of Governmental Organizations, Programs, Activities, and Functions, issued by the U.S. General Accounting Office; (B) the Single Audit Act; (C) OMB Circular A-133, Audits of States, Local Governments, and Nonprofit Organizations, as applicable; (D) the Uniform Grant Management Standards; and (E) generally accepted accounting principles. (2) A AAA must provide DADS and the Office of Inspector General of the Health and Human Services Commission with a report of the audit conducted in accordance with paragraph (1) of this subsection within 30 days following receipt of such report or within nine months following the end of the AAA's fiscal year that the audit covers, whichever is earlier. (3) A AAA must ensure that an audit of a subcontractor is performed by an independent certified public accounting firm in accordance with OMB Circular A-133 and review the report of the audit performed. (d) Indirect Cost Allocation Plan. (1) To demonstrate compliance with the Uniform Grant Management Standards, a AAA for which DADS is not the designated state coordinating agency must submit to DADS an Indirect Cost Allocation Plan approval letter from the state coordinating agency or federal cognizant agency. (2) A AAA for which DADS is the designated state coordinating agency must submit, in accordance with the Uniform Grant Management Standards and DADS requirements, an Indirect Cost Allocation Plan to DADS for its approval. (e) Unallowable costs. (1) Unallowable costs made by a AAA, as defined in OMB Circulars A-87 and A-122, and other applicable state and federal laws, rules, and regulations, may be identified: (A) by the public accounting firm that performed an audit of the AAA in accordance with subsection (c)(1) of this section; or (B) by DADS: (i) as the result of monitoring of the AAA or because of information contained in the audit report described in subsection (c)(2) of this section; or (ii) if a AAA fails to obtain an audit of a subcontractor in accordance with subsection (c)(3) of this section. (2) The AAA is liable to DADS for any unallowable costs identified in accordance with paragraph (1) of this subsection. (3) If DADS determines a AAA has unallowable costs, DADS sends the AAA a Letter of Notification of Disallowance with Intent to Recover Costs by certified or registered mail, requesting the AAA to resolve all findings and unallowable costs within six months of receipt of the letter, in accordance with OMB Circular A-133, unless an extension is granted by DADS. (f) Refunding of payments. (1) A AAA may be required to refund to DADS: (A) unallowable costs identified in accordance with subsection (e) of this section; or (B) amounts paid to the AAA in excess of those earned by the AAA. (2) Refunds may be made by the AAA by making payment to DADS or by DADS withholding payments to be made to the AAA. (3) A AAA that has made a refund to DADS in accordance with paragraph (1) of this subsection waives all rights to such funds and must not receive any of the funds as part of a future allocation. (g) Capital expenditures. A AAA must comply with and ensure that a service provider complies with capital expenditure guidelines set forth in the Uniform Grant Management Standards, OMB Circulars A-87 and A-122, and requirements developed by DADS, as applicable. (h) Budget submissions. (1) A AAA must submit to DADS, on an annual basis and in accordance with DADS requirements, a budget that supports an approved area plan. (2) A AAA may submit an amended budget that supports an approved area plan in accordance with DADS requirements. (i) Service and administrative match. (1) A AAA must; (A) provide funds and in-kind contributions, in accordance with the Older Americans Act, §304, to match the expenditures of federal funds made to DADS for the cost of providing goods and services; and (B) ensure that an appropriate portion of funds or in-kind contributions is generated to match the federal fund expenditure based on the cost of services it provides. (2) The valuation of services or goods as reported as in-kind must be based on fair market value. (3) A AAA may use state general revenue to match funds appropriated under Title III, Part E of the Older Americans Act. (4) A AAA must not use state general revenue to match administrative funds. (j) Program income. A AAA must administer and ensure that a service provider administers program income as described in DADS Program Instruction AAA - PI-305 Administering Program Income. (k) Adequate proportion. (1) In accordance with the Older Americans Act, §306(a)(2), a AAA must expend funds appropriated under Title III, Part B of the Older Americans Act to meet an adequate proportion requirement, as determined by DADS, for: (A) access services; (B) in-home services; and (C) legal assistance. (2) A AAA may request, in writing, by September 30 of each year, that DADS waive or revise the adequate proportion requirement for any of the categories of services listed in paragraph (1) of this subsection for the next federal fiscal year, in accordance with the Older Americans Act, §306(c). (A) The AAA must demonstrate to DADS there are sufficient services available in the requested category to meet the need for such services. (B) A AAA must submit a separate request for each category of service for which a waiver is sought. (3) A AAA must comply with DADS instructions regarding adequate expenditures for the Medication Management Program funds appropriated under the Older Americans Act, Title III, Part D. (l) Caregiver support program limitation. In accordance with the Older Americans Act, §373(g)(2)(C), a AAA may not use more than 10 percent of the funds appropriated under Title III, Part E of the Older Americans Act for the Caregiver Support Program for program participants 55 years of age and older who are providing primary care for children 18 years of age or younger. (m) Administrative services. A AAA that elects to utilize state general revenue for administrative services may not supplant existing federal funds appropriated for such services. Source Note: The provisions of this §213.153 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.153 AAA Fiscal Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201611 03/12/2026 (a) Purpose. This section establishes the process for a AAA to request approval to directly provide a service included in the AAA's area plan. In this section, to directly provide a service means to provide the service by a staff person or volunteer. (b) Services requiring approval to directly provide. For each service listed in the Service Definitions for Area Agencies on Aging, found at DADS website, DADS states whether a AAA must obtain approval from DADS to directly provide the service. If a AAA is required to obtain such approval, the AAA must request approval in accordance with this section. (c) Conditions for approval. In accordance with the Older Americans Act, §307(a)(8), DADS approves a AAA's request to directly provide a service only if: (1) the direct provision of the service by the AAA is necessary to ensure an adequate supply of the service; (2) the service is directly related to the AAA's administrative functions; or (3) the service can be provided more economically, and with comparable quality, by the AAA. (d) Non-emergency request. (1) Unless the request for approval is made because of an emergency as described in subsection (e) of this section, a AAA must request approval to directly provide a service by: (A) submitting a written request to DADS that: (i) identifies the service the AAA is requesting to directly provide; (ii) identifies the conditions in subsection (c) of this section that are the basis for the AAA's request; (iii) includes an explanation supporting the condition identified by the AAA; (iv) if the condition identified by the AAA is the one in subsection (c)(3) of this section, includes information comparing: (I) the cost of directly providing the service with the cost of not directly providing the service; and (II) the quality of the service if directly provided with the quality of the service if not directly provided; and (v) states the period of time for which the AAA requests to directly provide the service; and (B) providing any additional information to DADS upon request. (2) If DADS grants approval of a AAA's request to directly provide a service, the approval is effective for the period of time stated in paragraph (1)(A)(v) of this subsection, not to extend past the effective period of the AAA's current area plan. (3) If DADS grants approval for a AAA's non-emergency request to directly provide a service, the AAA must amend its area plan to include a provision that the service is being directly provided by the AAA. (e) Emergency request. (1) If a AAA is requesting approval to directly provide a service because an uncontrollable or unforeseen situation prevents immediate delivery of the service, the AAA must: (A) request provisional approval to directly provide the service by contacting the DADS AAA Section Manager by telephone and providing information to DADS as requested; and (B) if provisional approval is granted by DADS, request final approval to directly provide the service by: (i) submitting to DADS, within 36 hours after DADS grants provisional approval, a written explanation supporting the condition described in subsection (c)(1) of this section and a statement of the period of time for which the AAA requests to directly provide the service; and (ii) providing any additional information to DADS upon request. (2) If DADS grants provisional approval for a AAA to directly provide a service because of an emergency situation, the provisional approval is in writing and effective until DADS either grants or denies final approval. (3) If DADS grants final approval for a AAA to directly provide a service because of an emergency situation, the final approval is for a time period determined by DADS that: (A) does not exceed 180 days; or (B) does not extend past the effective period of the AAA's current area plan. (f) Extension of approval period. (1) A AAA may request that DADS grant an extension of a time period that the AAA may directly provide a service, as described in subsections (d)(2) and (e)(2) and (3) of this section. (2) A AAA's request to grant an extension must be in writing and include an explanation of why the extension is necessary. (3) Based on the written request, DADS may grant an extension of an approval period that does not extend past the effective period of a AAA's current area plan. Source Note: The provisions of this §213.155 adopted to be effective September 1, 2011, 36 TexReg 4811; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.155 Process for AAA to Request Approval to Directly Provide a Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201612 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201612 03/12/2026 (a) Purpose. This section establishes the requirements for data management, a service provided under the Older Americans Act and funded, in whole or in part, by DADS. (b) Service provider responsibilities. A AAA must perform or ensure that a service provider performs the data management activities described in DADS Program Instruction AAA - PI -312 Data Management Guide. Source Note: The provisions of this §213.157 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.157 Data Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201626 03/12/2026 (a) Purpose. This section establishes the requirements for transportation services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS. (b) Eligibility. A AAA must ensure a program participant who receives transportation services is: (1) 60 years of age and older; or (2) an informal caregiver authorized to receive transportation services in accordance with the Older Americans Act, §373(b)(5). (c) Operations. (1) A AAA must ensure a service provider provides transportation services that: (A) are for nonemergency purposes; (B) consist of transporting a program participant to and from activities as specified in the contract or vendor agreement; and (C) are, as defined in the Service Definitions for Area Agencies on Aging available at www.dads.state.tx.us, "demand response," "fixed route," or a combination of both. (2) A AAA must ensure that in providing transportation services, a service provider: (A) complies with applicable federal and state laws, rules, and regulations including the Americans with Disabilities Act; (B) employs or contracts with staff persons who are trained and have current certification in, as applicable, scheduling and dispatching, defensive driving, passenger handling and assistance, first aid and cardiopulmonary resuscitation and operating an automatic external defibrillator, if one is available; and (C) coordinates efforts to eliminate duplication and maximize resources. Source Note: The provisions of this §213.201 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.201 Transportation Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205188 03/12/2026 (a) Purpose. This section establishes the requirements for nutrition services, a service provided under Older Americans Act and funded, in whole or in part, by HHSC.(b) Policy. Nutrition services must be provided in compliance with all HHSC policies established by authority of Older Americans Act §305(a)(1)(C) (42 U.S.C. §3025(a)(1)(C)), relating to organization and responsibilities of the State.(c) Eligibility and assessment. A AAA must ensure that a person who receives a nutrition service is:(1) 60 years of age or older; or(2) eligible in accordance with Older Americans Act §339(2)(H) (42 U.S.C. §3030g-21(2)(H)) and §339(2)(I) (42 U.S.C. §3030g-21(2)(I)) and assessed for eligibility as required by Older Americans Act §339(2)(J) (42 U.S.C. §3030g-21(2)(J)) and the AAA Policies and Procedures Manual.(d) Nutrition screening. A AAA must conduct or ensure a meal provider conducts nutrition screening for a person receiving a nutrition service as required by Older Americans Act §339(2)(J) (42 U.S.C. §3030g-21(2)(J)).(e) Meal requirements. A AAA must ensure that a meal provider serves meals that comply with Older Americans Act §339(2)(A) (42 U.S.C. §3030g-21(2)(A)), relating to Dietary Guidelines for Americans, dietary reference intakes, and adjustments to meet special dietary needs of persons receiving nutrition services, and with the AAA Policies and Procedures Manual policies related to menus, standard recipes, and approval of menus.(f) Service days. A AAA must ensure that meals are provided in accordance with Older Americans Act §331 (42 U.S.C. §3030e) and §336 (42 U.S.C. §3030f), and with the AAA Policies and Procedures Manual policies, related to serving fewer than five meals a week.(g) Delivery of multiple meals. A AAA must complete or ensure that a meal provider completes a Determination of Type of Meal assessment in compliance with the AAA Policies and Procedures Manual for each person who receives other than hot meals or receives multiple meals at one time to determine the person can safely handle the type of meals to be delivered.(h) Facilities and food service. A AAA must ensure that a meal provider:(1) complies with 25 TAC Chapter 228 (relating to Retail Food) and 25 TAC Chapter 229 (relating to Food and Drug) in training staff, and the preparation, handling, and delivery of food; and(2) provides a copy of all facility inspection results required by state law or rule to the AAA.(i) Nutrition Services Incentive Program. A AAA must ensure that a meal provider:(1) complies with the Older Americans Act §311 (42 U.S.C. §3030a), relating to the Nutrition Services Incentive Program; and(2) includes eligible meals in reports to HHSC through which Nutrition Services Incentive Program cash is calculated as earned for distribution to AAAs.(j) Voluntary contributions. A AAA must ensure that a meal provider complies with Older Americans Act §315(b) (42 U.S.C. §3030c-2(b)), §213.151(l) of this chapter (relating to AAA Administrative Responsibilities), and the AAA Policies and Procedures Manual policies relating to voluntary contributions.(k) Meal cost recovery. A AAA must ensure that a meal provider:(1) posts the cost of a meal for purposes of cost recovery as described in paragraph (2) of this subsection;(2) recovers, at a minimum, the cost of a meal that is served to a person who is not eligible for a meal funded by the Older Americans Act; and(3) keeps payments for a meal served to an ineligible person separate from voluntary contributions from an eligible person.(l) Holding time. A AAA must ensure that a meal provider complies with state and local laws for the safe and sanitary handling of food.(1) A AAA must ensure that a congregate meal provider does not allow more than four hours to expire from the time the provider:(A) removes hot food from temperature control and the time the provider serves the hot food; or(B) removes cold food from temperature control and the time the provider serves the cold food.(2) A AAA must ensure that a home delivered meal provider limits the amount of time meals are in transit and does not allow more than four hours to expire from the time the provider:(A) removes hot food from temperature control and the time the provider delivers the hot food; or(B) removes cold food from temperature control and the time the provider delivers the cold food.(m) Nutrition outreach. A AAA must ensure that a meal provider develops and maintains a written outreach plan giving priority to people described in the Older Americans Act §306(a)(1) (42 U.S.C. §3026(a)(1)).(n) Nutrition education. In accordance with the Older Americans Act §339(2)(J) (42 U.S.C. §3030g-21(2)(J)), a AAA must ensure that an eligible person is provided with nutrition education annually and, if appropriate, nutrition counseling.(o) Political activity. A AAA must ensure that a meal provider does not:(1) use a congregate meal site for political campaigning except in those instances where a representative from each political party running in the campaign is given an equal opportunity to participate; or(2) distribute political materials at a congregate meal site.(p) Religious activities and prayer. A AAA must ensure that a meal provider does not:(1) allow a prayer or other religious activity to be officially sponsored, led, or organized by a staff person of a congregate meal site; or(2) prohibit a person from praying silently or audibly at a congregate meal site if the person so chooses.(q) Monitoring.(1) A AAA must monitor meal providers in compliance with 40 TAC §83.19(f), §213.151(e) of this chapter, and the AAA Policies and Procedures Manual.(2) A AAA must ensure that the Department of State Health Services or the local health authority, as applicable, monitors a food preparation site, at least annually.(3) A AAA must ensure that the meal provider submits the written report of the food preparation site monitoring to the AAA.(r) Emergencies and disasters. A AAA must ensure that a meal provider develops a plan and written procedures for emergencies and disasters to keep food, facilities, and equipment available to the extent possible, for people participating in the nutrition services program, in accordance with the AAA Policies and Procedures Manual policies giving priority to people 60 years of age or older.(s) Subcontracting by a meal provider. A AAA must require a meal provider to obtain written approval from the AAA before the meal provider contracts with any entity for meal preparation or service delivery.(t) Adoption by reference. HHSC adopts by reference as requirements for nutrition services the following:(1) OAA §§306(a)(1) (42 U.S.C. §3026(a)(1)), 311(42 U.S.C. §3030a), 315(b) (42 U.S.C. §3030c-2(b)), 331(42 U.S.C. §3030e), 336(42 U.S.C. §3030f, and 339(2) (42 U.S.C. §3030g-21(2)), as amended through Public Law 116-131, enacted March 25, 2020; and(2) the AAA Policies and Procedures Manual, adopted effective January 15, 2021. Source Note: The provisions of this §213.203 adopted to be effective September 1, 2008, 33 TexReg 7293; amended to be effective November 24, 2014, 39 TexReg 9264; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721; amended to be effective June 3, 2021, 46 TexReg 3415. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.203 Nutrition Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201628 03/12/2026 (a) Purpose. This section establishes the requirements for participant assessment services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS.(b) Provision of services.(1) Except as provided in paragraph (2) of this subsection, a AAA must enter into a vendor agreement for the provision of participant assessment services.(2) Regarding nutrition services described in §85.302 of this subchapter (relating to Nutrition Services), a AAA may contract with a nutrition services subcontractor for the provision of participant assessment services.(c) Service activities. Assessment services include only those activities that directly relate to the initial assessment of an individual seeking a service funded under the Older Americans Act and reassessment of a program participant. Such activities may include travel to and from the home of the individual seeking services or program participant for the purpose of conducting an assessment or reassessment.(d) Assessment and reassessment. A AAA must conduct or ensure that a service provider conducts:(1) a multidimensional assessment of an individual seeking services funded under the Older Americans Act to determine the type of service an individual needs; and(2) a reassessment of a program participant to determine the effectiveness of the services provided and whether there is a need for services to continue.(e) Authorization. Before a vendor conducts an assessment or reassessment as described in subsection (d) of this section, a AAA must ensure that the vendor obtains prior written authorization from the AAA. Source Note: The provisions of this §213.205 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.205 Participant Assessment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201629 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201629 03/12/2026 (a) Purpose. This section establishes the requirements for homemaker services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS. (b) Eligibility. A AAA must ensure that a program participant who receives homemaker services is: (1) 60 years of age or older; and (2) functionally impaired in the ability to perform instrumental activities of daily living as described in DADS Program Instruction AAA - PI 310 Activities of Daily Living/Instrumental Activities of Daily Living NAPIS Mapping Requirements. (c) Type of provider. A AAA may provide homemaker services as an agency managed service or as a consumer directed service, or as both. (1) Agency managed. Homemaker services that are agency managed are provided only by a vendor. (2) Consumer directed. Homemaker services that are consumer directed are provided by furnishing vouchers to a program participant, allowing the program participant to select a homemaker, establish a work schedule and payment rate, and provide the homemaker information and training on the program participant's needs. (d) Informing program participant of options. If a AAA provides homemaker services as both an agency managed service and as a consumer directed service, the AAA must inform a program participant that he or she may choose to receive homemaker services in either of those two ways. (e) Service authorization. Before homemaker services are provided by a vendor to a program participant, the AAA must ensure that the vendor obtains prior written authorization for the services from the AAA in accordance with §83.3(o)(2)(B) of this title (relating to System of Access and Assistance). (f) Homemaker services. Homemaker services include: (1) cleaning for the program participant, including: (A) cleaning after a program participant's personal care tasks; (B) emptying and cleaning a program participant's bedside toilet; (C) cleaning a program participant's bathroom; (D) changing a program participant's bed linens and making the program participant's bed; (E) cleaning the floor of a program participant's living area; (F) dusting an area used by a program participant; (G) taking a program participant's trash to an outside receptacle and moving the receptacle to a location for pick-up; (H) cleaning a program participant's stovetop and counters; (I) washing a program participant's dishes; and (J) cleaning a program participant's refrigerator and stove; (2) doing a program participant's laundry, including: (A) washing a program participant's laundry by hand or machine; (B) gathering and sorting laundry; (C) loading and unloading the washing machine and dryer in the program participant's residence; (D) using laundromat machines; (E) hanging laundry to dry; and (F) folding and putting away laundry; (3) shopping for the program participant, including: (A) preparing a shopping list; (B) going to the store and purchasing or picking up items; (C) picking up medication; and (D) storing the purchased items; (4) assisting a program participant in organizing and completing a home management routine; (5) performing necessary reading and writing tasks as directed by the program participant; (6) preparing meals for the program participant, including: (A) assisting in planning menus that are appropriate for the program participant's needs; (B) shopping for and storing food; (C) preparing and serving meals; and (D) utilizing sanitary practices for handling and preparing food; and (7) accompanying a program participant to obtain health care services and other necessary items and services unless prohibited by subsection (g)(7) of this section. (g) Prohibited activities. Homemaker services do not include the following: (1) personal assistance services described in §85.305(e)(1) - (2), (4) - (10), and (12) of this subchapter (relating to Personal Assistance Services); (2) repairs to the program participant's residence; (3) pet grooming; (4) yard maintenance; (5) moving heavy objects; (6) performing services for members of the household other than the program participant; (7) transporting the program participant in a vehicle unless proof of liability insurance covering such transportation has been verified, in writing, by the vendor; (8) performing tasks beyond the scope of the service authorization required by subsection (e) of this section; (9) accepting gifts from the program participant; (10) bringing persons to the program participant's residence who are not providing homemaker services to the program participant; (11) taking personal property from the program participant's residence; or (12) assuming control of the financial or personal affairs of the program participant or his or her estate including serving as power of attorney, guardian, or conservator. (h) Staffing qualification requirements for an agency-managed service. (1) A AAA must ensure that a vendor that has a program supervisor for homemaker services requires the program supervisor to: (A) meet one of the following criteria: (i) be a licensed nurse; (ii) have completed two years of full-time study in social or behavioral sciences at an accredited college or university; or (iii) have: (I) a high school diploma or high school equivalency certificate; and (II) have one of the following: (-a-) the equivalent of two years experience as a full-time employee in a supervisory capacity in a health care facility, health care agency, or other health care organization; or (-b-) the equivalent of one year experience as a full-time employee in a supervisory capacity in a health care facility, health care agency, or other health care organization and have completed one year of full-time study in social or behavioral sciences at an accredited college or university; and (B) have experience in: (i) housekeeping or home management; and (ii) meal preparation activities. (2) A AAA must ensure that a vendor requires a homemaker (that is, the person who provides homemaking services to the program participant): (A) to be an adult; (B) to have the ability to follow oral and written instructions and keep records; (C) to have previous experience providing care to a person 60 years of age or older or a disabled adult; (D) to demonstrate competency to perform homemaker services; (E) to not be the spouse or legal guardian of the program participant; and (F) to not live with the program participant. (i) Training and documentation requirements for an agency managed service. A AAA must ensure that a vendor: (1) trains homemakers to recognize and report changes in a program participant's health condition that may require emergency procedures or health services; (2) maintains documentation demonstrating compliance with paragraph (1) of this subsection; and (3) determines the need for, and requires homemakers to receive, other training as appropriate. (j) Information and assistance requirements for a consumer directed service. A AAA must: (1) give a program participant written information to assist the program participant in performing the following activities: (A) interviewing potential homemakers; (B) requiring potential homemakers to provide references; (C) checking references of homemakers; (D) selecting a homemaker who meets the qualifications described in subsection (h)(2) of this section; (E) deciding upon, in discussion with the homemaker, an hourly, daily, or weekly rate to be paid to the homemaker; (F) informing or training the homemaker on the specific needs of the program participant; (G) ensuring proper payment for homemaker services by recording the number of hours or days homemaker is used and the total amount claimed against the voucher; (H) ensuring federal tax guidelines for household employees are followed in accordance with IRS Publication 926; (I) notifying the AAA if the program participant's address changes; (J) monitoring the quality of the homemaker service provided; and (K) notifying the AAA if the program provider is dissatisfied with a homemaker; and (2) assist a program participant in finding a homemaker if such assistance is requested by the program participant. Source Note: The provisions of this §213.207 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.207 Homemaker Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201630 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201630 03/12/2026 (a) Purpose. This section establishes the requirements for personal assistance services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS. (b) Eligibility. A AAA must ensure that a program participant who receives personal assistance services is: (1) 60 years of age or older; and (2) functionally impaired in his or her ability to perform activities of daily living as described in DADS Program Instruction AAA - PI - 310 Activities of Daily Living/Instrumental Activities of Daily Living NAPIS Mapping Requirements. (c) Requirement for a licensed vendor to provide services. A AAA must enter into a vendor agreement for the provision of personal assistance services with an entity licensed by DADS as a home and community support services agency in accordance with Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies). (d) Service authorization. Before personal assistance services are provided by a vendor to a program participant, a AAA must ensure that the vendor obtains authorization for the services from the AAA in accordance with §83.3(o)(2)(B) of this title (relating to System of Access and Assistance). (e) Personal assistance services. Personal assistance services include: (1) bathing, which includes: (A) drawing water in sink, basin, or tub; (B) hauling or heating water; (C) laying out supplies; (D) assisting a program participant in or out of tub or shower; (E) sponge bathing and drying a program participant; (F) bed bathing and drying a program participant; (G) tub bathing and drying a program participant; and (H) providing standby assistance for a program participant while the program participant is engaged in bathing activities; (2) dressing, which includes: (A) dressing a program participant; (B) undressing a program participant; and (C) laying out clothes for a program participant; (3) meal preparation for a program participant, which includes: (A) assisting in planning menus that are appropriate for the program participant's needs; (B) cooking a full meal; (C) warming prepared food; (D) helping prepare meals; (E) planning meals; and (F) cutting a program participant's food for eating; (4) feeding a program participant, which includes: (A) spoon-feeding or bottle-feeding, but not tube feeding; (B) assisting a program participant with using eating and drinking utensils and adaptive devices; and (C) providing a program participant with standby assistance or encouragement while the program participant is eating; (5) exercising by walking with a program participant; (6) grooming a program participant, which includes: (A) caring for teeth; (B) shaving, including face, underarms, and legs; (C) caring for nails; and (D) laying out supplies; (7) routine hair and skin care, which includes: (A) washing a program participant's hair; (B) drying a program participant's hair; (C) assisting with setting, rolling or braiding a program participant's hair but not cutting or chemical processing of hair; (D) combing or brushing a program participant's hair; (E) applying nonprescription lotion to a program participant's skin; (F) washing hands and face of a program participant; (G) applying makeup to a program participant; and (H) laying out supplies; (8) assistance with self-administered medications, which includes: (A) reminding a program participant to take a medication at the prescribed time; (B) opening and closing a medication container; (C) pouring a predetermined quantity of liquid to be ingested; (D) returning a medication to the proper storage area; and (E) assisting in reordering medications from a pharmacy; (9) toileting, which includes: (A) changing a program participant's day briefs; (B) changing a program participant's colostomy bag, including emptying the catheter bag; (C) assisting a program participant with use of a bedpan, including emptying the bedpan; (D) assisting a program participant with the use of a urinal, including emptying the urinal; (E) assisting a program participant with feminine hygiene needs; (F) assisting a program participant with clothing during toileting; (G) assisting a program participant with toilet hygiene, including the use of toilet paper and washing hands; (H) changing a program participant's external catheter; (I) preparing toileting supplies and equipment but not preparing catheter equipment; and (J) providing standby assistance to the program participant during toileting activities; (10) transfer or ambulation of the program participant, which includes: (A) non-ambulatory movement of a program participant from one stationary position to another but not carrying the program participant; (B) adjusting or changing a program participant's position in a bed or chair; (C) assisting a program participant in rising from a sitting to a standing position; (D) assisting a program participant in positioning for use of a walking apparatus; (E) assisting a program participant with putting on and removing leg braces and prostheses for ambulation; (F) assisting a program participant with ambulation or using steps; (G) assisting a program participant with wheelchair ambulation; and (H) providing a program participant with standby assistance while the program participant is engaged in any of the activities listed in subparagraphs (A) - (G) of this paragraph; (11) home management (that is, assistance with housekeeping activities supporting the program participant's health and safety), which includes: (A) changing a program participant's bed linens; (B) cleaning a program participant's house; (C) laundering a program participant's clothes; (D) shopping for a program participant; (E) storing purchased items for a program participant; and (F) washing a program participant's dishes; and (12) escorting a program participant to obtain health care services and other necessary items and services except as prohibited by subsection (f)(6) of this section; (f) Prohibited activities. Personal assistance services do not include the following activities: (1) repairing a program participant's home; (2) grooming a program participant's pet; (3) moving heavy objects such as furniture for a program participant; (4) maintaining a program participant's yard; (5) performing services for members of a program participant's household other than the program participant; (6) transporting a program participant in a vehicle unless proof of liability insurance covering such transportation has been verified, in writing, by the vendor; (7) performing tasks not assigned by the supervisor of the provider of personal assistance services; (8) accepting gifts from a program participant; (9) bringing persons to a program participant's home who are not providing personal assistance services to the program participant; (10) taking personal property from a program participant's home; or (11) assuming control of the financial or personal affairs of a program participant or of his or her estate, including serving as power of attorney, guardian, or conservator. (g) Qualifications. A AAA must ensure that a person providing personal assistance services does not live with the program participant. Source Note: The provisions of this §213.209 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.209 Personal Assistance Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201631 03/12/2026 (a) This section establishes the requirements for adult day services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS. (b) Eligibility. A AAA must ensure that a program participant who receives adult day services: (1) is: (A) 60 years of age or older; and (B) at least moderately impaired in the ability to perform instrumental or ordinary activities of daily living; or (2) is qualified to receive services under Title III, Part E, of the Older Americans Act. (c) Requirement for licensed vendor to provide services. A AAA must enter into a vendor agreement for the provision of adult day services with an adult day care facility licensed in accordance with §98.11 of this title (relating to Criteria for Licensing). (d) Service authorization. Before adult day services are provided by a vendor to a program participant, a AAA must ensure that the vendor obtains authorization for the services from the AAA in accordance with §83.3(o)(2)(B) of this title (relating to System of Access and Assistance). (e) Description of adult day services. Adult day services consist of nursing services, physical rehabilitative services, nutrition services, socialization activities, and transportation services. (1) Nursing services. Nursing services must include: (A) assessing, observing, evaluating, and documenting a program participant's health condition, and instituting appropriate nursing interventions to stabilize or improve a program participant's condition or prevent complications; (B) assisting a program participant with self-administered medications including, but not limited to, ordering, maintaining, or administering the medications as directed by a physician or other health care practitioner acting within the scope of the practitioner's authority and license; (C) assisting a program participant with medical treatments, as directed by a physician or other health care practitioner acting within the scope of the practitioner's authority and license; (D) counseling a program participant on the program participant's health needs and involving family members and caregivers in the discussions regarding immediate and long-term health goals; and (E) providing or supervising personal day services to enable a program participant to restore, maintain, or improve the ability to perform activities of daily living and instrumental activities of daily living as defined in DADS Program Instruction AAA-PI-310 Activities of Daily Living/Instrumental Activities of Daily Living NAPIS Mapping Requirements. (2) Physical rehabilitative services. Physical rehabilitative services must include: (A) restorative nursing; and (B) group and individual exercises, including range of motion exercises. (3) Nutrition services. Nutrition services must include: (A) one hot meal served between the hours of 10:30 a.m. and 1:30 p.m. that: (i) is suitable in quantity and adequacy to attain and maintain nutritional requirements, including those of a special needs program participant; and (ii) consists of at least two ounces of meat, one-half cup of fruit or vegetables, one cup of milk, and two servings of bread; (B) special diets as required by a program participant's plan of care; (C) a supplementary mid-morning and mid-afternoon snack; (D) dietary counseling and nutrition education for a program participant and family member; and (E) assisting with meals, if necessary, for program participants with hand deformities, paralysis, hand tremors, or trouble chewing, including: (i) grinding meats and mashing vegetables; and (ii) spoon feeding, bread buttering, and opening containers such as milk or juice. (4) Socialization activities. Socialization activities are community interaction, cultural enrichment, educational, recreational, or other social activities held in the vendor's facility or in the community in a planned program to meet the social needs and interests of a program participant. A AAA must ensure that a service provider: (A) provides at least three social activities each day; and (B) posts a monthly activity calendar in a visible location at least one week in advance of the activities listed. (5) Transportation services. (A) Transportation services must include: (i) round trip transportation to a vendor's facility from a program participant's residence; and (ii) round trip transportation from a vendor's facility to medical appointments ordered by a physician or other health care practitioner acting within the scope of the practitioner's authority and license if it is necessary for a program participant to attend such therapies or appointments while at the facility. (B) If a vendor does not provide transportation directly, it must arrange for transportation from another person or organization. (C) A vehicle used for transportation services must be properly operated and maintained and have proper heating and cooling systems to maintain reasonable temperature levels inside the vehicle. (f) Staff qualifications. A AAA must ensure that staff persons of a service provider meet the qualifications described in §98.62(a) of this title (relating to Program Requirements). Source Note: The provisions of this §213.211 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.211 Adult Day Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201632 03/12/2026 (a) Purpose. This section establishes the requirements for ERS, a service provided under the Older Americans Act and funded, in whole or in part, by DADS.(b) Eligibility. A AAA must ensure that a program participant who receives emergency response services:(1) is 60 years of age or older;(2) meets at least one of the following criteria:(A) lives alone;(B) is routinely alone for eight or more hours during a 24-hour period; or(C) lives with an incapacitated person who is not able to call for help or otherwise assist in an emergency;(3) lives in a place other than an LTC facility, personal care home, foster care setting, or any other institutional setting where 24-hour supervision is available; and(4) is at risk, such as being prone to falling or having an existing medical condition that may be life-threatening if the program participant does not receive immediate assistance.(c) Requirement for licensed vendor to provide services. A AAA must enter into a vendor agreement for the provision of ERS with an entity licensed:(1) by the Public Security Bureau of the Texas Department of Public Safety as an alarms systems company; or(2) by the Department of State Health Services as a personal emergency response system provider.(d) Service authorization. Before ERS are provided by a vendor to a program participant, a AAA must ensure that the vendor obtains authorization for the services from the AAA in accordance with §83.3(o)(2)(B) of this title (relating to System of Access and Assistance).(e) Service activities. A AAA must ensure that the vendor:(1) coordinates and oversees the installation and management of the electronic monitoring system;(2) initiates services within 14 days after the service effective date on the authorization, unless prohibited by factors beyond its control such as a natural disaster; and(3) if a program participant is not available to receive services during the time frame described in paragraph (2) of this subsection, initiates services within 72 hours after being notified the program participant is available.(f) Responder requirements.(1) A AAA must, before emergency response services are initiated, obtain or must ensure that a vendor obtains from the program participant as many names, as possible, of persons who will serve as responders.(2) A AAA must designate or must ensure that a vendor designates public service personnel as the responder of last resort for each program participant.(g) Prerequisites to service. A AAA must ensure that, before initiating ERS, a vendor:(1) ensures the program participant:(A) has the capacity to properly operate the electronic monitoring system;(B) has a telephone with a private line, if the electronic monitoring system requires a private line to function properly; and(C) signs a release statement allowing a responder to make a forced entry into the program participant's residence to respond to an activated alarm call when there are no other means of entering the residence;(2) installs the electronic monitoring system;(3) trains a program participant on the use of the electronic monitoring system, including:(A) demonstrating to the program participant how the system works; and(B) demonstrating to the program participant how to activate an alarm call; and(4) explains to a program participant:(A) that the program participant must participate in a system check each month;(B) that the program participant must contact a service provider if:(i) the program participant's telephone number or address changes; or(ii) one or more of the program participant's responders changes;(C) that the program participant must not willfully abuse or damage the electronic monitoring system;(D) that a responder may forcibly enter a program participant's residence if necessary; and(E) the procedures for filing a grievance against a service provider.(h) Program participant file. A AAA must ensure that a vendor maintains a file for each program participant that includes:(1) the name, telephone number, address, and medical condition of the program participant;(2) the name and telephone number of the program participant's physician or primary health care provider;(3) the name and telephone number of each responder;(4) a record of all completed and attempted system checks;(5) a record of each alarm call;(6) a copy of all required notices sent to the AAA;(7) a signed release as required by subsection (g)(1)(C) of this section;(8) the program participant's acknowledgment the equipment belongs to the vendor;(9) if applicable, documentation showing approval from the AAA for the continuation of ERS after the time period authorized in accordance with subsection (d) of this section; and(10) if applicable, documentation stating that service delivery was suspended and the reason for the suspension.(i) Service delivery. A AAA must ensure that a vendor authorized to provide ERS:(1) is available and able to respond to an alarm call from a program participant 24 hours a day, seven days a week; and(2) in response to an alarm call:(A) attempts to contact the program participant, within one minute of the call, to verify an emergency exists before contacting a responder;(B) immediately contacts a responder if:(i) the program participant verifies there is an emergency; or(ii) the vendor is unable to reach the program participant;(C) documents an alarm call at the time it is received and after it is resolved and includes:(i) the name of the program participant;(ii) the date and time an alarm call is received, recorded in hours, minutes, and seconds;(iii) the time a monitor called the program participant in response to an alarm call, recorded in hours, minutes, and seconds;(iv) the name of the contacted responder;(v) a brief description of the incident; and(vi) a statement of how the incident was resolved;(3) notifies the responder within 24 hours after becoming aware of a significant change in the program participant's condition; and(4) notifies the AAA, in writing, of any significant change in a program participant's environment within seven days after becoming aware of the change, including:(A) a change of address; and(B) a change in the circumstances described in subsection (b)(2) of this section.(j) System checks. A AAA must ensure that a vendor:(1) conducts a system check by activating the call button to test the electronic monitoring system at least once during each calendar month;(2) documents a completed system check, including the date and time of a completed system check;(3) completes a system check three times on three different days within one week if a system check fails to activate the electronic monitoring system;(4) contacts a responder or caregiver (other than public service personnel) to conduct a system check if the vendor is unable to complete a system check after three attempts to schedule with the program participant; and(5) if unable to conduct a system check, notifies the AAA in writing within 10 days after:(A) the date and time of each attempted system check;(B) the date and time of each attempt to contact a responder other than public service personnel; and(C) the reason the program participant was unable to participate.(k) Equipment maintenance. A AAA must ensure that a vendor:(1) replaces or repairs faulty equipment in the program participant's electronic monitoring system within one business day after learning of the faulty equipment if the program participant is available to permit such repair or replacement;(2) if the program participant is not available as described in paragraph (1) of this subsection, replaces or repairs the equipment as soon as the program participant is available;(3) instructs the program participant or caregiver in replacing a battery;(4) visits a program participant's residence to check the electronic monitoring system equipment within five business days after the equipment has registered five or more "low battery" signals in a 72-hour period and replaces the defective battery during the visit, if necessary; and(5) documents and maintains a record of each instance of faulty equipment and low battery signal and includes in the documentation:(A) the date the vendor became aware of the faulty equipment or low battery signal;(B) the equipment or subscriber number;(C) a description of the problem; and(D) the date the entire equipment or a part of it was repaired or replaced.(l) Suspension and termination of services. A AAA must ensure that a vendor:(1) suspends services before the end of the authorization period and removes the equipment from a program participant's residence, if the vendor becomes aware that:(A) the program participant moves to an area where the vendor does not provide services or that is not in the AAA's planning and service area;(B) the program participant is admitted to an LTC facility, personal care home, foster care setting, or any other institutional setting where 24-hour supervision is available;(C) the program participant moves to a noninstitutional residence and the requirements in subsection (b)(2) of this section are not met;(D) the program participant dies; or(E) the program participant requests for services to be terminated; and(2) if services are suspended and equipment removed from a program participant's residence in accordance with paragraph (1) of this subsection:(A) notifies the AAA within the next business day after such removal; and(B) sends a case information form requesting service termination to the AAA within seven days after the notification.(m) Special reporting considerations. A AAA must ensure that a vendor notifies the AAA of any of the following events within one business day of learning that:(1) a program participant activated:(A) four false alarms that result in a response by fire department, police, sheriff, or ambulance personnel within a six-month period; or(B) 20 false alarms of any kind within a six-month period;(2) the program participant is away from the residence or is unable to participate in the service delivery for three consecutive months or more; or(3) the program participant is no longer able to operate the electronic monitoring system properly. Source Note: The provisions of this §213.213 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.213 Emergency Response Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201633 03/12/2026 (a) Purpose. This section establishes the requirements for residential repair services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS.(b) Eligibility. A AAA must ensure that a program participant who receives residential repair services:(1) is 60 years of age or older;(2) lives in a residence that requires repair or modification to enhance or address:(A) energy efficiency;(B) structural integrity; or(C) the health and safety of the program participant.(c) Requirement for vendor to provide services. A AAA must enter into a vendor agreement for the provision of residential repair services.(d) Service authorization. Before residential repair services are provided by a vendor to a program participant, a AAA must ensure that the vendor obtains authorization for the services from the AAA in accordance with §83.3(o)(2)(B) of this title (relating to System of Access and Assistance).(e) Intent of services. A AAA must ensure that the residential repairs made by a vendor are essential for maintaining the health, safety, and independence of the program participant living in the residence.(f) Unit of service. The unit of service of residential repair services is one residence receiving services totaling no more than $5,000 within the current federal fiscal year. A AAA may exceed the $5,000 limit if it has prior written approval from DADS.(g) Descriptions of residential repair services.(1) Structural services. Structural services are any repairs to the structure of the residence considered necessary to the health and safety of the program participant.(2) Accessibility modifications. Accessibility modifications are structural adaptations to meet the needs of a program participant who has a disabling condition.(3) Electrical services. Electrical services are replacement, repair, and installation of essential electrical wiring or fixtures including telephone wiring.(4) Plumbing services. Plumbing services are replacement, repair, and installation of essential plumbing lines or fixtures.(5) Weatherization services. Weatherization services are repairs and modifications or purchase of supplies that protect a residence from the effects of the weather, conserve energy, or provide alternative energy sources to heat or cool.(6) Safety and security modification. Safety and security modifications are measures taken to prevent accidents, fires, or intrusion into a dwelling and the repair, modification, treatment, or removal of safety hazards in the residence.(7) Essential appliances. Essential appliances are appliances necessary to sustain a healthy environment and independent living.(h) Rental units. If the residence in which a program participant is living is not owned by the program participant, a AAA must obtain a signed agreement from the owner authorizing the services before services are provided.(i) Prohibited activities. Residential repair services do not include the following activities:(1) construction, repair, or maintenance of outbuildings such as garages, carports, animal shelters, or greenhouses;(2) installation, repair, or maintenance of nonessential appliances and fixtures; and(3) beautification of property or other activities that are strictly for cosmetic purposes.(j) Services completed before payment. A AAA must ensure that before payment is made for residential repair services one of the following occurs:(1) the program participant acknowledges, in writing, the services have been completed; or(2) the AAA has confirmed by an on-site visit that the services have been completed. Source Note: The provisions of this §213.215 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.215 Residential Repair Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201634 03/12/2026 (a) Purpose. This section establishes the requirements for senior centers, a service provided under the Older Americans Act and funded, in whole or in part, by DADS.(b) Senior center services. As provided in the Older Americans Act, §102(36), a senior center is a community facility used for the organization and provision of a broad spectrum of services for persons 60 years of age or older, which may include provision of health (including mental health); social, nutritional, and educational services; and the provision of facilities for recreational activities.(c) Operations. A AAA must ensure that a service provider of a senior center:(1) complies with applicable local building codes and ordinances and applicable state and federal laws, rules, and regulations including the Americans with Disabilities Act and the Rehabilitation Act of 1973, Section 504;(2) establishes the senior center in an area central to and easily accessible by program participants;(3) conducts fire prevention inspections on a monthly basis using a trained senior staff person or volunteer of the service provider;(4) posts a copy of the latest fire prevention inspection report in a conspicuous place in the senior center and files the report at the senior center for review by the AAA;(5) keeps doors, outside stairs, and fire escapes free from obstruction and in proper condition;(6) has basic first aid supplies at the senior center available and maintained, clearly marked, and accessible to all senior center staff persons and program participants;(7) has an adequate number of service center staff persons available at the center, during the time the center is open to the public, who are certified in:(A) first aid;(B) cardiopulmonary resuscitation; and(C) operating an automatic external defibrillator, if one is available; and(8) develops written policies and procedures regarding senior center operations and makes them available to senior center staff persons and program participants.(d) Political activity. A AAA must ensure that a service provider does not:(1) use a senior center for political campaigning except in those instances where a representative from each political party running in the campaign is given an equal opportunity to participate; or(2) distribute political materials at a senior center.(e) Religious activities and prayer. A AAA must ensure that a service provider does not:(1) allow a prayer or other religious activity to be officially sponsored, led, or organized by a senior center staff person or volunteer; or(2) prohibit a program participant from praying silently or audibly at a senior center if the program participant so chooses.(f) Inventory. A AAA must maintain an accurate inventory of senior centers that were renovated, acquired, or constructed, in whole or in part, with funds provided by DADS.(g) Change in ownership or purpose of a senior center.(1) A AAA must ensure that:(A) a grantee of funds from DADS to purchase or construct a senior center notifies the AAA, in writing, of the purchase or construction of the center within 30 days after such purchase or completion; and(B) a grantee of funds described in subparagraph (A) of this paragraph and any successor owner of the senior center:(i) notifies the AAA, in writing, of:(I) a change in the ownership of the senior center; or(II) a change in the purpose of the senior center from the purpose for which it was purchased or constructed; and(ii) makes such notification 30 days before the change described in clause (i) of this subparagraph.(2) A AAA must notify DADS if, within 10 years after purchase of or 20 years after completion of construction of a senior center, either of the following occurs:(A) the owner of a senior center ceases to be a public or nonprofit private agency or organization; or(B) there is a change in the purpose of the senior center from the purpose for which it was purchased or constructed.(3) The notice required by paragraph (2) of this subsection must be in writing and be given to DADS within 10 days after a AAA is notified of the occurrence.(4) If, within 10 years after the purchase of a senior center or 20 years after the completion of construction of a senior center, either of the conditions described in paragraph (2) of this subsection occurs, the United States Government is entitled to recover from the owner of the senior center an amount to be determined by the Older Americans Act, §312.(h) Insurance. A AAA must ensure that the owner or operator of a senior center maintains insurance coverage for total replacement cost of the center and for the contents of a center funded by DADS. Source Note: The provisions of this §213.217 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.217 Senior Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201635 03/12/2026 (a) Purpose. This section establishes the requirements for respite voucher services, a service provided under the Older Americans Act and funded, in whole or in part, by DADS.(b) Description of services. Respite voucher services are the provision of vouchers to a program participant to allow the program participant to select a respite provider, establish a work schedule and payment rate, and provide the respite provider information and training on the program participant's needs.(c) Eligibility.(1) In accordance with the Older Americans Act, §372, a AAA must ensure that a program participant who receives respite voucher services is:(A) an adult who is an informal provider of in-home and community care for an individual who:(i) is 60 years of age or older; and(I) is unable to perform at least two activities of daily living without substantial human assistance, including verbal reminding, physical cueing, or supervision; or(II) due to a cognitive or other mental impairment, requires substantial supervision because the individual behaves in a manner that poses a serious health or safety hazard to the individual or another person; or(ii) has Alzheimer's disease or a related disorder with neurological and organic brain dysfunction; or(B) a person who is 55 years of age or older who:(i) is a grandparent, step-grandparent, or relative by blood, marriage, or adoption of an individual with a disability or a child;(ii) is the primary caregiver for the individual with a disability or the child because the individual's or child's biological or adoptive parents are unable or unwilling to serve as the primary caregiver; and(iii) lives with the individual with a disability or the child; and(I) has a legal relationship to the individual or the child, such as guardianship; or(II) is caring for the individual or the child informally.(2) An adult who is paid by a person or entity to provide caregiving services to an individual described in paragraph (1) of this subsection is not eligible to receive respite voucher services in regard to the same individual.(d) Targeting. In the provision of respite voucher services a AAA must ensure that:(1) priority is given to persons described in §85.201(f) of this chapter (relating to AAA Administrative Responsibilities);(2) for persons described in subsection (c)(1)(A)(ii) of this section, priority is given to persons who provide care for individuals who are 60 years of age or older with Alzheimer's disease or a related disorder with neurological and organic brain dysfunction; and(3) for persons described in subsection (c)(1)(B) of this section, priority is given to persons who provide care for children with severe disabilities.(e) Application process. A AAA must:(1) implement an application process to allow a person to apply for respite voucher services;(2) process the applications received, including verifying that the requirement described in subsection (c)(1)(A) or (c)(1)(B) of this section are met; and(3) notify the applicant of whether or not the application is approved.(f) Information for program participants. A AAA must give a program participant written information to assist the program participant in performing the following activities:(1) interviewing potential respite providers;(2) requiring potential respite providers to provide references;(3) checking references of respite providers;(4) selecting a qualified respite provider in accordance with subsection (g) of this section;(5) deciding upon, in discussion with the respite provider, an hourly, daily, or weekly rate to be paid to the provider;(6) informing or training the respite provider on the specific needs of the program participant;(7) ensuring proper payment for respite voucher services by recording the number of hours or days of respite used and the total amount claimed against the voucher;(8) ensuring federal tax guidelines for household employees are followed in accordance with IRS Publication 926;(9) notifying the AAA if the program participant's address changes;(10) monitoring the quality of the respite voucher services provided; and(11) notifying the AAA if the program provider is dissatisfied with a respite provider.(g) Qualifications of a respite provider. A respite provider selected by a program participant:(1) must be an adult;(2) may be, except as provided in paragraph (3) of this subsection, any person or entity, including a family member or friend of the program participant or a licensed adult day care facility; and(3) must not:(A) be the spouse or legal guardian of the program participant; or(B) live with the program participant.(h) Assistance in finding a respite provider. A AAA must assist a program participant in finding a respite provider if such assistance is requested by the program participant. Source Note: The provisions of this §213.219 adopted to be effective September 1, 2008, 33 TexReg 7293; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.219 Respite Voucher Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201624 03/12/2026 (a) Purpose. This section describes the formula used to distribute funds to a AAA in accordance with the Older Americans Act, §305(a)(2)(C).(b) AAA State General Revenue Base. A AAA is allocated a base amount of $60,000.(c) AAA Administration Base. In accordance with the Older Americans Act, an administration pool comprised of 10 percent of the federal allocation of funds to AAAs is established. From this amount, a AAA is allocated no less than $85,000.(d) AAA Supportive Services Base. A AAA is allocated a base amount of $115,000 for Title III Supportive Services.(e) AAA Nutrition Services Base. A AAA is allocated a base amount of $100,000 for Title III Nutrition Services.(f) AAA Rural Allocation. The rural allocation factor is based upon a three part formula:(1) a AAA with a population density factor that exceeds the statewide average of persons 60 years of age and older per square mile receives no rural allocation;(2) a AAA with a population density factor greater than 50 percent of the statewide average of persons 60 years of age and older per square mile, but less than the statewide average, receives a rural allocation of $15,000; and(3) a AAA with a population density factor of less than 50 percent of the statewide average of persons 60 years of age and older per square mile receives a rural allocation of $30,000.(g) Allocation of Remaining Funds. All remaining funds, except the funds allocated for the Ombudsman Program as described in 26 TAC §88.105 (relating to Fiscal Management and Monitoring of a Local Ombudsman Entity), are allocated in accordance with the following formula of weighted factors:(1) the total AAA region's population 60 years of age and older, weighted at 40 percent;(2) the total AAA region's population 60 years of age and older who are minorities, weighted at 10 percent; and(3) the total AAA region's population 60 years of age and older who are living on incomes below the poverty level, weighted at 50 percent. Source Note: The provisions of this §213.301 adopted to be effective September 1, 2011, 36 TexReg 4811; amended to be effective April 5, 2018, 43 TexReg 2027; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.301 AAA Funding Allocation Formula for Older Americans Act Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201625 03/12/2026 (a) Purpose. This section describes the process for handling award funds that are not spent by a AAA at the end of a federal fiscal year, including the process for distributing funds in the statewide carryover pool.(b) Award funds. HHSC allocates to a AAA federal funds awarded under the Older Americans Act to spend in implementing its area plan during a federal fiscal year. These funds are referred to in this section as "award funds."(c) Unspent award funds.(1) If, at the end of a federal fiscal year, a AAA has unspent award funds that were received in the first six-month period of the federal fiscal year, the unspent funds are handled as follows:(A) the AAA may spend up to five percent of the unspent award funds in the next federal fiscal year to implement its area plan; and(B) HHSC places any unspent award funds that are more than five percent in the statewide carryover pool.(2) The AAA may spend any unspent award funds received in the second six-month period of the fiscal year in the next federal fiscal year to implement its area plan.(d) Distribution of statewide carryover pool. The funds placed in the statewide carryover pool, as described in subsection (c)(1)(B) of this section, are distributed by HHSC:(1) in accordance with the formula described in subsection (e) of this section; and(2) to a AAA for the fiscal year before the distribution will occur if the following criteria are met:(A) the AAA has submitted to HHSC all reports listed in the AAA Report Due Date Schedule by the time and date listed on such schedule or by the time and date of an extension granted by HHSC in accordance with §85.201(d)(3) of this chapter (relating to AAA Administrative Responsibilities);(B) as determined by HHSC, the AAA meets all performance measures set by HHSC under the contract or is above or below such measures within five percent;(C) HHSC did not place unspent award funds of the AAA in the statewide carryover pool in accordance with subsection (c)(1)(B) of this section;(D) the AAA has not had a Level Three Sanction or Level Four Sanction imposed by HHSC in accordance with §81.13 of this title (relating to Compliance with Contractor Responsibilities, Rewards and Sanctions);(E) if unallowable costs have been identified for the AAA in accordance with §85.202(e) of this chapter (relating to AAA Fiscal Responsibilities), the AAA has either refunded the amount of such costs to HHSC or is current under a payment agreement approved by HHSC to refund the amount of such costs;(F) the AAA has met the adequate proportion requirement, which may include a waiver granted by HHSC, in accordance with §85.202(k) of this chapter; and(G) if the AAA is part of a host agency as defined in 26 TAC §88.2 (relating to Definitions), the AAA has complied with 26 TAC §88.406 (relating to Requirements Regarding Expenditures for the Ombudsman Program).(e) Formula for distribution of statewide carryover pool. HHSC distributes funds from the statewide carryover pool to AAAs that meet the criteria described in subsection (d) of this section as follows:(1) 50 percent of the funds are distributed in equal amounts to the qualifying AAAs; and(2) 50 percent of the funds are distributed to the qualifying AAAs in accordance with §85.501(g) and (h)(1) - (3) of this chapter (relating to the AAA Funding Allocation Formula for Older Americans Act Programs). Source Note: The provisions of this §213.303 adopted to be effective September 1, 2011, 36 TexReg 4811; amended to be effective April 5, 2018, 43 TexReg 2027; transferred effective November 15, 2020, as published in the Texas Register October 30, 2020, 45 TexReg 7721. 1 HEALTH AND HUMAN SERVICES COMMISSION 213 AREA AGENCIES ON AGING C IMPLEMENTATION OF THE OLDER AMERICANS ACT §213.303 Unspent Award Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219671 03/12/2026 (a) Purpose. This section describes the guidelines to determine the proportion of state money distributed to entities that operate a program under the National Senior Services Corps, as required by Texas Human Resources Code, §101.024.(b) National Senior Services Corps programs. Programs operated under the National Senior Services Corps include the Foster Grandparent Program, RSVP, and the Senior Companion Program.(c) Agreement with CNCS. DADS has a written agreement with the Corporation for National and Community Services (CNCS) in which:(1) DADS agrees to pay state general revenue DADS receives to fund programs under the National Senior Services Corps to CNCS; and(2) CNCS agrees to distribute the funds it receives from DADS to entities operating programs under the National Senior Services Corps.(d) Fund distribution guidelines. The guidelines by which funds are distributed to entities operating a National Senior Services Corps Program are as follows:(1) entities are distributed current funding based on amounts received by the entities in previous years;(2) new funding distributed to existing entities is distributed to those entities in equal amounts; and(3) a new entity receiving new funding receives no more than the lowest amount given to an entity in the previous year's distribution.(e) Specific amounts in agreement with CNCS. The specific amounts of funding distributed to entities operating a National Senior Services Corps Program are set forth in DADS written agreement with CNCS. Source Note: The provisions of this §214.1 adopted to be effective September 1, 2011, 36 TexReg 4812; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4934. 1 HEALTH AND HUMAN SERVICES COMMISSION 214 NATIONAL SENIOR SERVICES CORPS PROGRAM §214.1 Guidelines to Distribute Funds to Entities Operating a National Senior Services Corps Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224885 03/12/2026 (a) The Texas Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a Title XIX federally mandated program of prevention, diagnosis, and treatment for Medicaid clients from birth through age 20. In Texas, EPSDT is known as the Texas Health Steps (THSteps) Program. The Texas Department of State Health Services (department), by authorization of the Health and Human Services Commission (HHSC), operates and administers the outreach and informing, medical and dental check-ups, and the dental treatment utilization components of this program.(b) The rules in this chapter apply to the medical and dental check-up, dental treatment, dental utilization review, and the outreach and informing components of THSteps. Source Note: The provisions of this §256.1 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.1 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224886 03/12/2026 The following words or terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:(1) Authorized adult--A person, including an adult related to the child, who is authorized by a child's parent or guardian to accompany that child to a THSteps medical or dental check-up or treatment visit.(2) Client--Any individual under the age of 21 who has been determined eligible for Medicaid.(3) Department--Department of State Health Services.(4) EPSDT--Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a mandatory program under Medicaid that provides medical and dental check-ups, diagnosis, and treatment to eligible clients from birth through age 20. EPSDT is known in Texas as Texas Health Steps (THSteps).(5) Guardian--An individual legally authorized to make decisions, including medical consent, on behalf of a minor.(6) HHSC--Health and Human Services Commission.(7) Medicaid--The medical assistance program implemented by the State of Texas under the provisions of Title XIX of the Social Security Act, as amended, at 42 USC, §1396, et seq.(8) Medically necessary--Medical services that are supported by documentation which show the services are:(A) reasonable and necessary to prevent illness, medical or dental conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a client, or endanger life;(B) consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies;(C) consistent with the diagnoses of the conditions;(D) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;(E) not experimental or investigative; and(F) not primarily for the convenience of the client or provider.(9) OIG--Office of Investigator General at the Health and Human Services Commission.(10) THSteps--Texas Health Steps (THSteps) is the Texas name for the federally-mandated Medicaid program known as EPSDT.(11) TMPPM--Texas Medicaid Provider Procedures Manual.(12) TSBDE--The Texas State Board of Dental Examiners. Source Note: The provisions of this §256.2 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224887 03/12/2026 (a) The department, in collaboration with HHSC or its designee, informs clients and their families about THSteps benefits and services no later than 60 days after the Medicaid certification date and on a periodic basis thereafter using a combination of methods including written, oral, and in-person contact. Methods for informing include, but are not limited to, one or more of the following options: written or printed correspondence, telephone contact, or an in-person interaction with a THSteps outreach worker, which may include contractors designated and authorized to perform this function. THSteps uses procedures and methods suitable for effectively informing clients and their families who are illiterate, visually impaired, hard of hearing, or who cannot understand the English language.(b) Clients and families who become eligible for Medicaid after a period of ineligibility also are informed about THSteps benefits and services upon recertification and on a periodic basis thereafter. Source Note: The provisions of this §256.3 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.3 Outreach, Informing, and Support Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224888 03/12/2026 The department receives and refers, in accordance with state law and department policy, complaints and allegations of fraud, abuse, or waste regarding THSteps services, providers, and clients. The department accepts complaints and allegations in either written or verbal form and from any source. Source Note: The provisions of this §256.4 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.4 Receipt and Referral of Complaints and Allegations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224889 03/12/2026 (a) A THSteps medical check-up provider must be properly licensed, as required under state law, and must be a:(1) Doctor of Medicine or Doctor of Osteopathy;(2) public or private health care provider or facility that can perform the required medical check-up procedures under a physician's direction and responsibility;(3) advanced practice nurse whose educational curriculum included courses of study in advanced pediatric physical assessment of infants, children and adolescents; or(4) physician assistant.(b) A THSteps dental provider must be either a Doctor of Dental Surgery or a Doctor of Dental Medicine who is currently licensed by the TSBDE.(c) THSteps providers have the right to limit their practice and the right to choose whether to serve an eligible client, but providers must comply with all related requirements of the TMPPM and all relevant laws and regulations prohibiting discrimination, including 1 TAC §354.1002 (relating to Compliance with Civil Rights Act). Source Note: The provisions of this §256.5 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.5 THSteps Provider Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224890 03/12/2026 (a) The primary responsibilities of THSteps medical and dental providers are to:(1) operate in accordance with the laws, rules, regulations, and standards of care relating to the practice of their respective profession;(2) cease providing THSteps services and notify HHSC or its designee if the provider's professional license is suspended or revoked, unless the suspension or revocation is probated in its entirety and without conditions or limitations;(3) conduct check-ups and treatment services according to policies and procedures as published in the TMPPM and Medicaid bulletins and in accordance with the policies and procedures of the department;(4) provide clinic surroundings which will establish a good relationship between clinic personnel, the client and the client's family;(5) interpret and explain check-up and treatment results to the client or the client's parent, guardian, or authorized adult, during or immediately after the check-up;(6) make referrals for needed follow-up diagnosis and treatment services as indicated; and(7) assure that a parent, guardian or authorized adult who accompanies a client under age 15 to a THSteps medical or dental check-up or treatment visit, continues to wait for the client while the check-up or treatment takes place. Entities exempt from this parental accompaniment requirement are a child-care facility (as defined in the Human Resources Code, §42.002(3)), school health clinic, or Head Start program if the entity encourages parental involvement in and management of the health care of children receiving services. Parental involvement includes the exempt entity notifying the child's parent, guardian, or authorized adult before a THSteps medical or dental check-up or treatment visit, of the time and place of the child's appointment and encouraging the parent, guardian, or other authorized adult to attend. Notification must be done by the means of communication determined by the exempt entity to be the most effective. Such communication must be documented and may include, but is not limited to, one or more of the following options: a home visit from an outreach worker, written or printed correspondence, or telephone contact.(b) THSteps providers must obtain legally effective, written informed consent prior to the provision of THSteps check-ups or treatment services.(1) Consent by a person who may legally give consent is necessary for participation in THSteps medical or dental services. Consent requires the free exercise of choice without any force, fraud, deceit, constraint, or coercion by the person authorized to provide consent for the client.(2) There are basic elements necessary to consent. Clients or their parents or guardians who can give informed consent have the right to understand their health care needs and the different ways their health care problems can be treated. At a minimum, they must be informed of:(A) diagnosis;(B) scope of proposed treatment, including alternatives and risks;(C) anticipated results; and(D) need for administration of sedation or anesthesia, including risks. Source Note: The provisions of this §256.6 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.6 THSteps Provider Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224891 03/12/2026 Timely delivery of THSteps services, including outreach, informing and check-up services, may not be made if:(1) the client or family could not be located despite a good faith effort to do so; or(2) the client or family chooses not to receive available or recommended services in a timely manner after being informed. Source Note: The provisions of this §256.7 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT A GENERAL PROVISIONS §256.7 Exceptions to Timely Delivery of THSteps Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224892 03/12/2026 (a) Utilization of THSteps services is voluntary. Acceptance or refusal of THSteps services does not affect eligibility for or receipt of any other Medicaid service, or for future THSteps services.(b) All THSteps records about clients are considered confidential information, in accordance with the standards and requirements described in §33.30 of this title (relating to Confidentiality of Records).(c) Clients have a right to consent to or refuse treatment and actively participate in treatment decisions, including the right to refuse follow-up care or treatment recommended by the provider.(d) THSteps clients are entitled to receive:(1) medical and dental services when informed consent is given, including check-ups that are due as described in §33.41 of this title (relating to Periodicity of Medical and Dental Check-ups);(2) services free from abuse or harm from the provider or the provider's staff; and(3) only medically necessary treatment which meets professionally recognized standards of health care. Source Note: The provisions of this §256.20 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT B CLIENT RIGHTS §256.20 Client Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224893 03/12/2026 (a) Clients who are not enrolled in a Medicaid managed care plan have the freedom to choose any participating THSteps medical provider for their medical check-ups.(b) Clients who are enrolled in a Medicaid managed care plan need to check with their plan regarding the amount of freedom they have to choose a THSteps provider.(c) Clients have the freedom to choose any participating THSteps dental provider for dental check-ups and treatment services, except clients in the conservatorship of the Department of Family and Protective Services who receive all dental services from a managed care plan. Source Note: The provisions of this §256.21 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT B CLIENT RIGHTS §256.21 Freedom of Choice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224894 03/12/2026 (a) Federal and state laws and regulations prohibit the disclosure of information about Medicaid clients without effective consent by the client or on behalf of the client, except for purposes directly connected with the administration of the Medicaid program, as described in 42 USC, §1396a(a)(7); 42 CFR. §§431.301 - 431.306; Human Resources Code, §12.003 and §21.012; and Government Code, §552.101. Providers of THSteps services are not considered directly connected with the administration of the program. Although THSteps providers are not entitled to confidential information without prior consent, they are able to verify a client's eligibility status.(b) Entities with which HHSC or the department contracts to perform certain administrative functions, including contractors for outreach, informing, and transportation services, may receive confidential information without the client's consent, but only to the extent necessary to performance and administration of the contract. These contracted entities are bound by the same standards of confidentiality applicable to the Medicaid program, and they must provide effective safeguards to ensure confidentiality. Source Note: The provisions of this §256.30 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT C CONFIDENTIALITY §256.30 Confidentiality of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224895 03/12/2026 (a) Medical check-ups eligibility. Clients are eligible to receive THSteps medical check-ups and services from birth through the end of the month of their 21st birthday.(b) Dental Services Eligibility. Clients are eligible to receive THSteps dental check-ups beginning at six months of age or at the first eruption of primary teeth, whichever occurs first, through the end of the month of their 21st birthday. Clients are eligible for any medically necessary dental services from their date of birth. As described in the TMPPM, eligibility for certain dental services may require prior authorization, and for some services, clients lose eligibility on their 21st birthday. A specific exception applies to orthodontic services, as described in §33.71(c) of this title (relating to Orthodontic Services and Prior Authorization). Source Note: The provisions of this §256.40 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT D ELIGIBILITY AND PERIODICITY §256.40 Eligibility for Medical and Dental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224896 03/12/2026 (a) Medical check-ups periodicity. Clients are eligible to receive a comprehensive medical check-up at the intervals set forth in the TMPPM and current THSteps outreach and informing materials distributed to eligible clients and their families. The periodicity of medical check-ups is at least as frequent as that recommended by the American Academy of Pediatrics. Clients are also eligible to receive a medical check-up, even if one is not due under the periodicity schedule, if:(1) there are indications that a health screening is medically necessary; or(2) required to meet a state or federal law requirement, such as a child entering Head Start or foster care, or in a pre-adoptive placement.(b) Dental check-ups periodicity. Clients are eligible to receive dental check-ups at six-month intervals, based on the date of the client's last dental check-up. Clients less than three years of age may be eligible to receive dental check-ups at three-month intervals if identified during a dental visit as being at high risk for developing dental disease. Source Note: The provisions of this §256.41 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT D ELIGIBILITY AND PERIODICITY §256.41 Periodicity of Medical and Dental Check-ups https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224897 03/12/2026 (a) Clients are entitled to receive a comprehensive medical check-up for the early detection of health problems and the referral for definitive diagnosis and treatment when indicated by the check-up.(b) Following are the federally-mandated components of a THSteps comprehensive medical check-up:(1) comprehensive health and developmental history, including physical and mental health and development;(2) comprehensive unclothed physical examination;(3) immunizations appropriate for age and health history;(4) laboratory tests appropriate to age and risk, including lead toxicity screening; and(5) health education, including anticipatory guidance.(c) THSteps providers may be required to perform additional services or screening during a medical check-up, as described in the TMPPM.(d) THSteps providers may conduct mental health screenings, using one or more validated, standardized mental health screening tools, during each annual medical check-up for clients who are at least 12 years of age but younger than 19 years of age. THSteps providers are reimbursed for conducting one such screening annually.(e) THSteps providers may conduct maternal depression screenings for a client's mother, regardless of whether the mother is also a client, that are performed before the client's first birthday during a client's covered medical check-up. THSteps providers are reimbursed for conducting one such screening. Source Note: The provisions of this §256.60 adopted to be effective February 28, 2008, 33 TexReg 1550; amended to be effective June 25, 2018, 43 TexReg 4207; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT E MEDICAL CHECK-UPS §256.60 Medical Check-ups https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224898 03/12/2026 (a) In addition to dental check-ups, which may include radiographs and other diagnostic tests, clients are eligible to receive the following dental services and treatment, as described in detail in the TMPPM:(1) diagnostic;(2) preventive;(3) therapeutic (including orthodontic);(4) emergency; and(5) medically necessary treatment.(b) Prior authorization may be required for certain services and documentation requirements must be met, as described in detail in the TMPPM. All dental services are subject to utilization review, as described in §33.72 of this subchapter (relating to Dental Utilization Reviews).(c) THSteps dental providers are required to perform dental services as described in detail in the TMPPM.(d) THSteps dental providers may conduct an oral evaluation as a teledentistry dental service, as defined in Texas Occupations Code §111.001, for established clients using synchronous audiovisual technologies. Source Note: The provisions of this §256.70 adopted to be effective February 28, 2008, 33 TexReg 1550; amended to be effective March 3, 2025, 50 TexReg 993; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT F DENTAL SERVICES §256.70 Dental Preventive and Treatment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224899 03/12/2026 (a) Orthodontic services for cosmetic reasons only are not a covered Medicaid service. Orthodontic services must be prior authorized and are limited to treatment of severe handicapping malocclusion and other related conditions as described and measured by the procedures and standards published in the TMPPM.(b) Prior authorization for orthodontic services is not transferable to another provider.(c) Orthodontic services that are authorized and initiated before a client loses Medicaid eligibility or turns 21 years of age, can continue beyond the date the client loses eligibility if the services are completed within 36 months of initiation, as described in the TMPPM. Source Note: The provisions of this §256.71 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT F DENTAL SERVICES §256.71 Orthodontic Services and Prior Authorization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224900 03/12/2026 (a) Purpose. The purpose of dental utilization reviews is to ensure program fiscal integrity, to address the federal mandate requiring program funds be spent only as allowed under federal and state laws and regulations, and to ensure that services are appropriately provided to clients.(b) Recoupment of overpayments. If the results of a utilization review indicate overpayment for services delivered or that payment was made for services not delivered, recoupment is required. The appropriate agency or agency designee shall notify the provider in writing of any overpayment identified and the method of recoupment to be used.(c) Administrative actions and sanctions. Evaluation of a utilization review may result in one or more of the following administrative actions or sanctions by the appropriate agency or the agency's designee:(1) closure of the review with written notification to the provider;(2) discussion and interpretation of the utilization review results with the provider;(3) referral to the appropriate state licensing board or OIG; and(4) any other remedies authorized by rule, regulation, statute, or contract. Source Note: The provisions of this §256.72 adopted to be effective February 28, 2008, 33 TexReg 1550; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT F DENTAL SERVICES §256.72 Dental Utilization Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224901 03/12/2026 (a) Environmental lead investigations are a benefit of Medicaid for all THSteps clients with elevated blood lead levels as specified by federal guidelines.(b) The investigation to determine the source of lead is:(1) subject to the requirements in §37.338 and §37.339 of this title (relating to Reporting, Treatment and Investigation of Child Blood Lead Levels);(2) conducted by certified lead risk assessors who are employed by or contractors of the state health department or local health departments; and(3) limited to the child's home or primary residence. Source Note: The provisions of this §256.80 adopted to be effective December 27, 2010, 35 TexReg 11701; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 256 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT G ENVIRONMENTAL LEAD INVESTIGATIONS §256.80 Environmental Lead Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225225 03/12/2026 (a) Case Management for Children and Pregnant Women is a Medicaid benefit that assists an eligible client in gaining access to the necessary medical, social, educational, and other service needs related to a child with a health condition or health risk or a pregnant woman with a high-risk condition.(b) The rules in this chapter apply to Case Management for Children and Pregnant Women services delivered in fee-for-service and through a Medicaid managed care organization. Source Note: The provisions of this §257.1 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN A GENERAL PROVISIONS §257.1 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225226 03/12/2026 The following words or terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Access--The ability of an eligible client to obtain health and health-related services and other services related to nonmedical needs, as determined by factors such as:(A) the availability of Texas Health Steps services;(B) service acceptability to the eligible child, pregnant woman, or both;(C) the location of health care facilities and other resources;(D) transportation;(E) hours of facility operation; and(F) length of time available to see providers of health and health-related services or other services related to nonmedical needs.(2) Applicant--An agency, organization, or individual who submits an application to enroll as a state Medicaid provider of Case Management for Children and Pregnant Women services.(3) Case manager--An individual qualified under §257.19 of this title (relating to Case Manager Qualifications) who provides Case Management for Children and Pregnant Women services. A case manager may be an independent provider or an employee or contractor of a Medicaid-enrolled case management provider.(4) Case management services--Services provided under this chapter to an eligible client to assist the client in gaining access to necessary medical, social, educational, and other services for a child with a health condition or health risk or a pregnant woman with a high-risk condition. In this chapter, these services are also referred to as Case Management for Children and Pregnant Women services.(5) Child with a health condition or health risk--A child from birth through 20 years of age who has or is at risk for a medical condition, illness, injury, or disability that results in limitation of function, activities, or social roles in comparison with healthy peers of the same age in the general areas of physical, cognitive, emotional, or social growth and development.(6) Client--An individual who is eligible for and enrolled in the Texas Medicaid Program and meets the eligibility requirements listed in §257.5 of this chapter (relating to Client Eligibility) or the client's parent or legal guardian. (7) Client choice--A client is given the freedom to choose a provider, to the extent possible, from among providers available to the client.(8) Face-to-face--A visit conducted by a case manager with a client in person or utilizing synchronous audiovisual communications. (9) Family--A basic unit in society having at its nucleus: (A) one or more adults living together and cooperating in the care and rearing of the adult's or adults' biological or adopted children; or(B) a person or persons acting as an individual's family, foster family, guardian, or identifiable support person or persons.(10) Health and health-related services--Services that are provided to meet the preventive, primary, tertiary, and specialty health needs of an eligible client, including, medical and dental checkups, immunizations, acute care visits, pediatric specialty consultations, physical therapy, occupational therapy, audiology, speech language services, mental health professional services, pharmaceuticals, medical supplies, prenatal care, family planning, adolescent preventive health, durable medical equipment, nutritional supplements, prosthetics, eyeglasses, and hearing aids.(11) HHSC--The Texas Health and Human Services Commission or its designee, including a Medicaid managed care organization.(12) High-risk condition--Applies to a woman who is pregnant and has a medical or psychosocial condition that places the woman and the woman's fetus at a greater than average risk for complications, either during pregnancy, delivery, or after birth.(13) Medicaid--Medical assistance program implemented by the state under the provisions of Title XIX of the Social Security Act, as amended, at 42 U.S.C., §1396, et seq.(14) Nonmedical need--Nonmedical drivers of health are the conditions in the place where a person lives, learns, works, and plays and that affect a wide range of health risks and outcomes.(15) Provider--May be:(A) an agency approved by HHSC to provide Case Management for Children and Pregnant Women services and that is enrolled as a Medicaid provider; or(B) an individual approved by HHSC to provide Case Management for Children and Pregnant Women services and who is enrolled as a Medicaid provider.(16) Quality assurance review--A review conducted by HHSC of a provider's client records, internal quality assurance policy, outreach materials, and compliance with HHSC's rules and policies, including the qualifications of the provider's case managers as listed in §257.19 of this chapter.(17) TMPPM--Texas Medicaid Provider Procedures Manual.(18) Utilization review--A review conducted by HHSC of a provider's claims data in which trends have been identified that could indicate potential concerns with the delivery of case management services. Source Note: The provisions of this §257.3 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN A GENERAL PROVISIONS §257.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225227 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225227 03/12/2026 A client eligible for services under this chapter must be either a child with a health condition or health risk or a pregnant woman with a high-risk condition who:(1) is Medicaid-eligible in Texas;(2) is in need of Case Management for Children and Pregnant Women services; and(3) chooses such services. Source Note: The provisions of this §257.5 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN B CLIENT SERVICES §257.5 Client Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225228 03/12/2026 (a) Use of services is voluntary. Acceptance or refusal of services does not affect eligibility for or receipt of any other Medicaid services, or for future case management services.(b) All records about a client are considered confidential information, in accordance with the standards and requirements described in §257.9 of this subchapter (relating to Client Confidentiality).(c) A client has the right to:(1) actively participate in case management decisions, including the right to refuse services from a case manager;(2) receive services free from abuse or harm from a case manager;(3) have freedom of choice to choose a provider in the client's county of residence or service area, as applicable;(4) have freedom to request a transfer to another available case manager at any time; and(5) except as described in subsection (d) of this section, request a fair hearing, conducted in accordance with the rules in 1 TAC, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), within 90 days after receiving written notification that services have been denied, reduced, suspended, or terminated.(d) A client receiving Case Management for Children and Pregnant Women services through a Medicaid managed care organization (MCO) must:(1) use the MCO's complaint and appeal procedure as prescribed in 1 TAC §353.415 (relating to Member Complaint and Appeal Procedures); and(2) exhaust internal MCO appeals before requesting a fair hearing as described in subsection (c)(5) of this section. Source Note: The provisions of this §257.7 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN B CLIENT SERVICES §257.7 Client Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225229 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225229 03/12/2026 (a) Federal and state laws and regulations prohibit the disclosure of information about a Medicaid client without effective consent by the client or the client's parent or legal guardian, except for purposes directly connected with the administration of the Medicaid program, as described in:(1) 42 U.S.C. §1396a(a)(7); (2) 42 C.F.R. §§431.301 - 431.306; (3) Texas Human Resources Code §12.003 and §21.012; and(4) Texas Government Code §552.101.(b) A provider is not considered directly connected with the administration of the program. Although a provider is not entitled to confidential information without prior consent, the provider may verify a client's eligibility status.(c) An entity with which HHSC contracts to perform certain administrative functions, including contractors for outreach, informing, and transportation services, may receive confidential information without a client's consent, but only to the extent necessary to perform and administer the contract. A contracted entity is bound by the same standards of confidentiality applicable to the Medicaid program, and the entity must provide effective safeguards to ensure confidentiality. Source Note: The provisions of this §257.9 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN B CLIENT SERVICES §257.9 Client Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225230 03/12/2026 The following are the essential components of Case Management for Children and Pregnant Women services and an explanation of billable components.(1) Intake--A case manager's visit with a client, family, or guardian that includes the case manager collecting demographic information, health information, and other information relevant to determining the client's eligibility.(2) Comprehensive visit--A required visit conducted by a case manager face-to-face with a client, family, or guardian that includes the case manager completing the following:(A) Family Needs Assessment. A comprehensive assessment completed by a case manager to determine a client's need for any medical, educational, social, or other services required to address the client's short- and long-term health and well-being. A case manager must document this assessment on a Family Needs Assessment form, which must include:(i) taking a client's history;(ii) identifying the client's needs, assessing and addressing family issues that impact the client's health condition, health risk, high-risk condition, or nonmedical needs; and(iii) gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the client.(B) Service Plan. A plan for case management services completed by a case manager with a client or the client's parent or legal guardian that determines a planned course of action based on the information collected through the assessment required in paragraph (2)(A) of this section. A case manager must document the Service Plan on a Service Plan form, which must:(i) include activities and goals developed by the client in consultation with the case manager to address the medical, social, educational, and other services needed by the client; (ii) identify a course of action to respond to the assessed needs of the client, including identifying the individual responsible for contacting the appropriate service providers, and designating the time frame within which the client should access services; and(iii) be dated and signed by the Medicaid provider.(3) Referral and related activities. To help manage a client's care, a case manager making referrals and conducting related activities, such as scheduling appointments for the client, conducting collateral contacts with a non-eligible individual that are directly related to identify and help the client obtain needed services and link the client with:(A) medical, social, and educational providers; and(B) other programs and services that can provide services the client needs.(4) Follow-up visits by a case manager.(A) A case manager must make a follow-up visit:(i) as frequently as necessary to ensure a client's Service Plan is implemented and adequately addresses the client's needs;(ii) annually for a client who is eligible for case management for longer than 12 consecutive months; and(iii) as needed during the eligible postpartum period for a client who is a pregnant woman with a high-risk condition who may also have nonmedical needs.(B) During a follow up visit, a case manager must: (i) determine if:(I) services have been furnished to a client in accordance with the client's Service Plan; and(II) services in the initial Service Plan are adequate to address the client's needs; and (ii) complete a Service Plan Addendum form if the case manager identifies there has been a change in the client's needs or status and the initial Service plan needs to be revised.(5) The essential components of Case Management for Children and Pregnant Women services that are eligible for Medicaid reimbursement are the comprehensive visit and each follow-up visit performed in accordance with this section. (6) Case management services are not reimbursable if the services are provided: (A) to a client who does not meet the client eligibility requirements in §257.5 of this subchapter (relating to Client Eligibility); (B) to a client who has already received another case management service on the same day from the same billing provider; or (C) when a client is an inpatient at a hospital or other treatment facility. Source Note: The provisions of this §257.11 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN B CLIENT SERVICES §257.11 Components of Case Management for Children and Pregnant Women Services. https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225231 03/12/2026 (a) To be approved by HHSC as a provider, an applicant must:(1) not be listed on the HHSC Office of Inspector General's Excluded Individual/Entities nor on the U.S. HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE);(2) complete:(A) a pre-planning process with HHSC that includes a review of case manager qualifications listed in §257.19 of this subchapter (relating to Case Manager Qualifications) and an overview of case management activities as listed in §257.21 (Case Manager Responsibilities); and(B) the HHSC standardized case management training provided by HHSC; and(3) agree to:(A) employ or contract with one or more case managers who each meet at least one of the qualifications listed in §257.19 of this subchapter (relating to Case Manager Qualifications); and(B) comply with:(i) the rules, policies, and procedures of HHSC relating to Case Management for Children and Pregnant Women; and(ii) applicable state and federal laws governing participation of providers in the Medicaid program and enrollment as a state Medicaid provider.(b) HHSC notifies an applicant that complies with subsection (a) of this section whether HHSC approves the applicant's enrollment to be a Medicaid provider of Case Management for Children and Pregnant Women services. Source Note: The provisions of this §257.15 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN C PROVIDER QUALIFICATIONS AND RESPONSIBILITIES §257.15 Provider Qualifications and Approval Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225232 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225232 03/12/2026 A provider must:(1) operate in accordance with the laws, rules, regulations, and standards of care relating to the practice of the provider's respective license or certifications;(2) ensure the provider's case managers operate:(A) within the laws, rules, regulations, and standards of care relating to the practice of the case manager's respective license, or certification; and(B) only within the scope of the case manager's respective license or certification;(3) provide services:(A) according to policies and procedures as published in the TMPPM and Medicaid bulletins; and(B) in accordance with the policies and procedures of HHSC;(4) cease providing services and notify HHSC if the professional license of a case manager is suspended or revoked, with such notification to be provided to HHSC no later than seven calendar days after the date that the suspension or revocation is imposed;(5) assure that the provider's case managers attend required trainings provided by HHSC;(6) develop and maintain a quality management system for the provision of services with the primary goal of assisting clients in accessing necessary medical, social, educational, and other services related to the client's health condition, health risk, high-risk condition, or nonmedical need; (7) ensure that outreach activities:(A) do not impede freedom of client choice; and(B) comply with 1 TAC §371.27 (relating to Prohibition against Solicitation of Medicaid or CHIP Recipients); and (8) ensure that a client is given freedom of choice to choose a provider for case management. Source Note: The provisions of this §257.17 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN C PROVIDER QUALIFICATIONS AND RESPONSIBILITIES §257.17 Provider Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225233 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225233 03/12/2026 A provider that is an agency or an individual approved by HHSC to provide case management services must ensure a case manager meets at least one of the following qualifications:(1) an advanced practice registered nurse who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 301;(2) a registered nurse who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 301 and:(A) has a baccalaureate degree in nursing; or(B) has an associate degree in nursing and has:(i) at least two years of cumulative paid full-time work experience; or(ii) at least two years of cumulative, supervised full-time educational internship or practicum experience obtained in the last 10 years that included assessing the psychosocial and health needs of and making community referrals for:(I) children up to age 21; or(II) pregnant women;(3) a social worker who holds a license, other than a provisional or temporary license, under Texas Occupations Code Chapter 505, appropriate for the individual's practice, including the independent practice of social work;(4) a community health worker, as defined by Texas Health and Safety Code §48.001, that is certified as a community health worker by the Department of State Health Services; or(5) a doula who is certified in alignment with nationally recognized standards, as determined by HHSC, unless the doula qualifies as a certified community health worker under paragraph (4) of this subsection. Source Note: The provisions of this §257.19 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN C PROVIDER QUALIFICATIONS AND RESPONSIBILITIES §257.19 Case Manager Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225234 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225234 03/12/2026 A case manager must: (1) comply with all licensure or certification requirements of the appropriate issuing agency or state licensure or examining board, including the obligation to report all suspected child abuse or neglect; (2) cease providing services and notify HHSC if the case manager's professional license or certification is suspended or revoked, with such notification to be provided to HHSC no later than seven calendar days after the date that the suspension or revocation is imposed; (3) provide services convenient to a client, either in the client's home, an office setting, or other place of the client's preference; and (4) have knowledge of, and coordinate services with, providers of health and health-related services, non-covered services, and other active community resources. Source Note: The provisions of this §257.21 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN C PROVIDER QUALIFICATIONS AND RESPONSIBILITIES §257.21 Case Manager Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225235 03/12/2026 (a) The purpose of a utilization review and a quality assurance review is:(1) to ensure program fiscal integrity;(2) to address the federal mandate requiring program funds be spent only as allowed under federal and state laws and regulations; and(3) to ensure that a case manager provided Case Management for Children and Pregnant Women services to a client within the scope of the client's Service Plan. (b) HHSC conducts quality assurance and utilization reviews of all active providers to monitor claims, the quality of case management services, and compliance with Case Management for Children and Pregnant Women rule and policy. (c) A provider must cooperate with the quality assurance and utilization reviews. A provider will be given notification of upcoming reviews in accordance with the policies and procedures established by HHSC. (d) If the results of a provider's utilization review or quality assurance review as determined by HHSC, indicates overpayment, HHSC notifies the provider of the overpayment and gives the provider information about how to arrange for repayment. (e) If a provider becomes aware that the provider received an overpayment, the provider must notify the Medicaid claims administrator to arrange for repayment. Source Note: The provisions of this §257.23 adopted to be effective May 29, 2025, 50 TexReg 3129. 1 HEALTH AND HUMAN SERVICES COMMISSION 257 CASE MANAGEMENT FOR CHILDREN AND PREGNANT WOMEN C PROVIDER QUALIFICATIONS AND RESPONSIBILITIES §257.23 Compliance with Utilization Reviews and Quality Assurance Reviews and Overpayments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224542 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: (1) Abuse--(A) physical abuse; (B) sexual abuse; or (C) verbal or emotional abuse. (2) Actively involved--Significant, ongoing, and supportive involvement with an individual by a person, as determined by the individual, based on the person's: (A) interactions with the individual; (B) availability to the individual for assistance or support when needed; and (C) knowledge of, sensitivity to, and advocacy for the individual's needs, preferences, values, and beliefs. (3) Adaptive aids--A Community Living Assistance and Support Services (CLASS) Program service that: (A) enables an individual to retain or increase the ability to perform activities of daily living (ADLs) or perceive, control, or communicate with the environment in which the individual lives; and (B) meets one of the following criteria: (i) is an item included in the list of adaptive aids in the Community Living Assistance and Support Services Provider Manual; or (ii) is the repair or maintenance of an item on the list of adaptive aids in the Community Living Assistance and Support Services Provider Manual that is not covered by a warranty. (4) Adaptive behavior--The effectiveness with or degree to which an individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group as assessed by an adaptive behavior screening assessment. (5) Adaptive behavior level--The categorization of an individual's functioning level based on a standardized measure of adaptive behavior. There are four adaptive behavior levels ranging from mild limitations in adaptive skills (I) through profound limitations in adaptive skills (IV). (6) Adaptive behavior screening assessment--A standardized assessment used to determine an individual's adaptive behavior level, and conducted using the current version of one of the following assessment instruments: (A) American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS); (B) Inventory for Client and Agency Planning (ICAP); (C) Scales of Independent Behavior; or (D) Vineland Adaptive Behavior Scales. (7) ADLs--Activities of daily living. Basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (8) Agency foster home--This term has the meaning set forth in Texas Human Resources Code §42.002. (9) Alarm call--A signal transmitted from an individual's Community First Choice emergency response services (CFC ERS) equipment to the CFC ERS response center indicating that the individual needs immediate assistance. (10) ALF--Assisted living facility. A facility licensed in accordance with Texas Health and Safety Code (THSC), Chapter 247, Assisted Living Facilities. (11) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual. (12) Aquatic therapy--A specialized therapy that involves a low-risk exercise method performed in water to improve an individual's range of motion, flexibility, muscular strengthening and toning, cardiovascular endurance, fitness, and mobility. (13) Audio-only--An interactive, two-way audio communication platform that only uses sound. (14) Auditory integration training/auditory enhancement training--A CLASS Program service that provides specialized training to assist an individual to cope with hearing dysfunction or over-sensitivity to certain frequency ranges of sound by facilitating auditory processing skills and exercising the middle ear and auditory nervous system. (15) Auxiliary aid--A service or device that enables an individual with impaired sensory, manual, or speaking skills to participate in the person-centered planning process. An auxiliary aid includes interpreter services, transcription services, and a text telephone. (16) Behavior support plan--A comprehensive, individualized written plan based on a current functional behavior assessment that includes specific outcomes and behavioral techniques designed to teach or increase adaptive skills and decrease or eliminate target behaviors. (17) Behavioral support--A CLASS Program service that provides specialized interventions to assist an individual in increasing adaptive behaviors and replacing or modifying behaviors that prevent or interfere with the individual's inclusion in the community and which consist of the following activities: (A) conducting a functional behavior assessment; (B) developing an individualized behavior support plan; (C) training and consulting with an individual, family member, or other persons involved in the individual's care regarding the implementation of the behavior support plan; (D) monitoring and evaluating the effectiveness of the behavior support plan; (E) modifying, as necessary, the behavior support plan based on monitoring and evaluating the plan's effectiveness; and (F) counseling and educating an individual, family members, or other persons involved in the individual's care about the techniques to use in assisting the individual to control challenging or socially unacceptable behaviors. (18) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b). (19) Calendar day--Any day, including weekends and holidays. (20) Case management--A CLASS Program service that assists an individual in the following: (A) assessing the individual's needs; (B) enrolling into the CLASS Program; (C) developing the individual's individual plan of care (IPC); (D) coordinating the provision of CLASS Program services and CFC services; (E) monitoring the effectiveness of the CLASS Program services and CFC services and the individual's progress toward achieving the outcomes identified for the individual; (F) revising the individual's IPC, as appropriate; (G) accessing non-CLASS Program services and non-CFC services; (H) resolving a crisis that occurs regarding the individual; and (I) advocating for the individual's needs. (21) Case manager--A service provider of case management. (22) Catchment area--As determined by the Texas Health and Human Services Commission (HHSC), a geographic area composed of multiple Texas counties. (23) CDS option--Consumer directed services option. A service delivery option defined in 40 TAC §41.103 (relating to Definitions). (24) CFC--Community First Choice. (25) CFC ERS--CFC emergency response services. A CFC service that provides backup systems and supports used to ensure continuity of services and supports. CFC ERS includes electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices. (26) CFC ERS provider--The entity directly providing CFC ERS to an individual, which may be the DSA or a contractor of the DSA. (27) CFC FMS--CFC financial management services. A CFC service provided to an individual who receives only CFC PAS/HAB through the CDS option. (28) CFC PAS/HAB--CFC personal assistance services/habilitation. A CFC service: (A) that consists of: (i) personal assistance services, which provides assistance to an individual in performing ADLs and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including: (I) non-skilled assistance with the performance of the ADLs and IADLs; (II) household chores necessary to maintain the home in a clean, sanitary, and safe environment; (III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and (IV) assistance with health-related tasks; and (ii) habilitation, which provides assistance to an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, including: (I) self-care; (II) personal hygiene; (III) household tasks; (IV) mobility; (V) money management; (VI) community integration, including how to get around in the community; (VII) use of adaptive equipment; (VIII) personal decision making; (IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and (X) self-administration of medication; and (B) does not include transporting the individual, which means driving the individual from one location to another. (29) CFC support consultation--A CFC service that provides support consultation to an individual who receives only CFC PAS/HAB through the CDS option. (30) CFC support management--A CFC service that provides training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB. (31) CFR--Code of Federal Regulations. (32) CFS--Continued family services. A CLASS Program service described in Subchapter E of this chapter (relating to Support Family Services and Continued Family Services). (33) CLASS Program--The Community Living Assistance and Support Services Program. (34) CMA--Case management agency. A program provider that has a contract with HHSC to provide case management. (35) CMS--The Centers for Medicare & Medicaid Services. CMS is the agency within the United States Department of Health and Human Services that administers Medicare and Medicaid programs. (36) Cognitive rehabilitation therapy--A CLASS Program service that: (A) assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells or brain chemistry in order to enable the individual to compensate for lost cognitive functions; and (B) includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. (37) Competitive employment--Employment that pays an individual at least the minimum wage if the individual is not self-employed. (38) Contract--A provisional contract that HHSC enters into in accordance with 40 TAC §49.208 (relating to Provisional Contract Application Approval) that has a term of no more than 3 years, not including any extension agreed to in accordance with 40 TAC §49.208(e) or a standard contract that HHSC enters into in accordance with 40 TAC §49.209 (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with 40 TAC §49.209(d). (39) Controlling person--A person who: (A) has an ownership interest in a program provider; (B) is an officer or director of a corporation that is a program provider; (C) is a partner in a partnership that is a program provider; (D) is a member or manager in a limited liability company that is a program provider; (E) is a trustee or trust manager of a trust that is a program provider; or (F) because of a personal, familial, or other relationship with a program provider, is in a position of actual control or authority with respect to the program provider, regardless of the person's title. (40) Denial--An action taken by HHSC that: (A) rejects an individual's request for enrollment into the CLASS Program; (B) disallows a CLASS Program service or a CFC service requested on an IPC that was not authorized on the prior IPC; or (C) disallows a portion of the amount or level of a CLASS Program service or a CFC service requested on an IPC that was not authorized on the prior IPC. (41) Dental treatment--A CLASS Program service that: (A) consists of the following: (i) emergency dental treatments, which are procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures; (ii) routine preventative dental treatments, which are examinations, x-rays, cleanings, sealants, oral prophylaxes, and topical fluoride applications; (iii) therapeutic dental treatments, which include fillings, scaling, extractions, crowns, pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development; (iv) orthodontic dental treatments, which are procedures that include treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and (v) dental sedation, which is sedation necessary to perform dental treatment including non-routine anesthesia, (for example, intravenous sedation, general anesthesia, or sedative therapy prior to routine procedures) but not including administration of routine local anesthesia only; and (B) does not include cosmetic orthodontia. (42) DFPS--The Texas Department of Family and Protective Services. (43) Dietary services--A CLASS Program service that provides nutrition services, as defined in Texas Occupations Code §701.002. (44) Direct services--Includes the following services: (A) CLASS Program services other than case management, FMS, support consultation, support family services, CFS, and TAS; (B) CFC PAS/HAB; (C) CFC ERS; and (D) CFC support management. (45) DSA--Direct services agency. A program provider that has a contract with HHSC to provide direct services. (46) Employment assistance--A CLASS Program service that provides assistance to an individual to help the individual locate competitive employment in the community to the same degree of access as individuals not receiving CLASS Program services. (47) Enrollment IPC--The first individual plan of care (IPC) for an individual developed before the individual's enrollment into the CLASS Program. (48) Enrollment IPP--The first individual program plan (IPP) for an individual developed before the individual's enrollment into the CLASS Program in accordance with §259.67 of this chapter (relating to Development of IPPs). (49) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain. (50) FMS--Financial management services. A CLASS Program service that is defined in 40 TAC §41.103 and is provided to an individual participating in the CDS option. (51) FMSA--Financial management services agency. An entity, as defined in 40 TAC §41.103, that provides FMS. (52) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force: (A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and (B) who was killed in action or died while in service, or whose active duty otherwise ended. (53) Functional behavior assessment--An evaluation that is used to determine the underlying function or purpose of an individual's behavior, so an effective behavior support plan can be developed. (54) Good cause--As determined by HHSC, a reason outside the control of a CFC ERS provider that is an acceptable reason for the CFC ERS provider's failure to comply. (55) Group setting--A setting, other than an individual's residence, in which more than one individual or other person is receiving pre-vocational services or a similar service. (56) Habilitation--A CLASS Program service that allows an individual to reside successfully in a community setting by training the individual to acquire, retain, and improve self-help, socialization, and daily living skills or assisting the individual with ADLs. Habilitation services consist of the following: (A) habilitation training, which is interacting in person with an individual who is awake to train the individual in the following activities: (i) self-care; (ii) personal hygiene; (iii) household tasks; (iv) mobility; (v) money management; (vi) community integration; (vii) use of adaptive equipment; (viii) management of caregivers; (ix) personal decision making; (x) interpersonal communication; (xi) reduction of challenging behaviors; (xii) socialization and the development of relationships; (xiii) participating in leisure and recreational activities; (xiv) use of natural supports and typical community services available to the public; (xv) self-administration of medication; and (xvi) strategies to restore or compensate for reduced cognitive skills; (B) habilitation ADLs, which are: (i) interacting in person with an individual who is awake to assist the individual in the following activities: (I) self-care; (II) personal hygiene; (III) ambulation and mobility; (IV) money management; (V) community integration; (VI) use of adaptive equipment; (VII) self-administration of medication; (VIII) reinforce any therapeutic goal of the individual; (IX) provide transportation to the individual; and (X) protect the individual's health, safety and security; (ii) interacting in person or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and (iii) performing one of the following activities that does not involve interacting in person with an individual: (I) shopping for the individual; (II) planning or preparing meals for the individual; (III) housekeeping for the individual; (IV) procuring or preparing the individual's medication; or (V) arranging transportation for the individual; and (C) habilitation delegated, which is tasks delegated by a registered nurse (RN) to a service provider of habilitation in accordance with 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks By Registered Professional Nurses to Unlicensed Personnel For Clients With Acute Conditions Or In Acute Care Environments) or Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegations In Independent Living Environments For Clients With Stable and Predictable Conditions). (57) Health-related tasks--Specific tasks related to the needs of an individual that can be delegated or assigned by a licensed health care professional under state law to be performed by a service provider of CFC PAS/HAB. These include: (A) tasks delegated by a registered nurse (RN); (B) health maintenance activities, as defined in 22 TAC §225.4 (relating to Definitions), that may not require delegation; and (C) activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist. (58) HHSC--The Texas Health and Human Services Commission. (59) Hippotherapy--A specialized therapy that: (A) involves an individual interacting with and riding on horses; (B) is designed to improve the balance, coordination, focus, independence, confidence, and motor and social skills of the individual; and (C) is provided by two service providers at the same time, as described in §259.355(d)(11) of this chapter (relating to Qualifications of DSA Staff Persons). (60) Hospital--A public or private institution that is licensed or is exempt from licensure in accordance with THSC Chapters 13, 241, 261, or 552. (61) IADLs--Instrumental activities of daily living. Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community. (62) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program Services are provided and that is: (A) licensed in accordance with THSC Chapter 252; or (B) certified by HHSC, including a state supported living center. (63) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions. (64) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. An HHSC form used to determine the level of care (LOC) for an individual. (65) Individual--A person seeking to enroll or who is enrolled in the CLASS Program. (66) Individual transportation plan--A written plan developed by an individual's service planning team and documented on the HHSC individual transportation plan form. An individual transportation plan describes how transportation as a habilitation activity will be delivered to support an individual's desired goals and outcomes identified in the IPP. (67) Inpatient chemical dependency treatment facility--A facility licensed in accordance with THSC Chapter 464, Facilities Treating Persons with a Chemical Dependency. (68) In person or in-person--Within the physical presence of another person. In person or in-person does not include using videoconferencing or a telephone. (69) Institution for mental diseases--Has the meaning set forth in 42 CFR §435.1010. (70) Institutional services--Medicaid-funded services provided in a nursing facility or in an ICF/IID. (71) Intellectual disability--Consistent with THSC §591.003, significantly sub-average general intellectual functioning that is concurrent with deficits in adaptive behavior and originates during the developmental period. (72) IPC--Individual plan of care. A written plan developed by an individual's service planning team and documented on the HHSC Individual Plan of Care form. An IPC: (A) documents: (i) the type and amount of each CLASS Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year; and (ii) if an individual will receive CFC support management; and (B) is authorized by HHSC. (73) IPC cost--Estimated annual cost for CLASS Program services on an IPC. (74) IPC period--The effective period of an enrollment IPC and a renewal IPC as follows: (A) for an enrollment IPC, the period of time from the effective date of the enrollment IPC, as described in §259.65(g) of this chapter (relating to Development of an Enrollment IPC), through the last calendar day of the 11th month after the month in which enrollment occurred; and (B) for a renewal IPC, a 12-month period of time starting on the effective date of the renewal IPC, as described in §259.77(b) of this chapter (relating to Renewal IPC and Requirement for Authorization to Continue Services). (75) IPP--Individual program plan. A written plan developed in accordance with §259.67 of this chapter (relating to Development of IPPs) and documented on an HHSC Individual Program Plan form. (76) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person. (77) Licensed vocational nurse--A person licensed to provide vocational nursing in accordance with Texas Occupations Code Chapter 301. (78) Licensed vocational nursing--A CLASS Program service that provides vocational nursing, as defined in Texas Occupations Code §301.002. (79) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with THSC §533A.035. (80) LOC--Level of care. A determination given to an individual as part of the eligibility determination process based on data on the ID/RC Assessment. (81) Managed care organization--This term has the meaning set forth in Texas Government Code §543A.0001(11). (82) MAO Medicaid--Medical Assistance Only Medicaid. A type of Medicaid by which an individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits. (83) Massage therapy--A specialized therapy defined in Texas Occupations Code §455.001. (84) Medicaid--A program administered by CMS and funded jointly by the states and the federal government that pays for health care to eligible groups of low-income people. (85) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility. (86) Mental health facility--A facility licensed in accordance with THSC Chapter 577. (87) MESAV--Medicaid Eligibility Service Authorization Verification. The automated system that contains information regarding an individual's Medicaid eligibility and service authorizations. (88) Military family member--A person who is the spouse or child, regardless of age, of: (A) a military member; or (B) a former military member. (89) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch. (90) Minor home modifications--A CLASS Program service that: (A) makes a physical adaptation to an individual's residence that: (i) is necessary to address the individual's specific needs; and (ii) enables the individual to function with greater independence in the individual's residence or to control his or her environment; and (B) meets one of the following criteria: (i) is included on the list of minor home modifications in the Community Living Assistance and Support Services Provider Manual; or (ii) is the repair or maintenance of a minor home modification purchased through the CLASS Program that: (I) is needed after one year has elapsed from the date the minor home modification is complete; (II) is needed for a reason other than the minor home modification was intentionally damaged, as described in §259.285(c) of this chapter (relating to Repair or Replacement of Minor Home Modification); and (III) is not covered by a warranty. (91) Music therapy--A specialized therapy that uses musical or rhythmic interventions to restore, maintain, or improve an individual's social or emotional functioning, mental processing, or physical health. (92) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who assist and sustain an individual. (93) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death. (94) Nursing--One or more of the following CLASS Program services: (A) licensed vocational nursing; (B) registered nursing; (C) specialized licensed vocational nursing; and (D) specialized registered nursing. (95) Nursing facility--A facility that is licensed or is exempt from licensure in accordance with THSC Chapter 242. (96) Occupational therapy--A CLASS Program service that provides occupational therapy, as described in Texas Occupations Code §454.006. (97) Own home or family home--A residence that is not: (A) an ICF/IID; (B) a nursing facility; (C) an ALF; (D) a residential child-care facility unless it is an agency foster home; (E) a hospital; (F) a mental health facility; (G) an inpatient chemical dependency treatment facility; (H) a residential facility operated by the Texas Workforce Commission; (I) a residential facility operated by the Texas Juvenile Justice Department; (J) a jail; or (K) a prison. (98) PAS/HAB plan--Personal Assistance Services/Habilitation Plan. A written plan developed by an individual's service planning team and documented on the HHSC Personal Assistance Services (PAS)/Habilitation Plan form that describes the type and frequency of CFC PAS/HAB activities to be performed by a service provider. (99) Person--A corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, natural person, or any other legal entity that can function legally, sue or be sued, and make decisions through agents. (100) Person-centered planning process--The process described in §259.57 of this chapter (relating to Person-Centered Planning Process). (101) Physical abuse--Any of the following: (A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death; (B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual; (C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or (D) seclusion. (102) Physical therapy--A CLASS Program service that provides physical therapy, as defined in Texas Occupations Code §453.001. (103) Physician--Consistent with §558.2 of this title (relating to Definitions), a person who is: (A) licensed in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code Chapter 155; (B) licensed in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of an individual, and orders home health or hospice services for the individual in accordance with Texas Occupations Code §151.056(b)(4); or (C) a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service, if the person is not engaged in private practice, in accordance with the Texas Occupations Code §151.052(a)(8). (104) Platform--This term has the meaning set forth in Texas Government Code §521.0001(10). (105) Prevocational services--A CLASS Program service that provides services that are not job-task oriented and are provided to an individual whose service planning team does not expect to be employed, without receiving supported employment, within one year after the date prevocational services begin. Prevocational services prepare an individual for competitive employment and consist of: (A) assessment of vocational skills an individual needs to develop or improve upon; (B) individual and group instruction regarding barriers to employment; (C) training in skills: (i) that are not job-task oriented; (ii) that are related to goals identified in the individual's IPP for prevocational services; (iii) that are essential to obtaining and retaining competitive employment, such as the effective use of community resources, transportation, and mobility training; and (iv) for which an individual is not compensated more than 50 percent of the federal minimum wage or industry standard, whichever is greater; (D) training in the use of adaptive equipment necessary to obtain and retain competitive employment; and (E) transportation between the individual's place of residence and a group setting in which prevocational services are provided when other forms of transportation are unavailable or inaccessible. (106) Program provider--A person that has a contract with HHSC to provide CLASS Program services, excluding an FMSA. In the CLASS Program, there are two types of program providers, a DSA and a CMA. (107) Public emergency personnel--Personnel of a sheriff's department, police department, emergency medical service, or fire department. (108) Recreational therapy--A specialized therapy that provides recreational or leisure activities that assist an individual to restore, remediate, or habilitate the individual's level of functioning and independence in life activities; promote health and wellness; and reduce or eliminate the activity limitations caused by an illness or disabling condition. (109) Reduction--An action taken by HHSC as a result of a review of a revised IPC or renewal IPC that decreases the amount or level of a service authorized by HHSC on the prior IPC. (110) Registered nursing--A CLASS Program service that provides professional nursing, as defined in Texas Occupations Code §301.002. (111) Related condition--As defined in 42 CFR §435.1010, a severe and chronic disability that: (A) is attributed to: (i) cerebral palsy or epilepsy; or (ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability; (B) is manifested before the individual reaches 22 years of age; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in at least three of the following areas of major life activity: (i) self-care; (ii) understanding and use of language; (iii) learning; (iv) mobility; (v) self-direction; and (vi) capacity for independent living. (112) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the Community Living Assistance and Support Services Provider Manual.(113) Renewal IPC--An IPC developed in accordance with §259.79 of this chapter (relating to Renewal and Revision of an IPC). (114) Residential child-care facility--The term has the meaning set forth in Texas Human Resources Code §42.002. (115) Respite--A CLASS Program service that provides temporary assistance and support with an individual's ADLs if the individual has the same residence as a person who routinely provides the assistance and support to the individual, and the person is temporarily unavailable to provide such assistance and support. (A) If the person who routinely provides assistance and support, resides with the individual, and is temporarily unavailable to provide assistance and support, is a service provider of transportation as a habilitation activity or CFC PAS/HAB or an employee in the CDS option of transportation as a habilitation activity or CFC PAS/HAB, HHSC does not approve respite unless: (i) the service provider or employee routinely provides unpaid assistance and support with ADLs to the individual; (ii) the amount of respite does not exceed the amount of unpaid assistance and support routinely provided; and (iii) the service provider of respite or employee in the CDS option of respite does not have the same residence as the individual. (B) If the person who routinely provides assistance and support, resides with the individual, and is temporarily unavailable to provide assistance and support, is a service provider of support family services or CFS, HHSC does not approve respite unless: (i) for an individual receiving support family services, the individual does not receive respite on the same day the individual receives support family services; (ii) for an individual receiving CFS, the individual does not receive respite on the same day the individual receives CFS; and (iii) the service provider of respite or employee in the CDS option of respite does not have the same residence as the individual. (C) Respite consists of the following: (i) interacting in person with an individual who is awake to assist the individual in the following activities: (I) self-care; (II) personal hygiene; (III) ambulation and mobility; (IV) money management; (V) community integration; (VI) use of adaptive equipment; (VII) self-administration of medication; (VIII) reinforce any therapeutic goal of the individual; (IX) provide transportation to the individual; and (X) protect the individual's health, safety, and security; (ii) interacting in person or by telephone with an individual or an involved person regarding an incident that directly affects the individual's health or safety; and (iii) performing one of the following activities, which may not involve interacting in person with an individual: (I) shopping for the individual; (II) planning or preparing meals for the individual; (III) housekeeping for the individual; (IV) procuring or preparing the individual's medication; (V) arranging transportation for the individual; or (VI) protecting the individual's health, safety, and security while the individual is asleep. (116) Responder--A person designated to respond to an alarm call activated by an individual. (117) Revised IPC--An enrollment IPC or a renewal IPC that is revised during an IPC period in accordance with §259.79 of this chapter to add a new CLASS Program service or CFC service or change the amount of an existing service. (118) RN--Registered nurse. A person licensed to provide professional nursing in accordance with Texas Occupations Code Chapter 301. (119) Seclusion--The involuntary placement of an individual alone in an area from which the individual is prevented from leaving. (120) Service backup plan--A written plan developed in accordance with §259.89 of this chapter (relating to Service Backup Plans) to ensure continuity of critical program services if service delivery is interrupted. (121) Service planning team--A team consisting of: (A) the individual; (B) if applicable, the individual's LAR or actively involved person; (C) the individual's case manager; (D) a representative of the DSA; (E) other persons whose inclusion is requested by the individual, LAR, or actively involved person, including an managed care organization service coordinator, a family member, a friend, and a teacher; and (F) a person selected by the DSA, with the approval of the individual and LAR, who is: (i) professionally qualified by certification or licensure and has special training and experience in the diagnosis and habilitation of persons with the individual's related condition; or (ii) directly involved in the delivery of services and supports to the individual. (122) Service provider--A person who is an employee or contractor of a DSA who provides a direct service. (123) Sexual abuse--Any of the following: (A) sexual exploitation of an individual; (B) non-consensual or unwelcomed sexual activity with an individual; or (C) consensual sexual activity between an individual and a service provider, staff person, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff person, volunteer, or controlling person became a service provider, staff person, volunteer, or controlling person. (124) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent. (125) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person: (A) which may include sexual contact; and (B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice. (126) Specialized licensed vocational nursing--A CLASS Program service that provides licensed vocational nursing to an individual who has a tracheostomy or is dependent on a ventilator. (127) Specialized registered nursing--A CLASS Program service that provides registered nursing to an individual who has a tracheostomy or is dependent on a ventilator. (128) Specialized therapies--A CLASS Program service that promotes skills development, maintains skills, decreases inappropriate behaviors, facilitates emotional well-being, creates opportunities for socialization, or improves physical and medical status and consists of: (A) aquatic therapy; (B) hippotherapy; (C) massage therapy; (D) music therapy; (E) recreational therapy; and (F) therapeutic horseback riding. (129) Speech and language pathology--A CLASS Program service that provides speech-language pathology, as defined in Texas Occupations Code §401.001. (130) Staff person--A full-time or part-time employee of a program provider. (131) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC. (132) Store and forward technology--This term has the meaning set forth in Texas Occupations Code §111.001(2). (133) Support consultation--A CLASS Program service that is defined in 40 TAC §41.103 and may be provided to an individual who chooses to participate in the CDS option. (134) SFS--Support family services. A CLASS Program service that is described in Subchapter E of this chapter. (135) Supported employment--A CLASS Program service that provides assistance to sustain competitive employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed. (136) Synchronous audio-visual--An interactive, two-way audio and video communication platform that: (A) allows a service to be provided to an individual in real time; and (B) conforms to the privacy requirements under the Health Insurance Portability and Accountability Act. (137) System check--A test of the CFC ERS equipment to determine if: (A) the individual can successfully activate an alarm call; and (B) the equipment is working properly. (138) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas State Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C. (139) Target behavior--A behavior identified in a behavior support plan for reduction or elimination. (140) TAS--Transition assistance services. A CLASS Program service provided in accordance with Chapter 272 of this title (related to Transition Assistance Services) to an individual who is receiving institutional services and is eligible for and enrolling into the CLASS Program. (141) Telehealth services--This term has the meaning set forth in Texas Occupations Code §111.001. (142) Texas Workforce Commission--The state agency established under Texas Labor Code Chapter 301. (143) Therapeutic horseback riding--A specialized therapy that: (A) involves an individual interacting with and riding on horses; and (B) is designed to improve the balance, coordination, focus, independence, confidence, and motor and social skills of the individual. (144) THSC--Texas Health and Safety Code. Texas statutes relating to health and safety. (145) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures: (A) to: (i) harass, intimidate, humiliate, or degrade an individual; or (ii) threaten an individual with physical or emotional harm; and (B) that: (i) results in observable distress or harm to the individual; or (ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress. (146) Videoconferencing--An interactive, two-way audio and video communication: (A) used to conduct a meeting between two or more persons who are in different locations; and (B) that conforms to the privacy requirements under the Health Insurance Portability and Accountability Act. (147) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §259.5 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective April 1, 2025, 50 TexReg 2206. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §259.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212115 03/12/2026 (a) The CLASS Program is a Medicaid waiver program approved by CMS and operated by HHSC pursuant to §1915(c) of the Social Security Act. It provides community-based services and supports to an eligible individual as an alternative to the ICF/IID Program. CLASS Program services are intended to:(1) enhance the individual's integration into the community;(2) maintain or improve the individual's independent functioning; and(3) prevent the individual's admission to an institution.(b) HHSC limits the enrollment in the CLASS Program to the number of individuals approved by CMS or by available funding from the state.(c) The CLASS Program offers the following services approved by CMS:(1) adaptive aids;(2) auditory integration training/auditory enhancement training;(3) behavioral support;(4) case management;(5) cognitive rehabilitation therapy;(6) dental treatment;(7) habilitation;(8) licensed vocational nursing;(9) minor home modifications;(10) dietary services;(11) occupational therapy;(12) physical therapy;(13) prevocational services;(14) registered nursing;(15) respite, which consists of:(A) in-home respite; and(B) out-of-home respite;(16) speech and language pathology;(17) specialized licensed vocational nursing;(18) specialized registered nursing;(19) specialized therapies, which consist of:(A) aquatic therapy;(B) hippotherapy;(C) massage therapy;(D) music therapy;(E) recreational therapy; and(F) therapeutic horseback riding;(20) SFS;(21) CFS;(22) employment assistance;(23) supported employment;(24) TAS; and(25) if the individual's IPC includes at least one CLASS Program service to be delivered through the CDS option:(A) FMS; and(B) support consultation.(d) A DSA may only provide and bill for habilitation if the activity provided is transportation, as described in §259.5(56)(B)(i)(IX) of this subchapter (relating to Definitions).(e) CFC is a state plan option governed by 42 CFR, Part 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice) that provides the following services to individuals:(1) CFC PAS/HAB;(2) CFC ERS; and(3) CFC support management for an individual receiving CFC PAS/HAB. Source Note: The provisions of this §259.7 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §259.7 Description of the CLASS Program and CFC Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212116 03/12/2026 The CLASS Program does not provide for the following:(1) room and board, except for out-of-home respite described in §259.361(b)(2) of this chapter (relating to Respite and Dental Treatment);(2) special education and related services, as defined in 20 United States Code §1401 that otherwise are available to the individual through a state or local educational agency; and(3) vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 United States Code Chapter 16, Subchapter I. Source Note: The provisions of this §259.9 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §259.9 Excluded Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226067 03/12/2026 (a) An individual is eligible for CLASS Program services if:(1) the individual meets the financial eligibility criteria described in Appendix B of the CLASS Program waiver application approved by CMS and available on the HHSC website;(2) the individual is determined by HHSC to meet the LOC VIII criteria described in §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria);(3) the individual demonstrates a need for CFC PAS/HAB;(4) the individual's IPC has an IPC cost for CLASS Program services at or below 210 percent of the annualized cost of care in an ICF/IID using the unweighted average of the current non-state operated small facility daily rates for level of need, as defined by the ICF/IID program rules in §261.203 of this title (relating to Definitions), 1, 5, and 8 rounded to the nearest dollar, which as of September 1, 2025 is $149,774;(5) the individual is not enrolled in another waiver program or receiving a service that may not be received if the individual is enrolled in the CLASS Program, as identified in the Mutually Exclusive Services table in Appendix III of the Community Living Assistance and Support Services Provider Manual available on the HHSC website;(6) the individual resides in the individual's own home or family home; and(7) the individual requires the provision of:(A) at least one CLASS Program service per month or a monthly monitoring by a case manager; and(B) at least one CLASS Program service during an IPC period.(b) Except as provided in subsection (c) of this section, an individual is eligible for a CFC service under this chapter if the individual:(1) meets the criteria described in subsection (a) of this section;(2) requires the provision of the CFC service; and(3) is not receiving SFS or CFS.(c) To be eligible for a CFC service under this chapter, an individual receiving MAO Medicaid must, in addition to meeting the eligibility criteria described in subsection (b) of this section, receive a CLASS Program service at least monthly, as required by 42 CFR §441.510(d). Source Note: The provisions of this §259.51 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective September 17, 2025, 50 TexReg 6015. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.51 Eligibility Criteria for CLASS Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212118 03/12/2026 (a) HHSC maintains an interest list that contains the names of individuals interested in receiving CLASS Program services.(b) A person may request an individual's name be added to the CLASS interest list by:(1) calling HHSC's toll-free number; or(2) submitting a written request to HHSC.(c) If a request is made in accordance with subsection (b) of this section for an individual who resides in Texas, HHSC adds the individual's name to the CLASS interest list using the date HHSC receives the request as the CLASS interest list date.(d) For an individual under 22 years of age who is residing in a nursing facility located in Texas, HHSC adds the individual's name to the CLASS interest list using the date of admission to the nursing facility as the CLASS interest list date.(e) For an individual determined diagnostically or functionally ineligible during the enrollment process for the Deaf-Blind with Multiple Disabilities (DBMD) Program, Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program, or Medically Dependent Children Program (MDCP):(1) if the individual's name is not on the CLASS interest list, at the request of the individual or LAR, HHSC adds the individual's name to the CLASS interest list using the individual's interest list date for the program for which the individual was determined ineligible as the CLASS interest list date;(2) if the individual's name is on the CLASS interest list and the individual's interest list date for the program for which the individual was determined ineligible is earlier than the individual's CLASS interest list date, at the request of the individual or LAR, HHSC changes the individual's CLASS interest list date to the individual's interest list date for the program for which the individual was determined ineligible; or(3) if the individual's name is on the CLASS interest list and the individual's CLASS interest list date is earlier than the individual's interest list date for the program for which the individual was determined ineligible, HHSC does not change the individual's CLASS interest list date.(f) This subsection applies to an individual who was enrolled in MDCP and, because the individual did not meet the level of care criteria for medical necessity for nursing facility care or did not meet the age requirement of being under 21 years of age, was determined ineligible for MDCP after November 30, 2019.(1) At the request of the individual or LAR, HHSC adds the individual's name to the CLASS interest list:(A) using the MDCP interest list date as the CLASS interest list date, if the individual's name is not on the CLASS interest list but it was previously on the CLASS interest list; or(B) using the date HHSC receives the request as the CLASS interest list date, if the individual's name is not on the CLASS interest list and it never has been on the CLASS interest list.(2) At the request of the individual or LAR, HHSC changes the CLASS interest list date to the MDCP interest list date if the individual's MDCP interest list date is earlier than the individual's CLASS interest list date.(g) HHSC removes an individual's name from the CLASS interest list if:(1) the individual or LAR requests in writing that the individual's name be removed from the CLASS interest list, unless the individual is under 22 years of age and residing in a nursing facility;(2) the individual moves out of Texas, unless the individual is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the individual declines an offer of CLASS Program services or, as described in §259.55(d) of this subchapter (relating to Written Offer of CLASS Program Services), HHSC withdraws an offer of enrollment in the CLASS Program, unless:(A) the individual is a military family member living outside of Texas:(i) while the military member is on active duty; or(ii) for less than one year after the former military member's active duty ends; or(B) the individual is under 22 years of age and residing in a nursing facility;(4) the individual is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(5) the individual is deceased; or(6) HHSC has denied the individual enrollment in the CLASS Program and the individual or LAR:(A) has had an opportunity to exercise the individual's right to appeal the decision in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing), and:(B) either:(i) did not appeal the decision; or(ii) appealed and did not prevail.(h) If HHSC removes an individual's name from the CLASS interest list in accordance with subsection (g)(1) - (4) of this section, HHSC receives an oral or written request from a person to add the individual's name to the CLASS interest list within 90 calendar days after the name was removed, and the request is the individual's first request, HHSC:(1) adds the individual's name to the CLASS interest list using the CLASS interest list date that was in effect at the time the individual's name was removed from the CLASS interest list; and(2) notifies the individual or LAR in writing that the individual's name has been added to the CLASS interest list in accordance with paragraph (1) of this subsection.(i) If HHSC removes an individual's name from the CLASS interest list in accordance with subsection (g)(1) - (4) of this section, HHSC receives an oral or written request from a person to add the individual's name to the CLASS interest list more than 90 calendar days after the name was removed, and the request is the individual's first request, HHSC:(1) adds the individual's name to the CLASS interest list using as the CLASS interest list date:(A) the date HHSC receives the oral or written request; or(B) if HHSC determines extenuating circumstances exist, the CLASS interest list date that was in effect at the time the individual's name was removed from the CLASS interest list; and(2) notifies the individual or LAR in writing that the individual's name has been added to the CLASS interest list in accordance with paragraph (1) of this subsection.(j) If HHSC removes an individual's name from the CLASS interest list in accordance with subsection (g)(1) - (4) of this section, HHSC receives an oral or written request from a person to add the individual's name to the CLASS interest list, and the request is not the individual's first request:(1) HHSC adds the individual's name to the CLASS interest list using the date HHSC receives the oral or written request as the CLASS interest list date; and(2) HHSC notifies the individual or LAR in writing that the individual's name has been added to the CLASS interest list in accordance with paragraph (1) of this subsection.(k) If HHSC removes an individual's name from the CLASS interest list in accordance with subsection (g)(6) of this section and HHSC subsequently receives an oral or written request from a person to add the individual's name to the CLASS interest list, HHSC:(1) adds the individual's name to the CLASS interest list using the date HHSC receives the oral or written request as the CLASS interest list date; and(2) notifies the individual or LAR in writing that the individual's name has been added to the CLASS interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §259.53 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.53 CLASS Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212119 03/12/2026 (a) HHSC sends a written offer in accordance with this subsection.(1) HHSC sends a written offer of enrollment in the CLASS Program to:(A) the individual whose CLASS interest list date, assigned in accordance with §259.53 of this subchapter (relating to CLASS Interest List), is earliest on the CLASS interest list; or(B) an individual who is residing in a nursing facility and requesting CLASS Program services.(2) HHSC encloses with the written offer:(A) an HHSC Selection Determination form which includes a list of CMAs and DSAs serving the catchment area in which the individual resides; and(B) an HHSC CLASS Applicant Acknowledgement form.(b) An individual or LAR accepts the offer of enrollment in the CLASS Program by:(1) documenting the selection of one CMA and one DSA on the HHSC Selection Determination form; and(2) ensuring the completed HHSC Selection Determination form and HHSC CLASS Applicant Acknowledgement form are submitted to HHSC and postmarked or faxed no later than 60 calendar days after the date of the written offer.(c) If HHSC receives the completed HHSC Selection Determination form and HHSC CLASS Applicant Acknowledgement form, as described in subsection (b)(2) of this section, HHSC uses the HHSC Selection Determination form to notify the CMA and DSA of the individual's or LAR's selection of a CMA and a DSA.(d) HHSC withdraws an offer of enrollment in the CLASS Program made to an individual if:(1) the completed HHSC Selection Determination form and HHSC CLASS Applicant Acknowledgement form are postmarked or faxed more than 60 calendar days after the date of the written offer;(2) the individual or LAR does not complete the enrollment process as described in §259.61 of this division (relating to Process for Enrollment of an Individual);(3) the individual was offered enrollment in the CLASS Program because the individual was residing in a nursing facility but was discharged from the nursing facility before the effective date of the enrollment IPC; or(4) the individual has moved out of the state of Texas. Source Note: The provisions of this §259.55 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.55 Written Offer of CLASS Program Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212120 03/12/2026 (a) Person-centered planning is a process that empowers an individual to plan the individual's services and supports to achieve desired outcomes.(b) A program provider must ensure the person-centered planning process is led by the individual to the maximum extent possible. The individual's LAR has a participatory role, as needed and as defined by the individual, unless State law confers decision-making authority to the LAR.(c) The person-centered planning process must be used to develop an IPP, an HHSC IPP Addendum, a PAS/HAB plan, an enrollment IPC, a renewal IPC, a revised IPC, a service backup plan, and an individual transportation plan.(d) The person-centered planning process must:(1) include people chosen by the individual or LAR;(2) provide the information and support that the individual needs to lead the planning process and make informed choices and decisions;(3) occur at a time and location convenient to the individual and LAR;(4) consider the individual's cultural preferences;(5) provide information in plain language to the individual and in a manner that is accessible to the individual:(A) through the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act, if the individual requires such aids or services to communicate; and(B) through the provision of language services at no cost to the individual, including oral interpretation and written translations, if the individual has limited English proficiency;(6) use strategies for solving conflict or disagreement within the person-centered planning process;(7) provide information to the individual or LAR to allow the individual or LAR to make informed decisions, including decisions about CLASS Program and CFC services, the settings in which the individual receives a CLASS Program service or a CFC service, and service providers; and(8) inform the individual or LAR that the individual or LAR may request revisions to an IPP, a PAS/HAB plan, an enrollment IPC, a renewal IPC, a revised IPC, a service backup plan, or an individual transportation plan at any time by communicating the request to the CMA or DSA. Source Note: The provisions of this §259.57 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.57 Person-Centered Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212121 03/12/2026 (a) A home and community-based setting is a setting in which an individual receives CLASS Program services or CFC services. A home and community-based setting must have all of the following qualities based on the needs of the individual as documented in the individual's person-centered service plan.(1) A home and community-based setting is integrated in and supports the individual's access to the greater community to the same degree as a person not enrolled in a Medicaid waiver program, including opportunities for the individual to:(A) seek employment and work in a competitive integrated setting;(B) engage in community life;(C) control personal resources; and(D) receive services in the community.(2) A home and community-based setting is selected by an individual from among setting options, including non-disability specific settings and an option for a private unit in a setting in which SFS or CFS is provided. The setting options are identified and documented in an individual's IPP and are based on the individual's needs, preferences, and, for settings in which SFS or CFS is provided, resources available for room and board.(3) A home and community-based setting ensures an individual's rights of privacy, dignity and respect, and freedom from coercion and restraint.(4) A home and community-based setting optimizes, not regiments, individual initiative, autonomy, and independence in making life choices, including choices regarding daily activities, physical environment, and with whom to interact.(5) A home and community-based setting facilitates individual choice regarding services and supports, and the service providers who provide the services and supports.(b) In addition to the requirements in subsection (a) of this section, a DSA must ensure that a group setting in which prevocational services are provided:(1) allows an individual to:(A) control the individual's schedule and activities related to prevocational services;(B) have access to the individual's food at any time; and(C) receive visitors of the individual's choosing at any time; and(2) is physically accessible and free of hazards to an individual.(c) If a DSA becomes aware that a modification to a requirement described in subsection (b)(1) of this section is needed based on a specific assessed need of an individual:(1) the DSA must:(A) notify the case manager of the needed modification; and(B) provide the case manager with the information described in paragraph (2)(A) of this subsection as requested by the case manager; and(2) the case manager must, if notified by the DSA of a needed modification, convene a service planning team meeting in person or by videoconferencing to update the individual's IPP to include the following:(A) a description of the specific and individualized assessed need that justifies the modification;(B) a description of the positive interventions and supports that were tried but did not work;(C) a description of the less intrusive methods of meeting the need that were tried but did not work;(D) a description of the condition that is directly proportionate to the specific assessed need;(E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(G) the individual's or LAR's signature evidencing informed consent to the modification; and(H) the DSA's assurance that the modification will cause no harm to the individual; and(3) the DSA may implement the modification after the service planning team updates the IPP as required by paragraph (2) of this subsection.(d) Except as provided in subsection (e) of this section, a program provider must ensure that CLASS Program services and CFC services are not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a certified ICF/IID operated by a LIDDA or state supported living center is located but is distinct from the ICF/IID;(2) is located in a building on the grounds of, or immediately adjacent to a certified ICF/IID operated by a LIDDA or state supported living center;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building on the grounds of, or immediately adjacent to, a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(e) A program provider may provide a CLASS Program service or a CFC service to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (d) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings. Source Note: The provisions of this §259.59 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.59 Requirements for Home and Community-Based Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225002 03/12/2026 (a) After HHSC notifies a CMA, as described in §259.55(c) of this division (relating to Written Offer of CLASS Program Services), that an individual selected the CMA, the CMA must assign a case manager to perform the following functions as soon as possible, but no later than 14 calendar days after HHSC's notification: (1) verify that the individual resides in the catchment area for which the individual's selected CMA and DSA have a contract; (2) conduct an initial in-person visit in the individual's residence with the individual and LAR or actively involved person at a time convenient to the individual and LAR to: (A) provide an oral and written explanation of the following to the individual and LAR or actively involved person: (i) CLASS Program services, including TAS if the individual is receiving institutional services; (ii) CFC services; (iii) the mandatory participation requirements of an individual described in §259.103 of this chapter (relating to Mandatory Participation Requirements of an Individual); (iv) the CDS option described in §259.71 of this division (relating to CDS Option); (v) the right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing); (vi) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to HHSC by calling the toll-free telephone number at 1-800-458-9858; (vii) the process by which the individual, LAR, or actively involved person may file a complaint regarding case management as required by §52.117 of this title (relating to Complaint Process); (viii) that the HHSC Office of the Ombudsman toll-free telephone number at 1-877-787-8999 may be used to file a complaint regarding the CMA; (ix) voter registration, if the individual is 18 years of age or older; (x) that, while the individual is staying at a location outside the catchment area in which the individual resides but within the state of Texas for a period of no more than 60 consecutive days, the individual and LAR or actively involved person may request that the DSA provide: (I) transportation as a habilitation activity, as described in §259.5(56)(B)(i)(IX) of this subchapter (relating to Definitions); (II) out-of-home respite in a camp described in §259.361(b)(2)(D) of this chapter (relating to Respite and Dental Treatment); (III) adaptive aids; (IV) nursing; and (V) CFC PAS/HAB; (xi) the use of electronic visit verification, as required by 1 TAC Chapter 354, Subchapter O; and (xii) how to contact the individual's case manager; and (B) use the HHSC Understanding Program Eligibility - CLASS/DBMD form to provide an oral and written explanation to the individual or LAR, and obtain the individual's or LAR's signature and date on the form, to acknowledge understanding of: (i) the eligibility requirements for: (I) CLASS Program services, as described in §259.51(a) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); (II) CFC services for individuals who do not receive MAO Medicaid, as described in §259.51(b) of this subchapter; and (III) CFC services for individuals who receive MAO Medicaid, as described in §259.51(c) of this subchapter; (ii) the reasons CLASS Program services and CFC services may be suspended, as described in §259.157 of this chapter (relating to Suspension of CLASS Program Services or CFC Services); and (iii) that CLASS Program services and CFC services may be terminated as described in §§259.161, 259.163, 259.165, and 259.167 of this chapter (relating to Termination of CLASS Program Services and CFC Services With Advance Notice for Reasons Other Than Non-compliance with Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services With Advance Notice Because of Non-compliance With Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy; and Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy); and (C) educate the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and (3) give the individual or LAR the HHSC Waiver Program Verification of Freedom of Choice form to document the individual's or LAR's choice regarding the CLASS Program or the ICF/IID Program. (b) A CMA must: (1) as soon as possible, but no later than two business days after the case manager's initial in-person visit required by subsection (a)(2) of this section: (A) collect the information necessary for the CMA and DSA to process the individual's request for enrollment into the CLASS Program in accordance with the Community Living Assistance and Support Services Provider Manual; and (B) provide the individual's selected DSA with the information collected in accordance with subparagraph (A) of this paragraph; (2) assist the individual or LAR in completing and submitting an application for Medicaid financial eligibility, as required by §259.103(1) of this chapter; and (3) ensure that the case manager documents in the individual's record the progress toward completing a Medicaid application and enrolling into the CLASS Program. (c) If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days after the case manager's initial in-person visit, as required by §259.103(1) of this chapter, but is making good faith efforts to complete the application, the CMA: (1) may extend, in 30-calendar day increments, the time frame in which the application must be submitted to HHSC, except as provided in paragraph (2) of this subsection; (2) must not grant an extension that results in a time period of more than 365 calendar days from the date of the case manager's initial in-person visit; and (3) must ensure that the case manager documents each extension in the individual's record. (d) If an individual or LAR does not submit a Medicaid application to HHSC within 30 calendar days after the case manager's initial in-person visit, as required by §259.103(1) of this chapter, and is not making good faith efforts to complete the application, a CMA must request, in writing, that HHSC withdraw the offer of enrollment made to the individual in accordance with §259.55(d)(2) of this division. (e) If a DSA serving the catchment area in which an individual resides is not willing to provide CLASS Program services or CFC services to the individual because the DSA has determined that it cannot ensure the individual's health and safety, the CMA must provide to HHSC, in writing, the specific reasons the DSA has determined that it cannot ensure the individual's health and safety. (f) During the initial in-person visit described in subsection (a)(1) of the section, the case manager must determine whether an individual meets the following criteria: (1) the individual is being discharged from a nursing facility or an ICF/IID; (2) the individual has not previously received TAS; (3) the individual's proposed enrollment IPC will not include SFS; and (4) the individual anticipates needing TAS. (g) If a case manager determines that an individual meets the criteria described in subsection (f) of this section, the case manager must: (1) provide the individual or LAR with a list of TAS providers in the catchment area in which the individual will reside; (2) complete, with the individual or LAR, the HHSC Transition Assistance Services (TAS) Assessment and Authorization form found on the HHSC website in accordance with the form's instructions, which includes: (A) identifying the items and services described in §272.5(e) of this title (relating to Service Description) that the individual needs; (B) estimating the monetary amount for the items and services identified on the form, which must be within the service limit described in §259.73(a)(4) of this division (relating to Service Limits); and (C) documenting the individual's or LAR's choice of TAS provider; (3) submit the completed form to HHSC for authorization; (4) if HHSC authorizes the form, send the form to the TAS provider chosen by the individual or LAR; and (5) include TAS and the monetary amount authorized by HHSC on the individual's proposed enrollment IPC. (h) A DSA must ensure that the following functions are performed during an in-person visit in the individual's residence at a time convenient to the individual and LAR as soon as possible, but no later than 14 calendar days after the CMA provides information to the DSA as required by subsection (b)(1)(B) of this section: (1) a DSA staff person must: (A) inform the individual and LAR or actively involved person, orally and in writing: (i) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to HHSC by calling the toll-free telephone number at 1-800-458-9858; (ii) the process by which the individual, LAR, or actively involved person may file a complaint regarding CLASS Program services or CFC services provided by the DSA as required by §52.117 of this title; and (iii) that the HHSC toll-free telephone number at 1-800-458-9858 may be used to file a complaint regarding the DSA; and (B) educate the individual and LAR or actively involved person about protecting the individual from abuse, neglect, and exploitation; (2) an appropriate professional must complete an adaptive behavior screening assessment in accordance with the assessment instructions; and (3) an RN, in accordance with the Community Living Assistance and Support Services Provider Manual, must complete: (A) a nursing assessment, using the HHSC CLASS/DBMD Nursing Assessment form; (B) the HHSC Related Conditions Eligibility Screening Instrument form; and (C) the ID/RC Assessment. (i) A DSA must: (1) ensure that the primary diagnosis of the individual documented on the ID/RC Assessment is approved by a physician; (2) submit the following documentation to HHSC for HHSC's determination of whether the individual meets the LOC VIII criteria required by §259.51(a)(2) of this subchapter: (A) the completed adaptive behavior screening assessment; (B) the completed HHSC Related Conditions Eligibility Screening Instrument form; and (C) the completed ID/RC Assessment; and (3) send the completed HHSC CLASS/DBMD Nursing Assessment form described in subsection (h)(3)(A) of this section to the CMA. (j) In accordance with §259.63(a)(1) of this division (relating to Determination by HHSC of Whether an Individual Meets LOC VIII Criteria), HHSC reviews the documentation described in subsection (i)(2) of this section. (k) If a DSA receives written notice from HHSC in accordance with §259.63(c)(1) of this division that an individual meets the LOC VIII criteria, the DSA must notify the individual's CMA of HHSC's decision as soon as possible, but no later than one business day after receiving the notice from HHSC. (l) If HHSC determines that an individual does not meet the LOC VIII criteria, HHSC sends written notice of the denial of the individual's request for enrollment into the CLASS Program: (1) to the individual or LAR in accordance with §259.153(b) of this chapter (relating to Denial of a Request for Enrollment into the CLASS Program); and (2) to the individual's DSA and CMA in accordance with §259.63(d) of this division. (m) If a CMA receives notice from a DSA, as described in subsection (k) of this section, that HHSC determined that an individual meets the LOC VIII criteria, the case manager must: (1) ensure that the service planning team meets in person or by videoconferencing to develop: (A) a proposed enrollment IPC, a PAS/HAB plan, IPPs, and an HHSC IPP Addendum form for the individual in accordance with §259.65 of this division (relating to Development of an Enrollment IPC); and (B) an individual transportation plan, if transportation as a habilitation activity or as an adaptive aid is included on the proposed enrollment IPC; and (2) submit the documents described in paragraph (1) of this subsection to HHSC for review in accordance with §259.65 of this division. (n) HHSC reviews a proposed enrollment IPC in accordance with §259.69 of this division (relating to HHSC's Review of a Proposed Enrollment IPC) to determine if: (1) the proposed enrollment IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter; and (2) the CLASS Program services and CFC services specified in the proposed enrollment IPC meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this division. (o) A CMA and DSA must not provide a CLASS Program service or CFC service to an individual before HHSC notifies the CMA, in accordance with §259.69(c)(1) of this division, that the individual's request for enrollment into the CLASS Program has been approved. If a CMA or DSA provides CLASS Program services or CFC services to an individual before the effective date of the individual's enrollment IPC authorized by HHSC, HHSC does not reimburse the CMA or DSA for those services. (p) If HHSC notifies a CMA in accordance with §259.69(c)(1) of this division that an individual's request for enrollment is approved: (1) the CMA must ensure the case manager complies with §259.69(c)(2) of this division; and (2) the CMA and DSA must comply with §259.69(g) of this division. (q) If HHSC notifies a CMA in accordance with §259.69(e) of this division that an individual's request for enrollment into the CLASS Program is approved, but action is being taken by HHSC to deny a CLASS Program service or CFC service and modify the proposed enrollment IPC: (1) the CMA must comply with §259.69(f) of this division; and (2) the CMA and DSA must comply with §259.69(g) of this division. Source Note: The provisions of this §259.61 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.61 Process for Enrollment of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212123 03/12/2026 (a) To determine if an individual meets the LOC VIII criteria required by §259.51(a)(2) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services), HHSC reviews the documentation submitted by an individual's DSA:(1) described in §259.61(i)(2) of this division (relating to Process for Enrollment of an Individual); or(2) described in §259.75(a)(2) of this subchapter (related to Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria).(b) HHSC may request current data obtained from standardized evaluations and formal assessments related to the LOC VIII criteria. If HHSC makes such a request, a DSA must submit the information to HHSC no later than 10 calendar days after the date of the request.(c) If HHSC determines that an individual meets the LOC VIII criteria:(1) HHSC notifies the individual's DSA of the determination, in writing; and(2) the LOC VIII is effective:(A) on a date determined by HHSC; and(B) through the last calendar day of the IPC period.(d) If HHSC determines that an individual does not meet the LOC VIII criteria, HHSC notifies an individual's DSA and CMA of the determination, in writing. Source Note: The provisions of this §259.63 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.63 Determination by HHSC of Whether an Individual Meets LOC VIII Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212124 03/12/2026 (a) No later than 30 calendar days after the date a DSA notifies an individual's CMA of HHSC's determination that the individual meets the LOC VIII criteria, as described in §259.61(k) of this division (relating to Process for Enrollment of an Individual), the CMA must ensure that the individual's case manager: (1) convenes a service planning team meeting in person or by videoconferencing in which the service planning team: (A) reviews the HHSC CLASS/DBMD Nursing Assessment form completed by an RN as described in §259.61(h)(3) of this division; (B) addresses any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met; (C) documents on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed; (D) develops a PAS/HAB plan based on review of the information obtained from assessments conducted and observations made by a DSA as required by §259.61(h)(2) and (3) of this division; (E) develops a proposed enrollment IPC that: (i) documents each CLASS Program service and CFC service, other than CFC support management, to be provided to an individual; (ii) specifies the number of units of each CLASS Program service and CFC service, other than CFC support management, to be provided to an individual; (iii) for each CLASS Program service: (I) is within the service limit described in §259.73 of this division (relating to Service Limits); (II) if an adaptive aid, meets the requirements in Subchapter F, Division 1, of this chapter (relating to Adaptive Aids); and (III) if a minor home modification, meets the requirements in Subchapter F, Division 2, of this chapter (relating to Minor Home Modifications); (iv) for CFC ERS, meets the requirements in Subchapter F, Division 3, of this chapter (relating to CFC ERS); (v) identifies if an individual will receive CFC support management; (vi) describes any other service or support to be provided to the individual through sources other than CLASS Program services or CFC services; (vii) if the proposed enrollment IPC includes nursing or CFC PAS/HAB, identifies whether the service is critical to the individual's health and safety, as required by §259.89(a)(2) of this subchapter (relating to Service Backup Plans); (viii) if the individual will receive TAS, the TAS and the monetary amount authorized by HHSC; and(ix) if the individual chooses to receive services through the CDS option, identifies:(I) the name of the individual's FMSA; and(II) the type and estimated units of each CLASS Program service and CFC service provided through the CDS option;(F) develops an IPP for each CLASS Program service and CFC service listed on the proposed enrollment IPC, other than CFC support management, as required by §259.67 of this division (relating to Development of IPPs); (G) develops an HHSC IPP Addendum form; (H) if the proposed enrollment IPC identifies nursing or CFC PAS/HAB as critical, develops a service backup plan for the service in accordance with §259.89 of this subchapter; and (I) if transportation as a habilitation activity or as an adaptive aid is included on the proposed enrollment IPC, develops an individual transportation plan; and (2) if an individual may need cognitive rehabilitation therapy, assists the individual in obtaining an assessment as required by §259.311(h) of this chapter (relating to CMA Service Delivery). (b) A case manager must ensure that each CLASS Program service and CFC service on a proposed enrollment IPC, other than CFC support management: (1) is necessary to protect an individual's health and welfare in the community; (2) addresses an individual's related condition; (3) is not available to an individual through sources other than CLASS Program services or CFC services, including the Medicaid State Plan, other governmental programs, private insurance, or the individual's natural supports; (4) is the most appropriate type and amount of CLASS Program service and CFC service to meet an individual's needs; and (5) is cost effective. (c) If an individual or LAR, case manager, and DSA agree on the type and amount of services to be included in a proposed enrollment IPC, a case manager must: (1) if the service planning team meeting required by subsection (a)(1) of this section is conducted in person, ensure that during the service planning team meeting the proposed enrollment IPC is reviewed, signed as evidence of agreement, and dated by: (A) the individual or LAR; (B) the case manager; and (C) the DSA; or(2) if the service planning team meeting required by subsection (a)(1) of this section is conducted by videoconferencing, ensure that the proposed enrollment IPC is reviewed, signed as evidence of agreement, and dated by the individual or LAR and the DSA electronically, by fax, or by United States mail; and (3) no later than 30 calendar days before the effective date of the proposed enrollment IPC as determined by the service planning team: (A) submit to HHSC for its review: (i) the proposed enrollment IPC; (ii) the enrollment IPPs; (iii) the HHSC IPP Addendum form;(iv) the PAS/HAB plan; (v) the completed HHSC CLASS/DBMD Nursing Assessment form provided by the DSA in accordance with §259.61(i)(3) of this division;(vi) the ID/RC Assessment authorized by HHSC;(vii) the HHSC Non-Waiver Services form;(viii) the HHSC Verification of Freedom of Choice form;(ix) Choice List for the CLASS Program; (x) the individual transportation plan, if required by subsection (a)(1)(I) of this section;(xi) an HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by;(I) §259.255 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500);(II) §259.257 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More); (III) §259.275 of this chapter (relating to Requirements for Authorization to Purchase a Minor Home Modification); and(IV) §259.361 of this chapter (relating to Respite and Dental Treatment);(xii) an HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by:(I) §259.257 of this chapter; and(II) §259.275 of this chapter;(xiii) letters of denial from non-waiver resources, if any;(xiv) if the proposed enrollment IPC includes TAS, the HHSC Transition Assistance Services Assessment and Authorization form; and(xv) if the proposed enrollment IPC includes a skilled or a specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form; (B) send the DSA a copy of: (i) the proposed enrollment IPC; (ii) the enrollment IPPs;(iii) the HHSC IPP Addendum form;(iv) the PAS/HAB plan;(v) a service backup plan, if required by subsection (a)(1)(H) of this section; and (vi) the individual transportation plan, if required by subsection (a)(1)(I) of this section; and (C) if the proposed enrollment IPC includes a service the individual chooses to receive through the CDS option, send the FMSA a copy of: (i) the proposed enrollment IPC; (ii) the IPPs; (iii) the HHSC IPP Addendum form;(iv) the PAS/HAB plan; (v) a service backup plan, if is required by subsection (a)(1)(H) of this section; and (vi) the individual transportation plan, if required by subsection (a)(1)(I) of this section. (d) If an individual or LAR requests a CLASS Program service or CFC service that a case manager or DSA has determined does not meet the criteria described in subsection (b) of this section, does not meet the requirements described in Subchapter F of this chapter, or exceeds a service limit described in §259.73 of this division, a CMA must:(1) in accordance with the Community Living Assistance and Support Services Provider Manual, send the individual or LAR a written notice of the denial of the requested CLASS Program service or CFC service, copying the DSA and FMSA; (2) no later than 30 calendar days before the effective date of the proposed enrollment IPC as determined by the service planning team, submit to HHSC for its review: (A) the proposed enrollment IPC that:(i) includes the type and amount of CLASS Program services or CFC services in dispute and not in dispute; and (ii) is signed and dated by: (I) the individual or LAR; (II) the case manager; and (III) the DSA; (B) the IPPs;(C) the HHSC IPP Addendum form;(D) the PAS/HAB plan; and (E) the individual transportation plan, if required by subsection (a)(1)(I) of this section; and (3) if the individual will receive a service through the CDS option, send the FMSA a copy of: (A) the proposed enrollment IPC, (B) the IPPs; (C) the PAS/HAB plan; (D) a service backup plan, if required by subsection (a)(1)(H) of this section; and (E) the individual transportation plan, if required by subsection (a)(1)(I) of this section. (e) HHSC reviews a proposed enrollment IPC in accordance with §259.69 of this division (relating to HHSC's Review of a Proposed Enrollment IPC). (f) The process by which HHSC denies an individual's request for enrollment or denies a CLASS Program service or CFC service, based on HHSC's review of a proposed enrollment IPC, is described in §259.69(d) - (f) of this division. (g) The effective date of an enrollment IPC is the effective date proposed by the service planning team, unless HHSC modifies the effective date.(h) An enrollment IPC is effective for an IPC period. Source Note: The provisions of this §259.65 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.65 Development of an Enrollment IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212125 03/12/2026 (a) A case manager must ensure that an individual's service planning team:(1) develops an enrollment IPP for each CLASS Program service and CFC service listed on a proposed enrollment IPC, other than CFC support management, and submits the enrollment IPPs to HHSC in accordance with §259.65 of this division (relating to Development of an Enrollment IPC); and(2) develops a renewal or revised IPP for each CLASS Program service and CFC service, other than CFC support management, and submits the renewal or revised IPPs to HHSC in accordance with §259.79 of this subchapter (relating to Renewal and Revision of an IPC).(b) A case manager must ensure that an enrollment, renewal, or revised IPP:(1) includes justification for the service;(2) includes the total units of the service;(3) describes:(A) the outcomes to be achieved through the service; and(B) the actions and methods to be used to achieve the outcomes;(4) describes individualized goals for the service that:(A) are outcome-based;(B) are measurable; and(C) have a start date and projected completion date;(5) describes the individual's current natural supports and non-waiver and non-CFC services that will be or are available;(6) documents that the frequency and amount of the service does not replace existing natural supports, non-waiver resources, or non-CFC resources for which the individual may be eligible; and(7) documents the setting for each service, which must be selected by the individual or LAR from setting options.(c) A case manager must ensure that an enrollment, renewal, or revised IPP is reviewed, signed, and dated as evidence of agreement by:(1) the individual or LAR;(2) the case manager; and(3) the DSA. Source Note: The provisions of this §259.67 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.67 Development of IPPs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212126 03/12/2026 (a) HHSC reviews a proposed enrollment IPC, a PAS/HAB plan, enrollment IPPs, an HHSC IPP Addendum form and, if required by §259.65(a)(1)(I) of this division (relating to Development of an Enrollment IPC), the individual transportation plan to determine if:(1) the proposed enrollment IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); and(2) the CLASS Program services and CFC services specified in the IPC meet the requirements described in §259.65(a)(1)(E)(iii) and (iv) and §259.65(b) of this division.(b) At HHSC's request, a CMA must submit additional documentation supporting a proposed enrollment IPC to HHSC no later than 10 calendar days after HHSC's request.(c) If HHSC determines that a proposed enrollment IPC meets the requirements described in subsection (a) of this section:(1) HHSC notifies the CMA, in writing, that the individual's request for enrollment is approved; and(2) as soon as possible, but no later than one business day after the CMA receives HHSC's notification, the case manager must:(A) notify the individual or LAR of HHSC's approval of the request for enrollment;(B) send a copy to the individual or LAR and to the DSA of:(i) the enrollment IPC;(ii) the PAS/HAB Plan;(iii) the enrollment IPPs;(iv) the HHSC IPP Addendum form;(v) a service backup plan, if required by §259.65(a)(1)(H) of this division; and(vi) the individual transportation plan, if required by §259.65(a)(1)(I) of this division; and(C) if the individual will receive a service through the CDS option, send the FMSA a copy of the:(i) enrollment IPC;(ii) the PAS/HAB plan;(iii) the enrollment IPPs;(iv) the HHSC IPP Addendum form;(v) a service backup plan, if required by §259.65(a)(1)(H) of this division; and(vi) the individual transportation plan, if required by §259.65(a)(1)(I) of this division.(d) If HHSC determines that a proposed enrollment IPC does not meet the requirements described in subsection (a)(1) of this section, HHSC:(1) notifies the individual's CMA and DSA of such determination;(2) sends written notice to the individual or LAR that the individual's request for enrollment is denied; and(3) includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this subchapter (relating to Individual's Right to a Fair Hearing).(e) If HHSC determines that a proposed enrollment IPC meets the requirement described in subsection (a)(1) of this section, but one or more of the CLASS Program services or CFC services specified in the IPC does not meet the requirements described in subsection (a)(2) of this section, HHSC:(1) denies a CLASS Program service or CFC service;(2) modifies and approves the proposed enrollment IPC;(3) approves the individual's request for enrollment with the modified IPC; and(4) notifies the individual's CMA, in writing, of the action taken.(f) If HHSC notifies a CMA that an individual's request for enrollment into the CLASS Program is approved, but action is being taken by HHSC to deny a CLASS Program service or CFC service and modify the proposed enrollment IPC, as described in subsection (e) of this section, the CMA must comply with §259.155(c) of this chapter (relating to Denial of a CLASS Program Service or CFC Service).(g) If HHSC approves an individual's request for enrollment, a CMA and DSA must:(1) electronically access MESAV to determine if the information on an enrollment IPC or modified enrollment IPC is consistent with the information in MESAV;(2) if the information on the enrollment IPC or modified enrollment IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and(3) implement the enrollment IPC or modified enrollment IPC no later than seven calendar days after the effective date of the IPC. Source Note: The provisions of this §259.69 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.69 HHSC's Review of a Proposed Enrollment IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212127 03/12/2026 (a) During the initial in-person visit with an individual and LAR or actively involved person, as described in §259.61(a)(2) of this division (related to Process for Enrollment of an Individual), and annually thereafter, the CMA must ensure that the individual's case manager informs the individual and LAR or actively involved person of:(1) the CDS option in accordance with 40 TAC Chapter 41, Subchapter D (relating to Enrollment, Transfer, Suspension, and Termination); and(2) the CLASS Program services and CFC service provided through the CDS option, described in 40 TAC §41.108 (relating to Services Available Through the CDS Option).(b) If an individual or LAR chooses to participate in the CDS option, the case manager must:(1) use the list of FMSAs found on the HHSC website to provide the name and contact information to the individual or LAR of each FMSA providing services in the catchment area in which the individual lives;(2) document the individual's or LAR's choice of FMSA in accordance with HHSC's instructions;(3) document each service to be provided through the CDS option on the IPC;(4) if the only service to be provided through the CDS option is CFC PAS/HAB, include on the IPC:(A) CFC FMS instead of FMS; and(B) if the individual will receive support consultation, CFC support consultation instead of support consultation; and(5) ensure the individual or LAR completes the required forms as described in 40 TAC Chapter 41, Subchapter D. Source Note: The provisions of this §259.71 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.71 CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212128 03/12/2026 (a) The following limits apply to an individual's services:(1) for adaptive aids and dental treatment, a maximum combined cost of $10,000 during an IPC period, which includes the cost of repair and maintenance of an adaptive aid;(2) for minor home modifications:(A) a maximum cost of $10,000 during the time an individual is enrolled in the CLASS Program, which may be paid in one or more IPC periods; and(B) after reaching the $10,000 limit described in subparagraph (A) of this paragraph, a maximum cost of $300 for repair and maintenance during an IPC period;(3) for respite, a maximum of 30 days of in-home respite and out-of-home respite, combined, during an IPC period; and(4) for TAS, a maximum cost of $2,500.(b) An individual may receive TAS only once in the individual's lifetime. Source Note: The provisions of this §259.73 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.73 Service Limits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212129 03/12/2026 (a) A DSA must: (1) ensure that, no more than 120 calendar days before the expiration of an individual's IPC period, an RN must, in accordance with the Community Living Assistance and Support Services Provider Manual: (A) complete with the individual and LAR or actively involved person: (i) the HHSC Related Conditions Eligibility Screening Instrument form; and(ii) the ID/RC Assessment; and (B) meet in person with the individual and LAR or actively involved person at a time and place convenient to the individual to complete a nursing assessment of the individual using the HHSC CLASS/DBMD Nursing Assessment form; (2) submit to HHSC at least 60 calendar days before the expiration of an individual's IPC period:(A) the results of the most current adaptive behavior screening assessment; (B) the completed HHSC Related Conditions Eligibility Screening Instrument form; and (C) the completed ID/RC Assessment; and (3) send the completed HHSC CLASS/DBMD Nursing Assessment form to the CMA. (b) Information on the ID/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments of the individual. (c) HHSC reviews the documentation submitted by a DSA in accordance with subsection (a)(2) of this section to determine whether an individual meets the LOC VIII criteria required by §259.51(a)(2) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services). HHSC notifies the DSA of its determination in accordance with §259.63 of this subchapter (relating to Determination by HHSC of Whether an Individual Meets LOC VIII Criteria). (d) A DSA must ensure an appropriate professional completes an adaptive behavior screening assessment in accordance with the assessment instructions: (1) at least every five years after completion of the most current assessment; and (2) if significant changes that may be permanent occur in the individual's functioning.(e) If an individual's LOC VIII expires before HHSC determines whether the individual meets the LOC VIII criteria, as described in subsection (c) of this section: (1) the CMA and the DSA must continue to provide services to the individual until HHSC authorizes the proposed renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and (2) if HHSC determines that the individual meets the LOC VIII criteria, and the individual is otherwise eligible for the CLASS Program, HHSC will reimburse the CMA and DSA for services provided, as required by paragraph (1) of this subsection, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (a)(2) of this section. Source Note: The provisions of this §259.75 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.75 Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212130 03/12/2026 (a) A renewal IPC is effective for an IPC period.(b) The effective date of a renewal IPC is:(1) for renewal of an enrollment IPC, the first calendar day of the same month of the enrollment IPC's effective date in the following year; or(2) for any other renewal IPC, the first calendar day of the month after the month in which the IPC period expires.(c) A case manager must submit a proposed renewal IPC and obtain authorization from HHSC for the proposed renewal IPC in accordance with §259.79 of this division (relating to Renewal and Revision of an IPC) to continue providing services to an individual after the expiration of:(1) the IPC period of the individual's enrollment IPC; or(2) the IPC period of the individual's renewal IPC. Source Note: The provisions of this §259.77 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.77 Renewal IPC and Requirement for Authorization to Continue Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225003 03/12/2026 (a) Beginning the effective date of an individual's IPC, as determined by §259.65(g) of this subchapter (relating to Development of an Enrollment IPC) or §259.77(b) of this division (relating to Renewal IPC and Requirement for Authorization to Continue Services), a case manager must, in accordance with the Community Living Assistance and Support Services Provider Manual: (1) meet with the individual and LAR in person to conduct an IPP service review meeting at a time and place convenient to the individual and LAR; and (2) at least once during an IPC period, conduct an IPP service review meeting in person with the individual and LAR in the individual's residence. (b) During an IPP service review meeting described in subsection (a) of this section, a case manager must: (1) review the individual's progress toward achieving the goals and outcomes as described on the IPP for each service listed on the individual's IPC; (2) if the individual's IPC includes nursing or CFC PAS/HAB, and any of those services are not identified on the IPC as critical to meeting the individual's health and safety, discuss with the individual or LAR whether the service may now be critical to the individual's health and safety; (3) if a service backup plan has been implemented, discuss the implementation of the service backup plan with the individual or LAR to determine whether or not the plan was effective; (4) if the case manager determines that a service may now be critical to the individual's health and safety, as described in paragraph (2) of this subsection, or that the service backup plan was ineffective, as described in paragraph (3) of this subsection, document the determination for discussion at a service planning team meeting convened in accordance with subsection (c) or (d) of this section; (5) complete the HHSC IPP Service Review form in accordance with the Community Living Assistance and Support Services Provider Manual; and (6) ensure the individual or LAR signs and dates the HHSC IPP Service Review form. (c) No more than 90 calendar days before the end of an individual's current IPC period, the case manager must convene a service planning team meeting in person or by videoconferencing in which: (1) the service planning team: (A) reviews the HHSC CLASS/DBMD Nursing Assessment form completed by an RN as described in §259.75(a)(1)(B) of this division (relating to Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria); (B) addresses any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met; (C) documents on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed; (D) develops a proposed renewal IPC that: (i) documents each CLASS Program service and CFC service, other than CFC support management, to be provided to the individual; (ii) specifies the number of units of each CLASS Program service and CFC service, other than CFC support management, to be provided to the individual; (iii) for each CLASS Program service: (I) is within the service limit described in §259.73 of this subchapter (relating to Service Limits); (II) if an adaptive aid, meets the requirements in Subchapter F, Division 1, of this chapter (relating to Adaptive Aids); and (III) if a minor home modification, meets the requirements in Subchapter F, Division 2, of this chapter (relating to Minor Home Modifications); (iv) for CFC ERS, meets the requirements in Subchapter F, Division 3, of this chapter (relating to CFC ERS); (v) states if the individual will receive CFC support management; (vi) describes any other service or support to be provided to the individual through sources other than CLASS Program services or CFC services; (vii) if the proposed renewal IPC includes nursing or CFC PAS/HAB, identifies whether the service is critical to the individual's health and safety, as required by §259.89(a)(2) of this subchapter (relating to Service Backup Plans); (viii) if the individual chooses to receive services through the CDS option, identifies: (I) the name of the individual's FMSA; and (II) the type and estimated units of each CLASS Program service and CFC service provided through the CDS option; (E) develops a renewal IPP for each CLASS Program service and CFC service listed on the proposed renewal IPC, other than CFC support management, as required by §259.67 of this subchapter (relating to Development of IPPs); (F) develops a new HHSC IPP Addendum form; (G) develops a new PAS/HAB plan based on review of the information obtained from assessments conducted and observations made by a DSA as required by §259.61(h)(2) and (3) of this subchapter; (H) if the proposed renewal IPC identifies nursing or CFC PAS/HAB as critical, develops or revises a service backup plan for the service in accordance with §259.89 of this subchapter; and (I) if transportation as a habilitation activity or as an adaptive aid is included on the proposed renewal IPC, develops a new individual transportation plan; (2) the case manager: (A) provides an oral and written explanation of the following to an individual and LAR or actively involved person: (i) CLASS Program services; (ii) CFC services; (iii) the mandatory participation requirements described in §259.103 of this chapter (relating to Mandatory Participation Requirements of an Individual); (iv) the CDS option described in §259.71 of this subchapter (relating to CDS Option); (v) the right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing); (vi) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to HHSC by calling the toll-free telephone number at 1-800-458-9858; (vii) the process by which the individual, LAR, or actively involved person may file a complaint regarding case management as described in §52.117 of this title (relating to Complaint Process); (viii) that the HHSC Office of the Ombudsman toll-free telephone number at 1-877-787-8999 may be used to file a complaint regarding the CMA; (ix) voter registration, if the individual is 18 years of age or older; and (x) how to contact the individual's case manager; (B) provides an oral explanation to the individual and to the LAR or actively involved person that the individual, LAR, actively involved person may request: (i) that the individual transfer to a different CMA, DSA, or FMSA at any time while enrolled in the CLASS Program; (ii) that the DSA provide transportation as a habilitation activity, out-of-home respite in a camp described in §259.361(b)(2)(D) of this chapter (relating to Respite and Dental Treatment), adaptive aids, nursing, or CFC PAS/HAB while the individual is temporarily staying at a location outside the catchment area in which the individual resides but within the state of Texas for a period of no more than 60 consecutive days; and (iii) that the DSA provide transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB as described in clause (ii) of this subparagraph more than once during an IPC period; (C) uses the HHSC Understanding Program Eligibility - CLASS/DBMD form to provide an oral and written explanation to the individual or LAR, and obtain the individual's or LAR's signature and date on the form, to acknowledge understanding of the following: (i) the eligibility requirements for: (I) CLASS Program services, as described in §259.51(a) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); (II) CFC services for to individuals who do not receive MAO Medicaid, as described in §259.51(b) of this subchapter; and (III) CFC services for individuals who receive MAO Medicaid, as described in §259.51(c) of this subchapter; and (ii) that CLASS Program services or CFC services may be terminated as described in §§259.161, 259.163, 259.165, and 259.167 of this chapter (relating to Termination of CLASS Program Services and CFC Services With Advance Notice for Reasons Other Than Non-compliance with Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services With Advance Notice Because of Non-compliance With Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy; and Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy); (D) gives the individual and the LAR or actively involved person a written list of CMAs and DSAs serving the catchment area in which the individual resides; (E) has the individual or LAR select a CMA and DSA by completing an HHSC Selection Determination form as described in the Community Living Assistance and Support Services Provider Manual; (F) educates the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and (G) documents that the case manager complied with subparagraphs (A) - (F) of this paragraph; and (3) a DSA staff person: (A) provides an oral and written explanation of the following to the individual and LAR or actively involved person: (i) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to HHSC by calling the toll-free telephone number at 1-800-458-9858; (ii) the process by which the individual, LAR, or actively involved person may file a complaint regarding CLASS Program services or CFC services provided by the DSA as required by §52.117 of this title; (iii) that the HHSC toll-free telephone number at 1-800-458-9858 may be used to file a complaint; and (iv) how to contact the DSA; (B) educates the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; and (C) documents that the staff person complied with subparagraphs (A) and (B) of this paragraph. (d) Except as provided in subsection (e) of this section, no later than five business days after becoming aware that an individual's need for a CLASS Program service or CFC service changes, the case manager must: (1) convene a service planning team meeting in person or by videoconferencing in which the service planning team: (A) develops a proposed revised IPC; (B) if the proposed revised IPC includes nursing or CFC PAS/HAB: (i) identifies whether the service is critical to the individual's health and safety, as required by §259.89(a)(2) of this subchapter; and (ii) develops a new or revised service backup plan for the service in accordance with §259.89 of this subchapter; (C) if the IPC is revised because the individual wants to receive a service through the CDS option, identifies on the proposed revised IPC: (i) the name of the individual's FMSA; and (ii) the type and estimated units of each CLASS Program service and CFC service the individual wants to receive through the CDS option; (D) develops any revised IPPs; (E) if the individual's needs have substantially changed, develops a revised HHSC IPP Addendum form; (F) if the IPC needs to be revised to add CFC PAS/HAB or change the amount of CFC PAS/HAB, develops a new or revised PAS/HAB plan; and (G) if transportation as a habilitation activity or as an adaptive aid is included on the proposed revised IPC, develops a new or revised individual transportation plan; and (2) if the individual may need cognitive rehabilitation therapy, assist the individual to obtain an assessment as required by §259.311(h) of this chapter (relating to CMA Service Delivery). (e) If an individual receiving CFC PAS/HAB or the LAR requests CFC support management during an IPC year, the case manager must revise the IPC, as described in the Community Living Assistance and Support Services Provider Manual. (f) A case manager must: (1) ensure that a proposed renewal IPC or proposed revised IPC developed in accordance with subsection (c) or (d) of this section meets the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this subchapter; and (2) ensure that a renewal IPP or revised IPP, developed in accordance with subsection (c) or (d) of this section, is reviewed, signed, and dated as evidence of agreement by: (A) the individual or LAR; (B) the case manager; and (C) the DSA. (g) If an individual or LAR, case manager, and DSA agree on the type and amount of services to be included in a proposed renewal IPC or proposed revised IPC developed in accordance with subsection (c) or (d) of this section, the case manager must: (1) ensure that the proposed renewal IPC or proposed revised IPC is reviewed, signed, and dated as evidence of agreement by: (A) the individual or LAR; (B) the case manager; and (C) the DSA; (2) for a proposed renewal IPC, at least 30 calendar days before the end of the individual's IPC period: (A) submit to HHSC for its review: (i) the signed proposed renewal IPC; (ii) the signed renewal IPPs; (iii) the new HHSC IPP Addendum form; (iv) the new PAS/HAB plan; (v) the completed HHSC CLASS/DBMD Nursing Assessment form provided by the DSA in accordance with §259.75(a)(3) of this division; (vi) the ID/RC Assessment authorized by HHSC; (vii) the HHSC Non-Waiver Services form; (viii) Choice Lists for the CLASS Program; (ix) a service backup plan, if required by subsection (c)(1)(H) of this section; (x) the new individual transportation plan, if required by subsection (c)(1)(I) of this section; (xi) the HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by: (I) §259.255 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500); (II) §259.257 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More); (III) §259.275 of this chapter (relating to Requirements for Authorization to Purchase a Minor Home Modification); and (IV) §259.361 of this chapter; (xii) the HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by: (I) §259.257 of this chapter; and (II) §259.275 of this chapter; (xiii) denial documentation from non-waiver resources, if any; and (xiv) if a skilled or a specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form; (B) send the DSA a copy of: (i) the signed proposed renewal IPC; (ii) the signed renewal IPPs; (iii) the new HHSC IPP Addendum form; (iv) the new PAS/HAB plan, if required by subsection (c)(1)(G) of this section; (v) a service backup plan, if required by subsection (c)(1)(H) of this section; and (vi) the new individual transportation plan, if required by subsection (c)(1)(I) of this section; and (C) if the renewal IPC includes a service through the CDS option, send the FMSA a copy of: (i) the signed proposed renewal IPC; (ii) the signed renewal IPPs; (iii) the new HHSC IPP Addendum form; (iv) the new PAS/HAB plan, if required by subsection (c)(1)(G) of this section; (v) a service backup plan, if required by subsection (c)(1)(H) of this section; and (vi) the new individual transportation plan, if required by subsection (c)(1)(I) of this section; and (3) for a proposed revised IPC, at least 30 calendar days before the effective date of the proposed revised IPC determined by the service planning team: (A) submit to HHSC for its review: (i) the signed proposed revised IPC; (ii) the signed revised IPPs; (iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section; (iv) the HHSC Non-Waiver Services form; (v) the completed HHSC CLASS/DBMD Nursing Assessment form; (vi) a new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section; (vii) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section; (viii) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section; (ix) an HHSC Request for Adaptive Aids, Medical Supplies, Minor Home Modifications or Dental Services/Sedation form, if required by: (I) §259.255 of this chapter; (II) §259.257 of this chapter; (III) §259.275 of this chapter; and (IV) §259.361 of this chapter; (x) an HHSC Specifications for Adaptive Aids/Medical Supplies/Minor Home Modifications form, if required by: (I) §259.257 of this chapter; and (II) §259.275 of this chapter; (xi) denial documentation from non-waiver resources, if any; and (xii) if a skilled or specialized therapy, the HHSC Therapy Justifications - Attachment to IPP form; (B) send the DSA a copy of: (i) the signed proposed revised IPC; (ii) the signed revised IPPs; (iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section; (iv) the new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section; (v) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section; and (vi) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section; and (C) if the revised IPC includes a service through the CDS option, send the FMSA a copy of: (i) the signed proposed revised IPC; (ii) the signed revised IPPs; (iii) the revised HHSC IPP Addendum form, if required by subsection (d)(1)(E) of this section; (iv) the new or revised service backup plan, if required by subsection (d)(1)(B)(ii) of this section; (v) the new or revised PAS/HAB plan, if required by subsection (d)(1)(F) of this section; and (vi) the new or revised individual transportation plan, if required by subsection (d)(1)(G) of this section. (h) If an individual or LAR requests a CLASS Program service or a CFC service that the case manager or DSA has determined does not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) or §259.65(b) of this subchapter, the CMA must, in accordance with the Community Living Assistance and Support Services Provider Manual, send the individual or LAR written notice of the denial or proposed reduction of the requested CLASS Program service, copying the DSA and, if applicable, the FMSA. (i) If a CMA is required to send a written notice of the denial or proposed reduction of a CLASS Program service or CFC service, as described in subsection (h) of this section, the CMA must: (1) at least 30 calendar days before the end of the IPC period, submit to HHSC for its review: (A) a proposed renewal IPC or proposed revised IPC that includes the type and amount of CLASS Program services or CFC services in dispute and not in dispute, and is signed and dated by: (i) the individual or LAR; (ii) the case manager; and (iii) the DSA; (B) the renewal IPPs; (C) the new or revised HHSC IPP Addendum form; (D) the new or revised PAS/HAB plan, if required by subsection (c)(1)(G) or (d)(1)(F) of this section; and (E) the new or revised individual transportation plan, if required by subsection (c)(1)(I) or (d)(1)(G) of this section; and (2) if the individual receives a service through the CDS option, send the FMSA a copy of the documents submitted to HHSC in accordance with paragraph (1) of this subsection. (j) At HHSC's request, a CMA must submit additional documentation supporting a proposed renewal IPC or proposed revised IPC submitted to HHSC no later than 10 calendar days after the date of HHSC's request. (k) If HHSC determines that a proposed renewal IPC or proposed revised IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter and the CLASS Program services and CFC services specified in the IPC meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this subchapter: (1) HHSC notifies the individual's CMA, in writing, that the renewal IPC or revised IPC is authorized; (2) the CMA must send a copy of the authorized renewal or revised IPC to the DSA and, if the individual receives a service though the CDS option, to the FMSA; and (3) the CMA and the DSA must: (A) electronically access MESAV to determine if the information on the renewal or revised IPC is consistent with the information in MESAV; (B) if the information on the renewal or revised IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and (C) initiate CLASS Program services and CFC services for the individual in accordance with the individual's renewal or revised IPC no later than seven calendar days after the CMA receives HHSC's notification. (l) If an individual's IPC period expires before HHSC approves a proposed renewal IPC: (1) a CMA and DSA must continue to provide services to the individual until HHSC authorizes the proposed renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and (2) if HHSC authorizes the proposed renewal IPC as described in subsection (k)(1) of this section, HHSC will reimburse the CMA and DSA for services provided, as required by paragraph (1) of this subsection, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (i)(2) of this section from the DSA. (m) The process by which an individual's CLASS Program services or CFC services are terminated or denied based on HHSC's review of a proposed renewal IPC or proposed revised IPC is described in §259.83(c) - (e) of this division (relating to Utilization Review of an IPC by HHSC). (n) The IPC period of a revised IPC is the same IPC period as the enrollment IPC or renewal IPC being revised. Source Note: The provisions of this §259.79 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.79 Renewal and Revision of an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212132 03/12/2026 (a) If a DSA provides nursing, respite, an adaptive aid, dental treatment, or CFC PAS/HAB to an individual that is not included on the individual's IPC in accordance with §259.359(b) of this chapter (relating to DSA: Service Delivery), the DSA, must, no later than seven calendar days after providing the service, submit to the CMA:(1) documentation describing the circumstances necessitating the provision of the new service or the increase in the amount of the existing service; and(2) documentation by an RN of the RN's determination that the service was necessary to prevent the individual's health and safety from being placed in immediate jeopardy as required by §259.359(b) of this chapter.(b) No later than seven calendar days after the date a CMA receives the documentation described in subsection (a) of this section, the CMA must:(1) based on the documentation, develop a proposed revised IPC and a revised IPP; and(2) submit the proposed revised IPC, revised IPP, and documentation to HHSC.(c) HHSC authorizes a proposed revised IPC submitted in accordance with subsection (b) of this section only if, after reviewing the documentation described in subsection (a) of this section, it determines that the service was necessary to prevent an individual's health and safety from being placed in immediate jeopardy. At HHSC's request, a CMA must submit additional documentation supporting the proposed revised IPC to HHSC within 10 calendar days after HHSC's request.(d) If HHSC does not authorize a proposed revised IPC submitted in accordance with subsection (b) of this section, HHSC does not pay the DSA for the service provided. Source Note: The provisions of this §259.81 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.81 Revised IPC and Revised IPP for Services Provided to Prevent Immediate Jeopardy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212133 03/12/2026 (a) At HHSC's discretion, HHSC conducts a utilization review of an IPC to determine if:(1) the IPC cost is at or below the amount in §259.51(a)(4) of this subchapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); and(2) the CLASS Program services and CFC services specified in the IPC meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this subchapter (relating to Development of an Enrollment IPC).(b) If requested by HHSC, a program provider must submit documentation supporting an IPC to HHSC no later than 10 calendar days after HHSC's request.(c) If HHSC determines that an IPC does not have an IPC cost at or below the amount in §259.51(a)(4) of this subchapter, HHSC notifies the individual's CMA and DSA of such determination and sends written notice to the individual or LAR that the individual's CLASS Program services and CFC services are proposed for termination and includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing).(d) HHSC denies or proposes reduction of a CLASS Program service or CFC service if HHSC determines that an IPC has an IPC cost at or below the amount in §259.51(a)(4) of this subchapter but one or more of the CLASS Program services or CFC services specified in the IPC do not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this subchapter.(e) If HHSC denies or proposes reduction of a CLASS Program service or CFC service, as described in subsection (d) of this section, HHSC:(1) modifies and authorizes the IPC; and(2) notifies the individual's CMA, in writing, of the action taken.(f) If HHSC notifies a CMA of the denial or proposed reduction of an individual's CLASS Program services or CFC services and of the IPC modified in accordance with subsection (e) of this section:(1) for a denial of a CLASS Program service or CFC service:(A) the CMA must comply with §259.155(c) of this chapter (relating to Denial of a CLASS Program Service or CFC Service); and(B) the CMA and DSA must comply with §259.155(d) of this chapter; or(2) for a proposed reduction of a CLASS Program service or CFC service:(A) the CMA must comply with §259.159(c) and (e) of this chapter (relating to Reduction of a CLASS Program Service or CFC Service); and(B) the DSA must comply with §259.159(d) and (e) of this chapter.(g) The IPC period of an enrollment IPC or a renewal IPC modified by HHSC in accordance with subsection (e) of this section does not change as a result of HHSC's modification. Source Note: The provisions of this §259.83 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.83 Utilization Review of an IPC by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212134 03/12/2026 (a) A DSA must have and implement written policies and procedures to ensure compliance with §259.75(a)(2) and (3) of this division (relating to Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria).(b) A DSA's written policies and procedures must include using a written or electronic tracking system that alerts the DSA to activities that must occur for the DSA to timely submit documentation to HHSC as required by §259.75(a)(2) of this division. Source Note: The provisions of this §259.85 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.85 Tracking Annual Renewal of an ID/RC Assessment by a DSA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212135 03/12/2026 (a) A CMA must have and implement written policies and procedures to ensure compliance with §259.79(g)(2)(A) of this division (relating to Renewal and Revision of an IPC).(b) A CMA's written policies and procedures must include using a written or electronic tracking system that alerts the CMA to activities that must occur for the CMA to timely submit documentation to HHSC as required by §259.79(g)(2)(A) of this division. Source Note: The provisions of this §259.87 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.87 Tracking Annual Renewal of an IPC by a CMA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212136 03/12/2026 (a) If an individual's IPC includes nursing or CFC PAS/HAB, the case manager must ensure that:(1) the service planning team determines whether nursing or CFC PAS/HAB is critical to the individual's health and safety;(2) the individual's IPC identifies whether nursing or CFC PAS/HAB is critical to the individual's health and safety; and(3) the service planning team develops a service backup plan for each service identified as critical using the HHSC Provider Agency Model Service Backup Plan form, unless the service will be provided through the CDS option.(b) A case manager must ensure that:(1) a service backup plan developed in accordance with subsection (a)(3) of this section addresses any risk that might exist to the health and safety of the individual; and(2) if an action listed in the service backup plan includes the use of a natural support, the natural support receives pertinent information about the individual's needs and is able to protect the individual's health and safety.(c) If a service backup plan is implemented, a DSA must:(1) discuss the implementation of the service backup plan with the individual and the service providers or natural supports identified in the service backup plan to determine whether or not the plan was effective;(2) document whether or not the plan was effective; and(3) revise the plan with input from the service planning team if the DSA determines the plan was ineffective.(d) Requirements for developing a service backup plan for an individual receiving nursing or CFC PAS/HAB through the CDS option are described in 40 TAC §41.217 (relating to Employer Responsibilities Regarding Service Backup Plan). Source Note: The provisions of this §259.89 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §259.89 Service Backup Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212137 03/12/2026 An individual is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), if:(1) the individual's request for enrollment into the CLASS Program is denied or is not acted upon with reasonable promptness; or(2) the individual's CLASS Program services or CFC services have been denied, suspended, reduced, or terminated by HHSC. Source Note: The provisions of this §259.101 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES C RIGHTS AND RESPONSIBILITIES OF AN INDIVIDUAL §259.101 Individual's Right to a Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212138 03/12/2026 An individual or LAR must comply with the following mandatory participation requirements:(1) completing and submitting an application for Medicaid financial eligibility to HHSC no later than 30 calendar days after the case manager's initial in-person visit described in §259.61(a)(2) of this chapter (relating to Process for Enrollment of an Individual) or within another time frame permitted by §259.61(c) of this chapter;(2) participating on the service planning team to:(A) develop an enrollment IPC and an enrollment IPP, as described in §259.65 of this chapter (relating to Development of an Enrollment IPC) and §259.67 of this chapter (relating to Development of IPPs); and(B) develop renewal and revised IPC and IPPs, as described in §259.79 of this chapter (relating to Renewal and Revision of an IPC);(3) reviewing, agreeing to, signing, and dating an IPC and IPPs in accordance with §259.65 of this chapter, §259.67(c) of this chapter, and §259.79 of this chapter;(4) cooperating with the CMA and DSA in the delivery of CLASS Program services or CFC services listed on the individual's IPC, including:(A) working with the CMA and DSA to schedule meetings;(B) attending a scheduled meeting with the case manager or a service provider;(C) being available to receive CLASS Program services and CFC services;(D) notifying the CMA or DSA in advance if the individual or LAR is unable to attend a scheduled meeting or is unavailable to receive services in the individual's residence; and(E) admitting CMA and DSA representatives to the individual's residence for a scheduled meeting or to receive CLASS Program services or CFC services;(5) cooperating with the DSA's service providers to ensure progress toward achieving the goals and outcomes described in the IPP for each CLASS Program service or CFC service listed on the IPC;(6) if found by HHSC to be financially eligible for CLASS Program services based on the special institutional income limit, paying the required co-payment in a timely manner;(7) notifying the CMA and DSA if the individual receives notice from HHSC of a change in the status of the individual's financial eligibility for Medicaid;(8) not engaging in criminal behavior in the presence of the case manager or a service provider;(9) not permitting a person present in the individual's residence to engage in criminal behavior in the presence of a service provider or the case manager;(10) not engaging in a pattern of harassment of the case manager or a service provider that interferes with the ability to provide CLASS Program services or CFC services;(11) not acting in a manner that is threatening to the health and safety of the case manager or a service provider;(12) not permitting a person present in the individual's residence to:(A) engage in a pattern of harassment of the case manager or a service provider that interferes with the ability to provide CLASS Program services or CFC services; or(B) act in a manner that is threatening to the health and safety of the case manager or a service provider;(13) in accordance with §259.167 of this chapter (relating to Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy), not exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of the case manager or a service provider in immediate jeopardy;(14) not initiating or participating in fraudulent health care practices;(15) not engaging in behavior that endangers the individual's health or safety; and(16) not permitting a person present in the individual's residence to engage in behavior that endangers the individual's health or safety. Source Note: The provisions of this §259.103 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES C RIGHTS AND RESPONSIBILITIES OF AN INDIVIDUAL §259.103 Mandatory Participation Requirements of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212157 03/12/2026 (a) If a case manager receives a request from an individual or LAR to transfer to another CMA or DSA or receives notice from HHSC that an individual has requested to transfer to another CMA or DSA, the case manager must: (1) document in the individual's record the date the case manager received the request or notice to transfer; (2) give the individual and LAR a written list of CMAs and DSAs serving the catchment area in which the individual resides;(3) have the individual or LAR select a CMA or DSA by completing an HHSC Selection Determination form; and(4) within three business days, make transfer arrangements in accordance with the Community Living Assistance and Support Services Provider Manual with: (A) the individual or LAR; and (B) the receiving CMA or DSA. (b) A case manager must establish an effective date for an individual's transfer to another CMA or DSA that: (1) is at least 14 calendar days after the date the case manager receives the request or notice described in subsection (a) of this section; and (2) is agreed to by the current CMA, the individual or LAR, and the receiving CMA or DSA. (c) If an individual is transferring to another DSA, the case manager must obtain the number of service units to be transferred for each service on the individual's current IPC from the transferring DSA. (d) A current case manager must submit the following completed documents to HHSC before the effective date of a transfer to another CMA or DSA: (1) the individual's current IPC; (2) the HHSC IPC Service Delivery Transfer Worksheet form; and (3) the HHSC Selection Determination form. (e) The IPC period of an enrollment IPC or renewal IPC does not change when an individual transfers to another CMA or DSA. (f) If a case manager receives a request from an individual or LAR to transfer to another FMSA or receives notice from HHSC that an individual has requested to transfer to another FMSA, the case manager must: (1) give the individual and LAR a written list of FMSAs serving the county in which the individual resides;(2) have the individual or LAR select an FMSA from the list described in paragraph (1) of this subsection; and (3) comply with 40 TAC §41.403(c) (relating to Transfer Process). Source Note: The provisions of this §259.151 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.151 Coordination of Transfers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212158 03/12/2026 (a) HHSC denies an individual's request for enrollment into the CLASS Program if:(1) the individual does not meet the eligibility criteria described in §259.51 of this chapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); or(2) the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS Program services or CFC services to the individual because they have determined that they cannot ensure the individual's health and safety.(b) If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the CLASS Program and includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). HHSC sends a copy of the written notice to the individual's DSA, CMA, and if selected, FMSA. Source Note: The provisions of this §259.153 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.153 Denial of a Request for Enrollment into the CLASS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212159 03/12/2026 (a) HHSC denies a CLASS Program service or CFC service on an individual's IPC, based on a review described in §259.69 of this chapter (relating to HHSC's Review of a Proposed Enrollment IPC), §259.79 of this chapter (relating to Renewal and Revision of an IPC), or §259.83 of this chapter (relating to Utilization Review of an IPC by HHSC), if HHSC determines that the CLASS Program service or CFC service does not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this chapter (relating to Development of an Enrollment IPC). (b) If HHSC denies a CLASS Program service or CFC service on an individual's IPC, HHSC modifies the IPC and notifies the individual's CMA, in writing, of the denial. (c) If a CMA receives a written notice from HHSC denying a CLASS Program service or CFC service, the CMA must: (1) send a copy of the modified IPC to the DSA and, if the individual receives a service through the CDS option, to the FMSA; (2) in accordance with the Community Living Assistance and Support Services Provider Manual, send written notice to the individual or LAR of the denial of the service, copying the individual's DSA and, if the individual receives a service through the CDS option, the FMSA; and (3) include in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). (d) A CMA and DSA must: (1) electronically access MESAV to determine if the information on the modified IPC is consistent with the information in MESAV; (2) if the information on the modified IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and (3) implement the modified IPC. Source Note: The provisions of this §259.155 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.155 Denial of a CLASS Program Service or CFC Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212160 03/12/2026 (a) HHSC suspends an individual's CLASS Program services or CFC services if the individual:(1) is admitted to one of the following facilities:(A) an ICF/IID, unless the individual is receiving out-of-home respite in the facility in accordance with §259.361 of this chapter (relating to Respite and Dental Treatment);(B) a nursing facility, unless the individual is receiving out-of-home respite in the facility in accordance with §259.361 of this chapter;(C) an ALF;(D) a residential child-care facility, unless it is an agency foster home;(E) a hospital;(F) a mental health facility;(G) an inpatient chemical dependency treatment facility;(H) a residential facility operated by the Texas Workforce Commission;(I) a residential facility operated by the Texas Juvenile Justice Department;(J) a jail; or(K) a prison; or(2) leaves the state.(b) HHSC suspends services during the time that an individual is admitted to a facility or that the individual spends outside the state but is limited to 180 consecutive calendar days, unless HHSC approves an extension in accordance with subsection (g) of this section.(c) Within two business days after a CMA becomes aware that an individual has been admitted to a facility or has left the state as described in subsection (a) of this section, the CMA must submit a written request that HHSC suspend the individual's services.(d) If HHSC suspends an individual's services, HHSC sends a written notice to the CMA that includes the effective date of the suspension and the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing).(e) Within two business days after a CMA receives a notice described in subsection (d) of this section, the CMA must send the notice to the individual or LAR and, if applicable, to the FMSA.(f) HHSC may approve one or more 30-calendar-day extensions of a suspension if extenuating circumstances exist and the individual anticipates resuming participation in the CLASS Program during the extension.(g) To request an extension described in subsection (f) of this section, a CMA must:(1) submit the request in writing to HHSC; and(2) include documentation of the extenuating circumstances.(h) During the time HHSC suspends an individual's services, as described in subsection (b) of this section, the individual is not considered to be residing in a facility listed in subsection (a)(1) of this section or out of the state. Source Note: The provisions of this §259.157 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.157 Suspension of CLASS Program Services or CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212161 03/12/2026 (a) HHSC reduces a CLASS Program service or CFC service on an individual's IPC, based on a review described in §259.79 of this chapter (relating to Renewal and Revision of an IPC) or §259.83 of this chapter (relating to Utilization Review of an IPC by HHSC), if HHSC determines that the CLASS Program service or CFC service on the IPC does not meet the requirements described in §259.65(a)(1)(E)(iii) or (iv) and §259.65(b) of this chapter (relating to Development of an Enrollment IPC). (b) If HHSC proposes to reduce a CLASS Program service or CFC service on the individual's IPC, HHSC modifies the IPC and notifies the individual's CMA, in writing, of the proposed reduction. (c) After receiving a written notice from HHSC proposing to reduce a CLASS Program service or CFC service, a CMA must: (1) in accordance with the Community Living Assistance and Support Services Provider Manual: (A) send written notice to the individual or LAR of the proposal to reduce the service, copying the individual's DSA and, if the individual receives a service through the CDS option, the FMSA; (B) include with the written notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing); and(C) give the individual or LAR 10 calendar days to respond to the written notice before taking any action to reduce the service; and(2) send a copy of the modified IPC to the DSA and, if the individual receives a service through the CDS option, to the FMSA. (d) If the individual or LAR requests a fair hearing before the effective date of the reduction of a CLASS Program service or CFC service, as specified in the written notice, the modified IPC described in subsection (b) of this section may not be implemented and the DSA must provide the service to the individual in the amount authorized in the prior IPC while the appeal is pending. (e) If an individual or LAR does not request a fair hearing before the effective date of the reduction of a CLASS Program service or CFC service, a CMA and DSA must: (1) electronically access MESAV to determine if the information on the modified IPC is consistent with the information in MESAV; (2) if the information on the modified IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and (3) implement the modified IPC. Source Note: The provisions of this §259.159 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.159 Reduction of a CLASS Program Service or CFC Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212162 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212162 03/12/2026 (a) HHSC terminates an individual's CLASS Program services and CFC services if: (1) the individual does not meet the eligibility criteria described in §259.51 of this chapter (relating to Eligibility Criteria for CLASS Program Services and CFC Services); (2) the individual is admitted to one of the facilities listed in §259.157(a)(1) of this subchapter (relating to Suspension of CLASS Program Services or CFC Services) for more than 180 consecutive calendar days or beyond an extension of the individual's suspension that HHSC approved in accordance with §259.157(f) of this subchapter; (3) the individual leaves the state for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension in accordance with §259.157(f) of this subchapter; or (4) the DSAs serving the catchment area in which the individual resides are not willing to provide CLASS Program services or CFC services to the individual because they have determined that they cannot ensure the individual's health and safety. (b) No later than two business days after a CMA becomes aware that a situation described in subsection (a) of this section exists, the CMA must:(1) send a written request to HHSC to terminate CLASS Program services and CFC services for the individual; (2) send written supporting documentation with the request; and(3) if the reason for the requested termination of services is for the reason described in subsection (a)(4) of this section, include in the written supporting documentation the specific reasons the DSAs have determined that they cannot ensure the individual's health and safety. (c) Except as provided in subsection (e) of this section, HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS program services and CFC services. (d) After receiving a written notice from HHSC authorizing the proposed termination of CLASS Program services and CFC services, a CMA must, in accordance with the Community Living Assistance and Support Services Provider Manual: (1) send written notice of the proposed termination of services to the individual or LAR within two business days, copying the individual's DSA and, if the individual is receiving a service through the CDS option, to the FMSA; and(2) include in the written notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). (e) If the reason for the proposed termination of CLASS Program services and CFC services is based on an individual not meeting the eligibility criteria described in §259.51(a)(4) of this chapter and HHSC approves the proposed termination, HHSC:(1) sends written notice to the individual or LAR of the proposal to terminate CLASS Program services and CFC services, copying the written notice to the individual's DSA, CMA, and, if the individual is receiving a service through the CDS option, to the FMSA; (2) includes in the notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter; and(3) sends a copy of the written notice to the individual's DSA, CMA, and, if the individual is receiving a service through the CDS option, to the FMSA. (f) If an individual or LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must provide services to the individual in the amounts authorized in the IPC while the appeal is pending. Source Note: The provisions of this §259.161 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.161 Termination of CLASS Program Services and CFC Services with Advance Notice for Reasons Other Than Non-compliance with Mandatory Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212163 03/12/2026 (a) HHSC may terminate an individual's CLASS Program services and CFC services if the individual refuses to comply with a mandatory participation requirement described in §259.103 of this chapter (relating to Mandatory Participation Requirements of an Individual). (b) If a CMA becomes aware that an individual has not complied with a mandatory participation requirement described in §259.103 of this chapter, the CMA must immediately attempt to resolve the situation, including facilitating at least one in-person meeting between: (1) the individual or LAR; (2) a representative from the CMA; and (3) a representative from the DSA. (c) If, after making attempts to resolve the situation as required by subsection (b) of this section, a CMA determines that the situation cannot be resolved, the CMA must request, in writing, that HHSC terminate CLASS Program services and CFC services for the individual. The request must be sent to HHSC no later than two business days after the CMA's determination that the situation cannot be resolved and be supported by written documentation. The written documentation must include a description of: (1) the situation that resulted in the request to terminate CLASS Program services and CFC services; and (2) the attempts by the CMA and DSA to resolve the situation, including in-person meetings with the individual or LAR. (d) HHSC notifies the individual's CMA, in writing, of whether it authorizes the proposed termination of CLASS Program services and CFC services. (e) After receiving a written notice from HHSC authorizing the proposed termination of CLASS Program services and CFC services, a CMA must, in accordance with the Community Living Assistance and Support Services Provider Manual: (1) send written notice of the proposed termination of services to the individual or LAR within two business days, copying the individual's DSA and, if selected, FMSA; and(2) include in the written notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). (f) If an individual or LAR requests a fair hearing before the effective date of the termination of CLASS Program services and CFC services, as specified in the written notice, the DSA must provide the services to the individual in the amounts authorized in the IPC while the appeal is pending. Source Note: The provisions of this §259.163 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.163 Termination of CLASS Program Services and CFC Services with Advance Notice Because of Non-compliance with Mandatory Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212164 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212164 03/12/2026 (a) HHSC terminates an individual's CLASS Program services and CFC services if: (1) the CMA or DSA has factual information confirming the death of the individual; (2) the CMA or DSA receives a clear written statement signed by the individual that the individual no longer wishes to receive CLASS Program services and CFC services; (3) the individual's whereabouts are unknown, and the post office returns mail directed to the individual by the CMA or DSA, indicating no forwarding address; or (4) the CMA or DSA establishes that the individual has been accepted for Medicaid services by another state. (b) Within two business days after a CMA becomes aware that a situation described in subsection (a) of this section exists, the CMA must send a written request to HHSC to terminate CLASS Program services and CFC services for the individual. The written request to HHSC must include documentation supporting the request. (c) HHSC notifies an individual's CMA, in writing, of whether it authorizes the termination of CLASS Program services and CFC services for the individual. (d) After receiving a written notice from HHSC authorizing the termination of CLASS Program services and CFC services, a CMA must, in accordance with the Community Living Assistance and Support Services Provider Manual: (1) send written notice to the individual or LAR of the proposed termination, copying the individual's DSA and, if the individual is receiving a service through the CDS option, the FMSA; and(2) include with the written notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). Source Note: The provisions of this §259.165 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.165 Termination of CLASS Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212165 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212165 03/12/2026 (a) HHSC may terminate an individual's CLASS Program services and CFC services if the individual or a person in the individual's residence exhibits behavior that places the health and safety of the CMA's case manager or the DSA's service provider in immediate jeopardy.(b) If a CMA or DSA becomes aware that a situation described in subsection (a) of this section exists, the CMA or DSA must:(1) immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS; and(2) notify the CMA or DSA, as appropriate, and HHSC by telephone of the situation no later than the business day after the day the CMA or DSA becomes aware of the situation.(c) A CMA must, working with an individual's DSA, attempt to resolve the situation.(d) If, after making attempts to resolve the situation as required by subsection (c) of this section, a CMA determines that the situation cannot be resolved, the CMA must request, in writing, that HHSC terminate CLASS Program services and CFC services for the individual. The request must be sent to HHSC no later than two business days after HHSC was notified of the situation by the CMA or DSA and be supported by written documentation.(e) A CMA must include in the written documentation required by subsection (d) of this section:(1) a description of the situation that resulted in the request to terminate the individual's CLASS Program services and CFC services;(2) a detailed description of the attempts by the CMA to resolve the situation; and(3) if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.(f) HHSC notifies the individual's CMA and DSA, in writing, of whether it authorizes the termination of CLASS Program services and CFC services.(g) Upon receipt of a written notice from HHSC authorizing the termination of CLASS Program services and CFC services, a CMA must:(1) no later than the date of the termination of services, send written notice to the individual or LAR of the termination of services, copying the DSA and, if the individual receives a service through the CDS option, the FMSA; and(2) include in the written notice the individual's right to request a fair hearing in accordance with §259.101 of this chapter (relating to Individual's Right to a Fair Hearing). Source Note: The provisions of this §259.167 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.167 Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212166 03/12/2026 If an individual's CLASS Program services and CFC services are terminated in accordance with §§259.161, 259.163, 259.165, or 259.167 of this chapter (relating to Termination of CLASS Program Services and CFC Services With Advance Notice for Reasons Other Than Non-compliance with Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services With Advance Notice Because of Non-compliance With Mandatory Participation Requirements; Termination of CLASS Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy; and Termination of CLASS Program Services and CFC Services Without Advance Notice Because of Behavior Causing Immediate Jeopardy), the case manager must inform the individual of:(1) alternative long-term services and supports in the community, including CFC services available through a managed care organization; and(2) institutional services. Source Note: The provisions of this §259.169 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.169 Information About Services After Termination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212167 03/12/2026 (a) When HHSC receives a request for a fair hearing from an individual or LAR, HHSC sends a copy of the request to the individual's CMA. (b) A CMA must, no later than one business day after receiving an individual's request for a fair hearing from HHSC, submit a completed HHSC Fair Hearing Request Summary form, as described in the Community Living Assistance and Support Services Provider Manual, to HHSC. Source Note: The provisions of this §259.171 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D TRANSFER, DENIAL, SUSPENSION, REDUCTION, AND TERMINATION OF SERVICES §259.171 Requirement to Submit a Fair Hearing Request Summary to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212150 03/12/2026 In this subchapter:(1) a support family agency is the entity that contracts with HHSC to provide SFS in accordance with 40 TAC Chapter 49 (relating to Contracting for Community Services); and(2) a continued family agency is the entity that contracts with HHSC to provide CFS in accordance with 40 TAC Chapter 49. Source Note: The provisions of this §259.201 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.201 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212151 03/12/2026 (a) To receive SFS, an individual must be under 18 years of age.(b) To receive CFS, an individual must:(1) be 18 years of age or older;(2) reside with a support family; and(3) receive SFS immediately before receiving CFS.(c) An individual who receives SFS or CFS must not receive:(1) CFC PAS/HAB;(2) CFC ERS; or(3) transportation as a habilitation activity or as an adaptive aid. Source Note: The provisions of this §259.203 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.203 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212153 03/12/2026 (a) During a service planning team meeting to develop an enrollment, a revised, or a renewal IPC and IPP, a case manager must inform an individual or LAR of the following if the individual is interested in receiving SFS or CFS:(1) that if the individual or LAR selects SFS or CFS, the individual or LAR will be responsible for paying room and board in accordance with a residential agreement described in subsections (b) and (c) of this section;(2) that if the individual or LAR does not pay room or board as required by a residential agreement, the individual's support family may evict the individual in accordance with the residential agreement and state law; and(3) that if the individual is evicted by a support family and the individual or LAR has not paid the delinquent room or board, HHSC will deny the individual SFS or CFS until the individual or LAR pays the delinquent room or board.(b) An individual's support family agency or continued family agency must ensure that an individual receiving SFS or CFS has a written residential agreement with the support family.(c) The residential agreement required by subsection (b) of this section must include:(1) the physical address of the residence;(2) the name of the individual;(3) the name of the support family;(4) the beginning date of the residential agreement;(5) the date the residential agreement expires;(6) a provision that:(A) the support family and the individual or LAR agree that the residential agreement is a "lease," as defined in Texas Property Code Chapter 92 and that they are subject to state law governing residential tenancies, including Texas Property Code Chapters 24, 91, and 92 and Texas Rules of Civil Procedure Rule 510; and(B) to the extent allowed by law, in the event of a conflict or inconsistency between any provision of the residential agreement and any provision of state statutory law, including Texas Property Code Chapters 91 and 92, the provision in the residential agreement governs;(C) the individual or LAR is not waiving any right or remedy provided to tenants under state law, including the Texas Fair Housing Act in Texas Property Code Chapter 301, and is not agreeing to any notice period that is shorter than the notice period to which tenants are entitled under state law;(D) allows the individual or LAR to terminate the residential agreement before its expiration date without any obligation under the residential agreement except an obligation that accrued before the date of termination, if the individual permanently moves from the residence for any reason, including transferring to a different support family agency or continued family agency;(E) the support family agrees to refund to the individual or LAR an amount for room and board paid to the support family for the days that the individual was away from the residence because the individual permanently moved from the residence using the following formula to determine the daily amount for room and board (the monthly amount for room and board divided by the number of days in the month);(F) the individual may furnish and decorate the individual's bedroom;(G) the support family agrees to be responsible for all repairs to the residence of the support family, including the support family's real property or personal property, resulting from normal wear and tear, as defined in Texas Property Code §92.001;(H) that allows eviction of the individual only if:(i) the individual or LAR fails to pay room or board, which does not include any late fee; or(ii) the individual's CLASS Program services are terminated;(I) the support family will, before giving the individual or LAR a notice to vacate, give the individual or LAR a notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room or board;(J) if the individual or LAR pays the delinquent room or board within the period required by subparagraph (I) of this paragraph, the support family will not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual; and(K) the support family will not accelerate the entire balance of the unpaid room or board owed under the remainder of the term of the residential agreement if the individual or LAR violates the residential agreement and the violation does not result in an eviction;(7) the amount the individual or LAR is paying for room and board;(8) the day of the month that the amount for room and board is due, which will not be before the day of the month that an individual receives a primary source of income, such as supplemental security income and social security disability insurance;(9) the amount of a late fee, if any, which may be charged only once per month and will not exceed 10 percent of the amount for room and board, that the support family may charge the individual or LAR if room and board is not paid by the third day after it is due;(10) the signature of the support family; and(11) the signature of the individual or the LAR.(d) A support family must:(1) give the individual or LAR at least three calendar days to review, request changes, and sign the residential agreement;(2) ensure the residential agreement is fully executed before the individual begins living in a residence in which SFS or CFS is provided, except that an individual may begin living in one of these residences before a residential agreement is fully executed in the event of an emergency;(3) if an individual begins living in a residence in which SFS or CFS is provided before a residential agreement is fully executed because of an emergency, as allowed by paragraph (2) of this subsection:(A) document the details of the emergency; and(B) ensure the residential agreement is fully executed within seven calendar days after the individual begins living in the residence; and(4) provide one copy of the residential agreement to the individual or LAR within three business days after the date the residential agreement is fully executed.(e) If a support family agency or continued family agency becomes aware that a modification to the provision in the residential agreement that the individual may furnish and decorate the individual's bedroom is needed based on a specific assessed need of the individual, the support family agency or continued family agency must:(1) notify the case manager of the needed modification; and(2) provide the case manager with the information described in subsection (n) of this section as requested by the case manager.(f) If an individual or LAR is delinquent in payment of room or board and the support family wants to evict the individual, the support family agency or continued family agency must:(1) notify the case manager that the individual or LAR is delinquent in the payment of room or board under the residential agreement and that the support family wants to evict the individual;(2) after providing the notification required by paragraph (1) of this subsection, meet with the individual or LAR, including the representative payee if one has been appointed by the Social Security Administration, and the case manager to discuss the alleged non-payment of room or board and options to prevent an eviction; and(3) if the support family intends to proceed to evict the individual at the meeting required by paragraph (2) of this subsection:(A) give the individual or LAR a written notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room or board; and(B) provide the case manager with a copy of the written notice of proposed eviction.(g) If an individual or LAR pays the delinquent room or board within the period required by subsection (f)(3) of this section, the support family must not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual.(h) If an individual or LAR does not pay the delinquent room or board within the period required by subsection (f)(3) of this section, the support family agency or continued family agency:(1) must report the failure to pay to one of the following, as appropriate:(A) the Social Security Administration;(B) the probate court that appointed the individual's guardian; or(C) DFPS as an allegation of the LAR's exploitation or neglect of the individual;(2) must meet with the individual or LAR and the case manager to discuss alternative living settings for the individual; and(3) if the support family wants to proceed to evict the individual, the support family must:(A) give the individual or LAR a written notice to vacate the residence in accordance with the residential agreement and state law; and(B) send a copy of the written notice described in subparagraph (A) of this paragraph to the individual's case manager within one business day after the individual or LAR is given the notice.(i) If an individual is evicted by a support family and the individual or LAR has not paid the delinquent room or board, the case manager must convene a meeting or meetings to update the IPC and IPP as described in §259.79(c) or (d) of this chapter (relating to Renewal and Revision of an IPC). If the individual or LAR wants to keep SFS or CFS on the individual's IPC, the case manager must inform the individual or LAR at the meeting or meetings that HHSC will deny CFS and SFS, if included on the individual's IPC, until the individual pays the delinquent room or board.(j) If a support family evicts an individual who has an LAR and the LAR fails to arrange an alternative living setting for the individual, the support family agency or continued family agency must report the LAR's failure to DFPS as neglect of the individual and notify the case manager that such a report was made.(k) If an individual pays the delinquent room or board, a support family agency or continued family agency must, within one business day after the payment, notify the individual's case manager that the individual is no longer delinquent.(l) In each residence in which a support family agency provides SFS or a continued family agency provides CFS, the support family agency or the continued family agency must ensure that, except as provided in subsection (m) of this section:(1) an individual has privacy in the individual's bedroom;(2) an individual has the option not to share a bedroom with a roommate;(3) an individual sharing a bedroom has a choice of roommates;(4) a lock is installed on the individual's bedroom door at no cost to the individual and that:(A) the lock is operable by the individual; and(B) only the individual, a roommate of the individual, and the support family has keys to the individual's bedroom door;(5) an individual can furnish and decorate the individual's bedroom;(6) while in the residence, an individual has the freedom and support:(A) to control the individual's schedule and activities that are not part of the implementation plan; and(B) to have access to food at any time;(7) an individual may have visitors of the individual's choosing at any time; and(8) the residence is physically accessible and free of hazards to the individual.(m) If a support family agency or continued family agency becomes aware that a modification to a requirement described in subsection (l)(1) - (7) of this section is needed based on a specific assessed need of an individual, the support family agency or continued family agency must:(1) notify the case manager of the needed modification; and(2) provide the case manager with the information described in subsection (n) of this section as requested by the case manager.(n) A case manager must, if notified in accordance with subsection (e)(1) or (m)(1) of this section, convene a service planning team meeting to update the individual's IPP to include the following:(1) a description of the specific and individualized assessed need that justifies the modification;(2) a description of any positive interventions and supports that have been tried but did not work;(3) a description of any less intrusive methods of meeting the need that have been tried but did not work;(4) a description of the condition that is directly proportionate to the specific assessed need;(5) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(6) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(7) the individual's or LAR's signature on the IPP evidencing informed consent to the modification; and(8) the support family agency or continued family agency's assurance that the modification will cause the individual no harm.(o) After the service planning team updates the IPP as required by subsection (n) of this section, the support family may implement the modification.(p) A support family agency or a continued family agency must provide ongoing recruitment, support, training, and monitoring of SFS or CFS, including:(1) ensuring that a support family is available to serve an eligible individual;(2) helping an individual transition from institutional services to SFS;(3) supporting an individual living with a support family to prevent placement breakdown or admission to an institution;(4) providing an alternative support family when an individual's placement with a support family is no longer available or appropriate;(5) establishing a safe and permanent placement for an individual as approved by the service planning team;(6) training the support family to provide the SFS or CFS the service planning team assigns and as documented on the individual's IPC and IPP; and(7) monitoring and reporting to the case manager about the individual's placement, as often as needed but at least monthly, as described in §259.211(4) of this division (relating to Ongoing Support) and §259.213 of this division (relating to Monthly Monitoring). Source Note: The provisions of this §259.205 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.205 Residential Agreements, Requirements for Provider-Controlled Residential Settings, and Support Family Agency and Continued Family Agency Functions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212154 03/12/2026 (a) After receiving a referral from an individual's case manager for SFS or CFS, a support family agency or continued family agency must:(1) meet with the individual and LAR;(2) identify the SFS or CFS individual needs;(3) obtain any evaluations, written records, or other necessary information about the individual;(4) determine the criteria for a support family that will meet the specific needs of the individual;(5) locate a support family; and(6) keep the case manager informed of placement progress.(b) Before placement, a support family agency or continued family agency must:(1) ensure that a support family is verified by a child-placing agency licensed by HHSC;(2) provide orientation, to the support family on the SFS or CFS the support family agency or continued family agency identified the individual will need;(3) introduce the individual and LAR to the support family in person; and(4) obtain the LAR's agreement to the placement.(c) A support family agency or a continued family agency must facilitate the completion of written agreements and authorizations between the individual's LAR, the support family, and the support family agency or continued family agency. The written documents must include:(1) designation of who will participate in decisions about services, including any necessary delegation of authority for decisions by the LAR;(2) a description of how visits between the individual and the LAR will be arranged;(3) designation of who has the authority to make health care decisions for the individual, such as consenting to medical treatment, including any necessary delegation of this authority by the person with the legal responsibility to make health care decisions;(4) preferences agreed upon for:(A) religious issues;(B) cultural practices;(C) problem resolution processes; and(D) the type and amount of involvement by the LAR;(5) plans for routine and emergency communication and information exchange, including both oral and written communication; and(6) documentation of the financial responsibilities of all parties. Source Note: The provisions of this §259.207 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.207 Pre-Placement Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212155 03/12/2026 After completion of the authorizations and agreements described in §259.207(c) of this division (relating to Pre-Placement Activities), a support family, an LAR, and the support family agency or continued family agency must:(1) participate in the service planning team meeting described in §259.65(a)(1) of this chapter (relating to Development of an Enrollment IPC) in which the service planning team:(A) develops a transition plan;(B) includes SFS or CFS on the proposed enrollment IPC; and(C) develops an IPP for SFS or CFS;(2) provide copies of the agreements and authorizations listed in §259.207(c) of this division to the case manager;(3) train the support family to provide SFS or CFS as described on the IPP; and(4) assume the responsibility for moving the individual and the individual's possessions into the support family home. Source Note: The provisions of this §259.209 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.209 Placement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212156 03/12/2026 After an individual is placed with a support family, a support family agency or continued family agency must:(1) provide the support family with information on how to contact the support family agency or continued family agency staff at any time;(2) ensure accurate documentation of service delivery in accordance with the IPC and IPP;(3) assist the support family and the individual in accessing school and preschool services;(4) provide monthly progress notes to the case manager, including monthly summaries of:(A) the activities described in §259.217 of this division (relating to Support Family Duties);(B) socialization activities;(C) the use of non-waiver services; and(D) other services included on the IPP;(5) provide additional training to the support family as identified by the service planning team;(6) participate in the service planning team meetings as requested by the case manager, the LAR, the support family agency, or the DSA; and(7) provide to the case manager documentation of any changes to the agreements or authorizations described in §259.207(c) of this division (relating to Pre-Placement Activities) within seven calendar days after the change occurs. Source Note: The provisions of this §259.211 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.211 Ongoing Support https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212152 03/12/2026 (a) A support family agency or continued family agency must visit a support family's home at least once a month to determine if:(1) placement remains beneficial to the individual;(2) the environment remains healthy and safe; and(3) the rights of the individual are being protected.(b) To ensure that the individual's rights are being protected, during a visit described in subsection (a) of this section, a support family agency or continued family agency must determine if:(1) there is no evidence of abuse, neglect, or exploitation of the individual;(2) the individual participates in community functions;(3) the individual has adequate personal belongings; and(4) there are no restrictions on the individual's personal property, including money.(c) A support family agency or continued family agency must document each monthly visit, including verification of each item listed in subsections (a) and (b) of this section, and submit the documentation to the case manager no later than seven calendar days after the visit.(d) A support family agency or continued family agency must inform the case manager of any changes needed to an individual's IPP no later than five calendar days after the date the support family agency or continued family agency became aware of the need for a change. Source Note: The provisions of this §259.213 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.213 Monthly Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212168 03/12/2026 (a) A support family must be:(1) an agency foster home verified by a child-placing agency licensed by HHSC; and(2) a contractor of the support family agency or continued family agency who places an individual with the support family.(b) A support family must not provide services to more than three unrelated individuals at any one time in their home.(c) A support family must ensure that:(1) an individual participates in age-appropriate community activities; and(2) the support family home environment is healthy and safe for the individual.(d) A support family must provide services in a residence that the support family owns or leases. The residence must be a typical residence in a neighborhood and meet the needs of an individual and LAR. Source Note: The provisions of this §259.215 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.215 Support Family Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212169 03/12/2026 (a) A support family must provide services to an individual as authorized on the individual's IPC and as described on the individual's IPP, including:(1) direct personal assistance with activities of daily living;(2) assistance with meal planning and preparation;(3) assistance with housekeeping;(4) assistance with communication and mobility;(5) reinforcement of behavioral, educational, and therapeutic activities;(6) assistance with medications and the performance of tasks delegated by an RN;(7) supervision for the individual's safety;(8) transportation related to routine family activities; and(9) assistance with participation in community activities.(b) A support family must:(1) allow an individual's family members and friends access to the individual without arbitrary restrictions, unless exceptional conditions are justified by the individual's service planning team, documented on the IPP, and authorized by HHSC;(2) assist a school-age individual in receiving educational services five days a week in a six-hour-per-day program provided by the local school district;(3) ensure that no individual receives educational services at a state supported living center or in a state supported living center educational setting, unless contraindications are documented with justification by the service planning team;(4) ensure that a preschool-age individual receives an early childhood education with appropriate activities and services, including small group and individual play with peers without disabilities, unless contraindications are documented with justification;(5) provide an individual with age-appropriate activities that enhance self-esteem and maximize functional level; and(6) ensure the individual receives medical care prescribed by a physician, including:(A) doctors' appointments;(B) medications;(C) evaluations, therapies, and treatment; and(D) lab work and other medical tests. Source Note: The provisions of this §259.217 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E SUPPORT FAMILY SERVICES AND CONTINUED FAMILY SERVICES §259.217 Support Family Duties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212170 03/12/2026 (a) The only items and services that a DSA may purchase or lease as an adaptive aid are listed in the Community Living Assistance and Support Services Provider Manual. The repair and maintenance of an adaptive aid, not covered by a warranty, are also purchasable as an adaptive aid. (b) A DSA may not purchase or lease, as an adaptive aid, an item or service not listed in the Community Living Assistance and Support Services Provider Manual. (c) An adaptive aid must be the exclusive property of the individual to whom it is provided. Source Note: The provisions of this §259.251 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.251 Items and Services Purchasable as an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212171 03/12/2026 (a) The maximum amount HHSC approves as payment to a DSA for all adaptive aids and dental treatment combined for an individual is $10,000 per IPC period, which includes the cost of repair and maintenance of an adaptive aid. (b) To request authorization for repair and maintenance of an adaptive aid up to $300 per IPC period, a DSA is not required to follow the process described in §259.255 of this division (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500) but must include the amount requested on an individual's IPC as described in §259.65 of this chapter (relating to Development of an Enrollment IPC) or §259.79 of this chapter (relating to Renewal and Revision of an IPC). (c) A DSA must follow the process for requesting authorization to purchase an adaptive aid described in §259.255 of this division if: (1) requesting authorization for repair and maintenance of an adaptive aid in an amount that exceeds the $300 limit described in subsection (b) of this section; or (2) requesting authorization for repair and maintenance of an adaptive aid that is not purchased through the CLASS Program but is identical to an item or service that a DSA may purchase as an adaptive aid listed in the Community Living Assistance and Support Services Provider Manual. Source Note: The provisions of this §259.253 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.253 Authorization Limit for Adaptive Aids and Amount for Repair and Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212172 03/12/2026 (a) To purchase an adaptive aid costing less than $500 for an individual, a CMA must: (1) ensure that the individual's service planning team completes the Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form described in the Community Living Assistance and Support Services Provider Manual, evidencing its agreement that the adaptive aid recommended by the appropriate licensed professional is necessary; (2) no later than 14 calendar days after completing the requirement in paragraph (1) of this subsection, ensure that, in accordance with Subchapter B of this chapter (relating to Eligibility, Enrollment, and Review), the individual's service planning team includes the recommended adaptive aid in: (A) the individual's proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, as applicable; and (B) the individual's IPP; and (3) no later than 14 calendar days after completing the requirement described in paragraph (2) of this subsection, submit to HHSC: (A) the completed HHSC Request for Adaptive Aids, Medical Supplies, and Minor Home Modifications form; (B) the proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC described in paragraph (2)(A) of this subsection, as applicable; and (C) the individual's IPP described in paragraph (2)(B) of this subsection. (b) HHSC reviews the documentation described in subsection (a)(3) of this section and determines whether the proposed IPC is authorized in accordance with §259.69 of this chapter (relating to HHSC's Review of a Proposed Enrollment IPC) or §259.79 of this chapter (relating to Renewal and Revision of an IPC). (c) HHSC notifies a DSA in MESAV of whether the proposed IPC is authorized. HHSC notifies a CMA, in writing, of whether the proposed IPC is authorized. Source Note: The provisions of this §259.255 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.255 Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212173 03/12/2026 (a) To purchase an adaptive aid costing $500 or more for an individual, a CMA must: (1) ensure that the individual or LAR initiates a request for the adaptive aid by completing Part A of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form described in the Community Living Assistance and Support Services Provider Manual; (2) send the partially completed form to the DSA; (3) ensure that the individual's service planning team includes the cost of the specifications for the adaptive aid, as described in §259.259 of this division (relating to Requirements for Specifications for an Adaptive Aid), in: (A) the individual's proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, as applicable; and (B) the individual's IPP; and (4) no later than 14 calendar days after completing the requirements described in paragraph (3) of this subsection, submit to HHSC: (A) the proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC described in paragraph (3)(A) of this subsection, as applicable; and (B) the individual's IPP described in paragraph (3)(B) of this subsection. (b) The cost of the specifications included on an IPC and IPP as required by subsection (a)(3) of this section may not exceed an amount equal to three units of service of behavioral support, occupational therapy, physical therapy, or speech and language pathology, as applicable. (c) HHSC reviews the documentation described in subsection (a)(4) of this section and determines whether the proposed IPC is authorized in accordance with §259.69 of this chapter (relating to HHSC's Review of a Proposed Enrollment IPC) or §259.79 of this chapter (relating to Renewal and Revision of an IPC). (d) HHSC notifies a DSA in MESAV of whether the proposed IPC is authorized. HHSC notifies a CMA, in writing, of whether the proposed IPC is authorized. (e) If HHSC approves the proposed IPC for payment of the specifications, the DSA must: (1) no later than 30 calendar days after the date HHSC approves the IPC, obtain the specifications regarding the adaptive aid in accordance with §259.259 of this division and ensure that Part B of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form is completed; and (2) no later than 60 calendar days after obtaining the specifications: (A) obtain bids from vendors in accordance with §259.261 of this division (relating to Requirements for Bids of an Adaptive Aid); (B) select a vendor from which to purchase the adaptive aid; and (C) complete Part C of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form and send the form to the CMA. (f) A CMA must, no later than 14 calendar days after receipt of the form described in subsection (e)(2)(C) of this section: (1) complete Part D of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form, evidencing that the criteria described in §259.65(b) of this chapter (relating to Development of an Enrollment IPC) are met; (2) ensure that, in accordance with Subchapter B of this chapter (relating to Eligibility, Enrollment, and Review), the individual's service planning team includes the cost of the adaptive aid in: (A) the individual's proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, as applicable; and (B) the individual's IPP; and (3) no later than 14 calendar days after completing the requirement described in paragraph (2) of this subsection, submit to HHSC: (A) the completed HHSC Request for Adaptive Aids, Medical Supplies, and Minor Home Modifications form; (B) the proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC described in paragraph (2)(A) of this subsection, as applicable; (C) the individual's IPP described in paragraph (2)(B) of this subsection; and (D) documentation regarding bids required by §259.261 of this division. (g) HHSC reviews the documentation described in subsection (f)(3) of this section and determines whether the proposed IPC is authorized in accordance with §259.69 or §259.79 of this chapter. (h) HHSC notifies a DSA, in the electronic billing system, of whether the proposed IPC is authorized. HHSC notifies a CMA, in writing, of whether the proposed IPC is authorized. Source Note: The provisions of this §259.257 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.257 Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212174 03/12/2026 (a) If HHSC approves payment for specifications for an adaptive aid costing $500 or more in accordance with §259.257(c) of this division (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More), a DSA must: (1) obtain specifications from a licensed professional required by HHSC for that adaptive aid, as described in the Community Living Assistance and Support Services Provider Manual; and (2) ensure that the specifications: (A) include a complete description of the adaptive aid; and (B) are approved, in writing, by the individual or LAR and the DSA by completing the HHSC Specifications for Adaptive Aids/Minor Home Modifications form described in the Community Living Assistance and Support Services Provider Manual. (b) The DSA must obtain an invoice from the person who develops the specifications, substantiating the cost of the specifications. (c) The DSA must provide a copy of the specifications to an individual's CMA. Source Note: The provisions of this §259.259 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.259 Requirements for Specifications for an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212175 03/12/2026 (a) As required by §259.257(e)(2)(A) of this division (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More), for a recommended adaptive aid costing $500 or more, a DSA must obtain comparable bids for the requested adaptive aid from three vendors. Comparable bids describe the adaptive aid and any associated items or modifications identified in the completed HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form required by §259.257 of this division.(b) A bid obtained in accordance with subsection (a) of this section must include:(1) the total cost of the requested adaptive aid, which may be from a catalog, website, or brochure price list;(2) the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation, and other labor charges;(3) the date of the bid;(4) the name, address, and telephone number of the vendor, who may not be a relative of the individual;(5) for an adaptive aid other than interpreter service and specialized training for augmentative communication programs, a complete description of the adaptive aid and any associated items or modifications as identified in the completed HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form, which may include pictures or other descriptive information from a catalog, website, or brochure; and(6) for interpreter service and specialized training for augmentative communication programs, the number of hours of the service or training to be provided in person and the hourly rate of the service.(c) A DSA may obtain only one bid or two comparable bids for an adaptive aid if the DSA has written justification for obtaining less than three bids because the adaptive aid is available from a limited number of vendors.(d) If a DSA requests to purchase an adaptive aid that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. The following are examples of justifications that support payment of a higher bid:(1) the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and(2) the higher bid is from a vendor that is more accessible to the individual than another vendor.(e) If the requested adaptive aid is a vehicle modification, a DSA must obtain proof that the individual or individual's family member owns the vehicle for which the vehicle modification is requested.(f) A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid. Source Note: The provisions of this §259.261 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.261 Requirements for Bids of an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212176 03/12/2026 (a) Except as provided for a medical supply described in subsection (c) of this section, for an adaptive aid costing less than $500 and authorized by HHSC, a DSA must ensure that an individual receives the adaptive aid no later than 14 business days after one of the following dates, whichever is later: (1) the date HHSC approves the individual's proposed IPC that includes the recommended adaptive aid; or (2) the effective date of the individual's proposed IPC as determined by the service planning team. (b) Except as provided for a medical supply as described in subsection (c) of this section, for an adaptive aid costing $500 or more and authorized by HHSC, a DSA must ensure that an individual receives the adaptive aid no later than 30 business days after one of the following dates, whichever is later: (1) the date HHSC approves the individual's proposed IPC that includes the recommended adaptive aid; or (2) the effective date of the individual's proposed IPC as determined by the service planning team. (c) For an adaptive aid that is a medical supply, as listed in the Community Living Assistance and Support Services Provider Manual, a DSA must ensure that an individual receives the medical supply as follows: (1) for a medical supply that is not immediately needed by the individual, no later than five business days after one of the following dates, whichever is later: (A) the date HHSC approves the individual's proposed IPC that includes the recommended adaptive aid; or (B) the effective date of the individual's proposed IPC as determined by the service planning team; and (2) for a medical supply that is immediately needed by the individual, no later than two business days after the date HHSC approves the individual's proposed IPC that includes the recommended adaptive aid. (d) If a DSA cannot provide an adaptive aid in the time frame described in subsections (a), (b), or (c)(1) of this section, the DSA must comply with this subsection. (1) Other than for a medical supply, for an adaptive aid costing less than $500, the DSA must notify the individual and the individual's case manager, orally or in writing, before the 14-day time frame described in subsection (a) of this section expires: (A) that the adaptive aid will not be provided within the 14-day time frame; and (B) of a new proposed date for provision of the adaptive aid. (2) Other than for a medical supply, for an adaptive aid costing $500 or more, the DSA must notify the individual and the individual's case manager, orally or in writing, before the 30-day time frame described in subsection (b) of this section expires: (A) that the adaptive aid will not be provided within the 30-day time frame; and (B) of a new proposed date for provision of the adaptive aid. (3) For an adaptive aid that is a medical supply and not immediately needed by the individual, the DSA must notify the individual and the individual's case manager, orally or in writing, before the five-day time frame described in subsection (c)(1) of this section expires: (A) that the adaptive aid will not be provided within the five-day time frame; (B) the reasons why the medical supply will not be provided within the five-day time frame; and (C) of a new proposed date for provision of the medical supply. Source Note: The provisions of this §259.263 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.263 Time Frames for Providing Adaptive Aids to Individuals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212177 03/12/2026 (a) A DSA must ensure that if an adaptive aid is delivered to an individual by a commercial carrier, such as United Parcel Services or the United States Postal Service, the most cost-effective carrier is used.(b) A DSA may not use a commercial carrier to provide overnight delivery unless it is necessary to meet the time frame for a medical supply immediately needed by the individual, as described in §259.263(c)(2) of this division (relating to Time Frames for Providing Adaptive Aids to Individuals), and there is no other more cost-effective means to deliver the adaptive aid within that time frame. Source Note: The provisions of this §259.265 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.265 Cost Effective Delivery of Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212178 03/12/2026 (a) No later than 10 business days after an individual has received an adaptive aid, a DSA must ensure that: (1) the adaptive aid meets the specifications required by §259.257(e)(1) of this division (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More); and (2) a staff person involved in purchasing the adaptive aid for the individual: (A) contacts the individual to determine whether the adaptive aid meets the needs of the individual; and (B) documents the results of that contact on the HHSC Documentation of Completion of Purchase form described in the Community Living Assistance and Support Services Provider Manual. (b) If the DSA determines that the adaptive aid does not meet the specifications required by §259.257(e)(1) of this division, the DSA must work with the vendor to ensure that the adaptive aid meets the specifications no later than 30 calendar days after the DSA's determination. (c) If the staff person or individual or LAR determines that the adaptive aid does not adequately meet the individual's needs because the individual needs training or other assistance, or the adaptive aid requires repair or adjustment, the DSA must ensure that, no later than 14 business days after the determination, a person who is qualified to perform such training, assistance, repair, or adjustment visits the individual in person and performs the necessary functions. (d) If the individual or LAR has concerns about the adaptive aid that are not addressed by the DSA's compliance with subsections (b) and (c) of this section, the DSA must process the individual's or LAR's concerns as a complaint in accordance with 40 TAC §49.309 (relating to Complaint Process). Source Note: The provisions of this §259.267 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.267 Requirements of DSA Following Provision of Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212189 03/12/2026 (a) The only items or services that a DSA may purchase as a minor home modification are listed in the Community Living Assistance and Support Services Provider Manual. Except as provided by §259.285(c) of this division (relating to Repair or Replacement of Minor Home Modification), the repair and maintenance of a minor home modification purchased through the CLASS Program needed after one year has elapsed from the date the minor home modification is complete and that are not covered by a warranty are also purchasable as a minor home modification. (b) A DSA may not purchase, as a minor home modification, an item or service not listed in the Community Living Assistance and Support Services Provider Manual. (c) The following are examples of items and services that may not be purchased as a minor home modification: (1) general repair or maintenance of a residence (for example, repairing a leaking roof, a rotten porch, or termite damage; removing mold; or leveling a floor); (2) general remodeling of a residence that does not address an individual's specific needs; and (3) an adaptation that adds square footage to a residence. Source Note: The provisions of this §259.271 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.271 Items or Services Purchasable as a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212190 03/12/2026 (a) Except as provided in subsection (b) of this section, the maximum amount HHSC approves as payment to a DSA for all minor home modifications provided to an individual is $10,000 during the time period the individual is enrolled in the CLASS Program. (b) After reaching the $10,000 authorization limit described in subsection (a) of this section, HHSC may approve up to $300 per IPC period for repair and maintenance of minor home modifications purchased through the CLASS Program needed after one year has elapsed from the date the minor home modification is complete. (c) To request authorization for repair and maintenance of a minor home modification described in subsection (b) of this section, a DSA is not required to follow the process set forth in §259.275 of this division (relating to Requirements for Authorization to Purchase a Minor Home Modification) but must include the amount requested on an individual's IPC, as described in §259.65 of this chapter (relating to Development of an Enrollment IPC) or §259.79 of this chapter (relating to Renewal and Revision of an IPC). (d) A DSA must follow the process for requesting authorization to purchase a minor home modification described in §259.275 of this division if: (1) requesting authorization for repair and maintenance of a minor home modification in an amount that exceeds $300; or (2) requesting authorization for repair and maintenance of a minor home modification that is not purchased through the CLASS Program but is identical to an item or service that a DSA may purchase as a minor home modification listed in the Community Living Assistance and Support Services Provider Manual. (e) A request described under subsection (d) of this section and authorized by HHSC is counted toward the authorization limit described in subsection (a) of this section. Source Note: The provisions of this §259.273 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.273 Authorization Limit for Minor Home Modifications and Amount for Repair and Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212191 03/12/2026 (a) To purchase a minor home modification for an individual a CMA must: (1) ensure that the individual or LAR initiates a request for the minor home modification by completing Part A of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form described in the Community Living Assistance and Support Services Provider Manual; (2) send the partially completed form to the DSA; (3) ensure that the individual's service planning team includes the cost of the specifications for the requested minor home modification, as described in §259.277 of this division (relating to Requirements for Specifications for a Minor Home Modification), not to exceed $200, in: (A) the individual's proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, as applicable; and (B) the individual's IPP; and (4) no later than 14 calendar days after completing the requirement described in paragraph (3) of this subsection, submit to HHSC: (A) the proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, described in paragraph (3)(A) of this subsection, as applicable; and (B) the individual's IPP described in paragraph (3)(B) of this subsection. (b) HHSC reviews the documentation described in subsection (a)(4) of this section and determines whether the proposed IPC is authorized in accordance with §259.69 of this chapter (relating to HHSC's Review of a Proposed Enrollment IPC) or §259.79 of this chapter (relating to Renewal and Revision of an IPC). (c) HHSC notifies a DSA, in the electronic billing system, of whether the proposed IPC is authorized. HHSC notifies a CMA, in writing, of whether the proposed IPC is authorized. (d) If HHSC approves the proposed IPC for payment of the specifications, the DSA must: (1) no later than 30 calendar days after the date HHSC approves the IPC, obtain the specifications regarding the minor home modification in accordance with §259.277 of this division and ensure that Part B of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form is completed; (2) no later than 60 calendar days after obtaining the specifications: (A) if the minor home modification costs more than $1,000, obtain bids from vendors in accordance with §259.279 of this division (relating to Bid Requirements for a Minor Home Modification); (B) select a vendor to complete construction of the minor home modification; and (C) complete Part C of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form and send the form to the CMA; and (3) before construction of the minor home modification: (A) obtain written approval for construction of the modification from the owner of the property in question, unless such approval is granted in an applicable lease agreement; and (B) ensure that the selected vendor obtains any required building permits. (e) A CMA must, no later than 14 calendar days after receipt of the form described in subsection (d)(2)(C) of this section: (1) complete Part D of the HHSC Request for Adaptive Aids, Medical Supplies and Minor Home Modifications form, evidencing that the criteria described in §259.65(b) of this chapter (relating to Development of an Enrollment IPC) are met; (2) ensure that the individual's service planning team includes the cost of the minor home modification and the cost of the inspection of the minor home modification, not to exceed $150, in: (A) the individual's proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC, as applicable; and (B) the individual's IPP; and (3) no later than 14 calendar days after completing the requirement described in paragraph (2) of this subsection, submit to HHSC: (A) the completed HHSC Request for Adaptive Aids, Medical Supplies, and Minor Home Modifications form; (B) the proposed enrollment IPC, proposed renewal IPC, or proposed revised IPC described in paragraph (2)(A) of this subsection, as applicable; (C) the individual's IPP described in paragraph (2)(B) of this subsection; and (D) documentation regarding bids as required by §259.279 of this division. (f) HHSC reviews the documentation described in subsection (e)(3) of this section and determines whether the proposed IPC is authorized in accordance with §259.69 or §259.79 of this chapter. (g) HHSC notifies a DSA, in the electronic billing system, of whether the proposed IPC is authorized. HHSC notifies a CMA, in writing, of whether the proposed IPC is authorized. (h) The DSA must direct the vendor to begin construction of the minor home modification no later than seven calendar days after one of the following, whichever is later: (1) the date HHSC approves the individual's proposed IPC; or (2) the effective date of the individual's proposed IPC as determined by the service planning team. (i) A DSA must, no later than seven business days after it receives information that the minor home modification is completed, conduct an in-person inspection of the minor home modification in accordance with §259.281 of this division (relating to Inspection of a Minor Home Modification). Source Note: The provisions of this §259.275 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.275 Requirements for Authorization to Purchase a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212192 03/12/2026 (a) If HHSC approves payment for specifications for a minor home modification in accordance with §259.275(b) of this division (relating to Requirements for Authorization to Purchase a Minor Home Modification), a DSA must: (1) obtain specifications from a person who has experience in constructing home modifications; and (2) ensure that the specifications: (A) include a complete description of the minor home modification and any associated installations identified in the specifications; (B) include a drawing or picture of both the existing room, structure, or other area and the proposed modification made to scale; (C) comply with the Texas Accessibility Standards promulgated by the Texas Department of Licensing and Regulation unless: (i) the DSA determines that it is not structurally feasible to do so and the DSA documents, in writing, the basis for its determination; or (ii) the individual or LAR requests, in writing, that the specifications not be in compliance with the Texas Accessibility Standards; and (D) are approved, in writing, by each member of the service planning team by completing the HHSC Specifications for Adaptive Aids/Minor Home Modifications form described in the Community Living Assistance and Support Services Provider Manual. (b) The DSA must obtain an invoice from the person who develops the specifications, substantiating the cost of the specifications. Source Note: The provisions of this §259.277 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.277 Requirements for Specifications for a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212193 03/12/2026 (a) As required by §259.275(d)(2)(A) of this division (relating to Requirements for Authorization to Purchase a Minor Home Modification), for a minor home modification costing more than $1,000, a DSA must obtain comparable bids for the minor home modification from three vendors. Comparable bids describe the minor home modification and any associated installations identified in the specifications required by §259.275(d)(1) of this division.(b) A bid obtained in accordance with subsection (a) of this section must be based on the specifications and include:(1) an itemized list of materials and labor necessary to construct the modification;(2) the cost of each material and labor listed;(3) the date of the bid;(4) the name, address, and telephone number of the vendor;(5) a detailed explanation of the vendor's warranty for the modification, if any; and(6) a statement that the minor home modification will be made in accordance with all applicable state and local building codes.(c) A DSA may obtain only one bid or two comparable bids for a minor home modification if the DSA has written justification for obtaining less than three bids because the minor home modification is available from a limited number of vendors.(d) If a DSA requests to purchase a minor home modification that is not based on the lowest bid, the DSA must have written justification for payment of a higher bid. An example of a justification that supports payment of a higher bid is that the higher bid is based on the inclusion of a longer warranty for the minor home modification.(e) The person who developed the specifications required by §259.275(d)(1) of this division may be one of the bidders required by this section.(f) A DSA may not disclose information regarding a submitted bid to any other vendor who has submitted a bid or to a vendor who may submit a bid. Source Note: The provisions of this §259.279 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.279 Bid Requirements for a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212194 03/12/2026 (a) A DSA must conduct an in-person inspection of the minor home modification to determine if: (1) the minor home modification has been completed; (2) the minor home modification has been made in accordance with the specifications required by §259.275(d)(1) of this division (relating to Requirements for Authorization to Purchase a Minor Home Modification); and (3) the quality of workmanship of the minor home modification is adequate. (b) An inspection required by subsection (a) of this section may be performed by the person who developed the specifications unless that person is affiliated with the vendor who completed the minor home modification. (c) A DSA must obtain an invoice from the person who conducted the inspection, substantiating the cost of the inspection. (d) If, based on the inspection, the DSA determines that the minor home modification meets the conditions listed in subsection (a) of this section, the DSA must send a completed HHSC Documentation of Completion of Purchase form described in the Community Living Assistance and Support Services Provider Manual to the individual's CMA no later than seven business days after completion of the inspection. (e) If, based on the inspection, a DSA determines that the minor home modification does not meet the conditions listed in subsection (a) of this section, the DSA must ensure that the vendor meets the conditions no later than 30 calendar days after the DSA's determination. (f) A DSA may not submit a claim for payment of the minor home modification until the DSA determines that the minor home modification meets the conditions listed in subsection (a) of this section. Source Note: The provisions of this §259.281 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.281 Inspection of a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212195 03/12/2026 (a) A DSA must ensure that a minor home modification is completed no later than 60 calendar days after one of the following dates, whichever is later:(1) the date HHSC approves the proposed IPC that includes the cost of the minor home modification and inspection, as described in §259.275(e)(2) of this division (relating to Requirements for Authorization to Purchase a Minor Home Modification); or(2) the effective date of the proposed IPC as determined by the service planning team.(b) If a DSA determines that the minor home modification will not be completed within the time frame required by subsection (a) of this section, the DSA must notify the individual or LAR, and the case manager, in writing, of a new proposed date of completion. The proposed date of completion may not exceed 30 calendar days after the date required by subsection (a) of this section. Source Note: The provisions of this §259.283 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.283 Time Frames for Completion of Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212196 03/12/2026 (a) The repair or replacement of a minor home modification needed within one year after the date the minor home modification is complete is not purchasable as a minor home modification.(b) If a minor home modification requires repair or replacement within one year after the date of completion, the DSA must repair or replace the minor home modification at its own expense, except as provided in subsection (c) of this section.(c) If a minor home modification requires repair or replacement because the minor home modification was intentionally damaged, the repair or replacement must be done at the expense of the individual or LAR. Source Note: The provisions of this §259.285 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.285 Repair or Replacement of Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212197 03/12/2026 (a) A DSA must ensure that a staff person involved in purchasing the minor home modification for the individual: (1) visits the individual to determine whether the individual and LAR is satisfied with the minor home modification; and (2) documents the result of that visit on an HHSC Documentation of Completion of Purchase form described in Community Living Assistance and Support Services Provider Manual. (b) If the individual or LAR is not satisfied with the minor home modification, the DSA must process the individual's or LAR's dissatisfaction as a complaint in accordance with 40 TAC §49.309 (relating to Complaint Process). Source Note: The provisions of this §259.287 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.287 Satisfaction of Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212188 03/12/2026 (a) Eligibility for CFC ERS. A DSA must ensure that CFC ERS is provided only to an individual:(1) who is not receiving SFS or CFS; and(2) who:(A) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(B) would otherwise require extensive routine supervision.(b) Installing equipment.(1) A DSA must ensure that CFC ERS equipment is installed no later than 14 business days after one of the following dates, whichever is later:(A) the date HHSC approves the proposed IPC that includes CFC ERS; or(B) the effective date of the individual's IPC as determined by the service planning team.(2) At the time CFC ERS equipment is installed, a DSA must ensure that:(A) the equipment is installed in accordance with the manufacturer's installation instructions;(B) an initial test of the equipment is made;(C) the equipment has an alternate power source in the event of a power failure;(D) the individual is trained on the use of the equipment, including:(i) demonstrating how the equipment works; and(ii) having the individual activate an alarm call;(E) an explanation is given to the individual that the individual must:(i) participate in a system check each month; and(ii) contact the CFC ERS provider if:(I) the individual's telephone number or address changes; or(II) one or more of the individual's responders change; and(F) the individual is informed that a responder, in response to an alarm call, may forcibly enter the individual's home if necessary.(3) A DSA must ensure that the date and time of the CFC ERS equipment installation and compliance with the requirements in paragraphs (1) and (2) of this subsection are documented in the individual's record.(c) Securing responders. A DSA must ensure that, on or before the date CFC ERS equipment is installed:(1) an attempt is made to obtain from an individual, the names and telephone numbers of at least two responders, such as a relative or neighbor;(2) public emergency personnel:(A) is designated as a second responder if the individual provides the name of only one responder; or(B) is designated as the sole responder if the individual does not provide the names of any responders; and(3) the name and telephone number of each responder is documented in the individual's record.(d) Conducting a system check.(1) At least once during each calendar month a DSA must ensure that a system check is conducted on a date and time agreed to by an individual.(2) A DSA must ensure that the date, time, and result of the system check is documented in the individual's record.(3) If, as a result of the system check:(A) the equipment is working properly but the individual is unable to successfully activate an alarm call, the DSA must ensure that a request is made of the case manager to convene a service planning team meeting to determine if CFC ERS meets the individual's needs; or(B) the equipment is not working properly, the DSA must ensure that, no later than three calendar days after the date of the system check, the equipment is repaired or replaced.(e) Failing to complete a system check. If a system check is not conducted in accordance with subsection (d)(1) of this section, a DSA must ensure that:(1) the failure to comply is because of good cause; and(2) the good cause is documented in an individual's record.(f) Alarm call.(1) A DSA must ensure that an alarm call is responded to 24 hours a day, seven days a week.(2) A DSA must ensure that, if an alarm call is made, a CFC ERS provider:(A) within 60 seconds of the alarm call, attempts to contact an individual to determine if an emergency exists;(B) immediately contacts a responder, if as a result of attempting to contact the individual:(i) the CFC ERS provider confirms there is an emergency; or(ii) the CFC ERS provider is unable to communicate with the individual; and(C) documents the following information in the individual's record when the information becomes available:(i) the name of the individual;(ii) the date and time of the alarm call, recorded in hours, minutes, and seconds;(iii) the response time, recorded in seconds;(iv) the time the individual is called in response to the alarm call, recorded in hours, minutes, and seconds;(v) the name of the contacted responder, if applicable;(vi) a brief description of the reason for the alarm call; and(vii) if the reason for the alarm call is an emergency, a statement of how the emergency was resolved.(3) If an alarm call results in a responder being dispatched to an individual's home for an emergency, the DSA must ensure that:(A) the case manager receives written notice of the alarm call within one business day after the date of the alarm call;(B) if the CFC ERS provider is a contracted provider, the DSA receives written notice from the contracted provider within one business day after the alarm call; and(C) the written notices required by subparagraphs (A) and (B) of this paragraph are maintained in the individual's record.(g) Equipment failure.(1) A DSA must ensure that, if an equipment failure occurs, other than during a system check required by subsection (d)(1) of this section:(A) the individual is informed of the equipment failure; and(B) the equipment is replaced within one business day after the failure becomes known by the CFC ERS provider.(2) If an individual is not informed of the equipment failure or the equipment is not replaced in compliance with paragraph (1) of this subsection, a DSA must:(A) determine whether the failure to inform the individual or replace the equipment was because of good cause; and(B) as soon as possible, ensure that the individual is informed of the equipment failure and the equipment is replaced.(h) Low battery.(1) A DSA must ensure that, if the ERS equipment registers five or more "low battery" signals in a 72-hour period:(A) a visit to an individual's home is made to conduct a system check no later than five business days after the low battery signals occur; and(B) if the battery is defective, the battery is replaced during the visit.(2) If a system check or battery replacement is not made in accordance with paragraph (1) of this subsection, a DSA must:(A) determine whether the failure to conduct a system check or replace a defective battery was because of good cause; and(B) as soon as possible, conduct a system check and replace a defective battery.(i) Documenting equipment failure or low battery. A DSA must ensure that the following information is documented in an individual's record:(1) the date the equipment failure or low battery signal became known by the CFC ERS provider;(2) the equipment or subscriber number;(3) a description of the problem;(4) the date the equipment or battery was repaired or replaced; and(5) the good cause for failure to comply with subsections (g)(2)(A) and (h)(2)(A) of this section. Source Note: The provisions of this §259.89 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F ADAPTIVE AIDS, MINOR HOME MODIFICATIONS, AND CFC ERS §259.289 CFC ERS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212208 03/12/2026 A CMA must comply with:(1) this chapter;(2) 40 TAC Chapter 49 (relating to Contracting for Community Services); and(3) 40 TAC Chapter 41 (relating to Consumer Directed Services Option). Source Note: The provisions of this §259.301 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.301 CMA: Compliance with Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212198 03/12/2026 (a) A CMA must have and implement written policies and procedures that safeguard an individual against: (1) infectious and communicable diseases; (2) conflicts of interest with a staff person, volunteer, or controlling person of the CMA; (3) abuse, neglect, and exploitation; (4) acts of financial impropriety by a staff person, volunteer, or controlling person of the CMA; and (5) deliberate damage of personal possessions by a staff person, volunteer, or controlling person of the CMA.(b) A CMA must report a critical incident to HHSC and the DSA in accordance with the Appendix XIII of the Community Living Assistance and Support Services Provider Manual using the HHSC CLASS/DBMD Notification of Critical Incidents form.(c) A CMA program director who receives a copy of an HHSC initial intake report or a final investigative report from an FMSA in accordance with 40 TAC §41.702 (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Service Provider) or 40 TAC §41.703 (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of an FMSA) must give a copy of the report to the individual's case manager. Source Note: The provisions of this §259.303 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.303 Protection of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212199 03/12/2026 (a) If a CMA is notified by the DSA in accordance with §259.359(g)(2) of this chapter (relating to DSA: Service Delivery) that an individual is receiving transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB outside the catchment area in which the individual resides, the CMA must: (1) provide an oral explanation to the individual or LAR, on or before the 35th day of the period services have been provided outside the catchment area, that: (A) the individual must do one of the following before the 61st day of the period services have been provided outside the catchment area to ensure the continued provision of transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB: (i) transfer to a DSA contract for the catchment area in which the individual is receiving transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB; or (ii) return to the catchment area in which the individual resides; and (B) if the individual receives transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB outside the catchment area during a period of 60 consecutive days, the individual must return to the catchment area in which the individual resides and receive services in that catchment area before the DSA may accept another request from the individual or LAR that the DSA provide transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB outside the catchment area; (2) document that the CMA provided the oral explanation required by paragraph (1) of this subsection; and(3) if the individual or LAR expresses a desire for the individual to transfer to a DSA contract for the catchment area in which the individual is receiving transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB: (A) give the individual and LAR or actively involved person a written list of CMAs and DSAs serving the catchment area in which the individual is receiving transportation as a habilitation activity, out-of-home respite in a camp, adaptive aids, nursing, or CFC PAS/HAB; (B) have the individual or LAR select a CMA and DSA by completing an HHSC Selection Determination form, as described in the Community Living Assistance and Support Services Provider Manual; and (C) coordinate the individual's transfer in accordance with §259.151 of this chapter (relating to Coordination of Transfers). (b) If an individual requests that the case manager convene a meeting of the service planning team to discuss the DSA's reasons for declining a request to allow services to be provided outside the catchment area, as described in §259.359(h)(1)(B) of this chapter, the case manager must: (1) convene a meeting to review the reasons the DSA declined the request to allow services outside the catchment area; (2) facilitate a discussion between the individual or LAR and the DSA during the meeting regarding the reasons the DSA declined the request; and(3) document the results of the meeting. Source Note: The provisions of this §259.305 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.305 DSA Services Outside the Catchment Area https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212200 03/12/2026 (a) A CMA must have a full-time or part-time program director who:(1) manages and oversees the CMA's operations, including the provision of case management services to individuals enrolled with the CMA;(2) is at least 18 years of age;(3) has:(A) a bachelor's degree in a health and human services field and two years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(B) one of the following:(i) a high school diploma and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; and(4) is an employee of the CMA.(b) A CMA must ensure that a case manager working for the CMA:(1) has:(A) a bachelor's degree in a health and human services field, and two years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(B) one of the following:(i) a high school diploma and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities;(2) is an employee of the CMA;(3) is not employed by or contracting with a DSA to provide a direct service to an individual served by the CMA; and(4) is not a relative of the individual to whom the case manager is providing case management. Source Note: The provisions of this §259.307 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.307 Qualifications of CMA Staff Persons https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225004 03/12/2026 (a) A CMA must ensure that: (1) a CMA staff person completes training as described in the Community Living Assistance and Support Services Provider Manual;(2) a CMA staff person completes training on the CLASS Program and CFC, including the requirements of this chapter and the CLASS Program services and CFC services described in §259.7 of this chapter (relating to Description of the CLASS Program and CFC Option); and (3) a case manager completes a comprehensive non-introductory person-centered service planning training developed or approved by HHSC within six months after the case manager's date of hire. (b) A CMA must: (1) ensure that each CMA staff person and volunteer: (A) is trained on and knowledgeable of: (i) acts that constitute abuse, neglect, and exploitation; (ii) signs and symptoms of abuse, neglect, and exploitation; and (iii) methods to prevent abuse, neglect, and exploitation; (B) is instructed to report to HHSC immediately, but not later than 24 hours, after having knowledge or suspicion that an individual has been or is being abused, neglected, or exploited, by: (i) calling the HHSC toll-free telephone number, 1-800-458-9858; or (ii) using the HHSC online Texas Unified Licensure Information Portal; and (C) is provided with the instructions described in subparagraph (B) of this paragraph in writing; (2) conduct the activities described in paragraph (1)(A) - (C) of this subsection: (A) within one year after the person's most recent training on abuse, neglect, and exploitation and annually thereafter, if the CMA staff person or volunteer was hired before July 1, 2019; or (B) before assuming job duties and annually thereafter, if the CMA staff person or volunteer is hired on or after July 1, 2019; and (3) document: (A) the name of the person who received the training required by this subsection; (B) the date the training was conducted; and (C) the name of the person or organization who conducted the training. Source Note: The provisions of this §259.309 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.309 Training of CMA Staff Persons and Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212202 03/12/2026 (a) A CMA must ensure that: (1) a full-time case manager is assigned to provide case management to no more than 50 individuals at one time; (2) a part-time case manager is assigned to provide case management to no more than 25 individuals at one time; and (3) for a month in which a case manager does not meet with an individual or LAR as required by §259.79(a) of this chapter (relating to Renewal and Revision of an IPC), the case manager has an in-person or telephone contact with the individual or LAR or other persons acting on behalf of the individual, such as an advocate or family member, to provide case management. (b) In determining the number of individuals to which a case manager will be assigned, a CMA must consider:(1) the intensity of an individual's needs; (2) the frequency and duration of contacts the case manager will need to make with the individual; and (3) the amount of travel time involved in making such contacts. (c) A CMA must have: (1) an adequate number of case managers available to ensure the provision of case management to an individual at all times; and (2) a written process that ensures that case managers are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide case management. (d) A CMA must ensure that a case manager participates as a member of an individual's service planning team and uses the person-centered planning process when developing or revising required documentation in accordance with this chapter and the Community Living Assistance and Support Services Provider Manual. (e) A CMA must ensure that case management is provided to an individual in accordance with the individual's IPC. (f) A CMA must submit an IPC to HHSC within the time periods required by §259.65 of this chapter (relating to Development of an Enrollment IPC) and §259.79(g)(2)(A) and (g)(3)(A) of this chapter to ensure that a DSA receives reimbursement for the provision of CLASS Program services and CFC services. (g) A CMA must follow the process for requesting authorization to purchase dental treatment, as described in the Community Living Assistance and Support Services Provider Manual. (h) If an individual may need cognitive rehabilitation therapy, a case manager must assist the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-CLASS Program service. (i) A CMA must ensure that an individual's case manager complies with §259.205 of this chapter (relating to Residential Agreements, Requirements for Provider-Controlled Residential Settings, and Support Family Agency and Continued Family Agency Functions). Source Note: The provisions of this §259.311 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.311 CMA Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212203 03/12/2026 (a) A CMA must ensure that when a case manager provides case management, the case manager:(1) documents:(A) the date of contact;(B) a description of the case management activity performed;(C) the progress or lack of progress in achieving goals or outcomes in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcomes addressed;(D) the person with whom the contact occurred; and(E) the signature and title of the case manager who provided the contact; and(2) completes an HHSC Documentation of Services Delivered form to document the provision of case management that is supported by the documentation required in paragraph (1) of this subsection.(b) A CMA must ensure that, after a case manager makes the last entry on an HHSC Documentation of Services Delivered form, a staff person other than the case manager who completed the form signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.(c) A CMA must maintain a separate record for each individual receiving case management from the CMA. An individual's record must include:(1) the individual's current IPC and any other IPC authorized for the current IPC period;(2) the individual's current IPP and any other IPP developed for the current IPC period;(3) the individual's current HHSC IPP Addendum and any other HHSC IPP Addendum developed for the current IPC period;(4) the individual's current ID/RC Assessment;(5) the individual's current HHSC CLASS/DBMD Nursing Assessment form;(6) the individual's HHSC Waiver Program Verification of Freedom of Choice form completed at enrollment documenting the individual's or LAR's choice of the CLASS Program over the ICF/IID Program;(7) the individual's current HHSC Selection Determination form documenting the individual's or LAR's choice of a CMA and DSA;(8) the documentation required by subsection (a)(1) of this section;(9) the completed HHSC Documentation of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section; and(10) any other relevant documentation concerning the individual. Source Note: The provisions of this §259.313 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.313 CMA: Documentation of Services Delivered and Recordkeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212204 03/12/2026 (a) A CMA must, at least annually, conduct a survey of all individuals, LARs, and actively involved persons to determine their satisfaction with the provision of case management.(b) A CMA must develop a written quality assurance process to evaluate and improve the quality of case management provided by the CMA based, at least in part, on the results of the survey required by subsection (a) of this section.(c) At least annually, a CMA must:(1) review all final investigative reports from HHSC for an investigation described in §259.319(c) of this subchapter (relating to CMA: Requirements Related to the Abuse, Neglect, and Exploitation of an Individual) and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of case management services; and(2) evaluate critical incident data reported in accordance with §259.303(h) of this subchapter (relating to Protection of Individual) and identify program process improvements that help prevent the occurrence of critical incidents and improve service delivery. Source Note: The provisions of this §259.315 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.315 CMA: Quality Management Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225005 03/12/2026 If a CMA, staff person, volunteer, or controlling person of the CMA knows or suspects an individual is being or has been abused, neglected, or exploited, the CMA must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to HHSC immediately, but not later than 24 hours after having knowledge or suspicion, by: (1) calling the HHSC toll-free telephone number, 1-800-458-9858; or (2) using the HHSC online Texas Unified Licensure Information Portal. Source Note: The provisions of this §259.317 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.317 CMA: Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212206 03/12/2026 (a) If a report required by §259.317 of this subchapter (relating to CMA: Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation by a person who is not a staff person, volunteer, or controlling person of a CMA, the CMA must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) discuss with the individual or LAR alternative residential settings and additional services that may help ensure the individual's safety;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(4) preserve and protect evidence related to the allegation.(b) If a report required by §259.317 of this subchapter alleges abuse, neglect, or exploitation of an individual by a staff person, volunteer, or controlling person of a CMA; or if the CMA is notified by HHSC of an allegation of abuse, neglect, or exploitation by a staff person, volunteer, or controlling person of the CMA, the CMA must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator of the abuse, neglect, or exploitation does not have contact with the individual or any other individual until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) as soon as possible, but no later than 24 hours, after the CMA reports or is notified of the allegation, notify the individual, the LAR, and the DSA of:(A) the allegation report; and(B) the actions the CMA has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(c) During an HHSC investigation of an alleged perpetrator who is a staff person, volunteer, or controlling person of a CMA, the CMA must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the CMA;(B) individuals, staff persons, volunteers, and controlling persons; and(C) records pertinent to the investigation of the allegation; and(3) ensure that staff persons, volunteers, and controlling persons of the CMA comply with paragraphs (1) and (2) of this subsection.(d) After a CMA receives a final investigative report from HHSC for an investigation described in subsection (c) of this section, the CMA must:(1) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the CMA's authority to prevent the reoccurrence of abuse, neglect or exploitation, including disciplinary action against a staff person or volunteer of the CMA confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the CMA's authority, as necessary; and(3) immediately, but not later than five calendar days after the date the CMA receives the HHSC final investigative report, notify the individual and the LAR of:(A) the investigation finding; and(B) the action taken by the CMA in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection.(e) A CMA must not retaliate against:(1) a staff person, an individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations. Source Note: The provisions of this §259.319 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.319 CMA: Requirements Related to the Abuse, Neglect, and Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212207 03/12/2026 If a CMA submits documentation to HHSC in accordance with this chapter containing information that is not in English, the CMA must, at the same time, submit a translation of the information in English. Source Note: The provisions of this §259.321 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G ADDITIONAL CMA REQUIREMENTS §259.321 CMA: Requirement for Translation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212209 03/12/2026 A DSA must comply with:(1) this chapter;(2) 26 TAC Chapter 558 (relating to Licensing Standards for Home and Community Support Services Agencies);(3) 40 TAC Chapter 49 (relating to Contracting for Community Services); and(4) 1 TAC Chapter 354, Subchapter O (relating to Electronic Visit Verification). Source Note: The provisions of this §259.351 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.351 DSA: Compliance with Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212210 03/12/2026 (a) A DSA must have and implement written policies and procedures that safeguard an individual against: (1) infectious and communicable diseases; (2) conflicts of interest with a service provider, staff person, volunteer, or controlling person of the DSA; (3) acts of financial impropriety by a service provider, staff person, volunteer, or controlling person of the DSA; (4) abuse, neglect, and exploitation; and (5) deliberate damage of personal possessions by a service provider, staff person, volunteer, or controlling person of the DSA. (b) A DSA, in accordance with the Community Living Assistance and Support Services Provider Manual, must report critical incidents to HHSC and the CMA using the HHSC CLASS/DBMD Notification of Critical Incidents form. Source Note: The provisions of this §259.353 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.353 DSA: Protection of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212211 03/12/2026 (a) A DSA must ensure that a staff person meets the requirements of this section.(b) A service provider for a direct service must meet the qualifications in this subsection and in subsection (d) of this section.(1) A service provider for a direct service:(A) must be at least 18 years of age; and(B) except as provided by paragraphs (2) and (3) of this subsection, may not be a relative or guardian of the individual to whom the service provider is providing the direct service.(2) A service provider of transportation as a habilitation activity, prevocational services, respite, employment assistance, supported employment, or CFC PAS/HAB may be a relative or guardian of the individual unless prohibited by subsection (d)(21) of this section.(3) A service provider of minor home modifications may be a relative or guardian of the individual.(c) A DSA must have a full-time or part-time program director who:(1) manages and oversees the DSA's operations including the provision of CLASS Program services and CFC services to individuals enrolled with the DSA and has:(A) a bachelor's degree in a health and human services field and two years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(B) one of the following:(i) a high school diploma and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities;(2) is at least 18 years of age;(3) is an employee of the DSA; and(4) is not a relative of an individual being served by the DSA.(d) A DSA must ensure that CLASS Program services and CFC services are provided by qualified service providers in accordance with this subsection.(1) A service provider of registered nursing and of specialized registered nursing must be an RN.(2) A service provider of licensed vocational nursing and of specialized licensed vocational nursing must be a licensed vocational nurse.(3) A service provider of occupational therapy must be an occupational therapist or an occupational therapy assistant licensed in accordance with Texas Occupations Code Chapter 454.(4) A service provider of physical therapy must be a physical therapist or physical therapist assistant licensed in accordance with Texas Occupations Code Chapter 453.(5) A service provider of speech and language pathology must be a speech-language pathologist or a licensed assistant in speech-language pathology licensed in accordance with Texas Occupations Code Chapter 401.(6) A service provider of auditory integration training/auditory enhancement training must be an audiologist or a licensed assistant in audiology licensed in accordance with Texas Occupations Code Chapter 401.(7) A service provider of dental treatment must be a person licensed to practice dentistry, dental surgery, or dental hygiene in accordance with Texas Occupations Code Chapter 256.(8) A service provider of dietary services must be a dietician licensed in accordance with Texas Occupations Code Chapter 701.(9) A service provider of massage therapy must be a massage therapist licensed in accordance with Texas Occupations Code Chapter 455.(10) A service provider of therapeutic horseback riding must be a person certified by the Professional Association of Therapeutic Horsemanship International as a therapeutic riding instructor.(11) Hippotherapy must be provided by the following two service providers:(A) a service provider who is certified by the Professional Association of Therapeutic Horsemanship International as a therapeutic riding instructor; and(B) a service provider who is:(i) an occupational therapist licensed in accordance with Texas Occupations Code Chapter 454;(ii) an occupational therapy assistant licensed in accordance with Texas Occupations Code Chapter 454;(iii) a physical therapist licensed in accordance with Texas Occupations Code Chapter 453; or(iv) a physical therapist assistant licensed in accordance with Texas Occupations Code Chapter 453.(12) A service provider of recreational therapy must be a person:(A) who holds a credential as a certified therapeutic recreation specialist awarded by the National Council of Therapeutic Recreation Certification; or(B) who is certified as a therapeutic recreation specialist by the Consortium for Therapeutic Recreation/Activities Certification, Inc.(13) A service provider of music therapy is a person who holds a credential as a board certified music therapist awarded by the Certification Board for Music Therapists.(14) A service provider of aquatic therapy must:(A) be:(i) a massage therapist licensed in accordance with Texas Occupations Code Chapter 455;(ii) a person who holds a credential as a certified therapeutic recreation specialist awarded by the National Council of Therapeutic Recreation Certification; or(iii) a person who is certified as a therapeutic recreation specialist by the Consortium for Therapeutic Recreation/Activities Certification, Inc.; and(B) hold a certificate of completion of the "Basic Water Rescue" course from the American Red Cross or be certified by the American Red Cross as a lifeguard.(15) A service provider of behavioral support must:(A) be one of the following:(i) a psychologist licensed in accordance with Texas Occupations Code Chapter 501;(ii) a provisional license holder licensed in accordance with Texas Occupations Code Chapter 501;(iii) a psychological associate licensed in accordance with Texas Occupations Code Chapter 501;(iv) a clinical social worker licensed in accordance with Texas Occupations Code Chapter 505;(v) a licensed professional counselor licensed in accordance with Texas Occupations Code Chapter 503; or(vi) a behavior analyst certified by the Behavior Analyst Certification Board, Inc.; and(B) have received training in behavioral support or have experience in providing behavioral support.(16) A service provider of cognitive rehabilitation therapy must be:(A) a psychologist licensed in accordance with Texas Occupations Code Chapter 501;(B) a speech-language pathologist licensed in accordance with Texas Occupations Code Chapter 401; or(C) an occupational therapist licensed in accordance with Texas Occupations Code Chapter 454.(17) A service provider of prevocational services must have:(A) a bachelor's degree in a health and human services field, and two years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(B) one of the following:(i) a high school diploma and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state and four years' work experience in the delivery of services and supports to persons with related conditions or similar disabilities.(18) A service provider of employment assistance and a service provider of supported employment must have:(A) a bachelor's degree in rehabilitation, business, marketing, or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;(B) an associate's degree in rehabilitation, business, marketing, or a related human services field with one year of paid or unpaid experience providing services to people with disabilities; or(C) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities.(19) Documentation of the experience required by paragraph (18) of this subsection must include:(A) for paid experience, a written statement from a person who paid for the service or supervised the provision of the service; and(B) for unpaid experience, a written statement from a person who has personal knowledge of the experience.(20) A service provider of transportation as a habilitation activity or respite who is hired on or after July 1, 2015 must have:(A) a high school diploma;(B) a certificate recognized by a state as the equivalent of a high school diploma; or(C) both of the following:(i) a successfully completed written competency-based assessment demonstrating the service provider's ability to assist with ADLs and IADLs required for the individual to whom the service provider will provide transportation as a habilitation activity or respite; and(ii) at least three written personal references from persons who are not relatives of the service provider that evidence the service provider's ability to provide a safe and healthy environment for the individual.(21) A service provider of transportation as a habilitation activity, prevocational services, respite, employment assistance, supported employment, or CFC PAS/HAB may not be:(A) the parent of the individual if the individual is under 18 years of age; or(B) the spouse of the individual.(22) A service provider of SFS or CFS must meet the requirements described in §259.215(a) of this chapter (relating to Support Family Requirements).(23) A service provider of CFC PAS/HAB must:(A) have:(i) a high school diploma;(ii) a certificate recognized by a state as the equivalent of a high school diploma; or(iii) both of the following:(I) a successfully completed written competency-based assessment demonstrating the service provider's ability to perform CFC PAS/HAB tasks, including an ability to perform CFC PAS/HAB tasks required for the individual to whom the service provider will provide CFC PAS/HAB; and(II) at least three written personal references from persons not related by blood that evidence the service provider's ability to provide a safe and healthy environment for the individual; and(B) meet any other qualifications requested by the individual or LAR based on the individual's needs and preferences.(e) A DSA may not contract with or employ a service provider who is employed by or contracting with a CMA to provide case management to an individual served by the DSA.(f) A DSA must ensure that a staff person who transports an individual in a vehicle has:(1) a current Texas driver's license; and(2) vehicle liability insurance in accordance with state law. Source Note: The provisions of this §259.355 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.355 Qualifications of DSA Staff Persons https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225006 03/12/2026 (a) A DSA must ensure that: (1) a DSA staff person who has direct contact with an individual completes training described in the Community Living Assistance and Support Services Provider Manual; and (2) a DSA staff person whose duties include participating as a member of a service planning team completes HHSC's web-based Introductory Training within six months after assuming this duty. (b) A DSA must ensure that, before providing services to an individual: (1) a service provider of transportation as a habilitation activity completes: (A) two hours of orientation covering the following: (i) an overview of related conditions; and (ii) an explanation of commonly performed tasks regarding habilitation; (B) training in cardiopulmonary resuscitation and choking prevention that includes an in-person evaluation by a qualified instructor of the service provider's ability to perform these actions; and (C) training necessary to meet the needs and characteristics of the individual to whom the service provider is assigned, in accordance with the Community Living Assistance and Support Services Provider Manual, with training to occur in the individual's home with full participation from the individual, if possible; and (2) a service provider of CFC PAS/HAB completes: (A) two hours of orientation covering the following: (i) an overview of related conditions; and (ii) an explanation of commonly performed CFC PAS/HAB activities; (B) training in cardiopulmonary resuscitation and choking prevention that includes an in-person evaluation by a qualified instructor of the service provider's ability to perform these actions; and (C) training in the CFC PAS/HAB activities necessary to meet the needs and characteristics of the individual to whom the service provider is assigned, in accordance with the Community Living Assistance and Support Services Provider Manual, with training to occur in the individual's home with full participation from the individual, if possible. (c) A DSA must, if requested by an individual or LAR: (1) allow the individual or LAR to train a CFC PAS/HAB service provider in the specific assistance needed by the individual and to have the service provider perform CFC PAS/HAB in a manner that comports with the individual's personal, cultural, or religious preferences; and (2) ensure that a CFC PAS/HAB service provider attends training by HHSC so the service provider meets any additional qualifications desired by the individual or LAR. (d) The supervisor of a service provider of transportation as a habilitation activity or CFC PAS/HAB must, in accordance with the Community Living Assistance and Support Services Provider Manual, evaluate the performance of the service provider, in person, to ensure the needs of the individual are being met. The evaluation must occur annually. (e) A DSA must: (1) ensure that each service provider, staff person, and volunteer of the DSA: (A) is trained on and knowledgeable of: (i) acts that constitute abuse, neglect, and exploitation of an individual;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation; (B) is instructed to report to HHSC immediately, but not later than 24 hours, after having knowledge or suspicion that an individual has been or is being abused, neglected, or exploited, by:(i) calling the HHSC toll-free telephone number, 1-800-458-9858; or(ii) using the HHSC online Texas Unified Licensure Information Portal; and(C) is provided with the instructions described in subparagraph (B) of this paragraph in writing;(2) conduct the activities described in paragraph (1) of this subsection:(A) within one year after the person's most recent training on abuse, neglect, and exploitation and annually thereafter, if the service provider, staff person, or volunteer of the DSA was hired before July 1, 2019; or(B) before assuming job duties and annually thereafter, if the service provider, staff person, or volunteer of the DSA is hired on or after July 1, 2019; and(3) document:(A) the name of the person who received the training required by this subsection;(B) the date the training was conducted or completed; and(C) except for the training described in subsection (a)(2) of this section, the name of the person who conducted the training. Source Note: The provisions of this §259.357 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.357 Training of DSA Staff Persons, Service Providers, and Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212213 03/12/2026 (a) A DSA must ensure that: (1) CLASS Program services and CFC services, other than CFC support management, are provided to an individual in accordance with: (A) the individual's IPC; (B) the individual's IPP for that service; (C) the PAS/HAB plan, if applicable; and(D) for CLASS Program services, Appendix C of the CLASS waiver application approved by CMS and available on the HHSC website; (2) an adaptive aid, minor home modification, and CFC ERS meets the requirements described in Subchapter F of this chapter (relating to Adaptive Aids, Minor Home Modifications, and CFC ERS); (3) transportation as a habilitation activity or as an adaptive aid is provided in accordance with the individual's individual transportation plan; (4) if the individual obtains a plan of care as described in §259.311(h) of this chapter (relating to CMA Service Delivery), a qualified professional described in §259.355(d)(16) of this chapter (relating to Qualifications of DSA Staff Persons) provides and monitors the provision of cognitive rehabilitation therapy to the individual in accordance with the plan of care; and (5) CFC support management is provided to an individual or LAR described in the Community Living Assistance and Support Services Provider Manual if: (A) the individual is receiving CFC PAS/HAB; and (B) the individual or LAR requests to receive CFC support management. (b) A DSA must provide nursing, transportation as a habilitation activity, respite, an adaptive aid, dental treatment, or CFC PAS/HAB to an individual, even if not included on the individual's IPC, if an RN determines that the service is necessary to prevent the individual's health and safety from being placed in immediate jeopardy. If a DSA provides a service under this subsection, the DSA must submit documentation to the CMA as required by §259.81(a) of this chapter (relating to Revised IPC and Revised IPP for Services Provided to Prevent Immediate Jeopardy). (c) A DSA must have a written process that ensures that staff persons are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to provide a CLASS Program service or CFC service. (d) A DSA must ensure that a DSA staff person participates as a member of an individual's service planning team in accordance with this chapter and the Community Living Assistance and Support Services Provider Manual. (e) A DSA must inform the individual's case manager of changes needed to the individual's IPC or IPPs. (f) Except as provided in subsection (i) of this section, a DSA may accept or decline the request of an individual or LAR for the DSA to provide transportation as a habilitation activity, out-of-home respite in a camp described in §259.361(b)(2)(D) of this subchapter (relating to Respite and Dental Treatment), adaptive aids, nursing, or CFC PAS/HAB to the individual while the individual is temporarily staying at a location outside the catchment area in which the individual resides but within the state of Texas. (g) If a DSA accepts the request of an individual or LAR, as described in subsection (f) of this section, the DSA: (1) may provide transportation as a habilitation activity, out-of-home respite in a camp described in §259.361(b)(2)(D) of this subchapter, adaptive aids, nursing, or CFC PAS/HAB to the individual outside the catchment area during a period of no more than 60 consecutive days; (2) must, no later than three business days after the DSA begins providing services outside the catchment area, notify the individual's case manager in writing of the following: (A) that the individual is receiving services outside the catchment area in which the individual resides; (B) the location where the individual is receiving the services; (C) the estimated length of time the individual is expected to be outside the catchment area; and (D) contact information for the individual or LAR; and (3) must notify the individual's case manager in writing that the individual has returned to the catchment area in which the individual resides no later than three business days after becoming aware of the individual's return. (h) If a DSA declines the request of an individual or LAR, as described in subsection (f) of this section, the DSA must: (1) inform the individual or LAR: (A) of the reasons for declining the request; and (B) that the individual or LAR may request that the case manager convene a meeting of the service planning team to discuss the reasons for declining the request; and (2) no later than three business days after declining the request, inform the individual's case manager, in writing, that the request was declined and the reasons for declining the request. (i) If a DSA has provided transportation as a habilitation activity, out-of-home respite in a camp described in §259.361(b)(2)(D) of this subchapter, adaptive aids, nursing, or CFC PAS/HAB to an individual during a period of 60 consecutive days while the individual is temporarily staying at a location outside the catchment area in which the individual resides, the DSA may accept another request from the individual or LAR that the DSA provide services outside the catchment area only if the individual has returned to the catchment area in which the individual resides and received services in that catchment area. Source Note: The provisions of this §259.359 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.359 DSA: Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212214 03/12/2026 (a) Except as described in subsection (c) of this section, a service provider of physical therapy, occupational therapy, or speech and language pathology may provide physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service.(b) If a service provider of physical therapy, occupational therapy, or speech and language pathology provides physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service, a DSA must ensure that the service provider:(1) uses a synchronous audio-visual platform to interact with the individual, supplemented with or without asynchronous store and forward technology;(2) does not use an audio-only platform to provide the service; and(3) before providing the telehealth service:(A) obtains the written informed consent of the individual or LAR to provide the service; or(B) obtains the individual or LAR's oral consent to receive the telehealth service and document's the oral consent in the individual's record.(c) A DSA must ensure that a service provider of physical therapy, occupational therapy, or speech and language pathology performs certain services in person, as required by the Texas Medicaid Provider Procedures Manual. Such services must include:(1) a service that requires a physical agent modality or hands-on therapy, such as a paraffin bath, aquatic therapy, manual therapy, massage, and ultrasound;(2) orthotic management and training, initial encounter and subsequent encounters;(3) prosthetic management or training for an upper or lower extremity, initial encounter and subsequent encounters;(4) a wheelchair assessment and training; and(5) a complex rehabilitation technology assessment. Source Note: The provisions of this §259.360 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.360 Providing Physical Therapy, Occupational Therapy, and Speech and Language Pathology as a Telehealth Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212215 03/12/2026 (a) An individual may receive a maximum of 30 days of in-home and out-of-home respite combined, during an IPC period. (b) A DSA must ensure that: (1) in-home respite is provided in the individual's residence or the residence of a relative or friend that is not one of the settings listed in paragraph (2) of this subsection; (2) out-of-home respite is provided in one of the following settings: (A) an agency foster home; (B) a nursing facility; (C) an ICF/IID; (D) an approved outdoor camp accredited by the American Camping Association; (E) the residence of another person receiving a Medicaid waiver service; or (F) an ALF; and (3) the setting in which out-of-home respite is provided is: (A) acceptable to the individual or LAR; and (B) an accessible, safe, and comfortable environment for the individual and promotes the individual's health and welfare. (c) If a DSA provides out-of-home respite in a residence described in subsection (b)(2)(E) of this section, the DSA must: (1) obtain written approval from each person residing in the residence who is receiving a Medicaid waiver service, or LAR, for the provision of respite in the residence; and (2) ensure that no more than four persons receiving a Medicaid waiver service are residing in the residence. (d) The maximum amount HHSC approves as payment to a DSA for all dental treatment and adaptive aids combined for an individual is $10,000 per IPC period. (e) A DSA must follow the process for requesting authorization to purchase dental treatment described in the Community Living Assistance and Support Services Provider Manual. Source Note: The provisions of this §259.361 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.361 Respite and Dental Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212216 03/12/2026 (a) A DSA must ensure that for each direct service provided, except adaptive aids, dental treatment, minor home modifications, CFC ERS, CFC support management, and a direct service that is documented through an electronic visit verification system, as listed in 1 TAC §354.4005(b) (relating to Applicability), a service provider:(1) documents:(A) the type of service provided;(B) the date and the time the service begins and ends;(C) the type of contact (phone or in-person);(D) the name of the person with whom the contact occurred;(E) a description of the activity performed, unless the activity is a non-delegated task provided by an unlicensed service provider that is documented on an IPP;(F) the signature and title of the service provider; and(G) the progress or lack of progress in achieving a goal or outcome in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcome; and(2) completes an HHSC Documentation of Services Delivered form to document the provision of a direct service that is supported by the documentation required in paragraph (1) of this subsection.(b) A DSA must ensure that, after a service provider makes the last entry on an HHSC Documentation of Services Delivered form, a staff person other than the service provider signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.(c) A DSA must maintain a separate record for each individual receiving CLASS Program services and CFC services from the DSA. The individual's record must include:(1) a copy of the individual's current IPC and any other IPC authorized for the current IPC period;(2) a copy of the individual's current IPP and any other IPP developed for the current IPC period;(3) a copy of the individual's current PAS/HAB plan;(4) if transportation is included on the IPC as a habilitation activity or as an adaptive aid, a copy of the individual's individual transportation plan;(5) a copy of the individual's current ID/RC Assessment;(6) if the DSA was the individual's DSA when the individual enrolled in the CLASS Program:(A) the original ID/RC Assessment signed by a physician; or(B) the original level of care form signed by a physician and was in use before the ID/RC Assessment;(7) a copy of the current adaptive behavior screening assessment;(8) a copy of the current HHSC CLASS/DBMD Nursing Assessment form;(9) a copy of the current HHSC Related Conditions Eligibility Screening Instrument form;(10) any new or revised HHSC Provider Agency Model Service Backup Plan form for the current IPC period;(11) the documentation required by subsection (a)(1) of this section;(12) the completed HHSC Documentation of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section; and(13) any other relevant documentation concerning the individual. Source Note: The provisions of this §259.363 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.363 DSA: Documentation of Services Delivered and Recordkeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212217 03/12/2026 (a) A DSA must ensure that a service provider of employment assistance and a service provider of supported employment meets the qualifications described in §259.355(d)(18) of this subchapter (relating to Qualifications of DSA Staff Persons).(b) Before including employment assistance on an individual's IPC, a DSA must ensure and maintain documentation in the individual's record that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).(c) A DSA must ensure that employment assistance:(1) consists of an employment assistance service provider performing the following activities:(A) identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;(B) locating prospective employers offering employment compatible with the individual's identified preferences, skills, and requirements;(C) contacting a prospective employer on behalf of the individual and negotiating the individual's employment;(D) transporting the individual to help the individual locate competitive employment in the community; and(E) participating in service planning team meetings;(2) is not provided to an individual with the individual present at the same time that respite, transportation as a habilitation activity, prevocational services, supported employment, or CFC PAS/HAB is provided; and(3) does not include using Medicaid funds paid by HHSC to the DSA for incentive payments, subsidies, or unrelated vocational training expenses, such as:(A) paying an employer:(i) to encourage the employer to hire an individual; or(ii) to supervise, train, support, or make adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(B) paying the individual:(i) as an incentive to participate in employment assistance activities; or(ii) for expenses associated with the start-up costs or operating expenses of an individual's business.(d) Before including supported employment on an individual's IPC, a DSA must ensure and maintain documentation in the individual's record that supported employment is not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).(e) A DSA must ensure that supported employment:(1) consists of a supported employment service provider performing the following activities:(A) making employment adaptations, supervising, and providing training related to an individual's assessed needs;(B) transporting the individual to support the individual to be self-employed, work from home, or perform in a work setting; and(C) participating in service planning team meetings;(2) is not provided to an individual with the individual present at the same time that respite, transportation as a habilitation activity, prevocational services, employment assistance, or CFC PAS/HAB is provided; and(3) does not include:(A) sheltered work or other similar types of vocational services furnished in specialized facilities; or(B) using Medicaid funds paid by HHSC to the DSA for incentive payments, subsidies, or unrelated vocational training expenses, such as:(i) paying an employer:(I) to encourage the employer to hire an individual; or(II) to supervise, train, support, or make adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(ii) paying the individual:(I) as an incentive to participate in supported employment activities; or(II) for expenses associated with the start-up costs or operating expenses of an individual's business. Source Note: The provisions of this §259.365 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.365 Employment Assistance and Supported Employment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212218 03/12/2026 A DSA must not use seclusion. Source Note: The provisions of this §259.367 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.367 Prohibition of Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225007 03/12/2026 If a DSA, service provider, staff person, volunteer, or controlling person knows or suspects that an individual is being or has been abused, neglected, or exploited, the DSA must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to HHSC immediately, but not later than 24 hours after having knowledge or suspicion, by:(1) calling the HHSC toll-free telephone number, 1-800-458-9858; or(2) using the HHSC online Texas Unified Licensure Information Portal. Source Note: The provisions of this §259.369 adopted to be effective January 30, 2023, 48 TexReg 362; amended to be effective May 13, 2025, 50 TexReg 2813. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.369 DSA: Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212220 03/12/2026 (a) If a report required by §259.369 of this subchapter (relating to DSA: Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation by a person who is not a service provider, staff person, volunteer, or controlling person of a DSA, the DSA must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) discuss with the individual or LAR alternative residential settings and additional services that may help ensure the individual's safety;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(4) preserve and protect evidence related to the allegation.(b) If a report required by §259.369 of this subchapter alleges abuse, neglect, or exploitation by a service provider, staff person, volunteer, or controlling person of a DSA; or if the DSA is notified by HHSC of an allegation of abuse, neglect, or exploitation by a service provider, staff person, volunteer, or controlling person of the DSA, the DSA must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) as soon as possible, but no later than 24 hours after the DSA reports or is notified of the allegation, notify the individual, the LAR, and the case manager of:(A) the allegation report; and(B) the actions the DSA has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(c) During an HHSC investigation of an alleged perpetrator who is a service provider, staff person, volunteer, or controlling person of the DSA, a DSA must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the DSA;(B) individuals, service providers, staff persons, volunteers, and controlling persons; and(C) records pertinent to the investigation of the allegation; and(3) ensure that service providers, staff persons, volunteers, and controlling persons of the DSA comply with paragraphs (1) and (2) of this subsection.(d) After a DSA receives a final investigative report from HHSC for an investigation described in subsection (c) of this section, the DSA must:(1) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the DSA's authority to prevent the reoccurrence of abuse, neglect or exploitation, including disciplinary action against the service provider, staff person, or volunteer of the DSA confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the DSA's authority, as necessary; and(3) immediately, but not later than five calendar days after the date the DSA receives the HHSC final investigative report, notify the individual, the LAR, and the case manager of:(A) the investigation finding; and(B) the action taken by the DSA in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection.(e) A DSA must not retaliate against:(1) a service provider, staff person, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations.(f) At least annually, a DSA must:(1) review all final investigative reports from HHSC for investigations described in subsection (c) of this section and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services; and(2) evaluate critical incident data reported in accordance with §259.353(b) of this subchapter (relating to DSA: Protection of an Individual) and identify program process improvements that help prevent the occurrence of critical incidents and improve service delivery. Source Note: The provisions of this §259.371 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.371 DSA: Requirements Related to the Abuse, Neglect, and Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212221 03/12/2026 If a DSA submits documentation to HHSC in accordance with this chapter containing information that is not in English, the DSA must, at the same time, submit a translation of the information in English. Source Note: The provisions of this §259.373 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H ADDITIONAL DSA REQUIREMENTS §259.373 DSA: Requirement for Translation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212222 03/12/2026 (a) Other than the initial administrative fee, if HHSC reimburses a program provider for a claim for services that were delivered before the effective date on an IPC, HHSC applies the error to the total number of units reimbursed for such services.(b) If HHSC reimburses a DSA for more than four hours of nursing used to decide whether to delegate nursing tasks to a CFC PAS/HAB service provider, HHSC applies the error to the total number of units reimbursed in excess of the four hour maximum for such services.(c) If HHSC reimburses a DSA for more than 10 hours during an individual's IPC year for nursing to prevent service breaks caused by a CFC PAS/HAB service provider not being available to provide delegated nursing tasks, HHSC applies the error to the total number of units reimbursed in excess of the 10 hour maximum for such services. Source Note: The provisions of this §259.401 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I FISCAL MONITORING §259.401 Financial Errors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212223 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212223 03/12/2026 (a) HHSC may allow a program provider to use one or more of the exceptions described in subsections (c) - (p) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers:(1) if HHSC allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding §259.61(a)(2) of this chapter (relating to Process for Enrollment of an Individual), an initial visit for an individual who resides in the disaster area may be conducted by videoconferencing or in person.(d) Notwithstanding §259.61(h)(1)(A) and (B) of this chapter, a DSA staff person may complete the requirements described in §259.61(h)(1)(A) of this chapter for an individual who resides in the disaster area by videoconferencing or in person.(e) Notwithstanding §259.61(h)(2) of this chapter, an appropriate professional may complete an adaptive behavior screening assessment of an individual who resides in the disaster area by videoconferencing in accordance with the professional's licensing requirements or in person.(f) Notwithstanding §259.61(h)(3)(A) - (C) and §259.75(a)(1)(B) of this chapter (relating to Annual Review by HHSC of Whether an Individual Meets LOC VIII Criteria), an RN may complete the HHSC CLASS/DBMD Nursing Assessment form, the HHSC Related Conditions Eligibility Screening Instrument, and the ID/RC Assessment of an individual who resides in the disaster area by videoconferencing in accordance with the RN's licensing requirements or in person.(g) Notwithstanding §259.65(c)(1)(A) of this chapter (relating to Development of an Enrollment IPC), a case manager is not required to ensure an individual who resides in the disaster area or LAR signs and dates an enrollment IPC and IPP if:(1) the meeting required by §259.65(a)(1) of this chapter is conducted by videoconferencing;(2) the individual or LAR orally agrees with the enrollment IPC and IPPs; and(3) the case manager documents the individual's or LAR's oral agreement on the enrollment IPC and IPPs.(h) Notwithstanding §259.79(a)(1) and (2) of this chapter (relating to Renewal and Revision of an IPC), a case manager may conduct all IPP service review meetings with an individual who resides in the disaster area and LAR in person or by videoconferencing.(i) Notwithstanding §259.79(b)(6) of this chapter, a case manager is not required to ensure that an individual who resides in the disaster area or LAR signs the HHSC IPP Service Review form, if:(1) the meeting required by §259.79(a) of this chapter is conducted by videoconferencing;(2) the individual or LAR orally agree with the HHSC IPP Service Review form; and(3) the case manager documents the individual's or LAR's oral agreement on the HHSC IPP Service Review form.(j) If a service planning team meeting described in §259.79(c) is conducted by videoconferencing for an individual who resides in the disaster area, a case manager may:(1) on a renewal or revised IPP:(A) notwithstanding §259.79(f)(2)(A) of this chapter, replace the signature of an individual or LAR by documenting on the renewal or revised IPP that the individual or LAR orally agreed to the renewal or revised IPP; and(B) notwithstanding §259.79(f)(2)(C) of this chapter, obtain the signature of the DSA after the service planning team meeting; and(2) on a proposed renewal or proposed revised IPC:(A) notwithstanding §259.79(g)(1)(A) of this chapter, replace the signature of the individual or LAR by documenting on the proposed renewal or proposed revised IPC that the individual or LAR orally agreed to the proposed renewal or proposed revised IPC; and(B) notwithstanding §259.79(g)(1)(C) of this chapter, obtain the signature of the DSA after the service planning team meeting.(k) Notwithstanding §259.73(a)(1) of this chapter (relating to Service Limits), the combined cost for adaptive aids and dental treatment may exceed $10,000 during an IPC period if:(1) the requested adaptive aid or repair that causes the combined cost to be exceeded is:(A) an adaptive aid that replaces an adaptive aid that was destroyed as a result of the disaster; or(B) a repair of an adaptive aid that was damaged as a result of the disaster; and(2) the requested adaptive aid or repair added to the individual's IPC does not result in the combined cost of dental treatment and adaptive aids to exceed $15,000 during the IPC period, which includes the cost of repair and maintenance of an adaptive aid.(l) Notwithstanding §259.255(a) of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing Less Than $500), if an individual requests the repair or replacement of an adaptive aid damaged or destroyed as a result of a disaster:(1) a DSA must provide to the case manager:(A) a description of the repair or replacement of the adaptive aid that was damaged or destroyed as a result of the disaster; and(B) the cost of the repair or replacement of the adaptive aid;(2) the case manager must:(A) include the cost of the adaptive aid or repair, which must be within the cost described in subsection (k)(2) of this section, in the individual's:(i) proposed renewal or proposed revised IPC; and(ii) renewal or revised IPP;(B) obtain the individual or LAR's oral agreement to the proposed renewal or proposed revised IPC and IPP;(C) document the individual's or LAR's oral agreement on the proposed renewal or proposed revised IPC and IPP; and(D) sign the proposed renewal or proposed revised IPC and IPP;(3) the DSA must sign the proposed renewal or proposed revised IPC and IPP; and(4) the CMA must submit to HHSC, no later than 180 days after the effective date of the order or proclamation described in subsection (a) of this section:(A) the proposed renewal or proposed revised IPC;(B) the renewal or revised IPP;(C) the description of the repair or replacement described in paragraph (1) of this subsection; and(D) a written statement of the case manager that the requested adaptive aid or repair is not available through a third-party resource.(m) Notwithstanding §§259.257, 259.259, and 259.261 of this chapter (relating to Requirements for Authorization to Purchase an Adaptive Aid Costing $500 or More, Requirements for Specifications for an Adaptive Aid, and Requirements for Bids of an Adaptive Aid), if an individual requests the repair or replacement of an adaptive aid costing $500 or more damaged or destroyed as a result of a disaster:(1) the DSA must provide to the case manager:(A) a description of the repair or replacement of an adaptive aid that was damaged or destroyed as a result of the disaster; and(B) one bid for the repair or replacement of an adaptive aid from a vendor that includes:(i) the cost of the repair or replacement of the adaptive aid, which may be from a catalog, website, or brochure price list;(ii) the amount of any additional expenses related to the delivery of the adaptive aid, including shipping and handling, taxes, installation, and other labor charges;(iii) the date of the bid; and(iv) the name, address, and telephone number of the vendor, who may not be a relative of the individual;(2) the case manager must:(A) include the cost of the adaptive aid or repair, which must be within the cost described in subsection (k)(2) of this section, in the individual's:(i) proposed renewal or proposed revised IPC; and(ii) renewal or revised IPP;(B) obtain the individual's or LAR's oral agreement;(C) document the individual's or LAR's oral agreement on the proposed renewal or proposed revised IPC and IPP; and(D) sign the proposed renewal or proposed revised IPC and IPP;(3) the DSA must sign the proposed renewal or proposed revised IPC and IPP; and(4) the CMA must submit to HHSC, no later than 180 days after the effective date of the order or proclamation described in subsection (a) of this section:(A) the description and bid of the repair or replacement described in paragraph (1) of this subsection;(B) the proposed renewal or proposed revised IPC and IPP, completed as described in paragraphs (2) and (3) of this subsection; and(C) a written statement of the case manager that the requested adaptive aid or repair is not available through a third-party resource.(n) Notwithstanding §259.73(a)(2) of this chapter, the service limit for minor home modifications for an individual who resides in the disaster area may exceed $10,000 during the time the individual is enrolled in the CLASS program if:(1) the requested minor home modification or repair that causes the service limit to be exceeded is:(A) a minor home modification that replaces a minor home modification that was destroyed as a result of the disaster; or(B) a repair of a minor home modification that was damaged as a result of the disaster; and(2) the requested minor home modification or repair added to the individual's IPC does not exceed $15,000 for minor home modifications during the time the individual is enrolled in the CLASS program.(o) Notwithstanding §§259.275, 259.277, and 259.279 of this chapter (relating to Requirements for Authorization to Purchase a Minor Home Modification, Requirements for Specifications for a Minor Home Modification, and Bid Requirements for a Minor Home Modification), if an individual requests the repair or replacement of a minor home modification damaged or destroyed as a result of a disaster:(1) the DSA must provide to the case manager:(A) a description of the repair or replacement of the minor home modification that was damaged or destroyed as a result of the disaster; and(B) one bid for the repair or replacement of the minor home modification from a vendor that includes:(i) the cost of the repair or replacement of the minor home modification, which may be from a catalog, website, or brochure price list;(ii) the amount of any additional expenses related to the delivery of the minor home modification, including shipping and handling, taxes, installation, and other labor charges;(iii) the date of the bid; and(iv) the name, address, and telephone number of the vendor, who may not be a relative of the individual;(2) the case manager must:(A) include the cost of the minor home modification or repair, which must not exceed the cost described in subsection (n)(2) of this section, in the individual's:(i) proposed renewal or proposed revised IPC; and(ii) renewal or revised IPP;(B) obtain the individual or LAR's oral agreement;(C) document the individual's or LAR's oral agreement on the proposed renewal or proposed revised IPC and IPP; and(D) sign the proposed renewal or proposed revised IPC and IPP;(3) the DSA must sign the proposed renewal or proposed revised IPC and IPP; and(4) the CMA must submit to HHSC, no later than 180 days after the effective date of the order or proclamation described in subsection (a) of this section:(A) the description and bid of the repair or replacement described in paragraph (1) of this subsection;(B) the proposed renewal or proposed revised IPC and IPP, completed as described in paragraphs (2) and (3) of this subsection; and(C) a written statement of the case manager that the requested adaptive aid or repair is not available through a third-party resource.(p) Notwithstanding §259.357(b)(1)(B) and (b)(2)(B) of this chapter (relating to Training of DSA Staff Persons, Service Providers, and Volunteers), a service provider may complete an online training course in cardiopulmonary resuscitation and choking prevention but an in-person evaluation by a qualified instructor is not required to be completed, if:(1) as a result of the disaster, the service provider is unable to arrange for the in-person evaluation; and(2) the in-person evaluation is completed within 90 calendar days after the disaster ends. Source Note: The provisions of this §259.451 adopted to be effective January 30, 2023, 48 TexReg 362. 1 HEALTH AND HUMAN SERVICES COMMISSION 259 COMMUNITY LIVING ASSISTANCE AND SUPPORT SERVICES (CLASS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES J DECLARATION OF DISASTER §259.451 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222988 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Actively involved--Significant, ongoing, and supportive involvement with an individual by a person, as determined by the individual, based on the person's:(A) interactions with the individual;(B) availability to the individual for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the individual's needs, preferences, values, and beliefs.(3) Adaptive aid--A service in the Deaf Blind with Multiple Disabilities (DBMD) Program that:(A) enables an individual to retain or increase the ability to perform ADLs or perceive, control, or communicate with the environment in which the individual lives; and(B) meets one of the following criteria:(i) is an item included in the list of adaptive aids in the Deaf Blind with Multiple Disabilities Program Manual; or(ii) is the repair or maintenance of an item on the list of adaptive aids in the Deaf Blind with Multiple Disabilities Program Manual that is not covered by a warranty.(4) Adaptive behavior--The effectiveness with or degree to which an individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group as assessed by an adaptive behavior screening assessment.(5) Adaptive behavior level--The categorization of an individual's functioning level based on a standardized measure of adaptive behavior. There are four adaptive behavior levels ranging from mild limitations in adaptive skills (I) through profound limitations in adaptive skills (IV).(6) Adaptive behavior screening assessment--A standardized assessment used to determine an individual's adaptive behavior level, and conducted using the current version of one of the following assessment instruments:(A) American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS);(B) Inventory for Client and Agency Planning (ICAP);(C) Scales of Independent Behavior; or(D) Vineland Adaptive Behavior Scales.(7) ADLs--Activities of daily living. Basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring.(8) Agency foster home--This term has the meaning set forth in Texas Human Resources Code §42.002.(9) Alarm call--A signal transmitted from an individual's Community First Choice (CFC ) Emergency Response Services (ERS ) equipment to the CFC ERS response center indicating that the individual needs immediate assistance.(10) ALF--Assisted living facility. A facility licensed in accordance with Texas Health and Safety Code Chapter 247.(11) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual.(12) Audiology--A DBMD Program service that provides assessment and treatment by a licensed audiologist and includes training and consultation with an individual's family members or other support providers.(13) Auxiliary aid--A service or device that enables an individual with impaired sensory, manual, or speaking skills to participate in the person-centered planning process. An auxiliary aid includes interpreter services, transcription services, and a text telephone.(14) Behavior support plan--A comprehensive, individualized written plan based on a current functional behavior assessment that includes specific outcomes and behavioral techniques designed to teach or increase adaptive skills and decrease or eliminate target behaviors.(15) Behavioral emergency--A situation in which an individual is acting in an aggressive, destructive, violent, or self-injurious manner that poses a risk of death or serious bodily harm to the individual or others.(16) Behavioral support--A DBMD Program service that provides specialized interventions to assist an individual in increasing adaptive behaviors and replacing or modifying behaviors that prevent or interfere with the individual's inclusion in the community and consists of the following activities:(A) conducting a functional behavior assessment;(B) developing an individualized behavior support plan;(C) training and consulting with an individual, family member, or other persons involved in the individual's care regarding the implementation of the behavior support plan;(D) monitoring and evaluating the effectiveness of the behavior support plan;(E) modifying, as necessary, the behavior support plan based on monitoring and evaluating the plan's effectiveness; and(F) counseling and educating an individual, family members, or other persons involved in the individual's care about the techniques to use in assisting the individual to control challenging or socially unacceptable behaviors.(17) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(18) Calendar day--Any day, including weekends and holidays.(19) Case management--The DBMD Program service described in §260.337 of this chapter (relating to Case Management).(20) Case manager--A service provider of case management.(21) CDS option--Consumer directed services option. A service delivery option defined in §264.103 of this title (relating to Definitions).(22) CFC--Community First Choice.(23) CFC ERS--CFC emergency response services. A CFC service that provides backup systems and supports used to ensure continuity of services and supports. CFC ERS includes electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices.(24) CFC ERS provider--The entity directly providing CFC ERS to an individual, which may be the program provider or a contractor of the program provider.(25) CFC FMS--CFC financial management services. A CFC service provided to an individual who receives only CFC PAS/HAB through the CDS option.(26) CFC PAS/HAB--CFC personal assistance services/habilitation. A CFC service:(A) that consists of:(i) personal assistance services, which provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including:(I) non-skilled assistance with the performance of the ADLs and IADLs;(II) household chores necessary to maintain the home in a clean, sanitary, and safe environment;(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and(IV) assistance with health-related tasks; and(ii) habilitation, which provides assistance to an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, including:(I) self-care;(II) personal hygiene;(III) household tasks;(IV) mobility;(V) money management;(VI) community integration, including how to get around in the community;(VII) use of adaptive equipment;(VIII) personal decision making;(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and(X) self-administration of medication; and(B) does not include transporting the individual, which means driving the individual from one location to another.(27) CFC support consultation--A CFC service that provides support consultation to an individual who receives only CFC PAS/HAB through the CDS option.(28) CFC support management--A CFC service that provides training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB.(29) CFR--Code of Federal Regulations.(30) Chemical restraint--A medication used to control an individual's behavior or to restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition.(31) Chore services--A DBMD Program service, other than CFC PAS/HAB household chores, needed to maintain a clean, sanitary, and safe environment in an individual's home and consists of heavy household chores, such as washing floors, windows, and walls, securing loose rugs and tiles, and moving heavy items or furniture.(32) CMS--The Centers for Medicare & Medicaid Services. CMS is the agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.(33) Competitive employment--Employment that pays an individual at least minimum wage if the individual is not self-employed.(34) Contract--A provisional contract that the Texas Health and Human Services Commission enters into in accordance with §52.39 of this title (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §52.39(e) of this title or a standard contract that HHSC enters into in accordance with §52.41 of this title (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with §52.41(d) of this title.(35) Controlling person--A person who:(A) has an ownership interest in a program provider;(B) is an officer or director of a corporation that is a program provider;(C) is a partner in a partnership that is a program provider;(D) is a member or manager in a limited liability company that is a program provider;(E) is a trustee or trust manager of a trust that is a program provider; or(F) because of a personal, familial, or other relationship with a program provider, is in a position of actual control or authority with respect to the program provider, regardless of the person's title.(36) Day Activity and Health Services Program--This term has the meaning set forth in Texas Human Resource Code §103.003.(37) DBMD Program--The Deaf Blind with Multiple Disabilities Program.(38) Deafblindness--A chronic condition in which a person:(A) has deafness, which is a hearing impairment severe enough that most speech cannot be understood with amplification; and(B) has legal blindness, which results from a central visual acuity of 20/200 or less in the person's better eye, with correction, or a visual field of 20 degrees or less.(39) Denial--An action taken by HHSC that:(A) rejects an individual's request for enrollment into the DBMD Program;(B) disallows a DBMD Program service or a CFC service requested on an individual plan of care (IPC) that was authorized on the prior IPC; or(C) disallows a portion of the amount or level of a DBMD Program service or a CFC service requested on an IPC that was not authorized on the prior IPC.(40) Dental treatment--A DBMD Program service that:(A) consists of the following:(i) emergency dental treatments, which are procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures;(ii) routine preventative dental treatments, which are examinations, x-rays, cleanings, sealants, oral prophylaxes, and topical fluoride applications;(iii) therapeutic dental treatments, which include fillings, scaling, extractions, crowns, and pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development;(iv) orthodontic dental treatments, which are procedures that include treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and(v) dental sedation, which is sedation necessary to perform dental treatment including non-routine anesthesia, (for example, intravenous sedation, general anesthesia, or sedative therapy prior to routine procedures) but not including administration of routine local anesthesia only; and(B) does not include cosmetic orthodontia.(41) Developmental disability--As defined in the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Section 102(8), a severe, chronic disability of an individual five years of age or older that:(A) is attributable to a mental or physical impairment or combination of mental and physical impairments;(B) is manifested before the individual attains 22 years of age;(C) is likely to continue indefinitely; and(D) results in substantial functional limitations in three or more of the following areas of major life activity:(i) self-care;(ii) receptive and expressive language;(iii) learning;(iv) mobility;(v) self-direction;(vi) capacity for independent living; and(vii) economic self-sufficiency.(42) DFPS--Department of Family and Protective Services.(43) Dietary services--A DBMD Program service that provides nutrition services, as defined in Texas Occupations Code §701.002.(44) Employment assistance--A DBMD Program service that provides assistance to an individual to help the individual locate competitive employment in the community to the same degree of access as individuals not receiving DBMD Program services.(45) Employment readiness--The DBMD Program service described in §260.341 of this chapter (relating to Employment Services).(46) Employment readiness location--A location where employment readiness is provided.(47) Enrollment Individual Plan of Care (IPC)--The first IPC for an individual developed before the individual's enrollment into the DBMD Program.(48) Enrollment Individual Program Plan (IPP)--The first IPP for an individual developed before the individual's enrollment into the DBMD Program in accordance with §260.65 of this chapter (relating to Development of an Enrollment IPP).(49) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain.(50) FMS--Financial management services. A DBMD Program service that is defined in §264.103 of this title and provided to an individual participating in the CDS option.(51) FMSA--Financial management services agency. An entity, as defined in §264.103 of this title, that provides FMS.(52) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(53) Functional behavior assessment--An evaluation that is used to determine the underlying function or purpose of an individual's behavior, so an effective behavior support plan can be developed.(54) Functions as a person with deafblindness--Situation in which a person is determined:(A) to have a progressive medical condition, manifested before 22 years of age, that will result in the person having deafblindness; or(B) before attaining 22 years of age, to have limited hearing or vision due to protracted inadequate use of either or both of these senses.(55) Good cause--As determined by HHSC, A reason outside the control of a CFC ERS provider that is an acceptable reason for the CFC ERS provider's failure to comply.(56) HCSSA--Home and community support services agency. An entity required to be licensed under Texas Health and Safety Code (THSC) Chapter 142.(57) Health-related tasks--Specific tasks related to the needs of an individual that can be delegated or assigned by a licensed healthcare professional under state law to be performed by a service provider of CFC PAS/HAB. These include:(A) tasks delegated by a registered nurse (RN);(B) health maintenance activities, as defined in 22 TAC §225.4 (relating to Definitions), that may not require delegation; and(C) activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist.(58) HHSC--The Texas Health and Human Services Commission.(59) Hospital--A public or private institution that is licensed or is exempt from licensure in accordance with THSC Chapters 13, 241, 261, or 552.(60) IADLs--Instrumental activities of daily living. Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community.(61) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is A facility in which ICF/IID Program services are provided and that is:(A) licensed in accordance with THSC Chapter 252; or(B) certified by HHSC, including a state supported living center.(62) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions.(63) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. An HHSC form used to determine the LOC for an individual.(64) Impairment to independent functioning--An adaptive behavior level of II, III, or IV.(65) Individual--A person seeking to enroll or who is enrolled in the DBMD Program.(66) Individual transportation plan--A written plan developed by an individual's service planning team and documented on the HHSC Individual Transportation Plan form. The form is used to document how transportation as a residential habilitation activity will be delivered to support an individual's desired goals and outcomes for transportation as identified in the IPP.(67) Inpatient chemical dependency treatment facility--A facility licensed in accordance with THSC Chapter 464.(68) In person or in-person--Within the physical presence of another person. In person or in-person does not include using videoconferencing or a telephone.(69) Institution for mental diseases--Has the meaning set forth in 42 CFR §435.1010.(70) Institutional services--Medicaid-funded services provided in a nursing facility or in an ICF/IID.(71) Intellectual disability--Consistent with THSC §591.003, significantly sub-average general intellectual functioning that is concurrent with deficits in adaptive behavior and originates during the developmental period.(72) Intervener--A service provider with specialized training and skills in deafblindness who, working with one individual at a time, serves as a facilitator to involve an individual in home and community services and activities, and who is classified as an Intervener, Intervener I, Intervener II, or Intervener III in accordance with Texas Government Code §526.0404.(73) IPC--Individual plan of care. A written plan developed by an individual's service planning team and documented on the HHSC Individual Plan of Care form. An IPC:(A) documents:(i) the type and amount of each DBMD Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year; and(ii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(74) IPC period--The effective period of an enrollment IPC and a renewal IPC as follows:(A) for an enrollment IPC, the period of time from the effective date of the enrollment IPC, as described in §260.67(a)(1)(F) of this chapter (relating to Development of a Proposed Enrollment IPC), through the last calendar day of the 11th month after the month in which enrollment occurred; and(B) for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC as described in §260.77(a)(1) of this chapter (relating to Renewal and Revision of an IPP and IPC).(75) IPP--Individual program plan. A written plan that includes the information described in §260.65(b) of this chapter (relating to Development of an Enrollment IPP) and documented on an HHSC Individual Program Plan form.(76) Job-task oriented--Focused on developing a skill related to a specific type of employment.(77) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(78) Licensed assisted living--A DBMD Program service provided by a program provider in an ALF that is owned by the program provider.(79) Licensed home health assisted living--A DBMD Program service provided by a program provider licensed as a HCSSA, in a residence for no more than three individuals. The residence must be owned or leased by at least one of the residents and must not be owned or leased by a program provider.(80) Licensed vocational nursing--A DBMD Program service that provides vocational nursing, as defined in Texas Occupations Code §301.002.(81) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with THSC §533A.035.(82) LOC--Level of care. A determination given to an individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(83) LVN--Licensed vocational nurse. A person licensed to provide vocational nursing in accordance with Texas Occupations Code Chapter 301.(84) Managed care organization--This term has the meaning set forth in Texas Government Code §543A.0001.(85) MAO Medicaid--Medical Assistance Only Medicaid. A type of Medicaid by which an individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits.(86) Mechanical restraint--A mechanical device, material, or equipment used to control an individual's behavior by restricting the ability of the individual to freely move part or all of the individual's body. The term does not include a protective device.(87) Medicaid--A program administered by CMS and funded jointly by the states and the federal government that pays for health care to eligible groups of low-income people.(88) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(89) Mental health facility--A facility licensed in accordance with THSC Chapter 577.(90) MESAV--Medicaid Eligibility Service Authorization Verification. The automated system that contains information regarding an individual's Medicaid eligibility and service authorizations.(91) Military family member--A person who is the spouse or child, regardless of age, of:(A) a military member; or(B) a former military member.(92) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch.(93) Minor home modifications--A DBMD Program service that:(A) makes a physical adaptation to an individual's residence that:(i) is necessary to address the individual's specific needs; and(ii) enables the individual to function with greater independence in the individual's residence or to control his or her environment; and(B) meets one of the following criteria:(i) is included on the list of minor home modifications in the Deaf Blind with Multiple Disabilities Program Manual; or(ii) is the repair or maintenance of a minor home modification purchased through the DBMD Program that:(I) is needed after one year has elapsed from the date the minor home modification is complete;(II) is needed for a reason other than the minor home modification was intentionally damaged, as described in §260.329(c) of this chapter (relating to Repair or Replacement of a Minor Home Modification); and(III) is not covered by a warranty.(94) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who assist and sustain an individual.(95) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(96) Nursing--One or more of the following DBMD Program services:(A) licensed vocational nursing;(B) registered nursing;(C) specialized licensed vocational nursing; and(D) specialized registered nursing.(97) Nursing facility--A facility that is licensed or exempt from licensure in accordance with the THSC Chapter 242.(98) Occupational therapy--A DBMD Program service that provides occupational therapy, as described in Texas Occupations Code §454.006.(99) Orientation and mobility--A DBMD Program service that assists an individual to acquire independent travel skills that enable the individual to negotiate safely and efficiently between locations at home, school, work, and in the community.(100) PAS/HAB plan--Personal Assistance Services (PAS)/Habilitation Plan. A written plan developed by an individual's service planning team and documented on the HHSC Personal Assistance Services (PAS)/Habilitation Plan form that describes the type and frequency of CFC PAS/HAB activities to be performed by a service provider.(101) Person--A corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, natural person, or any other legal entity that can function legally, sue or be sued, and make decisions through agents.(102) Personal funds--The funds that belong to an individual, including earned income, social security benefits, gifts, and inheritances.(103) Person-centered planning process--The process described in §260.57 of this chapter (relating to Person-Centered Planning Process).(104) Personal leave day--A continuous 24-hour period, measured from midnight to midnight, when an individual who resides in a residence in which licensed assisted living or licensed home health assisted living is provided is absent from the residence for personal reasons.(105) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual;(C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or(D) seclusion.(106) Physical restraint--Any manual method used to control an individual's behavior, except for physical guidance or prompting of brief duration that an individual does not resist, that restricts:(A) the free movement or normal functioning of all or a part of the individual's body; or(B) normal access by an individual to a portion of the individual's body.(107) Physical therapy--A DBMD program service that provides physical therapy, as defined in Texas Occupations Code §453.001.(108) Physician--Consistent with §558.2 of this title (relating to Definitions), a person who is:(A) licensed in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code Chapter 155;(B) licensed in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of an individual, and orders home health or hospice services for the individual in accordance with Texas Occupations Code §151.056(b)(4); or(C) a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service if the person is not engaged in private practice, in accordance with the Texas Occupations Code §151.052(a)(8).(109) Program provider--A person that has a contract with HHSC to provide DBMD Program services, excluding an FMSA.(110) Protective device--An item or device, such as a safety vest, lap belt, bed rail, safety padding, adaptation to furniture, or helmet, if:(A) used only:(i) to protect an individual from injury; or(ii) for body positioning of the individual to ensure health and safety; and(B) not used to modify or control behavior.(111) Public emergency personnel--Personnel of a sheriff's department, police department, emergency medical service, or fire department.(112) Reduction--An action taken by HHSC as a result of a review of a revised IPC or renewal IPC that decreases the amount or level of a service authorized by HHSC on the prior IPC.(113) Registered nursing--A DBMD Program service that provides professional nursing, as defined in Texas Occupations Code §301.002.(114) Related condition--As defined in 42 CFR §435.1010, a severe and chronic disability that:(A) is attributed to:(i) cerebral palsy or epilepsy; or(ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability;(B) is manifested before the individual reaches 22 years of age;(C) is likely to continue indefinitely; and(D) results in substantial functional limitation in at least three of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(115) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the Deaf Blind with Multiple Disabilities Program Manual.(116) Renewal IPC--An IPC developed in accordance with §260.77 of this chapter.(117) Residential child-care facility--The term has the meaning set forth in Texas Human Resources Code §42.002.(118) Respite--A DBMD Program service described in §260.353 of this chapter (relating to Respite).(119) Responder--A person designated to respond to an alarm call activated by an individual.(120) Restraint--Any of the following:(A) a physical restraint;(B) a mechanical restraint; or(C) a chemical restraint.(121) Restrictive intervention--An action or procedure that limits an individual's movement, access to other individuals, locations, or activities, or restricts an individual's rights, including a restraint, a protective device, and seclusion.(122) Revised IPC--An enrollment IPC or a renewal IPC that is revised during an IPC period in accordance with §260.77 of this chapter to add a new DBMD Program service or CFC service or change the amount of an existing service.(123) RN--Registered nurse. A person licensed to provide professional nursing in accordance with Texas Occupations Code Chapter 301.(124) Seclusion--A restrictive intervention that is the involuntary placement of an individual alone in an area from which the individual is prevented from leaving.(125) Service backup plan--A written plan developed and revised by an individual's service planning team in accordance with §260.213 of this chapter (relating to Service Backup Plans) to ensure continuity of critical program services if service delivery is interrupted.(126) Service planning team--A team consisting of:(A) the individual;(B) if applicable, the individual's LAR or an actively involved person;(C) the individual's case manager;(D) one of the following persons who is not the case manager:(i) the program director; or(ii) an RN designated by the program provider;(E) other persons whose inclusion is requested by the individual, LAR, or actively involved person, including a managed care organization service coordinator, a family member, a friend, and a teacher; and(F) other persons selected by the program provider who are:(i) professionally qualified by certification or licensure and have special training and experience in the diagnosis and habilitation of persons with the individual's related condition; or(ii) directly involved in the delivery of services and supports to the individual.(127) Service provider--A person who is an employee or contractor of a program provider who provides a DBMD Program service or a CFC service directly to an individual.(128) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and a service provider, staff person, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff person, volunteer, or controlling person became a service provider, staff person, volunteer, or controlling person.(129) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(130) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(131) Significant subaverage general intellectual functioning--Consistent with THSC §591.003, measured intelligence on standardized general intelligence tests of two or more standard deviations (not including standard error of measurement adjustments) below the age-group mean for the tests used.(132) Specialized licensed vocational nursing--A DBMD Program service that provides licensed vocational nursing to an individual who has a tracheostomy or is dependent on a ventilator.(133) Specialized registered nursing--A DBMD Program service that provides registered nursing to an individual who has a tracheostomy or is dependent on a ventilator.(134) Speech-language pathology--A DBMD Program service that provides speech-language pathology as defined in Texas Occupations Code §401.001.(135) SSA--Social Security Administration.(136) SSI--Supplemental Security Income.(137) Staff person--A full-time or part-time employee of a program provider, other than a service provider.(138) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC.(139) Support consultation--A DBMD Program service that is defined in §264.103 of this title and may be provided an individual who chooses to participate in the CDS option.(140) Supported employment--A DBMD Program service that provides assistance to sustain competitive employment to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.(141) System check--A test of the CFC ERS equipment to determine if:(A) the individual can successfully activate an alarm call; and(B) the equipment is working properly.(142) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas State Secretary of State in accordance with Texas Government Code Chapter 2002, Subchapter C.(143) TAS--Transition Assistance Services. A DBMD Program service provided in accordance with Chapter 272 of this title (relating to Transition Assistance Services) to an individual who is receiving institutional services and is eligible for and enrolling into the DBMD Program.(144) Texas Workforce Commission--The state agency established under Texas Labor Code Chapter 301.(145) THSC--Texas Health and Safety Code. Texas statutes relating to health and safety.(146) TMHP--Texas Medicaid & Healthcare Partnership. The Texas Medicaid program claims administrator.(147) Transfer--The movement of an individual from a DBMD Program provider or a FMSA to a different DBMD Program provider or FMSA.(148) Trust fund account--An account at a financial institution that contains an individual's personal funds and is under the program provider's control.(149) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(150) Videoconferencing--An interactive, two-way audio and video communication:(A) used to conduct a meeting between two or more persons who are in different locations; and(B) that conforms to the privacy requirements under the Health Insurance Portability and Accountability Act.(151) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §260.5 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §260.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222989 03/12/2026 (a) The DBMD Program is a Medicaid waiver program approved by CMS and operated by HHSC pursuant to §1915(c) of the Social Security Act. It provides community-based services and supports to an eligible individual as an alternative to the ICF/IID Program. DBMD Program services are intended to:(1) enhance the individual's integration into the community;(2) maintain or improve the individual's independent functioning, and(3) prevent the individual's admission to an institution.(b) HHSC limits the enrollment in the DBMD Program to the number of individuals approved by CMS and funded by the State of Texas.(c) The DBMD Program offers the following services approved by CMS:(1) adaptive aids;(2) residential assistance, provided as:(A) licensed assisted living; or(B) licensed home health assisted living;(3) behavioral support;(4) case management;(5) chore services;(6) day habilitation;(7) dental treatment;(8) dietary services;(9) employment assistance;(10) employment readiness;(11) intervener services;(12) minor home modifications;(13) nursing;(14) occupational therapy;(15) orientation and mobility;(16) physical therapy;(17) residential habilitation;(18) respite, provided as:(A) in-home respite; or(B) out-of-home respite;(19) speech-language pathology;(20) audiology;(21) supported employment;(22) TAS; and(23) if the individual's IPC includes at least one DBMD Program service to be delivered through the CDS option:(A) FMS; and(B) support consultation.(d) A program provider may only provide and bill for residential habilitation if the activity provided is transportation, as described in §260.343(b)(1)(A)(ii)(I) of this chapter (relating to Day Habilitation, Residential Habilitation, and CFC PAS/HAB).(e) CFC is a state plan option governed by CFR, Title 42, Part 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice) that provides the following services to an individual:(1) CFC PAS/HAB;(2) CFC ERS; and(3) CFC support management for an individual receiving CFC PAS/HAB.(f) A program provider with a contract enrollment date on or after September 1, 2009, must serve all counties within an HHSC region.(g) A program provider with a contract enrollment date before September 1, 2009, may continue to serve only the counties specified in its contract. If such a program provider chooses to provide services in additional counties, the program provider does not have to serve all the counties within the HHSC region. Source Note: The provisions of this §260.7 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §260.7 Description of the DBMD Program and CFC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212510 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212510 03/12/2026 The DBMD Program does not provide:(1) room and board, except when out-of-home respite is provided in an outdoor camp accredited by the American Camping Association;(2) special education and related services defined in 20 United States Code §1401 that otherwise are available to the individual through a state or local educational agency;(3) vocational rehabilitation services that otherwise are available to the individual through a program funded under 29 United States Code Chapter 16, Subchapter I; or(4) a service not described in the DBMD Program waiver application approved by CMS and available on the HHSC website or this chapter. Source Note: The provisions of this §260.9 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES A DEFINITIONS, DESCRIPTION OF SERVICES, AND EXCLUDED SERVICES §260.9 Excluded Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226068 03/12/2026 (a) An individual is eligible for DBMD Program services if:(1) the individual meets the financial eligibility criteria as described in Appendix B of the DBMD Program waiver application approved by CMS and available on the HHSC website;(2) the individual is determined by HHSC to meet the LOC VIII criteria described in §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria);(3) the individual, as documented on the ID/RC Assessment: (A) has one or more diagnosed related conditions and, as a result:(i) has deafblindness;(ii) has been determined to have a progressive medical condition that will result in deafblindness; or(iii) functions as a person with deafblindness; and(B) has one or more additional disabilities that result in impairment to independent functioning;(4) the individual has an IPC with a cost for DBMD Program services at or below 210 percent of the annualized cost of care in an ICF/IID using the unweighted average of the current non-state operated small facility daily rates for level of need, as defined by the ICF/IID program rules in §261.203 of this title (relating to Definitions), 1, 5, and 8 rounded to the nearest dollar, which as of September 1, 2025 is $149,774;(5) the individual is not enrolled in another waiver program or receiving a service that may not be received if the individual is enrolled in the DBMD Program, as identified in the Mutually Exclusive Services table in Appendix V of the Deaf Blind with Multiple Disabilities Program Manual;(6) the individual does not reside in:(A) an ICF/IID;(B) a nursing facility;(C) an ALF, unless it provides licensed assisted living in the DBMD Program;(D) a residential child-care facility unless it is an agency foster home;(E) a hospital;(F) a mental health facility;(G) an inpatient chemical dependency treatment facility;(H) a residential facility operated by the Texas Workforce Commission;(I) a residential facility operated by the Texas Juvenile Justice Department;(J) a jail; or(K) a prison;(7) at least one program provider is willing to provide DBMD Program services to the individual;(8) the individual resides or moves to reside in a county served by a program provider; and(9) the individual requires the provision of:(A) at least one DBMD Program Service per month or a monthly monitoring by a case manager; and(B) at least one DBMD Program Service during an IPC period.(b) Except as provided in subsection (c) of this section, an individual is eligible for a CFC service under this chapter if the individual:(1) meets the criteria described in subsection (a) of this section;(2) requires the provision of the CFC service; and(3) is not receiving licensed assisted living or licensed home health assisted living.(c) To be eligible for a CFC service under this chapter, an individual receiving MAO Medicaid must, in addition to meeting the eligibility criteria described in subsection (b) of this section, receive a DBMD Program service at least monthly, as required by 42 CFR §441.510(d). Source Note: The provisions of this §260.51 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective September 17, 2025, 50 TexReg 6016. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.51 Eligibility Criteria for DBMD Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212512 03/12/2026 (a) HHSC maintains an interest list that contains the names of individuals interested in receiving DBMD Program services.(b) A person may request an applicant's name be added to the DBMD interest list by:(1) calling HHSC's toll-free number; or(2) submitting a written request to HHSC.(c) If a request is made in accordance with subsection (b) of this section for an individual who resides in Texas, HHSC adds the individual's name to the DBMD interest list:(1) if the individual resides in Texas; and(2) using the date HHSC receives the request as the DBMD interest list date.(d) For an individual determined diagnostically or functionally ineligible during the enrollment process for the Community Living Assistance and Support Services (CLASS) Program, Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program, or Medically Dependent Children Program (MDCP):(1) if the individual's name is not on the DBMD interest list, at the request of the individual or LAR, HHSC adds the individual's name to the DBMD interest list using the individual's interest list date for the program for which the individual was determined ineligible as the DBMD interest list date;(2) if the individual's name is on the DBMD interest list and the individual's interest list date for the program for which the individual was determined ineligible is earlier than the individual's DBMD interest list date, at the request of the individual or LAR, HHSC changes the individual's DBMD interest list date to the individual's interest list date for the program for which the individual was determined ineligible; or(3) if the individual's name is on the DBMD interest list and the individual's DBMD interest list date is earlier than the individual's interest list date for the program for which the individual was determined ineligible, HHSC does not change the individual's DBMD interest list date.(e) This subsection applies to an individual who was enrolled in MDCP and, because the individual did not meet the level of care criteria for medical necessity for nursing facility care or did not meet the age requirement of being under 21 years of age, was determined ineligible for MDCP after November 30, 2019.(1) At the request of the individual or LAR, HHSC adds the individual's name to the DBMD interest list:(A) using the MDCP interest list date as the DBMD interest list date, if the individual's name is not on the DBMD interest list but it was previously on the DBMD interest list; or(B) using the date HHSC receives the request as the DBMD interest list date, if the individual's name is not on the DBMD interest list and it never has been on the DBMD interest list.(2) At the request of the individual or LAR, HHSC changes the DBMD interest list date to the MDCP interest list date if the individual's MDCP interest list date is earlier than the individual's DBMD interest list date.(f) HHSC removes an individual's name from the DBMD interest list if:(1) the individual or LAR requests, in writing, that the individual's name be removed from the DBMD interest list;(2) the individual moves out of Texas, unless the individual is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the individual or LAR declines an offer of enrollment in the DBMD Program or, as described in §260.55(e) of this subchapter (relating to Written Offer of Enrollment in the DBMD Program), HHSC withdraws an offer of enrollment in the DBMD Program, unless the individual is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(4) the individual is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(5) the individual is deceased; or(6) HHSC has denied the individual enrollment in the DBMD Program and the individual or LAR:(A) has had an opportunity to exercise the individual's right to appeal the decision in accordance with §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing), and(B) either:(i) did not appeal the decision; or(ii) appealed and did not prevail.(g) If HHSC removes an individual's name from the DBMD interest list in accordance with subsection (f)(1) - (4) of this section, HHSC receives an oral or written request from a person to add the individual's name to the DBMD interest list within 90 calendar days after the name was removed, and the request is the individual's first request, HHSC:(1) adds the individual's name to the DBMD interest list using the DBMD interest list date that was in effect at the time the individual's name was removed from the DBMD interest list; and(2) notifies the individual or LAR, in writing, that the individual's name has been added to the DBMD interest list in accordance with paragraph (1) of this subsection.(h) If HHSC removes an individual's name from the DBMD interest list in accordance with subsection (f)(1) - (4) of this section, HHSC receives an oral or written request from a person to add the individual's name to the DBMD interest list more than 90 calendar days after the name was removed, and the request is the individual's first request, HHSC:(1) adds the individual's name to the DBMD interest list using as the DBMD interest list date:(A) the date HHSC receives the oral or written request; or(B) because of extenuating circumstances as determined by HHSC the DBMD interest list date that was in effect at the time the individual's name was removed from the DBMD interest list; and(2) notifies the individual or LAR, in writing, that the individual's name has been added to the DBMD interest list in accordance with paragraph (1) of this subsection.(i) If HHSC removes an individual's name from the DBMD interest list in accordance with subsection (f)(6) of this section, HHSC receives an oral or written request from a person to add the individual's name to the DBMD interest list, and the request is not the individual's first request:(1) HHSC adds the individual's name to the DBMD interest list using the date HHSC receives the oral or written request as the DBMD interest list date; and(2) HHSC notifies the individual or LAR, in writing, that the individual's name has been added to the DBMD interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §260.53 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.53 DBMD Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212513 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212513 03/12/2026 (a) HHSC sends a written offer of enrollment in the DBMD Program to:(1) the individual whose DBMD interest list request date, assigned in accordance with §260.53 of this subchapter (relating to DBMD Interest List), is earliest, unless the individual is a military family member living outside of Texas; or(2) an individual who is residing in a nursing facility and requesting enrollment in the DBMD Program.(b) HHSC encloses with the written offer:(1) a list of DBMD program providers;(2) a Documentation of Provider Choice form;(3) in accordance with 1 TAC §351.15 (relating to Information Regarding Community-based Services), a document explaining other currently available community-based long-term support options that might be appropriate to the individual's needs; and(4) an HHSC DBMD Applicant Acknowledgement form.(c) An individual or LAR accepts the offer of enrollment in the DBMD Program by:(1) selecting a program provider from the enclosed list;(2) documenting the selection of a program provider on the HHSC Documentation of Provider Choice form; and(3) ensuring the completed HHSC Documentation of Provider Choice form and HHSC DBMD Applicant Acknowledgement form are submitted to HHSC and postmarked or faxed no later than 60 calendar days after the date on the offer letter.(d) If HHSC receives the completed HHSC Documentation of Provider Choice form and HHSC DBMD Applicant Acknowledgement form, as described in subsection (c)(3) of this section, HHSC uses the HHSC Documentation of Provider Choice form to notify the program provider of the individual's or LAR's selection of a program provider.(e) HHSC withdraws an offer of enrollment in the DBMD Program made to an individual if:(1) the completed HHSC Documentation of Provider Choice form and HHSC DBMD Applicant Acknowledgement form are postmarked or faxed more than 60 calendar days after the date on the offer letter;(2) the individual or LAR does not complete the enrollment process as described in §260.61 of this division (relating to Process for Enrollment of an Individual);(3) the individual was offered enrollment in the DBMD Program because the individual was residing in a nursing facility but was discharged from the nursing facility before the effective date of the enrollment IPC; or(4) the individual has moved out of the state of Texas. Source Note: The provisions of this §260.55 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.55 Written Offer of Enrollment in the DBMD Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212514 03/12/2026 (a) Person-centered planning is a process that empowers an individual to plan the individual's services and supports to achieve desired outcomes.(b) A program provider must ensure the person-centered planning process is led by the individual to the maximum extent possible. The individual's LAR has a participatory role, as needed and defined by the individual, unless State law confers decision-making authority to the LAR.(c) The person-centered planning process must be used to develop an IPP, a PAS/HAB plan, an enrollment IPC, a renewal IPC, a revised IPC, a service backup plan, and an individual transportation plan.(d) The person-centered planning process must:(1) include people chosen by the individual or LAR;(2) provide the information and support the individual needs to lead the planning process and make informed choices and decisions;(3) occur at a time and location convenient to the individual and LAR;(4) consider the individual's cultural preferences;(5) provide information in plain language to the individual and in a manner that is accessible to the individual:(A) through the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and section 504 of the Rehabilitation Act, if the individual requires such aids or services to communicate; and(B) through the provision of language services at no cost to the individual, including oral interpretation and written translations, if the individual has limited English proficiency;(6) use strategies for solving conflict or disagreement within the person-centered planning process;(7) provide information to the individual or LAR to allow the individual or LAR to make informed decisions, including decisions about DBMD Program and CFC services, the settings in which the individual receives a DBMD Program service or a CFC service, and service providers; and(8) inform the individual or LAR that the individual or LAR may request revisions to an IPP, a PAS/HAB plan, an enrollment IPC, a renewal IPC, a revised IPC, a service backup plan, or an individual transportation plan at any time by communicating the request to the program provider. Source Note: The provisions of this §260.57 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.57 Person-Centered Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222990 03/12/2026 (a) A home and community-based setting is a setting in which an individual resides or receives DBMD Program services or CFC services. A home and community-based setting must have all of the following qualities based on the individual's strengths, preferences, and needs as documented in the individual's IPP.(1) The setting is integrated in and supports the individual's access to the greater community to the same degree as a person not enrolled in a Medicaid waiver program, including opportunities for the individual to:(A) seek employment and work in a competitive integrated setting;(B) engage in community life;(C) control personal resources; and(D) receive services in the community.(2) The setting is selected by an individual from among setting options, including non-disability specific settings and an option for a private unit in a setting in which licensed assisted living is provided. The setting options are identified and documented in an individual's IPP and are based on the individual's needs, preferences, and, for settings in which licensed assisted living is provided, resources available for room and board.(3) The setting ensures the individual's rights of privacy, dignity and respect, and freedom from coercion and restraint.(4) The setting optimizes, not regiments, individual initiative, autonomy, and independence in making life choices, including choices regarding daily activities, physical environment, and with whom to interact.(5) The setting facilitates individual choice regarding services and supports and the service providers who provide the services and supports.(b) Except as provided in subsection (c) of this section, a program provider must ensure that DBMD Program services and CFC services are not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a certified ICF/IID operated by a LIDDA or state supported living center is located but is distinct from the ICF/IID;(2) is located in a building on the grounds of, or immediately adjacent to, a certified ICF/IID operated by a LIDDA or state supported living center;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building on the grounds of, or immediately adjacent to, a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(c) A program provider may provide a DBMD Program service or a CFC service to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (b) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(d) A program provider must ensure that employment readiness is not provided in the residence of an individual or another person.(e) In addition to the requirements in subsection (a) of this section, a program provider must ensure that an employment readiness location:(1) allows an individual to:(A) control the individual's schedule and activities;(B) have access to the individual's food at any time; and(C) have visitors of the individual's choosing at any time; and(2) is physically accessible and free of hazards to an individual.(f) If an individual's service planning team determines that the requirements in subsection (e)(1)(A) and (B) of this section must be modified, the service planning team must:(1) revise the individual's IPP in accordance with §260.77 of this chapter (relating to Renewal and Revision of an IPP and IPC); and(2) document on the individual's IPP:(A) a description of the specific and individualized assessed need that justifies the modification;(B) a description of any positive interventions and supports that have been tried but did not work;(C) a description of any less intrusive methods of meeting the need that have been tried but did not work;(D) a description of the condition that is directly proportionate to the specific assessed need;(E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(G) the individual's or LAR's signature evidencing informed consent to the modification; and(H) the program provider's assurance that the modification will cause the individual no harm.(g) After the service planning team updates the IPP as required by subsection (f) of this section, the program provider must implement the modifications. Source Note: The provisions of this §260.59 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10339. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.59 Requirements for Home and Community-Based Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224204 03/12/2026 (a) After HHSC notifies a program provider, as described in §260.55(d) of this division (relating to Written Offer of Enrollment in the DBMD Program), that an individual selected the program provider, the program provider must assign a case manager to the individual. (b) A program provider must ensure that the assigned case manager contacts the individual or LAR by telephone, videoconferencing, or in person in the individual's residence as soon as possible but no later than five business days after the program provider receives the HHSC notification. During this initial contact, the case manager must: (1) verify that the individual resides in a county for which the program provider has a contract; (2) determine if the individual is currently enrolled in Medicaid; (3) determine if the individual is currently enrolled in another waiver program or receiving a service that may not be received if the individual is enrolled in the DBMD Program, as identified in the Mutually Exclusive Services table in Appendix V of the Deaf Blind with Multiple Disabilities Program Manual available on the HHSC website; and (4) schedule an initial in-person visit to be held in the individual's residence with the individual and LAR or actively involved person at a time convenient to the individual and LAR and no later than 30 calendar days after the program provider receives the HHSC notification. (c) During an initial in-person visit in an individual's residence at a time convenient to the individual and LAR, a case manager: (1) must provide an oral and written explanation to the individual or LAR: (A) of the DBMD Program services described in §260.7(c) of this chapter (relating to Description of the DBMD Program and CFC), including TAS if the individual is receiving institutional services; (B) of the CFC services described in §260.7(e) of this chapter; (C) of the individual's rights and responsibilities: (i) as described in §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing); and (ii) as described in §260.113 of this subchapter (relating to Mandatory Participation Requirements of an Individual); (D) the process by which the individual, LAR, or actively involved person may file a complaint regarding a program provider as required by §52.117 of this title (relating to Complaint Process); (E) that the HHSC toll-free telephone number at 1-800-458-9858 may be used to file a complaint regarding the program provider; (F) of the CDS option described in §260.71 of this division (relating to CDS Option); (G) of voter registration, if the individual is 18 years of age or older; (H) of how to contact the program provider, the case manager, and the RN; (I) that while the individual is staying at a location outside the contracted service delivery area but within the state of Texas for a period of no more than 60 consecutive days, the individual and LAR or actively involved person may request that the program provider provide: (i) transportation as a residential habilitation activity, as described in §260.343(b)(1)(A)(ii)(I) of this chapter (relating to Day Habilitation, Residential Habilitation, and CFC PAS/HAB); (ii) case management; (iii) nursing; (iv) out-of-home respite in a camp described in §260.353 of this chapter (relating to Respite); (v) adaptive aids; (vi) intervener services; or (vii) CFC PAS/HAB; (J) of the use of electronic visit verification, as required by 1 TAC Chapter 354, Subchapter O; and (K) that the individual, LAR, or actively involved person may report an allegation of abuse, neglect, or exploitation to HHSC by calling the toll-free telephone number at 1-800-458-9858; (2) must educate the individual, LAR, and actively involved person about protecting the individual from abuse, neglect, and exploitation; (3) must use the HHSC Understanding Program Eligibility - CLASS/DBMD form to provide an oral and written explanation to the individual or LAR, and obtain the individual's or LAR's signature and date on the form, to acknowledge understanding of: (A) the eligibility requirements for: (i) DBMD Program services, as described in §260.51(a) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services); (ii) CFC services for individuals who do not receive MAO Medicaid, as described in §260.51(b) of this subchapter; and (iii) CFC services for individuals who receive MAO Medicaid, as described in §260.51(c) of this subchapter; (B) the reasons DBMD Program services and CFC services may be suspended, as described in §260.85 of this chapter (relating to Suspension of DBMD Program Services and CFC Services); and (C) the reasons DBMD Program services and CFC services may be terminated as described in §§260.89, 260.101, 260.103, and 260.105 of this chapter (relating to Termination of DBMD Program Services and CFC Services With Advance Notice Due to Ineligibility or Leave from the State, Termination of DBMD Program Services and CFC Services With Advance Notice Due to Non-compliance with Mandatory Participation Requirements, Termination of DBMD Program Services and CFC Services Without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy, and Termination of DBMD Program Services and CFC Services Without Advance Notice Due to Behavior Causing Immediate Jeopardy); (4) must complete an ID/RC Assessment; (5) must give the individual or LAR the HHSC Verification of Freedom of Choice form to document the individual's or LAR's choice regarding the DBMD Program or the ICF/IID Program; (6) may complete an adaptive behavior screening assessment or ensure an appropriate professional described in the assessment instructions completes the adaptive behavior screening assessment; (7) may complete a Related Conditions Eligibility Screening Instrument or ensure an RN completes a Related Conditions Eligibility Screening Instrument; and (8) may ensure an RN completes a nursing assessment using the HHSC CLASS/DBMD Nursing Assessment form. (d) If an assessment described in subsection (c)(6) - (8) of this section is not completed during the initial in-person visit in the individual's residence, a case manager must ensure that the assessment is completed in person as soon as possible but no later than 10 business days after the date of the initial in-person visit. (e) If an individual is Medicaid eligible, is receiving institutional services, and anticipates needing TAS, a case manager must determine whether the individual meets the following criteria: (1) the individual is being discharged from a nursing facility or an ICF/IID; (2) the individual has not previously received TAS; (3) the individual's proposed enrollment IPC will not include licensed assisted living or licensed home health assisted living; and (4) the individual anticipates needing TAS. (f) If a case manager determines that an individual meets the criteria described in subsection (e) of this section, the case manager must: (1) provide the individual or LAR with a list of TAS providers in the service delivery area in which the individual will reside; (2) complete, with the individual or LAR, the HHSC Transition Assistance Services (TAS) Assessment and Authorization form in accordance with the form's instructions, which includes: (A) identifying the items and services as described in §272.5(e) of this title (relating to Service Description) that the individual needs; (B) estimating the monetary amount for the items and services identified on the form, which must be within the service limit described in §272.5(d) of this title; and (C) documenting the individual's or LAR's choice of TAS provider; (3) submit the completed form to HHSC for authorization; (4) if HHSC authorizes the form, send the form to the TAS provider chosen by the individual or LAR; and (5) include TAS and the monetary amount authorized by HHSC on the individual's proposed enrollment IPC. (g) Before an individual enrolls in the DBMD Program, a case manager must inform the individual or LAR that the individual may reside in the individual's own home or family home or may receive a DBMD residential service described in §260.351 of this chapter (relating to Residential Services). (h) A program provider must: (1) gather and maintain the information necessary to process an individual's request for enrollment in the DBMD Program using forms prescribed by HHSC in the Deaf Blind with Multiple Disabilities Program Manual;(2) assist an individual who does not have Medicaid financial eligibility or the individual's LAR to: (A) complete an application for Medicaid financial eligibility; and (B) submit the completed application to HHSC as soon as possible but no later than 30 calendar days after the case manager's initial in-person visit in the individual's residence; (3) document in an individual's record any problems or barriers the individual or LAR encounters that may inhibit progress towards completing: (A) the application for Medicaid financial eligibility; and (B) enrollment in the DBMD Program; and (4) assist the individual or LAR to overcome problems or barriers documented as described in paragraph (3) of this subsection. (i) If an individual or LAR does not submit a completed Medicaid application to HHSC as described in subsection (h)(2)(B) of this section as a result of problems or barriers documented in accordance with subsection (h)(3) of this section, but is making progress in collecting the documentation necessary to complete the application, the program provider: (1) may extend, in 30-calendar day increments, the time frame in which the application must be submitted to HHSC, except as provided in paragraph (2) of this subsection; (2) must not grant an extension that results in a time period of more than 365 calendar days from the date of the case manager's initial in-person visit in the individual's residence; (3) must ensure that the case manager documents the rationale for each extension in the individual's record; and (4) must notify a DBMD program specialist, in writing, if the individual or LAR: (A) does not submit a completed Medicaid application to HHSC no later than 365 calendar days after the date of the case manager's initial in-person visit in the individual's residence; or (B) does not cooperate with the case manager in completing the enrollment process described in this section. (j) A program provider must ensure that: (1) the related conditions documented on the ID/RC Assessment for the individual are on the HHSC Approved Diagnostic Codes for Persons with Related Conditions list contained in the Deaf Blind with Multiple Disabilities Program Manual;(2) the ID/RC Assessment is submitted to a physician for review; and (3) if the individual or LAR requests dental services, other than an initial dental exam, a dentist completes the HHSC Prior Authorization for Dental Services form as required by §260.339 of this chapter (related to Dental Treatment). (k) Not more than 10 business days after a program provider receives a signed and dated ID/RC Assessment from a physician establishing that an individual meets the requirements described in §260.51(a)(2) and (3) of this subchapter, the case manager must: (1) convene a service planning team meeting; and (2) ensure that the individual's service planning team: (A) reviews the HHSC CLASS/DBMD Nursing Assessment form completed by an RN; (B) reviews Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to address any information included in Addendum E to ensure the individual's needs are met; (C) documents on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E was addressed; (D) reviews the completed ID/RC assessment signed and dated by a physician; (E) reviews the adaptive behavior screening assessment; (F) reviews the HHSC Related Conditions Eligibility Screening Instrument form; (G) reviews the completed HHSC Prior Authorization for Dental Services form, if required by §260.339 of this chapter; (H) completes an enrollment IPP in accordance with §260.65 of this division (relating to Development of an Enrollment IPP); (I) completes a proposed enrollment IPC in accordance with §260.67 of this division (relating to Development of a Proposed Enrollment IPC); and (J) if the enrollment IPP and the proposed enrollment IPC include: (i) transportation provided as a residential habilitation activity or as an adaptive aid, develops an individual transportation plan; or (ii) nursing, intervener services, or CFC PAS/HAB, develops a service backup plan if required by §260.213 of this chapter (relating to Service Backup Plans). (l) As soon as possible but no later than 10 business days after an individual's service planning team completes an individual's enrollment IPP and proposed enrollment IPC, as described in subsection (k)(2) of this section, the case manager must: (1) submit the following documents, completed according to form instructions, to HHSC for review: (A) the proposed enrollment IPC; (B) the ID/RC Assessment signed by a physician; (C) the enrollment IPP; (D) the PAS/HAB plan; (E) the adaptive behavior screening assessment; (F) the HHSC Related Conditions Eligibility Screening Instrument form; (G) the HHSC DBMD Summary of Services Delivered form that documents pre-assessment services with supporting documentation; (H) the HHSC Verification of Freedom of Choice form; (I) the HHSC Non-Waiver Services form; (J) the HHSC Documentation of Provider Choice form; (K) the HHSC CLASS/DBMD Nursing Assessment form; (L) the HHSC Prior Authorization for Dental Services form, if required by §260.339 of this chapter; (M) the HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form, if required by: (i) §260.303 of this chapter (relating to Requirements for Authorization to Purchase or Lease an Adaptive Aid); (ii) §260.317 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000); or (iii) §260.319 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More); (N) the HHSC Provider Agency Model Service Backup Plan form, if required by §260.213 of this chapter; (O) the HHSC Specialized Nursing Certification form, if required by §260.347 of this chapter (relating to Nursing); (P) if a non-waiver resource is identified on the HHSC Non-Waiver Services form: (i) documentation to demonstrate that a service comparable to a DBMD Program service available from the non-waiver resource has been exhausted; or (ii) documentation to explain why a service comparable to a DBMD Program service offered by the non-waiver resource is not provided to the individual by the non-waiver resource; (Q) the HHSC Transition Assistance Services (TAS) Assessment and Authorization form, if required by subsection (f)(2) of this section; and (R) the individual transportation plan, if required by subsection (k)(2)(J)(i) of this section; and (2) if the individual will receive a service through the CDS option, send a copy of the proposed enrollment IPC, the enrollment IPP, and, if completed, the individual transportation plan to the FMSA. (m) No later than five business days after receiving a written notice from HHSC approving or denying an individual's request for enrollment, the program provider must notify the individual or LAR of HHSC's decision. If HHSC: (1) approves the request for enrollment, the program provider must initiate DBMD Program services and CFC services as described on the IPC; or (2) denies the request for enrollment, the program provider must send the individual or LAR a copy of HHSC's written notice of denial. (n) A program provider must not provide a DBMD Program service or CFC service to an individual before HHSC notifies the program provider, in accordance with §260.69(d)(1) of this division (relating to HHSC's Review of Request for Enrollment), that the individual's request for enrollment into the DBMD Program has been approved. If a program provider provides a DBMD Program service or CFC service to an individual before the effective date of the individual's enrollment IPC authorized by HHSC, HHSC does not reimburse the program provider for those services. (o) If HHSC notifies a program provider that an individual's request for enrollment is approved, the case manager must comply with §260.69(d)(2) of this subchapter. Source Note: The provisions of this §260.61 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective February 27, 2025, 50 TexReg 996. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.61 Process for Enrollment of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212517 03/12/2026 (a) HHSC requests an individual or LAR to choose a different program provider if the program provider chosen by the individual or LAR informs HHSC, in writing, that it cannot ensure the individual's health and welfare and is not willing to provide DBMD Program services or CFC services to the individual.(1) The program provider must include in the written notification to HHSC:(A) a description of the specific reasons the program provider cannot ensure the individual's health and welfare; and(B) a statement that the program provider is not willing to provide DBMD Program services or CFC services to the individual.(2) HHSC notifies the individual or LAR, in writing, that the program provider is not willing to provide DBMD Program services or CFC services to the individual because the program provider cannot ensure the individual's health and welfare. HHSC includes with the notice a list of program providers.(b) If an individual is unable to find a program provider willing to serve the individual, HHSC:(1) denies enrollment in the DBMD Program as described in §260.83(a)(2) of this subchapter (relating to Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service); and(2) if requested by the individual or LAR, adds the individual's name to the DBMD interest list as described in §260.53(c) of this subchapter (relating to DBMD Interest List). Source Note: The provisions of this §260.63 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.63 Program Provider Cannot Ensure Individual's Health and Welfare https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212518 03/12/2026 (a) To develop an enrollment IPP, a case manager must convene an in-person meeting with the service planning team in which the service planning team completes the individual's enrollment IPP for each DBMD Program service and CFC service, other than CFC support management, identified on the individual's proposed enrollment IPC.(b) A case manager must ensure an enrollment IPP:(1) identifies whether an individual will reside in the individual's own home or family home or in a DBMD residential setting described in §260.351 of this chapter (relating to Residential Services);(2) includes justification for each service and the total units indicated for each service;(3) describes:(A) the outcomes to be achieved through each service; and(B) the action and methods to be used to achieve the outcomes for each service;(4) describes individualized goals for each service that:(A) are outcome-based;(B) are measurable; and(C) have a start date and projected completion date; and(5) includes:(A) a description of the individual's strengths, preferences, and needs as identified by the individual, LAR, or both;(B) a description of the services and supports the individual needs to continue living in a community-based setting, as identified through the HHSC CLASS/DBMD Nursing Assessment form, ID/RC Assessment, HHSC Related Conditions Eligibility Screening Instrument form, and adaptive behavior screening assessment;(C) a description of the individual's current natural supports and non-waiver and non-CFC services that will be or are available;(D) documentation that the frequency and amount of each service included in the IPP and IPC do not replace existing natural supports or non-waiver and non-CFC resources for which the individual may be eligible;(E) if the IPC includes CFC PAS/HAB, whether the individual would like to receive CFC support management;(F) that the individual needs a service backup plan for nursing, intervener services, or CFC PAS/HAB, if the service planning team determined the service is critical to the individual's health and safety; and(G) that the case manager is responsible for monitoring the individual's service plan.(c) A case manager must:(1) ensure that an enrollment IPP is signed and dated by each member of the service planning team; and(2) maintain the enrollment IPP in the individual's record. Source Note: The provisions of this §260.65 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.65 Development of an Enrollment IPP https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212519 03/12/2026 (a) A program provider must ensure that an individual's case manager convenes an in-person meeting with the service planning team in which the service planning team: (1) develops a proposed enrollment IPC that: (A) documents the type of each DBMD Program service and CFC service, other than CFC support management, to be provided by the program provider; (B) documents the number of units or annual cost for each service; (C) if the individual will receive a service through the CDS option, documents:(i) the name of the individual's FMSA; and(ii) the type and number of units for each service to be provided through the CDS option;(D) documents whether the individual will receive CFC support management;(E) documents whether the individual needs a service backup plan for nursing, intervener services, or CFC PAS/HAB critical to the individual's health and safety; (F) documents an effective date of the IPC that:(i) is at least 10 business days after the case manager submits the proposed enrollment IPC to HHSC as described in §260.61(m)(1) of this division (relating to Process for Enrollment of an Individual); and(ii) does not overlap with the end date of another Medicaid waiver program or another HHSC-operated program described in the Deaf Blind with Multiple Disabilities Program Manual, other than the Day Activity and Health Services Program, in which the individual may have been enrolled; and(G) does not exceed the service limits described in: (i) Subchapter F, Divisions 1 - 3, of this chapter (relating to Service Descriptions and Requirements) if the enrollment IPC includes adaptive aids, minor home modifications, dental treatment, and respite; (ii) Subchapter F, Division 5, of this chapter (relating to CFC ERS) if the enrollment IPC includes CFC ERS; or (iii) §272.5(d) of this title (relating to Service Description), if the enrollment IPC includes TAS; (2) if the proposed enrollment IPC includes transportation as a residential habilitation activity or as an adaptive aid, develops an individual transportation plan; (3) if the proposed enrollment IPC includes TAS, completes the HHSC Transition Assistance Services (TAS) Assessment and Authorization form; and (4) identifies the individual's non-waiver resources using the HHSC Non-Waiver Services form. (b) A program provider must ensure that a DBMD Program service and CFC service, other than CFC support management, on a proposed enrollment IPC: (1) are necessary to protect the individual's health and welfare in the community; (2) address at least one of the individual's related conditions or the additional disability that impairs independent functioning; (3) supplements rather than replaces the individual's natural supports and other non-waiver services and supports for which the individual is eligible; (4) prevents the individual's admission to an institution; (5) are the most appropriate type and amount of DBMD Program services and CFC services to meet the individual's needs; and (6) are cost effective. (c) A program provider must: (1) ensure that a proposed enrollment IPC is signed and dated by each member of the service planning team; (2) submit a request for enrollment to HHSC as described in §260.61(l)(1) of this division; and (3) maintain in the individual's record the proposed enrollment IPC submitted to HHSC with the request for enrollment. (d) A program provider must maintain the following in the individual's record and provide a copy to HHSC upon request: (1) current data obtained from standardized evaluations and formal assessments related to the LOC VIII criteria and to support the individual's diagnoses, in accordance with §260.51(a)(2) and (3) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services); (2) documentation, including assessments of the individual, that support the DBMD Program services and CFC services recommended on the proposed enrollment IPC; and (3) documentation that DBMD Program services or CFC services recommended on the proposed enrollment IPC are not available from another source. Source Note: The provisions of this §260.67 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.67 Development of a Proposed Enrollment IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212520 03/12/2026 (a) HHSC reviews a request for enrollment submitted by a case manager in accordance with §260.61(l)(1) of this division (relating to Process for Enrollment of an Individual) to determine if:(1) the individual meets the requirements described in §260.51(a)(2) and (3) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services);(2) the proposed enrollment IPC has a cost at or below the amount in §260.51(a)(4) of this subchapter;(3) the goals and outcomes documented in the enrollment IPP for each DBMD Program service and CFC service, except for CFC support management, meet the criteria described in §260.65(b)(3) and (4) of this division (relating to Development of an Enrollment IPP);(4) the DBMD Program services and CFC services, except for CFC support management, specified in the proposed enrollment IPC meet the requirements described in §260.67(a)(1) and (b) of this division (relating to Development of a Proposed Enrollment IPC);(5) the individual is Medicaid-eligible due to receipt of Supplemental Security Income cash benefits or is determined by HHSC to be financially eligible for Medicaid; and(6) the individual meets the requirement described in §260.51(a)(5) of this subchapter.(b) To support the information in a proposed enrollment IPC and IPP, HHSC may request from a case manager a copy of the information described in §260.67(d) of this division.(c) If HHSC requests the information described in subsection (b) of this section, a case manager must submit the information to HHSC no later than 10 calendar days after the date of the request.(d) If HHSC determines that the individual's request for enrollment meets the requirements described in subsection (a) of this section:(1) HHSC notifies the program provider, in writing, that the individual's request for enrollment into the DBMD Program is approved; and(2) within 10 business days after receiving the written notice, the case manager must:(A) provide to the individual or LAR a copy of the enrollment IPC, the IPP, and if required by §260.213 of this chapter (relating to Service Backup Plans), a service backup plan; and(B) if the individual will receive a service through the CDS option, send the FMSA a copy of the enrollment IPC, the IPP, and if required by §260.61(k)(2)(J)(i) of this subchapter, the individual transportation plan.(e) HHSC notifies the individual's program provider, in writing, that the individual's request for enrollment is denied if the request for enrollment does not meet the requirements described in subsection (a) of this section.(f) If HHSC notifies a program provider that an individual's request for enrollment is denied, the program provider must send the individual or LAR written notice of the denial in accordance with §260.83(a) of this subchapter (relating to Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service).(g) If HHSC determines a DBMD Program service or CFC service specified in the proposed enrollment IPC does not meet the requirements described in §260.67(a)(1) and (b) of this division, HHSC:(1) denies the service;(2) modifies and approves the IPC;(3) approves the individual's request for enrollment with the modified IPC; and(4) notifies the program provider, in writing, of the action taken.(h) If HHSC notifies a program provider of the denial of a DBMD Program service or CFC service and of the modification of the proposed enrollment IPC in accordance with subsection (g) of this section, the program provider must:(1) implement the modified enrollment IPC; and(2) send the individual or LAR written notice of the denial of a DBMD Program service or a CFC service in accordance with §260.83(b) of this subchapter.(i) If HHSC approves an individual's request for enrollment, a program provider must:(1) electronically access MESAV to determine if the information on an enrollment IPC is consistent with the information in MESAV;(2) if the information on the enrollment IPC or modified enrollment IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency; and(3) implement the enrollment IPC or modified enrollment IPC no later than seven calendar days after the effective date of the IPC.(j) HHSC may approve the effective date of an IPC as requested on the proposed enrollment IPC or may modify the effective date.(k) HHSC's determination that an individual meets the requirements described in §260.51(a)(2) and (3) of this subchapter and approval of the proposed enrollment IPC is valid for the IPC period of the enrollment IPC. Source Note: The provisions of this §260.69 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.69 HHSC's Review of Request for Enrollment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212521 03/12/2026 (a) A program provider must ensure an individual's case manager informs the individual or LAR:(1) of the CDS option in accordance with 40 TAC Chapter 41, Subchapter D (relating to Enrollment, Transfer, Suspension, and Termination);(2) of the DBMD Program services and the CFC services that may be provided through the CDS option, as described in 40 TAC §41.108 (relating to Services Available Through the CDS Option); and(3) that the individual may elect to have one or more of those services provided through the CDS option.(b) If an individual or LAR chooses to participate in the CDS option, the case manager must:(1) provide the individual or LAR with an oral and written explanation of the CDS option using materials provided by HHSC, including the required CDS forms described in 40 TAC Chapter 41 (relating to Consumer Directed Services Option);(2) provide the individual or LAR with the name and contact information of each FMSA providing services in the county where the individual lives;(3) document the individual's or LAR's choice of FMSA in accordance with HHSC's instructions;(4) document each service to be provided through the CDS option on the IPC;(5) if the only service to be provided through the CDS option is CFC PAS/HAB, include on the IPC:(A) CFC FMS instead of FMS; and(B) if the individual will receive support consultation, CFC support consultation instead of support consultation; and(6) complete the required forms as described in 40 TAC Chapter 41.(c) For services to be provided through the CDS option, an individual or LAR and the FMSA must comply with 40 TAC Chapter 41.(d) A program provider must provide a service included on the IPC that the individual or LAR has elected not to have provided through the CDS option. Source Note: The provisions of this §260.71 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.71 CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212522 03/12/2026 (a) A program provider must have and implement written policies and procedures to ensure compliance with §260.77(b)(1) of this division (relating to Renewal and Revision of an IPP and IPC).(b) A program provider's written policies and procedures must include a written or electronic tracking system that alerts the program provider to activities that must occur for the program provider to timely submit documentation to HHSC as required by §260.77(b)(2) of this division. Source Note: The provisions of this §260.73 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.73 Tracking Annual Renewal of an ID/RC Assessment and an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212523 03/12/2026 (a) HHSC conducts a utilization review of an IPC to determine if:(1) the cost of the IPC meets the criteria described in §260.51(a)(4) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services); and(2) the DBMD Program services and CFC services specified in the IPC meet the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC).(b) If requested by HHSC, a program provider must submit documentation supporting an IPC to HHSC no later than 10 business days after the date of HHSC's request.(c) If HHSC determines that an IPC does not meet the criteria described in §260.51(a)(4) of this subchapter, HHSC notifies the program provider of such determination and sends written notice to the individual or LAR that the individual's DBMD Program services and CFC services are proposed for termination and includes in the notice the individual's right to request a fair hearing in accordance with §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing).(d) If HHSC determines that an IPC meets the criteria described in §260.51(a)(4) of this subchapter but one or more DBMD Program services or CFC services specified in the IPC do not meet the requirements described in §260.67(a)(1) and (b) of this subchapter, HHSC:(1) denies or reduces the service, as appropriate;(2) modifies and approves the IPC; and(3) notifies the program provider, in writing, of the action taken.(e) If HHSC notifies a program provider of the denial or reduction of a DBMD Program service or CFC service, and of the modification of the IPC in accordance with subsection (d) of this section, the program provider must send the individual or LAR written notice and provide services in accordance with:(1) §260.83(b)(2) and (3) of this subchapter (relating to Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service); or(2) §260.87(b) and (c) of this subchapter (relating to Reduction of a DBMD Program Service or a CFC Service). Source Note: The provisions of this §260.75 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.75 Utilization Review of an IPC by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212524 03/12/2026 (a) Case manager's review. (1) Beginning the effective date of an individual's IPC, as determined in accordance with §260.69(j) of this subchapter (relating to HHSC's Review of Request for Enrollment), a case manager must, in accordance with the schedule in the Deaf Blind with Multiple Disabilities Program Manual, meet with the individual and LAR in person at a time convenient to the individual and LAR in the individual's home, or if requested by the individual or LAR, in another location to: (A) review whether the DBMD Program services and CFC services are being provided in accordance with the IPC and IPP; (B) review the individual's progress toward achieving the goals and outcomes described in the IPP for each service listed on the individual's IPC; (C) determine if the services are meeting the individual's needs; (D) determine if the individual's needs have changed; (E) review assessments, evaluations, and progress notes prepared by service providers since the previous review; (F) if the individual's IPC includes nursing, intervener services, or CFC PAS/HAB, and none of these services are identified as critical to the individual's health and safety, discuss with the individual or LAR whether any of these services may now be critical to the individual's health and safety and needs a service backup plan; and (G) if the individual has a service backup plan for nursing, intervener services, or CFC PAS/HAB, discuss with the individual or LAR:(i) whether the service backup plan, if implemented, was effective;(ii) whether the service backup plan needs to be revised; and(iii) whether the service backup plan needs to be discontinued because the service is no longer critical to the individual's health and safety.(2) A case manager must: (A) document the results of a meeting described in paragraph (1) of this subsection in the individual's record using the HHSC IPP Service Review form or a form the program provider develops that includes the information on the HHSC form; (B) document on the HHSC IPP Service Review form or a form the program provider developed:(i) if nursing, intervener services, or CFC PAS/HAB has become critical to the individual's health and safety, and the individual does not have a service backup plan for the service, that the individual now needs a service backup plan for nursing, intervener services, or CFC PAS/HAB; and(ii) if the individual has a service backup plan for nursing, intervener services, or CFC PAS/HAB, document on the IPP review form that: (I) the service planning team did not revise the service backup plan because it was effective; (II) the service planning team revised the service backup plan to address any problems or concerns regarding implementation of the service backup plan; or(III) the service planning team discontinued the service backup plan because the service is no longer critical to the individual's health and safety; (C) ensure the individual or LAR signs and dates the IPP review form; and(D) provide a copy of the completed HHSC IPP Service Review form or a form the program provider developed to the individual or LAR within 10 business days after the date of the meeting described in paragraph (1) of this subsection. (3) A case manager, no later than five business days after the date of a meeting described in paragraph (1) of this subsection, must convene a service planning team meeting: (A) if the case manager:(i) identifies needed changes in the individual's services; or (ii) determines that nursing, intervener services, or CFC PAS/HAB services may now be critical to the individual's health and safety, as described in paragraph (1)(F) of this subsection, or that the service backup plan was ineffective, as described in paragraph (1)(G) of this subsection; (B) if the individual or LAR requests a revision of the IPP or IPC; or(C) if the service planning team determines that any of the requirements in §260.403(a)(1) - (6) of this chapter (relating to Requirements for Program Provider-Owned Residential Settings) must be modified.(4) During a service planning team meeting described in paragraph (3) of this subsection, using the person-centered planning process, a case manager must: (A) develop a revised IPP that meets the requirements described in §260.65 of this subchapter (relating to Development of an Enrollment IPP); (B) develop a proposed revised IPC that meets the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC); and (C) if: (i) the proposed revised IPC includes transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; and (ii) the proposed revised IPC includes nursing, intervener services, or CFC PAS/HAB services, ensure compliance with §260.213 of this chapter (relating to Service Backup Plans). (5) A case manager must: (A) ensure the revised IPP and proposed revised IPC is signed and dated by each member of the service planning team; and (B) no later than 10 business days after the date of the service planning team meeting, submit to HHSC: (i) a copy of the signed and dated proposed revised IPC ; (ii) a copy of the signed and dated revision IPP; (iii) an individual transportation plan, if required by paragraph (4)(C)(i) of this subsection; (iv) an HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form, if required by §260.303 of this chapter (relating to Requirements for Authorization to Purchase or Lease an Adaptive Aid), §260.317 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000), or §260.319 of this chapter (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More); (v) an HHSC Specifications for Minor Home Modifications form, if required by §260.321 of this chapter (relating to Specifications for a Minor Home Modification); (vi) an HHSC Prior Authorization for Dental Services form, if required by §260.339 of this chapter (relating to Dental Treatment); and (vii) an HHSC Specialized Nursing Certification form, if required by §260.347 of this chapter (relating to Nursing). (b) Annual review by the service planning team. (1) No more than 90 calendar days before the end of an individual's IPC period: (A) the case manager must complete an ID/RC Assessment; (B) an RN must complete an annual nursing assessment of the individual using the HHSC CLASS/DBMD Nursing Assessment form; (C) an RN or the case manager must complete a Related Conditions Eligibility Screening Instrument;(D) the case manager or an appropriate professional described in the assessment instructions must complete an adaptive behavior screening assessment:(i) if at least five years have passed after the date of the most current assessment; or(ii) if significant changes have occurred in the individual's functioning; (E) the case manager must convene an in-person meeting of the service planning team to:(i) review the HHSC CLASS/DBMD Nursing Assessment form completed by the RN; (ii) address any information included in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form, Recommendations/Coordination of Care, to ensure the individual's needs are met; (iii) document on the HHSC CLASS/DBMD Coordination of Care form how the information in Addendum E of the HHSC CLASS/DBMD Nursing Assessment form was addressed;(iv) develop a renewal IPP that meets the requirements in §260.65 of this subchapter;(v) develop a proposed renewal IPC that meets the requirements described in §260.67(a)(1) and (b) of this subchapter; (vi) develop the following if the proposed renewal IPC: (I) includes transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; or (II) includes nursing, intervener services, or CFC PAS/HAB, develop a service backup plan or a service backup plan revision if required by §260.213 of this chapter (relating to Service Backup Plans); and (vii) ensure the renewal IPP and proposed renewal IPC is signed and dated by each member of the service planning team; and (F) the case manager must: (i) provide an oral and written explanation of the topics described in §260.61(c)(1) - (3) of this subchapter (relating to Process for Enrollment of an Individual) to the individual or LAR; (ii) educate the individual and LAR about protecting the individual from abuse, neglect, and exploitation; (iii) provide an oral explanation to the individual or LAR that the individual may transfer to a different program provider; (iv) give the individual or LAR an HHSC Documentation of Provider Choice form and have the individual or LAR designate the selection of a DBMD program provider on the form; (v) if the individual or LAR selects a different DBMD program provider on the HHSC Documentation of Provider Choice form, coordinate the individual's transfer in accordance with §260.79 of this subchapter (relating to Coordination of Transfers); (vi) orally explain that the individual or LAR may request the provision of transportation provided as a residential habilitation activity, case management, nursing, out-of-home respite in a camp, adaptive aids, intervener services, or CFC PAS/HAB while the individual is staying at a location outside the contracted service delivery area but within the state of Texas for a period of no more than 60 consecutive days; and (vii) have documentation that the activities required under clauses (i) - (vi) of this subparagraph were performed. (2) A case manager must, no later than 10 business days after the date of the service planning team meeting described in paragraph (1)(E) of this subsection, but at least 30 calendar days before the end of the current IPC period, submit to HHSC: (A) the signed and dated proposed renewal IPC; (B) the signed and dated renewal IPP; (C) the PAS/HAB plan;(D) the renewal ID/RC Assessment; (E) the results of an adaptive behavior screening assessment, if completed as described in paragraph (1)(D) of this subsection; (F) the HHSC Related Conditions Eligibility Screening Instrument form; (G) the HHSC Non-Waiver Services form; (H) the HHSC Documentation of Provider Choice form; (I) the HHSC CLASS/DBMD Nursing Assessment form; (J) an individual transportation plan, if required by subsection (a)(4)(C)(i) of this section; and (K) the documentation described in subsection (a)(5)(B) of this section. (c) Review and revision in an emergency. If a program provider delivers a DBMD Program service or CFC PAS/HAB to an individual in an emergency to ensure the individual's health and welfare and the service is not on the IPC and IPP or exceeds the amount on the IPP, a case manager must: (1) as soon as possible, but no later than five business days after providing the service, convene a service planning team meeting at a time and location convenient to the individual or LAR to:(A) develop a revised IPP that:(i) meets the requirements described in §260.65 of this subchapter; and(ii) includes documentation of how the requested service addressed the emergency; and(B) develop a proposed revised IPC that meets the requirements described in §260.67(a)(1) and (b) of this chapter;(2) if the revised IPP and proposed revised IPC includes nursing, intervener services, or CFC PAS/HAB, develop a service backup plan of service backup plan revision, if required by §260.213 of this chapter; (3) ensure the revised IPP and proposed revised IPC is signed and dated by each member of the service planning team; and (4) no later than 10 business days after the service planning meeting described in paragraph (1) of this subsection, submit to HHSC: (A) a copy of the signed and dated proposed revised IPC; (B) a copy of the signed and dated revision IPP; and (C) the documentation described in subsection (a)(5)(B) of this section. (d) Review and revision other than the reviews described in subsections (a) - (c) of this section. If a program provider becomes aware at any time during an individual's IPC period that changes to the individual's services may be necessary, the case manager must: (1) as soon as possible but no later than five business days after becoming aware that changes to the individual's services may be necessary, convene a service planning team meeting at a time and location convenient to the individual or LAR to review and, if determined necessary, develop:(A) a revised IPP that meets the requirements described in §260.65 of this chapter; and(B) a proposed revised IPC that meets the requirements described in §260.67(a)(1) and (b) of this subchapter; (2) if the revised IPP and proposed revised IPC: (A) include transportation provided as a residential habilitation activity or as an adaptive aid, develop an individual transportation plan; or (B) include nursing, intervener services, or CFC PAS/HAB services, ensure compliance with §260.213 of this chapter; (3) ensure the revised IPP and proposed revised IPC are signed and dated by each member of the service planning team; and (4) no later than 10 business days after the date of the service planning meeting described in paragraph (1) of this subsection, submit to HHSC: (A) a copy of the signed and dated proposed revised IPC; (B) a copy of the signed and dated revised IPP; (C) an individual transportation plan, if required by paragraph (2)(A) of this subsection; and (D) the documentation described in subsection (a)(5)(B) of this section. (e) Determination by HHSC of whether an individual meets LOC VIII and additional criteria. (1) HHSC reviews the documentation described in subsection (b)(1)(A) - (E) of this section to determine whether an individual meets the LOC VIII and additional criteria required by §260.51(a)(2) and (3) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services). (2) HHSC may request current data obtained from standardized evaluations and formal assessments related to an individual's LOC VIII. If HHSC makes such a request, the case manager must submit the information to HHSC no later than 10 calendar days after the date of the request. (3) HHSC notifies a program provider, in writing, of whether or not an individual meets the LOC VIII. If HHSC determines that an individual meets the LOC VIII, the LOC VIII is effective: (A) on a date determined by HHSC; and (B) through the last calendar day of the IPC period. (4) If an individual's LOC VIII expires before HHSC determines whether the individual meets the LOC VIII, as described in paragraphs (1) - (3) of this subsection: (A) a program provider must continue to provide services to the individual until HHSC approves a proposed renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and (B) if HHSC determines that an individual meets the LOC VIII, and the individual is otherwise eligible for the DBMD Program, HHSC will reimburse the program provider for services provided, as required by subparagraph (A) of this paragraph, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (b)(2)(E) - (G) of this section. (f) HHSC's review of a proposed revised IPC or a proposed renewal IPC. (1) HHSC reviews a proposed revised IPC or a proposed renewal IPC to determine if the proposed IPC meets:(A) the requirement described in §260.51(a)(4) of this subchapter; and (B) the requirements described in §260.67(a)(1) and (b) of this subchapter. (2) At HHSC's request, a case manager must submit additional documentation supporting a revised IPC or a proposed renewal IPC no later than 10 calendar days after the date of the request. (3) If HHSC determines that a proposed revised IPC or a proposed renewal IPC meets the requirements: (A) HHSC notifies the program provider, in writing, of its determination; and (B) no later than 10 business days after receiving the written notice, the case manager must: (i) provide to the individual or LAR a copy of the renewal IPC and renewal IPP, and if required by §260.213 of this chapter, any new or revised service backup plan; and (ii) if the individual will receive a service through the CDS option, send the FMSA a copy of the renewal IPC, the renewal IPP, and if required by this section, the individual transportation plan. (g) If an individual's IPC period expires before HHSC approves a renewal IPC: (1) a program provider must continue to provide services to the individual until HHSC approves the renewal IPC to ensure continuity of care and prevent the individual's health and welfare from being jeopardized; and (2) if HHSC approves the renewal IPC as described in subsection (f) of this section, HHSC will reimburse the program provider for services provided, as required by paragraph (1) of this subsection, for a period of not more than 180 calendar days before the date HHSC receives the documentation described in subsection (b)(2) of this section. (h) Verifying the IPC and MESAV are consistent. A program provider must: (1) electronically access MESAV to determine if the information on a revised IPC or a renewal IPC is consistent with the information in MESAV; and (2) if the information on the revised IPC or renewal IPC is inconsistent with the information in MESAV, notify HHSC of the inconsistency. (i) Process to terminate, deny, or reduce program services. The process by which an individual's DBMD program services or CFC services are terminated, denied, or reduced based on HHSC's review of a revised IPC or a renewal IPC is described in §260.75(c) - (e) of this division (relating to Utilization Review of an IPC by HHSC). Source Note: The provisions of this §260.77 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.77 Renewal and Revision of an IPP and IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212525 03/12/2026 (a) After receiving written notice from an individual or LAR of the individual's intention to transfer to another program provider, a program provider must:(1) document in the individual's record the date the transfer request was received;(2) coordinate transfer arrangements, including designating an effective date for transfer that is at least 14 calendar days after the date of the transfer request documented in the individual's record, with:(A) the individual or LAR; and(B) the receiving program provider;(3) review and complete the Service Delivery Transfer Worksheet with the individual or LAR and the receiving program provider; and(4) arrange with the receiving program provider to transfer the individual's personal funds, if applicable.(b) Before the effective date of the transfer, the current program provider must submit the completed Service Delivery Transfer Worksheet to HHSC and the receiving program provider.(c) The receiving program provider must ensure:(1) that delivery of the individual's services is not disrupted as a result of the transfer;(2) that a case manager meets with the individual or LAR in person within 14 calendar days after the effective date of transfer to review the Service Delivery Transfer Worksheet; and(3) if necessary, that the case manager convenes a service planning team meeting to review and revise the IPC in accordance with the appropriate subsection of §260.77 of this subchapter (relating to Renewal and Revision of an IPP and IPC).(d) HHSC does not authorize a change in an individual's IPC period upon the individual's transfer from one program provider to another program provider.(e) If the individual is participating in the CDS option and intends to transfer to another FMSA, the transferring and receiving FMSAs must also follow the process described in 40 TAC §41.403 (relating to Transfer Process). Source Note: The provisions of this §260.79 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.79 Coordination of Transfers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212526 03/12/2026 (a) An individual receiving licensed assisted living or licensed home health assisted living may take personal leave days.(b) The program provider:(1) may charge the individual or LAR for room and board for each personal leave day taken;(2) may bill HHSC for the daily rate for licensed assisted living facility or a licensed home health assisted living for personal leave days taken by the individual during a calendar year within the limit specified in the Deaf Blind with Multiple Disabilities Program Manual; and(3) must not bill the individual for the licensed assisted living or licensed home health assisted living daily rate for personal leave days. Source Note: The provisions of this §260.81 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.81 Personal Leave for Individual Receiving Licensed Assisted Living or Licensed Home Health Assisted Living https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212527 03/12/2026 (a) Denial of an Individual's Request for Enrollment.(1) HHSC denies an individual's request for enrollment in the DBMD Program if:(A) the individual does not meet the eligibility criteria described in §260.51(a) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services);(B) the individual or LAR fails to submit a completed Medicaid application to HHSC within one calendar year after the date of the case manager's initial in-person visit in the individual's residence; or(C) the individual cannot obtain services from at least one program provider.(2) HHSC sends a written notice of denial for enrollment in the DBMD Program to the program provider that the program provider, upon receipt, must send to the individual or LAR, copying the FMSA if applicable.(3) If the individual or LAR requests a fair hearing, the program provider is not required to provide services to the individual while the appeal is pending.(b) Denial of a DBMD Program service or a CFC Service.(1) HHSC denies a DBMD Program service or a CFC service requested on the individual's IPC if HHSC determines, following utilization review conducted as described in §260.75 of this subchapter (relating to Utilization Review of an IPC by HHSC), that the service does not meet the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC).(2) HHSC sends a written notice with the effective date of the denial to the program provider that the program provider, upon receipt but no later than 12 calendar days before the effective date of denial, must send to the individual or LAR, copying the FMSA, if applicable.(3) If the service denied by HHSC is requested:(A) on an enrollment IPC submitted by the program provider in accordance with §260.61 of this subchapter (relating to Process for Enrollment of an Individual) and the individual or LAR requests a fair hearing, the program provider is not required to provide the service while the appeal is pending; or(B) on a revision or renewal IPC submitted by the program provider in accordance with §260.77 of this subchapter (relating to Renewal and Revision of an IPP and IPC) and the individual or LAR requests a fair hearing before the effective date of denial specified in the written notice, the program provider:(i) is not required to provide the service while the appeal is pending if the service was not authorized by HHSC on the prior IPC; or(ii) must provide the service at the previously approved amount or level while the appeal is pending if the service was authorized by HHSC on the prior IPC. Source Note: The provisions of this §260.83 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.83 Denial of Request for Enrollment in the DBMD Program or of a DBMD Program Service or a CFC Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212528 03/12/2026 (a) Except as described in §260.81 of this subchapter (relating to Personal Leave for Individual Receiving Licensed Assisted Living or Licensed Home Health Assisted Living) or if the individual receives out-of-home respite, HHSC suspends an individual's DBMD Program services and CFC services if the individual:(1) is admitted to one of the following facilities:(A) an ICF/IID;(B) a nursing facility;(C) an ALF that does not provide licensed assisted living in the DBMD Program;(D) a residential child-care facility unless it is an agency foster home;(E) a hospital;(F) a mental health facility;(G) an inpatient chemical dependency treatment facility;(H) a facility operated by the Texas Workforce Commission;(I) a residential facility operated by the Texas Juvenile Justice Department; or(J) a jail or prison; or(2) leaves the state.(b) HHSC suspends services during the time that an individual is admitted to the facility or that the individual spends outside the state but is limited to 180 consecutive calendar days unless HHSC approves an extension in accordance with subsection (g) of this section.(c) Within two business days after a program provider becomes aware that an individual has been admitted to a facility or has left the state as described in subsection (a) of this section, the program provider must submit a written request that HHSC suspend the individual's services.(d) If HHSC suspends an individual's services, HHSC sends a written notice to the program provider that includes the effective date of the suspension and the individual's right to request a fair hearing as described in §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing).(e) Within two business days after a program provider receives a notice described in subsection (d) of this section, the program provider must send the notice to the individual or LAR and, if applicable, the FMSA.(f) If an individual or LAR requests a fair hearing, the program provider is not required to provide services to the individual while the appeal is pending.(g) HHSC may approve one or more 30-calendar-day extensions of a suspension if extenuating circumstances exist and the individual anticipates resuming participation in the DBMD Program during the extension.(h) To request an extension described in subsection (g) of this section, a program provider must:(1) submit the request, in writing, to HHSC; and(2) include documentation of the extenuating circumstances.(i) During the time HHSC suspends an individual's services, as described in subsection (b) of this section, the individual is not considered to be residing in a facility listed in subsection (a)(1)of this section or out of the state. Source Note: The provisions of this §260.85 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.85 Suspension of DBMD Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212529 03/12/2026 (a) HHSC reduces an individual's DBMD Program services or CFC services if, during review of an individual's IPC conducted as described in §260.75 of this subchapter (relating to Utilization Review of an IPC by HHSC), HHSC determines that the amount or a service on the individual's IPC does not meet the requirements described in §260.67(a)(1) and (b) of this subchapter (relating to Development of a Proposed Enrollment IPC).(b) HHSC sends a written notice with the effective date of the reduction to the program provider that the program provider, upon receipt but no later than 12 calendar days before the effective date of reduction, must send to the individual or LAR, copying the FMSA if applicable.(c) If an individual or LAR requests a fair hearing before the effective date of the reduction specified in the written notice, the program provider must provide the DBMD Program service or the CFC service at the amount or level approved by HHSC on the prior IPC while the appeal is pending. Source Note: The provisions of this §260.87 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.87 Reduction of a DBMD Program Service or a CFC Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212530 03/12/2026 (a) Except as provided in subsection (c) of this section, HHSC terminates:(1) an individual's DBMD Program services if the individual does not meet the eligibility criteria described in §260.51(a) of this subchapter (relating to Eligibility Criteria for DBMD Program Services and CFC Services);(2) an individual's CFC services if the individual does not meet the eligibility criteria described in §260.51(b) or (c) of this subchapter; and(3) an individual's DBMD Program services and CFC services if:(A) the individual is admitted to one of the facilities listed in§260.85(a) of this subchapter (relating to Suspension of DBMD Program Services and CFC Services) for more than 180 consecutive calendar days or beyond an extension of the individual's suspension that HHSC approved in accordance with §260.85(g) of this subchapter; or(B) the individual leaves the State of Texas for more than 180 consecutive calendar days and HHSC has not extended the individual's suspension in accordance with §260.85(g) of this subchapter.(b) Within two business days after becoming aware that a situation described in subsection (a) of this section exists, the program provider must request, in writing, that HHSC terminate DBMD Program services and CFC services, or DBMD Program services, or CFC services for the individual.(1) The program provider must include supporting documentation with the request to terminate services.(2) If the reason for the requested termination of services is that the program provider is not willing to provide DBMD Program services or CFC services to the individual, the program provider must document the following in the individual's record:(A) the specific reasons the program provider is not willing to provide DBMD Program services or CFC services to the individual; and(B) efforts made to locate another DBMD program provider willing to provide DBMD Program services and CFC services to the individual and the results of those efforts.(c) HHSC may, under extenuating circumstances, temporarily continue DBMD Program services and CFC services if an individual is determined by HHSC not to be financially eligible for Medicaid.(d) HHSC sends a written notice with the effective date of the termination to the program provider that the program provider, upon receipt but no later than 12 calendar days before the effective date of the termination, must send to the individual or LAR, copying the FMSA, if applicable.(e) If the individual or LAR requests a fair hearing before the effective date of the termination specified in the written notice, the program provider must continue to provide services to the individual while the appeal is pending. Source Note: The provisions of this §260.89 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.89 Termination of DBMD Program Services and CFC Services With Advance Notice Due to Ineligibility or Leave from the State https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212531 03/12/2026 (a) HHSC may terminate an individual's DBMD Program services and CFC services if the individual refuses to comply with a mandatory participation requirement described in §260.113 of this subchapter(relating to Mandatory Participation Requirements of an Individual).(b) If a program provider becomes aware that an individual has not complied with a mandatory participation requirement, the program provider must immediately attempt to resolve the situation including facilitating at least one in-person meeting with the individual or LAR.(c) If attempts to resolve the situation fail, the program provider must request, in writing, that HHSC terminate DBMD Program services and CFC services for the individual. Within two business days after concluding that the situation cannot be resolved, the program provider must send the written request with written supporting documentation to HHSC. The program provider must include in the written documentation a description of:(1) the situation that resulted in the request to terminate DBMD Program services and CFC services; and(2) the attempts by the program provider to resolve the situation, including in-person meetings with the individual or LAR.(d) HHSC sends a written notice with the effective date of the termination to the program provider that the program provider, upon receipt but no later than 12 calendar days before the effective date of termination, must send to the individual or LAR, copying the FMSA if applicable.(e) If the individual or LAR requests a fair hearing before the effective date of the termination specified in the written notice, the program provider must continue to provide services to the individual while the appeal is pending. Source Note: The provisions of this §260.101 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.101 Termination of DBMD Program Services and CFC Services with Advance Notice Due to Non-compliance with Mandatory Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212532 03/12/2026 (a) HHSC terminates an individual's DBMD Program services and CFC services if any of the following situations exist:(1) the program provider has factual information confirming the death of the individual;(2) the program provider receives a clear written statement signed by the individual that:(A) the individual no longer wishes to receive DBMD Program services and CFC services; or(B) gives information that requires termination of services and indicates that the individual understands that this must be the result of supplying that information;(3) the individual's whereabouts are unknown, and the post office returns program provider mail directed to the individual or LAR indicating no forwarding address; or(4) the program provider establishes the fact that the individual has been accepted for Medicaid services by another state.(b) Within two business days after becoming aware that a situation described in subsection (a) of this section exists, the program provider must request, in writing, that HHSC terminate DBMD Program services and CFC services for the individual. The program provider must submit supporting documentation with the request.(c) HHSC sends a written notice with the effective date of the termination to the program provider that the program provider, upon receipt, must send to the individual or LAR, copying the FMSA, if applicable.(d) If the individual or LAR requests a fair hearing, the program provider is not required to provide services to the individual while the appeal is pending. Source Note: The provisions of this §260.103 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.103 Termination of DBMD Program Services and CFC Services without Advance Notice for Reasons Other Than Behavior Causing Immediate Jeopardy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212533 03/12/2026 (a) HHSC may terminate an individual's:(1) DBMD Program services and CFC services if an individual or a person in the individual's residence exhibits behavior that places the health and safety of the program provider's service provider in immediate jeopardy; or(2) DBMD Program services if an individual receiving licensed assisted living or licensed home health assisted living exhibits behavior that places the health and safety of another individual residing in the same residence or a service provider in immediate jeopardy.(b) If a program provider becomes aware that a situation described in subsection (a)of this section exists, the program provider must:(1) immediately file a report with the appropriate law enforcement agency and, if appropriate, make an immediate referral to DFPS;(2) within one business day after the program provider becomes aware of the situation, notify HHSC by fax, mail, or IDD Operations Portal of the situation; and(3) if feasible, attempt to resolve the situation.(c) If after making attempts to resolve the situation, as required by subsection (b)(3) of this section, a program provider determines that the situation cannot be resolved, the program provider must:(1) request, in writing, that HHSC terminates an individual's:(A) DBMD Program services and CFC services in accordance with subsection (a)(1) of this section; or(B) DBMD Program services in accordance with (a)(2) of this section;(2) submit the written request to HHSC within two business days after the program provider notifies HHSC in accordance with subsection (b)(2) of this section; and(3) include with the written request:(A) a description of the situation that resulted in the request to terminate the individual's services;(B) a description of the program provider's attempts to resolve the situation or an explanation of why the attempt was not feasible; and(C) if available, a copy of any report issued by a law enforcement agency or DFPS regarding the situation.(d) HHSC notifies the individual's program provider, in writing, of whether it authorizes the termination of DBMD Program services and CFC services.(e) Upon receipt of written notice from HHSC authorizing the termination of DBMD Program services and CFC services, the program provider must, no later than the date of the termination of services, send written notice to the individual or LAR of such termination, copying the FMSA, if applicable. The program provider must include in the notice the individual's right to request a fair hearing in accordance with §260.111 of this subchapter (relating to Individual's Right to a Fair Hearing). Source Note: The provisions of this §260.105 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.105 Termination of DBMD Program Services and CFC Services without Advance Notice Due to Behavior Causing Immediate Jeopardy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212534 03/12/2026 If HHSC terminates an individual's DBMD Program services and CFC services, the program provider must ensure that the case manager informs the individual of:(1) alternative long-term services and supports in the community, including CFC services through a managed care organization; and(2) institutional services. Source Note: The provisions of this §260.107 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.107 Offering Access to Other Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212535 03/12/2026 If HHSC terminates an individual's DBMD Program services, the individual or LAR may request the individual's name be placed on the DBMD interest list in accordance with §260.53(b) of this subchapter(relating to DBMD Interest List). Source Note: The provisions of this §260.109 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.109 Individual Whose DBMD Program Services are Terminated May Request Name be Added to DBMD Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212536 03/12/2026 An individual is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A, (relating to Uniform Fair Hearing Rules), if:(1) the individual's request for eligibility for the DBMD Program is denied or is not acted upon with reasonable promptness; or(2) the individual's DBMD Program services or CFC services have been denied, suspended, reduced, or terminated by HHSC. Source Note: The provisions of this §260.111 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.111 Individual's Right to a Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212537 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212537 03/12/2026 An individual or LAR must comply with the following mandatory participation requirements:(1) completing and submitting an application for Medicaid financial eligibility to HHSC in accordance with §260.61(h)(2) of this subchapter (relating to Process for Enrollment of an Individual) or within another time frame permitted by §260.61(i) of this subchapter if the individual does not have Medicaid financial eligibility;(2) participating on the service planning team to:(A) develop an enrollment IPP, as described in §260.65 of this chapter (relating to Development of an Enrollment IPP);(B) develop a proposed enrollment IPC, as described in §260.67 of this subchapter (relating to Development of a Proposed Enrollment IPC); and(C) review and revise the IPP and IPC, as described in §260.77 of this subchapter (relating to Renewal and Revision of an IPP and IPC);(3) reviewing, agreeing to, signing, and dating an IPP and IPC;(4) utilizing natural supports and other non-waiver and non-CFC services and supports for which the individual may be eligible before accessing DBMD Program services and CFC services;(5) cooperating with the program provider in the delivery of DBMD Program services and CFC services listed on the individual's IPC, including:(A) working with the program provider to schedule meetings;(B) attending a scheduled meeting with the case manager or a service provider;(C) being available to receive DBMD Program services and CFC services;(D) notifying the program provider in advance if the individual or LAR is unable to keep an appointment or is unavailable to receive services in the individual's residence; and(E) admitting program provider representatives to the individual's residence for a scheduled meeting or to receive DBMD Program services and CFC services;(6) cooperating with the program provider's service providers to ensure progress toward achieving the goals and outcomes described in the IPP;(7) if found by HHSC to be financially eligible for DBMD Program services based on the special institutional income limit, paying the required co-payment in a timely manner;(8) notifying the program provider if the individual receives notice from HHSC of a change in the status of the individual's financial eligibility for Medicaid;(9) not engaging in criminal behavior in the presence of a service provider or, if the individual receives licensed assisted living or licensed home health assisted living, another individual residing in the same residence;(10) not permitting a person present in the individual's residence to engage in criminal behavior in the presence of a service provider or, if the individual receives licensed assisted living or licensed home health assisted living, another individual residing in the same residence;(11) not acting in a manner that is threatening to the health and safety of a service provider or, if the individual receives licensed assisted living or licensed home health assisted living, another individual residing in the same residence;(12) not permitting a person present in the individual's residence to act in a manner that is threatening to the health and safety of the case manager or a service provider or, if the individual receives licensed assisted living or licensed home health assisted living, of another individual residing in the same residence;(13) not exhibiting behavior or permitting a person present in the individual's residence to exhibit behavior that places the health and safety of a service provider in immediate jeopardy;(14) not initiating or participating in fraudulent health care practices;(15) not engaging in behavior that endangers the individual's health or safety;(16) not permitting a person present in the individual's residence to engage in behavior that endangers the individual's health or safety; and(17) paying room and board on time if the individual receives licensed assisted living. Source Note: The provisions of this §260.113 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES B ELIGIBILITY, ENROLLMENT, AND REVIEW §260.113 Mandatory Participation Requirements of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212538 03/12/2026 A program provider must comply with:(1) this chapter;(2) Chapter 558 of this title (relating to Licensing Standards for Home and Community Support Services Agencies);(3) if providing licensed assisted living, Chapter 553 of this title (relating to Licensing Standards for Assisted Living Facilities);(4) 40 TAC Chapter 41 (relating to Consumer Directed Services Option);(5) 40 TAC Chapter 49 (relating to Contracting for Community Services); and(6) 1 TAC Chapter 354, Subchapter O (relating to Electronic Visit Verification). Source Note: The provisions of this §260.151 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES C COMPLIANCE WITH RULES §260.151 Program Provider Compliance with Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212539 03/12/2026 (a) A program provider must have and implement written policies and procedures that safeguard an individual against: (1) infectious and communicable diseases; (2) conflicts of interest with a service provider, staff person, volunteer, or controlling person; (3) abuse, neglect, and exploitation; (4) acts of financial impropriety by a service provider, staff person, volunteer, or controlling person; and (5) deliberate damage of personal possessions by a service provider, staff person, volunteer, or controlling person. (b) A program provider must not use seclusion. (c) A program provider must complete the HHSC Notification Regarding a Death in HCS, TxHmL, DBMD Programs form to notify HHSC, in writing, of an individual's death within 24 hours after learning of the death. (d) A program provider, in accordance with the Deaf Blind with Multiple Disabilities Program Manual, must report critical incidents to HHSC using the HHSC CLASS/DBMD Notification of Critical Incidents form. (e) A program provider must ensure a program director who receives a copy of an HHSC initial intake report or a final investigative report from an FMSA, in accordance with 40 TAC §41.702 (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Service Provider) or 40 TAC §41.703 (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of an FMSA), sends a copy of the report to the individual's case manager. Source Note: The provisions of this §260.201 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.201 Protection of Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222991 03/12/2026 (a) A program provider must employ a program director who is responsible for the program provider's day-to-day operations. The program director must:(1) have a minimum of one year of paid experience in community programs planning and providing direct services to individuals with deafness, blindness, or multiple disabilities and have a master's degree in a health and human services related field;(2) have a minimum of two years of paid experience in community programs planning and providing direct services to individuals with deafness, blindness, or multiple disabilities, and have a bachelor's degree in a health and human services related field; or(3) have been a program director for the DBMD Program provider on or before June 15, 2010.(b) A program provider must ensure that a case manager:(1) has:(A) a bachelor's degree in a health and human services related field and a minimum of two years of experience in the delivery of direct services to individuals with disabilities;(B) an associate degree in a health and human services related field and a minimum of four years of experience providing direct services to individuals with disabilities; or(C) a high school diploma or certificate recognized by a state as the equivalent of a high school diploma and a minimum of six years of experience providing direct services to individuals with disabilities; and(2) either:(A) is fluent in the individual's preferred communication methods (American sign language, tactile symbols, communication boards, pictures, or gestures); or(B) within six months after being assigned to an individual, becomes fluent in the individual's communication methods.(c) For purposes of subsection (d) of this section and consistent with Texas Government Code §526.0404, "deafblind-related course work" means educational courses designed to improve a person's:(1) knowledge of deafblindness and its effect on learning;(2) knowledge of the role of intervention and ability to facilitate the intervention process;(3) knowledge of areas of communication relevant to deafblindness, including methods, adaptations, and use of assistive technology, and ability to facilitate the development and use of communication skills for a person with deafblindness;(4) knowledge of the effect that deafblindness has on a person's psychological, social, and emotional development and ability to facilitate the emotional well-being of a person with deafblindness;(5) knowledge of and issues related to sensory systems and ability to facilitate the use of the senses;(6) knowledge of motor skills, movement, orientation, and mobility strategies and ability to facilitate orientation and mobility skills;(7) knowledge of the effect that additional disabilities have on a person with deafblindness and the ability to provide appropriate support; or(8) professionalism and knowledge of ethical issues relevant to the role of an intervener.(d) A program provider must ensure that:(1) an intervener:(A) is at least 18 years of age;(B) is not:(i) the spouse of the individual to whom the intervener is assigned; or(ii) if the individual is under 18 years of age, a parent of the individual to whom the intervener is assigned;(C) holds a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma;(D) has at least two years of experience working with individuals with developmental disabilities; and(E) has the ability to proficiently communicate in the functional language of the individual to whom the intervener is assigned;(2) an intervener I:(A) meets the requirements for an intervener described in paragraph (1) of this subsection;(B) has at least six months of experience working with persons who have deafblindness or function as persons with deafblindness;(C) completed at least eight semester credit hours in deafblind-related course work at a college or university accredited by:(i) a state agency recognized by the United States Department of Education; or(ii) a non-governmental entity recognized by the United States Department of Education; and(D) has completed a practicum that is at least one semester credit hour in deafblind-related course work at a college or university accredited by:(i) a state agency recognized by the United States Department of Education; or(ii) a non-governmental entity recognized by the United States Department of Education;(3) an intervener II:(A) meets the requirements for an intervener I described in paragraph (2) of this subsection;(B) has at least nine months of experience working with persons who have deafblindness or function as persons with deafblindness; and(C) has completed at least an additional 10 semester credit hours in deafblind-related course work at a college or university accredited by:(i) a state agency recognized by the United States Department of Education; or(ii) a non-governmental entity recognized by the United States Department of Education; and:(4) an intervener III:(A) meets the requirements for an intervener II described in paragraph (3)(A) of this subsection;(B) has at least one year of experience working with persons with deafblindness or function as persons with deafblindness; and(C) holds an associate degree or bachelor's degree in a course of study with a focus on deafblind-related course work from a college or university accredited by:(i) a state agency recognized by the United States Department of Education; or(ii) a non-governmental entity recognized by the United States Department of Education.(e) A program provider must ensure that a service provider who interacts directly with an individual is able to communicate with the individual.(f) A program provider must ensure that a service provider of a therapy described in §260.355(a) of this chapter (relating to Therapies) is licensed by the State of Texas as described in §260.355(b) of this chapter.(g) A program provider must ensure that a service provider of employment assistance or a service provider of supported employment:(1) is at least 18 years of age;(2) is not:(A) the spouse of the individual; or(B) a parent of the individual if the individual is under 18 years of age; and(3) has:(A) a bachelor's degree in rehabilitation, business, marketing, or a related human services field with six months of paid or unpaid experience providing services to people with disabilities;(B) an associate degree in rehabilitation, business, marketing, or a related human services field with one year of paid or unpaid experience providing services to people with disabilities; or(C) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, with two years of paid or unpaid experience providing services to people with disabilities.(h) Documentation of the experience required by subsection (g) of this section must include:(1) for paid experience, a written statement from a person who paid for the service or supervised the provision of the service; and(2) for unpaid experience, a written statement from a person who has personal knowledge of the experience.(i) A program provider must ensure that a service provider of employment readiness:(1) be at least 18 years of age;(2) is not:(A) the parent of the individual if the individual is under 18 years of age; or(B) the spouse of the individual; and(3) has:(A) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; and(B) documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(i) a written competency-based assessment of the ability to document service delivery and observations of individuals receiving services; and(ii) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals receiving services.(j) A program provider must ensure that dental treatment is provided by a person licensed to practice dentistry or dental hygiene in accordance with Texas Occupations Code Chapter 256.(k) A program provider must ensure that a service provider not required to meet the other education or experience requirements described in this section:(1) is 18 years of age or older;(2) has:(A) a high school diploma;(B) a certificate recognized by a state as the equivalent of a high school diploma; or(C) the following:(i) documentation of a proficiency evaluation of experience and competence to perform job tasks including an ability to provide the required services needed by the individual as demonstrated through a written competency-based assessment; and(ii) at least three personal references from persons not related by blood that evidence the person's ability to provide a safe and healthy environment for the individual; and(3) except for a service provider of chore services, either:(A) is fluent in the communication method preferred by the individual to whom the service provider is assigned, including American sign language, tactile symbols, communication boards, pictures, and gestures; or(B) has the ability to become fluent in the communication methods used by an individual within three months after being assigned to the individual.(l) A program provider must ensure that:(1) a vehicle in which a service provider transports an individual has a valid Vehicle Identification Certificate of Inspection, in accordance with state law; and(2) a service provider who transports an individual in a vehicle has:(A) a current Texas driver's license; and(B) vehicle liability insurance, in accordance with state law.(m) A service provider:(1) must not be a parent of the individual to whom the service provider is providing any service, if the individual is under 18 years of age;(2) must not be the spouse of the individual to whom the service provider is providing any service;(3) must not be a relative or guardian of the individual to whom the service provider is providing an adaptive aid; and(4) must not be a relative or guardian of the individual to whom the service provider is providing any of the following services, if the individual is 18 years of age or older:(A) assisted living;(B) case management;(C) behavioral support;(D) dental treatment;(E) dietary services;(F) FMS, if the individual is participating in the CDS option;(G) occupational therapy;(H) orientation and mobility;(I) physical therapy;(J) speech and language pathology;(K) audiology; and(L) support consultation, if the individual is participating in the CDS option.(n) A service provider of CFC PAS/HAB must:(1) have:(A) a high school diploma;(B) a certificate recognized by a state as the equivalent of a high school diploma; or(C) both of the following:(i) a successfully completed written competency-based assessment demonstrating the service provider's ability to perform CFC PAS/HAB tasks, including an ability to perform CFC PAS/HAB tasks required for the individual to whom the service provider will provide CFC PAS/HAB; and(ii) at least three written personal references from persons not related by blood that evidence the service provider's ability to provide a safe and healthy environment for the individual; and(2) meet any other qualifications requested by the individual or LAR based on the individual's needs and preferences.(o) The program provider must maintain documentation in a service provider's employment, contract, or personal service agreement file that the service provider meets the requirements of this section. Source Note: The provisions of this §260.203 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.203 Qualifications of Program Provider Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222992 03/12/2026 (a) General orientation training. A program provider must ensure that a program director and a service provider complete a general orientation curriculum before assuming job duties and annually thereafter.(1) The general orientation curriculum must include training on:(A) the rights of an individual;(B) confidentiality;(C) the program provider's complaint process; and(D) the DBMD Program and CFC, including the requirements of this chapter and the DBMD Program services and CFC services specified in §260.7 of this chapter (relating to Description of the DBMD Program and CFC).(2) A program provider must document:(A) the name of the person who received the training required by this subsection;(B) the date the training was conducted; and(C) the name of the person who conducted the training.(b) Abuse, neglect, and exploitation training. A program provider must:(1) ensure that a program director, service provider, staff person, and volunteer:(A) are trained on and knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation;(B) are instructed to report an allegation of abuse, neglect, or exploitation of an individual as described in §260.219 of this subchapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual); and(C) are provided with the instructions, in writing, described in subparagraph (B) of this paragraph;(2) conduct the activities described in paragraph (1) of this subsection:(A) within one year after the person's most recent training on abuse, neglect, and exploitation and annually thereafter, if the program director, service provider, staff person, or volunteer was hired before July 1, 2019; or(B) before assuming job duties and annually thereafter, if the program director, service provider, staff person, or volunteer is hired on or after July 1, 2019; and(3) document:(A) the name of the person who received the training required by this subsection;(B) the date the training was conducted; and(C) the name of the person who conducted the training.(c) Cardiopulmonary resuscitation and choking prevention training. A program provider must ensure training on cardiopulmonary resuscitation and choking prevention in accordance with this subsection.(1) A program provider must ensure that a program director, a case manager, an intervener, and a service provider of licensed assisted living, licensed home health assisted living, day habilitation, employment assistance, employment readiness, transportation provided as a residential habilitation activity, respite, supported employment, and CFC PAS/HAB have current certification in:(A) cardiopulmonary resuscitation; and(B) choking prevention.(2) The training received to obtain the certification must include an in-person evaluation by a qualified instructor of the trainee's ability to perform the actions listed in paragraph (1) of this subsection.(3) A program provider must ensure that:(A) a program director, a case manager, an intervener, and a service provider of licensed assisted living, licensed home health assisted living, day habilitation, employment assistance, transportation provided as a residential habilitation activity, respite, employment readiness, and supported employment have the certification described in paragraph (1) of this subsection before assuming job duties; and(B) a CFC PAS/HAB service provider has the certification described in paragraph (1) of this subsection:(i) within 90 calendar days after the original effective date of this section, if the CFC PAS/HAB service provider was hired on or before the original effective date of this section; or(ii) before assuming job duties, if the CFC PAS/HAB service provider is hired after the original effective date of this section.(4) A program provider must maintain a copy of the certification required by paragraph (1) of this subsection. The certification must be issued by the organization granting the certification.(d) HHSC DBMD Computer Based Training.(1) A program provider must ensure that a program director and case manager complete the HHSC Deaf Blind with Multiple Disabilities Waiver Computer Based Training and receive a score of at least 80 percent on the examination included in the training:(A) within 90 days after October 1, 2019, and annually thereafter, if the program director or case manager was hired before October 1, 2019; or(B) within 90 days after assuming job duties and annually thereafter, if the program director or case manager is hired on or after October 1, 2019.(2) A program provider must maintain a copy of the certification from the training required by this subsection, issued by HHSC, showing that the person successfully completed the training.(e) DBMD Program Case Management Training.(1) A program provider must ensure that a program director and case manager complete, within six months after assuming job duties, the DBMD Program Case Management Training provided by HHSC or training developed by the program provider. A program provider that develops and conducts its own training must ensure that:(A) the training addresses the following elements from the HHSC DBMD Program Case Management Training:(i) the DBMD Program service delivery model, which includes:(I) the role of the case manager and DBMD Program provider;(II) the role of the service planning team;(III) person-centered planning; and(IV) the CDS option;(ii) DBMD Program services, including how these services:(I) complement other Medicaid services;(II) supplement family supports and non-waiver services available in the individual's community; and(III) prevent admission to an institution;(iii) DBMD Program process and procedures for:(I) eligibility and enrollment;(II) service planning, service authorization, and program plans;(III) access to non-waiver resources; and(IV) complaint procedures and the fair hearing process; and(iv) rules, policies, and procedures about:(I) prevention of abuse, neglect, and exploitation of an individual;(II) reporting abuse, neglect, and exploitation to local and state authorities; and(III) financial improprieties involving an individual; and(B) the staff person who develops and conducts the training successfully completes the DBMD Program Case Management Training provided by HHSC before developing or conducting training.(2) A program provider must:(A) for the training required by this subsection that is provided by HHSC, maintain a copy of the certificate issued by HHSC that the person completed the training; or(B) for the training required by this subsection that is developed and conducted by the program provider, maintain a copy of a certificate or form letter issued by the program provider that includes:(i) the name of the person who received the training;(ii) the date the training was conducted; and(iii) the name of the person conducting the training.(f) DBMD Program Service Provider Training.(1) A program provider must ensure that:(A) a case manager, within six months after assuming job duties, completes the DBMD Program Service Provider Training as described in paragraph (2) of this subsection;(B) a program director, if providing intervener services, licensed assisted living, licensed home health assisted living, case management, day habilitation, employment assistance, nursing, specialized nursing, transportation provided as a residential habilitation activity, respite, supported employment, employment readiness, or CFC PAS/HAB to an individual, completes, within six months after assuming job duties, the DBMD Program Service Provider Training as described in paragraph (2) of this subsection;(C) an intervener and a service provider of licensed assisted living, licensed home health assisted living, day habilitation, employment assistance, employment readiness, nursing, specialized nursing, transportation provided as a residential habilitation activity, respite, or supported employment, within 90 calendar days after assuming job duties, complete the DBMD Program Service Provider Training described in paragraph (2) of this subsection; and(D) a CFC PAS/HAB service provider completes the DBMD Program Service Provider Training:(i) within 90 days after the original effective date of this section, if the CFC PAS/HAB service provider was hired on or before the original effective date of this section; or(ii) within 90 calendar days after assuming job duties, if the CFC PAS/HAB service provider is hired after the original effective date of this section.(2) The DBMD Program Service Provider Training is provided by HHSC or developed by a program provider. If the training is developed by the program provider, the training must address the following elements from the HHSC DBMD Program Service Provider Training curriculum:(A) methods and strategies for communication;(B) active participation in home and community life;(C) orientation and mobility;(D) behavior as communication;(E) causes and origins of deafblindness; and(F) vision, hearing, and the functional implications of deafblindness.(3) A program provider that develops and conducts its own training, as described in paragraph (2) of this subsection, must ensure that the staff person who develops and conducts the training successfully completes the DBMD Program Service Provider Training provided by HHSC before developing or conducting training.(4) A program provider must:(A) for the training required by this subsection that is provided by HHSC, maintain a copy of the certificate issued by HHSC that the person completed the training; or(B) for the training required by this subsection that is developed and conducted by the program provider, maintain a copy of a certificate or form letter issued by the program provider that includes:(i) the name of the person who received the training;(ii) the date the training was conducted; and(iii) the name of the person conducting the training.(g) Training on needs of an individual.(1) Except as provided in paragraph (3) of this subsection, a program provider must ensure an intervener and a service provider of licensed assisted living, licensed home health assisted living, day habilitation, employment assistance, transportation provided as a residential habilitation activity, respite, supported employment, employment readiness, and CFC PAS/HAB, complete training on the needs of an individual:(A) before providing services to the individual;(B) at least annually; and(C) if the individual's needs change.(2) Training on the needs of an individual must include:(A) the special needs of the individual, including the individual's:(i) methods of communication;(ii) specific visual and audiological loss; and(iii) adaptive aids;(B) managing challenging behavior, including training in:(i) prevention of aggressive behavior; and(ii) de-escalation techniques; and(C) instruction in the individual's home with full participation by the individual, LAR, or other actively involved person, as appropriate, concerning the specific tasks to be performed.(3) A program provider must ensure that a CFC PAS/HAB service provider hired before the original effective date of this section receives the training required by this subsection within 90 days after the original effective date of this section, annually thereafter, and if the individual's needs change.(4) A program provider must document:(A) the name of the person who received the training required by this subsection;(B) the date the training was conducted;(C) the name of the individual;(D) the topic of the training; and(E) the name of the person who conducted the training.(h) Training on delegated tasks.(1) A program provider must ensure a service provider performing a delegated task is:(A) trained to perform the delegated task in accordance with state law and rules:(i) before providing services to an individual;(ii) annually thereafter; and(iii) if the individual's needs change; and(B) supervised by a physician or nurse in accordance with state law and rules.(2) A program provider must document:(A) the name of the person who received the training required by this subsection;(B) the date the training was conducted;(C) the name of the individual;(D) the topic of the training; and(E) the name of the person who conducted the training.(i) Person-centered planning training.(1) A program provider must ensure that:(A) a case manager completes a comprehensive non-introductory person-centered planning training developed or approved by HHSC within six months after the case manager's date of hire; and(B) a service provider whose duties include participating as a member of a service planning team completes HHSC's web-based Introductory Training within six months after assuming this duty.(2) A program provider must maintain documentation that includes:(A) for the training described in paragraph (1)(A) of this subsection:(i) the name of the case manager who received the training;(ii) the date the training was conducted; and(iii) the name of the person or organization that conducted the training; and(B) for the training described in paragraph (1)(B) of this subsection:(i) the name of the service provider who completed the training; and(ii) the date the service provider completed the training.(j) Training requested for a CFC PAS/HAB service provider. If requested by an individual or LAR, a program provider must:(1) allow the individual or LAR to:(A) train a CFC PAS/HAB service provider in the specific assistance needed by the individual; and(B) have the service provider perform CFC PAS/HAB in a manner that comports with the individual's personal, cultural, or religious preferences; and(2) ensure that a CFC PAS/HAB service provider attends training by HHSC so the service provider meets any additional qualifications desired by the individual or LAR.(k) Training on protective devices. A program provider must ensure compliance with the training and training documentation requirements described in §260.215(c)(8) and (9) of this subchapter (relating to Protective Devices).(l) Training on restraints. A program provider must ensure compliance with the training and documentation requirements described in §260.217(d)(3) of this subchapter (relating to Restraints). Source Note: The provisions of this §260.205 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.205 Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212542 03/12/2026 (a) A program provider must ensure that: (1) a full-time case manager is assigned to provide case management services to no more than 30 individuals or other persons receiving services through another Medicaid waiver at one time; (2) a part-time case manager is assigned to provide case management services to no more than 15 individuals or other persons receiving services through another Medicaid waiver at one time; and (3) for a month in which a case manager does not meet with an individual or LAR as required by §260.77(a) of this chapter (relating to Renewal and Revision of an IPP and IPC), the case manager has contact with the individual, LAR, primary caregiver, or actively involved person in person, by videoconferencing, or by telephone, to provide case management. (b) In determining the number of individuals or other persons receiving services through another Medicaid waiver at one time to whom a case manager will be assigned, a program provider must take into consideration: (1) the intensity of needs of each individual or person; (2) the frequency and duration of contacts the case manager will need to make with the individual or person; and (3) the amount of travel time involved in making such contacts. (c) A program provider must have: (1) a sufficient number of case managers available at all times to ensure the provision of case management services; and (2) a written process that ensures a case manager can readily become familiar with an individual to whom the case manager is not ordinarily assigned but to whom the case manager may be required to provide case management services. (d) A program provider must have written policies and procedures that ensure backup service providers are or can readily become familiar with individuals to whom they are not ordinarily assigned but to whom they may be required to deliver services. (e) A program provider must provide each DBMD Program service and CFC service authorized in an individual's IPC in accordance with: (1) the individual's current IPC; (2) the individual's current IPP; and (3) the requirements in this chapter. (f) A program provider must ensure a copy of an individual's IPP is distributed or made available to each service provider who provides a service on the IPP.(g) A program provider must: (1) provide or ensure the provision of each DBMD Program service listed in §260.7(c) of this chapter (relating to Description of the DBMD Program and CFC); (2) provide the assisted living service as either licensed assisted living or licensed home health assisted living in accordance with §260.351 of this chapter (relating to Residential Services); (3) provide or ensure the provision of each CFC service listed in §260.7(e) of this chapter; and (4) ensure that CFC support management is provided to an individual or LAR as described in the Deaf Blind with Multiple Disabilities Program Manual if: (A) the individual is receiving CFC PAS/HAB; and (B) the individual or LAR requests to receive CFC support management. (h) A program provider must offer an individual choices and opportunities for accessing and participating in community activities, including employment opportunities and experiences available to peers without disabilities, and provide supports necessary for an individual to participate in those activities consistent with an individual's or LAR's choice and the individual's IPC and IPP. (i) A program provider may accept or decline the request of an individual or LAR for the provision of transportation provided as a residential habilitation activity, nursing, out-of-home respite in a camp, case management, adaptive aids, intervener services, or CFC PAS/HAB to the individual while the individual is staying at a location outside the program provider's contracted service delivery area but within the state of Texas. (j) If a program provider accepts the request of an individual or LAR, as described in subsection (i) of this section, the program provider: (1) may provide transportation provided as a residential habilitation activity, nursing, out-of-home respite in a camp, adaptive aids, intervener services, CFC PAS/HAB, and case management services at the requested location; (2) must document in the service delivery log: (A) that the individual is receiving services outside the program provider's contracted service delivery area; (B) the location where the individual is receiving the services; (C) the estimated length of time the individual is expected to be outside the program provider's contracted service delivery area; and (D) contact information for the individual or LAR; (3) must, if the individual receives services outside the program provider's contracted service delivery area for 30 consecutive days, inform the individual or LAR, on or before the 35th day, that: (A) to ensure the continued provision of the services, the individual must do one of the following before the 61st day: (i) transfer to a program provider that has a contracted service delivery area that includes the area in which the individual is receiving the services; or (ii) return to the program provider's contracted service delivery area; and (B) if the individual receives services outside the program provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that area before the program provider may accept another request from the individual or LAR for the provision of the services outside the program provider's contracted service delivery area; and (4) must, if the individual or LAR expresses a desire for the individual to transfer to a program provider that has a contracted service delivery area that includes the area in which the individual is receiving services: (A) give the individual and LAR the HHSC Documentation of Provider Choice form for the contracted service delivery area in which the individual is receiving the services; (B) have the individual or LAR select a program provider and designate that selection on the HHSC Documentation of Provider Choice form; and (C) coordinate the individual's transfer in accordance with §260.79 of this chapter (relating to Coordination of Transfers). (k) If the program provider declines the request of an individual or LAR, as described in subsection (i) of this section, the program provider must: (1) inform the individual or LAR orally or in writing: (A) of the reasons for declining the request; and (B) that the individual may request a service planning team meeting to discuss the reasons for declining the request; and (2) document the discussion and the final outcome if the service planning team meeting is held. (l) If a program provider or case manager is unable to meet a time frame specified in this chapter, it must be for a reason not directly caused by the program provider or case manager, or for a reason beyond the program provider's or case manager's control, such as a man-made or natural disaster. The program provider or case manager must document the program provider's or case manager's efforts to meet a time frame and maintain the documentation in the individual's record. The documentation must include: (1) the reason the time frame could not be met, which must be beyond the program provider's or case manager's control; and (2) a description of the program provider's or case manager's ongoing efforts to meet a time frame. Source Note: The provisions of this §260.207 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.207 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212543 03/12/2026 (a) A program provider must ensure that for each service provided, except adaptive aids, dental treatment, minor home modifications, CFC ERS, CFC support management, licensed assisted living, licensed home health assisted living, and a service that is documented through an electronic visit verification system, as listed in 1 TAC §354.4005(b) (relating to Applicability), a service provider completes an HHSC DBMD Summary of Services Delivered form to document:(1) the type of service provided;(2) the date and the time the service begins and ends;(3) the type of contact (phone or in-person);(4) the name of the person with whom the contact occurred;(5) a description of the service activity performed, unless the activity is a non-delegated task provided by an unlicensed service provider that is documented on the IPP; and(6) the signature and title of the service provider.(b) A program provider must ensure that, after a service provider makes the last entry on an HHSC DBMD Summary of Services Delivered form, a staff person other than the service provider signs and dates the form as a timekeeper as verification of the accuracy of the information on the form.(c) A program provider must ensure that an individual's record includes:(1) a copy of the individual's current IPC and any other IPC authorized for the current IPC period;(2) a copy of the individual's current IPP and any other IPP developed for the current IPC period;(3) a copy of the individual's current ID/RC Assessment;(4) if the program provider was the individual's program provider when the individual enrolled in the DBMD Program:(A) the original ID/RC Assessment signed by a physician; or(B) the original level of care form signed by a physician that was in use before the ID/RC Assessment;(5) a copy of the current adaptive behavior screening assessment;(6) a copy of the current Related Conditions Eligibility Screening Instrument;(7) the documentation required by subsection (a) of this section;(8) the completed HHSC Summary of Services Delivered forms signed and dated by a timekeeper as required by subsection (b) of this section;(9) any other relevant documentation concerning the individual;(10) documentation of the progress or lack of progress in achieving a goal or outcome in the individual's IPP in observable, measurable terms that directly relate to the specific goal or outcome addressed, including:(A) assessments, evaluations, and progress notes prepared by a service provider for review by a case manager in accordance with §260.77(a)(1)(E) of this chapter (relating to Renewal and Revision of an IPP and IPC);(B) the IPP reviews for the current IPC period prepared by a case manager in accordance with §260.77(a)(2) of this chapter; and(C) if the IPP includes day habilitation, transportation provided as a residential habilitation activity, and CFC PAS/HAB, the individual's progress or lack of progress in achieving the following outcomes:(i) the ability to effectively communicate the individual's wants and needs to a service provider of day habilitation, transportation provided as a residential habilitation activity, or CFC PAS/HAB;(ii) the ability to actively participate in ADLs and IADLs to the extent of the individual's ability;(iii) the ability to implement the individual's choices;(iv) the ability to access and participate in community activities; and(v) the ability to move safely and efficiently within the setting in which the individual receives day habilitation, transportation provided as a residential habilitation activity, or CFC PAS/HAB;(11) the individual's HHSC Verification of Freedom of Choice form completed at enrollment documenting the individual's or LAR's choice of the DBMD Program over the ICF/IID Program;(12) the individual's current HHSC Documentation of Provider Choice form documenting the individual's or LAR's choice of a program provider;(13) if required by §260.213 of this subchapter (relating to Service Backup Plans), any new or revised HHSC Provider Agency Model Service Backup Plan form for nursing, intervener services, or CFC/PAS HAB for the current IPC period;(14) if the IPC includes transportation provided as a residential habilitation activity or as an adaptive aid, a copy of the individual's transportation plan;(15) if a protective device is used, the documentation required by §260.215 of this subchapter (relating to Protective Devices); and(16) if a restraint is used, the documentation required by §260.217 of this subchapter (relating to Restraints). Source Note: The provisions of this §260.209 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.209 Documentation of Services Delivered and Recordkeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212544 03/12/2026 (a) A program provider must conduct an annual survey of individuals, LARs, and actively involved person to determine satisfaction with services.(b) At least annually, a program provider must:(1) review all final investigative reports from HHSC and based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services; and(2) evaluate critical incident data reported in accordance with §260.201(d) of this subchapter (relating to Protection of Individual), compare the program provider's use of restraint to aggregate data provided by HHSC on HHSC's website, and identify program process improvements that help prevent the occurrence of critical incidents and improve service delivery. Source Note: The provisions of this §260.211 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.211 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212545 03/12/2026 (a) If an individual's IPC includes nursing, intervener services, or CFC/PAS HAB, a case manager must ensure that the service planning team determines if an individual needs a service backup plan or a service backup plan revision during:(1) the process of enrollment described in §260.61 of this chapter (relating to Process for Enrollment of an Individual);(2) each of the reviews described in §260.77 of this chapter (relating to Renewal and Revision of an IPP and IPC); and(3) an individual's transfer from one program provider to another.(b) If the service planning team determines that an individual needs a service backup plan for nursing, intervener services, or CFC PAS/HAB services critical to the individual's health and safety, the case manager must document on the individual's IPP and IPC which services require a service backup plan.(c) If a service that requires a service backup plan will be provided by a program provider, a case manager must:(1) develop, with input from the service planning team, the service backup plan for each service identified as critical using the HHSC Provider Agency Model Service Backup Plan form; and(2) ensure that:(A) the service backup plan addresses emergencies, including when the failure of a service provider to appear as scheduled presents a risk to an individual's health and welfare; and(B) if the action in the service backup plan identifies a natural support, that a person providing the natural support receives pertinent information about the individual's needs and is able to protect the individual's health and safety.(d) If a service backup plan is implemented in accordance with subsection (c) of this section, the service planning team must revise the service backup plan to address any problems or concerns from the individual, case manager, service provider, or a person providing the natural support regarding implementation of the service backup plan. Source Note: The provisions of this §260.213 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.213 Service Backup Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212546 03/12/2026 (a) A protective device is a restrictive intervention that a program provider may use in accordance with this section.(b) A program provider must not use a protective device to modify or control an individual's behavior, for disciplinary purposes, for convenience, or as a substitute for an effective, less restrictive method.(c) Before a program provider uses a protective device, the program provider must:(1) have an RN conduct an assessment of the individual's needs;(2) consider less restrictive methods that, if effective, would accomplish the purpose of the protective device;(3) document in the individual's record the reasons why less restrictive methods would not be effective;(4) obtain and retain in the individual's record written consent of the individual or LAR to use a protective device;(5) provide oral and written notification to the individual or LAR of the right at any time to withdraw consent for the use of the protective device;(6) have an RN, with input from the individual, the individual's LAR, the individual's service planning team, and other professional personnel, develop a written service plan, which may be part of the individual's plan of care as defined in §558.2 of this title (relating to Definitions), signed by a physician, that describes:(A) the type of device and the circumstances under which it may be used;(B) how to use the protective device and any contraindications specific to the individual;(C) how and when to document the use of the protective device;(D) how to monitor the protective device; and(E) when and whom the program staff must notify of the use of a protective device;(7) ensure the service planning team reviews and approves the written service plan;(8) ensure that each service provider who will use a protective device has been trained in the proper use of the protective device; and(9) ensure the training is documented in the service provider's record.(d) A program provider that uses a protective device must:(1) document in the individual's record any use of the protective device in accordance with the written service plan;(2) ensure that an RN, with input from the individual's service planning team and other professional personnel, at least annually, and when the individual's needs change:(A) evaluates and documents in the individual's record the effects of the protective device on the individual's health and welfare; and(B) reviews the use of a protective device to determine its effectiveness and the need to continue the protective device; and(3) ensure that an RN, in accordance with subsection (c)(6) of this section, revises the service plan when the individual's service planning team and physician determine that a protective device is not effective or needed. Source Note: The provisions of this §260.215 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.215 Protective Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212547 03/12/2026 (a) A restraint is a restrictive intervention that a program provider may use in accordance with this section.(b) A program provider providing licensed assisted living must comply with §553.267(a)(3)(A) and (D) of this title (relating to Rights).(c) A program provider must ensure that a six-bed ICF/IID providing respite complies with §551.42(e)(4) of this title (relating to Standards for a Facility).(d) A program provider providing licensed home health assisted living:(1) must not use restraints:(A) for disciplinary purposes, retaliation, coercion, or retribution;(B) for the convenience of a service provider or other persons; or(C) as a substitute for an effective, less restrictive method;(2) may use a restraint only:(A) if the use is authorized, in writing, by a physician and specifies:(i) the circumstances under which the restraint may be used; and(ii) the duration for which the restraint may be used; or(B) if the use is necessary in a behavioral emergency to protect an individual or others from injury;(3) except in a behavioral emergency, must ensure:(A) that a service provider who uses a restraint has been trained in the use of the restraint:(i) before using the restraint;(ii) annually; and(iii) when the individual's needs change; and(B) that the training is documented in the service provider's record;(4) must not use a restraint under any circumstance if it:(A) obstructs the individual's airway, including a procedure that places anything in, on, or over the individual's mouth or nose;(B) impairs the individual's breathing by putting pressure on the individual's torso;(C) interferes with the individual's ability to communicate; or(D) places the individual in a prone or supine position;(5) must ensure that if a physical restraint is used in a behavioral emergency:(A) it must be a restraint in which the individual's limbs are held close to the body to limit or prevent movement and that does not violate the provisions of paragraph (4) of this subsection;(B) that as soon as possible but no later than one hour after the use of the restraint, the service provider notifies an RN of the restraint;(C) that after the RN is notified of the use of the restraint, the service provider documents the RN's instructions to the service provider;(D) that medical services are obtained for the individual as necessary;(E) the program provider:(i) with the individual's consent, makes an appointment with a physician no later than the end of the first business day after the use of restraint and document in the individual's record that the appointment was made; or(ii) if the individual refuses to see a physician, documents the refusal in the individual's record; and(F) that as soon as possible but no later than 24 hours after the use of restraint, the program provider notifies one of the following persons, if there is such a person, that the individual has been restrained:(i) the individual's LAR; or(ii) an actively involved person with the individual's care, unless the release of this information would violate other law;(6) that uses a restraint must document in an individual's record:(A) the use of the restraint;(B) time and date the restraint was used;(C) name of person administering the restraint;(D) type of restraint and duration used; and(E) if used in a behavioral emergency:(i) events preceding the use of the restraint;(ii) actions taken after the use of the restraint; and(iii) types of intervention attempted before the use of the restraint; and(7) in order to decrease the frequency of the use of restraint, and to minimize the risk of harm to an individual, must ensure that a service provider is aware of and adheres to the findings of the nursing assessment required in §260.61(c)(8) of this chapter (relating to Process for Enrollment of an Individual) or in §260.77(b)(1)(B) of this chapter (relating to Renewal and Revision of an IPP and IPC) for each individual. Source Note: The provisions of this §260.217 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.217 Restraints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224205 03/12/2026 If a program provider, service provider, staff person, volunteer, or controlling person knows or suspects that an individual is being or has been abused, neglected, or exploited, the program provider must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation: (1) for an individual receiving licensed assisted living, in accordance with Chapter 553 of this title (relating to Licensing Standards for Assisted Living Facilities); or (2) for an individual who is not receiving licensed assisted living, to HHSC immediately, but not later than 24 hours, after having knowledge or suspicion by: (A) calling the HHSC Abuse Hotline toll-free telephone number, 1-800-458-9858; or (B) using the HHSC online Texas Unified Licensure Information Portal. Source Note: The provisions of this §260.219 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective February 27, 2025, 50 TexReg 996. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.219 Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212549 03/12/2026 (a) If a report required by §260.219 of this subchapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation by a person who is not a service provider, staff person, volunteer, or controlling person, a program provider must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) discuss with the individual or LAR alternative residential settings and additional services that may help ensure the individual's safety;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(4) preserve and protect evidence related to the allegation.(b) If a report required by §260.219 of this subchapter alleges abuse, neglect, or exploitation by a service provider, staff person, volunteer, or controlling person or if a program provider is notified by HHSC of an allegation of abuse, neglect, or exploitation by a service provider, staff person, volunteer, or controlling person, the program provider must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) as soon as possible, but no later than 24 hours after the program provider reports or is notified of the allegation, notify the individual, the LAR, and the case manager of:(A) the allegation report; and(B) the actions the program provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(c) During an HHSC investigation of an alleged perpetrator who is a service provider, staff person, volunteer, or controlling person, a program provider must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the program provider;(B) individuals, service providers, staff persons, volunteers, and controlling persons; and(C) records pertinent to the investigation of the allegation; and(3) ensure that service providers, staff persons, volunteers, and controlling persons comply with paragraphs (1) and (2) of this subsection.(d) After a program provider receives a final investigative report from HHSC for an investigation described in subsection (c) of this section, the program provider must:(1) if the allegation of abuse, neglect, or exploitation is confirmed or substantiated by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the program provider's authority to prevent the reoccurrence of abuse, neglect, or exploitation, including disciplinary action against the service provider, staff person, or volunteer confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the program provider's authority, as necessary; and(3) immediately, but not later than five calendar days after the date the program provider receives the HHSC final investigative report, notify the individual, the LAR, and the case manager of:(A) the investigation finding; and(B) the action taken by the program provider in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection.(e) A program provider must not retaliate against:(1) a staff person, service provider, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations. Source Note: The provisions of this §260.221 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.221 Requirements Related to the Reporting of Abuse, Neglect, and Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212550 03/12/2026 If a program provider submits documentation to HHSC containing information that is not in English, the program provider must, at the same time, submit a translation of the information in English. Source Note: The provisions of this §260.223 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES D ADDITIONAL PROGRAM PROVIDER PROVISIONS §260.223 Requirement for Translation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212551 03/12/2026 (a) If a program provider offers assistance with personal funds management, the program provider must have written authorization from an individual or LAR before accepting an individual's personal funds for deposit in a trust fund account. The program provider must:(1) ensure the written authorization is signed and dated by the individual or LAR;(2) provide the individual or LAR with a copy of the original written authorization; and(3) maintain the original of the written authorization in the individual's record.(b) Before the program provider accepts an individual's personal funds for deposit in a trust fund account, the program provider must inform the individual or LAR, orally and in writing, of:(1) the individual's rights and responsibilities regarding personal funds management; and(2) the program provider's responsibilities for providing assistance with managing the individual's personal funds in a trust fund account as described in this subchapter.(c) The program provider must not require an individual or LAR to request the program provider's assistance with management of the individual's personal funds. Source Note: The provisions of this §260.251 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.251 Request for Assistance with Personal Funds Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212552 03/12/2026 (a) A program provider that assists an individual with personal funds management must:(1) establish a trust fund account;(2) identify the trust fund account in accordance with the financial institution's requirements for trustee accounts;(3) ensure the trust fund account is insured under federal or state law;(4) deposit the individual's personal funds in the trust fund account; and(5) ensure an individual's personal funds are not commingled with the program provider's funds in the trust fund account.(b) The program provider must maintain a trust fund account as:(1) a pooled checking account containing the personal funds of two or more individuals for whom the program provider manages personal funds;(2) a checking account containing the personal funds of one individual with a financial institution chosen by the program provider and approved, in writing, by the individual or LAR; or(3) a checking account containing the personal funds of one individual with a financial institution chosen by the individual or LAR.(c) A program provider that maintains a trust fund account as a pooled checking account must establish an individual checking account as described in subsection (b)(2) or (3) of this section if an individual or LAR requests, in writing, that the individual's personal funds not be maintained in the pooled checking account described in subsection (b)(1) of this section. Source Note: The provisions of this §260.253 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.253 Establishing a Trust Fund Account https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212553 03/12/2026 (a) When managing a trust fund account, a program provider must:(1) maintain documentation of an individual's personal funds that:(A) follows generally accepted accounting principles; and(B) includes:(i) the individual's name;(ii) identification of individual's representative or person assigned to receive the individual's income, if any;(iii) admission date;(iv) individual's earned interest, if any;(v) documentation of each transaction; and(vi) receipts for purchases and payments, including cash register tapes or sales statements from a vendor;(2) ensure an individual's personal funds are expended only for the individual's use and benefit;(3) reimburse the individual if the individual's personal funds are lost or stolen while in the program provider's control;(4) not charge an individual or LAR for the administrative handling of a trust fund checking account;(5) provide the individual or LAR with a quarterly statement for the individual's personal funds held by the program provider in a trust fund account that includes the following:(A) name and location of the financial institution for the trust fund account;(B) account number for the trust fund account;(C) the statement coverage period;(D) the balance at the beginning of the statement period;(E) all deposits and withdrawals;(F) interest earned, if any; and(G) ending balance; and(6) retain all statements from the financial institution regarding the trust fund account.(b) A program provider must not charge bank fees to an individual or LAR if the individual's personal funds are maintained by the program provider in:(1) a pooled checking account; or(2) an individual checking account at a financial institution chosen by the program provider at the written request of the individual or LAR.(c) If an individual or LAR chooses to have the program provider maintain the individual's personal funds in an individual checking account at a financial institution chosen by the individual or LAR, the individual or LAR must pay the bank fees.(d) If the trust fund account is a pooled checking account, as described in §260.253(b)(1) of this subchapter (relating to Establishing a Trust Fund Account), that pays interest, the program provider must:(1) distribute the interest to each individual for whom the program provider maintains personal funds; and(2) prorate the actual interest:(A) at the time the financial institution pays the interest; and(B) on the basis of the individual's balance of personal funds in the account at the time the financial institution pays the interest.(e) Within 72 hours after receiving a written request from an individual or LAR for an accounting of the individual's personal funds maintained in a trust fund account, a program provider must provide the individual or LAR with a written record of the individual's personal funds maintained by the program provider in a trust fund account. Source Note: The provisions of this §260.255 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.255 Maintaining a Trust Fund Account https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212554 03/12/2026 When an individual whose personal funds are maintained in a trust fund account requests disbursement of a portion or all of the personal funds, a program provider must:(1) determine if the individual has a sufficient amount of personal funds on deposit in the trust fund account to cover the requested disbursement;(2) if the individual has a sufficient amount of personal funds on deposit in the trust fund account, provide the individual with requested funds within 72 hours after receiving the request; and(3) if the individual does not have a sufficient amount of personal funds on deposit in the trust fund account, notify the individual, in writing, that the individual does not have sufficient personal funds in the trust fund. Source Note: The provisions of this §260.257 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.257 Individual's Access to Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212555 03/12/2026 (a) A program provider may maintain a petty cash fund with a portion of the personal funds maintained in the pooled checking account for the purpose of providing an individual with small amounts of cash, typically five dollars or less.(b) A program provider must:(1) maintain the petty cash fund in a secure place;(2) set a dollar limit on the amount of a disbursement from the petty cash fund;(3) reconcile the petty cash fund at least monthly;(4) maintain a ledger of petty cash fund transactions that documents each deposit and disbursement; and(5) include the following information in the ledger for each disbursement:(A) name of the individual;(B) date of the disbursement;(C) amount of the disbursement; and(D) signature of the individual or LAR or, if the individual or LAR is unable to sign the ledger, at least one witness. Source Note: The provisions of this §260.259 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.259 Petty Cash Fund https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212556 03/12/2026 (a) A program provider must maintain a written trust fund ledger in which the following information is documented:(1) date and amount of each deposit or withdrawal;(2) source of each deposit;(3) name of the individual on whose behalf the deposit is made;(4) reason for each withdrawal;(5) name of the person or entity who receives withdrawn funds; and(6) balance after each transaction.(b) A program provider must ensure an individual or LAR signs the trust fund ledger or a trust fund transaction form for each deposit and withdrawal at the time of the transaction.(1) For a withdrawal, if an individual or LAR is unable to sign the trust fund ledger or trust fund transaction form, the program provider must obtain the signature of one person as a witness to the withdrawal.(2) A program provider does not have to obtain a signature for a withdrawal that meets the definition of a recurring payment as described in §260.263 of this subchapter (relating to Recurring Payments). Source Note: The provisions of this §260.261 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.261 Trust Fund Transactions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212557 03/12/2026 (a) A program provider may make recurring payments on behalf of an individual using funds from the trust fund account if the individual or LAR submits a written authorization to the program provider.(1) A program provider must ensure the written authorization:(A) is signed and dated by the individual or LAR;(B) includes the name of the business or entity to which the recurring payment is made;(C) includes the amount of the recurring payment or, if the recurring payment is not a set amount, a description of the method for determining the amount of the recurring payment; and(D) date the recurring payments begin.(2) A program provider must maintain the original authorization in the individual's record.(b) An individual or LAR must request and approve the program provider to stop recurring payments on behalf of the individual.(1) The authorization must be in writing.(2) The program provider must document the request, including the:(A) name of the business or entity to which the recurring payment is made; and(B) date the payment will stop. Source Note: The provisions of this §260.263 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.263 Recurring Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212558 03/12/2026 (a) When a program provider makes a direct payment from the trust fund account to a vendor for an item or service authorized by the individual or LAR, the program provider must obtain a receipt from the vendor. The program provider must ensure the receipt includes:(1) the name of the individual;(2) the date the receipt was created;(3) the dollar amount;(4) a description of the item purchased; and(5) the name of the business or entity from which the purchase was made.(b) For payments made from a trust fund, a program provider must obtain on the receipt:(1) the signature of the individual or LAR; or(2) if the individual or representative cannot sign or is not available to sign, the signature of at least one witness to the payment. Source Note: The provisions of this §260.265 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.265 Receipt for Direct Payment to Vendor from Trust Fund Account https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212559 03/12/2026 A program provider must:(1) ensure trust fund documentation and supporting documents are readily accessible and retrievable for review by HHSC representatives and all applicable federal and state agencies or their representatives; and(2) allow HHSC representatives and all applicable federal and state agencies or their representatives to make copies of trust fund related documentation and supporting documents at no charge. Source Note: The provisions of this §260.267 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.267 Trust Fund Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212560 03/12/2026 If an individual or LAR submits a written request for the return of the balance of the individual's personal funds held by the program provider, the program provider must provide the funds to the individual or LAR within five business days after receipt of the written request. Source Note: The provisions of this §260.269 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.269 Trust Fund Refund https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212561 03/12/2026 (a) When an individual transfers or is terminated from the DBMD Program, the program provider must:(1) return the individual's personal funds to the individual or LAR and provide a written final accounting of those funds to the individual or LAR:(A) in person; or(B) by certified mail with return receipt;(2) complete the refund and provide a final accounting within 10 business days after:(A) the effective date of the transfer; or(B) the date of the individual's termination;(3) not make any payment using the individual's personal funds after receiving the notice of the individual's transfer or termination; and(4) maintain the following documentation in the individual's trust fund record:(A) a copy of the final accounting of the individual's personal funds;(B) the amount refunded to the individual or LAR;(C) the date the refund was made;(D) the method of refund; and(E) the signature of the individual or LAR if the refund was in cash or a copy of the check if the refund was made by check.(b) If an individual's termination from the DBMD Program is because the individual is deceased, the program provider must:(1) make a bona fide effort to locate the beneficiary, heir, or executor of a deceased individual's estate within 30 calendar days after the individual's death;(2) if the individual was a Social Security beneficiary, contact the SSA;(3) refund a deceased individual's personal funds and provide a final written accounting of those funds to the individual's beneficiary, heir, or executor either:(A) in person; or(B) by certified mail with return receipt;(4) complete and provide a final written accounting within 30 calendar days after the individual's death, if the beneficiary, heir, or executor is known, located, or identified;(5) not make any payments out of a deceased individual's trust fund; and(6) maintain the following documentation in the individual's trust fund record:(A) copy of the final accounting of the individual's personal funds;(B) amount refunded to the beneficiary, heir, or executor of the deceased individual's estate;(C) date the refund was made; and(D) method of refund.(c) To clear the account of an individual who is deceased but whose beneficiary, heir, or executor cannot be located within 30 calendar days after the individual's death, the program provider must:(1) if the funds in the individual's account include Social Security or SSI benefits, follow SSA instructions;(2) forward the individual's personal funds other than Social Security or SSI benefits to HHSC with the following information:(A) individual's name;(B) individual's social security number; and(C) the amount of money being submitted to HHSC; and(3) maintain the following in the trust fund record:(A) documentation of the program provider's efforts to locate the beneficiary, heir, or executor of a deceased individual's estate; and(B) proof of submission of the personal funds to HHSC. Source Note: The provisions of this §260.271 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES E ASSISTANCE WITH PERSONAL FUNDS MANAGEMENT §260.271 Trust Fund Procedures for Individual Transfer and Termination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212562 03/12/2026 (a) HHSC approves a maximum of $10,000 per an individual's IPC period for adaptive aids, to include repair and maintenance. (b) A program provider may: (1) purchase or lease only an adaptive aid listed in the Deaf Blind with Multiple Disabilities Program Manual; (2) purchase repair and maintenance of an adaptive aid purchased through the DBMD Program but not covered by a warranty; or (3) purchase repair and maintenance of an adaptive aid that was not purchased through the DBMD Program but is identical to an adaptive aid listed in the Deaf Blind with Multiple Disabilities Program Manual. (c) A program provider must ensure that: (1) a purchased adaptive aid is the exclusive property and for the exclusive use of the individual for whom it is purchased; and (2) a leased adaptive aid is for the exclusive use of the individual for whom it is leased. (d) HHSC does not pay for enhancements to an adaptive aid or for repair and maintenance of an enhancement paid for by non-waiver resources. Source Note: The provisions of this §260.301 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.301 Authorization Amount and Other Limits for Adaptive Aids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212563 03/12/2026 (a) If an individual's service planning team identifies a need for an adaptive aid, a program provider must ensure the service planning team includes the adaptive aid in: (1) an enrollment IPP and enrollment IPC developed in accordance with §260.65 of this chapter (relating to Development of an Enrollment IPP) and §260.67 of this chapter (relating to Development of a Proposed Enrollment IPC); or (2) a revision or renewal IPC and IPP developed in accordance with §260.77(a) -(d) of this chapter (relating to Renewal and Revision of an IPP and IPC). (b) A program provider must: (1) ensure an HHSC Rationale for Adaptive Aids, Medical Supplies and Minor Home Modifications form is completed in accordance with the Deaf Blind with Multiple Disabilities Program Manual by the appropriate licensed professional; (2) determine, as described in §260.67(b) of this chapter, if a non-waiver resource is available for the adaptive aid and, if applicable, obtain a written denial from the non-waiver resource; (3) consider leasing the adaptive aid on a short-term basis, if: (A) the permanent need for the adaptive aid cannot be determined; or (B) the individual has an immediate need for the adaptive aid; and (4) estimate the cost for the item, and if the adaptive aid is expected to: (A) cost less than $500, document in the IPP the justification for the vendor selected; or (B) cost $500 or more, follow the process described in §260.305 of this subchapter (relating to Requirements for Bids for an Adaptive Aid); (5) if the proposed adaptive aid is a computer: (A) obtain an evaluation from an appropriate professional, as described in the Deaf Blind with Multiple Disabilities Program Manual, that addresses: (i) the individual's needs; (ii) computer specifications; and (iii) necessary orientation and training; and (B) ensure that the actual cost of an evaluation obtained as described in this paragraph does not exceed $500. (c) A program provider must electronically access TMHP information to verify that an adaptive aid requested on an IPC in accordance with this section has been approved by HHSC utilizing MESAV. Source Note: The provisions of this §260.303 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.303 Requirements for Authorization to Purchase or Lease an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212564 03/12/2026 (a) For an adaptive aid that costs $500 or more, a program provider must:(1) obtain comparable bids for the requested adaptive aid from three vendors; and(2) ensure the vendors are not related to the individual.(b) A program provider must ensure a bid obtained in accordance with subsection (a) of this section includes:(1) the total cost of the requested adaptive aid, which may be from a catalog, website, or brochure price list;(2) the amount of any additional expenses related to the delivery of the adaptive aid, to include warranty, shipping and handling, taxes, installation, and other labor charges;(3) the date of the bid, which must be within 30 calendar days before the date of the service planning team meeting at which the adaptive aid was recommended;(4) the name, address, and telephone number of the vendor;(5) for an adaptive aid other than interpreter services and specialized training for augmentative communication programs, a complete description of the adaptive aid and any associated items or modifications, which may include pictures or other descriptive information from a catalog, website, or brochure; and(6) for interpreter services and specialized training for augmentative communication programs, the number of hours to be provided and the hourly rate of the service.(c) A program provider may obtain only one bid or two comparable bids for an adaptive aid if the program provider provides written documentation that the adaptive aid is available only from those vendors.(d) A program provider must choose the lowest bid unless the program provider has written documentation that justifies selection of the higher bid, other than personal preference. The following are examples of justifications that support payment of a higher bid:(1) the higher bid is based on the inclusion of a longer warranty for the adaptive aid; and(2) the higher bid is from a vendor that is more accessible to the individual than another vendor.(e) If the adaptive aid is a vehicle modification, a program provider must obtain written approval from the vehicle's owner before making the modification. The owner must sign and date the approval.(f) A program provider must ensure the specifications for a vehicle modification include:(1) information on the vehicle to be modified, including:(A) the year and model of the vehicle;(B) a determination that the vehicle to be modified is the individual's primary vehicle;(C) proof of ownership of the vehicle;(D) current state inspection and registration for the vehicle;(E) any required state insurance for the vehicle; and(F) the mileage of the vehicle; and(2) information on the needed modifications, including;(A) an itemized list of parts and accessories, including prices;(B) an itemized list of required labor, including labor charges; and(C) warranty coverage.(g) If a vehicle modification costs $1,000 or more and the vehicle has been driven more than 75,000 miles or is over four years old, a program provider must:(1) obtain a written evaluation by an Automotive Service Excellence certified technician to ensure the sound mechanical condition of all major components of the vehicle;(2) document the experience of the mechanic doing the evaluation; and(3) include the actual cost of the written evaluation as part of the invoice cost not to exceed $150. Source Note: The provisions of this §260.305 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.305 Requirements for Bids for an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212565 03/12/2026 (a) A program provider must ensure an individual receives an adaptive aid, other than a medically necessary supply or device: (1) costing less than $500 within 14 business days after one of the following dates, whichever is later: (A) the date HHSC approves the proposed IPC that includes the recommended adaptive aid; or (B) the effective date of the individual's IPC as determined by the service planning team; and (2) costing $500 or more within 30 business days after one of the following dates, whichever is later: (A) the date HHSC approves the proposed IPC that includes the recommended adaptive aid; or (B) the effective date of the individual's IPC as determined by the service planning team. (b) For an adaptive aid that is a medically necessary supply or device listed in the Deaf Blind with Multiple Disabilities Program Manual, a program provider must ensure an individual receives the medical supply as follows: (1) for a medically necessary supply or device that is not immediately needed by the individual, within five business days after one of the following dates, whichever is later: (A) the date HHSC approves the proposed IPC that includes the recommended medically necessary supply or device; or (B) the effective date of the individual's IPC as determined by the service planning team; and (2) for a medically necessary supply or device that is immediately needed by the individual, within two business days after the date HHSC approves the IPC that includes the recommended medically necessary supply or device. (c) If a program provider is unable to meet the delivery time frames described in subsections (a) or (b) of this section, a program provider may deliver the adaptive aid at a later date if: (1) the reason for the delay is: (A) beyond the program provider's control; and (B) not caused directly by the program provider; (2) a program provider notifies the individual or LAR and HHSC, orally and in writing, of the delay and provides a revised delivery date; and (3) a program provider provides the notice to the individual or LAR and HHSC on or before the expiration of the delivery time frames described in subsections (a) or (b) of this section. (d) A program provider must document the time and date of the oral notice described in subsection (c)(2) of this section in an individual's record and retain a copy of the written notice in the individual's record. Source Note: The provisions of this §260.307 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.307 Time Frames for Providing an Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212566 03/12/2026 (a) A program provider must ensure that if an adaptive aid is delivered to an individual by a commercial carrier, such as United Parcel Service or the United States Postal Service, the most cost-effective carrier is used.(b) A program provider may not use a commercial carrier to provide overnight delivery unless it is necessary to meet the time frame for a medically necessary supply or device immediately needed by an individual and there is no other more cost-effective means to deliver the adaptive aid within that time frame. Source Note: The provisions of this §260.309 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.309 Cost Effective Delivery of Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212567 03/12/2026 (a) A program provider must ensure, upon delivery of the adaptive aid to an individual and before the adaptive aid is used, that the individual, unpaid caregiver, and service providers are provided with appropriate orientation and training in the proper use of the adaptive aid. (b) Within 10 business days after an individual has received an adaptive aid, a program provider must: (1) contact the individual to: (A) determine if the adaptive aid meets the needs of the individual; and (B) determine if appropriate orientation and training were provided to the individual on proper use of the adaptive aid; and (2) document the result of that contact on the HHSC Documentation of Completion of Purchase form as described in the Deaf Blind with Multiple Disabilities Program Manual. (c) If a program provider determines that an adaptive aid does not adequately meet an individual's needs because the individual needs training or other assistance, or the adaptive aid requires repair or adjustment, the program provider must: (1) ensure that, within 14 business days after the determination, a person who is qualified to perform such training, assistance, repair, or adjustment visits the individual in person and performs the necessary functions; and (2) document in the individual's record that the necessary training, assistance, repair, or adjustment is completed. Source Note: The provisions of this §260.311 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.311 Requirements of Program Provider Following Provision of Adaptive Aid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212568 03/12/2026 (a) A program provider may purchase as a minor home modification: (1) only those items and services listed in the Deaf Blind with Multiple Disabilities Program Manual; and (2) the necessary repair and maintenance of a minor home modification purchased through the DBMD program if: (A) at least one year has elapsed from the date the minor home modification was completed; and (B) the minor home modification is not covered by a warranty. (b) A program provider may not purchase, as a minor home modification, an item or service not listed in the Deaf Blind with Multiple Disabilities Program Manual. (c) The following are examples of items and services that may not be purchased as a minor home modification: (1) general repair or maintenance of a residence, for example, repairing a leaking roof, rotten porch, termite damage, or leveling a floor; (2) general remodeling of a residence that does not address an individual's specific needs; (3) an adaptation that adds square footage to a residence; and (4) construction of new room, including installation of plumbing and electricity. Source Note: The provisions of this §260.313 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.313 Items or Services Purchasable as a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212569 03/12/2026 (a) Except as provided in subsection (b) of this section, the maximum amount HHSC approves as payment for minor home modifications provided to an individual is $10,000 for the lifetime of the individual. (b) In addition to the $10,000 lifetime limit described in subsection (a) of this section, HHSC may approve up to $300 per IPC period for repair and maintenance of minor home modifications purchased through the DBMD Program if at least one year has elapsed since the date the minor home modification was completed. (c) Except as provided in subsection (d) of this section, a program provider is not required to follow the process in §260.317 of this division (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000) to request approval for repair and maintenance of a minor home modification, but must include the amount requested: (1) in an enrollment IPC developed in accordance with §260.67 of this chapter (relating to Development of a Proposed Enrollment IPC); or (2) in a revision or renewal IPC developed in accordance with §260.77(a) - (d) of this chapter (relating to Renewal and Revision of an IPP and IPC). (d) A program provider must follow the process described in §260.317 of this division if requesting authorization for repair and maintenance of a minor home modification if: (1) the minor home modification is not purchased through the DBMD Program but is identical to an item or service that a program provider may purchase as a minor home modification listed in the Deaf Blind with Multiple Disabilities Program Manual; or (2) the amount exceeds the $300 limit described in subsection (b) of this section and the individual has not reached the $10,000 lifetime limit described in subsection (a) of this section. (e) A request described under subsection (d) of this section and authorized by HHSC is counted toward the $10,000 lifetime limit described in subsection (a) of this section if the individual has not reached the lifetime limit. Source Note: The provisions of this §260.315 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.315 Authorization Limit for Minor Home Modifications and Amount for Repair and Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212570 03/12/2026 (a) To purchase a minor home modification for an individual that costs less than $1,000, a program provider: (1) does not have to obtain specifications as described in §260.321 of this division (relating to Specifications for a Minor Home Modification); (2) includes the cost of the minor home modification and the cost of the inspection of the minor home modifications, not to exceed $150, in an IPC and IPP developed in accordance with: (A) for an enrollment IPP and enrollment IPC, §260.65 of this chapter (relating to Development of an Enrollment IPP) and §260.67 of this chapter (relating to Development of a Proposed Enrollment IPC); or (B) for a revision or renewal IPP and IPC, §260.77(a) - (d) of this chapter (relating to Renewal and Revision of an IPP and IPC); (3) ensures the case manager: (A) obtains an HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form completed in accordance with the Deaf Blind with Multiple Disabilities Program Manual; and (B) submits to HHSC: (i) the IPC and IPP: (I) in accordance with §260.61(l)(1) of this chapter (relating to Process for Enrollment of an Individual), for an individual requesting enrollment in the DBMD Program; or (II) in accordance with §260.77(a) - (d) of this chapter for an individual receiving DBMD Program services; and (ii) the completed HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form. (b) HHSC reviews the documentation submitted in accordance with subsection (a)(3)(B) of this section and makes a determination in accordance with: (1) for an enrollment IPC and IPP, §260.69 of this chapter (relating to HHSC's Review of Request for Enrollment); or (2) for a revision or renewal IPC and IPP, §260.77(f) of this chapter. (c) Before construction of a minor home modification begins, a program provider must: (1) obtain written approval for construction of the modification from the owner of the property in question, unless such approval is granted in an applicable lease agreement; and (2) ensure that the selected vendor obtains any required building permits. (d) A program provider must direct a vendor to begin construction of a minor home modification within seven calendar days after one of the following, whichever is later: (1) the date HHSC approves the proposed IPC; or (2) the effective date of the IPC as determined by the service planning team. Source Note: The provisions of this §260.317 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.317 Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212571 03/12/2026 (a) To purchase a minor home modification for an individual that costs $1,000 or more, a program provider must: (1) ensure that the individual's service planning team includes the cost, not to exceed $200, of the specifications for the requested minor home modification in the individual's IPP and IPC developed in accordance with: (A) for an enrollment IPP and enrollment IPC, §260.65 of this chapter (relating to Development of an Enrollment IPP) and §260.67 of this chapter (relating to Development of a Proposed Enrollment IPC); or (B) for a revision or renewal IPP and IPC, §260.77(a) - (d) of this chapter (relating to Renewal and Revision of an IPP and IPC); and (2) ensure the case manager: (A) obtains an HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form completed in accordance with the Deaf Blind with Multiple Disabilities Program Manual; and (B) submits to HHSC: (i) the IPC and IPP: (I) in accordance with §260.61(l)(1) of this chapter (relating to Process for Enrollment of an Individual) for an individual requesting enrollment in the DBMD Program; or (II) in accordance with §260.77(a) - (d) of this chapter for an individual receiving DBMD Program services; and (ii) the completed HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form. (b) HHSC reviews the documentation submitted in accordance with subsection (a)(2)(B) of this section, and makes a determination in accordance with: (1) for an enrollment IPP and enrollment IPC, §260.69 of this chapter (relating to HHSC's Review of Request for Enrollment); or (2) for a revision or renewal IPP and IPC, §260.77(f) of this chapter. (c) If HHSC approves the IPC for payment of the specifications, a program provider must: (1) within 30 calendar days after the date HHSC approves the IPC, obtain the specifications in accordance with §260.321 of this division (relating to Specifications for a Minor Home Modification); and (2) within 60 calendar days after the specifications are obtained: (A) obtain bids from vendors in accordance with §260.323(a) - (c) of this division (relating to Bid Requirements for a Minor Home Modification); and (B) select a vendor in accordance with §260.323(d) of this division to complete construction of the minor home modification. (d) A program provider must: (1) include the cost of the minor home modification from the bid submitted by the vendor selected as described in subsection (c)(2)(B) of this section and the cost of the inspection of the minor home modification, not to exceed $150, in an IPC and IPP developed in accordance with: (A) for an enrollment IPP and enrollment IPC, §260.65 of this chapter and §260.67 of this chapter; or (B) for a revision or renewal IPP and IPC, §260.77(a) - (d) of this chapter; and (2) ensure the case manager submits the IPC and IPP to HHSC: (A) in accordance with §260.61(l)(1) of this chapter for an individual requesting enrollment in the DBMD Program; or (B) in accordance with §260.77(a) - (d) of this chapter for an individual receiving DBMD Program services. (e) HHSC reviews the documentation submitted in accordance with subsection (d)(2) of this section, and makes a determination in accordance with: (1) §260.69 of this chapter, for an enrollment IPP and enrollment IPC; or (2) §260.77(f) of this chapter, for a revision or renewal IPP and IPC. (f) Before construction of a minor home modification begins, a program provider must: (1) obtain written approval for construction of the modification from the owner of the property in question, unless such approval is granted in an applicable lease agreement; and (2) ensure that the selected vendor obtains any required building permits. (g) A program provider must direct a vendor to begin construction of a minor home modification within seven calendar days after one of the following, whichever is later: (1) the date HHSC approves the proposed IPC; or (2) the effective date of the IPC as determined by the service planning team. Source Note: The provisions of this §260.319 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.319 Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212572 03/12/2026 (a) If HHSC authorizes payment for specifications of a minor home modification in accordance with §260.319 of this division (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More), a program provider must: (1) obtain the specifications from a person who has experience in constructing home modifications; (2) ensure that the specifications: (A) include a complete description of the minor home modification and any associated installations identified in the specifications; (B) include a drawing or picture of both the existing room, structure, or other area and the proposed modification made to scale; and (C) comply with the Texas Accessibility Standards promulgated by the Texas Department of Licensing and Regulation unless: (i) a program provider determines that it is not structurally feasible to do so and documents, in writing, the basis for its determination; or (ii) an individual or LAR requests, in writing, that the specifications not be in compliance with the Texas Accessibility Standards; and (D) ensure the HHSC Specifications for Minor Home Modifications form is completed as described in the Deaf Blind with Multiple Disabilities Program Manual. (b) A program provider must obtain an invoice from the person who develops the specifications. The cost of the specifications must not exceed $200. Source Note: The provisions of this §260.321 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.321 Specifications for a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212573 03/12/2026 (a) For a minor home modification that costs $1,000 or more, a program provider must obtain comparable bids for the minor home modification from three vendors. Comparable bids describe the minor home modification and any associated installations identified in the specifications required by §260.319 of this division (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More).(b) A program provider must obtain bids that:(1) are based on the specifications obtained in accordance with §260.321 of this division (relating to Specifications for a Minor Home Modification); and(2) include:(A) an itemized list of materials and labor necessary to construct the modification;(B) the cost of each material and labor listed;(C) the date of the bid;(D) the name, address, and telephone number of the vendor;(E) a detailed explanation of the vendor's warranty for the modification, if any; and(F) a statement that the vendor will make the minor home modification in accordance with the specifications obtained in accordance with §260.321 of this division and all applicable state and local building codes.(c) A program provider may obtain only one bid or two comparable bids for a minor home modification if the program provider provides written documentation that the minor home modification is available only from those vendors.(d) A program provider must choose the lowest bid unless the program provider has written documentation that justifies selection of the higher bid. An example of a justification that supports payment of a higher bid is that the higher bid is based on the inclusion of a longer warranty for the minor home modification.(e) The person who developed the specifications required by §260.321 of this division may be one of the bidders required by this section. Source Note: The provisions of this §260.323 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.323 Bid Requirements for a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212574 03/12/2026 (a) A program provider must ensure that a minor home modification is completed within 60 calendar days after the date the vendor begins construction as directed by the program provider, in accordance with:(1) §260.317(d) of this division (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000); or(2) §260.319(g) of this division (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More).(b) If a program provider determines that a minor home modification will not be completed within the time frame required by subsection (a) of this section, the program provider must notify the individual, in writing, of a new proposed date of completion. The new proposed date of completion must not be more than 30 calendar days after the time frame required by subsection (a) of this section.(c) A program provider must maintain of copy of the notice described in subsection (b) of this section in an individual's record.(d) If, before a minor home modification is completed, an individual or LAR notifies the program provider of the individual's intention to transfer, the program provider must ensure that the minor home modification is completed before the effective date of the transfer. Source Note: The provisions of this §260.325 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.325 Time Frames for Completion of Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212575 03/12/2026 (a) A program provider must, within seven calendar days after receiving information that a minor home modification is complete, ensure that an experienced inspector determines that: (1) the minor home modification is complete; (2) the minor home modification is made in accordance with the specifications required by §260.321 of this division (relating to Specifications for a Minor Home Modification); and (3) the quality of workmanship of the minor home modification is adequate. (b) A program provider must ensure that an inspector is not the vendor who completed the minor home modification and is not related to the individual. (c) The person who developed the specifications may perform the inspection required by subsection (a) of this section unless that person is affiliated with the vendor who completed the minor home modification. (d) A program provider must obtain an invoice not to exceed $150 from the person who conducted the inspection substantiating the cost of the inspection. (e) If, based on the inspection, a program provider determines that the minor home modification meets the conditions listed in subsection (a) of this section, the program provider must: (1) complete an HHSC Documentation of Completion of Purchase form as described in the Deaf Blind with Multiple Disabilities Program Manual; (2) maintain the original in the individual's file; and (3) provide a copy to the individual or LAR within seven business days after completion of the inspection. (f) If, based on the inspection, a program provider determines that a minor home modification does not meet the conditions listed in subsection (a) of this section, the program provider must ensure the vendor meets the conditions within 30 calendar days after the program provider's determination. (g) A program provider may not submit a claim for payment of a minor home modification until the program provider determines that the minor home modification meets the conditions listed in subsection (a) of this section. Source Note: The provisions of this §260.327 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.327 Inspection of a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212576 03/12/2026 (a) HHSC does not authorize repair or maintenance of a minor home modification for one year after the date the minor home modification is completed.(b) If a minor home modification requires repair or replacement within one year after the date of completion, a program provider must repair or replace the minor home modification at its own expense unless the repair or replacement is a result of intentional damage or neglect by the individual or a person in the individual's residence.(c) If a minor home modification requires repair or replacement because the minor home modification was intentionally damaged, the repair or replacement must be done at the expense of the individual or LAR. Source Note: The provisions of this §260.329 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.329 Repair or Replacement of a Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212577 03/12/2026 (a) A program provider must ensure that a service provider involved in purchasing the minor home modification for the individual: (1) contacts the individual by phone or during an in-home visit within seven business days after completion of the inspection as described in §260.327 of this division (relating to Inspection of a Minor Home Modification) to determine whether the individual or LAR is satisfied with the minor home modification; and (2) documents the result of the contact on an HHSC Documentation of Completion of Purchase form as described in the Deaf Blind with Multiple Disabilities Program Manual. (b) If an individual or LAR is not satisfied with the minor home modification, the program provider must process the individual's or LAR's dissatisfaction as a complaint in accordance with 40 TAC §49.309 (relating to Complaint Process). Source Note: The provisions of this §260.331 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.331 Individual's Satisfaction with Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212588 03/12/2026 (a) A program provider must ensure that a behavioral support service provider:(1) is licensed as a psychologist in accordance with the Texas Occupations Code Chapter 501;(2) is a provisional license holder licensed in accordance with the Texas Occupations Code Chapter 501;(3) is licensed as a psychological associate in accordance with the Texas Occupations Code Chapter 501;(4) is licensed as a licensed behavior analyst in accordance with the Texas Occupations Code Chapter 506;(5) is licensed as a clinical social worker in accordance with the Texas Occupations Code Chapter 505;(6) is licensed as a professional counselor in accordance with the Texas Occupations Code Chapter 503; or(7) is a behavior communication specialist who has:(A) a master's or a doctoral degree in special education, psychology, or a related human services discipline from an accredited university or college, and three years of experience providing direct services to individuals who have deafblindness; or(B) a bachelor's degree in psychology or special education from an accredited university or college and seven years of experience providing direct services to individuals who have deafblindness and multiple disabilities.(b) A program provider must ensure that the behavioral support service provider:(1) conducts an assessment of an individual's maladaptive behavior identified by the service planning team with an emphasis on communication barriers as a contributing factor;(2) analyzes assessment findings;(3) develops an individualized behavior support plan that describes strategies to address communication barriers consistent with goals and outcomes identified in the IPP;(4) trains and consults with individual's family members and other service providers on implementation of the behavior support plan;(5) monitors and evaluates effectiveness of the behavior support plan; and(6) modifies the behavior support plan, as necessary.(c) A program provider must ensure the behavioral support service provider conducts periodic evaluations of the individual's progress toward achieving the goals and outcomes described in the IPP with updates to the program provider.(d) A program provider may bill HHSC for the following activities by a behavioral support service provider:(1) assessing and evaluating the need for behavioral support services;(2) developing and implementing a behavior support plan;(3) periodic evaluations of the individual's progress toward achieving the goals and outcomes described in the behavior support plan, including updates to the program provider;(4) providing direct therapeutic intervention;(5) consulting with the individual's psychiatrist;(6) interacting with the individual or LAR regarding the individual's condition and progress toward or achievement of goals;(7) training and consulting with individual's family members and other service providers concerning implementation of the behavior support plan;(8) participating in service planning team meetings, if requested;(9) if the behavioral support service provider is licensed as described in subsection (a)(1) or (3) of this section, supervising and training an unlicensed service provider, for example, a service provider of day habilitation or CFC PAS/HAB, within the scope of 22 TAC Part 21, (relating to the Texas State Board of Examiners of Psychologists); and(10) participating in a fair hearing at the request of a member of the service planning team to provide information within the scope of the service provider's licensure or certification, as appropriate. Source Note: The provisions of this §260.333 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.333 Behavioral Support https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212589 03/12/2026 (a) A program provider must ensure that chore services are provided only when an individual residing in a setting other than a residential setting described in §260.351 of this division (relating to Residential Services) or another person residing with the individual is not capable of performing or financially providing for those chores. Examples of chore services include such heavy household chores as:(1) washing floors, windows, and walls;(2) tacking down loose rugs and tiles; and(3) moving heavy items of furniture.(b) If an individual is residing in a rental property other than a residential setting described in §260.351 of this division, the program provider must review the lease agreement and determine whether the landlord is responsible for performing similar services before including chore services on the IPC. If the landlord is responsible for performing similar services, the program provider must not include chore services on the IPC.(c) A program provider must:(1) ensure that a person providing chore services:(A) can read, write, and follow directions; and(B) can perform household tasks; and(2) maintain documentation in the personnel record that the service provider of chore services meets the requirements in paragraph (1) of this subsection.(d) A program provider must not provide chore services to an individual receiving licensed assisted living or licensed home health assisted living. Source Note: The provisions of this §260.335 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.335 Chore Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212578 03/12/2026 (a) A program provider must ensure that case management is provided in accordance with an individual's IPP, IPC, and Appendix C of the DBMD Program waiver application approved by CMS and available on the HHSC website, including:(1) initiating and overseeing the process of assessment and reassessment of the individual's LOC;(2) initiating and overseeing the process of the review of service plans at enrollment, annually, and as needed, including if requested by the individual or LAR;(3) observing the individual in the individual's home and determining the intent and level of the individual's communication;(4) if necessary, determining from the individual's non-verbal communication, the individual's likes and dislikes;(5) leading the service planning team to use the person-centered planning process to develop a service plan that optimizes the opportunities for the individual to use the individual's abilities and to integrate in community settings;(6) using the individual's knowledge of sign language and other communication systems to make the individual as aware as possible of the individual's service plan and options;(7) communicating with service planning team members to ensure that the service plan is carried out appropriately;(8) monitoring the success of the service plan by observing the individual at home and in the community;(9) monitoring the provision of services included in the service plan on an ongoing basis; and(10) monitoring services that assist the individual in gaining access to needed waiver and other state plan services, including medical, social, educational, and non-wavier services.(b) The only activities that a program provider may bill as case management are:(1) an in-person, email, phone call, or text message contact with an individual;(2) an in-person, email, phone call, or text message contact with the LAR, primary caregiver, or an actively involved person regarding the individual's services;(3) a phone call, text message, email, letter, or meeting with HHSC or community resources regarding the individual's services; and(4) working with service providers regarding the individual, including:(A) reviewing services, goals, and outcomes, as described in the individual's IPC and IPP;(B) providing the training described in §260.205(g) of this chapter (relating to Training);(C) monitoring training strategies used by service providers to carry out the goals and outcomes described in the IPP; and(D) activities performed as a member of the service planning team. Source Note: The provisions of this §260.337 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.337 Case Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212579 03/12/2026 (a) Dental treatment consists of the following:(1) emergency dental treatments, which are procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures that are required to prevent the imminent loss of teeth; and treatment of injuries to the teeth or supporting structures;(2) routine preventative dental treatments, which are examinations, x-rays, cleanings, sealants, oral prophylaxes, and topical fluoride applications;(3) therapeutic dental treatments, which include fillings, scaling, extractions, crowns, and pulp therapy for permanent and primary teeth; restoration of carious permanent and primary teeth; maintenance of space; and limited provision of removable prostheses when masticatory function is impaired, when an existing prosthesis is unserviceable, or when aesthetic considerations interfere with employment or social development;(4) orthodontic dental treatments, which are procedures that include treatment of retained deciduous teeth; cross-bite therapy; facial accidents involving severe traumatic deviations; cleft palates with gross malocclusion that will benefit from early treatment; and severe, handicapping malocclusions affecting permanent dentition with a minimum score of 26 as measured on the Handicapping Labio-lingual Deviation Index; and(5) dental sedation, which is sedation necessary to perform dental treatment including non-routine anesthesia, (for example, intravenous sedation, general anesthesia, or sedative therapy prior to routine procedures) but does not include the administration of routine local anesthesia only.(b) Dental treatment does not include cosmetic orthodontia.(c) HHSC approves the following amounts as the maximum for an individual's dental treatment:(1) $2,500 per IPC period for services described in subsection (a)(1) - (4) of this section; and(2) $2,000 per IPC period for sedation, other than the administration of routine local anesthesia, as described in subsection (a)(5) of this section.(d) For an initial dental exam, a program provider may include up to $200 on the IPC without submitting a completed HHSC Prior Authorization for Dental Services form signed by the individual's dentist to HHSC for approval. For all other dental treatments, a program provider must submit a completed HHSC Prior Authorization for Dental Services form that has been signed by the individual's dentist to HHSC with the IPC for authorization.(e) If a program provider determines emergency dental treatment is necessary to ensure an individual's health and welfare and the necessary service is not included on the individual's IPC and IPP or exceeds the amount included in the IPC for dental treatment, a program provider must submit a revised IPC and revised IPP to HHSC in accordance with §260.77(c) of this chapter (relating to Renewal and Revision of an IPP and IPC ).(f) For an individual under 21 years of age, a program provider must first access dental treatment benefits through the Texas Health Steps--Comprehensive Care Program before dental treatment may be provided under the DBMD Program.(g) A program provider must maintain, in the individual's record, a copy of the dentist's invoice for dental treatment.(h) HHSC does not reimburse a program provider for cosmetic orthodontia. Source Note: The provisions of this §260.339 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.339 Dental Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222993 03/12/2026 (a) A program provider must ensure that a service provider of employment assistance or a service provider of supported employment meets the qualifications described in §260.203(g) of this chapter (relating to Qualifications of Program Provider Staff).(b) Before including employment assistance on an individual's IPC, a program provider must ensure and maintain documentation in the individual's record that employment assistance is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).(c) A program provider must ensure that employment assistance:(1) consists of a service provider performing the following activities:(A) identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;(B) locating prospective employers offering employment compatible with an individual's identified preferences, skills, and requirements;(C) contacting a prospective employer on behalf of an individual and negotiating the individual's employment;(D) transporting the individual to help the individual locate competitive employment in the community; and(E) participating in service planning team meetings;(2) is provided in accordance with the individual's IPC and with Appendix C of the DBMD waiver application approved by CMS and available on the HHSC website;(3) is not provided to an individual with the individual present at the same time that one of the following services is provided:(A) day habilitation;(B) transportation provided as a residential habilitation activity;(C) supported employment;(D) respite; or(E) CFC PAS/HAB; and(4) does not include using Medicaid funds paid by HHSC to a program provider for incentive payments, subsidies, or unrelated vocational training expenses, such as:(A) paying an employer:(i) to encourage the employer to hire an individual; or(ii) for supervision, training, support, or adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(B) paying the individual:(i) as an incentive to participate in employment assistance activities; or(ii) for expenses associated with the start-up costs or operating expenses of an individual's business.(d) Before including supported employment on an individual's IPC, a program provider must ensure and maintain documentation in the individual's record that supported employment is not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).(e) A program provider must ensure that supported employment:(1) consists of a service provider performing the following activities:(A) making employment adaptations, supervising, and providing training related to an individual's assessed needs;(B) transporting the individual to support the individual to be self-employed, work from home, or perform in a work setting; and(C) participating in service planning team meetings;(2) is provided in accordance with the individual's IPC and with Appendix C of the DBMD waiver application approved by CMS and available on the HHSC website;(3) is not provided to an individual with the individual present at the same time that one of the following services are provided:(A) day habilitation;(B) transportation provided as a residential habilitation activity;(C) employment assistance;(D) respite; or(E) CFC PAS/HAB; and(4) does not include:(A) sheltered work or other similar types of vocational services furnished in specialized facilities; or(B) using Medicaid funds paid by HHSC to a program provider for incentive payments, subsidies, or unrelated vocational training expenses, such as:(i) paying an employer:(I) to encourage the employer to hire an individual; or(II) to supervise, train, support, or make adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(ii) paying the individual:(I) as an incentive to participate in supported employment activities; or(II) for expenses associated with the start-up costs or operating expenses of an individual's business.(f) Employment readiness:(1) is assistance that prepares an individual to participate in employment;(2) provides the following person-centered activities:(A) teaching generalized habilitative skills necessary to prepare an individual to participate in employment;(B) training in the use of adaptive equipment necessary to obtain and retain employment skills; and(C) achieving generalized vocational goals consistent with the outcomes identified in an individual's IPP;(3) is not job-task oriented;(4) includes activities for which an individual is compensated in accordance with applicable laws and regulations;(5) provides personal assistance for an individual who cannot manage personal care needs during employment readiness activities; and(6) includes:(A) transportation between an individual's place of residence and an employment readiness location;(B) transportation from one employment readiness location to another employment readiness location; and(C) securing transportation as described in paragraph (6)(A) or (6)(B) of this subsection.(g) A program provider may provide employment readiness to an individual only if the individual's service planning team does not expect the individual to be competitively employed within one year after the date employment readiness begins.(h) A program provider may not provide employment readiness to an individual who is:(1) receiving supported employment; or(2) engaged in competitive employment.(i) Before employment readiness is included on an individual's enrollment IPC, renewal IPC, or revised IPC, a program provider must ensure:(1) an HHS Employment First Discovery Tool is completed in accordance with §284.105 of this title (relating to Uniform Process) and supports the provision of employment readiness to the individual; and(2) documentation is maintained in the individual's record that employment readiness is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.). Source Note: The provisions of this §260.341 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.341 Employment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212581 03/12/2026 (a) Day habilitation.(1) Before including day habilitation on an individual's IPC, a program provider must ensure and maintain documentation in the individual's record that day habilitation is not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §701 et seq.) or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.).(2) A program provider must ensure that day habilitation includes:(A) assistance in acquiring, retaining, or improving the self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life;(B) providing the individual with individualized activities:(i) in environments designed to foster the development of skills and behavior supportive of greater independence and personal choice consistent with achieving the outcomes identified in the individual's IPP; and(ii) designed to reinforce therapeutic outcomes targeted by other DBMD Program services, CFC services, school, or other support providers; and(C) providing transportation necessary for the individual's participation in day habilitation activities, such as shopping, swimming, going to the park, or other community activities.(3) A program provider must ensure day habilitation:(A) is provided to an individual in a non-residential setting separate from the individual's own or family home or the residence in which the individual receives licensed assisted living or licensed home health assisted living that:(i) is accessible to and usable by the individual;(ii) is maintained in good repair;(iii) has at least two means of egress; and(iv) is in continuous compliance with applicable local building codes and ordinances and applicable state and federal laws, rules, and regulations;(B) reinforces:(i) therapeutic outcomes identified by other DBMD Program services and CFC services; and(ii) for an individual eligible for public education services, education goals in the Individualized Education Program (IEP) and services provided by the school district;(C) includes transportation necessary for the individual's participation in day habilitation activities; and(D) is not provided to an individual at the same time that any of the following services are provided:(i) employment assistance with the individual present;(ii) supported employment with the individual present;(iii) transportation provided as a residential habilitation activity;(iv) 24-hour licensed assisted living;(v) 24-hour licensed home health assisted living;(vi) respite; or(vii) CFC PAS/HAB.(4) A program provider must ensure a day habilitation service provider works with one individual at a time unless the individual's service planning team documents on the IPP that the individual's needs can be met with a day habilitation service provider to individual ratio of one-to-two or one-to-three.(5) A program provider must ensure that for a service-provider-to-individual ratio higher than one-to-three, that the IPP includes a recommendation from the service planning team and supporting documentation of the individual's ability to integrate and meaningfully participate in an environment with a ratio higher than one-to-three.(6) A program provider may bill for time spent by a day habilitation service provider:(A) in direct contact with an individual;(B) participating as a member of an individual's service planning team; or(C) performing tasks delegated by a physician or RN.(b) Residential habilitation.(1) A program provider must ensure:(A) residential habilitation:(i) is not provided to an individual receiving licensed assisted living or licensed home health assisted living;(I) in the individual's own or family home; or(II) in a setting outside the individual's own or family home appropriate for the type of residential habilitation activities described in the individual's IPP;(ii) includes:(I) transportation; or(II) assistance in securing transportation;(III) assistance with ambulation and mobility;(IV) reinforcement of behavioral support or therapy activities;(V) assistance with medications and the performance of tasks delegated by an RN in accordance with state law;(VI) supervision of the individual's safety and security;(VII) assistance with acquisition, retention, or improvement in skills related to activities of daily living, including:(-a-) personal grooming and cleanliness;(-b-) bed making and household chores; and(-c-) preparation and consumption of food;(VIII) use of natural supports and typical community services; and(IX) social interaction and participation in leisure activities; and(iii) is not provided to the individual at the same time that one of the following services are provided:(I) employment assistance with the individual present;(II) supported employment with the individual present;(III) day habilitation;(IV) respite; or(V) CFC PAS/HAB; and(B) a residential habilitation service provider works with no more than one individual at a time.(2) A program provider may bill for time spent by a residential habilitation service provider transporting an individual.(c) CFC PAS/HAB.(1) A program provider must ensure CFC PAS/HAB is not provided to an individual receiving licensed assisted living or licensed home health assisted living.(2) A program provider must ensure CFC PAS/HAB is not provided to an individual at the same time that one of the following services are provided:(A) employment assistance with the individual present;(B) supported employment with the individual present;(C) day habilitation;(D) respite; or(E) transportation provided as a residential habilitation activity.(3) A program provider must ensure a CFC PAS/HAB service provider works with no more than one individual at a time.(4) If an individual's IPC includes CFC PAS/HAB, a program provider must ensure compliance with §260.213 of this chapter (relating to Service Backup Plans). Source Note: The provisions of this §260.343 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.343 Day Habilitation, Residential Habilitation, and CFC PAS/HAB https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212582 03/12/2026 (a) A program provider must ensure an intervener:(1) works with no more than one individual at a time;(2) makes sights, sounds, and activities accessible to the individual by learning the specific communication system of the individual;(3) provides communication and information to an individual concerning the individual's environment that otherwise would be available through vision and hearing;(4) develops and prepares activities for the individual;(5) forms a working alliance with the individual's family members, neighbors, employers, and professionals with whom the individual has contact;(6) participates on the individual's service planning team;(7) transports the individual to gain access to community services and resources required by the IPP;(8) instructs and supports the individual in skills related to community involvement; and(9) uses interpersonal communication, including sign language, speech, tangible communication symbols, gestures, calendars, and augmentative communication devices.(b) A program provider must document the following outcomes for intervener services in an individual's record:(1) the individual effectively communicates wants and needs to the intervener;(2) the individual actively participates in ADLs to the extent of the individual's ability;(3) the individual's choices are implemented;(4) the individual is able to access and participate in community activities; and(5) the individual is able to move safely and efficiently within home and community settings.(c) If requested by HHSC, a program provider must be able to demonstrate the outcomes described in subsection (b) of this section.(d) A program provider must ensure that an intervener is reimbursed in accordance with the career ladder described in §260.203(d) of this chapter (relating to Qualifications of Program Provider Staff). Source Note: The provisions of this §260.345 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.345 Intervener https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212583 03/12/2026 (a) A program provider must ensure that nursing:(1) is ordered or prescribed by a physician or other medical practitioner acting within the scope of the practitioner's license; and (2) is provided in accordance with: (A) Texas Occupations Code Chapter 301;(B) 22 TAC Chapter 217;(C) 22 TAC Chapter 224; and(D) 22 TAC Chapter 225.(b) If an individual requires specialized licensed vocational nursing or specialized registered nursing, a program provider's RN must complete the HHSC Specialized Nursing Certification form as described in the Deaf Blind with Multiple Disabilities Program Manual and obtain HHSC authorization before providing specialized licensed vocational nursing or specialized registered nursing. (1) The RN must indicate on the form that a physician has determined the individual requires: (A) use of a ventilator at least six hours per day; or (B) tracheostomy care at least once per day to include cleansing, dressing, and suctioning of the tracheostomy. (2) The program provider must: (A) ensure the case manager submits the completed form to HHSC with the IPC; and (B) keep the original completed form in the individual's record. (c) If HHSC approves specialized licensed vocational nursing or specialized registered nursing for an individual, the program provider must bill for specialized licensed vocational nursing or specialized registered nursing provided to the individual after the date of HHSC's authorization of these services. (d) If an individual's IPC includes nursing, a program provider must ensure compliance with §260.213 of this chapter (relating to Service Backup Plans). (e) A program provider may bill HHSC at the RN, LVN, specialized RN, or specialized LVN rates only for the following nursing activities: (1) interacting in person or by telephone with an individual to provide professional or vocational nursing for which there is a documented or immediate medical necessity, including: (A) preparing and administering medication or treatment ordered by a physician, podiatrist, or dentist; (B) assisting or observing self-administration of medication; and (C) assessing an individual's health status; (2) interacting in person or by telephone with a person, except a service provider of nursing, case management, or a therapy, regarding the health status of an individual; (3) performing health care procedures ordered or prescribed by a physician or medical practitioner and required by standards of professional practice or law to be performed by licensed nursing personnel; (4) delegating, verifying the competency of, and supervising an unlicensed person in the performance of a task delegated in accordance with 22 TAC Part 11 (relating to Texas Board of Nursing); (5) providing training to a service provider that is specific to an individual; (6) providing training or orientation to an individual, LAR, family member, or service provider concerning an adaptive aid or minor home modification; and (7) participating in service planning team meetings. (f) A program provider may bill HHSC at a nursing rate for a nurse's performance of delegated tasks if: (1) a service provider to whom a nurse has delegated the performance of delegated tasks is unavailable to perform those tasks; (2) a backup service provider is unavailable; and (3) the individual's health and welfare would be endangered if those tasks are not delivered. (g) If a program provider bills HHSC as described in subsection (f) of this section, the program provider: (1) must not bill for more than 10 hours of such services per IPC period; (2) must document in the individual's record: (A) efforts made to find a service provider who is not an RN or LVN to perform the delegated tasks; and (B) reasons the failure to provide the delegated tasks would endanger the individual's health and welfare. Source Note: The provisions of this §260.347 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.347 Nursing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212584 03/12/2026 (a) A program provider must ensure an orientation and mobility service provider:(1) evaluates an individual's ability to use existing senses to determine the individual's position within the environment, including home, school, work, and other community settings;(2) develops a plan that:(A) identifies the individual's goals and outcomes; and(B) enables the individual to acquire skills to safely move from one place to another within the environment, including home, school, work, and other community settings; and(3) trains other service providers to:(A) create an environment in home, school, work, and community settings that enhances the individual's ability to move safely and efficiently; and(B) carry through on goals and outcomes identified in the plan.(b) A program provider must ensure an orientation and mobility service provider:(1) has:(A) certification from the Academy for the Certification of Vision Rehabilitation and Education Professionals; or(B) the National Orientation and Mobility Certification through the National Blindness Professional Certification Board; or(2) has a bachelor's or master's degree in orientation and mobility from a college or university accredited by a state agency or a non-governmental entity recognized by the United States Department of Education.(c) A program provider may bill HHSC for orientation and mobility only for the following activities:(1) assessing and evaluating the need for services;(2) developing and implementing the plan described in subsection (a)(2) of this section;(3) evaluating the individual's progress toward achieving the goals and outcomes described in the IPP with updates to the program provider;(4) providing direct intervention;(5) interacting with the individual or LAR regarding the individual's needs and progress toward achieving orientation and mobility goals;(6) consulting with family members and other service providers regarding the individual's needs and progress toward achieving orientation and mobility goals;(7) participating in service planning team meetings, when requested;(8) training other service providers to carry through on orientation and mobility goals and outcomes; and(9) participating in a fair hearing at the request of a member of the service planning team to provide information concerning orientation and mobility goals and outcomes. Source Note: The provisions of this §260.349 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.349 Orientation and Mobility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212585 03/12/2026 (a) General.(1) A program provider may provide residential services as:(A) licensed assisted living, either 18-hour or 24-hour; or(B) licensed home health assisted living, either 18-hour or 24-hour.(2) A program provider must:(A) provide personal assistance with ADLs and IADLs;(B) provide assistance with housekeeping;(C) provide therapeutic social and recreational activities;(D) provide on-site response staff to meet scheduled or unpredictable needs;(E) provide supervision of an individual's safety and security; and(F) provide, make arrangements for, transportation other than medical transportation.(3) An individual receiving either licensed assisted living or licensed home health assisted living must not receive:(A) in-home respite;(B) out-of-home respite;(C) transportation provided as a residential habilitation activity;(D) chore services;(E) CFC PAS/HAB; or(F) nursing services except those required for program eligibility.(4) A program provider must ensure that an individual transitioning from institutional services to either licensed assisted living or licensed home health assisted living does not receive TAS.(5) If an individual is absent from the individual's residence for six or more hours in a day, the program provider may bill for 18-hour licensed assisted living or 18-hour licensed home health assisted living and must not bill for 24-hour licensed assisted living or 24-hour licensed home health assisted living.(6) If an individual's IPC includes day habilitation, the program provider may bill for 18-hour licensed assisted living or 18-hour licensed home health assisted living for a day on which the individual participates in day habilitation, but must not bill for 24-hour licensed assisted living or 24-hour licensed home health assisted living.(7) A program provider must maintain documentation of the daily census using the HHSC Daily Census Documentation form or a form developed by the program provider that documents the information on the HHSC Daily Census Documentation form.(8) A program provider must ensure that an individual's record includes the individual's progress or lack of progress in achieving the following outcomes for residential services:(A) the ability to effectively communicate the individual's wants and needs to a residential services service provider;(B) the ability to actively participate in activities of daily living to the extent of the individual's ability;(C) the ability to implement the individual's choices;(D) the ability to access and participate in community activities; and(E) the ability to move safely and efficiently within home and community settings.(b) Licensed assisted living.(1) A program provider must provide licensed assisted living to no more than six persons in an ALF owned by the program provider.(2) A program provider must not bill HHSC for the cost of a minor home modification for an individual who is receiving licensed assisted living.(3) A program provider must not charge an individual or LAR a pet deposit for a service animal, including a guide dog, signal dog, or other animal individually trained to provide assistance to an individual who is receiving licensed assisted living.(4) A program provider must maintain a ledger in accordance with generally accepted accounting principles with amounts paid for room and board by an individual who is receiving licensed assisted living.(5) A program provider must provide a receipt for amounts paid for room and board by an individual who is receiving licensed assisted living.(c) Licensed home health assisted living.(1) A program provider must not allow more than three persons to reside in a residence in which the program provider provides licensed home health assisted living.(2) A program provider must ensure that a residence in which licensed home health assisted living is provided:(A) is accessible to and usable by the individuals receiving services in the residence;(B) is maintained in good repair;(C) has at least two means of egress from:(i) the living areas; and(ii) the individuals' bedrooms;(D) has working smoke alarms installed to detect smoke in the kitchen, living areas, and the individuals' bedrooms;(E) has a universal, fully-charged, and unexpired fire extinguisher easily accessible:(i) from the kitchen;(ii) from the laundry area;(iii) from the vicinity of a hot water heater or furnace;(iv) from each bedroom area; and(v) on each floor of a multi-level residence;(F) has a first aid kit that complies with American Red Cross recommendations with contents that are not out-of-date;(G) has water temperature that does not exceed 110 degrees Fahrenheit from faucets used by an individual who cannot self-regulate the water temperature from a faucet the individual uses;(H) has a locked container that can be used to store the medications for the individual as required by paragraph (3) of this subsection;(I) has a place to store flammable or poisonous substances in a manner that makes them inaccessible to the individuals; and(J) has a working carbon monoxide detector installed in each individual's bedroom.(3) A program provider must ensure:(A) an individual's prescribed medication is stored in a locked container and in the original container labeled with:(i) individual's name;(ii) date dispensed;(iii) instructions;(iv) name of medication with dosage; and(v) physician's name;(B) a medication requiring refrigeration is kept separate from food in a clearly labeled, designated locked container;(C) a medication that is no longer needed by the individual or that is past its expiration date is disposed of according to federal and state laws and regulations;(D) a medication prescribed for one individual is not given to another individual; and(E) an individual takes prescribed medications according to the physician's instructions and over-the-counter medications according to the package directions.(4) A program provider must conduct a home inspection and document the results of the inspection to determine compliance with the requirements in paragraph (2) of this subsection for a residence:(A) before providing services and annually thereafter for a residence not used to provide licensed home health assisted living services before September 1, 2014; or(B) before September 30, 2014 and annually thereafter for a residence used to provide licensed home health assisted living before September 1, 2014.(5) A program provider must ensure correction of any noncompliance found during the home inspection and document the correction.(6) A program provider must:(A) develop and implement a written emergency response plan for the residence that describes the actions a program provider will take in the event of an emergency, such as a fire or other man-made or natural disaster, including evacuation or sheltering-in-place of the individual, as appropriate; and(B) ensure that:(i) the emergency response plan takes into account the abilities of the individual to follow the plan;(ii) the individual receives instruction concerning the emergency response plan:(I) within 48 hours after the individual moves into the residence and annually thereafter; and(II) if the individual's ability to follow the emergency response plan changes;(iii) the individual's service providers demonstrate competence in implementing the emergency response plan at the time job duties are assumed and annually thereafter;(iv) the emergency response plan is reviewed and revised by the program provider when necessary and at least annually; and(v) a copy of the current emergency response plan is:(I) maintained in the residence; and(II) accessible to service providers.(7) A program provider must ensure:(A) an individual successfully participates in a fire drill within 48 hours after the individual moves into the residence;(B) all individuals in the residence successfully participate in a fire drill at least every 90 calendar days, with at least two drills per year conducted when at least one individual is sleeping; and(C) an individual successfully participates in a fire drill within 48 hours after a change occurs in the individual's condition that may negatively affect the individual's ability to participate in a fire drill.(8) A program provider must ensure:(A) the residence has furnishings that are safe for the individual in all common areas;(B) a bedroom in the residence:(i) has at least:(I) 80 square feet of floor space for a single occupancy room; and(II) 60 square feet of floor space per individual in a double occupancy room;(ii) was built as a bedroom when the residence was built, or was remodeled under a permit that meets local building codes;(iii) is finished with walls or partitions of standard construction that go from floor to ceiling;(iv) is adequately ventilated and lighted;(v) has at least one window that will open freely and remain open from the inside without special tools;(vi) has no more than two beds in any room;(vii) has adequate drawer and closet space; and(viii) provides comfortable sleeping arrangements for the individual;(C) the residence has a common telephone or other communication system usable by the individual and for which:(i) an individual has an opportunity to have input on residence procedures concerning:(I) time limits on calls; and(II) privacy during an individual's use of the phone; and(ii) a program provider does not charge an individual for local calls; and(D) bathrooms have adequate supplies of towels, washcloths, soap, and toilet tissue at all times.(9) A program provider must ensure that an individual living in a residence where the individual receives licensed home health assisted living has a written "lease," as defined in Texas Property Code Chapter 92, with the owner of the residence or with an individual who leases from the owner of the residence. The lease must provide the same responsibilities and protections against eviction that tenants have under state law governing residential tenancies, including Texas Property Code Chapters 24, 91, and 92 and the Texas Rules of Civil Procedure Rule 510. Source Note: The provisions of this §260.351 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.351 Residential Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212586 03/12/2026 (a) General.(1) A program provider must ensure that respite consists of the following:(A) assistance with ADLs;(B) assistance with functional living tasks;(C) assistance with planning and preparing meals;(D) transportation or assistance in securing transportation;(E) assistance with ambulation and mobility;(F) reinforcement of behavioral support or therapy activities;(G) assistance with medications and the performance of tasks delegated by an RN in accordance with state law;(H) supervision of the individual's safety and security; and(I) activities that facilitate the individual's:(i) inclusion in community activities;(ii) use of natural supports and typical community services;(iii) social interaction:(iv) participation in leisure activities; and(v) daily and functional living skills.(2) A program provider may deliver respite as:(A) in-home respite; or(B) out-of-home respite.(3) A program provider must not:(A) bill HHSC for more than 30 calendar days or 720 hours of respite per IPC period;(B) provide respite to an individual receiving licensed assisted living or licensed home health assisted living;(C) permit an individual's spouse or a service provider of transportation provided as a residential habilitation activity or CFC PAS/HAB with whom the individual lives to provide respite; or(D) provide respite to an individual with the individual present at the same time that one of the following services are provided to the individual:(i) employment assistance;(ii) supported employment;(iii) day habilitation;(iv) transportation provided as a residential habilitation activity; or(v) CFC PAS/HAB.(4) A program provider must ensure that a respite service provider meets the qualifications described in §260.203 of this chapter (relating to Qualifications of Program Provider Staff) and the training requirements described in §260.205 of this chapter (relating to Training).(b) In-home respite. A program provider must ensure that in-home respite is provided in the private residence of:(1) the individual;(2) the individual's family; or(3) a respite service provider.(c) Out-of-home respite.(1) A program provider must ensure that out-of-home respite is provided in a location listed in paragraph (2) of this subsection acceptable to the individual or LAR that:(A) is an accessible, safe, and comfortable environment for the individual; and(B) promotes the individual's health and welfare.(2) A program provider must provide out-of-home respite in:(A) an ICF/IID with a certified capacity of six or less persons;(B) an ALF with a licensed capacity of six or less persons; or(C) an outdoor camp accredited by the American Camp Association.(3) A program provider may provide out-of-home respite in a residence in which licensed assisted living or licensed home health assisted living is provided if:(A) a vacancy exists in the residence;(B) the individual or LAR approves; and(C) the service planning team for each individual receiving services in that residence makes a determination that the respite visit will cause no threat to the health, safety, and welfare, or rights and needs of that individual. Source Note: The provisions of this §260.353 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.353 Respite https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212587 03/12/2026 (a) A program provider must provide or ensure the provision of the following therapies:(1) occupational therapy;(2) physical therapy;(3) speech-language pathology;(4) audiology; and(5) dietary services.(b) A program provider must ensure a therapy:(1) is delivered by an appropriately licensed service provider, as follows:(A) for occupational therapy, an occupational therapist licensed in accordance with Texas Occupations Code Chapter 454;(B) for physical therapy, a physical therapist licensed in accordance with Texas Occupations Code Chapter 453;(C) for speech-language pathology, a speech-language pathologist licensed in accordance with Texas Occupations Code Chapter 401;(D) for audiology, an audiologist licensed in accordance with Texas Occupations Code Chapter 401; or(E) for dietary services, a dietitian licensed in accordance with Texas Occupations Code Chapter 701.(2) includes, as appropriate, the following activities:(A) screening and assessment;(B) developing and implementing a treatment plan that, as appropriate, includes a plan to:(i) transfer a therapy task to an unlicensed service provider; and(ii) change the role of the therapist to a supervisory role;(C) directing therapeutic intervention in accordance with the appropriate chapter of the Texas Occupations Code;(D) consulting with or training of family members and other service providers;(E) participating on an individual's service planning team, when appropriate;(F) informing the physician and other appropriate professionals of changes in the individual's health status that may require a change in the IPC;(G) preparing a report to the case manager as described in subsection (g) of this section;(H) supervising and training an unlicensed service provider within the scope of applicable state statutes and rules; and(I) conducting assessments and preparing specifications for the procurement of an adaptive aid or minor home modification; and(3) is provided to an individual at a location agreeable to the individual or LAR.(c) A program provider must:(1) obtain a physician's order for therapy before the delivery of the therapy;(2) ensure that the physician's order includes the following:(A) individual's name;(B) type of therapy;(C) frequency and duration of therapy;(D) other instructions, if applicable;(E) physician's name and medical specialty; and(F) effective date of the order; and(3) retain the physician's order in the individual's record.(d) A program provider may accept faxed physician's orders for therapy services.(1) The program provider does not have to obtain a countersignature of the faxed orders by the prescribing physician.(2) The program provider must ensure the faxed orders are legible.(e) If requested by an individual's service planning team, a service provider of a therapy may screen an individual for therapy services without obtaining a physician's order.(f) A program provider may bill HHSC only for the following therapy activities:(1) screening, assessing, and evaluating the need for services;(2) developing and implementing a treatment plan;(3) periodically evaluating the individual's progress toward achieving the goals and outcomes described in the IPP for the therapy service and providing updates to the program provider;(4) providing direct therapeutic intervention;(5) interacting with the individual or LAR regarding the individual's condition and progress toward or achievement of goals;(6) training the individual to use an adaptive aid;(7) delegating therapy tasks to an unlicensed person in accordance with rules of the appropriate licensing board;(8) consulting with family members and other service providers regarding the individual's DBMD Program and CFC services;(9) informing the physician and the program provider of changes in the individual's health status requiring a service plan change;(10) participating in service planning team meetings, if requested;(11) supervising and training an unlicensed service provider within the scope of the therapy examining board rules;(12) participating in a fair hearing at the request of a member of the service planning team to provide information within the scope of the service provider's license;(13) assisting with writing specifications for adaptive aids; and(14) providing consultation or justification for the procurement of an adaptive aid or minor home modification.(g) A program provider must ensure an appropriately licensed therapist provides a report to the individual's case manager at least 10 calendar days before the review described in §260.77(a) of this chapter (relating to Renewal and Revision of an IPP and IPC) that:(1) reviews the individual's progress toward achieving the goals and outcomes described in the IPP for that therapy;(2) reviews whether the services are meeting the individual's needs;(3) documents whether the individual's needs have changed; and(4) documents attempts to teach maintenance services and techniques to other service providers. Source Note: The provisions of this §260.355 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.355 Therapies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222994 03/12/2026 A program provider must not bill for and HHSC does not reimburse for:(1) services provided to an individual before HHSC's approval of the individual's request for enrollment in the DBMD Program;(2) supervision of service providers unless providing delegated tasks;(3) phone calls, text messages, emails, letters, or meetings with HHSC or community resources that do not directly address an individual's services;(4) administrative meetings or staff meetings;(5) in-service training, general training, continuing education, or conferences;(6) employee conferences or evaluations;(7) filing claims for services;(8) traveling to and from an individual's residence, except when a service provider of day habilitation, employment readiness, transportation provided as a residential habilitation activity, or in-home respite is transporting the individual;(9) processing paperwork or completing records or reports;(10) services not included on an approved IPC;(11) services that are mutually exclusive;(12) other services and activities not authorized, permitted, or allowed under this chapter;(13) routine care and supervision that a family member is legally obligated to provide;(14) activities or supervision for which a payment is made by a source other than Medicaid;(15) room and board;(16) any expense related to providing transportation provided as a residential habilitation activity, nursing, out-of-home respite in a camp, case management, adaptive aids, intervener services, or CFC PAS/HAB outside the program provider's contracted service delivery area, including costs for transportation or lodging;(17) transportation provided as a residential habilitation activity, nursing, out-of-home respite in a camp, case management, adaptive aids, intervener services, or CFC PAS/HAB provided to an individual outside the program provider's contracted service delivery area if the individual has received services outside the program provider's contracted service delivery during a period of more than 60 consecutive days;(18) two or more services provided at the same time by the same service provider; or(19) an item or service provided to an individual at the request of the individual or LAR that is not a reimbursable item in the DBMD Program. Source Note: The provisions of this §260.357 adopted to be effective February 26, 2023, 48 TexReg 896; amended to be effective January 1, 2025, 49 TexReg 10337. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.357 Non-Billable Time and Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212591 03/12/2026 (a) A program provider must ensure that CFC ERS is provided only to an individual:(1) who is not receiving licensed assisted living or home health licensed assisted living; and(2) who:(A) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(B) would otherwise require extensive routine supervision.(b) Installing equipment.(1) A program provider must ensure that CFC ERS equipment is installed within 14 business days after one of the following dates, whichever is later:(A) the date HHSC approves the proposed IPC that includes CFC ERS; or(B) the effective date of the individual's IPC as determined by the service planning team.(2) At the time CFC ERS equipment is installed, a program provider must ensure that:(A) the equipment is installed in accordance with the manufacturer's installation instructions;(B) an initial test of the equipment is made;(C) the equipment has an alternate power source in the event of a power failure;(D) the individual is trained on the use of the equipment, including:(i) demonstrating how the equipment works; and(ii) having the individual activate an alarm call;(E) an explanation is given to the individual that the individual must:(i) participate in a system check each month; and(ii) contact the CFC ERS provider if:(I) the individual's telephone number or address changes; or(II) one or more of the individual's responders change; and(F) the individual is informed that a responder, in response to an alarm call, may forcibly enter the individual's home if necessary.(3) A program provider must ensure that the date and time of the CFC ERS equipment installation and compliance with the requirements in paragraphs (1) and (2) of this subsection are documented in the individual's record.(c) Securing responders. A program provider must ensure that, on or before the date CFC ERS equipment is installed:(1) an attempt is made to obtain from an individual, the names and telephone numbers of at least two responders, such as a relative or neighbor;(2) public emergency personnel:(A) is designated as a second responder if the individual provides the name of only one responder; or(B) is designated as the sole responder if the individual does not provide the names of any responders; and(3) the name and telephone number of each responder is documented in the individual's record.(d) Conducting a system check.(1) At least once during each calendar month a program provider must ensure that a system check is conducted on a date and time agreed to by the individual.(2) A program provider must ensure that the date, time, and result of the system check is documented in the individual's record.(3) If, as a result of the system check:(A) the equipment is working properly but the individual is unable to successfully activate an alarm call, the program provider must ensure that a request is made of the case manager to convene a service planning team meeting to determine if CFC ERS meets the individual's needs; or(B) the equipment is not working properly, the program provider must ensure that, within three calendar days of the system check, the equipment is repaired or replaced.(e) Failing to complete a system check. If a system check is not conducted in accordance with subsection (d)(1) of this section, a program provider must ensure that:(1) the failure to comply is because of good cause; and(2) the good cause is documented in the individual's record.(f) Alarm call.(1) A program provider must ensure that an alarm call is responded to 24 hours a day, seven days a week.(2) A program provider must ensure that, if an alarm call is made, the CFC ERS provider:(A) within 60 seconds of the alarm call, attempts to contact the individual to determine if an emergency exists;(B) immediately contacts a responder, if as a result of attempting to contact the individual:(i) the CFC ERS provider confirms there is an emergency; or(ii) the CFC ERS provider is unable to communicate with the individual; and(C) documents the following information in the individual's record when the information becomes available:(i) the name of the individual;(ii) the date and time of the alarm call, recorded in hours, minutes, and seconds;(iii) the response time, recorded in seconds;(iv) the time the individual is called in response to the alarm call, recorded in hours, minutes, and seconds;(v) the name of the contacted responder, if applicable;(vi) a brief description of the reason for the alarm call; and(vii) if the reason for the alarm call is an emergency, a statement of how the emergency was resolved.(3) If an alarm call results in a responder being dispatched to the individual's home for an emergency, the program provider must ensure that:(A) the case manager receives written notice of the alarm call within one business day after the alarm call;(B) if the CFC ERS provider is a contracted provider, the program provider receives written notice from the contracted provider within one business day after the alarm call; and(C) the written notices required by subparagraphs (A) and (B) of this paragraph is maintained in the individual's record.(g) Equipment failure.(1) A program provider must ensure that, if an equipment failure occurs, other than during a system check required by subsection (d)(1) of this section:(A) the individual is informed of the equipment failure; and(B) the equipment is replaced within one business day after the failure becomes known by the CFC ERS provider.(2) If an individual is not informed of the equipment failure or the equipment is not replaced in compliance with paragraph (1) of this subsection, the program provider must:(A) determine whether the failure to inform the individual or replace the equipment was because of good cause; and(B) as soon as possible, ensure that the individual is informed of the equipment failure and the equipment is replaced.(h) Low battery.(1) A program provider must ensure that, if the ERS equipment registers five or more "low battery" signals in a 72-hour period:(A) a visit to an individual's home is made to conduct a system check within five business days after the low battery signals occur; and(B) if the battery is defective, the battery is replaced during the visit.(2) If a system check or battery replacement is not made in accordance with paragraph (1) of this subsection, a program provider must:(A) determine whether the failure to conduct a system check or replace a defective battery was because of good cause; and(B) as soon as possible, conduct a system check and replace a defective battery.(i) Documenting equipment failure or low battery. A program provider must ensure that the following information is documented in an individual's record:(1) the date the equipment failure or low battery signal became known by the CFC ERS provider;(2) the equipment or subscriber number;(3) a description of the problem;(4) the date the equipment or battery was repaired or replaced; and(5) the good cause for failure to comply with subsections (g)(1) and (h)(1) of this section. Source Note: The provisions of this §260.359 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES F SERVICE DESCRIPTIONS AND REQUIREMENTS §260.359 CFC ERS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212592 03/12/2026 (a) During a service planning team meeting to develop an enrollment, a revised, or a renewal IPP, a case manager must inform an individual or LAR of the following if the individual is interested in receiving licensed assisted living:(1) that if the individual or LAR selects licensed assisted living, the individual or LAR will be responsible for paying the cost of room and board in accordance with a residential agreement described in subsections (b) and (c) of this section;(2) that if the individual or LAR does not pay room and board as required by a residential agreement, the individual's program provider may evict the individual in accordance with the residential agreement and state law; and(3) that if the program provider evicts the individual:(A) the individual will not receive licensed assisted living until the delinquent room and board is paid; and(B) the IPC will be revised to own home or family home if the delinquent room and board is not paid.(b) An individual's program provider must ensure that an individual receiving licensed assisted living has a written residential agreement with the program provider.(c) The residential agreement required by subsection (b) of this section must include:(1) the physical address of the residence;(2) the name of the individual;(3) the name of the program provider;(4) the beginning date of the residential agreement;(5) the date the residential agreement expires;(6) a provision that:(A) the program provider and the individual or LAR agree that the residential agreement is a "lease," as defined in Texas Property Code Chapter 92 and that they are subject to state law governing residential tenancies, including Texas Property Code Chapters 24, 91, and 92 and the Texas Rules of Civil Procedure Rule 510;(B) to the extent allowed by law, in the event of a conflict or inconsistency between any provision of the residential agreement and any provision of state statutory law, including Texas Property Code Chapters 91 and 92, the provision in the residential agreement governs;(C) the individual or LAR is not waiving any right or remedy provided to tenants under state law, including the Texas Fair Housing Act in Texas Property Code Chapter 301, and is not agreeing to any notice period that is shorter than the notice period to which tenants are entitled under state law;(D) allows the individual to terminate the residential agreement before its expiration date without any obligation under the residential agreement except an obligation that accrued before the date of termination, if the individual permanently moves from the residence for any reason, including transferring to a different program provider;(E) if the individual permanently moves from the residence, the program provider agrees to refund any amount the individual has paid under the residential agreement for days the individual did not reside in the residence;(F) an amount refunded under the circumstances described in paragraph (13) of this subsection will be calculated by:(i) dividing the monthly amount the individual pays under the residential agreement by the number of days in the month; and(ii) multiplying the quotient from subparagraph (A) of this paragraph by the number of days for which the individual paid but did not reside in the residence;(G) the individual may furnish and decorate the individual's bedroom;(H) the program provider agrees to be responsible for all repairs to the residence resulting from normal wear and tear, as defined in Texas Property Code §92.001;(I) the individual will pay for damages to property in the residence if the individual caused the damage and the damage is not ordinary wear and tear;(J) allows eviction of the individual only if:(i) the individual or LAR fails to pay room or board, which does not include any late fee; or(ii) the individual's DBMD Program services are terminated;(K) the program provider will, before giving the individual or LAR a notice to vacate, give the individual or LAR a notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room or board;(L) if the individual or LAR pays the delinquent room and board within the period required by subparagraph (K) of this paragraph, the program provider will not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual; and(M) the program provider will not accelerate the entire balance of the unpaid room and board owed under the remainder of the term of the residential agreement if the individual or LAR violates the residential agreement and the violation does not result in an eviction;(7) the amount the individual or LAR is paying for room and board;(8) the day of the month that the amount for room and board is due, which must not be before the day of the month an individual receives a primary source of income such as supplemental security income and social security disability insurance;(9) the amount of a late fee, if any, which may be charged only once per month and must not exceed 10 percent of the amount for room and board, that the program provider may charge the individual or LAR if room and board is not paid by the third day after it is due; and(10) the signature of the program provider and individual or the LAR.(d) A program provider must:(1) give the individual or LAR at least three calendar days to review, request changes, and sign the residential agreement;(2) ensure the residential agreement is fully executed before the individual begins living in a residence in which licensed assisted living is provided, except that the individual may begin living in such a residence before the residential agreement is fully executed in the event of an emergency;(3) if an individual begins living in a residence in which licensed assisted living is provided before a residential agreement is fully executed because of an emergency, as allowed by paragraph (2) of this subsection:(A) document the details of the emergency; and(B) ensure the residential agreement is fully executed within seven calendar days after the individual begins living in the residence; and(4) provide one copy of the residential agreement to the individual or LAR within three business days after the date the residential agreement is fully executed.(e) If a program provider becomes aware that a modification to the provision in the residential agreement that the individual may furnish and decorate the individual's bedroom is needed based on a specific assessed need of an individual, the program provider must:(1) notify the case manager of the needed modification; and(2) provide the case manager the documentation described in §260.403(b)(2) of this chapter (relating to Requirements for Program Provider-Owned Residential Settings).(f) If a case manager receives a notification and documentation as described in subsection (e) of this section, the case manager must convene a meeting of the service planning team to revise the individual's IPP in accordance with §260.403(b) of this chapter.(g) After the service planning team revises the individual's IPP, as required by subsection (f) of this section, the program provider may implement the modification.(h) If an individual or LAR is delinquent in payment of room or board and the program provider wants to evict the individual, the program provider must:(1) notify the case manager that the individual or LAR is delinquent in the payment of room or board under the residential agreement and that the program provider wants to evict the individual;(2) after providing the notification required by paragraph (1) of this subsection, meet with the individual or LAR, including the representative payee if one has been appointed by the Social Security Administration, and the case manager to discuss the alleged non-payment of room or board and options to prevent an eviction; and(3) if the program provider intends to proceed to evict the individual, at the meeting required by paragraph (2) of this subsection:(A) give the individual or LAR a written notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room and board; and(B) provide the case manager with a copy of the written notice of proposed eviction.(i) If the individual or LAR pays the delinquent room or board within the period required by subsection (h)(3) of this section, the program provider must not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual.(j) If the individual or LAR does not pay the delinquent room and board within the period required by subsection (h)(3) of this section, the program provider:(1) must report the failure to pay to one of the following as appropriate:(A) the SSA;(B) the probate court that appointed the individual's guardian; or(C) DFPS as an allegation of the LAR's exploitation or neglect of the individual;(2) must meet with the individual or LAR to discuss alternative living settings for the individual; and(3) if the program provider wants to proceed to evict the individual, the program provider must:(A) give the individual or LAR a written notice to vacate the residence in accordance with the residential agreement and state law; and(B) send a copy of the written notice described in subparagraph (A) of this paragraph to the individual's case manager within one business day after the individual or LAR is given the notice.(k) If an individual is evicted by a program provider and the individual or LAR has not paid the delinquent room and board, the case manager must convene a meeting or meetings to revise the IPP and revise the IPC as described in §260.77 of this chapter (relating to Renewal and Revision of an IPP and IPC). If the individual or LAR wants to keep licensed assisted living on the individual's IPC, the case manager must inform the individual or LAR at the meeting or meetings that HHSC will deny licensed assisted living if included on the individual's IPC, until the individual pays the delinquent room and board.(l) If a program provider evicts an individual who has an LAR and the LAR fails to arrange an alternative living setting for the individual, the program provider must report the LAR's failure to DFPS as neglect of the individual and notify the case manager that such report was made.(m) If an individual pays the delinquent room and board, a program provider must, within one business day after the payment, notify the individual's case manager that the individual is no longer delinquent. Source Note: The provisions of this §260.401 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G PROGRAM PROVIDER-OWNED RESIDENTIAL SETTINGS §260.401 Residential Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212593 03/12/2026 (a) A program provider must ensure that, except as provided in subsection (b) of this section, in a residence in which licensed assisted living is provided:(1) an individual has privacy in the individual's bedroom;(2) an individual has the option not to share a bedroom with a roommate;(3) an individual sharing a bedroom has a choice of roommates;(4) a lock is installed on the individual's bedroom door at no cost to the individual, and that:(A) the lock is operable by the individual; and(B) only the individual, a roommate of the individual, and staff designated by the program provider have keys to the individual's bedroom door;(5) an individual can furnish and decorate the individual's bedroom;(6) while in the residence, an individual has the freedom and support:(A) to control the individual's schedules and activities that are not part of the IPP for licensed assisted living; and(B) to have access to food at any time;(7) an individual may have visitors of the individual's choosing at any time; and(8) the residence is physically accessible and free of hazards to the individual.(b) If an individual's service planning team determines that any of the requirements in subsection (a)(1) - (6) of this section must be modified, the service planning team must:(1) revise the individual's IPP in accordance with §260.77 of this chapter (relating to Renewal and Revision of an IPP and IPC); and(2) document on the individual's IPP:(A) a description of the specific and individualized assessed need that justifies the modification;(B) a description of any positive interventions and supports that have been tried but did not work;(C) a description of any less intrusive methods of meeting the need that have been tried but did not work;(D) a description of the condition that is directly proportionate to the specific assessed need;(E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(G) the individual's or LAR's signature on the IPP evidencing informed consent to the modification; and(H) the program provider's assurance that the modification will cause the individual no harm.(c) After the service planning team revises an individual's IPP, as required by subsection (b) of this section, the program provider must implement the modification. Source Note: The provisions of this §260.403 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES G PROGRAM PROVIDER-OWNED RESIDENTIAL SETTINGS §260.403 Requirements for Program Provider-Owned Residential Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212594 03/12/2026 (a) HHSC may allow a program provider to use one or more of the exceptions described in subsections (c) - (n) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers:(1) if HHSC allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding §260.61(c) of this chapter (relating to Process for Enrollment of an Individual), an initial visit for an individual who resides in the disaster area may be conducted by videoconferencing or in person.(d) If the initial visit described in subsection (c) of this section is conducted by videoconferencing:(1) the case manager may complete the requirements described in §260.61(c)(1) - (3) of this chapter by videoconferencing;(2) the case manager or an appropriate professional must not complete an adaptive behavior screening assessment required by §260.61(c)(6) of this chapter by videoconferencing;(3) the case manager or an RN must not complete a Related Conditions Eligibility Screening Instrument required by §260.61(c)(7) of this chapter by videoconferencing;(4) an RN may complete a nursing assessment of an individual who resides in the disaster area required by §260.61(c)(8) in accordance with the RN's licensing requirements by videoconferencing or in person;(5) the case manager must not perform the assessment needed to complete the ID/RC Assessment required by §260.61(c)(4) of this chapter by videoconferencing; and(6) the signature of the individual or LAR on a Waiver Program Verification of Freedom of Choice form required by §260.61(c)(5) of this chapter may be replaced by the case manager noting on the form that the individual or LAR chose the DBMD Program over the ICF/IID Program.(e) Notwithstanding §260.67(a) of this chapter (relating to Development of a Proposed Enrollment IPC), a service planning team meeting for an individual who resides in the disaster area may be conducted by videoconferencing or in person.(f) If the service planning team meeting described in subsection (e) of this section is conducted by videoconferencing:(1) the case manager may obtain the signatures of the service planning team members other than the individual or LAR on the proposed enrollment IPC required by §260.67(c)(1) of this chapter after the service planning team meeting; and(2) the case manager may replace the signature of the individual or LAR on the proposed enrollment IPC required by §260.67(c)(1) of this chapter by noting on the enrollment IPC that the individual or LAR orally agreed to the proposed enrollment IPC.(g) Notwithstanding §260.77(a) of this chapter (relating to Renewal and Revision of an IPP and IPC), a case manager may meet with an individual who resides in the disaster area and the LAR by videoconferencing or in person.(h) Notwithstanding §260.77(b)(1)(E), (c)(1), or (d)(1) of this chapter, a service planning team meeting for an individual who resides in the disaster area may be conducted by videoconferencing or in person.(i) If a service planning team meeting described in subsection (h) of this section is conducted by videoconferencing, a case manager must:(1) replace the signature of an individual or LAR required by §260.77(a)(5)(A), (b)(1)(E)(vii), (c)(3), or (d)(3) of this chapter by documenting on the new or revised IPP that the individual or LAR orally agreed to the new or revised IPP;(2) obtain the signatures of the service planning team members required by §260.77(a)(5)(A), (b)(1)(E)(vii), (c)(3), or (d)(3) of this chapter, other than the individual or LAR, on the revision or renewal IPP after the service planning team meeting;(3) replace the signature of the individual or LAR on a proposed renewal or proposed revised IPC required by §260.77(a)(5)(A), (b)(1)(E)(vii), (c)(3), or (d)(3) of this chapter by documenting on the proposed renewal or proposed revised IPC that the individual or LAR orally agreed to the proposed renewal or proposed revised IPC; and(4) obtain the signatures of the service planning team members required by §260.77(a)(5)(A), (b)(1)(E)(vii), (c)(3), or (d)(3) of this chapter, other than the individual or LAR, on the revision or renewal IPC after the service planning team meeting.(j) Notwithstanding §260.77(a)(2)(C) of this chapter, a case manager is not required to ensure that an individual who resides in the disaster area or LAR sign the HHSC IPP Service Review form or a form the program provider developed, if:(1) the meeting required by §260.77(a) of this chapter is conducted by telephone or videoconferencing;(2) the individual or LAR orally agree with the HHSC IPP Service Review form or a form the program provider developed; and(3) the case manager documents the individual's or LAR's oral agreement on the HHSC IPP Service Review form or a form the program provider developed.(k) Notwithstanding §260.301(a) of this chapter (relating to Authorization Amount and Other Limits for Adaptive Aids), the service limit may be exceeded if:(1) the requested adaptive aid or repair that causes the service limit to be exceeded is:(A) an adaptive aid that replaces an adaptive aid that was destroyed as a result of the disaster; or(B) the repair of an adaptive aid that was damaged as a result of the disaster; and(2) the requested adaptive aid or repair added to the individual's IPC does not exceed a total limit of $15,000 during the IPC period, which includes the cost of repair and maintenance of an adaptive aid.(l) Notwithstanding §260.303(a)(1) and (b) of this chapter (relating to Requirements for Authorization to Purchase or Lease an Adaptive Aid) and §260.305(a)(1), (c), (d), (f) and (g) of this chapter (relating to Requirements for Bids for an Adaptive Aid), if an individual requests the repair or replacement of an adaptive aid damaged or destroyed as result of a disaster:(1) instead of the service planning team completing the HHSC Rationale for Adaptive Aids, Medical Supplies, and Minor Home Modifications form, the program provider must obtain:(A) a description of the repair or replacement of an adaptive aid that was damaged or destroyed as a result of the disaster; and(B) one bid for the requested repair or replacement of an adaptive aid from a vendor that complies with §260.305(b) of this chapter; and(2) the case manager must submit to HHSC, no later than 180 days after the effective date of the order or proclamation described in subsection (a) of this section:(A) the renewal or revised IPC;(B) the renewal or revised IPP;(C) the description and bid of the repair or replacement described in paragraph (1) of this subsection; and(D) a written statement that the requested adaptive aid or repair is not available through a third-party resource.(m) Notwithstanding §260.315(a) of this chapter (relating to Authorization Limit for Minor Home Modification and Amount for Repair and Maintenance), the service limit of minor home modifications for an individual who resides in the disaster area may be exceeded if:(1) the requested minor home modification that causes the service limit to be exceeded is:(A) a minor home modification that replaces a minor home modification that was destroyed as a result of the disaster; or(B) a repair of a minor home modification that was damaged as a result of the disaster; and(2) the requested minor home modification or repair added to the individual's IPC does not exceed the total limit of $15,000 for a minor home modification during the time the individual is enrolled in the DBMD program.(n) Notwithstanding §§260.317, 260.319, 260.321, and 260.323 (relating to Requesting Authorization to Purchase a Minor Home Modification that Costs Less than $1,000, Requesting Authorization to Purchase a Minor Home Modification that Costs $1,000 or More, Specifications for a Minor Home Modification, and Bid Requirements for a Minor Home Modification), if an individual requests the repair or replacement of a minor home modification damaged or destroyed as a result of a disaster:(1) the program provider must obtain:(A) a description of the repair or replacement of a minor home modification that was damaged or destroyed as a result of the disaster; and(B) one bid for the requested repair or replacement of a minor home modification from a vendor that includes:(i) the total cost of the requested minor home modification, which may be from a catalog, website, or brochure price list;(ii) the amount of any additional expenses related to the delivery of the minor home modification, including shipping and handling, taxes, installation, and other labor charges;(iii) the date of the bid; and(iv) the name, address, and telephone number of the vendor, who may not be a relative of the individual;(2) the case manager must:(A) include the cost of the minor home modification or repair in the individual's proposed renewal or proposed revised IPC and IPP;(B) obtain the individual or LAR's oral agreement;(C) document the individual's or LAR's oral agreement on the proposed renewal or proposed revised IPC and IPP; and(D) sign the proposed renewal or proposed revised IPC and IPP;(3) the program director or the RN designated by the program provider must sign the proposed renewal or proposed revised IPC and IPP; and(4) the program provider must submit to HHSC, no later than 180 days after the effective date of the order or proclamation described in subsection (a) of this section:(A) the proposed renewal or proposed revised IPC;(B) the renewal or revised IPP;(C) the description and bid of the repair or replacement described in paragraph (1) of this subsection; and(D) a written statement that the requested minor home modification or repair is not available through a third-party resource.(o) Notwithstanding §260.205(c)(1) and (2) of this chapter (relating to Training), a program director, a case manager, an intervener, and a service provider may complete an online training course in cardiopulmonary resuscitation and choking prevention but an in-person evaluation by a qualified instructor is not required to be completed, if:(1) as a result of the disaster, the service provider is unable to arrange for the in-person evaluation; and(2) the in-person evaluation is completed within 90 calendar days after the disaster ends. Source Note: The provisions of this §260.451 adopted to be effective February 26, 2023, 48 TexReg 896. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES H DECLARATION OF DISASTER §260.451 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211644 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Calendar day--Any day, including weekends and holidays.(2) Case manager--A service provider of case management.(3) CFC--Community First Choice. A state plan option governed by Code of Federal Regulations, Title 42, Chapter 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice).(4) Community setting--A setting accessible to the general public within an individual's community.(5) Day habilitation--A DBMD Program service.(6) DBMD Program--The Deaf Blind with Multiple Disabilities Program.(7) DFPS--Texas Department of Family and Protective Services.(8) HHSC--The Texas Health and Human Services Commission.(9) Hospital--A public or private institution licensed or exempt from licensure in accordance with Texas Health and Safety Code (THSC) Chapters 13, 241, 261, or 552.(10) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. An HHSC form HHSC uses to determine the LOC for an individual.(11) Individual--A person seeking to enroll or who is enrolled in the DBMD Program.(12) Individualized skills and socialization--A DBMD Program service described in this subchapter. The two types of individualized skills and socialization are on-site individualized skills and socialization and off-site individualized skills and socialization.(13) Individualized skills and socialization provider--A legal entity licensed in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements).(14) IPC--Individual Plan of Care. A written plan developed by an individual's service planning team and documented on the HHSC Individual Plan of Care form. An IPC:(A) documents:(i) the type and amount of each DBMD Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year; and(ii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(15) IPC period--The effective period of an enrollment IPC and a renewal IPC as follows:(A) for an enrollment IPC, the period of time from the effective date of the enrollment IPC, as described in the rules governing the DBMD Program, through the last calendar day of the 11th month after the month in which enrollment occurred; and(B) for a renewal IPC, a 12-month period of time starting on the effective date of a renewal IPC as described in the rules governing the DBMD Program.(16) IPP--Individual Program Plan. A written plan developed in accordance with the rules governing the DBMD Program and documented on an HHSC Individual Program Plan form.(17) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(18) LOC--Level of care. A determination given to an individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(19) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(20) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(21) Program provider--A person that has a contract with HHSC to provide DBMD Program services, excluding a financial management services agency.(22) Service provider--A person who directly provides a DBMD Program service or a CFC service to an individual.(23) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C. Source Note: The provisions of this §260.501 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.501 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211645 03/12/2026 (a) The two types of individualized skills and socialization are on-site individualized skills and socialization and off-site individualized skills and socialization.(b) A program provider must ensure that individualized skills and socialization is provided by an individualized skills and socialization provider. An individualized skills and socialization provider must be the program provider or a contractor of the program provider.(c) An individualized skills and socialization provider must ensure that individualized skills and socialization:(1) provides person-centered activities related to:(A) acquiring, retaining, or improving self-help skills and adaptive skills necessary to live successfully in the community and participate in home and community life; and(B) gaining or maintaining independence, socialization, community participation, current or future volunteer goals, or employment goals consistent with achieving the outcomes identified in an individual's IPP;(2) supports the individual's pursuit and achievement of employment through school, vocational rehabilitation, the DBMD Program service of employment assistance, or the DBMD Program service of supported employment;(3) provides personal assistance for an individual who cannot manage personal care needs during an individualized skills and socialization activity;(4) as determined by an assessment conducted by a registered nurse, provides assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician; and(5) does not include activities in which an individual:(A) produces marketable goods; and(B) is paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act.(d) An individualized skills and socialization provider must ensure that on-site individualized skills and socialization:(1) is provided in a building or a portion of a building that is owned or leased by an individualized skills and socialization provider;(2) includes transportation of an individual from one on-site individualized skills and socialization location to another on-site individualized skills and socialization location;(3) promotes an individual's development of skills and behavior that support independence and personal choice; and(4) is not provided in:(A) a setting in which an individual must not reside, as set forth in the rules governing the DBMD Program; or(B) the residence of an individual or another person.(e) An individualized skills and socialization provider must ensure that individualized skills and socialization is not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a state supported living center or a certified intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) operated by a local intellectual and developmental disability authority (LIDDA) is located but is distinct from the state supported living center or the certified ICF/IID operated by a LIDDA;(2) is located in a building that is on the grounds of or immediately adjacent to a state supported living center or a certified ICF/IID operated by a LIDDA;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building that is on the grounds of or immediately adjacent to a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(f) An individualized skills and socialization provider may provide individualized skills and socialization to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (e) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(g) The setting in which on-site individualized skills and socialization is provided must:(1) allow an individual to:(A) control the individual's schedule and activities related to on-site individualized skills and socialization;(B) have access to the individual's food at any time; and(C) have visitors of the individual's choosing at any time; and(2) be physically accessible and free of hazards to an individual.(h) If an individual's service planning team determines that any of the requirements in subsection (g)(1) of this section must be modified, the service planning team must revise the individual's IPP in accordance with the rules governing the DBMD Program to include the following:(1) a description of the specific and individualized assessed need that justifies the modification;(2) a description of any positive interventions and supports that have been tried but did not work;(3) a description of any less intrusive methods of meeting the need that have been tried but did not work;(4) a description of the condition that is directly proportionate to the specific assessed need;(5) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(6) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(7) the individual's or LAR's signature on the IPP evidencing informed consent to the modification; and(8) the program provider's assurance that the modification will cause the individual no harm.(i) An individualized skills and socialization provider must ensure that off-site individualized skills and socialization:(1) provides activities that:(A) integrate an individual into the community; and(B) promote the individual's development of skills and behavior that support independence and personal choice;(2) is provided in a community setting chosen by the individual from among available community setting options;(3) includes transportation of an individual from an on-site individualized skills and socialization location to an off-site individualized skills and socialization location and between off-site individualized skills and socialization locations; and(4) is not provided in:(A) a building in which on-site individualized skills and socialization is provided;(B) a setting in which an individual must not reside, as set forth in the rules governing the DBMD Program, unless:(i) the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in such a setting; or(ii) off-site individualized skills and socialization is provided in an event open to the public; or(C) the residence of an individual or another person, unless the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in the residence.(j) An individualized skills and socialization provider or the program provider is not responsible for the cost, if any, of an individual to participate in an off-site activity. Source Note: The provisions of this §260.503 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.503 Description of Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211646 03/12/2026 (a) A program provider must make both on-site individualized skills and socialization and off-site individualized skills and socialization available to an individual.(b) An individualized skills and socialization provider must provide on-site individualized skills and socialization and off-site individualized skills and socialization in accordance with an individual's IPC and IPP. Source Note: The provisions of this §260.505 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.505 Provision of Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211647 03/12/2026 (a) The ratio of service providers of individualized skills and socialization to persons receiving services:(1) on-site must be no higher than one service provider of individualized skills and socialization to three individuals and other persons receiving individualized skills and socialization or a similar service (1:3); and(2) off-site must be no higher than one service provider of individualized skills and socialization to two individuals and other persons receiving individualized skills and socialization or a similar service (1:2).(b) A ratio described in subsection (a) of this section may include persons enrolled in other waiver programs receiving individualized skills and socialization or persons receiving a similar service; however, the ratio must be the ratio required by subsection (a) of this section.(c) A service provider of individualized skills and socialization assigned to the individuals represented in a ratio described in subsection (a) of this section must provide services only to the individuals and other persons represented in the ratio. Source Note: The provisions of this §260.507 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.507 Staffing Ratios https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211648 03/12/2026 Notwithstanding other rules governing the DBMD Program, effective March 1, 2023, day habilitation is not a service in the DBMD Program. Source Note: The provisions of this §260.509 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.509 Discontinuation of Day Habilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211649 03/12/2026 A program provider must ensure that:(1) a case manager includes individualized skills and socialization on an individual's enrollment IPC in accordance with the rules governing the DBMD Program;(2) a case manager renews or revises an IPC to include individualized skills and socialization in accordance with the rules governing the DBMD Program;(3) a case manager ensures that:(A) an enrollment IPC or renewal IPC with an effective date on or after March 1, 2023 does not include day habilitation; and(B) an IPC that is revised during the period of March 1, 2023 through February 29, 2024 includes only the amount of day habilitation that the program provider provided to the individual before March 1, 2023; and(4) if an individual or the individual's LAR wants the individual to receive on-site or off-site individualized skills and socialization but not both, the case manager documents the decision in the individual's IPP. Source Note: The provisions of this §260.511 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.511 Including Individualized Skills and Socialization on an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211650 03/12/2026 (a) A service provider of individualized skills and socialization must meet the staff qualifications described in §559.227(a)(2) of this title (relating to Program Requirements).(b) A service provider of individualized skills and socialization who provides transportation must meet the staff qualifications described in §559.227(a)(3) of this title.(c) A service provider of individualized skills and socialization must complete the following training in accordance with rules governing the DBMD Program:(1) general orientation training;(2) DBMD Program Service Provider Training;(3) training on needs of an individual to whom the service provider is providing individualized skills and socialization; and(4) training on delegated tasks, if the service provider is performing delegated tasks for an individual receiving individualized skills and socialization.(d) A service provider of individualized skills and socialization must meet:(1) the initial training requirements described in §559.227(k)(1)(B)(i), (ii), and (v) of this title; and(2) the ongoing training requirements described in §559.227(k)(2)(A)(i), (ii), and (iv) of this title. Source Note: The provisions of this §260.513 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.513 Service Provider Qualifications and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211651 03/12/2026 If a program provider contracts with an individualized skills and socialization provider to provide individualized skills and socialization to an individual, the program provider must:(1) comply with 40 TAC §49.308 (relating to Subcontractors);(2) ensure the individualized skills and socialization provider complies with:(A) §260.503(c) - (e) of this subchapter (relating to Description of Individualized Skills and Socialization); and(B) §260.505 of this subchapter (relating to Provision of Individualized Skills and Socialization); and(3) ensure that a service provider of individualized skills and socialization meets the training requirements described in §260.513(c) of this subchapter (relating to Service Provider Qualifications and Training). Source Note: The provisions of this §260.515 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.515 Contracting to Provide Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211652 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211652 03/12/2026 (a) HHSC pays a program provider for on-site individualized skills and socialization and off-site individualized skills and socialization in accordance with the reimbursement rates.(b) If an individual's DBMD Program services and CFC services are suspended or terminated, a program provider must not submit a claim for on-site individualized skills and socialization or off-site individualized skills and socialization provided during the period of the individual's suspension or after the termination, except the program provider may submit a claim for the first calendar day of the individual's suspension or termination.(c) A program provider must not bill for and HHSC does not pay a program provider for on-site individualized skills and socialization or off-site individualized skills and socialization, or recoups any payments made to the program provider for on-site individualized skills and socialization or off-site individualized skills and socialization:(1) if individualized skills and socialization is not provided in accordance with this subchapter and Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements);(2) if the individual receiving individualized skills and socialization is, at the time individualized skills and socialization was provided, ineligible for the DBMD Program;(3) if individualized skills and socialization is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;(4) if individualized skills and socialization is provided during a period of time for which the individual did not have an LOC determination;(5) if individualized skills and socialization is not provided in accordance with the individual's IPP;(6) if the program provider did not comply with 40 TAC §49.305 (relating to Records);(7) if the claim for the service did not meet the requirements in 40 TAC §49.311 (relating to Claims Payment);(8) if individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide individualized skills and socialization as described in §260.513 of this subchapter (relating to Service Provider Qualifications and Training) and §559.227 of this title (relating to Program Requirements);(9) if the program provider did not comply with the DBMD Program Manual;(10) if HHSC determines that individualized skills and socialization would have been paid for by a source other than the DBMD Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for individualized skills and socialization;(11) if individualized skills and socialization was not provided; or(12) if individualized skills and socialization is provided during a period of time that the individual produced marketable goods and was paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act.(d) HHSC does not pay a program provider for day habilitation or recoups any payments made to the program provider for day habilitation provided on or after March 1, 2023, even if an individual's IPC includes day habilitation on or after March 1, 2023.(e) HHSC conducts contract and fiscal monitoring in accordance with rules governing the DBMD Program to determine whether a program provider is in compliance with this subchapter. Source Note: The provisions of this §260.517 adopted to be effective January 1, 2023, 47 TexReg 8681. 1 HEALTH AND HUMAN SERVICES COMMISSION 260 DEAF BLIND WITH MULTIPLE DISABILITIES (DBMD) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) SERVICES I INDIVIDUALIZED SKILLS AND SOCIALIZATION §260.517 Program Provider Reimbursement for Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201127 03/12/2026 The purpose of this subchapter is to describe:(1) policies and procedures for the Intermediate Care Facilities for the Mentally Retarded (ICF/MR) Program in Texas;(2) responsibilities of program providers in the ICF/MR Program;(3) rights and protections for persons applying for and receiving ICF/MR Program services; and(4) responsibilities of mental retardation authorities (MRAs). Source Note: The provisions of this §261.201 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING A GENERAL REQUIREMENTS §261.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201128 03/12/2026 This subchapter applies to provider applicants, program providers, and MRAs. Source Note: The provisions of this §261.202 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING A GENERAL REQUIREMENTS §261.202 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201129 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Active treatment--Continuous, aggressive, consistent implementation of a program of habilitation, specialized and generic training, treatment, health services, and related services. Active treatment does not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous active treatment program. The program must be directed toward:(A) the acquisition or maintenance of the behaviors necessary for the individual to function with as much self-determination and independence as possible; and(B) the prevention or deceleration of regression or loss of current optimal functional status.(2) Actively involved--Significant, ongoing, and supportive involvement with an individual by a person, as determined by the individual's IDT, based on the person's:(A) interactions with the individual;(B) availability to the individual for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the individual's needs, preferences, values, and beliefs.(3) Adult--A person who is 18 years of age or older.(4) Affiliate--An employee or independent contractor of a provider applicant or a person with a significant financial interest in a provider applicant, including the following:(A) if the provider applicant is a corporation, then each officer, director, stockholder with an ownership of at least 5 percent, subsidiary, and parent company;(B) if the provider applicant is a limited liability company, then each officer, member, subsidiary, and parent company;(C) if the provider applicant is an individual, then the individual's spouse, each partnership and each partner thereof of which the individual is a partner and each corporation in which the individual is an officer, director, or stockholder with an ownership of at least 5 percent;(D) if the provider applicant is a partnership, then each partner and parent company; or(E) if the provider applicant is a group of co-owners under any other business arrangement, then each owner, officer, director, or the equivalent thereof under the specific business arrangement, and each parent company.(5) Applicant--A person seeking enrollment in the ICF/IID Program or seeking admission to a facility.(6) Applied income--The portion of an individual's cost of care that the individual is responsible for paying. The amount of an individual's applied income is determined by the policies and procedures authorized by the Health and Human Services Commission and depends on the individual's earned and unearned income.(7) Assignment--The transfer of rights, interests, and obligations of the program provider agreement from the program provider to another person.(8) Aversive stimulus--A stimulus that is unpleasant, noxious, startling, or painful; is applied after an inappropriate behavior; and is intended to suppress the inappropriate behavior.(9) Behavior intervention plan--A written plan prescribing the systematic application of behavioral techniques regarding an individual that, at a minimum, contains:(A) reliable and representative baseline data regarding the targeted behavior;(B) a specific objective to decrease or eliminate the targeted behavior;(C) a functional analysis of the events which contribute to or maintain the targeted behavior;(D) detailed procedures for implementing the plan;(E) ongoing, written quantitative data of the targeted behavior;(F) written descriptions of incidents of the targeted behavior including the individual's actions and staff interventions;(G) methods for evaluating plan effectiveness;(H) procedures for making necessary plan revisions at least annually; and(I) a fading process for one-to-one supervision, if the individual is assigned an LON 9.(10) Budgeted amount--The amount of cash that may be disbursed to an individual at regular intervals; for example, weekly, monthly, for discretionary spending without obtaining a sales receipt for the expenditure.(11) Campus-based facility--A facility that is located on the grounds of a state supported living center or the ICF/IID Program component of Rio Grande State Center.(12) CARE--DADS Client Assignment and Registration System, a database with demographic and other data about an individual who is receiving services and supports or on whose behalf services and supports have been requested.(13) Certified capacity--The maximum number of individuals who may reside in a facility, as set forth in the facility's provider agreement.(14) CFR (Code of Federal Regulations)--The compilation of federal agency regulations.(15) Community Center--A community center established under the THSC, Chapter 534, Subchapter A.(16) Community program provider--A program provider acting on behalf of a facility that is not a campus-based facility.(17) CRCG (Community Resource Coordination Group)--A local interagency group composed of public and private agencies that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, available on the Health and Human Services Commission website at www.hhsc.state.tx.us/crcg/crcg.htm.(18) DADS--The Department of Aging and Disability Services.(19) Day--Calendar day, unless otherwise specified.(20) Department--Department of Aging and Disability Services.(21) Discharge--The absence, for a full day or more, of an individual from the facility in which the individual resides, if such absence is not during a therapeutic, extended, or special leave, as described in §9.226 of this subchapter (relating to Leaves).(22) DPoC (directed plan of correction)--A plan developed by DADS sanction team that requires a program provider to take specified actions within specified time frames to correct the program provider's failure to meet one or more federal standards of participation (SoPs) or conditions of participation (CoPs) or lack of compliance with one or more state rules.(23) Effortful task--A task directed by staff that requires physical effort by an individual performed after an inappropriate behavior, including required exercise, negative practice, and restitutional overcorrection.(24) Emergency situation--An unexpected situation involving an individual's health, safety, or welfare, of which a person of ordinary prudence would determine that the LAR should be informed, such as:(A) an individual needing emergency medical care;(B) an individual being removed from his residence by law enforcement;(C) an individual leaving his residence without notifying staff and not being located; and(D) an individual being moved from his residence to protect the individual (for example, because of a hurricane, fire, or flood).(25) Excluded--Temporarily or permanently prohibited by a state or federal authority from participating as a provider in a federal health care program, as defined in 42 USC §1302a-7b(f).(26) Exclusionary time-out--A procedure by which an individual is, after an inappropriate behavior, placed alone in an enclosed area in which positive reinforcement is not available and from which egress is physically prevented by staff until appropriate behavior is exhibited.(27) Facility--An intermediate care facility for individuals with an intellectual disability or related conditions.(28) Family-based alternative--A family setting in which the family provider or providers are specially trained to provide support and in-home care for children with disabilities or children who are medically fragile.(29) Full day--A 24-hour period extending from midnight to midnight.(30) Highly restrictive procedure--The application of an aversive stimulus, exclusionary time-out, physical restraint, a requirement to engage in an effortful task, or other technique with a similar degree of restriction or intrusion to manage an individual's inappropriate behavior.(31) Hospice--An entity that is primarily engaged in providing care to terminally ill individuals and is approved by DADS to participate in the Medicaid Hospice Program in accordance with §30.30 of this title (relating to General Contracting Requirements).(32) ICAP (Inventory for Client and Agency Planning)--A validated, standardized assessment that measures the level of supervision an individual requires and, thus, the amount and intensity of services and supports an individual needs.(33) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions.(34) ICF/MR Program--ICF/IID Program.(35) ID/RC Assessment Form--A form used by DADS for LOC determination and LON assignment.(36) IDT (interdisciplinary team)--A group of people assembled by the program provider who possess the knowledge, skills, and expertise to assess an individual's needs and make recommendations for the individual's IPP. The group includes the individual, LAR, intellectual disability professionals and paraprofessionals and, with approval from the individual or LAR, other concerned persons.(37) Individual--A person enrolled in the ICF/IID Program.(38) Intellectual disability--Significant sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.(39) IPP (individual program plan)--A plan developed by an individual's IDT that identifies the individual's training, treatment, and habilitation needs and describes services to meet those needs.(40) IQ (intelligence quotient)--A score reflecting the level of an individual's intelligence as determined by the administration of a standardized intelligence test.(41) LAR (legally authorized representative)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and may include a parent, guardian, managing conservator of a minor individual, a guardian of an adult individual, or legal representative of a deceased individual.(42) LOC (level of care)--A determination given by DADS to an individual as part of the eligibility process based on data submitted on the ID/RC Assessment Form.(43) Local authority--An entity to which the Health and Human Services Commission's authority and responsibility described in TSHC §531.002(11) has been delegated.(44) LON (level of need)--An assignment given by DADS to an individual upon which reimbursement for ICF/IID Program services is based. The LON assignment is derived from the service level score obtained from the administration of the ICAP to the individual and from selected items on the ID/RC Assessment Form.(45) Long Term Care Plan--The plan required by THSC, §533.062, which is developed by DADS and specifies, in part, the capacity of the ICF/IID Program in Texas.(46) Major dental treatment--A dental treatment, intervention, or diagnostic procedure that:(A) has a significant recovery period;(B) presents a significant risk;(C) employs a general anesthetic; or(D) in the opinion of the individual's physician, involves a significant invasion of bodily integrity that requires an incision or the extraction of bodily fluids that produces substantial pain, discomfort, or debilitation.(47) Major medical treatment--A medical, surgical, or diagnostic procedure or intervention that:(A) has a significant recovery period;(B) presents a significant risk;(C) employs a general anesthetic; or(D) in the opinion of the individual's physician, involves a significant invasion of bodily integrity that requires an incision or the extraction of bodily fluids that produces substantial pain, discomfort, or debilitation.(48) Medical necessity--The need for a treatment decision that is essential to avoid adversely affecting an individual's mental or physical health or the quality of care rendered.(49) Mental retardation--Intellectual disability.(50) MRA (mental retardation authority)--A local authority.(51) MR/RC--ID/RC Assessment Form.(52) Natural support network--Those persons, including family members, church members, neighbors, and friends, who assist and sustain an individual with supports that occur naturally within the individual's environment and that are not reimbursed or purposely developed by a person or system.(53) Negative practice--A procedure in which an individual is required, after an inappropriate behavior, to repeatedly engage in an activity that is similar to the inappropriate behavior.(54) Non-state operated facility--A facility for which the program provider is an entity other than DADS, such as a community center or private organization.(55) Occupational therapist (OT)--A person licensed by the Texas Board of Occupational Therapy Examiners to practice occupational therapy, as defined in Texas Occupations Code §454.002(4).(56) PDP (person-directed plan)--A plan of services and supports developed under the direction of an individual or LAR with the support of a local authority or program provider staff and other people chosen by the individual or LAR.(57) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship.(58) Permanency Planning Review Screen--A screen in CARE that, when completed by a local authority, identifies community supports needed to achieve an individual's permanency planning outcomes and provides information necessary for approval of the individual's initial and continued residence in a facility.(59) Personal funds--The funds that belong to an individual, including earned income, social security benefits, gifts, and inheritances.(60) Personal hold--(A) A manual method, except for physical guidance or prompting of brief duration, used to restrict:(i) free movement or normal functioning of all or a portion of an individual's body; or(ii) normal access by an individual to a portion of the individual's body.(B) Physical guidance or prompting of brief duration becomes a physical restraint if the individual resists the guidance or prompting.(61) Petty cash fund--Personal funds managed by a program provider that are maintained for individuals' cash expenditures.(62) Physical restraint--A manual method, or a physical or mechanical device, material, or equipment attached or adjacent to an individual's body that the individual cannot remove easily, that restricts freedom of movement or normal access to an individual's body. This term includes a personal hold.(63) Physical therapist (PT)--A person licensed by the Texas Board of Physical Therapy Examiners to practice physical therapy, as defined in Texas Occupations Code §453.001(4).(64) Pooled account--A trust fund account containing the personal funds of more than one individual.(65) Professional--A person who is licensed or certified by the State of Texas in a health or human services occupation or who meets DADS criteria to be a case manager, service coordinator, qualified intellectual disability professional, or certified psychologist as described in §5.161 of this title (relating to TDMHMR-Certified Psychologist).(66) Program provider--An entity with whom DADS has a provider agreement.(67) Provider agreement--A written agreement between DADS and a program provider that obligates the program provider to deliver ICF/IID Program services.(68) Provider applicant--An entity seeking to participate as a program provider.(69) Psychoactive medication--Any medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and that is used to exercise an effect upon the central nervous system for the purposes of influencing and modifying behavior, cognition, or affective state.(70) Qualified intellectual disability professional (QIDP)--A person with at least a bachelor's degree who has at least one year of experience working with persons with an intellectual disability or related conditions.(71) Qualified rehabilitation professional (QRP)--A person who holds one or more of the following certifications in good standing:(A) certification as an assistive technology professional or a rehabilitation engineering technologist issued by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA);(B) certification as a seating and mobility specialist issued by RESNA; or(C) certification as a rehabilitation technology supplier issued by the National Registry of Rehabilitation Technology Suppliers.(72) Related condition--Consistent with 42 CFR §435.1010, a severe and chronic disability that:(A) is attributed to:(i) cerebral palsy or epilepsy; or(ii) any other condition, other than mental illness, found to be closely related to intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with intellectual disability, and requires treatment or services similar to those required for individuals with intellectual disability;(B) is manifested before the individual reaches 22 years of age;(C) is likely to continue indefinitely; and(D) results in substantial functional limitation in at least three of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(73) Required exercise--A procedure in which an individual, after an inappropriate behavior, performs or is guided by staff to perform a series of physical movements that are incompatible with the inappropriate behavior.(74) Restitutional overcorrection--A procedure in which an individual is required to correct the consequences of an inappropriate behavior by performing a task that improves the individual's environment.(75) Sales receipt--A written statement issued by the seller that includes:(A) the date it was created; and(B) the cost of the item or service.(76) Separate account--A trust fund account containing the personal funds of only one individual.(77) Specially constituted committee--A committee designated by the program provider in accordance with 42 CFR §483.440(f)(3) that consists of staff, LARs, individuals (as appropriate), qualified persons who have experience or training in contemporary practices to change an individual's inappropriate behavior, and persons with no ownership or controlling interest in the facility. The committee is responsible, in part, for reviewing, approving, and monitoring individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to individuals' safety and rights.(78) SSI--Supplemental Security Income.(79) State-operated facility--A facility for which DADS is the program provider.(80) TAC (Texas Administrative Code)--A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C.(81) TDHS--Formerly, this term referred to the Texas Department of Human Services; it now refers to DADS, except in the context of Medicaid eligibility it refers to the Health and Human Services Commission.(82) THSC (Texas Health and Safety Code)--Texas statutes relating to health and safety.(83) Third Party--An individual, entity, or program other than DADS or the program provider, that is or may be liable to pay all or part of the expenditures for ICF/IID Program services, including:(A) a commercial insurance company offering health or casualty insurance to individuals or groups (including both experience-rated insurance contracts and indemnity contracts);(B) a profit or nonprofit prepaid plan offering either medical services or full or partial payment for services; and(C) an organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans.(84) Trust fund account--An account at a financial institution in the program provider's control that contains personal funds.(85) Unclaimed personal funds--Personal funds managed by the program provider that have not been transferred to the individual or LAR within 30 days after the individual's discharge.(86) Unidentified personal funds--Personal funds managed by the program provider for which the program provider cannot identify ownership.(87) USC (United States Code)--A compilation of statutes enacted by the United States Congress.(88) Vendor hold--Temporary suspension of ICF/IID payments from DADS to a program provider.(89) Wheeled mobility system--An item of durable medical equipment that is a customized, powered, or manual mobility device or a feature or component of the device, including the following:(A) seated positioning components;(B) powered or manual seating options;(C) specialty driving controls;(D) multiple adjustment frame;(E) nonstandard performance options; and(F) other complex or specialized components.(90) Working day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b). Source Note: The provisions of this §261.203 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective September 1, 2001, 26 TexReg 5384; amended to be effective March 31, 2002, 27 TexReg 2475; amended to be effective January 5, 2003, 27 TexReg 12251; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6795; amended to be effective July1, 2007, 32 TexReg 3856; amended to be effective July 1, 2012, 37 TexReg 4606; amended tobe effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING A GENERAL REQUIREMENTS §261.203 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201131 03/12/2026 (a) The department will accept an application for enrollment: (1) from a provider applicant, if the department determines that new or existing ICF/MR Program beds authorized in the Long Term Care Plan for People with Mental Retardation and Related Conditions are available for allocation to a program provider for a new facility not to exceed a capacity of six; (2) from an assignee, if the department receives notice that a provider agreement is being assigned; or (3) from a provider applicant, if the provider applicant provides residential services funded with general revenue that have been authorized by the department to be refinanced as ICF/MR Program services. (b) The department will publish a notice in the Texas Register , an official publication of the Texas Office of the Secretary of State (http://www.sos.state.tx.us/texreg/index.html), if it is accepting applications for enrollment in accordance with subsection (a)(1) of this section. (c) A provider applicant must request an application for enrollment in accordance with the published notice and must submit the application according to the notice and the department's application instructions. (d) A provider applicant must complete all portions of the application for enrollment and provide information according to the department's application instructions, including but not limited to: (1) providing an operational or organizational plan that describes in detail how the provider applicant will ensure sufficient staff resources are available to provide all services required by the ICF/MR Program; and (2) providing the resume or curriculum vita of the provider applicant's employee or contractor who will manage and oversee the provision of ICF/MR Program services, which: (A) demonstrates that the employee or contractor has a minimum of three years verifiable work experience in planning and providing direct services to people with mental retardation or other developmental disabilities; and (B) is accompanied by letter(s) of reference verifying the work experience in subparagraph (A) of this paragraph. (e) The department may reject an application for enrollment for good cause, including but not limited to: (1) the application is incomplete in any aspect; (2) the application is not submitted in accordance with the department's application instructions or published notice; (3) the application was submitted under the circumstances described in subsection (a)(1) of this section and requests a capacity exceeding six; (4) the application contains false information; (5) the application does not contain original signatures and dates; (6) the department has terminated a contract with the provider applicant or its affiliate during the three years prior to the application date; (7) the provider applicant or its affiliate has been excluded or debarred; (8) another state or federal agency has terminated a contract, licensure, or certification of the provider applicant or its affiliate during the three years prior to the application date; (9) the provider applicant or its affiliate has an outstanding Medicaid program audit exception or other unresolved financial liability owed to the State of Texas; (10) the provider applicant or its affiliate is ineligible to enroll as a Medicaid provider for reasons relating to criminal history records as set forth in department rules; or (11) the provider applicant or its affiliate terminated a provider agreement in a federal health care program, as defined in 42 USC, §1302a-7b(f), while an adverse action or sanction was in effect. (f) The department will review an application for enrollment received by the department and provide written notice to the provider applicant stating whether the application was approved or rejected. (g) The department will not enter into a provider agreement with a provider applicant whose application for enrollment is rejected. (h) If a provider applicant's application for enrollment is approved: (1) the department will notify the state survey agency of the application approval; and (2) the provider applicant must contact the state survey agency to initiate licensure and certification action. Source Note: The provisions of this §261.206 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING B PROVIDER ENROLLMENT §261.206 Application Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201130 03/12/2026 (a) To obtain a provider agreement under §9.208 of this division (relating to Provider Agreement), a provider applicant whose application for enrollment is approved must receive licensure under THSC, Chapter 252, if applicable, and certification as an ICF/IID by DADS within 270 days from the date DADS approves the application, except as provided in subsection (b) of this section.(b) DADS may, for good cause, grant an extension of the 270 day period described in subsection (a) of this section for a period of time to be determined by DADS if a provider applicant submits to DADS a written request for an extension, including supporting documentation, prior to the expiration of the 270 day period. For purposes of this subsection, good cause includes, but is not limited to:(1) construction of the facility is delayed for causes beyond the provider applicant's control, such as a natural disaster;(2) DADS is unable to make an on-site visit to the facility within the 270 day period, through no fault of the provider applicant; or(3) construction of the facility is delayed because of litigation regarding the construction or operation of the facility.(c) DADS does not enter into a provider agreement with a provider applicant who does not obtain licensure and certification in accordance with this section. Source Note: The provisions of this §261.207 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING B PROVIDER ENROLLMENT §261.207 Certification and Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201132 03/12/2026 (a) DADS enters into a provider agreement only with a provider applicant that has received licensure under THSC, Chapter 252, if applicable, and certification by DADS in accordance with §9.207 of this division (relating to Certification and Licensure).(b) The effective date of a provider agreement is the effective date of certification by DADS.(c) A provider agreement remains in effect until it is terminated. Source Note: The provisions of this §261.208 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING B PROVIDER ENROLLMENT §261.208 Provider Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201134 03/12/2026 A program provider must comply with:(1) applicable state laws and rules, including but not limited to:(A) this subchapter;(B) Chapter 409, Subchapter A of this title (relating to General Reimbursement Methodology for all Medical Assistance Programs);(C) Chapter 409, Subchapter B of this title (relating to Adverse Actions);(D) Chapter 409, Subchapter C of this title (relating to Fraud and Abuse and Recovery of Benefits);(E) Chapter 419, Subchapter G of this title (relating to Medicaid Fair Hearings);(F) 1 TAC Chapter 355, Subchapter D (relating to Reimbursement Methodology); and(G) 1 TAC §§355.701-355.709; and(2) applicable federal laws and regulations, including but not limited to:(A) 42 CFR Parts 440, 441, 442, 455, 456, and 483; and(B) 45 CFR Parts 46, 80, 84, 90, and 91. Source Note: The provisions of this §261.211 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.211 Compliance with State and Federal Laws https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201133 03/12/2026 Program providers that, in accordance with the THSC, §252.003, are exempt from the license required by THSC, §252.031, must comply with the following subchapters of 40 TAC Chapter 90 (relating to Intermediate Care Facilities for Persons with Mental Retardation or Related Conditions):(1) Subchapter C (relating to Standards for Licensure);(2) Subchapter D (relating to General Requirements for Facility Construction); and(3) Subchapter F (relating to Inspections, Surveys, and Visits). Source Note: The provisions of this §261.212 adopted to be effective July 26, 2001, 26 TexReg 5402; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.212 Non-licensed Providers Meeting Licensure Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201135 03/12/2026 (a) A program provider must maintain a copy of the following records for each individual:(1) the birth certificate;(2) relevant legal documents including documents relating to guardianship, marital status, custody of a minor, or immigration status, if any;(3) the Social Security card;(4) a current photograph;(5) immunization records;(6) height and weight records;(7) seizure records, if any;(8) the most recent physician's orders, including treatment and diet orders;(9) the most recent nursing care plan, if any;(10) the most recent laboratory test results, if any;(11) any significant medical reports, including reports regarding the most recent chest X-ray, electrocardiogram (EKG), and electroencephalogram (EEG), if any;(12) the most recent medical examination results and a summary of the medical history, including all major surgeries, significant acute illnesses, and injuries requiring hospitalization or a long recovery period;(13) a summary of the medication history for the last five years or from the time services were initiated, whichever is most recent, including start and stop dates, dose ranges, effectiveness and reactions of all long-term medications and antibiotics;(14) the most recent dental examination results and a summary of the dental history, including all oral surgeries, extractions, restorations, appliances, and types of anesthesia required for dental work;(15) the social history and the most recent psychological examination results;(16) Medicaid and, if applicable, Medicare or third-party insurance cards;(17) records necessary to disclose the nature and extent of services provided to the individual; and(18) any other records required by this subchapter or the provider agreement.(b) A program provider must retain the records described in subsection (a) of this section until the latest of the following occurs:(1) five years elapse from the date the records were created;(2) any audit exception or litigation involving the records is resolved; or(3) the individual becomes 21 years of age.(c) A program provider must, upon request, make available to the department or its designee the records described in subsection (a) of this section. Source Note: The provisions of this §261.213 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.213 Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201136 03/12/2026 (a) The certified capacity of a facility will be established by the department. (b) A program provider may request that the department decrease the certified capacity of its facility. (1) The class of a non-state operated facility that has its certified capacity decreased will be determined according to 1 TAC §355.456(b) (relating to Rate Setting Methodology) for reimbursement purposes. (2) The department will amend the Long Term Care Plan for People with Mental Retardation and Related Conditions to reflect the decrease in certified capacity of a facility or will determine that beds authorized by the Long Term Care Plan for People with Mental Retardation and Related Conditions are available for allocation. (c) To ensure appropriate utilization of state schools and state centers, the department may increase the certified capacity of a state school and state center, if the total capacity of all state schools and state centers does not exceed the authorized bed capacity for "campus facilities" in the Long Term Care Plan for People with Mental Retardation and Related Conditions . (d) If the department determines that redistributing the certified capacity of one or more existing facilities, other than state schools or state centers, into two or more new, smaller facilities may improve utilization of ICF/MR resources, the department may publish notice in the Texas Register that it is accepting requests from program providers to redistribute the certified capacity of their facilities. A program provider may submit a request to redistribute capacity. Such a request must be submitted according to the published notice and the department's instructions. After reviewing the submitted requests, the department may negotiate a plan and enter into an agreement with a program provider to redistribute the program provider's certified capacity. Source Note: The provisions of this §261.214 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.214 Certified Capacity of a Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201137 03/12/2026 (a) Prior to relocating its facility, a program provider must receive department approval of a facility relocation application obtained from the department, if certification of the facility at a new physical address will be sought.(b) To request the approval required by subsection (a) of this section, a program provider must, prior to the facility relocation, complete and submit to the department's Office of Medicaid Administration, a facility relocation application.(c) After reviewing an application, the department will provide written notice to the program provider of its approval or denial. An incomplete application will not be approved.(d) If the department approves the application for facility relocation, the department will notify the state survey agency of the facility relocation and request that the state survey agency initiate licensure and certification action of the relocated facility.(e) Prior to the relocation, the program provider must notify each individual residing in the facility and LAR in writing of the date of facility relocation and the address of the relocated facility or explain to the individual or LAR why shorter notification was necessary.(f) At the time of relocation, the program provider must notify the MRA in whose local service area the facility has relocated of the name and address of the relocated facility in writing.(g) If the relocated facility is licensed in accordance with state law and determined by the state survey agency to meet certification requirements, the department will initiate an amendment to the provider agreement to reflect the address of the relocated facility. The program provider must execute and submit the amendment to the department. Source Note: The provisions of this §261.215 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.215 Relocation of Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201138 03/12/2026 (a) A program provider must notify the department's Office of Medicaid Administration in writing at least 30 days prior to the date of a proposed assignment. The notice must include:(1) the legal name and federal tax identification number of the proposed assignee;(2) the proposed date of the assignment, which must be on the first day of a month;(3) the provider vendor number of the assignor;(4) an application for enrollment obtained from the department and completed by the assignee as required for provider applicants by §419.206(d) of this title (relating to Application Process); and(5) a copy of the assignment agreement, which must include a statement that the assignee:(A) must keep, perform, and fulfill all of the terms, conditions, and obligations that must be performed by the assignor under the provider agreement;(B) is subject to all pending conditions that exist against the assignor including, but not limited to, any plan of correction, audit exception, vendor hold, or proposed contract termination; and(C) is liable to the department for any liabilities or obligations that arise from any act, event, or condition that occurred or existed prior to the effective date of the assignment and that is identified in any survey, review, or audit conducted by the department.(b) The department may establish the date of assignment if:(1) notice of a proposed assignment is not provided to the department at least 30 days prior to the proposed date of assignment; or(2) the proposed date of assignment is not on the first day of a month.(c) Upon receipt of notice provided in accordance with subsection (a) of this section, the department will:(1) impose a vendor hold on payments due to the assignor under the provider agreement until an audit conducted in accordance with §419.269 of this title (relating to Audits) is complete; and(2) review the application for enrollment.(d) After the department reviews the application for enrollment, the department will provide written notice to the assignee and assignor stating whether the application is approved or rejected.(e) The department may reject an application for enrollment for the same reasons a provider applicant's application for enrollment may be rejected as set forth in §419.206(e) of this title (relating to Application Process). If the department rejects the application for enrollment, the assignor may withdraw the proposed assignment. If the assignment is not withdrawn, the department may terminate the assigned provider agreement.(f) If the department approves the proposed assignee's application for enrollment, the department will notify the state survey agency of the assignment and request that the state survey agency initiate licensure and certification action.(g) The assignor must, prior to the effective date of the assignment, give written notice to each individual residing in the facility or LAR of the proposed assignment and the proposed effective date of the assignment.(h) If the facility is licensed in accordance with state law and determined by the state survey agency to meet certification requirements on or before the 90th day after the effective date of the assignment, the department will pay the assignee for services provided on and after the effective date of the assignment, except the department will not pay the assignee for any period of time during the 90-day period that the facility was determined by the state survey agency to not meet certification requirements.(i) If the facility is not licensed in accordance with state law and determined by the state survey agency to meet certification requirements on or before the 90th day after the effective date of the assignment, the department will terminate the provider agreement effective on the 91st day. A survey completed more than 90 days after the effective date of the assignment will not be used to determine if the facility met the licensure and certification requirements within the 90-day period.(j) During the 90-day period after the effective date of the assignment, the provider agreement is subject to sanctions, including termination, in accordance with Division 7 of this subchapter (relating to Provider Agreement Sanctions).(k) Upon the effective date of the assignment, the assignee:(1) must keep, perform, and fulfill all of the terms, conditions and obligations that must be performed by the assignor under the provider agreement;(2) is subject to all pending conditions which exist against the assignor, including but not limited to, any plan of correction, audit exception, vendor hold, or proposed contract termination; and(3) is liable to the department for any liabilities or obligations that arise from any act, event, or condition that occurred or existed prior to the effective date of the assignment and that is identified in any survey, review, or audit conducted by the department.(l) The assignor must complete and submit billing claims to the department in accordance with §419.219 of this title (relating to Provider Reimbursement) for services that were provided prior to the effective date of the assignment. Source Note: The provisions of this §261.217 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.217 Assignment of Provider Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201139 03/12/2026 (a) In this section, the terms "close" and "closure" refer to a facility ceasing to operate. The terms do not include temporarily relocating individuals who reside in a facility.(b) Except as provided in subsection (c) of this section, if a program provider intends to voluntarily close a facility, the program provider must submit to DADS, at least 60 days before the facility closes, written notice of the program provider's intent to close the facility, which includes:(1) the anticipated date of closure; and(2) a description of how the facility will discharge and relocate an individual who resides in the closing facility to a new residence.(c) If, for reasons beyond the program provider's control, the program provider cannot provide the notice required by subsection (b) of this section at least 60 days before the program provider anticipates closing the facility, the program provider must state in the notice the reason why a shorter time period is necessary.(d) The program provider must comply with §9.227 of this subchapter (relating to Discharge from a Facility).(e) If a facility is closing, DADS imposes a vendor hold on payments due to the program provider under the provider agreement until an audit conducted in accordance with §9.269 of this subchapter (relating to Audits) is complete.(f) A program provider that closes a facility may request that DADS suspend some or all of the facility's certified capacity for up to one year after the facility closes.(g) To request that a facility's certified capacity be suspended:(1) the facility's certified capacity must be eight or less;(2) the facility must not be the subject of any proposed or pending enforcement action; and(3) the program provider must:(A) voluntarily close the facility; and(B) submit a letter to DADS requesting suspension of the facility's certified capacity.(h) A letter submitted in accordance with subsection (g)(3)(B) of this section must include:(1) the legal name and address of the program provider;(2) the closing facility's name and address;(3) the facility's identification number;(4) the facility's contract number;(5) the facility's license number and expiration date, if the facility is licensed;(6) the certified capacity of the facility;(7) the certified capacity for which the program provider is requesting the suspension;(8) the anticipated closure date of the facility;(9) justification for the suspension of certified capacity; and(10) a statement regarding the possible use of the certified capacity in the future.(i) Within 30 days after DADS receives a program provider's letter, as described in subsection (g)(3)(B) of this section, DADS notifies the program provider in writing whether DADS has approved or denied the program provider's request to suspend capacity.(j) If DADS approves a request to suspend capacity, the notification from DADS states:(1) the period of time the capacity is suspended, which must not exceed one year;(2) the effective date of the suspension;(3) the certified capacity being suspended; and(4) the capacity available, which must not exceed six per facility.(k) After DADS approves a request to suspend capacity, DADS does not extend the period of time for which capacity is suspended.(l) A program provider may not transfer a facility's suspended capacity to another entity.(m) DADS may rescind its approval of a request to suspend certified capacity. If DADS rescinds its approval, the suspended capacity reverts to the control of DADS.(n) A program provider does not receive an administrative hearing to challenge DADS denial of a request to suspend capacity or DADS rescission of its approval to suspend capacity.(o) To activate a facility's suspended certified capacity, the program provider must submit an application for enrollment in the ICF/IID Program in accordance with Division 2 of this subchapter (relating to Provider Enrollment) before the suspension period ends. If a program provider does not submit an application for enrollment in the ICF/IID Program before the suspension period ends, the suspended capacity is not available to the program provider and reverts to the control of DADS. If DADS rejects a program provider's application for enrollment in the ICF/IID Program, the suspended capacity is not available to the program provider and reverts to the control of DADS. Source Note: The provisions of this §261.218 adopted to be effective April 17, 2016, 41 TexReg 2600; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.218 Voluntary Facility Closure and Suspension of Certified Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201140 03/12/2026 (a) The department will pay a program provider for ICF/ID Program services provided to individuals enrolled in the ICF/ID Program. Such services include:(1) room and board;(2) active treatment; and(3) medical services.(b) The department will reimburse a program provider other than a state supported living center, El Paso State Center or the Rio Grande State Center for durable medical equipment in accordance with 1 TAC §355.455 (relating to Payments to Non-State Operated Facilities) and the department's written procedures for durable medical equipment reimbursement.(c) A program provider must accept the current reimbursement rate or the rate as it may hereafter be amended, as payment in full for ICF/ID Program services provided to an individual enrolled in the ICF/ID Program, and make no additional charge to the individual, any member of the individual's family, or any other source for any item or service including a third party payor, except as allowed by federal or state laws, rules or regulations or the Medicaid State Plan.(d) If DADS has established the probable existence of a third-party for ICF/ID Program services provided by a non-state operated facility at the time a claim is filed, DADS rejects the claim and returns it to the program provider for a determination of the amount of liability. When the amount of liability is determined, DADS pays the claim to the extent that payment allowed under the HHSC rate payment schedule exceeds the amount of the third party's payment.(e) If a claim is returned to a program provider for a determination of liability in accordance with subsection (d) of this section, the program provider must:(1) submit the claim to the identified third-party for a determination of the amount of liability;(2) keep all documentation of actions taken to determine the amount of liability by the third-party; and(3) certify to DADS the actions the program provider has taken to determine the liability of the third-party in accordance with instructions from DADS.(f) To receive payment for ICF/ID Program services, a program provider must:(1) prepare and submit a clean claim, as defined in 42 CFR §447.45(b), for such services in accordance with this subchapter and the information available from the state Medicaid claims administrator; and(2) submit such a claim within 12 months after the date of service or the date the individual's eligibility is established, whichever is later.(g) For the purposes of this section, "date of service" is defined as the last day of the month in which the service was provided.(h) If a program provider submits a claim to a third-party, the requirement to submit the claim to the state Medicaid claims administrator in accordance with subsection (f) of this section is not affected. In addition, the program provider must allow 110 days to elapse after the date the claim was submitted to the third-party before submitting the claim to the state Medicaid claims administrator.(i) The department will not pay a program provider or will recoup payments made for services provided to an individual:(1) if the individual does not meet the eligibility criteria described in §9.236 of this chapter (relating to Eligibility Criteria);(2) if enrollment of the individual is not complete, as described in §9.244(l) of this chapter (relating to Applicant Enrollment in the ICF/MR Program);(3) if the individual does not have a valid LOC determination;(4) if the program provider does not have a signed and dated ID/RC Assessment Form for the individual;(5) if the ID/RC Assessment Form electronically transmitted to the department for the individual does not contain information identical to information on the signed ID/RC Assessment Form;(6) if the individual is an inpatient of a hospital or nursing facility, is enrolled in a waiver program established under §1915(c) of the Social Security Act, or has elected to receive hospice care in accordance with §30.16 of this title (relating to Election of Hospice Care);(7) during a discharge of an individual, including the effective date of discharge as described in §9.227(b) of this chapter (relating to Discharge From a Facility);(8) except as provided in this subsection, if the program provider does not have a provider agreement with the department;(9) if the program provider does not submit a clean claim for the service in accordance with subsection (f) of this section; or(10) if DADS returns a claim to the program provider in accordance with subsection (d) of this section and the program provider:(A) does not submit the claim to the identified third party; or(B) does not submit the claim to the identified third party in time to be paid in accordance with subsection (h) of this section.(j) The department may pay a program provider for ICF/ID services up to 30 days after its provider agreement has expired or been terminated if the services were provided to individuals admitted to the facility before the effective date of the expiration or termination and reasonable efforts are being made to move the individuals from the facility. Source Note: The provisions of this §261.219 adopted to be effective September 1, 2001, 26 TexReg 5384; amended to be effective January 5, 2003, 27 TexReg 12251; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective July 1, 2012, 37 TexReg 4606; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.219 Provider Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206698 03/12/2026 (a) Based on Texas Health and Safety Code §533A.062(b-1) (relating to Plan on Long-Term Care for Persons with an Intellectual Disability), and as authorized by the Long-Term Care Plan for Individuals with Intellectual Disabilities and Related Conditions, the Texas Health and Human Services Commission (HHSC) must:(1) review the state-wide bed capacity of community intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID); and(2) develop a process to reallocate beds held in suspension by HHSC.(b) As provided in §551.14 of this title (relating to Increase in Capacity), a facility may not increase its capacity without approval from HHSC.(c) For purposes of this section only, "applicant" means a person who requests reallocated Medicaid beds in accordance with this section. An applicant may be a person:(1) who is not a program provider;(2) who is a program provider operating a licensed facility; or(3) who is a program provider operating a facility that is exempt from licensure in accordance with Texas Health and Safety Code §252.003 (relating to Exemptions).(d) Notwithstanding §261.206 of this chapter (relating to Application Process), the following provisions establish the process for HHSC Long-term Care Regulation to reallocate ICF/IID Medicaid beds.(e) If an applicant wants to request reallocated Medicaid beds, the applicant:(1) can request no more than six reallocated beds for each facility;(2) interested in obtaining reallocated beds must:(A) complete form HHSC 3642, ICF/IID Medicaid Bed Reallocation Application; and(B) email the application and all supporting documentation to: Medicaid_Bed_Allocation@hhs.texas.gov.(f) For the reallocation, HHSC calculates the number of available beds based on the numbers of surrendered or expired beds made available during the relevant state fiscal years.(g) When HHSC receives a complete application for reallocation, HHSC:(1) processes the application in the order received;(2) reviews the application to determine if the applicant meets the criteria for reallocation;(3) determines if ICF/IID beds are available for reallocation;(4) verifies the applicant is immediately ready to use the beds;(5) determines if the applicant demonstrates a need for the beds as described in subsection (g) of this section; and(6) if the applicant is a current program provider, determines whether the applicant has an acceptable regulatory compliance history with HHSC.(h) The applicant must provide documentation that demonstrates the need for the requested reallocated beds by providing:(1) data demonstrating occupancy rates of 80 percent or greater for nine of the 12 months preceding the application if the applicant is a current program provider;(2) documentation of a wait list, such as letters from individuals or family members attesting that they want to receive services from the applicant; or(3) any other documentation showing a need for a new ICF/IID.(i) HHSC considers the regulatory compliance history for any facility operated by the applicant. An acceptable regulatory compliance history means that, in the preceding 24 months, the applicant and controlling persons have not received any of the following sanctions:(1) termination of Medicaid or Medicare certification;(2) termination of Medicaid contract;(3) denial, suspension or revocation of a provider license;(4) cumulative Medicaid or Medicare civil monetary penalties totaling more than $5,000 in a single facility;(5) imposition of civil penalties pursuant to Texas Health and Safety Code §252.064;(6) denial of payment for new admissions;(7) a pattern of substantial or repeated licensing or Medicaid sanctions, including administrative penalties; or(8) a condition listed in §551.17 of this title (relating to Criteria for Denying a License or Renewal of a License).(j) An applicant having no compliance history to consider must meet all other criteria for reallocation.(k) If an applicant meets all criteria for reallocation and ICF/IID beds are available, HHSC approves the application, grants the number of beds requested, up to a maximum of six beds, and sends an approval letter to the applicant.(l) On approval of the reallocation, the applicant must submit an initial application in the Texas Unified Licensure Information Portal within 30 days from the date of the approval letter. The applicant must also complete the provider enrollment and Medicaid contracting process as referenced in §261.206 of this chapter and §261.208 of this chapter (relating to Provider Agreement).(m) If the applicant fails to complete and submit the initial application, the reallocation application is cancelled, and HHSC will reallocate the beds to another approved applicant or hold the beds until another provider is approved.(n) If HHSC denies the initial application or the applicant does not complete the provider enrollment or Medicaid contracting process, HHSC reallocates the beds to another approved applicant or holds the beds until approval of another applicant.(o) If HHSC revokes the reallocation of beds, HHSC notifies the person to whom the beds were allocated. The person may not appeal the revocation of capacity.(p) Once HHSC reallocates all available beds, HHSC will place any approved applicants who did not receive reallocated beds on a waiting list. As additional beds become available for reallocation, HHSC will contact approved applicants on the wait list. Source Note: The provisions of this §261.220 adopted to be effective November 8, 2021, 46 TexReg 7637. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING C PROVIDER ADMINISTRATIVE REQUIREMENTS §261.220 Medicaid Bed Reallocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201141 03/12/2026 (a) A program provider that arranges for durable medical equipment for an individual residing in the facility must ensure that:(1) the individual receives the equipment prescribed;(2) the equipment fits properly, if applicable; and(3) the individual's caregivers, as appropriate, receive instruction regarding the equipment's use.(b) To receive payment for a wheeled mobility system or for a major modification to a wheeled mobility system, a program provider must comply with paragraphs (1) - (5) of this subsection.(1) The program provider must ensure that an occupational therapist or a physical therapist:(A) conducts a clinical assessment of the individual receiving the wheeled mobility system;(B) documents in detail the medical need for a specific wheeled mobility system and all necessary accessories, as determined during the clinical assessment; and(C) signs and dates the written assessment.(2) The program provider must ensure that a QRP who is directly employed by or contracting with the program provider:(A) is present for and directly involved in the clinical assessment of the individual described in paragraph (1) of this subsection;(B) is not the same person who conducts the clinical assessment described in paragraph (1) of this subsection;(C) is present when the wheeled mobility system is delivered, directs the fitting of the system, and ensures that the system is appropriate for the individual; and(D) verifies that the wheeled mobility system functions correctly for the individual.(3) The program provider must receive prior authorization to obtain a wheeled mobility system for an individual by submitting the following documentation to DADS in accordance with instructions issued by DADS:(A) a prescription, signed and dated by a physician, that describes in detail the wheeled mobility system, including all necessary components, needed by the individual;(B) the clinical assessment described in paragraph (1) of this subsection; and(C) documentation that a QRP was present for and involved in the clinical assessment of the individual.(4) The program provider must submit to DADS, in accordance with instructions issued by DADS, documentation that a QRP conducted the activities described in paragraph (2)(C) and (D) of this subsection.(5) The program provider must maintain a copy of the documentation described in paragraphs (3) and (4) of this subsection in the individual's record. Source Note: The provisions of this §261.221 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.221 Durable Medical Equipment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201142 03/12/2026 (a) As required by Texas Government Code, §531.153, a program provider must incorporate permanency planning as an integral part of the IPP for each individual under 22 years of age residing in the facility. In order to accomplish the permanency planning goal in accordance with §9.244(f) of this subchapter (relating to Applicant Enrollment in the ICF/MR Program), the program provider must identify in the IPP, as appropriate to the individual's needs:(1) for an individual under 18 years of age, the activities, supports, and services that, when provided or facilitated by the program provider or MRA, will enable the individual to live with a family; or(2) for an individual age 18 to 22 years of age, the activities, supports, and services that, when provided or facilitated by the program provider or MRA, will result in the individual having a consistent and nurturing environment in the least restrictive setting, as defined by the individual and LAR.(b) A program provider must take the following actions to assist an MRA in conducting permanency planning for an individual under 22 years of age:(1) cooperate with the MRA responsible for conducting permanency planning by:(A) allowing access to an individual's records or providing other information in a timely manner as requested by the MRA or the Health and Human Services Commission;(B) participating in meetings to review the individual's permanency plan; and(C) identifying, in coordination with the individual's MRA, activities, supports, and services that can be provided by the family, LAR, program provider, or the MRA to prepare the individual for an alternative living arrangement;(2) encourage regular contact between the individual and LAR and, if desired by the individual and LAR, between the individual and advocates and friends in the community to continue supportive and nurturing relationships;(3) encourage participation in IDT meetings by the LAR, and, if desired by the individual or LAR, by family members, advocates, and friends in the community;(4) provide the IPP summary to the individual's MRA;(5) keep a copy of the individual's current permanency plan in the individual's record; and(6) refrain from providing the LAR with inaccurate or misleading information regarding the risks of moving the individual to another facility or community setting.(c) Within three days after the admission of an individual under 22 years of age, a program provider must notify the following entities of such admission and provide information in accordance with subsection (d) of this section:(1) the MRA in whose local service area the facility is located (see www.dads.state.tx.us/contact/mra/index.cfm for a listing of MRAs by county or city);(2) the CRCG for the county in which the LAR lives (see www.hhsc.state.tx.us/crcg/crcg.htm for a listing of CRCG chairpersons by county); and(3) the local school district for the area in which the facility is located, if the individual is at least three years of age, or the early childhood intervention (ECI) program for the county in which the facility is located, if the individual is less than three years of age (see www.dars.state.tx.us/ecis/index.shtml or call 1-800-250-2246 for a listing of ECI programs by county).(d) The program provider's notification given by the program provider in accordance with subsection (c) of this section must include the following information about an individual:(1) full name;(2) gender;(3) ethnicity;(4) birth date;(5) Social Security number;(6) LAR's name, address and county of residence;(7) date of admission to the facility;(8) name and address of the facility;(9) name and phone number of person submitting the notification;(10) those services from the following listing that will facilitate the individual's permanency planning outcomes:(A) personal and family support services provided in the individual's home;(B) residential services provided outside the individual's family or own home;(C) vocational services; and(D) training services provided outside of the individual's family or own home, including specialized professional services.(e) A program provider must:(1) request from and encourage an LAR to provide the following information for an individual during the annual IPP meeting and, for an applicant, upon admission:(A) the LAR's:(i) name;(ii) address;(iii) telephone number;(iv) driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(v) place of employment and the employer's address and telephone number;(B) the name, address, and telephone number of a relative of the individual or other person whom DADS or the program provider may contact in an emergency situation, a statement indicating the relationship between that person and the individual, and at the LAR's option:(i) that person's driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(ii) the name, address, and telephone number of that person's employer; and(C) a signed acknowledgement of responsibility stating that the LAR agrees to:(i) notify the program provider of any changes to the contact information submitted; and(ii) make reasonable efforts to participate in the individual's life and in planning activities for the individual; and(2) inform the LAR that if the information described in paragraph (1) of this subsection is not provided or is not accurate and the program provider and DADS are unable to locate the LAR as described in subsections (j) and (k) of this section, DADS refers the case to the Department of Family and Protective Services.(f) For an individual under 22 years of age, a program provider must:(1) make reasonable accommodations to promote the participation of the LAR in all planning and decision-making regarding the individual's care, including participating in:(A) the initial development and annual review of the individual's IPP;(B) decision-making regarding the individual's medical care;(C) routine IDT meetings; and(D) decision-making and other activities involving the individual's health and safety; and(2) ensure that reasonable accommodations include:(A) conducting a meeting in person or by telephone, as mutually agreed upon by the program provider and the LAR;(B) conducting a meeting at a time and, if the meeting is in person, at a location that is mutually agreed upon by the program provider and the LAR;(C) if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and(D) providing a language interpreter, if appropriate.(g) For an individual under 22 years of age, a program provider must provide written notice to the LAR of a meeting to conduct an annual review of the individual's IPP no later than 21 days before the meeting date and request a response from the LAR.(h) If an emergency situation occurs, a program provider must attempt to notify the LAR as soon as the emergency situation allows and request a response from the LAR.(i) If an LAR does not respond to a notice of the individual's IPP review meeting, a request for the LAR's consent, or an emergency situation, the program provider must attempt to locate the LAR by contacting a person identified by the LAR in the contact information described in subsection (e) of this section.(j) No later than 30 days after the date a program provider determines that it is unable to locate the LAR, the program provider must notify DADS of that determination and request that DADS initiate a search for the LAR.(k) If, within one year of the date DADS receives the notification described in subsection (j) of this section, DADS is unable to locate the LAR, DADS refers the case to:(1) the Child Protective Services Division of the Department of Family and Protective Services if the individual is under 18 years of age; or(2) the Adult Protective Services Division of the Department of Family and Protective Services if the individual is 18-22 years of age.(l) Before an individual who is under 18 years of age, or who is 18-22 years of age and for whom an LAR has been appointed, is transferred to another facility operated by the transferring program provider, the program provider must attempt to obtain consent for the transfer from the LAR unless the transfer is made because of a serious risk to the health and safety of the individual or another person.(m) A program provider must document compliance with the requirements of this section in the individual's record. Source Note: The provisions of this §261.222 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6795; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.222 Permanency Planning and LAR Participation for Individuals Under 22 Years of Age https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201143 03/12/2026 (a) At a facility other than a state school or state center, the IDT must discuss living options with the individual and LAR at least annually or upon the request of the individual or LAR. The facility must use the Community ICF/MR Living Options instrument, copies of which are available on the department's website at www.mhmr.state.tx.us/CentralOffice/Medicaid/i.html or by contacting Office of Medicaid Administration, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711. State schools and state centers must discuss living options with the individual and LAR in accordance with §412.274 of this title (relating to Consideration of Living Options for Individuals Residing in State MR Facilities).(1) During the discussion, the IDT must use information obtained from the MRA in whose local service area the facility is located to inform the individual and LAR of the different types of alternative living arrangements, including:(A) other ICF/MR Program providers--state schools and state centers and community-based ICF/MRs;(B) waiver services under §1915(c) of the Social Security Act; and(C) other community-based services and supports.(2) The IDT must document the discussion in the IDT summary and file the summary in the individual's record.(3) If the individual or LAR expresses interest in an alternative living arrangement, the program provider must send a copy of the IDT summary to the MRA in whose local service area the facility is located.(b) If an MRA receives an IDT summary, the MRA must, within 30 days after receiving the IDT summary:(1) contact the individual or LAR to discuss the alternative living arrangements in which the individual or LAR has expressed an interest; and(2) determine if the individual or LAR is interested in seeking an alternative living arrangement in another MRA's local service area and, if so, notify the MRA for that local service area.(c) The MRA for the local service area in which the individual or LAR is interested in seeking an alternative living arrangement must:(1) enter on the Client Assignment and Registration (CARE) system the individual's name and the specific type of service requested, if that service will not be available within 30 days of the date of request; and(2) assist the individual or LAR in accessing the service requested when it becomes available. Source Note: The provisions of this §261.223 adopted to be effective September 1, 2001, 26 TexReg 5384; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.223 Review of Living Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201144 03/12/2026 (a) As described in §411.61 of this title, (relating to Memorandum of Understanding Concerning Capacity Assessment for Self Care and Financial Management) a program provider must perform a capacity assessment for an individual receiving services from that program provider if the program provider:(1) believes a guardian of the person or the estate for that individual may be appropriate and a referral to the appropriate court for guardianship is anticipated; or(2) is directed to do so by a court.(b) In conducting the capacity assessment, the program provider must use the Capacity Assessment for Self Care and Financial Management. Copies of this assessment may be obtained by contacting the Office of Policy Development, Texas Department of Mental Health and Mental Retardation, 909 West 45th Street, Austin, Texas, 78756, 512/206-4516, or from the Texas Department of Human Services Long Term Care Policy web site at www.dhs.state.tx.us.(c) The capacity assessment must be performed by the professional designated by the IDT with assistance from other staff or consultants as requested by the professional or directed by the IDT. Source Note: The provisions of this §261.224 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.224 Capacity Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201145 03/12/2026 (a) In this section, "serious physical injury" is defined as in Chapter 711 of this title (relating to Investigations in DADS and DSHS Facilities and Related Programs).(b) A program provider that, in accordance with THSC §252.003, is exempt from licensure under THSC §252.031 must report the following incidents to DADS Consumer Rights and Services at 1-800-458-9858 within one hour after suspecting or learning of the incident:(1) alleged (Class I) physical abuse of an individual, as defined in Chapter 711 of this title, that caused or may have caused serious physical injury;(2) alleged (Class I) sexual abuse of an individual, as defined in Chapter 711 of this title;(3) sexual activity between individuals resulting from coercion, physical force, or taking advantage of the disability of an individual;(4) sexual activity involving an individual who is less than 18 years of age;(5) the pregnancy of an individual;(6) individual-to-individual aggression that results in serious physical injury;(7) the death of an individual; and(8) the inability to locate an individual if:(A) the individual's health or safety is at risk; or(B) the individual's location has been unknown for more than eight hours.(c) Within five working days after making a report described in subsection (b) of this section, the program provider must:(1) conduct a thorough investigation of the incident; and(2) send a written investigation report on Form 3613A, Provider Investigation Report, to DADS Consumer Rights and Services. Source Note: The provisions of this §261.225 adopted to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.225 Reporting Incidents to DADS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201146 03/12/2026 (a) An individual's absence from a facility must meet the requirements of this section to be considered a therapeutic leave, an extended therapeutic leave, or a special leave.(b) An individual is on a therapeutic leave if:(1) the individual is absent from the facility one full day or more but less than four consecutive full days;(2) the individual's IPP provides for therapeutic leave; and(3) except as provided in subsection (e) of this section, the individual has stayed in the facility overnight since being on a prior therapeutic leave or extended therapeutic leave.(c) An individual is on an extended therapeutic leave if:(1) the individual is absent from the facility four consecutive full days or more;(2) the number of days used by the individual for extended therapeutic leave does not exceed ten during the calendar year in which the leave is being taken;(3) the individual's IPP provides for the extended therapeutic leave; and(4) except as provided in subsection (e) of this section, the individual has stayed overnight in the facility since being on a prior extended therapeutic leave or therapeutic leave.(d) An individual is on a special leave if:(1) the individual is absent from the facility one full day or more;(2) the individual's IPP provides for and describes the expected benefits of the special leave;(3) during the absence, sufficient direct care staff of the program provider are with the individual to meet the requirements set forth in 42 CFR §483.430(d);(4) during the absence, the program provider incurs the usual costs associated with providing services to the individual, including but not limited to costs necessary to provide meals, lodging, and staff; and(5) during the absence, the program provider provides the active treatment specified in the individual's IPP.(e) Once per calendar year, an individual may take a therapeutic leave immediately before or after an extended therapeutic leave without staying overnight in the facility between the two leaves.(f) There is no limit on the number of therapeutic leaves or special leaves an individual may take.(g) A program provider must maintain the following written documentation for each leave taken by an individual:(1) the name of the individual;(2) the type of leave taken (i.e., therapeutic, extended therapeutic, or special); and(3) the dates and times of the individual's departure from and return to the facility.(h) Within three days after an individual's return from leave, a program provider must electronically submit a completed Client Movement form to the department. Source Note: The provisions of this §261.226 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.226 Leaves https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201147 03/12/2026 (a) When a discharge occurs, a program provider must comply with 42 CFR §483.440(b)(4) and (5) and this section.(b) The effective date of a discharge is the first full day the individual is absent from the facility.(c) Prior to the effective date of a discharge, a program provider must take the following action or document why such action is not feasible:(1) notify the individual, LAR, and the individual's MRA of the proposed discharge in writing at least 30 days before the effective date of the proposed discharge;(2) document the reason for the proposed discharge and, if the reason is that the facility can no longer meet the individual's needs, explain why;(3) counsel the individual or LAR about the proposed discharge, including the potential outcomes of the proposed discharge; and(4) develop a final summary and post-discharge plan in accordance with 42 CFR §483.440(b)(5) and provide a copy of both documents to the individual, LAR, and the individual's MRA.(d) If any actions required by subsection (c) of this section are not feasible prior to the effective date of a discharge, a program provider must, within 7 days after the effective date of the discharge, complete the required actions.(e) Within 3 days after the effective date of a discharge, a program provider must:(1) electronically submit a completed Client Movement Form to the department; and(2) submit a paper copy of the completed Client Movement Form to the appropriate TDHS Medicaid eligibility worker.(f) Except when an individual requires immediate admission to a psychiatric facility for inpatient services as provided in subsection (i) of this section, if a program provider proposes a discharge due to the individual's maladaptive behavior, the discharge must be approved in writing by the department prior to the effective date of the discharge. To request approval, the program provider must submit the following documentation to the department's Office of Medicaid Administration:(1) a description of the maladaptive behavior(s);(2) a summary of all behavioral interventions attempted, ranging from the most positive to the most restrictive, with the individual's response to these interventions, and reasons the interventions were ineffective in decreasing or eliminating the behavior(s);(3) chronological psychoactive medication history, including start and stop dates of medications, dose changes to medications, and reasons for discontinuance or changes to dosages (e.g., adverse reactions, allergies, or increase in target symptoms);(4) evidence of participation by a psychologist in the IDT meeting discussing the proposed discharge;(5) evidence of approval of the proposed discharge by the facility's specially constituted committee;(6) a description of the proposed living arrangement for the individual after the effective date of the discharge; and(7) a written agreement from a representative of the proposed living arrangement to accept the individual on or after the effective date of the discharge.(g) The department will review the documentation submitted in accordance with subsection (f) of this section and, within 14 days after receiving the documentation, provide written notice to the program provider of its approval or denial of the discharge.(h) If a proposed discharge is approved by the department in accordance with subsection (g) of this section, a psychologist must participate in the development of the post-discharge plan described in subsection (c)(4) of this section.(i) If the reason for a discharge is that the individual requires immediate admission to a psychiatric facility for inpatient services, a program provider other than a state school or state center must, within three days after the effective date of the discharge, notify the Office of Medicaid Administration and the individual's MRA of:(1) the individual's admission to the psychiatric facility; and(2) whether the program provider intends to re-admit the individual to the facility and, if not, why the individual will not be re-admitted.(j) During a discharge, a program provider may accept payment from the individual or other person to hold the individual's residential placement in the facility if a written contract, signed and dated by the program provider and the individual or the other person, is executed prior to each discharge that specifies:(1) the amount, not to exceed the department's rate of reimbursement for the individual's LON on the effective date of discharge, that the individual or other person agrees to pay the program provider to hold the individual's residential placement;(2) the period of time for which the individual's residential placement in the facility will be held by the program provider;(3) that the program provider is not obligated to hold the individual's residential placement after the period of time described in paragraph (2) of this subsection; and(4) agreement by the program provider that the individual or other person may terminate the contract immediately upon written notice to the program provider. Source Note: The provisions of this §261.227 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.227 Discharge From a Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201148 03/12/2026 (a) A specialized augmentative communication device system (ACD), also referred to as a speech-generating device system, is reimbursable if purchased by a program provider for a resident and all requirements of this section are met.(b) A program provider must request and receive authorization from DADS before purchasing an ACD, referred to in this section as "prior authorization." The request for prior authorization must include:(1) an evaluation and recommendation from a licensed speech therapist to purchase the ACD;(2) a signed statement from the resident's attending physician that the ACD is medically necessary for the resident to maximize his functional communication; and(3) a minimum of two bids for the ACD or a request for an exception to the two-bid minimum if the recommended ACD is available through only one vendor.(c) The evaluation and recommendation from the licensed speech therapist must include:(1) a description of how the ACD will specifically meet the needs of the resident;(2) detailed instructions for training on the use of the ACD for the resident, program provider staff, and resident's family (if applicable);(3) a diagnosis relevant to the need for the ACD; and(4) the specific ACD being recommended.(d) If an ACD costs more than $10,000, DADS facilitates an independent speech language review, at DADS' expense, to determine necessity for the ACD.(e) After receiving prior authorization from DADS, the program provider must purchase the ACD.(f) To obtain reimbursement from DADS, a program provider must submit to DADS the receipt for payment for the ACD and a copy of the prior authorization from DADS.(1) A program provider must fully investigate and use funding sources to pay for an ACD before submitting the request for reimbursement to DADS. If another funding source will pay for part of the cost of the ACD, the program provider may request reimbursement from DADS for the balance of the cost if the requirements in subsections (b) and (c) of this section are met. If another funding source is available, DADS reimburses the program provider no more than the balance remaining after other sources are used fully.(2) A program provider must submit the request for reimbursement to DADS within one year after the date of purchase.(3) DADS reimburses the amount of the authorized bid or the balance remaining after all other sources are used fully.(g) If DADS denies a request for reimbursement because the program provider did not receive prior authorization or did not submit the necessary documentation for the ACD, the program provider is responsible for the cost of the ACD.(h) If DADS denies a prior authorization request, the resident may request a Medicaid fair hearing in accordance with 1 TAC Chapter 357, Subchapter A.(i) Only the resident may use the ACD, and the program provider must identify the ACD as the personal property of the resident.(1) Upon discharge from the facility, the resident must retain the ACD. If the resident dies, the ACD must be transferred to the resident's estate. If the ACD is donated or sold to the program provider by the resident or the resident's estate, the program provider must document the transaction.(2) The program provider is responsible for repairing and maintaining the ACD while the resident resides in the facility. Source Note: The provisions of this §261.228 adopted to be effective August 1, 2009, 34 TexReg 4741; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.228 Augmentative Communication Device System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201149 03/12/2026 (a) The following definitions apply to this section:(1) Critical incident means:(A) a medication error;(B) a serious physical injury;(C) a behavior intervention plan that authorizes restraint;(D) an emergency personal restraint;(E) an emergency mechanical restraint; or(F) an emergency psychoactive medication restraint.(2) Emergency mechanical restraint means the use of a mechanical restraint on an individual not in accordance with a written behavior intervention plan approved by the individual's IDT.(3) Emergency personal restraint means the use of a personal restraint on an individual not in accordance with a written behavior intervention plan approved by the individual's IDT.(4) Emergency psychoactive restraint means the use of a psychoactive medication restraint on an individual not in accordance a written behavior intervention plan approved by the individual's IDT.(5) A behavior intervention plan that authorizes restraint means a behavior intervention plan approved by the individual's IDT that authorizes personal restraint, mechanical restraint, or psychoactive medication restraint.(6) Mechanical restraint means the use of a device that restricts the free movement of part or all of an individual's body, including the use of an anklet, a wristlet, a camisole, a helmet with fasteners, a mitt with fasteners, a vest, a waist strap, a head strap, or a restraining sheet, but does not include the use of a device that provides support for functional body position or proper balance, such as a wheelchair belt, or that is used for medical treatment, such as a helmet to prevent injury during a seizure.(7) Medication error means a difference between what is prescribed to an individual who self-administers medication under the supervision of the program provider or who has medication administered by the program provider and what the individual actually takes, but does not include an individual's refusal to take medication. The following are examples of medication errors:(A) an individual takes medication that is not prescribed for the individual, including medication that has been discontinued for the individual or that was improperly labeled;(B) an individual takes an amount of medication different from the amount prescribed or the route prescribed for the individual;(C) an individual does not take a prescribed dose of medication within one hour before or one hour after the prescribed time; and(D) an individual does not take a medication as prescribed in relation to a meal.(8) Personal restraint means the application of pressure, except physical guidance or prompting of brief duration that restricts the free movement of part or all of an individual's body.(9) Psychoactive medication restraint means the use of a chemical, including a pharmaceutical, to control an individual's activity, if the chemical is not a standard treatment for the individual's medical or psychiatric condition.(10) Serious physical injury is an injury determined serious by a physician, physician assistant, advance practice nurse, or a registered nurse, regardless of the cause or setting in which the injury occurred. A serious physical injury may include a fracture, a dislocation of any joint, an internal injury, a contusion larger than two and half inches in diameter, a concussion, a second or third degree burn, a laceration requiring sutures.(b) A program provider must report to DADS the following information related to the critical incidents that occur in a calendar month:(1) the number of medication errors;(2) the number of individuals who have behavior intervention plans that authorize restraint;(3) the number of times emergency personal restraint was used;(4) the number of times emergency mechanical restraint was used;(5) the number of times emergency psychoactive medication restraint was used;(6) the number of times a serious physical injury was sustained;(7) the number of times a serious physical injury was sustained due to personal restraint;(8) the number of times a serious physical injury was sustained due to mechanical restraint;(9) the number of times a serious physical injury was sustained due to psychoactive medication restraint;(10) the number of individuals who required restraint;(11) the number of individuals who required emergency personal restraint;(12) the number of individuals who required emergency mechanical restraint; and(13) the number of individuals who required emergency psychoactive medication restraint.(c) The program provider must make a report described in subsection (b) of this section within 30 days after the last day of the month in which the critical incidents occur. A program provider must make a separate report for each facility.(d) A program provider must evaluate its use of restraint at least annually. The evaluation must, at a minimum, compare aggregate data provided by DADS at www.dads.state.tx.us for similarly sized facilities.(e) Based on its evaluation, the program provider must develop and implement a plan to reduce the use of restraints. Source Note: The provisions of this §261.229 adopted to be effective November 30, 2011, 36 TexReg 8048; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.229 Critical Incident Reporting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201150 03/12/2026 (a) In this section, the term "program provider" does not include a program provider that operates a campus-based facility.(b) In this section, the following terms have the following meanings.(1) Day habilitation center--A building or a portion of a building:(A) that is not located within a program provider's facility;(B) that the program provider or a subcontractor of the program provider owns or leases; and(C) in which active treatment is provided to an individual by the program provider or a subcontractor of the program provider.(2) Emergency preparedness and response plan--A written plan that describes the actions that will be taken to protect individuals, including evacuation or sheltering-in-place, in the event of an emergency in a day habilitation center, such as a fire or other man-made or natural disaster.(c) If a program provider operates a day habilitation center, the program provider must:(1) conduct, at least once every 90 days, a fire drill during which individuals evacuate the day habilitation center;(2) prominently post, in an area of the day habilitation center that is readily accessible to individuals, employees, contractors, volunteers, and visitors, a notice of the requirement to report an allegation of abuse, neglect, or exploitation of an individual and how to report such an allegation to the Department of Family and Protective Services (DFPS) toll free telephone number at 1-800-647-7418; and(3) have an emergency preparedness and response plan.(d) If a subcontractor of a program provider operates a day habilitation center, the program provider must:(1) have a written agreement with the subcontractor that requires the subcontractor:(A) to conduct, at least once every 90 days, a fire drill during which individuals evacuate the day habilitation center;(B) to have an emergency preparedness and response plan;(C) to prominently post, in an area of the day habilitation center that is readily accessible to individuals, employees, contractors, volunteers, and visitors, a notice of the requirement to report an allegation of abuse, neglect, or exploitation of an individual and how to report such an allegation to the DFPS toll free telephone number at 1-800-647-7418;(D) to search the nurse aide registry (NAR) and the employee misconduct registry (EMR), before the subcontractor hires an unlicensed applicant for employment, contracts with an unlicensed independent contractor, or uses an unlicensed volunteer who will have direct contact with an individual receiving active treatment in the day habilitation center, using the DADS Internet website to confirm that the unlicensed applicant, independent contractor, or volunteer is not listed in either registry as unemployable;(E) to provide written information to the unlicensed applicant, independent contractor, or volunteer about the EMR that complies with the requirements of §93.3(c) of this title (relating to Employment and Registry Information);(F) to search the NAR and the EMR at least once every twelve months using the DADS Internet website to confirm that the unlicensed employee, independent contractor, or volunteer is not listed in either registry as unemployable;(G) to conduct a criminal history check and verify that the unlicensed applicant's, independent contractor's, or volunteer's criminal history information does not include a conviction that bars employment under the Texas Health and Safety Code §250.006, before the unlicensed applicant, independent contractor, or volunteer has direct contact with an individual receiving active treatment in the day habilitation center; and(H) to provide active treatment to the individual in accordance with the individual's IPP and keep a copy of the IPP in the day habilitation center;(2) monitor the subcontractor to ensure that the subcontractor is in compliance with the written agreement described in paragraph (1) of this subsection; and(3) maintain records of its monitoring of the subcontractor. Source Note: The provisions of this §261.230 adopted to be effective September 28, 2016, 41 TexReg 7511; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING D PROVIDER SERVICE REQUIREMENTS §261.230 Requirements for a Day Habilitation Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201178 03/12/2026 (a) To be eligible for the ICF/MR Program, a person must:(1) meet the LOC I or LOC VIII criteria described in §419.238 of this title (relating to Level of Care I Criteria) and §419.239 of this title (relating to Level of Care VIII Criteria);(2) be in need of and able to benefit from the active treatment provided in the 24-hour supervised residential setting of an ICF/MR; and(3) be eligible for Supplemental Security Income (SSI) or be determined by TDHS to be financially eligible for Medicaid.(b) Circumstances under which a person is not in need of and able to benefit from active treatment include when the person:(1) has been diagnosed by a licensed physician as having "brain death";(2) does not respond in any way to the living environment;(3) has a health condition that prevents participation in active treatment; or(4) is generally able to function with little supervision or without a program of continuous active treatment. Source Note: The provisions of this §261.236 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.236 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201179 03/12/2026 (a) An LOC for a person must be requested from the department by electronically transmitting a completed MR/RC Assessment, indicating the recommended LOC, to the department. The electronically transmitted MR/RC Assessment must contain information identical to the information on the signed MR/RC Assessment described in subsection (b) of this section.(b) Information on the MR/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments that measure physical, emotional, social, and cognitive factors. A paper copy of the person's signed MR/RC Assessment and documentation supporting the recommended LOC must be maintained in the person's record.(c) The department will make an LOC determination in accordance with §419.238 of this title (relating to ICF/MR LOC I Criteria) and §419.239 of this title (relating to ICF/MR LOC VIII) based on the department's review of information reported on the person's MR/RC Assessment.(d) The department will notify the requestor electronically if the LOC is authorized. The department will send written notification to the requestor and the person or LAR if the LOC is denied.(e) An initial LOC is valid for 180 days after its effective date.(f) The effective date of a person's initial LOC is the date requested by the MRA, which may be no earlier than 30 days prior to the date the person's MR/RC Assessment is electronically transmitted to the department. Source Note: The provisions of this §261.237 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.237 Level of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201180 03/12/2026 (a) To meet the LOC I criteria, a person must:(1) meet the following criteria:(A) have a full scale intelligence quotient (IQ) score of 69 or below, obtained by administering a standardized individual intelligence test; or(B) have a full scale IQ score of 75 or below, obtained by administering a standardized individual intelligence test, and have a primary diagnosis by a licensed physician of a related condition that is included on the list of diagnostic codes for persons with related conditions that are approved by DADS and posted on its website at www.dads.state.tx.us; and(2) have an adaptive behavior level of I, II, III, or IV (i.e., mild to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior.(b) If a person has a sensory or motor deficit for which a specially standardized intelligence test or a certain portion of a standardized intelligence test is appropriate, the appropriate test or portion thereof and the resultant score should be used.(c) If a full scale IQ score cannot be obtained from a standardized intelligence test due to age, functioning level, or other severe limitations, an estimate of a person's intellectual functioning should be documented with clinical justification. Source Note: The provisions of this §261.238 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 30, 2011, 36 TexReg 8048; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.238 ICF/MR Level of Care I Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201166 03/12/2026 To meet the LOC VIII criteria, a person must:(1) have a primary diagnosis by a licensed physician of a related condition that is included on the list of diagnostic codes for persons with related conditions that are approved by DADS and posted on its website at www.dads.state.tx.us; and(2) have an adaptive behavior level of II, III, or IV (i.e., moderate to extreme deficits in adaptive behavior) obtained by administering a standardized assessment of adaptive behavior. Source Note: The provisions of this §261.239 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 30, 2011, 36 TexReg 8048; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.239 ICF/MR Level of Care VIII Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201167 03/12/2026 (a) An LON for a person must be requested from the department by electronically transmitting a completed MR/RC Assessment, indicating the recommended LON, and submitting any supporting documentation required by §419.242 of this title (relating to Supporting Documentation for Level of Need). The electronically transmitted MR/RC Assessment must contain information identical to the information on the signed MR/RC Assessment described in subsection (c) of this section.(b) Supporting documentation must be received by the department within seven days after the completed MR/RC Assessment is electronically transmitted to the department.(c) A paper copy of the person's signed MR/RC Assessment and the supporting documentation must be maintained in the person's record.(d) The department will assign an LON 1, LON 5, LON 6, LON 8, or LON 9, to a person in accordance with the criteria described in §419.241 of this title (relating to Level of Need Criteria).(e) The department will assign an LON to a person based on the department's review of information reported on the person's MR/RC Assessment, including the ICAP service level score, and any supporting documentation required by §419.242 of this title (relating to Supporting Documentation for Level of Need).(f) Within 21 days after receiving an MR/RC Assessment and any supporting documentation, the department will request additional documentation, electronically approve the recommended LON, or send written notification to the requestor that the recommended LON has been denied.(g) If additional documentation is requested, the department will review any additional documentation submitted in accordance with its request and electronically approve the recommended LON or send written notification to the requestor that the recommended LON has been denied.(h) The department may review a recommended or assigned LON at any time to determine if it is appropriate. If the department reviews a recommended or assigned LON, documentation supporting the LON must be submitted to the department in accordance with the department's request. The department may modify an LON and recoup or deny payment based on its review. Source Note: The provisions of this §261.240 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.240 Level of Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201168 03/12/2026 (a) The department will assign one of five LONs as follows:(1) An intermittent LON (LON 1) will be assigned if the person's ICAP service level score equals 7, 8, or 9;(2) A limited LON (LON 5) will be assigned if the person's ICAP service level score equals 4, 5, or 6, or an LON 1 is increased in accordance with subsection (b) or (d) of this section;(3) An extensive LON (LON 8) will be assigned if the person's ICAP service level score equals 2 or 3, or an LON 5 is increased in accordance with subsection (b) or (d) of this section;(4) A pervasive LON (LON 6) will be assigned if the person's ICAP service level score equals 1, or an LON 8 is increased in accordance with subsection (b) or (d) of this section; and(5) Regardless of a person's ICAP service level score, a pervasive plus LON (LON 9) will be assigned if the person meets the criteria set forth in subsection (c) of this section.(b) An LON 1, LON 5, or LON 8 will be increased to the next LON by the department, due to a person's dangerous behavior, if the supporting documentation described in §419.242 (1) (relating to Supporting Documentation for Level of Need) is submitted to the department proving that:(1) the person exhibits dangerous behavior that could cause serious physical injury to the person or others;(2) a written behavior intervention plan has been implemented for the person;(3) more staff members are needed and available than would be needed if the person did not exhibit dangerous behavior;(4) management of the individual's behavior requires that staff members are constantly prepared to physically prevent the dangerous behavior or intervene when the behavior occurs; and(5) the person's MR/RC Assessment is correctly scored with a "1" in the "Behavior" section.(c) An LON 9 will be assigned by the department, due to the person's extremely dangerous behavior, if the supporting documentation described in §419.242(2) (relating to Supporting Documentation for Level of Need) is submitted to the department proving that:(1) the person exhibits extremely dangerous behavior that is life threatening to the person or to others such that specified staff must be at arm's length during waking hours;(2) a written behavior intervention plan has been implemented for the person;(3) management of the person's behavior requires a staff member to exclusively and constantly supervise the person during the person's waking hours, which must be at least 16 hours per day;(4) the staff member assigned to supervise the person has no other duties during such assignment; and(5) the person's MR/RC Assessment is correctly scored with a "2" in the "Behavior" section.(d) An LON 1, LON 5, or LON 8 will be increased to the next LON by the department, due to a person's extraordinary medical needs, if the supporting documentation described in §419.242(3) (relating to Supporting Documentation for Level of Need) is submitted to the department proving that:(1) the person's extraordinary medical needs require direct nursing treatment in excess of 180 minutes per week;(2) the provision of nursing treatment is documented by a nurse in the person's medical record to include the amount of time spent for treatment; and(3) the person's MR/RC Assessment is correctly scored with a "6" in the "Nursing" section. Source Note: The provisions of this §261.241 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.241 Level of Need Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201169 03/12/2026 The following supporting documentation, at a minimum, must be submitted to the department when requesting an LON:(1) if a request is made to increase an LON 1, LON 5, or LON 8 in accordance with §419.241(b) of this title (relating to Level of Need Criteria), due to a person's dangerous behavior:(A) the person's IPP;(B) the person's ICAP assessment booklet;(C) the person's person directed plan (PDP), if available;(D) the person's behavior intervention plan; and(E) written descriptions (e.g. incident reports or progress notes) of specific incidents of the dangerous behavior and the staff interventions;(2) if a request is made for an LON 9 in accordance with §419.241(c) of this title (relating to Level of Need Criteria), due to the person's extremely dangerous behavior:(A) the person's IPP;(B) the person's ICAP assessment booklet;(C) the person's PDP, if available;(D) the person's behavior intervention plan;(E) written descriptions (e.g. incident reports or progress notes) of specific incidents of the extremely dangerous behavior and the staff interventions; and(F) time sheets that verify the assignment of a staff member to exclusively and constantly supervise the person during the person's waking hours, which must be at least 16 hours per day;(3) if a request is made to increase an LON 1, LON 5, or LON 8 in accordance with §419.241(d) of this title (relating to Level of Need Criteria), due to a person's extraordinary medical needs:(A) the person's IPP;(B) the person's ICAP assessment booklet;(C) the person's PDP, if available; and(D) description, frequency, and duration of each type of nursing treatment; and(4) if a request is made to increase an individual's existing LON based on the results of an ICAP assessment:(A) the individual's previous ICAP assessment booklet;(B) the individual's latest ICAP reassessment;(C) the individual's IPP;(D) program progress notes; and(E) the individual's PDP, if available. Source Note: The provisions of this §261.242 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.242 Supporting Documentation for Level of Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201170 03/12/2026 (a) If a program provider who has requested an LON for a person disagrees with the LON assigned by the department, the program provider may request that the department reconsider the LON.(b) A program provider may receive reconsideration only if the program provider submitted the supporting documentation as required by §419.240(b) of this title (relating to Level of Need).(c) To request reconsideration of an LON assigned by the department, a program provider must submit a written request for reconsideration to the department within 10 days after receiving notice that the recommended LON was denied. The program provider must include additional clinical and supporting documentation with the request.(d) Within 21 days after receiving a request for reconsideration from a program provider, the department will electronically approve the recommended LON or send written notification to the program provider that the recommended LON has been denied. Source Note: The provisions of this §261.243 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.243 Reconsideration of Level of Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201171 03/12/2026 (a) Except as provided in subsection (b) of this section, only an MRA may request enrollment of an applicant by DADS.(b) A program provider may request enrollment of an applicant by DADS in accordance with subsection (k) of this section if the applicant:(1) has received ICF/MR services from a non-state operated facility during the 180 days before the enrollment request; and(2) is not moving from or seeking admission to a state school or state center.(c) An MRA must request an applicant's enrollment if:(1) the program provider selected by the applicant or LAR notifies the MRA in writing that admission to the program provider's facility has been offered to the applicant; and(2) the applicant or LAR notifies the MRA that the applicant or LAR chooses to accept the admission offered by the program provider.(d) If an MRA receives the notifications described in subsection (c) of this section, the MRA must comply with §5.159(c) of this title (relating to Assessment of Individual's Need for Services and Supports) including providing an explanation to the applicant or LAR of the services and supports for which the applicant may be eligible. For an applicant under 22 years of age, an MRA must also comply with the following requirements:(1) Except as provided in paragraphs (2) and (3) of this subsection, before placement of an applicant in a facility, the MRA must inform the LAR:(A) of the benefits of living in a family or community setting;(B) that the placement of the applicant is considered temporary; and(C) that an ongoing permanency planning process is required.(2) If an MRA is notified of a request for enrollment after the applicant is admitted to the facility, the MRA must provide the information described in paragraph (1) of this subsection to the LAR not later than the 14th working day after the date the MRA is notified of the request for the enrollment, unless this time period is extended by the LAR.(3) An MRA does not have to comply with paragraph (1) or (2) of this subsection if the applicant has been committed to a facility under Chapter 46B, Code of Criminal Procedure, or Chapter 55, Family Code.(e) To request an applicant's enrollment, an MRA must, within 15 working days after the MRA receives both notifications described in subsection (c) of this section:(1) initiate, monitor, and support the processes necessary to obtain a financial eligibility determination for the applicant if Medicaid financial eligibility has not been established;(2) obtain an ICAP score for the applicant by:(A) reviewing and endorsing an existing ICAP for the applicant; or(B) administering the ICAP if an ICAP score for the applicant does not exist, is not available, or is not endorsed by the MRA; and(3) request or review an LOC determination and LON for the applicant by:(A) completing and electronically submitting an MR/RC Assessment, if the applicant does not have a current LOC determination; or(B) reviewing the existing MR/RC Assessment for the applicant if the applicant has a current LOC determination and:(i) if the MRA does not endorse the existing MR/RC Assessment, completing and electronically submitting a new MR/RC Assessment recommending a revised LOC or LON; or(ii) if the MRA endorses the existing MR/RC Assessment, notifying the selected program provider in writing that no changes to the current LOC or LON are recommended.(f) Upon notification of a request for enrollment of an applicant under 22 years of age, an MRA must take or ensure that the following actions are taken to conduct permanency planning:(1) The MRA must convene a permanency planning meeting with the LAR and, if possible, the applicant before admission or, if notified of a request for enrollment after the applicant's admission, not later than the 14th working day after the date the MRA is notified of the request.(2) Before the permanency planning meeting, the MRA staff must review the applicant's records and, if possible, meet the applicant.(3) During the permanency planning meeting, the meeting participants must discuss and choose one of the following goals:(A) for an applicant under 18 years of age:(i) to live in the applicant's family home where the natural supports and strengths of the applicant's family are supplemented, as needed, by activities and supports provided or facilitated by the MRA or program provider; or(ii) to live in a family-based alternative in which a family other than the applicant's family:(I) has received specialized training in the provision of support and in-home care for an individual under 18 years of age with mental retardation;(II) will provide a consistent and nurturing environment in a family home that supports a continued relationship with the applicant's family to the extent possible; and(III) if necessary, will provide an enduring, positive relationship with a specific adult who will be an advocate for the applicant; or(B) for an applicant 18-22 years of age, to live in a setting chosen by the applicant or LAR in which the applicant's natural supports and strengths are supplemented by activities and supports provided or facilitated by the MRA or program provider, and to achieve a consistent and nurturing environment in the least restrictive setting, as defined by the applicant and LAR.(4) To accomplish the goal chosen in accordance with paragraph (3) of this subsection, the meeting participants must discuss and identify:(A) the problems or issues that led the applicant or LAR to request admission to a facility;(B) the applicant's daily support needs;(C) for an applicant under 18 years of age:(i) barriers to having the applicant reside in the family home;(ii) supports that would be necessary for the applicant to remain in the family home; and(iii) actions that must be taken to overcome the barriers and provide the necessary supports;(D) for an applicant 18-22 years of age, the barriers to the applicant moving to a consistent and nurturing environment as defined by the applicant and LAR;(E) the importance for the applicant to live in a long-term nurturing relationship with a family;(F) alternatives to the applicant living in an institutional setting;(G) the applicant's and LAR's need for information and preferences regarding those alternatives;(H) how, after admission to the facility, to facilitate regular contact between the applicant and the applicant's family, and, if desired by the applicant and family, between the applicant and advocates and friends in the community to continue supportive and nurturing relationships;(I) natural supports and family strengths that will assist in accomplishing the identified permanency planning goal;(J) activities and supports that can be provided by the family, MRA, or program provider to achieve the permanency planning goal;(K) assistance needed by the applicant's family:(i) in maintaining a nurturing relationship with the applicant; and(ii) preparing the family for the applicant's eventual return to the family home or move to a family-based alternative; and(L) action steps, both immediate and long term, for achieving the permanency plan goal.(5) The MRA must make reasonable accommodations to promote the participation of the LAR in a permanency planning meeting, including:(A) conducting a meeting in person or by telephone, as mutually agreed upon by the MRA and LAR;(B) conducting a meeting at a time and, if the meeting is in person, at a location that is mutually agreed upon by the MRA and LAR;(C) if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and(D) providing a language interpreter, if appropriate.(6) The MRA must develop a permanency plan using, as appropriate:(A) the Permanency Planning Instrument for Children Under 18 Years of Age; or(B) the Permanency Planning Instrument for Individuals 18-22 Years of Age.(7) The MRA must:(A) complete the Permanency Planning Review Screen in CARE before an applicant is admitted to a facility unless the MRA is not given prior notice of the admission;(B) keep a copy of the Permanency Planning Review Approval Status View Screen from CARE in the applicant's record; and(C) provide a copy of the permanency plan to the program provider, the applicant, and the LAR.(g) If an applicant is under 22 years of age, the MRA must inform the applicant and LAR that they may request a volunteer advocate to assist in permanency planning. The applicant or LAR may:(1) select a person who is not employed by or under contract with the MRA or a program provider; or(2) request the MRA to designate a volunteer advocate.(h) If an applicant or LAR requests that the MRA designate a volunteer advocate or the MRA cannot locate the LAR, the MRA must attempt to designate a volunteer advocate to assist in permanency planning who is, in order of preference:(1) an adult relative who is actively involved with the applicant;(2) a person who:(A) is part of the applicant's natural support network; and(B) is not employed by or under contract with the MRA or a program provider; or(3) a person or a child advocacy organization representative who:(A) is knowledgeable about community services and supports;(B) is familiar with the permanency planning philosophy and processes; and(C) is not employed by or under contract with the MRA or a program provider.(i) If the MRA is unable to locate a volunteer advocate locally, the MRA must request assistance from a statewide advocacy organization in identifying an available volunteer advocate who meets the requirements described in subsection (h) of this section. If the statewide advocacy organization is unable to assist the MRA in identifying a volunteer advocate, the MRA must document all efforts to designate a volunteer advocate in accordance with subsection (h) of this section.(j) If DADS notifies an MRA that it has authorized an applicant's LOC, the MRA must immediately notify the applicant or LAR of such authorization and provide the selected program provider with copies of all enrollment documentation and associated supporting documentation including relevant assessment results and recommendations and the applicant's ICAP booklet and, if available, the applicant's service plan.(k) To request an applicant's enrollment as permitted by subsection (b) of this section, a program provider must ensure that the applicant has a current LOC.(1) If an applicant does not have a current LOC, the program provider must complete and electronically submit an MR/RC Assessment to DADS.(2) If the program provider submits an MR/RC Assessment, DADS notifies the program provider electronically if the LOC is authorized or sends written notification to the program provider and the applicant or LAR if the LOC is denied.(l) An applicant's enrollment is complete if:(1) DADS has authorized an LOC for the applicant;(2) the Social Security Administration has determined that the applicant is eligible for SSI or the Health and Human Services Commission determines the applicant is financially eligible for Medicaid;(3) the program provider has electronically submitted a completed Client Movement Form to DADS; and(4) admission to the facility has been approved by the DADS commissioner or designee for the applicant who is under 22 years of age, based on information submitted as described in subsection (f) of this section.(m) A program provider must maintain a paper copy of the completed MR/RC Assessment with all the necessary signatures and documentation supporting the recommended LOC and LON. Source Note: The provisions of this §261.244 adopted to be effective September 1, 2001, 26 TexReg 5384; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6795; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.244 Applicant Enrollment in the ICF/MR Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201172 03/12/2026 (a) To avoid interruption in payment from the department, a program provider must request to renew an individual's existing LOC prior to its expiration date.(b) To request to renew an individual's existing LOC, a program provider must follow the procedures for requesting an LOC described in §419.237 of this title (relating to Level of Care).(c) The department will make an LOC determination and notify the program provider of its determination in accordance with §419.237 of this title (relating to Level of Care).(d) The effective date of a renewed LOC is:(1) the date the MR/RC was electronically transmitted to the department, if a different date is not requested; or(2) a requested effective date within 45 days after the MR/RC was electronically transmitted to the department.(e) A renewed LOC is valid for 364 days after its effective date. Source Note: The provisions of this §261.245 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.245 Renewal of Level of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201173 03/12/2026 (a) A program provider must request to renew an individual's existing LON when renewing an existing LOC in accordance with §419.245(b) of this title (relating to Renewal of Level of Care).(b) A program provider must request to revise an individual's existing LON if:(1) the individual's adaptive functioning or behavioral or medical condition changes such that the individual's current LON is no longer accurate;(2) the results of an ICAP assessment indicate that the individual's current LON is no longer accurate; or(3) the information submitted for the individual's current LON resulted in an inaccurate LON.(c) To request to renew or revise an individual's existing LON, a program provider must follow the procedures for requesting an LON described in §419.240 of this title (relating to Level of Need).(d) The department will assign an LON and notify the program provider of the assignment in accordance with §419.240 of this title (relating to Level of Need). Source Note: The provisions of this §261.246 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.246 Renewal and Revision of Level of Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201174 03/12/2026 (a) A program provider must re-administer the ICAP to an individual if:(1) three years have elapsed since the ICAP was last administered to the individual;(2) changes in the individual's functional skills or behavior occur that are not expected to be of a short duration or cyclical in nature; or(3) the individual's skills and behavior are inconsistent with the individual's LON.(b) If the results from the ICAP indicate that the individual's LON is no longer accurate, a program provider must request a revision to the LON in accordance with §419.246(b) of this title (relating to Renewal and Revision of Level of Need). Source Note: The provisions of this §261.247 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.247 Re-administration of the ICAP https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201175 03/12/2026 (a) The department will not pay a program provider for ICF/MR Program services provided during a period of time in which the individual's LOC lapsed unless the program provider requests and is granted a reinstatement of the LOC in accordance with this section.(b) To request reinstatement of an LOC, a program provider must electronically transmit to the department an MR/RC Assessment indicating:(1) a code "E" in the "Purpose" section; and(2) the beginning and ending dates of the period of time for which the individual's LOC lapsed.(c) The department will not grant a request for reinstatement of an LOC:(1) if the individual does not have a current LOC;(2) to establish program eligibility;(3) to renew an LOC;(4) to obtain an LOC for a period of time for which an LOC has been denied;(5) to revise an LON; or(6) for a period of time during which the individual is not eligible for Medicaid.(d) If the department grants a reinstatement, the reinstatement will be for a period of not more than 180 days prior to the date of electronic transmission of the MR/RC Assessment described in subsection (b) of this section.(e) A program provider must maintain a paper copy of the completed MR/RC Assessment with all necessary signatures in the individual's record. The signed MR/RC Assessment must contain information identical to the information on the electronically transmitted MR/RC Assessment. Source Note: The provisions of this §261.248 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.248 Lapsed Level of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201176 03/12/2026 Any individual whose request for eligibility for the ICF/MR Program is denied or is not acted upon with reasonable promptness, or whose ICF/MR Program services have been terminated, suspended or reduced by the department is entitled to a fair hearing in accordance with Chapter 419, Subchapter G of this title (relating to Medicaid Fair Hearings). Source Note: The provisions of this §261.249 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.249 Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201177 03/12/2026 An MRA must, within six months after the initial permanency planning meeting and every six months thereafter until an individual either turns 22 years of age or leaves the facility to live in a family setting:(1) provide written notice to the LAR of a meeting to conduct a review of the individual's permanency plan no later than 21 days before the meeting date and include a request for a response from the LAR;(2) convene a meeting to review the individual's permanency plan in accordance with §9.244(f)(2) - (5) of this subchapter (relating to Applicant Enrollment in the ICF/MR Program), with an emphasis on changes or additional information gathered since the last permanency plan was developed;(3) develop a permanency plan in accordance with §9.244(f)(6) of this subchapter;(4) perform actions regarding a volunteer advocate as described in §9.244(g) - (i) of this subchapter;(5) complete the Permanency Planning Review Screen in CARE within 10 days after the meeting;(6) ensure that approval for the individual to continue to reside in the facility is obtained every six months from the DADS commissioner and the Health and Human Services Commission executive commissioner;(7) keep a copy of the Permanency Planning Review Approval Status View Screen from CARE in the individual's record; and(8) provide a copy of the permanency plan to the program provider, the individual, and the LAR. Source Note: The provisions of this §261.250 adopted to be effective September 1, 2006, 31 TexReg 6795; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING E ELIGIBILITY, ENROLLMENT AND REVIEW §261.250 Permanency Planning Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201194 03/12/2026 (a) A program provider must implement this division according to the generally accepted accounting principles of the American Institute of Certified Public Accountants.(b) A program provider must develop and implement written policies and procedures regarding personal funds that protect the financial interest of an individual and, at a minimum, require the program provider:(1) to instruct an individual in handling personal funds consistent with the individual's abilities and understanding;(2) to allow an individual to hold and manage personal funds to the extent of the individual's abilities; and(3) to comply with 20 CFR Part 404, Subpart U, and 20 CFR Part 416, Subpart F, if the Social Security Administration has appointed the program provider as the representative payee.(c) A program provider must reimburse an individual for personal funds lost or stolen while the funds are under the program provider's control. Source Note: The provisions of this §261.251 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.251 Protecting Individuals' Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201195 03/12/2026 At the time of admission to a facility, and if changes to services or charges occur, a program provider must provide each individual or LAR with written notification containing the following information:(1) a written explanation of §9.253(d) and (e) of this division (relating to Determining Management of Personal Funds), which describe who may manage personal funds;(2) a list of items and services included in the program provider's ICF/IID Program reimbursement rate for which the individual will not be charged;(3) a list of items and services for which the individual may be charged;(4) a statement that the individual or LAR may have the Social Security Administration appoint a representative payee to receive the individual's federal benefits in accordance with 20 CFR Part 404, Subpart U, and 20 CFR Part 416, Subpart F;(5) a statement that, if the Social Security Administration has appointed the program provider as the representative payee for an individual's social security benefits, the provider must comply with 20 CFR Part 404, Subpart U, and 20 CFR Part 416, Subpart F;(6) a statement that, if the program provider manages the individual's personal funds, the program provider will make available the individual's personal funds record, as described in §9.256(h) of this division (relating to Program Provider-Managed Personal Funds), upon the request of the individual or LAR within 72 hours after receiving a request for a copy of the personal funds record from the individual or LAR; and(7) a statement that, if the individual or LAR requests withdrawal of all personal funds managed by the program provider, or if the individual is discharged from the facility, the program provider will disburse funds managed by the program provider in accordance with §9.258 of this division (relating to Closing Trust Fund Accounts) and, if the program provider is the representative payee, in accordance with 20 CFR Part 404, Subpart U, and 20 CFR Part 416, Subpart F. Source Note: The provisions of this §261.252 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.252 Notice Regarding Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201196 03/12/2026 (a) Within 30 days after an individual is admitted to a facility, the IDT must determine if the individual has the ability to:(1) manage his or her personal funds; and(2) decide who manages his or her personal funds.(b) The determination must be based on an assessment of the individual's understanding of financial management, including:(1) mathematical concepts;(2) budgeting personal funds;(3) monetary denominations; and(4) financial obligations.(c) The results of the assessment and the IDT's determination must be documented, signed by the IDT, and made a part of the individual's IPP.(d) If an individual does not have an LAR and is determined to have the ability to decide who manages his or her personal funds or if an individual has an LAR, a program provider must allow the individual or LAR to choose one of the following to manage his or her personal funds and document such choice in the individual's IPP:(1) the individual, if the individual is determined to have the ability to manage his or her personal funds;(2) the individual's LAR;(3) the program provider; or(4) another person identified by the individual or LAR who has agreed in writing to manage the individual's personal funds.(e) If an individual is determined not to have the ability to decide who manages his or her personal funds and the individual has no LAR, a program provider must manage the individual's personal funds in accordance with this subchapter.(f) A program provider must reassess an individual's understanding of financial management at least annually and if the program provider has reason to believe that the individual's ability has changed. Source Note: The provisions of this §261.253 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.253 Determining Management of Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201197 03/12/2026 A program provider must not charge an individual or require an individual to expend personal funds for items and services that are the program provider's responsibility to provide, except as authorized by §9.255(a)(1) of this title (relating to Items and Services Purchased with Personal Funds), because they are included in the ICF/MR Program reimbursement rate or are covered by other Medicaid programs. These items and services include:(1) medical services and therapies, e.g., physical exams, physical therapy, occupational therapy, and nutritional, speech, audiological, psychological, social, and medical evaluations;(2) prescribed and over-the-counter medication:(A) for an individual who is not eligible for Medicare Part D benefits; or(B) for an individual who is eligible for Medicare Part D benefits if the medication is prescribed and is in a category that is not covered by Medicare Part D;(3) medical equipment and supplies, e.g., nasogastric tubes, feeding pumps, catheters, sheepskins, and egg crate pads;(4) laboratory services;(5) eye exams and eyeglasses, except:(A) the difference between the Medicaid payment and the actual cost of the eyeglasses as authorized by §9.255(a)(2) of this title; or(B) as authorized by §9.255(a)(6) of this title;(6) non-cosmetic dental services and items, e.g., intra- and extra-oral examinations, prescribed dental treatments and follow-up visits, dentures, braces, crowns, toothbrushes, toothpaste, mouthwash, dental floss, and disclosing solution;(7) specialized equipment and adaptive devices that are medically necessary or are necessary to meet the objectives in the individual's IPP, e.g., hearing aids, hearing aid batteries, electric razor, shoe closures, and shoe insoles;(8) training and habilitation services, e.g., vocational training, congregate training, and day activity services;(9) behavioral reinforcers used in behavior modification programs, e.g., candy, soft drinks, cereal, coffee, toys, and magazines;(10) meals, snacks, and special diets, as listed on the program provider's menu, whether provided at the facility or elsewhere;(11) non-cosmetic personal hygiene items, e.g., shampoo, conditioner, soap, deodorant, anti-perspirant, body lotion, insect repellant, suncreen, shaving supplies, comb, hair brush, facial tissues, toilet tissue, sanitary napkins, tampons, and diapers;(12) shampooing, haircutting, basic hairstyling, and shaving, including mustache and beard trimming;(13) laundering personal clothing;(14) facility furnishings and housewares, e.g., bedroom furniture, kitchenware, bath towels, dish towels, and bed linens;(15) repairing and maintaining the facility's physical plant, including training and day activity areas;(16) expenses that are associated with activities that are part of the program provider's recreational program e.g., meals, lodging, registrations, and tickets;(17) transportation costs to and from:(A) an activity included in an individual's IPP, including health care services, congregate training, day activity services and supported employment, except for competitive employment; or(B) an activity that is part of the program provider's recreational program;(18) fees charged by financial institutions, including service fees and check printing charges, if an individual's personal funds are managed in a pooled account or if the program provider chooses to manage those funds in a separate account;(19) managing an individual's personal funds; and(20) a charge incurred if the program provider mismanages an individual's personal funds. Source Note: The provisions of this §261.254 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective January 1, 2006, 30 TexReg 7890; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.254 Items and Services Provided by the Program Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201198 03/12/2026 (a) A program provider may charge an individual or allow an individual to expend personal funds for the following items and services:(1) an item or service that the program provider is responsible for providing, if the individual requests a specific type or brand of item or service that the program provider does not provide, and the program provider documents in the individual's record:(A) the individual's written, signed request for a specific type or brand and the reason a specific type or brand has been requested or if the individual is determined not to have the ability to make such a request, the IDT's approval for a specific type or brand;(B) the type or brand that is provided at the program provider's expense; and(C) the reason the program provider does not provide the type or brand requested;(2) the difference between the Medicaid payment and the actual cost of the eyeglasses, if the individual chooses a style or feature not paid for by Medicaid;(3) clothing;(4) cosmetic dental procedures;(5) transportation costs, other than those described in §419.254(17) of this title (relating to Items and Services Provided by the Program Provider):(A) if reimbursement to a third party for private transportation does not exceed the current state mileage reimbursement rate; and(B) if adequate documentation is provided by a third party to the program provider to support the expenditure;(6) repair or replacement of personal property that is damaged, lost, or stolen by the individual, if the expenditure is approved by the committee;(7) snacks and meals, if the individual chooses items not listed on the program provider's menu;(8) the individual's budgeted amount;(9) activities that are not part of the program provider's recreational program and are independently chosen by the individual;(10) dry cleaning;(11) hair setting, permanent waves, hair color treatments, and beauty supplies, such as hair rollers and hair spray;(12) cosmetics and perfume;(13) cosmetic manicures, pedicures, and facials;(14) charges to hold the individual's residential placement in the facility as described in §419.227(j) of this title (relating to Discharge From a Facility)(15) school supplies, school fees, and other educational expenses;(16) fees charged by a financial institution, if the individual manages his or her personal funds or the individual requests that the program provider manage his or her personal funds in a separate account; and(17) applied income.(b) Items purchased with an individual's personal funds must not be available for general use by program provider staff or other individuals. Source Note: The provisions of this §261.255 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.255 Items and Services Purchased with Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201199 03/12/2026 (a) Accounting for personal funds. If a program provider manages personal funds, the program provider must comply with this section and ensure that:(1) a complete accounting of personal funds entrusted to the program provider is maintained;(2) personal funds are not commingled with program provider funds or the funds of any person other than another individual for whom the program provider manages personal funds; and(3) personal funds are only expended for the individual's use and benefit and in a manner and for purposes determined to be in the individual's best interest.(b) Account requirements. A program provider must manage personal funds in a trust fund account.(1) The program provider may manage personal funds in a pooled account or a separate account. If the program provider chooses a pooled account, an individual may request and receive a separate account. The program provider may also maintain some personal funds in a petty cash fund.(2) Trust fund accounts must be insured under federal or state law.(3) The program provider must retain all statements from financial institutions regarding trust fund accounts.(4) The program provider must reconcile such statement with the account ledger as described in subsection (c)(1)(A) and (2)(A) of this section and personal ledger as described in subsection (h)(1)(F) of this section within 30 days after receiving such statement.(c) Types of accounts.(1) Pooled accounts. If a program provider manages personal funds in a pooled account, the program provider must:(A) maintain an account ledger that separately identifies each financial transaction, including:(i) the name of the individual for whom the transaction was made;(ii) the date and amount of the transaction, including interest; and(iii) the balance after the transaction;(B) title the account "Name of facility), Resident Trust Fund Account" or a similar title that shows a fiduciary relationship exists between an individual and the program provider; and(C) if the personal funds of Medicaid and private-pay individuals are pooled, obtain a signed, dated statement from private pay individuals allowing the program provider to release financial information to DADS, Health and Human Services Commission, Texas Attorney General's Medicaid Fraud Control Unit, and US Department of Health and Human Services.(2) Separate accounts. If a program provider manages personal funds in a separate account, the program provider must:(A) maintain an account ledger that identifies each financial transaction, including:(i) the date and amount of the transaction, including interest; and(ii) the balance after the transaction; and(B) title the account "(Program Provider's Name), (Individual's Name) Trust Fund Account" or a similar title that shows a fiduciary relationship exists between an individual and the program provider.(d) Petty cash fund. If a program provider maintains some personal funds in a petty cash fund, the program provider must:(1) set a limit on the amount maintained in the petty cash fund;(2) set a limit on the amount of a single expenditure from the petty cash fund;(3) maintain a petty cash fund ledger that includes:(A) the date and amount of each transaction;(B) the name of the individual for whom each transaction was made; and(C) the balance after each transaction.(e) Interest. If personal funds accrue interest, a program provider must prorate and distribute the interest earned to each participating individual.(f) Depositing personal funds. A program provider must deposit in a trust fund account all funds that it receives on behalf of the individual. If the deposit slip documents deposits for more than one individual, the program provider must indicate on the deposit slip the amount allocated to each individual.(g) Access to personal funds.(1) An individual's IDT must, based on the individual's assessment described in §9.253 of this division (relating to Determining Management of Personal Funds), determine:(A) if there is a need for a budgeted amount and, if so, set the amount; and(B) if there is a need to restrict the individual's use of personal funds and, if so, make a recommendation to the specially constituted committee.(2) If the individual's IDT makes a recommendation to the specially constituted committee to restrict an individual's use of to personal funds, the specially constituted committee's decision is documented, signed by the specially constituted committee members, and made a part of the individual's IPP.(h) Personal funds record.(1) A program provider must maintain a personal funds record for each individual that includes:(A) the name of the individual;(B) the name of the individual's LAR and representative payee, as applicable;(C) the date of the individual's admission to the facility;(D) the individual's budgeted amount;(E) the account number and location of all accounts in which the individual's personal funds are managed;(F) a personal ledger that includes the date and amount of each transaction and the balance after each transaction; and(G) any contribution acknowledgment as described in §9.261 of this division (relating to Contributions).(2) The personal ledger reconciled in accordance with subsection (b)(4) of this section must not be less than zero. If reconciled balance is less than zero, the program provider must deposit in and credit to the individual's trust fund account the amount that increases such balance to zero.(3) At least quarterly, and within 72 hours after receiving a request from the individual or LAR, the program provider must provide to the individual or LAR a copy of the individual's personal ledger.(i) Documenting expenditures and deposits.(1) Expenditures.(A) Except as provided in subparagraph (C) of this paragraph, a program provider must retain a sales receipt for each expenditure.(i) If a sales receipt documents an expenditure for more than one individual, the program provider must indicate on the sales receipt the amount allocated to each individual.(ii) If a sales receipt does not include the specific item or service purchased or the name of the seller, the program provider must attach such documentation.(B) The program provider must explain each expenditure to the individual and request that the individual sign the receipt. If the program provider determines that the individual does not understand the explanation, the individual does not sign the receipt, or the individual's signature is illegible, a witness to the expenditure must sign the receipt. The witness must not be responsible for managing personal funds or responsible for supervising persons performing such duties.(C) A sales receipt is not required for an expenditure:(i) if the program provider makes a purchase on behalf of an individual from a vending machine;(ii) if an expenditure is within the individual's budgeted amount and the program provider obtains an acknowledgment signed by the individual indicating that the funds were received;(iii) if the program provider releases funds in response to a written request in accordance with §9.257 of this division (relating to Requests for Personal Funds from Trust Fund Accounts); or(iv) if the program provider obtains written approval for alternative documentation from DADS before the expenditure is made.(2) Deposits. Except for deposits made electronically, a program provider must retain a deposit slip issued by the financial institution for each deposit. Source Note: The provisions of this §261.256 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.256 Program Provider-Managed Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201200 03/12/2026 If a program provider receives a request from an individual or other person except program provider staff to expend an individual's personal funds without obtaining a receipt and the individual's IDT determines that the expenditure is in the best interest of the individual, the program provider may release such funds to the requestor.(1) The request must be written, signed by the requestor, and specify the amount and purpose of the expenditure.(2) A check is not considered a written request for personal funds, even if it is written and signed by the individual. Source Note: The provisions of this §261.257 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.257 Requests for Personal Funds from Trust Fund Accounts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201201 03/12/2026 (a) Ownership change. Within 30 days after the effective date of a change in facility ownership, the previous program provider must:(1) reconcile each statement issued by a financial institution with the account ledger and the personal ledger;(2) provide the new program provider with a list of all individuals whose personal funds were managed by the previous program provider and their trust fund account balances and personal ledger balance as of the effective date of the transfer;(3) transfer to the new program provider all personal funds managed by the previous program provider;(4) retain a receipt from the new program provider indicating the amount of the transfer; and(5) submit to the department any unidentified personal funds.(b) Written notice. If the individual or LAR provides written notice that another person has been chosen to manage the individual's personal funds, a program provider must, within 30 days after receiving the notice:(1) reconcile the individual's statement issued by the financial institution with the account ledger and the personal funds ledger;(2) transfer all of the individual's personal funds to the person chosen;(3) retain a receipt from the person indicating the amount of the transfer; and(4) provide to the person a copy of the individual's current personal funds record.(c) Discharge. If the individual is discharged from the facility, a program provider must, within 30 days after the discharge:(1) reconcile the individual's statement issued by a financial institution with the account ledger and personal funds ledger;(2) transfer all personal funds managed by the program provider:(A) to the admitting facility, if the individual is discharged to another facility; or(B) to the individual or LAR, if the individual is not discharged to another facility;(3) retain a receipt from the admitting facility, individual, or LAR indicating the amount of the transfer; and(4) provide to the admitting facility, individual, or LAR the individual's current personal funds record.(d) Unclaimed personal funds. Within 180 days after identifying any unclaimed personal funds, a program provider must make a good faith effort to locate the individual to whom the funds belong or LAR. If the individual or LAR:(1) is located, the program provider must transfer the funds to the individual or LAR; or(2) is not located, the program provider must send to TDMHMR, Attn: Cashier, P.O. Box 12668, Austin, Texas 78691:(A) a statement that the funds are unclaimed;(B) the program provider's name, address, and vendor identification number;(C) the individual's name, social security number, date of birth, and last known address;(D) the LAR's name and address;(E) a check payable to TDMHMR for the amount of the unclaimed personal funds; and(F) documentation of the program provider's efforts to locate the individual or LAR. Source Note: The provisions of this §261.258 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.258 Closing Trust Fund Accounts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201202 03/12/2026 A program provider must refund any private payment it received for services provided during a period covered by Medicaid, including retroactive coverage, within 30 days after accepting the Medicaid payment. Source Note: The provisions of this §261.259 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.259 Refunds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201203 03/12/2026 (a) A program provider may only collect applied income in accordance with the procedures authorized by TDHS.(b) If an individual's applied income has not been determined or the individual's earned or unearned income changes, a program provider must report such information to the TDHS Medicaid eligibility worker.(c) A program provider must maintain an applied income ledger for each individual that includes the amount of:(1) applied income owed by the individual;(2) applied income paid by the individual;(3) the difference between the applied income owed and the applied income paid by the individual; and(4) charges paid by the individual to hold the individual's residential placement in the facility as described in §419.227(j) of this title (relating to Discharge From a Facility)(d) Within 72 hours after receiving a request from the individual or LAR, a program provider must provide to the individual or LAR a copy of the individual's applied income ledger. Source Note: The provisions of this §261.260 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.260 Applied Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201204 03/12/2026 If the individual or LAR makes a contribution to a program provider using personal funds, the program provider and the contributor must sign and date an acknowledgement that the program provider's services are not predicated on a contribution and the contribution is voluntary. The acknowledgement must be made a part of the individual's personal funds record. Source Note: The provisions of this §261.261 adopted to be effective January 1, 2001, 25 TexReg 12790; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.261 Contributions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201205 03/12/2026 (a) DADS may periodically monitor a trust fund account to assure compliance with this section. DADS notifies a program provider of monitoring plans and gives a report of the findings to the program provider.(b) DADS may, as a result of monitoring, refer a program provider to the Health and Human Services Commission Office of Inspector General (OIG) for an audit.(c) The program provider must provide all records and other documents required by §9.256 of this division (relating to Program Provider-Managed Personal Funds) to DADS upon request.(d) DADS provides the program provider with a report of the findings, which may include corrective actions that the program provider must take and internal control recommendations that the program provider may follow.(e) To dispute the report of findings, the program provider may request:(1) an informal review in accordance with §9.263(a) of this division (relating to Informal Review and Administrative Hearing); or(2) an administrative hearing in accordance §9.263(b) of this division.(f) If the program provider does not request an informal review or an administrative hearing and the report of findings requires corrective actions, the program provider must complete corrective actions within 60 days after receiving the report of findings.(g) If the program provider does not complete corrective actions required by DADS within 60 days after receiving the report of findings, DADS may impose a vendor hold on payments due to the program provider under the provider agreement until the program provider completes corrective actions.(h) If DADS imposes a vendor hold in accordance with subsection (g) of this section, the program provider may request an administrative hearing in accordance with §9.263(b)(5) of this division. If the failure to correct is upheld, DADS continues the vendor hold until the program provider completes the corrective actions. Source Note: The provisions of this §261.262 adopted to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.262 Trust Fund Monitoring and Audits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201206 03/12/2026 (a) Informal review.(1) A program provider that disputes the report of findings described in §9.262(d) of this division (relating to Trust Fund Monitoring and Audits) may request an informal review. The purpose of an informal review is to provide for the informal and efficient resolution of the matters in dispute. An informal review is conducted according to the following procedures:(A) DADS must receive a written request for an informal review by United States (U.S.) mail, hand delivery, special mail delivery, or fax no later than 15 days after the date on the written notification of the report of findings described in §9.262(d) of this division.(i) If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first working day after the 15th day is the final day the written request is accepted.(ii) A request for an informal review that is not received by the stated deadline is not accepted.(B) A program provider must submit a written request for an informal review:(i) by U.S. mail to DADS Trust Fund Monitoring Unit, Attn: Manager, P.O. Box 149030, Mail Code W-340, Austin, Texas 78714-9030;(ii) hand delivery or special mail delivery to 701 West 51st Street, Austin, Texas 78751-2321; or(iii) by fax to (512) 438-3639.(C) A program provider must, with its request for an informal review:(i) submit a concise statement of the specific findings it disputes;(ii) specify the procedures or rules that were not followed;(iii) identify the affected cases;(iv) describe the reason the findings are being disputed; and(v) include supporting information and documentation that directly demonstrates that a disputed finding is not correct.(D) DADS does not grant a request for an informal review that does not meet the requirements of this subsection.(2) Upon receipt of a request for an informal review, the Trust Fund Monitoring Unit Manager coordinates the review of the information submitted.(A) Additional information may be requested by DADS and must be received in writing by U.S. mail, hand delivery, special mail, or fax in accordance with paragraph (1)(B)(i) - (iii) of this subsection no later than 15 days after the date the program provider receives the written request for additional information. If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first working day after the 15th day is the final day the additional information is accepted.(B) DADS sends its written decision to the program provider by certified mail, return receipt requested.(i) If the original findings are upheld, DADS continues the schedule of deficiencies and requirement for corrective action.(ii) If the original findings are reversed, DADS issues a corrected schedule of deficiencies with the written decision.(iii) If the original findings are revised, DADS issues a revised schedule of deficiencies including any revised corrective action.(iv) If the original findings are upheld or revised, the program provider may request an administrative hearing in accordance with subsection (b) of this section.(v) If the original findings are upheld or revised and the program provider does not request an administrative hearing, the program provider has 60 days from the date of receipt of the written decision to complete the corrective actions.(I) If the program provider does not complete the corrective actions by that date, DADS may impose a vendor hold. If DADS imposes a vendor hold, the program provider may request an administrative hearing in accordance with subsection (b)(5) of this section.(II) If the failure to correct is upheld, DADS continues the vendor hold until the program provider completes the corrective action.(b) Administrative hearing.(1) The program provider must submit a written request for an administrative hearing under this section to: HHSC Appeals Division, P.O. Box 149030, Mail Code W-613, Austin, Texas 78714-9030.(2) The written request for a formal hearing must be received within 15 days after:(A) the date on the written notification of the report of findings described in section §9.262(d) of this division; or(B) the program provider receives the written decision sent as described in subsection (a)(2)(B) of this section.(3) An administrative hearing is conducted in accordance with 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(4) No later than 60 days after a final determination is issued as a result of an administrative hearing requested by a program provider under §9.262(e)(2) of this division or subsection (a)(2)(B)(iv) of this section, the program provider must complete any corrective action required by DADS or be subject to a vendor hold on payments due to the program provider under the provider agreement until the program provider completes corrective action. If DADS imposes a vendor hold, the program provider may request an administrative hearing in accordance with paragraph (5) of this subsection. If the failure to correct is upheld, DADS continues the vendor hold until the program provider completes the corrective action.(5) If DADS imposes a vendor hold under §9.262(g) of this division, subsection (a)(2)(B)(v) of this section, or paragraph (4) of this subsection, the program provider may request an administrative hearing within 15 days after receiving notice of the failure to correct and the vendor hold. The administrative hearing is limited to the issue of whether the program provider completed the corrective action. Source Note: The provisions of this §261.263 adopted to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING F PERSONAL FUNDS §261.263 Informal Review and Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201207 03/12/2026 (a) DADS may impose a directed plan of correction (DPoC) on one or more of a program provider's facilities, a vendor hold on payments due under one or more of a program provider's agreements, or both if:(1) the program provider is determined as a result of an inspection or survey to not meet one or more of the federal ICF/IID standards of participation (SoPs) or conditions of participation (CoPs) and DADS determines that the program provider's failure to meet such SoPs or CoPs resulted in or may result in serious injury to or death of an individual residing in the program provider's facility;(2) the program provider is determined as a result of an inspection or survey to not meet one or more of the SoPs and DADS determines that the program provider's failure to meet such SoPs indicates a pervasive lack of active treatment;(3) the program provider is determined as a result of an inspection or survey to not meet one of more of the SoPs or CoPs or to not be compliant with one or more state rules applicable to the ICF/IID program and DADS determines, based on its review of previous inspection or survey findings related to the program provider, that the program provider's failure to meet the SoPs or CoPs or noncompliance with state rules indicates:(A) a pattern of error in a particular discipline, such as nursing or psychology; or(B) deficient program provider practices or procedures, such as inadequate staffing or insufficient staff training; or(4) it is determined:(A) during a follow-up certification review that the program provider failed to correct previous findings of the survey and did not meet one or more additional SoPs, CoPs, or state rules; and(B) that the program provider's continued failure to meet the SoPs, CoPs, or state rules indicates significant deficient practices that resulted in or may result in serious injury to or death of an individual residing in the program provider's facility.(b) When making a determination in accordance with subsection (a) of this section, DADS reviews the inspection or survey reports documenting the program provider's failure to meet the SoPs, CoPs, or state rules, which may include a description of:(1) the situation or occurrence that led to the deficiency;(2) the program provider's response to the situation or occurrence; and(3) the program provider's practices at the time of the situation or occurrence.(c) DADS imposes a DPoC or vendor hold in accordance with subsection (a) of this section only on a facility that has been determined to meet the criteria described in subsection (a)(1), (2), (3), or (4) of this section. Source Note: The provisions of this §261.266 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING G PROVIDER AGREEMENT SANCTIONS §261.266 DADS Review of Inspection or Survey Findings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201208 03/12/2026 (a) The department will send written notice to the program provider of its intent to impose a DPoC, a vendor hold, or both in accordance with §419.266 of this title (relating to Department Review of State Survey Agency Findings).(b) Within 10 days after receipt of a notice of intent to impose a DPoC sent in accordance with subsection (a) of this section, a program provider may submit written recommendations to the department regarding the content of the DPoC.(c) The department will send the final DPoC to the program provider within 30 days after the date of the notice sent in accordance with subsection (a) of this section.(d) The department will monitor a program provider to determine if the program provider has implemented or completed the DPoC. Such monitoring may include reviews of documentation and on-site facility visits.(e) If a facility is the subject of a DPoC and the facility fails to implement the DPoC, the department may impose a vendor hold on payments due under the provider agreement for that facility.(f) The department will release a vendor hold imposed in accordance with subsection (e) of this section if the department determines that the program provider has implemented the DPoC.(g) The department will release a vendor hold imposed in accordance with §419.266 of this title if the state survey agency determines that the program provider meets the SoPs, CoPs, or state rules that caused the vendor hold. Prior to such a determination, the department may release such a vendor hold if the state survey agency determines that circumstances of immediate jeopardy identified by the state survey agency have been removed. Source Note: The provisions of this §261.267 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING G PROVIDER AGREEMENT SANCTIONS §261.267 Directed Plan of Correction and Vendor Hold Based on State Survey Agency Findings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201209 03/12/2026 (a) DADS may terminate a provider agreement:(1) for reasons set forth in federal or state laws, rules or regulations, including this subchapter and 1 TAC Chapter 355 (relating to Reimbursement Rates);(2) if the program provider fails to comply with the terms of the provider agreement, including failure of the program provider's facility to maintain ICF/IID Program certification;(3) if federal or state laws, rules or regulations are enacted, amended, repealed or judicially interpreted so as to render the fulfillment of the provider agreement by either the program provider or DADS unfeasible or impossible, and DADS and program provider cannot agree upon amendments to the provider agreement necessary to comply with such changes to laws, rules or regulation;(4) if a certification made by the program provider in the provider agreement is false or becomes inaccurate;(5) if DADS determines that a program provider has failed to implement a DPoC in accordance with §9.267 of this division (relating to Directed Plan of Correction and Vendor Hold Based on State Survey Agency Findings); or(6) if, during an 18-month period, three vendor holds are imposed on payments due under that provider agreement in accordance with §9.267 of this division.(A) A vendor hold may be used to terminate a provider agreement in accordance with this paragraph regardless of whether there was an actual interruption of payment to the program provider.(B) A vendor hold may be used no more than once to terminate a provider agreement in accordance with this paragraph.(b) If DADS proposes to terminate a provider agreement, DADS may place a vendor hold on payments due to the program provider under the provider agreement until:(1) an audit of the program provider's financial records, conducted in accordance with §9.269 of this division (relating to Audits) is completed;(2) a review of the program provider's fiscal accountability cost report, conducted in accordance with 1 TAC §355.452 (relating to Cost Reporting Procedures) and 1 TAC §355.457 (relating to Cost Finding Methodology) is completed; and(3) any amounts owed to DADS as a result of the audit and review are resolved.(c) If DADS proposes to terminate a provider agreement, DADS sends a written notice of the proposed termination to the program provider. The program provider may submit a written request for an informal reconsideration (IR) in accordance with paragraph (1) of this subsection.(1) DADS considers a request for an IR only if the program provider submits the request and any supporting documentation the program provider wants DADS to consider to DADS, within seven days after receiving DADS notice of proposed termination.(2) If the program provider submits a timely request for an IR, DADS provides a written response to the program provider affirming or reversing the proposed termination.(3) If the program provider does not submit a timely request for an IR, or DADS affirms the proposed termination, DADS proceeds with the proposed termination in accordance with subsection (d) of this section.(d) If DADS proposes to terminate a provider agreement after the process described in subsection (c) of this section, DADS sends a second written notice of the proposed termination to the program provider. The program provider may submit a written request for an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing).(e) If DADS proposes to terminate a provider agreement and the program provider requests an administrative hearing in accordance with 1 TAC §357.484, DADS does not terminate the provider agreement before the completion of the administrative hearing, but payments to the program provider may be withheld by DADS.(1) If the final decision of the administrative hearing is favorable to DADS or the program provider does not make a timely request for an administrative hearing, then payments withheld will not be made by DADS to the program provider.(2) If the final decision is favorable to the program provider, then DADS pays amounts withheld and resumes payment under the provider agreement.(f) If DADS terminates a provider agreement, DADS does not enter into a new provider agreement with the program provider until at least two days have elapsed from the effective date of the termination.(g) DADS may enter into a new provider agreement with a program provider that has had its provider agreement terminated if:(1) within 30 days after termination, the program provider requests a new provider agreement; and(2) within 90 days after termination, DADS determines that all deficiencies or actions that led to termination of the provider agreement have been corrected and the program provider is otherwise qualified to enter into a provider agreement.(h) In determining whether to enter into a new provider agreement with a program provider that has had its provider agreement terminated, DADS considers:(1) the nature, severity, and pervasiveness of the deficiencies or actions that led to termination of the provider agreement; and(2) the facility's or the program provider's history of compliance with ICF/IID Program requirements.(i) The term and effective date of a new provider agreement entered into in accordance with subsection (f) of this section will be determined by DADS.(j) If DADS determines not to enter into a new provider agreement:(1) a local authority must assist DADS in relocating individuals who choose to move from the facility; and(2) the program provider must assist DADS or the local authority in relocating individuals who choose to move from the facility. Source Note: The provisions of this §261.268 adopted to be effective January 1, 2001, 25 TexReg 12790; amended to be effective March 31, 2002, 27 TexReg 2475; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING G PROVIDER AGREEMENT SANCTIONS §261.268 Termination of Provider Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201210 03/12/2026 (a) The department will periodically audit a program provider to monitor compliance with §419.219 of this subchapter (relating to Provider Reimbursement) and Division Six (relating to Personal Funds). The department will notify the program provider of the audit date.(b) A program provider must maintain the following records;(1) personal funds records, as described in §419.256(h) of this title (relating to Program Provider-Managed Personal Funds);(2) trust fund account ledgers, as described in §419.256(c)(1)(A) and (c)(2)(A) of this title (relating to Program Provider-managed Personal Funds);(3) statements from financial institutions regarding trust fund accounts;(4) petty cash fund ledgers as described in §419.256(d)(3) of this title (relating to Program Provider-Managed Personal Funds);(5) written requests for personal funds from trust fund accounts, as described in §419.257 of this title (relating to Requests for Personal Funds from Trust Fund Accounts);(6) documentation of expenditures and deposits of personal funds, as described in §419. 256(i) of this title (relating to Program Provider-Managed Personal Funds);(7) documentation of an individual's ability to manage personal funds and decisions regarding management of personal funds, as described in §419.253 of this title (relating to Determining Management of Personal Funds);(8) documentation regarding requests for specific types or brands of items and services, as described in §419. 255(a) of this title (relating to Items and Services Purchased With Personal Funds);(9) applied income ledgers, as described in §419.260(c) of this title (relating to Applied Income);(10) applied income payment plans from TDHS;(11) agreements to hold the individual's residential placement in the facility as described in §419.227(j) of this title (relating to Discharge From a Facility);(12) statements from financial institutions regarding operating accounts;(13) facility census and admission/discharge records;(14) leave records as described in §419.226 of this title (relating to Leaves); and(15) IPP's and supporting documentation.(c) If the records required by subsection (b) of this section, or any other records required to be maintained by this subchapter, are not made available by the program provider when requested by the department, or the department determines that the records are not auditable, the department may impose a vendor hold on payments due to the program provider under the provider agreement until the records are available and auditable. If the program provider does not provide such records in accordance with instructions from the department, the department may terminate the provider agreement.(d) The department will provide the program provider with a report of the audit findings, which may include corrective actions that must be taken by the program provider and internal control recommendations that may be followed by the program provider. Corrective actions include making refunds to individuals or the department, entering ledger adjustments, submitting unidentified funds to the department, and establishing and maintaining records and systems. The program provider may request an administrative hearing in accordance with Division Eight of this subchapter (relating to Administrative Hearings) to contest corrective actions required by the department pursuant to this subsection.(e) If the report of audit findings requires corrective actions and the program provider does not make a request for an administrative hearing in accordance with Division 8 of this subchapter (relating to Administrative Hearings), the program provider must complete corrective actions within 60 days after receiving the report of audit findings.(f) If the program provider does not complete corrective actions required by the department within 60 days after receiving the report of audit findings, the department may:(1) impose a vendor hold on payments due to the program provider under the provider agreement until the program provider completes corrective actions;(2) recoup payments due to the program provider under the provider agreement to make refunds to individuals or the department; and(3) terminate the provider agreement.(g) Notwithstanding the other provisions set forth in this section, the department may terminate the provider agreement for repeated failure to comply with §419.219 of this subchapter (relating to Provider Reimbursement) and Division Six (relating to Personal Funds), as determined by audits conducted in accordance with this section. Source Note: The provisions of this §261.269 adopted to be effective September 1, 2001, 26 TexReg 5384; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING G PROVIDER AGREEMENT SANCTIONS §261.269 Audits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201211 03/12/2026 (a) DADS suspends payments owed to a program provider under a provider agreement if DADS is notified by the Health and Human Services Commission Office of Inspector General (OIG) that payments must be withheld because of receipt of reliable evidence involving fraud or willful misrepresentation under the Medicaid Program in accordance with 42 CFR §455.23(a).(b) DADS suspends payments in accordance with subsection (a) of this section until:(1) OIG notifies DADS that it must pay amounts suspended and resume payment under the provider agreement; or(2) OIG notifies DADS that it must terminate the provider agreement in accordance with §9.268 of this division (relating to Termination of Provider Agreement.) Source Note: The provisions of this §261.270 adopted to be effective November 4, 2013, 38 TexReg 7724; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING G PROVIDER AGREEMENT SANCTIONS §261.270 Suspension of Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201212 03/12/2026 (a) A program provider may request an administrative hearing in accordance with Chapter 409, Subchapter B of this title (relating to Adverse Actions) if the department takes or proposes to take the following action:(1) vendor hold;(2) termination of a provider agreement;(3) recoupment of payments made to the program provider; or(4) denial of a program provider's request for payment.(b) If the basis of an administrative hearing requested under subsection (a) of this section is a dispute regarding a LON assignment, a program provider may receive an administrative hearing only if reconsideration was requested by the program provider in accordance with department rule. Source Note: The provisions of this §261.273 adopted to be effective July 26, 2001, 26 TexReg 5402; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING H ADMINISTRATIVE HEARINGS §261.273 Administrative Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201213 03/12/2026 (a) An individual may elect to receive hospice care in a facility if the individual is eligible for such care in accordance with 40 TAC §30.10 (relating to Eligibility Requirements). An individual's LAR or surrogate decision-maker, appointed in accordance with §405.237 of this title (relating to Appointment and Qualifications of a Surrogate Decision-Maker), may elect hospice care for the individual.(b) If hospice care is elected for an individual in accordance with 40 TAC §30.16 (relating to Election of Hospice Care), the program provider for the individual must contract with the designated hospice or discharge the individual in accordance with §419.227 of this title (relating to Discharge from a Facility).(c) Before hospice care is provided to an individual at a facility:(1) the program provider and the hospice must execute a contract, as described in subsection (d) of this section;(2) the program provider and the hospice must review the individual's MR/RC Assessment to determine if a revision to the individual's LON is needed in accordance with §419.246 of this subchapter (relating to Renewal and Revision of Level of Need);(3) the program provider must provide a signed copy of the completed MR/RC Assessment to the hospice; and(4) the program provider must notify the TDMHMR Help Desk at (888) 952-4357 that the individual has elected to receive hospice care.(d) A contract between a program provider and a hospice must establish the amount the hospice will pay the program provider for the individual's room and board and must require the hospice and the program provider to develop a plan of care for the individual. In this section, "room and board" includes performance of personal care services, including assistance with activities of daily living, administration of medication, maintaining the cleanliness of an individual's room, and supervision and assistance with durable medical equipment and prescribed therapies.(e) A program provider must continue to provide services in accordance with this subchapter to an individual receiving hospice care in a facility. If the individual, or the LAR on the individual's behalf, chooses continued participation in active treatment and such treatment, in the opinion of the individual's physician, is not contraindicated by the individual's condition, it must be provided in accordance with the individual's ability to participate in it.(f) A program provider must pay the quality assurance fee described in 1 TAC Chapter 352 (relating to Quality Assurance Fee for Long-Term Care Facilities) for an individual receiving hospice care in a facility of the program provider.(g) Hospice staff will not be considered facility staff to establish or maintain a staff-to-client ratio. Source Note: The provisions of this §261.274 adopted to be effective January 5, 2003, 27 TexReg 12251; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING I HOSPICE SERVICES §261.274 Hospice Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201228 03/12/2026 (a) The purpose of this division is to describe a process by which certain treatment decisions are made by an IDT, surrogate decision-maker, or surrogate consent committee on behalf of an individual who lacks the capacity to make an informed decision about the proposed treatment, medication, or procedure and has no LAR. A treatment decision involves giving or denying consent for a treatment, medication, or procedure for an individual.(b) The process described in this division applies only to a treatment decision for an individual regarding:(1) the use of a psychoactive medication;(2) a highly restrictive procedure;(3) major medical treatment;(4) major dental treatment;(5) a risk to individual protection and rights; or(6) the release of records related to the individual's condition or treatment to facilitate the treatment to which a surrogate decision-maker or surrogate consent committee has consented.(c) This division does not apply to a decision for an individual regarding:(1) experimental research;(2) sterilization:(3) management of funds;(4) electroconvulsive treatment; or(5) abortion. Source Note: The provisions of this §261.281 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.281 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201214 03/12/2026 This division applies to a community program provider. It does not apply to a program provider acting on behalf of a campus-based facility. Source Note: The provisions of this §261.282 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.282 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201215 03/12/2026 (a) If a community program provider is seeking a decision regarding any of the matters described in §9.281(b)(1) - (5) of this division (relating to Purpose) for an adult individual who does not have an LAR, the community program provider must conduct an assessment of the individual to determine whether the individual has the capacity to make an informed decision.(b) To conduct the assessment, the community program provider must:(1) provide the following information to the individual:(A) a description of the condition that the proposed treatment, medication, or procedure is intended to improve or cure;(B) a description of the proposed treatment, medication, or procedure, including:(i) the individual's need for it; and(ii) the potential benefits and risks of it to the individual;(C) a description of any generally accepted alternatives to the proposed treatment, medication, or procedure, including the risks and potential benefits of the alternatives to the individual;(D) the reasons the alternatives were not proposed for the individual, if applicable;(E) the time frames involved, such as immediacy of the need for the proposed treatment, medication, or procedure and the length of time that consent will be effective; and(F) that the individual has the right to refuse to give consent or withdraw consent;(2) take into consideration the individual's values and beliefs; and(3) determine whether the individual has the capacity to make an informed decision by demonstrating a basic understanding of the information provided in paragraph (1) of this subsection and communicating a decision, free from coercion or undue influence, about the proposed treatment, medication, or procedure.(c) The community program provider must provide the information described in subsection (b)(1) of this section in non-technical terminology by using the individual's primary language or mode of communication.(d) The community program provider must document the following:(1) the specific information provided to the individual as described in subsection (b)(1) of this section; and(2) the reasons the community program provider determined that the individual does or does not have the capacity to make an informed decision. Source Note: The provisions of this §261.283 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.283 Informed Decision Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201216 03/12/2026 (a) If, based on the assessment described in §9.283 of this division (relating to Informed Decision Assessment), a community program provider determines that an individual has the capacity to make an informed decision and to communicate the decision, free from coercion or undue influence, about the proposed treatment, medication, or procedure, the community program provider must allow the individual to consent to or refuse the proposed treatment, medication, or procedure.(b) If, based on the assessment described in §9.283 of this division, the community program provider determines that the individual does not have the capacity to make an informed decision about the proposed treatment, medication, or procedure, the community program provider must obtain an informed decision from:(1) the individual's IDT, in accordance with §9.285 of this division (relating to IDT Decisions);(2) a surrogate decision-maker in accordance with §9.286 of this division (relating to Surrogate Decision-Maker); or(3) a surrogate consent committee in accordance with §9.288 of this division (relating to Surrogate Consent Committee Decisions), §9.289 of this division (relating to Submission of Application Packet for Surrogate Consent Committee), §9.291 of this division (relating to Notice of Hearing and Documents Provided to Surrogate Consent Committee), and §9.293 of this division (relating to Surrogate Consent Committee Hearing). Source Note: The provisions of this §261.284 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.284 Making Informed Decisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201217 03/12/2026 (a) An IDT may:(1) consent to the following changes regarding administration of a psychoactive medication subsequent to the initial consent for the medication given by a surrogate consent committee, if such changes pose no significant risk to an individual based on the judgment of the prescribing health care professional and other health care professionals involved in the individual's care:(A) an increase or decrease in the dosage of the medication; and(B) a change of medication within the same therapeutic drug class; and(2) make a decision that involves risk to the individual protection and rights not specifically reserved to a surrogate decision-maker or a surrogate consent committee.(b) An IDT's consent to a change regarding the administration of a psychoactive medication, as described in subsection (a)(1) of this section, is only valid until the expiration of the initial consent by the surrogate consent committee.(c) The IDT must document, in the individual's record, a decision made in accordance with subsection (a) of this section, including the deliberations of the IDT in reaching the decision. Source Note: The provisions of this §261.285 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.285 IDT Decisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201218 03/12/2026 (a) A community program provider must develop and implement written procedures for identifying and using a surrogate decision-maker in accordance with the provisions of this division.(b) A surrogate decision-maker may:(1) consent to major medical treatment;(2) consent to major dental treatment;(3) consent to release of records related to the individual's condition or treatment to facilitate the treatment to which the surrogate decision-maker has consented; and(4) make a decision that involves risk to individual protection and rights.(c) A surrogate decision-maker may not consent to the use of psychoactive medication or a highly restrictive procedure.(d) If, based on the assessment described in §9.283 of this division (relating to Informed Decision Assessment), a community program provider determines that an individual does not have the capacity to make an informed decision about matters listed in subsection (b) of this section, the community program provider must determine if one of the following persons, in order of descending preference, is available and willing to act as the surrogate decision-maker for the individual:(1) an actively involved spouse;(2) an actively involved adult child who has the waiver and consent of all other actively involved adult children of the individual to act as the sole decision-maker;(3) an actively involved parent or stepparent;(4) an actively involved adult sibling who has the waiver and consent of all other actively involved adult siblings of the individual to act as the sole decision-maker; or(5) any other actively involved adult relative who has the waiver and consent of all other actively involved adult relatives of the individual to act as the sole decision-maker.(e) If a community program provider is aware of a dispute as to the right of a person to act as a surrogate decision-maker, the community program provider must inform the persons involved that the dispute may be resolved only by a court of record under the Texas Probate Code, Chapter XIII.(f) If a community program provider identifies a person to be a surrogate decision-maker in accordance with subsection (d) of this section, the community program provider must document the identity of that person in the individual's record.(g) If a community program provider is unable to identify a surrogate decision-maker in accordance with subsection (d) of this section, including because of an unresolved dispute, the community program provider must document the reason the community program provider was unable to identify a surrogate decision-maker. Source Note: The provisions of this §261.286 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.286 Surrogate Decision-Maker https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201219 03/12/2026 (a) A community program provider must provide the following information to a person identified as a surrogate decision-maker in accordance with §9.286 of this division (relating to Surrogate Decision-Maker):(1) a description of the condition that the proposed treatment, medication, or procedure is intended to improve or cure;(2) a description of the proposed treatment, medication, or procedure, including:(A) the individual's need for it; and(B) the potential benefits and risks of it to the individual;(3) a description of any generally accepted alternatives to the proposed treatment, medication, or procedure, including the risks and potential benefits of the alternatives to the individual;(4) the reasons the alternatives were not proposed for the individual, if applicable;(5) the time frames involved, such as immediacy of the need for the proposed treatment, medication, or procedure and the length of time that consent will be effective; and(6) that the surrogate decision-maker may:(A) refuse to give consent or withdraw consent after it is given;(B) defer to a surrogate consent committee for a specific decision; and(C) withdraw as the surrogate decision-maker.(b) A community program provider must document in the individual's record:(1) the specific information provided to the surrogate decision-maker as described in subsection (a) of this section;(2) the decision made by the surrogate decision-maker, and:(A) if consent is given, include a copy of the written consent given by the surrogate decision-maker; or(B) if consent is denied, document the reason for the denial, if known;(3) withdrawal of consent after it is given by the surrogate decision-maker and, if known, the reason for the withdrawal;(4) deferral by the surrogate decision-maker for a specific decision and, if known, the reason for the deferral; and(5) withdrawal of the surrogate decision-maker and, if known, the reason for the withdrawal. Source Note: The provisions of this §261.287 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.287 Provider Responsibilities Regarding Surrogate Decision-Maker https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201220 03/12/2026 A surrogate consent committee may:(1) consent to the use of a psychoactive medication;(2) consent to the use of a highly restrictive procedure;(3) consent to major medical treatment;(4) consent to major dental treatment;(5) make a decision that involves risk to individual protection and rights; and(6) consent to release of records related to the individual's condition or treatment to facilitate the treatment to which the surrogate consent committee has consented. Source Note: The provisions of this §261.288 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.288 Surrogate Consent Committee Decisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201221 03/12/2026 (a) A community program provider must submit an application packet for a treatment decision by a surrogate consent committee, as described in §9.288 of this division (relating to Surrogate Consent Committee Decisions), if:(1) the community program provider is unable to identify a surrogate decision-maker in accordance with §9.286(d) of this division (relating to Surrogate Decision-Maker), including because of an unresolved dispute described in §9.286(e) of this division;(2) an identified surrogate decision-maker has deferred a specific decision to the surrogate consent committee; or(3) the community program provider is seeking a decision regarding the use of a psychoactive medication or a highly restrictive procedure.(b) A community program provider must submit an application packet for a treatment decision in accordance with written instructions from DADS. The application packet must include:(1) a completed, original SDM Form 2700, Application for a Treatment Decision by a Surrogate Consent Committee;(2) a completed, original SDM Form 2725, List of Persons to Receive Notification of SCC Hearing;(3) a completed, original SDM Form 2750, SDM Data Form;(4) the applicable certification of need form; and(5) appropriate supporting documentation.(c) The instructions and forms described in subsection (b) of this section are available on the DADS website at www.dads.state.tx.us.(d) Upon request by DADS, the community program provider must submit additional information related to the application packet for a treatment decision.(e) If DADS determines that the community program provider has not completed the application process within a reasonable period of time, DADS does not proceed with the application process and closes the case.(f) If DADS closes the case and a treatment decision is still required in accordance with subsection (a) of this section, the community program provider must submit a new application packet in accordance with subsection (b) of this section.(g) DADS notifies the community program provider, in writing, if DADS closes the case.(h) If DADS approves an application packet for a treatment decision, DADS appoints a surrogate consent committee in accordance with §9.290 of this division (relating to Appointment and Qualifications of a Surrogate Consent Committee). Source Note: The provisions of this §261.289 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.289 Submission of Application Packet for Surrogate Consent Committee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201222 03/12/2026 (a) If DADS approves an application packet for a treatment decision, DADS appoints a surrogate consent committee that:(1) is composed of at least three but not more than five volunteers who:(A) are 18 years of age or older;(B) are not employees or contractors of the community program provider;(C) do not manage or exercise supervisory control over:(i) the community program provider or the employees of the community program provider; or(ii) any company, corporation, or other legal entity that manages or exercises control over the community program provider or the employees of the community program provider;(D) do not have a financial interest in the community program provider or in any company, corporation, or other legal entity that has a financial interest in the community program provider;(E) are not parents, siblings, spouses, or children of the individual for whom a treatment decision is being sought; and(F) have completed a training program conducted by DADS; and(2) includes at least one volunteer who:(A) is a health care professional who is licensed or registered in Texas and who has specialized training in medicine, psychopharmacology, nursing, or psychology; or(B) has demonstrated expertise or interest in the care and treatment of individuals with mental retardation.(b) DADS appoints one of the volunteers on the surrogate consent committee to be chairperson of the committee. Source Note: The provisions of this §261.290 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.290 Appointment and Qualifications of a Surrogate Consent Committee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201223 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201223 03/12/2026 (a) DADS sends notice of a surrogate consent committee hearing to:(1) each volunteer on the surrogate consent committee; and(2) the community program provider.(b) The notice described in subsection (a) of this section includes:(1) the date, time, and location of the hearing;(2) the name of the individual for whom a treatment decision is sought; and(3) the type of treatment decision to be considered at the hearing.(c) DADS sends each volunteer on the surrogate consent committee, in addition to the notice of hearing described in subsection (a) of this section:(1) relevant portions of the application packet; and(2) a written consultation from a DADS health care professional licensed or registered in Texas to assist the committee in determining the individual's best interest regarding the treatment decision.(d) A community program provider must give notice of the surrogate consent committee hearing to:(1) the individual for whom a treatment decision is being sought;(2) the individual's actively involved spouse, adult child, parent, adult sibling, stepparent, or other adult relative; and(3) any person known to have a demonstrated interest in the care and welfare of the individual, such as an advocate or a friend identified by the individual.(e) Concerning a notice required by subsection (d)(1) of this section, a community program provider must:(1) include in the notice:(A) the date, time, and location of the hearing; and(B) the type of treatment decision to be considered at the hearing;(2) explain the notice to the individual using the individual's primary language or mode of communication; and(3) document that the explanation required in paragraph (2) of this subsection was given.(f) Concerning a notice required by subsection (d)(2) and (3) of this section, a community program provider must:(1) include in the notice:(A) the date, time, and location of the hearing;(B) the name of the individual for whom a treatment decision is sought;(C) the type of treatment decision to be considered at the hearing;(D) a copy of the completed, original SDM Form 2700, Application for a Treatment Decision by a Surrogate Consent Committee; and(E) a statement concerning the opportunity to:(i) attend the hearing and present evidence or testimony personally or through a representative; and(ii) appeal the surrogate consent committee's decision in accordance with THSC, §597.053; and(2) send the notice in writing and by certified mail. Source Note: The provisions of this §261.291 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.291 Notice of Hearing and Documents Provided to Surrogate Consent Committee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201224 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201224 03/12/2026 (a) Before a surrogate consent committee hearing, the chairperson of the committee must review the documentation described in §9.291(c) of this division (relating to Notice of Hearing and Documents Provided to Surrogate Consent Committee) and determine if additional information is needed to assist the committee in making a treatment decision.(b) If the chairperson determines that additional information is needed, the chairperson must request the information from DADS.(c) Before the hearing, a volunteer on the surrogate consent committee may interview and observe the individual for whom the treatment decision is sought and consult with a person who may be able to provide information to assist the committee in making the treatment decision, including information about the personal opinions, beliefs, and values of the individual. Source Note: The provisions of this §261.292 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.292 Review and Consultation Prior to Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201225 03/12/2026 (a) A person notified of a surrogate consent committee hearing, as required by §9.291(a) and (d) of this division (relating to Notice of Hearing and Documents Provided to Surrogate Consent Committee), is entitled to be present at the hearing and to present evidence or testimony personally or through a representative.(b) A community program provider must ensure that:(1) the individual for whom the treatment decision is sought is present at the hearing, if practicable;(2) the individual's record is at the hearing; and(3) an audio recording of the hearing is made.(c) At a surrogate consent committee hearing, the committee:(1) must review the documentation described in §9.291(c) of this division and any additional information provided to the committee by DADS;(2) must interview and observe the individual, if practicable, and document its impressions of the interview and observation;(3) must review evidence or hear testimony from a person notified of the hearing as required by §9.291(a) and (d) of this division, or the person's representative, if the person or the person's representative makes a request to present evidence or testimony at the hearing; and(4) may review evidence or hear testimony from any person who may be able to assist the committee in making a treatment decision.(d) After the surrogate consent committee has reviewed all evidence and heard all testimony, the committee must enter into closed deliberations and make the treatment decision.(e) In making the treatment decision, the surrogate consent committee must determine, based on clear and convincing evidence, whether the proposed treatment, medication, or procedure is in the best interest of the individual.(1) If a majority of the volunteers on the surrogate consent committee determine that the proposed treatment, medication, or procedure is in the best interest of the individual, the committee must consent to the proposed treatment, medication, or procedure.(2) If a majority of the volunteers on the surrogate consent committee determine that the proposed treatment, medication, or procedure is not in the best interest of the individual, the committee must deny consent to the proposed treatment, medication, or procedure.(f) If the surrogate consent committee consents to the proposed treatment, medication, or procedure, the committee must determine the date on which the consent becomes effective and the duration of the consent.(g) If an application for a guardianship proceeding for the individual has been filed before the surrogate consent committee makes a treatment decision, the committee must, before continuing with the hearing, make one of the following determinations:(1) a person has not been appointed guardian of the person for the individual within five days after suspension of the committee proceeding in accordance with §9.294 of this division (relating to Notice of Guardianship Proceeding); or(2) there is a medical necessity, based on clear and convincing evidence, that the treatment decision be made within five days after the hearing date.(h) Formal rules of evidence are not applicable to a surrogate consent committee hearing.(i) A surrogate consent committee must conduct the hearing and document its treatment decision in accordance with written instructions from DADS available at www.dads.state.tx.us.(j) A community program provider must:(1) send to DADS in accordance with written instructions from DADS available at www.dads.state.tx.us:(A) the audio recording of a hearing made in accordance with subsection (b) of this section;(B) the documentation completed by the surrogate consent committee; and(C) the written evidence presented at the hearing; and(2) send to a person notified of a surrogate consent committee hearing, as required by §9.291(a) and (d) of this division, the documentation completed by the surrogate consent committee. Source Note: The provisions of this §261.293 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.293 Surrogate Consent Committee Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201226 03/12/2026 (a) If before a surrogate consent committee makes a treatment decision, the committee is informed that an application for a guardianship proceeding for an individual has been filed with a court, the chairperson of the committee must suspend the committee proceeding for five days unless a medical necessity exists that requires a treatment decision to be made during the five-day period.(b) If the chairperson suspends a committee proceeding and a person has not been appointed guardian for the individual within five days after the suspension, the chairperson must resume the committee proceeding. Source Note: The provisions of this §261.294 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.294 Notice of Guardianship Proceeding https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201227 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201227 03/12/2026 A surrogate decision-maker or volunteer on a surrogate consent committee who consents or denies consent on behalf of an individual and who acts in good faith, reasonably, and without malice is not criminally or civilly liable for that action. Source Note: The provisions of this §261.295 adopted to be effective July 1, 2007, 32 TexReg 3856; transferred effective October 1, 2020, as published in the Texas Register August 28, 2020, 45 TexReg 6127. 1 HEALTH AND HUMAN SERVICES COMMISSION 261 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS (ICF/IID) PROGRAM--CONTRACTING J SURROGATE DECISION-MAKING §261.295 Liability for Treatment Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212802 03/12/2026 The purpose of this subchapter is to describe certain policies, procedures, and requirements of the TxHmL Program. Source Note: The provisions of this §262.1 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212803 03/12/2026 This chapter applies to:(1) a program provider;(2) a LIDDA;(3) an applicant and the applicant's LAR; and(4) an individual and the individual's LAR. Source Note: The provisions of this §262.2 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222999 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Actively involved--Significant, ongoing, and supportive involvement with an applicant or individual by a person, as determined by the applicant's or individual's service planning team or program provider, based on the person's:(A) interactions with the applicant or individual;(B) availability to the applicant or individual for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the applicant's or individual's needs, preferences, values, and beliefs.(3) ADLs--Activities of daily living. Basic personal everyday activities including tasks such as eating, toileting, grooming, dressing, bathing, and transferring.(4) Agency foster home--This term has the meaning set forth in Texas Human Resources Code §42.002.(5) Applicant--A Texas resident seeking services in the Texas Home Living (TxHmL) Program.(6) Audio-only--An interactive, two-way audio communication platform that only uses sound.(7) Auxiliary aid--A service or device that enables an individual with impaired sensory, manual, or speaking skills to participate in the person-centered planning process. An auxiliary aid includes interpreter services, transcription services, and a text telephone.(8) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(9) Calendar day--Any day, including weekends and holidays.(10) CDS option--Consumer directed services option. A service delivery option as defined in §264.103 of this title (relating to Definitions).(11) CFC--Community First Choice.(12) CFC ERS--CFC emergency response services.(13) CFC FMS--The term used for financial management services on the individual plan of care (IPC) of an applicant or individual if the applicant will receive or the individual receives only CFC personal assistance services (PAS)/habilitation (HAB) through the CDS option.(14) CFC support consultation--The term used for support consultation on the IPC of an applicant or individual if the applicant will receive or the individual receives only CFC PAS/HAB through the CDS option.(15) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.(16) Competitive employment--Employment that pays an individual at least minimum wage if the individual is not self-employed.(17) Comprehensive nursing assessment--A comprehensive physical and behavioral assessment of an individual, including the individual's health history, current health status, and current health needs, that is completed by a registered nurse (RN).(18) Contract--A provisional contract or a standard contract.(19) Delegated nursing task--A nursing task delegated by a registered nurse to an unlicensed person in accordance with:(A) 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and(B) 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).(20) DFPS--The Department of Family and Protective Services.(21) DID--Determination of intellectual disability. This term has the meaning set forth in §304.102 of this title (relating to Definitions).(22) DID report--Determination of intellectual disability report. This term has the meaning set forth in §304.102 of this title.(23) EVV--Electronic visit verification. This term has the meaning set forth in 1 TAC §354.4003 (relating to Definitions).(24) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain.(25) Group setting--A setting, other than an individual's residence, in which more than one individual or other person receives employment readiness, employment assistance, supported employment, or a similar service.(26) FMS--Financial management services.(27) FMSA--Financial management services agency. As defined in §264.103 of this title, an entity that provides FMS to an individual participating in the CDS option.(28) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(29) HCS--Home and Community-based Services. Services provided through the HCS Program operated by the Texas Health and Human Services Commission (HHSC) as authorized by CMS in accordance with §1915(c) of the Social Security Act.(30) Health maintenance activities--This term has the meaning set forth in 22 TAC §225.4 (relating to Definitions).(31) Health-related tasks--Specific tasks related to the needs of an individual, which can be delegated or assigned by a licensed health care professional under state law to be performed by a service provider of CFC PAS/HAB. This includes tasks delegated by an RN; health maintenance activities, that may not require delegation; and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist.(32) HHSC--The Texas Health and Human Services Commission.(33) Hospital--A public or private institution licensed or exempt from licensure in accordance with Texas Health and Safety Code (THSC) Chapters 13, 241, 261, or 552.(34) IADLs--Instrumental activities of daily living. Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community.(35) ICAP--Inventory for Client and Agency Planning. An instrument designed to assess a person's needs, skills, and abilities.(36) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided and that is:(A) licensed in accordance with THSC Chapter 252; or(B) certified by HHSC, including a state supported living center.(37) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions.(38) ID/RC Assessment--Intellectual Disability/Related Conditions Program Assessment. A form used by HHSC for level of care determination and level of need assignment.(39) Implementation plan--A written document developed by a program provider for an individual for each TxHmL Program service, except community support, and for each CFC service, except CFC support management, on the individual's IPC to be provided by the program provider. An implementation plan includes:(A) a list of outcomes identified in the person-directed plan that will be addressed using TxHmL Program services and CFC services;(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:(i) observable, measurable, and outcome-oriented; and(ii) derived from assessments of the individual's strengths, personal goals, and needs;(C) a target date for completion of each objective;(D) the number of units of TxHmL Program services and CFC services needed to complete each objective;(E) the frequency and duration of TxHmL Program services and CFC services needed to complete each objective; and(F) the signature and date of the individual, legally authorized representative (LAR), and the program provider.(40) In person or in-person--Within the physical presence of another person who is awake. In person or in-person does not include using videoconferencing or a telephone.(41) Individual--A person enrolled in the TxHmL Program.(42) Initial IPC--The first IPC for an individual developed before the individual's enrollment into the TxHmL Program.(43) Inpatient chemical dependency treatment facility--A facility licensed in accordance with THSC Chapter 464, Facilities Treating Persons with a Chemical Dependency.(44) Intellectual disability--This term has the meaning set forth in §304.102 of this title.(45) IPC--Individual plan of care. A written plan that:(A) states:(i) the type and amount of each TxHmL Program service and each CFC service, except for CFC support management, to be provided to an individual during an IPC year;(ii) the services and supports to be provided to the individual through resources other than TxHmL Program services or CFC services, including natural supports, medical services, and educational services; and(iii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(46) IPC cost--Estimated annual cost of TxHmL Program services included on an IPC.(47) IPC year--The effective period of an initial IPC and renewal IPC as described in this paragraph.(A) Except as provided in subparagraph (B) of this paragraph, the IPC year for an initial and renewal IPC is a 365-calendar day period starting on the begin date of the initial or renewal IPC.(B) If the begin date of an initial or renewal IPC is March 1 or later in a year before a leap year or January 1 - February 28 of a leap year, the IPC year for the initial or renewal IPC is a 366-calendar day period starting on the begin date of the initial or renewal IPC.(C) A revised IPC does not change the begin or end date of an IPC year.(48) Job-task oriented--Focused on developing a skill related to a specific type of employment.(49) LAR--Legally authorized representative. A person authorized by law to act on behalf of a person with regard to a matter described in this subchapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(50) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with THSC §533A.035.(51) LOC--Level of care. A determination given to an applicant or individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(52) LON--Level of need. An assignment given by HHSC to an applicant or individual that is derived from the ICAP service level score and from selected items on the ID/RC Assessment.(53) Managed care organization--This term has the meaning set forth in Texas Government Code §543A.0001.(54) MAO Medicaid--Medical Assistance Only Medicaid. A type of Medicaid by which an applicant or individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits.(55) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(56) Mental health facility--A facility licensed in accordance with THSC Chapter 577, Private Mental Hospitals and Other Mental Health Facilities.(57) Military family member--A person who is the spouse or child (regardless of age) of:(A) a military member; or(B) a former military member.(58) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch.(59) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who voluntarily assist an individual to achieve the individual's identified goals.(60) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(61) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(62) PDP--Person-directed plan. A plan developed with an applicant or individual and LAR using an HHSC form that:(A) describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual and LAR and to ensure the applicant's or individual's health and safety; and(B) includes the setting for each service, which must be selected by the individual or LAR from setting options.(63) Performance contract--A written agreement between HHSC and a LIDDA for the performance of delegated functions, including those described in THSC §533A.035.(64) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual;(C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or(D) seclusion.(65) Platform--This term has the meaning set forth in Texas Government Code §521.0001.(66) Post-move monitoring visit--A visit conducted by the service coordinator in accordance with the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook.(67) Pre-move site review--A review conducted by the service coordinator in accordance with HHSC's IDD PASRR Handbook.(68) Professional therapies--Services that consist of the following:(A) audiology services;(B) behavioral support;(C) dietary services;(D) occupational therapy services;(E) physical therapy services; and(F) speech and language pathology.(69) Program provider--A person, as defined in §52.3 of this title (relating to Definitions), that has a contract with HHSC to provide TxHmL Program services, excluding an FMSA.(70) Provisional contract--A contract that HHSC enters into with a program provider in accordance with §52.39 of this title (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §52.39(e) of this title.(71) Related condition--A severe and chronic disability that:(A) is attributed to:(i) cerebral palsy or epilepsy; or(ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability;(B) is manifested before the individual reaches age 22;(C) is likely to continue indefinitely; and(D) results in substantial functional limitation in at least three of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(72) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the TxHmL Program Billing Requirements.(73) Renewal IPC--An IPC developed for an individual in accordance with §262.302(a) of this chapter (relating to Renewal and Revision of an Individual's IPC).(74) Residential child care facility--The term has the meaning set forth in Texas Human Resources Code §42.002.(75) Revised IPC--An IPC that is revised during an IPC year in accordance with §262.302 of this chapter to add a new TxHmL Program service or CFC service or change the amount of an existing service.(76) RN--Registered nurse. A person licensed to practice professional nursing in accordance with Texas Occupations Code Chapter 301.(77) Service backup plan--A plan that ensures continuity of a service that is critical to an individual's health and safety if service delivery is interrupted.(78) Service coordination--A service as defined in §331.5 of this title (relating to Definitions).(79) Service coordinator--An employee of a LIDDA who provides service coordination to an individual.(80) Service planning team--One of the following:(A) for an applicant or individual other than one described in subparagraph (B) or (C) of this paragraph, a planning team consisting of:(i) an applicant or individual and LAR;(ii) the service coordinator; and(iii) other persons chosen by the applicant, individual, or LAR, for example, a staff member of the program provider, a family member, a friend, or a teacher;(B) for an applicant 21 years of age or older who is residing in a nursing facility and enrolling in the TxHmL Program, a planning team consisting of:(i) the applicant and LAR;(ii) service coordinator;(iii) a staff member of the program provider;(iv) providers of specialized services;(v) a nursing facility staff person who is familiar with the applicant's needs;(vi) other persons chosen by the applicant or LAR, for example, a family member, a friend, or a teacher; and(vii) at the discretion of the LIDDA and with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability; or(C) for an individual 21 years of age or older who has enrolled in the TxHmL program from a nursing facility or ICF/IID or has enrolled in the TxHmL Program as a diversion from admission to an institution, including a nursing facility or ICF/IID, for 180 days after enrollment, a planning team consisting of:(i) the individual and LAR;(ii) the service coordinator;(iii) a staff member of the program provider;(iv) other persons chosen by the individual or LAR, for example, a family member, a friend, or a teacher; and(v) at the discretion of the LIDDA and with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability.(81) Service provider--A person, who may be a staff member, who directly provides a TxHmL Program service or CFC service to an individual.(82) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and a service provider, staff member, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff member, volunteer, or controlling person became a service provider, staff member, volunteer, or controlling person.(83) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(84) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(85) Staff member--An employee or contractor of a TxHmL Program provider.(86) Standard contract--A contract that HHSC enters into with a program provider in accordance with §52.41 of this title (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with §52.41(d) of this title.(87) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC.(88) Store and forward technology--This term has the meaning set forth in Texas Occupations Code §111.001(2).(89) Synchronous audio-visual--An interactive, two-way audio and video communication platform that:(A) allows a service to be provided to an individual in real time; and(B) conforms to the privacy requirements under the Health Insurance Portability and Accountability Act.(90) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code Chapter 2002, Subchapter C.(91) Telehealth service--This term has the meaning set forth in Texas Occupations Code §111.001.(92) Temporary Admission--A stay in a facility listed in §262.505(a) of this chapter (relating to Suspension of TxHmL Program Services and CFC Services) for 270 calendar days or less or, if an extension is granted in accordance with §262.505(h) of this chapter, a stay in such a facility for more than 270 calendar days.(93) THSC--Texas Health and Safety Code. Texas statute relating to health and safety.(94) Transfer IPC--An IPC that is developed in accordance with §262.501 of this chapter (relating to Process for Individual to Transfer to a Different Program Provider or FMSA) or §262.502 of this chapter (relating to Process for Individual to Receive a Service Through the CDS Option that the Individual is Receiving from a Program Provider) when an individual transfers to another program provider or chooses a different service delivery option.(95) Transition plan--A written plan developed in accordance with §303.701 of this title (relating to Transition Planning for a Designated Resident) for an applicant residing in a nursing facility who is enrolling in the TxHmL Program.(96) Transportation plan--A written plan based on person-directed planning and developed with an applicant or individual using HHSC Individual Transportation Plan form available on the HHSC website. A transportation plan is used to document how community support will be delivered to support an individual's desired outcomes and purposes for transportation as identified in the PDP.(97) TxHmL Program--The Texas Home Living Program operated by HHSC as authorized by CMS in accordance with §1915(c) of the Social Security Act. The TxHmL Program provides community-based services and supports to eligible individuals who live in their own homes or in their family homes.(98) Vendor hold--A temporary suspension of payments that are due to a program provider under a contract.(99) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(100) Videoconferencing--An interactive, two-way audio and video communication:(A) used to conduct a meeting between two or more persons who are in different locations; and(B) that conforms to the privacy requirements under the Health Insurance Portability and Accountability Act.(101) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §262.3 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212805 03/12/2026 (a) The TxHmL Program is a Medicaid waiver program approved by CMS pursuant to §1915(c) of the Social Security Act. It provides community-based services and supports to eligible individuals who live in their own homes or in their family homes.(b) Enrollment in the TxHmL Program is limited to the number of individuals in specified target groups and to the geographic areas approved by CMS.(c) TxHmL Program services described in §262.5 of this subchapter (relating to Description of TxHmL Program Services) are selected for inclusion in an individual's IPC to ensure the individual's health, safety, welfare, and integration in the community. TxHmL Program services and CFC Services supplement rather than replace the individual's natural supports and other community services for which the individual may be eligible and prevent the individual's admission to an institutional setting.(d) CFC is a state plan option governed by 42 CFR Chapter 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice) that provides the following services to individuals:(1) CFC PAS/HAB;(2) CFC ERS; and(3) CFC support management for an individual receiving CFC PAS/HAB.(e) HHSC has grouped Texas counties into geographical areas, referred to as "local service areas," each of which is served by a LIDDA. HHSC has further grouped the local service areas into "waiver contract areas." A list of the counties included in each local service area and waiver contract area is available on the HHSC website.(1) A program provider may provide TxHmL Program services and CFC services only to persons residing in the counties specified for the program provider in the HHSC automated enrollment and billing system.(2) A program provider must have a separate contract for each waiver contract area served by the program provider.(3) A program provider may have a contract to serve one or more local service areas within a waiver contract area, but the program provider must serve all of the counties within each local service area covered by the contract.(4) A program provider may not have more than one contract per waiver contract area.(f) A program provider must comply with all applicable state and federal laws, rules, and regulations.(g) The CDS option is a service delivery option, described in 40 TAC Chapter 41 (relating to Consumer Directed Services Option), in which an individual or LAR employs and retains service providers and directs the delivery of a service through the CDS option, as described in 40 TAC §41.108 (relating to Services Available Through the CDS Option). Source Note: The provisions of this §262.4 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.4 Description of the TxHmL Program and CFC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222998 03/12/2026 (a) TxHmL Program services are described in this section and in Appendix C of the TxHmL Program waiver application approved by CMS.(1) Adaptive aids include devices, controls, or items that are necessary to address specific needs identified in an individual's service plan. Adaptive aids enable an individual to maintain or increase the ability to perform ADLs or the ability to perceive, control, or communicate with the environment in which the individual lives.(2) Audiology is the provision of audiology as defined in the Texas Occupations Code Chapter 401.(3) Speech and language pathology is the provision of speech-language pathology as defined in the Texas Occupations Code Chapter 401.(4) Occupational therapy is the provision of occupational therapy as described in the Texas Occupations Code Chapter 454.(5) Physical therapy is the provision of physical therapy as defined in the Texas Occupations Code Chapter 453.(6) Dietary is the provision of nutrition services as defined in the Texas Occupations Code Chapter 701.(7) Behavioral support is the provision of specialized interventions that:(A) assist an individual to increase adaptive behaviors to replace or modify maladaptive or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in home and family life or community life; and(B) improve an individual's quality of life.(8) Day habilitation is assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in a location other than the residence of an individual. Day habilitation does not include in-home day habilitation.(9) In-home day habilitation is assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in the individual's residence.(10) Dental treatment is:(A) emergency dental treatment;(B) preventive dental treatment;(C) therapeutic dental treatment; and(D) orthodontic dental treatment, excluding cosmetic orthodontia.(11) Minor home modifications are physical adaptations to an individual's residence to address specific needs identified by an individual's service planning team.(12) Licensed vocational nursing is the provision of licensed vocational nursing as defined in the Texas Occupations Code Chapter 301.(13) Registered nursing is the provision of professional nursing as defined in the Texas Occupations Code Chapter 301.(14) Specialized registered nursing is the provision of registered nursing to an individual who has a tracheostomy or is dependent on a ventilator.(15) Specialized licensed vocational nursing is the provision of licensed vocational nursing to an individual who has a tracheostomy or is dependent on a ventilator.(16) Community support provides transportation to an individual.(17) Respite provides temporary relief for an unpaid caregiver of an individual in a location other than the individual's residence.(18) In-home respite provides temporary relief for an unpaid caregiver of an individual in the individual's residence.(19) Employment assistance provides assistance to help an individual locate paid employment in the community.(20) Supported employment provides assistance, in order to sustain competitive employment, to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.(21) Employment readiness is assistance that prepares an individual to participate in employment. Employment readiness services are not job-task oriented.(b) The services described in this subsection are for an individual who is receiving at least one TxHmL Program service through the CDS option.(1) FMS is a service defined in §264.103 of this title (relating to Definitions).(2) Support consultation is a service defined in §264.103 of this title. Source Note: The provisions of this §262.5 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.5 Description of TxHmL Program Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212807 03/12/2026 CFC services are described in this subsection and in the Medicaid State Plan approved by CMS and available on the HHSC website.(1) CFC PAS/HAB:(A) consists of:(i) personal assistance services that provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including:(I) non-skilled assistance with the performance of the ADLs and IADLs;(II) household chores necessary to maintain the home in a clean, sanitary, and safe environment;(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and(IV) assistance with health-related tasks; and(ii) habilitation that provides assistance to an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, such as:(I) self-care;(II) personal hygiene;(III) household tasks;(IV) mobility;(V) money management;(VI) community integration, including how to get around in the community;(VII) use of adaptive equipment;(VIII) personal decision making;(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and(X) self-administration of medication; and(B) does not include transporting the individual, which means driving the individual from one location to another.(2) CFC support management provides training to an individual or LAR on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB, as described in the TxHmL Handbook, if:(A) the individual is receiving CFC PAS/HAB; and(B) the individual or LAR requests to receive CFC support management.(3) CFC ERS consists of backup systems and supports used to ensure continuity of services and supports, including electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices and is provided only to an individual who:(A) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(B) would otherwise require extensive routine supervision. Source Note: The provisions of this §262.6 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.6 Description of CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212808 03/12/2026 If a program provider or LIDDA submits documentation to HHSC containing information that is not in English, the program provider or LIDDA must, at the same time, submit a translation of the information in English. Source Note: The provisions of this §262.7 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.7 Requirement for Translation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212809 03/12/2026 (a) An RN must complete a comprehensive nursing assessment of an individual in person:(1) if the initial IPC includes a sufficient number of RN nursing units for the program provider's RN to perform a comprehensive nursing assessment as described in §262.103(o)(1) of this chapter (relating to Process for Enrollment of Applicants);(2) if there is a significant change in an individual's health or functional status:(A) that, based on a determination by the RN, will not normally resolve itself without further intervention; and(B) requires review or revision of the IPC;(3) at least annually if a nursing service is on the individual's renewal IPC;(4) before an unlicensed service provider performs a delegated nursing task; and(5) if the RN who completed the most recent comprehensive nursing assessment of the individual is no longer providing a nursing service to the individual, except as provided in subsection (b) of this section.(b) The comprehensive nursing assessment required to be completed in accordance with subsection (a)(5) of this section does not have to be completed in person if:(1) the comprehensive nursing assessment is not the annual comprehensive nursing assessment; and(2) an unlicensed service provider is not performing a delegated nursing task or a health maintenance activity for the individual.(c) An RN must document a comprehensive nursing assessment required by subsection (a) of this section using the HHSC Comprehensive Nursing Assessment form or a form that contains all of the same elements as the HHSC Comprehensive Nursing Assessment form. Source Note: The provisions of this §262.8 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.8 Comprehensive Nursing Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212810 03/12/2026 (a) Except as described in subsection (c) of this section, a service provider of physical therapy, occupational therapy, or speech and language pathology may provide physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service.(b) If a service provider of physical therapy, occupational therapy, or speech and language pathology provides physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service, a program provider must ensure that the service provider:(1) uses a synchronous audio-visual platform to interact with the individual, supplemented with or without asynchronous store and forward technology;(2) does not use an audio-only platform to provide the service; and(3) before providing the telehealth service:(A) obtains the written informed consent of the individual or LAR to provide the service; or(B) obtains the individual or LAR's oral consent to receive the telehealth service and documents the oral consent in the individual's record.(c) A program provider must ensure that a service provider of physical therapy, occupational therapy, or speech and language pathology performs certain services in person, as required by the Texas Medicaid Provider Procedures Manual. Such services include:(1) a service that requires a physical agent modality or hands-on therapy, such as a paraffin bath, aquatic therapy, manual therapy, massage, and ultrasound;(2) orthotic management and training, initial encounter, and subsequent encounters;(3) prosthetic management or training for an upper or lower extremity, initial encounter, and subsequent encounters;(4) a wheelchair assessment and training; and(5) a complex rehabilitation technology assessment. Source Note: The provisions of this §262.9 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §262.9 Providing Physical Therapy, Occupational Therapy, and Speech and Language Pathology as a Telehealth Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226069 03/12/2026 (a) An applicant or individual is eligible for TxHmL Program services if:(1) the applicant or individual meets the financial eligibility criteria as described in Appendix B of the TxHmL waiver application approved by CMS and available on the HHSC website;(2) the applicant or individual meets one of the following criteria:(A) based on a DID and as determined by HHSC in accordance with §262.104 of this subchapter (relating to LOC Determination), the applicant or individual qualifies for an ICF/IID LOC I as defined in §261.238 of this title (relating to ICF/MR Level of Care I Criteria); or(B) meets the following criteria:(i) based on a DID and as determined by HHSC in accordance with §262.105 of this subchapter (relating to LON Assignment), qualifies for one of the following levels of care:(I) an ICF/IID LOC I as defined in §261.238 of this title; or(II) an ICF/IID LOC VIII as defined in §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria);(ii) meets one of the following:(I) resides in a nursing facility immediately before enrolling in the TxHmL Program; or(II) is at imminent risk of entering a nursing facility as determined by HHSC; and(iii) is offered TxHmL Program services designated for a member of the reserved capacity group "Individuals with a level of care I or VIII residing in a nursing facility" included in Appendix B of the TxHmL Program waiver application approved by CMS and available on the HHSC website;(3) the applicant or individual has been assigned an LON in accordance with §262.105 of this subchapter;(4) the applicant or individual has an IPC cost that does not exceed 50 percent of the annualized cost of care in an ICF/IID using the current non-state operated small facility daily rate for LON 1, rounded to the nearest dollar, which as of September 1, 2025 is $31,684;(5) the applicant or individual is not enrolled in another waiver program and is not receiving a service that may not be received if the individual is enrolled in the TxHmL Program, as identified in the Mutually Exclusive Services table in Appendix I of the TxHmL Handbook available on the HHSC website;(6) the applicant or individual has chosen, or the applicant's or individual's LAR has chosen, participation in the TxHmL Program over participation in the ICF/IID Program;(7) the applicant's or individual's service planning team concurs that the TxHmL Program services and, if applicable, non-TxHmL Program services for which the applicant or individual may be eligible are sufficient to ensure the applicant's or individual's health and welfare in the community;(8) the applicant or individual does not reside in:(A) a hospital;(B) an ICF/IID;(C) a nursing facility;(D) an assisted living facility licensed or subject to being licensed in accordance with THSC Chapter 247;(E) a residential child care facility licensed by HHSC unless it is an agency foster home;(F) an inpatient chemical dependency treatment facility;(G) a mental health facility;(H) a residential facility operated by the Texas Workforce Commission; or(I) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison; and(9) the applicant or individual requires the provision of:(A) at least one TxHmL Program service per month or a monthly monitoring visit by a service coordinator as described in §262.701(o) of this chapter (relating to LIDDA Requirements for Providing Service Coordination in the TxHmL Program); and(B) at least one TxHmL Program service per IPC year.(b) Except as provided in subsection (c) of this section, an applicant or individual is eligible for a CFC service under this subchapter if the applicant or individual:(1) meets the criteria described in subsection (a) of this section; and(2) requires the provision of the CFC service.(c) To be eligible for a CFC service under this chapter, an applicant or individual receiving MAO Medicaid must, in addition to meeting the eligibility criteria described in subsection (b) of this section, receive a TxHmL Program service at least monthly, as required by 42 CFR §441.510(d), which may not be met by a monthly monitoring visit by a service coordinator as described in §262.701(o)(1) and (2) of this chapter. Source Note: The provisions of this §262.101 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective September 17, 2025, 50 TexReg 6017. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.101 Eligibility Criteria for TxHmL Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212812 03/12/2026 (a) A LIDDA must maintain an up-to-date interest list of applicants interested in receiving TxHmL Program services for whom the LIDDA is the applicant's designated LIDDA in the HHSC data system.(b) A person may request that an applicant's name be added to the TxHmL interest list by contacting the LIDDA serving the Texas county in which the applicant or person resides.(c) If a request is made in accordance with subsection (b) of this section for an applicant who resides in Texas, a LIDDA must add the applicant's name to the TxHmL interest list using the date the LIDDA receives the request as the TxHmL interest list date.(d) For an applicant determined diagnostically or functionally ineligible during the enrollment process for the Community Living Assistance and Support Services (CLASS) Program, Deaf-Blind with Multiple Disabilities (DBMD) Program, or Medically Dependent Children Program (MDCP):(1) if the applicant's name is not on the TxHmL interest list, at the request of the applicant or LAR, HHSC adds the applicant's name to the TxHmL interest list using the applicant's interest list date for the program for which the applicant was determined ineligible as the TxHmL interest list date;(2) if the applicant's name is on the TxHmL interest list and the applicant's interest list date for the program for which the applicant was determined ineligible is earlier than the applicant's TxHmL interest list date, at the request of the applicant or LAR, HHSC changes the applicant's TxHmL interest list date to the applicant's interest list date for the program for which the applicant was determined ineligible as the TxHmL interest list date; or(3) if the applicant's name is on the TxHmL interest list and the applicant's TxHmL interest list date is earlier than the applicant's interest list date for the program for which the applicant was determined ineligible, HHSC does not change the applicant's TxHmL interest list date.(e) This subsection applies to an applicant who was enrolled in MDCP and, because the individual did not meet the LOC criteria for medical necessity for nursing facility care or did not meet the age requirement of being under 21 years of age, was determined ineligible for MDCP after November 30, 2019.(1) At the request of the applicant or LAR, HHSC adds the applicant's name to the TxHmL interest list:(A) using the MDCP interest list date as the TxHmL interest list date, if the applicant's name is not on the TxHmL interest list but it was previously on the TxHmL interest list; or(B) using the date HHSC receives the request as the TxHmL interest list date, if the applicant's name is not on the TxHmL interest list and it never has been on the TxHmL interest list.(2) At the request of the applicant or LAR, HHSC changes the TxHmL interest list date to the MDCP interest list date if the applicant's MDCP interest list date is earlier than the applicant's TxHmL interest list date.(f) HHSC or the LIDDA removes an applicant's name from the TxHmL interest list if:(1) the applicant or LAR requests in writing that the applicant's name be removed from the TxHmL interest list;(2) the applicant moves out of Texas, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the applicant declines an offer of TxHmL Program services or, as described in §262.103(f) of this subchapter (relating to Process for Enrollment of Applicants), an offer of TxHmL Program services is withdrawn, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(4) the applicant is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(5) the applicant is deceased; or(6) HHSC has denied the applicant enrollment in the TxHmL Program and the applicant or LAR has had an opportunity to exercise the applicant's right to appeal the decision in accordance with §262.601 of this chapter (relating to Fair Hearing) and did not appeal the decision, or appealed and did not prevail.(g) If HHSC or the LIDDA removes an applicant's name from the TxHmL interest list in accordance with subsection (f)(1) - (4) of this section and, within 90 calendar days after the name was removed, the LIDDA receives an oral or written request from a person to add the applicant's name to the TxHmL interest list:(1) the LIDDA must notify HHSC of the request; and(2) HHSC:(A) adds the applicant's name to the TxHmL interest list using the TxHmL interest list date that was in effect at the time the applicant's name was removed from the TxHmL interest list; and(B) notifies the applicant or LAR in writing that the applicant's name has been added to the TxHmL interest list in accordance with subparagraph (A) of this paragraph.(h) If HHSC or the LIDDA removes an applicant's name from the TxHmL interest list in accordance with subsection (f)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the TxHmL interest list within 90 calendar days after the name was removed, and the request is the applicant's first request:(1) the LIDDA must notify HHSC of the request; and(2) HHSC:(A) adds the applicant's name to the TxHmL interest list using the TxHmL interest list date that was in effect at the time the applicant's name was removed from the TxHmL interest list; and(B) notifies the applicant or LAR in writing that the applicant's name has been added to the TxHmL interest list in accordance with subparagraph (A) of this paragraph.(i) If HHSC or the LIDDA removes an applicant's name from the TxHmL interest list in accordance with subsection (f)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the TxHmL interest list more than 90 calendar days after the name was removed, and the request is the applicant's first request:(1) one of the following occurs:(A) the LIDDA adds the applicant's name to the TxHmL interest list using the date the LIDDA receives the oral or written request as the TxHmL interest list date; or(B) if HHSC determines that extenuating circumstances exist, HHSC adds the applicant's name to the TxHmL interest list using the TxHmL interest list date that was in effect at the time the applicant's name was removed from the TxHmL interest list as the TxHmL interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the TxHmL interest list in accordance with paragraph (1) of this subsection.(j) If HHSC or the LIDDA removes an applicant's name from the TxHmL interest list in accordance with subsection (f)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the TxHmL interest list, and the request is not the applicant's first request:(1) the LIDDA adds the applicant's name to the TxHmL interest list using the date the LIDDA receives the oral or written request as the TxHmL interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the TxHmL interest list in accordance with paragraph (1) of this subsection.(k) If HHSC or the LIDDA removes an applicant's name from the TxHmL interest list in accordance with subsection (f)(6) of this section and the LIDDA subsequently receives an oral or written request from a person to add the applicant's name to the TxHmL interest list:(1) the LIDDA must add the applicant's name to the TxHmL interest list using the date the LIDDA receives the oral or written request as the TxHmL interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the TxHmL interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §262.102 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.102 TxHmL Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222997 03/12/2026 (a) HHSC notifies a LIDDA, in writing, when the opportunity for enrollment in the TxHmL Program becomes available in the LIDDA's local service area and directs the LIDDA to offer enrollment to the applicant:(1) whose interest list date, assigned in accordance with §262.102 of this subchapter (relating to TxHmL Interest List), is earliest on the statewide interest list for the TxHmL Program as maintained by HHSC;(2) whose name is not coded in the HHSC data system as having been determined ineligible for the TxHmL Program and who is receiving services from the LIDDA that are funded by general revenue in an amount that would allow HHSC to fund the services through the TxHmL Program; or(3) who is a member of a target group identified in the approved TxHmL waiver application.(b) Except as provided in subsection (c) of this section, a LIDDA must offer enrollment in the TxHmL Program in writing and deliver it to the applicant or LAR by United States mail or by hand delivery.(c) A LIDDA must offer enrollment in the TxHmL Program to an applicant described in subsection (a)(2) or (3) of this section in accordance with HHSC's procedures.(d) A LIDDA must include in a written offer that is made in accordance with subsection (a)(1) of this section:(1) a statement that:(A) if the applicant or LAR does not respond to the offer of enrollment in the TxHmL Program within 30 calendar days after the LIDDA's written offer, the LIDDA withdraws the offer; and(B) if the applicant is currently receiving services from the LIDDA that are funded by general revenue and the applicant or LAR declines the offer of enrollment in the TxHmL Program, the LIDDA terminates those services that are similar to services provided in the TxHmL Program; and(2) the HHSC Deadline Notification form, which is available on the HHSC website.(e) If an applicant or LAR responds to an offer of enrollment in the TxHmL Program, a LIDDA must:(1) provide the applicant, LAR, and, if the LAR is not a family member, at least one family member (if possible) both an oral and a written explanation of the services and supports for which the applicant may be eligible, including the ICF/IID Program (both state supported living centers and community-based facilities), waiver programs authorized under §1915(c) of the Social Security Act, and other community-based services and supports, using the HHSC Explanation of Services and Supports document which is available on the HHSC website;(2) provide the applicant and LAR both an oral and a written explanation of all TxHmL Program services and CFC services using the HHSC Understanding Program Eligibility and Services form, which is available on the HHSC website; and(3) give the applicant or LAR the HHSC Waiver Program Verification of Freedom of Choice form, which is available on the HHSC website to document the applicant's choice between the TxHmL Program or the ICF/IID Program.(f) A LIDDA must withdraw an offer of enrollment in the TxHmL Program made to an applicant or LAR if:(1) within 30 calendar days after the LIDDA's offer made to the applicant or LAR in accordance with subsection (a)(1) of this section, the applicant or LAR does not respond to the offer of enrollment in the TxHmL Program;(2) within seven calendar days after the applicant or LAR receives the HHSC Waiver Program Verification of Freedom of Choice form from the LIDDA in accordance with subsection (e)(3) of this section, the applicant or LAR does not use the form to document the applicant's choice of the TxHmL Program;(3) within 30 calendar days after the applicant or LAR receives the contact information regarding all available program providers in the LIDDA's local service area in accordance with subsection (k)(2)(A) of this section, the applicant or LAR does not document a choice of a program provider using the HHSC Documentation of Provider Choice form, which is available on the HHSC website;(4) the applicant or LAR does not complete the necessary activities to finalize the enrollment process and HHSC has approved the withdrawal of the offer; or(5) the applicant has moved out of the State of Texas.(g) If a LIDDA withdraws an offer of enrollment in the TxHmL Program made to an applicant, the LIDDA must notify the applicant or LAR of such action, in writing, by certified United States mail.(h) If an applicant is currently receiving services from a LIDDA that are funded by general revenue and the applicant declines the offer of enrollment in the TxHmL Program, the LIDDA must terminate those services that are similar to services provided in the TxHmL Program.(i) If a LIDDA terminates an applicant's services in accordance with subsection (h) of this section, the LIDDA must notify the applicant or LAR of the termination, in writing, by certified United States mail and provide an opportunity for a review in accordance with §301.155 of this title (relating to Notification and Appeals Process).(j) A LIDDA must retain in an applicant's record:(1) the HHSC Waiver Program Verification of Freedom of Choice form;(2) the HHSC Documentation of Provider Choice form;(3) the HHSC Deadline Notification form; and(4) any correspondence related to the offer of enrollment in the TxHmL Program.(k) If an applicant or LAR accepts the offer of enrollment in the TxHmL Program, the LIDDA must compile and maintain information necessary to process the applicant's request for enrollment in the TxHmL Program.(1) The LIDDA must complete an ID/RC Assessment in accordance with §262.104(a)(1) of this subchapter (relating to LOC Determination).(A) The LIDDA must:(i) do one of the following:(I) conduct a DID in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability) except that the following activities must be conducted in person:(-a-) a standardized measure of the individual's intellectual functioning using an appropriate test based on the characteristics of the individual; and(-b-) a standardized measure of the individual's adaptive abilities and deficits reported as the individual's adaptive behavior level; or(II) review and endorse a DID report in accordance with §304.403 of this title (relating to Review and Endorsement of a Determination of Intellectual Disability Report); and(ii) determine whether the applicant has been diagnosed by a licensed physician as having a related condition.(B) The LIDDA must:(i) conduct an ICAP assessment in person; and(ii) recommend an LON assignment to HHSC in accordance with §262.105 of this subchapter (relating to LON Assignment).(C) The LIDDA must enter the information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC in accordance with §262.104(a)(2) of this subchapter and §262.105(a) of this subchapter and submit supporting documentation as required by §262.106 of this subchapter (relating to HHSC Review of LON).(2) The LIDDA must:(A) provide names and contact information to the applicant or LAR for all program providers in the LIDDA's local service area;(B) arrange for meetings or visits with potential program providers as requested by the applicant or the LAR; and(C) ensure that the applicant's or LAR's choice of a program provider is documented on the HHSC Documentation of Provider Choice form and that the form is signed by the applicant or LAR and retained by the LIDDA in the applicant's record.(3) The LIDDA must assign a service coordinator who, together with other members of the service planning team, must:(A) develop a PDP; and(B) if CFC PAS/HAB is included on the PDP, complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form, which is available on the HHSC website, to determine the number of CFC PAS/HAB hours the applicant needs.(4) The CFC PAS/HAB assessment form required by paragraph (3)(B) of this subsection must be completed in person with the individual unless the following conditions are met, in which case the form may be completed by videoconferencing or telephone:(A) the service coordinator gives the individual the opportunity to complete the form in person in lieu of completing it by videoconferencing or telephone and the individual agrees to the form being completed by videoconferencing or telephone; and(B) the individual receives appropriate in-person support during the completion of the form by videoconferencing or telephone.(l) A service coordinator must:(1) in accordance with Chapter 264, Subchapter D of this title (relating to Enrollment, Transfer, Suspension, and Termination):(A) inform the applicant or LAR of the applicant's right to participate in the CDS option; and(B) inform the applicant or LAR that the applicant or LAR may choose to have one or more services provided through the CDS option, as described in §264.108 of this title (relating to Services Available Through the CDS Option); and(2) if the applicant or LAR chooses to participate in the CDS option, comply with §262.701(r) of this chapter (relating to LIDDA Requirements for Providing Service Coordination in the TxHmL Program).(m) The service coordinator must develop an initial IPC with the applicant or LAR based on the PDP and in accordance with §262.301 of this chapter (relating to IPC Requirements).(n) If an applicant or LAR chooses to receive a TxHmL Program service or CFC service provided by a program provider, the service coordinator must review the initial IPC with potential program providers as requested by the applicant or the LAR.(o) A service coordinator must:(1) ensure that the initial IPC includes a sufficient number of RN nursing units for the program provider's RN to perform a comprehensive nursing assessment, unless:(A) nursing services are not on the initial IPC and the applicant or LAR and selected program provider have determined that no nursing tasks will be performed by an unlicensed service provider as documented on the HHSC Nursing Task Screening Tool form; or(B) an unlicensed service provider will perform a nursing task and a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician;(2) if an applicant or LAR refuses to include a sufficient number of RN nursing units on the initial IPC for the program provider's RN to perform a comprehensive nursing assessment as required by paragraph (1) of this subsection:(A) inform the applicant or LAR that the refusal:(i) will result in the applicant not receiving nursing services from the program provider; and(ii) if the applicant needs community support, employment readiness, day habilitation, employment assistance, supported employment, respite, or CFC PAS/HAB from the program provider, will result in the applicant not receiving the service unless:(I) the program provider's unlicensed service provider does not perform nursing tasks in the provision of the service; and(II) the program provider determines that it can ensure the applicant's health, safety, and welfare in the provision of the service; and(B) document the refusal of the RN nursing units on the initial IPC for a comprehensive nursing assessment by the program provider's RN in the applicant's record;(3) negotiate and finalize the initial IPC and the date services will begin with the selected program provider, consulting with HHSC if necessary to reach agreement with the selected program provider on the content of the initial IPC and the date services will begin;(4) ensure that the applicant or LAR signs and dates the initial IPC and provides the signed and dated IPC to the service coordinator in person, electronically, by fax, or by United States mail;(5) ensure that the selected program provider signs and dates the initial IPC, demonstrating agreement that the services will be provided to the applicant; and(6) sign and date the initial IPC to demonstrate that the service coordinator agrees that the requirements described in §262.301(c) of this chapter have been met.(p) A service coordinator must:(1) provide an oral and written explanation to the applicant or LAR of the following information using the HHSC Understanding Program Eligibility and Services form, which is available on the HHSC website:(A) the eligibility requirements for TxHmL Program services as described in §262.101(a) of this subchapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services); and(B) if the applicant's PDP includes CFC services:(i) the eligibility requirements for CFC services as described in §262.101(b) of this subchapter to applicants who do not receive MAO Medicaid; and(ii) the eligibility requirements for CFC services as described in §262.101(c) of this subchapter to applicants who receive MAO Medicaid; and(2) provide an oral and written explanation to the applicant or LAR of:(A) the reasons TxHmL Program services may be terminated as described in §262.507 of this chapter (relating to Termination of TxHmL Program Services and CFC Services with Advance Notice) and §262.508 of this chapter (relating to Termination of TxHmL Program Services and CFC Services without Advance Notice); and(B) if the applicant's PDP includes CFC services, the reasons CFC services may be terminated as described in §262.507 and §262.508 of this chapter.(q) After an initial IPC is finalized and signed in accordance with subsection (o) of this section, the LIDDA must:(1) enter the information from the initial IPC in the HHSC data system and electronically submit the information to HHSC;(2) keep the original initial IPC in the individual's record;(3) ensure the information from the initial IPC entered in the HHSC data system and electronically submitted to HHSC contains information identical to the information on the initial IPC; and(4) submit other required enrollment information to HHSC;(r) HHSC notifies the applicant or LAR, the selected program provider, the FMSA, if applicable, and the LIDDA of its approval or denial of the applicant's enrollment. If the enrollment is approved, HHSC authorizes the applicant's enrollment in the TxHmL Program through the HHSC data system and issues an enrollment letter to the applicant that includes the effective date of the applicant's enrollment in the TxHmL Program.(s) The selected program provider and the individual or LAR must develop:(1) an implementation plan for:(A) TxHmL Program services, except for community support, that is based on the individual's PDP and initial IPC; and(B) CFC services, except for CFC support management, that is based on the individual's PDP, IPC, and if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(2) a transportation plan, if community support is included on the PDP.(t) Before the applicant's service begin date, a LIDDA must provide to the selected program provider and FMSA, if applicable:(1) copies of all enrollment documentation and associated supporting documentation, including relevant assessment results and recommendations;(2) the completed ID/RC Assessment;(3) the IPC;(4) the applicant's PDP; and(5) if CFC PAS/HAB is included on the PDP, a copy of the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form.(u) In accordance with §262.401(a)(5)(N) of this chapter (relating to Program Provider Reimbursement), if a selected program provider provides services before the date of an applicant's enrollment into the TxHmL Program, HHSC does not pay the program provider for the services. Source Note: The provisions of this §262.103 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.103 Process for Enrollment of Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212814 03/12/2026 (a) A LIDDA must request an LOC from HHSC for an applicant in accordance with this subsection.(1) The LIDDA must complete an ID/RC Assessment for an applicant that:(A) includes the LOC recommended by a person qualified to perform an initial evaluation of LOC in accordance with Appendix B of the TxHmL Program waiver application approved by CMS; and(B) is signed and dated in accordance with the instructions for completing the ID/RC Assessment.(2) The LIDDA must enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC.(3) The LIDDA must ensure that the information entered in the HHSC data system and electronically submitted to HHSC in accordance with paragraph (2) of this subsection is identical to the information on the completed ID/RC Assessment.(4) The LIDDA must send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.(b) A LIDDA must request an LOC for an individual from HHSC in accordance with this subsection.(1) No more than 60 calendar days before the expiration date of an individual's ID/RC Assessment, a LIDDA must:(A) complete an ID/RC Assessment that:(i) includes the LOC recommended by a person qualified to perform a reevaluation of LOC in accordance with Appendix B of the TxHmL Program waiver application approved by CMS; and(ii) is signed and dated in accordance with the instructions for completing the ID/RC Assessment; and(B) enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC.(2) A LIDDA must:(A) ensure that the information entered in the HHSC data system and electronically submitted to HHSC is identical to the information on the completed ID/RC Assessment;(B) within three calendar days after entering the information in the HHSC data system and electronically submitting the information to HHSC, provide the program provider with a copy of the completed ID/RC Assessment; and(C) send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.(3) If the LIDDA enters information from a completed ID/RC Assessment in the HHSC data system and electronically submits the information to HHSC on a date that is more than 180 calendar days after the expiration date of the previous ID/RC Assessment, the LIDDA must:(A) send to HHSC a copy of the completed ID/RC Assessment by a method, as instructed by HHSC, that:(i) includes the recommended LOC; and(ii) is signed and dated in accordance with the instructions for completing the ID/RC Assessment;(B) within three calendar days after sending the completed ID/RC Assessment to HHSC, provide the program provider with a copy of the completed ID/RC Assessment; and(C) submit documentation supporting the ID/RC Assessment to HHSC, as requested by HHSC.(c) Information on an ID/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments that measure physical, emotional, social, and cognitive factors. A LIDDA must maintain the signed and dated ID/RC Assessment and documentation supporting the recommended LOC in an applicant's or individual's record.(d) When HHSC receives a request for an LOC in accordance with subsection (a) or (b) of this section, HHSC determines if an applicant or individual qualifies for an LOC required by §262.101(a)(2) of this subchapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services).(e) HHSC approves an LOC or sends a written notification:(1) to the applicant, individual, or LAR that the applicant or individual is not eligible for TxHmL Program services or CFC services and provides the applicant, individual, or LAR with an opportunity to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing);(2) to the LIDDA that the LOC has been denied; and(3) to the program provider using the HHSC data system that the LOC has been denied, if the applicant has selected a program provider or an individual is receiving services from a program provider.(f) An LOC determination is valid for a period of time as described in this subsection.(1) Except as provided in paragraph (2) of this subsection, an LOC determination is valid for a 365-calendar day period starting on the begin date of the ID/RC Assessment.(2) If the begin date of the ID/RC Assessment is March 1 or later in a year before a leap year or January 1 - February 28 of a leap year, the LOC determination is valid for a 366-calendar day period starting on the begin date of the ID/RC Assessment.(g) An ID/RC Assessment submitted in accordance with subsection (b) of this section is effective on the date after the individual's previous ID/RC Assessment expires. Source Note: The provisions of this §262.104 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.104 LOC Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212815 03/12/2026 (a) A LIDDA must request that HHSC assign an LON for an applicant or individual by entering the information from the completed ID/RC Assessment in the HHSC data system and electronically submitting the information to HHSC that includes the recommended LON and, as appropriate, submitting supporting documentation in accordance with §262.106(b) of this subchapter (relating to HHSC Review of LON). The electronically submitted ID/RC Assessment must contain information identical to the information on the signed and dated ID/RC Assessment.(b) A LIDDA must, in accordance with §262.106(a) of this subchapter, submit supporting documentation to HHSC as requested by HHSC for a review of a recommended or assigned LON.(c) A LIDDA must maintain the applicant's or individual's ICAP assessment booklet supporting the recommended LON in the applicant's or individual's record and other documentation supporting the requested LON, including:(1) the individual's PDP, including the deliberations and conclusions of the applicant's or individual's service planning team;(2) assessments and interventions by qualified professionals; and(3) behavior support plans.(d) If a pervasive plus LON (LON 9) is recommended, a LIDDA must maintain documentation that proves:(1) the applicant or individual exhibits extremely dangerous behavior that could be life threatening to the applicant or individual or to others;(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the extremely dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the extremely dangerous behavior occurs;(3) management of the applicant's or individual's behavior requires a person to exclusively and constantly supervise the individual during the individual's waking hours, which must be at least 16 hours per day;(4) the person supervising the individual has no other duties or activities during the period of supervision; and(5) the individual's ID/RC Assessment is correctly scored with a "2" in the "Behavior" section.(e) HHSC assigns an LON for an individual based on the individual's ICAP service level score, information reported on the individual's ID/RC Assessment, and required supporting documentation.(f) A LIDDA must submit documentation supporting a recommended LON to HHSC in accordance with HHSC instructions regarding LON packet submission available on the HHSC website.(g) HHSC assigns one of five LONs as follows:(1) an intermittent LON (LON 1) is assigned if the individual's ICAP service level score equals 7, 8, or 9;(2) a limited LON (LON 5) is assigned if the individual's ICAP service level score equals 4, 5, or 6;(3) an extensive LON (LON 8) is assigned if the individual's ICAP service level score equals 2 or 3;(4) a pervasive LON (LON 6) is assigned if the individual's ICAP service level score equals 1; and(5) regardless of an individual's ICAP service level score, an LON 9 is assigned if the individual meets the criteria set forth in subsection (i) of this section.(h) An LON 1, 5, or 8, determined in accordance with subsection (g) of this section, is increased to the next LON by HHSC, due to an individual's dangerous behavior, if supporting documentation submitted to HHSC proves that:(1) the individual exhibits dangerous behavior that could cause serious physical injury to the individual or others;(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;(3) more service providers are needed and available than would be needed if the individual did not exhibit dangerous behavior;(4) service providers are constantly prepared to physically prevent the dangerous behavior or intervene when the behavior occurs; and(5) the individual's ID/RC Assessment is correctly scored with a "1" in the "Behavior" section.(i) HHSC assigns an LON 9 if supporting documentation submitted to HHSC proves that:(1) the individual exhibits extremely dangerous behavior that could be life threatening to the individual or to others;(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the extremely dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;(3) management of the individual's behavior requires a service provider to exclusively and constantly supervise the individual during the individual's waking hours, which must be at least 16 hours per day;(4) the service provider assigned to supervise the individual has no other duties during such assignment; and(5) the individual's ID/RC Assessment is correctly scored with a "2" in the "Behavior" section.(j) A service coordinator must conduct an ICAP assessment in accordance with this subsection.(1) A service coordinator must conduct an ICAP assessment of an individual:(A) within three years after the individual's enrollment and every third year thereafter;(B) if changes in the individual's functional skills or behavior occur that are not expected to be of short duration or cyclical in nature; or(C) if the individual's skills and behavior are inconsistent with the individual's assigned LON.(2) If the results of an ICAP assessment demonstrate that the individual's LON assignment may not be accurate, the service coordinator must submit a completed ID/RC Assessment to HHSC recommending a revision of the individual's LON assignment.(k) A LIDDA must retain in the individual's record results and recommendations of individualized assessments and other pertinent records documenting the recommended LON assignment. Source Note: The provisions of this §262.105 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.105 LON Assignment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212816 03/12/2026 (a) HHSC may review a recommended or assigned LON at any time to determine if it is appropriate. If HHSC reviews an LON, a LIDDA must submit documentation supporting the LON to HHSC in accordance with HHSC's request. Based on its review, HHSC may modify an LON.(b) Documentation supporting a recommended LON must be submitted by the LIDDA and received by HHSC within seven calendar days after the LIDDA has entered the information from the completed ID/RC Assessment in the HHSC data system and electronically submitted the information to HHSC.(c) Within 21 calendar days after receiving the supporting documentation, HHSC:(1) requests additional documentation;(2) electronically approves the recommended LON and establishes the effective date; or(3) notifies the service coordinator in the HHSC data system that the recommended LON has been denied.(d) HHSC reviews any additional documentation submitted in accordance with HHSC request and electronically approves the recommended LON or notifies the service coordinator in the HHSC data system that the recommended LON has been denied. Source Note: The provisions of this §262.106 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.106 HHSC Review of LON https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212817 03/12/2026 (a) A LIDDA may request that HHSC reconsider an LON assignment.(b) A LIDDA may receive reconsideration only if the LIDDA submitted documentation supporting the recommended LON as required by §262.106(b) of this subchapter (relating to HHSC Review of LON).(c) To request reconsideration of an LON assignment, the LIDDA must submit a written request for reconsideration to HHSC within 10 calendar days after receipt of the notification from HHSC that the recommended LON was denied. A LIDDA may send HHSC documentation, in addition to that required by §262.106(b) of this subchapter, to support the request for reconsideration of an LON assignment.(d) Within 21 calendar days after receipt of a request for reconsideration, HHSC electronically approves the recommended LON or sends written notification that the recommended LON has been denied to the service coordinator. Source Note: The provisions of this §262.107 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §262.107 Reconsideration of LON Assignment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212818 03/12/2026 (a) Person-centered planning is a process that empowers an applicant or individual to plan the applicant's or individual's services and supports to achieve desired outcomes.(b) The service coordinator and program provider must ensure the person-centered planning process is led by the individual to the maximum extent possible. The individual's LAR has a participatory role, as needed and as defined by the individual, unless State law confers decision-making authority to the LAR.(c) The person-centered planning process must be used to develop a PDP, implementation plan, initial IPC, renewal IPC, revised IPC, service backup plan, and transportation plan.(d) The person-centered planning process must:(1) include people chosen by the applicant, individual, or LAR;(2) provide the information and support the applicant or individual needs to lead the planning process and make informed choices and decisions;(3) occur at a time and location convenient to the applicant or individual and LAR;(4) consider the applicant's or individual's cultural preferences;(5) provide information in plain language to the applicant or individual in a manner that is accessible to:(A) the applicant or individual through the provision of an auxiliary aid at no cost to the applicant or individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act; and(B) the applicant or individual with limited English proficiency through the provision of language services at no cost to the applicant or individual, including oral interpretation and written translations;(6) use strategies for solving conflict or disagreement within the person-centered planning process;(7) provide information to the individual or LAR to allow the individual or LAR to make informed decisions including:(A) a written and oral description of the services available in the TxHmL Program; and(B) the name and qualifications of the individual's service providers in writing; and(8) inform the individual or LAR that the individual or LAR may request revisions to the PDP, implementation plan, initial IPC, renewal IPC, revised IPC, service backup plan, and transportation plan at any time by communicating the request to the service coordinator or the program provider.(e) A program provider must participate in a service planning team meeting if requested by the individual or LAR. Source Note: The provisions of this §262.201 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) C PERSON-CENTERED PLANNING AND SERVICE SETTINGS §262.201 Person-Centered Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223000 03/12/2026 (a) A home and community-based setting is a setting in which an individual receives TxHmL Program services or CFC services. A home and community-based setting must have all of the following qualities, based on the needs and preferences of an individual as documented in the individual's PDP.(1) The setting is integrated in and supports the individual's access to the greater community to the same degree as a person not enrolled in a Medicaid waiver program, including opportunities for the individual to:(A) seek employment and work in a competitive integrated setting;(B) engage in community life;(C) control personal resources; and(D) receive services in the community.(2) The setting is selected by the individual from among setting options, including non-disability specific settings. The setting options are identified and documented in the PDP and are based on the individual's needs and preferences.(3) The setting ensures an individual's rights of privacy, dignity and respect, and freedom from coercion and restraint.(4) The setting optimizes, not regiments, individual initiative, autonomy, and independence in making life choices, including choices regarding daily activities, physical environment, and with whom to interact.(5) The setting facilitates individual choice regarding services and supports, and the service providers who provide the services and supports.(b) Except as provided in subsection (c) of this section, a program provider must ensure that TxHmL Program services and CFC services are not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a certified ICF/IID operated by a LIDDA or state supported living center is located but is distinct from the ICF/IID;(2) is located in a building on the grounds of, or immediately adjacent to, a certified ICF/IID operated by a LIDDA or state supported living center;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building on the grounds of, or immediately adjacent to, a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(c) A program provider may provide a TxHmL Program service or a CFC service to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (b) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(d) In addition to the requirements in subsection (a) of this section, a program provider must ensure that a group setting:(1) allows an individual to:(A) control the individual's schedule and activities;(B) have access to the individual's food at any time; and(C) receive visitors of the individual's choosing at any time; and(2) is physically accessible and free of hazards to an individual.(e) If a program provider becomes aware that a modification to a requirement described in subsection (d)(1) of this section is needed based on a specific assessed need of an individual, the program provider must:(1) notify the service coordinator of the needed modification; and(2) provide the service coordinator with the information described in §262.701(v) of this chapter relating to (LIDDA Requirements for Providing Service Coordination in the TxHmL Program) as requested by the service coordinator.(f) If a service coordinator receives a notification as described in subsection (e) of this section, the service coordinator must convene a service planning team meeting to update the PDP as described §262.701(v) of this chapter.(g) after the service planning team updates the PDP as required by subsection (f) of this section, the program provider may implement the modifications. Source Note: The provisions of this §262.202 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) C PERSON-CENTERED PLANNING AND SERVICE SETTINGS §262.202 Requirements for Home and Community-Based Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223001 03/12/2026 (a) An IPC must be based on the PDP and specify:(1) the type and amount of each TxHmL Program service and CFC service to be provided to the individual during an IPC year;(2) the services and supports to be provided to the individual through resources other than TxHmL Program services or CFC services during an IPC year, including natural supports, medical services, day activity, and educational services;(3) if an individual will receive CFC support management; and(4) if there are any TxHmL Program services or CFC services identified on the PDP as critical, requiring a service backup plan.(b) If an applicant's or individual's IPC includes only CFC PAS/HAB to be delivered through the CDS option, a service coordinator must include in the IPC:(1) CFC FMS instead of FMS; and(2) if the applicant or individual will receive support consultation, CFC support consultation instead of support consultation.(c) The type and amount of each TxHmL Program service and CFC service in an IPC:(1) must be necessary to protect the individual's health and welfare in the community;(2) must not be available to the individual through any other source, including the Medicaid State Plan, other governmental programs, private insurance, or the individual's natural supports;(3) must be the most appropriate type and amount to meet the individual's needs;(4) must be cost effective;(5) must be necessary to enable community integration and maximize independence;(6) if an adaptive aid or minor home modification, must:(A) be included on HHSC's approved list in the TxHmL Program Billing Requirements; and(B) be within the service limit described in §262.304 of this subchapter (relating to Service Limits);(7) if an adaptive aid costing $500 or more, must be supported by a written assessment from a licensed professional specified by HHSC in the TxHmL Program Billing Requirements;(8) if a minor home modification costing $1,000 or more, must be supported by a written assessment from a licensed professional specified by HHSC in the TxHmL Program Billing Requirements;(9) if dental treatment, must be within the service limit described in §262.304 of this subchapter;(10) if CFC PAS/HAB, must be supported by the HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(11) if employment readiness, must be:(A) supported by a an HHSC Employment First Discovery Tool that is completed in accordance with §284.105 of this title (relating to Uniform Process); and(B) within the service limit described in §262.304 of this subchapter. Source Note: The provisions of this §262.301 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §262.301 IPC Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212821 03/12/2026 (a) Renewal and Revision of an IPC. At least annually, and before the expiration of an individual's IPC, the individual's IPC must be renewed and revised in accordance with this subsection and HHSC's instructions.(1) At least 30 but no more than 90 calendar days before the expiration of an individual's IPC, the service coordinator must:(A) notify the service planning team that the individual's PDP must be reviewed and updated;(B) convene a meeting with the service planning team to:(i) review and update the individual's PDP and develop a renewal IPC; and(ii) if CFC PAS/HAB is included on the PDP, complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form to determine the number of CFC PAS/HAB hours the individual needs;(C) ensure the individual or LAR signs the finalized PDP; and(D) use the HHSC Understanding Program Eligibility and Services form to provide an individual or LAR both an oral and a written explanation of:(i) the eligibility requirements for the TxHmL Program as described in §262.101(a) of this chapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services);(ii) if the individual's PDP includes CFC services:(I) the eligibility requirements for CFC services as described in §262.101(b) of this chapter to individuals who do not receive MAO Medicaid; and(II) the eligibility requirements for CFC services as described in §262.101(c) of this chapter to individuals who receive MAO Medicaid;(iii) all TxHmL Program services as described in §262.5 of this chapter (relating to Description of TxHmL Program Services) and all CFC services as described in §262.6 of this chapter (relating to Description of CFC Services);(iv) the reasons TxHmL Program services may be terminated as described in §262.507 of this chapter (relating to Termination of TxHmL Program Services and CFC Services with Advance Notice) and §262.508 of this chapter (relating to Termination of TxHmL Program Services and CFC Services without advance notice) or suspended as described in §262.505 of this chapter (relating to Suspension of TxHmL Program Services and CFC Services); and(v) if the individual's PDP includes CFC services, the reasons CFC services may be terminated as described §262.507 of this chapter and §262.508 of this chapter or suspended as described in §262.505 of this chapter.(2) The HHSC HCS/TxHmL CFC PAS/HAB Assessment form required by paragraph (1)(B)(ii) of this subsection must be completed in person with the individual unless the following conditions are met, in which case the form may be completed by videoconferencing or telephone:(A) the service coordinator gives the individual the opportunity to complete the form in person in lieu of completing it by videoconferencing or telephone and the individual agrees to the form being completed by videoconferencing or telephone; and(B) the individual receives appropriate in-person support during the completion of the form by videoconferencing or telephone.(3) The service coordinator must convene a meeting with the service planning team to develop a revised IPC and update the PDP if:(A) a new service is being added to or a current service is being removed from the IPC; or(B) the amount of a service is being increased or decreased and requires the addition of, removal of, or a change to an outcome in the PDP.(4) The service coordinator must ensure that the updated finalized PDP is signed by the individual or LAR.(5) If the amount of an existing service on an IPC is being increased or decreased or a requisition fee is added or removed and the addition of, removal of, or a change to an outcome in the PDP is not required, the service coordinator is not required to convene a meeting with the service planning team to develop a revised IPC, but must document the reasons for the revised IPC.(6) A service coordinator must:(A) sign and date the renewal or revised IPC;(B) ensure that the individual or LAR signs and dates the renewal or revised IPC and provides the signed and dated IPC to the service coordinator in person, electronically, by fax, or by United States mail;(C) ensure that the program provider signs and dates the renewal or revised IPC demonstrating agreement that the services will be provided to the individual;(D) after the renewal or revised IPC is signed and dated, enter information from the renewal or revised IPC in the HHSC data system and electronically submit the information to HHSC;(E) ensure that the information entered in the HHSC data system and electronically submitted to HHSC is identical to the information on the original signed and dated renewal or revised IPC; and(F) keep the original signed and dated renewal or revised IPC in the individual's record.(7) The service coordinator, within 10 calendar days after the PDP is updated, must send a copy of the following to the program provider, the individual or LAR and, if applicable, the FMSA:(A) the updated PDP;(B) the renewal or revised IPC; and(C) if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form.(8) The program provider must convene a meeting with the individual or LAR to develop, before the effective date of the renewal IPC or revised IPC:(A) an implementation plan for:(i) TxHmL Program services, except for community support, that is based on the individual's PDP and renewal IPC; and(ii) CFC services, except for CFC support management, that is based on the individual's PDP, and renewal or revised IPC, and if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(B) a transportation plan, if community support is included on the PDP.(b) If an individual or LAR requests support management during an IPC year, the service coordinator must revise the IPC as described in subsection (a)(3) of this section. Source Note: The provisions of this §262.302 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §262.302 Renewal and Revision of an Individual's IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212822 03/12/2026 (a) HHSC may review an IPC to determine if:(1) the type and amount of TxHmL Program services and CFC services specified in the IPC meet the requirements described in §262.301 of this subchapter (relating to IPC Requirements); and(2) the IPC exceeds the cost limit as described in §262.101(a)(4) of this chapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services).(b) If requested by HHSC for an IPC review described in subsection (a) of this section, a LIDDA must submit documentation supporting the IPC to HHSC.(c) Based on a review of an IPC, HHSC may deny or reduce an TxHmL Program service or a CFC service in accordance with §262.504 of this chapter (relating to Denial of TxHmL Program Services or CFC Services) and §262.506 of this chapter (relating to Reduction of TxHmL Program Services or CFC Services). Source Note: The provisions of this §262.303 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §262.303 HHSC Review of an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223002 03/12/2026 (a) The following limits apply to an individual's TxHmL Program services:(1) for adaptive aids, $10,000 during an IPC year;(2) for dental treatment, $1,000 during an IPC year;(3) for minor home modifications:(A) $7,500 during the time the individual is enrolled in the TxHmL Program, which may be paid in one or more IPC years;(B) a maximum of $300 for repair and maintenance during the IPC year; and(4) for day habilitation and in-home day habilitation combined, 260 units during an IPC year; and(5) for employment readiness and individualized skills and socialization combined:(A) 1560 hours during an IPC year;(B) six hours per calendar day; and(C) five days per calendar week.(b) A program provider may request, in accordance with the TxHmL Program Billing Requirements, authorization of a requisition fee:(1) for an adaptive aid that is in addition to the $10,000 service limit described in subsection (a)(1) of this section;(2) for dental treatment that is in addition to the $1,000 service limit described in subsection (a)(2) of this section; or(3) for a minor home modification that is in addition to the $7,500 service limit described in subsection (a)(3)(A) of this section. Source Note: The provisions of this §262.304 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §262.304 Service Limits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223003 03/12/2026 (a) Program provider reimbursement.(1) HHSC pays a program provider for services as described in this paragraph.(A) HHSC pays for community support, nursing, in-home respite, respite, employment readiness, day habilitation, in-home day habilitation, employment assistance, supported employment, professional therapies, and CFC PAS/HAB in accordance with the reimbursement rate for the specific service.(B) HHSC pays for adaptive aids, minor home modifications, and dental treatment based on the actual cost of the item or service and, if requested, a requisition fee in accordance with the TxHmL Program Billing Requirements available on the HHSC website.(C) HHSC pays for CFC ERS based on the actual cost of the service not to exceed the reimbursement rate ceiling for CFC ERS.(2) To be paid for the provision of a service, a program provider must submit a service claim that meets the requirements in §52.121 of this title (relating to Claims Payment) and the TxHmL Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers.(3) If an individual's TxHmL Program services or CFC services are suspended or terminated, a program provider must not submit a claim for services provided during the period of the individual's suspension or after the termination except the program provider may submit a claim for a service provided on the first calendar day of the suspension or termination.(4) If a program provider submits a claim for an adaptive aid that costs $500 or more or for a minor home modification that costs $1,000 or more, the claim must be supported by a written assessment from a licensed professional specified by HHSC in the TxHmL Program Billing Requirements and other documentation as required by the TxHmL Program Billing Requirements.(5) HHSC does not pay a program provider for a service or recoups any payments made to the program provider for a service if:(A) the individual receiving the service was, at the time the service was provided, ineligible for the TxHmL Program or Medicaid benefits, or was an inpatient of a hospital, nursing facility, or ICF/IID;(B) the service was not included on the signed and dated IPC of the individual in effect at the time the service was provided;(C) the service was not provided in accordance with the TxHmL Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(D) the service was not documented in accordance with the TxHmL Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(E) the program provider did not comply with §52.109 of this title (relating to Records);(F) the claim for the service was not prepared and submitted in accordance with the TxHmL Program Billing Requirements or the CFC Billing Requirements Guidelines for HCS and TxHmL Program Providers;(G) the program provider did not have the documentation described in subsection (a)(4) of this section;(H) before including employment assistance on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that employment assistance was not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §701 et seq.) or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(I) before including supported employment on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that supported employment was not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(J) employment readiness, if before including the employment readiness on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that employment readiness was not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(K) HHSC determines that the service would have been paid for by a source other than the TxHmL Program;(L) the service was provided by a service provider who did not meet the qualifications to provide the service as described in the TxHmL Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(M) the service was not provided in accordance with a signed and dated IPC meeting the requirements set forth in §262.301 of this subchapter (relating to IPC Requirements);(N) the service was not provided in accordance with the PDP or the implementation plan;(O) the service was provided before the individual's date of enrollment into the TxHmL Program;(P) for community support, the service was not provided in accordance with a transportation plan and §262.5(a)(16) of this chapter (relating to Description of TxHmL Program Services);(Q) the service was not provided; or(R) for CFC PAS/HAB, in-home day habilitation, and in-home respite, if the service claim for the service did not match the EVV visit transaction as required by 1 TAC §354.4009(a)(4) (relating to Requirements for Claims Submission and Approval).(6) A program provider must refund to HHSC any overpayment made to the program provider within 60 days after the program provider's discovery of the overpayment or receipt of a notice of such discovery from HHSC, whichever is earlier.(7) Except as provided in paragraph (8) of this subsection, if HHSC approves an LOC requested in accordance with §262.104(b)(3) of this chapter (relating to LOC Determination), HHSC pays a program provider for services provided to an individual for a period of not more than 180 calendar days after the individual's previous ID/RC Assessment expires.(8) If HHSC determines that an ID/RC Assessment was submitted more than 180 calendar days after the expiration date of the previous ID/RC Assessment because of circumstances beyond a program provider's control, HHSC may pay the program provider for a period of more than 180 calendar days after the individual's previous ID/RC Assessment expires.(9) HHSC does not withhold payments to a program provider if a LIDDA fails to enter information from an individual's renewal IPC and the program provider continues to provide services in accordance with the most recent IPC authorized by HHSC.(b) Provider fiscal compliance reviews.(1) HHSC conducts provider fiscal compliance reviews to determine a program provider is in compliance with:(A) this chapter;(B) the TxHmL Program Billing Requirements;(C) the CFC Billing Requirements for HCS and TxHmL Program Providers;(D) Chapter 52, Subchapter C of this title (relating to Requirements of a Contractor); and(E) the program provider's Community Services Contract-Provider Agreement.(2) HHSC conducts provider fiscal compliance reviews in accordance with the Provider Fiscal Compliance Review Protocol set forth in the TxHmL Program Billing Requirements and the CFC Billing Requirements for HCS and TxHmL Program Providers. As a result of a provider fiscal compliance review, HHSC may:(A) recoup payments from a program provider; and(B) based on the amount of unverified claims, require a program provider to develop and submit, in accordance with HHSC's instructions, a corrective action plan that improves the program provider's billing practices.(3) A corrective action plan required by HHSC in accordance with paragraph (2)(B) of this subsection must:(A) include:(i) the reason the corrective action plan is required;(ii) the corrective action to be taken;(iii) the person responsible for taking each corrective action; and(iv) a date by which the corrective action will be completed that is no later than 90 calendar days after the date the program provider is notified the corrective action plan is required;(B) be submitted to HHSC within 30 calendar days after the date the program provider is notified the corrective action plan is required; and(C) be approved by HHSC before implementation.(4) Within 30 calendar days after HHSC receives a corrective action plan, HHSC notifies the program provider if HHSC approves the corrective action plan or if the plan requires changes.(5) If HHSC requires a program provider to develop and submit a corrective action plan in accordance with paragraph (2)(B) of this subsection and the program provider requests an administrative hearing for the recoupment in accordance with §262.602 of this chapter (relating to Program Provider's Right to Administrative Hearing), the program provider is not required to develop or submit a corrective action plan while a hearing decision is pending. HHSC notifies the program provider if the requirement to submit a corrective action plan or the content of such a plan changes based on the outcome of the hearing.(6) If a program provider does not submit a corrective action plan or complete a required corrective action within the time frames described in paragraph (3) of this subsection, HHSC may impose a vendor hold on payments due to the program provider until the program provider takes the corrective action.(7) If a program provider does not submit a corrective action plan or complete a required corrective action within 30 calendar days after the date a vendor hold is imposed in accordance with paragraph (6) of this subsection, HHSC may terminate the contract. Source Note: The provisions of this §262.401 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) E REIMBURSEMENT BY HHSC §262.401 Program Provider Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212825 03/12/2026 (a) If a service coordinator receives information that an individual wants to transfer to a different program provider or FMSA, or that an LAR wants the individual to transfer to a different program provider or FMSA, the service coordinator must:(1) if the information was received from the individual or LAR, document the date the information was received in the individual's record;(2) if the information was received from a person other than the individual or LAR, within three business days after the information was received:(A) contact the individual or LAR to confirm whether the individual wants to transfer or the LAR wants the individual to transfer to a different program provider or FMSA; and(B) if the service coordinator makes the confirmation described in subparagraph (A) of this paragraph, document such confirmation in the individual's record; and(3) within three business days after receiving information from the individual or LAR that the individual wants to transfer or the LAR wants the individual to transfer to a different program provider or FMSA or making the confirmation described in paragraph (2)(A) of this subsection:(A) explain to the individual or LAR that the individual may transfer to a program provider whose enrollment has not reached its service capacity in the HHSC data system or FMSA of the individual's or LAR's choice; and(B) provide the individual or LAR the names and contact information of all program providers or FMSAs in the geographic location preferred by the individual or LAR.(b) After the individual or LAR selects a different program provider or FMSA, the service coordinator must coordinate with the individual, LAR, the transferring program provider or FMSA, and the receiving program provider or FMSA to determine a transfer effective date that is:(1) not earlier than the date of the meeting described in subsection (c)(2) of this section; and(2) agreed to by the service coordinator, the individual or LAR, and the receiving program provider.(c) On or before the transfer effective date, the service coordinator must:(1) take action to complete the HHSC Request for Transfer of Waiver Program Services form in accordance with the TxHmL Handbook;(2) convene a meeting with the individual or LAR and the receiving program provider or receiving FMSA to develop a transfer IPC;(3) send the individual's IPC, ID/RC Assessment, and PDP to the receiving program provider or the receiving FMSA;(4) if the individual is transferring to a different program provider, request the following records of the individual from the transferring program provider;(A) pertinent medication records and medical information;(B) Medicaid card;(C) Medicare information, if applicable;(D) the ICAP assessment booklet and computer scoring sheet;(E) trust fund/financial records and any money due the individual;(F) behavior support plan, if applicable;(G) guardianship information, if applicable; and(H) any other pertinent information to ensure health and safety or continuity of services;(5) within two business days after receipt of the records requested in accordance with paragraph (4) of this subsection, send the records to the receiving program provider; and(6) if, within three business days after requesting that the program provider provide records as described in paragraph (4) of this subsection, the service coordinator does not receive all of the records requested, notify HHSC that the records were not received.(d) Within 10 business days after the transfer effective date, the service coordinator must:(1) complete data entry into the HHSC data system in accordance with the TxHmL Handbook after the activities described in subsection (c) of this section are completed; and(2) send the transfer IPC and HHSC Request for Transfer of Waiver Program Services form to HHSC. Source Note: The provisions of this §262.501 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.501 Process for Individual to Transfer to a Different Program Provider or FMSA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212826 03/12/2026 (a) If a service coordinator receives information that an individual wants to receive a service through the CDS option that the individual is receiving from a program provider or that an LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider, the service coordinator must:(1) if the information was received from the individual or LAR, document the date the information was received in the individual's record;(2) if the information was received from a person other than the individual or LAR, within three business days after the information was received:(A) contact the individual or LAR to confirm whether the individual wants to receive or the LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider; and(B) if the service coordinator makes the confirmation described in subparagraph (A) of this paragraph, document such confirmation in the individual's record; and(3) within three business days after receiving information from the individual or LAR that the individual wants to receive or the LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider or making the confirmation described in paragraph (2) of this subsection:(A) explain to the individual or LAR that the individual may select an FMSA of the individual's or LAR's choice; and(B) provide the individual or LAR the names and contact information of all FMSAs in the geographic location preferred by the individual or LAR.(b) After the individual or LAR selects an FMSA, the service coordinator must coordinate with the individual, LAR, the transferring program provider and the receiving FMSA to determine a transfer effective date that is:(1) not earlier than the date of the meeting described in subsection (c)(2) of this section; and(2) agreed to by the service coordinator, the individual or LAR, and the receiving FMSA.(c) On or before the transfer effective date, the service coordinator must:(1) take action to complete HHSC Request for Transfer of Waiver Program Services form in accordance with the TxHmL Handbook;(2) convene a meeting with the individual or LAR to develop a transfer IPC; and(3) send the individual's IPC to the receiving FMSA and obtain the signature of the receiving FMSA on the IPC and Request for Transfer of Waiver Program Services form.(d) Within 10 business days after the transfer effective date, the service coordinator must:(1) complete data entry in the HHSC data system in accordance with the TxHmL Handbook after the activities described in subsection (c) of this section are completed; and(2) send the transfer IPC and HHSC Request for Transfer of Waiver Program Services form to HHSC. Source Note: The provisions of this §262.502 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.502 Process for Individual to Receive a Service Through the CDS Option that the Individual is Receiving from a Program Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212827 03/12/2026 (a) HHSC denies an individual's request for enrollment into the TxHmL Program if the individual does not meet the eligibility criteria described in §262.101 of this chapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services).(b) If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the TxHmL Program and includes in the notice the individual's right to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing).(c) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider. Source Note: The provisions of this §262.503 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.503 Denial of a Request for Enrollment into the TxHmL Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212828 03/12/2026 (a) HHSC denies a TxHmL Program service or CFC service on an individual's IPC, based on a review described in §262.303 of this chapter (relating to HHSC Review of an IPC) or §262.302 of this chapter (relating to Renewal and Revision of an Individual's IPC), if HHSC determines that the TxHmL Program service or CFC service does not meet the requirements described in §262.301(c) of this chapter (relating to IPC Requirements).(b) If HHSC denies a TxHmL Program service or CFC service on the individual's IPC, HHSC:(1) modifies the IPC in the HHSC data system; and(2) sends written notice to the individual or LAR of the denial of the service and includes in the notice the individual's right to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing).(c) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider. Source Note: The provisions of this §262.504 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.504 Denial of TxHmL Program Services or CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212829 03/12/2026 (a) HHSC suspends an individual's TxHmL Program services or CFC services if the individual is under a temporary admission to one of the following facilities:(1) a hospital;(2) an ICF/IID;(3) a nursing facility;(4) an assisted living facility licensed in accordance with Texas Health and Safety Code Chapter 247, Assisted Living Facilities;(5) a residential child care facility licensed by HHSC unless it is an agency foster home;(6) an inpatient chemical dependency treatment facility;(7) a mental health facility;(8) a residential facility operated by the Texas Workforce Commission; or(9) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison.(b) If a service coordinator becomes aware that an individual who is receiving a service from a program provider is under a temporary admission, the service coordinator must, within one business day after becoming aware of the temporary admission, notify the individual's program provider of the temporary admission.(c) If a program provider becomes aware that an individual is under a temporary admission, the program provider must, within one business day after becoming aware of the temporary admission, enter a suspension of the individual's TxHmL Program services and CFC services in the HHSC data system.(d) If a program provider enters a suspension of the individual's TxHmL Program services and CFC services in the HHSC data system, the program provider must notify the individual's service coordinator of the suspension within one business day after the suspension is entered in the system.(e) During a temporary admission, an individual is not considered to be residing in the facility.(f) If an individual's program services are suspended, the service coordinator must, at least every 30 calendar days after the effective date of the suspension, review the individual's circumstances and document in the individual's record:(1) the reasons for continuing the suspension if the individual is likely to remain in the facility;(2) whether the individual anticipates resuming participation in the TxHmL Program after the suspension ends; and(3) the anticipated date the individual will be discharged from the facility, if the individual is not likely to remain in the facility.(g) If a service coordinator determines that an individual's suspension should be extended, the service coordinator must request that HHSC extend the suspension by completing and submitting the HHSC Request to Continue Suspension of Waiver Program Services form to HHSC before:(1) the end of the first 270 calendar days of the temporary admission; or(2) the end of a 30 calendar-day extension previously granted by HHSC.(h) HHSC may extend an individual's suspension for 30 calendar days based on a service coordinator's request as described in subsection (g) of this section.(i) A program provider must remove the entry of a suspension of the individual's TxHmL Program services and CFC services from the HHSC data system and resume the provision of services to the individual if the program provider becomes aware that the individual is discharged from the facility to which the individual has been under temporary admission. Source Note: The provisions of this §262.505 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.505 Suspension of TxHmL Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212830 03/12/2026 (a) HHSC proposes a reduction of a TxHmL Program service or CFC service on an individual's IPC, based on a review described in §262.303 of this chapter (relating to HHSC Review of an IPC) or §262.302 of this chapter (relating to Renewal and Revision of an Individual's IPC), if HHSC determines that the TxHmL Program service or CFC service does not meet the requirements described in §262.301(c) of this chapter (relating to IPC Requirements).(b) If HHSC proposes a reduction of a TxHmL Program service or CFC service on the individual's IPC, HHSC sends written notice to the individual or LAR of the proposed reduction of the service and includes in the notice the individual's right to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing).(c) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider.(d) If the individual or LAR requests a fair hearing before the effective date of the reduction of a TxHmL Program service or CFC service, as specified in the written notice, the service is not reduced and the program provider must provide the service to the individual in the amount authorized in the current IPC while the appeal is pending.(e) If the individual or LAR does not request a fair hearing before the effective date of the reduction of a TxHmL Program service or CFC service, HHSC modifies the IPC in the HHSC data system. Source Note: The provisions of this §262.506 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.506 Reduction of TxHmL Program Services or CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212831 03/12/2026 (a) HHSC terminates an individual's TxHmL Program services and CFC services if:(1) the individual does not meet the eligibility criteria described in §262.101(a)(1) - (7) and (c) of this chapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services); or(2) the individual or LAR refuses to cooperate in the provision or planning of services and:(A) the refusal is documented by the program provider and the service coordinator; and(B) the service coordinator has explained to the individual or LAR, in writing, that the refusal may result in termination of TxHmL Program services and CFC services.(b) If a service coordinator becomes aware that a situation described in subsection (a) of this section exists, the service coordinator must, as soon as practicable, convene a service planning team meeting to discuss the situation. If, after the meeting, the service coordinator determines that the situation cannot be resolved, the service coordinator must request that HHSC terminate the individual's services. To make this request, the service coordinator must complete HHSC Request for Termination of Services form and submit the form to HHSC.(c) If the basis of a service coordinator's request to terminate the individual's services is the reason described in subsection (a)(2) of this section, the service coordinator must include the following information with the completed HHSC Request for Termination of Services form submitted to HHSC:(1) a detailed description of how the individual or LAR refused to cooperate in the provision or planning of services;(2) a copy of the documentation of the refusal by the service coordinator and program provider as required by subsection (a)(2)(A) of this section; and(3) a copy of the written explanation provided to the individual or LAR that the refusal may result in termination of TxHmL Program services and CFC services, as required by subsection (a)(2)(B) of this section.(d) If HHSC receives a completed HHSC Request for Termination of Services form and, if required, the information described in subsection (b) of this section from a service coordinator, HHSC reviews the form and the information. If HHSC approves the request, HHSC sends written notice to the individual or LAR of the proposal to terminate TxHmL Program services and CFC services. The notice includes the individual's right to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing).(e) If the individual or LAR requests a fair hearing before the effective date of the termination of TxHmL Program services and CFC services, as specified in the written notice, the program provider must provide services to the individual in the amounts authorized in the IPC while the appeal is pending Source Note: The provisions of this §262.507 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.507 Termination of TxHmL Program Services and CFC Services with Advance Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212832 03/12/2026 (a) HHSC terminates an individual's TxHmL Program services and CFC services if any of the following situations exists:(1) the individual is admitted to one of the facilities listed in §262.505(a)(1) - (9) of this subchapter (relating to Suspension of TxHmL Program Services and CFC Services):(A) for more than 270 consecutive calendar days; and(B) HHSC has not extended the individual's suspension in accordance with §262.505(h) of this subchapter;(2) the service coordinator or program provider has factual information confirming the death of the individual;(3) the service coordinator or program provider receives a clear written statement signed by the individual or LAR that the individual no longer wants TxHmL Program services;(4) the individual's whereabouts are unknown, and the post office returns mail directed to the individual by the service coordinator or program provider without indicating a forwarding address; or(5) HHSC establishes that the individual has been accepted for Medicaid services by another state.(b) If a service coordinator becomes aware that a situation described in subsection (a) of this section exists, the service coordinator must request that HHSC terminate the individual's services. To make this request, the service coordinator must complete HHSC Request for Termination of Services form and submit the form to HHSC.(c) If HHSC receives a form from a service coordinator requesting that HHSC terminate the individual's services, HHSC sends written notice to the individual or LAR of the termination of TxHmL Program services and CFC services. The notice includes the individual's right to request a fair hearing in accordance with §262.601 of this chapter (relating to Fair Hearing). Source Note: The provisions of this §262.508 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F TRANSFERS, DENIALS, SUSPENSIONS, REDUCTIONS, AND TERMINATIONS §262.508 Termination of TxHmL Program Services and CFC Services without Advance Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212833 03/12/2026 An applicant whose request for eligibility for the TxHmL Program is denied or is not acted upon with reasonable promptness, or an individual whose TxHmL Program services or CFC services have been terminated, suspended, denied, or reduced by HHSC, receives notice of the right to request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules). Source Note: The provisions of this §262.601 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) G HEARINGS §262.601 Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212834 03/12/2026 A program provider may request an administrative hearing if HHSC takes or proposes to take the following action:(1) vendor hold;(2) contract termination;(3) recoupment of payments made to the program provider; or(4) denial of a program provider's claim for payment. Source Note: The provisions of this §262.602 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) G HEARINGS §262.602 Program Provider's Right to Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223004 03/12/2026 (a) A LIDDA must offer TxHmL Program services to an applicant in accordance with §262.103 of this chapter (relating to Process for Enrollment of Applicants). (b) A LIDDA must process enrollments of individuals in the TxHmL Program in accordance with §262.103 of this chapter. (c) A LIDDA must be objective in the process to assist an individual or LAR in the selection of a program provider or FMSA and train all LIDDA staff who may assist an individual or LAR in the process. (d) A LIDDA must, upon the enrollment of an individual and annually thereafter, inform the individual or LAR orally and in writing of the following: (1) the telephone number of the LIDDA to file a complaint; (2) the toll-free telephone number of the HHSC IDD Ombudsman, 1-800-252-8154, to file a complaint; and (3) the toll-free telephone number of DFPS, 1-800-647-7418, to report an allegation of abuse, neglect, or exploitation. (e) A LIDDA must maintain for each individual for an IPC year: (1) a copy of the IPC; (2) the PDP and, if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; (3) a copy of the ID/RC Assessment; (4) documentation of the activities performed by the service coordinator in providing service coordination; and (5) any other pertinent information related to the individual. (f) For an individual receiving TxHmL Program services and CFC services within a LIDDA's local service area, the LIDDA must provide the individual's program provider a copy of the individual's current PDP, IPC, and ID/RC Assessment. (g) A LIDDA must ensure that a service coordinator is an employee of the LIDDA and meets the requirements of this subsection. (1) A service coordinator must meet the minimum qualifications and LIDDA staff training requirements described in Chapter 331 of this title (relating to LIDDA Service Coordination ), except as described in paragraph (2) of this subsection. (2) Notwithstanding §331.19(b) of this title (relating to Staff Person Training), a service coordinator must complete a comprehensive non-introductory person-centered service planning training developed or approved by HHSC within six months after the service coordinator's date of hire, unless an extension of the six month timeframe is granted by HHSC. (3) A service coordinator must receive training about the following within the first 90 calendar days after beginning service coordination duties: (A) rules governing the TxHmL Program and CFC; and (B) Chapter 264 of this title (relating to Consumer Directed Services Option). (h) A LIDDA must ensure that a service coordinator: (1) initiates, coordinates, and facilitates the person-centered planning process to meet the desires and needs as identified by an individual and LAR in the individual's PDP, including: (A) scheduling service planning team meetings; and (B) documenting on the PDP whether, for each TxHmL Program service or CFC service identified on the PDP, the service is critical to meeting the individual's health and safety as determined by the service planning team; (2) coordinates the development and implementation of the individual's PDP; (3) coordinates and develops an individual's IPC based on the individual's PDP; (4) coordinates and monitors the delivery of TxHmL Program services and CFC services and non-TxHmL Program and non-CFC services; and (5) document whether an individual progresses toward desired outcomes identified on the individual's PDP from the individual's and LAR's perspectives. (i) A LIDDA must inform an individual or LAR of the name of the individual's service coordinator and how to contact the service coordinator. (j) A service coordinator must: (1) assist the individual or LAR or actively involved person in exercising the legal rights of the individual; (2) provide an individual, LAR, or family member with a written copy of the booklet, Your Rights in the Texas Home Living (TxHmL) Program, available on the HHSC website, and an oral explanation of the rights described in the booklet: (A) at the time the individual enrolls in the TxHmL Program; (B) when the booklet is revised; (C) upon request of the individual, LAR, or family member; and (D) if one of the following occurs: (i) the individual becomes 18 years of age; (ii) a guardian is appointed for the individual; or (iii) a guardianship for the individual ends; (3) document compliance with paragraph (2) of this subsection in the individual's record and include: (A) the signature of the individual or LAR; and (B) the signature of the service coordinator; (4) ensure that the individual and LAR participate in developing a PDP and IPC that meet the individual's identified needs and service outcomes and that the individual's PDP is updated annually and if the individual's needs or outcomes change; (5) if a behavioral support plan includes techniques that involve restriction of individual rights or intrusive techniques, discuss with the service planning team to determine whether the techniques will be approved by the service planning team; (6) if notified by the program provider that an individual or LAR has refused a comprehensive nursing assessment and that the program provider has determined that it cannot ensure the individual's health, safety, and welfare in the provision of community support, day habilitation, in-home day habilitation, employment readiness, employment assistance, supported employment, respite, or CFC PAS/HAB: (A) inform the individual or LAR of the consequences and risks of refusing the assessment, including that the refusal will result in the individual not receiving: (i) nursing services; or (ii) community support, day habilitation, in-home day habilitation, employment readiness, employment assistance, supported employment, respite, or CFC PAS/HAB, if the individual needs one of those services and the program provider has determined that it cannot ensure the health, safety, and welfare of the individual in the provision of the service; and (B) notify the program provider if the individual or LAR continues to refuse the assessment after the discussion with the service coordinator; (7) inform the individual or LAR of decisions regarding denial, suspension, reduction, or termination of services and the individual's or LAR's right to request a fair hearing as described in §262.601 of this chapter (relating to Fair Hearing); and (8) in accordance with §262.501 (relating to Process for Individual to Transfer to a Different Program Provider or FMSA), manage the process to transfer an individual's TxHmL Program services and CFC services from one program provider to another or transfer from one FMSA to another. (k) When a service coordinator becomes aware that a change to an individual's PDP or IPC may be needed, the service coordinator must discuss the need for the change with the individual or LAR, the individual's program provider, and other appropriate persons. (l) At least 30 calendar days before the expiration of an individual's IPC, the service coordinator must: (1) update the individual's PDP with the individual's service planning team; and (2) if the individual receives a TxHmL Program service or a CFC service from a program provider, submit to the program provider and the individual or LAR: (A) the updated PDP; and (B) if CFC PAS/HAB is included on the PDP, a copy of the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form. (m) A service coordinator must: (1) complete the HHSC TxHmL Service Coordination Notification form with the individual or LAR and provide a copy of the completed form to the individual or LAR: (A) upon receipt of HHSC approval of the enrollment of the individual; (B) if the form is revised; (C) at the request of the individual or LAR; and (D) if one of the following occurs: (i) the individual becomes 18 years of age; (ii) a guardian is appointed for the individual; or (iii) a guardianship for the individual ends; and (2) retain a copy of the completed form in the individual's record. (n) A service coordinator must conduct: (1) a pre-move site review for an applicant 21 years of age or older who is enrolling in the TxHmL Program from a nursing facility or as a diversion from admission to a nursing facility; and (2) post-move monitoring visits for an individual 21 years of age or older who enrolled in the TxHmL Program from a nursing facility or has enrolled in the TxHmL Program as a diversion from admission to a nursing facility. (o) A service coordinator must have contact with an individual in person, by videoconferencing, or telephone to provide service coordination during a month in which it is anticipated that the individual will not receive a TxHmL Program service unless: (1) the individual's TxHmL Program services have been suspended; or (2) the service coordinator had an in-person contact with the individual that month to comply with §331.11(d) of this title (relating to LIDDA's Responsibilities). (p) In addition to the requirements described in Chapter 331 of this title (relating to LIDDA Service Coordination), a LIDDA must: (1) comply with: (A) this subchapter; (B) Chapter 264 of this title; and (C) Chapter 301, Subchapter M of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers); and (2) ensure that a rights protection officer, as required by §334.113 of this title (relating to Rights Protection Officer at a State MR Facility or MRA), who receives a copy of an HHSC initial intake report or a final investigative report from an FMSA, in accordance with §264.702 of this title (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Service Provider) or §264.703 of this title (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of an FMSA), gives a copy of the report to the individual's service coordinator. (q) A service coordinator must: (1) at least annually, in accordance with Chapter 264, Subchapter D of this title (relating to Enrollment, Transfer, Suspension, and Termination): (A) inform the individual or LAR of the individual's right to participate in the CDS option; and (B) inform the individual or LAR that the individual or LAR may choose to have one or more services provided through the CDS option, as described in §264.108 of this title (relating to Services Available Through the CDS Option); and (2) document compliance with paragraph (1) of this subsection in the individual's record. (r) If an individual or LAR chooses to participate in the CDS option, the service coordinator must: (1) provide names and contact information to the individual or LAR of all FMSAs providing services in the LIDDA's local service area; (2) document the individual's or LAR's choice of FMSA on HHSC Consumer Participation Choice form; (3) document, in the individual's PDP, a description of the services provided through the CDS option; and (4) develop with the individual or LAR and other members of the service planning team a transportation plan if an individual's PDP includes community support to be delivered through the CDS option. (s) For an individual participating in the CDS option, a service coordinator must recommend that HHSC terminate the individual's participation in the CDS option if the service coordinator determines that: (1) the individual's continued participation in the CDS option poses a significant risk to the individual's health, safety, or welfare; or (2) the individual, LAR, or designated representative has not complied with Chapter 264, Subchapter B (relating to Responsibilities of Employers and Designated Representatives). (t) To make a recommendation described in subsection (s) of this section, a service coordinator must submit the following documentation to HHSC: (1) the services the individual receives through the CDS option; (2) the reason why the recommendation is made; (3) a description of the attempts to resolve the issues before making the recommendation; and (4) any other supporting documentation, as appropriate. (u) A service coordinator must do the following regarding responsibilities related to EVV: (1) for an applicant who will receive a service that requires the use of EVV from the program provider or through the CDS option: (A) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the applicant or LAR; (B) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (C) provide the individual or LAR with a copy of the signed form; (D) perform the activities described in subparagraph (A) - (C) of this paragraph before the individual's enrollment; and (E) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record; (2) for an individual who will receive a service that requires the use of EVV from the program provider or who is transferring to another program provider or LIDDA and will receive a service that requires the use of EVV from the program provider or through the CDS option: (A) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the individual or LAR; (B) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (C) provide the individual or LAR with a copy of the signed form; (D) perform the activities described in subparagraphs (A)-(C) of this paragraph on or before the effective date of the transfer to another program provider or LIDDA; and (E) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record; and (3) for an individual who will receive a service that requires the use of EVV through the CDS option or who will transfer to another FMSA and is receiving a service requiring the use of EVV: (A) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the individual or LAR; (B) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (C) provide the individual or LAR with a copy of the signed form; (D) perform the activities described in subparagraphs (A)-(C) of this paragraph before the individual receives the EVV required service through the CDS option or on or before the effective date of the transfer to another FMSA; and (E) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record.(v) If notified by a program provider that a requirement described in §262.202 (d)(1) of this chapter (relating to Requirements for Home and Community-Based Settings), needs to be modified, a service coordinator must update the individual's PDP to include the following:(1) a description of the specific and individualized assessed need that justifies the modification;(2) a description of the positive interventions and supports that were tried but did not work;(3) a description of the less intrusive methods of meeting the need that were tried but did not work;(4) a description of the condition that is directly proportionate to the specific assessed need;(5) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(6) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; (7) the individual's or LAR's signature evidencing informed consent to the modification; and(8) the program provider's assurance that the modification will cause no harm to the individual. Source Note: The provisions of this §262.701 adopted to be effective March 1, 2023, 48 TexReg 1055; amended to be effective January 1, 2025, 49 TexReg 10352. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H LIDDA REQUIREMENTS §262.701 LIDDA Requirements for Providing Service Coordination in the TxHmL Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212836 03/12/2026 (a) HHSC may allow program providers and service coordinators to use one or more of the exceptions described in subsections (c) - (j) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers and LIDDAs:(1) if it allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding the definition of "implementation plan" in §262.3 of this chapter (relating to Definitions), the signature of an individual who resides in the disaster area is not required on the individual's implementation plan, if:(1) the meeting required by §262.302(a)(8) of this chapter (relating to Renewal and Revision of an Individual's IPC) is conducted by videoconferencing or telephone;(2) the individual or LAR orally agrees with the implementation plan; and(3) the program provider documents the individual's or LAR's oral agreement on the implementation plan.(d) Notwithstanding §262.8(a) of this chapter (relating to Comprehensive Nursing Assessment), the comprehensive nursing assessment completed by an RN is not required to be completed in person for an individual who resides in the disaster area, if the RN conducts the assessment as a telehealth service or by telephone.(e) Notwithstanding §262.103(k)(1)(A)(i)(I)(-a-) and (-b-) of this chapter (relating to Process for Enrollment of Applicants), a LIDDA is not required to conduct a standardized measure of intellectual functioning in person, or to conduct a standardized measure of adaptive abilities in person for an individual who resides in the disaster area, if the LIDDA conducts the standardized measures by videoconferencing.(f) Notwithstanding §262.103(k)(1)(B)(i) of this chapter, a LIDDA is not required to conduct an ICAP assessment in person for an individual who resides in the disaster area if the LIDDA conducts the ICAP assessment by videoconferencing.(g) Notwithstanding §262.302(a)(1)(C) and (a)(4) of this chapter, a service coordinator is not required to ensure that an individual who resides in the disaster area or LAR sign the PDP, if:(1) the meeting required by §262.302(a)(1)(B) and (a)(3) of this chapter is conducted by videoconferencing or telephone;(2) the service coordinator documents on the PDP the reason for and the topics discussed at the meeting;(3) the individual or LAR orally agrees with the PDP; and(4) the service coordinator documents the individual's or LAR's oral agreement on the PDP.(h) Notwithstanding §262.302(a)(6)(B) of this chapter, a service coordinator is not required to ensure that an individual who resides in the disaster area or LAR signs and dates a renewal or revised IPC, if:(1) the meeting required by §262.302(a)(1)(B) and (a)(3) of this chapter is conducted by videoconferencing or telephone;(2) the service coordinator documents on the renewal or IPC the reason for and the topics discussed at the meeting;(3) the individual or LAR orally agrees with the renewal or revised IPC; and(4) the service coordinator documents the individual's or LAR's oral agreement on the renewal or the revised IPC.(i) Notwithstanding §262.304(a)(1) of this chapter (relating to Service Limits), the service limit for adaptive aids for an individual who resides in the disaster area may be exceeded if:(1) the requested adaptive aid that causes the service limit to be exceeded is:(A) an adaptive aid that replaces an adaptive aid destroyed as a result of the disaster; or(B) the repair of an adaptive aid that was damaged as a result of the disaster;(2) the addition of the requested adaptive aid to the individual's IPC does not result in:(A) the service limit of adaptive aids being exceeded by more than $5,000; or(B) the individual's IPC cost limit for TxHmL program services being exceeded as described in §262.101(a)(4) of this chapter (relating to Eligibility Criteria for TxHmL Program Services and CFC Services);(3) the program provider:(A) includes the cost of the requested adaptive aid on the revised IPC; and(B) submits to HHSC, within 180 days after the effective date of the order or proclamation described in subsection (a) of this section, a written request to HHSC to approve the requested adaptive aid that includes:(i) a description of the adaptive aid that is replacing the adaptive aid destroyed as a result of the disaster, which may include pictures or other descriptive information from a catalog, website, or brochure;(ii) a description of the repair to an adaptive aid that was damaged as a result of the disaster;(iii) one bid for the requested adaptive aid from a vendor that includes:(I) the total cost of the requested adaptive aid; and(II) the name, address, and telephone number of the vendor who must not be a relative of the individual; and(iv) a statement from the program provider that the adaptive aid is not available through a third party resource; and(4) the requested adaptive aid is approved by HHSC.(j) Notwithstanding §262.304(a)(3) of this chapter, the service limit for minor home modifications for an individual who resides in the disaster area may be exceeded if:(1) the requested minor home modification that causes the service limit to be exceeded is:(A) a minor home modification that replaces a minor home modification that was destroyed as a result of the disaster; or(B) the repair of a minor home modification that was damaged as a result of the disaster;(2) the addition of the requested minor home modification to the individual's IPC does not result in:(A) the service limit of minor home modification being exceeded by more than $3,750; or(B) the individual's IPC cost limit for TxHmL program services being exceeded as described in §262.101(a)(4) of this chapter;(3) the program provider:(A) includes the cost of the requested minor home modification on the revised IPC;(B) submits to HHSC, within 180 days after the effective date of the order or proclamation described in subsection (a) of this section, a written request to HHSC to approve the requested minor home modification that includes:(i) a description of the minor home modification that is replacing the minor home modification destroyed as a result of the disaster, which may include pictures or other descriptive information from a catalog, website, or brochure;(ii) a description of the repair to a minor home modification that was damaged as a result of the disaster;(iii) one bid for the requested minor home modification from a vendor that includes:(I) the total cost of the requested minor home modification; and(II) the name, address, and telephone number of the vendor who must not be a relative of the individual; and(iv) a statement from the program provider that the minor home modification is not available through a third party resource; and(4) the requested minor home modification is approved by HHSC. Source Note: The provisions of this §262.801 adopted to be effective March 1, 2023, 48 TexReg 1055. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) I DECLARATION OF DISASTER §262.801 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211653 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211653 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.(1) Applicant--A Texas resident seeking services in the Texas Home Living Program (TxHmL).(2) Calendar day--Any day, including weekends and holidays.(3) CDS employer--Consumer directed services employer. This term has the same meaning as the term "employer" set forth in 40 TAC §41.103 (relating to Definitions).(4) CDS option--Consumer directed services option. This term has the meaning set forth in 40 TAC §41.103.(5) CFC--Community First Choice. A state plan option governed by Code of Federal Regulations, Title 42, Chapter 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice).(6) CFC PAS/HAB--CFC personal assistance services/habilitation.(7) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.(8) Community setting--A setting accessible to the general public within an individual's community.(9) Day habilitation--A TxHmL Program service that provides assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in a location other than the residence of an individual.(10) DFPS--The Department of Family and Protective Services.(11) FMSA--Financial management services agency. This term has the meaning set forth in 40 TAC §41.103.(12) HHSC--The Texas Health and Human Services Commission.(13) Hospital--A public or private institution licensed or exempt from licensure in accordance with Texas Health and Safety Code (THSC) Chapters 13, 241, 261, or 552.(14) ICAP--Inventory for Client and Agency Planning.(15) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. A form used by HHSC for level of care determination and level of need assignment.(16) Implementation plan--A written document developed by a program provider for an individual that, for each TxHmL Program service and CFC service on the individual's individual plan of care (IPC) to be provided by the program provider except for community support and CFC support management, includes:(A) a list of outcomes identified in the person-directed plan that will be addressed using TxHmL Program services and CFC services;(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:(i) observable, measurable, and outcome-oriented; and(ii) derived from assessments of the individual's strengths, personal goals, and needs;(C) a target date for completion of each objective;(D) the number of units of TxHmL Program services and CFC services needed to complete each objective;(E) the frequency and duration of TxHmL Program services and CFC services needed to complete each objective; and(F) the signature and date of the individual, legally authorized representative, and the program provider.(17) Individual--A person enrolled in the TxHmL Program.(18) Individualized skills and socialization provider--A legal entity licensed in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements).(19) Initial IPC--The first IPC for an individual developed before the individual's enrollment into the TxHmL Program.(20) IPC--Individual plan of care. A written plan that:(A) states:(i) the type and amount of each TxHmL Program service and each CFC service, except for CFC support management, to be provided to an individual during an IPC year;(ii) the services and supports to be provided to the individual through resources other than TxHmL Program services or CFC services, including natural supports, medical services, and educational services; and(iii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(21) IPC year--The effective period of an initial IPC and renewal IPC as described in this paragraph.(A) Except as provided in subparagraph (B) of this paragraph, the IPC year for an initial and renewal IPC is a 365-calendar day period starting on the begin date of the initial or renewal IPC.(B) If the begin date of an initial or renewal IPC is March 1 or later in a year before a leap year or January 1 - February 28 of a leap year, the IPC year for the initial or renewal IPC is a 366-calendar day period starting on the begin date of the initial or renewal IPC.(C) A revised IPC does not change the begin or end date of an IPC year.(22) LAR--Legally authorized representative. A person authorized by law to act on behalf of a person with regard to a matter described in this subchapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(23) LOC--Level of care. A determination given to an applicant or individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(24) LON--Level of need. An assignment given by HHSC to an applicant or individual that is derived from the ICAP service level score and from selected items on the ID/RC Assessment.(25) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(26) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(27) PDP--Person-directed plan. A plan developed using an HHSC form that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual and LAR and to ensure the applicant's or individual's health and safety.(28) Program provider--A person, as defined in 40 TAC §49.102 (relating to Definitions), that has a contract with HHSC to provide TxHmL Program services, excluding a financial management services agency.(29) Renewal IPC--An IPC required to be developed for an individual at least 30 but not more than 90 calendar days before the expiration of the individual's IPC in accordance with rules governing the TxHmL Program.(30) Revised IPC--An initial IPC or renewal IPC that is revised during the IPC year in accordance with rules governing the TxHmL Program to add a new TxHmL Program service or CFC service or change the amount of an existing service.(31) Service coordinator--An employee of a local intellectual and developmental disability authority who provides service coordination to an individual.(32) Service provider--A person who directly provides a TxHmL Program service or CFC service to an individual.(33) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C.(34) TxHmL Program--The Texas Home Living Program. Source Note: The provisions of this §262.901 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.901 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211654 03/12/2026 The following are the three types of individualized skills and socialization:(1) on-site individualized skills and socialization;(2) off-site individualized skills and socialization; and(3) in-home individualized skills and socialization. Source Note: The provisions of this §262.903 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.903 Types of Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211655 03/12/2026 (a) Individualized skills and socialization is a TxHmL Program service described in this section.(b) On-site and off-site individualized skills and socialization:(1) provide person-centered activities related to:(A) acquiring, retaining, or improving self-help skills and adaptive skills necessary to live successfully in the community and participate in home and community life; and(B) gaining or maintaining independence, socialization, community participation, current or future volunteer goals, or employment goals consistent with achieving the outcomes identified in an individual's PDP;(2) support the individual's pursuit and achievement of employment through school, vocational rehabilitation, the TxHmL Program service of employment assistance, or the TxHmL Program service of supported employment;(3) provide personal assistance for an individual who cannot manage personal care needs during an individualized skills and socialization activity;(4) as determined by an assessment conducted by a registered nurse, provide assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician; and(5) do not include activities in which an individual:(A) produces marketable goods; and(B) is paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act.(c) On-site individualized skills and socialization:(1) is provided in a building or a portion of a building that is owned or leased by an individualized skills and socialization provider;(2) includes transportation of an individual from one on-site individualized skills and socialization location to another on-site individualized skills and socialization location;(3) promotes an individual's development of skills and behavior that support independence and personal choice; and(4) is not provided in:(A) a setting in which an individual must not reside, as set forth in the rules governing the TxHmL Program; or(B) the residence of an individual or another person.(d) An individualized skills and socialization provider must ensure that individualized skills and socialization is not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a state supported living center or a certified intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) operated by a local intellectual and developmental disability authority (LIDDA) is located but is distinct from the state supported living center or the certified ICF/IID operated by a LIDDA;(2) is located in a building that is on the grounds of or immediately adjacent to a state supported living center or a certified ICF/IID operated by a LIDDA;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building that is on the grounds of or immediately adjacent to a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(e) An individualized skills and socialization provider may provide individualized skills and socialization to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (d) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(f) The setting in which on-site individualized skills and socialization is provided must:(1) allow an individual to:(A) control the individual's schedule and activities related to on-site individualized skills and socialization;(B) have access to the individual's food at any time; and(C) have visitors of the individual's choosing at any time; and(2) be physically accessible and free of hazards to an individual.(g) If an individualized skills and socialization provider becomes aware that a modification to a requirement described in subsection (f)(1) of this section is needed based on a specific assessed need of an individual, the individualized skills and socialization provider must inform the individual's program provider of the needed modification.(1) The program provider must:(A) notify the service coordinator of the needed modification; and(B) provide the service coordinator the information described in paragraph (2)(A) of this subsection as requested by the service coordinator.(2) A service coordinator must, if notified by the program provider of a needed modification, convene a service planning team meeting to update the individual's PDP to include the following:(A) a description of the specific and individualized assessed need that justifies the modification;(B) a description of the positive interventions and supports that were tried but did not work;(C) a description of the less intrusive methods of meeting the need that were tried but did not work;(D) a description of the condition that is directly proportionate to the specific assessed need;(E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(G) the individual's or LAR's signature evidencing informed consent to the modification; and(H) the program provider's assurance that the modification will cause no harm to the individual.(3) After the service planning team updates the PDP as required by paragraph (2) of this subsection, the individualized skills and socialization provider may implement the modifications.(h) Off-site individualized skills and socialization:(1) provides activities that:(A) integrate an individual into the community; and(B) promote the individual's development of skills and behavior that support independence and personal choice;(2) is provided in a community setting chosen by the individual from among available community setting options;(3) includes transportation of an individual from an on-site individualized skills and socialization location to an off-site individualized skills and socialization location and between off-site individualized skills and socialization locations; and(4) is not provided in:(A) a building in which on-site individualized skills and socialization is provided;(B) a setting in which an individual must not reside, as set forth in the rules governing the TxHmL Program, unless:(i) the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in such a setting; or(ii) off-site individualized skills and socialization is provided in an event open to the public; or(C) the residence of an individual or another person, unless the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in the residence.(i) An individualized skills and socialization provider or the program provider is not responsible for the cost, if any, of an individual to participate in an off-site activity. Source Note: The provisions of this §262.905 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.905 Description of On-Site and Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211656 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211656 03/12/2026 (a) In-home individualized skills and socialization is:(1) assistance with acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary to reside and participate successfully in the community;(2) the provision of age-appropriate activities that enhance self-esteem and maximize functional level;(3) reinforcement of skills or lessons taught:(A) in school or other settings; or(B) during the provision of any TxHmL Program service or non-waiver service;(4) the provision of personal assistance for an individual who cannot manage personal care needs during the provision of in-home individualized skills and socialization; and(5) as determined by an assessment conducted by a registered nurse, assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician.(b) One of the following criteria must be met for an individual to receive in-home individualized skills and socialization:(1) a physician must document that the individual's medical condition justifies the provision of in-home individualized skills and socialization;(2) a licensed professional or behavioral supports service provider must document that the individual's behavioral issues justify the provision of in-home individualized skills and socialization; or(3) the individual must be 55 years of age or older and request to receive in-home individualized skills and socialization. Source Note: The provisions of this §262.907 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.907 Description of and Criteria for an Individual to Receive In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211657 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211657 03/12/2026 (a) HHSC may allow program providers to use one or both of the exceptions in subsections (c) and (d) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers:(1) if it allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding §262.907 of this subchapter (relating to Description of and Criteria for an Individual to Receive In-Home Individualized Skills and Socialization), an individual who resides in the disaster area is not required to meet any of the criteria described in §262.907(b) of this subchapter to receive in-home individualized skills and socialization.(d) Notwithstanding §262.913 of this subchapter (relating to Provision of In-Home Individualized Skills and Socialization), if an individual who resides in the disaster area does not meet any of the criteria described in §262.907(b) of this subchapter to receive in-home individualized skills and socialization, a program provider is not required to obtain the documentation described in §262.913(b) of this subchapter. Source Note: The provisions of this §262.909 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.909 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211658 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211658 03/12/2026 (a) On-site and off-site individualized skills and socialization must be provided by an individualized skills and socialization provider. An individualized skills and socialization provider must be the program provider or a contractor of the program provider.(b) A program provider must make both on-site individualized skills and socialization and off-site individualized skills and socialization available to an individual.(c) An individualized skills and socialization provider must provide on-site individualized skills and socialization and off-site individualized skills and socialization in accordance with an individual's PDP, IPC, and implementation plan. Source Note: The provisions of this §262.911 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.911 Provision of On-Site and Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211659 03/12/2026 (a) A program provider must ensure that in-home individualized skills and socialization is provided in the residence of the individual receiving the service.(b) In-home individualized skills and socialization is not required to be provided by an individualized skills and socialization provider.(c) Before providing in-home individualized skills and socialization to an individual, a program provider must obtain documentation:(1) from a physician that the individual's medical condition justifies the provision of in-home individualized skills and socialization;(2) from a licensed professional or behavioral supports service provider that the individual's behavioral issues justify the provision of in-home individualized skills and socialization; or(3) that the individual is 55 years of age or older and requests to receive in-home individualized skills and socialization. Source Note: The provisions of this §262.913 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.913 Provision of In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211660 03/12/2026 The service limit for the combined total of on-site, off-site, and in-home individualized skills and socialization is:(1) 1,560 hours during an IPC year;(2) six hours per calendar day; and(3) five days per calendar week. Source Note: The provisions of this §262.915 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.915 Service Limit for On-Site, Off-Site, and In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211661 03/12/2026 (a) The ratio of service providers of off-site individualized skills and socialization to persons receiving services off-site must be:(1) no higher than one service provider of off-site individualized skills and socialization to eight individuals with an LON 1 or an LON 5 without an enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:8);(2) no higher than one service provider of off-site individualized skills and socialization to two individuals with an LON 8 or an LON 6 and other persons receiving off-site individualized skills and socialization or a similar service (1:2);(3) no higher than one service provider of off-site individualized skills and socialization to two individuals with an LON 1 or an LON 5 with the level one enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:2);(4) no higher than one service provider of off-site individualized skills and socialization to one individual with an LON 1, LON 5, LON 8, or LON 6 with the level two enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:1); and(5) no higher than one service provider of off-site individualized skills and socialization to one individual with an LON 9 and other persons receiving off-site individualized skills and socialization or a similar service (1:1).(b) A ratio described in subsection (a) of this section may include individuals with different LONs and other persons receiving off-site individualized skills and socialization or a similar service. If the ratio includes individuals with different LONs or other persons receiving off-site individualized skills and socialization or a similar service, the ratio must be one of the following, whichever is the lowest staffing ratio:(1) the staffing ratio for the individual with highest level of need;(2) the staffing ratio required by §263.2017(a) of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), if a person in the HCS Program is one of the persons represented in the ratio; or(3) the staffing ratio required by §260.507(a) of this title (relating to Staffing Ratios), if a person in the DBMD Program is one of the persons represented in the ratio.(c) A service provider of off-site individualized skills and socialization assigned to the individuals represented in the staffing ratio required by subsection (a) of this section must provide services only to the individuals and other persons represented in the ratio. Source Note: The provisions of this §262.917 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.917 Staffing Ratios for Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211662 03/12/2026 Notwithstanding other rules governing the TxHmL Program, effective March 1, 2023, day habilitation, which includes in-home day habilitation, is not a service in the TxHmL Program. Source Note: The provisions of this §262.919 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.919 Discontinuation of Day Habilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211663 03/12/2026 (a) If an applicant wants to receive on-site or off-site individualized skills and socialization, or wants to receive and meets the criteria for in-home individualized skills and socialization:(1) a service coordinator must include the type of individualized skills and socialization on the applicant's PDP and the type and amount of individualized skills and socialization on the initial IPC in accordance with the rules governing the TxHmL Program; and(2) a program provider must develop an implementation plan for on-site, off-site, and in-home individualized skills and socialization.(b) To renew or revise an IPC to include on-site, off-site, or in-home individualized skills and socialization, a service coordinator and program provider must comply with rules governing the TxHmL Program, which include developing an implementation plan that describes on-site, off-site, and in-home individualized skills and socialization.(c) If an individual or the individual's LAR wants the individual to receive on-site or off-site individualized skills and socialization, but not both, the service coordinator must document the decision in the individual's PDP.(d) A service coordinator must ensure that an initial IPC that is effective on or after March 1, 2023, does not include day habilitation.(e) A service coordinator must ensure that a renewal IPC that is effective on or after March 1, 2023, does not include day habilitation.(f) A program provider or service coordinator must ensure that a revised IPC with an effective date that is during the period of March 1, 2023, through February 29, 2024, includes only the amount of day habilitation that the program provider provided to the individual before March 1, 2023. Source Note: The provisions of this §262.921 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.921 Including On-Site, Off-Site, and In-Home Individualized Skills and Socialization on an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211664 03/12/2026 (a) A service provider of in-home individualized skills and socialization must be at least 18 years of age and:(1) have a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(2) have documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(A) a written competency-based assessment of the ability to document service delivery and observations of the individuals to be served; and(B) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals being served.(b) A service provider of in-home individualized skills and socialization must complete training as required by the rules governing the TxHmL Program. Source Note: The provisions of this §262.923 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.923 Service Provider Qualifications and Training for In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211665 03/12/2026 (a) Except as provided in subsection (b) of this section, HHSC pays for on-site, off-site, and in-home individualized skills and socialization provided to an individual at the reimbursement rates for on-site, off-site and in-home individualized skills and socialization regardless of the individual's LON.(b) If approved in accordance with §262.927 of this subchapter (relating to Enhanced Staffing Rate) HHSC pays:(1) a level one enhanced staffing rate for off-site individualized skills and socialization for an individual with an LON 1 or LON 5; and(2) a level two enhanced staffing rate for off-site individualized skills and socialization for an individual with an LON 1, LON 5, LON 8, or LON 6.(c) If an individual's TxHmL Program services and CFC services are suspended or terminated, a program provider must not submit a claim for on-site, off-site, or in-home individualized skills and socialization provided during the period of the individual's suspension or after the termination, except that the program provider may submit a claim for the first day of the individual's suspension or termination.(d) HHSC does not pay a program provider for on-site, off-site, or in-home individualized skills and socialization, or recoups any payments made to the program provider for on-site, off-site, or in-home individualized skills and socialization if:(1) the individual receiving on-site, off-site, or in-home individualized skills and socialization was, at the time on-site, off-site, or in-home individualized skills and socialization was provided, ineligible for the TxHmL Program;(2) on-site, off-site, or in-home individualized skills and socialization is provided to an individual during a period of time for which there is not a signed, dated, and authorized IPC for the individual;(3) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;(4) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which the individual did not have an LOC determination;(5) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with a signed, dated, and authorized IPC that includes on-site, off-site, or in-home individualized skills and socialization;(6) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the individual's PDP or implementation plan;(7) on-site, off-site, or in-home individualized skills and socialization is provided before the individual's enrollment date into the TxHmL Program;(8) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with this subchapter;(9) on-site or off-site individualized skills and socialization is not provided in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements);(10) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the TxHmL Program Billing Requirements;(11) on-site, off-site, or in-home individualized skills and socialization is not documented in accordance with the TxHmL Program Billing Requirements;(12) the program provider did not comply with 40 TAC §49.305 (relating to Records);(13) the claim for on-site, off-site, or in-home individualized skills and socialization did not meet the requirements in 40 TAC §49.311 (relating to Claims Payment) or the TxHmL Program Billing Requirements;(14) HHSC determines that on-site, off-site, or in-home individualized skills and socialization would have been paid for by a source other than the TxHmL Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for on-site, off-site, or in-home individualized skills and socialization;(15) on-site or off-site individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide on-site or off-site individualized skills and socialization as described in §559.227(a) of this title (relating to Program Requirements) and the TxHmL Program Billing Requirements;(16) in-home individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide in-home individualized skills and socialization as described in §262.923 of this subchapter (relating to Service Provider Qualifications and Training for In-Home Individualized Skills and Socialization) and the TxHmL Program Billing Requirements;(17) on-site, off-site, or in-home individualized skills and socialization was not provided;(18) on-site or off-site individualized skills and socialization is provided during a period of time that the individual produced marketable goods and was paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act;(19) in-home individualized skills and socialization is not provided in the residence of the individual as required by §262.913(a) of this subchapter (relating to Provision of In-Home Individualized Skills and Socialization); or(20) in-home individualized skills and socialization is provided to an individual without the documentation required by §262.913(c) of this subchapter.(e) HHSC does not pay a program provider for day habilitation, or recoups any payments made to the program provider for day habilitation, if day habilitation is provided on or after March 1, 2023, even if an individual's IPC includes day habilitation on or after March 1, 2023.(f) HHSC conducts provider fiscal compliance reviews, also known as billing and payment reviews, in accordance with rules governing the TxHmL Program and the TxHmL Program Billing Requirements to determine whether a program provider is in compliance with this subchapter. Source Note: The provisions of this §262.925 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.925 Program Provider Reimbursement for On-Site, Off-Site, and In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211666 03/12/2026 (a) A program provider may request a level one enhanced staffing rate for off-site individualized skills and socialization described in §262.925(b) of this subchapter (relating to Program Provider Reimbursement for On-Site, Off-Site, and In-Home Individualized Skills and Socialization) for an individual with a LON 1 or LON 5 who receives off-site individualized skills and socialization from the program provider.(b) A program provider may request a level two enhanced staffing rate for off-site individualized skills and socialization described in §262.925(b) of this subchapter for an individual with a LON 1, LON 5, LON 8, or LON 6 who receives off-site individualized skills and socialization from the program provider.(c) A service coordinator must request a level one enhanced staffing rate for an individual with a LON 1 or LON 5 or request a level two enhanced staffing rate for an individual with a LON 1, LON 5, LON 8, or LON 6 for off-site individualized skills and socialization described in §262.925(b) of this subchapter for an individual who receives off-site individualized skills and socialization through the CDS option if the CDS employer asks the service coordinator to request the enhanced staffing rate.(d) A program provider or service coordinator makes the request described in subsections (a) - (c) of this section by submitting the following documentation to HHSC:(1) a completed HHSC Enhanced Staffing Rate Request Form;(2) the most recent ICAP scoring booklet;(3) the most recent ID/RC Assessment;(4) the most recent PDP;(5) the most recent implementation plan for individualized skills and socialization; and(6) other documentation that supports the individual's request for an enhanced staffing rate, which may include:(A) the behavior support plan;(B) a physician's order;(C) an assessment completed by a service provider of a professional therapy;(D) the nursing assessment; and(E) the CFC PAS/HAB assessment.(e) HHSC approves a request made in accordance with subsections (a) - (d) of this section if the documentation submitted to HHSC demonstrates that to participate in off-site individualized skills and socialization, the individual requires more service provider support than the individual typically receives. The requirement for additional support may be because of the individual's mobility, medical, or behavioral needs.(f) HHSC may review an approved enhanced staffing rate at any time to determine if it is appropriate. If HHSC reviews an enhanced staffing rate, a program provider or service coordinator must submit documentation supporting the enhanced staffing rate to HHSC in accordance with HHSC's request.(g) HHSC notifies a program provider or service coordinator that an enhanced staffing rate is approved or denied through the HHSC data system.(h) A service coordinator must notify the CDS employer and FMSA of HHSC's approval or denial described in subsection (g) of this section.(i) A program provider may request an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing) if HHSC:(1) denies a request made in accordance with subsection (a) or (b) of this section; or(2) denies an enhanced staffing rate based on a review described in subsection (f) of this section. Source Note: The provisions of this §262.927 adopted to be effective January 1, 2023, 47 TexReg 8688. 1 HEALTH AND HUMAN SERVICES COMMISSION 262 TEXAS HOME LIVING (TxHmL) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J INDIVIDUALIZED SKILLS AND SOCIALIZATION §262.927 Enhanced Staffing Rate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212838 03/12/2026 The purpose of this chapter is to describe certain policies, procedures, and requirements of the HCS Program. Source Note: The provisions of this §263.1 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212839 03/12/2026 This chapter applies to:(1) a program provider;(2) a LIDDA;(3) an applicant and the applicant's LAR; and(4) an individual and the individual's LAR. Source Note: The provisions of this §263.2 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223005 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Actively involved--Significant, ongoing, and supportive involvement with an applicant or individual by a person, as determined by the applicant's or individual's service planning team or program provider, based on the person's:(A) interactions with the applicant or individual;(B) availability to the applicant or individual for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the applicant's or individual's needs, preferences, values, and beliefs.(3) ADLs--Activities of daily living. Basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring.(4) Agency foster home--This term has the meaning set forth in Texas Human Resources Code §42.002.(5) ALF--Assisted living facility. A facility licensed in accordance with Texas Health and Safety Code Chapter 247, Assisted Living Facilities.(6) Applicant--A Texas resident seeking services in the Home and Community-Based Services Program.(7) Audio-only--An interactive, two-way audio communication platform that only uses sound.(8) Auxiliary aid--A service or device that enables an individual with impaired sensory, manual, or speaking skills to participate in the person-centered planning process. An auxiliary aid includes interpreter services, transcription services, and a text telephone.(9) Business day--Any day except a Saturday, Sunday, or national or state holiday listed in Texas Government Code §662.003(a) or (b).(10) Calendar day--Any day, including weekends and holidays.(11) CDS option--Consumer directed services option. A service delivery option as defined in §264.103 of this title (relating to Definitions).(12) CFC--Community First Choice.(13) CFC ERS--CFC emergency response services.(14) CFC FMS--The term used for financial management services on the individual plan of care (IPC) of an applicant or individual if the applicant will receive or the individual receives only CFC personal assistance services (PAS)/habilitation (HAB) through the CDS option.(15) CFC support consultation--The term used for support consultation on the IPC of an applicant or individual if the applicant will receive or the individual receives only CFC PAS/HAB through the CDS option.(16) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.(17) Competitive employment--Employment that pays an individual at least minimum wage if the individual is not self-employed.(18) Comprehensive nursing assessment--A comprehensive physical and behavioral assessment of an individual, including the individual's health history, current health status, and current health needs, that is completed by a registered nurse (RN).(19) Contract--A provisional contract or a standard contract.(20) CRCG--Community resource coordination group. A local interagency group, composed of public and private agencies, that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, available on the Texas Health and Human Services Commission (HHSC) website.(21) Delegated nursing task--A nursing task delegated by an RN to an unlicensed person in accordance with:(A) 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and(B) 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).(22) Designated Representative--This term has the meaning set forth in §264.103 of this title.(23) DFPS--The Department of Family and Protective Services.(24) DID--Determination of intellectual disability. This term has the meaning set forth in §304.102 of this title (relating to Definitions).(25) DID report--Determination of intellectual disability report. This term has the meaning set forth in §304.102 of this title.(26) Emergency--An unexpected situation in which the absence of an immediate response could reasonably be expected to result in a risk to the health and safety of an individual or another person.(27) Emergency situation--An unexpected situation involving an individual's health, safety, or welfare, of which a person of ordinary prudence would determine that the legally authorized representative (LAR) should be informed, such as an individual:(A) needing emergency medical care;(B) being removed from the individual's residence by law enforcement;(C) leaving the individual's residence without notifying a staff member or service provider and not being located; and(D) being moved from the individual's residence to protect the individual (for example, because of a hurricane, fire, or flood).(28) EVV--Electronic visit verification. This term has the meaning set forth in 1 TAC §354.4003 (relating to Definitions).(29) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain.(30) Family-based alternative--A family setting in which the family provider or providers are specially trained to provide support and in-home care for children with disabilities or children who are medically fragile.(31) FMS--Financial management services.(32) FMSA--Financial management services agency. As defined in §264.103 of this title, an entity that provides financial management services to an individual participating in the CDS option.(33) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(34) Four-person residence--A residence:(A) that a program provider leases or owns;(B) in which at least one person but no more than four persons receive:(i) residential support;(ii) supervised living;(iii) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person's own resources); or(iv) respite;(C) that, if it is the residence of four persons, at least one of those persons receives residential support;(D) that is not the residence of any persons other than a service provider, the service provider's spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and(E) that is not a setting described in §263.501(b) of this chapter (relating to Requirements for Home and Community-Based Service Settings).(35) GRO--General residential operation. This term has the meaning set forth in Texas Human Resources Code §42.002.(36) Group setting--A setting, other than an individual's residence, in which more than one individual or other person receives employment readiness, employment assistance, supported employment, or a similar service.(37) HCS--Home and Community-based Services. Services provided through the HCS Program operated by HHSC as authorized by CMS in accordance with §1915(c) of the Social Security Act.(38) Health maintenance activities--This term has the meaning set forth in 22 TAC §225.4 (relating to Definitions).(39) Health-related tasks--Specific tasks related to the needs of an individual, which can be delegated or assigned by a licensed health care professional under state law to be performed by a service provider of CFC PAS/HAB. This includes tasks delegated by an RN; health maintenance activities, that may not require delegation; and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist.(40) HHSC--The Texas Health and Human Services Commission.(41) Hospital--A public or private institution licensed or exempt from licensure in accordance with Texas Health and Safety Code (THSC) Chapters 13, 241, 261, or 552.(42) IADLs--Instrumental activities of daily living. Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community.(43) ICAP--Inventory for Client and Agency Planning. An instrument designed to assess a person's needs, skills, and abilities.(44) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided and that is:(A) licensed in accordance with THSC Chapter 252; or(B) certified by HHSC, including a state supported living center.(45) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions.(46) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. A form used by HHSC for level of care determination and level of need assignment.(47) Implementation plan--A written document developed by a program provider for an individual, for each HCS Program service, except supported home living, and for each CFC service, except CFC support management, on the individual's IPC to be provided by the program provider. An implementation plan includes:(A) a list of outcomes identified in the person-directed plan that will be addressed using HCS Program services and CFC services;(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:(i) observable, measurable, and outcome-oriented; and(ii) derived from assessments of the individual's strengths, personal goals, and needs;(C) a target date for completion of each objective;(D) the number of units of HCS Program services and CFC services needed to complete each objective;(E) the frequency and duration of HCS Program services and CFC services needed to complete each objective; and(F) the signature and date of the individual, LAR, and the program provider.(48) In person or in-person--Within the physical presence of another person who is awake. In person or in-person does not include using videoconferencing or a telephone.(49) Individual--A person enrolled in the HCS Program.(50) Initial IPC--The first IPC for an individual developed before the individual's enrollment into the HCS Program.(51) Inpatient chemical dependency treatment facility--A facility licensed in accordance with THSC Chapter 464, Facilities Treating Persons with a Chemical Dependency.(52) Intellectual disability--This term has the meaning set forth in §304.102 of this title.(53) IPC--Individual plan of care. A written plan that:(A) states:(i) the type and amount of each HCS Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year;(ii) the services and supports to be provided to the individual through resources other than HCS Program services or CFC services, including natural supports, medical services, and educational services; and(iii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(54) IPC cost--Estimated annual cost of HCS Program services included on an IPC.(55) IPC year--The effective period of an initial IPC and renewal IPC as described in this paragraph.(A) Except as provided in subparagraph (B) of this paragraph, the IPC year for an initial and renewal IPC is a 365-calendar day period starting on the begin date of the initial or renewal IPC.(B) If the begin date of an initial or renewal IPC is March 1 or later in a year before a leap year or January 1 - February 28 of a leap year, the IPC year for the initial or renewal IPC is a 366-calendar day period starting on the begin date of the initial or renewal IPC.(C) A revised IPC does not change the begin or end date of an IPC year.(56) Job-task oriented--Focused on developing a skill related to a specific type of employment.(57) LAR--Legally authorized representative. A person authorized by law to act on behalf of another person with regard to a matter described in this chapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(58) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with THSC §533A.035.(59) LOC--Level of care. A determination given to an applicant or individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(60) LON--Level of need. An assignment given by HHSC to an individual upon which reimbursement for host home/companion care, supervised living, residential support, in-home day habilitation, and day habilitation is based.(61) Managed care organization--This term has the meaning set forth in Texas Government Code §543A.0001.(62) MAO Medicaid--Medical Assistance Only Medicaid. A type of Medicaid by which an applicant or individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits.(63) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(64) Mental health facility--A facility licensed in accordance with THSC Chapter 577, Private Mental Hospitals and Other Mental Health Facilities.(65) Military family member--A person who is the spouse or child (regardless of age) of:(A) a military member; or(B) a former military member.(66) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch.(67) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who voluntarily assist an individual to achieve the individual's identified goals.(68) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(69) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(70) PDP--Person-directed plan. A plan developed with an applicant or individual and LAR using an HHSC form that:(A) describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual and LAR and to ensure the applicant's or individual's health and safety; and(B) includes the setting for each service, which must be selected by the individual or LAR from setting options.(71) Performance contract--A written agreement between HHSC and a LIDDA for the performance of delegated functions, including those described in THSC §533A.035.(72) Permanency planner--A person who:(A) develops a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form; and(B) performs other permanency planning activities for an applicant or individual under 22 years of age.(73) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an applicant or individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship.(74) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual;(C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or(D) seclusion.(75) Platform--This term has the meaning set forth in Texas Government Code §521.0001.(76) Post-move monitoring visit--A visit conducted by the service coordinator in accordance with the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook.(77) Pre-enrollment minor home modifications assessment--An assessment performed by a licensed professional as required by the HCS Program Billing Requirements to determine the need for pre-enrollment minor home modifications.(78) Pre-move site review--A review conducted by the service coordinator in accordance with HHSC's IDD PASRR Handbook.(79) Professional therapies--Services that consist of the following:(A) audiology;(B) occupational therapy;(C) physical therapy;(D) speech and language pathology;(E) behavioral support;(F) cognitive rehabilitation therapy;(G) dietary services; and(H) social work.(80) Program provider--A person, as defined in §52.3 of this title(relating to Definitions), that has a contract with HHSC to provide HCS Program services, excluding an FMSA.(81) Provisional contract--A contract that HHSC enters into with a program provider in accordance with §52.39 of this title (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §52.39(e) of this title.(82) Related condition--A severe and chronic disability that:(A) is attributed to:(i) cerebral palsy or epilepsy; or(ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability;(B) is manifested before the individual reaches age 22;(C) is likely to continue indefinitely; and(D) results in substantial functional limitation in at least three of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(83) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the HCS Program Billing Requirements.(84) Renewal IPC--An IPC developed for an individual in accordance with §263.302(a) of this chapter (relating to Renewal and Revision of an IPC).(85) Residential child care facility--This term has the meaning set forth in Texas Human Resources Code §42.002.(86) Revised IPC--An initial IPC or a renewal IPC that is revised during an IPC year in accordance with §263.302(b) or (d) of this chapter to add a new HCS Program service or CFC service or change the amount of an existing service.(87) RN--Registered nurse. A person licensed to practice professional nursing in accordance with Texas Occupations Code Chapter 301.(88) Service backup plan--A plan that ensures continuity of critical program services if service delivery is interrupted.(89) Service coordination--A service as defined in §331.5 of this title (relating to Definitions).(90) Service coordinator--An employee of a LIDDA who provides service coordination to an individual.(91) Service planning team--One of the following:(A) for an applicant or individual other than one described in subparagraph (B) or (C) of this paragraph, a planning team consisting of:(i) an applicant or individual and LAR;(ii) service coordinator; and(iii) other persons chosen by the applicant or individual or LAR, for example, a staff member of the program provider, a family member, a friend, a teacher, or if applicable, the permanency planner;(B) for an applicant 21 years of age or older who is residing in a nursing facility and enrolling in the HCS Program, a planning team consisting of:(i) the applicant and LAR;(ii) the service coordinator;(iii) if the applicant is at least 21 years of age but younger than 22 years of age, the permanency planner;(iv) a staff member of the program provider;(v) providers of specialized services;(vi) a nursing facility staff person who is familiar with the applicant's needs;(vii) other persons chosen by the applicant or LAR, for example, a family member, a friend, or a teacher; and(viii) at the discretion of the LIDDA and with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability; or(C) for an individual 21 years of age or older who has enrolled in the HCS Program from a nursing facility or ICF/IID or has enrolled in the HCS Program as a diversion from admission to an institution, including a nursing facility or ICF/IID, for 365 calendar days after enrollment, a planning team consisting of:(i) the individual and LAR;(ii) the service coordinator;(iii) if the individual is at least 21 years of age but younger than 22 years of age and resides in a three-person residence or four-person residence, the permanency planner;(iv) a staff member of the program provider;(v) other persons chosen by the individual or LAR, for example, a family member, a friend, or a teacher; and(vi) at the discretion of the LIDDA and with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability.(92) Service provider--A person, who may be a staff member, who directly provides an HCS Program service or CFC service to an individual.(93) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and a service provider, staff member, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff member, volunteer, or controlling person became a service provider, staff member, volunteer, or controlling person.(94) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(95) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(96) Specialized services--This term has the meaning set forth in §303.102 of this title (relating to Definitions).(97) Staff member--An employee or contractor of an HCS program provider.(98) Standard contract--A contract that HHSC enters into with a program provider in accordance with §52.41 of this title (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with §52.41(d) of this title.(99) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC.(100) Store and forward technology--This term has the meaning set forth in Texas Occupations Code §111.001(2).(101) Supported Decision-Making Agreement--This term has the meaning set forth in Texas Estates Code §1357.002(4).(102) Synchronous audio-visual--An interactive, two-way audio and video communication platform that:(A) allows a service to be provided to an individual in real time; and(B) conforms to the privacy requirements under the Health Insurance Portability and Accountability Act.(103) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code Chapter 2002, Subchapter C.(104) TANF--Temporary Assistance for Needy Families.(105) TAS--Transition assistance services.(106) Telehealth service--This term has the meaning set forth in Texas Occupations Code §111.001.(107) Temporary admission--A stay in a facility listed in §263.705(a) of this chapter (relating to Suspension of HCS Program Services and CFC Services) for 270 calendar days or less or, if an extension is granted in accordance with §263.705(h) of this chapter, a stay in such a facility for more than 270 calendar days.(108) Three-person residence--A residence:(A) that a program provider leases or owns;(B) in which at least one person but no more than three persons receive:(i) residential support;(ii) supervised living;(iii) a non-HCS Program service similar to residential support or supervised living (for example, services funded by DFPS or by a person's own resources); or(iv) respite;(C) that is not the residence of any person other than a service provider, the service provider's spouse or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and(D) that is not a setting described in §263.501(b) of this chapter.(109) THSC--Texas Health and Safety Code. Texas statutes relating to health and safety.(110) Transfer IPC--An IPC that is developed in accordance with §263.701 of this chapter (relating to Process for Individual to Transfer to a Different Program Provider or FMSA) and §263.702 of this chapter (relating to Process for Individual to Receive a Service Through the CDS Option that the Individual is Receiving from a Program Provider) when an individual transfers to another program provider or chooses a different service delivery option.(111) Transition plan--A written plan developed in accordance with §303.701 of this title (relating to Transition Planning for a Designated Resident) for an applicant residing in a nursing facility who is enrolling in the HCS Program.(112) Transportation plan--A written plan based on person-directed planning and developed with an applicant or individual using the HHSC Individual Transportation Plan form available on the HHSC website. A transportation plan is used to document how supported home living will be delivered to support an individual's desired outcomes and purposes for transportation as identified in the PDP.(113) Vendor hold--A temporary suspension of payments that are due to a program provider under a contract.(114) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(115) Videoconferencing--An interactive, two-way audio and video communication:(A) used to conduct a meeting between two or more persons who are in different locations; and(B) that conforms to the privacy requirements under the Health Insurance Portability and Accountability Act.(116) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §263.3 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212841 03/12/2026 (a) The HCS Program is a Medicaid waiver program approved by CMS pursuant to §1915(c) of the Social Security Act. It provides community-based services and supports to eligible individuals as an alternative to the ICF/IID Program. The HCS Program is operated by HHSC.(b) Enrollment in the HCS Program is limited to the number of individuals in specified target groups and to the geographic areas approved by CMS.(c) HCS Program services described in §263.5 of this subchapter (relating to Description of HCS Program Services) and CFC services described in §263.6 of this subchapter (relating to Description of CFC Services) are selected for inclusion in an individual's IPC to ensure the individual's health, safety, welfare, and integration in the community. HCS Program services and CFC Services supplement rather than replace the individual's natural supports and other community services for which the individual may be eligible and prevent the individual's admission to an institutional setting.(d) CFC is a state plan option governed by 42 CFR Chapter 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice).(e) HHSC has grouped Texas counties into geographical areas, referred to as "local service areas," each of which is served by a LIDDA. HHSC has further grouped the local service areas into "waiver contract areas." A list of the counties included in each local service area and waiver contract area is available on the HHSC website.(1) A program provider may provide HCS Program services and CFC services only to persons residing in the counties specified for the program provider in the HHSC automated enrollment and billing system.(2) A program provider must have a separate contract for each waiver contract area served by the program provider.(3) A program provider may have a contract to serve one or more local service areas within a waiver contract area, but the program provider must serve all of the counties within each local service area covered by the contract.(4) A program provider may not have more than one contract per waiver contract area.(f) A program provider must comply with all applicable state and federal laws, rules, and regulations.(g) The CDS option is a service delivery option, described in 40 TAC Chapter 41 (relating to Consumer Directed Services Option), in which an individual or LAR employs and retains service providers and directs the delivery of a service through the CDS option, as described in 40 TAC §41.108 (relating to Services Available Through the CDS Option). Source Note: The provisions of this §263.4 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.4 Description of the HCS Program and CFC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223006 03/12/2026 (a) HCS Program services are described in this section and in Appendix C of the HCS Program waiver application approved by CMS and available on the HHSC website.(1) Adaptive aids are devices, controls, or items that are necessary to address specific needs identified in an individual's service plan. Adaptive aids enable an individual to maintain or increase the ability to perform ADLs or the ability to perceive, control, or communicate with the environment in which the individual lives.(2) Audiology is the provision of audiology as defined in the Texas Occupations Code Chapter 401.(3) Speech and language pathology is the provision of speech-language pathology as defined in the Texas Occupations Code Chapter 401.(4) Occupational therapy is the provision of occupational therapy as described in the Texas Occupations Code Chapter 454.(5) Physical therapy is the provision of physical therapy as defined in the Texas Occupations Code Chapter 453.(6) Dietary services are the provision of nutrition services as defined in the Texas Occupations Code Chapter 701.(7) Behavioral support is the provision of specialized interventions that:(A) assist an individual to increase adaptive behaviors to replace or modify maladaptive or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in home and family life or community life; and(B) improve an individual's quality of life.(8) Social work is the provision of social work as defined in Texas Occupations Code Chapter 505.(9) Cognitive rehabilitation therapy is assistance to an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions, including reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.(10) Day habilitation is assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in a location other than the residence of an individual. Day habilitation does not include in-home day habilitation.(11) In-home day habilitation is assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in an individual's residence.(12) Dental treatment is:(A) emergency dental treatment;(B) preventive dental treatment;(C) therapeutic dental treatment; and(D) orthodontic dental treatment, excluding cosmetic orthodontia.(13) Minor home modifications are physical adaptations to an individual's home to address specific needs identified by an individual's service planning team and include pre-enrollment minor home modifications which are modifications completed before an applicant is discharged from a nursing facility, an ICF/IID, or a GRO and before the effective date of the applicant's enrollment in the HCS Program.(14) Licensed vocational nursing is the provision of licensed vocational nursing as defined in the Texas Occupations Code Chapter 301.(15) Registered nursing is the provision of professional nursing as defined in the Texas Occupations Code Chapter 301.(16) Specialized registered nursing is the provision of registered nursing to an individual who has a tracheostomy or is dependent on a ventilator.(17) Specialized licensed vocational nursing is the provision of licensed vocational nursing to an individual who has a tracheostomy or is dependent on a ventilator.(18) Supported home living is transportation of an individual with a residential type of "own/family home."(19) Host home/companion care is residential assistance provided in a residence that is owned or leased by the service provider of host home/companion care or the individual and is not owned or leased by the program provider. The service provider of host home/companion care must live in the same residence as the individual receiving the service.(20) Supervised living is residential assistance provided in a three-person residence or four-person residence in which service providers are present in the residence and are able to respond to the needs of individuals during normal sleeping hours.(21) Residential support is residential assistance provided in a three-person residence or four-person residence in which service providers are present and awake in the residence whenever an individual is present in the residence.(22) Respite is temporary relief for an unpaid caregiver in a location other than the individual's home for an individual who has a residential type of "own/family home."(23) In-home respite is temporary relief for an unpaid caregiver in the individual's home for an individual who has a residential type of "own/family home."(24) Employment assistance is assistance to help an individual locate paid employment in the community.(25) Supported employment is assistance, in order to sustain competitive employment, to an individual who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed.(26) Employment readiness is assistance that prepares an individual to participate in employment. Employment readiness services are not job-task oriented.(27) TAS is assistance to an applicant in setting up a household in the community before being discharged from a nursing facility, an ICF/IID, or a GRO and before enrolling in the HCS Program and consists of:(A) for an applicant whose initial IPC does not include residential support, supervised living, or host home/companion care:(i) paying security deposits required to lease a home, including an apartment, or to establish utility services for a home;(ii) purchasing essential furnishings for a home, including a table, a bed, chairs, window blinds, eating utensils, and food preparation items;(iii) paying for expenses required to move personal items, including furniture and clothing, into a home;(iv) paying for services to ensure the health and safety of the applicant in a home, including pest eradication, allergen control, or a one-time cleaning before occupancy; and(v) purchasing essential supplies for a home, including toilet paper, towels, and bed linens; and(B) for an applicant whose initial IPC includes residential support, supervised living, or host home/companion care:(i) purchasing bedroom furniture;(ii) purchasing personal linens for the bedroom and bathroom; and(iii) paying for allergen control.(b) The services described in this subsection are for an individual who is receiving at least one HCS Program service through the CDS option.(1) FMS is a service defined in §264.103 of this title (relating to Definitions).(2) Support consultation is a service defined in §264.103 of this title. Source Note: The provisions of this §263.5 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.5 Description of HCS Program Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212843 03/12/2026 (a) CFC services are described in this subsection and in the Medicaid State Plan approved by CMS and available on the HHSC website.(1) CFC PAS/HAB:(A) consists of:(i) personal assistance services that provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including:(I) non-skilled assistance with the performance of the ADLs and IADLs;(II) household chores necessary to maintain the home in a clean, sanitary, and safe environment;(III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and(IV) assistance with health-related tasks; and(ii) habilitation that provides assistance to an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, such as:(I) self-care;(II) personal hygiene;(III) household tasks;(IV) mobility;(V) money management;(VI) community integration, including how to get around in the community;(VII) use of adaptive equipment;(VIII) personal decision making;(IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and(X) self-administration of medication; and(B) does not include transporting the individual, which means driving the individual from one location to another.(2) CFC support management provides training to an individual or LAR on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB, as described in the HCS Handbook, if:(A) the individual is receiving CFC PAS/HAB; and(B) the individual or LAR requests to receive CFC support management.(3) CFC ERS consists of backup systems and supports used to ensure continuity of services and supports, including electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices and is provided only to an individual who:(A) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(B) would otherwise require extensive routine supervision.(b) CFC PAS/HAB and CFC ERS are not available to an individual who is receiving:(1) host home/companion care;(2) supervised living; or(3) residential support. Source Note: The provisions of this §263.6 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.6 Description of CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212844 03/12/2026 If a program provider or LIDDA submits documentation to HHSC containing information that is not in English, the program provider or LIDDA must, at the same time, submit a translation of the information in English. Source Note: The provisions of this §263.7 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.7 Requirement for Translation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212845 03/12/2026 (a) An RN must complete a comprehensive nursing assessment of an individual in person:(1) if the initial IPC includes a sufficient number of RN nursing units for the program provider's RN to perform a comprehensive nursing assessment as described in §263.104(k)(9) of this chapter (relating to Process for Enrollment of Applicants);(2) if there is a significant change in an individual's health or functional status:(A) that, based on a determination by the RN, will not normally resolve itself without further intervention; and(B) requires review or revision of the IPC;(3) at least annually if a nursing service is on the individual's renewal IPC;(4) before an unlicensed service provider performs a delegated nursing task; and(5) if the RN who completed the most recent comprehensive nursing assessment of the individual is no longer providing a nursing service to the individual, except as provided in subsection (b) of this section.(b) The comprehensive nursing assessment required to be completed in accordance with subsection (a)(5) of this section does not have to be completed in person if:(1) the comprehensive nursing assessment is not the annual comprehensive nursing assessment; and(2) an unlicensed service provider is not performing a delegated nursing task or a health maintenance activity for the individual.(c) An RN must document a comprehensive nursing assessment required by subsection (a) of this section using the HHSC Comprehensive Nursing Assessment form or a form that contains all of the same elements as the HHSC Comprehensive Nursing Assessment form. Source Note: The provisions of this §263.8 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.8 Comprehensive Nursing Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212837 03/12/2026 (a) Except as described in subsection (c) of this section, a service provider of physical therapy, occupational therapy, or speech and language pathology may provide physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service.(b) If a service provider of physical therapy, occupational therapy, or speech and language pathology provides physical therapy, occupational therapy, or speech and language pathology to an individual as a telehealth service, a program provider must ensure that the service provider:(1) uses a synchronous audio-visual platform to interact with the individual, supplemented with or without asynchronous store and forward technology;(2) does not use an audio-only platform to provide the service; and(3) before providing the telehealth service:(A) obtains the written informed consent of the individual or LAR to provide the service; or(B) obtains the individual or LAR's oral consent to receive the telehealth service and documents the oral consent in the individual's record.(c) A program provider must ensure that a service provider of physical therapy, occupational therapy, or speech and language pathology performs services in person, as required by the Texas Medicaid Provider Procedures Manual. Such services include:(1) a service that requires a physical agent modality or hands-on therapy, such as a paraffin bath, aquatic therapy, manual therapy, massage, and ultrasound;(2) orthotic management and training, initial encounter, and subsequent encounters;(3) prosthetic management or training for an upper or lower extremity, initial encounter, and subsequent encounters;(4) a wheelchair assessment and training; and(5) a complex rehabilitation technology assessment. Source Note: The provisions of this §263.9 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) A GENERAL PROVISIONS §263.9 Providing Physical Therapy, Occupational Therapy, and Speech and Language Pathology as a Telehealth Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226070 03/12/2026 (a) An applicant or individual is eligible for HCS Program services if the applicant or individual:(1) meets the financial eligibility criteria as described in Appendix B of the HCS Program waiver application approved by CMS and available on the HHSC website;(2) meets one of the following criteria:(A) based on a DID and as determined by HHSC in accordance with §263.105 of this subchapter (relating to LOC Determination), qualifies for an ICF/IID LOC I, as defined in §261.238 of this title (relating to ICF/MR Level of Care I Criteria);(B) as determined by HHSC in accordance with §263.105 of this subchapter, qualifies for an ICF/IID LOC I as defined in §261.238 of this title or ICF/IID LOC VIII, as defined in §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria), and has been determined by HHSC:(i) to have an intellectual disability or a related condition;(ii) to need specialized services; and(iii) to be inappropriately placed in a Medicaid certified nursing facility based on an annual resident review conducted in accordance with the requirements of Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR); or(C) meets the following criteria:(i) based on a DID and as determined by HHSC in accordance with §261.237 of this title (relating to Level of Care) qualifies for one of the following levels of care:(I) an ICF/IID LOC I as defined in §261.238 of this title; or(II) an ICF/IID LOC VIII as defined in §261.239 of this title;(ii) meets one of the following:(I) resides in a nursing facility immediately before enrolling in the HCS Program; or(II) is at imminent risk of entering a nursing facility as determined by HHSC; and(iii) is offered HCS Program services designated for a member of the reserved capacity group "Individuals with a level of care I or VIII residing in a nursing facility" included in Appendix B of the HCS Program waiver application approved by CMS and available on the HHSC website;(3) has an IPC cost that does not exceed:(A) 210 percent of the annualized cost of care in an ICF/IID using the current non-state operated small facility daily rate for LON 8, rounded to the nearest dollar for an applicant or individual with an LON 1, LON 5, or LON 8, which as of September 1, 2025, is $169,182;(B) 210 percent of the annualized cost of care in an ICF/IID using the current non-state operated small facility daily rate for LON 6, rounded to the nearest dollar for an applicant or individual with an LON 6, which as of September 1, 2025, is $211,822; or(C) 210 percent of the annualized cost of care in an ICF/IID using the current non-state operated small facility daily rate for LON 9, rounded to the nearest dollar for an applicant or individual with an LON 9, which as of September 1, 2025, is $392,318;(4) is not enrolled in another waiver program and is not receiving a service that may not be received if the individual is enrolled in the HCS Program as identified in the Mutually Exclusive Services table in Appendix II of the HCS Handbook available on the HHSC website;(5) does not reside in:(A) a hospital;(B) an ICF/IID;(C) a nursing facility;(D) an ALF;(E) a residential child care facility licensed by HHSC unless it is an agency foster home;(F) an inpatient chemical dependency treatment facility;(G) a mental health facility;(H) a residential facility operated by the Texas Workforce Commission; or(I) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison; and(6) requires the provision of:(A) at least one HCS Program service per month or a monthly monitoring visit by a service coordinator as described in §263.901(e)(40) of this chapter (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program); and(B) at least one HCS Program service per IPC year.(b) For applicants or individuals with spouses who live in the community, the income and resource eligibility requirements are determined according to the spousal impoverishment provisions in §1924 of the Social Security Act and as specified in the Medicaid State Plan.(c) Except as provided in subsection (d) of this section, an applicant or individual is eligible for a CFC service under this chapter if the applicant or individual:(1) meets the criteria described in subsection (a) of this section;(2) requires the provision of the CFC service; and(3) is not receiving host home/companion care, supervised living, or residential support.(d) To be eligible for a CFC service under this chapter, an applicant or individual receiving MAO Medicaid must, in addition to meeting the eligibility criteria described in subsection (c) of this section, receive an HCS Program service at least monthly, as required by 42 CFR §441.510(d), which may not be met by a monthly monitoring visit by a service coordinator as described in §263.901(e)(40) of this chapter. Source Note: The provisions of this §263.101 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective September 17, 2025, 50 TexReg 6019. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.101 Eligibility Criteria for HCS Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212847 03/12/2026 (a) Individuals and eligible couples determined to be financially eligible based on the special institutional income limit may be required to share in the cost of HCS Program services. The method for determining the individual's or couple's co-payment is described in subsections (b) and (c) of this section and documented on the HHSC Waiver Program Co-Pay Worksheet.(b) The co-payment amount as determined by HHSC is the individual's or couple's remaining income after all allowable expenses have been deducted. The co-payment amount is applied only to the cost of HCS Program services specified on each individual's IPC. The co-payment must not exceed the cost of services actually delivered. The co-payment must be paid by the individual or couple, authorized representative, or trustee directly to the program provider in accordance with the HHSC determination. When calculating the co-payment amount for an individual or a couple whose income exceeds the maximum personal needs allowance, the following are deducted:(1) the cost of the individual's or couple's maintenance needs, which must be equivalent to the special institutional income limit for eligibility under the Texas Medicaid program;(2) the cost of the maintenance needs of the individual's or couple's dependent children, which is an amount equivalent to the TANF basic monthly grant for children or a spouse with children, using the recognizable needs amounts in the TANF Budgetary Allowances Chart; and(3) the costs incurred for medical or remedial care that are necessary but are not subject to payment by Medicare, Medicaid, or any other third party, which include the costs of health insurance premiums, deductibles, and co-insurance.(c) When calculating the co-payment amount for individuals with community spouses, HHSC determines the amount of the recipient's income applicable to payment in accordance with §1924 of the Social Security Act and 42 CFR §435.726. Source Note: The provisions of this §263.102 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.102 Calculation of Co-payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212848 03/12/2026 (a) A LIDDA must maintain an up-to-date interest list of applicants interested in receiving HCS Program services for whom the LIDDA is the applicant's designated LIDDA in the HHSC data system.(b) A person may request that an applicant's name be added to the HCS interest list by contacting the LIDDA serving the Texas county in which the applicant or person resides.(c) If a request is made in accordance with subsection (b) of this section for an applicant who resides in Texas, a LIDDA must add the applicant's name to the HCS interest list using the date the LIDDA receives the request as the HCS interest list date.(d) For an applicant under 22 years of age who is residing in an ICF/IID or nursing facility located in Texas, HHSC adds the applicant's name to the HCS interest list using the date of admission to the ICF/IID or nursing facility as the HCS interest list date.(e) For an applicant determined diagnostically or functionally ineligible during the enrollment process for the Community Living Assistance and Support Services (CLASS) Program, Deaf-Blind with Multiple Disabilities (DBMD) Program, or Medically Dependent Children Program (MDCP):(1) if the applicant's name is not on the HCS interest list, at the request of the applicant or LAR, HHSC adds the applicant's name to the HCS interest list using the applicant's interest list date for the program for which the applicant was determined ineligible as the HCS interest list date;(2) if the applicant's name is on the HCS interest list and the applicant's interest list date for the program for which the applicant was determined ineligible is earlier than the applicant's HCS interest list date, at the request of the applicant or LAR, HHSC changes the applicant's HCS interest list date to the applicant's interest list date for the program for which the applicant was determined ineligible; or(3) if the applicant's name is on the HCS interest list and the applicant's HCS interest list date is earlier than the applicant's interest list date for the program for which the applicant was determined ineligible, HHSC does not change the applicant's HCS interest list date.(f) This subsection applies to an applicant who was enrolled in MDCP and, because the applicant did not meet the LOC criteria for medical necessity for nursing facility care or did not meet the age requirement of being under 21 years of age, was determined ineligible for MDCP after November 30, 2019.(1) At the request of the applicant or LAR, HHSC adds the applicant's name to the HCS interest list:(A) using the MDCP interest list date as the HCS interest list date, if the applicant's name is not on the HCS interest list but it was previously on the HCS interest list; or(B) using the date HHSC receives the request as the HCS interest list date, if the applicant's name is not on the HCS interest list and it never has been on the HCS interest list.(2) At the request of the applicant or LAR, HHSC changes the HCS interest list date to the MDCP interest list date if the applicant's MDCP interest list date is earlier than the applicant's HCS interest list date.(g) HHSC or the LIDDA removes an applicant's name from the HCS interest list if:(1) the applicant or LAR requests in writing that the applicant's name be removed from the HCS interest list, unless the applicant is under 22 years of age and residing in an ICF/IID or nursing facility;(2) the applicant moves out of Texas, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the applicant declines an offer of HCS Program services or, as described in §263.104(f) of this subchapter (relating to Process for Enrollment of Applicants), an offer of HCS Program services is withdrawn, unless:(A) the applicant is a military family member living outside of Texas:(i) while the military member is on active duty, or(ii) for less than one year after the former military member's active duty ends; or(B) the applicant is under 22 years of age and residing in an ICF/IID or nursing facility;(4) the applicant is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(5) the applicant is deceased; or(6) HHSC has denied the applicant enrollment in the HCS Program and the applicant or LAR has had an opportunity to exercise the applicant's right to appeal the decision in accordance with §263.801 of this chapter (relating to Fair Hearing) and did not appeal the decision or appealed and did not prevail.(h) If HHSC or the LIDDA removes an applicant's name from the HCS interest list in accordance with subsection (g)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the HCS interest list within 90 calendar days after the name was removed, and the request is the applicant's first request:(1) the LIDDA must notify HHSC of the request; and(2) HHSC:(A) adds the applicant's name to the HCS interest list using the HCS interest list date that was in effect at the time the applicant's name was removed from the HCS interest list; and(B) notifies the applicant or LAR in writing that the applicant's name has been added to the HCS interest list in accordance with subparagraph (A) of this paragraph.(i) If HHSC or the LIDDA removes an applicant's name from the HCS interest list in accordance with subsection (g)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the HCS interest list more than 90 calendar days after the name was removed, and the request is the applicant's first request:(1) one of the following occurs:(A) the LIDDA adds the applicant's name to the HCS interest list using the date the LIDDA receives the oral or written request as the HCS interest list date; or(B) if HHSC determines that extenuating circumstances exist, HHSC adds the applicant's name to the HCS interest list using the HCS interest list date that was in effect at the time the applicant's name was removed from the HCS interest list as the HCS interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the HCS interest list in accordance with paragraph (1) of this subsection.(j) If HHSC or the LIDDA removes an applicant's name from the HCS interest list in accordance with subsection (g)(1)-(4) of this section, the LIDDA receives an oral or written request from a person to add the applicant's name to the HCS interest list, and the request is not the applicant's first request:(1) the LIDDA adds the applicant's name to the HCS interest list using the date the LIDDA receives the oral or written request as the HCS interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the HCS interest list in accordance with paragraph (1) of this subsection.(k) If HHSC or the LIDDA removes an applicant's name from the HCS interest list in accordance with subsection (g)(6) of this section and the LIDDA subsequently receives an oral or written request from a person to add the applicant's name to the HCS interest list:(1) the LIDDA must add the applicant's name to the HCS interest list using the date the LIDDA receives the oral or written request as the HCS interest list date; and(2) HHSC notifies the applicant or LAR in writing that the applicant's name has been added to the HCS interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §263.103 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.103 HCS Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223007 03/12/2026 (a) HHSC notifies a LIDDA, in writing, when the opportunity for enrollment in the HCS Program becomes available in the LIDDA's local service area and directs the LIDDA to offer enrollment to an applicant: (1) whose interest list date, assigned in accordance with §263.103 of this subchapter (relating to HCS Interest List), is earliest on the statewide interest list for the HCS Program maintained by HHSC; or (2) who is a member of a target group identified in the HCS Program waiver application approved by CMS. (b) Except as provided in subsection (c) of this section, a LIDDA must offer enrollment in the HCS Program in writing and deliver it to the applicant or LAR by United States mail or by hand delivery. (c) A LIDDA must offer enrollment in the HCS Program to an applicant described in subsection (a)(2) of this section in accordance with HHSC's procedures. (d) A LIDDA must include in a written offer that is made in accordance with subsection (a)(1) of this section: (1) a statement that: (A) if the applicant or LAR does not respond to the offer of enrollment in the HCS Program within 30 calendar days after the LIDDA's written offer, the LIDDA withdraws the offer; and (B) if the applicant is currently receiving services from the LIDDA that are funded by general revenue and the applicant or LAR declines the offer of enrollment in the HCS Program, the LIDDA terminates those services funded by general revenue that are similar to services provided in the HCS Program; and (2) the HHSC Deadline Notification form, which is available on the HHSC website. (e) If an applicant or LAR responds to an offer of enrollment in the HCS Program, a LIDDA must: (1) provide the applicant, LAR, and, if the LAR is not a family member, at least one family member if possible, both an oral and written explanation of the services and supports for which the applicant may be eligible, including the ICF/IID Program, both state supported living centers and community-based facilities, waiver programs authorized under §1915(c) of the Social Security Act, and other community-based services and supports, using the HHSC Explanation of Services and Supports document, which is available on the HHSC website; (2) provide the applicant and LAR both an oral and a written explanation of all HCS Program services and CFC services using the HHSC Understanding Program Eligibility and Services form, which is available on the HHSC website; and (3) give the applicant or LAR the HHSC Waiver Program Verification of Freedom of Choice form, which is available on the HHSC website, to document the applicant's choice between the HCS Program or the ICF/IID Program. (f) A LIDDA must withdraw an offer of enrollment in the HCS Program made to an applicant or LAR if: (1) within 30 calendar days after the LIDDA's offer made to the applicant or LAR in accordance with subsection (a)(1) of this section, the applicant or LAR does not respond to the offer of enrollment in the HCS Program; (2) within seven calendar days after the applicant or LAR receives the HHSC Waiver Program Verification of Freedom of Choice form from the LIDDA in accordance with subsection (e)(3) of this section, the applicant or LAR does not use the form to document the applicant's choice, the HCS Program or the ICF/IID Program; (3) within 30 calendar days after the applicant or LAR receives the contact information for all program providers in the LIDDA's local service area in accordance with subsection (j)(3) of this section, the applicant or LAR does not document the choice of a program provider using the HHSC Documentation of Provider Choice form, which is available on the HHSC website; (4) the applicant or LAR does not complete the necessary activities to finalize the enrollment process and HHSC has approved the withdrawal of the offer; or (5) the applicant has moved out of the State of Texas. (g) If a LIDDA withdraws an offer of enrollment in the HCS Program made to an applicant, the LIDDA must notify the applicant or LAR of such action, in writing, by certified United States mail. (h) If an applicant is currently receiving services from a LIDDA that are funded by general revenue and the applicant or LAR declines the offer of enrollment in the HCS Program, the LIDDA must terminate those services funded by general revenue that are similar to services provided in the HCS Program. (i) If a LIDDA terminates an applicant's services in accordance with subsection (h) of this section, the LIDDA must notify the applicant or LAR of the termination, in writing, by certified United States mail and provide an opportunity for a review in accordance with §301.155 of this title (relating to Notification and Appeals Process). (j) If an applicant or LAR accepts the offer of enrollment in the HCS Program, the LIDDA must compile and maintain information necessary to process the applicant's request for enrollment. (1) If the applicant's financial eligibility for the HCS Program must be established, the LIDDA must initiate, monitor, and support the processes necessary to obtain a financial eligibility determination. (2) The LIDDA must complete an ID/RC Assessment in accordance with §263.105 of this subchapter (relating to LOC Determination) and §263.106 of this subchapter (relating to LON Assignment). (A) The LIDDA must: (i) do one of the following: (I) conduct a DID in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability) except that the following activities must be conducted in person: (-a-) a standardized measure of the individual's intellectual functioning using an appropriate test based on the characteristics of the individual; and (-b-) a standardized measure of the individual's adaptive abilities and deficits reported as the individual's adaptive behavior level; or (II) review and endorse a DID report in accordance with §304.403 of this title (relating to Review and Endorsement of a Determination of Intellectual Disability Report); and (ii) determine whether the applicant has been diagnosed by a licensed physician as having a related condition. (B) The LIDDA must: (i) conduct an ICAP assessment in person; and (ii) recommend an LON assignment to HHSC in accordance with §263.106 of this subchapter. (C) The LIDDA must enter the information from the completed ID/RC Assessment and electronically submit the information to HHSC for approval in accordance with §263.105(a) of this subchapter and §263.106(a) of this subchapter and, if applicable, submit supporting documentation as required by §263.107(c) of this subchapter (relating to HHSC Review of LON). (3) The LIDDA must provide names and contact information to the applicant or LAR for all program providers in the LIDDA's local service area. (4) The LIDDA must assign a service coordinator who, together with other members of the applicant's service planning team, must: (A) develop a PDP; (B) if CFC PAS/HAB is included on the PDP, complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form, which is available on the HHSC website, to determine the number of CFC PAS/HAB hours the applicant needs; and (C) develop an initial IPC in accordance with §263.301(c) of this chapter (relating to IPC Requirements). (5) The CFC PAS/HAB Assessment form required by paragraph (4)(B) of this subsection must be completed in person with the individual unless the following conditions are met in which case the form may be completed by videoconferencing or telephone: (A) the service coordinator gives the individual the opportunity to complete the form in person in lieu of completing it by videoconferencing or telephone and the individual agrees to the form being completed by videoconferencing or telephone; and (B) the individual receives appropriate in-person support during the completion of the form by videoconferencing or telephone. (6) A service coordinator must discuss the CDS option with the applicant or LAR in accordance with §263.401(a) and (b) of this chapter (relating to CDS Option). (k) A service coordinator must: (1) arrange for meetings and visits with potential program providers as requested by an applicant or LAR; (2) review the initial IPC with potential program providers as requested by the applicant or LAR; (3) ensure that the applicant's or LAR's choice of a program provider is documented on the HHSC Documentation of Provider Choice form and that the form is signed by the applicant or LAR; (4) negotiate and finalize the initial IPC and the date services will begin with the selected program provider, consulting with HHSC if necessary to reach agreement with the selected program provider on the content of the initial IPC and the date services will begin; (5) determine whether the applicant meets the following criteria: (A) is being discharged from a nursing facility, an ICF/IID, or a GRO; and (B) anticipates needing TAS; (6) if the service coordinator determines that the applicant meets the criteria described in paragraph (5) of this subsection: (A) complete, with the applicant or LAR and the selected program provider, the HHSC Transition Assistance Services (TAS) Assessment and Authorization form, which is available on the HHSC website, in accordance with the form's instructions, which includes: (i) identifying the TAS the applicant needs; and (ii) estimating the monetary amount for each transition assistance service identified, which must be within the service limit described in §263.304(a)(6) of this chapter (relating to Service Limits); (B) submit the completed form to HHSC to determine if TAS is authorized; (C) send the form authorized by HHSC to the selected program provider; and (D) include the TAS and the monetary amount authorized by HHSC on the applicant's initial IPC; (7) determine whether an applicant meets the following criteria: (A) is being discharged from a nursing facility, an ICF/IID, or a GRO; (B) has not met the maximum service limit for minor home modifications as described in §263.304(a)(3)(A) of this chapter; and (C) anticipates needing pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment; (8) if the service coordinator determines that an applicant meets the criteria described in paragraph (7) of this subsection: (A) complete, with the applicant or LAR and selected program provider, the HHSC Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form, which is available on the HHSC website, in accordance with the form's instructions, which includes: (i) identifying the pre-enrollment minor home modifications the applicant needs; (ii) identifying the pre-enrollment minor home modifications assessments conducted by the program provider; and (iii) based on documentation provided by the program provider as required by the HCS Program Billing Requirements, stating the cost of: (I) the pre-enrollment minor home modifications identified on the form, which must be within the service limit described in §263.304(a)(3)(A) of this chapter; and (II) the pre-enrollment minor home modifications assessments conducted; (B) submit the completed form to HHSC to determine if pre-enrollment minor home modification and pre-enrollment minor home modifications assessments are authorized; (C) send the form authorized by HHSC to the selected program provider; and (D) include the pre-enrollment minor home modifications, pre-enrollment minor home modifications assessments, and the monetary amount for these services authorized by HHSC on the applicant's initial IPC; (9) if an applicant or LAR chooses a program provider to deliver supported home living, nursing, host home/companion care, residential support, supervised living, respite, employment assistance, supported employment, employment readiness, in-home day habilitation, day habilitation, or CFC PAS/HAB, ensure that the initial IPC includes a sufficient number of RN nursing units for the program provider's RN to perform a comprehensive nursing assessment unless: (A) nursing services are not on the IPC and the applicant or LAR and selected program provider have determined that no nursing tasks will be performed by an unlicensed service provider as documented on the HHSC Nursing Task Screening Tool form; or (B) an unlicensed service provider will perform a nursing task and a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician; (10) if an applicant or LAR refuses to include on the initial IPC a sufficient number of RN nursing units for the program provider's RN to perform a comprehensive nursing assessment as required by paragraph (9) of this subsection: (A) inform the applicant or LAR that the refusal: (i) will result in the applicant not receiving nursing services from the program provider; and (ii) if the applicant needs host home/companion care, residential support, supervised living, supported home living, respite, employment assistance, supported employment, employment readiness, in-home day habilitation, day habilitation, or CFC PAS/HAB from the program provider, will result in the individual not receiving that service unless: (I) the program provider's unlicensed service provider does not perform nursing tasks in the provision of the service; and (II) the program provider determines that it can ensure the applicant's health, safety, and welfare in the provision of the service; and (B) document the refusal of the RN nursing units on the initial IPC for a comprehensive nursing assessment by the program provider's RN in the applicant's record; (11) ensure that the applicant or LAR signs and dates the initial IPC and provides the signed and dated IPC to the service coordinator in person, electronically, by fax, or by United States mail; (12) ensure that the selected program provider signs and dates the initial IPC, demonstrating agreement that the services will be provided to the applicant; (13) sign and date the initial IPC, which indicates that the service coordinator agrees that the requirements described in §263.301(c) of this chapter have been met; (14) using the HHSC Understanding Program Eligibility and Services form, which is available on the HHSC website, provide an oral and written explanation to the applicant or LAR: (A) of the eligibility requirements for HCS Program services as described in §263.101(a) of this subchapter (relating to Eligibility Criteria for HCS Program Services and CFC Services); (B) if the applicant's PDP includes CFC services: (i) of the eligibility requirements for CFC services as described in §263.101(c) of this subchapter to applicants who do not receive MAO Medicaid; and (ii) of the eligibility requirements for CFC services as described in §263.101(d) of this subchapter to applicants who receive MAO Medicaid; (C) that HCS Program services may be terminated if: (i) the individual no longer meets the eligibility criteria described in §263.101(a) of this subchapter; or (ii) the individual or LAR requests termination of HCS Program services; and (D) if the applicant's PDP includes CFC services, that CFC services may be terminated if: (i) the individual no longer meets the eligibility criteria described in §263.101(c) or (d) of this subchapter; or (ii) the individual or LAR requests termination of CFC services. (l) A LIDDA must conduct permanency planning in accordance with §263.902(a) - (f) of this chapter (relating to Permanency Planning). (m) After an initial IPC is finalized and signed in accordance with subsection (k) of this section, the LIDDA must: (1) enter the information from the initial IPC in the HHSC data system and electronically submit it to HHSC; (2) keep the original initial IPC in the individual's record; (3) ensure the information from the initial IPC entered in the HHSC data system and electronically submitted to HHSC contains information identical to the information on the initial IPC; and (4) submit other required enrollment information to HHSC. (n) HHSC notifies the applicant or LAR, the selected program provider, the FMSA, if applicable, and the LIDDA of its approval or denial of the applicant's enrollment. When the enrollment is approved, HHSC authorizes the applicant's enrollment in the HCS Program through the HHSC data system and issues an enrollment letter to the applicant that includes the effective date of the applicant's enrollment in the HCS Program. (o) Before the applicant's service begin date, the LIDDA must provide to the selected program provider and FMSA, if applicable: (1) copies of all enrollment documentation and associated supporting documentation, including relevant assessment results and recommendations; (2) the completed ID/RC Assessment; (3) the initial IPC; (4) the applicant's PDP; and (5) if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form. (p) Except for the provision of TAS, pre-enrollment minor home modifications, and a pre-enrollment minor home modifications assessment, the selected program provider must not initiate services until notified of HHSC's approval of the applicant's enrollment. (q) The selected program provider and the individual or LAR must develop: (1) an implementation plan for: (A) HCS Program services, except for supported home living, that is based on the individual's PDP and IPC; and (B) CFC services, except for CFC support management, that is based on the individual's PDP, IPC, and if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and (2) a transportation plan, if supported home living is included on the PDP. (r) A LIDDA must retain in an applicant's record: (1) the HHSC Waiver Program Verification of Freedom of Choice form; (2) the HHSC Documentation of Provider Choice form, if applicable; (3) the HHSC Deadline Notification form; and (4) any other correspondence related to the offer of enrollment in the HCS Program. Source Note: The provisions of this §263.104 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.104 Process for Enrollment of Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212850 03/12/2026 (a) A LIDDA must request an LOC from HHSC for an applicant in accordance with this subsection.(1) The LIDDA must complete an ID/RC Assessment for an applicant that:(A) includes the LOC recommended by a person qualified to perform an initial evaluation of LOC in accordance with Appendix B of the HCS Program waiver application approved by CMS; and(B) is signed and dated in accordance with the instructions for completing the ID/RC Assessment.(2) The LIDDA must enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC.(3) The LIDDA must ensure that the information entered in the HHSC data system and electronically submitted to HHSC is identical to the information on the completed ID/RC Assessment.(4) The LIDDA must send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.(b) A program provider must request an LOC for an individual from HHSC in accordance with this subsection.(1) No more than 60 calendar days before the expiration date of an individual's ID/RC Assessment, a program provider must:(A) complete an ID/RC Assessment that:(i) includes the LOC recommended by a person qualified to perform a reevaluation of LOC in accordance with Appendix B of the HCS Program waiver application approved by CMS; and(ii) is signed and dated by the program provider in accordance with the instructions for completing the ID/RC Assessment; and(B) enter information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information.(2) A program provider must:(A) ensure that the information entered and electronically submitted in the HHSC data system is identical to the information on the completed ID/RC Assessment;(B) within three calendar days after entering and electronically submitting the information in the HHSC data system, provide the service coordinator with a copy of the completed ID/RC Assessment; and(C) send a copy of the completed ID/RC Assessment and supporting documentation to HHSC, as requested by HHSC.(3) If the program provider enters information from a completed ID/RC Assessment in the HHSC data system and electronically submits the information on a date that is more than 180 calendar days after the expiration date of the previous ID/RC Assessment, the program provider must:(A) send to HHSC a copy of the completed ID/RC Assessment by a method, as instructed by HHSC, that:(i) includes the recommended LOC; and(ii) is signed and dated by the program provider in accordance with the instructions for completing the ID/RC Assessment;(B) within three calendar days after sending the completed ID/RC Assessment to HHSC, provide the service coordinator with a copy of the completed ID/RC Assessment; and(C) submit documentation supporting the ID/RC Assessment to HHSC, as requested by HHSC.(c) For an LOC requested in accordance with subsection (b) of this section, within seven calendar days after a program provider enters information from a completed ID/RC Assessment in the HHSC data system and electronically submits the information, the service coordinator or a LIDDA representative other than the service coordinator must:(1) review the information entered in the HHSC data system and electronically submitted, to determine if the information in the HHSC data system is identical to the information on the completed ID/RC Assessment the service coordinator received from the program provider;(2) enter in the HHSC data system:(A) the service coordinator's name and date of review; and(B) one of the following:(i) that the service coordinator agrees with the ID/RC Assessment, if the information in the HHSC data system is identical to the completed ID/RC Assessment; or(ii) that the service coordinator disagrees with the ID/RC Assessment, if the information in the HHSC data system is not identical to the completed ID/RC Assessment; and(3) if the service coordinator or a LIDDA representative other than the service coordinator enters in the HHSC data system that the service coordinator disagrees with the ID/RC Assessment, notify HHSC and the program provider of the service coordinator's disagreement in accordance with HHSC's instructions.(d) For an LOC requested in accordance with subsection (b) of this section, HHSC considers a service coordinator's agreement or disagreement with an ID/RC Assessment in making an LOC determination.(e) Information on an ID/RC Assessment must be supported by current data obtained from standardized evaluations and formal assessments that measure physical, emotional, social, and cognitive factors. A signed and dated ID/RC Assessment and documentation supporting the recommended LOC must be maintained in an individual's record.(f) When HHSC receives a request for an LOC in accordance with subsection (a) or (b) of this section, HHSC determines if an applicant or individual qualifies for an LOC required by §263.101(a)(2) of this subchapter (relating to Eligibility Criteria for HCS Program Services and CFC Services).(g) HHSC approves an LOC or sends a written notification:(1) to the applicant, individual, or LAR that the applicant or individual is not eligible for HCS Program services or CFC services and provides the applicant, individual, or LAR with an opportunity to request a fair hearing in accordance with §263.801 of this chapter (relating to Fair Hearing);(2) to the LIDDA that the LOC has been denied; and(3) to the program provider using the HHSC data system that the LOC has been denied, if the applicant has selected a program provider or an individual is receiving services from a program provider.(h) An LOC determination is valid for a period of time as described in this subsection.(1) Except as provided in paragraph (2) of this subsection, an LOC determination is valid for a 365-calendar day period starting on the begin date of the ID/RC Assessment.(2) If the begin date of the ID/RC Assessment is March 1 or later in a year before a leap year or January 1-February 28 of a leap year, the LOC determination is valid for a 366-calendar day period starting on the begin date of the ID/RC Assessment.(i) An ID/RC Assessment submitted in accordance with subsection (b) of this section is effective on the date after the individual's previous ID/RC Assessment expires.(j) If the LON of an individual receiving HCS Program services changes from a LON 5, LON 8, LON 6, or LON 9 to a LON 1, HHSC notifies the LIDDA of the change using the HHSC HCS Level of Care Redetermination Cover Sheet form.(1) The LIDDA must, within 30 business days after receiving the notification:(A) conduct a DID in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability);(B) complete the LIDDA section of the HHSC HCS Level of Care Redetermination Cover Sheet form, and return the form to HHSC; and(C) submit a copy of the results of the new DID and any other pertinent information regarding the reassessment of the individual to HHSC.(2) If the LIDDA is unable to complete the requirements described in paragraph (1) of this subsection within the 30-business day timeframe, the LIDDA must notify HHSC of the reasons for the delay.(3) HHSC reviews the information submitted by the LIDDA regarding the redetermination and notifies the LIDDA and the HCS program provider of the review decision using the HHSC HCS Level of Care Redetermination Cover Sheet form.(k) For an individual who is receiving all services through the CDS option and, therefore, does not have a program provider, the service coordinator:(1) must perform the functions of the program provider described in subsection (b) of this section; and(2) is not required to comply with subsection (c) of this section. Source Note: The provisions of this §263.105 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.105 LOC Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212851 03/12/2026 (a) A LIDDA must request an LON for an applicant from HHSC at the time an applicant is enrolled into the HCS Program. The LON is requested by entering the information from a completed ID/RC Assessment, that includes the recommended LON and is signed and dated by the service coordinator, in the HHSC data system and electronically submitting the information to HHSC. The electronically submitted ID/RC Assessment must contain information identical to the information on the signed and dated ID/RC Assessment.(b) A program provider must request an LON for an individual from HHSC in accordance with this subsection.(1) Before the expiration of an ID/RC Assessment, the program provider must enter the information from the completed ID/RC Assessment in the HHSC data system and electronically submit the information to HHSC that includes the recommended LON and is signed and dated by the program provider.(2) The program provider must ensure the information from the completed ID/RC Assessment entered in the HHSC data system and electronically submitted contains information that is identical to the information on the signed and dated ID/RC Assessment.(3) The program provider must, within three calendar days after submission, provide the service coordinator with a copy of the signed and dated ID/RC Assessment.(4) If applicable, the program provider must submit supporting documentation to HHSC as required by §263.107(c) of this chapter (relating to HHSC Review of LON).(c) For an LON requested in accordance with subsection (b) of this section, within seven calendar days after the program provider enters the information from the completed ID/RC Assessment in the HHSC data system and electronically submits the information:(1) the service coordinator or a LIDDA representative other than the service coordinator must review the ID/RC Assessment in HHSC data system and enter in the HHSC data system:(A) the service coordinator's name and date; and(B) whether the service coordinator agrees or disagrees with how the ID/RC Assessment was entered in the HHSC data system; and(2) if the service coordinator disagrees with how the ID/RC Assessment was entered in the HHSC data system, the service coordinator and program provider must resolve the disagreement.(d) If the service coordinator disagrees with the ID/RC Assessment for a reason other than how the ID/RC Assessment was entered in the HHSC data system, the service coordinator must notify the individual, LAR, HHSC, and the program provider of the service coordinator's disagreement in accordance with HHSC instructions.(e) The service coordinator's agreement or disagreement is considered in HHSC review of an ID/RC Assessment submitted in accordance with subsection (b) of this section.(f) The program provider must maintain documentation supporting the recommended LON in the individual's record.(g) HHSC assigns an LON to an individual based on the individual's ICAP service level score, information reported on the individual's ID/RC Assessment, and required supporting documentation. Documentation supporting a recommended LON must be submitted to HHSC in accordance with HHSC guidelines.(h) HHSC assigns one of five LONs as follows:(1) an intermittent LON (LON 1) is assigned if the individual's ICAP service level score equals 7, 8, or 9;(2) a limited LON (LON 5) is assigned if the individual's ICAP service level score equals 4, 5, or 6;(3) an extensive LON (LON 8) is assigned if the individual's ICAP service level score equals 2 or 3;(4) a pervasive LON (LON 6) is assigned if the individual's ICAP service level score equals 1; and(5) regardless of an individual's ICAP service level score, a pervasive plus LON (LON 9) is assigned if the individual meets the criteria set forth in subsection (j) of this section.(i) An LON 1, 5, or 8, determined in accordance with subsection (g) of this section, is increased to the next LON by HHSC, due to an individual's dangerous behavior, if supporting documentation submitted to HHSC proves that:(1) the individual exhibits dangerous behavior that could cause serious physical injury to the individual or others;(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;(3) more service providers are needed and available than would be needed if the individual did not exhibit dangerous behavior;(4) service providers are constantly prepared to physically prevent the dangerous behavior or intervene when the behavior occurs; and(5) the individual's ID/RC Assessment is correctly scored with a "1" in the "Behavior" section.(j) HHSC assigns an LON 9 if supporting documentation submitted to HHSC proves that:(1) the individual exhibits extremely dangerous behavior that could be life threatening to the individual or to others;(2) a written behavior support plan has been implemented that meets HHSC guidelines and is based on ongoing written data, targets the extremely dangerous behavior with individualized objectives, and specifies intervention procedures to be followed when the behavior occurs;(3) management of the individual's behavior requires a service provider to exclusively and constantly supervise the individual during the individual's waking hours, which must be at least 16 hours per day;(4) the service provider assigned to supervise the individual has no other duties during such assignment; and(5) the individual's ID/RC Assessment is correctly scored with a "2" in the "Behavior" section.(k) An LON 1, 5, or 8, determined in accordance with subsection (g) of this section, is increased to the next LON by HHSC, due to an individual's high medical needs, if:(1) the individual has an ID/RC Assessment reflecting a frequency code of "6" in the "Nursing" section;(2) a completed HHSC Level of Need (LON) Review/Increase Cover Sheet form is submitted to HHSC; and(3) supporting documentation described in subsection (l) of this section submitted to HHSC with the cover sheet form proves that the individual requires 181 minutes or more per week of:(A) a nursing service listed in §263.5(a)(14) - (17) of this chapter (relating to Description of HCS Program Services) provided in person;(B) in-person nursing services provided by another source; or(C) a combination of the nursing services described in subparagraphs (A) and (B) of this paragraph.(l) The following supporting documentation must be submitted to HHSC as described in subsection (k)(3) of this section:(1) a completed HHSC Medical Increase Worksheet - HCS Program Only form, identifying:(A) a description of the ongoing medical condition requiring the individual to receive 181 minutes or more of in-person nursing services per week;(B) a description of the in-person treatments that need to be provided to the individual and the in-person nursing tasks that need to be performed for the individual;(C) the frequency of a nursing task that needs to be performed and the amount of time required to complete the nursing task; and(D) if applicable, extenuating circumstances that may contribute to the individual's need to receive 181 minutes or more of in-person nursing services per week;(2) the individual's most current:(A) implementation plan for the nursing services listed in §263.5(a)(14) - (17) of this chapter that are provided in person;(B) ICAP assessment booklet and computer scoring sheet;(C) PDP; and(D) comprehensive nursing assessment;(3) nursing notes of all in-person nursing services provided to the individual within the immediate 30 days before the date the ID/RC Assessment is electronically submitted to HHSC;(4) service planning notes relating to the individual's ongoing medical issues completed within the immediate 365 days before the ID/RC Assessment is electronically submitted to HHSC;(5) any professional assessments that discuss the changes in the individual's medical condition or changes in needed medical interventions completed within the immediate 365 days before the date the ID/RC Assessment is electronically submitted; and(6) other documents evidencing that the individual requires 181 minutes or more of in-person nursing services per week, such as:(A) focused or quarterly nursing assessments;(B) physician's orders;(C) medication administration records; and(D) treatment sheets, if used.(m) A program provider must conduct an ICAP assessment in accordance with this subsection.(1) A program provider must conduct an ICAP assessment of an individual:(A) within three years after the individual's enrollment and every third year thereafter;(B) if changes in the individual's functional skills or behavior occur that are not expected to be of short duration or cyclical in nature; or(C) if the individual's skills and behavior are inconsistent with the individual's assigned LON.(2) If the results of an ICAP assessment demonstrate that the individual's LON assignment may not be accurate, the program provider must submit a completed ID/RC Assessment to HHSC recommending a revision of the individual's LON assignment. Source Note: The provisions of this §263.106 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.106 LON Assignment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212852 03/12/2026 (a) HHSC may review a recommended or assigned LON at any time to determine if it is appropriate. If HHSC reviews an LON, documentation supporting the LON must be submitted to HHSC in accordance with HHSC's request. HHSC may modify an LON and recoup or deny payment based on its review.(b) Before assigning an LON, HHSC reviews documentation supporting the recommended LON if:(1) an LON is requested that is an increase from the individual's current LON;(2) an LON 9 is requested in accordance with §263.106(j) of this subchapter (relating to LON Assignment);(3) an LON is requested in accordance with §263.106(i) of this subchapter; or(4) an LON is requested in accordance with §263.106(k) and (l) of this subchapter.(c) Documentation supporting a recommended LON described in subsection (b) of this section must be submitted to HHSC and received by HHSC within seven calendar days after electronically submitting the recommended LON.(1) Within 21 calendar days after receiving the supporting documentation, HHSC:(A) requests additional documentation;(B) electronically approves the recommended LON; or(C) notifies the program provider and the service coordinator in the HHSC data system that the recommended LON has been denied.(2) HHSC reviews any additional documentation submitted in accordance with HHSC's request and:(A) electronically approves the recommended LON; or(B) notifies the program provider and the service coordinator in the HHSC data system that the recommended LON has been denied. Source Note: The provisions of this §263.107 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.107 HHSC Review of LON https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212853 03/12/2026 (a) If a program provider disagrees with an LON assignment, the program provider may request that HHSC reconsider the assignment.(b) The program provider may receive reconsideration only if the program provider submitted documentation supporting the recommended LON as required by §263.107(c) of this subchapter (relating to HHSC Review of LON).(c) To request reconsideration of an LON assignment, the program provider must submit a written request for reconsideration to HHSC within 10 calendar days after receipt of the notification from HHSC that the recommended LON was denied. A program provider may send HHSC documentation, in addition to that required by §263.107(c) of this subchapter, to support the request for reconsideration of an LON assignment.(d) Within 21 calendar days after receipt of a request for reconsideration, HHSC electronically approves the recommended LON or sends written notification that the recommended LON has been denied to the program provider and the service coordinator. A written notification that the recommended LON has been denied gives the program provider the right to request an administrative hearing in accordance §263.802 of this chapter (relating to Program Provider's Right to Administrative Hearing). Source Note: The provisions of this §263.108 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) B ELIGIBILITY, ENROLLMENT, AND REVIEW §263.108 Reconsideration of LON Assignment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212854 03/12/2026 (a) Person-centered planning is a process that empowers an applicant or individual to plan the applicant's or individual's services and supports to achieve desired outcomes.(b) The service coordinator and program provider must ensure the person-centered planning process is led by the individual to the maximum extent possible. The individual's LAR has a participatory role, as needed and as defined by the individual, unless State law confers decision-making authority to the LAR.(c) The person-centered planning process must be used to develop a PDP, implementation plan, initial IPC, renewal IPC, revised IPC, service backup plan, and transportation plan.(d) The person-centered planning process must:(1) include people chosen by the applicant, individual, or LAR;(2) provide the information and support the applicant or individual needs to lead the planning process and make informed choices and decisions;(3) occur at a time and location convenient to the applicant or individual and LAR;(4) consider the applicant's or individual's cultural preferences;(5) provide information in plain language to the applicant or individual in a manner that is accessible to:(A) the applicant or individual through the provision of an auxiliary aid at no cost to the applicant or individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act; and(B) the applicant or individual with limited English proficiency through the provision of language services at no cost to the applicant or individual, including oral interpretation and written translations;(6) use strategies for solving conflict or disagreement within the person-centered planning process;(7) provide information to the individual or LAR to allow the individual or LAR to make informed decisions including:(A) a written and oral description of the services available in the HCS Program; and(B) the name and qualifications of the individual's service providers, in writing; and(8) inform the individual or LAR that the individual or LAR may request revisions to the PDP, implementation plan, initial IPC, renewal IPC, revised IPC, service backup plan, and transportation plan at any time by communicating the request to the service coordinator or the program provider.(e) A program provider must participate in a service planning team meeting if requested by the individual or LAR. Source Note: The provisions of this §263.201 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) C PERSON-CENTERED PLANNING §263.201 Person-Centered Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223008 03/12/2026 (a) An IPC must be based on the PDP and specify: (1) the type and amount of each HCS Program service and CFC service to be provided to an individual during an IPC year; (2) the services and supports to be provided to the individual through resources other than HCS Program services or CFC services during an IPC year, including natural supports, medical services, day activity, and educational services; (3) if an individual will receive CFC support management; and (4) if there are any HCS Program services or CFC services identified on the PDP as critical, requiring a service backup plan. (b) If an applicant's or individual's IPC includes only CFC PAS/HAB to be delivered through the CDS option, a service coordinator must include in the IPC: (1) CFC FMS instead of FMS; and (2) if the applicant or individual will receive support consultation, CFC support consultation instead of support consultation. (c) The type and amount of each HCS Program service and CFC service in an IPC: (1) must be necessary to protect the individual's health and welfare in the community; (2) must not be available to the individual through any other source, including the Medicaid State Plan, other governmental programs, private insurance, or the individual's natural supports; (3) must be the most appropriate type and amount to meet the individual's needs; (4) must be cost effective; (5) must be necessary to enable community integration and maximize independence; (6) if an adaptive aid or minor home modification, must: (A) be included on HHSC's approved list in the HCS Program Billing Requirements; and (B) be within the service limit described in §263.304 of this subchapter (relating to Service Limits); (7) if an adaptive aid costing $500 or more, must be supported by a written assessment from a licensed professional specified by HHSC in the HCS Program Billing Requirements; (8) if a minor home modification costing $1,000 or more, must be supported by a written assessment from a licensed professional specified by HHSC in the HCS Program Billing Requirements; (9) if dental treatment, must be within the service limit described in §263.304 of this subchapter; (10) if respite, must be within the service limit described in §263.304 of this subchapter; (11) if TAS, must be: (A) supported by a Transition Assistance Services (TAS) Assessment and Authorization form authorized by HHSC; and (B) within the service limit described in §263.304(a)(6)(A) or (B) of this subchapter; (12) if pre-enrollment minor home modifications, must be: (A) supported by a written assessment from a licensed professional if required by the HCS Program Billing Requirements; (B) supported by a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by HHSC; (C) within the service limit described in §263.304(a)(3)(A) of this subchapter; (13) if a pre-enrollment minor home modifications assessment, must be supported by a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by HHSC; (14) if CFC PAS/HAB, must be supported by the HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(15) if employment readiness, must be:(A) supported by an HHSC Employment First Discovery Tool that is completed in accordance with §284.105 of this title (relating to Uniform Process); and(B) within the service limit described in §263.304 of this subchapter. Source Note: The provisions of this §263.301 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §263.301 IPC Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212856 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212856 03/12/2026 (a) Renewal of an IPC. At least annually and before the expiration of an individual's IPC, an individual's IPC must be renewed in accordance with this subsection and HHSC's instructions.(1) At least 60 but no more than 90 calendar days before the expiration of an individual's IPC, the service coordinator must:(A) notify the service planning team that the individual's PDP must be reviewed and updated;(B) convene a meeting of the service planning team to:(i) review and update the individual's PDP; and(ii) if CFC PAS/HAB is included on the PDP, complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form to determine the number of CFC PAS/HAB hours the individual needs; and(C) use the HHSC Understanding Program Eligibility and Services form to provide the individual or LAR both an oral and written explanation of:(i) the eligibility requirements for the HCS Program as described in §263.101(a) of this chapter (relating to Eligibility Criteria for HCS Program Services and CFC Services);(ii) if the individual's PDP includes CFC services:(I) the eligibility requirements for CFC services as described in §263.101(c) of this chapter to individuals who do not receive MAO Medicaid; and(II) the eligibility requirements for CFC services as described in §263.101(d) of this chapter to individuals who receive MAO Medicaid;(iii) all HCS Program services and CFC services as described in §263.4 of this chapter (relating to Description of the HCS Program and CFC);(iv) the reason HCS Program services and CFC services may be suspended as described in §263.705(a) of this chapter (relating to Suspension of HCS Program Services and CFC Services); and(v) the reason HCS Program services and CFC services may be terminated as described in §263.707 of this chapter (relating to Termination of HCS Program Services and CFC Services with Advance Notice) and §263.708 of this chapter (relating to Termination of HCS Program Services and CFC Services Without Advance Notice).(2) The HHSC HCS/TxHmL CFC PAS/HAB Assessment form required by paragraph (1)(B)(ii) of this subsection must be completed in person with the individual unless the following conditions are met, in which case the form may be completed by videoconferencing or telephone:(A) the service coordinator gives the individual the opportunity to complete the form in person in lieu of completing it by videoconferencing or telephone and the individual agrees to the form being completed by videoconferencing or telephone; and(B) the individual receives appropriate in-person support during the completion of the form by videoconferencing or telephone.(3) The service coordinator, within 10 calendar days after the PDP is updated, must send a copy of the following to the program provider, the individual or LAR and, if applicable, the FMSA:(A) the updated PDP; and(B) if CFC PAS/HAB is included on the PDP, a copy of the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form.(4) The program provider must ensure that a meeting between the service planning team and the program provider occurs at least 30 but no more than 60 calendar days before the expiration of the individual's IPC to:(A) review the PDP and, if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(B) develop the renewal IPC that meets the requirements described in §263.301(c) of this subchapter (relating to IPC Requirements), including completion of the CDS option portion of the renewal IPC, if applicable, and the non-HCS Program services and non-CFC services.(5) The program provider must convene a meeting with the individual or LAR to develop, before the effective date of the renewal IPC:(A) an implementation plan for:(i) HCS Program services, except for supported home living, that is based on the individual's PDP and renewal IPC; and(ii) CFC services, except for CFC support management, that is based on the individual's PDP, and renewal IPC, and if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(B) a transportation plan, if supported home living is included on the PDP.(6) Within seven calendar days after development of the renewal IPC as required by paragraph (4) of this subsection, the program provider must comply with the requirements in subsection (e)(1) of this section.(7) Within seven calendar days after the program provider enters the information from the renewal IPC in the HHSC data system and electronically submits the information to HHSC as required by subsection (e)(1)(C) of this section, the service coordinator must comply with the requirements in subsection (e)(2) of this section.(8) The program provider must provide HCS Program services and CFC services in accordance with:(A) an implementation plan that is based on:(i) the individual's PDP;(ii) the renewal IPC; and(iii) if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(B) a transportation plan, if supported home living is included on the PDP.(b) Revisions to an IPC. Except as provided in subsection (f) of this section, a service coordinator or a program provider may determine whether an individual's IPC needs to be revised to add a new HCS Program service or CFC service or change the amount of an existing service.(1) The service coordinator must notify the program provider if the service coordinator determines that the IPC needs to be revised.(2) The program provider must notify the service coordinator if the program provider determines that the IPC needs to be revised.(3) Within 14 calendar days after the notification required by paragraph (1) or (2) of this subsection:(A) if the IPC needs to be revised to add CFC PAS/HAB, the service planning team must complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form in order to determine the number of CFC PAS/HAB hours the individual needs;(B) if the IPC needs to be revised to change the amount of CFC PAS/HAB, the service planning team must update the HHSC HCS/TxHmL CFC PAS/HAB Assessment form to reflect the amount of CFC PAS/HAB needed to meet the individual needs;(C) the service coordinator must send a copy of the completed or updated HHSC HCS/TxHmL CFC PAS/HAB Assessment form to the program provider for review;(D) if a new service is being added or a current service is being removed from the IPC or the amount of a service is being increased or decreased and requires the addition of, removal of, or a change to an outcome in the PDP:(i) the service coordinator must convene a meeting with the service planning team to update the PDP; and(ii) the service planning team and the program provider must convene a meeting to develop a revised IPC;(E) if the amount of an existing service is being increased or decreased or a requisition fee is added or removed and does not require the addition of, removal of, or a change to an outcome in the PDP:(i) the program provider must develop a revised IPC; and(ii) the service coordinator must document the reasons for the IPC revision;(F) the program provider must convene a meeting with the individual or LAR to revise:(i) the implementation plan for:(I) HCS Program services, except for supported home living, that is based on the individual's PDP and revised IPC; and(II) CFC services, except for CFC support management, that is based on the individual's PDP, revised IPC, and if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(ii) the transportation plan, if supported home living is modified on the PDP or IPC; and(G) the program provider must comply with the requirements in subsection (e)(1) of this section.(4) The CFC PAS/HAB Assessment form required by paragraph (3)(A) of this subsection must be completed in person with the individual unless the following conditions are met, in which case the form may be completed by videoconferencing or telephone:(A) the service coordinator gives the individual the opportunity to complete the form in person in lieu of completing it by videoconferencing or telephone and the individual agrees to the form being completed by videoconferencing or telephone; and(B) the individual receives appropriate in-person support during the completion of the form by videoconferencing or telephone.(5) The service coordinator, within 10 calendar days after the PDP is updated, must send a copy of the following to the program provider, the individual or LAR and, if applicable, the FMSA:(A) the updated PDP; and(B) if CFC PAS/HAB was updated on the PDP, a copy of the updated HHSC HCS/TxHmL CFC PAS/HAB Assessment form.(6) Within seven calendar days after the program provider enters the information from the revised IPC in the HHSC data system and electronically submits the information to HHSC as required by subsection (e)(1)(C) of this section, the service coordinator must comply with the requirements in subsection (e)(2) of this section.(7) The program provider must provide HCS Program services and CFC services in accordance with:(A) an implementation plan that is based on:(i) the individual's PDP;(ii) the revised IPC; and(iii) if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; and(B) the revised transportation plan, if revised in accordance with paragraph (3)(F)(ii) of this subsection.(c) Revision of an IPC before delivery of services. Except as provided by subsection (d) of this section, if an individual's service planning team and program provider determine that the IPC must be revised to add a new HCS Program service or CFC service or change the amount of an existing service, the program provider must revise the IPC in accordance with subsection (b) of this section before the delivery of a new or increased service.(d) Emergency provision of services and revision of an IPC.(1) If an emergency necessitates the provision of an HCS Program service or CFC service to ensure the individual's health and safety and the service is not on the IPC or exceeds the amount on the IPC, the program provider may provide the service before revising the IPC. The program provider must, within one business day after providing the service:(A) document:(i) the circumstances that necessitated providing the new HCS Program service or CFC service or the increase in the amount of the existing HCS Program service or CFC service; and(ii) the type and amount of the service provided;(B) notify the service coordinator of the emergency provision of the service and that the IPC must be revised; and(C) upon request, provide a copy of the documentation required by subparagraph (A) of this paragraph to the service coordinator.(2) Within seven calendar days after providing the service:(A) the service planning team and the program provider must develop a revised IPC;(B) the service planning team must update the PDP and, if appropriate, complete the HHSC HCS/TxHmL CFC PAS/HAB Assessment form if adding CFC PAS/HAB to the IPC, or update the HHSC HCS/TxHmL CFC PAS/HAB Assessment form if changing the amount of CFC PAS/HAB on the IPC;(C) the program provider must:(i) revise the implementation plan that is based on the individual's PDP and revised IPC; and(ii) develop or revise a transportation plan, if supported home living is added to or modified on the PDP or IPC; and(D) the program provider must comply with the requirements in subsection (e)(1) of this section.(3) Within seven calendar days after the program provider enters the information from the revised IPC in the HHSC data system and electronically submits the information to HHSC as required by subsection (e)(1)(C) of this section, the service coordinator must comply with the requirements in subsection (e)(2) of this section.(4) The program provider must provide HCS Program services and CFC services in accordance with:(A) an implementation plan that is based on the individual's PDP and the revised IPC; and(B) the transportation plan developed or revised in accordance with paragraph (2)(C)(ii) of this subsection.(e) Submitting a renewal and revised IPC to HHSC. A renewal or revised IPC must be submitted to HHSC in accordance with this subsection.(1) A program provider must:(A) sign and date the renewal or revised IPC;(B) ensure that the individual or LAR signs and dates the renewal or revised IPC and provides the signed and dated IPC to the service coordinator in person, electronically, by fax, or by United States mail;(C) after the renewal or revised IPC is signed and dated, enter information from the renewal or revised IPC in the HHSC data system and electronically submit the information to HHSC;(D) ensure that the information entered in the HHSC data system and electronically submitted is identical to the information on the original signed and dated renewal or revised IPC;(E) within three calendar days after entering the information in the HHSC data system and electronically submitting the information, ensure the service coordinator receives a copy of the original signed and dated renewal or revised IPC; and(F) keep the original signed and dated renewal or revised IPC in the individual's record.(2) The service coordinator must review the information entered and submitted in the HHSC data system from the original signed and dated renewal or revised IPC and:(A) enter the service coordinator's name and date in the HHSC data system; and(B) enter in the HHSC data system whether the service coordinator agrees or disagrees that the requirements described in §263.301(c) of this subchapter have been met.(3) If the service coordinator disagrees with how the IPC was entered in the HHSC data system, the service coordinator and program provider must resolve the disagreement.(4) If the service coordinator disagrees with the IPC for a reason other than how the IPC was entered in the HHSC data system, the service coordinator must notify the individual, LAR, HHSC and the program provider of the service coordinator's disagreement in accordance with HHSC instructions.(f) Revision of an IPC to include CFC support management. If an individual or LAR requests CFC support management during an IPC year, the service coordinator or the program provider must revise the IPC as described in the HCS Handbook.(g) Renewal and revision of an IPC when all services are through the CDS option. For an individual who is receiving all services through the CDS option and, therefore, does not have a program provider, the service coordinator must:(1) perform the functions of the program provider described in this section; and(2) is not required to comply with subsection (e)(2) of this section. Source Note: The provisions of this §263.302 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §263.302 Renewal and Revision of an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212857 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212857 03/12/2026 (a) HHSC may review an IPC to determine if the type and amount of HCS Program services and CFC services specified in the IPC meet the requirements described in §263.301(c) of this subchapter (relating to IPC Requirements).(1) If an IPC submitted to HHSC exceeds 100 percent of the estimated annualized average per capita cost for ICF/IID Program services, a LIDDA or program provider must immediately submit documentation supporting the IPC to HHSC, including a copy of the signed and dated IPC, the PDP, the implementation plans for the services on the IPC, and assessments. A LIDDA or program provider must submit additional documentation as requested by HHSC.(2) If requested by HHSC for an IPC other than one described in paragraph (1) of this subsection:(A) a LIDDA must submit documentation supporting an initial IPC to HHSC; and(B) a LIDDA or program provider must submit documentation supporting a renewal or revised IPC to HHSC.(b) HHSC considers a service coordinator's agreement or disagreement that a renewal or revised IPC meets the requirements described in §263.301(c) of this subchapter, as required by §263.302(e)(3) of this subchapter (relating to Renewal and Revision of an IPC), in its review of an IPC.(c) Based on a review of an IPC, HHSC may deny or reduce an HCS Program service or a CFC service in accordance with §263.704 of this chapter (relating to Denial of HCS Program Services or CFC Services) and §263.706 of this chapter (relating to Reduction of HCS Program Services or CFC Services). Source Note: The provisions of this §263.303 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §263.303 HHSC Review of an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223009 03/12/2026 (a) The following limits apply to an individual's HCS Program services: (1) for adaptive aids, $10,000 during an IPC year; (2) for dental treatment, $2,000 during an IPC year; (3) for minor home modifications and pre-enrollment minor home modifications combined: (A) $7,500 during the time the individual is enrolled in the HCS Program, which may be paid in one or more IPC years; and (B) a maximum of $300 for repair and maintenance during an IPC year; (4) for respite and in-home respite combined, 300 hours during an IPC year; (5) for day habilitation and in-home day habilitation combined, 260 units during an IPC year; (6) for TAS: (A) $2,500 if the applicant's initial IPC does not include residential support, supervised living, or host home/companion care; or (B) $1,000 if the applicant's initial IPC includes residential support, supervised living, or host home/companion care; and(7) for employment readiness and individualized skills and socialization combined:(A) 1560 hours during an IPC year; (B) six hours per calendar day; and(C) five days per calendar week. (b) An individual may receive TAS only once in the individual's lifetime. (c) A program provider may request, in accordance with the HCS Program Billing Requirements, authorization of a requisition fee: (1) for dental treatment that is in addition to the $2,000 service limit described in subsection (a)(2) of this section; (2) for a minor home modification that is in addition to the $7,500 service limit described in subsection (a)(3)(A) of this section; or (3) for an adaptive aid that is in addition to the $10,000 service limit described in subsection (a)(1) of this section. Source Note: The provisions of this §263.304 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) D DEVELOPMENT AND REVIEW OF AN IPC §263.304 Service Limits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212859 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212859 03/12/2026 (a) If supported home living, respite, nursing, employment assistance, supported employment, cognitive rehabilitation therapy, or CFC PAS/HAB is included in an applicant's PDP, and the applicant's PDP does not include residential support, supervised living, or host home/companion care, the service coordinator must:(1) inform the applicant or LAR of the applicant's right to participate in the CDS option or discontinue participation in the CDS option at any time, except as provided in 40 TAC §41.405(a) (relating to Suspension of Participation in the CDS Option);(2) inform the applicant or LAR that the applicant or LAR may choose to have supported home living, respite, nursing, employment assistance, supported employment, cognitive rehabilitation therapy, or CFC PAS/HAB provided through the CDS option;(3) provide the applicant or LAR a copy of the HHSC Consumer Directed Services Option Overview form, the HHSC Consumer Directed Services Responsibilities form, and the HHSC Employee Qualification Requirements form, which are found at the HHSC website and which contain information about the CDS option, including a description of FMS and support consultation;(4) provide an oral explanation of the information contained in the HHSC Consumer Directed Services Option Overview form, the HHSC Consumer Directed Services Responsibilities form, and the HHSC Employee Qualification Requirements form to the applicant or LAR; and(5) provide the applicant or LAR the opportunity to choose to participate in the CDS option and document the applicant's or LAR's choice on the HHSC Consumer Participation Choice form, which is available on the HHSC website.(b) If an applicant or LAR chooses to participate in the CDS option, the service coordinator must:(1) provide names and contact information to the applicant or LAR regarding all FMSAs providing services in the LIDDA's local service area;(2) document the applicant's or LAR's choice of FMSA on the Consumer Participation Choice form;(3) document, in the individual's PDP, a description of the service provided through the CDS option; and(4) document, in the individual's PDP, whether the service is critical to meeting the individual's health and safety as determined by the service planning team.(c) For an individual who is receiving supported home living, respite, nursing, employment assistance, supported employment, cognitive rehabilitation therapy, or CFC PAS/HAB, and is not receiving residential support, supervised living, or host home/companion care, the service coordinator must, at least annually:(1) inform the individual or LAR of the individual's right to participate in the CDS option or discontinue participation in the CDS option at any time;(2) provide the individual or LAR a copy of the Consumer Directed Services Option Overview, Consumer Directed Services Responsibilities, and Employee Qualification Requirements forms, which are available on the HHSC website and which contain information about the CDS option, including FMS and support consultation;(3) provide an oral explanation of the information contained in the Consumer Directed Services Option Overview, Consumer Directed Services Responsibilities and Employee Qualification Requirements forms to the individual or LAR; and(4) provide the individual or LAR the opportunity to choose to participate in the CDS option and document the individual's choice on the Consumer Participation Choice form, which is available on the HHSC website.(d) If an individual or LAR chooses to participate in the CDS option, the service coordinator must:(1) provide names and contact information to the individual or LAR regarding all FMSAs providing services in the LIDDA's local service area;(2) document the individual's or LAR's choice of FMSA on the Consumer Participation Choice form;(3) document, in the individual's PDP, a description of the service provided through the CDS option;(4) document, in the individual's PDP, whether the service is critical to meeting the individual's health and safety as determined by the service planning team; and(5) notify the program provider of the individual's or LAR's decision to participate in the CDS option.(e) The service coordinator must document in the individual's PDP that the information described in subsections (c) and (d)(1) of this section was provided to the individual or LAR.(f) If an individual's PDP includes supported home living to be delivered through the CDS option, the service coordinator must develop, with the individual or LAR and other members of the service planning team, a transportation plan.(g) For an individual participating in the CDS option, the service coordinator must recommend that HHSC terminate the individual's participation in the CDS option (that is, terminate FMS and support consultation) if the service coordinator determines that:(1) the individual's continued participation in the CDS option poses a significant risk to the individual's health or safety; or(2) the individual or LAR has not complied with 40 TAC Chapter 41, Subchapter B (relating to Responsibilities of Employers and Designated Representatives).(h) If the service coordinator makes a recommendation in accordance with subsection (g) of this section, the service coordinator must:(1) document:(A) a description of the service recommended for termination;(B) the reasons why termination is recommended; and(C) a description of the attempts to resolve the issues before recommending termination;(2) obtain other supporting documentation, as appropriate; and(3) if the individual receives a service from the program provider, notify the program provider that the IPC needs to be revised.(i) Within seven calendar days after notification in accordance with subsection (h)(3) of this section:(1) the service planning team and the program provider must comply with the requirements described in §263.302(d)(2)(A) - (D) of this chapter (relating to Renewal and Revision of an IPC); and(2) the service coordinator must send the documentation described in subsection (h)(1) and (2) of this section to HHSC. Source Note: The provisions of this §263.401 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) E CDS OPTION §263.401 CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223010 03/12/2026 (a) A home and community-based setting is a setting in which an individual resides or receives HCS Program services or CFC services. A home and community-based setting must have all of the following qualities, based on the needs and preferences of an individual as documented in the individual's PDP.(1) The setting is integrated in and supports the individual's access to the greater community to the same degree as a person not enrolled in a Medicaid waiver program, including opportunities for the individual to:(A) seek employment and work in a competitive integrated setting;(B) engage in community life;(C) control personal resources; and(D) receive services in the community.(2) The setting is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a setting in which residential support, supervised living, or host home/companion care is provided. The setting options are identified and documented in the PDP and are based on the individual's needs, preferences, and, for settings in which residential support, supervised living, or host home/companion care is provided, resources available for room and board.(3) The setting ensures an individual's rights of privacy, dignity, and respect, and freedom from coercion and restraint.(4) The setting optimizes, not regiments, individual initiative, autonomy, and independence in making life choices, including choices regarding daily activities, physical environment, and with whom to interact.(5) The setting facilitates individual choice regarding services and supports and the service providers who provide the services and supports.(b) Except as provided in subsection (c) of this section, a program provider must ensure that HCS Program services and CFC services are not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a certified ICF/IID operated by a LIDDA or state supported living center is located but is distinct from the ICF/IID;(2) is located in a building on the grounds of, or immediately adjacent to, a certified ICF/IID operated by a LIDDA or state supported living center;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building on the grounds of, or immediately adjacent to, a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(c) A program provider may provide an HCS Program service or a CFC service to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (b) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(d) In addition to the requirements in subsection (a) of this section, a program provider must ensure that a group setting:(1) allows an individual to:(A) control the individual's schedule and activities;(B) have access to the individual's food at any time; and(C) receive visitors of the individual's choosing at any time; and(2) is physically accessible and free of hazards to an individual.(e) If a program provider becomes aware that a modification to a requirement described in subsection (d)(1) of this section is needed based on a specific assessed need of an individual, the program provider must:(1) notify the service coordinator of the needed modification; and(2) provide the service coordinator with the information described in §263.901(e)(21) of this chapter relating to (LIDDA Requirements for Providing Service Coordination in the HCS Program) as requested by the service coordinator.(f) If a service coordinator receives a notification as described in subsection (e) of this section, the service coordinator must convene a service planning team meeting to update the PDP as described §263.901(e)(21) of this chapter.(g) After the service planning team updates the PDP as required by subsection (f) of this section, the program provider may implement the modifications. Source Note: The provisions of this §263.501 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F REQUIREMENTS FOR SERVICE SETTINGS AND PROGRAM PROVIDER OWNED OR CONTROLLED RESIDENTIAL SETTINGS §263.501 Requirements for Home and Community-Based Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213255 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213255 03/12/2026 (a) The requirements in this section are in addition to the requirements described in §263.501 of this subchapter (relating to Requirements for Home and Community-Based Service Settings).(b) In each residence in which a program provider provides residential support, supervised living, or host home/companion care, the program provider must ensure that, except as provided in subsection (c) of this section:(1) an individual has privacy in the individual's bedroom;(2) an individual has the option not to share a bedroom with a roommate;(3) an individual sharing a bedroom has a choice of roommates;(4) a lock is installed on the individual's bedroom door at no cost to the individual and that:(A) the lock is operable by the individual; and(B) only the individual, a roommate of the individual, and staff designated by the program provider have keys to the individual's bedroom door;(5) an individual can furnish and decorate the individual's bedroom;(6) while in the residence, an individual has the freedom and support:(A) to control the individual's schedule and activities that are not part of the implementation plan; and(B) to have access to food at any time;(7) an individual may have visitors of the individual's choosing at any time; and(8) the residence is physically accessible and free of hazards to the individual.(c) If a program provider becomes aware that a modification to a requirement described in subsection (b)(1) - (7) of this section is needed based on a specific assessed need of an individual, the program provider must:(1) notify the service coordinator of the needed modification; and(2) provide the service coordinator the information described in §263.901(e)(21) of this chapter relating to (LIDDA Requirements for Providing Service Coordination in the HCS Program) as requested by the service coordinator.(d) If a service coordinator receives a notification as described in subsection (c) of this section, the service coordinator must convene a service planning team meeting to update the PDP as described §263.901(e)(21) of this chapter.(e) After the service planning team updates the PDP as required by subsection (d) of this section, the program provider may implement the modifications. Source Note: The provisions of this §263.502 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F REQUIREMENTS FOR SERVICE SETTINGS AND PROGRAM PROVIDER OWNED OR CONTROLLED RESIDENTIAL SETTINGS §263.502 Requirements for Program Provider Owned or Controlled Residential Settings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213256 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213256 03/12/2026 (a) During a service planning team meeting to develop or update an individual's PDP, a service coordinator must inform an individual or LAR of the following if the individual is interested in receiving residential assistance:(1) that the residential setting options available in the HCS Program consist of:(A) a residence in which the individual receives host home/companion care;(B) a three-person residence in which the individual receives residential support or supervised living; or(C) a four-person residence in which the individual receives residential support or supervised living;(2) that if the individual or LAR selects a residence described in paragraph (1) of this subsection, the individual or LAR will be responsible for paying room and board in accordance with a residential agreement described in subsections (b) and (c) of this section;(3) that if the individual or LAR does not pay room or board as required by a residential agreement, the individual's program provider or service provider of host home/companion care may evict the individual in accordance with the residential agreement and state law; and(4) that if an individual is evicted by a program provider or service provider of host home/companion care and the individual or LAR has not paid the delinquent room or board, HHSC will deny the individual residential support, supervised living, or host home/companion care until the individual or LAR pays the delinquent room or board.(b) An individual's program provider must ensure that:(1) an individual living in a three-person residence or four-person residence or LAR has a written residential agreement with the program provider; and(2) an individual living in a residence in which host home/companion care is provided or LAR has a written residential agreement with the service provider of host home/companion care if the individual does not own the residence or lease the residence from another person.(c) The residential agreement required by subsection (b) of this section must include:(1) the physical address of the residence;(2) the name of the individual;(3) if a three-person residence or four-person residence, the name of the program provider;(4) if a residence in which host home/companion care is provided, the name of the service provider of host home/companion care;(5) the beginning date of the residential agreement;(6) the date the residential agreement expires;(7) a provision that:(A) the program provider or service provider of host home/companion care and the individual or LAR agree that the residential agreement is a "lease," as defined in Texas Property Code Chapter 92 and that they are subject to state law governing residential tenancies, including Texas Property Code Chapters 24, 91, and 92 and Texas Rules of Civil Procedure Rule 510; and(B) to the extent allowed by law, in the event of a conflict or inconsistency between any provision of the residential agreement and any provision of state statutory law, including Texas Property Code Chapters 91 and 92, the provision in the residential agreement governs;(8) a provision that the individual or LAR is not waiving any right or remedy provided to tenants under state law, including the Texas Fair Housing Act in Texas Property Code Chapter 301, and is not agreeing to any notice period that is shorter than the notice period to which tenants are entitled under state law;(9) the amount the individual or LAR is paying for room determined in accordance with the rules governing the HCS Program or a description of other consideration for room, if the individual is paying in kind in lieu of a monetary amount;(10) the amount the individual or LAR is paying for board determined in accordance with the rules governing the HCS Program or a description of other consideration for board, if the individual is paying in kind in lieu of a monetary amount;(11) the day of the month that the amount for room and board is due, which will not be before the day of the month that an individual receives a primary source of income, such as supplemental security income and social security disability insurance;(12) the amount of a late fee, if any, which may be charged only once per month and will not exceed 10 percent of the amount for room and board, that the program provider or host home/companion care service provider may charge the individual or LAR if room and board is not paid by the third day after it is due;(13) a provision that allows the individual or LAR to terminate the residential agreement before its expiration date without any obligation under the residential agreement except an obligation that accrued before the date of termination, if the individual permanently moves from the residence for any reason, including transferring to a different program provider;(14) a provision that the program provider or service provider of host home/companion care agrees to refund to the individual or LAR an amount for room and board paid to the program provider or services provider for the days that the individual was away from the residence because the individual permanently moved from the residence using the following formula to determine the daily amount for room and board (the monthly amount for room and board ÷ the number of days in the month);(15) a provision that the individual may furnish and decorate the individual's bedroom;(16) a provision that the program provider or service provider of host home/companion care agrees to be responsible for all repairs to the residence of the program provider or service provider of host home/companion care, including the program provider's or service provider's real property or personal property, resulting from normal wear and tear, as defined in Texas Property Code §92.001;(17) a provision that allows eviction of the individual only if:(A) the individual or LAR fails to pay room or board, which does not include any late fee; or(B) the individual's HCS Program services are terminated;(18) a provision that the program provider or service provider of host home/companion care will, before giving the individual or LAR a notice to vacate, give the individual or LAR a notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room or board;(19) a provision that if the individual or LAR pays the delinquent room or board within the period required by paragraph (18) of this subsection, the program provider or service provider of host home/companion care will not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual;(20) a provision that the program provider or service provider of host home/companion care will not accelerate the entire balance of the unpaid room or board owed under the remainder of the term of the residential agreement if the individual or LAR violates the residential agreement and the violation does not result in an eviction;(21) the signature of the program provider or service provider of host home/companion care; and(22) the signature of the individual or the LAR.(d) The program provider must:(1) give the individual or LAR at least three calendar days to review, request changes, and sign the residential agreement;(2) ensure the residential agreement is fully executed before the individual begins living in a three-person residence, four-person residence, or a residence in which host home/companion care is provided, except that an individual may begin living in one of these residences before a residential agreement is fully executed in the event of an emergency;(3) if an individual begins living in a three-person residence, four-person residence, or a residence in which host home/companion care is provided before a residential agreement is fully executed because of an emergency, as allowed by paragraph (2) of this subsection:(A) document the details of the emergency; and(B) ensure the residential agreement is fully executed within seven calendar days after the individual begins living in the residence; and(4) provide one copy of the residential agreement to the individual or LAR within three business days after the date the residential agreement is fully executed.(e) If a program provider becomes aware that a modification to the provision in the residential agreement that the individual may furnish and decorate the individual's bedroom is needed, based on a specific assessed need of an individual, the program provider must:(1) notify the service coordinator of the needed modification; and(2) provide the service coordinator the information described in §263.901(e)(21) of this chapter relating to (LIDDA Requirements for Providing Service Coordination in the HCS Program) as requested by the service coordinator.(f) If a service coordinator receives a notification as described in subsection (e) of this section, the service coordinator must convene a meeting of the service planning team to update the PDP in accordance with §263.901(e)(21) of this chapter.(g) After the service planning team updates the PDP as required by §263.901(e)(21) of this chapter, the program provider may implement the modification.(h) If an individual or LAR is delinquent in payment of room or board and the program provider or service provider wants to evict the individual, the program provider must:(1) notify the service coordinator that the individual or LAR is delinquent in the payment of room or board under the residential agreement and that the program provider or service provider wants to evict the individual;(2) after providing the notification required by paragraph (1) of this subsection, meet with the individual or LAR, including the representative payee if one has been appointed by the Social Security Administration, and the service coordinator to discuss the alleged non-payment of room or board and options to prevent an eviction; and(3) if the program provider or service provider intends to proceed to evict the individual at the meeting required by paragraph (2) of this subsection:(A) give the individual or LAR a written notice of proposed eviction that allows the individual or LAR at least 60 calendar days to pay the delinquent room or board; and(B) provide the service coordinator with a copy of the written notice of proposed eviction.(i) If the individual or LAR pays the delinquent room or board within the period required by subsection (h)(3) of this section, the program provider or service provider of host home/companion care must not give the individual or LAR a notice to vacate or otherwise proceed to evict the individual.(j) If the individual or LAR does not pay the delinquent room or board within the period required by subsection (h)(3) of this section, the program provider:(1) must report the failure to pay to one of the following as appropriate:(A) the Social Security Administration;(B) the probate court that appointed the individual's guardian; or(C) DFPS as an allegation of the LAR's exploitation or neglect of the individual;(2) must meet with the individual or LAR and the service coordinator to discuss alternative living settings for the individual; and(3) if the program provider or service provider wants to proceed to evict the individual, the program provider must:(A) give the individual or LAR a written notice to vacate the residence in accordance with the residential agreement and state law; and(B) send a copy of the written notice described in subparagraph (A) of this paragraph to the individual's service coordinator within one business day after the individual or LAR is given the notice.(k) If an individual is evicted by a program provider or service provider of host home/companion care and the individual or LAR has not paid the delinquent room or board, the service coordinator must convene a meeting or meetings to update the PDP and revise the IPC as described in §263.302(b)(3)(D) of this chapter (relating to Renewal and Revision of an IPC). If the individual or LAR wants to keep residential support, supervised living, or host home/companion care on the individual's IPC, the service coordinator must inform the individual or LAR at the meeting or meetings that HHSC will deny residential support, supervised living, or host home/companion care, if included on the individual's IPC, until the individual pays the delinquent room or board.(l) If a program provider evicts an individual who has an LAR and the LAR fails to arrange an alternative living setting for the individual, the program provider must report the LAR's failure to DFPS as neglect of the individual and notify the service coordinator that such a report was made.(m) If an individual pays the delinquent room or board, a program provider must, within one business day after the payment, notify the individual's service coordinator that the individual is no longer delinquent. Source Note: The provisions of this §263.503 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) F REQUIREMENTS FOR SERVICE SETTINGS AND PROGRAM PROVIDER OWNED OR CONTROLLED RESIDENTIAL SETTINGS §263.503 Residential Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223011 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223011 03/12/2026 The following requirements apply to program provider reimbursement.(1) HHSC pays a program provider as described in this paragraph.(A) HHSC pays for supported home living, professional therapies, nursing, respite, in-home respite, employment assistance, supported employment, and CFC PAS/HAB in accordance with the reimbursement rate for the specific service.(B) HHSC pays for host home/companion care, residential support, supervised living, employment readiness, in-home day habilitation and day habilitation in accordance with the individual's LON and the reimbursement rate for the specific service.(C) HHSC pays for adaptive aids, minor home modifications, and dental treatment based on the actual cost of the item and, if requested, a requisition fee in accordance with the HCS Program Billing Requirements available on the HHSC website.(D) HHSC pays:(i) for TAS based on a Transition Assistance Services (TAS) Assessment and Authorization form authorized by HHSC and the actual cost of the TAS as evidenced by purchase receipts required by the HCS Program Billing Requirements; and(ii) if requested, a TAS service fee in accordance with the HCS Program Billing Requirements.(E) HHSC pays for pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment based on a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by HHSC and the actual cost of the pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment, as evidenced by documentation required by the HCS Program Billing Requirements.(F) Subject to the requirements in the HCS Program Billing Requirements, HHSC pays for TAS, pre-enrollment minor home modifications, and a pre-enrollment minor home modifications assessment regardless of whether the applicant enrolls with the program provider.(G) HHSC pays for CFC ERS based on the actual cost of the service, not to exceed the reimbursement rate ceiling for CFC ERS.(2) To be paid for the provision of a service, a program provider must submit a service claim that meets the requirements in §52.121 of this title (relating to Claims Payment) and the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers.(3) If an individual's HCS Program services or CFC services are suspended or terminated a program provider must not submit a claim for services provided during the period of the individual's suspension or after the termination, except that the program provider may submit a claim for the first day of the individual's suspension or termination for the following services:(A) in-home day habilitation;(B) day habilitation;(C) supported home living;(D) in-home respite;(E) respite;(F) employment assistance;(G) supported employment;(H) employment readiness;(I) professional therapies;(J) nursing; and(K) CFC PAS/HAB.(4) If a program provider submits a claim for an adaptive aid that costs $500 or more or for a minor home modification that costs $1,000 or more, the claim must be supported by a written assessment from a licensed professional specified by HHSC in the HCS Program Billing Requirements and other documentation as required by the HCS Program Billing Requirements.(5) HHSC does not pay a program provider for:(A) a service or recoups any payments made to the program provider for a service if:(i) except for an individual receiving TAS, pre-enrollment minor home modifications, or a pre-enrollment minor home modifications assessment, the individual receiving the service was, at the time the service was provided, ineligible for the HCS Program or Medicaid benefits, or was an inpatient of a hospital, nursing facility, or ICF/IID;(ii) except for TAS, pre-enrollment minor home modifications, and a pre-enrollment minor home modifications assessment:(I) the service was provided to an individual during a period of time for which there was not a signed, dated, and authorized IPC for the individual;(II) the service was provided during a period of time for which there was not a signed and dated ID/RC Assessment for the individual;(III) the service was provided during a period of time for which the individual did not have an LOC determination;(IV) the service was not provided in accordance with a signed, dated, and authorized IPC meeting the requirements set forth in §263.301(c) of this chapter (relating to IPC Requirements);(V) the service was not provided in accordance with the individual's PDP or implementation plan;(VI) the service was provided before the individual's enrollment date into the HCS Program; or(VII) the service was not included on the signed, dated, and authorized IPC of the individual in effect at the time the service was provided, except as permitted by §263.302(d) of this chapter (relating to Renewal and Revision of an IPC);(iii) the service was not provided in accordance with the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(iv) the service was not documented in accordance with the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(v) the program provider did not comply with §52.109 of this title (relating to Records);(vi) the claim for the service was not prepared and submitted in accordance with the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(vii) the claim for the service did not meet the requirements in §52.121 of this title (relating to Claims Payment) or the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(viii) the program provider does not have the documentation described in paragraph (3) of this section;(ix) HHSC determines that the service would have been paid for by a source other than the HCS Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for the service;(x) the service was provided by a service provider who did not meet the qualifications to provide the service as described in the HCS Program Billing Requirements or the CFC Billing Requirements for HCS and TxHmL Program Providers;(xi) the service was paid at an incorrect LON because the information entered in the HHSC data system from a completed ID/RC Assessment was not identical to the information on the completed ID/RC Assessment; or(xii) the service was not provided;(B) supervised living or residential support, if the program provider provided the supervised living or residential support service in a residence in which four individuals or other persons receiving similar services live without HHSC's approval as described in rules governing the HCS Program;(C) employment assistance, if before including the employment assistance on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that employment assistance was not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(D) supported employment, if before including the supported employment on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that supported employment was not available to the individual under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(E) employment readiness, if before including the employment readiness on an individual's IPC, the program provider did not ensure and maintain documentation in the individual's record that employment readiness was not available to the individual under a program funded under §110 of the Rehabilitation Act of 1973 or under a program funded under the Individuals with Disabilities Education Act (20 U.S.C. §1401 et seq.);(F) host home/companion care, residential support, or supervised living, if the host home/companion care, residential support, or supervised living was provided on the day of the individual's suspension or termination of HCS Program services;(G) TAS, if the TAS, was not provided in accordance with a Transition Assistance Services (TAS) Assessment and Authorization form authorized by HHSC;(H) pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment, if the pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment, was not provided in accordance with a Home and Community-based Services (HCS) Program Pre-enrollment MHM Authorization Request form authorized by HHSC;(I) a CFC service, if the CFC service, was provided to an individual receiving host home/companion care, supervised living, or residential support;(J) supported home living, if the supported home living, was not provided in accordance with a transportation plan and §263.5(a)(18) of this chapter (relating to Description of HCS Program Services); or(K) CFC PAS/HAB, in-home day habilitation provided to an individual with a residential type of "own/family home," or in-home respite, if the CFC PAS/HAB, in-home day habilitation, or in-home respite, did not match the EVV visit transaction as required by 1 TAC §354.4009(a)(4) (relating to Requirements for Claims Submission and Approval).(6) A program provider must refund to HHSC any overpayment made to the program provider within 60 calendar days after the program provider's discovery of the overpayment or receipt of a notice of such discovery from HHSC, whichever is earlier.(7) Except as provided in paragraph (8) of this section, if HHSC approves an LOC requested in accordance with §263.105(b)(3) of this chapter (relating to LOC Determination), HHSC pays a program provider for services provided to an individual for a period of not more than 180 calendar days after the individual's previous ID/RC Assessment expires.(8) If HHSC determines that a program provider submitted an ID/RC Assessment more than 180 calendar days after the expiration date of the previous ID/RC Assessment, because of circumstances beyond the program provider's control, HHSC may pay the program provider for a period of more than 180 calendar days after the date the individual's previous ID/RC Assessment expired.(9) HHSC conducts provider fiscal compliance reviews to determine whether a program provider is in compliance with:(A) this chapter;(B) the HCS Program Billing Requirements;(C) the CFC Billing Requirements for HCS and TxHmL Program Providers;(D) Chapter 52, Subchapter C of this title (relating to Requirements of a Contractor); and(E) the program provider's Community Services Contract-Provider Agreement.(10) HHSC conducts provider fiscal compliance reviews in accordance with the Provider Fiscal Compliance Review Protocol set forth in the HCS Program Billing Requirements and the CFC Billing Requirements for HCS and TxHmL Program Providers. As a result of a provider fiscal compliance review, HHSC may:(A) recoup payments from a program provider; and(B) based on the amount of unverified claims, require a program provider to develop and submit, in accordance with HHSC's instructions, a corrective action plan that improves the program provider's billing practices.(11) A corrective action plan required by HHSC in accordance with paragraph (10)(B) of this section must:(A) include:(i) the reason the corrective action plan is required;(ii) the corrective action to be taken;(iii) the person responsible for taking each corrective action; and(iv) a date by which the corrective action will be completed that is no later than 90 calendar days after the date the program provider is notified the corrective action plan is required;(B) be submitted to HHSC within 30 calendar days after the date the program provider is notified the corrective action plan is required; and(C) be approved by HHSC before implementation.(12) Within 30 calendar days after HHSC receives a corrective action plan, HHSC notifies the program provider if HHSC approves the corrective action plan or if the plan requires changes.(13) If HHSC requires a program provider to develop and submit a corrective action plan in accordance with paragraph (10)(B) of this section and the program provider requests an administrative hearing for the recoupment in accordance with §263.802 of this chapter (relating to Program Provider's Right to Administrative Hearing), the program provider is not required to develop or submit a corrective action plan while a hearing decision is pending. HHSC notifies the program provider if the requirement to submit a corrective action plan or the content of such a plan changes based on the outcome of the hearing.(14) If a program provider does not submit a corrective action plan or complete a required corrective action within the time frames described in paragraph (11) of this section, HHSC may impose a vendor hold on payments due to the program provider until the program provider takes the corrective action.(15) If a program provider does not submit a corrective action plan or complete a required corrective action within 30 calendar days after the date a vendor hold is imposed in accordance with paragraph (14) of this section, HHSC may terminate the contract. Source Note: The provisions of this §263.601 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) G REIMBURSEMENT BY HHSC §263.601 Program Provider Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212864 03/12/2026 (a) If a service coordinator receives information that an individual wants to transfer to a different program provider or FMSA, or that an LAR wants the individual to transfer to a different program provider or FMSA, the service coordinator must:(1) if the information was received from the individual or LAR, document the date the information was received in the individual's record;(2) if the information was received from a person other than the individual or LAR, within three business days after the information was received:(A) contact the individual or LAR to confirm whether the individual wants to transfer or the LAR wants the individual to transfer to a different program provider or FMSA; and(B) if the service coordinator makes the confirmation described in subparagraph (A) of this paragraph, document such confirmation in the individual's record; and(3) within three business days after receiving information from the individual or LAR that the individual wants to transfer or the LAR wants the individual to transfer to a different program provider or FMSA or making the confirmation described in paragraph (2)(A) of this subsection:(A) explain to the individual or LAR that the individual may transfer to a program provider whose enrollment has not reached its service capacity in the HHSC data system or FMSA of the individual's or LAR's choice; and(B) provide the individual or LAR the names and contact information of all program providers or FMSAs in the geographic location preferred by the individual or LAR.(b) After the individual or LAR selects a different program provider or FMSA, the service coordinator must coordinate with the individual, LAR, the transferring program provider or FMSA, and the receiving program provider or FMSA to determine a transfer effective date that is:(1) not earlier than the date of the meeting described in subsection (c)(2) of this section; and(2) agreed to by the service coordinator, the individual or LAR, and the receiving program provider.(c) On or before the transfer effective date, the service coordinator must:(1) take action to complete the HHSC Request for Transfer of Waiver Program Services form in accordance with the HCS Handbook;(2) convene a meeting with the individual or LAR and the receiving program provider or receiving FMSA to develop a transfer IPC;(3) send the individual's IPC, ID/RC, and PDP to the receiving program provider or the receiving FMSA;(4) if the individual is transferring to a different program provider, request the following records of the individual from the transferring program provider;(A) pertinent medication records and medical information;(B) Medicaid card;(C) Medicare information, if applicable;(D) the ICAP booklet and summary sheet;(E) trust fund/financial records and any money due the individual;(F) behavior support plan, if applicable;(G) guardianship information, if applicable; and(H) any other pertinent information to ensure health and safety or continuity of services;(5) within two business days after receipt of the records requested in accordance with paragraph (4) of this subsection, send the records to the receiving program provider; and(6) if, within three business days after requesting that the program provider provide records as described in paragraph (4) of this subsection, the service coordinator does not receive all of the records requested, notify HHSC that the records were not received.(d) If an individual was evicted by a program provider or service provider of host home/companion care and the individual or LAR has not paid the delinquent room or board, but wants to include residential support, supervised living, or host home/companion care on the individual's IPC, the service coordinator must inform the individual or LAR at the meeting described in subsection (c)(2) of this section that HHSC will deny residential support, supervised living, or host home/companion care, if included on the individual's IPC, until the individual pays the delinquent room or board.(e) Within 10 business days after the transfer effective date, the service coordinator must:(1) complete data entry into the HHSC data system in accordance with the HCS Handbook after the activities described in subsection (c) of this section are completed; and(2) send the transfer IPC and HHSC Request for Transfer of Waiver Program Services form to HHSC. Source Note: The provisions of this §263.701 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.701 Process for Individual to Transfer to a Different Program Provider or FMSA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212865 03/12/2026 (a) If a service coordinator receives information that an individual wants to receive a service through the CDS option that the individual is receiving from a program provider or that an LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider, the service coordinator must:(1) if the information was received from the individual or LAR, document the date the information was received in the individual's record;(2) if the information was received from a person other than the individual or LAR, within three business days after the information was received:(A) contact the individual or LAR to confirm whether the individual wants to receive or the LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider; and(B) if the service coordinator makes the confirmation described in subparagraph (A) of this paragraph, document such confirmation in the individual's record; and(3) within three business days after receiving information from the individual or LAR that the individual wants to receive or the LAR wants the individual to receive a service through the CDS option that the individual is receiving from a program provider or making the confirmation described in paragraph (2)(A) of this subsection:(A) explain to the individual or LAR that the individual may select an FMSA of the individual's or LAR's choice; and(B) provide the individual or LAR the names and contact information of all FMSAs in the geographic location preferred by the individual or LAR.(b) After the individual or LAR selects an FMSA, the service coordinator must coordinate with the individual, LAR, the transferring program provider and the receiving FMSA to determine an transfer effective date that is:(1) not earlier than the date of the meeting described in subsection (c)(2) of this section; and(2) agreed to by the service coordinator, the individual or LAR, and the receiving FMSA.(c) On or before the transfer effective date, the service coordinator must:(1) take action to complete the HHSC Request for Transfer of Waiver Program Services form in accordance with the HCS Handbook;(2) convene a meeting with the individual or LAR to develop a transfer IPC; and(3) send the individual's IPC to the receiving FMSA and obtain the signature of the receiving FMSA on the IPC and the HHSC Request for Transfer of Waiver Program Services form.(d) Within 10 business days after the transfer effective date, the service coordinator must:(1) complete data entry in the HHSC data system in accordance with the HCS Handbook after the activities described in subsection (c) of this section are completed; and(2) send the transfer IPC and the HHSC Request for Transfer of Waiver Program Services form to HHSC. Source Note: The provisions of this §263.702 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.702 Process for Individual to Receive a Service Through the CDS Option that the Individual is Receiving from a Program Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212866 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212866 03/12/2026 (a) HHSC denies an individual's request for enrollment into the HCS Program if the individual does not meet the eligibility criteria described in §263.101 of this chapter (relating to Eligibility Criteria for HCS Program Services and CFC Services).(b) If HHSC denies an individual's request for enrollment, HHSC sends written notice to the individual or LAR of the denial of the individual's request for enrollment into the HCS Program and includes in the notice the individual's right to request a fair hearing in accordance with §263.801 of this chapter (Fair Hearing).(c) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider. Source Note: The provisions of this §263.703 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.703 Denial of a Request for Enrollment into the HCS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212867 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212867 03/12/2026 (a) HHSC denies an HCS Program service or CFC service on an individual's IPC, based on a review described in §263.303 of this chapter (relating to HHSC Review of an IPC) or §263.302 of this chapter (relating to Renewal and Revision of an IPC), if HHSC determines that the HCS Program service or CFC service does not meet the requirements described in §263.301(c) of this chapter (relating to IPC Requirements).(b) HHSC denies residential support, supervised living, or host home/companion care on an individual's IPC if:(1) the individual was evicted from:(A) a three-person residence;(B) a four-person residence; or(C) a residence in which host home/companion care is provided; and(2) the individual has not paid the delinquent room or board.(c) If HHSC denies an HCS Program service or CFC service on the individual's IPC, HHSC:(1) modifies the IPC in the HHSC data system; and(2) sends written notice to the individual or LAR of the denial of the service and includes in the notice the individual's right to request a fair hearing in accordance with §263.801 of this chapter (Fair Hearing).(d) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider. Source Note: The provisions of this §263.704 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.704 Denial of HCS Program Services or CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212868 03/12/2026 (a) HHSC suspends an individual's HCS Program services and CFC services if the individual is under a temporary admission to one of the following facilities:(1) a hospital;(2) an ICF/IID;(3) a nursing facility;(4) an ALF;(5) a residential child care facility licensed by HHSC unless it is an agency foster home;(6) an inpatient chemical dependency treatment facility;(7) a mental health facility;(8) a residential facility operated by the Texas Workforce Commission; or(9) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison.(b) If a service coordinator becomes aware that an individual who is receiving a service from a program provider is under a temporary admission, the service coordinator must, within one business day after becoming aware of the temporary admission, notify the individual's program provider of the temporary admission.(c) If a program provider becomes aware that an individual is under a temporary admission, the program provider must, within one business day after becoming aware of the temporary admission, enter a suspension of the individual's HCS Program services and CFC services in the HHSC data system.(d) If a program provider enters a suspension of the individual's HCS Program services and CFC services in the HHSC data system, the program provider must notify the individual's service coordinator of the suspension within one business day after the suspension is entered in the system.(e) During a temporary admission, an individual is not considered to be residing in the facility.(f) If an individual's program services are suspended, the service coordinator must, at least every 30 calendar days after the effective date of the suspension, review the individual's circumstances and document in the individual's record:(1) the reasons for continuing the suspension if the individual is likely to remain in the facility;(2) whether the individual anticipates resuming participation in the HCS Program after the suspension ends; and(3) the anticipated date the individual will be discharged from the facility, if the individual is not likely to remain in the facility.(g) If a service coordinator determines that an individual's suspension should be extended, the service coordinator must request that HHSC extend the suspension by completing and submitting the HHSC Request to Continue Suspension of Waiver Program Services form to HHSC before:(1) the end of the first 270 calendar days of the temporary admission; or(2) the end of a 30 calendar-day extension previously granted by HHSC.(h) HHSC may extend an individual's suspension for 30 calendar days based on a service coordinator's request as described in subsection (g) of this section.(i) A program provider must remove the entry of a suspension of the individual's HCS Program services and CFC services from the HHSC data system and resume the provision of services to the individual if the program provider becomes aware that the individual is discharged from the facility to which the individual has been under temporary admission. Source Note: The provisions of this §263.705 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.705 Suspension of HCS Program Services and CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212869 03/12/2026 (a) HHSC proposes a reduction of an HCS Program service or CFC service on an individual's IPC, based on a review described in §263.303 of this chapter (relating to HHSC Review of an IPC) or §263.302 of this chapter (relating to Renewal and Revision of an IPC), if HHSC determines that the HCS Program service or CFC service does not meet the requirements described in §263.301(c) of this chapter (relating to IPC Requirements).(b) If HHSC proposes a reduction of an HCS Program service or CFC service on the individual's IPC, HHSC sends written notice to the individual or LAR of the proposed reduction of the service and includes in the notice the individual's right to request a fair hearing in accordance with §263.801 of this chapter (Fair Hearing).(c) HHSC sends a copy of the written notice to the individual's service coordinator and the program provider.(d) If the individual or LAR requests a fair hearing before the effective date of the reduction of an HCS Program service or CFC service, as specified in the written notice, the service is not reduced and the program provider must provide the service to the individual in the amount authorized in the current IPC while the appeal is pending.(e) If the individual or LAR does not request a fair hearing before the effective date of the reduction of an HCS Program service or CFC service, HHSC modifies the IPC in the HHSC data system. Source Note: The provisions of this §263.706 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.706 Reduction of HCS Program Services or CFC Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212870 03/12/2026 (a) HHSC terminates an individual's HCS Program services and CFC services if the individual does not meet the eligibility criteria described in §263.101(a)(1) - (4), (6), (c), and (d) of this chapter (relating to Eligibility Criteria for HCS Program Services and CFC Services).(b) If a service coordinator becomes aware that a situation described in subsection (a) of this section exists, the service coordinator must, as soon as practicable, convene a service planning team meeting to discuss the situation. If after the meeting, the service coordinator determines that the situation cannot be resolved, the service coordinator must request that HHSC terminate the individual's services. To make this request, the service coordinator must complete HHSC Request for Termination of Services form and submit the form to HHSC.(c) If HHSC receives a form from a service coordinator requesting that HHSC terminate the individual's services, HHSC sends written notice to the individual or LAR of the proposal to terminate HCS Program services and CFC services. The notice includes the individual's right to request a fair hearing in accordance with §263.801 of this chapter (relating to Fair Hearing).(d) If the individual or LAR requests a fair hearing before the effective date of the termination of HCS Program services and CFC services, as specified in the written notice, the program provider must provide services to the individual in the amounts authorized in the IPC while the appeal is pending. Source Note: The provisions of this §263.707 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.707 Termination of HCS Program Services and CFC Services with Advance Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212871 03/12/2026 (a) HHSC terminates an individual's HCS Program services and CFC services if any of the following situations exists:(1) the individual is admitted to one of the facilities listed in §263.705(a)(1) - (9) of this subchapter (relating to Suspension of HCS Program Services and CFC Services):(A) for more than 270 consecutive calendar days; and(B) HHSC has not extended the individual's suspension in accordance with §263.705(h) of this subchapter;(2) the service coordinator or program provider has factual information confirming the death of the individual;(3) the service coordinator or program provider receives a clear written statement signed by the individual or LAR that the individual no longer wants HCS Program services;(4) the individual's whereabouts are unknown, and the post office returns mail directed to the individual by the service coordinator or program provider without indicating a forwarding address; or(5) HHSC establishes that the individual has been accepted for Medicaid services by another state.(b) If a service coordinator becomes aware that a situation described in subsection (a) of this section exists, the service coordinator must request that HHSC terminate the individual's services. To make this request, the service coordinator must complete HHSC Request for Termination of Services form and submit the form to HHSC.(c) If HHSC receives a form from a service coordinator requesting that HHSC terminate the individual's services, HHSC sends written notice to the individual or LAR of the termination of HCS Program services and CFC services. The notice includes the individual's right to request a fair hearing in accordance with §263.801 of this chapter (relating to Fair Hearing). Source Note: The provisions of this §263.708 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) H TRANSFER, DENIALS, SUSPENSION, REDUCTION, AND TERMINATION §263.708 Termination of HCS Program Services and CFC Services Without Advance Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212872 03/12/2026 An applicant whose request for eligibility for the HCS Program is denied or is not acted upon with reasonable promptness, or an individual whose HCS Program services or CFC services have been terminated, suspended, denied, or reduced by HHSC, receives notice of the right to request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules). Source Note: The provisions of this §263.801 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) I HEARINGS §263.801 Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212873 03/12/2026 (a) A program provider may request an administrative hearing if HHSC takes or proposes to take the following action:(1) vendor hold;(2) contract termination;(3) recoupment of payments made to the program provider; or(4) denial of a program provider's claim for payment, including denial of a retroactive LOC and denial of a recommended LON.(b) If the basis of an administrative hearing requested under this section is a dispute regarding an LON assignment, the program provider may receive an administrative hearing only if reconsideration was requested by the program provider in accordance with §263.108 of this chapter (relating to Reconsideration of LON Assignment). Source Note: The provisions of this §263.802 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) I HEARINGS §263.802 Program Provider's Right to Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223012 03/12/2026 (a) In addition to the requirements described in Chapter 331 of this title (relating to LIDDA Service Coordination), a LIDDA must: (1) comply with: (A) this chapter; (B) Chapter 264 of this title (relating to Consumer Directed Services Option); and (C) Chapter 301, Subchapter M of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers); and (2) ensure that a rights protection officer required by §334.113 of this title (relating to Rights Protection Officer at a State MR Facility or MRA), who receives a copy of an HHSC initial intake report or a final investigative report from an FMSA in accordance with §264.702 of this title (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Service Provider) or §264.703 of this title (relating to Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of an FMSA), gives a copy of the report to the individual's service coordinator. (b) A LIDDA must ensure that a service coordinator is an employee of the LIDDA and meets the requirements of this subsection. (1) A service coordinator must meet the minimum qualifications and LIDDA staff training requirements described in Chapter 331 of this title except as described in paragraph (2) of this subsection. (2) Notwithstanding §331.19(b)(2)(B) of this title (relating to Staff Person Training), a service coordinator must complete a comprehensive non-introductory person-centered service planning training developed or approved by HHSC within six months after the service coordinator's date of hire, unless an extension of the six month timeframe is granted by HHSC. (3) A service coordinator must receive training about the following within the first 90 calendar days after beginning service coordination duties: (A) rules governing the HCS Program and CFC; and (B) Chapter 264 of this title. (c) A LIDDA must have a process for receiving and resolving complaints from a program provider related to the LIDDA's provision of service coordination or the LIDDA's process to enroll an applicant in the HCS Program. (d) If, as a result of monitoring, the service coordinator identifies a concern with the implementation of the PDP, the LIDDA must ensure that the concern is communicated to the program provider and attempts are made to resolve the concern. The LIDDA may refer an unresolved concern to HHSC by calling the HHSC IDD Ombudsman toll-free telephone number at 1-800-252-8154. (e) A service coordinator must: (1) assist an individual, LAR, or actively involved person in exercising the legal rights of the individual; (2) provide an individual, LAR, or family member with the booklet, Your Rights In the Home and Community-based Services (HCS) Program, available on the HHSC website, and the HHSC HCS Rights Addendum form, and an oral explanation of the rights in the booklet and the form: (A) upon the individual's enrollment in the HCS Program; (B) upon revision of the booklet or the form; (C) upon request; and (D) if one of the following occurs: (i) the individual becomes 18 years of age; (ii) a guardian is appointed for the individual; or (iii) a guardianship for the individual ends; (3) document the provision of the information required by paragraph (2) of this subsection, and ensure that the documentation is signed by: (A) the individual or LAR; and (B) the service coordinator; (4) ensure that, upon enrollment of an individual and annually thereafter, the individual or LAR is informed orally and in writing of the following: (A) the telephone number of the LIDDA to file a complaint; (B) the toll-free telephone number of the HHSC IDD Ombudsman, 1-800-252-8154, to file a complaint; and (C) the toll-free telephone number of DFPS, 1-800-647-7418, to report an allegation of abuse, neglect, or exploitation; (5) maintain for an individual for an IPC year: (A) a copy of the IPC; (B) the PDP and, if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form; (C) a copy of the ID/RC Assessment; (D) documentation of the activities performed by the service coordinator in providing service coordination; and (E) any other pertinent information related to the individual; (6) initiate, coordinate, and facilitate the person-centered planning process to meet the goals and outcomes identified by an individual and LAR in the individual's PDP, including scheduling service planning team meetings; (7) to meet the needs of an individual as those needs are identified, develop for the individual a full range of services and resources using: (A) providers for services other than HCS Program services and CFC services; and (B) advocates or other actively involved persons; (8) ensure that the PDP for an applicant or individual: (A) is developed, reviewed, and updated in accordance with: (i) §263.104(j)(4)(A) of this chapter (relating to Process for Enrollment of Applicants); (ii) §263.302 of this chapter (relating to Renewal and Revision of an IPC); and (iii) §331.11 of this title (relating to LIDDA's Responsibilities); and (B) document, for each HCS Program service, other than supervised living and residential support, and for each CFC service, whether the service is critical to the individual's health and safety as determined by the service planning team; (9) ensure that the updated finalized PDP is signed by the individual or LAR; (10) participate in the development, renewal, and revision of an individual's IPC in accordance with §263.104 and §263.302 of this chapter; (11) ensure the service planning team participates in the renewal and revision of the IPC for an individual in accordance with §263.302 of this chapter and ensure the service planning team completes other responsibilities and activities as described in this chapter; (12) notify the service planning team if the service coordinator receives notification from the program provider that: (A) an individual's behavior requires the implementation of a behavior support plan; or (B) based on an annual review by the program provider, an individual's behavior support plan needs to continue; (13) if a change to an individual's PDP is needed, other than as required by §263.302 of this chapter: (A) communicate the need for the change to the individual or LAR, the program provider, and other appropriate persons; (B) update the PDP as necessary; and (C) within 10 calendar days after the PDP is updated, send a copy of the updated PDP to the program provider, the individual or LAR and, if applicable, the FMSA; (14) provide an individual's program provider a copy of the individual's current PDP; (15) monitor the provision of HCS Program services, CFC services, and non-HCS Program and non-CFC services to an individual; (16) document whether an individual or LAR perceives that the individual is progressing toward desired outcomes identified on the individual's PDP; (17) together with the program provider, ensure the coordination and compatibility of HCS Program services and CFC services with non-HCS Program and non-CFC services, including, in coordination with the program provider, assisting an individual in obtaining a neurobehavioral or neuropsychological assessment and plan of care from one of the following professionals: (A) a psychologist licensed in accordance with Texas Occupations Code Chapter 501; (B) a speech-language pathologist licensed in accordance with Texas Occupations Code Chapter 401; or (C) an occupational therapist licensed in accordance with Texas Occupations Code Chapter 454; (18) for an individual who has had a guardian appointed, determine, at least annually, if the letters of guardianship are current; (19) if individual does not have a guardian: (A) ensure that the service planning team determines whether the individual would benefit from having a guardian or a less restrictive alternative to a guardian; (B) if the service planning team determines that the individual would benefit from having a less restrictive alternative to a guardian such as a supported decision making agreement, take appropriate actions to implement such an alternative; and (C) if the service planning team determines that the individual would benefit from having a guardian, make a referral to the appropriate court if: (i) the individual would not benefit from a less restrictive alternative to a guardian; or (ii) the individual would benefit from having a less restrictive alternative to a guardian but implementing such an alternative is not feasible; (20) immediately notify the program provider if the service coordinator becomes aware that an emergency necessitates the provision of an HCS Program service or a CFC service to ensure the individual's health or safety and the service is not on the IPC or exceeds the amount on the IPC; (21) if notified by the program provider that a requirement described in §263.501(d)(1) of this chapter (relating to Requirements for Home and Community-Based Settings), §263.502(b)(1) - (7) of this chapter (relating to Requirements for Program Provider Owned or Controlled Residential Settings) or §263.503(c)(15) of this chapter (relating to Residential Agreements) needs to be modified, update the individual's PDP to include the following: (A) a description of the specific and individualized assessed need that justifies the modification; (B) a description of the positive interventions and supports that were tried but did not work; (C) a description of the less intrusive methods of meeting the need that were tried but did not work; (D) a description of the condition that is directly proportionate to the specific assessed need; (E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification; (F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated; (G) the individual's or LAR's signature evidencing informed consent to the modification; and (H) the program provider's assurance that the modification will cause no harm to the individual; (22) if notified by the program provider that an individual or LAR has refused a comprehensive nursing assessment and that the program provider has determined it cannot ensure the individual's health, safety, and welfare in the provision of host home/companion care, residential support, supervised living, supported home living, respite, employment assistance, supported employment, employment readiness, in-home day habilitation, day habilitation, or CFC PAS/HAB: (A) inform the individual or LAR of the consequences and risks of refusing the assessment, including that the refusal will result in the individual's not receiving: (i) nursing services; or (ii) host home/companion care, residential support, supervised living, supported home living, respite, employment assistance, supported employment, employment readiness, in-home day habilitation, day habilitation, or CFC PAS/HAB, if the individual needs one of those services and the program provider has determined that it cannot ensure the health and safety of the individual in the provision of the service; and (B) notify the program provider if the individual or LAR continues to refuse the assessment after the discussion with the service coordinator; (23) if the service coordinator determines that HCS Program services or CFC services provided for an individual should be terminated, including for a reason described in §263.104(k)(14)(C) or (D) of this chapter: (A) document a description of: (i) the situation that resulted in the service coordinator's determination that services should be terminated; and (ii) the attempts by the service coordinator to resolve the situation; (B) send a written recommendation to terminate the individual's HCS Program services or CFC services to HHSC and include the documentation required by subparagraph (A) of this paragraph; and (C) provide a copy of the written recommendation and the documentation required by subparagraph (A) of this paragraph to the program provider; (24) if an individual requests termination of all HCS Program services or all CFC services, within ten calendar days after the individual's request: (A) inform the individual or LAR of: (i) the individual's option to transfer to another program provider; (ii) the consequences of terminating HCS Program services and CFC services; and (iii) possible service resources upon termination, including CFC services through a managed care organization; and (B) submit documentation to HHSC that: (i) states the reason the individual is making the request; and (ii) demonstrates that the individual or LAR was provided the information required by subparagraph (A)(ii) and (iii) of this paragraph; (25) be objective in assisting an individual or LAR in selecting a program provider or FMSA; (26) at the time of assignment and as changes occur, ensure that an individual and LAR and program provider are informed of the name of the individual's service coordinator and how to contact the service coordinator; (27) unless contraindications are documented with justification by the service planning team, ensure that a school-age individual receives educational services in a six-hour-per-day program, five days per week, provided by the local school district and that no individual receives educational services at a state supported living center or at a state center; (28) unless contraindications are documented with justification by the service planning team, ensure that a pre-school-age individual receives an early childhood education with appropriate activities and services, including small group and individual play with peers without disabilities; (29) unless contraindications are documented with justification by the service planning team, ensure that an individual who is 18 years or older has opportunities to participate in day activities of the individual's or LAR's choice that promote achievement of PDP outcomes; (30) unless contraindications are documented with justification by the service planning team, ensure that each individual is offered choices and opportunities for accessing and participating in community activities and experiences available to peers without disabilities; (31) assist an individual to meet as many of the individual's needs as possible by using generic community services and resources in the same way and during the same hours as these generic services are used by the community at large; (32) for an individual receiving host home/companion care, residential support, or supervised living, ensure that the individual or LAR is involved in planning the individual's residential relocation, except in a case of an emergency; (33) if the program provider notifies the service coordinator that the program provider is unable to locate the parent or LAR to assist the LIDDA in conducting permanency planning or if notified by the LIDDA that the LIDDA is unable to locate the parent or LAR in accordance with §263.902(g)(9) of this subchapter (relating to Permanency Planning): (A) make reasonable attempts to locate the parent or LAR by contacting a person identified by the parent or LAR in the contact information described in paragraph (35)(A) and (B) of this subsection; and (B) notify HHSC, no later than 30 calendar days after the date the service coordinator determines the service coordinator is unable to locate the parent or LAR, of the determination and request that HHSC initiate a search for the parent or LAR; (34) if the service coordinator determines that a parent's or LAR's contact information described in paragraph (35)(A) of this subsection is no longer current: (A) make reasonable attempts to locate the parent or LAR by contacting a person identified by the parent or LAR in the contact information described in paragraph (35)(B) of this subsection; and (B) notify HHSC, no later than 30 calendar days after the date the service coordinator determines the service coordinator is unable to locate the parent or LAR, of the determination and request that HHSC initiate a search for the parent or LAR; (35) request from and encourage the parent or LAR of an individual under 22 years of age requesting or receiving supervised living or residential support to provide the service coordinator with the following information: (A) the parent's or LAR's: (i) name; (ii) address; (iii) telephone number; (iv) driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and (v) place of employment and the employer's address and telephone number; (B) name, address, and telephone number of a relative of the individual or other person whom HHSC or the service coordinator may contact in an emergency situation, a statement indicating the relationship between that person and the individual, and at the parent's or LAR's option: (i) that person's driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and (ii) the name, address, and telephone number of that person's employer; and (C) a signed acknowledgement of responsibility stating that the parent or LAR agrees to: (i) notify the service coordinator of any changes to the contact information submitted; and (ii) make reasonable efforts to participate in the individual's life and in planning activities for the individual; (36) within three business days after an individual under 22 years of age begins receiving supervised living or residential support: (A) provide the information listed in subparagraph (B) of this paragraph to the following: (i) the CRCG for the county in which the individual's LAR lives (see the HHSC website for a listing of CRCG chairpersons by county); and (ii) the local school district for the area in which the individual's residence is located, if the individual is at least three years of age, or the early childhood intervention (ECI) program for the county in which the individual's residence is located, if the individual is under three years of age (see the HHSC website to search for an ECI program by zip code or by county); and (B) as required by subparagraph (A) of this paragraph, provide the following information to the entities described in subparagraph (A) of this paragraph: (i) the individual's full name; (ii) the individual's sex; (iii) the individual's ethnicity; (iv) the individual's birth date; (v) the individual's social security number; (vi) the LAR's name, address, and county of residence; (vii) the date of initiation of supervised living or residential support; (viii) the address where supervised living or residential support is provided; and (ix) the name and phone number of the person providing the information; (37) for an applicant or individual under 22 years of age seeking or receiving supervised living or residential support: (A) make reasonable accommodations to promote the participation of the LAR in all planning and decision making regarding the individual's care, including participating in: (i) the initial development and annual review of the individual's PDP; (ii) decision making regarding the individual's medical care; (iii) routine service planning team meetings; and (iv) decision making and other activities involving the individual's health and safety; (B) ensure that reasonable accommodations include: (i) conducting a meeting in person, by videoconferencing, or by telephone, as mutually agreed upon by the program provider and the LAR; (ii) conducting a meeting at a time and location, if the meeting is in person, that is mutually agreed upon by the program provider and the LAR; (iii) if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and (iv) providing a language interpreter, if appropriate; (C) provide written notice to the LAR of a meeting to conduct an annual review of the individual's PDP at least 21 calendar days before the meeting date and request a response from the LAR regarding whether the LAR intends to participate in the annual review; (D) before an individual who is under 18 years of age, or who is at least 18 years of age and under 22 years of age and has an LAR, moves to another residence operated by the program provider, attempt to obtain consent for the move from the LAR unless the move is made because of a serious risk to the health or safety of the individual or another person; and (E) document compliance with subparagraphs (A) - (D) of this paragraph in the individual's record; (38) in accordance with Chapter 303, Subchapter G of this title (relating to Transition Planning) conduct: (A) a pre-move site review for an applicant 21 years of age or older who is enrolling in the HCS Program from a nursing facility or as a diversion from admission to a nursing facility; and (B) post-move monitoring visits for an individual 21 years of age or older who enrolled in the HCS Program from a nursing facility or has enrolled in the HCS Program as a diversion from admission to a nursing facility; (39) do the following to inform applicants and individuals about responsibilities related to EVV: (A) for an applicant who will receive a service that requires the use of EVV from the program provider or through the CDS option: (i) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the applicant or LAR; (ii) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (iii) provide the individual or LAR with a copy of the signed form; (iv) perform the activities described in clause (i) - (iii) of this subparagraph before the individual's enrollment; and (v) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record; (B) for an individual who will receive a service that requires the use of EVV from the program provider or who is transferring to another program provider or LIDDA and will receive a service that requires the use of EVV from the program provider or through the CDS option: (i) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the individual or LAR; (ii) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (iii) provide the individual or LAR with a copy of the signed form; (iv) perform the activities described in clause (i)-(iii) of this subparagraph on or before the effective date of the IPC that includes the EVV required service or the effective date of the transfer to another program provider or LIDDA; and (v) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record; and (C) for an individual who will receive a service that requires the use of EVV through the CDS option or who will transfer to another FMSA and is receiving a service requiring the use of EVV: (i) orally explain the information in the HHSC Electronic Visit Verification Responsibilities and Additional Information form to the individual or LAR; (ii) sign the HHSC Electronic Visit Verification Responsibilities and Additional Information form to attest to explaining the information and to providing a copy to the individual or LAR; (iii) provide the individual or LAR with a copy of the signed form; (iv) perform the activities described in clause (i)-(iii) of this subparagraph before the individual receiving the EVV required service through the CDS option or on or before the effective date of the transfer to another FMSA; and (v) maintain the completed HHSC Electronic Visit Verification Responsibilities and Additional Information form in the individual's record; (40) have contact with an individual in-person, by videoconferencing, or telephone to provide service coordination during a month in which it is anticipated that the individual will not receive an HCS Program service unless: (A) the individual's HCS Program services have been suspended; or (B) the service coordinator had an in-person contact with the individual that month to comply with §331.11(d) of this title (relating to LIDDA's Responsibilities); (41) within one business day after the meeting to revise an IPC described in §263.503(k) of this chapter (relating to Residential Agreements), submit the following documentation to HHSC if the individual or LAR wants to keep residential support, supervised living, or host home/companion care on the individual's IPC: (A) a completed HHSC Notification of Service Coordinator Disagreement form; (B) a copy of the written notice of proposed eviction described in §263.503(h)(3) of this chapter; (C) a copy of the written notice to vacate described in §263.503(j)(3) of this chapter; (D) progress notes from any meetings related to the eviction; and (E) a copy of the individual's PDP; and (42) within one business day after receiving the notice from a program provider described in §263.503(m) of this chapter, notify HHSC that the individual is no longer delinquent in room or board payments. Source Note: The provisions of this §263.901 adopted to be effective March 1, 2023, 48 TexReg 1080; amended to be effective January 1, 2025, 49 TexReg 10368. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J LIDDA REQUIREMENTS §263.901 LIDDA Requirements for Providing Service Coordination in the HCS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212875 03/12/2026 (a) The provisions contained in this section apply to an applicant under 22 years of age moving from a family setting and requesting supervised living or residential support.(b) A LIDDA must, during the enrollment process:(1) review the applicant's records, and, if possible, meet the applicant before the meeting described in paragraph (3) of this subsection;(2) inform the applicant and LAR:(A) of the benefits of living in a family setting;(B) that the placement of the applicant is considered temporary; and(C) that an ongoing permanency planning process is required; and(3) convene a permanency planning meeting with the LAR and, as appropriate, the applicant.(c) During the permanency planning meeting, the meeting participants must:(1) discuss and choose one of the following goals:(A) to live in the applicant's home or family home where the natural supports and strengths of the applicant's family are supplemented, as needed, by activities and supports provided or facilitated by the LIDDA or program provider; or(B) to live in a family-based alternative with a family other than the applicant's family who:(i) has received specialized training in the provision of support and in-home care for an individual under 22 years of age with an intellectual disability or a related condition;(ii) will provide a consistent and nurturing environment in a family home that supports a continued relationship with the applicant's family to the extent possible; and(iii) will provide an enduring, nurturing parental relationship with a specific adult; and(2) to accomplish the goal chosen in accordance with paragraph (1) of this subsection, discuss and identify:(A) the issues that led the applicant or LAR to request supervised living or residential support;(B) the applicant's daily support needs;(C) barriers to having the applicant reside in the family home;(D) supports that would be necessary for the applicant to remain in the family home;(E) actions that must be taken to overcome the barriers and provide the necessary supports;(F) the importance for the applicant to live in a long-term nurturing relationship with a family;(G) alternatives to the applicant living in an institutional setting;(H) the applicant's and LAR's need for information and preferences regarding those alternatives;(I) how, after the applicant's enrollment, to facilitate regular contact between the applicant and the applicant's family, and, if desired by the applicant and family, between the applicant and advocates and friends in the community to continue supportive and nurturing relationships;(J) natural supports and family strengths that will assist in accomplishing the identified permanency planning goal;(K) activities and supports that can be provided by the family, LIDDA, or program provider to achieve the permanency planning goal;(L) assistance needed by the applicant's family:(i) in maintaining a nurturing relationship with the applicant; and(ii) preparing the family for the applicant's eventual return to the family home or move to a family-based alternative; and(M) action steps, both immediate and long term, for achieving the permanency plan goal.(d) A LIDDA must make reasonable accommodations to promote the participation of the LAR in a permanency planning meeting, including:(1) conducting a meeting in person, by videoconferencing, or by telephone, as mutually agreed upon by the LIDDA and LAR;(2) conducting a meeting at a time and, if the meeting is in person, at a location that is mutually agreed upon by the LIDDA and LAR;(3) if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and(4) providing a language interpreter, if appropriate.(e) A LIDDA must:(1) develop a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form found on the HHSC website;(2) complete the Permanency Planning Review Screen in HHSC data system during enrollment to obtain approval for an applicant to receive residential support or supervised living;(3) keep a copy of the Permanency Planning Review Approval Status View Screen from HHSC data system in the applicant's record; and(4) provide a copy of the permanency plan to the program provider, the applicant, and the LAR.(f) A LIDDA must inform the applicant and LAR that they may request a volunteer advocate to assist in permanency planning.(1) The applicant or LAR may:(A) select a person who is not employed by or under contract with the LIDDA or a program provider; or(B) request the LIDDA to designate a volunteer advocate.(2) If an applicant or LAR requests that the LIDDA designate a volunteer advocate or the LIDDA cannot locate the applicant's LAR, the LIDDA must attempt to designate a volunteer advocate to assist in permanency planning who is, in order of preference:(A) an adult relative who is actively involved with the applicant;(B) a person who:(i) is part of the applicant's natural supports; and(ii) is not employed by or under contract with the LIDDA or a program provider; or(C) a person or a child advocacy organization representative who:(i) is knowledgeable about community services and supports;(ii) is familiar with the permanency planning philosophy and processes; and(iii) is not employed by or under contract with the LIDDA or a program provider.(3) If a LIDDA is unable to locate a volunteer advocate locally, the LIDDA must request assistance from a statewide advocacy organization in identifying an available volunteer advocate who meets the requirements described in subsection (f)(2)(C) of this section. If the statewide advocacy organization is unable to assist the LIDDA in identifying a volunteer advocate, the LIDDA must document all efforts to designate a volunteer advocate in accordance with subsection (f)(2) of this section.(g) Until an individual either becomes 22 years of age or is no longer receiving supervised living or residential support, a LIDDA must do the following six months after the date of the initial permanency planning meeting and every six months thereafter:(1) provide written notice to the LAR of a meeting to conduct a review of the individual's permanency plan no later than 21 calendar days before the meeting date and include a request for a response from the LAR;(2) convene a permanency planning meeting with the LAR and, if possible, the individual, to review the individual's current permanency plan in accordance with subsections (c) and (d) of this section, with an emphasis on changes or additional information gathered since the last permanency plan was developed;(3) during the permanency planning meeting, develop a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form available on the HHSC website;(4) perform the actions regarding a volunteer advocate as described in subsection (f) of this section;(5) complete the Permanency Planning Review Screen in the HHSC data system within 10 calendar days after the date of the permanency planning meeting;(6) ensure that approval for the individual to continue to receive residential support or supervised living is obtained every six months from the HHSC executive commissioner or designee;(7) keep a copy of the Permanency Planning Review Approval Status View Screen from the HHSC data system in the individual's record;(8) provide a copy of the permanency plan to the program provider, the individual, and the LAR; and(9) if the LIDDA determines it is unable to locate the parent or LAR, notify the service coordinator of such determination.(h) If a LIDDA receives information that an individual under 22 years of age who has been enrolled in the HCS Program moved from a family setting and started receiving supervised living or residential support, the LIDDA must, within the timeframes described in the performance contract between HHSC and the LIDDA:(1) provide an explanation of services and supports and other information in accordance with §263.104(e)(1) of this chapter (relating to Process for Enrollment of Applicants); and(2) take actions to conduct permanency planning as described in subsections (b) - (f) of this section. Source Note: The provisions of this §263.902 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J LIDDA REQUIREMENTS §263.902 Permanency Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212876 03/12/2026 If, within one year after the date HHSC receives the notification described in §263.901(e)(33)(B) or (34)(B) of this subchapter (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program), HHSC is unable to locate the parent or LAR, HHSC refers the case to:(1) the Child Protective Services Division of DFPS if the individual is under 18 years of age; or(2) the Adult Protective Services Division of DFPS if the individual is at least 18 years of age and under 22 years of age. Source Note: The provisions of this §263.903 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) J LIDDA REQUIREMENTS §263.903 Referral from HHSC to DFPS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212877 03/12/2026 (a) HHSC may allow program providers and service coordinators to use one or more of the exceptions described in subsections (c) - (j) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers and LIDDAs:(1) if it allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding the definition of "implementation plan" in §263.3 of this chapter (relating to Definitions), the signature of an individual who resides in the disaster area is not required on the individual's implementation plan, if:(1) the meeting required by §263.302(a)(5)(A) of this chapter (relating to Renewal and Revision of an IPC) is conducted by videoconferencing or telephone;(2) the individual or LAR orally agrees with the implementation plan; and(3) the program provider documents the individual's or LAR's oral agreement on the implementation plan.(d) Notwithstanding §263.8(a) of this chapter (relating to Comprehensive Nursing Assessment), the comprehensive nursing assessment completed by an RN is not required to be completed in person for an individual who resides in the disaster area, if the RN conducts the assessment as a telehealth service or by telephone.(e) Notwithstanding §263.104(j)(2)(A)(i)(I)(-a-) and (-b-), of this chapter (relating to Process for Enrollment of Applicants), a LIDDA is not required to conduct a standardized measure of intellectual functioning in person, or to conduct a standardized measure of adaptive abilities in person for an individual who resides in the disaster area, if the LIDDA conducts the standardized measures by videoconferencing.(f) Notwithstanding §263.104(j)(2)(B)(i) of this chapter, a LIDDA is not required to conduct an ICAP assessment in person for an individual who resides in the disaster area if the LIDDA conducts the ICAP assessment by videoconferencing.(g) Notwithstanding §263.302(e)(1)(B) of this chapter, a program provider is not required to ensure that an individual who resides in the disaster area or LAR signs and dates a renewal or revised IPC, if:(1) the meeting required by §263.302(a)(4) and (b)(3)(D)(ii) of this chapter is conducted by videoconferencing or telephone;(2) the program provider documents on the renewal or IPC the reason for and the topics discussed at the meeting;(3) the individual or LAR orally agrees with the renewal or revised IPC; and(4) the program provider documents the individual's or LAR's oral agreement on the renewal or the revised IPC.(h) Notwithstanding §263.304(a)(1) of this chapter (relating to Service Limits), the service limit of adaptive aids for an individual who resides in the disaster area may be exceeded if:(1) the requested adaptive aid that causes the service limit to be exceeded is:(A) an adaptive aid that replaces an adaptive aid destroyed as a result of the disaster; or(B) the repair of an adaptive aid that was damaged as a result of the disaster;(2) the addition of the requested adaptive aid to the individual's IPC does not result in:(A) the service limit of adaptive aids being exceeded by more than $5,000; or(B) the individual's IPC cost limit for HCS program services being exceeded as described in §263.101(a)(3)(A), (B), and (C) of this chapter (relating to Eligibility Criteria for HCS Program Service and CFC Services);(3) the program provider:(A) includes the cost of the requested adaptive aid on the revised IPC; and(B) submits to HHSC, within 180 days after the effective date of the order or proclamation described in subsection (a) of this section, a written request to HHSC to approve the requested adaptive aid that includes:(i) a description of the adaptive aid that is replacing the adaptive aid destroyed as a result of the disaster, which may include pictures or other descriptive information from a catalog, web-site or brochure;(ii) a description of the repair to an adaptive aid that was damaged as a result of the disaster;(iii) one bid for the requested adaptive aid from a vendor that includes:(I) the total cost of the requested adaptive aid; and(II) the name, address and telephone number of the vendor who must not be a relative of the individual; and(iv) a statement from the program provider that the adaptive aid is not available through a third party resource; and(4) the requested adaptive aid is approved by HHSC.(i) Notwithstanding §263.304(a)(3)(A) and (B) of this chapter, the service limit of minor home modifications for an individual who resides in the disaster area may be exceeded if:(1) the requested minor home modification that causes the service limit to be exceeded is:(A) a minor home modification that replaces a minor home modification that was destroyed as a result of the disaster; or(B) the repair of a minor home modification that was damaged as a result of the disaster;(2) the addition of the requested minor home modification to the individual's IPC does not result in:(A) the service limit of minor home modification being exceeded by more than $3,750; or(B) the individual's IPC cost limit for HCS program services being exceeded as described in §263.101(a)(3)(A), (B), or (C) of this chapter;(3) the program provider:(A) includes the cost of the requested minor home modification on the revised IPC;(B) submits to HHSC, within 180 days after the effective date of the order or proclamation described in subsection (a) of this section, a written request to HHSC to approve the requested minor home modification that includes:(i) a description of the minor home modification that is replacing the minor home modification destroyed as a result of the disaster, which may include pictures or other descriptive information from a catalog, web-site, or brochure;(ii) a description of the repair to a minor home modification that was damaged as a result of the disaster;(iii) one bid for the requested minor home modification from a vendor that includes:(I) the total cost of the requested minor home modification; and(II) the name, address and telephone number of the vendor who must not be a relative of the individual; and(iv) a statement from the program provider that the minor home modification is not available through a third party resource; and(4) the requested minor home modification is approved by HHSC.(j) Notwithstanding §263.901(e)(9) of this chapter, a service coordinator is not required to ensure that an individual who resides in the disaster area or LAR sign the PDP, if:(1) the meeting required by §263.302(a)(1)(B) and (b)(3)(D)(i) of this chapter is conducted by videoconferencing or telephone;(2) the service coordinator documents on the PDP the reason for and the topics discussed at the meeting;(3) the individual or LAR orally agrees with the PDP; and(4) the service coordinator documents the individual's or LAR's oral agreement on the PDP. Source Note: The provisions of this §263.1000 adopted to be effective March 1, 2023, 48 TexReg 1080. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) K DECLARATION OF DISASTER §263.1000 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211673 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.(1) Applicant--A Texas resident seeking services in the Home and Community-based Services (HCS) Program.(2) Calendar day--Any day, including weekends and holidays.(3) CFC--Community First Choice. A state plan option governed by Code of Federal Regulations, Title 42, Chapter 441, Subpart K, regarding Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice).(4) CFC PAS/HAB--CFC personal assistance services/habilitation.(5) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs.(6) Community setting--A setting accessible to the general public within an individual's community.(7) Day habilitation--An HCS Program service that provides assistance with acquiring, retaining, or improving self-help, socialization, and adaptive skills provided in a location other than the residence of an individual.(8) DFPS--The Department of Family and Protective Services.(9) HCS Program--The Home and Community-based Services Program.(10) HHSC--The Texas Health and Human Services Commission.(11) Hospital--A public or private institution licensed or exempt from licensure in accordance with Texas Health and Safety Code (THSC) Chapters 13, 241, 261, or 552.(12) ICAP--Inventory for Client and Agency Planning.(13) ID/RC Assessment--Intellectual Disability/Related Conditions Assessment. A form used by HHSC for level of care determination and level of need assignment.(14) Implementation plan--A written document developed by a program provider for an individual that, for each HCS Program service and CFC service on the individual's individual plan of care (IPC) to be provided by the program provider, except for supported home living and CFC support management, includes:(A) a list of outcomes identified in the person-directed plan that will be addressed using HCS Program services and CFC services;(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:(i) observable, measurable, and outcome-oriented; and(ii) derived from assessments of the individual's strengths, personal goals, and needs;(C) a target date for completion of each objective;(D) the number of units of HCS Program services and CFC services needed to complete each objective;(E) the frequency and duration of HCS Program services and CFC services needed to complete each objective; and(F) the signature and date of the individual, legally authorized representative, and the program provider.(15) Individual--A person enrolled in the HCS Program.(16) Individualized skills and socialization provider--A legal entity licensed in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements).(17) Initial IPC--The first IPC for an individual developed before the individual's enrollment into the HCS Program.(18) IPC--Individual plan of care. A written plan that:(A) states:(i) the type and amount of each HCS Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year;(ii) the services and supports to be provided to the individual through resources other than HCS Program services or CFC services, including natural supports, medical services, and educational services; and(iii) if an individual will receive CFC support management; and(B) is authorized by HHSC.(19) IPC year--The effective period of an initial IPC and renewal IPC as described in this paragraph.(A) Except as provided in subparagraph (B) of this paragraph, the IPC year for an initial and renewal IPC is a 365-calendar day period starting on the begin date of the initial or renewal IPC.(B) If the begin date of an initial or renewal IPC is March 1 or later in a year before a leap year or January 1 - February 28 of a leap year, the IPC year for the initial or renewal IPC is a 366-calendar day period starting on the begin date of the initial or renewal IPC.(C) A revised IPC does not change the begin or end date of an IPC year.(20) LAR--Legally authorized representative. A person authorized by law to act on behalf of another person with regard to a matter described in this chapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(21) LOC--Level of care. A determination given to an applicant or individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment.(22) LON--Level of need. An assignment given by HHSC to an individual upon which reimbursement for certain services is based.(23) Medicaid HCBS--Medicaid home and community-based services. Medicaid services provided to an individual in an individual's home and community, rather than in a facility.(24) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(25) PDP--Person-directed plan. A plan developed using an HHSC form that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual and LAR and to ensure the applicant's or individual's health and safety.(26) Program provider--A person, as defined in 40 TAC §49.102 (relating to Definitions), that has a contract with HHSC to provide HCS Program services, excluding a financial management services agency.(27) Renewal IPC--An IPC developed for an individual in accordance with the rules governing the HCS Program.(28) Revised IPC--An initial IPC or a renewal IPC that is revised during an IPC year in accordance with the rules governing the HCS Program to add a new HCS Program service or CFC service or change the amount of an existing service.(29) Service coordinator--An employee of a local intellectual and developmental disability authority who provides service coordination to an individual.(30) Service provider--A person who directly provides an HCS Program service or CFC service to an individual.(31) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C. Source Note: The provisions of this §263.2001 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2001 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211674 03/12/2026 The following are the three types of individualized skills and socialization:(1) on-site individualized skills and socialization;(2) off-site individualized skills and socialization; and(3) in-home individualized skills and socialization. Source Note: The provisions of this §263.2003 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2003 Types of Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211675 03/12/2026 (a) Individualized skills and socialization is an HCS Program service described in this section.(b) On-site and off-site individualized skills and socialization:(1) provide person-centered activities related to:(A) acquiring, retaining, or improving self-help skills and adaptive skills necessary to live successfully in the community and participate in home and community life; and(B) gaining or maintaining independence, socialization, community participation, current or future volunteer goals, or employment goals consistent with achieving the outcomes identified in an individual's PDP;(2) supports the individual's pursuit and achievement of employment through school, vocational rehabilitation, the HCS Program service of employment assistance, or the HCS Program service of supported employment;(3) provides personal assistance for an individual who cannot manage personal care needs during an individualized skills and socialization activity;(4) as determined by an assessment conducted by a registered nurse, provides assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician; and(5) does not include activities in which an individual:(A) produces marketable goods; and(B) is paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act.(c) On-site individualized skills and socialization:(1) is provided in a building or a portion of a building that is owned or leased by an individualized skills and socialization provider;(2) includes transportation of an individual from one on-site individualized skills and socialization location to another on-site individualized skills and socialization location;(3) promotes an individual's development of skills and behavior that support independence and personal choice; and(4) is not provided in:(A) a setting in which an individual must not reside, as set forth in the rules governing the HCS Program; or(B) the residence of an individual or another person.(d) An individualized skills and socialization provider must ensure that individualized skills and socialization is not provided in a setting that is presumed to have the qualities of an institution. A setting is presumed to have the qualities of an institution if the setting:(1) is located in a building in which a state supported living center or a certified intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) operated by a local intellectual and developmental disability authority (LIDDA) is located but is distinct from the state supported living center or the certified ICF/IID operated by a LIDDA;(2) is located in a building that is on the grounds of or immediately adjacent to a state supported living center or a certified ICF/IID operated by a LIDDA;(3) is located in a building in which a licensed private ICF/IID, a hospital, a nursing facility, or other institution is located but is distinct from the ICF/IID, hospital, nursing facility, or other institution;(4) is located in a building that is on the grounds of or immediately adjacent to a hospital, a nursing facility, or other institution except for a licensed private ICF/IID; or(5) has the effect of isolating individuals from the broader community of persons not receiving Medicaid HCBS.(e) An individualized skills and socialization provider may provide individualized skills and socialization to an individual in a setting that is presumed to have the qualities of an institution as described in subsection (d) of this section, if CMS determines through a heightened scrutiny review that the setting:(1) does not have the qualities of an institution; and(2) does have the qualities of home and community-based settings.(f) The setting in which on-site individualized skills and socialization is provided must:(1) allow an individual to:(A) control the individual's schedule and activities related to on-site individualized skills and socialization;(B) have access to the individual's food at any time; and(C) have visitors of the individual's choosing at any time; and(2) be physically accessible and free of hazards to an individual.(g) If an individualized skills and socialization provider becomes aware that a modification to a requirement described in subsection (f)(1) of this section is needed based on a specific assessed need of an individual, the individualized skills and socialization provider must inform the individual's program provider of the needed modification.(1) The program provider must:(A) notify the service coordinator of the needed modification; and(B) provide the service coordinator the information described in paragraph (2)(A) of this subsection as requested by the service coordinator.(2) A service coordinator must, if notified by the program provider of a needed modification, convene a service planning team meeting to update the individual's PDP to include the following:(A) a description of the specific and individualized assessed need that justifies the modification;(B) a description of the positive interventions and supports that were tried but did not work;(C) a description of the less intrusive methods of meeting the need that were tried but did not work;(D) a description of the condition that is directly proportionate to the specific assessed need;(E) a description of how data will be routinely collected and reviewed to measure the ongoing effectiveness of the modification;(F) the established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;(G) the individual's or LAR's signature evidencing informed consent to the modification; and(H) the program provider's assurance that the modification will cause no harm to the individual.(3) After the service planning team updates the PDP as required by paragraph (2) of this subsection, the individualized skills and socialization provider may implement the modifications.(h) Off-site individualized skills and socialization:(1) provides activities that:(A) integrate an individual into the community; and(B) promote the individual's development of skills and behavior that support independence and personal choice;(2) is provided in a community setting chosen by the individual from among available community setting options;(3) includes transportation of an individual from an on-site individualized skills and socialization location to an off-site individualized skills and socialization location and between off-site individualized skills and socialization locations; and(4) is not provided in:(A) a building in which on-site individualized skills and socialization is provided;(B) a setting in which an individual must not reside, as set forth in the rules governing the HCS Program, unless:(i) the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in such a setting; or(ii) off-site individualized skills and socialization is provided in an event open to the public; or(C) the residence of an individual or another person, unless the off-site individualized skills and socialization activity is a volunteer activity performed by an individual in the residence.(i) An individualized skills and socialization provider or the program provider is not responsible for the cost, if any, of an individual to participate in an off-site activity. Source Note: The provisions of this §263.2005 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2005 Description of On-Site and Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211676 03/12/2026 (a) In-home individualized skills and socialization is:(1) assistance with acquiring, retaining, and improving self-help, socialization, and adaptive skills necessary to reside and participate successfully in the community;(2) the provision of age-appropriate activities that enhance self-esteem and maximize functional level;(3) reinforcement of skills or lessons taught:(A) in school or other settings; or(B) during the provision of any HCS Program service or non-waiver service;(4) the provision of personal assistance for an individual who cannot manage personal care needs during the provision of in-home individualized skills and socialization; and(5) as determined by an assessment conducted by a registered nurse, assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician.(b) One of the following criteria must be met for an individual to receive in-home individualized skills and socialization:(1) a physician must document that the individual's medical condition justifies the provision of in-home individualized skills and socialization;(2) a licensed professional or behavioral supports service provider must document that the individual's behavioral issues justify the provision of in-home individualized skills and socialization; or(3) the individual must be 55 years of age or older and request to receive in-home individualized skills and socialization. Source Note: The provisions of this §263.2007 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2007 Description of and Criteria for an Individual to Receive In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211677 03/12/2026 (a) HHSC may allow program providers to use one or both of the exceptions in subsections (c) and (d) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC notifies program providers:(1) if it allows an exception to be used; and(2) if an exception is allowed to be used, the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) In this section "disaster area" means the area of the state specified in an executive order or proclamation described in subsection (a) of this section.(c) Notwithstanding §263.2007 of this chapter (relating to Description of and Criteria for an Individual to Receive In-Home Individualized Skills and Socialization), an individual who resides in the disaster area is not required to meet any of the criteria described in §263.2007(b) of this chapter to receive in-home individualized skills and socialization.(d) Notwithstanding §263.2013 of this chapter (relating to Provision of In-Home Individualized Skills and Socialization), if an individual who resides in the disaster area does not meet any of the criteria described in §263.2007(b) of this chapter to receive in-home individualized skills and socialization, a program provider is not required to obtain the documentation described in §263.2013(b) of this chapter. Source Note: The provisions of this §263.2009 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2009 Exceptions to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211678 03/12/2026 (a) On-site and off-site individualized skills and socialization must be provided by an individualized skills and socialization provider. An individualized skills and socialization provider must be the program provider or a contractor of the program provider.(b) A program provider must make both on-site individualized skills and socialization and off-site individualized skills and socialization available to an individual.(c) An individualized skills and socialization provider must provide on-site individualized skills and socialization and off-site individualized skills and socialization in accordance with an individual's PDP, IPC, and implementation plan. Source Note: The provisions of this §263.2011 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2011 Provision of On-Site and Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211679 03/12/2026 (a) A program provider must ensure that in-home individualized skills and socialization is provided in the residence of the individual receiving the service.(b) In-home individualized skills and socialization is not required to be provided by an individualized skills and socialization provider.(c) Before providing in-home individualized skills and socialization to an individual, a program provider must obtain documentation:(1) from a physician that the individual's medical condition justifies the provision of in-home individualized skills and socialization;(2) from a licensed professional or behavioral supports service provider that the individual's behavioral issues justify the provision of in-home individualized skills and socialization; or(3) that the individual is 55 years of age or older and requests to receive in-home individualized skills and socialization. Source Note: The provisions of this §263.2013 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2013 Provision of In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211680 03/12/2026 The service limit for the combined total of on-site, off-site, and in-home individualized skills and socialization is:(1) 1560 hours during an IPC year;(2) six hours per calendar day; and(3) five days per calendar week. Source Note: The provisions of this §263.2015 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2015 Service Limit for On-Site, Off-Site, and In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211667 03/12/2026 (a) The ratio of service providers of off-site individualized skills and socialization to persons receiving services off-site must be:(1) no higher than one service provider of off-site individualized skills and socialization to eight individuals with an LON 1 or an LON 5 without an enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:8);(2) no higher than one service provider of off-site individualized skills and socialization to two individuals with an LON 8 or an LON 6 and other persons receiving off-site individualized skills and socialization or a similar service (1:2);(3) no higher than one service provider of individualized skills and socialization to two individuals with an LON 1 or an LON 5 with the level one enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:2);(4) no higher than one service provider of off-site individualized skills and socialization to one individual with an LON 1, LON 5, LON 8, or LON 6 with the level two enhanced staffing rate and other persons receiving off-site individualized skills and socialization or a similar service (1:1); and(5) no higher than one service provider of off-site individualized skills and socialization to one individual with an LON 9 and other persons receiving off-site individualized skills and socialization or a similar service (1:1).(b) A ratio described in subsection (a) of this section may include individuals with different LONs and other persons receiving off-site individualized skills and socialization or a similar service. If the ratio includes individuals with different LONs or other persons receiving off-site individualized skills and socialization or a similar service, the ratio must be one of the following, whichever is the lowest staffing ratio:(1) the staffing ratio for the individual with highest level of need;(2) the staffing ratio required by §262.917(a) of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), if a person in the TxHmL Program is one of the persons represented in the ratio; or(3) the staffing ratio required by §260.507(a) of this title (relating to Staffing Ratios), if a person in the DBMD Program is one of the persons represented in the ratio.(c) A service provider of off-site individualized skills and socialization assigned to the individuals represented in a ratio in subsection (a) of this section must provide services only to the individuals and other persons represented in the ratio. Source Note: The provisions of this §263.2017 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2017 Staffing Ratios for Off-Site Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211668 03/12/2026 Notwithstanding other rules governing the HCS Program, effective March 1, 2023, day habilitation, which includes in-home day habilitation, is not a service in the HCS Program. Source Note: The provisions of this §263.2019 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2019 Discontinuation of Day Habilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211669 03/12/2026 (a) If an applicant wants to receive on-site or off-site individualized skills and socialization, or wants to receive and meets the criteria for in-home individualized skills and socialization:(1) a service coordinator must include the type of individualized skills and socialization on the applicant's PDP and the type and amount of individualized skills and socialization on the initial IPC in accordance with the rules governing the HCS Program; and(2) a program provider must develop an implementation plan for on-site, off-site, and in-home individualized skills and socialization.(b) To renew or revise an IPC to include on-site, off-site, or in-home individualized skills and socialization, a service coordinator and program provider must comply with rules governing the HCS Program, which include developing an implementation plan that describes on-site, off-site, and in-home individualized skills and socialization.(c) If an individual or the individual's LAR wants the individual to receive on-site or off-site individualized skills and socialization, but not both, the service coordinator must document the decision in the individual's PDP.(d) A service coordinator must ensure that an initial IPC that is effective on or after March 1, 2023, does not include day habilitation.(e) A program provider must ensure that a renewal IPC that is effective on or after March 1, 2023, does not include day habilitation.(f) A program provider or service coordinator must ensure that a revised IPC with an effective date that is during the period of March 1, 2023, through February 29, 2024, includes only the amount of day habilitation that the program provider provided to the individual before March 1, 2023. Source Note: The provisions of this §263.2021 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2021 Including On-Site, Off-Site, and In-Home Individualized Skills and Socialization on an IPC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211670 03/12/2026 (a) A service provider of in-home individualized skills and socialization must be at least 18 years of age and:(1) have a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(2) have documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(A) a written competency-based assessment of the ability to document service delivery and observations of the individuals to be served; and(B) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals being served.(b) A service provider of in-home individualized skills and socialization must complete training as required by the rules governing the HCS Program. Source Note: The provisions of this §263.2023 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2023 Service Provider Qualifications and Training for In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211671 03/12/2026 (a) Except as provided in subsection (b) of this section, HHSC pays for on-site, off-site, and in-home individualized skills and socialization provided to an individual in accordance with an individual's LON and the reimbursement rates for on-site, off-site, and in-home individualized skills and socialization.(b) If approved in accordance with §263.2027 of this subchapter (relating to Enhanced Staffing Rate) HHSC pays:(1) a level one enhanced staffing rate for off-site individualized skills and socialization for an individual with a LON 1 or LON 5; and(2) a level two enhanced staffing rate for off-site individualized skills and socialization for an individual with an LON 1, LON 5, LON 8, or LON 6.(c) If an individual's HCS Program services and CFC services are suspended or terminated, a program provider must not submit a claim for on-site, off-site, or in-home individualized skills and socialization provided during the period of the individual's suspension or after the termination, except that the program provider may submit a claim for the first day of the individual's suspension or termination.(d) HHSC does not pay a program provider for on-site, off-site, or in-home individualized skills and socialization, or recoups any payments made to the program provider for on-site, off-site, or in-home individualized skills and socialization, if:(1) the individual receiving on-site, off-site, or in-home individualized skills and socialization was, at the time on-site, off-site, or in-home individualized skills and socialization was provided, ineligible for the HCS Program;(2) on-site, off-site, or in-home individualized skills and socialization is provided to an individual during a period of time for which there is not a signed, dated, and authorized IPC for the individual;(3) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which there is not a signed and dated ID/RC Assessment for the individual;(4) on-site, off-site, or in-home individualized skills and socialization is provided during a period of time for which the individual did not have an LOC determination;(5) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with a signed, dated, and authorized IPC that includes on-site, off-site, or in-home individualized skills and socialization;(6) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the individual's PDP or implementation plan;(7) on-site, off-site, or in-home individualized skills and socialization is provided before the individual's enrollment date into the HCS Program;(8) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with this subchapter; (9) on-site or off-site individualized skills and socialization is not provided in accordance with Chapter 559, Subchapter H of this title (relating to Individualized Skills and Socialization Provider Requirements);(10) on-site, off-site, or in-home individualized skills and socialization is not provided in accordance with the HCS Program Billing Requirements;(11) on-site, off-site, or in-home individualized skills and socialization is not documented in accordance with the HCS Program Billing Requirements;(12) the program provider did not comply with 40 TAC §49.305 (relating to Records);(13) the claim for on-site, off-site, or in-home individualized skills and socialization did not meet the requirements in 40 TAC §49.311 (relating to Claims Payment) or the HCS Program Billing Requirements;(14) HHSC determines that on-site, off-site, or in-home individualized skills and socialization would have been paid for by a source other than the HCS Program if the program provider had submitted to the other source a proper, complete, and timely request for payment for on-site, off-site, or in-home individualized skills and socialization;(15) on-site or off-site individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide on-site or off-site individualized skills and socialization in accordance with §559.227(a) of this title (relating to Program Requirements) and the HCS Program Billing Requirements;(16) in-home individualized skills and socialization is provided by a service provider who did not meet the qualifications to provide in-home individualized skills and socialization as described in §263.2023 of this subchapter (relating to Service Provider Qualifications and Training for In-Home Individualized Skills and Socialization) and the HCS Program Billing Requirements;(17) on-site, off-site, or in-home individualized skills and socialization was paid at an incorrect LON because the information entered in the HHSC data system from a completed ID/RC Assessment is not identical to the information on the completed ID/RC Assessment;(18) on-site, off-site, or in-home individualized skills and socialization was not provided;(19) on-site or off-site individualized skills and socialization is provided during a period of time that the individual produced marketable goods and was paid below minimum wage for producing the goods in accordance with Section 14(c) of the Fair Labor Standards Act;(20) in-home individualized skills and socialization is not provided in the residence of the individual as required by §263.2013(a) of this subchapter (relating to Provision of In-Home Individualized Skills and Socialization); or(21) in-home individualized skills and socialization is provided to an individual without the documentation required by §263.2013(c) of this subchapter.(e) HHSC does not pay a program provider for day habilitation, or recoups any payments made to the program provider for day habilitation, if day habilitation is provided on or after March 1, 2023, even if an individual's IPC includes day habilitation on or after March 1, 2023.(f) HHSC conducts provider fiscal compliance reviews, also known as billing and payment reviews, in accordance with rules governing the HCS Program and the HCS Program Billing Requirements to determine whether a program provider is in compliance with this subchapter. Source Note: The provisions of this §263.2025 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2025 Program Provider Reimbursement for On-Site, Off-Site, and In-Home Individualized Skills and Socialization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211672 03/12/2026 (a) A program provider may request a level one enhanced staffing rate for off-site individualized skills and socialization described in §263.2025(b) of this subchapter (relating to Program Provider Reimbursement for Individualized Skills and Socialization) for an individual with a LON 1 or LON 5 by submitting the following documentation to HHSC:(1) a completed HHSC Enhanced Staffing Rate Request Form;(2) the most recent ICAP scoring booklet;(3) the most recent ID/RC Assessment;(4) the most recent PDP;(5) the most recent implementation plan for individualized skills and socialization; and(6) other documentation that supports the individual's request for an enhanced staffing rate, which may include:(A) the behavior support plan;(B) a physician's order;(C) an assessment completed by a service provider of a professional therapy;(D) the nursing assessment; and(E) the CFC PAS/HAB assessment.(b) A program provider may request a level two enhanced staffing rate for off-site individualized skills and socialization described in §263.2025(b) of this subchapter for an individual with a LON 1, LON 5, LON 8, or LON 6 by submitting the documentation described in subsection (a) of this section.(c) HHSC approves a request made in accordance with subsection (a) or (b) of this section if the documentation submitted to HHSC demonstrates that to participate in off-site individualized skills and socialization, the individual requires more service provider support than the individual would receive with the individual's assigned LON. The requirement for additional support may be because of the individual's mobility, medical, or behavioral needs.(d) HHSC may review an approved enhanced staffing rate at any time to determine if it is appropriate. If HHSC reviews an enhanced staffing rate, a program provider must submit documentation supporting the enhanced staffing rate to HHSC in accordance with HHSC's request.(e) HHSC notifies a program provider that an enhanced staffing rate is approved or denied through the HHSC data system.(f) A program provider may request an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing) if HHSC:(1) denies a request made in accordance with subsection (a) or (b) of this section; or(2) denies an enhanced staffing rate based on a review described in subsection (d) of this section. Source Note: The provisions of this §263.2027 adopted to be effective January 1, 2023, 47 TexReg 8698. 1 HEALTH AND HUMAN SERVICES COMMISSION 263 HOME AND COMMUNITY-BASED SERVICES (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) L INDIVIDUALIZED SKILLS AND SOCIALIZATION §263.2027 Enhanced Staffing Rate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219777 03/12/2026 This chapter describes:(1) the CDS option available to an individual or the individual's LAR;(2) the process for the enrollment and participation of an individual in the CDS option;(3) the responsibilities and requirements of an individual, LAR, or DR participating in the CDS option;(4) the minimum qualifications for a person or entity providing services to an individual participating in the CDS option;(5) the responsibilities and requirements of a person or entity providing services under the CDS option;(6) the method of payment to a person or entity providing services to an individual participating in the CDS option; and(7) the oversight applicable to a person or entity providing services under the CDS option. Source Note: The provisions of this 264.101 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.101 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219778 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Adult--A person who is 18 years of age or older.(3) Actively involved--Involvement with an individual that the individual or LAR and other members of the individual's service planning team deems to be of a quality nature based on the following:(A) observed interactions of the person with the individual;(B) a history of advocating for the best interests of the individual;(C) knowledge and sensitivity to the individual's preferences, values, and beliefs;(D) ability to communicate with the individual; and(E) availability to the individual for assistance or support when needed.(4) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual.(5) Allowable cost--A billable service or item that is within the rate and spending limits of the rate established by HHSC and that meets the requirements of an individual's program.(6) Applicant--Depending on the context, an applicant is:(A) a person applying for employment with an employer;(B) a person or legal entity applying for a contract with an employer to deliver services to an individual; or(C) a person enrolling in a program in which the CDS option is available to the individual as described in §41.108 of this subchapter (relating to Services Available Through the CDS Option).(7) Budget--A written projection of expenditures for each service delivered through the CDS option.(8) Budgeted unit rate--The unit rate calculated for employee wages and benefits in the budgeting process for services delivered through the CDS option. The rate is calculated after employer support services have been budgeted.(9) CAS Program--Community Attendant Services Program. A Medicaid state plan program authorized under Title XIX of the Social Security Act and described in Chapter 47 of this title (relating to Primary Home Care, Community Attendant Services, and Family Care Programs).(10) Case manager--A person who provides case management services to an individual. The case manager assists an individual who receives services in gaining access to needed services, regardless of the funding source for the services, and assists with other duties in accordance with the rules of the individual's program.(11) CDS option--Consumer directed services option. A service delivery option in which an individual or LAR employs and retains service providers and directs the delivery of program services.(12) CDSA--An FMSA.(13) CFC--Community First Choice. The CFC option described in 1 Texas Administrative Code (TAC) Chapter 354, Subchapter A, Division 27 (relating to Community First Choice).(14) CFC PAS/HAB--CFC personal assistance services/habilitation. A Medicaid state plan service provided through CFC.(15) CFC support management--Training on how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB.(16) CLASS Program--Community Living Assistance and Support Services Program. A Medicaid waiver program approved by CMS under Title XIX, §1915(c) of the Social Security Act and described in Chapter 45 of this title (relating to Community Living Assistance and Support Services and Community First Choice (CFC) Services).(17) CMPAS Program--Consumer Managed Personal Attendant Services Program. A program authorized under Title XX, Subtitle A of the Social Security Act and described in Chapter 44 of this title (relating to Consumer Managed Personal Attendant Services (CMPAS) Program).(18) Contractor--A person, who performs one or more program services, offers service to the general public, performs services for payment, and with whom an employer has a written service agreement. A contractor directs and controls when and how the work is performed as well as the business aspect of the job including expenses and the business relationship. A contractor may be a sole proprietor.(19) Controlling person--A person who:(A) has an ownership interest in an FMSA;(B) is an officer or director of a corporation that is an FMSA;(C) is a partner in a partnership that is an FMSA;(D) is a member or manager in a limited liability company that is an FMSA;(E) is a trustee or trust manager of a trust that is an FMSA; or(F) because of a personal, familial, or other relationship with an FMSA, is in a position of actual control or authority with respect to the FMSA, regardless of the person's title.(20) DADS--HHSC.(21) DBMD Program--Deaf Blind with Multiple Disabilities Program. A Medicaid waiver program approved by CMS under Title XIX, §1915(c) of the Social Security Act and described in Chapter 42 of this title (relating to Deaf Blind with Multiple Disabilities (DBMD) Program and Community First Choice (CFC) Services).(22) DFPS--The Department of Family and Protective Services.(23) DR--Designated representative. A willing adult appointed by the employer to assist with or perform the employer's required responsibilities to the extent approved by the employer.(24) Employee--A person employed by an employer through a service agreement to deliver program services and who is paid an hourly wage for those services, including a support advisor.(25) Employer--An individual or LAR who chooses to participate in the CDS option, and, therefore, is responsible for hiring and retaining service providers to deliver program services.(26) Employer support services--Services and items the employer needs to perform employer and employment responsibilities, as described in §41.507(a)(1) of this chapter (relating to Employer Support Services Budgeting).(27) Entity--An organization that has a legal identity such as a corporation, limited partnership, limited liability company, professional association, or cooperative.(28) EVV system--Electronic visit verification system. As defined in §68.102 of this title (relating to Definitions), an electronic visit verification system that:(A) allows a service provider to electronically report:(i) the service recipient's identity;(ii) the service provider's identity;(iii) the date and time the service provider begins and ends the delivery of services;(iv) the location of service delivery; and(v) tasks performed by the service provider; and(B) meets other guidelines described on the HHSC website.(29) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain.(30) FC Program--Family Care Program. A program authorized under Title XX, Subtitle A of the Social Security Act and described in Chapter 47 of this title.(31) FMS--Financial management services. Services delivered by an FMSA to an employer or DR as described in §41.309(a) of this chapter (relating to Financial Management Services, CFC Support Management, and Vendor Fiscal/Employer Agent Responsibilities).(32) FMSA--A financial management services agency. A person, as defined in §49.102 of this title (relating to Definitions), that contracts with HHSC to provide FMS.(33) HCS Program--Home and Community-based Services Program. A Medicaid waiver program approved by CMS under Title XIX, §1915(c) of the Social Security Act and described in Chapter 9, Subchapter D of this title (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC)).(34) HHSC--The Texas Health and Human Services Commission.(35) Individual--A person enrolled in a program in which the CDS option is available, as described in §41.108 of this subchapter.(36) LAR--Legally authorized representative. A person authorized or required by law to act on behalf of an individual with regard to a matter described in this chapter, including a parent of a minor, guardian of a minor, managing conservator of a minor, or the guardian of an adult.(37) LIDDA--Local intellectual and developmental disability authority. An entity designated by the HHSC executive commissioner, in accordance with Texas Health and Safety Code §533A.035.(38) Minor--A person who is 17 years of age or younger.(39) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(40) Non-program resource--A resource, other than an individual's HHSC program.(41) Parent--A natural, legal, foster, or adoptive parent of a minor.(42) PHC Program--Primary Home Care Program. A Medicaid state plan program authorized under Title XIX of the Social Security Act and described in Chapter 47 of this title.(43) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual;(C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or(D) seclusion.(44) Relative--A person related to an employer within the fourth degree of consanguinity or within the second degree of affinity.(45) Seclusion--The involuntary placement of an individual alone in an area from which the individual is prevented from leaving.(46) Service agreement--A written agreement or acknowledgment between two parties that defines the relationship and lists respective roles and responsibilities.(47) Service backup plan--A documented plan to ensure that critical services delivered through the CDS option are provided to an individual when normal service delivery is interrupted or there is an emergency.(48) Service coordinator--An employee of a LIDDA who is responsible for assisting an applicant, individual, or LAR to access needed medical, social, educational, and other appropriate services, including an HHSC program or service. A service coordinator provides case management services to an individual.(49) Service plan--A document developed in accordance with rules governing an individual's program that identifies the services to be provided to the individual, the number of units of each service to be provided, and the projected cost of each service.(50) Service planning team--A group of people identified in accordance with the requirements of an individual's program. Some HHSC programs refer to the service planning team as an interdisciplinary team.(51) Service provider--An employee, contractor, or vendor.(52) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and a service provider, staff person, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff person, or controlling person became a service provider, staff person, or controlling person.(53) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(54) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(55) Staff person--An employee, contractor, or volunteer of an FMSA.(56) Support advisor--An employee who provides support consultation to an employer or DR.(57) Support consultation--An optional service that is provided by a support advisor and provides a level of assistance and training beyond that provided by the FMSA through FMS or CFC support management. Support consultation helps an employer to meet the required employer responsibilities of the CDS option and to successfully manage the delivery of program services.(58) TxHmL Program--Texas Home Living Program. A Medicaid waiver program approved by CMS under Title XIX, §1915(c) of the Social Security Act and described in Chapter 9, Subchapter N of this title (relating to Texas Home Living (TxHmL) Program and Community First Choice (CFC)).(59) Vendor--A person or entity selected by an employer or DR to deliver goods, items, or services other than a direct service to an individual. Examples of vendors include a building contractor, an electrician, a durable medical equipment provider, a pharmacy, and a medical supply company.(60) Vendor fiscal/employer agent--The entity responsible for conducting payroll activities, including withholding, filing, and depositing taxes on behalf of an employer in the CDS option, in accordance with Section 3504 of the Internal Revenue Code and with Revenue Procedure 2013-39.(61) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(62) Volunteer--A person who works for an FMSA without compensation, other than reimbursement for actual expenses.(63) Working day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b). Source Note: The provisions of this §264.103 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2011, 35 TexReg 11709; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective March 20, 2016, 41 TexReg 1925; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.103 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219779 03/12/2026 This chapter applies to the following:(1) an individual or LAR who elects to be the employer for services delivered through the CDS option;(2) a DR;(3) a CDSA;(4) a support advisor;(5) a service provider; and(6) a case manager or service coordinator. Source Note: The provisions of this §264.105 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.105 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219783 03/12/2026 (a) An individual or LAR may elect the CDS option if:(1) the individual's program offers the CDS option;(2) one or more program services in the individual's authorized service plan are available for delivery through the CDS option;(3) the individual or LAR agrees to perform, or to appoint a DR to perform, the employer responsibilities required for participation in the CDS option;(4) the individual or LAR selects a CDSA to provide FMS; and(5) the individual or LAR has developed and received approval from the service planning team for each required service back-up plan.(b) If an individual or LAR elects to participate in the CDS option, the individual or LAR:(1) selects a CDSA to provide FMS;(2) with the assistance of the CDSA, budgets funds allocated in the individual's service plan for delivery through the CDS option; and(3) recruits, screens, hires, trains, manages, and terminates service providers.(c) An individual or LAR, as the employer, may appoint in writing a willing adult as the DR to assist in performing employer responsibilities. Source Note: The provisions of this §264.107 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.107 Overview of the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219784 03/12/2026 (a) The CDS option is available in the following programs:(1) the CLASS Program, if the individual does not receive in the CLASS Program:(A) support family services; or(B) continued family services;(2) the DBMD Program, if the individual does not receive in the DBMD Program:(A) licensed assisted living; or(B) licensed home health assisted living;(3) the HCS Program, if the individual does not receive in the HCS Program:(A) residential support;(B) supervised living; or(C) host home/companion care;(4) the TxHmL Program;(5) the PHC Program;(6) the CAS Program;(7) the FC Program; and(8) the CMPAS Program.(b) Except for an individual who receives a service described in subsection (a)(1)(A) or (B), (a)(2)(A) or (B), or (a)(3)(A), (B), or (C) of this section, an individual enrolled in a program described in subsection (a)(1) - (4) of this section may choose to receive the following services through the CDS option:(1) the CLASS Program:(A) habilitation;(B) in-home respite;(C) nursing;(D) occupational therapy;(E) out-of-home respite;(F) physical therapy;(G) speech therapy;(H) employment assistance;(I) supported employment;(J) cognitive rehabilitation therapy;(K) CFC PAS/HAB; and(L) any other service provided through the CDS option as listed on HHSC's website;(2) the DBMD Program:(A) employment assistance;(B) intervener;(C) residential habilitation;(D) respite;(E) supported employment;(F) CFC PAS/HAB; and(G) any other service provided through the CDS option as listed on the HHSC website;(3) the HCS Program:(A) cognitive rehabilitation therapy;(B) employment assistance;(C) nursing;(D) supported employment;(E) supported home living;(F) respite;(G) CFC PAS/HAB; and(H) any other service provided through the CDS option as listed on HHSC's website; and(4) the TxHmL Program:(A) adaptive aids;(B) audiology services;(C) behavioral support;(D) community support;(E) day habilitation;(F) dental treatment;(G) dietary services;(H) employment assistance;(I) nursing;(J) minor home modifications;(K) occupational therapy;(L) physical therapy;(M) respite;(N) speech/language pathology services;(O) supported employment;(P) CFC PAS/HAB; and(Q) any other service provided through the CDS option as listed on HHSC's website. Source Note: The provisions of this §264.108 adopted to be effective September 1, 2014, 39 TexReg 6604; amended to be effective March 20, 2016, 41 TexReg 1925; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.108 Services Available Through the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219789 03/12/2026 (a) At the time of an individual's enrollment in a DADS program that offers the CDS option, and at least annually thereafter, a case manager, service coordinator, or other person designated by the individual's program must:(1) provide written materials on the CDS option to the individual or LAR;(2) meet with and provide the individual or LAR with an oral explanation of the CDS option specific to the individual's program; and(3) complete Form 1581, Consumer Directed Services Option Overview.(b) An individual or LAR may request that a case manager, service coordinator, or other person designated by the individual's program provide additional oral and written information to the individual or LAR regarding the CDS option or assist with enrollment in the CDS option at any time. The case manager, service coordinator, or designee must comply within five working days after receipt of the request.(c) An individual or LAR declining participation in the CDS option may at any time elect to participate in the CDS option while receiving services through a DADS program that offers the CDS option.(d) An individual or LAR who decides to participate in the CDS option must, with assistance from a case manager or service coordinator, complete the following forms:(1) Form 1582, Consumer Directed Services Responsibilities;(2) Form 1583, Employee Qualification Requirements;(3) Form 1584, Participant Choice for Consumer Directed Services;(4) Form 1585, Acknowledgement of Responsibility for Exemption from Nursing Licensure for Certain Services through Consumer Directed Services, or Form 1733, Employer and Employee Acknowledgement of Exemption from Nursing License for Certain Services Delivered through Consumer Directed Services, if required by the policies of the individual's program; and(5) Form 1586, Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option, if the service is available in the individual's program.(e) An individual or LAR who elects to participate in the CDS option must complete the self-assessment in Form 1582, Consumer Directed Services Responsibilities, and if applicable, complete any assessment required by the individual's program.(f) An individual or LAR who is not able to complete the self-assessment must appoint a DR in order to participate in the CDS option.(g) The person appointed as the DR by the individual or LAR must:(1) be willing to serve as the individual's or LAR's DR for participation in the CDS option;(2) be or become actively involved with the individual; and(3) complete the self-assessment in Form 1582, and any assessment required by the individual's program. Source Note: The provisions of this §264.109 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.109 Enrollment in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219790 03/12/2026 (a) Service planning for an individual who chooses to participate in the CDS option is completed in accordance with the rules and requirements of the individual's program in the same manner as if services are delivered through a program provider. Service planning includes:(1) determining the individual's needs;(2) determining service levels;(3) justifying changes to the service plan;(4) maintaining costs and cost ceilings;(5) reviewing services; and(6) obtaining approval for planned services.(b) A case manager or service coordinator must adhere to rules and requirements of the individual's program and in Subchapter D of this chapter (relating to Enrollment, Transfer, Suspension, and Termination) if the individual's services or a request for services is recommended for:(1) denial;(2) reduction;(3) suspension; or(4) termination.(c) A case manager or service coordinator must provide an oral explanation of an action recommended by a service planning team. The procedure for requesting a fair hearing must be provided orally and in accordance with the individual's program requirements. Source Note: The provisions of this §264.111 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION A INTRODUCTION §264.111 Service Planning in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219795 03/12/2026 (a) An employer may appoint a willing adult as a DR to assist or to perform employer responsibilities. The employer maintains responsibility and accountability for decisions and actions taken by the DR.(b) If the employer chooses to appoint a DR or change a DR, or is required to appoint a DR at enrollment in the CDS option, as described in §41.109 of this chapter (relating to Enrollment in the CDS Option), the employer must complete DADS Form 1720, Appointment of Designated Representative.(1) The employer must notify the FMSA by fax or telephone within two working days after the appointment or change of a DR.(2) If the employer notifies the FMSA by telephone, the employer must fax or mail a copy of Form 1720 to the FMSA within five working days after the appointment or change of a DR.(c) The employer, if appointing a DR who is not a relative, must:(1) obtain the DR's information required on the Appointment of Designated Representative Form (Form 1720) and request the FMSA to perform a criminal history background check through the Department of Public Safety's (DPS) public Criminal History Conviction Database website; and(2) not appoint or retain a DR who is not a relative who:(A) has a criminal history that indicates the person has been convicted of an offense included in Texas Health and Safety Code (THSC), §250.006(a); or(B) has a criminal history that indicates the person has been convicted of an offense included in THSC, §250.006(b) within the previous five years.(d) If an employer decides to revoke the appointment of a DR, the employer must:(1) complete DADS Form 1721, Revocation of Appointment of Designated Representative; and(2) provide a copy of the completed form to the FMSA within two calendar days after the effective date of the revocation.(e) Based on documentation provided by the FMSA of an employer's inability to meet employer responsibilities, the service planning team or the FMSA may recommend that the employer designate a DR to assist with or to perform employer responsibilities.(f) A DR must not:(1) sign or represent himself as the employer;(2) be paid to perform employer responsibilities;(3) be an employee of the employer;(4) have a spouse employed by the employer; or(5) provide a program service to the individual. Source Note: The provisions of this §264.205 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.205 Employer Appointment of a Designated Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219796 03/12/2026 If the court has appointed a guardian for an individual enrolled in the CDS option, the court appointed guardian must provide the FMSA, at CDS enrollment and the beginning of each service plan year, with documentation of guardianship or documentation of efforts to obtain documentation from the court. Source Note: The provisions of this §264.206 adopted to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.206 Proof of Guardianship for the Employer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219797 03/12/2026 An employer and the DR must:(1) complete the initial orientation conducted by the FMSA in the residence of the individual in accordance with §41.307 of this chapter (relating to Initial Orientation of an Employer);(2) complete:(A) DADS Form 1736, Documentation of Employer Orientation, upon completion of the orientation; and(B) if applicable, one of the following:(i) DADS Form 1733, Employer and Employee Exemption from Nursing License for Certain Services; or(ii) DADS Form 1585, Statement of Responsibilities for Consumer Directed Services;(3) enter into an agreement with the FMSA by signing and dating:(A) DADS Form 1735, Employer and Financial Management Services Agency (FMSA) Agreement; and(B) the Service Provision Requirements Addendum to DADS Form 1735;(4) complete DADS Form 1726, Relationship Definitions in Consumer Directed Services;(5) send the original completed forms or a copy of the forms described in this section to the FMSA within five calendar days after the date of the initial orientation; and(6) ensure services are not initiated until after the FMSA receives the completed forms; and(7) retain the original completed forms or a copy of the forms described in paragraphs (2) - (4) of this section. Source Note: The provisions of this §264.207 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective September 1, 2014, 39 TexReg 6604; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.207 Initial Orientation of an Employer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219798 03/12/2026 Within five calendar days after a request from a CDSA, an employer must provide necessary information and documentation to the CDSA for registration by the CDSA as the employer's agent with the Internal Revenue Service, the Texas Workforce Commission, and other government agencies as applicable. Source Note: The provisions of this §264.209 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.209 Employer-Agent Registration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219806 03/12/2026 An employer must agree to accept FMS from the selected FMSA, as described in §41.309 of this chapter (relating to Financial Management Services, CFC Support Management, and Vendor Fiscal/Employer Agent Responsibilities). Source Note: The provisions of this §264.211 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective March 20, 2016, 41 TexReg 1925; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.211 Financial Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219807 03/12/2026 An employer or DR may request employer support services if employer support services are included in an approved budget. Source Note: The provisions of this §264.213 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.213 Employer Support Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219808 03/12/2026 (a) An individual's service planning team consists of persons required or allowed by the individual's program.(b) An employer must attend and participate in the individual's service planning meeting. An employer's DR may also attend the meeting with approval of the individual or LAR.(c) An employer or DR must provide documentation related to services, service delivery, and participation in the CDS option when requested by a case manager or service coordinator.(d) An employer or DR must, when requesting a change in a service or the addition of a service for delivery through the CDS option, provide the service planning team with documentation of circumstances that require a revision to the individual's service plan. Source Note: The provisions of this §264.215 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.215 Employer Role in the Service Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219809 03/12/2026 (a) An employer or DR must develop a service backup plan, using DADS Form 1740, CDS Service Backup Plan, if requested by the case manager or service coordinator, in accordance with §41.404(b) of this chapter (relating to Ensuring Development and Monitoring Service Backup Plans).(b) The actions listed in a service backup plan may include the use of:(1) paid service providers;(2) unpaid service providers, such as family members, and friends;(3) non-program services; or(4) respite, if included in the authorized service plan.(c) A service backup plan, including any revised plan, must be approved by the case manager or service coordinator in accordance with §41.404(c) of this chapter before implementation by the employer or DR.(d) An employer or DR must:(1) budget sufficient funds in the CDS option budget to implement a service backup plan;(2) comply with §41.511 of this chapter (relating to Budget Revisions and Approval);(3) review a service backup plan annually;(4) revise a service backup plan at any time, including after a review required by paragraph (3) of this subsection, if:(A) the employer or DR determines the service backup plan was ineffective;(B) a change occurs in the availability of service backup plan resources;(C) the employer or DR redistributes funds that are not utilized in implementing a service backup plan; or(D) the case manager or service coordinator notifies the employer or DR that the service backup plan was determined ineffective and that the plan must be revised as described in §41.404(e) of this chapter; and(5) provide a copy of the initial and revised service backup plan to the FMSA within five working days after the plan is approved by the case manager or service coordinator in accordance with §41.404(c) of this chapter. Source Note: The provisions of this §264.217 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective September 1, 2014, 39 TexReg 6604; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.217 Employer Responsibilities Regarding Service Backup Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219810 03/12/2026 (a) An employer must:(1) review the CDSA report as described in §41.317 of this chapter (relating to CDSA Reports) for each service delivered to the individual through CDS; and(2) initiate budget revisions based on the CDSA report if needed to ensure that sufficient funds and units of a service are available through the end date of the individual's service plan.(b) An employer may request that the CDSA provide the report on a monthly basis. Source Note: The provisions of this §264.219 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.219 CDSA Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219811 03/12/2026 (a) A written corrective action plan may be required from an employer or DR if the employer or DR:(1) hires an ineligible service provider;(2) submits incomplete, inaccurate, or late documentation of service delivery;(3) does not follow the budget;(4) does not comply with program requirements related to the CDS option; or(5) does not meet other employer responsibilities.(b) An employer must provide written corrective action plans to the person requiring the plan within 10 calendar days after receiving the request. Corrective action plans may be requested in writing by:(1) a CDSA, related to employer responsibilities;(2) a case manager or service coordinator;(3) a service planning team; or(4) a DADS representative.(c) A written corrective action plan must include:(1) the reason the corrective action plan is required;(2) the action to be taken;(3) the person responsible for each action; and(4) the date the action must be completed.(d) An employer or DR may request assistance in the development or implementation of a corrective action plan from:(1) the CDSA or others if the plan is related to employer responsibilities, as described in this subchapter;(2) if applicable, the support advisor as described in Subchapter F of this chapter (relating to Support Consultation Services and Support Advisor Responsibilities); and(3) the case manager, service coordinator, or others if the corrective action plan is related to program rules or requirements. Source Note: The provisions of this §264.221 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.221 Corrective Action Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219812 03/12/2026 (a) An employer must complete Form 1728, Liability Acknowledgment, for each applicant for employment.(b) An employer must document on Form 1728:(1) if the employer is, or is not, a subscriber to workers' compensation through the Texas Department of Insurance, Division of Workers' Compensation; and(2) the arrangements, if any, that the employer has made for work-related injuries or illness incurred by an employee if the employer is not a subscriber to workers' compensation.(c) An employer must maintain the original Form 1728 completed for an applicant and provide a copy to the CDSA.(d) An employer may request assistance from the CDSA to subscribe to workers' compensation through the Texas Department of Insurance, Division of Workers' Compensation if the employer elects to subscribe to the state workers' compensation program. Source Note: The provisions of this §264.223 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.223 Liability Acknowledgment and Workers' Compensation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219813 03/12/2026 (a) Before an applicant can become an employee, an employer or DR must:(1) obtain the applicant's information required on the Criminal History and Registry Checks Form 1725 to conduct a criminal history background check through the Texas Department of Public Safety (DPS) secure online website;(2) sign the certification section on Form 1725 acknowledging that criminal history records and reports include confidential information that must not be shared, released, or otherwise disclosed, under penalty of law; and(3) request that the FMSA obtain the criminal history report from the secure online DPS Criminal History Conviction Database website.(b) If the employer or DR asks the FMSA to send the criminal history report to the employer or DR, the employer or DR must receive the original criminal history report sent by the FMSA, using a DPS-approved secure method of dissemination, before hiring the applicant.(c) A criminal history report must be dated no more than 30 calendar days before the applicant's date of hire.(d) An employer or DR must not hire an applicant or retain an employee who:(1) has a criminal history that indicates the applicant or employee has been convicted of an offense included in Texas Health and Safety Code (THSC), §250.006(a); or(2) has a criminal history that indicates the applicant or employee has been convicted of an offense included in THSC, §250.006(b) within the previous five years.(e) An employer or DR must retain a copy of Form 1725 completed as described in subsection (a)(2) of this section for each employee in accordance with record retention requirements described in §41.243 of this chapter (relating to Record Retention).(f) An employer or DR, within five calendar days after making the hiring decision, must destroy the criminal history record documents obtained from DPS for all applicants, whether or not hired or retained by the employer or DR, as described in subsection (a)(3) of this section as follows:(1) for paper records, shredding, pulping, or burning; and(2) for electronic records, destroying the media or using specialized software to copy over the data.(g) An employer or DR may, at any time, obtain or request that the FMSA obtain an updated criminal history report for a current employee.(h) Within five calendar days after receiving a criminal history report from the FMSA under subsection (g) of this section, the employer or DR must destroy the report using a method described in subsection (f) of this section.(i) An employer or DR must immediately terminate an employee if an updated criminal history report indicates that the employee has been convicted of an offense included in THSC, §250.006(a), or the employee has been convicted of an offense included in THSC, §250.006(b) within the previous five years.(j) The cost of obtaining a criminal history report must be budgeted by the employer or DR in accordance with §41.507(d)(2) of this chapter (relating to Employer Support Services Budgeting) and be paid as an employer support service expenditure, except for the report of an applicant or current employee who is:(1) only providing CFC PAS/HAB; or(2) providing support consultation to an individual who is receiving only CFC PAS/HAB through the CDS option.(k) When contracting with an entity, the employer or DR and the entity must complete a service agreement in which the entity certifies that the entity has checked and verified that each person delivering a service to the individual on behalf of the entity has not been convicted of an offense listed in THSC, §250.006(a), or an offense listed in THSC, §250.006(b) within the previous five years. Source Note: The provisions of this §264.225 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective March 20, 2016, 41 TexReg 1925; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.225 Criminal History Check of an Applicant for Employment and an Employee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219814 03/12/2026 (a) For each applicant for employment, an employer or DR must:(1) obtain the applicant's required information on the Criminal History and Registry Checks, (Form 1725) necessary to conduct an initial and annual check of the DADS Nurse Aide Registry and the Employee Misconduct Registry; and(2) request that the FMSA obtain and document the results of the registry check for an applicant using Form 1725 and send a copy to the employer or DR.(b) The result of a registry check must be obtained within 30 calendar days before the hire date and within 30 calendar days after each annual employment anniversary.(c) An employer must not employ an applicant, and must immediately discharge an employee upon verification that the person is listed:(1) as revoked in the Nurse Aide Registry; or(2) as unemployable in the Employee Misconduct Registry.(d) An employer must:(1) submit to the FMSA, for each applicant, contractor or vendor, the information required to conduct a monthly check of the Texas Health and Human Services Commission (HHSC) - Office of Inspector General (OIG) List of Excluded Individuals/Entities and the United States Department of Health and Human Services (HHS) - OIG Excluded Individuals/Entities Search online searchable databases; and(2) not employ an applicant, contractor or vendor or immediately discharge an employee, contractor or vendor if listed on the HHSC or the HHS List of Excluded Individuals and Entities.(e) An employer must obtain and maintain a copy of completed Form 1725 documenting the results of the registry checks.(f) When contracting with an entity, the employer and the entity must complete a service agreement in which the entity certifies that it has checked and verified that each person delivering a service to the individual on behalf of the contractor is in compliance with, and will maintain compliance with, this section. Source Note: The provisions of this §264.227 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.227 Required Registry Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219815 03/12/2026 (a) An employer or DR must, for each service that requires a service provider to be licensed, certified, or have other official or legal permission to perform a specific service:(1) obtain and retain a copy or other documentation on file to verify the current status of the applicant's license, certification, or other permission; and(2) submit a copy of the document verifying current status to the CDSA.(b) An employer or DR must:(1) obtain and retain documentation while the service provider is providing services to verify that the service provider's license, certification, or other legal or official permission is maintained; and(2) provide documentation to the CDSA within 30 calendar days after the renewal date of the service provider's license, certification, or other permission.(c) If applicable, the employer or DR must obtain a copy from the service provider of:(1) the current complaint procedure for each of the service provider's authorities; and(2) the service provider's professional liability insurance coverage.(d) An employer is responsible for services delivered by the service provider prior to the employee receiving verification of a service provider's eligibility in writing from the CDSA.(e) When contracting with an entity, the employer and the entity must complete a service agreement in which the entity certifies that the entity has checked and verified that each person delivering a service to the individual on behalf of the entity is in compliance with, and will maintain compliance with, this section. Source Note: The provisions of this §264.229 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.229 Licensure and Certification Verification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219816 03/12/2026 (a) When an applicant is hired, the employer or DR must ensure that the applicant completes Form 1724, New Service Provider Packet Cover Sheet, and supplies any required support documentation before being employed or retained by the employer or DR for the delivery of services to the individual. The employer or DR must provide Form 1724 to the CDSA.(b) An employer or DR must:(1) withdraw an offer of employment if a person is not eligible for employment based on results of US Citizenship and Immigration Services, Form I-9, Employment Eligibility Verification or regulations of any government agency;(2) verify continued eligibility of employment based on the requirements of the US Citizenship and Immigration Services using Form I-9, Employment Eligibility Verification;(3) maintain a copy of renewed supporting documents; and(4) submit a copy of renewed supporting documentation to the CDSA.(c) An employer or DR must immediately terminate an employee or contractor that does not maintain eligibility to:(1) be employed or retained; or(2) provide the service or services to an individual.(d) If an employee or contractor is permitted, by program rule or with employer approval, to transport the individual, the employer or DR must obtain, maintain, and update copies of the employee's or contractor's:(1) current Texas Driver License; and(2) current proof of minimum auto insurance as required by the State of Texas.(e) An employer or DR may obtain additional background or reference checks on applicants, employees, and contractors. Charges for the costs of background or reference checks must be in the individual's approved budget before the expense is incurred, if the expense will be paid through the individual's budget.(f) If an applicant that has previously been terminated by the employer is being considered as a service provider through the CDS option, the employer or DR must determine eligibility in the same manner as required for a new employee or a new contractor.(g) An employer or DR must obtain written notice from the CDSA that an applicant, employee, or contractor is eligible to be hired, retained, or maintained for service delivery before services are delivered.(h) When contracting with an entity, the employer and the entity must complete a service agreement in which the entity certifies that the entity has checked and verified that each person delivering a service to the individual on behalf of the entity is in compliance with, and will maintain compliance with, this section. Source Note: The provisions of this §264.231 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.231 Verification of Eligibility of an Employee or Contractor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219817 03/12/2026 (a) An employer or DR must:(1) provide initial, ongoing, and annual training to a service provider on the topics described in HHSC Form 1732, Management and Training of Service Provider, and the applicable Service Provision Requirements Addendum to HHSC Form 1735, Employer and Financial Management Services Agency (FMSA) Agreement; and(2) manage a service provider in accordance with HHSC Form 1732 and the applicable addendum to HHSC Form 1735.(b) An employer or DR must:(1) complete HHSC Form 1732 to document:(A) the training required by subsection (a)(1) of this section;(B) the management of a service provider required by subsection (a)(2) of this section; and(C) an evaluation of the service provider's performance at least annually after the date of hire;(2) sign and date the completed form;(3) ensure the service provider signs and dates the completed form;(4) give the service provider a copy of the signed form; and(5) send a copy of the signed form to the FMSA within 30 calendar days after the date the form is signed by the employer or DR and the service provider. Source Note: The provisions of this §264.233 adopted to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.233 Training and Management of Service Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219818 03/12/2026 (a) An employer or DR must:(1) obtain, verify, and retain documentation that a vendor meets and maintains the eligibility requirements of an individual's program for the services to be delivered; and(2) submit documentation of the vendor's eligibility and continued eligibility to the CDSA before services are delivered.(b) A vendor must be in compliance with any requirements of law or of the individual's program, including:(1) applicable licensing or certification standards;(2) local building codes;(3) the Americans with Disabilities Act of 1990 as amended; and(4) state requirements for automotive adaptive equipment and vehicle modifications.(c) An employer or DR must obtain written approval from the CDSA that a vendor has met the requirements detailed in subsection (a) of this section before the vendor delivers services to the individual. Source Note: The provisions of this §264.235 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.235 Verification of Eligibility for Vendors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219819 03/12/2026 (a) An employer or DR must, before an employee, contractor, or vendor provides services to an individual, ensure that required DADS service agreements have been completed between:(1) the employer and the employee;(2) the employer and the contractor; and(3) the employer and a vendor, if required by DADS.(b) An employer must assist the CDSA in obtaining the required DADS service agreement form between:(1) the CDSA and the employee;(2) the CDSA and individual contractor or entity contactor; and(3) the CDSA and a vendor, if required by DADS.(c) An employer must ensure that the CDSA receives the completed service agreement described in subsection (b) of this section.(d) A CDSA must not make payment to a service provider until the completed service agreement is received. Source Note: The provisions of this §264.237 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.237 Service Provider Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219820 03/12/2026 (a) The employer or DR must ensure that services provided through the CDS option:(1) are included on the individual's HHSC authorized service plan and, if required by the program rules, included on any other plan such as the habilitation plan or implementation plan;(2) are budgeted in the employer budget;(3) are provided only to the individual;(4) are not provided if the individual receiving services becomes ineligible for program services; and(5) meet requirements for payment in accordance with program rules and §41.241 of this subchapter (relating to Payment of Services).(b) If nursing services are included on the service plan, the employer or DR must:(1) if the employer or DR hires an RN to deliver the service, obtain a completed HHSC Form 1747, Acknowledgment of Nursing Requirements, from the RN before the RN provides nursing services to the individual;(2) if the employer or DR hires a licensed vocational nurse (LVN) to deliver the service, obtain a completed HHSC Form 1747 from the LVN before the LVN provides nursing services to the individual;(3) maintain completed HHSC Forms 1747 in the individual's home and send a copy of the completed forms to the FMSA before delivery of nursing services; and(4) if program rules require that the individual's program provider's nurse complete the initial and annual nursing assessment:(A) provide a copy of the program provider's nursing assessment, including the number of nursing hours authorized, to the CDS nurse; and(B) if the CDS nurse disagrees with the number of authorized nursing hours, ensure that the CDS nurse provides justification to the service planning team for consideration and a possible service plan revision.(c) If HHSC determines that an employer or DR is not in compliance with this section, HHSC may require the employer to develop and implement a corrective action plan in accordance with §41.221 of this subchapter (relating to Corrective Action Plans). Source Note: The provisions of this §264.238 adopted to be effective September 1, 2014, 39 TexReg 6604; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.238 Service Delivery Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219821 03/12/2026 (a) An employer or DR must ensure that documentation of services delivered includes:(1) each element required by an individual's program; and(2) service dates within the same calendar month.(b) In addition to documentation generated by an EVV system, documentation of services delivered must include:(1) time sheets for employees who are not required to document their time worked using an EVV system as required by Chapter 68 of this title (relating to Electronic Visit Verification (EVV) System);(2) time sheets or invoices for contractors;(3) invoices for vendors;(4) receipts when payment has been made for a service; and(5) other documentation in accordance with requirements of the individual's program.(c) Unless using an EVV system as required by Chapter 68 of this title:(1) an employer or DR must review documentation of services delivered and obtain corrections or revisions before submitting the document to the CDSA for payment;(2) the person making an error or omission on documentation of services delivered must:(A) enter the omission; and(B) for an error, make correction by:(i) making one line through the error;(ii) entering the correction; and(iii) initialing and dating the correction; and(3) the employer or DR must sign and date the documentation of services delivered after the last entry or correction made by the service provider to signify approval for payment of the documentation of services delivered. Source Note: The provisions of this §264.239 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2011, 35 TexReg 11709; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.239 Documentation of Services Delivered https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219822 03/12/2026 (a) Only the employer or DR may approve the documentation of services delivered described in §41.239 of this chapter (relating to Documentation of Services Delivered).(b) An employer or DR must submit to the CDSA approved documentation of services delivered for payment on or before the due date established by the CDSA.(c) Unless using an EVV system as required by Chapter 68 of this title (relating to Electronic Visit Verification (EVV) System), an employer or DR must obtain a correction and submit the corrected and approved documentation of services delivered to the CDSA within three calendar days after receiving a request for corrected documentation of services delivered from the CDSA.(d) The CDSA does not pay for services delivered until receipt of approved documentation.(e) Overtime pay for employees must be calculated and paid in accordance with current state or federal laws and regulations for payment of overtime.(f) DADS does not pay, and the CDSA must not pay, for purchases or services that:(1) are not in an approved budget at time of purchase;(2) do not meet requirements for payment through the individual's program or this chapter;(3) are provided by a service provider:(A) before the CDSA provides written approval of the service provider's eligibility to deliver the service, even if the CDSA determines later that the service provider was eligible to deliver the service;(B) while the service provider was not eligible to deliver services because the service provider did not have a valid license, certificate, or other formal permission to provide the service or failed to meet other qualifications for service delivery; or(C) when the service provider's relationship to the employer, individual, or DR is prohibited for service delivery;(4) are delivered when the individual receiving services is not eligible for services at the time of service delivery;(5) are available through a non-program resource;(6) are available through another service within the individual's program;(7) do not meet:(A) the needs of the individual;(B) the employment-related requirements; or(C) the employer-related responsibilities; or(8) exceed the rate or amount approved for the service.(g) If the employer or DR does not meet an employer responsibility or due date, DADS does not pay and the CDSA must not pay related finance charges, interest, and fees. Source Note: The provisions of this §264.241 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2011, 35 TexReg 11709; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.241 Payment of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219823 03/12/2026 (a) An employer must, for at least five years after services are delivered through the CDS option, maintain documentation required by:(1) this chapter;(2) the individual's program; or(3) government agencies with regulatory authority over employer and employer-agent responsibilities.(b) An employer must retain documentation of:(1) services delivered to an individual through the CDS option;(2) payments by the CDSA to service providers;(3) service provider qualifications;(4) employer responsibilities;(5) employer-agent responsibilities; and(6) contracts, service agreements, and required supporting documentation.(c) An employer must maintain all documentation:(1) until all litigation or claims are resolved, if any litigation or claim involving these records is ongoing, regardless of the five-year period; and(2) in accordance with the regulating government agency's requirement for specific documentation when the record retention requirement is more than five years.(d) An employer must allow representatives of DADS and other appropriate government agencies to examine and copy records during normal business hours and days.(e) DADS may take adverse action if the employer fails to maintain records as required or to provide records upon request.(f) An employer must ensure confidentiality and security of all records.(g) If records are discarded, the employer must ensure confidentiality and security of the information. Source Note: The provisions of this §264.243 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION B RESPONSIBILITIES OF EMPLOYERS AND DESIGNATED REPRESENTATIVES §264.243 Record Retention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219824 03/12/2026 (a) An FMSA must:(1) comply with Chapter 49 of this title (relating to Contracting for Community Services);(2) have at least one eligible employee or contractor to provide support consultation services as defined in Subchapter F of this chapter (relating to Support Consultation Services and Support Advisory Responsibilities);(3) operate as a Vendor Fiscal/Employer Agent (VF/EA) in accordance with §3504 of the Internal Revenue Code; and(4) participate in all mandatory training provided or authorized by HHSC.(b) An FMSA must not:(1) use a third party to file and report payroll taxes to the Internal Revenue Service on behalf of an employer;(2) provide FMS to an individual who is receiving case management services or service coordination from the FMSA or a controlling person, as defined in §49.102 of this title (relating to Definitions) of the FMSA, except in the Consumer Managed Personal Attendant Services program.(c) An individual receiving FMS, the individual's LAR, or DR, must not be:(1) the individual's FMSA; or(2) a controlling person, as defined in §49.102 of this title, of the individual's FMSA.(d) An FMSA must:(1) conduct training to ensure a staff person is:(A) knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation;(B) instructed to report an allegation of abuse, neglect, or exploitation of an individual as described in §41.701(c) of this chapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual); and(C) provided with the instructions described in subparagraph (B) of this paragraph in writing; and(2) provide the training described in paragraph (1) of this subsection before a staff person assumes job duties and annually thereafter. Source Note: The provisions of this §264.301 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective September 1, 2014, 39 TexReg 6604; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.301 Contracting as an FMSA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219825 03/12/2026 (a) An FMSA must apply for and obtain one Federal Employer Identification Number (FEIN) for the sole purpose of filing and depositing federal income tax withholding and employment taxes (i.e., Medicare and Social Security (FICA) and Federal Unemployment Insurance taxes) on behalf of employers it represents as a vendor fiscal/employer agent. The one FEIN must cover all states and programs under which the entity functions as a FMSA.(b) An FMSA must obtain IRS approval to act as an agent for each employer it represents by:(1) obtaining, within 30 calendar days after the employer enrolls into the CDS option, a separate FEIN for each employer it represents by completing and submitting an IRS Form SS-4, Application for Employer Identification Number unless the employer uses an existing FEIN for the CDS option;(2) requesting that the employer, who uses an existing FEIN for the CDS option, inform the FMSA if the FEIN is being used for other purposes;(3) retaining a copy of an executed IRS Form SS-4 or other documentation provided by the CDS employer who already has an FEIN for each employer on file;(4) applying for and receiving agent authorization from the IRS by completing and submitting an IRS Form 2678, Employer/Payer Appointment of Agent, within 30 calendar days after the employer enrolls into the CDS option, for each employer it represents; and(5) retaining a copy of executed IRS Form 2678 for each employer on file.(c) The FMSA must register as a reporting agent with the Texas Workforce Commission (TWC) for the sole purpose of filing and depositing state unemployment taxes.(d) The FMSA must revoke the FMSA's IRS and TWC agent status within 30 calendar days after becoming aware that the person no longer qualifies for the program, the employer no longer qualifies to be an employer, the individual transfers to another FMSA, or the individual no longer uses the CDS option. Source Note: The provisions of this §264.303 adopted to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.303 Obtaining and Revoking Federal and State Approval to be a Vendor Fiscal/Employer Agent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219826 03/12/2026 (a) The FMSA must, if the employer requests to appoint a person who is not a relative as DR, use the information provided by the employer on the Appointment of Designated Representative form (Form 1720) to:(1) obtain the criminal history information directly from the Texas Department of Public Safety's (DPS) public online criminal history website; and(2) notify the employer, using Form 1720, if the DR has been convicted of an offense included in Texas Health and Safety Code (THSC), §250.006(a), or has been convicted of an offense included in THSC, §250.006(b) within the previous five years and cannot be appointed as DR.(b) An FMSA must maintain the following documentation regarding an employer's DR:(1) Form 1720, Appointment of a Designated Representative, for:(A) initial designations; and(B) any change to an appointment of a DR; and(2) Form 1721, Revocation of Representative, if the employer elects to revoke the appointment of a DR.(c) An FMSA must communicate with and accept direction from the employer's DR to the extent delegated by the employer on Form 1720. Source Note: The provisions of this §264.305 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.305 Appointment of a Designated Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219827 03/12/2026 An FMSA must obtain at CDS enrollment and the beginning of each service plan year from the court appointed guardian of an individual using the CDS option, current documentation of guardianship or documentation of the guardian's efforts to obtain documentation from the court. The FMSA must maintain the documentation. Source Note: The provisions of this §264.306 adopted to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.306 Proof of Guardianship for Financial Management Services Agencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219828 03/12/2026 (a) An FMSA must conduct an initial face-to-face orientation with the employer, and the DR if applicable, in the residence of the individual, in which the FMSA:(1) explains to the employer and DR the roles, rules, and responsibilities that apply to an employer, service provider, FMSA, and state agencies, including:(A) the employer budget based on the authorized service plan;(B) the hiring process, including documents and forms to be completed for new employees; and(C) managing paper and electronic timesheets, due dates, payday schedules, and disbursing employee payroll checks;(2) reviews with and gives the employer and DR a printed document that clearly states the FMSA's:(A) normal hours of operation;(B) key persons to contact with issues or questions and how to contact these persons; and(C) the complaint process, including how to file a complaint with the FMSA or about the FMSA;(3) reviews with the employer and DR, HHSC Form 1735, Employer and Financial Management Services Agency Service Agreement, and the applicable Service Provision Requirements Addendum to the form, emphasizing rule and policy requirements of the individual's program, including:(A) service definitions;(B) service provider qualifications;(C) required documentation to be kept in the individual's home;(D) training requirements for service providers;(E) program staff who will be reviewing the employer's records; and(F) if applicable, nursing requirements as described on HHSC Form 1747;(4) reviews with and gives to the employer and DR a printed or an electronic document that describes how to report an allegation of abuse, neglect, or exploitation of the individual to DFPS as described in §41.701(a)(1)(A) or (B) of this chapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual); and(5) educates the employer and DR about protecting the individual from abuse, neglect, and exploitation.(b) The FMSA must provide to the employer or DR a printed or an electronic copy of the HHSC Consumer Directed Services (CDS) Option Employer Manual.(c) The FMSA and employer must complete HHSC Form 1736, Documentation of Employer Orientation, upon conclusion of the orientation.(d) The FMSA must sign and date a completed HHSC Form 1735 signed and dated by the employer before initiation of the CDS option. Source Note: The provisions of this §264.307 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2009, 33 TexReg 10509; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.307 Initial Orientation of an Employer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219829 03/12/2026 (a) An FMSA must provide FMS to an employer or DR. FMS consists of the following activities:(1) providing an initial orientation as described in §41.307 of this chapter (relating to Initial Orientation of an Employer);(2) after the initial orientation, doing the following annually:(A) providing to the employer and DR a printed or an electronic document that contains an explanation of how to report allegations of abuse, neglect, and exploitation of the individual to DFPS as described in §41.701(a)(1)(A) or (B) of this chapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual); and(B) educating the employer and DR about protecting the individual from abuse, neglect, and exploitation;(3) providing ongoing training, assistance, and support for employer-related responsibilities;(4) assisting an employer to verify qualifications of service providers before services are delivered, including citizenship status;(5) monitoring continued eligibility of service providers;(6) approving and monitoring budgets for services delivered through the CDS option;(7) collecting and processing service provider timesheets or invoices approved by the employer;(8) processing payroll, including calculating employee withholdings and employer contributions and depositing these funds with applicable federal, state, and local agencies;(9) complying with applicable government regulations concerning employee withholdings, garnishments, mandated withholdings, and benefits;(10) preparing and filing required tax forms and reports;(11) paying allowable expenses incurred by the employer;(12) providing status reports concerning the individual's budget, expenditures, and compliance with CDS option requirements; and(13) responding to the employer or DR as soon as possible, but at least within two working days after receipt of information requiring a response from the FMSA, unless indicated otherwise in this chapter.(b) An FMSA must provide, in accordance with HHSC's instructions, CFC support management to an individual or LAR if:(1) the individual is receiving CFC PAS/HAB; and(2) the individual or LAR requests to receive CFC support management.(c) An FMSA must complete HHSC Form 1739 Service Provider Agreement with an employer's service provider before issuing the initial payment for services to the service provider.(d) An FMSA must accept a designated fee established by HHSC as payment in full for FMS provided.(e) An FMSA must maintain originals or copies of records to document compliance with this section.(f) An FMSA must not provide FMS and case management services to the same individual as prohibited in §41.301 of this chapter (relating to Contracting as an FMSA). Source Note: The provisions of this §264.309 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective March 20, 2016, 41 TexReg 1925; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.309 Financial Management Services, CFC Support Management, and Vendor Fiscal/Employer Agent Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219830 03/12/2026 If requested, a CDSA must assist an employer or DR to plan, budget, and purchase allowable employer support services and goods for:(1) employer-related activities;(2) employment-related activities; and(3) support consultation. Source Note: The provisions of this §264.311 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.311 Employer Support Services and Support Consultation Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219831 03/12/2026 (a) An FMSA may participate as a member of an individual's service planning team when requested by the individual or LAR and agreed to by the FMSA.(b) Within three working days after receiving a request from an employer, DR, case manager, service coordinator, or HHSC, the FMSA must provide information related to an individual's participation in the CDS option.(c) The FMSA must document and notify a case manager or service coordinator of issues or concerns related to an individual's participation in the CDS option, including:(1) allegations of fraud;(2) concerns about the individual's health, safety, or welfare;(3) non-delivery or extended breaks in services;(4) noncompliance with employer responsibilities;(5) noncompliance with service back-up plans; or(6) over or under utilization of services or funds allocated in the individual's service plan for delivery of services to the individual through the CDS option and in accordance with the requirements of the individual's program. Source Note: The provisions of this §264.313 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.313 Individual Service Planning Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219832 03/12/2026 A CDSA must:(1) assist an employer as requested to revise budgets to meet service back-up plan strategies approved by the individual's service planning team;(2) review, validate, and approve revised budgets in accordance with §41.511 of this chapter (relating to Budget Revisions and Approval);(3) reimburse documented, budgeted, allowable expenses incurred related to implementing service back-up plan strategies; and(4) retain a copy of service back-up plans received from the employer. Source Note: The provisions of this §264.315 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.315 Service Back-up Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219833 03/12/2026 A CDSA must:(1) compile a report in accordance with the format provided by DADS addressing each service delivered through the CDS option, including the actual number of hours or units of service delivered;(2) provide the report no less than quarterly, and monthly if requested, to:(A) the employer or DR; and(B) the case manager or service coordinator; and(3) provide a copy of the report to DADS, upon request by a DADS representative. Source Note: The provisions of this §264.317 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.317 CDSA Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219834 03/12/2026 (a) A CDSA may require that the employer or DR develop a written corrective action plan related to employer responsibilities, such as:(1) an ineligible service provider is hired or retained for service delivery;(2) documentation of service delivery is incomplete, inaccurate, or late;(3) the budget has not been followed;(4) the rules in this chapter have not been followed; or(5) other employer responsibilities are not followed.(b) If requested by an employer or DR, a CDSA must assist the employer or DR in the development and implementation of a corrective action plan related to employer responsibilities in the CDS option. A corrective action plan must include:(1) the reason the corrective action plan is required;(2) the action to be taken;(3) the person responsible for the action; and(4) the date the action must be completed. Source Note: The provisions of this §264.319 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.319 Corrective Action Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219835 03/12/2026 (a) A CDSA must verify that an applicant for employment has completed, signed, and dated Form 1728, Liability Acknowledgment, before approving the applicant for hire by the employer.(b) A CDSA must assist an employer if requested to obtain coverage for employee work-related injuries, including:(1) workers' compensation through the Texas Department of Insurance, Division of Workers Compensation; or(2) other options listed on Form 1728. Source Note: The provisions of this §264.321 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.321 Liability Acknowledgment and Workers' Compensation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219836 03/12/2026 (a) The FMSA must ensure that the employer or DR signs the Criminal History and Registry Checks form (Form 1725) acknowledging that criminal history reports are confidential and must not be shared, released, or otherwise disclosed, under penalty of law.(b) The FMSA must, using the applicant information provided by the employer on the Criminal History and Registry Checks Form (Form 1725):(1) obtain the criminal history record information directly from the Texas Department of Public Safety's (DPS) secure online criminal history website within two working days after the CDS employer or DR requests the information; and(2) if requested by the CDS employer or DR, using a DPS-approved secure method, send the original printed document of the criminal history record information to the employer within two working days after receiving the request.(c) The criminal history report must not be dated more than 30 calendar days before the date the applicant is hired.(d) The FMSA must review the criminal history report on each applicant and notify the employer or DR in writing, using the Criminal History Registry Checks form (Form 1725), if the applicant has been convicted of an offense listed in Texas Health and Safety Code (THSC), §250.006(a), or an offense listed in THSC, §250.006(b) within the previous five years, and the applicant must not be hired or retained.(e) The FMSA must maintain a copy of the Criminal History and Registry Checks form (Form 1725) for an applicant hired by an employer or DR.(f) The FMSA, within five calendar days after the hiring decision, must destroy the criminal history record information obtained from DPS as described in subsection (b)(1) of this section for all applicants, whether or not hired or retained by the employer or DR, as follows:(1) for paper records, shredding, pulping, or burning; and(2) for electronic records, destroying the media or using specialized software to copy over the data.(g) The FMSA must obtain an updated criminal history report for an employee, if requested by the employer or DR. If the results of the updated report indicate the employee has been convicted of an offense listed in THSC, §250.006(a), or an offense listed in THSC, §250.006(b) within the previous five years, the FMSA must notify the employer or DR that the person must be terminated immediately as an employee.(h) Within five calendar days after obtaining the criminal history report under subsection (g) of this section, the FMSA must destroy the report using a method described in subsection (f) of this section.(i) The cost of obtaining a criminal history report must be budgeted by the employer or DR in accordance with §41.507(d)(2) of this chapter (relating to Employer Support Services Budgeting) and be paid as an employer support service expenditure, except for the report of an applicant or employee who is:(1) only providing CFC PAS/HAB; or(2) providing support consultation to an individual who is receiving only CFC PAS/HAB through the CDS option.(j) From the fee established by the Health and Human Services Commission for providing FMS, an FMSA must pay the cost of obtaining the criminal history report of an applicant or employee who is:(1) only providing CFC PAS/HAB; or(2) providing support consultation to an individual who is receiving only CFC PAS/HAB through the CDS option.(k) The amount paid for a criminal history report must be the amount stated on a receipt to the FMSA for purchase of the criminal history report. Source Note: The provisions of this §264.323 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; amended to be effective March 20, 2016, 41 TexReg 1925; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.323 Criminal History Check of an Applicant for Employment and to be an Employee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219837 03/12/2026 (a) For each applicant for delivery of services through the CDS option as an employee, an FMSA must:(1) check DADS' Nurse Aide Registry and Employee Misconduct Registry not more than 30 calendar days prior to the hire date;(2) document and maintain the results of each applicant registry check on Form 1725, Criminal Conviction History and Registry Check; and(3) provide a copy of completed Form 1725 for each applicant to the employer.(b) For each applicant for delivery of services through the CDS option as an employee, contractor, or vendor, an FMSA, prior to hiring, must:(1) check the Texas Health and Human Services Commission (HHSC) - Office of Inspector General (OIG) List of Excluded Individuals/Entities and the United States Department of Health and Human Services (HHS) - OIG Excluded Individuals/Entities Search online searchable databases; and(2) document the results and retain the documentation on file.(c) To comply with the Centers for Medicare and Medicaid Services reporting requirements and 42 Code Federal Regulations §1003.102(a)(2), an FMSA must immediately report any Medicaid exclusion findings to HHSC-OIG using the self-reporting mechanism located on the HHSC-OIG website.(d) The FMSA must obtain a copy of Form 1725 documenting the results of the registry checks if the employer or DR directly conducts a check of the registries.(e) The FMSA must not approve an applicant for employment or for a contract or a vendor upon verification that the person is listed:(1) as revoked in the Nurse Aide Registry;(2) as unemployable in the Employee Misconduct Registry; or(3) on the HHSC or HHS list of excluded individuals or entities. Source Note: The provisions of this §264.325 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.325 Required Registry Checks of an Applicant to be an Employee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219838 03/12/2026 (a) For each applicant for delivery of services through the CDS option as an employee, contractor, or vendor, the FMSA must:(1) obtain and review documentation from the employer, DR, or applicant that is required to verify each required qualification of the applicant;(2) notify the employer or DR of required documentation not received;(3) notify the employer or DR using the Verification of Applicant Form (DADS Form 1729) within three working days after receipt of all required documentation that the applicant is or is not qualified to be hired or retained for delivery of the specific service or services; and(4) retain documentation on file if the applicant is hired or retained by the employer or DR for service delivery.(b) The FMSA must review documentation provided by the employer, DR, applicant, or service provider, to determine if the applicant or service provider meets eligibility, licensure, certification or training requirements of the individual's program and government regulations to deliver an intended service and that the planned service meets those requirements.(c) Before services can be delivered, the FMSA must review Form 1724, New Service Provider Packet Cover Sheet, and any required supporting documentation provided by the employer, DR, or service provider and notify the employer, within two working days, to withdraw an offer of employment if the service provider is not eligible for employment based on results of reviewing the US Citizenship and Immigration Services, Form I-9, Employment Eligibility Verification or regulations of any government agency.(d) Before services can be delivered, the FMSA must verify an employee's or a contractor's social security number with the Social Security Administration.(e) The FMSA must not pay for services delivered if the FMSA has not provided written notice to the employer or DR of the service provider's eligibility even if the service provider is determined later by the FMSA to be eligible.(f) The FMSA must pay, but not claim reimbursement through DADS, for services delivered if the FMSA notified the employer or DR in error that the applicant was eligible.(g) If an applicant has previously been terminated by the employer or DR, the employer or DR and the FMSA must complete the eligibility process as a new applicant. Source Note: The provisions of this §264.327 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.327 Verification of Applicants for Employees, Contractors, and Vendors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219839 03/12/2026 (a) For each employee, contractor, or vendor, an FMSA must:(1) obtain from the employer, DR, or service provider a copy of a renewed license or certificate, if required by the individual's program, within 30 calendar days after the expiration date of the current document on file required to maintain qualifications;(2) notify the employer or DR to send required documentation to the FMSA, if not received within the 30 days;(3) notify the employer or DR in writing within three working days after receipt of all required documentation if the service provider is not qualified to continue service delivery; and(4) retain the documentation on file.(b) The FMSA must obtain and retain documentation on file that the service provider continues to meet qualifications as required by the individual's program rules, policies, and manuals, and other state and federal regulations including:(1) an annual check of DADS Nurse Aide Registry and Employee Misconduct Registry; and(2) a monthly check of the Texas Health and Human Services Commission (HHSC) - Office of Inspector General (OIG) List of Excluded Individuals/Entities and the United States Department of Health and Human Services (HHS) - OIG Excluded Individuals/Entities Search online searchable databases.(c) The FMSA must notify the employer or DR in writing to immediately terminate a service provider if the person is:(1) listed as revoked in the Nurse Aide Registry;(2) listed as unemployable in the Employee Misconduct Registry; or(3) is listed on the HHSC or HHS List of Excluded Individuals and Entities.(d) To comply with the Centers for Medicare and Medicaid Services reporting requirements and 42 Code of Federal Regulations §1003.102(a)(2)), an FMSA must immediately report any Medicaid exclusion findings to HHSC-OIG using the self-reporting mechanism located on the HHSC-OIG website.(e) The FMSA must obtain an updated criminal conviction history check for an employee, if requested by the employer or DR. If the results of the updated check indicate the person has been convicted of a crime listed in Texas Health and Safety Code (THSC), §250.006(a), or an offense listed in THSC, §250.006(b) within the previous five years, the FMSA must notify the employer or DR that the person must be terminated immediately as an employee.(f) The FMSA must not pay for services delivered by a service provider if the FMSA has not documented continuing qualifications for service delivery to the employer or DR, even if the service provider is determined later by the FMSA to be qualified.(g) The FMSA must pay, and not claim reimbursement through DADS, for services delivered by a service provider if the FMSA had notified the employer or DR in error that the service provider was qualified.(h) The FMSA must not pay, and must not claim reimbursement from DADS, for services delivered on dates that the service provider was not eligible. Source Note: The provisions of this §264.329 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective July 1, 2013, 38 TexReg 3990; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.329 Continued Eligibility of an Employee, Contractor, or Vendor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219840 03/12/2026 (a) If required by the individual's program, and the CDSA has not received a copy of a completed program-required evaluation from the employer or DR within 20 calendar days after the due date, the CDSA must notify the employer or DR in writing that a copy must be provided to the CDSA within 14 calendar days after receipt of the notice.(b) The CDSA must provide the DADS satisfaction survey of CDSA services to the employer or DR for each individual enrolled with the CDSA:(1) annually;(2) upon transfer to another CDSA; and(3) upon termination from the CDS option.(c) If a response to the satisfaction survey described in subsection (b) of this section is not received from the employer or DR within 14 calendar days after the survey is provided to the employer, the CDSA must conduct the satisfaction survey with the employer or DR by telephone.(d) The CDSA must:(1) retain completed satisfaction surveys received and conducted; and(2) make the satisfaction surveys available to DADS on request. Source Note: The provisions of this §264.331 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.331 Evaluation of Job Performance and Satisfaction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219772 03/12/2026 (a) After initial orientation of the employer by the CDSA and before additional FMS may be provided by the CDSA, the CDSA must receive from the employer a completed copy of Form 1735, Service Agreement between the Employer and the Consumer Directed Services Agency, and required attachments.(b) Before the CDSA pays an eligible service provider, the CDSA must obtain a completed original of the DADS provided Service Acknowledgment Between a Service Provider and the Consumer Directed Services Agency, and required attachments, for:(1) each employee of the employer;(2) each contractor retained by the employer; and(3) each vendor retained by the employer, if required in instructions for completion of the DADS Service Acknowledgment Between a Service Provider and the Consumer Directed Services Agency. Source Note: The provisions of this §264.333 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.333 Service Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219773 03/12/2026 (a) The CDSA must verify that the service provider:(1) documents each element required by the individual's program;(2) documents service dates within the same calendar month; and(3) unless using an EVV system as required by Chapter 68 of this title (relating to Electronic Visit Verification (EVV) System), has a dated signature of the employer or DR on all documentation of services delivered.(b) Documentation must include:(1) time sheets for employees who are not required to document their time using an EVV system as required by Chapter 68 of this title;(2) time sheets or invoices for contractors;(3) invoices for vendors;(4) receipts when payment has been made for a service; and(5) other documentation in accordance with requirements of the individual's program.(c) A CDSA must:(1) verify the accuracy of the document;(2) verify that documentation is completed in accordance with §41.239 of this chapter (relating to Documentation of Services Delivered);(3) if necessary, obtain corrected documentation approved by the employer or DR; and(4) process and issue payment. Source Note: The provisions of this §264.335 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2011, 35 TexReg 11709; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.335 Documentation of Services Delivered https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219774 03/12/2026 (a) A CDSA must make payments in accordance with posted pay dates and required time frames unless delay is documented by the CDSA as being caused by an employer, DR, or service provider.(b) A CDSA approves and pays for purchases through the CDS option only if:(1) documentation provided is in accordance with §41.239 of this chapter (relating to Documentation of Services Delivered) and §41.335 of this chapter (relating to Documentation of Services Delivered); and(2) services, goods, or items documented are included in the approved budget before purchase.(c) A CDSA must pay only:(1) the actual hours and minutes of service in accordance with the individual's program;(2) the actual cost of the service or item, not to exceed the established budget unit rate or amount for the service;(3) the budgeted employee benefits accrued based on hours worked by employees; and(4) purchases of services and items if funds have been accrued based on units delivered.(d) A CDSA must not request payment from DADS, and DADS does not pay, for services, goods, or items that:(1) include finance charges, interest, or assessed late fees or charges;(2) services, goods, or items that are delivered by a service provider who:(A) was not approved in writing by the CDSA before service delivery, even if the CDSA determines later that the service provider was eligible to deliver the service; or(B) was not eligible to provide the service at the time of delivery;(3) are available through another service within the individual's program;(4) are available through a non-program resource;(5) are not included in an approved budget before purchase or delivery of the service or item; or(6) the individual was not eligible for.(e) A CDSA must bill accrued funds either at the time the funds are paid or deposited by the CDSA.(f) A CDSA must make billing adjustments:(1) for payments received that:(A) have not been paid by the CDSA; and(B) are not due from the CDSA; and(2) when:(A) the service plan period ends;(B) the individual transfers to another CDSA; or(C) the individual terminates the CDS option.(g) A CDSA must ensure that payment of overtime pay for employees is calculated and paid in accordance with current state and federal laws and regulations for payment of overtime.(h) A CDSA must receive a copy of the documentation of services delivered dated by the service provider and the employer or DR before issuing a subsequent payment to the employee when the previous payment was based on a time sheet received in an electronic format through e-mail. Source Note: The provisions of this §264.337 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.337 Payment of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219775 03/12/2026 (a) An FMSA must maintain records to support claims submitted to HHSC and payments received from HHSC.(b) An FMSA must, in accordance with generally accepted accounting principles and HHSC requirements, document and maintain financial records, including:(1) deposit slips, bank statements, cancelled checks, and receipts;(2) purchase orders;(3) invoices;(4) journals and ledgers;(5) time sheets, payroll, and tax records;(6) records, forms, and reports required by the Internal Revenue Service, the Texas Workforce Commission, and other applicable government agencies;(7) insurance coverage related to staff persons, including claims and payments;(8) equipment inventory records;(9) the FMSA's internal accounting procedures; and(10) chart of accounts.(c) An FMSA must retain in an employer's record an initial intake report and a final investigative report received from HHSC and a completed HHSC Form 1719. Source Note: The provisions of this §264.339 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective September 1, 2014, 39 TexReg 6604; amended to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION C ENROLLMENT AND RESPONSIBILITIES OF FINANCIAL MANAGEMENT SERVICES AGENCIES (FMSAS) §264.339 Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219776 03/12/2026 The enrollment process is conducted in accordance with §41.109 of this chapter (relating to Enrollment in the CDS Option). Within five working days after receipt of a completed Form 1584, Consumer Participation Choice, by an eligible individual or LAR, or upon receipt of Form 1584 and within five working days after eligibility determination for an applicant applying for program services, a case manager or service coordinator must provide the following documentation to the CDSA:(1) Form 1584;(2) the individual's authorized service plan;(3) the individual's plan of care; and(4) if not provided in paragraph (1) - (3) of this section:(A) the date the employer may begin incurring expenses to initiate start-up activities and to incur recruitment and hiring expenses;(B) the date the employer may begin delivery of program services through the employer's service providers;(C) the number of units, the approved rate, or the amount authorized in the individual's service plan for each service to be delivered through the CDS option;(D) the total funds authorized for each program service to be delivered through the CDS option; and(E) the authorized schedule of service delivery per day, week, month, or other time frame specific to the service. Source Note: The provisions of this §264.401 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.401 Enrollment Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219780 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219780 03/12/2026 (a) An individual's CDSA must process a request by the individual or LAR to transfer from one CDSA to another CDSA in accordance with transfer procedures and requirements of the individual's program.(b) The transferring CDSA must, within five working days after receipt of a request to transfer:(1) account in writing for the funds allocated in the individual's service plan or plan of care and budgets and:(A) bill DADS for funds in the individual's budget that the CDSA must pay on behalf of the employer;(B) make payments within required time frames;(C) submit billing adjustments for prior claims and payments from DADS that will not be paid, or deposited by the CDSA for accrued funds, for:(i) deposits, withholdings, and employee and employer contributions; and(ii) a pending payment that will transfer to the receiving CDSA;(2) notify the employer and the individual's case manager or service coordinator in writing of the number of units and the amount of funds remaining in each budget after the scheduled transfer date;(3) transfer all employer-related and employer-agent related information and reports applicable to the individual's budgets, payroll, accrual amounts, and payables:(A) to the receiving CDSA at the time of transfer; and(B) to the receiving CDSA and the employer as received or filed by the transferring CDSA following the transfer;(4) distribute a final CDSA report in accordance with §41.317 of this chapter (relating to CDSA Reports) and provide the report to the employer, DR, case manager, service coordinator, and the receiving CDSA within five working days after the individual's transfer; and(5) submit a satisfaction survey to the employer or DR in accordance with §41.331 of this chapter (relating to Annual Evaluation of Job Performance and Satisfaction).(c) Within five working days after the receipt of a request to transfer, the case manager or service coordinator must:(1) process the individual's request to transfer from one CDSA to another CDSA in accordance with the requirements of the individual's program and this chapter;(2) calculate the number of units or amount of funds needed to complete the service plan period based on the individual's current service plan;(3) revise the service plan to indicate the number of units or amount of funds calculated in this subsection effective the date of transfer and:(A) approve only the units and funds calculated as needed if units and funds remaining in the budget meet or exceed the needed number or units or amount of funds to complete the service period, or approve only the amount remaining in the budget for the period remaining in the individual's service plan; and(B) provide a copy of the transferring service plan to the receiving CDSA and employer before the effective date of the transfer; and(4) provide a copy of the individual's revised service plan to the transferring CDSA, the receiving CDSA, and the employer or DR.(d) The employer or DR must provide documentation to the receiving CDSA within five working days after the transfer date to establish and maintain eligibility of each current employee, contractor, and vendor before the service provider being paid by the receiving CDSA. The employer or DR must also provide other documentation requested by the receiving CDSA.(e) The receiving CDSA must:(1) enroll the individual and employer with the CDSA, including registering the CDSA as the employer-agent within program transfer time frames; and(2) initiate FMS and employer-agent responsibilities in accordance with this chapter, including:(A) conducting an initial orientation in the individual's residence only if the current employer has not received an initial orientation from a CDSA;(B) entering into the required service agreement with the employer; and(C) obtaining the required DADS service agreements with each of the employer's service providers before issuing an initial payment to the service provider in accordance with §41.333 of this chapter (relating to Service Agreements). Source Note: The provisions of this §264.403 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.403 Transfer Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219781 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219781 03/12/2026 (a) A service planning team must determine if a service the individual is receiving through the CDS option is critical to the individual's health and safety.(b) The case manager or service coordinator must request and ensure that the employer or DR develop a service backup plan, using DADS Form 1740, CDS Service Backup Plan, if:(1) a service backup plan is required by the rules of the individual's program; or(2) the service planning team determines that a service is critical to the health and safety of the individual in accordance with subsection (a) of this section.(c) The case manager or service coordinator must approve a service backup plan, including a revised plan, before implementation by the employer or DR.(d) The case manager or service coordinator must review each service backup plan during monitoring and at the annual service plan meeting to determine if the plan was implemented and effective.(e) If, after a review required by subsection (d) of this section, the case manager or service coordinator determines the service backup plan was ineffective, the case manager or service coordinator must notify the employer or DR of the determination and that the employer must revise the service backup plan in accordance with §41.217(d)(4)(D) of this chapter (relating to Employer Responsibilities Regarding Service Backup Plan). Source Note: The provisions of this §264.404 adopted to be effective September 1, 2014, 39 TexReg 6604; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.404 Ensuring Development, Approval, and Review of Service Backup Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219782 03/12/2026 (a) An employer may request voluntary suspension of participation in the CDS option and request that all program services be delivered through a program provider at any time.(b) The suspension must last at least 90 calendar days.(c) The employer must notify the individual's case manager or service coordinator of intent to reactivate participation in the CDS option.(d) A CDSA must monitor an individual's program eligibility and notify the individual's case manager or service coordinator of a lapse of program eligibility.(e) The case manager or service coordinator must notify the individual's service planning team of the individual's loss of eligibility to determine if suspension of participation in the CDS option is recommended. If participation in the CDS option is suspended, the case manager or service coordinator must give notice to the individual or LAR in accordance with the requirements of the individual's program.(f) If participation in the CDS option is suspended, FMS and, if applicable, support consultation, are suspended in the individual's service plan. Source Note: The provisions of this §264.405 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.405 Suspension of Participation in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219785 03/12/2026 (a) An employer may request voluntary termination of participation in the CDS option and receive services through a program agency provider at any time. The termination must last at least 90 calendar days.(b) An individual may be involuntarily terminated from participation in the CDS option in accordance with the requirements of the individual's program.(c) FMS and, if applicable, support consultation, are terminated in the individual's service plan when participation in the CDS option is terminated.(d) An individual's case manager or service coordinator convenes the individual's service planning team concerning issues that may warrant immediate termination of the individual's participation in the CDS option. On review of the information, the service planning team may recommend immediate termination of participation in the CDS option when:(1) the individual's health or welfare is immediately jeopardized by the individual's participation in the CDS option;(2) the DR has been convicted of an offense under Chapter 32 of the Penal Code or an offense barring employment as listed in the Texas Health and Safety Code, §250.006(a) and (b); or(3) DADS or another government agency with applicable regulatory authority recommends that participation in the CDS option be immediately terminated.(e) If an individual, LAR, or DR does not implement and successfully complete the following steps and interventions, an individual's service planning team may recommend termination of participation in the CDS option in accordance with the individual's program requirements:(1) eliminate jeopardy to the individual's health or welfare;(2) successfully direct the delivery of program services through CDS;(3) meet employer responsibilities;(4) successfully implement corrective action plans; or(5) appoint a DR or access other available supports to assist the employer in meeting employer responsibilities.(f) Before a CDSA recommends involuntary termination of participation in the CDS option to an individual's case manager or service coordinator, the CDSA must:(1) provide documentation to the individual's case manager or service coordinator of additional and ongoing training and supports provided by the CDSA when an employer or DR demonstrates noncompliance with employer responsibilities;(2) provide assistance requested by the employer or DR to develop and implement a corrective action plan;(3) provide documentation of any corrective action plan required of the employer or DR by the CDSA in accordance with §41.221 of this chapter (relating to Corrective Action Plans); and(4) notify the case manager or service coordinator in writing in accordance with the requirements of the individual's program when recommending termination of an individual's participation in the CDS option.(g) On receipt of a recommendation for involuntary termination from the CDSA or other party, the individual's case manager or service coordinator must:(1) provide assistance with accessing supports and developing and implementing a corrective action plan related to noncompliance with program and CDS requirements;(2) document interventions utilized by the individual, employer, or DR to eliminate noncompliance with program requirements for delivery of program services through the CDS option; and(3) convene the service planning team to:(A) consider recommendations related to the individual's participation in the CDS option;(B) recommend additional interventions to be implemented to protect the individual's health and welfare for continued participation in the CDS option; and(C) make revisions to the individual's service plan if needed.(h) If the individual's service planning team recommends termination of participation in the CDS option, the CDSA must:(1) provide a final report as described in §41.219 of this chapter (relating to CDSA Reports) to the employer and the case manager or service coordinator within five working days after an individual's termination;(2) provide copies to the employer of documentation as received and filed on behalf of the employer following the individual's termination from the CDS option; and(3) submit a satisfaction survey to the employer within five working days after the termination date in accordance with §41.331 of this chapter (relating to Annual Evaluation of Job Performance and Satisfaction).(i) The individual's case manager or service coordinator must meet requirements of the individual's program and this chapter for termination of service to include documentation of all proceedings and notices in accordance with the individual's program requirements.(j) If the service planning team recommends terminating participation in the CDS option, an individual's case manager or service coordinator must document:(1) the reasons for the recommendation;(2) the conditions and time frame established by the individual's service planning team that the individual must meet prior to re-enrollment in the CDS option;(3) justification for any time period for a termination in excess of the minimum 90-day requirement; and(4) if applicable, the conditions and time frame specified by a hearing officer as the result of a fair hearing that upholds the termination.(k) When an individual's participation in the CDS option is terminated, the case manager or service coordinator must take steps and interventions in accordance with the requirements of the individual's program to:(1) ensure continuity of delivery of program services that were being delivered through the CDS option; and(2) document arrangements made for delivery of program services that were being delivered through the CDS option to be delivered by the individual's program provider or other resources. Source Note: The provisions of this §264.407 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2009, 33 TexReg 10509; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.407 Termination of Participation in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219786 03/12/2026 (a) Following suspension or termination of participation in the CDS option, an individual or LAR must request re-enrollment in the CDS option by notifying the individual's case manager or service coordinator.(b) If an individual or LAR wishes to re-enroll in the CDS option, the case manager or service coordinator must:(1) review the reason that the individual was suspended or terminated from the CDS option;(2) verify that the individual has fulfilled the minimum 90-day period and any conditions specified by the individual's service planning team or a hearing officer, if applicable;(3) verify how each issue that contributed to the suspension or termination has been resolved; and(4) refer the request for re-enrollment in the CDS option to the individual's service planning team and follow requirements of the individual's program, including:(A) revising the individual's service plan and re-enrolling the individual in the CDS option upon approval; and(B) issuing a denial and providing information related to requesting a fair hearing if the request is not approved.(c) If approved for re-enrollment, the CDSA must:(1) provide an initial orientation in accordance with §41.307 of this chapter (relating to Initial Orientation of an Employer) following the individual's re-enrollment in the CDS option if the current employer or DR has not received initial orientation; and(2) notify the employer, DR, and the individual's case manager or service coordinator in writing within two working days after any repeat of prior noncompliance or additional noncompliance with requirements of the individual's program or this chapter during the individual's participation in the CDS option. Source Note: The provisions of this §264.409 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION D ENROLLMENT, TRANSFER, SUSPENSION, AND TERMINATION §264.409 Re-enrollment for Participation in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219787 03/12/2026 (a) The employer or DR, with assistance obtained from the CDSA or others, must:(1) develop a budget for each program service to be delivered through the CDS option;(2) project expenditures of funds allocated in the individual's authorized service plan for the effective period of the service plan;(3) use applicable budget workbooks available through DADS at www.dads.state.tx.us/business/communitycare/cds/CDSforms.html;(4) request assistance from the CDSA as needed;(5) submit each budget to the CDSA for review; and(6) obtain written approval for each budget from the CDSA before initiating services or making purchases for payment.(b) The CDSA must:(1) provide assistance as requested or needed by the employer or DR to develop a budget for each service to be delivered through the CDS option;(2) use appropriate budget workbooks available through DADS to review, calculate, and validate each budget; and(3) provide written approval to the employer or DR of each budget before implementation. Source Note: The provisions of this §264.501 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.501 Budget Development https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219788 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219788 03/12/2026 An employer or DR must budget the amount established by the Health and Human Services Commission for payment of FMS delivered by the CDSA for each program service to be delivered through the CDS option. Source Note: The provisions of this §264.503 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.503 Financial Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219791 03/12/2026 (a) An employer or DR must, when developing a budget that includes payroll expenses for an employee: (1) budget to pay an employee who is a "personal attendant," as defined in 1 TAC §355.7051(a) (relating to Base Wage for a Personal Attendant), at least the base wage specified in 1 TAC §355.7051(c), (d)(2), or (f).(2) budget employee benefits, if chosen by the employer or DR: (A) as provided in: (i) this chapter; (ii) Section 1000, Wages and Benefits Plan, of the Consumer Directed Services Handbook available at http://www.dads.state.tx.us/handbooks/CDS/1000/index.htm; or (iii) Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook available at http://www.dads.state.tx.us/handbooks/CDS/appendix/XI/index.htm; (B) that are in accordance with requirements of the individual's program: (i) an allowable cost, as defined in §41.103 of this chapter (relating to Definitions); (ii) reasonable, with regard to the cost of the service, good, or item; and (iii) necessary to meet employer responsibilities; (C) that are within the approved rate and spending limits established for the service; (D) that are accrued and paid based on actual hours worked; and (E) that may include any of the following: (i) increased wages; (ii) paid vacation; (iii) paid holiday; (iv) paid sick leave; (v) medical insurance; (vi) taxable work-related expenses; (vii) coverage of work-related injuries or illnesses for employees, including workers' compensation or options listed in "Liability Notice to Applicants for Employment," Section II, of Form 1728, Liability Acknowledgment; (viii) a hire-on bonus, paid when an employee is hired, and the amount budgeted for the bonus must be accrued from hours worked by the person within the first three months of employment; (ix) a bonus, based on the employee's job performance, that is budgeted and accrued from hours worked as a portion of the budget unit rate from hours worked by the employee, not to extend beyond the end date of the individual's service plan; (x) a bonus, based on the employee's length of employment, with the employer, if budgeted and accrued as a portion of the budget unit rate from hours worked by the employee, not to extend beyond the end date of the individual's service plan; and (xi) employer contributions for employee benefits; (3) make budget revisions if necessary to compensate for payment of overtime pay that must be calculated and paid in accordance with current state and federal labor laws and regulations. (b) An employer or DR must: (1) complete, but not sign, Form 1730, Employee Wage and Benefits Plan, for each employee at the time of hire and when an employee's wages or benefits are being changed; (2) submit the form to the FMSA for approval; (3) obtain written approval from the FMSA; and (4) after FMSA approval, sign the form and obtain the employee's signature on Form 1730 on or before the employee's first day of work or the effective date of the change. (c) An FMSA must: (1) review the employer's budgeted payroll spending decisions; (2) review Form 1730 for each employee at time of hire and as revised by the employer or DR; (3) verify that each applicable budget workbook and Form 1730 is within the approved budget; (4) notify the employer in writing of the approval or disapproval of Form 1730 and work with the employer or DR to resolve those issues that prevent the approval of Form 1730; and(5) comply with 1 TAC §355.7051(c), (d)(2), or (f) (relating to Base Wage for a Personal Attendant). Source Note: The provisions of this §264.505 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective January 1, 2014, 38 TexReg 9630; amended to be effective September 1, 2015, 40 TexReg 5466; amended to be effective March 20, 2016, 41 TexReg 1925; amended to be effective May 10, 2020, 45 TexReg 2887; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.505 Payroll Budgeting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219792 03/12/2026 (a) An employer or DR may budget employer support services and start-up expenses, through the services that are delivered by one or more employees in the CDS option.(1) Employer support services:(A) include:(i) employment-related expenses, as described in subsection (d) of this section;(ii) employer-related expenses, as described in subsection (e) of this section; and(iii) support consultation services, as described in subsection (f) of this section when available in the individual's program; and(B) exclude non-allowable expenditures listed in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook available at http://www.dads.state.tx.us. (2) Start-up expenses must be:(A) budgeted for purchases projected before the delivery of services through the CDS option; and(B) accrued from the budgeted unit rate for services scheduled for delivery through the CDS option within the first three months of initiation of the CDS option.(b) An employer or DR:(1) may budget up to 10 percent of the amount available, after the FMSA portion is calculated, in those services delivered by one or more employees;(2) must not budget more than $600 annually or more than $50 per month if less than 12 months remain in the service plan for employer support services, including:(A) employment-related expenses; and(B) employer-related expenses;(3) must not budget more than the remaining amount of the 10 percent maximum for support consultation services; and (4) may budget any remaining amount in the affected program service for employee compensation.(c) An employer or DR must, for funds remaining in employer support services, budget the remaining funds to:(1) employee compensation (wages and benefits); or (2) with approval of the individual's service planning team, support consultation services in accordance with subsection (f) of this section and Subchapter F of this chapter (relating to Support Consultation Services and Support Advisor Responsibilities). (d) An employer or DR may budget allowable, necessary, and reasonable employment-related services, goods, or items, including: (1) recruiting expenses;(2) obtaining a criminal history report from the Texas Department of Public Safety, except for the report of an applicant or employee who is:(A) only providing CFC PAS/HAB; or(B) providing support consultation to an individual who is receiving only CFC PAS/HAB through the CDS option;(3) purchased employee job-specific training;(4) cardio-pulmonary resuscitation training;(5) first-aid training;(6) supplies required for an employee or provider of the service to perform a task, if not available through the individual's program or other source and the purchase is allowable through the individual's program;(7) non-taxable employee benefits; and(8) services, goods, and items specifically approved by the individual's program as an employer support service or included as allowable expenditures in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook available at http://www.dads.state.tx.us/handbooks/CDS/appendix/XI/index.htm. (e) An employer or DR may budget employer-related services, goods, or items required to meet employer responsibilities, including:(1) basic office equipment, which may include a basic fax machine for the purpose of submitting documents to the FMSA; (2) mailing costs; (3) expenses related to making copies;(4) file folders and envelopes; and(5) services, goods, and items specifically approved by the individual's program as an employer support service or included as allowable expenditures in Appendix XI, Allowable and Non-Allowable Expenditures, in the Consumer Directed Services Handbook. (f) If support consultation services are approved by the individual's service planning team, the employer or DR must budget the service within the spending limits in subsection (b) of this section for employer support services and obtain approval of the budget from the FMSA before implementation of the service.(g) An employer or DR must, before requesting additional funds available for support consultation:(1) provide the individual's case manager or service coordinator with justification for the specific services requested through support consultation;(2) verify with the case manager or service coordinator the availability of non-program resources for the requested service; and(3) obtain approval from the individual's service planning team for additional funds for support consultation in accordance with subsection (h) of this section.(h) If the service planning team approves additional funds for support consultation, the team must reallocate funds within the individual's service plan without increasing the total cost of the individual's service plan. Source Note: The provisions of this §264.507 adopted to be effective January 1, 2007, 31 TexReg 10352; amended to be effective March 20, 2016, 41 TexReg 1925; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.507 Employer Support Services Budgeting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219793 03/12/2026 (a) An employer or DR must, for each initial and annual budget:(1) request assistance from the CDSA as needed;(2) complete and modify budgets as directed by the CDSA; and(3) receive written approval from the CDSA before implementation of the budget and initiation of service delivery through the CDS option.(b) A CDSA must:(1) review each budget and notify the employer of any issue, spending limit, or of any services, goods, or items in the budget that prevent approval of the budget;(2) assist the employer or DR in developing and revising a budget so that the budget can be validated by the CDSA; and(3) provide written approval for each initial and annual budget to the employer. Source Note: The provisions of this §264.509 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.509 Budget Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219794 03/12/2026 (a) An employer or DR must make budget revisions if:(1) a change to the individual's authorized service plan affects funding for a program service delivered through the CDS option;(2) a budget has been or will be exceeded before the end date of the service plan;(3) authorized units, unit rate, or amount of funds allocated have changed;(4) an amount paid for one or more services, goods, or items affects the approved budget;(5) strategies are added or revisions are made to a service back-up plan;(6) funds budgeted for a service back-up plan are not used or needed; or(7) the CDSA, the case manager or service coordinator, the individual's service planning team, or a DADS representative require a revision.(b) An employer or DR must:(1) submit budget revisions to the CDSA for approval; and(2) not implement revised budgets until written approval is received from the CDSA.(c) A CDSA must:(1) provide assistance to the employer or DR related to budget revisions as requested or needed by the employer;(2) validate the budget; and(3) provide written approval to the employer or DR before the revision is implemented by the employer or DR. Source Note: The provisions of this §264.511 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION E BUDGETS §264.511 Budget Revisions and Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219799 03/12/2026 (a) Support consultation, if available through the individual's program, is an optional service available to an individual participating in the CDS option. Support consultation is delivered to:(1) an employer;(2) an employer's DR; or(3) an individual receiving services through the CDS option if that individual will be the employer within six months of the initiation of support consultation services to the individual.(b) Support consultation is provided by a person who meets the qualifications of a support advisor. A support advisor may be:(1) a contractor of the employer; or(2) an employee or contractor of:(A) a CDSA; or(B) another entity.(c) Support consultation must provide:(1) a level of training, assistance, and support that does not duplicate or replace the services delivered through FMS, case management services, or other available program or non-program service or resource;(2) practical skills training and assistance to successfully manage service providers for authorized program services delivered through the CDS option; and(3) skills training and assistance for:(A) recruiting, screening, and hiring workers;(B) developing and documenting job descriptions;(C) verifying employment eligibility and qualifications;(D) completing documents required to:(i) employ an individual;(ii) retain a contractor or vendor; and(iii) manage service providers;(E) communicating effectively, solving problems, and documenting employer responsibilities in the CDS option;(F) developing, revising, and implementing service back-up plans;(G) performing employer responsibilities;(H) complying with the individual's program and this chapter; and(I) developing ongoing decision making skills for employer-related and employment-related situations.(d) An employer or DR may budget and initiate support consultation services while the individual is participating in the CDS option. Before initiation of the service, the employer or DR must:(1) identify the person or persons (the employer, the DR, or the individual within six months after becoming the employer) to receive the service and establish goals specific to the service;(2) obtain approval of the goals established for the service from the individual's service planning team;(3) develop a budget for support consultation; and(4) obtain approval of the budget from the CDSA.(e) An employer or DR, a case manager or service coordinator, a CDSA, or a DADS representative may recommend that the individual's service planning team approve support consultation services for an individual if:(1) the individual receiving services through the CDS option will become the employer within six months after the service is initiated;(2) the employer or DR demonstrate a need for the service;(3) the individual's health and welfare may regress without additional support for managing and directing service providers; or(4) other reasons that the service planning team has determined justify the need for the service.(f) If the individual's service planning team authorizes support consultation, the team must:(1) approve the funds, the duration, and the frequency of the service;(2) assist with development of goals and ensure that the activities required to meet the goals through support consultation comply with this chapter;(3) approve the goals for support consultation and the person or persons who will receive the service (the individual, employer, or DR); and(4) terminate the service when goals are met. Source Note: The provisions of this §264.601 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION F SUPPORT CONSULTATION SERVICES AND SUPPORT ADVISORY RESPONSIBILITIES §264.601 Support Consultation Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219800 03/12/2026 (a) A person must meet the following qualifications to be eligible to deliver support consultation as a support advisor:(1) be:(A) at least 18 years old;(B) a high school graduate or posses certification of equivalency; and(C) a person who does not provide a program service to the individual, other than support consultation and FMS through the CDS option;(2) have documentation of attendance and completion of:(A) initial training required by and conducted or authorized by DADS; and(B) ongoing training if required by and conducted or authorized by DADS;(3) meet criteria of:(A) §41.225 of this chapter (relating to Criminal Conviction History Checks);(B) §41.227 of this chapter (relating to Required Registry Checks);(C) §41.231 of this chapter (relating to Verification of Eligibility of an Employee or Contractor) if contracted by the employer; and(D) requirements of the individual's program when applicable; and(4) be:(A) retained by the employer; or(B) an employee or contractor of:(i) a CDSA; or(ii) another entity.(b) To provide support consultation as a support advisor, a person must demonstrate competency in the delivery of support consultation services as determined by DADS. To be a support advisor, the person must demonstrate competency to DADS in:(1) principles of self-determination;(2) the provisions of this chapter;(3) the provisions and requirements of DADS home and community-based programs offering the CDS option, including:(A) the scope and definition of services provided by each program;(B) requirements for documentation of service delivery;(C) allowable and non-allowable expenditures; and(D) the application of CDS in each program;(4) methods for accessing information and resources timely through government agencies, including DADS, related to the CDS option and employer responsibilities;(5) documentation requirements to meet employer responsibilities; and(6) roles and responsibilities of:(A) the support advisor;(B) the CDSA;(C) the case manager or service coordinator;(D) the individual receiving services;(E) the employer;(F) service providers;(G) the DR; and(H) traditional program providers and agencies.(c) An employer or DR must not retain a support advisor applicant for service delivery before:(1) receiving authorization for support consultation by the individual's service planning team;(2) obtaining written approval from the CDSA of the budget for funds for the service; and(3) obtaining written approval from the CDSA of the applicant's eligibility.(d) An employer or DR must ensure that a support advisor meets the service provider requirements of this chapter, including:(1) obtaining documentation required to verify the applicant's qualifications and eligibility to provide support consultation services; and(A) submit documentation to the CDSA for review of the person's eligibility;(B) obtaining approval from the CDSA of the person's eligibility to provide support consultation services; and(C) maintaining documentation to verify continued eligibility during service delivery;(2) entering into a service agreement with the contractor using the appropriate DADS form;(3) assisting the CDSA in obtaining a completed service agreement between the support advisor and the CDSA before initial payment for delivery of services; and(4) retaining documentation of services delivered by the contractor.(e) Upon retaining a support advisor employed by or contracted with a CDSA or an entity, the employer must obtain from the CDSA or the entity documentation required to verify the individual's qualifications and ongoing eligibility to provide support consultation services. Source Note: The provisions of this §264.603 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION F SUPPORT CONSULTATION SERVICES AND SUPPORT ADVISORY RESPONSIBILITIES §264.603 Support Advisor Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219801 03/12/2026 (a) A support advisor must provide practical skills training in accordance with the individual's service plan, including:(1) principles of self-determination;(2) compliance requirements of the individual's program as related to services delivered through the CDS option;(3) completion of forms, assessments, and other documents required for the individual's program that require individual or LAR input or completion;(4) recruiting, screening, and hiring workers, preparing job descriptions, verifying employment eligibility and qualifications, and training for employees;(5) completion of documents required to employ an individual, retain a contractor or vendor, and manage service providers;(6) recruitment and procurement of employees, contractors, and vendors;(7) negotiations of service agreements, including pricing and scheduling of services, goods, and items;(8) management of service providers for authorized program services delivered through the CDS option;(9) effective communication, decision making, and problem-solving skills to meet employer responsibilities;(10) development, revision, and implementation of service back-up plans;(11) compliance with the individual's program and this chapter;(12) tools for accessing information, resources, and assistance timely through government agencies, including DADS, as needed through means available to the individual, employer, or DR;(13) contacting appropriate persons or entities based on their roles, responsibilities, and eligibility related to the individual's program or the CDS option, including:(A) a case manager or service coordinator;(B) potential and current service providers, including:(i) an employee;(ii) a contractor;(iii) a vendor;(iv) a CDSA; and(v) a support advisor;(C) traditional program provider agencies;(D) government agencies, including DADS and the Department of Family and Protective (DFPS); and(E) the employer, the individual, and the DR; and(14) ongoing employer-related skills.(b) A support advisor must provide assistance, as required in accordance with the individual's service plan, including:(1) completing forms, assessments, and other documents required by the individual's program that require individual or LAR input or completion;(2) recruiting, screening, and hiring workers, preparing job descriptions, verifying employment eligibility, qualifications, and training for employees;(3) completing documents required to employ an individual, retain a contractor or vendor, or managing service providers;(4) recruiting and retaining employees, contractors, and vendors;(5) negotiating service agreements, including pricing and scheduling of services, goods, and items;(6) managing service providers for authorized program services delivered through the CDS option;(7) helping an individual to meet employer responsibilities by using effective communication, decision making, and problem-solving skills;(8) developing, revising, and implementing service back-up plans;(9) accessing information, resources, and assistance through government agencies, including DADS, as needed through means available to the individual, employer, or DR;(10) contacting appropriate persons or entities based on their roles, responsibilities, and eligibility related to the individual's program or the CDS option, including:(A) a case manager or service coordinator;(B) potential and current service providers including:(i) an employee;(ii) a contractor;(iii) a vendor;(iv) a CDSA; or(v) a support advisor;(C) traditional program provider agencies;(D) government agencies, including DADS and DFPS; and(E) the employer, the individual, and the DR; and(11) ongoing employer-related skills.(c) A support advisor must document service delivery in accordance with the requirements of the individual's program.(d) A support advisor must notify the individual's case manager or service coordinator:(1) when service goals have been met;(2) if the person receiving support consultation is unable or unwilling to cooperate with service delivery; or(3) of the progress and status of the service required by the individual's program. Source Note: The provisions of this §264.605 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION F SUPPORT CONSULTATION SERVICES AND SUPPORT ADVISORY RESPONSIBILITIES §264.605 Support Advisor Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219802 03/12/2026 (a) If an employer or DR knows or suspects that an individual is being or has been abused, neglected, or exploited, the employer or DR must:(1) report the knowledge or suspicion to DFPS:(A) for an individual who is in the HCS Program or TxHmL Program, immediately, but not later than one hour, after having knowledge or suspicion by:(i) calling the toll-free telephone number, 1-800-647-7418; or(ii) using the DFPS website; or(B) for an individual who is in the DBMD Program, CLASS Program, PHC Program, CAS Program, or FC Program, immediately, but not later than 24 hours, after having knowledge or suspicion by:(i) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(ii) using the DFPS Abuse Hotline website;(2) take actions to secure the safety of the individual;(3) obtain immediate and ongoing medical or psychological services for the individual as necessary;(4) when taking the actions described in paragraphs (2) and (3) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(5) preserve and protect evidence related to the allegation.(b) An employer or DR must ensure a service provider who knows or suspects that an individual is being or has been abused, neglected, or exploited, complies with the reporting requirement in subsection (a)(1)(A) or (B) of this section.(c) If an FMSA, a staff person, or a controlling person knows or suspects that an individual is being or has been abused, neglected, or exploited, the FMSA must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to DFPS:(1) for an individual who is in the HCS Program or TxHmL Program, immediately, but not later than one hour, after having knowledge or suspicion by:(A) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-647-7418; or(B) using the DFPS Abuse Hotline website; or(2) for an individual who is in the DBMD Program, CLASS Program, PHC Program, CAS Program, or FC Program, immediately, but not later than 24 hours, after having knowledge or suspicion by:(A) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(B) using the DFPS Abuse Hotline website. Source Note: The provisions of this §264.701 adopted to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION G ALLEGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION §264.701 Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219803 03/12/2026 (a) If a report required by §41.701(a) or (b) of this subchapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation by a service provider; or if an employer, DR, or FMSA is notified by HHSC of an allegation of abuse, neglect, or exploitation by a service provider:(1) the employer or DR must:(A) obtain immediate and ongoing medical or psychological services for the individual as necessary;(B) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual until HHSC completes the investigation; and(C) when taking the actions described in paragraphs (A) and (B) of this subsection, avoid compromising the investigation or further traumatizing the individual;(D) preserve and protect evidence related to the allegation, including timesheets and other employee-related documentation;(E) cooperate with the HHSC investigation as requested by HHSC, including providing documentation and participating in an interview; and(F) ensure that service providers comply with subparagraphs (C) and (D) of this paragraph; and(2) the FMSA must:(A) preserve and protect evidence related to the allegation, including timesheets and other employee-related documentation;(B) cooperate with the HHSC investigation as requested by HHSC, including providing documentation and participating in an interview; and(C) ensure that staff persons and controlling persons comply with subparagraphs (A) and (B) of this paragraph.(b) Within one working day after receiving the initial intake report from HHSC for an allegation of abuse, neglect, or exploitation described in subsection (a) of this section, the FMSA must send a copy of the report by fax or secure email to:(1) the program director of the entity employing the individual's case manager for an individual enrolled in the CLASS Program or the DBMD Program;(2) the rights protection officer, as required by §4.113 of this title (relating to Rights Protection Officer at a State MR Facility or MRA), of the LIDDA employing the individual's service coordinator for an individual enrolled in the HCS Program or the TxHmL Program; or(3) the individual's HHSC regional office for an individual enrolled in the PHC Program, the CAS Program, or the FC Program.(c) For an individual enrolled in:(1) the DBMD Program or CLASS Program, a program director is required to give the initial intake report received from the individual's FMSA to the individual's case manager as described in §42.401 of this title (relating to Protection of Individual) or §45.702 of this title (relating to Protection of Individual, Initial and Annual Explanations, and Offering Access to Other Services); or(2) the HCS Program or TxHmL Program, a rights protection officer is required to give the initial intake report received from the individual's FMSA to the individual's service coordinator as described in §9.190 of this title (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program) or §9.583 of this title (relating to TxHmL Program Principles for LIDDAs).(d) A case manager or service coordinator who receives an initial intake report must:(1) within four working days after receiving the report, convene a service planning team meeting in person or by phone to review the report and discuss the actions the employer has taken or will take to protect the individual during the HHSC investigation, which may include:(A) if a service backup plan is required by §41.404 of this title (relating to Ensuring Development, Approval, and Review of Service Backup Plans), implementing the service backup plan to have a person other than the alleged perpetrator provide services; and(B) requesting a voluntary suspension of participation in the CDS option in accordance with §41.405 of this chapter (relating to Suspension of Participation in the CDS Option);(2) document in writing any actions that have been or will be taken as a result of the allegation; and(3) if appropriate, recommend termination of the CDS option in accordance with §41.407 of this chapter (relating to Termination of Participation in the CDS Option).(e) After receiving a final investigative report from HHSC for an allegation of abuse, neglect, or exploitation described in subsection (a) of this section, the FMSA must:(1) within one working day after receiving the report, send a copy of the report by fax or secure email to:(A) the program director of the entity employing the individual's case manager for an individual enrolled in the CLASS Program or the DBMD Program;(B) the rights protection officer, as required by §4.113 of this title, of the LIDDA employing the individual's service coordinator for an individual enrolled in the HCS Program or the TxHmL Program; or(C) the individual's HHSC regional office for an individual enrolled in the PHC Program, the CAS Program, or the FC Program; and(2) within five working days after receiving the report:(A) use the report to complete HHSC Form 1719, Notification of Investigatory Findings; and(B) send the completed form to the alleged perpetrator.(f) For an individual enrolled in:(1) the DBMD Program or CLASS Program, a program director is required to give the final investigative report received from the individual's FMSA to the individual's case manager as described in §42.401 of this title or §45.702 of this title; or(2) the HCS Program or TxHmL Program, a rights protection officer is required to give the final investigative report received from the individual's FMSA to the individual's service coordinator as described in §9.190 of this title or §9.583 of this title.(g) If the final investigative report confirms the allegation, contains an inconclusive finding, or includes concerns and recommendations, the case manager or service coordinator:(1) must:(A) within four working days after receiving the report, convene a service planning team meeting in person or by phone to discuss the content of the report, including any concerns and recommendations by HHSC; and(B) document in writing any actions that have been or will be taken by the employer as a result of the findings in the report or the concerns and recommendations by HHSC; and(2) if appropriate, recommend termination of the CDS option, in accordance with §41.407 of this chapter. Source Note: The provisions of this §264.702 adopted to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION G ALLEGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION §264.702 Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Service Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219804 03/12/2026 (a) If a report required by §41.701(c) of this subchapter (relating to Reporting Allegations of Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation of an individual by a staff person or a controlling person; or if an FMSA is notified by HHSC of an allegation of abuse, neglect, or exploitation by a staff person or a controlling person, the FMSA must:(1) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual receiving services from the FMSA until HHSC completes the investigation; and(2) preserve and protect evidence related to the allegation.(b) Within one working day after receiving the initial intake report from HHSC for an allegation of abuse, neglect, or exploitation described in subsection (a) of this section, the FMSA must send a copy of the report by fax or secure email to:(1) the program director of the entity employing the individual's case manager for an individual enrolled in the CLASS Program or the DBMD Program;(2) the rights protection officer, as required by §4.113 of this title (relating to Rights Protection Officer at a State MR Facility or MRA), of the LIDDA employing the individual's service coordinator for an individual enrolled in the HCS Program or the TxHmL Program; or(3) the individual's HHSC regional office for an individual enrolled in the PHC Program, the CAS Program, or the FC Program.(c) During an HHSC investigation of an alleged perpetrator who is a staff person or controlling person:(1) an FMSA must:(A) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(B) provide HHSC access to:(i) sites owned, operated, or controlled by the FMSA;(ii) staff persons and controlling persons; and(iii) records pertinent to the investigation of the allegation; and(C) ensure that staff persons and controlling persons comply with subparagraphs (A) and (B) of this paragraph; and(2) the employer or DR must:(A) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(B) provide HHSC access to:(i) service providers; and(ii) records pertinent to the investigation of the allegation; and(C) ensure that service providers comply with subparagraph (A) of this paragraph.(d) For an individual enrolled in:(1) the DBMD Program or CLASS Program, a program director is required to give the initial intake report received from the individual's FMSA to the individual's case manager as described in §42.401 of this title (relating to Protection of Individual) or §45.702 of this title (relating to Protection of Individual, Initial and Annual Explanations, and Offering Access to Other Services); or(2) the HCS Program or TxHmL Program, a rights protection officer is required to give the initial intake report received from the individual's FMSA to the individual's service coordinator as described in §9.190 of this title (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program) or §9.583 of this title (relating to TxHmL Program Principles for LIDDAs).(e) A case manager or service coordinator who receives an initial intake report must:(1) within four working days after receiving the report, convene a service planning team meeting in person or by phone to review the report and discuss the actions the employer has taken or will take, which may include:(A) transferring to a different FMSA in accordance with §41.403 of this chapter (relating to Transfer Process) to protect the individual during the HHSC investigation; and(B) requesting a voluntary suspension of participation in the CDS option in accordance with §41.405 of this chapter (relating to Suspension of Participation in the CDS Option);(2) document in writing any actions that have been or will be taken as a result of the allegation; and(3) if appropriate, recommend termination of the CDS option in accordance with §41.407 of this chapter (relating to Termination of Participation in the CDS Option).(f) After an FMSA receives a final investigative report from HHSC for an investigation described in subsection (c) of this section, the FMSA must:(1) within one working day after receiving the report, send a copy of the report by fax or secure email to:(A) the program director of the entity employing the individual's case manager for an individual enrolled in the CLASS Program or the DBMD Program;(B) the rights protection officer, as required by §4.113 of this title, of the LIDDA employing the individual's service coordinator for an individual enrolled in the HCS Program or the TxHmL Program; or(C) the individual's HHSC regional office for an individual enrolled in the PHC Program, the CAS Program, or the FC Program; and(2) within five working days after receiving the report:(A) use the report to complete HHSC Form 1719, Notification of Investigatory Findings;(B) send the completed form to the alleged perpetrator; and(C) take action within the FMSA's authority in response to the HHSC investigation, including, disciplinary action against a staff person confirmed to have committed abuse, neglect, or exploitation.(g) For an individual enrolled in:(1) the DBMD Program or CLASS Program, a program director is required to give the final investigative report received from the individual's FMSA to the individual's case manager as described in §42.401 of this title or §45.702 of this title; or(2) the HCS Program or TxHmL Program, a rights protection officer is required to give the final investigative report received from the individual's FMSA to the individual's service coordinator as described in §9.190 of this title or §9.583 of this title.(h) If a final investigative report confirms the allegation, contains an inconclusive finding, or includes concerns and recommendations, a case manager or service coordinator must:(1) within four working days after receiving the report, convene a service planning team meeting in person or by phone to discuss the content of the report, including any concerns and recommendations by HHSC; and(2) document in writing any actions that have been or will be taken by the employer as a result of the findings in the report or the concerns and recommendations by HHSC.(i) An FMSA must not retaliate against:(1) a staff person, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations.(j) At least annually, an FMSA must review all final investigative reports from HHSC for investigations described in subsection (c) of this section and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of FMS. Source Note: The provisions of this §264.703 adopted to be effective October 1, 2019, 44 TexReg 5074; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION G ALLEGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION §264.703 Requirements Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of an FMSA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219805 03/12/2026 DADS oversees roles and responsibilities of the following:(1) an individual or LAR who elects to be the employer for services delivered through the CDS option;(2) a DR;(3) a CDSA;(4) a support advisor;(5) a service provider;(6) a case manager; and(7) a service coordinator. Source Note: The provisions of this §264.801 adopted to be effective January 1, 2007, 31 TexReg 10352; transferred effective September 1, 2024, as published in the July 12, 2024, issue of the Texas Register, 49 TexReg 5177. 1 HEALTH AND HUMAN SERVICES COMMISSION 264 CONSUMER DIRECTED SERVICES OPTION H OVERSIGHT §264.801 Oversight https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218975 03/12/2026 This chapter describes:(1) the SRO available to an individual or the individual's LAR;(2) the process for enrollment and participation of an individual in the SRO;(3) the responsibilities and requirements of an individual, LAR, or representative participating in the SRO;(4) the responsibilities and requirements of a person or entity providing services under the SRO; and(5) the people and entities DADS oversees in the SRO. Source Note: The provisions of this §265.1 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION A INTRODUCTION §265.1 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218976 03/12/2026 This chapter applies to the following:(1) an individual or LAR who elects to manage services delivered through the SRO;(2) a representative;(3) an SRO provider;(4) a support advisor;(5) a service provider; and(6) a case manager or service coordinator. Source Note: The provisions of this §265.2 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION A INTRODUCTION §265.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218977 03/12/2026 (a) SRO is a service delivery option available to an individual or LAR who wants some control over the individual's service providers but does not want to assume all employer responsibilities, as required by the CDS option.(b) In the SRO, the individual, LAR, or representative selects, trains, and supervises a service provider, while payroll and personnel functions remain with the SRO provider.(c) DADS offers the SRO at the same time as the CDS option. Source Note: The provisions of this §265.3 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION A INTRODUCTION §265.3 Overview of the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218978 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:(1) Adult--A person who is 18 years of age or older.(2) Applicant--Depending on the context, an applicant is:(A) a person applying for employment with an SRO provider;(B) a person or legal entity applying for a contract with an SRO provider to deliver services to an individual; or(C) a person applying for services through a program.(3) Case manager--A person who provides case management services to an individual. The case manager assists an individual who receives program services in gaining access to needed services, regardless of the funding source for the services, and assists with other duties as required by the individual's program.(4) CDS option--Consumer Directed Services option. A service delivery option in which an individual or LAR employs and retains service providers and directs the delivery of program services as described in Chapter 41 of this title (relating to Consumer Directed Services Option).(5) DADS--The Department of Aging and Disability Services.(6) Entity--An organization that has a legal identity such as a corporation, limited partnership, limited liability company, professional association, or cooperative.(7) FMSA--Financial management services agency. An entity that contracts with DADS to provide financial management services, as defined in §41.103 of this title (relating to Definitions).(8) Individual--A person enrolled in a program.(9) LAR--Legally authorized representative. A person authorized or required by law to act on behalf of an individual with regard to a matter described in this chapter, including a parent, guardian, managing conservator of a minor, or the guardian of an adult.(10) Management agreement--A negotiated agreement between an individual and an SRO provider that establishes each party's responsibilities to create and sustain quality services. A management agreement also establishes a schedule for the individual or LAR and the SRO provider to meet to assess the individual's well-being and the quality of services provided.(11) Program--A community services program administered by DADS.(12) Provider--An entity that has a contract with DADS to provide program services.(13) Representative--A willing adult who volunteers to assist an individual or LAR with selection, training, and daily management of a service provider.(14) Service back-up plan--A documented plan to ensure that critical program services delivered through the SRO are provided to an individual when normal service delivery is interrupted.(15) Service coordinator--An employee of a mental retardation authority who is responsible for assisting an applicant, individual, or LAR to access needed medical, social, educational, and other appropriate services, including program services. A service coordinator provides case management services to an individual.(16) Service plan--A document developed in accordance with rules governing an individual's program to identify the program services to be provided to the individual, the number of units of each service to be provided, and the projected cost of each service.(17) Service planning team--A group of people determined by the requirements of an individual's program that meet to discuss and make decisions or recommendations regarding an individual's program services. Some programs refer to the service planning team as an interdisciplinary team.(18) Service provider--An employee, contractor, or vendor of the SRO provider.(19) SRO--Service responsibility option. A service delivery option in which an individual or LAR selects, trains, and provides daily management of a service provider, while the fiscal, personnel, and service back-up plan responsibilities remain with an SRO provider.(20) SRO orientation--A mandatory training provided by a support advisor to inform an individual or LAR about SRO responsibilities and tools to use for successful management of the SRO.(21) SRO provider--A provider who volunteers to enroll as an SRO provider and amend its program services contract to allow an individual receiving one or more services from the provider to have a service delivered through SRO.(22) Support advisor--A person who provides support consultation to an employer, representative, or individual receiving services through the SRO.(23) Support consultation--A service provided by a support advisor that provides the required SRO orientation and additional support when needed by the individual to effectively carry out responsibilities under the SRO. Support consultation helps an individual or LAR meet the required daily management responsibilities of the SRO. Source Note: The provisions of this §265.4 adopted to be effective January 1, 2009, 33 TexReg 10510; amended to be effective September 1, 2014, 39 TexReg 6629; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION A INTRODUCTION §265.4 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218979 03/12/2026 (a) At the time an individual chooses to participate in the SRO, and, at least annually thereafter, a case manager, service coordinator, or other person designated by the individual's program must: (1) provide the individual or LAR a copy of DADS' Service Responsibility Option Roles and Responsibilities form, the It's Your Choice brochure, and DADS' Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option form; (2) provide an oral explanation of the information contained in the Service Responsibility Option Roles and Responsibilities and Acknowledgement of Information Regarding Support Consultation Services in the Consumer Directed Services (CDS) Option forms to the applicant or LAR; (3) document the individual's choice on DADS' Consumer Participation Choice form; (4) present the SRO provider list and the support advisor list to the individual; (5) instruct the individual to contact the selected support advisor within one day after the individual signs DADS' Consumer Participation Choice form; and (6) document the individual's SRO provider and support advisor on DADS' Consumer Participation Choice form. (b) An individual or LAR may request that a case manager, service coordinator, or other person designated by the individual's program provide additional information to the individual or LAR regarding the SRO or assist with enrollment in the SRO at any time. The case manager, service coordinator, or designee must comply within five working days after receipt of the request. (c) An individual or LAR who initially declines participation may elect to participate in the SRO at any time if the individual's program offers the SRO. (d) The case manager or service coordinator will notify the SRO provider in the same manner as a program provider is notified of selection as directed by program rules and policy. Source Note: The provisions of this §265.11 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.11 Enrollment in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218980 03/12/2026 (a) A case manager, service coordinator, or other person designated by the individual's program completes service planning in the SRO in the same manner as services delivered through a program provider.(b) A service plan must identify and document:(1) an individual's services;(2) an individual's service needs;(3) an individual's service levels;(4) changes to the service plan, including an explanation of a change;(5) that the service plan does not exceed the individual's costs caps and cost limits; and(6) the approval for planned services. Source Note: The provisions of this §265.12 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.12 Service Planning in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218981 03/12/2026 (a) Upon choosing to participate in the SRO and before the first meeting with an SRO provider, an individual or LAR must complete the SRO orientation. (b) During the SRO orientation, the individual or LAR must complete: (1) DADS' SRO Self-Assessment Checklist to identify additional training and other support needed to ensure the individual's success in daily management of services; (2) DADS' SRO Roles and Responsibilities Agreement; (3) DADS' Planning For Success and the Risk Planning Checklist to identify informal supports to be included in the individual's service back-up plan; (4) a service back-up plan for critical services containing specific strategies, the sequence of activities, and service back-up plan contact information; (5) a review of the resources available to an individual participating in the SRO; (6) a review of the responsibility for potential liability if the individual or service provider is injured while doing tasks under the individual's training and supervision; (7) a review of the management agreement that will be negotiated with the SRO provider; (8) a checklist of the characteristics and skills an SRO provider will seek in a potential service provider; and (9) documentation that an individual is choosing a representative and the specific management tasks the representative will assume. (c) The individual or LAR must have the completed forms at the initial meeting with the SRO provider. Source Note: The provisions of this §265.13 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.13 SRO Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218982 03/12/2026 (a) At the initial meeting with the SRO provider, the individual or LAR presents the service back-up plan to the SRO provider that includes:(1) specific back-up plan strategies;(2) the specific steps to implement each strategy, including contact with the SRO provider; and(3) the contact information for each person or entity listed in the service back-up plan.(b) The SRO provider and the individual must mutually approve the service back-up plan.(c) The individual must notify the SRO provider if the service provider is unable to provide services.(d) If a service provider is unable to provide services, an individual must:(1) implement the service back-up plan;(2) request a back-up service provider from the SRO provider; or(3) inform the SRO provider that services will not be needed. Source Note: The provisions of this §265.14 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.14 Service Back-up Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218983 03/12/2026 (a) At the initial meeting with an SRO provider, an individual or LAR and the SRO provider must negotiate a management agreement that establishes:(1) the responsibilities of the individual and the SRO provider;(2) how often quality assurance visits will occur; and(3) how often quality assurance phone contacts will occur.(b) The management agreement must be updated and documented at least annually.(c) The meeting schedule specified in the management agreement replaces the program-required supervisory visits. Source Note: The provisions of this §265.15 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.15 Management Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218984 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218984 03/12/2026 (a) A potential service provider must pass the pre-employment screenings, including criminal history and registry checks, conducted by an SRO provider in order to be eligible to be selected as a service provider.(b) An individual, LAR, or representative interviews and selects service providers who:(1) have been recommended by the individual; or(2) are currently employed by the SRO provider and match the skills and traits identified by the individual during the SRO orientation.(c) The individual must notify the SRO provider of the individual's choice of service providers no later than one day following the last interview conducted.(d) If the individual has not selected a service provider, and up to three potential service providers have been sent within the period prior to service initiation in accordance with the individual's program rules and policy, the case manager or service coordinator must call a service planning team meeting to determine what additional supports and education from the support advisor might help the individual select a service provider. Source Note: The provisions of this §265.16 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.16 Service Provider Selection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218985 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218985 03/12/2026 (a) At or before the time a service provider starts delivering services, an individual, LAR or representative must train the selected service provider on the specific manner in which the individual prefers the approved tasks in the service plan to be delivered.(b) If negotiated with an individual, an SRO provider may assist with the service provider orientation in the individual's home.(c) An individual must document the service provider orientation, including:(1) the tasks to be performed;(2) the training aspects specific to the needs of the individual;(3) the date on which orientation was completed;(4) any scheduled follow-up training to be conducted; and(5) an evaluation of the orientation.(d) The individual must provide documentation of the service provider orientation to the SRO provider within 14 calendar days after the completion of the orientation. Source Note: The provisions of this §265.17 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.17 Service Provider Orientation Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218986 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218986 03/12/2026 (a) An individual, LAR, or representative who chooses to participate in the SRO serves as the daily manager of service delivery, including scheduling and managing a service provider.(b) The individual who chooses to participate in the SRO must ensure the service provider is following the service plan, including:(1) ensuring and verifying that the service provider does only the tasks listed in the service plan and works only the number of hours listed in the service plan;(2) complying with SRO provider policies, including payroll policies;(3) reviewing, approving, and signing service provider time sheets; and(4) ensuring that the service provider submits time sheets to the SRO provider within the required time frames. Source Note: The provisions of this §265.18 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.18 Individual Responsibilities in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218987 03/12/2026 An individual, LAR, or representative must:(1) evaluate a service provider's job performance at the time designated by the SRO provider; and(2) document and submit each performance evaluation to the SRO provider. Source Note: The provisions of this §265.19 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION B RESPONSIBILITIES OF INDIVIDUALS CHOOSING TO PARTICIPATE IN THE SRO §265.19 Supervision and Evaluation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218988 03/12/2026 To become an SRO provider, a provider must:(1) have a current program contract with DADS;(2) request a contract amendment to the program contract that allows an individual receiving one or more services from the provider to have a service delivered through SRO; and(3) have at least one person employed by the provider attend and complete the SRO training authorized by DADS. Source Note: The provisions of this §265.21 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION C RESPONSIBILITIES OF AN SRO PROVIDER §265.21 Contracting as an SRO Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218989 03/12/2026 (a) At the initial meeting with an individual, an SRO provider must:(1) negotiate a management agreement with the individual;(2) discuss and approve a service back-up plan with the individual;(3) provide SRO provider time sheets to the individual and explain the submission process, including how frequently time sheets must be completed and submitted; and(4) orient the individual to the SRO provider's evaluation process, including forms and the schedule for evaluating service providers.(b) During service provider selection, the SRO provider must:(1) screen a potential service provider, including conducting criminal history and registry checks in accordance with §49.304 of this title (relating to Background Checks); and(2) send potential service providers, including those recommended by the individual, to the individual to interview.(c) When the individual has selected a service provider, the SRO provider must:(1) explain the SRO to the service provider, including that the SRO provider is the employer of record and that the individual is the daily manager of services;(2) explain to the service provider that if the service provider has health or safety concerns about the individual and cannot resolve the issue after talking with the individual, the service provider must contact the SRO provider; and(3) provide basic training and orientation to service providers regarding comprehensive precautions, SRO provider policies, complaint procedures, and emergency procedures.(d) After services have begun, the SRO provider must:(1) receive and process time sheets from the service provider;(2) send a back-up service provider, within the time frame required by an individual's program, if requested by the individual or if the individual does not implement the service back-up plan; and(3) send new potential service providers, within the time frame required by an individual's program, to interview at the individual's request.(e) The SRO provider must:(1) notify a case manager or service coordinator of issues or concerns related to an individual's participation in the SRO:(A) immediately if possible, but at least within 24 hours after becoming aware of:(i) allegations of abuse, neglect, exploitation, or fraud; or(ii) concerns about the individual's health, safety, or welfare; and(B) within seven days after becoming aware of:(i) non-delivery of services or extended breaks in services;(ii) noncompliance with SRO management responsibilities;(iii) noncompliance with a service back-up plan; or(iv) over- or under-utilization of services or funds allocated in the individual's service plan for delivery of services to the individual through the SRO and in accordance with the requirements of the individual's program; and(2) document any issues or concerns related to an individual's participation in the SRO on DADS' Case Information form. Source Note: The provisions of this §265.22 adopted to be effective January 1, 2009, 33 TexReg 10510; amended to be effective September 1, 2014, 39 TexReg 6629; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION C RESPONSIBILITIES OF AN SRO PROVIDER §265.22 SRO Provider Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218990 03/12/2026 (a) An individual may request voluntary termination of participation in the SRO at any time.(b) A case manager or service coordinator must terminate support consultation in the individual's service plan when participation in the SRO is terminated.(c) The termination must last at least 90 calendar days before the individual may be considered for re-enrollment in the SRO. Source Note: The provisions of this §265.31 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION D TERMINATION OF THE SRO §265.31 Voluntary Termination of Participation in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218991 03/12/2026 (a) A case manager or service coordinator may involuntarily terminate an individual from participation in the SRO, in accordance with the requirements of the individual's program, in any of the following situations:(1) non-delivery of services or extended breaks in services;(2) noncompliance with SRO management responsibilities;(3) noncompliance with a service back-up plan; or(4) over- or under-utilization of services or funds allocated in the individual's service plan for delivery of services to the individual through the SRO and in accordance with the requirements of the individual's program.(b) Before involuntarily terminating an individual from participation in the SRO, an individual's case manager or service coordinator must convene the individual's service planning team, including the support advisor, to:(1) provide assistance with accessing supports and developing and implementing a corrective action plan related to noncompliance with program and SRO requirements;(2) document interventions utilized by the individual, support advisor, or representative to eliminate noncompliance with program requirements for the management of program services through the SRO; and(3) consider options to:(A) recommend additional interventions to be implemented under the guidance of the support advisor to protect the individual's health and welfare for continued participation in the SRO; or(B) recommend termination of the SRO and ensure that services are provided through the program provider.(c) If an individual, LAR, or representative does not correct the issue identified in subsection (a) of this section that caused the service planning team to initiate the steps outlined in subsection (b) of this section, the individual's case manager or service coordinator involuntarily terminates the individual from participation in the SRO. Source Note: The provisions of this §265.32 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION D TERMINATION OF THE SRO §265.32 Involuntary Termination of Participation in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218992 03/12/2026 (a) An individual's case manager or service coordinator must immediately convene the individual's service planning team concerning issues that may warrant immediate termination of the individual's participation in the SRO, including:(1) allegations of abuse, neglect, exploitation, or fraud; and(2) concerns about the individual's health, safety, or welfare.(b) On review of the information, the service planning team may recommend immediate termination of participation in the SRO if the individual's health or welfare is jeopardized by the individual's participation in the SRO.(c) If recommended by the service planning team, the case manager or service coordinator must terminate an individual's participation in SRO so that the individual receives services through a program provider. Source Note: The provisions of this §265.33 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION D TERMINATION OF THE SRO §265.33 Immediate Jeopardy and Involuntary Termination of Participation in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218993 03/12/2026 (a) Support consultation is provided by a person who meets the qualifications of a support advisor as described in Chapter 41 of this title (relating to Consumer Directed Services Option). A support advisor may be an employee or contractor of:(1) An FMSA; or(2) another entity.(b) Support consultation must include:(1) a level of training, assistance, and support that does not duplicate or replace case management services, or another available program or non-program service or resource; and(2) practical skills training and assistance to successfully manage service providers for authorized program services delivered through the SRO. Source Note: The provisions of this §265.41 adopted to be effective January 1, 2009, 33 TexReg 10510; amended to be effective September 1, 2014, 39 TexReg 6629; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION E SUPPORT CONSULTATION §265.41 Support Consultation Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218994 03/12/2026 (a) A support advisor must conduct the initial SRO orientation. The support advisor must document and notify the SRO provider and case manager or service coordinator that the individual has completed the orientation before SRO services can begin.(b) A support advisor must assist an individual, in accordance with the individual's service plan, with:(1) completing forms, assessments, and other documents required by the individual's program that require individual or LAR input or completion;(2) complying with requirements of the individual's program as related to services delivered through the SRO;(3) interviewing potential service providers, preparing job descriptions, and training service providers;(4) managing service providers for authorized program services delivered through the SRO;(5) helping an individual to use effective communication, decision-making, and problem-solving skills;(6) developing, revising, and implementing service back-up plans;(7) developing, revising, and implementing corrective action plans;(8) complying with the requirements of the individual's program and this chapter;(9) contacting appropriate persons or entities based on their roles, responsibilities, and eligibility, including:(A) a case manager or service coordinator; and(B) government agencies, including DADS and the Department of Family and Protective Services; and(10) teaching ongoing supervisory-related skills.(c) A support advisor must document service delivery in accordance with the requirements of the individual's program.(d) A support advisor must use DADS' Case Notification form to notify an individual's case manager or service coordinator:(1) if the individual receiving support consultation is unable or unwilling to cooperate with service delivery; and(2) of the progress and status of the service as required by the individual's program. Source Note: The provisions of this §265.42 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION E SUPPORT CONSULTATION §265.42 Support Advisor Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218995 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218995 03/12/2026 Payment rates for the SRO are the same rates determined for the program when services are delivered through a program provider. Source Note: The provisions of this §265.51 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION F BUDGET §265.51 Service Provider Payment in the SRO https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218996 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218996 03/12/2026 A person to whom this chapter applies must report any suspicion or knowledge of abuse, neglect, or exploitation of an individual in accordance with existing state laws and DADS rules. Source Note: The provisions of this §265.61 adopted to be effective January 1, 2009, 33 TexReg 10510; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION G REPORTING ALLEGATIONS §265.61 Reporting Allegations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218997 03/12/2026 DADS oversees roles and responsibilities of the following:(1) an individual or LAR who chooses to participate in the SRO;(2) a representative;(3) an FMSA;(4) a support advisor;(5) an SRO provider;(6) a case manager; and(7) a service coordinator. Source Note: The provisions of this §265.71 adopted to be effective January 1, 2009, 33 TexReg 10510; amended to be effective September 1, 2014, 39 TexReg 6629; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3933. 1 HEALTH AND HUMAN SERVICES COMMISSION 265 SERVICE RESPONSIBILITY OPTION H OVERSIGHT §265.71 Oversight https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209659 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. Individual subchapters may have definitions that are specific to the subchapter.(1) APRN--Advanced practice registered nurse. A registered nurse licensed under Texas Occupations Code Chapter 301 to practice as an advanced practice registered nurse.(2) Attending physician--A person who:(A) is any of the following:(i) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he or she performs that function or action;(ii) an APRN who meets the training, education, and experience requirements as described in 42 CFR §410.75(b); or(iii) a physician assistant who meets the requirements in 42 CFR §410.74(c); and(B) is identified by the individual, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individual's medical care.(3) Cap year--The 12-month period ending September 30 used in the application of the caps on hospice reimbursement specified in §266.217 of this chapter (relating to Medicaid Hospice Payments and Limitations).(4) CFR--Code of Federal Regulations.(5) CHC--Continuous home care. A category of care provided during a period of crisis consisting primarily of skilled nursing care.(6) CMS--Centers for Medicare and Medicaid Services. The federal agency that provides funding and oversight for the Medicare and Medicaid programs.(7) Crisis--A sudden or severe intensification of symptoms that appropriate medical intervention and nursing services could reasonably be expected to ameliorate. Expected fluctuations in an individual's condition related to the end of life process are not a crisis.(8) Curative--Designed to restore a person to health.(9) Employee--An employee, as defined in the Social Security Act §210(j) (42 U.S.C. §410), of the hospice or, if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice unit. The term "employee" also refers to a volunteer under the jurisdiction of the hospice.(10) HHSC--Texas Health and Human Services Commission.(11) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions.(12) IDT--Interdisciplinary team. An interdisciplinary team must include persons who are qualified and competent to practice in the following professional roles:(A) physician who is an employee or under contract with the hospice who may also be the hospice medical director or the hospice medical director's designee;(B) an APRN who:(i) is an employee or under contract with the hospice; and(ii) may perform the assessment described in §266.203(d) of this chapter (relating to Certification of Terminal Illness);(C) a registered nurse;(D) a social worker; and(E) a pastoral or other counselor.(13) Licensed vocational nurse--A nurse licensed under Texas Occupations Code Chapter 301 to practice vocational nursing.(14) Period of crisis--A period of time during which an individual requires continuous care that is primarily skilled nursing care to achieve palliation or management of acute medical symptoms.(15) Physician--A doctor of medicine or doctor of osteopathy currently licensed by the Texas Medical Board to practice medicine or osteopathy at the time and place the service is provided.(16) Physician Assistant--An individual who is licensed as a physician assistant under Texas Occupations Code Chapter 204.(17) Representative--An individual who has been authorized under state law to terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill individual who is mentally or physically incapacitated.(18) RN--Registered nurse. An individual licensed under Texas Occupations Code Chapter 301 to practice professional nursing.(19) SIA--Service intensity add-on. Payments for direct patient care provided by a social worker or an RN during the last seven days of life when provided during routine home care.(20) Skilled nursing care--Tasks that are determined by the assessing RN to require the skill of a licensed nurse when considering the inherent complexity of the task, the condition of the individual, and the accepted standards of medical and nursing practice.(21) Social worker--A person who is currently licensed as a social worker under Texas Occupations Code Chapter 505.(22) TAC--Texas Administrative Code.(23) Terminally ill--The individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.(24) TMHP--Texas Medicaid & Healthcare Partnership. The Texas Medicaid program claims administrator.(25) Utilization review--Medical record review of paid hospice claims to determine if provider compliance meets the requirements for payment of services. Source Note: The provisions of this §266.101 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM A INTRODUCTION §266.101 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209660 03/12/2026 A hospice must submit written information to HHSC in accordance with the instructions on the HHSC website. Source Note: The provisions of this §266.103 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM A INTRODUCTION §266.103 Submitting Written Information to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209661 03/12/2026 (a) An individual who is eligible may elect to receive hospice care during one or more of the following election periods:(1) an initial 90-day period;(2) a subsequent 90-day period; or(3) an unlimited number of subsequent 60-day periods.(b) The election periods are available in the order listed and may be elected consecutively or separately at different times.(c) An individual receiving Medicaid hospice services on the date this rule becomes effective may continue receiving those services until the current election period expires. Any subsequent election period is a 60-day period under subsection (a)(3) of this section. Source Note: The provisions of this §266.201 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.201 Duration of Hospice Care Coverage: Election Periods https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209662 03/12/2026 (a) Written certification.(1) For the initial election period, a hospice must obtain a signed and dated Physician Certification of Terminal Illness Form that meets the requirements of this section before the hospice submits an initial request for payment, but no more than 15 days before the election period begins.(2) For an election period after the initial election period, a hospice must obtain a signed and dated Physician Certification of Terminal Illness Form that meets the requirements of this section before the previous period expires, but no more than 15 days before the next election period begins.(3) The hospice must submit the Physician Certification of Terminal Illness Form to the TMHP Long Term Care Online Portal.(b) Oral certification. If a hospice does not obtain the written certification required by subsection (a)(1) of this section within two days after an initial election period begins, the hospice must obtain an oral certification that meets the requirements of this section no later than two days after the initial election period begins. The hospice must obtain a written certification before it submits a claim for payment. An election period is described in §266.201 of this subchapter (relating to Duration of Hospice Care Coverage: Election Periods).(c) Content of certification. An oral or written certification must:(1) specify that an individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course;(2) include a physician narrative that states individual-specific clinical course, exam findings, and laboratory and diagnostic testing results that support the physician's judgement that the individual is terminally ill; and(3) include clinical information that supports the medical prognosis, which may be provided orally for an oral certification and must be provided with accompanying documentation for a written certification.(d) Additional requirement for election period after the subsequent 90-day election period. To determine an individual's continued eligibility for hospice care for an election period after the subsequent 90-day election period, a hospice physician or hospice APRN must perform a face-to-face assessment of the individual.(1) The hospice must ensure a face-to-face assessment is performed before each subsequent election period begins, but no more than 30 days before the subsequent election period begins.(2) For an individual who is dually eligible for Medicare and Medicaid, a Medicare face-to-face encounter satisfies the requirement for a face-to-face assessment.(e) Sources of certification. The hospice must obtain the certification required by subsection (a) or (b) of this section from:(1) for the initial election period:(A) the medical director of the hospice or a physician who is a member of the hospice IDT; and(B) the individual's attending physician, if the individual has an attending physician; and(2) for an election period after the initial election period, a physician described in paragraph (1)(A) of this subsection.(f) Documentation.(1) After the hospice receives a certification:(A) for an oral certification, the hospice physician or RN must make an entry in the individuals' hospice record that includes the name of the physician who made the oral certification, the clinical information that supports the prognosis, the date the hospice received the certification, the signature of the staff person who makes the entry, and the date of the entry; and(B) for a written certification, the hospice staff must file the written certification and supporting documentation in the individual's hospice record.(2) For an election period after the subsequent 90-day election period, the hospice record must include clearly labeled documentation of the face-to-face assessment. Source Note: The provisions of this §266.203 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.203 Certification of Terminal Illness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209663 03/12/2026 (a) Filing an election statement. An individual who meets the eligibility requirements for hospice care may elect hospice by filing the Individual Election/Cancellation/Update Form with a particular hospice. If the individual is physically or mentally incapacitated, the individual's representative may file the form. If the individual is dually eligible for Medicaid and Medicare, the individual must elect the Medicaid and Medicare hospice benefit at the same time.(b) Content of election statement. The election statement must include the following:(1) identification of the particular hospice that will provide care to the individual;(2) the individual's or representative's acknowledgment that the individual or representative has been given a full explanation of the palliative rather than curative nature of hospice care as it relates to the individual's terminal illness;(3) acknowledgment that certain Medicaid services, as set forth in subsection (d) of this section, are waived by the election;(4) the effective date of the election, which may be the first day of hospice care or a later date, but must be no earlier than the date of the election statement; and(5) the signature of the individual or representative.(c) Duration of election. An election to receive hospice care will continue through the initial election period and the subsequent election periods without a break in care as long as the individual:(1) remains in the care of a hospice; and(2) does not revoke the election under the provisions of §266.207 of this subchapter (relating to Revoking the Election of Hospice Care).(d) Waiver of other benefits. For the duration of an election of hospice care, an individual 21 years of age or older waives all rights to the following Medicaid services:(1) hospice care provided by a hospice other than the hospice designated by the individual unless the care is provided under arrangements made by the designated hospice; and(2) any Medicaid services related to the treatment of the terminal condition for which hospice care was elected, or a related condition for which the hospice care was elected, or that are equivalent to hospice care except for services:(A) provided by the designated hospice;(B) provided by another hospice under arrangements made by the designated hospice; or(C) provided by the individual's attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services.(e) Re-election of hospice benefits. If an election has been revoked in accordance with §266.207 of this subchapter, the individual, or the individual's representative, if the individual is mentally or physically incapacitated, may at any time file an election in accordance with this section.(f) Record retention. The hospice must retain copies of all election forms in the hospice record for the individual and the individual's nursing facility or ICF/IID record, if applicable. Providers must meet the record retention requirements specified in 40 TAC Chapter 49 (relating to Contracting for Community Services).(g) The hospice must submit the Individual Election/Cancellation/Update Form to the TMHP Long Term Care Online Portal. Source Note: The provisions of this §266.205 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.205 Election of Hospice Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209664 03/12/2026 (a) An individual or representative may revoke the individual's election of hospice care at any time during an election period. If the individual is dually eligible for Medicaid and Medicare, the individual must revoke the Medicaid and Medicare hospice election at the same time.(b) To revoke the election of hospice care, the individual or representative must file the Individual Election/Cancellation/Update Form with the hospice.(c) The revocation effective date may not be earlier than the date the revocation is made.(d) An individual, upon revoking the election of hospice care for a particular election period:(1) is no longer covered under Medicaid for hospice care;(2) resumes Medicaid coverage of the benefits waived under §266.205(d) of this subchapter (relating to Election of Hospice Care); and(3) may at any time elect to receive hospice coverage as long as the individual meets eligibility requirements.(e) The hospice must submit the Individual Election/Cancellation/Update Form to the TMHP Long Term Care Online Portal. Source Note: The provisions of this §266.207 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.207 Revoking the Election of Hospice Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209665 03/12/2026 To be eligible for Medicaid hospice payment, the hospice must document that services provided meet the following requirements.(1) The hospice providing the services must have a Medicaid hospice contract with HHSC on the date it provides services.(2) The services must be reasonable and necessary for the palliation or management of the terminal illness, as well as conditions related to the terminal illness.(3) The hospice must deliver the services on or after the date the individual elects hospice care in accordance with §266.205 of this subchapter (relating to Election of Hospice Care) but before the date the individual revokes the election of hospice care in accordance with §266.207 of this subchapter (relating to Revoking the Election of Hospice Care).(4) The hospice election statement must identify the hospice requesting payment as the individual's hospice provider.(5) A physician must certify that the individual receiving hospice services is terminally ill in accordance with §266.203 of this subchapter (relating to Certification of Terminal Illness).(6) The individual receiving services must be eligible for Medicaid.(7) The hospice must establish an individualized plan of care prior to initiating services.(8) The services the hospice provides must be consistent with the plan of care.(9) If the individual receiving services lives in a nursing facility or ICF/IID, the hospice must have a contract with that nursing facility or ICF/IID.(10) If the individual receiving services is dually eligible for Medicare and Medicaid, the hospice service must not be covered by the Medicare hospice benefit.(11) The hospice must submit both the Individual Election/Cancellation/Update Form and the Physician Certification of Terminal Illness Form to the TMHP Long Term Care Online Portal. Source Note: The provisions of this §266.209 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.209 Requirements for Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209666 03/12/2026 CHC is provided only during a period of crisis for a maximum of five consecutive days to maintain an individual at the individual's place of residence.(1) A minimum of eight hours of CHC must be provided during a 24-hour day that begins and ends at midnight. The care need not be continuous. For example, four hours could be provided in the morning and another four hours in the evening of that day.(2) Skilled nursing care must be provided for the identified crisis for more than half of the CHC period and must be provided by either an RN or licensed vocational nurse. The RN or licensed vocational nurse must be an employee of the hospice providing services. For an individual residing in a nursing facility, the skilled nursing care requirement is not met when facility staff provided skilled nursing care for the crisis. For the purpose of CHC, skilled nursing care includes at least one of the following:(A) administration of intravenous or intramuscular medications;(B) insertion, sterile irrigation, and replacement of catheters;(C) initial clinical assessment for specific therapeutic responses; or(D) application of dressings involving prescription medications.(3) Homemaker, home health aide services, medical social work, or chaplain services may be provided to supplement the nursing care. The hospice must document why the physician considers social work or chaplain services necessary to ameliorate the crisis and what these services accomplished during CHC. On-call staff may be used to provide CHC but must be on site, providing care to the individual in the individual's place of residence to be considered for inclusion in CHC hours.(4) The hospice must have a signed physician's order for skilled nursing care. The physician's order must:(A) be specific to the identified crisis and be dated before the initiation of CHC, but not more than three days before the initiation of CHC;(B) document the rationale for increased nursing needs and care; and(C) be in the individual's hospice record and plan of care.(5) The attending physician, hospice medical director or his designee, and the IDT must establish the plan of care before initiating CHC. The hospice RN must coordinate the plan of care. The plan of care must:(A) be updated when the individual's condition changes; and(B) include the following:(i) a description of the specific crisis and how the hospice plans to resolve the crisis;(ii) the needs of the individual;(iii) identification of the services needed to meet the needs of both the individual and family, including management of discomfort and symptom relief;(iv) the scope and frequency of the services needed to meet the needs of both the individual and family;(v) documentation of daily physician care plan oversight; and(vi) clinical findings and documentation that support the scope and frequency of crisis care needed.(6) Before initiating CHC, the hospice must advise and discuss with the family or responsible party that temporary alternate placement may be necessary at the end of the five consecutive days. The hospice must document the discussion with the family or responsible party in the individual's records, including:(A) the date and time of the discussion;(B) the names and titles of the participating IDT members;(C) at least one potential alternate placement; and(D) any other outcomes of the discussion. Source Note: The provisions of this §266.211 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.211 Continuous Home Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209667 03/12/2026 (a) If the hospice believes that the period of crisis will extend beyond five consecutive days, the IDT must discuss the temporary alternate placement available to meet the needs of the individual during the period of crisis, such as a hospital or nursing facility. This discussion must occur and be documented before the fifth day of the crisis. If, after this discussion, the hospice believes that an extension of CHC is necessary instead of alternate placement, the hospice must fax a Request for CHC Extension Form to HHSC.(1) The extension request must be faxed to HHSC by the fourth day of the CHC period.(2) The extension request must include:(A) a description of the specific crisis and how the hospice plans to resolve the crisis;(B) documentation of all CHC provided during the period of crisis for which the hospice is seeking the extension;(C) physician's orders;(D) documentation of daily physician plan of care oversight;(E) documentation that skilled nursing care was provided as more than half of the care given in a 24-hour period for each of the three days of CHC;(F) documentation of the IDT's discussion regarding alternate placement prior to the initiation of CHC; and(G) documentation of the reasons the CHC period must be extended, including the reasons the originally documented alternate placement is no longer appropriate or desired.(b) HHSC denies the CHC extension request if the documentation is incomplete.(c) HHSC reviews documentation faxed on or before the fourth consecutive day of the period of crisis within 16 work hours of receiving the documentation if it is sent in accordance with the instructions in subsection (a)(1) of this section.(d) HHSC will not consider requests faxed after the fourth consecutive day of the period of crisis.(e) HHSC will not consider multiple requests for extensions for the same period of crisis.(f) HHSC notifies a hospice in writing, via fax, of its decision no later than the end of the fifth consecutive day of the period of crisis.(g) If HHSC denies the request for an extension of CHC, HHSC sends a notice of denial to the individual whose CHC the hospice was seeking to extend. The notice of denial informs the individual of the individual's right to request a Medicaid fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(h) If HHSC denies the request for an extension of CHC, HHSC pays the hospice at the routine home care rate or inpatient care rate, if applicable, for subsequent days of care.(i) The approval of a CHC extension request is not an approval of the initial CHC period, nor an approval for the care provided during the extension period. HHSC will conduct a review of all paid CHC claims to determine compliance with eligibility requirements for the hospice payment. Source Note: The provisions of this §266.213 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.213 Extension of Continuous Home Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209668 03/12/2026 (a) Respite care is short-term inpatient care provided to an individual only when necessary to relieve the family members or other persons caring for the individual at home.(b) Respite care can be provided by:(1) a hospice that meets the condition of participation for providing inpatient care directly; or(2) a hospital or nursing facility that also meets the Medicare standards regarding 24-hour nursing service and patient areas.(c) Respite care may be provided only on an occasional basis and may not be reimbursed for more than five consecutive days at a time.(d) Respite care may not be provided when the hospice patient is a nursing home resident. Source Note: The provisions of this §266.215 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.215 Respite Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209669 03/12/2026 (a) Medicaid hospice per diem and hourly rates. For each day that an individual is under the care of a hospice, the hospice is paid an amount applicable to the type and intensity of the services furnished to the individual. HHSC pays a daily rate for routine home care, in-patient respite care, and general inpatient care. For CHC and the SIA, the amount of payment is based on the number of hours of care furnished to the individual on that day.(1) Routine home care. The hospice is paid the routine home care rate for each day the individual is at home, under the care of the hospice, and not receiving CHC. The appropriate routine home care rate is determined as follows.(A) For routine home care delivered during the first 60 days an individual is receiving hospice care, the routine home care rate is the higher base payment rate.(B) For routine home care delivered after the first 60 days an individual is receiving hospice care, the routine home care rate is the reduced base payment rate.(C) If an individual receiving hospice services is discharged and readmitted to hospice not more than 60 days after the discharge, HHSC will count all days the individual received hospice services since the original hospice admission in determining the proper base payment rate.(D) If an individual receiving hospice services is discharged and readmitted to hospice more than 60 days after the discharge, HHSC disregards the previous hospice admission in determining the proper base payment rate.(2) Service Intensity Add-on. The hospice is paid an SIA in addition to the routine home care rate for visits provided by an RN or social worker during the last seven days of a hospice election ending with an individual discharged due to death. The SIA is the CHC hourly rate, multiplied by the number of hours of care provided by the RN or social worker, up to 4 hours during a 24-hour day that begins and ends at midnight. To claim the SIA, a hospice must submit:(A) documentation of the in-person, skilled services provided by the RN, the social worker, or both;(B) the times the services were provided; and(C) the Individual Election/Cancellation/Update Form indicating the hospice election was canceled due to death.(3) Continuous Home Care. The hospice is paid the CHC rate when direct patient care is provided. The CHC rate is divided by 24 hours to arrive at an hourly rate. A minimum of 8 hours of direct patient care must be provided per day. For every hour, or part of an hour, direct patient care is furnished, the hourly rate is paid to the hospice up to 24 hours a day. HHSC pays for a maximum of five consecutive days of CHC unless HHSC receives and grants a request for an extension of CHC. If the hospice ceases to provide direct patient care, CHC has ended.(4) Inpatient respite care. The hospice is paid at the inpatient respite care rate for each day on which the individual is in an approved inpatient facility and is receiving respite care. Payment for respite care may be made for a maximum of five days at a time including the date of admission but not counting the date of discharge. Payment for the sixth and any subsequent days is at the routine home care rate.(A) An individual who receives hospice respite care in a nursing facility and returns home after the respite care does not have to be in a Medicaid bed in the nursing facility.(B) Respite care days are subject to the limitation on total hospice inpatient care days, as outlined in subsection (c) of this section.(C) If the individual dies while receiving inpatient respite care, HHSC pays the inpatient respite care rate for the day of death.(5) General Inpatient Care. Payment is made at the general inpatient rate for each day on which the individual is in an approved inpatient facility and is receiving general inpatient care.(A) The general inpatient care rate is paid for the day of admission and all subsequent inpatient days except the day of discharge.(B) For the day of discharge, HHSC pays the routine home care rate.(C) If the individual dies while in an inpatient facility, HHSC pays the general inpatient care rate for the day of death.(D) General inpatient care days are subject to the limitation on total hospice inpatient care days, as outlined in subsection (c) of this section.(b) Medicaid payments for physician services. The hospice:(1) is paid for hospice physician services in accordance with the HHSC reimbursement rates for physician services;(2) is paid for physician services on the day of discharge if the physician provides direct patient services on that day;(3) is not paid for hospice physician services when the services are provided by physicians who are not on staff with the hospice or who are independent contractors under contract with the hospice; and(4) must include physician services in the hospice plan of care and clinical records.(c) Medicaid payment limitations for inpatient care. During the cap year, the aggregate number of inpatient hospice care days must not exceed 20 percent of the total number of hospice care days for the same cap year. This limitation is applied once each year, at the end of the cap year for each Medicaid hospice provider. A day counts as an inpatient hospice care day only if it is a day on which the individual who has elected hospice care receives inpatient respite care or general inpatient care. The limitation is calculated as follows.(1) The maximum allowable number of inpatient days is calculated by multiplying the total number of days of Medicaid hospice care by 0.2.(2) If the total number of days of inpatient care furnished to Medicaid hospice patients is less than or equal to the maximum, no adjustment is necessary.(3) If the total number of days of inpatient care exceeds the maximum allowable number, the limitation is determined by:(A) calculating a ratio of the maximum allowable days to the number of actual days of inpatient care and multiplying this ratio by the total reimbursement for inpatient care that was made;(B) multiplying excess inpatient care days by the reduced base payment routine home care rate;(C) adding together the amounts calculated in subparagraphs (A) and (B) of this paragraph; and(D) comparing the amount calculated under subparagraph (C) of this paragraph with interim payments made to the hospice for inpatient care during the cap year.(d) Medicaid aggregate payment limitations. During the cap year, the aggregate payments to a hospice are subject to an annual aggregate cap. This limitation is applied once each year, at the end of the cap year for each Medicaid hospice provider. A hospice's aggregate cap is calculated by multiplying the adjusted cap amount, as determined under paragraph (1) of this subsection, by the number of Medicaid beneficiaries, as determined under paragraph (2) of this subsection.(1) Cap Amount. The cap amount was set at $6,500 in 1983 and is updated using one of two methodologies described in subparagraphs (A) and (B) of this paragraph.(A) For accounting years that end on or after October 1, 2025, the cap amount is adjusted for inflation by using the percentage change in the medical care expenditure category of the Consumer Price Index (CPI) for urban consumers that is published by the Bureau of Labor Statistics. This adjustment is made using the change in the CPI from March 1984 to the fifth month of the cap year.(B) For accounting years that end before October 1, 2025, the cap amount is the cap amount for the preceding accounting year updated by the percentage update to payment rates for hospice care for services furnished during the fiscal year beginning on October 1st preceding the beginning of the accounting year as determined pursuant to the Social Security Act §1814(i)(1)(C) (42 U.S.C. §1395f), including the application of any productivity or other adjustments to the hospice percentage update.(2) Number of Medicaid Beneficiaries. For purposes of this paragraph, HHSC adopts by reference the streamlined methodology and the patient-by-patient proportional methodology in 42 CFR §418.309(b) and (c), effective October 1, 2018, to determine the number of Medicaid beneficiaries for purposes of the aggregate cap. A hospice determines the number of Medicaid beneficiaries using the same methodology it uses to determine the number of Medicare beneficiaries under 42 CFR §418.309(b) or (c).(e) Recoupment of Excess Payments. HHSC recoups payments in excess of the limitations for inpatient care and the aggregate payment limitations, pursuant to §266.225 and §266.227 of this subchapter (relating to Informal Review and Review Decision and Notice), from subsequent Medicaid hospice provider claims.(f) Pediatric Concurrent Care.(1) An individual under 21 years of age who elects to receive Medicaid hospice care may receive Medicaid services related to the treatment of the terminal illness, or a related condition, for which the hospice care was elected concurrently with the hospice care.(2) The hospice is responsible for hospice services related to the terminal illness or a related condition. The hospice is not responsible for acute care services related to the treatment of the terminal illness or a related condition or for services unrelated to the terminal illness or a related condition. Source Note: The provisions of this §266.217 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.217 Medicaid Hospice Payments and Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209670 03/12/2026 (a) Hospice staff must cooperate with HHSC staff during utilization review of hospice services and the review of hospice clinical records.(b) The hospice must respond within 30 calendar days after HHSC makes a request for information.(c) HHSC staff review most claims for payment after they are paid and recoup any overpayments, pursuant to §266.225 and §266.227 of this subchapter (relating to Informal Review and Review Decision and Notice).(d) HHSC staff review claims for the SIA before paying the SIA. Source Note: The provisions of this §266.219 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.219 Utilization Review and Control Activities Performed by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209671 03/12/2026 (a) Types of Documentation Required. A hospice must maintain the following information on each individual receiving Medicaid hospice services.(1) Signed hospice election and discharge forms.(2) Signed Physician's Certification of Terminal Illness.(3) Physician narratives.(4) Documentation of each face-to-face assessment.(5) Patient history and physical exams before and during the provision of hospice services, including previous and new diagnoses, emergency room visits, and ability to perform activities of daily living.(6) Physician consultation reports, orders, and progress notes.(7) Hospital admission and discharge reports.(8) Plans of care covering all periods during which the hospice provides services to the individual.(9) Nursing assessments and nursing notes.(10) IDT meeting notes.(11) Medication administration records, including doses, frequency, and routes.(12) Signs and symptoms, anthropometric measurements, weights, oral intake, and laboratory and diagnostic testing results supporting the conclusion that the individual's condition is terminal.(13) Other documentation supporting the plan of care, service delivery, and outcome of services.(14) Summary of circumstances surrounding the death, including date, time, family in attendance, and hospice staff in attendance.(b) Requirements for Physician's Orders. A hospice must have a signed physician's order that:(1) covers the time period for which hospice services were provided; and(2) documents the terminal illness and related medical need for skilled nursing care, as provided.(c) Requirements for the Plan of Care. A hospice must maintain a plan of care for each individual receiving Medicaid hospice services. The plan of care must meet the following criteria.(1) The plan of care must relate to the identified terminal illness.(2) The plan of care must be updated every 15 days, or when the individual's condition changes if sooner than 15 days, and include any change in the individual's status.(3) The plan of care must include the following:(A) a description of the individual's service needs and how the hospice plans to meet those needs;(B) the baseline condition of the individual at the beginning of the election period including symptoms documented with location, severity, and frequency;(C) identification of the specific interventions and services necessary for the management of the symptoms including the intensity, frequency, duration, and scope of services;(D) physician orders for the specific interventions and services necessary; and(E) the measurable outcomes anticipated from implementing the plan of care and reasonable timeframes expected for achieving those measurable outcomes.(d) Requirements for Physician Services on the Day of Discharge. To request payment for physician services on the day of discharge, the hospice must submit to HHSC proof that:(1) the physician is a hospice employee; and(2) the physician provided direct services to the patient on the day of discharge.(e) Requirements for all documentation. All documentation must be:(1) clearly labeled to indicate what type of documentation it is;(2) legible to a reader other than the author; and(3) signed and dated. Source Note: The provisions of this §266.221 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.221 Hospice Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209672 03/12/2026 (a) HHSC recoups from a hospice under 40 TAC §49.533 (relating to Recoupment) amounts paid to the hospice for a service if the hospice has not complied with the requirements described in this chapter.(b) Recoupment amounts for hospice eligibility and level of service utilization reviews.(1) HHSC recoups 100 percent of the hospice claim amount for the dates of service reviewed when the hospice fails to provide HHSC the following:(A) the Individual Election/Cancellation/Update Form completed in accordance with §266.205 of this subchapter (relating to Election of Hospice Care);(B) the Physician Certification of Terminal Illness Form completed in accordance with §266.203 of this subchapter (relating to Certification of Terminal Illness);(C) a physician narrative that meets the minimum criteria in §266.203(c)(2) of this subchapter; or(D) if the individual receiving hospice services is in an election period after the subsequent 90-day election period, documentation of the face-to-face assessment required by §266.203(d) of this subchapter.(2) HHSC recoups 50 percent of the hospice claim amount for the dates of service reviewed when the hospice fails to provide nursing assessments and notes.(3) HHSC recoups 30 percent of the hospice claim amount for the dates of service reviewed when the hospice fails to provide HHSC supporting clinical documentation related to the terminal illness and the progression of the terminal illness, including signs and symptoms, anthropometric measurements, weights, oral intake, and laboratory and diagnostic testing.(4) HHSC recoups 25 percent of the hospice claim amount for the dates of service reviewed when the hospice fails to provide HHSC with documentation of an initial plan of care and updated plans of care as required by §266.211 of this subchapter (relating to Continuous Home Care) and §266.221 of this subchapter (relating to Hospice Documentation Requirements).(c) Recoupment amounts for CHC reviews.(1) HHSC recoups 100 percent of the CHC claim amount for the dates of service reviewed when the hospice fails to provide HHSC the following:(A) documentation establishing that a crisis existed;(B) a physician's order for CHC; or(C) documentation establishing that the individual received care for at least 8 hours within a 24-hour day during the period of crisis.(2) HHSC recoups 50 percent of the CHC claim for the dates of service reviewed when the hospice fails to provide HHSC documentation establishing that the hospice agency employees provided skilled nursing care for more than 50 percent of the period of crisis.(3) HHSC recoups 25 percent of the CHC claim amount for the dates of service reviewed when the hospice fails to provide HHSC the following as required by §266.211 of this subchapter and §266.221 of this subchapter:(A) the plan of care specific to the identified crisis and dated before the initiation of CHC;(B) documentation that is legible to a reader other than the author, clear, complete, signed or initialed, and dated in accordance with hospice policy and currently accepted standards of practice; or(C) documentation that is signed and appropriately authenticated, which means the hospice is able to authenticate each handwritten and electronic signature of a primary author who has reviewed and approved the entry.(4) HHSC recoups 10 percent of the CHC claim amount for the dates of service reviewed when the hospice fails to provide HHSC documentation of the discussion of temporary alternate placement required by §266.211(6) of this subchapter, including documentation of the IDT meeting and who participated in the IDT meeting.(d) Other. HHSC will recoup the amount of any overpayment discovered. Source Note: The provisions of this §266.223 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.223 Recoupment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209673 03/12/2026 (a) Before HHSC issues a notice of proposed recoupment amount under 40 TAC §49.533(c) (relating to Recoupment), HHSC gives a hospice:(1) a description of the alleged rule violation warranting the proposed recoupment;(2) the amount of the proposed recoupment; and(3) the option to:(A) request an informal review to demonstrate that the hospice did not commit the alleged violation; or(B) accept the proposed recoupment.(b) A hospice's request for an informal review must:(1) be received by HHSC within 10 calendar days after the hospice receives the description of the alleged violation and amount of the proposed recoupment from HHSC; and(2) contain documentation that refutes the alleged violation.(c) HHSC conducts the informal review by reviewing the hospice's written response and supporting evidence.(d) HHSC provides the hospice with official notice of the outcome of the informal review. Source Note: The provisions of this §266.225 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.225 Informal Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209674 03/12/2026 (a) HHSC issues a notice of proposed recoupment under 40 TAC §49.533(c) (relating to Recoupment), if HHSC upholds or modifies a proposed recoupment after the informal review.(b) The notice of proposed recoupment includes:(1) a description of the alleged rule violations warranting the proposed recoupment;(2) the amount of the proposed recoupment;(3) HHSC's decision to uphold or modify the proposed recoupment issued after an informal review; and(4) the option for the hospice to:(A) accept the proposed recoupment; or(B) appeal the proposed recoupment as provided in 40 TAC §49.541 (relating to Contractor's Right to Appeal). Source Note: The provisions of this §266.227 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM B UTILIZATION REVIEW §266.227 Review Decision and Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209675 03/12/2026 (a) To be eligible to elect hospice care under Medicaid, an individual must:(1) be certified as Medicaid eligible by HHSC or the Social Security Administration; and(2) be certified as being terminally ill in accordance with §266.203 of this chapter (relating to Certification of Terminal Illness).(b) If dually eligible, an individual must elect the hospice benefit under both the Medicare and Medicaid programs. Source Note: The provisions of this §266.301 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.301 Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209676 03/12/2026 (a) An individual or representative may change the particular hospice from which the individual receives hospice care once in each election period. If the recipient is dually eligible for Medicaid and Medicare, the individual must change the Medicaid and Medicare hospice providers at the same time.(b) The change of the designated hospice is not a revocation of the election for the period in which it is made.(c) To change the designated hospice, the individual or representative must file, with both the hospice from which care has been received and with the newly designated hospice, a statement that includes the following information:(1) the name of the hospice from which the individual has received care and the name of the hospice from which the individual plans to receive care; and(2) the date the change is to be effective.(d) Both the hospice from which the individual has received care and the hospice from which the individual plans to receive care must submit an Individual Election/Cancellation/Discharge Form on the TMHP Long Term Care Online Portal. Source Note: The provisions of this §266.303 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.303 Change of the Designated Hospice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209677 03/12/2026 (a) A hospice participating in the Medicaid Hospice Program must comply with this chapter and applicable federal regulations and state rules, including 42 CFR Part 418; 26 TAC Chapter 558 (relating to Licensing Standards for Home and Community Support Services Agencies); and 40 TAC Chapter 49 (relating to Contracting for Community Services).(b) A hospice participating in the Medicaid Hospice Program must not have restrictive policies or practices, including:(1) requiring an individual to execute a will with the hospice named as legatee or devisee;(2) assigning an individual's life insurance to the hospice;(3) transferring an individual's property to the hospice;(4) requiring an individual to pay a lump sum or make any other payment or concession to the hospice beyond the recognized Medicaid rate;(5) controlling or restricting an individual or legal representative in using the individual's personal needs allowance while in a nursing facility or an ICF/IID;(6) restricting an individual from transferring or withdrawing from the Medicaid Hospice Program at will, except as provided by state law;(7) denying appropriate hospice care to an individual on the basis of the individual's race, religion, color, national origin, sex, age, disability, marital status, or source of payment; and(8) preventing or requiring the execution of written or unwritten directives to reject life-sustaining procedures by an adult individual.(c) If a hospice provides services to a resident of a nursing facility or an ICF/IID, the hospice must have a written contract for the provision of services with the nursing facility or ICF/IID.(d) Medicaid hospice-nursing facility per diem rates. The Medicaid Hospice Program pays the Medicaid hospice provider a hospice-nursing facility rate that is no less than 95 percent of the Medicaid nursing facility rate for each individual in a nursing facility to take into account the room and board furnished by the facility. When the hospice-nursing facility rate is paid to the hospice provider, the Medicaid vendor payment to the nursing facility is not paid. Room and board services include the performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies.(e) Medicaid hospice-ICF/IID per diem rates. The Medicaid Hospice Program pays the Medicaid hospice provider a hospice-ICF/IID rate that is no less than 95 percent of the ICF/IID rate for each individual in an ICF/IID to take into account the room and board furnished by the facility. When the hospice-ICF/IID rate is paid to the hospice provider, the Medicaid vendor payment to the ICF/IID is not paid. Room and board services include the performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies.(f) Medicaid payments on Medicare coinsurance for drugs and biologicals. For Medicare-Medicaid individuals only, the Medicaid Hospice Program pays the Medicaid hospice provider a five percent coinsurance on prescription drugs and biologicals, not to exceed $5.00 per prescription.(g) Medicaid payments for Medicare respite coinsurance. For Medicare-Medicaid individuals only, the Medicaid Hospice Program pays the hospice provider a five percent coinsurance for each day of respite care for up to five consecutive days of a hospice coinsurance period. Source Note: The provisions of this §266.305 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.305 General Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209678 03/12/2026 (a) At least 10 days before a hospice terminates its contract with HHSC, the hospice must:(1) for each individual receiving Medicaid hospice services, submit an Individual Election/Cancellation/Update Form to the TMHP Long Term Care Online Portal indicating the individual has changed his designated hospice or revoked his election of hospice care; and(2) for each individual receiving Medicaid hospice services who is changing his designated hospice, ensure that a copy of the individual's active record is sent to the receiving hospice in order to ensure continuity of care and services to the individual.(b) Submission of the Individual Election/Cancellation/Update Form to the TMHP Long Term Care Online Portal is governed by §266.303 of this subchapter (relating to Change of the Designated Hospice) and §266.207 of this chapter (relating to Revoking the Election of Hospice Care). Source Note: The provisions of this §266.307 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.307 Voluntary Termination of Hospice Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209679 03/12/2026 (a) Physical therapy services, occupational therapy services, and speech-language pathology services must be available and, when provided, offered in a manner consistent with accepted standards of practice.(b) Lab services must be provided under the following conditions.(1) If the hospice engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the FDA, such testing must be in compliance with all applicable requirements of 42 CFR Part 493.(2) If the hospice chooses to refer specimens for laboratory testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and sub-specialties of services in accordance with the applicable requirements of 42 CFR Part 493. Source Note: The provisions of this §266.309 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.309 Condition of Participation--Physical Therapy, Occupational Therapy, and Speech-language Pathology https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209680 03/12/2026 (a) CMS may approve a waiver for nursing services or occupational, physical, and speech therapies provided by a hospice which is located in a non-urbanized area. The location of a hospice that operates in several areas is considered to be the location of its central office. The hospice must provide evidence that it was operational on or before January 1, 1983, and that it made a good faith effort to hire a sufficient number of nurses or therapists to provide services directly. CMS bases its decision on whether to approve a waiver application on the following:(1) the current Bureau of the Census designations for determining non-urbanized areas;(2) evidence that a hospice was operational on or before January 1, 1983, including:(A) proof that the organization was established to provide hospice services on or before January 1, 1983;(B) evidence that hospice-type services were furnished to patients on or before January 1, 1983; and(C) evidence that the hospice care was a discrete activity rather than an aspect of another type of provider's patient care program on or before January 1, 1983; and(3) evidence that a hospice made a good faith effort to hire nurses or therapists, including:(A) copies of advertisements in local newspapers that demonstrate recruitment efforts;(B) job descriptions for nurse employees or therapists;(C) evidence that salary and benefits are competitive for the area; and(D) evidence of any other recruiting activities, such as recruiting efforts at health fairs and contacts with nurses or therapists at other providers in the area.(b) A waiver request for occupational, physical, and speech therapies must be submitted in writing to HHSC.(c) HHSC will recommend in writing, approval or disapproval of the requested waiver for occupational, physical, and speech therapies to CMS within 30 days of receiving the request.(d) CMS receives requests for waivers of nursing services without the involvement of HHSC.(e) Any waiver request is deemed to be granted unless it is denied within 60 days after it is received.(f) Waivers will remain effective for one year at a time.(g) CMS may approve a maximum of two one-year extensions for each initial waiver. If a hospice wishes to receive a one-year extension, the hospice must submit a certification to CMS, prior to the expiration of the waiver period, that the employment market for nurses and therapists has not changed significantly since the time the initial waiver was granted. Source Note: The provisions of this §266.311 adopted to be effective July 26, 2022, 47 TexReg 4331. 1 HEALTH AND HUMAN SERVICES COMMISSION 266 MEDICAID HOSPICE PROGRAM C CONTRACTING REQUIREMENTS §266.311 Waiver Requirements for Nursing Services or Occupational, Physical, and Speech Therapies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219761 03/12/2026 This chapter establishes the requirements for agencies contracting to provide services to eligible elderly clients through the Texas Department of Human Services' Programs of All-Inclusive Care for the Elderly (PACE). Source Note: The provisions of this §270.2 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.2 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219762 03/12/2026 (a) Programs of All-Inclusive Care for the Elderly (PACE) provide community-based acute and long-term care services to persons who meet the medical requirements for nursing facility care and can be served safely in the community. PACE is jointly funded and administered by the Centers for Medicare and Medicaid Services and the state of Texas. The PACE provider agency receives a monthly capitation payment and is at full risk for the delivery of all services needed by the client.(b) Rules governing the operation of the PACE program are contained in 42 Code of Federal Regulations, Part 460. These regulations, as currently written or amended in the future, are incorporated by reference as the rule base for operating the PACE program in Texas. Source Note: The provisions of this §270.4 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.4 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219763 03/12/2026 The words and terms used in this chapter have the following meanings, unless the context clearly indicates otherwise.(1) Capitation--The uniform per client monthly amount that DADS pays to a provider agency.(2) CFR--The Code of Federal Regulations.(3) CMS--The Centers for Medicare and Medicaid Services.(4) DADS--The Department of Aging and Disability Services or its successor agency.(5) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, or Coast Guard:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(6) Individual--A person seeking to enroll or who is enrolled in PACE services.(7) Interdisciplinary Team (IDT)--The IDT is a team of persons who interact and collaborate to assess clients and plan for their care. The IDT must include the client's primary care physician, registered nurse, Programs of All-Inclusive Care for the Elderly (PACE) center director, social worker, physical therapist, occupational therapist, activities director, dietician, home care coordinator, personal care attendant or his or her representative, and driver or his or her representative.(8) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(9) Military family member--A person who is the spouse or child (regardless of age) of:(A) a military member; or(B) a former military member.(10) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch.(11) Nursing facility--A facility required to be licensed under Texas Health and Safety Code, Chapter 242.(12) PACE--Programs of All-Inclusive Care for the Elderly.(13) PACE contract--A written agreement between DADS and the provider agency to provide PACE services for one year.(14) Program agreement--A three-party agreement between the provider agency, CMS, and DADS.(15) Provider agency--An entity that delivers required PACE services under a PACE contract and a program agreement.(16) Respite services--Services provided to an individual unable to care for himself or herself, because of the absence or need for relief of those persons normally providing the care.(17) Service area--The geographic area served by a provider agency according to its program agreement and PACE contract. Source Note: The provisions of this §270.6 adopted to be effective March 24, 2004, 29 TexReg 2923; amended to be effective September 1, 2014, 39 TexReg 6674; amended to be effective February 23, 2017, 42 TexReg 695; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.6 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219764 03/12/2026 (a) To become a provider agency, an applicant must:(1) be selected by DADS, through a request for proposals process, to submit an application to CMS to become a provider agency;(2) be approved by CMS as described in 42 CFR, Part 460, Subpart B to be a provider agency;(3) enter into a program agreement with CMS and DADS as described in 42 CFR, Part 460, Subpart C; and(4) be licensed as an adult daycare center.(b) An applicant that meets the requirements in subsection (a)(1) - (4) of this section must apply for a PACE contract with DADS to provide PACE services in accordance with §49.203 of this title (relating to Provisional Contract Application Process), as if applying for a provisional contract. DADS approves or denies the request for a contract in accordance with §49.207 and §49.208 of this title (relating to Provisional Contract Application Denial and Provisional Contract Application Approval).(c) A provider agency must:(1) comply with provisions of this chapter and 42 CFR, Part 460;(2) meet all applicable local, state, and federal regulations;(3) maintain the program agreement; and(4) maintain licensure as an adult daycare center.(d) The following apply to a provider agency's PACE contract as if the provider agency is a contractor:(1) §49.210 of this title (relating to Contractor Change of Ownership or Legal Entity);(2) Chapter 49, Subchapter C of this title (relating to Requirements of a Contractor);(3) §49.413 of this title (relating to Investigation);(4) §49.414 of this title (relating to Financial Review);(5) Chapter 49, Subchapter E of this title (relating to Enforcement by DADS and Termination by Contractor); and(6) Chapter 49, Subchapter F of this title (relating to Review by DADS of Expiring or Terminated Contract).(e) At the end of the term of the PACE contract, DADS may renew the PACE contract. If DADS does not renew the PACE contract, DADS notifies the provider agency in writing.(f) DADS terminates the PACE contract during the contract term if the program agreement is terminated. DADS notifies the provider agency in writing if a PACE contract is terminated. Source Note: The provisions of this §270.8 adopted to be effective March 24, 2004, 29 TexReg 2923; amended to be effective September 1, 2014, 39 TexReg 6674; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.8 Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219765 03/12/2026 (a) A provider agency must maintain an up-to-date interest list of individuals who are interested in receiving PACE services and reside in the provider agency's service area.(b) A person may request an individual's name be added to the PACE interest list maintained by the provider agency serving the service area in which the individual resides by submitting a request in person, by phone, or in writing, and providing the following information:(1) the name of the individual;(2) the date of the request for PACE services;(3) the individual's physical and mailing addresses;(4) the individual's birth date;(5) the individual's contact phone number;(6) the name and phone number of the LAR, if applicable; and(7) the name and phone number of the person requesting services on behalf of the individual, if different from the LAR.(c) When a PACE vacancy occurs, a provider agency offers the vacancy to the individual whose name is first on the PACE provider agency's interest list.(d) A provider agency removes an individual's name from the PACE interest list if:(1) the individual accepts a PACE vacancy;(2) the individual or LAR requests in writing that the individual's name be removed from the interest list;(3) the individual moves out of the service area, unless the individual is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) or less than one year after the former military member's active duty ends;(4) the individual or LAR declines the offer of PACE services, unless the individual is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(5) the individual is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(6) the individual or LAR fails to respond to a PACE vacancy offer within 30 days after receiving the offer; or(7) the individual is deceased. Source Note: The provisions of this §270.10 adopted to be effective February 23, 2017, 42 TexReg 695; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.10 Interest List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219766 03/12/2026 (a) To be eligible for participation the applicant must:(1) be 55 years old or older;(2) meet the medical necessity criteria for nursing facility care in accordance with §19.2401 of this title (relating to General Qualifications for Medical Necessity Determinations);(3) live in a Programs of All-Inclusive Care for the Elderly (PACE) service area; and(4) be determined by the PACE Interdisciplinary Team (IDT) as able to be safely served in the community.(b) To be eligible for Medicaid capitated payment the applicant must be eligible for full Medicaid benefits through one of the following methods:(1) be eligible for Supplemental Security Income (SSI) benefits;(2) have been eligible for and received SSI benefits, and continue to be eligible for Medicaid as a result of coverage mandated by federal law; or(3) be eligible for Medicaid benefits, if institutionalized.(c) To obtain and maintain eligibility, the client must agree to accept the provider agency and its contractors as the client's only service provider.(d) If the provider agency denies enrollment because the IDT determines that the applicant cannot be served safely in the community, the agency must:(1) notify the applicant in writing of the reason for the denial;(2) refer the individual to alternative services, as appropriate;(3) maintain supporting documentation for the denial; and(4) notify the Centers for Medicare and Medicaid Services and the Department of Aging and Disability Services of the denial and make the supporting documentation available for review. Source Note: The provisions of this §270.12 adopted to be effective March 24, 2004, 29 TexReg 2923; amended to be effective February 1, 2010, 35 TexReg 653; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.12 Client Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219767 03/12/2026 Programs of All-Inclusive Care for the Elderly (PACE) clients must reside in:(1) their own home;(2) a relative's home;(3) a licensed assisted living facility;(4) a licensed nursing facility; or(5) an adult foster care home that contracts with the Texas Department of Human Services. Source Note: The provisions of this §270.14 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.14 Living Arrangements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219768 03/12/2026 (a) The provider agency must complete a medical necessity and level of care assessment based on the client's total needs.(b) The provider agency must electronically transmit the medical necessity and level of care assessment to the agency with which the Texas Health and Human Services Commission (HHSC) contracts for medical necessity determinations.(c) The provider agency must enroll any eligible applicant within 60 calendar days after the date of the medical necessity and level of care assessment.(d) The provider agency must complete another medical necessity and level of care assessment and submit it to the agency with which HHSC contracts for medical necessity determinations 12 months after the initial assessment.(1) If the client meets the state's medical necessity criteria and the client has an irreversible or progressive diagnosis, or a terminal illness that could reasonably be expected to result in death in the next six months, and the Department of Aging and Disability Services (DADS) determines that there is no reasonable expectation of improvement or significant change in the client's condition because of severity of a chronic condition or the degree of impairment of functional capacity, DADS will permanently waive the annual recertification requirement and the client may be deemed to be continually eligible for PACE. The medical necessity and level of care assessment must have sufficient documentation to substantiate the client's prognosis and the client's functional capacity.(2) In addition, if DADS determines that a PACE client no longer meets the medical necessity criteria for nursing facility care, the client may be deemed to continue to be eligible for PACE until the next annual reassessment, if, in the absence of PACE services, it is reasonable to expect that the client would meet the nursing facility medical necessity criteria within the next six months.(e) The provider agency's licensed nurse must complete the medical necessity and level of care assessment for the provider agency. The licensed nurse must be registered with the agency with which HHSC contracts for medical necessity determinations as having, within the last two years, received and passed a state-approved training on the medical necessity and level of care assessment. Source Note: The provisions of this §270.16 adopted to be effective March 24, 2004, 29 TexReg 2923; amended to be effective September 1, 2008, 33 TexReg 7291; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.16 Medical Necessity Assessments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219769 03/12/2026 A provider agency must provide a client the services, listed in 42 Code of Federal Regulations §460.92, that are approved by the Interdisciplinary Team. Source Note: The provisions of this §270.18 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.18 Program Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219770 03/12/2026 (a) Internal appeal.(1) Any client who is denied program services is entitled to an appeal through the provider agency.(2) If the client also chooses to file an external appeal, the provider agency must assist the client in filing an external appeal.(b) External appeals. Any client covered by:(1) Medicaid may file an appeal through the Texas Medicaid hearing process; or(2) Medicare, but not Medicaid, may file an appeal through the Centers for Medicare and Medicaid Services hearing process. Source Note: The provisions of this §270.20 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.20 Right to Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219771 03/12/2026 (a) The provider agency must accept the Medicaid capitation payment as payment in full for all services to a Medicaid eligible client.(b) If the client is also a Medicare beneficiary, the Centers for Medicare and Medicaid Services will also pay a Medicare capitation payment to the provider agency.(c) An exception to subsection (a) of this section occurs when a client enters a nursing facility and the client has applied income. To receive this exception:(1) the provider agency must collect the client's applied income, unless the purpose of the stay is for the client to receive respite care; and(2) the applied income must be determined in accordance with §§15.100, 15.450, 15.501-15.503, and 15.506 of this title (relating to Definitions; General Principles Concerning Income; Vendor Living Arrangements; Allowable Deductions; Protection of Spousal Income and Resources; and Mandatory Payroll Deductions from Earned Income). Source Note: The provisions of this §270.22 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.22 Medicaid Capitation Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219759 03/12/2026 (a) The provider agency determines whether the applicant meets enrollment requirements.(b) The enrollment effective date is the first day of the month after the provider agency receives the signed enrollment form.(c) The client may voluntarily disenroll from Programs of All-Inclusive Care for the Elderly (PACE) at any time, but the effective date of disenrollment must be the last day of the month.(d) The provider agency may recommend involuntary disenrollment of a client for the reasons described in 42 Code of Federal Regulations §460.164. To involuntarily disenroll a client:(1) the documentation of the recommendation must be sent to the PACE program manager in the Texas Department of Human Services (DHS) state office; and(2) the disenrollment becomes effective only when DHS confirms the provider agency adequately documented acceptable grounds for disenrollment. Source Note: The provisions of this §270.24 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.24 Enrollment and Disenrollment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219760 03/12/2026 The provider agency must:(1) collect and enter data into the DataPACE system;(2) generate and maintain monthly reports from the DataPACE system; and(3) make the reports available to the Texas Department of Human Services. Source Note: The provisions of this §270.26 adopted to be effective March 24, 2004, 29 TexReg 2923; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4933. 1 HEALTH AND HUMAN SERVICES COMMISSION 270 CONTRACTING TO PROVIDE PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) §270.26 Data Collection and Reporting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226019 03/12/2026 The following words and terms have the following meanings when used in these sections, unless the context clearly indicates otherwise.(1) Abuse--Means:(A) the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an older adult or person with a disability by the person's caretaker, family member, or other individual who has an ongoing relationship with the person; or(B) any involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (indecent exposure) or Texas Penal Code Chapter 22 (assaultive offenses), committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.(2) Activities of daily living (ADL)--Fundamental tasks required for a person to care for themselves independently. Activities that are essential to daily self-care, including bathing, dressing, grooming, toileting, housekeeping, shopping, meal preparation, and others.(3) Adult--A person at least 18 years of age, or an emancipated minor.(4) Adult Foster Care (AFC)--A Title XX of the Social Security Act program that provides a 24-hour living arrangement with supervision in an Adult Foster Care home for a person who is unable to continue living independently in the person's own home because of physical, mental, or emotional limitations.(5) Applicant--A person initially requesting services.(6) Attendant--A person who is employed by a provider agency to give personal care or housekeeping services or both to a person eligible for Community Attendant Services, Family Care, or Primary Home Care, according to a service plan.(7) Caregiver--A relative, guardian, representative payee, or person who has contact with the applicant or client that is frequent enough or regularly scheduled enough that a personal relationship exists or the applicant or client perceives that person as having a role in helping the applicant or client to meet basic needs.(8) Caregiver support--Relief or rest from caregiving duties given to or arranged for the caregiver of an HHSC client.(9) Caseworker--An HHSC employee responsible for determining eligibility and case management activities.(10) Client--A person determined eligible for Community Care Services Eligibility (CCSE) services or programs.(11) Community Attendant Services (CAS)--A non-technical, medically related Title XIX of the Social Security Act community care program available to an eligible person whose health problems limit the person from performing ADLs in accordance with a practitioner's statement of medical need.(12) Community care service or program--Services or programs provided within the client's own home, neighborhood, or community, as alternatives to institutional care.(13) Community Care Services Eligibility (CCSE) services or programs--A group of HHSC programs or services that provide a variety of Title XIX of the Social Security Act and Title XX of the Social Security Act community-based services:(A) Adult Foster Care (AFC);(B) Community Attendant Services (CAS);(C) Consumer Managed Personal Attendant Services (CMPAS);(D) Day Activity Health Services (DAHS);(E) Emergency Response Services (ERS);(F) Family Care (FC);(G) Home Delivered Meals (HDM);(H) Primary Home Care (PHC);(I) Residential Care (RC); and(J) Special Services to Persons with Disabilities (SSPD).(14) Community services interest list--A list containing the names of people interested in receiving a Title XX of the Social Security Act community care service or program when Title XX of the Social Security Act funds are available.(15) Consumer Managed Personal Attendant Services (CMPAS)--A Title XX of the Social Security Act HHSC program that provides personal assistance services to people who have physical disabilities who are mentally and emotionally competent and willing to supervise their attendant or have someone who can supervise the attendant for them. The individual interviews, selects, trains, supervises, and releases their personal assistants.(16) Day Activity Health Services (DAHS)--Provides Title XX of the Social Security Act or Title XIX of the Social Security Act services designed to meet an adult's needs in a DAHS facility licensed by HHSC.(17) Earned income--Cash or liquid resources that a person receives for services performed as an employee or because of self-employment. All other income is unearned income.(18) Emancipated minor--A person under 18 who has the power and capacity of an adult. This includes a minor who has had the disabilities of minority removed by a court of law or a minor who, with or without parental consent, has been married. Marriage includes common-law marriage.(19) Emergency Care (EC)--A program authorized under Title XX of the Social Security Act that provides a 24-hour living arrangement in an HHSC licensed facility for as many as 30 days while the case worker seeks permanent care arrangements. EC may be provided in Adult Foster Care (AFC) homes and in Residential Care (RC) facilities. (20) Emergency Response Services (ERS)--Title XX of the Social Security Act services that are provided through an electronic monitoring system that is used by adults living with functional impairment who live alone or who are socially isolated in the community.(21) Emotional or verbal abuse--Any use of verbal communication or other behavior to humiliate, intimidate, vilify, degrade, or threaten with harm.(22) Expedited response--A face-to-face or phone contact with an applicant by the caseworker within five calendar days of the date of the applicant's request for services.(23) Exploitation--The illegal or improper act or process of a caregiver, family member, or other person who has an ongoing relationship with an older adult or person with a disability that involves using, or attempting to use, the resources of the older adult or person with a disability, including the person's social security number or other identifying information, for monetary or personal benefit, profit, or gain without the informed consent of the person.(24) Facility--A legal entity that contracts with HHSC to deliver day services or 24-hour residential services to a client.(25) Family Care (FC)--A program authorized under Title XX of the Social Security Act that provides personal attendant services to an eligible person.(26) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Space Force, or Coast Guard:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(27) Fraud--A deliberate misrepresentation or intentional concealment of information to receive or be reimbursed for the delivery of services to which the person is not entitled.(28) Functional need--A person's requirement for assistance with activities of daily living, caused by a physical or mental limitation or disability.(29) HHSC--Texas Health and Human Services Commission, or its designee.(30) HHSC region--One of eleven regions of Texas that provide access to and support for HHSC services.(31) Home Delivered Meals (HDM)--A program authorized under Title XX of the Social Security Act that provides meal delivery to an eligible person in the person's home.(32) Immediate response--A face-to-face or phone contact with an applicant by the caseworker within 24 hours of the applicant's request for services.(33) Income eligible--An adult who is not categorically eligible but has income and resources equal to or less than the eligibility level established by HHSC.(34) Institution--A nursing home, an intermediate care facility for people with intellectual and developmental disabilities, a state supported living center, or a state hospital.(35) Liquid resource--Cash or financial instruments that could be converted to cash within 20 workdays.(36) Medicaid-eligible--A person eligible for federal medical assistance, or eligible for medical assistance only (MAO) in a nursing home or while living in the community or through a federally approved waiver.(37) Medicare--Federal health insurance for anyone at least 65 years of age and some people with certain disabilities or conditions.(38) Military family member--A person who is the spouse or child, regardless of age, of:(A) a military member; or(B) a former military member.(39) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Space Force, or Coast Guard on active duty who has declared and kept Texas as the military member's state of legal residence in the manner offered by the applicable military branch.(40) Neglect--The failure to provide for oneself the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide the goods or services.(41) Older adult--A person at least 65 years of age.(42) Person--An individual. The term person is used when addressing information relevant to both an applicant and a client.(43) Person with a disability--A person who, because of physical, mental, or developmental impairments, is limited temporarily or permanently in the person's capacity to adequately perform one or more essential activities of daily living. This includes personal and health care, moving around, communicating, and housekeeping.(44) Personal leave--Any leave from a residential care facility except for hospitalization or institutionalization. A day of personal leave is any period of 24 consecutive hours.(45) Primary Home Care (PHC)--A Title XIX of the Social Security Act non-technical, medically related personal attendant service to a person eligible for Medicaid whose health problems limit the person's ability to perform activities of daily living, in accordance with a practitioner's statement of medical need.(46) Provider agency--An agency that has contracted with HHSC to provide programs or services that HHSC has authorized for people.(47) Regional nurse--A registered nurse employed by HHSC who authorizes CAS, PHC, and DAHS.(48) Residential Care (RC)--A Title XX of the Social Security Act Assisted Living and Emergency Care program that provides a 24-hour living arrangement in an HHSC licensed facility.(49) Resource--Any cash or other liquid assets or any real or personal property owned by a person and spouse that could be converted to cash to use for support and maintenance.(50) Responder--A person who responds to an Emergency Response Services (ERS) call activated by a client. Responders may include relatives, neighbors, volunteers, or staff of a sheriff's department, police department, emergency medical service, or fire department.(51) Responsible person--A person who is:(A) an applicant or client's parent or legal guardian; or(B) anyone an adult applicant or client designates as the applicant's or client's representative.(52) Special Services to Persons with Disabilities (SSPD)--A Title XX of the Social Security Act program that provides services in various settings to help people develop the skills needed to live independently in the community.(53) Supplemental Security Income (SSI)--Monthly payments made by the Social Security Administration (SSA) to an older person or person with disabilities who meets the requirements for public aid. SSA determines eligibility for SSI.(54) Unearned income--Income received by a person from sources other than self-employment or employee work activities.(55) Unmet need--A requirement for assistance with activities of daily living that cannot be met adequately on an ongoing basis by friends, relatives, volunteers, or service agencies other than HHSC.(56) Verbal referral--A referral made by the caseworker to the provider agency in person or by phone, no later than the first workday after the caseworker's determination that the applicant meets the criteria for an expedited response or an immediate response to a request for service and needs immediate service initiation. Source Note: The provisions of this §271.1 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective June 1, 1991, 16 TexReg 2608; amended to be effective December 1, 2000, 25 TexReg 11081; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY A DEFINITIONS §271.1 Definitions of Program Terms https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226020 03/12/2026 (a) HHSC maintains, for each HHSC region, a community services interest list for each community care services eligibility service or program authorized under Title XX of the Social Security Act.(b) A person or responsible person may request in person, by phone, or in writing that HHSC add a person's name to a Title XX of the Social Security Act community services interest list. The person making the request must provide a Texas address for the person.(c) HHSC adds a person's name to a community services interest list if:(1) a request is made in accordance with subsection (b) of this section; or(2) an applicant's name is on the interest list for an HHSC region and the applicant or a responsible person notifies HHSC that the applicant has moved to another HHSC region and requests that the applicant's name be added to the interest list for the HHSC region to which the applicant has moved.(d) HHSC adds an applicant's name to a community services interest list with an interest list request date as follows:(1) for a request to add an applicant's name to the interest list made in accordance with subsection (b) of this section, the date of the request; or(2) for a request to add an applicant's name to the interest list made in accordance with subsection (c)(2) of this section, the date of the original request made in accordance with subsection (b) of this section.(e) HHSC removes an applicant's name from a community services interest list if:(1) the applicant or responsible person requests that the applicant's name be removed from the interest list;(2) the applicant moves out of Texas, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the applicant is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(4) the applicant or responsible person declines an offer of a community care service or program when contacted by HHSC, as described in §271.7 of this subchapter (relating to Interest Lists) unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(5) the applicant is deceased; or(6) HHSC denies an applicant's eligibility for the community care service or program and the applicant has had an opportunity to exercise the right to appeal the decision in accordance with Title 1 Texas Administrative Code (TAC), Part 15, §357.3 (relating to Authority and Right to Appeal) or §271.155 of this chapter (relating to Denial, Reduction, and Termination of Benefits) and did not appeal the decision, or appealed and did not prevail.(f) If HHSC removes an applicant's name from a community services interest list in accordance with subsection (e)(1) - (4) of this section and, within 90 calendar days after the name was removed, HHSC receives an oral or written request to reinstate the applicant's name on the interest list, HHSC:(1) reinstates the applicant's name to the interest list with an interest list request date described in subsection (d)(1) or (2) of this section; and(2) notifies the applicant in writing that the applicant's name has been reinstated to the interest list in accordance with paragraph (1) of this subsection.(g) If HHSC removes an applicant's name from a community services interest list in accordance with subsection (e)(1) - (4) of this section and, more than 90 calendar days after the name was removed, HHSC receives an oral or written request to reinstate the applicant's name on the community services interest list, HHSC:(1) adds the applicant's name to the community services interest list with a request date of:(A) the date HHSC receives the oral or written request to reinstate; or(B) because of extenuating circumstances as determined by HHSC, the original request date described in subsection (d)(1) or (2) of this section; and(2) notifies the applicant in writing that the applicant's name has been added to the community services interest list in accordance with paragraph (1) of this subsection.(h) If HHSC removes an applicant's name from a community services interest list in accordance with subsection (e)(6) of this section and HHSC subsequently receives an oral or written request to reinstate the applicant's name on the community services interest list, HHSC:(1) adds the applicant's name to the community services interest list with a request date of the date HHSC receives the oral or written request to reinstate; and(2) notifies the applicant in writing that the applicant's name has been added to the community services interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §271.5 adopted to be effective May 23, 2016, 41 TexReg 3749; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY B INTEREST LISTS §271.5 Community Services Interest Lists https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226021 03/12/2026 When a community care service or program authorized under Title XX of the Social Security Act becomes available in a HHSC region, HHSC contacts the applicant whose community services interest list request date, assigned in accordance with §271.5(d) of this subchapter (relating to Interest Lists), is earliest on the community services interest list for the community care service or program that is available, and offers the community care service or program to the applicant.(1) If the applicant or responsible person declines the offer of the community care service or program, HHSC removes the applicant's name from the community services interest list for the community care service or program, as described in §271.5(e)(4) of this subchapter.(2) If the applicant or responsible person accepts the offer of the community care service or program, a caseworker contacts the applicant to conduct an eligibility determination for the community care service or program. Source Note: The provisions of this §271.7 adopted to be effective May 23, 2016, 41 TexReg 3749; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY B INTEREST LISTS §271.7 Enrollment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226022 03/12/2026 (a) To receive Community Care Services Eligibility (CCSE) services or programs, a person must meet income, resource, age, and need criteria.(b) A person who lives in a nursing facility is not eligible to receive CCSE services or programs.(c) A mandatory participant in the Medicaid Home and Community Based Services (HCBS) program must receive Primary Home Care (PHC) and Title XIX of the Social Security Act Day Activity and Health Services (DAHS) through the HCBS Program. Source Note: The provisions of this §271.51 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective February 1, 2008, 32 TexReg 7267; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.51 Eligibility for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226023 03/12/2026 To receive Community Care Services Eligibility services or programs, a person must:(1) be categorically eligible by receiving Supplemental Security Income (SSI), Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Medicaid, Specified Low-income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB) benefits; or(2) be income eligible. The person's and spouse's countable income must be equal to or less than the income limit set by HHSC. For an individual person, this amount is the same as the special income limit set for institutional care (medical assistance only) by the Texas Legislature. For a couple, the income limit is twice the special income limit. Source Note: The provisions of this §271.53 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective December 1, 1990, 15 TexReg 5504; amended to be effective January 1, 1992, 16 TexReg 6860; amended to be effective September 1, 1993, 18 TexReg 4645; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.53 Income and Income Eligibles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226024 03/12/2026 Countable income is determined by totaling gross income from all the following sources, less all applicable exclusions and exemptions. Applicable exclusions and exemptions are specified in §271.57 and §271.59 of this subchapter (relating to Eligibility).(1) Total gross earnings including money, wages, commissions, tips, piece-rate payments, cash bonuses, or salary received for work performed as an employee is considered income. This also encompasses pay for members of the armed forces, including allotments from any armed forces pay received by a member of the family group from a person not living in the home.(2) Self-employment income, including farm income, is considered self-employment income when either the applicant, client, or spouse is actively involved or materially participating in producing the income.(3) Social security and railroad retirement benefits are considered income.(4) Dividends from stocks or membership in associations, and periodic receipts from estates of trust funds are considered income. These payments are averaged over a 12-month period.(5) Rental payments to the person from the rent of housing, store, or other property, as well as from boarders or lodgers, is considered income.(6) Net income derived from oil, gas, or mineral rights is considered income and can include both lease and royalty payments. These payments are averaged over a 12-month period.(7) Payments received from mortgages or contracts is considered income.(8) Public assistance payments are considered income and include Temporary Assistance to Needy Families, Supplemental Security Income, and general assistance. Cash payments from a county or city are also included.(9) Veterans' pensions and compensation checks are considered income and may include money paid periodically by the Veterans Administration to disabled members of the armed forces or to survivors of deceased veterans, subsistence allowances paid to veterans for education and on-the-job training, and refunds paid to ex-servicemen as GI insurance premiums.(10) Educational loans, grants, fellowships, and scholarships are considered income.(11) Unemployment compensation received from government employment insurance agencies or private companies during periods of unemployment is considered income. Strike benefits received from union funds are also included.(12) Workers compensation and disability payments are considered income and include compensation received periodically from private or public insurance companies for injuries incurred at work.(13) Alimony is considered income.(14) Regular monthly cash support payments from friends or relatives is considered income.(15) Pensions, annuities, and irrevocable trust fund payments paid to a retired person or the retired person's survivors by a former employer or by a union, either directly or through an insurance company is considered income. Periodic payments from annuities, insurance, irrevocable trust fund payments, and civil service pensions are included.(16) Payments received from the applicant's or client's share of a life estate are considered income. Source Note: The provisions of this §271.55 adopted to be effective January 1, 1998, 22 TexReg 12544; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.55 Determination of Countable Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226025 03/12/2026 Income may be fully or partially countable or may be excluded from the current eligibility budget. Excludable income will continue to be monitored by the caseworker at each financial review to determine how eligibility is affected. Excludable sources of income include:(1) deductions from earned income, including social security payments, Medicare premium payments, bonds, pensions, and union dues;(2) the first $65 of an applicant's, client's, or couple's net earned income, plus 1/2 of the remainder;(3) loans, grants, scholarships, and fellowship funds obtained and used under conditions that preclude the use for current living costs; any portion used to pay any other expense cannot be excluded;(4) Veterans Administration aid-and-attendance benefits, homebound elderly benefits, and payments to certain eligible veterans for purchase of medications;(5) infrequent or irregular income received less frequently than once a month that averages $20 per month or less;(6) 1/3 of the total amount of child support payments for an eligible child; and(7) allowable exclusions from self-employment income, as indicated on the following chart.Attached Graphic Source Note: The provisions of this §271.57 adopted to be effective January 1, 1998, 22 TexReg 12544; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.57 Income from Excludable Sources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226026 03/12/2026 Exempt income is not included in the income eligibility calculation. Once identified and documented, caseworkers will not be required to monitor exempt income at subsequent financial redeterminations. Sources of exempt income include:(1) interest income;(2) cash received from the sale of a resource is a resource, not income;(3) income of minor children who are supported by or dependent upon the client;(4) refunds from the Internal Revenue Service for earned income tax credit;(5) reimbursement from an insurance company for health insurance claims;(6) any cash from a non-governmental medical or social services organization if the cash is:(A) for medical or social services already received by the applicant or client and approved by the organization, and which does not exceed the value of those services; or(B) a payment restricted to the future purchase of a medical or social service;(7) proceeds of either a commercial loan or an informal loan, for which repayment is required with or without interest:(A) the amount borrowed is not counted as income in the month in which it is received, but is considered to be a resource in the following months; and(B) to claim exemption of the proceeds of a loan, an applicant or client must prove that they acknowledge an obligation to repay and that a plan for repayment exists; if these conditions can be verified, no written contract is required;(8) the amount of the cost-of-living increase in any pension or benefit, received on or after January 1, 1985, that would cause the client to be ineligible for continued community care services or programs. This exclusion applies only to clients who are already receiving community care services or programs, or case management, and would become ineligible because of the increase; it does not apply to applicants;(9) in-kind income, such as food, clothing, shelter, rent subsidies;(10) one-time or lump-sum payments from any source;(11) payments from the Agent Orange Settlement Fund or any other fund established in settlement of the Agent Orange product liability litigation, as Public Law 101-239 exempts the payments from countable income and resources; the law is retroactive as of January 1, 1989;(12) any payment received under the Radiation Exposure Compensation Act (Public Law 101-246);(13) any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;(14) payments to volunteers under the Domestic Volunteer Services Act, this exclusion applies to:(A) any payments to volunteers in the Retired Senior Volunteer Program, Foster Grandparent Program, and the Senior Companion Program; and(B) payments under Title III of the same act, which includes the Service Corps of Retired Executives (SCORE), the Active Corps of Executives (ACE), and the Action Cooperative Volunteer Program (ACV);(15) interest or other earnings on any designated account established for Supplemental Security Income (SSI) clients under 18 years of age for retroactive benefits, as required by Public Law 104-193, effective August 22, 1996;(16) payments by the Federal Disaster Assistance Administration authorized by the Disaster Relief Act, as amended;(17) value of any housing assistance paid on a house under the United States Housing Act of 1937, the National Housing Act, the Housing and Urban Development Act of 1965, §101, or Title V of the Housing Act of 1949, as authorized by Public Law 94-375;(18) home energy assistance, except food or clothing, under Public Laws 97-377 and 97-424 is assistance in cash or in-kind that is provided by a private, nonprofit organization or a utility company, and examples include heating, cooling, weatherization, storm windows, and blankets;(19) reparation payments received by Holocaust survivors from the Federal Republic of Germany made periodically or as a lump sum, and HHSC accepts the applicant's or client's signed statement of amounts involved and dates of payment; Public Law 101-508 established this exemption effective January 1, 1991;(20) payments from a state-administered fund to aid victims of crime; Public Law 101-508 established this exemption effective May 1, 1991;(21) payments a state or local government may make as relocation assistance; Public Law 101-508 established this exemption effective October 15, 1990;(22) hazardous duty pay of a spouse or parent absent from the home because of active military service;(23) restitution payments made by the United States government under Public Law 100-383 to Japanese-Americans or, to the Japanese-Americans' survivors, who were interned or relocated during World War II;(24) reparation payments received under §§500-506 of the Austrian General Social Insurance Act;(25) payments under the Netherlands' Act on Benefits for Victims of Persecution Wet Uitkering Vervolgingsslachtoffers (WUV) 1940-1945; or(26) payment from any source made to an applicant or a client because of the applicant's or client's status as victims of Nazi persecution; Public Law 103-286 established this exemption effective August 1, 1994. Source Note: The provisions of this §271.59 adopted to be effective January 1, 1998, 22 TexReg 12544; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.59 Income from Exempt Sources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226027 03/12/2026 (a) A person must be at least 18 years of age, or an emancipated minor, to receive Community Care Services Eligibility (CCSE) services or programs, except:(1) a person of any age may receive CCSE Medicaid-funded day activity and health services;(2) a person of any age who is not eligible for the Texas STAR Kids program may receive CCSE Medicaid-funded Community Attendant Services; and(3) a person must be at least 21 years of age to receive CCSE Primary Home Care services, except a current CCSE Primary Home Care services client who is eligible for Texas STAR Kids and who becomes 21 years of age on or before February 29, 2008.(b) A person under 21 years of age who is eligible for the Texas STAR Kids program may be eligible for community care services or programs provided through the Texas STAR Kids program. Source Note: The provisions of this §271.61 adopted to be effective February 2, 1989, 13 TexReg 5751; amended to be effective July 1, 1991, 16 TexReg 3197; amended to be effective September 3, 1991, 16 TexReg 4493; amended to be effective September 1, 2007, 32 TexReg 5385; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.61 Age https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226028 03/12/2026 (a) HHSC uses the HHSC Needs Assessment Questionnaire and Task/Hour Guide form to determine a person's functional need and unmet need for:(1) Community Attendant Services (CAS);(2) Family Care (FC);(3) Primary Home Care (PHC);(4) Home Delivered Meals (HDM);(5) Adult Foster Care (AFC);(6) Residential Care (RC);(7) Consumer Managed Personal Attendant Services (CMPAS);(8) Emergency Response Services (ERS); and(9) Special Services to Persons with Disabilities Program (SSPD).(b) To receive a service or program described in subsection (a) of this section, a person must have a functional need and an unmet need for the program or service. Source Note: The provisions of this §271.63 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective May 23, 2016, 41 TexReg 3749; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.63 Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226029 03/12/2026 (a) Type of payment. The following statutes provide that some payments made to members of Indian tribes are exempt from income and resources as specified in paragraphs (1)-(4) of this subsection, or only from income as specified in paragraph (5) of this subsection.(1) Indian Judgment Funds Distribution Act--Public Law 93-134. Effective October 19, 1973, per capita distribution payments to members of Indian tribes who are due judgment funds, according to a plan of the Secretary of the Interior or, legislation when a plan cannot be prepared or is not approved by Congress, are exempted from income and resources. This does not include payments of funds distributed or held in trust according to public laws enacted before October 19, 1973.(2) Distribution of Indian Judgment Funds--Public Law 97-458. Effective January 12, 1983, Indian judgment funds held in trust or distributed per capita, pursuant to an approved plan, or the fund's availability, are exempted from income and resources. Indian judgment funds include interest and investment income accrued while the funds are held in trust. Initial purchases made with distributed judgment funds are exempted from resources.(3) Per Capita Act--Public Law 98-64.(A) Effective August 2, 1983, per capita distributions of all funds held in trust by the Secretary of the Interior to members of an Indian tribe are exempted from income and resources.(B) Any local tribal funds that a tribe distributes to individuals on a per capita basis, but which have not been held in trust by the Secretary of the Interior are not exempted from income and resources under this provision. Example: Tribally-managed gaming revenues.(4) Alaska Native Claims Settlement Act (ANCSA)--Public Law 100-241.(A) Effective February 3, 1988, the following items received from a native corporation are exempted from income and resources: (i) cash received from a native corporation, including cash dividends on stock received from a native corporation, to the extent it does not exceed $2,000, per individual per year;(ii) stock, including stock issued or distributed by a native corporation as a dividend or distribution on stock;(iii) a partnership interest;(iv) land or an interest in land, including land or an interest in land received from a native corporation as a dividend or distribution on stock; and(v) an interest in a settlement trust.(B) The ANCSA also provides that up to $2,000 in retained distributions from a native corporation may be exempted from resources for each year beginning with 1988.(5) Payments from Individual Interests in Trust or Restricted Lands--Public Law 103-66.(A) Effective January 1, 1994, up to $2,000 per year received by Indians that is derived from individual interests in trust or restricted lands is exempted from income.(B) Interests of individual Indians in trust or restricted lands are exempted from resources.(b) Payments to specific Indian tribes and groups. The following statutes provide that certain payments made to members of specified Indian tribes and groups are exempt from income and resources. (1) Distribution of Per Capita Funds--Public Law 85-794. Effective August 28, 1958, per capita payments to members of the Red Lake Band of Chippewa Indians from the proceeds of the sale of timber and lumber on the Red Lake Reservation are exempted from income and resources.(2) Distribution of Judgment Funds--Public Law 92-254. Effective March 18, 1972, per capita distribution payments by the Blackfeet and Gros Ventre tribal governments to members, which resulted from judgment funds to the tribes, are exempted from income and resources. (3) Distribution of Claims Settlement Funds--Public Law 93-531 and Public Law 96-305. Effective December 22, 1974, settlement fund payments to members of the Hopi and Navajo Tribes, and the availability of such funds, are exempted from income and resources.(4) Receipts from Lands Held in Trust for Indian Tribes--Public Law 94-114.(A) Effective October 17, 1975, receipts derived from the following trust lands and distributed to members of designated Indian tribes are exempted from income and resources.(B) The first four Indian groups had lands conveyed with mineral rights before Public Law 94-114; that law conveyed the rest of the lands to the remaining Indian groups.Attached Graphic(5) Distribution of Judgment Funds--Public Law 94-189. Effective December 31, 1975, judgment funds distributed per capita to, or held in trust for, members of the Sac and Fox Indian Nation, and the availability of such funds, are exempted from income and resources. (6) Distribution of Judgment Funds--Public Law 94-540. Effective October 18, 1976, judgment funds distributed per capita to, or held in trust for, members of the Grand River Band of Ottawa Indians, and the availability of such funds, are exempted from income and resources.(7) Distribution of Judgment Funds--Public Law 95-433. Effective October 10, 1978, any judgment funds distributed per capita to members of the Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation are exempted from income and resources.(8) Receipts from Lands Held in Trust--Public Law 95-498. Effective October 21, 1978, receipts derived from trust lands awarded to the Pueblo of Santa Ana and distributed to members of that tribe are exempted from income and resources.(9) Receipts from Lands Held in Trust--Public Law 95-499. Effective October 21, 1978, receipts derived from trust lands awarded to the Pueblo of Zia and distributed to members of that tribe are exempted from income and resources.(10) Distribution of Judgment Funds--Public Law 96-318. Effective August 1, 1980, any judgment funds distributed per capita or made available for programs for members of the Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma are exempted from income and resources.(11) Maine Indian Claims Settlement Act--Public Law 96-420. Effective October 10, 1980, all funds and distributions to members of the Passamaquoddy Tribe, the Penobscot Nation, and the Houlton Band of Maliseet Indians under the Maine Indian Claims Settlement Act, and the availability of such funds, are exempted from income and resources.(12) Distribution of Judgment Funds--Public Law 97-95. Effective December 17, 1981, any distributions of judgment funds to members of the San Carlos Tribe of Arizona are exempted from income and resources.(13) Distribution of Judgment Funds--Public Law 97-371. Effective December 20, 1982, any distributions of judgment funds to members of the Wyandot Tribe of Indians of Oklahoma are exempted from income and resources.(14) Distribution of Judgment Funds--Public Law 97-372. Effective December 20, 1982, distributions of judgment funds to members of the Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, the Eastern Shawnee Tribe of Oklahoma, and the Cherokee Band of Shawnee descendants) are exempted from income and resources.(15) Distribution of Judgment Funds--Public Law 97-376. Effective December 21, 1982, judgment funds distributed per capita or made available for programs for members of the Miami Tribe of Oklahoma and the Miami Indians of Indiana are exempted from income and resources.(16) Distribution of Judgment Funds--Public Law 97-402. Effective December 31, 1982, distributions of judgment funds to members of the Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribal Community, and the Jamestown Band of Clallam Indians) are exempted from income and resources.(17) Distribution of Judgment of Funds--Public Law 97-403. Effective December 31, 1982, judgment funds distributed per capita or made available for programs for members of the Pembina Chippewa Indians (Turtle Mountain Band, Chippewa Cree Tribe, Minnesota Chippewa Tribe, and Little Shell Band of Chippewa Indians of Montana) are exempted from income and resources.(18) Distribution of Judgment Funds--Public Law 97-408. Effective January 3, 1983, per capita distributions of judgment funds to members of the Gros Ventre and Assiniboine Tribes of Fort Belknap Indian Community, and the Papago Tribe of Arizona, are exempted from income and resources.(19) Distribution of Judgment Funds--Public Law 97-436. Effective January 8, 1983, up to $2,000 of per capita distributions of judgment funds to members of the Confederated Tribes of the Warm Springs Reservation are exempted from income and resources.(20) Distribution of Judgment Funds--Public Law 98-123. Effective October 13, 1983, judgment funds distributed to the Red Lake Band of Chippewa Indians are exempted from income and resources.(21) Distribution of Judgment Funds--Public Law 98-124. Effective October 13, 1983, funds distributed per capita or family interest payments for members of the Assiniboine Tribe of the Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana are exempted from income and resources.(22) Distribution of Claims Settlement Funds--Public Law 98-432. Effective September 28, 1984, judgment funds and income therefrom distributed to members of the Shoalwater Bay Indian Tribe are exempted from income and resources.(23) Distribution of Claims Settlement Funds--Public Law 98-500. Effective October 19, 1984, all distributions to heirs of certain deceased Indians under the Old Age Assistance Claims Settlement Act are exempted from income and resources.(24) Distribution of Judgment Funds--Public Law 98-602. Effective October 30, 1984, judgment funds distributed per capita or made available for any tribal program, for members of the Wyandotte Tribe of Oklahoma and the Absentee Wyandottes, are exempted from income and resources.(25) Distribution of Judgment Funds--Public Law 99-130. Effective October 28, 1985, per capita and dividend payment distributions of judgment funds to members of the Santee Sioux Tribe of Nebraska, the Flandreau Santee Sioux Tribe, and the Prairie Island Sioux, Lower Sioux, and Shakopee Mdewakanton Sioux Communities of Minnesota are exempted from income and resources.(26) Distribution of Judgment funds--Public Law 99-146. Effective November 11, 1985, funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi are exempted from income and resources.(27) Distribution of Claims Settlement Funds--Public Law 99-264. Effective March 24, 1986, distributions of claims settlement funds to members of the White Earth Band of Chippewa Indians as allottees, or the member's heirs, are exempted from income and resources.(28) Distribution of Judgment Funds--Public Law 99-346. Effective June 30, 1986, payments or distributions of judgment funds, and the availability of any amount for such payments or distributions, to members of the Saginaw Chippewa Indian Tribe of Michigan are exempted from income and resources.(29) Distribution of Judgment Funds--Public Law 99-377. Effective August 8, 1986, judgment funds distributed per capita or held in trust for members of the Chippewas of Lake Superior and the Chippewas of the Mississippi are exempted from income and resources.(30) Distribution of Judgment Funds--Public Law 100-139. Effective October 26, 1987, judgment funds distributed to members of the Cow Creek Band of Umpqua Tribe of Indians are exempted from income and resources.(31) Aleutian and Pribil of Islands Restitution Act--Public Law 100-383. Effective August 10, 1988, per capita restitution payments made to eligible Aleuts who were relocated or interned during World War II are exempted from income and resources.(32) Distribution of Claims Settlement Funds--Public Law 100-411. Effective August 22, 1988, per capita payments of claims settlement funds to members of the Coushatta Tribe of Louisiana are exempted from income and resources.(33) Hoopa-Yurok Settlement Act--Public Law 100-580. Effective October 31, 1988, funds distributed per capita for members of the Hoopa Valley Indian Tribe and the Yurok Indian Tribe are exempted from income and resources.(34) Distribution of Judgment Funds--Public Law 100-581. Effective November 1, 1988, judgment funds held in trust by the United States, including interest and investment income accruing on such funds, and judgment funds made available for programs or distributed to members of the Wisconsin Band of Potawatomi (Hannahville Indian Community and Forest County Potawatomi) are exempted from income and resources.(35) Distribution of Money and Land--Public Law 101-41. Effective June 21, 1989, all funds, assets, and income from the trust fund transferred to the members of the Puyallup Tribe under the Puyallup Tribe of Indians Settlement Act of 1989 are exempted from income and resources.(36) Distribution of Judgment Funds--Public Law 101-277. Effective April 30, 1990, judgment funds distributed per capita, or held in trust, or made available for programs, for members of the Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Indians of Florida, and the independent Seminole Indians of Florida (plus any interest and investment income accruing on the funds held in trust), and the availability of those funds, are exempted from income and resources.(37) Distribution of Settlement Funds--Public Law 101-503. Effective November 3, 1990, payments, funds, distributions, or income derived from them under the Seneca Nation Settlement Act of 1990 are exempted from income and resources.(38) Distribution of Settlement Fund--Public Law 101-618. Effective November 16, 1990, per capita distributions of settlement funds under the Fallon Paiute Shoshone Indian Tribes Water Rights Settlement Act of 1990 are exempted from income and resources.(39) Distribution of Settlement Funds--Public Law 103-116. Settlement funds, assets, income, payments or distributions from trust funds to members of the Catawba Indian Tribe under the Catawba Indian Tribe of South Carolina Land Claims Settlement Act of 1993 are exempted from income and resources.(40) Distribution of Settlement Funds--Public Law 103-436. Effective November 2, 1994, settlement funds held in trust, including interest and investment income accruing on such funds, and payments made to members of the Confederated Tribes of the Colville Reservation under the Confederated Tribes of the Colville Reservation Grand Coulee Dam Settlement Act are exempted from income and resources.(41) Distribution of Settlement Funds--P.L. 103-444. Payments made or benefits granted by the Crow Boundary Settlement Act of 1994 are excluded from income and resources.(42) Western Shoshone Claims Distribution Act--P.L. 108-270. Effective July 7, 2004, per capita distribution judgment funds to members of the Western Shoshone Indians are excluded from income and resources. Source Note: The provisions of this §271.65 adopted to be effective January 1, 1998, 22 TexReg 12544; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.65 Indian-related Exemptions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214474 03/12/2026 Some services and programs described in this chapter are not available in all geographic areas of Texas. Source Note: The provisions of this §271.67 adopted to be effective February 2, 1989,13 TexReg 5751; amended to be effective May 23, 2016, 41 TexReg 3749; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.67 Service Availability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226030 03/12/2026 (a) To receive Family Care (FC) services, a person must meet the minimum functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to receive FC, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility.(1) A person must meet the income and resource guidelines established by HHSC in §§271.53, 271.55, 271.89, and 271.91 of this subchapter (relating to Eligibility); and(2) be ineligible to receive attendant care services funded through Medicaid.(b) If eligible, a person may receive one or more of the following services:(1) personal care;(2) household tasks;(3) meal preparation; and(4) escort.(c) Family Care services are provided in a client's residence. A person is not eligible to receive Family Care services while living in:(1) a hospital;(2) a skilled nursing facility;(3) an intermediate care facility;(4) an assisted living facility;(5) a foster care setting;(6) a jail or prison;(7) a state supported living center;(8) a state hospital; or(9) any other setting where sources outside the family care program are available to provide care.(d) The person must require at least six hours of Family Care services per week to be eligible, unless the person:(1) requires Family Care to provide caregiver support to the caregiver;(2) lives in the same home as another client receiving Family Care (FC) services, Home and Community-based Services (HBCS) personal assistance services, Community Attendant Services (CAS), or Primary Home Care (PHC) services;(3) receives one or more of the following services through HHSC or other resources:(A) Congregate or Home Delivered Meals;(B) assistance with activities of daily living from a home health aide;(C) Day Activity and Health Services; or(D) Special Services to Persons with Disabilities in day activity and health services;(4) receives aid-and-attendance benefits from the Veterans Administration; or(5) is determined, based upon the functional assessment, to be at high risk of institutionalization without Family Care.(e) The caseworker establishes a priority status for each person based on the functional assessment. A person is considered to have priority status if the following criteria are met.(1) The person is completely unable to perform one or more of the following activities without hands-on assistance from another person:(A) transferring into or out of bed or a chair, or on or off a toilet;(B) feeding;(C) getting to or using the toilet;(D) preparing a meal; or(E) taking self-administered prescribed medications.(2) During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the family care attendant.(3) The caseworker determines that there is a high likelihood the person's health, safety, or well-being would be jeopardized if family care services were not provided on a single given shift.(f) A client with priority status may receive no more than 42 hours of service per week.(g) A client without priority status may receive no more than 50 hours of service per week. Source Note: The provisions of this §271.69 adopted to be effective March 29, 1982, 7 TexReg 1190; amended to be effective March 1, 1983, 8 TexReg 525; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective January 11, 1985, 9 TexReg 6188; amended to be effective January 1, 1986, 10 TexReg 4696; amended to be effective July 1, 1986, 11 TexReg 2827; amended to be effective December 1, 1986, 11 TexReg 4581; amended to be effective May 15, 1989, 14 TexReg 1935; amended to be effective September 1, 1990, 15 TexReg 4579; amended to be effective May 15, 1992, 17 TexReg 3162; amended to be effective August 5, 1992, 17 TexReg 5121; amended to be effective October 1, 1992, 17 TexReg 6374; amended to be effective November 15, 1992, 17 TexReg 7464; amended to be effective September 1, 1993, 18 TexReg 4754; amended to be effective September 1, 1993, 18 TexReg 4881; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.69 Family Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226031 03/12/2026 To receive Home Delivered Meals (HDM), a person must meet the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure a person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to receive HDM, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility. Source Note: The provisions of this §271.71 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective April 15, 1996, 21 TexReg 2404; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.71 Home-Delivered Meals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226032 03/12/2026 To receive Adult Foster Care (AFC), a person must have the approval of the Community Care Services Eligibility unit supervisor and meet the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to be eligible, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility. Source Note: The provisions of this §271.73 adopted to be effective March 29, 1982, 7 TexReg 1190; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective July 1, 1986, 11 TexReg 2827; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.73 Adult Foster Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226033 03/12/2026 To receive Special Services to Persons with Disabilities (SSPD), a person must meet the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure a person's ability to perform activities of daily living. This yields a score, which is a measure of a person's level of functional need. HHSC sets the minimum required score for a person to receive SSPD, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility. An applicant may be admitted to the SSPD program only if the applicant's needs do not exceed the program's available services. Source Note: The provisions of this §271.75 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective October 16, 1989, 14 TexReg 4788; amended to be effective October 1, 1992, 17 TexReg 6374; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.75 Special Services to Persons with Disabilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226034 03/12/2026 To be eligible for Day Activity and Health Services (DAHS), a person must:(1) be Medicaid-eligible or meet the income and resource guidelines established in §§271.53, 271.55, 271.89, and 271.91 of this subchapter (relating to Eligibility);(2) have an unmet need for DAHS as determined by HHSC;(3) while receiving DAHS, not receive a service that is identified as being mutually exclusive to DAHS in the Mutually Exclusive Services table in Appendix XX of the Community Care Services Eligibility Handbook available at www.hhs.texas.gov;(4) have a chronic medical diagnosis and physician's orders for DAHS on the HHSC Day Activity and Health Services (DAHS) Physician's Orders form; and(5) have one or more functional limitations and the potential for receiving therapeutic benefit from DAHS as determined by HHSC review of the Day Activity and Health Services (DAHS) Health Assessment/Individual Service Plan form completed in accordance with §211.203 of this title (relating to Written Referrals for Services) or §211.204 of this title (relating to DAHS Facility-Initiated Referrals). Source Note: The provisions of this §271.77 adopted to be effective August 31, 2004, 29 TexReg 8376; amended to be effective May 23, 2016, 41 TexReg 3749; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.77 Day Activity and Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226035 03/12/2026 A person must meet the eligibility criteria for Community Care Services Eligibility (CCSE) services or programs, but the person does not have to receive the services to receive case management. Ineligible applicants receiving only information and referral services are not eligible for case management. Source Note: The provisions of this §271.79 adopted to be effective February 1, 1989, 13 TexReg 5751; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.79 Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226036 03/12/2026 (a) To be eligible for Primary Home Care (PHC) or Community Attendant Services (CAS) a person must meet the minimum functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to receive PHC, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility. A person must also:(1) be Medicaid-eligible in a community setting or be eligible under the provisions of the Social Security Act, §1929(b)(2)(B); (2) have a medical need for assistance with personal care:(A) the person's medical condition must be the cause of the person's functional impairment in performing personal care tasks; and(B) a person diagnosed with mental illness, intellectual and developmental disabilities, or both, are not considered to have established medical need based solely on such diagnosis, however, the diagnoses do not disqualify a person for eligibility as long as the person's functional impairment is related to a coexisting medical condition;(3) have a signed and dated practitioner's statement that includes a statement that the person has a current medical need for assistance with personal care tasks and other activities of daily living and:(A) requires at least six hours of service per week; or(B) requires fewer than six hours of service per week and may be eligible if the person:(i) requires primary home care or community attendant services to provide caregiver support to the caregiver;(ii) lives in the same home as another person receiving Primary Home Care, Community Attendant Services, Family Care, or Texas Home and Community-Based Services (HCBS) personal assistance services;(iii) receives one or more of the following services through HHSC or other resources:(I) Congregate or Home Delivered Meals;(II) assistance with activities of daily living from a home health aide;(III) Day Activity and Health Services; or(IV) Special Services to Persons with Disabilities in day activity and health services;(iv) receives aid-and-attendance benefits from the Veterans Administration; (v) receives services through the Medically Dependent Children Program (MDCP); or(vi) is determined, based upon the functional assessment, to be at high risk of institutionalization without Primary Home Care or Community Attendant Services.(b) To receive services, a person must reside in a place other than:(1) a hospital;(2) a skilled nursing facility;(3) an intermediate care facility;(4) an assisted living facility;(5) a foster care setting;(6) a jail or prison;(7) a state supported living center;(8) a state hospital; or(9) any other setting where sources outside the primary home care or community attendant program are available to provide personal care.(c) A client with priority status may receive no more than 42 hours of service per week. A client without priority status may receive no more than 50 hours of service per week.(d) The caseworker establishes a priority status for each client based on the functional assessment. A client is considered to have priority status if the following criteria are met.(1) The client is completely unable to perform one or more of the following activities without hands-on assistance from another person:(A) transferring into or out of bed or a chair, or on or off a toilet;(B) feeding;(C) getting to or using the toilet;(D) preparing a meal; or(E) taking self-administered prescribed medications.(2) During a normally scheduled service shift, no one is readily available who is capable and who is willing to provide the needed assistance other than the attendant.(3) The caseworker determines that there is a high likelihood the client's health, safety, or well-being would be jeopardized if services are not provided on a single given shift. Source Note: The provisions of this §271.81 adopted to be effective November 1, 1982, 7 TexReg 3504; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective January 1, 1986, 10 TexReg 4696; amended to be effective July 1, 1986, 11 TexReg 2827; amended to be effective October 21, 1988, 13 TexReg 4529; amended to be effective September 1, 1990, 15 TexReg 4579; amended to be effective September 3, 1991, 16 TexReg 4493; amended to be effective May 15, 1992, 17 TexReg 3162; amended to be effective July 1, 1992, 17 TexReg 3999; amended to be effective August 5, 1992, 17 TexReg 5121; amended to be effective October 1, 1992, 17 TexReg 6374; amended to be effective November 15, 1992, 17 TexReg 7464; amended to be effective September 1, 1993, 18 TexReg 4754; amended to be effective October 1, 1994, 19 TexReg 6234; amended to be effective July 1, 1996, 21 TexReg 5326; amended to be effective February 15, 1997, 22 TexReg 905; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.81 Primary Home Care or Community Attendant Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226037 03/12/2026 (a) Allocation of time for escort services on the client needs assessment is allowed only if it can be documented that one of the following occurs at least once a month:(1) accompanying the client to a clinic, doctor's office, or other trips made for the purpose of obtaining medical diagnosis or treatment; or(2) waiting in the doctor's office or clinic with a client when necessary due to the client's condition or distance from home.(b) Additional time may not be allocated for escort services for purposes other than those described in subsection (a) of this section. However, the client may elect to substitute escort services for time allotted to any other task. Source Note: The provisions of this §271.83 adopted to be effective March 15, 1999, 24 TexReg 1193; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.83 Time Allocation for Escort Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226038 03/12/2026 (a) Eligibility for Residential Care (RC) is based on the following criteria.(1) The person must be income eligible or Medicaid-eligible, not in an institution.(2) The person must meet the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to receive RC, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility.(3) The person's needs may not exceed the facility's capability under its licensed authority.(4) The person must have financial resources at or below the level established by HHSC.(b) The client must contribute to the total cost of the care that the client receives, including payment for room and board. The room and board amount is calculated from the client's gross income. The client is responsible for paying this amount directly to the provider agency. The client may be required to pay a copayment based on the amount of income remaining after all allowances are deducted. (1) The client keeps a monthly allowance for the client's personal and medical expenses. The Medicaid client keeps $123; a qualified Medicare beneficiary, non-Medicaid, keeps $182; and the non-Medicaid, non-QMB client keeps $211 and the part B Medicare premium fee.(2) In addition to the monthly allowance, a client with earned income keeps all of the earned income up to a maximum of $65 per month.(3) The client's contribution must not, when added to HHSC's payment, exceed the rate established for residential care.(c) The client is eligible for 14 days of personal leave from the residential care facility each calendar year. If the client does not pay the bedhold charge for days of personal leave that exceed the limits, the client may lose their space in the facility.(d) To reserve the client's space in the facility during hospital, nursing home, or institutional stays, the client must pay the copayment or the facility's bedhold charge, whichever is lower. If the copayment amount is less than the bedhold charge, HHSC pays the difference. Nursing home and institutional stays are limited to 30 days. There is no limit to the length of hospital stays. Source Note: The provisions of this §271.85 adopted to be effective December 5, 1986, 11 TexReg 4755; amended to be effective April 15, 1990, 15 TexReg 1070; amended to be effective January 1, 1992, 16 TexReg 6860; amended to be effective March 15, 1999, 24 TexReg 1193; amended to be effective September 1, 2003, 28 TexReg 6951; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.85 Residential Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226039 03/12/2026 (a) Eligibility for Emergency Care (EC) is based on the following criteria:(1) the applicant:(A) has lost their home or caregiver; or(B) has been discharged from a hospital or institution; or(C) is in a similar emergency situation; and(2) the applicant:(A) is income-eligible or Medicaid-eligible, not in an institution; and(B) meets the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the applicant's ability to perform activities of daily living. This yields a score, which is a measure of the applicant's level of functional need. HHSC sets the minimum required score for a person to receive EC, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility.(3) The applicant's needs may not exceed the facility's capability under its licensed authority.(b) A client receiving Emergency Care is eligible for services for up to and including 30 days while HHSC seeks a permanent care arrangement. If the client is not placed within the initial 30-day period, the client is eligible to receive services for up to one 30-day extension, for a total of 60 days.(c) Emergency Care is terminated by HHSC when the approved service period is over or when suitable care arrangements have been made. HHSC redetermines Emergency Care eligibility each time a request for services is made. Source Note: The provisions of this §271.87 adopted to be effective March 1, 1983, 8 TexReg 530; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective June 1, 1985, 10 TexReg 1293; amended to be effective December 5, 1986, 11 TexReg 4755; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.87 Emergency Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226040 03/12/2026 A person is not eligible for Community Care Services Eligibility (CCSE) services or programs if the value of nonexempt resources owned by the person exceeds $5,000. A couple is not eligible for CCSE services if the value of nonexempt resources the couple owns exceeds $6,000. Source Note: The provisions of this §271.89 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective December 1, 1990, 15 TexReg 6198; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.89 Resource Limits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226041 03/12/2026 In determining eligibility for Community Care Services Eligibility (CCSE) services or programs, HHSC considers the following to be resources. (1) Liquid resources, including cash on hand, certificates of deposit, checking or savings accounts, money market funds, revocable trust funds, savings certificates, stocks, or bonds. Liquid resources also include the person's or couple's portion of money in a checking or savings account or a money market fund held jointly with another person.(A) Jointly held liquid resources are the resources of the person if the person has unrestricted access to the funds regardless of the source. The person may move the portion of jointly held funds in a joint account to a new account. The new account may be jointly owned, but all funds in the new account are the person's.(B) Money received as a nonrecurring lump sum payment is not considered a resource until 30 days after the date of receipt. Lump sum payments include, but are not limited to, income tax refunds; earned income tax credits or rebates; one-time bonuses from mineral rights; retroactive lump sum social security, SSI, or railroad retirement benefits; lump sum insurance settlements; one-time gifts, awards, or prizes; and refunds from rental or utility deposits. The person is responsible for reporting the receipt of a lump sum payment.(2) Nonliquid resources, including nonexempt licensed or unlicensed vehicles; buildings and land not designated as homestead that are not producing income or are producing income less than 6% of the equity value; and any other property not specifically excluded. Source Note: The provisions of this §271.91 adopted to be effective February 1, 1989, 13 TexReg 5751; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.91 Countable Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226042 03/12/2026 In determining eligibility for Community Care Services Eligibility (CCSE) services or programs, HHSC does not consider the following to be resources and are considered to be excluded for eligibility purposes. Any item not listed as an exclusion is considered a resource.(1) Homestead is any structure used by the person as a home, including other buildings and all contiguous land. Mobile homes, houseboats, and motor homes are considered structures. Vacant property is not a homestead. Contiguous land means all land adjacent to the home, including any land separated only by roads, rivers, and streams. Land is contiguous as long as it is not separated by property owned by another person. The homestead is excluded as a resource regardless of its location, even if the person no longer lives there, unless the person has purchased another residence. If the person owns two houses, the person's homestead is the property the person uses as a home. Only one homestead may be excluded for each person or couple.(2) Personal property includes household goods and personal effects.(3) Property essential to employment includes tools and equipment required for employment or self-employment.(4) Prepaid burials include burial arrangements, burial insurance, and burial plots.(5) Life insurance is the cash surrender value of all life insurance.(6) Vehicles include:(A) one passenger car or other vehicle, such as a van or truck, used for transportation, or one unlicensed vehicle;(B) a second vehicle may be excluded if it is:(i) specially equipped to enable a person with a disability to drive; or(ii) essential to the employment or self-employment of the family; and(C) any additional vehicles, licensed or unlicensed, are considered resources.(7) Income-producing property that annually produces net income equal to or greater than 6% of the property's equity value. The equity value is the current market value of the property less any recorded encumbrances.(8) Installment contracts from mortgages, notes, or loans are the value of installment contracts for the sale of land, other property, or repayment of loans, if the contract or agreement is producing income according to the fair market value at the time of the agreement. An installment is a mortgage or similar contract in which the buyer promises to pay a fixed amount over a period of time until the principal of the note is paid. Even though the seller retains legal title, the property is not considered a countable resource as long as the buyer is fulfilling the contractual obligation. The payment is considered income.(9) Disaster assistance includes government payments granted for the rebuilding of homes destroyed or damaged in a disaster.(10) Energy assistance includes payments or allowances for energy assistance made under any federal, state, or local law.(11) Supplemental Nutrition Assistance Program (SNAP) benefits are the value of SNAP benefits and USDA-donated foods.(12) Inaccessible resources are the cash value of resources inaccessible to the person, including irrevocable trust funds, property in probate, and pension funds. Real property that the person or family is making a good faith effort to sell is exempt. The person or family must ask a fair price for the property, according to its current market value. Property is also exempt if it is jointly owned and the other co-owners refuse to sell.(13) Mineral rights are the value of mineral rights.(14) A life estate is the right a person has to property during a person's lifetime. A remainder interest is the right of ownership to the property when the life estate holder dies.(15) Replacement value of excluded resources if lost, damaged, or stolen is the cash received from an insurance company for replacing the resource and is not considered for three months if it is real property. Any cash not spent within the specified time period is considered a resource.(16) Monthly gross income is all income received monthly and is counted as income in the month received and excluded as a resource in that month.(17) Sale of a homestead are proceeds from the sale of a homestead up to six months after the proceeds become available to the seller. The six months gives the person time to acquire another homestead. If the person does so, any balance from the original sale must be considered as an available resource. If, before the end of the six-month period, the person declares the person has no intention of acquiring another homestead, the proceeds from the sale must be counted as an available resource.(18) Agent Orange settlement payments received from the Agent Orange settlement fund or any other fund established in settlement of the Agent Orange product liability litigation.(19) Radiation exposure compensation payments received under the Radiation Exposure Compensation Act (Public Law 101-246).(20) livestock are not counted as a resource;(21) earned income tax credit (EITC) refunds from the Internal Revenue Service are not counted as a resource. Source Note: The provisions of this §271.93 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective December 1, 1990, 15 TexReg 6198; amended to be effective December 1, 1991, 16 TexReg 5406; amended to be effective January 1, 1992, 16 TexReg 6860; amended to be effective September 1, 1993, 18 TexReg 4645; amended to be effective July 1, 1994, 19 TexReg 4200; amended to be effective August 1, 1994, 19 TexReg 5105; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.93 Resource Exclusions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226043 03/12/2026 (a) To receive Emergency Response Services (ERS), a person must meet the functional need criteria as set by HHSC. HHSC uses a standardized assessment instrument to measure the person's ability to perform activities of daily living. This yields a score, which is a measure of the person's level of functional need. HHSC sets the minimum required score for a person to receive ERS, which HHSC may periodically adjust commensurate with available funding. HHSC will seek stakeholder input before making any change in the minimum required score for functional eligibility.(b) The person must also meet the following requirements:(1) live alone, be alone routinely for eight or more hours each day, or live with a person who could not call for help or otherwise assist the applicant or client in an emergency;(2) be mentally alert enough to operate the equipment properly, in the judgment of the HHSC caseworker;(3) have a phone with a private line, if the system requires a private line to function properly;(4) be willing to sign a release statement that allows the responder to make a forced entry into the applicant's or client's home if the responder is asked to respond to an activated alarm call and has no other means of entering the home to respond; and(5) live in a place other than a skilled institution, assisted living facility, foster care setting, or any other setting where 24-hour supervision is available. Source Note: The provisions of this §271.95 adopted to be effective May 1, 1984, 9 TexReg 2166; amended to be effective August 1, 1984, 9 TexReg 3876; amended to be effective July 1, 1986, 11 TexReg 2827; amended to be effective April 29, 1988, 13 TexReg 1547; amended to be effective April 15, 1996, 21 TexReg 2404; amended to be effective August 31, 2004, 29 TexReg 8376; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.95 Emergency Response Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226044 03/12/2026 A Residential Care client cannot receive Residential Care services and Community Attendant Services, Family Care, or Primary Home Care services at the same time. Source Note: The provisions of this §271.97 adopted to be effective December 5, 1986, 11 TexReg 4755; amended to be effective August 15, 1988, 13 TexReg 3649; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY C ELIGIBILITY §271.97 Residential Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226045 03/12/2026 (a) Information collected to determine eligibility for services, whether collected by HHSC staff or provider agencies, is confidential.(b) The applicant is entitled to an interview during HHSC's determination of an applicant's eligibility for Community Care Services Eligibility (CCSE) services. A person who is already receiving services from HHSC or for whom the Social Security Administration has already verified that income and resources are below the CCSE income or resource limit is not required to submit an application.(c) An applicant or the applicant's responsible person applying for services provided with regard to income must sign an application for assistance form. A non-Medicaid applicant or the applicant's responsible person applying for retroactive reimbursement for Medicaid-covered attendant services must also sign an application for assistance form. The date of application is the date HHSC receives the signed application. Applicants must provide accurate information about income and resources.(d) Eligibility for CCSE services for an income-eligible applicant is determined within 30 calendar days after a signed application is received. For categorically-eligible applicants, eligibility must be determined within 30 calendar days after either the applicant's assessment or face-to-face contact with the caseworker, whichever comes first. No further action is needed if the person withdraws the request for services before the assessment is started or completed, an application form is received, or a face-to-face contact is made.(e) Non-Medicaid applicants or the applicant's responsible person applying for Medicaid-covered attendant services may be reimbursed for services provided up to three months before the month of receipt of a completed, signed, and dated application.(f) The client must report promptly any changes in income, resources, or family size; loss of assistance grant or Medicaid benefits; or other changes in functional ability or circumstances that affect eligibility. The client is subject to fraud prosecution if the client willfully fails to report changes and continues to receive services for which the client is not eligible.(g) A Medicaid-certified applicant for CCSE-purchased services who requires a verbal referral is eligible to receive CCSE-purchased services when the applicant's eligibility for Medicaid is verified. A non-Medicaid certified applicant who meets the requirements for a verbal referral is eligible to receive CCSE-purchased services while income and resources are verified.(1) To be eligible, this applicant must:(A) be a new applicant for CCSE services or programs;(B) appear to be eligible based on the declaration of income and resources on the applicant's application for services or have possession of a current Medicaid card; and(C) meet the age and need criteria for the CCSE service the applicant requires.(2) The eligibility period for non-Medicaid applicants begins on the date of application.(3) To continue receiving services, a non-Medicaid client must provide within 30 days of the application date the information needed to verify the client's income and resource amounts. Source Note: The provisions of this §271.151 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective June 1, 1991, 16 TexReg 2053; amended to be effective October 1, 1995, 20 TexReg 6830; amended to be effective July 1, 1996, 21 TexReg 5327; amended to be effective April 1, 1997, 22 TexReg 1897; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.151 Application for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226046 03/12/2026 (a) To continue receiving services, the client must meet the Community Care Services Eligibility (CCSE) requirements at the time of recertification of financial eligibility and reassessment of needs.(b) An applicant whose services were terminated in the past due to the applicant or someone in the applicant's home being a threat to the health or safety of the client, HHSC staff, or provider agency staff may authorize services if the applicant signs a form authorizing release of information, and:(1) the applicant or person in the home who posed the threat has been treated or is receiving treatment by a licensed or certified physician, psychiatrist, or psychologist and can furnish a letter saying that the applicant or person is no longer a threat to self or others; or(2) the applicant or person in the home allows a collateral contact with the applicant's or person in the home's physician, psychiatrist, or psychologist, and the contact indicates that the applicant or person in the home is no longer a threat to self or others; or(3) the person in the home who posed the threat no longer poses the threat. Source Note: The provisions of this §271.153 adopted to be effective March 29, 1982, 7 TexReg 1193; amended to be effective March 22, 1983, 8 TexReg 842; amended to be effective April 15, 1990, 15 TexReg 205; amended to be effective January 1, 1996, 20 TexReg 9748; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.153 Recertification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226047 03/12/2026 (a) A person may request an appeal of any decision that denies, reduces, or ends the person's benefits. The effective date of the action depends on the situation, as shown in the following table.Attached Graphic(b) A client is entitled to be notified 10 calendar days before any reduction or termination of services, or to have the notification mailed 12 calendar days before the date of reduction or termination. If a client threatened the client's own health or safety or that of others, purchased services may be terminated without advance notice.(c) A client is not eligible for Community Care Services Eligibility (CCSE) services or programs when the client:(1) dies;(2) is admitted to an institution;(3) has a physician who requests service termination, Medicaid services only;(4) requests service termination or repeatedly refuses to accept help, except in an involuntary protective services case; or(5) refuses to comply with the service plan.(d) The client is not eligible for Emergency Response Services if the client:(1) abuses the service by activating:(A) four false alarms which result in a response by fire department, police, sheriff, or ambulance personnel within a six-month period; or(B) 20 false alarms of any kind within a six-month period;(2) is admitted to a skilled institution, personal care home, foster care setting, or any other setting where 24-hour supervision is available;(3) in the caseworker's judgment, is no longer mentally alert enough to operate the equipment properly, situations include:(A) damage to the equipment;(B) the equipment is disconnected and the client received two warnings that are documented in the case record;(C) refusal to participate in the monthly system checks; or(4) is away from the home or is unable to participate in the service delivery for three consecutive months or more.(e) The client is not eligible for Residential Care if the client is required to contribute to the cost of the client's care but refuses to do so.(f) If the client repeatedly and directly or knowingly and passively condones the behavior of someone in the client's home and thus, refuses, more than three times, to comply with service delivery provisions, the caseworker may terminate services. Refusal to comply with service delivery provisions includes actions by the client or someone in the client's home that prevent determining eligibility, carrying out the service plan, and monitoring the services. Before services are terminated, the client is entitled to receive written notification that services will end if the client does not comply with service delivery provisions or if the client continues to condone someone's behavior that results in non-compliance with service delivery provisions. Also, before services are terminated, the caseworker must make a referral to Texas Department of Family and Protective Services if the caseworker suspects or knows that the client is being abused, neglected, or exploited by the person who prevents delivery provisions. Services continue pending the outcome of the APS investigation. If an applicant's services were terminated in the past due to the applicant's failure to comply with a service plan, the applicant must agree to cooperate with HHSC staff to facilitate service delivery. Source Note: The provisions of this §271.155 adopted to be effective February 1, 1989, 13 TexReg 5751; amended to be effective April 15, 1990, 15 TexReg 205; amended to be effective June 1, 1991, 16 TexReg 2053; amended to be effective October 1, 1992, 17 TexReg 6374; amended to be effective November 15, 1992, 17 TexReg 7241; amended to be effective March 15, 1993, 18 TexReg 1170; amended to be effective March 1, 1994, 19 TexReg 272; amended to be effective January 1, 1996, 20 TexReg 9748; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.155 Denial, Reduction, and Termination of Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214501 03/12/2026 (a) To receive payment, each adult foster care provider must send a completed purchase voucher for adult foster care providers form to DHS for each month the foster care client lives in the home. The daily rate paid to adult foster care providers is $11.75; after September 1, 1996, the daily rate paid to adult foster care providers is $13.64.(b) Enrollment of an adult foster home means that the home is meeting all standards or appropriate waivers have been obtained.(c) The caseworker, with supervisory approval, may disenroll an adult foster home if the provider is not able to care for the client(s) because of health reasons. The provider is required to submit, when requested by the department, a physician's statement that he is physically and mentally able to continue providing personal care and 24-hour supervision.(d) Adult foster care providers may be disenrolled for noncompliance with the minimum standards for adult foster care or other program rules. Adult foster care providers and applicants have a right to appeal the decision to not approve their application to be a provider or to disenroll the home. The administrative law judge is the department employee appointed to preside over the hearing.(e) Representatives of the Texas Department of Human Services may enter the premises of the DHS enrolled foster home at any time to make inspections or to privately interview the clients receiving assistance from the Texas Department of Human Services.(f) The Texas Department of Human Services pays the daily rate for up to 14 days of leave for each 12-consecutive-month period when an authorized client is away from the foster home. Payment for leave in excess of 14 days per year is the responsibility of the client. Any bedhold charges are between the client and provider because they have negotiated a monthly room and board agreement. Bedhold charges, however, may not exceed the daily room and board rate.(g) The adult foster care provider is responsible for notifying the caseworker when a client is away from the foster home for personal leave or hospitalization. Source Note: The provisions of this §271.157 adopted to be effective March 29, 1982, 7 TexReg 1193; amended to be effective March 15, 1988, 13 TexReg 882; amended to be effective March 27, 1989, 14 TexReg 992; amended to be effective May 15, 1989, 14 TexReg 2030; amended to be effective March 27, 1991, 16 TexReg 1508; amended to be effective September 1, 1991, 16 TexReg 4174; amended to be effective November 11, 1991, 16 TexReg 5406; amended to be effective February 1, 1997, 22 TexReg 847; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.157 Special Casework Procedures for Adult Foster Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226048 03/12/2026 (a) The Adult Foster Care client must:(1) provide accurate information about the client's ability to function in the community and in a foster home setting;(2) pay the amount of room and board specified in the client and provider agreement;(3) report changes or occurrences that would affect the client or provider; and(4) participate in selecting an adult foster care home in which to live.(b) The client and the client's responsible person are entitled to:(1) receive in writing, before authorization of adult foster care, a list of the client's rights and responsibilities;(2) be informed of all available services in the home and of the charges for services not paid for by the HHSC;(3) be informed that the client keeps a personal needs allowance;(4) file complaints about abuse, neglect, exploitation, or inadequate care, as those terms are defined by the statute or rule that governs the investigation of ANE, without discrimination or reprisal for voicing grievances;(A) with HHSC, Complaint and Incident Intake, when the AFC facility is licensed as an assisted living facility (ALF); or(B) with the Texas Department of Family and Protective Services, Adult Protective Services (APS) when the AFC serves three or fewer residents unrelated to the owner;(5) privacy and confidentiality;(6) have the client's physical person and property treated with dignity and respect; and(7) be free from physical or mental abuse, corporal punishment, and any physical or chemical restraints imposed for purposes of discipline or convenience. Source Note: The provisions for this §271.159 adopted to be effective March 15, 1988, 13 TexReg 882; amended to be effective March 27, 1989, 14 TexReg 992; amended to be effective December 1, 1990, 15 TexReg 6318; amended to be effective May 15, 1992, 17 TexReg 2782; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523; amended to be effective September 10, 2025, 50 TexReg 5936. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.159 Adult Foster Care Client Rights and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214503 03/12/2026 Adult foster care clients must be allowed to keep funds for personal needs and medical expenses as specified in paragraphs (1)-(3) of this section.(1) Clients with Medicaid coverage must be allowed to keep at least $50 a month for personal needs.(2) Clients without Medicaid coverage must be allowed to keep at least $85 a month for personal needs and medical expenses.(3) All clients must be allowed to keep at least one-half of any cost-of-living adjustment received on or after January 1, 1993. Source Note: The provisions of this §271.161 adopted to be effective January 1, 1993, 17 TexReg 8582; transferred effective September 15, 2023, as published in the August 18, 2023, issue of the Texas Register, 48 TexReg 4523. 1 HEALTH AND HUMAN SERVICES COMMISSION 271 COMMUNITY CARE SERVICES ELIGIBILITY D CASE MANAGEMENT §271.161 Adult Foster Care Personal Needs and Medical Expenses Allowance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212881 03/12/2026 This chapter:(1) establishes the requirements for transition assistance services (TAS) provided through:(A) the Community Living Assistance and Support Services Program;(B) the Medically Dependent Children Program; and(C) the Deaf Blind with Multiple Disabilities Program; and(2) provides information regarding TAS in the Home and Community-based Services Program. Source Note: The provisions of this §272.1 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective July 1, 2015, 40 TexReg 2786; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES A INTRODUCTION §272.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212878 03/12/2026 The following words and terms have the following meanings when used in this chapter, unless the context clearly indicates otherwise:(1) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(2) Case manager--The person who is responsible for case management activities in the Community Living Assistance and Support Services (CLASS), Medically Dependent Children Program (MDCP), and Deaf Blind with Multiple Disabilities (DBMD) Programs.(3) CLASS Program--Community Living Assistance and Support Services Program. A Medicaid waiver program authorized by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act and operated by the Texas Health and Human Services Commission (HHSC) under Chapter 259 of this title (relating to Community Living Assistance and Support Services (CLASS) Program and Community First Choice (CFC) Services).(4) Day--A calendar day, unless otherwise specified in the text. A calendar day includes Saturday, Sunday, and a national or state holiday listed in Texas Government Code §662.003(a) or (b).(5) DBMD Program--Deaf Blind with Multiple Disabilities Program. A Medicaid waiver program authorized by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act and operated by HHSC under Chapter 260 of this title (relating to Deaf Blind with Multiple Disabilities (DBMD) Program and Community First Choice (CFC) Services).(6) Facility--(A) a nursing facility, for an individual enrolling in MDCP; or(B) a nursing facility or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), for an individual enrolling in the DBMD Program or CLASS Program.(7) GRO--General Residential Operation. This term has the meaning set forth in Texas Human Resources Code, §42.002.(8) HHSC--The Texas Health and Human Services Commission.(9) HCS Program--Home and Community-based Services Program. A Medicaid waiver program authorized by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act and operated by HHSC under Chapter 263 of this title (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC)).(10) HCS program provider--A person, as defined in 40 TAC §49.102 (relating to Definitions), that has a contract with HHSC to provide HCS Program services, excluding a financial management services agency.(11) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is licensed in accordance with Texas Health and Safety Code, Chapter 252, or certified by HHSC.(12) Individual--A person for whom HHSC authorizes the delivery of transition assistance services (TAS).(13) IPC--Individual plan of care.(14) LAR--Legally authorized representative. A person authorized by law to act on behalf of another person with regard to a matter described in this chapter, including a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(15) MDCP--Medically Dependent Children Program. A Medicaid waiver program authorized by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act and operated by HHSC under 1 TAC §353.1155 (relating to Medically Dependent Children Program).(16) Nursing facility--A facility licensed in accordance with Texas Health and Safety Code, Chapter 242.(17) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the Transition Assistance Services Orientation Handbook.(18) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas State Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C.(19) TAS--Transition assistance services.(20) TAS provider--A person, as defined in 40 TAC §49.102, that has a contract with HHSC to provide TAS in accordance with 40 TAC Chapter 49 (relating to Contracting for Community Services). Source Note: The provisions of this §272.3 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective July 1, 2015, 40 TexReg 2786; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES A INTRODUCTION §272.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212879 03/12/2026 (a) TAS assists an individual in setting up a household in the community before being discharged from:(1) a nursing facility and enrolling in MDCP; or(2) a nursing facility or an ICF/IID and enrolling in the DBMD Program or CLASS Program.(b) HHSC does not authorize TAS if an individual's enrollment IPC includes any of the following services:(1) support family services in the CLASS Program;(2) continued family services in the CLASS Program;(3) licensed assisted living in the DBMD Program; or(4) licensed home health assisted living in the DBMD Program.(c) An individual may receive TAS only once in the individual's lifetime.(d) An individual may receive a maximum of $2,500 for TAS.(e) TAS consists of:(1) payment of security deposits required to lease a home, including an apartment, or to establish utility services for a home;(2) purchase of essential furnishings for a home, including a table, a bed, chairs, window blinds, eating utensils, and food preparation items;(3) payment of expenses required to move personal items, including furniture and clothing, into a home;(4) payment for services to ensure the health and safety of the individual in a home, including pest eradication, allergen control, or a one-time cleaning before occupancy; and(5) purchase of essential supplies for a home, including toilet paper, towels, and bed linens. Source Note: The provisions of this §272.5 adopted to be effective July 1, 2015, 40 TexReg 2786; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES A INTRODUCTION §272.5 Service Description https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212880 03/12/2026 (a) An individual being discharged from a nursing facility, an ICF/IID, or a GRO and enrolling in the HCS Program may receive TAS from an HCS program provider in accordance with Chapter 263 of this title (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC)).(b) An HCS program provider may contract with a TAS provider to provide TAS in accordance with Chapter 263 of this title. Source Note: The provisions of this §272.7 adopted to be effective July 1, 2015, 40 TexReg 2786; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES A INTRODUCTION §272.7 TAS in the HCS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212882 03/12/2026 A TAS provider must comply with this chapter and 40 TAC Chapter 49 (relating to Contracting for Community Services). Source Note: The provisions of this §272.11 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective September 1, 2014, 39 TexReg 6674; amended to be effective July 1, 2015, 40 TexReg 7286; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES B TAS PROVIDER REQUIREMENTS §272.11 Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205364 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205364 03/12/2026 A TAS provider must ensure that an employee or contractor who delivers TAS under this chapter:(1) is at least 18 years old;(2) has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma;(3) is not the individual's:(A) relative;(B) LAR; or(C) in MDCP, the primary caregiver;(4) does not live with the individual; and(5) is capable of delivering TAS and complying with the documentation requirements under this chapter. Source Note: The provisions of this §272.21 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective July 1, 2015, 40 TexReg 7286; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES C STAFF REQUIREMENTS §272.21 Staff Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212883 03/12/2026 (a) A TAS provider must:(1) deliver TAS to an individual for whom the TAS provider receives, from the individual's case manager, a completed Transition Assistance Services (TAS) Assessment and Authorization form authorized by HHSC;(2) deliver to the individual the specific TAS authorized on the form;(3) purchase TAS for the individual within the monetary amount authorized on the form; and(4) submit a service claim to HHSC only after all of the authorized TAS has been delivered to the individual.(b) A TAS provider must complete the delivery of TAS to the individual at least two days before the individual's facility discharge date unless the delay in delivery is beyond the control of the TAS provider.(c) If a TAS provider does not deliver the authorized TAS in accordance with subsection (b) of this section, the TAS provider must:(1) document the following:(A) a description of the pending TAS;(B) the reason for the delay;(C) the date the TAS provider anticipates it will deliver the pending TAS or specific reasons why the TAS provider cannot anticipate a delivery date; and(D) a description of the TAS provider's ongoing efforts to deliver the TAS; and(2) at least two days before the facility discharge date, provide the information described in paragraph (1) of this subsection to:(A) the individual or LAR, or in MDCP, the individual's primary caregiver; and(B) the case manager.(d) A TAS provider must, within one business day after TAS has been delivered, notify the following persons that TAS has been delivered:(1) the individual or LAR, or in MDCP, the individual's primary caregiver; and(2) the case manager. Source Note: The provisions of this §272.33 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective July 1, 2015, 40 TexReg 7286; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES D SERVICE DELIVERY REQUIREMENTS §272.33 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212884 03/12/2026 (a) A TAS provider must maintain service delivery documentation in the individual's record, including:(1) the individual's name and Medicaid number;(2) the TAS provider's name and contract number;(3) a description of the TAS delivered;(4) the date the TAS was purchased;(5) the date the TAS was delivered;(6) the total monetary amount of the TAS purchased, including taxes and delivery fees;(7) the original purchase receipts; and(8) the dated signature of the employee or contractor who delivered the TAS.(b) If a TAS provider does not complete the delivery of TAS to the individual by the due date described in §272.33(b) of this chapter (relating to Service Delivery), the TAS provider must maintain the documentation required in §272.33(c)(1) of this chapter in the individual's record. Source Note: The provisions of this §272.41 adopted to be effective August 31, 2004, 29 TexReg 8381; amended to be effective September 1, 2014, 39 TexReg 6674; amended to be effective July 1, 2015, 40 TexReg 7286; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3619; amended to be effective March 1, 2023, 48 TexReg 1129. 1 HEALTH AND HUMAN SERVICES COMMISSION 272 TRANSITION ASSISTANCE SERVICES E CLAIM PAYMENTS AND DOCUMENTATION §272.41 Record Keeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224768 03/12/2026 The purpose of this subchapter is to describe the criteria used to determine whether a provider is eligible to receive Medicaid reimbursement for inpatient hospital services to people aged 65 and older in an institution for mental diseases (IMD) and to describe the methods by which patient and provider eligibility are established and reimbursement for covered services is accomplished. This subchapter applies to all IMD providers. Source Note: The provisions of this §273.1 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.1 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224769 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Department--The Department of State Health Services or its designee.(2) HHSC--The Health and Human Services Commission or its designee.(3) Inpatient hospital services--Services provided under the supervision of a physician in an IMD that meets the requirements for psychiatric hospitals in 42 CFR §482.60(b), (c), and (d) and meets utilization review requirements in 42 CFR §482.30(a), (b), (d), and (e) unless the utilization review requirements have been waived pursuant to §1903(i)(4) of the Social Security Act and 42 CFR Part 456, Subpart H.(4) Institution for mental diseases (IMD)--A hospital of more than 16 beds that is primarily engaged in providing psychiatric diagnosis, treatment, and care of individuals with mental diseases, including medical care, nursing care, and related services.(5) IMD provider--An IMD that has an agreement with the department to provide IMD services.(6) IMD services--Inpatient hospital services provided by an IMD provider for the care and treatment (including room and board) of individuals with mental diseases including, but not limited to:(A) initiation, titration, or change in medication;(B) monitoring and assessing by qualified mental health professionals;(C) suicide precautions;(D) redirection of inappropriate behaviors and/or reinforcement of appropriate behaviors;(E) group and individual therapies;(F) structured skills training activities; and(G) nursing services.(7) Mental diseases--Diseases listed as mental disorders in the latest editions of the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders, with the exception of mental retardation and chemical dependency disorders.(8) Qualified mental health professional--A person acting within the scope of his or her training and licensure or certification, who is a:(A) licensed social worker, as defined by the Social Work Practice Act, Occupations Code, §505.002(6);(B) licensed professional counselor, as defined by the Licensed Professional Counselor Act, Occupations Code, §503.002(4); (C) physician, as defined by the Medical Practice Act, Occupations Code, §151.002(12), or a person employed by any agency of the United States having a license to practice medicine in any state of the United States;(D) licensed nurse as provided for and defined in the Nursing Practice Act, Occupations Code, Chapter 301; or(E) psychologist, as defined by the Psychologists' Licensing Act, Occupations Code, §501.002(5). Source Note: The provisions of this §273.3 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224770 03/12/2026 (a) IMD provider reimbursement is limited to IMD services provided to individuals:(1) who are age 65 years or older;(2) who have one or more mental disease;(3) who have no acceptable alternate placement as determined by the individual's treatment team;(4) who are eligible for participation in the Texas Medicaid program;(5) who are not eligible for medical compensation from other payment sources;(6) who have been certified by a licensed physician to need inpatient hospitalization for the care and treatment of a mental disease;(7) who meet all other federal, state, and local regulations applicable to admission to a mental hospital; and(8) for whom the department has authorized IMD services based on medical necessity, as follows:(A) Requests for initial authorization for IMD services must be submitted to the department within seven calendar days after the first day for which Medicaid reimbursement for the provision of IMD services will be requested.(B) Requests for authorization of continued stay must be submitted no later than seven calendar days prior to the end date of the initial and all subsequent authorizations. Initial and continued stay authorizations are valid for up to 31 calendar days.(b) Any Medicaid eligible individual whose request for eligibility for IMD services is denied or is not acted upon with reasonable promptness, or whose IMD services have been terminated, suspended, or reduced by the department is entitled to a fair hearing, conducted in accordance with rules for fair hearings described in Title 1, Texas Administrative Code, Chapter 357, Subchapter A (relating to Medicaid Fair Hearings). A request for a fair hearing must be submitted to the department and received within 90 days from the date the notice of denial of eligibility for IMD services or notice of termination, suspension, or reduction of IMD services is mailed. Source Note: The provisions of this §273.5 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.5 Eligible Population https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224771 03/12/2026 (a) To be eligible for reimbursement for IMD services, an IMD provider must:(1) submit an approved application for enrollment through means established by the department, to include evidence that the provider:(A) meets the Medicare conditions of participation referenced in 42 CFR §482.60(b);(B) is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO);(C) if applicable, licensed as a mental hospital under the Texas Health and Safety Code, Chapter 577; and(D) has a consistent historical pattern of accepting persons involuntarily committed for inpatient mental health treatment as evidenced by having provided mental health services to a minimum of 20 persons, 65 years of age or older, involuntarily committed for inpatient mental health treatment under the Texas Health and Safety Code, Chapters 573 and 574, during the two-year period immediately preceding the date of application for participation.(2) have in effect a written provider agreement with the department which:(A) describes respective responsibilities of the provider and the department, including arrangements to ensure:(i) joint planning efforts;(ii) development of alternative methods of care;(iii) access by the department and HHSC to the institution, its patients, and patients' records when necessary to carry out the agencies' responsibilities;(iv) recording, reporting, and exchanging medical and social information about the patients; and(v) other procedures that may be required to achieve the purposes of the agreement;(B) assures the capacity of the provider to admit, readmit from alternate care, and treat both eligible persons voluntarily seeking services under the Texas Health and Safety Code, Chapter 572, and persons involuntarily committed for inpatient mental health treatment under the Texas Health and Safety Code, Chapters 573 and 574;(C) assures that the provider is meeting the requirements specified in 42 CFR §440.140(a) pertaining to providers of inpatient hospital services to persons age 65 or older in institutions for mental diseases;(D) assures that the provider is in compliance with those provisions of the Texas Administrative Code, Title 25, Part I, that relate to patient care and treatment in inpatient mental health facilities;(E) assures that the provider is serving a patient population in which more than 50% currently require institutionalization because of a mental disease; and(F) assures that the provider will submit cost reports and audit data in a manner authorized by the department.(b) An IMD provider's eligibility for reimbursement must be renewed periodically at a time designated by the department, but not to exceed two years.(c) Evidence of compliance with subsection (a) of this section is validated through reviews by the department, which occur at intervals decided upon by the department. For each Medicaid patient, the department additionally reviews:(1) the adequacy of services available to meet the patient's current health needs and promote the patient's maximum physical, mental, and psychosocial well-being; and(2) the necessity or desirability of the patient's continued placement in the IMD, including an examination of barriers to serving the patient in a less restrictive setting and the efforts of the IMD to achieve a less restrictive placement for the patient.(d) If the IMD provider fails to provide evidence of compliance with subsection (c) of this section, then the provider may be required to take corrective action based on the findings contained in the department's report. If corrective action is required, the IMD provider must submit a corrective action plan to the department for approval. Failure to implement the corrective action plan constitutes a contract violation and the IMD provider may be subjected to any sanctions provided for in the contract, including termination. Source Note: The provisions of this §273.7 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.7 IMD Provider Eligibility for Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224772 03/12/2026 (a) Reimbursement for IMD services provided to eligible individuals begins on the date established by written notice from the department and is contingent upon validation of evidence of IMD provider eligibility as described in §419.375(c) of this title (relating to IMD Provider Eligibility for Reimbursement).(b) An IMD provider's agreement with the department is subject to termination with written notice on the date that any of the following occurs:(1) loss of Medicare and/or JCAHO certification;(2) if applicable, loss of licensure as a psychiatric hospital;(3) failure to meet requirements specified in 42 CFR §440.140(a) pertaining to providers of inpatient hospital services in institutions for mental diseases;(4) demonstrated noncompliance with those provisions of the Texas Administrative Code, Title 25, Part I, that relate to patient care and treatment in inpatient mental health facilities, or with state laws governing admission and treatment of persons with mental illness;(5) breach of the written provider agreement described in §419.375(a)(2) of this title (relating to IMD Provider Eligibility for Reimbursement);(6) termination of participation as a Medicaid provider by HHSC; or(7) evidence of noncompliance with the rules in this subchapter or a corrective action plan that is based on findings made by the department in a review described in §419.375(c) of this title.(c) Failure to submit an acceptable cost report in the required time frame constitutes a contract violation and may result in sanctions provided for in the contract, including a hold of vendor payments.(d) Termination of the IMD provider agreement is an adverse action for which the IMD provider is entitled to a contested case hearing as described in Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating to Formal Appeals).(e) IMD providers that receive Medicaid reimbursement for IMD services are governed by Texas Administrative Code, Title 1, Chapter 371 (relating to Medicaid and other Health and Human Services Fraud and Abuse Program Integrity. Source Note: The provisions of this §273.9 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.9 IMD Provider Reimbursement and Termination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224773 03/12/2026 IMD providers must be in compliance with the following rules, as applicable, regarding discharge of individuals receiving IMD services: (1) Chapter 412, Subchapter D of this title (relating to Mental Health Services--Admission, Continuity and Discharge; and(2) Chapter 411, Subchapter J of this title (relating to Standards of Care and Treatment in Psychiatric Hospitals). Source Note: The provisions of this §273.11 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.11 Discharge Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224774 03/12/2026 This subchapter shall be distributed to:(1) executive management, and program staff of Central Office;(2) chief executive officers of all IMD providers; and(3) advocacy organizations. Source Note: The provisions of this §273.13 adopted to be effective December 20, 1998, 23 TexReg 12683; amended to be effective July 3, 2007, 32 TexReg 4010; transferred effective April 30, 2025, as published in the April 18, 2025, issue of the Texas Register, 50 TexReg 2483. 1 HEALTH AND HUMAN SERVICES COMMISSION 273 MENTAL HEALTH SERVICES--MEDICAID STATE OPERATING AGENCY RESPONSIBILITIES A INSTITUTIONS FOR MENTAL DISEASES §273.13 Distribution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209486 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209486 03/12/2026 This chapter establishes contract requirements for providers and participation requirements for individuals in the Texas Department of Aging and Disability Services (DADS) Consumer Managed Personal Attendant Services (CMPAS) Program. Source Note: The provisions of this §275.1 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM A INTRODUCTION §275.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209487 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209487 03/12/2026 The following words and terms have the following meanings when used in this chapter, unless the context clearly indicates otherwise:(1) Abuse--Any of the following:(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual.(3) Applicant--A Texas resident who requests services under the CMPAS Program.(4) Assessor of need--A provider employee responsible for determining an applicant's or individual's need for CMPAS.(5) Attendant--A person who provides direct care to an individual.(6) Block grant option--One of three CMPAS Program service delivery and payment options. In the block grant option, the individual is the employer of record of an attendant and the provider is the employer of record of a substitute attendant.(7) CDS option--Consumer directed services option. One of three CMPAS Program service delivery and payment options. In the CDS option, the individual is the employer of record of the attendant and substitute attendant.(8) Chemical restraint--A medication used to control an individual's behavior or to restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition.(9) CMPAS Program--Consumer Managed Personal Attendant Services Program. An HHSC program for personal attendant services in which individuals manage their attendant services to varying degrees.(10) Contract--The written agreement between HHSC and a provider to provide services to individuals eligible under this chapter in exchange for payment.(11) Contract manager--An HHSC employee who is responsible for the overall management of a contract.(12) Controlling person--A person who:(A) has an ownership interest in a provider;(B) is an officer or director of a corporation that is a provider;(C) is a partner in a partnership that is a provider;(D) is a member or manager in a limited liability company that is a provider;(E) is a trustee or trust manager of a trust that is a provider; or(F) because of a personal, familial, or other relationship with a provider, is in a position of actual control or authority with respect to the provider, regardless of the person's title.(13) DADS--HHSC.(14) DADS region--HHSC region. A region of Texas designated by HHSC in which the CMPAS Program is available.(15) DADS regional designee--An HHSC employee appointed by the HHSC regional director of an HHSC region.(16) Day--A calendar day, including weekends and holidays.(17) DFPS--The Department of Family and Protective Services.(18) Exploitation--(A) in the traditional service option and the block grant option, exploitation means the illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain, including theft as defined in Chapter 31 of the Texas Penal Code; and(B) in the CDS option, exploitation means the illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain.(19) Family member--A person who has a duty under state law to provide care for an individual.(20) FMSA--Financial management services agency. An entity that contracts with HHSC to provide financial management services, as defined in §41.103 of this title (relating to Definitions).(21) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, or Coast Guard:(A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and(B) who was killed in action or died while in service, or whose active duty otherwise ended.(22) Health-related task--An activity of daily living, a health maintenance task, or a nursing task, as described in 22 TAC Chapter 225.(23) HHSC--The Texas Health and Human Services Commission.(24) Home and community support services agency--An agency licensed under Texas Health and Safety Code, Chapter 142.(25) IDT--Interdisciplinary team. A designated group of persons, as described in §44.502(a) of this chapter (relating to Convening an IDT).(26) Individual--A person enrolled in the CMPAS Program. A reference in this chapter to "individual" includes the individual's LAR, unless the context indicates otherwise.(27) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, including the guardian of an adult.(28) Mechanical restraint--A mechanical device, material, or equipment used to control an individual's behavior by restricting the ability of the individual to freely move part or all of the individual's body.(29) Military family member--A person who is the spouse or child (regardless of age) of:(A) a military member; or(B) a former military member.(30) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch.(31) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(32) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual; or(C) the use of a restraint or seclusion.(33) Physical restraint--Any manual method used to control an individual's behavior, except for physical guidance or prompting of brief duration that an individual does not resist, that restricts:(A) the free movement or normal functioning of all or a part of the individual's body; or(B) normal access by an individual to a portion of the individual's body.(34) Practitioner--A physician currently licensed in Texas, Louisiana, Arkansas, Oklahoma, or New Mexico; a physician assistant currently licensed in Texas; or an advanced practice registered nurse licensed by the Texas Board of Nursing.(35) Practitioner's statement--The HHSC Practitioner's Statement of Medical Need form.(36) Provider--A home and community support services agency that contracts with HHSC to provide services under the CMPAS Program.(37) Restraint--Any of the following:(A) a chemical restraint;(B) a mechanical restraint; or(C) a physical restraint.(38) Representative--An adult designated by an individual, such as the individual's spouse, relative, or friend, who volunteers to assist the individual with a responsibility of the individual described in this chapter.(39) Seclusion--The involuntary placement of an individual alone in an area from which the individual is prevented from leaving.(40) Section 1915(c)--A section of the Social Security Act that allows states to establish, by waiver of certain Medicaid requirements, alternative community-based services for individuals who qualify for institutional services.(41) Service plan--A document that lists the service tasks and states the hours of services agreed to by the individual and assessor of need.(42) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and an attendant, staff person, or controlling person, unless a consensual sexual relationship with an adult individual existed before the attendant, staff person, or controlling person became an attendant, staff person, or controlling person.(43) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(44) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(45) Staff person--An employee, contractor, or volunteer of a provider.(46) State mental health facility--A Texas state hospital or a state center with an inpatient psychiatric component.(47) Substitute attendant--A person who, on a temporary basis and in place of an attendant, provides services to an individual.(48) Traditional service option--One of three CMPAS Program service delivery and payment options. In the traditional service option, the provider is the employer of record of the attendant and substitute attendant.(49) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(50) Working day--Any day except a Saturday, Sunday, or national or state holiday listed in Texas Government Code §662.003(a) or (b). Source Note: The provisions of this §275.3 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective May 23, 2016, 41 TexReg 3746; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM A INTRODUCTION §275.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209488 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209488 03/12/2026 The CMPAS Program is a non-Medicaid program that provides attendant care services to enhance and maintain an individual's integration into the community, including participation in employment and education or training opportunities, and community volunteering designed to help the individual enter and remain in the workforce and in the community. The CMPAS Program includes a co-payment provision based on income to allow an individual to participate in the program regardless of income. The program empowers an individual to self-direct services to the greatest extent possible under one of three service delivery options: the traditional service option, the block grant option, or the consumer directed services option. Source Note: The provisions of this §275.5 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM A INTRODUCTION §275.5 Description of the CMPAS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209489 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209489 03/12/2026 (a) To be eligible to receive services under the CMPAS Program, an applicant must:(1) be age 18 years of age or older;(2) obtain and submit to the provider's assessor of need a completed practitioner's statement;(3) be assessed under §44.203 of this subchapter (relating to Assessment and Eligibility Determination) as needing assistance with at least one personal care task and needing an allowable service for at least five hours per week;(4) be able and willing to:(A) self-direct the attendant; or(B) designate a relative or friend who is willing and able to direct the attendant without compensation;(5) reside in an area in which CMPAS Program services are available;(6) have a service plan developed under §44.203(a)(6)(A) of this subchapter that does not exceed 52 hours per week of CMPAS Program services;(7) choose one of the three service delivery options described in Subchapter D of this chapter (relating to Service Delivery Options);(8) not be receiving services in:(A) a hospital;(B) a nursing facility;(C) a state supported living center;(D) a state mental health facility; or(E) an intermediate care facility for individuals with an intellectual disability or related conditions.(b) An individual is not eligible to receive services under the CMPAS Program if the individual is receiving:(1) other community services and supports, either Medicaid or non-Medicaid, under a service plan that exceeds the reimbursement rate that would have been paid for the same individual to receive services in a nursing facility;(2) services under any of the following DADS programs:(A) Primary Home Care, including Family Care (FC) and Community Attendant Services (CAS);(B) Residential Care; or(C) Adult Foster Care;(3) services under a §1915(c) Medicaid waiver program;(4) regular or ongoing attendant services under either of the following DADS programs:(A) Special Services to Persons with Disabilities; or(B) In-Home and Family Support.(c) An individual may not receive services under the CMPAS Program if the individual is Medicaid eligible and lives in a managed care service area, unless the individual's spouse was employed as the individual's attendant and the individual chose to remain in CMPAS when the managed care service area was expanded to include the individual's place of residence. Source Note: The provisions of this §275.25 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.25 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209490 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209490 03/12/2026 (a) HHSC maintains a CMPAS interest list for each HHSC region. An interest list contains the names of applicants who are interested in receiving services through the CMPAS Program.(b) A person may request that an applicant's name be added to a CMPAS interest list in an HHSC region by contacting:(1) a provider;(2) an HHSC regional office, or(3) the 2-1-1 Texas Program.(c) If a person contacts a provider, as described in subsection (b) of this section, the provider must follow HHSC's instructions in the CMPAS Provider Manual available at the HHSC website, to request the applicant's:(1) name;(2) a physical address in Texas and a mailing address;(3) birth date;(4) phone number;(5) social security number;(6) current living arrangements;(7) employment status;(8) HHSC's individual number; and(9) status regarding receipt of Supplemental Security Income.(d) Within five working days after the contact described in subsection (b)(1) of this section, a provider must send to an HHSC regional office:(1) the applicant information obtained in accordance with subsection (c) of this section; and(2) the date and time the person contacted the provider.(e) HHSC adds an applicant's name to a CMPAS interest list if:(1) a request is made in accordance with subsection (b) of this section; or(2) an applicant's name is on the interest list for an HHSC region and the applicant or a representative notifies HHSC that the applicant has moved to another HHSC region and requests that the applicant's name be added to the interest list for the HHSC region to which the applicant has moved.(f) HHSC adds an applicant's name to an interest list with an interest list request date as follows:(1) for a request to add an applicant's name to the interest list made in accordance with subsection (b) of this section, the date of the request; or(2) for a request to add an applicant's name to the interest list made in accordance with subsection (e)(2) of this section, the date of the original request made in accordance with subsection (b) of this section.(g) HHSC removes an applicant's name from a CMPAS interest list if:(1) the applicant or LAR requests that the applicant's name be removed from the interest list;(2) the applicant moves out of Texas, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(3) the applicant or LAR declines an offer of CMPAS Program services, unless the applicant is a military family member living outside of Texas:(A) while the military member is on active duty; or(B) for less than one year after the former military member's active duty ends;(4) the applicant is a military family member living outside of Texas for more than one year after the former military member's active duty ends;(5) the applicant is deceased; or(6) HHSC denies an applicant's eligibility for the CMPAS Program and the applicant has had an opportunity to exercise the applicant's right to request a fair hearing in accordance with §44.503 of this chapter (relating to Fair Hearing) and did not request a fair hearing, or requested a fair hearing and did not prevail.(h) If HHSC removes an applicant's name from a CMPAS interest list in accordance with subsection (g)(1) - (4) of this section and, within 90 calendar days after the name was removed, HHSC receives an oral or written request from a person to reinstate the applicant's name on the interest list, HHSC:(1) reinstates the applicant's name to the interest list with an interest list request date described in subsection (f)(1) or (2) of this section; and(2) notifies the applicant in writing that the applicant's name has been reinstated to the interest list in accordance with paragraph (1) of this subsection.(i) If HHSC removes an applicant's name from a CMPAS interest list in accordance with subsection (g)(1) - (4) of this section and, more than 90 calendar days after the name was removed, HHSC receives an oral or written request from a person to reinstate the applicant's name on the interest list, HHSC:(1) adds the applicant's name to the interest list with an interest list request date of:(A) the date HHSC receives the oral or written request; or(B) because of extenuating circumstances as determined by HHSC, the original request date described in subsection (f)(1) or (2) of this section; and(2) notifies the applicant in writing that the applicant's name has been added to the interest list in accordance with paragraph (1) of this subsection.(j) If HHSC removes an applicant's name from a CMPAS interest list in accordance with subsection (g)(6) of this section and HHSC subsequently receives an oral or written request from a person to reinstate the applicant's name on the interest list, HHSC:(1) adds the applicant's name to the interest list with an interest list request date of the date HHSC receives the oral or written request; and(2) notifies the applicant in writing that the applicant's name has been added to the interest list in accordance with paragraph (1) of this subsection. Source Note: The provisions of this §275.27 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective May 23, 2016, 41 TexReg 3746; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.27 CMPAS Interest Lists https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224543 03/12/2026 (a) Within 30 days after the provider receives a referral from DADS regional office, the provider must: (1) ensure that the assessor of need conducts an initial on-site assessment with the applicant; (2) determine CMPAS Program eligibility in accordance with §44.201 of this subchapter (relating to Eligibility Criteria); (3) inform the applicant, both orally and in writing, of all applicable publicly funded programs that offer attendant services and allow the applicant to choose whether to participate in CMPAS; (4) keep in the applicant's record a written record of the notification given in accordance with paragraph (3) of this subsection and the applicant's signed and dated acknowledgement and choice document; (5) assess the applicant's service needs by using the DADS Needs Assessment Questionnaire and Task/Hour Guide form available at www.dads.state.tx.us; and (6) for an eligible applicant: (A) develop a service plan based on the results of the assessment questionnaire that: (i) includes the number of hours and tasks negotiated between the applicant and the assessor of need; and (ii) is agreed to and signed by the applicant and assessor of need; (B) determine with the applicant the amount of the applicant's co-payment under §44.501 of this chapter (relating to Determining an Individual's Co-payment) and explain to the applicant that making co-payments is required to remain eligible for CMPAS; (C) explain orally and give written information to the applicant on the available service delivery options described in Subchapter D of this chapter (relating to Service Delivery Options); (D) have the applicant sign and date a service delivery option choice document; and (E) keep the signed and dated service delivery choice document in the applicant's file. (b) If the applicant's service plan includes a health-related task, the provider must: (1) before an attendant performs a health-related task, verify that the task: (A) may be performed under Texas Government Code §546.0104; (B) does not require nurse or physician delegation; or (C) is properly delegated under: (i) 22 TAC Part 11, Chapter 225; or (ii) Texas Occupations Code, Chapter 157; and (2) if a health-related task is delegated, maintain records in the applicant's file that: (A) identify and are signed and dated by the delegating physician or registered nurse; (B) include the name of the individual, the names of the attendants performing the delegated health-related tasks for the individual, and a description of the specific health-related tasks to be performed; and (C) comply with the Texas Nurse Practice Act, the Medical Practice Act, and any other applicable state or federal law. (c) The provider must notify an applicant who is not eligible for services in writing by mailing the DADS Notification of Community Care Services form within three days after the date of the decision. This form notifies the applicant of the right to a fair hearing and explains how to request a fair hearing. (d) The provider must send DADS written notice of the disposition of the referral. The provider must ensure that DADS receives the notice within 30 days after the provider receives the referral from DADS. If the provider does not notify DADS within the 30-day period, DADS may impose contract sanctions on the provider. (e) The provider must document any failure to complete the assessment activities within the 30-day period, including the reasons for the delay, the provider's ongoing efforts to complete the assessment, and the anticipated date of completion. The reasons for delay must be beyond the provider's control. The provider must send the documentation of delays to the DADS regional designee by the due date in subsection (d) of this section. (f) Upon receiving notice from the provider of an applicant's eligibility to receive services in the CMPAS Program, the DADS regional designee will enter the CMPAS authorization in DADS Service Authorization System. Source Note: The provisions of this §275.29 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983; amended to be effective April 1, 2025, 50 TexReg 2207. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.29 Assessment and Eligibility Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209492 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209492 03/12/2026 A provider must reassess an individual annually and any time there is a change in the individual's status, as follows:(1) Annual reassessments. A provider must annually reassess an individual in accordance with §44.203 of this subchapter (relating to Assessment and Eligibility Determination). The provider must complete each on-site annual reassessment no later than one year after the service initiation date and no later than one year after each reassessment.(2) Reassessment upon change in individual status. When a provider learns that an individual's status may have changed in a way that may affect the individual's eligibility for or receipt of services, the provider must reassess the individual. In doing so, the provider may consider only those factors in §44.203 of this subchapter that have changed since the previous assessment. A change in individual status that requires reassessment may include a change in:(A) income, deductions, or exclusions; or(B) the individual's need for attendant care services, the service plan, or the hours of service.(3) Notice of eligibility. A provider must send a notice of eligibility and, if applicable, notice of the right to a fair hearing to an individual within five working days after a reassessment using the DADS Notification of Community Services form. Source Note: The provisions of this §275.31 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.31 Reassessments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209493 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209493 03/12/2026 (a) An individual and the assessor of need must agree to and sign a service plan change.(b) A provider must:(1) implement a change to an individual's co-payment to be effective on the first day of the month following a reassessment;(2) notify the DADS regional designee in writing of a service plan change within seven days after the completion of a reassessment using a single document that contains:(A) the date the notification document was completed;(B) the contract number;(C) the service plan change and effective date of the service plan change;(D) the name of the individual;(E) the service tasks assigned to the individual's attendant;(F) the name of the assessor of need;(G) the service schedule;(H) the signature of the assessor of need; and(I) the date the notification document was signed;(3) provide a copy of the service plan change to the individual including, if applicable, a notice of the right to a fair hearing;(4) document a service plan change:(A) in the individual's file; and(B) according to the terms of the contract; and(5) implement a service plan change within three days after notification by the DADS regional designee that the service plan has been entered into the service authorization system.(c) The DADS regional designee enters the change in the individual's service plan into the service authorization system and notifies the provider. Source Note: The provisions of this §275.33 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.33 Service Plan Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209494 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209494 03/12/2026 (a) Service plan disagreements. If a provider and individual disagree on the number of hours of service or service tasks to be on the individual's service plan:(1) the provider must offer the individual orally and in writing an informal dispute resolution (IDR) process through a meeting of the individual's IDT; and(2) if the individual disagrees with the provider's decision after going through the IDR process, the individual may request a fair hearing as provided in §44.503 of this chapter (relating to Fair Hearing).(b) Co-payment disagreements. If a provider and individual disagree on the amount of the individual's co-payment:(1) the provider must offer the individual orally and in writing an IDR process through a meeting of the individual's IDT; and(2) if the individual disagrees with the provider's decision after going through the IDR process, the individual may request a fair hearing as provided in §44.503 of this chapter. Source Note: The provisions of this §275.35 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM B ELIGIBILITY AND SERVICE PLANS §275.35 Service Plan and Co-payment Disagreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209495 03/12/2026 (a) When CMPAS Program funding becomes available in a DADS region, the DADS regional designee:(1) refers to the region's provider the applicant whose interest list request date, assigned in accordance with §44.202(e) of this chapter (relating to CMPAS Interest Lists), is earliest on the region's CMPAS interest list; and(2) informs the provider of any other DADS program services the applicant is receiving, the cost of those services, and the approved service period for those services.(b) If DADS refers an applicant to a region's provider, as described in subsection (a)(1) of this section, the provider must comply with the requirements in §44.203 of this chapter (relating to Assessment and Eligibility Determination).(c) The provider must provide CMPAS Program services to all applicants and individuals DADS refers to the provider unless the assessor of need determines and documents:(1) an applicant is not eligible for CMPAS;(2) the provider and other sources of support are unable to meet an applicant's or individual's needs without risking the individual's health and safety;(3) the environment in an applicant's or individual's home is a serious threat to the health and safety of an attendant; or(4) an individual, or someone in the individual's home, seriously threatens the health and safety of an attendant.(d) The provider must conduct an IDT meeting in accordance with the requirements of §44.502 of this chapter (relating to Convening an Interdisciplinary Team) if it determines it cannot provide CMPAS Program services to an individual for any of the reasons described in subsection (c)(2) - (4) of this section.(e) The provider must begin providing services to an individual within seven days after the DADS regional designee enters the CMPAS authorization in DADS Service Authorization System, as described in §44.203 of this chapter. Source Note: The provisions of this §275.51 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective May 23, 2016, 41 TexReg 3746; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.51 Initiation of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209496 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209496 03/12/2026 To participate as a provider in the CMPAS Program, the provider must:(1) maintain a license from HHSC under 26 TAC Chapter 558 (relating to Licensing Standards for Home and Community Support Services Agencies) in one or more of the following categories of licensure:(A) personal assistance services;(B) licensed home health services; or(C) licensed and certified home health services;(2) comply with the requirements of 26 TAC Chapter 558;(3) comply with Chapter 49 of this title (relating to Contracting for Community Services);(4) obtain required training to function as an FMSA for those individuals who choose the CDS option for CMPAS services;(5) comply with the requirements described in this chapter;(6) have contract compliance monitored by an HHSC contract manager;(7) be able to provide services under all three service delivery options; and(8) provide case management services, including:(A) determining applicant eligibility and co-payment amount;(B) preparing individual registration data entry forms;(C) assessing and reassessing individual needs using the HHSC Assessment Questionnaire and Task/Hour Guide; and(D) developing a service plan.(9) comply with the requirements of 1 TAC §355.7051(d) (relating to Base Wage for a Personal Attendant). Source Note: The provisions of this §275.53 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective September 1, 2014, 39 TexReg 6630; amended to be effective October 1, 2019, 44 TexReg 5106; amended to be effective May 10, 2020, 45 TexReg 2888; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.53 Provider Qualifications and Responsibilities in All CMPAS Service Delivery Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209497 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209497 03/12/2026 For a person to be an attendant in the CMPAS Program, the person must:(1) be age 18 years of age or older;(2) be able to work part or all of the hours needed by the individual;(3) agree to be interviewed by the individual;(4) have reliable transportation to the individual's home;(5) demonstrate to the satisfaction of the individual that the person is capable of performing the tasks included in the individual's service plan, including being able to take direction from the individual or the individual's representative; and(6) meet the requirements for unlicensed personnel at §97.247 of this title (relating to Verification of Employability and Use of Unlicensed Persons) and the requirements of Texas Health and Safety Code, Chapter 250 concerning nurse aid registry and criminal history checks. Source Note: The provisions of this §275.55 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.55 Attendant Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209498 03/12/2026 (a) Allowable tasks. Except as otherwise provided in subsection (b) of this section, an attendant may perform one or more of the following tasks for an individual enrolled in the CMPAS Program:(1) personal care tasks required to maintain the individual's physical health, including:(A) bathing;(B) dressing and undressing;(C) preparing meals;(D) assisting with eating, including:(i) assisting with eating and drinking utensils and adaptive devices; and(ii) providing standby assistance or encouragement;(E) exercising;(F) toileting, including:(i) changing an incontinence brief;(ii) assisting with the use of a bedpan or urinal;(iii) assisting with feminine hygiene needs, including menstruation supplies;(iv) assisting with clothing during toileting, including raising, lowering, removal or replacement of garments for hygiene needs;(v) assisting with toilet hygiene, including the use of toilet paper and washing hands;(vi) changing an external catheter;(vii) preparing toileting supplies and equipment but not preparing catheter equipment unless it is a delegated task as described in paragraph (4) of this subsection; and(viii) providing standby assistance;(G) positioning;(H) assisting with self-administered medication, including administration through a permanently placed feeding tube;(I) grooming;(J) routine hair and skin care; and(K) transfer or ambulation, including lifting;(2) home management tasks that support the individual's health and safety, including:(A) changing the bed linens and making the bed;(B) housekeeping services, including cleaning and laundry;(C) shopping for or with the individual;(3) escorting assistance tasks, including:(A) accompanying the individual outside the home to support the individual to live in the community;(B) assisting with or arranging for transportation and escorting on public transit, but not providing transportation;(C) accompanying the individual to a clinic, doctor's office, or other trip made for the purpose of obtaining a medical diagnosis or treatment; and(D) waiting in a doctor's office or clinic with an individual if necessary due to the individual's condition or distance from home;(4) delegated health-related tasks; and(5) health-related tasks that do not require delegation.(b) Unallowable tasks. An attendant must not perform any task for an individual if:(1) performing the task would require additional licensure beyond the license held by the attendant or provider, including nursing services that have not been properly delegated to the attendant;(2) the task is not among those listed in subsection (a) of this section;(3) the task is not contained in the individual's service plan; or(4) performing the task would be fraudulent or illegal. Source Note: The provisions of this §275.57 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.57 Allowable and Unallowable Tasks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209499 03/12/2026 An attendant may perform an allowable task for an individual in the individual's home, at a work site, or in another appropriate location, including a shopping mall, a movie theater, or a community event. Source Note: The provisions of this §275.59 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.59 Location of Tasks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209500 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209500 03/12/2026 Before providing services to an individual, a provider must educate and train the individual in:(1) rights and responsibilities of the individual;(2) skills for recruiting, selecting, instructing, supervising, and dismissing attendants, if desired by the individual;(3) procedures for preparing attendant time sheets, as described in §44.504(b)(1) of this chapter (relating to Records);(4) procedures for the CMPAS Program service delivery option that the individual chooses; and(5) rights and responsibilities of the attendant and the substitute attendant. Source Note: The provisions of this §275.61 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.61 Individual Training by a Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209501 03/12/2026 An applicant, individual, or the LAR or representative of an applicant or individual must:(1) obtain and submit a practitioner's statement to the assessor of need;(2) negotiate with the assessor of need at an assessment or reassessment to determine which allowable tasks in §44.304 of this subchapter (relating to Allowable and Unallowable Tasks) are included in the individual's service plan;(3) select, supervise, and release from service an attendant;(4) train and supervise a personal attendant in the specifics of the delivery of services;(5) certify the attendant's time worked on or after the last day of each recording period by:(A) verifying, signing, dating, and submitting to the provider the attendant's time sheet; or(B) if applicable, submitting appropriate certification of the attendant's time worked through a provider's electronic service delivery documentation system;(6) notify the provider within 10 days after the date the individual begins receiving services under another HHSC program that duplicates the services provided under the CMPAS Program;(7) submit any required co-payment to the provider as required by §44.501 of this chapter (relating to Determining an Individual's Co-payment);(8) provide proof of income to the assessor of need upon request;(9) obtain and submit to the assessor of need a proper physician's order and physician's or registered nurse's documentation for any delegated health-related task to be included in the service plan before the task is included in the service plan; and(10) inform the provider and HHSC within 10 days after a change in the individual's:(A) mailing or residence address;(B) telephone number;(C) physical condition that may affect the need for services;(D) total monthly income, as calculated in accordance with §44.501(f) of this chapter;(E) income exclusions, as described in §44.501(i) of this chapter; and(F) monthly deductions, as described in §44.501(j) of this chapter. Source Note: The provisions of this §275.63 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.63 Individual Responsibilities in All CMPAS Service Delivery Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209502 03/12/2026 (a) A provider must suspend services to an individual if:(1) the individual changes residence to outside the state of Texas;(2) the individual moves to a location where the provider does not provide CMPAS Program services to the individual except as provided for in §44.403 of this chapter (relating to Attendant Services Provided Outside the Provider Contracted Service Delivery Area in the Traditional Services Option);(3) the individual dies;(4) the individual is admitted to:(A) a hospital;(B) a nursing facility;(C) a state supported living center;(D) a state mental health facility; or(E) an intermediate care facility for individuals with an intellectual disability or related conditions;(5) the individual requests that services end;(6) the individual, representative, or someone in the individual's home, as applicable, refuses to:(A) supervise the attendant;(B) adhere to the service plan; or(C) otherwise comply with a requirement of the CMPAS Program;(7) the individual or representative, as applicable, does not have the ability to:(A) supervise the attendant;(B) adhere to the service plan; or(C) otherwise comply with a requirement of the CMPAS Program;(8) the individual does not submit a co-payment as required by §44.501 of this chapter (relating to Determining an Individual's Co-payment);(9) the individual does not provide a practitioner's statement as required by §44.307 of this subchapter (relating to Individual Responsibilities in All CMPAS Service Delivery Options); or(10) the provider becomes aware that the individual no longer meets eligibility requirements for the CMPAS Program.(b) The provider may suspend services if:(1) the individual or someone in the individual's home engages in discrimination in violation of law;(2) the individual or representative fails to effectively manage attendant care, including problems with:(A) hiring, selecting, or retaining an attendant for reasons other than workforce issues;(B) reaching an agreement on the amount of reimbursement the provider will retain in the block grant option; or(C) completing or submitting required program documentation; or(3) the individual or someone in the individual's home exhibits reckless behavior that may result in imminent danger to the health or safety of the individual, the attendant, or another person.(c) Under the circumstances described in subsection (b)(3) of this section, the provider must immediately report the situation to:(1) DFPS or other appropriate protective services agency;(2) local law enforcement; and(3) the HHSC regional designee.(d) Within seven days after suspending an individual's services, the provider must notify the HHSC regional designee of the suspension in writing and provide a copy of the notice to the individual. The written notice of suspension must include:(1) the date of service suspension;(2) the reason for the suspension;(3) the duration of the suspension, if known; and(4) an explanation of the provider's attempts to resolve the problem that caused the suspension, and the reasons why the problem was not resolved.(e) A provider must convene an IDT meeting, as described in §44.502 of this chapter (relating to Convening an IDT), within seven days after sending the written notice of suspension, if services are suspended for a reason described in subsection (a)(6) and (7) or (b)(1) - (3) of this section.(f) A provider must resume services after a suspension:(1) after an individual returns home, if applicable;(2) on the date specified in writing by the HHSC regional designee;(3) as a result of a recommendation by the IDT; or(4) after the provider receives notification from the HHSC regional designee that the provider must resume services pending the outcome of a fair hearing.(g) The provider must send written notice to the HHSC regional designee that services have resumed within seven days after the date services resume. Source Note: The provisions of this §275.65 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.65 Suspension of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209503 03/12/2026 A provider may terminate services for the same reasons for suspending services, listed in §44.308 of this subchapter (relating to Suspension of Services). If a provider intends to terminate services the provider must:(1) send written notice of the termination to the individual;(2) inform the individual in the written notice of:(A) the termination date;(B) the reason for termination;(C) the right to appeal the termination decision in accordance with §44.503 of this chapter (relating to Fair Hearing); and(D) the individual's right to continue to receive services pending a fair hearing; and(3) notify the DADS regional designee of the termination in writing. Source Note: The provisions of this 275.67 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.67 Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209504 03/12/2026 A provider must not use restraint or seclusion. Source Note: The provisions of this §275.69 adopted to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.69 Prohibition of Restraint and Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209505 03/12/2026 (a) A provider, before providing services to an individual and on an annual basis, must:(1) inform the individual and representative of how to report allegations of abuse, neglect, or exploitation to DFPS and provide the individual with the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400, in writing; and(2) educate the individual and representative about how to protect the individual from abuse, neglect, and exploitation.(b) Before a staff person assumes job duties, and on at least an annual basis, a provider must:(1) train a staff person:(A) about acts that constitute abuse, neglect, and exploitation;(B) about signs and symptoms of abuse, neglect, and exploitation;(C) about methods to prevent abuse, neglect, and exploitation; and(D) to report to DFPS immediately, but not later than 24 hours, after the staff person has knowledge or suspects that an individual is being or has been abused, neglected, or exploited by:(i) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(ii) using the DFPS Abuse Hotline website; and(2) provide the staff person with the reporting requirements described in paragraph (1)(D) of this subsection in writing.(c) If a provider, staff person, or controlling person knows or suspects that an individual is being or has been abused, neglected, or exploited, the provider must report, or ensure that the person with knowledge or suspicion reports, the allegation of abuse, neglect, or exploitation to DFPS immediately, but not later than 24 hours, after having knowledge or suspicion by:(1) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(2) using the DFPS Abuse Hotline website.(d) If a report required by subsection (c) of this section alleges abuse, neglect, or exploitation of an individual, or if the provider is notified of an allegation of abuse, neglect, or exploitation, the provider must:(1) take necessary actions to secure the safety of the individual; and(2) as soon as possible, but no later than 24 hours, after the provider reports or is notified of the allegation, notify the individual or LAR of:(A) the allegation report; and(B) the actions the provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required under this subsection.(e) A provider must not retaliate against:(1) a staff person, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including the use of restraint or seclusion; or(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including the use of restraint or seclusion.(f) A provider, on at least an annual basis, must:(1) review all reports of abuse, neglect, or exploitation of an individual of which the provider is notified and all final investigative reports received from HHSC for an investigation described in §44.443 of this chapter (relating to Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is an Attendant or Substitute Attendant) and §44.444 of this chapter (relating to Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of a Provider); and(2) based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services. Source Note: The provisions of this §275.71 adopted to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM C SERVICE DELIVERY IN ALL CMPAS OPTIONS §275.71 Provider Responsibilities Related to the Abuse, Neglect, and Exploitation of an Individual in All CMPAS Service Delivery Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209506 03/12/2026 In the traditional service option, the individual retains control over certain personnel decisions, including selecting, supervising, and dismissing the attendant, but the provider is the employer of record for the attendant and substitute attendant. Source Note: The provisions of this 275.101 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.101 Description of the Traditional Service Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209507 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209507 03/12/2026 In the traditional service option, a provider must:(1) comply with the requirements of §44.302 of this chapter (relating to Provider Qualifications and Responsibilities in All CMPAS Service Delivery Options);(2) maintain and supervise a pool of substitute attendants to provide attendant services upon the individual's request;(3) refer prospective attendants to the individual until the individual selects an attendant;(4) hire an attendant who meets the qualifications of §44.303 of this chapter (relating to Attendant Qualifications) and whom the individual agrees to supervise;(5) if an individual has not selected a prospective attendant within seven days after the date the assessor of need determined the individual to be eligible for services:(A) confer with the individual;(B) identify the reasons the individual has not selected an attendant; and(C) provide training when necessary to enable the individual to select an attendant;(6) provide to an attendant an initial orientation training before the attendant provides services to an individual that includes the following topics:(A) basic interpersonal skills;(B) needs of persons with disabilities;(C) first aid;(D) universal safety precautions;(E) safety and emergency procedures;(F) proper completion of required forms;(G) explanation of the individual's role as supervisor;(H) explanation of the provider's responsibilities to attendants;(I) attendant rights and responsibilities;(J) specific information needed to provide tasks to the individual;(K) reporting changes in the individual's condition to the provider; and(L) instructions to provide only authorized tasks according to the service plan, unless the individual pays for additional time with the individual's own funds;(7) assume all responsibility for paying and filing attendant income and unemployment taxes and associated paperwork;(8) assume liability for attendant work-related injuries to the same extent as any employer;(9) prepare payroll and distribute payroll checks to attendants as required by state and federal law;(10) actively intervene to resolve problems between an individual and the individual's attendant when they cannot resolve problems on their own;(11) determine the salary and benefit package of an attendant;(12) not discriminate against an attendant or applicant in violation of law;(13) accept responsibility for acts of an attendant, to the same extent as any employer would be responsible for the acts of an employee, while the attendant performs services for the individual; and(14) conduct on-site visits in addition to those described in §44.203 of this chapter (relating to Assessment and Eligibility Determination) and §44.204 of this chapter (relating to Reassessments), based on the specific needs of the individual or attendant, but at least annually, to assess and document whether the:(A) individual's service plan is adequate;(B) individual continues to need the services;(C) individual needs a service plan change;(D) attendant remains competent to perform the allowable tasks; and(E) attendant is performing the allowable tasks. Source Note: The provisions of this §275.103 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.103 Provider Responsibilities in the Traditional Service Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209508 03/12/2026 (a) A provider may develop a service plan that includes, at the request of the individual, services provided while the individual is temporarily staying at a location outside the provider's contracted service delivery area but within the State of Texas.(b) The service plan must not exceed the weekly authorized hours.(c) The provider may accept or decline the request of an individual for the provision of services while the individual is temporarily staying at a location outside the contracted service delivery area but within the State of Texas.(1) If the provider accepts the individual's request, the provider:(A) may provide services to the individual during a period of no more than 60 consecutive days;(B) must, within three days after the provider begins providing services to the individual, notify the DADS regional designee in writing of the following:(i) that the individual is receiving services outside the provider's contracted service delivery area;(ii) the location where the individual is receiving services;(iii) the estimated length of time the individual is expected to be outside the contracted service delivery area; and(iv) contact information for the individual;(C) must notify the DADS regional designee in writing that the individual has returned to the provider's contracted service delivery area within three working days after becoming aware of the individual's return; and(D) is not required to pay for expenses incurred by attendants delivering services outside the contracted service delivery area.(2) If the provider declines the request of an individual as described in subsection (a) of this section, the provider must orally inform the individual:(A) of the reasons for declining the request;(B) that the individual may request a meeting with the provider and the DADS regional designee to discuss the reasons for declining the request; and(C) within three days after declining the request, inform the DADS regional designee, in writing, that the request was declined and the reasons for declining the request.(d) If an individual receives services outside the provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that service delivery area before the provider can agree to another request from the individual for provision of services outside the provider's contracted service delivery area.(e) If the individual intends to remain outside the provider's contracted service delivery area for a period of more than 60 consecutive days, the provider must convene an interdisciplinary team meeting, including the DADS regional designee, as provided by §44.502 of this chapter (relating to Convening an Interdisciplinary Team) to consider options available to the individual for continuation of services. Source Note: The provisions of this §275.105 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.105 Attendant Services Provided Outside the Provider Contracted Service Delivery Area in the Traditional Services Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209509 03/12/2026 Individuals who choose the traditional service option must comply with the responsibilities listed in §44.307 of this chapter (relating to Individual Responsibilities in All CMPAS Service Delivery Options) and must:(1) actively assist the provider in recruiting attendants and substitute attendants by seeking out and referring potential attendants to the provider;(2) select an attendant from among the potential attendants whom the provider refers to the individual;(3) actively assist in delegating, directing, and training for tasks being performed;(4) not discriminate against any potential attendant, attendant, or substitute attendant in violation of law; and(5) interview any prospective attendant whom the provider refers to the individual and inform the provider within seven days after the referral of whether the individual selects the attendant. Source Note: The provisions of this §275.107 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.107 Individual Responsibilities in the Traditional Service Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209510 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209510 03/12/2026 Effective September 1, 2013, an individual may not choose the block grant option. An individual receiving CMPAS services through the block grant option on that date may continue to receive services under this option but, if the individual chooses another service delivery option, the individual may not return to the block grant option. In the block grant option, the individual is the employer of record for an attendant and is responsible for payroll, filing tax-related reports, and developing a monthly budget. The provider is the employer of record for a substitute attendant. Source Note: The provisions of this §275.125 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.125 Description of the Block Grant Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209474 03/12/2026 In the block grant option, a provider must:(1) comply with the requirements of §44.302 of this chapter (relating to Provider Qualifications and Responsibilities in All CMPAS Service Delivery Options);(2) reimburse the individual for attendant wages and employment taxes paid by the individual;(3) negotiate with the individual and agree on an amount that the provider will retain from reimbursements made under §44.505 of this chapter (relating to Reimbursement) to compensate the provider for its services to the individual, based on the provider's actual cost of providing services to the individual, which may include:(A) the cost of providing substitute attendants;(B) the cost of providing administrative services;(C) the history of the individual's use of substitute attendants; and(D) the need for provider intervention;(4) maintain and supervise a pool of substitute attendants to provide attendant services at the individual's request;(5) provide each substitute attendant an initial orientation before the attendant provides services to the individual that includes the following topics:(A) basic interpersonal skills;(B) needs of persons with disabilities;(C) first aid;(D) universal safety precautions;(E) safety and emergency procedures;(F) proper completion of required forms;(G) explanation of the individual's role as supervisor;(H) explanation of the provider agency's responsibilities to attendants;(I) attendant rights and responsibilities;(J) specific information needed to provide tasks to the individual;(K) reporting changes in the individual's condition to the provider; and(L) instructions to provide only authorized tasks in accordance to the service plan, unless the individual pays for additional time with the individual's own funds;(6) send a substitute attendant at the individual's request; and(7) for an individual the provider learns is failing to fully perform a duty the individual is required to perform as the attendant's employer of record:(A) counsel the individual regarding the consequences of noncompliance;(B) offer the individual the choice of the traditional services option; and(C) consider suspending services as provided by §44.308 of this chapter (relating to Suspension of Services) if the individual does not choose the traditional service option and does not perform the duties as the employer of record. Source Note: The provisions of this §275.127 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.127 Provider Responsibilities in the Block Grant Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209475 03/12/2026 In the block grant option, an individual must:(1) comply with the requirements of §44.307 of this chapter (relating to Individual Responsibilities in All CMPAS Service Delivery Options);(2) select, hire, and pay the individual's attendants as the employer of record;(3) before the individual's attendant provides a service and on an annual basis:(A) train an attendant regarding abuse, neglect, and exploitation, as described in HHSC Form 1732, Management and Training of Service Provider;(B) sign and date Form 1732 and have the attendant sign and date the form to document completion of the training; and(C) send a copy of the signed form to the provider within 30 days after the date the form is signed by the individual and the attendant;(4) resolve any employment-related problems or disagreements directly with the attendant;(5) not discriminate against an attendant or applicant in violation of law;(6) assume liability for work-related attendant injuries and responsibility for work-related attendant conduct to the same extent as any employer would assume liability for injuries and responsibility for conduct of an employee;(7) spend funds received from the provider that were reimbursed under §44.505 of this chapter (relating to Reimbursement) on attendant wages, employment-related tax payments, and employee benefits;(8) prepare and sign an agreement with the attendant that includes:(A) the tasks the attendant is to perform for the individual;(B) the schedule the attendant will work for the individual;(C) the hourly rate the individual will pay the attendant, which must be at least the base wage specified in 1 TAC §355.7051(d) (relating to Base Wage for a Personal Attendant);(D) the schedule the individual will use to pay the attendant (at least twice per month);(E) the reasons the individual may terminate the attendant's employment; and(F) a requirement that the attendant provide the individual at least 24 hours advance notice if unable to work a scheduled shift;(9) supervise the attendant's recording of hours worked, including signing, dating, and submitting the attendant's time sheet to the provider on or after the last day of the reporting period during which services were provided; and(10) submit to the provider, within 30 days after filing, copies of any employment-related government forms the individual files for the attendant as the employer of record, including all required Internal Revenue Service obligations and required reports to the Texas Workforce Commission. Source Note: The provisions of this §275.129 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; amended to be effective May 10, 2020, 45 TexReg 2888; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.129 Individual Responsibilities in the Block Grant Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209476 03/12/2026 In the consumer directed services option, an individual is the employer of record for an attendant and substitute attendant but the provider is responsible for payroll for attendants and substitute attendants and filing tax-related reports for attendants and substitute attendants. Source Note: The provisions of this §275.151 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.151 Description of the Consumer Directed Services Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209477 03/12/2026 In the CDS option, a provider must:(1) comply with the requirements of §44.302 of this chapter (relating to Provider Qualifications and Responsibilities in All CMPAS Service Delivery Options);(2) function as an FMSA to provide financial management services to an individual;(3) approve and monitor a budget for services delivered through the CDS option;(4) manage payroll, including calculating employee withholdings and employer contributions and depositing the funds with the appropriate agencies;(5) comply with applicable government regulations concerning employee withholding, garnishments, mandated withholding, and benefits;(6) prepare and file required tax forms and reports;(7) pay allowable expenses incurred by the individual;(8) obtain employer-agent status with the Internal Revenue Service, the Texas Workforce Commission, and any other appropriate government agencies within the time frame established by each agency;(9) perform all employer-agent responsibilities required by government agencies that regulate the relationship between the employer-agent and the individual acting as the employer of record, and maintain an original or a copy of each form required to document compliance; and(10) attend, at least annually, HHSC's training for FMSAs. Source Note: The provisions of this §275.153 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.153 Provider Responsibilities in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209478 03/12/2026 (a) In the CDS option, an individual must:(1) comply with the requirements in §44.307 of this chapter (relating to Individual Responsibilities in All CMPAS Service Delivery Options);(2) perform the employer responsibilities described in Chapter 41 of this title (relating to Consumer Directed Services Option), with the exception of the responsibilities described in Chapter 41, Subchapter G of this title (relating to Allegations of Abuse, Neglect and Exploitation);(3) train each attendant and substitute attendant, during the initial orientation and on an annual basis, regarding abuse, neglect, and exploitation, as described in HHSC Form 1732, Management and Training of Service Provider;(4) sign and date Form 1732 and have the attendant or substitute attendant sign and date the form to document completion of the training; and(5) send a copy of the signed form to the provider within 30 days after the date the form is signed by the individual and the attendant or substitute attendant.(b) In the CDS option, if an individual knows or suspects that the individual is being or has been abused, neglected, or exploited, the individual must:(1) report the abuse, neglect, or exploitation to DFPS immediately, but not later than 24 hours, after the abuse, neglect, or exploitation occurred by:(A) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(B) using the DFPS Abuse Hotline website;(2) take actions to secure the individual's safety;(3) obtain immediate and ongoing medical or psychological services, as necessary;(4) when taking the actions described in paragraphs (2) and (3) of this subsection, avoid compromising the investigation or causing further trauma to the individual;(5) preserve and protect evidence related to the allegation; and(6) ensure an attendant or substitute attendant who knows or suspects that the individual is being or has been abused, neglected, or exploited, reports the allegation of abuse, neglect, or exploitation to DFPS immediately, but not later than 24 hours, after having knowledge or suspicion by:(A) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(B) using the DFPS Abuse Hotline website. Source Note: The provisions of this §275.155 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.155 Individual Responsibilities in the CDS Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209479 03/12/2026 (a) This section applies in the CDS option to alleged abuse, neglect, or exploitation by an attendant or substitute attendant:(1) when an allegation is reported as required by §44.311(c) of this chapter (relating to Provider Responsibilities Related to the Abuse, Neglect, and Exploitation of an Individual in All CMPAS Service Delivery Options);(2) when an allegation is reported as required by §44.442 of this division (relating to Individual Responsibilities in the CDS Option); or(3) if a provider or individual is notified by HHSC of an allegation.(b) An individual must:(1) obtain immediate and ongoing medical or psychological services, as necessary;(2) take actions to secure the individual's safety, including if necessary, ensuring that the individual does not have contact with the alleged perpetrator until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or causing further trauma to the individual;(4) preserve and protect evidence related to the allegation, including time sheets and other employee-related documentation;(5) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview; and(6) ensure that attendants or substitute attendants comply with paragraphs (4) and (5) of this subsection.(c) A provider must:(1) preserve and protect evidence related to the allegation, including time sheets and other employee-related documentation;(2) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview; and(3) ensure that staff persons and controlling persons comply with paragraphs (1) and (2) of this subsection.(d) A provider who receives an initial intake report for an allegation of abuse, neglect, or exploitation described in subsection (a) of this section, must:(1) within four working days after receiving the report, convene an IDT meeting in person or by phone to review the report and discuss the actions the individual has taken or will take to protect the individual during the HHSC investigation, which may include having an attendant or substitute attendant other than the alleged perpetrator provide services;(2) document in writing any actions that have been or will be taken as a result of the allegation; and(3) if appropriate, offer the individual the choice of receiving services through the traditional service option and consider a suspension of services as described in §44.308 of this chapter (relating to Suspension of Services), if the individual does not choose the traditional service option.(e) After a provider receives the final investigative report from HHSC for an allegation of abuse, neglect, or exploitation described in subsection (a) of this section, the provider must:(1) within four working days after receiving the report, if the report confirms the allegation, contains an inconclusive finding, or includes concerns and recommendations by HHSC:(A) convene an IDT meeting in person or by phone to discuss the content of the report, including any concerns and recommendations by HHSC; and(B) document in writing any actions that have been or will be taken by the individual as a result of the findings in the report or the concerns and recommendations by HHSC;(2) within five working days after receiving the report:(A) use the report to complete Form 1719, Notification of Investigatory Findings; and(B) send the completed form to the alleged perpetrator; and(3) if appropriate, offer the individual the choice of receiving services through the traditional service option and consider a suspension of services, as described in §44.308 of this chapter, if the individual does not choose the traditional service option.(f) A provider must maintain in an individual's record an initial intake report and a final investigative report received from HHSC and a completed Form 1719. Source Note: The provisions of this §275.157 adopted to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.157 Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is an Attendant or Substitute Attendant https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209480 03/12/2026 (a) This section applies in the CDS option to an allegation of abuse, neglect, or exploitation by a staff person or a controlling person:(1) when the allegation is reported as required by §44.311(c) of this chapter (relating to Provider Responsibilities Related to the Abuse, Neglect, and Exploitation of an Individual in All CMPAS Service Delivery Options);(2) when the allegation is reported as required by §44.442 of this division (relating to Individual Responsibilities in the CDS Option); or(3) if a provider or individual is notified by HHSC of an allegation.(b) A provider must:(1) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual receiving services from the provider until HHSC completes the investigation; and(2) preserve and protect evidence related to the allegation.(c) During an HHSC investigation of an alleged perpetrator who is a staff person or controlling person:(1) a provider must:(A) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(B) provide HHSC access to:(i) sites owned, operated, or controlled by the provider;(ii) individuals, staff persons, and controlling persons; and(iii) records pertinent to the investigation of the allegation; and(C) ensure that staff persons and controlling persons comply with subparagraphs (A) and (B) of this paragraph; and(2) an individual must:(A) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(B) provide HHSC access to:(i) attendants and substitute attendants; and(ii) records pertinent to the investigation of the allegation; and(C) ensure that attendants and substitute attendants comply with subparagraph (A) of this paragraph.(d) Within four working days after receiving an initial intake report for an allegation described in subsection (a) of this section, a provider must:(1) convene an IDT meeting in person or by phone to discuss the report and the actions the individual has taken or will take to protect the individual during the HHSC investigation; and(2) document in writing any actions that have been or will be taken as a result of the allegation.(e) After a provider receives a final investigative report from HHSC for an investigation described in subsection (a) of this section, the provider must:(1) within four working days after receiving the report, if the report confirms the allegation, contains an inconclusive finding, or includes concerns and recommendations by HHSC:(A) convene an IDT meeting in person or by phone to discuss the content of the report, including any concerns and recommendations by HHSC; and(B) document in writing any actions that have been or will be taken by the individual as a result of the findings in the report or the concerns and recommendations by HHSC; and(2) within five working days after receipt of the report:(A) use the report to complete Form 1719, Notification of Investigatory Findings; and(B) send the completed form to the alleged perpetrator; and(3) take appropriate action within the provider's authority in response to the HHSC investigation, including disciplinary action against a staff person confirmed to have committed abuse, neglect, or exploitation.(f) A provider must maintain in an individual's record an initial intake report and a final investigative report received from HHSC and a completed Form 1719. Source Note: The provisions of this §275.159 adopted to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM D SERVICE DELIVERY OPTIONS §275.159 Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of a Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209481 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209481 03/12/2026 (a) An individual's co-payment is a percentage of the monthly cost of services provided to the individual. To calculate an individual's co-payment, a provider must: (1) determine the individual's total net monthly income in accordance with subsections (f) - (i) of this section; (2) determine the individual's co-payment percentage by using the individual's net monthly income and the CMPAS co-pay schedule located in the DADS Consumer Managed Personal Assistance Services Provider Manual; (3) inform the individual of the individual's estimated monthly co-payment by multiplying the authorized hours of service per month by the hourly reimbursement rate, multiplied by the co-payment percentage; (4) calculate the amount of the individual's actual monthly co-payment each month by multiplying the individual's co-payment percentage amount by the reimbursement rate, multiplied by the number of hours of service actually provided during the month. (b) An individual who suffers undue hardship as a result of legal financial obligations for reasons such as a catastrophic illness of the individual or a family member may request that his or her co-payment be temporarily reduced or waived. To request a reduction or waiver of a co-payment, the individual must make the request to the assessor of need and document the legal financial obligation that necessitates the reduction or waiver. (1) The provider may approve a reduction or waiver for a three-month period. The individual must resubmit a new request to receive three-month extensions to the waiver or reduction. (2) If the provider does not approve a reduction or waiver, the provider must offer the individual orally and in writing an informal dispute resolution (IDR) process which includes a meeting of the IDT and notify the individual of the right to a fair hearing as provided by §44.503 of this subchapter (relating to Fair Hearing). (c) The provider must bill a co-payment amount to an individual by or on the 15th day of the month following the month in which services were provided. The bill must show the co-payment percentage, the reimbursement rate, the total number of hours of service for the month, the total cost, and the actual amount of the co-payment due. If payment is not made within 15 days after billing, the provider must send a second notice to the individual within 10 days after the bill was due. If the individual does not pay the amount due by the 20th day of the month after the month in which the second notice was sent, the provider must suspend services. (d) A provider must not charge an individual a fee for late payment. (e) In collecting monthly co-payments, a provider must: (1) provide the individual a receipt containing the provider's name, individual's name, amount paid, and the date of the payment; (2) retain a copy of the receipt; (3) deduct the co-payment from reimbursement claims submitted to DADS under §44.505 of this subchapter (relating to Reimbursement); and (4) maintain a current individual co-payment ledger system, in accordance with generally accepted accounting principles, that reflects all charges to and all payments by an individual. (f) A provider must calculate an individual's total monthly income by adding: (1) the gross monthly earnings of the individual and the individual's spouse, including: (A) employee wages or salary; and (B) commissions, tips, piece-rate payments, and cash bonuses; (2) the net monthly receipts of the individual and the individual's spouse from non-farm self-employment, calculated by subtracting business expenses from gross receipts, as described in subsection (g) of this section; (3) the net monthly receipts of the individual and the individual's spouse from farm self-employment, calculated by subtracting business expenses from gross receipts, as described in subsection (h) of this section; (4) the gross monthly benefits received by the individual and the individual's spouse, including: (A) pensions, retirement, disability, and survivors' benefits; (B) education loans, scholarships, and grants to the extent funds are or may be applied to living costs; (C) payments from annuities, insurance, and irrevocable trust funds; (D) public assistance payments, such as Temporary Assistance to Needy Families or Supplemental Security Income, and including general assistance from a local government source; (E) court-ordered support payments, such as alimony and child support payments for a minor child; (F) unemployment compensation and union strike payments; (G) workers' compensation payments or other compensation for work injuries; (H) Veterans Administration payments, such as subsistence allowances and refunds of GI insurance premiums; and (I) other monthly support, such as allotments or payments from friends or relatives; and (5) the net monthly income from property of the individual or the individual's spouse, calculated by averaging receipts over a 12-month period, including: (A) dividends and interest payments; (B) receipts from a life estate, other estate, or trust fund; (C) income from a mortgage, promissory note, or other negotiable instrument; (D) income from lease of mineral rights, calculated by subtracting the following prorated payments from gross royalties or lease payments: (i) property taxes (not including windfall profit taxes); and (ii) excise taxes; and (E) income from rental property, including rent from boarders, calculated by subtracting the following prorated payments from gross receipts: (i) mortgage interest; (ii) property repair and maintenance expenses (not including improvements or depreciation charges); (iii) property insurance; and (iv) property taxes. (g) For purposes of calculating net monthly receipts from non-farm self-employment in accordance with subsection (f)(2) of this section: (1) gross receipts means the value of all goods sold and services provided by the non-farm self-employment enterprise; and (2) business expenses means the actual operating expenses of the non-farm self-employment enterprise, including: (A) purchased goods or services; (B) rent; (C) utilities; (D) depreciation charges; (E) wages and salaries; and (F) business taxes, which do not include personal income taxes. (h) For purposes of calculating net monthly receipts from farm self-employment in accordance with subsection (f)(3) of this section: (1) gross receipts means the value of all goods sold and services provided by the farm self-employment enterprise, except for goods and services used for family living. Gross receipts include receipts from: (A) the sale of crops; (B) the rental of farm equipment; (C) the sale of wood, sand, gravel, and similar items; and (D) government crop loans; (2) business expenses means the actual operating expenses of the farm self-employment enterprise, including: (A) the cost of feed, fertilizer, seed, and other farming supplies; (B) wages and salaries; (C) depreciation charges; (D) rent; (E) interest on farm mortgages; (F) farm building repairs; and (G) farm taxes, which do not include personal income taxes. (i) A provider must calculate an individual's income exclusions by adding: (1) payments to satisfy a judgment of the Indian Claims Commission or its successor agency, the U.S. Court of Claims; (2) any payment received under the federal Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970; (3) education loan, grant, and scholarship funds that are not or cannot be applied to living costs; (4) Veterans Administration payments, such as aid-and-attendance benefits, homebound elderly benefits, and payments for purchase of medications; (5) in-kind credits, such as rent subsidies; (6) infrequent or irregular payments from any source that occur no more often than once a quarter and that do not exceed $20 a month; (7) reimbursements from an insurance company for health insurance claims; and (8) grants, such as those made through the DADS In-Home and Family Support Program. (j) A provider must calculate an individual's income deductions by adding: (1) the prorated monthly cost of tuition and books when enrolled in an accredited institution of higher education or skills training program; (2) $93 for the individual's spouse; (3) $93 for each dependent of the individual; (4) $93 for the individual; (5) funds the law requires be withheld, such as deductions for income taxes or to comply with the Federal Insurance Contributions Act (FICA); (6) amounts spent on disability-related equipment that cost more than $500, such as wheelchair-compatible vans, vehicle modifications, and power wheelchairs (not including transportation costs); (7) amounts dedicated to be spent on disability-related equipment that costs more than $500, such as wheelchair-compatible vans, vehicle modifications, and power wheelchairs (not including transportation costs), in accordance with the following requirements: (A) the individual must identify to the provider the equipment to be purchased and must submit to the provider a written estimate of the cost of the equipment including a dealer's estimate or an advertisement with a listed purchase price of comparable equipment; (B) the individual must open a dedicated account for the exclusive purpose of purchasing identified equipment; (C) the first $500 deposited does not reduce the monthly income; (D) the individual must provide an estimate of the amount deposited each month to the dedicated account, the date the deposit is made each month, and the estimated date of the purchase; (E) the individual must report each month to the provider the actual amount deposited in the dedicated account for that month and the accumulated total in the account; (F) based on the individual's report, the provider must make the corresponding deduction from the individual's monthly income and any interest earned on the dedicated account will not be included as income if the interest payments are eventually used to purchase the equipment; (G) the individual must report to the provider when any funds are withdrawn from the account for any purpose other than for the purchase of the equipment and the provider must include this amount as income for the month in which these funds are withdrawn; (H) the individual must report to the provider when the funds are withdrawn from the account at the time the purchase is made and furnish a sales receipt showing the purchase price and date of purchase; and (I) the individual must close the account after the purchase of the equipment and report to the provider the amount of any remaining funds, which the provider must include as income for the month in which the account is closed; (8) child-care costs (actual expenses the individual paid to someone to care for his or her child, not including child support payments) up to $350 per month for each child through age 5, and up to $200 per month for each child age 6-12; (9) annualized costs of expenditures for health insurance premiums for the individual and the individual's spouse and dependents, and for medical treatment and prescriptions for the individual, the individual's spouse and the individual's dependents that are not reimbursed by insurance; and (10) annual contributions to a retirement plan in an amount up to 20 percent of the individual's total income as calculated in accordance with subsection (f) of this section. (k) To determine an individual's net monthly income for co-payment purposes, a provider must: (1) determine the individual's total monthly income in accordance with subsection (f) of this section; (2) subtract from that amount the income exclusions calculated in accordance with subsection (i) of this section; and (3) subtract from that amount the income deductions calculated in accordance with subsection (j) of this section. Source Note: The provisions of this §275.201 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM E ADDITIONAL PROGRAM REQUIREMENTS §275.201 Determining an Individual's Co-payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209482 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209482 03/12/2026 (a) An IDT must include:(1) the individual;(2) a provider representative; and(3) other persons as requested by the individual.(b) A provider must convene an IDT meeting:(1) within five working days after:(A) an individual accepts the provider's offer for an informal dispute resolution process due to a service plan or co-payment disagreement, as described in §44.206 of this chapter (relating to Service Plan and Co-payment Disagreements);(B) the provider determines it cannot provide services to an individual for any of the health and safety reasons described in §44.301(c)(2) - (4) of this chapter (relating to Initiation of Services); or(C) the provider identifies the need to discuss with the individual a service delivery issue that prevents the provider from carrying out a provider responsibility described in this chapter;(2) as described in §44.308(e) of this chapter (relating to Suspension of Services); or(3) as described in §44.443 of this chapter (relating to Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is an Attendant or Substitute Attendant) and §44.444 of this chapter (relating to Provider and Individual Responsibilities in the CDS Option Related to HHSC Investigations When an Alleged Perpetrator is a Staff Person or a Controlling Person of a Provider).(c) If a provider is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the provider must:(1) convene the IDT meeting with the available members;(2) send documentation of the IDT meeting to the individual; and(3) document in the individual's record the provider's efforts to convene an IDT meeting with all the members described in subsection (a) of this section.(d) The IDT must:(1) meet by telephone conference call or in person;(2) discuss the specific reason for conducting the IDT meeting;(3) identify any possible solutions to resolve the specific reason for the meeting; and(4) make recommendations to the provider and the individual.(e) Within two working days after an IDT meeting, a provider must:(1) document:(A) the specific reason for calling the IDT meeting;(B) the names of the IDT members attending the meeting;(C) the recommendations of the IDT to the provider and the individual; and(D) the actions to be taken or that have been taken by the provider or the individual;(2) provide a written copy of the documentation to the individual; and(3) notify the individual of the right to request a fair hearing, as provided by §44.503 of this subchapter (relating to Fair Hearing), if an action to be taken or that has been taken by the provider denies, reduces, or terminates the individual's services. Source Note: The provisions of this §275.203 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM E ADDITIONAL PROGRAM REQUIREMENTS §275.203 Convening an IDT https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209483 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209483 03/12/2026 (a) An individual may request a fair hearing for any action that affects the co-payment of the individual or that denies, reduces, or terminates benefits in accordance with 1 TAC Part 15, Chapter 357, Subchapter A. DADS does not continue services pending a hearing if a suspension or termination is based on §44.308(b)(3) of this chapter (relating to Suspension of Services). The individual's provider must attend a hearing to explain any decision or action that led to the hearing.(b) The provider must notify the DADS regional designee of a request for a fair hearing within 24 hours after the provider receives the request. DADS notifies the provider whether to continue services pending the fair hearing officer's decision.(c) The provider must notify the DADS regional designee of the fair hearing officer's decision and of any action the provider takes as a result of that decision within 24 hours after the provider receives the hearing decision. Source Note: The provisions of this §275.205 adopted to be effective October 1, 2013, 38 TexReg 6606; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM E ADDITIONAL PROGRAM REQUIREMENTS §275.205 Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209484 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209484 03/12/2026 (a) General requirements. A provider must develop and maintain records in accordance with:(1) this chapter; and(2) Chapter 49, Subchapter C, of this title (relating to Requirements of a Contractor).(b) Service delivery documentation. A provider must develop and maintain service delivery records as described in this subsection.(1) A provider must:(A) maintain for each individual the attendant time sheets an individual submits to the provider as required in §44.307(5) of this chapter (relating to Individual Responsibilities in All CMPAS Service Delivery Options);(B) ensure that each attendant time sheet is a single document that contains:(i) the name of the individual;(ii) the name of the attendant who provided services to the individual;(iii) the beginning and ending dates of the service delivery period;(iv) the specific days and times the attendant worked;(v) the signature of the attendant, or another person designated by the attendant, and the date signed; and(vi) the signature of the individual, representative, or another person designated by the individual or representative, and the date signed to certify the time worked and verify the services performed by the attendant as documented on the time sheet;(C) ensure that if another person signs and dates an attendant's time sheet for the attendant, the provider documents the reason the attendant is unable to complete or sign the time sheet and the name of the person the attendant authorized to sign the time sheet for the attendant; and(D) ensure that if another person signs and dates an attendant's time sheet for an individual or representative, the provider documents the reason the individual or representative was unable to sign the time sheet and the name of the person the individual or representative authorized to sign the time sheet for the individual or representative.(2) A provider must develop and maintain records to demonstrate the provider's compliance with:(A) §44.203 of this subchapter (relating to Assessment and Eligibility Determination);(B) §44.206 of this chapter (relating to Service Plan and Co-payment Disagreements);(C) §44.308 of this chapter (relating to Suspension of Services);(D) §44.309 of this chapter (relating to Termination of Services);(E) §44.501 of this subchapter (relating to Determining an Individual's Co-Payment); and(F) §44.502 of this subchapter (relating to Convening an IDT).(c) Financial records. A provider must, in accordance with generally accepted accounting principles (GAAP) and HHSC requirements, document and maintain financial records:(1) to support claims submitted to HHSC and payments received from HHSC; and(2) to support each individual's co-payment as calculated by the provider in accordance with §44.501 of this subchapter (relating to Determining an Individual's Co-payment), including documentation to support income, exclusions and deductions.(d) Required financial records. A provider's financial records must include:(1) the amount of payments received from HHSC, including:(A) the voucher number;(B) the warrant number;(C) the date of receipt; and(D) any other information necessary to trace deposits of payments received and payments made from the payments received in the provider's accounting system;(2) deposit slips, bank statements, cancelled checks, and receipts;(3) purchase orders;(4) invoices;(5) journals and ledgers;(6) time sheets, payroll, and tax records;(7) Internal Revenue Service, Department of Labor, and other required governmental financial records(8) records of insurance coverage, claims, and payments, including medical, liability, fire and casualty, and workers' compensation records;(9) equipment inventory records;(10) records of the provider's internal accounting procedures;(11) a chart of accounts, as defined by GAAP; and(12) records of company policies.(e) Subcontractor records. If a provider uses a subcontractor, the provider must maintain records of the subcontractor's activities in accordance with §49.308 of this title (relating to Subcontracts). The provider must maintain records to support subcontractor claims.(f) Failure to maintain records. If a provider fails to maintain records in accordance with this section, HHSC may initiate a corrective action plan and pursue any appropriate sanction against the provider. Source Note: The provisions of this §275.207 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM E ADDITIONAL PROGRAM REQUIREMENTS §275.207 Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209485 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209485 03/12/2026 (a) General billing requirements. A provider must submit to HHSC a claim for services provided to an individual in accordance with §49.311 of this title (relating to Claims Payment).(b) Billing requirements relating to attendant tasks. A provider must bill HHSC:(1) only for the allowable tasks described in §44.304 of this chapter (relating to Allowable and Unallowable Tasks) that comprise services actually delivered to an individual in accordance with the individual's service plan authorized by HHSC;(2) in accordance with the hourly rate negotiated by HHSC; and(3) for attendant tasks in quarter-hour increments, meaning that:(A) time worked that is not an exact quarter-hour must be rounded up to a quarter-hour if it is eight minutes or more; and(B) time worked that is less than eight minutes must not be billed. Source Note: The provisions of this §275.209 adopted to be effective October 1, 2013, 38 TexReg 6606; amended to be effective October 1, 2019, 44 TexReg 5106; transferred effective August 1, 2022, as published in the Texas Register July 8, 2022, 47 TexReg 3983. 1 HEALTH AND HUMAN SERVICES COMMISSION 275 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES (CMPAS) PROGRAM E ADDITIONAL PROGRAM REQUIREMENTS §275.209 Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220792 03/12/2026 This chapter establishes the requirements for facilities contracting to provide assisted living and residential care services to eligible clients through the Texas Department of Human Services Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program and the Community Care for the Aged and Disabled (CCAD) Residential Care (RC) Program. The requirements described in this chapter apply to both CBA AL/RC and CCAD RC, unless otherwise specified in the text. Source Note: The provisions of this §276.1 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES A INTRODUCTION §276.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220793 03/12/2026 The words and terms used in this chapter have the following meanings, unless the context clearly indicates otherwise.(1) Assisted living services--Services provided in an assisted living facility to eligible Texas Department of Human Services (DHS) clients under the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) or the Community Care for Aged and Disabled (CCAD) Residential Care (RC) programs.(2) Assisted Living/Residential Care (AL/RC) Program--A 24-hour residential care program for CBA clients.(3) Attendant--A facility employee who provides direct care to clients. An attendant may have other duties in addition to direct client care.(4) Case manager--A DHS employee who is responsible for case management activities. Activities include eligibility determination, client registration, assessment and reassessment of client need, service plan development, and intercession on the client's behalf.(5) Client--A CCAD or CBA client, as defined in Chapter 48 of this title (relating to Community Care for Aged and Disabled), who is eligible to receive services under this chapter.(6) Community Based Alternatives (CBA)--A Medicaid program that provides services to eligible adults who are aged and/or disabled as an alternative to institutional care in a nursing facility. CBA services are provided in accordance with the waiver provisions of §1915(c) of the Social Security Act (42 U.S.C. §1396n(c)).(7) Community Care for Aged and Disabled (CCAD)--A group of DHS programs that provides a variety of Title XIX and Title XX-funded community-based services.(8) Contract--The formal, written agreement between DHS and an assisted living facility to provide services to DHS clients eligible under this chapter in exchange for reimbursement.(9) Contract manager--A DHS employee who is responsible for the overall management of the contract with the assisted living facility.(10) Contracted assisted living facility--An assisted living facility that contracts with DHS to provide CBA AL/RC services or CCAD RC services or both. Any reference to facility in this chapter means contracted assisted living facility, unless otherwise specified in the text.(11) Copayment--The amount of personal income a client must pay to the facility toward the cost of care.(12) Days--Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.(13) Facility manager--The facility employee who is responsible for the day-to-day operation of a facility.(14) Licensed assisted living facility--A facility licensed by DHS Long Term Care Regulatory under the Health and Safety Code, Chapter 247.(15) Personal leave day--A continuous 24-hour period, measured from midnight to midnight, when the client is absent from the facility for personal reasons.(16) Representative--The client's spouse, other responsible party, or legal representative.(17) Residential Care (RC) Program--An assisted living and emergency care program for CCAD clients.(18) Room and board--The amount of personal income a client must pay to the facility toward the cost of lodging and food.(19) Signature--A person's name or a mark representing his/her name on a document to certify it is correct. Initials are not an acceptable substitute for a signature.(20) Trust fund--The services provided when the facility performs or assists with money management at the written request of the client or the client's representative.(21) Witness--A person who signs to verify distribution to or from a trust fund. A witness is identified in the client file by name, address, and relationship to the client, the client's representative, or the facility. A witness can be any person except:(A) the person(s) responsible for accounting for the client's trust fund;(B) the supervisor of the person(s) responsible for the client's trust fund;(C) a person supervised by the person(s) responsible for the client's trust fund; or(D) the person(s) who accepts the withdrawn funds.(22) Working days--Days DHS is open for business. Source Note: The provisions of this §276.3 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES A INTRODUCTION §276.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220794 03/12/2026 (a) General contracting requirements. A facility must meet all provisions described in this chapter and Chapter 49 of this title (relating to Contracting for Community Services).(b) Number of beds. The facility must specify in its contract the number of beds for clients of the Department of Aging and Disability Services (DADS), as follows:(1) The facility must ensure that the number of contracted DADS beds are in rooms that meet the requirements in §46.13 of this chapter (relating to Housing Options).(2) The facility must ensure the number of DADS clients served by the facility does not exceed the number of contracted DADS beds.(3) The facility may adjust the number of beds for DADS clients by contract amendment.(c) Disclosure statement requirements. The facility must ensure that the Assisted Living Disclosure Statement, as required by Chapter 92 of this title (relating to Licensing Standards for Assisted Living Facilities), does not conflict with the program requirements.(d) Client referrals. The facility must accept all DADS referrals unless:(1) the referral would cause the facility to exceed licensed capacity;(2) the referral would cause the facility to exceed the number of beds for DADS clients that the facility has specified in its contract; or(3) the facility is unable to meet the client's needs and has followed the procedures described in §46.35 of this chapter (relating to Interdisciplinary Team). Source Note: The provisions of this §276.11 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2014, 39 TexReg 6634; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.11 Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220795 03/12/2026 (a) Setting. A facility must specify in the contract the type(s) of setting(s) it uses to provide assisted living services according to the following guidelines:(1) Assisted living apartment. An assisted living apartment setting is a living unit that is a private space with living and sleeping areas, a kitchen, a bathroom, and adequate storage space. The bedroom must be single occupancy, except when the participant requests double occupancy in writing. The living unit must have private kitchen and bath facilities.(A) Size. Assisted living apartments must have a minimum of 220 square feet, not including the bathroom. Current contracted assisted living apartments that do not meet the square footage requirement may remain at their current size unless the apartment is remodeled. Remodeling includes:(i) the construction, removal, or relocation of walls and partitions;(ii) the construction of foundations, floors, or ceiling-roof assemblies;(iii) the expansion or alteration of safety systems, including:(I) sprinkler;(II) fire alarm; and(III) emergency systems; or(iv) the conversion of space in a facility to a different use.(B) Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.(C) Bathroom. The bathroom must be a separate room in the individual's living area with a toilet, sink, and an accessible bath.(2) Residential care apartment. A residential care apartment setting is a living unit that is a private space with connected sleeping, kitchen, and bathroom areas and adequate storage space. The bedroom must be double occupancy. The living unit must have private kitchen and bath facilities.(A) Size. Residential care apartments must have a minimum of 350 square feet of space per client. Indoor common areas used by Department of Aging and Disability Services (DADS) clients must be included in computing the minimum square footage. The portion of the common area allocated must not exceed usable square footage divided by the maximum number of individuals who have access to the common areas.(B) Kitchen. The kitchen is an area equipped with a sink, refrigerator, a cooking appliance, adequate space for food preparation, and storage space for utensils and supplies. The cooking appliance must be a stove, microwave, or built-in surface unit. The cooking appliance must be able to be removed or disconnected.(C) Bathroom. The bathroom must contain a toilet, sink, and an accessible bath.(3) Residential care non-apartment. A residential care non-apartment setting is a living unit that does not meet either the definition of an assisted living apartment or a residential care apartment. A living unit must not exceed double occupancy.(4) Personal Care 3. A Personal Care 3 setting is only available in the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program, and must meet the following qualifications:(A) The facility must be licensed for four to 16 beds in a residential care non-apartment setting.(B) The facility must provide 60% or more of its CBA clients with a single occupancy bedroom.(C) The facility must maintain a minimum staffing ratio of one direct care staff member for every:(i) four clients, including private pay clients, during the day and evening shifts; and(ii) eight clients, including private pay clients, during the night shift.(D) Sixty percent or more of the total clients served each month must require one-to-one staff assistance as documented on the DADS medical necessity and level of care assessment in one or more of the following activities of daily living:(i) transferring;(ii) eating; or(iii) toileting.(b) Occupancy. The facility must provide each client with a private (singe occupancy) or semi-private (double occupancy) living unit. Source Note: The provisions of this §276.13 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective January 1, 2006, 30 TexReg 8701; amended to be effective September 1, 2008, 33 TexReg 7285; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.13 Housing Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220796 03/12/2026 (a) The facility may charge the client or the client's representative for additional items or services that the Texas Department of Human Services (DHS) does not require the facility to provide. The client or the client's representative must request and approve the additional items or services in writing.(b) The facility must not charge the client or the client's representative for any service provided to the client as required by its contract with DHS.(c) The facility must inform the client or the client's representative of the additional items or services and the charges for those items or services at the following times:(1) at admission;(2) before a change in the additional items, services, or charges; and(3) when the client requests the additional items or services.(d) The facility may charge the client or the client's representative for additional items or services, including:(1) private telephone;(2) television and/or radio for personal use;(3) cable television services;(4) personal comfort items, including smoking materials, notions and novelties, and confections;(5) cosmetics and grooming items and services in excess of those required;(6) personal clothing;(7) personal reading material;(8) gifts purchased on behalf of a client;(9) flowers and plants;(10) social events and entertainment outside the scope of the required activities program;(11) the cost of being a single occupant in a double occupancy room, except for:(A) a therapeutically required single occupancy room, such as isolation for infection control; or(B) services provided in the assisted living apartment setting, as defined in §46.13(a)(1) of this chapter (relating to Housing Options);(12) specially prepared or alternative food requested instead of the food generally prepared by the facility;(13) the actual amount of the fee charged by the bank for checks written by the client or the client's representative that are returned for non-sufficient funds;(14) charges for damage to the facility beyond expected wear and tear. The facility must not charge a security/damage deposit to DHS clients; and(15) pet deposit. A pet deposit does not apply to service animals. A service animal is any guide dog, signal dog, or other animal trained to provide assistance to an individual with a disability. Source Note: The provisions of this §276.15 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.15 Additional Services and Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220797 03/12/2026 (a) Daily service delivery documentation. The facility must document the client's daily service delivery.(1) The daily service delivery documentation must contain the:(A) client name;(B) facility contract number issued by the Department of Aging and Disability Services (DADS);(C) coverage period of the daily service delivery documentation;(D) tasks assigned;(E) tasks performed during the coverage period;(F) signature of the facility manager or supervisor; and(G) date of signature of the facility manager or supervisor.(2) The daily service delivery documentation must be on a single document. If services delivered during the coverage period exceed the space on the single document, the facility may use multiple pages. The daily service delivery document must clearly indicate the number of pages used for the coverage period.(b) Daily census documentation. The facility must document the daily census of clients.(1) The daily census documentation must contain the:(A) name of the facility;(B) facility contract number issued by DADS;(C) coverage period of the daily census documentation;(D) name of each client served during the coverage period;(E) one of the following categories for the daily status of each client for each day during the coverage period:(i) admission;(ii) discharge;(iii) present;(iv) personal leave;(v) institutional leave;(vi) emergency care (emergency care applies only to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program); and(vii) ineligible emergency care (ineligible emergency care applies only to the CCAD RC program);(F) total of each type of daily status during the coverage period;(G) signature of the authorized timekeeper; and(H) date of the authorized timekeeper's signature.(2) The daily census documentation must be on a single document. If the number of clients served during the coverage period exceeds the space on the single document, the facility may use multiple pages. The daily census document must clearly indicate the number of pages used for the coverage period.(c) Registered nurse access. The facility must allow the home and community support services agency's registered nurse access to the client's medical and service plan records for use in the assessment. Source Note: The provisions of this §276.19 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2014, 39 TexReg 6634; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.19 Recordkeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220798 03/12/2026 (a) A unit of service is one billable day of authorized service delivered to a client.(b) The unit rate reimbursed by the Department of Aging and Disability Services (DADS) includes any copayment. The combined reimbursement from DADS and the client or the client's representative for the required services described in §46.41 of this chapter (relating to Required Services) must not exceed the unit rate plus room and board specified for each type of setting. The unit rate does not include charges for services described in §46.15 of this chapter (relating to Additional Services and Fees).(c) The facility must deduct the copayment amount from reimbursement claims submitted to DADS.(d) The facility must not bill DADS for the day of discharge, unless the discharge is due to the death of the client.(e) The facility must bill the double occupancy (Residential Care Apartment) rate for clients in the single occupancy (Assisted Living Apartment) setting who request double occupancy.(f) The facility must bill DADS for the balance of the bedhold charge for any clients whose daily copayment is less than the maximum bedhold charge allowed by DADS.(1) The facility must determine the client's daily copayment amount by dividing the client's monthly copayment charge by the number of days in the month.(2) The facility must deduct the client's daily copayment amount from the bedhold rate and submit the claim to DADS.(3) This subsection does not apply to the Assisted Living (AL) services allowed in the Community Based Alternatives (CBA) Program.(g) The facility may bill DADS for emergency care provided to clients for:(1) up 60 days per authorization for eligible clients; or(2) five days for a client ineligible for emergency care.(h) The facility must not bill for services provided before or after the authorized effective dates for CBA AL or Community Care for Aged and Disabled (CCAD) Residential Care (RC) services, as those dates are determined by DADS.(i) When the facility requests a level of care reset, the facility may bill DADS at the new payment rate effective the date of the new assessment. The facility may request only two level of care resets during each calendar year for each CBA client for the following time periods:(1) January through June; and(2) July through December.(j) CCAD RC services will be reimbursed at the double occupancy rate, regardless of the actual occupancy. Source Note: The provisions of this §276.21 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2008, 33 TexReg 7285; amended to be effective September 1, 2014, 39 TexReg 6634; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.21 Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220799 03/12/2026 Financial errors include the errors described in this section.(1) The facility is reimbursed for services, but the daily census documentation and the daily service delivery documentation are missing for the period for which services are reimbursed. The Department of Aging and Disability Services (DADS) applies the error to the total number of units reimbursed for the billing period for which forms are missing.(2) The facility is reimbursed for units that exceed the units recorded on daily census documentation and daily service delivery documentation. DADS applies the error to the total number of units reimbursed in excess of units recorded.(3) The facility is reimbursed for units of service and the client did not receive services. DADS applies the error to the total number of units reimbursed for the days the client did not receive services.(4) The facility is reimbursed for units of service and the client was Medicaid ineligible. DADS applies the error to the total number of units reimbursed for the days the client was Medicaid ineligible. This does not apply to the Community Care for Aged and Disabled (CCAD) Residential Care (RC) program. Source Note: The provisions of this §276.23 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2014, 39 TexReg 6634; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES B PROVIDER CONTRACTS §276.23 Financial Errors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220800 03/12/2026 The facility must have staff as described in §92.41 of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities). Source Note: The provisions of this §276.31 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.31 Staff Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220805 03/12/2026 (a) General training requirements. The facility must provide all staff with training as described in §92.41 of this title (relating to Standards for Type A and Type B Assisted Living Facilities).(b) Facility manager. In addition to the requirements described in subsection (a) of this section, the facility must train the facility manager on the following topics:(1) facility requirements for the Community Care for Aged and Disabled (CCAD) Residential Care (RC) or Assisted Living (AL) Services allowed in the Community Based Alternatives (CBA) programs or both, as applicable; and(2) client characteristics and needs.(c) Attendants. In addition to the requirements described in subsection (a) of this section, the facility must train the attendant in performing the tasks identified on the service plan described in §46.39(d) of this chapter (relating to Service Initiation). Source Note: The provisions of this §276.33 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2014 39 TexReg 6634; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.33 Staff Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220806 03/12/2026 (a) Interdisciplinary Team (IDT). The IDT is a designated group that includes the following individuals who meet when the need arises to discuss service delivery issues:(1) the client or the client's representative, or both;(2) a facility representative; and(3) a Texas Department of Human Services (DHS) representative. A DHS representative may be:(A) the case manager (or designee);(B) the contract manager (or designee); or(C) the regional nurse (or designee).(b) Convening an IDT meeting.(1) The facility must convene an IDT meeting within three working days of the date the facility identifies a service delivery issue.(2) If the facility is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the facility must send the documentation of the IDT meeting described in subsection (e) of this section to the Regional Administrator for the DHS region in which the client resides.(A) The documentation must be sent within five working days of the date of the IDT meeting.(B) Further action may be required by the facility, based on a review of the IDT meeting documentation.(c) IDT meeting.(1) The IDT meeting may be conducted by telephone conference call or in person.(2) The IDT must:(A) evaluate the issue;(B) identify any solutions to resolve the issue; and(C) make recommendations to the facility.(d) IDT meeting outcome. The facility must do one of the following within two working days after the IDT meeting:(1) implement the recommendations of the IDT; or(2) discharge the client from the facility and refer the case back to the case manager for referral to another facility.(e) Documentation of the IDT meeting. The facility must document the IDT meeting in the client file, including the:(1) specific reasons for calling the IDT meeting;(2) participants of the IDT meeting. If all members described in subsection (a) of this section are unable to participate, the facility must document all efforts made to convene an IDT meeting with all the members;(3) recommendations of the IDT;(4) efforts made to resolve the issue;(5) facility's action as a result of the IDT recommendations; and(6) reasons for the facility's actions. Source Note: The provisions of this §276.35 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.35 Interdisciplinary Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220807 03/12/2026 (a) Amount. The facility must collect the copayment and room and board amounts indicated on the Texas Department of Human Services' (DHS's) Notification of Community Care Services form or DHS's Notification of Community Based Alternatives (CBA) Services form. This subsection does not apply to clients who receive Community Care for Aged and Disabled emergency care service.(b) Due date.(1) The facility must designate a due date for copayment and room and board in writing. The due date must be during the same month the copayment and room and board is applied.(2) The facility must collect the entire copayment and room and board on or before the due date. If the due date falls on a weekend or a holiday, the facility must collect the entire copayment and room and board on or before the first working day thereafter.(3) If the client or the client's representative fails to pay the entire copayment and room and board by the due date, the facility must notify the client or the client's representative and the case manager in writing no later than the first working day after the due date.(c) Credit balances.(1) A credit balance is an amount due to the client or the client's representative when there is an overpayment by the client or the client's representative.(2) The facility must handle credit balances as follows:(A) The facility must provide written notice of a credit balance (client notice) to the client or the client's representative within 35 days of receipt of the payment resulting in a credit balance. The client notice may be the first monthly statement following the receipt of the payment resulting in a credit balance, if the monthly statement specifies the credit balance.(B) The facility must offer the client or the client's representative the following options in the client notice:(i) the client or the client's representative may choose to provide the corrected payment, and the facility will return the original amount paid;(ii) the facility will provide the client or the client's representative with a refund of the credit balance; or(iii) the client or the client's representative may choose to have the credit balance applied to the following month's payment. The client may choose to spread the credit balance over several months.(C) If the client or the client's representative fails to contact the facility within 35 days of the date of the client notice, the facility must, on the 35th day:(i) provide the client or the client's representative with a refund of the credit balance or apply the credit balance to the following month's payment; and(ii) provide written notice of the facility's choice of action to the client or the client's representative. The written notice of the facility's choice of action may be a monthly statement if the monthly statement specifies the facility's choice of action.(d) Copayment and room and board receipts.(1) The facility must provide receipts for all copayment and room and board payments received from or on behalf of clients at the time the payment is received.(2) The facility must keep a copy of all copayment and room and board receipts.(3) Copayment and room and board receipts must contain the following elements if the elements are not contained in the copayment and room and board ledger described in subsection (e) of this section:(A) the name of the client;(B) the month, day, and year the payment was received;(C) the total amount collected;(D) the specific amounts of copayment and room and board collected; and(E) the month and year of the coverage period for the payment received.(4) Copayment receipts may be in any format.(e) Copayment and room and board ledger. The facility must maintain a copayment and room and board ledger system in any format for each client.(1) The facility may keep the copayment and room and board ledger systems as separate ledgers, or the facility may combine both ledgers into a single ledger system. If the facility chooses to keep a single ledger system, a separate entry must be made for each copayment and room and board entry.(2) The copayment and room and board ledger system must reflect the following:(A) all charges for copayment and room and board by client;(B) all payments for copayment and room and board made by or on behalf of a client;(C) all credits for copayment and room and board by client, including the:(i) specific amount credited;(ii) month and year of the coverage period of the credit;(iii) type of payment credited; and(iv) reason for the credit; and(D) a running balance by client.(3) The facility must record all activities on the copayment and room and board ledger system within 35 days or by the next billing cycle, whichever is sooner.(4) The copayment and room and board ledger must be maintained in accordance with generally accepted accounting principles (GAAP).(f) Refunds upon discharge. The facility must refund the client's copayment and room and board for the remaining days of the month following the date of discharge or death. The refund must be made within ten working days of awareness that the client will be discharged or is deceased. The facility must document the date of awareness of the client's discharge from the facility. Source Note: The provisions of this §276.37 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.37 Copayment and Room and Board https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220801 03/12/2026 (a) Negotiated move-in date. The facility must negotiate a move-in date with the Texas Department of Human Services (DHS) case manager and the client or the client's representative.(b) Reserved space. The facility must reserve a living unit for three days from the agreed upon move-in date for each referred client. The facility may request another referral after three days if the move-in date is not re-negotiated.(c) Client and facility agreement. The facility must have a written agreement with the client or the client's representative. Both parties must sign the written agreement before or at the time of admission. The written agreement must include the following:(1) bedhold policies for hospital and nursing facility stays;(2) personal leave policies and charges;(3) eviction procedures;(4) all available services in the facility; and(5) charges for services not paid by DHS and charges not included in the facility's basic daily rate, as described in §46.15 of this chapter (relating to Additional Services and Fees).(d) Health assessment and service plan.(1) The facility must complete a health assessment and develop an individual service plan as described in §92.41(c) of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities).(2) In addition to the items described in §92.41(c) of this title, the health assessment developed by the facility must contain the following items:(A) vision patterns;(B) skin conditions;(C) body control problems; and(D) vital signs, height, and weight.(3) The health assessment and individual service plan must be completed:(A) within 72 hours of admission to the facility; and(B) by the appropriate person(s).(i) The facility manager or a nurse must complete the health assessment and individual service plan.(ii) A nurse must complete the medication administration portion of the health assessment for Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) clients. If the nurse is a licensed vocational nurse (LVN), a registered nurse (RN) must sign off on the medication administration portion of the health assessment. Source Note: The provisions of this §276.39 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.39 Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220802 03/12/2026 (a) Service delivery. The facility must provide services according to the service plan completed for the client.(b) Required services. Services include:(1) Personal care. The facility must provide or assist with personal care services identified on the service plan completed for the client. Personal care services are activities related to the care of the client's physical health that include at a minimum:(A) bathing;(B) dressing;(C) grooming;(D) routine hair and skin care;(E) exercising;(F) toileting;(G) medication administration, including injections, except in the Community Care for Aged and Disabled (CCAD) Residential Care (RC) Program;(H) transferring/ambulating, except in a Type A assisted living facility;(I) twenty-four-hour supervision, which means the facility must:(i) conduct checks or visits to each client as identified in the client's service plan, to ensure that each client is safe and well; and(ii) document the checks and visits in the client's file;(J) meal services, which means the facility must:(i) provide meal services as described in §92.41(m) of this title (relating to Standards for Type A, Type B, and Type E Assisted Living Facilities);(ii) offer dietary counseling and nutrition education to the client;(iii) modify food texture, including:(I) chopping, grinding, and mashing foods for clients who have trouble chewing; and(II) cutting up food into bite size pieces for clients who have trouble cutting food; and(iv) assist with eating, including:(I) assistance with spoon-feeding in instances when the client is temporarily ill;(II) bread buttering; and(III) opening containers or pouring liquids for clients with hand deformities, paralysis, or hand tremors.(2) Home management. The facility must provide or assist with activities related to housekeeping that are essential to the client's health and comfort, including:(A) changing bed linens;(B) housecleaning;(C) laundering;(D) shopping;(E) storing purchased items in the client's living unit, including medical supplies delivered to Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) clients; and(F) washing dishes.(3) Transportation and escort.(A) The facility must provide the client with transportation, escort, or both to:(i) local community areas where a client may purchase items to meet his or her personal needs or conduct personal business according to the facility's published schedule;(ii) recreational activities, field/community trips according to the facility's published schedule; and(iii) the nearest available medical provider for medical appointments, therapies, and other medical care.(B) The facility must make arrangements for other transportation for the client to the medical care provider of the client's choice if the client's medical provider is not the nearest available provider.(4) Social and recreational activities. The facility must provide a minimum of four scheduled social and recreational activities per week.(A) Activity requirements. The social and recreational activities must be:(i) planned to meet the social needs and interests of the clients; and(ii) listed on a monthly calendar that is posted in plain view at the facility at least one week in advance.(B) Types of activities. Social and recreational activities include:(i) activities that require group and client-initiated activities;(ii) opportunities to interact with other people;(iii) interaction, cultural enrichment, educational, or recreational activities; and(iv) other social activities on site or in the community.(5) Participation in the client assessment. The facility must designate someone who is familiar with the CBA AL/RC client's needs and service plan to participate in the client's assessment by a home and community support services agency's licensed nurse. A facility is not required to designate someone to participate in a client's assessment in the CCAD RC Program.(6) Emergency care. The facility must provide emergency care as authorized by the case manager.(A) Emergency care is assisted living services provided to clients while the case manager seeks a permanent living arrangement.(B) Emergency care services do not apply to the CBA AL/RC program. Source Note: The provisions of this §276.41 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2008, 33 TexReg 7285; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.41 Required Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220803 03/12/2026 (a) The facility must complete a new service plan anytime there is a need for a change in the client's service plan.(b) The facility must implement service plan changes within seven days from the assessment date. Source Note: The provisions of this §276.43 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.43 Service Plan Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220804 03/12/2026 (a) The facility must notify the Department of Aging and Disability Services (DADS) when one of the following happens:(1) significant changes in the client's health and/or condition;(2) the client temporarily enters an institution;(3) serious occurrences or emergencies involving the client or facility staff;(4) the client or the client's representative requests that services end;(5) the client refuses to comply with the service plan;(6) the client engages in discrimination in violation of applicable law;(7) the client or the client's representative fails to pay copayment;(8) the client uses ten personal leave days in the current calendar year;(9) the client or the client's representative requests to move to another facility; or(10) the facility believes that a client's functional needs have changed such that it will impact the client's level of care, if the facility provides assisted living services under the Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) Program and participates in the attendant compensation rate option.(b) The facility must notify the client's DADS case manager orally or by facsimile about the change no later than one DADS working day after the change happens. If the facility's first notification is oral, the facility must send written notification to the case manager within five working days of the initial notification. Source Note: The provisions of this §276.45 adopted to be effective September 1, 2003, 28 TexReg 6941; amended to be effective September 1, 2008, 33 TexReg 7285; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.45 Required Notifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220811 03/12/2026 (a) The facility must suspend services when one of the following happens:(1) the client dies;(2) the client moves from the facility;(3) the client is discharged because he threatens the health or safety of himself or other clients in the facility;(4) the client is permanently admitted to an institution;(5) the Texas Department of Human Services (DHS) enforces sanctions against the facility by terminating the contract;(6) the client's eligibility is denied; or(7) the case manager requests that services be suspended or terminated.(b) The facility must notify the client's DHS case manager orally or by facsimile about the suspension no later than one DHS workday after services are suspended. If the facility's first notification is oral, the facility must send written notification to the case manager within five working days of the initial notification. Source Note: The provisions of this §276.47 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.47 Suspension of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220808 03/12/2026 (a) Institution. An institution is defined as a hospital, nursing facility, state school, state hospital, or intermediate care facility serving persons with mental retardation or a related condition.(b) Institutional leave. Institutional leave is when clients are absent from the facility because they temporarily enter an institution.(c) Bedhold. The facility must hold the client's bed:(1) for a Community Care for Aged and Disabled (CCAD) Residential Care (RC) client for:(A) 60 days if the client is in a hospital; or(B) 30 days if the client is in any other type of institution; and(2) for a Community Based Alternatives (CBA) Assisted Living/Residential Care (AL/RC) client for 60 days if the client is in any type of institution.(d) Bedhold charges. The facility must charge the client or the client's representative for bedhold during institutional leave.(1) Bedhold charges for a CCAD RC client are the bedhold rate established by the Texas Department of Human Services (DHS), plus room and board charges.(2) Bedhold charges for a CBA AL/RC client are the room and board charges.(e) Refund of copayment. The facility must not charge the client or the client's representative more than the maximum amount allowed by DHS for bedhold. The facility must refund the client's copayment for the days the client uses institutional leave.(1) The facility must refund any copayment paid by a CCAD RC client or the client's representative that is in excess of the bedhold amount. If the client's copayment amount is less than the bedhold charge, DHS pays the difference as described in §46.21 of this chapter (relating to Reimbursement).(2) The facility must refund all copayments paid by a CBA AL/RC client or the client's representative.(3) The refund must be made according to the procedures in §46.37(c) of this chapter (relating to Copayment and Room and Board).(f) Billing during institutional leave. The facility must charge the client or the client's representative only the bedhold amount for the date of admission to an institution. The facility must charge the client or the client's representative the full rate for date of return.(g) Notification of institutional leave. The facility must notify the DHS case manager of any institutional leave as described in §46.45 of this chapter (relating to Required Notifications). Source Note: The provisions of this §276.49 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.49 Institutional Leave https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220809 03/12/2026 (a) Personal leave. A client is entitled to 14 days of personal leave per calendar year.(b) Client charges. The facility must collect the entire copayment and room and board charges for all personal leave days.(c) Texas Department of Human Services (DHS) payment during personal leave. The facility must not bill DHS for more than 14 days of personal leave taken by the client each calendar year.(d) Notification of personal leave days. The facility must notify the DHS case manager of personal leave days as described under §46.45 of this chapter (relating to Required Notifications).(e) Charge for exceeding personal leave days. The client is responsible for all charges for services if he exceeds the allowable limit of personal leave days. Source Note: The provisions of this §276.51 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.51 Personal Leave https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220810 03/12/2026 (a) Client discharge. The facility must convene an Interdisciplinary Team (IDT) meeting, as described in §46.35 of this chapter (relating to Interdisciplinary Team) before discharging a client, except when the client threatens the health or safety of others or himself. The facility must notify the DHS case manager as described under §46.47 of this chapter (relating to Suspension of Services).(b) Assistance with move. The facility must help the client prepare for transfer or discharge.(c) Refunds. The facility must refund the following:(1) copayment and room and board, as described in §46.37(f) of this chapter (relating to Copayment and Room and Board); and(2) trust fund balances, as described in §46.71 of this chapter (relating to Trust Fund Procedures for Client Discharge). Source Note: The provisions of this §276.53 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES C PROVIDER REQUIREMENTS §276.53 Client Terminations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220812 03/12/2026 (a) Clients have the right to:(1) perform their own money management;(2) request that the facility provide or assist with money management; or(3) designate another person to provide or assist with money management.(b) The case manager will inform the facility if a client wishes the facility to provide or assist with money management.(c) The facility must not require clients to request the facility provide or assist with money management. The facility must have the client's or the client's representative's written authorization to provide or assist with money management.(d) The facility must provide a written statement of the trust fund rights and responsibilities regarding the client's financial affairs. The written statement must:(1) be provided to each client or client's representative who chooses to have the facility provide or assist with money management;(2) be provided at the time of admission or request; and(3) include the following:(A) a statement that the facility must not require clients to allow the facility to provide or assist with money management;(B) the client or the client's representative's written request and authorization to provide or assist with money management; and(C) any charge by the facility for providing or assisting with money management is included in the facility's basic rate. Source Note: The provisions of this §276.61 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.61 Trust Fund Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220813 03/12/2026 (a) Bank account.(1) The contracted assisted living facility must keep funds received from or on behalf of a client for a trust fund in a separate bank account from the facility's operating funds. The account must be identified as "Trustee, (Name of Facility), Client's Trust Fund Account."(2) The facility may use the following type of checking accounts for the trust fund:(A) a pooled checking account, which is a single checking account that contains all the personal funds received from each client utilizing the trust fund;(B) a client-choice individual checking account, which is a single checking account that contains only the personal funds of a single client. The client or the client's representative must request this type of trust fund in writing; or(C) a facility-choice individual checking account, which is a single checking account that contains only the funds of a single client. This type of trust fund is set up for the convenience of the facility.(b) Commingled funds. A facility may commingle the trust funds of private-pay clients and Texas Department of Human Services (DHS) clients.(1) Each private-pay client or the client's representative whose funds are commingled with DHS client funds must sign and date a permission form upon admission or at the time of request for trust fund services. The permission form must include:(A) permission for the facility to commingle the personal funds of the private pay client with DHS clients;(B) permission for the facility to maintain trust fund records of private-pay clients in the same manner as the DHS client's trust fund records; and(C) a provision allowing inspection of the private-pay client's trust fund records by DHS staff.(2) The facility must keep financial records of private pay clients with commingled funds in the same manner as the financial records of DHS clients as specified in this chapter.(c) Banking charges.(1) The facility is responsible for bank fees for the trust fund kept in a pooled checking account or in facility-choice individual checking accounts. The facility must not charge these fees to the client or the client's representative. The facility may report these fees as allowable costs on its cost report.(2) The client or the client's representative is responsible for bank fees for the trust fund kept in client-choice individual checking accounts.(3) The facility must not charge the client or the client's representative for the administrative handling of any allowable type of checking account. The facility may report these costs on its cost report.(d) Interest earned. The facility must distribute the interest earned on the pooled checking account, if the pooled checking account is interest-bearing, to all clients utilizing the trust fund. The facility must prorate the actual interest earned to each client's account:(1) at the time the financial institution pays the interest; and(2) on the basis of the client's balance at the time the financial institution pays the interest. Source Note: The provisions of this §276.63 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.63 Trust Fund Bank Account https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220814 03/12/2026 (a) Transactions.(1) The facility must keep records of all trust fund transactions.(2) Facility staff must record on the client's trust-fund ledger or deposit/withdrawal document at least the following:(A) the date and amount of each deposit;(B) the source of each deposit;(C) the date and amount of each withdrawal;(D) the reason for each withdrawal;(E) the name of the person or entity who accepted the withdrawn funds; and(F) the balance after each transaction.(3) The client or the client's representative must sign for each withdrawal transaction at the time of the transaction.(A) The signature must be on the trust-fund ledger, deposit/withdrawal document, or trust fund receipt.(B) At least one witness must sign for each withdrawal transaction if the client or the client's representative cannot sign.(C) A signature is not required if the payment meets the definition of a recurring payment as described in subsection (c) of this section.(4) The facility must record transactions within 14 days of occurrence.(b) Bulk purchases. The facility may make bulk purchases for items used by multiple clients.(1) The bulk purchase must be traceable to individual clients.(2) The receipt for the bulk purchase must show the following:(A) the names of the clients for whom the purchase was made; and(B) the portion of the total price charged to each client.(3) The facility must not charge the client or the client's representative more than the actual cost of the client's portion of items that are purchased in bulk.(c) Recurring payments.(1) The facility must obtain the client's or the client's representative's written request and authorization to make recurring payments on behalf of the client. The written authorization must include the:(A) name of the business or entity to which the recurring payment is made;(B) amount of the recurring payment. If the recurring payment is not a set amount, the authorization must include the method for determining the amount of the recurring payment;(C) date the payment will begin; and(D) signature and signature date of the client or the client's representative.(2) The client or the client's representative must request and authorize the facility to stop recurring payments on behalf of the client.(A) The authorization may be oral or written.(B) The facility must document the request, including the:(i) name of the business or entity to which the recurring payment is made; and(ii) date the payment will stop.(3) The facility is not required to have a receipt for recurring payments made on behalf of the client.(d) Petty cash fund.(1) A petty cash fund is part of the pooled checking account trust fund kept on hand in cash by the facility. The petty cash fund is used for disbursement to clients for the purchase of minor items.(2) The facility must keep the petty cash fund locked.(3) The facility must set a dollar limit for petty cash transactions.(A) The facility must document:(i) the dollar limit of petty cash transactions; and(ii) a list of any exceptions to the petty cash transaction limit, if applicable.(B) The facility must follow the procedures in subsection (a) of this section for withdrawals that exceed the petty cash transaction limit.(4) The facility must keep records of all petty cash fund transactions. The petty cash fund record must be a:(A) petty cash fund ledger; or(B) petty cash fund receipt.(5) A petty cash fund ledger or receipt must include the:(A) name of the client;(B) date of the withdrawal;(C) amount of the withdrawal; and(D) signature of client or the client's representative, or at least one witness if the client or the client's representative cannot sign.(6) The facility must use the following guidelines to replenish the petty cash fund:(A) Count the money in the petty cash fund.(B) Determine the difference between amount in the petty cash fund and the amount needed in the petty cash fund.(C) Cash a check for the difference between the amount in the petty cash fund and the amount needed in the petty cash fund.(i) Write the check for cash on the appropriate checking account, either the:(I) pooled trust fund checking account; or(II) individual client trust fund checking account.(ii) Indicate "petty cash fund" in the "memo" line of the check.(D) Put the cash in the petty cash fund.(7) The facility must reconcile the petty cash fund at least monthly.(8) The facility must follow the requirements for transactions in subsection (a) of this section to post petty cash fund transactions to the trust fund ledger. However, the client's or the client's representative's signature is not required on the trust fund ledger or trust fund receipt if the client's or the client's representative's signature is on the petty cash fund ledger or receipt.(e) Receipts.(1) A trust fund receipt is required when a direct payment is made from the client's trust fund. The facility may use printed receipts from vendors as trust fund receipts only if:(A) all elements from paragraph (4) of this subsection are present; or(B) any missing elements from paragraph (4) of this subsection are added.(2) A trust fund receipt is required when a payment is received by the facility on behalf of a client. This is not applicable to funds direct-deposited to the trust fund account.(3) A trust fund receipt is not required when the client or the client's representative makes a direct purchase with funds withdrawn from the trust fund. The withdrawn funds must meet the requirements listed in subsection (a) of this section.(4) A trust fund receipt must contain the:(A) name of the client;(B) month, day, and year the receipt was written or created;(C) total amount of money spent or received for the client;(D) specific item(s) purchased; and(E) name of the business or entity from which the purchase was made or the payment received.(5) A trust fund receipt may contain the signature of the client or the client's representative for payments made from the trust fund. At least one witness must sign for each payment made if the client or the client's representative cannot sign.(f) Limitations on withdrawals. The facility must not use the client's personal funds to purchase any item or service that the Texas Department of Human Services requires the facility to provide. The facility must purchase additional items or service with the client's personal funds only as described in §46.15 of this chapter (relating to Additional Services and Fees). Source Note: The provisions of this §276.65 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.65 Trust Fund Transactions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220815 03/12/2026 (a) Accounting and records.(1) The facility must keep written records of all financial transactions involving the client's personal funds that the facility is holding, safeguarding, and accounting. The written records may be in any format.(2) The facility must keep the accounting records in accordance with generally accepted accounting principles (GAAP).(3) The facility must keep records in accordance with its fiduciary duties for client trust funds.(4) The facility must include at least the following in the accounting records:(A) each client's name;(B) identification of each client's representative or person assigned to receive the client's income, if any;(C) admission date;(D) each client's earned interest, if any;(E) documentation of each transaction; and(F) receipts for purchases and payments, including cash register tapes or sales statements from a seller.(b) Quarterly statement. The facility must provide quarterly statements to the client or the client's representative, as described in §92.125(a)(3)(L) of this title (relating to Resident's Bill of Rights and Provider Bill of Rights).(c) Access to trust fund records.(1) The facility must make an individual client's financial record and supporting documents available at any time during working hours to the client, the client's representative, and the Texas Department of Human Services.(2) This review can be made without prior notification. Source Note: The provisions of this §276.67 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.67 Trust Fund Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220816 03/12/2026 (a) The facility must return the full balance of the client's personal funds held in the facility to the client or the client's representative immediately upon request if the request is made during normal business hours. For purposes of this subsection, normal business hours are 8:00 a.m. to 5:00 p.m. on working days, or at the beginning of the next normal business hours if the request is received during hours other than normal business hours.(b) The facility must return the full balance of the client's personal funds that the facility has deposited in any bank account to the client or the client's representative within ten working days of request. This refund must include any interest reported as of the date of the request. Source Note: The provisions of this §276.69 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.69 Trust Fund Refunds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220817 03/12/2026 (a) Client transfer.(1) The facility must write a check to the resident for all funds held in the pooled checking account. This must include any interest accrued.(2) The facility must complete the transfer within ten working days of the effective date of the transfer.(3) The facility must not make any payments out of a client's trust fund after the effective date of transfer, except as described in this subsection.(4) The cleared check will suffice as a receipt.(b) Client discharge.(1) The facility must refund the discharged client's personal funds and provide a final accounting of those funds to the client or the client's representative either:(A) in person; or(B) by mail via certified return receipt.(2) The facility must complete the refund and provide a final accounting within ten working days of the date of discharge, or the date of the facility's awareness of the client's discharge, whichever is later.(3) The facility must not make any payment out of a discharged client's trust fund, except as described in this subsection.(4) The facility must maintain the following documentation in the client's trust fund record:(A) a copy of the final accounting of the client's personal funds;(B) the amount refunded to the discharged client or the client's representative;(C) the date the refund was made. The date the refund was made is either:(i) the date the funds were refunded in person; or(ii) the date the certified return receipt shows the refund was mailed; and(D) the method of refund. The facility must:(i) obtain the signature of the client or the client's representative if the refund was in cash; or(ii) document the check number if the refund was made by check.(c) Client death.(1) The facility must refund the deceased client's personal funds and provide a final accounting of those funds to the beneficiary, heir, or executor of the deceased client's estate either:(A) in person; or(B) by mail via certified return receipt.(2) The facility must complete the refund and provide a final accounting within 30 days of awareness of the client's death, if the beneficiary, heir, or executor is known, located, or identified. The facility must make a bona fide effort to locate the beneficiary, heir, or executor of a deceased client's estate within 30 days.(3) The facility must not make any payments out of a deceased client's trust fund, except as described in this subsection.(4) The facility must maintain the following documentation in the client trust fund record:(A) a copy of the final accounting of the client's personal funds;(B) the amount refunded to the beneficiary, heir, or executor of the deceased client's estate;(C) the date the refund was made. The date the refund was made is either:(i) the date the funds were refunded in person; or(ii) the date the certified return receipt shows the refund was mailed; and(D) the method of refund. The facility must:(i) obtain the signature of the client or the client's representative if the refund was in cash; or(ii) document the check number if the refund was made by check.(5) The facility must use the following procedures to clear the client's account if it is unable to locate or identify the beneficiary, heir, or executor of a deceased client's estate within 30 days:(A) The facility must send the personal funds of the deceased client to the Texas Department of Human Services (DHS), Fiscal Division, P.O. Box 149055, Austin, Texas 78714-9055 with the following information:(i) the client's name;(ii) the client's social security number; and(iii) the amount of money being submitted to DHS for escheat.(B) The facility must maintain the following in the client trust fund record:(i) documentation of the facility's efforts to locate the beneficiary, heir, or executor of a deceased client's estate; and(ii) proof of submission of the personal funds of a deceased client to DHS.(d) Contract assignment.(1) The assignor (the facility transferring the contract) must transfer the bank balances of the trust fund to the assignee (the facility to which the contract assignment is made) either:(A) in person; or(B) by mail via certified return receipt.(2) The assignor must complete the transfer within five working days of the effective date of the contract assignment.(3) The assignor must not make any payments out of a client's trust fund after the effective date of the contract assignment, except as described in this subsection.(4) The assignor must provide the assignee with a list of the clients who are utilizing the trust fund and their balances.(5) The assignee must provide the assignor with a receipt for the transfer of these funds. The receipt must contain the following elements:(A) the date of the transfer of funds. The date the transfer was made is either the:(i) date the funds were refunded in person; or(ii) date the certified return receipt shows the refund was mailed;(B) the name of the assignor;(C) the amount received by the assignee; and(D) the check number for the transfer of funds.(6) The assignor must keep the receipt for audit purposes. Source Note: The provisions of this §276.71 adopted to be effective September 1, 2003, 28 TexReg 6941; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7640. 1 HEALTH AND HUMAN SERVICES COMMISSION 276 CONTRACTING TO PROVIDE ASSISTED LIVING AND RESIDENTIAL CARE SERVICES D TRUST FUNDS §276.71 Trust Fund Procedures for Client Discharge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219378 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219378 03/12/2026 (a) This chapter establishes the requirements for a provider contracting to provide community-based services to an individual through the PHC Program, CAS Program, and FC Program. In these programs, services may be provided through the provider option, the service responsibility option (SRO), or the consumer directed services (CDS) option of service delivery. The SRO is described in Chapter 43 of this title (relating to Service Responsibility Option) and the CDS option is described in Chapter 41 of this title (relating to Consumer Directed Services Option).(b) The requirements in this chapter apply to the PHC Program, CAS Program, and FC Program unless otherwise specified in the text. Source Note: The provisions of this §277.1 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS A INTRODUCTION §277.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219379 03/12/2026 The following words, terms, and phrases have the following meanings when used in this chapter, unless the context clearly indicates otherwise:(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) ADL--Activity of daily living. An activity that is essential to daily self-care. An ADL does not include a service that must be provided or supervised by licensed personnel.(3) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual.(4) Attendant--A person who provides authorized tasks to an individual.(5) CAS Program--Community Attendant Services Program. A Medicaid state plan program authorized under Title XIX, §1929(b) of the Social Security Act that provides personal attendant services to an eligible individual.(6) Case worker--An HHSC employee who is responsible for case authorization and management activities.(7) Chemical restraint--A medication used to control an individual's behavior or to restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition.(8) Contract manager--An HHSC employee who is responsible for the overall management of the contract with the provider.(9) Controlling person--A person who:(A) has an ownership interest in a provider;(B) is an officer or director of a corporation that is a provider;(C) is a partner in a partnership that is a provider;(D) is a member or manager in a limited liability company that is a provider;(E) is a trustee or trust manager of a trust that is a provider; or(F) because of a personal, familial, or other relationship with a provider, is in a position of actual control or authority with respect to the provider, regardless of the person's title.(10) Days--Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.(11) DFPS--The Department of Family and Protective Services.(12) Expedited referral--In the PHC Program or CAS Program, an oral request from a case worker to a provider when the case worker determines that an individual's needs require that pre-initiation activities be completed in less than 14 days.(13) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain. In the FC Program, if services are not provided through the CDS option, exploitation includes theft as defined in Chapter 31 of the Texas Penal Code.(14) FC Program--Family Care Program. A program authorized under Title XX, Subtitle A, of the Social Security Act that provides personal attendant services to an eligible individual.(15) Financial management services--A service, as defined in §41.103 of this title (relating to Definitions), that is provided to an individual participating in the consumer directed services option.(16) FMSA--Financial management services agency. As defined in §41.103 of this title, an entity that provides financial management services to an individual participating in the consumer directed services option.(17) Functional limitation--An individual's requirement for assistance with one or more ADLs caused by a physical limitation or disability.(18) HHSC--The Texas Health and Human Services Commission.(19) IADL--Instrumental activities of daily living. Activities related to living independently in the community.(20) Imminent danger--An immediate or real threat.(21) Individual--A person who is enrolled in the PHC Program, CAS Program, or FC Program and, unless the context indicates otherwise, the person's representative.(22) Mechanical restraint--A mechanical device, material, or equipment used to control an individual's behavior by restricting the ability of the individual to freely move part or all of the individual's body.(23) Medical need--A medical diagnosis that results in a functional limitation.(24) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death.(25) Non-priority--The eligibility status for service delivery as determined by the case worker for an individual who does not meet the criteria described in §48.2918(d) of this title (relating to Primary Home Care or Community Attendant Services). Services delivered to such an individual may be referred to as non-priority services, and an attendant who serves such an individual may be referred to as a non-priority attendant.(26) Notice--Includes oral, fax, secure email, and other forms of written notice.(27) Oral notice--Directly speaking with a person. Oral notice does not include a message left by voice mail.(28) PHC Program--Primary Home Care Program. A Medicaid state plan program authorized under Title XIX, §1902(a)(10)(A) of the Social Security Act that provides personal attendant services to an eligible individual.(29) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual; or(C) the use of a restraint or seclusion.(30) Physical restraint--Any manual method used to control an individual's behavior, except for physical guidance or prompting of brief duration that an individual does not resist, that restricts:(A) the free movement or normal functioning of all or a part of the individual's body; or(B) normal access by an individual to a portion of the individual's body.(31) Practitioner--A person who holds a doctor of medicine or doctor of osteopathy degree and is currently licensed in Texas, Louisiana, Arkansas, Oklahoma or New Mexico; a physician assistant currently licensed in Texas; or a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice registered nurse.(32) Practitioner's statement--The HHSC Practitioner's Statement of Medical Need form.(33) Priority--The eligibility status for service delivery as determined by the case worker for an individual who meets the criteria described in §48.2918(d) of this title. Services delivered to such an individual may be referred to as priority services, and an attendant who serves such an individual may be referred to as a priority attendant.(34) Provider--A licensed home and community support services agency that has a contract with HHSC to provide PHC Program, CAS Program, and FC Program services.(35) Reckless behavior--Acting with conscious indifference to the consequences.(36) Regional nurse--An HHSC employee who is responsible for authorizing the CAS Program for an individual.(37) Representative--An individual's spouse, other responsible party, designated representative, or legally authorized representative.(38) Restraint--Any of the following:(A) a chemical restraint;(B) a mechanical restraint; or(C) a physical restraint.(39) Routine referral--In the PHC Program or CAS Program, a written request from the case worker to a provider to evaluate an individual for service delivery when the case worker determines that the individual's needs do not require an expedited referral.(40) Seclusion--The involuntary placement of an individual alone in an area from which the individual is prevented from leaving.(41) Secure email--Electronic mail that uses sufficient precautions to protect the privacy and security of identifying information in compliance with the requirements of the Health Insurance Portability and Accountability Act of 1996.(42) Service delivery plan--A single document that is agreed upon and signed by an individual and a provider containing the elements described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities). A single document may be more than one page.(43) Service schedule--A schedule for delivering attendant services containing the elements described in §47.45(a)(2)(C)(iii) of this chapter.(44) Sexual abuse--Any of the following:(A) sexual exploitation of an individual;(B) non-consensual or unwelcomed sexual activity with an individual; or(C) consensual sexual activity between an individual and a staff person or controlling person, unless a consensual sexual relationship with an adult individual existed before the staff person or controlling person became a staff person or controlling person.(45) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(46) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person:(A) which may include sexual contact; and(B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice.(47) Staff person--An employee, contractor, or volunteer of a provider.(48) Supervisor--A provider employee who:(A) coordinates the delivery of services in an individual's service delivery plan;(B) supervises attendants; and(C) meets the requirements for a supervisor in accordance with 26 TAC §558.404 (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services).(49) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade an individual; or(ii) threaten an individual with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the individual; or(ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress.(50) Volunteer--A person who works for a provider without compensation, other than reimbursement for actual expenses.(51) Working day--Any day except a Saturday, Sunday, or national or state holiday listed in Texas Government Code §662.003(a) or (b). Source Note: The provisions of this §277.3 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS A INTRODUCTION §277.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219380 03/12/2026 (a) General contracting requirements. A provider must comply with this chapter and Chapter 49 of this title (relating to Contracting for Community Services).(b) Services provided. The provider must deliver only personal assistance services, as defined in §97.2 of this title (relating to Definitions). Source Note: The provisions of this §277.11 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective September 1, 2014, 39 TexReg 6635; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS B PROVIDER CONTRACTS §277.11 Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219381 03/12/2026 (a) General training. A provider must train a supervisor as described in 26 TAC §558.245 (relating to Staffing Policies).(b) Program-specific training. The provider must ensure the supervisor understands the applicable rules and procedures of the PHC Program, CAS Program, and FC Program. Source Note: The provisions of this §277.21 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS C STAFF REQUIREMENTS §277.21 Supervisor Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219382 03/12/2026 An attendant must:(1) meet the requirements described in 26 TAC §558.404(c) (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services);(2) not be a legal parent, foster parent, or spouse of a parent of a minor who receives services in the CAS Program;(3) not be the spouse of the individual who receives the service, except for services in the FC Program; and(4) not be designated by an HHSC case worker on HHSC's Authorization for Community Care Services form as "Do not hire." Source Note: The provisions of this §277.23 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS C STAFF REQUIREMENTS §277.23 Attendant Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219383 03/12/2026 (a) Orientation. In addition to the requirements described in this section, a provider must ensure each attendant is oriented as described in 26 TAC Chapter 558, Subchapter C, (relating to Minimum Standards for All Home and Community Support Services Agencies) and 26 TAC §558.404 (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). Orientation is not required for a supervisor when providing personal assistance services.(b) Method of orientation.(1) A supervisor must determine the method of attendant orientation, which may be conducted:(A) in person, with the participation of the individual; or(B) by telephone or in person at any location without the participation of the individual at the discretion of the supervisor, if the attendant:(i) meets the requirements described in 26 TAC §558.701 (relating to Home Health Aides);(ii) has six continuous months of experience in delivering attendant care;(iii) has been oriented to the individual and there are service delivery plan changes; or(iv) has previously provided services to the individual.(2) The supervisor may use discretion to determine if the attendant needs to be oriented if:(A) the attendant previously provided services to the individual; and(B) the service delivery plan has not changed since the attendant provided services to the individual.(c) Due dates. The supervisor must orient each attendant on or before the time the attendant begins to provide attendant services.(d) Documentation of attendant orientation.(1) The supervisor must record the attendant orientation on a single document that includes:(A) the individual's name and number assigned to the individual by HHSC;(B) the attendant's name;(C) the date of the attendant orientation;(D) if the orientation was conducted in person with the individual or without the participation of the individual;(E) information about how the individual's condition affects the performance of tasks;(F) the tasks to be performed;(G) the service schedule;(H) the number of hours of service the attendant is to provide;(I) the total number of hours of service the individual is authorized to receive;(J) safety and emergency procedures, including universal precautions;(K) specific situations about which the attendant must notify the provider, including:(i) changes in the individual's needs;(ii) incidents that affect the individual's condition;(iii) hospitalization of the individual;(iv) the individual's absence or relocation from home; and(v) the attendant's inability to work; and(L) the signature of:(i) the supervisor who conducts the orientation;(ii) the attendant who is oriented, if present; and(iii) the individual, if present.(2) The provider must maintain documentation of the attendant orientation in the individual's file. Source Note: The provisions of this §277.25 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS C STAFF REQUIREMENTS §277.25 Attendant Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219384 03/12/2026 The PHC Program, CAS Program, and FC Program include the following tasks:(1) assistance with ADLs, including:(A) bathing, which is:(i) drawing water in sink, basin, or tub;(ii) hauling or heating water;(iii) laying out supplies;(iv) assisting in or out of tub or shower;(v) sponge bathing and drying;(vi) bed bathing and drying;(vii) tub bathing and drying; and(viii) providing standby assistance for safety;(B) dressing, which is:(i) dressing the individual;(ii) undressing the individual; and(iii) laying out clothes;(C) meal preparation, which is:(i) cooking a full meal;(ii) warming up prepared food;(iii) planning meals;(iv) helping prepare meals; and(v) cutting an individual's food for eating;(D) feeding/eating, which is:(i) spoon-feeding;(ii) bottle-feeding;(iii) assisting with using eating and drinking utensils and adaptive devices, not including tube feeding; and(iv) providing standby assistance or encouragement;(E) exercise, which is walking with the individual;(F) grooming, shaving, or oral care, which is:(i) shaving;(ii) brushing teeth;(iii) shaving underarms and legs, when requested;(iv) caring for nails; and(v) laying out supplies;(G) routine hair or skin care, which is:(i) washing hair;(ii) drying hair;(iii) assisting with setting, rolling, or braiding hair, not including cutting or chemical processing of hair;(iv) combing or brushing hair;(v) applying nonprescription lotion to skin;(vi) washing hands and face;(vii) applying makeup; and(viii) laying out supplies;(H) assistance with self-administration of medication as defined in 26 TAC §558.2 (relating to Definitions);(I) toileting, which is:(i) changing diapers;(ii) changing colostomy bag or emptying catheter bag;(iii) assisting on or off bedpan;(iv) assisting with the use of a urinal;(v) assisting with feminine hygiene needs;(vi) assisting with clothing during toileting;(vii) assisting with toilet hygiene, including the use of toilet paper and washing hands;(viii) changing external catheter;(ix) preparing toileting supplies and equipment, not including preparing catheter equipment; and(x) providing standby assistance;(J) transfer, which is:(i) non-ambulatory movement from one stationary position to another, not including carrying;(ii) adjusting or changing the individual's position in a bed or chair (positioning); and(iii) assisting in rising from a sitting to a standing position; and(K) ambulation, which is:(i) assisting in positioning for use of a walking apparatus;(ii) assisting with putting on and removing leg braces and prostheses for ambulation;(iii) assisting with ambulation or using steps;(iv) assisting with wheelchair ambulation; and(v) providing standby assistance; and(2) assistance with IADLs, including:(A) cleaning, including:(i) cleaning up after the individual's ADLs;(ii) emptying and cleaning the individual's bedside commode;(iii) cleaning the individual's bathroom;(iv) changing the individual's bed linens and making the individual's bed;(v) cleaning floor of living areas used by the individual;(vi) dusting areas used by the individual;(vii) carrying out the trash and setting out garbage for pick up;(viii) cleaning stovetop and counters;(ix) washing the individual's dishes; and(x) cleaning refrigerator and stove;(B) laundry, including:(i) doing hand wash;(ii) gathering and sorting;(iii) loading and unloading machines in residence;(iv) using laundromat machines;(v) hanging clothes to dry;(vi) folding and putting away clothes; and(C) shopping, including:(i) preparing a shopping list;(ii) going to the store and purchasing or picking up items;(iii) picking up medication; and(iv) storing the individual's purchased items; and(D) escorting, including:(i) accompanying the individual outside the home to support the individual in living in the community;(ii) arranging for transportation, not including direct individual transportation;(iii) accompanying the individual to a clinic, doctor's office, or location for medical diagnosis or treatment; and(iv) waiting in the doctor's office or clinic with an individual if necessary due to client's condition or distance from home. Source Note: The provisions of this §277.41 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS D SERVICE DELIVERY PLAN DEVELOPMENT §277.41 Allowable Tasks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219385 03/12/2026 (a) Referrals in the PHC Program and CAS Program. HHSC makes a referral to a provider to begin pre-initiation activities in the PHC Program and CAS Program.(1) Methods of referral.(A) If an individual's needs require that a provider complete pre-initiation activities in less than 14 days after a referral, the case worker makes an expedited referral by oral notice and on HHSC's Authorization for Community Care Services form.(B) If an individual's needs do not require that a provider complete pre-initiation activities in less than 14 days after a referral, the case worker makes a routine referral on HHSC's Authorization for Community Care Services form.(2) A provider must accept all referrals.(3) After a provider receives a referral, the provider must conduct the pre-initiation activities as described in §47.45 of this subchapter (relating to Pre-Initiation Activities).(b) Authorizations in the PHC Program and CAS Program. After a provider completes the pre-initiation activities, HHSC makes an authorization determination and notifies the provider that services are authorized by sending the provider an HHSC Authorization for Community Care Services form.(c) Authorizations in the FC Program. HHSC does not make a referral to a provider before authorizing services in the FC Program.(1) HHSC authorizes services for an individual in the FC Program by sending a provider an HHSC Authorization for Community Care Services form.(2) A provider must accept all authorizations.(3) After a provider receives an authorization, the provider must conduct the pre-initiation activities as described in §47.45 of this subchapter. Source Note: The provisions of this §277.43 adopted to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS D SERVICE DELIVERY PLAN DEVELOPMENT §277.43 Referrals and Authorizations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219386 03/12/2026 (a) Pre-initiation activities.(1) For each referral for the PHC Program or CAS Program or for each authorization for the FC Program, a supervisor must conduct an evaluation.(A) An evaluation must be a single document that includes the individual's self-report of:(i) the dates and reasons for any hospitalization within the last three months; and(ii) the assistance needed for the individual to perform ADLs and IADLs, including any assistive devices or medical equipment used by the individual.(B) If the provider determines during the evaluation that the individual exhibits reckless behavior that results in imminent danger to the health and safety of the individual or provider staff, the provider must convene an Interdisciplinary Team meeting as described in §47.49 of this subchapter (relating to Interdisciplinary Team) to discuss the barriers to service delivery.(2) For each referral for the PHC Program or CAS Program, or for each authorization for the FC Program, a supervisor must develop a service delivery plan that:(A) is agreed upon and signed by the individual and the provider;(B) indicates the location of service delivery; and(C) records the following:(i) the tasks which the individual is authorized to receive;(ii) the total weekly hours of service HHSC authorizes the individual to receive;(iii) the service schedule, which must include as necessary, based on an individual's needs, certain time periods for the delivery of specified tasks;(iv) frequency of supervisory visits; and(v) a statement that:(I) only the tasks described in §47.41 of this subchapter (relating to Allowable Tasks), and agreed to on the service delivery plan, may be provided; and(II) the provider is not responsible for meeting the applicant's needs other than by providing the tasks described in §47.41 of this subchapter and agreed to on the service delivery plan.(3) In the PHC Program or CAS Program, a provider must obtain a complete Practitioner's Statement of Medical Need form and submit the form for HHSC's review as described in §47.47 of this subchapter (relating to Determination of Medical Need).(A) Routine referrals.(i) A provider must send a copy of a complete Practitioner's Statement of Medical Need form to HHSC before HHSC may authorize an individual to receive services.(ii) A provider must send a copy of the form by fax, secure email, or mail.(B) Expedited referrals.(i) HHSC may authorize services for an individual if the provider notifies HHSC that the provider has received a complete practitioner's statement that documents the individual's medical condition is the cause of the individual's functional impairment.(ii) After notification that a provider has the completed practitioner's statement described in clause (i) of this subparagraph, HHSC and the provider will negotiate a service initiation date.(iii) For HHSC to pay a provider beginning on the negotiated service initiation date, the provider must send the complete practitioner's statement to HHSC within 7 working days after service initiation.(iv) If a provider does not send the complete practitioner's statement to HHSC within 7 working days after service initiation, HHSC does not pay the provider until HHSC receives the completed practitioner's statement. In this circumstance, HHSC changes the service initiation date to the date HHSC receives the completed practitioner's statement.(v) The signature date of the practitioner must be on or before the negotiated service initiation date.(b) Service delivery plan variances.(1) A provider in the PHC Program and CAS Program must notify the case worker when the initial service delivery plan developed by the provider:(A) has more hours than the number of hours on the referral portion of HHSC's Authorization for Community Care Services form; or(B) has no ADLs.(2) A provider in the FC Program must:(A) notify the case worker when the initial service delivery plan developed by the provider has more hours than the number of hours authorized on HHSC's Authorization for Community Care Services form; and(B) provide services according to HHSC's Authorization for Community Care Services form until the provider receives a new form from the case worker.(c) Pre-initiation activities due date. A provider must:(1) in the PHC Program or CAS Program complete the pre-initiation activities as follows:(A) for routine referrals, within 14 days after one of the following dates, whichever is later:(i) the referral date on HHSC's Authorization for Community Care Services form; or(ii) the date the provider receives the referral, unless the provider fails to stamp the receipt date on HHSC's Authorization for Community Care Services form, in which case the referral date will be used to determine timeliness; and(B) for expedited referrals, by the date negotiated between the case worker and provider, which must be less than 14 days after the oral request; and(2) in the FC Program, complete the pre-initiation activities within 14 days after the provider receives HHSC's Authorization for Community Care Services form.(d) Delay in pre-initiation activities.(1) A provider may delay meeting the due dates in subsection (c) of this section only for reasons beyond its control such as natural or other disasters. The provider must continue efforts to complete pre-initiation activities and set a date, if possible, for completion of pre-initiation activities.(2) A provider must document any failure to complete the pre-initiation activities for routine referrals by the due date, including:(A) the reason for the delay;(B) either the date the provider anticipates it will complete the pre-initiation activities or specific reasons why the provider cannot anticipate a completion date; and(C) a description of the provider's ongoing efforts to complete pre-initiation activities.(3) A provider must notify the case worker of any failure to complete the pre-initiation activities for expedited referrals before the negotiated date for completion of pre-initiation activities. The case worker may refer the individual to another provider.(e) Documentation of pre-initiation activities.(1) A provider may combine the evaluation and service delivery plan into a single document, but each item must be clearly identifiable.(2) A provider must maintain documentation of the pre-initiation activities in the individual's file. Source Note: The provisions of this §277.45 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS D SERVICE DELIVERY PLAN DEVELOPMENT §277.45 Pre-Initiation Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219387 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219387 03/12/2026 (a) Determining medical need. A provider must obtain and submit a complete Practitioner's Statement of Medical Need form to HHSC for review, as described in §47.45 of this subchapter, (relating to Pre-Initiation Activities) for:(1) an individual whom HHSC refers to the provider, unless the individual requests and is to receive FC Program services;(2) an individual currently receiving FC Program services whom HHSC refers to the provider for the PHC Program or CAS Program; and(3) an individual currently receiving services whom HHSC refers to the provider to have medical need reassessed, as requested by the case worker, such as when the initial medical need was established for a limited time.(b) Submitting a Practitioner's Statement of Medical Need form. A provider must submit a complete form to:(1) the case worker for the PHC Program; and(2) the regional nurse for the CAS Program.(c) Reinstatement of services after termination. If HHSC notifies a provider that services are terminated, all pre-initiation activities, including medical need determination, must be completed before services are reinstated.(d) Mental illness and intellectual disability. An individual diagnosed with a mental illness, an intellectual disability, or both, is not considered to have established medical need based solely on such diagnoses, but may establish medical need through a related diagnosis that results in a functional limitation. Source Note: The provisions of this §277.47 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS D SERVICE DELIVERY PLAN DEVELOPMENT §277.47 Determination of Medical Need https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219388 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219388 03/12/2026 (a) Interdisciplinary Team (IDT). The IDT is a designated group that includes the following people who meet when the provider identifies the need to discuss service delivery issues or barriers to service delivery:(1) the individual or the individual's representative, or both;(2) a provider representative; and(3) an HHSC representative, who may be:(A) the case worker or designee;(B) the case worker's supervisor or designee;(C) the contract manager or designee; or(D) the regional nurse or designee.(b) Convening an IDT meeting.(1) The provider must convene an IDT meeting:(A) within three working days of the date the provider suspends services to an individual under §47.71(a)(7) or (b) of this chapter (relating to Suspensions); or(B) within seven working days of the date the provider identifies an issue that prevents the provider from carrying out a requirement of the PHC Program, CAS Program, or FC Program.(2) A provider must make and document a good faith effort to include all members of the IDT described in subsection (a) of this section.(3) If the provider is unable to convene an IDT meeting with all the members described in subsection (a) of this section, the provider must convene the IDT meeting with the available members and send the documentation of the IDT meeting described in subsection (e) of this section to the Regional Director for the HHSC region in which the individual resides. The documentation must be sent within five working days after the date of the IDT meeting.(c) IDT meeting.(1) The IDT meeting may be conducted by telephone or in person.(2) The IDT must:(A) evaluate the issue;(B) identify any solutions to resolve the issue; and(C) make recommendations to the provider.(d) IDT meeting outcome. The provider must do one of the following within two working days after the IDT meeting:(1) implement the recommendations of the IDT; or(2) discharge the individual from the provider and refer the individual to the case worker for referral to another provider.(e) Documentation of the IDT meeting. The provider must document the IDT meeting in the individual's file, including the:(1) specific reasons for calling the IDT meeting;(2) participants in the IDT meeting;(3) recommendations of the IDT;(4) action as a result of the IDT recommendations; and(5) reasons for the provider's actions. Source Note: The provisions of this §277.49 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS D SERVICE DELIVERY PLAN DEVELOPMENT §277.49 Interdisciplinary Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219389 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219389 03/12/2026 An individual receiving services in the PHC Program, CAS Program, or FC Program may choose one of the following three service delivery options.(1) Agency option. In the agency option:(A) the provider is responsible for personnel decisions, such as selecting, supervising, and dismissing the attendant who provides services to the individual, with input from the individual;(B) the provider is responsible for:(i) recruitment of attendants and substitute attendants, a responsibility the individual may share;(ii) payroll for attendants and substitute attendants; and(iii) filing tax-related reports of attendants and substitute attendants;(C) the provider is the employer of record of attendants and substitute attendants; and(D) the provider is responsible for providing substitute attendants.(2) Consumer directed services (CDS) option. In the CDS option, as described in Chapter 41 of this title (relating to Consumer Directed Services Option):(A) the individual recruits, hires, manages, and fires attendants;(B) the individual is the employer of record of his or her attendant and substitute attendant;(C) the individual is responsible for providing substitute attendants; and(D) the FMSA is responsible for financial management services, including:(i) registering as the individual's employer-agent with the Internal Revenue Service and the Texas Workforce Commission;(ii) managing payroll for attendants and substitute attendants, including filing tax-related reports;(iii) tracking expenditures; and(iv) submitting quarterly expenditure reports to the employer and case worker; and(E) the FMSA is not required to be licensed under 26 TAC Chapter 558 (relating to Licensing Standards for Home and Community Support Services Agencies) when performing the functions described in subparagraph (D) of this paragraph.(3) Service responsibility option (SRO). In the SRO, as described in Chapter 43 of this title (relating to Service Responsibility Option):(A) the individual selects, manages, supervises, and dismisses attendants;(B) the provider is the employer of record for the attendant and substitute attendant;(C) the provider is responsible for:(i) providing substitute attendants if necessary;(ii) managing payroll for attendants and substitute attendants; and(iii) filing tax-related reports of attendants and substitute attendants;(D) the individual and supervisor must negotiate the frequency of supervisory visits;(E) the individual is responsible for the new attendant orientation; and(F) the provider is required to be licensed under 26 TAC Chapter 558 if performing the functions described in subparagraph (C) of this paragraph. Source Note: The provisions of this §277.57 adopted to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.57 Service Delivery Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219390 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219390 03/12/2026 (a) Service initiation. A provider must initiate services:(1) in the PHC Program and CAS Program:(A) for routine referrals described in §47.43 of this chapter (relating to Referrals and Authorizations), within seven days after the provider receives the authorization on HHSC's Authorization for Community Care Services form; and(B) for expedited referrals described in §47.43 of this chapter, on the date negotiated between the case worker and provider; and(2) in the FC Program, within 14 days after the following, whichever is later:(A) the authorization date on HHSC's Authorization for Community Care Services form; or(B) the date the provider receives the authorization on HHSC's Authorization for Community Care Services form, unless the provider fails to stamp the receipt date on the form, in which case the authorization date is used to determine timeliness.(b) Notification of service initiation. Within 14 days after initiating services, the provider must send notice of service initiation to the case worker.(c) Delay in service initiation. A provider may delay service initiation only for reasons not directly caused by the provider, or reasons beyond its control, such as natural or other disasters. The provider must continue efforts to initiate services and set a date, if possible, for service initiation. The provider must document any failure to initiate services by the applicable due date in subsection (a) of this section, including:(1) the reason for the delay;(2) either the date the provider anticipates it will initiate services, or specific reasons why the provider cannot anticipate a service initiation date; and(3) a description of the provider's ongoing efforts to initiate services.(d) Documentation of service initiation. The provider must maintain documentation of service initiation in the individual's file. Source Note: The provisions of this §277.61 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.61 Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219391 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219391 03/12/2026 (a) Service interruptions. A service interruption occurs when, on a particular day or time when services are scheduled:(1) the individual requests that:(A) no hours of service be provided;(B) fewer hours of service than reflected in the service schedule be provided; or(C) a specific attendant not provide services to the individual;(2) the individual is not at home;(3) services are suspended as described in §47.71 of this subchapter (relating to Suspensions); or(4) services are not delivered for other reasons beyond the control of the provider, such as acts of nature and other disasters.(b) Delivery of services.(1) A provider must ensure:(A) services are delivered according to the service delivery plan described in §47.45 of this chapter (relating to Pre-Initiation Activities);(B) all authorized and scheduled services are provided to an individual, except in the case of a service interruption as described in subsection (a) of this section; and(C) an individual does not receive, during a calendar month, more than five times the weekly authorized hours on HHSC's Authorization for Community Care Services form.(2) A provider must not exceed the weekly authorized hours except in the case of a temporary increase if requested by an individual based on the individual's need due to an unusual circumstance.(c) Service interruption documentation.(1) In the case of an individual whose services are considered priority, the provider must document all service interruptions by the 30th day after the date the individual's services are scheduled but not delivered.(2) In the case of an individual whose services are considered non-priority, the provider must document all service interruptions that exceed 14 consecutive days by the 30th day after the day service interruption exceeds 14 consecutive days.(A) For a fixed service schedule, the service interruption begins on the first day services are scheduled but not delivered.(B) For a variable service schedule, the service interruption begins the Sunday following the week the individual did not receive all the weekly hours on a service plan approved by the individual.(3) The reason documented must be a reason listed in subsection (a) of this section.(4) If the provider learns of a service interruption after the deadlines listed in paragraphs (1) and (2) of this subsection, the provider must document the following as soon as the provider learns of the service interruption:(A) the reason for the service interruption;(B) the reason for the delay in documenting the service interruption; and(C) the date the provider learned of the service interruption.(d) Service delivery outside the individual's home but within a provider's contracted service delivery area.(1) A provider may develop a service plan that includes services regularly delivered at a location other than the individual's home.(2) A service plan must not exceed the weekly hours authorized on HHSC's Authorization for Community Care Services form.(3) A provider may deliver services outside the individual's home when the service plan does not include the regular delivery of such services.(4) A provider:(A) may deliver services outside the individual's home only if the individual requests such services;(B) is not required to pay for expenses incurred as a result of an attendant delivering services outside the individual's home;(C) must make a reasonable effort to deliver services at a location other than an individual's home when requested by the individual;(D) must maintain written justification if the individual's request was not granted; and(E) must document in the individual's record:(i) each instance when the individual requested services at a location other than the home;(ii) whether the individual's request was granted;(iii) what services were provided; and(iv) where the services were delivered.(e) Service delivery outside a provider's contracted service delivery area.(1) A provider may develop a service plan that includes, at the request of the individual, services provided while the individual is temporarily staying at a location outside the provider's contracted service delivery area but within the state of Texas.(2) A service plan must not exceed the weekly hours authorized on HHSC's Authorization for Community Care Services form.(3) A provider may accept or decline the request of an individual for the provision of services while the individual is temporarily staying at a location outside the contracted service delivery area but within the state of Texas.(A) If a provider accepts an individual's request, the provider:(i) may provide services to the individual during a period of no more than 60 consecutive days;(ii) must, within three days after the provider begins providing services to the individual outside the provider's contracted service delivery area, notify the individual's case worker in writing of the following:(I) that the individual is receiving services outside the provider's contracted service delivery area;(II) the location where the individual is receiving services;(III) the estimated length of time the individual is expected to be outside the contracted service delivery area; and(IV) contact information for the individual;(iii) must notify the individual's case worker in writing that the individual has returned to the provider's contracted service delivery area within three working days after becoming aware of the individual's return; and(iv) is not required to pay for expenses incurred by an attendant delivering services outside the contracted service delivery area.(B) If a provider declines an individual's request, the provider must:(i) inform the individual orally or in writing:(I) of the reasons for declining the request; and(II) that the individual may request a meeting with the case worker and the provider to discuss the reasons for declining the request; and(ii) inform the individual's case worker in writing, within three days after declining the request, that the request was declined and the reasons for declining the request.(4) If an individual receives services outside a provider's contracted service delivery area during a period of 60 consecutive days, the individual must return to the contracted service delivery area and receive services in that service delivery area before the provider may agree to another request from the individual for the provision of services outside the provider's contracted service delivery area.(5) If an individual intends to remain outside a provider's contracted service delivery area for a period of more than 60 consecutive days, HHSC transfers the individual to a provider selected by the individual that has a contracted service delivery area that includes the area in which the individual is receiving services. HHSC coordinates the transfer in accordance with §47.69 of this subchapter (relating to Transfers).(f) Service delivery documentation.(1) A provider must document the delivery of services electronically or on a paper timesheet, to include:(A) the provider name;(B) the provider vendor number;(C) the attendant's name;(D) the individual's name;(E) the individual's HHSC number;(F) the specific service delivery period, including month, day, and year, as applicable;(G) the tasks assigned;(H) the units of service delivered;(I) the dates services were delivered; and(J) certification that the attendant delivered the documented tasks.(2) For electronic service delivery documentation systems, each attendant must enter a unique identifier to certify the services delivered.(3) For paper service delivery documentation systems, a timesheet must have a specific service delivery period not exceeding one calendar month.(A) Except as provided in subparagraph (B) of this paragraph, each attendant delivering services must sign the timesheet or make a mark representing the attendant's name to certify the services delivered and that the timesheet is correct.(B) An attendant who is unable to sign or mark the timesheet may designate another person to sign the timesheet. A provider must maintain written documentation of the:(i) reason an attendant is unable to sign or mark the timesheet; and(ii) identity of the person designated to sign the timesheet on behalf of the attendant.(g) Documentation of service delivery. A provider must maintain documentation of service delivery in an individual's record. Source Note: The provisions of this §277.63 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective October 1, 2013, 38 TexReg 6621; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.63 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219392 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219392 03/12/2026 (a) Supervisory visits. A supervisor must conduct in-person supervisory visits to assess and document on a single form whether:(1) the service delivery plan is adequate;(2) the individual continues to need the services;(3) the individual needs a service delivery plan change;(4) the attendant continues to be competent to provide the authorized tasks; and(5) the attendant is delivering the authorized tasks.(b) Frequency. A supervisor must establish the frequency of in-person supervisory visits, based on the specific needs of the individual, the attendant, or both. The frequency of in-person supervisory visits must be at least annually.(c) Documentation of supervisory visits. The provider must maintain documentation of each supervisory visit in the individual's file.(d) Combining a supervisory visit and a new attendant orientation. A supervisor may conduct a scheduled supervisory visit and a new attendant orientation at the same time. Source Note: The provisions of this §277.65 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.65 Supervisory Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219393 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219393 03/12/2026 (a) Increase in hours or terminations.(1) A provider must submit written notification to the case worker within seven days after learning of any change that may:(A) require an increase in hours in the individual's service delivery plan; or(B) result in the termination of services due to the individual receiving no ADLs, except for the FC Program.(2) The notification must include the:(A) date the provider learned of the need for the change;(B) reason for the change;(C) type of change, including the number of hours of service; and(D) signature and date of the provider representative.(b) Decrease in hours. The provider must develop a new service delivery plan, as described in §47.45(a)(2) of this chapter (relating to Pre-Initiation Activities), within 21 days of the provider identifying the need for an ongoing decrease in hours from the service delivery plan currently approved by the individual.(c) Immediate increase in hours of service.(1) The provider must notify the case worker, or designee, of the reason an individual requires an immediate increase in hours of service, and must obtain approval from HHSC of both the number of additional hours of service to be provided the individual and the effective date of the change.(2) The provider must implement the immediate increase in hours of service on the negotiated effective date of the change.(3) The provider must document the immediate increase in hours of service. Documentation must include:(A) the date the provider received approval for the change;(B) the name of the HHSC staff who approved the change;(C) the effective date of the change; and(D) the number of hours of service authorized.(4) The provider must maintain documentation regarding an immediate increase in hours of service in the individual's file.(d) Implementation of service delivery plan changes described in subsections (a) - (c) of this section. The provider must implement the service delivery plan change on the following date, whichever is later:(1) the authorization begin date on HHSC's Authorization for Community Care Services form; or(2) five days after the date the provider receives HHSC's Authorization for Community Care Services form, unless the provider fails to stamp the receipt date on the form, in which case the authorization begin date on the form will be used to determine timeliness.(e) Delay in implementation of service delivery plan changes described in subsections (a) - (c) of this section. If a provider does not implement a service delivery plan change on the effective date of the change, the provider must set a new implementation date. The provider must document by the next working day any failure to implement a service delivery plan change on the effective date of the change. The documentation must include:(1) the reason for the failure to timely implement the service delivery plan change; and(2) the new implementation date.(f) Temporary service delivery plan changes.(1) A provider may temporarily change an individual's service delivery plan if:(A) the individual requests and requires temporary assistance with allowable tasks not identified on the service delivery plan due to a change in circumstances or available supports; and(B) the change in tasks does not increase the total approved hours of service or continue for more than 60 days.(2) If a temporary change in tasks on the service delivery plan will continue for more than 60 days or result in more hours of service provided than have been approved, a provider must:(A) request and obtain a new HHSC Authorization for Community Care Services form; and(B) provide services according to HHSC's Authorization for Community Care Services form until the provider receives a new form from the case worker.(3) A provider must maintain the following documentation in an individual's file regarding a temporary change in the service delivery plan:(A) the specific change in the service delivery plan;(B) the duration of the temporary change; and(C) the reason for the temporary change. Source Note: The provisions of this §277.67 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.67 Service Delivery Plan Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219394 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219394 03/12/2026 (a) Negotiation of an individual's transfer from one provider to another. The providers involved in an individual's transfer must coordinate with the case worker to negotiate the transfer date.(b) Initiation of services. The receiving provider must initiate services on the negotiated date. The negotiated date is the begin date on HHSC's Authorization for Community Care Services form.(c) Evaluation and service delivery plan. On or before the begin date, the receiving provider must:(1) conduct an evaluation, as described in §47.45 of this chapter (relating to Pre-Initiation Activities); and(2) develop a service delivery plan, as described in §47.45 of this chapter. Source Note: The provisions of this §277.69 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.69 Transfers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219395 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219395 03/12/2026 (a) Required suspensions. A provider must suspend services if:(1) an individual temporarily or permanently leaves the provider's contracted service delivery area during a time when the individual would routinely receive services and the individual does not request the provision of services outside the provider's contracted service delivery area;(2) the provider declines the request of the individual for the provision of services outside of the provider's contracted service delivery area and the individual leaves the service delivery area;(3) the individual moves to a location where services cannot be provided under the PHC Program, CAS Program, or FC Program;(4) the individual dies;(5) the individual is admitted to an institution, which is a:(A) hospital;(B) nursing facility;(C) state supported living center;(D) state hospital;(E) intermediate care facility serving individuals with an intellectual disability or related conditions; or(F) correctional facility.(6) the individual requests that services end;(7) for individuals receiving services in the PHC Program or CAS Program, HHSC denies the individual's Medicaid eligibility; or(8) the individual or someone in the individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, the attendant, or another person, in which case the provider must make an immediate referral to:(A) DFPS or other appropriate protective services agency;(B) local law enforcement, if appropriate; and(C) the individual's case worker.(b) Optional suspensions. The provider may suspend services if:(1) the individual or someone in the individual's home engages in discrimination against a provider or HHSC employee in violation of applicable law; or(2) the individual refuses services for more than 30 consecutive days.(c) Notification of service suspension. A provider must notify the case worker of any suspension by the first working day after the provider suspends services. The notice must include:(1) the date of service suspension;(2) the reason for the suspension;(3) the duration of the suspension, if known; and(4) for a suspension under subsection (a)(8) or (b) of this section, a written explanation of the circumstances surrounding the suspension.(d) Interdisciplinary Team (IDT) meeting. A provider must convene an IDT meeting, as described in §47.49 of this chapter (relating to Interdisciplinary Team), if services are suspended under subsection (a)(8) or (b) of this section.(e) Resuming services after suspension. This subsection does not apply to subsection (a)(8) or (b)(1) of this section.(1) A provider must resume services after suspension on the earliest of the following:(A) after the individual's return home, or the date the provider becomes aware of the individual's return home, if applicable;(B) on the date specified in writing by the case worker;(C) as a result of a recommendation by the IDT; or(D) upon the provider's receipt of notification from the case worker that the provider must resume services pending the outcome of an appeal.(2) A provider must notify the case worker of the date services resume within seven days after that date. Source Note: The provisions of this §277.71 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2013, 38 TexReg 6621; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.71 Suspensions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219396&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219396 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219396&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219396 03/12/2026 (a) Reauthorization request.(1) Upon receipt of the annual HHSC Authorization for Community Care Services form, a provider must request annual reauthorization for the CAS Program.(2) The provider must send the following to the regional nurse to obtain annual reauthorization:(A) HHSC's Authorization for Community Care Services form received from the case worker; and(B) a signed statement indicating whether the supervisor agrees or disagrees with the tasks and hours indicated on HHSC's Authorization for Community Care Services form, and if the supervisor disagrees, the statement must provide the specific reasons for disagreeing with the hours and tasks on this form.(b) Reauthorization request due date. A provider must submit the information described in subsection (a)(2) of this section to the regional nurse within 14 days after one of the following dates, whichever is later:(1) the referral date on HHSC's Authorization for Community Care Services form; or(2) the date the provider receives HHSC's Authorization for Community Care Services form, unless the provider fails to stamp the receipt date on the form, in which case the referral date will be used to determine timeliness.(c) Authorization determination. HHSC makes the authorization determination and notifies the provider before the annual reauthorization is due.(d) Documentation of annual reauthorization. A provider must maintain documentation of the written request for reauthorization for the CAS Program in the individual's file. Source Note: The provisions of this §277.73 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.73 Annual Reauthorization for the CAS Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219397&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219397 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219397&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219397 03/12/2026 A provider must not use restraint or seclusion. Source Note: The provisions of this §277.74 adopted to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS E SERVICE REQUIREMENTS §277.74 Prohibition of Restraint and Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219398&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219398 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219398&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219398 03/12/2026 (a) Applicability. This section does not apply to individuals who are receiving FC Program services.(b) Verification of Medicaid eligibility. A provider must verify each month that an individual remains Medicaid eligible. A provider may verify the individual's current Medicaid eligibility by:(1) viewing the individual's HHSC Medicaid Identification form; or(2) using the current systems available to verify the individual's Medicaid eligibility.(c) Reimbursement. HHSC does not pay a provider for services delivered to an individual who is not eligible for Medicaid at the time the provider delivered the services. Source Note: The provisions of this §277.81 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS F CLAIMS PAYMENT AND DOCUMENTATION §277.81 Monitoring Medicaid Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219399&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219399 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219399&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219399 03/12/2026 HHSC conducts monitoring reviews of a provider as described in Chapter 49 of this title (relating to Contracting for Community Services) and in this chapter. Source Note: The provisions of this §277.83 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS F CLAIMS PAYMENT AND DOCUMENTATION §277.83 Monitoring Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219373 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219373 03/12/2026 (a) Applicability.(1) This section does not apply to the FC Program.(2) A provider that chooses to request retroactive payment must comply with the requirements of this section.(b) Definition of retroactive payment. A retroactive payment is payment by HHSC to a provider for services under the PHC Program or CAS Program that are provided before the date the case worker determines the individual's eligibility for the services.(c) Reimbursement.(1) The provider may be reimbursed for services provided before the date HHSC receives a completed, signed, and dated copy of HHSC's Application for Assistance--Aged and Disabled form:(A) for up to three months for an individual who does not have Medicaid eligibility at the time of the request for retroactive payment; and(B) for an indefinite period for an individual who is Medicaid eligible at the time of the request for retroactive payment.(2) HHSC only reimburses the provider for the:(A) services described in §47.41 of this chapter (relating to Allowable Tasks);(B) number of hours of services allowed the individual as described in §48.2918(c) of this title (relating to Primary Home Care or Community Attendant Services); and(C) allowable costs of the PHC Program or CAS Program, as described in 1 TAC, Chapter 355, Subchapter A, (relating to Cost Determination Process).(3) HHSC does not reimburse the provider for the retroactive period if:(A) the provider fails to submit the required documentation within the required time frames; or(B) the individual provided services does not meet the requirements described in subsection (d) of this section.(d) Requirements before requesting retroactive payment. The provider may not request retroactive payment unless:(1) the individual appears to be Medicaid eligible as defined in §48.1201 of this title (relating to Definition of Program Terms);(2) the provider obtains a Practitioner's Statement of Medical Need form as described in §47.47 of this chapter (relating to Determination of Medical Need);(3) the individual requires assistance with at least one ADL as described in §47.41 of this chapter; and(4) the provider has verified and documented that the individual is not already receiving services under the PHC Program or CAS Program from another provider.(e) Pre-initiation activities. The provider must complete the pre-initiation activities described in §47.45(a) of this chapter (relating to Pre-Initiation Activities).(f) Intake referral. On the day that the provider completes the pre-initiation activities, the provider must contact HHSC and make an intake referral by providing HHSC information on the individual to start the eligibility process.(g) Service initiation. HHSC does not pay a provider for services provided to an individual before the date the provider completes the pre-initiation activities and processes the intake referral as described in subsections (e) and (f) of this section.(h) Requesting retroactive payment.(1) A provider's written request for retroactive payment must include:(A) a copy of the service delivery plan;(B) a copy of HHSC's Practitioner's Statement of Medical Need form; and(C) the retroactive payment information, including the:(i) name of the provider;(ii) contact information for the individual;(iii) date services were started;(iv) tasks provided to the individual, including both tasks allowed and not allowed by the PHC Program or CAS Program;(v) weekly hours of service provided to the individual, including hours allotted to tasks allowed and not allowed by the PHC Program or CAS Program; and(vi) cost per hour of service charged to the individual.(2) The provider must submit the written request for retroactive payment:(A) to the case worker or, if no case worker has been assigned, to HHSC intake staff; and(B) within seven days after the date the provider processes the intake referral.(i) Charges to individuals who receive services.(1) The provider may charge an individual for services for which the provider intends to request retroactive payment, unless the individual is Medicaid eligible.(2) The provider must reimburse the entire amount of all payments made by the individual to the provider for eligible services, even if those payments exceed the amount HHSC will reimburse for the services, if HHSC determines that the individual is eligible for the PHC Program or CAS Program.(j) Documentation of retroactive payment requests. The provider must maintain documentation of retroactive payment requests in the individual's file. Source Note: The provisions of this §277.85 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS F CLAIMS PAYMENT AND DOCUMENTATION §277.85 Retroactive Payment Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219374 03/12/2026 (a) Billing requirements. A provider must not bill HHSC for:(1) more hours than an individual's weekly authorization, except when services are delivered as described in §47.63(b)(2) of this chapter (relating to Service Delivery);(2) services delivered in a licensed facility, if the facility is required by the license to provide those services;(3) services provided outside the contracted service delivery area except if provided in compliance with §47.63(e) of this chapter; and(4) services or tasks that duplicate any services or tasks provided to the individual by another source.(b) Hourly rate. A provider must agree to accept the hourly rate authorized by HHSC.(c) Documentation. A provider must maintain the documentation described in this chapter to be eligible for reimbursement.(d) Rounding. A provider must bill HHSC for services in quarter-hour increments, rounding up to the next quarter-hour if the actual time worked is eight minutes or more, and rounding down to the previous quarter hour if the actual time worked is less than eight minutes.(e) Allowable tasks. A provider must bill HHSC only for the tasks described in §47.41 of this chapter (relating to Allowable Tasks). Source Note: The provisions of this §277.89 adopted to be effective June 1, 2004, 29 TexReg 5113; amended to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2013, 38 TexReg 6621; amended to be effective September 1, 2014, 39 TexReg 6635; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS F CLAIMS PAYMENT AND DOCUMENTATION §277.89 Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219375 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219375 03/12/2026 (a) HHSC conducts utilization review of a service delivery plan and supporting documentation at any time to:(1) determine the appropriateness of services;(2) validate a service provision; or(3) evaluate the quality of services.(b) A provider, consumer directed services employer, and FMSA must submit documentation supporting the service delivery plan to HHSC as requested by HHSC.(c) If HHSC determines that one or more of the tasks specified in a service delivery plan do not meet the requirements described in Subchapter D of this chapter (relating to Service Plan Development) or Subchapter E of this chapter (relating to Service Requirements), HHSC denies or reduces the hours or tasks, modifies the service delivery plan effective from the date of the utilization review, and sends written notification of the denial or reduction to the individual and provider.(d) In addition to the utilization review conducted in accordance with subsection (a) of this section, HHSC may conduct utilization reviews of providers and services based on utilization patterns and trends. Source Note: The provisions of this §277.91 adopted to be effective June 1, 2009, 34 TexReg 2802; amended to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS G UTILIZATION REVIEW §277.91 Utilization Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219376 03/12/2026 (a) A provider must:(1) ensure that an individual and representative are, before or at the time the individual begins receiving services and at least once every 12 months thereafter:(A) informed of how to report allegations of abuse, neglect, or exploitation to DFPS and are provided with the Abuse Hotline toll-free telephone number, 1-800-252-5400, in writing; and(B) educated about protecting the individual from abuse, neglect, and exploitation;(2) ensure that each staff person is:(A) trained and knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent the occurrence of abuse, neglect, and exploitation;(B) instructed to report to DFPS immediately, but not later than 24 hours, after having knowledge or suspicion that an individual is being or has been abused, neglected, or exploited by:(i) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(ii) using the DFPS Abuse Hotline website; and(C) provided with the instructions described in subparagraph (B) of this paragraph in writing; and(3) conduct the activities described in paragraph (2) of this subsection before a staff person assumes job duties and at least annually.(b) If a provider, staff person, or controlling person knows or suspects that an individual is being or has been abused, neglected, or exploited, the provider must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to DFPS immediately, but not later than 24 hours, after having knowledge or suspicion by:(1) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-252-5400; or(2) using the DFPS Abuse Hotline website.(c) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation of an individual, or if the provider is notified of an allegation of abuse, neglect, or exploitation, the provider must:(1) take necessary actions to secure the safety of the individual; and(2) notify the individual or representative as soon as possible, but no later than 24 hours, after the provider reports or is notified of the allegation:(A) of the allegation report; and(B) the actions the provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual.(d) A provider must not retaliate against:(1) a staff person, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including the use of a restraint or seclusion; or(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of the individual, including the use of a restraint or seclusion.(e) At least annually, a provider must review all reports of abuse, neglect, or exploitation of an individual of which the provider is notified, and all final investigative reports received from HHSC for investigations described in §47.103 of this subchapter (relating to Requirements for Providers Related to the Abuse, Neglect, and Exploitation of an Individual Receiving Services in the PHC Program and CAS Program Through the Agency Option or the Service Responsibility Option) and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services. Source Note: The provisions of this §277.101 adopted to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS H ALLEGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION §277.101 Requirements for Providers Related to the Abuse, Neglect, or Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219377 03/12/2026 (a) This section applies only when an individual is receiving services in the PHC Program or CAS Program through the agency option or the service responsibility option.(b) If a report required by §47.101(b) of this subchapter (relating to Requirements for Providers Related to the Abuse, Neglect, or Exploitation of an Individual) alleges abuse, neglect, or exploitation of an individual by a staff person or controlling person or if a provider is notified by HHSC of an allegation of abuse, neglect, or exploitation of an individual by a staff person or controlling person, the provider must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual receiving services from the provider until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) as soon as possible, but no later than 24 hours, after the provider reports or is notified of an allegation, notify the individual, the representative, and the case worker of:(A) the allegation report; and(B) the actions the provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(c) During an HHSC investigation of an alleged perpetrator who is a staff person or controlling person, a provider must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in interviews;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the provider;(B) individuals, staff persons, and controlling persons; and(C) records pertinent to the investigation of the allegation; and(3) ensure that a staff person or controlling person complies with paragraphs (1) and (2) of this subsection.(d) After a provider receives a final investigative report from HHSC for an investigation described in subsection (c) of this section, the provider must:(1) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the provider's authority to prevent the reoccurrence of abuse, neglect, or exploitation, including disciplinary action against the staff person confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the provider's authority, as necessary; and(3) immediately, but not later than five calendar days after the date the provider receives the HHSC final investigative report, notify the individual, the representative, and the case worker of:(A) the investigation finding; and(B) the action taken by the provider in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection. Source Note: The provisions of this §277.103 adopted to be effective October 1, 2019, 44 TexReg 5138; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4436. 1 HEALTH AND HUMAN SERVICES COMMISSION 277 PRIMARY HOME CARE, COMMUNITY ATTENDANT SERVICES, AND FAMILY CARE PROGRAMS H ALLEGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION §277.103 Requirements for Providers Related to the Abuse, Neglect, and Exploitation of an Individual Receiving Services in the PHC Program and CAS Program Through the Agency Option or the Service Responsibility Option https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219017 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Adult--A person who is 18 years of age or older.(2) Applicant--A Texas resident interested in receiving benefits through the IH/FSP.(3) Calendar day--Any day, including weekends and holidays.(4) Case manager--A DADS employee who is responsible for case management activities for an individual, including eligibility determination, enrollment, assessment and reassessment of the individual's need, service plan development, and intercession on the individual's behalf.(5) Disability--A physical impairment that:(A) is likely to continue indefinitely;(B) results in substantial functional limitations in one or more of the following areas of major life activity as defined on the Disabilities Screening Instrument:(i) self-care;(ii) receptive and expressive language;(iii) learning;(iv) mobility;(v) self-direction; or(vi) capacity for independent living; and(C) reflects the person's need for treatment or services that are lifelong or of extended duration.(6) Disabilities Screening Instrument--A DADS form used to determine the disability and the type and severity of functional limitations experienced by an applicant or individual.(7) Household--Includes(A) the following people listed on an applicant's Internal Revenue Service (IRS) income tax return:(i) the applicant;(ii) the spouse of the applicant if they file jointly; and(iii) all dependents; or(B) the following people listed on the applicant's parent's or legal guardian's IRS income tax return:(i) the applicant;(ii) the parent or legal guardian of the applicant; and(iii) all dependents.(8) IH/FSP--In-Home and Family Support Program.(9) IH/FSP interest list--A community care interest list, maintained in accordance with §48.1302 of this chapter (relating to Community Care Interest Lists) for the IH/FSP.(10) Individual--A person receiving benefits through the IH/FSP. Individual in this subchapter may also be referred to as a client or a consumer.(11) Legal guardian--A person appointed by a court to make decisions and act on behalf of an individual.(12) Responsible party--A person who is:(A) an applicant's or individual's natural or surrogate parent or legal guardian; or(B) anyone an adult applicant or individual designates as the applicant's or individual's representative with regard to a matter described in this subchapter.(13) Service Plan--A plan, documented on a DADS form, that includes DADS-approved items or services that will meet an individual's care needs in a community-based setting. Source Note: The provisions of this §278.1 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective May 23, 2016, 41 TexReg 3749; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219018 03/12/2026 (a) When an opening in the IH/FSP becomes available in a DADS region, DADS contacts the applicant whose interest list request date, assigned in accordance with §48.1302(d) of this chapter (relating to Community Care Interest Lists), is earliest on the region's IH/FSP interest list and offers the IH/FSP to the applicant.(1) If the applicant or responsible party declines the offer of the IH/FSP, DADS removes the applicant's name from the region's IH/FSP interest list, as described in §48.1302(e)(4) of this chapter.(2) If the applicant or responsible party accepts the offer of the IH/FSP, DADS contacts the applicant to conduct an initial interview or to schedule an appointment for the initial interview. DADS may conduct the initial interview with an applicant or responsible party either by telephone or face-to-face.(b) If DADS is unable to conduct the initial interview, as described in subsection (a)(2) of this section, DADS sends the applicant the DADS In-Home and Family Support Program Appointment Notice form with the date, time, and location for the appointment.(1) If the applicant, without prior notification, does not keep two appointments scheduled in writing, the case manager sends the applicant the DADS Notification of In-Home and Family Support Program Benefits form to provide written notice that the applicant's eligibility is denied unless the applicant contacts the IH/FSP office within 12 calendar days after the date of the form to schedule an appointment and keeps that appointment.(2) The completed DADS Notification of In-Home and Family Support Program Benefits form includes:(A) the reason for the denial;(B) the effective date of the denial; and(C) the applicant's right to appeal in accordance with §48.2710 of this subchapter (relating to Right to Appeal).(c) If DADS determines an applicant is eligible for the IH/FSP, DADS notifies the applicant in writing using DADS Notification of In-Home and Family Support Program Benefits form.(d) If DADS denies an applicant's eligibility for the IH/FSP, DADS notifies the applicant in writing using the DADS Notification of In-Home and Family Support Program Benefits form. The completed form includes:(1) the reason for the denial;(2) the effective date of the denial; and(3) the applicant's right to appeal in accordance with §48.2710 of this subchapter. Source Note: The provisions of this §278.3 adopted to be effective May 23, 2016, 41 TexReg 3749; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.3 Eligibility Determination Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219019 03/12/2026 (a) Applicants with household income at or below the Texas median income level are eligible without a copayment requirement. (b) Applicants with income at or above 105% of the Texas median income level must contribute to the cost of services in the IH/FSP. (c) SSI recipients who are determined to have a disability are categorically eligible and are exempt from the copayment requirement. (d) Copayments are determined according to the State Median Income (SMI) for the federal fiscal year. A client whose income is at or below the SMI for his household size has no copayment. A client whose income is at or greater than 105% of the SMI will be assessed a copayment. The copayment begins at 10% of the cost of the items/services and increases in 10% increments until 100% of the cost of items/services is reached, at which point the client is ineligible. The copayment is assessed as follows: Attached Graphic(e) Applicants must provide to the caseworker all required documentation of earned or unearned income or both. This income is considered in determining financial eligibility. The following income is exempt from income eligibility calculation: (1) Proceeds of either a commercial or an informal loan for which repayment is required with or without interest. To claim exemption of the proceeds of a loan, a client must prove that he acknowledges an obligation to repay and that some plan for repayment exists. If these can be verified, no written contract is required. (2) Payments from the Agent Orange Settlement Fund or any other fund established in the settlement of the Agent Orange Product liability litigation (Public Law 101-239). (3) Any payment received under the Radiation Exposure Compensation Act (Public Law 101-246). (4) Value of any housing assistance paid on a house under the United States Housing Act of 1937, the National Housing Act, §101 of the Housing and Urban Development Act of 1965, or Title V of the Housing Act of 1949 as authorized by Public Law 94-347. (5) Payment from any source made to individuals because of their status as victims of Nazi persecution (Public Law 103-286). (f) An applicant 18 or older who lives with a spouse or relatives has the household income considered only if he was reported as a dependent on the personal income tax return form or if he filed a joint tax return with his spouse. (g) An applicant who has earned income at or below the limits listed in IRS Publication 17 must sign a statement reporting the amount of earned income, unless he filed a personal income tax return claiming a refund for federal withholding. If he files this type of a tax return, he must present it to the caseworker as documentation of earned income. (h) Upon request from the caseworker, the applicant or his responsible party must furnish the documentation or verification needed to determine eligibility within 10 days of the interview. If the applicant fails to provide the information requested, the caseworker notifies the applicant in writing, specifying the information that is needed and advising that failure to furnish the information could result in denial of the application. If the applicant has not furnished the information and is not making a good faith effort to obtain the information, the caseworker denies the application at the end of the 45-day application processing period. (i) Consumers must notify the caseworker within 10 calendar days of a change in their circumstances that were considered in determining their eligibility or copayment amount. Source Note: The provisions of this §278.5 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective February 1, 1991, 15 TexReg 7618; amended to be effective May 1, 1992, 17 TexReg 2610; amended to be effective December 1, 1992, 17 TexReg 7797; amended to be effective October 1, 1993, 18 TexReg 6026; amended to be effective October 15, 1994, 19 TexReg 7807; amended to be effective October 1, 1995, 20 TexReg 7079; amended to be effective October 1, 1996, 21 TexReg 8953; amended to be effective October 1, 1997, 22 TexReg 9489; amended to be effective August 15,1998, 23 TexReg 7849; amended to be effective November 1, 2000, 25 TexReg 10375; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.5 Income Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219020 03/12/2026 (a) Applicants must meet the definition of disabilities specified in the Human Resources Code, Chapter 35.(b) The applicant or responsible party must sign the IH/FSP disabilties screening instrument.(c) The applicant must give permission to obtain verification of the diagnosis, limitations, and prognosis of his disability through either a signed physician's statement or clinical, educational, medical, diagnostic, and evaluation records. If clinical, educational, medical, diagnostic, or evaluation records are questionable or do not clearly establish the disability, a signed physician's statement must be provided.(d) Individuals who reside in intermediate care facilities, skilled nursing facilities, personal care homes, ICF-MR/RC facilities, board and care homes, or DHS foster homes with four or more adults are not eligible for IH/FSP services. Individuals who reside in DHS foster homes which care for three or more minors that are under the department's temporary or permanent managing conservatorship are eligible for IH/FSP services.(e) An applicant may not receive IH/FSP services if he is receiving the same services from another support program. If he is eligible for another program's services and not receiving them, the applicant must provide documentation to the caseworker as to why the services are not being provided from the other program. Source Note: The provisions of this §278.7 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective February 1, 1996, 21 TexReg 331; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.7 Functional Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219021 03/12/2026 (a) A client may receive either or both of the following two categories of program benefits.(1) The client may receive a one-time cash grant for architectural renovation or other capital expenditure to improve or facilitate the care, treatment, therapy, or general living conditions of the person who has a disability. A capital expenditure is defined as any one-time purchase costing more than $250. At its discretion and subject to available funding, the Texas Department of Human Services (DHS) may set the maximum grant at zero to $3,600.(2) The client may also receive a cash subsidy grant to purchase services covered under §48.2706 of this title (relating to Allowable In-Home and Family Support Program (IH/FSP) Services). At its discretion and subject to available funding, the Texas Department of Human Services (DHS) may set the maximum grant at zero to $3,600.(b) The service plan is based on the applicant's statement of need, which indicates the services and capital expenditure or architectural renovation that will meet his care needs in a community-based setting. The applicant, assisted by the In-Home and Family Support Program (IH/FSP) caseworker, selects the programs or provider of services that he will use to meet his care needs without service duplication or overlap. The items or services purchased must be approved by the IH/FSP caseworker and must be on the list of allowable IH/FSP services.(c) The applicant is responsible for providing cost estimates for the services he intends to purchase with the IH/FSP subsidy.(d) The applicant or the applicant's responsible party must obtain three written bids to determine the lowest cost for capital expenditures, architectural modification(s), or both, that cost $1,000 or more.(e) In order for a sole source estimate to be accepted, the caseworker must document that no other source is available, explain the consumer's highly specialized need for the particular item/service, and specify all efforts made to locate additional resources. The supervisor must approve all sole source capital expenditure purchases. Source Note: The provisions of this §278.9 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective September 1, 1992, 17 TexReg 5460; amended to be effective December 1, 1992, 17 TexReg 7797; amended to be effective September 1, 2003, 28 TexReg 6951; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.9 Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219022 03/12/2026 The following IH/FSP services may be purchased with a service subsidy:(1) medical, surgical, therapeutic, diagnostic, and other health services related to a person's disability;(2) counseling or training programs that help a household to provide proper care for a disabled family member, help a person with a disability in an independent living situation, or provide for the special needs of the family or person with a disability;(3) attendant care, home health aide services, homemaker services, and chore services that provide assistance with training, routine body functions, dressing, preparing and consuming food, and ambulating;(4) respite assistance for a family;(5) transportation services for the person with a disability;(6) transportation, room, and board costs incurred by a person with a disability or his family during evaluation or treatment that has been preapproved by the Texas Department of Human Services. Estimates of meals, travel, and lodging costs must be submitted to the IH/FSP caseworker for prior approval. Travel expense reimbursement should be made based on the current state rate allowed for travel expenses;(7) the purchase or lease of special equipment or architectural modifications of a home, if:(A) the equipment or modification costs less than $250.01; and(B) the equipment or modification is necessary to improve or facilitate the care, treatment, therapy, or general living conditions of a person with a disability, as it relates to the person's disability; and(8) other services requested by the applicant and prior-approved by the state office section manager. Source Note: The provisions of this §278.11 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective December 1, 1992, 17 TexReg 7797; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.11 Allowable In-Home and Family Support Program (IH/FSP) Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219023 03/12/2026 (a) The In-Home and Family Support Program (IH/FSP) service subsidy and capital expenditure cash grant must be used only for allowable goods, supplies, or services that specifically and directly relate to the care of the person with a physical disability.(b) To participate in the IH/FSP, an applicant or his responsible party must agree in writing to provide receipts for all services, goods, or supplies purchased with program funds and the amount of copayment, if applicable. If an applicant refuses to sign the agreement, his application for program services is denied.(c) The applicant must agree to submit receipts for service subsidy funds, and the copayment amount, if any, at intervals designated by the Texas Department of Human Services (DHS) during the 12-month certification period. A one-time submittal of receipts is required for the capital expenditure grant. If the applicant fails to furnish the required receipts, he is denied eligibility and may be required to make restitution for amounts for which there are no receipts. The receipts that are returned to verify how the program funds were spent must be approved allowable purchases and must not be dated prior to the date the individual was certified as eligible for the IH/FSP. Receipts are due within six months from date of approved certification. The receipts must:(1) include specifications of modification/renovation, equipment or services to be purchased.(2) include date item delivered/purchased.(3) include vendor's name and identifying information;(4) be marked paid.(5) be an original;(6) be for items or services provided after the date of certification or eligibility determination.(d) Applicants must be residents of Texas and must live in a community-based setting, or they must live in a community living arrangement within 60 days from the date the case is assigned to the IH/FSP caseworker.(e) Clients are limited to the maximum grants set by DHS minus their copayment amounts.(f) Architectural modifications to leased or rented property are subsidized only if the landlord or owner submits written approval for the modifications to the department.(g) Applicants must not receive services from both the DHS IH/FSP and the Texas Department of Mental Health and Mental Retardation (TXMHMR) IH/FSP. Individuals are served by DHS IH/FSP and TXMHMR IH/FSP according to the guidelines specified in paragraphs (1) - (3) of this subsection.(1) Individuals not eligible for DHS IH/FSP because of eligibility for TXMHMR IH/FSP services (Texas Health and Safety Code, Chapter 535, Subchapter A; 25 TAC §401.681 et seq) include:(A) individuals with mental illness as defined by the Texas Health and Safety Code, §571.003, who meet all criteria for TXMHMR IH/FSP eligibility specified in 25 TAC §401.685;(B) individuals with mental retardation according to the Mentally Retarded Persons Act, Texas Health and Safety Code, §591.003, who meet all criteria for TXMHMR IH/FSP eligibility specified in 25 TAC §401.685;(C) individuals with a pervasive developmental disorder beginning in childhood, including autism, that meets the criteria established in the most recent edition of the Diagnostic and Statistical Manual; and(D) individuals under four years old, with a developmental delay as defined by TXMHMR in 25 TAC §401.683 (relating to Definitions).(2) DHS serves individuals with physical disabilities, four years or older, who meet all other eligibility criteria, contingent upon available funds.(3) DHS serves individuals denied assistance by the TXMHMR IH/FSP who have physical disabilities and have been determined not to have a diagnosis of mental illness or mental retardation, or who have been denied assistance based on 25 TAC §401.685(4), if they meet all eligibility criteria for DHS's program. If no openings are available in DHS's program, the individuals will be placed on the waiting list based on the original date of request for services from TXMHMR.(h) Individuals enrolled in the Community Living Assistance and Support Services program or the Community Based Alternatives program are not eligible to receive benefits in the IH/FSP. Source Note: The provisions of this §278.13 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective June 30, 1992, 17 TexReg 3844; amended to be effective December 1, 1992, 17 TexReg 7797; amended to be effective June 1, 1993, 18 TexReg 2857; amended to be effective April 1, 1994, 19 TexReg 1043; amended to be effective June 15, 1995, 20 TexReg 3735; amended to be effective October 1, 1995, 20 TexReg 7079; amended to be effective August 15, 1996, 21 TexReg 7061; amended to be effective September 1, 2000, 25 TexReg 6559; amended to be effectiveSeptember 1,2003, 28 TexReg 6951; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.13 Program Restrictions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219024 03/12/2026 (a) The amounts of service subsidies and capital expenditures are based on costs of services minus the required copayment amounts up to the maximum grants set by the Texas Department of Human Services.(b) The service subsidy is issued in intervals no greater than six months during the 12-month period of eligibility. Continued program eligibility is contingent upon verification by the IH/FSP caseworker that all program benefits, including the copayment amount, are spent according to program requirements.(c) If an applicant does not receive a capital expenditure amount at the beginning of his first year of eligibility and his need for the capital expenditure arises during that year, and if he has already received the first subsidy less a copayment, if applicable, but has not been issued a second subsidy, then the copayment factor is applied only to the capital expenditure amount.(d) Should an applicant need the capital expenditure at the beginning of his second year of eligibility, the copayment percentage is applied as outlined in subsection (a) of this section.(e) The subsidy amount is distributed to consumers in a manner that does not affect eligibility for other support programs.(f) Consumers who use only a portion of their capital expenditure or service subsidy may be issued the remainder of these program benefits contingent upon the availability of program funds.(g) After the initial certification, the availability of program funds and the consumer's continued need for the one-time grant determine the disbursement of the capital expenditure subsidy. Source Note: The provisions of this §278.15 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective December 15, 1992, 17 TexReg 8168; amended to be effective September 1, 2003, 28 TexReg 6951; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.15 Service Subsidy and Capital Expenditure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219025 03/12/2026 In-Home and Family Support Program (IH/FSP) applicants or their responsible parties must obtain a state payee identification number before IH/FSP payments can be made. Source Note: The provisions of this §278.17 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective December 1, 1992, 17 TexReg 7797; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.17 Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219026 03/12/2026 (a) Applicants have the right to appeal if they have been denied eligibility or have their benefits reduced, or for any other adverse action.(b) An applicant must exercise his right to appeal within 90 calendar days from the effective date of the decision or from the notice of adverse action date, whichever is later.(c) If a consumer is already receiving IH/FSP services and his benefits are denied or reduced, he must submit to the caseworker a request for a hearing within 12 calendar days from the date on the notification letter, to continue receiving services while the appeal is pending. He may be able to continue receiving the subsidy until the hearing is completed if the request is submitted within the 12-day time frame. If the results of the appeal agree with the denial or reduction of benefits, the consumer may be asked to pay back the amount of the subsidy provided during the appeal period.(d) The caseworker must attend the hearing. Source Note: The provisions of this §278.19 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective June 15, 1995, 20 TexReg 3735; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.19 Right To Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219027 03/12/2026 (a) Recertification occurs after 12 months of continuous program eligibility. To be recertified, the consumer must:(1) provide updated eligibility information to the In-Home and Family Support Program caseworker;(2) furnish current income verification; and(3) complete a new program participant agreement.(b) The caseworker must send written notification to the client within 15 days of the date the client furnishes the required information, informing him about his continued eligibility or ineligibility. Source Note: The provisions of this §278.21 adopted to be effective April 4, 1988, 13 TexReg 1393; amended to be effective May 1, 1990, 15 TexReg 1963; amended to be effective December 1, 1992, 17 TexReg 7797; amended to be effective June 15, 1995, 20 TexReg 3735; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.21 Recertification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219005 03/12/2026 The following words and terms, when used in the portions of this chapter applying to the TLC program (§§48.2721-48.2725), have the following meanings, unless the content clearly indicates otherwise.(1) Case manager--An employee of the Texas Department of Human Services (DHS) who provides case management services, or an employee of an agency that has contracted with DHS to provide relocation services or case management services. The case manager determines eligibility and benefit levels in the TLC program, subject to final approval by DHS.(2) CBA--The Community Based Alternatives program, a Medicaid waiver program, based on the Social Security Act, §1915(c), which provides a comprehensive array of community-based services for adults age 21 and older who meet the medical necessity criteria for nursing facility care, and who meet all other eligibility criteria for this waiver.(3) CLASS--The Community Living Assistance and Support Services program, a Medicaid waiver program, based on the Social Security Act, §1915(c), which provides a comprehensive array of community-based services for certain individuals who qualify for an intermediate care facility for the mentally retarded (ICF-MR) VIII level of care, and who meet all other eligibility criteria for this waiver. This program operates in designated counties in Texas.(4) Community setting--A community setting is any living arrangement chosen by the individual that allows that individual to receive services from the particular waiver program or other community care program providing services to that individual. A community setting is a long-term living arrangement other than a nursing facility; state hospital; state school; medical, rehabilitation, or psychiatric hospital; school for the deaf or blind, Texas Youth Commission facility, Texas Department of Criminal Justice facility, or ICF-MR facility.(5) DB-MD--The Deaf-Blind with Multiple Disabilities program, a Medicaid waiver program, based on the Social Security Act, §1915(c), which provides a comprehensive array of community-based services for certain individuals who qualify for an intermediate care facility for the mentally retarded (ICF-MR) VIII level of care, and who meet all other eligibility criteria for this waiver. This program operates in designated counties in Texas.(6) DHS--The Texas Department of Human Services.(7) Institutional setting--A long-term care nursing facility licensed by DHS.(8) MDCP--The Medically Dependent Children Program, a Medicaid waiver program, based on the Social Security Act, §1915(c), which provides community-based services to individuals under the age of 21 years who meet the medical necessity criteria for nursing facility or hospital care, and who meet all other eligibility criteria for this waiver.(9) Promoting Independence--An initiative of the Texas Department of Human Services, under the direction of the Texas Health and Human Services Commission (HHSC), to promote opportunities for a person with a disability to live in the most appropriate care setting of his choice.(10) TLC--The Promoting Independence Transition to Life in the Community program, a component of the In-home and Family Support Program (IHFSP), which provides a one-time financial grant or other short-term financial assistance to individuals to help them move from a Medicaid-funded residence in a nursing facility into a community setting. The rules and procedures described in §§48.2701-48.2711 do not apply to §§48.2721-48.2725, which govern TLC services. An individual may not receive services under §§48.2701-48.2711 concurrently with services received through the program described in §§48.2721-48.2725. An individual who has received TLC services and wants services described in §§48.2701-48.2711 must apply under the request and application procedures described in those sections. Source Note: The provisions of this §278.23 adopted to be effective June 2, 2002, 27 TexReg 4587; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.23 Definitions for the Transition to Life in the Community (TLC) Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219006 03/12/2026 To be eligible to receive benefits from the In-home and Family Support (IHFSP) TLC program, the individual must:(1) not have received prior benefits through the TLC program.(2) be a Texas Medicaid recipient who resides in a licensed nursing facility.(3) be expected to be able to move to a community setting within 60 days after transition funds are made available to the individual.(4) participate in developing a budget that indicates the financial ability to maintain ongoing household expenses after the temporary TLC assistance, including any temporary rental assistance, has been exhausted.(5) need assistance with relocation expenses that cannot be met by other resources owned by, or available to, the individual.(6) be accepted for services in one of the following service programs:(A) Community Based Alternatives (CBA);(B) Community Living Assistance and Support Services (CLASS);(C) Medically Dependent Children Program (MDCP);(D) Deaf-Blind with Multiple Disabilities (DB-MD);(E) other DHS community care service programs; or(F) other Medicaid-funded community-based service program offering ongoing services. Source Note: The provisions of this §278.25 adopted to be effective June 2, 2002, 27 TexReg 4587; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.25 Transition to Life in the Community (TLC) Client Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219007 03/12/2026 (a) An individual requesting TLC benefits, or an authorized representative, must sign an application for TLC benefits.(b) An individual requesting TLC services must agree in writing to:(1) provide to the Texas Department of Human Services (DHS) receipts for all goods, services, or supplies purchased with program funds and make restitution to DHS for funds that were not spent and/or were spent for goods, services, or supplies that were not approved by DHS; and(2) return or release any unspent TLC funds if unable to move to a community setting within 60 days after the funds are made available. A single extension of 60 days may be allowed if the individual can provide a plan to move to the community within the 60-day extension period.(c) Individuals requesting temporary rental assistance must agree in writing to the following conditions:(1) The applicant must file an application for subsidized housing through the federal Department of Housing and Urban Development, the Texas Department of Housing and Community Affairs, a public housing authority, or another program providing housing or rental assistance, and provide a copy of this application to DHS before rental assistance may be approved through the TLC program.(2) The rental assistance is limited to the difference between $2,500 and the sum of all other transitional assistance received through the TLC program, up to a maximum of $2,500 total, with no expectation of additional funds or extensions of this service.(3) The applicant must notify the case manager within 10 days of learning that the individual will receive sustainable housing for which TLC rental assistance is not required, or will receive subsidized housing through the U.S. Department of Housing and Urban Development, the Texas Department of Housing and Community Affairs, a public housing authority, or other program providing housing or rental assistance.(4) Rental assistance will cease if the individual receives sustainable housing for which TLC rental assistance is not required, or receives housing subsidized through the U.S. Department of Housing and Urban Development, the Texas Department of Housing and Community Affairs, a public housing authority, or other program providing housing or rental assistance.(d) If no funds are available for TLC program services, the name of an individual who has requested TLC benefits is placed on an interest list for the TLC program.(e) If funds become available to serve individuals on the interest list, names of individuals are removed from the interest list in the order in which the state office of DHS is notified that the service plan for the Community Based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Medically Dependent Children Program (MDCP), Deaf-Blind with Multiple Disabilities (DB-MD) programs, other DHS community care services, or other Medicaid-funded community-based service program has been developed for an individual who has applied for TLC benefits. Source Note: The provisions of this §278.27 adopted to be effective June 2, 2002, 27 TexReg 4587; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.27 Application for Transition to Life in the Community (TLC) Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219008 03/12/2026 (a) TLC program benefits are contingent upon the availability of funds budgeted for this program to the Texas Department of Human Services (DHS).(b) An eligible individual may receive up to a maximum of $2,500 to pay for the following expenses related to moving and household start-up costs, if the expenses are approved by the case manager and DHS:(1) expenses directly related to moving, such as the cost of paying others to move household belongings, the cost of moving cartons, and the cost of transporting the individual to the community setting;(2) rent deposits, limited to the first and last month's rent plus reasonable damage and security deposits;(3) utility deposits, including deposits required by electricity, gas, water, wastewater, telephone, and sanitation companies;(4) cooking utensils, dishes, cleaning supplies, furniture, appliances, towels, sheets, blankets, and other items needed to set up a household;(5) other moving-related expenses and household start-up costs approved by the case manager and DHS; and(6) temporary rental assistance payments.(c) Availability of funds and approval of benefits must be confirmed by DHS before commitment is made to disburse funds.(d) The TLC program will not provide benefits that the individual is eligible for and able to receive through any other program.(e) The TLC program benefits may not include items or services that are included in the reimbursement rate for Community Based Alternatives (CBA), Community Living Assistance and Support Services (CLASS), Medically Dependent Children Program (MDCP), Deaf-Blind with Multiple Disabilities (DB-MD), other DHS community care contracted providers, or other Medicaid-funded community-based service programs.(f) If individuals requesting TLC benefits will share a common household, the information in paragraphs (1)-(2) of this subsection apply:(1) If all individuals meet the eligibility criteria, each individual may receive a grant up to the maximum as long as no duplication of expenses occurs.(2) If only one household member meets the eligibility criteria, only the eligible household member may receive the grant. The ineligible household member's moving-related expenses and household start-up costs may be included in the eligible household member's grant, subject to the $2,500 limit, provided the ineligible household member is moving to the same community setting as the eligible household member.(g) Payments may be made directly to the eligible individual, or authorized representative, by employees of organizations under contract with DHS to provide relocation services or case management, or through DHS Community Care In-home and Family Support staff, according to procedures developed by DHS. Source Note: The provisions of this §278.29 adopted to be effective June 2, 2002, 27 TexReg 4587; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.29 Transition to Life in the Community (TLC) Program Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219009 03/12/2026 (a) The individual requesting TLC funds, or the authorized representative acting on the individual's behalf, will be notified if the individual's name is placed on an interest list because funds are not available at the time of the request.(b) The individual requesting TLC funds, or the authorized representative, will receive written notification after a decision has been made regarding eligibility for TLC benefits. If the individual is determined eligible, the written notice states the amount of the benefits the individual will receive.(c) The individual who has been notified of the eligibility decision regarding TLC funds may request a hearing to appeal the denial of eligibility or the amount of benefits, if the benefits are less than the maximum benefit of $2,500 and if the request is made within 90 days of the date of notification of the eligibility decision.(d) If an individual is denied TLC funds because they receive housing for which TLC rental assistance is not required, or receive subsidized housing from the U.S. Department of Housing and Urban Development, the Texas Department of Housing and Community Affairs, a local public housing authority, or other program providing housing or rental assistance, the denial will not be affected by an appeal.(e) The maximum funds available for all approved transition expenses to an individual under the TLC program is $2,500, with no additional funds available even if an individual files an appeal. Source Note: The provisions of this §278.31 adopted to be effective June 2, 2002, 27 TexReg 4587; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM A IN-HOME AND FAMILY SUPPORT PROGRAM §278.31 Transition to Life in the Community (TLC) Client Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219010 03/12/2026 Providers of adult foster care services must comply with this subchapter and Chapter 49 of this title (relating to Contracting for Community Services). Source Note: The provisions of this §278.101 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective September 1, 2014, 39 TexReg 6637; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.101 Compliance with Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219011 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219011 03/12/2026 (a) The provider must:(1) be a responsible, mature, healthy adult (18 years of age or older) capable of meeting the needs of the residents in the home;(2) be physically and mentally able to perform all the required duties and tasks;(3) be able to communicate directly with the resident and the resident's family;(4) show evidence of an examination for tuberculosis performed within six months prior to the date of enrollment from a licensed physician or a local health department with negative results or, if the results are positive, provide a physician's statement that the disease is non-communicable;(5) not deliver direct services when the provider has a communicable disease or illness, but ensure that a resident's needs are met by an approved substitute provider;(6) ensure that persons whose behavior or health status endangers the residents are not allowed at the home;(7) provide, at the time of enrollment, three references for the provider and the substitute provider from persons not related to the provider or substitute provider;(8) not be the spouse of a resident in the provider's care;(9) live in and share the same household (i.e., have common living areas that are not detached from the home) with the residents;(10) be the primary caregiver of the residents;(11) be the owner or lessee of the adult foster home;(12) submit to the Department of Aging and Disability Services (DADS) a statement providing information concerning any felony or misdemeanor convictions, and any pending criminal charges against the provider before enrollment and, if the information changes, during the term of its contract;(13) have at least one approved substitute provider, who the provider is responsible for paying, before the enrollment process is completed;(14) receive orientation covering the topics listed on the adult foster care program orientation checklist before serving residents, and familiarize all substitute providers with the topics;(15) participate in six hours of in-service training annually on topics approved by DADS, which must include:(A) training on acquired immune deficiency syndrome, human immune deficiency virus, and cultural diversity within one year after enrollment, unless DADS grants a 60-day extension; and(B) training on first aid within two years after enrollment, unless DADS grants a 60-day extension, and annually thereafter;(16) demonstrate the ability to read and comprehend the minimum standards for adult foster care, the resident and provider agreements, service plans, and DADS directives, unless the provider enrolled as an AFC provider before January 1, 1994;(17) prior to initial enrollment, demonstrate and maintain financial stability, independent of DADS provider payment, and demonstrate the ability to meet existing financial obligations;(18) not represent any other residential settings that the provider owns or operates as DADS-enrolled homes and report Texas Department of Family and Protective Services investigations of these settings to DADS; and(19) agree to abide by all policies and procedures of DADS.(b) A person who is barred from employment under Chapter 250 of the Texas Health and Safety Code may not be an AFC provider. Source Note: The provisions of this §278.103 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective December 1, 2013, 38 TexReg 8680; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.103 Provider Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219012 03/12/2026 A substitute provider must meet the requirements specified in §48.8902(a)(1) - (8), (12), and (16) of this subchapter (relating to Provider Qualifications) and §48.8904 of this subchapter (relating to Individuals Who May Not Provide Adult Foster Care Services). The Department of Aging and Disability Services reserves the right to disapprove a substitute provider or attendant. The provider must orient any substitute caregiver to the home and the residents to the following:(1) the location of fire extinguishers;(2) evacuation procedures;(3) location of residents' records;(4) location of telephone numbers for the residents' physicians, the provider, and other emergency contacts;(5) location of medications;(6) introduction to residents; and(7) instructions for caring for each resident. Source Note: The provisions of this §278.105 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective December 1, 2013, 38 TexReg 8680; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.105 Substitute Provider Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219013 03/12/2026 Individuals who are disqualified under the Health and Safety Code, Chapter 250, may not provide adult foster care services. Source Note: The provisions of this §278.107 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective May 1, 1997, 22 TexReg 3592; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.107 Individuals Who May Not Provide Adult Foster Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219014 03/12/2026 All homes in which adult foster care is provided must:(1) have bedrooms with at least 80 square feet of floor space in a single occupancy room, and at least 60 square feet of floor space per client in a double occupancy room. The bedrooms must:(A) be close enough in proximity to the provider to alert the provider to nighttime needs or emergencies, or they must be equipped with a call bell or intercom;(B) have been constructed as sleeping areas when the home was built, or have been remodeled under permit that meets local requirements;(C) be finished with walls or partitions of standard construction which go from floor to ceiling; and(D) be ventilated and lighted with at least one window that will open freely and remain open from the inside without special tools;(2) provide each resident with a bed and sufficient drawer and closet space in the resident's bedroom;(3) have no more than two beds in any room;(4) have comfortable sleeping arrangements for residents;(5) provide at least one comfortable sitting chair per resident in each bedroom;(6) provide at least one grab bar in the bathtub/shower area and a slip-proof surface in the bathtub/shower area;(7) have adequate supplies of soap and toilet paper for each bathroom. Residents must be provided with individual towels and wash cloths;(8) provide a sketch of the home floor plan showing the dimensions and the purpose of all rooms and specifying where residents and household members will sleep. As arrangements change, an updated floor plan must be provided to Department of Human Services (DHS) staff;(9) have a conspicuously posted emergency/disaster evacuation plan that specifies what procedures residents follow in case of emergency, and hold evacuation drills at least every six months with at least one of the two required annual drills occurring during sleeping hours;(10) have at least one working telephone available in the home for residents to make calls. The foster care caseworker, the client, the client's family or guardian, and the client's physician must be kept informed of the provider's current telephone number. The client has the right to give out the telephone number. Limitations on the use of the telephone must be specified in the house rules. Providers must not charge recipients for the use of the telephone for local calls;(11) have emergency telephone numbers, including the adult foster care caseworker's number, located at or near the telephone;(12) have an operational smoke detection system. Battery operated detectors are acceptable;(13) have a portable ABC-type fire extinguisher charged and ready for use;(14) have first-aid supplies on the premises, as recommended by the American Red Cross;(15) have at least one communal dining table with adequate seating for all residents at the same time;(16) provide space and furniture for residents' visitors;(17) provide laundry service for the residents as part of the room and board rate;(18) meet all applicable state and local building, zoning, and housing codes;(19) be maintained, repaired, and cleaned so that the homes are not hazardous to residents in care (including yards). There must be no accumulation of garbage, debris, rubbish, or offensive odors. If house pets are kept indoors, sanitation must be maintained. Swimming pools must be fenced;(20) have screens on windows and doors used for ventilation;(21) have equipment and furnishings that are safe for residents;(22) have flammable and poisonous substances, explosives, and firearms stored and inaccessible to residents;(23) maintain room temperatures at levels which are comfortable to residents. Heating and cooling systems must be in good working order. Maintain hot water temperatures in resident areas between 100 degrees Fahrenheit and 125 degrees Fahrenheit;(24) have food preparation areas and equipment clean, free of offensive odors, and in good repair. Utensils, dishes, and glassware must be washed in hot soapy water, rinsed, and stored to prevent contamination; and(25) store soiled linens and clothing in containers in an area separate from food storage, kitchen, and dining areas. Source Note: The provisions of this §278.109 adopted to be effective January 1, 1994, 18 TexReg 8232; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.109 Home Enrollment Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219015 03/12/2026 (a) To receive payment from the Department of Aging and Disability Services (DADS), an adult foster care provider must:(1) not exceed the capacity for which an adult foster care home is enrolled or licensed regardless of whether the residents are receiving adult foster care services or private pay services;(2) serve only those foster care and private pay residents approved by DADS to ensure that the provider can meet the needs of all residents;(3) not provide room and board to any individuals who are under 18 years of age and who are not related to the provider;(4) comply with all applicable fire, health, and safety laws, ordinances, and regulations;(5) obtain the necessary fire safety and health inspections and comply with any resulting requirements;(6) be inspected at least annually by fire safety authorities and meet or exceed the regulations. The provider must correct any hazardous conditions identified in the inspection within the time specified by the inspector, or before DADS enrollment/reassessment of the home, whichever is earlier;(7) be inspected at least annually by health authorities and meet or exceed the regulations. If local health authorities are unable to inspect the home, adult foster care staff may conduct the inspection using the health inspection checklist. The provider must correct any unsanitary and unsafe conditions identified by the inspection within the time specified by the inspector, or before DADS enrollment/reassessment of the home, whichever is earlier;(8) demonstrate the ability to evacuate all residents from the home within three minutes;(9) interview a prospective resident before or at the time of admission to determine the needs of the prospective resident and whether the home can meet these needs;(10) orient any new resident, within 72 hours of arrival, on fire safety, how to respond to a fire alarm, and how to exit from the home in an emergency; and(11) except in the case of emergency evacuations, notify DADS of a change of residence before the change. The new home must meet all adult foster care requirements and be enrolled in the adult foster care program before payments can be made. Enrollment is not retroactive.(b) Adult foster care homes serving five, six, seven, or eight residents must also:(1) ensure the presence of an additional member of the staff who has been approved by the adult foster care caseworker at least two hours a day for homes serving five residents, and four hours a day for homes serving six residents, including private pay residents;(2) ensure the presence of an additional member of the staff who has been approved by the caseworker at least six hours a day for homes serving seven residents, and eight hours a day for homes serving eight residents, including private pay residents; and(3) ensure that additional qualified staff are on-site for the specified number of hours, during the hours from 6 a.m. until 8 p.m. The provider must have records to document that qualified staff were serving residents for the required number of hours each day.(c) An adult foster care provider that must be licensed in accordance with Chapter 49 of this title (relating to Contracting for Community Services) must:(1) provide a copy of the assisted living facility license to DADS adult foster care staff each time the license is renewed; and(2) report to DADS adult foster care staff any licensure problems identified by DADS Regulatory Services. Source Note: The provisions of this §278.111 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective November 1, 1996, 21 TexReg 10310; amended to be effective September 1, 2014, 39 TexReg 6637; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.111 Enrollment and Licensure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219016 03/12/2026 (a) Resident care and services. The adult foster care provider must:(1) provide services to residents according to the individual service plan and the resident/provider agreement;(2) meet all requirements and conditions stated on the resident/provider agreement, approval of foster care, and resident service plan;(3) ensure that an approved substitute provider is present in the home if at least one resident remains in the home when the provider plans to be absent from the home for more than three hours in a 24-hour period. Residents whose care plans specify the need for 24-hour supervision may not be left without the supervision of an approved substitute provider for any period of time;(4) receive prior approval from the adult foster care caseworker or supervisor if he plans to be absent for more than 24 hours. The proposed substitute provider must have prior Department of Aging and Disability Services (DADS) approval. The provider must ensure that the substitute provider is aware of and takes responsibility for meeting resident needs and providing services according to the residents service plans and the requirements of these standards. If two adults in the home have been approved as dual providers, this notification is not necessary when one provider leaves for more than 24 hours;(5) ensure that residents are not abused, neglected, or exploited while in foster care. Validated reports of the provider, the provider's family, or employees willfully inflicting injury, physical suffering, intimidation, or mental anguish on any resident in the home shall constitute grounds for immediate removal of the home from enrollment;(6) respond to, investigate, and document resident complaints and report unresolved complaints to the adult foster care caseworker within five days of receipt of the complaint;(7) have clearly defined house rules, including smoking policies. House rules must be shared with the resident before moving to the foster home;(8) take appropriate action if he finds that a resident threatens the health or safety of others or himself; and(9) provide the resident with a final accounting of the resident's funds and refund any monies owed to the resident within five days of discharge. Any unused room and board money must be reimbursed within 30 days.(b) The foster care provider providing services to three or less residents must comply with Title 42 United States Code §1396a(w) regarding advance directives.(c) Recordkeeping. The adult foster care provider must:(1) maintain for each resident a record with the following information:(A) the names, addresses, and telephone numbers of:(i) person(s) other than DADS staff to be notified in case of emergency, (if any);(ii) the resident's physician, (if any); and(iii) the resident's adult foster care caseworker;(B) current and past copies of the client and provider agreement, signed by the resident and/or responsible party, provider, and the adult foster care caseworker;(C) current and past copies of the approval of adult foster care;(D) current and past copies of the client service plan;(E) any DADS communications regarding the resident;(F) personal papers of the resident, such as life insurance policies, burial arrangements, savings accounts, etc., if requested by the resident; and(G) records related to assistance provided the resident with money management, payments, distribution of personal allowance, expenditures, etc.;(2) file claims for services according to DADS rules using the appropriate DADS forms and agree to accept the claimed amount as full payment from DADS for services provided. Nursing facility waiver residents are required to pay a co-payment.(d) Reporting and notification. The adult foster care provider must:(1) report to the adult foster care caseworker, within 24 hours or the next work day after awareness of the change, all significant changes in the resident's physical health, mental and/or behavior status;(2) report to the adult foster care caseworker pending resident hospitalizations before the hospitalization, and unplanned hospitalizations within 24 hours of the hospitalization or the next work day;(3) report pending hospital discharges of approved residents to the adult foster care caseworker before the actual discharge, or on the day the resident returns to the foster care setting, to ensure continued resident appropriateness;(4) notify the adult foster care caseworker, at a minimum, within 24 hours or the next work day after a resident is away from or vacates the adult foster home;(5) notify the adult foster care caseworker immediately by telephone upon becoming aware of the following: death of a resident, serious physical injury or distress of a resident, offense against the resident, or public indecency of a resident. The provider must submit a written report within 48 hours of the verbal report. The provider must also notify the police in the following situations: the death of a resident in the foster home, serious physical injury resulting from assault or battery, offenses against the resident, and public indecency;(6) notify the adult foster care caseworker about serious occurrences involving the provider, the home, or the residents. These may include, but are not limited to, fire, accidents, altercations among residents, break-ins, or illness of the provider or residents. The provider must notify the caseworker by telephone no later than the next calendar day after awareness of the occurrence;(7) notify the adult foster care caseworker before any resident receives home health services;(8) notify the adult foster care caseworker when the provider, substitute provider, or a family member is the subject of an adult protective services investigation. The provider must notify the adult foster care caseworker within 24 hours of the beginning of the investigation or the next work day; and(9) report to the adult foster care caseworker's supervisor or another adult foster care staff person any of the required notifications if the caseworker is not available to speak with the provider.(e) Responding/acting. The adult foster care provider must:(1) upon awareness, obtain medical attention for a resident exhibiting signs of physical injury, pain, or discomfort;(2) seek medical attention/care on the same day of awareness for a resident exhibiting acute changes in physical health, mental or behavior status; and(3) follow DADS adult foster care directives related to resident care within the specified time frames.(f) Nutrition. The adult foster care provider must:(1) provide a resident with at least three meals daily which meet each resident's dietary and nutritional needs;(2) consider a resident's food preferences and make reasonable accommodations within his dietary needs;(3) serve a variety of foods, within the resident's dietary needs; and(4) follow special diets as prescribed in writing by the resident's physician.(g) Medications. The adult foster care provider must comply with the following rules regarding the storage and management of medications:(1) prescription medications must be in the original container labeled with the resident's name, date, instructions, name of medication and dosage, and the physician's name;(2) medications requiring refrigeration must be separated from food in a clearly labeled, designated locked container;(3) medications must be transferred with the resident when the resident leaves the home. Medications must be disposed of when resident medication regimen changes, or when the medication is out of date;(4) medications prescribed for one resident must not be taken by or given to any other resident;(5) the adult foster care provider must ensure that a resident takes over-the-counter medications according to the package directions. Excessive use of these medications must be reported to the adult foster care caseworker;(6) the adult foster care provider must ensure that all medications are taken as prescribed and in a timely manner according to the instructions on the medication label or instructions from the resident's physician;(7) the adult foster care provider may administer medications only as allowed by state law or regulation; and(8) prescription medications must be kept in a locked container.(h) Resident rights and responsibilities. The adult foster care provider must:(1) inform the resident verbally and in writing, before or at the time of admission, of his rights and responsibilities. The rights and responsibilities include rules governing resident conduct, complaints, bedhold policies for hospital and personal leave, and eviction procedures. The policies must not violate the rules specified in this subchapter nor adversely affect the resident's health or safety. All policies must have an effective date. If the provider amends any policy, each resident must be informed before the change becomes effective. A written copy of these policies must be given to the resident to initial and date. This copy must be filed in the resident's casefolder. A copy of the policies must also be given to the resident. If the resident is unable to read or understand the policies, a copy must be given to the person responsible for him;(2) allow the resident to manage his finances or trust funds. The provider must assist the resident in managing his finances only if the resident requests assistance in writing. The resident may rescind this authorization at any time by doing so in writing;(3) investigate all problems, deficiencies, and non-compliance with policies, procedures, and standards which are reported by the resident or DADS staff within five workdays from receipt of the report. A copy of the documented complaint must be submitted to the adult protective services caseworker within 30 days of the receipt of the report;(4) provide each resident with a general orientation about his needs and the tasks to be provided before or at the time the service begins;(5) not require a resident to perform services for the provider or other residents; and(6) treat each resident with dignity and respect. The provider must guarantee certain basic rights to each resident living in his home. Such rights include the right to privacy, humane care and environment, safety of personal possessions and funds, receipt of visitors, confidentiality of personal records, freedom of religion, freedom from physical or mental abuse, neglect and exploitation, freedom from physical or chemical restraints, freedom from financial exploitation, and the right to voice grievances without retribution or intimidation.(i) Transportation. Adult foster care providers must provide or make arrangements to meet the transportation needs of a resident for medical appointments/care, shopping for personal needs, and church activities as identified by the adult foster care caseworker. An escort must also be provided if specified in the individual service plan for a resident.(j) Provider rights. Each provider must post a providers' bill of rights in a prominent place in the foster home. The bill of rights must state that the adult foster care provider has the right to:(1) be shown consideration and respect that recognizes the dignity and individuality of the provider;(2) terminate the client/provider agreement after a written 30-day notice;(3) terminate the client/provider agreement immediately, after notice to DADS, if the provider finds that a resident creates a serious or immediate threat to the health, safety, or welfare of the provider or the other residents of the foster home;(4) refuse to perform services for the resident or the resident's family other than those specified in the client/provider agreement;(5) refuse to accept a person referred to the foster home if the referral is inappropriate;(6) refuse to allow the presence of illegal drugs and weapons in the home; and(7) be made aware of a resident's problems, including aggressive or violent behavior, disease, alcoholism, or drug abuse.(k) Termination of services. Adult foster care providers cannot terminate services to a resident without the prior approval of the adult foster care caseworker or supervisor, unless the resident creates a serious or immediate threat to the health, safety, or welfare of the provider or the other residents of the foster home. Source Note: The provisions of this §278.113 adopted to be effective January 1, 1994, 18 TexReg 8232; amended to be effective November 1, 1994, 19 TexReg 8132; amended to be effective September 1, 2014, 39 TexReg 6637; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4061. 1 HEALTH AND HUMAN SERVICES COMMISSION 278 ADULT FOSTER CARE (AFC) PROGRAM B MINIMUM STANDARDS FOR ADULT FOSTER CARE §278.113 Provider Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205340 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205340 03/12/2026 This chapter establishes the requirements for a provider contracting to provide emergency response services (ERS) to individuals through the Department of Aging and Disability Services (DADS) Community Based Alternatives (CBA) Program, the Consolidated Waiver Program (CWP), and the Community Care for Aged and Disabled (CCAD) ERS Program. Source Note: The provisions of this §279.1 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES A INTRODUCTION §279.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205341 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205341 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:(1) Alarm call--A signal transmitted from the equipment to the provider's response center indicating that an individual needs immediate assistance.(2) Call button--An electronic device that, when pressed, triggers an alarm call to the provider's response center to alert the provider that an individual needs immediate assistance. The device may be held in the hand, worn around the neck, hung on a garment, or kept within an individual's reach.(3) Case manager--A DADS employee who is responsible for case management activities for an individual, including eligibility determination, enrollment, assessment and reassessment of the individual's need, service plan development, and intercession on the individual's behalf.(4) CBA--Community Based Alternatives. A Medicaid waiver program that provides services to eligible adults who are aged or disabled or both as an alternative to institutional care in a nursing facility. CBA services are provided in accordance with the waiver provisions of §1915(c) of the Social Security Act (42 U.S.C. §1396n(c)).(5) CCAD--Community Care for Aged and Disabled. A group of DADS programs that provide a variety of Title XX-funded community-based services.(6) Contract--A written agreement between DADS and a provider to provide ERS to an individual in exchange for payment.(7) Contract manager--A DADS employee who is responsible for the overall management of a contract with a provider.(8) Coordinator--A provider employee who is responsible for the management and provision of ERS and who ensures that services are delivered as described in this chapter.(9) CWP--Consolidated Waiver Program. A Medicaid waiver program that provides home and community-based services to people who are eligible for care in a nursing facility care or an intermediate care facility for persons with mental retardation or related conditions (ICF-MR/RC). CWP services are provided in accordance with the waiver provisions of §1915(c) of the Social Security Act (42 U.S.C. §1396n(c)).(10) DADS--Department of Aging and Disability Services.(11) Day--Any reference to a day means a calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.(12) ERS--Emergency response services. A CCAD program and a service provided through the CBA and CWP programs that provides electronic monitoring services for functionally impaired adults who live alone or who are functionally isolated in the community. In the CBA and CWP programs, ERS helps assure health and safety in the community.(13) Equipment--The system used in an individual's home to provide electronic monitoring services.(14) Imminent danger--An immediate, real threat to a person's safety.(15) Individual--A person who has been determined eligible to receive ERS. A reference in this chapter to "individual" includes the individual's representative, unless the context indicates otherwise.(16) Installer--A volunteer, a subcontractor, or an employee of a provider who connects, maintains, or repairs the equipment.(17) Institution--A hospital, a nursing facility, a state mental retardation facility, a state mental health facility, or an ICF-MR/RC.(18) Monitor--A volunteer, a subcontractor, or an employee of a provider who monitors ERS and ensures that an alarm call is responded to immediately.(19) Negotiated referral--A request from a case manager to a provider to begin services on a particular date due to an individual's needs, or a service start date that is negotiated between the case manager and the provider.(20) Provider--An entity that has a contract with DADS to provide ERS.(21) Public service personnel--A staff member of a sheriff's department, police department, emergency medical service, or fire department.(22) Reckless behavior--Acting with conscious indifference to the consequences.(23) Representative--An individual's spouse, other responsible party, or legal representative.(24) Responder--A person designated by an individual to respond to an emergency call activated by the individual. A responder may be a relative, a neighbor, or a volunteer.(25) Response center--The site where a provider's ERS monitoring system is located.(26) Routine referral--A request from a case manager to a provider to begin ERS for which the case manager determines that an individual's needs do not require a negotiated referral.(27) Subcontractor--An organization or an individual who delivers a component of ERS for the provider for a fee and is not an employee or volunteer of the provider.(28) Suspension--A temporary stoppage of ERS to an individual without loss of the individual's ERS eligibility.(29) System check--A successful activation of the call button by an individual or a test of the equipment by the provider.(30) Termination--A permanent stoppage of ERS to an individual by DADS.(31) Working day--Any day except Saturday, Sunday, a state holiday, or a federal holiday. Source Note: The provisions of this §279.3 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES A INTRODUCTION §279.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205342 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205342 03/12/2026 (a) A provider must comply with this chapter and Chapter 49 of this title (relating to Contracting for Community Services).(b) A provider must:(1) have emergency monitoring capability 24 hours a day, seven days a week; and(2) be equipped to provide verifiable data using technology capable of producing a printed record of:(A) the type of alarm code (test, accidental, or emergency);(B) the unit subscriber number;(C) the date; and(D) the time of the activated alarm in seconds. Source Note: The provisions of this §279.21 adopted to be effective March 1, 2006, 31 TexReg 1307; amended to be effective September 1, 2014, 39 TexReg 6672; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES B CONTRACTING REQUIREMENTS §279.21 General Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205343 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205343 03/12/2026 Any written notification to DADS from a provider required by this chapter must be sent by mail, fax, or hand-delivery, unless otherwise specified. E-mail is not an acceptable form of written notification. Source Note: The provisions of this §279.23 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES B CONTRACTING REQUIREMENTS §279.23 Written Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205344 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205344 03/12/2026 (a) Coordinator. A coordinator must:(1) understand the rules of this chapter and ERS procedures; and(2) be able to communicate with:(A) other provider staff;(B) an individual;(C) the case manager; and(D) other people involved with ERS.(b) Installer.(1) An installer must:(A) meet the requirements of an alarm systems installer as described in the Occupations Code, Chapter 1702;(B) be able to communicate with an individual; and(C) be able to show identification issued by the provider.(2) A provider must ensure that an installer is competent in the following areas:(A) installation procedures;(B) proper use of the equipment; and(C) Federal Communications Commission requirements on equipment installation.(c) Monitor. A monitor must be able to:(1) communicate with an individual and a responder;(2) respond to an alarm call as described in §52.409 of this chapter (relating to Alarm Calls);(3) monitor and document an alarm call from the time an alarm call is received to the time an individual receives assistance;(4) conduct and document a system check as described in §52.407 of this chapter (relating to System Checks); and(5) identify an individual's health history and functioning levels.(d) Documentation. A provider must document that a provider staff member as described in subsections (a) - (c) of this section:(1) is competent to perform his job duties before he begins his job; and(2) meets the applicable requirements of this chapter. Source Note: The provisions of this §279.51 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES C STAFF REQUIREMENTS §279.51 Provider Staff Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205345 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205345 03/12/2026 (a) Responder responsibilities. A responder must:(1) go to the individual's home if an alarm call is made to a provider; and(2) take appropriate action, including contacting public service personnel, based on the situation.(b) Securing responders. A provider must attempt to secure the names of at least two responders from an individual on or before the date the provider initiates services.(1) If the provider is able to secure the name of only one responder from an individual, the provider must:(A) designate public service personnel in place of the individual's second responder; and(B) document the reason the provider could secure the name of only one responder.(2) If a provider is unable to secure the names of any responders from an individual, the provider must:(A) designate public service personnel in place of the individual's responders; and(B) send written notification to the case manager of the inability to secure the names of any responders within 14 days after initiating services.(c) Responder orientation. A provider must:(1) orient a responder in person, by telephone, or in writing on the responder's responsibilities on or before the date the responder is first contacted by the provider and asked to respond to an alarm call;(2) document the following information concerning the orientation:(A) the name and telephone number of the responder;(B) the name of the individual;(C) the date the responder was secured;(D) the date of orientation;(E) the method of orientation; and(F) the topics covered; and(3) ensure that a responder receives written procedures on how to respond to an alarm call and document the date the procedures were provided to the responder. The provider may mail the written procedures to the responder.(d) Replacing a responder.(1) A provider must secure a replacement responder when an individual's responder is no longer able to participate.(A) If an individual has two responders, a provider must secure a second responder within seven days after becoming aware that the individual will no longer have two responders.(B) If an individual has one responder, a provider must secure a replacement responder within four days after becoming aware that the individual's sole responder is no longer able to participate.(C) If a provider is unable to secure any replacement responders, the provider must:(i) designate public service personnel in place of the replacement responders; and(ii) provide the case manager with written notification within 14 days after the provider determines it cannot secure a replacement responder.(2) A provider must document:(A) the date the provider became aware that a responder was no longer able to participate; and(B) the date the provider secured a replacement responder.(e) Current responders. A provider must maintain a record of the names of current responders for each individual. Source Note: The provisions of this §279.53 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES C STAFF REQUIREMENTS §279.53 Responders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205346 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205346 03/12/2026 (a) A provider must accept all DADS referrals for ERS.(b) DADS refers an individual to a provider either with a negotiated referral or a routine referral.(1) A case manager makes a negotiated referral:(A) by phone; and(B) on DADS' Notification of Community Based Alternatives (CBA) Services, Authorization of Community Care Services, or Notification of Consolidated Waiver Program (CWP) Services form.(2) A case manager makes a routine referral on DADS' Notification of Community Based Alternatives (CBA) Services, Authorization of Community Care Services, or Notification of Consolidated Waiver Program (CWP) Services form. Source Note: The provisions of this §279.71 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.71 Referrals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205347&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205347 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205347&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205347 03/12/2026 (a) Service initiation requirements. To initiate services, a provider must:(1) secure responders, as described in §52.303 of this chapter (relating to Responders);(2) install the equipment as described in §52.405 of this chapter (relating to Equipment Installation);(3) train an individual on the use of the equipment, including:(A) demonstrating how the equipment works; and(B) having the individual activate an alarm call;(4) explain to the individual:(A) that the individual must participate in a system check each month;(B) that the individual must contact the provider if:(i) his telephone number or address changes; or(ii) one or more of his responders change; and(C) that the individual must not willfully abuse or damage the equipment;(5) inform the individual that a responder can forcibly enter an individual's home if necessary;(6) obtain a signed release for forcible entry; and(7) inform an individual of the procedures for filing a complaint against a provider.(b) Service initiation due dates.(1) If DADS refers an individual to a provider with a routine referral, the provider must initiate services within 14 days after the service effective date given on the appropriate form listed in §52.401(b)(2) of this chapter (relating to Referrals), or within 14 days after the date the provider receives the form, whichever is later.(2) If DADS refers an individual to a provider with a negotiated referral, the provider must initiate services on the date orally negotiated with the case manager.(3) If an individual is not available during the time frames described in paragraph (1) or (2) of this subsection, a provider must initiate services within 72 hours after becoming aware that an individual is available, or within 72 hours after the date the individual is available, whichever is later.(c) Delay in service initiation. A provider must document any failure to initiate services by the applicable date in subsection (b) of this section.(1) DADS does not hold the provider accountable if a service delay is:(A) beyond the control of the provider; and(B) not directly caused by the provider.(2) Documentation must include:(A) the reason for the delay;(B) either the date the provider anticipates it will initiate services or specific reasons the provider cannot anticipate a service initiation date; and(C) a description of the provider's ongoing efforts to initiate services.(d) Documentation of service initiation. A provider must maintain documentation of service initiation in an individual's file. Source Note: The provisions of this §279.73 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.73 Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205348 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205348 03/12/2026 (a) During an initial home visit, an installer must:(1) install and make an initial test of the equipment;(2) ensure that the equipment has an alternate power source in the event of a power failure;(3) install within limits set forth in manufacturers' installation instructions; and(4) if necessary:(A) purchase a telephone extension cord;(B) connect and run a telephone extension cord not to exceed 50 feet between the wall jack and the equipment; and(C) safely tack the telephone extension cord against the wall or floorboard to prevent a hazard to an individual.(b) An installer is not required to:(1) adapt the physical environment in an individual's home to make it compatible with the equipment;(2) arrange or pay for relocation of the telephone; or(3) purchase or install electrical extension cords. An installer must not use an electrical extension cord when installing equipment.(c) A provider must document a failure to install the equipment, including:(1) the reason for the delay;(2) the date the provider anticipates it will install the equipment or the specific reason the provider cannot anticipate a date; and(3) a description of the provider's ongoing efforts to install the equipment, if applicable. Source Note: The provisions of this §279.75 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.75 Equipment Installation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205349&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205349 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205349&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205349 03/12/2026 (a) Purpose. The purpose of a system check is to ensure:(1) that an individual can successfully make an alarm call; and(2) that the equipment is working properly.(b) Conducting a system check.(1) A provider must conduct a system check at least once during each calendar month.(2) The system check must be conducted during normal working hours or as negotiated with the individual.(3) A provider must document a completed system check. The documentation must include the date and time of the completed system check and confirm that the individual was contacted.(c) Failure to complete a system check.(1) When a system check failure occurs, a provider must attempt to complete the system check a total of three times during the calendar month. The attempts must occur on three different days.(2) If a provider is unable to complete a successful system check after three attempts and does not have a documented reason why the system checks have not been completed, the provider must ask a responder to attempt to find out why the individual is unable to complete the system check.(3) If a provider is unable to complete a system check during a calendar month, the provider must provide written notification to the case manager by the 15th day of the month after the system check was due. The written notification must include:(A) the date and time of each attempted system check;(B) the date and time of each attempt to contact a responder other than public service personnel; and(C) the reason the individual was unable to participate, if known.(d) If a provider is unable to complete a system check due to equipment failure, the provider must replace the equipment as described in §52.411(a)(2) of this chapter (relating to Equipment Maintenance). Source Note: The provisions of this §279.77 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.77 System Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205350 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205350 03/12/2026 (a) Response time. A provider must respond to an alarm call within 60 seconds of the alarm, 24 hours a day, seven days a week.(b) Response to alarm calls. A provider must, in response to an alarm call:(1) record the response time in seconds;(2) attempt to contact the individual to verify that an emergency exists before contacting a responder; and(3) immediately contact a responder if:(A) the individual verifies there is an emergency; or(B) the provider is unable to reach the individual.(c) Documentation of alarm calls.(1) A provider must document an alarm call at the time the alarm call is received and after it is resolved. The documentation must include:(A) the name of the individual;(B) the date and time the provider receives the alarm call, recorded in hours, minutes, and seconds;(C) the time the monitor called the individual in response to the alarm call, recorded in hours, minutes, and seconds;(D) the name of the contacted responder, if applicable;(E) a brief description of the incident; and(F) a statement of how the incident was resolved.(2) A provider must provide written notification to the case manager by the next working day after an alarm call that results in a responder being dispatched to an individual's home. Source Note: The provisions of this §279.79 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.79 Alarm Calls https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205351 03/12/2026 (a) Equipment failure. A provider must:(1) contact an individual by the end of the next working day after learning of an equipment failure; and(2) replace the equipment:(A) by the end of the next working day after learning of an equipment failure if the individual is available; or(B) by the end of the third working day after learning of an equipment failure if the individual is not available within one working day.(b) Low battery. A provider must visit an individual's home to check the equipment within five working days after the equipment has registered five or more "low battery" signals in a 72-hour period. The provider must replace a defective battery during the visit.(c) Documentation. A provider must document and maintain a record of each equipment failure and low battery signal. The documentation must include:(1) the date the provider became aware of the equipment failure or low battery signal;(2) the equipment or subscriber number;(3) a description of the problem; and(4) the date the equipment is repaired or replaced. Source Note: The provisions of this §279.81 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.81 Equipment Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205352 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205352 03/12/2026 (a) Interdisciplinary team (IDT). An IDT is a designated group of people who meet when the need arises to discuss service delivery issues. An IDT meeting must include:(1) the individual or the individual's representative or both;(2) a provider representative; and(3) a DADS representative, who is:(A) a case manager (or designee);(B) a contract manager (or designee); or(C) a regional nurse (or designee).(b) Convening an IDT meeting. A provider must convene an IDT meeting within three working days after the date the provider:(1) suspends services to an individual for reasons explained in §52.419 of this chapter (relating to Suspension); or(2) identifies an issue that prevents the provider from carrying out a requirement of this chapter.(c) IDT meeting.(1) A provider may conduct an IDT meeting by telephone conference call or in person.(2) The IDT must:(A) evaluate the service delivery issue;(B) identify solutions to resolve the service delivery issue; and(C) make recommendations to the provider.(d) IDT meeting outcome. A provider must implement the recommendations of an IDT within two working days after the IDT meeting.(e) Documentation of an IDT meeting. A provider must document an IDT meeting in the individual's file, including:(1) the specific reason for calling the IDT meeting;(2) the names of the participants in the IDT meeting;(3) the provider's attempts to convene an IDT meeting with all the members if all members described in subsection (a) of this section are unable to participate in the meeting;(4) the IDT's recommendations;(5) the provider's action as a result of the IDT recommendations; and(6) the reasons for a provider's actions.(f) Failure to convene an IDT meeting with a DADS representative present. If a provider convenes an IDT meeting without a DADS representative present, the provider must send the documentation described in subsection (e) of this section to the designated DADS staff for the region in which the individual resides.(1) The documentation must be sent within five working days after the date of the IDT meeting.(2) After reviewing the IDT meeting documentation, the designated DADS staff may require the provider to take further action. Source Note: The provisions of this §279.83 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.83 Interdisciplinary Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205353 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205353 03/12/2026 A provider must provide written notification to the case manager within seven days after becoming aware of a change in an individual's surroundings. Examples of a change include:(1) a change of address; and(2) a change in household composition. Source Note: The provisions of this §279.95 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.95 Changes in an Individual's Surroundings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205354 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205354 03/12/2026 (a) Required notification. A provider must provide written notification to the case manager if:(1) an individual complains of pain;(2) an individual requests that services end;(3) an individual is temporarily admitted to an institution;(4) an individual abuses the service by activating:(A) four false alarms within a six-month period that result in a response by the fire department, police, sheriff, or ambulance; or(B) 20 false alarms of any kind within a six-month period;(5) a provider makes three unsuccessful attempts for three consecutive months to contact an individual for a monthly system check;(6) an individual or someone in an individual's home engages in illegal discrimination against a provider staff or DADS employee; or(7) an individual or someone in an individual's home exhibits reckless behavior, which may result in imminent danger to the health and safety of the individual, provider staff, or another person. If this occurs, the provider must immediately notify:(A) the Department of Family and Protective Services or other appropriate protective services agency;(B) local law enforcement, if appropriate; and(C) the case manager.(b) Method and due date. A provider must notify the case manager orally or by fax no later than one working day after becoming aware of a circumstance detailed in subsection (a) of this section. If the provider's first notification is oral, the provider must send written notification to the case manager within five working days of the oral notification. Written notification must include:(1) the date the provider became aware of a circumstance detailed in subsection (a) of this section; and(2) the reason for the written notification.(c) Allowed payment. A provider may continue to receive payment when the provider is unable to conduct a monthly system check for the reasons outlined in subsection (a) of this section for three consecutive months. In order to receive payment, the provider must:(1) comply with the requirements of §52.407(b) of this chapter (relating to System Checks); and(2) convene an IDT meeting, as described in §52.413 of this chapter (relating to Interdisciplinary Team) to address subsection (a)(5) and (6) of this section. Source Note: The provisions of this §279.97 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.97 Required Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205355 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205355 03/12/2026 (a) Required suspensions. A provider must suspend services to an individual if the individual:(1) permanently leaves the state or moves to a county where the provider does not contract with DADS to provide ERS;(2) permanently moves to a location where ERS cannot be provided, such as an assisted living facility;(3) dies;(4) is admitted to an institution for more than 120 consecutive days; or(5) is no longer mentally alert enough to operate the equipment properly.(b) Notification. A provider must notify the case manager orally or by fax no later than one working day after suspending services. If a provider's notification is oral, the provider must send written notification to the case manager within five working days after the oral notification. Written notification must include:(1) the date services were suspended; and(2) the reason services were suspended.(c) Payment. DADS does not pay a provider after the month in which services were suspended. Source Note: The provisions of this §279.99 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.99 Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205356 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205356 03/12/2026 (a) If DADS terminates ERS, a provider may be paid for the last month of service, regardless of how many days of service were provided that month, if:(1) the provider has already conducted a system check that month before the termination of services;(2) the provider conducted a system check on the day it picked up the equipment; or(3) the provider could not complete a system check because:(A) the individual's telephone was disconnected;(B) the individual damaged the equipment;(C) the equipment was picked up at a location other than the individual's home; or(D) the individual changed his telephone number or address without allowing the provider to remove the equipment from the individual's home.(b) The provider must:(1) document the results of the final system check; or(2) document the reason the provider was unable to complete a system check. Source Note: The provisions of this §279.101 adopted to be effective March 1, 2006, 31 TexReg 1307; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES D SERVICE DELIVERY §279.101 Termination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205357 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205357 03/12/2026 Individual's file. A provider must maintain the following information for each individual:(1) the individual's name, telephone number, address, and medical condition;(2) the name and telephone number of each responder;(3) a record of all completed and attempted system checks;(4) a record of each alarm call;(5) a copy of all required notices sent to the case manager;(6) a signed release for forcible entry;(7) acknowledgement that the equipment belongs to the provider;(8) if applicable, documentation showing approval for the continuation of service delivery; and(9) if applicable, documentation showing that service delivery is suspended. Source Note: The provisions of this §279.151 adopted to be effective March 1, 2006, 31 TexReg 1307; amended to be effective September 1, 2014, 39 TexReg 6672; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES E CLAIMS PAYMENT AND DOCUMENTATION §279.151 Record Keeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205358 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205358 03/12/2026 (a) Unit rate ceiling. A provider must agree to accept and DADS pays only the unit rate ceiling established by the Health and Human Services Commission.(b) Documentation. The provider must maintain the documentation described in this chapter to be eligible for payment. Source Note: The provisions of this §279.153 adopted to be effective March 1, 2006, 31 TexReg 1307; amended to be effective September 1, 2014, 39 TexReg 6672; transferred effective July 1, 2021, as published in the June 11, 2021 issue of the Texas Register, 46 TexReg 3617. 1 HEALTH AND HUMAN SERVICES COMMISSION 279 CONTRACTING TO PROVIDE EMERGENCY RESPONSE SERVICES E CLAIMS PAYMENT AND DOCUMENTATION §279.153 Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204270 03/12/2026 (a) This chapter implements Texas Government Code, Chapter 541, which authorizes the Texas Health and Human Services Commission (HHSC) to establish a pediatric tele-connectivity resource program for rural Texas by awarding grants to support nonurban health care facilities in establishing the capability to provide pediatric telemedicine services.(b) The Pediatric Tele-Connectivity Resource Program for Rural Texas will continue until all appropriations are expended. Source Note: The provisions of this §280.1 adopted to be effective March 15, 2021, 46 TexReg 1645. 1 HEALTH AND HUMAN SERVICES COMMISSION 280 PEDIATRIC TELECONNECTIVITY RESOURCE PROGRAM FOR RURAL TEXAS §280.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204271 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Grant Program--The Pediatric Tele-Connectivity Resource Program for Rural Texas.(2) Grant recipient--A nonurban health care facility awarded a grant under this chapter.(3) HHSC--The Texas Health and Human Services Commission.(4) Nonurban health care facility--As defined by Texas Government Code §541.001(1).(5) Pediatric tele-specialty provider--As defined by Texas Government Code §541.001(4).(6) Telemedicine medical services--As defined by Texas Government Code §541.001(7). Source Note: The provisions of this §280.3 adopted to be effective March 15, 2021, 46 TexReg 1645. 1 HEALTH AND HUMAN SERVICES COMMISSION 280 PEDIATRIC TELECONNECTIVITY RESOURCE PROGRAM FOR RURAL TEXAS §280.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204272 03/12/2026 (a) Use of grant funds. A grant recipient uses grant funds awarded under this chapter:(1) to purchase equipment necessary for implementing telemedicine medical services;(2) to modernize the facility's information technology infrastructure and secure information technology support to ensure an uninterrupted two-way video signal that is compliant with the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191), as referenced in Texas Government Code, §541.003;(3) to pay a contracted pediatric tele-specialty provider for telemedicine medical services; or(4) to pay for other activities, services, supplies, facilities, resources, and equipment that HHSC determines necessary for the grant recipient to use telemedicine medical services.(b) Role of HHSC. HHSC will administer funding in the form of grants to an eligible nonurban health care facility.(c) Grant eligibility requirements. To be eligible for a grant under this chapter, a nonurban health care facility must:(1) have a quality assurance program that measures the compliance of the facility's health care providers with the facility's medical protocols;(2) have at least one full-time equivalent physician, on staff, who has training and experience in pediatrics and one person who is responsible for ongoing nursery and neonatal support and care;(3) have a designated neonatal intensive care unit or an emergency department;(4) have a commitment to obtaining neonatal or pediatric education from a tertiary facility to expand the facility's depth and breadth of telemedicine medical service capabilities; and(5) have the capability of maintaining records and producing reports that measure the effectiveness of a grant received by the facility under this chapter.(d) Role of the stakeholder workgroup. HHSC may establish a stakeholder workgroup to assist HHSC:(1) in developing, implementing, and evaluating the Grant Program; and(2) in preparing a report on the results and outcomes of the grants awarded under this chapter.(e) Stakeholder workgroup member compensation. A stakeholder workgroup member is not entitled to any form of compensation for serving on the workgroup and may not be reimbursed for travel or other expenses incurred while conducting the business of the workgroup.(f) Compliance. A grant recipient must comply with:(1) the requirements described in this chapter; and(2) all other applicable state and federal laws, rules, regulations, policies, and guidelines.(g) Program evaluation. HHSC evaluates the use of grant funds based on criteria as defined by HHSC.(h) Grant funding distribution. HHSC distributes funding on a schedule defined by HHSC.(i) Reporting responsibilities and protocol. No later than December 1 of each even-numbered year, HHSC reports the results and outcomes of grants awarded under this chapter to the Governor and members of the Legislature. The report is comprised of information provided by the grant recipient as defined by HHSC.(j) Audits. A grant recipient is subject to audit and recovery of grant funds by the HHSC Office of the Inspector General, as provided in 1 TAC, §371.11 (relating to Scope). Source Note: The provisions of this §280.5 adopted to be effective March 15, 2021, 46 TexReg 1645. 1 HEALTH AND HUMAN SERVICES COMMISSION 280 PEDIATRIC TELECONNECTIVITY RESOURCE PROGRAM FOR RURAL TEXAS §280.5 Grant Program Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219028 03/12/2026 This chapter establishes the requirements for provider agencies providing home-delivered meals to eligible adults through the Texas Department of Human Services' Home-Delivered Meals Program. Source Note: The provisions of this §281.1 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219029 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Adult--A person who is 18 years old or older or is an emancipated minor.(2) Case manager--A DADS employee who is responsible for case management activities. Activities include eligibility determination, registration, assessment and reassessment of need, service plan development, and intervention on an individual's behalf.(3) Client--An individual.(4) Contract--The formal, written agreement between DADS and a provider agency to provide services in the HDM Program.(5) Contract manager--A DADS employee who is responsible for the overall management of the contract with the provider agency.(6) DADS--The Department of Aging and Disability Services.(7) Dietary consultant--A dietitian who is licensed by the Texas State Board of Examiners of Dietitians; or a person with a baccalaureate degree with major studies in food and nutrition, dietetics, or food service management.(8) Director--The person who is responsible for the overall operation of a provider agency.(9) Emancipated minor--A person who is under 18 years of age who has achieved or been granted the power and legal capacity of an adult. This includes a minor who has had the disabilities of minority removed by a court of law, or a minor who has been married, with or without parental consent.(10) Food service supervisor--The person who is responsible for supervising and managing the food preparation operations of a provider agency.(11) Home-Delivered Meals (HDM) Program--A program serving individuals receiving Community Based Alternatives Medicaid waiver services funded by Title XIX of the Social Security Act or individuals receiving Community Care Aged and Disabled services funded by Title XX of the Social Security Act and administered by DADS in which a provider agency delivers meals to an individual.(12) Individual--A person eligible to receive services under this chapter.(13) Meal transport carrier--A container that is used by the provider agency to transport home-delivered meals that may be easily damaged. The container must be enclosed and either insulated or equipped to maintain food temperature to protect the meals from contamination, crushing, or spillage.(14) Provider agency--An organization or entity that delivers meals to an individual in accordance with the contract and this chapter.(15) Suspension of services--A temporary cessation of HDM services by a program provider or DADS without loss of program or Medicaid eligibility.(16) Termination--A DADS action that ends an individual's service authorization for the HDM Program.(17) Therapeutic medical diet--A menu supplied to an individual by a provider agency that includes:(A) meals prepared without the addition of salt, seasoning, or flavoring; or(B) meals that may deviate from the standard menu pattern as required by the individual's medical condition.(18) Working day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b). Source Note: The provisions of this §281.3 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective June 12, 2014, 39 TexReg 4657; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219030 03/12/2026 (a) A provider agency must comply with Chapter 49 of this title (relating to Contracting for Community Services).(b) A provider agency and its subcontractors must comply with reporting requirements for the USDA incentive program.(1) The reporting requirements of the USDA incentive program are provided annually through a DADS memo to contracted agencies.(2) A provider agency must maintain documentation of all eligible meals delivered under the USDA incentive program according to the terms of the contract.(3) This subsection does not apply to Title XIX (Medicaid) funded home-delivered meals contracts.(c) A provider agency that wants to contract with DADS to provide home-delivered meals must agree to provide services:(1) for a specific number of service days, with a minimum of five meals per week;(2) within specific geographic service areas established in the contract;(3) to all eligible clients in a service area unless services are suspended or unless the provider agency is unable to provide a certain therapeutic medical diet; and(4) for the reimbursement rate that DADS negotiates with the provider agency on an annual basis. This negotiated rate must be within the DADS unit rate ceiling then in effect. Source Note: The provisions of this §281.5 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective September 1, 2014, 39 TexReg 6672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.5 Contracting Requirements for Provider Agencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219031 03/12/2026 (a) A provider agency must use the services of a dietary consultant who is:(1) a dietitian licensed by the Texas State Board of Examiners of Dietitians; or(2) has a baccalaureate degree whose major field of study is in food and nutrition, dietetics, or food service management.(b) A provider agency must also employ a director who:(1) is a high school graduate, or who has passed a general education development (GED) examination, and has at least one year of experience working in an organization providing social services to individuals; or(2) has two years of college or university credit.(c) All employees or volunteers of a provider agency who are under 18 years of age must be supervised by an employee or volunteer who is at least 18 years of age, and must receive the required training as described in §55.9 of this chapter (relating to Training Requirements).(d) A provider agency must maintain documentation to show that staff and volunteers meet requirements outlined in subsections (a) - (c) of this section, according to the terms of the contract. Source Note: The provisions of this §281.7 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.7 Staff Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219032 03/12/2026 (a) A provider agency must provide and document at least one hour of training initially to all staff, including volunteers, who come in contact with clients by serving and/or delivering meals before the staff or volunteers assume duties. The training must be provided in person or in a written document approved by the contract manager. Training topics must include:(1) client confidentiality;(2) procedures used in handling emergency situations involving clients;(3) sanitary methods used in serving and delivering meals;(4) general knowledge and basic techniques of working with the aged and individuals with disabilities; and(5) personal hygiene.(b) A provider agency must provide at least two hours of training to staff and volunteers who come in contact with clients other than through serving or delivering meals before they assume duties. Training topics must include:(1) client confidentiality;(2) procedures used in handling emergency situations involving clients;(3) general knowledge and basic techniques of working with the aged and individuals with disabilities; and(4) orientation on applicable Texas Department of Human Services and provider agency forms, procedures, and policies.(c) A provider agency must provide at least two hours of training to the food service supervisor before the supervisor assumes duties. Training for the supervisor must include:(1) personal hygiene;(2) food storage, preparation, and service;(3) equipment cleaning before, during, and after meal service;(4) selections of proper utensils and equipment for transporting and serving foods;(5) automatic and manual dishwashing procedures; and(6) accident prevention.(d) A provider agency must provide the food service supervisor with at least six hours of additional training to be completed no later than 30 days from the assumption of duties. This additional training may be waived if the food service supervisor can produce documentation of at least six hours of prior training or experience in the required topics. The provider agency must provide training on any of the topics not previously received. Training for the food service supervisor on food preparation topics must include:(1) practical procedures for food preparation, storage, and serving;(2) portion control of food in appropriate dishes;(3) use of standardized recipes;(4) nutritional needs and meal pattern requirements of clients to be served; and(5) quality control of:(A) flavor;(B) consistency;(C) texture;(D) temperature; and(E) appearance (including the use of garnishes).(e) Documentation of training must include name of attendee, trainer, topics covered, date, time, and duration and must be maintained according to the terms of the contract. Source Note: The provisions of this §281.9 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.9 Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219033 03/12/2026 A provider agency must provide nutrition education on a monthly basis, either verbally or in writing, to clients. An annual written plan for nutrition education must be developed, identifying subject matter, method of presentation, materials used, and source of the information presented. This plan must be maintained according to the terms of the contract. Source Note: The provisions of this §281.11 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.11 Nutrition Education https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219034 03/12/2026 (a) A provider agency must follow procedures and maintain facilities that comply with all applicable state and local laws and regulations related to fire, health, sanitation, and safety; and food preparation, handling, and service activities.(b) A provider agency must provide a copy of all required inspection results to the contract manager within five calendar days of the provider agency's receipt of the results. Source Note: The provisions of this §281.13 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.13 Compliance with Laws and Regulations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219035 03/12/2026 (a) A dietary consultant must approve each menu with a list of allowable substitutions as meeting one-third of the recommended daily dietary allowance. The approval must be dated before the date the meal is served. A provider agency may not deviate from the approved menu and its allowable substitutions, unless the provider agency is providing a therapeutic medical diet.(b) Planned menus must provide foods with a variety of flavor, consistency, texture, and temperature.(c) A provider agency must maintain approved menus that meet the terms of the contract. Source Note: The provisions of this §281.15 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.15 Menus https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219036 03/12/2026 (a) A provider agency must plan and manage food production through the use of standardized recipes. These menus must be adjusted to yield the number of servings needed, provide consistency in quality of the food prepared, and maintain documented nutrient content of the food prepared.(b) A provider agency must keep documentation to show it has complied with the requirements for recipes, according to the terms of the contract. Source Note: The provisions of this §281.17 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.17 Standard Recipes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219037 03/12/2026 (a) A provider agency must keep documentation from the client's physician of the client's need for a therapeutic medical diet, according to the terms of the contract.(b) A provider agency must determine the extent to which the provider agency can provide therapeutic medical diets. Source Note: The provisions of this §281.19 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.19 Modified Diets https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219038 03/12/2026 A provider agency may use frozen, chilled, or shelf-stable meals for emergency or inclement weather situations, emergency situations, and for situations approved by the contract manager on a case-by-case basis, if the following conditions exist:(1) Sanitary and safe conditions for storage, thawing, and preparation of the meal can be provided by the provider agency and the client.(2) Meals can be safely handled by the client, or by another available person if the client is unable to do so. Source Note: The provisions of this §281.21 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.21 Frozen, Chilled, or Shelf-Stable Meals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219039 03/12/2026 (a) A provider agency must use supplies and meal transport carriers so that hot foods are packaged and transported separately from cold foods.(b) A provider agency must use meal transport carriers to transport trays or containers of hot or cold foods that may be easily damaged and must enclose the carriers to protect such food from contamination, crushing, or spillage. The provider agency must equip these carriers with insulation and/or supplemental hot or cold sources, as necessary to maintain safe temperatures.(c) Meal packaging must be:(1) sealed to prevent moisture loss or spillage to the outside of the container;(2) maintained at a safe temperature throughout transport;(3) designed with compartments to separate food items for visual appeal and minimize spillage between compartments; and(4) easy for the client to open. Source Note: The provisions of this §281.23 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.23 Meal Packaging https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219040 03/12/2026 (a) A provider agency must initiate services within 10 calendar days from the effective date of the Texas Department of Human Services (DHS) referral.(b) If a provider agency does not begin services within the 10-day period, it must notify the case manager, orally or by fax, by the 11th calendar day after the effective date of the DHS referral, or the first working day after the 11th calendar day. If the initial notification is oral, the provider agency must send written notification to the case manager within five working days of the initial verbal notification. The provider agency must include the reasons for the delay and the date services are scheduled to begin.(c) A provider agency must return to the case manager the Authorization for Community Care Services form for Title XX services, or the Case Information form for Title XIX services, within 21 calendar days from the date of the referral, with the following information:(1) the date services were initiated;(2) the number of meals to be provided per week; and(3) the scheduled days for delivering meals.(d) The provider agency must sign and date the form, return it to the case manager, and maintain a copy in the client's record, according to the terms of the contract. Source Note: The provisions of this §281.25 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.25 Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219041 03/12/2026 (a) A provider agency must deliver hot food within four hours of the time the hot food is removed from cooking or reheating equipment.(b) A provider agency must prepare and package meals so that delivery is made within the required delivery period of 10:30 a.m. to 1:30 p.m. or as approved by the contract manager on a case-by-case basis.(c) Food temperature of meals prepared and packaged for delivery at the preparation site must be below 41 degrees Fahrenheit for cold food items and above 140 degrees Fahrenheit for hot food items.(d) A provider agency must provide meals according to DADS service authorization form.(1) The provider agency must document each meal as being delivered or undelivered.(2) The provider agency must deliver the meal to the individual or responsible party.(A) If the individual or responsible party is not present to accept the meal, the provider agency must not leave the meal.(B) The provider agency must handle undelivered meals in accordance with its policy on undelivered meals.(C) The provider agency must document the meal as undelivered and document the reason it was unable to deliver the meal. Documentation must be maintained according to the terms of the contract. If there is no documentation available to support a reason acceptable to DADS for the meals being marked as undelivered, DADS considers this a break in service.(e) If an individual or responsible party is not home to accept delivery of a meal for two consecutive service days or for three nonconsecutive service days in a calendar month, the provider agency must notify the individual's case manager within one working day after the date of the last unsuccessful delivery.(1) The provider agency must notify the individual's case manager orally or by fax.(2) If the provider agency notifies the case manager orally, the provider agency must send written notification to the case manager within five working days of the initial notification. Source Note: The provisions of this §281.27 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective June 12, 2014, 39 TexReg 4657; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.27 Service Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219042 03/12/2026 (a) A provider agency must have written procedures in place to ensure it investigates and reports to the appropriate persons or entities any significant changes in the client's physical or mental condition or environment. These procedures must require the following:(1) The provider agency notifies a client's case manager, orally or by fax, within one working day after becoming aware of significant changes in the client's physical or mental condition or environment.(2) If the provider agency notifies the case manager orally, the provider agency must send written notification to the case manager within five working days of the initial verbal notification.(3) The provider agency retains the following in its files, according to the terms of the contract:(A) a copy of the written procedures;(B) reports of significant changes received;(C) investigations of reports; and(D) a copy of the written notification to the case manager.(b) A provider agency must inform the client about safety, health, or fire hazards identified in the client's home when the provider agency discovers these hazards. The provider agency must retain documentation of such communications in its files, according to the terms of the contract.(c) A provider agency must notify the Texas Department of Human Services (DHS) personnel listed in paragraph (2) of this subsection, orally or by fax, within one working day after an incident that may prevent the provider agency from delivering meals to one or more clients.(1) A reportable incident includes:(A) weather-related emergency;(B) fire; or(C) other natural disaster.(2) The provider agency must report an incident to:(A) the contract manager;(B) the clients' case manager(s) or supervisors; or(C) both the contract manager and the clients' case manager(s) or supervisors.(3) If the provider agency notifies the case manager orally, the provider agency must send written notification to the contract manager or case manager, or both, within five working days of the initial notification.(4) The provider agency must retain documentation, including the written notification, of an incident that may prevent meal delivery. Documentation must be retained in the files, according to the terms of the contract.(d) A provider agency must have written procedures to provide food to clients in emergencies and disasters. The provider agency must have a copy of the procedures in its files, according to the terms of the contract. Source Note: The provisions of this §281.29 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.29 Significant Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219043 03/12/2026 (a) A provider agency must give clients the opportunity to complete a customer satisfaction survey at least once every 12 months.(b) The provider agency must use the results from the completed customer satisfaction surveys to establish benchmarks and to make necessary improvements identified through the surveys.(c) The provider agency must conduct monitoring at the food preparation site at least annually to document holding times, safe food temperatures, and quality of meals. The provider agency must provide a copy of the food preparation site monitoring results to the contract manager within five working days of the monitoring visit.(d) The provider agency must document all quality control measures and retain them in provider agency files according to the terms of the contract. Source Note: The provisions of this §281.31 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.31 Provider Agency Quality Control Measures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219044 03/12/2026 (a) For Title XIX and Title XX services, a provider agency must suspend an individual's services if:(1) the individual leaves the state or moves out of the provider agency's geographic service area;(2) the individual dies;(3) the individual is admitted to a hospital, nursing facility, or institution;(4) the individual or someone in the individual's home threatens the health or safety of a person delivering meals;(5) the individual requests that services be suspended; or(6) the individual's case manager directs the provider agency to suspend the individual's services.(b) If a provider agency suspends Title XIX or Title XX services for a reason listed in subsection (a) of this section, the provider agency must notify the individual's case manager within one working day after the suspension of services.(1) The provider agency must notify the individual's case manager orally or by fax of the reason for the service suspension.(2) If the provider agency notifies the case manager orally, the provider agency must send written notification to the case manager within five working days after the date of the oral notification.(c) For Title XIX services, a provider agency may recommend to DADS that an individual's services be suspended and for Title XX services, a provider agency may suspend an individual's services if:(1) the individual or someone in the individual's home racially discriminates against the person delivering meals to the individual's home;(2) the individual or someone in the individual's home sexually harasses the person delivering meals to the individual's home; or(3) the individual or responsible party is not home to accept delivery of a meal for two consecutive service days or for three nonconsecutive service days in a calendar month.(d) If a provider agency recommends a suspension of Title XIX services for a reason listed in subsection (c) of this section, the provider agency must notify an individual's case manager as described in subsection (b)(1) and (2) of this section. DADS suspends services in accordance with Chapter 48, Subchapter J of this title (relating to Community-Based Alternatives (CBA) Program).(e) If a provider agency suspends Title XX services for a reason listed in subsection (c) of this section, the provider agency must notify an individual's case manager as described in subsection (b)(1) and (2) of this section. Source Note: The provisions of this §281.33 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective June 12, 2014, 39 TexReg 4657; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.33 Suspension of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219045 03/12/2026 A provider agency must implement service plan changes within seven calendar days from the effective date on the Authorization for Community Care Services form for Title XX services, or the Notification of Community Based Alternatives (CBA) Services form for Title XIX services. Source Note: The provisions of this §281.35 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.35 Service Plan Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219046 03/12/2026 (a) If DADS terminates HDM services to an individual, the individual's case manager sends the provider agency:(1) the Authorization for Community Care Services form for Title XX services; or(2) the Notification of Community Based Alternatives (CBA) Services form for Title XIX services.(b) A provider agency must not provide HDM services on or after the effective date stated on the form from the case manager described in subsection (a) of this section, unless DADS notifies the provider agency that HDM services may be provided. Source Note: The provisions of this §281.37 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective June 12, 2014, 39 TexReg 4657; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.37 Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219047 03/12/2026 A provider agency must maintain a record of names of employees and volunteers who deliver meals. Source Note: The provisions of this §281.39 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective September 1, 2014, 39 TexReg 6672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.39 Recordkeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219048 03/12/2026 (a) A provider agency must accept the contracted reimbursement rates as payment in full for the meals provided and seek no other reimbursements from any source, except as allowed by DADS.(b) For Title XX services, a provider agency:(1) must provide an individual with an opportunity to donate toward the cost of a meal;(2) must not require the individual to donate toward the cost of a meal;(3) may provide the individual with a donation schedule that only suggests an amount based on income range of the program population being served, but may not determine an individual's donation amount using an individual's income;(4) must protect the individual's privacy with respect to the individual's donations;(5) must establish appropriate procedures to secure and account for all donations made; and(6) must use all of an individual's donations to support or expand services for which the individual donated, in accordance with state and federal laws.(c) DADS may reimburse a provider agency for up to two failed deliveries per month per individual if:(1) a meal delivery is attempted;(2) the individual or responsible party is not home to accept it; and(3) the individual's services were not suspended or terminated by DADS or the provider agency on the dates of the two failed deliveries.(d) One unit of service is one meal per individual per contracted day. Source Note: The provisions of this §281.41 adopted to be effective March 1, 2004, 29 TexReg 1672; amended to be effective June 12, 2014, 39 TexReg 4657; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.41 Billing and Claims Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219049 03/12/2026 A provider agency must:(1) comply with the complaint procedures outlined under Chapter 49 of this title (relating to Contracting for Community Care Services); and(2) promptly contact the local health authorities to report complaints involving two or more persons with symptoms of food-borne illnesses that have occurred within a similar timeframe after consuming food from the provider agency, and request the local health authorities initiate an investigation of these complaints. The provider agency must report such complaints as detailed in Chapter 49 of this title. Source Note: The provisions of this §281.43 adopted to be effective March 1, 2004, 29 TexReg 1672; transferred effective June 28, 2024, as published in the June 7, 2024, issue of the Texas Register, 49 TexReg 4063. 1 HEALTH AND HUMAN SERVICES COMMISSION 281 CONTRACTING TO PROVIDE HOME-DELIVERED MEALS §281.43 Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221043 03/12/2026 This chapter establishes the requirements for provider agencies contracting to provide services to eligible clients through the Texas Department of Human Services (DHS) Special Services to Persons with Disabilities (SSPD) Program. Source Note: The provisions of this §282.1 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES A INTRODUCTION §282.1 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221044 03/12/2026 The following words and terms in this chapter have the following meanings, unless the context clearly indicates otherwise:(1) 24-Hour Shared Attendant Care--A clustered living arrangement that has attendant care available to clients on a 24-hour basis.(2) Adult day care facility--A facility licensed by the Texas Department of Human Services (DHS) Long Term Care Regulatory (LTCR) under the Human Resources Code, Chapter 103.(3) Attendant Care--Non-skilled services provided by an unlicensed person, which include personal care, housekeeping, supervision, meal preparation, and escort.(4) Client--A client, as defined in Chapter 48 of this title (relating to Community Care for Aged and Disabled), who is eligible to receive services under this chapter.(5) Community Care for Aged and Disabled (CCAD)--A group of DHS programs that provides a variety of state-funded and Title XIX-funded community-based services.(6) Contract--The formal, written agreement between DHS and a provider agency to provide services to DHS clients eligible under this chapter in exchange for reimbursement.(7) Contract manager--A DHS employee who is responsible for the overall management of the contract with the provider agency.(8) Days--Any reference to days means calendar days, unless otherwise specified in the text. Calendar days include weekends and holidays.(9) DHS--The Texas Department of Human Services.(10) Director--The provider agency employee who is responsible for the day-to-day operation of the agency.(11) Provider agency--An entity that contracts with DHS to provide Special Services to Persons with Disabilities (SSPD) services. Any reference to provider agency means the following, unless otherwise specified in the text:(A) a home and community support services agency licensed by DHS LTCR under the Health and Safety Code, Chapter 142;(B) an adult day care facility; or(C) any other legal entity described in the procedures developed in the DHS region where SSPD services are provided.(12) Special Services to Persons with Disabilities (SSPD)--A program for CCAD clients that is designed to assist clients in:(A) developing the skills needed to remain in the community as independently as possible; and(B) achieve habilitative or re-habilitative goals.(13) Staff--A provider agency employee or volunteer who provides direct care services to a client. Source Note: The provisions of this §282.3 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES A INTRODUCTION §282.3 What do certain words and terms in this chapter mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221045 03/12/2026 The provider agency must:(1) comply with Chapter 49 of this title (relating to Contracting for Community Services);(2) deliver services under the appropriate license for the setting in which the provider agency will deliver SSPD services; and(3) comply with the plan of operation, which is incorporated in the contract by reference. Source Note: The provisions of this §282.11 adopted to be effective April 1, 2004, 29 TexReg 2381; amended to be effective September 1, 2014, 39 TexReg 6673; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES B PROVIDER AGENCY CONTRACTS §282.11 What general contract requirements must the provider agency follow? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221046 03/12/2026 The provider agency may deliver services in the following settings:(1) 24-Hour Shared Attendant Care;(2) an adult day care facility; or(3) other settings approved by the contract manager. Source Note: The provisions of this §282.13 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES B PROVIDER AGENCY CONTRACTS §282.13 What are the settings in which the provider agency may deliver services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221047 03/12/2026 Any written information that DHS requires the provider agency to send to DHS must be sent by mail, fax, or hand-delivery. DHS does not accept e-mail delivery. Source Note: The provisions of this §282.15 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES B PROVIDER AGENCY CONTRACTS §282.15 How is written information sent to DHS? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221048 03/12/2026 Yes. The provider agency must develop a plan of operation. Source Note: The provisions of this §282.21 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.21 Must the provider agency develop a plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221049 03/12/2026 The provider agency's plan of operation must:(1) identify the services and tasks the provider agency provides under the contract;(2) state the hours of operation and the setting in which the services are provided;(3) specify the number and types of staff delivering the services;(4) state the qualifications and competencies of staff. The plan of operation must state how the provider agency will ensure that staff receive initial and ongoing training as described in Subchapter D of this chapter (relating to Staff Development);(5) describe the methods and procedures for determining client eligibility, if this is required by the procedures developed in the DHS region where services are delivered;(6) describe the services provided to eligible clients. The provider agency must offer the services required by the procedures developed in the DHS region where services are delivered;(7) describe the methods and procedures for providing services to clients; and(8) state the method for documenting the services that are delivered. Source Note: The provisions of this §282.23 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.23 What must the provider agency's plan of operation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221050 03/12/2026 The contract manager approves the provider agency's plan of operation. Source Note: The provisions of this §282.25 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.25 Who approves the provider agency's plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221051 03/12/2026 The provider agency must make a written request for approval of the plan of operation. Source Note: The provisions of this §282.27 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.27 How must the provider agency request approval of the plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221052 03/12/2026 The provider agency must request approval of the plan of operation:(1) to allow the approval to coincide with the effective date of the contract; and(2) before implementing a change made to an ongoing plan of operation. Source Note: The provisions of this §282.29 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.29 When must the provider agency request approval of the plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221053 03/12/2026 The provider agency must notify the contract manager no later than 30 days before the effective date of change desired by the provider agency. Source Note: The provisions of this §282.31 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.31 When must the provider agency notify the contract manager of a change made to the plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221054 03/12/2026 The provider agency must provide written notice to the contract manager. Source Note: The provisions of this §282.33 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.33 How must the provider agency notify the contract manager of a change to the plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221055 03/12/2026 The contract manager will provide written notice of approval or disapproval. Source Note: The provisions of this §282.35 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.35 How will the provider agency know that a change to the plan of operation has been approved? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221056 03/12/2026 The provider agency must implement a change to the plan of operation on the date the provider agency requests to implement the change in the plan of operation. This date cannot be before the date the contract manager provides written approval of the change. Source Note: The provisions of this §282.37 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES C PLAN OF OPERATION §282.37 When must the provider agency implement a change to the plan of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221057 03/12/2026 The provider agency must:(1) maintain a written plan for developing and enhancing the performance of staff responsible for providing the SSPD services; and(2) ensure that staff are trained and competent to provide services to clients according to the service plan. Source Note: The provisions of this §282.41 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.41 What are the provider agency's responsibilities for staff development? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221058 03/12/2026 The provider agency's written plan for staff development must include the:(1) schedule for training, including the length of time;(2) curriculum, including specific topics;(3) training objectives;(4) method of training; and(5) names of the instructors. Source Note: The provisions of this §282.43 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.43 What must the provider agency's written plan for staff development include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221059 03/12/2026 The provider agency must give all staff the following training during the first three months of employment:(1) three hours of training on the following topics:(A) orientation to community resources;(B) the provider agency's policies and procedures;(C) 29 United States Code §794 (relating to Nondiscrimination under Federal grants and programs); and(D) confidentiality of records; and(2) 21 hours of training on the following topics, which may be on-the-job training under the supervision of tenured staff and must include:(A) techniques of working with persons with disabilities to assist them in living as independently as possible; and(B) knowledge of the individual clients' conditions. Source Note: The provisions of this §282.45 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.45 What initial training must the provider agency give staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221060 03/12/2026 The contract manager may waive the additional 21 hours of training. Source Note: The provisions of this §282.47 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.47 Which training requirements may be waived? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221061 03/12/2026 The provider agency must make a written request for a waiver from the contract manager. Source Note: The provisions of this §282.49 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.49 How must the provider agency request a waiver for the additional 21 hours of training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221062 03/12/2026 The provider agency must request the waiver at least 30 days before a staff member requiring a waiver provides any services. Source Note: The provisions of this §282.51 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.51 When must the provider agency request a waiver for the additional 21 hours of training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221063 03/12/2026 The contract manager will send a written notice of approval or disapproval to the provider agency. Source Note: The provisions of this §282.53 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.53 How will the provider agency know if the waiver request is approved? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221064 03/12/2026 No. Source Note: The provisions of this §282.55 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.55 Can a staff member who requires a waiver provide any services before approval of the waiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221065 03/12/2026 The provider agency must include the following information for each staff member for whom it requests a waiver:(1) name;(2) job title;(3) specific education or experience that qualifies the staff member for the waiver; and(4) a statement that he or she is competent in providing services. Source Note: The provisions of this §282.57 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.57 What information must the provider agency include in the request for a waiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221066 03/12/2026 The provider agency must give direct care staff at least two hours of ongoing training every three months, after the first three months of employment. Source Note: The provisions of this §282.59 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.59 What ongoing training must the provider agency give staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221067 03/12/2026 The provider agency must include in-service training related to the direct services provided by staff in the ongoing training. Source Note: The provisions of this §282.61 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES D STAFF DEVELOPMENT §282.61 What must the provider agency include in the ongoing training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221068 03/12/2026 The provider agency must deliver services identified in:(1) the client's service plan; and(2) the provider agency's plan of operation. Source Note: The provisions of this §282.71 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES E SERVICE DELIVERY §282.71 What services must the provider agency deliver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221069 03/12/2026 The client's service plan is a document that contains the services, tasks, and frequency of services a particular client will receive. These services must be part of the provider agency's service array outline in the plan of operation. Source Note: The provisions of this §282.73 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES E SERVICE DELIVERY §282.73 What is the client's service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221070 03/12/2026 The provider agency must develop the service plan. Source Note: The provisions of this §282.75 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES E SERVICE DELIVERY §282.75 Who must develop the service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221071 03/12/2026 The provider agency must develop the service plan before services are initiated. Source Note: The provisions of this §282.77 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES E SERVICE DELIVERY §282.77 When must the provider agency develop the service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221072 03/12/2026 The provider agency must initiate services:(1) within 14 days after the referral date (Item 1) on the DHS Authorization for Community Care Services form; or(2) as required by the procedures developed in the DHS region where services are delivered. Source Note: The provisions of this §282.79 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES E SERVICE DELIVERY §282.79 When must the provider agency initiate services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221073 03/12/2026 (a) An emergency is an unforeseen circumstance or combination of circumstances involving a client that:(1) requires immediate action on the part of the provider agency; or(2) results in a client's urgent need for assistance or relief.(b) Emergencies are described in more detail in the procedures developed in the DHS region where services are delivered. Source Note: The provisions of this §282.91 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.91 What is considered an emergency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221074 03/12/2026 The provider agency must report any emergencies to:(1) the contract manager; and(2) any other persons or entities required by the procedures developed in the DHS region where services are delivered. Source Note: The provisions of this §282.93 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.93 Who must the provider agency notify of emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221075 03/12/2026 The provider agency must notify the required persons by the next working day after the emergency. A working day is a day DHS is open for business. Source Note: The provisions of this §282.95 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.95 When must the provider agency notify the required persons of emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221076 03/12/2026 (a) The provider agency must notify the required persons of emergencies orally or by fax.(1) Voice mail is not considered oral notification.(2) The provider agency must notify other staff designated by the contract manager if the contract manager is not available.(b) If the provider agency's first notification is oral, the provider agency must send written notification to the required persons by the seventh day after the initial notification. Source Note: The provisions of this §282.97 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.97 How must the provider agency notify the required persons of emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221077 03/12/2026 The provider agency must give the following information to the required persons in the notice of emergencies:(1) the date of the emergency;(2) a description of the emergency;(3) how the emergency was handled; and(4) the outcome or resolution of the emergency. Source Note: The provisions of this §282.99 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.99 What information must the provider agency give to the required persons in the notice of emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221034 03/12/2026 The provider agency must maintain documentation of emergencies in the client file. Source Note: The provisions of this §282.101 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.101 Where must the provider agency maintain documentation of emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221035 03/12/2026 The provider agency must maintain the following documentation of emergencies:(1) the type of the emergency;(2) the name of the person or entity or both notified of the emergency;(3) the date the notice was given;(4) the method of notice; and(5) the information described in §58.99 of this chapter (relating to What information must the provider agency give to the required persons in the notice of emergencies?). Source Note: The provisions of this §282.103 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES F EMERGENCIES §282.103 What documentation of emergencies must the provider agency maintain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221036 03/12/2026 The provider agency must:(1) be licensed by DHS as a home and community support services agency as described in Chapter 97 of this title (relating to Licensing Standards for Home and Community Support Services Agencies);(2) deliver services in the SSPD Program under the Personal Assistance Services or Licensed Home Health categories of licensure;(3) arrange for each residence to have a telephone or an emergency response device for requesting assistance in emergency situations and for requesting assistance with activities of daily living;(4) have a written emergency assistance and evacuation plan for each residence. The local fire marshal must approve the evacuation plan;(5) train all clients in the emergency procedures and evacuation plan within three days from the date of service initiation. The provider agency must document in each client file that the client received the training;(6) ensure that at least one employee, certified in the following courses, is on the premises during the hours services are provided:(A) United States Department of Labor, Occupational Health and Safety Administration (OSHA) or equivalent first aid and personal safety; and(B) basic life-support and cardiopulmonary resuscitation; and(7) ensure that there are current physician's orders in accordance with applicable law if the attendant(s) provides delegated medical or nursing tasks. The provider agency must maintain a copy of all physician's orders in the client file. Source Note: The provisions of this §282.111 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES G ADDITIONAL REQUIREMENTS FOR 24-HOUR SHARED ATTENDANT CARE §282.111 What are the additional requirements for provider agencies delivering services in a 24-Hour Shared Attendant Care setting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221037 03/12/2026 In addition to the requirements described in §58.45 of this chapter (relating to What initial training must the provider agency give staff?), the 24-Hour Shared Attendant Care provider agency must train staff on the following within three days of employment:(1) fire, health, and safety laws; and(2) the provider agency's plan for emergency evacuation. Source Note: The provisions of this §282.113 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES G ADDITIONAL REQUIREMENTS FOR 24-HOUR SHARED ATTENDANT CARE §282.113 What are the additional initial training requirements for provider agencies delivering services in a 24-Hour Shared Attendant Care setting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221038 03/12/2026 The provider agency must obtain physician's orders on tasks as required by the provider agency's license. Source Note: The provisions of this §282.115 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES G ADDITIONAL REQUIREMENTS FOR 24-HOUR SHARED ATTENDANT CARE §282.115 Which tasks in 24-Hour Shared Attendant Care require physician's orders? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221039 03/12/2026 The provider agency must:(1) be licensed by DHS as an adult day care facility as described in Chapter 98 of this title (relating to Adult Day Care and Day Activity and Health Services Requirements);(2) ensure the director or the director's designee is at the facility during the hours of operation and when clients are present;(3) train clients in emergency procedures and the evacuation plan within three calendar days from the date of service initiation;(4) post a monthly schedule of program activities in plain view at least one week in advance of the effective date of the schedule; and(5) have enough materials for all clients to participate in program activities. Source Note: The provisions of this §282.121 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES H ADDITIONAL REQUIREMENTS FOR SERVICES PROVIDED IN AN ADULT DAY CARE FACILITY §282.121 What are the additional requirements for provider agencies delivering services in an adult day care facility setting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221040 03/12/2026 In addition to the requirements described in §58.45 of this chapter (relating to What initial training must the provider agency give staff?), the adult day care provider agency must train staff on the following within three days of employment:(1) fire, health, and safety laws; and(2) the provider agency's plan for emergency evacuation. Source Note: The provisions of this §282.123 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES H ADDITIONAL REQUIREMENTS FOR SERVICES PROVIDED IN AN ADULT DAY CARE FACILITY §282.123 What are the additional initial training requirements for provider agencies delivering services in an adult day care facility setting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221041 03/12/2026 The provider agency must maintain service delivery documentation that contains:(1) the name of the person delivering the services;(2) the client's name;(3) the client's Medicaid number;(4) the specific coverage period, including month, day, and year, as applicable;(5) the tasks assigned;(6) the units of service delivered;(7) the dates of service delivery; and(8) certification that the documented services were delivered. Source Note: The provisions of this §282.133 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES I CLAIMS PAYMENT AND DOCUMENTATION REQUIREMENTS §282.133 What are the service delivery documentation requirements for the SSPD Program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221042 03/12/2026 (a) For electronic service delivery documentation systems, each person delivering services inputs a unique identifier to certify the services delivered.(b) For paper service delivery documentation systems, each person delivering services signs the timesheet to certify the services delivered.(1) The person must sign his or her name or a mark representing his or her name on the timesheet to certify that it is correct. Initials are not an acceptable substitute for a signature.(2) A person delivering the services who is unable to sign the timesheet may designate another person to sign the timesheet. The provider agency must maintain written documentation of the:(A) reason the person delivering the services is unable to sign the timesheet; and(B) identity of the person authorized to sign the timesheet on behalf of the person delivering the services. Source Note: The provisions of this §282.135 adopted to be effective April 1, 2004, 29 TexReg 2381; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7641. 1 HEALTH AND HUMAN SERVICES COMMISSION 282 CONTRACTING TO PROVIDE SPECIAL SERVICES TO PERSONS WITH DISABILITIES I CLAIMS PAYMENT AND DOCUMENTATION REQUIREMENTS §282.135 How do persons delivering services certify that they delivered the documented services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221249 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221249 03/12/2026 (a) This chapter implements the determination, assessment, collection, and enforcement of the quality assurance fee authorized under Chapter 252, Health and Safety Code, Subchapter H.(b) The purpose of the quality assurance fee established under this chapter is to improve the quality of care provided to persons with mental retardation as follows:(1) the quality assurance fee is intended to support and/or maintain an increase in reimbursement to facilities that participate in the Medicaid program, subject to legislative appropriation for this purpose; and(2) the Department of Aging and Disability Services (DADS) may also offset allowable expenses to administer the quality assurance fee program against revenues generated by the collection of the quality assurance fee. Source Note: The provisions of this §283.1 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.1 Purpose of Chapter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221250 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221250 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) DADS--The Department of Aging and Disability Services.(2) Facility--Any of the following:(A) an intermediate care facility for the mentally retarded or the corporate parent of an intermediate care facility for the mentally retarded licensed under Chapter 252, Health and Safety Code; or(B) a facility operated according to the requirements of Chapter 252, Health and Safety Code, and owned and/or operated by a community mental health and mental retardation center as described in Chapter 534, Subchapter A, Health and Safety Code; or(C) a facility owned by DADS.(3) Total gross receipts--Money paid to a facility for services provided to residents, including daily rate claims, applied income, payments from private-pay residents, and bed-hold revenue. Effective September 1, 2009, the term does not include payments for durable medical equipment.(4) Total patient days--The sum of the total number of residents for which a facility receives payment for services from DADS or another source on behalf of a resident on each day of the month. Source Note: The provisions of this §283.3 adopted to be effective March 1, 2010, 35 TexReg 873; amended to be effective October 11, 2011, 36 TexReg 6771; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221251 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221251 03/12/2026 (a) Quality assurance fee. Effective January 1, 2008, the quality assurance fee for a facility is five and one-half percent of a facility owner's total gross receipts.(b) Quality assurance fee review. Every twelve months or on a schedule determined by DADS, DADS will review each facility owner's quality assurance fee payments from all of the owner's facilities combined. A facility owner's liability for the quality assurance fee may be adjusted following this review to ensure that the quality assurance fee equals five and one half percent of total gross receipts from all facilities. Source Note: The provisions of this §283.5 adopted to be effective March 1, 2010, 35 TexReg 873; amended to be effective October 11, 2011, 36 TexReg 6771; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.5 Quality Assurance Fee Determination Methodology https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221252 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221252 03/12/2026 (a) The following reports must be filed by a facility in accordance with DADS instructions:(1) the monthly patient day report required under subsection (c) of this section; and(2) the report of total gross receipts required under subsection (d) of this section.(b) Amended reports.(1) A facility may amend a report required under subsection (c) or (d) of this section.(2) An amended monthly patient day report must be filed no later than 20 calendar days after the last day of the month for which the report was filed.(3) An amended report of gross receipts must be filed no later than 10 calendar days after the filing of the report required under subsection (d) of this section.(c) Monthly patient day report.(1) A facility must report, not later than the 10th calendar day after the last day of a month, the total number of patient days for the facility during the preceding month.(2) A facility must file the report required by this subsection on forms or in the format and according to the instructions prescribed by DADS.(d) Reporting of gross receipts.(1) A facility must report, no later than October 31 of each year, money paid to the facility by private-pay residents and bed-hold revenue for the period of September 1 through August 31 immediately preceding the report. Notwithstanding the previous sentence, DADS may change a reporting period and reporting date if the percent of total gross receipts to be paid as QAF changes during a reporting period. DADS notifies a provider in writing if DADS changes a reporting period or reporting date in accordance with this subsection. DADS uses the amounts on file with the Claims Management System for daily rate claims and applied income, and the amounts reported by the facility for private-pay payments and bed-hold revenue to determine the total gross receipts.(2) A facility must file the report required by this subsection on forms or in the format and according to the instructions prescribed by DADS. Source Note: The provisions of this §283.7 adopted to be effective March 1, 2010, 35 TexReg 873; amended to be effective October 11, 2011, 36 TexReg 6771; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.7 Required Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221253 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221253 03/12/2026 (a) A facility must:(1) pay the amount of the quality assurance fee in accordance with DADS instructions not later than the 30th day after the last day of the month for which the fee is assessed; or(2) pay the amount of the quality assurance fee in accordance with DADS instructions and request an informal review of the calculation of the quality assurance fee in accordance with §11.8 of this chapter (relating to Informal Review).(b) DADS may review the calculation of the quality assurance fee to ensure its accuracy and instruct the facility to correct its calculation and payment. Source Note: The provisions of this §283.9 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.9 Payment and Collection of Quality Assurance Fee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221254 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221254 03/12/2026 (a) DADS monitors a facility's records or the record of any corporate parent or affiliate of a facility for the purpose of determining the total patient days and gross receipts of the facility.(b) The Health and Human Services Commission (HHSC) and DADS may not grant any exceptions from the quality assurance fee or the provision of any data necessary for DADS to calculate the fee.(c) HHSC or its designee audits quality assurance fee determinations in accordance with this subsection.(1) HHSC or its designee periodically audits the records of a facility and, if necessary, the corporate parent or affiliate of a facility to verify the amount of the quality assurance fee owned by the facility. The facility must allow HHSC or its designee to review and photocopy any records necessary to conduct the audit.(2) If a facility fails to maintain records or fails to allow HHSC or its designee to review and photocopy any records necessary to conduct an audit, an audit will be conducted with the records available.(3) HHSC or its designee provides the facility with a report of the final audit findings.(4) If the final audit findings show the facility owes additional amounts for the quality assurance fee, DADS notifies the facility of the amount due. If the final audit findings show the facility is owed money due to overpayment of the quality assurance fee, DADS refunds the amount owed to the facility owner. Source Note: The provisions of this §283.11 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.11 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221255 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221255 03/12/2026 (a) DADS will assess a financial penalty against a facility that:(1) fails to timely file the monthly facility report required under §11.4 of this chapter (relating to Required Reports);(2) files a false, erroneous, or fraudulent monthly facility report that DADS concludes resulted in the assessment of a quality assurance fee that is less than the facility should have been assessed; or(3) fails to timely pay a quality assurance fee assessed under §11.5 of this chapter (relating to Payment and Collection of Quality Assurance Fee).(b) A penalty assessed under this section is an amount equal to one-fourth the amount of the quality assurance fee for each month the quality assurance fee is late, not reported or unpaid.(c) DADS will notify a facility in writing of the assessment of a penalty under this section and the amount of the penalty.(d) DADS may make a referral to an appropriate authority in cases where it makes a good faith determination that a facility has:(1) committed fraud in the submission of information to DADS;(2) willfully submitted erroneous information to DADS; or(3) violated a requirement of its license or Medicaid certification.(e) DADS may suspend payments to a facility that fails to pay or report the quality assurance fee.(f) The assessment of a penalty under this section does not relieve a facility from:(1) providing services to residents in accordance with its obligations under contract or the law;(2) paying additional quality assurance fees that may be assessed to the facility; or(3) otherwise complying with licensure and certification requirements. Source Note: The provisions of this §283.13 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.13 Penalty https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221256 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221256 03/12/2026 (a) A facility that believes DADS incorrectly calculated the amount of a quality assurance fee as defined in this chapter may request an informal review from DADS in accordance with this section.(b) The purpose of an informal review is to provide for the informal and efficient resolution of the matters in dispute. An informal review is not a formal administrative hearing, but is a prerequisite to obtaining a formal administrative hearing and is conducted according to the following procedures:(1) The facility must request an informal review in writing to DADS, delivered by United States mail or special mail delivery to DADS no later than 20 calendar days after the date on the written notification of a calculation described in subsection (a) of this section.(2) A facility's written request for an informal review must include:(A) a concise statement of the specific actions or determinations the facility disputes;(B) the facility's recommended resolution; and(C) any supporting documentation the facility deems relevant to the dispute. It is the responsibility of facility to submit all pertinent information at the time of its request for an informal review.(c) On receipt of a request for informal review, DADS assigns the review to appropriate staff.(1) DADS coordinates a review by appropriate staff of the information submitted by the facility.(2) DADS may request additional information from the facility, which the facility must submit in writing to DADS within 14 calendar days after the request for additional information. Information received after 14 days may not be used in DADS written decision unless the interested party receives approval from DADS to submit the information after 14 days.(d) Within 30 days after the date the request for informal review is received by DADS or the date additional requested information is received by DADS, DADS sends the facility its written decision by certified mail, return receipt requested. Source Note: The provisions of this §283.15 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.15 Informal Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221257 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221257 03/12/2026 A facility that wishes to appeal an informal review decision under §11.8 of this chapter (relating to Informal Review) may request a hearing from the Health and Human Services Commission in accordance with Title 1, Part 15, Chapter 357, Subchapter I of the Texas Administrative Code (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §283.17 adopted to be effective March 1, 2010, 35 TexReg 873; transferred effective November 15, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8476. 1 HEALTH AND HUMAN SERVICES COMMISSION 283 QUALITY ASSURANCE FEE §283.17 Appeal of an Informal Review Decision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215388 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215388 03/12/2026 (a) The purpose of this chapter is to implement Texas Government Code §531.02448.(b) The rules in this chapter must be read in conjunction with the rules and policies related to the Medicaid programs listed in §284.103 of this chapter (relating to Applicability) in which an individual is enrolled. Source Note: The provisions of this §284.101 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215389 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215389 03/12/2026 This chapter applies to an individual receiving services under the following Medicaid programs authorized by Section 1915(c) or Section 1115 of the Social Security Act:(1) the Home and Community-based Services (HCS) Program;(2) the Texas Home Living (TxHmL) Program;(3) the Deaf Blind with Multiple Disabilities (DBMD) Program;(4) the Community Living Assistance and Support Services (CLASS) Program; and(5) the STAR+PLUS Home and Community-Based Services program. Source Note: The provisions of this §284.103 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.103 Applicability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215392 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215392 03/12/2026 (a) An individual's service planning team must determine during the person-centered planning process whether an individual desires to work and if so, the individual's case manager or service coordinator must:(1) document the individual's desire to work on the individual's person-centered service plan; and(2) complete the HHSC Employment First Discovery Tool available on the HHSC website to determine:(A) the individual's employment goals; and(B) the employment opportunities and employment services available to the individual through the program in which the individual is enrolled.(b) An individual's service planning team must use the individual's employment goals, employment opportunities, and the employment services chosen by the individual to develop the individual's person-centered service plan.(c) An individual's case manager or service coordinator must ensure that the requirements in subsections (a) and (b) of this section are followed when the individual's service planning team meets to:(1) develop the individual's person-centered service plan upon:(A) initial enrollment; and(B) for annual renewals; and(2) revise the individual's person-centered service plan if the purpose of the revision is because the individual expresses a desire to work and the individual's person-centered service plan does not include an employment service. Source Note: The provisions of this §284.105 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.105 Uniform Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215390 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215390 03/12/2026 The Texas Health and Human Services Commission (HHSC) utilizes the following strategies to increase the number of individuals receiving employment services from the Texas Workforce Commission (TWC) or through the waiver program in which an individual is enrolled:(1) use of the HHSC Employment First Discovery Tool identified in §284.105(a)(2) of this chapter (relating to Uniform Process);(2) maintain a memorandum of understanding between HHSC and TWC to enable data sharing between those agencies in order to measure the number of individuals utilizing employment services;(3) implement an employment-first policy jointly adopted by HHSC, the Texas Education Agency (TEA), and the TWC in accordance with Texas Government Code §531.02447(b); and(4) implement additional strategies as outlined in the Promoting Independence Plan, which is HHSC's plan for implementing its obligation to provide people with disabilities opportunities to live, work, and be served in integrated settings. Source Note: The provisions of this §284.107 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.107 Strategies to Increase Number of Individuals Receiving Employment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215391 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215391 03/12/2026 After completing the HHSC Employment First Discovery Tool, as described in §284.105(a)(2) of this chapter (relating to Uniform Process), if an individual's person-centered service plan does not include employment services through the waiver program in which the individual is enrolled, the individual's case manager or service coordinator must refer the individual to the Texas Workforce Commission (TWC) for employment services available through the TWC. Source Note: The provisions of this §284.109 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.109 Referrals to the Texas Workforce Commission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215393 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215393 03/12/2026 The Texas Health and Human Services Commission will ensure that the number of individuals receiving employment services from the Texas Workforce Commission or through the waiver programs in which the individuals are enrolled on December 31, 2023, is at least 5% greater than the number of individuals receiving employment services on December 31, 2022. Source Note: The provisions of this §284.111 adopted to be effective November 14, 2023, 48 TexReg 6357. 1 HEALTH AND HUMAN SERVICES COMMISSION 284 COMPETITIVE AND INTEGRATED EMPLOYMENT INITIATIVE FOR CERTAIN MEDICAID RECIPIENTS §284.111 Increasing the Number of Individuals Receiving Employment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219670 03/12/2026 (a) The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:(1) Waiver program--A program administered by the Department of Aging and Disability Services (DADS), other than the Texas Home Living Program, that provides services under a waiver granted by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act.(2) General revenue--State funds appropriated by the Texas Legislature for use by DADS.(3) Individual--A person applying for or enrolled in a waiver program.(b) DADS may use general revenue to pay for services above the individual cost limit of a waiver program for an individual if DADS determines:(1) the individual needs services that exceed the individual cost limit because the individual's health and safety cannot be protected by the services provided within the individual cost limit;(2) the individual receives waiver services at the individual cost limit;(3) federal financial participation is not available to pay for services above the individual cost limit; and(4) there is no other available living arrangement in which the individual's health and safety can be protected, as evidenced by:(A) an assessment conducted by DADS clinical staff; and(B) supporting documentation, including the individual's medical and service records.(c) Services funded by general revenue must be:(1) the same service array offered by the waiver program in which the individual is enrolled;(2) necessary to protect the individual's health and safety;(3) authorized using the waiver program's criteria; and(4) unavailable through other funding sources.(d) For an individual who has been receiving waiver program services since September 1, 2005, at a cost that exceeded the individual cost limit of the waiver program, DADS uses general revenue to pay for services above the individual cost limit if:(1) the services above the individual cost limit are necessary for the individual to live in the most integrated setting appropriate to the individual's needs; and(2) federal financial participation is not available to pay for the services above the individual cost limit. Source Note: The provisions of this §285.1 adopted to be effective September 1, 2008, 33 TexReg 7283; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4932. 1 HEALTH AND HUMAN SERVICES COMMISSION 285 USE OF GENERAL REVENUE FOR SERVICES EXCEEDING THE INDIVIDUAL COST LIMIT OF A WAIVER PROGRAM §285.1 Use of General Revenue for Services Exceeding the Individual Cost Limit of a Waiver Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220437 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220437 03/12/2026 (a) Causes for debarment. TDMHMR may remove contractual rights from an individual or legal entity for causes including, but not limited to, the following:(1) being found guilty, pleading guilty, pleading nolo contendere, or receiving a deferred adjudication in a criminal court, relating to:(A) obtaining, attempting to obtain, or performing a public or private contract or subcontract;(B) embezzlement, theft, forgery, bribery, falsification or destruction of records, any form of fraud, receipt of stolen property, or any other offense indicating moral turpitude or a lack of business integrity or honesty;(C) dangerous drugs, controlled substances, or other drug-related offense;(D) federal antitrust statutes arising from the submission of bids or proposals; or(E) any physical or sexual abuse or neglect offense;(2) being debarred from contracting by any unit of the federal government or any unit of a state government;(3) violating TDMHMR contract provisions including failing to perform according to the terms, conditions, and specifications or within the time limit(s) specified in the TDMHMR contract, including, but not limited to, the following:(A) failing to abide by applicable federal and state statutes, such as those regarding persons with disabilities and those regarding civil rights;(B) having a record of failure to perform or of unsatisfactory performance according to the terms of one or more contracts or subcontracts, if that failure or unsatisfactory performance has occurred within five years preceding the determination to debar. Application of this subsection will be made only for actions occurring after the effective date of these rules. Failure to perform and unsatisfactory performance includes, but is not limited to, the following:(i) failing to correct contract performance deficiencies after receiving written notice about them from TDMHMR or its authorized agents;(ii) failing to repay or make and follow through with arrangements satisfactory to the Department to repay identified overpayments or other erroneous payments, or assessed liquidated damages or penalties;(iii) failing to meet standards that are required for licensure or certification, or that are required by state or federal law, TDMHMR rule, or TDMHMR policy concerning TDMHMR contractors;(iv) failing to execute amendments required by TDMHMR;(v) billing for services or merchandise not provided to the consumer or TDMHMR;(vi) submitting cost reports containing costs not associated with and/or not covered by the contract or TDMHMR rules and instructions. Intent to increase individual or statewide rates or fees by submission of unallowable costs must be shown for a single cost report, but intent may be inferred when a pattern of submitting cost reports with unallowable costs is shown;(vii) submitting a false statement or misrepresentation which, if used, may increase individual or statewide rates or fees;(viii) charging consumer or patient fees contrary to TDMHMR rules or policy;(ix) failing to notify and reimburse TDMHMR or its agents for services TDMHMR paid for when the contractor received reimbursement from a liable third party;(x) failing to disclose or make available, upon demand, to TDMHMR or its representatives (including appropriate federal and state agencies) any records the contractor is required to maintain;(xi) failing to provide and maintain services within standards required by statute, regulation, or contract; or(xii) violating the TDMHMR provisions applicable to the contract or any rule or regulation issued by TDMHMR;(4) submitting an offer, bid, proposal or application that contains a false statement or misrepresentation or omits pertinent facts or documents that are material to the procurement;(5) engaging in any abusive or neglectful practice that results in or could result in death or injury to the consumers served by the contractor; or(6) violating any of the provisions outlined in §409.55 of this title (relating to Grounds for Fraud Referral and Administrative Sanction). For purposes of this subsection, any reference in Chapter 409, Subchapter C of this title (relating to Fraud and Abuse and Recovery of Benefits), to a violation of the Medicaid (Title XIX), Medicare (Title XVIII), or Title XX programs is expanded to include an identical violation within any programs of federal or state governments;(7) knowingly and willingly using a debarred person or entity as an employee, independent contractor, or agent to perform a contract with TDMHMR.(b) Conditions of debarment. Individuals, parts of entities, and entities that have been debarred may not:(1) receive a contract;(2) be allowed to retain a contract which has been awarded before debarment;(3) bid or otherwise make offers to receive a contract or subcontract;(4) participate in TDMHMR programs which do not require the provider to sign a contract or agreement; or(5) either personally or through a clinic, group, corporation or other association bill to or receive payment from TDMHMR for any services or supplies provided by the debarred entity on or after the effective date of the debarment. Additionally, TDMHMR will not pay for any services ordered, prescribed, or delivered by the debarred entity for TDMHMR recipients after the date of debarment. No costs associated with a debarred entity, including the salary, fringe benefits, overhead, payments to, or any other costs associated with an employee, owner, officer, director, board member, independent contractor, manager, or agent who was debarred may be included in a TDMHMR cost report or any other document which will be used to determine an individual payment rate, a statewide payment rate, or a fee.(c) Entities that may be debarred. Debarment may be applied against an individual, an entire legal entity, or a specified part of a legal entity. Source Note: The provisions of this §286.1 adopted to be effective March 25, 1997, 22 TexReg 2751; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 27, 2024, as published in the August 30, 2024, issue of the Texas Register, 49 TexReg 6755. 1 HEALTH AND HUMAN SERVICES COMMISSION 286 ICF/ID PROGRAMS--CONTRACTING §286.1 Causes for and Conditions of Debarment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220438 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220438 03/12/2026 (a) Causes for suspension. TDMHMR may place a contractor or potential contractor's contractual rights in suspension whenever TDMHMR finds that there is a reasonable basis to believe that grounds for debarment as specified in §406.64 of this title (relating to Conditions for and Conditions of Debarment) exists. Suspension may be imposed immediately following TDMHMR's notification to a contractor or potential contractor. In addition, suspension may be imposed on a potential contractor or subcontractor if he has an outstanding indictment or the department has information about an offense that is grounds for debarment.(b) Conditions of suspension.(1) TDMHMR may withhold payments, in whole or in part, to the affected contractor during the period of suspension.(2) TDMHMR may refuse to accept a bid, offer, application, or proposal from, or to award a contract to, the affected potential contractor during the period of suspension.(3) TDMHMR may cease referrals of additional consumers to the suspended entity.(4) If TDMHMR determines that the underlying reasons for the suspension have been resolved in favor of the contractor, TDMHMR must, if applicable:(A) pay the withheld payments for any services that may have been provided during the suspension and which meet the terms of an existing contract; and(B) resume contract payments.(5) If TDMHMR determines that underlying reasons for the suspension have not been resolved in favor of the contractor, TDMHMR will institute debarment proceedings.(6) Individuals and entities whose contractual rights have been placed in suspension may not:(A) receive a contract; or(B) submit an offer, bid, application or proposal for a contract.(c) Entities that may be suspended. A suspension may be applied against an individual, an entire legal entity, or a specified part of a legal entity. Source Note: The provisions of this §286.3 adopted to be effective March 25, 1997, 22 TexReg 2751; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 27, 2024, as published in the August 30, 2024, issue of the Texas Register, 49 TexReg 6755. 1 HEALTH AND HUMAN SERVICES COMMISSION 286 ICF/ID PROGRAMS--CONTRACTING §286.3 Causes for and Conditions of Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220439 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220439 03/12/2026 (a) Causes identified in §406.64(a)(1) of this title (relating to Causes for and Conditions of Debarment) are established by proof of pleading guilty or nolo contendere, or of the issuance of a deferred adjudication of guilt. If an appeal results in a reversal, contractual rights must be restored upon written request, unless another cause for their removal exists.(b) Causes identified in §406.64(a)(2) of this title (relating to Causes for and Conditions of Debarment) are based entirely upon the other state or federal agency's official notice that the contractor or potential contractor's rights have been removed.(c) The existence of all other causes for debarment or suspension must be established by a preponderance of the evidence. Source Note: The provisions of this §286.5 adopted to be effective March 25, 1997, 22 TexReg 2751; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 27, 2024, as published in the August 30, 2024, issue of the Texas Register, 49 TexReg 6755. 1 HEALTH AND HUMAN SERVICES COMMISSION 286 ICF/ID PROGRAMS--CONTRACTING §286.5 Proof Required for Debarment and Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220440 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220440 03/12/2026 (a) Contractors' right of notice and appeal. Contractors who have been placed in suspension or who have been debarred or who have been notified of proposed debarment have the appeal rights provided in Chapter 409, Subchapter B of this title (relating to Adverse Actions), governing provider appeal processes for adverse actions.(b) Potential contractors' rights of notice and appeal. Potential contractors who are placed in suspension or who have been debarred have all the notice and appeal rights provided in Chapter 409, Subchapter B of this title (relating to Adverse Actions), governing provider appeal processes for adverse actions.(c) Required content for notices of suspension and debarment. In addition to information required in the notice of adverse actions specified in Chapter 409, Subchapter B of this title (relating to Adverse Actions), notices must include the following, when applicable:(1) the grounds for the action (if an indictment or information is pending or has been returned, the nature of the irregularities is described in general terms without disclosing evidence);(2) the length of the suspension or debarment;(3) a statement explaining the effect of the suspension or debarment; and(4) a statement of whether the suspension or debarment is in effect throughout TDMHMR. Source Note: The provisions of this §286.7 adopted to be effective March 25, 1997, 22 TexReg 2751; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 27, 2024, as published in the August 30, 2024, issue of the Texas Register, 49 TexReg 6755. 1 HEALTH AND HUMAN SERVICES COMMISSION 286 ICF/ID PROGRAMS--CONTRACTING §286.7 Notice Requirements for Debarment and for Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217889 03/12/2026 (a) Health and Safety Code, Title 7, Chapter 534, Subchapter A, and this subchapter govern the establishment and operation of a community center.(b) The purpose of this subchapter is to describe requirements by which a community center is established and operated by a local agency with a plan approved by DADS and DSHS in accordance with Health and Safety Code, §534.001(e). Source Note: The provisions of this §300.1 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217890 03/12/2026 This subchapter applies to local agencies desiring to establish a new community center or affiliate with an existing community center and to all existing community centers established under Health and Safety Code, Title 7, Chapter 534. Source Note: The provisions of this §300.3 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217891 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Board of trustees--A body of persons selected and appointed in accordance with Health and Safety Code, Title 7, §534.002 or §534.003, and §534.004, §534.005, and §534.0065, that has responsibility for the effective administration of a community center.(2) Community center or center--A center established under Health and Safety Code, Title 7, Chapter 534, Subchapter A.(3) Current plan--The most recently approved initial or modified plan.(4) DADS--The Department of Aging and Disability Services.(5) DSHS--The Department of State Health Services.(6) Facility--A state hospital, state supported living center, or state center.(7) Initial plan--The plan developed by a board of trustees to establish a new community center.(8) Local agency--A county, municipality, hospital district, school district, or any organizational combination of two or more of these which may establish and operate a community center.(9) Local contribution--Funds or in-kind contribution by each local agency to a community center in the amount approved by DADS and DSHS, which includes local match if the center is a local authority.(10) Local authority--In accordance with Health and Safety Code, §533.035(a), an entity designated as a local mental retardation authority or a local mental health authority by the executive commissioner of the Health and Human Services Commission.(11) Local match--In accordance with Health and Safety Code, §534.066, those funds or in-kind support from a local authority that are required to match some or all of the state funds the local authority receives pursuant to a contract with DADS or DSHS.(12) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate persons with a severe and persistent mental illness which may be accompanied by chemical dependency or mental retardation.(13) Mental retardation services--All services concerned with research, prevention, and detection of mental retardation and all services related to the education, training, habilitation, care, treatment, and supervision of persons with mental retardation, except the education of school-age persons that the public educational system is authorized to provide.(14) Region--The area within the boundaries of the local agencies participating in the operation of a community center established under Health and Safety Code, Chapter 534, Subchapter A. Source Note: The provisions of this §300.5 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217892 03/12/2026 (a) Letter of intent. If a local agency decides to establish a new community center, then the local agency submits a letter of intent to DADS and DSHS outlining the proposed new center's region, governing structure, and other information pertinent to the formation of the proposed new center.(1) If the local agency submitting the letter of intent is not a county or counties, the letter must be accompanied by a letter of endorsement from the appropriate county judge or judges.(2) DADS and DSHS review the letter of intent using the following criteria:(A) the benefits of establishing a new center over affiliation with an existing center and the establishment of a new center is consistent with DADS's and DSHS's mission for the development of community services in Texas;(B) the population of the region of the proposed new center is at least 200,000 or large enough to support a center;(C) a comprehensive array of mental health and mental retardation services will be provided;(D) the extent of the local contribution supports the intent; and(E) the efficient provision of services is financially viable.(3) DADS and DSHS determine whether the letter of intent meets the criteria described in paragraph (2) of this section.(b) Appointment of board of trustees. If the local agency receives notice from DADS and DSHS that the letter of intent meets the criteria described in subsection (a)(2) of this section, the local agency prescribes the criteria and procedures for the appointment of members of a board of trustees as described in Health and Safety Code, §534.002 or §534.003, and §534.004, §534.005, and §534.0065. The local agency prescribes and makes available for public review the elements listed in Health and Safety Code, §534.004(a). If more than one local agency is involved, the local agencies shall enter into a contract of interlocal agreement that states the number of board members and the group from which the members are chosen, as provided in Health and Safety Code, §534.003(c).(c) Initial plan.(1) Submission. The board of trustees develops and submits to DADS and DSHS an initial plan to provide effective mental health and mental retardation services to the residents of the proposed region. The board of trustees shall appoint a mental health planning advisory council and a mental retardation planning advisory council to assist in developing the initial plan. A mental health planning advisory council must have at least 50 percent representation of persons or family members of persons who have received or are receiving mental health services. A mental retardation planning advisory council must have at least 50 percent representation of persons or family members of persons who have received or are receiving mental retardation services. A combined mental health and mental retardation planning advisory council shall have at least 50 percent representation of persons or family members of persons who have received or are receiving mental health or mental retardation services with an equal number of representatives for mental health services and mental retardation services. The board of trustees shall also seek input through a public process (e.g., public hearings, focus groups, town meetings) from the residents in the proposed region regarding local needs and priorities. The initial plan must include the following elements:(A) a comprehensive service description, which includes:(i) a statement of the mission, vision, values, and principles which establish the foundation of the proposed community center's local service delivery system;(ii) a definition of all populations to be served;(iii) a description of relevant internal and external assessments and evaluations for the local strategic planning process;(iv) a statement of local service needs and priorities;(v) identified gaps in services and supports in the local service delivery system;(vi) a description of existing local mental health and mental retardation resources and planned resource development activities;(vii) a statement of management needs and priorities to support an effective and efficient local service delivery system; and(viii) objectives, strategies, and outcomes;(B) a community center plan in a format required by DADS and DSHS available at www.dads.state.tx.us; and(C) a prospectus, which describes:(i) any proposed transfer of funds, assets, liabilities, personnel, and consumer and administrative records and information from a facility or existing community center and the time frames for transfer;(ii) other available funds;(iii) the arrangements for uninterrupted delivery of services; and(iv) the impact, and resolution if warranted, of current contractual obligations.(2) Review and approval.(A) DADS and DSHS review the initial plan.(B) If DADS and DSHS approve the initial plan, DADS and DSHS issue a certificate of recognition as a community center. Source Note: The provisions of this §300.7 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.7 Process to Establish a New Community Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217893 03/12/2026 (a) Submission. The board of trustees of a community center shall submit a modification of its current plan in accordance with this section as frequently as necessary to reflect changes in the community center's local agencies, functions, or region as described in paragraphs (1) - (3) of this subsection prior to implementing the changes. The modified plan shall be in the format required by DADS and DSHS available at www.dads.state.tx.us.(1) If a local agency wants to affiliate with an existing community center and the existing center agrees, then the board of trustees of the existing center submits to DADS and DSHS for approval a modification of the center's current plan to reflect such affiliation, including:(A) any proposed expansion of the center's region;(B) a copy of the new contract of interlocal agreement; and(C) official documentation (e.g., a resolution) confirming an intent to affiliate from each local agency and the proposed local agency.(2) If a local agency wants to terminate its affiliation with an existing community center, then the appointing authorities of the local agencies must terminate the original contract of interlocal agreement and enter into a new contract of interlocal agreement if more than one local agency remains. The board of trustees of the existing center submits to DADS and DSHS for approval a modification of the center's current plan to reflect the termination of such affiliation, including:(A) any change of the center's region;(B) a copy of the new contract of interlocal agreement, if applicable; and(C) official documentation (e.g., a resolution) from the local agency confirming its intent to terminate affiliation with the center.(3) If an existing community center wants to expand, reduce, or substantially amend its functions or region as described in its plan (e.g., changing the population served or creating or operating a non-profit corporation), the board of trustees of the center submits to DADS and DSHS for approval a modification of the center's current plan to reflect such changes.(b) Review and approval.(1) DADS and DSHS review the modified plan.(2) If DADS and DSHS approve the modified plan, DADS and DSHS notify the board of trustees in writing of the approval and issue a new certificate if appropriate. Source Note: The provisions of this §300.9 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.9 Modifying a Community Center's Current Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217894 03/12/2026 (a) Dissolution. If a community center proposes to cease operations and dissolve, the center's board of trustees and each local agency shall inform DADS and DSHS in writing of such a decision before dissolution. DADS, DSHS, the board of trustees, and each local agency shall agree to a plan of dissolution that addresses at least the following factors:(1) the center's assets and liabilities (including personnel);(2) necessary audits to be conducted;(3) closure activities, including arrangements for uninterrupted delivery of services;(4) the transfer, archival, and security of records and information; and(5) future plans for the region's service delivery system (e.g., affiliation with an existing center or establishment of a new center).(b) Merger. If two or more existing community centers agree to merge into a new community center, then before merging the boards of trustees of the involved centers submit to DADS and DSHS an initial plan in accordance with §411.305(c) of this title (relating to Process to Establish a New Community Center). The initial plan must represent the services to be provided in the combined expanded region and include a copy of the new contract of interlocal agreement and official documentation (e.g., a resolution) confirming an intent to merge from each local agency involved. Source Note: The provisions of this §300.11 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.11 Dissolution and Merger of Community Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217895 03/12/2026 (a) The DADS commissioner and the DSHS commissioner may appoint a manager or management team to manage and operate a community center in accordance with Health and Safety Code, §§534.038, 534.039, and 534.040. The DSHS commissioner may delegate responsibility for appointing a manager or management team to the DADS commissioner.(b) A community center may request a hearing to appeal the commissioners' decision to appoint a manager or management team in accordance with 1 Texas Administrative Code (TAC), Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). Requesting a hearing stays the appointment unless the commissioners based the appointment on a finding under Health and Safety Code, §§534.038(a)(2) or (4), which means the commissioners found that the community center or an officer or employee of the center misused state or federal money or endangers or may endanger the life, health, or safety of a person served by the center. Source Note: The provisions of this §300.13 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 1, 2003, 28 TexReg 6876; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.13 Appointment of Manager or Management Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217888 03/12/2026 (a) Each board of trustees shall:(1) retain all financial records, supporting documents, statistical records, and any other documents pertinent to its community center budgets, contracts, performance/workload measure, and persons served for a period of five years. If audit discrepancies have not been resolved at the end of five years, the records must be retained until resolution;(2) deposit community center funds through the Federal Deposit Insurance Corporation or the Federal Savings and Loan Insurance Corporation, or secure deposits using collateral in a manner that protects the deposited funds; and(3) ensure DADS and DSHS have unrestricted access to all facilities, records, data, and other information under control of the community center or its contractors as necessary to enable DADS and DSHS to audit, monitor, and review all financial and programmatic activities and services associated with the center as provided by Health and Safety Code, §534.033(a).(b) Each board of trustees shall receive training as required by Health and Safety Code, §534.006, and this subsection.(1) Before assuming office, new members must receive initial training, including:(A) the importance of local planning and the roles and functions of the board of trustees, planning advisory committees, community center staff, and other service organizations;(B) the current philosophies and program principles on which service delivery systems are founded, information about the service and support needs of people with mental illnesses, mental retardation, and related conditions, and the range of environments in which those services may be delivered;(C) an overview of mental illnesses, mental retardation, and related conditions;(D) an overview of the current local and state service delivery system, including descriptions of the types of mental health and mental retardation services provided by the community center; and(E) applicable state and federal laws, rules, standards, and regulations.(2) Utilizing input from persons who have received or are receiving services, their family members, and advocates, the training programs must provide orientation in the perspectives and issues of persons receiving services.(3) A community center shall develop an annual training program for its board of trustees.(A) Training methodologies may include:(i) presentations by staff at regular board sessions;(ii) on-site program visits;(iii) statewide and regional training conferences;(iv) seminars to enhance team building skills;(v) regional and cross-training with other community centers and their boards of trustees; and(vi) formal and informal meetings with tenured trustee members.(B) In addition to the topics required in Health and Safety Code, §534.006, and paragraphs (1) and (2) of this subsection, training topics may include:(i) risk management;(ii) budget analysis;(iii) consumer rights;(iv) strategic planning; and(v) new legislative and contractual requirements of community centers.(c) The approval and notification requirements in this subsection are in accordance with Health and Safety Code, §534.021.(1) A board of trustees must ensure that its community center receives written approval from DADS and DSHS prior to purchase, lease-purchase, or any other transaction which will result in the community center's ownership of real property, including buildings, if DADS's and DSHS's funds or local match are involved. In addition, for acquisition of nonresidential property, the community center must notify each local agency at least 30 days before it enters into a binding obligation to acquire the property.(2) A community center must provide written notification to DADS and DSHS and each local agency at least 30 days before it enters into a binding obligation to acquire real property, including a building, if the acquisition does not involve the use of DADS's and DSHS's funds or local match. Upon request, the commissioners may waive the 30-day requirement to notify DADS and DSHS on a case-by-case basis.(3) All notices and requests for approval are submitted on the Real Property Acquisition and Construction Review Form and accompanied by supporting information including, but not necessarily limited to:(A) the reason for purchasing the property or a brief explanation of the purpose it will serve;(B) a summary of the plan for paying for the property, including a statement regarding whether DADS's or DSHS's funds or local match will be used, and if DADS's or DSHS's funds will be used, how the funds will be used, such as directly or in the retirement of any debt associated with the acquisition;(C) if unimproved, an assessment of the suitability of the property for construction purposes or, if improved, an assessment of the current condition of the buildings;(D) an independent appraisal of the real estate the community center intends to purchase conducted by an appraiser certified by the Texas Appraiser Licensing and Certification Board; however, the board of trustees may waive this requirement if the purchase price is less than the value listed for the property by the local appraisal district and the property has been appraised by the local appraisal district within the past two years; and(E) a statement that the board of trustees and executive staff are not participating financially in the transaction and will derive no personal benefit from the transaction. Source Note: The provisions of this §300.15 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.15 Standards of Administration for Boards of Trustees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217886 03/12/2026 Each community center shall provide services in compliance with the Civil Rights Act of 1964, as amended, and the Americans With Disabilities Act (ADA) of 1990, and require the same of entities with which it contracts. Source Note: The provisions of this §300.17 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.17 Civil Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217887 03/12/2026 Pursuant to Health and Safety Code, §534.035, each community center must comply with the following review and audit procedures to provide reasonable assurance that the community center has adequate and appropriate fiscal controls.(1) Audit procedures.(A) Each board of trustees must ensure an annual financial and compliance audit of its accounts is conducted by a certified public accountant or public accountant licensed by the Texas State Board of Public Accountancy. At a minimum, the audit must be conducted in accordance with Government Auditing Standards.(B) DADS and DSHS may conduct on-site audits of a community center as determined by DADS's and DSHS's financial risk analysis of the center.(2) Review procedures.(A) DADS and DSHS will conduct a desk review of each community center's annual audit to determine audit quality and to identify findings and questioned costs.(B) DADS and DSHS will perform a financial risk analysis of each community center based on the center's annual audit and/or any financial information that the center is required to submit in accordance with §411.310(b)(1) of this title (relating to Standards of Administration for Boards of Trustees). Source Note: The provisions of this §300.19 adopted to be effective May 25, 2000, 25 TexReg 4540; amended to be effective September 11, 2011, 36 TexReg 5691; transferred effective May 13, 2024, as published in the Texas Register April 12, 2024, 49 TexReg 2321. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES A COMMUNITY CENTERS §300.19 Fiscal Controls https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221352 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221352 03/12/2026 (a) Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts by reference a rule of the Texas Education Agency (TEA) in 19 TAC §89.1115 (relating to Memorandum of Understanding Concerning Interagency Coordination of Special Education Services to Students with Disabilities in Residential Facilities).(b) The TEA rule contains the text of an MOU between the following state agencies:(1) TDMHMR;(2) TEA;(3) Texas Department of Human Services;(4) Texas Department of Health;(5) Texas Department of Protective and Regulatory Services;(6) Texas Interagency Council on Early Childhood Intervention;(7) Texas Commission on Alcohol and Drug Abuse;(8) Texas Juvenile Probation Commission; and(9) Texas Youth Commission.(c) The MOU concerns the provision of a free and appropriate education for school-age residents of residential facilities and is required by the Texas Education Code, §29.012(d).(d) Copies of the MOU are filed in the Office of Policy Development, TDMHMR, 909 West 45th Street, Austin, Texas 78756, and may be reviewed during regular business hours. Source Note: The provisions of this §300.101 adopted to be effective November 15, 1999, 24 TexReg 10091; amended to be effective February 18, 2003, 28 TexReg 1392; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8749. 1 HEALTH AND HUMAN SERVICES COMMISSION 300 STATE AUTHORITY RESPONSIBILITIES B INTERAGENCY AGREEMENTS §300.101 Interagency Coordination of Special Education Services to Students with Disabilities in Residential Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219912 03/12/2026 The purpose of this subchapter is to comply with the Texas Health and Safety Code, §534.052, §534.055, and §534.065. Source Note: The provisions of this §301.1 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219913 03/12/2026 This subchapter applies to all contracts for goods and services awarded by a local authority. Source Note: The provisions of this §301.3 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219914 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Application--Documents prepared by a respondent in response to a request for applications.(2) Best value--The optimum combination of economy and quality that is the result of fair, efficient, and practical procurement decision-making and which achieves the following objectives:(A) promote fairness and competition for local authority contracts;(B) support the delivery of services and benefits that best meets the needs of clients of programs administered by the local authority;(C) promote timely, high quality, and responsive performance by contractors; and(D) encourage and reward the continuing participation of quality contractors.(3) Business entity--A sole proprietorship, partnership, firm, corporation, holding company, joint-stock company, receivership, trust, or any other entity recognized by law.(4) Consumer--A person in the priority population or otherwise designated in the performance contract as eligible for community services.(5) Contract--A written agreement, including a purchase order, between a local authority and a business entity that obligates the entity to provide goods or services in exchange for money or other valuable consideration.(6) Contract management--Initiating, procuring, awarding, monitoring, and enforcing a contract.(7) Contract term--The period of time during which a contract is in effect, identified by a starting and ending date.(8) Contractor--A business entity that has a contract for goods or services with a local authority.(9) Goods--Tangible personal property and intellectual property.(10) Intellectual property--Any intangible asset that consists of human knowledge and ideas (e.g., software).(11) Local authority--An entity designated by the TDMHMR commissioner in accordance with the Texas Health and Safety Code, §533.035(a).(12) Local service area--A geographic area composed of one or more Texas counties delimiting the population which may receive community services from a local authority.(13) Participated--To have taken action as an officer or employee through decision, approval, disapproval, recommendation, giving advice, investigation, or similar action.(14) Particular matter--A specific investigation, application, request for a ruling or determination, proceeding related to the development of policy, contract, claim, charge, accusation, arrest, or judicial or other proceeding.(15) Performance contract--The contract between TDMHMR and a local authority in which TDMHMR agrees to pay the local authority a specified sum and in which the local authority agrees to provide local match, for, at a minimum, ensuring and/or monitoring the provision of specified mental health and mental retardation services in a local service area.(16) Priority population--Those groups of persons with mental illness and mental retardation identified in TDMHMR's current strategic plan as being most in need of mental health and mental retardation services.(17) Proposal--Documents prepared by a respondent in response to a request for proposals.(18) Respondent--A business entity that submits an oral, written, or electronic response to a solicitation. The term is intended to include "applicant," "offeror," "proposer," and other similar terminology to describe a business entity that responds to a solicitation.(19) Response--An oral, written, or electronic "offer," "proposal," "quote," "application," or other applicable expression of interest to a solicitation.(20) Services--(A) Community services--Mental health and mental retardation services required to be available in each local service area pursuant to the Texas Health and Safety Code, §534.053(a), for which TDMHMR contracts through the performance contract as well as all other services specified in the performance contract.(B) Non-community services--All services other than community services.(21) Solicitation--A notification of the local authority's intent to purchase community services (e.g., request for proposals and request for applications).(22) TDMHMR--The Texas Department of Mental Health and Mental Retardation. Source Note: The provisions of this §301.5 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219915 03/12/2026 (a) All purchases of goods and services must be made pursuant to a contract.(b) Conflicts of interests and standards of conduct for local authority employees and officers.(1) Conflicts of interest. Local authority employees and officers may not have a conflict of interest in contracts management. An employee or officer has a conflict of interest when the employee, officer, a partner of the employee or officer, or a person related within the second degree of consanguinity or affinity to the employee or officer, has or intends to have:(A) employment with a respondent or contractor;(B) paid consultation with a respondent or contractor;(C) membership on a respondent's or contractor's board of directors;(D) ownership of 10% or more of the voting stock of shares of a respondent or contractor;(E) ownership of 10% or more or $5,000 or more of the fair market value of a respondent or contractor; or(F) income from a respondent or contractor in excess of 10% of the employee's, officer's, or related person's gross income for the previous year.(2) Standards of conduct. The local authority must develop and enforce standards of conduct governing its employees' and officers' who participate in contracts management, which prohibits such employees and officers from:(A) accepting or soliciting any gift, favor, service, or benefit from a business entity, respondent, or contractor that might reasonably tend to influence the employee or officer in the discharge of official duties relating to contract management, or that the employee or officer knows or should know is being offered with the intent to influence the employee's or officer's official duties; or(B) intentionally or knowingly soliciting, accepting, or agreeing to accept any benefit for having exercised official powers or for having performed official duties in favor of another business entity, respondent, or contractor.(c) Conflicts of interests and standards of conduct for a respondent and its officers and employees.(1) Conflict of interest. A respondent and its officers and employees responsible for development of a response or performance of a contract for which the respondent is submitting a response may not be related within the second degree of consanguinity or affinity to a local authority employee or officer participating in the contract management for the contract for which the respondent is submitting a response.(2) Standards of conduct.(A) A respondent and its officers and employees may not attempt to induce any business entity to submit or not to submit a response.(B) A respondent and its officers and employees must arrive at its response independently and without consultation, communication, or agreement for the purposes of restricting competition.(C) A respondent and its officers and employees may not have a relationship with any person, at the time of submitting the response or during the contract term, that may interfere with fair competition.(D) A respondent and its officers and employees may not participate in the development of specific criteria for award of the contract, nor participate in the selection of the response to be awarded the contract.(d) The local authority may not contract with a former officer or employee of the local authority if the contract relates to a particular matter (as defined) in which the former officer or employee participated (as defined) during the period of employment, either through personal involvement or because the case or proceeding was a matter within the officer's or employee's official responsibility, unless:(1) the former employee was compensated on the last day of service or employment below the amount prescribed by the General Appropriations Act for salary group 17, Schedule A, or salary group 9, Schedule B, of the position classification salary schedule; or(2) the former officer or employee is employed by a state agency or another local authority.(e) The local authority must ensure that its contractors comply with all contract provisions regardless of whether a contractor subcontracts some or all of the contract.(f) A local authority may make advance payments to a contractor provided the payments meet a public purpose, ensure adequate consideration, and sufficient controls are in place to ensure accomplishment of the public purpose. With the exception of contracts paid on a capitated basis, at the end of each contract term the contractor must return to the local authority any state or federal funds received from or through TDMHMR which have not been encumbered.(g) The local authority is prohibited from contracting with a business entity that is currently:(1) held in abeyance or barred from the award of a federal or state contract; or(2) is not in good standing for state tax, pursuant to the Texas Business Corporation Act, Texas Civil Statutes, Article 2.45.(h) The local authority must ensure each contractor is provided information relating to the local authority's policies and procedures that are relevant to the contractor.(i) The local authority shall ensure quality community services are provided to consumers, including during the transition from one contractor to another.(j) When purchasing goods and services, the local authority shall comply with the Uniform Grant and Contracts Management Standards (UGMS) promulgated by the Governor's Office of Budget and Planning (pursuant to the Texas Government Code, Chapter 783, and 1 TAC, Part 1, Chapter 5, Subchapter A, Division 4), except to the extent that any provision in §412.55(a)(2) of this title (relating to Contract Procurement) conflicts with UGMS, Part III (State Uniform Administrative Requirements for Grants and Cooperative Agreements), Subpart C (Post-Award Requirements; Changes Property, and Subawards), Section __.36(d) (Procurement), then §412.55(a)(2) of this title (relating to Contract Procurement) shall control. In UGMS:(1) the terms "recipient" and "grantee" apply to TDMHMR;(2) the terms "subrecipient" and "subgrantee" apply to the local authority; and(3) the terms "vendor" and "subcontractor" apply to a contractor (as defined in this subchapter), unless the contractor operates as a "subgrantee" as defined under UGMS, Part III (State Uniform Administrative Requirements for Grants and Cooperative Agreements), Subpart A (General), Section __.3 (Definitions). Source Note: The provisions of this §301.7 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.7 Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219916 03/12/2026 (a) Procurement method. The local authority must develop and enforce procurement procedures that comply with this subchapter.(1) Goods and non-community services. The local authority must acquire goods and non-community services by any procurement method described in the Uniform Grant and Contracts Management Standards (UGMS), Section __.36(d), that provides the best value to the local authority.(2) Community services. The local authority must acquire community services by a procurement method described in this subchapter that provides the best value to the local authority. All community services must be procured competitively in accordance with §412.58 of this title (relating to Competitive Procurement of Community Services Contracts) unless the local authority determines that the community service(s):(A) can be procured non-competitively in accordance with §412.59 of this title (relating to Non-competitive Procurement of Community Services Contracts); or(B) should be procured through open enrollment in accordance with §412.60 of this title (relating to Open Enrollment).(b) Relevant factors. The local authority must consider all relevant factors in determining best value, which may include:(1) any installation cost;(2) the delivery terms;(3) the quality and reliability of the respondent's goods or services;(4) the extent to which the goods or services meet the local authority's needs;(5) indicators of probable respondent performance under the contract, such as past offeror performance, the respondent's financial resources and ability to perform, the respondent's experience and responsibility, and the respondent's ability to provide reliable maintenance agreements;(6) the impact on the ability of the local authority to comply with laws and rules relating to historically underutilized businesses or relating to the procurement of goods and services from persons with disabilities;(7) the total long term cost to the local authority of acquiring the respondent's goods or services;(8) the cost of any employee training associated with the acquisition;(9) the effect of an acquisition on the local authority's productivity;(10) the acquisition price;(11) whether the respondent can perform the contract or provide the service(s) within the contract term, without delay or interference;(12) the respondent's history of compliance with the laws relating to its business operations and the affected service(s) and whether it is currently in compliance;(13) whether the respondent's financial resources are sufficient to perform the contract and to provide the service(s);(14) whether necessary or desirable support and ancillary services are available to the respondent;(15) the character, responsibility, integrity, reputation, and experience of the respondent;(16) the quality of the facilities and equipment available to or proposed by the respondent;(17) the ability of the respondent to provide continuity of services;(18) the ability of the respondent to meet all applicable written policies, principles, and regulations; and(19) any other factor relevant to determining the best value for the local authority in the context of a particular acquisition.(c) Award. All contracts must be awarded based on best value, as determined by considering all relevant factors.(d) Renewal of community services contracts. The local authority may renew a community services contract only if the contract meets best value as determined by considering all relevant factors. Source Note: The provisions of this §301.9 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.9 Procurement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219917 03/12/2026 (a) The local authority is prohibited from amending a community services contract:(1) to increase the contract amount by more than 25%; or(2) to add a new community service unless the contract was procured through open enrollment.(b) Upon written request by an unsuccessful respondent, the local authority must provide information concerning why the respondent's response was not selected for award.(c) The local authority must develop written procedures that provide respondents an opportunity to protest a contract award.(1) The procedures must allow respondents to protest matters relating to:(A) alleged conflict of interests;(B) alleged failure of the local authority to comply with statute or rule; and(C) alleged failure of the local authority to comply with its procurement procedures.(2) The procedures must describe the local authority's process for reviewing and resolving protests.(d) The local authority must maintain for five years or until the end of any litigation concerning the contract the following contract management documentation:(1) justification for non-competitive procurement as permitted in §412.59(a) of this title (relating to Non-competitive Procurement of Community Services Contracts), if applicable;(2) the solicitation and any modifications or revisions made to the solicitation;(3) all responses to the solicitation and any modifications or revisions made to such responses;(4) the evaluations of all responses and evidence that the local authority considered all relevant factors;(5) written correspondence between the local authority and respondents prior to contract award;(6) optional or required credentials (certifications, licenses, accreditations), if any;(7) written protests, if any, and their disposition;(8) the executed contract;(9) written correspondence between the local authority and the contractor concerning the contractor's performance; and(10) copies of any audits performed or required by the local authority. Source Note: The provisions of this §301.11 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.11 Community Services Contracting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219918 03/12/2026 (a) The local authority must ensure that all its community services contracts are consistent with the local authority's performance contract and with the model contracts designed by TDMHMR as required by the Texas Health and Safety Code, §534.055(c).(b) The local authority must include in all of its community services contracts that are funded by TDMHMR provisions stating:(1) the contract term;(2) the community service(s) to be purchased;(3) the identification of all parties;(4) the total allowable payment or, if the community service is procured through open enrollment or is on a capitated basis, the rate of payment;(5) the method of payment;(6) that the contractor must comply with all applicable federal and state laws, rules, and regulations, including:(A) Title VI of the Civil Rights Act of 1964;(B) Section 504 of the Rehabilitation Act of 1973;(C) the Americans with Disabilities Act of 1990 (ADA); and(D) the Age Discrimination in Employment Act of 1967;(7) that if, as a result of a change to a TDMHMR rule or state or federal law, the contractual obligations of the contractor are materially changed or a significant financial burden is placed on the contractor, then the parties may renegotiate in good faith to amend the contract;(8) that no consumer will be excluded from participation in, denied the benefits of, or unlawfully discriminated against, in any program or activity funded by the contract on the grounds of race, color, ethnicity, national origin, religion, sex, age, disability, or political affiliation in accordance with applicable laws;(9) that all documents pertinent to the contract, including consumer records, will be retained by the contractor for a period of five years;(10) that all consumer-identifying information will be maintained by the contractor as confidential in accordance with applicable law and Chapter 414, Subchapter A of this title (relating to Client-Identifying Information);(11) that the contractor, its licensed staff, and other appropriate staff (such as QMHP-CS) will be credentialed before services are delivered to consumers by such contractor and staff;(12) a dispute resolution process;(13) the clearly defined performance expectations which directly relate to the community service's objectives, including goals, outputs, and measurable outcomes, and that the contractor must provide services in accordance with such expectations;(14) that any allegation of abuse, neglect, or exploitation of a consumer under the contract will be reported in accordance with applicable law, TDMHMR rules, and Texas Department of Protective and Regulatory Services rules;(15) that AIDS/HIV workplace guidelines, similar to those adopted by TDMHMR and AIDS/HIV confidentiality guidelines and consistent with state and federal law, will be adopted and implemented by the contractor;(16) that the contractor will comply with the relevant TDMHMR rules, certifications, accreditations, and licenses, that are specified in the contract;(17) that services will be provided in accordance with consumers' treatment plans;(18) that pursuant to Texas Health and Safety Code, §534.061, TDMHMR, the local authority, and their designees, including independent financial auditors, shall have, with reasonable notice, unrestricted access to all facilities, records, data, and other information under the control of the contractor as necessary to enable the local authority to audit, monitor, and review all financial and programmatic activities and services associated with the contract;(19) any sanctions and remedies the local authority may take in response to the contractor's failure to comply with the contract provisions; and(20) that the contractor will immediately notify the local authority of any change, or potential change, in its status that could affect its inclusion in the provider network.(c) The local authority must include in all of its community services contracts for residential services that are funded by TDMHMR provisions stating:(1) that the contractor shall provide evidence of criminal history record information on the contractor's applicants, employees, and volunteers, pursuant to the Texas Health and Safety Code, §533.007 and Chapter 250; the Texas Government Code, §411.115; and Chapter 414, Subchapter K of this title (relating to Criminal History Clearances); and(2) that if an applicant, employee, or volunteer of the contractor has a criminal history relevant to his or her employment as described in Chapter 414, Subchapter K of this title (relating to Criminal History Clearances), then the contractor will take appropriate action with respect to the applicant, employee, or volunteer, including terminating or removing the employee or volunteer from direct contact with consumers served by the contractor.(d) Community services contracts that require the contractor to assume responsibility for the funds of a consumer must contain provisions requiring the contractor to have and abide by a written policy, which is subject to approval by the local authority, for protecting and accounting for such funds in accordance with generally accepted accounting principles. Source Note: The provisions of this §301.13 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.13 Provisions for Community Services Contracts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219919 03/12/2026 Competitive procurement methods for community services are as follows.(1) Informal solicitation.(A) Determination. The local authority may competitively procure community services through informal solicitation if the contract amount does not exceed $25,000.(B) Solicitation.(i) The local authority must solicit business entities that provide the type of community service(s) being procured and attempt to obtain at least three responses for the service's specifications. Solicitation and responses may be oral, written, or electronic.(ii) Documentation for informal solicitation must include:(I) the names and telephone numbers of the business entities contacted and the date of contact;(II) the specifications for the community service(s); and(III) all responses.(C) Award. The award of a contract procured through informal solicitation is made in accordance with §412.55(c) of this title (relating to Contract Procurement).(2) Request for proposals (RFP).(A) Determination. The local authority may competitively procure community services through an RFP.(B) Solicitation.(i) The local authority must make a reasonable effort to give notice of its intent to contract for community services to providers of the community service(s) in the authority's local service area. The local authority must publish an RFP Notice in a local newspaper or professional association newsletter or announce by direct mail to all known providers of those community service(s) at least 10 calendar days, but not more than 90 calendar days, prior to the due date for the submission of proposals. An RFP Notice must include:(I) the contract term;(II) a general description of the community service(s) to be purchased;(III) the geographic area to be served;(IV) any limitations on who may submit a proposal;(V) the procedures for obtaining an RFP; and(VI) the date and time by which proposals must be received by the local authority.(ii) The local authority must provide an RFP to each business entity that requests one. The local authority may not restrict competition by unreasonably eliminating or limiting participation in the procurement process. An RFP must include:(I) a detailed description of the community service(s) to be purchased, the consumer eligibility criteria, and all other information included in the RFP Notice;(II) the approximate number of consumers to be served pursuant to the contract;(III) method of payment;(IV) a detailed description of information to be included in a proposal;(V) instructions for the submission of questions concerning the procurement;(VI) instructions for the submission of proposals;(VII) respondent eligibility requirements for contract award (e.g., credentials for providing the community service(s), such as applicable certifications, licenses; evidence of compliance or ability to comply with relevant TDMHMR rules; evidence of accessibility; evidence of financial solvency; and evidence of liability insurance);(VIII) assurances that:(-a-) the respondent has no conflict of interest and meets the standards of conduct requirements pursuant to §412.54(c) of this title (relating to Accountability);(-b-) the respondent is not currently held in abeyance or barred from the award of a federal or state contract; and(-c-) the respondent is not delinquent in a tax owed the state under Chapter 171, Tax Code, pursuant to the Texas Business Corporation Act, Texas Civil Statutes, Article 2.45;(IX) the criteria for evaluation of proposals and contract award; and(X) all relevant factors the local authority will use to determine best value.(iii) A proposal must include:(I) the respondent's name, address, telephone number, and type of business entity; and(II) all information required in paragraphs (2)(B)(ii)(IV), (VII), and (VIII) of this subsection.(iv) Changes to an RFP may be made by the local authority prior to the date designated for submission of proposals if everyone who has obtained an RFP is notified of the changes and is provided equal opportunity to respond.(v) The local authority must keep all information contained in proposals confidential until a contract has been awarded.(vi) Any changes to a proposal must be made by the respondent in writing and must be received by the local authority prior to the submission date and time.(vii) The local authority may validate any information in a proposal by using outside sources or materials.(C) Award.(i) For a proposal to be considered for award, the respondent must follow the instructions and meet the requirements specified in the RFP.(ii) After the proposal submission date, the local authority may obtain clarification or confirmation of information submitted in a proposal if such information is necessary to complete the award process; however, no respondent may be given information which would give that respondent a competitive advantage over any other respondent.(iii) Negotiations may be conducted with a respondent to complete the procurement process or to complete an evaluation of a proposal.(I) If only one proposal is received that may be considered for award, the local authority and the respondent may negotiate the contract requirements as necessary to complete the procurement process.(II) If more than one proposal is received that may be considered for award, the local authority may negotiate to further evaluate proposals and to select one or more respondents for award; however, no respondent may be given information which will give that respondent a competitive advantage over any other respondent.(iv) The award of a contract procured through an RFP must be made in accordance with §412.55(c) of this title (relating to Contract Procurement).(v) The local authority may cancel an RFP without award. Source Note: The provisions of this §301.15 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.15 Competitive Procurement Methods for Community Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219920 03/12/2026 (a) Determination. The local authority may procure community services non-competitively only if:(1) the procurement is pursuant to the Texas Health and Safety Code, §533.017;(2) the services are proprietary to a single source or only one source can or will provide the service;(3) the services will be provided by a governmental entity;(4) there exists an emergency situation in which a delay may result in harm to a consumer who is to receive the community service;(5) the services are for less than $5000 and the total amount was not divided to qualify for a non-competitive procurement; or(6) a competitive procurement was attempted and either no qualified response or only one qualified response was received.(b) Award. The award of a contract procured non-competitively must be made in accordance with §412.55(c) of this title (relating to Contract Procurement). Source Note: The provisions of this §301.17 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.17 Non-competitive Procurement of Community Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219921 03/12/2026 (a) Determination. The local authority may issue a Request for Applications (RFA) to procure community services through open enrollment in accordance with this section.(b) Solicitation.(1) The local authority must publish in a local newspaper or professional association newsletter an RFA Notice to providers of all community services the local authority intends to procure through open enrollment. In addition, the local authority must continuously and prominently display such RFA Notice at the local authority's administrative office(s). At least once every two years the local authority must publish in a local newspaper or professional association newsletter an RFA Notice to providers of all community services currently procured through open enrollment. The RFA Notice must include:(A) a brief description of the types of community services the local authority intends to procure through open enrollment;(B) the geographic area to be served;(C) the procedure for obtaining an application; and(D) the date and time by which applications must be submitted, if any.(2) A local authority must provide an application to each business entity that requests one. An RFA must include:(A) a detailed description of each type of community service the local authority intends to procure through open enrollment, the consumer eligibility criteria, and all other information included in the RFA Notice;(B) the rate of payment for each type of community service and the method used to determine that rate;(C) a detailed description of the information to be included in an application;(D) instructions for the submission of applications;(E) respondents eligibility requirements for contract award (e.g., credentials for providing the community service(s), such as applicable certifications, licenses; evidence of compliance or ability to comply with relevant TDMHMR rules; evidence of accessibility; evidence of providing quality services; evidence of financial solvency; and evidence of liability insurance); and(F) assurances that:(i) the respondent is not currently held in abeyance or barred from the award of a federal or state contract; and(ii) the respondent is currently in good standing for state tax, pursuant to the Texas Business Corporation Act, Texas Civil Statutes, Article 2.45.(3) An application must include the following information:(A) the respondent's name, address, telephone number, and type of business entity;(B) all information required in paragraph (2)(C), (E), and (F) of this subsection; and(C) a statement that the respondent agrees to provide the specified community service(s) at the rate of payment described in the RFA.(c) Award.(1) The local authority may obtain clarification or confirmation of information submitted in an application.(2) The local authority must award a contract to all respondents whose applications are complete and who meet all requirements specified in the RFA.(3) All contracts for each type of community service provided through open enrollment must contain the same contract term, conditions, provisions, and requirements, including a statement that the contractor is prohibited from:(A) offering any gift with a value in excess of $10 to potential consumers; and(B) soliciting potential consumers through direct-mail or by telephone. Source Note: The provisions of this §301.19 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.19 Open Enrollment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219922 03/12/2026 (a) The local authority must maintain, and make available to consumers, current information about each community services contractor participating in its provider network. The information must represent all participating contractors fairly and must be organized and relevant to consumers.(b) The local authority must allow consumers to choose freely, without influence by any local authority staff or representative, any contractor participating in the provider network that provides the type of community service which the local authority has authorized for the consumer. Source Note: The provisions of this §301.21 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.21 Consumer Access to Participating Community Services Contractors in Provider Network https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219923 03/12/2026 (a) Monitoring. The local authority must maintain a contracts management system that ensures each community services contractor performs in accordance with the provisions of the contract. The local authority shall monitor each community services contractor's compliance with the contract and evaluate the contractor's provision of services, including:(1) competency of the contractor to provide care;(2) consumers' access to services;(3) safety of the environment in which services are provided;(4) continuity of care;(5) compliance with the performance expectations (referenced in §412.57(b)(13) of this title (relating to Provisions for Community Services Contracts));(6) satisfaction of consumers and family members with services provided; and(7) utilization of resources.(b) Enforcing. The local authority shall enforce each community services contract. The local authority shall develop policies and procedures regarding contract enforcement that address the use of at least the following enforcement actions:(1) training;(2) technical assistance for contractors;(3) a plan of correction; and(4) sanctions, which may include:(A) withholding or recouping funds;(B) imposing financial penalties;(C) requiring service delivery at no additional cost to the local authority;(D) suspending participation in the provider network;(E) contract amendment; and(F) contract termination. Source Note: The provisions of this §301.23 adopted to be effective April 22, 2001, 26 TexReg 2845; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES A CONTRACTS MANAGEMENT FOR LOCAL AUTHORITIES §301.23 Monitoring and Enforcing Community Services Contracts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221242 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221242 03/12/2026 The purpose of this subchapter is to protect consumers at a facility, local authority, community center, or contract provider of residential services, and the property of those consumers. To do so, this subchapter:(1) describes the process by which criminal history clearances are conducted for applicants for employment or volunteer status with facilities, local authorities, community centers, and contract providers of residential services;(2) requires facilities, local authorities, community centers, and contract providers of residential services to have an effective self-reporting procedure for employees and volunteers; and(3) describes the process by which registry clearances are conducted for applicants for employment or volunteer status with facilities, local authorities, community centers, and contract providers of residential services. Source Note: The provisions of this §301.51 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.51 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221243 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221243 03/12/2026 (a) This subchapter applies to:(1) facilities (which include TDMHMR Central Office);(2) local authorities; and(3) community centers.(b) Facilities, local authorities, and community centers must require their contract providers of residential services, including residences certified by the intermediate care facilities for the mentally retarded or persons with a related condition (ICF/MR or ICF/MR/RC) program that are owned and operated by a local authority or community center, to comply with the applicable provisions of this subchapter.(c) This subchapter does not apply to residences certified by the ICF/MR or ICF/MR/RC program that are owned by a local authority or community center but operated under contract by a private provider, or that are privately owned and operated. Criminal history and registry clearances are conducted for such residences in accordance with rules of the Texas Department of Human Services (TDHS) in 40 TAC §§76.101- 76.106. Source Note: The provisions of this §301.53 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.53 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221244 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221244 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Applicant--At the employer's discretion, either a person who is one of a select number of final candidates for a position as an employee or volunteer or a person to whom the employer intends to offer a position as an employee or volunteer. The term "applicant" does not include a member of the Texas MHMR Board, a member of a local authority's or community center's board of trustees, or a member of a facility's, local authority's, or community center's advisory committee that is not a public responsibility committee (PRC).(2) Community center--A community mental health and mental retardation center established under the Texas Health and Safety Code, Title 7, Chapter 534, Subchapter A.(3) Consumer--An individual receiving services from a facility, local authority, community center, or contract provider of residential services.(4) Conviction--The adjudication of guilt, plea of guilty or nolo contendere, or the assessment of probation or community supervision for a violation of the Penal Code.(5) Facility--Any state hospital, state school, or state center operated by TDMHMR, or TDMHMR Central Office.(6) Local authority--An entity designated by the TDMHMR commissioner in accordance with the Texas Health and Safety Code, §533.035(a).(7) Provider--Any entity or person who contracts with a facility, local authority, or community center to deliver residential services to individuals with mental illness or mental retardation who have been furloughed or discharged from a facility or community center as described in the Texas Government Code, §411.115(b). This does not include private ICF/MR or ICF/MR/RC providers.(8) Professional clinical intern--A person who is enrolled in a formal clinical rotation at a university/college in a professional training program accredited by the appropriate licensing authority or board of examiners, or is engaged in a recognized graduate level, clinical professional degree program. Professional degree programs include, but are not limited to, clinical psychology, dentistry, medicine, nursing, occupational therapy, pharmacy, physical therapy, psychiatry, and social work.(9) Registry--(A) The Nurse Aide Registry maintained by the Texas Department of Human Services in accordance with §94.11 of Title 40 (relating to Registry, Findings, Inquiries); and(B) the Employee Misconduct Registry maintained by the Texas Department of Human Services in accordance with the Texas Health and Safety Code, Chapter 253.(10) Visiting group--A group of varying individuals associated with an organization (e.g., civic, fraternal, corporate, religious, social, service, or education), which is not affiliated with a facility, local authority, community center, or provider, that visits a facility, local authority, community center, or provider (e.g., tours) or participates in a special event and has constant and adequate staff supervision.(11) Volunteer--An individual who is not part of a visiting group and who provides time or services to consumers, a facility, local authority, community center, volunteer services council, or provider without compensation from the facility, local authority, community center, volunteer services council, or provider other than reimbursement for actual expenses. The term does not include a professional clinical intern.(12) Volunteer services council--A 501(c)(3) organization that is formed for the purpose of generating resources on behalf of a facility, local authority, or community center. Source Note: The provisions of this §301.55 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.55 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221245 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221245 03/12/2026 (a) Each facility, local authority, community center, and provider must conduct:(1) a pre-employment criminal history and registry clearance of all applicants (as defined) for employment; and(2) a pre-assignment criminal history and registry clearance of all applicants for volunteer status.(b) A provider that is required to conduct criminal history and registry clearances in accordance with the Texas Health and Safety Code, Chapter 250, must provide evidence of compliance with that law to the facility, local authority, or community center with which it contracts.(c) For professional clinical interns, a written agreement must exist between the facility, local authority, or community center and the university/college. The written agreement must include:(1) a statement that responsibility for the care of consumers is retained by the facility, local authority, or community center;(2) a statement that background checks of professional clinical interns must ensure compliance with subsection (d) of this section; and(3) a description of how background checks of professional clinical interns will be conducted and funded.(d) The following individuals may not be employed by, assigned volunteer status at, or serve as a professional clinical intern at, a facility, local authority, community center, or provider:(1) an individual who has been convicted of any of the criminal offenses listed in subsection (g) of this section;(2) an individual who has been convicted of a criminal offense that the facility, local authority, community center, or provider has determined to be a contraindication to employment or volunteer status at that entity;(3) an individual who is listed as revoked in the Nurse Aide Registry; or(4) an individual who is listed as unemployable in the Employee Misconduct Registry.(e) The facility, local authority, community center, or provider must inform applicants in writing at the time that application is made of the following:(1) that a pre-employment/pre-assignment criminal history and registry clearance will be conducted;(2) the types of criminal offenses for which a conviction would bar employment or volunteer status as required by law;(3) that conviction of other types of criminal offenses may be considered a contraindication to employment or volunteer status at that entity; and(4) that being listed as revoked in the Nurse Aide Registry or being listed as unemployable in the Employee Misconduct Registry would bar employment or volunteer status.(f) An applicant who is not listed as revoked in the Nurse Aide Registry and who is not listed as unemployable in the Employee Misconduct Registry may be employed on a temporary or interim basis pending a criminal history clearance if an emergency exists in which there is a risk to the health and safety of consumers as a result of unfilled positions or in which the operations of the organization are severely impaired as determined by the chief executive officer of the facility, local authority, community center, or provider.(1) The applicant must furnish the employer with an affidavit stating that the applicant has not been convicted of any of the criminal offenses listed in subsection (g) of this section or any criminal offense that the employer has determined is a contraindication to employment. The affidavit will be kept in the applicant's file. A sample affidavit may be obtained by contacting Human Resource Services, TDMHMR, P.O. Box 12668, Austin, Texas 78711-2668.(2) Within 72 hours of the time the person is employed on a temporary or interim basis, the facility, local authority, community center, or provider must initiate a criminal history clearance of that person as described in §414.505 of this title (relating to Obtaining or Requesting Criminal History Record Information and Checking Registry).(3) If the criminal history record information reveals a conviction for any of the criminal offenses listed in subsection (g) of this section or for any criminal offense that the employer has determined is a contraindication to employment, then the facility, local authority, community center, or provider must immediately discharge the person as unemployable.(4) An applicant may not receive volunteer assignment on a temporary or interim basis pending a criminal history clearance.(g) Consistent with the Texas Health and Safety Code, §250.006, convictions of criminal offenses which constitute an absolute bar to employment are:(1) criminal homicide (Penal Code, Chapter 19);(2) kidnapping and unlawful restraint (Penal Code, Chapter 20);(3) indecency with a child (Penal Code, §21.11);(4) sexual assault (Penal Code, §22.011);(5) aggravated assault (Penal Code, §22.02);(6) injury to a child, elderly individual, or disabled individual (Penal Code, §22.04);(7) abandoning or endangering a child (Penal Code, §22.041);(8) aiding suicide (Penal Code, §22.08);(9) agreement to abduct from custody (Penal Code, §25.031);(10) sale or purchase of a child (Penal Code, §25.08);(11) arson (Penal Code, §28.02);(12) robbery (Penal Code, §29.02);(13) aggravated robbery (Penal Code, §29.03);(14) a conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed under paragraphs (1) - (13) of this subsection; and(15) a conviction which occurred within the previous five years for:(A) assault that is punishable as a Class A misdemeanor or as a felony (Penal Code, §22.01);(B) burglary (Penal Code, §30.02);(C) theft that is punishable as a felony (Penal Code, Chapter 31);(D) misapplicateion of fiduciary property or property of a financial institution that is punishable as a Class A misdemeanor or felony (Penal Code, §32.45); or(E) securing execution of a document by deception that is punishable as a Class A misdemeanor or a felony (Penal Code, §32.46). Source Note: The provisions of this §301.57 adopted to be effective February 6, 2002, 27 TexReg 749; amended to be effective September 1, 2003, 28 TexReg 6885; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.57 Pre-employment and Pre-assignment Clearance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221246 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221246 03/12/2026 (a) Facilities must obtain criminal history record information directly from the Texas Department of Public Safety (TDPS) by contacting Crime Records Services, TDPS, P.O. Box 4143, Austin, TX 78765-4143.(b) Local authorities and community centers may:(1) pay a private agency to obtain criminal history record information directly from TDPS; or(2) obtain criminal history record information directly from the Texas Department of Public Safety (TDPS) by contacting Crime Records Services, TDPS, P.O. Box 4143, Austin, TX 78765-4143.(c) In addition to obtaining criminal history record information from TDPS, facilities, local authorities, community centers, and providers must obtain criminal history information for applicants who have lived outside the State of Texas at any time during the two years preceding the application for employment/volunteer status through the FBI using a complete set of fingerprints on the official FBI card. The FBI charges for this information. The official FBI card may be obtained from Human Resource Services, TDMHMR, P.O. Box 12668, Austin, TX 78711-2668.(d) A provider that is not required to conduct criminal history clearances in accordance with the Texas Health and Safety Code, Chapter 250, must obtain criminal history record information through the facility, local authority, or community center with which it contracts.(e) Facilities, local authorities, community centers, and providers must check the Employee Misconduct Registry and the Nurse Aide Registry by calling 1-800-452-3934. Source Note: The provisions of this §301.59 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.59 Obtaining or Requesting Criminal History Record Information and Checking Registry https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221247 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221247 03/12/2026 (a) Facilities, local authorities, community centers, and providers will have written policies and procedures consistent with this subchapter that describe how information obtained through a criminal history and registry clearance will be processed and later destroyed. The policies and procedures must include:(1) processes that protect the confidentiality of criminal history record information pursuant to the Texas Health and Safety Code, §250.007;(2) the process for notifying an applicant if:(A) the applicant's criminal history record information identifies a conviction barring, or a contraindication to, employment or volunteer status; or(B) the applicant is listed as revoked in the Nurse Aide Registry or is listed as unemployable in the Employee Misconduct Registry;(3) information on how an applicant can address inaccuracies in criminal history record information (i.e., the opportunity to be heard by Texas Department of Public Safety (TDPS), pursuant to Texas Health and Safety Code, §250.005(b)) if the applicant believes he/she has been unjustly denied employment or volunteer status as a result of inaccurate criminal history record information; and(4) procedures for destroying all criminal history record information obtained in accordance with this subchapter after an employment/volunteer decision has been made or personal action has been taken, as required by the Texas Government Code, §411.115(e).(b) If an applicant's criminal history record information identifies a conviction barring employment or volunteer status or if the applicant is listed as revoked in the Nurse Aide Registry or is listed as unemployable in the Employee Misconduct Registry, then the applicant must be notified in writing of the following:(1) the existence of the TDPS or FBI record of the conviction or the registry listing;(2) the applicant's ineligibility for employment or volunteer status because of the conviction or registry listing; and(3) how to address possible inaccuracies in criminal history record information (i.e., the opportunity to be heard by Texas Department of Public Safety (TDPS), pursuant to Texas Health and Safety Code, §250.005(b)) or how to address a possibly inaccurate registry listing (i.e., by calling TDHS registry administrators at 1-800-458-9858). Source Note: The provisions of this §301.61 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.61 Criminal History Record Information and Registry Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221248 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221248 03/12/2026 (a) Upon the effective date of this subchapter, each facility, local authority, community center, and provider must initiate a registry check of all current employees and volunteers. If an employee/volunteer is listed as revoked in the Nurse Aide Registry or listed as unemployable in the Employee Misconduct Registry, then the employer must immediately discharge the employee or volunteer.(b) Following employment with or assignment of volunteer status at a facility, local authority, community center, or provider, all employees and volunteers must report to a person designated by that facility, local authority, community center, or provider:(1) any subsequent convictions or offenses for which they are charged; and(2) a subsequent listing as revoked in the Nurse Aide Registry or listing as unemployable in the Employee Misconduct Registry.(c) A facility, local authority, community center, or provider may conduct subsequent criminal history and registry checks on any employee or volunteer at any time it deems appropriate.(d) Each facility, local authority, community center, and provider must develop written policies and procedures consistent with this subchapter describing how it will respond to information obtained through self-reporting and subsequent criminal history and registry checks.(1) Pursuant to the Texas Health and Safety Code, §533.007(b), adverse personnel action may not be taken if the information received pertains to arrest warrants or wanted persons' notices. However, the employer may reassign the employee/volunteer to a non-direct care area until resolution of the matters relating to the arrest warrant or wanted persons' notice.(2) If the information reflects a conviction for an offense listed in §414.504(g) of this title (relating to Pre-employment and Pre-assignment Clearance), then consideration may be given to any contention by the employee/volunteer concerning errors of fact or identity in the criminal history record information. While the employee/volunteer is attempting to rectify the accuracy of the information, the employer must remove the employee/volunteer from direct contact with consumers. If the employee or volunteer fails to rectify the accuracy of the information, as provided by Texas Health and Safety Code, §250.005(b), then the employer must immediately discharge the employee or volunteer.(3) If the information reflects a conviction for an offense determined to be a contraindication to employment or volunteer status, then consideration may be given to any contention by the employee/volunteer concerning errors of fact or identity in the criminal history record information. While the employee/ volunteer is attempting to rectify the accuracy of the information, the employer may remove the employee/volunteer from direct contact with consumers. If the employee or volunteer fails to rectify the accuracy of the information, as provided by Texas Health and Safety Code, §250.005(b), then the employer must immediately discharge the employee or volunteer.(4) If the information indicates the employee/volunteer is listed as revoked in the Nurse Aide Registry or listed as unemployable in the Employee Misconduct Registry, then the employer must immediately discharge the employee or volunteer. Source Note: The provisions of this §301.63 adopted to be effective February 6, 2002, 27 TexReg 749; transferred effective October 30, 2024, as published in the October 18, 2024, issue of the Texas Register, 49 TexReg 8475. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES B CRIMINAL HISTORY AND REGISTRY CLEARANCES §301.63 Self-Reporting and Subsequent Criminal History and Registry Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219924 03/12/2026 The purpose of this subchapter is to comply with the Texas Health and Safety Code, §534.067, by establishing a uniform fee collection policy for local mental health authorities that:(1) is equitable;(2) provides for collections; and(3) maximizes contributions to local revenue. Source Note: The provisions of this §301.101 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219925 03/12/2026 (a) This subchapter applies to all local mental health authorities for community services contracted for through the performance contract that the authority provides directly or through subcontractors to members of the priority population. This subchapter also applies to persons in the priority population, and parents of persons under age 18 years in the priority population, who are seeking or receiving services.(b) This subchapter does not apply to:(1) programs and services that are prohibited by statute or regulation from charging fees to persons served (e.g., Early Childhood Intervention Program);(2) the department's In-Home and Family Support Program;(3) inpatient services in a state mental health facility and non-crisis residential services as described in the performance contract; and(4) specialized services mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987, as amended by OBRA 90, for preadmission screening and annual resident reviews (PASARR) provided to non-Medicaid eligible persons.(c) In this subchapter all references to a parent means the requirement is applicable to the parent of a person under age 18 years who is in the priority population and who is seeking or receiving services. Source Note: The provisions of this §301.103 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219926 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Ability to pay--The person has third-party coverage that will pay for needed services, the person's maximum monthly fee is greater than zero, or the person has identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ). (2) Community services or services--Except for inpatient services in a state mental health facility and non-crisis residential services, the required and optional mental health services described in the performance contract, including: (A) 24-hour emergency screening and rapid crisis stabilization services; (B) community-based crisis residential services or inpatient services in a mental health facility that is not a state mental health facility; (C) community-based assessments, including the development of interdisciplinary treatment plans, and diagnosis and evaluation services; (D) family support services, including respite care; (E) case management services; (F) medication-related services, including medication clinics, laboratory monitoring, medication education, mental health maintenance education, and the provision of medication; and (G) psychosocial rehabilitation programs, including social support activities, independent living skills, and vocational training. (3) Department--The Department of State Health Services. (4) Extraordinary expenses--Major medical or health related expenses, major casualty losses, and child care expenses for the previous year or projections for the next year. (5) Family members-- (A) For an unmarried person under the age of 18 years--The person, the person's parents, and the dependents of the parents, if residing in the same household; (B) For an unmarried person age 18 years or older--The person and his/her dependents; (C) For a married person of any age--The person, his/her spouse, and their dependents. (6) Full subsidy eligible individual-An individual who has income below 135 percent of the federal poverty level applicable to the individual's family size and has resources that do not exceed the limits specified in 42 CFR §423.773(b). A full subsidy individual is eligible to receive premium and cost-sharing subsidies for Medicare Part D prescription drug plans. All individuals who are dually eligible for Medicaid and Medicare are full subsidy eligible individuals. (7) Gross income--Revenue from all sources before taxes and other payroll deductions. The term does not include child support received. (8) Inability to pay--The person's maximum monthly fee is zero and the person: (A) does not have third-party coverage; (B) has third-party coverage, but has exceeded the maximum benefit of the covered service(s) or the third-party coverage will not pay because the services needed by the person are not covered services; or (C) has not identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ). (9) Income-based public insurance--Government funded third-party coverage that bases eligibility on income e.g., CHIP and Medicaid. (10) LMHA or local mental health authority--An entity designated as the local mental health authority by the department in accordance with the Texas Health and Safety Code, §533.035(a). (11) Performance contract--A written agreement between the department and a LMHA for the provision of one or more functions as described in the Texas Health and Safety Code, §533.035(a). (12) Person--A person in the priority population who is seeking or receiving services through a LMHA. (13) Priority population--Those groups of persons with mental illness identified in the department's current strategic plan as being most in need of mental health services. (14) Significant financial change--Any change in the person's (or parent's) financial documentation, as described in §412.105(d) of this title (relating to Accountability), that affects the person's (or parent's) ability to pay. Examples of a significant financial change are: (A) a reduction in income due to the loss of a job or due to a reduction in hours worked on a job; (B) an increase in income because of an inheritance or a salary increase; (C) an increase or decrease in the number of family members; (D) the gain or loss of third-party coverage; and (E) an increase or decrease in extraordinary expenses. (15) Standard charge--A fixed price for a community service or unit of service. (16) State mental health facility--A state hospital or a state center with an inpatient component. (17) Team--The interdisciplinary team, multidisciplinary team, or treatment team. (18) Third-party coverage--A public or private payer of community services for a specific person that is not the person (e.g., Medicaid, Medicare, private insurance, CHIP, TRICARE). Source Note: The provisions of this §301.105 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219927 03/12/2026 The department supports the following principles:(1) Persons are charged for services based on their ability to pay.(2) Procedures for determining ability to pay are fair, equitable, and consistently implemented.(3) Paying for services in accordance with his/her ability to pay reinforces the role of the person as a customer.(4) Earned revenues are optimized.(5) The department is the payer of last resort. Source Note: The provisions of this §301.107 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.107 Principles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219928 03/12/2026 (a) Prohibition from denying services. Local mental health authorities are prohibited from denying services to a person:(1) because of the person's inability to pay for the services;(2) in crisis because:(A) a financial assessment has not been completed;(B) financial responsibility has not been determined;(C) the person has a past-due account; or(D) the person had his/her services involuntarily reduced or terminated for non-payment under §412.109(d) of this title (relating to Payments, Collections, and Non-payment); or(3) pending resolution of an issue relating solely to payment for services, including failure of the person (or parent) to comply with any requirement in subsections (c), (d), (e), and (g) of this section.(b) Identifying funding sources. Local authorities are responsible for identifying and accessing available funding sources other than the department, and for assisting persons (and parents) in identifying and accessing available funding sources other than the department, to pay for services. Available funding sources may include third-party coverage, state and/or local governmental agency funds (e.g., crime victims fund), Qualified Medicare Beneficiary (QMB) Program, indigent pharmaceutical programs, or a trust that provides for the person's healthcare and rehabilitative needs.(c) Requirement for parents to enroll their children in income-based public insurance. Parents of children who may be eligible for Medicaid or the Children's Health Insurance Program (CHIP) must enroll their children in Medicaid or CHIP or provide documentation that they have been denied Medicaid or CHIP benefits or that their Medicaid or CHIP enrollment is pending. The LMHA shall provide assistance as needed to facilitate the enrollment process.(d) Financial documentation. If requested by the LMHA, persons (or parents) must provide the following financial documentation:(1) annual or monthly gross income/earnings, if any;(2) extraordinary expenses (as defined) paid during the past 12 months or projected for the next 12 months;(3) number of family members (as defined); and(4) proof of any third-party coverage.(e) Authorizing third-party coverage payment to the LMHA. Persons (and parents) with third-party coverage must execute an assignment of benefits authorizing third-party coverage payment to the LMHA.(f) Failure to comply.(1) Except as provided by paragraph (2) of this subsection, if the person (or parent) fails to comply with any requirement in subsections (c) - (e) or (h) of this section, then the LMHA will charge the person (or parent) the standard charge(s) for services. If, within 30 days after the person (or parent) initially failed to comply, the person (or parent) complies with the requirements, then the LMHA will adjust the person's account to retroactively reflect compliance.(2) The LMHA will not charge the person the standard charge(s) for services if the LMHA makes a decision, based on a clinical determination that is documented and includes input from the person's team, that the person's failure to comply is related to the person's mental illness. The clinical determination must be reassessed at least every three months. If the LMHA decides that a person's failure to comply is related to the person's mental illness, then the LMHA must develop and implement a plan to reduce or eliminate the barriers related to the person's failure to comply.(g) Requirement for adult persons to apply for SSI to become eligible for Medicaid. Adult persons who may be eligible for Medicaid must apply for Supplemental Security Income (SSI) or provide documentation that they have been denied SSI or that their SSI application is pending. The LMHA shall provide assistance as needed to facilitate all aspects of the application process. If the adult person is unable to act in accordance with the requirement because of the person's mental illness, then the LMHA must develop and implement a plan to reduce or eliminate the barriers related to the person's inability to act in accordance with the requirement.(h) Requirement for persons to enroll in Medicare Part D prescription drug plan.(1) A person who is a full subsidy eligible individual under Medicare Part D must choose and enroll in a Medicare Part D prescription drug plan.(2) The LMHA shall educate persons who are not full subsidy eligible individuals about the benefits of enrollment in a Medicare Part D prescription drug plan. The LMHA shall assess whether enrollment in a Medicare Part D prescription drug plan will be cost effective to the person and to the LMHA and shall provide the results of this assessment to the person to assist him or her determine whether to enroll in a Medicare Part D prescription drug plan. If the person decides to enroll in a Medicare Part D prescription drug plan, The LMHA may pay the person's incurred costs under the Medicare Part D prescription drug plan.(3) The LMHA shall provide assistance as needed to facilitate all aspects of the Medicare Part D enrollment process. If the person is unable to act in accordance with the requirements set forth in paragraph (1) or (2) of this subsection because of the person's mental illness, lack of adequate notification, or other circumstances beyond the individual's control, the LMHA shall continue to provide medications and must develop and implement a plan to reduce or eliminate the barriers related to the person's inability to act in accordance with the requirement. Source Note: The provisions of this §301.109 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.109 Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219929 03/12/2026 (a) Financial assessment. The LMHA must conduct and document a financial assessment for each person within the first 30 days of services. The LMHA must update each person's financial assessment at least annually and whenever a significant financial change (as defined) occurs as long as the person continues to receive services. The financial assessment is accomplished using the financial documentation listed in §412.105(d) of this title (relating to Accountability), which represents the finances of the: (1) person who is age 18 years or older and the person's spouse; or (2) parents of the person who is under age 18 years. (b) Maximum monthly fee. A person's maximum monthly fee is based on the financial assessment and calculated using the Monthly Ability-To-Pay Fee Schedule, referenced as Exhibit A in §412.113 of this title (relating to Exhibit). The calculation is based on the number of family members and annual gross income, reduced by extraordinary expenses paid during the past 12 months or projected for the next 12 months. No other sliding scale is used. (1) A maximum monthly fee that is greater than zero is established for persons who are determined as having an ability to pay. If two or more members of the same family are receiving services, then the maximum monthly fee is for the family. (2) A maximum monthly fee of zero is established for persons who are determined as having an inability to pay. (c) Third-party coverage. (1) Third-party coverage that will pay. A person with third-party coverage that will pay for needed services is determined as having an ability to pay for those services. (2) Third-party coverage that will not pay. (A) If the person's third-party coverage will not pay for needed services because the LMHA does not have an approved provider on its network, then the LMHA will propose to refer the person to his/her third-party coverage to identify a provider for which the third-party coverage will pay unless: (i) the LMHA is identified as being responsible for providing court-ordered outpatient services to the person; (ii) the LMHA is able to negotiate adequate payment for services with the person's third-party coverage; or (iii) the person (or parent) voluntarily agrees to pay the standard charge(s) for the needed service(s). (B) If the LMHA proposes to refer the person to his/her third-party coverage as described in paragraph (2)(A) of this subsection, then the LMHA will provide written notification to the person (or parent) in accordance with §412.109(e)(1) of this title (relating to Payments, Collections, and Non-payment), which provides an opportunity to appeal. The LMHA must also comply with §412.109(e)(2) - (3) as initiated by the person (or parent). (C) If the LMHA refers the person to his/her third-party coverage, then the LMHA will assist the person (or parent) in identifying a provider for which the third-party coverage will pay. (D) If a person who has been referred to his/her third-party coverage is unable to identify or access needed services from an approved provider or if access will be unduly delayed, then the LMHA will: (i) assist the person (or parent) in resolving the matter with the third-party coverage (e.g., contacting customer service at the third-party coverage, filing a complaint with the third-party coverage or the Texas Department of Insurance); and (ii) if clinically indicated, ensure the provision of the needed services to the person pending resolution. (E) The LMHA will maintain documentation of: (i) all referrals as described in paragraph (2)(C) of this subsection; (ii) all assistance as described in paragraph (2)(D)(i) of this subsection; and (iii) whether the person received services pending resolution as described in paragraph (2)(D)(ii) of this subsection. (d) Social Security work incentive provisions. A person who identified payment for specific needed services in his/her approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense ) is determined as having an ability to pay for the specific services. Persons are not required to identify payment for any service for which they may be eligible as part of their approved plan for utilizing the Social Security work incentive provisions. (e) Notification. After a financial assessment is conducted, the LMHA must provide written notification to the person (or parents) that includes: (1) the determination of whether the person (or parent) has an ability or an inability to pay; (2) a copy of the financial assessment form that is signed by the person (or parent) and a copy of the Monthly Ability-to-Pay Fee Schedule, with the applicable areas indicated (i.e., annual gross income, number of family members); (3) the amount of the maximum monthly fee; (4) the name and phone number of at least one LMHA staff who the person (or parent) may contact during office hours to discuss the information contained in the written notification; and (5) a statement that the person (or parent) may voluntarily pay more than the maximum monthly fee. Source Note: The provisions of this §301.111 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.111 Determination of Ability to Pay https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219930 03/12/2026 Each LMHA must establish, at least annually, a reasonable standard charge for each community service as indicated in the performance contract. The standard charge must cover, at a minimum, the LMHA's cost of ensuring the provision of the service. Source Note: The provisions of this §301.113 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.113 Standard Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219931 03/12/2026 (a) Monthly account.(1) The LMHA will maintain a monthly account for each person that lists all services provided to the person during the month and the standard charges for the services. Each service listed will indicate whether the service is:(A) covered by Medicare third-party coverage;(B) covered by non-Medicare third-party coverage;(C) not covered by third-party coverage; or(D) identified for payment in the person's approved plan utilizing Social Security work incentive provisions.(2) If a person has exceeded the maximum third-party coverage benefit of a particular covered service, then that service is indicated as not covered by third-party coverage.(b) Accessing funding sources. The LMHA must access all available funding sources before using the department's funds to pay for a person's services. Funding sources may include third-party coverage, state and/or local governmental agency funds (e.g., crime victims fund), Qualified Medicare Beneficiary (QMB) Program, indigent pharmaceutical programs, or a trust that provides for the person's healthcare and rehabilitative needs.(c) Billing third-party coverage. The LMHA will bill the person's third-party coverage the monthly account amount for covered services. If the LMHA has negotiated a reimbursement amount with the third-party coverage that is different from the monthly account amount, then the LMHA may bill the third-party coverage the negotiated reimbursement amount for covered services.(d) Billing the person (or parents).(1) No third-party coverage. If the monthly account amount for services not covered by third-party coverage:(A) exceeds the person's maximum monthly fee (MMF), then the amount is reduced to equal the MMF and the LMHA bills person (or parent) the MMF; or(B) is less than the person's MMF, then the LMHA bills the person (or parent) the monthly account amount for services not covered by third-party coverage.(2) Medicare third-party coverage. Nothing in this paragraph is intended to conflict with any applicable law, rule, or regulation with which a LMHA must comply.(A) The following amounts are added to equal the total amount applied toward the person's MMF:(i) the amount of all applicable co-payments and co-insurance for services listed in the monthly account as covered by Medicare third-party coverage;(ii) the amount Medicare third-party coverage was billed but did not pay because the deductible hasn't been met; and(iii) the monthly account amount for services not covered by third-party coverage.(B) If the total amount applied toward the person's MMF as described in paragraph (2)(A) of this subsection:(i) exceeds the person's MMF, then the amount is reduced to equal the MMF and the LMHA bills person (or parent) the MMF; or(ii) is less than the person's MMF, then the LMHA bills the person (or parent) the total amount applied toward the MMF.(3) Non-Medicare third-party coverage.(A) Cost-sharing exceeds MMF. If the amount of all applicable co-payments, co-insurance, and deductibles for services listed in the monthly account as covered by non-Medicare third-party coverage exceeds the person's MMF, then the LMHA bills the person (or parent) all applicable co-payments, co-insurance, and deductibles.(B) Cost-sharing does not exceed MMF.(i) If the amount of all applicable co-payments, co-insurance, and deductibles for services listed in the monthly account as covered by non-Medicare third-party coverage does not exceed the person's MMF, then the following amounts are added to equal the total amount applied toward the person's MMF:(I) the amount of all applicable co-payments, co-insurance, and deductibles; and(II) the monthly account amount for services not covered by third-party coverage.(ii) If the total amount applied toward the person's MMF as described in paragraph (3)(B) of this subsection:(I) exceeds the person's MMF, then the amount is reduced to equal the MMF and the LMHA bills person (or parent) the MMF; or(II) is less than the person's MMF, then the LMHA bills the person (or parent) the total amount applied toward the MMF.(C) Annual cost-sharing limit. If the person (or parent) has reached his/her annual cost-sharing limit (i.e., maximum out-of-pocket expense) as verified by the non-Medicare third-party coverage, then the LMHA will not bill the person (or parent) any co-payments, co-insurance, or deductibles, as applicable to the annual cost-sharing limit, for services covered by the non-Medicare third-party coverage for the remainder of the policy-year.(4) Social Security work incentive provisions.(A) If the person identified a payment amount for specific services in his/her approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense), then the LMHA bills the person the monthly account amount for the specific services up to the identified payment amount. If the monthly account amount for the specific services is greater than the identified payment amount, then the remaining balance is applied toward the person's MMF.(B) The following amounts are added to equal the total amount applied toward the person's MMF:(i) any remaining balance as described in paragraph (4)(A) of this subsection; and(ii) the monthly account amount for services not covered by third-party coverage.(C) If the total amount applied toward the person's MMF as described in paragraph (4)(B) of this subsection:(i) exceeds the person's MMF, then the amount is reduced to equal the MMF and the LMHA bills person (or parent) the MMF; or(ii) is less than the person's MMF, then the LMHA bills the person (or parent) the total amount applied toward the MMF.(e) Statements.(1) The LMHA will send to persons (and parents) who have been determined as having the ability to pay monthly or quarterly statements that include:(A) an itemized list, at least by date and by type, of all services provided during the period;(B) the standard charge for each service;(C) the total charge for the period;(D) the amount paid (or to be paid) by each funding source; and(E) the amount to be paid by the person (or parent).(2) Unless requested otherwise, the LMHA does not send statements to persons (or parents) who have an ability to pay if they maintain a zero balance (i.e., the person (or parent) does not currently owe any money).(3) Unless requested otherwise, the LMHA does not send statements to persons (or parents) who have an inability to pay. Source Note: The provisions of this §301.115 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; amended to be effective February 19, 2017, 42 TexReg 561; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.115 Billing Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219932 03/12/2026 (a) Payment and collection.(1) Persons (and parents) are responsible for promptly paying all charges owed to the LMHA.(2) The LMHAs are responsible for making reasonable efforts to collect payments from all available funding sources before accessing the department's funds to pay for persons' services.(b) Financial hardship. If a person (or parent) claims financial hardship as provided in this subsection, then the LMHA must determine whether a significant financial change (as defined) has occurred. If a significant financial change has occurred, then the LMHA must immediately update the person's (or parent's) financial assessment as required in §412.106(a) of this title (relating to Determination of Ability to Pay).(1) If a person (or parent) claims, and provides documentation, that financial hardship prevents prompt payment of all charges owed, then the LMHA may arrange for the person (or parent) to pay a lesser amount each month.(2) If a person (or parent) claims that financial hardship prevents prompt payment of all charges owed, then the LMHA must arrange for the person (or parent) to pay a lesser amount each month only if the person has third-party coverage that is neither income-based public insurance nor Medicare and the person's cost-sharing exceeds his/her MMF. The lesser amount:(A) will be no more than the person's MMF, if the person's MMF is greater than zero; or(B) will be no more than $5.00, if the person's MMF is zero.(3) Although the person (or parent) may pay a lesser amount each month because a portion of the charges will be deferred, the person (or parent) is still responsible for paying all charges owed.(c) Discontinuing charges to persons (or parents) for services. If the LMHA makes a decision, based on a clinical determination that is documented and includes input from the person's team, that being charged for services and receiving statements will result in a reduction in the functioning level of the person or the person's (or parent's) refusal or rejection of the needed services, then the LMHA will discontinue charging the person (or parent) for services and stop sending statements. The clinical determination must be reassessed at least every three months. If the LMHA decides to discontinue charging the person (or parent) for services, then the LMHA must develop and implement a plan to address the issues related to the person's functioning level or the person's (or parent's) refusal or rejection of the needed services.(d) Involuntary reduction or termination of services for non-payment by person (or parent).(1) The LMHA will address the past-due account of a person (or parent) who is not making payments to ensure reasonable efforts to secure payments are initiated with the person (or parent). For example, if the LMHA determines that non-payment is related to financial hardship, then the LMHA may assist the person (or parent) in making arrangements to pay a lesser amount each month in accordance with subsection (a)(2) of this section or if the LMHA makes a decision, based on a clinical determination that is documented and includes input from the person's team, that non-payment is related to the person's mental illness, then the person's treatment/service plan may be modified to address the non-payment.(2) If the LMHA makes a decision, based on a clinical determination that is documented and includes input from the person's team, that non-payment is not related to the person's mental illness and, despite reasonable efforts to secure payment, the person (or parent) does not pay, then the LMHA may propose to involuntarily reduce or terminate the person's services. The LMHA may not propose to involuntarily reduce or terminate the person's services if the proposed action would cause the person's mental or physical health to be at imminent risk of serious deterioration or the LMHA is identified as being responsible for providing court-ordered outpatient services to the person.(3) If the LMHA proposes to involuntarily reduce or terminate the person's services, then the LMHA must:(A) maintain clinical documentation that the proposed action would not cause the person's mental or physical health to be at imminent risk of serious deterioration;(B) provide written notification to the person (or parent) in accordance with subsection (e)(1) of this section and comply with subsection (e)(2) - (3) as initiated by the person (or parent).(e) Notification, Appeal, and Review.(1) Notification. The LMHA will notify the person (or parent) in writing of the proposed action (i.e., to involuntarily reduce or terminate the person's services or refer the person to his/her third-party coverage) and the right to appeal the proposed action in accordance with §401.464 of this title (relating to Notification and Appeals Process). The notification will describe the time frames and process for requesting an appeal and include a copy of this subchapter. If the person (or parent) requests an appeal within the prescribed time frame, then the LMHA may not take the proposed action while the appeal is pending. The LMHA may take the proposed action if the person (or parent) does not request a review within the prescribed time frame.(2) Appeal and appeal decision. The appeal is conducted in accordance with §401.464(g) of this title. The local mental health authority will notify the person (or parent) in writing of the appeal decision in accordance with §401.464(h) of this title and the right to have the appeal decision reviewed by the department's Mental Health and Substance Abuse Client's Rights Office (1-800-252-8154) if the person (or parent) is dissatisfied with the appeal decision. The notification must describe the time frames and process for requesting a review.(3) Review of appeal decision. If the person (or parent) is dissatisfied with the appeal decision, then the person (or parent) may request a review by the department's Mental Health and Substance Abuse Client's Rights Office. A request for review must be submitted to the department's Mental Health and Substance Abuse Client's Rights Office, Mail Code 2019, P.O. Box 12668, Austin, TX 78751, within 10 working days of receipt of the appeal decision. If the person (or parent) requests a review within the prescribed time frame, then the LMHA may not take the proposed action while the review is pending. The LMHA may take the proposed action if the person (or parent) does not request a review within the prescribed time frame and the appeal decision upholds the decision to take the proposed action.(A) A person (or parent) who requests a review may choose to have the reviewer conduct the review:(i) by telephone conference with the person (or parent) and a representative from the LMHA and make a decision based upon verbal testimony made during the telephone conference and any documents provided by the person (or parent) and the LMHA; or(ii) by making a decision based solely upon documents provided by the person (or parent) and the LMHA without the presence of any of the parties involved.(B) The review:(i) will be conducted no sooner than 10 working days and no later than 30 working days of receipt of the request for review unless an extension is granted by the director of the department's Mental Health and Substance Abuse Client's Rights Office;(ii) will include an examination of the pertinent information concerning the proposed action and may include consultation with the department's Mental Health and Substance Abuse Client's Rights Office clinical staff and staff who are responsible for the policy contained in this subchapter;(iii) will result in a final decision which will uphold, reverse, or modify the original decision to take the proposed action; and(iv) is the final step of the appeal process for involuntarily reducing or terminating the person's services for non-payment and for referring the person to his/her third-party coverage.(C) Within five working days after the review, the reviewer will send written notification of the final decision to the person (or parent) and the LMHA .(D) The LMHA will take appropriate action consistent with the final decision.(f) Prohibition of financial penalties. The LMHA may not impose financial penalties on a person (or parent).(g) Debt collection. Local authorities must make reasonable efforts to collect debts before an account is referred to a debt collection agency. Local authorities must document their efforts at debt collection.(1) Local authorities must incorporate into a written agreement or contract for debt collection provisions that state that both parties shall:(A) maintain the confidentiality of the information and not disclose the identity of the person or any other identifying information; and(B) not harass, threaten, or intimidate persons and their families.(2) Local authorities will enforce the provisions contained in paragraph (1) of this subsection. Source Note: The provisions of this §301.117 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.117 Payments, Collections, and Non-payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219933 03/12/2026 The Monthly Ability-To-Pay Fee Schedule, referenced as Exhibit A in §412.113 of this title (relating to Exhibit), is based on 150% of the Federal Poverty Guidelines. The department may revise the Monthly Ability-To-Pay Fee Schedule, based on any changes in the Federal Poverty Guidelines. Source Note: The provisions of this §301.119 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.119 Monthly Ability-to-Pay Fee Schedule https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219934 03/12/2026 In accordance with a prescribed training program developed by the department, all local mental health authority staff who are involved in implementing or explaining the content of this subchapter must demonstrate competency prior to performing tasks related to charging for community services and annually thereafter. Source Note: The provisions of this §301.121 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.121 Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219935 03/12/2026 (a) The department will develop a brochure that contains the policies for charging for community services that are contained in this subchapter, including:(1) a general reference to the statutory trust exemption; and(2) information related to claiming financial hardship.(b) The LMHA must provide persons (and parents) a copy of the brochure prior to their entry into services, except in a crisis. Source Note: The provisions of this §301.123 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.123 Brochure for Persons (and Parents) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219936 03/12/2026 This subchapter references Exhibit A--The Monthly Ability-To-Pay Fee Schedule, copies of which are available by contacting Mental Health and Substance Abuse Program Services, Department of State Health Services, Mail Code 2018, P.O. Box 13247, Austin, TX 78711-2668. Source Note: The provisions of this §301.125 adopted to be effective September 1, 2002, 27 TexReg 2041; amended to be effective September 15, 2005, 30 TexReg 5806; transferred effective August 15, 2024, as published in the July 19, 2024, issue of the Texas Register, 49 TexReg 5361. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES C CHARGES FOR COMMUNITY SERVICES §301.125 Exhibit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215660 03/12/2026 (a) The TXMHMR service system is dedicated to providing mental health and mental retardation services/supports which are viewed as satisfactory by persons receiving those services/supports and their legally authorized representatives. Therefore, local authorities and their contractors shall take steps to assure that these persons:(1) have a method to express their concerns or dissatisfaction;(2) are assisted to do so in a constructive way; and(3) have their concerns or dissatisfaction addressed through a review process.(b) A request to review decisions described in this section may be made by the person requesting or receiving services/supports, the person's legal representative, or any other individual with the person's consent.(c) At the time of admission into services and on an annual basis thereafter, the local authority and its contractors shall provide to persons who receive services/supports and their legally authorized representatives written notification in a language and/or method understood by the individual of the local authority or its contractor's policy for addressing concerns or dissatisfaction with services/supports. The notification shall explain:(1) an easily understood process for persons and legally authorized representatives to request a review of their concerns or dissatisfaction by the local authority or its contractor, whichever is appropriate;(2) how the person may receive assistance in requesting the review;(3) the timeframes for the review; and(4) the method by which the person is informed of the outcome of that review.(d) Local authorities and their contractors shall notify persons and legally authorized representatives in writing in a language and/or method understood by the individual of the following decisions and of the process to appeal by requesting a review of those decisions:(1) a decision to deny the person services/supports at the conclusion of a local authority's procedure which determines whether the person meets the criteria for the priority population; and(2) a decision to terminate services/supports and follow-along from the local authority or its contractor, if appropriate.(e) The written notification referred to in subsection (d) of this section must:(1) be given or mailed to the person and the legally authorized representative within ten working days of the date the decision was made;(2) state the reason for the decision;(3) explain that the person and legally authorized representative may contact either the local authority or its contractor, whichever is appropriate, within 30 days of receipt of notification if dissatisfied with the decision and request that the decision be reviewed in accordance with subsection (g) of this section; and(4) include name(s), phone number(s) and address(es) of one or more accessible staff to contact during office hours.(f) If a person or legally authorized representative believes that the local authority or its contractor has made a decision to involuntarily reduce services by changing the amount, duration, or scope of services/supports provided and is dissatisfied with that decision, then the person may request in writing that the decision be reviewed in accordance with subsection (g) of this section.(g) The review by the local authority or its contractor shall:(1) begin within ten working days of receipt of the request for a review and be completed within ten working days of the time it begins unless an extension is granted by the CEO of the local authority or its contractor, whichever is appropriate;(2) begin immediately upon receipt of the request and be completed within five working days if the decision is related to a crisis service;(3) be conducted by an individual(s) who was not involved in the initial decision;(4) include a review of the original decision which led to the person's dissatisfaction;(5) result in a decision to uphold, reverse, or modify the original decision; and(6) provide the person an opportunity to express his or her concerns in person or by telephone to the individual reviewing the decision. The review shall also allow the person to:(A) have a representative talk with the reviewer; or(B) submit his or her concerns in writing, on tape, or in some other fashion.(h) Following a review, either the local authority or its contractor, whichever is appropriate, shall explain to the person and legally authorized representative in writing and also in person or by telephone, if requested, the action it will take or, if no action will be taken, why it will not change the decision or believes such action would not be in the person's best interest. This is the final step in the review process.(i) The notification and review process described in this section:(1) is applicable only to services/supports funded by TXMHMR and provided or contracted for by its local authorities;(2) does not preclude a person or legally authorized representative's right to reviews, appeals, or other actions that accompany other funds administered through a local authority or its contractors, or to other appeals processes provided for by other state and federal laws, e.g., Texas Health and Safety Code, Title 7, Chapter 593 (Persons with Mental Retardation Act); 42 USC §1396 (Medicaid statute); and Texas Human Resources Code, Chapter 73 (Chapter 621 of this title (relating to Early Childhood Intervention)), Early Childhood Intervention programs as funded by the Texas Interagency Council for Early Childhood Intervention. Source Note: The provisions of this §301.155 adopted to be effective February 11, 1994, 19 TexReg 591; amended to be effective January 3, 1997, 21 TexReg 12402; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective January 1, 2024, as published in the Texas Register December 1, 2023, 48 TexReg 7081. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES D LIDDA, LMHA, AND LBHA NOTIFICATION AND APPEAL PROCESS §301.155 Notification and Appeals Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198572 03/12/2026 The purpose of this subchapter is to establish the process for a local mental health authority (LMHA) to assemble and maintain a network of service providers as required by the Health and Safety Code, §533.035(b) - (f). Source Note: The provisions of this §301.251 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.251 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198573 03/12/2026 This subchapter applies to local mental health authorities (LMHAs) and their use of funds disbursed by the Department of State Health Services (department) pursuant to the Health and Safety Code, §533.035(b), which authorizes the department to distribute funds to LMHAs for mental health services. Source Note: The provisions of this §301.253 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.253 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198574 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Critical infrastructure--The resources necessary to ensure services are available without significant disruption to the individuals served by the LMHA and to allow the LMHA to fulfill its obligations under the performance contract.(2) Department--The Texas Department of State Health Services.(3) Discrete services--Individual services provided as part of a defined level of care.(4) External provider--An organization that provides mental health services that is not an LMHA, or an individual who provides mental health services who is not an employee of an LMHA.(5) Individual--An individual seeking or receiving mental health services through an LMHA, or the individual's legally authorized representative.(6) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.(7) Licensed psychiatric hospital--A hospital that is:(A) A private psychiatric hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units) rules; or(B) an identifiable inpatient mental health services unit in a hospital licensed under Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital) rules.(8) LOC or level of care--A designation given to the department's standardized packages of mental health services which specify the amount, and duration of mental health services to be provided to an individual, based on the uniform assessment and utilization management guidelines referenced in §416.17 of this title (relating to Guidelines).(9) Local Authority Network Advisory Committee (LANAC)--The committee established under Health and Safety Code, §533.0351 to advise the department on technical and administrative issues that directly affect LMHA responsibilities. The committee has equal numbers of representatives from eight stakeholder groups.(10) Local mental health authority (LMHA)--An entity designated as a local mental health authority according to the Health and Safety Code, §533.035(a).(11) Local service area--A geographic area composed of one or more Texas counties defining the population that may receive mental health services through an LMHA.(12) Network development--The addition of new provider organizations, services, or capacity to an LMHA's external provider network.(13) Performance contract--The contract between the department and an LMHA that is in effect at the time of an action required under this subchapter.(14) Planning and Network Advisory Committee (PNAC)--The advisory committee of local stakeholders established by an LMHA as required by the performance contract.(15) Provider or service provider--An organization or person who delivers mental health services.(16) Qualified provider--A provider that is:(A) a practitioner with the minimum qualifications required by the performance contract; or(B) an organization that demonstrates the ability to provide services described in the performance contract, as specified in the department's approved procurement template.(17) Routine outpatient services--Services available in a level of care, excluding inpatient, residential and most crisis services. Routine outpatient services include office-based crisis intervention provided as part of rehabilitation services during normal business hours but exclude all other crisis services.(18) Service capacity--The estimated number of individuals that can be served in each level of care with available resources.(19) Specialized services--Services that are not generally provided by the individual's treatment team, including stand-alone crisis and residential services. Source Note: The provisions of this §301.255 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.255 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198575 03/12/2026 (a) Use of resources. An LMHA must maximize funds available to provide services by minimizing overhead and administrative costs and achieving purchasing efficiencies. Strategies that an LMHA must consider in achieving this objective include joint efforts with other local authorities related to authority functions, administrative activities, and service delivery.(b) Establishing a network. Each LMHA must demonstrate a reasonable effort to establish and maintain a network of qualified providers. In developing the network, the LMHA must consider public input, ultimate cost-benefit, and client care issues to ensure individual choice and best use of public funds.(c) Developing a plan. Each LMHA must develop a biennial (2-year) local network development plan (plan) to guide the development of the LMHA's provider network. The plan must reflect local needs and priorities and must be designed to maximize individual choice and individual access to services provided by qualified providers. The plan is a framework for network development based on a biennial assessment of provider availability and is not intended to limit procurement and contracting. LMHAs are expected to consider opportunities for network development that develop between planning periods. Such opportunities include new funding and/or services and inquiries from interested providers.(d) Involving the PNAC. The local PNAC must be actively involved in developing the plan. The local PNAC must receive information and training related to Provider Network Development, including the provisions of this subchapter and Health and Safety Code §533.035, §533.03521, and §533.0358. Source Note: The provisions of this §301.257 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.257 Local Network Development https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198578 03/12/2026 An LMHA may only provide services if one or more of the following conditions is present.(1) The LMHA determines that interested, qualified providers are not available to provide services in the LMHA's service area or that no providers meet procurement specifications.(2) The network of external providers does not provide the minimum level of individual choice. A minimal level of individual choice is present if individuals and their legally authorized representatives can choose from two or more qualified providers.(3) The network of external providers does not provide individuals with access to services that is equal to or better than the level of access in the local network, including services provided by the LMHA, as of a date determined by the department. An LMHA relying on this condition must submit the information necessary for the department to verify the level of access.(4) The combined volume of services delivered by external providers is not sufficient to meet 100 percent of the LMHA's service capacity for each level of care identified in the LMHA's plan.(5) Existing agreements restrict the LMHA's ability to contract with external providers for specific services during the two-year period covered by the LMHA's plan. If the LMHA relies on this condition, the department shall require the LMHA to submit copies of relevant agreements.(6) The LMHA documents that it is necessary for the LMHA to provide specified services during the two-year period covered by the LMHA's plan to preserve critical infrastructure needed to ensure continuous provision of services. An LMHA relying on this condition must:(A) document that it has evaluated a range of other measures to ensure continuous delivery of services, including but not limited to those identified by the LANAC and the department at the beginning of each planning cycle;(B) document implementation of appropriate other measures;(C) identify a timeframe for transitioning to an external provider network, during which the LMHA shall procure an increasing proportion of the service capacity from external provider in successive procurement cycles; and(D) give up its role as a service provider at the end of the transition period if the network has multiple external providers and the LMHA determines that external providers are willing and able to provide sufficient added service volume within a reasonable period of time to compensate for service volume lost should any one of the external provider contracts be terminated. Source Note: The provisions of this §301.259 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.259 Conditions Permitting LMHA Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198576 03/12/2026 (a) Website maintenance. The department shall maintain a website with information about network development.(b) Planning schedule and templates. Using input from the Local Authority Network Advisory Committee, the department will develop a biennial schedule and templates for the local network development plan and provider profile. In addition, the department will work with the LANAC to develop a list of measures that may be helpful in stabilizing the provider network and ensuring continuous delivery of services.(c) LMHA information. The department shall post minimum service requirements and service capacity information for each local service area on its website. Service capacity information includes:(1) the performance contract targets for the number of adults and children to be served by the LMHA;(2) the current state funding allocation for the LMHA;(3) the number of individuals served in each level of care in the previous fiscal year; and(4) the demographic breakout of individuals services in the previous fiscal year.(d) List of interested provider organizations. The department shall create and maintain a list showing the provider organizations interested in contracting with each LMHA.(1) The department's website must allow provider organizations to submit a description of their qualifications and indicate their interest in providing services in each local service area.(2) The website also must provide a mechanism for providers to send their information directly to LMHAs.(3) The department shall post information submitted by interested provider organizations on the department's website. The purpose of the list of interested provider organizations is to inform procurement decisions made by LMHAs, but the list may not be interpreted as conclusive evidence of the existence of interested, qualified provider organizations for purposes of determining that procurement is required.(e) Public access to plans. The department's website must provide public access to approved plans. Source Note: The provisions of this §301.261 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.261 Department Website https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198577 03/12/2026 An LMHA shall evaluate the potential for network development.(1) The LMHA must seek and use available information to identify and contact potential provider organizations, including the list of interested provider organizations posted on the department's website.(2) The LMHA must also consider current contractors, providers who have contacted the LMHA within the past two years, and other service providers in the local service area.(3) If a provider has submitted printed or electronic documentation of interest, the LMHA may not eliminate the provider from consideration during the planning process without evidence that the provider:(A) is no longer interested; or(B) is clearly not qualified or capable of providing services in accordance with applicable state and local laws and regulations.(4) The potential for network development exists if an LMHA has one or more provider organizations interested in providing routine outpatient or specialized services.(5) If an LMHA identifies the potential for network development, it must develop a procurement plan. The plan shall include all opportunities for network development, except as limited by the conditions listed in §412.755 of this title (relating to Conditions Permitting LMHA Service Delivery). This includes opportunities to add new services, new provider organizations, and/or additional capacity. An LMHA may choose to procure discrete services if it can ensure the integrity of levels of care and effective service coordination. Source Note: The provisions of this §301.263 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.263 Network Development Evaluation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198579 03/12/2026 (a) Plan preparation. An LMHA must use the results of its network development evaluation described in §412.757 of this title (relating to Network Development Evaluation) to create its draft plan.(b) Plan content applicable to all LMHAs. All plans must include the following components.(1) The LMHA's projected service capacity for each level of care based on service data from the previous fiscal year for services provided under the performance contract and any information about changes that will impact the service capacity.(2) Baseline data specified by the department showing the type and quantity of services provided by the LMHA and by external providers.(3) A description of the process the LMHA used to evaluate the potential for network development and the results of that evaluation, including any information relating to specific services or populations.(4) A list of the LMHA's external providers, including all current contractors and any other providers with whom the LMHA had a contract or agreement in effect during any part of the current or previous fiscal year. The list shall include the number of contracts and agreements with individual peer support providers, but not the names of individual peer support providers without their written consent.(c) Plan content for LMHAs with potential for network development. If an LMHA identifies the potential for network development, the plan must also include the following elements.(1) A description of the LMHA's plans for procurement, including:(A) the adult and children's services to be procured;(B) the capacity to be procured for each service;(C) the geographic area(s) in which services would be procured;(D) the procurement method(s) to be used; and(E) the timeline(s) for conducting the procurement.(2) The rationale for any provision that would limit individual choice or prevent procurement of all available capacity offered by external provider organizations.(A) The rationale must address any proposed restrictions on:(i) the type of service to be procured;(ii) the volume of services to be procured;(iii) the geographic area in which services would be procured; or(iv) the number of providers to be accepted.(B) The rationale for limiting procurement must be based on one or more of the conditions identified in §412.755 of this title (relating to Conditions Permitting LMHA Service Delivery).(C) The rationale must provide a basis for the proposed level of restriction, including the volume of services to be provided by the LMHA. An LMHA may be required to submit additional data to support its rationale.(3) A description of the strategies the LMHA would use to maximize funds available to provide services, as required in §412.754(c) of this title (relating to Local Network Development).(4) A summary of procurement activities from past network and development planning cycles and the results of those efforts.(5) If an LMHA is not procuring all available capacity offered by external provider organizations, the timeframe and steps for achieving full procurement of the external provider capacity identified in its network development evaluation, not to exceed the LMHA's capacity. Source Note: The provisions of this §301.265 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.265 Content of the Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198580 03/12/2026 (a) Distributing the draft plan. An LMHA shall post the draft plan on its website and invite public comment for at least 30 days. The LMHA shall send notice of the opportunity for comment to key stakeholders, including local consumer and advocacy groups, all licensed psychiatric hospitals in the LMHA's service area, and all providers identified in its network development evaluation.(b) Responding to public comment. The LMHA shall acknowledge and consider all comments received and make any revisions it deems appropriate.(c) Plan submission. The LMHA shall submit its proposed plan to the department with:(1) a summary of the public comments received; and(2) the LMHA's response to the comments. Source Note: The provisions of this §301.267 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.267 Public Comment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198581 03/12/2026 (a) Department review. The department shall review each plan to ensure compliance with the requirements of this subchapter and to determine whether the LMHA is making reasonable attempts to develop its provider network.(1) The department shall establish a mechanism for stakeholder involvement in the review process.(2) In reviewing an LMHA's plan, the department shall evaluate the level of effort made by the LMHA to achieve compliance and the rationale and any supporting documentation for its decisions and plans. This evaluation must include:(A) the LMHA's response to public comment;(B) the LMHA's past efforts and progress made in developing a network of external providers;(C) the specific context of the local service area, including population density and distribution, existing service organizations, and local priorities;(D) the potential impact on individual choice and access; and(E) input from the LMHA's PNAC.(3) The department may require an LMHA to submit additional information or documentation.(b) Department approval. The department shall notify an LMHA of its decision within the timeframe established at the beginning of the planning cycle.(1) The department shall approve the plan if it determines that the LMHA:(A) is in compliance with the requirements of this subchapter; and(B) is making reasonable attempts to develop an available and appropriate external provider base that is sufficient to meet the needs of individuals in its local service area.(2) The department may require the LMHA to make revisions before approving the plan. If revisions are required, the department will determine a timeframe for resubmission.(c) Posting the approved plan. After the department approves the plan, the LMHA shall post the approved version on its website. The posting must include the summary of public comments and the LMHA's response.(d) Implementation. An LMHA shall conduct procurement as described in its approved plan.(e) Amendment. If an LMHA determines it is unable to conduct the procurement as originally approved by the department, it shall submit a request for plan amendment to the department within 30 days of making the determination. An amendment is not required to expand the scope of a planned procurement or to conduct additional procurements outside of what is approved by the department. The department will evaluate the amendment request using the same process used for the original plan. Any proposed amendment must be approved in writing by the department and posted on the LMHA's website before it is implemented.(f) List of external providers. The LMHA must maintain a current list of external providers on its website, including the name of each organization or private practitioner and the services provided. The list shall include the number of contracts and agreements with individual peer support providers, but not the names of individual peer support providers. Source Note: The provisions of this §301.269 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.269 Plan Approval and Implementation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198582 03/12/2026 (a) Procurement procedures. An LMHA shall develop and implement procurement procedures that comply with applicable state laws and rules. The LMHA may procure mental health services by any procurement method allowed by applicable statutes and rules that provides the best value to the LMHA.(b) Content of the procurement document. A procurement document shall include:(1) the actual or maximum rate of payment for providing the services, as applicable;(2) the criteria for determining whether an applicant is a qualified provider; and(3) a detailed description of information to be included in a proposal, including:(A) how the provider would meet the cultural and linguistic needs of the individuals in the LMHA's local service area; and(B) how the provider would involve individuals, legally authorized representatives, and families at the policy and practice levels within the respondent's organization.(c) Publication. An LMHA shall publicize the procurement document by:(1) posting on the Electronic State Business Daily;(2) posting on the LMHA's website;(3) posting a link on the department website;(4) sending to providers known to be interested in providing services in the LMHA's local service area; and(5) sending to local consumer and advocacy organizations and local private psychiatric hospitals.(d) Provider follow-up. If a provider submits printed or electronic documentation of interest but does not submit an application, the LMHA shall attempt to contact the provider to determine why the provider withdrew from the process.(e) Provider standards. An LMHA shall not apply more rigorous standards and requirements to external providers than it applies to its own programs and staff. This does not preclude the LMHA from requiring documentation and reporting necessary to verify compliance with the terms of the contract.(f) Provider compensation. An LMHA shall pay external providers a fair and reasonable rate in relation to the local prevailing market.(g) Monitoring and enforcement. An LMHA shall implement effective procedures for contract monitoring and enforce the requirements set out in applicable rules and contract provisions. Examples include standards for service delivery, cultural and linguistic competency, and consumer protections. Source Note: The provisions of this §301.271 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.271 Procurement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198583 03/12/2026 Report content. An LMHA shall submit a post procurement report to the department within 30 days of completing a procurement described in the LMHA's approved plan. If procurement is conducted through open enrollment, the LMHA shall submit a procurement report at intervals specified in the timeline established by the department at the beginning of the planning cycle. The report must include:(1) a list of the applications received in response to the procurement;(2) the results of the procurement;(3) an updated list of the LMHA's external providers; and(4) the responses from providers who did not complete the procurement process regarding their reasons for withdrawing from consideration, if applicable. Source Note: The provisions of this §301.273 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.273 Post Procurement Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198584 03/12/2026 (a) Local appeal process. An LMHA shall establish an appeal process for providers that:(1) is available to any provider who submitted a written statement of interest or participated in any phase of the procurement process; and(2) includes an opportunity for informal review and resolution as well as a formal appeal procedure.(b) Department review. If an issue cannot be resolved at the local level and involves an alleged violation by the LMHA of a state rule or contract provision, either the LMHA or the provider may submit the issue to the department in writing for review. Potential actions that may be taken by the department shall be defined in the performance contract. The decision of the Commissioner or his designee will be final. Source Note: The provisions of this §301.275 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.275 Appeals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198571 03/12/2026 (a) Individual choice. An LMHA shall give consumers the opportunity to choose from any available provider in the LMHA's provider network offering services for which the individual is authorized at the time of admission and at least annually thereafter.(b) Changing providers. Individuals may request and change providers at any time.(c) Provider information. An LMHA shall maintain a current list of providers and a provider profile for each provider in the network, including the LMHA, on its website. The LMHA's website must also provide instructions for requesting a change in providers as described in §401.464 of this title (relating to Notification and Appeals Processes).(1) The provider list must include the following information about each provider:(A) name;(B) service locations and the services provided at each location; and(C) contact information, including the provider's website address.(2) The provider profile is a standardized form completed by the provider, may include information such as staffing patterns, special features of service delivery, and cultural and linguistic specialization. An LMHA shall use the provider profile template established by the department at the beginning of the planning cycle. The LMHA may add additional items to the provider profile based on input from the local PNAC.(d) Provider selection process. The LMHA shall inform individuals, verbally and in writing, that they may choose to receive services from any available provider in the LMHA's network that offers the authorized services. The LMHA shall also provide individuals with a neutral presentation of available providers consistent with the plan to support consumer transition to the external network described in subsection (f) of this section. When an individual is given the opportunity to choose a provider, the LMHA shall:(1) state that the individual may change providers at any time;(2) give the individual the provider list, provider profiles, and a written copy of the procedures for requesting a change in providers;(3) allow a reasonable period of time and make an area available for the individual to review the materials and make a decision; and(4) maintain documentation of the individual's choice of provider.(e) An LMHA shall not offer or schedule services before the individual selects a provider. If an individual is unable to select a provider or does not select a provider before leaving the first appointment, the LMHA shall provide the consumer with an appointment for ongoing services at an assigned provider. Except as provided in subsection (f) of this section, assignments shall rotate equally among all available external providers. In this situation, the LMHA shall also provide the individual with information about how to have the appointment rescheduled with a different provider.(f) External network transition plan. The LMHA shall develop and implement a plan to promote consumer transition to the external network when a new provider joins the network.(1) The plan shall be developed with input from the LMHA's PNAC, any local consumer-operated organization, and its external providers.(2) LMHAs may emphasize benefits of receiving services from an external provider, but shall not favor one provider over another except to identify service sites that may be more convenient for a client.(3) The plan may include reassigning consumers to external providers based on geographic proximity, but must give them the option of choosing a different provider instead.(4) The plan may include directing new individuals to choose an external provider, but must give them the option of choosing an LMHA service site instead. Source Note: The provisions of this §301.277 adopted to be effective January 1, 2015, 39 TexReg 10478; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES F PROVIDER NETWORK DEVELOPMENT §301.277 Individual Selection of Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198539 03/12/2026 (a) The purpose of this subchapter is to establish performance requirements and standards for the provision of mental health community services, as authorized by the Texas Health and Safety Code, §534.052.(b) This subchapter applies to persons and entities with which the department contracts, including local mental health authorities (LMHA), managed care organizations (MCO), providers of mental health rehabilitative services, as defined in §419.453 of this title (relating to Definitions), and providers of mental health case management services, as defined in §412.403 of this title (relating to Definitions), and requires that they ensure the performance requirements and standards in this subchapter are met in the provision of mental health community services. Source Note: The provisions of this §301.301 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.301 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198540 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198540 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Access--The ability to obtain mental health community services based upon components such as availability and acceptability of services to the individual, or the individual's Legally Authorized Representative (LAR) on the individual's behalf, transportation, distance, hours of operation, language, and the cultural competency of staff members. Barriers to access may be structural, financial, or specific to the individual.(2) Adolescent--An individual who is at least 13 years of age, but younger than 18 years of age.(3) Adult--An individual who is 18 years of age or older.(4) Advanced practice nurse--A staff member who is a registered nurse approved by the Texas Board of Nursing as a clinical nurse specialist in psychiatric/mental health or nurse practitioner in psychiatric/mental health, in accordance with Texas Occupations Code, Chapter 301.(5) Advocacy--Support for an individual or family member in expressing and resolving issues or concerns regarding access to or quality and appropriateness of services.(6) Appeal--A mechanism for an independent review of an adverse determination.(7) Assessment--A systematic process for measuring an individual's service needs.(8) Child--An individual who is at least three years of age, but younger than 13 years of age.(9) Competency--Demonstrated knowledge and skilled performance of a particular activity.(10) Continuity of services--Services that ensure uninterrupted services are provided to an individual during a transition between service types (e.g., inpatient services, outpatient services) or providers, in accordance with applicable rules (e.g., Chapter 412, Subchapter D of this title (relating to Mental Health Services - Admission, Continuity, and Discharge)). These activities include:(A) assisting with admissions and discharges;(B) facilitating access to appropriate services and supports in the community, including identifying and connecting the individual with community resources;(C) participating in the individual's treatment plan development and reviews;(D) promoting implementation of the individual's treatment plan or continuing care plan; and(E) facilitating coordination and follow-up between the individual and the individual's family, as well as with available community resources.(11) COPSD or co-occurring psychiatric and substance use disorders--The co-occurring diagnoses of psychiatric disorders and substance use disorders.(12) Credentialing--A process to review and approve a staff member's educational status, experience, and licensure status (as applicable) to ensure that the staff member meets the departmental requirements for service provision. The process includes primary source verification of credentials, establishing and applying specific criteria and prerequisites to determine the staff member's initial and ongoing competency and assessing and validating the staff member's qualification to deliver care. Re-credentialing is the periodic process of reevaluating the staff's competency and qualifications.(13) Crisis--A situation in which:(A) the individual presents an immediate danger to self or others; or(B) the individual's mental or physical health is at risk of serious deterioration; or(C) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk of serious deterioration.(14) Crisis services--Mental health community services or other necessary interventions provided to an individual in crisis.(15) CSSP or community services specialist--A staff member who, as of August 31, 2004:(A) received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state;(B) had three continuous years of documented full-time experience in the provision of mental health rehabilitative services or case management services; and(C) demonstrated competency in the provision and documentation of mental health rehabilitative or case management services in accordance with Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services) and Chapter 412, Subchapter I of this title (relating to Mental Health Case Management Services).(16) Cultural competency--Demonstrated knowledge and skill by a staff member to effectively respond to an individual's needs through knowledge of communication, actions, customs, beliefs, and values, within the individual's racial, ethnic, religious beliefs, disability, and social groups.(17) Department--Department of State Health Services (DSHS).(18) Department-approved algorithm--An evidence-based process for providing psychiatric care to adults with severe and persistent mental illnesses and children and adolescents with serious emotional disturbance, consisting of consensus-derived guidelines for medication treatment, training and support for physicians, standardized documentation, and patient and family education.(19) DSM--The current edition of the Diagnostic Statistical Manual of Mental Disorders published by the American Psychiatric Association.(20) Emergency care services--Mental health community services or other necessary interventions directed to address the immediate needs of an individual in crisis in order to assure the safety of the individual and others who may be placed at risk by the individual's behaviors, including, but not limited to, psychiatric evaluations, administration of medications, hospitalization, stabilization or resolution of the crisis.(21) Face-to-face--A contact with an individual that occurs in person. Face-to-face does not include contacts made through the use of video conferencing or telecommunication technologies, including telemedicine.(22) Family member--Any person who an individual identifies as being a member of their family.(23) Family partner--An experienced, trained primary caregiver (i.e., parent of an individual with a mental illness or serious emotional disturbance) who provides peer mentoring, education, and support to the caregivers of a child who is receiving mental health community services.(24) HIPAA--The Health Insurance Portability and Accountability Act, 42 U.S.C. §1320d et seq.(25) Identifying information--The name, address, date of birth, social security number, or any information by which the identity of an individual can be determined either directly or by reference to other publicly available information. The term includes medical records, graphs, and charts that contain an individual's information; statements made by the individual either orally or in writing while receiving mental health community services; videotapes, audiotapes, photographs, and other recorded media; and any acknowledgment that an individual is receiving or has received services from a state facility, LMHA, MCO, or provider.(26) Indicator--A defined, measurable variable used to monitor the quality or appropriateness of an important aspect of an individual's care or service or an organization's performance of related functions, processes, or outcomes. Indicators can measure activities, events, occurrences, or outcomes for which data can be collected to allow comparison with a threshold, a benchmark, or prior performance.(27) Individual--A person who is seeking or receiving mental health community services from or through a provider.(28) LAR or legally authorized representative--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.(29) LCDC or licensed chemical dependency counselor--A counselor licensed by the department pursuant to the Texas Occupations Code, Chapter 504.(30) LCSW or licensed clinical social worker--A staff member who is licensed as a clinical social worker by the Texas State Board of Social Worker Examiners in accordance with the Texas Occupations Code, Chapter 505.(31) LMFT or licensed marriage and family therapist--A staff member who is licensed as a licensed marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists in accordance with Texas Occupations Code, Chapter 502.(32) LMHA or local mental health authority--An entity designated as the local mental authority by the department in accordance with the Texas Health and Safety Code, §533.035(a).(33) LOC or level of care--A designation given to the department's standardized packages of mental health community services, based on the uniform assessment and the utilization management guidelines, which recommend the type, amount, and duration of mental health community services to be provided to an individual.(34) LPC or licensed professional counselor--A staff member who is licensed as a licensed professional counselor by the Texas State Board of Examiners of Professional Counselors in accordance with Texas Occupations Code, Chapter 503.(35) LPHA or licensed practitioner of the healing arts--A staff member who is:(A) a physician;(B) a licensed professional counselor (LPC);(C) a licensed clinical social worker (LCSW);(D) a psychologist;(E) an advanced practice registered nurse (APRN);(F) a physician assistant (PA); or(G) a licensed marriage and family therapist (LMFT).(36) LVN or licensed vocational nurse--A staff member who is licensed as a licensed vocational nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.(37) Management information system--An information system designed to supply an LMHA or MCO with information needed to plan, organize, staff, direct, and control their operations and clinical decision-making.(38) MCO or managed care organization--An entity that has a current Texas Department of Insurance certificate of authority to operate as a Health Maintenance Organization (HMO) in the Texas Insurance Code, Chapter 843, or as an approved nonprofit health corporation in the Texas Insurance Code, Chapter 844, and that provides mental health community services pursuant to a contract with the department.(39) Medical necessity--The need for a service that:(A) is reasonable and necessary for the diagnosis or treatment of a mental health disorder or a co-occurring psychiatric and substance use disorder (COPSD) in order to improve or maintain an individual's level of functioning;(B) is provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;(C) is furnished in the most clinically appropriate, available setting in which the service can be safely provided;(D) is provided at a level that is safe and appropriate for the individual's needs and facilitates the individual's recovery; and(E) could not be omitted without adversely affecting the individual's mental or physical health or the quality of care rendered.(40) Medical record--The systematic, organized account, compiled by health care providers, of information relevant to the services provided to an individual. This includes an individual's history, present illness, findings on examination, treatment and discharge plans, details of direct and indirect care and services, and notes on progress.(41) Mental health community services--All services medically necessary to treat, care for, supervise, and rehabilitate individuals who have a mental illness or emotional disorder or a COPSD. These services include services for the prevention of and recovery from such disorders, but do not include inpatient services provided in a state facility.(42) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, dementia, substance use disorder, mental retardation, or pervasive developmental disorder) that:(A) substantially impairs an individual's thought, perception of reality, emotional process, development, or judgment; or(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.(43) Peer provider--A staff member who:(A) has received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state;(B) has at least one cumulative year of receiving mental health community services; and(C) is under the direct clinical supervision of an LPHA.(44) Physician--A staff member who is:(A) licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code, Chapter 155; or(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board.(45) Physician assistant--A staff member who has specialized psychiatric/mental health training and who is licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners in accordance with Texas Occupations Code, Chapter 204.(46) Provider--Any person or legal entity that contracts with the department, an LMHA, or an MCO to provide mental health community services to individuals, including that part of an LMHA or MCO directly providing mental health community services to individuals. The term includes providers of mental health case management services and providers of mental health rehabilitative services.(47) Psychologist--A staff member who is licensed as a psychologist by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.(48) QMHP-CS or qualified mental health professional-community services--A staff member who is credentialed as a QMHP-CS who has demonstrated and documented competency in the work to be performed and:(A) has a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major (as determined by the LMHA or MCO in accordance with §412.316(d) of this title (relating to Competency and Credentialing)) in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; (B) is a registered nurse (RN); or (C) completes an alternative credentialing process as determined by the LMHA or MCO in accordance with §412.316(c) and (d) of this title relating to (Competency and Credentialing).(49) Recovery--The process by which a person becomes able or regains the ability to live, work, learn, and participate fully in his or her community.(50) Referral--The process of identifying appropriate services and providing the information and assistance needed to access them.(51) RN or registered nurse--A staff member who is licensed as a registered nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.(52) Restraint--The same meaning as defined in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).(53) Routine care services--Mental health community services provided to an individual who is not in crisis.(54) Safety monitoring--Ongoing observation of an individual to ensure the individual's safety. An appropriate staff person must be continuously present in the individual's immediate vicinity, provide ongoing monitoring of the individual's mental and physical status, and ensure rapid response to indications of a need for assistance or intervention. Safety monitoring includes maintaining continuous visual contact with frequent face-to-face contacts as needed.(55) Screening Activities performed by a Qualified Mental Health Professional--Community Services (QMHP-CS) to gather triage information to determine the need for in-depth assessment. The QMHP-CS collects this information through face-to-face or telephone interviews with the individual or collateral. This service includes screenings to determine if the individual's need is emergent, urgent, or routine (which is conducted prior to the face-to-face assessment to determine the need for emergency services).(56) Seclusion--The same meaning as defined in Chapter 415, Subchapter F of this title.(57) Staff member--Anyone who works or provides services for an LMHA, MCO, or provider as an employee, contractor, intern, or volunteer.(58) Support services--Mental health community services delivered to an individual, LAR, or family member(s) to assist the individual in functioning in the individual's chosen living, learning, working, and socializing environments.(59) Telemedicine--The use of health care information exchanged from one site to another via electronic communications for the health and education of the individual or provider, and for the purpose of improving patient care, treatment, and services. This definition applies only for purposes of this subchapter and does not affect, modify, or relate in any way to other rules defining the term or regulating the service, or to any statutory definitions or requirements.(60) Uniform assessment--An assessment tool developed by the department that includes, but is not limited to, the Adult Texas Recommended Assessment Guidelines (TRAG), the Children and Adolescent Texas Recommended Assessment Guidelines, and the department-approved algorithms.(61) Urgent care services--Mental health community services or other necessary interventions provided to persons in crisis who do not need emergency care services, but who are potentially at risk of serious deterioration.(62) Utilization management exception--The authorization of additional amounts of services based on medical necessity when the individual has reached the maximum service units of their currently authorized level of care (LOC).(63) Utilization management guidelines--Guidelines developed by the department that establish the type, amount, and duration of mental health community services for each LOC.(64) Volunteer--A person who receives no remuneration for the provision of time, individual attention, or assistance to individuals receiving mental health community services from entities or providers governed by this subchapter. Volunteers may include:(A) community members;(B) family members of individuals served when not acting in their capacity as a family member;(C) employees when not acting in their capacity as employees; and(D) individuals served when acting on behalf of another individual. Source Note: The provisions of this §301.303 adopted to be effective April 29, 2009, 34 TexReg 2603; amended to be effective February 19, 2017, 42 TexReg 561; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.303 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198541 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198541 03/12/2026 (a) Compliance with Divisions 2 - 3 of this subchapter requires: (1) the LMHA and MCO to comply with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter; (2) the LMHA and MCO to obligate by contract the providers in their networks to comply with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter; (3) the LMHA and MCO to monitor their providers for compliance with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter; and (4) providers of mental health case management or mental health rehabilitative services to comply with §412.311(e) of this title (relating to Leadership), §412.312 of this title (relating to Environment of Care and Safety), §412.313 of this title (relating to Rights and Protection), §412.314(e) of this title (relating to Access to Mental Health Community Services), §412.315 of this title (relating to Medical Records System), and §412.316 of this title (relating to Competency and Credentialing), contained in Division 2 of this subchapter, and with all the sections in Division 3 of this subchapter. (b) Providers must comply with the department's Utilization Management Guidelines, which are incorporated by reference, if contractually obligated to provide any mental health community services, including mental health rehabilitative, mental health case management, supported housing, supported employment, or Assertive Community Treatment (ACT). The department is responsible for monitoring compliance by providers that contract with the department and the LMHA and MCO are responsible for requiring and monitoring compliance of providers in their networks. Source Note: The provisions of this §301.305 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.305 Responsibility for Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198542 03/12/2026 (a) Organizational planning and communication. The LMHA and MCO must define and implement organizational plans and systems as described in this subchapter (e.g., quality management plan, utilization management plan) and ensure that there are mechanisms in place that facilitate effective communication throughout the organization to promote the provision of quality mental health community services.(b) Management of key processes and functions. The LMHA and MCO must define organizational and clinical processes and functions, including performance activities, as well as:(1) allocate adequate, appropriate resources; and(2) provide oversight for such processes and functions.(c) Management information system. The LMHA, MCO, and provider must ensure their management information systems provide timely, accurate, and accessible information that supports clinical, administrative, and fiscal decision-making.(d) Consumer advocacy. The LMHA and MCO must encourage and support advocacy for individuals accessing mental health community services.(e) Conflict of interest and dual relationships. The LMHA and MCO must develop and implement policies and procedures to ensure that all staff members refrain from activities and relationships whereby personal, financial, professional, or other relationships could compromise or interfere with independent judgment creating a conflict of interest or otherwise having the potential to harm or exploit individuals and families.(f) Collaboration with other health care agencies and community resources. The LMHA and MCO must demonstrate efforts to collaborate with other health care agencies and community resources to address the physical and behavioral health care needs of individuals, as well as to ensure that these needs are met. Source Note: The provisions of this §301.321 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.321 Leadership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198543 03/12/2026 (a) Safe environment. The LMHA, MCO, and provider must:(1) ensure service delivery sites (including, but not limited to, facilities and vehicles) are safe, sanitary, and free from hazards, including but not limited to:(A) hand washing facilities and supplies in restrooms and in areas where staff have routine physical contact with individuals (e.g., exam rooms, medication areas, laboratories);(B) a utility area with necessary equipment for the safe and required cleaning or disposal of instruments, equipment, and sharps;(C) locked areas for storing drugs, needles, syringes, hazardous materials, other potentially dangerous equipment, and toxic chemical products; and(D) adequate prevention of exposure to tobacco smoke and other environmental pollutants.(2) ensure delivery sites are prepared to manage onsite life threatening emergencies, and that each site will have:(A) a written plan for the management of onsite medical emergencies requiring ambulance services, hospitalization, or hospital treatment;(B) emergency resuscitative drugs, supplies, and equipment appropriate to the needs of individuals and staff qualifications;(C) written protocols and instructions for disasters and other emergencies; and(D) documented disaster drills appropriate for local conditions.(3) comply with the most current edition of the National Fire Protection Association's Life Safety Code, and related codes, standards, and other applicable requirements;(4) implement an infection control plan and procedures for group residential services, clinics, and other areas where a high volume of people congregate, that address the prevention, education, management, and monitoring of significant infections. Components addressed in the plan must include:(A) prevention and management of infection in the service delivery site(s);(B) reporting of reportable diseases as required by Chapter 97, Subchapter A of this title (relating to Control of Communicable Diseases);(C) compliance with the Human Immunodeficiency Virus Services Act (Texas Health and Safety Code, §85.001 et seq.), the Communicable Disease Prevention and Control Act (Texas Health and Safety Code, §81.001 et seq.), and other applicable laws (e.g., the Americans with Disabilities Act of 1990, 42 U.S.C. §12101 et seq.; and the Rehabilitation Act of 1973, 29 U.S.C. §701 et seq.);(D) identification of illnesses and conditions for which an individual's participation in mental health community services is safely allowed;(E) identification of illnesses and conditions for which an individual's participation in mental health community services is restricted and the procedures for minimizing exposure and facilitating an individual's transfer to a more appropriate setting;(5) implement safeguards regarding hazardous equipment and weather; and(6) implement procedures for the disposal of biohazardous wastes that minimize the risks of contamination, injury, and disease transmission.(b) Sufficient staff. The provider must have sufficient number of qualified and competent staff members on duty to ensure the safety of individuals and adequacy of mental health community services, including responding to crises during the provision of mental health community services.(c) Compliance with state and federal law. The provider must comply with all applicable state and federal law and regulations, including those relating to:(1) blood borne pathogens;(2) food borne pathogen exposure controls; and(3) tuberculosis exposure controls.(d) Limited use of restraint or seclusion.(1) Restraint. In outpatient settings, a provider may only use restraint if the intervention is:(A) necessary to address a behavioral health emergency, as defined in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs); and(B) performed according to the department's rules described in Chapter 415, Subchapter F of this title.(2) Seclusion. Seclusion is prohibited in outpatient settings with the exception of partial hospitalization programs for children or adolescents. A provider may only use seclusion in those programs if the conditions in paragraph (1)(A) - (B) of this subsection are met. Source Note: The provisions of this §301.323 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.323 Environment of Care and Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198544 03/12/2026 (a) Non-coercive policy. The LMHA, MCO, and provider must ensure that an individual's refusal of a particular mental health community service (e.g., psychoactive medication) does not preclude the individual from accessing other medically necessary mental health community services.(b) Non-discrimination. The LMHA, MCO, and provider may not unlawfully discriminate against any individual based on race, color, national origin, religion, sex, age, or disability. The LMHA and MCO and provider may not deny medically necessary mental health community services based on an individual's sexual orientation or political affiliation.(c) Initial and ongoing eligibility. In determining an individual's initial and ongoing eligibility for any service, an LMHA, MCO, and provider may not exclude an individual based on the following factors:(1) the individual's past or present mental illness or substance use diagnosis or services;(2) the individual's past or present involvement in the criminal or juvenile justice system;(3) medications prescribed to the individual in the past or present;(4) the presumption of the individual's inability to benefit from treatment;(5) the individual's use or continued use of alcohol, tobacco, or other drugs; or(6) the individual's level of success in prior treatment episodes.(d) Protection against abuse, neglect, and exploitation. The LMHA, MCO, and provider must comply with the requirements described in Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers).(e) Dignity and rights. The LMHA, MCO, and provider must implement procedures that address the rights of individuals in compliance with applicable state and federal laws, regulations, and department rules described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services), and must provide individuals the right to choose from the list of providers within the LMHA's or MCO's network if there is more than one provider available.(f) Charges for mental health community services. The LMHA and MCO and provider must comply with all applicable federal and state laws and department rules described in Chapter 412, Subchapter C of this title (relating to Charges for Community Services) regarding the establishment of charges and the collection of fees for the provision of mental health community services.(g) Confidentiality. The LMHA and MCO and provider must comply with all applicable federal and state laws, rules, and regulations governing confidentiality of identifying information of individuals with mental illness and/or substance use disorders, including those described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and 42 Code of Federal Regulations (CFR) Part 2 (Confidentiality of Alcohol and Drug Abuse Patient Records).(h) Research. If the LMHA or MCO or provider conducts research, then the research must be conducted in accordance with applicable state and federal laws, rules, and regulations, including 45 CFR Part 46 (Protection of Human Subjects). Source Note: The provisions of this §301.325 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.325 Rights and Protection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214075 03/12/2026 (a) Adequate provider network. The LMHA and MCO must maintain a provider network that is adequate and qualified to provide all mental health community services that the LMHA and MCO are required to provide under a contract with the department.(b) Crisis screening and response system. The LMHA and MCO must have a crisis screening and response system in operation 24 hours a day, every day of the year, that is available to individuals throughout its contracted service delivery area. The telephone system to access the crisis screening and response system must include a toll-free crisis hotline number and be easily accessible and well publicized. Calls to the crisis hotline must be answered by a hotline staff member who is trained in compliance with this subchapter. The hotline must have teletypewriter (TTY) capabilities or other assistive technology that is available and effective.(c) Telephone access. In addition to the crisis screening and response system described in subsection (b) of this section, the LMHA and MCO must ensure the availability of a telephone system and call center that allows individuals to contact the LMHA or MCO through a toll-free number that must:(1) operate without using telephone answering equipment at least on business days during normal business hours, except on national holidays, due to uncontrollable interruption of service, or with prior approval of the department;(2) have sufficient staff to operate efficiently;(3) collect, document, and store detailed information, including special needs information, on all telephone inquiries and calls;(4) during times other than those described in paragraph (1) of this subsection provide electronic call answering methods that include an outgoing message providing the crisis hotline telephone number, in languages relevant to the service area, for callers to leave a message; and(5) return routine calls before the end of the next business day for all messages left after hours.(d) Timely services based on need. The LMHA or local behavioral health authority (LBHA), as defined at Texas Health and Safety Code §533.0356 must arrange mental health services for an individual within the following time frames.(1) Crisis services.(A) Hotline calls. For all calls to the toll-free crisis hotline:(i) a staff member must answer each call within 30 seconds, on average, at least 95 percent of the time;(ii) the LMHA, LBHA, or their subcontractors must train a staff member in crisis screening to conduct a crisis hotline screening as provided in the LMHAs' and LBHAs' contract with the Texas Health and Human Services Commission; and(iii) if the staff member determines the call is a potential crisis, a staff member trained in crisis screening, in accordance with clause (ii) of this subparagraph, must begin a telephone screening no later than one minute after the determination is made.(B) Emergency care services. If a staff member determines during a screening that an individual is experiencing a crisis that may require emergency care services, the staff member trained in crisis screening, in accordance with subparagraph (A)(ii) of this paragraph, must:(i) take immediate action to address the emergency situation to ensure the safety of all parties involved;(ii) activate the immediate screening and assessment processes as described in §301.351 of this subchapter (relating to Crisis Services); and(iii) provide or obtain mental health community services or other necessary interventions to stabilize the crisis.(C) Urgent care services. If the screening indicates that an individual needs urgent care services, a QMHP-CS must within eight hours of the initial incoming hotline call or notification of a potential crisis situation:(i) perform a face-to-face assessment; and(ii) provide or obtain mental health community services or other necessary interventions to stabilize the crisis.(2) Routine care services. If the screening indicates that an individual needs routine care services, a QMHP-CS must perform a uniform assessment within 14 days after the screening. If the assessment indicates an LOC for routine care services, the individual must begin receiving services immediately. When the provision of the service package is not possible because services are at capacity, the individual must be referred to an available practitioner appropriate to meet the individual's needs or be placed on a waiting list for services, subject to the following exceptions:(A) individuals eligible for Medicaid who are determined to be in need of Mental Health Case Management, under Chapter 306, Subchapter E of this title, or Mental Health Rehabilitative Services, under Chapter 306, Subchapter F of this title, cannot be placed on a waiting list and must be served.(B) individuals eligible for Medicaid who are determined to need services other than Mental Health Case Management, under Chapter 306, Subchapter E of this title, and Mental Health Rehabilitative Services, under Chapter 306, Subchapter F of this title, must be referred to appropriate, available practitioners of that service. Only if an appropriate Medicaid practitioner is not available may the individual be placed on a waiting list. All efforts undertaken to refer Medicaid individuals must be documented.(e) Communication with individuals. The LMHA, MCO, and provider must ensure effective communication with the individual and LAR (if applicable) in an understandable format as appropriate to meet the needs of individuals, which may require using:(1) interpretative services;(2) translated materials; or(3) a staff member who can effectively respond to the cultural (e.g., customs, beliefs, actions, and values) and language needs of the individual and LAR (if applicable).(f) Service information. The LMHA and MCO must proactively disseminate to individuals and their LAR (if applicable) information about mental illness and the LMHA's or MCO's mental health community services in a format and language that is easily understood and based on the demographics for any group comprising more than 10 percent of the population in the local service area. Information about mental illness and the LMHA's or MCO's community services must be in a format and language that is easily understood by individuals with a disability (e.g., deafness, hard of hearing, and blindness).(g) Access to emergency medical and crisis services. The LMHA and MCO must develop procedures for its providers' use in accessing emergency medical and crisis services for individuals.(h) Continuity of services. The LMHA and MCO must ensure that individuals:(1) are provided continuity of services as defined by the department; and(2) are informed of whom to contact regarding continuity and coordination of their services, in accordance with Chapter 412, Subchapter D of this title (relating to Mental Health Services--Admission, Continuity, and Discharge).(i) Referral for physical health services. If a nursing or medical assessment indicates physical health needs outside the scope of the provider's competency, credentialing, or capacity to treat, the LMHA and MCO must make and document appropriate referrals to other healthcare providers and provide adequate follow up at subsequent visits to confirm access to the referrals. Source Note: The provisions of this §301.327 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237; amended to be effective July 3, 2023, 48 TexReg 3505. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.327 Access to Mental Health Community Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198546 03/12/2026 (a) Maintenance of medical records. The LMHA, MCO, and the provider must ensure:(1) protection against unauthorized access, disclosure, modification or destruction of medical records, whether accidental or deliberate;(2) the availability, integrity, utility, authenticity, and confidentiality of information within the medical record;(3) a current, organized, legible, and comprehensive records system that:(A) conforms to good professional practice;(B) permits effective clinical review and audit; and(C) facilitates prompt and systematic retrieval of information;(4) a medical records system with sufficient redundancy to ensure access to individual records; and(5) compliance with applicable federal and state laws, rules, and regulations, including HIPAA, 42 CFR Part 2, and the requirements described in Chapter 414, Subchapter A of this title (relating to Protected Health Information).(b) Disaster recovery plan. The LMHA, MCO, and the provider must maintain a written disaster recovery plan for information resources that will ensure service continuity. Source Note: The provisions of this §301.329 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.329 Medical Records System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198547 03/12/2026 (a) Competency of staff members, including volunteers. The LMHA, MCO, and provider must implement a process to ensure the competency of staff members prior to providing services that, at a minimum:(1) ensures services are provided by staff members who are operating within the scope of their license, job description, or contract specification;(2) ensures that the mental health community services provided by peer providers are limited to mental health rehabilitative, supported employment, supported housing, parent support group, and family partner services; and(3) defines competency-based expectations for each position as follows:(A) required competencies must be included for all staff members, including adequate, accurate knowledge of:(i) the nature of severe and persistent mental illness and serious emotional disturbances;(ii) the recovery and resiliency model of mental illness and serious emotional disturbance;(iii) the dignity and rights of an individual, as described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);(iv) identifying, preventing, and reporting abuse, neglect, and exploitation, in accordance with Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers);(v) individual confidentiality, as described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and other relevant state and federal laws affecting confidentiality of medical records, including Title 42 CFR Part 2;(vi) interacting with an individual who has a physical disability such as a hearing or visual impairment;(vii) responding to an individual's language and cultural needs through knowledge of customs, beliefs, and values of various, racial, ethnic, religious, and social groups;(viii) exposure control of blood borne pathogens;(ix) identification of an individual as being in a crisis and accessing emergency or urgent care services;(x) proper documentation of services provided; and(xi) planning and training for responding to severe weather, disasters, and bioterrorism;(B) critical competencies must be included for positions in which a staff member's primary job duties are related to individual service contacts and interactions and include, but are not limited to, adequate and accurate knowledge of:(i) cardio pulmonary resuscitation (CPR);(ii) first aid;(iii) safe management of verbally and physically aggressive behavior;(iv) utilization of assistive technology such as communication devices with individuals who are deaf or hard of hearing; and(v) seizure response and assessment;(C) specialty competencies must be included for positions in which a staff member performs specialized services and tasks and include adequate and accurate knowledge of specialized services and tasks, such as:(i) the requirements of this subchapter;(ii) age appropriate clinical assessment including the uniform assessment;(iii) age appropriate engagement techniques (e.g., motivational interviewing);(iv) use of telemedicine equipment;(v) the utilization management guidelines;(vi) developing and implementing an individualized treatment plan;(vii) appropriate actions to take in a crisis (e.g., screening, intervention, management and if applicable, suicide/homicide precautions);(viii) services for co-occurring psychiatric and substance use disorders described in Chapter 411, Subchapter N of this title (relating to Standards for Services to Individuals with Co-Occurring Psychiatric and Substance Use Disorders (COPSD));(ix) accessing resources within the local community;(x) strategies for effective advocacy and referral for an individual;(xi) infection control;(xii) recognition, reporting, and recording of side effects, contraindications, and drug interactions of psychoactive medication;(xiii) age appropriate rehabilitative approaches;(xiv) proficiency in specimen collection;(xv) the peer-provider or consumer-operated service model;(xvi) assessment and intervention with children, adolescents, and families; and(xvii) clinical specialties directly related to the services to be performed.(D) crisis hotline competencies must be included for positions in which a staff member routinely answers the crisis hotline and include adequate and accurate knowledge of:(i) the nature of severe and persistent mental illness and serious emotional disturbances and COPSD;(ii) behavioral health crisis situations;(iii) operating a telephone system to access behavioral health crisis screening and response;(iv) age appropriate crisis intervention and response;(v) utilization of assistive technology such as communication devices with individuals who are deaf or hard of hearing;(vi) advocacy for treatment in the most clinically appropriate, available environment; and(vii) applicable privacy laws, rules, and regulations including those described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and in Title 42 CFR Part 2.(E) telemedicine competencies must be included for positions in which a staff member's job duties are related to assisting with telemedicine services and include adequate and accurate knowledge of:(i) operation of the telemedicine equipment; and(ii) how to use the equipment to adequately present the individual.(4) requires staff members to demonstrate competencies in the following manner:(A) all staff members must demonstrate required competencies before contact with individuals, confidential information, or protected health information and periodically throughout the staff member's tenure of employment or association with the LMHA, MCO, or provider;(B) all staff members in positions that require critical competencies must demonstrate the critical competencies before contact with individuals and periodically throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider;(C) all staff members in positions that require specialty competencies must demonstrate the specialty competencies before providing the specialized service(s) or performing the specialized task(s) and periodically throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider; and(D) all staff members in positions that require crisis hotline competencies must demonstrate those competencies before providing crisis hotline services and at least annually throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider.(b) Competency of crisis services providers. The LMHA and MCO must develop and implement policies and procedures governing the provision of crisis services to ensure that providers with which they contract or employ for the provision of crisis services are trained in:(1) crisis access and age appropriate assessment and intervention services;(2) advocacy for the most clinically appropriate, available environment; and(3) community referral resources.(c) Credentialing and appeals. Before providing services, the LMHA and MCO must:(1) implement a timely credentialing and re-credentialing process for all its licensed staff members, peer providers, family partners, and every QMHP-CS and CSSP;(2) ensure that documentation verifying a staff member's credentialing and re-credentialing is maintained in the staff member's personnel records;(3) have a process for staff members to appeal credentialing and re-credentialing decisions; and(4) require providers to:(A) use the LMHA's or MCO's credentialing and re-credentialing and appeals processes for all of the provider's licensed staff, QMHP-CSs, CSSPs, peer providers, family partners, and utilization management job functions; or(B) implement a credentialing and re-credentialing process for all of the provider's licensed staff, QMHP-CSs, CSSPs, peer providers, family partners, and utilization management job functions that meets the LMHA's or MCO's credentialing and re-credentialing criteria and have a process for those staff members to appeal credentialing and re-credentialing decisions.(d) Additional requirements for credentialing a QMHP-CS. For credentialing as a QMHP-CS who is not a registered nurse, the credentialing and re-credentialing process described in subsection (c) of this section must include:(1) determining the minimum number of coursework hours that is equivalent to a major and whether a combination of coursework hours in the specified areas is acceptable;(2) reviewing the individual's coursework; and(3) justifying and documenting the credentialing decisions; or(4) completing an alternative credentialing process identified by the department.(e) Additional requirements for credentialing as a CSSP. For credentialing as a CSSP, the credentialing and re-credentialing process described in subsection (c) of this section must include:(1) verifying a high school diploma or high school equivalent certificate issued in accordance with the law of the issuing state;(2) verifying three continuous years of documented full-time experience in the provision of mental health case management or rehabilitative services prior to August 31, 2004;(3) reviewing the staff member's provision and documentation of mental health case management or rehabilitative services; and(4) certifying, justifying, and documenting the credentialing decisions.(f) Additional requirements for credentialing as a peer provider. For credentialing as a peer provider, the credentialing and re-credentialing process described in subsection (c) of this section or the alternative credentialing by an organization recognized by the department must, at minimum, include:(1) verifying a high school diploma or high school equivalent certificate issued in accordance with the law of the issuing state;(2) verifying at least one cumulative year of receiving mental health community services for a disorder that is treated in the target population for Texas;(3) demonstration of competency in the provision and documentation of mental health rehabilitative services, supported employment, or supported housing; and(4) justifying and documenting the credentialing decisions.(g) Additional requirements for utilization management job functions. For credentialing as a staff member who performs utilization management job functions, the credentialing and re-credentialing process described in subsection (c) of this section must include:(1) the staff member's job description indicating the performance of utilization management functions;(2) if the staff member is not the utilization management physician, the staff member's job description indicating they neither provide services nor supervise service providers;(3) documenting licenses;(4) documenting training and supervision received; and(5) justifying and documenting credentialing decisions.(h) Maintaining documented personnel information. The LMHA, MCO, and provider must maintain personnel files for each staff member that include:(1) a current, signed job description for each staff member;(2) documented, periodic performance reviews;(3) copies of current credentials and training; and(4) criminal background checks. Source Note: The provisions of this §301.331 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.331 Competency and Credentialing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198548 03/12/2026 (a) Quality management plan. The LMHA and MCO must develop a written quality management plan that includes:(1) the quality management program description and work plan;(2) measurable objective indicators to detect the need for improvement;(3) procedures and timelines for taking appropriate action when problems are identified; and(4) approval by the LMHA or MCO governing body.(b) Quality management program. The LMHA and MCO must implement a quality management program that includes:(1) a structure that ensures the program is implemented system-wide;(2) allocation of adequate resources for implementation;(3) oversight by professionals with adequate and appropriate experience in quality management;(4) activities and processes that address identified clinical and organizational problems including fidelity and data integrity;(5) periodic reporting of quality management program activities to its governing body, providers and other appropriate staff members and community stakeholders such as peer and family organizations;(6) processes to systematically monitor, analyze, and improve performance of provider services and outcomes for individuals;(7) review of the provider's treatment to determine:(A) whether it is consistent with the department's approved evidenced-based practices and the fidelity manual; and(B) the accuracy of assessments and treatment planning;(8) ongoing monitoring of the quality of crisis services, access to services, service delivery, and continuity of services;(9) provision of technical assistance to providers related to quality oversight necessary to improve the quality and accountability of provider services;(10) use of reports and data from the department to inform performance improvement activities and assessment of unmet needs of individuals, service delivery problems, and effectiveness of authority functions for the local service area;(11) mechanisms to measure, assess, and reduce incidents of abuse, neglect, and exploitation;(12) mechanisms to improve individuals' rights protection processes;(13) risk management processes such as competency determinations, and the management and reporting of incidents and deaths; and(14) coordination of activities and information management with the utilization management (UM) program, including participation in UM oversight activities.(c) The LMHA and MCO must establish an integrated system to sufficiently monitor the quality management program for effectiveness on a regular basis and update the quality management plan as needed. Source Note: The provisions of this §301.333 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.333 Quality Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198549 03/12/2026 (a) Utilization management plan. The LMHA and MCO must develop a written utilization management plan that includes:(1) the utilization management program plan description and work plan;(2) requirements relating to the utilization management committee credentials, job functions, meetings, and training;(3) how the utilization management program's effectiveness in meeting goals will be evaluated;(4) how improvements will be made on a regular basis;(5) the oversight and control mechanisms to ensure that UM activities meet required standards when they are delegated to an administrative services organization or a DSHS-approved entity; and(6) approval by the LMHA or MCO governing body.(b) Utilization management program. The LMHA and MCO must implement a utilization management program under the direction of a psychiatrist licensed in Texas as required by its contract with the department, and in accordance with the utilization management guidelines, as updated and amended.(c) Authorization of services. The LMHA and MCO must ensure that it has a timely authorization system in place to ensure medically necessary services are delivered without delay and with prior authorization, except that the delivery of crisis services does not require prior authorization but rather must be authorized subsequent to delivery. The LMHA and MCO will review requests for authorization of services, determine if services should be authorized and if so which services to authorize. Services must be authorized using the department's utilization management guidelines and based on the uniform assessment, diagnosis, additional clinical information submitted by the requestor, and clinical judgment. The determination and documentation of services to be authorized will occur according to the following timeframes:(1) crisis intervention services--within two business days of the date of service;(2) inpatient services--within sufficient time to ensure medically necessary services are delivered without delay;(3) all other mental health community services, including outpatient and add-on services upon receipt but no later than three business days and prior to service delivery; and(4) reauthorization for continuing services according to established timeframes in the utilization management guidelines, as updated and amended.(d) Appeal and Medicaid fair hearing procedures. The LMHA and MCO must implement procedures to give notice of the right to a timely and objective appeal process for all individuals receiving community mental health services, in accordance with §401.464 of this title (relating to Notification and Appeals Process). For individuals eligible for Medicaid, the LMHA and MCO must implement procedures that provide notice of the right to request a fair hearing, as described in Title 1, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules for the Medicaid, TANF, and Food Stamp Programs), to an individual whose service or benefits are denied, reduced, suspended, or terminated. The procedures regarding notice of the right to a Medicaid fair hearing must comply with department policy, which may be included in contract provisions.(e) Waiting list maintenance requirements. The LMHA must comply with the department's policy on waiting list maintenance requirements, which may be included in contract provisions and is subject to the requirements set forth in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services). Source Note: The provisions of this §301.335 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.335 Utilization Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198550 03/12/2026 (a) Coordinating provision of crisis services. The LMHA and MCO must develop and implement policies and procedures governing the provision of crisis services that:(1) identify providers' roles and responsibilities in responding to a crisis;(2) describe the coordination of crisis services to be required among providers of crisis services, law enforcement, the judicial system, and other community entities; and(3) comply with Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services).(b) Immediate screening and assessment.(1) Screening and assessment. All providers of crisis services must be available 24 hours a day, every day of the year, to perform immediate screenings and assessments of individuals in crisis, including assessments to determine risk of deterioration and immediate danger to self or others. Crisis assessments cannot be delegated to law enforcement officials.(2) QMHP-CS assessment. Individuals experiencing a crisis, as determined by a QMHP-CS screening, must be assessed face-to-face or via telemedicine by someone who is at least credentialed as a QMHP-CS within one hour after the individual presents to the provider in a crisis, either via the crisis hotline or a face-to-face encounter (e.g., walk-in). The QMHP-CS must provide ongoing crisis services until the crisis is resolved or the individual is placed in a clinically appropriate environment.(c) LPHA consultation. An LPHA must always be available for consultation with the QMHP-CS.(d) Physician assessment. If the individual requires emergency care services, as determined by the QMHP-CS's assessment of risk of deterioration and danger as described in subsection (b) of this section, then the provider of crisis services must have a physician, preferably a psychiatrist, perform a face-to-face or telemedicine assessment of the individual as soon as possible, but not later than 12 hours after the QMHP-CS's assessment to determine the need for emergency services.(e) Documenting crisis services. The provider of crisis services must maintain documentation of the crisis services, including:(1) the date the service was provided;(2) the beginning and end time of the crisis contact;(3) the name and any other identifying information of the individual to whom the service was provided (if given);(4) the location where the service was provided;(5) the behavioral description of the presenting problem;(6) lethality (e.g., suicide, violence);(7) substance use or abuse;(8) trauma, abuse, or neglect;(9) the outcome of the crisis (e.g., individual in hospital, individual with friend and scheduled to see doctor at 9:00 a.m. the following day);(10) the names and titles of staff members involved;(11) all actions (including rehabilitative interventions and referrals to other agencies) used by the provider to address the problems presented;(12) the response of the individual, and if appropriate, the response of the LAR and family members;(13) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA or a QMHP-CS;(14) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service; and(15) follow up activities, which may include referral to another provider.(f) Communication of crisis contacts. If an individual who is currently receiving mental health services has experienced a crisis and has been assessed in accordance with subsection (b) of this section, the provider of crisis services must communicate in writing (e.g., e-mail or fax) the details of the crisis contact to the provider of ongoing mental health services to ensure that the individual receives continuity of care and treatment and include such communication in the medical record. This crisis contact communication:(1) may not disclose any substance abuse-related information unless disclosed in compliance with federal law as described in 42 CFR Part 2;(2) must take place no later than the next business day after conclusion of the crisis contact; and(3) may disclose mental health information for the purpose of continuity of care and treatment without the individual's consent if disclosure is made in accordance with:(A) Texas Health and Safety Code, §533.009 (relating to Exchange of Patient and Client Records), when the provider of ongoing services is part of the department's service delivery system; or(B) in accordance with Texas Health and Safety Code, §611.004(a)(7) (relating to the Authorized Disclosure of Confidential Information other than in Judicial or Administrative Proceeding), when the provider of ongoing services is not part of the department's service delivery system. Source Note: The provisions of this §301.351 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.351 Crisis Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198551 03/12/2026 (a) Assessment and documentation. At the first routine face-to-face or telemedicine contact with an individual seeking routine care services, as described in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services,) a QMHP-CS with appropriate supervision and training must perform an assessment of the individual. The assessment must be documented and must include:(1) the individual's identifying information;(2) completion of the appropriate uniform assessment(s) and assessment guideline calculations;(3) present status and relevant history, including education, employment, housing, legal, military, developmental, and current available social and support systems;(4) co-occurring mental illness, emotional disturbance, substance abuse, chemical dependency, or developmental disorder;(5) relevant past and current medical and psychiatric information, which may include trauma history;(6) information from the individual and LAR (if applicable) regarding the individual's strengths, needs, natural supports, describe community participation, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;(7) if the individual is an adult without an LAR, the needs and desire of the individual for family member involvement in treatment and mental health community services;(8) the identification of the LAR's or family members' need for education and support services related to the individual's mental illness or emotional disturbance and the plan to facilitate the LAR's or family members' receipt of the needed education and support services;(9) recommendations and conclusions regarding treatment needs; and(10) date, signature, and credentials of staff member completing the assessment.(b) Diagnostics. The diagnosis of a mental illness must be:(1) rendered by an LPHA, acting within the scope of his/her license, who has interviewed the individual, either face-to-face or via telemedicine;(2) based on the DSM;(3) documented in writing, including the date, signature, and credentials of the person making the diagnosis; and(4) supported by and included in the assessment.(c) Provision of services. The LMHA, MCO, and provider must require each provider to implement procedures to ensure that individuals are provided mental health community services based on:(1) the department's uniform assessment and utilization management guidelines;(2) medical necessity as determined by an LPHA; and(3) health management needs as determined by a physician, physician assistant, or registered nurse.(d) Prerequisites to provision of services.(1) Routine care services. For routine care services, before providing mental health community services to an individual, the provider must:(A) obtain authorization from the department or its designee for the type(s), amount, and duration of mental health community services to be provided to the individual in accordance with the appropriate uniform assessment and utilization management guidelines;(B) obtain a determination of medical necessity from an LPHA; and(C) in collaboration with the individual and their LAR (if applicable), develop a treatment plan for the individual that includes a list of the type(s) of mental health community services authorized in accordance with subparagraph (A) of this paragraph.(2) Crisis services. For crisis services, as described in §412.321 of this title (relating to Crisis Services), a provider must deliver services in accordance with the utilization management guidelines and authorization of services and timeframes described in §412.318(c) of this title (relating to Utilization Management). A diagnosis is not required when services are delivered in crisis situations.(e) Content and timeframe of treatment plan. Each provider must develop a written treatment plan, in consultation with the individual and their LAR (if applicable), within 10 business days after the date of receipt of notification from the department or its designee that the individual is eligible and has been authorized for routine care services.(1) At minimum, a staff member credentialed as a QMHP-CS is responsible for completing and signing the treatment plan. The treatment plan must reflect input from each of the disciplines of treatment to be provided to the individual based upon the assessment. The treatment plan must include:(A) a description of the presenting problem;(B) a description of the individual's strengths;(C) a description of the individual's needs arising from the mental illness or serious emotional disturbance;(D) a description of the individual's co-occurring substance use or physical health disorder, if any;(E) a description of the recovery goals and objectives based upon the assessment, and expected outcomes of the treatment in accordance with paragraph (2) of this subsection;(F) the expected date by which the recovery goals will be achieved;(G) a list of resources for recovery supports, (e.g., community volunteer opportunities, family or peer organizations, 12-step programs, churches, colleges, or community education); and(H) a list of the type(s) of services within each discipline of treatment that will be provided to the individual (e.g., psychosocial rehabilitation, medication services, substance abuse treatment, supported employment), and for each type of service listed, provide:(i) a description of the strategies to be implemented by staff members in providing the service and achieving goals;(ii) the frequency (e.g., weekly, twice a month, monthly), number of units (e.g., 10 counseling sessions, two skills training sessions), and duration of each service to be provided (e.g., .5 hour, 1.5 hours); and(iii) the credentials of the staff member responsible for providing the service.(2) The goals and objectives with expected outcomes required by paragraph (1)(E) of this subsection must:(A) specifically address the individual's unique needs, preferences, experiences, and cultural background;(B) specifically address the individual's co-occurring substance use or physical health disorder, if any;(C) be expressed in terms of overt, observable actions of the individual;(D) be objective and measurable using quantifiable criteria; and(E) reflect the individual's self-direction, autonomy, and desired outcomes.(3) The individual and LAR (if applicable) must be provided a copy of the treatment plan and each subsequent treatment plan reviewed and revised.(f) Review of treatment plan.(1) Each provider must:(A) review the individual's treatment plan prior to requesting an authorization for the continuation of services;(B) review the treatment plan in its entirety, as permitted under confidentiality laws by considering input from the individual, the individual's LAR (if applicable), and each of the disciplines of treatment;(C) determine if the plan is adequately addressing the needs of the individual; and(D) document progress on all goals and objectives and any recommendation for continuing services, any change from current services, and any discharge from services.(2) In addition to the required review under paragraph (1) of this subsection, a provider may review the treatment plan in the following instances:(A) if clinically indicated; and(B) at the request of the individual or the LAR (if applicable), or the primary caregiver of a child or adolescent.(3) Any time the treatment plan is reviewed, the provider must:(A) meet with the individual either face to face or via telemedicine to solicit and consider input from the individual regarding a self-assessment of progress toward the recovery goals, as described in subsection (e)(1)(E) of this section;(B) solicit and consider the input from each of the disciplines of treatment in assessing the individual's progress toward the recovery goals and objectives with expected outcomes, described in subsection (e)(1)(E) of this section;(C) solicit and consider input from the LAR (if applicable) or primary caregiver, if the individual is a child or adolescent regarding the level of satisfaction with the services provided; and(D) document all the input described in subparagraphs (A) - (C) of this paragraph.(g) Revisions to the treatment plan. If, after any review of the treatment plan, the provider determines it does not adequately address the needs of the individual, the provider must appropriately revise the content of the plan.(h) Discharge Summary. Not later than 21 calendar days after an individual's discharge, whether planned or unplanned, the provider must document in the individual's medical record:(1) a summary, based upon input from all the disciplines of treatment involved in the individual's treatment plan, of all the services provided, the individual's response to treatment, and any other relevant information;(2) recommendations made to the individual or their LAR (if applicable) for follow up services, if any; and(3) the individual's last diagnosis, based on the DSM. Source Note: The provisions of this §301.353 adopted to be effective April 29, 2009, 34 TexReg 2603; amended to be effective February 19, 2017, 42 TexReg 561; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.353 Provider Responsibilities for Treatment Planning and Service Authorization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198552 03/12/2026 (a) Prescribing of psychoactive medication. The LMHA and MCO must ensure that psychoactive medication is prescribed in accordance with Chapter 415, Subchapter A of this title (relating to Prescribing of Psychoactive Medication).(b) Medication service delivery. The LMHA, MCO, and provider must implement written procedures to ensure safe medication-related service delivery that include, but are not limited to, the following.(1) A procedure for physician delegation of medical acts to non-physicians. The procedure must address delegation protocols to advanced practice nurses and/or physician assistants, delegation of medical acts to nursing and/or unlicensed staff, and the frequency of physician supervision over the staff member to whom a delegation is made. The procedure must provide a method to ensure the staff members are acting within the scope of their license and is qualified and trained to perform the medical act.(2) A procedure for RNs to make assignments to LVNs or delegate to unlicensed staff members nursing acts for the care of stable individuals with common, well-defined health problems with predictable outcomes. The procedure must address the types of nursing acts that may be delegated, the method to ensure the staff member is trained and qualified to perform a delegated nursing act, and the frequency of nursing supervision of the unlicensed staff member in accordance with Texas Occupations Code, Chapter 301 (relating to the Nursing Practice Act).(3) A procedure for medication administration by licensed medical or nursing staff that addresses who may access and administer medications, timely administration, documentation of administration, and monitoring of administration, and that complies with applicable professional licensing standards and rules.(4) A procedure for medication handling that addresses:(A) dispensing;(B) labeling and record keeping of sample medications;(C) limiting access to physician stock medications;(D) patient assistance/indigent medication program;(E) mechanisms to ensure safe temperature-controlled storage and transport of medication;(F) controlled drugs;(G) disposal/destruction of medication; and(H) locked areas and maintaining security.(5) A procedure by which a physician, a physician's assistant, or an RN assesses and determines whether an individual can self-administer medication and whether it can be done without supervision.(6) A procedure for training and assessing the competency of staff members to perform supervision of self-administration of medication, including:(A) medication actions;(B) target symptoms;(C) understanding prescription labels;(D) potential toxicity;(E) side effects;(F) adverse reactions;(G) proper storage of medications; and(H) reporting and documentation requirements.(7) A procedure for providing appropriate supervision of staff members who are supervising self-administration of medication.(8) A procedure for medication errors that defines the most common types of medication errors and provides for:(A) the accurate documentation of medication errors;(B) the reporting of medication errors to the physician within one hour of their occurrence;(C) a mechanism for determining medication error trends;(D) a mechanism for analyzing both individual medication errors and trends for quality improvement; and(E) the reporting of medication errors, as appropriate. Source Note: The provisions of this §301.355 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.355 Medication Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198553 03/12/2026 (a) Administration of the uniform assessment. The uniform assessment must be administered face-to-face or via telemedicine with the individual and the LAR (if applicable) or primary caregiver as clinically appropriate according to the child's or adolescent's age, functioning, and current living situation.(b) Age and developmentally appropriate mental health community services. All mental health community services delivered to children and adolescents by a provider must be, for each child and adolescent, age-appropriate, developmentally appropriate, and consistent with academic development.(c) Separation of individuals by age. A provider that delivers mental health community services to children and adolescents in group settings (e.g., residential, day programs, group therapy, partial hospitalization, and inpatient) must separate children and adolescents from adults. The provider must further separate children from adolescents according to age and developmental needs, unless there is a clinical or developmental justification in the medical record.(d) Transition to mental health community services for adults. The provider must develop a transition plan for each adolescent who will need mental health community services for adults. The transition plan must be developed in consultation with the adolescent (and LAR if applicable) and future providers with adequate time to allow both current and future providers to transition the adolescent into adult services without a disruption in services. The transition plan must include:(1) a summary of the mental health community services and treatment the adolescent received as a child and adolescent;(2) the adolescent's current status (e.g., diagnosis, medications, uniform assessment guideline calculation, and unmet needs);(3) information from the adolescent and the LAR regarding the adolescent's strengths, preferences for mental health community services, and responsiveness to past interventions;(4) a description of the mental health community services the adolescent will receive as an adult;(5) a list of resources for other recovery supports such as volunteer opportunities, family or peer organizations, 12-step programs, churches, colleges, or community education;(6) documentation that the adolescent's services continued throughout the transition without disruptions; and(7) documentation of the follow up to ensure successful transition to adult services. Source Note: The provisions of this §301.357 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.357 Additional Standards of Care Specific to Mental Health Community Services for Children and Adolescents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198554 03/12/2026 The LMHA, MCO, and provider must ensure that if a provider uses telemedicine, it is implemented in accordance with written procedures and using a protocol approved by the LMHA's or MCO's medical director. Procedures regarding the provision of telemedicine service must include the following requirements:(1) clinical oversight by the LMHA's or MCO's medical director or designated physician responsible for medical leadership;(2) contraindications for telemedicine use;(3) qualified people to ensure the safety of the individual being served by telemedicine at the remote site; and(4) use by credentialed or licensed providers who provide clinical care within the scope of their credential or license. Source Note: The provisions of this §301.359 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.359 Telemedicine Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198555 03/12/2026 (a) Progress note content. Except for crisis services as described in §412.321 of this title (relating to Crisis Services) and day programs for acute needs as described in Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services), and case management services as described in Chapter 412, Subchapter I of this title (relating to Mental Health Case Management Services), a provider must document the provision of all other mental health community services, each service encounter and include at least the following:(1) the name of the individual to whom the service was provided, including the LAR or primary caregiver, if applicable;(2) the type of service provided;(3) the date the service was provided;(4) the begin and end time of the service;(5) the location where the service was provided;(6) a summary of the activities that occurred;(7) the modality of the service provision (e.g., individual, group);(8) the method of service provision (e.g., face-to-face, phone, telemedicine);(9) the training methods used, if applicable (e.g., instructions, modeling, role play, feedback, repetition);(10) the title of the curriculum being used, if applicable;(11) the treatment plan objective(s) that was the focus of the service;(12) the progress or lack of progress in achieving treatment plan goals;(13) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA, a QMHP-CS, a pharmacist, a CSSP, an LVN, a peer provider or otherwise credentialed, as required for that service; and(14) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service.(b) Frequency of documentation. The documentation required in subsection (a) of this section must be made within two business days after each contact that occurs to provide mental health community services.(c) Retention. Documentation must be retained in compliance with applicable federal and state laws, rules, and regulations. Source Note: The provisions of this §301.361 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.361 Documentation of Service Provision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198556 03/12/2026 (a) Clinical supervision. Clinical supervision must be accomplished by an LPHA or a QMHP-CS as follows:(1) by conducting a documented meeting with the staff member being supervised at least monthly; and(2) for peer providers, by conducting an additional monthly documented observation of the peer provider providing mental health community services.(b) Policies and procedures. The LMHA or MCO will develop and implement written policies and procedures for supervision of all applicable levels of staff members providing services to individuals.(c) Licensed staff member supervision. All licensed staff members must be supervised in accordance with their practice act and applicable rules.(d) QMHP-CS supervision. A QMHP-CS's designated clinical duties must be clinically supervised by:(1) a QMHP-CS; or(2) an LPHA if the QMHP-CS is clinically supervising the provision of mental health community services.(e) CSSP supervision. A CSSP's designated clinical duties must be clinically supervised by a QMHP-CS. The CSSP must have access to clinical consultation with an LPHA when necessary.(f) Family partner supervision. A family partner is supervised by the mental health children's director, clinic director, case management supervisor, or wraparound supervisor.(g) Peer provider supervision. A peer provider's designated clinical duties must be clinically supervised by an LPHA.(h) Peer review. The LMHA, MCO, and provider must implement a peer review process for licensed staff members that:(1) promotes sound clinical practice;(2) promotes professional growth; and(3) complies with applicable state laws (e.g., Medical Practice Act, Nursing Practice Act, Vocational Nurse Act) and rules.(i) Documentation. All clinical supervision must be documented. Source Note: The provisions of this §301.363 adopted to be effective April 29, 2009, 34 TexReg 2603; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1237. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES G MENTAL HEALTH COMMUNITY SERVICES STANDARDS §301.363 Supervision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220782 03/12/2026 The purpose of this subchapter is to provide clinical peer review procedures and, separately, administrative review procedures to be followed upon the death of an individual receiving services directly operated or contracted for by a community mental health center, and their respective contract providers, in order to improve the quality of care. Source Note: The provisions of this §301.401 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.401 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220783 03/12/2026 The provisions of this subchapter apply to community mental health centers and to their respective contract providers. Source Note: The provisions of this §301.403 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.403 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220784 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Administrative death review--An administrative/quality assurance review activity to identify non-clinically related problems requiring correction and opportunities to improve the quality of care.(2) Attending physician--A physician licensed to practice medicine in the State of Texas who is responsible for the general medical care and/or psychiatric care of the individual served.(3) Chief executive officer or CEO--The executive director of a community center.(4) Clinical death review--A clinical quality assurance/peer review activity conducted to identify clinically related problems requiring correction and opportunities to improve the quality of care pursuant to the statutes that authorize peer review activities in the State of Texas.(5) Community center--A community mental health center organized pursuant to the Texas Health and Safety Code, Title 7, Chapter 534, §534.053 (formerly the Texas Mental Health and Mental Retardation Act, §3, as amended, Texas Civil Statutes, Article 5547-201 et seq.).(6) Contract provider--An entity which, through written agreement or contract, is providing services to an individual served by a community center, including entities regulated by other governmental agencies.(7) Deceased--An individual who, at death, is receiving services directly operated or contracted for by a community center.(8) HHSC--The Texas Health and Human Services Commission.(9) Investigating officer--A physician or registered nurse who is neither the attending physician nor anyone significantly involved as the primary provider of treatment to the deceased immediately preceding the death.(10) Registered nurse--A nurse licensed by the Texas Board of Nurse Examiners to practice professional nursing in the State of Texas.(11) Unusual circumstances--A death which occurs under circumstances including, but not limited to, the following: unnatural death; death by unlawful means or suspicion of death by unlawful means; absence of witnesses; suicide or suspicion of suicide; or death within 24 hours of admission to the community center. Source Note: The provisions of this §301.405 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.405 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220785 03/12/2026 (a) Each community center shall develop separate clinical peer review and administrative review procedures consistent with this subchapter to be implemented at the time that a determination has been made to conduct a death review.(b) When appropriate, the community center CEO or designee shall notify the deceased's personal representative (primary or emergency correspondent(s)) of the death; provide an explanation of the relevant facts related to the death; and inform them of their right to examine the deceased's medical information relevant to the death, death certificate, and autopsy findings, if any. A physician shall request consent to conduct an autopsy when appropriate.(c) Immediately after determination of the need to conduct an administrative death review, the community center CEO shall be responsible for ensuring that the completed HHSC reporting form is submitted to HHSC. Source Note: The provisions of this §301.407 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.407 Community Centers: Actions Taken upon the Death of an Individual Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220786 03/12/2026 (a) When a death has been determined to require an administrative death review, a copy of the certificate of death shall be made a part of the deceased's record, when possible.(b) When appropriate, the property of the deceased will be disposed of under the provisions of the Texas Probate Code. Source Note: The provisions of this §301.409 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.409 Community Centers: General Guidelines upon Death of an Individual Served https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220787 03/12/2026 (a) Within one working day of the knowledge of death of an individual receiving services in an HHSC-funded or HHSC-contracted program, the community center CEO is responsible for conducting a preliminary review to determine whether:(1) the death occurred on the premises of an HHSC-funded or HHSC-contracted program (e.g., the individual dies in his/her sleep at an MHA/MRA funded group home);(2) the death occurred while the individual was participating in HHSC-funded or HHSC-contracted program activities (e.g., the individual dies in a community hospital after being transferred from the community center; the individual drowns while on a psychosocial program outing);(3) other conditions indicate that the death may reasonably have been related to the individual's care or activities as part of the community center program (e.g., the individual overdoses on a psychoactive drug; the individual dies by suicide); or(4) other conditions indicate that although the death is not reasonably related to the individual's care or activities as part of the community center program, an evaluation of policy is warranted (e.g., the individual dies of a chronic illness in a community hospital).(b) If none of the conditions described in subsection (a) of this section is met, then the community center CEO may elect not to conduct an administrative death review. Documentation that this preliminary review was conducted must be included in the deceased's record.(c) If any of the conditions described in subsection (a) of this section are met, an administrative death review must be conducted in compliance with this section. In addition, the need for a clinical death review must be determined as described in §405.272 of this subchapter (relating to Community Centers: Clinical Death Review Determination). Source Note: The provisions of this §301.411 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.411 Community Centers: Administrative Death Review Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220788 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220788 03/12/2026 (a) Upon notification of a death requiring an administrative death review, the community center CEO or designee shall appoint a physician or registered nurse as the investigating officer, as defined in this subchapter, who shall begin a preliminary investigation based upon the deceased's medical record, particularly the circumstances leading to the transfer to a facility or outpatient status where death occurred, and other information he/she deems appropriate.(b) Within seven working days of the knowledge of death, the CEO, and investigating officer shall use the preliminary investigation information to determine whether the death should be reviewed clinically, in compliance with §405.274 of this subchapter (relating to Community Centers: Clinical Death Review).(1) The determination shall be based upon the possible need for review of clinical policies and procedures, the opportunity for professional education, and/or the opportunity to improve patient care through medical practice.(2) It shall also be determined whether a preliminary administrative death review should proceed before the completion of the clinical death review, addressing the issue described in §405.275(c)(2) of this subchapter (relating to Community Centers: Administrative Death Review) or should be deferred until the submission of the recommendations of the clinical death review committee.(3) The deliberations and findings of a preliminary administrative death review will be considered at the final administrative death review after receipt of the recommendations of the clinical death review committee.(c) If it has been determined that a clinical death review is unnecessary, then the CEO shall be responsible for forwarding to the administrative death review committee the following:(1) a summary of the preliminary investigation information;(2) a copy of the death/discharge summary, if available;(3) a copy of the death certificate, bearing a valid diagnosis, if available;(4) a copy of the preliminary or full autopsy report, if available; and(5) the probable final diagnosis, including contributory causes, and reasons for variance from the death certificate, if any. Source Note: The provisions of this §301.413 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.413 Community Centers: Clinical Death Review Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220789 03/12/2026 (a) Each community center shall develop and implement procedures consistent with this subchapter for the timely reporting and review of deaths.(b) Deaths subject to a clinical death review will be reviewed by a medical review committee pursuant to the statutes that authorize peer review activities in the State of Texas, consisting of the previously appointed investigating officer and at least two other medical/nursing professionals (M.D., D.O., or R.N.), one of which should be a medical professional whom is neither an employee of the community center nor was the deceased's attending physician (if such medical professional is not available, then the effort to obtain external membership must be documented in the information sent to the administrative death review committee). Of these three committee members, all must be either medical doctors or registered nurses. The community center CEO shall appoint one of the three medical/nursing professionals as chair of the clinical death review committee. For the purposes of this subchapter the term employee does not refer to consultants or contractors. Additionally, the membership of the clinical death review committee may include the community center CEO and/or the director of clinical quality assurance, designee, or the person who is responsible for clinical quality assurance functions.(1) Upon determination of the need for a clinical death review, the investigating officer shall provide to the clinical death review committee:(A) the individual's medical record;(B) a copy of the death certificate, bearing a valid diagnosis, if available;(C) a copy of the preliminary or full autopsy report, if available;(D) the probable final diagnosis, including contributory causes, and reasons for variance from the death certificate, if any; and(E) a briefing of possible issues involving clinically related community center operational policies and procedures and quality of medical care.(2) Within 14 calendar days (or 45 days in which an autopsy is performed, or for deaths occurring at medical facilities to which the individual was transferred before death) of the determination of the need for a clinical death review, the clinical death review committee shall meet to review the information the investigating officer has provided as described in subsection (b)(1) of this subsection. On the basis of the review, the committee shall evaluate the quality of medical and nursing care given before death and shall formulate written recommendations, if appropriate, for changes in policy and procedures, professional education, operations, or patient care. Suspected abuse or neglect must be reported in accordance with the rules of the Texas Department of Family and Protective Services.(c) Within 21 calendar days of the determination of the need for a clinical death review (or 52 days in cases in which an autopsy is performed, or for deaths occurring at medical facilities to which the individual was transferred before death), the clinical death review committee shall submit to the administrative death review committee the following:(1) the clinical death review committee's recommendations;(2) a copy of the death/discharge summary, if available;(3) a copy of the death certificate, bearing a valid diagnosis, if available;(4) the probable final diagnosis, including contributory causes, and reasons for variance from the death certificate, if any; and(5) documentation of the effort to obtain an external medical professional, if no such person was available.(d) To maintain the effectiveness of the death review process, HHSC may conduct reviews of the community center's clinical death review process.(e) The community center CEO is authorized to grant variances from the timelines by this section on a case-by-case basis. Reasons for timeline variances must be justified and documented. Source Note: The provisions of this §301.415 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.415 Community Centers: Clinical Death Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220790 03/12/2026 (a) The community center CEO shall convene an administrative death review committee:(1) immediately after the determination of the need for an administrative death review, if a clinical death review was not conducted;(2) when a preliminary administrative death review is to take place as determined in §405.272(b) of this subchapter (relating to Community Centers: Clinical Death Review Determinations); or(3) immediately after the receipt of the information from the clinical death review committee as described in §405.274(c) of this subchapter (relating to Community Centers: Clinical Death Review).(b) The membership of the administrative death review committee shall consist of:(1) three senior administrative and medical personnel (e.g., CEO, medical director, director of nursing, director of quality assurance, etc.) one of whom shall be designated as the chair by the CEO;(2) a representative of the public, external to HHSC and not related to or associated with the deceased (e.g., a member of the public responsibility committee, a member of the community hospital's ethics committee, a family member, an advocate, a consumer, etc.). If such representative of the public is not available, then the effort to obtain external membership must be documented in the information sent to HHSC; and(3) other individuals appropriate to the death being reviewed (e.g., the investigating officer).(c) The purpose of the administrative death review committee is to:(1) review the information and recommendations provided by the clinical death review committee and/or from the preliminary investigation;(2) review operational policies and procedures and continuity of care issues which may have affected the care of the individual and formulate written recommendations for changes in policies and procedures, if appropriate; and(3) act upon the recommendations described in paragraphs (1) and (2) of this subsection.(d) If information presented during the administrative review indicates the need for a clinical death review or a re-review, then the administrative death review committee has the authority to request such review.(e) Suspected abuse or neglect must be reported in accordance with the rules of the Texas Department of Family and Protective Services.(f) Within 14 calendar days of the determination of the need for an administrative death review (or 45 days in cases in which an autopsy is performed, or for deaths occurring at medical facilities to which the individual was transferred before death) or within 14 calendar days after the receipt of the information from the clinical death review committee, the administrative death review committee shall submit the following elements to HHSC:(1) a copy of the death/discharge summary, if available;(2) a copy of the death certificate, bearing a valid diagnosis, if available;(3) a copy of the preliminary or full autopsy report, if available;(4) the probable final diagnosis, including contributory causes, and reasons for variance from the death certificate, if any;(5) a copy of the clinical death review committee's recommendations, if such review was conducted;(6) a copy of the administrative death review committee's recommendations; and(7) if applicable, documentation of the effort to obtain external membership for the clinical death review committee and/or the administrative death review committee, if no such medical professional and/or representative of the public was available.(g) A summary of the resulting actions taken in response to the recommendations of the administrative and clinical death review committees shall be forwarded by the CEO or designee to HHSC within 28 calendar days following the submission of the elements contained in subsection (f)(1) - (7) of this section. Source Note: The provisions of this §301.417 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.417 Community Centers: Administrative Death Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220791 03/12/2026 Utilizing information gathered from the elements submitted in §405.275(f)(6) and (g) of this subchapter (relating to Community Centers: Administrative Death Review), the community center CEO shall report to the community center's board of trustees any systemic issues emerging from death reviews and the corrective actions taken, on a routine basis or when necessary. Source Note: The provisions of this §301.419 adopted to be effective June 1, 1993, 18 TexReg 2133; amended to be effective May 26, 2022, 47 TexReg 3056; transferred effective October 18, 2024, as published in the September 20, 2024, issue of the Texas Register, 49 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES H DEATHS OF INDIVIDUALS SERVED BY COMMUNITY MENTAL HEALTH CENTERS §301.419 Reporting of Systemic Issues Emerging from Death Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219061 03/12/2026 The purpose of this subchapter is to comply with Texas Health and Safety Code, §534.067, by establishing a uniform fee collection policy for an MRA that:(1) is equitable;(2) provides for collections; and(3) maximizes contributions to local revenue. Source Note: The provisions of this §301.501 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.501 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219062 03/12/2026 (a) This subchapter applies to an MRA for community services contracted for through the performance contract that the MRA provides directly or through a subcontractor to a member of the MR priority population. This subchapter also applies to an adult person in the MR priority population and a parent of a person under age 18 years in the MR priority population.(b) This subchapter does not apply to:(1) a program or service that is prohibited by statute or regulation from charging a fee to a person served;(2) the DADS In-Home and Family Support Program--Mental Retardation;(3) residential services as described in the performance contract; and(4) specialized services mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1987, as amended by OBRA 90, for a preadmission screening and resident review (PASARR) provided to a non-Medicaid eligible person. Source Note: The provisions of this §301.503 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.503 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219063 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Ability to pay--The person has third-party coverage that will pay for needed services, the person's maximum monthly fee is greater than zero, or the person has identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense). (2) Community services or services--Except for residential services, eligibility determination, and screening, the required and optional mental retardation services described in the performance contract. (3) DADS--The Department of Aging and Disability Services. (4) Extraordinary expenses--Major medical or health related expenses, major casualty losses, and child care expenses for the previous year or projections for the next year. (5) Family members-- (A) For an unmarried person under age 18 years--The person, the person's parents, and the dependents of the parents, if residing in the same household; (B) For an unmarried person age 18 years or older--The person and the person's dependents; or (C) For a married person of any age--The person, the person's spouse, and their dependents. (6) Gross income--Revenue from all sources before taxes and other payroll deductions. The term does not include child support received. (7) Inability to pay--The person's maximum monthly fee is zero and the person: (A) does not have third-party coverage; (B) has third-party coverage, but has exceeded the maximum benefit of the covered service(s) or the third-party coverage will not pay because the services needed by the person are not covered services; or (C) has not identified payment for a needed service or services in an approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense). (8) Income-based public insurance--Government funded third-party coverage that bases eligibility on income (i.e., CHIP and Medicaid). (9) MMF--Maximum monthly fee. A fee that is calculated in accordance with §2.106(b) of this chapter (relating to Determination of Ability to Pay). (10) MRA--Mental retardation authority. An entity to which the Health and Human Services Commission's authority and responsibility described in Texas Health and Safety Code, §531.002(11) have been delegated. (11) MR priority population--Groups of persons identified in the Health and Human Services Commission's current strategic plan as being most in need of mental retardation services. (12) Parent--A biological or adoptive parent of a person under age 18 years. (13) Performance contract--A written agreement between DADS and an MRA for the provision of one or more functions as described in Texas Health and Safety Code, §533.035(a). (14) Person--A person in the MR priority population who is seeking or receiving services through an MRA. (15) Significant financial change--Any change in the person's (or parent's) financial status as shown in the financial documentation, as described in §2.105(d) of this subchapter (relating to Accountability), that affects the person's (or parent's) ability to pay. Examples of a significant financial change are: (A) a reduction in income due to the loss of a job or due to a reduction in hours worked on a job; (B) an increase in income because of an inheritance or a salary increase; (C) an increase or decrease in the number of family members; (D) the gain or loss of third-party coverage; and (E) an increase or decrease in extraordinary expenses. (16) Standard charge--A fixed price for a community service or unit of service. (17) Team--A person's service planning team. (18) Third-party coverage--A public or private payer of community services (e.g., Medicaid, Medicare, private insurance, CHIP, TRICARE). Source Note: The provisions of this §301.505 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.505 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219064 03/12/2026 (a) Prohibition from denying services. An MRA is prohibited from denying services:(1) to a person because of the person's inability to pay for the services;(2) to a person in crisis, and the denial is because:(A) a financial assessment has not been completed;(B) financial responsibility has not been determined;(C) the person has a past-due account; or(D) the person had services involuntarily reduced or terminated for non-payment under §2.109(d) of this subchapter (relating to Payments, Collections, and Non-payment); or(3) to a person pending resolution of an issue relating solely to payment for services, including failure of the person (or parent) to comply with any requirement in subsection (c), (d), (e), or (g) of this section.(b) Identifying funding sources. An MRA must identify and access available funding sources other than DADS, and assist a person (or parent) in identifying and accessing available funding sources other than DADS, to pay for services. Available funding sources may include third-party coverage, state and/or local governmental agency funds (e.g., crime victims fund), Qualified Medicare Beneficiary (QMB) Program, or a trust that provides for the person's need for community services.(c) Requirement for a parent to enroll a child in income-based public insurance. A parent of a child who may be eligible for Medicaid or the Children's Health Insurance Program (CHIP) must enroll the child in Medicaid or CHIP or provide documentation that the child has been denied Medicaid or CHIP benefits or that the child's Medicaid or CHIP enrollment is pending. An MRA must provide assistance as needed to facilitate the enrollment process.(d) Financial documentation. A person (or parent) must provide the following financial documentation:(1) annual or monthly gross income/earnings, if any;(2) extraordinary expenses (as defined) paid during the past 12 months or projected for the next 12 months;(3) number of family members (as defined); and(4) proof of any third-party coverage.(e) Authorizing third-party coverage payment to the MRA. A person (or parent) with third-party coverage must execute an assignment of benefits authorizing third-party coverage payment to the MRA.(f) Failure to comply.(1) Except as provided by paragraph (2) of this subsection, if the person (or parent) fails to comply with any requirement in subsection (c), (d), (e), or (g) of this section, then the MRA must charge the person (or parent) the standard charge(s) for services. If, within 30 days after the person (or parent) initially failed to comply, the person (or parent) complies with the requirements, then the MRA must adjust the person's account to retroactively reflect compliance.(2) The MRA may not charge the person the standard charge(s) for services if the MRA makes a decision, which is documented and includes input from the person's team, that the person's failure to comply is related to the person's functioning limitations. The decision must be reassessed at least annually. If the MRA decides that a person's failure to comply is related to the person's functioning limitations, then the MRA must develop and implement a plan to reduce or eliminate the barriers related to the person's failure to comply.(g) Requirement for an adult person to apply for Supplemental Security Income (SSI) to become eligible for Medicaid. An adult person who may be eligible for Medicaid must apply for SSI or provide documentation that the person has been denied SSI or that the person's SSI application is pending. The MRA must provide assistance as needed to facilitate all aspects of the application process. Source Note: The provisions of this §301.507 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.507 Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219065 03/12/2026 (a) Financial assessment. (1) An MRA must conduct and document a financial assessment for a person within 30 days after the person begins to receive services. (2) Except for a Medicaid recipient who is receiving Supplemental Security Income (SSI) benefits but not receiving employment income, the MRA must update a person's financial assessment at least annually while the person is receiving services. The MRA must monitor the continuing availability of benefits for a person with income-based public insurance. (3) The MRA must update a person's financial assessment if the person experiences a significant financial change. (4) The financial assessment must be conducted using the financial documentation listed in §2.105(d) of this subchapter (relating to Accountability) that represents the finances of: (A) the person who is age 18 years or older and the person's spouse; or (B) the parents of the person who is under age 18 years. (b) MMF. A person's MMF is based on the financial assessment and calculated using the Monthly Ability-To-Pay Fee Schedule, as referenced in §2.110 of this subchapter (relating to Monthly Ability-To-Pay Fee Schedule). The calculation is based on the number of family members and annual gross income, reduced by extraordinary expenses paid during the past 12 months or projected for the next 12 months. No other sliding scale is used. (1) An MMF that is greater than zero is established for a person who is determined as having an ability to pay. If two or more members of the same family are receiving services, then the MMF is for the family. (2) An MMF of zero is established for a person who is determined as having an inability to pay. (c) Third-party coverage. (1) Third-party coverage that will pay. A person with third-party coverage that will pay for needed services is determined as having an ability to pay for those services. (2) Third-party coverage that will not pay. (A) If the person's third-party coverage will not pay for needed services because the MRA does not have an approved provider on its network, then the MRA must propose to refer the person to the person's third-party coverage to identify a provider for which the third-party coverage will pay unless: (i) the MRA is identified as being responsible for providing court-ordered services to the person; (ii) the MRA is able to negotiate adequate payment for services with the person's third-party coverage; or (iii) the person (or parent) voluntarily agrees to pay the standard charge(s) for the needed service(s). (B) If the MRA proposes to refer the person to the person's third-party coverage as described in paragraph (2)(A) of this subsection, then the MRA must provide written notification to the person (or parent) in accordance with §2.109(e)(1) of this subchapter (relating to Payments, Collections, and Non-payment), which provides an opportunity to appeal. The MRA must also comply with §2.109(e)(2) - (3) of this subchapter as initiated by the person (or parent). (C) If the MRA refers the person to third-party coverage, then the MRA must assist the person (or parent) in identifying a provider for which the third-party coverage will pay. (D) If a person who has been referred to third-party coverage is unable to identify or access needed services from an approved provider or if access will be unduly delayed, then the MRA must: (i) assist the person (or parent) in resolving the matter with the third-party coverage (e.g., contacting customer service at the third-party coverage, filing a complaint with the third-party coverage or the Texas Department of Insurance); and (ii) if indicated, ensure the provision of the needed services to the person pending resolution. (E) The MRA must maintain documentation of: (i) all referrals as described in paragraph (2)(C) of this subsection; (ii) all assistance as described in paragraph (2)(D)(i) of this subsection; and (iii) whether the person received services pending resolution as described in paragraph (2)(D)(ii) of this subsection. (d) Social Security work incentive provisions. A person who identified payment for specific needed services in the person's approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense) is determined as having an ability to pay for the specific services. A person is not required to identify payment for any service for which the person may be eligible as part of the person's approved plan for utilizing the Social Security work incentive provisions. (e) Notification. After a financial assessment is conducted, the MRA must provide written notification to the person (or parent) that includes: (1) the determination of whether the person (or parent) has an ability or an inability to pay; (2) a copy of the financial assessment form and a copy of the Monthly Ability-to-Pay Fee Schedule, with the applicable areas indicated (i.e., annual gross income, number of family members); (3) the amount of the MMF; (4) the name and phone number of at least one MRA staff who the person (or parent) may contact during office hours to discuss the information contained in the written notification; and (5) a statement that the person (or parent) may voluntarily pay more than the maximum monthly fee. Source Note: The provisions of this §301.509 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.509 Determination of Ability to Pay https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219066 03/12/2026 An MRA must establish, at least annually, a reasonable standard charge for a community service as indicated in the performance contract. The standard charge must cover, at a minimum, the MRA's cost of ensuring the provision of the service. Source Note: The provisions of this §301.511 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.511 Standard Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219067 03/12/2026 (a) Monthly account. (1) The MRA must maintain a monthly account for a person that lists all services provided to the person during the month and the standard charges for the services. Each service listed must indicate whether the service is: (A) covered by Medicare third-party coverage; (B) covered by non-Medicare third-party coverage; (C) not covered by third-party coverage; or (D) identified for payment in the person's approved plan utilizing Social Security work incentive provisions. (2) If a person has exceeded the maximum third-party coverage benefit of a particular covered service, then that service is indicated as not covered by third-party coverage. (b) Accessing funding sources. The MRA must access all available funding sources before using DADS funds to pay for a person's services. Funding sources may include third-party coverage, state and/or local governmental agency funds (e.g., crime victims fund), Qualified Medicare Beneficiary (QMB) Program, or a trust that provides for the person's need for community services. (c) Billing third-party coverage. The MRA bills the person's third-party coverage the monthly account amount for covered services. If the MRA has negotiated a reimbursement amount with the third-party coverage that is different from the monthly account amount, then the MRA may bill the third-party coverage the negotiated reimbursement amount for covered services. (d) Billing the person (or parent). (1) No third-party coverage. If the monthly account amount for services not covered by third-party coverage: (A) exceeds the person's MMF, then the amount is reduced to equal the MMF and the MRA bills the person (or parent) the MMF; or (B) is less than the person's MMF, then the MRA bills the person (or parent) the monthly account amount for services not covered by third-party coverage. (2) Medicare third-party coverage. Nothing in this paragraph is intended to conflict with any applicable law, rule, or regulation with which an MRA must comply. (A) The following amounts are added to equal the total amount applied toward the person's MMF: (i) the amount of all applicable co-payments and co-insurance for services listed in the monthly account as covered by Medicare third-party coverage; (ii) the amount Medicare third-party coverage was billed but did not pay because the deductible hasn't been met; and (B) If the total amount applied toward the person's MMF as described in paragraph (2)(A) of this subsection: (i) exceeds the person's MMF, then the amount is reduced to equal the MMF and the MRA bills the person (or parent) the MMF; or (ii) is less than the person's MMF, then the MRA bills the person (or parent) the total amount applied toward the MMF. (3) Non-Medicare third-party coverage. (A) Cost-sharing exceeds MMF. If the amount of all applicable co-payments, co-insurance, and deductibles for services listed in the monthly account as covered by non-Medicare third-party coverage exceeds the person's MMF, then the MRA bills the person (or parent) all applicable co-payments, co-insurance, and deductibles. (B) Cost-sharing does not exceed MMF. (i) If the amount of all applicable co-payments, co-insurance, and deductibles for services listed in the monthly account as covered by non-Medicare third-party coverage does not exceed the person's MMF, then the following amounts are added to equal the total amount applied toward the person's MMF: (I) the amount of all applicable co-payments, co-insurance, and deductibles; and (II) the monthly account amount for services not covered by third-party coverage. (ii) If the total amount applied toward the person's MMF as described in paragraph (3)(B)(i) of this subsection: (I) exceeds the person's MMF, then the amount is reduced to equal the MMF and the MRA bills person (or parent) the MMF; or (II) is less than the person's MMF, then the MRA bills the person (or parent) the total amount applied toward the MMF. (C) Annual cost-sharing limit. If the person (or parent) has reached the person's annual cost-sharing limit (i.e., maximum out-of-pocket expense) as verified by the non-Medicare third-party coverage, then the MRA must not bill the person (or parent) any co-payments, co-insurance, or deductibles, as applicable to the annual cost-sharing limit, for services covered by the non-Medicare third-party coverage for the remainder of the policy-year. (4) Social Security work incentive provisions. (A) If the person identified a payment amount for specific services in the person's approved plan utilizing Social Security work incentive provisions (i.e., Plan to Achieve Self-Sufficiency; Impairment Related Work Expense), then the MRA bills the person the monthly account amount for the specific services up to the identified payment amount. If the monthly account amount for the specific services is greater than the identified payment amount, then the remaining balance is applied toward the person's MMF. (B) The following amounts are added to equal the total amount applied toward the person's MMF: (i) any remaining balance as described in paragraph (4)(A) of this subsection; and (ii) the monthly account amount for services not covered by third-party coverage. (C) If the total amount applied toward the person's MMF as described in paragraph (4)(B) of this subsection: (i) exceeds the person's MMF, then the amount is reduced to equal the MMF and the MRA bills person (or parent) the MMF; or (ii) is less than the person's MMF, then the MRA bills the person (or parent) the total amount applied toward the MMF. (e) Statements. (1) The MRA must send to a person (or parent) who has been determined as having the ability to pay monthly or quarterly statements that include: (A) an itemized list, at least by date and by type, of all services provided during the period; (B) the standard charge for each service; (C) the total charge for the period; (D) the amount paid (or to be paid) by each funding source; and (E) the amount to be paid by the person (or parent). (2) Unless requested otherwise, the MRA may not send a statement to a person (or parent) who has an ability to pay if the person (or parent) maintains a zero balance (i.e., the person (or parent) does not currently owe any money). (3) Unless requested otherwise, the MRA may not send a statement to a person (or parent) who has an inability to pay. Source Note: The provisions of this §301.513 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.513 Billing Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219068 03/12/2026 (a) Payment and collection.(1) A person (or parent) must promptly pay all charges owed to the MRA.(2) An MRA must make reasonable efforts to collect payments from all available funding sources before accessing DADS funds to pay for a person's services.(b) Financial hardship. If a person (or parent) claims financial hardship as provided in this subsection, then the MRA must determine whether a significant financial change (as defined) has occurred. If a significant financial change has occurred, then the MRA must immediately update the person's (or parent's) financial assessment as required in §2.106(a) of this subchapter (relating to Determination of Ability to Pay).(1) If a person (or parent) claims, and provides documentation, that financial hardship prevents prompt payment of all charges owed, then the MRA may arrange for the person (or parent) to pay a lesser amount each month.(2) If a person (or parent) claims that financial hardship prevents prompt payment of all charges owed, then the MRA must arrange for the person (or parent) to pay a lesser amount each month only if the person has third-party coverage that is neither income-based public insurance nor Medicare and the person's cost-sharing exceeds the person's MMF. The lesser amount:(A) will be no more than the person's MMF, if the person's MMF is greater than zero; or(B) will be no more than $5.00, if the person's MMF is zero.(3) Although the person (or parent) may pay a lesser amount each month because a portion of the charges will be deferred, the person (or parent) is still responsible for paying all charges owed.(c) Discontinuing charges to a person (or parent) for services. If the MRA makes a decision, which is documented and includes input from the person's team, that being charged for services and receiving statements will result in a significant reduction in the functioning of the person or the person's (or parent's) refusal or rejection of the needed services, then the MRA must stop charging the person (or parent) for services and stop sending statements. The decision must be reassessed at least annually. If the MRA decides to discontinue charging the person (or parent) for services, then the MRA must develop and implement a plan to address the issues related to the person's functioning limitations or the person's (or parent's) refusal or rejection of the needed services.(d) Involuntary reduction or termination of services for non-payment by person (or parent).(1) The MRA must address the past-due account of a person (or parent) who is not making payments to ensure reasonable efforts to secure payments are initiated with the person (or parent). For example, if the MRA determines that non-payment is related to financial hardship, then the MRA may assist the person (or parent) in making arrangements to pay a lesser amount each month in accordance with subsection (a)(2) of this section or if the MRA makes a decision, which is documented and includes input from the person's team, that non-payment is related to the person's functioning limitations, then the person's service plan may be modified to address the non-payment.(2) If the MRA makes a decision, which is documented and includes input from the person's team, that non-payment is not related to the person's functioning limitations and, despite reasonable efforts to secure payment, the person (or parent) does not pay, then the MRA may propose to involuntarily reduce or terminate the person's services. The MRA may not propose to involuntarily reduce or terminate the person's services if:(A) the proposed action would result in a significant reduction in the person's functioning;(B) the proposed action would put at risk the person's health, safety, or support system; or(C) the MRA is identified as being responsible for providing court-ordered services to the person.(3) If the MRA proposes to involuntarily reduce or terminate the person's services, then the MRA must:(A) maintain documentation that the proposed action would not result in a significant reduction in the person's functioning or put at risk the person's health, safety, or support system; and(B) provide written notification to the person (or parent) in accordance with subsection (e)(1) of this section and comply with subsection (e)(2) - (3) as initiated by the person (or parent).(e) Notification, Appeal, and Review.(1) Notification. The MRA must notify the person (or parent) in writing of the proposed action (i.e., to involuntarily reduce or terminate the person's services or refer the person to third-party coverage) and the right to appeal the proposed action in accordance with §2.46 of this chapter (relating to Notification and Appeals Process). The notification must describe the time frames and process for requesting an appeal and include a copy of this subchapter. If the person (or parent) requests an appeal within the prescribed time frame, then the MRA must not take the proposed action while the appeal is pending. The MRA may take the proposed action if the person (or parent) does not request a review within the prescribed time frame.(2) Appeal and appeal decision. The MRA must conduct the appeal in accordance with §2.46(g) of this chapter. The MRA must notify the person (or parent) in writing of the appeal decision in accordance with §2.46(h) of this chapter and the right to have the appeal decision reviewed by the Office of Consumer Rights and Services at DADS if the person (or parent) is dissatisfied with the appeal decision. The notification must describe the time frames and process for requesting a review.(3) Review of appeal decision. If the person (or parent) is dissatisfied with the appeal decision, then the person (or parent) may request a review by the Office of Consumer Rights and Services at DADS. A request for review must be submitted to the Office of Consumer Rights and Services, Department of Aging and Disability Services, P.O. Box 149030, MC E-249, Austin, TX 78714-9030, within 10 working days after receipt of the appeal decision. If the person (or parent) requests a review within the prescribed time frame, then the MRA must not take the proposed action while the review is pending. The MRA may take the proposed action if the person (or parent) does not request a review within the prescribed time frame and the appeal decision upholds the decision to take the proposed action.(A) A person (or parent) who requests a review may choose to have the reviewer conduct the review:(i) by telephone conference with the person (or parent) and a representative from the MRA and make a decision based upon verbal testimony made during the telephone conference and any documents provided by the person (or parent) and the MRA; or(ii) by making a decision based solely upon documents provided by the person (or parent) and the MRA without the presence of any of the parties involved.(B) The review:(i) is conducted no sooner than 10 working days and no later than 30 working days after receipt of the request for review unless an extension is granted by the director of the Office of Consumer Rights and Services;(ii) includes an examination of the pertinent information concerning the proposed action and may include consultation with DADS staff who are responsible for the policy contained in this subchapter;(iii) results in a final decision which will uphold, reverse, or modify the original decision to take the proposed action; and(iv) is the final step of the appeal process for involuntarily reducing or terminating the person's services for non-payment and for referring the person to third-party coverage.(C) Within five working days after the review, the reviewer sends written notification of the final decision to the person (or parent) and the MRA.(D) The MRA must take appropriate action consistent with the final decision.(f) Prohibition of financial penalties. The MRA must not impose financial penalties on a person (or parent).(g) Debt collection. The MRA must make reasonable efforts to collect debts before an account is referred to a debt collection agency. The MRA must document its efforts at debt collection.(1) The MRA must incorporate into a written agreement or contract for debt collection provisions that state that both parties must:(A) maintain the confidentiality of the information and not disclose the identity of the person or any other identifying information; and(B) not harass, threaten, or intimidate a person or the person's family.(2) The MRA must enforce the provisions contained in paragraph (1) of this subsection. Source Note: The provisions of this §301.515 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.515 Payments, Collections, and Non-payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219069 03/12/2026 The Monthly Ability-To-Pay Fee Schedule, which can be found at www.dads.state.tx.us, is based on 150% of the Federal Poverty Guidelines. DADS may revise the Monthly Ability-To-Pay Fee Schedule, based on any changes in the Federal Poverty Guidelines. Source Note: The provisions of this §301.517 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.517 Monthly Ability-to-Pay Fee Schedule https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219070 03/12/2026 MRA staff who are involved in implementing or explaining the content of this subchapter must receive initial training and demonstrate competency prior to performing tasks related to charging for community services. Such staff must demonstrate competency annually thereafter. Source Note: The provisions of this §301.519 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.519 Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219071 03/12/2026 (a) DADS makes available on its website a brochure that contains the policies for charging for community services that are contained in this subchapter, including:(1) a general reference to the statutory trust exemption; and(2) information related to claiming financial hardship.(b) An MRA must provide a person (or parent) a copy of the brochure prior to the person's entry into services, except in a crisis. Source Note: The provisions of this §301.521 adopted to be effective September 1, 2002, 27 TexReg 2041; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective November 1, 2007, 32 TexReg 7494; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES J CHARGES FOR COMMUNITY SERVICES §301.521 Brochure for a Person (or Parent) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218470 03/12/2026 The purpose of this subchapter is to require a mental retardation authority (MRA) or a community center to:(1) have an effective procedure for conducting criminal history and registry checks on an applicant, employee, contractor, or volunteer of the MRA or community center;(2) have an effective procedure for requiring an employee, contractor, or volunteer of the MRA or community center to self-report a conviction or charge of a criminal offense or a registry listing; and(3) require a contract agency to conduct criminal history and registry checks on an applicant, employee, contractor, or volunteer of the contractor agency in accordance with this subchapter. Source Note: The provisions of this §301.601 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.601 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218471 03/12/2026 This subchapter applies to:(1) an MRA; and(2) a community center. Source Note: The provisions of this §301.603 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.603 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218472 03/12/2026 The following words and terms, when used in this subchapter (relating to Criminal History and Registry Checks for MRAs and Community Centers), have the following meanings, unless the context clearly indicates otherwise:(1) Applicant--A person to whom an MRA, community center, or contract agency intends to offer employment, a contract, or volunteer status.(2) Community center--A community mental health and mental retardation center established under the Texas Health and Safety Code, Title 7, Chapter 534, Subchapter A.(3) Contract--An agreement between an MRA, community center, or contract agency and a contractor whose contractual duties may put the contractor in direct contact with an individual.(4) Contract agency--A person that contracts with an MRA or community center to provide an employee or contractor whose duties may put the employee or contractor in direct contact with an individual.(5) Contractor--A person who contracts with an MRA, community center, or contract agency and whose contractual duties may put the person in direct contact with an individual.(6) Conviction--The adjudication of guilt for a criminal offense. The term does not include deferred adjudication community supervision as described in Texas Health and Safety Code, §250.006(d).(7) DADS--The Department of Aging and Disability Services.(8) Employee--A person who is employed by an MRA, community center, or contract agency and whose duties may put the person in direct contact with an individual.(9) Individual--A person receiving services that are funded by or through DADS and provided by an MRA or community center or provided by a contract agency through a contract with an MRA or community center.(10) MRA--Mental retardation authority. An entity designated in accordance with Texas Health and Safety Code, §533.035(a).(11) Registry--(A) The employee misconduct registry maintained by DADS in accordance with Texas Health and Safety Code, Chapter 253, and Chapter 93 of this title (relating to Employee Misconduct Registry (EMR)); or(B) The nurse aide registry maintained by DADS in accordance with §94.10 of this title (relating to Registry, Findings, and Inquiries).(12) Volunteer--A person who provides services to an MRA, community center, or contract agency without compensation from the MRA, community center, or contract agency, other than reimbursement for actual expenses, and whose duties may put the person in direct contact with an individual. Source Note: The provisions of this §301.605 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.605 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218473 03/12/2026 (a) An MRA or community center may not hire, enter into a contract with, or assign volunteer status to an applicant with the MRA or community center who:(1) has a conviction of an offense listed in Texas Health and Safety Code §250.006(a);(2) has a conviction of an offense listed in Texas Health and Safety Code §250.006(b), during the five years before the proposed employment or contractual or volunteer status;(3) has a conviction of an offense that the MRA or community center determines is a contraindication to employment or contractual or volunteer status; or(4) is listed as unemployable in a registry.(b) An MRA or community center may not continue to employ, contract with, or give volunteer status to a person who:(1) has a conviction of an offense listed in Texas Health and Safety Code §250.006(a);(2) has a conviction of an offense listed in Texas Health and Safety Code §250.006(b), during the five years before the MRA or community has knowledge of the conviction;(3) has a conviction of an offense that the MRA or community center determines is a contraindication to employment or contractual or volunteer status; or(4) is listed as unemployable in a registry.(c) An MRA or community center must give an applicant with the MRA or community center the following information, in writing, when the applicant makes an application for employment or contractual or volunteer status:(1) that criminal history and registry checks will be conducted on the applicant;(2) the types of criminal offenses for which a conviction prohibits employment by law;(3) that a conviction of other types of criminal offenses may be considered a contraindication to employment or contractual or volunteer status;(4) that a registry check will be conducted to determine if an applicant is listed as unemployable; and(5) that a registry check will be conducted annually to determine if an employee, contractor, or volunteer is listed as unemployable. Source Note: The provisions of this §301.607 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.607 Prohibition to Employment or Contractual or Volunteer Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218474 03/12/2026 (a) Criminal history check.(1) Before making an offer of employment or contractual or volunteer status to an applicant, an MRA or community center must conduct a criminal history check by:(A) obtaining criminal history record information from the Texas Department of Public Safety (TDPS); and(B) if the applicant has lived outside the State of Texas at any time during the two years before making the application for employment or contractual or volunteer status with an MRA or community center, obtaining criminal history information from the Federal Bureau of Investigation.(2) An MRA or community center may conduct a criminal history check on an employee, contractor, or volunteer of the MRA or community center at any time the MRA or community center determines it is necessary.(b) Registry check.(1) Before making an offer of employment or contractual or volunteer status to an applicant, an MRA or community center must conduct a registry check by searching both registries listed in §4.503(11) of this subchapter (relating to Definitions) to determine if the applicant is listed as unemployable.(2) An MRA or community center must conduct a registry check annually to ensure that an employee, contractor, or volunteer of the MRA or community center is not listed as unemployable. The MRA and community center must retain a copy of the results of an annual registry check.(3) An MRA or community center may conduct a registry check to determine if an employee, contractor, or volunteer of the MRA or community center is listed as unemployable at any time the MRA or community center determines it is necessary. Source Note: The provisions of this §301.609 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.609 Conducting Criminal History and Registry Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218475 03/12/2026 An MRA or community center must require an employee, contractor, or volunteer of the MRA or community center to report to a staff person designated by the MRA or community center:(1) a criminal offense that the employee, contractor, or volunteer is charged with or convicted of after starting employment or volunteer status or after the execution of the contractor's contract; or(2) a listing of the employee, contractor, or volunteer as unemployable in a registry after starting employment or volunteer status or after the execution of the contractor's contract. Source Note: The provisions of this §301.611 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.611 Self-Reporting a Criminal Offense Charge or Conviction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218476 03/12/2026 (a) An MRA or community center must have written procedures consistent with this subchapter (relating to Criminal History and Registry Checks for MRAs and Community Centers) that describes how information obtained through criminal history and registry checks is processed, including:(1) procedures that protect the confidentiality of criminal history record information pursuant to Texas Health and Safety Code §250.007 and Texas Government Code §411.115;(2) procedures for notifying an applicant, employee, volunteer, or contractor if:(A) the criminal history record information of the applicant, employee, volunteer, or contractor identifies a conviction that prohibits or contraindicates employment or contractual or volunteer status; or(B) the applicant, employee, or volunteer is listed as unemployable in a registry;(3) procedures for notifying an applicant, employee, volunteer, or contractor how to address inaccuracies in criminal history record information (i.e., the opportunity to be heard by Texas Department of Public Safety) if the person believes he or she has been unjustly denied employment or contractual or volunteer status as a result of criminal history record information that is incorrect or relates to another person;(4) procedures for documenting the results of criminal history and registry checks of an applicant, employee, volunteer, or contractor;(5) procedures for maintaining a copy of the results of the annual registry checks in the file of an employee, contractor, or volunteer of the MRA or community center;(6) procedures for destroying all criminal history record information obtained in accordance with this subchapter immediately after an employment or volunteer decision has been made or personnel action has been taken, as required by Texas Government Code §411.115(e); and(7) procedures for destroying all criminal history record information related to a contractor of the MRA or community center obtained in accordance with this subchapter immediately after execution of the contract.(b) An MRA or community center must develop written procedures consistent with this subchapter describing how it will respond to information obtained through self-reporting and subsequent criminal history and registry checks.(1) Pursuant to the Texas Health and Safety Code, §533.007(b), an MRA or community center may not take adverse personnel action against an employee of the MRA or community center if the information received pertains to an arrest warrant or wanted persons information. However, the MRA or community center may reassign the employee until resolution of the matter relating to the arrest warrant or wanted persons information.(2) If the information obtained by self-reporting or from a criminal history check states that the employee, contractor, or volunteer of an MRA or community center has a conviction for an offense described in §4.505(b)(1) - (3) of this subchapter (relating to Prohibition to Employment or Contractual or Volunteer Status), the MRA or community center may consider a contention by the employee, contractor, or volunteer that the information is incorrect or that it relates to another person. The MRA or community center may give the employee, contractor, or volunteer a reasonable period of time to have the information corrected, but the MRA or community center must reassign the employee, contractor, or volunteer to duties that are not contraindicated by the conviction. If the employee, contractor, or volunteer fails to get the information corrected as provided by Texas Health and Safety Code §250.005(b), the MRA or community center must immediately discharge the employee or volunteer or terminate the contractor's contract.(3) If the information obtained by self-reporting or a registry check states that an employee, contractor, or volunteer of the MRA or community center is listed as unemployable in a registry, the MRA or community center must immediately discharge the employee or volunteer or terminate the contractor's contract. Source Note: The provisions of this §301.613 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.613 LIDDA and Community Center Policies Related to Criminal History and Registry Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218477 03/12/2026 (a) An MRA or community center must require a contract agency to conduct criminal history and registry checks on an applicant with the contract agency.(b) An MRA or community center must require a contract agency to annually conduct a registry check on an employee, contractor, or volunteer with the contract agency.(c) An MRA or community center must require a contract agency to require an employee, contractor, or volunteer of the contract agency to report to the contract agency:(1) a criminal offense that the employee, contractor, or volunteer is convicted of or charged with after starting employment or volunteer status or after the execution of the contractor's contract; and(2) a listing of the employee, contractor, or volunteer as unemployable in a registry after starting employment or volunteer status or after the execution of the contractor's contract.(d) An MRA or community center must require a contract agency to conduct criminal history and registry checks on an employee, contractor, or volunteer of the contract agency if the contract agency has reason to believe the employee, contractor, or volunteer may have a criminal history that makes the employee, contractor, or volunteer unqualified or unsuitable for employment or contractual or volunteer status or may be listed as unemployable on a registry.(e) An MRA or community center must prohibit a contract agency from allowing an employee, contractor, or volunteer of the contract agency to have direct contact with an individual if the contract agency becomes aware that:(1) a criminal history check indicates that the employee, contractor, or volunteer is not qualified or suitable; or(2) the employee, contractor, or volunteer is listed as unemployable in a registry. Source Note: The provisions of this §301.615 adopted to be effective October 6, 2011, 36 TexReg 6513; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES L CRIMINAL HISTORY AND REGISTRY CLEARANCES IN LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES §301.615 Contract Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218478 03/12/2026 The purpose of this subchapter is to implement §48.255(c) of the Human Resources Code, which requires TDMHMR to develop joint rules with the Texas Department of Protective and Regulatory Services (TDPRS) to facilitate investigations in local authorities and community centers and to describe the requirements for:(1) reporting allegations of abuse, neglect, and exploitation of persons served;(2) ensuring the safety and protections of persons served involved in allegations;(3) facilitating investigations; and(4) ensuring proper disciplinary or other action is taken when abuse, neglect, or exploitation is confirmed. Source Note: The provisions of this §301.651 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.651 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218479 03/12/2026 (a) This subchapter applies to local authorities and community centers. However, local authorities and community centers that are Medicaid providers of a home and community-based services waiver program must comply with TDMHMR rules governing the home and community-based services waiver program when addressing abuse, neglect, and exploitation in the home and community-based services waiver program.(b) Local authorities and community centers are responsible for amending their contracts to ensure contractors' compliance with this subchapter. Source Note: The provisions of this §301.653 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.653 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218480 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Abuse--For purposes of reporting allegations, the term is defined by the investigatory agency. For purposes of classifying allegations as part of the TDMHMR Client Abuse and Neglect Reporting System (CANRS), the term is defined in CANRS Definitions, which is referenced as Exhibit A of §414.562 of this title (relating to Exhibits).(2) Administrator--The individual in charge of a local authority or community center, or designee.(3) Agent--Any individual not employed by a local authority, community center, or contractor, but working under the auspices of the local authority, community center, or contractor (e.g., student, volunteer).(4) Allegation--A report by an individual suspecting or having knowledge that a person served has been or is in a state of abuse, neglect, or exploitation as defined by the investigatory agency or in CANRS Definitions, which is referenced as Exhibit A in §414.562 of this title.(5) Clinical practice--Relates to the demonstration of professional competence by a licensed professional.(6) Community center--A community mental health center, community mental retardation center, or community mental health and mental retardation center, established under the Texas Health and Safety Code, Title 7, Chapter 534, Subchapter A.(7) Confirmed--The finding of an investigation if there is a preponderance of credible evidence to support that abuse, neglect, or exploitation occurred.(8) Contractor--Any organization, entity, or individual who contracts with a local authority or community center to provide mental health or mental retardation services to a person served. The term includes a local independent school district with which a local authority or community centers has a memorandum of understanding (MOU) for educational services.(9) Contractor CEO--The individual in charge of a contractor that has one or more employees excluding the CEO.(10) Exploitation--For purposes of reporting allegations, the term is defined by the investigatory agency. For purposes of classifying allegations as part of the TDMHMR CANRS, the term is defined in CANRS Definitions, which is referenced as Exhibit A in §414.562 of this title.(11) Investigatory agency--An agency with statutory authority to investigate abuse, neglect, and exploitation of a person served by a local authority, community center, or contractor. For example, the Texas Department of Protective and Regulatory Services investigates allegations in local authorities and community centers (including intermediate care facilities for the mentally retarded or persons with a related condition (ICF/MR or ICF/MR/RC) operated by a local authority or community center) and all contractors of local authorities and community centers except psychiatric hospitals; the Texas Department of Health (TDH) investigates allegations in psychiatric hospitals; and the Texas Commission on Alcohol and Drug Abuse (TCADA) investigates allegations in TCADA-funded programs operated by a local authority or community center pursuant to a contract with TCADA.(12) Local authority--An entity designated by the TDMHMR commissioner in accordance with the Texas Health and Safety Code, §533.035(a).(13) Neglect--For purposes of reporting allegations, the term is defined by the investigatory agency. For purposes of classifying allegations as part of the TDMHMR CANRS, the term is defined in CANRS Definitions, which is referenced as Exhibit A in §414.562 of this title.(14) Perpetrator--An individual who has committed an act of abuse, neglect, or exploitation.(15) Person served--(A) Any person with mental illness or mental retardation receiving services from a local authority or community center or through a contract with a local authority or community center who is registered or assigned in the Client Assignment and Registration (CARE) system; or(B) any child or disabled person as defined in the Human Resources Code, Chapter 48, who is otherwise receiving services from a local authority or community center or through a contract with a local authority or community center.(16) Professional review--A review of clinical and/or professional practice(s) by peer professionals.(17) Retaliatory action--Any action intended to inflict emotional or physical harm or inconvenience on an employee, agent, or person served that is taken because he or she has reported abuse, neglect, or exploitation. Retaliatory action includes, but is not limited to, harassment, disciplinary measures, discrimination, reprimand, threat, and criticism. Source Note: The provisions of this §301.655 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.655 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218481 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218481 03/12/2026 (a) Promulgate and implement policies and procedures. Each local authority and community center shall promulgate and implement policies and procedures that meet the requirements of this section.(b) Prohibition of abuse, neglect, and exploitation. Each local authority, community center, and contractor shall ensure that its employees and agents are informed of the prohibition of abuse, neglect, and exploitation of persons served.(c) Identifying programs and investigatory agencies.(1) Each local authority, community center, and contractor shall ensure that the name and phone number of the investigatory agency are clearly identified and displayed for its employees and agents at each of its program and service delivery sites.(2) Each local authority and community center shall provide to each investigatory agency a list of the names and addresses of its contracted and non-contracted program and service delivery sites in the investigatory agency's purview, including the name of the staff who will serve as contact for investigators, as required in subsection (g)(1) of this section.(d) Reporting abuse, neglect, and exploitation and securing evidence.(1) Each local authority, community center, and contractor shall require its employees and agents who suspect or have knowledge of abuse, neglect, or exploitation of a person served to:(A) make a verbal report to the investigatory agency immediately, but in no case more than one hour after suspicion or knowledge of the abuse, neglect, or exploitation, in compliance with existing state laws, rules, memorandums of understanding, and this subchapter;(B) as needed, assist any individual in making a report when the individual alleging abuse, neglect, or exploitation is not an employee or agent, (e.g., a person served, a guest); and(C) secure evidence related to the allegation in accordance with "Guidelines for Securing Evidence" referenced as Exhibit B in §414.562 of this title (relating to Exhibits).(2) Failure to make reports of abuse, neglect, or exploitation immediately without sufficient justification is considered a violation of this section and makes the employee or agent subject to disciplinary or other appropriate action and possible criminal prosecution.(3) In addition to the reporting requirement described in paragraph (1)(A) of this subsection, reports regarding alleged sexual exploitation committed by a mental health services provider are made to the prosecuting attorney in the county in which the alleged sexual exploitation occurred and any state licensing board that has responsibility for the mental health services provider's licensing in accordance with the Texas Civil Practice and Remedies Code, §81.006. A copy of the Texas Civil Practice and Remedies Code, §81.006, and §81.001, which includes the definitions of "sexual exploitation" and "mental health services provider," is referenced as Exhibit C in §414.562 of this title (relating to Exhibits).(e) Notifying contractor CEO. If the administrator is notified of an allegation involving a contractor, then the administrator must immediately notify the contractor CEO of the allegation unless the contractor CEO is the alleged perpetrator. If the contractor CEO is the alleged perpetrator, then the administrator shall ensure the activities described in subsections (f), (h), and (i) are accomplished.(f) Safeguarding the alleged victim. Immediately upon notification of an allegation by the investigatory agency the administrator or contractor CEO shall ensure necessary measures are taken to secure the safety of the alleged victim(s) involved in the allegation, including:(1) ensuring immediate and on-going medical and psychological attention is provided to the alleged victim(s), as necessary; and(2) separating the alleged victim(s) from the alleged perpetrator(s) until an investigation has been completed.(g) Prohibiting retaliatory action. Any employee or agent, or any individual affiliated with an employee or agent is prohibited from engaging in retaliatory action against an employee, agent, or person served who in good faith reports an allegation. Any employee or agent found to have engaged in retaliatory action is subject to disciplinary or other appropriate action.(1) Any employee or agent who believes he or she is being subjected to retaliatory action upon making a report of abuse, neglect, or exploitation, or who believes an allegation has been ignored without cause, should immediately contact the administrator or contractor CEO and may also contact the Office of Consumer Services and Rights Protection - Ombudsman at TDMHMR's Central Office, at the toll free number 1-800-252-8154.(2) Retaliatory action against a person served which might be considered abuse, neglect, or exploitation must be reported in accordance with this section.(h) Facilitating investigations.(1) Administrators and contractor CEOs shall ensure the designation of a contact staff at each program and service delivery site who will be responsible for coordinating with the investigator to ensure the availability of and access to private interview space, private telephones, and employees, agents, and persons served.(2) Administrators and contractor CEOs shall require employees and agents to cooperate with investigators so that investigators are afforded immediate access to persons served, employees, agents, records of persons served, and other documents requested by the investigator.(3) Falsification of fact during an investigation is considered a violation of this section and makes the employee or agent subject to disciplinary or other appropriate action and possible criminal prosecution.(i) Referring allegations involving clinical practice. If the investigator refers to the administrator or contractor CEO an allegation involving the clinical practice of a licensed professional, then the administrator or contractor CEO shall refer the allegation for professional review or, if the local authority, community center, or contractor does not have a professional review process, the administrator or contractor CEO shall refer the allegation to the appropriate licensing authority. The administrator or contractor CEO shall ensure relevant conclusions of a professional review are submitted to the appropriate licensing authority.(j) Facilitating resolution of other issues.(1) Administrators and contractor CEOs shall ensure that general complaints and administrative issues that are referred to them by an investigator are reviewed and resolved in a timely manner.(2) Local authorities, community centers, and contractors shall afford TDMHMR immediate access to persons served, employees, agents, records of persons served, and other documents when TDMHMR responds to a complaint that the health, welfare, or safety of a person served may be jeopardized. Source Note: The provisions of this §301.657 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.657 Responsibilities of Local Authorities, Community Centers, and Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218482 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218482 03/12/2026 (a) Each local authority and community center shall promulgate and implement policies and procedures that meet the requirements of this section.(b) As soon as possible, but no later than 24 hours following notification of an allegation by the investigatory agency, the administrator or contractor CEO shall notify the alleged victim and the alleged victim's guardian or parent (if the alleged victim is a minor) of the allegation.(c) The administrator or contractor CEO shall ensure that the victim or alleged victim, guardian, or parent (if the victim or alleged victim is a minor) is notified of:(1) the finding and any decisions made after review and/or appeal of the finding;(2) the method to appeal the finding, if any;(3) how to receive a copy of the investigative report; and(4) if the allegation is confirmed, the disciplinary or other action taken against the perpetrator. Source Note: The provisions of this §301.659 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.659 Information To Be Provided to Victim or Alleged Victim and Others https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218483 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218483 03/12/2026 (a) TDPRS submits a copy of the investigative report to the administrator or contractor CEO or both in accordance with Chapter 711 of Title 40 (relating to Investigations in TDMHMR Facilities and Related Programs).(b) The administrator or contractor CEO may not change a confirmed finding made by a TDPRS investigator. The administrator or contractor CEO may request a review of the finding or the methodology used to conduct the investigation in accordance with Chapter 711 of Title 40 (relating to Investigations in TDMHMR Facilities and Related Programs). Source Note: The provisions of this §301.661 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.661 Investigations Conducted by the Texas Department of Family and Protective Services (DFPS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218484 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218484 03/12/2026 (a) Each local authority and community center shall promulgate and implement policies and procedures that meet the requirements of this section.(b) Administrators and contractor CEOs must take appropriate disciplinary or other action in confirmed cases of abuse, neglect, and exploitation involving employees and agents.(1) If the investigatory agency has a process by which the administrator or contractor CEO can request a review of the finding and a review is requested, then the outcome of the review is final and forms the basis for disciplinary action.(2) If the investigatory agency does not have a process by which the administrator or contractor CEO can request a review of the finding, the investigatory agency's finding is final and forms the basis for disciplinary action.(c) Nothing in this subchapter precludes an administrator or contractor CEO from taking disciplinary or other appropriate action pending investigation, including termination of employment. If disciplinary or other action is taken before the investigation is complete, then the executive director or CEO shall notify the investigator of such action and the investigation continues.(d) Administrators and contractor CEOs shall ensure that disciplinary or other appropriate action, including seeking criminal prosecution as appropriate, is taken when an employee or agent fails to make reports immediately without sufficient justification or an employee or agent is found to have made a false statement of fact during an investigation. Source Note: The provisions of this §301.663 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.663 Disciplinary and Other Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218485 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218485 03/12/2026 If the perpetrator or alleged perpetrator is an employee or agent of a local authority, community center, or contractor, or the perpetrator is unknown, then the administrator shall ensure that a Client Abuse and Neglect Reporting form (AN-1-A) is completed within 14 calendar days of the receipt of the investigative report or decision made after review or appeal using the CANRS Definitions and the CANRS Classifications. (The Client Abuse and Neglect Reporting form (AN-1-A), the CANRS Definitions, and the CANRS Classifications are referenced as Exhibits E, A, and D, respectively, in §414.562 of this title (relating to Exhibits).) Within one working day after completion of the AN-1-A form, the administrator shall ensure that:(1) the information contained in the completed AN-1-A is entered into the Client Abuse and Neglect Reporting System (CANRS); or(2) if access to CANRS is unavailable, a copy of the completed AN-1-A is forwarded for data entry to the Office of Consumer Services and Rights Protection - Ombudsman, TDMHMR, P.O. Box 12668, Austin, TX 78711-2668. Source Note: The provisions of this §301.665 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.665 Data Reporting Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218486 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218486 03/12/2026 (a) The reports, records, and working papers used by or developed in the investigative process by an investigatory agency, and the investigatory agency's resulting investigative report, are confidential and may be disclosed only as allowed by law or rule.(b) Upon request, the administrator or contractor CEO will provide a copy of the investigative report to the victim or alleged victim or guardian with the identities of other persons served and any information determined confidential by law concealed. The administrator or contractor CEO may charge a reasonable fee for providing a copy of the investigative report.(c) Advocacy, Inc. is entitled to access the records of persons served in accordance with 42 USC §10805 and §10806 or §6042(a)(2)(I) (Protection and Advocacy of Individuals with Mental Illness and Protection and Advocacy of Individuals with Developmental Disabilities). A copy of 42 USC §10805, §10806, and §6042(a)(2)(I) are referenced as Exhibit F in §414.562 of this title (relating to Exhibits). Source Note: The provisions of this §301.667 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.667 Confidentiality of Investigative Process and Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218487 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218487 03/12/2026 (a) Each local authority, community center, and contractor shall ensure that all employees and agents demonstrate a thorough understanding of the relevant elements of reporting, investigating, and preventing abuse, neglect, and exploitation, before contact with persons served and annually thereafter. The relevant elements of reporting, investigating, and preventing abuse, neglect, and exploitation include:(1) the acts and signs of possible abuse, neglect, and exploitation;(2) the prohibition of abuse, neglect, and exploitation of persons served;(3) the disciplinary consequences for:(A) committing abuse, neglect, and exploitation;(B) failing to report abuse, neglect, or exploitation; and(C) failing to cooperate with an investigation;(4) the procedures for reporting allegations of abuse, neglect, and exploitation;(5) the prohibition of retaliatory action and the consequences for engaging in retaliatory action;(6) the methods for preventing abuse, neglect, and exploitation; and(7) memoranda of understanding and rules of investigatory agencies.(b) Each local authority, community center, and contractor shall ensure that employees and agents who will routinely perform any job duty in proximity to persons served demonstrate competency in the safe management of verbally and physically aggressive behavior before contact with persons served and annually thereafter.(c) Each local authority, community center, and contractor shall ensure that documentation of the competencies of its employees and agents is maintained. Source Note: The provisions of this §301.669 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.669 Competency of Employees and Agents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218488 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218488 03/12/2026 The Office of Consumer Services and Rights Protection - Ombudsman in TDMHMR's Central Office is responsible for the maintenance of systems that provide statistical trends in abuse, neglect, and exploitation in local authorities and community centers. Source Note: The provisions of this §301.671 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.671 HHSC Oversight Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218489 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218489 03/12/2026 The following exhibits are referenced in this subchapter:(1) Exhibit A--CANRS Definitions;(2) Exhibit B--"Guidelines for Securing Evidence";(3) Exhibit C--a copy of the Texas Civil Practice and Remedies Code, §81.001 and §81.006;(4) Exhibit D--CANRS Classifications;(5) Exhibit E--Client Abuse and Neglect Report form (AN-1-A); and(6) Exhibit F--a copy of 42 USC §10805, §10806, and §6042(a)(2)(I). Source Note: The provisions of this §301.673 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.673 Exhibits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218490 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218490 03/12/2026 Reference is made to the following statutes and rules:(1) Texas Health and Safety Code, Chapter 534, Subchapter A, and §533.035(a);(2) Texas Civil Practices and Remedies Code, Chapter 81;(3) Human Resources Code, §48.255(c);(4) 42 USC §10805, §10806, and §6042(a)(2)(I); and(5) Texas Administrative Code, Title 40, Chapter 711 (relating to Investigations in TDMHMR Facilities and Related Programs). Source Note: The provisions of this §301.675 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.675 References https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218491 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218491 03/12/2026 (a) This subchapter shall be distributed to:(1) members of the Texas MHMR Board;(2) investigatory agencies;(3) executive, management, and program staff of Central Office;(4) administrators of all local authorities and community centers; and(5) advocacy organizations.(b) Each administrator is responsible for disseminating copies of this subchapter to:(1) employees and agents;(2) contractors; and(3) any person served or other individual desiring a copy.(c) Each contractor CEO is responsible for disseminating copies of this subchapter to all employees and agents. Source Note: The provisions of this §301.677 adopted to be effective July 1, 2001, 26 TexReg 4708; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective May 31, 2024, as published in the May 3, 2024, issue of the Texas Register, 49 TexReg 3019. 1 HEALTH AND HUMAN SERVICES COMMISSION 301 LOCAL AUTHORITY RESPONSIBILITIES M ABUSE, NEGLECT, AND EXPLOITATION IN LOCAL AUTHORITIES AND COMMUNITY CENTERS §301.677 Distribution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203928 03/12/2026 (a) The purpose of this subchapter is to set forth the standards and provide the criteria for mental health first aid (MHFA) training provided by a local mental health authority (LMHA) and a local behavioral health authority (LBHA) for their respective contractors, public school district employees, higher education employees, and community members located within an LMHA and an LBHA service area, as required by Texas Health and Safety Code, Chapter 1001, Subchapter H, §§1001.201 - 1001.206.(b) The MHFA curriculum is owned and updated by the National Council for Behavioral Health. Source Note: The provisions of this §302.1 adopted to be effective June 3, 2014, 39 TexReg 4258; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 468; amended to be effective January 10, 2021, 46 TexReg 305. 1 HEALTH AND HUMAN SERVICES COMMISSION 302 IDD-BH TRAINING A MENTAL HEALTH FIRST AID §302.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198064 03/12/2026 This subchapter applies to local mental health authorities and local behavioral health authorities. Source Note: The provisions of this §302.3 adopted to be effective June 3, 2014, 39 TexReg 4258; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 468. 1 HEALTH AND HUMAN SERVICES COMMISSION 302 IDD-BH TRAINING A MENTAL HEALTH FIRST AID §302.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203929 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Educator--A person who is required to hold a certificate issued under the Education Code, Subchapter B, Chapter 21, specifically; a teacher, teacher intern or teacher trainee, librarian, educational aide, administrator, educational diagnostician, school nurse, or school counselor.(2) HHSC--Texas Health and Human Services Commission or its designee.(3) Local behavioral health authority (LBHA)--An entity designated as a local behavioral health authority by HHSC in accordance with Texas Health and Safety Code, §533.0356.(4) Local mental health authority (LMHA)--An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code, §531.002(a) and §533.035.(5) Mental health first aid (MHFA)--The assistance provided to a person who is developing a mental health issue or who is experiencing a mental health crisis until appropriate professional treatment is received or until the crisis resolves. Source Note: The provisions of this §302.5 adopted to be effective June 3, 2014, 39 TexReg 4258; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 468; amended to be effective January 10, 2021, 46 TexReg 305. 1 HEALTH AND HUMAN SERVICES COMMISSION 302 IDD-BH TRAINING A MENTAL HEALTH FIRST AID §302.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203930 03/12/2026 (a) Any person approved to train local mental health authority (LMHA) and local behavioral health authority (LBHA) employees or contractors as mental health first aid (MHFA) trainers shall be qualified, pursuant to Texas Health and Safety Code, §1001.202(d), to provide training in:(1) the potential risk factors and warning signs for various mental illnesses, including depression, anxiety, trauma, psychosis, eating disorders, substance abuse disorders, and self-injury;(2) the prevalence of various mental illnesses in the United States and the need to reduce the stigma associated with mental illness;(3) an action plan used by employees or contractors that involves the use of skills, resources, and knowledge to assess a situation and develop and implement an appropriate intervention to assist a person experiencing a mental health crisis to obtain appropriate, professional care; and(4) the evidence-based professional, peer, social, and self-help resources available to help individuals with mental illness.(b) Two or more LMHAs and LBHAs may collaborate and share resources to provide training for employees or contractors of the authorities under this section.(c) All persons or entities that train LMHA and LBHA employees or contractors as MHFA trainers shall be certified by an authority of:(1) MHFA-USA;(2) MHFA-Australia; or(3) other entities approved by HHSC. Source Note: The provisions of this §302.7 adopted to be effective June 3, 2014, 39 TexReg 4258; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 468; amended to be effective January 10, 2021, 46 TexReg 305. 1 HEALTH AND HUMAN SERVICES COMMISSION 302 IDD-BH TRAINING A MENTAL HEALTH FIRST AID §302.7 Mental Health First Aid Training Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203931 03/12/2026 (a) The local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs) are responsible for ensuring their contractors provide mental health first aid (MHFA) training to educators and non-educators consistent with the MHFA protocol, as required by Texas Health and Safety Code, §1001.203(d).(b) An MHFA training must:(1) be conducted by a person trained as an MHFA trainer;(2) provide participants with the skills necessary to help an individual experiencing a mental health crisis until the individual is able to obtain appropriate professional care; and(3) include:(A) instruction in a five-step strategy for helping an individual experiencing a mental health crisis, including assessing risk, listening respectfully to and supporting the individual, and identifying professional help and other supports for the individual;(B) an introduction to the risk factors and warning signs for mental illness and substance abuse problems;(C) experiential activities to increase participants' understanding of the impact of mental illness on individuals and families; and(D) a presentation of evidence-supported treatment and self-help strategies.(c) An LMHA and LBHA may contract with a regional education service center to provide an MHFA training program to university employees, school district employees, and school resource officers under this section.(d) Two or more LMHAs or LBHAs may collaborate and share resources to develop and operate an MHFA training program under this section.(e) The LMHA and LBHA shall ensure that training is taught without modification, substitution or subtraction of the MHFA-USA or MHFA-Australia, as applicable, content or format unless authorized by HHSC-approved training entities set forth in §302.7 of this subchapter (relating to Mental Health First Aid Training Protocols).(f) LMHAs and LBHAs are responsible for ensuring their contractors comply with the provisions of this subchapter and applicable provisions of the contract between HHSC and the LMHA and LBHA.(g) The LMHA and LBHA must submit the annual Plan for Mental Health First Aid Training Programs by July 1 of each state fiscal year, as required by Texas Health and Safety Code, §1001.204. The LMHA and LBHA must submit the information for the annual report by September 30 of each year, as required by Texas Health and Safety Code, §1001.205. Source Note: The provisions of this §302.9 adopted to be effective June 3, 2014, 39 TexReg 4258; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 468; amended to be effective January 10, 2021, 46 TexReg 305. 1 HEALTH AND HUMAN SERVICES COMMISSION 302 IDD-BH TRAINING A MENTAL HEALTH FIRST AID §302.9 Local Mental Health Authority and Local Behavioral Health Authority Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206150 03/12/2026 (a) The purpose of this chapter is to:(1) describe the responsibilities of a LIDDA, LMHA, and LBHA related to PASRR, to ensure that:(A) an individual seeking admission to a NF or a resident of a NF receives a PL1 to identify whether the individual or resident is suspected of having MI, ID, or DD; and(B) an individual seeking admission to a NF or resident suspected of having MI, ID, or DD receives a PE or resident review to confirm MI, ID, or DD and, if confirmed, to evaluate whether the individual or resident needs NF care and needs specialized services;(2) describe the responsibilities of a LIDDA related to a designated resident who receives habilitative service planning and transition planning as described in Subchapters E, F, and G of this chapter (relating to Habilitation Coordination, Habilitative Service Planning for a Designated Resident, and Transition Planning); and(3) describe the responsibilities of an LMHA and LBHA related to a resident with MI who is eligible for MI specialized services as described in Subchapter I of this chapter (relating to MI Specialized Services).(b) The rules regarding the responsibilities of a NF related to PASRR are in Chapter 554, Subchapter BB of this title (relating to Nursing Facility Responsibilities Related to Preadmission Screening and Resident Review (PASRR)). Source Note: The provisions of this §303.101 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) A GENERAL PROVISIONS §303.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217826 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Actively involved person--An individual who has significant, ongoing, and supportive involvement with a designated resident, as determined by the SPT based on the individual's:(A) observed interactions with the designated resident;(B) availability to the designated resident for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the designated resident's needs, preferences, values, and beliefs.(2) Acute care hospital--A health care facility in which an individual receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition, or recovery from surgery and:(A) may include a long-term acute care hospital, an emergency room within an acute care hospital, or an inpatient rehabilitation hospital; and(B) does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.(3) Alternate placement assistance--Assistance provided to a resident to locate and secure services chosen by the resident or LAR that meets the resident's needs in a setting other than a NF. Alternate placement assistance includes transition planning, pre-move site review, and post-move monitoring.(4) APRN--Advance practice registered nurse. An individual licensed to practice professional nursing as an advance practice registered nurse in accordance with Texas Occupations Code Chapter 301.(5) Audio-only--An interactive, two-way audio communication that uses only sound and that meets the privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include audio-visual or in-person communication.(6) Audio-visual--An interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audio-visual does not include audio-only or in-person communication.(7) Behavioral support--An IHSS that:(A) is assistance provided for a designated resident to increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the designated resident's interpersonal relationships across all service and social settings;(B) is delivered in the NF or in a community setting; and(C) consists of:(i) assessing the behaviors to be targeted in an appropriate behavior support plan and analyzing those assessment findings;(ii) developing an individualized behavior support plan that reduces or eliminates the target behaviors, assisting the designated resident in achieving the outcomes identified in the HSP;(iii) training and consulting with the LAR, family members, NF staff, other support providers, and the designated resident about the purpose, objectives, and methods of the behavior support plan;(iv) implementing the behavior support plan or revisions to the behavior support plan and documenting service delivery in accordance with the IDD Habilitative Specialized Services Billing Guidelines;(v) monitoring and evaluating the success of the behavior support plan implementation;(vi) revising the behavior support plan as necessary; and(vii) participating in SPT and IDT meetings.(8) Business day--Any day except Saturday, Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(9) Calendar day--Any day, including weekends and holidays.(10) CMWC--Customized manual wheelchair. In accordance with §554.2703(5) of this title (relating to Definitions) and consistent with the requirements of Texas Human Resources Code §32.0425, a wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of a designated resident.(11) Collateral contact--A person who is knowledgeable about the individual seeking admission to a NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.(12) Coma--A state of unconsciousness characterized by the inability to respond to sensory stimuli as documented by a physician.(13) Convalescent care--A type of care provided after an individual's release from an acute care hospital that is part of a medically prescribed period of recovery.(14) Day habilitation--An IHSS that:(A) is assistance provided for a designated resident to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to successfully and actively participate in all service and social settings;(B) is delivered in a setting other than the designated resident's NF;(C) does not include services provided under the Day Activity and Health Services program;(D) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 Code of Federal Regulations (CFR) §483.24; and(E) consists of:(i) individualized activities consistent with achieving the outcomes identified in a designated resident's HSP to attain, learn, maintain, or improve skills;(ii) activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;(iii) services in a group setting at a location other than a designated resident's NF for up to five days per week, six hours per day, on a regularly scheduled basis;(iv) personal assistance for a designated resident who cannot manage personal care needs during the day habilitation activity;(v) transportation between the NF and the day habilitation site, as well as during the day habilitation activity necessary for a designated resident's participation in day habilitation activities; and(vi) participating in SPT and IDT meetings.(15) DD--Developmental disability. A disability that meets the criteria described in the definition of "persons with related conditions" in 42 CFR §435.1010.(16) Delirium--A serious disturbance in an individual's mental abilities that results in a decreased awareness of the individual's environment and confused thinking.(17) Designated resident--An individual:(A) whose PE or resident review is positive for ID or DD;(B) who is 21 years of age or older;(C) who is a Medicaid recipient; and(D) who is a resident or has transitioned to the community from a NF within the previous 365 days.(18) DME--Durable medical equipment. The items described in §554.2703(10) of this title.(19) Emergency protective services--Services furnished by the Department of Family and Protective Services to an elderly or disabled individual who has been determined to be in a state of abuse, neglect, or exploitation.(20) Employment assistance--An IHSS that:(A) is assistance provided for a designated resident who requires intensive help locating competitive employment in the community; and(B) consists of:(i) identifying a designated resident's employment preferences, job skills, and requirements for a work setting and work conditions;(ii) locating prospective employers offering employment compatible with a designated resident's identified preferences, skills, and requirements;(iii) contacting prospective employers on a designated resident's behalf and negotiating the designated resident's employment;(iv) transporting a designated resident between the NF and the site where employment assistance services are provided and as necessary to help the designated resident locate competitive employment in the community; and(v) participating in SPT and IDT meetings.(21) Essential supports--Those supports identified in a transition plan that are critical to a designated resident's health and safety and that are directly related to a designated resident's successful transition to living in the community from residing in a NF.(22) Exempted hospital discharge--A category of NF admission that occurs when a physician has certified that an individual who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition for which the individual was hospitalized.(23) Expedited admission--A category of NF admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite, or coma.(24) Extenuating circumstances--Circumstances beyond the LIDDA's, LMHA's or LBHA's control that prevents meeting in person. A disaster declared by the governor is excluded from this definition.(25) Habilitation coordination--Assistance for a designated resident residing in a NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the designated resident and LAR on the designated resident's behalf.(26) Habilitation coordinator--An employee of a LIDDA who provides habilitation coordination.(27) HHSC--The Texas Health and Human Services Commission.(28) HHSC instructor-led training--Training delivered by an HHSC employee.(29) HSP--Habilitation service plan. A plan developed by the SPT while a designated resident is residing in a NF that:(A) is individualized and developed through a person-centered approach;(B) identifies the designated resident's:(i) strengths;(ii) preferences;(iii) desired outcomes; and(iv) psychiatric, behavioral, nutritional management, and support needs as described in the NF comprehensive care plan or MDS assessment; and(C) identifies the specialized services that will accomplish the desired outcomes of the designated resident, or the LAR's on behalf of the designated resident, including amount, frequency, and duration of each service.(30) ID--Intellectual disability, as defined in 42 CFR §483.102(b)(3)(i).(31) IDD--Intellectual and developmental disability.(32) IDT--Interdisciplinary team. A team consisting of:(A) a resident with MI, ID, or DD;(B) the resident's LAR, if any;(C) an RN from the NF with responsibility for the resident;(D) a representative of:(i) the LIDDA, if the resident has ID or DD;(ii) the LMHA or LBHA, if the resident has MI; or(iii) the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and(E) others as follows:(i) a concerned person whose inclusion is requested by the resident or LAR;(ii) an individual specified by the resident, LAR, NF, LIDDA, LMHA, or LBHA, as applicable, who is professionally qualified, certified, or licensed with special training and experience in the diagnosis, management, needs, and treatment of people with MI, ID, or DD; and(iii) a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.(33) IHSS--IDD habilitative specialized services. IHSS are:(A) behavioral support;(B) day habilitation;(C) employment assistance;(D) independent living skills training; and(E) supported employment.(34) ILST--Independent living skills training. An IHSS that:(A) is assistance provided for a designated resident that is consistent with the designated resident's HSP;(B) is provided in the designated resident's NF or in a community setting;(C) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 CFR §483.24; and(D) consists of:(i) habilitation and support activities that foster improvement of or facilitate a designated resident's ability to attain, learn, maintain, or improve functional living skills and other daily living activities;(ii) activities that help preserve the designated resident's bond with family members;(iii) activities that foster inclusion in community activities generally attended by people without disabilities;(iv) transportation to facilitate a designated resident's employment opportunities and participation in community activities, and between the designated resident's NF and a community setting; and(v) participating in SPT and IDT meetings.(35) Implementation plan--A plan for each IHSS on the designated resident's plan of care that includes:(A) a list of the designated resident's outcomes identified in the HSP that will be addressed using IHSS;(B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are:(i) observable, measurable, and outcome-oriented; and(ii) derived from assessments;(C) a target date for completion of each objective;(D) the frequency, amount, and duration of IHSS needed to complete each objective; and(E) the signature and date of the designated resident, LAR, and service provider agency.(36) In-person (or in person)--Within the physical presence of another person. In-person or in person does not include audio-visual or audio-only communication.(37) LAR--Legally authorized representative. An individual authorized by law to act on behalf of an individual seeking admission to a NF or resident with regard to a matter described by this chapter, and who may be the parent of a minor child, the legal guardian, or the surrogate decision maker.(38) LBHA--Local behavioral health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533.0356.(39) LCSW--Licensed clinical social worker. An individual who is licensed as a licensed clinical social worker in accordance with Texas Occupations Code Chapter 505.(40) Licensed psychologist--An individual who is licensed as a psychologist in accordance with Texas Occupations Code Chapter 501.(41) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.(42) LMFT--Licensed marriage and family therapist. An individual who is licensed as a marriage and family therapist in accordance with Texas Occupations Code Chapter 502.(43) LMHA--Local mental health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533.035.(44) LPC--Licensed professional counselor. An individual who is licensed as a professional counselor in accordance with Texas Occupations Code Chapter 503.(45) LTC online portal--Long term care online portal. A web-based application used by Medicaid providers to submit forms, screenings, evaluations, and other information.(46) MCO service coordinator--Managed care organization service coordinator. The staff person assigned by a resident's Medicaid managed care organization to ensure access to and coordination of needed services.(47) MDS assessment--Minimum data set assessment. A standardized collection of demographic and clinical information that describes a resident's overall condition, which a licensed NF in Texas is required to submit for a resident admitted into the facility.(48) MI--Mental illness. Serious mental illness, as defined in 42 CFR §483.102(b)(1).(49) MI quarterly meeting--A quarterly meeting that is convened by the LMHA or LBHA for a resident with MI to develop, review, or revise the PCRP and the transition plan, if the resident is transitioning to the community.(50) MI specialized services--Specialized services for a resident with MI, if eligible, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:(A) crisis intervention services;(B) day programs for acute needs;(C) medication training and support services;(D) psychiatric diagnostic interview examination;(E) psychosocial rehabilitation services;(F) routine case management; and(G) skills training and development.(51) NF--Nursing facility. A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code Chapter 242.(52) NF comprehensive care plan--A comprehensive care plan, defined in §554.2703(3) of this title.(53) NF PASRR support activities--Actions a NF takes in coordination with a LIDDA, LMHA, or LBHA to facilitate the successful provision of an IHSS or MI specialized service, including:(A) arranging transportation for a NF resident to participate in an IHSS or a MI specialized service outside the facility;(B) sending a resident to a scheduled IHSS or MI specialized service with food and medications required by the resident; and(C) stating in the NF comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IHSS or MI specialized services.(54) NF specialized services--The following specialized services available to a resident with ID or DD:(A) therapy services;(B) CMWC; and(C) DME.(55) PA--Physician assistant. An individual who is licensed as a physician assistant in accordance with Texas Occupations Code Chapter 204.(56) PASRR--Preadmission screening and resident review. A federal requirement in 42 CFR Part 483, Subpart C that requires states to prescreen all individuals seeking admission to a Medicaid-certified NF for ID, DD, and MI.(57) PCRP--Person-centered recovery plan. For a resident with MI, the PCRP identifies the services and supports that are needed to:(A) meet the needs of the resident with MI;(B) achieve the desired outcomes; and(C) maximize the ability for the resident with MI to live successfully in the most integrated setting possible.(58) PE--PASRR level II evaluation. An evaluation as described in §303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process):(A) of an individual seeking admission to a NF who is suspected of having MI, ID, or DD; and(B) performed by a LIDDA, LMHA, or LBHA to determine if the individual has MI, ID, or DD and, if so, to:(i) assess the individual's need for care in a NF;(ii) assess the individual's need for specialized services; and(iii) identify alternate placement options.(59) Physician--An individual who is licensed to practice medicine in accordance with Texas Occupations Code Chapter 155.(60) PL1--PASRR level I screening. The process of screening an individual seeking admission to a NF to identify whether the individual is suspected of having MI, ID, or DD.(61) Plan of care--A written plan that includes:(A) the IHSS required by the NF baseline care plan or NF comprehensive care plan;(B) the frequency, amount, and duration of each IHSS to be provided for the designated resident during a plan year; and(C) the services and supports to be provided for the designated resident through resources other than PASRR.(62) Preadmission process--A category of NF admission:(A) from a community setting, such as a private home, an assisted living facility, a group home, a psychiatric hospital, or jail, but not an acute care hospital or another NF; and(B) that is not an expedited admission or an exempted hospital discharge.(63) QIDP--Qualified intellectual disability professional. An individual who meets the qualifications described in 42 CFR §483.430(a).(64) QMHP-CS--Qualified mental health professional-community services. An individual who meets the qualifications of a QMHP-CS as defined in §301.303 of this title (relating to Definitions).(65) Referring entity--The entity that refers an individual to a NF, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.(66) Relocation specialist--An employee or contractor of an MCO who provides outreach and relocation activities to individuals in NFs who express a desire to transition to the community.(67) Resident--An individual who resides in a NF.(68) Resident review--An evaluation of a resident performed by a LIDDA, LMHA, or LBHA as described in §303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process):(A) for a resident whose PE is positive for MI, ID, or DD who experienced a significant change in condition, to:(i) assess the resident's need for continued care in a NF;(ii) assess the resident's need for specialized services; and(iii) identify alternate placement options; and(B) for a resident suspected of having MI, ID, or DD, to determine whether the resident has MI, ID, or DD and, if so:(i) assess the resident's need for continued care in a NF;(ii) assess the resident's need for specialized services; and(iii) identify alternate placement options.(69) Resident with MI--An individual:(A) who is a resident of a NF;(B) whose PE or resident review is positive for MI;(C) who is at least 18 years of age; and(D) who is a Medicaid recipient.(70) Respite--Services provided on a short-term basis to an individual because of the absence of or the need for relief by the individual's unpaid caregiver for a period not to exceed 14 days.(71) RN--Registered nurse. An individual licensed to practice professional nursing as a registered nurse in accordance with Texas Occupations Code Chapter 301.(72) Service coordination--Assistance in accessing medical, social, educational, and other appropriate services and supports, including alternate placement assistance, that will help an individual to achieve a quality of life and community participation acceptable to the individual and LAR on the individual's behalf.(73) Service coordinator--An employee of a LIDDA who provides service coordination.(74) Service provider agency--An entity that has a contract with HHSC to provide IHSS for a designated resident.(75) Severe physical illness--An illness resulting in ventilator dependence or a diagnosis, such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, or congestive heart failure, that results in a level of impairment so severe that the individual could not be expected to benefit from specialized services.(76) Significant change in condition--Consistent with §554.801(2)(C)(ii) of this title (relating to Resident Assessment), when a resident experiences a major decline or improvement in the resident's status that:(A) will not normally resolve itself without further intervention by NF staff or by implementing standard disease-related clinical interventions;(B) has an impact on more than one area of the resident's health status; and(C) requires review or revision of the NF comprehensive care plan, or both.(77) Specialized services--The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a resident who has a PE or resident review that is positive for MI, ID, or DD:(A) NF specialized services;(B) IHSS; and(C) MI specialized services.(78) SPT--Service planning team. A team convened by a LIDDA staff person that develops, reviews, and revises the HSP and the transition plan for a designated resident. The team must include:(A) the designated resident;(B) the designated resident's LAR, if any;(C) the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the designated resident is transitioning to the community;(D) the MCO service coordinator, if the designated resident does not object;(E) the person who develops a permanency plan using the HHSC Permanency Planning Instrument for Children Under 22 Years of Age form and performs other permanency planning activities for a designated resident under 22 years of age, if the designated resident is at least 21 years of age but younger than 22 years of age;(F) while the designated resident is in a NF:(i) a NF staff person familiar with the designated resident's needs; and(ii) an individual providing a specialized service for the designated resident or a representative of a provider agency that is providing specialized services for the designated resident;(G) if the designated resident is transitioning to the community:(i) a representative from the community program provider, if one has been selected; and(ii) a relocation specialist;(H) a representative from the LMHA or LBHA, if the designated resident's PE is positive for MI;(I) a concerned person whose inclusion is requested by the designated resident or the LAR; and(J) at the discretion of the LIDDA, an individual who is directly involved in the delivery of services for people with ID or DD.(79) Supported employment--An IHSS that:(A) is assistance provided for a designated resident:(i) who requires intensive, ongoing support to be self-employed, work from the designated resident's residence, or work in an integrated community setting at which people without disabilities are employed; and(ii) to sustain competitive employment in an integrated community setting; and(B) consists of:(i) making employment adaptations, supervising, and providing training related to the designated resident's assessed needs;(ii) transporting the designated resident between the NF and the site where the supported employment services are provided and as necessary to support the designated resident to be self-employed, work from the designated resident's residence, or work in an integrated community setting; and(iii) participating in SPT and IDT meetings.(80) Surrogate decision maker--An actively involved family member of a resident who has been identified by an IDT in accordance with Texas Health and Safety Code §313.004 and who is available and willing to consent to medical treatment on behalf of the resident.(81) Terminal illness--A medical prognosis that an individual's life expectancy is six months or less if the illness runs its normal course and that is documented by a physician's certification in the individual's medical record maintained by a NF.(82) Therapy services--In accordance with §554.2703(46) of this title, assessment and treatment to help a designated resident learn, keep, or improve skills and functioning of daily living affected by a disabling condition. Therapy services are referred to as habilitative therapy services. Therapy services are limited to:(A) physical therapy;(B) occupational therapy; and(C) speech therapy.(83) Transition plan--A plan developed by the SPT or MI quarterly meeting attendees that describes the activities, timetable, responsibilities, services, and essential supports involved in assisting a designated resident or resident with MI to transition from residing in a NF to living in the community.(84) Uniform assessment--The HHSC-approved uniform assessment tool for adult mental health services. Source Note: The provisions of this §303.102 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) A GENERAL PROVISIONS §303.102 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206152 03/12/2026 (a) An individual seeking admission to a NF, a resident, or an individual's or resident's LAR may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules) to appeal:(1) a PE that is negative for ID, DD, or MI;(2) a denial of a specialized service; or(3) the reduction, suspension, or termination of an IHSS or MI specialized service.(b) If the hearing officer reverses a denial, reduction, or termination of a specialized service, the LIDDA, the LMHA, the LBHA, the service provider agency, or the NF, as applicable, must ensure the provision of the specialized service. Source Note: The provisions of this §303.103 adopted to be effective September 1, 2021, 4 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) A GENERAL PROVISIONS §303.103 Fair Hearing Process for PASRR Determination and Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217830 03/12/2026 (a) A referring entity must complete a PL1 when an individual is seeking admission into a NF through the preadmission process, and:(1) if the PL1 indicates the individual is suspected of having MI, ID, or DD:(A) must notify the LIDDA, LMHA, or LBHA, as applicable; and(B) must provide a copy of the PL1 to the LIDDA, LMHA, or LBHA, as applicable; and(2) if the PL1 indicates the individual is not suspected of having MI, ID, or DD, must provide a copy of the completed PL1 to the NF.(b) If a LIDDA, LMHA, or LBHA is provided a copy of a PL1 in accordance with subsection (a)(1)(B) of this section, the LIDDA, LMHA, or LBHA must:(1) comply with §303.302(a)(1) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process);(2) complete a PE in accordance with §303.302(a)(2) of this chapter;(3) comply with §303.302(b) and (c) of this chapter; and(4) make reasonable efforts to arrange for available community services and supports in the least restrictive setting to avoid NF admission, if the individual seeking admission to a NF, or the individual's LAR on the individual's behalf, wants to remain in the community. Source Note: The provisions of this §303.201 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) B PASRR SCREENING AND EVALUATION PROCESS §303.201 Preadmission Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206154 03/12/2026 If the LTC online portal generates a notice to the LIDDA, LMHA, or LBHA that an individual suspected of having MI, ID, or DD is being admitted to a NF through the expedited admission process, the LIDDA, LMHA, or LBHA, as applicable, must:(1) complete a PE or resident review in accordance with §303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process); and(2) comply with §303.302(b) and (c) of this chapter. Source Note: The provisions of this §303.202 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) B PASRR SCREENING AND EVALUATION PROCESS §303.202 Expedited Admission Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206155 03/12/2026 A LIDDA, LMHA, or LBHA must conduct a resident review in accordance with §303.204 of this subchapter (relating to Resident Review Process) for a resident of a NF admitted through an exempted hospital discharge process if:(1) the resident's stay in the NF has exceeded 30 days; and(2) the resident's PL1 indicates the resident is suspected of having MI, ID, or DD. Source Note: The provisions of this §303.203 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) B PASRR SCREENING AND EVALUATION PROCESS §303.203 Admission Process for Exempted Hospital Discharge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206156 03/12/2026 (a) The LTC online portal generates an automated notification to a LIDDA, LMHA, or LBHA that a resident review must be completed if:(1) a resident with MI, ID, or DD experiences a significant change in condition as defined in §303.102 of this chapter (relating to Definitions); or(2) a resident suspected of having MI, ID, or DD:(A) was admitted as an exempted hospital discharge and has exceeded the allowed 30-day stay in the NF; or(B) is determined by a NF or HHSC to need a resident review for any other reason.(b) A LIDDA, LMHA, or LBHA that receives an automated notification in accordance with subsection (a) of this section must:(1) complete a resident review in accordance with §303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process); and(2) comply with §303.302(b) and (c) of this chapter. Source Note: The provisions of this §303.204 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) B PASRR SCREENING AND EVALUATION PROCESS §303.204 Resident Review Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206157 03/12/2026 (a) A referring entity must:(1) complete the PL1 for an individual seeking admission into a NF;(2) contact a NF selected by the individual or LAR to notify the NF of the individual's interest in admission; and(3) provide the completed PL1 as follows:(A) to the NF selected by the individual or LAR:(i) for an individual who is being admitted through an expedited admission or an exempted hospital discharge; or(ii) for an individual who is being admitted through a preadmission process and is not suspected of having MI, ID, or DD; and(B) to the LIDDA, LMHA, or LBHA, as applicable, for an individual who is suspected of having MI, ID, or DD, and is being admitted through a preadmission process.(b) If a referring entity is a family member, LAR, other personal representative selected by the individual, or a representative from an emergency placement source, the referring entity may request assistance from the NF, LIDDA, LMHA, or LBHA in completing the PL1. Source Note: The provisions of this §303.301 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) C RESPONSIBILITIES §303.301 Referring Entity Responsibilities Related to the PASRR Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217828 03/12/2026 (a) A LIDDA, LMHA, or LBHA, as applicable, must:(1) enter in the LTC online portal the data from a PL1 completed by a referring entity in accordance with §303.201(a)(1) of this chapter (relating to Preadmission Process) for an individual who is suspected of having MI, ID, or DD and who is seeking admission to a NF through the preadmission process;(2) complete a PE or resident review as follows:(A) within 72 hours after receiving a copy of the PL1 from the referring entity in accordance with §303.201(a)(1)(B) of this chapter or notification from the LTC online portal in accordance with §303.202 or §303.204(a) of this chapter (relating to Expedited Admission Process and Resident Review Process, respectively):(i) call the referring entity or NF to schedule the PE or resident review; and(ii) meet in person, or in extenuating circumstances meet via audio-visual communication, with the individual or resident at the referring entity or NF to gather information to complete the PE or resident review; and(B) within seven days after receiving a copy of the PL1 from the referring entity or notification from the LTC online portal:(i) complete the PE or resident review by:(I) reviewing the individual's or resident's:(-a-) medical records;(-b-) relevant service records, including those available in online databases, such as the Client Assignment and Registration (CARE) system, Clinical Management for Behavioral Health Services (CMBHS), and LTC online portal; and(-c-) previous PEs, service plans, and assessments from other LIDDAs, LMHAs, or LBHAs;(II) meeting with the individual's LAR or resident's LAR in person, via audio-visual communication, or via audio-only communication according to the LAR's preference;(III) communicating with a collateral contact as necessary;(IV) providing information to the individual seeking admission or resident and the individual's LAR or resident's LAR, if any, about community services, supports, and programs for which the individual or resident may be eligible; and(V) obtaining additional information as needed; and(ii) enter the data from the PE or resident review in the LTC online portal; and(3) within three business days after entering the data from the PE or resident review in the LTC online portal:(A) if the PE or resident review is positive for MI, ID, or DD, provide the individual seeking admission or resident or the individual's LAR or resident's LAR with a summary of the results of the PE or resident review, using HHSC forms; or(B) if the PE or resident review is negative for MI, ID, or DD, provide the individual seeking admission or resident or the individual's LAR or resident's LAR notice of the right to a fair hearing, using HHSC forms.(b) If an individual seeking admission to a NF or a resident has a PE or resident review that is positive for ID, DD, or MI and a NF certifies in the LTC online portal that it cannot meet the needs of the individual or resident, then the LIDDA, LMHA, or LBHA, as applicable, must assist the individual, resident, or LAR in choosing another NF that will certify it can meet the needs of the individual or resident.(c) If an individual seeking admission to a NF or a resident has a PE or resident review that is positive for ID, DD, or MI and a NF certifies in the LTC online portal that it can meet the needs of the resident or certifies in the LTC online portal that it can meet the needs of the individual and admits the individual, the LIDDA, LMHA or LBHA, as applicable, must:(1) coordinate with the NF to schedule an IDT meeting to discuss specialized services;(2) ensure a habilitation coordinator or QMHP-CS or both, as applicable, participates in person, or via audio-visual communication in extenuating circumstances, in the resident's IDT meeting as scheduled by the NF and collaborate with the other members of the IDT to:(A) identify which of the specialized services recommended for the resident that the resident, or LAR on the resident's behalf, wants to receive;(B) identify the NF PASRR support activities for the resident; and(C) determine whether the resident is best served in a facility or community setting;(3) within five business days after receiving notification from the LTC online portal that the NF entered information from the IDT meeting, confirm the LIDDA's, LMHA's, or LBHA's participation in the meeting and the specialized services recommended in the LTC online portal; and(4) if Medicaid or other funding is available:(A) initiate MI specialized services within 20 business days after the date of the IDT meeting; and(B) provide the MI specialized services agreed upon in the IDT meeting to the resident.(d) The LIDDA, LMHA, or LBHA must develop a written policy that describes the process the LIDDA, LMHA, or LBHA will follow to address challenges related to the participation in receiving IHSS or MI specialized services by the designated resident, resident with MI, or LAR.(e) The LIDDA must ensure that a designated resident or LAR is informed orally and in writing of the processes for filing complaints as follows:(1) the telephone number of the LIDDA to file a complaint;(2) the telephone number of the IDD Ombudsman to file a complaint about the LIDDA;(3) the telephone number of Complaint and Incident Intake to file a complaint about IHSS or the NF;(4) the telephone number of DFPS Statewide Intake to report an allegation of abuse, neglect, or exploitation; and(5) the telephone number of the Long-Term Care Ombudsman to file a complaint that relates to action, inaction, or a decision by any individual or entity who provides care or makes decisions related to a designated resident, that may adversely affect the health, safety, welfare, or rights of the designated resident.(f) The LMHA or LBHA must ensure that a resident with MI or LAR is informed orally and in writing of the processes for filing complaints as follows:(1) the telephone number of the LMHA or LBHA to file a complaint;(2) the telephone number of the Ombudsman for Behavioral Health to file a complaint about MI specialized services or about an LMHA or LBHA;(3) the telephone number of Complaint and Incident Intake to file a complaint about the NF;(4) the telephone number of DFPS Statewide Intake to report an allegation of abuse, neglect, or exploitation; and(5) the telephone number of the Long-Term Care Ombudsman to file a complaint that relates to action, inaction, or a decision by any individual or entity who provides care or makes decisions related to a resident with MI, that may adversely affect the health, safety, welfare, or rights of the resident with MI.(g) If an individual seeking admission to a NF or a resident has a PE or resident review that is positive for MI and ID or MI and DD, the LIDDA is responsible for coordinating with the NF to schedule the IDT meeting to discuss specialized services.(h) Before the LIDDA, LMHA, or LBHA staff conducts the meeting required in subsection (a)(2)(A)(ii) of this section via audio-visual communication, they must:(1) do one of the following:(A) obtain the written informed consent of the individual, designated resident, or LAR; or(B) obtain the individual's, designated resident's, or LAR's oral consent and document the oral consent in the individual's or designated resident's record; and(2) document in the individual's or designated resident's record a description of the extenuating circumstances that prevented meeting in person with the individual or the designated resident.(i) If the LIDDA, LMHA, or LBHA does not obtain the written or oral consent required by subsection (h) of this section, the LIDDA, LMHA, or LBHA must conduct the meeting required in subsection (a)(2)(A)(ii) of this section by meeting with the LAR and NF staff most familiar with the individual or designated resident, to:(1) review and gather all necessary information to complete the PE; and(2) enter the PE in the LTC online portal. Source Note: The provisions of this §303.302 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) C RESPONSIBILITIES §303.302 LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217829 03/12/2026 (a) A LIDDA must ensure a PE or resident review is conducted by an individual who:(1) is a QIDP; or(2) has one of the following qualifications and at least one year of experience working directly with individuals with ID or DD:(A) RN;(B) LCSW;(C) LPC;(D) LMFT;(E) Licensed Psychologist;(F) APRN; or(G) Physician.(b) An LMHA or LBHA must ensure a PE or resident review is conducted by an individual who is a:(1) QMHP-CS;(2) RN;(3) LCSW;(4) LPC;(5) LMFT;(6) Licensed Psychologist;(7) APRN;(8) Physician; or(9) PA.(c) A LIDDA, LMHA, and LBHA must:(1) before a staff person conducts a PE or resident review, ensure the staff person:(A) receives HHSC instructor-led training about how to conduct a PE and resident review; and(B) demonstrates competency in completing a PE and resident review; and(2) maintain documentation of the training received by a staff person who conducts a PE or resident review. Source Note: The provisions of this §303.303 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) C RESPONSIBILITIES §303.303 Qualifications and Requirements for Staff Person Conducting a PE or Resident Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206160 03/12/2026 (a) A LIDDA, LMHA, or LBHA must accept the reimbursement rate established by HHSC as payment in full for the following activities:(1) completing a PE or resident review in accordance with §303.302(a)(2) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process);(2) assisting an individual who is seeking admission to a NF, or a resident with MI, ID, or DD, or the individual's or resident's LAR in choosing another NF that will certify it can meet the needs of the individual or resident as described in §303.302(b) of this chapter;(3) participating in the resident's IDT meeting; and(4) confirming in the LTC online portal the information required by §303.302(c)(3) of this chapter.(b) The reimbursement rate for the activities described in subsection (a) of this section includes travel costs associated with the activities. HHSC does not pay any additional amounts for travel. A LIDDA, LMHA, or LBHA must not request reimbursement for travel time or travel costs associated with the activities described in subsection (a) of this section. Source Note: The provisions of this §303.401 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) D VENDOR PAYMENT §303.401 Reimbursement for a PE or Resident Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206161 03/12/2026 A habilitation coordinator must:(1) be an employee of a LIDDA;(2) have a bachelor's or advanced degree from an accredited college or university with a major in a social, behavioral, or human service field, such as psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human development, gerontology, educational psychology, education, or criminal justice; and(3) have at least one year of experience working directly with individuals with ID or DD. Source Note: The provisions of this §303.501 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) E HABILITATION COORDINATION §303.501 Qualifications of a Habilitation Coordinator https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217831 03/12/2026 (a) A LIDDA must ensure:(1) a habilitation coordinator completes the following training before providing habilitation coordination:(A) training that addresses:(i) appropriate LIDDA policies, procedures, and standards;(ii) this chapter, other HHSC rules relating to the provision of specialized services, and other HHSC rules affecting the LIDDA;(iii) HHSC's IDD PASRR Handbook;(iv) developing and implementing an HSP;(v) conducting assessments, service planning, coordination, and monitoring;(vi) providing crisis prevention and management;(vii) community support services;(viii) presenting community living options using HHSC-developed materials and forms, and offering educational opportunities and informational activities about community living options;(ix) arranging visits to community providers;(x) accessing specialized services for a designated resident;(xi) the rights of an individual with an ID, including the right to live in the least restrictive setting appropriate to the person's individual needs and abilities and in a variety of living situations, as described in the Persons with an Intellectual Disability Act, Texas Health and Safety Code Chapter 592 and in an HHSC-developed rights handbook; and(xii) advocacy for individuals with ID or DD;(B) the HHSC computer-based training, "An Overview of the PASRR Process;" and(C) additional trainings designated by HHSC through the IDD-PASRR Handbook, broadcasts, or other communications;(2) a habilitation coordinator completes HHSC approved computer-based person-centered planning and practices training within the first 60 days of performing habilitation coordination duties;(3) a habilitation coordinator completes all HHSC instructor-led training related to PASRR habilitation coordination within the first 60 days of performing habilitation coordination duties;(4) a supervisor, team lead, or quality monitoring staff person who has successfully completed the trainings in paragraphs (2) and (3) of this subsection reviews and signs off on work completed by a habilitation coordinator until the habilitation coordinator completes the trainings required in paragraphs (2) and (3) of this subsection; and(5) a habilitation coordinator completes person-centered thinking training approved by HHSC within the first year of performing habilitation coordination duties.(b) A LIDDA must:(1) ensure a habilitation coordinator demonstrates competency in providing habilitation coordination; and(2) maintain documentation of the training received by habilitation coordinators. Source Note: The provisions of this §303.502 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) E HABILITATION COORDINATION §303.502 Required Training for a Habilitation Coordinator https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217832 03/12/2026 (a) A LIDDA must ensure a habilitation coordinator documents all contacts, including:(1) whether the contact was in person, via audio-visual communication, or via audio-only communication;(2) the date of contact;(3) the description of the habilitation coordination activities provided;(4) the name of the person with whom the contact occurred and the person's relationship to the designated resident; and(5) the habilitation coordinator's name and title.(b) A LIDDA must retain documentation in compliance with applicable federal and state laws, rules, and regulations unless instructed by HHSC to retain documentation for a longer period of time. Source Note: The provisions of this §303.503 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) E HABILITATION COORDINATION §303.503 Documenting Habilitation Coordination Contacts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206163 03/12/2026 (a) A LIDDA must ensure a habilitation coordinator maintains the following documentation in a designated resident's record: (1) all assessments used for service planning;(2) all documentation of habilitation coordination contacts as described in §303.503(a) of this chapter (relating to Documenting Habilitation Coordination Contacts);(3) documentation related to monitoring specialized services, including:(A) the initiation and delivery of all specialized services provided for the designated resident, including reasons for delays and all follow-up activities;(B) the designated resident's and LAR's satisfaction with all specialized services; and(C) the designated resident's progress or lack of progress toward achieving goals and outcomes identified in the HSP, including whether the designated resident is maintaining progress toward achieving goals and outcomes from the designated resident's and LAR's perspectives; (4) the current NF comprehensive care plan;(5) the current HSP;(6) all documents and forms used to:(A) identify the designated resident's need for specialized services; and(B) conduct SPT meetings, including written reports from SPT members who are providers of specialized services and completed forms related to assessing for habilitative needs;(7) the completed HHSC forms that document discussions with the designated resident and LAR about the range of community living options and alternative services and supports available;(8) all pertinent information related to the designated resident, such as guardianship paperwork and consents;(9) the current plan of care; and(10) an implementation plan for each IHSS that appears on the plan of care.(b) For a designated resident who has refused habilitation coordination, a LIDDA must maintain the following documentation in a designated resident's record:(1) all completed Refusal of Habilitation Coordination forms;(2) documentation of the specialized services discussed in the initial IDT and any SPT or IDT specialized services review meeting; and(3) the completed HHSC forms that document discussions with the designated resident and LAR about the range of community living options and alternative services and supports available. Source Note: The provisions of this §303.504 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) E HABILITATION COORDINATION §303.504 Documentation Maintained by a LIDDA in a Designated Resident's Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217833 03/12/2026 (a) A LIDDA must assign a habilitation coordinator to each designated resident within two business days after a PE is completed if the PE is positive for ID or DD.(1) The habilitation coordinator must attend the initial IDT and provide habilitation coordination while the designated resident is residing in the NF.(2) A designated resident may refuse habilitation coordination.(b) Unless a designated resident has refused habilitation coordination, the assigned habilitation coordinator must:(1) assess and reassess quarterly, and as needed, the designated resident's habilitative service needs by gathering information from the designated resident and other appropriate sources, such as the LAR, family members, social workers, and service providers, to determine the designated resident's habilitative needs and preferences and the specialized services that will address those needs and preferences;(2) develop and revise, as needed, an individualized HSP in accordance with HHSC's rules and IDD PASRR Handbook, and using HHSC forms;(3) assist the designated resident to access needed specialized services agreed upon in an IDT or SPT meeting, including:(A) monitoring to determine if a specialized service agreed upon in an IDT or SPT meeting is requested within required timeframes in accordance with the IDD PASRR Handbook or documenting delays and the habilitation coordinator's follow-up activities; and(B) ensuring the delivery of all specialized services agreed upon in an IDT or SPT meeting or documenting delays and the habilitation coordinator's follow-up activities;(4) coordinate other habilitative programs and services that can address needs and achieve outcomes identified in the HSP;(5) facilitate the coordination of the designated resident's HSP and NF comprehensive care plan, including ensuring the HSP is shared with members of the SPT within 10 calendar days after the HSP is updated or renewed;(6) monitor and provide follow-up activities that consist of:(A) monitoring the initiation and delivery of all specialized services agreed upon in an IDT or SPT meeting and following up when delays occur;(B) monitoring the designated resident's and LAR's satisfaction with all specialized services; and(C) determining the designated resident's progress or lack of progress toward achieving goals and outcomes identified in the HSP from the designated resident's and LAR's perspectives;(7) meet with the designated resident to provide habilitation coordination:(A) at least monthly if the designated resident is receiving a specialized service in addition to habilitation coordination; and(i) meet in person at least quarterly or more frequently as determined by the SPT using the findings of the HHSC Habilitative Assessment form; and(ii) subject to subsection (d) of this section, meet via audio-visual communication in a month when a meeting is not conducted in person; or(B) at least quarterly in person, if the designated resident is receiving only habilitation coordination, unless the designated resident or the designated resident's LAR requests more frequent meetings;(8) convene and facilitate an SPT meeting:(A) at least quarterly; and(B) between quarterly SPT meetings if:(i) there is a change in the designated resident's service needs or medical condition; or(ii) requested by the designated resident or LAR;(9) coordinate with the NF in accessing medical, social, educational, and other appropriate services and supports that will help the designated resident achieve a quality of life acceptable to the designated resident and LAR on the resident's behalf;(10) initially and annually thereafter:(A) provide the designated resident and LAR an oral and written explanation of the designated resident's rights in accordance with the IDD PASRR Handbook; and(B) inform the designated resident and LAR both orally and in writing of all the services available and requirements pertaining to the designated resident's participation;(11) for a designated resident who has a guardian, determine at least annually if the letters of guardianship are current; and(12) if appropriate, for a designated resident who does not have a guardian, ensure the SPT discusses whether the designated resident would benefit from a less restrictive alternative to guardianship or from guardianship and make appropriate referrals.(c) Regardless of whether the designated resident is receiving or has refused habilitation coordination, the habilitation coordinator must:(1) address community living options with the designated resident and LAR by:(A) offering the educational opportunities and informational activities about community living options that are periodically scheduled by the LIDDA;(B) providing information about the range of community living services, supports, and alternatives, identifying the services and supports the designated resident will need to live in the community, and identifying and addressing barriers to community living in accordance with HHSC's IDD PASRR Handbook and using HHSC materials at the following times:(i) six months after the initial presentation of community living options during the PE described in §303.302(a)(2)(B)(i) of this Chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process) and at least every six months thereafter;(ii) when requested by the designated resident or LAR;(iii) when the habilitation coordinator is notified or becomes aware that the designated resident, or the LAR on the designated resident's behalf, is interested in speaking with someone about transitioning to the community; and(iv) when notified by HHSC that the designated resident's response in Section Q of the MDS Assessment indicates the resident is interested in speaking with someone about transitioning to the community; and(C) arranging visits to community providers and addressing concerns about community living; and(2) annually assess the designated resident's habilitative service needs by gathering information from the designated resident and other appropriate sources, such as the LAR, family members, social workers, and service providers, to determine the designated resident's habilitative needs and preferences.(d) Before the habilitation coordinator conducts the meeting described in subsection (b)(7)(A)(ii) of this section via audio-visual communication, the habilitation coordinator must:(1) obtain the written informed consent of the designated resident or LAR; or(2) obtain the designated resident's or LAR's oral consent and document the oral consent in the designated resident's record.(e) If the habilitation coordinator does not obtain the written or oral consent required by subsection (d) of this section, the habilitation coordinator must document the designated resident's or LAR's refusal in the designated resident's record. Source Note: The provisions of this §303.601 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) F HABILITATIVE SERVICE PLANNING FOR A DESIGNATED RESIDENT §303.601 Habilitation Coordination for a Designated Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217834 03/12/2026 (a) The SPT for a designated resident must:(1) meet at least quarterly, as convened by the habilitation coordinator;(2) ensure that the designated resident, regardless of whether he or she has an LAR, participates in the SPT to the fullest extent possible and receives the support necessary to do so, including communication supports;(3) develop an HSP for the designated resident;(4) review and monitor identified risk factors, such as choking, falling, and skin breakdown, and report to the proper authority if they are not addressed;(5) make timely referrals, service changes, and revisions to the HSP as needed;(6) considering the designated resident's preferences, monitor to determine if the designated resident is provided opportunities for engaging in integrated activities:(A) with residents who do not have ID or DD; and(B) in community settings with people who do not have a disability; and(7) develop the plan of care for a designated resident who receives IHSS.(b) Each member of the SPT for a designated resident must:(1) consistent with the SPT member's role, assist the habilitation coordinator in ensuring the designated resident's needs are being met; and(2) participate in an SPT meeting in person, via audio-visual communication, or via audio-only communication, except as described in subsection (c)(3) or (e) of this section;(c) An SPT member who is a provider of a specialized service must:(1) submit to the habilitation coordinator a copy of all assessments of the designated resident that were completed by the provider or provider agency;(2) submit a written report describing the designated resident's progress or lack of progress to the habilitation coordinator at least five days before a quarterly SPT meeting; and(3) participate in an SPT meeting, in person, via audio-visual communication, or via audio-only communication, unless the habilitation coordinator determines participation by the provider is not necessary.(d) If a habilitation coordinator determines participation by a provider is not necessary as described in subsection (c)(3) of this section, the habilitation coordinator must:(1) base the determination:(A) on the information in the written report submitted in accordance with subsection (c)(2) of this section; and(B) on the needs of the SPT; and(2) document the reasons for exempting participation.(e) A habilitation coordinator must facilitate a quarterly SPT meeting in person, or in extenuating circumstances via audio-visual communication.(f) Before the habilitation coordinator conducts the meeting described in subsection (e) of this section via audio-visual communication, the habilitation coordinator must:(1) do one of the following:(A) obtain the written informed consent of the designated resident or LAR; or(B) obtain the oral consent of the designated resident or LAR and document the oral consent in the designated resident's record; and(2) document in the designated resident's record a description of the extenuating circumstances which required the use of audio-visual communication.(g) If the habilitation coordinator does not obtain the written or oral consent required by subsection (f) of this section, the habilitation coordinator must:(1) document the designated resident's or LAR's refusal in the designated resident's record; and(2) convene an SPT meeting in person as soon as possible after the extenuating circumstances no longer exist. Source Note: The provisions of this §303.602 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) F HABILITATIVE SERVICE PLANNING FOR A DESIGNATED RESIDENT §303.602 Service Planning Team Responsibilities Related to Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206166 03/12/2026 (a) The habilitation coordinator must:(1) facilitate the coordination of the designated resident's plan of care, including ensuring the plan of care is shared with members of the SPT within 10 calendar days after the plan of care is developed, updated, or renewed;(2) assist a designated resident, LAR, or actively involved person in exercising the legal rights of the designated resident as a citizen and as a person with a disability, including protection of rights and options to avoid unnecessary rights restrictions;(3) provide a designated resident, LAR, or family member with a written and oral explanation of the rights of a designated resident receiving IHSS;(4) document the explanation of rights required by paragraph (3) of this subsection and ensure that the documentation is signed by:(A) the designated resident or LAR; and(B) the habilitation coordinator;(5) immediately notify the NF and service provider agency if the habilitation coordinator becomes aware of an emergency that impacts the designated resident's health or safety;(6) be objective in assisting a designated resident or LAR in selecting a service provider agency;(7) ensure that a designated resident, LAR, and service provider agency are informed of the name of the designated resident's habilitation coordinator and how to contact the habilitation coordinator; and(8) give the service provider agency a copy of the NF baseline care plan or NF comprehensive care plan, whichever is most current.(b) If the habilitation coordinator identifies a concern with the implementation of the plan of care, the habilitation coordinator must ensure the concern is communicated to the service provider agency and attempts are made to resolve the concern. Source Note: The provisions of this §303.603 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) F HABILITATIVE SERVICE PLANNING FOR A DESIGNATED RESIDENT §303.603 Habilitation Coordination for a Designated Resident Receiving IHSS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217835 03/12/2026 (a) A LIDDA must assign a service coordinator for a designated resident if the designated resident, or the LAR on the designated resident's behalf, expresses an interest in moving to the community and has selected a community program.(b) A service coordinator must facilitate the development, revisions, implementation, and monitoring of a transition plan in accordance with HHSC's IDD PASRR Handbook and using HHSC forms. A transition plan must identify the services and supports a designated resident needs to live in the community, including those essential supports that are critical to the designated resident's health and safety.(c) The SPT for a designated resident must:(1) meet as convened by the service coordinator;(2) ensure that the designated resident, regardless of whether he or she has an LAR, participates in the SPT to the fullest extent possible and receives the support necessary to do so, including communication supports; and(3) conduct transition planning activities and develop a transition plan for the designated resident.(d) Consistent with an SPT member's role, each SPT member must:(1) assist the service coordinator in developing, revising, implementing, and monitoring a designated resident's transition plan to ensure a successful transition to the community for the designated resident; and(2) participate in an SPT meeting in person, via audio-visual communication, or via audio-only communication, except as described in subsection (e) or (g) of this section.(e) An SPT member who is a provider of a specialized service must participate in an SPT meeting, in person, via audio-visual communication, or via audio-only communication, unless the service coordinator determines participation by the provider is not necessary.(f) If a service coordinator determines participation by a provider is not necessary as described in subsection (e) of this section, the service coordinator must:(1) base the determination on the needs of the SPT; and(2) document the reasons for exempting participation.(g) At an SPT meeting convened by a service coordinator, the service coordinator must facilitate the SPT meeting in person, or in extenuating circumstances via audio-visual communication.(h) For a designated resident who is transitioning to the community, a service coordinator must, in accordance with HHSC's IDD PASRR Handbook and using HHSC forms, conduct and document a pre-move site review of the designated resident's proposed residence in the community to determine whether all essential supports in the designated resident's transition plan are in place before the designated resident's transition to the community.(i) If the SPT makes a recommendation that a designated resident continue to reside in a NF, the SPT must:(1) document the reasons for the recommendation; and(2) include in the designated resident's transition plan:(A) the barriers to moving to a more integrated setting; and(B) the steps the SPT will take to address those barriers.(j) Before the service coordinator conducts the meetings described in subsection (g) of this section via audio-visual communication, the service coordinator must:(1) do one of the following:(A) obtain the written informed consent of the designated resident or LAR; or(B) obtain the oral consent of the designated resident or LAR and document the oral consent in the designated resident's record; and(2) document in the designated resident's record a description of the extenuating circumstances which required the use of audio-visual communication.(k) If the service coordinator does not obtain the written or oral consent required by subsection (j) of this section, the service coordinator must:(1) document the designated resident's or LAR's refusal in the designated resident's record; and(2) convene an SPT meeting in person as soon as possible after the extenuating circumstances no longer exist. Source Note: The provisions of this §303.701 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) G TRANSITION PLANNING §303.701 Transition Planning for a Designated Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195743 03/12/2026 For a designated resident who has transitioned to the community, a service coordinator must conduct post-transition monitoring activities in accordance with HHSC's IDD PASRR Handbook and using HHSC forms, including conducting a post-move monitoring visit:(1) within seven days after a designated resident transitions to the community;(2) between eight and 45 days after transition; and(3) between 46 and 90 days after transition. Source Note: The provisions of this §303.702 adopted to be effective July 7, 2019, 44 TexReg 3265. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) G TRANSITION PLANNING §303.702 Post-transition Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217836 03/12/2026 (a) A LIDDA must ensure that a service coordinator complies with Chapter 331 of this title (relating to LIDDA Service Coordination), including documenting in the transition plan the frequency and duration of service coordination while the designated resident is in the NF.(b) A LIDDA must ensure:(1) a service coordinator who conducts transition planning completes the following training before providing service coordination for a designated resident:(A) training that addresses:(i) this chapter;(ii) HHSC's IDD PASRR Handbook;(iii) the role of a relocation specialist and MCO service coordinator for a NF resident who wants to transition to the community;(iv) services available through Texas Medicaid State Plan and all home and community-based services programs for individuals with ID or DD, such as, access to nursing, durable medical equipment and supplies, and transition assistance supports;(v) developing and implementing a transition plan for a designated resident;(vi) an overview of community living options, educational opportunities, and informational activities about community living options; and(vii) the rights of an individual with ID, including the right to live in the least restrictive setting appropriate to the person's individual needs and abilities and in a variety of living situations, as described in the Persons with an Intellectual Disability Act, Texas Health and Safety Code Chapter 592 and an HHSC-developed rights handbook;(B) the HHSC computer-based training, "An Overview of the PASRR Process;" and(C) additional trainings designated by HHSC through the IDD-PASRR Handbook, broadcasts, or other communications;(2) a service coordinator who conducts transition planning completes HHSC approved computer-based person-centered planning and practices training within the first 60 days of performing service coordination duties;(3) a service coordinator who conducts transition planning completes all HHSC instructor-led training related to PASRR service coordination for transition planning within the first 60 days of performing transition planning duties;(4) a supervisor, team lead, or quality monitoring staff person who has successfully completed the trainings in paragraphs (2) and (3) of this subsection reviews and signs off on work completed by a service coordinator until the service coordinator completes the trainings required in paragraphs (2) and (3) of this subsection; and(5) a service coordinator who conducts transition planning completes HHSC approved person-centered thinking training within the first year of performing transition planning duties.(c) A LIDDA must:(1) ensure a service coordinator who conducts transition planning demonstrates competency in conducting transition planning; and(2) maintain documentation of the training received by service coordinators who conduct transition planning. Source Note: The provisions of this §303.703 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) G TRANSITION PLANNING §303.703 Requirements for Service Coordinators Conducting Transition Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206169 03/12/2026 (a) HHSC conducts a compliance review of each LIDDA, LMHA, and LBHA to determine if the LIDDA, LMHA, and LBHA are in compliance with the requirements for a LIDDA, LMHA, and LBHA described in this chapter.(b) A LIDDA, LMHA, and LBHA must submit to HHSC a plan of correction in accordance with the performance contract for any item of non-compliance. HHSC may take action as specified in the performance contract if a LIDDA, LMHA, or LBHA fails to submit a plan of correction or implement an approved plan of correction. Source Note: The provisions of this §303.801 adopted to be effective July 7, 2019, 44 TexReg 3265; amended to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) H COMPLIANCE REVIEW §303.801 Compliance Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217845 03/12/2026 (a) An LMHA or LBHA staff must conduct the uniform assessment to determine which level of care the resident with MI will receive.(b) Some of the MI specialized services for a resident with MI are described in more detail in this subsection.(1) Skills training and development. Training provided to a resident with MI that:(A) addresses the severe and persistent MI and symptom-related problems that interfere with the functioning of the resident with MI;(B) provides opportunities for the resident with MI to acquire and improve skills needed to function as appropriately and independently as possible in the community; and(C) facilitates community integration for the resident with MI and increases the length of community residency for the resident with MI.(2) Medication training and support services. Education and guidance provided to a resident with MI and family members about the medications of the resident with MI and their possible side effects as described in §306.315 of this title (relating to Medication Training and Support Services).(3) Psychosocial rehabilitation services. Social, educational, vocational, behavioral, and cognitive interventions provided by the therapeutic team members of a resident with MI that address deficits in their ability to develop and maintain social relationships, occupational or educational achievement, independent living skills, or housing. Psychosocial rehabilitative services include the following component services:(A) coordination services;(B) crisis related services;(C) employment related services;(D) housing related services;(E) independent living services; and(F) medication related services.(4) Case management. A primarily site-based service to assist a resident with MI or LAR in gaining and coordinating access to necessary care and services appropriate to the needs of the resident with MI.(5) Psychiatric diagnostic interview examination. An assessment of a resident with MI that includes relevant past and current medical and psychiatric information and a documented diagnosis by a licensed professional practicing within the scope of his or her license. Source Note: The provisions of this §303.901 adopted to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.901 Description of MI Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206170 03/12/2026 A resident with MI is eligible for MI specialized services funded by Medicaid if the resident with MI requires the provision of at least one MI specialized service. Source Note: The provisions of this §303.902 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.902 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206171 03/12/2026 (a) The MI specialized services team must include:(1) the resident with MI;(2) the resident with MI's LAR, if any;(3) the QMHP-CS assigned to the resident with MI;(4) a representative of the LMHA or LBHA providing the MI specialized services;(5) the MCO service coordinator, if the resident with MI does not object;(6) a NF staff person familiar with the resident with MI's needs; and(7) if the resident with MI is transitioning to the community:(A) a representative from the community program provider, if one has been selected; and(B) a relocation specialist.(b) The MI specialized services team may also include a concerned individual whose inclusion is requested by the resident with MI or the LAR. Source Note: The provisions of this §303.903 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.903 MI Specialized Services Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206172 03/12/2026 The LMHA or LBHA staff person administering the uniform assessment must be certified in administering the uniform assessment. Source Note: The provisions of this §303.904 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.904 Qualifications for Conducting the Uniform Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217846 03/12/2026 (a) The LMHA or LBHA must comply with §303.302 of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process).(b) At the initial IDT meeting, an LMHA or LBHA staff must:(1) review the MI specialized services recommended on the PE;(2) explain the uniform assessment;(3) ensure the resident with MI, or LAR on behalf of the resident with MI, understands the purpose of the uniform assessment; and(4) have the resident with MI, or LAR on behalf of the resident with MI, agree or decline to receive the uniform assessment and MI specialized services.(c) Within 20 business days after the IDT meeting, if the resident with MI or LAR agrees, the LMHA or LBHA must:(1) complete the uniform assessment;(2) develop the PCRP; and(3) for a resident with MI only, convene a meeting in person, or in extenuating circumstances via audio-visual communication, to discuss the results of the uniform assessment and PCRP, and to determine the MI specialized services the resident with MI will receive.(d) Attendees at the meeting convened in accordance with subsection (c)(3) of this section must include:(1) the QMHP-CS who is familiar with the needs of the resident with MI;(2) the resident with MI;(3) the LAR for the resident with MI, if any; and(4) a NF staff person familiar with the needs of the resident with MI.(e) At the meeting convened in accordance with subsection (c)(3) of this section, the QMHP-CS must ensure the resident with MI, regardless of whether he or she has an LAR, participates in the meeting to the fullest extent possible and receives the support necessary to do so, including communication supports.(f) The LMHA or LBHA must provide a copy of the completed uniform assessment and PCRP to the NF for inclusion in the NF comprehensive care plan for the resident with MI within 10 calendar days after the meeting convened in accordance with subsection (c)(3) of this section.(g) Before the LMHA or LBHA conducts the meeting described in subsection (c)(3) of this section via audio-visual communication, the LMHA or LBHA must:(1) do one of the following:(A) obtain the written informed consent of the resident with MI or LAR; or(B) obtain oral consent from the resident with MI or LAR and document the oral consent in the record of the resident with MI; and(2) document in the record of the resident with MI a description of the extenuating circumstances which required the use of audio-visual communication.(h) If the LMHA or LBHA does not obtain the written or oral consent required by subsection (g) of this section, the LMHA or LBHA must:(1) document the resident with MI's or LAR's refusal in the record of the resident with MI; and(2) convene a meeting in person as soon as possible after the extenuating circumstances no longer exist. Source Note: The provisions of this §303.905 adopted to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.905 Process for Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206176 03/12/2026 The QMHP-CS, in conjunction with the MI specialized services team, develops, reviews at least quarterly, and revises as needed the PCRP for each resident with MI in accordance with §301.353(e)-(g) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization). Source Note: The provisions of this §303.906 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.906 Person-Centered Recovery Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217847 03/12/2026 (a) At least quarterly, the QMHP-CS must convene an MI quarterly meeting with the MI specialized services team, in person, or in extenuating circumstances via audio-visual communication, to:(1) review the PCRP to determine whether the MI specialized services previously identified remain relevant; and(2) determine whether the current uniform assessment accurately reflects the need for MI specialized services in the identified frequency for the resident with MI, in the amount, and duration, or if an updated uniform assessment is required.(b) The MI specialized services team initiates revisions to the PCRP in response to changes to the needs of the resident with MI.(1) Any MI specialized services team member may ask the QMHP-CS to convene a meeting at any time to discuss whether the PCRP for the resident with MI needs to be revised to add a new MI specialized service or change the frequency, amount, or duration of an existing MI specialized service.(2) The QMHP-CS must convene a meeting within seven calendar days after learning of the need to revise the PCRP for the resident with MI.(c) If the MI specialized services team agrees to add a new MI specialized service to the PCRP or determines an updated uniform assessment is required, a QMHP-CS must, within seven calendar days after the meeting is held, update the uniform assessment and provide it to the MI specialized services team.(d) The QMHP-CS must:(1) document revisions on the PCRP within five calendar days after a team meeting; and(2) retain the revised PCRP documentation in the LMHA or LBHA record for the resident with MI.(e) Within ten calendar days after the PCRP is updated or renewed, the QMHP-CS must send each member of the MI specialized services team a copy of the revised PCRP.(f) If the MI specialized services team determines a new MI specialized service is needed or determines a change in the frequency, amount, or duration of an existing service is needed, the PCRP must be revised before the LMHA or LBHA delivers a new or updated service.(g) Before the QMHP-CS conducts the meeting described in subsection (a) of this section via audio-visual communication, the QMHP-CS must:(1) do one of the following:(A) obtain the written informed consent of the resident with MI or LAR; or(B) obtain the oral consent from the resident with MI or LAR and document the oral consent in the record of the resident with MI; and(2) document in the record of the resident with MI the extenuating circumstances which required the use of audio-visual communication.(h) If the QMHP-CS does not obtain the written or oral consent required by subsection (g) of this section, the QMHP-CS must:(1) document the refusal of the resident with MI or LAR in the record of the resident with MI; and(2) convene an MI specialized services team meeting in person as soon as possible after the extenuating circumstances no longer exist. Source Note: The provisions of this §303.907 adopted to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.907 Renewal and Revision of Person-Centered Recovery Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206175 03/12/2026 (a) The LMHA or LBHA must begin delivering all MI specialized services in accordance with the PCRP within five business days after the MI specialized services team meeting.(b) Before delivering an MI specialized service, the LMHA or LBHA must:(1) confirm that the resident with MI is a Medicaid recipient; and(2) receive authorization to deliver the MI specialized services in accordance with §306.311 of this title (relating to Service Authorization and Recovery Plan).(c) The LMHA or LBHA must ensure that a resident with MI's progress or lack of progress toward achieving an identified outcome from the resident with MI's or LAR's perspective is accurately and consistently documented in observable, measurable terms.(d) The LMHA or LBHA must monitor a resident with MI's and LAR's satisfaction with MI specialized services.(e) The LMHA or LBHA must inform the NF of any significant changes to the resident with MI's behavioral or medical condition during the provision of MI specialized services. Source Note: The provisions of this §303.908 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.908 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217848 03/12/2026 (a) When a resident with MI refuses the uniform assessment or MI specialized services, the LMHA or LBHA must:(1) ask the resident with MI or the LAR to sign the Refusal of PASRR MI Specialized Services form and document on the form if the resident with MI or LAR refuses to sign;(2) inform the resident with MI that a follow-up visit will be conducted every 30 days for 90 days after the initial IDT meeting;(3) conduct a follow-up visit every 30 days for 90 days after the initial IDT meeting and make the 90th day follow-up visit the first MI quarterly meeting; and(4) if the resident with MI or the LAR refuses the uniform assessment or MI specialized services at the first MI quarterly meeting, inform the resident with MI and the LAR that an annual IDT meeting is required and will be conducted, at which time the uniform assessment and MI specialized services will be offered again.(b) A resident with MI and their LAR, if applicable, may agree to receive the uniform assessment or MI specialized services at any time. Source Note: The provisions of this §303.909 adopted to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.909 Refusal of the Uniform Assessment or MI Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217849 03/12/2026 (a) The LMHA or LBHA must suspend MI specialized services for a resident with MI when:(1) the resident with MI is admitted to an acute care hospital for fewer than 30 days and is returning to the same NF; or(2) the resident with MI loses Medicaid eligibility.(b) The LMHA or LBHA may terminate one or more MI specialized services of a resident with MI if:(1) the resident with MI loses Medicaid eligibility for more than 90 days;(2) the resident with MI or LAR requests the MI specialized services be terminated; or(3) the MI specialized services team, which includes the resident with MI and LAR, agrees the resident with MI no longer benefits from the MI specialized services. Source Note: The provisions of this §303.910 adopted to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.910 Suspension and Termination of MI Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206180 03/12/2026 (a) If a resident with MI only, or the LAR on the resident with MI's behalf, expresses an interest in moving to the community, the QMHP-CS must facilitate the development of, revisions to, implementation of, and monitoring of a transition plan.(b) A transition plan must identify the services and supports a resident with MI needs to live in the community, including those essential supports that are critical to the resident with MI's health and safety. Source Note: The provisions of this §303.911 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.911 Transition Planning for Residents with MI Only https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217850 03/12/2026 The LMHA or LBHA must maintain the following documentation in the record of the resident with MI:(1) all assessments used for service planning;(2) documentation related to the initiation and delivery of MI specialized services, including reasons for delays and all follow-up activities;(3) documentation related to monitoring MI specialized services, including:(A) the satisfaction with MI specialized services by the resident with MI or the LAR; and(B) progress or lack of progress toward achieving goals and outcomes identified in the PCRP;(4) documentation of all meetings required by this chapter;(5) guardianship paperwork and consents, if applicable; and(6) documentation of the refusal of MI specialized services or uniform assessments or both by the resident with MI, if applicable. Source Note: The provisions of this §303.912 adopted to be effective September 1, 2021, 46 TexReg 5419; amended to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.912 Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206182 03/12/2026 (a) The LMHA or LBHA must allow access to the resident with MI or the resident with MI's record by:(1) advocacy agencies; and(2) HHSC staff.(b) The LMHA or LBHA must develop, update as necessary, and implement a written quality assurance process to evaluate and improve the quality of MI specialized services delivered by the LMHA or LBHA. Source Note: The provisions of this §303.913 adopted to be effective September 1, 2021, 46 TexReg 5419. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.913 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217851 03/12/2026 (a) The LMHA or LBHA must ensure:(1) an LMHA or LBHA staff responsible for coordinating MI specialized services completes the following training before coordinating MI specialized services:(A) training that addresses:(i) appropriate LMHA or LBHA policies, procedures, and standards;(ii) this chapter, other HHSC rules relating to the provision of specialized services, and other HHSC rules affecting the LMHA or LBHA; and(iii) HHSC's PASRR MI Handbook;(B) the HHSC computer-based PASRR training, "An Overview of the PASRR Process;" and(C) additional trainings designated by HHSC through IDD-PASRR Handbook, PASRR MI Handbook, broadcasts, or other communications;(2) an LMHA or LBHA staff completes HHSC approved computer-based person-centered planning and practices training within the first 60 days of coordinating MI specialized services;(3) a supervisor, team lead, or quality monitoring staff person who has successfully completed the training in paragraph (2) of this subsection reviews and signs off on work completed by an LMHA or LBHA staff until an LMHA or LBHA staff completes the training required in paragraph (2) of this subsection; and(4) an LMHA or LBHA staff responsible for coordinating MI specialized services completes HHSC approved person-centered thinking training within the first year of coordinating MI specialized services.(b) The LMHA or LBHA must:(1) ensure an LMHA or LBHA staff responsible for coordinating MI specialized services demonstrates competency in the coordination of MI specialized services; and(2) maintain documentation of the training received by the LMHA or LBHA staff. Source Note: The provisions of this §303.914 adopted to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) I MI SPECIALIZED SERVICES §303.914 Required Training for an LMHA or LBHA Staff Responsible for Coordinating MI Specialized Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217844 03/12/2026 (a) HHSC may allow LIDDAs, LMHAs, and LBHAs to use one or more of the exceptions described in subsection (c) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC will notify LIDDAs, LMHAs, and LBHAs when an exception is permitted and the date the exception must no longer be used, which may be before the declaration of a state of disaster expires.(b) Subject to the notification by HHSC, the following flexibilities may be available to LIDDAs, LMHAs, and LBHAs to the extent the flexibility is permitted by and does not conflict with other laws or obligations of the LIDDAs, LMHAs, and LBHAs and is allowed by federal and state law.(c) LIDDAs, LMHAs, and LBHAs, for services normally provided in person, may use audio-visual communication or audio-only communication methods to engage with the individual or resident to carry out the requirements in:(1) §303.302(a)(2)(A)(ii) of this chapter (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process);(2) §303.601(b)(7) of this chapter (relating to Habilitation Coordination for a Designated Resident);(3) §303.602(e) of this chapter (relating to Service Planning Team Responsibilities Related to Specialized Services);(4) §303.701(g) of this chapter (relating to Transition Planning for a Designated Resident);(5) §303.905(c)(3) of this chapter (relating to Process for Service Initiation); and(6) §303.907(a) of this chapter (relating to Renewal and Revision of Person-Centered Recovery Plan).(d) LIDDAs, LMHAs, and LBHAs that use the flexibilities allowed under subsection (c) of this section, must comply with:(1) all guidance on the application of the rules during the declaration of disaster that is published by HHSC on its website or in another communication format HHSC determines appropriate; and(2) all policy guidance applicable to the rules identified in subsection (c) of this section issued by HHSC's Medicaid and CHIP Services.(e) LIDDAs, LMHAs, and LBHAs must ensure any method of contact complies with all applicable requirements related to security and privacy of information. Source Note: The provisions of this §303.1000 adopted to be effective April 15, 2024, 49 TexReg 2287. 1 HEALTH AND HUMAN SERVICES COMMISSION 303 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) J DISASTER RULE FLEXIBILITIES §303.1000 Flexibilities to Certain Requirements During Declaration of Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206821 03/12/2026 (a) The purpose of this chapter is to describe the criteria used and the process followed:(1) by an authorized provider employed by or contracting with a local intellectual and developmental disability authority (LIDDA) or a state supported living center (SSLC), to conduct a diagnostic assessment for intellectual disability (ID), autism spectrum disorder (ASD), and a related condition; and(2) by a LIDDA or SSLC, to review a determination of ID or a diagnosis of ASD, or related condition for endorsement.(b) This chapter identifies the qualifications and requirements of an authorized provider employed by or contracting with a LIDDA or an SSLC. Source Note: The provisions of this §304.101 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT A GENERAL PROVISIONS §304.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206822 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) ABL--Adaptive behavior level. The categorization of an individual's functioning level of adaptive behavior into one of five levels ranging from minimal limitations (0) through profound limitations (IV).(2) Adaptive behavior--The effectiveness with or degree to which an individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group as assessed by a standardized measure.(3) ASD--Autism spectrum disorder. As described in the most current Diagnostic and Statistical Manual of Mental Disorders (DSM), a disorder characterized by persistent impairment in reciprocal social communication and social interaction and restricted, repetitive patterns of behavior, interests, or activities. These symptoms are present from early childhood and limit or impair everyday functioning.(4) Asperger disorder--A neurodevelopmental disorder characterized by severe, sustained, clinically significant impairment of social interaction or communication skills and restricted, repetitive, and stereotyped patterns of behavior or interests. Symptoms may present later during the individual's development. Since the expanded definition of ASD in the DSM, effective 2013, Asperger disorder is subsumed under the diagnosis of ASD.(5) Authorized provider--A person who is:(A) a physician licensed to practice in Texas;(B) a psychologist licensed to practice in Texas; or(C) a certified authorized provider.(6) Certified authorized provider--A person who is certified by the Texas Health and Human Services Commission (HHSC) as described in §304.302 of this chapter (relating to Certified Authorized Provider).(7) Developmental period--The period of time between birth and before the individual reaches 18 years of age.(8) Diagnostic assessment--An assessment, including a determination of intellectual disability (DID), conducted to determine if an individual meets the criteria for a diagnosis of intellectual disability (ID), ASD, or a related condition.(9) Diagnostic assessment report--The written report from a diagnostic assessment not conducted by an authorized provider employed by or contracting with a local intellectual and developmental disability authority (LIDDA) or state supported living center (SSLC), including reports completed by private entities or schools.(10) DID--Determination of intellectual disability. An assessment conducted in accordance with §304.401 of this chapter (relating to Conducting a Determination of Intellectual Disability) by an authorized provider to determine if an individual meets the criteria for a diagnosis of intellectual disability as defined in paragraph (15) of this section.(11) DID report--Determination of intellectual disability report. The findings of the DID conducted by an authorized provider employed by or contracting with a LIDDA or SSLC written in accordance with §304.402 of this chapter (relating to The Determination of Intellectual Disability Report).(12) DSM--The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.(13) Endorsement--The process by which a previous assessment report, including a DID report, which meets the requirements in §304.402 of this chapter, is determined by an authorized provider to be a current representation of the individual's functioning for the purposes of diagnosis and service eligibility. When appropriate, an endorsement is completed in lieu of a DID.(14) HHSC--Texas Health and Human Services Commission.(15) ID--Intellectual disability. Consistent with Texas Health and Safety Code (THSC), §591.003, significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.(16) Individual--A person who is the subject of a diagnostic assessment or who has been determined to be in the LIDDA priority population.(17) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and who may be a parent, guardian, or managing conservator of a minor individual, or a guardian of an adult individual.(18) LIDDA--Local intellectual and developmental disability authority. An entity designated in accordance with THSC, §533A.035(a).(19) LIDDA priority population--Local intellectual and developmental disability authority priority population. A group comprised of persons who meet one or more of the following descriptions:(A) a person with an ID;(B) a person with ASD;(C) a person with a related condition on the current HHSC-approved list of related conditions, available on the HHSC website, who is eligible for and enrolling in services in the Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF/IID) Program, the Home and Community-based Services (HCS) Program, the Texas Home Living (TxHmL) Program or other HHSC-approved programs;(D) a nursing facility resident who is eligible for specialized services for an ID or a related condition pursuant to §1919(e)(7) of the Social Security Act (United States Code, Title 42, §1396r(e)(7));(E) a child who is eligible for Early Childhood Intervention services through HHSC; or(F) a person diagnosed by an authorized provider as having a pervasive developmental disorder (PDD) or Asperger disorder through a diagnostic assessment completed before 2013.(20) LIDDA services--Local intellectual and developmental disability authority services. Services provided by or through a LIDDA that are funded with general revenue pursuant to a performance contract with HHSC.(21) PDD--Pervasive developmental disorder. A severe and pervasive impairment in the developmental areas of reciprocal social interaction skills or communication skills, or the presence of stereotyped behaviors, interests, and activities manifested during the individual's development. Since the expanded definition of ASD in the DSM, effective 2013, PDD is subsumed under the diagnosis of ASD.(22) Related condition--As defined in the Code of Federal Regulations (CFR), Title 42, §435.1010, a severe and chronic disability that:(A) is attributable to:(i) cerebral palsy or epilepsy; or(ii) any other condition, other than mental illness, found to be closely related to an ID because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an ID, and requires treatment or services similar to those required for persons with an ID;(B) is manifested before the person reaches age 22;(C) is likely to continue indefinitely; and(D) results in substantial functional limitation in three or more of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(23) Residential care facility--A facility defined in THSC, §591.003.(24) SSLC--State supported living center.(25) Subaverage general intellectual functioning--Consistent with THSC, §591.003, measured intelligence on standardized general intelligence tests of two or more standard deviations (not including standard error of measurement adjustments) below the age-group mean for the tests used.(26) TAC--Texas Administrative Code.(27) THSC--Texas Health and Safety Code. Source Note: The provisions of this §304.102 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT A GENERAL PROVISIONS §304.102 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206824 03/12/2026 (a) A LIDDA uses information from a DID report or a diagnostic assessment report endorsed as a DID that was conducted in accordance with Subchapter D of this chapter (relating to Determination of Intellectual Disability) to determine an individual's eligibility for LIDDA services.(b) HHSC uses information from a DID report or a diagnostic assessment report endorsed as a DID that was conducted in accordance with Subchapter D of this chapter to determine an individual's eligibility for certain services and supports provided through HHSC.(c) An individual may receive the following time-limited services without first being determined to be a person with an intellectual disability:(1) emergency services provided in accordance with THSC, §593.027 or §593.0275; and(2) respite care in a residential care facility provided in accordance with THSC, §593.028. Source Note: The provisions of this §304.201 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT B PURPOSE OF THE DETERMINATION OF INTELLECTUAL DISABILITY §304.201 Use of Information from a DID or Diagnostic Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206823 03/12/2026 (a) An individual or the individual's LAR may make a written request for a DID on a form provided by HHSC to:(1) the SSLC or LIDDA serving the area in which the individual resides; or(2) a psychologist licensed to practice in Texas; or(3) a physician licensed to practice in Texas.(b) An authorized provider must conduct the DID.(c) A DID conducted by an authorized provider who is not employed by or contracting with a LIDDA or SSLC, must be reviewed in accordance with §304.403 of this chapter (relating to Review and Endorsement of a Determination of Intellectual Disability Report) to establish eligibility for services. Source Note: The provisions of this §304.202 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT B PURPOSE OF THE DETERMINATION OF INTELLECTUAL DISABILITY §304.202 Request for a Determination of Intellectual Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206825 03/12/2026 If the DID is conducted at a LIDDA or SSLC, the LIDDA or SSLC must:(1) inform the person who requested the DID and the person assessed, orally and in writing, of the right to:(A) an additional, independent DID to be conducted at the person's expense if the person questions the validity or results of the DID; and(B) an administrative hearing to contest the findings concerning ID, as described in 40 TAC Chapter 4, Subchapter D (relating to Administrative Hearings under Texas Health and Safety Code, Title 7, Subtitle D); and(2) document that the person who requested the DID and the person assessed were informed orally and in writing of these rights. Source Note: The provisions of this §304.203 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT B PURPOSE OF THE DETERMINATION OF INTELLECTUAL DISABILITY §304.203 Right to an Independent Determination of Intellectual Disability or Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206826 03/12/2026 (a) An authorized provider employed by or contracting with an SSLC may conduct a DID only for an individual receiving services from that SSLC.(b) At a LIDDA or an SSLC, a person conducting a DID must be:(1) a psychologist licensed to practice in Texas who is employed by or contracting with the LIDDA or SSLC and who has completed:(A) graduate course work in assessing intellectual and adaptive behavior for individuals with an ID or developmental disability; or(B) one year of supervised experience in assessing intellectual and adaptive behavior for individuals with an ID or developmental disability;(2) a physician licensed to practice in Texas who is employed by or contracting with the LIDDA or SSLC and who has completed:(A) one year of employment experience in the field of ID; and(B) an internship or residency that includes specialized training in assessing intellectual and adaptive behavior for individuals with an ID or developmental disability or 12 hours of specialized continuing education in assessing individual intellectual and adaptive behavior; or(3) a certified authorized provider, as described in §304.302 of this subchapter (relating to Certified Authorized Provider). Source Note: The provisions of this §304.301 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT C AUTHORIZED PROVIDERS §304.301 Qualifications and Requirements for an Authorized Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206827 03/12/2026 (a) To designate an employee or contractor of the LIDDA or SSLC who is not a licensed psychologist or physician as a certified authorized provider, a LIDDA or SSLC may submit a request to HHSC, in accordance with HHSC procedures, available on the HHSC website.(b) A level I certified authorized provider must:(1) be a current employee of the LIDDA or SSLC;(2) be:(A) a provisionally licensed psychologist;(B) a licensed psychological associate (LPA), other than an LPA authorized to practice independently (LPA-IP);(C) a licensed specialist in school psychology (LSSP); or(D) recognized as a certified authorized provider prior to September 1, 2013 as provided per written approval by Texas Department of Mental Health and Mental Retardation (TDMHMR) or Department of Aging and Disability Services (DADS) prior to September 1, 2013, to conduct a Determination of Mental Retardation (DMR) or DID;(3) have supervised experience or successful completion of graduate course work in assessing intellectual and adaptive behavior for individuals with an ID or developmental disability; and(4) have one year of employment, internship, or practicum in the field of ID.(c) A level II certified authorized provider:(1) must be employed by or contracting with the LIDDA or SSLC;(2) must be a psychological associate licensed to practice in Texas who is authorized to practice independently in accordance with 22 TAC §463.8 (relating to Licensed Psychological Associate);(3) must have supervised experience or successful completion of graduate course work in assessing intellectual and adaptive behavior for individuals with an ID or developmental disability; and(4) must have one year of employment, internship, or practicum in the field of ID.(d) A certified authorized provider is permitted to conduct a DID in accordance with this chapter only while functioning as an employee or contractor of the requesting LIDDA or SSLC, as applicable.(e) HHSC may, at any time, revoke a person's designation as a certified authorized provider. Source Note: The provisions of this §304.302 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT C AUTHORIZED PROVIDERS §304.302 Certified Authorized Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206828 03/12/2026 (a) In conducting a DID, an authorized provider employed by or contracting with a LIDDA or SSLC must:(1) adhere to the Determination of Intellectual Disability (DID): Best Practice Guidelines, available on the HHSC website;(2) interview and observe the individual in-person or in real time using audio-visual technology; and(3) perform a diagnostic assessment that, at a minimum, includes:(A) a standardized measure of the individual's intellectual functioning using an appropriate test based on the characteristics of the individual;(B) a standardized measure of the individual's adaptive abilities and deficits reported as the individual's ABL;(C) a review of evidence supporting the origination of ID during the individual's developmental period, which includes but is not limited to, as available:(i) reports concerning the cause of the suspected ID;(ii) results of all relevant assessments;(iii) types of services the individual has received or is receiving;(iv) reports by other people, including the individual's family members and friends; and(v) educational records; and(D) a review of the individual's previous and current psychological and psychiatric treatments and diagnoses, as available.(b) An authorized provider employed by or contracting with a LIDDA or SSLC must conduct the interview and assessment described in subsection (a) of this section using diagnostic techniques and appropriate accommodations adapted to the individual's age; cultural background; ethnic origins; language; and physical, behavioral, or sensory capabilities.(c) A previous diagnostic assessment, social history, or relevant record from another entity, including a school district, public or private agency, or another authorized provider, may be used to meet the requirements in subsection (a)(3)(A) or (a)(3)(B) of this section if the authorized provider employed by or contracting with the LIDDA or SSLC who is conducting the DID considers the assessment, social history, or relevant record to be a valid reflection of the individual's current level of functioning. Source Note: The provisions of this §304.401 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT D DETERMINATION OF INTELLECTUAL DISABILITY §304.401 Conducting a Determination of Intellectual Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206829 03/12/2026 (a) An authorized provider employed by or contracting with a LIDDA or SSLC must complete a written report of the DID that is dated, signed, and includes the license number or, when applicable, the certification number of the authorized provider. The written DID report must contain:(1) background information summarizing the individual's:(A) developmental history, including a description of the evidence of origination of ID during the individual's developmental period; and(B) previous and current psychological and psychiatric evaluations, treatments and diagnoses;(2) results of current intellectual and adaptive behavior assessments, including:(A) instrument names;(B) composite or full-scale scores;(C) cluster, area, and specific or subscale scores, if available; and(D) overall intellectual functioning and ABL;(3) a narrative description of:(A) test results, including the individual's relative strengths and weaknesses;(B) testing conditions, including any accommodations provided or technology used; and(C) any relevant impact on the test results related to the individual's:(i) cultural background;(ii) primary language;(iii) communication style;(iv) physical or sensory impairments;(v) motivation;(vi) attentiveness;(vii) emotional and behavioral factors; and(viii) home and family variables;(4) an integrative summary that includes diagnostic impressions, conclusions, and diagnoses, including applicable diagnostic codes; and(5) recommendations, including a statement of:(A) whether the individual has an ID; and(B) if applicable, whether the individual has:(i) ASD as described in §304.503 of this chapter (relating to Autism Spectrum Disorder); or(ii) a related condition on the current HHSC-approved list of related conditions.(b) An authorized provider must provide the written DID report to the individual or individual's LAR who requested the DID within 30 days after completing the interview and diagnostic assessment described in §304.401(a) of this subchapter (relating to Conducting a Determination of Intellectual Disability).(c) If a DID has been ordered by a court for guardianship proceedings, the authorized provider who conducts the DID:(1) must submit the written findings and recommendations as specified in the court's order; and(2) may submit a current capacity assessment regarding self-care and financial management of the individual using an HHSC-approved form. Source Note: The provisions of this §304.402 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT D DETERMINATION OF INTELLECTUAL DISABILITY §304.402 The Determination of Intellectual Disability Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206830 03/12/2026 (a) An individual or the individual's LAR may make a written or oral request to the LIDDA serving the area in which the individual resides for a review of an existing DID report or a diagnostic assessment that reflects current functioning to determine eligibility. An authorized provider may:(1) endorse the DID report;(2) endorse the diagnostic assessment report;(3) conduct additional testing to determine eligibility; or(4) conduct a new DID.(b) Except as provided in subsection (d) of this section, if an individual has been determined to have an ID, ASD, or a related condition on the current HHSC-approved list of related conditions, by an authorized provider who is not employed by or contracting with the LIDDA at which the individual or the individual's LAR is seeking services, the LIDDA must ensure that:(1) the diagnostic assessment report is reviewed by an authorized provider employed by or contracting with the LIDDA; and(2) the authorized provider conducting the review interviews and observes the individual in-person or in real time using audio-visual technology.(c) Except as provided in subsection (d) of this section, if an individual has been determined to have an ID, ASD, or a related condition on the current HHSC-approved list of related conditions, by an authorized provider who is not employed by or contracting with the SSLC at which the individual is receiving services, the SSLC must ensure that:(1) the diagnostic assessment report is reviewed by an authorized provider employed by or contracting with the SSLC; and(2) the authorized provider conducting the review interviews and observes the individual in-person or in real time using audio-visual technology.(d) An authorized provider employed by or contracting with a LIDDA or SSLC:(1) may, but is not required to, endorse a DID conducted by another authorized provider employed by or contracting with a LIDDA or SSLC; and(2) must not endorse a DID that they conducted without adhering to endorsement requirements in subsections (b) - (c) of this section.(e) If a diagnostic assessment report reviewed in accordance with subsection (b) or (c) of this section is endorsed by the authorized provider employed by or contracting with the LIDDA or SSLC as a valid reflection of the individual's current level of functioning, within 30 days after the review is completed:(1) the authorized provider must:(A) document the outcome of the review; and(B) inform the individual or the individual's LAR orally and in writing of the outcome of the review; and(2) the LIDDA or SSLC must inform the individual or the individual's LAR orally and in writing of the right to an administrative hearing to contest the determination of ID, as described in 40 TAC Chapter 4, Subchapter D (relating to Administrative Hearings under Texas Health and Safety Code, Title 7, Subtitle D).(f) If a DID or other diagnostic assessment report reviewed in accordance with subsection (b) or (c) of this section is not endorsed by the authorized provider as a valid reflection of the individual's current level of functioning, the authorized provider must, within 30 days after the review is completed:(1) inform the individual or the individual's LAR orally and in writing of:(A) the outcome of the review; and(B) the opportunity to have an authorized provider employed by or contracting with the LIDDA or SSLC conduct a diagnostic assessment at no expense to the individual or the individual's LAR; and(2) the LIDDA or SSLC must inform the individual or the individual's LAR orally and in writing of the right to an administrative hearing to contest the determination of ID, as described in 40 TAC Chapter 4, Subchapter D. Source Note: The provisions of this §304.403 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT D DETERMINATION OF INTELLECTUAL DISABILITY §304.403 Review and Endorsement of a Determination of Intellectual Disability Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206831 03/12/2026 (a) When an individual relocates from one local service area or SSLC to another local service area or SSLC, the sending LIDDA or SSLC must ensure the following documentation is provided to the receiving LIDDA or SSLC:(1) previous and current psychological and psychiatric evaluations;(2) documents regarding treatments and diagnoses;(3) available diagnostic assessments and previous DIDs; and(4) any other information requested by the receiving LIDDA or SSLC.(b) When an individual relocates from one local service area or SSLC to another local service area or SSLC, the receiving LIDDA or SSLC may:(1) accept the DID report;(2) review and endorse the current DID report in accordance with §304.403 of this subchapter (relating to Review and Endorsement of a Determination of Intellectual Disability Report); or(3) conduct a new DID. Source Note: The provisions of this §304.404 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT D DETERMINATION OF INTELLECTUAL DISABILITY §304.404 Elements of a Transfer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206832 03/12/2026 (a) If an individual is determined not to have an ID, an authorized provider employed by or contracting with a LIDDA may use information from the DID report to assist in establishing the individual's eligibility for certain Medicaid services based on the existence of a related condition on the current HHSC-approved list of related conditions and §261.238 of this title (relating to ICF/MR Level of Care I Criteria) or §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria).(b) The DID report must include information about the date of onset and a description of the individual's deficits, skills, behaviors, and current functioning level. Source Note: The provisions of this §304.502 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT E INTELLECTUAL DISABILITY AND RELATED CONDITIONS §304.502 Related Condition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206833 03/12/2026 (a) If an individual is determined not to have an ID, an authorized provider employed by or contracting with a LIDDA may use information from the DID report to assist in establishing the individual's eligibility for LIDDA services based on the existence of ASD.(b) The DID report must include information about the date of onset and a description of the individual's deficits, skills, behaviors, and current functioning level that support the criteria for ASD described in the current DSM. Source Note: The provisions of this §304.503 adopted to be effective November 30, 2021, 46 TexReg 8062. 1 HEALTH AND HUMAN SERVICES COMMISSION 304 DIAGNOSTIC ASSESSMENT E INTELLECTUAL DISABILITY AND RELATED CONDITIONS §304.503 Autism Spectrum Disorder https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198032 03/12/2026 The purpose of this subchapter is to improve existing mental health services provided by the entities defined in §411.653 of this title (relating to Definitions) by establishing standards to ensure the effective and coordinated provision of services to individuals who require specialized support or treatment due to co-occurring psychiatric and substance use disorders (COPSD). Source Note: The provisions of this §306.1 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198033 03/12/2026 (a) The provisions of this subchapter apply to entities defined in §411.653 of this title (relating to Definitions).(b) The provisions of this subchapter are in addition to requirements contained in other DSHS rules. This subchapter does not supercede other DSHS rules that may also apply to the provision of services to individuals as defined in §411.653 of this title. Source Note: The provisions of this §306.3 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198034 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Access--An individual's ability to obtain the psychiatric and substance use disorder services needed. (2) Adolescent--A person who is 13 through 17 years of age. (3) Adult--A person who is 18 years of age or older. (4) Child--A person who is 3 through 12 years of age. (5) Contract--A legally enforceable written agreement for the purchase of services. (6) Co-occurring psychiatric and substance use disorders (COPSD)--The co-occurring diagnoses of psychiatric disorders and substance use disorders. (7) Diagnostic and Statistical Manual of Mental Disorders (DSM)--The most recent edition of the American Psychiatric Association's official classification of mental disorders. (8) Entity or entities--The terms used to refer to the following: (A) local mental health authorities (LMHAs); (B) Managed care organizations (MCOs); (C) state mental health facilities (SMHF); and (D) Medicaid providers who are required to comply with Chapter 419, Subchapter L of this title, governing Mental Health Rehabilitative Services, or Chapter 412, Subchapter I of this title, governing Mental Health Case Management Services. (9) Family member--Anyone an individual identifies as being involved in the individual's life (e.g., the individual's parent, spouse, child, sibling, significant other, or friend). (10) Individual-- (A) For an LMHA--An adult with COPSD, adolescent with COPSD, or child with COPSD seeking or receiving services from or through the LMHA or its provider. (B) For an MCO--An enrolled adult with COPSD, adolescent with COPSD, or child with COPSD seeking or receiving services from or through the MCO or its provider. (C) For an SMHF--An adult with COPSD, adolescent with COPSD, or child with COPSD seeking or receiving services from or through the SMHF or its provider. (D) For a provider of rehabilitative services or a provider of mental health case management services reimbursed by Medicaid--An adult with COPSD, adolescent with COPSD, or child with COPSD seeking or receiving rehabilitative services or mental health case management services reimbursed by Medicaid. (11) Integrated assessment--An assessment of an individual to gather both substance use and psychiatric information. (12) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter (e.g., a parent, guardian, or managing conservator of a child or adolescent, a guardian of an adult, or a personal representative of a deceased individual). (13) Local mental health authority (LMHA)--An entity designated as the local mental health authority by the DSHS in accordance with the Health and Safety Code, §533.035(a). (14) Managed care organization (MCO)--An entity that has a current Department of Insurance certificate of authority to operate as a health maintenance organization (HMO) under Insurance Code, Subchapter C of Chapter 843, or as an approved nonprofit health corporation under Insurance Code, Chapter 884. (15) Psychiatric disorder--An emotional disturbance in a child or adolescent or a psychiatric disorder in an adult who is a member of the mental health priority population as defined in the Health and Human Services System Strategic Plan 2011 - 2015. (16) Readiness to change--An individual's emotional and cognitive awareness of the need to change, coupled with a commitment to change. (17) Services--Services provided to treat a psychiatric or substance use disorder. (18) Staff--Full- or part-time employees, contractors, and interns of an entity. (19) Substance use disorder--The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which meets criteria described in the current Diagnostic and Statistical Manual of Mental Disorders for substance abuse or substance dependence. (20) Support services--Services delivered to an individual, legally authorized representative (LAR) or family member(s) to assist the individual in functioning in the living, learning, working, and socializing environments. (21) Treatment plan--A written document developed by the provider, in consultation with the individual (and LAR on the individual's behalf), that is based on assessments of the individual and which addresses the individual's strengths, needs, goals, and preferences regarding service delivery as referenced in §412.322 of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) of Chapter 412, Subchapter G of this title, governing Mental Health Community Services Standards. Source Note: The provisions of this §306.5 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198035 03/12/2026 (a) Entities, entities' contracted providers, and each of their respective staff providing service to an individual with COPSD shall ensure that services are provided in compliance with applicable licensure, scope of practice and other law and:(1) address both psychiatric and substance use disorders;(2) are provided within established practice guidelines for this population; and(3) facilitate individuals or LARs in accessing available services they need and choose, including self-help groups.(b) The services provided to an individual with COPSD shall comply with applicable licensure, scope of practice and other law and be provided:(1) by staff who are competent in the areas identified in §411.658 of this title (relating to Specialty Competencies of Staff Providing Services to Individuals with COPSD);(2) in an individual or small group setting;(3) in an age, gender, and culturally appropriate manner; and(4) in accordance with the individual's treatment plan. Source Note: The provisions of this §306.7 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.7 Services to Individuals with COPSD https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198036 03/12/2026 (a) Entities must comply with this subchapter.(b) Entities that are LMHAs, MCOs, or SMHFs must require providers, by contract, to comply with §411.654 of this title (relating to Services to Individuals with COPSD), §411.657 of this title (relating to Access to Services), §411.658 of this title (relating to Specialty Competencies of Staff Providing Services to Individuals with COPSD), and §411.660 of this title (relating to Screening, Assessment, and Treatment Planning).(c) Entities must monitor staff and contract providers who provide services to an individual with COPSD for compliance with the applicable provisions of §§411.657 - 411.660 of this title.(d) An entity that is an MCO must comply and must require staff to comply with Chapter 404, Subchapter E of this title, governing Rights of Persons Receiving Mental Health Services. Source Note: The provisions of this §306.9 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.9 Responsibility for Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198037 03/12/2026 (a) DSHS must make available training resources for the competencies identified in §411.658 of this title (relating to Specialty Competencies of Staff Providing Services to Individuals with COPSD).(b) DSHS must require LMHAs and SMHFs to develop quality management systems that ensure an appropriate integrated assessment for each individual and the appropriate delivery of services. Source Note: The provisions of this §306.11 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.11 DSHS Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198038 03/12/2026 (a) In determining an individual's initial and ongoing eligibility for any service, an entity may not exclude an individual based on the following factors:(1) the individual's past or present mental illness or substance use diagnosis or services;(2) medications prescribed to the individual in the past or present;(3) the presumption of the individual's inability to benefit from treatment;(4) the specific substance used by the individual;(5) the individual's continued substance use; or(6) the individual's level of success in prior treatment episodes.(b) Entities must ensure that an individual's refusal of a particular service does not preclude the individual from accessing other needed mental health or substance abuse services.(c) The LMHAs, MCOs, and SMHFs must ensure that individuals have access to staff who meet specialty competencies described in §411.658 of this title (relating to Specialty Competencies of Staff Providing Services to Individuals with COPSD).(d) Entities must establish and implement procedures to ensure the continuity of screening, assessment, and treatment services provided to individuals. Source Note: The provisions of this §306.13 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.13 Access to Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198039 03/12/2026 (a) Entities must ensure that services to individuals are age and culturally appropriate and are provided by staff within their scope of practice who have the following minimum knowledge, technical, and interpersonal competencies prior to providing services. (1) Knowledge competencies: (A) knowledge of the fact that psychiatric and substance use disorders are potentially recurrent relapsing disorders, and that although abstinence is the goal, relapses can be opportunities for learning and growth; (B) knowledge of the impact of substance use disorders on developmental, social, and physical growth and development of children and adolescents; (C) knowledge of interpersonal and family dynamics and their impact on individuals; (D) knowledge of the current Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for psychiatric disorders and substance use disorders and the relationship between psychiatric disorders and substance use disorders; (E) knowledge regarding the increased risks of self-harm, suicide, and violence in individuals; (F) knowledge of the elements of an integrated treatment plan and community support plan for individuals; (G) basic knowledge of pharmacology as it relates to individuals; (H) basic understanding of the neurophysiology of addiction; (I) basic knowledge of withdrawal symptoms and their potential risk factors to clients; (J) knowledge of the phases of recovery for individuals; (K) knowledge of the relationship between COPSD and Axis III disorders; and (L) basic knowledge of self-help in recovery. (2) Technical competencies: (A) ability to perform age-appropriate assessments of individuals; and (B) ability to formulate an individualized treatment plan and community support plan for individuals. (3) Interpersonal competencies: (A) ability to tailor interventions to the process of recovery for individuals; (B) ability to tailor interventions with readiness to change; and (C) ability to support individuals who choose to participate in 12-step recovery programs. (b) Within 90 days of the effective date of this subchapter, entities must ensure that staff who provide services to individuals with COPSD, and who have not previously done so, have demonstrated the competencies described in subsection (a) of this section. These competencies may be evidenced by compliance with current licensure requirements of the governing or supervisory boards for the respective disciplines involved in serving individuals with COPSD or by documentation regarding the attainment of the competencies described in subsection (a) of this section. For unlicensed staff delivering these services, these competencies are evidenced by documentation regarding their attainment as required in subsection (a) of this section. Source Note: The provisions of this §306.15 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.15 Specialty Competencies of Staff Providing Services to Individuals with COPSD https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198040 03/12/2026 (a) The LMHAs and MCOs must develop and implement a plan for quality management of services to individuals with COPSD as required in §412.317 (relating to Quality Management) of Chapter 412, Subchapter G of this title, governing Mental Health Community Services Standards.(b) The SMHFs must develop and implement a plan for quality management of services to individuals. The plan must be incorporated into the Improving Organizational Performance System (IOPS) and must identify clinical measures. The plan must describe the following:(1) activities for measuring, assessing, and improving processes for delivering services in accordance with this subchapter; and(2) methods for evaluating and improving outcomes for individuals receiving services. Source Note: The provisions of this §306.17 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.17 Quality Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198041 03/12/2026 (a) Screening and assessment. When a screening determines an assessment is necessary, an integrated assessment must be conducted to consider relevant past and current medical, psychiatric, and substance use information, including:(1) information from the individual (and LAR on the individual's behalf) regarding the individual's strengths, needs, natural supports, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;(2) the needs and desire of the individual for family member involvement in treatment and services if the individual is an adult without an LAR; and(3) recommendations and conclusions regarding treatment needs and eligibility for services for individuals.(b) Treatment plan development.(1) The individual (and LAR on the individual's behalf, if applicable) must be involved in all aspects of planning the individual's treatment. If the individual has requested the involvement of a family member, then the provider must attempt to involve the family member in all aspects of planning the individual's treatment.(2) The treatment plan must identify services to be provided and must include measurable outcomes that address COPSD.(3) The treatment plan must identify the LAR's or family members' need for education and support services related to the individual's mental illness and substance abuse and a method to facilitate the LAR's or family members' receipt of the needed education and support services.(4) The individual, LAR, and, if requested, family member, must be given a copy of the treatment plan.(c) Treatment plan review. Each individual's treatment plan must be reviewed in accordance with DSHS-defined timeframes and the review must be documented.(d) Progress notes. The medical record notes must contain a description of the individual's progress towards goals identified in the treatment plan, as well as other clinically significant activities or events.(e) Episode of care summary. Upon discharge or transfer of an individual from one entity to another, the individual's medical record must identify the services provided according to this subchapter and the items referenced in §412.322 (relating to Provider Responsibilities for Treatment Planning and Service Authorization) of Chapter 412, Subchapter G of this title, governing Mental Health Community Services Standards. Source Note: The provisions of this §306.19 adopted to be effective September 7, 2003, 28 TexReg 7396; amended to be effective November 17, 2011, 36 TexReg 7669; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 467. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM A STANDARDS FOR SERVICES TO INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE USE DISORDERS (COPSD) §306.19 Screening, Assessment, and Treatment Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205060 03/12/2026 The purpose of this subchapter is to establish standards to ensure the proper care and treatment of individuals with a mental illness or serious emotional disturbance who are receiving services in crisis stabilization units licensed in accordance with Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units) and Texas Health and Safety Code Chapter 577. Source Note: The provisions of this §306.41 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.41 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205059 03/12/2026 This subchapter applies to crisis stabilization units licensed in accordance with Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units) and Texas Health and Safety Code Chapter 577. Source Note: The provisions of this §306.43 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.43 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224544 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Administrator--A person or entity that has authority to represent a facility and is responsible for implementing and supervising its administrative policies and procedures and for administratively supervising the provision of services to individuals on a day-to-day basis. (2) Administrator's designee--A staff member designated in a facility's written policies and procedures to act for a specified purpose on behalf of the administrator. (3) Admission--The acceptance of an individual for crisis stabilization services based on a physician's order issued in accordance with §306.55 (relating to Voluntary Admission Criteria and Intake Process) and §306.57 (relating to Involuntary Admission Criteria and Intake Process) of this subchapter. (4) Admission examination--A psychiatric examination and physical assessment conducted by a physician, to determine if an individual requesting voluntary admission to an inpatient mental health facility meets clinical criteria for admission, in accordance with Texas Health and Safety Code §572.0025(f). (5) Adolescent--An individual at least 13 years of age, but younger than 18 years of age. (6) Adult--An individual 18 years of age or older. (7) Adult caregiver--An adult person whom a parent has authorized to provide temporary care for a child, as defined in Texas Family Code §34.0015(1). (8) APRN--Advanced practice registered nurse. A registered nurse licensed by the Texas Board of Nursing and as provided in Texas Occupations Code §301.152. (9) Assessment--The administrative process an inpatient mental health facility uses to gather information from an individual to determine if the admission is clinically justified, in accordance with Texas Health and Safety Code §572.0025(h)(2), including a medical history and the problem for which the individual is seeking treatment. (10) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021. (11) Child--An individual at least three years of age, but younger than 13 years of age. (12) Confidential information--Any communication or record (whether oral, written, electronically stored or transmitted, or in any other form) that consists of or includes any or all of the information that must be protected from unauthorized use or disclosure as required by applicable state or federal laws, and as defined in 1 TAC §390.1(5) (relating to Definitions). (13) Crisis stabilization services--Short-term residential treatment designed to reduce acute symptoms of a mental illness or serious emotional disturbance of an individual and prevent admission of the individual to an inpatient mental health facility. (14) CSU--Crisis stabilization unit. A short-term residential treatment unit designed to reduce an individual's acute symptoms of mental illness or serious emotional disturbance instead of admission to an inpatient mental health facility, licensed in accordance with Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units) and Texas Health and Safety Code Chapter 577. (15) Day--Calendar day, unless otherwise specified. (16) DD--Developmental disability. As listed in Texas Health and Safety Code §531.002(15), a severe, chronic disability attributable to mental or physical impairment or a combination of mental and physical impairments that: (A) manifest before the individual reaches 22 years of age; (B) are likely to continue indefinitely; (C) reflect the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of a lifelong or extended duration and are individually planned and coordinated; and (D) result in substantial functional limitations in three or more of the following categories of major life activity: (i) self-care; (ii) receptive and expressive language; (iii) learning; (iv) mobility; (v) self-direction; (vi) capacity for independent living; and (vii) economic self-sufficiency. (17) Discharge--The formal release of an individual from the custody and care of an inpatient mental health facility in accordance with Texas Health and Safety Code §572.004. (18) Emergency medical condition--In accordance with the Emergency Medical Treatment & Labor Act (42 U.S.C. §1395dd) (Relating to examination and treatment for emergency medical conditions and women in labor), a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: (A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (B) serious impairment to bodily functions; (C) serious dysfunction of any bodily organ or part; or (D) in the case of a pregnant woman having contractions: (i) inadequate time to arrange a safe transfer to a hospital before delivery; or (ii) a transfer posing a threat to the health or safety of the woman or the unborn child. (19) General hospital--A hospital operated primarily to diagnose, care for, and treat individuals who are physically ill and licensed in accordance with Texas Health and Safety Code Chapter 241. (20) HHSC--Texas Health and Human Services Commission or its designee. (21) ID--Intellectual disability. Consistent with Texas Health and Safety Code §591.003, significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and originates during the developmental period. (22) IDT--Interdisciplinary team. A group of licensed, credentialed, and unlicensed staff members who possess the knowledge, skills, and expertise to develop and implement an individual's treatment or recovery plan and also includes: (A) the individual's treating physician; (B) the individual, and the individual's LAR or adult caregiver, if applicable; (C) the staff members identified in the treatment or recovery plan as responsible for providing or ensuring the provision of each treatment in accordance with §568.61(c)(1)(E)(iii) of this title (relating to Inpatient Mental Health Treatment and Treatment Planning); (D) any person identified by the individual, and the individual's LAR or adult caregiver if applicable, unless clinically contraindicated; and (E) other staff members as clinically appropriate. (23) Individual--A person seeking or receiving services under this subchapter. (24) Inpatient mental health facility--A mental health facility that can provide 24-hour residential and psychiatric services and that is: (A) a facility operated by HHSC; (B) a private mental hospital licensed by HHSC; (C) a community center, facility operated by or under contract with a community center or other entity HHSC designates to provide mental health services; (D) an identifiable part of a general hospital in which diagnosis, treatment, and care for individuals with mental illness is provided and that is licensed by HHSC; or (E) a hospital operated by a federal agency. (25) Intake--The administrative process for gathering information about an individual and giving an individual information about an inpatient mental health facility and the facility's treatment and services, in accordance with Texas Health and Safety Code §572.0025(h)(3). (26) Involuntarily-admitted individual--An individual receiving inpatient mental health facility services based on an admission made in accordance with: (A) Texas Health and Safety Code Chapter 573 and described in §306.57(a) of this subchapter; or (B) Texas Health and Safety Code §574.021 and described in §306.57(f) of this subchapter. (27) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual regarding a matter described in this subchapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (28) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356. (29) Legal holiday--A holiday listed in the Texas Government Code §662.021 and an officially designated county holiday applicable to a court in which proceedings under the Texas Mental Health Code are held. (30) LIDDA--Local intellectual and developmental disability authority. An entity designated as the local intellectual and developmental disability authority by HHSC in accordance with Texas Health and Safety Code §533A.035. (31) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a). (32) LPHA--Licensed practitioner of the healing arts. A person who possesses any of the following state licenses is considered an LPHA and is automatically certified as a qualified mental health professional-community services (QMHP-CS): (A) a physician; (B) a physician assistant; (C) an APRN; (D) a licensed psychologist; (E) a licensed professional counselor; (F) a licensed clinical social worker; or (G) a licensed marriage and family therapist. (33) LVN--Licensed vocational nurse. A person licensed as a vocational nurse by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301. (34) Medical director--A physician who is board eligible or certified in psychiatry by the American Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry and who provides clinical and policy oversight for the CSU. (35) Medical record--A compilation of systematic and organized information relevant to the services provided to an individual. (36) Medical services--Acts or services provided by a physician acting as described in Texas Occupations Code Chapter 151, or as delegated by a physician, in accordance with Texas Occupations Code Chapter 157. (37) Mental illness--An illness, disease, or condition, other than a sole diagnosis of epilepsy, dementia, substance use disorder, ID, or DD that: (A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or (B) grossly impairs behavior as demonstrated by recent disturbed behavior. (38) Monitoring--One or more staff members observing an individual in person continuously or at pre-determined intervals; as ordered by a physician or physician-delegated physician's assistant (PA) or APRN; or by established protocol; and intervening when necessary to protect the individual from harming self or others. (39) Nursing facility--A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code Chapter 242. (40) Nursing services--Acts or services provided by a registered nurse (RN) acting within the RN's scope of practice and assigned to an LVN, or delegated to an unlicensed person, in accordance with Texas Occupations Code Chapter 301. (41) Nursing staff--A person required to be licensed in accordance with Texas Occupations Code Chapter 301 to engage in professional or vocational nursing or the person delegated to perform common nursing functions under the authority of an RN. (42) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by Texas Government Code §547.0002, which serves as a neutral party to help individuals, including individuals who are uninsured or have public or private health benefit coverage and behavioral health care providers navigate and resolve issues related to the individual's access to behavioral health care, including care for mental health conditions and substance use disorders. (43) PA--Physician's assistant. A person licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners in accordance with Texas Occupations Code Chapter 204. (44) PASRR--Preadmission screening and resident review. (45) PASRR Level I screening--The process of screening an individual seeking admission to a nursing facility to identify whether the individual is suspected of having a mental illness, ID, or DD. (46) PASRR Level II evaluation--A face-to-face evaluation: (A) of an individual seeking admission to a nursing facility who is suspected of having a mental illness, ID, or DD; and (B) performed by a LIDDA, LHMA, or LBHA to determine if the individual has a mental illness, ID, or DD and, if so, to: (i) assess the individual's need for care in a nursing facility; (ii) assess the individual's need for specialized services; and (iii) identify alternate placement options. (47) Peer specialist--A person who uses lived experience, in addition to skills learned in formal training, to deliver strengths-based, person-centered services to promote an individual's recovery and resiliency, in accordance with 1 TAC Chapter 354, Subchapter N (relating to Peer Specialist Services). (48) Physician--A staff member: (A) licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code Chapter 155; or (B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board. (49) Pre-admission screening--The clinical process used by a QMHP-CS or LPHA to gather information from an individual, including a medical history, any history of substance use, trauma, and the problem for which the individual is seeking treatment to determine if a physician should conduct an admission examination. (50) Preliminary examination--The psychiatric examination and assessment for medical stability performed and documented by a physician in accordance with Texas Health and Safety Code §573.022 to determine if emergency detention in an inpatient mental health facility is clinically justified for an individual for whom: (A) an application for emergency detention is filed in accordance with Texas Health and Safety Code §573.011; (B) a peace officer or emergency medical services personnel of an emergency medical services provider transporting the individual in accordance with a memorandum of understanding executed in accordance with Texas Health and Safety Code §573.005 files a notification of detention completed by the peace officer in accordance with Texas Health and Safety Code §573.002(a); or (C) the LAR transporting their adult ward, without the assistance of a peace officer, in accordance with Texas Health and Safety Code §573.003, files an application for detention in accordance with Texas Health and Safety Code §573.004. (51) Psychosocial rehabilitative services--Services that assist an individual in regaining and maintaining daily living skills required to function effectively in the community. (52) QMHP-CS--Qualified mental health professional-community services. A staff member who is credentialed as a QMHP-CS who has demonstrated and documented competency in the work to be performed and: (A) has a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; (B) is an RN; or (C) completes an alternative credentialing process as determined by an LMHA or LBHA in accordance with HHSC requirements. (53) Recovery--A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. (54) Recovery or treatment plan--A written plan: (A) is developed in collaboration with the individual, and the individual's LAR or adult caregiver if applicable, and a QMHP-CS or LPHA; (B) is amended at any time based on an individual's needs or requests; (C) guides the recovery process and fostering resiliency; (D) is completed in conjunction with the assessment tool adopted by HHSC; (E) identifies the individual's changing strengths, capacities, goals, preferences, needs, and desired outcomes; and (F) includes recommended services and supports or reasons for the exclusion of services and supports. (55) Restraints--Any personal, mechanical, or chemical restraint defined in 25 TAC §415.253 (relating to Definitions). (56) RN--Registered nurse. A staff member licensed as a registered nurse by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301. (57) Screening--Activities performed by a QMHP-CS to: (A) collect triage information either in person, or through telephone or telehealth interviews with an individual or collateral contact; (B) determine if the individual's need is emergent, urgent, or routine, and conducted before the in person or telehealth assessment to determine the need for emergency services; and (C) determine the need for immediate assessment and mental health treatment recommendations. (58) Seclusion--The involuntary separation of an individual from other individuals for any period of time and or the placement of the individual alone in an area from which the individual is prevented from leaving, as defined in 25 TAC §415.253(28). (59) SED--Serious emotional disturbance. A diagnosed mental health disorder that substantially disrupts a child's or adolescent's ability to function socially, academically, and emotionally in accordance with Texas Government Code §547.0051. (60) Serious physical injury--An injury determined by a physician, or physician-delegated PA or APRN, to require treatment by an appropriately licensed medical professional or licensed healthcare professional, or in an emergency department or licensed hospital. (61) Stabilize--With respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the individual's transfer from a facility or, if the emergency medical condition for a woman is that she is in labor, that the woman has delivered the child and the placenta. (62) Staff member--Personnel including a full-time and part-time employee, contractor, or intern, but excluding a volunteer. (63) Staffing plan--A written plan that: (A) demonstrates the number, qualifications, and responsibilities of staff members, including the administrator or designee, are appropriate for the size and scope of the services provided and that workloads are reasonable to meet the needs of individuals receiving services; and (B) identifies staffing patterns, hours of coverage, and plans for providing back-up staff in emergencies. (64) Substance use disorder--The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which meets the criteria described in the current edition of the Diagnostic Statistical Manual of Mental Disorders for substance use disorders. (65) TAC--Texas Administrative Code. (66) Telehealth service--A health-care service, other than telemedicine medical services, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional's license, certification or entitlement to an individual at a different physical location other than the health professional using telecommunications or information technology, in accordance with Texas Occupation Code §111.001(3). (67) Telemedicine medical service--A health-care service delivered to an individual at a different physical location using telecommunications or information technology by: (A) a physician licensed in Texas; or (B) a health professional who acts under the delegation and supervision of a physician licensed in Texas and within the scope of the health professional's license in Texas. (68) Transfer--The movement (including the discharge) of an individual outside a facility at the facility's direction, but it does not include such a movement of an individual who has been declared dead or leaves the facility without the facility's permission. (69) Treating physician--A physician who coordinates and oversees an individual's treatment. (70) Unit--A discrete and identifiable area of an inpatient mental health facility that includes individuals' rooms or other living areas and is separated from another similar area: (A) by a locked door; (B) by a floor; or (C) because the other similar area is in a different building. (71) UP--Unlicensed person. A person, not licensed as a health care provider, who provides certain health related tasks and functions in a complementary or assistive role to the RN in providing direct care of an individual or carrying out common nursing functions as described in 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments) and care in conformity with this chapter: (A) who is monetarily compensated, including nurse aides, assistants, attendants, technicians, and other individuals providing care or assistance of health-related services; or (B) who is a professional nursing student, not licensed as an RN or LVN, providing care for monetary compensation and not as part of their formal education. (72) Voluntarily admitted individual--An individual receiving facility services based on an admission in accordance with: (A) §306.55 of this subchapter (relating to Voluntary Admission Criteria and Intake Process); or (B) §306.59 of this subchapter (relating to Voluntary Treatment Following Involuntary Admission). Source Note: The provisions of this §306.45 adopted to be effective May 27, 2021, 46 TexReg 3257; amended to be effective April 1, 2025, 50 TexReg 2207. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.45 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205062 03/12/2026 (a) The CSU must be open and provide services to individuals 24-hours a day, seven days a week, including admissions, based on the CSU's capability and capacity.(b) The CSU must develop, and the medical director must approve, the CSU's written policies and procedures that ensure the CSU's compliance with this subchapter.(c) All staff members must comply with this subchapter and the policies and procedures of the CSU.(d) A CSU administrator, or administrator's designee must take appropriate measures to ensure a staff member's compliance with this subchapter and the policies and procedures of the CSU.(e) A CSU nursing supervisor must ensure all orders issued by a physician, or physician-delegated PA or APRN, for an individual are appropriately implemented pursuant to state nursing licensure requirements.(f) Except as provided by §306.51 of this subchapter (relating to Admission Criteria) or applicable state law, a physician may delegate any of the medical services described in this subchapter in accordance with Texas Occupations Code Chapter 157, Subchapter A.(g) A CSU must comply with the following HHSC rules:(1) Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units);(2) 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(3) 25 TAC Chapter 415, Subchapter A (relating to Prescribing Psychoactive medication);(4) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services);(5) 25 TAC Chapter 414, Subchapter I (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services);(6) 25 TAC Chapter 417, Subchapter K (relating to Abuse, Neglect and Exploitation in TDMHMR Facilities); and(7) 22 TAC Chapter 174, Subchapter B (relating to Mental Health Services).(h) A CSU physician is prohibited from administering:(1) electroconvulsive therapy, a treatment in which controlled, medically applied electrical current results in a therapeutic seizure, usually attenuated by anesthesia and muscle relaxants; and(2) a chemical or gaseous agent used to induce a seizure for therapeutic purposes, instead of, or as a substitute for, electroconvulsive therapy. Source Note: The provisions of this §306.47 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.47 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205058 03/12/2026 A CSU must develop and implement written admission criteria that:(1) the CSU medical director approves;(2) uniformly applies to all individuals;(3) permits the voluntary admission of an individual only if the following criteria are met:(A) the individual is authorized to do so in accordance with Texas Health and Safety Code §572.001;(B) the individual has a mental illness or SED;(C) the services provided in the CSU may reduce the individual's acute symptoms; and(D) the CSU provides clinically appropriate environmental restrictions and levels of monitoring, described in §306.87 of this subchapter (relating to Protection of an Individual Receiving Crisis Stabilization Unit Services), that:(i) ensures the safety of the individual; and(ii) prevent the individual from causing serious harm to self or others;(4) prevents voluntary admission of an individual who:(A) is not authorized to request admission in accordance with Texas Health and Safety Code §572.00 or does not have the capacity to consent to diagnosis, observation, care and treatment, as determined by a physician;(B) presents to the CSU for an emergency detention preliminary examination, in accordance with Texas Health and Safety Code §573; and(C) presents to the CSU on an order of protective custody or who has been committed to court-ordered inpatient mental health treatment in accordance with Texas Health and Safety Code, Chapter 574;(5) prevents voluntary or involuntary admission of an individual who:(A) requires specialized care not available at the CSU; or(B) has a physical medical condition that is unstable and could reasonably be expected to require immediate inpatient treatment for the condition;(6) allows temporary acceptance of an individual for whom an emergency detention application is filed, or for whom a peace officer has detained, by:(A) temporarily accepting an individual for preliminary examination for whom an application of detention has been filed initiating an emergency detention proceeding in accordance with Texas Health and Safety Code §573.021(a); or(B) filing an application and obtaining a written order of protective custody as part of an individual's evaluation for court-ordered Inpatient Mental Health Services in accordance with Texas Health and Safety Code Chapter 574, Subchapter B;(7) includes a process for attempts to gain consent for administration of psychoactive medications from an individual, and an individual's LAR or adult caregiver, as required by applicable law and rule. Source Note: The provisions of this §306.51 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.51 Admission Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205054 03/12/2026 (a) Pre-admission screening and assessment.(1) Before admission to a CSU, an individual must meet clinical criteria for admission, as determined by pre-admission screening and assessment.(2) An individual who voluntarily presents to the CSU may leave the CSU at any time during the pre-admission screening and assessment process before the individual's admission.(3) Pre-admission screening and assessment of an individual must:(A) occur either in the CSU or in the community at any location where mental health crisis services are provided; and(B) be provided by a QMHP-CS or LPHA trained in accordance with HHSC screening and assessment requirements policy and displaying competency in all domains of crisis screening and assessment in accordance with §301.331(b) of this title (relating to Competency and Credentialing).(b) CSU screening and assessment policy. CSU screening and assessment policy must include a process for:(1) accessing an individual's community-based screening and assessment; and(2) conducting CSU screenings that address the criteria for immediate:(A) assessment of risk of deterioration and danger to self and others;(B) medical screening and assessment; and(C) psychiatric examination;(3) ensuring an individual who is waiting for a physician examination remains in a location that is determined to be clinically appropriate and available; and(4) ensuring that an individual who presents to a CSU for pre-admission screening and assessment is afforded the protections in §306.87 of this subchapter (relating to Protection of an Individual receiving Crisis Stabilization Unit Services).(c) Screening. Pre-admission screening identifies the acuity of the individual's crisis episode and determines the need for further assessments, including assessments to determine risk of deterioration and immediate danger to self and others, in accordance with Texas Health and Safety Code §572.0025(f) and §573.021. The initial screening of an individual must lead to:(1) immediate and appropriate referrals; and(2) documentation that incorporates the following domains:(A) suicide risk screening;(B) homicide risk screening; and(C) risk of deterioration.(d) Assessment. If a pre-admission screening indicates an individual requires immediate assessment to determine risk of deterioration and immediate danger to self and others, the assessment must be conducted with the individual, either in person or through the use of telemedicine medical services or telehealth services in accordance with 22 TAC §174.9(2) (relating to Provision of Mental Health Services), and must include:(1) a suicide assessment that documents current and past suicide risks regarding suicidal ideation, plans, and past suicide attempts;(2) a psychosocial assessment that includes historical and current information including identification of social, psychological, environmental, and cultural factors that may be contributing to the emergency; and(3) a mental health assessment, documenting symptomology, functionality, historical and current diagnosis, and treatment for mental illnesses or serious emotional disturbances and, when available:(A) a review of records of past treatment;(B) a review of history from collateral sources as permitted by Health Insurance Portability and Accountability Act;(C) a consult with current healthcare providers;(D) a review of history of previous treatment and the response to that treatment, including a record of dose, response, side effects and adherence to past psychiatric medications; and(E) an up-to-date record of all medications currently prescribed, and the name of the physician or provider with prescriptive authority.(e) Physician examination. If a pre-admission assessment indicates an individual requires immediate physician examination to determine clinical need for CSU admission, the examination may not be delegated to a non-physician, in accordance with Texas Health and Safety Code §572.0025(f), and:(1) must be conducted with the individual, either in person or through telemedicine medical services, in accordance with Texas Health and Safety Code §572.0025(f) and §573.021; and(2) must include:(A) a physical examination consisting of an assessment for medical stability; and(B) a psychiatric examination. Source Note: The provisions of this §306.53 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.53 Pre-admission Screening and Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205055 03/12/2026 (a) CSU staff members, trained in accordance with §306.83(h) - (i) of this subchapter (relating to Staff Training), must conduct the intake and admission process in accordance with Texas Health and Safety Code §572.0025(e) and §572.0025(h)(3).(b) Voluntary admission into a CSU may be requested by:(1) an individual 16 years of age or older, in accordance with Texas Health and Safety Code §572.001;(2) the parent, managing conservator, or guardian of an individual younger than 18 years of age, in accordance with Texas Health and Safety Code §572.001 or Texas Family Code Chapter 35A;(3) the adult caregiver of an individual, who has obtained an order under Texas Family Code Chapter 35A when the individual is younger than 18 years of age; or(4) an individual with capacity to consent.(c) A request for admission must be made in accordance with Texas Health and Safety Code §572.001 and must:(1) be in writing and signed by the individual, and the individual's parent, adult caregiver, or LAR; and(2) include a statement that the individual:(A) has capacity to consent to the administration of psychoactive medication, administered in accordance with Texas Health and Safety Code §576.025;(B) agrees to voluntarily remain in the CSU until discharge; and(C) consents to diagnosis, observation, care and treatment until the earlier of one of the following occurrences:(i) the discharge of the individual; or(ii) the individual leaves the CSU after a request for discharge is made, in accordance with Texas Health and Safety Code §572.004.(d) Voluntary admission occurs only if:(1) a request for admission is made in accordance with subsection (c) of this section;(2) the individual receives pre-admission screening and assessment, in accordance with the CSU's written policies and procedures, to determine if a physician admission examination is required:(A) if the pre-admission screening and assessment is conducted by a physician, the physician may conduct the pre-admission screening and assessment as part of the physician admission examination referenced in §306.53(d) of this division (relating to Pre-admission Screening and Assessment); and(B) if the QMHP-CS or LPHA conducting pre-admission screening and assessment determines:(i) the individual does not need a physician admission examination, then the CSU may not admit the individual and must refer the individual to alternative services, as appropriate and available, including LMHA, LBHA, or LIDDA crisis services; or(ii) the individual does need a physician-admission examination, a physician must conduct an admission examination of the individual before CSU admission;(3) a physician in accordance with Texas Health and Safety Code §572.0025 (f):(A) conducts either in person or through telemedicine medical services, or consults with a physician who conducted, a physical assessment and psychiatric admission examination within 72 hours before or 24 hours after admission, as described in §306.53 of this division (relating to Pre-Admission Screening and Assessment), and may not delegate the examination to a non-physician; and(B) provides an admission order;(i) in writing and signed by the issuing physician; or(ii) if the order is provided orally or, if the electronic order is unsigned, an original signed order must be provided to the facility within 24 hours;(4) the administrator or administrator's designee has signed a written statement agreeing to admit the individual, in accordance with Texas Health and Safety Code §572.0025; and(5) a CSU staff member, trained in accordance with §306.83(i) of this subchapter, completes intake procedures in accordance with Texas Health and Safety Code §572.0025(e) and §572.0025(h)(3), that includes:(A) obtaining relevant information about the individual, including information about finances, insurance benefits, and advance directives;(B) explaining, orally and in writing, the individual's rights in a language and format easily understandable to the individual, or the individual's LAR or adult caregiver, as applicable;(C) explaining, orally and in writing, the CSU's services and treatment as they relate to the individual;(D) informing the individual, orally and in writing, of the existence, telephone number, and address of the protection and advocacy system established in Texas;(E) informing the individual of the availability of information and assistance from the Ombudsman by contacting the Ombudsman at 1-800-252-8154 or online at hhs.texas.gov/ombudsman, and the Health Facility Licensing complaints line at 1-888-973-0022; and(F) determining whether the individual comprehends the information provided in accordance with subparagraphs (B) - (E) of this paragraph.(e) An individual who is admitted to a CSU before the physical assessment and psychiatric admission examination is conducted must be discharged by the physician immediately if the physician conducting the physical assessment and psychiatric examination of the individual determines the individual does not meet the clinical standards to receive inpatient mental health services, in accordance with Texas Health and Safety Code §572.0025(f-1).(f) A CSU that discharges an individual under the circumstances described in (e) of this section may not bill the individual or the individual's third-party payor for the temporary admission of the individual to the CSU, in accordance with Texas Health and Safety Code §572.0025(f-2). Source Note: The provisions of this §306.55 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.55 Voluntary Admission Criteria and Intake Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205056 03/12/2026 (a) Criteria for involuntary admission under order of emergency detention. In accordance with Texas Health and Safety Code §573.021, a CSU administrator may accept an individual for a preliminary examination who is:(1) apprehended, and transported to the CSU by a peace officer, in accordance with Texas Health and Safety Code §573.001(a) and §573.005; or(2) an adult who is transported to the CSU by the individual's family member or LAR in accordance with Texas Health and Safety Code §573.003.(b) Preliminary examination under order of emergency detention. A physician must conduct an individual's preliminary examination in accordance with Texas Health and Safety Code §573.021 and as described in §306.53(d) of this division (relating to Pre-admission Screening and Assessment). The individual's preliminary examination must:(1) occur as soon as possible, but no later than 12 hours after:(A) the individual is apprehended by the peace officer; or(B) the individual's LAR transports the individual to the CSU for emergency detention; and(2) include:(A) an assessment for medical stability; and(B) a psychiatric examination to determine if the individual meets the criteria described in the emergency detention requirements listed in subsection (c) of this section.(c) Requirements for emergency detention. When clinically indicated, a CSU physician may initiate an emergency detention proceeding in accordance with Texas Health and Safety Code §572.004(d). A CSU physician may admit an individual for emergency detention in accordance with Texas Health and Safety Code §573.022(a)(2), only if:(1) a physician determines from the preliminary examination that:(A) the individual has a mental illness;(B) the individual evidences a substantial risk of serious harm to self or others;(C) the described risk of harm is imminent unless the individual is immediately detained; and(D) emergency detention is the least restrictive means by which the necessary detention may be accomplished;(2) a physician makes a written statement, in accordance with Texas Health and Safety Code §573.022 that:(A) documents the determination described in paragraph (1) of this subsection; and(B) describes:(i) the nature of the individual's mental illness or SED;(ii) the specific risk of harm to self or others the individual evidences, demonstrated either by behavior or evidence of severe emotional distress;(iii) the deterioration of mental condition to the extent that the individual cannot remain at liberty; and(iv) the detailed information on which the physician based the determination described in paragraph (1) of this subsection;(3) the physician writes an order admitting the individual for emergency detention based on the determination described in paragraph (1) of this subsection; and(4) the individual meets the CSU's admission criteria, as required by §306.51 of this division (relating to Admission Criteria).(d) Release of an individual from emergency detention.(1) A CSU administrator, or administrator's designee, must release an individual accepted for a preliminary examination if:(A) a preliminary examination of the individual has not been conducted within 12 hours, in accordance with Texas Health and Safety Code §573.021; or(B) the individual is not admitted to the CSU under order of emergency detention on completion of the preliminary examination in accordance with Texas Health and Safety Code §573.023(a).(2) A CSU administrator, or administrator's designee, must release an individual determined ineligible for admission under emergency detention in accordance with the requirements in Texas Health and Safety Code §576.007. Before releasing an individual, the CSU must:(A) make a reasonable effort to notify the individual's LAR, if applicable, and any other person authorized by the individual of the individual's release;(B) document the individual's refusal of notification in the individual's medical record, if applicable; and(C) coordinate with the individual, the individual's LAR, if applicable, or the apprehending county to arrange the individual's transportation after release, in accordance with Texas Health and Safety Code §573.024(a) - (d), to:(i) the location of the individual's apprehension;(ii) the individual's residence in this state; or(iii) another suitable location identified by the individual or LAR, if applicable.(e) Intake under Emergency Detention. A CSU staff member, trained in accordance with §306.83(h) - (i) of this subchapter (relating to Staff Training), must:(1) conduct the intake of an individual as soon as possible, but no later than 24 hours after the time an individual is apprehended for emergency detention, as described in §306.55 of this division (relating to Voluntary Admission Criteria and Intake Process; and(2) advise the individuals of their rights and determine whether the individual comprehends the rights for individuals apprehended, detained, or transported for emergency detention provided in accordance with Texas Health and Safety Code §573.025 and consent rights and information described in §306.51 and §306.55 of this division, and if the staff member determines that the individual:(A) comprehends the information, the CSU must document in the individual's medical record the reasons for such determination; or(B) does not comprehend the information, the staff member must:(i) repeat the explanation to the individual daily within 24-hour intervals until the individual demonstrates comprehension of the information or is discharged, whichever occurs first; and(ii) document in the individual's medical record the individual's response to each explanation and whether the individual demonstrated comprehension of the information.(f) Criteria for involuntary admission under an order of protective custody.(1) When clinically indicated, a CSU physician may initiate an application to request an order of protective custody of an individual in accordance with Texas Health and Safety Code §574.021.(2) A CSU physician may admit an individual under an order of protective custody only if a court has issued a protective custody order in accordance with Texas Health and Safety Code §574.022.(g) Intake under order of protective custody.(1) A CSU staff member trained in accordance with §306.83(h) - (i) of this subchapter:(A) must conduct an intake of an individual, as described in §306.55(d)(5)(A) - (D) and §306.55(d)(5)(F) of this division, as soon as possible, but no later than 24 hours after the time an individual is accepted for protective custody; and(B) advise the individual of their rights in accordance with Texas Health and Safety Code §573.0025 and determine whether the individual comprehends the rights and consent information described in §306.51 of this division and §306.55(d)(5) of this division.(2) If the CSU staff member determines that the individual:(A) comprehends the information, the staff member must document in the individual's medical record the reasons for such determination; or(B) does not comprehend the information, the staff member must:(i) repeat the explanation to the individual daily until the individual demonstrates comprehension of the information or is discharged, whichever occurs first; and(ii) document in the individual's medical record the individual's response to each explanation and whether the individual demonstrated comprehension of the information.(3) A CSU staff member is not required to conduct another intake if the intake was conducted when the individual was admitted, or within 24 hours before the issuance of the order of protective custody. Source Note: The provisions of this §306.57 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.57 Involuntary Admission Criteria and Intake Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205057 03/12/2026 A CSU may provide crisis stabilization services to an individual who was involuntarily admitted in accordance with §306.57(a) and (f) of this division (relating to Involuntary Admission Criteria and Intake Process) if:(1) the individual no longer meets the involuntary treatment criteria described in §306.79 of this subchapter (relating to Discharge of an Involuntarily-Admitted Individual);(2) the individual submits a written request to the CSU treating physician for voluntary crisis stabilization services, as described in §306.55 of this division (relating to Voluntary Admission Criteria and Intake Process); and(3) the individual's treating physician examines the individual and, based on that examination, writes an order for voluntary crisis stabilization services that meets the requirements of §306.51 of this division (relating to Admission Criteria). Source Note: The provisions of this §306.59 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.59 Voluntary Treatment Following Involuntary Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205063 03/12/2026 (a) A CSU physician, or physician-delegated PA or APRN, must provide an individual with the medical services documented in the individual's recovery or treatment plan developed in accordance with §306.65 of this division (relating to Crisis Stabilization Services and Recovery or Treatment Planning).(b) A CSU must have a medical director who directs, monitors, and evaluates the psychiatric services provided.(c) A CSU administrator, or administrator's designee, must assign a treating physician to each individual and document the assignment in the individual's medical record at the time the CSU administrator, or administrator's designee, admits the individual.(d) A physician, PA, APRN, or RN must perform an individual's initial physical health assessment within 24 hours after the individual's presentation, as ordered. The physical assessment includes:(1) an evaluation and documentation of the presence or absence of cognitive signs suggesting delirium and the need for emergency intervention;(2) a general medical history that addresses conditions that may affect the individual's current condition, including a review of symptoms focused on conditions (such as a history of trauma) that may present with psychiatric symptoms or cause cognitive impairment;(3) a review of medical conditions that may cause similar psychiatric symptoms or complicate the individual's condition; and(4) access to phlebotomy and laboratory results.(e) A physician must conduct an initial psychiatric evaluation of an individual, including:(1) a description of the individual's medical history;(2) a determination of the individual's mental status;(3) a description of the presenting problems, the onset, and the duration and severity of mental health or substance use disorder symptoms leading to CSU admission;(4) an estimation of the individual's intellectual functioning, memory functioning and orientation;(5) a description of the individual's strengths and needs; and(6) the diagnoses of the individual's mental illness, SED, and if applicable, any substance use disorders, ID, or DD.(f) A physician, or physician-delegated PA or APRN, must re-evaluate the individual once every 96 hours or more often as clinically indicated after the initial examination described in subsection (e) of this section. This re-evaluation information may be included in the physician's, APRN's, or PA's discharge summary if the individual is discharged within the initial 96-hour period, as described in §306.71(b) of this subchapter (relating to Discharge Planning).(g) A CSU medical director must ensure, as appropriate under the circumstances:(1) the provision of medical services to an individual in response to an emergency medical condition in accordance with the plan required by §306.89 of this subchapter (relating to Crisis Stabilization Unit Response to an Emergency Medical Condition);(2) the provision of other medical services, as needed by the individual;(3) the referral of the individual to an appropriate health care provider; or(4) the transfer of the individual to a health care entity that can provide the medical services.(h) At least one physician, or physician-delegated PA or APRN, must be available 24 hours a day, 365 days a year, either in person or by telecommunication, to provide medical consultation to staff members in accordance with §306.85 of this subchapter (relating to Minimum Staffing Requirements). Source Note: The provisions of this §306.61 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.61 Crisis Stabilization Unit Medical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205064 03/12/2026 (a) Nursing services in treatment plan. CSU nursing staff must provide nursing services to an individual in accordance with the individual's recovery or treatment plan developed in accordance with §306.65 of this division (relating to Crisis Stabilization Services and Recovery or Treatment Planning).(b) Nursing supervisor. A CSU must have a nursing supervisor who is an RN and who directs, monitors, and evaluates the nursing services provided.(c) Assessment. An RN must conduct and complete an individual's initial comprehensive nursing assessment within eight hours before or after the individual's admission.(d) Evaluation or reassessment.(1) An individual must receive a documented nursing evaluation or reassessment based on the individual's needs:(A) at least 12 hours following the initial comprehensive nursing assessment required in subsection (c) of this section; and(B) at recurring 12-hour intervals until the individual's discharge.(2) If an LVN conducts the individual's evaluation at a 12-hour interval, an RN must reassess the individual at least every 24 hours after the initial comprehensive nursing assessment is conducted.(e) Verification of licensure. A CSU nursing supervisor must verify that a member of the nursing staff, for whom a license is required, has a valid license at the time the staff member assumes responsibilities at the CSU and maintains the license throughout the staff member's employment with the CSU. Source Note: The provisions of this §306.63 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.63 Crisis Stabilization Unit Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205065 03/12/2026 (a) A CSU staff member must provide an individual crisis stabilization services under the direction of a physician and in accordance with the individual's recovery or treatment plan and the service requirements. Such treatment includes medical services and nursing services described in §306.61 of this division (relating to Crisis Stabilization Unit Medical Services) and §306.63 of this division (relating to Crisis Stabilization Unit Nursing Services).(b) Nursing staff must develop and implement an initial or preliminary nursing care plan within the first 24 hours after admission. This plan must be based on the findings of the initial comprehensive nursing assessment and any pre-admission assessment information that is available at the time of admission.(c) The IDT must collaborate in developing the individual's recovery or treatment plan based on the findings of:(1) the individual's physical examination identified in §306.63 of this division;(2) the individual's psychiatric evaluation identified in §306.61 of this division;(3) the individual's initial comprehensive nursing assessment identified in §306.63 of this division;(4) an assessment of the individual's risk of harm to self or others, identified in §306.53 of this subchapter (relating to Pre-Admission Screening and Assessment); and(5) the psychosocial assessment identified in §306.53 of this subchapter.(d) The recovery or treatment plan must contain:(1) a list of all the individual's diagnoses with notation as to which diagnoses will be treated at the CSU, including:(A) at least one mental illness or SED diagnosis according to the current edition of the Diagnostic and Statistical Manual of Mental Disorders;(B) any substance use disorder diagnosis according to the current edition of the Diagnostic and Statistical Manual of Mental Disorders; and(C) any non-psychiatric conditions;(2) a description of all treatment interventions intended to address the individual's condition, including:(A) all medications prescribed and the symptoms each medication is intended to address;(B) psychosocial rehabilitative services;(C) counseling or psychotherapies; and(D) peer specialist services, as available, and in accordance with 1 TAC §354.3013 (relating to Services Provided);(3) a documented level of monitoring assigned to the individual by the physician, or physician-delegated PA or APRN;(4) an identification of additional assessments and evaluations to be conducted, including:(A) risk of harm to self or others;(B) history of trauma; and(C) emerging health issues;(5) a description of any potential barriers to the individual's discharge; and(6) a description of any medical or nursing services.(e) A member of the IDT reviews the recovery or treatment plan and evaluates its effectiveness:(1) at least 72 hours after being implemented; or(2) any time there is a change in the individual's condition based on:(A) a medical re-evaluation described in §306.61 of this division;(B) a nursing reassessment described in §306.63 of this division;(C) a request by the individual, or the individual's LAR or adult caregiver, as applicable; or(D) receiving information regarding recommended services and supports needed by the individual after discharge.(f) A member of the IDT discusses all revisions with the individual, and the individual's adult caregiver or LAR, as necessary, to obtain feedback and agreement from the individual, and the individual's LAR or adult caregiver, as applicable, before implementing the individual's revised recovery or treatment plan. Source Note: The provisions of this §306.65 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.65 Crisis Stabilization Services and Recovery or Treatment Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205066 03/12/2026 (a) In addition to the service requirements in this division, a child or adolescent must receive additional assessments, including a developmental assessment and history of trauma assessment, performed by an LPHA with appropriate training and experience in the assessment and treatment of children in a crisis setting. The assessments must:(1) be administered in person or through telehealth or telemedicine medical services; and(2) include the individual's parents, LAR, or adult caregiver, as applicable and as clinically appropriate according to the child's or adolescent's age, functioning, and current living situation.(b) Services delivered to a child or an adolescent must be:(1) age-appropriate;(2) developmentally appropriate;(3) trauma-informed; and(4) consistent with the child's or adolescent's academic development.(c) Children must be separated from adolescents, based on age and developmental needs, unless there is clinical or developmental justification in the child or adolescent's medical record. Both children and adolescents must be separated from adults, required in §306.87(d) of this subchapter (relating to Protection of an Individual Receiving Crisis Stabilization Unit Services).(d) Education services must be available as required by the Texas Education Agency.(e) When a child or adolescent surpasses the maximum age for their current unit or CSU, the unit or CSU administrator, or administrator's designee, must transition the child or adolescent to a different age-appropriate unit or CSU. Source Note: The provisions of this §306.67 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.67 Additional Standards of Care for Children and Adolescents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205067 03/12/2026 (a) A QMHP-CS or LPHA must begin discharge planning for an individual at the time of the individual's admission.(1) Discharge planning must involve the individual, the IDT, the individual's LAR or adult caregiver, as applicable, and any other person authorized by the individual and the individual's adult caregiver or LAR if applicable, unless clinically contraindicated.(2) Discharge planning must be provided in accordance with §510.41(m)(3) of this title (relating to Facility Functions and Services) and include:(A) the IDT recommendations for services and supports, including placement needs, that should be provided after discharge;(B) the IDT arrangements for the recommended services and supports;(C) a PASRR screening, as required by paragraph (3) of this subsection; and(D) the IDT post-discharge care information provided in a language and format easily understandable to the individual, and the individual's LAR or adult caregiver, if applicable.(3) An individual considered for discharge from the CSU to a Medicaid-certified nursing facility must have a PASRR Level I screening completed, in accordance with the Code of Federal Regulations, Title 42, Part 483, Subpart B (relating to Requirements for Long-Term Care Facilities) before discharge; and(4) if the screening indicates that the individual has a mental illness, ID, or DD, the CSU staff member coordinating the individual's transfer must contact and arrange for the designated LMHA, LBHA, or LIDDA to conduct a PASRR Level II evaluation of the individual before CSU discharge, in accordance with Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)).(b) The individual's treating physician must prepare a written discharge summary that includes:(1) a description of the individual's treatment at the CSU and the response to that treatment;(2) a description of the individual's condition at discharge;(3) a description of the individual's placement after discharge;(4) a description of the services and supports the individual will receive after discharge;(5) a final diagnosis based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders; (6) a description, including dosage instructions, of the prescribed medications the individual will need until the individual is evaluated by a physician, or provider with prescriptive authority; and(7) the name of the person or entity responsible for providing and paying for the medication referenced in paragraph (6) of this subsection, which is not required to be the CSU.(c) The CSU staff member coordinating the individual's discharge must provide a copy of the discharge summary as authorized by state and federal law, to LMHA, LBHA, LIDDA, or other community providers and consult with them to ensure continuity of care for the individual upon discharge from the CSU.(d) The CSU staff member coordinating the individual's discharge must contact and coordinate with the individual's existing service providers and in accordance with the Health Insurance Portability and Accountability Act or other law prior to the individual's discharge. (e) If the individual, or the individual's LAR, adult caregiver, or others authorized by the individual, refuse to participate in the discharge planning, the CSU staff member coordinating the individual's discharge must document the circumstances of the refusal in the individual's medical record.(f) If extremely hazardous weather conditions exist or a disaster occurs, the physician may request the presiding judge or magistrate of a court that has jurisdiction over proceedings brought in accordance with Texas Health and Safety Code Chapter 574 to extend the period during which the individual may be detained in accordance with Texas Health and Safety Code §572.004(e). Source Note: The provisions of this §306.71 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.71 Discharge Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205068 03/12/2026 (a) The CSU staff member coordinating the individual's discharge must notify the parent, LAR, or adult caregiver of the pending discharge of a child or adolescent, unless clinically contraindicated, in accordance with §568.82(b) of this title (relating to Discharge Notices and Release of Minors). If the treatment team believes notifying the individual's parent, LAR, or adult caregiver is clinically contraindicated, CSU staff must notify Texas Department of Family Protective Services.(b) In accordance with Texas Health and Safety Code §576.007, before discharging any adult, the CSU staff member coordinating the individual's discharge must make a reasonable effort to notify the individual's LAR, adult caregiver, and others authorized by the individual and LAR or adult caregiver, of the discharge if the individual, LAR, or adult caregiver grants permission for the notification.(c) Upon discharge, the CSU staff member coordinating the individual's discharge must provide the individual with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, in accordance with 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services) and required by Texas Health and Safety Code §576.008. Source Note: The provisions of this §306.73 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.73 Discharge Notices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205069 03/12/2026 (a) In accordance with 25 TAC Chapter 404, Subchapter E, all individuals voluntarily admitted to a CSU for treatment of mental illness or SED have the right to be discharged within four hours of a request for release unless the individual's treating physician, (or another physician, if the treating physician, is not available) determines that there is cause to believe the individual might meet the criteria for emergency detention.(b) When a CSU staff member is informed that a voluntarily-admitted individual wants to leave the CSU, or the individual's LAR or adult caregiver requests the individual be discharged, the CSU staff member must, in accordance with Texas Health and Safety Code §572.004 and 25 TAC Chapter 404, Subchapter E:(1) inform the individual, and the individual's LAR or adult caregiver, if applicable, that the request must be in writing and signed, timed, and dated by the requestor; if the request for discharge is verbal, then the four hours begins at the time of a verbal request and must be documented in the medical record. Inform the individual or the individual's LAR of the potential four-hour delay from the time of the verbal request;(2) assist the individual as soon as possible, with documenting the verbal request for discharge or creating a written request for discharge and presenting the request to the individual for the individual's signature; and(3) inform the LAR or adult caregiver to submit written approval to the CSU administrator, or administrator's designee, for the CSU treating physician to discharge an individual younger than 18 years of age if the LAR or adult caregiver signed for the individual's admission to the CSU.(c) If a voluntarily-admitted individual, or the individual's LAR or adult caregiver, if applicable, submits a verbal or written request for discharge from a CSU, the CSU staff member must:(1) immediately notify the treating physician, or another CSU physician if the treating physician is not available, of the request after the request becomes known to the CSU; and(2) file the request in the individual's medical record.(d) If the physician, notified in subsection (b) of this section, and in accordance with Texas Health and Safety Code §572.004, does not have reasonable cause to believe that the individual may meet the criteria for court-ordered inpatient mental health services or emergency detention, the treating physician must discharge the individual within the four-hour time frame described in subsection (b) of this section.(e) If the physician, notified in subsection (b) of this section, and in accordance with Texas Health and Safety Code §572.004, has reasonable cause to believe that the individual may meet criteria for court-ordered inpatient mental health services or emergency detention, the physician must examine the individual as soon as possible, but no later than 24 hours after the individual requests discharge from the CSU.(1) If the physician conducting the examination described in this subsection determines that the individual does not meet criteria for court-ordered inpatient mental health services or emergency detention, the treating physician must discharge the individual upon completion of the examination.(2) If a physician does not examine an individual for involuntary treatment criteria within 24 hours after the individual requests CSU discharge, the treating physician must discharge the individual even if the physician believes the individual may meet criteria for court-ordered inpatient mental health services or emergency services.(f) If the physician conducting the examination described in subsection (e) of this section determines that the voluntarily-admitted individual meets the criteria for court-ordered inpatient mental health services or emergency detention, a CSU physician must, by 4:00 p.m. on the next business day, in accordance with Texas Health and Safety Code §572.004:(1) file an application for court-ordered inpatient mental health services or emergency detention within 24 hours after the individual requests discharge from the CSU, and obtain a court order for further detention of the individual; or(2) discharge the individual.(g) If the CSU treating physician intends to detain a voluntarily-admitted individual and file an application to obtain a court order for further detention of the individual, a physician must in accordance with Texas Health and Safety Code §572.004:(1) notify the individual of such intention; and(2) document the reasons for the decision to detain the individual in the individual's medical record.(h) A CSU treating physician is not required, in accordance with Texas Health and Safety Code §572.004, to complete the discharge process described in this section if the voluntarily-admitted individual makes a written statement to withdraw the request for discharge. Source Note: The provisions of this §306.75 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.75 Discharge of a Voluntarily-Admitted Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205070 03/12/2026 Except as allowed by paragraph (3) of this section, a CSU physician must discharge a voluntarily-admitted individual on the 14th day after the individual's admission, unless:(1) the individual's treating physician orders the individual's discharge before the 14th day;(2) the individual's treating physician orders the individual's transfer to other treatment or services, in accordance with §306.91 of this subchapter (relating to Transfers);(3) a physician, or physician-delegated PA or APRN, documents in the individual's medical record the medical necessity and clinical rationale for extending the length of stay beyond 14 days; or(4) an individual under 18 years of age was admitted under an order of Temporary Authorization, issued in accordance with Texas Family Code Section §35A.005(d), in which case the individual must be discharged by the tenth day after the date the order for temporary authorization is issued. Source Note: The provisions of this §306.77 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.77 Maximum Length of Stay for a Voluntarily-Admitted Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205071 03/12/2026 (a) Discharge from emergency detention.(1) Except as provided by §306.59 of this subchapter (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code §573.021 and §573.023, an involuntarily-admitted individual under emergency detention must be immediately discharged from a CSU if:(A) the administrator or the administrator's designee determines, based on a physician's determination, that the individual no longer meets the criteria described in subsection (b)(1) of this section; or(B) except as provided in subsection (b) of this section, 48 hours have lapsed from the time the individual was presented to the CSU and the CSU has not obtained a court order for the individual's further detention.(2) In accordance with Texas Health and Safety Code §573.021(b), if the 48-hour period described in paragraph (1)(B) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the patient was presented to the CSU, the involuntarily-admitted individual may be detained until 4:00 p.m. on such business day.(3) In accordance with Texas Health and Safety Code §573.021(b), the 48-hour custody period described in paragraph (1)(B) of this subsection includes any time during which the individual in custody spends waiting in the CSU for medical care before receiving a preliminary examination.(b) Discharge under protective custody order. Unless an involuntarily-admitted individual consents to voluntary treatment, a CSU physician must immediately discharge the individual under an order of protective custody if:(1) the CSU administrator or designee determines that, based on a physician's determination, the individual no longer meets the criteria for protective custody described in Texas Health and Safety Code §574.022;(2) the CSU administrator or designee does not receive notice that the individual's continued detention is authorized after a probable cause hearing held within the time frame prescribed by Texas Health and Safety Code §574.025;(3) a final order for court-ordered inpatient mental health services has not been entered within the time frame prescribed by Texas Health and Safety Code §574.005; or(4) an order to release the individual is issued in accordance with Texas Health and Safety Code §574.028. Source Note: The provisions of this §306.79 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.79 Discharge of an Involuntarily-Admitted Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205072 03/12/2026 (a) A medical record must be maintained for each individual, in accordance with §510.41(g) of this title (relating to Facility Functions and Services). The medical record must include:(1) a signed voluntary commitment, signed order of protective custody or police officer's warrant, or a notice of detention;(2) a signed informed consent to treatment, including medication, or documentation of the individual's refusal;(3) documentation of the reasons the individual, LAR, family members, or other adult caregivers state the individual was admitted to the CSU;(4) justification for each mental illness or serious emotional disturbance diagnosis and any substance use disorder diagnosis;(5) the level of monitoring assigned and implemented for the individual, including any changes to the level of monitoring;(6) the individual's written recovery or treatment plan;(7) the name of the individual's treating physician;(8) written findings of the physical examination;(9) written findings of the psychiatric evaluation, the nursing assessment, and any other assessment of the individual conducted by a staff member, including any re-evaluation or re-assessment;(10) a summary of any revisions made to the written recovery or treatment plan;(11) the progress notes for the individual as described in subsection (b) of this section;(12) documentation of the individual's monitoring by UPs, LVNs, and any assigned staff members responsible for such monitoring, including observations of the individual at pre-determined intervals;(13) documentation of the discharge planning activities;(14) the discharge summary; and(15) documentation of the individual's medical, mental health, and substance use history.(b) Progress notes are required for each individual. A physician, a physician-delegated PA or APRN, or RN and any assigned staff members providing services to an individual must document the individual's progress and response to treatment provided in the individual's recovery or treatment plan. Source Note: The provisions of this §306.81 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.81 Medical Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205073 03/12/2026 (a) In accordance with §301.331 of this title (relating to Competency and Credentialing), a CSU administrator, or administrator's designee, must:(1) ensure that services are provided by staff members who are operating within their scope of their license, credentialing, job description, or contract specification, and in accordance with applicable state law and rule, including 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services);(2) define competency-based expectations for each CSU staff position and ensure each staff member receives initial training before the staff member assumes responsibilities required by the CSU and annually throughout the staff member's employment with the CSU; and(3) require all staff members to demonstrate required competencies delineated in §301.331(a)(3)(A) of this title, including:(A) identifying, preventing, and reporting abuse, exploitation, and neglect of individuals and unprofessional or unethical conduct, in accordance with 25 TAC §417.515 (relating to Staff Training in Identifying, Reporting, and Preventing Abuse, Neglect, and Exploitation);(B) an individual's dignity and rights, in accordance with 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services); and(C) protection of an individual's confidential information, in accordance with relevant state and federal laws, including 42 Code of Federal Regulations, Part 2.(b) All UPs and any direct care staff members providing services to an individual must receive training and instruction in the following topics and demonstrate critical competencies delineated in §301.331(a)(3)(B) of this title, before the staff member assumes responsibilities required by the CSU and annually throughout the staff member's employment with the CSU:(1) the implementation of the interdisciplinary treatment program for each individual before performing direct care duties without direct supervision; and(2) the specialized needs of child, adolescent, and geriatric individuals, and individuals diagnosed with an ID or DD.(c) An RN, LVN, and UP must receive training in:(1) monitoring for individual safety; and(2) infection control.(d) A CSU nursing supervisor or designee must provide orientation training to a nursing staff member when the CSU nursing supervisor initially assigns the staff member to a unit on either a temporary or long-term basis.(1) The orientation must include a review of:(A) the location of equipment and supplies on the unit;(B) the staff member's responsibilities on the unit;(C) relevant information about individuals on the unit;(D) relevant schedules of staff members and individuals; and(E) procedures for contacting the staff member's supervisor.(2) A CSU administrator, or administrator's designee, must document the provision of orientation to nursing staff.(e) A staff member routinely providing treatment to, working with, or providing consultation about a geriatric individual must receive training in the social, psychological, and physiological changes associated with aging.(f) A QMHP-CS or LPHA whose responsibilities include specialized services and tasks, including screening and assessment, must receive training in, and display specialty competencies for, tasks delineated in §301.331(a)(3)(C) of this title, before providing services for individuals and annually throughout the QMHP-CS's employment or association with the CSU.(g) QMHP-CS and LPHA training must include instruction, including:(1) age and developmentally appropriate clinical assessment, intervention, and engagement techniques;(2) use of telemedicine equipment;(3) developing and implementing an individualized treatment or recovery plan;(4) developing and implementing an individualized discharge plan and referring an individual to local community resources;(5) appropriate actions to take in a crisis; and(6) clinical specialties directly related to the services to be performed.(h) In accordance with Texas Health and Safety Code §572.0025(e), any staff member whose responsibilities include conducting an individual's intake must receive at least eight hours of intake training:(1) before conducting an intake; and(2) annually throughout the staff member's employment or association with the CSU.(i) For any staff member whose responsibilities include conducting an individual's intake, intake training must include instruction regarding:(1) obtaining relevant information about the individual, including information about finances, insurance benefits, and advance directives;(2) explaining, orally and in writing, the individual's rights;(3) explaining, orally and in writing, the CSU's services and treatment as they relate to the individual;(4) informing the individual in writing, of the existence, telephone number, and address of the protection and advocacy system established in Texas;(5) informing the individual about the availability of information and assistance from the Ombudsman by contacting the Ombudsman at 1-800-252-8154 or online at hhs.texas.gov/ombudsman, and the Health Facility Licensing complaints line at 1-888-973-0022; and(6) determining whether the individual comprehends the information provided in accordance with paragraphs (2) - (5) of this subsection.(j) A staff member who may initiate a restraint or seclusion must receive training in, and demonstrate competency in, performing such interventions in accordance with applicable law and rule, including 25 TAC §415.260 (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency), use of de-escalation techniques, and reporting requirements.(k) A staff member providing direct care must earn and maintain certification in Basic Life Support provided by the American Heart Association or the American Red Cross:(1) before assuming responsibilities at the CSU; or(2) no later than 30 days after the staff member is hired by the CSU if another staff member who has such certification is physically present and on duty on the same unit on which the uncertified staff member is on duty.(l) A CSU administrator, or administrator's designee must:(1) document when a staff member has successfully completed a training required by this section, including:(A) the date of the training;(B) the length of the training session; and(C) the name of the instructor.(2) Maintain certification or other evidence issued by the American Heart Association or the American Red Cross that a staff member has successfully completed the training in Basic Life Support.(m) A staff member must perform in accordance with required training and the staff member's credentials. Source Note: The provisions of this §306.83 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.83 Staff Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205074 03/12/2026 (a) A CSU nursing supervisor, or designee, must adhere to nurse staffing requirements delineated in §510.41(c)(8) and (j) of this title (relating to Facility Functioning and Services) and the following parameters when determining minimum staffing plans required by subsections (b) - (d) of this section.(1) Staff included in the minimum staffing plan must:(A) always be physically available while on duty; and(B) have job duties that do not prevent ongoing and consistent supervision of individuals receiving crisis stabilization services.(2) The minimum staffing plan must increase or decrease based on CSU census and acuity, individual level of monitoring and precautions, and developmental level, gender, age, and other individual needs and characteristics of individuals receiving crisis stabilization services.(3) A staff member on one-to-one supervision of an individual cannot be included in the CSU's minimum staffing plan.(b) The minimum staffing plan includes:(1) one physician, preferably a psychiatrist, or physician-delegated PA or APRN, onsite or at minimum immediately available through telecommunication or telephone 24 hours a day, seven days a week;(2) one LVN or one RN physically present and on duty 24 hours a day, seven days a week, when an individual is present in the CSU;(3) one RN available onsite within ten minutes after being contacted by a staff member, if an RN is not physically present and on duty when an individual is in the CSU;(4) one QMHP-CS onsite from 8:00 a.m. to 5:00 p.m., Monday through Friday; and(5) two UPs onsite 24 hours a day, seven days a week.(c) A nursing supervisor or an RN charge nurse receiving clinical and administrative consultation from the facility administrator and medical director or on-call physician, APRN, or PA must be available, in person or by telephone, 24 hours a day, seven days a week, to provide clinical oversight to CSU RNs, LVNs, QMHP-CSs, and UPs.(d) The nursing supervisor or designee must develop and implement a written staffing plan describing the number of RNs, LVNs, and UPs on each unit for each shift, in accordance with subsections (a) and (b) of this section, that meet the following requirements:(1) The staffing plan must be based on the census, needs, and characteristics of individuals, and acuity of the CSU.(2) The nursing supervisor or designee must document the nursing supervisor's or designee's determinations regarding the factors described in paragraph (1) of this subsection:(A) at the time the staffing plan is developed; and(B) when the nursing supervisor or designee makes any revisions to the staffing plan based on a change in such factors.(3) A CSU nursing supervisor must retain the staffing plan and the documentation required by paragraph (2) of this subsection for two years.(4) The nursing supervisor or designee must revise the staffing plan, as necessary. Source Note: The provisions of this §306.85 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.85 Minimum Staffing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205075 03/12/2026 (a) At the time an individual is admitted, a CSU nursing supervisor or designee must implement the level of monitoring ordered by the physician, or physician-delegated PA or APRN, based on the individual's needs and in accordance with this section, 25 TAC §415.260 (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency), and §415.266 (relating to Observation, Monitoring, and Care of the Individual in Restraint or Seclusion Initiated in Response to a Behavioral Emergency).(b) All CSU staff must contribute to the protection of individuals by:(1) modifying the CSU environment based on the individual's needs, including:(A) providing furnishings that do not present safety hazards to the individual;(B) securing or removing objects that are hazardous to the individual;(C) installing any necessary safety devices; and(D) making roommate assignments and other decisions affecting the interaction of the individual with other individuals, based on individual needs and vulnerabilities;(2) monitoring the individual in accordance with the physician's, or physician-delegated PA's or APRN's, order and CSU written policies and procedures; and(3) documenting the individual's level of monitoring ordered by the physician, or physician-delegated PA or APRN, in the individual's medical record.(c) A CSU medical director must ensure:(1) each level of monitoring is defined in the CSU's policies and procedures, including a description of the responsibilities of staff members for each level of monitoring identified; and(2) implementation of the level of monitoring ordered by the physician, or physician-delegated PA or APRN, based on the individual's needs.(d) In accordance with Texas Health and Safety Code §321.002, a CSU administrator or administrator's designee, must keep children and adolescents separate from adults.(e) All CSU staff must maintain an individual's confidential information in accordance with the Health Insurance Portability and Accountability Act rules and 1 TAC Chapter 390, Subchapter A (relating to Standards Relating to the Electronic Exchange of Health Information). CSU staff must:(1) be knowledgeable of and obey all current state and federal laws and regulations relating to confidential information regarding the provision of services; and(2) not disclose confidential information without the express written consent of the individual, and individual's LAR or adult caregiver, if applicable, except as permitted by the Health Insurance Portability and Accountability Act or other law.(f) Qualified CSU staff must adhere to transportation requirements provided in accordance with 25 TAC §404.156 (relating to Additional Rights of Persons Receiving Residential Mental Health Services at Department Facilities) and Texas Health and Safety Code §574.045 and §574.0455 if the CSU provides transportation. Source Note: The provisions of this §306.87 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.87 Protection of an Individual Receiving Crisis Stabilization Unit Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205076 03/12/2026 (a) A CSU administrator, or administrator's designee, must:(1) identify common emergency medical conditions of individuals the CSU staff will likely encounter; and(2) develop a written plan describing the specific and appropriate action the CSU staff members will take to stabilize each identified common emergency medical condition, approved in writing by the medical director, as required by §306.61 of this subchapter (relating to Crisis Stabilization Unit Medical Services), which includes:(A) the administration of first aid and Basic Life Support when clinically indicated;(B) the use of the supplies and equipment described in subsection (f) of this section; and(C) if the action is facilitating transfer of the individual, a description of the method of transportation, and the name and location of the hospital to which an individual will be transferred.(b) At least one physician, or physician-delegated PA or APRN, must, at all times:(1) be physically present at a CSU to respond to an individual's emergency medical condition; or(2) be available to staff members by telephone, radio, or audiovisual telecommunication device to provide medical consultation as soon as possible, but not longer than 30 minutes.(c) If a CSU physician, or physician-delegated PA or APRN, determines an individual has an emergency medical condition:(1) the CSU physician, or physician-delegated PA or APRN, must act to stabilize the emergency medical condition within the capability of the CSU staff's abilities and in accordance with the plan required by subsection (a)(2) of this section, and summon emergency medical services (EMS) for transfer to a general hospital; and(2) EMS transfers the individual to a general hospital from the CSU, an RN must, as soon as possible:(A) inform the general hospital to which the transfer is made, by telephone, of:(i) the general condition and medical diagnoses of the individual;(ii) the medications administered, and treatments provided, to the individual by the CSU; and(iii) the prognosis of the individual; and(B) provide a copy of the individual's medical records to the general hospital to which the transfer is made.(d) A CSU administrator, or administrator's designee, must have a written agreement with a general hospital that the hospital will accept, for medical treatment and care, an individual transferred from the CSU in accordance with subsection (c) of this section.(e) The CSU must have at least one staff member on each shift certified in Basic Life Support and available to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.(f) The CSU must have an adequate amount of appropriate emergency supplies and equipment immediately available and fully operational at the CSU to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section, including, at a minimum:(1) oxygen;(2) manual breathing bags and masks;(3) an automated external defibrillator; and(4) a first aid kit.(g) A CSU administrator, or administrator's designee, must have a written natural disaster response policy and an active shooter policy. Source Note: The provisions of this §306.89 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.89 Crisis Stabilization Unit Response to an Emergency Medical Condition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205077 03/12/2026 (a) A CSU administrator, or administrator's designee, must facilitate an individual's transfer as soon as possible to an appropriate and available inpatient mental health facility, which may include contacting law enforcement to transfer an individual under an emergency detention who has not yet been admitted or obtaining permission from the court that issued the order of protective custody to transfer the individual, as appropriate, if:(1) a physician, or physician-delegated PA or APRN, determines the individual is at serious risk of harm to self or others in the CSU and the CSU is unable to provide an adequate assurance of safety for the individuals or others in the CSU;(2) during a 24-hour period, the individual is placed in:(A) seclusion more than twice or for more than a total of four hours; or(B) a restraint for more than 60 consecutive minutes; or(3) the individual becomes the subject of:(A) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code §574.034; or(B) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code §574.035.(b) A CSU administrator, or administrator's designee, must immediately facilitate an individual's transfer to a general hospital or another health care entity, as appropriate, if the individual:(1) requires specialized care not available at the CSU; or(2) has a physical medical condition that is unstable and could reasonably be expected to require inpatient treatment for the condition.(c) An administrator of a CSU solely serving children and adolescents must immediately facilitate an individual's transfer to an inpatient mental health facility serving adults when the individual:(1) turns 18 years of age; and(2) does not meet criteria for discharge from CSU treatment services. Source Note: The provisions of this §306.91 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.91 Transfers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205078 03/12/2026 A CSU administrator, or administrator's designee, must develop and implement a written plan to evaluate the effectiveness of any plan of correction the CSU administrator, or administrator's designee, submits to an external review entity. Source Note: The provisions of this §306.95 adopted to be effective May 27, 2021, 46 TexReg 3257. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM B STANDARDS OF CARE IN CRISIS STABILIZATION UNITS §306.95 Response to External Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210215 03/12/2026 The purpose of this subchapter is to describe the requirements for an applicant to be certified by the Texas Health and Human Services Commission as a Texas Certified Community Behavioral Health Clinic. Source Note: The provisions of this §306.101 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210216 03/12/2026 The provisions of this subchapter apply to applicants defined in §306.105 of this subchapter (relating to Definitions). Source Note: The provisions of this §306.103 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210217 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Applicant--An entity applying or reapplying for certification as a Texas Certified Community Behavioral Health Clinic (T-CCBHC).(2) Application--A Texas Health and Human Services Commission form submitted by an applicant for T-CCBHC certification and recertification.(3) Community needs assessment--A systematic approach to identifying community needs and determining program capacity to address the needs of the population being served. The needs assessment is objective and includes input from people receiving services, program staff, and other key community stakeholders.(4) Crisis stabilization--Services to address a mental health or substance use crisis, including suicide crisis response and services capable of addressing crises related to substance use.(5) Family-centered--Developmentally appropriate and youth guided care that recognizes active participation between families and caregivers and professionals as a cornerstone to the planning, delivery, and evaluation of services.(6) Governmental entity--A state agency or a political subdivision of the state, such as a city, county, hospital district, hospital authority, or state entity.(7) HHSC--The Texas Health and Human Services Commission or its designee.(8) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Health and Safety Code, §533.0356(a).(9) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Health and Safety Code, §533.035(a).(10) Person--An individual receiving services under this subchapter.(11) Person-centered--Care that is strengths-based, trauma informed, and focuses on individual capacities, preferences, and goals that gives the person the opportunity to optimize their self-defined quality of life, choice, control, and self-determination through meaningful exploration and discovery of unique preferences, needs, and wants while ensuring medical and non-medical needs are met via means that are exclusively for the benefit of the person and supports them to reach their full potential.(12) T-CCBHC--Texas Certified Community Behavioral Health Clinic. An entity certified in accordance with this subchapter. Source Note: The provisions of this §306.105 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210218 03/12/2026 An applicant must meet the criteria in this section for certification. (1) Staffing requirements. (A) Staffing plans must reflect findings of the community needs assessment.(B) Staff members must have, and be currently active with, all necessary state-required licenses and accreditations to deliver required services. (C) Staff members must be trained to serve the needs of the clinic's patient population as identified through the community needs assessment and in compliance with Section 223(a)(2)(A) of the Protecting Access to Medicare Act of 2014. (D) Staff must be trained in a person-centered and family-centered approach.(2) Availability and accessibility of services. The applicant cannot deny or limit services based on a person's inability to pay. (3) Care coordination.(A) The applicant must coordinate care across settings and providers to ensure seamless transitions for the person across the full spectrum of health services including acute, chronic, and behavioral health.(B) The T-CCBHC must have a health information technology system that includes an electronic health record and must have a plan in place focusing on ways to improve care coordination using health information technology. (4) Scope of services. (A) The applicant must provide or, with HHSC approval, arrange for the provision of the following services:(i) crisis mental health services, including 24-hour mobile crisis services, crisis intervention services, and safety monitoring; (ii) screening, assessment, and diagnosis, including risk assessment;(iii) person-centered treatment planning or similar processes, including risk assessment and crisis planning;(iv) outpatient mental health and substance use services; (v) outpatient clinic primary care screening and monitoring of key health indicators and health risk;(vi) mental health targeted case management as defined in Texas Administrative Code, Title 1, Part 15, §353.1403 (relating to Definitions);(vii) psychiatric rehabilitation services;(viii) peer specialist services and family partner supports; and(ix) intensive, community-based mental health care for members of the armed forces and veterans.(B) Crisis mental health services must be provided regardless of a person's place of residence, homelessness, or lack of a permanent address.(5) Quality and other reporting. (A) A T-CCBHC must report encounter data, clinical outcomes data, quality data, and other data HHSC requests.(B) A T-CCBHC must have health information technology systems that allow reporting on data and quality measures.(6) Organizational authority. (A) The applicant must be a non-profit or governmental entity; or an entity operated under the authority of the Indian Health Service, an Indian tribe or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq. ), or an urban Indian organization pursuant to a grant or contract with the Indian Health Service under title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq. ).(B) The applicant must be operational as an entity listed under subparagraph (A) of this paragraph for a minimum of two years in Texas before applying for T-CCBHC certification.(C) The applicant's T-CCBHC must have a governing board. The governing board must:(i) be comprised of at least 51 percent families, consumers, and people in recovery from behavioral health conditions; or(ii) establish an advisory committee that meets the requirements of clause (i) of this subparagraph and provides meaningful input to the governing board about the T-CCBHC's polices, processes, and services. Source Note: The provisions of this §306.107 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.107 Certification Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210219 03/12/2026 (a) An applicant must submit a completed HHSC application to be considered for certification or recertification, using application information and instructions provided on the HHSC website.(b) HHSC prioritizes review and approval of LMHA and LBHA T-CCBHC applications as appropriate.(c) HHSC reviews an application in accordance with the T-CCBHC eligibility requirements in §306.107 of this subchapter (relating to Certification Eligibility) and may deny an application for certification for good cause, including:(1) the application is incomplete in any aspect;(2) the application is not submitted in accordance with HHSC's application instructions or published notice;(3) the application contains false information;(4) HHSC, any other agency in Texas or in another state, or federal agency has terminated the applicant's contract, licensure, or certification for cause at any point in the three years preceding the application submission date;(5) the applicant is excluded or debarred from contracting with the State of Texas or the federal government;(6) the applicant has an outstanding Medicaid program audit exception or other unresolved financial liability owed to the State of Texas;(7) the applicant is ineligible to enroll as a Medicaid provider for reasons relating to criminal history records as set forth in state rules; or(8) the applicant terminated a provider agreement in a federal health care program, as defined in 42 U.S.C, §1302a-7b(f), while an adverse action or sanction was in effect.(d) An applicant must submit supporting documentation and participate in HHSC conducted interviews to confirm the applicant meets each criterion in §306.107 of this subchapter.(e) Applicants must submit appropriate documentation in response to no more than two requests from HHSC for supplemental information within a timeframe agreed upon by the applicant and HHSC not to exceed 60 calendar days from the date of HHSC's first request. Source Note: The provisions of this §306.109 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.109 Application Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210220 03/12/2026 (a) In order to maintain certification, T-CCBHCs must coordinate with other T-CCBHCs that deliver services in the same geographic service area to ensure services are not duplicated for persons receiving services from more than one T-CCBHC.(b) T-CCBHC certification does not replace Texas regulations regarding provision of services or contract requirements. T-CCBHCs must maintain all required licenses throughout the certification period. Any regulatory license revocations, of either facility or professional licenses, that result in a T-CCBHC being unable to operate within the State of Texas will preclude the T-CCBHC from continuing as certified.(c) T-CCBHC certification is approved for three years, subject to parameters outlined in §306.109(c) of this subchapter (relating to Application Process).(d) T-CCBHCs may reapply for certification if eligible in accordance with §306.109 of this subchapter.(e) To ensure prevention of a lapse in certification, T-CCBHCs must submit an application, as defined in §306.105(2) of this subchapter (relating to Definitions), to be considered for recertification. Applications must be submitted no earlier than 180 calendar days before the expiration of certification, but not later than 60 calendar days before the expiration of certification. Source Note: The provisions of this §306.111 adopted to be effective September 29, 2022, 47 TexReg 6198. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM C TEXAS CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS §306.111 Certification Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224262 03/12/2026 (a) The purpose of this subchapter is to:(1) provide requirements on admission, discharge, and continuity of care; and(2) address the interrelated roles and responsibilities of state hospitals, facilities with contracted psychiatric beds (CPBs), local mental health authorities (LMHAs), local behavioral health authorities (LBHAs), and local intellectual and developmental disability authorities (LIDDAs) in the delivery of mental health and co-occurring substance use disorder (SUD) services to individuals. (b) This subchapter establishes criteria for individuals receiving mental health services and SUD services and provides guidelines related to: (1) clinically appropriate placement in an inpatient, residential, or community setting based on screening and assessment of the individual; (2) timely access to evaluation and mental health, SUD, and other services in the least restrictive and most appropriate setting; and (3) transitioning care between service types and providers for individuals receiving mental health or SUD services at state hospitals, CPBs, LMHAs, LBHAs, and LIDDAS, effectively and without interruption. Source Note: The provisions of this §306.151 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.151 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224263 03/12/2026 (a) This subchapter applies to: (1) a state hospital; (2) a CPB;(3) an LMHA; (4) an LBHA; and(5) a LIDDA.(b) An LMHA or LBHA must require its subcontractors to comply with this subchapter. Source Note: The provisions of this §306.152 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.152 Application and Responsibility for Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224264 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Absence--When an individual, previously admitted to a state hospital or CPB, and not discharged from the admitting facility, is physically away from the facility for any reason, including hospitalization, home visit, special activity, or unauthorized departure. (2) Admission--Includes: (A) an individual's acceptance to a state hospital or CPB for voluntary or involuntary inpatient or residential treatment services; or (B) the acceptance of an individual in the mental health priority population into LMHA or LBHA services. (3) Adolescent--An individual who is 13 years of age, but younger than 18 years of age. (4) Adult--An individual who is at least 18 years of age or older. (5) Advance directive--As used in this subchapter, includes: (A) an instruction made under Texas Health and Safety Code Chapter 166; or (B) a declaration for mental health treatment made in accordance with Civil Practice and Remedies Code Chapter 137. (6) Alternate provider--An entity that provides mental health services or SUD services in the community but does not provide these services under contract with an LMHA or LBHA. (7) APRN--Advanced practice registered nurse. A registered nurse licensed by the Texas Board of Nursing to practice as an advanced practice registered nurse as provided by Texas Occupations Code §301.152. (8) Assessment--The administrative process a state hospital or CPB uses to gather information from an individual, including a medical history and the concerns for which the individual is seeking treatment, to determine whether the individual should be examined by a physician to determine if admission is clinically justified, as defined by Texas Health and Safety Code §572.0025(h)(2). (9) Assessment professional--In accordance with Texas Health and Safety Code §572.0025(c) - (d), a staff member of a state hospital or CPB, whose responsibilities include conducting the intake assessment described in §306.175(g) of this subchapter (relating to Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed) and §306.176(e) of this subchapter (relating to Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention), and who is: (A) a physician licensed to practice medicine under Texas Occupations Code Chapter 155; (B) a physician assistant licensed under Texas Occupations Code Chapter 204; (C) an APRN licensed under Texas Occupations Code Chapter 301; (D) a registered nurse licensed under Texas Occupations Code Chapter 301; (E) a psychologist licensed under Texas Occupations Code Chapter 501; (F) a psychological associate licensed under Texas Occupations Code Chapter 501; (G) a licensed professional counselor licensed under Texas Occupations Code Chapter 503; (H) a licensed social worker licensed under Texas Occupations Code Chapter 505; or (I) a licensed marriage and family therapist licensed under Texas Occupations Code Chapter 502. (10) Audio-only technology--A synchronous interactive, two-way audio communication that uses only sound and that conforms to privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include audiovisual or in-person communication.(11) Audiovisual technology--A synchronous interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audiovisual does not include audio-only or in-person communication.(12) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021. (13) Capacity--An individual's ability to understand and appreciate the nature and consequences of a decision regarding the individual's medical treatment, and the ability of the individual to reach an informed decision in the matter. (14) Child--An individual who is at least three years of age, but younger than 13 years of age. (15) CoC liaison--Continuity of care liaison. A dedicated full-time staff member who is a QMHP-CS or LPHA that facilitates continuity of care. (16) Continuity of care--Activities designed to ensure an individual is provided uninterrupted services during a transition between inpatient and outpatient services and that assist the individual and LAR, if applicable, in identifying, accessing, and coordinating LMHA or LBHA services and other appropriate services and supports in the community needed by the individual, including: (A) assisting with admissions and discharges; (B) facilitating access to appropriate services and supports in the community, including identifying and connecting the individual with community resources, and coordinating the provision of services; (C) participating in developing and reviewing the individual's recovery or treatment plan; (D) promoting implementation of the individual's recovery or treatment plan; and (E) coordinating notification of continuity of care services between the individual and the individual's family and any other person providing support as authorized by the individual and LAR, if applicable. (17) Continuity of care worker--A LIDDA staff member responsible for providing continuity of care services. (18) COPSD--Co-occurring psychiatric and substance use disorder. (19) COPSD model--An application of evidence-based practices for an individual diagnosed with co-occurring conditions of psychiatric and substance use disorder. (20) CPB--Contracted psychiatric bed. A facility with an HHSC-contracted psychiatric bed that:(A) includes a community mental health hospital and a private psychiatric bed that: (i) is authorized by an LMHA or LBHA; and (ii) is used for inpatient care in the community; and (B) does not include a crisis respite unit, crisis residential unit, an extended observation unit, or a crisis stabilization unit. (21) CRCG--Community Resource Coordination Group. A local interagency group comprised of public and private providers who collaborate to develop individualized service plans for individuals whose needs may be met through interagency coordination and cooperation. CRCGs are established and operate in accordance with a Memorandum of Understanding on Services for Persons Needing Multiagency Services, as required by Texas Government Code Chapter 522, Subchapter D. (22) Crisis--A situation in which: (A) an individual presents an immediate danger to self or others; (B) an individual's mental or physical health is at risk of serious deterioration; or (C) an individual believes the individual presents an immediate danger to self or others, or the individual's mental or physical health is at risk of serious deterioration. (23) Crisis treatment alternatives--Community-based facilities or units and services providing short-term, residential crisis treatment to ameliorate a behavioral health crisis in the least restrictive and most appropriate environment, including crisis stabilization units, extended observation units, crisis residential units, and crisis respite units. The intensity and scope of services varies by facility type and is available in a local service area based upon the local needs and characteristics of the community. (24) Day--A calendar day, unless otherwise specified. (25) DD--Developmental disability. A disability that meets the criteria described in Texas Health and Safety Code §531.002(15). (26) Designated LMHA or LBHA--The LMHA or LBHA: (A) that serves the individual's county of residence, which is determined in accordance with §306.162 of this subchapter (relating to Determining County of Residence); or (B) that does not serve the individual's county of residence but has taken responsibility for ensuring the individual's services. (27) DFPS--Texas Department of Family and Protective Services or its designee.(28) Discharge--Means:(A) the release of an individual from the custody and care of a provider of inpatient services; or(B) the termination of LMHA or LBHA services delivered to an individual by the individual's LMHA or LBHA.(29) Discharge planning specialist--A designated state hospital staff member responsible for coordinating continuity of care services with a specific focus on an individual's community transition in accordance with Texas Health and Safety Code §534.0535. This term is synonymous with a "transition support specialist."(30) Discharged unexpectedly--A discharge from the custody and care of a provider of inpatient services: (A) due to an individual's unauthorized departure; (B) at the individual's request; (C) due to a court releasing the individual; (D) due to the death of the individual; or (E) due to the execution of an arrest warrant for the individual. (31) DSM--Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.(32) Emergency medical condition--This term has the meaning assigned by the Emergency Medical Treatment and Active Labor Act (42 U.S.C. §1395dd), regarding Examination and treatment for emergency medical conditions and women in labor.(33) Family partner--An experienced, trained primary caregiver, such as the parent of an individual with a mental illness or serious emotional disturbance, who provides peer mentoring, education, and support to the caregivers of a child who is receiving mental health community services in accordance with Chapter 301, Subchapter G of this title (relating to Mental Health Community Services Standards).(34) Furlough--The authorization for an individual to leave from a state hospital or CPB for longer than a 72-hour period in accordance with Texas Health and Safety Code Chapter 574, Subchapter F.(35) HHSC--Texas Health and Human Services Commission or its designee. (36) ID--Intellectual disability. A disability that meets the criteria in Texas Health and Safety Code §591.003. (37) Individual--A person seeking or receiving services under this subchapter. (38) Inpatient services--Residential psychiatric treatment provided to an individual in: (A) a state hospital;(B) a CPB; (C) a hospital licensed under Texas Health and Safety Code Chapter 241 or Chapter 577; (D) a crisis stabilization unit licensed under Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units); or(E) any other type of mental health hospital. (39) In person or in-person--Within the physical presence of another person. In person or in-person does not include audiovisual or audio-only communication.(40) Intake assessment--The administrative process conducted by an assessment professional for: (A) gathering information about an individual, including the psychiatric and medical history, social history, symptomology, and support system; and(B) giving the individual information about the facility and the facility's treatment and services. (41) Involuntary admission--An individual receiving inpatient services based on an admission to a state hospital or CPB in accordance with:(A) §306.176 of this subchapter (relating to Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention);(B) §306.177 of this subchapter (relating to Admission Criteria Under Order of Protective Custody or Court-ordered Inpatient Mental Health Services); (C) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code §574.034 or Texas Family Code Chapter 55;(D) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code §574.035 or Texas Family Code Chapter 55; (E) an order for commitment issued as described in Texas Code of Criminal Procedure Chapter 46B; or(F) an order for commitment issued as described in Texas Code of Criminal Procedure Chapter 46C.(42) LAR--Legally authorized representative. A person authorized by state law to act on behalf of an individual. (43) LBHA--Local behavioral health authority. An entity designated as an LBHA by HHSC in accordance with Texas Health and Safety Code §533.0356(a).(44) LIDDA--Local intellectual and developmental disability authority. An entity designated by HHSC in accordance with Texas Health and Safety Code §533A.035(a). (45) LMHA--Local mental health authority. An entity designated as an LMHA by HHSC in accordance with Texas Health and Safety Code §533.035(a). (46) LMHA or LBHA network provider--An entity that provides mental health and SUD services in the community pursuant to a contract or memorandum of understanding with an LMHA or LBHA, including that part of an LMHA or LBHA directly providing mental health services. (47) LMHA or LBHA services--Inpatient mental health and outpatient mental health and SUD services provided by an LMHA or LBHA network provider to an individual in the individual's home community. (48) Local service area--A geographic area composed of one or more Texas counties defining the population that may receive services from an LMHA, LBHA, or LIDDA. (49) LPHA--Licensed practitioner of the healing arts. This term has the meaning as defined in §301.303 of this title (relating to Definitions).(50) Mental illness--This term has the meaning as assigned by Texas Health and Safety Code §571.003.(51) MH priority population--Mental health priority population. As identified in state performance contracts with LMHAs or LBHAs, those groups of children and adolescents with SED, or adults with severe and persistent mental illness, assessed as in need of mental health services. (52) Minor--An individual younger than 18 years of age who has not been emancipated under Texas Family Code Chapter 31. (53) Nursing facility--A Medicaid-certified facility licensed in accordance with Texas Health and Safety Code Chapter 242. (54) Offender with special needs--An individual who has a terminal or serious medical condition, a mental illness, an ID, a DD, or a physical disability, and is served by the Texas Correctional Office on Offenders with Medical or Mental Impairments as provided in Texas Health and Safety Code Chapter 614. (55) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by HHSC in accordance with Texas Government Code §531.9933.(56) Outpatient management plan--The prescribed regimen of medical, psychiatric, or psychological care or treatment as defined in Texas Code of Criminal Procedure Article 46C.263(c).(57) PASRR--Preadmission screening and resident review as defined in §303.102 of this title (relating to Definitions).(58) Pass--The authorization for an individual to leave from a state hospital or CPB for not more than a 72-hour period in accordance with Texas Health and Safety Code Chapter 574, Subchapter F. (59) PE--PASRR level II evaluation. This term has the meaning as defined in §303.102 of this title.(60) Peer specialist--A person who uses lived experience, in addition to skills learned in formal training, to deliver strengths-based, person-centered services to promote an individual's recovery and resiliency in accordance with 1 TAC Chapter 354, Subchapter N (relating to Peer Specialist Services). (61) Permanent residence--The physical location in the community where an individual lives, or if a minor, where the minor's parents or legal guardian lives. A post office box is not considered a permanent residence. (62) PL1--PASRR level I screening. This term has the meaning as defined in §303.102 of this title.(63) Preliminary examination--An assessment for medical stability and a psychiatric examination in accordance with Texas Health and Safety Code §573.022(a)(2). (64) QMHP-CS--Qualified mental health professional-community services. An LMHA or LBHA staff member who meets the qualifications and performs the functions described in Chapter 301, Subchapter G of this title (relating to Mental Health Community Services Standards). (65) Recovery--A process of change through which an individual improves the individual's health and wellness, lives a self-directed life, and strives to reach the individual's full potential. (66) Recovery or treatment plan--A written plan: (A) developed in collaboration with an individual or LAR and a QMHP-CS or LPHA as defined in §301.303 of this title; (B) amended at any time based on an individual's needs or requests; (C) that guides the recovery treatment process and fosters resiliency; (D) completed in conjunction with the uniform assessment; (E) that identifies the individual's changing strengths, capacities, goals, preferences, needs, and desired outcomes; and (F) that includes recommended services and supports or reasons for the exclusion of services and supports. (67) Screening--Activities to: (A) collect triage information through interviews with an individual or collateral contact; (B) determine if the individual's need is emergent, urgent, or routine, and conducted before the assessment to determine the need for emergency services; and (C) determine the need for an in-depth assessment. (68) SED--Serious emotional disturbance. A disorder that meets the criteria described in Texas Government Code §547.0051. (69) SSLC--State supported living center. Consistent with Texas Health and Safety Code §531.002, a residential facility operated by HHSC to provide an individual with an ID a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills. (70) State hospital--Consistent with Texas Health and Safety Code §552.002, a mental health facility operated by HHSC, including Waco Center for Youth.(71) SUD--Substance use disorder. The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which meets the criteria for SUD as described in the version of the DSM currently recognized by HHSC.(72) TAC--Texas Administrative Code. (73) TCOOMMI--Texas Correctional Office on Offenders with Medical or Mental Impairments or its designee. (74) Treating physician--A physician who coordinates and oversees an individual's treatment. (75) Treatment team--A group of treatment providers, working with an individual, the LAR, if applicable, and the LMHA, LBHA, or LIDDA in a coordinated manner to provide comprehensive mental health, SUD, and ID services to the individual. (76) Uniform assessment--An assessment tool adopted by HHSC under §301.353 of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) used for recommending an individual's level of care. (77) Voluntary admission--An individual receiving inpatient services based on an admission made in accordance with:(A) §306.175 of this subchapter;(B) §306.178 of this subchapter (relating to Voluntary Treatment Following Involuntary Admission);(C) Texas Health and Safety Code §572.002; or(D) Texas Health and Safety Code §572.0025. Source Note: The provisions of this §306.153 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.153 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224265 03/12/2026 (a) Any individual who is eligible for Medicaid and whose request for eligibility to receive LMHA or LBHA Medicaid services is denied or is not acted upon with reasonable promptness is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearings Rules).(b) Any individual who is eligible for Medicaid and whose services have been terminated, suspended, or reduced by HHSC is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A.(c) Any individual who has not applied for or is not eligible for Medicaid, whose request for eligibility to receive LMHA or LBHA services is denied or is not acted upon with reasonable promptness, or whose services have been terminated, suspended, or reduced by a provider, is entitled to notification and right of appeal in accordance with §301.155 of this title (relating to Notification and Appeals Process). (d) At any time, an individual may obtain additional information and resources on the HHSC website and from the Ombudsman by calling toll-free 1-800-252-8154. Source Note: The provisions of this §306.154 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.154 Notification and Appeals Process for Local Mental Health Authority or Local Behavioral Health Authority Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224266 03/12/2026 LMHAs and LBHAs must develop policies and procedures that require: (1) the LMHA or LBHA to employ at least one dedicated full-time staff member who is a QMHP-CS or LPHA to act as the CoC liaison to support continuity of care activities;(2) a CoC liaison to delegate continuity of care responsibilities to other continuity of care staff, if necessary;(3) a CoC liaison not to have assigned duties outside of activities supporting continuity of care and related functions;(4) an alternate staff member to act as the CoC liaison in the absence of the person identified as the primary CoC liaison; (5) communication and facilitation of services between the continuity of care team and parties involved in the individual's care, including:(A) a mental health peer specialist or a recovery support peer specialist as described in 1 TAC §354.3159 (relating to Core and Supplemental Training); or(B) a family partner;(6) coordination with other state agencies responsible for the care of a child such as DFPS, the Texas Department of Criminal Justice, or the Texas Juvenile Justice Department;(7) initiation of contact with the parties involved in the individual's care at a state hospital or CPB within three business days after admission;(8) coordination of post-discharge activities with local community parties involved in the individual's care, including other LMHAs, LBHAs, and LIDDAs;(9) a CoC liaison to conduct continuity of care activities, including responding to communications from a facility within three business days after the facility sent the communication;(10) the LMHA or LBHA to provide notification of the CoC liaison's contact information, including if there is a CoC liaison personnel change, and the CoC liaison's designated alternate staff member's contact information within three business days to each facility that has an individual admitted in the LMHA's or LBHA's care;(11) a QMHP-CS or LPHA acting as the CoC liaison to maintain the QMHP-CS' certification as a QMHP-CS or the LPHA's licensure as an LPHA;(12) identification of a process for obtaining services and resources for an individual, as needed;(13) LMHA or LBHA representation by an assigned CoC liaison in treatment team meetings at a state hospital or CPB as requested by the facility;(14) the availability of a CoC liaison to communicate with providers from 8:00 a.m. to 5:00 p.m. on business days, coordinate coverage to respond to continuity of care service needs 24 hours a day, and follow up as necessary to ensure continuity of care needs are met;(15) monitoring of the number of individuals who are currently admitted to state hospitals or CPBs and the number of individuals who are discharged from these facilities; (16) a CoC liaison to conduct a uniform assessment, either in person or by audiovisual technology, to ensure a level of care determination is made within ten business days before discharge;(17) a CoC liaison ensures all LMHA, LBHA, or LIDDA appointments are scheduled in advance for needed programs and services to minimize any disruption in services or support at the time of discharge and community integration;(18) LMHA or LBHA staff to participate in all applicable court proceedings;(19) LMHA or LBHA staff to participate in the development of an outpatient management plan for an individual who is on a Texas Code of Criminal Procedure Chapter 46C commitment and whom a state hospital identifies as suitable for outpatient placement; and (20) a CoC liaison to initiate transition planning with the receiving LMHA or LBHA when the individual is changing LMHAs or LBHAs. Source Note: The provisions of this §306.155 adopted to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.155 Local Mental Health Authority, Local Behavioral Health Authority, and Continuity of Care Liaison Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224267 03/12/2026 (a) If an individual in an LMHA's or LBHA's local service area is in crisis, the LMHA or LBHA must ensure: (1) immediate screening by a staff member trained in crisis screening, in accordance with §301.327(d)(1)(A)(ii) of this title (relating to Access to Mental Health Community Services); and(2) if emergency care services are recommended based on the screening, ensure the staff member complies with §301.327(d)(1)(B) of this title. (b) When the crisis is resolved, the LMHA or LBHA must assess the individual using the uniform assessment and determine: (1) referral for ongoing services at the LMHA or LBHA; (2) referral to an alternate provider; (3) referral to community-based crisis treatment alternative as described in §306.163 of this division (relating to Most Appropriate and Available Treatment Options); (4) the individual's transportation by identifying and ensuring the individual's transportation needs were met; or (5) no referral is needed. (c) If an individual who is not in crisis presents for services, an LMHA or LBHA staff member: (1) must determine whether the individual's county of residence is within the LMHA's or LBHA's local service area; and (2) who is a QMHP-CS or LPHA must conduct a screening. (d) If the individual's county of residence is within the LMHA's or LBHA's local service area and the screenings described in subsections (b) and (c) of this section indicates an intake assessment is needed, the LMHA or LBHA must conduct an assessment in accordance with §301.353(a) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization). (1) The LMHA or LBHA must serve an individual in the MH priority population designated by HHSC. For an individual in the MH priority population, the LMHA or LBHA must identify which services the individual may be eligible to receive and, if applicable, must:(A) provide services immediately; or (B) place the individual on a waiting list for services and refer the individual to other community resources. (2) An individual who is enrolled in Medicaid must receive services immediately in accordance with §301.327 of this title (relating to Access to Mental Health Community Services) and pursuant to Medicaid regulations and policies. (3) An LMHA or LBHA must serve an individual in accordance with §301.327 of this title. (4) For an individual not in the MH priority population, the LMHA or LBHA must provide the individual with written notification within three business days regarding: (A) the denial of services and the opportunity to appeal in accordance with §306.154 of this subchapter (relating to Notification and Appeals Process for Local Mental Health Authority or Local Behavioral Health Authority Services); and (B) how to contact the Ombudsman in a language the individual understands for information or assistance at 1-800-252-8154 or on the HHSC website. Source Note: The provisions of this §306.161 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.161 Screening and Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224268 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224268 03/12/2026 (a) County of Residence for Adults. (1) An adult's county of residence is the county of the adult's permanent residence or, if applicable, the county of the LAR's permanent residence, unless there is a preponderance of evidence to the contrary. If the adult is not a Texas resident or indicates no permanent address, the adult's county of residence is the county in which the evidence indicates the adult resides. (2) If an adult is unable to communicate the location of the adult's permanent residence, there is no evidence indicating the location of an adult's permanent residence, or if an adult is not a Texas resident, the adult's county of residence is the county in which the adult is physically present when the adult requests or requires services.(3) The county in which the paying LMHA or LBHA is located is the adult's county of residence if the individual receives services:(A) delivered in the local service area of another LMHA or LBHA for an adult's community mental health services; or(B) for an adult's living arrangement located outside the paying LMHA's or LBHA's local service area. (b) County of Residence for Minors. (1) Except as provided in paragraph (2) of this subsection, a minor's county of residence is the county in which the minor's LAR's permanent residence is located. (2) A minor's county of residence is the county in which the minor currently resides if: (A) it cannot be determined in which county the minor's LAR's permanent residence is located; (B) a state agency is the minor's LAR; (C) the minor does not have an LAR; or (D) the minor is at least 16 years of age and self-enrolling into services.(3) A minor in DFPS conservatorship may continue receiving services from the LMHA or LBHA where the minor was last enrolled in services until another appropriate placement is established. Once placement is established, the transferring LMHA or LBHA will hold a transfer meeting with the receiving LMHA or LBHA and the minor's LAR. (c) Disagreements regarding county of residence initiated by an LMHA or LBHA. (1) The LMHA or LBHA must initiate or continue providing clinically necessary services, including discharge planning, until a disagreement regarding county of residence is resolved.(2) If an LMHA or LBHA initiates a disagreement regarding county of residence that the executive directors of the affected LMHAs or LBHAs cannot resolve, the HHSC performance contract manager of the affected LMHAs or LBHAs resolves the disagreement. (d) Disagreements regarding county of residence initiated by an individual or another person or entity on behalf of the individual. The Ombudsman may consult with the HHSC performance contract manager of the affected LMHAs or LBHAs and help resolve a disagreement initiated by an individual or by another person or entity on behalf of the individual. (e) Changing county of residence status. If an individual currently receiving LMHA or LBHA services moves the individual's permanent residence to a county within the local service area of another LMHA or LBHA, the LMHAs or LBHAs affected by the change must comply with §306.195 of this subchapter (relating to Changing Local Mental Health Authorities or Local Behavioral Health Authorities). Source Note: The provisions of this §306.162 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.162 Determining County of Residence https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224269 03/12/2026 (a) Recommendation for treatment. The designated LMHA or LBHA is responsible for recommending the most appropriate and available treatment alternative for an individual in need of mental health or SUD services. (b) Inpatient services. (1) Before an LMHA or LBHA refers an individual for inpatient services, the LMHA or LBHA must screen and assess the individual to determine if the individual requires inpatient services. (2) If the screening and assessment indicates the individual requires inpatient services and inpatient services are the least restrictive and most appropriate setting available, the LMHA or LBHA must refer the individual: (A) to a state hospital or CPB, if the LMHA or LBHA determines that the individual meets the criteria for admission; or (B) to an LMHA or LBHA network provider of inpatient services. (3) If the individual is identified in the applicable HHSC automation system as having an ID or a DD, the LMHA or LBHA must inform the designated LIDDA that the individual has been referred for inpatient services. (4) If the LMHA, LBHA, or LMHA or LBHA-network provider refers the individual for inpatient services, the LMHA or LBHA must communicate necessary information to the contracted inpatient provider before or at the time of admission, including the individual's: (A) identifying information, including address; (B) legal status, for example regarding guardianship, charges pending, or custody, as applicable; (C) pertinent medical and medication information, including known disabilities; (D) behavioral information, including information regarding COPSD; (E) other pertinent treatment information; (F) finances, third-party coverage, and other benefits, if known; and (G) advance directive. (5) If an LMHA or LBHA, other than the individual's designated LMHA or LBHA, refers the individual for inpatient services, the state hospital or CPB must notify the individual's designated LMHA or LBHA of the referral for inpatient services by the end of the next business day. (6) The designated LMHA or LBHA must assign a CoC liaison to an individual admitted to a state hospital, a CPB, or an LMHA or LBHA inpatient services network provider. (7) If the individual has an ID or a DD, the designated LIDDA must assign a continuity of care worker to the individual. (8) The LMHA or LBHA CoC liaison, and LIDDA continuity of care worker as applicable, are responsible for the facilitation of the individual's continuity of services. (9) The LMHA or LBHA is responsible for continuity of care and must plan to the greatest extent possible for the successful transition of individuals who are determined by a state hospital or CPB to be clinically appropriate for discharge from these facilities to a community setting in accordance with Texas Health and Safety Code §534.0535. (c) Community-based crisis treatment options. (1) An LMHA or LBHA must ensure the provision of crisis services to an individual experiencing a crisis while the individual is in its local service area. (2) An individual in need of a higher level of care, but not requiring inpatient services, has the option, as available, for admission to other services such as a diversion center, crisis respite unit, crisis residential unit, extended observation unit, or crisis stabilization unit. (d) LMHA or LBHA Services. (1) If an LMHA or LBHA admits an individual to LMHA or LBHA services, the LMHA or LBHA must ensure the provision of services in the least restrictive and most appropriate setting available. (2) The LMHA or LBHA must assign, to an individual receiving services, a staff member who is responsible for coordinating the individual's services. (e) Court Ordered Treatment. The LMHA or LBHA must provide services to an individual ordered by a court to participate in outpatient mental health services or competency restoration services, if available, when the court identifies the LMHA or LBHA as being responsible for those services. (f) Referral to alternate provider. (1) If an individual requests a referral to an alternate provider, and there is not a court order to receive services from the LMHA or LBHA, the LMHA or LBHA must make a referral to an alternate provider in accordance with the individual's request. (2) If an individual has third-party coverage, but the coverage will not pay for needed services because the designated LMHA or LBHA does not have a provider in its network that is approved by the third-party coverage, the designated LMHA or LBHA must comply with §301.111(c)(2) of this title (relating to Determination of Ability to Pay). Source Note: The provisions of this §306.163 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.163 Most Appropriate and Available Treatment Options https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224270 03/12/2026 (a) With the exceptions of Waco Center for Youth, a maximum-security unit, and an adolescent forensic unit, a state hospital or CPB may admit an individual who has been assessed by an LMHA or LBHA and recommended for inpatient admission only if the individual has a mental illness and because of the mental illness: (1) presents a substantial risk of serious harm to self or others; or (2) evidences a substantial risk of mental or physical deterioration. (b) An individual's admission to a state hospital or CPB may not occur if the individual: (1) has a condition that requires medical care that is not available at the state hospital or CPB; or (2) has a physical medical condition that is unstable and could reasonably require inpatient medical treatment for the condition. (c) If an individual arrives at a state hospital or CPB for mental health services, and the designated LMHA or LBHA did not screen or refer the individual as described in §306.163 of this subchapter (relating to Most Appropriate and Available Treatment Options): (1) the state hospital or CPB must notify the designated LMHA or LBHA that the individual has presented for services at the state hospital or CPB within three business days of the individual's presentation for services; and (2) the state hospital or CPB physician must determine if the individual has an emergency medical condition and decide whether the facility has the capability to treat the emergency medical condition. (A) If the state hospital or CPB has the capability to treat the emergency medical condition, the facility must admit the individual in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA) as described in 42 U.S.C. §1395dd. (B) If the state hospital or CPB does not have the capability to treat the emergency medical condition, the facility must provide evaluation and treatment within its capability to stabilize the individual and arrange for the individual to be transferred to a hospital that has the capability to treat the emergency medical condition in accordance with EMTALA and, as applicable, Medicare and Medicaid regulations. (d) If an LMHA or LBHA authorized an individual's admission to a state hospital or CPB, and the facility determines that the individual does not meet inpatient criteria for admission, the facility must contact the designated LMHA or LBHA to coordinate alternate outpatient community services at the time of the admission denial. (e) The designated LMHA or LBHA must contact the individual or LAR within 24 hours after being notified that the individual does not meet inpatient admission criteria and notify the individual or LAR that the LMHA or LBHA will provide referrals and referral follow-up for ongoing services as clinically indicated to address the individual's mental health or other needs. Source Note: The provisions of this §306.171 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.171 General Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224271 03/12/2026 An individual's admission to a maximum-security unit may occur only if the individual is: (1) committed pursuant to Texas Code of Criminal Procedure Chapter 46B or Chapter 46C and determined to require admission to a maximum-security unit; or (2) determined manifestly dangerous in accordance with 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness). Source Note: The provisions of this §306.172 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.172 Admission Criteria for Maximum-Security Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224272 03/12/2026 (a) An adolescent forensic unit may admit an adolescent only if the adolescent meets the criteria described in paragraphs (1), (2), or (3) of this subsection. (1) Condition of probation or parole. The adolescent's admission to an adolescent forensic unit fulfills a condition of probation or parole for a juvenile offense if the adolescent: (A) based on a clinical evaluation, is determined to need mental health treatment in a secure treatment setting to address a risk of dangerousness or delinquent conduct; (B) has COPSD; or (C) has exhausted available community resources for treatment and has a letter written by the local CRCG that confirms available community resources have been exhausted. (2) Commitment under Texas Family Code Chapter 55. The adolescent has been committed to a mental health facility under the Texas Family Code Chapter 55, Subchapter C or D. (3) Determined manifestly dangerous. The adolescent has been determined manifestly dangerous in accordance with 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness). (b) An adolescent may not be admitted to an adolescent forensic unit if the adolescent has an ID. Source Note: The provisions of this §306.173 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.173 Admission Criteria for an Adolescent Forensic Unit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224273 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224273 03/12/2026 (a) An individual's admission to Waco Center for Youth may occur only if the individual: (1) is an adolescent, whose age at admission allows adequate time for treatment programming before reaching 18 years of age; (2) has an SED based on the version of the DSM currently recognized by HHSC;(3) has a history of behavior adjustment concerns; (4) needs a structured treatment program in a residential facility; and (5) is currently receiving LMHA or LBHA services or inpatient services at a state hospital or CPB and has been referred for admission to Waco Center for Youth by: (A) the LMHA, LBHA, or CRCG who confirms that:(i) all appropriate community-based resources have been exhausted; and(ii) Waco Center for Youth is the least restrictive and most appropriate environment needed; or(B) a state hospital; or (C) DFPS, as an adolescent under the agency's managing conservatorship in accordance with Texas Health and Safety Code §554.0001.(b) Waco Center for Youth must not admit: (1) an individual who is younger than 13 years of age or an adolescent whose age at admission does not allow adequate time for treatment programming based on individual case review before reaching 18 years of age; (2) an adolescent who has been found to have engaged in delinquent conduct or conduct indicating a need for supervision under the Texas Family Code, Title 3; (3) an adolescent who is acutely psychotic, suicidal, homicidal, or seriously violent; or (4) an adolescent who is determined to have an ID. (c) If Waco Center for Youth denies admission for services, Waco Center for Youth must provide the adolescent's LAR and LMHA or LBHA written notification within three business days stating: (1) the reason for the denial of services; and (2) that the LAR may appeal the denial by contacting the LMHA or LBHA. (d) If an adolescent receiving services at Waco Center for Youth requires admission to a psychiatric hospital or another setting or program, the discharge planning process from the psychiatric hospital or another setting or program must include the written clinical appropriateness of readmission to Waco Center for Youth as jointly determined by the psychiatric hospital or another setting or program and Waco Center for Youth.(e) With the agreement of the adolescent's treatment team, the Waco Center for Youth leadership, psychiatric hospital leadership, and the adolescent's LAR, Waco Center for Youth must prioritize the adolescent for readmission.(f) If a denial occurs under subsection (c) of this section and the adolescent is not currently receiving services from the appropriate LMHA or LBHA, the LMHA or LBHA must assess the adolescent for eligible services and continuity of care based on the adolescent's clinical needs. Source Note: The provisions of this §306.174 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.174 Admission Criteria for Waco Center for Youth https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224274 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224274 03/12/2026 (a) Request for voluntary admission. (1) In accordance with Texas Health and Safety Code §572.001, a request for voluntary admission of an individual with a mental illness may only be made by: (A) the individual, if the individual is at least 16 years of age or older; (B) an LAR who meets the criteria described in paragraph (4)(A)(i) or (iii) of this subsection, if the individual is younger than 18 years of age; or (C) an LAR who meets the criteria described in paragraph (4)(A)(ii) of this subsection, if the admission is sought pursuant to the provisions of Texas Health and Safety Code §572.001(c-1) - (c-4).(2) In accordance with Texas Health and Safety Code §572.001(b) and (e), a request for admission must: (A) be in writing and signed by the individual or LAR making the request; and (B) include a statement that the individual or LAR making the request: (i) agrees that the individual will remain in the state hospital or CPB until the individual's discharge; and (ii) consents to diagnosis, observation, care, and treatment of the individual until: (I) the discharge of the individual; or (II) the individual is entitled to leave the state hospital or CPB, in accordance with Texas Health and Safety Code §572.004, after a request for discharge is made. (3) The consent given under paragraph (2)(B)(ii) of this subsection does not waive an individual's rights described in: (A) Chapter 320, Subchapter A of this title (relating to Rights of Individuals Receiving Mental Health Services); (B) Chapter 307, Subchapter I of this title (relating to Electroconvulsive Therapy (ECT)); (C) Chapter 320, Subchapter B of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services); and (D) Chapter 320, Subchapter C of this title (relating to Interventions in Mental Health Services). (4) An LAR is a person authorized by state law to act on behalf of an individual for the purposes of:(A) admission, transfer, or discharge that includes: (i) a parent, non-DFPS managing conservator, or guardian; (ii) a representative of DFPS for a minor under DFPS conservatorship pursuant to Texas Health and Safety Code §572.001 (c-2) - (c-4); or (iii) a person authorized by a district court under Texas Family Code Chapter 35A to consent for the temporary admission of a minor; or (B) consent on behalf of an individual regarding a matter described in this subchapter other than admission, transfer, or discharge that includes: (i) persons described in subparagraph (A) of this paragraph; (ii) a person eligible to consent to treatment for a minor under Texas Family Code §32.001(a); and (iii) an agent acting under a Medical Power of Attorney under Texas Health and Safety Code Chapter 166 or a Declaration for Mental Health Treatment under Texas Civil Practice and Remedies Code Chapter 137. (b) Failure to meet admission criteria. If a physician of a state hospital or CPB determines that an individual does not meet admission criteria and that community resources may appropriately serve the individual, the facility must contact the LMHA, LBHA, or LIDDA to discuss the availability and appropriateness of community-based services for the individual. The LMHA, LBHA, or LIDDA must:(1) contact the individual and LAR, if applicable, no later than 24 hours after the LMHA, LBHA, or LIDDA is notified of the failure to meet the admission criteria; and(2) provide referrals and referral follow-up for ongoing services as clinically indicated to address the individual's mental health needs and SUD needs.(c) Examination. (1) A physician must conduct an examination on an individual requesting voluntary admission in accordance with this subsection. (2) In accordance with Texas Health and Safety Code §572.0025(f)(1)(A), a physician must conduct a physical and psychiatric examination, either in person or through audiovisual or other telecommunications technology within 72 hours before voluntary admission or 24 hours after voluntary admission, that includes: (A) an assessment for medical stability; (B) a psychiatric examination; and (C) if indicated, an assessment for a SUD. (3) In accordance with Texas Health and Safety Code §572.0025(f)(1); the physician may not delegate the examination to a non-physician. (d) Meets admission criteria. If, after examination, a physician determines that an individual meets the admission criteria of a state hospital or CPB, the state hospital or CPB must admit the individual. (e) To meet the needs of an individual who does not meet admission criteria to a state hospital or CPB, an LMHA or LBHA, as applicable, must:(1) provide community mental health services and supportive services to the individual; or(2) refer the individual or LAR to community mental health services and supportive services.(f) Capacity to consent. (1) If a physician determines that an individual whose consent is necessary for a voluntary admission does not have the capacity to consent to diagnosis, observation, care, and treatment, the state hospital or CPB may not voluntarily admit the individual. (2) When appropriate, the state hospital or CPB may initiate an emergency detention proceeding in accordance with Texas Health and Safety Code Chapter 573 or file an application for court-ordered inpatient mental health services in accordance with Texas Health and Safety Code Chapter 574. (g) Intake assessment. Before voluntary admission of an individual, in accordance with Texas Health and Safety Code §572.0025(b), an assessment professional for a state hospital or CPB, must conduct an intake assessment with the individual and LAR, if applicable, to: (1) obtain relevant information about the individual, including: (A) psychiatric and medical history; (B) social history; (C) symptomology; (D) support systems; (E) finances; (F) third-party coverage or insurance benefits; and (G) advance directives; (2) explain, orally and in writing, the individual's rights described in Chapter 320, Subchapter A of this title; (3) explain, orally and in writing, the state hospital's or CPB's services and treatment as the services and treatment relate to the individual; (4) explain, orally and in writing, the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008; and (5) explain, orally and in writing, the individual trust fund account, charges for services, and the financial responsibility form. (h) Requirements for voluntary admission.(1) An individual or LAR must make a request for admission in accordance with subsection (a) of this section; (2) a physician must: (A) in accordance with Texas Health and Safety Code §572.0025(f)(1): (i) conduct an examination in accordance with subsection (c) of this section within 72 hours before the admission or 24 hours after the admission; or (ii) consult with a physician who has conducted an examination in accordance with subsection (c) of this section within 72 hours before the admission or 24 hours after the admission; (B) determine that the individual meets the admission criteria of the state hospital or CPB and that admission is clinically justified; and (C) issue an order admitting the individual; (3) in accordance with Texas Health and Safety Code §572.0025(f)(2), the administrator or designee of the state hospital or CPB must sign a written statement agreeing to admit the individual; and (4) in accordance with Texas Health and Safety Code §572.0026, the state hospital or CPB must have available space for the individual.(i) Documentation of admission order. In accordance with Texas Health and Safety Code §572.0025(f)(1), the order described in subsection (h)(2)(C) of this section is issued: (1) in writing and signed by the issuing physician; or (2) orally or electronically if, within 24 hours after its issuance, the state hospital or CPB has a written order signed by the issuing physician. (j) Periodic evaluation. To determine the need for continued inpatient treatment, a physician or physician's designee must evaluate and document justification for continued stay for an individual voluntarily receiving acute inpatient treatment as often as clinically indicated, but no less than once a week. Source Note: The provisions of this §306.175 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.175 Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224275 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224275 03/12/2026 (a) Acceptance for preliminary examination. In accordance with Texas Health and Safety Code §573.021 and §573.022, a state hospital or CPB must accept for a preliminary examination: (1) an individual, of any age, who has been apprehended and transported to the state hospital or CPB by a peace officer or by emergency medical services personnel in accordance with Texas Health and Safety Code §573.001 or §573.012; or (2) an adult who has been transported to the state hospital or CPB by the adult's guardian in accordance with Texas Health and Safety Code §573.003. (b) Preliminary examination. (1) A physician must conduct a preliminary examination of an individual as soon as possible but not more than 12 hours after the individual is transported to the state hospital or CPB for emergency detention. (2) The preliminary examination must consist of: (A) an assessment for medical stability; and (B) a psychiatric examination, including a substance use assessment if indicated, to determine if the individual meets the criteria described in subsection (c)(1) of this section. (c) Requirements for emergency detention. The state hospital or CPB may admit an individual for emergency detention if: (1) in accordance with Texas Health and Safety Code §573.022(a)(2), a physician determines from the preliminary examination that: (A) the individual has a mental illness; (B) the individual evidences a substantial risk of serious harm to himself or others; (C) the described risk of harm is imminent unless the individual is immediately detained; and (D) emergency detention is the least restrictive means by which the necessary detention may be accomplished; (2) in accordance with Texas Health and Safety Code §573.022(a)(3), a physician must make a written statement documenting the determination described in paragraph (1) of this subsection and describing: (A) the nature of the individual's mental illness; (B) the risk of harm the individual evidences, demonstrated either by the individual's behavior or by evidence of severe emotional distress and deterioration in the individual's mental condition to the extent that the individual cannot remain at liberty; and (C) the detailed information on which the physician based the determination; (3) the physician issues and signs a written order admitting the individual for emergency detention; and (4) the individual meets the admission criteria of the state hospital or CPB. (d) Release. (1) The state hospital or CPB must release the individual accepted for a preliminary examination if: (A) a preliminary examination of the individual has not been conducted within 12 hours after the individual is apprehended and transported to the facility by the peace officer or transported for emergency detention; or (B) in accordance with Texas Health and Safety Code §573.023(a), the individual is not admitted for emergency detention on completion of the preliminary examination. (2) If the state hospital or CPB does not admit the individual on an emergency detention in accordance with Texas Health and Safety Code Chapter 573, the facility must contact the designated LMHA or LBHA to provide referrals and referral follow-up for ongoing services as clinically indicated to address the individual's mental health needs. (A) The LMHA or LBHA in the individual's county of residence must contact the individual within 24 hours of being notified that the individual does not meet emergency detention criteria. (B) The LMHA or LBHA must provide referrals and referral follow-up for ongoing services as clinically indicated to address the individual's mental health needs, as applicable, when the individual does not meet admission criteria to a state hospital or CPB. (3) In accordance with Texas Health and Safety Code §576.007(a), if an individual who is an adult is not admitted on emergency detention, the state hospital or CPB must make a reasonable effort to notify the individual's family, or any other person providing support as authorized by the individual and LAR, if applicable, before the individual is released. (e) Intake assessment. An assessment professional for a state hospital or CPB must conduct an intake assessment as soon as possible, but not later than 24 hours after an individual is admitted for emergency detention. All documents related to the intake assessment must be provided to the individual or LAR and include: (1) a request for relevant information about the individual, such as: (A) psychiatric and medical history; (B) social history; (C) symptomology; (D) support systems; (E) finances; (F) third-party coverage or insurance benefits; and (G) advance directives; and(2) a written and oral explanation of:(A) the individual's rights described in Chapter 320, Subchapter A of this title(relating to Rights of Individuals Receiving Mental Health Services); (B) the state hospital's or CPB's services and treatment as the services and treatment relate to the individual; (C) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008; and (D) the individual's trust fund account, charges for services, and the financial responsibility form. Source Note: The provisions of this §306.176 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.176 Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224276 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224276 03/12/2026 (a) A state hospital or CPB may admit an individual after receiving: (1) an order of protective custody only if a court has issued a protective custody order in accordance with Texas Health and Safety Code §574.022 and the facility has received it; or (2) for court-ordered inpatient mental health services only if a court has issued: (A) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code §574.034, or Texas Family Code Chapter 55; (B) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code §574.035, or Texas Family Code Chapter 55; (C) an order for commitment issued in accordance with the Texas Code of Criminal Procedure Chapter 46B; or (D) an order for commitment issued in accordance with the Texas Code of Criminal Procedure Chapter 46C. (b) If a state hospital or CPB admits an individual in accordance with subsection (a) of this section, a physician, PA, or APRN must issue and sign a written order admitting the individual.(c) A state hospital or CPB must conduct an intake assessment with the individual, and LAR, if applicable, as soon as possible, but not later than 24 hours after the individual is admitted under a protective custody order or court-ordered inpatient mental health services. The intake assessment must include: (1) a request for relevant information about the individual, including: (A) psychiatric and medical history; (B) social history; (C) symptomology; (D) support systems; (E) finances; (F) third-party coverage or insurance benefits; and (G) advance directives; and(2) a written and oral explanation provided to the individual or LAR of:(A) the individual's rights described in Chapter 320, Subchapter A of this title(relating to Rights of Individuals Receiving Mental Health Services); (B) the state hospital's or CPB's services and treatment as the services and treatment relate to the individual; and (C) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008. Source Note: The provisions of this §306.177 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.177 Admission Criteria Under Order of Protective Custody or Court-ordered Inpatient Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224277&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224277 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224277&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224277 03/12/2026 A state hospital or CPB must continue to provide inpatient services to an individual involuntarily receiving treatment after the individual is eligible for discharge as described in §306.204 of this subchapter (relating to Discharge of an Individual Involuntarily Receiving Treatment), if, after consultation with the designated LMHA or LBHA: (1) the state hospital or CPB obtains written consent for voluntary inpatient services that meets the requirements of a request for voluntary admission, as described in §306.175(a) of this subchapter (relating to Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed); and (2) the individual's treating physician: (A) examines the individual; and (B) based on the examination in subparagraph (A) of this paragraph, issues an order for voluntary inpatient services that meets the requirements of §306.175(i) of this subchapter. Source Note: The provisions of this §306.178 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.178 Voluntary Treatment Following Involuntary Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224278 03/12/2026 (a) The individual, LAR, if applicable, any other person authorized by the individual, state hospital staff, or the designated LMHA or LBHA, may initiate a request to transfer an individual from one state hospital to another state hospital. (b) A transfer between state hospitals may occur when deemed advisable by the administrator of the transferring state hospital with the agreement of the administrator of the receiving state hospital based on: (1) the condition and desires of the individual; (2) geographic residence of the individual; (3) program and bed availability; and (4) geographical proximity to the individual's family and any other person authorized by the individual and LAR, if applicable. (c) An individual voluntarily receiving treatment may not be transferred without the consent of the individual or LAR who made the request for voluntary admission in accordance with §306.175(a)(1) of this subchapter (relating to Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed).(d) In accordance with Texas Health and Safety Code §575.011 and §575.017, if a state hospital transfers an individual receiving court-ordered inpatient mental health services from one state hospital to another state hospital, the transferring state hospital must notify the committing court and the designated LMHA, LBHA, or LIDDA of the transfer. (e) If a prosecuting attorney has notified the state hospital administrator that an individual has criminal charges pending, the administrator must notify the judge of the court before which charges are pending if the individual transfers to another state hospital. (f) For an individual transferring between a state hospital and a maximum-security unit or adolescent forensic unit, 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness) governs the transfer. Source Note: The provisions of this §306.191 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.191 Transfers Between State Hospitals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224279 03/12/2026 (a) For an individual transferring from a state hospital to an SSLC:(1) the state hospital and designated LIDDA must comply with: (A) Chapter 904, Subchapter C, of this title (relating to Transfers); and (B) Texas Health and Safety Code §575.013 and §575.017; and (2) the state hospital must not transfer the individual before the judge of the committing court enters an order approving the transfer. (b) For an individual transferring from an SSLC to a state hospital: (1) the following rules and statutes govern the transfer:(A) Section 902.1 of this title (relating to Transfer of an Individual from a State Supported Living Center to a State Hospital); (B) Texas Health and Safety Code §594.034; and(C) Texas Health and Safety Code §575.012; and (2) the receiving state hospital and the initiating SSLC must notify the designated LMHA, LBHA, or LIDDA of the transfer. Source Note: The provisions of this §306.192 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective January 5, 2022, 46 TexReg 9397; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.192 Transfers Between a State Hospital and a State Supported Living Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224280 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224280 03/12/2026 A transfer between a state hospital and an out-of-state facility is governed by Chapter 903 of this title (relating to Interstate Compact on Mental Health and Intellectual and Developmental Disabilities). Source Note: The provisions of this §306.193 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.193 Transfers Between a State Hospital and an Out-of-State Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224281 03/12/2026 (a) In accordance with Texas Health and Safety Code §575.011, §575.014, and §575.017, an individual may transfer between a state hospital and a psychiatric hospital not operated by HHSC. The state hospital must notify the designated LMHA or LBHA of the transfer. A state hospital must not transfer an individual voluntarily receiving treatment without the consent of the individual or LAR who made the request for voluntary admission in accordance with §306.175(a)(1) of this subchapter (relating to Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed). (b) In accordance with Texas Health and Safety Code §575.015, an individual may transfer from a state hospital to a federal agency. The transferring state hospital must notify the designated LMHA or LBHA of the transfer. (c) In accordance with Texas Health and Safety Code §575.016 and §575.017, an individual may transfer from a facility of the institutional division of the Texas Department of Criminal Justice to a state hospital. Source Note: The provisions of this §306.194 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.194 Transfers Between a State Hospital and Another Facility in Texas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224282 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224282 03/12/2026 (a) If an individual currently receiving LMHA or LBHA services intends to move the individual's permanent residence to a county within the local service area of another LMHA or LBHA and seek services from the new LMHA or LBHA the following requirements apply. (1) The originating LMHA or LBHA must: (A) ensure the CoC liaison submits requested information to the new LMHA or LBHA, including treatment information pertinent to the individual's continuity of care within seven days after the request, and coordinate an intake appointment at the receiving LMHA or LBHA;(B) ensure the CoC liaison initiates transition planning with the receiving LMHA or LBHA in accordance with §306.155(20) of this subchapter (relating to Local Mental Health Authority, Local Behavioral Health Authority, and Continuity of Care Liaison Responsibilities); (C) educate the individual or LAR on the provisions of this subchapter regarding the individual's transfer, consisting of: (i) information regarding walk-in intake services, if applicable, where no appointment is scheduled for the individual's initial intake to determine eligibility; (ii) the rights of an individual eligible for services; (iii) notification for the receiving LMHA or LBHA of the individual's intent to move the individual's permanent residence;(iv) the point of contact at the receiving LMHA or LBHA;(v) the 988 Suicide and Crisis Lifeline; and(vi) the receiving LMHA's or LBHA's crisis hotline; (D) assist in facilitating and scheduling the intake appointment at the new LMHA or LBHA once the relocation has been confirmed; (E) ensure the individual has sufficient medication for up to 90 days or to last until the medication management appointment date at the receiving LMHA or LBHA; and(F) maintain the individual's case in open status in the applicable HHSC automation system for 90 days or until notified that the individual has been admitted to services at the receiving LMHA or LBHA, whichever occurs first. (2) The receiving LMHA or LBHA must:(A) initiate transition planning with the originating LMHA or LBHA;(B) promptly request records pertinent to the individual's treatment, with the individual's consent or the consent of the LAR;(C) conduct an intake assessment in accordance with §301.353(a) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) and determine whether the individual should receive services immediately or be placed on a waiting list for services;(D) if the individual is eligible and is not on the waitlist, authorize an initial 180 days of services for an adult and 90 days for a child or an adolescent for transitioning and ongoing care, including the provision of medications;(E) authorize the individual in the same level of care at the initial assessment in accordance with §301.327 of this title (relating to Access to Mental Health Community Services) and pursuant to Medicaid regulations and policies;(F) provide the appropriate services based on the clinical needs of the individual;(G) if there are resource limitations for the receiving LMHA or LBHA, follow the process outlined in §301.327 of this title; and(H) initiate contact with individual within 14 days.(3) If the individual or LAR seeks services from the new LMHA or LBHA without prior knowledge of the originating LMHA or LBHA: (A) the receiving LMHA or LBHA must: (i) initiate transition planning with the originating LMHA or LBHA; (ii) promptly request records pertinent to the individual's treatment, with the individual's consent, if applicable; (iii) conduct an intake assessment in accordance with §301.353(a) of this title and determine whether the individual should receive services immediately or be placed on a waiting list for services; and (iv) if the individual is eligible and is not on the waitlist, authorize an initial 180 days of services for an adult and 90 days for a child or an adolescent for transitioning and ongoing care, including the provision of medications; and (B) the originating LMHA or LBHA must: (i) submit requested information to the new LMHA or LBHA within seven days after the request; and (ii) maintain the individual's case in open status in the applicable HHSC automation system for 90 days or until notified that the individual has been admitted to services at the new LMHA or LBHA, whichever occurs first. (4) If the new LMHA or LBHA denies services to the individual during the transition period, or reduces or terminates services at the conclusion of the authorized period, the new LMHA or LBHA must notify the individual or LAR in writing within ten business days of the proposed action and the right to appeal the proposed action in accordance with §306.154 of this subchapter (relating to Notification and Appeals Process for Local Mental Health Authority or Local Behavioral Health Authority Services). (b) Requirements related to an individual receiving inpatient services at a state hospital or CPB. If an individual at a state hospital or CPB or LAR informs the state hospital or CPB that the individual intends to move the individual's permanent residence to a county within the local service area of another LMHA or LBHA and seek services from the new LMHA or LBHA: (1) the state hospital or CPB must notify the following of the individual's intent to move the individual's permanent residence upon discharge: (A) the originating LMHA or LBHA, if the individual was receiving LMHA or LBHA services from the originating LMHA or LBHA before admission to the state hospital or CPB; and (B) the new LMHA or LBHA; (2) the following must participate in the individual's discharge planning in accordance with §306.201 of this subchapter (relating to Discharge Planning): (A) the state hospital or CPB; (B) the new LMHA or LBHA; and (C) the originating LMHA or LBHA, if the individual was receiving LMHA or LBHA services from the originating LMHA or LBHA before admission to the state hospital or CPB; and (3) if the individual was receiving LMHA or LBHA services from the originating LMHA or LBHA before admission to the state hospital or CPB, the originating LMHA or LBHA must maintain the individual's case in open status in the applicable HHSC automation system for 90 days or until notified that the individual is admitted to services at the new LMHA or LBHA, whichever occurs first. Source Note: The provisions of this §306.195 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.195 Changing Local Mental Health Authorities or Local Behavioral Health Authorities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224284 03/12/2026 (a) At the time of an individual's admission to a state hospital or CPB, the designated LMHA or LBHA, if applicable, and the state hospital or CPB must begin discharge planning for the individual. The state hospital or CPB must send an electronic admission initial notification within three business days to the appropriate LMHA, LBHA, and LIDDA to initiate discharge planning. (b) The designated LMHA or LBHA CoC liaison or other designated staff; the designated LIDDA continuity of care worker, if applicable; the individual; the LAR, if applicable; and any other person authorized by the individual, such as guardian ad litem or attorney ad litem, must participate in discharge planning with the state hospital or CPB. The state hospital or CPB must initiate coordination of discharge planning.(1) Except for the state hospital or CPB treatment team and the individual, involvement in discharge planning may be through teleconference or video-conference calls.(2) The state hospital or CPB must invite the LMHA, LBHA, or LIDDA, as applicable, to routine recovery or treatment plan meetings as well as any additional meetings that arise specific to discharge planning. The state hospital or CPB must notify meeting participants a minimum of 24 hours before each scheduled meeting regarding recovery or treatment planning and any additional meetings specific to discharge planning. (3) The state hospital or CPB must ensure the development and completion of the discharge plan as listed in subsection (c) of this section and coordinate with the LMHA, LBHA, or LIDDA, if applicable, before the individual's discharge.(4) The LMHA or LBHA must facilitate the transition of individuals who are determined by the state hospital or CPB to be medically appropriate for discharge in accordance with Texas Health and Safety Code §534.0535 from a facility to a community setting by connecting the individuals to resources available in the individuals' county of residence or choice. (c) Discharge planning must consist of the following activities: (1) Considering all pertinent information about the individual's clinical needs, the state hospital or CPB must identify and recommend specific clinical services and supports needed by the individual after discharge or while on pass or furlough. (2) The state hospital or CPB and the LMHA, LBHA, or LIDDA, if applicable, must jointly identify, recommend, and help coordinate access to services for the individual and LAR, if applicable, regarding specific non-clinical services and supports needed by the individual after discharge, including the individual's need for housing, supported employment, education resources, and food assistance, clothing resources, and other supplemental supports or governmental benefits as applicable. (3) If an individual needs a living arrangement, the LMHA or LBHA CoC liaison or LIDDA continuity of care worker must:(A) identify a living arrangement consistent with the individual's clinical needs and preference that is available and has accessible services and supports as agreed upon by the individual or LAR; or(B) ensure the individual or LAR is referred to housing services and support the individual through the process of obtaining and applying for housing services during the discharge planning process if a living arrangement is unavailable. (4) The LMHA or LBHA CoC liaison or LIDDA continuity of care worker in collaboration with the individual and LAR, if applicable, must identify potential providers and resources for the recommended services and supports and arrange for provision of services upon discharge in accordance with Texas Health and Safety Code §534.0535. (5) The state hospital or CPB must attempt to educate the individual and LAR, if applicable, to prepare the individual for care after discharge or while on pass or furlough. (6) The state hospital or CPB must provide the individual and LAR, if applicable, with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008. (7) The LMHA, LBHA, or LIDDA must comply with the PASRR processes as described in Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)) for an individual referred to a nursing facility. (d) Before an individual's discharge or approval for a pass or furlough: (1) the individual's treatment team must ensure the development of a plan to include the individual's stated goals. The plan must consist of: (A) a description of the individual's living arrangement after discharge, or while on pass or furlough, that reflects the individual's preferences, choices, and available community resources; (B) arrangements and referrals for the available and accessible services and supports agreed upon by the individual or LAR recommended in the individual's discharge plan; (C) a written description of recommended clinical and non-clinical services and supports the individual receives after discharge or while on pass or furlough;(D) documentation of arrangements and referrals for the services and supports recommended upon discharge or while on pass or furlough. (E) a description of behavioral health symptoms identified at discharge or before a pass or furlough, including any symptoms that may disrupt the individual's stability in the community; (F) the individual's goals, strengths, interventions, and objectives as stated in the individual's discharge plan in the state hospital or CPB; (G) comments or additional information; (H) a final diagnosis based on the version of the DSM currently recognized by HHSC;(I) the names, contact information, and addresses of providers to whom the individual will be referred for any services or supports after discharge or while on pass or furlough; and (J) a description of: (i) the types and amount of medication the individual needs after discharge or while on pass or furlough until the individual is evaluated by a physician; or (ii) for 90 days after discharge, the person or entity responsible for providing and paying for the medication. (2) The state hospital or CPB must request that the individual or LAR sign the discharge plan and document in the discharge plan whether the individual or LAR agree or disagree with the plan. (3) If the individual or LAR refuses to sign the discharge plan described in paragraph (2) of this subsection, the state hospital or CPB must document in the individual's record whether the individual or LAR agrees to the plan or not, reasons stated, and any other circumstances of the refusal. (4) If applicable, the individual's treating physician must document in the individual's record reasons why the individual does not require continuing care or a discharge plan. (5) If the LMHA or LBHA disagrees with the state hospital or CPB treatment team's decision concerning discharge: (A) the treating physician of the state hospital or CPB must consult with the LMHA or LBHA physician or designee to resolve the disagreement within 24 hours; and(B) if the disagreement continues unresolved, the medical director or designee of the state hospital or CPB must refer the issue to the Texas State Hospitals Chief Medical Officer to render a final determination. (e) Discharge notice to family or LAR. (1) In accordance with Texas Health and Safety Code §576.007, before discharging an adult, the state hospital or CPB must make a reasonable effort to notify the individual's family or any identified person providing support to the individual. Discharge notification requires authorization by the individual or LAR.(2) Before discharging an individual who is at least 16 years of age, but younger than 18 years of age, who voluntarily consented for the individual's own admission, the state hospital or CPB must make a reasonable effort to notify the individual's LAR, if applicable, of the discharge within 72 hours before the date of discharge. (3) Before discharging a minor for whom a parent, managing conservator, or guardian provided consent for admission, the state hospital or CPB must notify the minor's LAR of the discharge. (f) Release of minors. Upon discharge, the state hospital or CPB may release a minor only to the minor's LAR or the LAR's designee. (1) If the LAR or the LAR's designee is unwilling to retrieve the minor from the state hospital or CPB and the LAR is not a state agency: (A) the state hospital or CPB must: (i) notify DFPS, so DFPS can take custody of the minor from the state hospital or CPB; (ii) refer the matter to the LMHA or LBHA to schedule a meeting with representatives from the required agencies described in subsection (f)(2)(A) of this section, the LAR, and minor to explore resources and make recommendations; (iii) document the LMHA or LBHA referral in the discharge plan; (iv) refer the matter to the local CRCG to schedule a meeting with representation from the required agencies described in subsection (f)(2)(A) of this section, the LAR, and the minor to explore resources and make recommendations; and(v) document the CRCG referral in the discharge plan; and(B) the medical directors or the medical directors' designees of the state hospital or CPB; designated LMHA, LBHA, or LIDDA; and DFPS must meet to develop and finalize the discharge recommendations. (2) If the LAR is a state agency unwilling to assume physical custody of the minor from the state hospital or CPB, the state hospital or CPB must: (A) refer the matter to the local CRCG office, or state CRCG office if applicable, to schedule a meeting with representatives from the member agencies, in accordance with 40 TAC, Part 19, Chapter 702, Subchapter E (relating to Memorandum of Understanding with Other State Agencies), the LAR, and minor to explore resources and make recommendations; and (B) document the CRCG referral in the discharge plan. (g) Notice to the designated LMHA, LBHA, or LIDDA. At least 24 hours before an individual's planned discharge, pass, or furlough, and no later than 24 hours after an unexpected discharge, a state hospital or CPB must notify the designated LMHA, LBHA, or LIDDA of the anticipated or unexpected discharge and convey the following information about the individual: (1) identifying information, including address and contact information of the individual or LAR; (2) legal status, for example, regarding guardianship, charges pending, or custody if the individual is a minor; (3) the day and time the individual will be discharged or participating in a pass or furlough; (4) the individual's destination address after discharge, or while on pass or furlough; (5) medical information; (6) current medications; (7) clinical documentation, including information regarding a COPSD, an ID, or a DD; and (8) other pertinent treatment information, including the discharge plan. (h) Discharge packet. (1) At a minimum, a discharge packet must include: (A) the discharge plan; (B) referral instructions, including: (i) state hospital or CPB contact person; (ii) name of the designated LMHA or LBHA CoC liaison or LIDDA continuity of care worker; (iii) names of community resources and providers to whom the individual is referred, including contacts, appointment dates and times, addresses, and phone numbers; (iv) a description of to whom or where the individual is released upon discharge, including the individual's intended residence, address, and phone number; (v) instructions for the individual or LAR; (vi) medication regimen and prescriptions, as applicable; and (vii) dated signature of the individual or LAR and a member of the state hospital or CPB treatment team; (C) copies of all available, pertinent, current summaries, and assessments; and (D) the treating physician's orders. (2) At discharge, or while on pass or furlough, the state hospital or CPB provides a copy of the discharge packet or pass or furlough plan to the individual and LAR, if applicable. An individual or LAR may request additional records.(3) Within 24 hours after discharge, or while on pass or furlough, the state hospital or CPB must send a copy of the discharge packet or pass or furlough plan to: (A) the designated LMHA, LBHA, or LIDDA; and (B) the providers to whom the individual is referred, including: (i) an LMHA or LBHA network provider, if the LMHA or LBHA is responsible for ensuring the individual's services after discharge or while on pass or furlough; (ii) an alternate provider if the individual requested referral to an alternate provider; and (iii) a county jail if the individual will be transported to the county jail upon discharge. (i) Unexpected Discharge. (1) The state hospital or CPB and the designated LMHA, LBHA, or LIDDA must make reasonable efforts to provide discharge planning for an individual discharged unexpectedly. (2) If there is an unexpected discharge, the state hospital or CPB social worker or a designee must document the reason for not completing discharge planning activities in the individual's record. (j) Transportation. A state hospital or CPB must: (1) initiate and secure transportation in collaboration with an LMHA, an LBHA, or a LIDDA pursuant to an individual's discharge or pass or furlough plan; and (2) inform a designated LMHA, LBHA, or LIDDA of an individual's transportation needs after discharge or while on pass or furlough. (k) Discharge summary. (1) Within ten days after an individual's discharge, the individual's physician of the state hospital or CPB must complete a written discharge summary for the individual. (2) Within 21 days after an individual's discharge from an LMHA or LBHA, the LMHA or LBHA must complete a written discharge summary for the individual. (3) The written discharge summary must include: (A) a description of the individual's treatment and the individual's response to that treatment; (B) a description of the level of care for services received; (C) a description of the individual's level of functioning at discharge; (D) a description of the individual's living arrangement after discharge; (E) a description of the community services and supports the individual will receive after discharge; (F) a final diagnosis based on the version of the DSM currently recognized by HHSC; and (G) a description of the amount of medication available to the individual, if applicable. (4) The discharge summary must be sent to the individual's: (A) designated LMHA, LBHA, or LIDDA, as applicable; and (B) providers to whom the individual was referred. (5) Documentation of refusal. If the individual or LAR refuses to participate in the discharge planning, the circumstances of the refusal must be documented in the individual's record.(l) An LMHA or LBHA must provide continuity of care services designed to support joint discharge planning efforts in accordance with Texas Health and Safety Code §534.0535. Source Note: The provisions of this §306.201 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.201 Discharge Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224285 03/12/2026 (a) Three Admissions Within 180 Days. An individual admitted to a state hospital or CPB three times within 180 days is considered at risk for future admission to inpatient services. To prevent potentially unnecessary admissions to an inpatient facility, the designated LMHA or LBHA must: (1) during discharge planning, review the individual's previous recovery or treatment plans to determine the effectiveness of the clinical services received; (2) include in the recovery or treatment plan: (A) non-clinical supports, such as those provided by a mental health peer specialist or recovery support peer specialist, identified to support the individual's ongoing recovery; and (B) recommendations for services and interventions from the individual's current or previous care plan that support the individual's strengths and goals and prevent unnecessary admission to a state hospital or CPB; (3) determine the availability and level of care, including type, amount, scope, and duration of clinical and non-clinical supports, such as those provided by a mental health peer specialist or recovery support peer specialist, that promote ongoing recovery and prevent unnecessary admission to a state hospital or CPB; and (4) consider appropriateness of the individual's continued stay in the state hospital or CPB. (b) Discharge Planning Specialists. Pursuant to Texas Health and Safety Code §534.053, each state hospital must designate at least one employee to deliver continuity of care services for individuals who are determined medically appropriate for discharge from the facility. The state hospital must concentrate the provision of continuity of care services for individuals who have been: (1) admitted to and discharged from a state hospital three or more times during a 30-day period; or (2) in the state hospital for longer than 365 consecutive days. (c) Nursing Facility Referral or Admission. (1) In accordance with 42 CFR Part 483, Subpart C, and as described in Chapter 554, Subchapter BB of this title (relating to Nursing Facility Responsibilities Related to Preadmission Screening and Resident Review (PASRR)), a nursing facility must coordinate with the referring entity to ensure the referring entity screens the individual for admission to the nursing facility before the nursing facility admits the individual. (2) As the referring entity, the state hospital or CPB must complete a PL1 Screening and forward the completed form in accordance with §303.301 of this title (relating to Referring Entity Responsibilities Related to the PASRR Process). (3) The LMHA, LBHA, or LIDDA must conduct a PE in accordance with Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)). (4) If a nursing facility admits an individual while on pass or furlough, the designated LMHA or LBHA must conduct and document, including justification for its recommendations, the activities described in paragraphs (5) and (6) of this subsection. (5) The designated LMHA or LBHA must make at least one in-person contact with the individual at the nursing facility while on pass or furlough. The contact must consist of: (A) a review of the individual's record at the nursing facility; and (B) discussions with the individual, the LAR, if applicable, the nursing facility staff, and other staff who provide care to the individual regarding: (i) the individual's needs and the care the individual is receiving; (ii) the ability of the nursing facility to provide the appropriate care; (iii) the provision of mental health services, if needed by the individual; and (iv) the individual's adjustment to the nursing facility. (6) Before the end of the initial pass or furlough period described in §306.205(a) of this subchapter (relating to Pass or Furlough from a State Hospital or Facility with a Contracted Psychiatric Bed, the designated LMHA or LBHA must recommend to the state hospital or CPB one of the following: (A) discharging the individual if the LMHA or LBHA determines that: (i) the nursing facility is capable and willing to provide appropriate care to the individual after discharge; (ii) any mental health services needed by the individual are being provided to the individual while residing in the nursing facility; and (iii) the individual and LAR, if applicable, agrees to the nursing facility admission; (B) extending the individual's pass or furlough period in accordance with §306.205(a)(2) of this subchapter; (C) returning the individual to the state hospital or CPB in accordance with §306.205 of this subchapter (relating to Pass or Furlough from a State Hospital or a Facility with a Contracted Psychiatric Bed); or (D) initiating involuntary admission to the state hospital or CPB in accordance with §306.176 (relating to Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention) and §306.177 (relating to Admission Criteria Under Order of Protective Custody or Court-ordered Inpatient Mental Health Services) of this subchapter. (d) Assisted Living. (1) A state hospital, a CPB, an LMHA, or an LBHA may only refer an individual to an assisted living facility that is licensed under Texas Health and Safety Code Chapter 247. (2) As required by Texas Health and Safety Code §247.063(b), if a state hospital, a CPB, an LMHA, or an LBHA gains knowledge of an assisted living facility not operated or licensed by the state, the state hospital, CPB, LMHA, or LBHA must report the name, address, and telephone number of the facility to HHSC Complaint and Incident Intake at 1-800-458-9858. (e) Minors. (1) To the extent permitted by medical privacy laws, the state hospital or CPB and designated LMHA or LBHA must make a reasonable effort to involve a minor's LAR or the LAR's designee in the treatment and discharge planning process. (2) A minor committed to or placed in a state hospital or CPB under Texas Family Code Chapter 55, Subchapter C or D, shall be discharged in accordance with the Texas Family Code Chapter 55, Subchapter C or D as applicable. (f) An individual suspected of having an ID. If a state hospital or CPB suspects an individual has an ID, the state hospital or CPB must notify the designated LMHA or LBHA CoC liaison and the designated LIDDA to: (1) assign a LIDDA continuity of care worker to the individual; and (2) conduct an assessment in accordance with Chapter 304 of this title (relating to Diagnostic Assessment). (g) Criminal Code. (1) Texas Code of Criminal Procedure Chapter 46B.(A) An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Article 46B.102 may only be discharged by order of the committing court under Texas Code of Criminal Procedure, Article 46B.107.(B) An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Article 46B.073 must be discharged and transferred, in accordance with Texas Code of Criminal Procedure Article 46B.081 through Article 46B.083. (C) For an individual committed under Texas Code of Criminal Procedure Chapter 46B, who is discharged and returned to the committing court, the state hospital or CPB, within 24 hours after discharge, must notify the following of the discharge: (i) the individual's designated LMHA or LBHA; and (ii) the TCOOMMI. (2) Texas Code of Criminal Procedure Chapter 46C: Insanity defense. An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Chapter 46C may only be discharged by order of the committing court in accordance with Texas Code of Criminal Procedure Article 46C.253 or Article 46C.268. (h) Offenders with special needs following discharge from a state hospital or CPB. The LMHA or LBHA must comply with the requirements as defined by the LMHA's and LBHA's TCOOMMI contract for offenders with special needs. (1) An LMHA or LBHA that receives a referral for an offender with special needs in the MH priority population from a county or city jail at least 24 hours before the individual's release must complete one of the following actions: (A) if the offender with special needs is currently receiving LMHA or LBHA services, the LMHA or LBHA must: (i) notify the offender with special needs of the referral from a county or city jail; (ii) arrange an in-person contact between the offender with special needs and a QMHP-CS to occur within 15 days after the individual's release; and (iii) ensure that the QMHP-CS, at the in-person contact, reassesses the individual and arranges for appropriate services, including transportation needs at the time of release; (B) if the individual is not currently receiving LMHA or LBHA services from the LMHA or LBHA that is notified of the referral, the LMHA or LBHA must:(i) ensure that at the in-person contact required in subparagraph (A) of this paragraph, the QMHP-CS conducts a pre-admission assessment in accordance with §301.353(a) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization); and (ii) comply with §306.161(b) of this subchapter (relating to Screening and Assessment), as applicable; or (C) if the LMHA or LBHA is unable to conduct an in-person contact with the individual required in paragraph (1)(A) of this subsection, the LMHA or LMHA must document the reasons for not doing so in the individual's record. (2) If an LMHA or LBHA is notified of the anticipated release from prison or a state jail of an offender with special needs in the MH priority population who is currently taking psychoactive medications for a mental illness and who will be released with a 30-day supply of the psychoactive medications, the LMHA or LBHA must arrange an in-person contact required in paragraph (1)(A) of this subsection between the individual and QMHP-CS within 15 days after the individual's release. (A) If the offender with special needs is released from state prison or state jail after hours or the LMHA or LBHA is otherwise unable to schedule the in-person contact required in paragraph (2) of this subsection before the individual's release, the LMHA or LBHA must make a good faith effort to locate and contact the individual. If the designated LMHA or LBHA is unable to have an in-person contact with the individual within 15 days after being released, the LMHA or LBHA must document the reasons for not doing so in the individual's record. (B) At the in-person contact required in paragraph (2) of this subsection: (i) the QMHP-CS with appropriate supervision and training must perform an assessment in accordance with §301.353(a) of this title and comply with §306.161(b) and (c) of this subchapter, as applicable; and (ii) if the LMHA or LBHA determines that the offender with special needs should receive services immediately, the LMHA or LBHA must arrange for the individual to meet with a physician or designee authorized by state law to prescribe medication before the individual requires a refill of the prescription. (C) If the LMHA or LBHA is unable to conduct an in-person contact with the offender with special needs required in paragraph (2) of this subsection, the LMHA or LBHA must document the reasons for being unable to do so in the individual's record. (3) If the offender with special needs is on parole or probation, the state hospital or CPB must notify a representative of TCOOMMI before the discharge of the individual known to be on parole or probation. Source Note: The provisions of this §306.202 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.202 Special Considerations for Discharge Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224286 03/12/2026 (a) A state hospital or CPB must discharge an individual voluntarily receiving treatment if the administrator or designee of the state hospital or CPB concludes that the individual can no longer benefit from inpatient services based on the physician's determination, as delineated in Division 5 of this subchapter (relating to Discharge and Absences from a State Hospital or a Facility with a Contracted Psychiatric Bed). (b) If an individual voluntarily receiving treatment or LAR makes a written request for discharge: (1) the state hospital or CPB must discharge the individual in accordance with Texas Health and Safety Code §572.004; and (2) the individual or LAR must sign, date, and document the time on the discharge request. (c) In accordance with Texas Health and Safety Code §572.004, if an individual informs a staff member of a state hospital or CPB of the individual's desire to leave the state hospital or CPB, the state hospital or CPB must: (1) as soon as possible, assist the individual in documenting the written request and obtaining the necessary signature; and (2) within four hours after a written request is made known to the state hospital or CPB, notify: (A) the treating physician; or (B) another physician who is a state hospital or CPB staff member, if the treating physician is not available during that period. (d) Results of physician notification required by subsection (c)(2) of this section. (1) In accordance with Texas Health and Safety Code §572.004(c) and (d): (A) a state hospital or CPB, based on a physician's determination, must discharge an individual within the four-hour period described in subsection (c)(2) of this section; or (B) if the physician who is notified in accordance with subsection (c)(2) of this section has reasonable cause to believe that the individual may meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician must examine the individual as soon as possible, but no later than 24 hours, after the request for discharge is made known to the state hospital or CPB. (2) Reasonable cause to believe that the individual may meet the criteria for court-ordered inpatient mental health services or emergency detention. (A) If a physician does not examine an individual who may meet the criteria for court-ordered inpatient mental health services or emergency detention within 24 hours after the request for discharge is made known to the state hospital or CPB, the facility must discharge the individual. (B) If a physician, in accordance with Texas Health and Safety Code §572.004(d), examines the individual as described in paragraph (1)(B) of this subsection and determines that the individual does not meet the criteria for court-ordered inpatient mental health services or emergency detention, the state hospital or CPB must discharge the individual upon completion of the examination. (C) If a physician, in accordance with Texas Health and Safety Code §572.004(d), examines the individual as described in paragraph (1)(B) of this subsection and determines that the individual meets the criteria for court-ordered inpatient mental health services or emergency detention, the state hospital or CPB, by 4:00 p.m. on the next business day, must: (i) if the state hospital or CPB intends to detain the individual, require the physician or designee, in accordance with Texas Health and Safety Code §572.004(d), to: (I) file an application for court-ordered inpatient mental health services or emergency detention and obtains a court order for further detention of the individual; (II) notify the individual and LAR, if applicable, of such intention; and (III) document in the individual's record the reasons for the decision to detain the individual; or (ii) discharge the individual. (e) In accordance with Texas Health and Safety Code §572.004(i), after a written request from a minor individual admitted under §306.175(a)(1)(B) of this subchapter (relating to Voluntary Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed, the state hospital or CPB must: (1) notify the minor's parent, managing conservator, or guardian of the request and: (A) if the minor's parent, managing conservator, or guardian objects to the discharge, the minor continues receiving voluntary treatment; or (B) if the minor's parent, managing conservator, or guardian does not object to the discharge, the minor individual is discharged and released to the minor's LAR; and (2) document the request in the minor's record. (f) In accordance with Texas Health and Safety Code §572.004(f)(1), a state hospital or CPB is not required to complete the requirements described in this section if the individual documents and signs a written statement withdrawing the request for discharge. Source Note: The provisions of this §306.203 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.203 Discharge of an Individual Voluntarily Receiving Inpatient Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224287 03/12/2026 (a) Discharge from emergency detention. (1) Except as provided by §306.178 of this subchapter (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code §573.021(b) and §573.023(b), a state hospital or CPB must immediately discharge an individual under emergency detention if: (A) the state hospital administrator, administrator of the CPB, or designee concludes, based on a physician's determination, the individual no longer meets the criteria in §306.176(c)(1) of this subchapter (relating to Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention); or (B) except as provided in paragraph (2) of this subsection: (i) 48 hours has elapsed from the time the individual was presented to the state hospital or CPB; and (ii) the state hospital or CPB has not obtained a court order for further detention of the individual. (2) In accordance with Texas Health and Safety Code §573.021(b), if the 48-hour period described in paragraph (1)(B)(i) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the individual was presented to the state hospital or CPB, the state hospital or CPB may detain the individual until 4:00 p.m. on such business day. (b) Discharge under order of protective custody. Except as provided by §306.178 of this subchapter and in accordance with Texas Health and Safety Code §574.028, a state hospital or CPB must immediately discharge an individual under an order of protective custody if: (1) the state hospital administrator, administrator of the CPB, or designee determines that, based on a physician's determination, the individual no longer meets the criteria described in Texas Health and Safety Code §574.022(a); (2) the state hospital administrator, administrator of the CPB, or designee does not receive notice that the individual's continued detention is authorized after a probable cause hearing held within the period prescribed by Texas Health and Safety Code §574.025(b); (3) a final order for court-ordered inpatient mental health services has not been entered within the period prescribed by Texas Health and Safety Code §574.005; or (4) an order to release the individual is issued in accordance with Texas Health and Safety Code §574.028(a). (c) Discharge under court-ordered inpatient mental health services. (1) Except as provided by §306.178 of this subchapter and in accordance with Texas Health and Safety Code §574.085 and §574.086(a), a state hospital or CPB must immediately discharge an individual under a temporary or extended order for inpatient mental health services if: (A) the order for inpatient mental health services expires; or (B) the state hospital administrator, administrator of the CPB, or designee concludes that, based on a physician's determination, the individual no longer meets the criteria for court-ordered inpatient mental health services. (2) In accordance with Texas Health and Safety Code §574.086(b), before discharging an individual in accordance with paragraph (1) of this subsection, the state hospital administrator, administrator of the CPB, or designee must consider whether the individual should receive court-ordered outpatient mental health services in accordance with a modified order described in Texas Health and Safety Code §574.061. (3) In accordance with Texas Health and Safety Code §574.081, at the time an individual receiving court-ordered inpatient mental health services is furloughed or discharged from a state hospital or CPB, the state hospital or CPB must provide and pay for psychoactive medication and any other medication prescribed to counteract adverse side effects of psychoactive medication. This requirement also applies for a patient on a pass.(A) A state hospital or CPB is only required to provide or pay for these medications if funding to cover the cost of the medications is available to be paid to the facility for this purpose from HHSC. (B) The state hospital or CPB must provide or pay for the medications in an amount sufficient to last until the individual can see a physician, or provider with prescriptive authority, but the state hospital or CPB is not required to provide or pay for more than a seven-day supply. (C) The state hospital or CPB must inform an individual if funding is not available to provide or pay for the medications upon pass, furlough, or discharge, and if funding is not available, the individual's designated LMHA or LBHA is responsible for providing psychoactive medications as provided in §306.207(2)(A) of this division (relating to Post Discharge or Furlough: Contact and Implementation of the Recovery or Treatment Plan), if applicable. (4) An individual committed under Texas Code of Criminal Procedure Chapter 46B or 46C may only be discharged as provided by §306.202(f) of this division (relating to Special Considerations for Discharge Planning). (d) Discharge packet. A state hospital administrator, administrator of a CPB, or designee must forward a discharge packet, as provided in §306.201(h) of this division (relating to Discharge Planning), of any individual committed under the Texas Code of Criminal Procedure to the jail and the LMHA or LBHA in accordance with state and federal privacy laws. Source Note: The provisions of this §306.204 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective January 20, 2021, 46 TexReg 457; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.204 Discharge of an Individual Involuntarily Receiving Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224288 03/12/2026 (a) An individual who is under consideration for discharge as described in §306.203 of this division (relating to Discharge of an Individual Voluntarily Receiving Treatment) or §306.204(c) of this division (relating to Discharge of an Individual Involuntarily Receiving Treatment) may leave the state hospital or CPB while on pass or furlough if the state hospital or CPB and the designated LMHA or LBHA agree that a pass or furlough will be beneficial in implementing the individual's recovery or treatment plan. The designated LMHA or LBHA is responsible for monitoring the individual while the individual is on pass or furlough.(1) If an individual on an involuntary commitment under Texas Health and Safety Code Chapter 574 is authorized for a pass or furlough, the state hospital or CPB must notify the committing court of the individual's absence.(2) The state hospital or CPB may extend an initial pass or furlough if:(A) requested by the designated LMHA or LBHA; and(B) the extension is clinically justified.(3) A furlough that exceeds 60 days must be approved by:(A) the state hospital administrator or designee, or the administrator of the CPB or designee; and(B) the designated LMHA or LBHA executive director or designee. (4) The state hospital or CPB must not authorize a pass or furlough that exceeds the expiration date of the individual's order for inpatient mental health services.(b) The administrator of a state hospital or CPB may contact a peace officer as described under Texas Health and Safety Code §574.083 if:(1) an individual is absent without authority from a state hospital or CPB;(2) the individual has violated the conditions of a pass or furlough; or(3) the individual's condition has deteriorated to the extent that the individual's continued absence under pass or furlough is not appropriate. (c) If the individual is detained in a nonmedical facility by a peace officer, the LMHA or LBHA must ensure the individual receives proper care and medical attention in accordance with Texas Health and Safety Code §574.083. (d) In accordance with Texas Health and Safety Code §574.084, an individual's furlough may be revoked only after an administrative hearing held in accordance with this subsection. (1) The state hospital or CPB must conduct a hearing by a hearing officer who is a mental health professional not directly involved in treating the individual. (2) The state hospital or CPB must: (A) hold an informal hearing within 72 hours after the individual returns to the facility; (B) provide the individual or LAR and facility staff members an opportunity to present information supporting the state hospital's or CPB's position; and (C) provide the individual or LAR the option to select another person or staff member to serve as the individual's advocate. (3) Within 24 hours after the conclusion of the hearing, the hearing officer must determine if:(A) revocation of the furlough is justified because:(i) the individual was absent without authority from the facility;(ii) the individual violated the conditions of the furlough; or(iii) the individual's condition deteriorated to the extent the individual's continued furlough was inappropriate; or(B) the furlough was justified.(4) The hearing office must render the final decision in writing, including the basis for the hearing officer's decision, and place the decision in the individual's file. (5) If the hearing officer's decision does not revoke the furlough, the individual may leave the state hospital or CPB pursuant to the conditions of the furlough. (6) The state hospital or CPB must ensure the individual's record includes a copy of the hearing officer's report. (e) Only the committing criminal court may grant a pass or furlough from a state hospital or CPB for individuals committed under Texas Code of Criminal Procedure Chapter 46B or 46C. Source Note: The provisions of this §306.205 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.205 Pass or Furlough from a State Hospital or a Facility with a Contracted Psychiatric Bed https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224289 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224289 03/12/2026 (a) The designated LMHA or LBHA must:(1) contact an individual following discharge or furlough from a state hospital or CPB; (2) implement the individual's recovery or treatment plan within seven days after discharge in accordance with this section; and(3) ensure the successful transition of the individual determined by the state hospital or CPB to be medically appropriate for discharge in accordance with Texas Health and Safety Code §534.0535. (b) LMHA or LBHA contact after discharge or furlough. (1) The designated LMHA or LBHA must contact an individual in person or using audiovisual technology within seven days after discharge or furlough of an individual who is: (A) discharged or on furlough from a state hospital or CPB and referred to the LMHA or LBHA for services or supports as indicated in the recovery or treatment plan; (B) discharged from an LMHA or LBHA-network provider of inpatient services and referred to the LMHA or LBHA for services or supports as indicated in the recovery or treatment plan; (C) discharged from an alternate provider of inpatient services and receiving LMHA or LBHA services from the designated LMHA or LBHA at the time of admission and who, upon discharge, is referred to the LMHA or LBHA for services or supports as indicated in the recovery or treatment plan; (D) discharged from the LMHA's or LBHA's crisis stabilization unit or any overnight crisis facility and referred to the LMHA or LBHA for services or supports as indicated in the discharge plan; or (E) an offender with special needs discharged from a state hospital or CPB returning to jail. (2) During the contact required by paragraph (1)(A) of this paragraph, the designated LMHA or LBHA must: (A) reassess the individual; (B) ensure the provision of the services and supports specified in the individual's recovery or treatment plan by making the services and supports available and accessible as determined by the individual's level of care; and (C) assist the individual in accessing the services and supports specified in the individual's recovery or treatment plan. (3) The designated LMHA or LBHA must develop or review an individual's recovery or treatment plan in accordance with §301.353(e) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) and consider treatment recommendations in the state hospital's or CPB's discharge plan within ten business days after the contact required by paragraph (1)(A) of this paragraph. (4) The designated LMHA or LBHA must make a good faith effort to contact an individual as required by paragraph (1)(A) of this paragraph. If the designated LMHA or LBHA does not have the required contact with the individual, the LMHA or LBHA must document the attempts made and reasons the contact did not occur in the individual's record. (c) For an individual whose recovery or treatment plan identifies the designated LMHA or LBHA as responsible for providing or paying for the individual's psychoactive medications, the designated LMHA or LBHA must ensure: (1) the provision of psychoactive medications for the individual; and (2) the individual has an appointment with a physician or designee authorized by state law to prescribe medication before the earlier of the following events: (A) the individual's supply of psychoactive medication from the state hospital or CPB has been depleted; or (B) the 15th day after the individual is on furlough or discharged from the state hospital or CPB. (d) The designated LMHA or LBHA must document in an individual's record the LMHA's or LBHA's activities described in this section, and the individual's responses to those activities. Source Note: The provisions of this §306.207 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.207 Post Discharge or Furlough: Contact and Implementation of the Recovery or Treatment Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224283 03/12/2026 (a) Screening training. As required by Texas Health and Safety Code §572.0025(e), a state hospital or CPB staff member whose responsibilities include conducting a screening described in Division 3 of this subchapter (relating to Admission to a State Hospital or a Facility with a Contracted Psychiatric Bed--Provider Responsibilities) must receive at least eight hours of training in the state hospital's or CPB's screening. (1) The screening training must provide instruction regarding: (A) obtaining relevant information about the individual, including information about finances, third-party coverage or insurance benefits, and advance directives; (B) explaining, orally and in writing, the individual's rights described in Chapter 320, Subchapter A of this title(relating to Rights of Individuals Receiving Mental Health Services); (C) explaining, orally and in writing, the state hospital's or CPB's services and treatment as the services and treatment relate to the individual; (D) explaining, orally and in writing, the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008; and (E) determining whether an individual comprehends the information provided in accordance with subparagraphs (B) - (D) of this paragraph. (2) Up to six hours of the following training may count toward the screening training required by this subsection: (A) 25 TAC §417.515 (relating to Staff Training in Identifying, Reporting, and Preventing Abuse, Neglect, and Exploitation); and (B) §320.29 of this title (relating to Staff Training in Rights of Individuals Receiving Mental Health Services). (b) Intake assessment training. As required by Texas Health and Safety Code §572.0025(e), if a state hospital's or CPB's internal policy permits an assessment professional to determine whether a physician should conduct an examination on an individual requesting voluntary admission, the assessment professional must receive at least eight hours of training in conducting an intake assessment pursuant to this subchapter. (1) The intake assessment training must provide instruction regarding assessing and diagnosing in accordance with §301.353 of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization). (2) An assessment professional must receive intake training: (A) before conducting an intake assessment; and (B) annually throughout the professional's employment or association with state hospital or CPB. (c) Documentation of training. A state hospital or CPB must document that each staff member and each assessment professional whose responsibilities include conducting the screening or intake assessment have successfully completed the training described in subsections (a) and (b) of this section, including: (1) the date of the training; (2) the length of the training session; and (3) the name of the instructor. (d) Performance in accordance with training. Each staff member and each assessment professional whose responsibilities include conducting the screening or intake assessment must perform the assessments in accordance with the training required by this section. Source Note: The provisions of this §306.221 adopted to be effective May 20, 2020, 45 TexReg 3301; amended to be effective February 23, 2025, 50 TexReg 997. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM D MENTAL HEALTH SERVICES--ADMISSION, DISCHARGE, AND CONTINUITY OF CARE §306.221 Screening and Intake Assessment Training Requirements at a State Hospital and a Facility with a Contracted Psychiatric Bed https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198047 03/12/2026 The subchapter describes requirements for providing mental health case management services (MH case management services) funded by or through the department. Source Note: The provisions of this §306.251 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.251 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198048 03/12/2026 The subchapter applies to providers of MH case management services. Source Note: The provisions of this §306.253 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.253 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198049 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Adolescent--An individual who is at least 13 years of age, but younger than 18 years of age.(2) Adult--An individual who is 18 years of age or older.(3) Assessment or reassessment--A systematic process for determining an individual's need for any clinically necessary medical, educational, social, or other services (e.g., taking client history, gathering information from other sources, identifying the needs of the individual, and completing related documentation).(4) Business day--Any day except a Saturday, Sunday, or legal holiday listed in the Texas Government Code, §662.021.(5) Case manager--An employee who provides MH case management services.(6) Child--An individual who is at least three years of age, but younger than 13 years of age.(7) CFR--Code of Federal Regulations.(8) Community based--A description of the location where routine or intensive case management services are provided (i.e., in an individual's community).(9) Community mental health center or CMHC--An entity established in accordance with the Texas Health and Safety Code, §534.001, as a community mental health center or a community mental health and mental retardation center.(10) Community resources--People or entities providing services that address the identified needs of individuals receiving MH case management services (e.g., providers of medical care, food, clothing, child care, employment, or housing).(11) Community services specialist or CSSP--A staff member who, as of August 31, 2004:(A) has received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state; and(B) has had three continuous years of documented full-time experience in the provision of MH case management services; and(C) has demonstrated competency in the provision and documentation of MH case management services in accordance with this subchapter and the MH Case Management Billing Guidelines. (12) Crisis--A situation in which:(A) the individual presents an immediate danger to self or others;(B) the individual's mental or physical health is at risk of serious deterioration; or(C) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk of serious deterioration.(13) Day--A calendar day, unless otherwise specified.(14) Department--Department of State Health Services (DSHS).(15) Designee--A person or entity named by the department to act on its behalf.(16) Dual relationship--A situation that occurs if a case manager interacts with an individual in more than one capacity, whether it be before, during, or after the professional, social, or business relationship. Dual relationships can occur simultaneously or consecutively.(17) Employee--A person who receives a W2 Wage and Tax Statement from a provider.(18) Individual--A person seeking or receiving MH case management services.(19) Institution for mental diseases or IMD--Based on 42 CFR §435.1009, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing psychiatric diagnosis, treatment, or care of individuals with mental illness, including medical attention, nursing care, and related services.(20) Intensive case management--A focused effort to coordinate community resources that assist a child or adolescent in gaining access to necessary care and services appropriate to the child's or adolescent's needs. The standards for providing intensive case management services are set forth in §412.407 of this title (relating to MH Case Management Services Standards).(21) Intensive case management plan or plan--A written document that is part of the medical record and is developed by a case manager, in collaboration with the individual and the individual's LAR or primary caregiver, that identifies services needed by the individual and sets forth a plan for how the individual may gain access to the identified services.(22) Legally authorized representative or LAR--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.(23) Level of care or LOC--A designation given to the department's standardized packages of mental health services, based on the uniform assessment and the utilization management guidelines, which specify the type, amount, and duration of MH case management services to be provided to an individual.(24) Life domains--Areas of life in which a child or adolescent has unmet needs, including, but not limited to safety, health, emotional, psychological, social, educational, cultural, and legal needs. (25) Local Behavioral Health Authority (LBHA)--An entity designated as the local behavioral health authority in accordance with Texas Health and Safety Code, §533.0356.(26) Medically necessary--A clinical determination made by an LPHA that services:(A) are reasonable and necessary for the treatment of a mental health disorder or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;(B) are provided in accordance with accepted standards of practice in behavioral health care;(C) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;(D) are at the most appropriate level or amount of service that can be safely provided; and(E) could not have been omitted without adversely affecting the individual's mental and/or physical health or the quality of care rendered.(27) Mental health (MH) case management services--Activities that assist an individual in gaining and coordinating access to necessary care and services appropriate to the individual's needs. Case management activities include assessment, recovery planning, referral and linkage, and monitoring and follow up. Activities may be provided as routine case management or intensive case management.(28) Monitoring and follow-up--Activities and contacts that are necessary to ensure that referrals and linkages are effectively implemented and adequately addressing the needs of the individual. The activities and contacts may be with the individual, LAR, primary caregiver, family members, providers, or other people and entities to determine whether services are being furnished, the adequacy of those services, and changes in the needs or status of the individual.(29) Primary caregiver--A person 18 years of age or older who:(A) has actual care, control, and possession of a child or adolescent; or (B) has assumed responsibility for providing shelter and care for an adult.(30) Provider--An entity that is:(A) a community mental health center that has a contract with the department to provide general revenue-funded MH case management services, Medicaid-funded MH case management services, or both;(B) a Local Behavioral Health Authority (LBHA) that has a contract with the department to provide general revenue-funded MH case management services, or a subcontractor of a LBHA.(31) Qualified mental health professional-community services or QMHP-CS--A staff member who meets the definition of a QMHP-CS set forth in Subchapter G of this chapter (relating to Mental Health Community Services Standards).(32) Recovery--A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.(33) Recovery plan or treatment plan--A written plan developed with the individual and, as required, the LAR and a QMHP-CS that specifies the individual's recovery goals, objectives, and strategies/interventions in conjunction with the uniform assessment that guides the recovery process and fosters resiliency as further described in §412.322(e) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) concerning content and timeframe of treatment plan.(34) Recovery planning--A systematic process for ensuring the individual's active participation and allowing the LAR, and the primary caregiver and others to develop goals and identify a course of action to respond to the clinically assessed needs. The assessed needs may address medical, social, educational, and other services needed by the individual.(35) Referral and linkage--Activities that help link an individual with medical, social, and educational providers, and with other programs and services that are capable of providing needed services (e.g., referrals to providers for needed services and scheduling appointments).(36) Routine case management--Services that assist an individual in gaining and coordinating access to necessary care and services appropriate to the individual's needs. The standards for providing routine case management services are set forth in §412.407 of this title.(37) Site based--The location where routine case management services are usually provided (i.e., the case manager's place of business). (38) Staff member--Provider personnel, including a full-time and part-time employee, contractor, or intern, but excluding a volunteer.(39) Strengths based--The concept used in service delivery that identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the child, adolescent, LAR, or primary caregiver, and family, their community, and other team members. The focus is on increasing functional strengths and assets rather than on the elimination of deficits.(40) TAC--Texas Administrative Code.(41) Uniform assessment--An assessment adopted by the department that is used for recommending an appropriate level of care (LOC).(42) Utilization management guidelines--Guidelines developed by the department that establish the type, amount, and duration of MH case management services for each LOC.(43) Wraparound process planning or other department-approved model--A strengths-based course of action involving a child or an adolescent and family, including any additional people identified by the child or adolescent, LAR, primary caregiver, and family, that results in a unique set of community services and natural supports that are individualized for the child or adolescent to achieve a positive set of identified outcomes. Source Note: The provisions of this §306.255 adopted to be effective February 14, 2013, 38 TexReg 647; amended to be effective March 27, 2017, 42 TexReg 1458; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.255 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198050 03/12/2026 (a) The provider must comply with Subchapter G of this chapter (relating to Mental Health Community Services Standards).(b) The provider must assign a case manager to an individual within two business days after receiving notification from the department or its designee that the individual has been authorized to receive MH case management services.(c) The provider must ensure that an alternate case manager acts as the individual's assigned case manager if an individual's assigned case manager is not available.(d) The provider must maintain case manager-to-individual ratios sufficient to perform the responsibilities of a case manager in accordance with this subchapter.(e) The provider is responsible for a case manager's compliance with this subchapter. Source Note: The provisions of this §306.257 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.257 Provider Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198051 03/12/2026 For an individual to be eligible for MH case management services, the individual must:(1) be a resident of the State of Texas;(2) be an adult with a severe and persistent mental illness, or a child or adolescent with a serious emotional disturbance who may have a diagnosis described in paragraph (3) of this section;(3) not have a single diagnosis of an intellectual or developmental disability or a substance use disorder; and(4) qualify for an LOC that includes MH case management services. Source Note: The provisions of this §306.259 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.259 Eligibility for MH Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198052 03/12/2026 (a) A provider must:(1) ensure that a QMHP-CS administers the uniform assessment to the individual at intervals specified by the department and obtain a recommended LOC for the individual;(2) evaluate the clinical needs of the individual to determine if the amount of MH case management services associated with the recommended LOC described in the utilization management guidelines is sufficient to meet those needs; and(3) ensure that an LPHA reviews the recommended LOC and verifies whether the services are medically necessary.(b) If the provider determines that the type of MH case management services associated with the recommended LOC is sufficient to meet the individual's needs, the provider must submit to the department or its designee a request for service authorization according to the recommended LOC.(c) If the provider determines that the type of MH case management services associated with the recommended LOC is not sufficient to meet the individual's needs, the provider must submit to the department or its designee:(1) a request for an authorization of an LOC that is sufficient to meet the individual's need or a request for authorization of additional units of service; and(2) the clinical justification for the request.(d) The department or its designee makes the initial determination of an individual's LOC using the uniform assessment which is referenced in §412.416 of this title (relating to Guidelines) and the utilization management guidelines, which are referenced in §412.416 of this title. If the LOC includes MH case management services, the department or its designee will authorize the individual to receive either routine or intensive case management services.(e) Upon receipt of a request submitted according to subsection (c) or (d) of this section, the department or its designee will:(1) review the documentation submitted by the provider;(2) based on the review of documentation and an evaluation of available resources, authorize or deny an LOC for the individual, and if authorized, it authorizes the individual to receive either routine or intensive MH case management services; and(3) communicate to the individual or LAR, no longer than seven business days after the determination has been made, whether the service has been authorized or denied. Source Note: The provisions of this §306.261 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.261 Authorization for MH Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198053 03/12/2026 (a) Assessment. An individual is assessed according to §412.406 of this title (relating to Authorization for MH Case Management Services) to determine the LOC necessary to address the individual's needs. If the individual needs either routine or intensive case management the provider must assign a case manager according to §412.404(b) of this title (relating to Provider Requirements). MH case management services, as well as attempts to provide case management, must be documented according to §412.413 of this title (relating to Documenting MH Case Management Services).(1) MH case management services must:(A) be delivered according to the department's utilization management guidelines, which are described in §412.415 of this title (relating to Fair Hearings and Appeal Processes); and(B) include regular, but at least annual, monitoring of service effectiveness and proactive crisis planning and management.(2) Case managers must recognize that:(A) an LAR as authorized by law may act on behalf of an individual in matters such as accepting or declining services; and(B) a primary caregiver who is not the individual's LAR is included in recovery planning and discussions that relate to the individual if written permission is obtained from the individual or LAR.(b) Routine case management. Routine case management is provided to eligible adults, children, or adolescents and is primarily a site-based service. A case manager assigned to an individual who is authorized to receive routine case management services must:(1) meet face-to-face with the individual and the individual's LAR or primary caregiver within 14 days after the case manager is assigned to the individual or document why the meeting did not occur;(2) assist the individual in identifying the individual's immediate needs and in determining access to community resources that may address those needs;(3) identify the strengths, service needs, and assistance required to address the identified needs;(4) identify the goals and actions required to meet the individual's identified needs;(5) specify the goals and actions to be accomplished;(6) develop a timeline for obtaining the needed services;(7) take the steps that are necessary to accomplish the goals required to meet the individual's identified needs by using referral, linking, advocacy, and monitoring;(8) meet face-to-face with the individual upon the individual's, the LAR's, or the primary caregiver's request, or document why the meeting did not occur;(9) reassess the individual's needs at least annually or as changes occur;(10) meet face-to-face with the LAR, with or without the child or adolescent being present, to provide a service that assists the child or adolescent in gaining and coordinating access to necessary care and services;(11) meet face-to-face with the individual and the LAR or primary caregiver upon notification of a clinically significant change in the individual's functioning, life status, or service needs, or document why the meeting did not occur;(12) if notified that the individual is in crisis, coordinate with the appropriate providers of emergency services to respond to the crisis, as described in Chapter 412, Subchapter G, specifically §412.321 of this title (relating to Crisis Services); and(13) develop a timeline for reevaluating the individual's needs.(c) Intensive case management. Intensive case management is provided to eligible children and adolescents and is primarily community-based. A case manager assigned to a child or adolescent who is authorized to receive intensive case management services must:(1) develop an intensive case management plan (plan) based on the child's or adolescent's needs that may include information across life domains from relevant sources, including:(A) the child or adolescent;(B) the LAR or primary caregiver;(C) other agencies and organizations providing services to the child or adolescent;(D) the individual's medical record; and(E) other sources identified by the individual, LAR, or primary caregiver;(2) meet face-to-face with the child or adolescent and the LAR or primary caregiver:(A) within seven days after the case manager is assigned to the child or adolescent;(B) within seven days after discharge from an inpatient psychiatric setting, whichever is later; or(C) document the reasons the meeting did not occur;(3) meet face-to-face with the child or adolescent and the LAR or primary caregiver according to the child's or adolescent's plan or document why the meeting did not occur;(4) identify the child or adolescent's strengths, service needs, and assistance that will be required to address the identified needs in the plan;(5) comply with subsection (b)(4) - (13) of this section;(6) incorporate wraparound process planning or other department-approved model in developing a plan that addresses the child's or adolescent's unmet needs across life domains, in accordance with the department's utilization management guidelines and subsection (d) of this section;(7) take steps that are necessary to assist the child or adolescent in gaining access to the needed services and service providers, including:(A) making referrals to potential service providers;(B) initiating contact with potential service providers;(C) arranging, and if necessary to facilitate linkage, accompanying the child or adolescent to initial meetings and non-routine appointments;(D) arranging transportation to ensure the child's or adolescent's attendance;(E) advocating with service providers; and(F) providing relevant information to service providers;(8) monitor the child's or adolescent's progress toward the outcomes set forth in the plan, including:(A) gathering information from the child or adolescent, current service providers, LAR, primary caregiver, and other resources;(B) reviewing pertinent documentation, including the child's or adolescent's clinical records, and assessments;(C) ensuring that the plan was implemented as agreed upon;(D) ensuring that needed services were provided;(E) determining whether progress toward the desired outcomes was made;(F) identifying barriers to accessing services or to obtaining maximum benefit from services;(G) advocating for the modification of services to address changes in the needs or status of the child or adolescent;(H) identifying emerging unmet service needs;(I) determining whether the plan needs to be modified to address the child's or adolescent's unmet service needs more adequately;(J) revising the plan as necessary to address the child's or adolescent's unmet service needs;(K) a description of the intensive case management services to be provided by the case manager; and(L) a statement of the maximum period of time between face-to-face contacts with the child or adolescent, and the LAR or primary caregiver, determined in accordance with the utilization management guidelines.(d) Wraparound process planning. Wraparound process planning or other department-approved model may include, but is not limited to:(1) a list of identified natural strengths and supports;(2) a crisis plan developed in collaboration with the LAR, caregiver, and family that identifies circumstances to determine a crisis that would jeopardize the child's or adolescent's tenure in the community and the actions necessary to avert such loss of tenure;(3) a prioritized list of the child's or adolescent's unmet needs that includes a discussion of the priorities and needs expressed by the child or adolescent and the LAR or primary caregiver;(4) a description of the objective and measurable outcomes for each of the unmet needs as well as a projected time frame for each outcome;(5) a description of the actions the child or adolescent, the case manager, and other designated people take to achieve those outcomes; and(6) a list of the necessary services and service providers and the availability of the services. Source Note: The provisions of this §306.263 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.263 MH Case Management Services Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198054 03/12/2026 A provider must, in accordance with Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services), notify the individual or LAR and, if the individual is a child or adolescent, the primary caregiver in writing of the process for making a complaint to the provider's client rights officer. Source Note: The provisions of this §306.265 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.265 Making a Complaint https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198055 03/12/2026 (a) A case manager must not provide MH case management services to an individual if a dual relationship exists.(b) Activities that do not constitute MH case management services are identified in the department's MH Case Management Billing Guidelines as referenced in §412.416 of this title (relating to Guidelines).(c) The provider must ensure that a conflict of interest does not exist if the same case manager is providing other, non-case management services.(d) The provider must ensure that providers of case management services cannot authorize services.(e) The receipt of MH case management services cannot be conditioned upon receipt of other services. Source Note: The provisions of this §306.267 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.267 Service Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198056 03/12/2026 (a) Notification. The provider must notify the department or its designee if the provider has reason to believe that:(1) the individual no longer meets the eligibility criteria for MH case management services as set forth in §412.405 of this title (relating to Eligibility for MH Case Management Services);(2) the LAR of an individual has refused MH case management services on behalf of the individual;(3) the adult or LAR has refused MH case management services;(4) the provider cannot locate the individual and the provider has documented multiple attempts to locate the individual over a period of two consecutive months;(5) the individual has died;(6) the individual has established or intends to establish residency outside of the provider's service area; or(7) if MH case management services are terminated for any reason described in paragraphs (1) - (6) of this subsection, the provider shall document the reason for terminating MH case management services.(b) Termination. The department or designee shall terminate MH case management services provided to an individual if:(1) the department or designee is notified of any of the circumstances described in subsection (a) of this section;(2) it is determined that the individual no longer meets the eligibility criteria for MH case management services as set forth in §412.405 of this title; or(3) the individual is not eligible for Medicaid and the department or its designee determines that there are insufficient resources to continue to provide MH case management services to the individual. Source Note: The provisions of this §306.269 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.269 Notification and Terminations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198057 03/12/2026 (a) A case manager must be:(1) a QMHP-CS or a CSSP;(2) an employee of the provider; and(3) competent according to §412.412 of this title (relating to MH Case Management Employee Competencies).(b) The provider may require additional education and experience for a case manager.(c) An employee who supervises a case manager must be an employee of the provider and either:(1) be a QMHP-CS;(2) be competent according to §412.412 of this title and have experience in providing MH case management services; or(3) hold a master's degree in a related field;(4) demonstrate competency according to §412.412 of this title;(5) demonstrate competency in knowledge of community resources; and(6) demonstrate competency in MH case management evidenced-based practices. Source Note: The provisions of this §306.271 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.271 MH Case Management Employee Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224545 03/12/2026 (a) The provider must implement a process to ensure the competency of a case manager and a case manager supervisor that, at a minimum, ensures: (1) an accurate knowledge of the requirements of this subchapter and the following subchapters of this title: (A) Chapter 412, Subchapter G of this title (relating to Mental Health Community Services Standards); (B) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services); (C) Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers); and (D) Chapter 411, Subchapter N of this title (relating to Standards for Services to Individuals with Co-Occurring Psychiatric and Substance Use Disorders (COPSD)); (2) an accurate understanding of the nature of mental illness and serious emotional disturbance; (3) an awareness and sensitivity in communicating and coordinating services with an individual who has a special physical need such as a hearing or visual impairment; (4) the ability to respond to an individual's language and cultural needs through knowledge of customs, beliefs, and values of various, racial, ethnic, religious, and social groups; (5) the ability to complete the uniform assessment; (6) the ability to understand and apply the utilization management guidelines; (7) the ability to develop and implement a plan if the case manager is providing intensive case management services to a child or adolescent; (8) the ability to identify an individual in crisis; (9) knowledge of appropriate actions to take in managing a crisis; (10) an understanding of the developmental needs of an adult, a child, or an adolescent; (11) an understanding of the wraparound planning process or other department-approved model, if the case manager is providing intensive case management services to a child or adolescent; (12) knowledge of health and human services available to a child or adolescent as described in Texas Government Code §546.0052, if the case manager is providing intensive case management services to a child or adolescent; (13) knowledge of available resources within the local community; (14) knowledge of strategies for advocating effectively on behalf of individuals; and (15) the ability to document the MH case management services described in §412.413 of this title (relating to Documenting MH Case Management Services). (b) The provider shall require each case manager and case manager supervisor, prior to providing MH case management services, to: (1) demonstrate the competencies described in subsection (a) of this section; and (2) ensure that documentation verifying competencies is maintained in the personnel record of each case manager and case manager supervisor. Source Note: The provisions of this §306.273 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469; amended to be effective April 1, 2025, 50 TexReg 2207. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.273 MH Case Management Employee Competencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198059 03/12/2026 (a) Location of documentation. MH case management services, as well as attempts to provide MH case management services, as described in this section, must be documented in the individual's medical record.(1) For routine case management, the case manager must document the information required by §412.407(b)(3) - (6) of this title (relating to MH Case Management Services Standards), as well as the steps taken to meet the individual's goals and needs as required by §412.407(b)(7) of this title, in the individual's medical record.(2) For intensive case management:(A) the assigned case manager must include the intensive case management plan required by §412.407(c)(1) of this title in the individual's medical record; and(B) the assigned case manager must document steps taken to meet the individual's goals and needs as required by §412.407(c)(7) of this title in the individual's progress notes.(b) Assessment and reassessment. As a result of the face-to-face meetings, assessments, and reassessments required in §412.407 of this title, the case manager must document the individual's:(1) identified strengths, service needs, and assistance given to address the identified need; and(2) specific goals and actions to be accomplished.(c) Service documentation. The case manager must document the following for all services provided:(1) the event or behavior that occurs while providing the MH case management service or the reason for this specific encounter;(2) the person, persons, or entity, including other case managers, with whom the encounter or contact occurred;(3) the recovery plan goal(s) that was the focus of the MH case management service, including the progress or lack of progress in achieving recovery plan goal(s);(4) the timeline for obtaining the needed services;(5) the specific intervention that is being provided;(6) the plan to proceed based upon the facts presented in this encounter or the resolution, if any;(7) the date the MH case management service was provided;(8) the begin and end time of the MH case management service;(9) the location where the MH case management service was provided and whether it was a face-to-face or telephone contact;(10) the signature of the employee providing the MH case management service and their credentials; and(11) the timeline for reevaluating the needed services.(d) Crisis service documentation. In addition to the requirements described in subsection (a) of this section, a provider must document the following for crisis intervention services:(1) the documentation required by Chapter 412, Subchapter G, specifically §412.321(e) of this title (relating to Crisis Services); and(2) the outcome of the individual's crisis.(e) Refusing MH case management services. If the individual refuses MH case management services, the case manager must:(1) document the reason for the refusal in the progress notes of the individual's medical record; and(2) request that the individual sign a waiver of MH case management services that is filed in the individual's medical record.(f) Documentation retention. The provider must retain documentation in compliance with applicable records retention requirements in federal and state laws, rules, and regulations. Source Note: The provisions of this §306.275 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.275 Documenting MH Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198060 03/12/2026 (a) In accordance with §412.407 of this title (relating to MH Case Management Services Standards), a billable event is a face-to-face contact during which the case manager provides an MH case management service to an:(1) individual who is Medicaid eligible; or(2) LAR on behalf of a child or adolescent who is Medicaid eligible.(b) A unit of service for MH case management services is 15 continuous minutes.(c) The department shall not reimburse a provider for Medicaid MH case management services if:(1) the individual who was provided the service did not meet the eligibility requirements set forth in §412.405 of this title (relating to Eligibility for MH Case Management Services) at the time the service was provided;(2) the service provided was an integral and inseparable part of another service;(3) the service was provided by a person who was not qualified in accordance with §412.411(a) of this title (relating to MH Case Management Employee Qualifications);(4) the service provided was not the type, amount, and duration authorized by the department or its designee;(5) the service was not provided or documented in accordance with this subchapter;(6) the service provided is in excess of eight hours per individual per day; or(7) the services provided do not conform to the requirements set forth in the department's MH Case Management Billing Guidelines. (d) The department shall not reimburse a provider for Medicaid MH case management services for coordination activities that are included in the provision of:(1) rehabilitative crisis intervention services, as described in Chapter 419, Subchapter L, specifically §419.457 of this title (relating to Crisis Intervention Services); or(2) psychosocial rehabilitative services, as described in Chapter 419, Subchapter L, specifically §419.459 of this title (relating to Psychosocial Rehabilitative Services).(e) If Medicaid-funded MH case management services are continued prior to a fair hearing, as required by 1 TAC §357.11 (relating to Notice and Continued Benefits), the provider may file a claim for such services.(f) An individual is eligible for Medicaid-funded MH case management services if, in addition to the criteria set forth in §412.405 of this title, the individual is:(1) eligible for Medicaid;(2) not an inmate of a public institution, as defined in 42 CFR §435.1009;(3) not a resident of an intermediate care facility for persons with mental retardation as described in 42 CFR §440.150; (4) not a resident of an IMD;(5) not a resident of a Medicaid-certified nursing facility, unless the individual has been determined through a pre-admission screening and resident review assessment to be eligible for the specialized service of MH case management services or the individual is expected to be discharged to a non-institutional setting within 180 days;(6) not a recipient of MH case management services under another Medicaid program (e.g., the Home and Community Services waiver program or Texas Health Steps); and(7) not a patient of a general medical hospital. Source Note: The provisions of this §306.277 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.277 Medicaid Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198061 03/12/2026 (a) Right of Medicaid-eligible individual to request a fair hearing. Any Medicaid eligible individual whose request for eligibility for MH case management services is denied or is not acted upon with reasonable promptness, or whose MH case management services have been terminated, suspended, or reduced by the department, is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(b) Right of non-Medicaid eligible individual to request an appeal. Any individual who has not applied for or is not eligible for Medicaid whose request for eligibility for MH case management services is denied or is not acted upon with reasonable promptness, or whose MH case management services have been terminated, suspended, or reduced by a local mental health authority or its contractor, is entitled to notification and right of appeal in accordance with the department's rules concerning such matters for non-Medicaid-eligible individuals. Source Note: The provisions of this §306.279 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.279 Fair Hearings and Appeal Processes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198062 03/12/2026 The following guidelines, as revised, are referenced in this subchapter. For information about obtaining copies of the guidelines contact the Department of State Health Services, Mental Health Program Services, P.O. Box 149347, Mail Code 2018, Austin, TX 78714-9347, (512) 467-5427 or access them electronically. (1) Uniform assessment guidelines are available online at: http://www.dshs.state.tx.us/mhprograms/RDMAssess.shtm.(2) Utilization management guidelines for adults and children are available online at: http://www.dshs.state.tx.us/mhprograms/RDMClinGuide.shtm. (3) MH Case Management Billing Guidelines are available at: http://www.dshs.state.tx.us/Layouts/ContentPage.aspx?PageID=35712&id=8589961742&terms=billing+guidelines. Source Note: The provisions of this §306.281 adopted to be effective February 14, 2013, 38 TexReg 647; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 469. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM E MENTAL HEALTH CASE MANAGEMENT §306.281 Guidelines https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198585 03/12/2026 The purpose of this subchapter is to describe the requirements for providing mental health (MH) rehabilitative services that includes the following:(1) crisis intervention services;(2) medication training and support services;(3) psychosocial rehabilitative services;(4) skills training and development services; and(5) day programs for acute needs. Source Note: The provisions of this §306.301 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.301 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198586 03/12/2026 This subchapter applies to providers of MH rehabilitative services funded through Medicaid, or a general revenue contract with the department. Source Note: The provisions of this §306.303 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.303 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198587 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Adolescent--An individual who is at least 13 years of age, but younger than 18 years of age.(2) Adult--An individual who is 18 years of age or older.(3) APRN or Advanced practice registered nurse--A staff member who is a registered nurse approved by the Texas Board of Nursing as a clinical nurse specialist in psychiatric/mental health or nurse practitioner in psychiatric/mental health, in accordance with Texas Occupations Code, Chapter 301. The term is synonymous with "advanced nurse practitioner."(4) Authorization period--The duration for which the provider has obtained authorization in accordance with §416.6(a) of this title (relating to Service Authorization and Recovery Plan).(5) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code, §662.021.(6) CFP or Certified family partner--A person who:(A) is 18 years of age or older;(B) has received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the laws applicable to the issuing agency;(C) has at least one year of lived experience raising a child or adolescent with an emotional or mental health issues as a parent or LAR;(D) has at least one year of experience navigating a child-service system (e.g., mental health, juvenile justice, social security, or special education) as a parent or LAR; and(E) has successfully completed the certified family partner (CFP) training and passed the certification examination recognized by the department.(7) CFR--The Code of Federal Regulations.(8) Child--An individual who is at least three years of age, but younger than 13 years of age.(9) Crisis--A situation in which:(A) an individual presents an immediate danger to self or others;(B) an individual's mental or physical health is at risk of serious deterioration; or(C) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk of serious deterioration.(10) CSSP or community services specialist--A staff member who, as of August 30, 2004:(A) received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state;(B) has had three continuous years of documented full-time experience in the provision of MH rehabilitative services; and(C) has demonstrated competency in the provision and documentation of MH rehabilitative services in accordance with this subchapter and the MH Rehabilitative Services Billing Guidelines.(11) CSU or crisis stabilization unit--A crisis stabilization unit licensed under the Texas Health and Safety Code, Chapter 577; and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units).(12) Day--Calendar day, unless otherwise specified.(13) Department--The Department of State Health Services.(14) Direct clinical supervision--An LPHA's or QMHP's interaction with a staff member who delivers MH rehabilitative services to ensure that MH rehabilitative services are clinically appropriate and in compliance with this subchapter by:(A) conducting a documented meeting with the staff member at regularly scheduled intervals; and(B) conducting documented observations of the staff member providing MH rehabilitative services at a frequency determined by the supervisor based on the staff member's skill level.(15) Face-to-face--A contact with an individual that occurs when the individual is in the physical presence of the staff member who is delivering the service. Face-to-face does not include contacts made through the use of electronic media.(16) Group--A face-to-face service delivery modality involving at least one staff member and:(A) two to eight adults; or(B) two to six children or adolescents and may include their LARs or primary caregivers, which do not count toward the group size limit.(17) Health risk factors--Circumstances that contribute to the premature death and disabling chronic diseases such as heart disease, diabetes and cancers. They include, but are not limited to, substance abuse or addiction, high blood pressure, tobacco use, high blood glucose, use of and side effects of some neuroleptic medications, physical inactivity, overweight and obesity, and unsafe sex.(18) IMD or institution for mental diseases--Based on 42 CFR §435.1009, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of individuals with serious mental illness, including medical attention, nursing care, and related services.(19) Individual--A person seeking or receiving MH rehabilitative services.(20) In vivo--The individual's natural environment (e.g., the individual's residence, work place, or school).(21) LAR or legally authorized representative--A person authorized by law to act on behalf of an adult, child, or adolescent with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.(22) LMFT or Licensed marriage and family therapist--An individual who is licensed as a licensed marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists in accordance with Texas Occupations Code, Chapter 502.(23) Licensed medical staff member--A staff member who is:(A) a physician (MD) or (DO);(B) a physician assistant (PA);(C) an APRN;(D) a registered nurse (RN);(E) an LVN; or(F) a pharmacist.(24) LPC or Licensed professional counselor--A person who is licensed as a licensed professional counselor by the Texas State Board of Examiners of Professional Counselors in accordance with Texas Occupations Code, Chapter 503.(25) LOC or level of care--A designation given to the department's standard sets of mental health services, based on the uniform assessment and utilization management guidelines referenced in §416.17 of this title (relating to Guidelines), which specify the type, amount, and duration of MH rehabilitative services to be provided to an individual.(26) LPHA or licensed practitioner of the healing arts--This term shall have the meaning set forth in the §412.303 of this title (relating to Definitions).(27) LVN or licensed vocational nurse--A staff member who is licensed as a vocational nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.(28) Mental health (MH) rehabilitative services--Services that:(A) are individualized, age-appropriate training and instructional guidance that restore an individual's functional deficits due to serious mental illness or SED;(B) are designed to improve or maintain the individual's ability to remain in the community as a fully integrated and functioning member of that community; and(C) consist of the following services:(i) crisis intervention services;(ii) medication training and support services;(iii) psychosocial rehabilitative services;(iv) skills training and development services; and(v) day programs for acute needs.(29) Medicaid provider--A Medicaid-enrolled provider with which the department has a Medicaid provider agreement to provide MH rehabilitative services under the State's Medicaid Program.(30) Medical necessity or medically necessary--A clinical determination made by an LPHA that services:(A) are reasonable and necessary for the treatment of a serious mental illness; or to improve, maintain, or prevent deterioration of functioning resulting from such a disorder;(B) are provided in accordance with accepted standards of practice in behavioral health care;(C) are furnished in the most appropriate and least restrictive setting in which services can be safely provided;(D) are at the most appropriate level or amount of service that can be safely provided; and(E) could not have been omitted without adversely affecting the individual's mental and/or physical health or the quality of care rendered.(31) Mental health disorder--Health conditions involving changes in thinking, mood, and/or behaviors that are associated with distress or impaired functioning. When mental health disorders are more severe, they are called serious mental illnesses, which includes anxiety disorder, attention-deficit/hyperactivity disorder, depressive and other mood disorders, eating disorders, schizophrenia, and others.(32) Nursing services--Services provided or delegated by an RN acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 301.(33) On site--At a location operated by a provider or a person or entity under arrangement with the provider.(34) PA or Physician assistant--A staff member who is licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners in accordance with Texas Occupations Code, Chapter 204.(35) Peer provider--A staff member who:(A) has received:(i) a high school diploma; or(ii) a high school equivalency certificate issued in accordance with the law of the issuing state; and(B) has at least one cumulative year of receiving mental health services for a disorder that is treated in the target population for Texas.(36) Pharmacist--A staff member who is licensed as a pharmacist by the Texas State Board of Pharmacy in accordance with Texas Occupations Code, Chapter 558.(37) Physician--A staff member who is:(A) licensed as a physician by the Texas Medical Boards in accordance with Texas Occupations Code, Chapter 155 (Medical Doctor or Doctor of Osteopathy); or(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board.(38) Primary caregiver--A person 18 years of age or older who has actual care, control, and possession of a child or adolescent.(39) Problem-solving--The use of specific steps and strategies to analyze and evaluate a problematic situation in order to determine a course of action to resolve the problematic situation.(40) Provider--An entity with which the department has a contractual agreement to provide MH Rehabilitative Services, including a Medicaid provider.(41) Psychologist--A staff member who is licensed as a psychologist by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.(42) QMHP-CS or qualified mental health professional-community services--A staff member who meets the definition of a QMHP-CS set forth in §412.303 of this title (relating to Definitions).(43) Recovery--A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.(44) Recovery plan or treatment plan--A written plan developed with the individual and, as required, the LAR and a QMHP-CS that specifies the individual's recovery goals, objectives, and strategies/interventions in conjunction with the uniform assessment that guides the recovery process and fosters resiliency as further described in §412.322(e) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization).(45) Resilience--The ability to cope with and recover from adversity and stress.(46) RN or registered nurse--A staff member who is licensed as a registered nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.(47) SED or Serious emotional disturbance--A diagnosed mental health disorder that substantially disrupts a child's or adolescent's ability to function socially, academically, and emotionally.(48) Serious mental illness--An illness, disease, disorder, or condition (other than a sole diagnosis of epilepsy, dementia, substance use disorder, or intellectual or developmental disability) that:(A) substantially impairs an individual's thought, perception of reality, emotional process, development, or judgment; or(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.(49) Staff member--Personnel of a provider including a full-time or part-time employee, contractor, intern, or volunteer.(50) Therapeutic team--A group of staff members who work together in a coordinated manner for the purpose of providing comprehensive mental health services to an individual.(51) Uniform assessment--An assessment adopted by the department that is used for recommending an approved level of care (LOC).(52) Utilization management guidelines--Guidelines developed by the department that suggest the type, amount, and duration of mental health services for each LOC. Source Note: The provisions of this §306.305 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.305 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198588 03/12/2026 (a) Compliance with MH community standards. In addition to complying with this subchapter, a provider must also comply with Chapter 412, Subchapter G of this title (relating to Mental Health Community Services Standards) in the provision of MH rehabilitative services, as described in §412.304(a)(4) and (b) of this title (relating to Responsibility for Compliance).(b) Staff supervision and oversight. A provider must develop policies and procedures in accordance with this subchapter for the supervision and oversight of staff members who provide MH rehabilitative services. Staff members who provide supervision must have experience in providing rehabilitative services and training in supervising rehabilitative services. The MH rehabilitative services provided by a:(1) CFP must be directly supervised by a staff member who is credentialed as a QMHP-CS at minimum and who must have at least one year experience in the department-approved recovery and resilience protocol;(2) peer provider must be under the direct clinical supervision of an LPHA;(3) CSSP must be clinically supervised by a QMHP-CS;(4) QMHP-CS must be clinically supervised by at least another QMHP-CS; and(5) QMHP-CS supervisor of another QMHP-CS must be clinically supervised by an LPHA.(c) Subcontract for providing services.(1) A provider may choose to have any MH rehabilitative service provided by a person or entity through a subcontract.(2) A provider must ensure that, if MH rehabilitative services are provided through a subcontract, then the subcontractor complies with all applicable federal and state laws, rules, and regulations, and any provider manuals and policy clarification letters promulgated by the department.(d) Prohibitions against discrimination and retaliation.(1) A provider may not discriminate against or deny services to an individual based on race, color, national origin, religion, sex, sexual orientation, age, disability, co-occurring disorder, or political affiliation.(2) A provider must ensure that an individual's refusal of any service offered by the provider does not preclude the individual from accessing a needed MH rehabilitative service. Source Note: The provisions of this §306.307 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.307 General Requirements for Providers of MH Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198589 03/12/2026 An individual is eligible for MH rehabilitative services if:(1) the individual:(A) is a resident of the State of Texas;(B) is an adult with a serious mental illness or a child or adolescent with a serious emotional disturbance (SED); and(C) qualifies for an LOC; and(2) a determination that such services are medically necessary has been made by an LPHA who is:(A) an employee of the department;(B) an employee of an entity designated to make such determinations on behalf of the department; or(C) a contractor of an entity designated to make such determinations on behalf of the department, if the LPHA is not otherwise employed by or contracting with an entity providing MH rehabilitative services through a subcontract. Source Note: The provisions of this §306.309 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.309 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198590 03/12/2026 (a) Prerequisites to providing services. With the exception of crisis intervention services:(1) the provider must obtain prior authorization from the department or its designee for the MH rehabilitative services to be provided in accordance with the uniform assessment, which is referenced in §416.17 of this title (relating to Guidelines); and the utilization management guidelines, which are referenced in §416.17 of this title; and(2) an LPHA must determine whether the need for MH rehabilitative services meets the definition of medical necessity.(b) Recovery planning.(1) In collaboration with the individual or LAR, develop a recovery plan in accordance with §412.322(e) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization) that also includes a list of the type(s) of MH rehabilitative services authorized in accordance with subsection (a)(1) of this section.(2) A provider must develop the recovery plan required by paragraph (1) of this subsection within 10 days after the authorization date.(c) Documenting medical necessity for crisis intervention services.(1) An LPHA must, within two business days after crisis intervention services are provided:(A) determine whether the crisis intervention services met the definition of medical necessity; and(B) if the crisis intervention services were determined to meet medical necessity, document the medical necessity for such services.(2) A provider is not required to develop a recovery plan for providing crisis intervention services.(d) Reauthorization of MH rehabilitative services.(1) Prior to the expiration of the authorization period or depleting the amount of services authorized:(A) the provider must make a determination of whether the individual continues to need MH rehabilitative services; and(B) an LPHA must determine whether the continuing need for MH rehabilitative services meets the definition of medical necessity.(2) If the determination is that the individual continues to need MH rehabilitative services and that such services are medically necessary, the provider must:(A) request another authorization from the department or its designee for the same type and amount of MH rehabilitative service previously authorized; or(B) submit a request to the department or its designee, with documented clinical reasons for such request, to change the type or amount of MH rehabilitative services previously authorized if:(i) the provider determines that the type or amount of MH rehabilitative services previously authorized is inappropriate to address the individual's needs; and(ii) the criteria described in the utilization management guidelines for changing the type or amount of MH rehabilitative services has been met.(e) Recovery plan review.(1) In collaboration with the individual or LAR or primary caregiver, the provider must, review the recovery plan to determine if the plan adequately assists the individual in achieving recovery through the identified goals, objectives, and needs:(A) at intervals set forth in the utilization management guidelines;(B) as clinically indicated; and(C) at the request of the individual, LAR, or primary caregiver.(2) At the time the recovery plan is reviewed, the provider must:(A) solicit active participation of the individual and LAR or primary caregiver of a child or adolescent regarding the services received to date and whether the services received have led to improvement and/or if there are other services to address unmet needs; and(B) document such input.(f) Revisions to the recovery plan. If, after review of the recovery plan, the provider in collaboration with the individual or LAR determines that the recovery plan does not adequately address the needs of the individual, the provider must, as appropriate:(1) revise the content of the recovery plan; or(2) must document medical necessity if there is a change in an LOC; and(3) request authorization for a change in the type or amount of the MH rehabilitative services authorized consistent with subsection (d)(2) of this section. Source Note: The provisions of this §306.311 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.311 Service Authorization and Recovery Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198591 03/12/2026 (a) Description. Crisis intervention services are interventions provided in response to a crisis in order to reduce or manage symptoms of serious mental illness or SED and to prevent admission of an individual to a more restrictive environment. Crisis intervention services consist of the following interventions:(1) an assessment of dangerousness of the individual to self or others;(2) the coordination of emergency care services in accordance with §412.314 of this title (relating to Access to Mental Health Community Services);(3) behavior skills training to assist the individual in reducing distress and managing symptoms;(4) problem-solving;(5) reality orientation to help the individual identify and manage his or symptoms of serious mental illness or SED; and(6) providing instruction, structure, and emotional support to the individual in adapting to and coping with immediate stressors.(b) Conditions.(1) Crisis intervention services may be provided to:(A) an adult; or(B) a child or adolescent.(2) Crisis intervention services must be provided one-to-one.(3) Crisis intervention services may be provided:(A) on site; or(B) in vivo.(4) Crisis intervention services must be provided by a QMHP-CS at a minimum.(5) Crisis intervention services may not be provided to an individual who is currently admitted to a CSU.(6) Crisis intervention services may be provided to an individual without first obtaining authorization from the department, or its designee, in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan).(7) Crisis intervention services may be provided without a recovery plan described in §416.6 of this title. Source Note: The provisions of this §306.313 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.313 Crisis Intervention Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198592 03/12/2026 (a) Description. Medication training and support services consist of education and guidance about medications and their possible side effects. The department has reviewed and approved the use of the materials that are available on the department's internet site at: http://www.dshs.state.tx.us/mhsa/patient-family-ed/ and other materials which have been formally reviewed and approved by the department, to assist an individual in:(1) understanding the nature of an adult's serious mental illness or a child's or adolescent's SED;(2) understanding the concepts of recovery and resilience within the context of the serious mental illness;(3) understanding the role of the individual's prescribed medications in reducing symptoms and increasing or maintaining the individual's functioning;(4) identifying and managing the individual's symptoms and potential side effects of the individual's medication;(5) learning the contraindications of the individual's medication;(6) understanding the overdose precautions of the individual's medication; and(7) learning self-administration of the individual's medication.(b) Conditions.(1) Medication training and support services may be provided to:(A) an eligible adult;(B) an eligible child or adolescent; or(C) the LAR or primary caregiver of an eligible adult, child, or adolescent.(2) Medication training and support services provided to an adult may be provided:(A) individually; or(B) in a group.(3) Medication training and support services provided to a child or adolescent may be provided:(A) individually; or(B) in a group.(4) Medication training and support services provided to an LAR or primary caregiver may be provided:(A) individually; or(B) in a group, except that the adult, child or adolescent may also be present.(5) Medication training and support services may be provided:(A) on site; or(B) in vivo.(6) Medication training and support services provided to an adult or LAR must be provided by:(A) a QMHP-CS;(B) a CSSP;(C) a peer provider; or(D) a licensed medical staff member.(7) Medication training and support services provided to a child, adolescent, LAR, or primary caregiver must be provided by:(A) a QMHP-CS;(B) a CSSP;(C) a CFP; or(D) a licensed medical staff member.(8) Medication training and support services may not be provided to an individual who is currently admitted to a CSU.(c) Frequency and duration. The provision of medication training and support services must be in accordance with the amount and duration for which the provider has obtained authorization in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan). Source Note: The provisions of this §306.315 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.315 Medication Training and Support Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198593 03/12/2026 (a) Description. Psychosocial rehabilitative services are social, behavioral, and cognitive interventions provided by members of an individual's therapeutic team that build on strengths and focus on restoring the individual's ability to develop and maintain social relationships, occupational or educational achievement, and other independent living skills that are affected by or the result of a serious mental illness in adults. Psychosocial rehabilitative services may also address the impact of co-occurring disorders upon the individual's ability to reduce symptomology and increase daily functioning. Psychosocial rehabilitative services that include, but are not limited to, the following component services:(1) independent living services;(2) coordination services;(3) employment related services;(4) housing related services;(5) medication related services; and(6) crisis related services.(b) Conditions.(1) Psychosocial rehabilitative services:(A) may only be provided to an eligible adult;(B) may be provided individually or in a group;(C) may be provided on site or in vivo;(D) must be provided by a member of the individual's therapeutic team; and(E) may not be provided to an individual who is currently admitted to a CSU.(2) The therapeutic team must be constituted and organized in a manner that ensures that:(A) the team includes a sufficient number of staff to adequately address the rehabilitative needs of individuals assigned to the team;(B) team members are appropriately credentialed to provide the full array of component services;(C) team members have regularly scheduled team meetings either in person or by teleconference; and(D) every member of the team is knowledgeable of the needs and of the services available to the specific individuals assigned to the team.(3) Independent living services, coordination services, employment related services, and housing related services, as described in subsection (c)(1) - (4) of this section, must be provided by:(A) a QMHP-CS;(B) a CSSP; or(C) a peer provider.(4) Medication related services, as described in subsection (c)(5) of this section, must be provided by licensed medical personnel.(5) Crisis related services, as described in subsection (c)(6) of this section, must be provided by a QMHP-CS.(6) As part of providing the coordination services described in subsection (c)(2) of this section, a QMHP-CS must conduct the uniform assessment at intervals specified by the department to determine the type, amount, and duration of MH rehabilitative services.(c) Components of psychosocial rehabilitative services. Psychosocial rehabilitative services include, but are not limited to, the following.(1) Independent living services assist an individual in acquiring the most immediate, fundamental functional skills needed to enable the individual to reside in the community and avoid more restrictive levels of treatment or reducing behaviors or symptoms that prevent successful functioning in the individual's environment of choice. Such services include training in symptom management, personal hygiene, nutrition, food preparation, exercise, money management and community integration activities.(2) Coordination services are training activities that assist an individual in improving his or her ability to gain and coordinate access to necessary care and services appropriate to the needs of the individual. Coordination services include, but are not limited to, instruction and guidance in such areas as:(A) assessment--identifying strengths and areas of need across life domains;(B) recovery planning--prioritizing needs and establishing life and treatment goals, selecting interventions, developing and revising recovery plans that include wellness, relapse prevention, and crisis plans;(C) access--identifying potential service providers and support systems across all life domains (e.g., medical, social, educational, substance use), initiating contact with providers and support systems including advocacy groups;(D) coordination--setting appointments, arranging transportation, facilitating communication between providers; and(E) advocacy--(i) asserting treatment needs, requesting special accommodations, evaluating provider effectiveness and compliance with the agreed upon recovery plan; and(ii) requesting improvements and modifications to ensure maximum benefit from the services and supports.(3) Employment related services provide supports and skills training that are not job-specific and focus on developing skills to reduce or manage the symptoms of serious mental illness that interfere with an individual's ability to make vocational choices or obtain or retain employment. Such services consist of:(A) instruction in dress, grooming, socially and culturally appropriate behaviors, and etiquette necessary to obtain and retain employment;(B) training in task focus, maintaining concentration, task completion, and planning and managing activities to achieve outcomes;(C) instruction in obtaining appropriate clothing, arranging transportation, utilizing public transportation, accessing and utilizing available resources related to obtaining employment, and accessing employment-related programs and benefits (e.g., unemployment, workers' compensation, and Social Security);(D) interventions or supports provided on or off the job site to reduce behaviors or symptoms of serious mental illness that interfere with job performance or that interfere with the development of skills that would enable the individual to obtain or retain employment; and(E) interventions designed to develop natural supports on or off the job site to compensate for skill deficits that interfere with job performance.(4) Housing related services develop an individual's strengths and abilities to manage the symptoms of the individual's serious mental illness that interfere with the individual's capacity to obtain or maintain tenure in independent integrated housing. Such services consist of:(A) skills training related to:(i) home maintenance and cleanliness;(ii) problem-solving with the individual's landlord and neighbors, mortgage lender, or homeowners association; and(iii) maintaining appropriate interpersonal boundaries; and(B) supportive contacts with the individual to reduce or manage the behaviors or symptoms related to the individual's serious mental illness that interfere with maintaining independent integrated housing.(5) Medication related services provide training regarding an individual's medication adherence. Such services consist of training in:(A) the importance of the individual taking the medications as prescribed;(B) the self-administration of the individual's medication;(C) determining the effectiveness of the individual's medications;(D) identifying side-effects of the individual's medications; and(E) contraindications for medications prescribed.(6) Crisis related services respond to an individual in crisis in order to reduce symptoms of serious mental illness or SED and to prevent admission of the individual to a more restrictive environment.(d) Frequency and duration. The provision of psychosocial rehabilitative services must be in accordance with the amount and duration for which the provider has obtained authorization in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan). Source Note: The provisions of this §306.317 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.317 Psychosocial Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198594 03/12/2026 (a) Description.(1) Skills training and development services is training provided to an eligible individual or the LAR or primary caregiver of an eligible adult, child, or adolescent. Such training:(A) addresses serious mental illness or SED and symptom-related problems that interfere with the individual's functioning and living, working, and learning environment;(B) provides opportunities for the individual to acquire and improve skills needed to function as appropriately and independently as possible in the community; and(C) facilitates the individual's community integration and increases his or her community tenure.(2) Skills training and development services consist of teaching an individual the following skills:(A) skills for managing daily responsibilities (e.g., paying bills, attending school, and performing chores);(B) communication skills (e.g., effective communication and recognizing or change problematic communication styles);(C) pro-social skills (e.g., replacing problematic behaviors with behaviors that are socially and culturally appropriate or developing interpersonal relationship skills necessary to function effectively with family, peer, teachers, or other people in the community);(D) problem-solving skills;(E) assertiveness skills (e.g., resisting peer pressure, replacing aggressive behaviors with assertive behaviors, and expressing one's own opinion in a manner that is socially appropriate);(F) social skills and expanding the individual social support network, (e.g., selection of appropriate friends and healthy activities);(G) stress reduction techniques (e.g., progressive muscle relaxation, deep breathing exercises, guided imagery, and selected visualization);(H) anger management skills (e.g., identification of antecedents to anger, calming down, stopping and thinking before acting, handling criticism, avoiding and disengaging from explosive situations);(I) skills to manage the symptoms of serious mental illness or SED and to recognize and modify unreasonable beliefs, thoughts and expectations;(J) skills to identify and utilize community resources and informal supports;(K) skills to identify and utilize acceptable leisure time activities (e.g., identifying pleasurable leisure time activities that will foster acceptable behavior); and(L) independent living skills (e.g., money management, accessing and using transportation, grocery shopping, maintaining housing, maintaining a job, and decision making).(3) Skills training and development services consist of:(A) assisting the child or adolescent in learning the skills described in paragraph (2) of this subsection; and(B) increasing the LAR's or primary caregiver's understanding of and ability to respond to the individual's needs identified in the uniform assessment or documented in the recovery plan.(b) Conditions.(1) Skills training and development services may be provided to:(A) an eligible adult;(B) an eligible child or adolescent; or(C) the LAR or primary caregiver of an individual.(2) Skills training and development services provided to an individual, LAR, or primary caregiver of a child or adolescent may be provided:(A) individually; or(B) in a group.(3) Skills training and development services may be provided:(A) on site; or(B) in vivo.(4) Skills training and development services provided to an individual must be provided according to curricula approved by the department.(5) Skills training and development services provided to an adult or LAR must be provided by:(A) a QMHP-CS;(B) a CSSP; or(C) a peer provider.(6) Skills training and development services provided to a child or adolescent, LAR, or primary caregiver must be provided by:(A) a QMHP-CS;(B) a CSSP; or(C) a CFP.(7) Skills training and development services may not be provided to an individual who is currently admitted to a CSU.(c) Frequency and Duration. The provision of skills training and development services must be in accordance with the amount and duration for which the provider has obtained authorization in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan). Source Note: The provisions of this §306.319 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.319 Skills Training and Development Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198595 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198595 03/12/2026 (a) Description. Day programs for acute needs provide short term, intensive treatment to an individual who requires multidisciplinary treatment in order to stabilize acute psychiatric symptoms or prevent admission to a more restrictive setting. Day programs for acute needs:(1) are provided in a highly structured and safe environment with constant supervision;(2) ensure an opportunity for frequent interaction between an individual and staff members;(3) are services that are goal oriented and focus on:(A) reality orientation;(B) symptom reduction and management;(C) appropriate social behavior;(D) improving peer interactions;(E) improving stress tolerance;(F) the development of coping skills; and(4) consist of the following component services:(A) psychiatric nursing services;(B) pharmacological instruction;(C) symptom management training; and(D) functional skills training.(b) Conditions.(1) Day programs for acute needs:(A) may only be provided to eligible adults;(B) may be provided in a setting with any number of individuals; and(C) may be provided:(i) on site; or(ii) in a short-term, crisis-resolution oriented residential treatment setting that is not:(I) a general medical hospital;(II) a psychiatric hospital; or(III) an IMD.(2) Except as provided by paragraphs (4) and (5) of this subsection, day programs for acute needs must be provided by:(A) a QMHP-CS;(B) a CSSP; or(C) a peer provider.(3) Day programs for acute needs must, at all times:(A) have a sufficient number of staff members to ensure safety and program adequacy; and(B) at a minimum include:(i) one RN for every 16 individuals at the day program's location;(ii) one physician to be available by phone, with a response time not to exceed 15 minutes;(iii) two staff members who are QMHP-CSs, CSSPs, or peer providers at the day program's location;(iv) one additional QMHP-CS who is not assigned full-time to another day program to be physically available, with a response time not to exceed 30 minutes; and(v) additional QMHP-CSs, CSSPs, or peer providers at the day program's location sufficient to maintain a ratio of one staff member to every four individuals.(4) Psychiatric nursing services, as described in subsection (c)(1) of this section, must be provided by an RN at the day program's location.(5) Pharmacological instruction, as described in subsection (c)(2) of this section, must be provided by a licensed medical personnel.(c) Components of day programs for acute needs.(1) Psychiatric nursing services consist of:(A) a nursing assessment;(B) the coordination of medical activities (e.g., referrals to specialists and scheduling medical laboratory tests);(C) the administration of medication;(D) laboratory specimen collections and screenings (e.g., the Abnormal Involuntary Movement Scale);(E) emergency medical interventions as ordered by a physician; and(F) other nursing services.(2) Pharmacological instruction is training to an individual that addresses medication issues related to the crisis precipitating the provision of day programs for acute needs. Such medication issues consist of:(A) the role of the individual's medications in stabilizing acute psychiatric symptoms or preventing admission to a more restrictive setting;(B) the identification of substances that reduce the effectiveness of the individual's medications;(C) appropriate interventions to reduce side effects of the medications; and(D) the self-administration of the individual's medication.(3) Symptom management training assists an individual in recognizing and reducing her or his symptoms and includes training the individual on:(A) the identification of thoughts, feelings, or behaviors that indicate the onset of acute psychiatric symptoms;(B) developing coping strategies to address the symptoms;(C) ways to avoid symptomatic episodes;(D) identification of external circumstances that trigger the onset of the acute psychiatric symptoms; and(E) relapse prevention strategies.(4) Functional skills training assists an individual in acquiring the skills needed to enable the individual to continue to reside in the community and avoid more restrictive levels of treatment and includes training the individual on:(A) personal hygiene;(B) nutrition;(C) food preparation;(D) money management;(E) socially and culturally appropriate behavior; and(F) accessing and participating in community activities.(d) Frequency and duration. The provision of day programs for acute needs must be in accordance with the amount and duration for which the provider has obtained authorization in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan). Source Note: The provisions of this §306.321 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.321 Day Programs for Acute Needs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198596 03/12/2026 (a) MH rehabilitative services documentation. A rehabilitative services provider must document the following for all MH rehabilitative services:(1) the name of the individual to whom the service was provided;(2) the type of service provided;(3) the specific goal or objective addressed, modality, and method used to provide the service;(4) the date the service was provided;(5) the begin and end time of the service;(6) the location where the service was provided;(7) the signature of the staff member providing the service and a notation of their credential (e.g., a QMHP-CS, a pharmacist, a CSSP, a CFP, or a peer provider);(8) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service;(9) any pertinent information required to be documented by the curricula, protocol, or practice approved by the department; and(10) the outcome or response, as applicable:(A) for crisis intervention service, the outcome of the crisis;(B) for psychosocial coordination services, the outcome of the services;(C) for day programs for acute needs, the progress or lack of progress in stabilizing the individual's acute psychiatric symptoms; or(D) for all other services, the individual's response, including the progress or lack of progress in achieving recovery plan goals and objectives.(b) Crisis services documentation. In addition to the requirements described in subsection (a) of this section, when providing crisis services, a provider must document the information required by §412.321(e) of this title (relating to Crisis Services).(c) Medical necessity documentation. An LPHA must document that MH rehabilitative services are medically necessary when the services are authorized and reauthorized.(d) Frequency of documentation.(1) Day programs for acute needs. For day programs for acute needs, the documentation required by subsection (a)(1) - (9) and (10)(C) of this section must be made daily.(2) Programs other than day programs for acute needs. For MH rehabilitative services other than day programs for acute needs, the documentation required by subsection (a)(1) - (9) and (10)(A), (B), and (D) of this section must be made after each face-to-face contact that occurs to provide the MH rehabilitative service.(3) Medical necessity. An LPHA must document medical necessity in accordance with §416.6 of this title (relating to Service Authorization and Recovery Plan).(4) Retention. A provider must retain documentation in compliance with applicable federal and state laws, rules, and regulations. Source Note: The provisions of this §306.323 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.323 Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198597 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198597 03/12/2026 (a) General competency of staff members. In accordance with §412.316 of this title (relating to Competency and Credentialing), a provider must ensure the competency of staff members prior to providing services.(b) MH rehabilitative services training and competency of staff members. A provider must ensure that staff members providing MH rehabilitative services receive initial training and ensure the competency of a staff member who provides or supervises the provision MH rehabilitative services in the following areas:(1) the nature of serious mental illness and SED;(2) the concepts of recovery and resilience;(3) the department-approved curricula, protocol, or practice;(4) the rehabilitative practice techniques found in curricula, program practices, and protocols; and(5) the prevalence of health risk factors.(c) Additional training related to children and adolescents. A staff member who routinely provides or supervises the provision of MH rehabilitative services to a child or adolescent must receive training and demonstrate competency as required by subsection (b) of this section and in the following areas:(1) the aspects of a child's or adolescent's growth and development (including physical, emotional, cognitive, educational and social) and the treatment needs of a child and adolescent; and(2) the department's approved skills training curricula, protocol, or practice guidelines.(d) Except for the direct clinical supervision of a peer provider, which must be provided by an LPHA, the clinical supervision of the provision of MH rehabilitative services must be provided by a staff member who is, at minimum, a QMHP-CS.(e) Approved curricula. If a staff member provides MH rehabilitative services through a department-approved curricula, protocol, or practice guideline, the staff member must be trained in the implementation of the curriculum, protocol, or practice guideline.(f) Follow-up training. In addition to the training required in subsection (a) of this section, staff members may be required to receive additional training as determined by the department.(g) Training documentation. A provider must document that a staff member has successfully completed the training and has demonstrated competencies in the areas described in subsection (a) of this section. Source Note: The provisions of this §306.325 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.325 Staff Member Competency and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198598 03/12/2026 (a) Billable and non-billable activities.(1) A Medicaid provider may only bill for medically necessary MH rehabilitative services that are provided face-to-face to:(A) a Medicaid-eligible individual;(B) the LAR of a Medicaid-eligible adult (on behalf of the adult); or(C) the LAR or primary caregiver of a Medicaid-eligible child or adolescent (on behalf of the child or adolescent).(2) The cost of the following activities are included in the Medicaid MH rehabilitative services reimbursement rate(s) and may not be directly billed by the Medicaid provider:(A) developing and revising the recovery plan and interventions that are appropriate to an individual's needs;(B) staffing and team meetings to discuss the provision of MH rehabilitative services to a specific individual;(C) monitoring and evaluating outcomes of interventions, including contacts with a person other than the individual;(D) documenting the provision of MH rehabilitative services;(E) a staff member traveling to and from a location to provide MH rehabilitative services;(F) all services provided within a day program for acute needs that are delivered by a staff member, including services delivered in response to a crisis or an episode of acute psychiatric symptoms; and(G) administering the uniform assessment to individuals who are receiving psychosocial rehabilitative services.(b) Non-reimbursable activities.(1) The department will not reimburse a Medicaid provider for any MH rehabilitative services provided to an individual who is:(A) a resident of an intermediate care facility for persons with an intellectual or developmental disability as described in 42 CFR §440.150;(B) a resident in an IMD;(C) an inmate of a public institution as defined in 42 CFR §435.1009;(D) a resident in a Medicaid-certified nursing facility unless the individual has been determined through a pre-admission screening and annual resident review assessment to be eligible for the specialized service of MH rehabilitative services;(E) a patient in a general medical hospital; or(F) not Medicaid-eligible.(2) With the exception of crisis intervention services and psychosocial rehabilitative services that are being provided to resolve a crisis situation, the department will not reimburse a Medicaid provider for any combination of MH rehabilitative services delivered in excess of eight hours per individual per day. In addition, the department will not reimburse a Medicaid provider for more than:(A) two hours per individual per day of medication training and support services;(B) four hours per individual per day of psychosocial rehabilitative services when the psychosocial rehabilitative services are being provided in non-crisis situations;(C) four hours per individual per day of skills training and development services; and(D) six hours per individual per day of day programs for acute needs.(3) The department will not reimburse a Medicaid provider for:(A) an MH rehabilitative service that is not included in the individual's recovery plan (except for crisis intervention services documented in accordance with §416.6(b) of this title (relating to Service Authorization and Recovery Plan)) and psychosocial rehabilitative services provided in a crisis situation;(B) an MH rehabilitative service that is not authorized in accordance with §416.6 of this title (except for crisis intervention services documented in accordance with §416.6(b) of this title);(C) an MH rehabilitative service provided in excess of the amount authorized in accordance with §416.6(a)(1) of this title;(D) an MH rehabilitative service provided outside of the duration authorized in accordance with §416.6(b) of this title;(E) a psychosocial rehabilitative service provided to an individual receiving MH case management services in accordance with Chapter 412, Subchapter I of this title (relating to MH Case Management);(F) an MH rehabilitative service that is not documented in accordance with §416.12 of this title (relating to Documentation Requirements);(G) an MH rehabilitative service provided to an individual who does not meet the eligibility criteria as described in §416.5 of this title (relating to Eligibility);(H) an MH rehabilitative service provided to an individual who does not have a current uniform assessment (except for crisis intervention services documented in accordance with §416.6(b) of this title);(I) an MH rehabilitative service provided to an individual who is not present, awake, and participating during such service;(J) an MH rehabilitative service that is provided via electronic media;(K) a crisis service provided to an individual who does not have a serious mental illness; and(L) any other activity or service identified as non-reimbursable in the department's MH Rehabilitative Services Billing Guidelines, referenced in §416.17 of this title (relating to Guidelines).(c) Services provided same time and same day.(1) If a Medicaid provider provides more than one MH rehabilitative service to an individual at the same time and on the same day, the Medicaid provider may bill for only one of the services provided.(2) A Medicaid provider may bill for a MH rehabilitative service provided to a child or adolescent's LAR or primary caregiver at the same time and on the same day the child or adolescent is receiving another MH rehabilitative service only if the staff member providing the service to the LAR or primary caregiver is different from the staff member providing the service to the child or adolescent.(d) Services provided before a fair hearing. If the provision of a MH rehabilitative service is continued prior to a fair hearing decision being rendered, as required by 1 TAC §357.7 (relating to Agency and Designee Responsibilities), the Medicaid provider may bill for such service. Source Note: The provisions of this §307.327 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.327 Medicaid Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198599 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198599 03/12/2026 (a) Qualifications. To become a Medicaid provider of MH rehabilitative services, an entity must:(1) be established as a community mental health center in accordance with Texas Health and Safety Code, §534.001, that:(A) provides services comparable to MH rehabilitative services and the services described in the Texas Health and Safety Code, §534.053(a)(1) - (7);(B) is in compliance with Chapter 412, Subchapter G of this title (relating to Mental Health Community Services Standards);(C) conducts criminal history clearances on all contractors delivering MH rehabilitative services and all employees and applicants of the Medicaid provider to whom an offer of employment is made and ensures that individuals do not come in contact with and are not provided services by an employee or contractor of the Medicaid provider (or employee or contractor of contractors delivering MH rehabilitative services under a contract with the Medicaid provider) who has a conviction for any of the criminal offenses listed in Texas Health and Safety Code, §250.006, or for any criminal offense that the Medicaid provider has determined to be a contraindication to employment; and(D) has a Medicaid provider agreement with the department to provide MH rehabilitative services; or(2) be a corporation incorporated or registered to do business in the State of Texas that:(A) has completed an application evidencing that it:(i) provides services comparable to MH rehabilitative services and the services described in the Texas Health and Safety Code, §534.053(a)(1) - (7);(ii) is in compliance with Chapter 412, Subchapter G, of this title;(iii) has demonstrated a history of providing, as well as the capacity to continue to provide, services to individuals required to submit to mental health treatment:(I) under the Texas Code of Criminal Procedure, Article 17.032 (relating to Release on Personal Bond of Certain Mentally Ill Defendants), or Article 42.12 §11(d) (relating to Community Supervision); and(II) under the Texas Health and Safety Code, Chapter 573 (relating to Emergency Detention) and Chapter 574 (relating to Court-Ordered Mental Health Services); and(iv) conducts criminal history clearances on all contractors delivering MH rehabilitative services and all employees and applicants of the corporation to whom an offer of employment is made and ensures that individuals do not come in contact with and are not provided services by an employee or contractor of the corporation (or employee or contractor of contractors delivering MH rehabilitative services under a contract with the corporation) who has a conviction for any of the criminal offenses listed in Texas Health and Safety Code, §250.006, or for any criminal offense that the corporation has determined to be a contraindication to employment;(B) has had its application information confirmed by an on-site visit by the department;(C) has had its application approved by the department; and(D) has signed a Medicaid provider agreement with the department to provide MH rehabilitative services.(b) Compliance. A Medicaid provider must:(1) comply with all applicable federal and state laws, rules, and regulations, and any Medicaid provider manuals and policy clarification letters promulgated by the department;(2) document and bill for reimbursement of MH rehabilitative services in the manner and format prescribed by the department;(3) allow the department access to all individuals and individuals' records;(4) maintain capacity to provide those services that are described in Texas Health and Safety Code, §534.053(a)(1) - (7); and(5) maintain capacity to provide services to individuals required to submit to mental health treatment:(A) under the Texas Code of Criminal Procedure, Article 17.032 (relating to Release on Personal Bond of Certain Mentally Ill Defendants), or Article 42.12 §11(d) (relating to Community Supervision); and(B) under the Texas Health and Safety Code, Chapter 573 (relating to Emergency Detention) and Chapter 574 (relating to Court-Ordered Mental Health Services). Source Note: The provisions of this §306.329 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.329 Medicaid Provider Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198600 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198600 03/12/2026 (a) Right of Medicaid-eligible individual to request a fair hearing. Any Medicaid-eligible individual whose request for eligibility for MH rehabilitative services is denied or is not acted upon with reasonable promptness, or whose MH rehabilitative services have been terminated, suspended, or reduced by the department is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(b) Notice. The Medicaid provider must notify the department or its designee if the provider has reason to believe that an individual's MH rehabilitative services should be denied, reduced or terminated.(c) Right of non-Medicaid eligible individual to request a review. Any individual who has not applied for or is not eligible for Medicaid whose request for eligibility for MH rehabilitative services is not acted upon with reasonable promptness, or whose MH rehabilitative services have been terminated, suspended, or reduced by a local mental health authority or its contractor is entitled to the right of review and notification in accordance with the department's rules concerning such matters for non-Medicaid-eligible individuals. Source Note: The provisions of this §306.331 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.331 Fair Hearings and Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198601 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198601 03/12/2026 The following guidelines are referenced in this subchapter. For information about obtaining copies of the guidelines contact the Department of State Health Services, Mental Health Program Services Section, Mail Code 2018, P.O. Box 149347, Austin, Texas 78714-9347, (512) 467-5427 or access them electronically.(1) The uniform assessment guidelines are available at: http://www.dshs.state.tx.us/mhprograms/RDMAssess.shtm.(2) The utilization management guidelines for adults and children are available at: http://www.dshs.state.tx.us/mhprograms/RDMClinGuide.(3) Patient and family education resources are available at http://www.dshs.state.tx.us/mhsa/patient-family-ed/.(4) Medicaid MH Rehabilitative Services Billing Guidelines are available at: http://www.dshs.state.tx.us/mhsa/rdm/billing/. Source Note: The provisions of this §306.333 adopted to be effective January 22, 2014, 39 TexReg 299; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1239. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM F MENTAL HEALTH REHABILITATIVE SERVICES §306.333 Guidelines https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203967 03/12/2026 The purpose of this subchapter is to require the use and maintenance of the Texas Health and Human Services Commission (HHSC) Psychiatric Drug Formulary. Source Note: The provisions of this §306.351 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.351 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203968 03/12/2026 (a) This subchapter applies to HHSC facilities, HHSC-funded community behavioral health centers (including substance use treatment providers), local authorities, and their respective contractors for medications and medication-related services funded by HHSC. The HHSC Psychiatric Drug Formulary in its entirety applies to all HHSC facilities in all circumstances except when HHSC transfers an individual to a general hospital to receive non-mental health acute care services.(b) HHSC facilities and local authorities are responsible for drafting contracts with their contractors that provide HHSC-funded medications and medication-related services to ensure that contractors comply with this subchapter. Source Note: The provisions of this §306.352 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.352 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203971 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Adverse drug reaction--Any response to a drug that is noxious and unintended and occurs at doses normally used in humans.(2) Contractor--An entity that provides HHSC-funded mental health services pursuant to a contract with a service system component or HHSC.(3) Drug entity--A specific chemical compound and all its pharmaceutically equivalent salt forms that are used in the diagnosis, cure, mitigation, treatment or prevention of disease.(4) Emergency--A situation in which it is immediately necessary to administer medication to an individual to prevent:(A) imminent probable death or substantial bodily harm to the individual because the individual:(i) overtly or continually is threatening or attempting to commit suicide or serious bodily harm; or(ii) is behaving in a manner that indicates that the individual is unable to satisfy the individual's need for nourishment, essential medical care, or self-protection; or(B) imminent serious physical or emotional harm to others as indicated by threats, attempts, or other acts the individual overtly or continually makes or commits.(5) HHSC--Texas Health and Human Services Commission.(6) HHSC facility--A facility operated by HHSC, including state hospitals and state supported living centers.(7) HHSC Psychiatric Drug Formulary--A listing by nonproprietary name of all drugs approved for use by service system components and their contractors that is updated annually, at a minimum.(8) Individual--Any person receiving services from a service system component or contractor.(9) Interim Formulary Update--An update to the HHSC Psychiatric Drug Formulary, which is incorporated into the HHSC Psychiatric Drug Formulary.(10) Local authority--A local mental health authority designated in accordance with Texas Health and Safety Code, §533.035(a), a local behavioral health authority designated in accordance with Texas Health and Safety Code, §533.0356, and a local intellectual and developmental disability authority designated in accordance with Texas Health and Safety Code §533A.035(a).(11) Mental health services--Any services concerned with the diagnosis, treatment, and care of individuals for a mental illness (known as serious emotional disturbance in reference to children and adolescents), which may be accompanied by a co-occurring diagnosis.(12) PEFC--Psychiatric Executive Formulary Committee. A committee composed of representatives from the state hospitals, state supported living centers, community behavioral health entities, and others as selected by the state hospitals associate commissioner in consultation with the state supported living center associate commissioner, the behavioral health services associate commissioner, and the intellectual and developmental services associate commissioner. The committee is responsible for the formulation of broad professional policies regarding the evaluation, selection, handling, use, administration, and all other matters relating to the use of drugs and devices in an HHSC facility, local authority, and their respective contractors for medications and medication-related services funded by HHSC.(13) Pharmacy and Therapeutics Committee--An HHSC facility committee composed of physicians, pharmacists, registered nurses, and others as selected by the facility head, or their designee, that assists in the formulation of broad professional policies regarding the evaluation, selection, distribution, handling, use, administration, and all other matters relating to the use of drugs and devices in the facility.(14) Practitioner--A person who acts within the scope of a professional license to prescribe, distribute, administer, or dispense a prescription drug or device, (e.g. a physician, registered nurse, advanced practice registered nurse, physician assistant, licensed vocational nurse, pharmacist, or dentist).(15) Reserve drug--A formulary drug with specific guidelines for use as described in the HHSC Psychiatric Drug Formulary.(16) Service system component--HHSC, an HHSC facility, and a local authority. Source Note: The provisions of this §306.353 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.353 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203969 03/12/2026 (a) HHSC maintains a closed formulary (HHSC Psychiatric Drug Formulary) that lists drugs approved by the PEFC for use by service system components and their contractors.(b) A drug is not available for general use by service system components or their contractors unless it is approved by the PEFC. Drugs not listed in the HHSC Psychiatric Drug Formulary or Interim Formulary Update may not be used except under the limited circumstances described in §306.359 of this subchapter (relating to Prescribing Non-formulary Drugs).(c) The use of formulary drugs in unusual clinical situations or the use of unusual drug combinations must be accompanied by written justification in the individual's medical record. Additional clinical consultation in these situations should occur as deemed necessary by the prescribing practitioner.(d) Reserve drugs may be prescribed for use outside the guidelines described in the formulary if the prescription is justified in the individual's medical record and reviewed in audits of reserve drug use conducted by the service system component as clinically indicated.(e) Drug research conducted at an HHSC facility is governed by 25 TAC Chapter 414, Subchapter P (relating to Research in TDMHMR Facilities). Local authorities conducting drug research must comply with all applicable state and federal laws, rules, and regulations, including 45 CFR Part 46, as required by §301.325 of this title (relating to Rights and Protection). Source Note: The provisions of this §306.354 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.354 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203970 03/12/2026 (a) Drugs are listed in the HHSC Psychiatric Drug Formulary by their nonproprietary names. The list is based on a modified format of the American Hospital Formulary Service Drug Information and includes an alphabetical index. The use of proprietary names, which may follow in parentheses, is for information purposes only and is not meant to be an endorsement. Cost comparisons and prescribing information are provided as determined necessary by the PEFC. The HHSC Psychiatric Drug Formulary provides tables summarizing the recommended dosage ranges for the psychotropic drugs for clinician reference. These tables are intended as guidelines and are not intended to replace other references or the clinician's clinical judgment. Clinicians should consult the approved Food and Drug Administration product labeling or other clinical resources on the appropriate prescribing of psychoactive medications. The HHSC Psychiatric Drug Formulary notes limitations recommended by the PEFC regarding the use of a drug, including specific limitations or guidelines for the use of a reserve drug.(b) The Interim Formulary Update conforms to the same format as the HHSC Psychiatric Drug Formulary and shall be incorporated into the annual HHSC Psychiatric Drug Formulary. Source Note: The provisions of this §306.355 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.355 Organization of HHSC Psychiatric Drug Formulary https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203972 03/12/2026 (a) The PEFC maintains and updates the HHSC Psychiatric Drug Formulary by:(1) recommending standards of drug use that discourage unnecessary duplication of therapeutic alternatives and encourage the highest standards of medical and pharmacy practice;(2) periodically reviewing the drugs listed in the formulary to ensure consistency with need, effectiveness, risk, and cost;(3) consulting with experts in clinical pharmacy, pharmacology, and other medical specialties as necessary to objectively assess drugs under consideration; and(4) considering the applications submitted in accordance with §306.357 of this subchapter (relating to Adding a Drug to the HHSC Psychiatric Drug Formulary) or as:(A) presented by committee members; or(B) submitted by other qualified persons at the invitation of the PEFC chairperson.(b) The PEFC may make other recommendations concerning drug use and policy.(c) Approval of a drug entity for inclusion in the HHSC Psychiatric Drug Formulary does not imply approval of all formulations for that drug. The PEFC designates the formulations that are allowed for general use by service system components and their contractors.(d) Approval of a drug formulation constitutes approval of all brands of the product that have been proven to be bioequivalent as listed in the then-current Approved Drug Products with Therapeutic Equivalence Evaluations, published by the United States Food and Drug Administration.(e) For a drug entity that has known bioequivalency problems, the PEFC may limit its use to a specific brand based on objective clinical pharmacokinetic data. Source Note: The provisions of this §306.356 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.356 Responsibilities of the Psychiatric Executive Formulary Committee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203973 03/12/2026 (a) Applying to have a drug added to the HHSC Psychiatric Drug Formulary.(1) Any member of the PEFC, any service system component practitioner, or any contract practitioner may apply to have a drug added to the HHSC Psychiatric Drug Formulary by completing the New Drug Application form found in the HHSC Psychiatric Drug Formulary on the HHSC Psychiatric Formulary website.(2) Include the following with the New Drug Application form:(A) published articles in biomedical literature that substantiate the efficacy and safety of the proposed drug;(B) information on the advantages of the proposed drug compared with similar formulary drugs;(C) a list of formulary drugs that the proposed drug would replace or supplement; and(D) cost effectiveness data.(b) Submitting the application.(1) An HHSC facility practitioner or HHSC facility contract practitioner shall submit the application to the facility's pharmacy and therapeutics committee for approval. If the committee approves the application, the committee forwards the application to the PEFC.(2) A non-facility service system component practitioner or non-facility service system component contract practitioner shall submit the application to the component's clinical/medical director or designee who determines if the application is appropriate and complete, and if so, shall forward the application to the PEFC.(3) A member of the PEFC shall submit the application directly to the PEFC.(c) Considering the application. The PEFC considers the drug application and shall:(1) approve the proposed drug's inclusion and, if appropriate, approve audit criteria and recommend dosage guidelines;(2) approve the proposed drug on a trial basis for a specified period of time;(3) approve the proposed drug as a reserve drug, with guidelines;(4) postpone the decision until a later meeting; or(5) deny the proposed drug's inclusion. Source Note: The provisions of this §306.357 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.357 Adding a Drug to the HHSC Psychiatric Drug Formulary https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203974 03/12/2026 (a) Changes to the HHSC Psychiatric Drug Formulary are based on need, effectiveness, risk, and cost as contained in current and unbiased biomedical literature.(b) The HHSC Psychiatric Drug Formulary is updated and published once a year, at a minimum. Quarterly updates to the HHSC Psychiatric Drug Formulary, if any, will be listed in an Interim Formulary Update. Source Note: The provisions of this §306.358 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.358 Changing the HHSC Psychiatric Drug Formulary https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203975 03/12/2026 (a) Non-formulary drugs may be prescribed:(1) if no formulary drug exists that is as safe or effective in the specified situation;(2) if a limited trial of the drug is safer or more effective than any drug listed in the formulary, based on available medical evidence and the prescribing practitioner's clinical judgment;(3) if the course of therapy established prior to the individual's admission to the facility where he or she is being treated would be interrupted; or(4) in an emergency.(b) Each local authority shall develop and enforce written policies and procedures for monitoring and approving the prescribing of non-formulary drugs by its practitioners and contract practitioners.(c) HHSC shall develop and enforce written policies and procedures for monitoring and approving the prescribing of non-formulary drugs by HHSC facility practitioners and facility contract practitioners. Source Note: The provisions of this §306.359 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.359 Prescribing Non-formulary Drugs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203976 03/12/2026 (a) Each local authority shall develop written policies and procedures for reporting adverse drug reactions to the Food and Drug Administration.(b) HHSC shall develop written policies and procedures for HHSC facilities for reporting adverse drug reactions to the Food and Drug Administration. Source Note: The provisions of this §306.360 adopted to be effective February 24, 2021, 46 TexReg 1246. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM G USE AND MAINTENANCE OF THE HEALTH AND HUMAN SERVICES COMMISSION PSYCHIATRIC DRUG FORMULARY §306.360 Adverse Drug Reactions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224290 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224290 03/12/2026 The purpose of this subchapter is to establish methods and parameters of service delivery for individuals receiving general revenue-funded behavioral health services that the Texas Health and Human Services Commission (HHSC) determines are clinically effective and cost-effective in accordance with Texas Government Code §548.0002. Source Note: The provisions of this §306.361 adopted to be effective February 23, 2025, 50 TexReg 997 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM H BEHAVIORAL HEALTH SERVICES--TELECOMMUNICATIONS §306.361 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224291 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224291 03/12/2026 This subchapter applies to:(1) a local mental health authority (LMHA);(2) a local behavioral health authority (LBHA);(3) an HHSC-funded substance use intervention provider;(4) an HHSC-funded substance use treatment provider; and(5) a subcontracted provider of an LMHA, LBHA, HHSC-funded substance use intervention provider, and HHSC-funded substance use treatment provider. Source Note: The provisions of this §306.363 adopted to be effective February 23, 2025, 50 TexReg 997 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM H BEHAVIORAL HEALTH SERVICES--TELECOMMUNICATIONS §306.363 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224292 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Audio-only technology--A synchronous interactive, two-way audio communication that uses only sound and that conforms to privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include audiovisual or in-person communication.(2) Audiovisual technology--A synchronous interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audiovisual does not include audio-only or in-person communication.(3) CFR--Code of Federal Regulations.(4) HHSC--Texas Health and Human Services Commission or its designee.(5) HIPAA--The Health Insurance Portability and Accountability Act, 42 U.S.C. §1320d et seq.(6) Individual--A person seeking or receiving services under this subchapter.(7) In person or in-person--Within the physical presence of another person. In person or in-person does not include interacting with an individual through audiovisual or audio-only communication.(8) LAR--Legally authorized representative. A person authorized by state law to act on behalf of an individual.(9) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356.(10) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a).(11) Provider--A person or entity that contracts to deliver services under this subchapter with:(A) HHSC;(B) an LMHA;(C) an LBHA;(D) an HHSC-funded substance use intervention provider; or(E) an HHSC-funded substance use treatment provider. Source Note: The provisions of this §306.365 adopted to be effective February 23, 2025, 50 TexReg 997 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM H BEHAVIORAL HEALTH SERVICES--TELECOMMUNICATIONS §306.365 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224293 03/12/2026 (a) A provider may deliver services as permitted under this subchapter, if such delivery is permitted under the provider's state license, permit, or other legal authorization.(b) If a behavioral health service has a procedure code that is billable in Medicaid, but the service is funded through general revenue, a provider must adhere to:(1) the Texas Medicaid Provider Procedures Manual and the Behavioral Health and Case Management Services Handbook posted on the Texas Medicaid and Healthcare Partnership website;(2) the Texas Medicaid Provider Procedures Manual and Telecommunications Services Handbook posted on the Texas Medicaid and Healthcare Partnership website; and(3) other Medicaid guidance concerning delivery of behavioral health services by audiovisual technology and audio-only technology.(c) A provider may deliver behavioral health services that do not have a procedure code billable in Medicaid either in person, by audiovisual technology, or by audio-only technology.(d) A provider delivering behavioral health services by audiovisual technology or audio-only technology as permitted under this subchapter must:(1) deliver behavioral health services in person or use audiovisual technology rather than audio-only technology, whenever possible; (2) offer the option of in-person service delivery and not require an individual to receive services through audiovisual technology or audio-only technology;(3) defer to the needs of the individual receiving services, allowing the method of service delivery to be accessible, person-centered and family-centered, and driven primarily by the individual's choice rather than provider convenience;(4) only deliver the service by audiovisual technology and audio-only technology if agreed to by the individual or LAR;(5) determine that providing the service by audiovisual technology or audio-only technology is clinically appropriate and safe;(6) deliver services in compliance with state standards set forth in Texas Health and Safety Code §533.035(d) and §533.0356(h), Texas Health and Safety Code Chapter 464, and in accordance with applicable HHSC rules; and(7) maintain the confidentiality of protected health information as required by 42 CFR Part 2, 45 CFR Parts 160 and 164, Texas Occupations Code Chapter 159, Texas Health and Safety Code Chapter 611, and other applicable federal and state law.(e) A provider must ensure any software or technology used complies with all applicable state and federal requirements, including HIPAA confidentiality and data encryption requirements, and with the United States Department of Health and Human Services rules implementing HIPAA confidentiality and data encryption requirements. Source Note: The provisions of this §306.367 adopted to be effective February 23, 2025, 50 TexReg 997 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM H BEHAVIORAL HEALTH SERVICES--TELECOMMUNICATIONS §306.367 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224294 03/12/2026 (a) A provider must accurately document the services rendered and identify the method of service delivery. Documentation requirements for behavioral health services delivered by audiovisual technology or audio-only technology are the same as for service delivery in person.(b) Before delivering a behavioral health service by audio-only technology, a provider must:(1) obtain informed consent from the individual or LAR except when doing so is not feasible or could result in death or injury to the individual;(2) if applicable, document in the individual's medical record that informed consent was obtained verbally; and(3) document the reason why the provider delivered services by audio-only technology.(c) A provider must adhere to documentation requirements in accordance with publications and conditions described in §306.367(b) of this subchapter (relating to General Provisions) if the general revenue-funded behavioral health service has a procedure code that is billable in Medicaid. Source Note: The provisions of this §306.369 adopted to be effective February 23, 2025, 50 TexReg 997 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM H BEHAVIORAL HEALTH SERVICES--TELECOMMUNICATIONS §306.369 Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206699 03/12/2026 (a) In the event of a state of disaster declared pursuant to Texas Government Code §418.014 for statewide disasters or limited areas subject to the declaration, the flexibilities listed under subsection (c) of this section will be available until the state of disaster is terminated.(b) Telehealth and telemedicine have the same meaning as the terms telehealth services and telemedicine medical services defined in §111.001 of the Texas Occupations Code (relating to Definitions).(c) The following flexibilities are available to community behavioral health providers to the extent such providers are providing services under Title 25, Part 1 or Title 26, Part 1 of the Texas Administrative Code (TAC) and to the extent the flexibilities do not conflict with federal or state laws, regulations, rules, or orders.(1) For rules under Title 25, Part 1 and Title 26, Part 1 of the TAC that require a community behavioral health provider to deliver certain services:(A) through face-to-face or in-person contact, such as the following rules, the provider may use telehealth, telemedicine, video-conferencing, or telephonic methods to engage with the individual to provide these services, to the extent such use is permitted within the scope of the provider's state license, permit, or other legal authorization:(i) §301.327 of this title (relating to Access to Mental Health Community Services);(ii) §301.351 of this title (relating to Crisis Services);(iii) §301.353 of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization);(iv) §301.357 of this title (relating to Additional Standards of Care Specific to Mental Health Community Services for Children and Adolescents);(v) §301.359 of this title (relating to Telemedicine Services);(vi) §306.207 of this chapter (relating to Post Discharge or Absence for Trial Placement: Contact and Implementation of the Recovery or Treatment Plan);(vii) §306.263 of this chapter (relating to MH Case Management Services Standards);(viii) §306.275 of this chapter (relating to Documenting MH Case Management Services);(ix) §306.277 of this chapter (relating to Medicaid Reimbursement);(x) §306.305 of this chapter (relating to Definitions);(xi) §306.323 of this chapter (relating to Documentation Requirements);(xii) §306.327 of this chapter (relating to Medicaid Reimbursement);(xiii) §307.53 of this title (relating to Eligibility Criteria and HCBS-AMH Assessment);(xiv) 25 TAC §415.10 (relating to Medication Monitoring); and(xv) 25 TAC §415.261 (relating to Time Limitation on an Order for Restraint or Seclusion Initiated in Response to a Behavioral Emergency); or(B) in a specific physical space or on site, such as 25 TAC §414.554 (relating to Responsibilities of Local Authorities, Community Centers, and Contractors), the provider may deliver the service using virtual platforms, such as telephone or videoconferencing.(2) Section 307.5 of this title (relating to Eligibility Criteria) that require a child or adolescent participating in the Youth Empowerment Services (YES) Waiver Program to reside with their legally authorized representative to receive services may reside with another responsible adult. Providers must ensure the alternate residency complies with any applicable requirements related to participation in the YES Waiver Program. The flexibility allowed under this subsection IS NOT IN EFFECT unless and until the Centers for Medicare & Medicaid Services approves HHSC's request for activation of Appendix-K.(3) For rules under Title 25, Part 1 and Title 26, Part 1 of the TAC that require staff training through face-to-face or in-person contact or in a specific physical space or on site, staff training may be done on virtual platforms.(4) For rules under Title 25, Part 1 and Title 26, Part 1 of the TAC where HHSC may issue guidance to extend timeframe flexibilities:(A) the extended timeframe may not be longer than 120 days for compliance with staff training requirements based on training availability and feasibility during, or resulting from, a declared disaster; and(B) an individual's or staff member's health or safety shall not be compromised by the flexibilities for training requirements provided in:(i) §306.83 of this chapter (relating to Staff Training); and(ii) §301.331 of this title (relating to Competency and Credentialing).(d) Providers that avail themselves of the flexibilities allowed under subsection (c) of this section, must comply with:(1) all guidance on the application of the rules during the declaration of disaster that is published by HHSC on its website or in another communication format HHSC determines appropriate; and(2) all policy guidance applicable to the rules identified in subsection (c) of this section issued by the Texas Health and Human Service Commission Medicaid Services Department.(e) Providers must ensure any method of contact complies with all applicable requirements related to security and privacy of information. Source Note: The provisions of this §306.1251 adopted to be effective November 15, 2021, 46 TexReg 7639. 1 HEALTH AND HUMAN SERVICES COMMISSION 306 BEHAVIORAL HEALTH DELIVERY SYSTEM X DISASTER RULE FLEXIBILITIES FOR BEHAVIORAL HEALTH PROVIDERS §306.1251 Disaster Flexibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198086 03/12/2026 (a) Purpose. The purpose of this subchapter is to implement a pilot program, under the waiver provisions of the federal Social Security Act, §1915(c), that prevents or reduces institutionalization of children and adolescents with severe emotional disturbance (SED), enables more flexibility in providing intensive community-based services for children and adolescents with SED, and provides support for their families by improving access to services.(b) Application. The subchapter applies to:(1) persons and entities that have a Medicaid provider agreement to provide the waiver program services, as described in this subchapter;(2) local mental health authorities (LMHAs), which have administrative responsibilities under the waiver program; and(3) children and adolescents who are applicants for or recipients of services under the waiver program. Source Note: The provisions of this §307.1 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.1 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198087 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Adolescent--An individual who is at least 13 years of age, but younger than 19 years of age.(2) Assessment--A set of standardized assessment measures used by the department to determine level of need as set forth in the approved waiver.(3) Child--An individual who is at least three years of age, but younger than 13 years of age.(4) Department--Department of State Health Services.(5) LAR or legally authorized representative--A person authorized by law to act on behalf of a child or adolescent with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.(6) LMHA or local mental health authority--An entity designated as the local mental authority by the department in accordance with the Health and Safety Code, §533.035(a).(7) LPHA or licensed practitioner of the healing arts--A person who is:(A) a physician;(B) a licensed professional counselor;(C) a licensed clinical social worker;(D) a licensed psychologist;(E) an advanced practice nurse; or(F) a licensed marriage and family therapist.(8) Provider--Any person or legal entity that has an agreement with the department and the single state Medicaid agency to provide the waiver program services, as described in the approved waiver.(9) SED or severe emotional disturbance--A child or adolescent with a serious functional impairment or acute severe psychiatric symptomatology as identified by the assessment.(10) Waiver program--A Medicaid program that provides waiver program services to a limited number of eligible children or adolescents, in accordance with the provisions of the waiver approved under the federal Social Security Act, §1915(c).(11) Waiver program services--Medicaid community-based services provided under the approved waiver program. Source Note: The provisions of this §307.3 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198088 03/12/2026 (a) To participate in the waiver program, the child or adolescent must meet the following eligibility criteria:(1) be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver;(2) live in a county included in the waiver program;(3) be reasonably expected to qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines, as defined in the approved waiver, in the absence of waiver services;(4) reside:(A) in a non-institutional setting with the child's or adolescent's LAR; or(B) in the child's or adolescent's own home or apartment, if legally emancipated; and(5) choose, or have the LAR choose, the waiver program services as an alternative to care in an inpatient psychiatric facility, in accordance with the provisions of the approved waiver.(b) The participating child or adolescent must be determined to meet the eligibility criteria in subsection (a) of this section on an annual basis to continue in the waiver program.(c) The department reserves the right to limit, in each county, the number of eligible children or adolescents that may participate in the waiver program, in accordance with the provisions of the approved waiver. Source Note: The provisions of this §307.5 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.5 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198089 03/12/2026 The receipt of certain waiver program services may be dependent upon the child's or adolescent's and/or LAR's ability to make a co-payment. Source Note: The provisions of this §307.7 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.7 Co-payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198090 03/12/2026 (a) Each child and adolescent determined eligible to participate in the waiver program is assigned a mental health case manager, subject to the rules in Chapter 412, Subchapter I, of this title (relating to Mental Health Case Management Services). The mental health case manager must coordinate with the child or adolescent, LAR, waiver service providers and LMHA to develop an IPC that is based upon the assessment.(b) The initial IPC must be reviewed by an LPHA at the LMHA that serves the geographic area of the participant's residence before forwarding to the department for approval. The IPC must be approved by the department before a provider can begin delivering waiver program services. To be approved, the IPC must:(1) promote the child's or adolescent's inclusion into the community;(2) protect the child's or adolescent's health and welfare in the community;(3) supplement, rather than replace, the child's or adolescent's natural and other non-waiver program support systems and resources;(4) be designed to prevent or reduce the likelihood of the child's or adolescent's admission to an inpatient psychiatric facility; and(5) be the most appropriate type and amount of services to meet the child's or adolescent's needs.(c) The IPC must be reviewed by an LPHA at the LMHA and submitted to the department for approval as part of the annual eligibility determination required under §419.3 of this title (relating to Eligibility Criteria). Any recommended changes to the IPC outside the annual review process must be approved by the department.(d) To demonstrate that the waiver program services specified in the IPC meet the requirements described in subsection (b) of this section, the LMHA must submit the following to the department:(1) an assessment of the child or adolescent that identifies and supports the waiver program services included in the IPC; and(2) documentation that natural and other non-waiver program support systems and resources are unavailable or are insufficient to meet the goals specified in the IPC.(e) The department may conduct utilization review of an IPC and supporting documentation at any time to determine if the services specified in the IPC meet the requirements described in subsection (b) of this section. If the department determines that one or more of the services specified in the IPC do not meet the requirements described in subsection (b) of this section, the department may deny, reduce, or terminate the service, modify the IPC, and send written notification to the child or adolescent, LAR, and the provider.(f) In addition to the utilization review conducted in accordance with subsection (e) of this section, the department may conduct utilization review of the provider and the provision of waiver program services at any time.(g) The cost of implementing the IPC must be within the cost ceiling identified by the department and the single state Medicaid agency. For children and adolescents with service needs that exceed the cost ceiling, the department has a process to ensure that their needs are met, which includes examining third-party resources or possible transition to other waiver programs or inpatient services. Source Note: The provisions of this §307.9 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.9 Individual Plan of Care (IPC) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198091 03/12/2026 (a) The LMHA is required to develop a transition plan for an adolescent who will become 19 years of age while receiving services under the waiver program. The transition plan must be developed at least six months prior to the month the adolescent becomes 19 years of age to ensure that the adolescent is appropriately transitioned to adult services.(b) The transition plan, required under subsection (a) of this section, must be developed in consultation with the adolescent and, if appropriate, the LAR, as well as future providers, allowing adequate time for a smooth transition of the adolescent into adult services. The transition plan must include:(1) a summary of the mental health community services and treatment received while in the waiver program;(2) the adolescent's current assessment, e.g., diagnosis, medications, level of functioning, and unmet needs;(3) information from the adolescent and the LAR, if appropriate, regarding the adolescent's strengths, preferences for mental health community services, and responsiveness to past interventions; and(4) an IPC that:(A) indicates the mental health and other community services the adolescent will receive at the point of becoming 19 years of age; and(B) ensures the adolescent will be provided a smooth transition to adult services. Source Note: The provisions of this §307.11 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.11 Transition Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198084 03/12/2026 (a) Inquiry List. A list, maintained by each LMHA, of children and adolescents as defined by §419.2 of this title (relating to Definitions) who are interested in receiving YES Waiver program services and who reside in the LMHA's service area.(1) Only a child or adolescent or the child's or adolescent's LAR may place a child's or adolescent's name on the inquiry list.(2) The LMHA must assign the child or adolescent a registration date on the inquiry list that is based on the chronological date and time the phone call or voice message requesting YES Waiver program services was received.(b) Maintenance of Inquiry List. The LMHA must maintain an up-to-date inquiry list.(1) The LMHA must remove a child's or adolescent's name from the inquiry list if it is documented that:(A) the child or adolescent or LAR has requested verbally or in writing that the child or adolescent's name be removed from the inquiry list;(B) the child or adolescent or LAR has declined verbally or in writing YES Waiver program services;(C) the child or adolescent or LAR has not responded to the LMHA's notification of a waiver vacancy within 30 calendar days of the LMHA's notification of the vacancy;(D) the child or adolescent has moved out of Texas; or(E) the child or adolescent is deceased.(2) If a child's or adolescent's name is removed from an inquiry list in accordance with paragraph (1) of this subsection, and if the child or adolescent, LAR, or LMHA requests that the child's or adolescent's name be reinstated on the inquiry list, the child or adolescent, LAR, or LMHA may request that the department review the circumstances under which the child's or adolescent's name was removed from the LMHA's inquiry list. At its discretion the department may:(A) reinstate the child's or adolescent's name on the inquiry list according to the original date the child or adolescent or LAR requested the child's or adolescent's name be added in accordance with subsection (a) of this section; or(B) add the child's or adolescent's name to the inquiry list according to the date the child or adolescent or LAR requested that the department review the circumstances under which the child or adolescent's name was removed.(c) Denial of enrollment. The department shall remove a child's or adolescent's name from an LMHA's inquiry list if the department has denied the child's or adolescent's enrollment in the YES Waiver program and the child or adolescent or LAR has had an opportunity to exercise the child or adolescent's right to appeal the decision in accordance with §419.8 of this title (relating to Right to Fair Hearing) and did not appeal the decision, or appealed the decision and did not prevail.(d) Reserve capacity. There are a percentage of vacancies in the YES Waiver program that are reserved for children or adolescents who are at imminent risk of being relinquished to state custody.(1) If a child or adolescent whose name has been added to the LMHA's inquiry list must wait to be enrolled, then the LMHA must screen the child or adolescent for imminent risk of relinquishment.(2) If the LMHA determines that the child or adolescent may be at imminent risk of relinquishment, the LMHA must complete the YES Waiver Reserve Capacity Screening Form and submit to the department for review.(3) If the department determines that the child or adolescent is at imminent risk of relinquishment, the department must authorize the LMHA to complete the enrollment process within three business days.(4) If a child or adolescent is denied reserve capacity, then the LMHA must assign the child or adolescent a registration date on the inquiry list that is based on the chronological date and time the phone call or voice message requesting YES Waiver program services was received in accordance with subsection (a)(2) of this section. Source Note: The provisions of this §307.13 adopted to be effective October 16, 2016, 41 TexReg 8069; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.13 Inquiry List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198085 03/12/2026 The LMHA or the department must notify the child or adolescent, and LAR, of the right to a fair hearing, conducted in accordance with the rules in 1 Texas Administrative Code, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), under the following circumstances:(1) a child or adolescent is denied participation in the waiver program, unless the reason for the denial is the program participation limit referred to in §419.3(c) of this title (relating to Eligibility Criteria);(2) a child or adolescent is denied continued participation in the waiver program; or(3) waiver program services for a child or adolescent are denied, reduced, suspended, or terminated. Source Note: The provisions of this §307.15 adopted to be effective November 19, 2009, 34 TexReg 8038; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 471. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM A YOUTH EMPOWERMENT SERVICES (YES) §307.15 Right to Fair Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196102 03/12/2026 (a) The purpose of this subchapter is to implement the Home and Community-Based Services--Adult Mental Health (HCBS-AMH) program, providing home and community-based services to individuals with a serious mental illness who are eligible for or currently receiving Medicaid in accordance with the Medicaid state plan and applicable state legislative direction.(b) The subchapter applies to:(1) a person or entity contracting with HHSC to provide HCBS-AMH services, as described in this subchapter;(2) an entity having administrative responsibilities under this program; and(3) an individual applying for or enrolled in the HCBS-AMH program. Source Note: The provisions of this §307.51 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.51 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196103 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.(1) Activities of daily living--Routine daily activities. These activities include:(A) performing personal hygiene activities;(B) dressing;(C) meal planning and preparation;(D) managing finances;(E) shopping for food, clothing, and other essential items;(F) performing essential household chores;(G) communicating by phone or other media;(H) navigating public transportation;(I) participating in the community; and(J) other activities as defined by HHSC.(2) Adult--An individual 18 years of age or older.(3) Assessor--A qualified mental health professional-community services as defined in 25 TAC Chapter 412, Subchapter G (relating to Mental Health Community Services Standards) who conducts the HCBS-AMH assessment evaluating an individual's need for HCBS-AMH.(4) Designee--A person or entity named by HHSC to act on its behalf.(5) HCBS--Home and community-based services.(6) HCBS-AMH--Home and community-based services-adult mental health.(7) HCBS-AMH assessment--A set of HHSC-defined standardized assessment measures used by HHSC to determine an individual's level of need based on an individual's strengths and needs. The HCBS-AMH assessment serves as the basis for the IRP.(8) HHSC--Texas Health and Human Services Commission, or its designee.(9) Individual--A person seeking or receiving services under this subchapter.(10) IRP--Individual recovery plan. A written, individualized plan, developed in accordance with 25 TAC Chapter 412, Subchapter D (relating to Mental Health Services--Admission, Continuity, and Discharge) and 25 TAC §412.322 (relating to Provider Responsibilities for Treatment Planning and Service Authorization) in consultation with the individual and LAR, if applicable, identifying necessary HCBS-AMH services the provider will deliver to the individual and which serves as the treatment plan or recovery plan.(11) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual as defined in Texas Health and Safety Code §241.151.(12) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by Texas Government Code §531.02251, which serves as a neutral party to help consumers, including consumers who are uninsured or have public or private health benefit coverage, and behavioral health care providers navigate and resolve issues related to consumer access to behavioral health care, including care for mental health conditions and substance use disorders.(13) Provider--A person or entity that contracts with HHSC to provide services under this subchapter.(14) Serious mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, neurocognitive disorders, substance use disorder, or intellectual disability) that:(A) substantially impairs thought, perception of reality, emotional process, development, or judgment; or(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior. Source Note: The provisions of this §307.52 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.52 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196104 03/12/2026 (a) To participate in the HCBS-AMH program, an assessor must conduct an HCBS-AMH assessment on each individual for HHSC to determine that the individual meets the needs-based eligibility criteria for HCBS-AMH.(1) The assessor must consult with the individual, the individual's LAR, if applicable, treatment team, providers, and other persons according to the needs and desire of the individual to conduct the HCBS-AMH assessment.(2) The HCBS-AMH assessment must:(A) be conducted face-to-face as permitted under Medicaid guidelines;(B) take into account the ability of the individual to perform two or more activities of daily living; and(C) assess the individual's need for HCBS-AMH.(b) For HHSC to determine an individual eligible to participate in HCBS-AMH, the individual must meet criteria in accordance with applicable state legislative direction and eligibility requirements as set forth in the Medicaid state plan, including:(1) having three years or more of consecutive or cumulative inpatient psychiatric hospitalizations during the five years before initial enrollment in the HCBS-AMH program;(2) having two or more psychiatric crises and four or more discharges from correctional facilities during the three years before initial enrollment in HCBS-AMH; or(3) having two or more psychiatric crises and fifteen or more total emergency department documented contacts in which services are delivered during the three years before initial enrollment in HCBS-AMH.(c) The HCBS-AMH assessment must be repeated at least annually for each individual, and when circumstances necessitate a re-assessment, using the same requirements outlined in subsections (a) and (b) of this section.(d) HHSC approves each HCBS-AMH initial eligibility assessment, annual assessment, and assessment conducted based on a change in circumstances. Source Note: The provisions of this §307.53 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.53 Eligibility Criteria and HCBS-AMH Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196105 03/12/2026 (a) An IRP must:(1) prepare for the individual's effective transition to the community;(2) promote the individual's inclusion into the community;(3) protect the individual's health and welfare in the community;(4) supplement, rather than replace, the individual's natural support systems and resources;(5) be designed to prevent or reduce the individual's likelihood of:(A) an inpatient psychiatric facility admission;(B) a correctional facility admission; and(C) an emergency department visit in which services are delivered;(6) include the most appropriate type and amount of services to meet the individual's needs;(7) prevent the provision of unnecessary or inappropriate care;(8) be based on the individual's preferences, needs, and goals; and(9) be developed with the individual, LAR, individual's treatment team and providers, and other persons according to the needs and desire of the individual.(b) An HHSC-approved designee must review the IRP and submit it to HHSC for its approval.(c) An HHSC-approved designee must submit to HHSC, with the IRP:(1) an HCBS-AMH assessment of the individual identifying the individual's needs and supporting the HCBS-AMH included in the IRP; and(2) documentation that non-HCBS-AMH support systems and resources are unavailable or are insufficient to meet the goals specified in the IRP.(d) A provider must obtain HHSC's approval of the IRP before the provider may deliver HCBS-AMH program services.(e) HHSC may conduct a utilization review of an IRP and supporting documentation at any time to determine if the services specified in the IRP meet the requirements described in subsection (a) of this section.(f) If HHSC determines one or more of the services specified in the IRP do not meet the requirements described in subsection (a) of this section, HHSC may:(1) deny, reduce, or terminate the service; or modify the IRP; and(2) send written notification to the individual, LAR, and the provider according to §307.57 of this subchapter (relating to Fair Hearings Process).(g) The cost of the IRP must be reasonable as determined by HHSC. Source Note: The provisions of this §307.54 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.54 Individual Recovery Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196106 03/12/2026 A co-payment for HCBS-AMH services may be assessed as described in 25 TAC Chapter 412, Subchapter C (relating to Charges for Community Services). Source Note: The provisions of this §307.55 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.55 Co-payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196107 03/12/2026 (a) A prospective provider may request and submit an application to HHSC to provide HCBS-AMH at any time. The application sets forth the qualifications to be a provider.(b) HHSC must approve the provider and enter into a contract with the provider before the provider serves any individual.(c) HCBS providers must comply with any applicable federal or state law or rule. Source Note: The provisions of this §307.56 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.56 Provider Qualifications and Contracting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196108 03/12/2026 (a) Right of an individual to request a fair hearing. Any individual whose request for eligibility to receive HCBS-AMH is denied or is not acted upon with reasonable promptness, or whose services have been terminated, suspended, or reduced by HHSC, is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(b) At any time, an individual may contact the Ombudsman for additional information and resources by calling toll-free (1-800-252-8154) or online at hhs.texas.gov/ombudsman. Source Note: The provisions of this §307.57 adopted to be effective July 23, 2019, 44 TexReg 3637. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM B HOME AND COMMUNITY-BASED SERVICES--ADULT MENTAL HEALTH PROGRAM §307.57 Fair Hearings Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224295 03/12/2026 The purpose of this subchapter is to provide standards for jail-based competency restoration as required by Texas Code of Criminal Procedure Chapter 46B, relating to Incompetency to Stand Trial. Jail-based competency restoration includes: (1) mental health services; (2) intellectual disability services; (3) co-occurring psychiatric and substance use disorder treatment services; (4) competency restoration education in the county jail for an individual found incompetent to stand trial; (5) discharge planning services; and(6) continuity of care services. Source Note: The provisions of this §307.101 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224296 03/12/2026 This subchapter applies to a local mental health authority, local behavioral health authority, or a subcontractor of a local mental health authority or local behavioral health authority delivering jail-based competency restoration authorized by Texas Code of Criminal Procedure Chapter 46B, regardless of the funding source for the jail-based competency restoration program. Source Note: The provisions of this §307.103 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224297 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise. (1) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021.(2) CFR--Code of Federal Regulations.(3) Competency restoration--The treatment or education process for restoring an individual's ability to consult with the individual's attorney with a reasonable degree of rational understanding, including a rational and factual understanding of the court proceedings and charges against the individual as defined in Texas Code of Criminal Procedure Article 46B.001. (4) Competency restoration training module--An HHSC-approved training module used by program staff members to provide legal education to an individual receiving competency restoration services.(5) COPSD--Co-occurring psychiatric and substance use disorder. (6) Court--A court of law presided over by a judge, judges, or a magistrate in civil and criminal cases. (7) Day--A calendar day, unless otherwise specified.(8) Extension--As described in Texas Code of Criminal Procedure Article 46B.080(d), an extension begins on the later of:(A) the date the court enters the order under Article 46B.080(a); or(B) the date competency restoration services begin pursuant to the order entered under Article 46B.080(a).(9) Good standing--Entities eligible to contract with HHSC pursuant to HHSC procurement and contract rules and guidelines.(10) HHSC--Texas Health and Human Services Commission or its designee. (11) ID--Intellectual disability. Consistent with Texas Health and Safety Code §591.003, significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior as defined in §304.102 of this title (relating to Definitions) and originating before age 18. (12) Individual--A person receiving services under this subchapter. (13) Inpatient mental health facility--The term has the meaning assigned in Texas Health and Safety Code §571.003. (14) IST--Incompetent to stand trial. The term has the meaning described in Texas Code of Criminal Procedure Article 46B.003. (15) JBCR--Jail-based competency restoration. Competency restoration services in a county jail setting provided in a designated space separate from the space used for the general population of the county jail. (16) JBCR program--A jail-based competency restoration program developed and implemented by a county or counties in accordance with the Texas Code of Criminal Procedure Article 46B.091.(17) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356. (18) Legally authorized representative--A person authorized by state law to act on behalf of an individual with regard to a matter described in this subchapter.(19) LIDDA--Local intellectual and developmental disability authority. An entity designated as the local intellectual and developmental disability authority by HHSC in accordance with Texas Health and Safety Code §533A.035(a). (20) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a). (21) LPHA--Licensed practitioner of the healing arts. A person who is: (A) a physician; (B) a physician assistant; (C) an advanced practice registered nurse; (D) a licensed psychologist; (E) a licensed professional counselor; (F) a licensed clinical social worker; or (G) a licensed marriage and family therapist. (22) Mental illness--An illness, disease, or condition as defined by Texas Health and Safety Code §571.003. (23) Non-clinical services--Services that support an individual's care but do not provide direct diagnosis, treatment, or care for the individual.(24) OCR--Outpatient competency restoration. As defined in Chapter 307, Subchapter D of this title (relating to Outpatient Competency Restoration), a community-based program with the specific objective of attaining restoration to competency pursuant to Texas Code of Criminal Procedure Chapter 46B.(25) Program staff member--An employee or person with whom the program contracts or subcontracts for the provision of JBCR. A program staff member includes specially trained security officers, all licensed and credentialed staff, and other people directly contracted or subcontracted to provide JBCR to an individual. (26) QIDP--Qualified intellectual disability professional as defined in 42 CFR §483.430(a). (27) QMHP-CS--Qualified mental health professional-community services as defined in Chapter 301, Subchapter G of this title (relating to Mental Health Community Services Standards). (28) Residential care facility--A state supported living center or the Intermediate Care Facilities for Individuals with an Intellectual Disability (ICF-IID) component of the Rio Grande State Center. (29) Safety plan--An individualized written plan to prevent or manage crises.(30) Serious injury--An injury determined by a physician to require medical treatment by a licensed medical professional (e.g., physician, dentist, physician's assistant, or advance practice nurse) or requires medical treatment in an emergency department or licensed hospital. (31) Significantly sub-average general intellectual functioning--Consistent with Texas Health and Safety Code §591.003, measured intelligence on standardized general intelligence tests of two or more standard deviations (not including standard error of measurement adjustments) below the age-group mean for the test used. (32) SUD--Substance use disorder. The use of one or more substances, including alcohol, which significantly and negatively impacts one or more major areas of life functioning, and which meets the criteria for substance use disorder as described in the HHSC-recognized edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.(33) TAC--Texas Administrative Code.(34) Treatment team--A group of treatment providers, including a psychiatrist and LPHA; the individual; and the individual's legally authorized representative, if any, who work together in a coordinated manner to provide competency restoration services to the individual. Source Note: The provisions of this §307.105 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224298 03/12/2026 (a) A JBCR program must meet the standards set forth in Texas Code of Criminal Procedure Article 46B.091.(b) A JBCR program must:(1) be an LMHA or LBHA in good standing with HHSC; or(2) a subcontractor of an LMHA or LBHA in good standing with HHSC.(c) An LMHA or LBHA must contract with the county to provide JBCR.(d) An LMHA or LBHA that provides JBCR must comply with Chapter 301, Subchapter A of this title (relating to Contracts Management for Local Authorities) and the contract management and oversight requirements of the Texas Comptroller of Public Accounts. Source Note: The provisions of this §307.107 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.107 JBCR Program Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224299 03/12/2026 A JBCR program must:(1) use a multidisciplinary treatment team focused on the objective of restoring the individual to competency to stand trial;(2) employ or contract for the services of at least one psychiatrist; (3) provide JBCR through licensed professionals, QMHP-CSs, or QIDPs as permitted by their professional license or credentials; (4) provide weekly competency restoration hours commensurate to the treatment hours provided as part of a competency restoration program at an inpatient mental health facility; (5) provide JBCR in a designated space in the jail, separate from the space used for the general population of the jail;(6) ensure coordination of general health care; (7) provide mental health treatment, SUD treatment, and referral to ID services to individuals, as clinically indicated, for competency restoration;(8) supply clinically appropriate psychoactive medications for purposes of administering court-ordered medication to individuals as applicable and in accordance with Texas Code of Criminal Procedure Article 46B.086 or Texas Health and Safety Code §574.106; and (9) assess individuals for suicidality and homicidality and develop a safety plan based on the needs of the individual. Source Note: The provisions of this §307.109 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.109 Service Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224300 03/12/2026 (a) A JBCR program must recruit, train, and maintain qualified program staff members with documented competency in accordance with Chapter 301, Subchapter G, Division 2 of this title (relating to Organizational Standards), specifically: (1) §301.327(e) of this title (relating to Access to Mental Health Community Services); (2) §301.329 of this title (relating to Medical Records System); and (3) §301.331 of this title (relating to Competency and Credentialing). (b) Before providing services, a JBCR program must train each program staff member and ensure demonstrated competence in: (1) the rights of an individual receiving mental health services as described in Chapter 320, Subchapter A of this title (relating to Rights of Individuals Receiving Mental Health Services); (2) the rights of an individual with an intellectual disability and a legally authorized representative as described in Chapter 334 of this title (relating to Rights of Individuals with an Intellectual Disability); (3) identifying, preventing, and reporting abuse, neglect, and exploitation in accordance with the Texas Commission on Jail Standards or HHSC as set forth in applicable state laws and rules; and (4) using a protocol for preventing and managing aggressive behavior, including preventative de-escalation intervention strategies. Source Note: The provisions of this §307.111 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.111 JBCR Program Staff Member Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224301 03/12/2026 A JBCR program must develop and implement written policies and procedures for: (1) maintaining a list of each program staff member providing JBCR, including:(A) position and credentials;(B) reporting structure; and(C) responsibilities;(2) maintaining program staff member training records;(3) describing JBCR eligibility as determined by the JBCR program, intake and assessment, and treatment planning as described in §307.121 of this subchapter (relating to Treatment Planning), and transition and discharge processes to include coordination and continuity of care planning with an LMHA, LBHA, or LIDDA, or an LMHA, LBHA, or LIDDA subcontractor; (4) describing how an individual is assessed for: (A) suicidality and homicidality; (B) the degree of suicidality and homicidality; (C) the development of a safety plan; (5) developing a safety plan that must document:(A) warning signs, including thoughts, images, changes in mood and behavior, or situations that may prompt a crisis;(B) internal coping strategies that distract from crisis thoughts and urges;(C) a process for communicating safety concerns and recommended precautions to the jail relating to an individual participating in JBCR;(D) the process for identifying and addressing suicidal and homicidal means;(6) outlining a JBCR program's process to assess, evaluate, and report to the court an individual's restoration to competency status and readiness for return to court as specified in Texas Code of Criminal Procedure Articles 46B.077(b) and 46B.079; (7) addressing how a program staff member collaborates with the jail medical provider to address continuity of care, treatment, and overall therapeutic environment during evenings and weekends, including responding to behavioral health crisis or physical health crisis consistent with §301.351(a) and (e) of this title (relating to Crisis Services); (8) educating an individual about the individual's rights while participating in JBCR;(9) coordinating with the court concerning the JBCR program's ability to provide services to a new participant within 72 hours after admission in accordance with §307.117 of this title and Texas Code of Criminal Procedure Article 46B.073(d); and (10) accommodating individual needs through adaptive materials and approaches as needed, including accommodations for language barriers and disabilities. Source Note: The provisions of this §307.113 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.113 Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224302 03/12/2026 (a) If there is an OCR program available to serve the individual, a JBCR program must collaborate with the OCR program to screen the individual for OCR services. The individual must be deemed ineligible for OCR in accordance with Chapter 307, Subchapter D of this title (relating to Recommendation Regarding Outpatient Competency Restoration Program Admission) before a JBCR program makes a recommendation to the court regarding the individual's eligibility for JBCR.(b) If there is not an OCR program available to serve the individual, a JBCR program must screen the individual to determine if JBCR is appropriate and make a recommendation to the court regarding the individual's eligibility for JBCR. Source Note: The provisions of this §307.115 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.115 Individual Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224303 03/12/2026 (a) A JBCR program may only admit an individual to JBCR upon receipt of a court order requiring the individual to participate in JBCR under Texas Code of Criminal Procedure Chapter 46B, Subchapter D.(b) In accordance with Texas Code of Criminal Procedure Article 46B.0735, the initial competency restoration period begins on the later of:(1) the date the individual is:(A) ordered to participate in OCR services; or(B) committed to a mental health facility, residential care facility, or JBCR; or(2) the date competency services begin.(c) When a JBCR program determines an individual is eligible for JBCR, the program must ensure the individual will receive competency restoration services no later than 72 hours after admission to the JBCR program. (d) A JBCR program must, when necessary, seek a court order for psychoactive medications in accordance with Texas Health and Safety Code §574.106 or Texas Code of Criminal Procedure Article 46B.086. Source Note: The provisions of this §307.117 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.117 Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224304 03/12/2026 A JBCR program must: (1) inform the individual receiving JBCR of the individual's rights in accordance with Chapter 320, Subchapter A of this title (relating to Rights of Individuals Receiving Mental Health Services) or Chapter 334 of this title (relating to Rights of Individuals with an Intellectual Disability), as applicable; (2) provide the individual with a copy of the rights handbook published for an individual receiving mental health services or an individual with an ID; and (3) explain to the individual receiving JBCR how to initiate a complaint and how to contact: (A) the HHS Office of the Ombudsman for complaints against the JBCR program; (B) the Texas Commission on Jail Standards for complaints against the county jail; and (C) the Texas protection and advocacy system. Source Note: The provisions of this §307.119 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.119 Rights of Individuals Receiving JBCR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224305 03/12/2026 Within five days after admission to JBCR, based on an individual's competency evaluation and JBCR program assessment, the JBCR program must develop the individual's treatment plan in accordance with Chapter 320, Subchapter A of this title (relating to Rights of Individuals Receiving Mental Health Services) and Chapter 301, Subchapter G of this title (relating to Mental Health Community Services Standards) to include the individual's: (1) strengths, to assist the individual in: (A) overcoming barriers to achieving a factual and rational understanding of legal proceedings; and (B) consulting with the individual's lawyer with a reasonable degree of rational understanding; (2) trauma history; (3) physical health concerns or issues; (4) medication and medication management; (5) level of family and community support; (6) mental health concerns or issues; (7) ID concerns or issues; (8) SUD or COPSD concerns or issues; and (9) specific non-clinical services and supports needed by the individual after discharge, including:(A) housing assistance;(B) food assistance;(C) governmental benefits;(D) clothing resources; and(E) other supplemental supports. Source Note: The provisions of this §307.121 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.121 Treatment Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224306 03/12/2026 (a) A JBCR program must submit the competency restoration training module for HHSC review and approval before providing services and annually thereafter. (b) A JBCR program must educate individuals using multiple learning formats, which may include: (1) discussion; (2) written text; (3) video; and (4) experiential methods, such as role-playing or mock trial. (c) A JBCR program must ensure an individual with accommodation needs receives adapted materials and approaches as needed, including accommodations for language barriers and disabilities. Source Note: The provisions of this §307.123 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.123 Competency Restoration Education https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224307 03/12/2026 (a) A JBCR program psychiatrist or psychologist who has the qualifications described by Texas Code of Criminal Procedure Article 46B.022 must evaluate the individual's competency and report to the court as required by Article 46B.079. (b) A JBCR program psychiatrist or psychologist must promptly send a report to the court, if at any time during an individual's commitment for JBCR, the JBCR psychiatrist or psychologist determines the individual is: (1) restored to competency; or (2) unlikely to be restored to competency in the foreseeable future.(c) If the JBCR program psychiatrist or psychologist determines that the individual has not restored to competency by the end of the 60th calendar day after the date the individual began receiving JBCR, the JBCR program must continue to provide competency restoration services to the individual for the period authorized under Texas Code of Criminal Procedure Chapter 46B, Subchapter D, including any extension ordered under Article 46B.080, unless the JBCR program is notified that space at a mental health facility or residential care facility or an OCR program appropriate for the individual is available and:(1) for an individual charged with a felony, not less than 45 calendar days are remaining in the initial restoration period; or(2) for an individual charged with a felony or misdemeanor, an extension has been ordered under Article 46B.080 and not less than 45 calendar days are remaining under the extension order.(d) After receipt of a notice under subsection (c) of this section, the JBCR program must collaborate with the court and the county jail to support the transfer of the individual without unnecessary delay to the appropriate mental health facility, residential care facility, or OCR program for the remainder of the period permitted by Texas Code of Criminal Procedure Article 46B.073(b), including any extension that may be ordered under Article 46B.080 if an extension has not previously been ordered under that article.(e) If the individual is not transferred, as referenced in subsection (d) of this section, and if the JBCR program psychiatrist or psychologist determines that the individual has not been restored to competency by the end of the period authorized under Texas Code of Criminal Procedure Chapter 46B, Subchapter D, the individual must be returned to the court for further proceedings. Source Note: The provisions of this §307.125 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.125 Procedures for Determining Competency Status in a JBCR Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224308 03/12/2026 (a) At any time an individual is restored to competency, the treatment team must collaborate with appropriate entities to facilitate: (1) continuity of care, including specific non-clinical services and supports needed by the individual after discharge, such as:(A) housing assistance;(B) food assistance;(C) governmental benefits;(D) clothing resources; and(E) other supplemental supports; and(2) the individual's discharge from the JBCR program to the individual's discharge setting, including:(A) the county jail; (B) the LMHA; (C) the LBHA; (D) the LIDDA;(E) other community mental health provider; or(F) the care of a responsible person. (b) If the individual is determined to be unlikely to restore to competency in the foreseeable future or is not restored after completing the JBCR program, the treatment team must collaborate with appropriate entities to facilitate:(1) continuity of care, including specific non-clinical services and supports needed by the individual after discharge, such as: (A) housing assistance;(B) food assistance;(C) governmental benefits;(D) clothing resources; and(E) other supplemental supports; and(2) the individual's discharge from the JBCR program to the individual's discharge setting, including:(A) a mental health facility; (B) a residential care facility; (C) the LMHA; (D) the LBHA; (E) the LIDDA; (F) other community mental health provider; or (G) the care of a responsible person. (c) If an individual is not restored to competency by the 60th day and is being transferred to a facility or OCR program, the JBCR treatment team must collaborate with appropriate entities to facilitate: (1) continuity of care, including specific non-clinical services and supports needed by the individual after discharge, such as:(A) housing assistance;(B) food assistance;(C) governmental benefits;(D) clothing resources; and(E) other supplemental supports; and(2) the individual's discharge from the JBCR program to:(A) a mental health facility; (B) a residential care facility; or (C) an OCR program. Source Note: The provisions of this §307.127 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.127 Preparation for Discharge from a JBCR Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224309 03/12/2026 (a) For the purposes of this section, "competency as determined by the JBCR psychiatrist or psychologist" refers to the clinical opinion of the psychiatrist or psychologist provided under Texas Code of Criminal Procedure Articles 46B.079(b) and 46B.091, as applicable.(b) A JBCR program must collect and report the following data for an individual admitted to a JBCR program, using HHSC's designated automation system: (1) individual outcomes: (A) the number of individuals on felony charges; (B) the number of individuals on misdemeanor charges; (C) date individual was ordered to JBCR;(D) date of first JBCR service provided;(E) whether the court granted an extension;(F) the average number of calendar days for an individual charged with a felony to be restored to competency, as determined by the JBCR psychiatrist or psychologist; (G) the average number of calendar days for an individual charged with a misdemeanor to be restored to competency, as determined by the JBCR psychiatrist or psychologist; (H) the number of individuals charged with a misdemeanor and not restored to competency, as determined by the JBCR psychiatrist or psychologist; (I) the number of individuals charged with a felony and not restored to competency, as determined by the JBCR psychiatrist or psychologist;(J) the number of individuals charged with a misdemeanor and restored to competency, as determined by the JBCR psychiatrist or psychologist; (K) the number of individuals charged with a felony and restored to competency, as determined by the JBCR psychiatrist or psychologist; (L) the average length of time between determination of non-restorability by the JBCR psychiatrist or psychologist and transfer to an inpatient mental health facility, residential care facility, or OCR program pursuant to Texas Code of Criminal Procedures Article 46B.091(j-1); (M) the number of individuals restored to competency as determined by the JBCR psychiatrist or psychologist in 60 calendar days or less; (N) the number of individuals found IST who were found ineligible for JBCR based on the JBCR program screening and the reason why;(O) the number of individuals not restored to competency and who were transferred to an inpatient mental health facility or residential care facility; and(P) the number of individuals whose charges were dismissed before completion of JBCR; and(2) administrative outcomes, in a format specified by HHSC, for the JBCR program, including: (A) the costs associated with operating the JBCR program; and (B) the number of: (i) reported and confirmed cases of abuse, neglect, and exploitation; (ii) reported and confirmed cases of rights violations; (iii) restraints and seclusions used; (iv) emergency medications used; (v) serious injuries; and (vi) deaths, in accordance with §320.143 of this title (relating to Documenting, Reporting, and Analyzing Restraint or Seclusion) or Chapter 301, Subchapter H of this title (relating to Deaths of Individuals Served by Community Mental Health Centers), as applicable. Source Note: The provisions of this §307.129 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.129 Outcome Measures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224310 03/12/2026 (a) In addition to any applicable federal or state law or rule, a JBCR program must comply with: (1) Texas Health and Safety Code Chapter 574 (relating to Court-Ordered Mental Health Services); (2) Texas Human Resources Code Chapter 48 (relating to Investigations and Protective Services for Elderly Persons and Persons with Disabilities);(3) 26 TAC:(A) Chapter 301, Subchapter G of this title (relating to Mental Health Community Services Standards); (B) Chapter 301, Subchapter H of this title (relating to Deaths of Individuals Served by Community Mental Health Centers);(C) Chapter 306, Subchapter A of this title (relating to Standards for Services to Individuals with Co-occurring Psychiatric and Substance Use Disorders (COPSD));(D) Chapter 320, Subchapter A of this title (relating to Rights of Individuals Receiving Mental Health Services);(E) Chapter 320, Subchapter C of this title (relating to Interventions in Mental Health Services);(F) Chapter 320, Subchapter D of this title (relating to Prescribing of Psychoactive Medication); and(G) Chapter 334 of this title (relating to Rights of Individuals with an Intellectual Disability).(b) Concerning confidentiality, a JBCR program must comply with the Health Insurance Portability and Accountability Act, 42 U.S.C. §1320d et seq and other applicable federal and state laws, including: (1) 42 CFR Part 2 and Part 51, Subpart D; (2) 45 CFR Parts 160 and 164, and Part 1326, Subpart C; (3) Texas Health and Safety Code Chapter 81, Subchapter F; (4) Texas Health and Safety Code Chapters 181, 595, and 611; (5) Texas Health and Safety Code §§533.009, 576.005, 576.007, and 614.017; (6) Texas Government Code Chapters 552 and 559; (7) Texas Occupations Code Chapter 159; and (8) Texas Business and Commerce Code §521.053. Source Note: The provisions of this §307.131 adopted to be effective August 6, 2018, 43 TexReg 5091; transferred effective February 15, 2020, as published in the Texas Register January 17, 2020, 45 TexReg 470; amended to be effective February 23, 2025, 50 TexReg 1022. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM C JAIL-BASED COMPETENCY RESTORATION PROGRAM §307.131 Compliance with Statutes, Rules, and Other Documents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203515 03/12/2026 The purpose of this subchapter is to provide standards for outpatient competency restoration (OCR) services provided to individuals ordered to participate in an OCR program pursuant to the Texas Code of Criminal Procedure Chapter 46B. Source Note: The provisions of this §307.151 adopted to be effective February 9, 2021, 46 TexReg 918. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.151 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203516 03/12/2026 This subchapter applies to:(1) local mental health authorities (LMHAs), local behavioral health authorities (LBHAs), and LMHA or LBHA subcontractors that administer OCR programs; and(2) other providers under contract with the Texas Health and Human Services Commission to administer an OCR program. Source Note: The provisions of this §307.153 adopted to be effective February 9, 2021, 46 TexReg 918. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.153 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212310 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings.(1) Adaptive behavior--The effectiveness with which, or degree to which, an individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group.(2) Competency restoration--The treatment or education process for restoring an individual's ability to consult with the individual's attorney with a reasonable degree of rational understanding, including a rational and factual understanding of the court proceedings and charges against the individual.(3) Court--A court of law presided over by a judge, judges, or a magistrate in civil and criminal cases.(4) Extension--The term has the meaning described in Texas Code of Criminal Procedure, Article 46B.080(d). An extension begins on the later of:(A) the date the court enters the order under Article 46B.080(a); or(B) the date competency restoration services begin pursuant to the order entered under Article 46B.080(a).(5) HHSC--Texas Health and Human Services Commission or its designee.(6) Individual--A person receiving services under this subchapter.(7) IST--Incompetent to stand trial. The term has the meaning described in Texas Code of Criminal Procedure, Article 46B.003.(8) LBHA--Local behavioral health authority. An entity designated as an LBHA by HHSC in accordance with Texas Health and Safety Code §533.0356.(9) LIDDA--Local intellectual and developmental disability authority. An entity designated as a LIDDA by HHSC in accordance with Texas Health and Safety Code §533A.035(a).(10) LMHA--Local mental health authority. An entity designated as an LMHA by HHSC in accordance with Texas Health and Safety Code §533.035.(11) Medical record--An organized account of information relevant to the medical services provided to an individual, including an individual's history, present illness, findings on examination, treatment and discharge plans, details of direct and indirect care and services, and notes on progress.(12) OCR--Outpatient competency restoration. A community-based program with the specific objective of attaining restoration to competency pursuant to Texas Code of Criminal Procedure Chapter 46B.(13) OCR provider--An entity identified in §307.153 of this subchapter (relating to Application) that provides OCR services.(14) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by Texas Government Code §531.02251, including care for mental health conditions and substance use disorders.(15) Subcontractor--A person or entity that contracts with an OCR provider to provide OCR services.(16) TAC--Texas Administrative Code. Source Note: The provisions of this §307.155 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.155 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212311 03/12/2026 (a) The OCR provider must assess the individual to determine if OCR services are appropriate by ensuring the following assessments are conducted by a person qualified to conduct the assessments pursuant to their state license, permit, or other legal authorization:(1) a clinical assessment, including substance use history; and(2) a violence risk assessment utilizing a validated risk assessment tool.(b) If an OCR provider determines that OCR services are appropriate for an individual, the provider must:(1) inform the court, in writing, that the individual is being recommended for admission into the OCR program; and(2) develop and submit a comprehensive treatment plan to the court in accordance with Texas Code of Criminal Procedure, Article 46B.0711(c)(1) or 46B.072(c)(1) as applicable, identifying the persons responsible for providing treatment to the individual and listing services the individual will be provided, including:(A) competency restoration education;(B) access to housing resources;(C) access to transportation resources; and(D) a regimen of medical, psychiatric, or psychological care or treatment.(c) If an OCR provider determines that OCR services are inappropriate for an individual, the provider must:(1) inform the court, in writing, of the individual's ineligibility for admission into the OCR program; and(2) document reasons for ineligibility in the individual's medical record. Source Note: The provisions of this §307.157 adopted to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.157 Recommendation Regarding Outpatient Competency Restoration Program Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212312 03/12/2026 (a) An OCR provider must admit an individual to an OCR program upon receipt of a court order requiring the individual to participate in OCR services under Texas Code of Criminal Procedure Chapter 46B, Subchapter D.(b) In accordance with Texas Code of Criminal Procedure, Article 46B.0735, the initial competency restoration period begins on the later of:(1) the date the individual is ordered to participate in OCR services; or(2) the date the individual is committed to a mental health facility, residential care facility, or jail-based competency restoration program; or(3) the date competency restoration services begin. Source Note: The provisions of this §307.159 adopted to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.159 Admission to an Outpatient Competency Restoration Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203519 03/12/2026 An OCR provider:(1) must make competency restoration education interactive and available in multiple learning formats to the individual receiving competency restoration education, which may include:(A) discussion;(B) written text and discussion;(C) recorded video and discussion; and(D) experiential learning, such as role-playing or mock trial, and discussion;(2) must ensure an individual who requires accommodations receives adapted materials and approaches as needed, including accommodations for language barriers and disabilities;(3) must make available an appropriate prescribed regimen of medical, psychiatric, or psychological care or treatment, including administration of psychoactive medication in accordance with 25 TAC Chapter 414, Subchapter I (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services);(4) may use telecommunications or information technology to provide competency restoration services that are compliant with the Health Insurance Portability and Accountability Act; and(5) must identify each person's role and responsibility in court proceedings in the OCR program's training module for individuals in the OCR program. Source Note: The provisions of this §307.161 adopted to be effective February 9, 2021, 46 TexReg 918. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.161 General Service Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212314 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212314 03/12/2026 (a) An OCR provider must:(1) regularly evaluate the individual's progress towards attainment of competency to stand trial and likeliness to restore to competency in the foreseeable future;(2) report the individual's progress toward achieving competency to the court in accordance with Texas Code of Criminal Procedure, Article 46B.077:(A) no later than the 14th day after the date competency restoration services begin; and(B) at least once each 30-day period following the date of the first report to the court after competency restoration services begin;(3) promptly report to the court the individual's attainment of competency or whether the individual is not likely to restore to competency in the foreseeable future in accordance with Texas Code of Criminal Procedure, Article 46B.079; and(4) notify the court no later than 15 days before the date on which the initial restoration period is to expire that the period is about to expire in accordance with Texas Code of Criminal Procedure, Article 46B.079.(b) The notice provided under subsection (a)(4) of this section may include a request for a 60-day extension of the initial restoration period for OCR services, and include an explanation for the request in accordance with Texas Code of Criminal Procedure, Article 46B.079(d). Source Note: The provisions of this §307.163 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.163 Assessment, Reassessment, Court Reporting, and Extension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212313 03/12/2026 (a) When an OCR provider discharges an individual from OCR services upon completion of court-ordered participation in the OCR program, the OCR provider must provide continuity of care services. Discharge planning begins upon admission into the OCR program and includes:(1) a plan for maintaining housing and utilities for three months or more after discharge;(2) coordination of ongoing services through the LMHA or LBHA in the individual's county of residence or the individual's designated LIDDA as provided in section 5000 of the LIDDA handbook available on HHSC's website;(3) the provision of medication and documentation of a scheduled psychiatric follow-up appointment after discharge;(4) completion of all appropriate benefits applications on behalf of any individual, including signing up for long-term subsidized housing;(5) confirmation that an assisted living facility to which an individual is referred is licensed under Texas Health and Safety Code Chapter 247 and Chapter 553 of this title (relating to Licensing Standards for Assisted Living Facilities) by contacting the HHSC Assisted Living Facility Licensing and Certification Unit, if applicable;(6) coordination of appropriate transfer to an inpatient treatment facility, if applicable; and(7) coordination of appropriate transfer if returned to custody.(b) For an unplanned discharge, an OCR provider must:(1) notify the court of the unplanned discharge;(2) make efforts to assist in facilitating service coordination with the LMHA or LBHA in the individual's county of residence or the individual's designated LIDDA to ensure the individual's continuity of care; and(3) document continuity of care efforts in the individual's medical record.(c) An OCR provider must document the reasons for the individual's failure to complete the OCR program in the individual's record, if applicable.(d) Before an individual is discharged from an OCR program, an OCR provider must collaborate with courts to encourage timely resolution of legal issues. Source Note: The provisions of this §307.165 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.165 Discharge Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212315 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212315 03/12/2026 (a) An OCR provider must collect and report the following data into HHSC's designated automation system for each individual admitted to or discharged from an OCR program, including:(1) whether the individual has been charged with a felony;(2) whether the individual has been charged with a misdemeanor;(3) whether the individual withdrew from the OCR program without the court's authorization;(4) whether the individual received an additional charge of a Class B misdemeanor or a higher category of offense while ordered to the OCR program;(5) whether the individual has been restored to competency within the timeframe allotted by statute;(6) the number of days from the day the court orders OCR to the day the individual begins participation in the OCR program;(7) the number of days an individual charged with a felony received treatment and services in the OCR program;(8) the number of days an individual charged with a misdemeanor received treatment and services in the OCR program;(9) whether an extension of services was sought for an individual charged with a felony;(10) whether an extension of services was sought for an individual charged with a misdemeanor;(11) whether an individual has not restored to competency at the conclusion of court-ordered services as determined by the court; and(12) types of services provided to the individual other than psychiatric services and competency restoration education.(b) In a format specified by HHSC, an OCR provider must submit costs associated with operating the OCR program to HHSC quarterly.(c) In a format specified by HHSC, an OCR provider must submit administrative outcomes on the OCR program regarding:(1) reported and confirmed cases of abuse, neglect, and exploitation;(2) reported and confirmed cases of rights violations;(3) restraints and seclusions used;(4) emergency medications used;(5) serious injuries; and(6) deaths. Source Note: The provisions of this §307.167 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.167 Data https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212316 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212316 03/12/2026 An OCR provider must develop and implement written policies and procedures that outline processes for:(1) maintaining a list of each staff member providing OCR services, including the staff members':(A) position and credentials;(B) reporting structure; and(C) responsibilities;(2) maintaining staff member training records;(3) describing an individual's eligibility and ineligibility criteria for OCR services;(4) screening an individual's appropriateness for OCR services;(5) admitting an individual within the OCR program provider's catchment area;(6) developing a treatment plan and discharge plan;(7) delivering all required components of competency restoration services;(8) admitting an individual:(A) who is referred by another LMHA, LBHA, or LIDDA that is outside of the OCR program's catchment area but is within close physical proximity to the OCR program;(B) who is without an OCR program in the individual's service area; and(C) where OCR services are potentially appropriate;(9) documenting the types of services provided in the OCR program other than competency restoration services in accordance with §307.161 of this subchapter (relating to General Service Requirements);(10) regularly monitoring, evaluating, and documenting the individual's progress towards attainment of competency to stand trial and likeliness to restore to competency in the foreseeable future in accordance with §307.163 of this subchapter (relating to Assessment, Reassessment, Court Reporting, and Extension);(11) notifying the court:(A) that the initial restoration period will expire and when it will expire;(B) if the individual has attained competency to stand trial or is not likely to attain competency in the foreseeable future;(C) of a request for an extension of continued restoration services as specified in the Texas Code of Criminal Procedure, Articles 46B.079(d) and 46B.080; and(D) the individual's readiness to return to court;(12) complying with reporting procedures specified in Texas Code of Criminal Procedure, Article 46B.079;(13) preparing for an individual's planned or unplanned discharge from the OCR program and ensuring continuity of care in accordance with §307.165 of this subchapter (relating to Discharge Requirements), as appropriate; and(14) educating an individual about the individual's rights and participation in the OCR program. Source Note: The provisions of this §307.169 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.169 Written Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203524 03/12/2026 An OCR provider must ensure staff members complete training and document evidence of training in the following:(1) trauma informed care;(2) cultural competency;(3) rights of persons receiving OCR services in accordance with §307.173 of this subchapter (relating to Rights);(4) identifying, preventing, and reporting abuse, neglect, and exploitation in accordance with 25 TAC Chapter 414, Subchapter L (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers) to the Texas Department of Family and Protective Services at 1-800-252-5400 or online at www.txabusehotline.org in accordance with applicable state laws and rules; and(5) using a protocol for preventing and managing aggressive behavior, including de-escalation intervention techniques in accordance with 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services). Source Note: The provisions of this §307.171 adopted to be effective February 9, 2021, 46 TexReg 918. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.171 Staff Member Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203525 03/12/2026 (a) An OCR provider must:(1) inform the individual receiving OCR services of the individual's rights in accordance with 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services) or 40 TAC Chapter 4, Subchapter C (relating to Rights of Individuals with an Intellectual Disability), as applicable;(2) provide the individual with a copy of the rights handbook published for an individual receiving mental health services or an individual with an ID; and(3) explain to the individual receiving OCR services how to initiate a complaint and how to contact:(A) the Ombudsman for complaints against the OCR provider; and(B) the Texas protection and advocacy agency.(b) The individual may contact the Ombudsman for additional information and resources, at any time, by calling toll-free at 1-800-252-8154 or online at hhs.texas.gov/ombudsman. Source Note: The provisions of this §307.173 adopted to be effective February 9, 2021, 46 TexReg 918. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.173 Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212317 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212317 03/12/2026 In addition to any applicable federal or state law or rule, an OCR provider must comply with:(1) Texas Health and Safety Code Chapter 574;(2) Texas Code of Criminal Procedure Chapter 46B;(3) Other applicable federal and state laws, including:(A) Health Insurance Portability and Accountability Act of 1996;(B) 42 CFR Part 2 and Part 51, Subpart D;(C) 45 CFR Parts 160 and 164;(D) Texas Health and Safety Code Chapters 181, 595, and 611;(E) Texas Health and Safety Code §533.009, §576.005, §576.007, and §614.017;(F) Texas Occupations Code Chapter 159; and(G) Texas Business and Commerce Code §521.053;(4) 25 TAC Chapter 405, Subchapter K (relating to Deaths of Persons Served by TXMHMR Facilities or Community Mental Health and Mental Retardation Centers) as it relates to community-based services and community centers;(5) Chapter 306, Subchapter A of this title (relating to Standards for Services to Individuals with Co-occurring Psychiatric and Substance Use Disorders (COPSD));(6) 25 TAC Chapter 414, Subchapter L (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers); and(7) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services). Source Note: The provisions of this §307.175 adopted to be effective February 9, 2021, 46 TexReg 918; amended to be effective February 9, 2023, 48 TexReg 519. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM D OUTPATIENT COMPETENCY RESTORATION §307.175 Compliance with Statutes and Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213221 03/12/2026 The purpose of this subchapter is to implement the relinquishment avoidance program in accordance with Texas Family Code Chapter 262, Subchapter E, which provides beds in residential treatment center operations to prevent the relinquishment of parental conservatorship to the Texas Department of Family and Protective Services solely to obtain mental health services for a child with a serious emotional disturbance. For this subchapter, the relinquishment avoidance program is called the Residential Treatment Center (RTC) Project. Source Note: The provisions of this §307.201 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213222 03/12/2026 This subchapter applies to:(1) residential treatment center (RTC) providers that contract with the Texas Health and Human Services Commission to provide RTC Project services;(2) local mental health authorities and local behavioral health authorities, with RTC Project administrative responsibilities; and(3) a child, and their legally authorized representative, who:(A) meet eligibility criteria as provided in §307.207 of this subchapter (relating to Eligibility Criteria to Participate in the RTC Project); and(B) are applicants or recipients of services from the RTC Project. Source Note: The provisions of this §307.203 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.203 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213211 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings:(1) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021.(2) Case manager--An employee of the local mental health authority (LMHA) or local behavioral health authority (LBHA) who provides mental health case management services.(3) Child--A person under 18 years of age as defined under Texas Human Resources Code §42.002 and not emancipated under state law.(4) DFPS--The Texas Department of Family and Protective Services.(5) Eligibility assessment--The process an LMHA or an LBHA uses to gather information from a child and the child's legally authorized representative to determine if the child meets eligibility criteria for receiving services through the Residential Treatment Center (RTC) Project.(6) HHSC--The Texas Health and Human Services Commission, or its designee.(7) LAR--Legally authorized representative. A person authorized by law to act on behalf of a child regarding a matter described in this subchapter, and may include a parent, legal guardian, or managing conservator of a child.(8) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356.(9) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a).(10) LPHA--Licensed practitioner of the healing arts. A person who is:(A) a physician;(B) a physician assistant;(C) an advanced practice registered nurse;(D) a licensed psychologist;(E) a licensed professional counselor;(F) a licensed clinical social worker; or(G) a licensed marriage and family therapist.(11) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by Texas Government Code §531.02251 serves as a neutral party to help individuals, including individuals who are uninsured or have public or private health benefit coverage, and behavioral health care providers navigate and resolve issues related to the individual's access to behavioral health care, including care for mental health conditions and substance use disorders.(12) RTC--Residential treatment center. A general residential operation regulated under Texas Human Resources Code Chapter 42 and Chapter 748 of this title (relating to Minimum Standards for General Residential Operations) for seven or more children that exclusively provides treatment services for children with emotional disorders.(13) RTC Project--The HHSC relinquishment avoidance program that provides residential mental health services to a child with a serious emotional disturbance without the child entering the managing conservatorship of DFPS, in accordance with Texas Family Code Chapter 262, Subchapter E.(14) RTC project team--The HHSC team that provides oversight of the RTC Project.(15) RTC contractor--A residential treatment center that contracts with HHSC to provide services under this subchapter.(16) SED--Serious emotional disturbance. A mental, behavioral, or emotional disorder of sufficient duration to result in functional impairment that substantially interferes with or limits a person's role or ability to function in family, school, or community activities in accordance with Texas Government Code §531.251.(17) Service planning team--A team that must develop, review, and revise the service plan and discharge plan. The team must consist of:(A) an RTC contractor;(B) in addition to the requirements outlined in Chapter 748, Subchapter I of this title (relating to Admission, Service Planning, and Discharge), the service planning team includes:(i) the child;(ii) the child's LAR;(iii) a representative from the LMHA or LBHA assigned to work with the child and family; and(iv) the child's individual and family therapist; and(C) other participants on the service planning team may include other individuals as requested by the child, the child's LAR, the LMHA or LBHA, or the RTC and agreed upon by the child's LAR. Source Note: The provisions of this §307.205 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.205 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213212 03/12/2026 (a) The child must:(1) be a resident of the State of Texas;(2) be younger than 18 years of age;(3) have an SED as determined by a professional authorized to make the determination within the scope of their Texas state license, permit, or other certification;(4) require residential treatment services, as outlined in §307.213 of this subchapter (relating to Assessing Eligibility); and(5) not be in DFPS managing conservatorship by written court order issued under Texas Family Code Chapter 153.(b) The child's parent or managing conservator must be at risk of relinquishing parental conservatorship of the child if there are no community-based mental health or financial resources available to adequately protect the safety and well-being of the child or others, including household members, because of the child's SED.(c) The child's LAR must attest to the appropriate referral source as described in §307.209(a) of this subchapter (relating to Referral Process) that the family is at risk of relinquishing the child for the sole purpose of accessing mental health services.(d) The RTC Project limits the number of children for participation in the RTC Project based on funding and placement availability. Source Note: The provisions of this §307.207 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.207 Eligibility Criteria to Participate in the RTC Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213213 03/12/2026 (a) A referral may occur in one of two ways:(1) An LAR, or an individual supporting the family with the LAR's consent, interested in the RTC Project requests a referral for treatment services through the child's designated LMHA or LBHA which then submits a referral to the RTC Project team; or(2) DFPS may submit a referral to the RTC Project team when DFPS receives an intake for which a referral may be appropriate.(b) Upon receipt of a referral from the RTC Project, the LMHA or LBHA schedules the child's eligibility assessment with the child's LAR.(c) The LMHA or LBHA must notify the child's LAR of the child's eligibility assessment results within two business days after eligibility is determined and send a complete application packet within two business days after its completion to the RTC Project team as outlined in §307.217 of this subchapter (relating to Application Packet).(d) If the child is eligible for RTC Project services, the RTC Project team places the child on the RTC Project interest list.(e) If the child's eligibility for the RTC Project is not approved at the time of the referral, the RTC Project notifies the LMHA or LBHA within seven business days. The LMHA or LBHA notifies the child's LAR, in writing, within seven business days after notification. The child's LAR may request a review of this decision as outlined in §307.215 of this subchapter (relating to Notification and Appeal Process). Source Note: The provisions of this §307.209 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.209 Referral Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213214 03/12/2026 (a) The child remains on the RTC Project interest list until the child is admitted to an RTC or removed from the interest list pursuant to §307.211(b) of this section.(b) The RTC Project team removes a child's name from the interest list if:(1) the RTC Project team determines the child is ineligible in accordance with §307.207 of this subchapter (relating to Eligibility Criteria to Participate in the RTC Project);(2) the child's LAR submits a request to remove the child's name from the RTC Project interest list verbally or in writing;(3) the child's LAR declines RTC Project services verbally or in writing;(4) the child's LAR declines LMHA or LBHA services verbally or in writing;(5) the child is placed in DFPS managing conservatorship by written court order issued under Texas Family Code Chapter 153;(6) the child is no longer a resident of Texas;(7) the child is committed to the Texas Juvenile Justice Department or the Texas Department of Criminal Justice;(8) the child is deceased;(9) The child is no longer in need of RTC Project services and has been on the interest list for over 30 calendar days as described in subsection (c) of this section;(10) the LMHA, LBHA, or RTC Project team has been unable to contact the child's LAR to complete the activities or documents required for the application packet;(11) the child is admitted for treatment through the RTC Project; or(12) the child has exhausted all placement options or has been denied admission into all eligible RTC operations participating in the RTC Project more than once, as outlined in the HHSC RTC Project policy manual.(c) If the child is no longer in need of RTC Project services, the child's LAR may request that the child remain on the RTC Project interest list for 30 calendar days in case such services are needed in the future. While the child is on the interest list, the LMHA or LBHA must monitor the child's need for RTC Project services and offer, provide, or secure services for the child at the appropriate level of care indicated by the child's eligibility assessment. Source Note: The provisions of this §307.211 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.211 Interest List Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213215 03/12/2026 (a) The LMHA or LBHA must designate a staff person who is a qualified mental health professional-community services, as defined in §301.303 of this title (relating to Definitions), or LPHA, to assess the child for eligibility within two business days after a request for referral is received from the LAR or the RTC Project team. The LMHA or LBHA must determine:(1) the most appropriate and available treatment options in accordance with §306.163 of this title (relating to Most Appropriate and Available Treatment Options); and(2) there are no other mental health services available to support the child in their community.(b) If the child's LAR informs the LMHA or LBHA that the child is at immediate risk of relinquishment to DFPS conservatorship, the LMHA or LBHA must assess the child within 24 hours for emergency eligibility. The children's mental health director or designee must evaluate if the child is at immediate risk of relinquishment to DFPS and if so, follow the procedures outlined under §307.217 of this subchapter (relating to Application Packet) and in the RTC Project policy manual posted on the HHSC website. Source Note: The provisions of this §307.213 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.213 Assessing Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213216 03/12/2026 (a) The LMHA or LBHA must inform the child's LAR, in writing, within seven business days of the child's removal from the interest list for RTC Project services for the applicable reasons provided in §307.211(b) of this subchapter (relating to Interest List Management).(b) If the child's name is removed from the interest list, the written notification to the child's LAR includes:(1) the reasons for the removal of the child's name from the interest list and the process for appealing the decision in accordance with this section;(2) the availability of information and assistance from the HHSC Ombudsman by contacting the Ombudsman at 1-800-252-8154 or online at hhs.texas.gov/ombudsman;(3) the telephone number and address of the protection and advocacy system established in Texas; and(4) information developed by DFPS regarding the process for initiating an intake with DFPS for possible investigation and filing of a Suit Affecting the Parent Child Relationship pursuant to Texas Family Code Title 5, Chapter 262.(c) An LAR whose child is determined ineligible for RTC Project services may appeal the decision by:(1) submitting a written request for review of the decision to the RTC Project team, as provided in the written notification, within 30 calendar days after the date of the RTC Project team's written denial;(2) including an explanation why the child's LAR disagrees with the denial; and(3) submitting any relevant supporting documentation for RTC Project eligibility.(d) The RTC Project team reviews and responds to the child's LAR's appeal within ten business days after receiving the appeal and informs the child's LAR, in writing, of the appeal's outcome unless there are extenuating circumstances necessitating an extension. The extension will be communicated with the child's LAR. Source Note: The provisions of this §307.215 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.215 Notification and Appeal Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213217 03/12/2026 (a) The LMHA or LBHA must ensure an application packet is completed for every child on the interest list who meets eligibility criteria for the RTC Project.(1) The LMHA or LBHA assists the child's LAR to complete the application packet and submits the completed application packet on behalf of the child's LAR to the RTC Project team.(2) The RTC Project team looks for RTC treatment for the child after eligibility is determined and the application packet is complete.(b) After the RTC Project team submits the child's application packet to the RTC contractor, the RTC contractor must:(1) review the application packet to determine eligibility for RTC contractor admission in accordance with Chapter 748, Subchapter I of this title (relating to Admission, Service Planning, and Discharge); and(2) notify the RTC Project team, in writing, of the child's eligibility for admission within two business days after the RTC contractor's determination is made.(c) If the RTC contractor determines they can admit and treat the child, the RTC Project team notifies the appropriate LMHA or LBHA within two business days, and the LMHA or LBHA notifies the child's LAR of the admission options within two business days after notification.(1) If there are multiple RTC treatment options, the RTC Project team notifies the appropriate LMHA or LBHA, and the LMHA or LBHA notifies the child's LAR within two business days after notification.(2) The child's LAR consults with the LMHA or LBHA and makes a final determination to accept or decline the RTC options.(3) The LMHA or LBHA notifies the RTC Project Team about the child's LAR's decision within two business days.(4) the RTC Project team authorizes the child's LAR's choice of available RTC options within two business days after notification.(d) If the RTC contractor determines they are unable to meet the treatment needs of the child at the RTC, the RTC contractor must notify the RTC Project team within two business days after making the determination and describe the reasons why the child cannot be admitted.(e) If all RTC contractors associated with the RTC Project deny the child's admission, the RTC Project team will notify the LMHA or LBHA that the child is denied by all RTC contractors within seven business days after the last contractor denial. The LMHA or LBHA must notify the child's LAR, in writing, within seven business days after notification. Source Note: The provisions of this §307.217 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.217 Application Packet https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213218 03/12/2026 (a) The LMHA or LBHA must not require an LAR to contact DFPS to initiate a referral to the RTC Project in accordance with Texas Family Code §262.353.(b) The LMHA or LBHA must designate a staff person as an RTC Project liaison responsible for receiving and submitting referrals to the RTC Project.(c) The LMHA or LBHA must assign a case manager after the child is determined eligible for the RTC Project. The LMHA or LBHA case manager must:(1) offer the child services at the appropriate level of care indicated by the eligibility assessment, including referrals to community resources as appropriate;(2) offer the child's LAR Certified Family Partner services, as defined in §306.305 of this title (relating to Definitions);(3) assist the child's LAR in applying for Medicaid or Medicaid Buy-In;(4) assist the child's LAR with completing the application packet after determined eligible for the RTC Project;(5) as part of the application packet, assist the child's LAR with obtaining either a psychiatric evaluation, psychosocial assessment, or psychological evaluation of the child that includes a mental health diagnosis, if one has not been completed within the past year or if it is not available. The mental health diagnosis must be determined by a professional authorized to make the determination within the scope of their Texas state license, permit, or other certification;(6) enroll the child in an RTC level of care, provided in the Utilization Management Guidelines and Manual posted on the HHSC website after the child's admission to the RTC;(7) attend service planning team meetings conducted by the RTC contractor;(8) submit monthly progress reports to the RTC Project team;(9) attend the child's discharge planning meeting conducted by the RTC contractor;(10) schedule a discharge follow-up appointment with the child and family after the child's discharge from the RTC; and(11) schedule a child's appointment with a physician, or designee authorized by Texas state law, to prescribe medications after the child's discharge from the RTC. Source Note: The provisions of this §307.219 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.219 Local Mental Health Authority and Local Behavioral Health Authority Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213219 03/12/2026 (a) RTC contractors must be licensed by HHSC Child Care Regulation and have a contract with HHSC to provide RTC Project services.(b) The RTC contractor must provide comprehensive residential treatment services as outlined in this subchapter, in the HHSC contract, and as described in the HHSC child-care minimum standards for general residential operations. The RTC must:(1) provide psychotherapy services that include individual and family therapy;(2) psychopharmacological therapy for the treatment of psychiatric illness with psychotropic medication on an ongoing basis if indicated based on psychiatric evaluation;(3) integrate a trauma-informed care approach into the care, treatment, and supervision of each child. Trauma-informed care is care that is child and family-centered and takes into consideration:(A) the unique culture, experiences, and beliefs of the child and family;(B) the impact traumatic experiences have on the life of the child;(C) the symptoms of childhood trauma;(D) an understanding of the child's personal trauma history;(E) the recognition of the child's trauma triggers;(F) methods of responding that improve the child's ability to trust, to feel safe, and to adapt to changes in the child's environment; and(G) the impact traumatic experiences have on the child's family;(4) include habilitation activities, such as vocational services, as appropriate; and(5) provide services in accordance with the HHSC provider contract.(c) The RTC contractor must assign an LPHA for each child. The LPHA or treatment director must:(1) ensure the delivery of therapeutic services to the child;(2) provide recommendations for the child's service plan, in consultation with the service planning team; and(3) provide recommendations for the child's discharge plan in consultation with the service planning team.(d) The RTC contractor must notify all members of the service planning team in writing at least two weeks in advance of the child's service plan meetings.(e) If the child's service planning team determines the child needs continued residential treatment beyond six months, and the RTC contractor does not have an agreement for an extended treatment curriculum with HHSC, the RTC must:(1) submit a request to the RTC Project team for the child's ongoing treatment before the sixth month of treatment in accordance with the RTC Project policy manual posted on the HHSC website; and(2) document in the child's service plan the need for an anticipated length of stay beyond the six-month timeframe, and why a less intensive level of care is not appropriate.(f) The service plan must:(1) be approved by the service planning team and must meet the requirements outlined in Chapter 748, Subchapter I of this title (relating to Admission, Service Planning, and Discharge); and(2) be reviewed monthly, and updated at least every 90 calendar days, in accordance with Chapter 748, Subchapter I of this title. If the child's needs change, the service plan must be updated to address the changes.(g) The child's LAR must be included by the RTC contractor in developing the child's service plan, and in meetings to the greatest extent possible, as provided in the Residential Treatment Center Project Family Agreement. If the child's LAR, or other parties responsible for the child's care are unable to participate, the RTC contractor must review the service plan to ensure that the child's service plan goals and level of care adequately address the child's treatment needs. Source Note: The provisions of this §307.221 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.221 Residential Treatment Center Contractor Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213220 03/12/2026 (a) The child may be discharged from the RTC Project:(1) when the service planning team determines that the child completed treatment and no longer requires a residential level of care;(2) when the child's LAR requests discharge from the operation; or(3) in accordance with Chapter 748, Subchapter I of this title (relating to Admission, Service Planning, and Discharge).(b) If the RTC contractor determines at any point throughout treatment that the child is not appropriate for continued treatment at the RTC and must be discharged in less than 14 calendar days:(1) the RTC contractor must notify the child's LAR and the LMHA or LBHA within 24 hours after the determination and before discharge;(2) the RTC contractor must notify the RTC Project team, in writing, within 24 hours, but no later than one business day, after the determination; and(3) the RTC contractor must conduct an emergency staffing with the child's service planning team for continuity of care services.(c) If the RTC contractor determines at any point throughout treatment that the child requires an emergency discharge, the RTC contractor must follow emergency discharge and transfer requirements in accordance with Chapter 748, Subchapter I of this title, and:(1) notify the child's LAR and LMHA or LBHA immediately after determining the child is not appropriate for continued treatment at the RTC and before the child's discharge;(2) notify the RTC Project team, in writing, within one business day after the determination is made; and(3) conduct an emergency staffing with the child's service planning team for continuity of care services.(d) The RTC contractor must develop the discharge plan in consultation with the service planning team.(1) The discharge plan must be approved by the treating psychiatrist and must meet the requirements outlined in Chapter 748, Subchapter I of this title; and(2) The RTC contractor must submit a copy of the child's:(A) final discharge plan to the child's LAR, LMHA or LBHA, and RTC Project team 30 calendar days before discharge;(B) recommendations regarding the child's educational needs to the child's LAR at the time of discharge; and(C) discharge summary to the child's LAR, LMHA or LBHA, and the RTC Project within seven calendar days after the child's discharge. Source Note: The provisions of this §307.223 adopted to be effective April 10, 2023, 48 TexReg 1829. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM E CHILDREN'S MENTAL HEALTH--RESIDENTIAL TREATMENT CENTER PROJECT §307.223 Discharge Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218893 03/12/2026 The purpose of this subchapter is to implement the Behavioral Health Partnership Program. This program delivers mental health and substance use resources to school districts served by a regional education service center and in which the local mental health authority (LMHA) or local behavioral health authority (LBHA) also delivers services. The program allows LMHAs and LBHAs to request a waiver to employ a professional who fulfills the duties outlined in Texas Education Code §8.152. Source Note: The provisions of this §307.251 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.251 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218894 03/12/2026 The subchapter applies to local mental health authorities and local behavioral health authorities. Source Note: The provisions of this §307.253 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.253 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218895 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.(1) BHPP liaison--Behavioral Health Partnership Program liaison. For purposes of this subchapter, a "non-physician mental health professional" as referenced under Texas Education Code §8.152 is included in the term "behavioral health partnership program liaison."(2) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021.(3) Child--An individual under 18 years of age as defined under Texas Human Resources Code §42.002 and not emancipated as described in Texas Family Code Chapter 31.(4) ESC--Regional education service center. An entity designated as the educational service center by the Texas Education Agency in accordance with Texas Education Code, Subtitle B, Chapter 8, Subchapter A.(5) HHSC--Texas Health and Human Services Commission or its designee.(6) LBHA--Local behavioral health authority. An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356.(7) LMHA--Local mental health authority. An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a).(8) LMSW--Licensed master social worker. A person who holds a master social worker license in accordance with Texas Occupations Code Chapter 505.(9) LPC associate--Licensed professional counselor associate. A person who holds a professional counselor associate license in accordance with 22 TAC §681.2 (relating to Definitions).(10) NPMHP--Non-Physician Mental Health Professional.(11) TAC--Texas Administrative Code. Source Note: The provisions of this §307.255 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.255 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218896 03/12/2026 A BHPP liaison must meet the qualifications as an NPMHP under Texas Health and Safety Code §571.003 or serve under a waiver approved by HHSC in accordance with §307.267 of this subchapter (relating to Texas Health and Human Services Commission Notification). Source Note: The provisions of this §307.257 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.257 Behavioral Health Partnership Program Liaison Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218897 03/12/2026 (a) The LMHA or LBHA must:(1) enter into a memorandum of understanding with the ESC to collaborate regarding the administration of this subchapter;(2) employ a BHPP liaison to serve as a mental health and substance use resource for school districts located in the region served by an ESC and in which the LMHA or LBHA delivers services;(3) pay the ESC a reasonable and negotiated cost-recovery fee, not to exceed $15,000 per year unless the LMHA or LBHA and the ESC agree to a higher amount, for providing the space and administrative support necessary for the BHPP liaison to carry out the professional duties outlined in Texas Education Code §8.155;(4) supervise the BHPP liaison;(5) consult with any other LMHA or LBHA in the region and the regional ESC for input on supervising the BHPP liaison and coordinating services provided by the BHPP liaison;(6) submit a written quarterly activity and evaluation report to the HHSC contract manager regarding the outcomes for school districts and students resulting from services delivered by a BHPP liaison in accordance with §307.263 of this subchapter (relating to Responsibilities of a Behavioral Health Partnership Program Liaison);(7) submit a written annual activity and evaluation report to the HHSC contract manager regarding the outcomes for school districts and students resulting from services delivered by a BHPP liaison in accordance with Texas Education Code§8.155;(8) submit a written waiver request to BHPP@hhs.texas.gov if required under Texas Education Code §8.152(c);(9) ensure an LMSW or an LPC associate is eligible for an HHSC waiver request as outlined in this subchapter and the LMSW or LPC associate has the ability to fulfill the duties outlined in this subchapter if a waiver is requested;(10) retain documentation in accordance with the LMHA's and LBHA's policies and procedures on efforts made to hire an NPMHP before submitting a waiver request; and(11) submit a new waiver request, as needed, if the HHSC BHPP liaison vacates the position.(b) If a BHPP liaison vacates the position within one year of approval of the waiver under subsection (a)(11) of this section, a new waiver request is not required.(c) If a BHPP liaison vacates the position more than a year after approval of the waiver under subsection (a)(11) of this section, the LMHA or LBHA must attempt to hire a professional pursuant to Texas Education Code §8.152 before requesting a waiver under subsection (a)(11) of this section. Source Note: The provisions of this §307.259 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.259 Local Mental Health Authority or Local Behavioral Health Authority Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218898 03/12/2026 If two or more LMHAs or LBHAs provide services in a region served by a regional ESC, the LMHA or LBHA that primarily operates in the county in which the center is located shall:(1) in making a hiring decision about a BHPP liaison, consult with the other LMHAs or LBHAs providing services in that region;(2) consult with the ESC before making the final hiring decision; and(3) employ the BHPP liaison. Source Note: The provisions of this §307.261 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.261 Determining which Local Mental Health Authority or Local Behavioral Health Authority Employs a Behavioral Health Partnership Program Liaison https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218899 03/12/2026 (a) A BHPP liaison must:(1) serve as a mental health and substance use resource for school districts located in the region served by a regional ESC in which the LMHA or LBHA provides services; and(2) operate within the scope of their professional state license.(b) A BHPP liaison is responsible for carrying out the following functions and duties required of an NPMHP in accordance with Texas Education Code §8.155, including:(1) helping school district personnel gain awareness and a better understanding of mental health and co-occurring mental health and substance use disorders;(2) assisting school district personnel to implement initiatives related to mental health or substance use under state law or agency rules, interagency memorandums of understanding, and related programs; and(3) ensuring school district personnel are aware of:(A) the list of recommended best practice-based programs and research-based practices developed under Texas Education Code §38.351;(B) other public and private mental health and substance use prevention, treatment, and recovery programs available in the school district, including evidence-based programs delivered by an LMHA or LBHA and other public and private mental health resources, such as the Texas School Mental Health Resources database as required by Texas Education Code §38.253; and(C) other available public and private mental health and substance use prevention, treatment, and recovery program resources administered by the LMHA or LBHA or HHSC to support school districts, students, and families;(4) on a monthly basis, facilitating mental health first aid training;(5) on a monthly basis, facilitating training on the effects of grief and trauma and providing support to children with intellectual or developmental disabilities who suffer from grief or trauma; and(6) on a monthly basis, facilitating training on prevention and intervention programs that have been shown to be effective in helping students cope with pressures to:(A) use alcohol, cigarettes, or illegal drugs; or(B) misuse prescription drugs.(c) A BHPP liaison employed under this subchapter must not treat or provide counseling to a student or provide advice to school district personnel regarding a specific student. Source Note: The provisions of this §307.263 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.263 Responsibilities of a Behavioral Health Partnership Program Liaison https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218900 03/12/2026 (a) If an LMHA or LBHA is unable to employ a person who qualifies as an NPMHP for the BHPP liaison position in its designated ESC, the LMHA or LBHA may request a waiver from the HHSC Executive Commissioner, or designee, to employ an LMSW or LPC associate to serve as the BHPP liaison, pursuant to Texas Education Code §8.152(c).(b) To apply for a waiver, the LMHA or LBHA must complete and submit the written HHSC Local Mental and Behavioral Health Authority Waiver Request Form to BHPP@hhs.texas.gov addressing the following information:(1) the name of the LMHA or LBHA requesting the waiver;(2) the LMHA or LBHA's staff member's name and contact information;(3) the LMHA or LBHA's recruitment efforts to hire an NPMHP;(4) the duration of time the LMHA or LBHA was unable to hire for this position before requesting a waiver; and(5) that the BHPP liaison waiver candidate is licensed as an LMSW or LPC associate. Source Note: The provisions of this §307.265 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.265 Texas Health and Human Services Commission Waiver Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218901 03/12/2026 The HHSC Executive Commissioner or designee will deliver written notification to the LMHA or LBHA within ten business days after receipt of the submission regarding:(1) whether the waiver request is approved; or(2) the opportunity to remedy and resubmit the waiver request if the waiver request is denied. Source Note: The provisions of this §307.267 adopted to be effective June 11, 2024, 49 TexReg 4056. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM F BEHAVIORAL HEALTH PARTNERSHIP PROGRAM §307.267 Texas Health and Human Services Commission Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218625 03/12/2026 The purpose of this division is to implement Texas Government Code §531.0993 by establishing a program to provide grants to county-based community collaboratives for the purpose of reducing:(1) recidivism by, the frequency of arrests of, and incarceration of persons with mental illness; and(2) the total waiting time for forensic commitment of persons with mental illness to a state hospital. Source Note: The provisions of this §307.301 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.301 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218626 03/12/2026 The following words and terms, when used in this division, have the following meanings, unless the context clearly indicates otherwise.(1) ACT--Assertive community treatment. A 24-hour team-based service that provides treatment, rehabilitation, and support services in the community to individuals who have a history of multiple psychiatric hospitalizations (two or more in 180 days or four or more in two years) or at least one hospitalization of greater than 30 days duration in the last two years. The provision of ACT requires the following.(A) Individuals identified as needing ACT services must be prioritized for supportive housing, supported employment, and co-occurring psychiatric and substance use disorder services as needed.(B) The use of an integrated services approach merging clinical and rehabilitation staff expertise, such as psychiatric, substance use, vocational or employment, and supportive housing, within one mobile service delivery system.(C) ACT Teams provide permanent supportive housing services, supported employment services, substance use services, psychotherapy services, and mental health rehabilitation services to individuals they serve with minimal external referrals for these services. Referrals are appropriate for specialized therapeutic modalities for complex trauma.(D) Services are delivered on an individual basis with the exception of group activities to reduce social isolation or address substance use issues.(E) The ACT Team has a maximum case ratio of 10 service recipients per staff person.(F) The ACT Team implements ACT services according to the Substance Abuse and Mental Health Services Administration's evidence-based practices and the guidelines defined by Health and Human Services Commission .(2) Applicant--An entity that submits a proposal to apply for a grant award that is part of a community collaborative.(3) Community collaborative--A partnership that includes a county, a local mental health authority, or local behavioral health authority that operates in the county, and each hospital district, if any, located in the county. A community collaborative may include other local entities designated by the collaborative's members.(4) Continuity of care--This term has the meaning set forth in §306.153 of this title (relating to Definitions).(5) FACT--Forensic assertive community treatment. A service delivery model intended for individuals with serious mental illness who are involved with the criminal justice system. These individuals may have co-occurring substance use and physical health disorders. FACT addresses the likelihood that an individual will engage in future illegal behavior in the form of a new crime or failure to comply with conditions of probation or parole, and factors that increase an individual's likelihood of re-offense, such as lack of employment or livable wages, or the presence of a substance use disorder.(6) Grantee--A recipient of a grant awarded under this division.(7) HHSC--The Texas Health and Human Services Commission.(8) Local behavioral health authority--An entity designated as the local behavioral health authority by HHSC in accordance with Texas Health and Safety Code §533.0356.(9) Local mental health authority--An entity designated as the local mental health authority by HHSC in accordance with Texas Health and Safety Code §533.035(a).(10) Mental health jail diversion program--A program that serves individuals with behavioral health needs who are involved, or at risk of involvement, in the criminal justice system by diverting the individuals from jail and providing the individuals with, or connecting them to, community mental health and substance use services.(11) Rapid response team--An interdisciplinary team that includes at least one behavioral health provider and may also include a first responder such as law enforcement or emergency management services. This team provides rapid assessment and deployment of resources for individuals who are experiencing acute clinical deterioration, or signs of imminent clinical deterioration, related to acute stress or a psychiatric condition that impairs or impedes their mental health in the community with the goal of preventing harm to self or to others, death, or an arrest that leads to justice involvement; preventing a higher intensive level of care, or hospitalization in the community; and connecting individuals to necessary behavioral health and intellectual disability services. Source Note: The provisions of this §307.303 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.303 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218627 03/12/2026 (a) A grant awarded under this division, and any addition to such a grant is, subject to the requirements of the contract executed by HHSC with the grantee as required under §307.313 of this division (relating to Contract Execution).(b) HHSC will provide a community collaborative that includes a county with a population of less than 250,000 with:(1) annual training opportunities related to this grant program posted on the HHSC website; and(2) technical assistance and provision of data to the community collaborative upon request as described in §307.311(e) of this division (Grant Proposals and Selection Process) up to six months before the release of a funding opportunity under Texas Government Code §531.0993.(c) A grant award is subject to the availability of appropriated state funds and may be canceled either before or after HHSC awards a grant if funding appropriated to HHSC for the grant is terminated, withdrawn, or insufficient.(d) As permitted under Texas Government Code §531.0993(d-2), in a given state fiscal year, if HHSC has appropriated but unawarded funds from the prior state fiscal year, HHSC will accept proposals from community collaboratives that were not selected in the previous fiscal year or that were selected as grant recipients in the previous fiscal year but require additional funding. Source Note: The provisions of this §307.305 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.305 General Conditions of a Grant https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218628 03/12/2026 A community collaborative must provide matching funds, as outlined by HHSC in the request for proposals, in alignment with Texas Government Code §531.0993(c-1), which can include gifts, grants, donations, or in-kind contributions from any person but must not include money from state funds. Source Note: The provisions of this §307.307 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.307 Eligible Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218629 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218629 03/12/2026 Grant proposals must meet the requirements and specifications set forth in the competitive request for proposal by HHSC. Projects eligible for grant funding include:(1) continuation of a mental health jail diversion program;(2) establishment or expansion of a mental health jail diversion program;(3) establishment of alternatives to competency restoration in a state hospital, including outpatient competency restoration, inpatient competency restoration in a setting other than a state hospital, or jail-based competency restoration;(4) provision of ACT in addition to the ACT required by the local mental health authority or local behavioral health authority performance contract or FACT with an outreach component;(5) provision of intensive mental health services and substance use treatment not readily available in the county;(6) provision of continuity of care services for an individual being released from a state hospital;(7) establishment of interdisciplinary rapid response teams to reduce law enforcement's involvement with mental health emergencies; and(8) provision of local community hospital, crisis, respite, or residential beds. Source Note: The provisions of this §307.309 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.309 Eligible Projects https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218630 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218630 03/12/2026 (a) Grant funds are made available to a local mental health authority or local behavioral health authority representing a community collaborative through a competitive request for proposal process.(b) An applicant must include in the proposal how the applicant will meet:(1) the objectives of reducing:(A) recidivism by, the frequency of arrests of, and incarceration of persons with mental illness; and(B) the total wait time for forensic commitment of persons with mental illness to a state hospital;(2) a statement indicating the amount of matching funds the collaborative is able to provide; and(3) a plan that:(A) is endorsed by each of the collaborative's member entities;(B) identifies a target population;(C) describes how the grant money and matching funds will be used;(D) includes outcome measures to evaluate the success of the plan; and(E) describes how the success of the plan in accordance with the outcome measures would further the state's interest in the grant program's purposes.(c) An applicant must submit a proposal for a grant directly to HHSC in the time and manner specified by HHSC. A proposal received after the deadline will not be considered. HHSC reviews and evaluates eligible, complete, and timely proposals in accordance with the evaluation methodology published in the request for proposal or other notice of potential grant award issued by HHSC.(d) From money appropriated to HHSC for each state fiscal year to implement this grant, HHSC reserves at least 20 percent of that total for grants to community collaboratives that include a county with a population of less than 250,000.(e) An applicant that includes a county with a population of less than 250,000 may request technical assistance or data from HHSC up to six months before the release of a funding opportunity.(f) To the extent money appropriated to HHSC for a state fiscal year to implement this grant remains available to HHSC after grant recipients are selected for the fiscal year, HHSC makes grants available using the money remaining for the fiscal year through a competitive request for proposal process. Subsection (d) of this section does not apply to this process. Source Note: The provisions of this §307.311 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.311 Grant Proposals and Selection Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218631 03/12/2026 Grantees are required to execute a contract with HHSC on mutually agreeable terms and conditions in the manner and format prescribed by HHSC. Grant funds may not be distributed to a grantee before the execution of a contract with HHSC. In addition to other requirements, the contract will require that the grantee comply with:(1) the performance objectives established by HHSC and monitored through progress reports;(2) any financial and reporting requirements established by HHSC;(3) all applicable policies and procedures; and(4) all applicable federal and state laws and their implementing regulations. Source Note: The provisions of this §307.313 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.313 Contract Execution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218632 03/12/2026 (a) Performance data for each grant-funded project must be submitted by grantees on a routine schedule as specified in the contract with HHSC.(b) Not later than the 90th day after the last day of the state fiscal year for which HHSC distributes a grant under this division, each grantee must prepare and submit a report to HHSC describing the effect of the grant money and matching funds in achieving the outcome measures in the plan submitted with the grantee's proposal.(c) HHSC may make inspections of the operation and provision of mental health services provided by a community collaborative under this grant to ensure state money appropriated for the grant program is used effectively. Source Note: The provisions of this §307.315 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.315 Project Review and Evaluation Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218618 03/12/2026 (a) The purpose of this division is to implement Texas Government Code §531.09936 by establishing a grant program to assist with the establishment or expansion of behavioral health centers or jail diversion centers in a local mental health authority or local behavioral health authority's local service area to provide:(1) additional forensic hospital beds and competency restoration services;(2) inpatient and outpatient mental health services to adults and children; and(3) services to reduce recidivism and the frequency of arrest, incarceration, and emergency detentions among persons with mental illness.(b) To the extent money is appropriated to HHSC for this program, HHSC, in cooperation with local mental health authorities and local behavioral health authorities located primarily in rural areas of this state, awards contracts to nonprofit organizations or governmental entities under this division. Source Note: The provisions of this §307.351 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.351 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218616 03/12/2026 The following words and terms, when used in this division, have the following meanings, unless the context clearly indicates otherwise.(1) Applicant--A non-profit or governmental entity that submits a proposal to apply for a grant under this division.(2) Governmental entity--This state, a political subdivision of this state, or an agency of this state.(3) Grantee--A recipient of funds awarded under this division.(4) HHSC--The Texas Health and Human Services Commission.(5) Local behavioral health authority--A local behavioral health authority designated by HHSC in accordance with Texas Health and Safety Code §533.0356.(6) Local mental health authority--A local mental health authority designated by HHSC in accordance with Texas Health and Safety Code §533.035(a).(7) Nonprofit organization--An organization that is exempt from federal income taxation under Section 501(a), Internal Revenue Code of 1986, by being listed as an exempt entity under Section 501(c)(3) of that code.(8) Rural--A county with a population of 250,000 or less. Source Note: The provisions of this §307.353 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.353 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218617 03/12/2026 (a) A grant under this division, and any extension, continuation, or addition to such funds, are subject to:(1) the availability of appropriated state funds;(2) a competitive award process established by HHSC; and(3) the requirements of the contract executed by HHSC with the grantee as required under §307.365 of this division (relating to Contract Execution).(b) HHSC will provide a governmental entity or nonprofit organization with:(1) annual training opportunities related to this grant program posted on the HHSC website; and(2) technical assistance and the provision of data upon request as described in §307.361(c) of this division (Grant Proposals and Selection Process) up to six months before the release of a funding opportunity under Texas Government Code §531.09936. Source Note: The provisions of this §307.355 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.355 General Conditions of a Grant https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218621 03/12/2026 In addition to the general conditions described in §307.355 of this division (relating to General Conditions of a Grant):(1) only governmental entities and nonprofit organizations are eligible for grants awarded under this division; and(2) a governmental entity or nonprofit organization must provide matching funds as outlined by HHSC in the request for proposals, which can include gifts, grants, donations, or in-kind contributions from any person but must not include money from state funds. Source Note: The provisions of this §307.357 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.357 Eligible Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218622 03/12/2026 Proposals must meet the requirements and specifications set forth in requests for proposals issued by HHSC. Proposals must be to expand or establish a behavioral health center or jail diversion center to provide one or more of the following types of services:(1) forensic hospital beds and competency restoration services;(2) inpatient and outpatient mental health services for adults and children, including counseling and psychiatric services; or(3) services to reduce recidivism and the frequency of arrest, incarceration, and emergency detentions among persons with mental illness in the local service area. Source Note: The provisions of this §307.359 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.359 Eligible Projects https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218619 03/12/2026 (a) An applicant must submit a proposal directly to HHSC in the time and manner specified by HHSC. A proposal received after the deadline specified by HHSC will not be considered.(b) HHSC reviews and evaluates eligible, complete, and timely proposals in accordance with the evaluation methodology published in the request for proposal or other notice of potential award issued by HHSC.(c) An applicant may request technical assistance or data from HHSC up to six months before the release of a funding opportunity under Texas Government Code §531.09936. Source Note: The provisions of this §307.361 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.361 Grant Proposals and Selection Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218620 03/12/2026 In selecting grant recipients, HHSC:(1) prioritizes proposals from applicants for services that will be provided primarily in rural areas;(2) considers the extent to which proposed services are already available in the area to be served; and(3) considers other criteria established by HHSC as described in the specific request for proposal or other notice of potential awards issued by HHSC. Source Note: The provisions of this §307.363 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.363 Selection Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218623 03/12/2026 Grantees are required to execute a contract with HHSC on mutually agreeable terms and conditions in the manner and format prescribed by HHSC. Grant funds may not be distributed to a grantee before the execution of a contract with HHSC. In addition to other requirements, the contract will require that the grantee comply with:(1) the performance objectives established by HHSC and monitored through progress reports;(2) any financial and reporting requirements established by HHSC;(3) all applicable policies and procedures; and(4) all applicable federal and state laws and their implementing regulations. Source Note: The provisions of this §307.365 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.365 Contract Execution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218624 03/12/2026 (a) Performance data for each grant-funded project must be submitted by grantees on a routine schedule determined by HHSC.(b) Not later than the 90th day after the last day of the state fiscal year for which HHSC distributes a grant under this division, each grantee must prepare and submit a report describing the effect of the grant money and matching funds in achieving the outcome measures in the plan submitted with the proposal.(c) HHSC may make inspections of the operation and provision of mental health services provided by a grantee under this section to ensure state money appropriated for the grant program is used effectively. Source Note: The provisions of this §307.367 adopted to be effective June 2, 2024, 49 TexReg 3802. 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM G BEHAVIORAL HEALTH GRANT AND FUNDING PROGRAMS §307.367 Project Review and Evaluation Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222753 03/12/2026 The purpose of this subchapter is: (1) to establish uniform procedures for informed consent to ECT; (2) to establish statewide reporting requirements for the use of ECT and other procedures; (3) to establish statewide registration requirements for ECT equipment; (4) to prohibit the use of ECT in persons under 16 years of age; (5) to prohibit the administration of ECT by any person not licensed to practice medicine in Texas; and (6) to provide explicit safeguards for patients in all facilities of the Texas Department of Mental Health and Mental Retardation, community mental health and mental retardation centers, private inpatient psychiatric hospitals licensed by the Texas Department of Health under the Texas Health and Safety Code, Chapter 577, and psychiatric units of hospitals licensed by the Texas Department of Health under the Texas Health and Safety Code, Chapter 241, by: (A) establishing appropriate limits for the therapeutic utilization of electroconvulsive therapy; (B) establishing current guidelines of the American Psychiatric Association and the Food and Drug Administration as the references of choice in questions of practice related to ECT, except to the extent that they conflict with the provisions of the Health and Safety Code, Title 7, Subtitle C, Chapter 578; and (C) prohibiting the use of chemical or gaseous agents for convulsive therapy except as a research procedure conducted in accordance with Subchapter Q of this chapter (relating to Departmental Procedures for the Protection of Human Subjects Involved in Research). Source Note: The provisions of this §307.501 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.501 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222754 03/12/2026 (a) The provisions of this subchapter apply to all organizations and individuals providing electroconvulsive therapy on an inpatient or outpatient basis, in or on a contractual basis with: (1) all facilities of the Texas Department of Mental Health and Mental Retardation; (2) community mental health and mental retardation centers; (3) psychiatric hospitals licensed by the Texas Department of Health under the Health and Safety Code, Chapter 577; and (4) psychiatric units of hospitals licensed by the Texas Department of Health under the Health and Safety Code, Chapter 241. (b) Pursuant to the Health and Safety Code, Title 7, Subtitle C, Chapter 578, the following provisions of this subchapter apply to all organizations and individuals administering ECT in Texas: (1) §405.104 of this title (relating to General Requirements); (2) §405.108 of this title (relating to Informed Consent to ECT); (3) §405.112(b) of this title (relating to Report of Electroconvulsive Therapy);(4) §405.114 of this title (relating to Registration of ECT Stimulus Apparatus); and(5) §405.115 of this title (relating to Enforcement and Penalties). Source Note: The provisions of this §307.503 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.503 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222755 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Chemical or gaseous agents--Those substances which may be capable of inducing a seizure and including, but not limited to, pentylenetetrazol (Metrazol) and flurothyl (Indoklon). (2) Chief executive officer--The superintendent or director of a state hospital, state school, or state center; the executive director of a community mental health and mental retardation center; or the person responsible for management and operation of a hospital or other health care facility or entity providing ECT. (3) Commissioner--The commissioner of the Texas Department of Mental Health and Mental Retardation. (4) Community mental health and mental retardation center--A community mental health and/or mental retardation center established by the Texas Health and Safety Code, Chapter 534. (5) Department--The Texas Department of Mental Health and Mental Retardation. (6) ECT--Electroconvulsive therapy. (7) Electroconvulsive therapy (ECT)--A treatment in which controlled, medically applied electrical current results in a therapeutic seizure, usually attenuated by anesthesia and muscle relaxants. (8) Fully qualified psychiatrist--A physician, licensed to practice medicine in Texas, who has completed approved residency training in psychiatry. (9) Informed consent--The knowing consent of a patient or the guardian of the person of the patient in keeping with the provisions of §405.108 of this title (relating to Informed Consent to ECT), so situated as to be able to exercise free power of choice without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion. If consent is given by the guardian of the person of a patient who has been adjudicated incompetent to manage his or her own personal affairs, then the decision must be based on knowledge of what the patient would desire, if known. (10) Insulin coma treatment--The production of a coma for therapeutic purposes through the administration of insulin. (11) Maintenance therapy--Treatment with electroconvulsive therapy on an individually determined intermittent schedule for purposes of preventing relapse. (12) Multiple-monitored ECT--The induction of more than one adequate seizure during one episode of anesthesia. (13) Nurse anesthetist--A nurse credentialed by the Board of Nurse Examiners as a nurse anesthetist. (14) Prefrontal sonic sound treatment--A treatment, not described or defined in biomedical literature, which is defined in California statutes governing ECT and other treatments as "The direct stimulation and/or destruction of brain cells or brain tissue by ultrasound for therapeutic purposes." (15) Psychosurgery--Surgical intervention to sever fibers connecting one part of the brain with another or to remove or to destroy brain tissue with the intent of modifying or altering severe disturbances of behavior, thought content, or mood. For purposes of this subchapter, the term does not include such surgery for the relief of intractable physical pain or the treatment of neurological disease or abnormality. (16) Regressive or depatterning ECT--The prolonged use of daily or more frequent treatments. (17) Reportable therapies--Electroconvulsive therapy, insulin coma treatment, "prefrontal sonic sound treatment," psychosurgery, multiple-monitored ECT, "regressive" or "depatterning" ECT, or any other convulsive or coma-producing therapy to treat mental illness. (18) Series of treatments--Usually six-15 treatments. (19) TXMHMR medical director--The department's medical director. (20) Treatment--The administration of electroconvulsive therapy, unilaterally or bilaterally, with anesthesia, under appropriate clinical conditions for monitoring, safety, and efficacy. Source Note: The provisions of this §307.505 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.505 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222756 03/12/2026 (a) Only a physician licensed to practice medicine in Texas may administer ECT and a physician may not delegate the act of administering the therapy. A nonphysician who administers ECT is considered to be practicing medicine in violation of the Medical Practice Act, Texas Civil Statutes, Article 4495b.(b) No person under the age of 16 shall receive ECT. (c) Prior to receiving ECT, every patient, voluntary or involuntary, competent or incompetent, shall be given full explanation of ECT consistent with the definition of ECT in §405.103 of this title (relating to Definitions) and meeting the requirements of §405.108 of this title (relating to Informed Consent to ECT).(d) If any patient, without regard to competency, objects to ECT and there is an alternative method of treatment (that is not contraindicated and which has a reasonable potential for success) to which the patient does not object, the alternative method shall be considered and, if mutually acceptable to the patient or the guardian of the person of the patient and the treating physician, shall be used. It is not to be inferred, however, that ECT should be held as a treatment of "last resort." Full documentation of the factors considered in arriving at the decision to use ECT, the consent process, the treatment procedures, and patient response to treatment shall be entered into the patient's permanent medical record.(e) The use of ECT for punishment, solely for control of behavior, for convenience of staff, in order to make patients more compliant, and the use of ECT in a discriminatory or abusive manner are explicitly prohibited. Source Note: The provisions of this §307.507 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.507 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222757 03/12/2026 (a) The major indications for the therapeutic use of ECT are major mood disorders. ECT may be considered for some other disorders, with appropriate consideration of the risk/benefit ratio.(b) The major contraindications to the therapeutic use of ECT are as follows:(1) absolute space-occupying intracranial pathology;(2) relative, requiring clinical consideration:(A) cardiovascular disease, including arrhythmias, myocardial disease, or coronary artery disease;(B) diseases which render a patient likely to suffer hemorrhage, including peptic ulcer, subdural hematoma, and aortic aneurysm;(C) degenerative diseases of the central nervous system; (D) glaucoma although it is recognized that intraocular pressure is not increased by ECT, and is, in fact, reduced during the seizure period, medications used adjunctively to the treatment may result in increased intraocular pressure. For patients with glaucoma, consideration should be given to pretreatment with physostigmine;(E) severe orthopedic disability. Source Note: The provisions of this §307.509 adopted to be effective January 1, 1992, 16 TexReg 7528; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.509 Indications and Contraindications for the Use of Electroconvulsive Therapy (ECT) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222758 03/12/2026 (a) A thorough evaluation of the patient's psychiatric and physical status with review of pertinent laboratory findings shall be done within 30 days prior to the initiation of a course of ECT and shall be recorded in the patient's permanent medical record. Physical evaluation shall include a neurological examination. Other determinations shall include, but not be limited to, the following:(1) laboratory as appropriate to medical history and/or conditions, such as:(A) complete blood count;(B) electrolytes; and(C) serum pseudocholinesterase if there is no documentation of successful use of muscle relaxant medication with general anesthesia, and if there is no record of previous testing;(2) x-rays as appropriate to medical history and/or conditions; (3) electrocardiogram.(b) Abnormalities reported or found in the neurological or cardiac evaluation shall be evaluated by a medical specialist in the appropriate field, such evaluation to be incorporated in writing into the patient's permanent record prior to initiation of ECT. Source Note: The provisions of this §307.511 adopted to be effective January 1, 1992, 16 TexReg 7528; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.511 Medical Evaluation Required Prior to a Course of Electroconvulsive Therapy (ECT) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222759 03/12/2026 (a) Before initiating a course of ECT, it shall be the responsibility of the attending physician who is not a fully qualified psychiatrist to obtain consultation from a fully qualified psychiatrist, licensed to practice medicine in Texas. (b) The consultant shall render a written report regarding the appropriateness and probable benefits to be obtained by administration of ECT. That report will be incorporated into the patient's permanent medical record. Source Note: The provisions of this §307.513 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.513 Consultation Required https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222760 03/12/2026 (a) Consent under this section is not valid unless the person giving consent understands the information presented and consents voluntarily and without coercion or undue influence. (b) A person who gives consent may revoke consent for any reason at any time, with revocation effective immediately. (c) Prior to each individual ECT treatment, consent to electroconvulsive therapy must be obtained. Unless the person consents in accordance with this subchapter, ECT may not be administered to: (1) a patient who is 16 years or older and voluntarily receiving services; (2) an involuntary patient who is 16 years or older and who has not been adjudicated incompetent to manage his or her own personal affairs; (3) an involuntary patient who is 16 years or older and who has been adjudicated incompetent to manage his or her own personal affairs, unless: (A) the patient has an appointed guardian of the person of the patient; (B) the guardian of the person consents to treatment in accordance with this section; and (C) the consent of the guardian is based on knowledge of what the patient would desire, if known. (d) Consent shall be documented by the signature of the person giving consent on the form entitled "Disclosure and Consent for Electroconvulsive Therapy" which is referenced as Exhibit A of §405.117 of this title (relating to Exhibits), and which shall include a supplemental statement about the individual patient containing the information in the form entitled "Supplemental Statement" which is referenced as Exhibit B of §405.117 of this title (relating to Exhibits), including: (1) indications for therapy for the patient; (2) medical evaluation results; (3) contraindications to therapy; (4) results of psychiatric and other medical consultation(s) relevant to ECT; and (5) for a patient 65 years of age or older: (A) known current medical conditions that may increase the possibility of injury or death as a result of ECT; and (B) statement by two physicians that the treatment is medically necessary. (e) The consent form shall be fully completed to explicitly state the following information: (1) the nature and seriousness of the mental condition requiring ECT; (2) the nature of the procedures to be followed, including anesthesia, and their purposes, including the identification of any procedures which are experimental; (3) the nature, degree, duration, and probability of significant risks and/or side effects and/or adverse effects resulting from ECT commonly known by the medical profession, including: (A) memory changes of events prior to, during, and immediately following the treatment; (B) fractures and dislocations of bones; (C) the probability of significant temporary post-treatment confusion requiring special care; and (D) the possibility of permanent memory dysfunction, especially noting the possible degree and duration of memory loss, the possibility of permanent, irrevocable memory loss, the remote possibility of seizures, and the possibility of death; (4) that there is a division of opinion as to the efficacy of the procedure; (5) the benefits reasonably to be expected; (6) the probable degree or duration of improvement or remission expected with or without the procedure; (7) a disclosure of any appropriate alternative procedures that might be advantageous for the patient; (8) an offer to answer any inquiries concerning the procedures; (9) an instruction that the consenting party is free to withdraw consent and to discontinue an individual treatment or a series of treatments at any time without prejudice to the care of the individual; (10) an instruction that consent is for one individual treatment, and that additional treatments shall require renewed written informed consent; and (11) the side effects of anesthesia shall also be explained. (f) Before a patient receives ECT, the hospital, facility, or physician administering the therapy shall ensure that: (1) the patient and the patient's guardian of the person, if any, receive a copy of the completed consent form, a written supplement containing related information concerning the individual patient, in the patient's primary language, if possible; (2) the consent form and supplement are orally explained to the patient and the patient's guardian of the person, if any, in simple, nontechnical terms in the patient's primary language, if possible, or by means reasonably calculated to communicate with a hearing-impaired or visually-impaired person, if applicable; (3) the patient or the patient's guardian of the person, as appropriate, signs the consent form, which states that the person has read and understood the consent form and written supplement; and (4) the signed consent form is made a part of the patient's permanent medical record. (g) In cases in which the individual giving consent is the guardian of the person, the requirements of the consent process may be fulfilled through a phone conversation that includes all of the elements that would be discussed in person, witnessed by one individual who is not the physician who will be administering ECT. A copy of the consent form and written supplement must be mailed or faxed to the individual giving consent prior to obtaining the initial informed consent. The consent must be obtained for each individual treatment. (h) For a patient 65 years of age or older, before each treatment series begins the hospital, facility, or physician administering the procedure shall: (1) ensure two physicians sign the appropriate section of the supplemental statement described in subsection (d)(5) of this section stating that the treatment is medically necessary; and (2) inform the patient and the patient's guardian of the person, if any, orally and in the supplemental statement described in subsection (d)(5) of this section, of any known current medical condition the patient has that may increase the possibility of injury or death as a result of the treatment. Source Note: The provisions of this §307.515 adopted to be effective December 10, 1993, 18 TexReg 8790; amended to be effective February 11, 1998, 23 TexReg 1089; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.515 Informed Consent to ECT https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222761 03/12/2026 (a) No more than 24 electroconvulsive therapy treatments may be administered to a given patient in any 12-month period, dated from the date of the first treatment except as provided in this subsection. (1) Exceptions to this limitation require, prior to the additional treatments: (A) for state facilities, the written approval of the department's medical director, who shall consider the recommendations of an independent, fully qualified psychiatrist who is not affiliated with the department except in a consultative capacity; or(B) for all other providers, the written concurrence of a fully qualified psychiatrist not involved in the patient's care. (2) All reports of such consultations shall become a part of the patient's permanent medical record. (b) The number of ECTs to be given in eight consecutive weeks shall ordinarily be limited to 15. In those cases in which it is considered clinically advantageous to exceed these numbers of treatments in any given series, the attending physician shall obtain a second consultative opinion from a fully qualified psychiatrist who is not directly associated with the patient's care. Source Note: The provisions of this §307.517 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.517 Limitations on Use: Number per Year and Number per Series of Treatments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222762 03/12/2026 (a) Personnel. ECT may be administered only by a licensed physician credentialed by the facility providing the treatment to use ECT, or by a licensed physician in training in an approved residency program under the direct supervision of a fully qualified psychiatrist so trained and credentialed. In specific circumstances a licensed physician who is not a fully qualified psychiatrist but who has demonstrated training and experience in the administration of ECT may administer ECT providing authorization has been provided in writing to the chief executive officer by the hospital or facility medical director. Assistants shall include a recovery nurse and an ECT treatment nurse or assistant trained in ECT procedures. (b) Equipment. Equipment available in the ECT room shall receive a general inspection on a regular basis. Equipment shall include, but not be limited to, the following:(1) an ECT machine of contemporary model which shall be calibrated at least semiannually;(2) a respiratory support system including oxygen, endotracheal intubation tray, suction apparatus, and equipment for tracheotomy;(3) a cardiac arrest tray with appropriate drugs;(4) a cardiac monitor and defibrillator. (c) Recovery area. A recovery area containing emergency equipment and supplies shall be used, the patients to be therein until adequately recovered and all vital signs are stable. The recovery room will be equipped and staffed to meet commonly accepted standards for postanesthesia units.(d) Anesthesia. Anesthesia practice shall meet commonly accepted standards for patient evaluation for anesthesia, informed consent, induction, maintenance, monitoring, and documentation of anesthesia.(1) General anesthesia shall be administered to all patients as a standard procedure during ECT. In the rare event that general anesthesia is contraindicated, the administering physician shall obtain consultation and written concurrence by two physicians, at least one of whom is a fully qualified psychiatrist.(2) Anesthesia shall be administered only by persons credentialed by the medical staff to do so, and who are: (A) licensed anesthesiologists; (B) licensed physicians credentialed and privileged in anesthesiology for ECT; or (C) nurse anesthetists (CRNA).(3) At least one person in attendance must be certified in advanced cardiorespiratory life support (ACLS). Source Note: The provisions of this §307.519 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.519 Personnel and Equipment Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222763 03/12/2026 No chemical or gaseous agent may be used as a means to induce a seizure for therapeutic purposes, in lieu of or as a substitute for electroconvulsive therapy, unless such procedure is conducted as a research investigation and meets all the requirements of Subchapter Q of this chapter (relating to Departmental Procedures for the Protection of Human Subjects Involved in Research). Source Note: The provisions of this §307.521 adopted to be effective January 1, 1992, 16 TexReg 7528; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.521 Prohibition of Induction of Seizure by Chemical or Gaseous Agent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222764 03/12/2026 (a) Reporting requirements for state facilities and community centers.(1) A report of each individual ECT administered to a patient shall be entered into the patient's medical record and shall include, but not be limited to, the following:(A) diagnosis for which ECT given; (B) date of treatment; (C) type of ECT machine used; (D) duration and strength of electrical stimulation; (E) all medications administered; and (F) any complications or adverse effects. (2) A report of all ECT treatments will be provided at the end of each month to the chief executive officer. The report shall include the following: (A) name, age, gender, and identification number of patient; (B) diagnosis for which ECT given; (C) dates and number of treatments given; and (D) any complications or adverse effects. (b) Reporting requirements for all providers. (1) On a quarterly basis, the chief executive officer of a mental hospital or other facility that administers ECT, psychosurgery, "prefrontal sonic treatment," or any other convulsive or coma-producing therapy to treat mental illness and any physician who administers ECT on an outpatient basis shall make a written report to the TXMHMR medical director containing the information requested on the form entitled "Report of ECT/Other Therapies" which is referenced as Exhibit C of §405.117 of this title (relating to Exhibits). The reporting format requires clinical data from before, after, and 30 days after treatment. (A) The facility and/or its medical staff shall require that the treating physician(s) provide complete, accurate, and timely information to the CEO for this purpose.(B) Reports must submitted to be received by the TXMHMR medical director not later than 30 days following the end of each state fiscal year quarter. For treatments administered in September, October, and November, the deadline is December 31; for December, January, and February, the deadline is March 31; for March, April, and May, the deadline is June 30; and for June, July, and August, the deadline is September 30.(2) The report will include, but may not be limited to, the following information for the quarter:(A) the number of persons who received the therapy, including: (i) the number of persons receiving voluntary mental health services who consented to the therapy;(ii) the number of involuntary patients who consented to the therapy; and(iii) the number of involuntary patients for whom a guardian of the person consented to the therapy;(B) the age, gender, and race of the persons receiving therapy; (C) the general source of the treatment payment;(D) the number of non-electroconvulsive treatments listed in paragraph (1) of this subsection;(E) the number of electroconvulsive treatments administered for each complete series of treatments, excluding maintenance treatments; (F) the number of maintenance electroconvulsive treatments administered; (G) the number of fractures, reported memory losses, incidents of apnea, and cardiac arrests without death;(H) autopsy findings if death followed within 14 days after the date of the administration of the therapy; and(I) other information that may be required by the department. (c) Reporting requirements for the department.(1) Annually the department shall compile the information reported under subsection (b) of this section by mental hospital, other facility, and private physician administering ECT on an outpatient basis. Private physicians and individual patients shall not be named or otherwise identified.(2) A copy of the report shall be filed with the governor and presiding officer of each house of the legislature.(3) The department shall use this information to analyze, audit, and monitor the use of ECT and other reportable procedures. Source Note: The provisions of this §307.523 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; amended to be effective February 11, 1998, 23 TexReg 1089; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.523 Report of ECT https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222765 03/12/2026 If ECT is to be given to patients on an outpatient basis, all the provisions of this subchapter apply. Source Note: The provisions of this §307.525 adopted to be effective January 1, 1992, 16 TexReg 7528; amended to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.525 ECT on Outpatient Basis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222766 03/12/2026 (a) A person may not administer ECT unless the equipment used to administer the therapy is registered annually with the department. All ECT stimulus apparatus must be registered with the department by the mental hospital or other facility or by the private physician administering ECT on an outpatient basis.(1) The department shall use the information to analyze, audit, and monitor the use of ECT. (2) The department shall file annually a report summarizing the information with the governor and the presiding officers of the legislature. The report shall not name or otherwise identify individual physicians or patients. (b) Within 30 days of the effective date of this subchapter, the applicant must complete and submit the form adopted by reference as Exhibit D, including a nonrefundable application fee of $50.00, for all items of ECT stimulus apparatus which are housed or used at a specific location. (c) Upon receipt of the application and fee, the department may conduct an investigation if it believes the stimulus apparatus in question may be dangerous or faulty. For purposes of investigation, any duly authorized agent of the department may at any time enter upon the premises of any facility in which ECT is administered to inspect the ECT stimulus apparatus or to take other action the department deems necessary to ascertain and assure compliance with state law and this section. Any such duly authorized agent may have access for the purposes of examination and transcription to such records and documents as the department deems relevant to the investigation. (d) The department may deny, suspend, or revoke a registration if it determines that the stimulus apparatus is dangerous or faulty. Such action is the subject of a contested case under the Administrative Procedure and Texas Register Act. Hearings will be conducted in accordance with Chapter 403, Subchapter O of this title (relating to Practice and Procedure with Respect to Administrative Hearings of the Department in Contested Cases). Source Note: The provisions of this §307.527 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.527 Registration of ECT Stimulus Apparatus https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222767 03/12/2026 (a) For private psychiatric hospitals and psychiatric units of general hospitals, the Texas Department of Health shall enforce the applicable rules and standards adopted by the department to the same extent as it enforces rules adopted by the Texas Board of Health. A violation of this subchapter is subject to the same consequences as a violation of a rule adopted by the Texas Board of Health. (b) A person who violates a provision of this subchapter may be subject to injunction, civil penalties, and related costs pursuant to the provisions of the Health and Safety Code, Chapter 571, §§571.022-.024, and Chapter 241, §241.055.(c) A person licensed by the Texas Department of Health or regulated by the department who violates a provision of this subchapter may be subject to administrative penalties and related costs pursuant to the Health and Safety Code, Chapter 571, §§571.025-.026, and Chapter 241, §241.058 and §241.0585. (d) A treatment facility or mental health facility that violates a provision of this subchapter is liable to a person receiving care or treatment from the facility who is harmed as a result of the violation, consistent with the provisions of the Health and Safety Code, Chapter 321, Subsections 321.003-.004. Source Note: The provisions of this §307.529 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.529 Enforcement and Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224662 03/12/2026 The following exhibits referenced in this subchapter are available by contacting TDMHMR, Policy Development, P.O. Box 12668, Austin, Texas 78711-2668: (1) Exhibit A--"Disclosure and Consent for Electroconvulsive Therapy":Attached Graphic(2) Exhibit B--"Supplemental Statement"; andAttached Graphic(3) Exhibit C--"Report of ECT/Other Therapies."Attached Graphic Source Note: The provisions of this §307.531 adopted to be effective February 11, 1998, 23 TexReg 1089; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9771 1 HEALTH AND HUMAN SERVICES COMMISSION 307 BEHAVIORAL HEALTH PROGRAM I ELECTROCONVULSIVE THERAPY (ECT) §307.531 Exhibits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221377 03/12/2026 The purpose of this subchapter is:(1) to provide to persons receiving mental health services:(A) a listing of the specific rights guaranteed to them;(B) the assurance that these rights must and will be made known to them, and, when applicable, to the persons having legal responsibility for them (i.e., parent of a minor, managing conservator, legal guardian of the person, limited legal guardian of the person); and(C) assistance in exercising their rights in a manner which does not conflict with the rights of other persons;(2) to require the development of rights handbooks and their distribution to persons receiving mental health services and, when applicable, to the persons with legal responsibility for them and other interested parties;(3) to require the appointment of a rights protection officer at each department facility and community MHMR center which provides mental health services; and(4) to ensure that department facility, community center, and psychiatric hospital employees are aware of the rights of persons receiving mental health services. Source Note: The provisions of this §320.1 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221376 03/12/2026 The provisions of this subchapter shall apply to each of the following in which mental health services are provided:(1) facilities of the Texas Department of Mental Health and Mental Retardation and their respective community-based programs;(2) community centers;(3) psychiatric hospitals; and(4) any program contracting with these entities. Source Note: The provisions of this §320.3 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221372 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221372 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Aversive conditioning--A highly restrictive behavior intervention designed to eliminate undesirable behavior patterns through learned associations with unpleasant stimuli or tasks.(2) Behavior interventions--Interventions to increase socially adaptive behavior and to modify maladaptive or problem behaviors and replace them with behaviors and skills that are adaptive and socially productive. Also referred to as "behavior management," "behavior training," "behavior therapy," and related terms.(3) Community center--A community mental health and mental retardation center established under the Texas Health and Safety Code, Title 7, Chapter 534.(4) Department--The Texas Department of Mental Health and Mental Retardation.(5) Department facilities--The state hospitals and state centers which provide mental health services, and their respective community-based programs.(6) Emergency--A situation in which, in the opinion of the treating physician, the immediate use of medication, or, in the opinion of the treating physician or other appropriate professional, the immediate use of restrictive techniques is essential to interrupt imminent physical danger to self or others.(7) Ethics Committee--A Texas Board of MHMR-approved body composed of clinicians, consumers, family members, and outside experts convened for the purpose of reviewing and resolving issues surrounding clinical care and treatment.(8) Hospital--A general or special hospital as defined in the Health and Safety Code, §241.003(4) and §241.003(11), that includes an identifiable part of the hospital for the provision of mental health services.(9) Informed consent--The knowing written consent of an individual or the individual's legally authorized representative, so situated as to be able to exercise free power of choice without undue inducement or any element of force, fraud, deceit, duress, or other form of constraint or coercion. The basic elements of information necessary for informed consent include all of the following presented in language or format easily understood by the individual:(A) a thorough explanation of the procedures to be followed and their purposes, including identification of any experimental procedures;(B) a description of any attendant discomforts and reasonably expected risks;(C) a description of any reasonably expected benefits;(D) a disclosure of any appropriate alternative procedures as well as their reasonably expected risks and benefits, including those that might result if no procedure is utilized;(E) an offer to answer any questions about the procedures; and(F) an instruction that the individual can withdraw consent and stop participating in the program or activity at any time without prejudice to the individual. Withdrawal of consent may be in any form, including noncompliance, active resistance, or a verbal or other expression of unwillingness to continue participating in any aspect of the program.(10) Highly restrictive interventions--Any intervention (e.g., aversive conditioning) that poses potentially increased physical, emotional, or psychological distress to the individual upon whom it is imposed.(11) Inpatient services--Residential services provided in a department facility, a licensed hospital unit, a licensed crisis stabilization unit, or a psychiatric hospital.(12) Intrusive searches--The tactile and/or visual examination of an individual's partially clothed (a state of undress that would not be acceptable in public) or fully unclothed body, personal belongings, or space designated for the storage of the individual's personal belongings. Intrusive searches do not include:(A) routine searches of belongings for contraband at the time of admission, return from pass, or transfer;(B) superficial external pat-downs by staff of the same sex;(C) daily room checks for housekeeping and chore completion;(D) physical assessments by nurses and physicians; and(E) searches of the person's outer clothing, hair, or mouth, unless the search is resisted by the person, in which case all procedures for intrusive searches are to be followed.(13) Mental health services--Includes all services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate mentally disordered and disabled persons, including persons mentally disordered and disabled from alcoholism and drug addiction.(14) Office of Consumer Services and Rights Protection (CSRP)--The office located within the department's central office which maintains the toll-free telephone line 1-800-252-8154 to receive rights-related complaints from persons receiving services at department facilities and community centers and which is responsible for assisting persons receiving mental health services with needed services and rights protection.(15) Psychiatric hospital--(A) An establishment licensed by the Texas Department of Health under the Texas Health and Safety Code, Chapter 577, offering inpatient services, including treatment, facilities, and beds for use beyond 24 hours, for the primary purpose of providing psychiatric assessment and diagnostic services and psychiatric inpatient care and treatment for mental illness. Such services must be more intensive than room, board, personal services, and general medical and nursing care. Although substance abuse services may be offered, a majority of beds (51%) must be dedicated to the treatment of mental illness in adults and/or children. Services other than those of an inpatient nature are not licensed or regulated by the Texas Department of Health and are considered only to the extent that they affect the stated resources for the inpatient components; or(B) That identifiable part of a hospital in which diagnosis, treatment, and care for persons with mental illness is provided and that is licensed by the Texas Department of Health under the Texas Health and Safety Code, Chapter 241.(16) Residential services--Twenty-four hour services provided and/or contracted by the department or a community center (e.g., structured group residential programs, halfway houses, hospital units providing MH services, licensed crisis stabilization units, etc.) or a psychiatric hospital.(17) Rights protection officer--An employee appointed by the head of a department facility or community center to protect and advocate for the rights of persons receiving mental health services.(18) Unusual medications--Medication that has not been approved by the Food and Drug Administration for use in the United States, or medication that is being used to treat conditions for which its use has not been demonstrated through rational scientific theory and evidence in biomedical literature, controlled clinical trials, or expert medical opinion. Source Note: The provisions of this §320.5 adopted to be effective December 10, 1993, 18 TexReg 8790; amended to be effective October 1, 1996, 21 TexReg 8505; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221373 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221373 03/12/2026 Persons receiving mental health services from department facilities, community centers, and psychiatric hospitals have the following rights.(1) The rights, benefits, responsibilities, and privileges guaranteed by the constitutions and laws of the United States and the State of Texas unless they have been restricted by specific provisions of law. These rights include, but are not limited to, the right to impartial access to and provision of treatment, regardless of race, nationality, religion, sex, ethnicity, sexual orientation, age, or disability; the right to petition for habeas corpus; the right to register and vote at elections; the right to acquire, use, and dispose of property including contractual rights; the right to sue and be sued; all rights relating to the granting, use, and revocation of licenses, permits, privileges, and benefits under law; the right to religious freedom; and rights concerning domestic relations.(2) The right to presumption of mental competency in the absence of a judicial determination to the contrary. Any questions regarding applicability of this right or a limitation on it should be referred for appropriate legal advice.(3) The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs, and promotes respect and dignity for each individual.(4) The right to appropriate treatment in the least restrictive appropriate setting available consistent with the protection of the individual and the protection of the community.(5) The right to be informed of those rules and regulations of the department facility, community center, or psychiatric hospital relating to expectations of the individual's conduct. Staff must document in the medical record the date and manner in which this information was provided.(6) The right to communication in a language and format understandable to the individual for all services provided.(7) The right to participate actively in the development and periodic review of an individualized treatment plan (extending to a parent or conservator of a minor, and the legal guardian of the person, when applicable); and the right to a timely consideration of any request for the participation of any other person in this process, with the right to be informed of the reasons for any denial of such a request. Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate.(8) The right to explanations of the care, procedures, and treatment to be provided; the risks, side effects, and benefits of all medications and treatment procedures to be used, including those that are unusual or experimental; the alternative treatment procedures that are available; and the possible consequences of refusing the treatment or procedure. This right extends to the parent or conservator of a minor, the legal guardian of the person, when applicable, and to any other person authorized by the individual served.(9) The right to refuse particular treatments without prejudice to participation in other programs, or without compromising access to other treatments or services solely because of the refusal.(10) The right to meet with the professional staff members responsible for the individual's care and to be informed of their professional discipline, job title, and responsibilities. In addition, the individual has the right to an explanation of the justification involving any proposed change in the appointment of staff members responsible for the individual's care.(11) The right to obtain an independent psychiatric, psychosocial, psychological, or medical examination or evaluation by a psychiatrist, physician, or nonphysician mental health professional of the individual's choice at the individual's own expense. The department facility, community center, or psychiatric hospital administrator shall allow the individual to obtain the examination or evaluation at any reasonable time. If the individual is a minor, the minor's parent, legal guardian, or managing or possessory conservator is entitled to obtain the examination or evaluation.(12) The right to be granted an in-house review of the individual treatment plan or specific procedure upon reasonable request as provided for in the written procedures of the department facility, community center, or psychiatric hospital.(13) The right to an explanation of the justification of any transfer of the individual to any program within or outside of the department facility, community center, or psychiatric hospital.(14) The right to participate actively in the development of a discharge plan addressing aftercare issues which include the individual's mental health, physical health, and social needs. This right extends to a parent or conservator of a minor, or the legal guardian of the person, when applicable. The individual also has the right to a timely consideration of any request for the participation of any other person in this discharge planning, with the right to be informed of the reasons for any denial of such a request. Staff must document in the medical record that the parent, guardian, conservator, or other person was notified of the date, time, and location of each meeting so that he or she could participate.(15) The right to information, upon request, pertaining to the cost of services rendered (itemized when possible), the sources of the program's reimbursement, and any limitations placed upon the duration of services. At department facilities and community centers, no person will be denied services due to an inability to pay for them.(16) The right to be free from unnecessary or excessive medication, which includes the right to give or withhold informed consent to treatment with psychoactive medication, unless the right has been limited by court order or in an emergency. This right extends to the parent or conservator of a minor or the legal guardian of the person, if applicable. For individuals receiving inpatient services at department facilities, community centers, or other mental health facilities when those services are operated by the department or funded by the department through a contractual or other agreement, this right may only be limited in accordance with the provisions of Chapter 405, Subchapter FF of this title (relating to Consent to Treatment with Psychoactive Medication).(17) The right to give or withhold informed consent to participate in research programs without compromising access to services to which the individual is otherwise entitled.(18) The right to give or withhold informed consent for the use or performance of any of the following (exceptions to this right must be in accordance with applicable laws, standards, or, for department facilities and community centers, department rules, and must be fully explained to the individual and the person authorized to give consent, if applicable):(A) surgical procedures;(B) electroconvulsive therapy (prohibited for minors under the age of 16);(C) unusual medications;(D) behavior therapy when aversive procedures are used or a right otherwise guaranteed in this rule is restricted;(E) hazardous assessment procedures;(F) audiovisual equipment; and(G) other procedures for which consent is required by law.(19) The right to withdraw consent at any time in any matter in which the person receiving services has previously granted consent, without limiting or compromising access to services or other treatment(s).(20) The right to be informed of the current and future use and disposition of products of special observation and audiovisual techniques, such as one-way vision mirrors, tape recorders, television, movies, or photographs.(21) The right to confidentiality of records and the right to be informed of the conditions under which information can be disclosed without the individual's consent. At department facilities and community centers, client-identifying information shall be disclosed in accordance with Chapter 403, Subchapter K of this title (relating to Client-Identifying Information). At psychiatric hospitals, client-identifying information shall be disclosed in accordance with the provisions of the Texas Health and Safety Code, §§576.005 and 611.001-611.005, and 42 Code of Federal Regulations, Part 2.(22) The right to be informed of a treating physician's intent to disclose information (when the physician determines such disclosure is in the individual's best interest) to a law enforcement officer or the individual's legally authorized representative when the disclosure is not specifically permitted by other law (e.g., information provided to law enforcement officers legally authorized to conduct investigations concerning complaints of abuse or denial of rights). Unless the individual is unavailable, this includes the right to be informed:(A) of the intent to disclose the information;(B) to whom the information will be disclosed; and(C) of the client's right to prohibit the information from being disclosed by providing contrary written instructions.(23) The right to have access to information contained in one's own record. The right extends to the parent or conservator of a minor (unless the minor is receiving chemical dependency services) and to the legal guardian of a person declared to be legally incompetent. Department facilities and community centers should also reference Chapter 403, Subchapter K of this title (relating to Client-Identifying Information) regarding this right.(A) Confidential information about another person who has not consented to the release shall be deleted from the record prior to its release, unless it is:(i) information relating to the individual that another person has provided;(ii) the identity of the person responsible for that information; or(iii) the identity of any person who provided information that resulted in the individual's commitment.(B) This right may be limited by a mental health professional if the professional determines that release of a portion of the information would be harmful to the individual's physical, mental, or emotional health.(C) Any denial of access to information shall be in keeping with, documented, and reviewed regularly according to provisions outlined in the Texas Health and Safety Code, §611.004 or §611.0045. Individuals also have the right to an independent review of any denial of access in accordance with Public Law 99-319 (Protection and Advocacy Act for Mentally Ill Individuals) or the Texas Health and Safety Code, §611.0045.(24) The right to be free from mistreatment, abuse, neglect, and exploitation. See 40 TAC Chapter 710, Subchapter A (concerning Abuse and Neglect of Persons Served by TXMHMR Facilities), 40 TAC Chapter 710, Subchapter B (concerning Client Abuse and Neglect in Community Mental Health and Mental Retardation Centers), and 40 TAC Chapter 710, Subchapter C (concerning Patient Abuse in Private Psychiatric Facilities).(25) The right to reasonable protection of personal property from theft or loss. At department facilities, the head of the facility must institute procedures to protect and adequately secure the personal property of persons served, including clothing. Community centers and psychiatric hospitals should develop and post procedures regarding protection and security of personal property of persons served.(26) The right not to be secluded or have physical restraint applied to the individual unless it has been prescribed by a physician, except in emergency situations. If physical restraint or seclusion is utilized, the reason for the medical order, the length of time restraint or seclusion has been ordered, and the behaviors necessary for the individual to be removed from restraint or seclusion shall be explained to the individual, and the restraint or seclusion shall be discontinued as soon as possible. Department facilities and community centers should reference Chapter 405, Subchapter F of this title (relating to Restraint and Seclusion in Mental Health Facilities) for more information regarding this right.(27) The right to fair compensation for labor performed for the department facility, community center, or psychiatric hospital in accordance with the Fair Labor Standards Act. Persons receiving services at department facilities and community centers have the right to be informed of the availability of employment opportunities at the department facility or in the community which may lead to competitive employment, as outlined in the Texas Health and Safety Code, §533.008 (§2.17A of the Texas Mental Health and Mental Retardation Act).(28) The right to be free from intrusive searches of person or possessions unless justified by clinical necessity, ordered by a physician, and witnessed. Any searches involving removal of any item of clothing shall be witnessed by an individual of the same sex as the person being searched and shall be conducted in a private area. Only physicians will perform body orifice searches.(29) The right to be transported to, from, and between department facilities (including community-based services), community centers, and psychiatric hospitals in a way that protects the dignity and safety of the individual. This includes:(A) the right of females to be transported or accompanied by a female attendant unless the individual is accompanied by her father, husband, adult brother, or adult son;(B) the right of all individuals not to be transported in a marked police or sheriff's car or accompanied by a uniformed officer unless other means are not available;(C) the right of all individuals not to transported with state prisoners;(D) the right of all individuals not to be physically restrained, unless necessary to protect the health and safety of the individual or of a person traveling with the individual, in which case procedures outlined in the Texas Health and Safety Code, §574.045, shall be followed; and(E) the right of all individuals to be provided reasonable opportunities to get food and water and use a bathroom.(30) The right to initiate a complaint. At department facilities and community centers, this includes the right to be informed of how to contact the facility or center rights protection officer (as outlined in §404.164 of this title (relating to Rights Protection Officer at Department Facilities and Community Centers)), the facility or center public responsibility committee, and the Office of Consumer Services and Rights Protection in central office (toll-free 1-800-252-8154, toll-free TDD 1-800-538-4870). At psychiatric hospitals, this includes the right to be informed of how to contact the Health Facility Licensure and Certification Division of the Texas Department of Health (toll-free 1-800-228-1570).(31) The right of any individual to make a complaint regarding denial of rights without any form of retaliation.(32) The right to have these rights and any additional rights explained aloud in a way the person served can understand within 24 hours of admission to services (refer to §404.163 of this title (relating to Communication of Rights to Individuals Receiving Mental Health Services)) and upon request. Persons admitted voluntarily have the right to have these rights and any additional rights explained aloud in a way the person served can understand prior to admission to services and upon request. Source Note: The provisions of this §320.7 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.7 Rights of All Individuals Receiving Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221374 03/12/2026 (a) Personal rights.(1) The following personal rights shall be provided to all persons receiving residential mental health services.(A) The right to communicate with persons outside the department facility, community center, or psychiatric hospital, in keeping with the general rules of the facility, including:(i) receiving visitors at reasonable times and places, allowing for as much privacy as possible;(ii) making phone calls at reasonable times, allowing for as much privacy as possible; and(iii) communicating by uncensored and sealed mail with others, except in the following situations:(I) When there is reason to suspect that the mail contains items such as illicit drugs or weapons which may present imminent risk of harm to the individual or others, the treating physician may authorize observing the opening of the mail by writing a specific order into the individual's chart explaining the potential harm, the reason for suspicion, and what mail is to be opened. The mail may then be opened by the individual in the presence of two members of the individual's treatment team. After inspecting the mail and removing any items which might present imminent risk of harm to the individual or others, the mail shall be given to the individual; those observing the opening of the mail may not read it.(II) If the individual is unable to open personal mail because of a physical limitation, a staff member may assist if documentation of the need for assistance is provided in the individual's record and if the individual requests or agrees to such assistance. An order authorizing this assistance must be signed by the treating physician and must be reviewed every seven days, except in the case of an individual with a chronic physical limitation, when the order may remain in effect until there is an improvement in the individual's condition. Other orders may be renewed as long as the condition exists. Staff members may offer to read mail to individuals unable to read because of illiteracy, blindness, or other reason, but staff members may not read the mail if the individual declines the offer.(III) Employees may observe the opening of packages received by individuals deemed not capable of protecting personal property. An order authorizing this limitation must be signed by the treating physician and must be reviewed every seven days, except in the case of an individual with a chronic limitation, when the order must be reviewed at least every 30 days. A diagnosis of mental illness or mental retardation is not in itself considered a chronic limitation. Any cash or articles received shall be recorded in the individual's record and placed in appropriate safekeeping accessible to the individual.(B) The right to keep and use personal possessions. This includes the right to wear one's own clothing and religious or other symbolic items. This right may be limited only if the use of the possession is determined by the treatment team to present imminent risk of harm, to present a security risk, or to prevent the individual from participating in the treatment plan. This includes the right to be free from searches of belongings except those searches based on reasonable belief that failure to search may present imminent risk of harm to the individual or others. A clinical justification must exist and be documented in the individual's record if access to or the use of any personal possession is limited or if a search of the individual's belongings is conducted.(C) The right to have an opportunity for physical exercise and for going outdoors, with or without supervision, as clinically indicated, at least daily. A physician's order limiting this right must be reviewed and renewed, if necessary, at intervals no longer than every three days and the findings of the review must be documented in the individual's record.(D) The right to have access, with or without supervision, as clinically indicated, to appropriate areas of the campus of the department facility, community MHMR center, or psychiatric hospital away from the individual's living unit, including, but not limited to, recreation and canteen/snack areas. The access should be available as frequently as the individual's clinical condition and schedule of therapeutic activities allow.(E) The right to have opportunities for suitable interactions with individuals of the opposite sex, with or without supervision, as appropriate for the individual.(2) For persons receiving inpatient services, the exercise of these rights may be limited by the treating physician only to the extent that the restriction is necessary to maintain the individual's physical and/or emotional well-being or to protect another person. If a restriction is imposed, the treating physician shall document the reasons for the restriction and the duration of the restriction in the individual's record. Unless otherwise specified, the written order must be reviewed within seven days, and if renewed, it must be renewed in writing at intervals no greater than every seven days. The treatment team should consider strategies to help the individual regain or resume the practice of the right.(A) A physician or physician's designee shall inform the individual of the clinical reasons for the restriction and its duration as soon as possible. The parent/conservator of a minor or the legal guardian of an individual, if applicable, shall also be informed of the restriction and its duration as appropriate.(B) The right to communicate with legal counsel, the department, the courts, or the state attorney general may not be restricted.(3) Except for the general rules of the program, there is no provision for limiting these rights for persons voluntarily admitted to a residential program other than an inpatient unit.(b) Additional rights. In addition to the rights outlined in subsection (a) of this section, persons receiving residential mental health services shall also have the following rights.(1) The right to have unrestricted visits from attorneys, internal advocates, representatives of Advocacy, Inc. with the consent of the person served, private physicians, or other mental health professionals at reasonable times and places. At department facilities, this right shall also include unrestricted visits from public responsibility committee members at reasonable times and places.(2) The right to be informed in writing and by any other means necessary for communication, at the time of admission to and discharge from inpatient services and upon request, of the existence and purpose of the protection and advocacy system in this state under the federal Protection and Advocacy for Mentally Ill Individuals Act of 1986 (Public Law 99-319). The notice must include the protection and advocacy system's telephone number and address. In Texas, the system is called Advocacy, Inc.(3) The right to wear suitable clothing which is neat, clean, and well-fitting. At department facilities and community centers, clothing will be obtained and provided for individuals not having such clothing.(4) The right to religious freedom. No person shall be forced to attend or engage in any religious activity.(5) The right to a timely consideration of a request for transfer to another room if another person in the room is unreasonably disturbing the individual, with the right to be informed of any reasons for any denial of such a request.(6) The right to receive appropriate treatment of any physical ailments essential to the treatment of a mental disorder and for a physical disorder arising in the course of an individual's inpatient psychiatric care. The manner in which these physical disorders are treated is the decision of the physician, consistent with good professional judgment. If the physician determines the procedures required for treatment to be elective rather than essential, the individual has the right to consult with a provider outside the facility for treatment at the individual's own expense.(7) The right of each adult individual admitted to an inpatient program to have the department facility, community center, or psychiatric hospital notify a person chosen by the individual of the admission if the individual grants permission. Documentation of the individual's granting or denial of that permission must be entered into the individual's clinical record. If such notification is refused upon admission, the individual served shall be reinformed of this right as the individual's condition changes.(8) The right of each adult individual admitted to an inpatient program to have the department facility, community center, or psychiatric hospital notify a person chosen by the individual prior to discharge or release if the individual grants permission. Documentation of the individual's granting or denial of that permission must be entered into the individual's clinical record.(9) The right of each adult individual admitted to an inpatient program to have the department facility, community center, or psychiatric hospital provide information about the right to make health care decisions and execute advance directives as allowed by state law.(10) Effective May 1, 1994, the right to written information, in the individual's primary language, if possible, about any prescription medications ordered by the treating physician. This information shall, at minimum, identify the major types of prescription medications; specify the conditions for which the medications are prescribed; identify the risks, side effects, and benefits associated with each type of medication; and include sources of detailed information about each particular medication. This right extends to the individual's family on request unless prohibited by state or federal confidentiality laws.(11) The right to receive, within four hours after the facility administrator or designee receives a written request, a list of the medications prescribed for administration to the individual while the individual is in the department facility, community center, or psychiatric hospital. The list must include the name, dosage, and administration schedule of each medication and the name of the physician who prescribed each medication. This right extends to a person designated by the individual and to the individual's legal guardian or managing conservator, if applicable. If sufficient time to prepare the list before discharge is not available, the list may be mailed within 24 hours after discharge to the individual or another appropriate, designated party.(A) If an individual informs a person associated with or employed by the department facility, community center, or psychiatric hospital of the individual's desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time.(B) Without regard to whether the individual agrees to sign the paperwork, the request will be documented and processed by staff.(12) The right to have a periodic review of the need for continued inpatient treatment. Source Note: The provisions of this §320.9 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.9 Rights of Individuals Receiving Residential Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221375 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221375 03/12/2026 In addition to the rights listed in §404.155 of this title (relating to Rights of Persons Receiving Residential Mental Health Services), persons receiving residential mental health services at department facilities have the following rights.(1) The right to be advised of the availability of trust fund accounts and other safekeeping for funds and articles of value. This right shall extend to the family of the person receiving services, who shall be informed of the existence of the trust fund as a means of protecting personal funds for the person served, and who shall be advised to send all monies, either checks or cash, to the cashier, and not to the individual or ward employees. Families shall be informed that the department facility is not responsible for funds mailed directly to the person served. The method of advising persons served and their families of this right is to be determined by each department facility.(2) The right of each individual admitted to an inpatient program of a department facility to have the state pay the cost of transportation home upon discharge or furlough unless the individual or someone responsible for the individual is able to do so.(3) The right of each individual admitted to an inpatient program of a department facility other than for substance abuse to be informed in writing at admission and upon discharge of the existence of the court monitor of the RAJ v. Jones settlement and to be informed of how to contact the monitor's office, the plaintiff's counsel, and organizations which provide free legal assistance. Source Note: The provisions of this §320.11 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.11 Additional Rights of Individuals Receiving Residential Mental Health Services at Health and Human Services Commission Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221381 03/12/2026 (a) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency or the person who requested admission on the individual's behalf have the right to request discharge. Any such person expressing a request for release shall be given an explanation of the process for requesting release and afforded the opportunity to request release in writing.(1) When a written request for release is presented to any direct care staff of the department facility, community center, or psychiatric hospital, it should be signed, dated, and timed by the individual or a person legally responsible for the individual.(2) If an individual informs a person associated with or employed by the department facility, community center, or psychiatric hospital of the individual's desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time. Without regard to whether the individual agrees to sign paperwork requesting discharge from services, the request will be documented and processed by staff. The refusal or inability of the individual to sign the request for discharge will be documented on the unsigned written request.(3) All written or prepared requests for discharge will be timed, dated, and signed by the staff member, who shall provide information to the individual that pursuant to law, during the ensuing period of up to 24 hours, the individual will be observed and evaluated to determine the clinical appropriateness of seeking an involuntary commitment to services. The form and format for requesting release and the information to be provided may be prescribed by the department.(b) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.(1) Each such person detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. All such persons have the right not to be detained beyond the completion of the in-person examination unless:(A) the person who filed the request for release files a written withdrawal of the request or asks a staff member to withdraw the request (the staff member must put the request in writing);(B) the person served, in the physician's clinical judgment, meets the criteria for involuntary commitment outlined in the Texas Health and Safety Code, §573.022, and an application for court-ordered mental health services, chemical-dependency services or emergency detention will be filed and an order obtained not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs and the individual is detained under the provisions of the relevant statute; or(C) the person receiving inpatient treatment for chemical dependency is a minor admitted with the consent of the parent, guardian, or conservator, and the individual who gave that consent objects in writing to the release of the minor after consultation with personnel of the department facility, community center, or psychiatric hospital.(2) If extremely hazardous weather conditions exist or a disaster occurs, the physician may request the judge of a court that has jurisdiction to extend the period under which the individual may be detained. The judge or a magistrate appointed by the judge may, by written order made each day, extend the period during which the individual may be detained until 4 p.m. on the first succeeding business day.(c) All persons voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right not to have an application for court-ordered mental health or chemical dependency services filed while receiving voluntary services unless, in the opinion of the physician responsible for the individual's treatment, the individual meets the criteria for court-ordered services as outlined in the Texas Health and Safety Code, §573.022, and either:(1) requests discharge;(2) is absent without authorization;(3) is unable to consent to appropriate and necessary psychiatric or chemical dependency treatment; or(4) refuses to consent to necessary and appropriate treatment recommended by the physician responsible for the individual's treatment and the physician completes a certificate of medical examination for medical illness that, in addition to the information required by the Texas Health and Safety Code, §574.011, includes the opinion of the physician that:(A) there is no reasonable alternative to the treatment recommended by the physician; and(B) the individual will not benefit from continued inpatient care without the recommended treatment.(d) Each of these persons has the right to be informed by the physician of the intent to file an application for court-ordered mental health services based on the criteria outlined in subsection (c) of this section.(e) Each of these person has the right to be free from threatening or coercive representations of actions that will result if the individual requests to leave a department facility, community center, or psychiatric hospital against medical advice, including representations that:(1) the individual will be subject to an involuntary commitment proceeding or subsequent emergency detention unless that representation is made by a physician or on the written instruction of a physician who has evaluated the individual within 48 hours prior to the representation;(2) the individual's insurance company will refuse to pay all or any portion of the medical expenses previously incurred; or(3) the person will be reported to an enforcement or regulatory agency (i.e., Department of Protective and Regulatory Services) merely because the person refuses to follow a treatment recommendation. However, this does not preclude reminding the individual of the consequences of requesting release as relate to any agreements the individual entered into as a condition of treatment, i.e., treatment as a condition of parole. Source Note: The provisions of this §320.13 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.13 Rights of Individuals Voluntarily Admitted to Inpatient Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221378 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221378 03/12/2026 The rights of each person apprehended and presented for emergency detention for inpatient mental health services at a department facility, community center, or psychiatric hospital are granted under the relevant sections of the Texas Mental Health Code (Texas Civil Statutes, Article 5547-1 et seq.).(1) Each person apprehended or detained, but not yet admitted, has the following rights.(A) The right to be advised of the location of detention, the reasons for detention, and that detention could result in a longer period of involuntary commitment.(B) The right to contact an attorney of the person's own choosing with opportunities to contact that attorney.(C) The right to be transferred back to the location of apprehension, or other suitable place, if not admitted for emergency detention, unless the person is arrested or objects to the return.(D) The right to be released if the head of the department facility, community center, or psychiatric hospital determines that any one of the criteria for emergency detention no longer applies.(E) The right to be informed that anything the person says to the personnel of the department facility, community center, or psychiatric hospital may be used in the proceeding for further detention.(F) The right to a preliminary examination by a physician conducted immediately upon arrival at the department facility, community center, or psychiatric hospital following apprehension to determine whether the person meets the criteria for admission for emergency detention. If a physician is not available to conduct the examination, steps shall immediately be taken to arrange for the examination as soon as possible, but in no case more than 24 hours after apprehension.(2) If the person is accepted for treatment on an emergency detention, the personnel of the department facility, community center, or psychiatric hospital shall immediately advise the person of the following rights.(A) The right not to be detained for more than 24 hours after the hour of initial detention unless an order for further detention is obtained, except that if the 24-hour period ends on a Saturday or Sunday or a legal holiday or before 4 p.m. on the first business day succeeding the Saturday, Sunday, or legal holiday, the period of detention shall end no later than 4 p.m. of the first succeeding business day. In the case of an extreme weather emergency or disaster, a judge may also extend the period of detention by written order for no more than 24 hours at a time.(B) The right to be released if the head of the department facility, community center, or psychiatric hospital determines that any one of the criteria for emergency detention, as outlined in the Texas Health and Safety Code, §573.022, no longer applies.(C) The right to be returned to the location of apprehension, place of residence, or other suitable place if released from emergency detention, unless the person is arrested or objects to the return.(D) The right to be informed that if a petition for court-ordered treatment is filed, the person is entitled to a judicial probable cause hearing no later than the 72nd hour after the hour of which detention begins under an order of protective custody except that if the 72-hour period ends on a Saturday or Sunday or a legal holiday, the hearing shall be held no later than the next day that is not a Saturday, Sunday, or legal holiday. In the case of an extreme weather emergency or disaster, a judge may also delay the hearing by written order for no more than 24 hours at a time.(E) The right to have an attorney appointed if the person does not have an attorney when application for court-ordered services is filed.(F) The right to communicate with the attorney at any reasonable time and to have assistance in contacting the attorney.(G) The right to present evidence and to cross-examine witnesses who testify on behalf of the petitioner at a hearing. Source Note: The provisions of this §320.15 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.15 Rights of Individuals Apprehended for Emergency Detention for Inpatient Mental Health Services Other Than for Substance Use https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221379 03/12/2026 The rights of each person apprehended and presented for emergency detention for inpatient chemical dependency services at a department facility, community center, or psychiatric hospital are granted under the relevant sections of the Texas Alcohol and Drug Abuse Services Act (Texas Civil Statutes, Article 5561c-2).(1) Each person apprehended or detained, but not yet admitted, for emergency detention has the following rights.(A) The right to be advised of the location of detention, the reasons for detention, and that detention could result in a longer period of involuntary commitment.(B) The right to contact an attorney of the person's own choosing with opportunities to contact that attorney.(C) The right to be transported back to the location of apprehension, or other suitable place, if not admitted for emergency detention, unless the person is arrested or objects to the return.(D) The right to be released if the head of the department facility, community center, or psychiatric hospital determines that any one of the criteria for emergency detention, as outlined in the Texas Health and Safety Code, §573.022, no longer applies.(E) The right to be informed that anything the person says to the personnel of the department facility, community center, or psychiatric hospital may be used in proceedings for further detention.(F) The right to have a preliminary examination by a physician conducted immediately upon arrival at the department facility, community center, or psychiatric hospital following apprehension to determine whether the person meets the criteria for admission for emergency detention. If a physician is not available to conduct the examination, steps shall immediately be taken to arrange for the examination as soon as possible, but in no case more than 24 hours after apprehension.(2) If a person is accepted for treatment on an emergency detention, the personnel of the department facility, community center, or psychiatric hospital shall immediately advise the person of the following rights.(A) The right not to be detained for more than 24 hours after the hour of initial detention unless an order for further detention is obtained, except that if the 24-hour period ends on a Saturday or a Sunday or legal holiday or before 4 p.m. on the first business day succeeding the Saturday, Sunday, or legal holiday, the period of detention shall end no later than 4 p.m. of the first succeeding business day. In the case of an extreme weather emergency or disaster, a judge may also delay the hearing by written order for no more than 24 hours at a time.(B) The right to be released if the head of the department facility, community center, or psychiatric hospital determines that the criteria for emergency detention, as outlined in the Texas Health and Safety Code, §573.022, no longer applies.(C) The right to be transferred back to the location of apprehension, or other suitable place, if released from emergency detention, unless the person is arrested or objects to the return.(D) The right to be informed that no later than the 24th hour after the hour of initial detention, the head of the department facility, community center, or psychiatric hospital may file a petition for court-ordered treatment, except that if the 24-hour period ends on a Saturday, Sunday, or legal holiday, the petition shall be filed no later than 4 p.m. of the first succeeding business day that is not a Saturday, Sunday, or legal holiday.(E) The right to be informed that if a petition for court-ordered treatment is filed, the person is entitled to a judicial probable cause hearing no later than the 72nd hour after the hour on which detention begins under an order of protective custody to determine whether the person should remain detained in the department facility, community center, or psychiatric hospital, except that if the period ends on Saturday, Sunday, or legal holiday, the hearing must be held no later than the next business day that is not a Saturday, Sunday, or legal holiday. In the case of an extreme weather emergency or disaster, a judge may also delay the hearing by written order for no more than 24 hours at a time.(F) The right to have an attorney appointed when application for court-ordered services is filed (if the person does not have an attorney).(G) The right to communicate with the attorney at any reasonable time and to have assistance in contacting the attorney.(H) The right to be informed that anything the person says to the personnel of the department facility, community center, or psychiatric hospital may be used in making a determination relating to detention, may result in the filing of a petition for court-ordered treatment, and may be used at a court hearing.(I) The right to present evidence and to cross-examine witnesses who testify on behalf of the petitioner at a hearing.(J) The right to refuse medication unless there is an imminent likelihood of serious physical injury to the person or others if the medication is refused.(K) The right to be informed that beginning on the 24th hour before a hearing for court-ordered treatment, the person may refuse to take medication unless the medication is necessary to save the person's life.(L) The right to request that a hearing be held in the county of which the person is a resident, if within the state. Source Note: The provisions of this §320.17 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.17 Rights of Individuals Apprehended for Emergency Detention for Inpatient Substance Use Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221380 03/12/2026 In addition to the applicable rights addressed in §404.154-404.159 of this title (relating to Rights of All Persons Receiving Mental Health Services; Rights of Persons Receiving Residential Mental Health Services; Additional Rights of Persons Receiving Residential Mental Health Services at Department; Rights of Persons Voluntarily Admitted to Inpatient Services; Rights of Persons Apprehended for Emergency Detention for Inpatient Mental Health Services (Other Than for Chemical Dependency); and Rights of Persons Apprehended for Emergency Detention for Inpatient Chemical Dependency Services), minors admitted to inpatient mental health services shall have the following rights.(1) The right to treatment by persons who have specialized education and training in the emotional, mental health, and chemical dependency problems and treatment of minors.(2) The right to receive inpatient services in an area separated from adults receiving services.(3) The right to regular communication with the individual's family. Other than in keeping with the general rules of the facility, this right may only be limited when the limitation is necessary to protect the individual's welfare in keeping with procedures outlined in §404.155(a)(2) of this title (relating to Rights of Persons Receiving Residential Mental Health Services). Source Note: The provisions of this §320.19 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.19 Special Rights of Minors Receiving Inpatient Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221383 03/12/2026 (a) The department will publish a rights handbook which will contain interpretations written in simple and nontechnical language of the various rights afforded individuals receiving mental health services, an explanation of the circumstances under which those rights may be limited, and an explanation of the appeals process. This handbook will be revised by the Office of Consumer Services and Rights Protection as necessary.(b) The department will publish a Teen's Bill of Rights and a Children's Bill of Rights ("The Little Dinosaur Named Wilbur," with supplementary material) which are adopted by reference as Exhibits B and C of this subchapter, respectively, with copies available from the Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668. The Teen's Bill of Rights and the Children's Bill of Rights will contain interpretations written in simple and nontechnical language of the rights afforded minors receiving mental health services, an explanation of the circumstances under which those rights may be limited, and organizations individuals may contact in the event of rights violations. The Teen's Bill of Rights and the Children's Bill of Rights will be revised as necessary.(1) The Teen's Bill of Rights is generally recommended for minors over the age of eight.(2) The Children's Bill of Rights is generally recommended for minors under the age of eight.(3) Notwithstanding these guidelines, staff should consider the developmental level of the minor being admitted in determining the appropriate document to be provided. Minors may also request and receive the rights handbook.(c) The handbook, Teen's Bill of Rights and/or Children's Bill of Rights, published by the department will be used as the formal document for rights notification for individuals admitted to department facilities, their community programs, and psychiatric hospitals operated by community centers. Community centers may distribute the handbook published by the department or may choose to publish their own version. Handbooks published by community centers must contain all rights outlined in the handbook published by the department and must be approved by the Office of Consumer Services and Rights Protection prior to their distribution.(d) Each handbook distributed must include the toll-free number of the Office of Consumer Services and Rights Protection (CSRP) in central office (1-800-252-8154), the toll free TDD number of CSRP (1-800-538-4870), the toll free number of Advocacy, Inc. (1-800-223-4206, both voice and TDD capabilities), the name, telephone number, and mailing address of the rights protection officer, and the mailing address of the public responsibility committee for the facility or community center which distributes it.(e) Immediately upon admission into services, each individual and the parent or conservator of a minor and the legal guardian of the person, when applicable, must be given the appropriate rights handbook. The parent, conservator, or legal guardian of a minor shall also receive a copy of the rights handbook in addition to the Teen's Bill of Rights and/or Children's Bill of Rights.(f) All handbooks must be printed in English and Spanish, and must be made available in any other language used by a significant percentage of the service area's population. Copies of the rights handbook must be displayed prominently at all times in all areas frequented by persons receiving services (e.g., day rooms, recreational rooms, waiting rooms, lobby areas). A sufficient number of copies will be kept on hand in each of these areas in order that a copy may be made readily available to anyone requesting one. The head of each department facility and community center shall appoint an individual responsible for ensuring that these requirements are met.(g) Nothing in this section shall preclude the use or distribution of additional brochures or materials outlining rights information provided the information does not conflict with information presented in the rights handbook. Source Note: The provisions of this §320.21 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.21 Rights Handbooks for Individuals Receiving Mental Health Services at Health and Human Services Commission Facilities, Community Centers, and Psychiatric Hospitals Operated by Community Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221384 03/12/2026 (a) The department will publish a Patient's Bill of Rights, which is herein adopted by reference as Exhibit A of this subchapter, with copies available from the Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668, which will contain interpretations written in simple and nontechnical language of the various rights afforded individuals receiving mental health services at psychiatric hospitals, an explanation of the circumstances under which those rights may be limited, and organizations individuals may contact in the event of rights violations. The Patient's Bill of Rights will be revised as necessary.(b) The department will publish a Teen's Bill of Rights and a Children's Bill of Rights ("The Little Dinosaur Named Wilbur," with supplementary material) which are adopted by reference as Exhibits B and C of this subchapter, respectively, with copies available from the Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668. The Teen's Bill of Rights and the Children's Bill of Rights will contain interpretations written in simple and nontechnical language of the rights afforded minors receiving mental health services at psychiatric hospitals, an explanation of the circumstances under which those rights may be limited, and organizations individuals may contact in the event of rights violations. The Teen's Bill of Rights and the Children's Bill of Rights will be revised as necessary.(c) The Patient's Bill of Rights, the Teen's Bill of Rights, and the Children's Bill of Rights published by the department will be used as the formal document for rights notification for individuals admitted to psychiatric hospitals which are not operated by community centers. At psychiatric hospitals operated by community centers, individuals admitted for services will receive the rights handbook as outlined in §404.161 of this title (relating to Rights Handbooks for Persons Receiving Mental Health Services at Facilities, Community Centers, and Psychiatric Hospitals Operated by Community Centers).(d) The Patient's Bill of Rights, the Teen's Bill of Rights, and the Children's Bill of Rights must be printed in English and Spanish, and must be made available in other languages of primary use by individuals admitted to each psychiatric hospital.(e) Immediately upon admission into services, each individual must be given the Patient's Bill of Rights, Teen's Bill of Rights, and/or Children's Bill of Rights.(1) A copy must also be given to the individual's parent or conservator of a minor and the legal guardian of the person, when applicable, and to any other person requested by the individual.(2) The parent/conservator of a minor shall receive a copy of the Patient's Bill of Rights in addition to the Teen's Bill of Rights and/or Children's Bill of Rights.(f) Copies of the Patient's Bill of Rights, Teen's Bill of Rights, and/or Children's Bill of Rights must be displayed prominently at all times in all areas frequented by persons receiving services (e.g., day rooms, recreational rooms, waiting rooms, lobby areas). A sufficient number of copies will be kept on hand in each of these areas in order that a copy may be made readily available to anyone requesting one.(g) Nothing in this section shall preclude the use or distribution of additional brochures or materials outlining rights information provided the information does not conflict with information presented in the rights handbook. Source Note: The provisions of this §320.23 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.23 Bill of Rights for Individuals Receiving Mental Health Services at Psychiatric Hospitals Not Operated by a Community Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221385 03/12/2026 (a) In addition to receiving a rights handbook, each newly admitted individual, the parent or conservator of a minor, and the guardian of the person shall be informed orally of all rights in his or her primary language using plain and simple terms within 24 hours of admission into services. Persons admitted for voluntary services shall be given this information prior to admission to services. The notification will also include an explanation of the circumstances under which those rights may be limited, and an explanation of how a complaint may be filed. This notification also must occur at least annually and upon any changes to this information. The method used to communicate the information should be designed for effective communication, tailored to meet each person's ability to comprehend, and responsive to any visual or hearing impairment.(b) Oral communication of rights shall be documented on a form bearing the date and signatures of the individual and/or the parent, conservator, or guardian, and the staff member who explained the rights. The form should be filed in the individual's chart. Psychiatric hospitals should use the form provided on the Patient's Bill of Rights. Department facilities should use the Receipt of Information Record (MHRS 9-1 Form). Community centers may use the MHRS 9-1 Form or a form of their own design which contains all of the applicable elements, so long as the form is used only for the documentation of communication of rights.(c) When the individual receiving services is unable or unwilling to sign the document which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness.(d) If the individual does not appear to understand the rights explanation, staff will attempt to provide another explanation periodically until understanding is reached or until discharge. The necessity for repeating the rights communication process will be documented, signed, and dated by staff. Source Note: The provisions of this §320.25 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.25 Communication of Rights to Individuals Receiving Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221386 03/12/2026 (a) The head of each department facility and each community center shall appoint a rights protection officer for the facility or center. The rights protection officer must be able to perform the duties of this office without any conflicts of interest.(b) The name, telephone number, and mailing address of the rights protection officer must be prominently posted in every program or residential area frequented by service recipients, including community outreach or contract programs. Individuals desiring to contact the rights protection officer must be allowed access to facility or center telephones to do so.(c) Duties required of the rights protection officer are specified at the discretion of the head of the facility or center, but must include the following:(1) receiving complaints/allegations of violations of rights, allegations of inadequate provision of services, and requests for advocacy from service recipients, their families, their friends, service providers, other facility or center personnel, other agencies, the general public, and the Office of Consumer Services and Rights Protection;(2) thoroughly investigating each such complaint received;(3) representing the expressed desires of the individuals served and advocating for the resolution of their grievances;(4) reporting the results of investigations and advocacy to service recipients and the complainants, consistent with the protection of the service recipients' right to have any identifying information remain confidential;(5) ensuring that the rights of individuals receiving services have been thoroughly explained to facility and center personnel through periodic training. The rights protection officer may provide the training directly or by consulting with facility or center training personnel; and(6) reviewing all policies, procedures, behavior therapy programs, and rules which affect the rights of persons receiving services. Source Note: The provisions of this §320.27 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.27 Rights Protection Officer at Health and Human Services Commission Facilities and Community Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221387 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221387 03/12/2026 This subchapter shall be thoroughly and periodically explained to all employees of each department facility, community center, and psychiatric hospital as follows.(1) All new employees shall receive the instruction on the content of this subchapter during their orientation training and prior to beginning work.(2) Within 60 days after the effective date of this subchapter, all current employees shall be briefed on its contents by the head of the department facility, community center, or psychiatric hospital or designee.(3) All supervisory personnel shall have a continuing responsibility to keep employees informed about rules governing rights of persons receiving mental health services and shall ensure that each employee receives training on the subject not less than once each calendar year. At department facilities and community centers, such training shall be reported to the department facility or community center's office for staff development. Psychiatric hospitals shall develop an appropriate means for maintaining training records.(4) A record shall be kept by the psychiatric hospital or the department facility or community center's office for staff development on each employee receiving orientation, annual training, or additional instruction in compliance with this section, including the date training was provided and the name of the individual conducting the training. Source Note: The provisions of this §320.29 adopted to be effective December 10, 1993, 18 TexReg 8790; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.29 Staff Training in Rights of Individuals Receiving Mental Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221382 03/12/2026 (a) Patients rights are guaranteed under the provisions of this subchapter. Although under special circumstances set out in this subchapter, certain rights can be limited without informed consent, it is usually mandatory and always preferable to obtain informed consent when limitation of rights is contemplated.(b) Except as otherwise noted in this subchapter, written informed consent must be obtained when a right guaranteed by law or department rule is limited.(1) The patient or legally authorized representative gives informed consent. Written informed consent is obtained from the:(A) adult individual, if legally competent and deemed to be capable of understanding the required elements which constitute informed consent;(B) guardian of the person of the adult individual if there has been a determination of mental incompetence by a court; or(C) parent or managing conservator of a minor under the age of 16.(2) Informed consent must be documented. Written informed consent is evidenced by a completed copy of the department's form for "Consent to Behavior Intervention," referenced as Exhibit A. Psychiatric hospitals and CSUs may use a different form provided that it includes all of the information included on the "Consent to Behavior Intervention" form.(3) Informed consent may be withdrawn at any time. If informed consent is withdrawn, the program must be discontinued immediately, and the treatment team must meet within three working days to modify the individual's treatment plan. Withdrawal of consent may be in any form including, but not limited to, passive noncompliance, active resistance, or a verbal or other expression of unwillingness to continue participating in any aspect of the program.(4) The limitation of the right or rights must be reviewed by the physician as appropriate but must occur at least on a monthly basis, unless otherwise specified.(5) Informed consent must be renewed. Written informed consent must be reviewed and renewed every six months.(c) Any limitation on rights is included as a part of the individual's comprehensive treatment plan. The treatment plan also includes a program that emphasizes positive approaches and uses positive behavioral interventions.(d) It is prohibited for limitation on rights to be used:(1) in retribution, as punishment, or as a means of controlling an individual by eliciting fear;(2) for the convenience of staff or as a consequence of insufficient staff;(3) as a substitute for a comprehensive treatment plan; or(4) in the absence of positive behavioral interventions.(e) Any limitation on rights will not:(1) deprive an individual of a basic human need (e.g., a bed at night, food, personal clothing, etc.) or the essentials of a normal hospital environment; or(2) alter the texture of a food item or use techniques that could result in failure to provide a nutritiously adequate diet. Foods used as edible reinforcers within a behavior intervention program are evaluated by the treatment team, including a qualified dietitian and physician, with consideration of the individual's nutritional status, needs, and preferences.(f) Additional approval required. Written informed consent must be obtained for behavior intervention programs using highly restrictive interventions. Additionally, the use of any procedures or programs employing aversive techniques, such as, but not limited to, faradic stimulation, require the unanimous documented written approval of the medical director of the facility, the CEO, and the Ethics Committee. Source Note: The provisions of this §320.31 adopted to be effective October 1, 1996, 21 TexReg 8505; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.31 Restriction of Rights as Part of Non-Emergency Behavioral Interventions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221371 03/12/2026 Restraint and seclusion shall be initiated, implemented, and monitored in keeping with the provisions of Chapter 405, Subchapter F of this title (relating to Voluntary and Involuntary Behavioral Interventions in Mental Health Programs). Source Note: The provisions of this §320.33 adopted to be effective October 1, 1996, 21 TexReg 8505; transferred effective November 29, 2024, as published in the November 1, 2024, issue of the Texas Register, 49 TexReg 8747. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS A RIGHTS OF INDIVIDUALS RECEIVING MENTAL HEALTH SERVICES §320.33 Restriction of Rights as Part of Emergency Behavioral Interventions: Restraint and Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223374 03/12/2026 The purpose of this subchapter is to provide procedures for obtaining consent for treatment with psychoactive medications from patients receiving voluntary or involuntary mental health services. Source Note: The provisions of this §320.51 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.51 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223375 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223375 03/12/2026 This subchapter applies to the following facilities providing inpatient mental health services:(1) a state hospital or state center operated by the Texas Department of Mental Health and Mental Retardation (TDMHMR);(2) a psychiatric hospital licensed under Texas Health and Safety Code (THSC), Chapter 577, and Chapter 134 of this title;(3) an identifiable mental health service unit of a hospital licensed under THSC, Chapter 241, and Chapter 133, Subchapter A of this title;(4) a crisis stabilization unit (CSU) licensed under THSC, Chapter 577, and Chapter 134 of this title; and(5) facilities operated by local mental health authorities or under contract to local mental health authorities Source Note: The provisions of this §320.53 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.53 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223378 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223378 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:(1) Capacity--A patient's ability to:(A) understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment; and(B) make a decision whether to undergo the proposed treatment.(2) Imminent--Ready to take place within seconds.(3) Informed consent--Consent given by a person or the person's legally authorized representative when each of the following conditions have been met:(A) Comprehension of information. The person giving the consent has been provided the information outlined in §320.404 of this title (relating to Information Required To Be Given) and has the capacity to give consent; and(B) Voluntariness. The consent has been given voluntarily.(4) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, who may be a parent, guardian, or managing conservator of a minor, the guardian of an adult, or the legal representative of a deceased individual.(5) Medication class--A group of medications with similar actions and indications for use, as outlined in the department's most recent "Classes of Psychoactive Medications Determined by the Texas Department of Mental Health and Mental Retardation." A copy of which may be obtained by contacting TDMHMR, Office of Office of the Medical Director, P.O. Box 12668, Austin, TX 78711-2668, or the TDMHMR website, www.mhmr.state.tx.us.(6) Mental health facility--A facility that can provide 24-hour residential and psychiatric services and that is:(A) a TDMHMR mental health facility that is a state hospital or state center operated by the Texas Department of Mental Health or Mental Retardation (TDMHMR);(B) a psychiatric hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title;(C) an identifiable mental health service unit of a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133, Subchapter A of this title;(D) a crisis stabilization unit (CSU) licensed under THSC, Chapter 577, and Chapter 134; or(E) a facility operated by a local mental health authority or under contract to a local mental health authority.(7) Minor--A person under 18 years of age who is not and has not been married or who has not had his or her disabilities of minority removed for general purposes.(8) Order for temporary or extended mental health services--A court-ordered commitment to mental health services Texas Health and Safety Code, §574.034 or §574.035.(9) Psychiatric emergency--A situation in which, in the opinion of the physician, it is immediately necessary to administer medication to ameliorate the signs and symptoms of a patient's mental illness and to prevent:(A) imminent probable death or substantial bodily harm to the patient because the patient:(i) is threatening or attempting to commit suicide or serious bodily harm; or(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or(B) imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits.(10) Psychoactive medication--Medication whose primary intended therapeutic effect is to treat or ameliorate the signs or symptoms of mental disorder, or to modify mood, affect, perception, or behavior, consistent with THSC, Chapter 574, Subchapter G, §574.101.(11) Refusal to consent to administration of psychoactive medication (refusal)--Actions which include the following behaviors:(A) The patient or legally authorized representative communicates orally, through sign language, or in writing that he or she refuses psychoactive medication.(B) The patient communicates through behavior that he or she refuses psychoactive medication, e.g., refusing to swallow oral medication or refusing to submit to hypodermic injection of psychoactive medication.(C) The patient pretends to swallow oral psychoactive medications, and the attending physician determines that the pretending behavior is due to an unwillingness to take the medication.(D) The patient gives either no response or a noncommittal response after he or she has received the standard risk-benefit explanation.(12) Service setting-An entity to which this subchapter applies, as described in §414.402 of this title, relating to Application, or a service site contracted to one of these entities.(13) TDMHMR mental health facility--A state hospital or state center operated by the Texas Department of Mental Health and Mental Retardation.(14) Ward--A person for whom a guardian has been appointed. Source Note: The provisions of this §320.55 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.55 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223379 03/12/2026 (a) The treating physician, registered nurse (RN), licensed vocational nurse (LVN), physician's assistant (PA), or registered pharmacist (RPh) will explain to the patient and to the patient's legally authorized representative, the information in paragraphs (1) - (10) of this subsection in simple, nontechnical language in the person's primary language, if possible. If the explanation is not provided by the treating physician, he or she must confirm the explanation with the patient and the patient's legally authorized representative, within two working days, not including weekends or legal holidays:(1) the nature of the patient's mental illness and condition;(2) the name of the medication and the beneficial effects on the patient's mental illness or condition expected as a result of treatment with that medication;(3) the probable health and mental health consequences to the patient of not taking the medication, including the occurrence, increase, or reoccurrence of symptoms of mental illness;(4) the existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication and why the physician rejects the alternative treatment;(5) a description of the proposed course of treatment with medication including any necessary evaluations and lab work;(6) the fact that side effects of varying degrees of severity are a risk of all medication;(7) the relevant side effects of the medication, including:(A) any side effects which are known to frequently occur in most persons;(B) any side effects to which the particular patient may be predisposed; and(C) the nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia;(8) the need to advise mental health facility staff immediately if any of these side effects occur;(9) an instruction that the patient may withdraw consent at any time without negative actions on the part of staff; and(10) the patient's rights under this section.(b) The patient and his or her LAR must also be provided a summary of this information in writing, along with an offer to answer any questions concerning the treatment. If the LAR is not present, the information must be mailed to the representative (via certified letter) within 24 hours, except on weekdays and legal holidays when the information will be mailed on the next business day. Source Note: The provisions of this §320.57 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.57 Information Required To Be Given https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223380 03/12/2026 (a) Informed medication consent must be obtained for each individual medication, not by medication class.(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR. A copy of which may be obtained by contacting TDMHMR, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668.(1) Any time the medication regimen is altered in a way that would result in a significant change in the risks or benefits for the patient, an explanation of the change will be provided to the patient and the patient's legally authorized representative. The explanation will include notification of the right to withdraw consent at any time.(2) A new consent will be obtained if a change to a different medication is prescribed.(c) If the patient or his or her LAR consents to the administration of psychoactive medication but refuses or is unable to execute the form, a witness to the consent will be obtained. The consent and its witnessing will be documented in the patient's medical record or on the MHRS 9-7 form (or other format including the same information) and placed in the medical record. The witness will confirm this consent by signing the consent form.(d) If the RN, LVN, PA, or RPh gives the initial explanation of the consent information to the patient, then the treating physician must confirm the explanation and the consent and sign the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays.(e) A patient's refusal or attempt to refuse to receive psychoactive medication, whether given verbally or by other indications or means, will be documented in the progress notes of the patient's clinical record or on the consent form (MHRS 9-7 form (or other format including the same information)).(f) An LAR's refusal to consent for the patient's treatment will be documented in the patient's medical record.(g) All consents will be reviewed with the patient and his or her legally authorized representative at least annually. The review will include a discussion of the information outlined in §414.404 of this title (relating to Information Required To Be Given) as well as a discussion of the patient and his or her legally authorized representative's wishes regarding continuation of the medication. Source Note: The provisions of this §320.59 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.59 Documentation of Informed Consent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223376 03/12/2026 (a) Psychoactive medications will not be administered to patients admitted to a mental health facility under the voluntary provisions of the Texas Health and Safety Code (THSC) or detained at a mental health facility under the THSC emergency detention or order of protective custody (OPC) provisions without informed consent from the patient or the patient's legally authorized representative unless the patient is in an psychiatric emergency and medication is administered as provided in §414.410 of this title (relating to Psychiatric Emergencies).(b) If an adult under a protective custody order as provided by THSC, Chapter 574, Subchapter B, is a ward, the guardian of the person of the ward may consent to the administration of psychoactive medication as prescribed by the ward's treating physician regardless of the ward's expressed preferences regarding treatment with psychoactive medication. Source Note: The provisions of this §320.61 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.61 Patients Admitted under Texas Statutes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223377 03/12/2026 Psychoactive medications will not be administered to patients committed to a mental health facility under an order for temporary or extended mental health services if the patient or the patient's legally authorized representative refuses the medication unless:(1) the patient is in a psychiatric emergency and medication is administered as provided in §414.410 of this title (relating to Psychiatric Emergencies);(2) the patient does not have a legally authorized representative and the administration of the medication, regardless of the patient's refusal, is authorized by an order as outlined in THSC §§574.101 - 574.110; or(3) the patient is a ward who is 18 years of age or older and the guardian of the person of the ward consents to the administration of psychoactive medication regardless of the ward's expressed preferences regarding treatment with psychoactive medication. Source Note: The provisions of this §320.63 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.63 Patients Committed to Mental Health Facilities under Provisions of the Texas Health and Safety Code https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223381 03/12/2026 (a) The decision to administer medication to a patient committed to a TDMHMR mental health facility under provisions other than THSC §574.034 or §574.035 must be is consistent with the holding in Sell v. United States, 123 S.Ct. 2174 (2003).(b) Nothing in this section is intended to preclude the administration of psychoactive medication to any patient in a psychiatric emergency as provided for in §414.410 of this title (relating to Psychiatric Emergencies). Source Note: The provisions of this §320.65 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.65 Patients Committed to Mental Health Facilities under Provisions Other than Those Found in the Texas Health and Safety Code (i.e., Code of Criminal Procedure, Family Code) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223382 03/12/2026 (a) The physician will order medications administered involuntarily under §414.407 of this title (relating to Patients Committed to Mental Health Facilities under Provisions of the Texas Health and Safety Code) or §414.411 of this title (relating to Order Authorizing Administration of Psychoactive Medication) to be given by the method most acceptable to the patient, if clinically appropriate.(b) The authority to administer a medication involuntarily to a patient under §414.407 or §414.411 of this title includes the authority to obtain evaluations and laboratory tests necessary to safely administer the medication. Source Note: The provisions of this §320.67 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.67 Involuntary Administration of Medication to Patients Committed to Mental Health Facilities under the Texas Health and Safety Code or by Court Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223383 03/12/2026 (a) Nothing in this subchapter is intended to preclude the administration of psychoactive medication to any patient in a psychiatric emergency.(b) If a physician issues an order to administer psychoactive medication to a patient without the patient's consent because of a psychiatric emergency, then the physician will document in the patient's clinical record in specific medical or behavioral terms:(1) why the order is necessary:(2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and(3) the reasons those treatments were rejected.(c) Treatment of the patient with the psychoactive medication will be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the patient's personal liberty.(d) A brief physical hold is not considered restraint for purposes of this subchapter provided that:(1) the individual currently exhibits behavior that meets the definition of psychiatric emergency as defined in this subchapter, or the individual is currently under a court order allowing the facility to administer medication without consent of the individual, the individual is refusing medication, and the medication ordered is permitted by the court order;(2) the purpose of administering medication is active treatment to reduce symptoms of a diagnosed mental illness;(3) using medication to reduce specified symptoms of a diagnosed mental illness is standard clinical practice;(4) the specific medication and dosage ordered can be clinically justified as in keeping with standard clinical practice and are appropriate for reduction of specified target symptoms; and(5) the physical hold is terminated as soon as the medication is administered.(e) When the psychiatric emergency is no longer imminent or present, medication prescribed without consent on an emergency basis must be safely discontinued. If continued use of medication is recommended on a regular basis, the physician must comply with provisions outlined in §414.406 of this title (relating to Patients Admitted Under Texas Statutes), §414.407 of this title (relating to Patients Committed to Mental Health Facilities Under Provisions of the Texas Health and Safety Code), or §414.408 of this title (relating to Patients Committed to Mental Health Facilities under Provisions Other than Those Found in the Texas Health and Safety Code (i.e., Code of Criminal Procedure, Family Code)), as appropriate.(f) In no case may inappropriate designation of a situation as a psychiatric emergency be used to circumvent the process of obtaining consent or applying to the court for an order authorizing administration of psychoactive medication. Source Note: The provisions of this §320.69 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.69 Psychiatric Emergencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223384 03/12/2026 (a) Filing of Petition. A physician who is treating a patient may petition a probate court or a court with probate jurisdiction for an order to authorize the administration of a class or classes of psychoactive medication regardless of the patient's refusal:(1) if the physician believes that the patient lacks the capacity to make a decision regarding the administration of the psychoactive medication;(2) if the physician determines that the medication is the proper course of treatment for the patient; and(3) if the patient is under an order for temporary or extended mental health services under THSC §574.034 or §574.035 and the patient, verbally or by other indication, refuses to take the medication voluntarily.(b) Hearing on petition. A hearing on a petition for an order to authorize the administration of psychoactive medication regardless of the patient's refusal will be held in accordance with provisions outlined in THSC §§576.104 - 574.106.(c) Issuance of order.(1) The court may issue an order authorizing the administration of one or more classes of psychoactive medication only if the court finds by clear and convincing evidence after the hearing that:(A) the patient lacks the capacity to make a decision regarding the administration of the proposed medication; and(B) treatment with the proposed medication is in the best interest of the patient.(2) In making its finding, the court shall consider:(A) the patient's expressed preferences regarding treatment with psychoactive medication;(B) the patient's religious beliefs;(C) the risks and benefits, from the perspective of the patient, of taking psychoactive medication;(D) the consequences to the patient if the psychoactive medication is not administered;(E) the prognosis for the patient if the patient is treated with psychoactive medication; and(F) alternatives to treatment with psychoactive medication.(3) An order entered under this subsection shall authorize the administration to a patient, regardless of the patient's refusal, of one or more classes of psychoactive medications specified in the petition and consistent with the patient's diagnosis. The order shall permit:(A) an increase or decrease in a medication's dosage;(B) reinstitution of medication authorized but discontinued during the period the order is valid; or(C) the substitution of a medication within the same medication class.(4) The issuance of an order authorizing administration of psychoactive medication is not a determination or adjudication of mental incompetency and does not limit in any other respect the patient's rights as a citizen or the patient's property rights or legal capacity.(d) Rights of patients.(1) A patient for whom an application for an order to authorize the administration of a psychoactive medication is filed is entitled to:(A) representation by a court-appointed attorney who is knowledgeable about issues to be adjudicated at the hearing;(B) meet with that attorney as soon as is practicable to prepare for the hearing and to discuss any of the patient's questions or concerns;(C) receive, immediately after the time of the hearing is set, a copy of the application and written notice of the time, place, and date of the hearing;(D) be told, at the time personal notice of the hearing is given, of the patient's right to a hearing and right to the assistance of an attorney to prepare for the hearing and to answer any questions or concerns;(E) be present at the hearing;(F) request from the court an independent expert; and(G) oral notification, at the conclusion of the hearing, of the court's determinations of the patient's capacity and best interests.(2) A patient may appeal an order under this subchapter in the manner provided by THSC §574.070 for appeal of an order requiring court-ordered mental health services. The order authorizing the administration of psychoactive medication remains effective pending the appeal.(e) Review and expiration of order.(1) An order authorizing the administration of psychoactive medication expires on the expiration or termination date of the order for temporary or extended mental health services in effect when the order for psychoactive medication is issued.(2) An order authorizing the administration of medication shall be reviewed by the court on an annual basis. Source Note: The provisions of this §320.71 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.71 Order Authorizing Administration of Psychoactive Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223385 03/12/2026 (a) TDMHMR will maintain an updated list of psychoactive medication classes to be used by the court. The list will be revised and distributed at least annually or more frequently as needed and will include the most common psychoactive medications. The list will be available from the Office of the Medical Director, TDMHMR, and on the TDMHMR website, www.mhmr.state.tx.us (Office of the Medical Director).(b) As provided by §414.411(c)(1) of this title (relating to Order Authorizing Administration of Psychoactive Medication), the court will only approve classes of medications unless the specific medication appears in the other category on the list or is not on the list and:(1) the medication is being used for a non-FDA approved indication; or(2) the medication is a recently FDA approved psychiatric medication. Source Note: The provisions of this §320.73 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.73 Designation of Medication Classes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223386 03/12/2026 (a) Each service setting will implement policies and procedures in accordance with this subchapter.(b) Self-monitoring of compliance will include the following components:(1) procedures to audit records for compliance;(2) procedures to analyze and report audit results to staff responsible for the informed consent process; and(3) procedures to improve the performance of individual employees, contractors, and agents, and to improve overall facility performance.(c) Each service setting will collect information related to obtaining consent to treatment with psychoactive medication and the use of psychoactive medication in psychiatric emergencies as may be required by the medical director of TDMHMR.(d) Each service setting will maintain a record of self-monitoring of compliance and may present these records to licensing or oversight authorities when requested. Source Note: The provisions of this §320.75 adopted to be effective August 31, 2004, 29 TexReg 8317; transferred effective December 27, 2024, as published in the November 29, 2024, issue of the Texas Register, 49 TexReg 9772. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS B CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION §320.75 Monitoring Compliance with Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222962 03/12/2026 The purpose of this subchapter is to reduce the use of restraint and seclusion as much as possible and to ensure that:(1) the least restrictive methods of intervention are used and that, wherever possible, alternatives are first attempted and determined ineffective; and(2) the rights and well-being of individuals are protected during the use of restraint or seclusion. Source Note: The provisions of this §320.101 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222958 03/12/2026 This subchapter applies to the following types of facilities:(1) a state hospital or a state center operated by the Department of State Health Services;(2) a psychiatric hospital licensed pursuant to Texas Health and Safety Code, Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities) to the extent and as provided by Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units);(3) a hospital that is licensed pursuant to Texas Health and Safety Code, Chapter 241 (relating to Hospitals) to the extent and as provided by Chapter 133 of this title (relating to Hospital Licensing), as follows:(A) an identifiable mental health services unit within the hospital; and(B) for all other areas within the hospital (including an emergency department), only to the extent that the requirements of this subchapter are consistent with, and not more stringent than, the requirements of the 42 CFR §482.13 (relating to Medicare Conditions of Participation); 42 CFR §489.20 (relating to Essentials of Provider Agreements); and §133.44 of this title (relating to Hospital Patient Transfer Policy).(4) a crisis stabilization unit licensed pursuant to Texas Health and Safety Code, Chapter 577 and Chapter 134 of this title;(5) the Waco Center for Youth;(6) a community mental health service provider governed by Chapter 412, Subchapter G of this title (relating to Mental Health Community Services Standards); and(7) the Texas Center for Infectious Disease, to the extent that mental health services are provided by that facility pursuant to its authority, under Texas Health and Safety Code, §13.004, to receive an individual who is mentally ill and who is infected with tuberculosis. Source Note: The provisions of this §320.103 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222959 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Advanced practice registered nurse or APRN--A registered nurse authorized by the Texas Board of Nursing to practice as an advanced practice registered nurse.(2) Behavioral emergency--A situation involving an individual who is behaving in a violent or self-destructive manner and in which preventive, de-escalative, or verbal techniques have been determined to be ineffective and it is immediately necessary to restrain or seclude the individual to prevent:(A) imminent probable death or substantial bodily harm to the individual because the individual is attempting to commit suicide or inflict serious bodily harm; or(B) imminent physical harm to others because of acts the individual commits.(3) Chemical restraint--The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition.(4) Chief executive officer (CEO)--The highest ranking administrator of a facility or such person's designee.(5) Clinical timeout--A procedure in which an individual, in response to verbal suggestion from a staff member, voluntarily enters and remains for a period of time in a designated area from which the individual is not prevented from leaving.(6) Competence--Demonstrated knowledge, skill, and ability.(7) Continuous face-to-face observation--An in-person line of sight that is maintained in an uninterrupted manner and is free of distraction.(8) Declaration for mental health treatment--A document making a statement of preferences or instructions for mental health treatment as set forth in Texas Civil Practice and Remedies Code, Chapter 137.(9) DSHS--The Department of State Health Services.(10) Emergency medical condition--A non-psychiatric medical condition manifesting itself by acute symptoms, including severe pain, of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or a threat to the health or safety of a pregnant woman or her unborn child.(11) Emergency medication--A psychoactive medication that is used to treat the signs and symptoms of mental illness in a psychiatric emergency, as that term is defined in Chapter 415, Subchapter A of this title (relating to Prescribing of Psychoactive Medication), when other interventions are ineffective or inappropriate.(12) Episode--The time period from the initiation of restraint or seclusion until the release of the individual.(13) Face-to-face--Describes a contact with an individual that occurs in person. Face-to-face does not include a contact made through the use of video or telecommunication conferencing or technologies, including telemedicine.(14) Facility--An entity to which this subchapter applies as identified in §415.252 of this title (relating to Application).(15) Individual--Any person receiving mental health services from a facility.(16) Initiate--The first overt act to restrain or seclude an individual.(17) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and who may include a parent, guardian, or managing conservator of a minor individual; guardian of the person of an adult individual; or person with activated power of attorney for health care decisions.(18) Mechanical restraint--Any device, material, or equipment that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely.(19) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities, and all services necessary to treat, care for, control, supervise, and rehabilitate persons who have a mental disorder or disability, including persons whose mental disorders or disabilities result from alcoholism or drug addiction.(20) Non-violent, non-self-destructive behavior--Behavior related to a non-psychiatric medical condition or symptom that indicates the need for an intervention to protect the individual from harm.(21) Personal restraint--Any manual method by which a person holds or otherwise bodily applies physical pressure that immobilizes or reduces the ability of the individual to move his or her body or a portion of his or her body.(22) Physician assistant--A person who is licensed under Texas Occupations Code, Chapter 204.(23) PRN--As needed (pro re nata).(24) Protective device--A device used to prevent injury or to permit wounds to heal.(25) Quiet time--A procedure in which an individual, on the individual's own initiative, enters and remains for a period of time in a designated area from which the individual is not prevented from leaving.(26) Registered nurse--A person who is licensed under Texas Occupations Code, Chapter 301, and who has demonstrated the clinical competencies required by this subchapter.(27) Restraint--The use of any personal restraint or mechanical restraint that immobilizes or reduces the ability of the individual to move his or her arms, legs, body, or head freely.(28) Seclusion--The involuntary separation of an individual from other individuals for any period of time and or the placement of the individual alone in an area from which the individual is prevented from leaving.(29) Seclusion room--A hazard-free room or other area in which direct observation of an individual can be maintained and from which the individual is prevented from leaving.(30) Serious injury--An injury determined by a physician to require medical treatment by a licensed medical professional (e.g., physician, osteopath, dentist, physician's assistant, or advance practice nurse), or requires medical treatment in an emergency department or licensed hospital.(31) Staff member--A person directly involved in an individual's care, including professionals who are credentialed and granted privileges by the facility, full-time and part-time employees, and contractors.(32) Supportive device--A device voluntarily used by an individual to posturally support the individual or to assist the individual who cannot obtain or maintain normal bodily functioning.(33) Treating physician--The physician assigned by the facility and designated in the individual's medical record as the physician responsible for the coordination and oversight of the implementation of an individual's comprehensive treatment plan and who is:(A) licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code, Chapter 155; or(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board.(34) Treatment team--A group of staff members, the individual, and LAR (if any) who work together in a coordinated manner for the purpose of providing comprehensive mental health services to an individual. Source Note: The provisions of this §320.105 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222960 03/12/2026 (a) Prohibition. Except as provided by this subchapter, the use of restraint or seclusion is prohibited.(b) Use of personal or mechanical restraint or seclusion. The use of personal or mechanical restraint or seclusion is permissible on the facility's premises, and personal or mechanical restraint is permissible for transportation of an individual only if implemented:(1) in accordance with this subchapter;(2) when less restrictive interventions (such as those listed in the safety plan if there is one) are determined ineffective to protect other individuals, the individual, staff members, or others from harm;(3) in accordance with, and using only those safe and appropriate techniques as determined by the facility's written policies or procedures and training program as specified in subsection (e) of this section;(4) by staff members who have been trained in accordance with the applicable requirements specified in §415.257 of this title (relating to Staff Member Training);(5) in connection with the applicable evaluation and monitoring requirements specified in §415.266 of this title (relating to Observation, Monitoring, and Care of the Individual in Restraint or Seclusion Initiated in Response to a Behavioral Emergency);(6) in accordance with the applicable initiation and physician order requirements specified in §415.260 of this title (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency);(7) in accordance with any alternative strategies and special considerations documented in the treatment plan pursuant to §415.259(c) of this title (relating to Special Considerations, Responsibilities, and Alternative Strategies);(8) when the type or technique of restraint or seclusion used is the least restrictive intervention that will be effective to protect the other individuals, the individual, staff members, or others from harm; and(9) is discontinued at the earliest possible time, regardless of the length of time identified in a physician's order.(c) Facility requirements. A facility's use of restraint and seclusion is prohibited unless:(1) the facility adopts, implements, and enforces written policies and procedures, in accordance with this subchapter, governing the use of restraint and seclusion;(2) the facility adopts, implements, and enforces a staff member training program that meets the requirements of §415.257 of this title; and(3) staff members of the facility are trained and have demonstrated competence in the use of restraint and seclusion in accordance with the facility's written policies and procedures and training program before assuming direct care duties and before performing restraint and seclusion on the individual.(d) Policy notification. Upon admission of an individual, or as soon as possible thereafter, the facility shall notify each individual and each individual's legally authorized representative (LAR), if any, of the facility's policies related to the use of restraint and seclusion. The policy notification may be a summary of the facility's policy. If an LAR cannot be notified, the facility shall document the reason in the individual's medical record.(e) This subchapter represents minimum standards. The facility may, through its written policies and procedures, adopt more stringent standards that are consistent with this subchapter and do not conflict with:(1) DSHS rules;(2) state or federal laws; and(3) applicable accreditation standards. Source Note: The provisions of this §320.107 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.107 General Requirements for Use of Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222961 03/12/2026 (a) The following practices are prohibited:(1) a personal or mechanical restraint shall not be used that:(A) obstructs the individual's airway, including a procedure that places anything in, on, or over the individual's mouth or nose;(B) impairs the individual's breathing, including applying pressure to the individual's torso or neck;(C) restricts circulation;(D) secures an individual to a stationary object while the individual is in a standing position;(E) causes pain to restrict an individual's movement (pressure points or joint locks); and(F) inhibits, reduces, or hinders the individual's ability to communicate; and(2) a chemical restraint.(b) A prone or supine hold shall not be used during a personal restraint. Should an individual become prone or supine during a restraint, then any staff member involved in administering the restraint shall immediately transition the individual to a side lying or other appropriate position.(c) Neither restraint nor seclusion shall be used:(1) as a means of discipline, retaliation, punishment, or coercion;(2) for the purpose of convenience of staff members or other individuals; or(3) as a substitute for effective treatment or habilitation.(d) The use of seclusion is prohibited except in a behavioral emergency. Source Note: The provisions of this §320.109 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.109 Prohibited and Restricted Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222964 03/12/2026 (a) If a facility's policies and procedures permit the use of mechanical restraint, only commercially available or DSHS-approved devices specifically designed for the safe and comfortable restraint of humans shall be used. Any alteration of commercially available devices or independent development of devices must:(1) be based on the individual's special physical needs, if any (e.g., obesity or physical impairment);(2) take into consideration any potential medical (including psychiatric) contraindications, including any history of physical or sexual abuse;(3) be approved by a committee whose membership and functions are specified in the bylaws of medical staff members of the facility; and(4) be described fully in writing, with a copy of the description and a photograph forwarded to the DSHS medical director for behavioral health for review. Such altered or independently developed device may not be used by the facility unless and until its use is approved, in writing, by the DSHS medical director for behavioral health.(b) A staff member shall inspect a device before and after each use to ensure that it is clean, in good repair, and is free from tears or protrusions that may cause injury. Damaged devices shall not be used to restrain an individual and shall be repaired or discarded.(c) Regardless of their commercial availability, the following types of devices shall not be used to implement a restraint:(1) those with metal wrist or ankle cuffs;(2) those with rubber bands, rope, cord, or padlocks or key locks as fastening devices;(3) long ties (e.g., leashes);(4) bed sheets;(5) gags;(6) spit hoods, or anything that obstructs an individual's airway, including a device that places anything in, on, or over the individual's mouth or nose; and(7) strait jackets.(d) Except as otherwise permitted in this subsection, all forms of restraint, as well as a form of restraint in conjunction with seclusion, are intended to be used independently of one another. The physician shall document the clinical justification in the individual's medical record for the simultaneous use of more than one mechanical restraint device, a mechanical restraint device and personal restraint, a mechanical restraint device and seclusion, or personal restraint and seclusion.(e) The following are approved mechanical restraint devices.(1) Anklets--Padded bands of cloth or leather that are secured around the individual's ankles or legs using hook-and-loop (e.g., Velcro®) or buckle fasteners and attached to a stationary object (e.g., bed or chair frame). The device shall not be secured so tightly as to interfere with circulation, or so loosely as to permit chafing of the skin.(2) Arm splints or elbow immobilizers--Strips of any material with padding that extend from below to above the elbow and which are secured around the arm with ties or hook-and-loop (e.g., Velcro®) tabs. If appropriate under the circumstances, they shall be secured so that the individual has full use of the hands. The device shall not be secured so tightly as to interfere with circulation, or so loosely as to permit chafing of the skin.(3) Belts--A cloth or leather band that is fastened around the waist and secured to a stationary object (e.g., chair frame) or used for securing the arms to the sides of the body. The device shall not be secured so tightly as to interfere with breathing or circulation.(4) Camisole--A sleeveless cloth jacket that covers the arms and upper trunk and is secured behind the individual's back. The device shall not be secured so tightly as to interfere with breathing or circulation or to cause muscle strain. Staff members shall exercise caution when using this device, if at all, because it may impair balance and the individual's ability to break a fall.(5) Chair restraint--A padded stabilized chair that supports all body parts and prevents the individual's voluntary egress from the chair without assistance (e.g., tabletop chair, Geri-chair). When wristlets or anklets are used to restrict movement from the chair, the devices must not be secured so tightly as to interfere with breathing or circulation.(6) Enclosed bed--A bed with high side rails or another type of side enclosure and, in some cases, an enclosure (e.g., mesh or rails) over the bed that prevents the individual's voluntary egress from the bed without assistance.(7) Helmet--A plastic, foam rubber, or leather head covering, such as a sports helmet, that may include an attached face guard but does not include a spit guard that interferes with breathing or obstructs the airway. The device shall be the proper size and the chinstrap shall not be so tight as to interfere with breathing or circulation.(8) Mittens--A cloth, plastic, foam rubber, or leather hand covering such as boxing and other types of sport gloves that are secured around the wrist or lower arm with elastic, hook-and-loop (e.g., Velcro®) tabs, ties, paper tape, pull strings, buttons, or snaps. The device shall not be secured so tightly as to interfere with circulation.(9) Restraining net--Mesh fabric that is placed over an individual's upper and lower trunk with the head, arms, and lower legs exposed; the net shall be secured over a mattress to a bed frame and shall never be placed over the individual's head. The restraining net shall be loose enough to allow some movement. The device shall not be secured so tightly as to interfere with breathing or circulation.(10) Restraint bed--A stretcher of steel frame construction with a fabric cover. The restraint bed shall have an adjustable backrest and a padded mat which shall be used under the individual's head and upper body to prevent injury. Approved wristlets, anklets, and belts shall be used to safely and securely limit the individual's physical activity.(11) Restraint board--A padded, rigid board to which an individual is secured face-up, unless that position is clinically contraindicated for that individual, in which case a clinically indicated position will be used and documented. This device shall not be used to restrain an individual in a behavioral emergency except when necessary to promptly transport an individual to another location.(12) Restraint chair or gurney--A chair or gurney manufactured for the purpose of transporting or restraining an individual.(13) Ties--A length of cloth or leather used to secure approved mechanical restraints (e.g., mittens, wristlets, arm splints, belts, anklets, vests) to a stationary object (e.g., bed or wheelchair frame) or to another approved mechanical restraint. Ties shall not be secured so tightly as to interfere with breathing or circulation.(14) Transport jacket--A heavy canvas sleeveless jacket that encases the arms and upper trunk, fastens with hook-and-loop (e.g., Velcro®) tabs and roller buckles, and is held in place with a strap between the legs. The device shall be used only as a temporary measure during transport.(15) Vest--A sleeveless cloth jacket that covers the upper trunk and is fastened in the back or front with ties or hook-and-loop tabs (e.g., Velcro®). The vest may be secured to a stationary object (e.g., bed or chair frame). The vest and ties shall not be secured so tightly as to interfere with breathing or circulation.(16) Wristlets--Padded cloth or leather bands that are secured around the individual's wrists or arms using hook-and-loop (e.g., Velcro®) or buckle fasteners and attached to a stationary object (e.g., bed frame, chair frame, or waist belt). The device shall not be secured so tightly as to interfere with circulation or so loosely as to permit chafing of the skin. Source Note: The provisions of this §320.111 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.111 Mechanical Restraint Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222965 03/12/2026 (a) The facilities to which this subchapter applies shall ensure that staff members are informed of their roles and responsibilities under this subchapter and are trained and demonstrate competence accordingly.(b) The training program shall be consistent with the requirements of this subchapter and shall:(1) target the specific needs of each patient population being served;(2) be tailored to the competency levels of the staff members being trained;(3) emphasize the importance of reducing and preventing the use of restraint and seclusion;(4) be evaluated annually, which shall include evaluation to ensure that the training program, as planned and as implemented, complies with the requirement of this section;(5) incorporate evidence-based best practices;(6) provide information about declarations for mental health treatment, including:(A) the right of individuals to execute declarations for mental health treatment; and(B) the duty of staff members and other health care providers to act in accordance with declarations for mental health treatment to the fullest extent possible.(c) Before assuming job duties involving direct care responsibilities, and at least annually thereafter, staff members other than physicians must receive training and demonstrate competence in at least the following knowledge and applied skills that shall be specific and appropriate to the population(s) the facility serves:(1) using team work, including team roles and techniques for facilitating team communication and cohesion;(2) identifying the causes of aggressive or threatening behaviors of individuals who need mental health services, including behavior that may be related to an individual's non-psychiatric medical condition;(3) identifying underlying cognitive functioning and medical, physical, and emotional conditions;(4) identifying medications and their potential effects;(5) identifying how age, weight, cognitive functioning, developmental level or functioning, gender, culture, ethnicity, and elements of trauma-informed care, including history of abuse or trauma and prior experience with restraint or seclusion, may influence behavioral emergencies and affect the individual's response to physical contact and behavioral interventions;(6) explaining how the psychological consequences of restraint or seclusion and the behavior of staff members can affect an individual's behavior, and how the behavior of individuals can affect a staff member;(7) applying knowledge and effective use of communication strategies and a range of early intervention, de-escalation, mediation, problem-solving, and other non-physical interventions, such as clinical timeout and quiet time; and(8) recognizing and appropriately responding to signs of physical distress in individuals who are restrained or secluded, including the risks of asphyxiation, aspiration, and trauma.(d) Before any staff member may initiate any restraint or seclusion the staff member shall receive training and demonstrate competence in:(1) safe and appropriate initiation and use of seclusion as a last resort in a behavioral emergency;(2) safe and appropriate initiation and application, and use of personal restraint as a last resort in a behavioral emergency;(3) safe and appropriate initiation and application, and use of mechanical restraint devices as a last resort in a behavioral emergency or as a protective or supportive device, and knowledge of the mechanical restraint devices permitted under §415.256 of this title (relating to Mechanical Restraint Devices) and approved by the facility; and(4) management of emergency medical conditions in accordance with the facility's policies and procedures and other applicable requirements for:(A) obtaining emergency medical assistance; and(B) obtaining training in and using techniques for cardiopulmonary respiration and removal of airway obstructions.(e) Before assuming job duties, and at least annually thereafter, a registered nurse or a physician assistant who is authorized to:(1) perform assessments of individuals who are in restraint or seclusion shall receive training, which shall include a demonstration of competence in:(A) monitoring cardiac and respiratory status and interpreting their relevance to the physical safety of the individual in restraint or seclusion;(B) recognizing and responding to nutritional and hydration needs;(C) checking circulation in, and range of motion of, the extremities;(D) providing for hygiene and elimination;(E) identifying and responding to physical and psychological status and comfort, including signs of distress;(F) assisting individuals in de-escalating, including through identification and removal of stimuli, that meet the criteria for a behavioral emergency if known;(G) recognizing when continuation of restraint or seclusion is no longer justified by a behavioral emergency; and(H) recognizing when to contact emergency medical services to evaluate and/or treat an individual for an emergency medical condition.(2) conduct evaluations of individuals, including face-to-face evaluations pursuant to §415.260(c) of this title (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency) of individuals who are in restraint or seclusion, shall receive training, which shall include a demonstration of competence in:(A) identifying restraints that are permitted by the facility, by this subchapter, and by other applicable law;(B) identifying stimuli that trigger behaviors;(C) identifying medical contraindications to restraint and seclusion;(D) recognizing psychological factors to be considered when using restraint and seclusion, such as sexual abuse, physical abuse, neglect, and trauma.(f) Before assuming job duties, and at least annually thereafter, staff members who are authorized to monitor, under the supervision of a registered nurse, individuals during restraint or seclusion shall receive training, which shall include a demonstration of competence in:(1) monitoring respiratory status;(2) recognizing nutritional and hydration needs;(3) checking circulation in, and range of motion of, the extremities;(4) providing for hygiene and elimination;(5) addressing physical and psychological status and comfort, including signs of distress;(6) assisting individuals in de-escalating, including through identification and removal of stimuli, if known.(7) recognizing when continuation of restraint or seclusion is no longer justified by a behavioral emergency; and(8) recognizing when to contact a registered nurse.(g) For physicians who may order restraint or seclusion, the facility's credentialing and privileging processes must require that such physicians:(1) demonstrate competency in ordering restraint or seclusion; and(2) receive training and refresher training in:(A) the use of alternatives to restraint or seclusion; and(B) how to reduce the physical and emotional harm caused by restraint or seclusion.(h) When a staff member's duties change, the facility shall reassess the staff member's training and competence and require and ensure the staff member's retraining, as required under this subchapter, based upon the facility's reassessment and the staff member's new duties.(i) The facility shall maintain documentation of training for each staff member. Documentation shall include the date that training was completed, the name of the instructor, a list of successfully demonstrated competencies, the date competencies were assessed, and the name of the person who assessed competence. Source Note: The provisions of this §320.113 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.113 Staff Member Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222963 03/12/2026 (a) Emergency medical condition. If an individual experiences an emergency medical condition while in restraint or seclusion, the staff member providing continuous face-to-face observation of the individual or other staff member must release the individual from restraint or seclusion as soon as possible, as indicated by the emergency medical condition, and the medical condition shall be assessed and treated.(1) The facility shall ensure that the individual's emergency medical condition is promptly addressed and that aid is rendered to the extent possible in accordance with the facility's policies and procedures for management of emergency medical conditions.(2) Unlocking the seclusion room door or fully releasing the restraints ends the episode.(3) If the situation continues to meet the criteria for a behavioral emergency after the individual's emergency medical condition is addressed, a staff member must obtain a new order for restraint or seclusion.(b) Emergency evacuation. If an emergency evacuation or evacuation drill occurs while an individual is in restraint or seclusion, the staff member providing continuous face-to-face observation of the individual or other staff member must release the individual from restraint or seclusion as soon as possible, as indicated by the circumstances that prompted the emergency evacuation or the evacuation drill, and staff members shall implement the facility's established procedures to ensure the individual's safety. Source Note: The provisions of this §320.115 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.115 Actions to be Taken to Release from Restraint or Seclusion for an Emergency Medical Condition or Evacuation Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222967 03/12/2026 (a) Special considerations. Before ordering restraint or seclusion, the physician shall take the following into consideration:(1) information about the individual that could contraindicate or otherwise affect the use of restraint or seclusion;(2) information obtained during the initial assessment of each individual at the time of admission or intake, including, but not limited to:(A) pre-existing medical conditions or any physical disabilities and limitations, including, without limitation, cognitive functioning, substance use disorders, obesity, or pregnancy, that would place the individual at greater risk during restraint or seclusion;(B) any history of sexual abuse, physical abuse, neglect, trauma, or previous restraint or seclusion that would place the individual at greater psychological risk during restraint or seclusion;(C) any history or trauma that would contraindicate seclusion, the type of restraint (personal or mechanical), or a particular type of restraint device for the individual;(D) cultural factors; and(E) information contained in a declaration for mental health treatment, if there is one.(b) Staff member responsibilities. Staff members shall:(1) respect and preserve the rights of an individual during restraint or seclusion. Rights of individuals are described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);(2) provide an environment that is protected and private from other individuals and that safeguards the personal dignity and well-being of an individual placed in restraint or seclusion;(3) ensure that undue physical discomfort, harm or pain to the individual does not occur when initiating or using restraint or seclusion;(4) use only the amount of physical force that is reasonable and necessary to implement a particular restraint or seclusion; and(5) use psychoactive medication in an emergency only in accordance with Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services). Physically holding an individual during a forced administration of a psychoactive medication, including for court-ordered medication, constitutes personal restraint.(c) Alternative strategies. The treatment team shall review and, when appropriate, implement and document alternative strategies for dealing with behaviors in each of the following circumstances:(1) in any case in which behaviors have necessitated the use of restraint or seclusion for the same individual more than two times during the individual's facility or program admission, or within any 30-day period, whichever period is shorter;(2) when two or more separate episodes of restraint or seclusion of any duration have occurred within the same 12 hour period; and(3) when an episode of restraint or seclusion has reached the maximum time permitted under §415.261(b) of this title (relating to Time Limitation on an Order for Restraint or Seclusion Initiated in Response to a Behavioral Emergency).(d) Treatment plan modification. If the circumstances described in subsection (c)(1) - (3) of this section recur or continue after treatment team review of alternative strategies under subsection (c) of this section, the treatment team shall consult with the facility's chief medical physician administrator or designee to explore alternative treatment strategies and a written modification of the individual's treatment plan. Source Note: The provisions of this §320.117 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.117 Special Considerations, Responsibilities, and Alternative Strategies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222968 03/12/2026 (a) Initiation.(1) Only staff authorized by the facility's policies and procedures and who have met the training requirements of §415.257 of this title (relating to Staff Member Training) and demonstrated competency in the facility's restraint and seclusion training program, may initiate personal restraint in a behavioral emergency.(2) Only a physician, registered nurse, or physician assistant in accordance with a physician's delegated authority, may initiate mechanical restraint or seclusion.(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion.(1) The physician's order for restraint or seclusion shall:(A) designate the specific intervention and procedures authorized, including any specific measures for ensuring the individual's safety, health, and well-being;(B) specify the date, time of day, and maximum length of time the intervention and procedures may be used, consistent with the time limitations provided for under §415.261 of this title (relating to Time Limitation on an Order for Restraint or Seclusion Initiated in Response to a Behavioral Emergency);(C) describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint or seclusion;(D) be signed and dated, including the time of the order, by the physician or the registered nurse who accepted the prescribing physician's telephone order.(2) If restraint or seclusion was ordered by telephone, the ordering physician shall personally sign and date the telephone order, including the time of the order, within 48 hours of the time the order was originally issued.(3) If the physician who ordered the intervention is not the treating physician, the physician ordering the intervention shall consult with the treating physician or physician designee as soon as possible. The physician who ordered the intervention shall document the consultation in the individual's medical record.(c) Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.(1) The face-to-face evaluation required by this subsection includes, but is not limited to, an assessment of the:(A) individual's immediate situation;(B) individual's reaction to the restraint or seclusion;(C) individual's medical and behavioral condition; and(D) need to continue or terminate the restraint or seclusion.(2) The Waco Center for Youth, a facility accredited as a residential treatment program, a physician or a registered nurse who is trained and has demonstrated competence to assess medical and psychiatric stability other than the registered nurse who initiated the use of restraint or seclusion shall conduct the face-to-face evaluation within two hours following the initiation of restraint or seclusion unless the individual is released prior to the expiration of the original order. If the individual is released prior to the expiration of the original order, the physician or registered nurse, shall conduct the face-to-face evaluation within 24 hours.(3) A physician may delegate the face-to-face evaluation to a physician assistant who is:(A) privileged to practice in the facility or that portion of the facility to which this subchapter applies; and(B) under the clinical supervision of a physician appointed by the facility's medical staff and privileged to practice in the facility or that portion of the facility.(4) If a physician assistant to whom the physician has delegated the face-to-face evaluation or a registered nurse who has conducted the face-to-face evaluation, in his or her professional judgment determines that the physician should evaluate the individual due to circumstances that are outside the physician assistant's or registered nurse's scope of practice or expertise, the physician assistant or registered nurse shall contact a physician and request that the physician perform a face-to-face evaluation of the individual. The physician assistant or registered nurse shall document the determination in the individual's medical record.(5) If the face-to-face evaluation is conducted by a registered nurse or physician assistant, the registered nurse or physician assistant shall consult the treating physician or physician designee who is responsible for the care of the individual as soon as possible after the completion of the one hour face-to-face evaluation and document the consultation in the individual's medical record. Source Note: The provisions of this §320.119 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.119 Initiation of Restraint or Seclusion in a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222969 03/12/2026 (a) Original order. A physician may order restraint or seclusion in response to a behavioral emergency for a period of time not to exceed:(1) 15 minutes for personal restraint;(2) one hour for mechanical restraint or seclusion for individuals under the age of 9;(3) two hours for mechanical restraint or seclusion for individuals ages 9 - 17; and(4) four hours for mechanical restraint or seclusion for individuals age 18 and older.(b) Order continuing use of restraint or seclusion. If the original order has not yet expired and the registered nurse has evaluated the individual face-to-face and determined the continuing existence of a behavioral emergency, the registered nurse must contact the physician. The physician shall conduct a face-to-face evaluation before issuing an order that continues the use of the restraint or seclusion. A physician may renew the original order provided it would not result in the use of:(1) personal restraint beyond 15 minutes total from the time of initiation of the original personal restraint;(2) mechanical restraint or seclusion beyond two hours total from the time of initiation of the original mechanical restraint or seclusion, for individuals under age 9;(3) mechanical restraint or seclusion beyond four hours total from the time of initiation of the original mechanical restraint or seclusion, for individuals ages 9 - 17; or(4) mechanical restraint or seclusion beyond eight hours total from the time of initiation of the original mechanical restraint or seclusion, for individuals age 18 and older.(c) Issuing and renewal documentation. The physician shall document the clinical justification for continuing the restraint or seclusion before issuing or renewing an order that continues the use of restraint or seclusion. Source Note: The provisions of this §320.121 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.121 Time Limitation on an Order for Restraint or Seclusion Initiated in Response to a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222966 03/12/2026 (a) The CEO or CEO's designee shall notify the individual's legally authorized representative if any, or authorized family member of each episode of restraint or seclusion initiated for the management of a behavioral emergency as follows:(1) except as provided by 42 Code of Federal Regulations, Part 2, and subsection (c) of this section, a staff member shall notify as soon as possible, but no later than 12 hours following the initiation of the restraint or seclusion, the legally authorized representative of a minor under age 18 who is not or has not been married; and(2) except as provided by subsection (c) of this section, in cases in which the adult individual has consented to have one or more specified family members informed regarding the individual's care, and the family member or members have agreed to be informed, a staff member will inform the family member or members of the restraint or seclusion episode within the time frame determined by prior agreement between the individual and specified family member(s).(b) The date and time of notification and the name of the staff member providing the notification must be documented in the individual's medical record. The documentation shall include any unsuccessful attempts, the phone number called, and the name(s) of person(s) with whom the staff member spoke.(c) As permitted by Texas Health and Safety Code, §611.0045(b), a professional may deny an individual's legally authorized representative access to any portion of an individual's record if the facility determines that the disclosure of such portion would be harmful to the individual's physical, mental, or emotional health. Source Note: The provisions of this §320.123 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.123 Family Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222970 03/12/2026 (a) The individual's right to retain personal possessions and personal articles of clothing may be suspended during mechanical restraint or seclusion when necessary to ensure the safety of the individual or others as described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services).(b) An inventory of any personal possessions or personal articles of clothing temporarily taken from the individual shall be listed in the individual's medical record. The inventory shall be witnessed by two staff members who shall sign or authenticate this list in individual's medical record. If personal articles of clothing are taken from the individual, appropriate other clothing shall be issued.(c) The items shall be kept in a locked place.(d) Upon release of the individual from a restraint, seclusion, or combination of the two, the individual, if willing, and two staff members shall be asked to sign documentation in the individual's medical record indicating the status of items returned and the date and time the items were returned.(e) If the individual is unwilling or unable to sign the documentation, a staff member shall document the refusal in the individual's medical record and list the items that were returned to the individual, the time they were returned, and the staff member who returned the items. Source Note: The provisions of this §320.125 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.125 Safekeeping of Personal Possessions During Mechanical Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222971 03/12/2026 (a) All off-premises transport. A registered nurse or physician assistant, as appropriate to the individual's clinical condition and the requirements of this subchapter, shall accompany the staff member(s) transporting an individual off premises when it has been clinically determined that during the time away from the facility the individual may require:(1) medical attention;(2) administration of medication; or(3) restraint.(b) Excursion off facility premises. A staff member may not restrain an individual being transported off facility premises unless the individual meets the criteria for a behavioral emergency, a physician orders the restraint, and transport is medically necessary with documented clinical justification.(1) If restraint is required while an individual is on an excursion off facility premises, the staff member initiating the restraint shall contact a registered nurse to assist in obtaining a physician's order for the restraint as soon as feasible within the applicable timeframes prescribed in this subchapter.(2) The staff members on the excursion shall implement, monitor, document, and report, in accordance with the requirements of this subchapter, any episode of restraint that occurs off premises.(c) Restraint initiated prior to transportation. A staff member may not restrain an individual being transported prior to departure unless the situation meets the criteria for a behavioral emergency or the individual has been determined and documented manifestly dangerous in accordance with Chapter 415, Subchapter G of this title (relating to Determination of Manifest Dangerousness) within one month prior to transportation, a physician orders the restraint, and transport is medically necessary with documented clinical justification.(1) If a behavioral emergency exists and a physician orders restraint prior to departure, at least one of the staff members accompanying the individual to the destination facility shall be a registered nurse.(2) A female staff member shall accompany a female individual.(3) If the duration of transport exceeds the maximum allowable duration of restraint on the original order, and a behavioral emergency continues to exist, or the person has been determined manifestly dangerous within one month prior to transportation, the registered nurse may either obtain a physician's telephone order to renew the restraint or obtain a new order for restraint, and renewal, as soon as feasible but within the applicable timeframes prescribed in this subchapter.(4) Staff members accompanying the individual from the originating facility shall implement, monitor, document, and report, in accordance with the requirements of this subchapter, a restraint that is ordered and implemented prior to transportation. If transportation is for the purposes of transfer to another facility, staff members at the originating facility must fax the required documentation to the destination facility on the day of transport. Staff members at the destination facility are responsible for filing the documentation in the individual's medical record at the destination facility.(d) Restraint initiated during transportation. If restraint is required following departure, a registered nurse shall obtain a physician's order from the originating facility for any restraint as soon as feasible within the applicable timeframes prescribed in this subchapter. If a registered nurse is not present during transportation, the staff member initiating any restraint shall contact a registered nurse to obtain a physician's order for the restraint as soon as possible within the applicable timeframes prescribed in this subchapter.(1) If an individual is restrained during transportation, the staff member accompanying the individual shall implement, monitor, document, and report the episode of restraint in accordance with the requirements of this subchapter, and shall ensure that all documentation required under this subchapter relating to the restraint, including the physician's order, is transmitted to the destination facility within 24 hours following the time the individual is delivered to the destination facility.(2) Staff members at the originating facility shall document and report restraint that is ordered and implemented during transportation. Staff members at the destination facility shall maintain documentation of the restraint at the destination facility.(e) Comfort during transportation. The staff members shall provide an individual in restraint during transport the care required under §415.266(c) of this title (relating to Observation, Monitoring, and Care of the Individual in Restraint or Seclusion Initiated in Response to a Behavioral Emergency). Source Note: The provisions of this §320.127 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.127 Restraint Off Facility Premises or for Transportation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222972 03/12/2026 (a) As soon as feasible after restraint or seclusion has been implemented in response to a behavioral emergency, the staff member shall refer to the individual's declaration for mental health treatment, if any, as a reference in determining and implementing an individual's preferences. The staff member shall communicate reassurance and commitment to the individual's safety on an ongoing basis, including inquiring as to how the staff member can assist the individual to de-escalate.(b) Communication with the individual shall be conducted in developmentally appropriate language and by a method that is understandable to the individual (e.g., American Sign Language, Spanish, Vietnamese) and that accommodates the individual's method of communication (e.g., releasing a hand of an individual who communicates using American Sign Language).(c) A staff member shall document in the individual's medical record all attempts to communicate with the individual and the individual's response to these attempts. Source Note: The provisions of this §320.129 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.129 Communicating with the Individual During Restraint or Seclusion Initiated in Response to a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222947 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222947 03/12/2026 (a) Observation.(1) A staff member of the same gender as the individual shall maintain continuous face-to-face observation of an individual in mechanical restraint, unless the individual's history or other factors indicate this would be contraindicated (e.g., sexual or physical abuse perpetrated by someone of the same gender, in which case a staff member of the opposite gender may be used).(2) A staff member who is not physically applying personal restraint shall maintain continuous face-to-face observation of an individual in personal restraint.(3) A staff member shall maintain continuous face-to-face observation of an individual in seclusion for at least one hour. After one hour, the staff member may monitor the individual continuously using simultaneous video and audio equipment in close proximity to the individual.(b) Monitoring. A staff member shall ensure adequate respiration and circulation of the individual in restraint at all times.(1) Respiratory status, circulation, and skin integrity must be monitored continuously and documented every 15 minutes (or more often if deemed necessary by the ordering physician). Cardiac status must be monitored and documented hourly (or more often if deemed necessary by the ordering physician).(2) An assigned staff member must perform range of motion exercises for each extremity, one extremity at a time, for at least five minutes no less frequently than every 60 minutes that an individual is in mechanical restraint.(c) Care. A staff member must provide for the hygiene, hydration, nutrition, elimination needs, and safety of an individual in restraint or seclusion. The individual in restraint or seclusion shall be provided:(1) bathroom privileges at least once every two hours (or more frequently, if requested and not contraindicated, or otherwise required by the individual's circumstances and physical or medical needs);(2) an opportunity to drink water or other appropriate liquids every two hours (or more frequently, if requested and not contraindicated, or otherwise required by the individual's circumstances and physical or medical needs);(3) an opportunity to bathe at least once daily (or more frequently, if clinically indicated or in the presence of incontinence);(4) medications and medical equipment as ordered;(5) regularly scheduled meals and snacks served on dishes that are appropriate for safety; and(6) an environment that is free of safety hazards, adequately ventilated during warm weather, adequately heated during cold weather, and appropriately lighted. Source Note: The provisions of this §320.131 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.131 Observation, Monitoring, and Care of the Individual in Restraint or Seclusion Initiated in Response to a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222948 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222948 03/12/2026 (a) A facility shall ensure that:(1) when personal restraint is used, staff members act to protect the individual's privacy as much as possible without compromising the safety of individuals or staff members during the episode;(2) if the individual does not calm and mechanical restraint is required, the individual is moved to a protected environment observable by other staff members and away from other individuals as soon as possible;(3) when a mechanical restraint is used, the individual has a protected environment that is observable by other staff members and is away from other individuals that safeguards the individual's personal dignity and well-being;(4) the individual is protected (e.g., from assault by others) while in restraint or seclusion; and(5) the facility uses a seclusion room, as defined in §415.253 of this title (relating to Definitions), for any individual placed in seclusion.(b) A facility shall develop and implement policies and procedures to ensure that it is in compliance with the requirements of this section. Source Note: The provisions of this §320.133 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.133 Safe and Appropriate Techniques for Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222949 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222949 03/12/2026 (a) If the individual appears to fall asleep while in mechanical restraint or seclusion, the registered nurse shall assess the individual to determine if the individual is asleep.(b) If the individual is determined to be asleep, the registered nurse shall instruct an authorized staff member to immediately release the individual from restraint or unlock the seclusion room door. Authorized staff members shall maintain continuous face-to-face observation until the individual is awake and re-evaluated by the registered nurse.(c) The registered nurse shall assess the individual upon awakening.(d) If the individual exhibits behaviors requiring restraint or seclusion upon awakening, the registered nurse shall obtain a new physician's order for any new initiation of restraint or seclusion. Source Note: The provisions of this §320.135 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.135 Actions to be Taken when an Individual Falls Asleep in Restraint or Seclusion Initiated in Response to a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222950 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222950 03/12/2026 (a) At the time of transfer of primary responsibility between staff members for the individual in restraint or seclusion, including transfer of responsibility at the change of shift, the staff member with primary responsibility must meet with the staff member who will assume primary responsibility to review the individual's status. A staff member shall monitor the individual during the transfer process.(b) The review shall be documented and shall include:(1) information regarding the time a restraint or seclusion was initiated;(2) the nature of the circumstances requiring restraint or seclusion;(3) the current status of the individual's physical, emotional, and behavioral condition;(4) any medication administered; and(5) the type of care needed. Source Note: The provisions of this §320.137 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.137 Transfer of Primary Responsibility for Individual in Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222951 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222951 03/12/2026 (a) Personal restraint. When a personal restraint has been initiated by a staff member, but the individual has not yet been evaluated by a physician, a physician's assistant, or a registered nurse, and the staff member determines that the individual's behavior has changed sufficiently to no longer require the personal restraint, the staff member must immediately release the individual from the restraint but shall remain with the individual until a physician, physician's assistant, or registered nurse has evaluated the individual for release based on a determination that the individual no longer requires the restraint or seclusion.(b) Mechanical restraint or seclusion. When a mechanical restraint or seclusion has been initiated, and the unsafe situation ends, a staff member shall contact a physician, a physician's assistant, or a registered nurse. The physician, physician's assistant, or registered nurse must evaluate the individual for release based on a determination as to whether the unsafe situation has resolved. A staff member must immediately release an individual whose behavior has been evaluated by a physician, physician's assistant, or registered nurse and determined to no longer require the restraint or seclusion. Source Note: The provisions of this §320.139 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.139 Release of an Individual From Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222952 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222952 03/12/2026 (a) Immediately following the release of an individual from restraint or seclusion, a staff member shall:(1) take action, if appropriate, to facilitate the individual's reentry into the social milieu by providing the individual with transition activities and an opportunity to return to ongoing activities;(2) observe the individual for at least 15 minutes; and(3) document in the individual's medical record the steps taken and observations made of the individual's behavior during this transition period.(b) The facility shall conduct or attempt to conduct debriefings based on the following:(1) identify what led to the episode and what could have been handled differently;(2) identify strategies to prevent future restraint or seclusion of the individual, taking into consideration suggestions from the individual and the individual's declaration for mental health treatment, if any;(3) ascertain whether the individual's physical well-being, psychological comfort, including trauma, and right to privacy were protected or otherwise addressed, as applicable;(4) counsel the individual(s) in relation to any trauma that may have resulted from the episode; and(5) when indicated, make appropriate modifications to the individual's treatment plan and/or the treatment plans of other individuals.(c) Following an episode of restraint or seclusion, the facility shall conduct, or attempt to conduct, the following debriefings.(1) Staff members who were involved in the episode, other staff members who the facility determine are appropriate, and supervisors shall debrief together as a support mechanism and to identify successes, problems, or necessary modifications as soon after the episode as is practicable in light of facility operations.(2) When clinically indicated and at a time when the individual has cognitive capacity to understand what could have been done differently to avoid restraint or seclusion, a staff member or members shall conduct a private discussion with the individual, the individual's LAR, if practicable, and family members, if clinically appropriate and available, with the consent of the individual.(3) If the episode was a restraint, when clinically indicated or upon request of individuals who witnessed the restraint, a staff member or members shall have a private discussion with individuals who witnessed the restraint.(d) If an individual has been discharged from the facility, does not have the cognitive capacity to understand what he or she could have done differently to avoid restraint or seclusion, where clinically inappropriate, or where not requested pursuant to subsection (c)(3) of this section, the facility does not need to attempt the debriefings described in subsection (c)(2) and (3) of this section. The facility shall document in the individual's medical record the reason for not conducting the debriefing described in subsection (c)(2) of this section.(e) Any debriefings conducted under subsection (c)(2) or (3) of this section shall be documented in the individual's medical record in a timely manner. Any debriefing conducted pursuant to subsection (c)(1) of this section shall be documented in accordance with facility policy. If debriefing is not conducted, the reasons for not completing the debriefing shall be documented in the individual's medical record. Source Note: The provisions of this §320.141 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.141 Actions to be Taken Following Release of an Individual from Restraint or Seclusion Initiated in Response to a Behavioral Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222953 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222953 03/12/2026 (a) Facility documentation. The facility shall document the assessment, monitoring, and evaluation of an individual in restraint or seclusion on a facility approved form. Documentation in an individual's medical record shall include:(1) the date and time the intervention began and ended;(2) the name, title, and credentials of any staff members present at the initiation of the intervention, with identification of the staff member's role in the intervention, including as an observer, or status as an uninvolved witness, as applicable;(3) the name of the individual restrained or secluded and the type of restraint or seclusion used;(4) the time and results of any assessments, observation, monitoring, and evaluations, including those required under this subchapter, and attention given to personal needs;(5) the physician's documentation of the order authorizing restraint or seclusion in accordance with the requirements of §415.260 of this title (relating to Initiation of Restraint or Seclusion in a Behavioral Emergency);(6) any specific alternatives and less restrictive interventions, including preventive or de-escalatory interventions that were attempted by any staff member prior to the initiation of restraint or seclusion, and the individual's response to any such intervention;(7) the individual's response to the use of restraint or seclusion; and(8) other documentation relating to an episode of restraint or seclusion otherwise required under this subchapter.(b) Report to CEO. Staff members shall report daily to the facility CEO or designee any use of a restraint or seclusion.(1) The CEO or designee shall take appropriate action to identify and correct unusual or unwarranted utilization patterns on a systemic basis, and shall address each specific use of restraint or seclusion that is determined or suspected of being improper at the time it occurs.(2) The CEO or designee shall maintain a central file containing the following information:(A) age, gender, and race of the individual;(B) deaths or injuries to the individual or staff members;(C) length of time the restraint or seclusion was used;(D) types and dosage of emergency medications administered during the restraint or seclusion, if any;(E) type of intervention, including each type of restraint used;(F) name of staff members who were present for the initiation of the restraint or seclusion; and(G) date, day of the week, and time the intervention was initiated.(c) Additional reporting in the case of death or serious injury. By the next business day following an individual's death or serious injury, facilities shall report the following information to the appropriate entity designated in subsection (d) of this section.(1) Each death or serious injury that occurs while an individual is in restraint or seclusion;(2) Each death that occurs within 24 hours after the individual has been removed from restraint or seclusion; and(3) Each death known to the facility that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a individual's death. "Reasonable to assume" in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.(d) Reporting deaths or serious injury. Facilities shall report the deaths or serious injuries of individuals in restraint or seclusion as follows.(1) Medicare- or Medicaid-certified facilities shall report a death to the appropriate office for the Center for Medicare and Medicaid Services in accordance with the federal death reporting requirements relating to restraint and seclusion.(2) Facilities that are neither Medicare- nor Medicaid-certified shall report a death or serious injury to DSHS's medical director for behavioral health.(3) In addition to reporting in accordance with paragraphs (1) and (2) of this subsection, all facilities licensed under Chapter 133 of this title (relating to Hospital Licensing) or Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units) shall report a death or serious injury to the Patient Quality Care Unit of DSHS's Division for Regulatory Services.(4) Facilities shall comply with any additional reporting requirements relating to restraint or seclusion to which they are subject, including any applicable reporting requirements under The Children's Health Act of 2000 and federal regulations promulgated pursuant to the Act.(e) Facility review of data. The facility shall review and analyze, at least quarterly, the data that is required by subsection (b)(2) of this section to identify and correct trends and patterns that may contribute to the use of restraint or seclusion (e.g., disproportionate use of restraint or seclusion with specific populations or shifts).(f) Continuous improvement. The facility shall use the data continuously to improve and ensure:(1) a positive environment that minimizes the use of an involuntary intervention;(2) the safety of every individual and staff member;(3) the use of restraint and seclusion is implemented in accordance with the requirements of this subchapter;(4) that the risks of injury and other negative effects to individuals and staff members are reduced; and(5) that policies and training curriculum incorporate the requirements of this subchapter.(g) On or before November 1, 2014, and quarterly thereafter, any facility that is a Medicare or Medicaid provider shall submit to DSHS the data required by Centers for Medicare and Medicaid Services for hospital-based inpatient psychiatric service measures related to the use of restraint or seclusion.(h) On or before November 1, 2015, and quarterly thereafter, a facility to which this subchapter applies shall prepare and submit to DSHS a report, consistent with the Department of State Health Services Behavioral Interventions Reporting Guidelines (guidelines) available at: http://www.dshs.state.tx.us/Licensing-Facilities.shtm, of the following data from the immediately preceding quarter:(1) interventions used during a behavioral emergency, including:(A) rate of seclusions (per 1,000 bed days);(B) rate of personal restraints (per 1,000 bed days);(C) rate of mechanical restraints (per 1,000 bed days); and(D) rate of emergency medication orders (per 1,000 bed days).(2) number of serious injuries related to an intervention used in a behavioral emergency.(3) number of deaths related to an intervention used in a behavioral emergency.(4) de-escalation techniques--description of all de-escalation techniques commonly used by the facility in connection with any of the emergency interventions described in paragraph (1) of this subsection. Source Note: The provisions of this §320.143 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.143 Documenting, Reporting, and Analyzing Restraint or Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222954 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222954 03/12/2026 (a) If an assessment reveals non-violent, non-self-destructive behavior, as defined in §415.253 of this title (relating to Definitions), the facility shall use the least restrictive intervention that effectively protects the individual from harm. If the intervention is a restraint as defined in this subchapter, it shall only be used in the following circumstances:(1) medically necessary;(2) ordered by a physician;(3) needed to ensure the individual's safety; and(4) used only after less restrictive interventions have been considered, or attempted and determined to be ineffective, or are judged to be unlikely to protect the individual or others from harm.(b) Prior to the application of a restraint for the management of non-violent, non-self-destructive behavior, an assessment of the individual shall be done to determine that the risks associated with the use of the restraint are outweighed by the risks of not using it.(c) The physician's order for the restraint shall specify:(1) a time limit on the use of the restraint;(2) any special considerations for the use of restraint;(3) the specific type of restraint to be used;(4) who is responsible for implementing the restraint; and(5) instructions for monitoring the individual.(d) The physician shall renew the order as frequently as determined by facility policy.(e) The order for the restraint shall be followed by consultation with the individual's treating physician if the restraint was not ordered by the individual's treating physician. The consultation shall be documented in the individual's medical record no later than the next business day, except that it shall be done sooner, when an earlier consultation is clinically indicated.(f) The care of the individual shall be based on a rationale that reflects consideration of the individual's medical needs and health status.(1) If the facility has made a clinical determination that its use of restraint for the management of non-violent, non-self-destructive behavior requires a frequency of assessment or an aspect of care or treatment that differs from the provisions of this subchapter governing restraint in a behavioral emergency, facility policies and procedures on the use of restraint for the management of non-violent, non-self-destructive behavior shall address:(A) the facility's required frequency of assessment of the individual during restraint; and(B) how the individual's circulation, hydration, elimination, level of distress and agitation, mental status, cognitive functioning, cardiac functioning, skin integrity, nutrition, exercise, and range of motion of extremities are to be assessed and addressed during restraint.(2) The plan for monitoring the individual and the rationale for the frequency of monitoring shall be documented in the individual's medical record.(g) A dentist at a facility, including any contractor providing dental services on the facility premises shall not restrain an individual for dental care or rehabilitation unless the restraint is ordered by the individual's physician. The dentist shall maintain a copy of the order in the individual's medical record and shall ensure compliance with the requirements of the order.(h) Whenever a restraint is ordered by a physician, the ordering physician shall prescribe the frequency of assessment required for the individual during restraint and how the individual's circulation, hydration, elimination needs, level of distress and agitation, mental status, cognitive functioning, cardiac functioning, skin integrity, nutrition, exercise, and range of motion of extremities are to be assessed and addressed during restraint. Source Note: The provisions of this §320.145 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.145 Use of Restraint in Situations Involving Non-violent, Non-self-destructive Behavior https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222955 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222955 03/12/2026 (a) Escort or brief physical prompt. An individual may be assisted to move from one location to another when guidance is needed if the individual agrees verbally or with gestures and is able to cooperate with the staff member who is attempting to assist the individual to move.(b) Activities of daily living. A staff member may assist an individual who is willing and able to cooperate with toileting, bathing, dressing, eating, or other personal hygiene activities that normally involve the use of touch.(c) Immediate danger of harm. A staff member may escort, prompt, or move an individual who is unable to respond in the affirmative or negative or is unable to move due to his or her psychiatric or medical condition if there is an imminent danger of harm to the individual because of a circumstance in the individual's immediate environment.(d) Immobilization during medical, dental, diagnostic, or surgical procedure. A positioning or securing device used to maintain the position of, limit mobility of, or temporarily immobilize an individual, with the individual's consent, during medical, dental, diagnostic, or surgical procedures and that is a standard part of the procedure is not considered a restraint. The care of the individual shall be based on a rationale that reflects consideration of the individual's medical needs and health status.(1) Facility policies and procedures on the use of immobilization during medical, dental, diagnostic and surgical procedures shall address:(A) the frequency of assessment of the individual during immobilization; and(B) how the individual's circulation, hydration, elimination needs, level of distress and agitation, mental status, cognitive functioning, cardiac functioning, skin integrity, nutrition, exercise, and range of motion of extremities are to be assessed during immobilization.(2) The plan for monitoring the individual and the rationale for the frequency of monitoring shall be documented in the individual's medical record. Source Note: The provisions of this §320.147 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.147 Permitted Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222956 03/12/2026 (a) The facility shall develop, implement, and enforce policies and procedures that address the use of clinical timeout and quiet time as preventive and de-escalating interventions to prevent a behavioral emergency from occurring and to alleviate or otherwise reduce the necessity for any use of restraint or seclusion.(b) The policies and procedures shall include the following requirements.(1) Clinical timeout. A staff member may suggest that an individual initiate clinical timeout.(A) Prior to clinical timeout, the staff member suggesting that an individual initiate clinical timeout shall explain to the individual that clinical timeout is voluntary.(B) Each time an individual uses clinical timeout, a staff member shall document that use in the individual's medical record.(C) The facility's documentation of any use of clinical timeout shall include a description of the conditions under which the clinical timeout was suggested and the individual's response to the suggestion.(D) A decision by the individual to decline to begin, or remain in, clinical timeout or similar interventions may not result in the staff member's use of restraint or seclusion of the individual, unless the initiation and use of the restraint or seclusion is permitted under, and otherwise meets the requirements of, this subchapter. To physically force or use personal restraint or coercion to direct the individual to a clinical timeout areas or to prevent an individual from leaving an area separated from other individuals receiving services, constitutes a restraint and/or seclusion and renders the procedure subject to the requirements for restraint or seclusion, as applicable, described in this subchapter.(2) Quiet time. An individual may request the use of quiet time and, unless clinically contraindicated, be granted quiet time.(A) Under no circumstances may a staff member mandate quiet time for an individual. If a staff member does so, or if the individual wishes to terminate any self-initiated use of quiet time, and a staff member requires the individual to remain, the situation becomes a restraint and/or seclusion, as applicable, and becomes subject to the requirements for restraint or seclusion, as applicable, described in this subchapter.(B) Unless a staff member terminates quiet time for clinical reasons, the individual may terminate quiet time at any time. Under no circumstances, except for clinical reasons, may a staff member coerce or force a client out of quiet time. If a staff member does so, the situation becomes a restraint and/or seclusion, and becomes subject to the requirements for restraint or seclusion, as applicable, described in this subchapter.(C) On every occasion that quiet time is denied or terminated for clinical reasons, a staff member shall document in the medical record the conditions under which the quiet time was denied or terminated. Source Note: The provisions of this §320.149 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.149 Clinical Timeout and Quiet Time https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222957 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222957 03/12/2026 (a) Voluntary use of protective and supportive devices. A protective or supportive device that is easily removable by the individual without a staff member's assistance is not restraint.(1) A protective or supportive device may only be used with the consent of the individual.(2) A supportive device must allow greater freedom of mobility than would be possible without the use of the device.(3) Use of a protective or supportive device shall be based upon a prior order of a physician, physician's assistant, or advanced practice registered nurse.(4) If an individual uses a protective or supportive device, the individual's treatment team shall include an occupational or physical therapist and the individualized treatment plan shall specify that a protective or supportive device is to be used and shall:(A) include any special considerations for the use of the device based on the findings of the comprehensive initial assessment performed at admission or intake;(B) include an outcome oriented goal;(C) describe the specific type of device to be used;(D) specify who is responsible for applying the device;(E) describe the plan for monitoring the individual; and(F) reflect periodic assessment, intervention, and evaluation by the treatment team, including the physical therapist, on an ongoing basis.(5) The facility shall have written policies and procedures that address the proper implementation of this subsection and monitoring requirements with reference to individuals with particular types of protective and supportive devices.(b) Involuntary use of protective and supportive devices. A protective or supportive device that is not easily removable by the individual without a staff member's assistance constitutes a restraint, and becomes subject to the requirements for restraint or seclusion, as applicable, described in this subchapter.(c) Protective devices for wound healing. After a wound has healed, the continued use of a protective device constitutes a mechanical restraint and becomes subject to the requirements for restraint or seclusion, as applicable, described in this subchapter. Source Note: The provisions of this §320.151 adopted to be effective July 22, 2014, 39 TexReg 5581; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9330. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS C INTERVENTIONS IN MENTAL HEALTH SERVICES §320.151 Protective and Supportive Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222870 03/12/2026 (a) The purpose of this subchapter is to establish standards for prescribing psychoactive medication to patients served by the state mental health and mental retardation system in Texas.(b) This subchapter is not a clinical guide to prescribing psychoactive medication and is not the only source of information concerning related issues of appropriate practice.(c) Accepted guidelines, as defined in §415.3 of this title (relating to Definitions) supplement the use of this subchapter. Source Note: The provisions of this §320.201 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222871 03/12/2026 (a) The provisions of this subchapter apply to the employees and contractors of:(1) the facilities of the Texas Department of Mental Health and Mental Retardation (TDMHMR); and(2) TDMHMR local authorities.(b) The provisions of this subchapter may not apply to prescribing practice in research projects that have been approved in accordance with TDMHMR's policies and procedures concerning the review and approval of research involving human subjects. Source Note: The provisions of this §320.203 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.203 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222872 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings:(1) Accepted guidelines--The Texas Implementation of Medication Algorithms (TIMA) or an alternative guideline formally approved in writing by the TDMHMR medical director. In cases in which none are formally approved, current professionally recognized clinical guidelines or accepted standards of care are considered the accepted guidelines.(2) Child psychiatrist--A physician who is certified by the American Board of Psychiatry and Neurology and holds a subspecialty certificate in child and adolescent psychiatry, or who is board eligible, i.e., has an active approved application on file in the board office, or who is currently in training in an approved residency and is supervised by a board eligible or board-certified child and adolescent psychiatrist.(3) DSM--The current edition of The Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Press.(4) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, who may be a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(5) Local authority (LA)--The entity designated by TDMHMR to plan, facilitate, coordinate, and ensure the provision of services to individuals with mental illness or mental retardation.(6) Medication error--Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional.(7) Physician--A doctor of medicine or osteopathy who holds a current license or institutional permit to practice medicine in Texas.(8) Plan of care--The written document specifying how comprehensive care of the person with mental illness or mental retardation is to be carried out (sometimes called the "multidisciplinary treatment plan" or "interdisciplinary plan of care").(9) Polypharmacy--Concurrent use of more than one psychoactive medication having identical or very similar mechanisms of action.(10) Prescribing professional--A physician or other health care professional who, as authorized by statute, may prescribe under the supervision of a physician.(11) PRN--As needed (pro re nata).(12) Psychiatric emergency--A situation in which, in the opinion of the physician, it is immediately necessary to administer medication to a patient to ameliorate the signs and symptoms of that patient's mental illness and to prevent:(A) imminent probable death or substantial bodily harm to the patient because the patient:(i) overtly or continually is threatening or attempting to commit suicide or serious bodily harm; or(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or(B) imminent physical or emotional harm to others, because of threats, attempts, or other acts the patient makes or commits.(13) Psychiatrist--A physician who is certified by the American Board of Psychiatry and Neurology or who is board eligible, i.e., has an active approved application on file in the board office, or a physician who is currently in training in such a program and is supervised by a board eligible or board certified psychiatrist.(14) Psychoactive medication--Medication whose primary intended therapeutic effect is to treat or ameliorate the signs or symptoms of mental disorder or to modify mood, affect, perception, or behavior, consistent with THSC, Chapter 574, Subchapter G, §574.101.(15) Service setting--A state mental health facility, state mental retardation facility, a local authority (LA) site, or a service site contracted to one of these entities.(16) Team--The patient, patient's LAR, and with the patient's consent, the patient's family members, and the group of professionals and direct care workers responsible for the care of the patient, sometimes called the "multidisciplinary team" or "interdisciplinary team." Source Note: The provisions of this §320.205 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.205 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222874 03/12/2026 (a) All state facilities and LAs will establish and implement written policies and procedures as approved by their medical staff in accordance with this subchapter.(b) The prescribing professional will practice within the scope of his or her license with supervision as appropriate to that license.(c) The prescribing of psychoactive medication will be in accordance with accepted guidelines. Use of psychoactive medication that falls outside accepted guidelines may be permissible if the clinical rationale is documented in the patient record.(d) In no case will psychoactive medication be used for punishment, for convenience of staff, as a substitute for appropriate psychosocial treatments, or in amounts that interfere with a patient's quality of life or plan of care.(e) The patient's plan of care will reflect any use of psychoactive medication as part of an integrated treatment approach aimed at increasing the patient's functioning and quality of life.(f) The prescribing professional will document the rationale for initiating, continuing, or discontinuing psychoactive medication in the clinical record.(g) Medications traditionally considered psychoactive may be prescribed for nonpsychiatric indications if such use is supported by accepted guidelines and the provisions of this subchapter would not apply.(h) If a service setting must meet other standards (external or otherwise), the more stringent standards will prevail.(i) The service setting will have policies and procedures governing the scope of practice regarding prescription of psychoactive medications when the prescribing professional is not a psychiatrist. These policies and procedures must require involvement of a psychiatrist and describe the nature, extent, and time frame of this involvement regarding the following:(1) initiation of any psychoactive medication;(2) significant changes in the medication regimen other than simple titration or substitution of equivalent medications;(3) institution of polypharmacy under §415.7(e)(4) of this title (relating to Prescribing Parameters); and(4) prescription of any regimen that falls outside accepted guidelines, including dosing guidelines.(j) Each service setting must ensure psychiatric consultation is available at all times. Source Note: The provisions of this §320.207 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.207 General Principles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222875 03/12/2026 (a) Prior to initiating psychoactive medication according to accepted guidelines, the prescribing professional will:(1) assess and document the medical history including the chief complaint, psychiatric history, substance use history, and medication history along with medication allergies of the patient;(2) conduct and document a mental status examination of the patient according to accepted guidelines;(3) assess and document the current physical status and general health of the patient in detail sufficient for safe prescription of the medication contemplated and may include a reference to a physical examination conducted within the past 12 months, a physical examination by the physician, or a referral of the patient for a more thorough examination as appropriate to health status and service setting;(4) assess and document the need for laboratory screening and other procedures to gather relevant clinical information; and(5) make and document the psychiatric diagnosis in accordance with the DSM and within the scope of the professional's license.(b) The prescribing professional will solicit input and discuss with the team the the proposed treatment with psychoactive medication.(c) If psychoactive medication known to cause movement disorders is contemplated, an appropriately trained and competent staff will screen the patient for abnormal involuntary movements using a standardized procedure such as the Abnormal Involuntary Movement Scale (AIMS) or Dyskensia Identification System Condensed User Scale (DISCUS), as appropriate, and document the result of the examination prior to initiation of the medication.(d) In a psychiatric emergency, the assessments and documentation required by this section will take place as soon as is feasible after the emergency. If the patient has already received such assessments during this treatment episode, then the prescribing professional will document only those assessments and decisions that directly relate to the emergency. Source Note: The provisions of this §320.209 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.209 Evaluation and Diagnosis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222876 03/12/2026 (a) Target signs and symptoms. The prescribing professional will identify and document the target signs and symptoms along with their initial frequency and severity for each medication prescribed prior to its initial use.(b) Choice of psychoactive medication. The prescribing professional will choose the psychoactive medication in accordance with accepted guidelines.(c) Laboratory and screenings. The prescribing professional will identify, order, and follow up any laboratory tests, screenings, or other procedures indicated by the proposed psychoactive medication and the physical condition of the patient in accordance with accepted guidelines.(d) Dose and route of administration. The prescribing professional will choose doses at or below the maximum doses indicated in the TDMHMR Formulary. Higher doses or unusual routes of administration may be used with documentation in the patient record of appropriate supporting clinical rationale. The use of nasogastric intubation requires consultation with a second physician with documentation of the consultation in the supporting clinical rationale.(e) Polypharmacy. The prescribing professional will not prescribe polypharmacy as a mechanism to avoid single drug dosage recommendations, adequate monotherapy drug trials, or adequate psychosocial treatment or programming. Polypharmacy is acceptable practice when:(1) overlapping medications are used as part of a change from one medication to another;(2) currently prescribed medication is not available in the route most appropriate to a psychiatric emergency situation;(3) documentation exists of inadequate patient response after simpler and safer regimens have been attempted following accepted guidelines; or(4) accepted guidelines provide no guidance and appropriate single drug trials have failed, provided the rationale for determining the choice to prescribe polypharmacy is documented to support the situation, and:(A) the prescribing professional is privileged through the medical staff privileging process to prescribe psychoactive medication; and(B) the prescribing professional is a psychiatrist, or in the case of a child patient, a child psychiatrist, or consults with a psychiatrist or a child psychiatrist as appropriate prior to initiating polypharmacy.(f) Orders not written in person. The service setting will have policies and procedures which govern orders not written in person (such as verbal, telephone, fax, or electronic orders) by the prescribing professional. These will address who may give orders, who may accept them, and how orders will be documented in the patient record. Orders will be authenticated by the prescribing professional within a time frame appropriate to the service setting as set forth in that setting's approved policies and procedures.(g) PRN orders. The prescribing professional may write PRN orders in accordance with accepted guidelines and Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication-Mental Health Services). The service setting will have policies and procedures for PRN orders that address:(1) indications;(2) appropriate medication classes and dosing, including maximum dose in 24 hours; and(3) time frames for:(A) medication administration;(B) order duration;(C) assessment of effectiveness;(D) continued PRN use; and(E) documentation standards that apply to the order itself and the assessments.(h) Psychiatric emergency orders. The physician may order a single, immediate administration of a psychoactive medication(s) for a psychiatric emergency. The service setting will have policies and procedures for emergency use of psychoactive medications in accordance with accepted guidelines and Chapter 414, Subchapter I of this title, governing Consent to Treatment with Psychoactive Medication-Mental Health Services, and Chapter 412, Subchapter H, governing Standards and Quality Assurance for Mental Retardation Community Services and Supports as appropriate that address:(1) indications;(2) appropriate medication classes and dosing, including maximum dose in 24 hours;(3) assessment of effectiveness;(4) patient education;(5) review with consideration of changing the current plan of care if a pattern of use of psychiatric emergency orders emerges; and(6) documentation time frames and standards that address the incident, the use of medications, and the outcome. Source Note: The provisions of this §320.211 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.211 Prescribing Parameters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222877 03/12/2026 (a) Emergency psychoactive medications are used to treat the signs and symptoms of mental illness in a psychiatric emergency when other interventions are ineffective or inappropriate.(b) The selection of the medication should take into account the patient's current medication regimen. Using a medication that the patient is currently prescribed is preferable, if clinically indicated.(c) All required documentation will be entered into the patient's record as soon as the emergency abates. Source Note: The provisions of this §320.213 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.213 Emergency Use of Psychoactive Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222878 03/12/2026 (a) All patients receiving psychoactive medication will receive timely ongoing face-to-face evaluation and documentation by the prescribing professional of:(1) data collected since the last follow-up, including data about the frequency, severity, and timing of target signs and symptoms;(2) effectiveness of the medication in treating target signs and symptoms; and(3) assessment for side effects and adverse effects.(b) Using the assessment data and with input from the team, the prescribing professional will continue or alter the medication regimen to maximize the benefit to the patient.(c) At initiation of a new medication or significant change in medication regimen, medication monitoring will occur as often as medically necessary and for the period of time needed to stabilize the clinical response. Such monitoring will occur at least weekly for one month in hospitals and crisis stabilization units (unless discharged in the interim) and at least monthly in outpatient and residential settings. Rationale for less frequent monitoring will be documented.(d) Further minimum frequencies of medication monitoring in patients are:(1) state mental health facility settings--monthly as described in subsections (a) and (b) of this section. Also, every 90 days, the medication monitoring includes review of consent issues and long-term consequences of psychoactive medication;(2) state mental retardation facility settings--monthly review of data with appropriate members of the team and every third month (quarterly) face-to-face evaluation of the patient. Rationale for less frequent monitoring will be documented;(3) LA programs--medication monitoring appointments will be scheduled quarterly as described in subsections (a) and (b) of this section. Rationale for less frequent monitoring will be documented.(e) For medications known to cause movement disorders, appropriately trained and competent staff will screen the patient quarterly for abnormal involuntary movements using a standardized procedure such as AIMS, document the results, and arrange for any appropriate follow-up with a psychiatrist or neurologist, if indicated.(f) Clinically significant adverse effects or side effects will be evaluated by a physician, managed according to accepted guidelines, and addressed in the plan of care.(g) Laboratory testing or other procedures needed for the continued safe and effective use of medication will be ordered according to accepted guidelines.(h) In any service setting that operates a pharmacy, the pharmacist will evaluate medication orders and patient medication records in accordance with the rules of the Texas State Board of Pharmacy (Texas Administrative Code, Title 22, Part 15) and will include a review for dosage range according to the TDMHMR Formulary, polypharmacy, and PRN use. The service setting will have policies and procedures in place for doing this review and the documentation and outcome of any questions arising out of this review. Source Note: The provisions of this §320.217 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.217 Medication Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222873 03/12/2026 Special populations will be managed according to accepted guidelines as appropriate to their special needs.(1) Patients with dyskinesias, including tardive dyskinesia.(A) A diagnosis of a dyskinesia will be verified by a psychiatrist or neurologist and documented in the patient record along with suspected or known duration and severity.(B) The patient and, as appropriate, family and LAR will receive relevant education about the diagnosis and its implications for psychoactive medication use.(C) Risks and benefits of continued psychoactive medication use will be assessed and communicated to the patient and, as appropriate, family or LAR. If continued use is recommended, a new consent for medication will be obtained.(D) If continued use of psychoactive medication is contemplated, then the prescribing professional, if not a psychiatrist or neurologist, must obtain and document consultation from a psychiatrist or neurologist.(2) Children.(A) Except in an emergency, if the prescribing professional is not a child psychiatrist, then prescribing psychoactive medication which falls outside accepted guidelines requires consultation from a child psychiatrist in addition to any other requirements.(B) If the prescribing professional is a child psychiatrist, then use of polypharmacy is governed as indicated in §415.7 of this title (relating to Prescribing Parameters).(3) Patients with mental retardation.(A) A specific psychiatric diagnosis will be made in accordance with the DSM prior to initiating psychoactive medication. If it is not possible to make a specific diagnosis in accordance with the DSM, clinical justification for initiating psychoactive medication will be documented.(B) Except in an emergency or acute psychiatric hospitalization, psychoactive medications are prescribed only after behavioral and clinical baselines have been established.(C) Specific target behaviors or clinical signs and quality of life outcomes must be objectively defined, quantified, and tracked using recognized empirical measurement methods appropriate to the service setting in order to monitor psychoactive medication efficacy.(4) Patients with substance use disorders.(A) Service settings will assess the occurrence of co-occurring psychiatric and substance use disorders during evaluations for medication, initiation of medication, and medication monitoring, and will have policies and procedures which address the assessment .(B) Provision of medication services to this population will be in accordance with accepted guidelines for patients with these comorbid conditions and will be in collaboration and coordination with other treatments that the patient may be receiving for substance use.(5) Pregnant or nursing patients.(A) Informed consent for use of psychoactive medication in this population must specifically document that the risk and benefits of that use on the fetus or infant have been discussed with the patient and, as appropriate, LAR and family.(B) Prior to prescribing psychoactive medication, the prescribing professional will seek to collaborate with the physician or clinic providing prenatal, postnatal, or pediatric care to include providing, with consent, appropriate documentation of diagnoses and plan of care to that service provider.(6) Geriatric patients. Service settings will have policies and procedures for prescribing psychoactive medication which are responsive to the special needs of geriatric patients..(7) Other special populations. Prescribing professionals will be aware that other populations exist that may have particular clinical or special risk factors associated with their treatment with psychoactive medications. Consultation with an appropriate specialist or expert will be considered when treating these populations. Source Note: The provisions of this §320.219 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.219 Special Populations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222879 03/12/2026 (a) Each service setting will have in place policies and procedures that address standards monitoring and related procedures for quality management of provision of psychoactive medication related services.(b) At a minimum, psychoactive medication utilization in each service setting must be reviewed and evaluated at least semiannually and strategies for improvement identified using accepted guidelines.(c) Required areas of review include:(1) appropriateness of prescribing (including choice of medication, dose, and route);(2) documentation;(3) polypharmacy;(4) emergency use of psychoactive medication;(5) PRN use;(6) medication errors;(7) adverse drug reactions; and(8) frequency of medication monitoring.(d) Medication utilization will be reviewed by the medical staff and necessary strategies for improvement approved by the medical staff for implementation. Source Note: The provisions of this §320.221 adopted to be effective August 31, 2004, 29 TexReg 8325; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10121. 1 HEALTH AND HUMAN SERVICES COMMISSION 320 RIGHTS OF INDIVIDUALS D PRESCRIBING OF PSYCHOACTIVE MEDICATION §320.221 Quality Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198602 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198602 03/12/2026 The purpose of this subchapter is to specify the requirements for department-funded prevention services providers to implement the primary prevention strategies set forth in 45 Code of Federal Regulations (CFR), §96.125, and to establish criteria for measuring the effectiveness of state agency-funded substance abuse preventions providers. In this subchapter, the term "prevention services" includes prevention activities. Source Note: The provisions of this §321.1 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES A PREVENTION §321.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198603 03/12/2026 This subchapter applies to providers of department-funded services for the prevention of substance abuse. Source Note: The provisions of this §321.3 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES A PREVENTION §321.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198604 03/12/2026 The following words and phrases when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.(1) ATOD--Alcohol, tobacco, and/or other drugs.(2) Department--The Department of State Health Services.(3) Participant--A person receiving substance abuse prevention services funded by a state agency.(4) Protective factors--Elements that serve to reduce the influence of risk factors and may have a positive effect on a person, group, or geographic area, thereby building resilience and decreasing the likelihood for developing risky behaviors that could lead to a substance abuse problem; e.g., parent or guardian involvement or safe living environment.(5) Risk factors--Elements that may have a negative effect on a person, group, or geographic area, thereby increasing the likelihood for developing risky behaviors that could lead to a substance abuse problem; e.g., living in a high crime or gang area, family history of ATOD problems, lack of a supportive adult, or poor academic performance.(6) Substance abuse prevention program provider--A person or entity who contracts with a state agency listed in §447.105 of this title (relating to Interagency Collaboration and Reporting) to provide substance abuse prevention services. Source Note: The provisions of this §321.5 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES A PREVENTION §321.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198605 03/12/2026 A comprehensive prevention program includes a broad array of prevention strategies directed at individuals who have not been identified as needing treatment for substance abuse. The comprehensive prevention programs shall include activities and strategies appropriate for the target group and are provided in a variety of settings for both the general population, as well as targeted sub-groups who are at high risk for substance abuse.(1) Universal Prevention. Universal prevention programs promote a proactive process that addresses the health and wellness of individuals, families, and communities by enhancing their protective factors. Services are designed to deter the use of ATOD and to foster the development of social and physical environments that facilitate healthy ATOD-free lifestyles. This program type is designed to target a very large audience or population, such as community, school or neighborhood that has not been identified on the basis of individual risk. The required strategies are as follows:(A) information dissemination;(B) education;(C) alternative activities;(D) problem identification and referral;(E) community-based process; and(F) environmental, as defined in 42 CFR, §96.125(b).(2) Selective Prevention. Selective prevention programs promote a proactive process to address and promote the health and wellness of individuals, families, and communities by enhancing protective factors and by averting factors that place an individual at risk for substance abuse. Services target individuals or subgroups of the general population who are determined to be at risk for substance abuse, such as children of substance abusers. This program type is designed to target individuals whose risk of developing a substance use or abuse disorder is significantly higher than average. The required strategies are as follows:(A) information dissemination;(B) education;(C) alternative activities;(D) problem identification and referral;(E) community-based process; and(F) environmental, as defined in 42 CFR, §96.125(b).(3) Indicated Prevention. Indicated prevention programs identify individuals who are experiencing early signs of substance abuse and other related problem behaviors associated with substance abuse. These individuals have not reached the point where a clinical diagnosis of substance abuse can be made. This program type is designed to target youth who are showing early warning signs of substance use, such as experimenting or abuse, and/or exhibiting other problem behaviors that may lead to substance use or abuse if not addressed. The required strategies are as follows:(A) information dissemination;(B) education;(C) alternative activities;(D) problem identification and referral;(E) community-based process; and(F) environmental, as defined in 42 CFR, §96.125(b).(4) Community Coalition Partnership. A community coalition partnership is a collaborative partnership of individuals and/or organizations that strives to prevent and reduce illegal and harmful use of ATOD by implementing community- and evidence-based environmental prevention strategies designed to affect the social, cultural, political, and economic processes of communities. The required strategies are as follows:(A) information dissemination;(B) community-based process; and(C) environmental, as defined in 42 CFR, §96.125(b).(5) Prevention Resource Center (PRC). A prevention resource center is a regional prevention education materials clearinghouse, and regional prevention training coordinating entity within each of the eleven Health and Human Services Commission's public health regions. The required strategies are as follows:(A) information dissemination;(B) community-based process; and(C) environmental, as defined in 42 CFR, §96.125(b). Source Note: The provisions of this §321.7 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES A PREVENTION §321.7 Program Description https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198606 03/12/2026 The purpose of this subchapter is to describe department-funded substance abuse intervention services programs. In general, interventions services are designed to address specific problems that, if left unresolved, can lead to substance abuse or dependence. Intervention services are designed to be flexible and responsive to changing community needs and budgetary constraints. Source Note: The provisions of this §321.51 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES B INTERVENTION §321.51 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198607 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198607 03/12/2026 This subchapter applies to providers of department-funded substance abuse intervention services. Source Note: The provisions of this §321.53 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES B INTERVENTION §321.53 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198608 03/12/2026 The following words and phrases when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.(1) Behavioral health services--Services that consist of mental health services and services for the prevention, intervention, and treatment of substance abuse.(2) Brief interventions--Practices designed to initiate resolution of a problem and motivate a person receiving services from a program provider to begin to do something about his or her substance abuse. Brief interventions are described in "Brief Interventions and Brief Therapies for Substance Abuse" (Treatment Improvement Protocol 34), published by the United States Department of Health and Human Services Center for Substance Abuse Treatment.(3) Case management--Services that assist and support persons receiving services from a program provider in developing skills to gain access to and obtain services from needed medical, social, educational and other service providers essential to meeting basic human needs. This function consists of assessment of needs, appropriate referrals, follow-up on referrals, and a plan of action with clear goals.(4) Colonias--A residential area along the Texas-Mexico border that lacks basic living needs, such as potable water and sewer systems, electricity, paved roads, and safe and sanitary housing. Colonias, while frequently found in unincorporated areas of the counties, are also found within city limits.(5) Contract--A written agreement between the department and a program provider providing intervention services.(6) Department--The Department of State Health Services.(7) Indicated target population--Indicated services include youth who are showing early warning signs of substance use, such as experimenting, or abuse and/or exhibiting other problem behaviors. This service targets youth in difficult situations resulting in problem behaviors that, if not addressed, may lead to substance use or abuse.(8) Outreach--The provision of health- and substance abuse-related information, activities, and services to a specified group that has traditionally been underserved. Outreach is a strategy for taking services and activities where the group resides and works.(9) Program provider--A person or entity that contracts with the department to provide substance abuse intervention services.(10) Referral--The process of identifying appropriate services and providing the information and assistance needed to obtain access to them.(11) Rural border--The area that extends 62 miles north of the Texas-Mexico border and encompasses 32 counties as described in the United States-Mexico La Paz agreement of 1983.(12) Screening--The process through which the program provider, person receiving services from the program provider, and available family determine the most appropriate initial course of action given the needs and characteristics of the person receiving services from the program provider and the available resources within the community. Screening includes determining whether a person receiving services from a program provider is appropriate and eligible for admission to a particular treatment service type.(13) Selective target population--The target population for selective prevention services is those individuals whose risk of developing a substance use or abuse disorder is significantly higher than average. These services target individuals or subgroups of the general population who are determined to be at risk for substance abuse, such as children of substance abusers.(14) Service coordination--Administrative, clinical, and evaluative activities that bring the person receiving services from the program provider, treatment services, community agencies, and other resources together to focus on issues and needs identified in the plan for treatment of the person receiving services. Service coordination, which includes case management and advocacy for the person receiving services, establishes a framework of action for the person receiving services to achieve specified goals. It involves collaboration with the person receiving services, and family and/or significant others; coordination of treatment and referral services, liaison activities with community resources and managed care systems, advocacy for the person receiving services, and ongoing evaluation of treatment progress and needs of the person receiving services.(15) State of Texas required training program--The State of Texas required training program on human immunodeficiency virus (HIV) antibody testing and counseling which is used as a tool to guide the discussion with a person receiving services from a program provider about his/her risk(s) as it relates to HIV, sexually transmitted disease (STD), hepatitis C virus (HCV), his/her most recent risk, and the development of incremental steps to reduce the person's risk for acquiring or transmitting HIV/STD/HCV. This State of Texas training program is required for all program providers performing HIV testing/counseling. Source Note: The provisions of this §321.55 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES B INTERVENTION §321.55 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198609 03/12/2026 The purpose of this subchapter is to describe department-funded substance abuse treatment programs and program providers. Source Note: The provisions of this §321.101 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES C TREATMENT §321.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198610 03/12/2026 This subchapter applies to providers of department-funded substance abuse treatment services. Source Note: The provisions of this §321.103 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES C TREATMENT §321.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=198611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 198611 03/12/2026 The following words and phrases when used in this subchapter shall have the following meanings unless the context clearly indicates otherwise.(1) Contract--A written agreement between the department and a program provider to provide substance abuse treatment services.(2) Case management--Services that assist and support persons receiving services from a program provider in developing skills to gain access to and obtain services from needed medical, social, educational and other service providers essential to meeting basic human needs. This function consists of assessment of needs, appropriate referrals, follow-up on referrals, and a plan of action with clear goals.(3) Department--The Department of State Health Services.(4) Medication-assisted therapies--Medications used in any treatment for addictions that includes a medication approved by the U.S. Food and Drug Administration for addiction detoxification or maintenance treatment.(5) Program provider--A person or entity that contracts with the department to provide substance abuse treatment services.(6) Substance use disorder--A broad term that includes substance abuse, substance dependence, substance withdrawal, substance intoxication, and other related disorders as described in the Diagnostic and Statistical Manual of Mental Disorders. Source Note: The provisions of this §321.105 adopted to be effective September 2, 2012, 37 TexReg 6600; transferred effective March 15, 2020, as published in the February 21, 2020 issue of the Texas Register, 45 TexReg 1240. 1 HEALTH AND HUMAN SERVICES COMMISSION 321 SUBSTANCE USE SERVICES C TREATMENT §321.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219074 03/12/2026 The purpose of this subchapter is to describe the role and responsibilities of a local intellectual and developmental disability authority (LIDDA), including those responsibilities described in THSC, §533.0355(b). Source Note: The provisions of this §330.1 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219075 03/12/2026 This subchapter applies to a LIDDA. Source Note: The provisions of this §330.3 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219076 03/12/2026 The following terms and phrases, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Actively involved--Significant, ongoing, and supportive involvement with an individual by a person, as determined by the LIDDA, based on the person's:(A) interactions with the individual;(B) availability to the individual for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the individual's needs, preferences, values, and beliefs.(2) Adaptive behavior--The effectiveness with or degree to which an individual meets the standards of personal independence and social responsibility expected of the individual's age and cultural group as assessed by a standardized measure.(3) Behavioral emergency--A situation in which severely aggressive, destructive, violent, or self-injurious behavior exhibited by an individual:(A) poses a substantial risk of imminent probable death of, or substantial bodily harm to, the individual or others;(B) has not abated in response to attempted preventive de-escalatory or redirection techniques;(C) is not addressed in a written behavioral support plan; and(D) does not occur during a medical or dental procedure.(4) Behavioral support--Specialized interventions that assist an individual with increasing adaptive behaviors to replace or modify maladaptive or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in home and family life or community life.(5) Capacity--A person's ability to:(A) understand the information provided to the person regarding a proposed psychoactive medication or behavioral support plan as described in §2.313(d)(1) or (e)(3) of this subchapter (relating to Health, Safety, and Rights); and(B) make a decision whether to take the proposed medication or accept the behavioral support plan.(6) CFC--Community First Choice. A Medicaid state plan benefit described in 1 TAC Chapter 354, Subchapter A, Division 27 (relating to Community First Choice).(7) CRCG--Community resource coordination group. A local interagency group composed of public and private agencies, organizations, and families that develops a coordinated plan of services and supports for an individual with complex needs. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More than One Agency, available at www.dads.state.tx.us.(8) DADS--The Department of Aging and Disability Services.(9) Designated LIDDA--The LIDDA assigned to an individual in DADS data system.(10) Developmental period--Birth through 17 years of age.(11) General revenue services--Non-residential intellectual and developmental disability services funded by general revenue through the performance contract, including:(A) eligibility determinations;(B) service coordination not funded by Medicaid Targeted Case Management; and(C) respite.(12) HCS Program--The Home and Community-based Services Program. A program operated by DADS and approved by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act that provides community-based services and supports to eligible individuals who live in their own homes or family homes or other residences permitted under DADS rules related to the HCS Program.(13) ICF/IID Program--The Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions Program. A program operated by DADS in accordance with the Social Security Act that provides Medicaid-funded residential services to individuals with an intellectual disability or a related condition.(14) Individual--A person seeking or receiving services and supports from a LIDDA.(15) Informed consent--Consent given by an individual or the individual's LAR if the person giving the consent:(A) is:(i) 18 years of age or older; or(ii) younger than 18 years of age and is or has been married or had the disabilities of minority removed for general purposes by court order as described in the Texas Family Code, Chapter 31;(B) has not been determined by a court to lack capacity to make decisions with regard to the matter for which consent is being sought;(C) has been provided the information described in §2.313(d)(1) or (e)(3) of this subchapter;(D) has the capacity to give consent, as determined by the prescribing physician or the professional who develops the behavioral support plan, as applicable; and(E) gives the consent voluntarily, free from coercion or undue influence.(16) Intellectual disability--Consistent with THSC, §591.003, significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.(17) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and who may be a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(18) LIDDA--Local intellectual and developmental disability authority. An entity designated in accordance with THSC, §533.035(a).(19) LIDDA priority population--As defined in §5.153 of this title (relating to Definitions).(20) Local planning--A broad-based community participatory process that identifies community values, service needs, and service priorities for individuals in the LIDDA priority population within a local service area and which guides resource development and allocation and results in a local plan that identifies goals and establishes strategies for accomplishment.(21) Local service area--A geographic area composed of one or more Texas counties as identified in the performance contract to be served by a LIDDA.(22) Medication class--A group of medications with similar actions and indications for use.(23) Performance contract--A written agreement between DADS and a LIDDA as required by THSC, §534.054, for the provision of one or more functions as described in THSC, §533.035(a), and for the provision of general revenue services. The performance contract allocates general revenue funds for the LIDDA to fulfill its role and responsibilities as a LIDDA.(24) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship.(25) Person-directed planning--A process that empowers the individual (and the LAR on the individual's behalf) to direct the development of a plan for services and supports that meet the individual's outcomes. The process:(A) identifies existing services and supports necessary to achieve the individual's outcomes;(B) identifies natural supports available to the individual and negotiates needed service system supports;(C) occurs with the support of a group of people chosen by the individual (and the LAR on the individual's behalf); and(D) accommodates the individual's style of interaction and preferences regarding time and setting.(26) Planning team--Persons convened by an individual's LIDDA to develop a plan of services and supports for an individual. The team includes:(A) the individual;(B) if applicable, the LAR or actively involved person;(C) the staff member assigned to the individual by the LIDDA; and(D) other persons chosen by the individual, LAR, or actively involved person.(27) Psychoactive medication--A medication for which the primary intended therapeutic effect is to treat or ameliorate the signs or symptoms of mental disorder, or to modify mood, affect, perception, or behavior.(28) Restraint--A manual method, except for physical guidance or prompting of brief duration, or a mechanical device to restrict:(A) the free movement or normal functioning of all or a portion of an individual's body; or(B) normal access by an individual to a portion of the individual's body.(29) Rights protection officer--As referenced in §4.113 of this title (relating to Rights Protection Officer at a State MR Facility or MRA), the staff member of a LIDDA whose primary duty is to advocate for the rights of individuals served by that LIDDA and to assist LARs in advocating for the rights of individuals.(30) Safety net functions--As referenced in THSC, §533.0355(a)(6), functions performed by a LIDDA with available resources to respond to an individual in the LIDDA priority population who has an intensive need or who is in crisis to protect the individual's health and safety.(31) Service coordination--A service provided by a LIDDA as defined in §2.553 of this chapter (relating to Definitions) contained in Subchapter L (relating to Service Coordination for Individuals with Mental Retardation).(32) Service coordinator--A LIDDA employee who:(A) meets the qualifications and has received training set forth in §2.559 of this chapter (relating to Minimum Qualifications) and §2.560 of this chapter (relating to Staff Training) contained in Subchapter L (relating to Service Coordination for Individuals with Mental Retardation); and(B) performs service coordination activities.(33) Services and supports--General revenue services and other publicly funded intellectual and developmental disability services.(34) Significantly subaverage general intellectual functioning--As defined in §5.153 of this title (relating to Definitions).(35) Specialized services--As defined in §17.102 of this title (relating to Definitions).(36) SSLC--State supported living center. A facility operated by DADS, including the ICF/IID component of the Rio Grande State Center, that provides services, including residential services, to individuals with a profound or severe intellectual disability or an intellectual disability with intensive medical or behavioral needs.(37) Staff member--Personnel of a LIDDA including a full-time and part-time employee and a contractor.(38) THSC--The Texas Health and Safety Code.(39) TxHmL Program--The Texas Home Living Program. A program operated by DADS and approved by the Centers for Medicare and Medicaid Services in accordance with §1915(c) of the Social Security Act, that provides community-based services and supports to eligible individuals who live in their own homes or in their family homes. Source Note: The provisions of this §330.5 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219077 03/12/2026 (a) A LIDDA's role is to serve as the single point of access to certain publicly funded services and supports for the residents within the LIDDA's local service area.(b) As the single point of access, a LIDDA's responsibilities include:(1) providing information about services and supports to an individual and LAR or actively involved person;(2) ensuring an individual's access into services and supports by:(A) conducting intake and eligibility activities for an individual seeking services and supports; and(B) enrolling or admitting an eligible individual into services and supports;(3) performing safety net functions;(4) ensuring the provision and oversight of general revenue services by:(A) developing and managing a network of general revenue services providers; and(B) establishing processes to monitor the performance of general revenue services providers;(5) conducting service coordination;(6) conducting utilization management;(7) conducting planning for the local service area, including ensuring involvement by a local advisory committee and other stakeholders;(8) conducting permanency planning for certain individuals under 22 years of age; and(9) protecting the rights of an individual.(c) This subchapter elaborates on the responsibilities listed in subsection (b) of this section and describes other responsibilities of a LIDDA. Source Note: The provisions of this §330.7 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.7 LIDDA's Role and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219078 03/12/2026 (a) Access. A LIDDA must have a place of business reasonably accessible to the residents of the local service area where an individual can request services and supports. The LIDDA must assist an individual for whom it is the designated LIDDA with accessing such services and supports. (b) Screening. (1) A LIDDA must develop and implement policies and procedures related to screening an individual seeking services and supports that address: (A) providing an oral and written explanation of services and supports to the individual and LAR or actively involved person and family member using DADS-approved documents; (B) gathering and documenting information to determine a need for services and supports; (C) triaging immediate needs to be responsive to a crisis situation; (D) determining whether a request can be met with resources at the LIDDA or whether the individual will be directed to alternate resources in the community; (E) assisting the individual or LAR in identifying services and supports preferences, documenting those preferences on the DADS-approved form, and maintaining a copy of the documentation; and (F) if the services and supports preferred by the individual or LAR are not available: (i) assisting the individual or LAR in gaining access to alternative services and supports and registering the individual's name on the appropriate interest lists; (ii) documenting efforts undertaken by the LIDDA to obtain the requested services and supports, including the names and addresses of programs and facilities to which the individual or LAR was referred; and (iii) documenting the services and supports for which the individual is waiting. (2) If the individual or LAR is seeking residential services, the LIDDA must develop and implement policies and procedures that address: (A) providing to the individual, LAR, and, unless the LAR is a family member, at least one family member (if possible) both an oral and written explanation of the residential services and supports for which the individual may be eligible, including: (i) as required by THSC, §533.038(d): (I) state supported living centers; (II) community ICFs/IID; (III) waiver services under §1915(c) of the Social Security Act; and (IV) other community-based services and supports; (ii) as required by THSC, §533.038(g)(1), a copy of the DADS-approved publication relating to residential options for individuals with an intellectual disability or related condition; and (iii) as required by THSC, §533.038(g)(2), information relating to whether appropriate residential services are available in each program for which the individual may be eligible, including state supported living centers, community ICFs/IID, waiver services, or other services located nearest to the residence of the individual; and (B) if an individual is under 22 years of age, providing to the LAR an explanation of permanency planning. (c) Intake. A LIDDA must develop and implement policies and procedures related to intake that address: (1) determining if an individual seeking services and supports is a member of the LIDDA priority population in accordance with Chapter 5, Subchapter D, of this title (relating to Diagnostic Assessment), and eligible for general revenue services; (2) determining an individual's eligibility for service coordination in accordance with §2.554 of this chapter (relating to Eligibility) contained in Subchapter L (relating to Service Coordination for Individuals with an Intellectual Disability), and documenting a description of the individual's preferences and needs using a person-directed planning process that is consistent with DADS Person Directed Planning Guidelines; (3) conducting a financial assessment as required by Subchapter C of this chapter (relating to Charges for Community Services) and assisting an individual with applying for Medicaid benefits, Supplemental Security Income, or Social Security Disability Income, if appropriate; (4) providing an explanation of rights of individuals with an intellectual disability in accordance with Chapter 4, Subchapter C of this title (relating to Rights of Individuals with an Intellectual Disability); and (5) providing information to the individual and LAR about the LIDDA complaint, notification, and appeal processes in accordance with Subchapter A of this chapter (relating to Local Authority Notification and Appeal). (d) Service coordination. (1) A LIDDA must offer an individual service coordination if the individual: (A) is eligible for Medicaid and service coordination; or (B) is not eligible for Medicaid, but is eligible for service coordination and will be enrolled in general revenue services other than service coordination. (2) A LIDDA must designate a staff member to authorize and monitor an individual's service need in accordance with the performance contract if the individual: (A) is not eligible for service coordination; and (B) will be enrolled in a general revenue service other than service coordination. (e) Enrollment into general revenue services. (1) A LIDDA must develop and implement policies and procedures related to enrollment into general revenue services that address: (A) developing a written plan of services and supports that uses a person-directed planning process and includes: (i) current services and supports, including existing natural supports; (ii) outcomes to be achieved by the individual and the general revenue services to be provided to the individual; (iii) any assessment to be conducted after enrollment; (iv) the reason for each general revenue service to be provided; and (v) the amount and duration of each general revenue service to be provided; and (B) authorizing the provision of the general revenue services identified in the plan. (2) Except for the provision of respite in an emergency, the LIDDA may not provide general revenue services unless authorized in accordance with the policies and procedures required by paragraph (1) of this subsection. (f) Enrollment activities for the ICF/IID, HCS, and TxHmL programs. (1) A LIDDA must enroll an individual in the ICF/IID, HCS, or TxHmL program, in accordance with the performance contract and DADS rules relating to those programs. (2) A LIDDA must conduct permanency planning for an individual under 22 years of age who is enrolling in an HCS Program residential setting or an ICF/IID in accordance with the performance contract and DADS rules relating to those programs. (g) Enrollment activities for Community First Choice (CFC). A LIDDA must conduct enrollment activities for an individual who is referred to the LIDDA by a Medicaid managed care organization and who is enrolling in CFC in accordance with the performance contract and the LIDDA contract with the Medicaid managed care organization. (h) Commitment or admission to a state supported living center (SSLC). (1) A LIDDA must perform its responsibilities related to an individual's commitment or admission to an SSLC in accordance with Subchapter F of this chapter (relating to Continuity of Services--State Facilities). (2) A LIDDA must conduct permanency planning for an individual under 22 years of age who resides in an SSLC in accordance with §2.283 of this chapter (relating to MRA and State MR Facility Responsibilities) contained in Subchapter F (relating to Continuity of Services--State Facilities), and the performance contract. (i) Safety net functions. A LIDDA must develop policies and procedures related to safety net functions that reflect the priorities of its local planning efforts and are responsive to the needs of its local service area. (j) PASRR Evaluations. A LIDDA must conduct Pre-admission Screening and Resident Review (PASRR) Evaluations as required by Chapter 17 of this title (relating to Pre-admission Screening and Resident Review (PASRR)) and the performance contract. Source Note: The provisions of this §330.9 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.9 Access, Intake, and Enrollment Related Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219079 03/12/2026 (a) Community living options information process at SSLCs. A LIDDA whose local service area includes an SSLC must implement the community living options information process for residents 22 years of age and older at the SSLC as required by the performance contract and DADS rules.(b) Continuity of services. A LIDDA must comply with Subchapter F (relating to Continuity of Services--State Services), Division 4 of this chapter (relating to Moving From a State Facility to an Alternative Living Arrangement), when an SSLC interdisciplinary team recommends an alternative living arrangement for an individual residing in the SSLC.(c) Permanency planning.(1) A LIDDA must conduct permanency planning for an individual under 22 years of age who is:(A) enrolled in the ICF/IID Program, including an SSLC; or(B) receiving residential support or supervised living from an HCS Program provider in the LIDDA local service area.(2) A LIDDA must conduct permanency planning in accordance with the performance contract and the following rules:(A) Section 2.283 of this chapter (relating to MRA and State MR Facility Responsibilities) contained in Subchapter F (relating to Continuity of Services--State Facilities);(B) Section 9.167 of this title (relating to Permanency Planning Reviews) contained in Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) Program); and(C) Section 9.250 of this title (relating to Permanency Planning Reviews) contained in Chapter 9, Subchapter E (relating to ICF/IID Program--Contracting).(d) Residents of nursing facilities who are eligible for specialized services. A LIDDA must ensure the provision of specialized services to a resident of a nursing facility in accordance with Chapter 17 of this title (relating to Pre-admission Screening and Resident Review (PASRR)) and the performance contract. Source Note: The provisions of this §330.11 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.11 LIDDA Responsibilities for Institutional Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219080 03/12/2026 (a) A LIDDA is responsible for ensuring the provision of and overseeing an array of general revenue services described in the performance contract that is responsive to the needs of its local service area.(b) A LIDDA must have policies and procedures that ensure on-going assessments are conducted for an individual, and the general revenue services in the individual's plan of services and supports are coordinated and monitored in accordance with §2.556 of this chapter (relating to MRA's Responsibilities) and §2.561 of this chapter (relating to Documentation of Service Coordination) contained in Subchapter L (relating to Service Coordination for Individuals with an Intellectual Disability).(c) A LIDDA must have policies and procedures related to respite (in-home, facility-based, or both) funded by general revenue that:(1) encourage the use of existing local providers of respite;(2) encourage participation by the individual and LAR or actively involved person in the choice of a qualified provider of in-home respite;(3) describe how in-home respite providers are selected and trained;(4) describe how emergency backup for in-home respite providers is provided;(5) address admission procedures; and(6) require development of a respite plan prior to the delivery of respite except in an emergency. Source Note: The provisions of this §330.13 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.13 Provision and Oversight of General Revenue Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219072 03/12/2026 (a) Protection of rights. A LIDDA must develop and implement policies and procedures that protect the rights of individuals and are consistent with Chapter 4, Subchapter C of this title (relating to Rights of Individuals with an Intellectual Disability).(b) Restrictions and limitations placed on an individual.(1) A LIDDA:(A) may implement behavioral support that involves restrictions or limitations placed on an individual only in accordance with paragraph (2) of this subsection and subsection (e) of this section;(B) must comply with subsection (f) of this section when using restraint, and for restraint used under subsection (f)(2)(A) or (B) of this section, also comply with paragraph (2) of this subsection; and(C) may place another type of restriction or limitation on an individual only if:(i) the restriction or limitation protects the individual's health or safety that is jeopardized by an identified behavior; and(ii) the LIDDA complies with paragraphs (2) and (3) of this subsection.(2) A LIDDA must ensure that any restriction or limitation placed on an individual, except for a restraint used under subsection (f)(2)(C) of this section, is reviewed and approved by the rights protection officer and, at the discretion of the LIDDA, other appropriate staff members who are not on the individual's planning team, before the restriction or limitation is implemented. If a restriction or limitation is implemented in an emergency, including a behavioral emergency, the LIDDA must notify the rights protection officer as soon as possible after implementation.(3) If a restriction or limitation not required to be in a behavioral support plan is approved in accordance with paragraph (2) of this subsection, the individual's plan of services and supports must:(A) include the restriction or limitation;(B) identify the circumstances or criteria to be met that will result in the removal of the restriction or limitation; and(C) require the planning team to review the restriction or limitation, as necessary but at least annually, to determine appropriateness.(c) Medication practices. A LIDDA's policies and procedures relating to medication practices must:(1) be consistent with accepted principles of practice and applicable state laws and regulations to ensure medication is administered safely and appropriately;(2) be approved in writing by a physician or registered nurse; and(3) address:(A) proper handling, storage, and disposal of medications;(B) proper use of telephone orders if the LIDDA allows for telephone orders;(C) administration of medications by staff members licensed or authorized to administer medications if the LIDDA allows for administration of medications;(D) supervision of self-administration of medication by an individual; and(E) documentation of follow-up and corrective action when medication errors occur.(d) Informed consent for psychoactive medication. Except as provided by paragraph (2) of this subsection, a physician employed or contracted by a LIDDA may prescribe psychoactive medication for an individual only if the individual or LAR has given written informed consent for the medication.(1) In seeking informed consent for a psychoactive medication, the prescribing physician must provide the individual and LAR:(A) an explanation of the medication and its purposes;(B) the expected beneficial effects, side effects, and risks of the medication;(C) the probable consequences of not taking the medication;(D) the existence and value of alternative forms of treatment, if any, and why the physician does not recommend the alternative treatment;(E) instruction that the individual or LAR may withdraw consent at any time without negative repercussions by a staff member or prejudicing the future provision of services;(F) an opportunity to ask questions concerning the medication and its use; and(G) the time period, not to exceed one year, for which the individual's or LAR's consent will be effective.(2) If an individual or LAR gives informed consent for a psychoactive medication but is physically unable to document the consent in writing, the prescribing physician must document in the individual's record that informed consent was given and the reason such consent was not documented by the individual or LAR.(3) Prior to changing an individual's medication regimen that would result in a change of medication class or in a significant change in the benefits, side effects, or risks to the individual, the physician must obtain written informed consent from the individual or LAR in accordance with this subsection.(e) Behavioral support.(1) A LIDDA's policies and procedures related to behavioral support must include:(A) the accepted standards of professional practice for the use of behavioral support, including the use of interventions during a behavioral emergency; and(B) a requirement that a provider of behavioral support:(i) is licensed as a psychologist in accordance with Texas Occupations Code, Chapter 501;(ii) is licensed as a psychological associate in accordance with Texas Occupations Code, Chapter 501;(iii) has been issued a provisional license to practice psychology in accordance with Texas Occupations Code, Chapter 501;(iv) is a certified authorized provider as described in §5.161 of this title (relating to Certified Authorized Provider);(v) is licensed as a licensed clinical social worker in accordance with Texas Occupations Code, Chapter 505;(vi) is licensed as a licensed professional counselor in accordance with Texas Occupations Code, Chapter 503; or(vii) is certified as a behavior analyst by the Behavior Analyst Certification Board, Inc.(2) Except as provided by paragraph (4) of this subsection, behavioral support interventions that involve restrictions or limitations placed on an individual or the use of intrusive techniques may only be provided in accordance with an approved written behavioral support plan. The behavioral support plan must:(A) be based on:(i) a functional assessment of the individual's behavior targeted by the plan; and(ii) input from the individual's planning team and other professionals, as appropriate;(B) describe the interventions to be used that are appropriate to the severity of the behavior targeted by the plan;(C) be consistent with the outcomes identified in the individual's plan of services and supports;(D) be approved by the individual's planning team prior to implementation;(E) be accepted by the individual or LAR as evidenced by the individual's or LAR's written informed consent;(F) provide for the collection of behavioral data concerning the targeted behavior; and(G) require the professional who developed the plan to:(i) educate the individual and LAR and other persons identified by the planning team (for example, family members and providers) regarding the purpose, objectives, methods and documentation of the behavioral support plan and subsequent revisions of the plan;(ii) monitor and evaluate the success of the behavioral support plan implementation as required by the plan;(iii) review, with other members of the individual's planning team, the behavioral support plan at least annually, or more often as indicated, to determine the effectiveness of the plan; and(iv) revise the plan as necessary, based on documented outcomes of the plan's implementation.(3) In obtaining informed consent as required by paragraph (2)(E) of this subsection, the professional who developed that plan must provide the individual or LAR:(A) a description of the interventions to be used in the behavioral support plan;(B) the expected beneficial effects and risks of the interventions;(C) the probable consequences of not using the interventions;(D) the existence and value of alternative interventions, if any, and why the professional does not recommend the alternative interventions;(E) oral and written notification that the individual or LAR may withdraw consent for the behavioral support plan at any time without negative repercussions by a staff member or prejudicing the future provision of services;(F) an opportunity to ask questions concerning the behavioral support plan; and(G) the time period, not to exceed one year, for which the individual's or LAR's consent will be effective.(4) A LIDDA may implement behavioral support that involves restrictions or limitations placed on an individual or the use of intrusive techniques without a behavioral support plan if the support is in response to a behavioral emergency. If such behavioral support is implemented more than twice during two consecutive months, the LIDDA must conduct a functional assessment to determine if a behavioral support plan is needed to reduce the frequency and severity of the behaviors exhibited during the behavioral emergency.(f) Restraint.(1) A LIDDA must have and implement a curriculum that ensures staff members are trained in the prevention and management of aggressive behavior. The curriculum must be consistent with the requirements of this subsection.(2) A staff member may use restraint only under the following circumstances:(A) in a behavioral emergency;(B) as part of a behavioral support plan that addresses inappropriate behavior exhibited voluntarily by an individual; or(C) in accordance with an order for the restraint from a physician, dentist, occupational therapist, or physical therapist.(3) A staff member is prohibited from using restraint:(A) in a manner that:(i) obstructs the individual's airway, including the placement of anything in, on, or over the individual's mouth or nose;(ii) impairs the individual's breathing by putting pressure on the individual's torso; or(iii) places the individual in a prone or supine position;(B) for disciplinary purposes (that is, for retaliation or retribution);(C) for the convenience of a staff member or other individuals; or(D) as a substitute for effective treatment or habilitation.(4) If restraint will be used as part of a behavioral support plan, the planning team must:(A) with the involvement of a physician or registered nurse, identify and document:(i) the individual's known physical or medical conditions that might constitute a risk to the individual during the use of restraint;(ii) the individual's ability to communicate; and(iii) other factors, such as the individual's:(I) cognitive functioning level;(II) height;(III) weight;(IV) emotional condition, including whether the individual has a history of having been physically or sexually abused; and(V) age; and(B) review and update with a physician or registered nurse, at least annually or when a condition or factor documented in accordance with paragraph (4)(A) of this subsection changes significantly.(5) If restraint is used in a behavioral emergency more than twice during two consecutive months, the planning team must ensure a functional assessment of the individual is conducted to determine if a behavioral support plan is needed to reduce the frequency and severity of the behaviors exhibited during the behavioral emergency.(6) If a staff member restrains an individual in accordance with paragraph (2) of this subsection, the staff member must:(A) use the minimal amount of force or pressure that is reasonable and necessary to ensure the safety of the individual and others;(B) safeguard the individual's dignity, privacy, and well-being; and(C) not secure the individual to a stationary object while the individual is in a standing position.(7) If a staff member restrains an individual in accordance with paragraph (2)(A) or (B) of this subsection, the staff member may only use a restraint hold in which the individual's limbs are held close to the body to limit or prevent movement and that is in compliance with paragraph (3)(A) of this subsection.(8) A staff member must release an individual from restraint:(A) as soon as the individual no longer poses a risk of imminent physical harm to the individual or others; or(B) as soon as possible if the individual in restraint experiences a medical emergency, as indicated by the medical emergency.(9) After restraining an individual in a behavioral emergency, a staff member must:(A) as soon as possible but no later than one hour after the use of restraint, notify a registered nurse, licensed vocational nurse, or a professional identified in subsection (e)(1)(B) of this section of the restraint;(B) ensure that medical services are obtained for the individual as necessary; and(C) discuss the circumstances of the restraint with a professional identified in subsection (e)(1)(B) of this section. Source Note: The provisions of this §330.15 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.15 Health, Safety, and Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224546 03/12/2026 (a) Local planning. (1) A LIDDA must conduct local planning in accordance with THSC, §533.0352, and ensure involvement of the local advisory committee and other stakeholders. (2) A LIDDA must participate in the local CRCG when an individual has complex needs and requires multiagency services. (3) A LIDDA must coordinate with local agencies to build an integrated service delivery system that ensures broad access to and information about community services, identifies the LIDDA's safety net functions, and maximizes the utilization of existing resources while avoiding duplication of effort and gaps in services. (b) Quality management. A LIDDA must develop a quality management program to monitor the performance of general revenue services providers and the LIDDA's compliance with the performance contract. (c) Utilization management. A LIDDA must have: (1) procedures describing how it authorizes general revenue services; and (2) methods for evaluating the effectiveness of the authorization procedures. (d) Information systems. A LIDDA must have information systems that: (1) capture valid and reliable data; and (2) accurately report required data to funding sources (for example, the Medicaid administration contractor, DADS, and other state and local agencies). (e) Network management. A LIDDA must develop and manage a network of qualified providers that offer an array of general revenue services described in the performance contract. (1) If the LIDDA is a provider of general revenue services, the LIDDA must have written procedures describing the qualifications and expectations of staff members. (2) If a provider of general revenue services is a contractor of the LIDDA, the LIDDA must: (A) ensure that the contract is procured and complies with the requirements of Subchapter B of this chapter (relating to Contracts Management for Local Authorities); (B) have a process for resolving complaints from contract providers; and (C) provide appropriate technical assistance and training to ensure that contract providers understand their contractual obligations (for example, documentation and billing). (f) Consideration of public input, ultimate cost-benefit, and client care issues. In accordance with THSC §533.035(c), a LIDDA must consider public input, ultimate cost-benefit, and client care issues to ensure individual choice and the best use of public money in: (1) assembling a network of general revenue services providers; (2) making recommendations relating to the most appropriate and available treatment alternatives for individuals in the need of services and supports; and (3) procuring services for a local service area, including a request for proposal or open-enrollment procurement method. (g) Interest list management. (1) A LIDDA must contact individuals on the HCS Program interest list and the TxHmL Program interest list as required by and in accordance with the performance contract. (2) A LIDDA must have policies and procedures for: (A) registering individuals on the LIDDA's interest list for general revenue services that complies with the requirements set forth in the Texas Government Code §526.0602, related to military members and their dependents; and (B) periodically contacting the individuals on the interest list. (h) Qualifications and availability of staff members. (1) Criminal history and registry clearances. A LIDDA must conduct criminal history and registry clearances for job and volunteer applicants in accordance with Chapter 4, Subchapter K, of this title (relating to Criminal History and Registry Clearances). (2) Availability of staff members. A LIDDA must ensure the continuous availability of trained and qualified staff members to ensure the provision of service coordination and general revenue services. (3) Qualifications of a staff member who is a service coordinator. A LIDDA must ensure that a staff member who is a service coordinator meets the qualifications set forth in §2.559 of this chapter (relating to Minimum Qualifications) contained in Subchapter L (relating to Service Coordination for Individuals with an Intellectual Disability). (4) Qualifications of a staff member other than a service coordinator. (A) A LIDDA must ensure that a staff member who is not a service coordinator and who directly provides general revenue services is at least 18 years of age and: (i) has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or (ii) has documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes: (I) written competency-based assessment of the ability to document service delivery and observations of an individual; and (II) at least three personal references from persons not related by blood or marriage that indicate the ability to provide a safe, healthy environment for an individual. (B) A LIDDA must: (i) document the required education and work experience for a staff member who is not a service coordinator and who directly provides general revenue services and the supervisor of such staff member by position classification, by position category, or by individual position; and (ii) ensure that a supervisor of a staff member who is not a service coordinator and who directly provides general revenue services has a minimum of one year experience working directly with people with intellectual disability or other developmental disabilities (for example, work experience, volunteer experience, or personal experience as a family member). (C) A LIDDA must ensure that a staff member who is not a service coordinator and who directly provides general revenue services and the supervisor of such staff member have required state certification or licensure. (5) Required competencies and skills relating to health, safety, and support needs of individuals. (A) A LIDDA must identify in writing the required competencies and skills for a staff member by position classification, position category, or individual position that meet the health, safety, and support needs of individuals and include: (i) time frames and frequency for the staff member to demonstrate competency; and (ii) a method for measuring the competency and skills of the staff member. (B) A LIDDA must maintain documentation that a staff member has demonstrated competencies and skills required by subparagraph (A) of this paragraph. Source Note: The provisions of this §330.17 adopted to be effective December 1, 2008, 33 TexReg 9512; amended to be effective January 8, 2012, 36 TexReg 9345; amended to be effective November 15, 2015, 40 TexReg 7821; transferred effective July 15, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4433; amended to be effective April 1, 2025, 50 TexReg 2208. 1 HEALTH AND HUMAN SERVICES COMMISSION 330 LIDDA ROLE AND RESPONSIBILITIES §330.17 LIDDA Administrative Functions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226376 03/12/2026 This chapter describes requirements for service coordination delivered by the LIDDA to an individual in the LIDDA priority population who desires services. Source Note: The provisions of this §331.1 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226377 03/12/2026 This chapter applies to all LIDDAs. Source Note: The provisions of this §331.3 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226378 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226378 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: (1) Actively involved person--For an individual who lacks the ability to provide legally adequate consent and who does not have an LAR, a person whose significant and ongoing involvement with the individual is determined by the individual's designated LIDDA to be supportive of the individual based on the person's: (A) observed interactions with the individual; (B) knowledge of and sensitivity to the individual's preferences, values, and beliefs; (C) availability to the individual for assistance or support; and (D) advocacy for the individual's preferences, values, and beliefs.(2) Audio-only--A synchronous interactive, two-way audio communication that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA). Audio-only includes the use of telephonic communication. Audio-only does not include audio-visual or in-person communication.(3) Audio-visual--A synchronous interactive, two-way audio and video communication that conforms to privacy requirements under HIPAA. Audio-visual does not include audio-only or in-person communication.(4) CFC services--Community First Choice services. State plan services described in 1 TAC Chapter 354, Subchapter A, Division 27 (relating to Community First Choice).(5) Comprehensive encounter (Encounter Type A)--Contact with an individual receiving services as defined in 1 TAC §355.746 (relating to Reimbursement Methodology for Mental Retardation Service Coordination) and including comprehensive encounters funded by general revenue.(6) Designated LIDDA--As identified in the HHSC data system, the LIDDA responsible for assisting an individual and LAR or actively involved person to access services and supports. (7) Duration--The specified period of time during which service coordination is provided to an individual.(8) Frequency--The minimum number of times during a specified period that an individual is to be contacted by a service coordinator in person based on the individual's need for contacts as determined by person-centered planning.(9) Follow-up encounter (Encounter Type B)--Contact with the individual receiving services as defined in 1 TAC §355.746 (relating to Reimbursement Methodology for Mental Retardation Service Coordination) and including follow-up encounters funded by general revenue.(10) General revenue--Funds appropriated by the Texas Legislature for use by HHSC. (11) HCS Program--The Home and Community-based Services Program. A program operated by HHSC as authorized by the Centers for Medicare & Medicaid Services in accordance with §1915(c) of the Social Security Act.(12) HHSC--The Texas Health and Human Services Commission. (13) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided. (14) ICF/IID level-of-care--A level-of-care described in §261.238 of this title (relating to ICF/MR Level of Care I Criteria) or §261.239 of this title (relating to ICF/MR Level of Care VIII Criteria). (15) ICF/IID Program-- A program operated by HHSC that provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions, as described in §1905(d) of the Social Security Act. (16) ICF/MR--ICF/IID.(17) In-person (or in person)--Within the physical presence of another person. In-person or in person does not include audio-visual or audio-only communication.(18) Individual--A person who is or is believed to be a member of the LIDDA priority population. (19) Institution--One of the following: (A) an ICF/IID; (B) a nursing facility licensed or subject to being licensed in accordance with THSC Chapter 242; (C) an assisted living facility licensed or subject to being licensed in accordance with THSC Chapter 247; (D) a child-care operation subject to regulation by HHSC as a general residential operation under Texas Human Resources Code Chapter 42; (E) a hospital;(F) an inpatient chemical dependency treatment facility; (G) a mental health facility;(H) a facility operated by the Texas Workforce Commission; or (I) a prison. (20) Institution for mental diseases--As defined in §273.3 of this title (relating to Definitions), a hospital of more than 16 beds that is primarily engaged in providing psychiatric diagnosis, treatment, and care of individuals with mental diseases, including medical care, nursing care, and related services. (21) Intellectual disability--Consistent with THSC §591.003, significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period. (22) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual with regard to a matter described in this chapter, and who may be a parent, guardian, or managing conservator of a child; or the guardian of an adult. (23) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC in accordance with THSC §533A.035. (24) LIDDA priority population--A population as defined in §304.102 of this title (relating to Definitions). (25) Local service area--A geographic area composed of one or more Texas counties defining the population that may receive services from a LIDDA. (26) MCO--Managed care organization. This term has the meaning set forth in Texas Government Code §543A.0001. (27) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship. (28) Person-centered planning--A philosophy and planning process that empowers an individual and, on the individual's behalf, an LAR or actively involved person, to direct the development of a plan of services and supports. (29) Plan of services and supports--A written plan that: (A) describes the desired outcomes identified by an individual, or an LAR or actively involved person on behalf of the individual; (B) describes the services and supports to be provided to the individual, including service coordination; (C) identifies the frequency of in-person contacts to be provided to the individual, in accordance with §331.11(h) of this chapter (relating to Designated LIDDA's Responsibilities); and(D) identifies the duration of service coordination to be provided to the individual. (30) Related condition--Consistent with 42 CFR §435.1010, a severe and chronic disability that: (A) is attributable to: (i) cerebral palsy or epilepsy; or (ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of people with intellectual disabilities, and requires treatment or services similar to those required for people with intellectual disabilities; (B) is manifested before the person reaches 22 years of age; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in three or more of the following areas of major life activity: (i) self-care; (ii) understanding and use of language; (iii) learning; (iv) mobility; (v) self-direction; and (vi) capacity for independent living. (31) Relative--A person related to the individual within the fourth degree of consanguinity or within the second degree of affinity. (32) Service coordination--Through both comprehensive and follow-up encounters, service coordination consists of assistance in accessing medical, social, educational, and other appropriate services and supports that will help an individual achieve a quality of life and community participation acceptable to the individual, or individual and LAR as follows: (A) crisis prevention and management--linking and assisting the individual and LAR or actively involved person to secure services and supports that will enable them to prevent or manage a crisis;(B) monitoring--ensuring that the individual receives needed services, evaluating the effectiveness and adequacy of services, and determining if identified outcomes are meeting the individual's needs and desires as indicated by the individual and LAR or actively involved person;(C) assessment--identifying the individual's needs and the services and supports that address those needs as they relate to the nature of the individual's presenting problem and disability; and(D) service planning and coordination--identifying, arranging, advocating, collaborating with other agencies, and linking for the delivery of outcome-focused services and supports that address the individual's needs and desires as indicated by the individual and LAR or actively involved person. (33) State hospital--Consistent with THSC §552.0011, a hospital operated by HHSC primarily to provide inpatient care and treatment for individuals with mental illness.(34) State supported living center--A state-supported and structured residential facility that is an ICF/IID operated by HHSC to provide persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC. (35) Subaverage general intellectual functioning--Consistent with THSC §591.003, measured intelligence on standardized general intelligence tests of two or more standard deviations (not including standard error of measurement adjustments) below the age-group mean for the tests used.(36) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code Chapter 2002, Subchapter C. (37) THSC--Texas Health and Safety Code. (38) TxHmL Program--The Texas Home Living Program. A program operated by HHSC as authorized by the Centers for Medicare & Medicaid Services in accordance with §1915(c) of the Social Security Act. Source Note: The provisions of this §331.5 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective August 1, 2005, 30 TexReg 4334; amended to be effective June 1, 2010, 35 TexReg 4439; amended to be effective March 20, 2016, 41 TexReg 1864; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226379 03/12/2026 (a) To be eligible for service coordination, an individual must: (1) be a member of the LIDDA priority population and meet at least one of the following criteria: (A) have two or more needs that require services and supports other than service coordination as documented by the HHSC Service Coordination Assessment form completed by the designated LIDDA and not reside in an institution; (B) be: (i) in the process of enrolling in the ICF/IID Program; (ii) in the process of enrolling in the HCS or TxHmL Program or be currently enrolled in the HCS or TxHmL Program; or (iii) in the process of enrolling in CFC services provided through an MCO; (C) be 21 years of age or older with an ICF/IID level-of-care and receiving CFC services through an MCO; (D) be seeking admission to a state supported living center; (E) be transitioning from an ICF/IID or from a nursing facility to community-based services; or (F) be transitioning from a state hospital or a facility with an HHSC-contracted psychiatric bed to community-based services; or (2) be a nursing facility resident who is eligible for specialized services for an intellectual disability or a related condition pursuant to §1919(e)(7) of the Social Security Act (U.S.C., Title 42, §1396r(e)(7)). (b) Community-based services as referenced in subsection (a)(1)(E) and (F) of this section does not include services provided in an ICF/IID or nursing facility or services provided in another institutional setting. Source Note: The provisions of this §331.7 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective August 1, 2005, 30 TexReg 4334; amended to be effective June 1, 2010, 35 TexReg 4439; amended to be effective March 20, 2016, 41 TexReg 1864; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.7 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226380 03/12/2026 (a) Service coordination may be funded by: (1) personal funds or third-party insurance other than Medicaid; (2) Medicaid targeted case management; or (3) general revenue. (b) Service coordination funded by Medicaid targeted case management: (1) may be provided only to an individual who is a Medicaid recipient and only if: (A) the individual meets at least one of the criteria described in §331.7(a)(1)(A) - (D) of this chapter (relating to Eligibility); or (B) the individual meets the criteria described in §331.7(a)(1)(E) or (a)(2) of this chapter and the service coordination is provided during the last 180 days before the individual transitions to community-based services from an ICF/IID or a nursing facility; and (2) may not be provided to an individual: (A) who resides in an institution for mental diseases; or (B) who is enrolled in a Medicaid waiver program other than the HCS or TxHmL Program. Source Note: The provisions of this §331.9 adopted to be effective June 1, 2010, 35 TexReg 4439; amended to be effective March 20, 2016, 41 TexReg 1864; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.9 Funding Service Coordination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226381 03/12/2026 (a) If a LIDDA determines an individual is eligible for and desires service coordination, the LIDDA must develop a plan of services and supports for the individual using person-centered planning that is consistent with the HHSC Person-Centered Planning Guidelines.(1) For the TxHmL and HCS Programs, the person-directed plan (PDP), as defined in §262.3 and §263.3 of this title (relating to Definitions), respectively, qualifies as a plan of services and supports. (2) For an individual receiving CFC services through an MCO, a completed HHSC Community First Choice Assessment form qualifies as a plan of services and supports. (b) A LIDDA must ensure that service coordination: (1) is provided to an individual in accordance with the individual's plan of services and supports; and (2) is not provided by an employee who is a relative of the individual or who has the same residence as the individual. (c) A LIDDA may provide crisis prevention and management to an individual without having first identified the need for such services in the individual's plan of services and supports.(d) A LIDDA must complete the HHSC Service Coordination Assessment form:(1) at intake to determine an individual's eligibility; (2) when the individual's needs change and the frequency of in-person contact in the individual's plan of services and supports needs to be revised; and(3) at least annually.(e) The HHSC Service Coordination Assessment must:(1) be completed by the service coordinator with the individual, or individual and LAR when applicable; and(2) identify the frequency of in-person service coordination contact.(f) A LIDDA must ensure that a service coordinator revises an individual's plan of services and supports:(1) if: (A) the individual's needs change; or (B) the individual, LAR or actively involved person, service provider, or other person provides relevant information indicating the appropriateness of revising the plan; and (2) using person-centered planning that is consistent with the HHSC Person-Centered Planning Guidelines. (g) Service coordination, during both comprehensive and follow-up encounters, must involve at least one of the four elements listed in the definition of "service coordination" in §331.5 of this chapter (relating to Definitions).(h) A LIDDA must ensure that a service coordinator meets with an individual in person in accordance with one of the following, whichever is the most frequent: (1) at least once every 90 days or more frequently in accordance with the HHSC Service Coordination Assessment form; or (2) for the minimum number of in-person contacts required by: (A) rules or other requirements of the program or services in which the individual is enrolled; or (B) a contract between HHSC and the LIDDA. (i) A service coordinator may meet with an individual via audio-only or audio-visual communication for a comprehensive encounter: (1) in a month when minimum in-person contact in accordance with subsection (h) of this section is not required; and(2) if, before the service coordinator conducts the meeting using audio-only or audio-visual communication, the service coordinator obtains:(A) the written consent of the individual or LAR, which may only be effective for up to a year; or(B) the individual's or LAR's verbal consent, which may only be effective for that encounter, and documents the verbal consent in the individual's record.(j) If a service coordinator does not obtain an individual's or LAR's written or verbal consent required by subsection (i)(2)(A) or (B) of this section respectively, the service coordinator must:(1) document the individual's or LAR's refusal to receive a comprehensive encounter via audio-only or audio-visual communication in the individual's record; and(2) conduct the comprehensive encounter in person.(k) If a service coordinator identifies a concern with implementation of the plan of services and supports, the LIDDA must:(1) communicate the concern to the entity providing the services and supports; and (2) ensure the entity makes attempts to resolve the concern.(l) In addition to the requirements in this chapter, a LIDDA must ensure service coordination is provided to individuals enrolled in the TxHmL Program in accordance with:(1) Chapter 262 of this title (relating to Texas Home Living (TxHmL) Program and Community First Choice (CFC)); and (2) Chapter 264 of this title (relating to Consumer Directed Services Option)). (m) In addition to the requirements in this chapter, a LIDDA must ensure service coordination is provided to individuals enrolled in the HCS Program in accordance with:(1) Chapter 263 of this title (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC)); and (2) Chapter 264 of this title. Source Note: The provisions of this §331.11 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective August 1, 2005, 30 TexReg 4334; amended to be effective June 1, 2010, 35 TexReg 4439; amended to be effective March 20, 2016, 41 TexReg 1864; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.11 LIDDA's Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226382 03/12/2026 A LIDDA is responsible for determining the number of cases per employee who provides service coordination based on factors such as individuals' needs, the frequency of in-person contacts, the duration of contacts, and travel time. Source Note: The provisions of this §331.13 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.13 Caseloads https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226383 03/12/2026 A LIDDA must terminate service coordination for an individual if: (1) the individual no longer meets the eligibility criteria for service coordination as set forth in §331.7 of this chapter (relating to Eligibility); or (2) the individual or the LAR no longer desires service coordination. Source Note: The provisions of this §331.15 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective August 1, 2005, 30 TexReg 4334; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.15 Termination of Service Coordination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226384 03/12/2026 (a) Service coordination may be provided only by an employee of a LIDDA. (b) Except as provided by subsection (d) of this section, an employee providing service coordination must have: (1) a bachelor's or advanced degree from an accredited college or university; (2) an associate degree in a social, behavioral, human service, or health-related field including, psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human development, gerontology, educational psychology, education, or criminal justice; or (3) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, and two years of paid or unpaid experience with individuals with intellectual or developmental disabilities. (c) A LIDDA, at its discretion, may require additional education and experience for employees who provide service coordination. (d) At the discretion of a LIDDA, an employee who was authorized to provide service coordination prior to October 16, 2022, pursuant to the rules in effect at the time the employee was hired, may provide service coordination without meeting the minimum qualifications described in subsection (b) of this section. Source Note: The provisions of this §331.17 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective June 1, 2010, 35 TexReg 4439; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 16, 2022, 47 TexReg 6883; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.17 Minimum Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226385 03/12/2026 (a) A LIDDA must ensure that the following employees complete the training as described in subsection (b) of this section: (1) an employee who provides service coordination; and (2) an employee who directly supervises or oversees the provision of service coordination. (b) A LIDDA employee described in subsection (a) of this section must: (1) within the first 90 days of the employee's date of hire, complete training that addresses: (A) appropriate LIDDA policies, procedures, and standards; (B) the LIDDA's performance contract requirements regarding service coordination; (C) plan of services and supports development and implementation; (D) person-centered planning consistent with the HHSC Person-Centered Planning Guidelines;(E) permanency planning; (F) crisis prevention and management, monitoring, assessment, and service planning and coordination; (G) community support services, including Medicaid state plan services such as CFC services; (H) advocacy for individuals; and (I) additional trainings designated by HHSC; and(2) within the first six months of the employee's date of hire, complete a comprehensive non-introductory person-centered service planning training approved by HHSC, unless HHSC grants an extension of the six-month timeframe.(c) A LIDDA must document the training completed in accordance with this section in the personnel record of each employee providing, supervising, or overseeing service coordination. Source Note: The provisions of this §331.19 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 20, 2016, 41 TexReg 1864; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.19 Staff Person Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226386 03/12/2026 (a) A LIDDA must document the required contacts described in the individual's plan of services and supports, including:(1) whether the contact was in person, via audio-visual communication, or via audio-only communication;(2) the location of the contact;(3) the date of the contact; (4) a description of which of the four elements of service coordination listed in the definition of "service coordination" in §331.5 of this chapter (relating to Definitions) were provided; (5) the progress or lack of progress in achieving goals or outcomes; (6) the person with whom the contact occurred; and (7) the name of the LIDDA employee who provided the contact and the employee's professional discipline, if applicable. (b) A LIDDA must ensure that service coordination activities are documented in the individual's record. (c) A LIDDA must identify the appropriate service code in the HHSC data system for all individuals receiving service coordination. (d) A LIDDA must retain documentation in compliance with applicable federal and state laws, rules, and regulations. Source Note: The provisions of this §331.21 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.21 Documentation of Service Coordination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226387 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226387 03/12/2026 (a) Any Medicaid-eligible individual whose request for eligibility for service coordination is denied or is not acted upon with reasonable promptness, or whose service coordination has been terminated, suspended, or reduced by HHSC is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules). (b) If a LIDDA decides to deny, involuntarily reduce, or terminate service coordination for a non-Medicaid-eligible individual, the LIDDA must notify the individual or LAR in writing of the decision and provide an explanation of the procedure for the individual or LAR to request a review by the LIDDA as required by Chapter 301, Subchapter D of this title (relating to LIDDA, LMHA, and LBHA Notification and Appeal Process). Source Note: The provisions of this §331.23 adopted to be effective August 31, 2004, 29 TexReg 8313; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective August 1, 2005, 30 TexReg 4334; amended to be effective June 1, 2010, 35 TexReg 4439; transferred effective July 1, 2022, as published in the Texas Register June 3, 2022, 47 TexReg 3275; amended to be effective October 19, 2025, 50 TexReg 6669. 1 HEALTH AND HUMAN SERVICES COMMISSION 331 LIDDA SERVICE COORDINATION §331.23 Review Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219053 03/12/2026 This subchapter describes:(1) the rights of an individual with mental retardation and of an LAR; and(2) procedures of DADS for informing and protecting the rights of:(A) an individual residing in a state MR facility or receiving services and supports from an MRA; and(B) an LAR. Source Note: The provisions of this §334.101 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219050 03/12/2026 This subchapter applies to:(1) a state MR facility; and(2) an MRA. Source Note: The provisions of this §334.103 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.103 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219051 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Actively involved person--A person with significant and ongoing involvement with an individual who lacks the ability to provide legally adequate consent and who does not have an LAR. The MRA providing services and supports to the individual or the state MR facility in which the individual resides determines if the person is actively involved based on the person's:(A) observed interactions with the individual;(B) knowledge of and sensitivity to the individual's preferences, values, and beliefs;(C) availability to the individual for assistance or support; and(D) advocacy for the individual's preferences, values, and beliefs.(2) DADS--The Department of Aging and Disability Services.(3) Individual--A person who has mental retardation.(4) LAR (legally authorized representative)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, which may be a parent, guardian, or managing conservator of a minor individual, or the guardian of an adult individual.(5) Local service area--A geographic area composed of one or more Texas counties that determines the MRA from which an individual may receive services.(6) Mental retardation--Consistent with THSC, §591.003, significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and originating during the developmental period.(7) MRA (mental retardation authority)--An entity to which the Texas Health and Human Services Commission's authority and responsibility described in THSC, §531.002(11) has been delegated.(8) PMRA (Persons with Mental Retardation Act)--Texas statutes relating to persons with mental retardation codified in THSC, Chapters 591 - 597.(9) Services and supports--Assistance to an individual through an MRA or a state MR facility, which may include:(A) eligibility determination;(B) service coordination;(C) community services; and(D) residential assistance.(10) State MR facility (state mental retardation facility)--A state school or a state center operated by DADS.(11) Subaverage general intellectual functioning--Consistent with THSC, §591.003, measured intelligence on standardized general intelligence tests of two or more standard deviations (not including standard error of measurement adjustments) below the age-group mean for the tests used.(12) THSC (Texas Health and Safety Code)--A codification of Texas statutes relating to health and safety. Source Note: The provisions of this §334.105 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219052 03/12/2026 The PMRA provides that an individual in Texas has the rights, benefits, and privileges guaranteed by the constitutions and laws of the United States and Texas, unless those rights, benefits, and privileges are lawfully restricted. The following specific rights listed in the PMRA are not exclusive and do not limit the rights otherwise guaranteed by the constitutions and laws of the United States and Texas:(1) the right to protection from exploitation and abuse, as described in THSC, §592.012;(2) the right to live in the least restrictive setting appropriate to the individual's needs and abilities and in a variety of living situations, as described in THSC, §592.013;(3) the right to receive publicly supported educational services, as described in THSC, §592.014;(4) the right to equal opportunities in employment, as described in THSC, §592.015;(5) the right to purchase, rent, or lease real property, as described in THSC, §592.016;(6) the right to adequate treatment and habilitative services, as described in THSC, §592.017;(7) the right to promptly receive a determination of mental retardation using diagnostic techniques that are adapted to that individual's cultural background, language, and ethnic origin to determine if the individual is in need of mental retardation services, as described in THSC, §592.018;(8) the right to request and promptly receive an administrative hearing to contest the findings of the determination of mental retardation, as described in THSC, §592.019;(9) the right to an additional, independent determination of mental retardation performed at the individual's expense if the individual questions the validity or results of the determination of mental retardation, as described in THSC, §592.020; and(10) the right to the presumption of competency, due process in guardianship proceedings, and fair compensation for the individual's labor for the economic benefit of another, regardless of any direct or incidental therapeutic value to the individual, as described in THSC, §592.021. Source Note: The provisions of this §334.107 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.107 Rights of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219054 03/12/2026 (a) An LAR has the authority to make certain decisions on an individual's behalf.(b) An individual receiving services and supports and an LAR have the following rights:(1) the right to participate in the development and periodic review of an individualized treatment plan and to receive the individual's progress in writing at reasonable intervals, as described in THSC, §§592.033 - 592.035;(2) the right to choose from several appropriate services, if possible, as described in THSC, §592.035(b);(3) the right to withdraw the individual from services and supports, as described in THSC, §592.036;(4) the right to not receive unnecessary or excessive medications, as described in THSC, §592.038;(5) the right to initiate a complaint on behalf of the individual, as described in THSC, §592.039;(6) the right to be given written notice of the rights guaranteed by the PMRA in plain and simple language when the individual begins to receive services and supports, as described in THSC, §592.040;(7) the right to have access to information contained in the individual's record, as described in THSC, §595.004; and(8) the right to request an administrative hearing to contest a proposed transfer or discharge of the individual from a state MR facility, the denial of a requested discharge or transfer of the individual from a state MR facility, or the results of a determination of mental retardation of the individual, as described in Subchapter D of this chapter (relating to Administrative Hearings Under the PMRA).(c) An individual residing in a state MR facility has the following additional rights, as described in THSC, §592.051 and §592.052:(1) the right to a normal residential environment;(2) the right to a humane physical environment;(3) the right to communication and visits;(4) the right to possess personal property; and(5) the right to prompt, adequate, and necessary medical and dental care and treatment for physical and mental ailments and to prevent an illness or disability. Source Note: The provisions of this §334.109 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.109 Rights of an Individual Receiving Services and Supports and an LAR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219055 03/12/2026 THSC, Chapter 591, Subchapter C, Penalties and Remedies, describes the penalties and remedies available for a violation of the rights of an individual guaranteed by the PMRA. Source Note: The provisions of this §334.111 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.111 Penalties for a Violation of Rights of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219056 03/12/2026 (a) A state MR facility and an MRA must employ a rights protection officer whose primary duty is to advocate for the rights of individuals served by that state MR facility or MRA and to assist LARs in advocating for the rights of individuals.(b) The superintendent of a state MR facility and the chief executive officer of an MRA must specify the duties of the rights protection officer, which must include:(1) receiving a complaint regarding the violation of an individual's or LAR's rights or the quality of services and supports;(2) investigating a complaint or forwarding the complaint to the appropriate investigatory entity;(3) advocating for the resolution of a complaint;(4) reporting the results of an investigation to the complainant, consistent with confidentiality rights;(5) reviewing policies, procedures, and practices of the state MR facility or MRA that affect the rights of an individual and LAR to ensure that the individual's and LAR's rights are protected;(6) serving as or coordinating with the liaison between the state MR facility or MRA and the Department of Family and Protective Services regarding allegations of abuse or neglect;(7) acting as the liaison between the state MR facility or MRA and advocacy organizations; and(8) acting as the liaison between the state MR facility or MRA and DADS Consumer Rights and Services.(c) The superintendent of a state MR facility and the chief executive officer of an MRA must ensure that the duties of the rights protection officer do not include any supervision of or responsibility for the delivery of services and supports that would represent a conflict of interest with the rights protection officer's primary duty of advocacy on an individual's and LAR's behalf.(d) A state MR facility and an MRA must ensure that in every program and residential area of the state MR facility and MRA:(1) the name, telephone number, e-mail address, and mailing address of the rights protection officer are posted conspicuously; and(2) a telephone is accessible for an individual to contact the rights protection officer. Source Note: The provisions of this §334.113 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.113 Rights Protection Officer at a State MR Facility or MRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219057 03/12/2026 (a) A state MR facility and an MRA must post DADS' Consumer Rights and Services toll-free number (1-800-458-9858) conspicuously in every program and residential area of the state MR facility or the MRA.(b) A consumer rights representative in DADS Consumer Rights and Services assists an individual or an LAR upon request if DADS or an MRA denies services to the individual, including admission to a state MR facility.(c) The consumer rights representative:(1) explains and provides information about services and supports and the rules, procedures, and guidelines applicable to the individual who has been denied services; and(2) assists the individual and the LAR in gaining access to appropriate services and supports or in placing the individual's name on an appropriate interest list. Source Note: The provisions of this §334.115 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.115 DADS Consumer Rights and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219058 03/12/2026 (a) DADS publishes handbooks describing the rights of an individual in simple, non-technical language and makes these handbooks available in English and in Spanish. (b) A state MR facility must give a copy of Your Rights in a State School or Center to an individual and LAR or actively involved person when the state MR facility admits the individual and annually thereafter. (c) An MRA must give a copy of Your Rights in Mental Retardation Community Programs to an individual and LAR or actively involved person when the individual applies to the MRA for services and supports and annually thereafter. (d) DADS provides copies of Your Rights in Mental Retardation Community Programs to an MRA upon request in any language used by a significant percentage of the population in the MRA's local service area. (e) A state MR facility and an MRA must conspicuously and at all times display the appropriate rights handbook in areas frequented by an individual, an individual's family member, or an LAR. The state MR facility and MRA must write in the handbook the name, telephone number, e-mail address, and mailing address of the rights protection officer at that state MR facility or MRA. (f) A state MR facility and an MRA must provide the appropriate rights handbook to a person who requests a copy. (g) The rights handbooks specified in subsections (b) and (c) of this section may be obtained: (1) through DADS' website at http://www.dads.state.tx.us/news_info/publications/brochures/index.html#consumer; (2) by writing the Department of Aging and Disability Services, Consumer Rights and Services, P.O. Box 149030, Mail Code E-249, Austin, Texas 78714-9030; or (3) by calling the toll-free number at 1-800-458-9858. (h) The following rights handbooks may be obtained by accessing the website or by writing or calling, as described in subsection (g)(1) - (3) of this section: (1) Your Rights in the Home and Community-based Services (HCS) Program; (2) Your Rights in the Texas Home Living Program; and (3) Your Rights in an ICF-MR Facility. (i) A state MR facility and an MRA may photocopy a rights handbook. Source Note: The provisions of this §334.117 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.117 Rights Handbooks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219059 03/12/2026 (a) When a state MR facility or MRA gives a copy of the rights handbook in accordance with §4.117 of this subchapter (relating to Rights Handbooks), the state MR facility or MRA must explain the rights described in the rights handbook to the individual and LAR or actively involved person in plain and simple language and in a manner that the individual and LAR or actively involved person can easily understand. The explanation must address:(1) circumstances under which the individual's rights may be limited;(2) procedures that must be followed by the state MR facility or MRA to limit the individual's rights; and(3) how and with whom a complaint about a violation of a right may be filed.(b) The language and manner used to provide the explanation must be designed for effective communication, tailored to meet the individual's ability to comprehend, and be responsive to any visual or hearing impairment.(c) If the individual is unable to comprehend the explanation of rights described in subsection (a) of this section, the explanation provided to the LAR or actively involved person meets the requirements of this section.(d) The state MR facility or MRA must document that the explanation of rights occurred. The documentation must state the name of the individual and the date that the explanation of rights occurred, and must include the dated signatures of the individual, LAR or actively involved person, and the staff member who explained the rights to the individual. The state MR facility or MRA must maintain the documentation in the individual's record. Source Note: The provisions of this §334.119 adopted to be effective January 1, 2007, 31 TexReg 10349; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.119 Communication of Rights to an Individual Receiving Services and Supports and to an LAR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219060 03/12/2026 An MRA must ensure that:(1) an employee of the MRA who will provide direct services and supports to an individual or will routinely perform job duties in proximity to an individual, and the supervisor of such an employee, receive instruction on the contents of this subchapter before starting job duties and annually thereafter; and(2) an employee of the MRA who will not provide direct services and supports to an individual and will not routinely perform job duties in proximity to an individual, and the supervisor of such an employee, receive instruction on the contents of this subchapter within two months after starting job duties and every two years thereafter. Source Note: The provisions of this §334.121 adopted to be effective January 1, 2007, 31 TexReg 10349; amended to be effective April 10, 2012, 37 TexReg 2435; transferred effective July 1, 2024, as published in the June 14, 2024, issue of the Texas Register, 49 TexReg 4435. 1 HEALTH AND HUMAN SERVICES COMMISSION 334 RIGHTS AND PROTECTION OF INDIVIDUALS WITH AN INTELLECTUAL DISABILITY §334.121 Staff Training in Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=216980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 216980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=216980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 216980 03/12/2026 (a) Definitions. The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Audio-only--A synchronous, interactive, two-way audio communication that uses only sound and that meets the privacy requirements of the Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication. Audio-only does not include face-to-face communication.(2) Audio-visual--A synchronous, interactive, two-way audio and video communication that conforms to privacy requirements under the Health Insurance Portability and Accountability Act. Audio-visual does not include audio-only or in-person communication.(3) Face-to-face--In-person or audio-visual communication that meets the requirements of the Health Insurance Portability and Accountability Act. Face-to-face does not include audio-only communication.(4) In-person (or in person)--Within the physical presence of another person. In-person or in person does not include audio-visual or audio-only communication.(b) The Texas Health and Human Services Commission (HHSC) may allow local intellectual and developmental disability authorities (LIDDAs) to use the flexibilities described in subsection (c) of this section while an executive order or proclamation declaring a state of disaster under Texas Government Code §418.014 is in effect. HHSC will notify LIDDAs when a flexibility is permitted and the date the flexibility must no longer be used, which may be before the declaration of a state of disaster expires.(c) Subject to the notification by HHSC, the following flexibilities may be available to LIDDAs to the extent the flexibility is permitted by and does not conflict with other laws or obligations of the LIDDA and is allowed by federal and state law.(1) Service coordination required to be provided in person under 26 TAC §331.11(d) of this title (relating to LIDDA's Responsibilities) may be provided using audio-visual or audio-only communication.(2) HHSC may extend the timeframes for LIDDAs in the following rules:(A) the timeframe to request an administrative hearing in 40 TAC §4.156 (relating to Request for an Administrative Hearing);(B) the timeframe for a person and legally authorized representative (LAR) to request a review of a decision to deny or terminate services in 26 TAC §301.155(e)(3) (relating to Notification and Appeals Process);(C) the timeframe for a person or the person's parent to comply with the applicable accountability requirement in 40 TAC §2.105(f)(1) (relating to Accountability) in order for the LIDDA to retroactively adjust the person's account; and(D) the timeframe for a person or parent to submit a request to review a LIDDA's appeal decision to HHSC in 40 TAC §2.109(e)(3) (relating to Payments, Collections, and Non-payment).(d) LIDDAs that use one or more of the flexibilities allowed under subsection (c) of this section must comply with:(1) all policy guidance applicable to the rules identified in subsection (c) of this section issued by HHSC Community Services Division during the declaration of disaster that is published by HHSC on its LIDDA website or in another communication format HHSC determines appropriate; and(2) all policy guidance applicable to the rules identified in subsection (c) of this section issued by HHSC Medicaid and CHIP Services.(e) LIDDAs must ensure audio-only or audio-visual communication complies with all applicable requirements related to security and privacy of information.(f) LIDDAs must notify the person, the LAR, or the person's parent if the person is younger than 18 years of age, of the extension of timeframes permitted under subsection (c)(2) of this section that apply to the person receiving services. Source Note: The provisions of this §338.1 adopted to be effective March 17, 2024, 49 TexReg 1475. 1 HEALTH AND HUMAN SERVICES COMMISSION 338 DISASTER RULE FLEXIBILITIES FOR LOCAL INTELLECTUAL AND DEVELOPMENTAL DISABILITY AUTHORITIES (LIDDAs) §338.1 Disaster Flexibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205202 03/12/2026 Under Human Resources Code, §117.074, this rule adopts standards governing the determination of rates paid for medical services provided by DARS. The rates determined under these standards are reevaluated annually.(1) Rates shall be established based on Medicare and Medicaid schedules for current procedural terminology (CPT). Where Medicare and Medicaid schedules are not applicable, rates that represent best value shall be established based on factors that include reasonable and customary industry standards for each specific service.(2) Rates shall be established at a level adequate to ensure availability of qualified providers, and in adequate numbers to provide assessment and treatment, and within a geographic distribution that mirrors consumer or claimant distribution.(3) Exceptions to established rates may be made on a case-by-case basis by the DARS medical director or optometric consultant. Source Note: The provisions of this §349.1 adopted to be effective March 12, 2012, 37 TexReg 1720; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3423. 1 HEALTH AND HUMAN SERVICES COMMISSION 349 PURCHASE OF GOODS AND SERVICES FOR REHABILITATION, INDEPENDENCE, AND EARLY CHILDHOOD INTERVENTION A RATE DETERMINATION FOR PURCHASE OF REHABILITATION, INDEPENDENCE, AND EARLY CHILDHOOD INTERVENTION MEDICAL SERVICES §349.1 Alternative Purchasing Methods - Rates for Medical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223920 03/12/2026 The following words and terms, when used in this chapter, will have the following meanings, unless the context clearly indicates otherwise.(1) Assessment--As defined in 34 CFR §303.321(a)(2)(ii), the ongoing procedures used by appropriate qualified personnel to assess the child's individual strengths and needs and determine the appropriate services to meet those needs throughout the period of a child's eligibility for ECI services.(2) Child--An infant or toddler under the age of three.(3) Child find--As described in 34 CFR §§303.115, 303.302, and 303.303, activities and strategies designed to locate and identify, as early as possible, infants and toddlers with developmental delay.(4) CFR--Code of Federal Regulations. The codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government.(5) Complaint--A formal written allegation submitted to HHSC stating that a requirement of IDEA Part C or an applicable federal or state regulation has been violated.(6) Comprehensive needs assessment--The process for identifying a child's unique strengths and needs, and the family's resources, concerns, and priorities in order to develop an IFSP. The comprehensive needs assessment:(A) is conducted by an interdisciplinary team as defined in paragraph (29) of this section; and(B) gathers information across developmental domains regarding the child's abilities to participate in the everyday routines and activities of the family.(7) Consent--As defined in 34 CFR §303.7 and meeting all requirements in 34 CFR §303.420.(8) Co-visits--When two or more ECI professionals deliver different services to the child during the same period of time. Co-visits are provided when a child will receive greater benefit from services being provided at the same time, rather than individually.(9) Days--Calendar days.(10) Developmental delay--As defined in Texas Human Resources Code §73.001(3) and determined to be significant in compliance with the criteria and procedures in Subchapter H of this chapter (relating to Eligibility, Evaluation, and Assessment).(11) Developmental screenings--General screenings provided by the ECI program to assess the child's need for further evaluation. (12) DFPS--Department of Family and Protective Services. The state agency that provides family reunification services for families. These services are provided to families and children to protect the children from abuse and neglect and help the family reduce the risk of abuse and neglect.(13) ECI--Early Childhood Intervention.(14) ECI professional--An individual employed by or under the direction of an ECI program who meets the requirements of qualified personnel as defined in 34 CFR §303.13(c) and §303.31, and who is knowledgeable in child development and developmentally appropriate behavior, possesses the requisite education and experience, and demonstrates competence to provide ECI services.(15) ECI program--In addition to the definition of early intervention service program as defined in 34 CFR §303.11, a program operated by a subrecipient of HHSC ECI with the express purpose of implementing a system to provide ECI services to children with developmental delays and their families.(16) ECI services--Individualized IDEA Part C services determined by the IFSP team to be necessary to support the family's ability to enhance their child's development. ECI services are further defined in 34 CFR §303.13 and §303.16 and §350.1105 of this chapter (relating to Capacity to Provide Early Childhood Intervention Services).(17) ECSE--Early Childhood Special Education. The state and federally mandated program for young children with disabilities ages three to five under IDEA Part B, Section 619.(18) EIS--Early intervention specialist. A credentialed professional who meets specific educational requirements established by HHSC ECI in §350.313(a) of this chapter (relating to Early Intervention Specialist) and has specialized knowledge in early childhood cognitive, physical, communication, social-emotional, and adaptive development.(19) Evaluation--The procedures used by qualified personnel to determine a child's initial and continuing eligibility for ECI services that comply with the requirements described in 34 CFR §303.21 and §303.321.(20) Face-to-face--The delivery of ECI services in-person or via telehealth.(21) FERPA--Family Educational Rights and Privacy Act of 1974, 20 USC §1232g, as amended, and implementing regulations at 34 CFR Part 99. Federal law that outlines privacy protection for parents and children enrolled in the ECI program. FERPA includes rights to confidentiality and restrictions on disclosure of personally identifiable information, and the right to inspect records.(22) Group services--ECI services provided at the same time to no more than four children and their parent or parents or routine caregivers per ECI professional to meet the developmental needs of the individual infant or toddler.(23) HHSC--Texas Health and Human Services Commission.(A) HHSC has the final authority and responsibility for the administration, supervision, and monitoring of programs and activities under this system.(B) HHSC has the final authority for the obligation and expenditure of funds and compliance with all applicable laws and rules.(24) HHSC ECI--Texas Health and Human Services Commission Early Childhood Intervention. The entity designated as the lead agency, as defined by 34 CFR §303.22. HHSC ECI is responsible for maintaining and implementing the statewide IDEA Part C system.(25) IDEA Part C--The Individuals with Disabilities Education Act, Part C, as amended in 2004.(26) IFSP--Individualized Family Service Plan as defined in 34 CFR §303.20. A written plan of care for providing ECI services and other medical, health, and social services to an eligible child and the child's family when necessary to enhance the child's development. The IFSP is considered complete when the parent has signed the IFSP and received a copy.(27) IFSP services--The individualized ECI services listed in the IFSP that have been determined by the IFSP team to be necessary to enhance an eligible child's development.(28) IFSP services pages--The standardized form designated by HHSC ECI that constitutes the required final pages of the IFSP used to record ECI services planned for the child.(29) IFSP team--An interdisciplinary team that meets the requirements in 34 CFR §303.24(b) and works collaboratively to develop, review, modify, and approve the IFSP. The IFSP team includes, at a minimum, the child's parent and at least two ECI professionals from different disciplines or professions.(A) At least one of the ECI professionals must be the family's assigned service coordinator.(B) At least one of the ECI professionals must be an LPHA.(C) At least one ECI professional must have been involved in conducting the evaluation. This may be the LPHA or another professional.(D) If the LPHA attending the IFSP meeting did not conduct the evaluation, the subrecipient must ensure that the most recent observations and conclusions of the LPHA who conducted the evaluation were communicated to the LPHA attending the initial IFSP meeting and incorporated into the IFSP.(E) Other team members may participate by other means acceptable to the team.(30) Interdisciplinary team--In addition to the definition of multidisciplinary team as defined in 34 CFR §303.24, a team that consists of at least two ECI professionals from different disciplines and the child's parent.(A) One of the ECI professionals must be an LPHA.(B) The team may include a teacher for the deaf and hard of hearing, a teacher for students with visual impairments, and a certified orientation and mobility specialist from the child's LEA, as appropriate.(C) Professionals on the team shall share a common perspective regarding infant and toddler development and developmental delay.(D) Professionals on the team must work collaboratively to:(i) conduct the evaluation and assessment;(ii) develop the IFSP; and(iii) provide ECI services.(31) LEA--Local educational agency as defined in 34 CFR §303.23.(32) LPHA--Licensed practitioner of the healing arts. A licensed physician, registered nurse, licensed physical therapist, licensed occupational therapist, licensed speech language pathologist, licensed professional counselor, licensed clinical social worker, licensed psychologist, licensed dietitian, licensed audiologist, licensed physician assistant, licensed marriage and family therapist, licensed intern in speech language pathology, licensed behavior analyst, or advanced practice registered nurse who is an employee or a subcontractor of an ECI subrecipient. LPHA responsibilities are further described in §350.312 of this chapter (relating to Licensed Practitioner of the Healing Arts).(33) Medicaid--The medical assistance entitlement program administered by HHSC.(34) MOU--Memorandum of understanding. A written document evidencing the understanding or agreement of two or more parties regarding the subject matter of the agreement.(35) Native language--As defined in 34 CFR §303.25.(A) When used with respect to an individual who is limited English proficient (as that term is defined in IDEA Part B, Section 602(18)), native language means:(i) the language normally used by that individual, or, in the case of a child, the language normally used by the parents of the child; and(ii) for evaluations and assessments conducted pursuant to 34 CFR §303.321(a)(5) and (a)(6), the language normally used by the child, if determined developmentally appropriate for the child by qualified personnel conducting the evaluation or assessment.(B) When used with respect to an individual who is deaf or hard of hearing, blind or visually impaired, or for an individual with no written language, "native language" means the mode of communication that is normally used by the individual (such as sign language, braille, or oral communication).(36) Natural environments--As defined in 34 CFR §303.26, settings that are natural or typical for a same-aged infant or toddler without a disability. A natural environment may include the home or community settings, include the daily activities of the child and family or caregiver, and must be consistent with the provisions of 34 CFR §303.126.(37) Parent--As defined in 20 USC §1401(23) and 34 CFR §303.27.(38) Personally identifiable information--As defined in 34 CFR §99.3 and 34 CFR §303.29.(39) Pre-enrollment--All family-related activities from the time the referral is received up until the time the parent signs the initial IFSP.(40) Primary referral sources--As defined in 34 CFR §303.303(c). (41) Public agency--HHSC and any other state agency or political subdivision of the state that is responsible for providing ECI services to eligible children under IDEA Part C.(42) Qualifying medical diagnosis--A diagnosed medical condition that has a high probability of developmental delay as determined by HHSC, as described in §350.811 of this chapter (relating to Qualifying Medical Diagnosis).(43) Referral date--The date the child's name and sufficient information to contact the family was obtained by the subrecipient.(44) Routine caregiver--An adult who:(A) has written authorization from the parent to participate in ECI services with the child, even in the absence of the parent;(B) participates in the child's daily routines;(C) knows the child's likes, dislikes, strengths, and needs; and(D) may be the child's relative, childcare provider, or other person who regularly cares for the child.(45) SEA--State educational agency as defined by 34 CFR §303.3(b).(46) Service coordinator--An employee or subcontractor of an ECI subrecipient who:(A) meets all applicable requirements in Subchapter C of this chapter (relating to Staff Qualifications);(B) is assigned to be the single contact point for the family;(C) is responsible for providing case management services as described in §350.405 of this chapter (relating to Case Management Services); and(D) is from the profession most relevant to the child's or family's needs or is otherwise qualified to carry out all applicable responsibilities.(47) SRS--Specialized rehabilitative services. Rehabilitative services outlined in §350.501 of this chapter (relating to Specialized Rehabilitative Services) that promote age-appropriate development by correcting deficits and teaching compensatory skills for deficits that directly result from medical, developmental, or other health-related conditions.(48) SST--Specialized skills training. As defined by 34 CFR 303.13(b)(14). SST seeks to reduce the child's functional limitations across developmental domains, including strengthening the child's cognitive skills, positive behaviors, and social interactions.(49) Subrecipient--A local private or public agency with proper legal status and governed by a board of directors or governing authority that accepts funds from HHSC to administer an ECI program.(50) Surrogate parent--A person assigned to act as a surrogate for the parent in compliance with IDEA Part C and this chapter.(51) TAC--Texas Administrative Code. A compilation of all state agency rules in Texas.(52) TCM--Targeted case management. Case management activities that meet criteria in §350.405(c) of this subchapter and are reimbursable by Medicaid when provided to Medicaid-enrolled children who are eligible for ECI.(53) TEA--Texas Education Agency. The state agency that oversees primary and secondary public education. It is headed by the commissioner of education.(54) Telehealth services--Health care services, other than telemedicine medical services, delivered by a health professional licensed, certified, or otherwise entitled to practice in Texas and acting within the scope of the health professional's license, certification, or entitlement to a patient who is located at a different physical location than the health professional using synchronous audio-visual telecommunications or information technology.(55) USC--United States Code. The official codification of the general and permanent federal statutes of the United States. Source Note: The provisions of this §350.103 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective May 1, 2014, 39 TexReg 3445; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES A GENERAL RULES §350.103 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203627 03/12/2026 (a) The contractor must develop and implement written policy and procedures to address accessibility and safety regulations for all buildings and offices where ECI programs are housed.(1) Buildings must be physically accessible to persons with disabilities.(2) Buildings must be inspected annually by a local or state fire authority. A safety and sanitation inspection must be completed annually. If the fire or safety and sanitation inspection indicates that hazards exist, these hazards must be corrected.(3) Buildings must comply with all requirements of any applicable licensing or regulatory body for these types of activities carried on in the building.(b) If the contractor provides early childhood intervention services in settings other than the child's home, the contractor must develop and implement written policy and procedures that address accessibility and safety issues.(c) The contractor's system for transportation services for children and families must meet all local and state legal requirements. Source Note: The provisions of this §350.105 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES A GENERAL RULES §350.105 Safety Regulations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223921 03/12/2026 (a) The subrecipient must implement written policies and procedures that cover the following areas:(1) administration of medication, if applicable;(2) infectious disease prevention and management, including: (A) adherence to universal precautions as defined by the Centers for Disease Control of the United States Public Health Service;(B) compliance with the Texas Communicable Disease Prevention and Control Act, Texas Health and Safety Code Chapter 81; and(C) immunization guidelines as specified by the Texas Department of State Health Services.(b) The subrecipient must follow all federal and state laws and regulations regarding providing services and maintaining records for families and children with Human Immunodeficiency Virus or other communicable diseases.(c) The subrecipient must not refuse to provide ECI services to a child based solely on the family's refusal or failure to obtain a vaccine or immunization for a particular infectious or communicable disease. The subrecipient is not in violation of this rule if the subrecipient adopts a policy requiring children receiving group services to be vaccinated or immunized against a particular infection or communicable disease if the policy provides an exemption from each required vaccination or immunization based on:(1) a reason of conscience, including a sincerely held religious belief, observance, or practice, that is incompatible with the administration of the vaccination or immunization; or(2) a recognized medical condition for which the vaccination or immunization is contraindicated.(d) The subrecipient must accept oral or written requests for an exemption. Source Note: The provisions of this §350.107 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES A GENERAL RULES §350.107 Health Standards for Early Childhood Intervention Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203644 03/12/2026 The purpose of procedural safeguards is to enforce the legal rights of children with developmental delays or disabilities and their families pertaining to early childhood intervention services. Procedural safeguards are integrated through every stage of a family's early childhood intervention services experience. These procedures are a part of, not separate from, the required programmatic processes. Source Note: The provisions of this §350.202 adopted to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.202 Procedural Safeguards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208173 03/12/2026 (a) The contractor shall be responsible for:(1) establishing or adopting procedural safeguards that meet the requirements of the federal and state regulations listed in §350.101 of this chapter (relating to Purpose) and that also meet additional requirements of this subchapter;(2) implementing the procedural safeguards; and(3) providing oral and written explanation to the parent regarding procedural safeguards during the pre-enrollment process and at other times when parental consent is required.(b) The contractor must make reasonable effort to provide appropriate interpreter or translation services in the child's native language as defined in 34 CFR §303.25 or other communication assistance necessary for a parent or child with limited English proficiency or communication impairments to participate in early childhood intervention services. Interpreter, translation, and communication assistance services are provided at no cost to the family.(c) The contractor must provide the family with the Early Childhood Intervention Parent Handbook. The contractor must document that the following were explained:(1) the family's rights;(2) the early childhood intervention process; and(3) early childhood intervention services. Source Note: The provisions of this §350.203 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.203 Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203646 03/12/2026 In accordance with 34 CFR §303.421, prior written notice is required to inform the parent of any actions the contractor proposes to take or not take, the reason for taking or not taking the action, and to remind the parent about the parent's rights regarding these actions. These actions include identification of the child, evaluation, IFSP meetings, and the provision of early childhood intervention services. Through prior written notice, the contractor:(1) provides the parent with sufficient notice of meetings to allow the parent time to prepare for the meeting and to invite other individuals if they choose;(2) keeps the parent informed about any action the contractor is proposing to take or not take; and(3) provides the parent with sufficient notice of actions the contractor will take unless the parent exercises his or her due process rights. Source Note: The provisions of this §350.204 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.204 Prior Written Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208166 03/12/2026 (a) Written parental consent provides documentation that the parent has been informed of and agrees, in writing, to the proposed action. Consent is voluntary and can be withdrawn by the parent at any time. Any action for which the parent has withdrawn consent must be stopped immediately.(b) In addition to the requirements in 34 CFR §303.420, written parental consent must be obtained before:(1) beginning any screening, except when performing a developmental screening on a child in the conservatorship of the Texas Department of Family and Protective Services;(2) conducting any evaluation or assessment procedures;(3) providing early childhood intervention services listed in the Individualized Family Service Plan (IFSP);(4) changing the type, intensity, or frequency of early childhood intervention services;(5) contacting medical professionals and other outside sources to coordinate and gather information about the child and family;(6) reporting personally identifiable information, including disposition of referral, electronically to statewide databases unless release is authorized without consent in the Family Education Rights and Privacy Act; or(7) releasing personally identifiable information except as allowed by §350.241 of this chapter (relating to Release of Records).(c) As required by 34 CFR §303.420(b), the contractor must adopt procedures designed to inform the parent of the nature of the recommended assessment or evaluation procedures and recommended early childhood intervention services that the parent has refused. The procedures may include:(1) providing the parent relevant literature or other materials; and(2) offering the parent peer counseling to enhance their understanding of the value of early childhood intervention and the inability to participate in the Individuals with Disabilities Education Act, Part C programs without consent.(d) If a specific assessment or service is determined necessary by the IFSP team, the contractor may not limit or deny that assessment or service because the parent has refused consent for another service or assessment. Source Note: The provisions of this §350.207 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.207 Parental Consent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223924 03/12/2026 The subrecipient must explain the contents of the IFSP to the parent or parents and obtain informed written consent from a parent before providing any ECI services. A parent has the right to: (1) be present and participate in the development of the IFSP; (2) have decisions about ECI services made based on the individualized needs of the child and family; (3) receive a full explanation of the IFSP, including the identified strengths and needs of the child and family, priorities of the family, the developmental goals for the child and the recommended services to meet those goals, and any identified service coordination and case management goals; (4) consent to some, but not all, ECI services; (5) receive all IFSP services for which the parent gives consent; (6) request an administrative hearing or file a complaint with HHSC if the parent does not agree with the other IFSP team members; (7) indicate disagreement in writing in the parent's native language with a part of the IFSP, even if the parent consents to ECI services; (8) have the IFSP written in the parent's native language, as defined in §350.103 of this chapter (relating to Definitions), or mode of communication; and (9) receive a complete copy of the IFSP in a timely manner. Source Note: The provisions of this §350.209 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.209 Parent Rights in the Individualized Family Service Plan Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203649 03/12/2026 When situations arise in which more than one person meets the definition of parent, as defined in 20 USC §1401 and in 34 CFR §303.27, the contractor must have a method of resolving conflicts in a manner that gives proper deference to the opinions and decisions of the individual or individuals who has the best legal right to act as the child's parent. Written rules or policies developed by the contractor must not violate other state or federal laws.(1) The biological or adoptive parent, unless such parent does not have legal authority to make health, educational or early childhood intervention services decisions for the child, has priority to act as the parent for the purposes of this chapter.(2) If a judicial decree or order identifies a specific person or persons to act as the child's parent to make health, educational, or early childhood intervention service decisions on behalf of a child, then the contractor acknowledges that person or persons to be the "parent."(A) The exception to this rule is that no state agency, no HHSC ECI contractor or provider, and no public agency that provides any paid services to a child or any family member of that child may act as the parent for the purposes of ECI.(B) Notwithstanding the preceding exception, an individual who is a biological or adoptive parent or family member of the child who has also been identified by a judicial decree to act as the "parent" of the child is not disqualified to act as parent. Source Note: The provisions of this §350.211 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.211 Parent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203650 03/12/2026 (a) The contractor shall ensure that the rights of children eligible under this chapter are protected if:(1) no parent can be identified; or(2) the contractor, after reasonable efforts, cannot discover the whereabouts of a parent.(b) The contractor must determine the need for and assign a surrogate parent for the child consistent with 34 CFR §303.422 and existing state laws and regulations. This must include a method for:(1) determining whether a child needs a surrogate parent;(2) assigning a surrogate parent within the required 30-day timeframe; and(3) providing training to ensure that the surrogate parent fully understands their role and responsibilities to represent the best interest of the child.(c) Criteria for selecting surrogates are as follows.(1) A person selected as surrogate must have no interest that conflicts with the interests of the child represented.(2) A person assigned as a surrogate parent must not be an employee of any state agency or a person or an employee of a person providing early childhood intervention services to the child or any family member of the child.(3) A person who qualifies to be a surrogate parent is not an employee solely because he or she is paid to serve as a surrogate parent.(4) A person selected as a surrogate parent must have knowledge and skills that ensure adequate representation of the interests of the child.(5) The requirements of paragraphs (1) - (4) of this subsection ensure that the surrogate parent does not hold a job or a position that would either bias the decisions made for the child or make the surrogate parent vulnerable to the possibility of administrative retaliation for the execution of their responsibilities.(6) If a person qualifies as a "parent" there is no need to appoint a "surrogate parent" and no need to meet the criteria in this subsection.(d) A surrogate parent may represent a child in all matters related to:(1) the evaluation and assessment of the child;(2) development and implementation of the child's IFSPs, including annual evaluations and periodic reviews;(3) the ongoing provision of early childhood intervention services to the child; and(4) any other rights established under this chapter. Source Note: The provisions of this §350.213 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.213 Surrogate Parents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208168 03/12/2026 (a) An individual or organization may file a complaint with the Texas Health and Human Services Commission (HHSC) alleging that a requirement of the Individuals with Disabilities Education Act, Part C or applicable federal and state regulations has been violated. The complaint must be in writing, be signed, and include the nature of the violation and a statement of the facts on which the complaint is based.(b) A complaint may be filed directly with HHSC without having been filed with the contractor or local program.(c) The alleged violation must have occurred not more than one year before the date that the complaint is received by the public agency unless a longer period is reasonable because the alleged violation continues for that child or other children.(d) Procedures for receipt of a complaint are as follows.(1) All complaints received by HHSC concerning early childhood intervention services shall be forwarded to the HHSC Director of ECI who will log and assign all complaints, monitor the resolution of those complaints, and maintain a copy of all complaints for a seven-year period.(2) A complaint should be clearly distinguished from a request for an administrative hearing under 40 TAC Chapter 101, Subchapter E, Division 3 (relating to Division for Early Childhood Intervention Services) and from a request for a hearing under §350.227 of this chapter (relating to Opportunity for a Hearing) concerning the requirements of the Federal Education Rights and Privacy Act. Source Note: The provisions of this §350.215 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.215 Early Childhood Intervention (ECI) Procedures for Filing Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208169 03/12/2026 (a) After receipt of the complaint, the Texas Health and Human Services Commission (HHSC) Director of Early Childhood Intervention (ECI) will assign a staff person to conduct an individual investigation, on-site if necessary, to make a recommendation to the HHSC Director of ECI for resolution of the complaint. The child's and family's confidentiality is protected during the complaint resolution process.(1) The complainant will have the opportunity to submit additional information, either orally or in writing, about the allegations in the complaint.(2) All relevant information will be reviewed and an independent determination made as to whether a violation of the requirements of the Individuals with Disabilities Education Act occurred.(b) The HHSC Director of ECI will resolve the complaint within 60 days of the receipt date.(c) An extension of the time limit under subsection (b) of this section shall be granted only if exceptional circumstances exist with respect to a particular complaint.(d) Complainants shall be informed in writing of the final decision of the HHSC Director of ECI. The HHSC Director of ECI's written decision to the complainant will address each allegation in the complaint and contain:(1) findings of fact and conclusions; and(2) reasons for the final decision.(e) To ensure effective implementation of the HHSC Director of ECI's final decision and to achieve compliance with any corrective actions, the HHSC Director of ECI will assign a staff person to provide technical assistance and appropriate follow-up to the parties involved in the complaint as necessary.(f) In resolving a complaint in which there is a finding of failure to provide appropriate services, the HHSC Director of ECI will remediate the denial of those services, including, as appropriate, the awarding of monetary reimbursement or other corrective action appropriate to the needs of the child and the child's family; and appropriate future provision of services for all infants and toddlers with disabilities and their families.(g) When a complaint is filed, the HHSC Director of ECI will offer mediation services as an alternative to proceeding with the complaint investigation. Mediation may be used when both parties agree to it. A parent's right to a due process hearing or complaint investigation will not be denied or delayed because the parent chose to participate in mediation. The complaint investigation will continue and be resolved within 60 days even if mediation is used as the resolution process.(h) If a written complaint is received that is also the subject of a request for an administrative hearing under 40 TAC Chapter 101, Subchapter E, Division 3 (relating to Division for Early Childhood Intervention Services) or a request for a hearing under §350.227 of this chapter (relating to Opportunity for a Hearing) concerning the requirements of the Federal Education Rights and Privacy Act, or contains multiple issues, of which one or more are part of those hearings, the part of the complaint that is being addressed in those hearings is set aside until the conclusion of the hearings. However, any issue in the complaint that is not a part of such action must be resolved within the 60-day timeline using the complaint procedures. Source Note: The provisions of this §350.217 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective June 1, 2013, 38 TexReg 3356; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.217 Procedures for Investigation and Resolution of Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208170 03/12/2026 (a) At any time, a party or all parties to a dispute involving a matter with respect to the provision of appropriate early childhood intervention services or a potential or actual violation of the Individuals with Disabilities Education Act, Part C or other applicable federal or Texas statutes or regulations or rules may request mediation of that dispute by sending the request in writing to the Texas Health and Human Services Commission (HHSC) Director of Early Childhood Intervention (ECI). A request for mediation must:(1) be in writing and signed by the requesting party;(2) state the dispute to be mediated with some detail showing it is a matter with respect to the provision of appropriate early childhood intervention services to a particular child or children, or that it is a matter with respect to a potential or actual violation of the Individuals with Disabilities Education Act, Part C or other applicable federal or Texas statutes or regulations or rules;(3) name the opposing party or parties and, if they have agreed to mediation, contain their signatures;(4) give contact information for all parties to the extent known by the requestor; and(5) show that the request for mediation has also been sent to all other parties or that attempts have been made to do so, if possible.(b) If the request for mediation is also a complaint pursuant to §350.215 of this subchapter (relating to Early Childhood Intervention Procedures for Filing Complaints), it will be handled both as a complaint and as a request for mediation under subsection (c) of this section. If the request for mediation is also a request for a due process hearing, it will be handled both as a request for a due process hearing and a request for mediation under subsection (c) of this section. If the request for mediation does not clearly designate itself as a complaint or request for a due process hearing, or if it does not comply with the filing requirements for those procedures, it will be handled only as a request for mediation under this section.(c) If the parties to a request for a due process hearing as described in 40 TAC §101.1107 (relating to Administrative Hearings Concerning Individual Child Rights) agree to mediate the dispute in accordance with 40 TAC §101.947 (relating to Mediation Procedures), those procedures shall apply, but the mediation shall also comply with the requirements of federal regulation 34 CFR §303.431.(d) If the parties to a complaint filed with HHSC under §350.215 of this subchapter agree to mediate the dispute in accordance with §350.217 of this subchapter (relating to Procedures for Investigation and Resolution of Complaints), the procedures in this section apply except for those in subsections (b) and (c) of this section.(e) If not all parties have agreed to mediation, HHSC will make reasonable efforts to contact the other parties and give them the opportunity to agree to or to decline mediation. If neither HHSC nor the requesting party is able to obtain agreement to mediate by all parties within a reasonable time, HHSC may notify the requesting party and treat the original request for mediation as having been declined by the other party or parties.(f) The parties may agree to mediate some or all of the disputes described in the request for mediation, and they may amend the disputes to be mediated by agreeing in writing.(g) If HHSC is not a party to the dispute being mediated, HHSC will not be a party to any mediation resolution agreement and will not sign it, but HHSC may assist in the enforcement of it if requested. Source Note: The provisions of this §350.218 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1280. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.218 Mediation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203631 03/12/2026 During pre-enrollment, the contractor must give the family a copy of the HHSC ECI Parent Handbook publication, which contains notice that fully informs the parent about their confidentiality rights as specified in 34 CFR §303.402. The contractor must explain the contents of the HHSC ECI Parent Handbook when initially providing the publication to the family and annually thereafter. Source Note: The provisions of this §350.219 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.219 Confidentiality Notice to Parents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203632 03/12/2026 (a) The parent of a child eligible under this chapter must be afforded the opportunity to inspect and review any records relating to evaluations and assessments, eligibility determination, development and implementation of the IFSP, individual complaints dealing with the child, and any other area under this chapter involving records about the child and the child's family. The records are covered by FERPA. Any participating agency, institution, or program which collects, maintains, or uses personally identifiable information from which information is obtained for the purpose of determining eligibility for or providing early childhood intervention services will be subject to these provisions. The contractor shall comply with a request without unnecessary delay and before any meeting regarding an IFSP or hearing relating to the identification, evaluation, or placement of the child, and in no case, more than 10 days after the request has been made.(b) The right to inspect and review records under this section includes the right to:(1) a response from the participating contractor to reasonable requests for explanations and interpretations of the records;(2) request that the contractor provide copies of the records containing the information if failure to provide those copies would effectively prevent the parent from exercising the right to inspect and review the records; and(3) have the parent's representative inspect and review the records.(c) The contractor may presume that the parent has authority to inspect and review records relating to his or her child unless the agency has been advised that the parent does not have the authority under applicable state law governing such matters as guardianship, separation, and divorce.(d) If any record includes information on more than one child, the parent of those children shall have the right to inspect and review only the information relating to their child or to be informed of that specific information.(e) The contractor must, on request, provide the parent a list of the types and locations of service records collected, maintained, or used by the contractor. Source Note: The provisions of this §350.221 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.221 Access Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203633 03/12/2026 (a) The contractor must make available to parents an initial copy of the child's early childhood intervention services record at no cost to the parents.(b) The contractor may charge a fee for copies of records which are made for the parent under this section if the fee does not effectively prevent the parent from exercising their right to inspect and review those records.(c) The contractor may not charge a fee to search for or to retrieve information under this section.(d) The contractor must provide copies to parents according to 34 CFR §303.405 and §303.409. Source Note: The provisions of this §350.223 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.223 Fees for Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223925 03/12/2026 (a) A parent who believes that information in records collected, maintained, or used under this section is inaccurate, misleading, or a violation of the privacy or other rights of the child, may request that the subrecipient amend the information. (b) The subrecipient decides whether to amend the information in accordance with the request no more than 30 days after the request is made.(c) If, after review of the request, the subrecipient decides the information is inaccurate, misleading, or otherwise in violation of the privacy or other rights of the child, it amends the record accordingly and informs the parent in writing. (d) If the subrecipient refuses to amend the information in accordance with the request, it informs the parent of the refusal, and advises the parent of the right to a hearing conducted in accordance with the requirements of FERPA. Source Note: The provisions of this §350.225 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.225 Amendment of Records at Parent's Request https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203635 03/12/2026 The contractor shall, on request, provide an opportunity for a hearing to challenge information in early childhood intervention records to ensure that it is not inaccurate, misleading, or otherwise in violation of the privacy or other rights of the child. This hearing must be conducted in accordance with FERPA. Source Note: The provisions of this §350.227 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.227 Opportunity for a Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203636 03/12/2026 The hearing must meet at a minimum the following FERPA requirements.(1) The contractor must hold the hearing within 30 days after it has received the request for the hearing from the parent.(2) The contractor must give the parent notice of the date, time, and place, reasonably in advance of the hearing.(3) The hearing may be conducted by any individual including an official of the contractor, who does not have a direct interest in the outcome of the hearing.(4) The contractor must give the parent a full and fair opportunity to present evidence relevant to the issues under FERPA, including, but not limited to, FERPA regulations at 34 CFR §99.21. The parent may, at their own expense, be assisted or represented by one or more individuals of his or her own choice, including an attorney.(5) The contractor must make its decision in writing within 30 days.(6) The decision must be based solely on the evidence presented at the hearing, and must include a summary of the evidence and the reasons for the decision. Source Note: The provisions of this §350.229 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.229 Minimum Requirements for Conducting a Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203637 03/12/2026 (a) If, as a result of the hearing, the contractor decides that the information is inaccurate, misleading, or otherwise in violation of the privacy or other rights of the child or family, it must amend the information accordingly and so inform the parent in writing.(b) If, as a result of the hearing, the contractor decides that the information is accurate and not misleading or otherwise in violation of the privacy or other rights of the child or family, it must inform the parent of the right to place in the record it maintains on the child or family, a statement commenting on the information or setting forth any reasons for disagreeing with the decision of the contractor.(c) Any explanation placed in the records of the child or family under this section must:(1) be maintained by the contractor as part of the records of the child or family as long as the record or contested portion is maintained; and(2) if the records of the child or family or the contested portion is disclosed by the contractor to any party, the explanation must also be disclosed to the party. Source Note: The provisions of this §350.231 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.231 Results of Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208171 03/12/2026 (a) Unless authorized to do so under 34 CFR §99.31 or the Uninterrupted Scholars Act (Public Law 112-278), parental consent must be obtained before personally identifiable information is:(1) disclosed to anyone other than officials or employees of Early Childhood Intervention (ECI) participating agencies collecting or using the information; or(2) used for any purpose other than meeting a requirement under this chapter.(b) A contractor may request that the parent provide a release to share information with others for legitimate purposes. However, when such a release is sought:(1) the parent must be informed of their right to refuse to sign the release;(2) the release form must list the agencies and providers to whom information may be given and specify the type of information that might be given to each;(3) the parent must be given the opportunity to limit the information provided under the release and to limit the agencies, providers, and persons with whom information may be shared. The release form must provide ample space for the parent to express in writing such limitations;(4) the release must be revocable at any time;(5) the consent to release information form must have a time limit:(A) not to exceed seven years after the child exits services or other applicable record retention period, as described in §350.237 of this subchapter (relating to Record Retention Period) for billing records; or(B) not to exceed one year for all other consents to release information; and(6) if the parent refuses to consent to the release of all or some personally identifiable information, the program will not release the information.(c) The contractor may disclose personally identifiable information without prior written parental consent if the disclosure meets one or more of the following conditions:(1) the disclosure is to another Texas Health and Human Services Commission (HHSC) ECI contractor during a transfer of services;(2) the disclosure is restricted to limited personal identification, as defined in §350.1203 of this chapter (relating to Definitions), being sent to the Local Education Agency (LEA) for child find purposes, unless the parent opted-out of the notification in accordance with §350.1213 of this chapter (relating to LEA Notification Opt Out);(3) the disclosure is to the Texas Department of Family and Protective Services for the purpose of reporting or cooperating in the investigation of suspected child abuse or neglect;(4) the disclosure is in response to a court order or subpoena;(5) the disclosure is to a federal or state oversight entity, including:(A) United States Department of Health and Human Services, or its designee;(B) Comptroller General of the United States, or its designee;(C) Office of the State Auditor of Texas, or its designee;(D) Office of the Texas Comptroller of Public Accounts, or its designee;(E) Medicaid Fraud Control Unit of the Texas Attorney General's Office, or its designee;(F) HHSC, including:(i) Office of Inspector General;(ii) Managed Care Organization Program personnel from HHSC, or designee;(iii) any other state or federal entity identified by HHSC, or any other entity engaged by HHSC; and(iv) any independent verification and validation contractor, audit firm, or quality assurance contractor acting on behalf of HHSC;(G) state or federal law enforcement agency; or(H) State of Texas Legislature general or special investigating committee or its designee; or(6) the disclosure meets the requirements of the Uninterrupted Scholars Act, which provides that:(A) the disclosure is to a caseworker or other representative of a State or local child welfare agency or tribal organization authorized to access the child's case plan;(B) the child is in foster care and the child welfare agency or organization is legally responsible, in accordance with State or tribal law, for the care and protection of the student; and(C) the disclosure must pertain to addressing the educational needs of the child. Source Note: The provisions of this §350.233 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 10, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.233 Release of Personally Identifiable Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203639 03/12/2026 (a) The contractor must protect the confidentiality of personally identifiable information at collection, storage, disclosure, and destruction stages.(b) One official for each contractor shall assume responsibility for ensuring the confidentiality of any personally identifiable information.(c) All persons collecting or using personally identifiable information must receive training or instruction regarding the state's policies and procedures.(d) Each contractor must maintain, for public inspection, a current listing of the names and positions of those employees within the agency who may have access to personally identifiable information. Source Note: The provisions of this §350.235 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.235 Safeguards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203640 03/12/2026 (a) The contractor must retain records for seven years after the child has been dismissed from services unless a longer period is required by state or federal law.(b) A contractor must allow HHSC and all appropriate federal and state agencies or their representatives to inspect, monitor, or evaluate client records, books, and supporting documents pertaining to services provided. The contractor and the subcontractors must make these documents available at reasonable times and for reasonable periods. Upon request, the contractor must submit copies of their records, at no cost, to HHSC ECI, the Texas Attorney General's Office, and representatives of the United States Department of Health and Human Services.(c) The contractor must keep financial and supporting documents, statistical records, and any other records pertinent to the services for which a claim was submitted to HHSC ECI or its agent. The records and documents must be kept for a minimum of seven years after the end of the contract period or for seven years after the end of the federal fiscal year in which services were provided if a contractor agreement/contract has no specific termination date in effect. If any litigation, claim, negotiations, open records request, administrative review, or audit involving these records begins before the seven year period expires, the contractor must keep the records and documents for not less than seven years or until all litigation, claims, negotiations, open records request, administrative review, or audit finds are resolved. The case is considered resolved when a final order is issued in litigation, or HHSC ECI and contractor enter into a written agreement. In this section, contract period means the beginning date through the ending date specified in the original agreement/contract; extensions are considered separate contract periods. Source Note: The provisions of this §350.237 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.237 Record Retention Period https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203641 03/12/2026 (a) "Destruction," as used in this section, means physical destruction or removal of personal identifiers from information so that the information is no longer personally identifiable.(b) The contractor must inform the parent when personally identifiable information collected, maintained, or used under this chapter is no longer needed to provide services to the child and family.(c) The information must be destroyed upon request of the parent; however, a permanent record of the child's name, address, phone number, service dates, delivered early childhood intervention services, and years completed and dismissed may be maintained without time limitation. Source Note: The provisions of this §350.239 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.239 Destruction of Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203642 03/12/2026 (a) With informed written parental consent, confidential Part C records may be provided to the public schools when the child is enrolled in school. If the parent refuses to consent, confidential Part C records may not be intermingled with public school records, including records relating to special education.(b) An agency or provider may not, without informed prior written parental consent, redisclose confidential information obtained from another agency or provider, unless such redisclosure is permitted under the terms of the original disclosure made to the agency or provider. Source Note: The provisions of this §350.241 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES B PROCEDURAL SAFEGUARDS AND DUE PROCESS PROCEDURES §350.241 Release of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223926 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Criminal background check--Review of fingerprint-based criminal history record information. (2) Dual relationships--When the person providing ECI services engages in activities with the family that go beyond his or her professional boundaries. (3) EIS active status--Refers to the current standing of an EIS who has maintained a current credential by fulfilling all necessary initial credentialing and renewal requirements by their respective due dates. An EIS is considered active upon completion of the current orientation to HHSC ECI and remains on active status by completing initial credentialing requirements and continuing education requirements as defined in §350.313 of this subchapter (relating to Early Intervention Specialist). (4) EIS inactive status--Refers to the current standing of an EIS who is not employed or subcontracting with an ECI program or does not hold a current active credential. (A) An EIS is considered on long-term inactive status when they are on inactive status for 48 months or more since the date the EIS credential was removed from their record or the date their employment was terminated.(B) An EIS is considered on short-term inactive status when they are on inactive status for less than 48 months since the date the EIS credential was removed from their record or the date their employment was terminated. (5) EIS past due status--Refers to the current standing of an EIS whose credential has lapsed.(A) An EIS is considered on past due status when:(i) the EIS fails to complete initial credentialing or renewal activities by the designated due date; or(ii) the EIS transfers from another ECI program and fails to complete the orientation to HHSC ECI within 30 days after their hire date, unless the EIS has documentation that they have completed the current orientation module.(B) An EIS is considered on long-term past due status when they are on past due status for 48 months or more since their credential lapsed.(C) An EIS is considered on short-term past due status when they are on past due status for less than 48 months since their credential lapsed.(6) EIS Registry--A system used by HHSC ECI to maintain current required EIS information submitted by ECI programs. (7) IPDP--Individualized Professional Development Plan. The training and technical assistance plan developed when a staff person begins employment at an ECI program. (8) Professional boundaries--Financial, physical, and emotional limits to the relationship between the ECI professional providing ECI services and the family. (9) Service coordinator active status--Refers to the current standing of a service coordinator who is employed by or subcontracting with an ECI program and is current with continuing education requirements specified by HHSC ECI. (10) Service coordinator inactive status--Refers to the current standing of a service coordinator who is not employed by or subcontracting with an ECI program or is not current with continuing education requirements specified by HHSC ECI. Source Note: The provisions of this §350.303 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.303 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203654 03/12/2026 Employment records, including information in the EIS Registry, are subject to the Public Information Act. Source Note: The provisions of this §350.305 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.305 Employment Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203655 03/12/2026 (a) Each contractor must maintain a procedure for local review of personnel grievances.(b) The contractor must inform staff of personnel grievance procedures. Source Note: The provisions of this §350.307 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.307 Personnel Grievances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223927 03/12/2026 (a) For the purposes of this section, the following terms are defined as follows. (1) Consultation--Evaluation and development of staff knowledge, skills, and abilities in the context of case-specific problem solving.(2) Record review--A review of documentation in child records to evaluate compliance with the requirements of this chapter, and quality, accuracy, and timeliness of documentation. It also includes feedback to staff to identify areas of strength and areas that need improvement.(3) Observation--Watching staff interactions with children and families and providing guidance and feedback about the interaction.(b) The subrecipient must comply with HHSC ECI requirements related to health regulations for all direct service staff. The subrecipient must comply with 2 CFR Part 3485 and Texas Health and Safety Code Chapter 81. (c) The subrecipient must comply with HHSC ECI requirements related to initial training requirements for direct service staff. Before providing services, all staff must: (1) with the exception of teachers of the deaf or hard of hearing, teachers of students with visual impairment, and certified orientation and mobility specialists, complete orientation training as required by HHSC ECI; (2) hold current certification in first-aid and cardiopulmonary resuscitation for children and infants; and (3) complete universal precautions training that aligns with recommendations from the Centers for Disease Control and Prevention. (d) The subrecipient must comply with HHSC ECI requirements related to continuing education requirements for direct service staff. All staff providing ECI services to children and families must maintain current certification in first aid and cardiopulmonary resuscitation for children and infants. (e) With the exception of teachers of the deaf or hard of hearing, teachers of students with visual impairments, and certified orientation and mobility specialists, the subrecipient must verify that all newly employed staff:(1) are qualified in terms of education and experience for their assigned scopes of responsibilities; (2) are competent to perform the job-related activities before providing ECI services; and (3) complete orientation training as required by HHSC ECI before providing ECI services. (f) The subrecipient must comply with HHSC ECI requirements related to supervision of direct service staff. A subrecipient must implement a system of supervision and oversight that consists of consultation, record review, and observation from a qualified supervisor. Supervisor qualifications are further described in §350.313(d) and §350.315(e) of this subchapter (relating to Early Intervention Specialist and Service Coordinator, respectively). (g) The subrecipient must follow all training requirements mandated by HHSC ECI. Source Note: The provisions of this §350.309 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.309 Minimum Requirements for All Direct Service Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208175 03/12/2026 (a) The contractor must complete a fingerprint-based criminal background check on every new hire, volunteer, or other person who will be working under the auspices of the contractor before the person has direct contact with children or families, including employees who have had a fingerprint-based check as a requirement of their professional licensure.(b) The contractor must complete a fingerprint-based criminal background check renewal on any employee, or any other person who will be working under the auspices of the contractor who has direct contact with children or families, at least every 24 months, unless the contractor uses Federal Bureau of Investigations (FBI) Rap Back and gets alerts of any new arrests and convictions. Employees who are covered by the FBI Rap Back service must complete fingerprint-based criminal background checks at least every five years. Employees deemed "unfingerprintable" by the Texas Department of Public Safety or other fingerprinting entity must have a name-based background check completed every 24 months. If at any time a contractor has reason to suspect an employee has been convicted of a crime specified in §745.661 of this title (relating to What types of criminal convictions may affect a subject's ability to be present at an operation?), the contractor must complete a fingerprint-based criminal background check renewal on the employee in question.(c) The contractor must ensure that all therapists providing Medicaid services for Early Childhood Intervention children are correctly enrolled with the Texas Medicaid Program. This requirement includes disclosing all criminal convictions and arrests as required by 1 TAC §371.1005 (relating to Disclosure Requirements). The Texas Health and Human Services Commission (HHSC) Office of Inspector General may recommend denial of an enrollment or re-enrollment based on criminal history, in accordance with 1 TAC §371.1011 (relating to Recommendation Criteria).(d) HHSC Child Care Licensing maintains three charts of criminal history requirements for people who regularly enter licensed child care facilities.(1) The three charts are published on the HHSC website:(A) Licensed or Certified Child Care Operations: Criminal History Requirements;(B) Foster or Adoptive Placements: Criminal History Requirements; and(C) Registered Child Care Homes and Listed Family Homes: Criminal History Requirements.(2) The contractor must review each employee's criminal background check to ensure that staff members who regularly enter regulated child care facilities or foster homes to provide early childhood intervention services do not have criminal convictions that would result in an absolute bar to entering them in compliance with §745.661 of this title.(e) If a criminal background check reveals criminal convictions that are not on the HHSC Child Care Licensing charts of criminal history requirements or would result in the individual being eligible for a HHSC Child Care Licensing risk assessment, the program director may conduct a risk assessment. The risk assessment process must include, at a minimum, consideration of:(1) the number of convictions;(2) the nature and seriousness of the crime;(3) the age of the individual at the time the crime was committed;(4) the relationship of the crime to the individual's fitness or capacity to serve in the role of an early childhood intervention professional;(5) the amount of time that has elapsed since the person's last conviction; and(6) any relevant information the individual provides or otherwise demonstrates. Source Note: The provisions of this §350.310 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.310 Criminal Background Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203658 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203658 03/12/2026 (a) The contractor must comply with HHSC ECI requirements related to minimum qualifications for licensed professionals. The contractor must verify and document that licensed professionals hold a current license in good standing in his or her discipline and practice within the scope of his or her specific state licensure laws and regulations.(b) A licensed professional must comply with the established licensing board requirements for the licensed professional's discipline for continuing education providing and receiving supervision and conduct. Source Note: The provisions of this §350.311 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.311 Licensed Professionals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223928 03/12/2026 (a) The LPHA participates in eligibility determination as part of the interdisciplinary team and provides necessary clinical knowledge for the IFSP team to plan and implement individualized services focused on helping families to support their children with attaining developmental goals within an interdisciplinary approach. (b) The LPHA is responsible for:(1) documenting the child's progress towards the IFSP goals; (2) recommending to the team modifications to the plan as needed; and (3) providing assessments or ongoing therapy services as planned on the IFSP. (c) The LPHA is required to sign the IFSP and in doing so acknowledges the planned services are reasonable and necessary. (d) The LPHA must provide ongoing monitoring and assessment of the IFSP, at least once every six months as part of the periodic review, in order to provide a professional opinion as to the effectiveness of services. Source Note: The provisions of this §350.312 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.312 Licensed Practitioner of the Healing Arts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223929 03/12/2026 (a) The subrecipient must comply with HHSC ECI requirements related to minimum qualifications for an EIS. (1) An individual who meets one of the following criteria is eligible for EIS credentialing.(A) Be registered as an EIS before September 1, 2011.(B) Hold a bachelor's or graduate degree from an accredited university with: (i) academic transcripts reflecting the successful completion of required coursework for an EIS, designated by HHSC ECI; or (ii) three years of experience within the last ten years working for an IDEA Part C program in the United States or a United States territory providing special instruction, as defined in 34 CFR §303.13(b)(14), or SST, as defined in §350.501(a)(4) of this chapter (relating to Specialized Rehabilitative Services), to infants and toddlers with developmental delays or disabilities and their families.(C) If an individual lacks some of the required coursework referenced in paragraph (1)(B)(i) of this subsection, they may complete applicable contact hours of continuing education:(i) up to the maximum amount set by HHSC ECI; and(ii) that meets HHSC ECI requirements. (b) The subrecipient must comply with HHSC ECI requirements related to initial credentialing for an EIS.(1) An EIS must read and sign the EIS code of ethics prior to the creation of an employee record on the EIS Registry.(2) An EIS must complete the current orientation to ECI training, as designated by HHSC ECI, and develop an IPDP with their supervisor within 30 days after the EIS's hire date.(3) An EIS must complete the EIS IPDP no more than one year after their hire date.(c) The subrecipient must comply with HHSC ECI requirements related to the biennial renewal of the EIS credential. (1) Every two years after obtaining the EIS credential, an EIS must complete a minimum of: (A) 20 contact hours of continuing professional education (CPE) that has been approved by their supervisor; and (B) three contact hours of CPE in ethics that has been approved by their supervisor. (d) The subrecipient must comply with HHSC ECI requirements related to supervision of an EIS. (1) The subrecipient must provide supervision for an EIS as defined in §350.309(f) of this subchapter (relating to Minimum Requirements for All Direct Service Staff) as required by HHSC ECI. (2) An EIS supervisor must: (A) have two years of experience providing ECI services, or two years of experience supervising staff who provide ECI services to children and families; and (B) meet the minimum requirements in subsection (a) of this section. (e) Requirements for EIS active status, EIS past due status, and EIS inactive status are as follows. (1) Only an EIS with active status is allowed to provide ECI services to children and families. (2) An EIS on past due status or inactive status may not perform any ECI services.(A) An EIS goes on past due status when: (i) the EIS fails to complete initial credentialing or renewal activities by the designated due date; or(ii) the EIS transfers from another ECI program and fails to complete the orientation to ECI within 30 days after their hire date, unless the EIS has documentation that they have completed the current orientation module.(B) An EIS goes on inactive status when the EIS is no longer employed by a subrecipient or has the EIS credential removed from their record in the Texas Kids Intervention Database System.(C) If, due to exceptional circumstances, an EIS is unable to submit documentation of completion of credentialing activities by the designated due date, the EIS's supervisor must contact the HHSC ECI EIS credentialing specialist as soon as he or she is aware the due date will not be met. The credentialing specialist and his or her supervisor will work with the EIS's supervisor and the EIS to determine an appropriate course of action.(f) Requirements for reinstating EIS active status are as follows.(1) An EIS who has been on short-term past due status or short-term inactive status must submit the required contact hours of continuing professional education and ethics training for their missed renewal dates.(2) An EIS who has been on long-term past due status or long-term inactive status must complete all initial credentialing activities in subsection (b) of this section.(3) EIS active status is considered reinstated after the information is entered into the EIS Registry and is approved by HHSC ECI. (g) The subrecipient must comply with HHSC ECI requirements related to ethics for an EIS. (1) The subrecipient must establish and maintain disciplinary procedures that apply to all EISs upon violations of standards of conduct in §350.314 of this subchapter (relating to EIS Code of Ethics).(2) An EIS who violates any of the standards of conduct is subject to the subrecipient's disciplinary procedures.(3) The subrecipient must complete an EIS Code of Ethics Incident Report in the EIS Registry when an EIS violates any of the standards of conduct.(h) Subrecipients must contact HHSC ECI when hiring a new EIS to verify if an EIS Code of Ethics Incident Report has been recorded in the EIS Registry. Source Note: The provisions of this §350.313 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.313 Early Intervention Specialist https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203661 03/12/2026 An EIS must observe and comply with the following standards of conduct.(1) An EIS must comply with the policies and procedures of both the contractor and HHSC ECI.(2) An EIS must operate only within the boundaries provided by their education, training, and credentials.(3) An EIS must take measures to avoid imposing or inflicting harm.(4) An EIS must truthfully represent their services, professional credentials, and qualifications. The EIS must inform families of the scope and limitations of their credentials.(5) An EIS must strive to maintain and improve their professional knowledge, skills, and abilities.(6) An EIS must maintain the confidentiality of families served by the contractor's ECI program in accordance with the policies and procedures of HHSC ECI.(7) An EIS must establish professional boundaries and avoid establishing dual relationships or conflicts of interest with families. Any prior relationships with a family member must be reported to the EIS's supervisor immediately.(8) Sexual or intimate relationships between an EIS and family members of a child enrolled in the contractor's ECI program that employs the EIS are prohibited during the child's enrollment and for three years after the child is no longer enrolled.(9) Financial relationships between the EIS and family members of a child enrolled in the contractor's ECI program that employs the EIS are prohibited during the child's enrollment.(10) An EIS must not exploit their position of trust and influence with a family by benefiting from relationships established as an EIS.(11) An EIS must not provide direct service while impaired, including impairments that are due to the use of medication, illicit drugs, or alcohol.(12) An EIS must not falsify documentation.(13) An EIS must not refuse to provide services for which they are credentialed on the basis of a child's or family's gender, race, ethnicity, color, religion, national origin, sexual orientation, political affiliation, socioeconomic status, or disability.(14) An EIS must make reasonable efforts to ensure that families receive appropriate services when the EIS is unavailable or anticipates discontinued employment with the contractor.(15) An EIS has a professional obligation to report unethical behavior demonstrated by colleagues throughout the ECI system to their program director and to the appropriate board or state agency. Source Note: The provisions of this §350.314 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.314 EIS Code of Ethics https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223930 03/12/2026 (a) The subrecipient must comply with HHSC ECI requirements related to minimum qualifications for service coordinators. (b) ECI service coordination, case management, and TCM as defined by §350.103 of this chapter (relating to Definitions) may only be provided by a service coordinator who is employed by or subcontracts with an ECI subrecipient.(1) A service coordinator must meet one of the following criteria: (A) be a licensed professional in a discipline relevant to early childhood intervention; (B) be an EIS or meet the qualifications for an EIS as defined in §350.313 of this subchapter (relating to Early Intervention Specialist);(C) be a registered nurse (with a diploma, an associate's, bachelor's, or advanced degree) licensed by the Texas Board of Nursing; or (D) hold a bachelor's degree or graduate degree from an accredited university with coursework that is relevant to ECI service coordination, as designated by HHSC ECI.(2) Before performing service coordination, case management, or TCM activities, a service coordinator must complete HHSC ECI-required case management training and develop an IPDP with their supervisor.(3) A service coordinator must complete all assigned activities on the service coordinator's IPDP no more than one year after the service coordinator's start date.(4) A service coordinator must effectively communicate in the family's native language or use an interpreter or translator. (c) A service coordinator who was employed as a service coordinator by a subrecipient before March 1, 2012, and who does not meet the requirements of subsection (b)(1) of this section, may continue to serve as a service coordinator at the subrecipient's discretion. (d) The subrecipient must comply with HHSC ECI requirements related to continuing education for service coordinators. A service coordinator must complete: (1) three contact hours of training in ethics every two years; (2) an additional three contact hours of training specifically relevant to case management every year; and (3) if the service coordinator does not hold a current license or credential that requires continuing professional education, an additional seven contact hours of continuing education approved by their supervisor every year. (e) The subrecipient must comply with HHSC ECI requirements related to supervision of service coordinators. (1) A subrecipient's supervision of service coordinators must meet the requirements outlined in §350.309(f) of this subchapter (relating to Minimum Requirements for All Direct Service Staff). (2) An individual employed by or subcontracting with a subrecipient must meet the following criteria to supervise a service coordinator. (A) A service coordinator supervisor must meet the minimum requirements in subsections (b) and (c) of this section. (B) A service coordinator supervisor must have two years of experience providing case management in an ECI program or another applicable community-based program. (f) Requirements for service coordinator active status and inactive status are as follows. (1) A service coordinator is on active status when all of the requirements in subsections (b) and (c) of this section have been approved by their supervisor. (2) A service coordinator goes on inactive status when: (A) the service coordinator fails to complete required training activities by the designated deadlines; or(B) the service coordinator is no longer employed by or subcontracting with a subrecipient.(3) If a service coordinator has been inactive for less than 48 months, active status is reinstated after the required training activities are completed and approved by the service coordinator's supervisor. (4) A service coordinator who has been on inactive status for 48 months or longer must complete the training requirements outlined in subsections (b)(2) and (b)(3) of this section. (g) The subrecipient must comply with HHSC ECI requirements related to ethics of service coordinators. Service coordinators must meet the established rules of conduct and ethics training required by their license or credential. A service coordinator who does not hold a license or credential must meet the rules of conduct and ethics established in §350.314 of this subchapter (relating to EIS Code of Ethics). Source Note: The provisions of this §350.315 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES C STAFF QUALIFICATIONS §350.315 Service Coordinator https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223931 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Case management--In compliance with §350.405 of this subchapter (relating to Case Management Services), case management means services provided to assist an eligible child and their family in gaining access to the rights and procedural safeguards under IDEA Part C and to needed medical, social, educational, developmental, and other appropriate services. Case management services may be provided via telehealth with the prior written consent of the parent. If the parent declines to consent to telehealth services, case management must still be provided. (2) Monitoring and assessment--Activities and contacts as described in §350.405 of this subchapter that are necessary to ensure that the IFSP, as described in Subchapter J of this chapter (relating to Individualized Family Service Plan), is effectively implemented and that the planned services adequately address the needs of the child. (3) Texas Health Steps--The name adopted by the state of Texas for the federally mandated Early and Periodic Screening, Diagnosis, and Treatment program. Source Note: The provisions of this §350.403 adopted to be effective September 1, 2009, 34 TexReg 5575; amended to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.403 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223932 03/12/2026 To receive ECI case management services, the child must meet the criteria established in Subchapter H of this chapter (relating to Eligibility, Evaluation, and Assessment), and the family must agree to receive services. Source Note: The provisions of this §350.404 adopted to be effective September 1, 2011, 36 TexReg 5403; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.404 Eligibility for Early Childhood Intervention Case Management Services. https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223933 03/12/2026 (a) Case management services may be provided via telehealth with the prior written consent of the parent. If the parent declines to consent to telehealth services, case management must still be provided. (b) All case management activities must be documented in the child's record. Case management activities include:(1) coordinating the performance of evaluations and assessments; (2) facilitating and participating in the development, review, and evaluation of the IFSP in accordance with Subchapter J of this chapter (relating to Individualized Family Service Plan); (3) supporting families to meet their needs by:(A) assisting families with identifying unmet needs; (B) assisting families with identifying available providers of services and supports; (C) making appropriate referrals and facilitating applications for services and supports; and(D) assisting with initial and ongoing contact to obtain services from medical, social, and educational providers to address identified needs and achieve goals specified in the IFSP; (4) following up with families and providers of services and supports to assist the child with timely access to services, and discussing the status of referrals to determine whether the services have met the child's identified needs, and whether ongoing assistance to ensure continued access will be necessary; (5) monitoring and assessment of the delivery and effectiveness of services at least every six months after the IFSP is developed. This process must: (A) be individualized and clearly related to the needs of the child and family; (B) collect information from family members, ECI professionals, and other entities and individuals who provide services or supports to the child and family to assess whether: (i) services are being provided in accordance with the child's IFSP; (ii) services are adequate to meet the child's and family's needs; (iii) all ECI professionals are effectively collaborating to address the child's and family's needs; and (iv) parents and routine caregivers are able to use the interventions being presented; (6) adjusting the IFSP if new needs, ineffectiveness, or barriers to services are identified; (7) assisting the parent or routine caregiver in advocating for the child; (8) coordinating with medical and other health providers to ensure services are effective in meeting the child's and family's needs; and (9) facilitating the child's transition to ECSE or other appropriate community services and supports. (c) TCM is case management that meets the following criteria. (1) The contact occurs with the parent or routine caregiver. (2) The contact occurs face-to-face or by telephone. (3) Contacts made in one day total at least eight minutes in duration. (4) The desired outcome of the contact is of direct benefit to a child who is eligible for ECI services. (5) During the contact the service coordinator performs a case management activity as described in subsection (a) of this section. (d) TCM must be offered to all families and documented in a child's record, regardless of the child's Medicaid enrollment.(e) Case management activities not defined as TCM occur when the service coordinator performs a case management activity as defined in subsection (a) of this section; and(1) the contact is with individuals other than a parent or routine caregiver; (2) the desired outcome of the contact is not of direct benefit to a child who is eligible for ECI services; (3) the contact is less than eight minutes in duration; or(4) the contact does not occur face-to-face or by telephone. Source Note: The provisions of this §350.405 adopted to be effective September 1, 2009, 34 TexReg 5575; amended to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.405 Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223934 03/12/2026 (a) A parent may refuse case management provided by the subrecipient. If the parent refuses case management activities, the service coordinator must: (1) document the parent's choice in the child's record; (2) provide the required ECI services during the pre-enrollment period, including scheduling and coordinating screenings, evaluations, and assessments; (3) coordinate the development, review, and evaluation of the IFSP, including any reviews, revisions, and the annual IFSP; and (4) provide and obtain all the accompanying required notices and consents. (b) When the parent refuses case management services, the subrecipient must not submit a claim for TCM to Medicaid. Source Note: The provisions of this §350.406 adopted to be effective September 1, 2011, 36 TexReg 5403; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.406 Parent Refusal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223935 03/12/2026 (a) Case management services are not reimbursable as Medicaid services when another payor is liable for payment or if case management services are associated with the proper and efficient administration of the Medicaid state plan. (b) Case management services associated with the following are not payable as TCM services under Medicaid: (1) Medicaid eligibility determinations and redeterminations; (2) Medicaid eligibility intake processing; (3) Medicaid preadmission screening; (4) prior authorization for Medicaid services; (5) required Medicaid utilization review; (6) Texas Health Steps program administration; (7) Medicaid "lock-in" provided for under the Social Security Act §1915(a); (8) services that are an integral or inseparable part of another Medicaid service; (9) outreach activities that are designed to locate individuals who are potentially eligible for Medicaid; and (10) any medical evaluation, examination, or treatment billable as a distinct Medicaid-covered benefit. However, referral arrangements and staff consultation for such services are reimbursable as case management services. Source Note: The provisions of this §350.407 adopted to be effective September 1, 2011, 36 TexReg 5403; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.407 Medicaid Service Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208179 03/12/2026 In order to be reimbursed for services specified in §350.405 of this subchapter (relating to Case Management Services), a provider must:(1) be an Early Childhood Intervention contractor of the Texas Health and Human Services Commission;(2) comply with all applicable federal and state laws and regulations governing the services provided;(3) ensure that services are provided by qualified staff as specified in Subchapter C of this chapter (relating to Staff Qualifications); and(4) be responsible for the service coordinator's compliance with this subchapter. Source Note: The provisions of this §350.409 adopted to be effective September 1, 2009, 34 TexReg 5575; amended to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.409 Conditions for Case Management Provider Agency Participation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223936 03/12/2026 (a) ECI case management services must be provided by service coordinators who meet the educational, training, and work experience requirements, commensurate with their job responsibilities, as specified in Subchapter C of this chapter (relating to Staff Qualifications). (b) The subrecipient is responsible for: (1) assigning one service coordinator for each eligible child and the child's family according to the following: (A) an initial service coordinator must be assigned at the time of referral; and (B) a new service coordinator may be assigned at the time the IFSP is developed or the original service coordinator may be retained;(2) ensuring that the service coordinator assigned by the subrecipient has a combination of education, training, and work experience relevant to the child's needs; and (3) appointing a new service coordinator if requested by the parent. Source Note: The provisions of this §350.411 adopted to be effective September 1, 2009, 34 TexReg 5575; amended to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.411 Assignment of Service Coordinator https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223937 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223937 03/12/2026 (a) The child's record must include: (1) whether the parent has declined recommended services; (2) the need for, and occurrences of, coordination with other service coordinators or case managers; and (3) whether case management goals have been achieved. (b) Documentation of each case management contact must include: (1) name of the child; (2) name of the ECI program;(3) name and credential of the assigned service coordinator; (4) date, start time, and duration of the contact; (5) physical location of the service coordinator at the time of contact (e.g., office, child's home, hospital, daycare); (6) method of service (face-to-face or telephone); (7) with whom the contact was made (e.g., parent, routine caregiver, physician); (8) a description of the case management activity performed as described in §350.405 of this subchapter (relating to Case Management Services); (9) course of action to respond to identified needs; (10) any relevant information provided by the family, or other individual or entity; and (11) service coordinator's signature. Source Note: The provisions of this §350.415 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.415 Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208181 03/12/2026 (a) Medicaid-eligible individuals. Any Medicaid-eligible individual whose request for eligibility for case management is denied or is not acted upon with reasonable promptness, or whose case management has been terminated, suspended, or reduced is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(b) All individuals. If an Early Childhood Intervention contractor denies, involuntarily reduces, or terminates case management for an individual, the individual has all rights to file complaints, request mediation, or request a hearing in accordance with Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures) and in accordance with 40 TAC Chapter 101, Subchapter E, Division 3 (relating to Division for Early Childhood Intervention Services). Source Note: The provisions of this §350.417 adopted to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES D CASE MANAGEMENT FOR INFANTS AND TODDLERS WITH DEVELOPMENTAL DISABILITIES §350.417 Due Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223938 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223938 03/12/2026 (a) SRS, as defined by §350.103 of this chapter (relating to Definitions), includes physical therapy, speech language pathology services, occupational therapy, and SST as defined in §350.103 of this chapter.(1) Physical therapy. (A) Physical therapy services are defined in 34 CFR §303.13(b)(9). (B) Physical therapy services must meet the requirements of subsection (b) of this section. (C) Physical therapy services must be provided by a licensed physical therapist who meets the requirements of 42 CFR §440.110(a) and all other applicable state and federal laws or a licensed physical therapy assistant when the assistant is acting under the direction of a licensed physical therapist in accordance with 42 CFR §440.110 and all other applicable state and federal laws. (2) Speech language pathology services. (A) Speech language pathology services are defined in 34 CFR 303.13(b)(15). (B) Speech language pathology services must meet the requirements of subsection (b) of this section. (C) Speech language pathology services must be provided by: (i) a licensed speech language pathologist (SLP) who meets the requirements of 42 CFR §440.110(c) and all other applicable state and federal laws; (ii) a licensed assistant in SLP when the assistant is acting under the direction of a licensed SLP in accordance with 16 TAC §111.52 (relating to Assistant in Speech-Language Pathology License--Practice and Duties of Assistants) and all other applicable state and federal laws; or (iii) a licensed intern when the intern is acting under the direction of an SLP who is licensed in accordance with 42 CFR §440.110 and all other applicable state and federal laws. (3) Occupational therapy. (A) Occupational therapy services are defined in 34 CFR §303.13(b)(8). (B) Occupational therapy services must meet the requirements of subsection (b) of this section. (C) Occupational therapy services must be provided by a licensed occupational therapist who meets the requirements of 42 CFR §440.110(b) and all other applicable state and federal laws or a certified occupational therapy assistant when the assistant is acting under the direction of a licensed occupational therapist in accordance with 40 TAC §373.2 (relating to Supervision of a Temporary Licensee) and all other applicable state and federal laws. (4) Specialized Skills Training. As defined in §350.103 of this chapter, SST: (A) includes skills training and anticipatory guidance for family members or other routine caregivers to ensure effective treatment and to enhance the child's development; (B) services must meet the requirements of subsection (b) of this section; and (C) must be provided by an EIS on active status as defined in §350.313 of this chapter (relating to Early Intervention Specialist).(b) SRS must: (1) be designed to create learning environments and activities that promote the child's acquisition of skills in one or more of the following developmental areas: physical/motor, communication, adaptive, cognitive, and social/emotional; (2) be provided in the child's natural environment, as defined in 34 CFR §303.26, unless the criteria listed in 34 CFR §303.126 are met and documented in the case record; and(3) meet the requirements of §350.1104 of this chapter (relating to Early Childhood Intervention Services Delivery). (c) Service authorization. (1) SRS must be recommended by an interdisciplinary team that includes an LPHA. (2) SRS must be documented in the child's IFSP in accordance with Subchapter J of this chapter (relating to Individualized Family Service Plan).(3) Services must be monitored by the interdisciplinary team as described in §350.1104 of this chapter. Source Note: The provisions of this §350.501 adopted to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES E SPECIALIZED REHABILITATIVE SERVICES §350.501 Specialized Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203673 03/12/2026 To receive ECI specialized rehabilitative services, a child must meet the following criteria:(1) eligibility criteria established in Subchapter H of this chapter (relating to Eligibility, Evaluation, and Assessment), and(2) have a need for specialized rehabilitative services as determined by the interdisciplinary team and identified on the IFSP which has been signed by an LPHA. Source Note: The provisions of this §350.503 adopted to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES E SPECIALIZED REHABILITATIVE SERVICES §350.503 Recipient Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208183 03/12/2026 To be reimbursed for services specified in §350.501 of this subchapter (relating to Specialized Rehabilitative Services), a contractor must:(1) comply with applicable federal and state laws and regulations governing the services provided;(2) ensure that services are provided by an Early Childhood Intervention (ECI) professional as defined in §350.103 of this chapter (relating to Definitions); and(3) be responsible for the ECI professional's compliance with this subchapter. Source Note: The provisions of this §350.505 adopted to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES E SPECIALIZED REHABILITATIVE SERVICES §350.505 Conditions for Provider Agency Participation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223939 03/12/2026 (a) Medicaid-eligible individuals. Any Medicaid-eligible individual whose request for eligibility for SRS is denied by Medicaid, or is not acted upon with reasonable promptness, or whose specialized rehabilitative services have been terminated, suspended, or reduced, is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules). (b) All individuals. If an ECI program denies, involuntarily reduces, or terminates SRS for an individual, the individual has the right to file complaints, request mediation, or request a hearing in accordance with Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures) and in accordance with 40 TAC Chapter 101, Subchapter E, Division 3 (relating to Division for Early Childhood Intervention Services). Source Note: The provisions of this §350.507 adopted to be effective September 1, 2011, 36 TexReg 5403; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES E SPECIALIZED REHABILITATIVE SERVICES §350.507 Due Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223948 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223948 03/12/2026 The following words and terms, when used in this subchapter, will have the following meanings, unless the context clearly indicates otherwise. (1) Public awareness--As described in 34 CFR §303.116 and §303.301. (2) Public outreach--The combined efforts of child find, public awareness, and interagency coordination. Source Note: The provisions of this §350.605 adopted to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.605 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223949 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223949 03/12/2026 (a) The subrecipient must plan and implement child find, public awareness, and interagency coordination goals and strategies that comply with IDEA Part C. (b) When HHSC provides language to use in communicating with primary referral sources, parents of infants and toddlers, or the general public, the subrecipient must use the provided language. Source Note: The provisions of this §350.607 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.607 Public Outreach https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223950 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223950 03/12/2026 (a) The subrecipient must document that it communicated any major HHSC ECI policy change concerning the information described in subsection (d) of this section to primary referral sources.(b) The purpose of child find efforts is to establish working relationships and effective communications with primary referral sources to support and promote the referral of children potentially eligible for ECI services. (c) The subrecipient must have written procedures that establish systems to: (1) inform primary referral sources of the requirement to refer children suspected of having a developmental delay or a medical diagnosis with a high probability of resulting in a developmental delay in a timely manner as established in 34 CFR §303.303; (2) accept referrals effectively; and (3) monitor referral dates and sources. (d) The subrecipient must document that primary referral sources listed in 34 CFR §303.303(c) have been provided current information on: (1) ECI eligibility criteria and evaluation process;(2) the ECI array of services; (3) how to explain ECI services to the family, including the coaching approach and the family's role; (4) how to make a referral to ECI; (5) the importance of informing families when a referral is made; and (6) the family cost share system of payments for ECI services. Source Note: The provisions of this §350.609 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.609 Child Find https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223951 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223951 03/12/2026 (a) The subrecipient must conduct public awareness activities to increase recognition of ECI programs in the community so that families with children who are potentially eligible for ECI services will access those services. (b) The subrecipient must document that families and the general public are provided current HHSC ECI materials on: (1) ECI service delivery, including the family's role and the coaching model; (2) eligibility criteria and the evaluation process; (3) the ECI array of services; (4) how to make a referral to ECI; and (5) the family cost share system of payments for ECI services. (c) The ECI program staff who conduct public awareness activities must be able to explain to families and the public the information listed in subsection (b) of this section. (d) The subrecipient must assist HHSC ECI as requested in public awareness activities, including informing families and their community of appropriate resources.(e) The subrecipient must establish and maintain ongoing relationships with public and private agencies that serve children and families in their community to: (1) increase quality referrals for ECI services; and (2) coordinate with community partners to increase access to resources and services for ECI children and families. Source Note: The provisions of this §350.611 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.611 Public Awareness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223952 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223952 03/12/2026 (a) The subrecipient must maintain a current inventory of ECI publications and public outreach materials provided by HHSC ECI. (b) Public outreach materials created by the subrecipient must comply with graphics standards required by HHSC ECI. Source Note: The provisions of this §350.613 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.613 Publications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223953 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223953 03/12/2026 (a) The purpose of interagency coordination is to enhance the subrecipient's child find and public awareness efforts and to coordinate with community partners to increase access to resources and services for ECI children and families. (b) The subrecipient must comply with all child find and public outreach requirements in all state-level HHSC ECI MOUs with TEA, Head Start and Early Head Start, DFPS, and any other state agency with which HHSC ECI enters into a MOU. (c) The subrecipient must coordinate with LEA representatives to facilitate an effective transition from ECI to ECSE services and the LEA provision of services for children who are deaf or hard of hearing or blind or visually impaired. Coordination activities focus on developing a joint understanding of: (1) eligibility requirements for public school services, including for Part B services; (2) the state-level MOUs with TEA; and (3) if applicable, MOUs with the LEAs. (d) The subrecipient must coordinate with representatives from Head Start and Early Head Start to ensure that families eligible for Head Start and Early Head Start have access to those services, as available. Coordination activities focus on developing a joint understanding of: (1) eligibility requirements for Head Start and Early Head Start placement; (2) the state-level MOU with Head Start and Early Head Start; (3) referral procedures; and (4) if applicable, the local MOU with Head Start and Early Head Start. (e) The subrecipient must ensure coordination of ECI services with local agencies, as required by 34 CFR §303.302 and other programs identified by HHSC ECI. (f) The subrecipient must maintain a current list of community resources for families that includes for each resource: (1) services provided; (2) contact information; (3) referral procedures; and (4) cost to families. (g) The subrecipient must document the reasonable efforts to mitigate any systemic issues with achieving the requirements of this section. Source Note: The provisions of this §350.615 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.615 Interagency Coordination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223954 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223954 03/12/2026 (a) The subrecipient must inform HHSC ECI of whom to contact within their office regarding public outreach efforts. (b) The subrecipient must establish goals, strategies, and activities to meet the requirements of this subchapter. The public outreach strategic planning process must include the review and incorporation of any major HHSC ECI policy change concerning the types of information described in §350.609(d) of this subchapter (relating to Child Find). (c) The strategic planning process must be coordinated with other subrecipients that share counties and primary referral sources. (d) The public outreach strategic planning process must include an annual evaluation of the success of the subrecipient's public outreach efforts with a focus on the: (1) number of children referred to the ECI program; (2) percentage of children referred that are determined eligible for the program; (3) percentage of children determined eligible that enroll in the program; (4) referral source and eligibility type; and (5) plans to address issues found in the evaluation of public outreach efforts. (e) Data in subsections (d)(1), (d)(2), and (d)(3) of this section must be broken down by race, ethnicity, and age at referral. (f) The subrecipient must be prepared to describe this strategic planning process and its outcomes to HHSC ECI upon request. Source Note: The provisions of this §350.617 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES F PUBLIC OUTREACH §350.617 Public Outreach Contact, Planning, and Evaluation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223955 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223955 03/12/2026 (a) The subrecipient must: (1) accept referrals for children younger than 36 months of age; (2) document in the child's record the referral date, source, and reason for referral; and (3) contact the family in a timely manner after receiving the referral. (b) The subrecipient must follow all requirements described in this chapter when a referral is received 45 days or more before the child's third birthday. (c) When a referral is received less than 45 days before the child's third birthday, the subrecipient is not required to conduct pre-enrollment procedures, an evaluation, an assessment, or an initial IFSP meeting. With written parental consent, if the toddler is potentially eligible for ECSE services: (1) the subrecipient must notify the LEA; and (2) HHSC coordinates the notification to the SEA. Source Note: The provisions of this §350.704 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.704 Referral Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203686 03/12/2026 Information received regarding an unborn child becomes a referral the day the contractor is notified of the child's birth. Source Note: The provisions of this §350.705 adopted to be effective September 1, 2011, 36 TexReg 5387; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.705 Child Referred before Birth https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223956 03/12/2026 (a) In order to facilitate discharge planning and provide continuity of care, a subrecipient may accept referrals for children who are residing in a hospital at the time of referral. (b) If a referral is received for a child who has an adjusted age of zero months or younger or who has a qualifying medical diagnosis, the subrecipient may choose to determine eligibility and complete the initial IFSP prior to the child's discharge from the hospital. The interdisciplinary team that determines eligibility and the IFSP team must include at least one ECI professional and a licensed or registered hospital professional who is familiar with the needs of the child and knowledgeable in the area or areas of concern. (1) The licensed or registered hospital professional will serve as the LPHA while the child is in the hospital. The LPHA on the IFSP team may participate by means other than face-to-face, if acceptable to the team and if the initial IFSP is conducted while the child is in the hospital. (2) The participating licensed or registered hospital professional is not required to complete the orientation training required in §350.309(c) of this chapter (relating to Minimum Requirements for All Direct Service Staff). Allowable licensed or registered hospital professionals include: (A) licensed physician; (B) registered nurse; (C) licensed physical therapist; (D) licensed occupational therapist; (E) licensed speech language pathologist; (F) licensed dietitian; (G) licensed audiologist; (H) licensed physician assistant; (I) licensed intern in speech language pathology; or (J) advanced practice registered nurse. Source Note: The provisions of this §350.706 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.706 Referrals Received While the Child is in the Hospital https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223957 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223957 03/12/2026 (a) When a child moves to Texas with a completed IFSP from another state, eligibility for Texas ECI services must be determined in accordance with Subchapter H of this chapter (relating to Eligibility, Evaluation, and Assessment). (b) The interdisciplinary team considers existing evaluation data and medical diagnoses, as documented on the out-of-state IFSP, as appropriate. (c) ECI services in Texas must be planned in accordance with Subchapter J of this chapter (relating to Individualized Family Service Plan and delivered in accordance with Subchapter K of this chapter (relating to Service Delivery). Source Note: The provisions of this §350.707 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.707 Child Referred with an Out-of-State Individualized Family Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223958 03/12/2026 (a) Pre-enrollment begins at the point of referral, includes the following activities, and ends when the parent signs the IFSP or a final disposition is reached. (1) The subrecipient must assign an initial service coordinator for the family and document the name of the service coordinator in the child's record. (2) The subrecipient must provide the family the HHSC ECI Parent Handbook and document in the child's record that the following were explained to the parent: (A) the family's rights regarding eligibility determination and enrollment; (B) the early childhood intervention process for determining eligibility and enrollment; and (C) the types of ECI services that may be delivered to the child and the manner in which they may be provided. (3) The subrecipient must provide pre-IFSP service coordination as defined in 34 CFR §303.13(b)(11) and §303.34. (4) The subrecipient must collect information on the child throughout the pre-enrollment process. (5) The subrecipient must assist the child and family in gaining access to the evaluation and assessment process, including: (A) scheduling the interdisciplinary initial evaluation and assessment; and (B) preparing the family for the evaluation and assessment process. (6) The subrecipient must comply with all requirements in Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures). (b) The subrecipient must explain to the family, before eligibility determination, the requirement to provide ECI services in the natural environment. (c) The subrecipient must determine the need for and appoint a surrogate parent in accordance with 34 CFR §303.422 and §350.213 of this chapter (relating to Surrogate Parents). Source Note: The provisions of this §350.708 adopted to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.708 Pre-Enrollment Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223959 03/12/2026 (a) Optional developmental screenings are done to determine the need for further evaluation. When a developmental screening is completed, the subrecipient must: (1) use an HHSC ECI-approved screening tool; and (2) train providers to administer the selected screening tool according to the requirements of the selected tool. (b) A parent has the right to request at any time:(1) a comprehensive evaluation after a developmental screening; or (2) a comprehensive evaluation instead of a developmental screening. (c) If the results of a child's developmental screening do not indicate a concern, the subrecipient must: (1) provide written documentation to the parent that further evaluation is not recommended; (2) offer the parent a comprehensive evaluation; and (3) conduct a comprehensive evaluation if requested by the parent. (d) In accordance with the MOU between HHSC ECI and DFPS, the subrecipient must coordinate with DFPS to accept a referral for a child under 36 months of age who is: (1) involved in a substantiated case of child abuse or neglect;(2) suspected to have a disability or developmental delay; or(3) identified as affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a Fetal Alcohol Spectrum Disorder (FASD).(e) Requirements for optional developmental screenings or comprehensive evaluations for a child who meets the criteria in subsection (d) of this section are as follows.(1) If the subrecipient receives a completed developmental screening from a health care provider for a child who is in DFPS conservatorship that indicates the child has a developmental delay, the subrecipient must offer a comprehensive evaluation to determine eligibility for ECI services.(2) If the subrecipient receives a referral for a child who meets one of the criteria in subsection (d) of this section, the subrecipient must offer either a developmental screening or proceed directly to comprehensive evaluation.(3) If the subrecipient receives a referral for a child who does not meet one of the criteria in subsection (d) of this section, the subrecipient follows their local procedures for accepting a referral, conducting a developmental screening, and completing an evaluation. Source Note: The provisions of this §350.709 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES G REFERRAL, PRE-ENROLLMENT, AND DEVELOPMENTAL SCREENING §350.709 Optional Developmental Screenings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223960 03/12/2026 The following words and terms, when used in this subchapter, will have the following meanings, unless the context clearly indicates otherwise. (1) Adjusted age--The chronological age of a child minus the number of weeks or months of prematurity.(2) Chronological age--The actual number of months and years a person has lived calculated from the date of birth to the present date. Source Note: The provisions of this §350.805 adopted to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.805 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223961 03/12/2026 (a) The subrecipient must ensure requirements in 34 CFR §303.321(a)(1) are met.(b) The subrecipient must determine that a child meets Texas eligibility requirements to provide ECI services to the child and family. (c) Subrecipients must apply the same eligibility criteria for all children residing in Texas. (d) If a child is determined eligible in one area of Texas, the child remains eligible if the family moves to another part of the state until the child's annual evaluation is due. (e) The subrecipient must comply with all requirements in Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures) when determining eligibility. (f) The subrecipient must provide prior written notice in accordance with §350.204 of this chapter (relating to Prior Written Notice) to the parent if a child is determined to be ineligible for ECI services. Source Note: The provisions of this §350.807 adopted to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.807 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223962 03/12/2026 (a) A child must be younger than 36 months of age and meet initial eligibility criteria to receive ECI services. Initial eligibility is established by: (1) documentation of a medically diagnosed condition that has a high probability of resulting in developmental delay; (2) meeting the TEA definition of deaf or hard of hearing or criteria for a visual impairment provided in 19 TAC §89.1040 (relating to Eligibility Criteria); or (3) a developmental delay, which must be evaluated as described in 34 CFR §303.321 and the delay is determined based on: (A) an evaluation using a standardized tool designated by HHSC ECI that indicates a delay of at least 25 percent in one or more of the following developmental areas: (i) communication; (ii) cognitive; (iii) gross motor; (iv) fine motor; (v) social emotional; or(vi) adaptive; (B) an evaluation using a standardized tool designated by HHSC ECI that indicates a delay of at least 33 percent if the child's only delay is in expressive communication; or (C) a qualitative determination of delay, as defined in §350.821 of this subchapter (relating to Qualitative Determination of Developmental Delay). (b) A child must meet the same eligibility standards in subsection (a)(3)(A) or (a)(3)(B) of this section on the designated tool to qualify for a qualitative determination of delay unless the child has an adjusted age or chronological age of under three months. Source Note: The provisions of this §350.809 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.809 Initial Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223963 03/12/2026 (a) The interdisciplinary team must review medical documentation to determine eligibility for a child who has a qualifying medical diagnosis. The subrecipient must maintain documentation reviewed for this purpose in the child's record. (1) Qualifying medical diagnoses are approved by the HHSC Director of ECI based on prevailing medical opinion that the diagnoses have a high probability of resulting in developmental delay.(2) HHSC ECI maintains a searchable database of qualifying medical diagnoses that is made available to the public. HHSC ECI will notify subrecipients and the public when changes to the database are made.(b) If a review of the child's records indicates that the child has a qualifying medical diagnosis, the interdisciplinary team must determine and document a need for ECI services as required in §350.837 of this chapter (relating to Needs Assessment). Source Note: The provisions of this §350.811 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.811 Qualifying Medical Diagnosis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223964 03/12/2026 (a) The interdisciplinary team may not determine a child ineligible if the child is suspected to be deaf or hard of hearing until all evaluations and assessments required in this section have been completed and reviewed by the interdisciplinary team.(b) The interdisciplinary team must determine any need for further hearing testing by analyzing risk factors and evaluation results during every evaluation to determine eligibility. (1) Evaluation results must include the items listed in §350.809 (relating to Initial Eligibility Criteria). (2) A hearing screening tool may be used when an evaluation tool is not administered for a child who is eligible based on a medical diagnosis or a child who meets the criteria of having a visual impairment as defined by 19 TAC §89.1040 (relating to Eligibility Criteria). (c) The subrecipient must refer the child to a licensed audiologist if the child has been identified as having a need for further hearing testing and the child has not had a hearing test within the six months prior to identifying the need. (1) If necessary to access a licensed audiologist, the subrecipient may refer the child to the child's primary health care provider. (2) The referral must be made: (A) within five working days; and (B) with parental consent. (d) If the subrecipient receives a hearing test that indicates the child is deaf or hard of hearing or receives documentation that the child has a medical condition that has a high probability of resulting in a developmental delay and sensory impairment, the subrecipient mustenroll the child and make a referral to the LEA. (1) The referral must be made within five business days after the subrecipient receives: (A) the hearing test, in which case the referral must include results of the hearing test; or (B) documentation indicating the child has a medical condition that has a high probability of resulting in a developmental delay and sensory impairment.(2) Per 20 USC §1232g(b)(1)(A), parental consent is not required for this referral, but the parent must be notified that the referral is being made.(3) If the child has not been tested by an audiologist, the subrecipient must assist the family in obtaining a hearing test and send the test results to the LEA within five business days of receiving the hearing test.(e) The subrecipient must refer any child who uses amplification to the LEA.(f) The Certified Teacher of the Deaf and Hard of Hearing from the LEA participates in the service planning process as part of the interdisciplinary team and, with written parental consent, completes any necessary evaluations. Source Note: The provisions of this §350.813 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective January 10, 2016, 41 TexReg 499; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.813 Deaf or Hard of Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223965 03/12/2026 (a) The interdisciplinary team may not determine a child ineligible if the child is suspected to be blind or visually impaired until all evaluations and assessments required in this section have been completed and reviewed by the interdisciplinary team.(b) The interdisciplinary team must determine any need for further vision testing by analyzing risk factors and evaluation results during every evaluation to determine eligibility. (1) Evaluation results must include the items listed in §350.809 (relating to Initial Eligibility Criteria).(2) A vision screening tool may be used when an evaluation tool is not administered for a child who is eligible based on a qualifying medical diagnosis or because the child meets the definition of deaf or hard of hearing in 19 TAC §89.1040 (relating to Eligibility Criteria).(c) The subrecipient must refer the child to an ophthalmologist or optometrist if the child has been identified as having a need for further vision testing and the child has not had a vision test within the six months prior to identifying the need.(1) If necessary to access an ophthalmologist or optometrist, the subrecipient may refer the child to the child's primary health care provider. (2) The referral must be made: (A) within five working days; and (B) with parental consent. (d) If the subrecipient receives a vision test that indicates the child is blind or visually impaired or receives documentation that the child has a physical or mental condition that has a high probability of resulting in a developmental delay and a sensory impairment, the subrecipient must enroll the child and make a referral to the LEA. With written parental consent consistent with §350.207 of this chapter (relating to Parental Consent), the subrecipient must also refer the child to the local office of the Health and Human Services Blind Children's Vocational Discovery and Development Program.(1) The referral must be made within five business days after the subrecipient receives:(A) a vision test that indicates the child is blind or visually impaired, in which case the referral must include results of the vision test; or(B) documentation indicating the child has a medical condition that has a high probability of resulting in a developmental delay and sensory impairment.(2) Per 20 USC §1232g(b)(1)(A), parental consent is not required for the referral to the LEA, but the parent must be notified that the referral is being made. (3) If the child has not been tested by an ophthalmologist, an optometrist, or a medical physician, the subrecipient must assist the family in obtaining a vision test and send the test results to the LEA within five business days of receiving the vision test.(e) The certified teacher of students with visual impairments and the certified orientation and mobility specialist from the LEA participate in the service planning process as part of the interdisciplinary team and, with written parental consent, complete any necessary evaluations. Source Note: The provisions of this §350.815 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.815 Visual Impairment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223966 03/12/2026 (a) The subrecipient must: (1) comply with all requirements in 34 CFR §303.321(b); (2) maintain all test protocols and other documentation used to determine eligibility and continuing eligibility in the child's record; and(3) ensure that all evaluations are conducted by qualified personnel. (b) The subrecipient must ensure evaluations to determine initial and continuing eligibility based on developmental delay, as defined in §350.809 of this subchapter (relating to Initial Eligibility Criteria), are conducted by at least two professionals from different disciplines with participation by the parent. (1) An LPHA must be one of the two professionals. (2) Service coordination is not considered a discipline for evaluation. (3) The evaluation procedures must include: (A) administration of a standardized tool designated by HHSC ECI; (B) taking the child's history, including interviewing the parent; (C) identifying the child's level of functioning in each of the developmental areas in 34 CFR §303.21(a)(1); (D) gathering information from other sources such as family members, other caregivers, medical providers, social workers, and educators, if necessary, to understand the full scope of the child's unique strengths and needs; (E) reviewing medical, educational, and other records; (F) in addition to requirements in 34 CFR §303.321(b), determining the most appropriate setting, circumstances, time of day, and participants for the evaluation to capture the most accurate picture of the child's ability to function in his or her natural environment; and (G) interpreting scores and determining delay through the application of informed clinical opinion to test results. (4) When a child's chronological or adjusted age is zero months or younger, use of the standardized tool or another protocol is not required. While the interdisciplinary team does not need to administer the standardized tool or protocol, the interdisciplinary team must complete a qualitative determination of developmental delay as described in §350.821 of this subchapter (relating to Qualitative Determination of Developmental Delay).(c) The subrecipient must consider other evaluations and assessments performed by outside entities when requested by the family. (1) The subrecipient must determine whether outside evaluations and assessments: (A) are consistent with HHSC ECI policies; (B) reflect the child's current status; and (C) have implications for IFSP development. (2) The subrecipient may discount or disregard evaluations and assessments performed by outside entities if the family: (A) does not allow full access to those records or entities;(B) does not consent to evaluations or assessments; or(C) does not cooperate in evaluations or assessments to verify their findings. Source Note: The provisions of this §350.817 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective May 1, 2014, 39 TexReg 3445; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.817 Developmental Delay https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203699 03/12/2026 In determining the extent of developmental delay, an adjustment for children born prematurely must be applied as follows:(1) age is adjusted for children born before 37 weeks gestation and is based on a 40-week term;(2) the developmental age must be measured against the adjusted age rather than chronological age until the child is 18 months old; and(3) the age adjustment cannot exceed 16 weeks. Source Note: The provisions of this §350.819 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.819 Age Adjustment for Children Born Prematurely https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223967 03/12/2026 Qualitative determination of developmental delay is applied as described in this section. (1) Qualitative determination of developmental delay may only be used at initial eligibility determination.(2) When a child's adjusted age or chronological age is zero months or younger, administration of the standardized tool or another protocol is not required. (3) The interdisciplinary team, which must include an LPHA who is knowledgeable in the area of concern, must document: (A) clinical findings; and (B) how those findings significantly interfere with the child's functional abilities. (4) When the evaluation results for a child, whose adjusted age or chronological age is greater than zero months, do not accurately reflect the child's development or ability to function in the natural environment, the interdisciplinary team must: (A) document this information in the child's record; and(B) proceed to a qualitative determination of developmental delay, which must be made by a team that includes an LPHA knowledgeable in the area of concern.(i) For a child with an adjusted or chronological age greater than zero months but less than three months, the interdisciplinary team qualitatively determines developmental delay by describing clinical findings and how those findings significantly interfere with the child's functional abilities. (ii) For a child with an adjusted or chronological age of at least three months, the interdisciplinary team must use the supplemental protocol designated by HHSC ECI to qualitatively determine developmental delay. The developmental domains and sub-domains that can be used for qualitative determination of delay are established by HHSC ECI. Source Note: The provisions of this §350.821 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.821 Qualitative Determination of Developmental Delay https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223968 03/12/2026 (a) The subrecipient must determine the child's eligibility for continued ECI services at least annually if the child is younger than 21 months of age at the previous eligibility determination. A child who is determined eligible at 21 months of age or older remains eligible for ECI until the child's third birthday or until the child has reached developmental proficiency, whichever happens first. (b) The subrecipient must comply with all requirements in 34 CFR §303.321(a)(3). (1) Continuing eligibility is based on one of the following: (A) a qualifying medical diagnosis confirmed by a review of the child's medical records with: (i) interdisciplinary team documentation of the continued need for ECI services; and (ii) documentation in the child's record of any change in medical diagnosis; (B) meeting the TEA definition of deaf or hard of hearing or criteria for a visual impairment documented in 19 TAC §89.1040 (relating to Eligibility Criteria) with: (i) interdisciplinary team documentation of the continued need for ECI services including the appropriate certified teacher or teachers from the LEA as specified in §350.813 and §350.815 of this subchapter (relating to Deaf or Hard of Hearing and Blindness or Visual Impairment, respectively); and (ii) documentation in the child's record of any change in hearing or vision status; or (C) a developmental delay determined by the administration of the standardized tool designated by HHSC ECI, with the child demonstrating a documented delay of at least 15 percent in one or more areas of development, including the use of adjusted age as specified in §350.819 of this subchapter (relating to Age Adjustment for Children Born Prematurely), as applicable. (2) If a child's initial eligibility is based on a qualitative determination of developmental delay, the subrecipient must re-determine eligibility using the criteria in subsection (b)(1) of this section no more than six months after initial eligibility is determined. (c) If the parent fails to consent or fails to cooperate in re-determination of eligibility, the child becomes ineligible. The subrecipient must provide prior written notice of ineligibility and consequent discontinuation of all ECI services to the family at least 14 days before the subrecipient discharges the child from the program, unless the parent: (1) immediately consents to and cooperates in all necessary evaluations and assessments; and (2) consents to all or part of a new IFSP. (d) The family has the right to oppose the actions described in subsection (c) of this section using their procedural safeguards including the rights to use local and state complaint processes, request mediation, or request an administrative hearing in accordance with 40 TAC §101.1107 (relating to Administrative Hearings Concerning Individual Child Rights). Source Note: The provisions of this §350.823 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.823 Continuing Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223969 03/12/2026 (a) The interdisciplinary team must document eligibility decisions regarding a child on an eligibility statement containing the elements required by HHSC ECI. (b) The eligibility statement must document the eligibility criteria that applies to the child. Only one of the following eligibility types may be listed on the eligibility statement:(1) a qualifying medical diagnosis;(2) meeting the criteria for deaf or hard of hearing or a visual impairment as defined by the TEA; or(3) completion of the elements required by HHSC ECI for a determination of developmental delay. (c) The eligibility statement must be: (1) completed for every child evaluated; (2) maintained in the child's record; and (3) updated when eligibility is re-determined. (d) The eligibility statement is valid: (1) for 12 months if the child is younger than 21 months of age when eligibility is determined;(2) until the child's third birthday for a child whose eligibility was determined at 21 months of age or older; or (3) for six months from the initial eligibility determination if eligibility was based on a qualitative determination of developmental delay. (e) If new information about additional qualifying criteria is discovered, the new information is documented in the child's record. The eligibility statement does not need to be changed or updated until eligibility is re-determined. Source Note: The provisions of this §350.825 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.825 Eligibility Statement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203703 03/12/2026 The interdisciplinary team considers the child's medical history before planning services and throughout the child's enrollment. The IFSP team must:(1) review pertinent medical information before developing the IFSP;(2) request additional health information necessary to develop an appropriate plan of service;(3) delay or adjust the implementation procedures or services until the necessary health information is obtained and reviewed;(4) continue to review medical records that become available after enrollment; and(5) delay or adjust the implementation of procedures or service if the health or safety of the child is in jeopardy. Source Note: The provisions of this §350.828 adopted to be effective March 7, 2015, 40 TexReg 939; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.828 Medical Review for ECI Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223970 03/12/2026 (a) The interdisciplinary team must complete a review of the child's nutrition status by any of the following methods no later than 28 days after the initial IFSP is developed: (1) a review of the child's medical records; (2) a review of the child's nutrition evaluation; (3) a review of a doctor's physical examination for the child; (4) a review of a nurses' evaluation for the child; (5) a thorough discussion of family routines; or (6) a review of nutrition risk factors. (b) The service coordinator must refer the child to a registered dietician if nutrition needs are identified. Source Note: The provisions of this §350.829 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.829 Review of Nutrition Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203705 03/12/2026 The interdisciplinary team must address assistive technology needs as part of the comprehensive needs assessment. This may be accomplished by:(1) a review of assistive technology needs by qualified therapist as part of the evaluation; or(2) administration of a screening tool which includes a review of the child's functioning and needs for assistance in positioning, mobility, communication, and play. Source Note: The provisions of this §350.831 adopted to be effective September 1, 2013, 38 TexReg 5524; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.831 Assistive Technology https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223971 03/12/2026 (a) Autism screening is not required if the child has been screened for autism spectrum disorder by another entity or has been identified as having autism spectrum disorder.(b) The subrecipient does not diagnose autism spectrum disorder.(c) If an enrolled child is 18 months or older, the interdisciplinary team must determine if the child: (1) has a family history of autism spectrum disorder;(2) has lost previously acquired language or other communication skills or social skills; or (3) exhibits a language or cognitive delay or unusual communication patterns combined with a social, emotional, or behavioral concern, including repetitive or stereotypical behaviors. (d) If the interdisciplinary team identifies any of the issues in subsection (c) of this section, a member of the team must explain to the family the importance of early screening for autism spectrum disorder.(e) The subrecipient must obtain written parental consent to refer the child to their licensed health care provider to complete an autism screening tool designated by HHSC ECI.(f) If the child is not screened by the child's licensed health care provider or the subrecipient is unable to receive the screening from the child's licensed health care provider in a timely manner, the subrecipient must obtain written parental consent to:(1) complete a screening for autism spectrum disorder using a tool designated as appropriate by HHSC ECI; and(2) if appropriate, complete any additional follow-up activities for a child who does not pass the screening. (g) The subrecipient must make appropriate referrals if needs are identified. Appropriate referrals may include: (1) a referral to appropriate clinicians for a child who does not pass the designated screening; and (2) the provision of case management to assist the parent with having an autism spectrum disorder screening done by the child's licensed health care provider if they do not consent to a screening by the subrecipient. (h) Screening for autism spectrum disorder using a tool designated as appropriate by HHSC ECI does not take the place of the appropriate evaluation of the child required under this subchapter. Source Note: The provisions of this §350.833 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.833 Autism Screening https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223972 03/12/2026 Subrecipients must have internal written procedures that establish a system of clinical oversight for eligibility determination. Clinical oversight, which is conducted by a person with knowledge of evaluation and assessment of young children, includes ensuring that: (1) HHSC ECI eligibility criteria is applied consistently to all children who are evaluated; (2) testing is administered and scored accurately according to the requirements of the selected tool designated by HHSC ECI; (3) evaluations to determine eligibility are comprehensive; (4) test scores are interpreted and determination of delay includes the application of informed clinical opinion; and (5) eligibility decisions are fully documented in: (A) the eligibility statement; and (B) progress note or evaluation report. Source Note: The provisions of this §350.835 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.835 Subrecipient Oversight https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223973 03/12/2026 (a) The IFSP team, which includes the service coordinator, must conduct a comprehensive needs assessment initially and annually as part of the IFSP process. The comprehensive needs assessment must include: (1) an assessment of the child; and(2) a family-directed assessment.(b) The assessment of the child must include: (1) a review of the results of the child's evaluation; (2) personal observations of the child; (3) the functional abilities and unique strengths of the child; and(4) the identification of the child's needs in each of the developmental areas listed in 34 CFR §303.21(a)(1). (c) The subrecipient must offer to conduct a family-directed assessment and comply with requirements in 34 CFR §303.321(c). The family-directed assessment must: (1) be voluntary on the part of each family member participating in the assessment; (2) be based on information obtained through the assessment as well as through an interview with those family members participating in the assessment; and(3) identify the family's resources, priorities, and concerns, as well as the supports and services necessary to enhance the family's capacity to meet the developmental needs of the child.(d) The IFSP team must assess and document the child's progress and needs of the family on an ongoing basis. Source Note: The provisions of this §350.837 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES H ELIGIBILITY, EVALUATION, AND ASSESSMENT §350.837 Needs Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223974 03/12/2026 The following words and terms, when used in this subchapter, will have the following meanings, unless the context clearly indicates otherwise. (1) Frequency--The number of days or sessions that a service will be provided within a specified period of time. (2) Functional ability--A child's ability to carry out meaningful behaviors in the context of everyday living, through skills that integrate development across domains. (3) IFSP goals--Statements of the measurable results that the family wants to see for their child or themselves. (4) Intensity--The length of time a service is provided during a session expressed as a specific amount of time instead of a range. (5) Method--If the service is delivered in a group or on an individual basis. (6) Periodic review--As defined in 34 CFR §303.342(b), a review by the IFSP team, based on the assessment of the child, that results in approval of or modifications to the IFSP. Source Note: The provisions of this §350.1003 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1003 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223975 03/12/2026 (a) The IFSP team must develop a written initial IFSP no more than 45 days after the date the subrecipient receives a referral on a child unless the child or parent is unavailable due to exceptional family circumstances documented in the child's record. The IFSP must be: (1) completed during a face-to-face meeting with a family in accordance with 20 USC §1436 and 34 CFR §§303.340 - 303.346; and (2) developed based on evaluation and assessment of a child as described in 34 CFR §303.321 and Subchapter H of this chapter (relating to Eligibility, Evaluation, and Assessment). (b) An IFSP must address the developmental needs of the child and the case management needs of the family as identified in the comprehensive needs assessment, unless the family declines to address a specified need. (c) A subrecipient must provide a parent with a copy of the IFSP and maintain the original IFSP in the child's record. (d) A subrecipient must deliver ECI services according to the IFSP. (e) An IFSP team must conduct a periodic review of the IFSP at least every six months in accordance with 34 CFR §303.342. (f) If a child was younger than 21 months of age on the date of the previous initial or annual IFSP meeting, an IFSP meeting must be conducted at least annually to evaluate and revise, as appropriate, the IFSP for a child and the child's family in accordance with 34 CFR §303.342. The meeting may be conducted by a method other than face-to-face if: (1) approved by the parent; (2) the subrecipient has a plan approved by HHSC for conducting annual IFSP meetings by a method other than face-to-face when appropriate for the child and family; and (3) the subrecipient documents how the LPHA's observations and conclusions of the re-evaluation of the child were communicated and incorporated into the IFSP. (g) If a child was 21 months of age or older on the date of the previous initial or annual IFSP, the IFSP team must conduct a periodic review that meets the requirements in §350.1017 of this subchapter (relating to Periodic Reviews).(h) Documentation in the child's record must reflect compliance with related state and federal requirements. (i) The subrecipient must comply with all requirements in Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures) during the IFSP process. Source Note: The provisions of this §350.1004 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1266; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1004 Individualized Family Service Plan Development https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223976 03/12/2026 (a) An interim IFSP may be developed for an eligible child and family who need supports and services to begin immediately. ECI services may begin before completing an evaluation and assessment if: (1) parental consent is obtained; (2) the interim IFSP includes the name of the assigned service coordinator; (3) the interim IFSP includes the services that have been determined to be needed immediately; and (4) the evaluation, assessment, and initial IFSP are completed within the 45-day timeframe in accordance with 34 CFR §303.310. (b) An annual interim IFSP may be developed for an eligible child and family who need supports and services to continue when exceptional family circumstances prevent the team from completing all required components of the annual meeting to evaluate the IFSP in accordance with §350.1019 of this subchapter (relating to Annual Meeting to Evaluate the Individualized Family Service Plan). ECI services may continue if: (1) parental consent is obtained; (2) the interim IFSP is in accordance with 34 CFR §303.342; (3) the interim IFSP includes the name of the assigned service coordinator; (4) the interim IFSP includes the services that have been determined to be needed; and (5) the evaluation, assessment, and all required components of the annual meeting to evaluate the IFSP must be completed within 45 days of the date the annual review of the IFSP was due. Source Note: The provisions of this §350.1007 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1007 Interim Individualized Family Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223977 03/12/2026 (a) The initial IFSP meeting and each annual meeting to evaluate the IFSP must be conducted by the IFSP team as defined in §350.103 of this chapter (relating to Definitions) and 34 CFR §303.343(a). (b) With parental consent, the subrecipient must also invite to the initial IFSP meeting and annual meetings to evaluate the IFSP: (1) Early Head Start or Migrant Head Start staff members, if the family is jointly served by either of these programs; and (2) representatives from other agencies serving or providing case management to the child or family, including Medicaid managed care programs. (c) If a child: (1) is documented to be deaf or hard of hearing as described in §350.809(2) of this chapter (relating to Initial Eligibility Criteria), the IFSP team for an initial IFSP meeting and annual IFSP evaluation meetings must include a certified teacher of the deaf and hard of hearing; or (2) has a documented visual impairment as described in §350.809(2) of this chapter (relating to Initial Eligibility Criteria), the IFSP team for an initial IFSP meeting and annual IFSP evaluation meetings must include a teacher of students with visual impairments and a certified orientation and mobility specialist.(d) Unless there is documentation that the LEA has waived notice, the subrecipient must: (1) provide the certified teacher required in subsection (c) of this section at least a 10-day written notice before the initial IFSP meeting, any annual meetings to evaluate the IFSP, or any review and evaluation when issues will be addressed that are related to or affected by the child being deaf, hard of hearing, or visually impaired; and(2) keep documentation of the notice in the child's record. (e) The IFSP team cannot plan deaf and hard of hearing or vision services or make any changes that affect those services if the certified teacher required in subsection (c) of this section is not in attendance. (f) The certified teacher required in subsection (c) of this section is not required to attend an IFSP review when the following criteria are met, but the subrecipient must obtain the teacher's input.(1) The IFSP review does not affect the child's vision or hearing services.(2) Changes made during the IFSP review are not affected by the child's hearing or visual status. (g) The IFSP team must route the IFSP within two business days to the certified teacher required in subsection (c) of this section for review and signature when changes to the IFSP do not affect the child's deaf and hard of hearing or vision services. (h) The certified teacher of the deaf and hard of hearing and the certified teacher of the students with visual impairments required in subsection (c) of this section may submit a request within five days of the IFSP meeting to have another IFSP meeting if the teacher disagrees with any portion of the IFSP. Source Note: The provisions of this §350.1009 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1009 Participants in Initial and Annual Individualized Family Service Plan Meetings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223978 03/12/2026 (a) The IFSP team must develop a written IFSP containing all requirements in 20 USC §1436(d) and 34 CFR §303.344. The IFSP must include the IFSP services pages and all of the required elements designated by HHSC ECI, including: (1) a description of the child's present levels of development, including: (A) information about the child's participation in the family's typical routines and activities; (B) the child's strengths; (C) the child's developmental needs; (D) the family's concerns and priorities; and (E) the child's functional abilities identified with codes for establishing the child outcome ratings, described in §350.1307 of this chapter (relating to Child Outcomes); (2) a description of the case management needs of the family; (3) measurable goals that address: (A) the child's and family's needs that were identified during pre-enrollment, evaluation, and assessment; (B) the child's functional developmental skills by describing targeted participation in everyday family and community routines and activities; and (C) when the IFSP goal is achieved and the action or skill is generalized; (4) services to: (A) address the goals in the IFSP; (B) enhance the child's functional abilities, behaviors, and participation in daily routines; and (C) strengthen the capacity of the family to meet the child's unique needs; (5) the discipline of each provider for every service planned; and (6) the name of the service coordinator. (b) IFSP services must be monitored by the IFSP team to assess child progress as described in §350.1017 of this subchapter (relating to Periodic Reviews). (c) If the IFSP team determines co-visits are necessary to meet the developmental needs of the child, the IFSP team must: (1) list each service on the IFSP; and (2) document in the IFSP a justification of how the child and family will receive greater benefit from the services being provided at the same time. (d) If providing services with the participation of the routine caregiver in the absence of the parent is necessary, the IFSP team must follow the requirements in §350.1016 of this subchapter (relating to Planning for Services to be Delivered with the Routine Caregiver). (e) If the IFSP team determines group services are necessary to meet the developmental needs of the child: (1) the group services must be planned in an IFSP that also contains individual IFSP services; and (2) the planned group services must be documented in the child's IFSP. (f) If the IFSP team determines that an IFSP goal cannot be achieved satisfactorily in a natural environment, the IFSP must contain a justification as to why an early childhood intervention service will be provided in a setting other than a natural environment, as determined appropriate by the parent and the rest of the IFSP team. (g) The contents of the IFSP must be fully explained to the parent. (h) The subrecipient must obtain the parent's signature on the IFSP services pages. The parent's signature on the IFSP services pages serve as written parental consent to provide the ECI services in the IFSP. (1) The written parental consent is valid for up to one year or until the IFSP team changes the type, intensity, or frequency of services. (2) The subrecipient must not provide ECI services in the IFSP without current written parental consent. (i) The subrecipient must obtain the dated signatures of every member of the IFSP team on the IFSP services pages. The IFSP must be signed by the LPHA on the team to acknowledge the planned services are reasonable and necessary. (j) The subrecipient must provide the parent a copy of the signed IFSP. (k) Any time the subrecipient assigns a new service coordinator, the following must be documented and attached to the IFSP: (1) the name of the new service coordinator; (2) the date of the change; and (3) the date the family was notified of the change and the method of notification. Source Note: The provisions of this §350.1015 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1015 Content of the Individualized Family Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203713 03/12/2026 (a) If delivering services with the participation of the routine caregiver in the absence of the parent is necessary, the IFSP team must:(1) document the names of the routine caregivers in the child's record;(2) obtain written parental consent before releasing personally identifiable information to the routine caregiver; and(3) obtain written authorization from the parent to provide early childhood intervention services with the routine caregiver.(b) A member of the IFSP team must contact the parent face-to-face or by telephone at least once every month to provide an update on services provided with a routine caregiver. Source Note: The provisions of this §350.1016 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1016 Planning for Services to be Delivered with the Routine Caregiver https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223979 03/12/2026 (a) Each periodic review must be conducted by individuals who meet the requirements in 34 CFR §303.343(b) and be completed in compliance with 34 CFR §303.342(b). The periodic review may be carried out by a meeting or by another means that is acceptable to the parents and other participants. (b) The child's record must contain documentation that includes all required elements designated by HHSC ECI. (1) Participation in the periodic review may be accomplished by a team member attending the meeting face-to-face or by telephone or by providing input and information in advance of the meeting. (2) If a team member participates by means other than a face-to-face meeting, the team member must give the service coordinator his or her most recent observations and conclusions about the child, and the team member must document how and when the information was shared. (3) If the team member is an LPHA who is not providing ongoing services to the child, he or she must have assessed the child face-to-face within the previous 45 days. (c) A periodic review is required at least every six months. (d) Additional periodic reviews of the IFSP are conducted more frequently than six-month intervals if requested by the parent or other IFSP team members. (e) The periodic review of the IFSP consists of the following actions, which must be documented in the child's record and be provided to the parent: (1) a review of the child's progress toward meeting each goal on the IFSP and the child's functional abilities related to the goal; (2) a review of the current developmental needs of the child and the needs of the family related to their ability to meet the developmental concerns and priorities; (3) a review of the case management needs of the child and the family; (4) the development of new goals or the modification of existing goals, as appropriate, that must be dated and attached to the IFSP; and (5) the reasons for any modification to the plan or the rationale for not changing the plan. (f) If the IFSP team adds transition steps and transition services as part of the periodic review, the team must follow the requirements in §350.1207(d) of this chapter (relating to Transition Planning). (g) If the team determines that changes to the type, intensity, or frequency of services are required: (1) the team completes the IFSP services pages and provides a copy to the parent; (2) the team must document the rationale for: (A) a change in intensity or frequency of a service; (B) the addition of a new service; or (C) the discontinuation of a service; and (3) the subrecipient must continue to provide planned ECI services not affected by the change while the IFSP team develops the IFSP revision and gathers required signatures. (h) If services remain the same, the documentation must describe the rationale for making no changes and for recommending continued services. (i) If new goals are developed, the documentation must be provided to the parent. (j) A change of service coordinator does not require a periodic review. Source Note: The provisions of this §350.1017 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1017 Periodic Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223980 03/12/2026 (a) The annual meeting to evaluate the IFSP is conducted after determination of continuing eligibility as described in §350.823 of this chapter (relating to Continuing Eligibility Criteria). (b) In addition to all requirements in 34 CFR §303.342, the documentation of an annual meeting to evaluate the IFSP must include a team discussion of: (1) a current description of the child including: (A) current evaluations and other information available from ongoing assessment of the child and family needs; (B) health, vision, hearing, and nutritional status; and (C) present levels of development related to the three annual child outcome ratings found in §350.1307of this chapter (relating to Child Outcomes); (2) progress toward achieving the IFSP goals; and (3) any needed modification of the goals and ECI services. (c) Services provided under an IFSP that has not been evaluated and is not based on a current evaluation and current assessment of needs do not meet the requirements for ECI services. (1) If the subrecipient is at fault, HHSC may disallow and recoup expenditures. (2) If the parent fails to consent or fails to cooperate in necessary re-evaluations or re-assessments, the subrecipient must respond as indicated in §350.823(c) of this chapter. (d) The parent retains procedural safeguards including the rights to use local and state complaint processes, request mediation, or request an administrative hearing pursuant to 40 TAC §101.1107 (relating to Administrative Hearings Concerning Individual Child Rights). Source Note: The provisions of this §350.1019 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES J INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) §350.1019 Annual Meeting to Evaluate the Individualized Family Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223981 03/12/2026 (a) ECI services needed by the child must be initiated in a timely manner and delivered as planned in the IFSP. (b) Only qualified staff members, as described in Subchapter C of this chapter (relating to Staff Qualifications), are authorized to provide ECI services. (c) The subrecipient must ensure that ECI services are appropriate, as determined by the IFSP team, and based on scientifically based research. (d) In addition to the requirements in 34 CFR §303.13, ECI services, with the exception cited in subsection (g) of this section, must be provided: (1) according to a plan and with a frequency that is individualized to the parent and child to effectively address the goals established in the IFSP; (2) only to children who are located in the state of Texas at the time a service is delivered; (3) in the presence of the parent or other routine caregiver, with an emphasis on enhancing the family's capacity to meet the developmental needs of the child; and (4) in the child's natural environment, as defined in 34 CFR §303.26, unless the criteria listed in 34 CFR §303.126 are met and documented in the case record.(e) With the written consent of the parent, ECI services may be provided via telehealth. If the parent declines to consent to telehealth for some or all services, those services must be provided in person. (f) ECI services must: (1) address the development of the whole child within the framework of the family; (2) enhance the parent's competence to maximize the child's participation and functional abilities within daily routines and activities; and (3) be provided in the context of natural learning activities in order to assist caregivers to implement strategies that will increase child learning opportunities and participation in daily life. (g) Family education and training, as defined in §350.1105(5) of this subchapter (relating to Capacity to Provide Early Childhood Intervention Services): (1) must be provided: (A) according to a plan and with a frequency that is individualized to the parent and child to effectively address the goals established in the IFSP; and (B) with a parent or other routine caregiver, with an emphasis on enhancing the family's capacity to meet the developmental needs of the child; and (2) may be provided: (A) when a child who resides in Texas is not located in the state at the time of service; and (B) in a setting other than a child's natural environment.(h) The subrecipient must provide a service coordinator and an interdisciplinary team for the child and family throughout the child's enrollment. (i) The subrecipient must make reasonable efforts to provide flexible hours in programming to allow the parent or routine caregiver to participate. (j) The subrecipient must comply with all requirements in Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures) when planning and delivering ECI services. (k) Services must be monitored by the IFSP team to assess child progress as described in §350.1017 of this chapter (relating to Periodic Reviews). Source Note: The provisions of this §350.1104 adopted to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES K SERVICE DELIVERY §350.1104 Early Childhood Intervention Services Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208279 03/12/2026 The contractor must have the capacity to provide all early childhood intervention services in 34 CFR §303.13 and additional early childhood intervention services described in this chapter. These services are the following:(1) Assistive Technology Device and Service--As defined in 34 CFR §303.13(b)(1).(2) Audiology Services--As defined in 34 CFR §303.13(b)(2), plus services provided by local educational agency personnel, including sign language and cued language services as defined in 34 CFR §303.13(b)(12).(3) Behavioral Intervention--Services delivered through a structured plan to strengthen developmental skills while specifically addressing severely challenging behaviors as determined by the Individualized Family Service Plan (IFSP) team. The behavior plan is developed by the IFSP team (that includes the plan supervisor) to:(A) identify goals;(B) conduct a functional assessment to determine the motivation for the behavior;(C) develop a hypothesis;(D) design support plans; and(E) implement, monitor, and evaluate outcomes.(4) Counseling--As family training, counseling, and home visits are defined in 34 CFR §303.13(b)(3). Counseling is provided when the nature and quality of the parent-child relationship interferes significantly with the Early Childhood Intervention child's development. Counseling focuses on the parent-child relationship or other critical care-giving relationships and helps the child meet developmental outcomes.(5) Family Education and Training--As family training, counseling, and home visits are defined in 34 CFR §303.13(b)(3). Family education and training is provided when the family needs information about general parenting techniques or environmental concerns. Information provided follows a specific scope and sequence. Information may be based on general child care, developmental education, or other specific curriculum. Family Education and Training can be provided to parents in group settings without the children present.(6) Health Services--As defined in 34 CFR §303.16.(7) Medical Services--As defined in 34 CFR §303.13(b)(5).(8) Nursing Services--As defined in 34 CFR §303.13(b)(6).(9) Nutrition Services--As defined in 34 CFR §303.13(b)(7).(10) Occupational Therapy--As defined in 34 CFR §303.13(b)(8).(11) Physical Therapy--As defined in 34 CFR §303.13(b)(9).(12) Psychological Services--As defined in 34 CFR §303.13(b)(10).(13) Service Coordination--As defined in 34 CFR §303.13(b)(11) and includes all requirements in 34 CFR §303.34.(14) Social Work Services--As defined in 34 CFR §303.13(b)(13).(15) Sign Language and Cued Language--As defined in 34 CFR §303.13(b)(12).(16) Specialized Skills Training--As defined in Subchapter E of this chapter (relating to Specialized Rehabilitative Services) plus the provision of special instruction as defined in 34 CFR §303.13(b)(14).(17) Speech-Language Pathology Services--As defined in 34 CFR §303.13(b)(15) and can include sign language and cued language services as defined in 34 CFR §303.13(b)(12).(18) Targeted Case Management--As defined in Subchapter D of this chapter (relating to Case Management for Infants and Toddlers with Developmental Disabilities).(19) Transportation and Related Costs--As defined in 34 CFR §303.13(b)(16).(20) Vision Services--As defined in 34 CFR §303.13(b)(17) plus services provided by local educational agency personnel. Source Note: The provisions of this §350.1105 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES K SERVICE DELIVERY §350.1105 Capacity to Provide Early Childhood Intervention Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203721 03/12/2026 (a) Group services must be:(1) recommended by the interdisciplinary team and documented on the IFSP only when participating in the group will assist the child to reach the goals in the IFSP;(2) planned as part of an IFSP that also contains individual services; and(3) limited to no more than four children and their parent(s) or other routine caregiver(s) per service provider.(b) When early childhood intervention services are provided in a group setting, the parent or other routine caregiver must participate in group services. Source Note: The provisions of this §350.1107 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES K SERVICE DELIVERY §350.1107 Group Services for Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223982 03/12/2026 (a) The state's General Appropriations Act authorizes reimbursement to the enrolled child's family for respite services that are not directly related to IFSP goals. (b) Respite services are defined as the care of an enrolled child by a relative or substitute caregiver on a short-term or intermittent basis to provide the child's parent with a break from caring for his or her child. Respite services do not include the routine care of a child for the purposes of allowing a parent to attend work or school. (c) The subrecipient must develop and implement a process for administering the state-funded reimbursement of respite services. (1) The subrecipient may collaborate with other ECI subrecipients within their respective consortium to administer the funds. (2) The subrecipient must identify existing respite resources in the community, including potential respite service providers and additional funding sources, before authorizing state-funded respite reimbursement. (3) The subrecipient may provide reimbursement for respite services up to the hourly limit set by HHSC ECI, based on the individual needs of the family. The subrecipient may exceed the hourly respite limit only if: (A) the family has more than one child enrolled in the ECI program; and (B) the IFSP team determines that the children cannot be cared for by a single respite provider. (4) If the parent and the service coordinator do not agree on the complexity of care, based on the needs of the child, and the ECI reimbursement rate, the subrecipient's ECI program director decides the complexity of care and reimbursement rate. (5) The subrecipient must have a process for prioritizing requests for state-funded respite reimbursement, and the process must include consideration of: (A) how respite will benefit the family relationship; and (B) past use of respite services. (6) If state respite funds are not available at the time of a request, the subrecipient places the eligible family on a waiting list for respite funds. (7) State respite funds cannot be used to pay: (A) insurance co-payments, insurance deductibles, or insurance premiums; (B) a parent to provide respite services to his or her own child; (C) individuals who live in the same household as the child; (D) individuals under 18 years of age; or (E) costs for the care of siblings of the eligible child. (d) The subrecipient must maintain auditable records of state-funded respite reimbursement. (e) The subrecipient must report the number of children whose families received state-funded reimbursement of respite services for each month of the contract period as directed by HHSC. (f) The service coordinator must: (1) assist the parent in identifying available family and community resources; (2) assist the parent in determining the type (for example, individual setting, group setting, care in the child's home, or care out of the child's home) and frequency of respite needed; (3) assist the parent in applying for available state funds for reimbursement of respite services, if needed; (4) determine the complexity of care, based on the needs of the child; (5) inform the parent of the following: (A) state funds under this provision are limited; (B) the state's annual hourly limits per child; (C) the hourly co-pay based on family size and income; (D) the state's level of reimbursement based upon the complexity of care, frequency, and hourly co-pay; (E) the subrecipient's criteria for prioritizing requests for state funds for reimbursement of respite services and placement on the waiting list; and (F) the process for requesting a review and decision by the program director if the parent and the service coordinator do not agree on the frequency and complexity of care, based on the needs of the child, and the ECI reimbursement rate. (g) The service coordinator must explain to the parent what responsibilities the parent has regarding state-funded reimbursement for respite services. The parent is responsible for: (1) selecting and supervising a respite provider; (2) scheduling the respite care with the provider; (3) paying the provider after the respite care is provided; (4) submitting the completed respite voucher to the subrecipient within one month of the voucher's expiration date; (5) assuming any liability for the selection and use of specific respite providers; and (6) complying with any potential tax or Internal Revenue Service requirements related to the use of state-funded respite reimbursement. (h) The following events must occur in order: (1) the subrecipient determines the number of hours and the level of care for each month, the number of months approved, the beginning and ending dates of the agreement, and the hourly co-pay required; (2) the subrecipient completes all required information on the respite funding agreement; (3) the parent, the service coordinator or other assigned staff member, and the program director (or designee) sign the completed respite funding agreement; (4) the subrecipient gives the parent a respite voucher for each calendar month in which respite services are approved; (5) the parent schedules respite with the respite provider; (6) the respite provider signs the respite voucher after providing the respite care; (7) the parent completes, signs, and returns the voucher to the subrecipient within one month of the voucher's expiration date; and (8) the subrecipient reimburses the parent no more than 30 days after the receipt of an accurately completed voucher. Source Note: The provisions of this §350.1108 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES K SERVICE DELIVERY §350.1108 State-Funded Respite Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223983 03/12/2026 Documentation of each service contact must include: (1) the name of the child; (2) the name of the subrecipient; (3) the name and the discipline of the ECI professional; (4) the date, start time, length of time, and place of service; (5) method (individual or group); (6) a description of the techniques by which the provider engaged the family or routine caregiver in activities to meet the developmental needs of the child, which includes: (A) coaching and strategies provided to the family or caregiver; (B) discussing how activities apply to child and family routines; and (C) modeling intervention techniques within everyday learning opportunities, including a description of the opportunity for the caregiver's return demonstration; (7) the IFSP goal or goals that were the focus of the intervention; (8) the child's progress related to the IFSP goals addressed during the service; (9) relevant new information about the child provided by the family or other routine caregiver; (10) the ECI professional's signature; and(11) the ECI professional's credential. Source Note: The provisions of this §350.1111 adopted to be effective September 1, 2011, 36 TexReg 5387; amended to be effective July 1, 2012, 37 TexReg 4621; amended to be effective September 1, 2013, 38 TexReg 5524; amended to be effective March 7, 2015, 40 TexReg 939; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES K SERVICE DELIVERY §350.1111 Service Delivery Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223984 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223984 03/12/2026 The following words and terms, when used in this subchapter, will have the following meanings, unless the context clearly indicates otherwise. (1) Community transition meeting--A meeting held to discuss how the subrecipient will assist the family with transitioning from ECI services to community services, activities, places, or programs that the family would like the child to participate in after exiting ECI services. (2) LEA notification--A notification sent to the LEA of a child who is potentially eligible for ECSE services.(3) LEA notification opt out--The parent's choice not to allow the subrecipient to send the child's limited personally identifiable information to the LEA to meet requirements in §350.1211 of this subchapter (relating to Local Education Agency Notification of Potential Eligibility for Early Childhood Special Education Services). (4) LEA transition conference--A meeting to discuss ECSE services and eligibility determination for children who are potentially eligible for ECSE services. (5) Limited personally identifiable information--The child's and parent's names, addresses, and phone numbers; child's date of birth; service coordinator's name; and language spoken by the child and family. (6) Transition planning--The process of identifying and documenting appropriate steps and transition services to support the child and family to smoothly and effectively transition from ECI services to ECSE services or other community services, activities, places, or programs that the family would like the child to participate in after exiting ECI services. Source Note: The provisions of this §350.1203 adopted to be effective May 1, 2014, 39 TexReg 3445; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1203 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208196 03/12/2026 (a) At the first meeting with the family after the referral, the contractor must explain:(1) circumstances that would cause the child to no longer meet the eligibility requirements for early intervention services; and(2) the Early Childhood Intervention transition process.(b) The contractor must provide the enrolled family an overview of transition concepts and activities, including:(1) ways to plan ahead and help the child adjust to and function in new settings;(2) future placement options for the child such as Local Education Agency (LEA) special education services, community childcare settings, and home care;(3) referral and contact information for relevant advocacy groups, local resources, parent support organizations, Medicaid programs, including waiver programs offering long-term services and supports if the child has a condition that would make them eligible for waiver programs, and other governmental agencies; and(4) LEA Notification requirements and the LEA Notification Opt Out option.(c) The contractor must document the transition conversation with the family in a progress note. Source Note: The provisions of this §350.1205 adopted to be effective May 1, 2014, 39 TexReg 3445; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1205 Transition Education and Information for the Family https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223985 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223985 03/12/2026 (a) Transition planning is a process for developing and updating appropriate transition steps and transition services: (1) jointly with families; and (2) based on recommendations from the IFSP team. (b) All transition activities must be documented in the child's record. (c) The IFSP must contain an appropriate general transition statement. (d) The subrecipient must conduct an IFSP meeting, which includes the parent, in accordance with 34 CFR §303.342(d) and (e) and §303.343(a), to plan and document transition steps and transition services. (1) Except as provided in subsections (f) and (g) of this section, the meeting to plan and document transition steps and transition services must be conducted: (A) no less than 90 days before the child's third birthday; and (B) not more than nine months before the child's third birthday. (2) If the child is referred and determined to be eligible for ECI services more than 45 but less than 90 days before the child's third birthday, transition steps and transition services must be included in the child's initial IFSP. (3) If transition planning occurs at a periodic review instead of an initial or annual IFSP meeting, the meeting must meet the requirements in 34 CFR §303.342(d) and (e) and §303.343(a). (4) The appropriate transition steps and transition services that the IFSP team plans at the meeting must be documented in the IFSP and must include: (A) timelines and responsible party for each transition activity; (B) discussions with and training of parents, as appropriate, regarding future placements and other matters related to the child's transition; (C) procedures to prepare the child for changes in service delivery, including steps to help the child adjust to and function in a new setting; (D) the family's choice for the child to transition into a community or educational program or for the child to remain in the home; (E) identification of transition steps and transition services, as determined by the IFSP team, to support the family's exit from ECI services to ECSE or other community services, activities, places, or programs the family would like the child to participate in after exiting ECI services; (F) confirmation that the transition notification, which requires child find information to be sent to the LEA, has occurred; (G) program options, if the child is potentially eligible for ECSE services, for the period from the child's third birthday through the remainder of the school year; and (H) for children who are likely to be eligible for long-term services and supports, information on Texas Medicaid waiver programs for people with disabilities or special health care needs, including information on how to add children to the waiver interest lists. (e) The child's planned transition steps and transition services must be updated and documented in the IFSP anytime the: (1) IFSP team identifies new transition steps and transition services; and (2) parent's goals for the child evolve and change. (f) At any time during the child's enrollment in ECI services, the IFSP team must, upon parental request, meet to plan steps to support the child and family to transition: (1) from one subrecipient to another subrecipient; (2) from one family setting to another family setting; or (3) when the family is moving out of state. (g) If the child is referred fewer than 45 days before the child's third birthday, the IFSP team is not required to plan transition steps and transition services. If the child is potentially eligible for ECSE services, the subrecipient must, with written parental consent, refer the child directly to the LEA as soon as possible. (h) The subrecipient must comply with all requirements in Subchapter B of this chapter (relating to Procedural Safeguards and Due Process Procedures). Source Note: The provisions of this §350.1207 adopted to be effective May 1, 2014, 39 TexReg 3445; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1207 Transition Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223986 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223986 03/12/2026 HHSC coordinates the SEA notification of children potentially eligible for ECSE, in compliance with 34 CFR §303.209(b). (1) HHSC will send notification of children potentially eligible for ECSE services to the SEA at least 90 days before each child's third birthday, or as soon as possible for children who are determined eligible for ECI services more than 45 but less than 90 days before the child's third birthday. (2) If a referral is received for a child fewer than 45 days before the child's third birthday and the child may be potentially eligible for ECSE services, HHSC will, with written parental consent, refer the child directly to the SEA. Source Note: The provisions of this §350.1209 adopted to be effective May 1, 2014, 39 TexReg 3445; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1209 State Education Agency Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223987 03/12/2026 (a) The IFSP team determines if a child who is two years old or older receiving ECI services is potentially eligible for ECSE. (b) If the IFSP team determines the child is potentially eligible for ECSE, the subrecipient must provide notification to the LEA as soon as possible, unless the parent opts out of the disclosure as described in §350.1213 of this subchapter (relating to The Family's Right to Opt Out of the Local Education Agency Notification). (1) Written parental consent is not required for the subrecipient to send the LEA Notification. (2) Written parental consent is required before sending information other than the child's limited personally identifiable information to the LEA. (c) For a child whose parent has not opted out of the disclosure as described in §350.1213 of this subchapter:(1) the subrecipient must notify the LEA at least 90 days before the child's third birthday that the child is potentially eligible for ECSE services; and (2) the subrecipient must send the LEA for the area in which the child resides the LEA Notification, which contains the child's limited personally identifiable information as defined in §350.1203(5) of this subchapter (relating to Definitions). (d) If the subrecipient determines a child is eligible for ECI services less than 90 days and more than 45 days before the child's third birthday, the subrecipient must determine as soon as possible whether the child is potentially eligible for ECSE services. (e) If the subrecipient receives a referral for a child fewer than 45 days before the child's third birthday and the child may be potentially eligible for ECSE: (1) the subrecipient must, with written parental consent, refer the child directly to the LEA; and (2) the subrecipient is not required to conduct pre-enrollment procedures, an evaluation, an assessment, or an initial IFSP meeting. (f) To assist the LEA in determining eligibility, the subrecipient, with written parental consent, must send the LEA the most recent: (1) evaluations; (2) assessments; and (3) IFSPs. Source Note: The provisions of this §350.1211 adopted to be effective May 1, 2014, 39 TexReg 3445; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1211 Local Education Agency Notification of Potential Eligibility for Early Childhood Special Education Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223988 03/12/2026 (a) The parent may choose not to allow the subrecipient to: (1) send the child's limited personally identifiable information to the LEA; and (2) notify the LEA of their child's potential eligibility for ECSE services.(b) The subrecipient must:(1) inform the parent of the LEA Notification requirements before the parent signs the initial IFSP and annually as part of the annual meeting to review the IFSP; and (2) explain the option to opt out of the LEA Notification to the parent and the consequences of this option. (c) The parent must inform the subrecipient of their decision to opt out of the LEA Notification in writing before the scheduled notification date. (d) The subrecipient must provide the parent written communication regarding LEA Notification that includes the following information: (1) what information will be disclosed to the LEA; (2) the scheduled LEA Notification date; (3) a clear statement that the parent must inform the subrecipient of their decision to opt out of the LEA Notification in writing before the scheduled notification date; and (4) an explanation that the child's limited personally identifiable information will be sent for LEA Notification, unless the parent informs the subrecipient of their decision to opt out of the LEA Notification before the scheduled notification date. (e) The subrecipient must provide the parent the written communication regarding LEA Notification as required in subsection (d) of this section at least 10 days before limited personally identifiable information is scheduled to be released for the LEA Notification.(f) If the parent opts out of the LEA Notification at any time before the scheduled notification date, the subrecipient must: (1) not send the child's limited personally identifiable information to the LEA; (2) inform the parent that even if he or she opts out of LEA Notification, he or she can later request that the child's limited personally identifiable information be sent to the LEA; and (3) document in the child's record: (A) the date the written communication regarding LEA Notification was provided to the parent; and (B) the parent's written request to opt out of LEA Notification. (g) If the subrecipient determines a child is eligible for ECI more than 45 days but less than 90 days before the child's third birthday and the IFSP team determines the child is potentially eligible for special education services, the subrecipient must: (1) immediately inform the parent of the LEA Notification requirements; (2) explain the option to opt out of the LEA Notification to the parent and the consequences of this option; and(3) comply with all other requirements in this section related to the family's right to opt out of the LEA Notification. Source Note: The provisions of this §350.1213 adopted to be effective May 1, 2014, 39 TexReg 3445; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1213 The Family's Right to Opt Out of the Local Education Agency Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223989 03/12/2026 (a) When the subrecipient provides the LEA Notification to the LEA less than 90 days before the child's third birthday, the subrecipient must include in the notification the reason for the delay. (b) The subrecipient must send the LEA for the area in which the child resides a late LEA Notification for any child aged 33-36 months who the IFSP team determines is potentially eligible for ECSE services, unless the parent has informed the subrecipient in writing of their decision to opt out of the LEA Notification. Source Note: The provisions of this §350.1215 adopted to be effective May 1, 2014, 39 TexReg 3445; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1215 Reporting Late Local Education Agency Notifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223990 03/12/2026 (a) If the parent gives approval to convene the LEA transition conference, the subrecipient must: (1) meet the requirements in 34 CFR §303.342(d) and (e) and §303.343(a), which require: (A) the face-to-face attendance of the parent and the service coordinator; and (B) at least one other ECI professional who is a member of the IFSP team who may participate through other means as permitted in 34 CFR §303.343(a)(2); (2) send an invitation at least 14 days in advance to the appropriate representatives for the LEA that serves the area where the child resides; (3) conduct the LEA transition conference at least 90 days before the child's third birthday. The transition conference may occur up to nine months before the child's third birthday; and (4) document the date of the conference in the child's record. (b) The subrecipient must conduct the LEA transition conference, even if the representatives for the LEA that serves the area where the child resides do not attend, and provide the parent information about ECSE and related services, including a description of the: (1) eligibility definitions; (2) timelines; (3) process for consenting to an evaluation and eligibility determination; and (4) extended year services. (c) The subrecipient is not required to conduct the LEA transition conference for children referred to the subrecipient's ECI program less than 90 days before the child's third birthday. (d) The 14-day timeline for inviting the LEA representative may be changed by written local agreement between the LEA and the subrecipient. (1) If the subrecipient becomes aware of a consistent pattern of the LEA representative not attending transition conferences, the subrecipient must make efforts to meet with the LEA to reach a cooperative agreement to maximize LEA participation. (2) The subrecipient may encourage the LEA representative to participate in the meeting by phone if unable to attend the meeting face-to-face.(e) If the parent gives approval to have an LEA transition conference, but does not give written consent to release records to the LEA, then the subrecipient may release only limited personally identifiable information to the LEA. With written parental consent, the subrecipient may release other personally identifiable information to the LEA. Source Note: The provisions of this §350.1217 adopted to be effective May 1, 2014, 39 TexReg 3445; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1217 Local Education Agency Transition Conference https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223991 03/12/2026 (a) The subrecipient may continue to provide ECI services to the child until the child's third birthday even if the Admission, Review, and Dismissal meeting has occurred and the Individualized Education Plan has been signed. (b) The subrecipient may discontinue ECI services if the child begins receiving the same services from the LEA when: (1) prior written notice is given to the parent regarding the discontinuation of ECI services; and (2) the IFSP is revised at an IFSP meeting. (c) All transition activities in this section must be clearly documented in the child's record. Source Note: The provisions of this §350.1219 adopted to be effective May 1, 2014, 39 TexReg 3445; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1219 Transition to Local Education Agency Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223992 03/12/2026 (a) The subrecipient must assist the family with transition activities to appropriate community settings before the child exits ECI if the:(1) subrecipient determines the child is not potentially eligible for ECSE services;(2) parent chooses for the child to transition to supports and services in the community other than or in addition to the LEA; (3) parent opts out of the LEA Notification;(4) parent refuses LEA services; or (5) child is determined to be ineligible for ECSE services. (b) In compliance with 34 CFR §303.209(c)(2), the subrecipient must make a reasonable effort to convene a Community Transition Meeting that meets the requirements in 34 CFR §303.342(d) and (e) and §303.343(a), which requires the attendance of the service coordinator and at least one other ECI professional who is a member of the IFSP team who may participate through other means as permitted in 34 CFR §303.343(a)(2), and also invite: (1) representatives of the identified community settings; (2) the Blind Children's Vocational Discovery and Development Program specialist if the child has a vision impairment or the HHSC Office for Deaf and Hard of Hearing Services regional specialist if the child is deaf or hard of hearing; and (3) other program or agency representatives as appropriate. Source Note: The provisions of this §350.1221 adopted to be effective May 1, 2014, 39 TexReg 3445; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES L TRANSITION §350.1221 Transition Into Community Supports and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223993 03/12/2026 (a) The subrecipient must collect and report information on child outcomes as directed by HHSC ECI and use that information to improve results for children and families. (b) Child outcomes address three areas of child functioning necessary for each child to be an active and successful participant at home and in the community. These three outcomes are that children will: (1) have positive social relationships; (2) acquire and use knowledge and skills; and (3) take appropriate action to meet their own needs. (c) An interdisciplinary team of at least two members must agree on the child outcome ratings for each enrolled child at entry, annual evaluation, and exit. (1) Entry ratings must be completed: (A) for every newly enrolled child who is 30 months of age or younger on the date of enrollment; (B) within two weeks of the initial IFSP or the first IFSP completed in Texas; and (C) on each of the three child outcomes for each child. (2) Annual ratings must include the progress item for each outcome and be completed: (A) within two weeks of each annual evaluation and IFSP; (B) independently of the entry ratings; and (C) on each of the three child outcomes for each child. (3) Exit ratings must include the progress item for each outcome and be completed: (A) for each child exiting the HHSC ECI system who had an entry rating and was enrolled in services for at least six months; and (B) within two weeks of the exit date. (d) Documentation must: (1) provide information that reflects the rating decisions of the interdisciplinary team; (2) record ratings on either the child outcomes summary form or in another section of the child's record as identified by the subrecipient; (3) include information related to the child's functional abilities across settings, situations, and people; and (4) identify sources of information such as evaluation, observation, or parent report. Source Note: The provisions of this §350.1307 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES M CHILD AND FAMILY OUTCOMES §350.1307 Child Outcomes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223994 03/12/2026 Family outcomes and indicators of family capacity are measured using a family survey. The subrecipient is required to deliver the family survey as directed by HHSC ECI to measure family outcomes and indicators. Source Note: The provisions of this §350.1309 adopted to be effective September 1, 2013, 38 TexReg 5524; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES M CHILD AND FAMILY OUTCOMES §350.1309 Family Outcomes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223995 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223995 03/12/2026 The following words and terms, when used in this subchapter, will have the following meanings, unless the context clearly indicates otherwise. (1) Ability to pay--The determination that the family is financially able to pay out-of-pocket for their child's ECI services. (2) Adjusted income--The dollar amount equal to the family's annual gross income minus their allowable deductions. The subrecipient uses adjusted income to determine the family's ability to pay and to calculate the family's maximum charge. (3) Allowable deductions--Certain unreimbursed family expenses that are subtracted from the family's gross income to calculate their adjusted income. (4) CHIP--The Children's Health Insurance Program administered by HHSC. (5) Dependent--Any person who meets the definition of 26 USC §152.(6) Family Cost Share System--The system of collecting reimbursement for ECI services from public insurance, private insurance, and out-of-pocket payments from families. (7) Family size--The total number of people in the family, including the child's parents who live in the home, the child, and other dependents of the parent. Other dependents do not have to live in the home, but they must be financially dependent upon the parent. (8) Federal poverty guidelines--The poverty guidelines updated periodically in the Federal Register by the United States Department of Health and Human Services under the authority of 42 USC §9902(2). (9) Gross income--All income received by the family considered income by the Internal Revenue Service before federal allowable deductions are applied. (10) Inability to pay--The determination that the family is financially unable to make out-of-pocket payments because the family has an adjusted income at or below 100 percent of the federal poverty level. (11) Maximum charge--The maximum out-of-pocket amount the subrecipient can charge the family for services delivered in one calendar month. (12) Out-of-pocket--Payment from the family for their child's ECI services. This includes insurance co-pays, co-insurance, and deductibles as well as payment for services not covered by the family's insurance. (13) Sliding fee scale--The HHSC-developed scale of maximum charges that is based on the federal poverty guidelines. (14) Third-party payor--A company, organization, insurer, or government agency that makes payments for the ECI services received by a child and family. Third-party payors include commercial insurance companies, health maintenance organizations, preferred provider organizations, and public insurance such as Medicaid, CHIP, and TRICARE. (15) TRICARE--The U.S. Department of Defense health care entitlement for active duty, Guard and Reserve, retired members of the military, and their eligible family members and survivors. Source Note: The provisions of this §350.1405 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1405 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203745 03/12/2026 (a) The contractor must administer the family cost share system in compliance with the requirements in this title, HHSC policy concerning ECI, and the contract.(b) In compliance with 34 CFR §303.510(a) and (b) and §303.203(b)(1), IDEA Part C funding is the payor of last resort for early childhood intervention services. The contractor must:(1) establish third-party billing systems, determine client eligibility for all third-party reimbursement sources, and complete and submit reimbursement requests to corresponding third-party sources, including private insurance, Medicaid programs, CHIP, and TRICARE;(2) coordinate funding sources for services required under IDEA Part C; and(3) use other funding for which the clients are eligible before billing services to the HHSC contract, which includes distribution of IDEA Part C funds. Source Note: The provisions of this §350.1407 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1407 Family Cost Share System Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203746 03/12/2026 (a) The parent has the right to:(1) receive certain early childhood intervention services at no cost in accordance with 34 CFR §303.521(b);(2) refuse any early childhood intervention services they do not wish to receive;(3) receive information about any method the contractor may use to verify the family's allowable deductions;(4) receive information about the contractor's process for determining their maximum charge before signing the family cost share agreement;(5) not have their personally identifiable information released for billing purposes without prior written consent; and(6) not have their private insurance billed without prior written consent.(b) If the family has an inability to pay, all IDEA Part C services are provided with no out-of-pocket charge to the parent. The family's inability to pay for early childhood intervention services will not result in the delay or denial of early childhood intervention services to the child or the family.(c) If the parent disagrees with the contractor's determination of the family's ability to pay, the calculated adjusted income, or the assigned maximum charge, the parent can:(1) request a review by the contractor manager or program director;(2) file an informal or formal complaint with the contractor;(3) contact the HHSC Office of the Ombudsman for help resolving a problem or concern with the contractor;(4) file a formal complaint with HHSC, in compliance with 34 CFR §303.434;(5) participate in mediation, in compliance with 34 CFR §303.431; and(6) participate in a due process hearing, in compliance with 34 CFR §303.436 or §303.441, whichever is applicable.(d) The contractor must provide the parent a copy of the ECI Family Cost Share publication before the contractor initially bills the child's third-party payor to pay for early childhood intervention services.(e) The ECI Family Cost Share publication:(1) explains the family cost share process;(2) describes the parent's procedural safeguards and related due process rights;(3) notifies the parent that:(A) parental consent must be obtained before the contractor releases personally identifiable information to third-party payors;(B) if the parent does not consent under 34 CFR §303.520(a)(2), the contractor must still make available those Part C services on the IFSP to which the parent has consented;(C) the parent has the right to withdraw their consent at any time;(D) the parent may incur potential costs for co-pays as a result of using their public insurance and potential costs such as co-pays, co-insurance, or deductibles as a result of using their private insurance to pay for early childhood intervention services; and(E) if the child has private insurance in addition to Medicaid, the private insurance is the primary payor and must be billed before filing a claim with Medicaid. Source Note: The provisions of this §350.1409 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1409 Parent Rights Related to the Family Cost Share System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223996 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223996 03/12/2026 (a) The ECI services provided with no out-of-pocket payment are: (1) child find; (2) evaluation and assessment; (3) development of the IFSP; (4) services for children who are deaf or hard of hearing or who have visual impairments; (5) case management; (6) translation and interpreter services; and (7) administrative and coordination activities related to the implementation of procedural safeguards and other components of the statewide system of ECI services. (b) ECI services provided at no out-of-pocket charge to the parent must: (1) not be denied or delayed if the family fails to provide information related to third-party coverage, gross income, or family size; (2) begin or continue regardless of whether or not the parent has a signed family cost share agreement; (3) not be denied or delayed if the family refuses to consent to bill or to release personally identifiable information to a third-party payor; (4) begin or continue during any period of reconsideration; and (5) continue during any suspension period. (c) If the family has an inability to pay, all ECI services are provided with no out-of-pocket charge to the family. Source Note: The provisions of this §350.1411 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1411 Early Childhood Intervention Services Provided with No Out-of-Pocket Payment from the Parent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223997 03/12/2026 (a) IFSP services subject to out-of-pocket payment are: (1) assistive technology; (2) behavioral intervention; (3) occupational therapy services; (4) physical therapy services; (5) speech-language pathology services; (6) nutrition services; (7) counseling services; (8) nursing services; (9) psychological services; (10) health services; (11) social work services; (12) transportation; (13) SST; (14) family education and training; and (15) any IFSP services to children with visual impairments or who are deaf or hard of hearing that are not part of a free appropriate public education provided by the LEA pursuant to Texas Education Code §29.003(b)(1) and Texas Administrative Code §89.1050(b).(b) The family pays out-of-pocket up to their maximum charge. The family's maximum charge is determined based on their placement on the HHSC ECI sliding fee scale, as described in §350.1431 of this subchapter (relating to Texas Health and Human Services Commission Early Childhood Intervention Sliding Fee Scale). Source Note: The provisions of this §350.1413 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1413 Individualized Family Service Plan Services Subject to Out-of-Pocket Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203749 03/12/2026 (a) The parent must sign a family cost share agreement. The parent's signature acknowledges their assigned maximum charge and provides written attestation that:(1) information regarding third-party coverage, family size, gross income, and allowable deductions is true and accurate; or(2) the parent chooses not to provide information regarding:(A) third-party coverage;(B) gross income and family size; or(C) allowable deductions.(b) The contractor must not initiate IFSP services subject to out-of-pocket payment until the parent signs the family cost share agreement.(c) At the annual meeting to evaluate the IFSP, the contractor must review the family cost share agreement, obtain current public and private insurance information, and re-calculate the family's assigned maximum charge. The parent must update and sign their family cost share agreement if family size, gross income, deductions, or third-party coverage is modified.(d) The parent must report changes to family size, gross income, deductions, and third-party coverage as soon as possible. When the parent reports a change, the contractor must review the family cost share agreement, obtain current public or private insurance information, and re-calculate the family's assigned maximum charge. The parent must update and sign their family cost share agreement.(e) When the parent signs an updated family cost share agreement, the new maximum charge takes effect the beginning of the following month.(f) If the child is in the conservatorship of the state, the contractor assigns the family a maximum charge of $0.(1) The foster parent must sign the family cost share agreement acknowledging the $0 maximum charge and attesting to the child's third-party status and foster care status.(2) The foster parent is not required to attest to family size, gross income, or allowable deductions. Source Note: The provisions of this §350.1417 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1417 Family Cost Share Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208199 03/12/2026 (a) The contractor must obtain written parental consent to bill and to release personally identifiable information to private insurance.(b) The contractor must obtain written parental consent when initially seeking to use their private insurance and each time there is an increase (in frequency, length, duration, or intensity) in the provision of services in the IFSP that requires the contractor to obtain written parental consent.(c) If private insurance denies payment of the claim, the contractor must bill the family up to their maximum charge, based on their placement on the sliding fee scale.(d) The contractor must adjust the amount billed to the family if the contractor or parent successfully disputes a denied claim.(e) The contractor must not deny or delay a child's services if:(1) the family does not have private insurance; or(2) the parent does not give consent to bill or to release personally identifiable information to their private insurance. If the parent does not give consent, the contractor bills the family up to their maximum charge, based on their placement on the sliding fee scale.(f) A family with private insurance will not be charged disproportionately more than a family without private insurance.(g) If a child is covered by private insurance only, once the contractor has verified that the private insurance plan will not pay for certain Early Childhood Intervention (ECI) services for a child, the contractor is not required to continue to bill the private insurance plan for those services for that child. The contractor must continue to bill for any services that the private insurance company does cover. The contractor must verify coverage for ECI services with the private insurance plan at least annually. Source Note: The provisions of this §350.1419 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1419 Private Insurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203751 03/12/2026 The policyholder is responsible for paying health care premiums based on their individual policy. The contractor includes insurance premiums when calculating the family's allowable deductions, but insurance premiums do not count toward meeting the maximum charge. Neither HHSC nor the contractor pays the family's private insurance premium. Source Note: The provisions of this §350.1421 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1421 Insurance Premiums https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203752 03/12/2026 (a) The contractor collects co-pays, co-insurance, and deductibles as set by the family's insurance plan, up to the family's maximum charge. The maximum charge includes and is not in addition to co-pays, co-insurance, and deductibles.(b) HHSC absorbs any additional costs that exceed the family's maximum charge, including costs for services not covered by insurance, co-pays, co-insurance, and deductibles. Source Note: The provisions of this §350.1423 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1423 Co-pays, Co-Insurance, and Deductibles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208200 03/12/2026 (a) Medicaid, Children's Health Insurance Program (CHIP), and TRICARE are public insurance programs.(b) The contractor must assist the parent to:(1) identify and access other available funding sources to pay for a child's early childhood intervention services; and(2) enroll a potentially eligible child in Medicaid or CHIP.(c) The contractor must not require a parent to enroll in public benefits or insurance programs as a condition of receiving early childhood intervention services.(d) If the child is not already receiving public insurance, the contractor must obtain written parental consent before billing. The contractor must waive the maximum charge while eligibility is being determined, not to exceed 90 days.(e) The contractor must obtain written parental consent to release personally identifiable information to Medicaid, CHIP, and TRICARE. If the parent does not give consent to release personally identifiable information, the contractor bills the parent up to their maximum charge, based on their placement on the sliding fee scale.(f) The contractor must not bill the parent if the child is enrolled in Medicaid and the parent gives consent to release personally identifiable information to Medicaid.(g) If the child is in foster care or kinship care, the contractor must obtain consent to release personally identifiable information to bill Medicaid.(h) If the child has private insurance in addition to Medicaid, the private insurance is the primary payor. The contractor must bill the private insurance every time before filing a claim with Medicaid for all services other than targeted case management or specialized skills training.(i) If the child has CHIP or TRICARE and the parent gives consent to release personally identifiable information, the contractor must bill the family for services not paid for by CHIP or TRICARE and for any co-pays, up to the family's maximum charge, based on their placement on the sliding fee scale.(j) If the child becomes ineligible for Medicaid, CHIP, or TRICARE, the contractor bills the parent up to their maximum charge, based on their placement on the sliding fee scale.(k) The contractor must not deny or delay a child's services if:(1) the family does not have public insurance; or(2) the parent does not give consent to release personally identifiable information to their public insurance. If the parent does not give consent, the contractor bills the family up to their maximum charge, based on their placement on the sliding fee scale.(l) A family with public insurance will not be charged disproportionately more than a family without public or private insurance. Source Note: The provisions of this §350.1425 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1425 Public Benefits and Insurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203754 03/12/2026 (a) Before initiating early childhood intervention services, the contractor determines the family's ability or inability to pay and calculates their out-of-pocket maximum charge.(b) The family's maximum charge is the total amount of money billed to the family for services delivered in one calendar month. The maximum charge includes payments for services not covered by insurance, co-pays, co-insurance, and deductibles.(c) The family's assigned maximum charge does not increase if the family has more than one child receiving IFSP services. Source Note: The provisions of this §350.1427 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1427 Maximum Charge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203755 03/12/2026 (a) The family size equals:(1) the total number of people living in the home, including the child's parent(s) and the child; and(2) other individuals who are financial dependents of the parent.(b) The family's annual gross income equals the total of all income received by the family. The gross income includes all income classified as taxable income by the Internal Revenue Service before federal allowable deductions are applied. If the parent does not attest to the family's annual gross income, the contractor must bill the family the full cost of services.(c) The family's allowable deductions are limited to the family's expenses in the following categories:(1) childcare and respite;(2) costs and fees associated with the adoption of a child;(3) court-ordered child support payments paid by the parent in the home for financially dependent children who were not included in the family size calculation; and(4) medical or dental expenses that are to primarily alleviate or prevent a physical or mental illness or defect. Allowable deductions for medical and dental expenses are limited to the cost of:(A) diagnosis, cure, alleviation, treatment, or prevention of disease;(B) treatment of any affected body part or function;(C) medical services legally delivered by physicians, surgeons, dentists, and other medical practitioners;(D) medications, medical supplies, and diagnostic devices;(E) medical and dental health care premiums;(F) transportation to receive medical or dental care; and(G) medical or dental debt that the family is paying on an established payment plan.(d) The contractor calculates the allowable deductions using the actual amounts the family paid over the previous 12 months and are expected to continue during the IFSP period and projections for new expenses expected to occur during the IFSP period. If the parent does not attest to the family's allowable deductions, the contractor determines the maximum charge based on the family's gross income. The contractor may implement written local policies requiring verification of allowable deductions in addition to the family's required written attestation.(e) The family's annual adjusted income equals the family's annual gross income minus the family's allowable deductions. Source Note: The provisions of this §350.1429 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1429 Family Size and Adjusted Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223998 03/12/2026 (a) The subrecipient must provide the family with a copy of the HHSC ECI sliding fee scale. Based on family size and income, placement on the HHSC ECI sliding fee scale determines the family's maximum charge for services received in one calendar month. (1) The HHSC ECI sliding fee scale assigns a set dollar amount as the maximum charge for adjusted income ranges less than or equal to 1000 percent of the federal poverty level. (2) HHSC calculates the maximum charge for each income range by applying a fixed percentage (ranging from 0.25 to 5 percent) to the mid-point income within each range based on the U.S. Department of Health and Human Services' most recently published federal poverty levels. (b) The family's maximum charge shall be pursuant to Figure: 26 TAC §350.1431(b) identified in this subsection. If the parent refuses to attest in writing that information about their third-party coverage, family size, and gross income is true and accurate, then the family monthly maximum payment equals the full cost of services. Attached Graphic Source Note: The provisions of this §350.1431 adopted to be effective March 7, 2015, 40 TexReg 953; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1431 Texas Health and Human Services Commission Early Childhood Intervention Sliding Fee Scale https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223999 03/12/2026 (a) The subrecipient must bill the family up to the family's maximum charge. (1) The total collection of payments, including third-party payment and the family's out-of-pocket payment, cannot exceed the actual cost of services. (2) The family's total out-of-pocket for the month cannot exceed the family's maximum charge. (b) A balance remaining unpaid by the parent 30 days after the bill date is delinquent unless the delay in payment is due to a delay in: (1) third-party reimbursement; or (2) notice of denial of a claim from a private or public third-party payor. Source Note: The provisions of this §350.1433 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective February 13, 2025, 50 TexReg 772. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1433 Billing Families for Individualized Family Service Plan Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208202 03/12/2026 (a) The contractor must suspend Individualized Family Service Plan (IFSP) services subject to an out-of-pocket payment as identified in §350.1413 of this subchapter (relating to IFSP Services Subject to Out-of-Pocket Payment from the Family) when the balance remains delinquent for 90 days. If the parent uses their public or private insurance, the 90-day time period begins the date the contractor receives notice that the claims are denied for reimbursement and all appeals are exhausted.(b) Before suspending IFSP services, the contractor must inform the parent that:(1) he or she has the option to request a:(A) review of the family cost share agreement, as described in §350.1417 of this subchapter (relating to Family Cost Share Agreement); or(B) reconsideration and adjustment of the family cost share obligation, as described in §350.1437 of this subchapter (relating to Extraordinary Circumstances);(2) IFSP services subject to an out-of-pocket payment will be suspended when a balance is delinquent for 90 days; and(3) the contractor cannot guarantee the same schedule or the same individual service provider if IFSP services are later reinstated.(c) Respite vouchers will be denied during a suspension period.(d) A notation must be made on the family cost share agreement that IFSP services subject to an out-of-pocket payment have been suspended due to non-payment.(e) The contractor must reinstate suspended IFSP services when the family's account is paid in full or the family negotiates an acceptable payment plan with the contractor. The IFSP team must reassess the appropriateness of the IFSP before reinstating IFSP services if IFSP services are suspended for more than six months. The contractor must document the reinstatement of IFSP services date on the IFSP and the family cost share agreement.(f) The contractor must maintain written local policy for collecting delinquent family cost share accounts. Documentation must reflect all reasonable attempts to collect unpaid balances. Reasonable attempts include multiple attempts at written notification, phone notification, and e-mail. Source Note: The provisions of this §350.1435 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941; amended to be effective March 17, 2022, 47 TexReg 1277. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1435 Suspension of Services for Nonpayment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203759 03/12/2026 (a) The contractor must develop a local process to reconsider and adjust the current or overdue family cost share obligation based on extraordinary circumstances.(b) Only the program director or designated administrator has authority to reconsider and adjust the family cost share obligation. The reconsideration may include an assessment of the parent's ability to pay the family cost share obligation in any particular month(s).(c) Extraordinary circumstances that require a reconsideration of the family cost share obligation are:(1) increase or decrease in income;(2) unexpected short-term medical expenses;(3) unanticipated childcare or respite expenses;(4) change in family size;(5) catastrophic loss such as fire, flood, or tornado;(6) short-term financial hardship such as major repair to the family home or car; or(7) other extenuating circumstances for which the family requests reconsideration.(d) The parent must attest in writing that information regarding extraordinary circumstances is true and accurate. The contractor may implement written local policy requiring verification of extraordinary circumstances from families, or the contractor may rely solely on the family's required written attestation. The contractor must deny a request for reconsideration if the parent refuses to provide written attestation that the information related to extraordinary circumstances is true and accurate.(e) The family's last signed IFSP and family cost share agreement remain in effect during the reconsideration process. Source Note: The provisions of this §350.1437 adopted to be effective May 1, 2014, 39 TexReg 3449; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1437 Extraordinary Circumstances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203760 03/12/2026 (a) The contractor must:(1) use revenue received from the family cost share system only for early childhood intervention services within the HHSC ECI system;(2) not supplant any other local fund sources; and(3) report fees collected to HHSC ECI as program income.(b) The family cost share agreement and any financial records related to income, deductions, and payment history shall be kept separate from the child's other educational records, and these records must not be forwarded to a school district or other non-ECI service provider(s) at any time unless requested by the family. All financial records must be maintained in a manner consistent with the Family Educational Rights and Privacy Act.(c) If a family transfers between HHSC ECI contractors, the family cost share agreement, other financial records, and the IFSP are transferred to the receiving HHSC ECI contractor.(d) The family cost share agreement and financial records are subject to subpoena. Source Note: The provisions of this §350.1439 adopted to be effective May 1, 2014, 39 TexReg 3449; amended to be effective June 30, 2019, 44 TexReg 3280; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 941. 1 HEALTH AND HUMAN SERVICES COMMISSION 350 EARLY CHILDHOOD INTERVENTION SERVICES N FAMILY COST SHARE SYSTEM §350.1439 Program Fiscal and Recordkeeping Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208108 03/12/2026 (a) Purpose. The purpose of this chapter is to implement the Children with Special Health Care Needs (CSHCN) Services Program as authorized by Health and Safety Code, Chapter 35, to provide the following services to eligible children:(1) early identification of children with special health care needs;(2) diagnosis and evaluation of children with special health care needs;(3) rehabilitation services to children with special health care needs;(4) development and improvement of standards and services for children with special health care needs;(5) case management services;(6) other family support services; and(7) access to health benefits plan coverage.(b) Common Name. The CSHCN Services Program may adopt a common name to facilitate and improve program marketing and recognition. Source Note: The provisions of this §351.1 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.1 Purpose and Common Name https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224547 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Act--The Children with Special Health Care Needs Services Act, Health and Safety Code, Chapter 35. (2) Advanced practice registered nurse--A registered nurse approved by the Texas Board of Nursing to practice as an advanced practice registered nurse. (3) Applicant--A person making an initial application or re-application for CSHCN Services Program services. (4) Case management services--Case management services include, but are not limited to: (A) planning, accessing, and coordinating needed health care and related services for children with special health care needs and their families. Case management services are performed in partnership with the child, the child's family, providers, and others involved in the care of the child and are performed as needed to help improve the well-being of the child and the child's family; and (B) counseling for the child and the child's family about measures to prevent the transmission of AIDS or HIV and the availability in the geographic area of any appropriate health care services, such as mental health care, psychological health care, and social and support services. (5) Child with special health care needs--A person who: (A) is younger than 21 years of age and who has a chronic physical or developmental condition; or (B) has cystic fibrosis, regardless of the person's age; and (C) may have a behavioral or emotional condition that accompanies the person's physical or developmental condition. The term does not include a person who has behavioral or emotional condition without having an accompanying physical or developmental condition. (6) CHIP--The Children's Health Insurance Program administered by the Texas Health and Human Services Commission under Title XXI of the Social Security Act. (7) Chronic developmental condition--A disability manifested during the developmental period for a child with special health care needs which results in impaired intellectual functioning or deficiencies in essential skills, which is expected to continue for a period longer than one year, and which causes a person to need assistance in the major activities of daily living or in meeting personal care needs. For the purpose of this chapter, a chronic developmental condition must include physical manifestations and may not be solely a delay in intellectual, mental, behavioral, or emotional development. (8) Chronic physical condition--A disease or disabling condition of the body, of a bodily tissue, or of an organ which will last or is expected to last for at least 12 months, that results, or without treatment, may result in limits to one or more major life activities, and that requires health and related services of a type or amount beyond those required by children generally. Such a condition may exist with accompanying developmental, mental, behavioral, or emotional conditions, but is not solely a delay in intellectual development or solely a mental, behavioral, or emotional condition. (9) Claim form--The document approved by the CSHCN Services Program for submitting a claim for processing and payment. (10) Client--A person who has applied for program services and who meets all CSHCN Services Program eligibility requirements and is determined to be eligible for program services. (A) New client: (i) a person who has applied to the program for the first time and who is determined to be eligible for program services; or (ii) a person who has re-applied to the program (after a lapse in eligibility) and who is determined to be eligible for program services. (B) Ongoing client--A client who currently is not on the program's waiting list. (C) Waiting list client--A client who currently is on the program's waiting list. (11) CMS--The Centers for Medicare and Medicaid Services. (12) Commission--The Texas Health and Human Services Commission. (13) Commissioner--The Commissioner of the Department of State Health Services. (14) Co-insurance--A cost-sharing arrangement in which a covered person pays a specified percentage of the charge for a covered service. The covered person may be responsible for payment at the time the health care service is provided. (15) Co-pay and co-payment--A cost-sharing arrangement in which a client pays a specified charge for a specified service. The client is usually responsible for payment at the time the health care service is provided. (16) CSHCN Services Program--The services program for children with special health care needs described in §38.1 of this title (relating to Purpose and Common Name). (17) Date of service (DOS)--The date a service is provided. (18) Deductible--A cost-sharing arrangement in which a client is responsible for paying a specific amount annually for covered services before an insurance carrier or plan begins to pay for covered services. (19) Dentist--An individual licensed by the State Board of Dental Examiners to practice dentistry in the State of Texas. (20) Department--The Department of State Health Services. (21) Diagnosis and evaluation services--The process of performing specialized examinations, tests, or procedures to determine whether a CSHCN Services Program applicant for health care benefits has a chronic physical or developmental condition as determined by a physician or dentist participating in the CSHCN Services Program or to help determine whether a waiting list client has an "urgent need for health care benefits" according to the criteria and protocol described in §38.16(e) of this title (relating to Procedures to Address Program Budget Alignment). (22) Disregards--An amount of money deducted from the family's total income for allowable expenses, such as child care. (23) Eligibility date for the CSHCN Services Program health care benefits--The effective date of eligibility for the CSHCN Services Program health care benefits is the date of receipt of a complete, approved application except in the following circumstances. (A) The effective date of eligibility for newborns who are not born prematurely will be the date of birth. Newborn means a child 28 days old or younger. (B) The effective date of eligibility for an applicant who is born prematurely shall be the day after the applicant has been out of the hospital for 14 consecutive days, but no earlier than the date of receipt of the application. (C) The effective date of eligibility following traumatic injury shall be the day after the acute phase of treatment ends, but no earlier than the date of receipt of the application. (D) The effective date of eligibility for applicants with spenddown is the date of receipt of the medical bills which document that spenddown has been met, following the receipt of a complete application. Only medical bills having a DOS within 12 months prior to or 6 months after the date of receipt of the application may be included to satisfy spenddown requirements. Medical bills for any member of the family for which the applicant, parent(s), guardian or managing conservator of the CSHCN Services Program applicant is responsible may be included. Medical bills used to meet spenddown cannot be paid by the CSHCN Services Program. (E) Excluding applications for clients who are known to be ineligible for Medicaid and the CHIP due to age, citizenship status, or insurance coverage, all applications must include a determination of eligibility from Medicaid and the CHIP. If the CSHCN Services Program application is received without a Medicaid determination, a CHIP determination, or other data or documents needed to process the application, it will be considered incomplete. The applicant will be notified that the application is incomplete and given 60 days to submit the Medicaid determination, CHIP denial or enrollment, or other missing data or documents to the CSHCN Services Program. If the application is made complete within the 60-day time limit, the client's eligibility effective date will be established as the date the CSHCN Services Program application was first received. If the application is made complete more than 60 days after initial receipt, the eligibility effective date will be established as the date the application was made complete. (24) Emergency--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent person with average knowledge of health and medicine could reasonably expect that the absence of immediate medical care could result in: (A) placing the person's health in serious jeopardy; (B) serious impairment to bodily functions; or (C) serious dysfunction of any bodily organ or part. (25) Emotional or behavioral condition--Behavior which varies significantly from normal, that is chronic and does not quickly disappear, and that is unacceptable because of social or cultural expectations. Emotional or behavioral responses which are so different from those of the generally accepted, age-appropriate norms of people with the same ethnic or cultural background as to result in significant impairment in social relationships, self-care, educational progress, or classroom behavior. Examples include but are not limited to the following: (A) an inability to build or maintain satisfactory age-appropriate interpersonal relationships with peers or adults; (B) dangerously aggressive, self-destructive, severely withdrawn, or noncommunicative behaviors; (C) a pervasive mood of unhappiness or depression; or (D) evidence of excessive anxiety or fears. (26) Facility--A hospital, psychiatric hospital, rehabilitation hospital or center, ambulatory surgical center, renal dialysis center, specialty center, or outpatient clinic. (27) Family--For the purpose of determining family size for program eligibility, the family includes the following persons who live in the same residence: (A) the applicant; (B) those related to the applicant as a parent, stepparent, or spouse who have a legal responsibility to support the applicant, or guardians or managing conservators who have a duty to provide food, shelter, education, and medical care for the applicant; (C) children under age 19 or wards of the applicant; and (D) children under age 19 or wards of a parent, stepparent, or spouse. (28) Family support services--Disability-related support, resources, or other assistance provided to the family of a child with special health care needs. The term may include services described by Part A of the Individuals with Disabilities Education Act (20 U.S.C. §1400 et seq.), as amended, and permanency planning, as that term is defined by Texas Government Code §546.0201. (29) Federal Poverty Level (FPL)--The minimum income needed by a family for food, clothing, transportation, shelter, and other necessities in the United States, according to the United States Department of Health and Human Services, or its successor agency or agencies. The FPL varies according to family size and after adjustment for inflation, is published annually in the Federal Register. (30) Federally qualified health center--A federally qualified health center is designated by CMS to provide core medical services to a Medically Underserved Population. (31) Financial independence--A state in which a person currently files his or her own personal U.S. income tax return and is not claimed as a dependent by any other person on his or her U.S. income tax return. (32) Guardian--A statutory officer appointed under the Texas Probate Code who has a duty to provide food, shelter, education, and medical care for his or her ward. (33) Health care benefits--CSHCN Services Program benefits consisting of diagnosis and evaluation services, rehabilitation services, medical home care management services, family support services, transportation related services, and insurance premium payment services. (34) Health insurance and health benefits plan--A policy or plan, individual, group, or government-sponsored, that an individual purchases or in which an individual participates that provides benefits when medical or dental costs are or would be incurred. Sources of health insurance include, but are not limited to, health insurance policies, buy-in programs, health maintenance organizations, preferred provider organizations, employee health welfare plans, union health welfare plans, medical expense reimbursement plans, United States Department of Defense or Department of Veterans Affairs benefit plans, Medicaid, CHIP, and Medicare. Benefits may be in any form, including, but not limited to, reimbursement based upon cost, cash payment based upon a schedule, or access without charge or at minimal charge to providers of medical or dental care. Benefits from a municipal or county hospital, joint municipal-county hospital, county hospital authority, hospital district, county indigent health care programs, or the facilities of a publicly supported medical school shall not constitute health insurance for purposes of this chapter. (35) Income--The gross income, either earned or unearned, before deductions over a given period of time for each family member. (36) Managing conservator--A person designated by a court to have daily legal responsibility for a child. (37) Medicaid--A program of medical care authorized by Title XIX of the Social Security Act and the Human Resources Code. (38) Medical home--A respectful partnership between a client, the client's family as appropriate, and the client's primary health care setting. A medical home is family centered health care that is accessible, continuous, comprehensive, coordinated, compassionate, and culturally competent. A medical home provides primary care that includes preventive care, care coordination, and appropriate referral and collaboration with specialist and other service providers as required. (39) Medicare--A federal program that provides medical care for people age 65 or older and the disabled as authorized by Title XVIII of the Social Security Act. (40) Natural home--The home in which a person lives that is either the residence of his or her parent(s), foster parent(s) or guardian, or extended family member(s), or the home in the community where the person has chosen to live, alone or with other persons. A natural home may utilize natural support systems such as family, friends, co-workers, and services available to the general population as they are available. (41) Other benefit--A benefit, other than a benefit provided under this chapter, to which a person is entitled for payment of the costs of services included in the scope of coverage of the CSHCN Services Program including, but not limited to, benefits available from: (A) an insurance policy, group health plan, health maintenance organization, or prepaid medical or dental care plan; (B) home, auto, or other liability insurance; (C) Title XVIII, Title XIX, or Title XXI of the Social Security Act (42 U.S.C. §§1395 et seq., 1396 et seq., and 1397aa et seq.), as amended; (D) the United States Department of Veterans Affairs; (E) the United States Department of Defense; (F) workers' compensation or any other compulsory employers' insurance program; (G) a public program created by federal or state law or under the authority of a municipality or other political subdivision of the state, excluding benefits created by the establishment of a municipal or county hospital, a joint municipal-county hospital, a county hospital authority, a hospital district, a county indigent health care program, or the facilities of a publicly supported medical school; or (H) a cause of action for the cost of care, including medical care, dental care, facility care, and medical supplies, required for a person applying for or receiving services from the department or a settlement or judgment based on the cause of action if the expenses are related to the need for services provided under this chapter. (42) Otologist--A physician whose specialty is diseases of the ear. (43) Permanency planning--A planning process undertaken for children with chronic illness or developmental disabilities who reside in institutions or are at risk of institutional placement, with the explicit goal of securing a permanent living arrangement that enhances the child's growth and development, which is based on the philosophy that all children belong in families and need permanent family relationships. Permanency planning is directed toward securing: a consistent, nurturing environment, an enduring, positive adult relationship(s), and a specific person who will be an advocate for the child throughout the child's life. Permanency planning provides supports to enable families to nurture their children, to reunite with their children when they have been placed outside the home, and to place their children in family environments. (44) Person--An individual, corporation, government or governmental subdivision or agency, business trust, partnership, association, or any other legal entity. (45) Physician--A person licensed by the Texas Medical Board to practice medicine in this state. (46) Physician assistant--A person licensed as a physician assistant by the Texas Physician Assistant Board. (47) Practitioner--A person who is licensed to practice medicine, dentistry, nursing or an allied health profession. (48) Prematurity or born prematurely--A child born at less than 36 weeks gestational age and hospitalized since birth. (49) Program--The Children with Special Health Care Needs (CSHCN) Services Program. (50) Provider--A person or facility as defined in §38.6 of this title (relating to Providers) that delivers services purchased by the CSHCN Services Program for the purpose of implementing the Act. (51) Rehabilitation services--The process of the physical restoration, improvement, or maintenance of a body function destroyed or impaired by congenital defect, disease, or injury which includes the following acute and chronic or rehabilitative services: (A) facility care, medical and dental care, and occupational, speech, and physical therapies; (B) the provision of medications, braces, orthotic and prosthetic devices, durable medical equipment, and other medical supplies; and (C) other services specified in this chapter. (52) Respite care--A service provided on a short-term basis for the purpose of relief to the primary care giver in providing care to individuals with disabilities. Respite services can be provided in either in-home or out-of-home settings on a planned basis or in response to a crisis in the family where a temporary caregiver is needed. (53) Rural health clinic--A rural health clinic is designated by CMS to provide core medical services in a Medically Underserved Area. (54) Routine child care--Child care for a child who needs supervision while the parent or guardian is at work, in school, or in job training. (55) Services--The care, activities, and supplies provided under the Act, including but not limited to, both acute and chronic or rehabilitative medical care, dental care, facility care, medications, durable medical equipment, medical supplies, occupational, physical, and speech therapies, family support services, case management services, and other care specified by program rules. (56) Social service organization--For purposes of this chapter, a for-profit or nonprofit corporation or other entity, not including individual persons, that provides funds for travel, meal, lodging, and family supports expenses in advance to enable CSHCN Services Program clients to obtain program services. (57) Specialty center--A facility and staff that meet the CSHCN Services Program minimum standards established in this chapter and are designated for use by CSHCN Services Program clients as part of the comprehensive services for a specific medical condition. (58) Spenddown--A process that allows an applicant to obtain program financial eligibility when the applicant's family income exceeds 200% of the FPL. The family must prove cumulative medical expenses that exceed the difference between the family income and 200% of the FPL income limit. (59) State--The State of Texas. (60) Subrogation--Assumption by third party, such as a second creditor or an insurance company, of another person's legal right to collect a debt or damages. (61) Supplemental Security Income Program (SSI)--Title XVI of the Social Security Act which provides for payments to individuals (including children under age 18) who are disabled and have limited income and resources. (62) Support--The contribution of money or services necessary for a person's maintenance, including, but not limited to, food, clothing, shelter, transportation, and health care. (63) Texas resident--A person who: (A) is physically present within the geographic boundaries of the state; (B) has an intent to remain within the state; (C) maintains an abode within the state (i.e., house or apartment, not merely a post office box); (D) has not come to Texas from another country for the purpose of obtaining medical care with the intent to return to the person's native country; (E) does not claim residency in any other state or country; and (i) is a minor child residing in Texas whose parent(s), managing conservator, guardian of the child's person, or caretaker (with whom the child consistently resides and plans to continue to reside) is a Texas resident; (ii) is a person residing in Texas who is the legally dependent spouse of a Texas resident; or (iii) is an adult residing in Texas, including an adult whose parent(s), managing conservator, guardian of the adult's person, or caretaker (with whom the adult resides and plans to continue to reside). (64) Treatment plan--The plan of care for the client (time and treatment specific) as certified by and implemented under the supervision of a physician or other practitioner in the program. (65) United States Public Health Service price--The average manufacturer price for a drug in the preceding calendar quarter under Title XIX of the Social Security Act, reduced by the rebate percentage, as authorized by the Veterans Health Care Act of 1992 (P.L. 102-585, November 4, 1992). (66) Urgent need for health care benefits--A need for health care services when the lack of those services would cause a permanent increase in disability, intense pain or suffering, or death. (67) Ward--An individual placed under the protection of a guardian, or a person who by reason of incapacity is under the protection of a court either directly or through a guardian appointed by the court. Source Note: The provisions of this §351.2 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982; amended to be effective April 1, 2025, 50 TexReg 2208. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208110 03/12/2026 (a) Eligibility for health care benefits. In order to be determined eligible for program health care benefits, applicants must meet the medical, financial, and other criteria in this section.(1) Medical or dental criteria. At least annually, a physician or dentist must certify that the person meets the definition of "child with special health care needs" as defined by §38.2(5) of this title (relating to Definitions). The medical or dental criteria certification must be based upon a physical examination conducted within the 12 months immediately preceding the date of certification. The physician or dentist must document the medical or dental diagnosis code and descriptor from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), or its successor, for the person's primary diagnosis that meets the medical or dental criteria certification definition and for each of the person's other medical or dental conditions for statistical and referral purposes. To facilitate application to the program for certain applicants, the program Medical Director or Assistant Medical Director may accept written documentation of medical or dental criteria certification submitted by a physician or dentist who is licensed to practice in a state or jurisdiction of the United States of America other than Texas. The program does not reimburse for written documentation of medical or dental criteria certification. If a physician or dentist requests coverage of diagnosis and evaluation services to determine if the person meets the definition of a "child with special health care needs" and the person meets all other eligibility criteria for health care benefits, then the person may be given up to 60 days of program coverage for diagnosis and evaluation services only. Only program providers as specified in §38.6 of this title (relating to Providers), may be reimbursed for services as defined in §38.2 of this title.(2) Financial criteria. Financial criteria are determined at least annually or as directed by statute. Financial criteria are based upon the determinations of income, family size, and disregards. All families must verify their income and disregards.(A) The income level for eligibility is 200% of the FPL. If the family income exceeds this level, and the applicant's family can document its responsibility for family medical bills incurred within 12 months prior to the application date or within 6 months after the financial eligibility denial date that are equal to or greater than the amount in excess of the 200% level, the applicant may be determined financially eligible for a period of 6 months, or as directed by statutory requirements, beginning on the eligibility date.(B) Applications to Medicaid and the SSI programs.(i) If actual or projected program expenditures for an ongoing client currently not eligible for Medicaid exceed $2,000 per year and the client's age and citizenship status meet Medicaid eligibility criteria, the client shall be required to apply for any applicable Medicaid programs and, if eligible, to participate in those programs in order to remain eligible for further program benefits. Within 60 days of the date of the notification letter, the client must submit to the program documentation of an eligibility determination from Medicaid. During this 60-day period, program coverage will continue. If the client does not provide documentation of an eligibility determination from Medicaid within the 60-day time limit, program coverage shall be terminated and may not be reinstated unless an eligibility determination is received. The program may grant the client a 30-day extension to obtain the determination.(ii) The program also may require an ongoing client for whom actual or projected expenditures exceed $2,000 per year to apply for the SSI program and, if eligible, to participate in that program in order to remain eligible for further program benefits. Within 60 days of the date of the notification letter, the client must submit to the program verification of a timely and complete application to SSI. During this 60-day period, program coverage will continue. If the client does not provide this verification within the 60-day time limit, program coverage may be terminated. With verification of an application to SSI, the program may continue coverage pending receipt of an SSI eligibility determination.(3) Health insurance.(A) All health insurance coverage insuring the applicant and family must be listed on the application. If insurance coverage was effective prior to program eligibility, such coverage must be kept in force. Noncompliance with this requirement may result in the termination of program benefits. If insurance cannot be maintained, the applicant or parent, guardian, or managing conservator must, upon request, provide to the program proof of:(i) cancellation from the insurer or plan sponsor;(ii) discontinuation of the insurance plan by the insurer or plan sponsor;(iii) exhaustion of the right to continue group insurance coverage as provided under federal or state law; or(iv) financial inability to continue paying the cost of any health insurance except CHIP.(B) Applicants or clients who may be eligible for coverage under Medicare, Medicaid, or CHIP by reason of citizenship, residency status, age, or medical condition must apply for coverage. Proof of eligibility determination must be received within 60 days of the date of notification by the program. With verification of an application to Medicare, Medicaid, CHIP, or an available health insurance plan, the program may extend this deadline pending receipt of an insurance eligibility determination. If the applicant or client is eligible for any health insurance or buy-in program, the applicant or client must be enrolled. Such insurance must be kept in force as though it were effective prior to program eligibility.(C) The program will assist in determining possible eligibility for insurance and may provide program benefits for ongoing clients during insurance application, enrollment, or limited or excluded coverage periods.(D) Before canceling, terminating, or discontinuing existing health insurance or electing not to enroll a client in available health insurance, including canceling, terminating, discontinuing, or not enrolling in CHIP, the parent, guardian, or managing conservator must notify the program 30 days prior to cancellation, termination, discontinuance, or end of the enrollment period. When the program provides assistance in keeping or acquiring health insurance, the parent, guardian, or managing conservator must maintain or enroll in the health insurance.(4) Age. The applicant, other than one with cystic fibrosis, must be under the age of 21.(5) Residency. The applicant must be a Texas resident.(6) Application.(A) Applications are available to anyone seeking assistance from the program. To be considered by the program, the application must be made on forms currently in use.(B) A person is considered to be an applicant from the time that the program receives an application. The program will respond in writing regarding eligibility status within 30 working days after the completed application is received. Applications will be considered:(i) denied if eligibility requirements are not met;(ii) incomplete if required information that includes a CHIP, Medicaid, or SSI determination or any other data and document(s) needed to process the application is not provided or if an outdated form is submitted; or(iii) approved if all criteria are met.(C) The denial of any application submitted to the program shall be in writing and shall include the reason(s) for such denial. The applicant has the right of administrative review and a fair hearing as set out in §38.13 of this title (relating to Right of Appeal).(D) Any person has the right to reapply for program coverage at any time or whenever the person's situation or condition changes.(7) Verification of information.(A) The program shall make the final determination on a person's eligibility using the information provided with the application. The program may request verification of any information provided by the applicant to establish eligibility.(B) The program shall verify selected information on the application. Documentation of date of birth, residency, income, and income disregards shall be required. The program shall notify the applicant and family in writing when specific documentation is required. It is the responsibility of the applicant and family to provide the required information.(C) Those applicants or clients financially eligible for CHIP, Medicaid, or other programs with eligibility income guidelines that meet the program's eligibility income guidelines, and who also meet the program age and residency requirements, will be considered financially eligible. The applicant, client, or family must notify the program, if the applicant or client is no longer eligible for such programs.(8) Determination of continuing eligibility for health care benefits. Financial criteria for eligibility for health care benefits must be re-established at least annually or as directed by statute. Medical or dental criteria must be re-established at least annually (i.e., within 365 days from the first day of the client's initial date of program eligibility or within 366 days during a leap year). Clients for health care benefits will be notified of program deadlines for re-establishment of eligibility. If an ongoing client for health care benefits does not meet program deadlines for submitting information required for the determination of continuing eligibility, the client's eligibility for health care benefits will end. If the then former client re-applies to the program after such lapse in eligibility and is determined eligible for health care benefits, the former client will be considered a new client. If the program has a waiting list for health care benefits, the new client will be placed on the waiting list in order according to the date and time the client is determined eligible for health care benefits.(b) Eligibility for case management services. The program may provide or reimburse for case management services to persons in need of such services who are Texas residents and who are determined not to have another primary provider or funding source for such services. The program's case management services are focused on individuals (and their families) who are eligible, seeking eligibility, or potentially seeking eligibility for the program's health care benefits (this includes clients who are on the waiting list for health care benefits). However, the program may offer and provide case management services to individuals (and their families) who are not eligible or not seeking eligibility for the program's health care benefits. Source Note: The provisions of this §351.3 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.3 Eligibility for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208111 03/12/2026 (a) Introduction. The program provides no direct medical services, but reimburses for services rendered by program providers or contractors. Clients must receive services as close to their home communities as possible unless program contracts or policies require treatment at specific facilities or specialty centers or the clients' conditions require specific specialty care.(b) Types of service.(1) Early identification. The program may conduct outreach activities to identify children for program enrollment, increase their access to care, and help them use services appropriately. Outreach services may include, but are not limited to:(A) promotion of the program to the general public or targeted to potential clients and providers;(B) development and distribution of educational materials to assist applicants and clients in the access and use of program services;(C) development and distribution of population-based educational materials concerning children with special health care needs;(D) integration with programs which screen for or provide treatment of newborn congenital anomalies or other specialty care; and(E) links with community, regional, or school-based clinics to identify, assess needs, and provide appropriate resources for children with special health care needs.(2) Diagnosis and evaluation services. These services may be covered for the purpose of determining whether an applicant meets the program definition of a child with special health care needs in order to receive health care benefits. Diagnosis and evaluation services must be prior authorized and coverage is limited in duration. If a physician or dentist requests coverage of diagnosis and evaluation services to determine if the applicant meets the definition of a "child with special health care needs" and the applicant meets all other eligibility criteria, then the applicant may be given up to 60 days of program coverage for diagnosis and evaluation services only. The program medical director or other designated medical staff may prior authorize limited coverage of diagnosis and evaluation services for waiting list clients if needed to help determine "urgent need for health care benefits" as described in §38.16(e) of this title (relating to Procedures to Address Program Budget Alignment). Only program providers may be reimbursed for diagnosis and evaluation services.(3) Rehabilitation services. Rehabilitation services means a process of physical restoration, improvement, or maintenance of a body function destroyed or impaired by congenital defect, disease, or injury which includes the following acute and chronic or rehabilitative services: facility care, medical and dental care, occupational, speech, and physical therapies, the provision of medications, braces, orthotic and prosthetic devices, durable medical equipment, other medical supplies, and other services specified in this chapter. To be eligible for program reimbursement, treatment must be for a client and must have been prescribed by a practitioner in compliance with all applicable laws and regulations of the State of Texas. Services may be limited and the availability of certain services described in the following subparagraphs is contingent upon implementation of automation procedures and systems.(A) Medical or dental assessment and treatment. A physician or dentist must provide medical or dental assessment and treatment services, including necessary laboratory and radiology studies. All practitioners must be licensed by the State of Texas, enrolled as providers in the program, and practicing within the scope of their respective licenses or registrations.(B) Outpatient mental health services. Outpatient mental health services are limited to no more than 30 encounters in a calendar year by all professionals licensed to provide mental or behavioral health services including psychiatrists, psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors per eligible client per calendar year. Coverage includes, but is not limited to psychological or neuropsychological testing, psychotherapy, and counseling.(C) Preventive and therapeutic dental services (including oral and maxillofacial surgery). Preventive and therapeutic dental services must be provided by licensed dentists enrolled to participate in the program. Coverage for therapeutic dental services, including prosthetics and oral and maxillofacial surgery, follows the Texas Medicaid program guidelines. Orthodontic care must be prior authorized and may be provided only for CSHCN Services Program eligible clients with diagnoses of cleft-craniofacial abnormalities, dentofacial abnormalities, or late effects of fractures of the skull and face bones.(D) Podiatric services. Podiatric services must be provided by licensed practitioners enrolled to participate in the program. Podiatrists are limited to services medically necessary to treat conditions of the foot and ankle. Podiatric services follow the Texas Medicaid program guidelines. Supportive devices, such as molds, inlays, shoes, or supports, must comply with coverage limitations for foot orthoses.(E) Treatment in program participating facilities. Hospital care must be provided in facilities that are enrolled as program providers. The length of stay is limited according to diagnosis, procedures required, and the client's condition.(i) Inpatient hospital care, coverage limitations, and inpatient psychiatric care.(I) Inpatient hospital care. Coverage excludes the following:(-a-) maternity care, newborn care, infertility treatment, or other reproductive services unless directly related to a covered chronic physical or developmental condition;(-b-) personal comfort items, such as television or newspaper delivery; and(-c-) private duty nursing or attendant care.(II) Coverage limitations. Coverage is limited to 60 days per calendar year. For stem cell transplantation, an additional 60 days coverage may be allowed.(III) Inpatient psychiatric care. Coverage is limited to inpatient assessment and crisis stabilization and is to be followed by referral to an appropriate public or private mental health program. Admission must be prior authorized. Services include those medically necessary and furnished by a Medicaid psychiatric hospital or facility under the direction of a psychiatrist.(ii) Inpatient rehabilitation care. Medically necessary inpatient rehabilitation care is limited to an initial admission not to exceed 30 days based on the functional status and potential of the client as certified by a physician participating in the program. Services beyond the initial 30 days may be approved by the program based upon the client's medical condition, plan of treatment, and progress. Payment for inpatient rehabilitation care is limited to 90 days during a calendar year.(iii) Ambulatory surgical care. Ambulatory surgical care is limited to the medically necessary treatment of a client and may be performed only in program approved ambulatory surgical centers as defined in §38.7 of this title (relating to Ambulatory Surgical Care Facilities).(iv) Emergency care. Care including, but not limited to hospital emergency departments, ancillary, and physician services, is limited to medical conditions manifested by acute symptoms of sufficient severity (including severe pain) such that a prudent person with average knowledge of health and medicine could reasonably expect that the absence of immediate medical care could result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. If a client is admitted to a non-participating program hospital provider following care in that provider's emergency room and the admitting facility declines to enroll or does not qualify as a program provider, the client must be discharged or transferred to a program provider as soon as the client's medical condition permits. All providers must enroll in order to receive reimbursement.(v) Care for renal disease. Renal dialysis is limited to the treatment of acute renal disease or chronic (end stage) renal disease. Treatment may be provided through a renal dialysis facility, inpatient or outpatient hospital, or in the client's home. Covered services include, but are not limited to dialysis, laboratory services, drugs and supplies, declotting shunts, on-site physician services, and appropriate access surgery. Renal transplants must be prior authorized, and approval is subject to the availability of funds. If funding is available, renal transplants may be covered in approved renal transplant centers if the projected cost of the transplant and follow-up care is less than that of continuing renal dialysis. Estimated cost of the renal transplant over a one-year period versus the cost of renal dialysis for one year at their facility must be documented. For each client 18 years of age and older, the transplant team must also provide a plan of care to be implemented after the client reaches 21 years of age and is no longer eligible for program services.(F) Orthotic and prosthetic devices. Orthotic and prosthetic devices must be prescribed by a practitioner licensed to do so and supplied by an orthotist or prosthetist licensed by the State of Texas.(G) Medications. Outpatient medications available through pharmacy providers, including over-the-counter products, must be prescribed by practitioners licensed to do so.(H) Nutrition services and nutritional products, excluding hyperalimentation and total parenteral nutrition (TPN).(i) Nutrition services. Nutrition services must be prescribed by a practitioner licensed to do so.(ii) Nutritional products. Nutritional products, including over-the-counter products, are limited to those covered by the program and prescribed by a practitioner licensed to do so, for the treatment of an identified metabolic disorder or other medical condition and serving as a medically necessary therapeutic agent for life and health or when part or all nutritional intake is through a tube.(I) Hyperalimentation and TPN Services. Services include, but are not limited to solutions and additives, supplies and equipment, customary and routine laboratory work, enteral supplies, and nursing visits. These services may be provided on a daily basis when oral intake cannot maintain adequate nutrition. Covered services must be reasonable, medically necessary, appropriate, and prescribed by a practitioner licensed to do so.(J) Medical foods. Coverage for medical foods is limited to the treatment of inborn metabolic disorders. Treatment for any other condition with medical foods requires documentation of medical necessity and prior authorization.(K) Durable medical equipment. All equipment must be prescribed by a practitioner licensed to do so. Some equipment may be ordered from a specific supplier.(L) Medical supplies. Supplies must be medically necessary for the treatment of an eligible client.(M) Professional vision services. Vision services medically necessary for the treatment of a client include, but are not limited to:(i) medically necessary eye examinations with refraction for diagnoses of refractive error, aphakia, diseases of the eye, or eye surgery;(ii) one eye examination with refraction for the purpose of obtaining eyewear during a calendar year; and(iii) one pair of non-prosthetic eye wear per calendar year prescribed by a practitioner licensed to do so.(N) Speech-language pathology and audiology. Speech-language pathology and audiology services medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a speech-language pathologist or audiologist licensed by the State of Texas. Program coverage of speech-language pathology and audiology services may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.(O) Hearing services include, but are not limited to, hearing screening, audiological assessment, otological examination, hearing aid evaluation, hearing aid devices, hearing aid fitting and repair, hearing aid batteries and supplies, and ear molds.(P) Occupational and physical therapy. Occupational and physical therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a therapist licensed by the State of Texas. Program coverage of physical and occupational therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.(Q) Certified respiratory care practitioner services. Respiratory therapy medically necessary for the treatment of a client must be prescribed by a practitioner licensed to do so and provided by a certified respiratory care practitioner. Program coverage of respiratory therapy may be limited to certain conditions, by type of service, by age, by the client's medical status, and whether the client is eligible for services for which a school district is legally responsible.(R) Home health nursing services. Home health nursing services must be medically necessary, be prescribed by a physician, and be provided only by a licensed and certified home and community support services agency participating in the program. Home health nursing services are limited to 200 hours per client per calendar year. Up to 200 additional hours of service per client per calendar year may be approved with documented justification of need and cost effectiveness.(S) Hospice care. Hospice care includes palliative care for clients with a presumed life expectancy of six months or less during the last weeks and months before death. Services apply to care for the hospice terminal diagnosis condition or illnesses. Treatment for conditions unrelated to the terminal condition or illnesses is unaffected. Hospice care must be prescribed by a practitioner licensed to do so who also is enrolled as a program provider.(4) Care management.(A) Medical home. Each program client should receive care in the context of a medical home.(i) Comprehensive, coordinated health care of infants, children, and adolescents should encompass the following services:(I) provision of preventive care, including but not limited to, immunizations, growth and development assessments, appropriate screening health care supervision, client and parental counseling about health care supervision, and client and parental counseling about health and psychological issues;(II) assurance of ambulatory and inpatient care for acute illness, 24 hours a day, seven days a week (including after hours and weekends);(III) provision of care over an extended period of time to enhance continuity;(IV) identification of the need for sub-specialty consultation and referrals, provision of medical information about the client to the consultant, evaluation of the consultant's recommendations, implementation of recommendations that are indicated and appropriate, and interpretation of the consultant's recommendations for the family;(V) interaction with school and community agencies to assure that the special health needs of the client are addressed;(VI) guidance and assistance needed to make the transition to all aspects of adult life, including adult health care, work, and independence; and(VII) maintenance of a central record and database containing all pertinent medical information about the client including information about hospitalizations.(ii) The CSHCN Services Program may require periodic reports from the medical home.(B) Case management. Case management services may be made available to program clients through public health regional offices or other resources to assist clients and their families in obtaining adequate and appropriate services to meet the client's health and related services needs. The program will make available case management as needed or desired to all clients who are eligible for health care benefits (includes clients who are on the waiting list for health care benefits). The program also may make available case management services to clients who are not eligible for the program's health care benefits.(5) Family support services. Family support services include disability-related support, resources, or other assistance and may be provided to the family of a client with special health care needs.(A) Eligibility. A client is eligible to receive family support services if:(i) the client is not receiving services from a Medicaid waiver program, and the family support needs cannot be met by services from other family support programs, such as the Department of Aging and Disability Services or the In-Home and Family Support Program; and(ii) the client's family collaborates with the assigned case manager to identify and pursue other sources of support and to develop a family assessment and service plan.(B) Processing and evaluation of requests.(i) Families of clients indicate their need for family support services by completing and signing an approved request form.(ii) Requests for family support services are processed in chronological order by the date of the request.(iii) All requests for family support services must be prior authorized (approved by the program prior to delivery).(iv) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title.(v) Some services or items may require a written statement from a physician, physical therapist, occupational therapist, or other healthcare professional to establish the disability-related nature of the request.(vi) Some services or items may require written bids.(vii) Persons requesting assistance are responsible for collaborating with their case managers to obtain information as necessary so that an accurate determination can be made in a timely manner.(viii) Families shall be notified in writing of the outcome of their requests for family support services.(ix) Families have the right to appeal a denial or partial approval as described in §38.13 of this title (relating to Right of Appeal).(C) Service plan and cost allowances.(i) The case manager and the client or family must develop a family assessment and service plan and complete a Family Support Services request packet to request a prior authorization for family support services.(ii) The program may establish annual cost allowances based upon the client's or family's level of assessed need for family support services not to exceed:(I) lifetime benefit of up to $3,600 per eligible client for minor home modifications; and(II) annual benefit of up to $3,600 per calendar year per eligible client for allowable family support services.(-a-) The annual benefit may increase to no more than $7,200 per eligible client for the purchase of vehicle lifts and modifications.(-b-) The lifetime benefit for minor home modifications and the annual benefit may be used in the same calendar year.(iii) Service plan cost allowances may be prorated for plans that cover less than one calendar year.(iv) Reimbursement:(I) may be made to the family or to the vendor enrolled as a program provider; and(II) may be reduced by the amount of a cost-sharing requirement, if applicable.(v) Reimbursement rates for respite providers are established by the client or family and the selected provider in collaboration with the case manager.(vi) The annual family assessment and service plan may be amended at any time, but must be reevaluated by the client or family and case manager at least annually.(D) Allowable services.(i) Family support services for program clients and their families include those allowable services and items that:(I) are above and beyond the scope of usual needs (i.e., basic clothing, food, shelter, medical care, and education);(II) are necessitated by the client's medical condition or disability; and(III) directly support the client's living in his or her natural home and participating in family life and community activities.(ii) Family support services may not be used to supplant services available through other public or private programs, but may be used to supplement services provided by other programs.(iii) Allowable services include:(I) respite care;(II) specialized child care costs for a client that are expenses directly related to the client's disability and special needs that are beyond the scope of community-based child care centers, including specialized training for the child care provider;(III) counseling, training programs, or conferences to obtain specific skills or knowledge related to the client's care that assists family members or caregiver(s) in maintaining the client in their home and to increase their knowledge and ability to care for the client;(IV) minor home modifications such as installation of a ramp, widening of doorways, bathroom modifications, and other home modifications to increase accessibility and safety;(V) vehicle lifts and modifications, such as wheelchair lifts or ramps, wheelchair tie-downs, occupant restraints, accessories, modifications such as raising roofs or doors if necessary for lift installation or usage, hand controls, and repairs of covered modifications not related to inappropriate handling or misuse of equipment and not covered by other resources;(VI) specialized equipment, including porch or stair lifts, air purification systems or air conditioners, positioning equipment, bath aids, supplies prescribed by licensed practitioners that are not covered through other systems, and other non-medical disability-related equipment that assists with family activities, promotes the client's self-reliance, or otherwise supports the family; and(VII) other disability-related services that support permanency planning, independence, or participation in family life and integrated or inclusive community activities.(E) Unallowable services. Family support funds may not be used to provide those services that do not relate to the client's disability and do not directly support the client's living in his or her natural home and participating in family life and integrated or inclusive community activities. Examples of unallowable services include, but are not limited to:(i) items for which a less expensive alternative of comparable quality is available;(ii) purchase or lease of vehicles or vehicle maintenance and repair;(iii) home mortgage or rent expenses or basic home maintenance and repair;(iv) income taxes;(v) medical services;(vi) services in segregated settings other than respite facilities or camps;(vii) insurance premiums;(viii) death benefits, burial policies, and funeral expenses;(ix) costs for allowable services incurred before the requested family support service is prior authorized;(x) non-medical foods, routine shelter, routine utilities, routine home repairs, routine home appliances, routine furnishings, fences, and yard work;(xi) medical benefit items or services paid for or reimbursed by private insurance, Medicaid, Medicare, CHIP, the CSHCN Services Program or other health insurance programs for which the client is eligible;(xii) services, equipment, or supplies that have been denied by Medicaid, CHIP, or the program because a claim was received after the filing deadline, because insufficient information was submitted, or because an item was considered inappropriate or experimental;(xiii) over-the-counter or prescription medications;(xiv) architectural modifications to a public facility;(xv) school tuition or fees, or equipment, items, or services that should be provided through the public school system;(xvi) items that could endanger the health and safety of the client;(xvii) routine child care;(xviii) computers and software unless for use as an assistive technology device or necessary to perform a critical or essential function, such as environmental control or written or oral communication, which the client is unable to perform without the computer;(xix) services provided by an individual under the age of 18 years or by the client's parent(s), guardian, or other individual(s) residing with the client; and(xx) services exclusively to support the care of siblings or other individual(s) residing with the client, but which are not necessary to meet the medical needs of the client.(F) Reduction or termination of services. Reasons for terminating or reducing family support services may include, but are not limited to:(i) the client no longer meets the eligibility criteria for the program;(ii) services available through the program are discontinued due to budget restrictions;(iii) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title;(iv) the client's family indicates that the need for family support services no longer exists;(v) the client moves out of Texas;(vi) the client is placed in a nursing facility or other institutional setting for an indefinite period of time;(vii) the client dies;(viii) the client's designated case manager is unable to locate the client and family; or(ix) the family knowingly does not comply with the family assessment and service plan in which case the family may also be liable for restitution.(6) Other types of services. The following services also are available through the program.(A) Ambulance services. Emergency ground, non-emergency ground and air ambulance services are covered for the medically necessary transportation of a client. Non-emergency ambulance transport is covered if the client cannot be transported by any other means without endangering the health or safety of the client and when there is a scheduled medical appointment for medically necessary care at the nearest appropriate facility. Transportation by air ambulance is limited to instances when the client's pickup point is inaccessible by land or when great distance interferes with immediate admission to the nearest appropriate medical treatment facility. Transports to out-of-locality providers are covered if a local facility is not adequately equipped to treat the client. Out-of-locality refers to one-way transfers 50 miles or more from point of pickup to point of destination.(B) Transportation. The program may provide transportation for a client and, if needed, a responsible adult, to and from the nearest medically appropriate facility (in Texas or in the United States 50 or fewer miles from the Texas border) to obtain medically necessary and appropriate health care services that are within the scope of coverage of the program and are provided by a program enrolled provider. The lowest-cost appropriate conveyance should be used. The program shall not assist if transportation is the responsibility of the client's school district or can be obtained through Medicaid. Transportation to out-of-state services located more than 50 miles from the Texas border will not be approved except as specified in §38.6(e) of this title (relating to Providers).(C) Meals and lodging. The program may provide meals and lodging to enable a client, accompanied by a parent, guardian, or their designee as needed, to obtain inpatient or outpatient care at a facility located away from their home. The reason for the inpatient or outpatient visit must be directly related to medically necessary treatment for the client that is provided by program enrolled providers and covered by the program. Meals and lodging associated with travel to services that are provided more than 50 miles from the Texas border will not be approved except as specified in §38.6(e) of this title.(D) Transportation of deceased. The program may provide the following services:(i) transportation cost for the remains of a client who expires in a program-approved facility while receiving program health care benefits, if the client was not in the family's city of residence in Texas, and the transportation cost of a parent or other person accompanying the remains from the facility to the place of burial in Texas that is designated by the parent or other person legally responsible for interment;(ii) embalming of the deceased if required by law for transportation;(iii) a coffin meeting minimum requirements if required by law for transportation; and(iv) any other necessary expenses directly related to the care and return of the client's remains.(E) Payment of insurance premiums, coinsurance, co-payments, and deductibles. The program may pay public or private health insurance premiums to maintain or acquire a health benefit plan or other third party coverage for the client, and if paying for such health insurance can reasonably be expected to be cost effective for the program. The program may pay for coinsurance and deductible amounts when the total amount paid (including all payers) to the provider does not exceed the amount allowed by the program for the covered service. The program may reimburse clients for co-payments paid for covered drugs. The program will not pay premiums, deductibles, coinsurance, or co-payments for clients enrolled in CHIP.(c) Services not covered. Services which are not covered by the program even though they may be medically necessary for and provided to a client include, but are not limited to:(1) treatments which are considered experimental or investigational;(2) chiropractic services;(3) care for premature infants;(4) care for alcohol or substance abuse;(5) pregnancy prevention, except when medically necessary for the specific treatment of a condition meeting the parameters of the "child with special health care needs" definition;(6) maternity care services specific to routine pregnancy care, labor and delivery, and maternal post-partum care;(7) infertility treatment;(8) services provided by a nursing home or facility; and(9) services provided while the client is in the custody of or incarcerated by any municipal, county, state, or federal governmental entity. Case management or prior approved family support services not provided by the governmental entity that are needed during the time when a client is transitioning from custody or incarceration into a community living setting may be covered.(d) Authorization and prior authorization of selected services.(1) Provider's responsibility. A program provider must request services in specific terms on department-prepared forms so that an authorization may be issued and sufficient monies encumbered to cover the cost of the service. If a service is authorized, payment may be made to the provider as long as the service is not covered by a third party resource and all billing requirements are met. Program authorization should not be considered an absolute guarantee of payment. Once a service is delivered and if the service requires authorization for payment, the authorization request for that service must be submitted within 95 days of the date of service.(2) Required prior authorization for selected services. At the program's option, selected services may require authorization prior to the delivery of services in order for payment to be made. Prior authorization requests must be submitted prior to the date of service.(3) While there is a waiting list for health care benefits, limitations in reimbursement or prior authorization may be instituted as provided in §38.16 of this title.(4) Denied authorization requests are authorization requests which are incomplete, submitted on the wrong form, lack necessary documentation, contain inaccurate information, fail to meet authorization request submission deadlines, are for ineligible persons, services, or providers, or are for clients who do not qualify for the health care benefit requested. Denied authorization requests may be corrected and resubmitted for reconsideration. Authorization requests must meet authorization request submission deadlines. Denied authorization requests may be appealed according to §38.13 of this title.(e) Pilot projects. The program may initiate and participate in pilot projects. New projects are possible only if funds are available in the current fiscal year. All pilot projects are limited to no more than 10% of the fiscal year appropriation. Source Note: The provisions of this §351.4 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.4 Covered Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208112 03/12/2026 (a) Rights. A client's parent(s), foster parent(s), guardian, or managing conservator, or an adult client has the right to:(1) apply for eligibility determination;(2) choose providers subject to program limitations;(3) be notified of modification, suspension, or termination of service;(4) refuse entry into the home to any employee, agent, or representative of the commission or the department;(5) appeal program decisions and receive a response within the deadline as described in §38.13 of this title (relating to Right of Appeal); and(6) have all client files and other information maintained in a confidential manner to the extent authorized by law.(b) Responsibilities. A client's parent(s), foster parent(s), guardian, or managing conservator, or an adult client has the responsibility to:(1) provide accurate medical information to providers and notify all providers of program coverage prior to delivery of services;(2) provide the program with accurate information regarding any change of circumstance which might affect eligibility within 30 days of such change;(3) receive and utilize services as close to the client's home community as possible, unless program contracts, policies, or a referral by a program provider requires the use of specific facilities or specialty centers;(4) reimburse the program if payments from health insurance or other benefits are made directly to the client or parent, guardian, or managing conservator for services or equipment purchased by the program;(5) consult with the provider regarding authorization of service from the program prior to service delivery;(6) utilize services provided by the program appropriately including keeping appointments and using supplies and equipment judiciously;(7) utilize health insurance (following all plan guidelines and paying required co-payments), other benefits, and assets and to inform service providers of same;(8) notify the program of any other benefits, as defined in §38.2 of this title (relating to Definitions), available to the client at the time of application or thereafter and any lawsuit(s) contemplated or filed concerning the cause of the medical condition for which the program has paid for services; and(9) bear a portion of the expense of medical or dental care if deemed financially able by the program. Items of routine daily living are not covered by the program.(c) Nondiscrimination. The department operates in compliance with Title VI, Civil Rights Act of 1964 (Public Law 88-352) and 45 Code of Federal Regulations, Part 80, so that no person will be excluded from participation in or otherwise subjected to discrimination on the grounds of race, color, or national origin. Source Note: The provisions of this §351.5 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.5 Rights and Responsibilities of a Client's Parent(s), Foster Parent(s), Guardian, or Managing Conservator, or an Adult Client https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208113 03/12/2026 (a) General requirements for participation. The Children with Special Health Care Needs Services Act, Health and Safety Code, §35.004, requires that all providers be approved to participate in the program according to program criteria and procedures.(1) Providers seeking approval for program participation must submit a completed application to the program or its designee including a signed provider agreement and all documents requested.(2) All approved program providers must agree to abide by program rules and regulations and not to discriminate against clients based on source of payment.(3) All program providers must agree to accept the program-allowed amount of payment (regardless of payer) as payment in full for services provided to program clients. Providers may collect allowable insurance or health maintenance organization co-payments in accordance with those plan provisions. Providers may not request or accept payment from the client or client's family for completing any program forms.(4) The program is the payer of last resort, and program providers must agree to utilize all other public or private benefits available to the client including, but not limited to, Medicaid or Medicaid waiver programs, CHIP, or Medicare, and casualty or liability coverage prior to requesting payment from the program. Providers must agree to attempt to collect payment from the payer of other benefits. The program may pay for certain services for which other benefits may be available but have not been definitively determined. If other benefits become available after the program has paid for the services, the program shall recover its costs directly from the payer of other benefits or shall request the provider of services to collect payment and reimburse the program.(5) Overpayments made on behalf of clients to program providers must be reimbursed to the program refund account by lump sum payment or, at the discretion of the department, in monthly installments or out of current claims due to be paid the provider. All providers must consent to on-site visits and audits by program staff or its designees.(6) All approved providers must agree to the following:(A) maintain and retain all necessary records and claims to fully document the services and supplies provided to a client for full disclosure to the program or its designee;(B) retain these records and claims for a period of five years from the date of service, the client's 21st birthday, or until all audit questions, appeal hearings, investigations, litigation, or court cases are resolved, whichever occurs last;(C) provide unconditionally upon request, free copies of and access to all records pertaining to the services for which claims are submitted to the program or its designees; and(D) allow the department, the Office of Inspector General, HHSC, or designees of these organizations access to its premises; and cooperate and assist with any audit or investigation.(7) All program providers of services also covered by Medicaid must enroll and remain enrolled as Title XIX Medicaid providers. In order to be reimbursed by Medicaid as the primary payer, a provider must be enrolled on the date of service. The program will not reimburse an enrolled provider for any service covered under Medicaid that was provided to a program client eligible for Medicaid at the time of service. If a service covered by the program is not covered by Medicaid, the provider of that service is not required to enroll as a Medicaid provider. Any provider excluded by Medicaid for any reason shall be excluded by the program.(8) Providers must comply with applicable Medicare standards.(9) If a license or certification is required by law to practice in the State of Texas, the provider must maintain the required license or certification and practice within the scope of the license, certification, registration, and any other applicable requirements.(10) All providers shall be responsible for the actions of their staff members who provide program services.(11) Any provider may withdraw from program participation at any time by so notifying the program in writing.(b) Denial, modification, suspension, and termination of provider enrollment.(1) The program may deny, modify, suspend, or terminate a provider's enrollment for the following reasons:(A) submitting false or fraudulent claims;(B) submitting false information on the enrollment application;(C) failing to provide and maintain quality services or medically acceptable standards;(D) not adhering to the provider agreement signed at the time of application or renewal for program participation;(E) conviction of any felony;(F) conviction of any misdemeanor involving moral turpitude;(G) disenrollment as a Medicaid provider;(H) violation of the standards of this chapter;(I) failure to submit a claim for reimbursement for an extended period of time, as specified by program policy; or(J) disciplinary action taken against the provider by the licensing authority under which the provider practices in the State of Texas or by the Texas Medicaid Program.(2) Prior to taking an action to deny, modify, suspend, or terminate the enrollment of a provider, the program shall give the provider written notice of an opportunity of appeal in accordance with §38.13 of this title (relating to Right of Appeal).(c) Provider types. Approved providers include, but are not limited to:(1) advanced practice registered nurses;(2) ambulance providers;(3) ambulatory surgical centers;(4) certified home and community support services agencies;(5) certified respiratory care practitioners;(6) dentists;(7) dietitians;(8) family support services providers;(9) federally qualified health centers;(10) genetic counselors;(11) hearing service professionals;(12) hospice care providers;(13) hospitals;(14) inpatient rehabilitation centers;(15) licensed speech-language pathologists;(16) lodging facilities;(17) medical supply and equipment companies;(18) mental and behavioral health professionals including, but not limited to, psychiatrists, licensed psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors;(19) occupational therapists and physical therapists;(20) optometrists and opticians;(21) orthotists and prosthetists;(22) pharmacies;(23) physicians;(24) physician assistants;(25) podiatrists;(26) renal dialysis centers;(27) rural health clinics; and(28) transportation companies or providers.(d) Requirements for specialty centers.(1) The program may accept as providers diagnostically specific specialty centers, such as bone marrow or other transplant centers, approved under the credentialing or approval standards and processes of the Texas Medicaid Program if such specialty centers also submit a program provider enrollment application.(2) Other specialty center standards. The program may establish standards to insure quality of care for children with special health care needs in the comprehensive diagnosis and treatment of specific medical conditions for specialty centers with Texas Medicaid Program separate credentialing standards as well as other specialty centers for which the Texas Medicaid Program has not established separate credentialing or approval standards for providers.(e) Out-of-state coverage.(1) Fifty or fewer miles from the Texas border. For clients who would otherwise experience financial hardship or be subject to clear medical risk, the program may cover services that are within the scope of the program and provided by health care providers in New Mexico, Oklahoma, Arkansas, or Louisiana located 50 or fewer miles from the Texas border.(2) More than 50 miles from the Texas border. The manager of the department unit having responsibility for oversight of the program may approve coverage of services that are within the scope of the program and provided by health care providers located within the United States and more than 50 miles from the Texas border in unique circumstances in which the program participating physician(s), the client, parent or guardian, and the program medical director or assistant medical director agree that:(A) an out-of-state provider is the provider of choice for quality care;(B) the medical literature indicates that the out-of-state treatment is accepted medical practice and is anticipated to improve the client's quality of life;(C) the same treatment or another treatment of equal benefit or cost is not available from Texas program providers; and(D) the out-of-state treatment should result in a decrease in the total projected program cost of the client's treatment.(3) The limitations of this paragraph do not apply to coverage for or payment to program providers of selected products or devices including, but not limited to, medical foods or hearing amplification devices which either are always less costly or are only available from out-of-state sources.(4) For program reimbursement, all program policies and procedures will apply including the requirement that all providers be program providers as defined by this section.(5) The program may cover costs of transportation and associated meals and lodging for a client and, if necessary, a responsible adult for travel to and from the location of out-of-state services that meet the program approval parameters in this subsection. Travel costs will be negotiated with approval of specific travel options based on overall cost effectiveness. Source Note: The provisions of this §351.6 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.6 Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208114 03/12/2026 (a) Ambulatory surgery services may be utilized by the program as a cost-efficient means of providing surgical care as long as quality of care is assured. Any hospital participating in the program whose accreditation by the Joint Commission includes hospital-sponsored ambulatory care services may provide ambulatory surgery services for program clients. The program will reimburse only approved ambulatory surgical care facilities for services to clients.(b) Freestanding ambulatory surgical care (ASC) facilities, even if governed by or affiliated with a hospital participating in the program, must apply for program approval. The program may contract with a limited number of facilities to contain costs. For approval to participate in the program, a freestanding ASC facility must meet the following criteria:(1) State licensure requirements. Facilities must comply with state licensure requirements for ambulatory surgical centers at §§135.1 - 135.29 of this title (relating to Operating Requirements for Ambulatory Surgical Centers).(2) Medicare certification. Facilities must comply with Medicare standards concerning ambulatory surgical services at 42 Code of Federal Regulations, Parts 405 and 416.(c) The program reimbursement for care at freestanding ASC facilities shall be limited to Levels I and II surgical procedures as designated by the American Society of Anesthesiologists. Source Note: The provisions of this §351.7 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.7 Ambulatory Surgical Care Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208115 03/12/2026 (a) The program will reimburse only an approved inpatient rehabilitation center for services provided to clients.(b) The criteria for inpatient rehabilitation center approval include the following.(1) The center shall have current accreditation by either the Joint Commission as a comprehensive physical rehabilitation program or the Commission on Accreditation of Rehabilitation Facilities as a comprehensive inpatient rehabilitation program.(2) The center shall be located in Texas.(3) The center shall be located outside Texas, in the United States within 50 miles of the Texas border. Source Note: The provisions of this §351.8 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.8 Inpatient Rehabilitation Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208116 03/12/2026 To assure that clients with cleft lip, cleft palate, or other craniofacial anomalies receive quality, comprehensive services, cleft-craniofacial teams requesting approval from the program must comply with the following standards:(1) All cleft-craniofacial surgical procedures are provided within the context and consultation of a coordinated, comprehensive, interdisciplinary cleft-craniofacial team and must be prior authorized. Team composition is consistent with current basic standards of the American Cleft Palate-Craniofacial Association.(2) A comprehensive cleft-craniofacial team will include an operating surgeon, orthodontist, speech-language pathologist, and at least one additional specialist from otolaryngology, audiology, pediatrics, genetics, social work, psychology, and general pediatric or prosthetic dentistry. Adjunct participants may be added as determined by the cleft-craniofacial team to meet the needs of individual clients.(3) The cleft-craniofacial surgical procedures and related cleft-craniofacial team services are provided in accordance with a client and family-oriented comprehensive treatment plan jointly developed by the client or family and the cleft-craniofacial team.(A) A copy of the comprehensive treatment plan will be given to the family (prior to the surgical procedures), the local or referring primary care physician, and other collaborative providers, e.g. local dentist, local speech therapist, case manager, etc. who will be providing services to the client.(B) The plan will include specific services to be provided by the members of the cleft-craniofacial team, action steps, persons responsible, and timeframes. Source Note: The provisions of this §351.9 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.9 Cleft-Craniofacial Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208117 03/12/2026 The program reimburses providers for covered services for clients. Payment may be made only after the delivery of the service, with the exception of meals, transportation, lodging, and insurance premium payments. Excluding allowable insurance or health maintenance organization co-payments, the client or client's family must not be billed for the service or be required to make a preadmission or pretreatment payment or deposit. Providers may not request or accept payment from the client or the client's family for completing any program forms. Providers must agree to accept established fees as payment in full. The program may negotiate reimbursement alternatives to reduce costs through requests for proposals, contract purchases, or incentive programs.(1) Payment or denial of claims. Payments made on behalf of a client will be for claims received by the program or its payment contractor within 95 days of the date of service, within 95 days from the date of discharge from inpatient hospital and inpatient rehabilitation facilities, within 95 days from the date the client's eligibility is added to program automation systems, or within the submission deadlines listed in paragraphs (1)(B)(ii) and (2) of this section, whichever is later. Claims for family support services, drug co-payments, and insurance premium payment assistance must be submitted within 95 days of the last day of the month in which services were provided. If the 95th day for receipt of a claim falls on a weekend or holiday, the deadline shall be extended to the next business day following the weekend or holiday. The program must process the claims of eligible providers within a period not to exceed 30 days of receipt and determination of proper evidence establishing the validity of claims, invoices, and statements. In cases where the program determines that a basis exists for further review, suspension, or other irregularity, extended processing time may be required. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) may waive the filing deadlines according to the conditions and circumstances specified in paragraphs (3) - (5) of this section. A claim must be processed and paid within 24 months of the date of service. Claims received by the program or its payment contractor after this time frame will not be considered for payment by the program.(A) Claims will be paid if submitted on claim forms approved by the program (including electronic claims submission systems) and if the required documentation is received with the claim.(B) Denied claims are claims which are incomplete, submitted on the wrong form, lack necessary documentation, contain inaccurate information, fail to meet the filing deadline, are for ineligible persons, services, or providers, or are for clients who do not qualify for the health care benefit claimed.(i) Corrected claims must be submitted on claim forms approved by the program along with required documentation within the filing deadline established in clause (ii) of this subparagraph.(ii) Denied claims may be corrected and resubmitted for reconsideration if received within 120 days of the last denial or adjustment to the original claim. If the results of the reconsideration process are unsatisfactory, denied claims may be appealed according to §38.13 of this title (relating to Right of Appeal).(2) Claims involving health insurance coverage, CHIP, or Medicaid. Any health insurance that provides coverage to the client must be utilized before the program can pay for services. Providers must file a claim with health insurance, CHIP, or Medicaid prior to submitting any claim to the program for payment. Claims with health insurance must be received by the program within 95 days of the date of disposition by the other third party resource, and no later than 365 days from the date of service. The program will consider claims received for the first time after the 365-day deadline if a third party resource recoups a payment made in error; however, the claim must be received by the program within 95 days from the third party's disposition. The program may pay for covered health care benefits during CHIP or other health insurance enrollment waiting periods. During these periods, providers may file claims directly with the program without evidence of denial by the other insurer.(A) Health insurance denial. If a claim is denied by health insurance, the provider may bill the program if the letter of denial also is submitted with the claim form. If the denial letter is not available, the provider must include on the claim form the date the claim was filed with the insurance company, the reason for the denial, name and telephone number of the insurance company, the policy number, the name of the policy holder and identification numbers for each policy covering the client, the name of the insurance company employee who provided the information on the denial of benefits, and the date of the contact.(B) Explanation of benefits (EOB). The health insurance EOB must accompany any claim sent to the program for payment if available. If the EOB is unavailable, the provider must include on the claim form the name and telephone number of the insurance company, the amount paid, the policy number, and name of the insured for each policy covering the client.(C) Late filing. Claims denied by health insurance on the basis of late filing will not be considered for payment by the program.(D) Deductibles and coinsurance. If the client has other third party coverage, the program may pay a deductible or coinsurance for the client as long as the total amount paid to the provider does not exceed the allowable amount for the covered service and conforms with current program policies regarding third party resources, deductible, and coinsurance.(3) Exceptions to the claim receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to the claim receipt or correction and resubmission deadlines provided in paragraphs (1) and (2) of this section if the delay in claim receipt or correction and resubmission is due to one of the following reasons:(A) damage to or destruction of the provider's business office or records by a catastrophic event or natural disaster including, but not limited to fire, flood, hurricane, or earthquake that substantially interferes with normal business operations of the provider;(B) damage to or destruction of the provider's business office or records caused by the intentional acts of an employee or agent of the provider only if:(i) the employment or agency relationship has been terminated; and(ii) the provider has filed criminal charges against the former employee or agent;(C) delay, error, or constraint imposed by the program in the eligibility determination of a client or in claims processing, or delay due to erroneous written information from the program or its designee, or another state agency; or(D) delay due to problems with the provider's electronic claim system or other documented and verifiable problems with claims submission.(4) Exception requests. Providers requesting an exception under paragraph (3)(A) - (D) of this section must submit an affidavit or statement from a person with personal knowledge of the facts detailing the exception being requested, the cause for the delay, verification that the delay was not caused by neglect, indifference, or lack of diligence of the provider or the provider's employee or agent, and any additional information requested by the program. All claims for which the provider requests an exception must accompany the request. The program will consider only the claim(s) attached to the request, and the exception request must be received by the program within 18 months from the date of service.(A) For exception requests under paragraph (3)(A) of this section, the provider must submit:(i) independent evidence of insurable loss;(ii) medical, accident, or death records; or(iii) a police or fire department report substantiating the damage or destruction.(B) For exception requests under paragraph (3)(B) of this section, the provider must submit a police or fire report substantiating the damage or destruction caused by the former employee or agent's criminal activity.(C) For exception requests under paragraph (3)(C) of this section, the provider must submit written documentation from the program, its designee, or another state agency containing the erroneous information or explanation of the delay, error, or constraint.(D) For exception requests under paragraph (3)(D) of this section, the provider must submit the following:(i) a written repair statement or invoice, a computer or modem generated error report indicating attempts to transmit the data failed for reasons outside the control of the provider, or an explanation for the system implementation or other claim submission problems;(ii) a detailed, written statement concerning the relationship of the computer problem to delayed claims submission; and(iii) the reason alternative billing procedures were not initiated after the problem(s) became known.(5) Other exceptions to claims receipt or correction and resubmission deadlines. The manager of the department unit having responsibility for oversight of the program or his or her designee(s) will consider a provider's request for an exception to claims receipt or correction and resubmission deadlines due to delays caused by entities other than the provider and the program under the following circumstances:(A) all claims that are to be considered for the same exception must accompany the request;(B) only the claim(s) that are attached to the request will be considered;(C) the exception request has been received by the program within 18 months from the date of service; and(D) the exception request includes an affidavit or statement from a representative of an original payer, a third party payer, or a person who has personal knowledge of the facts, stating the exception being requested, documenting the cause for the delay, and providing verification that the delay was caused by another entity and not the neglect, indifference, or lack of diligence of the provider or the provider's employee(s) or agent(s).(6) Program fees. The program establishes fees and payment methodologies for covered medical, dental, and other services based upon appropriated funds. All fees are subject to reductions or limitations authorized by §38.16(b)(2)(E) of this title (relating to Procedures to Address Program Budget Alignment).(7) Required documentation. The program may require documentation of the delivery of goods and services from the provider.(8) Overpayments.(A) Overpayments are payments made by the program due to the following:(i) duplicate billings;(ii) services paid by public or private insurance or other resources;(iii) payments made for services not delivered;(iv) services disallowed by the CSHCN Services Program; and(v) subrogation.(B) Overpayments made to providers must be reimbursed to the department by lump sum payment or, at the department's discretion, offset against current payments due to the provider for services to other clients. The department also shall require reimbursement of overpayments from any person or persons who have a legal obligation to support the client and have received payments from a payer of other benefits. Providers, clients, and person(s) responsible for clients may appeal proposed recoupment of overpayments by the department according to §38.13 of this title. Source Note: The provisions of this §351.10 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective January 1, 2004, 28 TexReg 11268; amended to be effective August 1, 2004, 29 TexReg 7103; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.10 Payment of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208118 03/12/2026 The program may contract on a bid basis for treatment, equipment, medications, supplies, program operations, and other services in order to conserve funds and administer the program effectively.(1) The program may enter into contracts or written agreements with persons or entities for the development and improvement of program standards and services.(2) The program may use consultants from any medical or dental specialty or other discipline to address specific issues or problems in relation to the identification, diagnosis and evaluation, rehabilitation, case management, other family support services, and health benefits coverage for clients.(3) With approval as required by law, the program may accept gifts and donations. Source Note: The provisions of this §351.11 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.11 Contracts, Written Agreements, and Donations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208119 03/12/2026 (a) Any person applying for or eligible for health care benefits from the program shall be notified in writing if the program proposes to deny, modify, suspend, or terminate such health care benefits because:(1) the application or other requested information is intentionally erroneous or falsified;(2) the applicant or family does not meet financial eligibility requirements;(3) the person does not meet Texas residency requirements;(4) information, including the receipt for a purchased family support service, was not provided when requested;(5) behavioral or emotional condition(s) exist, but no physical or developmental condition(s);(6) the client has received third party or liability payments and has failed to reimburse the department for services provided to the client;(7) the client attains the age of 21, except for adults with cystic fibrosis;(8) utilization review indicates inappropriate use of program services and the client and family fail to adhere to a plan established to direct or supervise the use of program services;(9) program funds are reduced or curtailed; or(10) the client is placed on a waiting list for program health care benefits.(b) The program will notify the parents, foster parents, guardian, managing conservator, adult applicant, or adult client in writing of the action, the reasons for the action, and the right of appeal in accordance with §38.13 of this title (relating to Right of Appeal). Source Note: The provisions of this §351.12 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective October 11, 2001, 26 TexReg 7870; amended to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.12 Denial, Modification, Suspension, or Termination of Program Eligibility or Eligibility for Health Care Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208120 03/12/2026 (a) Administrative review.(1) If the program denies eligibility to a program applicant, the program shall give the applicant written notice of the denial and the applicant's right to request an administrative review of the denial within 30 days of the date of the notification.(2) If the program proposes to modify, suspend, or terminate a client's eligibility for health care benefits (unless such program actions are authorized by §38.16 of this title (relating to Procedures to Address Program Budget Alignment)), the program shall give the client written notice of the proposed action and the client's right to request an administrative review of the proposed action within 30 days of the date of notification.(3) If the program denies a prior-authorization or authorization request for program services, the program shall give the client and provider written notice of the denial and the right of the client or provider to request an administrative review of the denial within 30 days of the date of notification.(4) A client, family, or provider may not request administrative review of the program's denial of a prior-authorization or authorization request for program services or reduced provider reimbursement amounts that are authorized by §38.16 of this title.(5) If the program denies a provider's claim that has been corrected and resubmitted for reconsideration according to §38.10(1)(B)(ii) of this title (relating to Payment of Services), the program shall give the provider written notice of the denial. The provider has the right to request an administrative review of the denial within 30 days of the date of notification.(6) If the program denies or proposes to modify, suspend, or terminate an individual provider's participation in the program, the program shall give the provider written notice of the proposed action and the provider's right to request an administrative review of the proposed action within 30 days of the date of notification.(7) If the program receives a written request for administrative review within 30 days of the date of the notification, the program shall conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program shall send the applicant, client, family, or provider written notice of:(A) the program decision, including the supporting reasons for the decision; or(B) the need for extended time to research the circumstances, including an expected date for response to the request.(8) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, family, or provider is presumed to have waived the administrative review as well as access to a fair hearing, and the program's action is final.(b) Fair hearing. If the applicant, client, family, or provider is dissatisfied with the program's decision and supporting reasons following the administrative review, the applicant, client, family, or provider may request a fair hearing in writing addressed to the Children with Special Health Care Needs Services Program, Purchased Health Services Unit, MC 1938, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347 within 20 days of receipt of the administrative review decision notice. If the applicant, client, family, or provider fails to request a fair hearing within the 20-day period, the applicant, client, family, or provider is presumed to have waived the request for a fair hearing, and the program may take final action. A fair hearing requested by an applicant, client, family, or provider shall be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures). Source Note: The provisions of this §351.13 adopted to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.13 Right of Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208121 03/12/2026 To ensure that cost-effective, quality, appropriate medical and related services are available and delivered to clients, the program may establish a system of program evaluation. Program evaluation may include information obtained from management about the program's operation and effectiveness, may establish guidelines and standards for program health care services, may monitor compliance with these established standards and guidelines, may identify and analyze patterns and trends in provider billing and service delivery, and may develop systems which promote family-centered, community-based alternatives that nurture and support children with special health care needs.(1) Quality assurance. The program may establish a system of monitoring the quality, medical necessity, and effectiveness of services.(A) Standards and guidelines. The program may develop standards and guidelines for services and providers reimbursed by the program to ensure that quality services are available.(B) Review of services. The program may conduct or contract for concurrent and/or retrospective review of client care services reimbursed by the program.(C) Provider review. The program may conduct periodic quality assurance reviews for provider services.(D) Survey of clients and families. The program shall survey clients periodically to assess the availability, appropriateness, effectiveness, accessibility, and cultural sensitivity of provided services.(2) Utilization review. Utilization review will assess the appropriateness of services provided to program clients by monitoring systems developed or contracted by the program.(3) Task forces. The program may establish advisory task forces.(4) Cooperation with other agencies. The department cooperates with public and private agencies and with persons interested in the welfare of children with special health care needs. The program will make every effort to establish cooperative agreements with other state agencies to define the responsibilities of each agency in relation to specific programs to avoid duplication of services.(5) Collaboration with stakeholders. The program values the participation of all stakeholders who have an interest in children with special health care needs and will make every effort to work collaboratively with stakeholders in the design, development, and implementation of program rules and policies.(6) Systems development activities. The program may conduct population-based systems development activities to improve and support the state's infrastructure for serving all children with special health care needs and their families by program staff or through contractors. Population-based systems development activities include, but are not limited to the development and maintenance of community-based systems such as case management, parent case management, parent networks, parent resource centers, parent or provider training, voucher programs, wellness centers, permanency planning, or other systems that may directly or indirectly support any family in Texas with the program. Source Note: The provisions of this §351.14 adopted to be effective July 1, 2001, 26 TexReg 2979; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.14 Development and Improvement of Standards and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208122 03/12/2026 (a) The program or the program's designee may recover the cost of services provided to a client from any person or entity who does not pay or reimburse the department as required by Health and Safety Code, §35.007.(b) The program or the program's designee may recover the cost of services provided to a client from any third party who has a legal obligation to pay for the services provided.(c) The program's right of recovery against a third party liable for the client's condition or injury is limited to the amount paid by the program for all claims submitted by program providers for covered services to treat the client's condition or injury.(d) The program or the program's designee may agree to waive all or part of the program's right to recover from a liable third party if:(1) the total of all claims from providers for the cost of services provided to the client exceeds the amount of the available recovery or settlement;(2) the program or the program's designee finds that enforcement of the program's right of recovery of the cost of services provided would adversely affect the client's long-term health and welfare; or(3) the program or the program's designee finds that the cost of recovery could exceed the cost of services provided by the program. Source Note: The provisions of this §351.15 adopted to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.15 Third Party Recovery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208123 03/12/2026 (a) The department must analyze actuarial cost projections concerning program administrative and client services to estimate the amount of funds needed in the fiscal year by the program to serve program clients and shall monitor such program cost projections and funding analyses at least monthly to determine whether the estimated amount of funds needed by the program will:(1) exceed the program's appropriated funds and other available resources for the fiscal year; or(2) be less than the program's appropriated funds and other available resources for the fiscal year.(b) When the program projects that the estimated amount of funds needed in the fiscal year by the program to serve program clients will exceed the program's appropriated funds and other available resources for the fiscal year, the program shall use the following methodology to reduce or limit the amount of funds to be expended by the program:(1) give clients and providers who will be directly affected written notice of any reductions or limitations of services, coverage, or reimbursements;(2) take the following actions in the order listed only until the projected amount of funds to be expended by the program approximately equals, but does not exceed, the program's appropriated funds and other available resources:(A) implement administrative efficiencies while avoiding changes which may jeopardize the quality and integrity of the program service delivery;(B) establish and administer a waiting list for health care benefits according to the procedures in this section;(C) at the same time the waiting list is established, the program shall:(i) provide only limited prior authorization for family support services for ongoing clients, as determined by the medical director or other designated medical staff, only in order to continue services already being provided at the time the waiting list is established, when the specific services are required to prevent out-of-home placement of the client (as documented by the program regional case management staff or contractors), or when the provision of such services is cost effective for the program;(ii) disallow prior authorization (coverage) of diagnosis and evaluation services for applicants who qualify for up to 60 days of program coverage for diagnosis and evaluation services only and refer such applicants to case management services; and(iii) allow limited prior authorization of diagnosis and evaluation services on a short-term basis only when such information is needed to assess whether clients on the waiting list have "urgent need for health care benefits" as described in subsection (e) of this section and only with prior authorization and approval by the medical director or other designated medical staff.(D) place new applicants or re-applicants with lapsed eligibility who are determined eligible for program health care benefits (new clients for health care benefits) on the waiting list. These clients will be ordered on the waiting list according to the date and time the client is determined eligible for program health care benefits;(E) reduce or limit reimbursements for contractual service providers while avoiding changes which may jeopardize the integrity of the contractor base and thereby decrease client access to services;(F) place clients who are eligible to receive program health care benefits and who currently are not on the waiting list (ongoing clients for health care benefits) on the waiting list. These clients will be ordered on the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following order of movement to the waiting list:(i) ongoing clients for health care benefits who have one or more sources of substantial health insurance coverage (such as Medicaid, CHIP, or other private health insurance similar in scope) in addition to the CSHCN Services Program (not including those ongoing clients for whom the program pays the insurance premiums);(ii) ongoing clients for health care benefits in the following order by age groups: 21 years of age or older, 20 years of age, 19 years of age, 18 years of age; and(iii) all other ongoing clients for health care benefits who do not have an urgent need for health care benefits;(G) employ additional measures to reduce or limit the amount of funds to be expended by the program as directed by rule.(c) If the procedures described in subsection (b)(2)(A) - (G) of this section enable the program to project that the estimated amount of funds to be expended by the program in the fiscal year approximately equals, but does not exceed, the program's appropriated funds and other available resources, the program shall take the following additional steps in order to provide health care benefits to as many clients with urgent need for health care benefits as possible who are currently on the waiting list.(1) generate cost savings by taking the following steps in the order listed:(A) give clients and providers who will be directly affected written notice of any reductions or limitations of services, coverage, or reimbursements;(B) reduce or limit reimbursements for contractual service providers while avoiding changes which may jeopardize the integrity of the contractor base and thereby decrease client access to services; and(C) employ additional measures to generate cost savings as directed by rule.(2) utilize cost savings generated to remove as many clients with urgent need for health care benefits as possible from the waiting list and provide health care benefits to those clients. Clients with urgent need for health care benefits will be removed from the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following group order:(A) clients who are less than 21 years old and who have an urgent need for health care benefits as described in subsection (e) of this section;(B) clients who are 21 years of age or older and who have an urgent need for health care benefits as described in subsection (e) of this section;(3) provide health care benefits (which may or may not include coverage of outstanding bills for health care benefits) for clients with urgent need for health care benefits who are removed from the waiting list;(A) as long as program cost savings funds are available; and(B) if the outstanding bills for health care benefits are for dates of service that are within the time period that program cost savings funds are available and provided the client was eligible for program health care benefits at the time of the dates of service;(4) provide limited health care benefits or payment of outstanding bills for health care benefits for clients with urgent need for health care benefits who are on the waiting list and remain on the waiting list. The program's coverage of such health care benefits may be limited in scope, amount, and duration and is not intended to be sustained over time. If limited health care benefits coverage includes coverage of family support services, the coverage of family support services must be limited according to the parameters set forth in subsection (b)(2)(C)(i) of this section. Clients with urgent need for health care benefits who are on the waiting list will be served in the same order used in paragraph (2) of this subsection to remove clients with urgent need for health care benefits from the waiting list. This coverage may be provided to clients with urgent need on the waiting list prior to or at any point during activities described by paragraphs (2) - (3) of this subsection only:(A) when projected cost savings funds are projected to be insufficient to remove clients with urgent need for health care benefits (or additional clients with urgent need for health care benefits) from the waiting list and maintain continuous program health care benefits coverage for those clients or when projected cost savings funds may lapse if not expended in this manner;(B) as long as program cost savings funds are available; and(C) if the outstanding bills for health care benefits are for dates of service that are within the time period that program cost savings funds are available and provided the client was eligible for program health care benefits at the time of the dates of service.(d) When the program projects that the estimated amount of funds to be expended by the program in the fiscal year is less than the program's appropriated funds and other available resources due to the cost reduction, limitation, or deferral procedures implemented according to subsections (b) or (c) of this section, or the program's receipt of additional funding, or funding analysis resulting in a projected amount of unobligated funds, the program shall increase the amount of funds to be expended by the program.(1) In an effort to expend unobligated funds (except for unobligated funds resulting from program actions taken according to subsection (c) of this section), the program shall utilize the following steps in the order listed only until the program projects that the estimated amount of unobligated funds will be expended by the program during the fiscal year:(A) take clients off the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following group order:(i) clients who are less than 21 years old and who have an urgent need for health care benefits as described in subsection (e) of this section;(ii) clients who are 21 years of age or older and who have an urgent need for health care benefits as described in subsection (e) of this section;(iii) all other clients who are less than 21 years old who do not have an urgent need for health care benefits; and(iv) all other clients who are 21 years of age or older who do not have an urgent need for health care benefits;(B) provide health care benefits for clients taken off the waiting list as long as program unobligated funds are available;(C) provide limited health care benefits for clients who are on the waiting list and remain on the waiting list, payment of outstanding bills for health care benefits for clients who are on the waiting list and remain on the waiting list, or payment of outstanding bills for health care benefits for clients who have been taken off the waiting list. The program's coverage of such health care benefits may be limited in scope, amount, and duration and is not intended to be sustained over time. If limited health care benefits coverage includes coverage of family support services, the coverage of family support services must be limited according to the parameters set forth in subsection (b)(2)(C)(i) of this section. This coverage may be provided at any point during activities described by subparagraphs (A) and (B) of this paragraph only:(i) when projected unobligated funds are projected to be insufficient to take clients (or additional clients) off the waiting list and maintain continuous program health care benefits coverage for those clients or when projected unobligated funds may lapse if not expended in this manner;(ii) as long as program unobligated funds are available; and(iii) if the outstanding bills for health care benefits are for dates of service that are within the time period that program unobligated funds are available and provided the client was eligible for program health care benefits at the time of the dates of service;(D) if the program projects that the amount of funds to be expended by the program in the fiscal year will be less than the program's appropriated funds and other available resources after no clients eligible for program health care benefits remain on the waiting list, the program may take the following actions in the following order:(i) eliminate limitations on prior authorization for family support services;(ii) provide prior authorized coverage of diagnosis and evaluation services for applicants who qualify for up to 60 days of program coverage for diagnosis and evaluation services only;(iii) remove any of the additional measures taken to reduce or limit the amount of funds to be expended by the program as directed by rule;(iv) remove any reductions or limitations to contractor reimbursements that have been implemented; and(v) expand program services.(2) In an effort to expend unobligated funds resulting from program actions taken according to subsection (c) of this section (unobligated cost savings funds that remain after all clients with urgent need for health care benefits have been removed from the waiting list and provided health care benefits), the program shall utilize the following steps in the order listed only until the program projects that the estimated amount of unobligated funds will be expended by the program during the fiscal year:(A) take additional clients off the waiting list according to the original date and time that starts the client's latest uninterrupted sequence of eligibility for program health care benefits and in the following group order:(i) clients who are less than 21 years old who do not have an urgent need for health care benefits and who are clients who were placed on the waiting list when they were ongoing clients and who have had no lapse in eligibility while on the waiting list;(ii) clients who are 21 years of age or older who do not have an urgent need for health care benefits and who are clients who were placed on the waiting list when they were ongoing clients and who have had no lapse in eligibility while on the waiting list;(B) provide health care benefits (which may or may not include coverage of outstanding bills for health care benefits) as stipulated in paragraph (1)(B) of this subsection for these clients taken off the waiting list;(C) provide limited health care benefits for clients identified in subparagraph (A)(i) and (ii) of this paragraph who are on the waiting list and remain on the waiting list, payment of outstanding bills for health care benefits for clients identified in subparagraph (A)(i) and (ii) of this paragraph who are on the waiting list and remain on the waiting list, or payment of outstanding bills for health care benefits for clients who have been taken off the waiting list. The program's coverage of such health care benefits may be limited in scope, amount, and duration and is not intended to be sustained over time. If limited health care benefits coverage includes coverage of family support services, the coverage of family support services must be limited according to the parameters set forth in subsection (b)(2)(C)(i) of this section. This coverage may be provided at any point during activities described by subparagraphs (A) and (B) of this paragraph and only as stipulated in paragraph (1)(C)(i) - (iii) of this subsection;(D) remove any of the additional measures taken to generate cost savings by rule according to subsection (c)(1)(C) of this section; and(E) remove any reductions or limitations to contractor reimbursements that have been implemented.(e) The program shall establish a protocol to be used by the medical director or other designated medical staff to determine whether a client has an "urgent need for health care benefits" by considering criteria including, but not limited to, the following:(1) the physician or dentist who signs the client's application or the treating physician or dentist attests or documents the physician's or dentist's determination that delay in receiving health care benefits could result in loss of life, permanent increase in disability, or intense pain and suffering;(2) the client or family states that no other source of health insurance coverage is available to the client;(3) information on the application for health care benefits indicates the complexity of the client's condition or need for care;(4) information received from program regional case management staff or contractors supports other information gathered or indicates that a delay in health care benefits could reasonably be expected to result in an out-of-home placement or institutionalization of the client because the family cannot continue to care for the client; and(5) information obtained from diagnosis and evaluation services as prior authorized by the program medical director or other designated medical staff.(f) The program central office may establish and administer the waiting list for health care benefits to address a budget shortfall.(1) In order to facilitate contacting clients on the waiting list, the program shall collect information including, but not limited to the following:(A) the client's name, address, and telephone number;(B) the name, address, and telephone number of a contact person other than the client;(C) the date of the client's earliest application for health care benefits;(D) the date on which the client became eligible for health care benefits;(E) the client's functional limitations or needs;(F) the range of services needed by the client; and(G) a date on which the client is scheduled for reassessment.(2) The waiting list is maintained continually from one fiscal year to the next. Clients must maintain eligibility for health care benefits to remain on the waiting list. A lapse of eligibility for health care benefits constitutes loss of position on the waiting list.(3) The program shall refer clients on the waiting list to other possible sources of services and shall contact waiting list clients periodically to confirm their continuing need for program services.(4) The program will offer case management services as needed or desired to all clients who are eligible for health care benefits including those on the waiting list for health care benefits. Source Note: The provisions of this §351.16 adopted to be effective March 27, 2003, 28 TexReg 2523; amended to be effective June 1, 2006, 31 TexReg 4200; amended to be effective October 3, 2010, 35 TexReg 8921; amended to be effective April 21, 2013, 38 TexReg 2362; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 982. 1 HEALTH AND HUMAN SERVICES COMMISSION 351 CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM §351.16 Procedures to Address Program Budget Alignment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207473 03/12/2026 The purpose of the Comprehensive Rehabilitation Services (CRS) program is to provide services that enhance the quality of life for persons who have a traumatic brain injury (TBI) or traumatic spinal cord injury (SCI), or both, and to enable them to function as independently as possible within the home environment and within the community by improving their mobility, self-care, and communication skills. Source Note: The provisions of this §352.1 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207474 03/12/2026 Legal authority for funding this program is provided by the comprehensive rehabilitation fund, as authorized by §111.060, Texas Human Resources Code, subrogation recovery pursuant to §111.059, Texas Human Resources Code, and by general revenue. Source Note: The provisions of this §352.3 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.3 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207475 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings for the Comprehensive Rehabilitation Services (CRS) Program unless the context clearly indicates otherwise:(1) Ancillary services--Goods and services that support core CRS services but are not primary interventions. Examples of ancillary services include supplies, medications, and transportation.(2) Aquatic therapy--A type of therapy that involves an exercise method in water to improve a person's range of motion, flexibility, muscular strength and toning, cardiovascular endurance, fitness, and/or mobility.(3) Art therapy--A type of therapy in which persons use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior, develop social skills, improve reality orientation, reduce anxiety, and/or increase self-esteem.(4) Audiological services--Evaluation and treatment of hearing, balance, or related disorders.(5) Basic Living Requirements (BLR)--A framework for determining whether the consumer should pay any of the cost of services which considers the family's net monthly income, liquid assets, and expenses an eligible consumer can reasonably be expected to incur including but not limited to home mortgage or rent payments, prescribed diet or medicine expenses, and other medical or disability related expenses.(6) Behavior management--A set of coordinated services that provide a person with specialized interventions designed to increase adaptive behaviors and to reduce maladaptive or socially unacceptable behaviors, up to and including violent dyscontrol, that prevent or interfere with the person's inclusion within the home environment and the community.(7) Case management--Services that assist consumers in the planning, coordination, monitoring, and evaluation of services with emphasis on quality of care, continuity of services, and cost-effectiveness.(8) Certified professional--A person with the knowledge, experience, and skills to perform a specific job who is paid for performing that job. The person's expertise is verified by a certificate earned by passing an exam that is accredited by an organization or association that monitors and upholds prescribed standards for the profession involved. Examples of certified professionals include a certified brain injury specialist, certified nursing assistant, certified medical assistant, certified medication aide, and certified nurse aide.(9) Chemical dependency services--Planned services that are structured to help a person abstain from using drugs and/or alcohol. Services include identifying and changing behavior patterns that are maladaptive, destructive, or injurious to health and which are related to or result from substance-related disorders, and identifying and changing behavior patterns to restore appropriate levels of physical, psychological, and social functioning.(10) Cognitive rehabilitation therapy (CRT)--A type of therapy that helps a person to learn or relearn cognitive skills that have been lost or altered due to a traumatic brain injury. Services will enable the person to compensate for lost cognitive functions and include reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.(11) Consumer participation--A monthly contribution the consumer (client) may be required to pay for participation in the Comprehensive Rehabilitation Services (CRS) Program.(12) Core services--A set of fundamental services that are essential to rehabilitation of persons who have a traumatic brain injury or traumatic spinal cord injury or both. Specific core services are based on assessed individualized needs.(13) CRS Program--Comprehensive Rehabilitation Services Program.(14) Dietary and nutritional services--Services that develop a prescribed diet to meet basic or special therapeutic nutritional needs.(15) Durable medical equipment and supplies--Equipment that provides therapeutic benefits to a person whose medical conditions require the equipment and supplies.(16) Family and caregiver education and training services--Information that provides a foundation for relationships with a person who has a traumatic brain injury or traumatic spinal cord injury, or both.(17) Family therapy--A specialized type of psychotherapy that helps families and caregivers in intimate relationships to nurture healing and development.(18) Group therapy--A type of therapy with two or more persons in addition to a therapist who have a common therapeutic purpose or to achieve a common goal.(19) Home modification--The use of assistive or adaptive equipment or devices that may be installed in a person's home to enable the person to perform household tasks. This equipment must be removable from the residence without causing permanent damage to the property. Examples include grab bars in bathrooms or portable ramps for persons who use wheelchairs or who have other mobility impairments.(20) Interdisciplinary team (IDT)--A team of professionals that closely coordinates services to achieve treatment goals in order to minimize a consumer's physical or cognitive disabilities and to maximize functional capacity.(21) Individual therapy--A collaborative process between a therapist and person that is intended to facilitate change and improve quality of life.(22) Inpatient comprehensive medical rehabilitation--Services provided, as recommended by an interdisciplinary team in a hospital setting, to address medical and rehabilitation issues that require 24-hour-a-day nursing services. These services are available to people who have a traumatic brain injury or traumatic spinal cord injury, or both.(23) Individualized written rehabilitation plan (IWRP)--A plan developed by CRS staff, which outlines the goals, services, and other aspects of service provision in the CRS Program. It may include elements of the individualized program plan developed by the provider and other members of the interdisciplinary team.(24) Lawful permanent resident--Any person not a citizen of the United States who is residing in the United States per legally recognized and lawfully recorded documentation identifying them as such. A lawful permanent resident is also known as a "Permanent Resident Alien," "Resident Alien Permit Holder," and "Green Card Holder."(25) Licensed professional--A person who has completed a prescribed program of study in a health field, and who has obtained a license indicating his or her competence to practice in that field. Examples of licensed professionals include a registered nurse, physician, and social worker.(26) Limited skilled-nursing--Skilled-nursing for a limited time. This service involves providing or delegating personal care services and medication administration consistent with rules established by the Texas Board of Nursing; assessing a patient to determine the care required; and delivering temporary skilled nursing services for minor illness, injury, or emergency for a period not to exceed 30 days.(27) Liquid assets--Cash and assets from savings or other accounts.(28) Massage therapy--A type of therapy involving the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for therapeutic purposes. Massage therapy constitutes a health care service if the massage therapy is for therapeutic purposes.(29) Medical services--Services or supplies that are needed for the diagnosis or treatment of medical conditions.(30) Mental restoration services--Limited or short term psychiatric services, including treatment and psychotherapy, for mental conditions that are stable or slowly progressive.(31) Music therapy--A type of therapy using musical or rhythmic interventions to restore, maintain, or improve a person's social or emotional functioning, mental processing, or physical health.(32) Net Monthly Income--Monthly take-home pay after taxes and other payroll deductions.(33) Neuropsychological and neuropsychiatric services--A comprehensive battery of tests to evaluate neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system functioning.(34) Occupational therapy--A type of therapy using evaluation and treatment to develop, recover, or maintain the daily living skills of persons who have a physical, mental, and/or cognitive disorder consistent with Occupational Therapy Practice Act, Occupations Code.(35) Orthosis--A custom-fabricated or custom-fitted medical device designed to provide for the support, alignment, prevention, or correction of a neuromuscular or musculoskeletal disease, injury, or deformity, consistent with the Orthotics and Prosthetics Act, Occupations Code.(36) Outpatient services--Medical treatment, without admittance to a hospital that corrects or modifies a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to independence. These services are available to people who have a traumatic brain injury or traumatic spinal cord injury, or both.(37) Over-the-counter medication--Medication that can be obtained without a prescription.(38) PABI--Post-acute brain injury--A brain injury at the post-acute stage, which is when the patient is medically stable and deemed ready to engage in intensive rehabilitation.(39) Paraprofessional--A person to whom a particular aspect of a professional task is delegated, but who is not licensed as a fully qualified professional. A paraprofessional is qualified, through experience, training, or a combination thereof, to provide services. Paraprofessionals must have, at a minimum, a high school diploma or its equivalent.(40) Personal assistance services--Services provided in a residential setting to a person who needs prompts and hands-on supports to participate in services. Services may include, but are not limited to, providing order, safety, and cleanliness assistance; assisting with medication or therapeutic regimens; preparing and serving meals; assisting with laundry; providing supervision and care to meet basic needs; and ensuring evacuation in case of an emergency.(41) Personal attendant care services--Services provided in a home setting to persons with approved medical needs only, and only when provision of services in the home setting is necessary to enable the person to participate in CRS service arrays, which may include assistance with toileting routines, transferring, bathing, dressing, medications, meals, and activities of daily living.(42) Physical restoration services--Services that correct or substantially modify, within a reasonable period of time, a physical condition that is stable or slowly progressive.(43) Physical therapy--A type of therapy that prevents, identifies, corrects, or alleviates acute or prolonged movement dysfunction or pain of anatomical or physiological origin.(44) Post-acute brain injury services--Services provided as recommended by an interdisciplinary team to address deficits in functional and cognitive skills based on individualized assessed needs. Services may include behavior management, the development of coping skills, and compensatory strategies. These services may be provided on a residential or non-residential basis.(45) Post-acute rehabilitation services--Post-acute brain injury services and post-acute spinal cord injury services.(46) Post-acute spinal cord injury services--Services provided as recommended by an interdisciplinary team to address deficits in functional skills based on individualized assessed needs. These services are provided in the home and in the community (non-residential settings).(47) Prescription medication--A medicine that legally requires a medical prescription to be dispensed.(48) Prosthesis--A custom-fabricated or custom-fitted medical device used to replace a missing limb, appendage, or other external human body part but that is not surgically implanted, consistent with the Orthotics and Prosthetics Act, Occupations Code. Accordingly, the term includes an artificial limb, hand, or foot.(49) Provider--An entity under contract with DARS to provide Comprehensive Rehabilitation Services.(50) Provider type--A term that refers to the types of service providers within the CRS Program, consisting of certified professionals, licensed professionals, and paraprofessionals.(51) Rancho Los Amigos Levels of Cognitive Functioning Scale--A scale developed at the Rancho Los Amigos Hospital in Downey, California, that describes eight levels of post-brain injury cognitive function. At "Level IV - Confused/Agitated," the patient is in a heightened state of activity with severely decreased ability to process information. The patient is detached from the present and responds primarily to his or her own internal confusion and behavior is frequently bizarre and non-purposeful relative to the patient's immediate environment.(52) Recreational therapy--A type of therapy involving recreational or leisure activities that assist in the restoration, remediation, or rehabilitation of a person's level of functioning and independence in life activities, and that promote health and wellness and reduce or eliminate the activity limitations associated with traumatic brain injury, traumatic spinal cord injury, or both.(53) Rehabilitation technology--Equipment or technology designed to help persons with disabilities perform tasks that would otherwise require assistance.(54) Room and board--Shelter, facilities and food, including the customary and usual diets in residential settings and prescribed nutritional meals or supplements.(55) Service arrays--A set of services provided to eligible persons who have a traumatic brain injury, traumatic spinal cord injury, or both; services are based on assessed individualized rehabilitation needs that consist of outpatient services, inpatient comprehensive medical rehabilitation services, post-acute brain injury services, and post-acute spinal cord injury services.(56) Speech-language pathology--The application of nonmedical principles, methods, and procedures for measurement, testing, evaluation, prediction, counseling, habilitation, rehabilitation, or instruction related to the development and disorders of communication, including speech, voice, language, oral pharyngeal function, or cognitive processes, for the purpose of evaluating, preventing, or modifying or offering to evaluate, prevent, or modify those disorders and conditions in an individual or a group, consistent with the Occupations Code.(57) Texas resident--A person who lives in Texas as evidenced by one of the following unexpired documents: a Texas driver's license, an identification card with an address issued by a governmental entity, a utility bill with an address, a voter registration card, a vehicle registration receipt, or other document approved by the Department of Assistive and Rehabilitative Services.(58) Third-party payer--A company, organization, insurer, or government agency other than DARS that makes payment for goods and services provided to a consumer.(59) Transportation--Travel and related expenses.(60) Traumatic brain injury (TBI)--An injury to the brain that is not degenerative or congenital; and caused by an external physical force, which may produce a diminished or altered state of consciousness, resulting in temporary or permanent impairment of cognitive abilities and/or physical functioning, and partial or total functional disability and/or psychosocial maladjustment.(61) Traumatic spinal cord injury (SCI)--An acute, traumatic lesion of neural elements in the spinal canal resulting in any degree of temporary or permanent sensory or motor deficit, and/or bladder or bowel dysfunction.(62) Vision services--A sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate, and enhance visual skills. Source Note: The provisions of this §352.5 adopted to be effective September 1, 2015, 40 TexReg 5346; amended to be effective March 13, 2016, 41 TexReg 1713; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207476 03/12/2026 (a) To meet the basic eligibility criteria for the Comprehensive Rehabilitation Services (CRS) program, there must a reasonable expectation that services will benefit the person by improving his or her ability to function within the home environment or within the community, and the person must:(1) have a traumatic brain injury or traumatic spinal cord injury that constitutes or results in a substantial impediment to the person's ability to function within the home environment or the community;(2) be at least 15 years of age;(3) be a U.S. citizen or lawful permanent resident, and a Texas resident (as defined in §107.705(52) of this subchapter (relating to Definitions));(4) not be participating in, or be eligible for and able to access, another rehabilitation program offering similar rehabilitation treatment or therapy services; however the person may participate in rehabilitation programs that offer complementary rehabilitation services;(5) be willing to participate in services; and(6) be medically stable, including no progression of deficits, no deterioration of physical and cognitive status, or both; not be in imminent need of any acute care; and be functioning at a Level IV of the Rancho Los Amigos Levels of Cognitive Functioning Scale or equivalent.(b) The person's continued eligibility for the CRS program will be reviewed and, if he or she no longer meets all criteria in subsection (a) of this section, program services may be discontinued. Source Note: The provisions of this §352.7 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.7 Basic Requirements for Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207477 03/12/2026 The Comprehensive Rehabilitation Services program service arrays are a set of services that may be provided to eligible persons who have a traumatic brain injury (TBI), traumatic spinal cord injury (SCI), or both; services are based on assessed individualized rehabilitation needs. The service arrays are:(1) inpatient comprehensive medical rehabilitation services, which include:(A) TBI inpatient comprehensive medical rehabilitation services; and(B) SCI inpatient comprehensive medical rehabilitation services.(2) post-acute brain injury (PABI) services, which include:(A) PABI residential services; and(B) PABI non-residential services.(3) post-acute spinal cord injury services (non-residential); and(4) outpatient services, which include:(A) TBI outpatient services; and(B) SCI outpatient services. Source Note: The provisions of this §352.9 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.9 Service Arrays https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207469 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207469 03/12/2026 The Comprehensive Rehabilitation Services program provides two service types that apply across all service arrays, although not all services may be utilized in all the arrays. The two service types are core services and ancillary services and are listed in paragraphs (1) and (2) of this section.(1) Core services, are a set of fundamental services essential to the rehabilitation of persons who have traumatic brain injury, traumatic spinal cord injury, or both. Core services may include:(A) aquatic therapy;(B) art therapy;(C) behavior management;(D) case management;(E) chemical dependency treatment;(F) cognitive rehabilitation therapy (CRT);(G) dietary nutritional services;(H) massage therapy;(I) medical services;(J) mental restoration services;(K) music therapy;(L) neuropsychiatric services;(M) neuropsychological services;(N) occupational therapy;(O) personal assistance services;(P) physical therapy;(Q) recreational therapy;(R) room and board; and(S) speech-language pathology.(2) Ancillary services, are goods and services that support core services, but are not primary interventions. Ancillary services may include the following:(A) audiology;(B) dietary nutritional services;(C) durable medical equipment (DME) and supplies;(D) family and caregiver education and training;(E) family therapy;(F) home modification;(G) limited skilled nursing;(H) mental restoration;(I) orthosis and prosthesis;(J) over the counter medications;(K) personal attendant care;(L) physical restoration;(M) prescription medications;(N) rehabilitation technology;(O) transportation; and(P) vision services. Source Note: The provisions of this §352.11 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.11 Service Types https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207470 03/12/2026 The following limitations apply to the Comprehensive Rehabilitation Services (CRS) program service arrays.(1) Inpatient comprehensive medical rehabilitation hospitalization services are subject to the following limitations:(A) No more than one year may have elapsed between the onset of injury and the time the person initiates contact with the agency in order for a person to receive these services.(B) No acute medical procedures are permitted.(C) Only inpatient facilities located within the state of Texas may be used.(D) Services are limited to a maximum of 90 days.(2) Post-acute rehabilitation services for persons who have a traumatic brain injury (TBI), traumatic spinal cord injury (SCI), or both, are subject to the following limitations:(A) Residential services are limited to persons who have a TBI, or a TBI and SCI.(B) Persons with an SCI are limited to receiving non-residential services.(C) Services are limited to a maximum of 180 days.(3) Outpatient services are subject to the following limitations:(A) No more than two years may have elapsed between the onset of injury and the time the person initiates contact with the agency in order for the person to receive these services.(B) Services are limited to a maximum of 120 hours.(4) At the time the person is discharged from post-acute rehabilitation services or inpatient comprehensive medical rehabilitation hospitalization services, prescribed drugs and medical supplies may not exceed a 30-day supply.(5) The purchase of CRS program services for eligible persons depends on the availability of CRS funds. Source Note: The provisions of this §352.13 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.13 Limitations of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207471 03/12/2026 (a) The consumer (client) participation is a monthly contribution the consumer (client) may be required to pay for participation in the Comprehensive Rehabilitation Services (CRS) Program. Consumer participation applies to consumers in active services, as well as those on the interest list who are both eligible and receiving services.(b) The consumer participation is required only for CRS consumers when the consumer's liquid assets exceed the basic living requirement (BLR) level calculated by the CRS Program, and consequently require the consumer to contribute an amount equal to this excess toward the cost of the goods and services provided by the CRS Program. The BLR calculation is based on:(1) 200 percent of current U. S. Department of Health and Human Services Poverty Guidelines;(2) DARS BLR tables for the current fiscal year;(3) DARS policies relating to consumer participation and BLR; and(4) information regarding the consumer's income, family status, and economic need.(c) The CRS Program calculates the amount of the consumer participation owed by the consumer for the goods and services that are provided, regardless of the availability of private insurance or other third-party payer reimbursements. The consumer's obligation for payment of any deductible, co-payment, or coinsurance is limited to the monthly consumer participation amount.(d) The consumer participation calculation will take into account:(1) the net monthly income and liquid assets of the consumer and the consumer's spouse, parents, or legal guardian or conservator;(2) allowable expenses, such as monthly home mortgage or rental payments, prescribed diets and medicines used by the consumer, debts imposed by court order; and(3) family size.(e) The consumer participation must not exceed the cost of the services provided by the CRS Program in a given month, and it is applied only in months that billable goods and services are provided by the CRS Program.(f) The consumer participation must be paid to the service provider by the consumer directly.(g) The consumer participation will be deducted from the amount paid to the service provider by the CRS Program and must be reflected in the service authorization given to the provider by the CRS Program.(h) The consumer may choose not to disclose financial information, but doing so may result in the presumption that the consumer has adequate resources to participate fully in the cost of CRS goods and services.(i) The consumer participation does not apply:(1) when the consumer is eligible for Supplemental Security Income or Social Security Disability Income.(2) to certain services, including:(A) assessments for determining eligibility;(B) assessments for determining rehabilitation needs, including associated maintenance and transportation;(C) rehabilitation counseling and guidance and referral for other services;(D) personal assistance services; and(E) any auxiliary aid or service that a consumer with a disability requires to participate in the CRS Program.(j) DARS management may waive the consumer participation when the consumer's participation towards the cost of services would prevent the consumer from receiving a necessary service.(k) The consumer participation must be reviewed annually by the CRS Program.(l) To the extent that the consumer is entitled to insurance-payment for services or receives payment for services from other governmental programs, third-party payers, or other private sources, DARS funds must not be used to pay for the services.(m) If the consumer, consumer's representative, or a court appointed guardian or representative disagrees with the calculated consumer participation amount, they can:(1) request a review by DARS;(2) contact the DARS Inquiries Line at 1-800-628-5115 for help resolving a problem or concern; or(3) file a formal complaint with DARS as noted in §107.715 of this chapter (relating to Complaint Resolution Process).(n) Information about CRS consumer participation procedures and BLR used to administer the CRS Program are available on the DARS website and for viewing at DARS, 4800 North Lamar Boulevard, Austin, Texas, between 8:00 a.m. and 5:00 p.m. on business days. Source Note: The provisions of this §352.14 adopted to be effective March 13, 2016, 41 TexReg 1713; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.14 Consumer (Client) Participation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207472 03/12/2026 (a) This provision applies to the resolution of a complaint through review of a determination made by the Comprehensive Rehabilitation Services (CRS) program, when the complaint concerns:(1) ineligibility for services;(2) denial of services; or(3) termination of services.(b) An applicant may file a complaint in writing to: CRS Program, Department of Assistive and Rehabilitative Services, 4900 N. Lamar Blvd., Austin, Texas 78751-2316. An applicant also may call DARS Inquiries at 1-800-628-5115 or send an email to dars.inquiries@dars.state.tx.us. In accordance with §117.072(b) of the Texas Human Resources Code, the CRS program provides a copy of the procedures under this subchapter to each applicant who wishes to file a complaint and to any person who is the subject of the complaint. DARS and CRS program staff members receive, evaluate, and seek satisfactory resolution to each complaint received.(c) A complaint regarding the CRS program must be filed within 180 calendar days of the matter giving rise to the complaint. A complaint filed after 180 calendar days will be dismissed without further review by DARS.(d) The complaint must contain:(1) the name of the person filing the complaint;(2) the name of the person for whom the complaint is filed;(3) the date of the incident that gave rise to the complaint;(4) the basis for the complaint;(5) a summary of the facts supporting the complaint; and(6) the specific relief requested.(e) DARS staff must make every effort to:(1) document the date that the complaint was received;(2) evaluate the complaint and seek facts from the parties involved;(3) provide a written decision within 60 calendar days to the complainant addressing each allegation;(4) provide technical assistance and appropriate follow up to the parties involved in the complaint, as necessary; and(5) retain the documentation of the complaint for five years.(f) On each complaint under this subchapter, the CRS program maintains a file containing the name of the person filing the complaint, the date the CRS program received the complaint, the subject matter of the complaint, the name of each person contacted concerning the complaint, a summary of the review, and an explanation of the actions taken, if any, to address the complaint.(g) At least quarterly until final disposition of the complaint, DARS shall notify the person filing the complaint and each person who is a subject of the complaint about the status of the investigation, unless the notice would jeopardize an investigation. Source Note: The provisions of this §352.15 adopted to be effective September 1, 2015, 40 TexReg 5346; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9422. 1 HEALTH AND HUMAN SERVICES COMMISSION 352 COMPREHENSIVE REHABILITATION SERVICES §352.15 Complaint Resolution Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208079 03/12/2026 These rules implement Texas Health and Safety Code, Chapter 41. Specifically, the rules establish eligibility requirements; outline program benefits and the methodology used by the program to remain within budgetary limitations; outline provider requirements and provider reimbursement; outline the rights and responsibilities of clients and providers; and stipulate the circumstances that allow for an administrative review. Source Note: The provisions of this §354.1 adopted to be effective April 16, 2015, 40 TexReg 2090; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208080 03/12/2026 The following words and terms, when used in this chapter, will have the following meanings unless the context clearly indicates otherwise. (1) Administrative review--A process that allows applicants, clients, and providers the opportunity to request an informal review of any intended program action that would suspend, modify, deny, or terminate their eligibility for enrollment, benefits participation in the program, or reimbursement for allowable products.(2) Allowable products--Blood factor replacement products indicated for the treatment of hemophilia and approved for payment by the program.(3) Applicant--A person making an initial application or re-application for the program.(4) Approved health plan--An insurance plan that provides coverage for hemophilia medical treatment.(5) Attestation--A statement by a person or the person's legally authorized representative attesting that:(A) the person does not have access to private health care insurance that provides coverage for the benefit, service, or assistance; or (B) the person has access to private health care insurance that provides coverage for the benefit, service, or assistance.(6) CHIP--The Children's Health Insurance Program administered by the Commission under Title XXI of the Social Security Act. (7) Claim--A request for payment or reimbursement of services or insurance premiums.(8) Client--A person who has applied for program services and who meets all program eligibility requirements and is determined to be eligible for program services, and may include:(A) a person who has applied to the program for the first time and is determined to be eligible for program services; (B) a person who has re-applied to the program (after a lapse in eligibility) and is determined to be eligible for program services; or (C) a person who has applied to the program and is determined to be eligible for program services and is currently on the program's waiting list. (9) Commission--The Health and Human Services Commission. (10) CSHCN Services Program--Children with Special Health Care Needs Services Program.(11) Date of service--The date the allowable products are dispensed. (12) Denial--An action by the program that disallows program eligibility, benefits, or administrative review requests.(13) Department--Department of State Health Services. (14) Eligibility date for program benefits--The effective date of client eligibility for program benefits is the date of receipt of a complete, approved application.(15) Exclusion--The federal and state offices of Inspector General maintain lists that exclude certain people or businesses from participating as service providers for federal and state health care programs.(16) Factor--A substance that is injected into the vein of a person with hemophilia to replace the missing blood clotting factor and allow the blood to clot properly.(17) Fair hearing--The informal hearing process the department follows in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures). (18) Family--In order to determine family size for the calculation of the applicant's percentage of the Federal Poverty Level for program eligibility, the family includes the following persons who live in the same residence: (A) the applicant; (B) any persons who have a legal responsibility to support the applicant; (C) children under age 18 or wards of the applicant; and (D) children under age 18 or wards of any persons who have a legal responsibility to support the applicant.(19) Federal Poverty Level guidelines (FPL)--The minimum income needed by a family for food, clothing, transportation, shelter, and other necessities in the United States, according to the United States Department of Health and Human Services, or its successor agency or agencies. FPL varies according to family size, and after adjustment for inflation, is published annually in the Federal Register. (20) Filing deadline--The last date that a claim may be received by the program and still be considered eligible for payment of benefits.(21) Hemophilia Assistance Program (program)--A state funded program that provides limited financial assistance to persons age 18 and older who have been diagnosed with hemophilia and meet other program eligibility requirements for blood factor replacement products that are administered or dispensed by program-approved providers or insurance premium payment assistance.(22) Hemophilia--A human physical condition characterized by bleeding, resulting from a genetically determined deficiency of a blood coagulation factor or an abnormal or deficient plasma procoagulant that prevents the blood from clotting properly. The diagnoses covered by the program include:(A) congenital factor VIII disorder (Hemophilia A); (B) congenital factor IX disorder (Hemophilia B); and (C) congenital factor XI disorder (Hemophilia C).(23) Income--The gross income, either earned or unearned, before deductions over a given period of time for each family member.(24) Incomplete claim--A request for payment or reimbursement of services or insurance premiums that is missing required information.(25) Insurance premium payment--A payment made to an approved health plan. (26) Medicaid--A program of medical care authorized by Title XIX of the Social Security Act and the Human Resources Code.(27) Medicare--A federal program that provides medical care for people age 65 or older and the disabled as authorized by Title XVIII of the Social Security Act.(28) Other Coverage--Coverage, in addition to benefit coverage as referenced in §37.114 of this title (related to Benefits and Limitations), to which a person is entitled for payment of the costs of services or insurance premiums included in the scope of coverage of the program, but not limited to, benefits available from:(A) an insurance policy, group health plan, health maintenance organization, or prepaid medical plan; (B) Title XVIII, Title XIX, or Title XXI of the Social Security Act (42 U.S.C. §§1395 et seq., 1396 et seq., and 1397aa et seq.), as amended; (C) the United States Department of Veterans Affairs; (D) the TRICARE program of the United States Department of Defense; (E) workers' compensation or any other compulsory employers' insurance program; (F) a public program created by federal or state law or under the authority of a municipality or other political subdivision of the state, excluding benefits created by the establishment of a municipal or county hospital, a joint municipal-county hospital, a county hospital authority, a hospital district, a county indigent health care program, or the facilities of a publicly supported medical school; or (G) a cause of action for the cost of care, including medical care, dental care, facility care, and medical supplies, required for a person applying for or receiving services from the department or a settlement or judgment based on the cause of action if the expenses are related to the need for services provided under this chapter.(29) Physician--An individual licensed by the Texas Medical Board to practice medicine in the state. (30) Prior Authorization--The process of getting approval from the program, before a product is dispensed, to determine if it can be considered for reimbursement.(31) Program--The Hemophilia Assistance Program.(32) Provider--Any individual or entity, as defined in §37.115, of this title (relating to Providers) approved by the program to provide allowable products to clients.(33) Recertification of Program Eligibility--Upon request of the program, clients must submit the information required in order to determine their continuing eligibility for program services.(34) Reimbursement--Payment of a claim for insurance premiums submitted by a client or allowable products administered or dispensed to a client submitted by a program provider.(35) Reimbursement rate--The program payment rate for allowable products, determined annually for the following fiscal year. (36) Social Security Administration (SSA)--A United States government agency that administers the social insurance programs in the United States. The agency covers a wide range of social security services, such as disability, retirement and survivors' benefits. (37) Social Security Disability Insurance (SSDI)--A payroll tax-funded, federal insurance program managed by the SSA, that provides income to people who are unable to work because of a disability.(38) State--The State of Texas.(39) Texas resident--A person who: (A) is physically present within the geographic boundaries of the state: (i) intends to remain within the state; (ii) maintains an abode within the state (i.e., house or apartment, not merely a post office box); (iii) has not come to the state from another country for the purpose of obtaining medical care with the intent to return to the person's native country; and (B) does not claim residency in any other state or country; or (C) is a person residing in the state who is the legally dependent spouse of a Texas resident; or (D) is an adult residing in the state, and plans to continue to reside, with a parent(s), managing conservator, guardian of the adult's person, or caretaker who is a Texas resident. Source Note: The provisions of this §354.3 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208081 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208081 03/12/2026 (a) Client Requirements. In order to be determined eligible for program benefits, applicants must meet the medical, age, residency, financial, and other criteria in this section, and submit a complete application for program benefits.(1) Medical criteria. A physician must certify that the applicant has a diagnosis of hemophilia.(2) Age. The applicant must be 18 years of age or older.(3) Residency. The applicant must be a Texas resident.(4) Financial criteria. Financial criteria are determined at least annually or as directed by the program. Financial criteria are based upon the determinations of income and family size. Income must be at or below 200% of the FPL.(5) Other criteria. The applicant must not be eligible for Medicaid or the Children's Health Insurance Program (CHIP). The program may require an applicant currently not enrolled in Medicaid, Medicare, CHIP, SSDI, or the CSHCN Services Program to apply for any of these applicable programs when the applicant's age, income, or medical disability determination meets the eligibility criteria for any of these programs and, if eligible, to participate in those programs.(6) Health Insurance. All health insurance coverage insuring the applicant must be attested to on the application. Noncompliance with this requirement may result in the termination of program benefits.(A) The program may require an applicant currently not enrolled in a health insurance plan to apply for an available insurance plan that is accessible and provides comprehensive coverage. The program may provide program benefits for ongoing clients during insurance application, enrollment, or limited or excluded coverage periods.(B) Before canceling, terminating, or discontinuing existing health insurance or electing not to enroll in available health insurance, the client, or person who has a legal responsibility for the client, must notify the program 30 days prior to cancellation, termination, discontinuance, or end of the enrollment period, whenever possible.(7) Application.(A) To be considered by the program, a complete application must be made on forms required by the department. The application must have the signature or mark of the applicant, or the applicant's legally authorized representative, and the physician's signature.(B) The program will make the determination of an applicant's eligibility using the information provided with the application. The program will verify information on the application, including required documentation of diagnosis, income, attestation of other coverage, date of birth, and residency.(C) The program may request additional documentation to verify information provided by the applicant to establish eligibility. The program will notify the applicant, or the applicant's legally authorized representative, in writing when specific documentation is required. It is the responsibility of the applicant, or the applicant's legally authorized representative, to provide the required documentation.(D) The program will determine eligibility when a completed application is received.(8) Eligibility Date. The effective date of eligibility for program benefits is the date of receipt of a complete, approved application.(9) Program Termination. If program coverage is terminated, the eligibility date for any subsequent eligibility period will be the date on which the program receives a subsequent completed application for program benefits.(b) Determination of continuing eligibility for program benefits. Income criteria, residency, and attestation of other coverage must be documented annually or as directed by the program for the recertification of program eligibility and benefits.(1) Clients are notified of program deadlines for recertification of eligibility.(2) If an ongoing client does not meet program deadlines for submitting information required for the determination of continuing eligibility, the client's eligibility for the program will end.(3) If a former client re-applies to the program, a new medical certification is not required, and their new eligibility date is determined to be the date the completed application is received. Source Note: The provisions of this §354.5 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.5 Program Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208082 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208082 03/12/2026 An eligible client may receive either blood factor replacement products or insurance premium payment assistance in the same fiscal year, but not at the same time.(1) Blood Factor Replacement Products. The program provides limited reimbursement to program providers for blood factor replacement products indicated for the treatment of hemophilia and prescribed to eligible clients for use in medical or dental facilities, or in the home.(2) Program benefits for allowable products are limited to those prescribed by a physician and dispensed by a program provider.(3) The program will pay for allowable products based upon:(A) available funds;(B) established limits for allowable products by type or category; and(C) the reimbursement rates established by the department.(4) Eligible clients with private or group health insurance for which the program does not provide insurance premium payment assistance must exhaust all benefits prior to receiving program benefits for allowable products.(5) Insurance Premium Payment Assistance. The program may assist eligible clients in obtaining public or private health insurance by providing insurance premium payment assistance if paying for such health insurance can reasonably be expected to be cost effective for the program.(6) The program is payer of last resort. Applicants and currently eligible clients are no longer eligible when they become eligible for the CHIP, SSDI, or Medicaid.(7) To meet budgetary limitations, the department may:(A) adjust the reimbursement rates established by the department;(B) restrict allowable products and insurance premium payments paid for under the program;(C) adjust the annual benefit limits; or(D) establish a waiting list of persons eligible for the program. Appropriate information will be collected from each applicant who is placed on a waiting list. The information will be used to facilitate contacting the applicant and to allow efficient enrollment of the applicant when benefits become available. Eligibility must be maintained while on the waiting list. Source Note: The provisions of this §354.7 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.7 Benefits and Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208083 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208083 03/12/2026 (a) Applicable provider types for the program include, but are not limited to:(1) pharmacies;(2) hospitals; or(3) blood banks.(b) In order for a provider to qualify for participation and to enroll in the program, the provider will:(1) be licensed by the state and practicing within the scope of their respective licenses, certifications, or registrations;(2) be a current Texas Medicaid Program provider;(3) enter into an agreement to participate in the program;(4) submit a completed program provider enrollment form to the program;(5) submit a completed department Child Support Certification form to the program;(6) agree to reimburse the program for any overpayments made to the provider by the program upon request;(7) not currently be on suspension as a program provider or as a Texas Medicaid Program provider; and(8) not have a current exclusion documented with the following agencies;(A) U.S. Department of Health and Human Services (HHS); or(B) the Commission.(9) Providers who have a suspension or exclusion documented will not be allowed to enroll with the program until the suspension or exclusion is resolved and removed.(c) Changes in provider ownership require termination of the current agreement and a new agreement must be executed under the new ownership.(d) The program may establish provider enrollment limitations in order to conserve funds, assure quality, and effectively administer the program.(e) The program may modify, suspend, deny, or terminate a provider's approval to participate for the following reasons:(1) submission of false or fraudulent claims;(2) failure to provide and maintain quality services;(3) failure to adhere to medically acceptable standards;(4) breach of the provider agreement;(5) disenrollment as a Texas Medicaid Program provider;(6) placement on the current exclusion listing; or(7) failure to submit a claim for reimbursement for an extended period of time, as specified by program policy. Source Note: The provisions of this §354.9 adopted to be effective April 16, 2015, 40 TexReg 2090; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.9 Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208084 03/12/2026 (a) Prior authorization is required for all allowable products.(b) The program reimburses program providers for allowable product(s) for eligible clients. Payment may be made only after the allowable product(s) has been dispensed and submission of a valid claim. Claims must be:(1) submitted on the claim form accepted by the program;(2) submitted by a program provider; and(3) filed directly with the program.(c) The program reimburses eligible clients for insurance premium payments made to program approved health plans. Reimbursements may be made after the program's receipt of a valid proof of insurance premium payment.(d) Filing Deadlines.(1) Complete claims must be received by the program within 95 calendar days from the end of the month of the date of service or 95 calendar days from the end of the month for which the premium was paid.(2) Incomplete and ineligible claims will be denied.(3) Denied claims may be considered for payment if the claim is corrected and resubmitted within 30 days following the date of the program notice of denial or within the initial 95 day filing deadline, whichever is later. Source Note: The provisions of this §354.11 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.11 Claims Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208076 03/12/2026 (a) Client Rights. The applicant, client, or legally authorized representative have the right to:(1) apply for eligibility determination;(2) choose providers subject to program limitations;(3) choose a health plan, if applicable, subject to program limitations;(4) be notified of program decisions relating to modifications, suspensions, denials, or terminations;(5) have all client files and other information maintained in a confidential manner to the extent authorized by law;(6) appeal program decisions and receive a response within the deadline as described in §37.119 of this title (relating to Right of Appeal); and(7) reapply for the program when eligibility for the program is denied or terminated.(b) Provider Rights. The provider has the right to:(1) apply and enroll as a provider;(2) be notified of program decision relating to modifications, suspensions, denials, or terminations;(3) have confidentiality of information in the manner and to the extent authorized by law;(4) appeal program decisions and receive a response within the deadline as described in §37.119 of this title; and(5) reapply for the program when eligibility for the program is denied or terminated.(c) Client Responsibilities. The applicant, client, or legally authorized representative have the responsibility to:(1) provide accurate medical information to providers and notify providers of program eligibility prior to delivery of services;(2) provide the program with accurate information regarding any change of circumstance which might affect eligibility and benefits within 30 days following such change; and(3) notify the program of any lawsuit(s) contemplated or filed concerning the cause of the medical condition for which the program has made payment.(d) Provider Responsibilities. The provider has the responsibility to:(1) enroll as a program provider and submit a completed application to the program, including all documents requested;(2) abide by the program rules and regulations;(3) not discriminate against applicants or clients based on source of payment; and(4) notify the program of any lawsuit(s) contemplated or filed concerning the cause of the medical condition for which the program has made payment. Source Note: The provisions of this §354.13 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.13 Rights and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208077 03/12/2026 (a) Any applicant or client shall be notified in writing of the action, the reason(s) for the action, and the right of appeal in accordance with §37.119 of this title (relating to Right of Appeal), if the program proposes to modify, suspend, deny, or terminate program eligibility or benefits for reasons, which include but are not limited to the following:(1) the application or other requested information is erroneous or falsified;(2) financial eligibility requirements are not met;(3) failure to establish or maintain Texas residency;(4) financial or residency documentation is not provided as required or requested;(5) failure to provide information when requested;(6) the client is or becomes incarcerated in a city, county, state, or federal jail, or prison;(7) the client is or becomes a ward of the state;(8) failure to receive allowable products through a program provider;(9) failure to reimburse the department, as requested, for overpayments made to the client; or(10) failure to continue insurance premium payments on individual or group insurance or prepaid medical plans, where such plans provide benefits for the care and treatment of persons who have hemophilia and eligibility for benefits under the plan(s) was effective prior to eligibility for the program, and failure to provide a statement on the application form outlining the reason(s) why such insurance cannot be maintained.(b) Any provider shall be notified in writing of the action, if the program modifies, suspends, denies, or terminates a client's benefits or provider's enrollment. The written notification shall include the reason(s) for the action. The reasons for modifying, suspending, denying, or terminating a provider's enrollment include, but are not limited to:(1) failure to maintain required current licensures or certifications in the state;(2) failure to maintain status as a Texas Medicaid Program provider;(3) failure to have a current program provider agreement on file;(4) failure to submit a completed department Child Support Certification form;(5) failure to notify the program of change of ownership;(6) failure to comply with all the provisions of the program provider agreement and the Provider Manual; or(7) the reduction or curtailment in funds available for the program. Source Note: The provisions of this §354.15 adopted to be effective April 16, 2015, 40 TexReg 2090; amended to be effective March 1, 2017, 42 TexReg 764; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.15 Modifications, Suspensions, Denials and Terminations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208078 03/12/2026 (a) Administrative Review.(1) When the program modifies, suspends, denies, or terminates eligibility or benefits, the program shall give written notice of and the reason(s) for the action. Applicants, clients, providers, or legally authorized representatives, have the right to request an administrative review of the action within 30 days of the notice date.(2) If the program denies a prior authorization request for program services, the program will give the client, provider, or a legally authorized representative, written notice of the denial and the right of the client, provider, or legally authorized representative, to request an administrative review of the denial within 30 days of the notice date.(3) If the program receives a written request for administrative review within 30 days of the notice date, the program will conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program will send the applicant, client, provider, or legally authorized representative, written notice of:(A) the program decision, including the supporting reason(s) for the decision; or(B) the need for extended time to research the circumstance(s), including an expected date for response to the request.(4) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, provider, or legally authorized representative, is presumed to have waived the administrative review as well as access to a fair hearing, and the program's action is final.(5) A client, provider, or legally authorized representative, may not request administrative review of the program's denial of a prior authorization request for program services or reduced provider reimbursement amounts that are authorized by §37.114(f) of this title (relating to Benefits and Limitations).(6) A client, provider, or legally authorized representative, may not request an administrative review of prior authorization decisions and reimbursement amounts for claims that are paid in accordance with the reimbursement rate as defined in §37.112(33) of this title (relating to Definitions).(b) Fair Hearing.(1) If the applicant, client, provider, or a legally authorized representative is dissatisfied with the program's decision and supporting reason(s) following the administrative review, the applicant, client, provider, or a legally authorized representative may request a fair hearing in writing addressed to the Hemophilia Assistance Program, Purchased Health Services Unit, Mail Code 1938, Department of State Health Services, P.O. Box 149347, Austin, Texas 78714-9347, within 20 days of receipt of the administrative review decision notice.(2) A fair hearing requested by an applicant, client, provider, or a legally authorized representative will be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).(3) If the applicant, client, provider, or a legally authorized representative fails to request a fair hearing within the 20-day period, the applicant, client, provider, or a legally authorized representative is presumed to have waived the request for a fair hearing, and the program may take final action. Source Note: The provisions of this §354.17 adopted to be effective April 16, 2015, 40 TexReg 2090; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 354 HEMOPHILIA ASSISTANCE PROGRAM §354.17 Right of Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208085 03/12/2026 (a) Purpose. The purpose of this chapter is to establish rules for the Epilepsy Program. The jurisdiction for these rules is granted in the Texas Health and Safety Code, Chapter 40.(b) Definitions. The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise.(1) Action--A denial, termination, suspension or reduction of the Epilepsy Program benefits or eligibility.(2) Applicant--An individual whose application for Epilepsy Program benefits has been submitted to a contracted provider and has not received a final determination of eligibility. This definition includes an individual whose application is submitted by a representative or person with legal authority to act for the individual.(3) Contracted Provider--Any individual or entity with department approval to furnish covered services to Epilepsy Program recipients.(4) Department--The Department of State Health Services.(5) Epilepsy--A chronic neurological condition characterized by abnormal electrical discharges in the brain manifested by two or more seizures. It is characterized by sudden, brief attacks of altered consciousness, motor activity, or sensory phenomena. Convulsive seizures are the most common form of attacks, but any recurrent seizure pattern is considered epilepsy.(6) Recipient--An individual who is eligible to receive Epilepsy Program benefits.(7) Request for Proposal (RFP)--A document intended to solicit proposals from interested parties that details qualifications and plans for provision of a specific service or range of services. Services may be targeted to a selected geographic area and/or special population group, or statewide coverage. Source Note: The provisions of this §355.1 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.1 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208086 03/12/2026 (a) A person shall meet all of the following requirements to be eligible for Epilepsy Program benefits:(1) have a diagnosis of epilepsy certified by a licensed physician, or be suspected of having epilepsy;(2) if younger than 21 years of age, be determined not eligible for benefits from the Children With Special Health Care Needs Program (CSHCN) or be currently on the CSHCN waiting list for services;(3) be a resident of Texas as determined in §37.213 of this title (relating to Residency and Residency Documentation Requirements); and not be:(A) incarcerated in city, county, state, or federal jail, or prison;(B) a ward of the state; or(C) a Medicaid-eligible nursing home recipient.(4) submit an application for benefits through a contracted provider; and(5) meet, or the person(s) who has a legal obligation to support the applicant meet, the financial guidelines as outlined in §37.215 of this title (relating to Financial Criteria);(b) If an applicant meets all eligibility requirements as outlined in subsection (a) of this section except for the financial guidelines outlined in subsection (a)(5) of this section, the applicant is eligible only for support services as outlined in §37.216 of this title (relating to Limitations and Benefits Provided).(c) A recipient may have all Epilepsy Program benefits modified, suspended, or terminated for any of the following reasons:(1) failure to maintain Texas residency or, upon demand, furnish evidence of such using the criteria in §37.213 of this title (relating to Residency and Residency Documentation Requirements);(2) failure to provide income verification as requested by the contracted provider to determine continued Epilepsy Program eligibility;(3) recipient is incarcerated in a city, county, state, or federal jail, or prison;(4) recipient becomes a ward of the state;(5) the contracted provider determines that the recipient has made a material mis-statement or misrepresentation on their application or any document required to support their application;(6) failure to continue premium payments on individual or group insurance, prepaid medical plan, and health insurance plans under the Social Security Act, Title XVIII, as amended, where such plans provide benefits for the care and treatment of persons who have epilepsy and the person's eligibility for benefits under the plans(s) was effective prior to eligibility for the Epilepsy Program, or provide a statement on the application form outlining the reason(s) why such insurance cannot be maintained; or(7) failure to receive services through a contracted provider.(d) In order to requalify for Epilepsy Program benefits, an applicant shall reapply and requalify for Epilepsy Program benefits when eligibility for program benefits is terminated. Source Note: The provisions of this §355.3 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.3 Recipient Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208087 03/12/2026 (a) An applicant for the Epilepsy Program shall meet, and a recipient shall continue to satisfy, the following residency requirements:(1) the individual shall be physically present within the geographic boundaries of the state;(2) the individual intends to remain within the state, whether permanently or for an indefinite period; and(3) the individual does not claim residency in any other state or country.(b) If the applicant is a minor child; or a legal dependent of, and residing with, a resident (such as an adult child or spouse); or a person under a legal guardianship, then the parent or parent(s), resident providing support, or legal guardian of the applicant shall meet all of the requirements of subsection (a) of this section.(c) If the applicant is a parent residing with his/her adult child who is a resident of Texas, residency may be determined through the adult child. If the applicant is a parent being supported by his/her adult child, whether or not the applicant is a resident of Texas, the residency may be determined by the adult child providing the required documents supporting the Texas residency of the parent. These provisions apply even if the legal guardianship has been established. Source Note: The provisions of this §355.5 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.5 Residency and Residency Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208088 03/12/2026 Persons meeting the eligibility requirements set forth in §37.212(a)(1), (2), (3) and (5) of this title (relating to Recipient Requirements) must make an application for benefits through an approved Epilepsy Program contracted provider.(1) Complete application. A complete application is required before any eligibility determination will be made. A complete application shall consist of all of the following:(A) a complete Application for Benefits, with the applicant's, or the applicant's representative's original signature or "mark;"(B) a diagnosis of epilepsy certified by a licensed physician, or a statement that the applicant is suspected of having epilepsy;(C) documentation of Texas residency as required by §37.213 of this title (relating to Residency and Residency Documentation Requirements);(D) applicant financial data. Acceptable data to establish the applicant's financial qualifications shall be submitted with the application.(2) Verification of Income. The contracted provider shall make the final determination of eligibility based on the information submitted with a completed application.(3) Eligibility date for Epilepsy Program benefits. The date on which a person's eligibility will be determined will be the date upon which a completed application is received by the contracted provider. The Epilepsy Program eligibility date will be the later of:(A) the date the contracted provider receives a completed application;(B) the date the applicant is no longer considered a ward of the state;(C) the date the applicant is no longer incarcerated in a city, county, state, or federal jail, or prison; or(D) the date the applicant established Texas residency. Source Note: The provisions of this §355.7 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.7 Application and Eligibility Date https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208089 03/12/2026 Financial need is established annually. The applicant or person who has a legal obligation to support the applicant must pursue and accept all income to which the applicant or person who has a legal obligation to support the applicant are legally entitled. Income is not considered to be available during a reasonable time allowed to pursue the income.(1) The income used to determine eligibility is the combined gross income (or the adjusted gross income if self-employed) of the applicant and of all persons who have a legal obligation to support the applicant.(2) Income includes earned wages, pensions or allotments, alimony, or any monies received on a regular basis for support purposes. Supplemental Security Income (SSI) for the disabled applicant is not included as income. Verification of income will be required as set out in §37.214(3) of this title (relating to Applications and Eligibility Date).(3) The income level for eligibility is established at 200% of the Federal Poverty Level Guidelines, currently published by the United States Department of Health and Human Services and adopted by the department. Source Note: The provisions of this §355.9 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.9 Financial Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208090 03/12/2026 (a) Benefits provided by the Epilepsy Program are outlined in the contract with each provider and may include the following:(1) diagnosis and treatment of epilepsy;(2) management of continuity of care;(3) integration of the personal, social, and vocational support services into the treatment plan; and(4) epilepsy education.(b) The Epilepsy Program benefits are limited to services received in Texas from a contracted provider.(c) Depending on the recipient's eligibility status, services will be provided based upon:(1) available funds;(2) any contract between the department and the recipient's service provider; and(3) any third-party liability.(d) The Epilepsy Program is the payor of last resort. Benefits are payable only after all third parties or government entities (e.g., private/group insurance or the Veterans Administration) have met their liability. Source Note: The provisions of this §355.11 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.11 Limitations and Benefits Provided https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208091 03/12/2026 (a) An Epilepsy Program applicant or recipient is entitled to a notice anytime a contracted Epilepsy Program provider intends to take action under this section.(b) The contracted Epilepsy Program provider shall provide a written notice of intent to take action under this section to the applicant or recipient not less than 20 days prior to the effective date of the action.(c) The notice of intent to take action shall contain the following information:(1) a statement of the action the contracted Epilepsy Program provider intends to take;(2) an explanation of the reasons for the action that the contracted Epilepsy Program provider intends to take; and(3) an explanation of the applicant's or recipient's right to request a fair hearing regarding the action.(d) A recipient or applicant aggrieved by the intent to take action may appeal the decision according to the procedures in §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures). If an aggrieved recipient requests a hearing, the department shall instruct the contracted provider not to terminate services to the recipient until a final decision has been rendered. Source Note: The provisions of this §355.13 adopted to be effective March 17, 2002, 27 TexReg 1791; amended to be effective October 8, 2006, 31 TexReg 8237; amended to be effective November 4, 2010, 35 TexReg 9738; amended to be effective July 2, 2015, 40 TexReg 4215; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 981. 1 HEALTH AND HUMAN SERVICES COMMISSION 355 EPILEPSY PROGRAM §355.13 Notice of Intent to Take Action and Fair Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225050 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise. (1) 24-hour-a-day shelter--A Texas Health and Human Services Commission-funded (HHSC-funded) shelter center facility that provides access, admittance, and temporary emergency residence for victims of family violence and their dependents, 24-hours-a-day, every day of the year.(2) Abuse of funds--Actions and statements that are inconsistent with sound fiscal or business practices, and result in unnecessary program costs, including reimbursement for unnecessary services or services that do not meet standards required by contract, statute, regulation, previously sent interpretations of any of the items listed, or authorized governmental explanations of any of the foregoing.(3) Advocacy--Providing information and assistance to increase survivor safety and access to needed resources or services. Advocacy is trauma-informed and requires understanding a survivor's self-stated experiences and needs.(4) Additional HHSC-funded shelter--Additional Texas Health and Human Services Commission-funded shelter. An additional shelter or shelters operated by a shelter center that meets the criteria in §356.202 and §356.203 of this chapter (relating to Additional HHSC-Funded Shelter Funding and Additional HHSC-Funded Shelter Requirements). (5) Client--A resident, nonresident, or program participant who receives a service from a shelter center, special nonresidential project center, or nonresidential center.(6) Community education--The efforts or activities performed to increase public awareness, including prevention activities, about family violence and the availability of services for victims of family violence. (7) Complaint--An official written statement of concern or grievance. The term is inclusive of the formal process by which current or former clients or employees may exercise their right to petition a family violence center.(8) Cooperative living agreement--An agreement between the shelter and residents that promotes health, safety, and daily shelter operations. (9) Crisis call hotline--A telephone number answered 24-hours-a-day, every day of the year, by trained volunteers, employees, or HHSC-approved service contractors who provide victims of family violence with: (A) immediate intervention through safety planning; (B) understanding and support; (C) information about shelter and nonresidential services; and (D) referrals to other supportive services. (10) Data breach--Any unauthorized use, disclosure, creation, maintenance, disposal, or transmission of personally identifying information in a manner not permitted by federal or state law. (11) Dating violence--An act, other than a defensive measure to protect oneself, by an individual that is against another individual with whom that person has or has had a dating relationship and that is: (A) intended to result in physical harm, bodily injury, assault, or sexual assault; (B) a threat that reasonably places the individual in fear of imminent physical harm, bodily injury, assault, or sexual assault; or (C) intended to inflict emotional harm, including an act of emotional abuse. (12) Executive director--The individual acting as the chief administrative or chief executive officer of a family violence center, regardless of the title of the individual's position.(13) Family violence--An act by a member of a family or household against another member of the family or household that is: (A) intended to result in physical harm, bodily injury, assault, or sexual assault; (B) a threat that reasonably places the member in fear of imminent physical harm, bodily injury, assault, or sexual assault, but does not include defensive measures to protect oneself; (C) intended to inflict emotional harm, including an act of emotional abuse; or (D) dating violence. (14) Fraud--An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the person making the deception or misrepresentation or some other person. The term does not include unintentional technical, clerical, or administrative errors.(15) Human trafficking--Trafficking that includes:(A) the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act is younger than 18 years of age;(B) the recruitment, harboring, transportation, provision, enticing, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery; and(C) the offenses described in Texas Penal Code Chapter 20A.(16) Limited English Proficiency (LEP)--A term describing individuals who do not speak English as their primary language and who have limited ability to read, speak, write, or understand English.(17) Nonresident--An adult or child victim of family violence who receives services from an HHSC-funded shelter center without receiving shelter or is served through a nonresidential center. (18) Nonresidential center--An HHSC-funded program that: (A) is operated by a public or private nonprofit organization; and (B) provides comprehensive nonresidential services to victims of family violence as outlined in §356.2101 of this chapter (relating to Nonresidential Center Services).(19) Personally identifying information--Individually identifying information for or about an individual including information likely to disclose the location of a victim of family violence, dating violence, sexual assault, or stalking, regardless of whether the information is encoded, encrypted, hashed, or otherwise protected, including a first and last name; a home or other physical address; contact information (including a postal, email, or Internet protocol address, or telephone or facsimile number); a social security number, driver license number, passport number, or student identification number; and any other information, including date of birth, racial or ethnic background, or religious affiliation, that would serve to identify an individual.(20) Primary prevention--Strategies, policies, and programs to stop both first-time perpetration and first-time victimization. Primary prevention is stopping family and dating violence before the violence occurs. Primary prevention includes:(A) school-based violence prevention curricula;(B) programs aimed at mitigating the effects on children of witnessing family or dating violence;(C) community campaigns designed to alter norms and values conducive to family or dating violence; (D) worksite prevention programs; and(E) training and education in parenting skills and self-esteem enhancement.(21) Program participant--An adult or child victim of family violence who receives services from an HHSC-funded nonresidential center or special nonresidential project.(22) Resident--An adult or child victim of family violence or dating violence who is admitted to a shelter center. (23) Secondary prevention--As defined by 45 Code of Federal Regulations (C.F.R.) §1370.2, identifying risk factors or problems that may lead to future family, domestic, or dating violence, and taking the necessary actions to eliminate the risk factors and the potential problem.(24) Shelter center--An HHSC-funded program that: (A) is operated by a public or private nonprofit organization; and (B) provides comprehensive residential and nonresidential services to victims of family violence as described in §356.701 of this chapter (relating to Shelter Center Services).(25) Special nonresidential project center--An HHSC-funded project that: (A) is operated by a public or private nonprofit organization; and(B) provides at least one specialized family violence service as described in §356.1401 of this chapter (relating to Special Nonresidential Project Services). (26) Standards--The minimum HHSC requirements as stated in this chapter.(27) Victim of family violence--Includes: (A) an adult member of a family or household who is subjected to an act of family violence; (B) a member of the household of the adult described in subparagraph (A) of this paragraph, other than the member of the household who commits the act of family violence, including an act of emotional abuse;(C) a member of the family or household who may have been subjected to sexual abuse; and (D) an individual who is subjected to an act of dating violence.(28) Waste--Practices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items, or services.(29) Written--When referring to any documentation, agreements, signage, materials, and other information or resources provided in writing to residents, nonresidents, or program participants, the term "written" encompasses information in digital format and any necessary accommodations for residents, nonresidents, or program participants with LEP, low literacy, visual impairment, and intellectual and developmental disabilities to ensure that the person is informed of all materials and relevant documents typically produced in writing. Accommodations may include:(A) verbal explanations;(B) pictograms;(C) translation;(D) interpretation; and(E) large-print materials. Source Note: The provisions of this §356.1 adopted to be effective December 23, 2007, 32 TexReg 9327; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM A DEFINITIONS §356.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225051 03/12/2026 The board of directors of a shelter center must: (1) ensure that the center operates in a manner that keeps the organization's mission and purpose focused without becoming involved in day-to-day operations; (2) hire the center's executive director, and explain the following:(A) the role of the board in supervising and evaluating the executive director;(B) the structures in place for evaluation; and(C) an overview of the board's and executive director's duties; (3) review regularly, as-a-whole, or as delegated to the center's finance committee, actual revenue and expenditures and compare them to budgeted revenue and estimated costs; (4) review and approve programs and budgets in accordance with the bylaws; (5) maintain and comply with current organizational bylaws; (6) review and approve policies for the organization's operation in accordance with the bylaws;(7) ensure that all board members are knowledgeable of all grant expectations as the grant expectations pertain to board members and their responsibilities under the Texas Health and Human Services Commission Family Violence Program shelter grant; (8) review and comply with the center's complaint policy and address any complaints escalated to the board; and(9) as a whole, or as delegated to board committee, review and approve program policy changes. Source Note: The provisions of this §356.101 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.101 Oversight and Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225052 03/12/2026 (a) The board members must be given a handbook within 60 days of starting their first term that contains the following: (1) the board member's job description; (2) a current list of board members with current contact information; (3) the organization's mission statement; (4) the organization's bylaws and a copy of the letter granting 501(c)(3) status; (5) a list of all committees, including appointed board members and assigned staff; (6) committee descriptions; (7) the organization's policies, including fiscal, administrative, and programmatic; (8) the organizational chart; (9) the history of the organization; (10) a list of program services and a brief description of each program; (11) the current budget, including funding sources and subcontractors; (12) a brief description of contract provisions with attorneys, auditors, or other professionals; (13) an explanation of the organization's insurance coverage, including directors' and officers' liability insurance or notification of inability to obtain insurance;(14) basic information about family violence;(15) a brief history of the Texas Family Violence Movement; (16) an explanation of the organization's efforts to support underserved populations; and(17) information on the intersection of family violence and barriers to services for underserved populations as well as a description of the organization's client and community demographics. (b) The handbook may be made available in an electronic format. Source Note: The provisions of this §356.102 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.102 Shelter Center's Board Handbook https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225053 03/12/2026 (a) Every year, each board member must receive the following: (1) an explanation of the center's mission, philosophy, and a brief history; (2) a discussion of the dynamics of family violence that includes power and control and trauma-informed services;(3) a description of the organization's current programs;(4) a review of the organization's policies to determine if any modifications need to be made and clarification of any policy changes made during the previous year;(5) training that includes information on the intersection of family violence and barriers to services for underserved populations as well as a description of the organization's client and community demographics;(6) an explanation of how the center is funded and future funding projections; (7) a discussion, presented by the appropriate board member, employee, or designated person, of the following: (A) a review of the duties of a nonprofit board of directors as outlined in the Texas Business Organizations Code §22.221, Texas Nonprofit Corporation Act;(B) the board's role and responsibilities related to legal and fiscal accountability; and(C) the current bylaws, including a discussion on:(i) meetings and attendance requirements; (ii) committee duties, structure, and assignments; (iii) fundraising and public relations responsibilities; and(iv) the conflict of interest policy.(8) an explanation of the working relationship between the board and staff, including which staff member to contact regarding questions or requests and which staff members contact board members routinely; and(9) the organization's confidentiality policy and the importance of confidentiality, which must include the training required by §356.616 of this chapter (regarding Confidentiality and Victim-Advocate Privilege Training). (b) New board members must receive this training within 60 days of starting their first term. Source Note: The provisions of this §356.103 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.103 Board of Directors Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225054 03/12/2026 Each board member must: (1) provide written assurance that the member is knowledgeable of and will comply with the confidentiality requirements of this chapter and the center's policies; (2) provide written assurance to the center that the board member will not use the position to obtain or access confidential resident or nonresident information when not authorized; and (3) provide written assurance to the center that the member is knowledgeable of, and will comply with, the victim-advocate privilege under Texas Family Code Chapter 93 and will not use the member's position to obtain or access privileged resident or nonresident information when not authorized. Source Note: The provisions of this §356.104 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.104 Confidentiality and Victim-Advocate Privilege https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225055 03/12/2026 A center may apply for a special nonresidential project contract; however, the proposed services may not be the same as those required under this subchapter. Source Note: The provisions of this §356.201 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.201 Special Nonresidential Project Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225056 03/12/2026 In order to qualify for additional shelter funding, a shelter center must: (1) be a current Texas Health and Human Services Commission (HHSC) shelter center grantee in good standing; (2) develop, maintain, and comply with written policies and procedures that describe the relationship between the shelter center and the additional shelter; and (3) ensure the additional shelter meets all additional shelter requirements in §356.203 of this division (relating to Additional HHSC-Funded Shelter Requirements). Source Note: The provisions of this §356.202 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.202 Additional HHSC-Funded Shelter Funding https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225057 03/12/2026 A center with more than one Texas Health and Human Services Commission (HHSC)-funded shelter must ensure that additional shelters: (1) have a freestanding shelter building in which residents are sheltered; (2) provide nonresidential services in the additional shelter service area; (3) provide services to an unserved or underserved population or geographic location as consistent with the current Texas Family Violence Services Plan;(4) provide the same services as a 24-hour-a-day shelter; (5) have local community representation on the center's board of directors; (6) have financial support; (7) have been operational for at least one year preceding the fiscal year for which funding is requested; (8) have housed residents in the past year; and(9) have at least one employee or volunteer:(A) on-site continuously when a resident is staying in the shelter; or (B) on-site or on-call 24-hours-a day, every day of the year, when no residents are staying in the shelter. Source Note: The provisions of this §356.203 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.203 Additional HHSC-Funded Shelter Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225058 03/12/2026 A center must develop, maintain, and comply with a written internal monitoring system to evaluate: (1) the quality of the center's required resident and nonresident services; (2) the accuracy of the fiscal and programmatic documentation; and (3) compliance with the policies and procedures specified in the center's contract with the Texas Health and Human Services Commission. Source Note: The provisions of this §356.204 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.204 Internal Monitoring System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225059 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may waive the maximum prescribed funding percentage, as described in Texas Human Resources Code §51.003(a), when one of the following occurs. (1) The center's income for the contract year decreased relative to the actual income received during the previous contract year. Decreases in funding caused by a center's noncompliance, negligence, or deficiencies will not be considered when making this calculation. (2) The center's HHSC award for center services increases. (b) If a center receives three or more funding waivers in a five-year period, the center may be subject to corrective action. Source Note: The provisions of this §356.205 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.205 Funding Waivers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225060 03/12/2026 To request a waiver from the maximum prescribed funding percentage, a center's board must submit: (1) a completed Family Violence Program Waiver Request Form prescribed by the Texas Health and Human Services Commission; (2) supporting documentation of the need for the waiver; and(3) a statement describing the center's efforts to raise funds compared to its budget. Source Note: The provisions of this §356.206 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.206 Requesting a Funding Waiver https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225061 03/12/2026 If a center's purpose is to provide services to a particular population, the center must have a plan for providing services to otherwise eligible victims who are not members of the targeted population. This plan may include referrals. Source Note: The provisions of this §356.208 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.208 Primary Services to an Unserved or Underserved Population https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225062 03/12/2026 A center must maintain an accounting system and records that:(1) follow Generally Accepted Accounting Principles (GAAP); (2) records revenue and expenditures; (3) establishes a chart of accounts that lists all accounts by an assigned number; (4) contains a general ledger and subsidiary ledgers; (5) maintains accounting documentation for all revenue and expenditures, including: (A) receipts or vouchers for revenue; (B) bank statements reconciled to the general ledger bank accounts; (C) journal entry justification;(D) canceled checks; (E) deposit slips; (F) approved invoices; (G) receipts; (H) leases; (I) contracts; (J) time and activity sheets; (K) inventory; and (L) cost allocation and indirect cost worksheets; (6) identifies all funding sources and expenditures by separate fund type; and (7) uses a double-entry accounting system, either cash, accrual, or modified accrual. Source Note: The provisions of this §356.301 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.301 Accounting System Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225063 03/12/2026 A center must develop, maintain, and comply with written internal policies and procedures to accurately document the non-Texas Health and Human Services Commission (HHSC) cash or non-cash resources required by HHSC under Texas Human Resources Code §51.003. Source Note: The provisions of this §356.302 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.302 Cash or Non-Cash Resources Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225064 03/12/2026 (a) A center must immediately report to the Texas Health and Human Services Commission (HHSC) Family Violence Program and HHSC Office of Inspector General any suspected or confirmed fraud, waste, or abuse of funds paid from the HHSC contract related to family violence service delivery, whether or not such suspected or confirmed fraud, waste, or abuse was committed by the center's employees or the center's subcontractors.(b) In addition to reporting to HHSC, the center must also report the fraud, waste, or abuse to the Office of Attorney General of Texas or the State Auditor's Office. (c) The center must fully cooperate with HHSC, the Office of Attorney General of Texas, the State Auditor's Office, or any other state or federal regulatory agency involved in the investigation of the allegation of fraud, waste, or abuse.(d) A center must not unlawfully disclose any personally identifying information of a victim in the course of reporting fraud, waste, or abuse.(e) The center must comply with 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Family Code Chapter 93 during the investigation. Source Note: The provisions of this §356.303 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.303 Fraud, Waste, and Abuse https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225065 03/12/2026 A center must develop, maintain, and comply with written personnel policies, approved by the board of directors, and procedures for its personnel handbook that standardize the everyday actions and conduct of all employees. All employees must have ongoing access to the personnel handbook. Employees must be notified of new or changed personnel policies in accordance with the center policies and in a timely manner. The handbook must address the following: (1) contract labor; (2) conflicts of interest; (3) family violence in the workplace to include support for any staff experiencing family violence and violence occurring at the workplace; (4) nepotism;(5) the center's non-discrimination policy; (6) a hiring process that is uniform for all candidates for a particular position and includes: (A) job posting; (B) job descriptions with essential job functions; (C) interviewing procedures; and (D) reference checking and responding to reference checking; (7) rules of conduct; (8) hours and days of operation; (9) employee benefits, including the accrual and use of paid time off; (10) employees' right to access their personnel files; (11) written and oral employee orientation, initial training, and employee development; (12) confidentiality requirements of employee records; (13) employee evaluation; (14) involuntary and voluntary termination; and (15) a complaint process for current and former employees, including the center's process for responding to a complaint. Source Note: The provisions of this §356.401 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.401 Personnel Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225066 03/12/2026 A center must maintain a personnel file for each employee. Each file must include at least the following information: (1) employment application or resume; (2) current job descriptions; (3) signed acknowledgment of confidentiality and victim-advocate privilege agreement to be updated annually; (4) signed acknowledgment of receipt of the current personnel handbook as described in §356.401 of this division (relating to Personnel Policies); (5) performance evaluations for every year of employment in accordance with the center's personnel policies; (6) documentation of orientation, initial training, and employee development; (7) any status or classification change; (8) all disciplinary actions and related documents, if any; and (9) letters of praise or criticism, if any. Source Note: The provisions of this §356.402 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.402 Personnel Files https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225067 03/12/2026 If under the jurisdiction of the Drug-Free Workplace Act, a center must develop, maintain, and comply with a written drug and alcohol policy that includes the following: (1) prohibition of use or possession of alcohol, illegal drugs, or drugs for which the employee does not have a prescription, if a prescription is required to possess the drug, while on duty; (2) a statement of practice rooted in a treatment and recovery approach; (3) a stated concern for employees and the recovery efforts of employees; (4) information on available programs and systems for assistance; and (5) a statement of confidentiality. Source Note: The provisions of this §356.403 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.403 Drug and Alcohol Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219258 03/12/2026 (a) A center must provide an oral orientation about the organization for all new employees within the first two days of employment.(b) Within two weeks after the first day of employment, all new employees must receive basic oral or written information regarding:(1) Dynamics of family violence;(2) A brief history of the Texas Battered Women's Movement;(3) A brief summary of current Texas laws that address family violence issues; and(4) Federal, state, and program requirements regarding confidentiality.(c) Direct service employees and their supervisors must also receive training on the following:(1) Crisis intervention;(2) Hotline skills, if applicable;(3) Peer counseling techniques;(4) Risk assessment and safety planning for victims of family violence;(5) Legal options for victims of family violence;(6) Economic options for victims of family violence;(7) The center's policies and procedures, including all Health and Human Services Commission required policies and procedures;(8) Sensitivity to cultural diversity;(9) Applicable civil rights laws and regulations;(10) All required documentation and procedures related to resident and nonresident issues; and(11) Confidentiality.(d) Training described in subsections (b) and (c) of this section may be provided electronically. Source Note: The provisions of this §356.404 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.404 New Employee Orientation and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225068 03/12/2026 (a) Every year, each employee must receive oral or written information regarding:(1) confidentiality and victim-advocate privilege requirements, including the center's policies for complying with the requirements; (2) federal, state, and program requirements as applicable to an employee's job description, including the requirements outlined in:(A) this subchapter; (B) 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act; and (C) the Texas Health and Human Services Commission contract related to family violence service delivery; and(3) information on the intersection of family violence and barriers to underserved populations, as well as a description of the organization's client and community demographics.(b) Direct service employees and their supervisors must also receive yearly training on the following:(1) best practices in family violence service delivery, including:(A) trauma-informed and survivor-centered advocacy and voluntary services;(B) access to services for underserved populations, including populations with disabilities;(C) the intersection of family violence and mental health;(D) the intersection of family violence and substance use; (E) technology and data safety; and(F) language and interpretation accessibility; and(2) relevant training or staff development on topics related to their job descriptions as family violence center employees. (c) Direct service supervisors must receive training that is relevant to the job descriptions of the people they supervise. (d) Employees with access to personally identifying information must receive yearly training in compliance with §356.616 of this subchapter (relating to Confidentiality and Victim-Advocate Privilege Training).(e) The training described in this section may be provided virtually or in person. Source Note: The provisions of this §356.405 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.405 Ongoing Employee Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225069 03/12/2026 A center facility must have: (1) a kitchen and eating area; (2) a group living area; (3) bathroom facilities, including toilets, lavatories, and bathing facilities; (4) sleeping facilities; (5) a private meeting area for individual and group services; (6) adequate safe space for children; (7) a developmentally appropriate, safe indoor play space equipped with toys in good repair and arts and craft supplies; (8) a developmentally appropriate, safe outdoor play area equipped with toys in good repair; (9) basic furnishings that are clean and in good repair, including: (A) beds and bed linens; (B) cribs; (C) dining room tables; (D) chairs; (E) highchairs; and (F) a place to store clothes, such as drawers or closets; (10) clearly marked exits;(11) smoke detectors, fire extinguishers, current fire inspections, and fire evacuation plans; (12) secure, clearly marked locations to store cleansers, solvents, and other hazardous items out of reach of children; and (13) a stocked first-aid kit in all center facilities in central locations and communal spaces, as specified by center policy, that is accessible to all employees, volunteers, and residents. Source Note: The provisions of this §356.501 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.501 Facility Requirements for the 24-Hour-a-Day Shelter Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219264 03/12/2026 A center must:(1) ensure food preparation, including storage of food, serving of food, and dining areas, is adequate and safe;(2) develop, maintain, and comply with written policies and procedures to ensure residents are provided with at least three well-balanced meals or ingredients for well-balanced meals and an additional two snacks a day for children;(3) develop, maintain, and comply with written policies and procedures that provide for alternative access to food and food preparation when the center's kitchen is closed;(4) develop, maintain, and comply with written policies and procedures that provide for alternative access to essential food and food preparation when the center's kitchen is inoperable;(5) make reasonable, Americans with Disabilities Act-compliant dietary accommodations for residents who require special medical diets, including those with food allergies;(6) not require residents to use Supplemental Nutrition Assistance Program (SNAP) food benefits (formerly known as food stamps) to purchase shelter meals;(7) when providing meals or food items, consider the diverse needs of the population of the center's service area; and(8) make reasonable accommodations for the center and residents regarding personal food items. Source Note: The provisions of this §356.502 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2010, 35 TexReg 7727; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.502 Preparing, Providing, and Serving Food to Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225070 03/12/2026 All Texas Health and Human Services Commission-funded shelter centers must have security systems that are operational 24-hours-a-day. The security system must include an alarm system, outside special lighting, and secure locks. Source Note: The provisions of this §356.503 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.503 Security System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225071 03/12/2026 (a) All Texas Health and Human Services Commission (HHSC)-funded shelter centers must develop, maintain, and comply with written policies and procedures to promote the safety and security of residents, nonresidents, employees, and volunteers. These policies and procedures must address: (1) intruders on the property, including an abuser; (2) threats of violence or assaults; (3) bomb threats; (4) threatening telephone calls; (5) power outages; (6) evacuations; (7) natural disasters (e.g., hurricanes, tornadoes, floods, and fires);(8) epidemics, pandemics, and other public health emergencies; and(9) technology safety and data security. (b) A center must notify HHSC immediately of any safety or security breaches listed in subsection (a) of this section that may disrupt services for 24 hours or longer, in accordance with §356.626 of this subchapter (relating to Disruption in Providing Services). A center must include in the notice to HHSC an overview of the incident with the dates of impact, next steps, and a point of contact.(c) The authorized person or persons responsible for the operation of a center may choose to make the location of emergency shelters public. If the address or location of any shelter center remains confidential, the location shall not be made public, except with written authorization of the individual or individuals responsible for the shelter operation.(d) A center that chooses to remain confidential pursuant to subsection (c) of this section must develop and maintain systems and protocols to remain confidential. Source Note: The provisions of this §356.504 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.504 Security Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225072 03/12/2026 All Texas Health and Human Services Commission-funded centers must have at least one employee or volunteer:(1) on-site continuously when a resident is staying in the shelter; or (2) on-site or on-call 24-hours-a day, every day of the year, when no residents are staying in the shelter. Source Note: The provisions of this §356.505 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.505 Shelter Center Staffing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225073 03/12/2026 A center must provide all residents with direct access to personal hygiene items without having to request the items from staff. When providing personal hygiene items, a center must consider the diverse needs of the population of the shelter service area. Source Note: The provisions of this §356.506 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.506 Providing Hygiene Items to Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225074 03/12/2026 A 24-hour-a-day shelter may be located in the following types of facilities: (1) a facility that exclusively serves victims of family violence; (2) a series of safe homes; or (3) a designated section of another kind of emergency shelter. Source Note: The provisions of this §356.507 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.507 Types of Facilities Allowed by the Texas Health and Human Services Commission for a 24-hour-a-Day Shelter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219271 03/12/2026 If the center uses a series of safe homes for shelter, it must:(1) have a written policy that addresses in-depth screening of each home, including the suitability of the house and host family or individual; and(2) meet the same standards as a regular 24-hour-a-day shelter except:(A) it is not required to have 24-hour employee or volunteer coverage; and(B) any material the Health and Human Services Commission requires to be posted can instead be placed in a notebook that is clearly labeled and visibly available for residents to read. Source Note: The provisions of this §356.509 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.509 Additional Requirements if a Shelter Center Uses a Series of Safe Homes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225075 03/12/2026 (a) A hotel or motel may not be used exclusively as a shelter center for a 24-hour-a-day shelter but may be used for overflow or used in outlying counties. (b) A trained staff member or volunteer must make themselves available to clients residing in hotels or motels, either in-person or remotely, at least once every 24-hour period to ensure that services are offered and that meals or adequate food and supplies to prepare meals are provided. (c) Clients residing in hotels or motels must have access to all services that shelter residents receive in the center. (d) When clients residing in hotels or motels prefer to have an in-person visit, the center must send a trained staff member or volunteer within a reasonable timeframe, as outlined in center policies. Source Note: The provisions of this §356.510 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.510 Using a Hotel or Motel as a Type of Shelter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225076 03/12/2026 At a minimum, a center must provide equal access to the services for victims of family violence outlined in 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Human Resources Code Chapter 51. Source Note: The provisions of this §356.601 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.601 Required Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225077 03/12/2026 A center may not charge or solicit contributions or donations in return for Texas Health and Human Services Commission-contracted services. Source Note: The provisions of this §356.602 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.602 Charging for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227366 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227366 03/12/2026 (a) The following individuals are eligible for services under this chapter:(1) victims of family violence or dating violence; or(2) victims of sexual assault or human trafficking when the sexual assault or human trafficking meets the definition of family violence or dating violence.(b) All victims described in this section are eligible for services regardless of the victim's current geographic location. (c) A center must not require a victim to participate in center activities as a condition of receiving shelter or services. Source Note: The provisions of this §356.603 adopted to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.603 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225079 03/12/2026 When determining eligibility for services, a center must comply with the following applicable state and federal laws and any amendments made to each of these laws. Policies and procedures must be written to ensure compliance with: (1) 42 United States Code (U.S.C.) §2000d, et seq., Title VI of the Civil Rights Act of 1964; (2) 29 U.S.C. §701, et seq., Section 504 of the Rehabilitation Act of 1973; (3) 42 U.S.C. §12101, et seq., Americans with Disabilities Act of 1990; (4) 42 U.S.C. §§6101- 6107, Age Discrimination Act of 1975; (5) 42 U.S.C. Chapter 110, the Family Violence Prevention and Services Act;(6) Texas Human Resources Code Chapter 51;(7) Texas Health and Safety Code §85.113, relating to Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection; and (8) Texas Health and Human Services Commission regulations regarding civil rights. Source Note: The provisions of this §356.604 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.604 Federal and State Laws Regarding Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219276 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219276 03/12/2026 A center must develop, maintain, and comply with written resident and nonresident eligibility and screening procedures that are based solely on the individual's status as a victim of family violence, without regard to:(1) income;(2) whether the individual contributes, donates, or pays for these services;(3) gender; or(4) sexual orientation. Source Note: The provisions of this §356.605 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.605 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225080 03/12/2026 A center may not deny services to an otherwise eligible victim as described in §356.603 of this division (relating to Eligibility) unless the center adopts written policies in accordance with this section that outline specific behaviors that would make a victim ineligible for such services. Under this section, these policies must: (1) address only behaviors that threaten the safety and security of shelter staff and residents; (2) apply equally to all people; (3) comply with the laws and regulations described in §356.604 of this division (relating to Federal and State Laws Regarding Eligibility); and (4) contain procedures that take into consideration the safety of a victim and requires appropriate referrals to other service providers. Source Note: The provisions of this §356.606 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.606 Denial of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225081 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225081 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures to assess the safety of providing services to a resident or nonresident whose services were previously involuntarily terminated and who is currently requesting services. (b) A center must assess each request for service from a person who was previously involuntarily terminated. (c) A center may not deny services to a victim who was previously involuntarily terminated based solely on the victim's previous involuntary termination. Source Note: The provisions of this §356.607 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.607 Eligibility of Previously Involuntarily Terminated Residents or Nonresidents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219279 03/12/2026 A center must:(1) serve people with limited English proficiency and take reasonable steps to ensure meaningful access to the program; and(2) develop, maintain, and comply with written policies and procedures for the access and delivery of services to people with limited English proficiency. Source Note: The provisions of this §356.608 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.608 Access to Services for People with Limited English Proficiency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225082 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225082 03/12/2026 A center must develop, maintain, and comply with procedures for helping a victim obtain other temporary shelter if the center's primary method of providing shelter is full. The procedure must include providing the victim with: (1) safety planning; (2) referrals to community resources; and(3) the explanation of nonresidential services and referral to connect with a nonresidential advocate if the victim chooses. Source Note: The provisions of this §356.609 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.609 Shelter at Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225083 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225083 03/12/2026 (a) For purposes of this section, the following words and terms have the following meanings: (1) "Emergency shelter or care" means shelter or care provided by a shelter center under Texas Family Code §32.201 and §32.202.(2) "Minor" means a person under 18 years of age who: (A) is not and has not been married; or(B) has not had the disabilities of minority removed for general purposes.(b) A shelter center may provide emergency shelter or care to a minor and the minor's child or children, if any, only during an emergency constituting an immediate danger to the physical health and safety of the minor or the minor's children. (c) Except as provided in subsection (d) of this section, a shelter center may not provide emergency shelter or care to a minor or the minor's children after the 15th day following the date on which the center began to provide the shelter or care. (d) With or without the consent of the minor's parent, managing conservator, or guardian, the shelter center may continue to offer emergency shelter or care to a minor and the minor's children, if any, after the 15th day if the minor: (1) is unmarried and is pregnant or is the parent of a child; (2) has qualified for financial assistance under Texas Human Resources Code, Chapter 31, and is on the waiting list for housing assistance; or (3) is 16 years of age or older; and (A) resides separate and apart from the minor's parent, managing conservator, or guardian, regardless of whether the parent, managing conservator, or guardian consents to the residence and regardless of the duration of the residence; and (B) manages the minor's own financial affairs, regardless of the source of income. (e) A shelter center may rely on the minor's written statement containing the grounds on which the minor has the capacity to consent to emergency shelter or care. (f) A victim who is under 18 years of age may consent to 24-hour-a-day shelter services provided by a shelter center, at any time and for any duration, if: (1) the victim is married or has been married; or (2) the victim has had the disabilities of minority removed for general purposes. Source Note: The provisions of this §356.610 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective December 16, 2015, 40 TexReg 8886; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.610 Emergency Shelter or Care for a Minor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225084 03/12/2026 (a) For the purposes of this section, "minor" means a person under 18 years of age who:(1) is not and has not been married; or(2) has not had the disabilities of minority removed for general purposes.(b) A shelter center may provide a nonresidential service to a minor if: (1) the center provides emergency shelter or care to the minor under §356.610 of this division (relating to Emergency Shelter or Care for a Minor); (2) the minor consents to counseling from a licensed or certified physician, psychologist, counselor, or social worker, under Texas Family Code §32.004, for: (A) suicide prevention; (B) chemical addiction or dependency; or (C) sexual, physical, or emotional abuse; (3) the center obtains consent from the minor's parent, managing conservator, or guardian to provide the minor with the nonresidential service; or (4) the center otherwise complies with Texas Family Code Chapter 32, even if the center does not obtain consent from the minor's parent, managing conservator, or guardian.(c) Notwithstanding subsection (b) of this section, a victim who is under 18 years of age may consent to a nonresidential service provided by a shelter center if: (1) the victim is married or has been married; or (2) the victim has had the disabilities of minority removed for general purposes. Source Note: The provisions of this §356.611 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective December 16, 2015, 40 TexReg 8886; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.611 Nonresidential Services for a Minor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225085 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures that: (1) outline behaviors that threaten the safety and security of staff, other residents, and nonresidents for which the center may terminate services;(2) do not allow for termination of a resident's or nonresident's services, for any reason other than behaviors that threaten the safety and security of shelter staff, other residents, and nonresidents;(3) allow considerations for residents and nonresidents to have contact with an abuser without grounds for termination; (4) address how current and former residents and nonresidents can appeal terminations and file complaints with the center; (5) apply equally to all people; (6) comply with: (A) the laws and regulations described in §356.604 of this division (relating to Federal and State Laws Regarding Eligibility); and(B) other applicable laws and regulations; and(7) allow a resident or nonresident to voluntarily terminate their services at any time.(b) Before the termination of services to a resident or a nonresident, regardless of whether the resident's or nonresident's termination is voluntary or involuntary, the center must make reasonable efforts to: (1) assist the resident or nonresident in re-evaluating the resident's or nonresident's safety plan; (2) assist in obtaining alternate resources for the resident or nonresident whose services are terminated; (3) provide written notice to the resident or nonresident of the termination; (4) provide written notice to the resident or nonresident of the right to file a complaint with the center and an explanation of the center's complaint procedure; and (5) upon request of the resident or nonresident, provide contact information for the Texas Health and Human Services Commission Family Violence Program for complaint purposes. Source Note: The provisions of this §356.612 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.612 Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225086 03/12/2026 A center must have a written general confidentiality and victim-advocate privilege policy that provides: (1) that the center will keep all information about a resident or nonresident confidential, including all personally identifying information and all communications, observations, and information made by and between or about adult and child residents and nonresidents, employees, contract staff, volunteers, interns, and board members; (2) a statement about the importance of confidentiality and victim-advocate privilege in maintaining the safety of: (A) victims; (B) victims' families; (C) volunteers; (D) employees; and (E) others related to the program; (3) the parameters of what must be held confidential and by whom, including internal communications between staff regarding residents and nonresidents; (4) the limits of confidentiality under the law; (5) the parameters of what must be held privileged, if claimed, and by whom, including internal communications between staff regarding residents and nonresidents;(6) the limits of any victim-advocate privileged information under the law;(7) a designation of custodian of the records, including digital records; and (8) procedures for: (A) retention and destruction of records; (B) responses to court orders; (C) release of information; (D) reports of abuse or suspected abuse of: (i) a child; (ii) a person 65 years of age or older; and (iii) a person with a disability; (E) requests for information under the Texas Public Information Act; (F) maintenance of records; and (G) access to records that comply with confidentiality provisions in state and federal law. Source Note: The provisions of this §356.613 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.613 General Confidentiality and Victim-Advocate Privilege Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225087 03/12/2026 (a) A center must provide to adult residents and nonresidents, verbally and in writing, the following information: (1) that adult residents and nonresidents have the right to access their records and the process by which the adult residents and nonresidents may access their records without incurring a fee; (2) the kind of information recorded, why, and the methods of collection; (3) who within the center has access to the resident's or nonresident's records; (4) an overview of the center's policy and practices on confidentiality; (5) an overview of the center's policy and practices on victim-advocate privilege;(6) current state and federal laws regarding the limits of confidentiality and victim-advocate privilege under the law, including mandatory reporting for abuse or suspected abuse of: (A) a child; (B) a person who is 65 years of age or older; and (C) a person with a disability; (7) an overview of the center's policy for responding to court orders; (8) an overview of the center's policy for requests for information under the Texas Public Information Act; (9) an overview of the center's policy for release of information; (10) when the records will be decoded or destroyed; and (11) an overview of what kind of information will remain in the record after a resident or nonresident terminates services. (b) If a center is unable to provide the information described in subsection (a) of this section in writing, the center must maintain documentation stating the reason why the information could not be provided in writing. Source Note: The provisions of this §356.614 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.614 Confidentiality and Victim-Advocate Privileged Information for Adult Residents and Nonresidents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225088 03/12/2026 (a) A center must require that all employees, contract staff, volunteers, board members, interns, and adult residents and adult nonresidents sign a confidentiality and victim-advocate privilege agreement. The confidentiality and victim-advocate privilege agreement must have a provision that states that confidentiality and victim-advocate privilege must be maintained after an employee, contract staff, volunteer, board member, intern, resident, or nonresident leaves the center. The signed confidentiality and victim-advocate privilege agreements must be placed: (1) in the personnel file of an employee; (2) in the corporate record of a board member; and (3) in the individual file of a contract staff, volunteer, intern, resident, and nonresident. (b) A center must have a written policy to ensure resident and nonresident confidentiality and victim-advocate privilege when there is a visitor on the premises in spaces where residents and nonresidents are present.(c) If a victim is unable to physically sign the confidentiality and victim-advocate privilege agreement required in subsection (a) of this section due to a bona fide emergency:(1) the victim must verbally agree to adhere to the confidentiality and victim-advocate privilege agreement; and(2) the center must:(A) maintain documentation of the verbal agreement; and(B) obtain a signed agreement as soon as feasible from the victim.(d) For the purposes of subsection (c) of this section, a "bona fide emergency" is one in which the victim has limited access to means of communication and may need to terminate communication abruptly in order to avoid detection of the communication by the victim's abuser. Source Note: The provisions of this §356.615 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.615 Confidentiality and Victim-Advocate Privilege Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225089 03/12/2026 A center must provide training annually to employees, board members, contract staff, volunteers, and interns who have access to personally identifying information on: (1) confidentiality policies and procedures; (2) victim-advocate privilege policies and procedures;(3) the importance of confidentiality for victims of family violence; (4) how information is recorded; (5) procedures for responding to court orders and any other requests for confidential or privileged information; (6) state and federal laws regarding confidentiality; and(7) state laws regarding the victim-advocate privilege under Texas Family Code Chapter 93. Source Note: The provisions of this §356.616 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.616 Confidentiality and Victim-Advocate Privilege Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225090 03/12/2026 A center must limit the information kept, both written and electronically, in a resident's or a nonresident's record to information necessary for: (1) statistical and funding purposes; (2) documenting the survivor-stated need for and delivery of services; and (3) protecting the liability of the center and its employees, contract staff, volunteers, interns, and board members. Source Note: The provisions of this §356.617 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.617 Information in Resident or Nonresident Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225091 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding entries into a resident or nonresident record to require that: (1) each entry in a resident or nonresident record be attributed to and dated by the employee or volunteer entering the information; (2) a resident's or nonresident's record does not include the names of other residents or nonresidents; and (3) if the center provides direct services for both a victim and an abuser, the center maintains a separate record on each, one for the victim and one for the abuser.(b) A center must develop, maintain, and comply with written policies and procedures that ensure residents or nonresidents may access and review all information in their record. (c) If a resident or nonresident contests an entry in the resident's or nonresident's record, the center must either: (1) remove the entry from the record; or (2) if the entry is not removed, note in the record that the resident or nonresident contested the entry. (d) A center may create and store entries into a resident or nonresident record electronically, provided that: (1) electronic entries are secure and attributed to an individual, which may include password-protected system access; and (2) records are kept in compliance with applicable state and federal laws, including 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and §356.504 and §356.619 of this subchapter (relating to Security Policies and Procedures and Maintaining Control Over Resident and Nonresident Records. Source Note: The provisions of this §356.618 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.618 Policies and Procedures Regarding Entries in a Resident or Nonresident Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225092 03/12/2026 A center must develop, maintain, and comply with written procedures that: (1) outline the responsibilities of the custodian of the records, designated by the center's executive director, for maintaining control over the residents' and nonresidents' records, including a court's access to the records; (2) require residents' and nonresidents' records to be kept secure and not be removed from the center's premises without the written permission of the custodian of the records; (3) provide for the safekeeping of residents' and nonresidents' records in the event of the center's closure; and (4) allow residents and nonresidents to access their records in the event of the center's closure without assessing a fee. Source Note: The provisions of this §356.619 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.619 Maintaining Control Over Resident and Nonresident Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225093 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225093 03/12/2026 (a) A center may not release resident or nonresident information, orally or in writing, unless the resident or nonresident completes a properly executed release of information form created by the center, for the purpose of consenting to the release of the resident's or nonresident's information. (b) Regardless of whether a center obtains a properly executed release of information form completed by a resident or nonresident, the center must release information in order to comply with the applicable state laws to report abuse or suspected abuse of: (1) a child; (2) a person who is 65 years of age or older; and (3) a person with a disability. (c) An abuser or suspected abuser of a minor or of an individual with a guardian, as well as the abuser or suspected abuser of a survivor parent of the minor or of the individual's guardian, may not consent to the release of the minor's or individual with a guardian's information.(d) For the purposes of this section, "minor" means a person under 18 years of age. Source Note: The provisions of this §356.620 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.620 Release of Resident or Nonresident Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225094 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225094 03/12/2026 The release of a resident's or nonresident's information form must include the following: (1) the name of no more than one person or one organization to which the information is being released; (2) the specific information to be released; (3) the beginning and ending dates the release is effective, not to exceed the resident's stay or the nonresident's active length of services; (4) the date and the signatures of the resident or nonresident and the employee or volunteer releasing the information; and (5) a statement of the resident's or nonresident's right to revoke, in writing, a release of information at any time. Source Note: The provisions of this §356.621 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.621 Release of Resident or Nonresident Information Document https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225095 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225095 03/12/2026 A center must develop, maintain, and comply with written policies and procedures for responding to court orders, subpoenas, search warrants, and writs of attachment. The written procedures must include: (1) what to do when a process server arrives with a court order or other legal document; (2) on whom court orders and other documents may be served, such as the custodian of the records, the executive director, or, in the executive director's absence, the designated staff; (3) which attorney or attorneys should be contacted; (4) the process by which the center will make reasonable attempts to provide notice to victims affected by a potential release of information;(5) who must discuss the court order or other legal documents and legal options with the resident or nonresident or other victim of family violence, and at what point; (6) information about compliance with state and federal confidentiality and victim-advocate privilege provisions;(7) the circumstances under which records may be released; and(8) an affirmative statement that the center will take steps necessary to protect the privacy and safety of the persons affected by the release of information under state and federal laws. Source Note: The provisions of this §356.623 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.623 Procedures Regarding Court Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225096 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225096 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures for any disruption anticipated to last 24-hours or longer that may affect the ability of the center to provide services in-person, by phone, or remotely. (b) Any disruption in the ability to provide services must be reported immediately to the Texas Health and Human Services Commission (HHSC). (c) The report to HHSC required by subsection (b) of this section must include a detailed description of the disruption and how services will be or were maintained. Source Note: The provisions of this §356.626 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.626 Disruption in Providing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225097 03/12/2026 (a) The Texas Health and Human Services Commission does not impose a maximum length of stay for a center resident. (b) If a center has a maximum length of stay, it must have a written policy explaining its necessity and the length of the maximum stay. (c) A center is required to offer a minimum stay of no less than 30 days from the date of entry into the shelter for a resident to use, if the resident chooses to do so.(d) A center's policies under §356.612 of this division (relating to Termination of Services) can be utilized within the 30-day minimum stay, if necessary. Source Note: The provisions of this §356.627 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.627 Length of Stay for Shelter Center Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219299 03/12/2026 A center must:(1) provide written rights to all residents and nonresidents;(2) make reasonable accommodations to provide written rights for residents and nonresidents with limited English proficiency; and(3) post resident and nonresident rights in a visible area within all center facilities. Source Note: The provisions of this §356.628 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.628 Resident and Nonresident Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225098 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding the security of a resident's belongings. (b) A resident must be informed in writing of: (1) how long personal belongings will be stored if the resident leaves a 24-hour-a-day shelter; and (2) what will happen to the resident's items if the resident does not pick the items up by the deadline. Source Note: The provisions of this §356.629 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.629 Resident's Belongings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225099 03/12/2026 (a) A center must have written policies and procedures about community education that: (1) ensure community education is provided to as many diverse groups as possible in each county where services are provided, including underserved communities; (2) focus part of the community education on informing victims of family violence of existing family violence services; and (3) comply with §356.608 and §356.638 of this division (relating to Access to Services for People with Limited English Proficiency and Access to Services for People with a Disability). (b) When providing community education, a center may: (1) use presentations; (2) use online media or virtual forums;(3) distribute written materials; and (4) establish and use media contacts. (c) A center may offer primary and secondary prevention as a component of community education. Source Note: The provisions of this §356.631 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.631 Community Education and Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219305 03/12/2026 A center must provide training for direct service volunteers that includes, but is not limited to:(1) A brief history of the Texas Battered Women's Movement;(2) The need for and benefit of shelter services;(3) The dynamics of family violence;(4) A brief summary of current Texas laws that address family violence issues;(5) Crisis intervention;(6) Hotline skills, if applicable;(7) Peer counseling techniques;(8) Risk assessment and safety planning;(9) The center's policies and procedures;(10) The organization's mission and philosophy;(11) Confidentiality;(12) Legal options for victims of family violence;(13) Economic options for victims of family violence;(14) Sensitivity to cultural diversity;(15) Community resources;(16) The need for community systems to be responsive to the needs of victims of family violence; and(17) Applicable civil rights laws and regulations. Source Note: The provisions of this §356.634 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.634 Content of Training for Direct Service Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225100 03/12/2026 If a center has non-direct service volunteers, the center must provide non-direct service volunteers with: (1) a basic orientation of the duties volunteers perform; (2) the center's policies and procedures regarding confidentiality and victim-advocate privilege; and (3) at a minimum, basic information about the organization's mission, philosophy, and policies. Source Note: The provisions of this §356.635 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.635 Content of Training for Non-Direct Service Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225101 03/12/2026 (a) A center must:(1) serve people with a disability and take reasonable steps to ensure meaningful access to the program;(2) take appropriate steps to ensure that communications with a victim with a disability, a victim's dependents with a disability, and members of the public with a disability are as effective as communications with persons who do not have a disability; and(3) furnish appropriate auxiliary aids and services when necessary to ensure that eligible individuals with a disability, including a victim, a victim's dependents, and members of the public, have equitable access to services. (b) The auxiliary aids and services described in subsection (a)(3) of this section may include qualified interpreters and large print materials. Source Note: The provisions of this §356.636 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.636 Access to Services for People with a Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225102 03/12/2026 A center must:(1) develop, maintain, and comply with a written advocacy service model that is:(A) voluntary;(B) trauma-informed; and(C) respects an individual's needs;(2) develop training requirements for all employees, contract staff, interns, and volunteers that provide direct services to survivors regarding the advocacy service model including the importance of and best practices for voluntary and trauma-informed services; and(3) have written policies and procedures to evaluate the effectiveness of the service model and report the results to the Texas Health and Human Services Commission as requested. Source Note: The provisions of this §356.637 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.637 Service Model https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225103 03/12/2026 (a) A center must provide, at a minimum, access to the following services, directly, by referral, or through formal arrangements with other agencies, and have written procedures regarding these services as described in this subchapter: (1) 24-hour-a-day shelter; (2) a crisis call hotline available 24 hours a day, in compliance with §356.608 and §356.636 of this subchapter (relating to Access to Services for People with Limited English Proficiency and Access to Services for People with a Disability); (3) emergency medical care; (4) crisis and intervention services, including understanding and support, information, education, referrals, and other resource assistance;(5) emergency transportation; (6) advocacy focused on:(A) economic and housing stability;(B) physical, behavioral, and mental health;(C) the needs of children who are victims and the children of victims; and(D) the civil and criminal legal systems, including identifying individual needs, legal rights and legal options, and providing support and accompaniment in pursuing those options;(7) ongoing safety planning services in collaboration with the self-stated priorities and needs of the victim of family violence;(8) community education regarding family violence and family violence prevention efforts;(9) counseling services; and(10) peer support services led by victims of family violence, including activities and other efforts that facilitate connections and the creation of community among victims of family violence.(b) All services must be provided under a voluntary and trauma-informed service model as described in §356.637 of this subchapter (relating to the Service Model). Source Note: The provisions of this §356.701 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.701 Shelter Center Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225104 03/12/2026 (a) A center must regularly report complete and accurate data through the secure file transport protocol designated by the Texas Health and Human Services Commission (HHSC). Data submission is due by the deadline specified in the HHSC contract related to family violence service delivery. HHSC reserves the right to impose sanctions if a center does not submit complete and accurate data by the deadline specified in the contract. (b) If extenuating circumstances exist, a center must contact HHSC via email before the due date of the data submission to request an extension of said due date.(c) A center must contact HHSC via email within two business days of discovering data errors or inconsistencies that will result in the center's inability to report accurate data in a timely manner.(d) When collecting and reporting data, a center must comply with state and federal confidentiality provisions. Data that a center submits must be in the aggregate and not contain personally identifying information.(e) Resident and nonresident data collected by a center for HHSC reporting must be provided voluntarily by a resident or nonresident and the resident or nonresident may refuse to offer any element of data at any time.(f) A center must notify HHSC within 24 hours after discovery of a data breach. Notification must include all information reasonably available to the center about the breach and contact information for the center's point of contact who will communicate with HHSC regarding the breach.(g) A center must provide written notification to HHSC by the third business day after discovery of a data breach of the following:(1) all reasonably available information about the data breach, and the center's investigation, to the extent practicable; (2) the date the data breach occurred;(3) the date of the center's and, if applicable, subcontractor's discovery of the data breach;(4) a brief description of the data breach, including how it occurred and who is responsible (or hypotheses, if not yet determined);(5) a brief description of the center's investigation into the data breach and the status of the investigation;(6) a description of the types and amount of confidential information involved;(7) the steps the center has taken to mitigate any harm or potential harm caused by the data breach, including without limitation the provision of sufficient resources to mitigate;(8) the steps the center has taken, or will take, to prevent or reduce the likelihood of recurrence of a similar data breach;(9) identify and describe any law enforcement that may be involved in the response to the data breach;(10) a reasonable schedule for the center to provide regular updates regarding response to the data breach, and(11) any reasonably available pertinent information, documents, or reports related to the data breach that HHSC requests following the report of the data breach. Source Note: The provisions of this §356.702 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.702 Reporting Data to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225105 03/12/2026 A center must have a written cooperative living agreement that outlines what can be reasonably expected from the staff and residents, including the center's and residents' responsibilities. This agreement must: (1) be posted in an area visible to residents;(2) take into consideration the wellbeing and safety of all residents; and(3) cannot be used as a means to terminate services, unless it also complies with §356.612 of this subchapter (relating to Termination of Services). Source Note: The provisions of this §356.703 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.703 Promoting Cooperative Living in the Shelter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225106 03/12/2026 A center must: (1) ensure that an individual trained in crisis intervention, or who has immediate access to someone who has had training, answers the crisis call hotline 24-hours-a-day, every day of the year;(2) accept collect calls and anonymous incoming calls; (3) list the hotline number across all relevant publications in the center's service area and on the center's website, if applicable; (4) provide a minimum of two hotline telephone lines; (5) ensure that the caller has direct access to a live person who is trained to assess the caller's safety and that a messaging system is not used to answer the hotline; (6) provide caller identification (ID) blocks on the center's numbers for outgoing calls;(7) ensure compliance with all state and federal laws, including the laws and regulations described in §356.604 of this subchapter (relating to Federal and State Laws Regarding Eligibility), when using the hotline to determine eligibility for services; (8) keep all hotline calls and any related documentation confidential; (9) provide meaningful access to persons with disabilities, as required by §356.636 of this subchapter (relating to Access to Services for People with a Disability); (10) ensure the center can provide meaningful access to people with limited English proficiency as required by §356.608 of this subchapter (relating to Access to Services for People with Limited English Proficiency); and (11) if the center uses caller ID or any other technology that establishes a record of calls on the hotline: (A) ensure there will not be a breach of confidentiality to third parties; and (B) comply with the confidentiality requirements as specified in the contract for family violence services with HHSC regarding the records generated by caller ID or other technology. Source Note: The provisions of this §356.704 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.704 Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225107 03/12/2026 (a) A center may transfer its crisis call hotline to another center only if:(1) there is a telephone or staffing disruption that will last for more than twenty-four hours;(2) the transferring center develops, maintains, and complies with written policies and procedures that address how the center receiving the transferred hotline calls meets the Texas Health and Human Services Commission's (HHSC) training requirements for all direct service staff and ensures immediate access to the receiving center's 24-hour-a-day services; and(3) the transferring center obtains HHSC's approval of the arrangement with the center receiving the transferred calls.(b) A center may transfer its crisis call hotline without obtaining HHSC's approval as described in subsection (a) of this section only when the center transfers the hotline to the National Domestic Violence Hotline.(c) A center may not transfer its crisis call hotline to law enforcement. Source Note: The provisions of this §356.705 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.705 Transferring the Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225108 03/12/2026 A center is not required to provide or pay for emergency medical care, but must: (1) maintain a current list of medical care resources that meet the diverse needs of survivors, including preventative care, and that can provide medical services for victims of family violence and their dependents, including, when available: (A) local affordable options; and(B) local physical, behavioral, and mental health resources; (2) develop, maintain, and comply with written policies and procedures about providing or arranging for emergency transportation to and from emergency medical facilities for shelter residents or victims of family violence and their dependents being considered for acceptance as residents; and (3) maintain and provide standard first aid medical supplies that are accessible to residents 24-hours-a-day. Source Note: The provisions of this §356.706 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.706 Medical Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225109 03/12/2026 A center must develop, maintain, and comply with written policies and procedures regarding all prescribed and non-prescribed medications used by residents, including: (1) self-administration of drugs and medications; (2) methods for safekeeping of drugs and medications; (3) staff's role relating to safekeeping of drugs and medications; and (4) a system that ensures adult residents have direct and immediate access to their own and their children's medication. Source Note: The provisions of this §356.707 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.707 Residents' Medications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225110 03/12/2026 (a) A center must ensure that an orientation is provided to a resident verbally and in writing, no later than 72 hours from entry into services. The orientation must be documented and comply with the requirements in this chapter as appropriate, and the Family Violence Prevention and Services Act (42 United States Code (U.S.C.) Chapter 110) regulations. The orientation must include:(1) an explanation of services available; (2) cooperative living agreement; (3) minimum length of stay; (4) the center's termination policy; (5) residents' rights; (6) a nondiscrimination statement, in accordance with the Family Violence Prevention and Services Act (42 U.S.C. Chapter 110); (7) complaint procedures;(8) contact information for the Texas Health and Human Services Commission (HHSC), as specified in the center's contract with HHSC; (9) safety and security procedures, including medication; (10) information about confidentiality and limits of confidentiality, as well as victim-advocate privilege and limits of victim-advocate privilege as required by §356.614 of this subchapter (Relating to Confidentiality and Victim-Advocate Privileged Information for Adult Residents and Nonresidents); (11) waivers of liability; and (12) a wellness check for all family members that addresses each person's immediate needs. (b) If a center is unable to provide the resident orientation in writing, the center must maintain documentation of the reason. Source Note: The provisions of this §356.708 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.708 Resident's Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225111 03/12/2026 (a) A center must ensure that an orientation is provided to a nonresident verbally and in writing during intake. The orientation must be documented and comply with the requirements of this chapter as appropriate, as well as the Family Violence Prevention and Services Act, at 42 United States Code (U.S.C.) Chapter 110, and the Family Violence Prevention and Services Act regulations, at 45 Code of Federal Regulations (C.F.R.) Part 1370. The orientation must include:(1) an explanation of services available; (2) the center's termination policy; (3) nonresidents' rights; (4) a nondiscrimination statement, in accordance with the Family Violence Prevention and Services Act (42 U.S.C. Chapter 110); (5) the center's complaint procedures;(6) contact information for the Texas Health and Human Services Commission (HHSC), as specified in the center's contract with HHSC; (7) safety and security procedures; (8) information about confidentiality and limits of confidentiality, as well as victim-advocate privilege and limits of victim-advocate privilege as required by §356.614 of this subchapter (relating to Confidentiality and Victim-Advocate Privileged Information for Adult Residents and Nonresidents); (9) waivers of liability; and (10) a wellness check for all family members that addresses each person's immediate needs. (b) If a center is unable to provide the person orientation in writing, the center must maintain documentation of the reason. Source Note: The provisions of this §356.709 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.709 Nonresident's Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225112 03/12/2026 (a) A center must document in writing each resident's and nonresident's self-stated needs and requests for available services to address these needs.(b) A center must attempt to re-evaluate the needs of the resident or nonresident regularly and at re-entry to the center.(c) A center must not use a resident's or nonresident's needs assessment to require the resident or nonresident to participate in services. Source Note: The provisions of this §356.710 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.710 Needs Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225113 03/12/2026 A center must provide at least one weekly voluntary support group for adult residents and adult nonresidents. Source Note: The provisions of this §356.711 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.711 Support Groups https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225114 03/12/2026 The center must: (1) have developmentally appropriate services available that are specific to meet the needs of children; (2) provide transportation or make transportation arrangements for child residents who attend school; (3) provide or arrange for school supplies and clothing for child residents; (4) provide at least one weekly voluntary, developmentally appropriate, support group for child residents; (5) provide at least one weekly, voluntary, developmentally appropriate recreational or social group for child residents; and (6) offer information and referral services for nonresident children if nonresident services are offered to the child's parent. Source Note: The provisions of this §356.713 adopted to be effective December 23, 2007, 32 TexReg 9328; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.713 Delivery of Children's Direct Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225115 03/12/2026 A center must offer developmentally appropriate services to child residents, including:(1) strategies to enhance safety, including:(A) safe use of technology; (B) safety within the shelter environment; and(C) safety at school, if applicable;(2) developmentally appropriate and trauma-informed understanding and support, including: (A) addressing needs identified by the child residents or parent residents; and (B) activities and information aimed at building self-esteem, problem solving, and recognizing that the child is not responsible for the violence; and (3) information about: (A) support systems; (B) available resources, including local partnerships within the community, particularly any resources with expertise in underserved populations, when available; (C) confidentiality and victim-advocate privilege; (D) dynamics of family violence and trauma; and(E) healthy relationships. Source Note: The provisions of this §356.714 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.714 Services for Children Residing in the Shelter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219313 03/12/2026 (a) A center must develop, maintain, and comply with written nonviolent disciplinary policies and procedures regarding child residents and child nonresidents, including policies and procedures for adult residents and adult nonresidents, employees, and volunteers who provide services to children.(b) The center must develop, maintain, and comply with written policies and procedures to:(1) ensure the safety of children in its facilities; and(2) maintain the safety of children when employees or volunteers take children on outings. Source Note: The provisions of this §356.715 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.715 Safety Policies and Procedures for Delivering Services to Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225116 03/12/2026 A center that provides child care may be subject to Texas Health and Human Services Commission regulation under Texas Human Resources Code Chapter 42, and relevant sections of Chapter 745, Chapter 743, and Chapter 746 of this title (relating to Licensing, Minimum Standards for Shelter Care, and Minimum Standards for Child-Care Centers, respectively), and any other relevant set of minimum standards. Source Note: The provisions of this §356.716 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.716 Child Care Permit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225117 03/12/2026 (a) A center must inform an adult resident about educational services for the resident's child. (b) A center must maintain knowledge of educational services available within the local community.(c) At a resident's request, a center must: (1) help the resident make arrangements for the child's continued education, including transportation; (2) accompany the resident to school meetings regarding the child's needs; and (3) act as a liaison to the school regarding provisions in a protective order that may directly affect the child's safety. (d) A center must develop, maintain, and comply with written policies and procedures regarding its educational services for children. Source Note: The provisions of this §356.718 adopted to be effective December 23, 2007, 32 TexReg 9328; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.718 Educational Services for Children of Adult Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225118 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding residents' and nonresidents' access to client assistance funds, when funds are available, that are consistent and equitable.(b) A center must provide direct client assistance funds to residents and nonresidents in compliance with the laws and regulations described in §356.604 of this subchapter (relating to Federal and State Laws Regarding Eligibility). Source Note: The provisions of this §356.719 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.719 Client Assistance Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225119 03/12/2026 (a) A center must ensure counseling services are available to residents and nonresidents either by:(1) employees, contract staff, interns, or volunteers of the center; or (2) counseling services providers contracted by the family violence center.(b) If a center is unable to provide counseling services in accordance with subsection (a) of this section, the center may offer a referral to a counseling service that is no cost to the resident or nonresident.(c) Counseling services may include both traditional and non-traditional modalities of counseling and support to meet the mental health and wellness needs of residents and nonresidents. Source Note: The provisions of this §356.720 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM B SHELTER CENTERS §356.720 Counseling Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219350 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219350 03/12/2026 The board must regularly review actual revenue and expenditures and compare them to budgeted revenue and estimated costs. Source Note: The provisions of this §356.801 adopted to be effective December 23, 2007, 32 TexReg 9332; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.801 Fiscal Oversight and Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219351 03/12/2026 The executive director or designee must give the board of directors a description of the Health and Human Services Commission contract within three months of the contract award, including program, administrative, and fiscal oversight responsibilities. Source Note: The provisions of this §356.802 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.802 Notification Regarding Special Nonresidential Projects https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225120 03/12/2026 Each board member of a special nonresidential project center must: (1) provide written assurance that the member is knowledgeable of and will comply with the confidentiality requirements of this chapter and the center's policies; and(2) if the center provides direct services, provide written assurance to the center that the board member will not use the position to obtain or access confidential program participant information when not authorized. Source Note: The provisions of this §356.803 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.803 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225121 03/12/2026 A center must develop, maintain, and comply with a written internal monitoring system to evaluate the following: (1) the quality of the special project's services; (2) the accuracy of the fiscal and programmatic documentation; and (3) compliance with the policies and procedures specified in the center's contract with the Texas Health and Human Services Commission. Source Note: The provisions of this §356.901 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.901 Internal Monitoring System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225122 03/12/2026 To request a variance or waiver from a specific requirement in this subchapter, the center must submit a completed Family Violence Program Waiver Request Form prescribed by the Texas Health and Human Services Commission demonstrating the need for the waiver. Source Note: The provisions of this §356.902 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.902 Requesting a Waiver https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219330 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219330 03/12/2026 If the special nonresidential project's purpose is to provide services to a particular population, the contractor must have a plan for providing services to otherwise eligible victims who are not members of the targeted population. This plan may include referrals. Source Note: The provisions of this §356.903 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.903 Primary Services to an Unserved or Underserved Population https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225123 03/12/2026 A center must maintain an accounting system and records that:(1) follow Generally Accepted Accounting Principles (GAAP);(2) record revenue and expenditures; (3) establish a chart of accounts that lists all accounts by an assigned number; (4) contain a general ledger and subsidiary ledgers; (5) maintain accounting documentation for all revenue and expenditures, including: (A) receipts or vouchers for revenue; (B) bank statements reconciled to the general ledger bank accounts; (C) journal entry justification;(D) canceled checks;(E) deposit slips; (F) approved invoices; (G) receipts; (H) leases; (I) contracts; (J) time and activity sheets; (K) inventory; and (L) cost allocation and indirect cost worksheets; (6) identify all funding sources and expenditures by separate fund type; and (7) use a double-entry accounting system, either cash, accrual, or modified accrual. Source Note: The provisions of this §356.1001 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1001 Accounting System Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225124 03/12/2026 A center must develop, maintain, and comply with written internal policies and procedures to accurately document the non-Texas Health and Human Services Commission (HHSC) cash or non-cash resources required by HHSC under Texas Human Resources Code §51.003. Source Note: The provisions of this §356.1002 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1002 Cash or Non-Cash Resources Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225125 03/12/2026 (a) A center must immediately report to the Texas Health and Human Services Commission (HHSC) Family Violence Program and HHSC Office of Inspector General any suspected or confirmed fraud, waste, or abuse of funds paid from the HHSC contract related to family violence service delivery, whether or not such suspected or confirmed fraud, waste, or abuse was committed by the center's employees or the center's subcontractors.(b) In addition to reporting to HHSC, the center must also report the fraud, waste, or abuse to the Office of Attorney General or the State Auditor's Office. (c) The center must fully cooperate with HHSC, the Office of Attorney General, the State Auditor's Office, or any other state or federal regulatory agency involved in the investigation of the allegation of fraud, waste, or abuse.(d) A center must not unlawfully disclose any personally identifying information of a victim in the course of reporting fraud, waste, or abuse.(e) The center must comply with 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Family Code Chapter 93 during the investigation. Source Note: The provisions of this §356.1003 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1003 Fraud, Waste, and Abuse https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225126 03/12/2026 A center must develop, maintain, and comply with written personnel policies, approved by the board of directors, and procedures for its personnel handbook that standardize the everyday actions and conduct of all employees. All employees must have ongoing access to the personnel handbook. Employees must be notified of new or changed personnel policies in accordance with center policies in a timely manner. The handbook must address the following: (1) contract labor; (2) conflicts of interest; (3) family violence in the workplace to include support for any staff experiencing family violence and violence occurring at the workplace; (4) nepotism; (5) a hiring process that is uniform for all candidates for a particular position and includes: (A) job posting; (B) job descriptions with essential job functions; (C) interviewing procedures; and (D) checking references and responding to reference checks; (6) rules of conduct; (7) hours and days of operation; (8) employee benefits, including the accrual and use of paid time off; (9) an employee's right to access the employee's personnel file; (10) written and oral employee orientation, initial training, and employee development; (11) confidentiality requirements of employee personnel files; (12) employee evaluations; (13) involuntary and voluntary termination; and (14) a complaint process for current and former employees, including the center's process for responding to a complaint. Source Note: The provisions of this §356.1101 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1101 Personnel Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225127 03/12/2026 A center must maintain a personnel file for each employee. Each file must include the following information: (1) employment application or resume; (2) current job descriptions; (3) signed acknowledgement of confidentiality agreement to be updated annually;(4) signed acknowledgment of receipt of the center's current personnel handbook as described in §356.1101 of this division (relating to Personnel Policies); (5) performance evaluations for every year of employment in accordance with the center's personnel policies; (6) documentation of orientation, initial training, and employee development; (7) any status or classification change; (8) all disciplinary actions and related documentation, if any; and (9) letters of praise or criticism, if any. Source Note: The provisions of this §356.1102 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1102 Personnel Files https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225128 03/12/2026 If under the jurisdiction of the Drug-Free Workplace Act, a center must develop, maintain, and comply with a written drug and alcohol policy that includes the following: (1) prohibition of use or possession of alcohol, illegal drugs, or drugs for which the employee does not have a prescription, if a prescription is required to possess the drug, while on duty; (2) a statement of practice rooted in a treatment and recovery approach; (3) a stated concern for employees and their recovery efforts; (4) information on available programs and systems for assistance; and (5) a statement of confidentiality. Source Note: The provisions of this §356.1103 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1103 Drug and Alcohol Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219334 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219334 03/12/2026 (a) A contractor must provide an oral orientation about the organization for all new employees within the first two days of employment.(b) Within two weeks after the first day of employment, all new employees must receive basic oral or written information regarding:(1) dynamics of family violence;(2) a brief history of the Texas Battered Women's Movement;(3) a brief summary of current Texas laws that address family violence issues; and(4) federal, state, and program requirements regarding confidentiality.(c) Direct service employees and their supervisors must also receive training on the following:(1) crisis intervention;(2) hotline skills, if applicable;(3) peer counseling techniques;(4) risk assessment and safety planning for victims of family violence;(5) legal options for victims of family violence;(6) economic options for victims of family violence;(7) the contractor's policies and procedures, including all Health and Human Services Commission required policies and procedures;(8) sensitivity to cultural diversity;(9) applicable civil rights laws and regulations;(10) all required documentation and procedures related to program participant issues; and(11) confidentiality.(d) Training described in subsections (b) and (c) of this section may be provided electronically. Source Note: The provisions of this §356.1104 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1104 New Employee Orientation and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225129 03/12/2026 (a) Every year, each employee must receive oral or written information regarding:(1) confidentiality requirements, including the center's policies for complying with requirements;(2) federal, state, and program requirements as applicable to an employee's job description, including the requirements outlined in:(A) this subchapter; (B) 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act; and(C) the Texas Health and Human Services Commission contract related to family violence service delivery; and(3) information on the intersection of family violence and barriers to underserved populations, as well as a description of the organization's client and community demographics.(b) Direct service employees and their supervisors must also receive yearly training on the following:(1) best practices in family violence service delivery, including:(A) trauma-informed and survivor-centered advocacy and voluntary services;(B) access to services for underserved populations, including populations with disabilities;(C) the intersection of family violence and mental health;(D) the intersection of family violence and substance use;(E) technology and data safety; and(F) language and interpretation accessibility; and(2) relevant training or staff development on topics related to their job descriptions as family violence center employees. (c) Direct service supervisors must receive training that is relevant to the job descriptions of the people they supervise.(d) Employees with access to personally identifying information must receive annual training in compliance with §356.1313 of this subchapter (relating to Confidentiality Training). (e) The training described in this section may be provided virtually or in person. Source Note: The provisions of this §356.1105 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1105 Ongoing Employee Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225130 03/12/2026 A center's facilities must have: (1) access to a private meeting area and adequate safe space for children; (2) a stocked first-aid kit in each facility in central locations and communal spaces, as specified by center policy, that is accessible to all employees, volunteers, and program participants; (3) secure, clearly marked locations to store cleansers, solvents, and other hazardous items out of reach from children;(4) access to bathroom facilities, including toilets and lavatories;(5) clearly marked exits; (6) smoke detectors, fire extinguishers, current fire inspections, and fire evacuation plans; and (7) basic furnishings that are clean and in good repair. Source Note: The provisions of this §356.1201 adopted to be effective December 23, 2007, 32 TexReg 9332; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1201 Facility Requirements for the Special Nonresidential Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225131 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures to promote the safety and security of program participants, employees, and volunteers as appropriate for the project. The written policies and procedures must address technology safety and data security. (b) If the special nonresidential project center provides direct services, the center must have a security system that is operational 24-hours-a-day. The security system must include an alarm system, outside lighting, and secure locks. Source Note: The provisions of this §356.1202 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1202 Security System Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225150 03/12/2026 At a minimum, a center must provide equal access to the services for victims of family violence that are outlined in 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Human Resources Code Chapter 51. Source Note: The provisions of this §356.1301 adopted to be effective December 23, 2007, 32 TexReg 9332; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1301 Required Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225151 03/12/2026 A center may not charge or solicit contributions or donations in return for Texas Health and Human Services Commission-contracted services. Source Note: The provisions of this §356.1302 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1302 Charging for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227367 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227367 03/12/2026 (a) The following individuals are eligible for services under this chapter:(1) victims of family violence or dating violence; or(2) victims of sexual assault or human trafficking when the sexual assault or human trafficking meets the definition of family violence or dating violence.(b) All victims described in this section are eligible for services regardless of the victim's current geographic location. (c) A center must not require a victim to participate in center activities as a condition of receiving services. Source Note: The provisions of this §356.1303 adopted to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1303 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225153 03/12/2026 When determining eligibility for services for a special nonresidential project, a center must comply with the following applicable state and federal laws and any amendments made to each of these laws. Policies and procedures must be written to ensure compliance with: (1) 42 United States Code (U.S.C.) §2000d, et seq., Title VI of the Civil Rights Act of 1964; (2) 29 U.S.C. §701, et seq., Section 504 of the Rehabilitation Act of 1973; (3) 42 U.S.C. §12101, et seq., Americans with Disabilities Act of 1990; (4) 42 U.S.C. §§6101 - 6107, Age Discrimination Act of 1975; (5) 42 U.S.C. Chapter 110, the Family Violence Prevention and Services Act;(6) Texas Human Resources Code Chapter 51;(7) Texas Health and Safety Code §85.113, relating to Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection; and(8) Texas Health and Human Services Commission regulations regarding civil rights. Source Note: The provisions of this §356.1304 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1304 Federal and State Laws Regarding Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219344 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219344 03/12/2026 A contractor must develop, maintain, and comply with written program participant eligibility and screening procedures that are based solely on the individual's status as a victim of family violence, without regard to:(1) income;(2) whether the individual contributes, donates, or pays for these services;(3) gender; or(4) sexual orientation. Source Note: The provisions of this §356.1305 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1305 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225154 03/12/2026 A center may not deny services to an otherwise eligible victim as described in §356.1303 of this division (relating to Eligibility) unless the center adopts written policies in accordance with this section that outline specific reasons or behaviors that would make a victim ineligible for such services. Under this section, these policies must: (1) address only behaviors that threaten the safety and security of staff and program participants; (2) apply equally to all people; (3) comply with the laws and regulations described in §356.1304 of this division (relating to Federal and State Laws Regarding Eligibility); and (4) contain procedures that take into consideration the safety of a victim and require appropriate referrals to other service providers. Source Note: The provisions of this §356.1306 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1306 Denial of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219343 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219343 03/12/2026 If a contractor provides direct services for a special nonresidential project, the contractor must:(1) serve people with limited English proficiency and take reasonable steps to ensure meaningful access to the program; and(2) develop, maintain, and comply with written policies and procedures for the access and delivery of services to people with limited English proficiency. Source Note: The provisions of this §356.1307 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1307 Access to Services for People with Limited English Proficiency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225155 03/12/2026 (a) For the purposes of this section, "minor" means a person under 18 years of age who:(1) is not and has not been married; or(2) has not had the disabilities of minority removed for general purposes.(b) A center may provide a nonresidential service to a minor if: (1) the minor consents to counseling from a licensed or certified physician, psychologist, counselor, or social worker, under Texas Family Code §32.004, for: (A) suicide prevention; (B) chemical addiction or dependency; or (C) sexual, physical, or emotional abuse; (2) the center obtains consent from the minor's parent, managing conservator, or guardian to provide the minor with the nonresidential service; or (3) the center otherwise complies with Texas Family Code Chapter 32, even if the center does not obtain consent from the minor's parent, managing conservator, or guardian.(c) Notwithstanding subsection (b) of this section, a victim who is under 18 years of age may consent to a nonresidential service provided by the center if: (1) the victim is married or has been married; or (2) the victim has had the disabilities of minority removed for general purposes. Source Note: The provisions of this §356.1308 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective December 16, 2015, 40 TexReg 8886; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1308 Nonresidential Services for a Minor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225156 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures that: (1) outline behaviors that threaten the safety and security of staff and other program participants for which the center may terminate services; (2) do not allow for termination of a program participant's services for any reason other than behaviors that threaten the safety and security of staff and other program participants;(3) allow considerations for program participants to have contact with an abusive partner without grounds for termination;(4) address how current and former program participants can appeal terminations and file complaints with the center; (5) apply equally to all people;(6) comply with:(A) the laws and regulations described in §356.604 of this division (relating to Federal and State Laws Regarding Eligibility); and(B) other applicable laws and regulations; and(7) allow a resident or nonresident to voluntarily terminate their services at any time.(b) Before the termination of services to a program participant, regardless of whether the program participant's termination is voluntary or involuntary, the center must make reasonable efforts to: (1) assist the program participant in re-evaluating the participant's safety plan; (2) assist in obtaining alternate resources for the program participant whose services are terminated; (3) provide written notice to the program participant of the termination; (4) provide written notice to the program participant of the right to file a complaint with the center and an explanation of the center's complaint procedure; and (5) upon request of the program participant, provide contact information for the Texas Health and Human Services Commission's Family Violence Program for complaint purposes. Source Note: The provisions of this §356.1309 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1309 Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225157 03/12/2026 A center must have a written general confidentiality policy that: (1) demonstrates that services will be delivered in a manner that ensures program participant confidentiality regarding records and information if the special nonresidential project provides direct services; (2) includes a statement about the importance of confidentiality in maintaining the safety of: (A) victims; (B) victims' families; (C) volunteers; (D) employees; and (E) others related to the program; (3) indicates the parameters of what must be held confidential and by whom, including internal communications to staff regarding program participants; (4) indicates the limits of confidentiality under the law; (5) designates the custodian of the records, including digital records; and(6) includes procedures for:(A) retention and destruction of records, including digital records;(B) responses to court orders;(C) release of information;(D) reports of abuse or suspected abuse of:(i) a child;(ii) a person 65 years of age or older; and(iii) a person with a disability;(E) requests for information under the Texas Public Information Act;(F) maintenance of records; and (G) access to records that comply with confidentiality provisions in state and federal law. Source Note: The provisions of this §356.1310 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1310 General Confidentiality Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225158 03/12/2026 (a) If direct services are provided to adult program participants, the center must provide the program participants, verbally and in writing, at least the following: (1) that program participants have the right to access their records and the process by which program participants may access their records without incurring a fee; (2) the kind of information recorded, why, and the methods of collection; (3) who within the organization has access to the program participants' case files and records; (4) an overview of the center's policy and practices on confidentiality;(5) current state and federal laws regarding the limits of confidentiality under the law, including mandatory reporting for abuse or suspected abuse of: (A) a child; (B) a person 65 years of age and older; and (C) a person with a disability; (6) an overview of the center's policy for responding to court orders; (7) an overview of the center's policy for requests for information under the Texas Public Information Act; (8) an overview of the center's policy for release of information; (9) when the records will be decoded or destroyed; and (10) an overview of what information will remain in the record after a program participant terminates services. (b) If a center is unable to provide the information described in subsection (a) of this section in writing, the center must maintain documentation stating the reason why the information could not be provided in writing. Source Note: The provisions of this §356.1311 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1311 Confidentiality Information for Program Participants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225159 03/12/2026 (a) A center must require that all employees, contract staff, volunteers, board members, interns, and adult program participants sign a confidentiality agreement. The confidentiality agreement must have a provision that states that confidentiality must be maintained after an employee, contract staff, volunteer, board member, intern, or program participant leaves the project. The signed confidentiality agreements must be placed: (1) in the personnel file of an employee; (2) in the corporate record of a board member; and (3) in the individual files of contract staff, volunteers, interns, and program participants. (b) A center must have a written policy to ensure program participant confidentiality when there is a visitor on the premises in spaces where program participants are present.(c) If a confidentiality agreement required in subsection (a) of this section cannot be physically signed:(1) the agreeing party must provide verbal agreement to adhere to the confidentiality agreement; and(2) the center must:(A) maintain documentation of the verbal agreement; and(B) obtain a signed agreement as soon as feasible for the agreeing party. Source Note: The provisions of this §356.1312 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1312 Confidentiality Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225160 03/12/2026 A center must provide training annually to employees, board members, contract staff, volunteers, and interns who have access to personally identifying information, on: (1) confidentiality policies and procedures; (2) the importance of confidentiality for victims of family violence; (3) how information is recorded; (4) procedures for responding to court orders and any other requests for confidential information; and(5) state and federal laws regarding confidentiality. Source Note: The provisions of this §356.1313 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1313 Confidentiality Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225161 03/12/2026 If a special nonresidential center provides direct services, the center must limit the information kept, both written and electronically, in a program participant's record to information necessary for: (1) statistical and funding purposes; (2) documenting the survivor-stated need for and delivery of services; and (3) protecting the liability of the center and the center's employees, contract staff, volunteers, interns, and board members. Source Note: The provisions of this §356.1315 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1315 Information in Program Participant Files https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227368 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227368 03/12/2026 (a) If a special nonresidential center involves direct services, the center must develop, maintain, and comply with written policies and procedures regarding entries into a program participant's record that require that:(1) each entry be attributed to and dated by the employee or volunteer entering the information;(2) the program participant record does not include the names of other program participants; and(3) if the center provides direct services for both a victim and an abuser, the center maintains a separate record for each, one for the victim and one for the abuser.(b) A center must develop, maintain, and comply with written policies and procedures to ensure a program participant may have access and review all information in the program participant's record.(c) If a program participant contests an entry in the program participant's record, the center must either:(1) remove the entry from the record; or(2) if the entry is not removed, note in the record that the program participant has contested the entry.(d) A center may create and store entries to a program participant's record electronically, provided that:(1) electronic entries are secure and attributed to an individual, which may include password-protected system access; and(2) records are kept following all state and federal laws, including:(A) 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act; (B) §356.1202 of this subchapter (relating to Security System Policies and Procedures); and(C) §356.1317 of this division (relating to Maintaining Control Over Program Participant Records). Source Note: The provisions of this §356.1316 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1316 Policies and Procedures Regarding Entries in a Program Participant's Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225163 03/12/2026 A center must develop, maintain, and comply with written procedures that: (1) outline the responsibilities of the custodian of the records, designated by the center's executive director, for maintaining control over program participants' records, including a court's access to the records; (2) require program participants' records are kept secure and not removed from the center's premises without the written permission of the custodian of the records; (3) provide for the safekeeping of program participants' records in the event of the center's closure; and (4) allow a program participant to access the program participant's record in the event of the center's closure without assessing a fee. Source Note: The provisions of this §356.1317 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1317 Maintaining Control Over Program Participant Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225164 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225164 03/12/2026 (a) A center may not release program participant information, orally or in writing, unless the program participant completes a properly executed release of information form created by the center, for the purpose of consenting to the release of the program participant's information.(b) This rule does not apply when responding to subpoenas, court orders, or other requests for information with which a center is legally required to comply. However, this subsection does not prohibit a center from asserting any relevant objections, claims of privilege, or other legally permissible responses prior to releasing such information. (c) Regardless of whether a center obtains a properly executed release of information form completed by a program participant, the center must release information in order to comply with the applicable state laws to report abuse or suspected abuse of: (1) a child; (2) a person who is 65 years of age or older; and (3) a person with a disability.(d) An abuser or suspected abuser of a minor or of an individual with a guardian, as well as the abuser or suspected abuser of a survivor parent of the minor or of a guardian of an individual, may not consent to the release of the information of the minor or the individual with a guardian.(e) For the purposes of this section, "minor" means a person under 18 years of age. Source Note: The provisions of this §356.1318 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1318 Release of Program Participant Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225165 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225165 03/12/2026 The release of a program participant's information form must include the following: (1) the name of no more than one person or one organization to which the information is being released; (2) specific information to be released; (3) the beginning and ending dates the release is effective, not to exceed the program participant's active length of services; (4) the date and the signatures of the program participant and the employee or volunteer releasing the information; and (5) a statement of the program participant's right to revoke, in writing, a release of information at any time. Source Note: The provisions of this §356.1319 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1319 Release of Program Participant Information Form https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225166 03/12/2026 A center must develop, maintain, and comply with written policies and procedures for responding to court orders, subpoenas, search warrants, and writs of attachment. The written procedures must include: (1) what to do when a process server arrives with a court order or other legal document; (2) on whom court orders and other documents may be served, such as the custodian of the records or the executive director, or, in the executive director's absence, the designated staff; (3) which attorney or attorneys should be contacted; (4) the process by which the center will make reasonable attempts to provide notice to victims affected by a potential release of information;(5) who must discuss the court order or other legal documents and legal options with the program participant or other victim of family violence, and at what point; (6) information about compliance with state and federal confidentiality and victim-advocate privilege provisions; (7) the circumstances under which records may be released; and (8) an affirmative statement that the center will take steps necessary to protect the privacy and safety of the persons affected by the release of information under state and federal laws. Source Note: The provisions of this §356.1321 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1321 Procedures Regarding Court Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225167 03/12/2026 (a) A center must:(1) serve people with a disability and take reasonable steps to ensure meaningful access to the program;(2) take appropriate steps to ensure that communications with a victim with a disability, a victim's dependents with a disability, and members of the public with a disability are as effective as communications with persons who do not have a disability; and(3) furnish appropriate auxiliary aids and services where necessary to ensure that eligible individuals with a disability, including a victim, a victim's dependents, and members of the public, have equitable access to services. (b) The auxiliary aids and services described in subsection (a)(3) of this section may include qualified interpreters and large print materials. Source Note: The provisions of this §356.1324 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1324 Access to Services for People with a Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225168 03/12/2026 If providing direct services, a center must:(1) develop, maintain, and comply with a written advocacy service model that is:(A) voluntary;(B) trauma-informed; and(C) respects an individual's needs;(2) develop training requirements for all employees, contract staff, interns, and volunteers that provide direct services to survivors regarding the advocacy service model including the importance of and best practices for voluntary and trauma-informed services; and(3) have written policies and procedures to evaluate the effectiveness of the service model and report the results to the Texas Health and Human Services Commission as requested. Source Note: The provisions of this §356.1325 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1325 Service Model https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225169 03/12/2026 As a part of the special nonresidential project, a center must: (1) provide:(A) community education or prevention relating to family violence; or (B) direct delivery of services for adult victims of family violence or the victims' children;(2) maintain a system of referring victims of family violence to needed resources available in the community, including a family violence shelter center and other housing resources;(3) demonstrate the project is addressing a need of an underserved or special population as identified by the Texas Health and Human Services Commission; and(4) demonstrate a process for obtaining voluntary feedback from the underserved or special population served. Source Note: The provisions of this §356.1401 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1401 Special Nonresidential Project Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225170 03/12/2026 (a) A center must regularly report complete and accurate data through the secure file protocol designated by the Texas Health and Human Services Commission (HHSC). Data submission is due by the deadline specified in the HHSC contract related to family violence service delivery. HHSC reserves the right to impose sanctions if a center does not submit complete and accurate data by the deadline specified in the contract. (b) If extenuating circumstances exist, a center must contact HHSC via email before the due date of the data submission to request an extension of said due date.(c) A center must contact HHSC via email within two business days of discovering data errors or inconsistencies that will result in the center's inability to report accurate data in a timely manner.(d) When collecting and reporting data, a center must comply with state and federal confidentiality provisions. Data that a center submits must be in the aggregate and not contain personally identifying information.(e) Program participant data collected by a center for HHSC reporting must be provided voluntarily by a program participant, and the program participant may refuse to offer any element of data at any time.(f) A center must notify HHSC within 24 hours after discovery of a data breach. Notification must include all information reasonably available to the center about the breach and contact information for the center's point of contact who will communicate with HHSC regarding the breach.(g) A center must provide written notification to HHSC by the third business day after discovery of a data breach of the following:(1) all reasonably available information about the data breach, and the center's investigation, to the extent practicable; (2) the date the data breach occurred;(3) the date of the center's and, if applicable, subcontractor's discovery of the data breach;(4) a brief description of the data breach, including how it occurred and who is responsible (or hypotheses, if not yet determined);(5) a brief description of the center's investigation into the data breach and the status of the investigation;(6) a description of the types and amount of confidential information involved;(7) the steps the center has taken to mitigate any harm or potential harm caused by the data breach, including without limitation the provision of sufficient resources to mitigate;(8) the steps the center has taken, or will take, to prevent or reduce the likelihood of recurrence of a similar data breach;(9) identify and describe any law enforcement that may be involved in the response to the data breach;(10) a reasonable schedule for the center to provide regular updates regarding response to the data breach; and(11) any reasonably available, pertinent information, documents, or reports related to the data breach that HHSC requests following the report of the data breach. Source Note: The provisions of this §356.1402 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1402 Reporting Data to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227369 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227369 03/12/2026 A center does not have to provide a crisis call hotline, but if the center does provide a hotline and it is funded by the Texas Health and Human Services Commission (HHSC), the center must:(1) ensure that an individual trained in crisis intervention, or who has immediate access to someone who has had training, answers the crisis call hotline 24-hours-a-day, every day of the year;(2) accept collect calls and anonymous incoming calls;(3) list the hotline number across all relevant publications in the center's service area and on the center's website, if applicable;(4) provide a minimum of two hotline telephone lines;(5) ensure that the caller has direct access to a live person who is trained to assess the caller's safety and that a messaging system is not used to answer the hotline;(6) provide caller identification (ID) blocks on the center's numbers for outgoing calls to program participants;(7) ensure compliance with all state and federal laws, including §356.1304 of this subchapter (relating to Federal and State Laws Regarding Eligibility), when using the hotline to determine eligibility for services;(8) keep all hotline calls and any related documentation confidential;(9) provide meaningful access to persons with disabilities, as required by §356.1324 of this subchapter (relating to Access to Services for People with a Disability);(10) ensure the center can provide meaningful access to people with limited English proficiency as required by §356.1307 of this subchapter (relating to Access to Services for People with Limited English Proficiency); and(11) if the center uses caller ID or any other technology that establishes a record of calls on the hotline, the center must:(A) ensure there will not be a breach of confidentiality to third parties; and(B) follow the confidentiality requirements stated in the contract for family violence services with HHSC about the records created by caller ID or other technology. Source Note: The provisions of this §356.1403 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1403 Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225172 03/12/2026 (a) A center may transfer its crisis call hotline to another center only if:(1) there is a telephone or staffing disruption that will last for more than twenty-four hours;(2) the transferring center develops, maintains, and complies with written policies and procedures that address how the center receiving the transferred hotline calls meets the Texas Health and Human Services Commission's (HHSC) training requirements for all direct service staff and ensures immediate access to the accepting center's 24-hours-a-day services; and(3) the transferring center obtains HHSC's approval of the arrangement with the center accepting the transferred calls.(b) A center may transfer its crisis call hotline without obtaining HHSC's approval as described in subsection (a) of this section only when the center transfers the hotline to the National Domestic Violence Hotline.(c) A center may not transfer its crisis call hotline to law enforcement. Source Note: The provisions of this §356.1404 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1404 Transferring the Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225173 03/12/2026 (a) If a center provides direct services, the center must ensure that an orientation is provided to a program participant verbally and in writing. The orientation must be documented and comply with the requirements in this chapter as appropriate, and the Family Violence Prevention and Services Act (42 United States Code (U.S.C.) Chapter 110) regulations. The orientation must include:(1) an explanation of services available; (2) the center's termination policy; (3) program participants' rights; (4) a nondiscrimination statement, in accordance with the Family Violence Prevention and Services Act (42 U.S.C. Chapter 110); (5) complaint procedures;(6) contact information for the Texas Health and Human Services Commission (HHSC), as specified in the center's contract with HHSC; (7) safety and security procedures; (8) information about confidentiality and victim-advocate privilege and the limits of confidentiality and victim-advocate privilege; (9) waivers of liability; and (10) a wellness check for the program participant that addresses each participant's immediate needs. (b) If a center is unable to provide the resident orientation in writing, the center must maintain documentation of the reason. Source Note: The provisions of this §356.1405 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1405 Program Participant's Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219371 03/12/2026 (a) A contractor must develop, maintain, and comply with written nonviolent disciplinary policies and procedures regarding child program participants, including policies and procedures for adult program participants, employees, and volunteers who provide services to children.(b) A contractor must develop, maintain, and comply with written policies and procedures to:(1) ensure the safety of children in its facilities; and(2) maintain the safety of children when employees or volunteers take children on outings. Source Note: The provisions of this §356.1407 adopted to be effective December 23, 2007, 32 TexReg 9332; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1407 Safety Policies and Procedures if Providing Services to Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225174 03/12/2026 A center that provides child care at the center may be subject to Texas Health and Human Services Commission regulation under Texas Human Resources Code Chapter 42, relevant sections of Chapter 745, Chapter 743, and Chapter 746 of this title (relating to Licensing, Minimum Standards for Shelter Care, and Minimum Standards for Child-Care Centers, respectively), and any other relevant set of minimum standards. Source Note: The provisions of this §356.1408 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1408 Child Care Permit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225175 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding residents' and nonresidents' access to assistance funds, when funds are available, that are consistent and equitable.(b) A center must provide direct client assistance funds in compliance with the laws and regulations described in §356.1304 of this subchapter (relating to Federal and State Laws Regarding Eligibility). Source Note: The provisions of this §356.1409 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM C SPECIAL NONRESIDENTIAL PROJECT CENTERS §356.1409 Client Assistance Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225140 03/12/2026 The board of directors of a nonresidential center must: (1) ensure that the center is operating in a manner that keeps the organization's mission and purpose focused, without becoming involved in day-to-day operations; (2) hire the center's executive director, and explain the following; (A) the role of the board in supervising and evaluating the executive director;(B) the structures in place for evaluation; and(C) an overview of the board's and executive director's duties;(3) review regularly, as-a-whole, or as delegated to the center's finance committee, actual revenue and expenditures and compare them to budgeted revenue and estimated costs; (4) review and approve programs and budgets in accordance with the bylaws; (5) maintain and comply with current organizational bylaws; (6) review and approve board policies for the organization's operation in accordance with the bylaws; (7) ensure that all board members are knowledgeable of all grant expectations as they pertain to board members and their responsibilities under the Texas Health and Human Services Commission Family Violence Program shelter grant;(8) review and comply with the center's complaint policy and address any complaints escalated to the board; and(9) as-a-whole, or as delegated to board committee, review and approve program policy changes. Source Note: The provisions of this 356.1501 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1501 Oversight and Accountability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225141 03/12/2026 (a) The board members must be given a handbook within 60 days of starting their first term that contains the following: (1) the board member's job description; (2) the current list of board members with current contact information; (3) the organization's mission statement; (4) the organization's bylaws and a copy of the letter granting 501(c)(3) status; (5) a list of all committees, including appointed board members and assigned staff; (6) committee descriptions; (7) the organization's policies, including fiscal, administrative, and programmatic; (8) the organizational chart; (9) the history of the organization; (10) a list of program services and a brief description of each program; (11) the current budget, including funding sources and subcontractors; (12) a brief description of contract provisions with attorneys, auditors, or other professionals; (13) an explanation of the organization's insurance coverage, including directors' and officers' liability insurance or notification of inability to obtain insurance;(14) basic information about family violence; (15) a brief history of the Texas Family Violence Movement; (16) an explanation of the organization's efforts to support underserved populations; and(17) information on the intersection of family violence and barriers to services for underserved populations as well as a description of the organization's client and community demographics. (b) The handbook may be made available in an electronic format. Source Note: The provisions of this §356.1502 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1502 Nonresidential Center's Board Handbook https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225142 03/12/2026 (a) Every two years, each board member must receive the following: (1) an explanation of the center's mission, philosophy, and a brief history; (2) a discussion of the dynamics of family violence that includes power and control and trauma-informed services;(3) a description of the organization's current programs; (4) a review of the organization's policies to determine if any modifications need to be made and clarification of any policy changes made during the previous year; (5) training that includes information on the intersection of family violence and barriers to services for underserved populations as well as a description of the organization's client and community demographics;(6) an explanation of how the center is funded and future funding projections; (7) a discussion, presented by the appropriate board member, employee, or designated person, of the following: (A) a review of the duties of a nonprofit board of directors as outlined in the Texas Business Organizations Code §22.221, Texas Nonprofit Corporation Act;(B) the board's role and responsibilities related to legal and fiscal accountability;(C) the current bylaws, including a discussion on:(i) meetings and attendance requirements;(ii) committee duties, structure, and assignments; (iii) fundraising and public relations responsibilities; and(iv) the conflict of interest policy;(8) an explanation of the working relationship between the board and staff, including which staff member to contact regarding questions or requests and which staff members contact board members routinely; and (9) the organization's confidentiality policy and the importance of confidentiality, which must include the training required by §356.2014 of this chapter (regarding Confidentiality and Victim-Advocate Privilege Training). (b) New board members must receive this training within 60 days of starting their first term. Source Note: The provisions of this §356.1503 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1503 Board of Directors Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225143 03/12/2026 Each board member must: (1) provide written assurance that the member is knowledgeable of and will comply with the confidentiality requirements of this chapter and the center's policies;(2) provide written assurance to the center that the board member will not use the position to obtain or access confidential program participant information when not authorized; and(3) provide written assurance to the center that the member is knowledgeable of, and will comply with, the victim-advocate privilege under Texas Family Code Chapter 93 and will not use the member's position to obtain or access privileged resident or nonresident information when not authorized. Source Note: The provisions of this §356.1504 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1504 Confidentiality and Victim-Advocate Privilege https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219181 03/12/2026 If a center's purpose is to provide services to a particular population, it must have a plan for providing services to otherwise eligible victims who are not members of the targeted population. This plan may include referrals. Source Note: The provisions of this §356.1601 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1601 Primary Services to an Unserved or Underserved Population https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225147 03/12/2026 A center may apply for a special nonresidential project contract; however, the proposed services may not be the same as those required under this subchapter. Source Note: The provisions of this §356.1602 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1602 Special Nonresidential Project Contract https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219183 03/12/2026 A center must develop, maintain, and comply with a written internal monitoring system to evaluate:(1) quality of the center's required program participant services;(2) accuracy of the fiscal and programmatic documentation; and(3) compliance with the policies and procedures specified in the center's contract with the Health and Human Services Commission. Source Note: The provisions of this §356.1603 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1603 Internal Monitoring System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225148 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may waive the maximum prescribed funding percentage, as described in Human Resources Code §51.003(a), when at least one of the following occurs. (1) The center's income for the contract year decreased relative to the actual income received during the previous contract year. Decreases in funding caused by a center's noncompliance, negligence, or deficiencies will not be considered when making this calculation. (2) The center's HHSC award for center services increases. (b) If a center receives three or more funding waivers in a five-year period, the center may be subject to corrective action. Source Note: The provisions of this §356.1604 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1604 Funding Waivers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225149 03/12/2026 To request a waiver from the maximum prescribed funding percentage, the center's board must submit: (1) a completed Family Violence Program Waiver Request Form prescribed by the Texas Health and Human Services Commission;(2) supporting documentation of the need; and(3) a statement describing the center's efforts to raise funds compared to its budget. Source Note: The provisions of this §356.1605 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1605 Requesting a Variance or Waiver https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225144 03/12/2026 A center must maintain an accounting system and records that:(1) follow Generally Accepted Accounting Principles (GAAP); (2) record revenue and expenditures; (3) establish a chart of accounts that lists all accounts by an assigned number; (4) contain a general ledger and subsidiary ledgers; (5) maintain accounting documentation for all revenue and expenditures, including: (A) receipts or vouchers for revenue; (B) bank statements reconciled to the general ledger bank accounts; (C) journal entry justification;(D) canceled checks; (E) deposit slips; (F) approved invoices; (G) receipts; (H) leases; (I) contracts; (J) time and activity sheets; (K) inventory; and (L) cost allocation and indirect cost worksheets; (6) identify all funding sources and expenditures by separate fund type; and (7) use a double-entry accounting system, either cash, accrual, or modified accrual. Source Note: The provisions of this §356.1701 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1701 Accounting System Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225145 03/12/2026 A center must develop, maintain, and comply with written internal policies and procedures to accurately document the non-Texas Health and Human Services Commission (HHSC) cash or non-cash resources required by HHSC under Texas Human Resources Code §51.003. Source Note: The provisions of this §356.1702 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1702 Cash or Non-Cash Resources Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225146 03/12/2026 (a) A center must immediately report to the Texas Health and Human Services Commission (HHSC) Family Violence Program and the HHSC Office of Inspector General any suspected or confirmed fraud, waste, or abuse of funds paid from the HHSC contract related to family violence service delivery, whether or not such suspected or confirmed fraud, waste, or abuse was committed by the center's employees or the center's subcontractors. (b) In addition to reporting to HHSC, a center must also report the fraud, waste, or abuse to the Office of the Attorney General of Texas or the State Auditor's Office. (c) A center must fully cooperate with HHSC, the Office of the Attorney General of Texas, the State Auditor's Office, or any other state or federal regulatory agency involved in the investigation of the allegation of fraud, waste, or abuse.(d) A center must not unlawfully disclose any personally identifying information of a victim in the course of reporting fraud, waste, or abuse.(e) A center must comply with 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Family Code Chapter 93 during the investigation. Source Note: The provisions of this §356.1703 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1703 Fraud, Waste, and Abuse https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225136 03/12/2026 A center must develop, maintain, and comply with written personnel policies, approved by the board of directors, and procedures for its personnel handbook that standardize the everyday actions and conduct of all employees. All employees must have ongoing access to the personnel handbook. Employees must be notified of new or changed personnel policies in accordance with the center's policies and in a timely manner. The handbook must address the following: (1) contract labor; (2) conflicts of interest; (3) family violence in the workplace to include support for any staff experiencing family violence and violence occurring at the workplace; (4) nepotism; (5) the organization's non-discrimination policy;(6) a hiring process that is uniform for all candidates for a particular position and includes: (A) job posting; (B) job descriptions with essential job functions; (C) interviewing procedures; and (D) reference checking and responding to reference checking; (7) rules of conduct; (8) hours and days of operation; (9) employee benefits, including the accrual and use of paid time off; (10) employees' right to access their personnel files; (11) written and oral employee orientation, initial training, and employee development; (12) confidentiality requirements of employee records; (13) employee evaluation; (14) involuntary and voluntary termination; and (15) a complaint process for current and former employees, which includes the center's response to a complaint. Source Note: The provisions of this §356.1801 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1801 Personnel Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225137 03/12/2026 A center must maintain a personnel file for each employee. Each file must include at least the following information: (1) employment application or resume; (2) current job description; (3) signed acknowledgment of confidentiality agreement to be updated annually; (4) signed acknowledgment of receipt of the current personnel handbook as described in §356.1801 of this division (relating to Personnel Policies); (5) performance evaluations for every year of employment in accordance with the center's personnel policies; (6) documentation of orientation, initial training, and employee development; (7) any status or classification change; (8) all disciplinary actions and related documentation, if any; and (9) letters of praise or criticism, if any. Source Note: The provisions of this §356.1802 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1802 Personnel Files https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225138 03/12/2026 If under the jurisdiction of the Drug-Free Workplace Act, a center must develop, maintain, and comply with a written drug and alcohol policy that includes the following: (1) prohibition of use or possession of alcohol, illegal drugs, or drugs for which the employee does not have a prescription, if a prescription is required to possess the drug, while on duty; (2) a statement of practice rooted in a treatment and recovery approach; (3) a stated concern for employees and their recovery efforts; (4) information on available programs and systems for assistance; and (5) a statement of confidentiality. Source Note: The provisions of this §356.1803 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1803 Drug and Alcohol Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219197 03/12/2026 (a) A center must provide an oral orientation about the organization for all new employees within the first two days of employment.(b) Within two weeks after the first day of employment, all new employees must receive basic oral or written information regarding:(1) dynamics of family violence;(2) a brief history of the Texas Battered Women's Movement;(3) a brief summary of current Texas laws that address family violence issues; and(4) federal, state, and program requirements regarding confidentiality.(c) Direct service employees and their supervisors must also receive training on the following:(1) crisis intervention;(2) hotline skills, if applicable;(3) peer counseling techniques;(4) risk assessment and safety planning for victims of family violence;(5) legal options for victims of family violence;(6) economic options for victims of family violence;(7) the center's policies and procedures, including all Health and Human Services Commission required policies and procedures;(8) sensitivity to cultural diversity;(9) applicable civil rights laws and regulations;(10) all required documentation and procedures related to program participant issues; and(11) confidentiality.(d) Training described in subsections (b) and (c) of this section may be provided electronically. Source Note: The provisions of this §356.1804 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1804 New Employee Orientation and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225139 03/12/2026 (a) Every year, each employee must receive oral or written information regarding:(1) confidentiality and victim-advocate privilege requirements, including the center's policies for complying with the requirements; (2) federal, state, and program requirements as applicable to an employee's job description, including the requirements outlined in:(A) this subchapter;(B) 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act; and(C) the Texas Health and Human Services Commission contract related to family violence service delivery; and(3) information on the intersection of family violence and barriers to underserved populations, as well as a description of the organization's client and community demographics.(b) Direct service employees and their supervisors must also receive yearly training on the following:(1) best practices in family violence service delivery, including:(A) trauma-informed and survivor-centered advocacy and voluntary services;(B) access to services for underserved populations, including populations with disabilities;(C) the intersection of family violence and mental health;(D) the intersection of family violence and substance use;(E) technology and data safety; and(F) language and interpretation accessibility; and(2) relevant training or staff development on topics related to their job descriptions as family violence center employees. (c) Direct service supervisors must receive training that is relevant to the job descriptions of the people they supervise. (d) Employees with access to personally identifying information must receive annual training in compliance with §356.2014 of this subchapter (relating to Confidentiality and Victim-Advocate Privilege Training).(e) The training described in this section may be provided virtually or in person. Source Note: The provisions of this §356.1805 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1805 Ongoing Employee Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225133 03/12/2026 A center's facility must have: (1) a private meeting area for individual or group services; (2) access to bathroom facilities, including toilets and lavatories; (3) adequate safe space for children; (4) basic furnishings that are clean and in good repair; (5) clearly marked exits;(6) smoke detectors, fire extinguishers, current fire inspections, and fire evacuation plans; (7) secure, clearly marked locations to store cleansers, solvents, and other hazardous items out of reach from children; and(8) a stocked first-aid kit in all center facilities in central locations and communal spaces, as specified by center policy, that is accessible to all employees, volunteers, and program participants. Source Note: The provisions of this §356.1901 adopted to be effective December 23, 2007, 32 TexReg 9335; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1901 Facility Requirements for the Nonresidential Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225134 03/12/2026 All Texas Health and Human Services Commission-funded centers must have security systems that are operational 24-hours-a-day. The security system must include an alarm system, outside lighting, and secure locks. Source Note: The provisions of this §356.1902 adopted to be effective December 23, 2007, 32 TexReg 9335; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1902 Security System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225135 03/12/2026 (a) All Texas Health and Human Services Commission (HHSC)-funded centers must develop, maintain, and comply with written policies and procedures to promote the safety and security of program participants, employees, and volunteers. These policies and procedures must address: (1) intruders on the property, including an abuser; (2) assaults; (3) bomb threats; (4) threatening telephone calls; (5) natural disasters (e.g., hurricanes, tornadoes, floods, and fires);(6) epidemics, pandemics, and other public health emergencies; (7) evacuations; (8) power outages; and (9) technology safety and data security. (b) A center must notify HHSC immediately of any safety or security breaches listed in subsection (a) of this section that may disrupt services for 24 hours or longer, in accordance with §356.2026 of this subchapter (relating to Disruption in Providing Services). A center must include in the notice to HHSC an overview of the incident with the dates of impact, next steps, and a point of contact. Source Note: The provisions of this §356.1903 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.1903 Security Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225176 03/12/2026 At a minimum, a center must provide equal access to the services for victims of family violence outlined in 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act, and Texas Human Resources Code Chapter 51. Source Note: The provisions of this §356.2001 adopted to be effective December 23, 2007, 32 TexReg 9335; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2001 Required Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225177 03/12/2026 A center may not charge or solicit contributions or donations in return for Texas Health and Human Services Commission-contracted services. Source Note: The provisions of this §356.2002 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2002 Charging for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227370 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227370 03/12/2026 (a) The following individuals are eligible for services under this chapter:(1) victims of family violence or dating violence; or(2) victims of sexual assault or human trafficking when the sexual assault or human trafficking meets the definition of family violence or dating violence.(b) All victims described in this section are eligible for services regardless of the victim's current geographic location. (c) A center must not require a victim to participate in center activities as a condition of receiving services. Source Note: The provisions of this §356.2003 adopted to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2003 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225179 03/12/2026 When determining eligibility for services, a center must comply with the following applicable state and federal laws and any amendments made to each of these laws. Policies and procedures must be written to ensure compliance with: (1) 42 United States Code (U.S.C.) §2000d, et seq., Title VI of the Civil Rights Act of 1964; (2) 29 U.S.C. §701, et seq., Section 504 of the Rehabilitation Act of 1973; (3) 42 U.S.C. §12101, et seq., Americans with Disabilities Act of 1990; (4) 42 U.S.C. §§6101-6107, Age Discrimination Act of 1975; (5) 42 U.S.C. Chapter 110, the Family Violence Prevention and Services Act;(6) Texas Human Resources Code Chapter 51;(7) Texas Health and Safety Code §85.113, relating to Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection; and (8) Texas Health and Human Services Commission regulations regarding civil rights. Source Note: The provisions of this §356.2004 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2004 Federal and State Laws Regarding Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219208 03/12/2026 A center must develop, maintain, and comply with written program participant eligibility and screening procedures that are based solely on the individual's status as a victim of family violence, without regard to:(1) income;(2) whether the individual contributes, donates, or pays for these services;(3) gender; or(4) sexual orientation. Source Note: The provisions of this §356.2005 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2005 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225180 03/12/2026 A center may not deny services to an otherwise eligible victim as described in §356.2003 of this division (relating to Eligibility) unless the center adopts written policies in accordance with this section that outline specific behaviors that would make a victim ineligible for such services. Under this section, these policies must: (1) address only behaviors that threaten the safety and security of staff and program participants; (2) apply equally to all people; (3) comply with the laws and regulations described in §356.2004 of this division (relating to Federal and State Laws Regarding Eligibility); and (4) contain procedures that take into consideration the safety of the victim and requires appropriate referrals to other service providers. Source Note: The provisions of this §356.2006 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2006 Denial of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225181 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures to assess the safety of providing services to a program participant whose services were previously involuntarily terminated and who is currently requesting services.(b) A center must assess each request for service from a person who was previously involuntarily terminated.(c) A center may not deny services to a victim who was previously involuntarily terminated based solely on the victim's previous involuntary termination. Source Note: The provisions of this §356.2007 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2007 Eligibility of Previously Involuntarily Terminated Program Participants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219211 03/12/2026 A center must:(1) serve people with limited English proficiency and take reasonable steps to ensure meaningful access to the program; and(2) develop, maintain, and comply with written policies and procedures for the access and delivery of services to people with limited English proficiency. Source Note: The provisions of this §356.2008 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2008 Access to Services for People with Limited English Proficiency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225182 03/12/2026 (a) For the purposes of this section, "minor" means a person under 18 years of age who:(1) is not and has not been married; or(2) has not had the disabilities of minority removed for general purposes.(b) A nonresidential center may provide a nonresidential service to a minor if: (1) the minor consents to counseling from a licensed or certified physician, psychologist, counselor, or social worker, under Texas Family Code §32.004, for: (A) suicide prevention; (B) chemical addiction or dependency; or (C) sexual, physical, or emotional abuse; (2) the center obtains consent from the minor's parent, managing conservator, or guardian to provide the minor with nonresidential services; or (3) the center otherwise complies with Texas Family Code Chapter 32, even if the center does not obtain consent from the minor's parent, managing conservator, or guardian. (c) Notwithstanding subsection (b) of this section, a victim who is a minor may consent to a nonresidential service provided by a nonresidential center if: (1) the victim is married or has been married; or (2) the victim has had the disabilities of minority removed for general purposes. Source Note: The provisions of this §356.2009 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective December 16, 2015, 40 TexReg 8886; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2009 Nonresidential Services for a Minor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225183 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures that: (1) outline behaviors that threaten the safety and security of staff and program participants for which the center may terminate services;(2) do not allow for termination of a program participant's services for any reason other than behaviors that threaten the safety and security of staff and other program participants;(3) allow considerations for program participants to have contact with an abusive partner without grounds for termination;(4) address how current and former program participants can appeal terminations and file complaints with the center; (5) apply equally to all people;(6) comply with: (A) the laws and regulations described in §356.604 of this division (relating to Federal and State Laws Regarding Eligibility); and(B) other applicable laws and regulations; and(7) allow a resident or nonresident to voluntarily terminate their services at any time.(b) Before termination of services to a program participant, regardless of whether the participant's termination is voluntary or involuntary, the center must make reasonable efforts to: (1) assist the program participant in re-evaluating the program participant's safety plan; (2) assist in obtaining alternate resources for the program participant whose services are terminated; (3) provide written notice to the program participant of the termination; (4) provide written notice to the program participant of the right to file a complaint with the center and an explanation of the center's complaint procedure; and (5) upon request of the program participant, provide contact information to the program participant for the Texas Health and Human Services Commission Family Violence Program for complaint purposes.(c) Program participants may voluntarily terminate their services at any time. Source Note: The provisions of this §356.2010 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2010 Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225184 03/12/2026 A center must have a written general confidentiality and victim-advocate privilege policy that provides: (1) that the center will keep all information about a resident or nonresident confidential, including all personally identifying information and all communications, observations, and information made by and between or about adult and child program participants, employees, contract staff, volunteers, interns, and board members; (2) a statement about the importance of confidentiality and victim-advocate privilege in maintaining the safety of: (A) victims; (B) victims' families; (C) volunteers; (D) employees; and (E) others related to the program; (3) the parameters of what must be held confidential and by whom, including internal communications between staff regarding program participants; (4) the limits of confidentiality under the law; (5) the parameters of what must be held privileged, if claimed, and by whom, including internal communications between staff regarding program participants;(6) the limits of any victim-advocate privileged information under the law;(7) a designation of custodian of the records; (8) procedures for: (A) retention and destruction of records; (B) responses to court orders; (C) release of information; (D) reports of abuse or suspected abuse of: (i) a child; (ii) a person 65 years of age or older; and (iii) a person with a disability; (9) requests for information under the Texas Public Information Act; (10) maintenance of records; and (11) access to records that comply with confidentiality provisions in state and federal law. Source Note: The provisions of this §356.2011 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2011 General Confidentiality and Victim-Advocate Privilege Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225185 03/12/2026 (a) A center must provide to adult program participants, verbally and in writing, the following information: (1) that program participants have the right to access their records and the process by which program participants may access their records without incurring a fee; (2) the kind of information recorded, why, and the methods of collection; (3) who within the center has access to the program participant's records; (4) an overview of the center's policy and practices on confidentiality; (5) an overview of the center's policy and practices on victim-advocate privilege;(6) current state and federal laws regarding the limits of confidentiality under the law, including mandatory reporting for abuse or suspected abuse of: (A) a child; (B) a person 65 years of age and older; and (C) a person with a disability; (7) an overview of the center's policy for responding to court orders; (8) an overview of the center's policy for requests for information under the Texas Public Information Act; (9) an overview of the center's policy for release of information; (10) when the records will be decoded or destroyed; and (11) an overview of what kind of information will remain in the record after a program participant terminates services. (b) If a center is unable to provide the information described in subsection (a) of this section in writing, the center must maintain documentation stating the reason why the information could not be provided in writing. Source Note: The provisions of this §356.2012 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2012 Confidentiality and Victim-Advocate Privileged Information for Adult Program Participants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225186 03/12/2026 (a) A center must require that all employees, contract staff, volunteers, board members, interns, and adult program participants sign a confidentiality and victim-advocate agreement. The confidentiality and victim-advocate agreement must have a provision that states that confidentiality must be maintained after an employee, contract staff, volunteer, board member, intern, or program participant leaves the center. The signed confidentiality and victim-advocate privilege agreements must be placed: (1) in the personnel file of an employee; (2) in the corporate records of a board member; and (3) in the individual file of contract staff, volunteers, interns, and program participants. (b) A center must have a policy in place to ensure survivor confidentiality when a visitor is on the premises in spaces where program participants are present.(c) If a victim is unable to physically sign the confidentiality and victim-advocate privilege agreement required in subsection (a) of this section due to a bona fide emergency:(1) the victim must verbally agree to adhere to the confidentiality and victim-advocate privilege agreement; and(2) the center must:(A) maintain documentation of the verbal agreement; and(B) obtain a signed agreement as soon as feasible from the victim.(d) For the purposes of subsection (c) of this section, a "bona fide emergency" is one in which the victim has limited access to means of communication and may need to terminate communication abruptly in order to avoid detection of the communication by the victim's abuser. Source Note: The provisions of this §356.2013 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2013 Confidentiality and Victim-Advocate Privilege Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225187 03/12/2026 A center must provide training annually to employees, contract staff, board members, volunteers, and interns who have access to personally identifying information on: (1) confidentiality policies and procedures; (2) victim-advocate privilege policies and procedures;(3) the importance of confidentiality for victims of family violence; (4) how information is recorded; (5) procedures for responding to court orders and any other requests for confidential or privileged information;(6) state and federal laws regarding confidentiality; and(7) state laws regarding victim-advocate privilege under Texas Family Code Chapter 93. Source Note: The provisions of this §356.2014 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2014 Confidentiality and Victim-Advocate Privilege Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225188 03/12/2026 A center must limit the information kept, both written and electronically, in a program participant's record to information necessary for: (1) statistical and funding purposes; (2) documenting the survivor-stated need for and delivery of services; and (3) protecting the liability of the center and its employees, contract staff, volunteers, interns, and board members. Source Note: The provisions of this §356.2015 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2015 Information in Program Participant Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227371 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding entries into a program participant's file that require that:(1) each entry be attributed to and dated by the employee or volunteer entering the information;(2) a program participant's record does not include the names of other program participants; and(3) if the center provides direct services for both the victim and the abuser, the center maintains a separate record for each, one for the victim and one for the abuser.(b) A center must develop, maintain, and comply with written policies and procedures that ensure a program participant may access and review all information in the participant's record.(c) If a program participant contests an entry made in the participant's record, the center must either:(1) remove the entry from the record; or(2) if the entry is not removed, note in the record that the program participant has contested the entry.(d) A center may create and store entries to a program participant's record electronically, provided that:(1) electronic entries are secure and attributed to an individual, which may include password-protected system access; and(2) records are kept following all state and federal laws, including:(A) 42 United States Code (U.S.C.) Chapter 110, the Family Violence Prevention and Services Act; (B) §356.1903 of this subchapter (relating to Security Policies and Procedures); and (C) §356.2017 of this division (relating to Maintaining Control Over Program Participant Records). Source Note: The provisions of this §356.2016 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2016 Policies and Procedures Regarding Entries in a Program Participant's Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225190 03/12/2026 A center must develop maintain, and comply with written procedures that: (1) outline the responsibilities of the custodian of the records, designated by the center's executive director, for maintaining control over program participants' records, including a court's access to the records; (2) require that program participants' records are kept secure and not removed from the center's premises without the written permission of the custodian of the records; (3) provide for the safekeeping of program participants' records in the event of the center's closure; and (4) allow a program participant to access the program participant's record in the event of the center's closure without assessing a fee. Source Note: The provisions of this §356.2017 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2017 Maintaining Control Over Program Participant Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225191 03/12/2026 (a) A center may not release program participant information, orally or in writing, unless the program participant completes a properly executed release of information form created by the center, for the purpose of consenting to the release of the program participant's information. (b) This section does not apply when responding to subpoenas, court orders, or other requests for information with which a center is legally required to comply. However, this subsection does not prohibit a center from asserting any relevant objections, claims of privilege, or other legally permissible responses prior to releasing such information.(c) Regardless of whether a written release of information form from a program participant is obtained, a center must release information in order to comply with the applicable state laws to report abuse or suspected abuse of: (1) a child; (2) a person 65 years of age and older; and (3) a person with a disability. (d) An abuser or suspected abuser of a minor or of an individual with a guardian, as well as the abuser or suspected abuser of a survivor parent of the minor or of a guardian of the individual, may not consent to the release of the information of the minor or individual with a guardian.(e) For the purposes of this section, "minor" means a person under 18 years of age. Source Note: The provisions of this §356.2018 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2018 Release of Program Participant Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225192 03/12/2026 The release of a program participant's information form must include the following: (1) the name of no more than one person or one organization to which the information is being released; (2) the specific information to be released; (3) the beginning and ending dates the release is effective, not to exceed the program participant's active length of services; (4) the date and the signatures of the program participant and the employee or volunteer releasing the information; and (5) a statement of the program participant's right to revoke, in writing, a release of information at any time. Source Note: The provisions of this §356.2019 adopted to be effective December 23, 2007, 32 TexReg 9335; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2019 Release of Program Participant Information Form https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225193 03/12/2026 A center must develop, maintain, and comply with written policies and procedures for responding to court orders, subpoenas, search warrants, and writs of attachment. The written procedures must include: (1) what to do when a process server arrives with a court order or other legal document; (2) on whom court orders and other documents may be served, such as the custodian of the records or the executive director, or, in the executive director's absence, designated staff; (3) which attorney or attorneys should be contacted; (4) the process by which the center will make reasonable attempts to provide notice to victims affected by a potential release of information;(5) who will discuss the court order or other legal documents and legal options with the program participant or other victim of family violence, and at what point; (6) information about compliance with state and federal confidentiality and victim-advocate privilege provisions; (7) the circumstances under which records may be released; and (8) an affirmative statement that the center will take steps necessary to protect the privacy and safety of the persons affected by the release of information under state and federal laws. Source Note: The provisions of this §356.2021 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2021 Procedures Regarding Court Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225194 03/12/2026 A nonresidential center must provide services to victims of family violence a minimum of 40 hours per week with a consistent schedule of service hours that best supports the needs of the community. Source Note: The provisions of this §356.2024 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2024 Minimum Hours for a Nonresidential Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219228 03/12/2026 A center must develop, maintain, and comply with written referral procedures for helping victims of family violence obtain temporary shelter. Source Note: The provisions of this §356.2025 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2025 Requirements if a Victim of Family Violence Needs Shelter Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225195 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures for any disruption anticipated to last 24 hours or longer that may affect the ability of the center to provide services either in person, by phone, or remotely.(b) Any disruption in the ability to provide services must be reported immediately to the Texas Health and Human Services Commission (HHSC). (c) The report to HHSC required by subsection (b) of this section must include a detailed description of the disruption and how services will be or were maintained. Source Note: The provisions of this §356.2026 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2026 Disruption in Providing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219230 03/12/2026 A center must:(1) provide written rights to all program participants;(2) make reasonable accommodations to provide written rights for program participants with limited English proficiency; and(3) post program participant rights in a visible area within all center facilities. Source Note: The provisions of this §356.2027 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2027 Program Participant Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225196 03/12/2026 (a) A center must have written policies and procedures about community education that: (1) ensure that community education is provided to as many diverse groups as possible in each county where services are provided, including underserved communities; (2) focus part of the community education on informing victims of family violence of existing family violence services; and (3) comply with §356.2008 and §356.2034 of this division (relating to Access to Services for People with Limited English Proficiency and Access to Services for People with a Disability). (b) When providing community education, a center must: (1) use presentations; (2) use online media or virtual forums;(3) distribute written materials; and (4) establish and use media contacts. (c) A center may offer primary and secondary prevention as a component of community education. Source Note: The provisions of this §356.2029 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2029 Community Education and Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219235 03/12/2026 A center must provide training for direct service volunteers that includes, but is not limited to:(1) a brief history of the Texas Battered Women's Movement;(2) the need for and benefit of shelter services;(3) the dynamics of family violence;(4) a brief summary of current Texas laws that address family violence issues;(5) crisis intervention;(6) hotline skills, if applicable;(7) peer counseling techniques;(8) risk assessment and safety planning;(9) the center's policies and procedures;(10) the organization's mission and philosophy;(11) confidentiality;(12) legal options for victims of family violence;(13) economic options for victims of family violence;(14) community resources;(15) sensitivity to cultural diversity;(16) the need for community systems to be responsive to the needs of victims of family violence; and(17) applicable civil rights laws and regulations. Source Note: The provisions of this §356.2032 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2032 Content of Training for Direct Service Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225197 03/12/2026 If a nonresidential center has non-direct service volunteers, the center must provide non-direct service volunteers with: (1) a basic orientation of the duties they perform; (2) the center's policies and procedures regarding confidentiality and victim-advocate privilege; and (3) basic information about the organization's mission, philosophy, and policies. Source Note: The provisions of this §356.2033 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2033 Content of Training for Non-Direct Service Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225198 03/12/2026 (a) A nonresidential center must:(1) serve people with a disability and take reasonable steps to ensure meaningful access to the program;(2) take appropriate steps to ensure that communications with a victim with a disability, a victim's dependents with a disability, and members of the public with a disability are as effective as communications with persons who do not have a disability; and(3) furnish appropriate auxiliary aids and services when necessary to ensure that eligible individuals with a disability, including a victim, a victim's dependents, and members of the public have equitable access to services.(b) Auxiliary aids and services described in subsection (a)(3) of this section may include qualified interpreters and large print materials. Source Note: The provisions of this §356.2034 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2034 Access to Services for People with a Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225199 03/12/2026 A nonresidential center must:(1) develop, maintain, and comply with a written advocacy service model that is: (A) voluntary;(B) trauma-informed; and(C) respects an individual's needs;(2) develop training requirements for all employees, contract staff, interns, and volunteers that provide direct services to survivors regarding the advocacy service model, including the importance of and best practices for voluntary and trauma-informed services; and (3) have written policies and procedures to evaluate the effectiveness of the service model and report the results to the Texas Health and Human Services Commission as requested. Source Note: The provisions of this §356.2035 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2035 Service Model https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225200 03/12/2026 (a) A center must provide access to the following services directly, by referral, or through formal arrangements with other agencies, and have written procedures regarding these services as described in this subchapter: (1) 24-hour-a-day shelter; (2) a crisis call hotline available 24 hours a day, in compliance with §356.2008 and §356.2034 of this subchapter (relating to Access to Services for People with Limited English Proficiency and Access to Services for People with a Disability); (3) emergency medical care; (4) crisis and intervention services, including understanding and support, information, education, referrals, and other resource assistance; (5) emergency transportation; (6) advocacy focused on: (A) economic and housing stability;(B) physical, behavioral, and mental health;(C) the needs of children who are victims and the children of victims; and(D) the civil and criminal legal systems, including identifying individual needs, legal rights and legal options, and providing support and accompaniment in pursuing those options;(7) ongoing safety planning services in collaboration with the self-stated priorities and needs of the victim of family violence;(8) community education regarding family violence and family violence prevention efforts;(9) counseling services; and(10) peer support services led by victims of family violence, including activities and other efforts that facilitate connections and the creation of community among victims of family violence.(b) All services must be provided under a voluntary and trauma-informed service model as described in §356.2035 of this subchapter (relating to the Service Model). Source Note: The provisions of this §356.2101 adopted to be effective December 23, 2007, 32 TexReg 9335; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2101 Nonresidential Center Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225201 03/12/2026 (a) A center must regularly report complete and accurate data through the secure file transport protocol designated by the Texas Health and Human Services Commission (HHSC). Data submission is due by the deadline specified in the HHSC contract related to family violence service delivery. HHSC reserves the right to impose sanctions if a center does not submit complete and accurate data by the deadline specified in the contract. (b) If extenuating circumstances exist, a center must notify HHSC in writing before the due date of the data submission to request an extension of said due date. (c) A center must contact HHSC via email within two business days of discovering data errors or inconsistencies that will result in the center's inability to report accurate data in a timely manner.(d) When collecting and reporting data, a center must comply with state and federal confidentiality provisions. Data a center submits must be in the aggregate and not contain personally identifying information.(e) Program participant data collected for HHSC reporting must be provided voluntarily by a program participant and a program participant may refuse to offer any element of data at any time.(f) A center must notify HHSC within 24 hours after discovery of a data breach. Notification must include all information reasonably available to the center about the breach and contact information for the center's point of contact who will communicate with HHSC regarding the breach.(g) A center must provide written notification to HHSC by the third business day after discovery of a data breach of the following:(1) all reasonably available information about the data breach, and the center's investigation, to the extent practicable; (2) the date the data breach occurred;(3) the date of the center's and, if applicable, subcontractor's discovery of the data breach;(4) a brief description of the data breach, including how it occurred and who is responsible (or hypotheses, if not yet determined);(5) a brief description of the center's investigation into the data breach and the status of the investigation;(6) a description of the types and amount of confidential information involved;(7) the steps the center has taken to mitigate any harm or potential harm caused by the data breach, including without limitation the provision of sufficient resources to mitigate;(8) the steps the center has taken, or will take, to prevent or reduce the likelihood of recurrence of a similar data breach;(9) identify and describe any law enforcement that may be involved in the response to the data breach;(10) a reasonable schedule for the center to provide regular updates regarding response to the data breach; and(11) any reasonably available, pertinent information, documents, or reports related to the data breach that HHSC requests following the report of the data breach. Source Note: The provisions of this §356.2102 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2102 Reporting Data to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227372 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227372 03/12/2026 (a) A center must operate a hotline and comply with Texas Health and Human Services Commission (HHSC) requirements unless another organization located in the nonresidential center's service area provides a hotline that complies with HHSC requirements.(b) If a center operates a hotline, the center must:(1) ensure that an individual trained in crisis intervention, or who has immediate access to someone who has had training, answers the crisis call hotline 24-hours-a-day, every day of the year;(2) accept collect calls and anonymous incoming calls;(3) list the hotline number across all relevant publications in the center's service area and on the center's website, if applicable;(4) provide a minimum of two hotline telephone lines;(5) ensure that the caller has direct access to a live person who is trained to assess the caller's safety and that a messaging system is not used to answer the hotline;(6) provide caller identification (ID) blocks on the center's numbers for outgoing calls;(7) ensure compliance with all state and federal laws, including §356.2004 of this subchapter (relating to Federal and State Laws Regarding Eligibility), when using the hotline to determine eligibility for services;(8) keep all hotline calls and any related documentation confidential;(9) provide equitable access to persons with a disability, as required by §356.2034 of this subchapter (relating to Access to Services for People with a Disability);(10) ensure the center can provide equitable access to people with limited English proficiency as required by §356.2008 of this subchapter (relating to Access to Services for People with Limited English Proficiency); and(11) if the center uses caller ID or any other technology that establishes a record of calls on the hotline, the center must:(A) ensure there will not be a breach of confidentiality to third parties; and(B) follow the confidentiality requirements stated in the contract for family violence services with HHSC about the records created by caller ID or other technology. Source Note: The provisions of this §356.2103 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970; amended to be effective January 29, 2026, 51 TexReg 408. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2103 Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225203 03/12/2026 (a) A center may transfer its crisis call hotline to another center only if:(1) there is a telephone or staffing disruption that will last for more than twenty-four hours;(2) the transferring center develops, maintains, and complies with written policies and procedures that address how the center receiving the transferred hotline calls meets the Texas Health and Human Services Commission's (HHSC) training requirements for all direct service staff and ensures immediate access to the accepting center's 24-hours-a-day services; and(3) the transferring center obtains HHSC's approval of the arrangement with the center accepting the transferred calls.(b) A center may transfer its crisis call hotline without obtaining HHSC's approval as described in subsection (a) of this section only when the center transfers the hotline to the National Domestic Violence Hotline.(c) A center may not transfer its crisis call hotline to law enforcement. Source Note: The provisions of this §356.2104 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2104 Transferring the Crisis Call Hotline https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225204 03/12/2026 A center is not required to provide or pay for emergency medical care, but must: (1) maintain a current list of medical care resources that meet the diverse needs of survivors, including preventative care, and that can provide medical services for victims of family violence and their dependents, including, when available: (A) local affordable options; and(B) local physical, mental, and behavioral health resources; (2) develop, maintain, and comply with written policies and procedures about providing or arranging for emergency transportation to and from emergency medical facilities for program participants or victims of family violence and their dependents being considered for acceptance as program participants; and (3) maintain and provide standard first aid medical supplies that are accessible to program participants 24-hours-a-day. Source Note: The provisions of this §356.2105 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2105 Medical Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225205 03/12/2026 (a) A center must ensure that an orientation is provided to a program participant verbally and in writing. The orientation must be documented and comply with the requirements in this chapter, as appropriate, and the Family Violence Prevention and Services Act (42 United States Code (U.S.C.) Chapter 110) regulations. The orientation must include:(1) an explanation of services available; (2) the center's termination policy; (3) program participants' rights; (4) a nondiscrimination statement, in accordance with the Family Violence Prevention and Services Act (42 U.S.C. Chapter 110); (5) complaint procedures;(6) contact information for the Texas Health and Human Services Commission (HHSC), as specified in the center's contract with HHSC; (7) safety and security procedures; (8) confidentiality and limits of confidentiality, as well as victim-advocate privilege and limits of victim-advocate privilege; (9) waivers of liability; and (10) a wellness check for all family members that addresses each person's immediate needs. (b) If a center is unable to provide the program participant's orientation in writing, the center must maintain documentation of the reason. Source Note: The provisions of this §356.2106 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2106 Program Participant's Orientation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225206 03/12/2026 (a) A center must document in writing each program participant's self-stated needs and requests for available services to address these needs.(b) A center must attempt to re-evaluate the needs of a program participant regularly and at re-entry to the center.(c) A center must not use a program participant's needs assessment to require the program participant to participate in services. Source Note: The provisions of this §356.2107 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2107 Needs Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225207 03/12/2026 A center must provide at least one weekly voluntary support group for adult program participants. Source Note: The provisions of this §356.2108 adopted to be effective December 23, 2007, 32 TexReg 9335; amended to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2108 Support Groups https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225208 03/12/2026 A center must: (1) have developmentally appropriate services available that are specific to meet the needs of children, including information and referral services; and (2) make reasonable accommodations to provide voluntary, developmentally appropriate recreational or social activities for children during the time in which the adult parent is receiving in-person services. Source Note: The provisions of this §356.2110 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507; amended to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2110 Delivery of Children's Direct Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219187 03/12/2026 (a) A center must develop, maintain, and comply with written nonviolent disciplinary policies and procedures regarding child program participants, including policies and procedures for adult program participants, employees, and volunteers who provide services to children.(b) A center must develop, maintain, and comply with written policies and procedures to:(1) ensure the safety of children in its facilities; and(2) maintain the safety of children when employees or volunteers take children on outings. Source Note: The provisions of this §356.2111 adopted to be effective September 1, 2013, 38 TexReg 4309; transferred effective April 1, 2024, as published in the March 8, 2024, issue of the Texas Register, 49 TexReg 1507. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2111 Safety Policies and Procedures for Delivering Services to Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225209 03/12/2026 A center that provides child care at the center may be subject to Texas Health and Human Services Commission regulation under Texas Human Resources Code Chapter 42, relevant sections of Chapter 745, Chapter 743, and Chapter 746 of this title (relating to Licensing, Minimum Standards for Shelter Care, and Minimum Standards for Child-Care Centers, respectively), and the relevant set of minimum standards. Source Note: The provisions of this §356.2112 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2112 Child Care Permit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225210 03/12/2026 (a) A center must develop, maintain, and comply with written policies and procedures regarding program participants' access to client assistance funds, when funds are available, that are consistent and equitable.(b) A center must provide direct client assistance funds to program participants in compliance with the laws and regulations described in §356.2004 of this subchapter (relating to Federal and State Laws Regarding Eligibility). Source Note: The provisions of this §356.2114 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2114 Client Assistance Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225211 03/12/2026 (a) A center must ensure counseling services are available to a program participant either by: (1) employees, contract staff, interns, or volunteers of the center; or(2) counseling services providers contracted by the center.(b) If a center is unable to provide counseling services in accordance with subsection (a) of this section, the center may offer a referral to a counseling service that is no cost to a program participant.(c) Counseling services can include both traditional and non-traditional modalities of counseling and support to meet the mental health and wellness needs of a program participant. Source Note: The provisions of this §356.2115 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM D NONRESIDENTIAL CENTERS §356.2115 Counseling Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225132 03/12/2026 The Texas Health and Human Services Commission (HHSC) shall create and maintain a written notice to be provided to victims of family violence, stalking, harassment, or terroristic threat to assist those in victims in obtaining services. The notice must be:(1) available in both English and Spanish;(2) available on the HHSC website; and(3) reviewed annually to determine if changes to the notice are necessary. Source Note: The provisions of this §356.2201 adopted to be effective May 20, 2025, 50 TexReg 2970. 1 HEALTH AND HUMAN SERVICES COMMISSION 356 FAMILY VIOLENCE PROGRAM E WRITTEN NOTICE TO VICTIMS §356.2201 Written Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225250 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225250 03/12/2026 The program provides services that promote to the fullest extent the integration and inclusion of a person with significant disabilities into society. Source Note: The provisions of this §357.101 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM A GENERAL RULES §357.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225251 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225251 03/12/2026 The legal authority for the program is published in the following federal and state law: (1) 29 United States Code (U.S.C.) §§796a-796f-6; (2) 45 Code of Federal Regulations, Part 1329; and(3) Texas Human Resources Code §117.080. Source Note: The provisions of this §357.103 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM A GENERAL RULES §357.103 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225252 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225252 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. (1) Ability to pay--The determination that a person is able to contribute financially toward the cost of independent living services. (2) Accessible format--An alternative way of providing to a person with disabilities the same information, functionality, and services provided to a person without a disability. Examples of accessible formats include braille, accessible digital content, large print, American Sign Language, and recorded audio. (3) Act--The Rehabilitation Act of 1973, as amended. (4) Adjusted income--The dollar amount that is equal to a household's annual gross income, minus allowable deductions. (5) Allotment--Funds distributed to a service provider by HHSC to provide services under this chapter. (6) Allowable deductions--Certain unreimbursed household expenses that are subtracted from a household's annual gross income to calculate the adjusted income. (7) Blind--A condition of having no more than 20/200 visual acuity in the better eye with correcting lenses or having visual acuity greater than 20/200 but with a field of vision in which the widest diameter subtends an angle no greater than 20 degrees. (8) CAP--Client Assistance Program. A federally funded initiative that provides information, assistance, and advocacy for people with disabilities who are seeking or receiving services from CAPs funded under the Act. The CAP is implemented by Disability Rights Texas (DRTx), a legal services organization whose mission is to protect the human, service, and legal rights of persons with disabilities in Texas. (9) CIL--Center for Independent Living. A private nonprofit agency for people with significant disabilities (regardless of age or income) that is not residential, is consumer-controlled, is community-based, takes a cross-disability approach; and(A) is designed and operated within a local community by persons with disabilities; and(B) provides an array of independent living services, including, at a minimum, independent living core services as they are defined in 29 United States Code (U.S.C.) §705(17).(10) Comparable services or benefits--Services and benefits that are provided or paid for, in whole or part, by other federal, state, or local public programs; by health insurance, third-party payers, or other private sources; or by the employee benefits that are available to a person and are commensurate in quality and nature to the services that the person would otherwise receive from a service provider. (11) Consumer participation--The financial contribution that a person may be required to pay for receiving independent living services. (12) Consumer participation agreement--A document signed by a person and a CIL that outlines the percentage of adjusted income a person is required to contribute toward the cost of services.(13) Consumer participation system--The system for determining and collecting the financial contribution that a person may be required to pay for receiving independent living services. (14) Federal poverty level guidelines--The poverty guidelines updated periodically in the Federal Register by the United States Department of Health and Human Services under the authority of 42 U.S.C. §9902(2). (15) Fee--A percentage of the full cost for a purchased service that a person pays. The percentage is based on the HHSC fee schedule and the fee does not exceed the maximum amount prescribed by HHSC. (16) HHSC--The Texas Health and Human Services Commission. (17) Independent living plan--A written plan in which a person and service provider have collaboratively identified the services that are needed to achieve the person's goal of living independently. (18) Independent Living Services Program--The group authorized to oversee the services outlined in 29 U.S.C. §705(17) and (18). In Texas, that authority rests with HHSC. May also be referred to as "the program."(19) Nonprofit organization--Any corporation, trust, association, cooperative, or other organization, not including an institution of higher education, that: (A) is operated primarily for scientific, educational, service, charitable, or similar purposes in the public interest; (B) is not organized primarily for profit; and (C) uses net proceeds to maintain, improve, or expand the operations of the organization. (20) Person--Anyone who has requested, applied for, or is receiving services through the Independent Living Services Program. (21) Private--An agency, organization, or institution that is not under federal or public supervision or control. (22) Representative--Anyone chosen by a person served in the program, including the person's parent, guardian, other family member, or advocate. If a court has appointed a guardian or representative, that person is the representative. Unless documentation is provided showing otherwise, a parent or court-appointed guardian is presumed to be the representative for a person who is under 18 years of age and is not emancipated or married.(23) Service provider--A CIL, nonprofit organization, organization, or other person who contracts with HHSC to provide independent living services. (24) Severe visual impairment--A condition of having a visual acuity with best correction of 20/70 or less in the better eye, a visual field of 30 degrees or less in the better eye, or having a combination of both. (25) Significant disability--A severe physical, mental, cognitive, or sensory impairment that substantially limits a person's ability to function independently in the family or community. (26) Sliding fee scale--The fee scale HHSC uses to determine the maximum financial contribution that a person may be required to pay for receiving independent living services. The scale is based on the federal poverty level guidelines.(27) Support services--Accommodations provided to a person to assist the person at an appointment with a service provider or vendor. Examples include translators, interpreters, braille, large print, and transportation.(28) Transition services--Services that: (A) facilitate the transition of a person with a significant disability from nursing homes and other institutions to home and community-based residences, with the requisite supports and services; (B) provide assistance to a person with a significant disability who is at risk of entering an institution so that the person may remain in the community; and (C) facilitate the transition of youth with significant disabilities, who were eligible for individualized education programs under section 614(d) of the Individuals with Disabilities Education Act, 20 U.S.C. §1414(d), and have completed secondary education or have otherwise left school to postsecondary life. (29) Vendor--A person or organization subcontracted by a service provider to provide independent living services.(30) Waived independent living plan--A written plan in which the service provider identifies on the behalf of the person the services that are needed to achieve the person's goal of living independently. The service provider writes the plan because the person has signed a waiver giving up the person's right to participate in the development of such a written plan. (31) Youth with a disability--A person with a disability who is at least 14 years of age but younger than 24 years of age. Source Note: The provisions of this §357.105 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM A GENERAL RULES §357.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225253 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225253 03/12/2026 (a) A service provider must adhere to the service provider's contracts and either the Independent Living Services Standards for Providers or the Independent Living Base/Operational Grant Standards for Service Providers, depending on the type of contract. (b) A service provider must ensure the quality of any services subcontracted to a vendor. Source Note: The provisions of this §357.107 adopted to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM A GENERAL RULES §357.107 Service Provider Standards and Contract Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225254 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225254 03/12/2026 (a) HHSC allocates to each service provider the funds needed to carry out the rules in this chapter. HHSC may consider the following when determining the amount allotted to each service provider: (1) service area; (2) population of the area served; and (3) history of service delivery. (b) Each service provider must administer the funds in accordance with the rules in this chapter. (c) When HHSC determines that a service provider will not spend all of the funds allotted for a fiscal year to carry out the rules in this chapter, HHSC may allot the projected unused portion to other service providers to provide the covered services in this chapter. The extra allotment is considered an increase in the other service providers' allotments for that fiscal year. (d) A service provider ensures comparable services or benefits are exhausted before using funds allocated under this chapter. Source Note: The provisions of this §357.201 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM B ALLOCATION OF FUNDS §357.201 Allocation of Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204052 03/12/2026 This subchapter provides information on independent living services. Source Note: The provisions of this §357.301 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM C INDEPENDENT LIVING SERVICES §357.301 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225255 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225255 03/12/2026 (a) To be eligible for independent living services, a person must: (1) have a significant disability as defined in §357.105 of this chapter (relating to Definitions); and (2) reside in Texas. (b) For purchased services, a service provider determines eligibility based on the documented diagnosis of a licensed practitioner, either at the at the time of eligibility or prior to the purchase of goods and services. For core services, a service provider may determine eligibility without a documented diagnosis. (c) Eligibility requirements are applied without regard to a person's race, religion, color, national origin, disability, age, sex, or in retaliation for prior civil rights activity. (d) After a service provider documents a person is eligible for services, the service provider: (1) notifies the person or the person's representative in writing about the person's fee, as described in §357.401 of this chapter (relating to Consumer Participation System); (2) verifies all potential comparable services or benefits that may be covered for independent living services, as provided under this chapter; and(3) maintains all related documentation. (e) If a service provider determines that a person is ineligible based on the criteria described in this section, the service provider must document the determination of ineligibility and provide HHSC with a copy that is signed and dated by the service provider's executive director or designee. (1) A service provider may determine a person to be ineligible for independent living services only after consultation with the person or the person's representative or after providing a clear opportunity for consultation. (2) A service provider notifies a person in writing of the action taken and informs the person or the person's representative about the person's rights and the means by which the person may appeal the action taken or file a complaint. (3) A service provider refers the person to other agencies and facilities, if appropriate, including to the Texas Workforce Commission's vocational rehabilitation program. (4) If a service provider determines that a person is ineligible for independent living services, the service provider reviews the person's status again within 12 months of the determination and whenever the service provider determines that the person's status has materially changed. (5) A service provider does not conduct a review of an ineligibility determination if:(A) the person refuses one;(B) the person no longer resides in Texas; or(C) the person's whereabouts are unknown. Source Note: The provisions of this §357.305 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM C INDEPENDENT LIVING SERVICES §357.305 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225256 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225256 03/12/2026 (a) General. (1) Unless a person signs a waiver in accordance with paragraph (2) of this subsection, a service provider works with the person or the person's representative to develop and periodically review an independent living plan in accordance with this section. (2) If a person or the person's representative knowingly and voluntarily signs a waiver stating that the person or the person's representative waives the right to participate in developing an independent living plan, a service provider develops a waived independent living plan on the person's behalf. (3) A service provider must provide each independent living service in accordance with the independent living plan or waived independent living plan. (b) Initiation and development of an independent living plan or a waived independent living plan. (1) A service provider develops a person's independent living plan or waived independent living plan after the person's eligibility is documented according to §357.305 of this subchapter (relating to Eligibility). The plan explains the goals or objectives established and the services to be provided. The plan indicates the anticipated duration of the service plan and the duration of each service. (2) A service provider provides a copy of the independent living plan or waived independent living plan and any amendments in an accessible format to the person or the person's representative. (c) Review. (1) An independent living plan or waived independent living plan is reviewed as often as necessary but at least annually to determine whether to continue, modify, or discontinue services or refer the person to a vocational rehabilitation program or other program. (2) A person reviews the independent living plan and, if necessary, revises it and agrees by signature to its terms. (d) Coordinating services. A person's independent living plan or waived independent living plan must be coordinated by the service provider, to the extent possible, with any of the following programs: (1) a vocational rehabilitation program; (2) a habilitation program, prepared under the Developmental Disabilities Assistance and Bill of Rights Act of 2000;(3) an education program, prepared under Part B of the Individuals with Disabilities Education Act; and(4) other community, state, or federal programs that align with the person's independent living goals.(e) Termination of services. If a service provider intends to terminate services to a person, the service provider documents the reason on the independent living plan or waived independent living plan and follows the procedures described in §357.305(e)(2) - (5) of this subchapter. Source Note: The provisions of this §357.307 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM C INDEPENDENT LIVING SERVICES §357.307 Independent Living Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225257 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225257 03/12/2026 (a) Independent living services are provided when funding is available. (b) A person is placed on a waiting list by a service provider when: (1) the service provider determines the person meets the eligibility requirements described in §357.305 of this subchapter (relating to Eligibility); (2) the person has an independent living plan or a waived independent living plan; and (3) there is no funding for a service on the independent living plan or the waived independent living plan that must be purchased. (c) A service provider must review the service provider's waiting list every six months to determine whether a person is still eligible for and interested in services. (d) A person is removed from a service provider's waiting list when:(1) funding becomes available; (2) the person is no longer eligible; or(3) the person is no longer interested in receiving services. Source Note: The provisions of this §357.309 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM C INDEPENDENT LIVING SERVICES §357.309 Waiting List https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225258 03/12/2026 (a) All services listed in subsection (d) of this section are subject to the funds HHSC allocates to each service provider as described in §357.201 of this chapter (relating to Allocation of Funds). (b) A service provider must make all services available in an accessible format for a person who relies on alternative modes of communication. (c) A service provider must provide each independent living service in accordance with a person's independent living plan or waived independent living plan. (d) A service provider may provide the following services under this chapter: (1) independent living core services, which are: (A) information and referral services; (B) independent living skills training; (C) peer counseling, including cross-disability peer counseling; (D) individual and systems advocacy; and (E) transition services; and (2) independent living services, which are: (A) counseling services, including psychological and psychotherapeutic services; (B) services for securing housing or shelter, including community living, that support the purposes and titles of the Act, and services related to securing adaptive housing, including making appropriate modifications to spaces that serve or are occupied by a person with a disability; (C) rehabilitation technology; (D) mobility training; (E) services and training for a person with cognitive and sensory disabilities, including life skills training and interpreter and reader services; (F) surveys, directories, and other materials that identify appropriate housing, recreation opportunities, accessible transportation, and other support services; (G) consumer information programs on the rehabilitation and independent living services that are available under the Act; (H) education and training necessary for living in a community and participating in community activities; (I) transportation, including referral services and training on the use of public transportation vehicles and systems; (J) physical rehabilitation; (K) therapeutic treatment; (L) the provision of needed prostheses and other appliances and devices; (M) social and recreational services, including individual and group; (N) training for youth with a disability that is designed to develop self-awareness, self-esteem, and the ability to self-advocate, self-empower, and explore career options; (O) services for children younger than 18 years of age; (P) federal, state, or local training, counseling, or other assistance designed to help a person with a significant disability become independent and productive and live a good life; (Q) preventive services that encourage independence and reduce the need for the services that are available under the Act; (R) awareness programs that encourage an understanding of a person with a significant disability and help the person integrate into the community; and (S) other services, as needed, which are consistent with the provisions of the Act. Source Note: The provisions of this §357.311 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM C INDEPENDENT LIVING SERVICES §357.311 Scope of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225259 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225259 03/12/2026 (a) A service provider administers the consumer participation system in accordance with the rules in this chapter, the standards, and the contract requirements. (b) A service provider provides independent living core services, as described in §357.311(d)(1) of this chapter (relating to Scope of Services), at no cost to the person. (c) Independent living services as described in §357.311(d)(2) of this chapter are subject to the rules in this subchapter. (d) A service provider gathers financial information about a person to determine the person's adjusted gross income and the percentage of the federal poverty level for that income. (e) A service provider charges a person a fee for each independent living service described in §357.311(d)(2) of this chapter, according to the person's percentage of the federal poverty level. Medical records charges, support services, and diagnostic assessments or evaluations for the purchase of independent living services are exempt from consumer participation.(f) A person or the person's representative signs a consumer participation agreement. Signing the agreement acknowledges the amount of the person's fee and provides written agreement that: (1) the information provided by the person or the person's representative about the person's household size, annual gross income, allowable deductions, and comparable services or benefits is true and accurate; or(2) the person or the person's representative chooses not to provide information about the person's household size, annual gross income, allowable deductions, and comparable services or benefits. (g) A service provider does not initiate or authorize the independent living services described in §357.311(d)(2) of this chapter until the person or the person's representative signs the consumer participation agreement. (h) If a person or the person's representative chooses not to provide information on the person's household size, annual gross income, allowable deductions, and comparable services or benefits, the person or the person's representative agrees to pay the entire cost of services. (i) A person reports to the service provider as soon as possible all changes to household size, annual gross income, allowable deductions, and comparable services or benefits and signs a new consumer participation agreement. (j) When a person signs a new consumer participation agreement, the new amount of the person's fee takes effect the beginning of the following month. The new amount is not retroactive. (k) A service provider must develop a process to reconsider a person's ability to pay the fee and adjust the person's fee based on circumstances that are both extraordinary and documented.(l) Only a service provider's executive director or designee has authority to reconsider and adjust a person's fee. (m) Extraordinary circumstances are: (1) an increase or decrease in income; (2) unexpected medical expenses; (3) unanticipated disability related expenses; (4) a change in family size; (5) catastrophic loss, such as a fire, flood, or tornado; (6) short-term financial hardship, such as a major repair to the person's home or personally owned vehicle; or (7) other extenuating circumstances for which the person makes a request and provides supporting documentation. (n) A person's calculated fee remains in effect during the reconsideration and adjustment process. (o) A service provider must: (1) only use program income that is received from the consumer participation system to provide the independent living services described in §357.311(d)(2) of this chapter; and (2) report fees collected to HHSC as program income. (p) A service provider must not use program income received from the consumer participation system to supplement funds from any other sources. (q) HHSC does not pay any portion of a person's fee. (r) A consumer participation agreement and all financial information collected by a service provider are subject to: (1) any data use agreement between HHSC and the service provider; and(2) subpoena. Source Note: The provisions of this §357.401 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM D CONSUMER PARTICIPATION §357.401 Consumer Participation System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225260 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225260 03/12/2026 (a) A service provider is required to use the HHSC fee schedule and instructions to calculate a person's fee. (b) Factors that affect a person's fee are: (1) household size; (2) annual gross income; and (3) allowable deductions. (c) Household size equals:(1) any person living inside or outside of the home who is eligible to be claimed as a dependent of a person on the person's federal income tax return; or(2) if a person is under 18 years of age, any other person living inside or outside of the home who is eligible to be claimed as a dependent of the person's parent or guardian on the parent or guardian's federal income tax return. (d) A person's annual gross income: (1) equals the total annual gross income received by the household; and (2) includes all income classified as taxable income by the Internal Revenue Service before federally allowable deductions are applied. (e) A person's allowable deductions are limited to expenses in the following categories: (1) attendant care; (2) rent or home mortgage payments; (3) court-ordered child support payments made by the person for financially dependent children who were not included in the calculation of household size; and (4) medical or dental expenses for treatment primarily intended to alleviate or prevent a physical or mental illness or manage a disability, with the expenses limited to the cost of: (A) diagnosis, cure, alleviation, treatment, or prevention of disease; (B) treatment of any affected body part or function; (C) medical services legally delivered by physicians, surgeons, dentists, and other medical practitioners; (D) medications, medical supplies, and diagnostic devices; (E) medical and dental health care insurance premiums; (F) transportation to receive medical or dental care; and (G) medical or dental debt that the family is paying on an established payment plan. (f) A service provider calculates the allowable deductions using the actual amounts a person paid during the previous 12-month period. (g) A person provides the most recent tax return available as proof of annual gross income and allowable deductions. If a person has no tax return, the person provides bank statements, medical records, receipts, proof of benefits awards, or other documentation to demonstrate annual gross income and allowable deductions. (h) If a person does not provide documentation supporting the household's allowable deductions, the service provider determines the person's fee based on the person's documented annual gross income with no allowable deductions. (i) A person's fee is equal to the amount on the HHSC fee schedule according to the household's annual adjusted income, that is, the annual gross income minus the allowable deductions. (j) A service provider uses the most current fee schedule and instructions published by HHSC to determine a person's fee. (k) The procedures, fee schedule, and instructions used to calculate a person's fee is available from HHSC between 8:00 a.m. and 5:00 p.m. on business days. Source Note: The provisions of this §357.403 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM D CONSUMER PARTICIPATION §357.403 Fee Schedule Amount https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225261 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225261 03/12/2026 (a) If a person has medical insurance that covers an independent living service received by the person, then the person's fee is either the insurance deductible, copayment, or coinsurance, or the amount calculated by the HHSC fee schedule, whichever is less. (b) A person pays the premiums for medical insurance. Neither HHSC nor a service provider pays the premiums. (c) The premiums for medical insurance do not count toward meeting the person's fee. Source Note: The provisions of this §357.405 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM D CONSUMER PARTICIPATION §357.405 Insurance Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225262 03/12/2026 (a) In accordance with applicable legal provisions, HHSC does not, directly or through contractual or other arrangements, exclude, deny benefits to, limit the participation of, or otherwise discriminate against any person on the basis of race, religion, color, national origin, disability, sex, age, or in retaliation for prior civil rights activity. For the purposes of receiving independent living services, a person must have a significant disability; however, that requirement is not considered discrimination against anyone on the basis of disability. (b) A service provider must notify a person in writing about the rights included in subsection (a) of this section; §357.401 of this chapter (relating to Consumer Participation System); and §357.503 of this subchapter (relating to Complaint Process):(1) when a person applies for services; (2) when the service provider determines that a person is ineligible for services; and (3) when the service provider intends to terminate a person's services. (c) A service provider must make personal rights available in an accessible format for a person who relies on alternative modes of communication. Source Note: The provisions of this §357.501 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM E PERSONAL RIGHTS §357.501 Personal Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225263 03/12/2026 (a) Filing a complaint through the HHSC Office of Ombudsman. (1) A person may file a complaint with the HHSC Office of Ombudsman alleging that a service provider violated a requirement of the program. A person may file a complaint directly with the HHSC Office of Ombudsman without filing the complaint with the service provider. (2) A complaint may be filed by: (A) mail: Texas Health and Human Services Commission, Office of the Ombudsman, MC H-700, P.O. Box 13247, Austin, Texas 78711-3247; (B) phone: 1-877-787-8999 or Relay Texas for people with a hearing or speech disability at 7-1-1 or 1-800-735-2989; (C) fax: 1-888-780-8099; or (D) online: on the HHS website, HHS Office of the Ombudsman. (3) More information regarding the complaint process may be obtained by calling the Office of the Ombudsman at 1-877-787-8999 or Relay Texas for people with a hearing or speech disability at 7-1-1 or 1-800-735-2989.(b) Filing a discrimination complaint with the HHSC Civil Rights Office (CRO).(1) The HHSC CRO sets policies and procedures to address complaints resulting from alleged discrimination.(2) A person may file a complaint with the HHSC CRO alleging that HHSC or an HHSC agency contractor discriminated against the person based on a protected category listed in §357.501(a) of this subchapter (relating to Personal Rights). A person may file a complaint directly with the HHSC CRO without filing the complaint with the service provider.(3) A discrimination complaint may be filed by:(A) phone: 1-888-388-6322 or 512-438-4313;(B) email: HHSCCivilRightsOffice@hhs.texas.gov;(C) fax: 512-438-5885; or(D) mail: Civil Rights Office, Health and Human Services Commission, P.O. Box 13247, Mail Code 1560, Austin, Texas 78711.(c) Filing a complaint with the Client Assistance Program (CAP). (1) The CAP is implemented by Disability Rights Texas (DRTx), a legal services organization whose mission is to protect the human, service, and legal rights of persons with disabilities in Texas. (2) DRTx advocates are not employees of HHSC. There are no fees for CAP services, which are provided by advocates and attorneys when necessary. Services are confidential. (3) A person enrolled in the program or the person's representative may file a complaint with DRTx alleging that a service provider violated a requirement of the program. A person may file a complaint directly with DRTx without filing the complaint with the service provider. (4) A complaint may be filed by: (A) phone: 1-800-252-9108; or (B) videophone: 1-866-362-2851. (5) More information about the complaint process is available by calling DRTx at 1-800-252-9108 or videophone at 1-866-362-2851. Source Note: The provisions of this §357.503 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM E PERSONAL RIGHTS §357.503 Complaint Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225264 03/12/2026 (a) HHSC provides technical assistance to a service provider, as needed, to help the service provider offer a full range of independent living services. (b) Technical assistance provided by HHSC may include: (1) help to expand a service provider's capacity to provide a full range of independent living services; and (2) training on: (A) the independent living philosophy; and (B) the administration, operation, evaluation, and performance of independent living services according to the rules in this chapter, the standards, and the contract requirements. Source Note: The provisions of this §357.601 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM F TECHNICAL ASSISTANCE AND TRAINING §357.601 Technical Assistance Provided by HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225265 03/12/2026 (a) HHSC refers a person seeking independent living services to a service provider as described in subsection (b) of this section. (b) If a person calls HHSC to request independent living services, HHSC: (1) gives the person the contact information for the nearest service provider, which can be found on the HHSC website under Independent Living Services; (2) obtains the person's permission to forward the person's name and contact information to the service provider; and (3) forwards the person's name and contact information to the service provider. Source Note: The provisions of this §357.701 adopted to be effective August 31, 2016, 41 TexReg 6066; transferred effective March 15, 2021, as published in the Texas Register February 26, 2021, 46 TexReg 1387; amended to be effective June 3, 2025, 50 TexReg 3248. 1 HEALTH AND HUMAN SERVICES COMMISSION 357 INDEPENDENT LIVING SERVICES PROGRAM G REFERRALS §357.701 Referrals Received by HHSC Employees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205563 03/12/2026 The purpose of the Texas Health and Human Services Commission (HHSC) Children's Autism Program is to provide autism services to children 3 through 15 years of age with an autism spectrum disorder. Services are provided through grant contracts with local community agencies and organizations utilizing Applied Behavior Analysis (ABA) or other treatment approaches. HHSC is authorized to implement the program only to the extent that funds are appropriated by the Texas Legislature. Source Note: The provisions of this §358.101 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM A GENERAL RULES §358.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224575 03/12/2026 The following statutes authorize the funding and rules for this program: (1) Texas Human Resources Code, §111.051; (2) Texas Human Resources Code, Chapter 117; and (3) Texas Government Code, §524.0005. Source Note: The provisions of this §358.103 adopted to be effective September 1, 2014, 39 TexReg 6680; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173; amended to be effective April 1, 2025, 50 TexReg 2209. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM A GENERAL RULES §358.103 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205565 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Adjusted gross income--The gross income of the family, as defined in this section, minus allowable deductions. Adjusted gross income is used to determine the amount of the monthly financial contribution required by a family.(2) Allowable deductions--Expenses that are not reimbursed by other sources. Allowable deductions are limited to:(A) the actual medical or dental expenses of the parent or dependent that are primarily related to alleviating or preventing a physical or mental defect or illness, were paid over the previous 12 months, are expected to continue during the eligibility period, and are limited to the cost of:(i) diagnosis, cure, alleviation, treatment, or prevention of disease;(ii) treatment of any affected body part or function;(iii) legal medical services delivered by physicians, surgeons, dentists, and other medical practitioners;(iv) medication, medical supplies, and diagnostic devices;(v) premiums paid for insurance that covers the expenses of medical or dental care;(vi) transportation to receive medical or dental care; and(vii) medical or dental debt that is being paid on an established payment plan;(B) child-care and respite expenses for a family member;(C) costs and fees associated with the adoption of a dependent child; and(D) court-ordered child support payments paid for a child who is not counted as a family member or dependent.(3) Applied behavior analysis (ABA)--The design, implementation, and evaluation of systematic environmental changes to produce socially significant change in human behavior through skill acquisition and the reduction of problematic behavior. Applied behavior analysis includes direct observation and measurement of behavior and the identification of functional relations between behavior and the environment. Contextual factors, establishing operations, antecedent stimuli, positive reinforcers, and other consequences are used to produce the desired behavior change.(4) Autism spectrum disorders--The disorders found in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) related to autism. An autism spectrum disorder (ASD) diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified, made under a previous DSM, is acceptable.(5) BCaBA--A board certified assistant behavior analyst.(6) BCBA--A board certified behavior analyst.(7) BCBA-D--A board certified behavior analyst-doctoral.(8) Child--A son, daughter, foster child, or stepchild who is under age 19 living in the home.(9) Contractor--A service provider under contract with HHSC to provide autism services.(10) Cost share--The amount of monthly financial contribution required of a family for a child to participate in the HHSC Children's Autism Program, as described in Subchapter F of this chapter (relating to Cost Share). The cost share is determined using the HHSC Fee Schedule and any applicable insurance deductible, coinsurance, and co-pay amounts. The cost share is the lesser of the fee determined using the HHSC fee schedule, or applicable insurance deductible, coinsurance, and co-pay amounts.(11) HHSC Comprehensive ABA services--ABA services that are provided to children 3 through 5 years of age by a HHSC contractor to treat all areas of developmental and behavioral needs.(12) HHSC Focused ABA services--ABA services that are provided to children 3 through 15 years of age by a HHSC contractor to treat one or more deficits or behaviors of excess rather than the full range of developmental domains.(13) Dependent--A child age 19 or older, parent, stepparent, grandparent, brother, sister, stepbrother, stepsister, or in-law; whose gross income is less than $3,900 a year; and for whom more than half of the person's support is provided for by the parent(s) or guardian(s) during the calendar year.(14) Direct contact--A term that applies to any person who has physical contact with, physical access to the home of, communication with, or access to confidential information regarding a child enrolled in the HHSC Children's Autism Program or the child's family. Direct contact does not include casual or inadvertent physical contact with, communication with, or contact at an educational presentation or seminar with a child enrolled in the HHSC Children's Autism Program or the child's family.(15) Family--The child's parent(s) or guardian(s), the child, other children under 19 years of age and other dependents of the parent or guardian.(16) Fiscal year--The state fiscal year. Begins on September 1 and ends on August 31 of the following year.(17) Gross income--All income received by the family for determination of the family's cost share, from whatever source, that is considered income by the Internal Revenue Service before federal allowable deductions are applied.(18) HHSC--The Texas Health and Human Services Commission.(19) Individualized Education Program (IEP)--A written document that is developed for each public school child who is eligible for special education.(20) Interest list--A list, maintained by the contractor, of families who have indicated an interest in receiving services, and who meet the eligibility criteria.(21) LEA--Local educational agency.(22) Parent--The child's natural or adoptive parent; or the child's guardian.(23) Parent training--Training that is provided to a parent or guardian as part of the ABA service, in the language used by the parents of the child when feasible. It is delivered either individually or in a group in a home, school, or clinic setting. It includes providing parent education on ABA in general; working collaboratively with parents to identify ways they can help their child at home to generalize learning to other environments, including school settings; and data review, program adjustment, and planning.(24) Qualified professional--An actively licensed physician or psychologist with training and background related to the diagnosis and treatment of neurodevelopmental disorders.(25) Texas resident--A person who resides in Texas and intends to remain in the state, either permanently or for an indefinite period.(26) Third-party payer--A company, organization, insurer, or government agency other than HHSC that makes payment for health care services received by an enrolled child.(27) Transition plan--A plan that identifies and documents appropriate steps and transition services to support the child and family to smoothly and effectively transition from the HHSC Children's Autism Program to LEA special education services or other community activities, places, or programs the family would like the child to participate in after exiting the HHSC Children's Autism Program.(28) Treatment plan--A written plan of care, including treatment goals, for providing HHSC autism treatment services to an eligible child and the child's family to enhance the child's development. The intensity and length of Children's Autism Program services is determined by the treatment goals included in the treatment plan. However, the length of autism services shall not exceed 24 months. Source Note: The provisions of this §358.105 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM A GENERAL RULES §358.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205566 03/12/2026 The purpose of this subchapter is to provide information regarding HHSC Focused ABA services. Source Note: The provisions of this §358.301 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.301 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205567 03/12/2026 (a) To be eligible for HHSC Focused ABA services, a child must:(1) be a Texas resident as defined in §105.105 of this chapter (relating to Definitions);(2) have a documented diagnosis on the autism spectrum made by a qualified professional; and(3) be 3 through 15 years of age.(b) Children become eligible on their third birthday and become ineligible on their 16th birthday.(c) The parent must participate in parent training, defined in §105.105 of this chapter in order for their child to receive services.(d) Eligibility for HHSC Focused ABA services does not guarantee enrollment into the HHSC Children's Autism Program. A child considered eligible for services by the contractor based on the criteria in this section is added to the contractor's interest list when there is no opening or funding available for HHSC Focused ABA services in the local HHSC Children's Autism Program. Source Note: The provisions of this §358.307 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.307 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205568 03/12/2026 (a) The contractor must:(1) enroll eligible children in HHSC Focused ABA services in accordance with the eligibility criteria in §105.307 of this subchapter (relating to Eligibility);(2) provide written information to families regarding the estimated maximum monthly cost of service and the estimated amount of cost share that will be required for payment of services based on the fee schedule and any applicable insurance deductible, co-insurance and co-pay described in Subchapter F of this chapter (relating to Cost Share);(3) verify benefits for all children identified with potential third-party payer coverage for services provided in the Autism Program and maintain related documentation on file; and(4) provide written notification of rights of the child and parents or guardians noted in Subchapter E of this chapter (relating to Autism Program Rights).(b) An offer of enrollment into HHSC Focused ABA services is based on the continued availability of funding and the contractor's ability to serve more children.(1) When a contractor is not immediately able to accept an eligible child into the HHSC Children's Autism Program, and the family is interested in enrolling in services, the contractor places the family on an interest list. The interest list is reviewed every six months to determine if families are still eligible and interested in services.(2) Children are removed from the interest list when an opening for services is available, the child is no longer eligible for the HHSC Children's Autism Program, or when the family indicates they are no longer interested.(3) Children who have received Focused Applied Behavior Analysis (ABA) Services and have remaining months of eligibility are given priority over children on the interest list who have not previously received services when they apply for additional Focused ABA Services if they continue to meet eligibility criteria and funds and staff capacity are available. Source Note: The provisions of this §358.309 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.309 Enrollment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205569 03/12/2026 The contractor must:(1) develop a written treatment plan with the family for each child served, including plans for generalization of learned skills and behaviors to other environments;(2) provide and document parent training as a component of the services. Documentation must include:(A) the date of the training;(B) the names of those who participated in the training; and(C) any information that was discussed and shared by the contractor;(3) provide ongoing analysis and evaluation of each child's progress;(4) document services provided to each child;(5) collect data on operationally defined target behaviors. Data on at least three data points will be collected at baseline, during treatment, and post-treatment for each behavior that is identified in the child's treatment plan. No additional pre- and post-testing is required;(6) document efforts to coordinate services with the school setting the child attends to promote generalization;(7) create with the family and maintain documented transition plans for each child leaving services;(8) maintain in the child's record the following documentation related to the transition plan:(A) timelines for each transition activity;(B) the family's choice for the child to transition into a community or educational program or for the child to remain in the home; and(C) appropriate steps and transition services to support the family's exit from the HHSC Children's Autism Program services to LEA special education services or other appropriate activities, places, or programs the family would like the child to participate in after exiting services; and(9) document all services provided, including parent training, including:(A) child's name;(B) date of service;(C) start and end time of service;(D) location of service;(E) names of those present for service;(F) contractor's signature;(G) description of the service and goals addressed; and(H) progress toward goals. Source Note: The provisions of this §358.311 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.311 Services Provided https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205570 03/12/2026 (a) The length of services for a child is based on the child's specific needs but must not exceed a maximum of 24 months in the HHSC Children's Autism Program in any combination of Comprehensive or Focused ABA services.(b) The contractor may provide up to 720 total hours of HHSC Focused ABA services to a child as long as the child meets the eligibility requirements in §105.307 of this chapter (relating to Eligibility). The contractor may not exceed 180 hours within a year of the first date of service.(c) The time-limited services are not affected by any modifications in the contract between HHSC and the contractors, or a change in the contractor.(d) HHSC Focused ABA services end when treatment goals are met or when service limits have been reached.(e) Service limits have been reached when the child:(1) has received 180 hours of services in a year;(2) has received 720 hours before his or her 16th birthday; or(3) reaches his or her 16th birthday.(f) Children who exit HHSC Focused ABA services with remaining hours of service may reapply for additional HHSC Focused ABA services based on the eligibility criteria in §105.307 of this chapter, the child's needs, available funding, and the contractor's ability to serve more children in accordance with §105.307 of this chapter. These children are given priority over children on the interest list who have not previously received services.(g) A family may choose to continue receiving services, at the family's expense, from the contractor after service limits noted in subsection (b) of this section have been reached. HHSC is not liable for any costs incurred after service limits have been reached, including any costs incurred by a contractor providing those services. Source Note: The provisions of this §358.313 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.313 Length of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205571 03/12/2026 (a) The child must attend at least 85 percent of scheduled HHSC Focused ABA services over the year. This is necessary for the child to fully benefit from the services, regardless of the reason for the absence.(b) Participation in parent training, a minimum of once every two weeks as defined in §105.105(23) of this chapter (relating to Definitions), is required for a child to receive services.(c) The parent and the child must participate in pre-test protocols upon enrollment into HHSC Focused ABA services. The parent and the child must participate in post-test protocols before exiting HHSC Focused ABA services.(d) If the parent and the child fail to meet these requirements, the child may be dismissed from the HHSC Children's Autism Program. The requirements may be waived with written approval by HHSC. Source Note: The provisions of this §358.315 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM C DARS FOCUSED ABA SERVICES §358.315 Participation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205572 03/12/2026 (a) In accordance with applicable legal provisions, the HHSC Children's Autism Program does not, directly, or through contractual or other arrangements, exclude, deny benefits to, limit the participation of, or otherwise discriminate against any person on the basis of age, color, disability, national origin, political belief, race, religion, sex, or sexual orientation. For purposes of this program, the child must have an autism spectrum disorder, and that requirement is not considered discrimination against any person on the basis of disability.(b) During the enrollment process, the contractor is required to provide the children and parents written notification of their rights included in subsection (a) of this section; §105.509 of this subchapter (relating to Complaint Process); §105.511 of this subchapter (relating to Confidentiality of Information); and §105.605(b) of this chapter (relating to Cost Share). Source Note: The provisions of this §358.507 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM E AUTISM PROGRAM RIGHTS §358.507 Rights of Children and Parents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205573 03/12/2026 (a) An individual or organization on behalf of a child enrolled in the HHSC Children's Autism Program may file a complaint with HHSC alleging that a requirement of the HHSC Children's Autism Program was violated. A complaint may be filed directly with HHSC without having been filed with the contractor.(b) A complaint regarding the HHSC Children's Autism Program must be filed within 180 calendar days of the alleged violation. A complaint filed 180 calendar days after the alleged violation may be dismissed without further review by the HHSC Children's Autism Program.(c) A complaint may be filed in any of the following ways:(1) by phone to the HHS Office of the Ombudsman at 1-877-787-8999; or(2) by online submission at hhs.texas.gov/ombudsman.(d) The complaint must contain the following information:(1) the name of the person filing the complaint;(2) the name of the child for whom the complaint is filed;(3) the name of the contractor;(4) the date of the incident;(5) the requirement and/or rule that was allegedly violated;(6) a summary of the facts of the alleged violation; and(7) the relief requested.(e) HHSC staff:(1) logs the date the complaint was received;(2) evaluates the complaint and seeks facts from the parties involved;(3) provides a written decision within 60 calendar days to the complainant addressing each allegation;(4) provides technical assistance and appropriate follow-up to the parties involved in the complaint as necessary; and(5) retains the documentation of the complaint for five years.(f) A complainant may appeal the determination of the complaint in writing. Such appeals must be submitted within 30 calendar days from the date of the written decision and will be addressed within 30 calendar days of receipt by HHSC. The appeal determination is final.(g) More information regarding the complaint process may be obtained by calling the HHS Office of the Ombudsman at 1-877-787-8999. Source Note: The provisions of this §358.509 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM E AUTISM PROGRAM RIGHTS §358.509 Complaint Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205574 03/12/2026 (a) The parent or guardian of a child who has been determined eligible for services must be afforded the opportunity to inspect and review any records relating to evaluations and assessments, eligibility determination, development and implementation of the treatment plan, individual complaints dealing with the child, and any other area involving records about the child and the child's family. If requested in writing by the child or the child's parent/guardian, the contractor must make all requested information in that child's record of services accessible to and must release the information to the requesting party in a timely manner. This includes a verified request for release of records by the child or parent/guardian to a third party. The right to inspect and review records under this section includes the right to:(1) a written response from the contractor to reasonable requests for explanations and interpretations of the records;(2) request that the contractor provide copies of the records containing the information if failure to provide those copies would effectively prevent the parent from exercising the right to inspect and review the records; and(3) have the child's or the parent's representative inspect and review the records.(b) The contractor may presume that the parent has authority to inspect and review records relating to his or her child unless the agency has been advised in writing with supporting documentation that the parent does not have the authority under applicable state law governing such matters as guardianship, separation, and divorce.(c) If any record includes information on more than one child, the parent of those children shall have the right to inspect and review only the information relating to their child or to be informed of that specific information. The provider will redact information regarding any other child from the record.(d) The contractor must, on request, provide the parent a list of the types and locations of service records collected, maintained, or used by the contractor. Source Note: The provisions of this §358.511 adopted to be effective December 22, 2015, 40 TexReg 9307; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM E AUTISM PROGRAM RIGHTS §358.511 Confidentiality of Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205575 03/12/2026 (a) Children who participate in the Autism Program must receive ABA services provided by staff under the supervision of master's or doctoral level Board Certified Behavior Analysts (BCBA or BCBA-D certification). BCBA or BCBA-D staff must have:(1) at least one year of experience in providing services to children within the age range of 3 through 15 years of age with diagnoses on the autism spectrum;(2) documented graduate-level coursework in behavioral assessment and intervention, selecting outcomes and strategies, behavior change procedures, experimental methods, and measuring and interpreting behavioral data; and(3) knowledge of typical child development for children 3 through 15 years of age.(b) All direct service staff members must receive training before working independently and on an ongoing basis.(c) The details of additional staff qualifications, including required supervision and training, are found in §392.203, Staff Qualifications, as it appears in Title 1, Part 15, Texas Health and Human Services Commission, Chapter 392, Purchase of Goods and Services for Specific Health and Human Services Commission Programs. Source Note: The provisions of this §358.515 adopted to be effective December 22, 2015, 40 TexReg 9307; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM E AUTISM PROGRAM RIGHTS §358.515 Staff Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205576 03/12/2026 (a) The family's cost share amount is the lesser of the:(1) HHSC fee schedule amount; or(2) applicable deductible, copayment, and coinsurance amounts when the family has insurance that covers the ABA services.(b) If the parent disagrees with the contractor's determination of the family's ability to pay the cost share, the parent can:(1) request a review by the contractor's manager or program director;(2) file an informal or formal complaint with the contractor;(3) contact the HHS Office of the Ombudsman at 1-877-787-8999, for help resolving a problem or concern with the contractor; and(4) file a formal complaint with HHSC as noted in §105.509 of this chapter (relating to Complaint Process). Source Note: The provisions of this §358.605 adopted to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM F COST SHARE §358.605 Cost Share https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205577 03/12/2026 (a) The contractor is required to use the HHSC Fee Schedule and instructions to calculate the monthly fee owed by the family for the services of each eligible child.(b) Factors that affect the amount of monthly fee include the:(1) monthly costs of services provided by the contractor as determined by the number of hours of service provided multiplied by the contractor's negotiated hourly rate with HHSC;(2) adjusted gross income of the family as determined by the federal tax return filed for the previous year; or if the family did not file, the family's gross income minus the allowable deductions as defined in §105.105 of this chapter (relating to Definitions);(3) family size calculated by summing the number of parents or guardians, the child, and other dependents of the parents or guardians as defined in §105.105 of this chapter; and(4) number of children from a single family who are enrolled in the HHSC Children's Autism Program.(c) The fee for a single family with multiple children in service must be calculated for each child monthly. The family will owe 100 percent of the fee amount for the child with the highest fee and 50 percent of each additional child's fee.(d) Information about HHSC procedures and the fee schedule used to administer the HHSC Children's Autism Program are available on the HHSC website. Source Note: The provisions of this §358.607 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM F COST SHARE §358.607 HHSC Fee Schedule Amount https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205578 03/12/2026 If the family has insurance that covers the ABA services and the in-network provider agreement between the insurance company and the HHSC Autism contractor requires that the contractor accept the deductible, copayment, or coinsurance and insurance reimbursement as payment in full, then the family's cost share amount is the lesser of the HHSC fee schedule amount or the deductible, copayment, or coinsurance. Source Note: The provisions of this §358.608 adopted to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM F COST SHARE §358.608 Insurance Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205579 03/12/2026 HHSC funds must not be used to pay for any portion of the required cost share. To the extent that the family or child is entitled to insurance-payment for services or receives payment for services from other governmental programs, third-party payers, or other private sources, HHSC funds must not be used to pay for the services until all other methods of payment have been applied. Source Note: The provisions of this §358.609 adopted to be effective September 1, 2014, 39 TexReg 6680; amended to be effective December 22, 2015, 40 TexReg 9307; amended to be effective September 4, 2018, 43 TexReg 5683; transferred effective August 1, 2021, as published in the July 9, 2021 issue of the Texas Register, 46 TexReg 4173. 1 HEALTH AND HUMAN SERVICES COMMISSION 358 CHILDREN'S AUTISM PROGRAM F COST SHARE §358.609 Payer of Last Resort https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207552 03/12/2026 The Blind Children's Vocational Discovery and Development Program (BCVDD Program) is administered by the Department of Assistive and Rehabilitative Services (DARS), Division for Blind Services (DBS). The purpose of the BCVDD Program is to supplement services provided by other state agencies to children who are blind and visually impaired. Source Note: The provisions of this §359.1 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207553 03/12/2026 The following statutes and regulations authorize or require the rules in this subchapter:(1) Texas Human Resources Code, §91.028; and(2) Texas Human Resources Code, §117.073. Source Note: The provisions of this §359.3 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.3 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207554 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.(1) Allowable costs--Expenses relating to case management services that are reasonable and necessary in the normal conduct of operations.(2) Blind--A visual loss that results in the best corrected visual acuity of 20/200 or less in the better eye, or a visual loss that results in a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees, which means a field of view no greater than 20 degrees in the better eye.(3) Case management--Assisting an eligible child under this subchapter in gaining access to medical, social, educational, vocational, and other appropriate services to help the child reach or maintain an optimal level of functioning in a community-based setting.(4) Case management bundled monthly rate--A prospective rate based on the average monthly cost of providing case management services for an eligible child under this subchapter.(5) Case note--A record of significant interactions in the provision of services. Case notes should document:(A) the place of service;(B) who was present when the service was provided;(C) the BCVDD Program Specialist's participation in the provision of services;(D) the relationship of the services provided to the child's plan of care/identified needs;(E) a summary of the child's response to services provided and observations of skills assessed;(F) impact of the identified need on the consumer; and(G) the plan for services to meet the identified needs or account of follow-up on services delivered.(6) Comparable services and benefits--Any service, benefit, or resource available to a child from another public or private source that provides in whole or in part the services that the child would otherwise receive from DARS DBS.(7) Comprehensive Assessment--An assessment, completed by the BCVDD Program specialist, for each consumer, in order to identify and describe the consumer's and family's needs.(8) Consumer--A child and/or family of a child with a visual impairment who has applied for, or who is receiving BCVDD Program services.(9) Contact--An action taken by a BCVDD Program specialist on behalf of an eligible child under this subchapter to locate, coordinate, and monitor necessary and appropriate services with a specific person or organization. A contact may be face-to-face or by telephone.(10) Core Service Areas--Service areas that all consumers need to master in order to successfully achieve personal and vocational goals, including: Adjustment to Blindness, Independent Living skills, Travel skills, Communication skills, Support Services, and Vocational Discovery and Development.(11) Deafblind--A combined loss of vision and hearing that significantly affects access to communication, learning, socialization, activities of daily living, and mobility.(12) Developmental services--Services that increase the capabilities and functional abilities of a child in a noneducational setting.(13) Educational support services--Services that help a child gain the maximum benefit from educational services provided by others.(14) Family service plan--A formal plan that is responsive to the child's needs; is developed and approved by the BCVDD Program specialist, family, and/or child; and contains a description of the child's planned services, agreements between the parent and DARS DBS, and other information necessary to administer the provisions of this subchapter.(15) Federal poverty guidelines--The poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services under the authority of 42 U.S.C. §9902(2).(16) Habilitation services--Services that develop a severely visually impaired child's skills for independent living and potential employment.(17) Nonsevere visual loss--A visual acuity in which one eye meets the definition of blind or severe visual loss and the acuity in the other eye with best correction is better than 20/70, or the visual acuity in both eyes with best correction is better than 20/70.(18) Parent--The child's natural or adoptive parent; or the spouse of the child's natural or adoptive parent; or the child's guardian or surrogate parent; or the spouse of the guardian or surrogate parent; or a person or spouse of the person who is acting as the child's parent. The person who is authorized to sign the application and plan, and who is authorized to make decisions regarding the child's services.(19) Permanent severely visually impaired child--A child with a visual impairment that has resulted in a permanent condition of blindness or severe visual loss; or a child who has been certified as blind or severely visually impaired by a local education agency; or a child who has been determined to be functioning as a person who is blind or who has a severe visual loss.(20) Referral--A child who has been referred to the BCVDD Program for services but for whom an application has not been completed.(21) Restoration services--Services to eliminate or reduce limitations imposed by a visual impairment on the functioning of a child and cosmetic services necessary to improve the physical appearance of the child's eyes when the eyes are abnormal to the extent that they negatively affect the child's social and emotional well-being.(22) Severe visual loss--A loss of vision in which the best corrected visual acuity is between 20/70 and 20/200 in the better eye; or a visual loss in which the visual field is 30 degrees or less but greater than 20 degrees with best correction.(23) Technology services--Services to provide a child access to an item, piece of equipment, or product system that maintains or improves the child's communication, independent living, social skills, or prevocational skills.(24) Visual impairment--An injury, disease, or other disorder that reduces, or if not treated will probably result in reducing, visual functioning; or a visual condition requiring cosmetic treatment, psychological assistance, counseling, or other assistance that DARS DBS can render. Source Note: The provisions of this §359.5 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207555 03/12/2026 (a) All forms and documents used in the administration of the BCVDD Program are available at any DARS DBS office, including the Central Office at 4800 North Lamar, Austin, Texas, between 8:00 a.m. and 5:00 p.m. on workdays.(b) DARS DBS rules are published on the DARS website at www.dars.state.tx.us. Source Note: The provisions of this §359.7 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.7 Public Access to Information, Forms, and Documents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207556 03/12/2026 (a) DARS DBS must consider comparable services and benefits before expending funds for all BCVDD Program services.(b) The child's parent must apply for assistance from any resource identified by DARS DBS that may be a resource for comparable services and benefits.(c) The child's parent must provide acceptable evidence of eligibility or ineligibility for comparable services and benefits to DARS DBS within 90 days from application, or additional expenditures may be suspended.(d) Whenever possible and practical, the child's parent's choice of health care professionals and other appropriate health care providers is honored, as long as the professionals and other appropriate health care providers are willing to accept reimbursement in accordance with §102.213 of this title (relating to Alternative Purchasing Methods - Rates for Medical Services).(e) DARS DBS must verify a child's eligibility for Medicaid at the time of application if the parent's income falls at or below 185 percent of the federal poverty guidelines as determined under the provisions of Division 4 of this subchapter (relating to Economic Resources and Consumer Participation). Source Note: The provisions of this §359.9 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.9 Comparable Services and Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207557 03/12/2026 DARS DBS does not pay for any service that is the school's responsibility under the Individuals with Disabilities Education Act (IDEA) or any federal or state rules and regulations adopted under IDEA. Source Note: The provisions of this §359.11 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.11 Services Provided by Schools https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207558 03/12/2026 All personal information furnished to and gathered by DARS DBS in the administration of this chapter, including names, addresses, records of agency evaluations, reports of medical examinations and treatments, financial information, and photographs, are confidential under Texas Human Resources Code §91.028(f) - (g). Source Note: The provisions of this §359.13 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.13 Confidentiality of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207559 03/12/2026 (a) BCVDD Program services must be initiated timely and delivered according to the family service plan.(b) Service delivery staff members are given written guidelines and training on:(1) developing comprehensive assessments and family service plans;(2) measuring and documenting consumer progress toward an expected outcome; and(3) authorizing services timely.(c) Specified time frames serve as benchmarks to service delivery staff members and monitoring staff members in evaluating a consumer's progress towards the expected outcome in the service plan.(d) Service delivery is monitored by supervisory or program specialist staff members through the use of onsite visits and a standard case review checklist. The checklist must contain sufficient information to evaluate case documentation, timely service delivery, and child progress toward goals. Source Note: The provisions of this §359.15 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.15 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207560 03/12/2026 (a) A child may be referred to the BCVDD Program by providing a name and address to any DARS DBS office by letter, telephone, direct contact, or another means.(b) BCVDD Program may refer a child to another DARS program if necessary to better meet the child's needs.(c) A child is considered an applicant for BCVDD Program services on the day DARS DBS receives a completed and signed application. Source Note: The provisions of this §359.51 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.51 Referral and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207561 03/12/2026 (a) To be eligible to receive services under this subchapter, an applicant must:(1) have a visual impairment;(2) reside in Texas; and(3) be 18 years of age or younger.(b) A person at least 18 years of age but under age 22 who meets the criteria in subsection (a)(1) and (2) of this section and who is enrolled in a secondary school may receive services under this subchapter if DARS DBS determines that children's services are appropriate for the person.(c) Eligibility requirements are applied without regard to the age, gender, race, color, creed, or national origin of the applicant.(d) Funding and providing services may be restricted by other criteria in the rules of this subchapter. Source Note: The provisions of this §359.53 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.53 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207562 03/12/2026 DARS DBS does not pay for any service that has not been authorized in advance. Source Note: The provisions of this §359.55 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.55 Prior Authorization of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207563 03/12/2026 (a) DARS DBS completes a comprehensive assessment to collect information to develop a family service plan that is designed to achieve the consumer's and family's habilitation goals.(b) The comprehensive assessment gathers information in all the core service areas to determine the need for medical, educational, developmental, social, or other services. Information to form a complete assessment is gathered by:(1) taking history of the child;(2) observing the child;(3) identifying the child's needs; and(4) gathering information from other sources, such as family members, medical providers; and educators. Source Note: The provisions of this §359.57 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.57 Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207564 03/12/2026 (a) DARS DBS develops a family service plan jointly with the child's parent when it has been determined that the child needs habilitation services.(b) The family service plan contains a description of the child's planned services, agreements between the parent and DARS DBS, and other information necessary to administer the provisions of this subchapter. Source Note: The provisions of this §359.59 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.59 Family Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207565 03/12/2026 (a) DARS DBS closes a child's case when:(1) the child is no longer eligible under §106.1423 of this subchapter (relating to Eligibility);(2) the child's planned services have been completed;(3) the child cannot be located;(4) the child has died; or(5) the parent refuses to cooperate with DARS DBS.(b) DARS DBS must inform the child's parent of its intent to close the child's case by sending a letter to the parent's last known address. No notice is sent if the case is being closed because of the death of the child. Source Note: The provisions of this §359.61 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.61 Case Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207566 03/12/2026 (a) A case may be reopened if the child's visual condition has worsened or the child needs additional habilitative services.(b) A case must not be reopened for the sole purpose of providing routine eye exams, glasses, contact lenses, or treatment such as drops for glaucoma and conjunctivitis, unless the BCVDD Program specialist suspects that a child's vision is threatened because of abuse or medical neglect. Source Note: The provisions of this §359.63 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.63 Reopening Closed Cases https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207567 03/12/2026 Services in this Division that are not case management services, with the exception of purchasing copies of existing records, are subject to application of Division 4 of this subchapter (relating to Economic Resources and Consumer Participation) and Division 5 of this subchapter (relating to Methods of Administration of BCVDD Program). Source Note: The provisions of this §359.101 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.101 Scope of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207568 03/12/2026 DARS DBS may pay for medical and diagnostic assessments jointly agreed to by the BCVDD specialist and parent that are necessary to determine the eligibility of a child and to initiate a service plan upon a finding of eligibility. Source Note: The provisions of this §359.103 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.103 Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207569 03/12/2026 DARS DBS may pay for physical examinations and other necessary medical specialty examinations jointly agreed to by the BCVDD Program specialist and parent when the BCVDD Program specialist determines that the examination is necessary for the child to participate in planned services. Source Note: The provisions of this §359.105 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.105 Physical Examinations and Other Medical Specialty Examinations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207570 03/12/2026 DARS DBS may provide nonmedical diagnostic evaluations that are necessary to plan developmental services only for children receiving habilitation services and if jointly agreed to by the BCVDD Program specialist and parent. Source Note: The provisions of this §359.107 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.107 Diagnostic Evaluations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207571 03/12/2026 The BCVDD Program pays for restoration services that are necessary to correct or substantially modify a child's eye condition within a reasonable period of time. Source Note: The provisions of this §359.109 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.109 Restoration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207572 03/12/2026 (a) The BCVDD Program may pay for travel services for the child and parents or travel companions when travel is necessary for services under this subchapter.(b) Travel services available to the child's parents or travel companions without cost to DARS DBS must be used first. Source Note: The provisions of this §359.111 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.111 Travel https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207573 03/12/2026 The BCVDD Program pays for child-care services provided only for parents of children receiving habilitation services and only to allow the family to participate in services that are expected to substantially contribute to the child's ability to benefit from habilitation services. Source Note: The provisions of this §359.113 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.113 Child Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207574 03/12/2026 DARS DBS may provide the following habilitation services only for a child and/or the family of a child who meets the definition of a "permanent severely visually impaired child":(1) adjustment to blindness services;(2) independent living skills;(3) travel;(4) communication;(5) support systems; and(6) vocational discovery and development. Source Note: The provisions of this §359.115 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.115 Habilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207575 03/12/2026 (a) Case management contacts on behalf of any eligible child under age 21 are subject to this subchapter, regardless of the family's ability to pay.(b) Case management means services provided under this subchapter to help BCVDD Program-eligible children gain access to medical, social, educational, vocational, and other appropriate services to help them reach or maintain an optimal level of functioning in a community-based setting. Case management includes:(1) coordinating the performance of evaluations and assessments including eye exams, eye specialty exams, and/or exams under anesthesia; arranging for other medical or nonmedical diagnostics; helping the family understand the results of diagnostic examinations; and communicating the results of diagnostic evaluations and assessments to educators and other professionals involved with the child;(2) facilitating the development, review, and evaluation of the family service plan in accordance with §106.1427 of this subchapter (relating to Assessment) and DARS DBS procedures; the plan is based on the child's applicable history and identified needs, the parent's input, and the results of all evaluations and assessments;(3) helping the family identify available service providers and making appropriate referrals to obtain services from medical, social, and educational providers to address identified needs and achieve goals;(4) following up with the family to help with timely access to services, to discuss the disposition of the referral with the family, and to determine if the services have met the child's needs;(5) monitoring and reassessing the delivery and effectiveness of services through contacts with the child, family members, school staff members, and service providers as frequently as necessary and at least annually to determine if:(A) services are being provided in accordance with the family service plan;(B) services are adequate; and(C) when the child has new needs or there are changes in the needs of the child, the family service plan and service arrangements are adjusted to address the identified needs;(6) facilitating the child's transition to educational, habilitative, or vocational services as appropriate;(7) documenting all case management activities, the child's and family's response to case management, whether the child and family have declined any services in the plan, and coordination with other case management providers.(c) Case management may be delivered face-to-face or by telephone.(1) Contacts are billable when the interaction:(A) is with an eligible child, and/or the child's parent, the child's caregiver, or other people directly related to identifying the eligible child's needs;(B) helps the eligible child access services;(C) identifies needs and supports to help the eligible child obtain services;(D) provides the BCVDD Program Specialist with useful feedback; or(E) alerts the BCVDD Program Specialist to changes in the eligible child's needs.(2) Contacts are billable to the family according to §106.1463 of this subchapter (relating to Case Management Reimbursement Charges).(d) Case management services are not billable to Medicaid when another payor is liable for payment or when case management services are associated with the proper and efficient administration of the state plan. Case management services associated with the following are not payable as optional case management services under Medicaid and may not be billed to families of children not receiving Medicaid:(1) Medicaid eligibility determinations and redeterminations;(2) Medicaid eligibility intake processing;(3) Medicaid preadmission screening;(4) prior authorization for Medicaid services;(5) required Medicaid utilization review;(6) Texas Health Steps program administration;(7) Medicaid "lock-in" provided for under the Social Security Act, §1915(a);(8) services that are an integral or inseparable part of another Medicaid service;(9) outreach activities that are designed to locate people who are potentially eligible for Medicaid; and(10) any medical evaluation, examination, or treatment billable as a distinct Medicaid-covered benefit. Source Note: The provisions of this §359.117 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.117 Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207576 03/12/2026 In order to receive BCVDD Program case management services, the recipient must meet the criteria established in §106.1423 of this subchapter (relating to Eligibility), have an identified need for case management, and agree to receive services. Source Note: The provisions of this §359.119 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.119 Eligibility for BCVDD Program Case Management Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207577 03/12/2026 (a) Medicaid-eligible people. Any Medicaid-eligible person whose request for eligibility for case management is denied or is not acted upon with reasonable promptness, or whose case management has been terminated, suspended, or reduced is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(b) All children. If BCVDD Program denies, involuntarily reduces, or terminates case management for a child, the child and family have all rights to file complaints in accordance with Texas Human Resources Code §117.028 and §117.072, and Division 6 of this subchapter (relating to Complaint Resolution Process). Source Note: The provisions of this §359.121 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.121 Due Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207578 03/12/2026 (a) DARS bills for case management contacts at a case-management bundled monthly rate equal to the rate set annually for case-management reimbursements to the Texas Health and Human Services Commission for Medicaid recipients.(b) A family who does not have Medicaid is billed on a sliding scale, based on the family's gross income and the number of persons residing in the household for whom the parent or legal guardians have legal and/or financial responsibility. Written information about the different levels at which families are billed is available according to §106.1407 of this subchapter (relating to Public Access to Information, Forms, and Documents). Source Note: The provisions of this §359.123 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.123 Case Management Reimbursement Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207579 03/12/2026 (a) The parent's economic resources must be determined before DARS DBS authorizes the purchase of certain services contained in Division 3 of this subchapter (relating to Services).(b) A child in the managing conservatorship of the Department of Family and Protective Services is considered to be a one-member family with no income.(c) Parents have the right to not disclose their economic resources. When this information is not disclosed, DARS DBS determines economic resources to be in excess of the allowable amount.(d) To determine the parent's participation in the cost of services that require an expenditure of BCVDD Program funds, DARS DBS considers the parent's gross monthly income, the number of family members for which the parent has financial responsibility, and the type of services the child is receiving. These factors shall be applied to percentages of the currently applicable federal poverty guidelines. Information about the currently applicable federal poverty guidelines, categories of services, and percentages in use by DARS DBS is available as described in §106.1407 of this subchapter (relating to Public Access to Information, Forms, and Documents).(e) Parents with gross monthly incomes at or below the percentage of federal poverty guidelines in use by DARS DBS are not required to pay part of the cost of services that require an expenditure of BCVDD Program funds.(f) Parents with gross monthly incomes above the federal poverty guidelines are required to pay part of the cost for services. In making this decision, DARS DBS considers extenuating circumstances that may prohibit the parents' ability to pay, such as medical costs and debts resulting from a permanent disability or chronic illness of the child or family member.(g) Gross monthly income is any funds available to the child and the child's parent, which includes, but is not limited to, the following:(1) wages or salary;(2) contributions from relatives, individuals, or organizations received on a regular basis;(3) child support payments;(4) net rentals from property;(5) scholarships and fellowships;(6) public assistance payments, including Social Security Income (SSI) and Temporary Assistance for Needy Families (TANF);(7) assistance from private welfare agencies;(8) income from stock dividends and bond interest;(9) any available pension, annuity, compensation, or insurance, including SSDI, health or hospitalization insurance plans, Worker's Compensation, veteran's benefits, Old Age and Survivors Insurance (OASI) from the Social Security Administration, labor union insurance and health and welfare benefits, and unemployment compensation;(10) participation in savings plans and deductions for savings bonds;(11) income from self-employment, which is defined as gross receipts, minus allowable Internal Revenue Service expenses, from one's own business that results in income. Gross receipts include the value of all goods sold and services rendered. Expenses include cost of goods sold, rent, utilities, wages and salaries paid, and business taxes (not personal income taxes or self-employment social security taxes); and(12) any other amounts generally recognized as income.(h) Gross monthly income at application for services is based on the family's current month's income or the average gross income for the previous three months, whichever is less.(i) If the provisions of subsection (h) of this section do not accurately reflect the family's economic status, the average of the preceding 12 months may be used.(j) DARS DBS seeks updated information about income periodically as considered necessary. Source Note: The provisions of this §359.151 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.151 Determination of Economic Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207580 03/12/2026 (a) The purpose of this division is to establish an order of selection for payment of services that may be used when funds are insufficient to serve all eligible children.(b) The public may contact DARS DBS at any local office to inquire if DARS DBS is operating under provisions of this division and to inquire about the expenditure category at which DARS DBS is operating. Source Note: The provisions of this §359.201 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207581 03/12/2026 (a) In determining whether to invoke a change in an order of selection, the assistant commissioner for DARS DBS applies the same criteria as those used in §106.707 of this chapter (relating to Application of an Order of Selection).(b) The order of selection is applied after eligibility for services is determined.(c) A service that can be paid from resources other than DARS DBS' may be provided to a child regardless of the order of selection. Source Note: The provisions of this §359.203 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.203 Application of an Order of Selection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207582 03/12/2026 (a) This provision applies to the resolution of a complaint through a review of a BCVDD Program determination concerning:(1) ineligibility for services;(2) financial participation in the cost of products or services;(3) denial of services; or(4) termination of services.(b) A family may file a complaint in writing to the DARS BCVDD Program, Department of Assistive and Rehabilitative Services, 4800 North Lamar, Austin, Texas, 78756. Or, a family may call DARS Inquiries at 1-800-628-5115 or send an email to: dars.inquiries@dars.state.tx.us. In accordance with §101.109 of this title (relating to Complaints), BCVDD Program provides, both to each person wishing to file a complaint and to any person who is the subject of the complaint, a copy of the procedures under this subchapter. DARS and BCVDD Program staff members receive, evaluate, and seek satisfactory resolution to each complaint received.(c) On each complaint under this subchapter, BCVDD Program maintains a file containing the name of the person filing the complaint, the date BCVDD Program received the complaint, the subject matter of the complaint, the name of each person contacted concerning the complaint, a summary of the informal review, and an explanation of the reason the file was closed if the agency closed the file without taking action other than to investigate the complaint. Source Note: The provisions of this §359.251 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES A BLIND CHILDREN'S VOCATIONAL DISCOVERY AND DEVELOPMENT PROGRAM §359.251 BCVDD Program Complaint Resolution Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207549 03/12/2026 The Blindness Education, Screening, and Treatment (BEST) Program is administered by the Department of Assistive and Rehabilitative Services (DARS), Division for Blind Services (DBS). The BEST program provides blindness prevention education, screening, and treatment to prevent blindness for Texas residents who are not covered under an adequate health benefit plan. Source Note: The provisions of this §359.501 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES B BLINDNESS EDUCATION, SCREENING, AND TREATMENT PROGRAM §359.501 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207547 03/12/2026 The following statutes and regulations authorize or require the rules in this subchapter:(1) Texas Human Resources Code, §91.027, which authorizes DBS to operate the program to the extent that funds are available under the Transportation Code §521.421(j) and §521.422(b); and(2) Texas Human Resources Code §117.074. Source Note: The provisions of this §359.503 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES B BLINDNESS EDUCATION, SCREENING, AND TREATMENT PROGRAM §359.503 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207548 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Blind (person who is)--A person whose visual acuity with best correction is 20/200 or less in the better eye; or a person with a limitation in the field of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees, which means a visual field of no greater than 20 degrees in the better eye.(2) DBS--Department of Assistive and Rehabilitative Services, Division for Blind Services.(3) MAPS--The Maximum Affordable Payment Schedule (MAPS) is a payment system used to purchase physical and mental restoration services for DARS-Division for Blind Services consumers. DBS uses MAPS codes that are based on the American Medical Association's Current Procedural Terminology (CPT) codes, the Healthcare Common Procedure Coding System (HCPCS), and reimbursement rates that are established by Medicare to pay for medical and psychological services for DARS-DBS consumers.(4) Medically urgent eye conditions--Conditions that include, but are not limited to, glaucoma, diabetic retinopathy, and detached retina. Any other medical condition, to qualify, must be determined to be medically urgent by both the referring physician and the DARS Division for Blind Services' medical/ophthalmologic consultant or his or her designee.(5) Program--Blindness Education, Screening, and Treatment Program (BEST).(6) Resident--A person who is present in Texas and intends to remain in the state, either permanently or for an indefinite period.(7) Vision screening--A nondiagnostic procedure that uses uniform testing techniques to assess a person's risk of vision loss and eye disease. Source Note: The provisions of this §359.505 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES B BLINDNESS EDUCATION, SCREENING, AND TREATMENT PROGRAM §359.505 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207550 03/12/2026 (a) The purpose of vision screening services is to identify persons in need of comprehensive professional vision examinations, and to detect problems that could limit a person's educational or vocational opportunities.(b) To be eligible to receive BEST vision screening services, a person must be an adult resident of the state.(c) Vision screening services may be provided through a contractor.(d) For information about the training and certification of vision screeners, contact the BEST program specialist at DBS, 4800 North Lamar Boulevard, Austin, Texas.(e) Persons receiving vision screenings receive the screening results and, if necessary, a recommendation regarding the need for a follow-up examination by an eye care professional.(f) When a referral is made for an eye examination to another organization, the referring organization's rules shall apply. A referral by the BEST program is not an endorsement of another agency, organization or eye care professional by DBS. Source Note: The provisions of this §359.507 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES B BLINDNESS EDUCATION, SCREENING, AND TREATMENT PROGRAM §359.507 Vision Screening Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207551 03/12/2026 (a) The purpose of treatment services is to prevent blindness by providing medical or surgical intervention to persons at risk who are not covered under an adequate health benefit plan.(b) To be eligible to receive treatment services from BEST, a person must be an adult resident of the state who:(1) has been referred to the BEST program by the person's treating physician or optometrist;(2) has certified to the physician or optometrist that the person does not have health insurance or other available resources with which to pay for prescribed treatment to prevent blindness; and(3) has been certified by the physician or optometrist as having a medically urgent eye condition that poses an imminent risk of permanent and significant visual loss if not treated with surgery or medical intervention.(c) The BEST program is funded with voluntary donations. It is expected that service demand will exceed program resources. Therefore, funds may not be available for treatment services at the time a person is referred for assistance.(d) If an eligible person is denied services by the BEST program based on the inadequacy of donations to cover the cost of services, the physician may request that the person be placed on a waiting list pending DBS receipt of adequate funds. Persons on the waiting list are served in order by referral date and time.(e) All treatment services, including prescription drugs, must be approved in advance by the BEST program to qualify for payment. All prescribed treatment services and requested payments must be itemized on the program's application form.(f) Over-the-counter and nonprescription drugs are not covered by the BEST program. Program assistance with the cost of eye-related drugs prescribed by a physician to prevent blindness is limited to the time the drugs are prescribed by the treating physician or optometrist or one year, whichever is less. The following are the procedures for payment for prescription drugs:(1) Payments for approved prescription drugs are made only to the person's pharmacy of choice.(2) DBS pays for the prescription upon receiving an invoice.(g) When the BEST Program pays for a medical or surgical treatment prescribed by a physician as medically necessary for a chronic eye condition such as glaucoma or diabetic retinopathy, the program may pay for no more than two follow-up examinations within the 12 months after the prescribed medical or surgical treatment.(h) Payments for treatment services are based on DBS' adopted rate schedule for eye-related medical services as specified in Texas Human Resources Code, §117.074 (also known as DBS's Maximum Affordable Payment Schedule).(i) Claims for payment must be received within 90 days from the date of each service. Claims received by the BEST program that lack the information necessary for processing are denied as incomplete claims. The resubmission of the claim containing the necessary information must be received by the program within 60 days from the last denial date, or payment will be declined. Excepted from this requirement is the payment for refills of drugs prescribed during the allowed period of one year.(j) The BEST program does not pay cancellation charges, charges for missed appointments, or any other charge incurred other than for the actual provision of services. Source Note: The provisions of this §359.509 adopted to be effective December 10, 2012, 37 TexReg 9644; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35. 1 HEALTH AND HUMAN SERVICES COMMISSION 359 DIVISION FOR BLIND SERVICES B BLINDNESS EDUCATION, SCREENING, AND TREATMENT PROGRAM §359.509 Treatment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203567 03/12/2026 The purpose of this subchapter is to set out the administration and general procedures governing the various programs of the Office for Deaf and Hard of Hearing Services. Source Note: The provisions of this §360.101 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES A GENERAL RULES §360.101 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203570 03/12/2026 The Office for Deaf and Hard of Hearing Services implements its general powers and duties under the following statutes:(1) Human Resources Code, Chapter 81;(2) Utilities Code, Chapter 56, Subchapter E;(3) Government Code, Chapter 57;(4) Civil Practice and Remedies Code, §21.003; and(5) Code of Criminal Procedure, Art. 38.31(g). Source Note: The provisions of this §360.103 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES A GENERAL RULES §360.103 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203571 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Americans with Disabilities Act (ADA)--A public law that provides a clear and comprehensive national mandate for eliminating discrimination against people with disabilities and that provides enforceable standards addressing discrimination against people with disabilities.(2) BEI--The Board for Evaluation of Interpreters.(3) BEI Certificate--The certificate awarded by DARS to an applicant who has passed designated written and performance tests; the certificate verifies that the person has skills to perform interpreting and transliterating, both expressively and receptively, and specifies the skill level at which the person can perform.(4) Certified court interpreter--A person who is a qualified interpreter as defined in the Code of Criminal Procedure, Article 38.31, or the Civil Practice and Remedies Code, §21.003 or who is certified under Subchapter B of this chapter (relating to Board for Evaluation of Interpreters) by DARS to interpret court proceedings for a person who is deaf or hard of hearing.(5) Certified interpreter--A person who holds a valid certificate awarded by DARS or RID. A RID-certified interpreter does not include a certified interpreter awarded through membership.(6) Certified medical interpreter--A person who is certified under Subchapter B of this chapter by DARS to interpret in medical settings for persons who are deaf or hard of hearing.(7) Certified trilingual interpreter--A person certified under Subchapter B of this chapter as meeting the proficiency standards established by DARS to facilitate communication both expressively and receptively in English, sign, and Spanish.(8) DARS--The Department of Assistive and Rehabilitative Services.(9) DHHS--The Office for Deaf and Hard of Hearing Services, Division for Rehabilitation Services, DARS.(10) Director--The director of the Office for Deaf and Hard of Hearing Services.(11) Intermediary interpreter--A person who is deaf or hard of hearing, who has passed an interpreter skills evaluation and is certified by DARS or RID, and who is proficient at facilitating communication both linguistically and culturally for a person who is deaf or deafblind.(12) Interpretation--The process of conveying a message both expressively and receptively from verbal/written language to sign or from sign to verbal/written language.(13) Interpreter or qualified interpreter--A person who is able to interpret effectively, accurately, and impartially both receptively and expressively, using any necessary specialized vocabulary.(14) Prerequisite certificate--The valid certificate required by DHHS that makes a person eligible to apply for a specialized certificate issued by DARS or to apply for a BEI advanced performance test.(15) Provisional certificate--The certificate awarded by DARS to an applicant currently certified in another jurisdiction who seeks a certificate in Texas.(16) RID--Registry of Interpreters for the Deaf, Inc., a national organization of interpreters that provides interpreter certification.(17) Specialty certificate--A trilingual certificate or court certificate awarded by DARS.(18) Transliteration--The process of conveying a message either from spoken language into a manually coded language or from manually coded language into a spoken language. Source Note: The provisions of this §360.105 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES A GENERAL RULES §360.105 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203568 03/12/2026 (a) DHHS maintains a registry of available qualified BEI interpreters for people who are deaf or hard of hearing. The registry is updated at least quarterly and is available on request at cost.(b) DARS maintains lists of certified court interpreters and other persons whom DARS has determined are qualified to act as court interpreters.(c) DHHS sends a list of certified court interpreters and other persons whom DARS has determined are qualified to act as court interpreters to each state court.(d) Copies of qualified interpreter lists may be obtained from DHHS upon request. Source Note: The provisions of this §360.107 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES A GENERAL RULES §360.107 Registry of Qualified Interpreters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203569 03/12/2026 DHHS has developed guidelines to clarify the circumstances under which interpreters certified by DARS are qualified to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Copies of the guidelines may be obtained from DHHS. Source Note: The provisions of this §360.109 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES A GENERAL RULES §360.109 Guidelines Concerning Qualification of Interpreters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203580 03/12/2026 The purpose of this division is to set out the administration and general procedures governing the certification of interpreters for people who are deaf or hard of hearing in Texas. Source Note: The provisions of this §360.201 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203583 03/12/2026 The Board for Evaluation of Interpreters program is specifically created under authority of the Human Resources Code, §81.007, with additional statutory authority generally contained in Human Resources Code, Chapter 81, and Government Code, Chapter 57. Source Note: The provisions of this §360.203 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.203 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203584 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Active Duty--Current full-time military service in the armed forces of the United States or active duty military service as a member of the Texas military forces, as defined by §437.001, Government Code, or similar military service of another state.(2) Armed Forces of the United States--The Army, Navy, Air Force, Coast Guard, or Marine Corps of the United States or a reserve unit of one of those branches of the armed forces.(3) BEI Board--The seven-person advisory board appointed by the executive commissioner of HHSC, or his or her designee, to assist in administering the BEI.(4) Certificates issued:(A) Basic certificate--A certificate issued by DARS to a person who has passed a written test of English proficiency and a skills evaluation ensuring a minimum competency standard to interpret in routine educational and social service settings.(B) Advanced certificate--A certificate issued by DARS to a person who has passed a written test of English proficiency and a skills evaluation ensuring a minimum competency standard to interpret in a variety of complex settings, such as routine medical, social service, K-12 and higher education, routine mental health, and routine quasi-legal.(C) Master certificate--A certificate issued by DARS to a person who has passed a written test of English proficiency and a skills evaluation ensuring a minimum competency standard to interpret in a variety of highly complex settings, such as medical, mental health, quasi-legal, and educational settings.(D) Court certificate--A certificate issued by DARS to a person who has passed a skills evaluation certifying that the person is qualified to interpret all proceedings of Texas courts, including county, municipal, and justice courts.(E) Intermediary--Level III certificate--A certificate issued by DARS to a person who is deaf or hard of hearing who has passed a skills evaluation certifying that the person possesses the ability to interpret for a wide range of communication styles, which may include but, not limited to non-standard signs/gestures, limited communication skills, characteristics of Deaf Culture that may not be familiar to hearing interpreters, deaf-blind, minimal language skills, and indigenous communication.(F) Intermediary--Level V certificate--A certificate issued by DARS to a person who is deaf or hard of hearing who has passed a skills evaluation certifying that the person possesses the ability to interpret in a variety of settings and situations requiring extensive knowledge and training in specialized fields including, but not limited to mental health/psychiatric, medical/surgical, court/legal and matters involving juveniles, demonstrates near flawless skills in interpreting for a wide range of communication styles, which can include-but not limited to non-standard signs/gestures, limited communication skills, characteristics of Deaf Culture that may not be familiar to hearing interpreters, deaf-blind, minimal language skills, and indigenous communication.(G) Oral Certificate: Basic (OC:B) certificate--A certificate issued by DARS to a person who has passed a skills evaluation in spoken-to-visible and visible-to-spoken communication, certifying that the person has basic proficiency in oral transliteration and speechreading.(H) Oral Certificate: Comprehensive (OC:C) certificate--A certificate issued by DARS to a person who has passed a skills evaluation in spoken-to-visible and visible-to-spoken communication, certifying that the person has advanced proficiency in oral transliteration and speechreading.(I) Oral Certificate: Visible (OC:V) certificate--A certificate issued by DARS to a person who is deaf or hard of hearing and who has passed a skills evaluation in visible-to-spoken communication, certifying that the person has advanced proficiency in oral transliteration and speechreading.(J) Trilingual Advanced certificate--A certificate issued by DARS to a person who has passed a written test of Spanish proficiency and a skills evaluation certifying that the person has the ability to meaningfully and accurately understand, produce, and transform ASL to and from English and Spanish in a culturally appropriate manner, in more complex situations for routine educational and social service settings, such as K-12 educational and administrative interactions.(K) Trilingual Master certificate--A certificate issued by DARS to a person who has passed a written test of Spanish proficiency and a skills evaluation certifying that the person has the ability to meaningfully and accurately understand, produce, and transform ASL to and from English and Spanish in a culturally appropriate manner, in the most complex situations including complex medical, complex mental health, quasi-legal, and educational settings.(L) Morphemic Sign System (MSS) certificate--A certificate issued by DARS to a person who has passed a skills evaluation certifying that the person can convey a message from verbal English into morphemic signs for English and from morphemic signs for English into verbal English.(M) Multiple-certificate holder--A BEI certificate holder who possesses or who is awarded more than one BEI certificate.(N) Signing Exact English (SEE) certificate--A certificate issued by DARS to a person who has passed a skills evaluation certifying that the person can convey a message from verbal English into Signed Exact English and from Signed Exact English into verbal English.(O) Level I certificate--A certificate issued by DARS to a person who has passed a written test to assess understanding of Code of Ethics and a skills evaluation certifying that the person can convey some daily interpreting situations where expressive skills are usually stronger than receptive skills and sign vocabulary is limited.(P) Level II certificate--A certificate issued by DARS to a person who has passed a written test to assess understanding of Code of Ethics and a skills evaluation certifying that the person can convey some routine interpreting situations where the person exhibits good transliterating or interpreting skills, but not both.(Q) Level III certificate--A certificate issued by DARS to a person who has passed a written test to assess understanding of Code of Ethics and a skills evaluation certifying that the person can convey most routine interpreting situations where the person exhibits good expressive and receptive interpreting skills, displays a clear distinction between interpreting and transliterating and possess a sign vocabulary.(R) Level IV certificate--A certificate issued by DARS to a person who has passed a written test to assess understanding of Code of Ethics and a skills evaluation certifying that the person exhibits strong expressive and receptive interpreting skills in settings such as medical, legal and psychiatric, demonstrates excellent use of ASL grammar and ASL features, transliterating skills are strong and processing is often at the textual level.(S) Level V certificate--A certificate issued by DARS to a person who has passed a written test to assess understanding of Code of Ethics and a skills evaluation certifying that the person exhibits very strong expressive and receptive interpreting skills in setting such as medical, legal and psychiatric, possess an extensive vocabulary, demonstrates sophisticated use of ASL grammar as well as ASL features and transliterates conceptually accurate with appropriate mouthing.(5) Court proceeding--A proceeding that is under the jurisdiction of Texas courts for civil cases and criminal actions, including arraignments, hearings, examining trials, trials, depositions, mediations, court-ordered arbitrations, or other forms of alternative dispute resolution.(6) Military service member--A person who is on active duty.(7) Military spouse--A person who is married to a military service member.(8) Military veteran--A person who served on active duty and who was discharged or released from active duty.(9) Trilingual interpreter services--Interpreting services provided by an otherwise qualified interpreter who is proficient in Spanish in addition to English and sign. Source Note: The provisions of this §360.205 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective May 1, 2014, 39 TexReg 3452; amended to be effective September 15, 2014, 39 TexReg 7342; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.205 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203581 03/12/2026 (a) The BEI Board assists in the testing and certifying of interpreters to verify that they have reached varying levels of proficiency in skills necessary to facilitate communication between people who are deaf or hard of hearing and people who are not deaf or hard of hearing.(b) The BEI Board recommends standards to DHHS for each of several levels of certification based on proficiency. Source Note: The provisions of this §360.207 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.207 Board for Evaluation of Interpreters Board https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203582 03/12/2026 (a) DHHS charges fees for written and performance examinations, for annual certificate renewal, for five-year recertification, and for provisional certificates, in amounts sufficient to recover the costs of the BEI certification program.(b) DHHS may waive any prerequisite to obtaining a certificate for an applicant after reviewing the applicant's credentials and determining that the applicant holds a certificate issued by another jurisdiction that has certification requirements substantially equivalent to those of DARS.(c) Copies of information about the following topics may be obtained from DHHS:(1) qualifications and prerequisites to testing for certification;(2) the certification process;(3) waivers of prerequisites; and(4) location, schedule, and current fees for interpreter examinations. Source Note: The provisions of this §360.209 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.209 Fees, Prerequisites, and Qualifications for Certification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203585 03/12/2026 (a) DHHS may issue a provisional certificate to an applicant currently certified in another jurisdiction who seeks a BEI certificate and who:(1) has been certified in good standing as an interpreter for at least two years in another jurisdiction, including a foreign country, that has certification requirements substantially equivalent to those of DARS;(2) has passed an examination recognized by DHHS relating to the practice of interpretation for people who are deaf or hard of hearing; and(3) is sponsored by an interpreter certified by DARS with whom the provisional-certificate holder will practice during the time he or she holds a provisional certificate.(b) DHHS may waive the requirement of subsection (a)(3) of this section for an applicant if DHHS determines that compliance with that subsection would be a hardship to the applicant.(c) A provisional certificate is valid until the date DHHS approves or denies the provisional certificate holder's application for a certificate. DARS will issue a certificate to the provisional certificate holder if:(1) the provisional certificate holder is eligible to be certified under §109.209 of this division (relating to Fees, Prerequisites, and Qualifications for Certification); or(2) the provisional certificate holder passes the part of the examination prescribed by DHHS to establish that he or she has the minimum level of English proficiency; and(3) DHHS verifies that the provisional certificate holder:(A) meets the academic and experience requirements for a certificate under this chapter; and(B) satisfies any other certification requirements under this chapter.(d) DHHS must approve or deny a provisional certificate holder's application for a BEI certificate not later than the 180th day after the date the provisional certificate is issued. DHHS may extend the 180-day period if the results of an examination have not been received by DHHS before the end of that period.(e) The decision of DHHS on issuance or denial of a BEI provisional certificate is final and may not be appealed. Source Note: The provisions of this §360.211 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.211 Provisional Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203586 03/12/2026 DHHS has established a fee schedule for compensation of raters. Copies of the current fee schedule may be obtained from DHHS. Source Note: The provisions of this §360.213 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.213 Compensation of Raters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203587 03/12/2026 (a) DARS, in administering the certification program, obtains criminal conviction records information on all applicants for certification and current certificate holders; the information may be used in determining whether applicants or certificate holders are eligible to obtain or maintain certification.(b) DARS certifies an applicant who passes the appropriate examinations prescribed by DARS and who satisfies the other qualifications required by the rules in this chapter.(c) Upon successful completion of all requirements for certification and approval by DHHS, the applicant is issued a card evidencing certification. Source Note: The provisions of this §360.215 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.215 Certification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203588 03/12/2026 (a) To apply for or to take any examination for a BEI Certificate, an applicant must:(1) be at least 18 years old;(2) have earned a high school diploma or its equivalent; and(3) not have a criminal conviction that could qualify as grounds for denial, probation, suspension, or revocation of a BEI certificate, or other disciplinary action against any holder of a BEI certificate.(b) To take the written Test of English Proficiency or to take the American Sign Language Proficiency Test for persons who are deaf or hard of hearing, an applicant must have:(1) met all the criteria in subsection (a) of this section; and(2) earned at least 30 credit hours from an accredited college or university, with a cumulative GPA of 2.0 or higher.(c) To take a BEI performance test, an applicant must have:(1) met all the criteria in subsection (a) of this section;(2) earned an associate degree and/or a minimum of 60 credit hours from an accredited college or university, with a cumulative GPA of 2.0 or higher, unless the applicant is applying for a court, medical, or trilingual certificate or except as provided in subsections (e) and (f) of this section; and(3) earned a passing score on the Test of English Proficiency, unless the applicant is applying for a court, medical, or trilingual certificate; or(4) earned a passing score on the American Sign Language Proficiency Test if the applicant is deaf or hard of hearing.(d) To apply for and to be issued a BEI certificate, an applicant must have:(1) met all criteria in subsection (a) of this section; and(2) earned an associate degree and/or a minimum of 60 credit hours from an accredited college or university, with a cumulative GPA of 2.0 or higher, except as provided in subsections (e) and (f) of this section; and earned a passing score on the requisite examination for the certificate level sought.(e) A BEI certificate holder who holds an active and valid BEI certificate awarded as a result of proceedings initiated before January 1, 2012, is exempt from the educational or degree requirements in subsections (b), (c), and (d) of this section, as long as the BEI certificate remains active and valid.(f) A BEI certificate holder who holds an active and valid BEI certificate awarded as a result of proceedings initiated before January 1, 2012, and who applies for an additional BEI certificate level after January 1, 2012, may be exempt from the educational or degree requirements of subsections (b), (c), and (d) of this section, if, at the time the certificate holder applies for, takes, and passes any BEI examination for the additional certificate, the BEI certificate holder:(1) has an active and valid BEI certificate that is fully compliant with BEI's annual certificate maintenance and five-year recertification rules and requirements;(2) is not under any type of active or pending disciplinary action from BEI or DHHS; and(3) satisfies all other rules and requirements applicable to the additional BEI certificate level sought.(g) A certified interpreter wanting to take a higher level BEI performance test must have the following prerequisite certificate for the corresponding BEI performance test:Attached Graphic Source Note: The provisions of this §360.217 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.217 Qualifications and Requirements for a BEI Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203589 03/12/2026 (a) A person who fails an examination may apply for reexamination at an examination that is scheduled no earlier than six months after the date the person failed the examination that is being retaken.(b) Examinations may be offered in the state at least twice a year at times and places designated by DHHS or by a designated testing facility. The current schedule of times and places for examinations may be obtained from DHHS or a designated testing facility.(c) An applicant who does not attend a scheduled examination forfeits the examination fee paid to DHHS. An applicant may attend a future examination without payment of additional fee if the DHHS-designated testing facility allows for the examination to be rescheduled or upon proof of missing an examination because of the following:(1) illness of the applicant or an immediate family member whom the applicant has responsibility to be with; or(2) documented evidence that the applicant was unable to attend the examination because of reasons beyond his or her control. Source Note: The provisions of this §360.219 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.219 Administration of Examination for BEI Interpreter Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203593 03/12/2026 (a) Certificates are valid for five years, subject to the certificate holder's payment of an annual certificate renewal fee. After expiration of the five-year certification cycle, a certificate holder must be recertified by DARS.(b) A certificate holder may be recertified if he or she:(1) provides written documentation of completing at least the minimum number of required continuing education units, as approved by DARS; or(2) achieves a passing score on a specified examination; and(3) is in compliance with all other applicable rules, including those relating to annual certificate renewal, recertification, eligibility, and qualifications.(c) DARS may not renew or recertify a certificate holder or a former certificate holder seeking to recertify through examination until:(1) all pending or unresolved complaints, disciplinary actions, or agency orders relating to the current or former certificate holder are resolved with DARS; and(2) payment of any required renewal or recertification fees are received by DARS within 30 days of their due date.(d) For multiple certificate holders possessing more than one BEI interpreter certificate, the following rules apply:(1) When a current BEI certificate holder is awarded an additional BEI certificate, the current and new certificates are assigned a single, new five-year certification cycle that begins on the award date of the newest BEI certificate(s).(2) The new five-year certification cycle and the annual renewal date each become due as of the award date of the newest BEI certificate.(3) All certificates are assigned one certificate number.(4) Any continuing education units (CEUs) earned prior to the multiple certificate award date are void.(5) The certificate holder, if not a military service member, has five years from the multiple certificate award date to earn all required CEUs. The certificate holder, if a military service member, has seven years from the multiple certificate award date to earn all required CEUs.(e) Information on current annual certificate renewal and five-year recertification requirements may be obtained from DARS. Source Note: The provisions of this §360.221 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective September 15, 2014, 39 TexReg 7342; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.221 Validity of Certificates and Recertification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203590 03/12/2026 (a) A person who is otherwise eligible to renew a certificate may renew an unexpired certificate by paying the required renewal fee to DHHS before the expiration date of the certificate. A person whose certificate has expired may not engage in activities that require a certificate until the certificate has been renewed.(b) A person who is not a military service member whose certificate has been expired for 90 days or less may renew the certificate by paying to DARS DHHS a renewal fee that is equal to one and one-half times the normally required renewal fee.(c) A person who is not a military service member whose certificate has been expired for more than 90 days but less than one year may renew the certificate by paying to DARS DHHS a renewal fee that is equal to two times the normally required renewal fee.(d) A person whose certificate has been expired for one year or more may not renew the certificate. The person may obtain a new certificate by complying with the requirements and procedures, including the examination requirements, for obtaining an original certificate.(e) A person who was certified in Texas, moved to another state, and is currently certified and has been in practice in the other state for the two years preceding the date of application may obtain a new certificate without reexamination. The person must pay a fee to DARS DHHS that is equal to two times the normally required renewal fee for the certificate.(f) Not later than the 30th day before the date a certificate will expire, DARS DHHS sends written notice of the impending expiration, and certificate renewal instructions, to the person at the person's last known address according to the records of DARS DHHS.(g) Failure to receive the notice of impending expiration from DARS DHHS, referenced in subsection (f) of this section, does not extend the expiration date of a certificate and does not exempt a person from any requirements of this subchapter.(h) A person whose court certificate has been expired not more than two years and who failed to renew the court and required BEI prerequisite certificate because the person was serving as a military service member may renew the expired court and prerequisite certificate by paying the required renewal fee to DARS DHHS. Source Note: The provisions of this §360.223 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.223 Certificate Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203591 03/12/2026 DHHS recognizes, prepares, and administers continuing education programs for its certificate holders. A certificate holder must participate in the programs to the extent required by DHHS to keep his or her certificate. Current requirements for continuing education and announcements of current training opportunities may be obtained from DHHS. Source Note: The provisions of this §360.225 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.225 Continuing Education Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203592 03/12/2026 (a) DARS may take disciplinary action against a certificate holder who is found to be in violation of a statute, rule, or policy of DARS, including any of the provisions of §101.1211 of this title (relating to Grounds for Denying, Revoking, or Suspending an Interpreter's Certificate).(b) A disciplinary action against a certificate holder may be composed of any one or a combination of the following actions:(1) revocation;(2) suspension;(3) probation;(4) denial; or(5) with respect to certified court interpreters only, assessment of an administrative penalty under the law.(c) All final disciplinary actions taken by DARS or by DHHS are permanently recorded and made available upon request as public information. Except for an informal reprimand, all disciplinary actions may be released in a press release, and may be transmitted to the RID or states licensed to use BEI tests, as appropriate.(d) A certificate holder whose certificate has expired for nonpayment of renewal fees or is the subject of a pending disciplinary action, complaint, or investigation continues to be subject to all statutory, rule, and procedural provisions of DARS governing certified interpreters until the certificate is revoked by DARS or becomes nonrenewable under the rules. Source Note: The provisions of this §360.227 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.227 Disciplinary Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203594 03/12/2026 (a) "Disability" has the meaning assigned by the ADA.(b) Applicants who request a reasonable accommodation based on a claimed disability are provided with reasonable accommodations if they meet the eligibility criteria set forth in this subchapter.(c) To be eligible for a reasonable accommodation based upon a diagnosed disability, a BEI applicant must make a written request and must:(1) provide written documentation from a licensed medical professional (a physician, psychiatrist, advanced practice registered nurse, or psychologist) that:(A) specifies the applicant's disability diagnosis or diagnoses;(B) explains how the applicant's disability substantially limits his or her ability to take the test for which the applicant is applying under current testing procedures;(C) provides guidance about recommended modifications that enable the applicant to test; and(D) is dated less than two years from the date the application was received for the test for which the applicant is seeking an accommodation; and(2) submit all documentation under cover of the certifying medical professional's letterhead and signature to DHHS.(d) DHHS determines what reasonable accommodations an eligible BEI applicant receives, and the determination is final. Source Note: The provisions of this §360.229 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.229 Examination Accommodations for Persons with Disabilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203595 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203595 03/12/2026 (a) All fees paid to DARS DHHS in relation to the Board for Evaluation of Interpreters (BEI) certification program are non-refundable. DARS is authorized to collect fees for written and performance tests, for annual certificate renewal, and for five-year recertification. The schedule of fees is as follows.(1) Administrative, application, and test fees:(A) Test of English Proficiency (TEP)--$95.(B) American Sign Language Proficiency Test for persons who are deaf or hard of hearing--$75.(C) Basic Performance Test--$145.(D) Advanced Performance Test--$170.(E) Master Performance Test--$195.(F) Oral Certificate: Basic (OC:B) Performance Test--$85.(G) Oral Certificate: Comprehensive (OC:C) Performance Test--$105.(H) Oral Certificate: Visible (OC:V) Performance Test--$50.(I) Signing Exact English (SEE) Performance Test--$85.(J) Morphemic Sign System (MSS) Performance Test--$85.(K) Performance Test for persons who are deaf or hard of hearing--$75.(L) Test of Spanish Proficiency (TSP)--$95.(M) Advanced Trilingual Performance Test--$160.(N) Master Trilingual Performance Test--$185.(O) Medical Performance Test--$185.(P) Court application fee--$50.(Q) Court Interpreter Performance Test--$185.(R) Court mentor application fee--$60.(S) Certificate card replacement--$25.(2) Application fees for persons applying for certification who are BEI certified by another state:(A) Basic certificate--$50.(B) Advanced certificate--$50.(C) Master certificate--$50.(3) Single certificate renewal and five-year recertification fees:(A) Annual certificate renewal (on time)--$75.(B) Annual certificate renewal (1-90 days after expiration date)--$112.50.(C) Annual certificate renewal (91-364 days after expiration date)--$150.(D) Court certificate annual renewal (on time)--$55.(E) Court certificate annual renewal (1-90 days after expiration date)--$82.50.(F) Court certificate annual renewal (91-364 days after expiration date)--$110.(G) Five-year recertification (on time)--$70.(H) Five-year recertification (1-90 days after expiration date)--$105.(I) Five-year recertification (91-364 days after expiration date)--$140.(J) Court certificate five-year recertification (on time)--$50.(K) Court certificate five-year recertification (1-90 days after expiration date)--$75.(L) Court certificate five-year recertification (91-364 days after expiration date)--$100.(4) Multiple certificate renewal and five-year recertification fees:(A) Annual certificate renewal (on time)--$105.(B) Annual certificate renewal (1-90 days after expiration date)--$157.50.(C) Annual certificate renewal (91-364 days after expiration date)--$210.(D) Five-year recertification (on time)--$100.(E) Five-year recertification (1-90 days after expiration date)--$150.(F) Five-year recertification (91-364 days after expiration date)--$200.(b) The application and test fees are waived for an applicant seeking court certification if the applicant is:(1) a military service member or military veteran whose military service, training, or education substantially meets all of the requirements for the license; or(2) a military service member, military veteran, or military spouse who holds a current license issued by another jurisdiction that has licensing requirements that are substantially equivalent to the requirements for the license in this state.(c) Any remittance submitted to DARS DHHS in payment of a required fee shall be in the form of a personal check, certified check, or money order unless this section requires otherwise. Checks drawn on foreign financial institutions are not acceptable.(d) An applicant whose check for the application and initial certification fee is returned marked insufficient funds, account closed, or payment stopped shall be allowed to reinstate the application by remitting to DARS DHHS a money order or check for guaranteed funds within 30 days of the date of the receipt of the notice by DARS DHHS. Otherwise, the application and the approval shall be invalid. A penalty fee of $25, in addition to the amount of the check, must be included with the payment remitted to the DARS DHHS office.(e) A certificate holder whose check for a renewal fee is returned marked insufficient funds, account closed, or payment stopped shall remit to DARS DHHS a money order or check for guaranteed funds within 30 days of the date of receipt of the notice by DARS DHHS. Otherwise, the certificate shall not be renewed. If a renewal card has already been issued, it shall be invalid. If the guaranteed funds are received after expiration date, a late renewal penalty fee shall be assessed. A penalty fee of $25, in addition to the amount of the check, must be included with the payment remitted to the DARS DHHS office.(f) Renewing an expired certificate within 12 months of the expiration date requires payment of the applicable renewal fee. Source Note: The provisions of this §360.231 adopted to be effective September 15, 2014, 39 TexReg 7342; amended to be effective August 2, 2015, 40 TexReg 4823; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.231 Schedule of Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203596 03/12/2026 The purpose of this division is to set out the administration and general procedures governing the certification of court interpreters for people who are deaf or hard of hearing in Texas. Source Note: The provisions of this §360.301 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.301 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203597 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203597 03/12/2026 DARS court interpreter certification is administered and enforced under the statutory authority of:(1) Government Code, Chapter 57;(2) Civil Practice and Remedies Code, §21.003; and(3) Code of Criminal Procedure, Art. 38.31(g). Source Note: The provisions of this §360.303 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.303 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203598 03/12/2026 The following words and terms, when used in this division, have the following meanings, unless the context clearly indicates otherwise.(1) DHHS-approved training or workshop--Court-related training or workshop approved by DHHS as satisfying specific training requirements for testing and continuing education for renewal.(2) Mentee--A certified interpreter who seeks to become a certified court interpreter and who receives instruction from a DHHS-approved mentor.(3) Mentor--A certified court interpreter who has applied to DHHS, has satisfied specific training and or testing requirements, and has been approved by DHHS to provide court interpreting instruction. Source Note: The provisions of this §360.305 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.305 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203599 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203599 03/12/2026 (a) In accordance with Government Code, §57.023, DARS prepares court interpreter examinations under this division that test an applicant's knowledge, skill, and efficiency in interpreting court proceedings.(b) DHHS determines content and format for examinations on legal and court procedure skills and knowledge and administers the examinations to applicants. Source Note: The provisions of this §360.307 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.307 Administration of Examination for Court Interpreter Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203600 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203600 03/12/2026 (a) These provisions apply to all proceedings of Texas courts, including county, municipal, and justice courts.(b) A person interpreting court proceedings in Texas courts must hold a current court interpreter certificate issued by DARS or a current legal certificate issued by RID. Source Note: The provisions of this §360.309 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.309 Requirements for Interpreting Court Proceedings in Texas Courts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203601 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203601 03/12/2026 (a) A BEI-certified court interpreter must provide the following written notification to the court: "Certified by DARS, Office for Deaf and Hard of Hearing Services. Complaints about the services provided by this person may be presented to DHHS." The notification must also be included on all contracts and invoices for court interpreter services.(b) In addition to the presentation of a person's court interpreter certificate card, which is required for qualification as a court interpreter for a particular case under §109.313 of this division (relating to Qualifications of Certified Court Interpreters), certified court interpreters must present their court interpreter certificate card upon the request of a court or an officer of the court.(c) A BEI-certified court interpreter must notify DHHS, in writing, within 30 days of any change in his or her name, address, or telephone number.(d) Failure by a BEI-certified court interpreter to satisfactorily fulfill the responsibilities under this division may be grounds for administrative sanctions by DARS under Government Code, §57.022(b)(8). Source Note: The provisions of this §360.311 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.311 Responsibilities of Certified Court Interpreters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203602 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203602 03/12/2026 (a) In each civil case, deposition, or criminal action in a Texas court for which a person interprets testimony, the person must be qualified, as that term is defined in Civil Practice and Remedies Code, §21.003, and Code of Criminal Procedure, Art. 38.31(g), as court interpreter for that particular case before beginning to interpret testimony.(b) A person must show proof that the person is qualified, as that term is defined in Civil Practice and Remedies Code, §21.003, and Code of Criminal Procedure, Art. 38.31(g), under this subsection to act as a court interpreter.(c) In order to act as court interpreter for a particular case, the person must present to the judge presiding, or to the court reporter at a deposition, either:(1) a current card issued by DARS, stating that the person is certified as a court interpreter; or(2) a current membership card issued in the name of the person by RID, carrying the designations "Certified" and "SC:L."(d) A qualified interpreter in a criminal action in a Texas court, including an arraignment, hearing, examining trial, and trial, for a person who has a hearing impairment that inhibits the person's comprehension of the proceedings or communication with others, must hold a current court interpreter certificate issued by DARS or a current legal certificate issued by RID. Source Note: The provisions of this §360.313 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.313 Qualifications of Certified Court Interpreters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203603 03/12/2026 (a) An applicant who is hearing must meet the following qualifications to become a Board for Evaluation of Interpreters (BEI)-certified court interpreter:(1) hold at least one BEI certificate at Level III, IV, V, IIIi, IVi, Vi, Advanced, Master, or Oral: Comprehensive; or hold certification from Registry of Interpreters for the Deaf (RID) with a Comprehensive Skills Certificate, Certificate of Interpretation/Certificate of Transliteration, Reverse Skills Certificate, Certified Deaf Interpreter, or Master Comprehensive Skills Certificate, or National Interpreter Certification Advanced or National Interpreter Certification Master;(2) pass the DARS DHHS-approved court interpreter written test, which may only be taken by applicants who hold one of the certificates listed in paragraph (1) of this subsection; and(3) pass the court performance test, which may only be taken by applicants who have passed the court interpreter written test.(b) An applicant who is deaf or hard of hearing, and cannot hear sufficiently to take the performance test, must meet the following qualifications to become a BEI-certified court interpreter:(1) hold at least one BEI certificate at Level III, IV, V, IIIi, IVi, Vi, Advanced, Master, or Oral: Comprehensive; or hold certification from Registry of Interpreters for the Deaf (RID) with a Comprehensive Skills Certificate, Certificate of Interpretation/Certificate of Transliteration, Reverse Skills Certificate, Certified Deaf Interpreter, or Master Comprehensive Skills Certificate, or National Interpreter Certification Advanced or National Interpreter Certification Master;(2) have completed the following hours of training and/or mentoring:(A) a minimum of 12 Continuing Education Units (CEUs), which is the equivalent of 120 clock hours, of DARS-DHHS approved courses of instruction in courtroom interpretation knowledge and skills;(B) a minimum of 120 hours of actual practice provided by a certified court interpreter who has been approved by DARS DHHS to act as a mentor; or(C) a combined minimum of 120 hours of instruction and mentoring; and(3) have passed the court interpreter written test, which may only be taken upon completion and approval by DARS DHHS that the applicant has completed the required training and/or mentoring, as set forth in paragraph (2) of this subsection.(c) An applicant must provide DARS DHHS with documentary proof that the applicant meets the requirements for testing and for certification.(d) Applicants who formerly held BEI court certification, but who are ineligible to renew their BEI court certification, must meet all applicable qualifications and requirements of this section.(e) A military service member or military veteran applicant who is deaf or hard of hearing may satisfy the training requirements in subsection (b)(2) of this section with verified military service, training, or education. This subsection does not apply to a military service member or military veteran applicant who is deaf or hard of hearing and who holds a restricted license issued by another jurisdiction or has an unacceptable criminal history according to the laws applicable to DARS.(f) A military service member, military veteran, or military spouse applicant will be issued an expedited BEI court interpreter certificate if the applicant holds a current license issued by another jurisdiction that has licensing requirements that are substantially equivalent to the requirements in subsections (a) or (b) of this section.(g) A person with an expired certification must not perform work for which a certification is required under Government Code, Chapter 57. Source Note: The provisions of this §360.315 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective May 1, 2014, 39 TexReg 3452; amended to be effective August 2, 2015, 40 TexReg 4823; amended to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.315 Qualifications and Requirements for Court Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203604 03/12/2026 (a) DARS DHHS-Approved Mentors.(1) A person intending to be a mentor must apply on a form provided by DARS DHHS and be approved by DARS DHHS.(2) To be a mentor for court interpreting, the person must:(A) meet the requirements for and hold court interpreter certification issued by DARS or RID for not less than one year;(B) pass the court interpreter written test; and(C) not have been subject to disciplinary action in the previous two years.(3) Mentors must conform to a course of training prescribed by DARS DHHS.(b) DARS DHHS-Approved Courses of Instruction.(1) An approved mentor must submit to DARS DHHS for each proposed mentee a written course outline and materials to be used during instruction.(2) DARS DHHS reviews the proposed course outline and materials and determines whether the course is approved.(c) Public or Private Training Programs.(1) DARS may contract with public or private educational institutions, and other entities, to administer training programs.(2) Instructors must hold a court interpreter certificate issued by DARS or Registry of Interpreters for the Deaf (RID), be a licensed attorney or paralegal, or be otherwise found to be qualified as an instructor by DARS DHHS.(3) In accordance with Government Code, §57.021(b), DARS suspends training offered by an institution if the training fails to meet the requirements established by DARS. Source Note: The provisions of this §360.317 adopted to be effective April 24, 2013, 38 TexReg 2513; amended to be effective August 2, 2015, 40 TexReg 4823; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.317 Training Programs for Certified Court Interpreters Managed by DARS or by Public or Private Educational Institutions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203605 03/12/2026 (a) In accordance with Civil Practice and Remedies Code, §21.006 and HB 2292, 78th Legislature (RS), §1.21, the certified court interpreter in civil cases and depositions must be paid a reasonable fee determined by the court after considering the recommended fees of DARS. If the certified court interpreter is required to travel, his or her actual expenses of travel, lodging, and meals relating to the case must be paid at the same rate provided for state employees. The certified court interpreter's fee and expenses must be paid from the general fund of the county in which the case was brought.(b) In accordance with Code of Criminal Procedure, Art. 38.31(f), and HB 2292, 78th Legislature (RS), §1.21, a certified court interpreter appointed in criminal actions is entitled to a reasonable fee determined by the court after considering the recommended fees of DARS. When travel of the certified court interpreter is involved, all the actual expenses of travel, lodging, and meals incurred by the certified court interpreter pertaining to the case he or she is appointed to serve must be paid at the same rate provided for state employees.(c) Under the authority of the Code of Criminal Procedure, Art. 38.31(f); Government Code, §57.022(b)(7); and Civil Practice and Remedies Code, §21.006, DARS establishes recommended fees to pay court-appointed certified court interpreters for persons who are deaf or hard of hearing, for interpreter services that must be provided in proceedings as set forth in the specific statutes.(d) These fees may be reviewed and revised as considered necessary by DHHS. The schedule of fees and any changes are posted on the DHHS website and are available upon request. Source Note: The provisions of this §360.319 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.319 Instructions for the Compensation of a Certified Court Interpreter and Designation of the Party or Entity Responsible for Payment of Compensation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203606 03/12/2026 DHHS may begin proceedings to impose administrative penalties or sanctions, or both, under Human Resources Code, Chapter 81 or Government Code, Chapter 57 if a person violates any provision of the following:(1) Government Code, Chapter 57;(2) Human Resources Code, Chapter 81;(3) Subchapter B of this chapter; or(4) an order of the director of DHHS. Source Note: The provisions of this §360.321 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.321 Administrative Sanctions Enforceable by DARS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203607 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203607 03/12/2026 (a) A person may not interpret for someone who is deaf or hard of hearing at a court proceeding or advertise or represent that the person is a certified court interpreter unless the person holds a current court interpreter certificate issued by DARS or a current legal certificate issued by RID.(b) Violation of the prohibition in this section is a Class A misdemeanor offense under Government Code, §57.027(a), and may also subject the violator to an administrative penalty assessed by DARS under Government Code, §57.027(b) and §109.321 of this division (relating to Administrative Sanctions Enforceable by DARS). Source Note: The provisions of this §360.323 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.323 Prohibited Acts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203608 03/12/2026 DARS or DHHS investigates allegations of violations and enforces this subchapter. Allegations of violations may also be referred to another appropriate enforcement or regulatory authority. Allegations concerning violations of this subchapter should be forwarded, in writing, to the director. Source Note: The provisions of this §360.325 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.325 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203609 03/12/2026 (a) Government Code, §57.027(a) provides that a person commits an offense if the person violates Government Code, Chapter 57, Subchapter B, pertaining to court interpreters for people who are deaf or hard of hearing, or a rule adopted under Government Code, Chapter 57, Subchapter B. An offense under Government Code, §57.027(a) is a Class A misdemeanor.(b) The provisions of this subchapter are adopted under the provision of law described in subsection (a) of this section, and violations are subject to criminal penalties. In addition, violations of the provisions of §109.307 of this division (relating to Administration of Examination for Court Interpreter Certificate) and §109.321 of this division (relating to Administrative Sanctions Enforceable by DARS) constitute direct violations of Government Code, §57.026, and are also subject to criminal penalties under Government Code, §57.027(a). Source Note: The provisions of this §360.327 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.327 Criminal Offense https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203572 03/12/2026 (a) DHHS investigates complaints and may initiate disciplinary action against a person alleged to perform court interpretation without certification or authorization as provided by this division. DHHS follows the investigative process and resulting action listed in paragraphs (1) - (3) of this subsection to ensure that affected people are afforded due process of law.(1) Upon receipt of a complaint from the public or from a DARS staff member, DHHS evaluates the information to determine if the evidence provides reasonable cause that a violation may have occurred.(2) If reasonable cause does not exist, an investigation is not initiated.(3) If reasonable cause is found, then the DHHS staff initiates an investigation to determine if a violation of law has occurred. DHHS' investigative process is as follows:(A) The person named in the complaint is advised of the complaint and the specific section of the Government Code, Chapter 57 that appears to have been violated.(B) The person is afforded the opportunity to respond to the complaint to show that the actions that precipitated the complaint are not in violation of the Government Code, Chapter 57.(C) If, after evaluation of the person's response, a violation appears evident, the person is afforded the opportunity for a hearing as provided to certificate holders under Chapter 101, Subchapter E, Divisions 1 and 4 of this title (relating to General Rules and Office for Deaf and Hard of Hearing Services) or for resolution of the complaint through a DARS order, which may include the imposition of an administrative penalty.(b) Complaints, allegations of violations, and findings of violations against a person, relating to the rules of this division may be considered as grounds for denial of pending or subsequent applications for interpreter certification from DARS and as grounds for disciplinary action against a holder of other DARS-issued certifications. Source Note: The provisions of this §360.329 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.329 Actions against Persons Not Certified as Court Interpreters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203573 03/12/2026 A court interpreter in a civil case or deposition in a Texas court must hold a current court interpreter certificate issued by DARS or a current legal certificate issued by RID. Source Note: The provisions of this §360.331 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.331 Court Interpreter Qualifications in Civil Cases or Depositions under the Civil Practice and Remedies Code https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203574 03/12/2026 The purpose of this division is to set out the administration and general procedures governing the certification of trilingual interpreters for persons who are deaf or hard of hearing in Texas. Source Note: The provisions of this §360.401 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.401 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203575 03/12/2026 DARS administers and enforces trilingual certification under authority of the Human Resources Code, Chapter 81. Source Note: The provisions of this §360.403 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.403 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203576 03/12/2026 (a) An applicant for a trilingual certificate must:(1) provide proof of holding one of the following certificates:(A) valid Board for Evaluation of Interpreters (BEI) Level I, II, III, IV, V, Basic, Advanced, or Master certificate; or(B) valid Registry of Interpreters for the Deaf (RID) Comprehensive Skills Certificate (CSC), Certificate of Interpretation (CI), and/or Certificate of Transliteration (CT); or(C) valid National Association of the Deaf-Registry of Interpreters for the Deaf (NAD-RID) National Interpreter Certification (NIC), National Interpreter Certification Advanced, or National Interpreter Certification Master; and(2) meet the following qualifications and requirements:(A) satisfy qualifications set forth in §109.217 of this chapter (relating to Qualifications and Requirements for a BEI Certificate);(B) submit the appropriate application and pay required fees;(C) pass the requisite examinations for the trilingual certificate sought, which include:(i) the Test of Spanish Proficiency; and(ii) a trilingual performance examination.(b) Trilingual certificate holders must satisfy the annual certificate renewal and five-year recertification requirements for both the prerequisite certificate and for the trilingual certificate. Source Note: The provisions of this §360.405 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.405 Qualifications and Requirements for a Trilingual Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203577 03/12/2026 The purpose of this division is to set out the administration and general procedures governing the certification of medical interpreters for persons who are deaf or hard of hearing in Texas. Source Note: The provisions of this §360.451 adopted to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.451 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203578 03/12/2026 DARS administers and enforces medical certification under the authority of the Human Resources Code, Chapter 81. Source Note: The provisions of this §360.453 adopted to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.453 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203579 03/12/2026 (a) An applicant for a medical certificate must:(1) provide proof of holding one of the following prerequisite certificates:(A) valid Board for Evaluation of Interpreters (BEI) Level III, IV, V, Advanced, or Master certificate; or(B) valid Registry of Interpreters for the Deaf (RID) Comprehensive Skills Certificate (CSC), Certificate of Interpretation (CI) and Certificate of Transliteration (CT); or(C) valid National Association of the Deaf-Registry of Interpreters for the Deaf (NAD-RID) National Interpreter Certification (NIC) Advanced, or National Interpreter Certification Master; and(2) meet the following qualifications and requirements:(A) satisfy qualifications set forth in §109.217 of this chapter (relating to Qualifications and Requirements for a BEI Certificate);(B) provide written proof to DARS DHHS that the applicant has completed DARS DHHS-approved courses of instruction in medical interpretation, with at least 80 credit hours;(C) submit the appropriate application;(D) pay any required fees; and(E) pass the Medical Performance Test.(b) Medical certificate holders must satisfy the annual certificate renewal and five-year recertification requirements for both the prerequisite certificate and the medical certificate. For the medical certificate, 20 clock hours of the continuing education unit requirement for the five-year recertification requirement must be in medical interpretation knowledge and skills. Source Note: The provisions of this §360.457 adopted to be effective April 6, 2016, 41 TexReg 2503; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES B BOARD FOR EVALUATION OF INTERPRETERS §360.457 Qualifications and Requirements for Medical Certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204417&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204417 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204417&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204417 03/12/2026 The purpose of this subchapter is to set out the administration and general procedures governing the Texas Health and Human Services Commission Office of Deaf and Hard of Hearing Services (ODHHS), Specialized Telecommunications Assistance Program (STAP). Source Note: The provisions of this §360.501 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.501 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204418&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204418 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204418&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204418 03/12/2026 STAP is created under the authority of the Texas Utilities Code Chapter 56, Subchapter E. Source Note: The provisions of this §360.503 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.503 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204419&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204419 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204419&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204419 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Application--The form ODHHS uses to gather and document information about a person to determine eligibility when applying for assistance under STAP.(2) Approved Equipment or Service--The equipment or service approved by ODHHS for reimbursement under STAP.(3) Basic Specialized Telecommunications Equipment--A basic device, or basic devices that work together as one device, determined by ODHHS to be necessary to provide effective access to the telephone network for a person whose disabilities impair the person's ability to access the telephone network.(4) Basic Specialized Telecommunications Service--A service, or services that work together as one service, determined by ODHHS to be necessary to provide effective access to the telephone network for a person whose disabilities impair the person's ability to access the telephone network.(5) Claimed Voucher--To claim a voucher, vendors are to provide voucher exchange information in the ODHHS STAP online claiming system. A vendor must be registered with STAP to receive access to the claiming system.(6) Entity--Any individual owner, partner, company, or other business organization.(7) Equipment Value--A monetary value established by ODHHS for allowable specialized telecommunications equipment or service, identified by make and model or service.(8) Financial Assistance--A type of assistance provided based on the monetary value established by a voucher for basic, specialized telecommunications equipment or service, where the value may not cover the full price of the equipment or service.(9) Financial Independence--An instance in which two or more otherwise eligible persons reside in the same household but are not dependent upon one another for financial support.(10) Functionally Equivalent Network Access--Access to the telephone network that provides communication access for a person with a disability, which is comparable to that of persons without a disability.(11) HHSC--Texas Health and Human Services Commission.(12) Legal Guardian--A person appointed by a court of competent jurisdiction to exercise the legal powers of another person.(13) ODHHS--The HHSC Office of Deaf and Hard of Hearing Services.(14) PUC--The Public Utility Commission of Texas.(15) Resident--A person who resides in Texas as evidenced by one of the following unexpired documents:(A) Texas driver's license;(B) ID card issued by a governmental entity with address;(C) utility bill with address;(D) voter registration card;(E) vehicle registration receipt;(F) official letter from a residential facility signed by the director or supervisor; or(G) other document approved by ODHHS.(16) Signature Authority--A person who represents a vendor and is authorized to sign and exchange vouchers on behalf of the vendor.(17) STAP--The Specialized Telecommunications Assistance Program.(18) STAP Vendor--An entity that sells basic specialized telecommunications equipment or services, as defined under STAP, and is registered with and approved by ODHHS. A STAP vendor includes any individual owners, partners, companies, or other entities with an ownership interest in the STAP vendor.(19) TUSF--The Texas Universal Service Fund.(20) Voucher--A financial assistance document issued by ODHHS to eligible applicants that is used to purchase a specified type of basic specialized telecommunications equipment or service from a STAP vendor.(21) Voucher Category--A specific class of basic specialized telecommunications equipment or services that provides the same or similar type of telephone network access.(22) Voucher Category Value--For a specific voucher category, ODHHS will determine a reasonable price, which is the maximum reimbursement amount for any basic specialized telecommunications equipment or service within that voucher category. Source Note: The provisions of this §360.505 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.505 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204420 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204420 03/12/2026 (a) In determining basic specialized telecommunications equipment or service available for voucher exchange, ODHHS applies the following criteria.(1) The equipment or service must be for the purpose of accessing the telephone network.(2) The primary function of the equipment or service must apply to telephone network access and not to daily living access, unless:(A) the equipment or service for daily living access enables a person to access the telephone network and is less expensive than equipment or service that functions primarily for telephone access, or(B) there is no other equipment or service available that enables telephone access.(3) A service must be less expensive than the basic specialized telecommunications equipment approved for a voucher under STAP and must be able to meet the same need.(b) ODHHS maintains a list of eligible specialized telecommunications equipment and services. Source Note: The provisions of this §360.507 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.507 Determination of Basic Specialized Telecommunications Equipment or Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204421 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204421 03/12/2026 (a) Preliminary assessment. To determine whether a person is eligible for a voucher, ODHHS conducts a preliminary assessment based on the certification section of the application. A person is eligible if ODHHS determines that the person:(1) has a disability that impairs the person's ability to effectively access the telephone network; and(2) can gain access to the telephone network and communicate effectively with basic specialized telecommunications equipment or a service authorized by the specific voucher applied without the assistance of another person.(b) Comprehensive assessment. An in-depth assessment that contains information necessary to identify the basic needs that enable the person to access telephone networks. If, after the preliminary assessment is completed, and additional information is needed to determine the appropriate basic voucher for an eligible person, ODHHS may conduct a comprehensive assessment of the person's disabilities, abilities, and needs, which may include medical information.(c) Final determination. ODHHS determines eligibility for a voucher, and the determination is final. Source Note: The provisions of this §360.509 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.509 Preliminary and Comprehensive Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204414&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204414 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204414&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204414 03/12/2026 (a) To be eligible for assistance from STAP, a person must:(1) be a resident of Texas;(2) be a person with a disability that impairs the person's ability to effectively access the telephone network;(3) be at least 5 years of age;(4) be in a situation where no other person in the household with the same type of disability needing comparable equipment has received a voucher for equipment unless persons in the household are financially independent of each other;(5) not have received a voucher from ODHHS for any specialized telecommunications equipment or services before the fifth anniversary of the date the person exchanged the previously issued voucher under STAP, unless before that anniversary, the person demonstrates that the person is no longer able to use the previous equipment or service received and has developed a need for a different type of specialized telecommunications equipment or service under STAP because of a change in the person's disability status;(6) be able to benefit from the specialized telecommunications equipment or service provided by the voucher in accessing the telephone network without assistance of another person; and(7) be certified as a person with a disability that impairs the person's ability to effectively access the telephone network, by an individual who meets the requirements of §360.513 of this subchapter (relating to Persons Authorized to Certify Disability).(b) A voucher recipient who has not exchanged an issued voucher in compliance with this subchapter, within the last five years, may be eligible for another voucher, as long as all other eligibility requirements are satisfied.(c) A voucher recipient who has returned the equipment or has stopped a service received through the exchange of a voucher, in compliance with this subchapter, may be eligible for another voucher if the equipment is returned or the service is stopped in compliance with §360.527 of this subchapter (relating to STAP Vendor Duties and Responsibilities).(d) A voucher recipient of an exchanged voucher in which the registered vendor was not reimbursed for the voucher exchanged in compliance with this subchapter, may be eligible for another voucher, as long as all other eligibility requirements are satisfied. Source Note: The provisions of this §360.511 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.511 Voucher Recipient Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204413&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204413 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204413&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204413 03/12/2026 (a) An applicant must be certified as a person with a disability that impairs the person's ability to effectively access the telephone network. The following may serve as certifiers:(1) licensed hearing aid specialists;(2) licensed audiologists;(3) licensed optometrists;(4) licensed physicians;(5) licensed advanced practice registered nurses;(6) Texas Workforce Commission vocational rehabilitation counselors;(7) state-certified teachers of persons who are deaf or hard of hearing;(8) licensed speech pathologists;(9) state-certified teachers of persons who are visually impaired;(10) state-certified teachers of persons who are speech-impaired;(11) state-certified special education teachers;(12) STAP specialists authorized to work under an ODHHS STAP Outreach and Training contract;(13) licensed social workers;(14) Independent Living Services specialists, such as rehabilitation counselors, authorized to work under an HHSC Independent Living Services contract;(15) ODHHS-approved specialists working in a disability-related field; or(16) any other professional approved by ODHHS.(b) An application must be properly certified before ODHHS can process and approve the application and issue the voucher.(c) Certifiers who have misrepresented an applicant's disability, certified an applicant without a disability, violated or who are under pending review of investigation for alleged violations of any HHSC, PUC, or other rules, policies, or laws relating to STAP may no longer be authorized to certify applications. Persons committing or suspected of committing such violations may be referred to PUC, to the certifier's licensing agency, or to both, as appropriate. Source Note: The provisions of this §360.513 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.513 Persons Authorized to Certify Disability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204415&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204415 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204415&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204415 03/12/2026 (a) Eligible applicants are issued an individually numbered voucher with a specified dollar value to be used toward the purchase of the specialized telecommunications equipment or service that must be listed on the voucher.(b) A voucher guarantees payment up to the amount specified on the voucher to a STAP vendor if all applicable rules, policies, procedures, and laws are satisfied.(c) A voucher may not cover the full price of applicable equipment or service available under STAP.(d) An eligible applicant exchanging a voucher for the purchase of a specialized telecommunications equipment or service is responsible for payment of the difference between the voucher's value and the price of the equipment or service.(e) A voucher is nontransferable and has no cash value.(f) A voucher expires on the date stated on the voucher and is no longer valid after the expired date.(g) A voucher cannot be exchanged before the voucher date stated on the voucher. Source Note: The provisions of this §360.515 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.515 Vouchers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204416 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204416 03/12/2026 (a) ODHHS determines the reasonable price for basic specialized telecommunications equipment or services for a voucher. The price becomes the voucher category value for a specific voucher.(b) The voucher category value as determined by ODHHS may not cover the entire cost of the basic specialized telecommunications equipment or service.(c) ODHHS reviews voucher category values at least annually. The voucher category value determination is based on factors that include reasonable and customary industry standards for each specific equipment or service.(d) ODHHS reviews eligibility criteria for a voucher category at least biennially. ODHHS solicits input from persons ODHHS considers knowledgeable in technology and in the telephone access needs of persons with disabilities.(e) Proposed voucher category values and eligibility criteria are posted to the ODHHS STAP webpage for comments 45 calendar days before final determinations are made for a voucher category. Comments obtained from the advance posting are considered in determining voucher category values and eligibility criteria for a voucher category.(f) ODHHS determines voucher category values and eligibility criteria for a voucher category, and the determination is final. Source Note: The provisions of this §360.517 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.517 Determination of Voucher Category Value and Eligibility Criteria for a Voucher https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204422 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204422 03/12/2026 (a) All information ODHHS receives in the application process for STAP, including names and addresses, may be used only to administer STAP.(b) ODHHS may not advertise, distribute, or publish the name, address, or other related information about a person who applies for assistance under STAP. Information concerning STAP is exempted from disclosure under the Public Information Act.(c) All STAP applicant information is the sole property of ODHHS. Source Note: The provisions of this §360.519 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.519 Consumer Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204423 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204423 03/12/2026 (a) ODHHS determines approved makes and models of equipment and specific services for voucher exchange for reimbursement to STAP vendors.(b) ODHHS reviews approved equipment and services at least annually. The approval of equipment and services are governed by §360.507 of this subchapter (relating to Determination of Basic Specialized Telecommunications Equipment or Service).(c) ODHHS determines approved makes and models of equipment and specific services, and the determination is final. Source Note: The provisions of this §360.521 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.521 Determination of Approved Equipment or Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204424&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204424 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204424&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204424 03/12/2026 (a) ODHHS determines a reasonable equipment value for approved makes and models of specialized telecommunications equipment and services to be paid to STAP vendors for exchanged vouchers.(b) ODHHS reviews equipment values at least annually. Equipment value determinations are based on factors that include reasonable and customary industry standards for approved equipment and specific services.(c) Proposed equipment values for approved equipment or services are posted to the ODHHS STAP web page for comments 45 calendar days before final determinations are made. Comments obtained from the advance posting are considered in determining equipment values for approved equipment and specific services.(d) ODHHS determines equipment values for reimbursement to a STAP vendor, and the determination is final. Source Note: The provisions of this §360.523 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.523 Equipment Values for Approved Equipment or Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204425&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204425 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204425&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204425 03/12/2026 (a) To be eligible to serve as a STAP vendor and receive reimbursements for STAP vouchers appropriately exchanged, an entity shall meet the following eligibility requirements:(1) complete the registration process;(2) maintain contact information to include current:(A) owners, principal partners, officers, company legal names, and Doing Business As (DBA) names;(B) telephone number;(C) email address;(D) physical address;(E) mailing address;(F) current Federal Employer Identification Number (FEIN);(G) bank information for STAP vendor reimbursement payments by direct deposit; and(H) names of individuals who are authorized to sign and exchange a voucher.(3) not be barred, debarred, suspended, proposed for debarment, declared ineligible, or excluded from participation in STAP by HHSC or any federal or Texas state agency; and(4) not owe any delinquent debts or outstanding obligations to TUSF or any Texas state agency.(b) In order to maintain eligibility, STAP vendors shall comply with the following requirements:(1) register annually; and(2) exchange or receive reimbursement for at least one STAP voucher every six months.(c) STAP vendors that have lost STAP eligibility because of failure to exchange or receive reimbursement for a voucher during a six-month period may request reinstatement by ODHHS in accordance with §360.533 of this subchapter (relating to Reinstatement of STAP Vendors). Source Note: The provisions of this §360.525 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.525 STAP Vendor Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204426&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204426 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204426&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204426 03/12/2026 (a) STAP vendors shall comply with all applicable rules, policies, procedures, and laws governing STAP to remain eligible to participate in and receive reimbursement under STAP.(b) Any STAP vendor failing to comply with subsection (a) of this section may be denied reimbursement.(c) STAP vendors shall supply only new equipment that was purchased by the STAP vendor directly from a supplier.(d) STAP vendors cannot receive STAP reimbursement for:(1) used equipment;(2) equipment paid for directly by a customer;(3) vouchers on which the vendor or one of the vendor's employees are also the named certifier before written approval by ODHHS;(4) vouchers that are not properly completed or redeemed in accordance with the voucher terms, conditions, and instructions;(5) returned equipment and requests to terminate services;(6) vouchers that are not claimed in the ODHHS STAP claiming system by the vendor in accordance with this subchapter, STAP policies, and STAP procedures; or(7) vouchers on which the certifier is working for or on behalf of the vendor and the certifier has violated or is under pending review or investigation for alleged violations of HHSC, PUC or other rules, policies, or laws regulating STAP.(e) STAP vendors shall allow voucher recipients to return equipment that was not damaged when the voucher recipient originally took possession, or stop a service without penalty, if the voucher recipient attempts to return the equipment or requests that the service be terminated within 30 calendar days after receipt of the equipment or service.(1) STAP vendors that can show they have made reasonable but unsuccessful attempts to retrieve or accept the return of the equipment from the voucher recipient, are not required to accept the return beyond the 30 calendar day requirement.(2) STAP vendors shall document any attempts to accept or retrieve equipment returned by the recipient.(f) STAP vendors shall provide a voucher recipient with a receipt if equipment is returned or service is terminated.(g) STAP vendors must contact ODHHS within 10 calendar days after equipment is returned or service is requested to be stopped in the event that equipment is returned, service is unused, or service is requested to be terminated by the STAP voucher recipient within 30 calendar days from voucher exchange date.(h) STAP vendors must reimburse TUSF within 30 calendar days after equipment is returned or service is requested to be stopped, if equipment is returned, service is unused, or service is requested to be terminated by the STAP voucher recipient within 30 calendar days from voucher exchange date.(i) STAP vendors shall not submit a voucher for reimbursement before 10 calendar days from the date of the voucher exchange and before the equipment or services is delivered.(j) STAP vendors shall provide efficient delivery of equipment or access to services no later than 10 calendar days after the voucher claim or communication with the STAP voucher recipient when the equipment or service will be delivered.(k) STAP vendors shall provide STAP voucher recipients information on, instructions to, or demonstration of the use and setup of the equipment as appropriate to help recipients understand how to use and set up the equipment before completing the sale and submitting the voucher for reimbursement.(l) STAP vendors shall ensure that when they work with or act as STAP certifiers, appropriate equipment is selected for the STAP applicant.(m) STAP vendors shall not assess a STAP voucher recipient an additional fee, cost, or penalty, in addition to the STAP vendor price, except a reasonable shipping cost for mail orders, when a STAP voucher recipient purchases equipment or services with a STAP voucher.(n) STAP vendors shall notify ODHHS in writing at least 60 calendar days before the intended effective date of any change in legal entity status, such as ownership or control, name change, federal or state legal status, bank routing information, or contact information.(o) STAP vendors shall retain records related to STAP, including purchase of the equipment or service exchanged, and the distribution or delivery of equipment or service to the voucher recipient for a minimum of six years from the date of the voucher exchange.(p) STAP vendors shall allow ODHHS to conduct an audit, investigation, and STAP oversight of their business.(1) During the six-year retention period, STAP vendors shall permit ODHHS, the State Auditor's Office, PUC, or their successor agencies, to conduct an audit or investigation of the STAP vendor in connection with funds received for reimbursement of a STAP voucher. STAP vendors will provide any books, documents, papers, and records that are pertinent to the exchange of a STAP voucher, for the purpose of conducting audits, examinations, or investigations, or for the production of excerpts and transcriptions.(2) STAP vendors shall cooperate fully in an audit, examination, investigation, funds validation, or in the production of excerpts and transcriptions.(3) STAP vendors shall provide documentation from third parties reflecting equipment or services purchased and the purchase price and records showing sales to non-STAP consumers.(4) STAP vendors shall permit ODHHS staff during any on-site monitoring visits to review all records and management control systems relevant to the exchange of a STAP voucher.(5) STAP vendors shall remedy, within 30 calendar days of notice, any weaknesses, deficiencies, or STAP noncompliance found as a result of a review, audit, or investigation as well as performance or fiscal exceptions found by ODHHS, the State Auditor's Office, PUC, any successor agencies, or any duly authorized representatives of said agencies.(6) STAP vendors shall refund disallowed costs or billed amounts or pay any other appropriate sanctions or penalties imposed by ODHHS directly to TUSF.(q) STAP vendors shall provide to the STAP voucher recipient, all equipment or services as authorized on the voucher.(r) STAP vendors shall ensure that individuals authorized to sign a STAP voucher receive training provided by ODHHS before signing or exchanging a STAP voucher.(s) STAP vendors shall not stamp, label, or affix any company information on any STAP-related promotional materials or applications as a form of marketing.(t) STAP vendors must exchange or receive reimbursement for at least one STAP voucher during the most recent six-month period. Failure to do so may result in automatic removal from the list of eligible STAP vendors.(u) STAP vendors shall ensure that the vendor's advertised purchase price for equipment or services is not arbitrarily inflated.(v) STAP vendors shall be accessible by telephone and in-person to provide assistance under STAP, including inquiries and complaints during standard business hours. Service representatives shall respond within 72 hours or 3 business days after the request for assistance is made, whichever occurs first. If a representative is not available to answer the telephone, an automated answering message system must provide callers with the vendor's company name and hours of operation and allow callers to leave a message.(w) STAP vendors shall maintain a website displaying current equipment and services available by the vendor for purchase with a STAP voucher, in an easy-to-understand format. Website information shall include:(1) the make, model, and cost to the STAP voucher recipient, or the cost above the established STAP equipment value for each equipment sold by the vendor under a STAP voucher;(2) specific named services and cost to the STAP voucher recipient, or the cost above the established STAP equipment value for each named service;(3) a description of equipment or service sufficient to cover functionality of the equipment needed for persons with disabilities in accessing the telephone networks; and(4) contact information, including physical business location, hours of service, and email address.(x) STAP vendors shall maintain a required inventory for demonstration purposes as established by ODHHS and ensure equipment or service from that inventory is made available to STAP voucher recipients for each voucher that the vendor intends to exchange for a STAP voucher. Vendors shall comply with the inventory requirements of newly added inventory within 30 calendar days after notice by ODHHS. STAP vendors shall update their websites within 10 calendar days after the date their inventory has been updated. Source Note: The provisions of this §360.527 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.527 STAP Vendor Duties and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204427&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204427 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204427&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204427 03/12/2026 (a) Not later than the 45th calendar day after the date ODHHS receives the voucher and all required supporting documentation from the STAP vendor, or the date the vendor has claimed the voucher in the ODHHS STAP claiming system, whichever date occurs later, the ODHHS will pay the STAP vendor from TUSF the lesser of the:(1) ODHHS established equipment value;(2) STAP vendor's advertised purchase price; or(3) voucher value established by ODHHS for the voucher category of the equipment or service exchanged.(b) Vouchers will not be reimbursed for partial exchanges. All equipment must be exchanged as authorized on the voucher.(c) STAP vendors will not be reimbursed for voucher exchanges that are made during any time the STAP vendor is barred, debarred, suspended, proposed for debarment, declared ineligible, or excluded from participation in STAP by HHSC or any federal or Texas state agency.(d) STAP vendors seeking reimbursement for the sale of STAP equipment from an additional source (such as Medicare, Medicaid, or private insurance) in conjunction with a voucher exchange may not receive more than the total price of the equipment from all sources.(e) A STAP vendor that exchanges a STAP voucher in person for the purchase of approved equipment or services in accordance with STAP requirements may request reimbursement from ODHHS. ODHHS will reimburse the STAP vendor from TUSF for a voucher exchanged in accordance with this subchapter and STAP policy when the STAP vendor claims the voucher in the ODHHS STAP claiming system, exchanges the voucher for equipment with the customer, and provides ODHHS with the following documentation:(1) a voucher documenting equipment or service exchanged and signed by both the voucher recipient, and vendor's registered signature authority on file with ODHHS certifying that the equipment or service was new, unused, and not reconditioned or obsolete and has been delivered to the voucher recipient; and(2) a receipt or invoice that contains:(A) a description of the equipment or service exchanged for the STAP voucher;(B) manufacturer and model number;(C) serial number; and(D) the total price charged to the voucher recipient, including the amount to be reimbursed by ODHHS for the equipment or service exchanged.(f) A STAP vendor that exchanges a STAP voucher by mail for the purchase of approved equipment or services in accordance with STAP policies and this subchapter may request reimbursement from ODHHS. ODHHS will reimburse a voucher (exchanged in accordance with this subchapter and STAP policies) upon receipt from the STAP vendor of:(1) proof of delivery of the equipment or service to the voucher recipient; and(2) a receipt or invoice that contains:(A) a description of the equipment or service exchanged by mail for the STAP voucher;(B) manufacturer and model number;(C) serial number; and(D) the total price charged to the voucher recipient, including the amount to be reimbursed by ODHHS for the equipment or service exchanged.(g) STAP vendors shall claim a voucher in the ODHHS STAP claiming system and submit voucher reimbursement requests, along with supporting documentation, to ODHHS within 120 calendar days after the date of the voucher exchange or the date shown on the proof of delivery.(h) Vouchers exchanged in violation of STAP requirements that are not corrected, and vouchers or supporting documentation submitted or claimed after 120 calendar days from the date of the voucher exchange will not be reimbursed.(i) Vouchers submitted that do not have supporting documentation, as required by this subchapter will not be reimbursed.(j) ODHHS may investigate whether the presentation of a voucher for payment represents a valid transaction for equipment or service under STAP.(k) If there is a dispute regarding the amount or propriety of the payment or whether the equipment or service is appropriate or adequate to meet the needs of the voucher recipient, ODHHS may:(1) delay or deny payment of a voucher to a STAP vendor until the dispute is resolved; or(2) provide payment of a voucher, conditional upon the return of the payment if the equipment is returned to the STAP vendor or if the service is not used by the voucher recipient.(l) Reimbursements may also be subject to other limitations or conditions determined by ODHHS to be just and reasonable, including investigation of whether the presentation of a STAP voucher represents a valid transaction for equipment or services under STAP.(m) If a dispute arises as to whether the submitted documentation is sufficient to create a presumption of a valid STAP sales transaction, ODHHS will make the final determination on the sufficiency of the documentation. Source Note: The provisions of this §360.529 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.529 Voucher Reimbursement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204428&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204428 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204428&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204428 03/12/2026 (a) A STAP vendor may be suspended from or lose eligibility to participate in STAP for any of the following:(1) failure to comply with the requirements of STAP;(2) seeking or receiving reimbursement for equipment or services that are not new, were not provided, or were provided only after seeking or receiving reimbursement;(3) seeking or receiving reimbursement for equipment or services on a voucher that is not a valid STAP voucher;(4) violating or suspicion of violating any ODHHS or other applicable rules, policies, or laws relating to STAP;(5) working with or serving as a certifier and failing to ensure appropriate equipment selection;(6) failure to repay TUSF for equipment or services for which the STAP vendor received reimbursement, but for which the STAP vendor did not provide the equipment or service, or was not otherwise entitled to reimbursement; or(7) being barred, debarred, suspended, proposed for debarment, declared ineligible, or excluded from doing business with, or receiving payments from, the federal or state government.(b) ODHHS will notify a STAP vendor in writing if ODHHS determines that the STAP vendor or service provider is suspended from STAP or is otherwise ineligible to participate in STAP. Source Note: The provisions of this §360.531 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.531 Suspension or Loss of STAP Vendor Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204429&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204429 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204429&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204429 03/12/2026 (a) A STAP vendor that has been suspended or otherwise determined to be ineligible to participate as a STAP vendor, may request reinstatement into STAP by:(1) submitting a written request to ODHHS for reinstatement; and(2) submitting written documentation showing that:(A) all STAP eligibility requirements have been satisfied; and(B) any violations or deficiencies that resulted in the suspension or ineligibility determination have been remedied.(b) ODHHS decision on a reinstatement request is final. Source Note: The provisions of this §360.533 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.533 Reinstatement of STAP Vendors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204412&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204412 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204412&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204412 03/12/2026 (a) ODHHS determines makes and models of approved equipment and specific services for a voucher that a STAP vendor is required to make available to a STAP voucher recipient.(b) ODHHS reviews the required inventory at least annually. The required inventory is determined by approved equipment and services that conform to §360.507 of this subchapter (relating to Determination of Basic Specialized Telecommunications Equipment or Service) and offers a STAP voucher recipient a reasonable selection.(c) Vendors are not required to have both the equipment inventory and the service inventory established for a voucher to be able to sell equipment or service under that voucher.(d) If a vendor does not exchange a specific voucher, an inventory for that voucher is not required.(e) The required inventory does not preclude vendors from selling additional allowable equipment or services. Source Note: The provisions of this §360.535 adopted to be effective March 30, 2021, 46 TexReg 2024. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES C SPECIALIZED TELECOMMUNICATIONS ASSISTANCE PROGRAM §360.535 Vendor Required Approved Equipment or Service Inventory https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203615 03/12/2026 The purpose of this subchapter is to set out the administration and general procedures governing the Deaf and Hard of Hearing Driver Identification Program. The program provides for the design and issuance of a Visor Identification Card that may be displayed in a motor vehicle that is operated by a person who is deaf or hard of hearing. Source Note: The provisions of this §360.601 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES D DEAF AND HARD OF HEARING DRIVER IDENTIFICATION PROGRAM §360.601 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203616 03/12/2026 The Deaf and Hard of Hearing Driver Identification Program is created under authority of the Human Resources Code, §81.019. Source Note: The provisions of this §360.603 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES D DEAF AND HARD OF HEARING DRIVER IDENTIFICATION PROGRAM §360.603 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203617 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Applicant--A person applying to DARS DHHS for a Visor Identification Card.(2) Application--The form that DHHS uses to gather and document information about an applicant for a Visor Identification Card under the Deaf and Hard of Hearing Driver Identification Program.(3) Visor Identification Card--The identification card issued by DHHS to an eligible driver who is deaf or hard of hearing for use in a motor vehicle operated by that driver. The card attaches to the vehicle's visor and identifies the driver as a person who is deaf or hard of hearing to facilitate communication during a traffic stop. Source Note: The provisions of this §360.605 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES D DEAF AND HARD OF HEARING DRIVER IDENTIFICATION PROGRAM §360.605 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203618 03/12/2026 (a) To be eligible for a Visor Identification Card, an applicant must:(1) be a resident of Texas;(2) have a valid driver's license or permit issued by a state agency authorized to issue driver's licenses;(3) be a person with a disability that impairs the person's ability to hear; and(4) submit a completed application to DHHS, along with any requested documentation and any applicable fee.(b) DHHS requires an applicant for a Visor Identification Card to provide acceptable proof that the applicant is deaf or hard of hearing. Acceptable proof may include the following:(1) medical proof as determined by DHHS that the applicant is deaf or hard of hearing;(2) a state-issued driver's license or permit which indicates that the applicant is deaf or hard of hearing; or(3) certification by a licensed physician, licensed advanced practice registered nurse, or licensed audiologist that the applicant has a hearing loss severe enough to possibly impede communication in some traffic stops.(c) DHHS determines eligibility for a Visor Identification Card, and the determination is final. Source Note: The provisions of this §360.607 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES D DEAF AND HARD OF HEARING DRIVER IDENTIFICATION PROGRAM §360.607 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203619 03/12/2026 (a) DHHS is responsible for the design and content of the Visor Identification Card.(b) DHHS issues all Visor Identification Cards.(c) The Visor Identification Card documents the name of the driver to whom it is issued and contains a DHHS-designated driver registration number.(d) DHHS maintains a registry of all holders of Visor Identification Cards.(e) DHHS may set a fee for each Visor Identification Card to defray the costs of administering the Deaf and Hard of Hearing Driver Identification Program. Source Note: The provisions of this §360.609 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES D DEAF AND HARD OF HEARING DRIVER IDENTIFICATION PROGRAM §360.609 Deaf and Hard of Hearing Driver Visor Identification Card https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203620 03/12/2026 The purpose of this subchapter is to set out the administration and general procedures governing the Certificate of Deafness for Tuition Waiver Program. The program provides a certificate to a person who applies for tuition waiver at a state-supported postsecondary school in Texas and whose sense of hearing is nonfunctional. Source Note: The provisions of this §360.701 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES E CERTIFICATE OF DEAFNESS FOR TUITION WAIVER PROGRAM §360.701 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203621 03/12/2026 The Certificate of Deafness for Tuition Waiver Program is created under authority of the Education Code, Chapter 54, §54.364. Source Note: The provisions of this §360.703 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES E CERTIFICATE OF DEAFNESS FOR TUITION WAIVER PROGRAM §360.703 Legal Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203622 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Applicant--A person applying to DARS DHHS for a Certificate of Deafness for Tuition Waiver.(2) Application--The form that DARS DHHS uses to gather and document information about an applicant for a Certificate of Deafness for Tuition Waiver under the Certificate of Deafness for Tuition Waiver Program.(3) Certificate of Deafness for Tuition Waiver--The certificate issued by DARS DHHS to an eligible applicant to certify that the applicant is a deaf person as defined by Education Code, §54.364(a)(3). The applicant may use the certificate to apply for a tuition waiver at any Texas state institution of higher education using public funds, as set forth in Education Code, §54.364(a)(5) and §61.003. Source Note: The provisions of this §360.705 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES E CERTIFICATE OF DEAFNESS FOR TUITION WAIVER PROGRAM §360.705 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203623 03/12/2026 (a) To be eligible for a Certificate of Deafness for Tuition Waiver, the applicant must:(1) submit an application to DARS DHHS for a Certificate of Deafness for Tuition Waiver;(2) be at least 17 years old at the time of application or, if less than 17, provide proof of being a high school senior or having a high school diploma or equivalent; and(3) establish functional deafness in that the applicant's sense of hearing is nonfunctional, after all necessary medical treatment, surgery, and use of hearing aids, for understanding normal conversation.(b) To establish functional deafness, an applicant whose mode of communication in the classroom is primarily visual must provide documentation verifying one of the following:(1) unaided average hearing loss in the better ear of 55 decibels (dB) or greater using 500, 1000, 2000, and 4000 Hz, as verified by a licensed audiologist or licensed fitter and dispenser of hearing instruments;(2) aided average hearing loss in the better ear of 30 dB or greater using 500, 1000, 2000, and 4000 Hz, as verified by a licensed audiologist or licensed fitter and dispenser of hearing instruments;(3) speech discrimination is less than 50 percent as verified by a licensed audiologist or a licensed fitter and dispenser of hearing instruments; or(4) other disabling conditions (with or without hearing loss) that result in a person's sense of hearing being nonfunctional as verified by a physician.(c) Eligibility for a Certificate of Deafness for Tuition Waiver is determined by DARS DHHS, and the determination is final.(d) The Certificate of Deafness for Tuition Waiver issued by DARS DHHS is not a determination that an applicant satisfies the residency requirement, or any other requirement set forth under Education Code, §54.364, for tuition waiver at any eligible institution.(e) DARS DHHS may request additional documentation to support an application for a Certificate of Deafness for Tuition Waiver. Failure to provide any requested documentation within the requested period may result in denial of an application. Source Note: The provisions of this §360.707 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES E CERTIFICATE OF DEAFNESS FOR TUITION WAIVER PROGRAM §360.707 Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203624 03/12/2026 (a) DARS DHHS is responsible for the design and content of the Certificate of Deafness for Tuition Waiver.(b) The Certificate of Deafness for Tuition Waiver documents the name of the person to whom it is issued and contains the signature of an authorized DARS DHHS representative. Source Note: The provisions of this §360.709 adopted to be effective April 24, 2013, 38 TexReg 2513; transferred effective March 1, 2021, as published in the Texas Register February 5, 2021, 46 TexReg 946. 1 HEALTH AND HUMAN SERVICES COMMISSION 360 OFFICE OF DEAF AND HARD OF HEARING SERVICES E CERTIFICATE OF DEAFNESS FOR TUITION WAIVER PROGRAM §360.709 Certificate of Deafness for Tuition Waiver https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208146 03/12/2026 (a) The purpose of the DADS Guardianship Services Program is to accept referrals for individuals from DFPS as defined in Texas Human Resources Code, §48.209; assess the individuals for capacity; apply for guardianship if determined appropriate; and serve as guardians who promote and enhance the well-being, dignity, and personal preferences of the individuals to the extent possible for as long as DADS serves as guardian. An individual referred by DFPS must have been found to be in a state of abuse, neglect, or exploitation.(b) DFPS makes a referral directly to the DADS Guardianship Services Program, or, if requested by the court with probate jurisdiction for the county in which an individual being referred resides, DFPS may also make a referral to the court in addition to the referral to the DADS Guardianship Services Program.(c) The DADS Guardianship Services Program files an application to be appointed as guardian or otherwise agrees to be appointed as guardian if the DADS Guardianship Services Program determines that:(1) DFPS found the individual to be in a state of abuse, neglect, or exploitation or the individual is a minor in the conservatorship of DFPS;(2) there is no less restrictive alternative to guardianship;(3) there is no other willing, able, and suitable person or program to serve as guardian;(4) the individual is eligible for the DADS Guardianship Services Program; and(5) the court finds the individual is an incapacitated person as defined in Texas Estates Code, §1002.017 and makes all other findings required by Texas Estates Code, §1101.101.(d) As provided by Texas Human Resources Code, §161.101(d), a court may not appoint DADS as permanent guardian unless DADS files an application with a court with probate jurisdiction or otherwise agrees to be appointed as permanent guardian.(e) The DADS Guardianship Services Program complies with the requirements of Texas Estates Code, Title 3 in performing its responsibilities as guardian of its wards. Source Note: The provisions of this §361.1 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES A GENERAL PROVISIONS §361.1 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208147 03/12/2026 (a) A term used in this chapter that is defined in Texas Estates Code, Chapter 1002 has the same meaning as defined in that section of the code.(b) In addition, the following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:(1) Agency--A state or local government or private not-for-profit organization that operates a guardianship program as defined by Texas Estates Code, §1002.016.(2) Assessment--The process of establishing whether DADS guardianship is appropriate for an individual referred by DFPS. The assessment includes a determination of whether the individual appears to meet the definition of an incapacitated person as defined by Texas Estates Code, §1002.017(2), and if the definition is met, whether the individual is totally without capacity or lacks capacity to do some, but not all, the tasks necessary to care for himself or herself or to manage his or her property, whether there is a less restrictive alternative to guardianship, and whether the individual meets the eligibility criteria for the DADS Guardianship Services Program.(3) Certificate of Medical Examination (CME)--A statement by a qualified physician attesting to whether, in the physician's medical opinion, an individual has capacity that complies with Texas Estates Code, §1101.103.(4) Contractor--An agency with which DADS has a contract to provide guardianship services for a fee.(5) DADS--The Department of Aging and Disability Services.(6) DADS Guardianship Services Program--The program operated by DADS that provides guardianship and related services to persons with diminished capacity.(7) Determination of intellectual disability (DID)--An examination, or an update or endorsement of a prior examination, that complies with Chapter 5, Subchapter D of this title (relating to Diagnostic Eligibility for Services and Supports--Intellectual Disability Priority Population and Related Conditions) and with Texas Estates Code, §1101.104.(8) DFPS--The Department of Family and Protective Services.(9) Diminished capacity--Some loss of an individual's ability due to a physical or mental condition to provide food, clothing, or shelter for the individual, to care for the individual's own physical health, or to manage the individual's own financial affairs. An individual referred to the DADS Guardianship Services Program has diminished capacity, but may or may not meet the legal definition of an incapacitated person.(10) Judicial Branch Certification Commission--The commission established under Texas Government Code, Chapter 152.(11) Person-directed planning--A process that empowers an individual and the legally authorized representative (LAR) on the individual's behalf to direct the development of a service plan for a ward that meets the individual's personal outcomes. The service plan must identify existing supports and services necessary to achieve the individual's outcomes, identify natural supports available to the individual and negotiate needed service system supports, occur with the support of a group of people chosen by the individual and the guardian as LAR on the individual's behalf, and accommodate the individual's style of interaction and preferences regarding time and setting.(12) Quality assurance plan--A written plan that describes a contractor's system of self-monitoring to ensure consistency and quality of care provided to a ward and ensure compliance with the Texas Estates Code, other requirements imposed by the courts, and other program policies, rules, and standards.(13) Reporter--A person who makes a referral to DFPS staff about a situation of alleged abuse, neglect, or exploitation of an elderly person or adult with a disability.(14) Service plan--A plan of care for a ward that ensures appropriate habilitation and rehabilitation services, including therapy, counseling, education, and training to the extent permitted by the ward's estate. Source Note: The provisions of this §361.3 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES A GENERAL PROVISIONS §361.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208148 03/12/2026 (a) To determine eligibility for services, the DADS Guardianship Services Program conducts an assessment of an individual referred by DFPS under Texas Human Resources Code, §48.209. The assessment may include identifying and arranging for services that do not require guardianship. An individual must meet the requirements of subsections (b) - (f) of this section, or DADS must agree to serve as guardian under subsection (g) of this section, for the individual to be eligible for the DADS Guardianship Services Program.(b) DADS authority under Texas Human Resources Code, §161.071 to be appointed by the court to serve as permanent guardian of the person or permanent guardian of the estate is limited to an individual referred to the DADS Guardianship Services Program by DFPS under Texas Human Resources Code, §48.209 or an individual for whom DADS otherwise agrees to serve as permanent guardian under Texas Human Resources Code, §161.101(d).(c) For the Child Protective Services Division (CPS) of DFPS to refer an individual for guardianship:(1) the individual must:(A) be at least 16 years of age and be in a conservatorship of DFPS; or(B) be at least 18 years of age, have been in CPS conservatorship on the day before turning 18 years of age, and in extended foster home placement after turning 18 years of age; and(2) CPS must have reason to believe that the individual will be substantially unable to provide for the individual's own food, clothing, or shelter, or to care for the individual's own health needs, or to manage the individual's own financial affairs when the individual becomes an adult.(d) The guardianship of an individual meeting the criteria in subsection (c) of this section, may not take effect before the individual's 18th birthday.(e) An individual referred by the Adult Protective Services Division (APS) of DFPS must be age 65 years of age or older, or 18 to 65 years of age and disabled. APS must also have reason to believe the individual is an incapacitated person, as defined by Texas Estates Code, §1002.017(2) and must have been determined to be in a state of abuse, neglect, or exploitation.(f) In order for DADS to serve as guardian, an individual must have private assets available to meet the expenses of day-to-day living, or be eligible for government benefits (for example, Medicaid, Social Security, or veteran benefits) that are sufficient to provide support. The DADS Guardianship Services Program is not liable for, and cannot provide, financial support for services provided to wards, including the cost of long-term care or burial expenses.(g) DADS must determine that becoming guardian of an individual referred by APS will provide an effective remedy for the abuse, neglect, or exploitation validated by APS. DADS must determine that becoming a guardian of an individual referred by CPS will enable DADS to effectively serve the needs of that ward.(h) In its sole discretion, DADS may otherwise agree to serve as permanent guardian of an individual under Texas Human Resources Code, §161.101(d). In deciding whether to serve as permanent guardian, DADS considers the following additional factors:(1) the risk of serious and imminent harm to the individual or the individual's estate if a guardian is not appointed;(2) the likelihood that guardianship will provide an effective remedy for the risk of serious harm to the individual and that DADS appointment will effectively serve the needs of the individual;(3) the availability to the individual in the local community of less restrictive alternatives and other persons or agencies to serve as guardian;(4) the history of investigations conducted by APS of the individual as an alleged victim of abuse, neglect, or exploitation and the likelihood of future investigations by APS; and(5) the availability of private assets or government benefits to pay for the needs of the ward. Source Note: The provisions of this §361.21 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES B ELIGIBILITY AND ASSESSMENT OF INDIVIDUALS FOR GUARDIANSHIP SERVICES §361.21 Eligibility for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208149 03/12/2026 (a) An assessment begins with the referral of an individual from either the Child Protective Services Division or the Adult Protective Services Division of DFPS.(b) The DADS Guardianship Services Program considers the conditions and circumstances of the elderly or disabled individual, as documented by DFPS and through DADS own review process, to determine whether a less restrictive alternative to guardianship is appropriate and available. If an appropriate, less restrictive alternative is identified and available, the DADS Guardianship Services Program either arranges for this alternative or provides a recommendation to DFPS to pursue the alternative.(c) If a less restrictive alternative is not appropriate and available, the DADS Guardianship Services Program conducts an assessment to determine if the individual appears to lack capacity. If the DADS Guardianship Services Program's assessment concludes that the individual appears to lack capacity, the DADS Guardianship Services Program arranges for a qualified physician to examine the individual and provide a Certificate of Medical Examination (CME). If the basis of the alleged incapacity is intellectual disability, the DADS Guardianship Services Program arranges for a determination of intellectual disability (DID).(d) If the CME states that the individual is incapacitated and guardianship is appropriate, or the DID states that the individual meets the criteria for a diagnosis of intellectual disability as the basis of incapacity and guardianship is appropriate, the DADS Guardianship Services Program attempts to identify a person or a guardianship program who is willing, able, and suitable to serve as guardian and requests that the person or guardianship program file an application for guardianship. If no such person or program can be identified, the DADS Guardianship Services Program files an application with the court that has probate jurisdiction in the county in which the individual resides. Only a court with probate jurisdiction may make the legal finding that an individual is an incapacitated person.(e) At the completion of the assessment, the DADS Guardianship Services Program notifies DFPS, or the court if the assessment was done in response to the court's request, of the outcome of the assessment.(f) If DFPS makes a referral to a probate court or the court appoints DADS as guardian through a court-initiated guardianship proceeding under Texas Estates Code, §1102.001, or both, the DADS Guardianship Services Program conducts an abbreviated assessment to determine if the individual is eligible for the DADS Guardianship Services Program. If the individual is not eligible for the DADS Guardianship Services Program, the DADS Guardianship Services Program files appropriate pleadings to rescind or reverse the appointment that state the reasons that DADS may not be appointed guardian. Source Note: The provisions of this §361.23 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES B ELIGIBILITY AND ASSESSMENT OF INDIVIDUALS FOR GUARDIANSHIP SERVICES §361.23 Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208150 03/12/2026 (a) At least annually after the DADS Guardianship Services Program's appointment as guardian for a ward, the DADS Guardianship Services Program evaluates the status of the ward to determine if:(1) the ward is still an incapacitated person and continues to need a guardian;(2) an alternate person or guardianship program is willing, able, and suitable to serve as successor guardian;(3) a less restrictive alternative to guardianship is now available and the ward can be restored to capacity;(4) a limited guardianship is appropriate and the ward can be partially restored to capacity; or(5) guardianship continues to effectively remedy the issues of the ward or meet the needs of the ward.(b) If the DADS Guardianship Services Program determines that the ward is still an incapacitated person and an alternate guardian can be identified, the DADS Guardianship Services Program notifies the appropriate court with probate jurisdiction and files an application to resign and have a successor guardian appointed.(c) If the DADS Guardianship Services Program determines that the ward is no longer an incapacitated person and no longer needs a guardian, the DADS Guardianship Services Program files an application with the court to have the ward restored to capacity. If a less restrictive alternative is appropriate and available, the DADS Guardianship Services Program refers the restored individual for the appropriate services.(d) At any time, if the DADS Guardianship Services Program becomes aware of another guardianship program or private professional guardian who is willing, able, and suitable to serve as a ward's successor guardian, and there is no family member or friend of the ward or other interested person who is willing, able, and suitable to serve as guardian, the DADS Guardianship Services Program notifies the appropriate court with probate jurisdiction of the other guardianship program or private professional guardian's willingness and ability to serve. DADS then files an application to resign and have a successor guardian appointed.(e) If the DADS Guardianship Services Program determines guardianship does not effectively remedy the issues of the ward or meet the needs of the ward, the DADS Guardianship Services Program files an application to resign or close the guardianship. Source Note: The provisions of this §361.25 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES B ELIGIBILITY AND ASSESSMENT OF INDIVIDUALS FOR GUARDIANSHIP SERVICES §361.25 Annual Review of a Ward's Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208151 03/12/2026 (a) Texas Human Resources Code, §161.103 gives DADS the authority to contract with an agency or a political subdivision of the state for the provision of guardianship services.(b) To the extent funds are appropriated by the legislature or made available by DADS, the DADS Guardianship Services Program contracts with one or more contractors to file an application with the probate courts and to serve as guardian of the person or guardian of the estate or both. The contractor must be able and willing to serve as guardian at a cost equal to or less than the cost of providing comparable guardianship services by the DADS Guardianship Services Program.(c) To be eligible for guardianship services through a contractor, an individual must be eligible to be a ward of the DADS Guardianship Services Program.(d) Funding from DADS guardianship contracts is intended to offset the contractor's cost of providing guardianship services. A contractor must not use DADS funds for a ward's daily living expenses or bill a ward for any other services.(e) A contractor must comply with the requirements in this subchapter and in Subchapters D - E of this chapter (relating to Records Management, and Contract Monitoring and Compliance). If a contract with the DADS Guardianship Services Program is terminated or is not renewed, a contractor may continue providing services through an alternate source of funds or apply to the courts to resign as guardian and have a successor guardian appointed. Source Note: The provisions of this §361.51 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.51 Guardianship Contracts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208124 03/12/2026 (a) To be eligible to apply for a guardianship contract with DADS, an agency must meet the definition of a guardianship program in Texas Estates Code, §1002.016.(b) An agency must agree to comply with the minimum standards for guardianship services established by the Judicial Branch Certification Commission under Texas Government Code, §155.101.(c) An agency must agree to comply with the certification requirements of the Judicial Branch Certification Commission as authorized in Texas Government Code, §155.102 for all individuals who will provide guardianship services to a ward of the program on behalf of DADS.(d) An agency must agree to terminate an employee who commits an action that results in the agency being removed as guardian by the courts. If the agency fails to take action against an employee or has demonstrated a pattern of activity resulting in removal as guardian by the courts within the previous five years, the agency may become ineligible to contract with the DADS Guardianship Services Program.(e) If an agency is held in contempt, fined, surcharged, removed as guardian, or found not suitable to serve as guardian by the courts, the DADS Guardianship Services Program may consider these actions in determining present and future eligibility and the agency may become ineligible to contract with the DADS Guardianship Services Program. Source Note: The provisions of this §361.53 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.53 Eligibility To Be a Guardianship Contractor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208125 03/12/2026 (a) An agency, in its application for a contract with DADS, must identify the population groups for whom it provides services, in terms of age, mobility, or other factors. The application must also specify the geographic areas within which it provides services.(b) A contractor must accept all referrals from DADS and apply for guardianship or successor guardianship if a contractor serves the county in which the incapacitated individual resides, and if the individual qualifies for the contractor's guardianship program, provided that the contractor is under the maximum service authorization level provided in the contract. If the contractor has reached the maximum service authorization level provided in the contract, DADS may offer the contractor an opportunity to apply for guardianship and provide services through other sources of funds.(c) If a contractor believes that DADS has assigned an individual for guardianship or successor guardianship who does not fit the guardianship program's eligibility criteria, the contractor may request that the DADS Guardianship Services Program management and the appropriate guardianship supervisor to reconsider the referral. The DADS Guardianship Services Program management or the appropriate guardianship supervisor may, at the management's or supervisor's discretion, withdraw the referral to the contractor. Source Note: The provisions of this §361.55 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.55 Acceptance of Referrals from DADS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208128 03/12/2026 A contractor must have written policies and procedures that:(1) identify the management structure of the agency and clearly reveal the decision-making authority and chain of command;(2) establish qualifications for employees and volunteers that indicate type of position, education required, and any licensure requirements;(3) describe hiring practices and ensure compliance with applicable state and federal laws;(4) describe what orientation will be provided to employees and volunteers, including what additional training will be provided if volunteers are used;(5) ensure that allegations of abuse, neglect, and exploitation are reported to DFPS as mandated by state law;(6) describe actions to be taken if a ward has a crisis and needs emergency help;(7) describe the minimum standards for guardianship adopted by rule by the Office of Court Administration when serving as a guardian;(8) include ethical standards for guardianship and estate matters;(9) include procedures for compliance with court orders and other local practices based upon the court system in the geographic area;(10) include a system for receiving complaints, recording the complaints, and taking action; and(11) include procedures for communication with DADS to include:(A) notification of a court hearing involving a DADS ward;(B) notification of a ward's death;(C) notification of a court order closing a guardianship;(D) notification of an unusual occurrence, such as a pregnancy or a serious illness; and(E) monthly reports to be sent to DADS. Source Note: The provisions of this §361.57 adopted to be effective September 1, 2006, 31 TexReg 6797; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.57 Policies and Procedures Required of Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208126 03/12/2026 (a) A contractor must:(1) provide an adequate number of qualified employees to meet the needs of wards that DADS refers to the contractor;(2) employ case managers who have the following qualifications:(A) be at least 21 years of age;(B) be a high school graduate or possess the general education development equivalent; and(C) have:(i) at least two years of relevant work experience related to guardianship; or(ii) the following educational or training requirements:(I) a minimum of a bachelor's degree conferred by a college or university accredited by an organization recognized by the Texas Higher Education Coordinating Board in a field related to guardianship, including but not limited to medical, mental health and intellectual disability, law, business, accounting, social work, sociology, psychology, human services, protective services, and criminal justice fields; or(II) completion of a course curriculum or training specifically related to guardianship approved by the Judicial Branch Certification Commission; and(D) are certified as a guardian by the Judicial Branch Certification Commission;(3) provide an orientation program that explains:(A) the responsibilities associated with each new employee's position;(B) the responsibilities of the guardianship program to the ward;(C) the relationship of the ward to the guardianship program and to DADS;(D) an overview of the Texas Estates Code and the program's responsibilities per the code;(E) an overview of any rules or regulations that affect the guardianship program;(F) an overview of aging and disability; medical issues, including medical treatment and medication; and end-of-life decisions;(G) the principles of person-directed planning including consideration of a ward's personal preferences, desires, religious beliefs, and living arrangements; and(H) the principle of substituted judgment and the best interest standard for decision-making;(4) maintain a copy of the information presented at the orientation for each employee and have signed documentation of attendance at the orientation; and(5) provide ongoing training based upon the needs of the ward as described in subsections (b) and (c) of this section and any changes in rules or state law.(b) Ongoing training as required in subsection (a)(5) of this section must be documented and each participant must sign that the participant attended the training. At a minimum, training must include:(1) recognizing and reporting abuse, neglect, and exploitation to the appropriate investigating agency;(2) cultural sensitivity and ethics;(3) financial management, including budgeting, record keeping, and bill paying;(4) case management, including service planning, service delivery, and an overview of guardianship;(5) housing and placement alternatives supporting the ward to live in the least restrictive setting appropriate to the ward's needs;(6) community resources;(7) recognition of the social needs of wards, such as recognition of birthdays, holidays, and the need for contact with family and friends; and(8) information regarding alternatives to guardianship, restoration of capacity, and modification of a guardianship.(c) In addition to the orientation and training specified in subsections (a)(3) and (b) of this section, a contractor must provide training to case managers in the following areas:(1) aging and disability, including mental illness, intellectual disability, related conditions, physical disabilities, and other diagnoses that affect the population being served;(2) legal issues, including civil commitment of persons with intellectual disability and mental illness, courtroom testimony, protocol, etiquette in the courtroom and other venues, and local court policies and procedures; and(3) estate management, including money management alternatives, record keeping, and completion of documents that will be filed with the court. Source Note: The provisions of this §361.59 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective January 20, 2008, 33 TexReg 432; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.59 Qualifications and Training Requirements for Contractor Employees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208127 03/12/2026 (a) A contractor that uses a volunteer who is not a certified guardian must ensure that the volunteer does not perform guardianship duties, but the volunteer may provide services that a DADS volunteer may provide under Texas Human Resources Code §161.114(c).(b) A contractor that uses a volunteer must:(1) provide training that is relevant to the services the volunteer will provide;(2) assign to the volunteer a supervisor who is a certified guardian and an employee of the contractor;(3) ensure that the volunteer does not provide services to a DADS ward until documentation and observation indicate the volunteer is qualified to work with the ward;(4) ensure that the volunteer's supervisor reviews all work completed by the volunteer;(5) ensure that the volunteer's supervisor countersigns all documentation completed by the volunteer;(6) ensure that the volunteer's supervisor meets with the volunteer at least once per month and documents the meeting;(7) ensure that the volunteer protects the health and safety of the ward;(8) provide additional training to the volunteer on skills needed to provide services at least annually; and(9) document training provided to the volunteer. Source Note: The provisions of this §361.61 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.61 Qualifications and Training Requirements for Volunteers of Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208129 03/12/2026 (a) A contractor must ensure that each employee and volunteer of the contractor who has contact with a DADS ward or with the estate or benefits of a ward:(1) has not been convicted of any crimes outlined in Texas Estates Code, §1104.353;(2) is not a person meeting the specifications in Texas Estates Code, §§1104.351 - 1104.357;(3) does not have charges pending from, has not admitted guilt for, or has not been found guilty of the offenses under the Texas Penal Code in subsection (b) of this section or any like offense under the law of another state or federal law, even if probation was granted, if deferred adjudication was granted on a plea of guilty, or if deferred adjudication was granted on a plea of no contest and no record exists, but the contractor has independent knowledge of these facts; and(4) does not have an interest that is adverse to a ward of the DADS Guardianship Services Program or any of its contractors under Texas Estates Code, §1055.001, including:(A) being an actual or potential creditor or debtor of the ward;(B) being an opposing party to a ward in a lawsuit;(C) being the guarantor of a ward's promissory note;(D) having a duty to account to a ward other than the normal duty to account arising from guardianships under its contract; or(E) having any other financial or other interest adverse to a ward.(b) To ensure compliance with subsection (a) of this section, DADS obtains criminal history record information (a criminal background check) relating to a prospective employee or volunteer of a contractor who will have access to a DADS ward, the estate of a DADS ward, or the benefits of a ward referred by the DADS Guardianship Services Program. Based on the criminal history record information, DADS notifies the contractor of the prospective employee's or volunteer's eligibility to be employed or to volunteer with a DADS ward. A contractor must not make an offer of employment to a prospective employee or allow a prospective employee or volunteer to have access to a DADS ward, the estate of a DADS ward, or the benefits of a DADS ward referred by the DADS Guardianship Services Program before DADS notifies the contractor of the person's eligibility for employment or volunteering. On an annual basis, DADS obtains criminal history record information related to an employee or volunteer of a contractor who has access to a DADS ward, the estate of a ward, or the benefits of a DADS ward referred by the DADS Guardianship Services Program.(1) The following offenses under the Texas Penal Code permanently bar an individual from employment or from volunteering with a contractor:(A) sexual offenses under Chapter 21;(B) §22.011, Sexual Assault;(C) §22.02, Aggravated Assault;(D) §22.021, Aggravated Sexual Assault;(E) §22.04, Injury to a Child, Elderly Individual, or Disabled Individual;(F) §22.041, Abandoning or Endangering a Child;(G) §22.05, Deadly Conduct;(H) §22.07, Terroristic Threat;(I) §22.08, Aiding Suicide;(J) §22.09, Tampering with Consumer Product;(K) offenses against the family under Title 6;(L) criminal homicide under Chapter 19;(M) kidnapping and unlawful restraint under Chapter 20, and trafficking of persons under Chapter 20A;(N) §28.02, Arson;(O) robbery under Chapter 29;(P) burglary and criminal trespass under Chapter 30;(Q) theft under Chapter 31; and(R) fraud under Chapter 32.(2) All other offenses under the Texas Penal Code or the Texas Health and Safety Code, Chapter 481 (Texas Controlled Substances Act) are a bar to employment or volunteering with a contractor but may be waived as described in subsection (c) of this section.(c) If an employee or volunteer has successfully fulfilled all requirements and conditions imposed by the court for an offense described in subsection (b)(2) of this section and if there are extenuating circumstances that justify the individual's employment or volunteering with the contractor, the contractor may make a written request to the director of the DADS Guardianship Services Program for a waiver of subsection (b)(2) of this section. The director will not waive the requirement for any offense described in subsection (b)(1) of this section. If the Judicial Branch Certification Commission does not approve certification of an employee or volunteer as a guardian based on a criminal history, the contractor may not assign the individual to work in any capacity with a DADS ward.(d) A contractor must conduct a background check through the National Sex Offenders Registry website on a person who requests an unsupervised visit with a DADS ward. The contractor must maintain documentation of a search query in the ward's file. The contractor may approve an unsupervised visit, regardless of whether the person is listed on the registry, if the contractor determines the unsupervised visit is in the best interest of the ward. If the contractor approves an unsupervised visit with a person who is listed on the registry, the contractor must document the reasons why the visit was approved. Source Note: The provisions of this §361.67 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective January 20, 2008, 33 TexReg 432; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.67 Criminal Background Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208130 03/12/2026 (a) A contractor must develop a quality assurance plan that describes the contractor's system of self-monitoring to ensure:(1) consistency and quality of care provided to wards of the guardianship program; and(2) compliance with:(A) the Texas Estates Code;(B) other requirements imposed by the courts; and(C) the guardianship provider handbook, other program policies, rules, and standards.(b) A contractor must make a copy of its quality assurance plan available to DADS contract monitoring staff at the request of DADS staff and before an annual contract monitoring review.(c) A contractor must review its quality assurance plan annually and update it as necessary. The contractor must provide a copy of an updated plan to the DADS contract manager if the plan is updated. Source Note: The provisions of this §361.69 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.69 Quality Assurance Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208131 03/12/2026 (a) A contractor must establish policies and procedures that describe:(1) an accounting system to ensure that payment is made by DADS to the contractor only if services provided have been rendered;(2) a tracking system that includes receipts and a description of the goods or services provided for all fiscal matters for wards served by the guardianship program;(3) a system to refund monies to DADS or to a ward if needed;(4) compliance with state and federal laws and regulations regarding sound accounting practices for the contractor; and(5) internal and external audits to be performed on a regular basis.(b) A contractor must accept payment from DADS as payment in full for services rendered. The contractor must not duplicate billing or receipt of other funds.(c) A contractor must not seek or accept reimbursement from a DADS ward to whom it provides purchased services.(d) A contractor must not collect:(1) payment from a ward;(2) a percentage of the Social Security or Supplemental Security Income check specified in the Omnibus Reconciliation Act of 1990; or(3) payment authorized by the court in accordance with Texas Estates Code, §1155.002 and §1155.003.(e) A contractor must not use DADS funds or DADS reimbursed staff time to provide guardianship or other services to an individual who has not been referred by DADS.(f) A contractor must provide all legal support necessary for the guardianship services contracted by DADS, including contested applications for guardianship.(g) A contractor must provide DADS staff access to the results of audits performed on DADS wards. Source Note: The provisions of this §361.71 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.71 Fiscal Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208132 03/12/2026 (a) Upon receipt of a referral from DADS, a case manager monitors the filing of legal documents, accountings, reports, notifications, and taxes as required by state law.(b) A case manager performs the following duties in accordance with the other duties and responsibilities outlined in the order granting guardianship:(1) locates, secures, and manages a ward's estate;(2) ensures that a ward has access to adequate care, protection, and services based upon identified needs and the service plan;(3) makes decisions on medical issues such as major surgery, life-threatening illness, treatment options, and, if guardian of the estate, makes decisions regarding the ward's estate other than routine expenditures for maintenance and education;(4) monitors to ensure inventory, appraisement, list of claims, and annual accountings have been completed;(5) completes annual reports of the guardian of the person;(6) hires professionals, including accountants, providers, repair persons, or realtors, with the funds of a ward's estate to perform services for the ward;(7) resolves issues or problems that affect a ward;(8) as much as possible, considers a ward's wishes and choices when decisions are being made about the ward;(9) maintains documentation of face-to-face visits;(10) informs the appropriate DADS and contractor staff concerning major issues involving a ward and documents all actions in the ward's record; and(11) ensures that cases that are closed or transferred, or if the guardianship is transferred to another case manager, has documentation that is complete and up-to-date. Source Note: The provisions of this §361.73 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective January 20, 2008, 33 TexReg 432; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.73 Roles and Responsibilities of Case Managers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208133 03/12/2026 (a) A contractor must report an allegation of abuse, neglect, or exploitation of a ward to DFPS within 24 hours of discovery of the alleged abuse, neglect, or exploitation.(b) If the investigating authority is an entity other than DFPS, a contractor must report an allegation of abuse, neglect, or exploitation of a ward within 24 hours of discovery of the alleged abuse, neglect, or exploitation.(c) A contractor must report an allegation of abuse, neglect, or exploitation of a ward to the DADS guardianship supervisor in the contractor's designated DADS region within 24 hours or by the next working day, whichever is later. The contractor must notify the DADS guardianship supervisor of the specific suspected abuse, neglect, or exploitation when it is reported to the investigating authority. The contractor must also report what actions have been taken to ensure the health and safety of the ward.(d) If the alleged perpetrator is a contractor's employee, the contractor must remove the employee from working with any DADS wards until all allegations have been investigated. If an allegation of abuse, neglect, or exploitation is found to be valid, the contractor must take appropriate action. If the perpetrator has the right to appeal and if the appeal process determines the employee was not the perpetrator, the agency must document the findings and reorient the employee before working again with DADS wards. Source Note: The provisions of this §361.75 adopted to be effective September 1, 2006, 31 TexReg 6797; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.75 Reporting of Abuse, Neglect, or Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208134 03/12/2026 A contractor must comply with all requirements of Texas Estates Code, Title 3. In addition, if a court with probate jurisdiction within a contractor's service area has specific local rules in addition to the requirements of the Texas Estates Code, the contractor must comply with those rules to the best of its ability, to the extent that the court's local rules do not conflict with provisions of the Texas Estates Code. Source Note: The provisions of this §361.77 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.77 Compliance with Probate Court Local Rules in Service Area https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208135 03/12/2026 (a) A contractor, rather than the contractor's employee or volunteer, is appointed by the court as guardian. A contractor must assign a primary case manager who meets the requirements described in §10.311(a)(2) of this subchapter, to each ward served under its contract with DADS. To ensure the ability to respond in a timely fashion in the event of an emergency, a contractor must assign back-up staff for when the primary case manager is unavailable.(b) If a contractor is appointed guardian of the person, the contractor must manage the ward's person according to the order appointing guardian of the person. This responsibility may include:(1) having physical possession of the ward;(2) caring for, supervising, and protecting the ward;(3) providing food, clothing, and shelter to the extent permitted by the ward's estate or government benefits;(4) consenting to medical, surgical, and psychiatric care, except for in-patient psychiatric commitment;(5) developing an annual service plan that ensures appropriate habilitation and rehabilitation services, including therapy, counseling, education, and training to the extent permitted by the ward's estate;(6) encouraging the ward to participate in the development of the service plan to the extent that the ward is capable;(7) building an adequate support system for the ward, including family, friends, and other appropriate collaterals;(8) ensuring monthly status contacts with the ward as described in subsection (d) of this section;(9) consulting with service providers periodically;(10) documenting case actions in files maintained for each ward; and(11) complying with all of the requirements of Texas Estates Code, Title 3, regarding guardianship of the person.(c) A contractor arranges care and services for the ward based on the identified needs of the ward to enhance the ward's quality of life. The contractor ensures that the ward has access to basic care and services, including:(1) a safe, clean environment;(2) assistance in performing basic life functions;(3) regular, nutritious meals;(4) any needed medical, psychiatric, habilitative, or other services; and(5) adequate supervision.(d) The contractor must have a face-to-face contact at least once a month with each ward served through the contract with DADS. To the extent possible, the primary case manager makes the monthly contacts. If the primary case manager is unable to make a monthly contact, the contact must be made by another certified guardian. If the ward's place of residence prevents face-to-face contact (for example, incarceration in a correctional facility), the contractor may substitute a phone contact with the ward or, if phone contact is not possible with the ward, with a person knowledgeable of the ward's current condition (for example a jailer, an attorney, a judge, a probation or parole officer, or a medical doctor). The case manager or other certified guardian must document the monthly contacts in the ward's file. Source Note: The provisions of this §361.79 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.79 Responsibilities of the Guardian of the Person https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208136 03/12/2026 (a) If a contractor is appointed as permanent guardian of the estate, the contractor must manage the ward's finances and assets according to the order appointing guardian of the estate. This responsibility may include:(1) locating and taking possession of the ward's assets;(2) securing the ward's property;(3) preparing the initial inventory, appraisement, and list of claims;(4) paying the ward's bills;(5) investing any money not needed for the care and maintenance of the ward;(6) ensuring that the ward is receiving all the income and benefits to which the ward is entitled;(7) selling the ward's property if it is in the ward's best interests;(8) filing annual accountings to courts and to government agencies administering benefits;(9) filing tax returns; and(10) complying with all requirements of Texas Estates Code, Title 3, regarding guardianship of the estate.(b) A contractor, its agents, employees or volunteers or their immediate family members or friends must not directly or indirectly purchase property of the ward. A contractor, a contractor's agent, employee, volunteer, or an immediate family member or friend of the contractor, agent, employee, or volunteer may not purchase the ward's property through another person. Source Note: The provisions of this §361.81 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.81 Responsibilities of Guardian of the Estate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208137 03/12/2026 (a) A contractor must develop and update at least annually a service plan for each ward for which it is appointed as guardian of the person. The service plan establishes a structured and systematic approach for delivery of services to a ward that maximizes quality of care, quality of life, and overall functioning of the ward.(b) A contractor must develop the initial service plan within three months after taking and filing the oath of guardianship and must update the service plan annually by the due date of the annual report required by the court.(c) A contractor may develop its own format for the service plan or may use a format provided by DADS. The service plan must include at least the following information:(1) a brief description of the current status of the ward;(2) a description of the needs of the ward in each of the following areas:(A) living arrangements and basic care;(B) medical, dental, vision, mental health, and intellectual disability services;(C) family, social, and recreational needs;(D) financial and legal services; and(E) diet and clothing preferences;(3) the plan or strategy for meeting the needs of the ward in the areas listed in paragraph (2) of this subsection; and(4) actions taken to date to accomplish the plan.(d) A service plan must be developed using the principles of person-directed planning and be developed in a culturally competent manner, to meet the ward's needs within the ward's cultural context. Resources such as family systems, natural helping networks, formal institutions within the ward's community, churches, and social organizations are used to resolve the ward's problems whenever possible and appropriate.(e) A contractor must ensure that services are provided by persons who can adequately communicate with the ward. The contractor may facilitate communication by using a translator or by other means if the contractor's employees do not speak the ward's language. A non-English speaking ward and the ward's family who attempt to communicate in English may require accommodation. Whenever possible, the contractor must offer the ward the option of communicating in the ward's preferred language, even if the ward can communicate adequately in English.(f) Whenever possible the ward's diet and clothing must reflect cultural preferences.(g) The service plan for the religious needs of the ward must reflect any lifelong pattern of religious affiliation. Funeral planning for the ward must reflect the cultural and religious values of the ward and the ward's family whenever possible. Source Note: The provisions of this §361.83 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES C CONTRACTOR REQUIREMENTS §361.83 Service Plans for Wards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208138 03/12/2026 (a) A contractor must not disclose information from the case record on a ward served under the contract with the DADS Guardianship Services Program in a manner that identifies the ward unless the disclosure is necessary to carry out the duties of the contractor, as described in subsection (b) of this section. Texas Human Resources Code, §161.111 makes information about a DADS guardianship case confidential, and this extends to the case record of DADS wards served through contracts with DADS. All records, reports, or working papers related to the case are confidential and are exempt from public disclosure under the Texas Open Records Act (Chapter 552, Government Code). DFPS Adult Protective Services Division records are also confidential under Texas Human Resources Code, §48.101.(b) Examples of situations that might require pertinent case information to be disclosed include:(1) arranging for the provision of services;(2) facilitating involuntary mental health or intellectual disability commitment;(3) cooperating with law enforcement during the criminal investigation of abuse, neglect, or exploitation; and(4) responding to a court order for disclosure.(c) If a contractor shares information about a ward, the contractor must advise the recipient of the information that the information is confidential and must not be further shared without permission.(d) DADS does not disclose to a contractor the name of a reporter who makes a complaint of abuse, neglect, or exploitation to DFPS. If a contractor learns the reporter's name or other identifying information, the contractor must not share this information with any other agency.(e) DADS guardianship staff may orally release the reporter's name to the courts, the district or county attorney, or law enforcement agencies if directed to do so by the judge trying the guardianship case. In the event a contractor learns a reporter's name or other identifying information, the contractor must not share this information with any other agency.(f) Upon written request to a contractor, the contractor may provide a copy of guardianship case information, except the name and other identifying information about a reporter, on a ward served under a DADS guardianship contract to the following:(1) the ward or the ward's guardian;(2) a court-appointed executor or administrator of a deceased ward's estate;(3) the ward's private attorney;(4) a guardian ad litem;(5) the attorney representing the proposed guardian in a guardianship proceeding initiated by the contractor;(6) a court investigator or court visitor appointed by the court in a guardianship proceeding;(7) Disability Rights Texas, the federally mandated protection and advocacy system; and(8) out-of-state protective agencies.(g) Upon oral request to a contractor, the contractor may release a copy of the guardianship case information, except the name and other identifying information about a reporter, to the attorney ad litem. If the attorney ad litem requests the name of the reporter and asserts this information is necessary to the attorney's ability to adequately represent the client, the contractor must notify the DADS Guardianship Services Program and request approval to release the information to the attorney ad litem. The contractor must not release information about the reporter to the attorney ad litem without written approval from the DADS Guardianship Services Program.(h) Upon oral or written request, a contractor must release a copy of the entire case record, including the name of the reporter and information from other agencies, to a law enforcement agency or prosecuting attorney requesting a case under current criminal investigation, prosecution, or litigation against the contractor or DADS. A law enforcement agency must provide proof of identity before the contractor may release the requested information.(i) If a contractor releases information to an individual or entity as allowed under this section, the contractor must record the following information in the ward's case record:(1) the name of the requestor;(2) the information that the contractor provided;(3) the date the contractor provided the information; and(4) a dated copy of the written request or date of the oral request.(j) When the DADS Guardianship Services Program makes a referral to a contractor, DADS does not provide the entire case record unless the contractor is awarded guardianship and submits a written request for this information. Upon referral to a contractor, DADS provides only the following information:(1) oral case record information, except the name and other identifying information about a reporter; and(2) written information, including the Client Assessment completed by the DADS guardianship specialist, medical and psychological information, names and addresses of relatives, financial information and documents, personal data (for example, Social Security number, Medicaid number, and date of birth) pertaining to the proposed ward, and a copy of the most recent photograph on file.(k) A contractor must comply with federally mandated restrictions concerning the sharing of the AIDS/HIV positive status of a ward or proposed ward with a proposed guardian.(l) If a contractor's case files contain confidential reports from other professional individuals or agencies (for example, physicians, psychologists, law enforcement, the Department of Assistive and Rehabilitative Services, or DFPS), the contractor must not release this information to anyone other than the ward or the ward's guardian without first contacting the issuing professional individual or agency for consent to release the information. If the professional individual or agency does not agree in writing to the request, the contractor must not release the information. If the ward or the ward's guardian requests confidential reports from a professional individual or agency, a contractor may release the information, except a police report.(m) A contractor may orally share case information, except the name and other identifying information about a reporter and the AIDS/HIV positive status of a ward or a proposed ward, with authorized personnel of a social services or medical agency working with the ward or the proposed ward to the extent this information is necessary for the agency to provide services to the ward or the proposed ward.(n) A contractor may release written case information, except the name and other identifying information about a reporter, to a social services or medical agency working with a ward or a proposed ward only if the proposed ward or the current guardian has authorized the release in writing. The social services or medical agency receiving the information must agree to keep the information confidential. Source Note: The provisions of this §361.151 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES D RECORDS MANAGEMENT §361.151 Confidentiality of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208139 03/12/2026 (a) A contractor must maintain all financial and contract-related records:(1) according to recognized fiscal and accounting practices; and(2) in accordance with DADS contract requirements.(b) A contractor must document interactions with a ward as soon as possible after the interaction. If the contractor cannot document at the time of an interaction, the documentation must:(1) be dated the day that it is written;(2) indicate the date of the interaction; and(3) be signed by or otherwise identify the individual who had the contact.(c) A contractor must sign all printed service delivery records in ink. White-out may not be used in any documentation. If there is a mistake, it must be crossed through, dated, and initialed.(d) Documentation stored via electronic means must include the name of the person who delivered the services, the date performed, and the date the entry was made.(e) Data must be readily accessible, read-only access must be provided to the DADS contract manager during contract reviews, and there must be a means to retrieve the data in case of electrical outage or equipment failure.(f) A contractor must not preprint or pre-enter any record of time on a form used to document all required elements of the services delivered, as provided in the program specific rules.(g) Records must include:(1) copies of all legal documents related to the ward, preferably file-stamped copies if documents are file-stamped by the court in the local area when submitted;(2) financial documents, including receipts of disbursements, bank account statements, trust fund statements, and investment statements;(3) documentation of all case actions, including monthly status updates;(4) case actions, including the monthly status update, which must be documented within 10 working days after the activity:(5) significant incidents regarding progress, illness, and accidents that may be used as part of the service plan for the ward;(6) termination records and transfer summaries;(7) ward status updates identifying abuse, neglect, or exploitation incidents referred to the appropriate investigative authority; and(8) a photograph of the ward updated within 90 calendar days after the contractor's initial qualification as guardian and every two years thereafter.(h) A contractor must maintain personnel records on every employee and volunteer, and must also maintain records on subcontractors if utilized. Source Note: The provisions of this §361.153 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES D RECORDS MANAGEMENT §361.153 Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208140 03/12/2026 (a) A contractor must maintain all records until the later of the following occurs:(1) seven years elapse from the expiration or termination date of the records; or(2) all litigation, claims, and audit findings involving the records are resolved.(b) Upon termination of a contract, the contractor must ensure the following:(1) records are stored and are accessible;(2) someone is responsible for adequately maintaining the records;(3) the DADS contract manager is notified in writing regarding the location of the records and who DADS may contact to access the records; and(4) if there is a change in the location of the records or a change in the person assigned to provide access to the records, the DADS contract manager is provided the updated information in writing within 10 calendar days after the change. Source Note: The provisions of this §361.155 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES D RECORDS MANAGEMENT §361.155 Maintenance of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208141 03/12/2026 (a) When a contractor accepts funds, it also accepts the authority of federal and state governments, including DADS as an agency of a state government, to perform reviews and audits and to have access to records.(b) DADS conducts monitoring reviews of a contractor's services to determine if the contractor is in compliance with the contract and program rules and requirements. A monitoring review is conducted at the location where the contractor is providing the services unless DADS specifies a different location.(c) At the conclusion of the review, DADS determines the level of compliance on each guardianship principle reviewed. Guardianship principles are set forth in the DADS guardianship provider handbook. If DADS considers the contractor substantially out of compliance with the contract and with the program rules and requirements, the contractor is subject to corrective action and may be subject to sanctions.(d) During the monitoring review, the contractor must provide:(1) adequate working space for reviewing the records; and(2) all records DADS requests for review.(e) During the monitoring review, DADS may:(1) review a sample of wards' records to determine the contractor's compliance with contract requirements;(2) interview wards and staff;(3) observe wards and staff;(4) interview individuals with whom agency staff interact on a regular basis, such as individuals associated with the probate courts; and(5) conduct other activities as appropriate.(f) DADS may conduct a follow-up monitoring review to determine if the contractor has corrected the findings identified at a preceding monitoring review. A follow-up monitoring review may:(1) be a focused review using targeted samples; and(2) focus only on those guardianship principles that DADS determined to be out of compliance at the immediately preceding monitoring review.(g) DADS may expand a monitoring review period or the review sample at any time. Source Note: The provisions of this §361.201 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES E CONTRACT MONITORING AND COMPLIANCE §361.201 Monitoring Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208142 03/12/2026 (a) DADS conducts a complaint investigation of a contractor's services if DADS receives complaints that relate to program rules or procedures, or the contractor's employees or volunteers.(b) DADS may conduct a complaint investigation at any time without notice to the contractor.(c) DADS does not disclose the name of the individual who made the complaint unless specifically ordered to by a court of law or requested by law enforcement to disclose to law enforcement.(d) During the complaint investigation, the contractor must provide:(1) adequate working space for reviewing the records; and(2) all records DADS requests for the review.(e) DADS may conduct a follow-up to the complaint investigation to determine if the contractor has corrected the findings identified during the complaint investigation. A follow-up complaint investigation may:(1) be a focused review using targeted samples;(2) focus only on those standards that DADS determined to be out of compliance at the immediately preceding complaint investigation; and(3) include:(A) a review of a sample of wards' records to determine if the allegations are valid and if the complaint affects more than the ward whom the complaint concerned;(B) interviews with wards and staff;(C) observation of wards and staff;(D) consultation with others, as appropriate; and(E) other activities, as appropriate.(f) DADS may expand the review period or the review sample for a complaint investigation or follow-up complaint investigation at any time. Source Note: The provisions of this §361.203 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES E CONTRACT MONITORING AND COMPLIANCE §361.203 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208143 03/12/2026 (a) Fiscal monitoring is the review of documentation that supports the contractor's billings as it exists at the time DADS staff arrive to conduct the review. DADS may recoup payment if the service delivery documentation does not support the contractor's billing.(b) DADS may conduct a fiscal monitoring review:(1) in conjunction with a monitoring review;(2) independently of a monitoring review;(3) when a contract is terminated; or(4) as a result of conducting a complaint investigation.(c) If DADS identifies fiscal errors, DADS recovers the funds without extrapolation. Source Note: The provisions of this §361.205 adopted to be effective September 1, 2006, 31 TexReg 6797; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES E CONTRACT MONITORING AND COMPLIANCE §361.205 Fiscal Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208145 03/12/2026 (a) DADS may impose a sanction if DADS determines that the contractor failed to follow the terms of the contract or the contractor failed to comply with program rules, policies, and procedures. Examples of these failures include:(1) jeopardizing a ward's health and safety;(2) failing to comply with a plan of correction;(3) failing to follow an agreed-upon audit resolution payment plan;(4) failing to provide services according to the contract or program requirements; or(5) a validated report of abuse, neglect, or exploitation when the perpetrator is an owner, employee, or volunteer who has contact with a ward or with the estate or benefits of a ward.(b) DADS may impose a sanction described in this subsection.(1) Plan of correction. DADS may require a contractor to submit a plan of correction that includes the date the findings will be corrected.(2) Protective action plan. DADS may require a contractor to take immediate action and put into place an abbreviated and immediate protective action plan if DADS identifies health or safety issues. The plan must address the contractor's actions to be taken to ensure the health and safety of the ward.(3) Recoupment. DADS may collect money the contractor owes as the result of overpayments or other billing irregularities or both.(4) Ward referral hold. DADS may stop referring new wards to the contractor. The ward referral hold is released when DADS determines the contractor has resolved the reason for the hold.(5) Contractor hold. DADS may withhold a contractor's payments. The contractor hold is released when DADS determines the contractor has resolved the reason for the hold.(6) Involuntary contract termination. DADS may terminate a contractor's contract for cause by citing the contractor's failure to comply with the terms of the contract or with DADS program rules, policies, and procedures. If DADS terminates a contract, DADS conducts a review to determine any overpayment or underpayment and makes a final review to determine if the contractor has met the terms of the contract. If the account is overpaid, the contractor must reimburse DADS within 30 calendar days after receiving written notice from DADS. If the account balance is not paid in full by that time, DADS may charge interest on all unpaid debts starting on the 31st day after the contractor received the written notice from DADS. Interest is computed on a simple interest basis in accordance with the Texas Finance Code, Chapter 304, on the unpaid balance due. DADS may charge and collect interest on installment payments. If an appeal is made, interest continues to accrue during any administrative appeal process extending beyond the 31st day after notice of a balance due. If any part of an appeal is found in the contractor's favor, the interest that accrued against the part of the appeal found in the contractor's favor is dismissed.(7) Suspension. DADS may temporarily suspend the contractor's right to conduct business with DADS. The causes for and conditions of suspension are described in subsection (a) of this section. A suspension is in effect until an investigation, hearing, or trial is concluded and DADS can make a determination about the agency's future right to contract. DADS may impute the conduct of an individual, corporation, partnership, or other association to the contractor.(c) A contractor may appeal an adverse action DADS takes against its contract. To appeal an action, the contractor must request the appeal in writing in accordance with 1 TAC Chapter 357, Subchapter I. Source Note: The provisions of this §361.207 adopted to be effective September 1, 2006, 31 TexReg 6797; amended to be effective February 9, 2015, 40 TexReg 609; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES E CONTRACT MONITORING AND COMPLIANCE §361.207 Sanctions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208144 03/12/2026 (a) A contractor may request an administrative review of the review team's methodology if the contractor suspects a formal compliance monitoring may not have been conducted according to established rules and procedures.(b) A contractor's request for an administrative review must:(1) be in writing;(2) identify the rules and procedures the contractor believes DADS failed to follow;(3) state the basis for believing the review was not conducted according to established rules and procedures; and(4) be received by DADS within 10 calendar days after the contractor's receipt of the written review findings.(c) DADS gives the contractor written notice of the result of the administrative review via certified mail. Source Note: The provisions of this §361.209 adopted to be effective September 1, 2006, 31 TexReg 6797; transferred effective March 15, 2022, as published in the February 25, 2022 issue of the Texas Register, 47 TexReg 983. 1 HEALTH AND HUMAN SERVICES COMMISSION 361 GUARDIANSHIP SERVICES E CONTRACT MONITORING AND COMPLIANCE §361.209 Administrative Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220615 03/12/2026 (a) The Health and Human Services Commission (commission) is responsible for distributing state assistance to eligible counties to the extent appropriated state funds are available.(b) The commission distributes funds to eligible counties based on a maximum annual allocation.(1) The maximum annual allocation will be based on such factors as spending history, population, and the number of residents living below the Federal Poverty Guideline.(2) The commission-established allocation of the state assistance funds will distinguish the amount of funds allocated between the counties that were eligible and received state assistance funds the prior state fiscal year, and other potentially eligible counties.(3) The commission may reallocate the unspent funds to eligible counties, up to the appropriated state assistance funds available for each county.(4) No county can be approved for more than the legislatively mandated or commission-established percent of the appropriated state assistance fund within a state fiscal year. Source Note: The provisions of this §363.1 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673; amended to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM A PROGRAM ADMINISTRATION §363.1 State Assistance Fund https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220616 03/12/2026 (a) If a health care provider and a governmental entity or hospital district cannot agree on a household's eligibility for assistance, the provider or the governmental entity or hospital district may submit the matter to the Health and Human Services Commission (commission) not later than the 90th day after the eligibility determination was issued.(b) The health care provider and the governmental entity or hospital shall submit all relevant information to the commission in accordance with the internal procedures established by the commission.(c) From the information submitted, the commission shall determine the household's eligibility for assistance.(d) Not later than the 45th day after the receipt of the matter, the commission shall notify each governmental entity or hospital district and the health care provider of the decision and the reasons for the decision. Source Note: The provisions of this §363.3 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673; amended to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM A PROGRAM ADMINISTRATION §363.3 Eligibility Dispute https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220617 03/12/2026 (a) The Health and Human Services Commission (commission) establishes the eligibility requirements and internal procedures for a county applying for state assistance.(b) The commission determines a county's eligibility for state assistance.(c) To be eligible for state assistance under this chapter, a county must provide the following information for September 1 to August 31 of each fiscal year:(1) the taxable value of property taxable by the county;(2) the county's applicable general revenue tax levy; and(3) the amount of sales and use tax revenue received by the county.(d) A county must submit the information required by subsection (c) of this section:(1) according to commission guidelines in the program policy manual; and(2) by the deadline prescribed by the commission. Source Note: The provisions of this §363.5 adopted to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM A PROGRAM ADMINISTRATION §363.5 Eligibility of a County for State Assistance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207805 03/12/2026 (a) An identifiable application is an application that minimally contains the applicant's name, address, signature, and the date signed.(b) The application file date is the date the county first receives an identifiable application.(c) A complete application is an application with at least the following information provided by the applicant:(1) the applicant's full name and address;(2) the applicant's social security number, if available;(3) the names of all other household members and their relationship to the applicant;(4) the applicant's county of residence;(5) information about any medical insurance and hospital or health care benefits for which the household members are eligible;(6) any transfer of title of a countable resource, including real property, that the applicant has made within three months before application or any time after certification;(7) the gross monthly income of each household member, excluding the income of any household member receiving Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), or Medicaid benefits;(8) the amount of liquid assets, the fair market value of vehicles, and the equity value of real property that the household members own;(9) the applicant's signature and the date the form is filled out; and(10) all needed verifications.(d) The application completion date is the date the county receives a complete Application for Assistance Form.(e) Day is defined as a calendar day, unless otherwise clearly defined. Source Note: The provisions of this §363.51 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM B DETERMINING ELIGIBILITY §363.51 Application Processing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220618 03/12/2026 (a) A person must live in the Texas county where the person applies for assistance.(b) No time limit is placed on a person's absence from the county. If a person proves county residency at application, the person remains a county resident until factual evidence proves otherwise.(c) A person is not required to live in a county.(d) A person is not considered a county resident, even if the person lives in the county, if the person:(1) is a student who is a minor; and(2) is primarily supported by a parent whose residence is in another county or state.(e) A person cannot qualify for county health care assistance from more than one county simultaneously.(f) A person is not required to have a permanent dwelling or fixed residence in the person's county to be considered a resident. Source Note: The provisions of this §363.53 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673; amended to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM B DETERMINING ELIGIBILITY §363.53 Residence https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207807 03/12/2026 (a) A county health care assistance household is a person living alone, or two or more persons living together, who are legally responsible for the support of the other person(s). Disqualified persons are not household members regardless of their legal responsibility for support.(b) An inmate in a county jail qualifies as a household if the inmate meets all other eligibility criteria.(c) A non-TANF foster care child qualifies as a household if the child meets all other eligibility criteria. A foster child in the managing conservatorship of a licensed, privately-funded 24-hour child care facility does not qualify for county health care assistance.(d) A person appealing a social security disability denial qualifies as a household if the person meets all other eligibility criteria.(e) Legal responsibility for support exists between persons who are legally married, a legal parent and a minor child, or a managing conservator and a minor child.(f) Non-household members are defined as individuals who cohabitate without legal responsibility.(g) A minor child is a person under 18 years of age who is not, or has not been, married and has not had the disabilities of minority removed for general purposes.(h) An adult is a person at least 18 years of age, or a younger person, who is or has been married or had the disabilities of minority removed for general purposes.(i) The following persons are disqualified from inclusion in the household:(1) a person who receives or is categorically eligible to receive Medicaid;(2) a person who receives TANF or SSI benefits; and(3) a Medicaid recipient who has exhausted a part or all of that recipient's Medicaid benefit.(j) The following persons are considered a one-person household:(1) an adult living alone;(2) an adult living with others who are not legally responsible for supporting each other;(3) a minor child living alone or with others who are not legally responsible for his support; or(4) a Medicaid-ineligible parent whose spouse and/or minor children are Medicaid-eligible.(k) The following persons living together are considered a household group:(1) two persons legally married to each other;(2) one or both legal parents and their legal minor children;(3) a managing conservator and a minor child and the conservator's spouse and other legal minor children, if any;(4) minor children who are siblings; or(5) both Medicaid-ineligible parents of Medicaid-eligible children.(l) When one household lives with another household, eligibility for each household must be determined independently. Source Note: The provisions of this §363.55 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM B DETERMINING ELIGIBILITY §363.55 Household https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207808 03/12/2026 (a) Definitions. The following words and terms when used within this chapter shall have the following meanings, unless the context clearly indicates otherwise.(1) Income--Any type of payment that is of gain or benefit to the household. As established by the department, income is either countable or exempt under the department-established budgeting process.(2) Earned income--Income related to employment and entitles the household to deductions not allowed for unearned income.(3) Unearned income--Payments received without performing work-related activities. It includes benefits from other programs.(4) Sponsored alien--A person who has been lawfully admitted to the United States for permanent residence under the Immigration and Nationality Act (8 U.S.C. §1101 et seq.) and who, as a condition of admission, was sponsored by a person who executed an affidavit of support on behalf of the person.(b) A county must subtract the work-related and childcare expense deductions allowed under department guidelines.(c) A household must pursue and accept all income to which the household is legally entitled. Reasonable time (at least three months) must be allowed for the household to pursue the income. The income is not considered available during this time.(d) Income from non-household members and/or disqualified household members is excluded, unless a county chooses to include the income of a person who executed an affidavit of support on behalf of the applicant and the income of the person's spouse, as authorized by Health and Safety Code, §61.008(a)(6).(e) If a county chooses to include the income of a person who executed an affidavit of support on behalf of a sponsored alien and the income of the person's spouse, the county shall adopt written procedures for processing the incomes of the sponsor and the sponsor's spouse. Source Note: The provisions of this §363.57 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; amended to be effective November 13, 2012, 37 TexReg 8975; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM B DETERMINING ELIGIBILITY §363.57 Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220619 03/12/2026 (a) Definitions. The following words and terms when used in this section shall have the following meanings, unless the context clearly indicates otherwise.(1) Assets--All items of monetary value owned by an individual, excluding personal possessions.(2) Resources--Both liquid and non-liquid assets a person can convert to meet his immediate needs. As established by the Health and Human Services Commission (commission), resources are either countable or exempt.(A) Liquid resources are resources that are readily negotiable, such as cash, checking or savings accounts, savings certificates, stocks, or bonds.(B) Non-liquid resources include vehicles, buildings, land, or certain other property.(3) Accessible resource--A resource that is legally available to the household.(4) Inaccessible resource--A resource that is not legally available to the household.(5) Personal possessions--Furniture, appliances, jewelry, clothing, livestock, farm equipment, and other items if the household uses them to meet personal needs essential for daily living.(6) Real property--Land and any improvements on it.(7) Fair market value--The amount of money an item would bring if sold in the current local market.(8) Equity--The fair market value of an item minus all money owed on it and the cost associated with its sale or transfer.(b) Resource Limit. The total value of non-exempt resources available to the household cannot exceed:(1) $3,000 for households which include the applicant or a relative living in the home who is aged or disabled; or(2) $2,000 for all other households.(c) The following criteria will be used to determine the household's resource limit category.(1) A related person is a person who meets the Temporary Assistance for Needy Families (TANF) relationship criteria, either biologically or by adoption.(2) An aged person is a person age 60 or older as of the last day of the month for which benefits are being requested.(3) A disabled person is a person who meets the TANF disability criteria.(d) In determining eligibility:(1) a county must not consider the value of the applicant's homestead;(2) a county must consider as a resource the value of a vehicle under commission-established guidelines;(3) a county must consider a household ineligible for assistance if the household transfers title of a countable resource for less than its fair market value within three months before application or any time after certification to reach resource eligibility guidelines;(4) a county must consider as a resource real property other than a homestead and must count that property in determining eligibility;(5) a county may disregard the applicant's real property if the applicant agrees to the terms of an enforceable obligation negotiated with the county to reimburse the county for all or part of the benefits received under the County Indigent Health Care Program; and(6) resources from non-household members or disqualified household members are excluded, unless a county chooses to include the resources of a person who executed an affidavit of support on behalf of a sponsored alien, as defined in §363.57(a)(4) of this subchapter (relating to Income), and the resources of the person's spouse, as authorized by Health and Safety Code, §61.008(a)(6).(e) If a county chooses to include the resources of a person who executed an affidavit of support on behalf of a sponsored alien and the resources of the person's spouse, the county shall adopt written procedures for processing the resources of the sponsor and the sponsor's spouse. Source Note: The provisions of this §363.59 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; amended to be effective November 13, 2012, 37 TexReg 8975; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673; amended to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM B DETERMINING ELIGIBILITY §363.59 Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220620 03/12/2026 (a) Except as specified in the Health and Human Services Commission-established service exclusions and limitations, counties are required to provide the following basic health care services to eligible households by reimbursing providers of services who meet the requirements of this chapter and the responsible county.(1) Inpatient hospital services. Services must be medically necessary and:(A) provided in an acute care hospital;(B) provided to hospital inpatients;(C) provided by or under the direction of a physician; and(D) provided for the care and treatment of patients.(2) Outpatient hospital services. Services must be medically necessary and:(A) provided in an acute care hospital or hospital-based ambulatory surgical center;(B) provided to hospital outpatients;(C) provided by or under the direction of a physician; and(D) are diagnostic, therapeutic, or rehabilitative.(3) Physician services. Services must be medically necessary and provided by a physician in the doctor's office, a hospital, a skilled nursing facility, or elsewhere.(4) Up to three prescriptions for drugs per recipient per month. New and refilled prescriptions count equally toward this total prescription limit. Drugs must be prescribed by a physician or other practitioner within the scope of practice under law. The quantity of drugs prescribed depends on the prescribing practice of the physician or other practitioner and the needs of the patient.(5) Skilled nursing facility services (SNF). Services must be medically necessary, ordered by a physician, and provided in a SNF that provides daily services on an inpatient basis.(6) Rural health clinic services. Rural health clinic services must be provided in a rural health clinic by a physician, a physician assistant (PA), an advanced practice registered nurse (APRN) licensed by the Texas Board of Nursing, such as a certified nurse practitioner, a certified nurse midwife, or other specialized nurse practitioner.(7) Family planning services. These are preventive health and medical services that assist an individual in controlling fertility and achieving optimal reproductive and general health.(8) Laboratory and x-ray services. These are technical laboratory and radiological services ordered and provided by, or under the direction of, a physician in an office or a similar facility other than a hospital outpatient department or clinic.(9) Immunizations. These are given when appropriate.(10) Medical screening services. These medical services include blood pressure, blood sugar, and cholesterol screening.(11) Annual physical examinations. These are examinations provided once per calendar year by a physician or a PA. Associated testing, such as mammograms, can be covered with a physician's referral. These services may also be provided by an APRN if the services are within the scope of practice of the APRN in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(b) The following services are optional health care services.(1) Ambulatory surgical center (ASC) services. These services must be provided in a freestanding ASC, and are limited to items and services provided in reference to an ambulatory surgical procedure, including those services on the Center for Medicare & Medicaid Services-approved list and selected Medicaid-only procedures.(2) Federally Qualified Health Center (FQHC) services. These services must be provided in an FQHC by a physician, a PA, an APRN, a clinical psychologist, or a clinical social worker.(3) PA services. These services must be medically necessary and provided by a PA under the direction of a physician and may be billed by and paid to the supervising physician.(4) APRN services. These services must be provided by an APRN licensed by the Texas Board of Nursing as a certified nurse practitioner, a clinical nurse specialist, a certified nurse midwife, or a certified registered nurse anesthetist. APRN services must be medically necessary, provided within the scope of practice of an APRN, and covered in the Texas Medicaid Program.(5) Counseling services. Psychotherapy services must be medically necessary based on a physician referral, and provided by a licensed professional counselor, a licensed master social worker-advanced clinical practitioner, a licensed marriage family therapist, or a doctorate-level psychologist. These services may also be provided based on an APRN referral if the referral is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(6) Diabetic medical supplies and equipment. These supplies and equipment must be medically necessary and prescribed by a physician. The county may require the supplier to receive prior authorization. Items covered are lancets, alcohol prep pads, syringes, test strips, Humulin pens, and glucometers. These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(7) Colostomy medical supplies and equipment. These supplies and equipment must be medically necessary and prescribed by a physician. The county may require the supplier to receive prior authorization. Items covered are colostomy bags/pouches; cleansing irrigation kits, paste, or powder; and skin barriers with flange (wafers). These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(8) Durable medical equipment. This equipment must be medically necessary; meet the Medicare/Medicaid requirements; and provided under a written, signed, and dated physician's prescription. The county may require the supplier to receive prior authorization. Items can be rented or purchased, whichever is the least costly. Items covered are crutches, canes, walkers, standard wheel chairs, hospital beds, home oxygen equipment (including masks, oxygen hose, and nebulizers), and reasonable and appropriate appliances for measuring blood pressure. These supplies and equipment may also be prescribed by an APRN if this is within the scope of the APRN's practice in accordance with the standards established by the Texas Board of Nursing in Title 22, Texas Administrative Code, Part 11 and the Nursing Practice Act in Title 3, Texas Occupations Code Chapter 301.(9) Home and community health care services. These services must be medically necessary; meet the Medicare/Medicaid requirements; and provided by a certified home health agency. A plan of care must be recommended, signed, and dated by the recipient's attending physician prior to care being given. A plan of care may also be recommended, signed, and dated by a PA or APRN who is licensed by the Texas Board of Nursing as a certified nurse practitioner or clinical nurse specialist. The county may require prior authorization. Items covered are registered nurse (RN) visits for skilled nursing observation, assessment, evaluation, and treatment provided a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered. Visits made for performing housekeeping services are not covered.(10) Dental care. These services must be medically necessary and provided by a doctor of dental surgery, a doctor of medicine in dentistry, or a doctor of dental medicine. The county may require prior authorization. Items covered are an annual routine dental exam and the least costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection, or extreme pain.(11) Vision care, including eyeglasses. The county may require prior authorization. Items covered are one examination of the eyes by refraction and one pair of prescribed glasses every 24 months.(12) Emergency medical services. These services are ground ambulance transport services. When the client's condition is life-threatening and requires the use of special equipment, life support systems, and close monitoring by trained attendants while en route to the nearest appropriate facility, ground ambulance transport is an emergency service.(13) Physical therapy services. These services must be medically necessary and may be covered if provided in a physician's office, a therapist's office, in an outpatient rehabilitation or freestanding rehabilitation facility, or in a licensed hospital. Services must be within the provider's scope of practice, as defined by Texas Occupations Code Chapter 453.(14) Occupational therapy services. These services must be medically necessary and may be covered if provided in a physician's office, a therapist's office, in an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider's scope of practice, as defined by Texas Occupations Code Chapter 454.(15) Other medically necessary services or supplies that the local governmental municipality/entity determines to be cost effective. Source Note: The provisions of this §363.101 adopted to be effective April 1, 2004, 29 TexReg 3177; amended to be effective February 28, 2008, 33 TexReg 1549; amended to be effective November 13, 2012, 37 TexReg 8975; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 673; amended to be effective September 18, 2024, 49 TexReg 7328. 1 HEALTH AND HUMAN SERVICES COMMISSION 363 COUNTY INDIGENT HEALTH CARE PROGRAM C PROVIDING SERVICES §363.101 Basic and Optional Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207811 03/12/2026 (a) The purpose of this subchapter is to establish a system of primary health care services for eligible individuals as prescribed by Health and Safety Code, Chapter 31. The rules in this subchapter do not apply to any subsequent subchapter.(b) The Department of State Health Services seeks to fund local projects that utilize early intervention and prevention of health problems with emphasis on primary and preventive services to women. Access to appropriate levels of health care can reduce health expenditures, mortality, morbidity, and improve individual productivity, health status, and economic growth. Source Note: The provisions of this §364.1 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.1 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207812 03/12/2026 The following words and terms, when used in this subchapter shall have the following meanings, unless the context clearly indicates otherwise.(1) Act--The Texas Primary Health Care Services Act, Health and Safety Code, Chapter 31.(2) Applicant--An individual and/or family applying to receive primary health care services.(3) Commission--The Texas Health and Human Services Commission.(4) Commissioner--The Commissioner of Health.(5) Department--The Department of State Health Services.(6) Eligible individual--An eligible recipient of primary health care services under the Act.(7) Other benefit--A benefit, other than a benefit provided under the Act, to which an individual is entitled for payment of the costs of primary health care services, including:(A) benefits available from:(i) an insurance policy, group health plan, or prepaid medical care plan;(ii) Title XVIII or Title XIX of the Social Security Act;(iii) the Veterans Administration;(iv) the Civilian Health and Medical Program of the Uniformed Services; and(v) workers compensation or any other compulsory employer's insurance program.(B) a public program created by federal or state law, or by an ordinance or rule of a municipality or political subdivision of the state, except those benefits created by the establishment of a city or county hospital, a joint city-county hospital, a county hospital authority, a hospital district, or by the facilities of a publicly supported medical school; or(C) benefits resulting from a cause of action for medical, facility, or medical transportation expenses, or a settlement or judgment based on the cause of action, if the expenses are related to the need for services provided by the Act.(8) Primary Health Care Services--May include the following:(A) diagnosis and treatment;(B) emergency medical services;(C) family planning services;(D) preventive health services;(E) health education;(F) laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services;(G) nutrition services;(H) health screening;(I) home health care;(J) dental care;(K) transportation;(L) prescription drugs and devices and durable supplies;(M) environmental health services;(N) podiatry services; and(O) social services.(9) Program--The primary health care services program created by the Act.(10) Provider--An entity that, through a grant or a contract with the department, delivers primary health care services that are purchased by the department for the purposes of the Act.(11) Recipient--An individual receiving primary health care services under the Act.(12) Request for proposal--A solicitation providing guidance and instructions issued by the department to entities interested in submitting applications to provide primary health care services under the Act.(13) Services--Primary health care services.(14) Texas resident--An individual who is physically present within the geographic boundaries of the state, and who:(A) intends to remain within the state, whether permanently or for an indefinite period;(B) does not claim residency in any other state or country;(C) is under 18 years of age, and at least one of his/her parents, managing conservator, or guardian is a bona fide resident of Texas;(D) is a person residing in Texas and his/her legally dependent spouse is a bona fide resident of Texas; or(E) is an adult residing in Texas whose legal guardian is a bona fide resident of Texas. Source Note: The provisions of this §364.3 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207813 03/12/2026 (a) Because budgetary limitations exist, all program providers shall offer at least the following priority services:(1) diagnosis and treatment;(2) emergency medical services;(3) family planning services;(4) preventive health services;(5) health education; and(6) laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services.(b) The department, through approved providers, shall provide for the delivery of primary health care services to those populations that demonstrate unmet needs due to the inaccessibility and/or unavailability of primary health care services. Unmet needs may be determined by, but are not limited to, the following criteria:(1) geographic area;(2) demography;(3) socioeconomic conditions;(4) key health indicators identified by the department with the assistance of the community; and(5) health resources available in the community.(c) The department may deliver services directly to eligible individuals if existing private or public providers or other resources in the service area are unavailable or unable to provide those services, as evidenced by the applications received during the Request for Proposals process. The department shall make determinations that providers or resources are unavailable or unable to provide services in accordance with Health and Safety Code, §31.005.(d) Individuals eligible for prescription drug benefits under Medicare, Part D, who reside in areas of the state served by program providers that offer prescription drugs as a primary health care service shall receive prescription drug benefits according to Medicare regulations and procedures. Individuals who are not eligible for prescription drug benefits under Medicare, Part D, who reside in areas of the state served by program providers that offer prescription drugs as a primary health care service shall receive covered prescription drugs dispensed by pharmacy providers according to this chapter. Source Note: The provisions of this §364.5 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.5 General Program Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207814 03/12/2026 (a) The department will reimburse providers for services rendered in accordance with the contracts between the providers and the department. The department shall pay only valid claims submitted according to the terms of the providers' contracts.(b) Except for prescription drugs covered under Medicare, Part D, primary health care providers will be reimbursed for services delivered to presumptively eligible clients. Source Note: The provisions of this §364.7 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.7 Provider Reimbursement for Primary Health Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207815 03/12/2026 (a) Individuals covered under the Primary Health Care Services Program are those who are not eligible for other benefits. Individuals eligible for prescription drug benefits under Medicare, Part D, who reside in areas of the state served by program providers that offer prescription drugs as a primary health care service may be eligible for other program services, and for prescription drugs not covered by Medicare, Part D.(b) Nothing in this section shall preclude a system of integrated eligibility with the commission.(c) In accordance with program policy, providers shall assure that each individual is:(1) in financial need based on a family income that does not exceed 200% of the current Federal Poverty Level guidelines; and(2) a Texas resident.(d) In accordance with program policy, providers:(1) shall assist applicants in completing the eligibility screening process and shall provide coverage if the applicant is potentially eligible for program services;(2) may collect co-payments from eligible individuals who receive primary health care services; and(3) shall provide services to potentially eligible individuals who require immediate medical attention on a presumptive eligibility basis.(e) Subsection (d)(4) of this section notwithstanding, no otherwise eligible individual unable to pay a co-payment may be denied services.(f) If funds are available, the program may pay co-payments required under federal regulations for eligible individuals receiving prescription drug benefits under Medicare, Part D, if the eligible individual resides in an area of the state served by a program provider that offers prescription drugs as a benefit under the primary health care service program.(g) No eligible individual or person legally responsible for an eligible individual shall be required to make a pre-treatment payment.(h) An individual found ineligible for program services may reapply at any time. Source Note: The provisions of this §364.9 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.9 Eligibility Requirements and Provision of Services to Recipients https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207816 03/12/2026 To maintain eligibility for program benefits, the recipient must continue to reside in Texas, be in financial need as defined by this subchapter, and inform the provider in writing or by telephone within 30 days of changes in the following:(1) permanent home address;(2) health insurance coverage;(3) employment;(4) other income; or(5) family composition. Source Note: The provisions of this §364.11 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.11 Maintaining Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207817 03/12/2026 (a) An individual is not eligible to receive services delivered under the Primary Health Care Services Program when the individual, or a person with a legal obligation to support the individual, is eligible for some other benefit that would pay for all or part of the services, unless coverage for those services has been denied.(b) An individual who applies for or receives primary health care services shall inform the provider at the time of application or at the time the individual receives services of any other benefit to which the individual or person who has a legal obligation to support the individual may be entitled.(c) The commissioner, or the manager of the department unit having responsibility for oversight of the primary health care services program, if so authorized by the commissioner, may waive enforcement of this section concerning individual applicants if enforcement of this section would deny services to a class of otherwise eligible individuals because of conflicting federal, state, or local laws or regulations. Source Note: The provisions of this §364.13 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.13 Coordination of Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207819 03/12/2026 The contractor may deny, modify, suspend, or terminate services to an applicant or recipient after written notice if:(1) the applicant has provided intentionally false or incomplete information on the applications form; or(2) the recipient is no longer eligible. Source Note: The provisions of this §364.15 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.15 Denial/Modification/Suspension/Termination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207820 03/12/2026 (a) A recipient or applicant aggrieved by the denial, modification, suspension or termination of services may appeal the program's decision according to the procedures in §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures). If an aggrieved recipient requests a hearing, the department shall not terminate services to the recipient until a final decision is rendered.(b) An applicant or recipient may not appeal a denial, modification, suspension, or termination of program services by the department if the department has restricted program services according to priorities established by §39.3(b) of this title (relating to General Program Requirements) and/or program funds are reduced or curtailed.(c) Upon final determination that benefits will be denied, modified, suspended, or terminated, the department will notify the recipient in writing. Source Note: The provisions of this §364.17 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.17 Appeals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207821 03/12/2026 (a) Program review activities will be accomplished through monitoring systems developed to ensure the delivery of appropriate services.(b) At least annually, the department shall review and determine the continued need for the services it provides directly in accordance with the methods and procedures used to make the initial determination prescribed by the Act and these sections.(c) The department will require providers to report information on service delivery as required by Health and Safety Code, Chapter 31, and the Primary Health Care Services Policy Manual. Source Note: The provisions of this §364.19 adopted to be effective May 28, 2006, 31 TexReg 4218; amended to be effective February 14, 2013, 38 TexReg 645; amended to be effective September 1, 2013, 38 TexReg 5505; transferred effective March 1, 2022, as published in the Texas Register February 11, 2022, 47 TexReg 674. 1 HEALTH AND HUMAN SERVICES COMMISSION 364 PRIMARY HEALTH CARE SERVICES PROGRAM A PRIMARY HEALTH CARE SERVICES PROGRAM §364.19 Program Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207459 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207459 03/12/2026 (a) Purpose. The purpose of this subchapter is to establish rules for the Kidney Health Care (KHC) program. The authority for these rules is granted in the Texas Health and Safety Code, Chapter 42.(b) Confidentiality of Information.(1) All information submitted, as required by this subchapter, may be verified at the discretion of the Department of State Health Services (department) with or without notice to applicants, clients, authorized entities, or providers of program benefits or services. This information is confidential to the extent authorized by law.(2) Information may be disclosed in summary, statistical, or other forms that do not identify particular individuals.(c) Forms. The program provides approved forms to applicants, clients, authorized entities, and providers. Source Note: The provisions of this §365.1 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.1 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207460 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207460 03/12/2026 The following words and terms when used in this subchapter have the following meanings, unless the context clearly indicates otherwise.(1) Access surgery--The surgical procedure which creates or maintains the access site necessary to perform dialysis.(2) Action--A suspension, modification, denial, or termination of program eligibility, benefits, or participation.(3) Administrative review--A process that allows applicants, clients, or providers the opportunity to request an informal review of any intended program action that would suspend, modify, deny, or terminate their eligibility, benefits or participation in the program.(4) Allowable amount--The maximum amount that the program will pay or reimburse for a covered benefit or service.(5) Applicant--A person who has submitted an application for program benefits and has not received a final determination of eligibility.(6) Authorized entity--Any individual or organization approved by the program to submit applications for benefits or travel verification reports on behalf of an applicant or client.(7) Claim--A request for payment or reimbursement of services.(8) Client--A person who has applied for program services and who meets all program eligibility requirements and is determined to be eligible for program services.(9) CMS--The Centers for Medicare and Medicaid Services.(10) Co-insurance--A cost-sharing arrangement in which a covered person is responsible for paying a specified percentage of the charge for a covered service or product.(11) Commissioner--The commissioner of the Department of State Health Services.(12) Co-pay/Co-payment--A cost-sharing arrangement in which a covered person is responsible for paying a specified or fixed charge for a covered service or product.(13) CRNA--Certified registered nurse anesthetist.(14) Date of service (DOS)--The date a service is rendered.(15) Denial--An action by the program that disallows program eligibility, benefits, or provider enrollment.(16) Department--The Department of State Health Services.(17) Effective date--The date a program client or enrolled provider is approved to receive program benefits or reimbursements.(18) End-Stage Renal Disease (ESRD)--The final stage of renal failure that requires dialysis or kidney transplant to reduce uremic symptoms and prevent the death of the patient.(19) Enrolled provider--Any individual or entity who has completed all the requirements located in the Texas Health and Human Services Commission rule at 1 TAC §392.605, Kidney Health Care Provider Requirements and Effective Dates, and is deemed enrolled by the program to furnish covered services to program clients including:(A) outpatient dialysis facilities;(B) out-of-state outpatient dialysis facilities;(C) hospitals and ambulatory surgical centers (ASCs) located in Texas and operating in compliance with applicable law;(D) out-of-state hospitals and ASCs;(E) military or Veterans Administration hospitals located in Texas which have a renal unit;(F) pharmacies approved as Texas Medicaid providers and licensed to operate within the United States and its territories, including mail order pharmacies;(G) physicians and certified registered nurse anesthetists (CRNAs) licensed in Texas;(H) out-of-state physicians and CRNAs; and(I) Medicare Prescription Drug Plan (PDP) providers.(20) Explanation of benefits (EOB)--A form, in paper or electronic format, which provides an explanation of benefits. It is used to explain a payment or denial of a claim.(21) Fair hearing--The informal hearing process the department follows under §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).(22) Filing deadline--The last date that a claim may be received by the program and still be considered eligible for benefit.(23) Final decision--A decision that is made by a decision maker after conducting a fair hearing under §§1.51 - 1.55 of this title.(24) Incomplete claim--A claim that is submitted to the program without the required information to enable determination of program liability or payment.(25) KHC--Kidney Health Care.(26) KHC formulary--A list of general therapeutic categories of drugs, over-the-counter products, and limited diabetic supplies that are covered for reimbursement by the program.(27) Low Income Subsidy (LIS)--The subsidy provided under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 for Medicare Part D plan premiums and related costs, at varying levels, for some low-income Medicare beneficiaries.(28) Medical benefit--Any medical treatment or procedure approved by the program as a covered service.(29) Medicare Advantage Plan--A Medicare health plan that is similar to a health maintenance organization, participating provider organization, or other Medicare health plan, and includes medical, drug coverage and other benefits.(30) Medicare Part A--Hospital insurance for people age 65 or older, or under age 65 with certain disabilities, that helps cover inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.(31) Medicare Part B--Health insurance for people age 65 or older, or under age 65 with certain disabilities, and any age with ESRD, that helps cover medically necessary services, such as doctors' services and outpatient care, and some preventive services.(32) Medicare Part D--Established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), it provides members with prescription drug coverage, expanded health plan options, improved health care access for rural Americans, and preventive care services.(33) Medicare Part D out-of-pocket expenses--Include premiums, deductibles, co-payments, or co-insurance amounts.(34) Medicare Part D Premium--The amount paid monthly under a Medicare Part D contract to insure coverage.(35) Medicare Prescription Drug Plan (PDP)--A stand-alone drug plan offered by insurers and other private companies to individuals eligible for Medicare Part D.(36) Medigap plan--A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Medicare coverage.(37) Modification--A change made to a client or provider account that can affect program benefits, eligibility, or enrollment.(38) Program--Kidney Health Care.(39) Provider--Any individual or entity who furnishes benefits or services to program clients.(40) Qualified Individual (QI) Program--A Medicaid program for beneficiaries who need help in paying for Medicare Part B premiums. The beneficiary must be entitled to Medicare Part A, have limited income and resources as calculated using federal and state guidelines, and not be otherwise eligible for Medicaid. For those who qualify, the Medicaid program pays full Medicare Part B premiums only.(41) Qualified Medicare Beneficiary (QMB) Program--A Medicaid program for beneficiaries who need help in paying for Medicare services. The beneficiary must be entitled to Medicare Part A, have limited income and resources as calculated using federal and state guidelines. For those who qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for Medicare services.(42) Reimbursement--Payment of a claim for covered benefits or services.(43) Reimbursement rate--The program payment rate for covered benefits or services.(44) Resubmitted claim--A claim that is submitted to the program more than once to correct errors.(45) Specified Low Income Medicare Beneficiary (SLMB) Program--A Medicaid program that pays for Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources as calculated using federal and state guidelines.(46) Suspension--An action by the program, which holds client benefits or reimbursement to enrolled providers pending satisfaction of a program request or requirement.(47) Termination--A final action by the program, which ends client or enrolled provider participation in the program.(48) Veterans programs--Health care programs authorized and administered by the United States Department of Veterans Affairs and the United States Department of Defense. Source Note: The provisions of this §365.2 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207461 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207461 03/12/2026 (a) A person must meet all of the following requirements to be eligible for program benefits:(1) have a diagnosis of ESRD; and(A) require a regular course of chronic renal dialysis treatments; or(B) have received a kidney transplant;(2) satisfy the Texas residency criteria as specified in subsection (b) of this section and not be:(A) in the custody of or incarcerated by a city, county, state, or federal entity; or(B) a ward of the state;(3) not be eligible for drug, transportation, and medical benefits under the Texas Medicaid Program;(4) submit a complete application for benefits; and(5) satisfy the financial criteria as specified in subsection (c) of this section.(b) Residency Requirements.(1) The following conditions must be met by an applicant and maintained by a client to satisfy the residency requirements in this section:(A) physically reside within the state; and(B) maintain a home or dwelling within the state.(2) If the applicant is residing with a person establishing residency on behalf of the applicant (such as a parent, legal guardian, managing conservator, sibling, adult child, or spouse), then that person must meet all of the requirements of paragraph (1) of this subsection.(3) All documents acceptable to meet residency requirements, as specified by the program, must be in the applicant's name, or in the name of the person establishing residency for the applicant, provide some verification of a Texas address or domicile, and be in English or be accompanied by an accurate English translation.(c) Financial Criteria. The applicant or the person(s) who has a legal obligation, as defined by state law, to support the applicant must have an annual gross income of less than $60,000. Income reported as "joint income" is considered as one income.(d) Maintenance of Benefits Eligibility.(1) A client must meet the following requirements within the first 3 months of program eligibility:(A) apply for medical, drug, and transportation benefits and Medicare Savings Plans (QMB, SLMB and QI) under Title XIX, Social Security Act (Medicaid);(B) apply for Medicare hospital and medical benefits under Title XVIII, Social Security Act (Medicare);(C) enroll in Medicare Part D benefits and apply for Low Income Subsidy under the Medicare Prescription Drug Improvement and Modernization Act of 2003, if Medicare eligible;(D) provide authorization for Medicare premium payments by the program as specified in §61.5 of this title (relating to Benefits and Limitations), if obligated to pay the Part A premium.(2) A client must meet the following requirements to continue benefit eligibility:(A) continue premium payments to health insurance plans under Medicare, individual or group health insurance plans, and prepaid medical plans, where enrollment was effective prior to program eligibility;(B) re-apply for LIS as required by the Social Security Administration;(C) re-apply for Medicaid benefits as requested by the program if there are changes in the client's status that would make the client potentially eligible for Medicaid benefits;(D) re-apply for Medicare hospital and medical benefits as requested by the program if there are changes in the client's status that would make the client potentially eligible for Medicare benefits; and(E) notify the program within 30 days of changes in the following:(i) permanent home address;(ii) treatment status;(iii) coverage under Medicaid, Medicare, individual or group insurance, Veterans programs, or any other health benefits coverage;(iv) location of treatment; and(v) income. Source Note: The provisions of this §365.3 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.3 Client Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207462 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207462 03/12/2026 Persons meeting the eligibility requirements set forth in §61.3(a) - (c) of this title (relating to Client Eligibility Requirements) must submit an application packet for benefits.(1) A complete application packet must be submitted by an authorized entity and include all of the following:(A) a completed, signed and dated program application;(B) a copy of the completed, signed and dated Centers for Medicare and Medicaid Services (CMS) End-Stage Renal Disease Medical Evidence Report or, with program approval, the Kidney Health Care Physician Assessment Form;(C) documentation of Texas residency as required by §61.3 of this title;(D) a copy of the applicant's social security card issued by the Social Security Administration (SSA), or an allowable substitute, as follows:(i) a copy of a SSA document which verifies the social security number; or(ii) a copy of a valid Medicare card, if the Medicare account is established in the applicant's own social security number and the social security number is printed on the Medicare card; and(E) applicant's financial data. The applicant or the person(s) legally obligated to support the applicant must verify income by providing one of the following:(i) a copy of the first page of the federal individual income tax return for the most recent tax year, if self-employed; or(ii) a statement of estimated or declared income for the current tax year, and supporting documentation.(2) Incomplete application. An application which does not meet all of the requirements of paragraph (1) of this section is incomplete. Incomplete applications may be returned to the submitting person or entity for correction or completion.(3) The program eligibility date is the date the program receives a complete application packet; if approved, the client receives an effective date.(4) If program benefits are terminated, the eligibility date for any subsequent benefit period is the date the program receives a subsequent complete application packet for program benefits.(5) An applicant whose eligibility for benefits is denied may appeal under §61.11 of this title (relating to Rights of Appeal). Source Note: The provisions of this §365.4 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.4 Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207463 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207463 03/12/2026 (a) Benefits.(1) Outpatient drugs and supplies listed on the current KHC formulary.(2) Transportation reimbursement for ESRD-related medical services.(3) Medical benefits, including:(A) access surgery-related services; and(B) chronic maintenance dialysis.(4) Medicare Part A and B premium payment. To qualify for this benefit, clients must:(A) be 65 years of age or older;(B) be accepted for Medicare hospital and medical insurance;(C) be obligated to pay the Part A premium;(D) not be eligible for the following types of Medicare savings programs:(i) QMB;(ii) SLMB; or(iii) QI; and(E) promptly submit all Medicare premium due notice statements to the program for payment.(5) Medicare Part B immunosuppressive drug co-insurance amounts. To qualify for this benefit, clients must:(A) be eligible for program drug benefits;(B) be accepted for Medicare hospital and medical insurance;(C) enroll in a Texas Medicare Part D Stand-Alone Plan;(D) not be enrolled in a Medigap plan;(E) not be enrolled in a Medicare Advantage Plan with drug coverage; and(F) not be eligible for the QMB Medicare Savings Program.(6) Limited Medicare Part D out-of-pocket expenses. To qualify for this benefit, clients must:(A) be eligible for program drug benefits;(B) be accepted for Medicare Part D benefits;(C) enroll in a Texas Medicare Part D stand-alone plan;(D) not be eligible for LIS from Medicare that covers full premium and deductible amounts; and(E) not be enrolled in a Medicare Advantage Plan with drug coverage.(7) Benefits are payable beyond the Medicare three-month qualifying period for eligible clients who have applied for and have been denied Medicare coverage based on ESRD. Clients must submit a copy of the official Social Security Administration Medicare denial notification (based on chronic renal disease) to the department.(b) Limitations.(1) Only enrolled providers may be reimbursed for covered services and allowable drugs.(2) Covered services are limited to a maximum allowable amount based upon:(A) available funds;(B) established limits for covered services by type or category;(C) an agreement between the department and the enrolled provider;(D) the reimbursement rates established by the department;(E) any co-payment or co-insurance applied to client service benefits; and(F) any third-party liability.(3) Clients eligible for drug coverage under Medicaid, Medicare Advantage Plan, individual or group insurance, Veterans programs, or any other health benefits coverage are not eligible to receive program drug benefits. A client that has exhausted drug coverage under Medicaid, Medicare Advantage Plan, individual or group insurance, Veterans programs, or any other health benefits coverage may be eligible to receive drug benefits from the program.(4) Access surgery benefits are payable only if the services are performed on or after the date Texas residency is established and not more than 180 days prior to the client's program effective date.(5) Program medical benefits are payable during the Medicare three-month qualifying period. Benefits are payable for services received on or after the client's program effective date. The three-month qualifying period is calculated from the first day of the month the client begins chronic maintenance dialysis. When a client becomes eligible for Medicare during the three-month period, program medical benefits are not payable from the date of Medicare eligibility.(6) Transportation reimbursement is available from the first day of the month following the program effective date for in-center dialysis clients or from the program effective date for transplant and home peritoneal dialysis clients.(7) Clients eligible for coverage under Medicaid, Medicare, individual or group insurance, Veterans programs, or any other health benefits coverage which cover the treatment of ESRD are not eligible to receive program medical benefits.(8) Clients receiving services, including access surgery, dialysis, or drug benefits through the Veterans Administration (VA) or the military may not be eligible to receive these services through the program, depending on the client's access to VA or military services.(9) The program is the payor of last resort. All third parties must be billed prior to the program. The Commissioner may waive this requirement in individually considered cases where its enforcement will deny services to a class of ESRD patients because of conflicting state or federal laws or regulations, under the Texas Health and Safety Code, §42.009.(10) If budgetary limitations exist, the department may:(A) restrict or categorize covered services. Categories will be prioritized based upon medical necessity, other third party eligibility and projected third party payments for the different treatment modalities, caseloads, and demands for services. Caseloads and demands for services may be based on current or projected data. In the event covered services must be reduced, they will be reduced in a manner that takes into consideration medical necessity and other third party coverage. The department may change covered services by adding or deleting specific services, entire categories or by making changes proportionally across a category or categories, or by a combination of these methods; or(B) establish a waiting list of eligible applicants. Information will be collected from each applicant who is placed on a waiting list to facilitate contacting the applicant when benefits become available and to allow efficient enrollment of the applicant for benefits. Source Note: The provisions of this §365.5 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.5 Benefits and Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207464 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207464 03/12/2026 (a) Drug benefit claims must be submitted electronically by the pharmacy to the designated claims processor for the program, except when paper submissions are allowed or required.(b) Medical benefit claims must be submitted to the program by the provider who rendered the service(s) to the program client or by the provider's designee.(c) Transportation benefit claims must be submitted to the program by the client or an authorized entity. Claims must be submitted electronically through the current automated claims payment system, except when the program allows or requires paper submissions.(d) Payments are made using the rates in effect on the date the service is rendered.(e) Claims for medical benefits will not be considered for payment by the program until the program has a fully executed agreement with the provider.(f) Incomplete or incorrect claims will not be considered for payment. Source Note: The provisions of this §365.7 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.7 Claims Submission and Payment Rates https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207465 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207465 03/12/2026 (a) The program must receive all claims within the claim filing deadlines established in this section.(1) Claims must be received no later than 95 days from the last day of the month in which services were provided.(2) Claims must be received no later than 60 days from the date on the program's notice of eligibility for newly approved clients.(b) In addition to the requirements in subsection (a) of this section, the program must receive claims for out-patient dialysis and access surgery services within 60 days from the date on the agreement approval letter for newly enrolled providers, but no later than 180 days from the date of service.(c) The program must receive all billing statements for Medicare Part D premium benefits from eligible PDPs within 95 days from the last day of each month for which the premium coverage applies.(d) The program must receive resubmitted claims within the deadlines established under subsections (a) - (c) of this section, or within 30 days from the date of the program's return letter or the program's EOB, whichever is later. Resubmitted claims must:(1) be resubmitted with a copy of the program's return letter or the program's EOB, if applicable;(2) be resubmitted on the original claim form, if applicable; and(3) contain no new or additional charges for service.(e) Pharmacies must submit claims for drug charges to the designated claims processor for the program in accordance with claim filing deadlines contained in 1 Texas Administrative Code, §354.1901, (relating to Pharmacy Claims).(f) Claims which are not received by the program within the filing deadlines will be denied payment. Source Note: The provisions of this §365.8 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.8 Claim Filing Deadlines https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207466 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207466 03/12/2026 (a) An applicant and client have the right to:(1) apply for eligibility determination;(2) choose providers subject to program limitations;(3) be notified of the program's decisions relating to modifications, suspensions, denials, or terminations; and(4) appeal the program's decisions and receive a response within the deadline as described in §61.11 of this title (relating to Rights of Appeal).(b) A provider has the right to:(1) be notified of the program's decision relating to modifications, suspensions, denials, or terminations; and(2) appeal the program's decisions and receive a response within the deadline as described in §61.11 of this title.(c) A client has the responsibility to:(1) provide accurate medical information to providers and notify providers of program eligibility prior to delivery of services;(2) abide by program rules and policies; and(3) notify the program of any lawsuit(s) contemplated or filed concerning the cause of the medical condition for which the program has made payment.(d) An enrolled provider has the responsibility to:(1) abide by program rules and policies;(2) not discriminate against applicants or clients based on source of payment; and(3) notify the program of any lawsuit(s) contemplated or filed concerning the cause of the medical condition for which the program has made payment.(e) An authorized entity has the responsibility to:(1) abide by program rules and policies; and(2) not discriminate against applicants or clients. Source Note: The provisions of this §365.9 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.9 Rights and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207467 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207467 03/12/2026 (a) An applicant's or client's eligibility for benefits may be modified, suspended, or denied for failing to comply with the applicant and client responsibilities listed in §61.3 of this title (relating to Client Eligibility Requirements) and §61.9(c) of this title (relating to Rights and Responsibilities).(b) A provider's participation may be modified, suspended or denied for failing to comply with the provider responsibilities listed in 1 TAC §392.605 (relating to Kidney Health Care Provider Requirements and Effective Dates) and §61.9(d) of this title.(c) A client's eligibility may be terminated for any of the following reasons:(1) failing to maintain Texas residency or to furnish evidence upon demand of residency using the criteria in §61.3 of this title;(2) failing to continue to meet the income requirements for program eligibility or to provide income data as requested by the department to determine continued program eligibility;(3) failing to reimburse the department as requested for overpayments made to the client;(4) failing to apply for medical, drug, and transportation benefits under Title XIX, Social Security Act (Medicaid);(5) becoming eligible for drug, transportation, and medical benefits under the Medicaid Program;(6) regaining native kidney function;(7) voluntarily discontinuing treatment for ESRD;(8) becoming incarcerated by or in the custody of a city, county, state, or federal entity;(9) becoming a ward of the state;(10) determination by the program that the client made a material misstatement or misrepresentation on their application or any document required to support their application;(11) determination by the program that the client submitted false claim(s); or(12) lack of a claim for benefits paid by the program on behalf of the client for a minimum period of 12 consecutive months.(d) Any action taken under subsections (a) or (c) of this section does not relieve the client, or the person(s) with legal obligation to support the client, of any financial obligation owed to the program.(e) A client must reapply for benefits when eligibility for program benefits is terminated.(f) A client who loses eligibility will not be reinstated until all outstanding debts owed to the program by the client are paid or arrangements acceptable to the program are made for payment.(g) A client whose benefits are modified or suspended, or whose eligibility is terminated, may appeal the program's decision under §61.11 of this title (relating to Rights of Appeal).(h) An enrolled provider's participation may be terminated or suspended for any of the following reasons:(1) loss of approval or exclusion from participation in the Medicare program;(2) exclusion from participation in the Medicaid program;(3) providing false or misleading information regarding any participation criteria;(4) material breach of any contract or agreement with the program;(5) filing false or fraudulent information or claims for program benefits;(6) failure to submit a payable claim to the program during a minimum period of 12 consecutive months; or(7) failure to maintain the participation criteria contained in 1 TAC §392.605.(i) Enrolled providers may appeal a termination or suspension under §61.11 of this title. Source Note: The provisions of this §365.10 adopted to be effective February 18, 2010, 35 TexReg 1220; amended to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.10 Modifications, Suspensions, Denials, and Terminations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207468 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207468 03/12/2026 (a) Administrative review.(1) If the program denies eligibility to an applicant, the program will give the applicant written notice of the denial and the applicant's right to request an administrative review of the denial within 30 days of the date of the notification.(2) If the program proposes to modify, suspend, or terminate a client's eligibility for covered benefits, the program will give the client written notice of the proposed action and the client's right to request an administrative review of the proposed action within 30 days of the date of notification.(3) If the program denies a prior-authorization or authorization request for program services, the program will give the client and provider written notice of the denial and the right of the client or provider to request an administrative review of the denial within 30 days of the date of notification.(4) If the program denies a client's or enrolled provider's claim for benefits or services, according to §61.7 of this title (relating to Claims Submission and Payment Rates) and §61.8 of this title (relating to Claim Filing Deadlines), the program will give the client or enrolled provider written notice of the denial. The client or enrolled provider has the right to request an administrative review of the denial within 30 days of the date of notification.(5) If the program denies or proposes to modify, suspend, or terminate a provider's participation in the program, the program will give the provider written notice of the proposed action and the provider's right to request an administrative review of the proposed action within 30 days of the date of notification.(6) The department establishes the program's reimbursement rates. Clients and providers may not request an administrative review of reimbursement amounts for claims that are paid in accordance with the reimbursement rates as described in §61.5 of this title (relating to Benefits and Limitations).(7) A client or provider may not request administrative review of the program's decision to restrict or categorize program services or reduce provider reimbursement amounts that are authorized by §61.5(b)(10) of this title.(8) If the program receives a written request for administrative review within 30 days of the date of the notification, the program will conduct an administrative review of the circumstances surrounding the proposed action. Within 30 days following receipt of a request for administrative review, the program will send the applicant, client, or provider written notice of:(A) the program decision, including the supporting reasons for the decision; or(B) the need for extended time to research the circumstances, including an expected date for response to the request.(9) If the program does not receive a written request for administrative review within 30 days of the date of the notification, the applicant, client, or provider is presumed to have waived the administrative review as well as access to a fair hearing, and the program's action is final.(b) Fair hearing.(1) If the applicant, client, or provider is dissatisfied with the program's decision and supporting reasons following the administrative review, the applicant, client, or provider may request a fair hearing in writing, addressed to the program, within 20 days of receipt of the administrative review decision notice.(2) If the program receives a written request for fair hearing within 20 days of receipt of the administrative review decision notice, a fair hearing will be conducted in accordance with §§1.51 - 1.55 of this title (relating to Fair Hearing Procedures).(A) The program may not terminate a client or enrolled provider's eligibility until a final decision is rendered under the department's fair hearings process.(B) The program may withhold claims payment pending final decision under the department's fair hearings process.(C) The program must release any withheld payments and reinstate participation if the final determination is in favor of the client or provider.(D) The program must not enter into, extend, or renew an agreement with a provider until a final decision is rendered under the department's fair hearings process.(3) If the applicant, client, or provider fails to request a fair hearing within the 20-day period, the applicant, client, or provider is presumed to have waived the request for a fair hearing, and the program may take final action. Source Note: The provisions of this §365.11 adopted to be effective March 27, 2016, 41 TexReg 2170; transferred effective January 15, 2022, as published in the December 31, 2021 issue of the Texas Register, 46 TexReg 9421. 1 HEALTH AND HUMAN SERVICES COMMISSION 365 KIDNEY HEALTH CARE §365.11 Rights of Appeal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222973 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Adjunctively income eligible--A determination that an applicant meets the income eligibility requirements by virtue of being able to document his or her eligibility for another program.(2) Applicant--A pregnant, breastfeeding or postpartum woman; infant; or child who is applying to receive WIC Program benefits and includes individuals who are subsequently applying after the expiration of a certification period.(3) Arms-length transaction--A good faith business transaction between parties, each acting voluntarily in his own self-interest, without necessary advantage to the other in a manner consistent with prevailing business practice.(4) Breastfeeding--The practice of feeding a mother's breastmilk to an infant on the average of at least once a day.(5) Breastfeeding woman--A woman up to one year postpartum who is breastfeeding.(6) Caretaker--An individual age 18 years or older who is related to and has custodial responsibility for a WIC Program participant during the majority of a participant's time awake each day.(7) Categorical eligibility--Eligibility for WIC Program benefits based on a person's status as a pregnant woman, breastfeeding woman, postpartum woman, infant, or child.(8) Certification--The implementation of criteria and procedures to assess and document each applicant's eligibility for the WIC Program.(9) Child--A person who has had his or her first birthday but has not yet had his or her fifth birthday.(10) Competent professional authority--An individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental foods.(11) Current income--The most recent income data and documentation available to the applicant; usually the income received by the family in the month prior to application.(12) Disqualification--The act of ending the WIC Program participation of a participant, authorized food vendor, or authorized local agency, whether as a punitive sanction or for administrative reasons.(13) Dual participation--Simultaneous participation in the WIC Program through one or more WIC clinics, or participation in the WIC Program and in the Commodity Supplemental Food Program at the same time.(14) Family--A group of related or non-related individuals who are living together as one economic unit, except that residents of a homeless facility or institution shall not be considered members of a single family.(15) Federal fiscal year--The 12-month period beginning October 1 of any calendar year and ending September 30 of the following calendar year.(16) Food instrument--A voucher, check, electronic benefits transfer card (EBT), coupon, or other document which is used by a participant to obtain supplemental foods.(17) Guardian--An individual legally appointed and responsible to look after the affairs of a minor.(18) Homeless facility--A facility which provides meal service and is a supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designated for, or ordinarily used as, a regular sleeping accommodation for human beings.(19) Homeless individual--A woman, infant, or child who lacks a fixed and regular nighttime residence; or whose primary nighttime residence is: a supervised publicly or privately operated shelter (including a welfare hotel, a congregate shelter, or a shelter for victims of domestic violence) designated to provide temporary living accommodation; an institution that provides a temporary residence for individuals intended to be institutionalized; a temporary accommodation in the residence of another individual not exceeding 365 days; or a public or private place not designated for, or ordinarily used as, a regular sleeping accommodation for human beings.(20) Infant--A person under one year of age.(21) Income--Gross income before deductions or net income after business deductions for farm or self-employed individuals.(22) Individual with disabilities--A person who has a physical or mental impairment that substantially limits one or more major life activities; a person who has a history or record of such an impairment; or a person who is perceived by others as having such an impairment. Major life activities include functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.(23) Instream migrant farmworker--A migrant farmworker who follows a route or travels from state to state seeking agricultural work and is not currently at his or her home base.(24) Licensed wholesaler or distributor--A business licensed in accordance with the Health and Safety Code, Chapter 431, the Texas Food, Drug, and Cosmetic Act, and Chapter 229 of this title (relating to Food and Drug).(25) Local agency--An entity under contract to the State agency to provide WIC Program nutrition services.(26) Migrant farmworker--An individual whose principle employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purpose of such employment, a temporary abode.(27) Minor--A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.(28) Newborn infant--An infant less than one month of age.(29) Nonprofit agency--A private agency which is exempt from income tax under the Internal Revenue Code of 1954, as amended.(30) Nutrition education--A benefit offered to WIC Program participants which consists of individual or group education sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize the relationships between nutrition and health, all in keeping with the individual's personal, cultural, and socioeconomic preferences.(31) Nutritional risk conditions--Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; other documented nutritionally-related medical conditions; dietary deficiencies that impair or endanger health; conditions that directly affect the nutritional health of a person; or conditions that predispose persons to inadequate nutritional patterns or nutritionally-related medical conditions, including, but not limited to, homelessness and migrancy.(32) Nutritional risk priorities--A system of priorities based on the participant's eligibility category (pregnant, postpartum, breastfeeding, infant, or child) and specific nutritional risk conditions with indices for identifying these conditions.(33) Nutritional risk priority system--A priority system which ranks participants according to the degree of need for supplemental foods represented by the nutritional risk conditions which the participant has. This system shall be used to prioritize new applicants and participants for eligibility for services when a local agency has reached its maximum participation level.(34) Parent--An individual's mother or father.(35) Participant--A pregnant woman, breastfeeding woman, postpartum woman, infant, or child who is receiving supplemental foods or food instruments under the WIC Program, and the breastfed infant of a participating breastfeeding woman.(36) Postpartum woman--A woman up to six months after termination of pregnancy.(37) Poverty income guidelines--The poverty income guidelines prescribed and adjusted annually by the United States Department of Health and Human Services, effective July 1 of each year.(38) Pregnant woman--A woman determined to have one or more embryos or fetuses in utero.(39) Price region--One or more geographic areas such as counties or zip codes with reasonably similar pricing of WIC-authorized foods grouped together for establishing vendor comparison groupings. Such areas may or may not be contiguous.(40) Proxy--Any person 16 years of age or older designated by a woman participant, or by a parent, guardian, or caretaker of an infant or child participant, to obtain and transact food instruments or to obtain supplemental foods on behalf of a participant. In certain circumstances, a proxy may be appointed by the state agency to transact food instruments for an infant, child, or participant under age 18 who is subject to disqualification but who would be at nutritional risk if benefits were terminated.(41) Regulations--United States Department of Agriculture regulations, 7 CFR Part 246.(42) Separate economic unit--A group of individuals who indicate that they have a source of income adequate to sustain the unit and usually purchase and prepare food separately from other individuals dwelling in the same household, or a group of individuals who intend to purchase and prepare food separately from other individuals dwelling in the same household after being certified as eligible to receive benefits from the WIC Program.(43) Shelf price--The price normally charged all customers by a vendor for an item sold by the vendor.(44) State agency--The Texas Department of Health in its role as administrator of the WIC Program.(45) Supplemental foods--Those foods containing nutrients determined to be beneficial for pregnant, breastfeeding, or postpartum women, infants, and children as prescribed by the United States Secretary of Agriculture.(46) United States Department of Agriculture (USDA)--The federal agency which funds the WIC Program.(47) Vendor account--A vendor approved by the state agency with one or more outlets.(48) Vendor agreement--The formal and legally binding agreement between the Texas Department of Health and a vendor authorized to accept and redeem WIC Program food instruments.(49) Vendor band--A comparison group of WIC Program vendors based on similar characteristics such as monthly WIC sales volume for each account or outlet, store size, location, number of checkout lanes, or store type.(50) Vendor competitive pricing--The process of comparing the cost of a standard WIC Program food package for a woman, infant, or child at an outlet to the cost of an average standard food package for the price region where the vendor is located. Vendor accounts or outlets with similar characteristics are compared within the same price region.(51) Vendor interactive training--A training session for vendors that includes a contemporaneous opportunity for questions and answers.(52) Vendor outlet--An individual store which operates and transacts WIC food instruments at a fixed location recognized by the U.S. postal system as an address, has an electric utility hook-up, is a store structure situated on a cement or pier-and-beam foundation, is not used simultaneously as a residence, has a minimum business area of 500 square feet, has clearly identifying signage, and is walk-in accessible directly from the street.(53) Verbal abuse--The verbal threat of physical abuse of local agency, state agency or vendor staff by a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant. Rude, vulgar, or generally abusive language is not verbal abuse.(54) WIC-only store--A vendor outlet that primarily transacts WIC food instruments or transacts WIC food instruments totaling a sales volume greater than its Food Stamp Program sales volume or is not authorized by the Food Stamp Program.(55) WIC program--The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) authorized by the Child Nutrition Act of 1966, §17, as amended.(56) WIC Vendor Profile Application--A form which includes demographic, financial, and other descriptive information for each vendor outlet. Source Note: The provisions of this §366.1 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective April 1, 2002, 27 TexReg 2014; amended to be effective October 1, 2003, 28 TexReg 6846; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222974 03/12/2026 (a) An individual shall be eligible to receive services when the individual receives local agency approval after meeting all of the following requirements.(1) Be determined categorically eligible.(A) If a woman, be pregnant or not more than six months postpartum if not breastfeeding or within one year postpartum if breastfeeding; or(B) If a child, be under age five.(2) Physically reside within the State.(A) The applicant shall provide documentation of residency within the local agency's approved service area.(i) The following documents shall be accepted as documentation of residency: utility bill; credit card bill; rent receipt; rental agreement; business letter from an office other than the local agency; other bills; letter from the person the applicant lives with accompanied by documentation of that person's address; voter registration card; property tax receipt; documentation by a third party such as the staff of a church, social service agency, legal-aid society, school, or a public health official, nurse, doctor, or elected public official; homeless facility documentation; or documentation of adjunctive income eligibility.(ii) If none of the documents referenced in this section exists, an applicant may provide a map indicating where the applicant lives.(iii) A homeless individual may complete a WIC Program affidavit stating he or she is homeless or is the parent, caretaker, or guardian of a homeless applicant.(B) If residency has been documented for another family member within the 60-day period prior to application, that documentation shall be sufficient for meeting the residency requirement.(3) Meet the income requirements as follows:(A) Income guidelines shall not exceed 185% of the federal poverty income guidelines.(B) Applicants shall provide documentation of the amount of current income received by each member of the family or separate economic unit within a family at each certification and subsequent certification as authorized by federal WIC regulations at 7 CFR §246.7.(C) Acceptable documentation of income are: check stubs stating current earnings; United States Internal Revenue Service form W-2 if less than 90 days old at the time of application and if reflective of current income; a signed statement from the employer; completion of WIC Program affidavit allowed in specific circumstances such as for homeless or those with no income; completion of WIC Program affidavit for self-employed individuals with no business accounting records or who are paid in cash and whose employer will not provide documentation of income; bankbook, if reflective of current income; current federal tax records; income receipt book or other accounting records if self-employed; foster child placement letter; other documentation which the local agency requests to use and which has been approved by the state agency; and the placement letter from the welfare agency legally responsible for a foster child.(i) Only one document no more than 60 days old which accurately reflects the applicant's income from each source is required, unless the applicant only receives such documentation annually, such as a Social Security Award letter.(ii) Instream migrant farmworkers and their families are required to provide documentation of meeting the income requirements only once every 12 months.(D) Certain applicants shall be deemed adjunctively income eligible as follows.(i) Applicants who are fully eligible to receive Food Stamps benefits or who are fully eligible or presumptively eligible to receive Temporary Assistance to Needy Families benefits or Medicaid benefits.(ii) Applicants who are members of families in which one other member is fully eligible or presumptively eligible to receive Temporary Assistance to Needy Families benefits.(iii) Applicants who are members of families in which a pregnant woman or infant is fully eligible or presumptively eligible to receive Medicaid benefits.(iv) Applicants shall provide documentation from one of the following categories as proof of their status as adjunctively income eligible:(I) The applicant shall provide written documentation from the other benefit program which shows current eligibility in the benefit program at the time of application to the WIC Program.(II) The applicant may grant permission for the local agency to conduct a phone or computer on-line verification from the benefit program on behalf of the client when the local agency has the capability to do so.(v) Applicants eligible to receive Food Stamp benefits shall provide documentation that the applicant himself or herself is fully eligible to receive such benefits.(vi) Applicants applying as adjunctively income eligible based on receipt of Food Stamps by a family member as head of household shall provide documentation that the person named as head of household for Food Stamps purposes is a member of the applicant's family and is fully eligible to receive such benefits.(vii) Applicants eligible to receive Temporary Assistance to Needy Families or Medicaid shall provide documentation that the applicant himself or herself is fully or presumptively eligible to receive such benefits.(viii) Applicants applying as adjunctively income eligible based on a family member's eligibility to receive Temporary Assistance to Needy Families or Medicaid shall provide documentation of the family member's receipt of such benefits and that the recipient is a member of the applicant's family.(ix) Applicants eligible for adjunctive income eligibility shall verbally declare their total gross family income or net income if self-employed.(E) Income eligibility shall be based on the total income of the family.(F) When determining an applicant's income eligibility for WIC Program services, the local agency shall determine the size of the applicant's family as follows:(i) All family members shall be counted except for individuals who qualify as a member of a separate economic unit.(I) A pregnant woman shall be counted as more than one person according to the number of children she expects to give birth to. If she is expecting one child, she shall be counted as two individuals; if she is expecting twins, she shall be counted as three individuals and so on.(II) A foster child shall be considered a separate family of one.(ii) Persons temporarily absent from the family may be counted if the following circumstances exist:(I) other members still consider the family to be the principal residence of the absent member;(II) the absence does not exceed six months;(III) the absence is for a purpose such as school, training, employment, hospitalization, or institutionalization; and(IV) the absent member continues to exercise customary family responsibilities such as income, planning, or physical care.(G) Some individuals may qualify as a separate economic unit as an exception if the unit has an adequate source of income and usually purchases and prepares food separately from other persons who live in the same dwelling or the unit intends after certification to purchase and prepare food separately from other persons who live in the same dwelling. The following shall not be certified as a separate economic unit:(i) minor children who live with their parent or parents;(ii) a child under age 18 who lives with family members who serve as managing conservators and provide more than half of the child's support, and the family members state that the child is under parental control;(iii) spouses; or(iv) two people who live together and represent themselves to the community as husband and wife.(H) Individuals who have been determined eligible for WIC Program services are not required to report changes in income during certification periods.(i) The local agency has no responsibility to monitor the continued income eligibility of the participant during the certification period.(ii) If the local agency becomes aware of changes in income during a certification period, the participant shall be reassessed for income eligibility under the rules for determining income eligibility.(4) Have one or more nutritional risk conditions as defined by the United States Department of Agriculture's national nutritional risk codes and conditions, nutritional risk priorities, and nutritional risk priority system.(A) At subsequent certification, if there is a possibility of regression in nutritional status without WIC nutrition education and supplemental foods, an applicant may be determined at nutrition risk for regression by the competent professional authority.(B) Regression shall be used only at a subsequent certification and only when no other risk condition can be determined.(C) Applicants may be certified for regression for one certification period only.(5) Be physically present at the initial WIC Program certification and the subsequent certification:(A) Exceptions may be granted in limited circumstances if approved by the competent professional authority as follows.(i) Newborn infants may be certified without being physically present if all required documentation is available, the local agency has elected to implement this practice, and the infant is physically presented to the local agency by the time the infant is six weeks of age.(ii) An applicant or parent, caretaker, or guardian of an applicant who is an individual with a disability may be certified without being physically present because he or she is unable to be physically present because of his or her disability.(I) Disability conditions which meet this standard are a medical condition that necessitates the use of medical equipment that is not easily transportable; a medical condition that requires confinement to bed rest; or a serious illness that may be exacerbated by coming into the local agency.(II) A verbal declaration by the applicant or parent, caretaker, or guardian of the applicant that the applicant has a disability and cannot be physically present is sufficient to request the exception.(iii) An infant, other than a newborn infant, or child may be certified without being physically present if being physically present would present an unreasonable barrier and the infant or child has documented ongoing health care from a health care provider other than the WIC local agency.(iv) An infant, other than a newborn infant, or child may be certified without being physically present if the infant or child was physically present at a WIC Program certification or subsequent certification within the one-year period which ended on the date the infant or child was last certified or subsequently certified and the infant or child is under the care of one or more working parents, caretakers, or guardians who verbally declare that their working status presents a barrier to bringing the infant or child to the WIC local agency.(B) Exemptions may be granted for one certification period, or for an extended period of time if the competent professional authority approves the extended period of time.(6) Provide documentation of identification:(A) The following documents shall be accepted as documentation of identification: birth certificate; hospital records, including a "crib" card, hospital wrist band, or discharge papers; baptismal certificate; marriage license; drivers license; WIC Family Identification Card; immunization card; school identification card; employment identification card; military identification card; official identification card with picture; passport or immigration records; letter from Medicaid, Food Stamps, Temporary Assistance to Needy Families, or the Supplemental Security Income Programs; indigent health care identification card; paycheck stub with imprinted name; voter registration card; identification card from another WIC local agency; Social Security card; housing or rental lease; loan papers from a bank or finance company; or property tax receipt.(B) Each local agency may designate additional documents which shall be accepted as documentation of identification with the approval of the state agency.(b) Citizenship is not a requirement for eligibility. Source Note: The provisions of this §366.3 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.3 Recipient Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222975 03/12/2026 (a) Regardless of their age, pregnant, breastfeeding, and postpartum participants may be designated as recipients of supplemental food benefits for themselves and/or their infants and/or children.(b) Regardless of their age, parents, guardians, caretakers, or foster parents of infant and/or child participants may be designated as recipients of supplemental food benefits for their infants and/or children.(c) Caretakers of a participant may be designated as recipients of supplemental food benefits for the participant if the caretakers are at least 18 years of age or older.(d) A proxy who is 16 years of age or older may be designated in writing by a WIC Program participant, or parent, caretaker, guardian of a participant, or a foster parent to act as the supplemental food benefit recipient. Each time a proxy is designated to act as the recipient, such designation shall be provided in writing to the local agency, and the proxy shall provide identification for himself or herself and present the participant's WIC Program family identification card.(e) Proxies of participants residing in a homeless facility, temporary shelter, or institution may pick up and redeem supplemental food benefits for all WIC Program participants in their respective homeless facilities, temporary shelters, or institutions. The state and local agencies shall ensure that adult participants are allowed to participate in the process of picking up and transacting food instruments to the greatest extent possible, within the institutional framework, so that they are aware of the foods prescribed for them as well as the intended benefits of such foods.(f) Recipients of supplemental food benefits shall sign the WIC Program Supplemental Information Form prior to receiving such benefits.(g) Recipients of supplemental food benefits shall provide identification at each issuance of food benefits.(h) Recipients of supplemental food benefits shall receive their benefits at the same time as they receive notification of eligibility for participation in the program. Source Note: The provisions of this §366.5 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.5 Recipients of Supplemental Food Benefits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222976 03/12/2026 (a) An applicant who has been determined eligible shall be enrolled and certified to receive WIC Program benefits as specified in this section. The certification period shall begin on the date the applicant is determined eligible.(b) A pregnant woman shall be certified to receive one set of food instruments each month for the duration of her pregnancy and is eligible to receive one set of food instruments between delivery of the baby and six weeks postpartum. The certification expiration date shall be set at six weeks after her expected delivery date.(c) A postpartum woman who is not breastfeeding shall be certified to receive one set of food instruments each month until she is six months postpartum. The certification expiration date shall be set for the day the woman is six months postpartum.(d) A breastfeeding woman shall be certified to receive one set of food instruments each month for up to one year. The certification expiration date shall be set to the last day of the month in which her infant turns one year old or she ceases breastfeeding, whichever occurs first.(e) A child one to five years of age shall be certified to receive one set of food instruments each month for a six-month period. The certification expiration date shall be set for the last day of the sixth month. For a child turning age five, the certification expiration date shall be set for the last day of the month the child turns age five.(f) An infant six months of age or older at the time of initial enrollment shall be certified to receive one set of food instruments each month for a six-month period. The certification expiration date shall be set for the last day of the sixth month.(g) An infant younger than six months of age at the time of initial enrollment shall be certified to receive one set of food instruments each month until the infant's first birthday. The certification expiration date shall be set for the day of the infant's first birthday. Source Note: The provisions of this §366.7 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; amended to be effective October 1, 2009, 34 TexReg 6120; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.7 Participant Certification Periods https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222977 03/12/2026 (a) An individual found ineligible for the WIC Program shall be notified in writing of the reason or reasons for ineligibility.(b) The notification shall inform the applicant or parent, caretaker, or guardian of a participant that he or she has a right to a fair hearing. Source Note: The provisions of this §366.9 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.9 Notification to Applicants of Ineligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222978 03/12/2026 (a) Each participant shall be notified at least 15 days prior to the expiration of each certification period that eligibility is about to expire.(b) At the time of the notice, participants who are eligible to apply for subsequent certification shall be notified of their categorical eligibility and that they must apply in order for WIC Program benefits to continue. Source Note: The provisions of this §366.11 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.11 Notification to Each Participant of Certification Expiration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222979 03/12/2026 (a) Participants whose certification in the WIC Program is terminated for program abuse, funding shortages which require that client caseloads be decreased, or a determination that the participant's income exceeds WIC Program eligibility limits, shall be notified 15 days in advance of the date of disqualification. Such notification shall be in writing and shall include the reason for disqualification and a statement of the participant's right to a fair hearing.(b) If the disqualification is the result of funding shortages as determined by the state agency, the written disqualification notice shall include the categories and priorities of participants being terminated.(c) If the participant's income is found to exceed WIC Program eligibility limits due to an assessment of income eligibility during a certification period, the participant shall be issued one month of food instruments at the time it is determined a reassessment is necessary. The participant shall be required to present current documentation of continuing income eligibility at the next visit. If the participant also is determined ineligible at the next visit, the individual shall be terminated for exceeding the income limits. Source Note: The provisions of this §366.13 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.13 Notification to Each Participant of Termination of Certification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222980 03/12/2026 (a) Standards used for determining eligibility and participation in the WIC Program shall be applied equally to all persons regardless of sex, age, disability, race, color, or national origin.(b) At the time of denial of participation or disqualification from the WIC Program, each individual shall be informed in writing of the right to a fair hearing and of the method by which a fair hearing may be requested.(1) Any individual has the right to appeal a state agency or local agency action which results in the individual's denial of participation in or termination from the WIC Program or the assessment of an administrative claim against the individual for repayment of the cash value of improperly issued benefits.(2) An individual may make an oral or written request for a fair hearing.(3) The oral or written request shall be made within 60 days of the date the state agency mails or gives the applicant or participant the written notice of adverse action.(4) Participants who appeal termination during a certification period and who appeal within 15 days of the date of notification of the termination, shall continue to receive WIC Program benefits until a hearing decision is reached or the certification period ends. An appeal after the 15-day time limit shall not result in continued benefits.(5) Applicants who are denied participation in the WIC Program at the initial certification determination or a subsequent certification determination may appeal the denial but shall not receive program benefits while the appeal is pending.(6) The hearing shall be scheduled within three weeks from the date the request is received.(7) The convenience of the appellant will be considered in the selection of the time and place of the hearing.(8) An impartial hearing official who did not participate in the decision under appeal shall be designated to conduct the hearing.(9) The appellant may be represented by an attorney or other person and shall have the right to examine, prior to the hearing, the documents and records presented in support of the decision under appeal.(10) During the hearing, the appellant shall have the opportunity to question or refute any testimony or other evidence and to confront and cross-examine witnesses.(11) The decision of the hearing official shall be based on oral and documentary evidence presented at the hearing.(12) The appellant and any designated representative shall be notified in writing of the hearing official's decision within 45 days from the date of the request for the hearing.(13) If the hearing decision is in favor of the appellant and benefits were discontinued or denied, benefits shall begin immediately.(14) If the hearing decision regarding suspension or disqualification from the WIC Program is in favor of the state agency, any benefits which were continued pending the outcome of the hearing decision shall be terminated by the local agency as soon as is administratively feasible.(15) If the hearing decision regarding the assessment of a claim against the appellant is in favor of the state agency, the state agency shall resume its efforts to collect the claim.(c) The state agency shall process complaints upon receipt from individuals who feel they have been treated unfairly or who have any other type of complaint about local agency actions or WIC Program policies and procedures.(1) Complaints may be presented either orally or in writing to the state agency.(2) The state agency shall document, to the extent possible, the name, address, and telephone number of the complainant; the specific location and name of the entity delivering services; the nature of the incident or action that led to the complaint; the names, titles, and business addresses of persons who may have knowledge of the complaint; and the date(s) during which the alleged actions occurred, or if continuing, the duration of such actions.(3) The identity of every complainant shall be kept confidential except to the extent necessary to carry out the investigation of the complaint.(4) The state agency shall immediately notify the local agency that a complaint has been filed and shall obtain information about the alleged actions unless the complaint alleges civil rights discrimination.(5) The state agency shall contact the complainant to relay what action has been taken, if any, or clarify any related policies, rules, or regulations of the WIC Program. Source Note: The provisions of this §366.15 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.15 Applicant and Participant Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222981 03/12/2026 (a) Participants and parents, guardians, client-designated proxies, state agency-appointed proxies, or caretakers of participants identified and documented as having abused the WIC Program shall be sanctioned.(b) If the state agency or the Office of Inspector General, Health and Human Services Commission, determines that a participant or parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant has received benefits unlawfully due to WIC Program abuse, including but not limited to dual participation, the matter may be referred for criminal prosecution.(c) Program violations means any intentional act of an applicant, participant, parent, guardian or caretaker of an infant or child applicant or participant, client-designated proxy, or state agency-designated proxy that violates Federal or State statutes, regulations, rules, policies or procedures governing the WIC Program. Violations include, but are not limited to, intentionally making a false or misleading statement; intentionally misrepresenting, concealing, or withholding facts to obtain benefits; exchanging food instruments or food for cash, credit, non-food items, or unauthorized foods, including foods in excess of that authorized; threatening to harm or physically harming local agency, vendor or state agency staff; and simultaneous participation in the Program in one or more than one WIC clinic or participation in the Commodity Supplemental Food Program during the same period of time.(d) The state agency, or local agency as directed by the state agency, shall initiate sanctions which may include disqualification from the Program for up to one year.(e) Upon a final determination by the Office of the Inspector General, Health and Human Services Commission, that a program violation has occurred, the following mandatory disqualifications shall apply.(1) For an offense where a claim of $100 or more is assessed, the participant shall be disqualified for one year.(2) For an offense where a participant illegally received benefits at more than one WIC office and the state agency or the Office of the Inspector General, Health and Human Services Commission, assesses a claim for such dual participation, the participant shall be disqualified for one year.(3) When the state agency or the Office of the Inspector General, Health and Human Services Commission, assesses a second or subsequent claim of any amount, the participant shall be disqualified for one year.(f) If after finding that a program violation has occurred, the Office of Inspector General, Health and Human Services Commission, further determines that the program violation does not warrant a one year mandatory disqualification, the following sanctions shall apply.(1) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant exchanges food instruments or food for cash or credit, the participant shall be disqualified for a period of six months for a first offense and 12 months for a second or subsequent offense.(2) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant exchanges food instruments or food for firearms, explosives, ammunition, controlled substances, alcohol, or tobacco products, the participant shall be disqualified for a period of six months for a first offense and 12 months for a second or subsequent offense.(3) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant exchanges food instruments or food for non-food items not listed in paragraph (2) of this subsection, the participant shall receive a warning for the first offense and shall be disqualified for a period of 12 months for a second or subsequent offense.(4) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant exchanges food instruments or food for unauthorized food including foods in excess of that authorized, the participant shall receive a warning for the first offense to and shall be disqualified for a period of 12 months for a second or subsequent offense.(5) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant threatens to harm local agency, vendor, or state agency staff, the participant shall be disqualified for a period of six months for a first offense and 12 months for a second or subsequent offense.(6) When a participant or a parent, guardian, client-designated proxy, state agency-appointed proxy, or caretaker of a participant physically harms local agency, vendor, or state agency staff, the participant shall be disqualified for a period of 12 months for a first offense and 12 months for a second or subsequent offense.(g) Exceptions to disqualification:(1) The state agency may decide not to impose a disqualification if, for violations which resulted in a claim assessed by the state agency against the participant, parent, guardian, client designated proxy, state agency-appointed proxy, or caretaker of a participant, full restitution is made within 30 days of receipt of a letter demanding repayment or a repayment schedule is agreed on.(2) The state agency may permit a disqualified participant to reapply for the program before the end of a disqualification period if, in the case of a violation where a claim was assessed by the state agency against the participant or parent, guardian, client-designated proxy, state-agency appointed proxy, or caretaker of a participant, full restitution is made or a repayment schedule is agreed upon.(3) The state agency may issue a waiver to appoint a person as a special proxy to transact food instruments and receive nutrition education for an infant, child, or participant under age 18 when the infant, child, or participant under age 18 will incur a serious health risk from the suspension of benefits.(h) The state agency may attempt to recover, in cash, the value of the benefits received by a participant or the parent, guardian, client-designated proxy, state agency-appointed proxy or caretaker of a participant as a result of participant abuse. The state agency may request and authorize the Office of the Inspector General, Health and Human Services Commission, to perform this recovery on its behalf.(1) The state agency or the Office of the Inspector General, Health and Human Services Commission, may determine the amount of the benefits improperly received by a participant through an independent review of local agency records and such other procedures as the state agency considers necessary under the specific circumstances. The state agency may request and authorize the Office of the Inspector General, Health and Human Services Commission, to perform this recovery on its behalf.(2) In cases involving criminal prosecutions for violations of law, repayment of cash value of benefits improperly received may become a part of any restitution agreement with the prosecutor and approved by the court. In such cases, the participant shall not have the right to a fair hearing by the department.(3) In cases involving an administrative claim but no criminal prosecution, the Office of the Inspector General, Health and Human Services Commission, shall notify the participant or parent, caretaker, or guardian of a participant in writing that a financial claim has been established and shall request repayment of an amount equal to the value of the benefits improperly received. The written notification shall include the reasons for the claim, the value of the benefits improperly received, the participant's right to a fair hearing, and shall state that the participant or parent, caretaker, or guardian of a participant may be subject to disqualification.(i) Collection of a financial claim assessed against a participant by offset of future benefits is not authorized. Source Note: The provisions of this §366.17 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective April 1, 2002, 27 TexReg 2014; amended to be effective June 4, 2006, 31 TexReg 4428; amended to be effective November 30, 2008, 33 TexReg 9505; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.17 Participant Fraud and Abuse https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222982 03/12/2026 (a) Selection of a local agency to provide WIC Program services will be based on the local agency priority system as follows:(1) A public or private nonprofit health agency which can provide ongoing routine pediatric and obstetric care or administrative services shall receive first priority consideration.(2) A public or private nonprofit health or human service agency which will enter into a written agreement with another agency for either ongoing pediatric and obstetric care or administrative services shall receive second priority consideration.(3) A public or private nonprofit health agency which will enter into a written agreement with private physicians licensed by the state to provide ongoing pediatric and obstetric care to a specific category of participants (women, infants, or children) shall receive third priority consideration.(4) A public or private nonprofit human service agency which will enter into a written agreement with private physicians licensed by the state to provide ongoing routine pediatric and obstetric care shall receive fourth priority consideration.(5) A public or private nonprofit human service agency which will provide ongoing routine pediatric and obstetric care through referral to a health provider shall receive fifth priority consideration.(6) No WIC Program funds shall be expended to reimburse private physicians for the health services performed.(b) The state agency shall establish an affirmative action plan each year to rank order each county's relative need for WIC Program services based on the total number of potentially eligible persons in each county.(c) All WIC Program initiation and expansion shall be executed utilizing a request for proposal (RFP) in accordance with state agency policy, state law, USDA Food and Nutrition Service Instruction 802-1, and the state agency's approved affirmative action plan under one of the following conditions:(1) the state agency determines it is in the best interests of the state to initiate an open competitive statewide RFP;(2) an existing WIC Program local agency is either disqualified as a provider of WIC Program services or does not wish to continue as a local agency;(3) a state agency health services region wishes to transfer direct WIC Program services to a local agency; or(4) a prospective agency satisfactorily documents to the state agency that a specific geographical area is underserved and the current WIC local agency providing services in that area is unable to provide services to that geographical area and declines to develop a collaborative effort to deliver services to meet the documented unmet need.(d) The state agency shall evaluate proposals to serve as a WIC Program local agency submitted in response to an RFP.(e) The state agency shall advise respondent agencies of the status of their applications to provide WIC Program services in accordance with the schedule of events in the public notice and the RFP.(f) In the event of an emergency or unexpected interruption of WIC Program services, the state agency WIC Director may waive any or all parts of the application process if necessary to ensure uninterrupted delivery of WIC services in a geographic area or areas. Source Note: The provisions of this §366.19 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective June 4, 2006, 31 TexReg 4428; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.19 Selection of a Local Agency as a WIC Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222983 03/12/2026 (a) Criteria for approving products for inclusion in the WIC Program food package are based on federal regulations, packaging, cost, cultural acceptability, and nutritive value.(b) A product shall meet the federal regulations governing the WIC Program food package in order to be considered for approval through the WIC Program.(c) The state agency may restrict the number of brands and types of any products in order to contain the cost of the food package and minimize the confusion for WIC participants. The state agency is not obligated to authorize every available food that meets the federal requirements.(d) The state agency shall review the WIC Program list of allowable foods annually to determine the need for adding or deleting food products. If the state agency determines that the list of allowable foods should be changed, the state agency shall notify the appropriate manufacturers of that intent.(e) The state agency may restrict the size of packages and types of containers of any products for any food type including limiting package size and container type within brands of products in order to contain the cost of the food package and minimize the confusion for WIC participant.(f) A product for any food type shall be available for retail purchase in Texas on or before the effective date of the approved food list or it will not be considered by the state agency for authorization.(g) The product form and marketing approach for any product for any food type shall be consistent with the promotion of good nutrition and education.(h) The state agency reserves the right to solicit rebates for any eligible foods from manufacturers through a competitive bid process.(i) The state agency reserves the right to determine the numbers and types of foods within a food type to be authorized.(j) In determining the number of brands and types of any products to be approved, the state agency may consider consumer, cultural, and/or ethnic acceptability, and suitability for children.(k) Products having similar names and package designs shall not be approved if the similarity in name and/or packaging would cause substantial confusion for vendors and/or participants.(l) Allowable foods may include: milk; cheese; eggs; tofu; soy-based beverages; breakfast cereal; juice; beans; peas; lentils; peanut butter; tuna; salmon; mackerel; sardines; fruits; vegetables; whole wheat bread; whole grain bread; brown rice; bulgur; oatmeal; whole grain barley; corn or whole wheat tortillas; infant cereal; infant fruits; infant vegetables; infant meats; infant formula; exempt infant formula; and WIC-eligible medical foods. Source Note: The provisions of this §366.21 adopted to be effective August 5, 2001, 26 TexReg 5642; amended to be effective April 1, 2002, 27 TexReg 2014; amended to be effective October 1, 2003, 28 TexReg 3495; amended to be effective June 4, 2006, 31 TexReg 4428; amended to be effective October 1, 2009, 34 TexReg 6120; transferred effective December 13, 2024, as published in the November 15, 2024, issue of the Texas Register, 49 TexReg 9329. 1 HEALTH AND HUMAN SERVICES COMMISSION 366 SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR WOMEN, INFANTS, AND CHILDREN (WIC) §366.21 Selection of Allowable WIC Program Supplemental Foods https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205520 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--(A) physical abuse;(B) sexual abuse; or(C) verbal or emotional abuse.(2) Actively involved person--An individual who has significant, ongoing, and supportive involvement with a designated resident, as determined by the SPT based on the individual's:(A) observed interactions with the designated resident;(B) availability to the designated resident for assistance or support when needed; and(C) knowledge of, sensitivity to, and advocacy for the designated resident's needs, preferences, values, and beliefs.(3) Acute care hospital--A health care facility in which an individual receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition, or recovery from surgery and:(A) may include a long-term acute care hospital, an emergency room within an acute care hospital, or an inpatient rehabilitation hospital; and(B) does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.(4) Alleged perpetrator--An individual alleged to have committed an act of abuse, neglect, or exploitation of a designated resident.(5) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b).(6) Calendar day--Any day, including weekends and holidays.(7) CFR--Code of Federal Regulations.(8) Chemical restraint--A medication used to control a designated resident's behavior or to restrict the designated resident's freedom of movement that is not a standard treatment for the designated resident's medical or psychological condition.(9) CMS--Centers for Medicare & Medicaid Services.(10) Competitive employment--Employment in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting and that pays a designated resident:(A) at or above minimum wage; and(B) not less than the customary wage and level of benefits paid by an employer to individuals who do not have disabilities performing the same or similar work.(11) Contract--A written agreement between HHSC and a service provider agency that obligates the service provider agency to provide a service for a designated resident in exchange for payment from HHSC.(12) Contract area--A geographic area composed of one or more Texas counties as identified in the contract to be served by a service provider agency.(13) Controlling person--An individual who:(A) has a controlling ownership interest in a service provider agency;(B) is a managing employee of a service provider agency;(C) has been delegated the authority to obligate or act on behalf of a service provider agency;(D) is an officer or director of a corporation that is a service provider agency;(E) is a partner in a partnership that is a service provider agency;(F) is a member or manager in a limited liability company that is a service provider agency;(G) is a trustee or trust manager of a trust that is a service provider agency;(H) because of a personal, familial, or other relationship with a service provider agency, is in a position of actual control or authority with respect to the service provider agency, regardless of the individual's title.(14) Critical incident--An event that:(A) involves a designated resident;(B) occurs during the provision of IHSS; and(C) may involve:(i) a serious injury;(ii) a medication error;(iii) a restraint;(iv) an emergency room visit, hospitalization, or call to 911 for a medical or psychiatric emergency;(v) an arrest;(vi) an unauthorized departure;(vii) an allegation or confirmation of abuse, neglect, or exploitation; or(viii) a death.(15) Day Activity and Health Services program--A program defined in Texas Human Resources Code §103.003(2).(16) DD--Developmental disability. A disability that meets the criteria described in the definition of "persons with related conditions" in 42 CFR §435.1010.(17) Designated resident--An individual:(A) whose PE or resident review is positive for ID or DD;(B) who is at least 21 years of age;(C) who is a Medicaid recipient; and(D) who is a resident or has transitioned to the community from a NF within the previous 365 days.(18) DFPS--The Texas Department of Family and Protective Services.(19) Exploitation--The illegal or improper act or process of using, or attempting to use, a designated resident or the resources of a designated resident for monetary or personal benefit, profit, or gain.(20) Habilitation coordination--Assistance for a designated resident residing in a NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the designated resident and LAR.(21) Habilitation coordinator--An employee of a LIDDA who provides habilitation coordination.(22) HHSC--The Texas Health and Human Services Commission.(23) HSP--Habilitation service plan, as defined in §303.102 of this title (relating to Definitions).(24) ID--Intellectual disability, as defined in 42 CFR §483.102(b)(3)(i).(25) IDD--Intellectual and developmental disability.(26) IDD PASRR Handbook--Intellectual and Developmental Disability Preadmission Screening and Resident Review Handbook.(27) IDT--Interdisciplinary team, as defined in §303.102 of this title.(28) IHSS--IDD habilitative specialized services, described in §368.201 of this chapter (relating to Description of IHSS).(29) Individual service provider--An individual, who may be an employee or contractor of the service provider agency, who directly provides an IHSS for a designated resident.(30) Initial plan of care--The first plan of care for a designated resident developed after an initial IDT meeting.(31) LAR--Legally authorized representative. An individual authorized by law to act on behalf of a designated resident about a matter described in this chapter and may include the legal guardian or surrogate decision maker.(32) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.(33) Local service area--A geographic area, composed of one or more Texas counties as identified in the LIDDA's performance contract to be served by a LIDDA.(34) Mechanical restraint--A mechanical device, material, or equipment used to control a designated resident's behavior by restricting the ability of the designated resident to freely move part or all of the designated resident's body.(35) MI--Mental illness. Serious mental illness, as defined in 42 CFR §483.102(b)(1).(36) Neglect--A negligent act or omission that caused physical or emotional injury or death to a designated resident or placed a designated resident at risk of physical or emotional injury or death.(37) NF--Nursing facility. A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code Chapter 242.(38) NF baseline care plan--A baseline care plan developed in accordance with 26 TAC §554.802(a) (relating to Comprehensive Person-Centered Care Planning).(39) NF comprehensive care plan--A comprehensive care plan, defined in 26 TAC §554.2703(3) (relating to Definitions).(40) PASRR--Preadmission screening and resident review. A federal requirement in 42 CFR Part 483, Subpart C.(41) PE--PASRR level II evaluation. A face-to-face evaluation:(A) of an individual seeking admission to a NF who is suspected of having MI, ID, or DD; and(B) performed by a LIDDA, local mental health authority, or local behavioral health authority to determine if the individual has MI, ID, or DD and, if so, to:(i) assess the individual's need for care in a NF;(ii) assess the individual's need for specialized services; and(iii) identify alternate placement options.(42) Physical abuse--Any of the following:(A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to a designated resident or placed a designated resident at risk of physical injury or death;(B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to a designated resident;(C) the use of a restraint on a designated resident not in compliance with federal and state laws and rules; or(D) seclusion.(43) Physical restraint--Any manual method used to control a designated resident's behavior, except for physical guidance or prompting of brief duration that a designated resident does not resist, that restricts:(A) the free movement or normal functioning of all or a part of the designated resident's body; or(B) normal access by a designated resident to a portion of the designated resident's body.(44) Plan of care--A written plan that includes:(A) the IHSS required by the NF baseline or comprehensive care plan;(B) the frequency, amount, and duration of each IHSS to be provided for the designated resident during a plan year; and(C) the services and supports to be provided for the designated resident through resources other than PASRR.(45) Plan year--A 12-month period starting on the date of the initial or annual IDT meeting. A revised or transfer plan of care does not change the begin or end date of a plan year.(46) Renewal plan of care--A plan of care developed for a designated resident in accordance with §368.302(a) of this chapter (relating to Renewal and Revision of a Plan of Care).(47) Restraint--Any of the following:(A) a physical restraint;(B) a mechanical restraint; or(C) a chemical restraint.(48) Revised plan of care--An initial or renewal plan of care that is revised during a plan year in accordance with §368.302(b) of this chapter to add a new IHSS or change the frequency, amount, or duration of an existing IHSS.(49) Seclusion--The involuntary placement of a designated resident alone in an area from which the designated resident is prevented from leaving.(50) Service provider agency--An entity that has a contract with HHSC to provide IHSS for a designated resident.(51) Sexual abuse--Any of the following:(A) sexual exploitation of a designated resident;(B) non-consensual or unwelcomed sexual activity with a designated resident; or(C) consensual sexual activity between a designated resident and an individual service provider, staff member, volunteer, or controlling person, unless a consensual sexual relationship with an adult designated resident existed before the individual service provider, staff member, volunteer, or controlling person became an individual service provider, staff member, volunteer, or controlling person.(52) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent.(53) Sexual exploitation--A pattern, practice, or scheme of conduct against a designated resident that can reasonably be construed as being for the purposes of sexual arousal or gratification of any individual:(A) which may include sexual contact; and(B) does not include obtaining information about a designated resident's sexual history within standard accepted clinical practice.(54) SPT--Service planning team, as defined in §303.102 of this title.(55) Staff member--An employee or contractor of a service provider agency.(56) Surrogate decision maker--An actively involved person who has been identified by an IDT in accordance with Texas Health and Safety Code §313.004 and who is available and willing to consent to medical treatment on behalf of the designated resident.(57) TAC--Texas Administrative Code.(58) TMHP--Texas Medicaid and Healthcare Partnership.(59) Transfer plan of care--An initial or renewal plan of care that is revised during a plan year in accordance with §368.501 of this chapter (relating to Transfer between Service Provider Agencies) to change the service provider agency selected by the designated resident or LAR.(60) Transition plan--A plan, defined in §303.102 of this title.(61) Vendor hold--A temporary suspension of payments that are due to a service provider agency under a contract.(62) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures:(A) to:(i) harass, intimidate, humiliate, or degrade a designated resident; or(ii) threaten a designated resident with physical or emotional harm; and(B) that:(i) results in observable distress or harm to the designated resident; or(ii) is of such a serious nature that a reasonable individual would consider it harmful or a cause of distress.(63) Volunteer--An individual who works for a service provider agency without compensation, other than reimbursement for actual expenses. Source Note: The provisions of this §368.101 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES A GENERAL PROVISIONS §368.101 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205521 03/12/2026 A service provider agency may request an administrative hearing in accordance with 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) if HHSC takes or proposes to take one or more of the following actions or sanctions:(1) vendor hold;(2) contract termination;(3) recoupment of payments made to the service provider agency; or(4) denial of the service provider agency's request for payment. Source Note: The provisions of this §368.102 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES A GENERAL PROVISIONS §368.102 Right to Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205522 03/12/2026 (a) IHSS are Medicaid state plan services that are authorized by HHSC prior to delivery.(b) IHSS listed in this subsection are selected for inclusion in a designated resident's plan of care to help the designated resident partially or fully attain, maintain, improve, or slow or prevent a decline in skills that were not fully acquired because of a congenital, genetic, or early acquired health condition.(1) Behavioral support:(A) is assistance provided for a designated resident to increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the designated resident's interpersonal relationships across all service and social settings;(B) is delivered in the NF or in a community setting; and(C) consists of:(i) assessing the behaviors to be targeted in an appropriate behavior support plan and analyzing those assessment findings;(ii) developing and getting the designated resident's or LAR's written consent to an individualized behavior support plan that reduces or eliminates the target behaviors, assisting the designated resident in achieving the outcomes identified in the HSP;(iii) training and consulting with the LAR, family members, NF staff, other support providers, and the designated resident about the purpose, objectives, and methods of the behavior support plan;(iv) documenting and implementing the behavior support plan or revisions to the behavior support plan;(v) monitoring and evaluating the success of the behavior support plan implementation;(vi) revising the behavior support plan as necessary; and(vii) participating in SPT and IDT meetings.(2) Day habilitation:(A) is assistance provided for a designated resident to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to successfully and actively participate in all service and social settings;(B) is delivered in a setting other than the designated resident's NF;(C) does not include services provided under the Day Activity and Health Services program;(D) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 CFR §483.24; and(E) consists of:(i) individualized activities consistent with achieving the outcomes identified in a designated resident's HSP to attain, learn, maintain, or improve skills;(ii) activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;(iii) services in a group setting at a location other than a designated resident's NF for up to five days per week, six hours per day, on a regularly scheduled basis;(iv) personal assistance for a designated resident who cannot manage personal care needs during the day habilitation activity;(v) transportation between the NF and the day habilitation site, as well as during the day habilitation activity necessary for a designated resident's participation in day habilitation activities; and(vi) participating in SPT and IDT meetings.(3) Employment assistance:(A) is assistance provided for a designated resident who requires intensive help locating competitive employment in the community; and(B) consists of:(i) identifying a designated resident's employment preferences, job skills, and requirements for a work setting and work conditions;(ii) locating prospective employers offering employment compatible with a designated resident's identified preferences, skills, and requirements;(iii) contacting prospective employers on a designated resident's behalf and negotiating the designated resident's employment;(iv) transporting a designated resident between the NF and the site where employment assistance services are provided and as necessary to help the designated resident locate competitive employment in the community; and(v) participating in SPT and IDT meetings.(4) Independent living skills training:(A) is assistance provided for a designated resident that is consistent with the designated resident's HSP;(B) is provided in the designated resident's NF or in a community setting;(C) includes expanded interactions, skills training activities, and programs of greater intensity or frequency beyond those a NF is required to provide by 42 CFR §483.24; and(D) consists of:(i) habilitation and support activities that foster improvement of or facilitate a designated resident's ability to attain, learn, maintain, or improve functional living skills and other daily living activities;(ii) activities that help preserve the designated resident's bond with family members;(iii) activities that foster inclusion in community activities generally attended by people without disabilities;(iv) transportation to facilitate a designated resident's employment opportunities and participation in community activities, and between the designated resident's NF and a community setting; and(v) participating in SPT and IDT meetings.(5) Supported employment:(A) is assistance provided for a designated resident:(i) who requires intensive, ongoing support to be self-employed, work from the designated resident's residence, or work in an integrated community setting at which people without disabilities are employed; and(ii) to sustain competitive employment in an integrated community setting; and(B) consists of:(i) making employment adaptations, supervising, and providing training related to the designated resident's assessed needs;(ii) transporting the designated resident between the NF and the site where the supported employment services are provided and as necessary to support the designated resident to be self-employed, work from the designated resident's residence, or work in an integrated community setting; and(iii) participating in SPT and IDT meetings. Source Note: The provisions of this §368.201 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES B SERVICES DESCRIPTION AND INITIATION §368.201 Description of IHSS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205523 03/12/2026 (a) A designated resident is eligible for IHSS funded by Medicaid if the designated resident:(1) resides in a NF; and(2) requires the provision of at least one IHSS.(b) A designated resident is eligible to receive employment assistance or supported employment services if they are not available for the designated resident through a program funded under the Rehabilitation Act of 1973. Source Note: The provisions of this §368.202 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES B SERVICES DESCRIPTION AND INITIATION §368.202 Eligibility Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205524 03/12/2026 (a) The habilitation coordinator must:(1) provide the designated resident or LAR the names and contact information of all service provider agencies that are in the contract area of the designated resident's NF, no later than the initial IDT meeting;(2) arrange for phone calls or meetings with the potential service provider agencies as requested by the designated resident or LAR;(3) review the HSP developed in accordance with §368.204(b)(3) of this subchapter (relating to Process for Service Initiation) with potential service provider agencies as requested by the designated resident or LAR;(4) ensure the designated resident's or LAR's choice of service provider agency is documented on the Documentation of Provider Choice Form and signed by the designated resident or LAR; and(5) notify the chosen service provider agency in writing and provide a copy of the designated resident's HSP and NF baseline or comprehensive care plan, whichever is most current, within three business days after the habilitation coordinator is notified of selection by the designated resident or LAR.(b) If the designated resident or LAR has not selected a service provider agency within 14 calendar days of the initial IDT meeting, the SPT collectively selects the service provider agency it believes can best meet the designated resident's needs. The SPT must actively involve the designated resident in the decision-making process to the extent possible. Source Note: The provisions of this §368.203 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES B SERVICES DESCRIPTION AND INITIATION §368.203 Process for Provider Selection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205525 03/12/2026 (a) A LIDDA must comply with §303.302 of this title (relating to LIDDA, LMHA, and LBHA Responsibilities Related to the PASRR Process).(b) At the initial IDT meeting, the habilitation coordinator, in conjunction with the IDT, must:(1) review the IHSS recommended on the PE and identify which IHSS:(A) the designated resident, or LAR on the designated resident's behalf, wants to receive; and(B) the IDT agrees the designated resident should receive;(2) verify that identified IHSS are required by the designated resident's NF baseline or comprehensive care plan; and(3) develop an HSP in accordance with §303.601(b)(2) of this title (relating to Habilitation Coordination for a Designated Resident).(c) Within seven calendar days of receiving the designated resident's NF baseline or comprehensive care plan in accordance with §368.203(a)(5) of this subchapter (relating to Process for Provider Selection), the service provider agency must:(1) ensure an individual service provider who meets the qualifications in §368.406 of this chapter (relating to Provider Qualifications) completes an assessment for each IHSS on the NF baseline or comprehensive care plan, using HHSC forms; and(2) send each assessment to the habilitation coordinator.(d) The habilitation coordinator must:(1) within 14 calendar days of sending the designated resident's NF baseline or comprehensive care plan to the service provider agency, convene an SPT meeting to:(A) discuss the assessments and recommended frequency, amount, and duration for each IHSS for which an assessment was conducted;(B) develop an initial plan of care, using HHSC forms, in accordance with §368.301 of this chapter (relating to Plan of Care) and HHSC's IDD PASRR Handbook; and(C) revise the HSP in accordance with §368.302 of this chapter (relating to Renewal and Revision of a Plan of Care);(2) ensure all required parties sign and date the initial plan of care in accordance with form instructions; and(3) submit the initial plan of care, including all assessments, to HHSC within three business days after the SPT meeting and:(A) retain the original initial plan of care in the designated resident's LIDDA record; and(B) send a copy of the initial plan of care to each member of the SPT.(e) If HHSC denies an IHSS for a designated resident, HHSC implements the fair hearings process in accordance with §368.602 of this chapter (relating to Fair Hearings).(f) If HHSC authorizes an IHSS for a designated resident, the service provider agency must initiate IHSS in accordance with §368.401 of this chapter (relating to Service Initiation and Delivery). Source Note: The provisions of this §368.204 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES B SERVICES DESCRIPTION AND INITIATION §368.204 Process for Service Initiation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205526 03/12/2026 (a) A plan of care must be developed for each designated resident in accordance with §368.204 of this chapter (relating to Process for Service Initiation) and reviewed and revised for each designated resident whenever the designated resident's needs for services and supports change, but no less than annually, in accordance with §368.302 of this subchapter (relating to Renewal and Revision of a Plan of Care).(b) A plan of care must specify the frequency, amount, and duration of each IHSS to be provided for a designated resident, as well as non-PASRR services and supports to be provided during the plan year. Each service in the plan of care must:(1) be necessary to help the designated resident partially or fully attain, maintain or improve skills, or slow or prevent a decline in skills;(2) not be available for the designated resident through any other source, including other state plan services, governmental programs, private insurance, or other resources; and(3) be supported by at least one outcome in the HSP as necessary to enable community integration and maximize independence.(c) Before submission to HHSC, the required SPT members must sign and date a designated resident's plan of care, indicating agreement that the services recommended in the plan of care meet the requirements of subsection (b) of this section and will be delivered by the service provider agency.(d) HHSC reviews a submitted initial, revised, or renewal plan of care and authorizes or denies the IHSS on the plan of care. Source Note: The provisions of this §368.301 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES C SERVICE AUTHORIZATIONS §368.301 Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205527 03/12/2026 (a) Renewal of the plan of care. At least annually, and no earlier than 334 calendar days after the date of the previous initial or annual SPT meeting, the SPT must:(1) review the HSP and plan of care to determine whether the outcomes and IHSS previously identified remain relevant; and(2) determine whether the current assessment accurately reflects the designated resident's need for an IHSS in the identified frequency, amount, and duration, or if an IHSS requires a new assessment.(b) Revisions to the plan of care. The habilitation coordinator, in collaboration with the SPT, initiates revisions to the HSP and plan of care at any time during the plan year in response to changes in the designated resident's needs and identified outcomes.(1) Any SPT member may ask the habilitation coordinator to convene an update SPT meeting to discuss whether a designated resident's plan of care needs to be revised to add a new IHSS or change the frequency, amount, or duration of an existing IHSS.(2) The habilitation coordinator must convene an update SPT meeting within seven calendar days after learning of the need to revise the designated resident's HSP or plan of care.(c) Assessments. If the SPT agrees to add a new IHSS to the plan of care or determines an IHSS requires a new assessment in accordance with subsections (a) and (b) of this section, the service provider agency must, within seven calendar days after the SPT meeting:(1) conduct an assessment for a recommended IHSS to determine the frequency, amount, and duration of the IHSS; and(2) send the assessment to the habilitation coordinator.(d) Submission to HHSC. The habilitation coordinator must:(1) submit annual renewals and necessary revisions of the plan of care to HHSC for authorization within ten calendar days after an SPT meeting; and(2) retain documentation in the designated resident's LIDDA record.(e) Sending documents to the SPT. The habilitation coordinator must send each member of the SPT a copy of the revised HSP and current plan of care within ten calendar days after the HSP or plan of care is updated or renewed.(f) Service delivery. If a designated resident's SPT determines a new IHSS or change in the frequency, amount, or duration of an existing service is needed, the plan of care must be revised or renewed in accordance with this section before the service provider agency delivers a new or increased service. Source Note: The provisions of this §368.302 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES C SERVICE AUTHORIZATIONS §368.302 Renewal and Revision of a Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205528 03/12/2026 (a) The service provider agency must serve each designated resident who selects the service provider agency unless:(1) enrollment has reached its service capacity identified in the contract; or(2) HHSC approves the service provider agency's request to waive this requirement.(b) The service provider agency must ensure the delivery of all IHSS in accordance with an implementation plan that, for each IHSS on the designated resident's plan of care, includes:(1) a list of the designated resident's outcomes identified in the HSP that will be addressed using IHSS;(2) specific objectives to address the outcomes required by paragraph (1) of this subsection that are:(A) observable, measurable, and outcome-oriented; and(B) derived from assessments;(3) a target date for completion of each objective;(4) the frequency, amount, and duration of IHSS needed to complete each objective; and(5) the signature and date of the designated resident, LAR, and service provider agency.(c) The service provider agency must develop an implementation plan for each IHSS within 14 calendar days after the initial, annual, or any other SPT meeting during which changes are made and send the implementation plan to the habilitation coordinator upon completion.(d) Annually, and when an IHSS is added or changed, the service provider agency must review each implementation plan and make any necessary updates.(e) Before delivering an IHSS, the service provider agency must:(1) receive authorization from HHSC to deliver the IHSS during the plan year in accordance with the current plan of care; and(2) confirm that the designated resident is a Medicaid recipient.(f) The service provider agency must initiate an IHSS within five calendar days after the service authorization has been added to Medicaid Eligibility Service Authorization Verification. Source Note: The provisions of this §368.401 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.401 Service Initiation and Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223265 03/12/2026 (a) The service provider agency must comply with:(1) all applicable state and federal laws and rules; and(2) HHSC Information Letters and HHSC Provider Letters regarding PASRR found on the HHSC website.(b) The service provider agency must comply with §303.602 of this title (relating to Service Planning Team Responsibilities Related to Specialized Services).(c) At least one individual service provider or representative from the service provider agency must participate in a designated resident's SPT meetings.(d) The service provider agency must ensure that a designated resident's progress or lack of progress toward achieving an identified outcome is accurately and consistently documented in observable or measurable terms in accordance with the IDD Habilitative Specialized Services Billing Guidelines, and that such documentation is provided to the habilitation coordinator as requested.(e) The service provider agency must inform the habilitation coordinator and NF within one business day of a circumstance or event that occurs in a designated resident's life or a change to a designated resident's condition that may affect the provision of services for the designated resident.(f) If the designated resident experiences any significant change in behavioral or medical condition while in the service provider agency's care, the service provider agency must notify:(1) the NF immediately; and(2) the habilitation coordinator within one business day.(g) The service provider agency must promote the independence and community integration of designated residents receiving IHSS.(h) The service provider agency, its staff members, and individual service providers must cooperate with LIDDA and NF staff.(i) The service provider agency must maintain a separate record for each designated resident served. The designated resident's record must include:(1) a copy of the current HSP and individual profile form;(2) a copy of the current plan of care;(3) an implementation plan for each IHSS that appears on the plan of care;(4) a current assessment for each IHSS on the plan of care;(5) a copy of the NF baseline or comprehensive care plan obtained from the habilitation coordinator, whichever is most current;(6) documentation that describes:(A) the designated resident's progress or lack of progress toward achieving the outcomes and objectives identified in the implementation plan; and(B) any changes to a designated resident's personal goals, condition, abilities, or needs; and(7) a behavior support plan, if one has been developed.(j) The service provider agency must comply with applicable federal and state laws and rules regarding confidentiality of information regarding a designated resident.(k) The service provider agency must ensure that all billing is correct and documented in accordance with the IDD Habilitative Specialized Services Billing Guidelines. Source Note: The provisions of this §368.402 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.402 Service Provider Agency Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205530 03/12/2026 (a) The service provider agency must assist the designated resident or LAR in exercising the same rights and responsibilities exercised by people without disabilities.(b) The service provider agency must protect and promote the following rights of the designated resident:(1) to be informed of requirements for participation as described in §368.601(c) of this chapter (relating to Termination and Suspension of IHSS);(2) to be informed of the designated resident's plan of care and implementation plan, including any restrictions affecting the designated resident's rights;(3) to participate in decisions and be informed of the reasons for decisions regarding plans for initiation, transfer, denial, suspension, or termination of IHSS;(4) to be informed about the designated resident's own physical and behavioral health and related progress;(5) to be informed of the name and qualifications of any individual providing services for the designated resident and to choose among various available individual service providers;(6) to receive visitors without prior notice to the service provider agency unless such rights are contraindicated by the designated resident's rights or the rights of others;(7) to have privacy in visitation with family and other visitors;(8) to make and receive telephone calls;(9) to attend religious activities of choice;(10) to participate in developing a transition plan that addresses assistance for the designated resident after he or she leaves the NF;(11) to be free from the use of unauthorized restraints;(12) to have a personalized plan of care and implementation plan, based on individualized assessments, that meet the designated resident's needs and abilities and enhance the designated resident's strengths;(13) to help decide what the implementation plan will be;(14) to be informed as to the progress or lack of progress being made in the execution of the implementation plan;(15) to complain at any time to a staff member, individual service provider, volunteer, controlling person, ombudsman or a representative of the designated protection and advocacy system in the state for individuals with mental illness or individuals with IDD;(16) to receive appropriate support and encouragement from a staff member, individual service provider, volunteer, or controlling person if the designated resident dislikes or disagrees with the services being rendered or thinks that his or her rights are being violated;(17) to be free from abuse, neglect, or exploitation;(18) to have service providers who are responsive to the designated resident;(19) to have privacy during services and care of personal needs;(20) to communicate, associate, and meet privately with individuals of his or her choice, unless this violates the rights of another individual;(21) to participate in social, recreational, and community group activities;(22) to have his or her LAR involved in activities, including:(A) being informed of all rights and responsibilities when the designated resident is receiving IHSS from the service provider agency, as well as any changes in rights or responsibilities before they become effective;(B) participating in the planning for IHSS; and(C) advocating for all rights of the designated resident;(23) to be informed of the designated resident's option to transfer to other service provider agencies as chosen by the designated resident or LAR as often as desired;(24) to complain to HHSC when the service provider agency's resolution of a complaint is unsatisfactory to the designated resident or LAR, and to be informed of the HHSC Complaint and Incident Intake telephone number to initiate complaints; and(25) to be free from the use of seclusion. Source Note: The provisions of this §368.403 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.403 Rights of Designated Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205531 03/12/2026 (a) The service provider agency must:(1) ensure any restriction affecting the designated resident is approved by the SPT and has written consent of the designated resident or LAR before the imposition of the restriction, except when an immediate threat to the designated resident's or another individual's health and safety exists; and(2) receive and act on complaints about the service provider agency's own staff members, individual service providers, or volunteers.(b) When a behavior support plan includes techniques that involve restriction of individual rights or intrusive techniques, the service provider agency must ensure that the implementation of such techniques includes:(1) verbal and written notification to the designated resident or LAR of the right to discontinue participation in the behavior support plan at any time;(2) assessment of the designated resident's needs and current level or severity of the behavior targeted by the plan;(3) use of techniques appropriate to the level or severity of the behavior targeted by the plan;(4) a written behavior support plan developed by a qualified individual service provider as described in §368.406(k) of this subchapter (relating to Provider Qualifications) with input from the designated resident, LAR, the designated resident's SPT, and other professional personnel;(5) collection and monitoring of behavioral data concerning the targeted behavior;(6) allowance for the decrease in the use of intervention techniques based on behavioral data;(7) allowance for revision of the behavior support plan when the desired behavior is not displayed or techniques are not effective;(8) consideration of the effects of the techniques in relation to the designated resident's physical and psychological well-being; and(9) at least annual review by the designated resident's SPT to determine the effectiveness of the services and the need to continue the techniques.(c) Upon suspicion or notification that a designated resident has been or is being abused, neglected, or exploited, the service provider agency must take necessary actions to secure the safety of the designated resident while the designated resident is in the service provider agency's care, in accordance with §368.405(c) -(d) of this subchapter (relating to Abuse, Neglect, and Exploitation of a Designated Resident). Source Note: The provisions of this §368.404 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.404 Ensuring the Safety of Designated Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205532 03/12/2026 (a) The service provider agency must:(1) ensure that a designated resident and LAR are, before initiation of IHSS and at least annually thereafter:(A) informed of how to report allegations of abuse, neglect, or exploitation to DFPS Statewide Intake and are provided with the toll-free telephone number in writing; and(B) educated about protecting the designated resident from abuse, neglect, and exploitation;(2) ensure that each staff member, individual service provider, and volunteer are:(A) trained and knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation;(B) instructed to report to DFPS Statewide Intake immediately, but not later than one hour after having knowledge or suspicion, that a designated resident has been or is being abused, neglected, or exploited, by:(i) calling the DFPS Abuse Hotline toll-free telephone number; or(ii) using the DFPS Abuse Hotline website; and(C) provided with the instructions described in subparagraph (B) of this paragraph in writing; and(3) conduct the activities described in paragraph (2)(A) - (C) of this subsection before a staff member, individual service provider, or volunteer begins job duties and at least annually thereafter.(b) If a service provider agency staff member, individual service provider, volunteer, or controlling person knows or suspects a designated resident is being or has been abused, neglected, or exploited, the service provider agency must report or ensure that the individual with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to DFPS Statewide Intake immediately, but not later than one hour after having knowledge or suspicion, by:(1) calling the DFPS Abuse Hotline toll-free telephone number; or(2) using the DFPS Abuse Hotline website.(c) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by an individual who is not an individual service provider, staff member, volunteer, or controlling person, the service provider agency must:(1) obtain emergency medical or psychological services, as necessary, for the designated resident, if the designated resident is in the service provider agency's care;(2) take necessary actions to secure the safety of the designated resident;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the designated resident; and(4) preserve and protect evidence related to the allegation.(d) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by an individual service provider, staff member, volunteer, or controlling person; or if the service provider agency is notified by HHSC of an allegation of abuse, neglect, or exploitation by an individual service provider, staff member, volunteer, or controlling person, the service provider agency must:(1) obtain emergency medical or psychological services and assist in obtaining ongoing medical or psychological services for the designated resident, as necessary;(2) take necessary actions to secure the safety of the designated resident, including ensuring that the alleged perpetrator does not have contact with the designated resident or any other individual receiving services from the service provider agency until HHSC completes the investigation;(3) avoid compromising the investigation or further traumatizing the designated resident when taking the actions described in paragraphs (1) and (2) of this subsection;(4) preserve and protect evidence related to the allegation; and(5) notify, as soon as possible, but no later than 24 hours after the service provider agency reports or is notified of the allegation, the designated resident, the LAR, the habilitation coordinator, and the NF of:(A) the allegation report; and(B) the actions the service provider agency has taken or will take based on the allegation, the condition of the designated resident, and the nature and severity of any harm to the designated resident, including the actions required by paragraph(2) of this subsection.(e) During an HHSC investigation of an alleged perpetrator who is an individual service provider, staff member, volunteer, or controlling person, the service provider agency must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the service provider agency;(B) designated residents, individual service providers, staff members, volunteers, and controlling persons; and(C) records pertinent to the investigation of the allegation;(3) ensure that staff members, individual service providers, volunteers, and controlling persons comply with paragraphs (1) and (2) of this subsection; and(4) ensure that, if the Chief Executive Officer (CEO) is named as an alleged perpetrator of abuse, neglect, or exploitation of a designated resident, an alternate to the CEO acts as the contact in an HHSC investigation and complies with subsections (d) - (g) of this section.(f) After the service provider agency receives a final investigative report from HHSC for an investigation described in subsection (e) of this section, the service provider agency must:(1) review the report, including any concerns and recommendations by HHSC, and:(A) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC, take action within the service provider agency's authority to prevent the reoccurrence of abuse, neglect or exploitation, including disciplinary action against the individual service provider, staff member, or volunteer confirmed to have committed abuse, neglect, or exploitation; or(B) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded, take appropriate action within the service provider agency's authority, as necessary;(2) immediately, but not later than five calendar days after the date the service provider agency receives the HHSC final investigative report:(A) notify the designated resident, the LAR, the habilitation coordinator, and the NF of:(i) the investigation finding; and(ii) the action taken by the service provider agency in response to the HHSC investigation as required by paragraph (1)(A) and (B) of this subsection; and(B) notify the designated resident or LAR of:(i) the process to appeal the investigation finding as described in Chapter 711, Subchapter J of this title (relating to Appealing the Investigation Finding); and(ii) the process for requesting a copy of the investigative report from the service provider agency; and(3) provide a copy of the HHSC final investigative report to the designated resident or LAR upon request, after removing any information that would reveal the identity of the reporter or of any designated resident who is not the alleged victim.(g) The service provider agency must not retaliate against:(1) a staff member, individual service provider, designated resident, or other individual who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of a designated resident; and(2) a designated resident because an individual on behalf of the designated resident files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of a designated resident. Source Note: The provisions of this §368.405 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.405 Abuse, Neglect, and Exploitation of a Designated Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205533 03/12/2026 (a) The service provider agency must maintain a continuous and adequate network of qualified individual service providers and must allow for choice whenever possible.(b) The service provider agency must ensure the continuous availability of trained and qualified individual service providers to provide the IHSS on a designated resident's plan of care.(c) The service provider agency must ensure that individual service providers are not the LAR of the designated resident and are not related to the designated resident in anything less than a third degree by blood or second degree by marriage.(d) The service provider agency must comply with applicable laws and rules to ensure that:(1) its operations meet necessary requirements; and(2) individual service providers possess legally necessary licenses, certifications, registrations, or other credentials and are in good standing with the appropriate professional agency before performing any function or delivering services.(e) The service provider agency must conduct initial and periodic training that ensures individual service providers are trained and qualified to deliver services as required by the current needs of the designated resident for whom they deliver services.(f) The service provider agency must:(1) prevent conflicts of interest between provider personnel and a designated resident;(2) prevent abuse, neglect, or exploitation of a designated resident;(3) prevent the restriction of rights of the designated resident; and(4) implement and maintain personnel practices that safeguard a designated resident against infectious and communicable diseases.(g) The service provider agency must ensure that an individual service provider of independent living skills training or day habilitation:(1) is at least 18 years of age; and(2) has one of the following:(A) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(B) documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(i) a written competency-based assessment of the ability to document service delivery and observations of a designated resident to be served; and(ii) at least three written personal references from individuals not related by blood or marriage to the individual service provider that indicate the individual service provider can provide a safe, healthy environment for a designated resident being served.(h) The service provider agency must ensure that an individual service provider of employment assistance or supported employment:(1) is at least 18 years of age; and(2) has one of the following:(A) a bachelor's degree in rehabilitation, business, marketing, or a related human services field, and at least six months of paid or unpaid experience providing services for people with disabilities;(B) an associate degree in rehabilitation, business, marketing, or a related human services field, and at least one year of paid or unpaid experience providing services for people with disabilities; or(C) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, and at least two years of paid or unpaid experience providing services for people with disabilities.(i) The service provider agency must ensure that experience required is evidenced by a written statement from an individual who:(1) paid for the service or supervised the provision of the service, for paid experience; and(2) has personal knowledge of the experience, for unpaid experience.(j) The service provider agency must ensure that an individual who provides transportation:(1) has a valid driver's license; and(2) transports designated residents in a vehicle insured in accordance with state law.(k) The service provider agency must ensure that an individual service provider of behavioral support:(1) is licensed as a psychologist in accordance with Texas Occupations Code, Chapter 501;(2) is licensed as a psychological associate in accordance with Texas Occupations Code, Chapter 501;(3) has been issued a provisional license to practice psychology in accordance with Texas Occupations Code, Chapter 501;(4) is licensed as a behavior analyst in accordance with Texas Occupations Code, Chapter 506;(5) is licensed as a clinical social worker in accordance with Texas Occupations Code, Chapter 505; or(6) is licensed as a professional counselor in accordance with Texas Occupations Code, Chapter 503. Source Note: The provisions of this §368.406 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.406 Provider Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205534 03/12/2026 (a) In the provision of IHSS for a designated resident, the service provider agency must cooperate with:(1) providers of services other than IHSS, including:(A) LIDDAs; and(B) NFs;(2) advocates or other actively involved persons; and(3) HHSC, other authorized agencies, or CMS.(b) The service provider agency must ensure personalized service delivery based upon the choices made by each designated resident or LAR.(c) The service provider agency must develop, update as necessary, and implement a written quality assurance process to evaluate and improve the quality of services delivered by the service provider agency based, at least in part, on the results of the survey required by subsection (d) of this section.(d) The service provider agency must, at least annually, conduct a satisfaction survey of designated residents, LARs, and actively involved persons and take action in accordance with subsection (c) of this section regarding any areas of dissatisfaction.(e) The service provider agency must comply with 40 TAC §49.309 (relating to Complaint Process) and identify process improvements to reduce the filing of complaints.(f) At least annually, the service provider agency must:(1) review all final investigative reports from HHSC for an investigation described in §368.405(e) of this subchapter (relating to Abuse, Neglect, and Exploitation of a Designated Resident) and, based on the review, identify and implement process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of IHSS; and(2) evaluate critical incident data submitted by the service provider agency in accordance with its contract and identify and implement process improvements that help prevent the occurrence of critical incidents and improve service delivery. Source Note: The provisions of this §368.407 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES D SERVICE PROVIDER AGENCY REQUIREMENTS §368.407 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205535 03/12/2026 (a) The habilitation coordinator must, upon receiving notice of a designated resident's or LAR's intention to transfer to another service provider agency:(1) confirm the designated resident or LAR wants to transfer;(2) explain that the designated resident or LAR may transfer to the service provider agency of the designated resident's or LAR's choice and provide the designated resident or LAR the names and contact information of all service provider agencies that are in the contract area of the designated resident's NF;(3) document in the designated resident's record the date the transfer request was received; and(4) make transfer arrangements, including completing appropriate documentation, in accordance with the IDD PASRR Handbook with:(A) the designated resident or LAR;(B) the transferring service provider agency; and(C) the receiving service provider agency.(b) The habilitation coordinator must establish an effective date for the designated resident's transfer that is:(1) a future date; and(2) agreed to by the habilitation coordinator, the designated resident or LAR, and the receiving service provider agency.(c) The transferring service provider agency and receiving service provider agency must cooperate with the habilitation coordinator's efforts to coordinate the designated resident's transfer by:(1) responding to requests for information or documentation related to the designated resident's IHSS within three business days of the request;(2) providing timely documentation to allow the habilitation coordinator to complete forms in accordance with the IDD PASRR Handbook; and(3) participating in meetings related to the designated resident's transfer in person or by phone, if requested.(d) Before the transfer effective date, the habilitation coordinator must convene a transfer meeting with, at a minimum, the designated resident or LAR, the receiving service provider agency, and the NF to:(1) determine which IHSS may require a new assessment;(2) develop a transfer plan of care; and(3) update the HSP.(e) The habilitation coordinator may invite other parties to the transfer meeting as requested or approved by the designated resident or LAR.(f) The LIDDA must submit the following to HHSC before the effective date of the transfer:(1) the designated resident's transfer plan of care; and(2) forms completed in accordance with the IDD PASRR Handbook.(g) The plan dates of an initial plan of care or renewal plan of care do not change upon a designated resident's transfer to another service provider agency under this section.(h) HHSC will not pay for IHSS delivered by the receiving service provider agency prior to the transfer effective date. Source Note: The provisions of this §368.501 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES E TRANSFERS §368.501 Transfer between Service Provider Agencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205538 03/12/2026 (a) When a designated resident moves from one NF to another NF within the same contract area and the same local service area without an intervening hospital stay, the habilitation coordinator must determine whether the designated resident, or LAR on the designated resident's behalf, wants to select a new service provider agency or continue receiving IHSS from the current service provider agency.(b) If the designated resident or LAR elects to have IHSS delivered by the current service provider agency:(1) the habilitation coordinator must document the designated resident's or LAR's choice and ensure the service provider agency is invited to the SPT meeting;(2) the designated resident may continue receiving, or suspend, any authorized IHSS that was delivered at the transferring NF until:(A) the receiving NF has convened the initial IDT meeting;(B) the IHSS assessments have been reviewed in accordance with §368.302 of this chapter (relating to Renewal and Revision of a Plan of Care); and(C) HHSC has authorized the IHSS to be delivered at the receiving NF; and(3) at the initial IDT meeting:(A) the IDT reviews the designated resident's IHSS;(B) the IDT may request a new assessment for any IHSS;(C) the habilitation coordinator develops an initial plan of care and obtains signatures from the required parties; and(D) the habilitation coordinator revises the HSP as necessary.(c) If the designated resident chooses to select a new service provider agency:(1) the habilitation coordinator and new service provider agency must comply with §368.203 of this chapter (relating to Process for Provider Selection) and §368.204 of this chapter (relating to Process for Service Initiation);(2) the new service provider agency must ensure IHSS are not delivered until HHSC has authorized the IHSS on the plan of care; and(3) the previous service provider agency must respond to the habilitation coordinator's requests for information or documentation related to the designated resident's IHSS within three business days of the request. Source Note: The provisions of this §368.502 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES E TRANSFERS §368.502 Transfer between Nursing Facilities in the Same Contract Area and Local Service Area https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205539 03/12/2026 (a) When a designated resident moves from one NF to another NF within the same local service area but in a different contract area without an intervening hospital stay, the habilitation coordinator must:(1) notify the service provider agency and determine whether the service provider agency has a contract in the new contract area; and(2) if the service provider agency has a contract in the new contract area, determine whether the designated resident wants to select a new service provider agency or continue receiving IHSS from the current service provider agency.(b) If the service provider agency has a contract in the new contract area and the designated resident or LAR elects to receive IHSS from the same service provider agency, the service provider agency may continue to deliver IHSS in accordance with §368.502(b) of this subchapter (relating to Transfer between Nursing Facilities in the Same Contract Area and Local Service Area).(c) If the designated resident or LAR chooses to select a new service provider agency:(1) the habilitation coordinator and new service provider agency must comply with §368.203 of this chapter (relating to Process for Provider Selection) and §368.204 of this chapter (relating to Process for Service Initiation);(2) the new service provider agency must ensure IHSS are not delivered until HHSC has authorized the IHSS on the plan of care; and(3) the previous service provider agency must respond to the habilitation coordinator's requests for information or documentation related to the designated resident's IHSS within three business days of the request. Source Note: The provisions of this §368.503 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES E TRANSFERS §368.503 Transfer between Nursing Facilities in Different Contract Areas and the Same Local Service Area https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205536 03/12/2026 (a) When a designated resident moves from a NF in one local service area to a NF in a different local service area but the same contract area without an intervening hospital stay, the transferring LIDDA must:(1) within three business days of learning that the designated resident will move or has moved:(A) determine whether the designated resident, or LAR on the designated resident's behalf, wants to select a new service provider agency or continue receiving IHSS from the current service provider agency; and(B) notify the receiving LIDDA of the move date and whether the designated resident or LAR wants to select a new service provider agency;(2) send the receiving LIDDA:(A) all assessments, including the PE;(B) the HSP and individual profile form;(C) the current plan of care; and(D) any other information requested by the receiving LIDDA;(3) terminate the IHSS on the current plan of care effective on the move date, if the designated resident or LAR wants to select a new service provider agency; and(4) terminate the habilitation coordination service authorization in accordance with the Habilitation Coordination Billing Guidelines.(b) When the designated resident moves to the NF in a new local service area, the receiving LIDDA must:(1) comply with Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)) and follow processes described in the IDD PASRR Handbook;(2) if the designated resident or LAR wants to select a new service provider agency, ensure the designated resident or LAR selects a new service provider agency in accordance with §368.203 of this chapter (relating to Process for Provider Selection); and(3) initiate IHSS at the NF in accordance with §368.204 of this chapter (relating to Process for Service Initiation).(c) If the designated resident or LAR elects to receive IHSS from the same service provider agency, the service provider agency may continue to deliver IHSS in accordance with §368.502(b) of this subchapter (relating to Transfer between Nursing Facilities in the Same Contract Area and Local Service Area).(d) If the designated resident selects a new service provider agency:(1) the new service provider agency must ensure IHSS are not delivered until HHSC has authorized the IHSS on the plan of care; and(2) the previous service provider agency must respond to the transferring or receiving LIDDA's requests for information or documentation related to the designated resident's IHSS within three business days of the request. Source Note: The provisions of this §368.504 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES E TRANSFERS §368.504 Transfer between Nursing Facilities in the Same Contract Area and Different Local Service Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205537 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205537 03/12/2026 (a) When a designated resident moves from a NF in one local service area to a NF in a different contract area and a different local service area without an intervening hospital stay, the transferring LIDDA must:(1) within three business days of learning that the designated resident will move or has moved:(A) notify the service provider agency and determine whether the service provider agency has a contract in the new local service area;(B) determine whether the designated resident wants to select a new service provider agency or continue receiving IHSS from the current service provider agency, if the service provider agency has a contract in the new local service area; and(C) notify the receiving LIDDA of the move date and whether the designated resident must select a new service provider agency;(2) send the receiving LIDDA:(A) all assessments, including the PE;(B) the HSP and individual profile form;(C) the current plan of care; and(D) any other information requested by the receiving LIDDA;(3) terminate the current plan of care effective on the move date, if the designated resident must select a new service provider agency; and(4) terminate the habilitation coordination service authorization in accordance with the Habilitation Coordination Billing Guidelines.(b) When the designated resident moves to the NF in a new local service area, the receiving LIDDA must:(1) comply with Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)) and follow processes described in the IDD PASRR Handbook;(2) if the designated resident must choose a new service provider agency, ensure the designated resident or LAR selects a new service provider agency in accordance with §368.203 of this chapter (relating to Process for Provider Selection); and(3) initiate IHSS at the NF in accordance with §368.204 of this chapter (relating to Process for Service Initiation).(c) If the service provider agency has a contract in the new local service area and the designated resident or LAR elects to receive IHSS from the same service provider agency, the service provider agency may continue to deliver IHSS in accordance with §368.502(b) of this subchapter (relating to Transfer between Nursing Facilities in the Same Contract Area and Local Service Area).(d) If the designated resident selects a new service provider agency:(1) the new service provider agency must ensure IHSS are not delivered until HHSC has authorized the IHSS on the plan of care; and(2) the previous service provider agency must respond to the transferring or receiving LIDDA's requests for information or documentation related to the designated resident's IHSS within three business days of the request. Source Note: The provisions of this §368.505 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES E TRANSFERS §368.505 Transfer between Nursing Facilities in Different Contract Areas and Local Service Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205540 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205540 03/12/2026 (a) A designated resident's IHSS are suspended if:(1) the designated resident is admitted to an acute care hospital for fewer than 30 days and is returning to the same NF;(2) the designated resident loses Medicaid eligibility;(3) the designated resident or LAR requests that IHSS be suspended when transferring from one NF to another NF without an intervening hospital stay; or(4) the designated resident has a change in health condition that temporarily prohibits participation in IHSS.(b) HHSC may terminate one or more of a designated resident's IHSS if:(1) the designated resident no longer meets the eligibility criteria specified in §368.202 of this chapter (relating to Eligibility Criteria);(2) the designated resident loses Medicaid eligibility for more than 90 days;(3) the designated resident or LAR requests that IHSS be terminated; or(4) the designated resident exhibits a persistent and prolonged pattern of failing to comply with the requirements described in subsection (c) of this section.(c) A designated resident or LAR must comply with the following participation requirements in the delivery of IHSS:(1) participating on the SPT to:(A) develop an initial plan of care as described in §368.204 of this chapter (relating to Process for Service Initiation); and(B) renew and revise the plan of care as described in §368.302 of this chapter (relating to Renewal and Revision of a Plan of Care);(2) reviewing, agreeing to, signing, and dating a plan of care in accordance with §368.301 of this chapter (relating to Plan of Care);(3) cooperating with the service provider agency and habilitation coordinator in the delivery of IHSS listed on the designated resident's plan of care;(4) cooperating with the service provider agency and habilitation coordinator to ensure progress toward achieving the outcomes, goals, and objectives described in the HSP and implementation plan;(5) not engaging in illegal behavior in the presence of the habilitation coordinator, individual service provider, or a staff member, volunteer, or controlling person of the service provider agency;(6) not repeatedly acting in a manner that is threatening to the health and safety of the individual service provider or a staff member, volunteer, or controlling person of the service provider agency;(7) not exhibiting behavior that places the health and safety of the individual service provider or a staff member, volunteer, or controlling person of the service provider agency in immediate jeopardy; and(8) not knowingly initiating or participating in fraudulent health care practices.(d) The service provider agency must develop a written policy that describes the process the service provider agency will follow to address challenges related to the designated resident's or LAR's participation in the program.(e) When requesting to terminate a designated resident's IHSS for the reason described in subsection (b)(4) of this section, the service provider agency and LIDDA must provide documentation demonstrating the service provider agency and LIDDA have followed the written policy required by subsection (d) of this section and made every attempt to:(1) engage the designated resident or LAR in meeting the participation requirements; and(2) ensure the designated resident's or LAR's inability to meet the participation requirements is not due to a failure of the designated resident's SPT.(f) The LIDDA and service provider agency must notify each other immediately if IHSS are suspended or terminated. Source Note: The provisions of this §368.601 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES F SERVICE SUSPENSION, TERMINATION, OR DENIAL §368.601 Suspension and Termination of IHSS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205541 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205541 03/12/2026 (a) A designated resident is entitled to a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules) if HHSC:(1) denies or does not act upon a designated resident's request for IHSS with reasonable promptness; or(2) suspends or terminates a designated resident's IHSS and the designated resident or LAR does not agree with the suspension or termination.(b) A designated resident receives notice of the right to request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A to appeal the adverse action.(c) If the hearing officer reverses a denial of IHSS, the service provider agency must ensure the provision of the IHSS. Source Note: The provisions of this §368.602 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES F SERVICE SUSPENSION, TERMINATION, OR DENIAL §368.602 Fair Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205542 03/12/2026 (a) HHSC pays a service provider agency for independent living skills training, day habilitation, employment assistance, supported employment, and behavioral support in accordance with the fee-for-service rate for the specific service, which can be found on the HHSC website.(b) To be paid for the provision of a service, the service provider agency must submit a service claim that meets the requirements in 40 TAC §49.311 (relating to Claims Payment) and the IDD Habilitative Specialized Services Billing Guidelines.(c) If a designated resident's IHSS are suspended or terminated, the service provider agency must not submit a claim for services provided during the period of the designated resident's suspension or after the termination, except that the service provider agency may submit a claim for the first day of the designated resident's suspension or termination.(d) HHSC does not pay the service provider agency for a service if:(1) the service is provided for a designated resident when there is not a signed, dated, and authorized plan of care for the designated resident; or(2) the designated resident is ineligible for Medicaid benefits at the time the service is provided.(e) HHSC recoups any payments made to the service provider agency for a service, if:(1) the service is not provided in accordance with:(A) a signed, dated, and authorized plan of care meeting the requirements set forth in §368.301 of this chapter (relating to Plan of Care);(B) the designated resident's HSP;(C) the designated resident's implementation plan; or(D) the IDD Habilitative Specialized Services Billing Guidelines;(2) the service is not documented in accordance with Texas Medicaid Provider's Procedures Manual found on the TMHP website and the IDD Habilitative Specialized Services Billing Guidelines;(3) the claim for the service does not meet the requirements in 40 TAC §49.311 or the IDD Habilitative Specialized Services Billing Guidelines;(4) HHSC determines that the service would have been paid for by another source if the service provider agency had submitted to the other source a proper, complete, and timely request for payment for the service;(5) the payment was for employment assistance or supported employment and the service provider agency does not ensure or maintain documentation in the designed resident's record that the service is not available for the designated resident through a program funded by the Rehabilitation Act of 1973;(6) the service is provided by an individual service provider who does not meet the qualifications to provide the service as described in §368.406 of this chapter (relating to Provider Qualifications) and the IDD Habilitative Specialized Services Billing Guidelines; or(7) the service is not provided.(f) The service provider agency must refund to HHSC any overpayment made to the service provider agency within 60 days after the service provider agency's discovery of the overpayment. Source Note: The provisions of this §368.701 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES G VENDOR PAYMENT §368.701 Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205543 03/12/2026 (a) A LIDDA provides habilitation coordination, in accordance with Chapter 303, Subchapter E of this title (relating to Habilitation Coordination) and Chapter 303, Subchapter F of this title (relating to Habilitative Service Planning for a Designated Resident), for a designated resident who agrees to receive habilitation coordination.(b) The LIDDA must, in the provision of habilitation coordination, ensure compliance with the requirements in this chapter, in addition to the requirements described in Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)).(c) The habilitation coordinator must notify the service provider agency if the habilitation coordinator becomes aware that a designated resident has discharged from the NF or has transferred from one NF to another NF. Source Note: The provisions of this §368.801 adopted to be effective September 1, 2021, 46 TexReg 4151. 1 HEALTH AND HUMAN SERVICES COMMISSION 368 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) HABILITATIVE SPECIALIZED SERVICES H LIDDA REQUIREMENTS §368.801 LIDDA Requirements for Providing Habilitation Coordination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=201943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 201943 03/12/2026 (a) For a human trafficking prevention training course to become approved by the Executive Commissioner, or designee, the course must meet the human trafficking training standards established by the Health and Human Services Commission.(b) The human trafficking prevention training course, at a minimum, must include:(1) types of human trafficking, including definitions;(2) vulnerability factors;(3) health impact;(4) identification;(5) assessment;(6) response; and(7) resources.(c) Health care practitioners who provide direct patient care, except physicians and nurses, must complete an approved human trafficking prevention training course for each license renewal, within the full license term as defined by each licensing entity.(d) A complete description of the human trafficking prevention training standards and training approval process is posted on the HHSC website. At least one approved course will be available without charge. Source Note: The provisions of this §370.1 adopted to be effective December 2, 2020, 45 TexReg 8523. 1 HEALTH AND HUMAN SERVICES COMMISSION 370 HUMAN TRAFFICKING RESOURCE CENTER §370.1 Human Trafficking Prevention Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213119 03/12/2026 These sections implement requirements and policies for the access and delivery of breast and cervical cancer screening and diagnostic services through the Texas Health and Human Services Commission Breast and Cervical Cancer Services Program. Source Note: The provisions of this §371.1 adopted to be effective July 1, 1992, 17 TexReg 3983; amended to be effective May 23, 2002, 27 TexReg 4355; amended to be effective June 27, 2007, 32 TexReg 3847; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213120 03/12/2026 The Breast and Cervical Cancer Mortality Prevention Act of 1990 (Act), Public Law 101-354, and its amendments (Public Law 103-183 and Public Law 105-340) establish a program of grants to states, territories, and tribal organizations for early detection of and prevention of mortality from breast and cervical cancer. The Texas Health and Human Services Commission, through a cooperative agreement with the Centers for Disease Control and Prevention and in compliance with the Act and its amendments, manages the delivery of breast and cervical cancer services statewide through the Breast and Cervical Cancer Services Program. Source Note: The provisions of this §371.3 adopted to be effective July 1, 1992, 17 TexReg 3983; amended to be effective May 23, 2002, 27 TexReg 4355; amended to be effective June 27, 2007, 32 TexReg 3847; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.3 Federal Authorization and Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213121 03/12/2026 (a) Health care providers must be enrolled in Texas Medicaid in order to apply as providers and be reimbursed for services provided in the Breast and Cervical Cancer Services (BCCS) Program, except in very limited circumstances.(b) If the Texas Health and Human Services Commission (HHSC) is unable to locate a sufficient number of eligible providers offering services in a certain region, HHSC may compensate other local providers for the provision of breast and cervical cancer screening and diagnostic services. Methodologies for determining if a certain region has a sufficient number of eligible providers may include:(1) estimated number of clients in need;(2) amount of funds available for allocation;(3) service capacity of the proposed provider for the provision of breast and cervical cancer screening and diagnostic services;(4) distance and/or time clients must travel to receive services; and(5) any other relevant factors HHSC deems relevant for determining provider access.(c) Upon request, BCCS Program providers must provide HHSC or its designee with all information HHSC or its designee requires to determine the provider's compliance with the program requirements.(d) If HHSC or its designee determines that a BCCS Program provider fails to comply with this section, HHSC or its designee will disqualify the provider from the BCCS Program.(e) If a BCCS Program provider is disqualified, HHSC or its designee will take appropriate action to:(1) assist a BCCS client to find an alternative provider; and(2) recoup any funds paid to the disqualified provider for BCCS services performed during the period of disqualification. Source Note: The provisions of this §371.5 adopted to be effective July 1, 1992, 17 TexReg 3983; amended to be effective May 23, 2002, 27 TexReg 4355; amended to be effective June 27, 2007, 32 TexReg 3847; amended to be effective September 1, 2016, 41 TexReg 6500; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.5 Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213122 03/12/2026 (a) In order for a woman to be eligible for Breast and Cervical Cancer Services, the woman must:(1) have a gross household income at or below 200% of the adopted federal poverty level; and(2) be uninsured (not have access to health insurance) or underinsured (whose health insurance does not fully cover breast and cervical cancer screening and/or diagnostic services).(b) A woman age 40 or older who meets eligibility criteria is eligible for breast cancer screening and diagnostic services. A woman under age 40 who meets eligibility criteria is eligible for breast cancer diagnostic services. A woman under age 40 who meets eligibility criteria may be eligible for screening services, based on Texas Health and Human Services Commission available funding.(c) A woman age 21 - 64 who meets eligibility criteria is eligible for cervical cancer screening services. A woman age 18 - 64 who meets eligibility criteria is eligible for cervical cancer diagnostic services. Source Note: The provisions of this §371.7 adopted to be effective June 27, 2007, 32 TexReg 3847; amended to be effective June 20, 2013, 38 TexReg 3788; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.7 Client Eligibility Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213123 03/12/2026 Participating providers shall provide or assure the provision of screening services in accordance with the most current evidence-based clinical guidance, as detailed in the Breast and Cervical Cancer Services policy manual. Source Note: The provisions of this §371.9 adopted to be effective June 27, 2007, 32 TexReg 3847; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.9 Screening Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213124 03/12/2026 Participating providers shall:(1) provide or assure provision of follow-up and case management services that comply with the Breast and Cervical Cancer Services policy manual; and(2) ensure that women eligible for services who have abnormal breast or cervical cancer screening or diagnostic results, receive follow-up services, including case management, until a diagnosis is reached and/or treatment for cancer is initiated. Source Note: The provisions of this §371.11 adopted to be effective June 27, 2007, 32 TexReg 3847; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.11 Follow-up and Case Management Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213125 03/12/2026 (a) Payment for clinical screening and diagnostic services shall be on a fee-for-service basis.(b) Payment will be subject to audit by the Texas Health and Human Services (HHSC). HHSC shall approve covered services at payment rates that shall not exceed the maximum state Medicare rate for that procedure. A list of procedures approved for payment shall be included in all requests for proposals and contracts. Source Note: The provisions of this §371.13 adopted to be effective July 1, 1992, 17 TexReg 3983; amended to be effective May 23, 2002, 27 TexReg 4355; amended to be effective June 27, 2007, 32 TexReg 3847; amended to be effective June 20, 2013, 38 TexReg 3788; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.13 Payment for Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213126 03/12/2026 Participating providers may charge clients fees for services in accordance with the Breast and Cervical Cancer Services policy manual. Source Note: The provisions of this §371.15 adopted to be effective July 1, 1992, 17 TexReg 3983; amended to be effective May 23, 2002, 27 TexReg 4355; amended to be effective June 27, 2007, 32 TexReg 3847; transferred effective December 1, 2021, as published in the Texas Register November 5, 2021, 46 TexReg 7643; amended to be effective March 20, 2023, 48 TexReg 1563. 1 HEALTH AND HUMAN SERVICES COMMISSION 371 BREAST AND CERVICAL CANCER SERVICES §371.15 Client Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224882 03/12/2026 The Woman's Right to Know Act, Health and Safety Code, Chapter 171, states that no person may perform an abortion without the voluntary and informed consent of the woman on whom the abortion is to be performed, and specifies the content of informational materials that must be offered to a woman to support her informed consent. Health and Safety Code, §171.014(d), requires the Department of State Health Services to adopt rules necessary for considering and making changes to the informational materials. Source Note: The provisions of this §373.1 adopted to be effective December 20, 2012, 37 TexReg 9775; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 373 A WOMAN'S RIGHT TO KNOW §373.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224883 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Booklet--"A Woman's Right to Know Information Material" that includes certain information specified in Health and Safety Code, Chapter 171.(2) Resource Directory--"A Woman's Right to Know Resource Directory" that includes a listing of programs and services specified in Health and Safety Code, Chapter 171.(3) Department--Department of State Health Services. Source Note: The provisions of this §373.3 adopted to be effective December 20, 2012, 37 TexReg 9775; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 373 A WOMAN'S RIGHT TO KNOW §373.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224884 03/12/2026 (a) As required by Health and Safety Code, §171.014(d), the department will review the materials annually to determine if changes to the content of the booklet are necessary.(b) The department shall update programs and services listed in the resource directory as needed and post on the Woman's Right to Know website in English and Spanish.(c) If changes are necessary to the booklet, the department will propose revisions in accordance with the following methods and procedures.(1) The department shall propose revisions to the booklet based on current and relevant science and evidence-based literature, medical professional resources, and government health and medical resources.(2) The department shall make current and relevant science and evidence-based literature reviewed available upon request.(3) The department shall also review the booklet to ensure that information on available assistance and services is current and that it is consistent with state and federal law.(4) The department will notify stakeholders of the annual review process through a public posting on the department's Woman's Right To Know website and the email distribution list. The department notification will include instructions on how to be added to the email distribution list.(5) The department will accept and review stakeholder input, including any suggested changes to the booklet, throughout the year.(6) The proposed revisions to the booklet will be posted on the department's Woman's Right To Know website and will be available for stakeholder comment for 30 days. The department will consider comments provided by stakeholders that pertain to the revisions being proposed by the department.(7) Revisions to the booklet will be guided by peer-reviewed scientific and medical literature, resources from professional medical organizations, and government health sources.(d) Upon annual review of the booklet, the department shall announce the release of the booklet as revised, and shall post the revised edition on the department's Woman's Right To Know website. The department will make the document available in print in English and in Spanish. Source Note: The provisions of this §373.5 adopted to be effective December 20, 2012, 37 TexReg 9775; transferred effective April 30, 2025, as published in the March 28, 2025, issue of the Texas Register, 50 TexReg 2235. 1 HEALTH AND HUMAN SERVICES COMMISSION 373 A WOMAN'S RIGHT TO KNOW §373.5 Review Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215365 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215365 03/12/2026 (a) Purpose. This chapter implements Texas Government Code §531.09915, which authorizes the Health and Human Services Commission to implement a competitive matching grant program to support the initial establishment and operation of community-based initiatives that promote identification of mental health issues and improve access to early intervention and treatment for children and families.(b) Grant objectives. The grants awarded under this chapter are intended to assist with the establishment or operation of community-based initiatives that may:(1) be evidence-based or otherwise demonstrate positive outcomes, including:(A) improved relationship skills;(B) improved self-esteem;(C) reduced involvement in the juvenile justice system;(D) participation in the relinquishment avoidance program under Texas Family Code Chapter 262, Subchapter E; and(E) avoidance of emergency room use; and(2) include:(A) training; and(B) services and supports for:(i) community-based initiatives;(ii) agencies that provide services to children and families;(iii) individuals who work with children or caregivers of children showing atypical social or emotional development or other challenging behaviors; and(iv) children in or at risk of placement in the foster care or juvenile justice system. Source Note: The provisions of this §374.1 adopted to be effective November 1, 2023, 48 TexReg 6213. 1 HEALTH AND HUMAN SERVICES COMMISSION 374 MENTAL HEALTH EARLY INTERVENTION AND TREATMENT GRANT §374.1 Purpose and Objectives https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215366 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215366 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Applicant--An entity eligible to apply for a grant.(2) Children--Individuals who are younger than 18 years of age.(3) Commission--The Health and Human Services Commission.(4) Early intervention--Services to identify and provide effective early support to children who are at risk of poor outcomes.(5) Grantee--A recipient of a grant awarded under this chapter. Source Note: The provisions of this §374.2 adopted to be effective November 1, 2023, 48 TexReg 6213. 1 HEALTH AND HUMAN SERVICES COMMISSION 374 MENTAL HEALTH EARLY INTERVENTION AND TREATMENT GRANT §374.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215367 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215367 03/12/2026 The following entities are eligible to apply for a grant:(1) a hospital licensed under Texas Health and Safety Code Chapter 241;(2) a mental hospital licensed under Texas Health and Safety Code Chapter 577;(3) a hospital district;(4) a local mental health authority, as defined in Texas Health and Safety Code §571.003;(5) a child-care facility, as defined in Texas Human Resources Code §42.002;(6) a county or municipality; and(7) a nonprofit organization that is exempt from taxation under §501(a), Internal Revenue Code of 1986, as an exempt entity described in §501(c)(3) of that code. Source Note: The provisions of this §374.3 adopted to be effective November 1, 2023, 48 TexReg 6213. 1 HEALTH AND HUMAN SERVICES COMMISSION 374 MENTAL HEALTH EARLY INTERVENTION AND TREATMENT GRANT §374.3 Eligibility Criteria for Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215368 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215368 03/12/2026 (a) Application and selection process.(1) An applicant must submit an application for a grant directly to the Commission in the time and manner specified by the Commission.(2) An application received after the deadline will not be considered.(3) A panel selected by the Commission reviews and evaluates eligible, complete, and timely applications in accordance with the evaluation methodology published in the request for proposal or other notice of potential grant award issued by the Commission.(b) Selection criteria. In selecting a grantee, the Commission must consider:(1) the extent to which an applicant's proposed program meets the objectives established by Texas Government Code §531.09915; and(2) other criteria established by the Commission as described in the specific request for proposal or other notice of potential grant award issued by the Commission.(c) Award prioritization. In selecting grantees, the Commission prioritizes entities that work with children and family members of children with a high risk of experiencing a crisis or developing a mental health condition to reduce:(1) the need for future intensive mental health services;(2) the number of children at risk of placement in foster care or the juvenile justice system; or(3) the demand for placement in:(A) a state hospital, as defined in Texas Health and Safety Code §552.0011;(B) an inpatient mental health facility, as defined in Texas Health and Safety Code §571.003; and(C) a residential behavioral health facility.(d) Contract execution.(1) Grantees are required to execute a contract with the Commission on mutually agreeable terms and conditions in the manner and format prescribed by the Commission.(2) The Commission does not distribute grant funds to a grantee before the execution of a contract with the Commission.(3) A grantee is required under the contract to comply with:(A) the performance objectives established by the Commission and monitored by the Commission through progress reports;(B) any financial and reporting requirements established by the Commission;(C) all applicable policies and procedures; and(D) all applicable federal and state laws and their implementing regulations. Source Note: The provisions of this §374.4 adopted to be effective November 1, 2023, 48 TexReg 6213. 1 HEALTH AND HUMAN SERVICES COMMISSION 374 MENTAL HEALTH EARLY INTERVENTION AND TREATMENT GRANT §374.4 Application and Selection Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221887 03/12/2026 (a) The purpose of this chapter is to implement the Texas Birthing Center Licensing Act, Health and Safety Code, Chapter 244, which requires birthing centers (centers) to be licensed by the Department of State Health Services (department) and requires the department to adopt rules governing the licensing and regulation of centers.(b) This chapter establishes general provisions, licensing procedures, enforcement, and operational and clinical standards for the provision and coordination of treatment and services.(c) This chapter applies to all centers as defined in §137.2 of this title (relating to Definitions). Such centers must be licensed in accordance with the provisions of this chapter. A person may not engage in the business of providing center services, or represent to the public that the person is a provider of such services for pay or other consideration without a license. Source Note: The provisions of this §503.1 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS A GENERAL PROVISIONS §503.1 Purpose and Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221888 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Act--Texas Birthing Center Licensing Act, Health and Safety Code, Chapter 244, relating to the licensure and regulation of centers.(2) Acute postpartum period--A minimum of two hours following the delivery of the placenta and until the client is clinically stable.(3) Administrator--A person who is delegated the responsibility for the implementation and proper application of policies, programs, and services established for the center.(4) Admission--A client that is accepted by the center after a risk assessment is performed.(5) Affiliate--With respect to an applicant or owner which is:(A) a corporation--includes each officer, director, stockholder with a direct ownership of at least 5.0%, subsidiary, and parent company;(B) a limited liability company--includes each officer, member, and parent company;(C) an individual--includes:(i) the individual's spouse;(ii) each partnership and each partner thereof of which the individual or any affiliate of the individual is a partner; and(iii) each corporation in which the individual is an officer, director, or stockholder with a direct ownership of at least 5.0%;(D) a partnership--includes each partner and any parent company; and(E) a group of co-owners under any other business arrangement--includes each officer, director, or the equivalent under the specific business arrangement and each parent company.(6) Applicant--The owner of a center which is applying for a license under the Act. This is the person in whose name the license will be issued.(7) Birth attendant--A physician, certified nurse-midwife (CNM), or a licensed midwife.(8) Center--A facility, place, or institution where a woman is scheduled to give birth. This term does not include a hospital, ambulatory surgical center, a nursing home, or the residence of the woman giving birth.(9) Certified nurse-midwife (CNM)--A person who is:(A) a registered nurse who is currently licensed under the Nursing Practice Act, Texas Occupations Code, Chapters 301, 303 and 304;(B) recognized as an advanced practice nurse by The Board of Nursing for the State of Texas; and(C) certified by the American College of Nurse-Midwives (ACNM) or ACNM Accreditation Council.(10) Client--A woman who is scheduled to give birth at a center and the newborn of that birth.(11) Clinical care--Direct provision of care to center clients.(12) Clinical care provider--A registered nurse (RN), licensed vocational nurse (LVN), physician assistant (PA), or adult unlicensed staff person who is capable of recognizing complications and who can care for the mother and newborn by performing the minimum duties set out in §137.48(d) of this title (relating to Labor and Birth Procedures).(13) Clinical director--A person who is responsible for advising and consulting with the staff of a center on all matters relating to the clinical management of all clients.(14) Critical item--All surgical instruments and objects that are introduced directly into the bloodstream or into other normally sterile areas of the body.(15) Decontamination--The physical and chemical process that renders an inanimate object safe for further handling.(16) Department--The Department of State Health Services.(17) Disinfection--The destruction or removal of vegetative bacteria, fungi, and most viruses but not necessarily spores; the process does not remove all organisms but reduces them to a level that is not harmful to health. There are three levels of disinfection:(A) high level disinfection--kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the Food and Drug Administration;(B) intermediate-level disinfection--kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a "tuberculocide" by the Environmental Protection Agency (EPA); and(C) low-level disinfection--kills some virus and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.(18) Health care facility--Any type of facility or home and community support services agency licensed (or equivalent) to provide health care in any state or certified for Medicare (Title XVIII) and Medicaid (Title XIX) participation in any state.(19) Hospital--A facility that is licensed under the Texas Hospital Licensing Law, Health and Safety Code, Chapter 241 or, if exempt from licensure, certified by the United States Department of Health and Human Services as in compliance with conditions of participation for hospitals in Title XVIII, Social Security Act (42 United States Code, §§1395 et seq.).(20) Initial license--The first license that is issued to an applicant indicating that the center meets all requirements of this chapter for a license.(21) Licensed health care professional--An individual licensed in the State of Texas to provide specific health care services within a defined scope of practice by their licensing rules or Act.(22) Licensed midwife--A person who practices midwifery and is licensed under the Texas Midwifery Act, Texas Occupations Code, Chapter 203.(23) Licensed premises--The location stated or described in the application that is licensed by the department.(24) Licensed vocational nurse (LVN)--A person who is currently licensed under the Nurse Practice Act, Texas Occupations Code, Chapters 301, 303, and 304, as a licensed vocational nurse.(25) Low-risk pregnancy--A pregnancy that is determined by history, application of a risk assessment, and prenatal care that broadly predicts an outcome of a normal, uncomplicated pregnancy.(26) Manager--The manager of the Facility Licensing Group of the Department of State Health Services or his or her designee.(27) Midwife--A certified nurse-midwife (CNM) or a licensed midwife.(28) Noncritical items--Items that come in contact with intact skin.(29) Notarized copy--A sworn affidavit stating that attached copies are true and correct copies of the original documents.(30) Person--An individual, firm, partnership, corporation, or association.(31) Physician--A person who is currently licensed under the Medical Practice Act, Texas Occupations Code, Chapters 151 - 165, to practice medicine.(32) Physician assistant (PA)--A person who is currently licensed under the Physician Assistant Licensing Act, Texas Occupations Code, Chapter 204, as a physician assistant.(33) Physician consultant--A physician who is currently licensed under the Medical Practice Act, Texas Occupations Code, Chapters 151 - 165, to practice medicine and who consults with a center.(34) Plan of correction--A written strategy for correcting a licensing violation. The plan of correction shall be developed by the facility and shall address the systems operations of the facility as the systems operations apply to the deficiency.(35) Policy--A written document which describes all procedures to be followed at the facility including medical and personnel issues which is to be maintained at the licensed premises for a minimum of five years.(36) Presurvey conference--A conference held with department staff and the applicant or his or her representatives to review licensure standards, survey documents, and provide consultation prior to the on-site licensure survey.(37) Quality assurance--An ongoing, objective, and systematic process of monitoring, evaluating, and improving the quality, appropriateness, and effectiveness of care.(38) Quality improvement--An organized, structured process that selectively identifies improvement projects to achieve improvements in products or services.(39) Referral hospital--A hospital that a center has identified as capable of providing care and services to mothers or infants who require the services of a physician.(40) Registered nurse (RN)--A person who is currently licensed under the Nurse Practice Act, Texas Occupations Code, Chapters 301, 303, and 304 as a registered nurse.(41) Risk-assessment--A process by which application of historical, physical, and laboratory data is used for the prediction of pregnancy outcome.(42) Semi-critical items--Items that come in contact with nonintact skin or mucous membranes. Semi-critical items may include respiratory therapy equipment and thermometers.(43) Standards--Minimum requirements under the Act and this chapter.(44) Sterile field--The operative area of the body and anything that directly contacts this area.(45) Sterilization--The use of a physical or chemical procedure to destroy all microbial life, including bacterial endospores.(46) Survey--A survey or investigation conducted by a representative of the department to determine if a licensee is in compliance with the statute and this chapter. A survey may be conducted onsite, by mail, by telephone, or by electronic communication methods. Source Note: The provisions of this §503.2 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS A GENERAL PROVISIONS §503.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221889 03/12/2026 (a) The schedule of fees for a license is as follows:(1) initial license fee is $2,000;(2) renewal license fee is $2,000; and(3) change of ownership license fee is $2,000.(b) The department will not consider an application as officially submitted until the applicant pays the licensing fee. The fee must accompany the application form.(c) A license fee paid to the department is not refundable.(d) Any remittance submitted to the department in payment of a required license fee must be in the form of a personal check, certified check, or money order made payable to the Department of State Health Services.(e) For all renewal licenses, the department is authorized to collect subscription and convenience fees, in amounts determined by the TexasOnline Authority, to recover costs associated with renewal processing through TexasOnline, in accordance with Texas Government Code, §2054.111.(f) The department may make periodic reviews of its license fee schedule to ensure that the fees imposed are in amounts reasonable and necessary to defray the cost to the department of administering the Act. Source Note: The provisions of this §503.3 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS A GENERAL PROVISIONS §503.3 Licensing Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221890 03/12/2026 (a) All first-time applications for a license are applications for an initial license.(b) The applicant must be at least 18 years of age.(c) A separate license is required for each place of business.(d) A center may not admit a client in labor until it has received an initial license.(e) The licensed location must be in Texas.(f) The owner of the center is responsible for ensuring the center's compliance with the Act and this chapter.(g) A license must be renewed biannually.(h) The license shall be displayed in a public area of the center that is readily accessible to patients, employees and visitors.(i) The license may not be transferred or assigned from one person to another person.(j) A center shall have the financial ability to carry out its functions under the Act and this chapter. Source Note: The provisions of this §503.4 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS A GENERAL PROVISIONS §503.4 General Provisions for Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221891 03/12/2026 (a) The application.(1) An applicant shall not misstate a material fact on any documents required to be submitted under this subsection.(2) The application form must be accurate and complete and must contain original signatures. The nonrefundable license fee must be submitted with the application.(3) The following information must be submitted on the original application form and the application shall be notarized:(A) information on the applicant including name, street address, mailing address, social security number or federal tax identification number, and if applicable, date of birth and driver's license number;(B) the name, mailing address, and street address of the center. The street address provided on the application must be the address from which the center will be operating and providing services;(C) a list of names and business addresses of all persons who own any percentage interest in the applicant including:(i) each limited partner and general partner if the applicant is a partnership; and(ii) each shareholder, member, director, and officer if the applicant is a corporation, limited liability company or other business entity;(D) a list of any businesses with which the applicant subcontracts and in which the persons listed under subparagraph (C) of this paragraph hold any percentage of the ownership;(E) if the applicant has held or holds a center license or has been or is an affiliate of another licensed center, the relationship, including the name and current or last address of the other center and the date such relationship commenced and, if applicable, the date it was terminated;(F) if the center is operated by or proposed to be operated under a management contract, the names and addresses of any person and organization having an ownership interest of any percentage in the management company;(G) a written plan for the orderly transfer of care of the applicant's clients and clinical records if the applicant is unable to maintain services under the license;(H) the organizational structure of the staffing for the center;(I) the names and addresses of the physicians, certified nurse-midwives, licensed midwives and other clinical care providers who will provide services at the center;(J) the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(i) any orders of denial, suspension, or revocation of a center license, a license for any health care facility in any state, or documentation as a midwife; or any other enforcement action, such as (but not limited to) court civil or criminal action;(ii) any orders of denial, suspension, or revocation of or other enforcement action against a center license, a license for any health care facility in any state, or documentation as a midwife which is or was proposed by the licensing agency and the status of the proposal;(iii) surrendering a license before expiration of the license or allowing a license to expire in lieu of the department proceeding with enforcement action;(iv) federal or state (any state) criminal felony arrests or convictions;(v) federal or state Medicaid or Medicare sanctions or penalties relating to the operation of a health care facility;(vi) operation of a health care facility that has been decertified in any state under Medicare or Medicaid; or(vii) debarment, exclusion, or contract cancellation in any state from Medicare or Medicaid;(K) for the two-year period preceding the application date, the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(i) federal or state (any state) criminal misdemeanor arrests or convictions;(ii) federal or state (any state) tax liens;(iii) unsatisfied final judgement(s);(iv) eviction involving any property or space used as a center or health care facility in any state;(v) injunctive orders from any court; or(vi) unresolved final state or federal Medicare or Medicaid audit exceptions; and(L) the telephone number, and fax number (if available) of the center and the telephone number where the administrator can usually be reached when the center is closed.(b) Applicant copy. The applicant shall retain a copy of all documentation that is submitted to the department.(c) Application processing. Upon the department's receipt of the application form, the required information described in subsection (a)(3) of this section, and the initial license fee from an applicant, the department shall review the material to determine whether it is complete and correct.(1) The time periods for reviewing the material shall be in accordance with §137.13 of this title (relating to Time Periods for Processing and Issuing a License).(2) If a center receives a notice from the department that some or all of the information required under subsection (a)(3) of this section is deficient, the center shall submit the required information no later than 60 calendar days from the date of the notice.(A) A center which fails to submit the required information within 60 calendar days from the notice date is considered to have withdrawn its application for an initial license. The license fee will not be refunded.(B) A center which has withdrawn its application must reapply for a license in accordance with this section, if it wishes to continue the application process. A new license fee is required.(d) Withdrawal of application process. If an applicant decides at any time not to continue the application process for an initial license, the application will be withdrawn upon written request from the applicant. The license fee will not be refunded.(e) Issuance of an initial license and renewal procedures.(1) Presurvey conference. Once the department has determined that the application form, the information required to accompany the application form, and the license fee are complete and correct, a representative from the department shall schedule a presurvey conference with the applicant in order to inform the applicant of the standards for the operation of the center. The presurvey conference may be waived by the department.(2) Survey recommendation.(A) The survey office shall verify compliance with the applicable provisions of the Act and this chapter and recommend that the center be issued an initial license or that the application be denied pursuant to §137.22 of this title (relating to License Denial, Suspension, Probation, or Revocation).(B) Upon recommendation by the survey office:(i) the department shall issue an initial license to an applicant that has been found to be in compliance with the provisions of the Act and this chapter; or(ii) the department shall deny the application if the center has been found to be out of compliance with the provisions of the Act and this chapter. The procedure for denial of a license shall be in accordance with §137.22 of this title.(3) Effective period of initial license. The initial license is valid for 24 months. The initial license expires on the last day of the month ending the licensure period.(4) General requirements during the initial license period.(A) A center shall comply with the provisions of the Act and this chapter during the initial license period.(B) If an applicant decides not to continue the application process, the application will be withdrawn upon written request. If an initial license has been issued, the applicant shall cease providing services and return the original license certificate to the department with its written request to withdraw. The department shall acknowledge receipt of the request to withdraw. The license fee will not be refunded.(f) Procedures for renewing a license.(1) The department will send notice of expiration to a licensee at least 60 calendar days before the expiration date of a license. If the licensee has not received notice of expiration from the department 45 calendar days prior to the expiration date, it is the duty of the licensee to notify the department and request a renewal form.(2) The licensee shall submit the renewal form to the department postmarked no later than 30 calendar days prior to the expiration date of the license:(A) a complete and correct renewal form which includes updated disclosure information and ownership and management information as required by subsection (a)(3) of this section; and(B) the renewal license fee.(3) The time periods for processing an application shall be in accordance with §137.13 of this title.(4) If timely and sufficient application is made for renewal, the license will not expire until the department issues the license or until the department denies renewal of the license.(5) The department shall issue a renewal license to a licensee who meets the minimum standards for a license in accordance with the provisions of the Act and this chapter.(6) Renewal licenses will be valid for 24 months.(g) Failure to timely renew.(1) General.(A) If a licensee fails to submit a timely and sufficient renewal form and fee in accordance with subsection (f) of this section, the department shall notify the licensee that the center must cease operation on the expiration date of the license.(B) No services shall be provided at the center after the expiration of the license.(2) Active military duty exception. If a licensee fails to timely renew his or her license because the licensee is or was on active duty with the armed forces of the United States of America serving outside the State of Texas, the licensee may renew the license pursuant to this paragraph.(A) Renewal of the license may be requested by the licensee, the licensee's spouse, or an individual having power of attorney from the licensee. The renewal form shall include a current address and telephone number for the individual requesting the renewal.(B) Renewal may be requested before or after the expiration of the license.(C) A copy of the official orders or other official military documentation showing that the licensee is or was on active military duty serving outside the State of Texas shall be filed with the department along with the renewal form.(D) A copy of the power of attorney from the licensee shall be filed with the department along with the renewal form if the individual having the power of attorney executes any of the documents required in this section.(E) A licensee renewing under this paragraph shall pay the applicable renewal fee.(F) A licensee is not authorized to operate the center for which the license was obtained after the expiration of the license unless and until the licensee actually renews the license.(G) This paragraph applies to a licensee who is a sole practitioner or a partnership with only individuals as partners where all of the partners were on active duty with the armed forces of the United States serving outside the State of Texas.(h) General requirements for renewal of license.(1) After the issuance of the initial license, a licensee is eligible for subsequent renewal of the license biannually if the licensee continues to comply with the provisions of the Act and this chapter and has applied for renewal of the license in accordance with subsection (f) of this section.(2) If a licensee makes a timely and sufficient application for renewal of a license, and an action to revoke, suspend, or deny renewal of the license is pending, the license does not expire but does extend until the application for renewal is granted or denied after the opportunity for a formal hearing. A renewal license will not be issued unless the department has determined the reason for the proposed action no longer exists.(3) Continuing compliance by the center with the provisions of the Act and this chapter is required during the previous 24-month license period in order for the license to be renewed.(4) The licensee shall not misstate or omit a material fact on any documents required to be submitted to the department or required to be maintained by the center in accordance with the provisions of the Act and this chapter.(5) During the license period, the center shall provide services to one or more clients and document the provision of services. The center must show proof that services have been provided under the license within the previous 24 months. Such documentation shall be available for review by a department surveyor.(6) If a licensee decides not to continue the application process for the renewal of a license, the application may be withdrawn upon written request. The applicant shall cease providing services and return the original license certificate to the department with its written request to withdraw. The department shall acknowledge receipt of the request to withdraw. The license fee will not be refunded.(i) On-site surveys. On-site surveys of the center shall be performed at a frequency prescribed by and in accordance with §137.21 of this title (relating to On-Site Surveys). Source Note: The provisions of this §503.11 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS B LICENSING PROCEDURES §503.11 Application Procedures and Issuance of Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221892 03/12/2026 (a) The following provisions apply to a change of ownership of a center and affect the condition of a license.(1) A license is not transferable or assignable from one person to another person.(2) A license issued by the department may not be materially altered in any way.(3) A change of ownership of a center is effective when the name of the licensed person reflected on the license certificate and original application is changed by the department to reflect the name of the person applying for the change of ownership.(4) A person who desires to receive a license in its name for a center licensed under the name of another person or to change the ownership of any center shall submit a new license application and the initial license fee at least 60 calendar days prior to the desired date of the change of ownership. The application shall be in accordance with §137.11(a) of this title (relating to Application Procedures and Issuance of Licenses).(5) An application for a change of ownership shall include a notarized affidavit signed by the previous owner acknowledging agreement with the change of ownership. If the applicant is a corporation, the application shall include a copy of the applicant's articles of incorporation. If the applicant is a business entity other than a corporation, the applicant shall include a copy of the sales agreement.(6) The previous owner's license shall be void on the effective date of the change of ownership.(7) This subsection does not apply if a licensee is simply revising its name as allowed by law (i.e., a corporation is amending the articles of incorporation to revise its name).(8) The sale of stock of a corporate licensee does not cause this subsection to apply.(b) The following business changes affect the condition of a license and shall be reported to the department.(1) If a center changes its business name, business address, telephone number of the center, administrator's telephone number, or fax number, the administrator must notify the department in writing within 15 calendar days after the effective date of the change.(2) If a center changes its administrator, the center shall provide the name of the new administrator and effective date to the department in writing no later than 30 calendar days following such change.(c) The licensee shall notify the department in writing within 15 calendar days when a center ceases operation. The licensee shall return the original license certificate to the department with the written notification. Source Note: The provisions of this §503.12 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS B LICENSING PROCEDURES §503.12 Change of Ownership or Services and Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221893 03/12/2026 (a) Definition. For purposes of this section, license means a license, permit, registration, or certificate issued by the Department of State Health Services (department) for a birthing center.(b) General. Time periods for processing and issuing a license.(1) The date a license application is received is the date the application reaches the Facility Licensing Group of the Department of State Health Services (department).(2) An application for an initial license is complete when the department has received, reviewed, and found acceptable the information described in §137.11(a)(3) of this title (relating to Application Procedures and Issuance of Licenses).(3) An application for a renewal license is complete when the department has received, reviewed, and found acceptable the information described in §137.11(f)(2) of this title.(4) An application for a change of ownership license is complete when the department has received, reviewed, and found acceptable the information described in §137.12 of this title (relating to Change of Ownership or Services and Closure).(c) Time periods. An application from a center for an initial license, renewal license, or change of ownership license shall be processed in accordance with the following time periods.(1) The first time period begins on the date the department receives the application and ends on the date the license is issued, or if the application is received incomplete, the period ends on the date the center is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 45 calendar days.(2) The second time period is 45 calendar days, which begins on the date the last item (information or fee) necessary to complete the application is received by the department and ends on the date the license is issued, or the facility is issued a written notice that the application is being proposed for denial.(3) If the applicant fails to submit the requested information and/or fee within 135 days of the date the department issued the written notice to the applicant as described in paragraph (1) of this subsection, that the application is incomplete and/or additional fees are owed, the application is considered withdrawn. Fees paid are not refundable. There will be no refund of the fee except as provided by subsections (d) and (f) of this section. A new application and fee must be submitted to the department.(d) Reimbursement of fees.(1) In the event the application is not processed in the time periods stated in subsection (c) of this section, the applicant has the right to make a written request within 30 days of the end of the second period that the department reimburse in full the fee paid in that particular application process.(2) If the department finds that good cause existed for exceeding the established periods, the request will be denied. The department will notify the applicant in writing of the denial of the reimbursement within 30 days of the department's receipt of the request for reimbursement.(e) Good cause for exceeding the period established is considered to exist if:(1) the number of applications for licenses to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;(2) another public or private entity utilized in the application process caused the delay;(3) conditions in violation of the rules exist which are noted in recent investigations or inspections;(4) the application is being held pending completion of an investigation, inspection, or enforcement action;(5) the application is incomplete in information, signature, and/or fee amount submitted; or(6) other conditions existed giving good cause for exceeding the established periods.(f) Appeal. If the request for reimbursement as authorized by subsection (d)(1) of this section is denied, the applicant may, within 30 days of being notified of the denial, appeal to the department for a resolution of the dispute. The applicant shall give written notice to the department requesting reimbursement of the fee paid because the application was not processed within the established time period. Within 30 days of receiving the appeal, the department shall submit a written report to the commissioner of the facts related to the processing of the application and describing the good cause for exceeding the established time periods. The commissioner then has 30 days to make the final decision and provide written notification of the decision to the applicant and the manager.(g) Hearings shall be conducted under the provision of contested case hearings pursuant to the Fair Hearing Procedures found in §§1.51 - 1.55 of this title. Source Note: The provisions of this §503.13 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS B LICENSING PROCEDURES §503.13 Time Periods for Processing and Issuing a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221894 03/12/2026 (a) Requirement for on-site surveys. A representative of the department may enter the premises of a license applicant or license holder at reasonable times to conduct a survey incidental to the issuance of a license, and at other times as it considers necessary to ensure compliance with the Act and the rules adopted under the Act.(b) Initial on-site survey.(1) The department shall conduct the on-site survey within 90 calendar days of the date of issuance of the initial license to determine if the center meets the requirements of the Act and this chapter.(2) The on-site survey shall include a standard-by-standard evaluation.(3) At the time of the initial on-site survey, the center shall assure that the administrator or his or her designee(s) is present during the survey.(4) If at the time of the initial on-site survey, the center has not admitted its first client for antepartum, intrapartum, or postpartum care, the center must notify the Manager, Health Facility Compliance Group, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756, when the first such admission and care delivery does occur.(A) Within seven calendar days of the first client admission, the center shall submit a copy of the clinical record to the department for review.(B) The department shall review the clinical record(s) to evaluate the center's compliance with the care delivery standards of this chapter.(5) Upon completion of the on-site survey, a department surveyor shall verify a center's compliance with the provisions of the Act and this chapter and recommend to the department:(A) that the center's initial license be continued for the duration of the initial license period; or(B) that the department propose an enforcement action.(c) Subsequent on-site surveys. After the initial on-site survey that is required for an initial license under subsection (b) of this section, an on-site survey shall be performed at least every three years with the following exceptions.(1) If the department has written deficiencies for the center under the following provisions of this chapter, that may pose a threat to the health and safety of the center's clients and/or staff, the department shall conduct another on-site survey no later than one year after issuance of the initial or renewal license:(A) §137.31 of this title (relating to Operational and Clinical Policies);(B) §137.32 of this title (relating to Organizational Structure and Delegation of Authority);(C) §137.33(4) and (5) of this title (relating to Personnel Policies);(D) §137.34 of this title (relating to Qualifications and Duties of Staff);(E) §137.36 of this title (relating to Physical and Environmental Requirements for Centers);(F) §137.37 of this title (relating to Infection Control Standards);(G) §137.38 of this title (relating to Disposition of Medical Waste);(H) §137.39 of this title (relating to General Requirements for the Provision and Coordination of Treatment and Services);(I) §137.40 of this title (relating to Risk Assessments);(J) §137.41 of this title (relating to Emergency Services);(K) §137.48 of this title (relating to Labor and Birth Procedures);(L) §137.49 of this title (relating to Care of the Newborn);(M) §137.50 of this title (relating to Discharge Procedures); and(N) §137.55 of this title (relating to Other State and Federal Compliance Requirements).(2) If the department has taken enforcement action against a center and the action allowed the center to remain licensed, the department shall conduct another on-site survey.(3) This subsection does not limit complaint surveys by the department.(d) Survey procedures.(1) Prior to the survey, the department may notify the applicant or licensee, in writing by fax or mail to the mailing address of the center, of the date and time of the survey. The department is not required to notify the applicant or licensee prior to a complaint investigation.(2) At the start of the survey, the department's surveyor shall notify the person who is in charge of a center of the nature and scope of the survey.(3) Except for a complaint investigation or a follow-up visit, a survey will include a standard-by-standard evaluation.(4) When the survey is completed, the surveyor shall hold an exit conference and fully inform the person who is in charge of the center of the preliminary findings of the survey and shall give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings. A written response may be filed and must be received by the department within 14 calendar days of receipt of the preliminary findings of the survey by the center. The surveyor shall identify any records that were duplicated. Any original center records that are removed from a center shall be removed only with the consent of the center.(5) After the survey is completed, the department shall provide the administrator of the center specific and timely written notice of the findings of the survey within 14 calendar days of the exit conference.(6) If the department determines that the center is in compliance with minimum standards at the time of the on-site inspection, the department will send a license to the center, if applicable.(7) If the surveyor determines there are no deficiencies found, a statement shall be provided to the center indicating this fact.(8) If the surveyor finds there are deficiencies, the center and the department shall comply with the following procedure.(A) The department shall provide the center with a statement of deficiencies within 14 calendar days of the exit conference.(B) The center administrator shall sign the written statement of deficiencies and return it to the department with its plan of correction(s) for each deficiency within 14 calendar days of its receipt of the statement of deficiencies. The signature does not indicate the person's agreement with deficiencies stated on the form.(C) The department shall determine if the written plan of correction is acceptable. If the plan of correction(s) is not acceptable to the department, the department shall notify the center and request that the plan of correction be modified and resubmitted no later than 14 calendar days from the date notified.(D) The center shall come into compliance in accordance with the plan of correction or no later than 60 calendar days prior to the expiration of the license, whichever is sooner.(E) Acceptance of a plan of correction by the department does not preclude the department from taking enforcement action as appropriate under §137.22 of this title (relating to License Denial, Suspension, Probation, or Revocation).(9) The department may refer issues and complaints relating to the conduct or actions by licensed health care professionals to their appropriate boards. Source Note: The provisions of this §503.21 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.21 On-Site Surveys https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221895 03/12/2026 (a) The department may deny, suspend, or revoke a license if the licensee or the center:(1) violates a provision of Texas Birthing Center Licensing Act, Health and Safety Code, Chapter 244;(2) fails to meet a requirement of this chapter;(3) fails to comply with an order of the commissioner of health or another enforcement procedure under the Act;(4) is involved in any action as described in §137.11(a)(3)(J) - (K) of this title (relating to Application Procedures and Issuance of Licenses); or(5) has been convicted of a felony or misdemeanor if the crime directly relates to the duties and responsibilities of a center.(A) In determining whether a criminal conviction directly relates, the department shall consider the provisions of Texas Occupations Code, Chapter 53.(B) The department may deny a person a license or suspend or revoke an existing license on the grounds that the person has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility. The department shall apply the requirements of the Texas Occupations Code, Chapter 53.(i) The department is entitled to obtain criminal history information maintained by the Texas Department of Public Safety (Government Code, §411.122), the Federal Bureau of Investigation Identification Division (Government Code, §411.087) or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.(ii) In determining whether a criminal conviction directly relates, the department shall consider the provisions of the Texas Occupations Code, §53.022 and §53.023.(iii) The following felonies and misdemeanors directly relate because these criminal offenses adversely affect a person's ability to own or operate a facility:(I) a misdemeanor or felony involving moral turpitude;(II) a misdemeanor or felony relating to deceptive business practices;(III) a misdemeanor or felony of practicing any health-related profession without a required license;(IV) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(V) a misdemeanor or felony under the Texas Penal Code (TPC):(-a-) Title 4 - offenses of attempting or conspiring to commit any of the offenses in this clause;(-b-) Title 5 - offenses against the person;(-c-) Title 7 - offenses against property;(-d-) Title 8 - offenses against public administration;(-e-) Title 9 - offenses against public order and decency;(-f-) Title 10 - offenses against public health, safety or morals; or(-g-) Title 11 - offenses involving organized crime.(VI) offenses listed in clause (iii) of this subparagraph are not exclusive in that the department may consider similar criminal convictions from other state, federal, foreign or military jurisdictions which indicate an inability or tendency for the person to be unable to own or operate a facility.(VII) a license holder's license shall be revoked on the license holder's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(6) fails to comply with applicable requirements within a designated probation period;(7) has a history of failure to comply with the rules adopted under this chapter;(8) has aided, abetted or permitted the commission of an illegal act;(9) has committed fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to the department or required to be maintained by the facility pursuant to the provisions of this chapter;(10) fails to pay administrative penalties; or(11) fails to implement plans of corrections to deficiencies cited by the department.(b) Notice. If the department proposes to deny, suspend or revoke a license, the department shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of the department or the department may personally deliver the notice. The notice to deny, suspend, or revoke a license shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before the action taken is final.(c) Within 25 days after the date of the notice, the applicant or license holder may notify the department, in writing, of acceptance of the department's determination. If the applicant or license holder does not accept the proposed action, a hearing may be requested. The request for a hearing must be submitted in writing to the Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756.(1) A hearing shall be conducted pursuant to the Administrative Procedure Act, Texas Government Code, Chapter 2001 and the department's formal hearing procedures in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures).(2) If the applicant or licensee does not request a hearing in writing within 25 days after the date of the notice, the licensee is deemed to have waived the opportunity for a hearing and the proposed action shall be taken.(3) If the applicant or licensee fails to appear or be represented at the scheduled hearing, the applicant or licensee is deemed to have waived the right to a hearing and the proposed action shall be taken.(d) A person who has had a center license revoked under this section may not apply for a license under this chapter for one year following the date of revocation.(e) Probation. In lieu of suspending or revoking the license, the department may schedule the facility for a probation period of not less than 30 days if the facility is found in repeated noncompliance and the facility's noncompliance does not endanger the health and safety of the public.(f) After a survey in which deficiencies were cited by the surveyor, a center may submit its license for voluntary cancellation in lieu of the department proceeding with enforcement action. The department may accept such submission or reject it and proceed with an enforcement action. The center, its owner(s), and its affiliates may not reapply for a license for six months from the date of the surrender or expiration.(g) If the department suspends a license, the suspension shall remain in effect until the department determines that the reason for suspension no longer exists. A department surveyor shall conduct a survey of the center prior to making a determination.(1) During the time of suspension, the suspended license holder shall return the original license certificate to the department.(2) If a suspension overlaps a renewal date, the suspended license holder shall comply with the renewal procedures in this chapter; however, the department may not renew the license until the department determines that the reason for suspension no longer exists.(3) If suspension is for more than one year, the suspended license holder may apply to the department for cancellation of the suspension only after one year following the initial date of the suspension.(h) If the department denies, revokes, or does not renew a license, a person may reapply for a license (subject to subsection (b) of this section), by complying with the requirements and procedures in this chapter at the time of reapplication. The department may refuse to issue a license if the reason for denial, revocation, or non-renewal continues to exist and may consider the enforcement history of the applicant, administrator or clinical director in making such a determination.(i) Upon revocation or nonrenewal, a license holder shall return the original license certificate to the department. Source Note: The provisions of this §503.22 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.22 License Denial, Suspension, Probation, or Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221896 03/12/2026 (a) The department may issue an emergency order to suspend a license issued under this chapter if the department has reasonable cause to believe that the conduct of a license holder creates an immediate danger to the public health and safety.(b) On written request of the license holder, the department shall conduct a hearing to determine if the emergency suspension is to continue, to be modified or to be rescinded. The hearing shall not be conducted earlier than the seventh day or later than the 10th day after the date the notice of the emergency suspension is sent to the license holder.(c) The hearing and any appeal are governed by the department's rules for a contested case hearing and Government Code, Chapter 2001. Source Note: The provisions of this §503.23 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.23 Emergency Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221897 03/12/2026 (a) Imposition of penalty.(1) The department may impose an administrative penalty on a person licensed under this chapter who violates the Act, this chapter, or an order adopted under this chapter.(2) A penalty collected under this section shall be deposited in the state treasury in the general revenue fund.(3) A proceeding to impose the penalty is considered to be a contested case under Government Code, Chapter 2001.(b) Amount of penalty.(1) The amount of the penalty may not exceed $1,000 for each violation. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty. The total amount of the penalty assessed for a violation continuing or occurring on separate days under this paragraph may not exceed $5,000.(2) In determining the amount of an administrative penalty assessed under this section, the department shall consider:(A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(B) the threat to health or safety caused by the violation;(C) the history of previous violations;(D) the amount necessary to deter a future violation;(E) whether the violator demonstrated good faith, including whether the violator made good faith efforts to correct the violation; and(F) any other matter that justice may require.(c) Report and notice of violation and penalty.(1) If the department initially determines that a violation occurred, the department shall give written notice of the report by certified mail to the person alleged to have committed the violation following the survey exit date.(2) The notice must include:(A) a brief summary of the alleged violation;(B) a statement of the amount of the recommended penalty based on the factors listed in subsection (b)(2) of this section; and(C) a statement of the person's right to a hearing on the occurrence of the violation, the amount of the penalty, or both.(d) Penalty to be paid or hearing requested.(1) Within 20 calendar days after the date the notice under subsection (c) of this section, is mailed, the person in writing may:(A) accept the determination and recommended penalty of the department; or(B) make a request for a hearing on the occurrence of the violation, the amount of the penalty, or both; and(C) request a pre-hearing conference to discuss the violation.(2) If the person accepts the determination and recommended penalty or if the person fails to respond to the notice, the commissioner of health (commissioner) or the commissioner's designee by order shall approve the determination and impose the recommended penalty.(e) Hearing.(1) If the person requests a hearing, it shall be conducted pursuant to the Administrative Procedure Act, Texas Government Code, Chapter 2001 and the department's formal hearing procedures.(2) All hearings shall be held in accordance with the requirements of the Health and Safety Code, Chapter 244.(f) Options following decision: pay or appeal. Within 30 calendar days after the date the order of the commissioner or commissioner's designee that imposes an administrative penalty becomes final, the person shall:(1) pay the penalty; or(2) appeal the penalty by filing a petition for judicial review of the commissioner's order contesting the occurrence of the violation, the amount of the penalty, or both; and(3) all appeals shall be under the substantial evidence rule.(g) Stay of enforcement of penalty. Stay of enforcement of penalty shall follow the procedures listed in Health and Safety Code, §244.016.(h) Collection of penalty. Collection of penalty shall follow the procedure listed in Health and Safety Code, §244.016.(i) Remittance of penalty and interest. The remittance of penalty and interest is governed by Health and Safety Code, §244.016(g). Source Note: The provisions of this §503.24 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.24 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221898 03/12/2026 (a) In accordance with §137.42 of this title (relating to Disclosure Requirements), all licensed centers are required to provide a client, and her guardian if the client is a minor or if guardianship is required, at the time of the initial visit, with a written statement that complaints relating to the center may be registered with the Manager, Health Facility Compliance Group, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756; Telephone (888) 973-0022; (512) 834-6650; and Fax (512) 834-6653.(b) Complaints may be registered with the department by telephone, fax or in writing at the address listed in subsection (a) of this section. A complainant may provide his or her name, address, and phone number to the department. Anonymous complaints may be registered if the complainant provides sufficient information.(c) The department will evaluate all complaints received.(d) A complaint containing allegations that are a violation of the Act or this chapter will be investigated by the department.(e) A department representative (surveyor) may enter the premises of a center at reasonable times as necessary to assure compliance with the Act and this chapter. The department is not required to notify the applicant or licensee prior to a complaint investigation.(f) If the department determines that the complaint does not come within the department's jurisdiction, the department shall advise the complainant and, if possible, refer the complainant to the appropriate governmental agency for handling such a complaint.(g) The department shall inform in writing a complainant who identifies himself or herself by name and address of the final disposition of the complaint.(h) A person may file a complaint with the department against a birthing center licensed under this chapter. A person who files a false complaint may be prosecuted under the Penal Code. Source Note: The provisions of this §503.25 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.25 Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221899 03/12/2026 (a) The department may appoint a monitor for a birthing center to ensure compliance with this chapter when the center's failure to comply with this chapter creates a serious threat to the health and safety of the public.(b) The birthing center shall be liable for the cost of the monitor.(c) The birthing center may propose up to three persons to act as a monitor. The department shall approve the monitor. The monitor shall be an individual or team of individuals, and must include a professional with birthing center experience. The monitor may not be or include individuals who are current or former employees of the birthing center or an affiliated facility. The purpose of the monitor is to observe, supervise, consult, and educate the birthing center employees, and report back to the department according to the terms of the agreed order.(d) A professional with birthing center experience shall:(1) have a minimum of three years clinical experience providing care to pregnant women and newborns;(2) be a certified nurse-midwife, licensed midwife, or physician with obstetrical experience; and(3) be currently licensed or certified in the State of Texas. Source Note: The provisions of this §503.26 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS C SURVEY PROCEDURES AND ENFORCEMENT §503.26 Appointment and Qualifications of a Monitor https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221900 03/12/2026 A center shall develop, implement, and enforce written policies governing the center's total operation and ensure that these policies are administered so as to provide quality health services in a safe environment. Source Note: The provisions of this §503.31 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.31 Operational and Clinical Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221901 03/12/2026 (a) A center shall establish a written organizational structure which shall clearly define the lines of authority and the delegation of responsibility for professional and nonprofessional staff.(b) The center shall appoint an administrator and a clinical director. The administrator and clinical director may be the same person and may be the owner.(1) The administrator shall be responsible for implementing and supervising the operational policies of the center.(2) The clinical director shall be responsible for implementing the clinical policies of the center.(c) The owner of a center is responsible for ensuring total compliance with the Act and the provisions of this chapter. Source Note: The provisions of this §503.32 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.32 Organizational Structure and Delegation of Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221902 03/12/2026 The center shall develop, implement, and enforce written policies governing all personnel staffed by the center. The personnel policies shall cover the following requirements:(1) job descriptions for all personnel providing client care;(2) orientation and training of all employees, volunteers, students and contractors;(3) an annual written evaluation of employee performance;(4) in-service and continuing education;(5) certification of all birth attendants by the American Heart Association or the American Red Cross in basic life support for health care providers; and(6) certification of all birth attendants by the American Academy of Pediatrics or the American Heart Association in neonatal resuscitation. Source Note: The provisions of this §503.33 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.33 Personnel Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221903 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221903 03/12/2026 (a) One person may act in the capacity of the administrator, the clinical director, and the birth attendant provided that person meets all the minimum qualifications set out in paragraphs (2)(A) and (3)(A) of this subsection and is capable of performing all of the duties specifically stated in paragraphs (1)(B), (2)(B), and (3)(B) of this subsection. The minimum qualifications and duties for the administrator, the clinical director, the birth attendant, other clinical care providers and nonprofessional personnel of a center are as follows.(1) Administrator.(A) Qualifications.(i) Shall not have been employed in the last year as an administrator with another center or health care facility at the time the center or facility was cited for violations of a licensing law or rule which resulted in enforcement action taken against the center or health related facility. For purposes of this clause only, the term "enforcement action" means license revocation, suspension, emergency suspension, or denial of a license or injunction action but does not include administrative or civil penalties.(ii) Shall not have been convicted of a felony or misdemeanor listed in §137.22 of this title (relating to License Denial, Suspension, Probation, or Revocation).(B) Duties.(i) Administratively supervise the provision of services at the center.(ii) Organize and direct the center's ongoing functions.(iii) Employ qualified staff.(iv) Ensure adequate education and evaluations of staff.(v) Supervise non-professional staff.(vi) Implement an effective budgeting and accounting system which must include an auditing system for monitoring state or federal funds. The administrator shall ensure all billings or insurance claims (e.g. Medicaid) submitted are accurate.(vii) Ensure that issues and complaints relating to the conduct or actions by licensed health care professional(s) are addressed and, if warranted, referred and reported to the appropriate board, and that such review and action taken is documented.(viii) Administratively conduct or supervise the resolution(s) of complaint(s) received from clients in the delivery of their care or services received at the center.(2) Clinical director.(A) Qualifications. A licensed physician, a certified nurse-midwife (CNM), or a licensed midwife.(B) Duties.(i) Develop, implement, and monitor the clinical policies of a birthing center and ensure the adherence to these policies.(ii) Advise and consult with the staff of the center on all matters relating to the clinical management of all clients.(iii) Supervise all birth attendants and all other persons who provide direct client care.(iv) Ensure the accuracy of public education information materials and activities in relation to pregnancy and birth, mother and newborn care, and the center.(3) Birth attendant.(A) Qualifications. A physician, certified nurse-midwife (CNM), or a licensed midwife.(B) Duties. Responsible for the clinical care provided to clients of the center.(4) Other clinical care providers.(A) Qualifications. Licensed, certified or trained appropriately for the care to be provided. Prior to providing direct client care the clinical director shall verify licensure, certification or competence. Shall be certified in CPR for health care providers.(B) Duties. Provides care only under the supervision of a birth attendant in accordance with all laws, rules and policies appropriate to his or her professional scope of practice.(5) Nonprofessional staff.(A) Qualifications. Nonprofessional staff must be able to demonstrate the knowledge, skills, and abilities of their specified job duty within the center. This staff must be at least 16 years old.(B) Duties. Responsible for the provision of nonclinical services such as housekeeping, laundry, and sanitation in the operation of the center.(b) A center shall ensure that its birth attendants meet the following requirements.(1) Licensed midwives must be licensed in accordance with Texas Midwifery Act, Occupations Code, Chapter 203.(2) Certified nurse-midwives (CNM) must maintain certification as a CNM as defined in §137.2 of this title (relating to Definitions).(3) Physicians must maintain current licensure as a physician as defined in §137.2 of this title.(c) A center shall ensure that the personnel record for each employee includes:(1) job descriptions for all personnel providing client care;(2) orientation and training of all employees, volunteers, students and contractors;(3) an annual written evaluation of employee performance;(4) in-service and continuing education;(5) evidence of current certification of all birth attendants by the American Heart Association or the American Red Cross in basic life support and the American Academy of Pediatrics or the American Heart Association in neonatal resuscitation; and(6) verification of current licensure or a current copy of the license for licensed personnel. Source Note: The provisions of this §503.34 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.34 Qualifications and Duties of Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221904 03/12/2026 The physical and environmental requirements for a center are as follows.(1) The center shall be located within a recommended 20 minutes but with a required maximum of 30 minutes normal driving time of a referral hospital. The department may approve the location of a center that is located a further distance away if the department finds that the health and safety of the clients of the center will not be adversely affected.(2) The center must have the capacity to provide clients with liquid nourishment. The center may provide commercially packaged food to clients in individual servings. If other food is provided by the center, it will be subject to the requirements of Chapter 228 of this title (relating to Retail Food).(3) The center must have a safe and sanitary environment equipped and maintained to protect the health and safety of clients and staff.(4) The center shall provide clean hand washing facilities for clients and staff including running water and soap.(5) The center must have two functioning sinks and one toilet.(6) The center must be equipped with emergency lighting and have a written fire and disaster plan.(7) The center must have equipment available to sterilize instruments, equipment, and supplies before reuse in the center in accordance with §137.37 of this title (relating to Infection Control Standards). Source Note: The provisions of this §503.36 adopted to be effective December 2, 2007, 32 TexReg 8507; amended to be effective February 18, 2018, 43 TexReg 577; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.36 Physical and Environmental Requirements for Centers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221905 03/12/2026 (a) A center shall develop, implement, and enforce written infection control policies and procedures to minimize the transmission of infection. Policies shall include educational course requirements; cleaning and laundry requirements; and decontamination, disinfection, sterilization, and storage of sterile supplies.(b) Universal/standard precautions.(1) Ensure that all staff complies with universal/standard precautions.(2) Establish procedures for monitoring compliance with universal/standard precautions.(3) Enforce a policy to ensure compliance of the center and all of the health care workers within the center with the Health and Safety Code, Chapter 85, Subchapter I, concerning the prevention of the transmission of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) by infected health care workers.(4) Require its health care workers to complete educational course work or training in infection control and barrier precautions, including basic concepts of disease transmission, scientifically accepted principles and practices for infection control and engineering and work practice controls.(c) Cleaning and laundry.(1) Adopt policies and procedures on cleaning the center.(2) Adopt policies and procedures for the handling, processing, storing, and transporting of clean and dirty laundry.(3) A center may provide cleaning and laundry services directly or by contract in accordance with Occupational Safety and Health Association standards.(d) Policies shall include receiving, cleaning, decontaminating, disinfecting, preparing and sterilization of critical items (reusable items), as well as those for the assembly, wrapping, storage, distribution, and quality control of sterile items and equipment.(1) Supervision. Shall be under the supervision of the clinical director.(2) Quantity of sterile surgical instruments. Ensure that surgical instruments are sufficient in number to meet the needs of the center.(3) Inspection of surgical instruments.(A) All instruments shall undergo inspection before being packaged for reuse or storage. Routine inspection of instruments shall be made to assure clean locks, crevices, and serrations.(B) Inspection procedures shall be thorough and include visual and manual inspection for condition and function.(i) Cutting edges shall be checked for sharpness; tips shall be properly aligned, and instruments shall be clean and free from buildup of soap, detergent, dried blood, or tissue.(ii) There shall be no evident cracks or fissures, and the hinges shall work freely.(iii) There shall be no corrosion or pitting of the finish.(iv) Rachets shall hold and be routinely tested.(C) Instruments needing maintenance shall be taken out of service and repaired by a qualified surgical instruments repair person.(D) Instrument identification shall not damage the instrument or its protective finish or compromise the sterilization process.(4) Items to be disinfected and sterilized.(A) Critical items.(i) Must be sterilized in accordance with this subsection.(ii) All items that come in contact with a sterile field during an operative procedure must be sterile.(B) Semi-critical items. High-level disinfection shall be used for semi-critical items.(C) Noncritical items. Intermediate-level or low-level disinfection shall be used for noncritical items.(5) Equipment and sterilization procedures. Effective sterilization of instruments depends on performing correct methods of cleaning, packaging, arrangement of items in the sterilizer, and storage. The following procedures shall be included in the written policies as required in this paragraph to provide effective sterilization measures.(A) Equipment. A center shall provide sterilization equipment adequate to meet the requirements for sterilization of critical items. Equipment shall be maintained and operated to perform, with accuracy, the sterilization of critical items.(B) Sterilizers. Steam sterilizers (saturated steam under pressure) shall be utilized for sterilization of heat and moisture stable items. Steam sterilizers shall be used according to manufacturer's written instructions.(C) Environmental requirements. Where cleaning, preparation, and sterilization functions are performed in the same room or unit, soiled or contaminated supplies and equipment shall be physically separated from the clean or sterilized supplies and equipment.(i) A center shall have a sink for hand washing. This sink shall not be used for cleaning instruments or disposal of liquid waste.(ii) A center shall have a separate sink for cleaning instruments and disposal of liquid waste. Hand washing may only be performed at this sink after it has been disinfected.(D) Preparation for sterilization.(i) All items to be sterilized shall be prepared to reduce the bioburden. All items shall be thoroughly cleaned, decontaminated, and prepared in a clean, controlled environment.(ii) One of the following methods of cleaning and decontamination shall be used as appropriate.(I) Manual cleaning. Manual cleaning of instruments at the sink is permitted.(II) Ultrasonic cleaning. The water must be changed more than once a shift. The chambers shall be covered to prevent potential hazards to personnel from aerosolization of the contents.(III) Washer-sterilizers. These machines must reach a temperature of 140 degrees Celsius (285 degrees Fahrenheit).(IV) Washer-decontaminator machines.(iii) All articles to be sterilized shall be arranged so all surfaces will be directly exposed to the sterilizing agent for the prescribed time and temperature.(E) Packaging.(i) All wrapped articles to be sterilized shall be packaged in materials recommended for the specific type of sterilizer and material to be sterilized, and to provide an effective barrier to microorganisms. Acceptable packaging includes peel pouches, perforated metal trays, or rigid trays. Muslin packs must be limited in size to 12 inches by 12 inches by 20 inches with a maximum weight of 12 pounds. Wrapped instrument trays must not exceed 17 pounds.(ii) All items shall be labeled for each sterilizer load as to the date and time of sterilization, the sterilizing load number, and the equipment.(F) External chemical indicators.(i) External chemical indicators, also known as sterilization process indicators, shall be used on each package to be sterilized, including items being flash sterilized to indicate that items have been exposed to the sterilization process.(ii) The indicator results shall be interpreted according to the manufacturer's written instructions and indicator reaction specifications.(G) Biological indicators.(i) The efficacy of the sterilizing process shall be monitored with reliable biological indicators appropriate for the type of sterilizer used.(ii) Biological indicators shall be included in at least one run a month.(iii) If a test is positive, the sterilizer shall immediately be taken out of service. A malfunctioning sterilizer shall not be put back into use until it has been serviced and successfully tested according to the manufacturer's recommendations.(iv) All available items shall be recalled and reprocessed if a sterilizer malfunction is found; and a list of all items which were used after the last negative biological indicator test shall be submitted to the administrator.(H) Sterilizers. Sterilizers shall be used according to manufacturer's written instructions.(I) Maintenance of sterility.(i) Items that are properly packaged and sterilized will remain sterile indefinitely unless the package becomes wet or torn, has a broken seal, is damaged in some way, or is suspected of being compromised.(ii) All packages must be inspected before use. If a package is torn, wet, discolored, has a broken seal, or is damaged, the item may not be used. The item must be returned to sterile processing for reprocessing.(J) Commercially packaged items. Commercially packaged items are considered sterile according to the manufacturer's instructions.(K) Storage of sterilized items. The loss of sterility is event-related, not time related. The center shall ensure proper storage and handling of items in a manner that does not aid the compromise of the packaging of the product.(i) Sterilized items shall be transported so as to maintain cleanliness, sterility, and to prevent physical damage.(ii) Sterilized items shall be stored in well-ventilated, limited access areas with controlled temperature and humidity.(iii) Sterilized items shall be positioned so that the packaging is not crushed, bent, compressed, or punctured.(iv) Storage of supplies shall be in areas that are designated for storage.(L) Disinfection.(i) The manufacturer's written instructions for the use of disinfectants shall be followed.(ii) An expiration date, determined according to manufacturer's written recommendations, shall be marked on the container of disinfection solution currently in use.(iii) Disinfectant solutions shall be kept covered and used in well-ventilated areas.(M) Performance records.(i) Performance records for all sterilizers shall be maintained for each cycle. These records shall be retained and available for review for a minimum of two years.(ii) Each sterilizer shall be monitored during operation for pressure, temperature, and time at desired temperature and pressure. A record shall be maintained either manually or machine generated and shall include:(I) the sterilizer identification;(II) sterilization date and time;(III) load number;(IV) duration and temperature of exposure phase;(V) identification of operator(s);(VI) results of biological tests and dates performed; and(VII) time-temperature recording charts from each sterilizer.(N) Preventive maintenance of all sterilizers shall be performed according to policy on a scheduled basis by qualified personnel, using the sterilizer manufacturer's service manual as a reference. A record shall be maintained for each sterilizer, retained at least two years, and shall be available for review. Source Note: The provisions of this §503.37 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.37 Infection Control Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221906 03/12/2026 A center shall meet requirements set forth by the department in §§1.131 - 1.137 of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(1) All special waste including blood, body fluids, placentas, sharps and biological indicators, shall be disposed of in accordance with §§1.131 - 1.137 of this title.(2) Placentas shall not be placed in the trash or dumpster for disposal.(3) A center may give the placenta to the client at the time of discharge upon request by the client. Source Note: The provisions of this §503.38 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.38 Disposition of Medical Waste https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221907 03/12/2026 (a) A center shall develop, implement, and enforce policies for the provision and coordination of treatment and services.(b) The center is responsible for all care provided to center clients on its licensed premises.(c) A center and the client shall have a written agreement for services. The center shall obtain an acknowledgment of receipt of the agreement. The center shall comply with the terms of the agreement. The written agreement shall include the following:(1) services to be provided;(2) who will provide the services; and(3) charges for services rendered.(d) When services are provided through a contract, a center must assure that these services are also provided in a safe and effective manner. If a center utilizes independent contractors, there shall be a written agreement between such independent contractors (i.e., per hour, per visit) and the center. The agreement shall be enforced by the center and clearly designate:(1) that clients are accepted for care only by the center;(2) the services to be provided by both parties;(3) the necessity to conform to the Act, this chapter, and all applicable center policies, including personnel qualifications; and(4) the manner in which services will be coordinated and evaluated by the center.(e) A center shall not commit an intentional or negligent act that adversely affects the health or safety of a client.(f) A center must ensure that its licensed health care professionals practice within the scope of their practice and within the constraints of applicable state laws and regulations governing their practice and must follow the facility's written policies and procedures.(g) A center may accept student midwives to provide them with clinical experience.(h) If a center has a contract or agreement with an accredited school of health care to use their center for a portion of a student's clinical experience, those students may provide care under the following conditions.(1) Students may be used in centers, provided the instructor gives classroom supervision and assumes responsibility for all student activities occurring within the center.(2) A student may administer medications only if:(A) on assignment as a student enrolled in their school of health care; and(B) the birth attendant within their licensed scope of practice is on the premises and directly supervises the administration of medication by the student.(3) Students shall not be considered when determining staffing needs required by the center.(i) A center shall comply with the following balance billing requirements.(1) A center may not violate a law that prohibits the center from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A center shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the center.(j) A center shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §503.39 adopted to be effective December 2, 2007, 32 TexReg 8507; amended to be effective April 15, 2021, 46 TexReg 2422; amended to be effective August 18, 2024, 49 TexReg 6217; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.39 General Requirements for the Provision and Coordination of Treatment and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221908 03/12/2026 (a) Risk assessment system. A center shall adopt, implement, and enforce a written risk assessment system that complies with this section, conforms to accepted standards of practice, and has been approved by the center's clinical director. The center shall apply the risk assessment system to clients prior to acceptance as a center client and throughout the pregnancy for continuation of services and during the postpartum period.(b) Admission. A birth attendant shall perform the risk assessment of a potential client prior to accepting the client for admission and shall only admit a client that has been assessed to have a low-risk pregnancy.(c) Change in risk status, transfer, and referral. Criteria for the assessment of a client who develops complications during pregnancy that would require the transfer or referral of the client or newborn from the center shall be reviewed and updated annually by the clinical director.(1) The center shall recognize and document in the client's clinical record when the client's condition deviates from a low-risk pregnancy at any time during the antepartum, intrapartum, or postpartum period. The center shall refer or transfer the client to a hospital or physician consultant in accordance with the written policies described in paragraph (2) of this subsection.(2) The center shall enforce policies for the transfer or referral of a client or newborn to a physician consultant or a referral hospital. The written policies shall include provisions:(A) for transfer to a hospital if emergency care is required;(B) for notifying the receiving physician prior to the transfer;(C) for notifying the receiving hospital prior to the transfer;(D) for sending a copy of the clinical record to the hospital or physician consultant at the time of transfer; and(E) describing the duties and responsibilities of staff during the transfer procedure.(3) The center shall document the transfer or referral in the client's clinical record in accordance with §137.53(9)(R) of this title (relating to Clinical Records). Source Note: The provisions of this §503.40 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.40 Risk Assessments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221909 03/12/2026 The center shall provide emergency services to clients when a critical situation develops at the center.(1) A center shall have an emergency call system for use when there is a critical situation. The center shall have available in the center personnel trained in cardiopulmonary resuscitation (CPR) to be available whenever there is a client in labor or during acute postpartum period.(2) A center shall provide emergency equipment and emergency medications as follows:(A) oxygen;(B) newborn manual breathing bags;(C) suction equipment for newborns;(D) a neutral thermal environment for resuscitation; and(E) other medications and equipment as approved by the clinical director. Source Note: The provisions of this §503.41 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.41 Emergency Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221910 03/12/2026 (a) At the time of initial visit a center must provide the client, and if the client is a minor, his or her guardian:(1) a written statement that complaints may be registered with the Manager, Health Facility Compliance Group, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756; telephone (888) 973-0022; (512) 834-6650; Fax (512) 834-6653; and(2) a disclosure statement and informed consent that explains the benefits, limitations, and risks of the services available to the client, and that describes the collaborative arrangements that the center has with physicians and referral hospitals.(b) A center shall ensure that its licensed midwives meet the disclosure requirements in the Texas Midwifery Act, Texas Occupations Code, Chapter 203. Source Note: The provisions of this §503.42 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.42 Disclosure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221911 03/12/2026 When prenatal care is provided, the center shall comply with accepted standards of practice. Source Note: The provisions of this §503.43 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.43 Prenatal Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221912 03/12/2026 (a) A birthing center that provides prenatal care to a pregnant woman during gestation or at delivery of an infant shall:(1) provide the woman with a resource list of the names, addresses, and telephone numbers of professional organizations that provide postpartum counseling and assistance to parents;(2) document in the patient's record that the patient received the information described in paragraph (1) of this subsection; and(3) retain the documentation for at least three years in the birthing center records.(b) The list must include resources a parent may contact to receive counseling and assistance for postpartum depression and other emotional traumas associated with pregnancy and parenting.(c) A birthing center that provides prenatal care to a woman during gestation or at delivery is presumed to have complied with this section, if the woman received prior prenatal care from another birthing center, physician, or midwife in this state during the same pregnancy. Source Note: The provisions of this §503.44 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.44 Parenting and Postpartum Counseling https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221913 03/12/2026 (a) A center shall adopt, implement, and enforce written procedures for consultation with physicians for clients who develop medical complications.(b) A physician consultant shall be a Texas licensed physician, preferably who practices obstetrics and/or pediatrics, and who is readily available by telephone or who is able to be present in the center or hospital to deliver emergency care. Source Note: The provisions of this §503.46 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.46 Physician Consultant Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221914 03/12/2026 (a) Drugs and biologicals must be handled and stored in a safe and effective manner in accordance with written policies and procedures established by the center and state and federal laws.(b) Drugs must be administered according to established written policies and procedures and accepted standards of practice, in accordance with state and federal laws. Source Note: The provisions of this §503.47 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.47 Procedures for Drugs and Biologicals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221915 03/12/2026 (a) Labor and birth shall be managed and attended by a birth attendant.(b) The birth attendant shall be trained in the use of emergency equipment.(c) A center shall ensure that its birth attendants encourage a client to seek medical care if the birth attendant recognizes a sign or symptom of a complication to the client's childbirth.(d) Other clinical care provider(s) and/or a birth attendant, shall be physically present in the center whenever a client is in the center until the client is discharged. The clinical care provider shall be capable of performing the following minimum duties:(1) monitoring the fetal heartbeat;(2) monitoring the mother's blood pressure, pulse, and temperature;(3) performing adult and infant cardiopulmonary resuscitation, if needed;(4) monitoring the newborn's heart rate, respiratory rate and body temperature; and(5) assessing the client's fundus and blood loss.(e) A birth attendant shall be physically present to conduct the delivery and be available during the acute postpartum period.(f) Interventions shall be limited to those required to accomplish a vaginal delivery.(g) No general, epidural, or subdural anesthetic agent shall be administered in a center. Source Note: The provisions of this §503.48 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.48 Labor and Birth Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221916 03/12/2026 A center shall adopt, implement, and enforce written policies and procedures for the care of the newborn. The clinical director shall review and revise the policies as necessary to reflect current practices. The policies shall include the following:(1) resuscitation of the newborn;(2) prophylactic treatment of the eyes;(3) documentation of a physical examination of the newborn performed before discharge;(4) referral for any abnormalities or problems;(5) the collection of blood for newborn screening; and(6) procedures for the detection of Rh and ABO isoimmunization. Source Note: The provisions of this §503.49 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.49 Care of the Newborn https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221917 03/12/2026 (a) The mother and newborn shall be discharged from the center when both are clinically stable and have met discharge criteria established by the center.(b) The mother and newborn shall not be discharged prior to two hours from the time of placenta.(c) If the mother or newborn remain at the center for medical reasons for more than 24 hours after birth, a report shall be filed with the Manager, Department of State Health Services, Health Facility Compliance Group, 1100 West 49th Street, Austin, Texas 78756. The report shall be filed within 48 hours after the birth describing the circumstances and reasons for the extended stay.(d) A center must provide the mother with written discharge instructions. The discharge instructions must include written guidelines detailing how the mother may obtain emergency assistance for herself and newborn. Source Note: The provisions of this §503.50 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.50 Discharge Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221918 03/12/2026 The center shall develop, implement, and enforce written policies to provide follow-up postnatal and postpartum care to the newborn and the mother either directly or by referral. Follow-up care may be provided in the center, at the mother's residence, by telephone, or by a combination of these methods in accordance with accepted standards of practice. Source Note: The provisions of this §503.51 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.51 Postpartum and Postnatal Care of the Mother and Newborn https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221919 03/12/2026 (a) Quality assurance program. The center shall adopt, implement, and enforce a written quality assurance (QA) program that includes all health and safety aspects of client care for both mother and newborn.(1) The quality assurance program shall include, but not be limited to:(A) a review of the clinical record(s);(B) incidences of morbidity and mortality of mother and newborn;(C) postpartum infections;(D) all cases transferred to a hospital for delivery, care of newborn, or postpartum care of mother;(E) incidents, problems and potential problems identified by staff of the center, including infection control;(F) address issues of unprofessional conduct by any member of the center's staff (including contract staff);(G) address the integrity of surgical instruments, medical equipment, and patient supplies;(H) address client referrals and consultations;(I) address medication therapy practices, if applicable; and(J) problems with compliance with any federal and state laws and rules.(2) This program must be reviewed and updated or revised at least annually.(3) The results of the quality assurance program must be reviewed and documented at least quarterly.(b) Quality assurance issues. The center shall identify and address quality assurance issues and implement corrective action plans as necessary. The outcome of any corrective action plans shall be documented. The outcome of the remedial action shall be documented.(c) Departmental review.(1) A representative(s) of the department shall verify that the center has a quality assurance program which addresses quality concerns and that center staff know how to access that process.(2) Attempts by the center to identify and correct deficiencies will not be used by the department as a basis for adverse action against the center. Source Note: The provisions of this §503.52 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.52 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221920 03/12/2026 The center must adopt, implement, enforce and maintain a clinical record system to assure that the care and services provided to each client is completely and accurately documented, and systematically organized to facilitate the compilation and retrieval of information. At the time of an on-site survey, all clinical records shall be readily retrievable for review within two hours of the request.(1) For each client, a center may keep a single file or separate files for each stage of service provided to the client.(2) The center shall have written procedures which are adopted, implemented, and enforced regarding the removal of records and the release of information. A center shall not release any portion of a client record to anyone other than the client except as allowed by law.(3) All information regarding the client's care and services shall be centralized in the client's record and be protected against loss or damage.(4) The center shall establish an area for client record storage at the center's place of business. The client record shall be stored at the place of business from which services are actually provided.(5) The center shall ensure that each client's record is treated with confidentiality, safeguarded against loss and unofficial use, and is maintained according to professional standards of practice.(6) The clinical record shall be an original, a microfilmed copy, an optical disc imaging system, or a certified copy. An original record includes manually signed paper records or electronically signed computer records. Computerized records shall meet all requirements of paper records including protection from unofficial use and retention for the period specified in paragraph (10) of this subsection. Systems shall assure that entries regarding the delivery of care or services may not be altered without evidence and explanation of such alteration.(7) Each entry to the client record shall be accurate, signed, and dated with the date of entry by the individual making the entry. Correction fluid or tape shall not be used in the record. Corrections shall be made by striking through the error with a single line and shall include the date the correction was made and the initials of the person making the correction.(8) Inactive client records may be preserved and stored on microfilm, optical disc or other electronic means. Security shall be maintained and records must be readily retrievable by the center within two hours of a request for a record(s) by the department.(9) The clinical record must contain the following:(A) client identifying information;(B) name of the client's birth attendant(s) and the name of all other clinical care providers;(C) initial risk assessment;(D) a disclosure statement and informed consent that is signed by a client that explains the benefits, limitations, and risks of the services available to them at the center, and that describes the collaborative arrangements that the center has with physicians and with referral hospitals;(E) the informed choice agreement required to be given a client by a licensed midwife, if applicable;(F) record of antepartum (prenatal) care;(G) history and physical examination of the clients;(H) laboratory procedures;(I) progress notes shall be written, signed and dated by the person rendering the service on the day service is rendered and incorporated into the client record on a timely basis;(J) medication list and medication administration record, if applicable;(K) intrapartum care;(L) newborn care;(M) postpartum care;(N) allergies and medication reactions;(O) documentation for consultation;(P) refusal of the client to comply with advice or treatment;(Q) discharge summary;(R) documentation of client transfers or referrals, if applicable; and(S) documentation that:(i) a birth certificate was filed; or(ii) if applicable, a death certificate was filed.(10) A center shall retain original client records for a minimum of five years after the discharge of the client. The center may not destroy client records that relate to any matter that is involved in litigation if the center knows the litigation has not been finally resolved.(11) If a center closes, there shall be an arrangement for the preservation of inactive records to ensure compliance with this section. The center shall send the department written notification of the reason for closure, the location of the client records and the name and address of the client record custodian. If a center closes with an active client roster, a copy of the active client record shall be transferred with the client to the receiving center or other health care facility in order to assure continuity of care and services to the client. Source Note: The provisions of this §503.53 adopted to be effective December 2, 2007, 32 TexReg 8507; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.53 Clinical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221921 03/12/2026 (a) Reportable conditions and incidents.(1) A center shall report communicable diseases required to be reported under the Health and Safety Code, §81.042, and in accordance with the department's rules under §§97.2 - 97.5 of this title (relating to Control of Communicable Diseases).(2) The following incidents shall be reported to the department in writing, by mail, or fax within five calendar days of the occurrence to the Manager of Health Facility Compliance Group, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756:(A) a death of a client, newborn, or death of a fetus during the course of labor occurring in the center; and(B) a death of a client or newborn occurring within 24 hours of discharge from the center or transfer to another health care facility.(b) Birth certificate filing requirements.(1) A center administrator or his or her designee shall:(A) file a birth certificate for each birth at the center; or(B) ensure that its birth attendants file the birth certificate in accordance with the Health and Safety Code, §192.003.(2) A center administrator, his or her designee, or any of its birth attendants shall comply with Health and Safety Code, §195.003 and §195.004.(c) Death certificate filing requirements. A center administrator or birth attendant shall file a death certificate in accordance with subsection (a)(2) of this section.(d) Data collection for birth defects. If the department requires data collection concerning birth defects under the Health and Safety Code, §87.022, the center or its birth attendants shall make available for review by the department or by an authorized agent clinical records or other information that are in the center's or birth attendant's custody or control and that relate to the occurrence of a birth defect specified by the board.(e) A center that donates human fetal tissue under Texas Health and Safety Code, Chapter 173, shall submit an annual report to the Health and Human Services Commission that includes for each donation the specific type of fetal tissue donated and the accredited public or private institution of higher learning that received the donation. The center shall submit the annual report no later than January 31st of the subsequent year. Source Note: The provisions of this §503.54 adopted to be effective December 2, 2007, 32 TexReg 8507; amended to be effective September 30, 2018, 43 TexReg 6288; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.54 Reporting and Filing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221922 03/12/2026 (a) A center utilizing the services of a licensed midwife shall ensure that all licensed midwives utilized do not violate the Texas Midwifery Act, Texas Occupations Code, Chapter 203, concerning prohibited acts and criminal penalties, while functioning in his or her capacity at or for the center.(b) A center shall ensure that its licensed midwives comply with Title 22 Texas Administrative Code, Chapter 831 (relating to Midwifery), while functioning in his or her capacity at or for the center.(c) A center that provides laboratory services shall meet the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88), 42 Code of Federal Regulations, §§493.1 - 493.1780 (CLIA 1988). CLIA 1988 applies to all centers with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. If a center accepts laboratory test results from another state or foreign country, such as Mexico, the laboratory documents must be reviewed and approved by a licensed health professional within his or her scope of practice.(d) A center utilizing the services of a registered nurse(s) shall ensure that its registered nurse(s) comply with the Nursing Practice Act, Texas Occupations Code, Chapters 301, 303, and 304, while functioning in his or her capacity at or for the center.(e) A center utilizing the services of a licensed vocational nurse(s) shall ensure that its licensed vocational nurse(s) comply with Texas Occupations Code, Chapters 301, 303, and 304, while functioning in his or her capacity at or for the center.(f) A center utilizing the services of a physician(s) shall ensure that its physician(s) comply with the Medical Practice Act, Texas Occupations Code, Chapters 151 - 165, while functioning in his or her capacity at or for the center.(g) A center utilizing the services of a physician assistant(s) shall ensure that its physician assistant(s) comply with the Physician Assistant Licensing Act, Texas Occupations Code, Chapter 204, while functioning in his or her capacity at or for the center.(h) A center that provides pharmacy services shall obtain a license as a pharmacy if required by the Texas Pharmacy Act, Texas Occupations Code, Chapters 551 - 569.(i) A center shall not use adulterated or misbranded drugs or devices in violation of the Health and Safety Code, §431.021. Adulterated drugs and devices are described in Health and Safety Code, §431.111. Misbranded drugs or devices are described in Health and Safety Code, §431.112.(j) A center shall not commit a false, misleading, or deceptive act or practice as that term is defined in the Deceptive Trade Practices-Consumer Protection Act, Business and Commerce Code, §17.46.(k) A birthing center must provide voluntary paternity establishment services in accordance with:(1) the Health and Safety Code, §192.012, Record of Acknowledgment of Paternity; and(2) the rules of the Office of the Attorney General found at 1 Texas Administrative Code, Chapter 55, Subchapter J (relating to Voluntary Paternity Acknowledgment Process).(l) A birthing center shall comply with Health and Safety Code, Chapter 47, relating to Hearing Loss in Newborns.(m) A center shall ensure that its birth attendants comply with Health and Safety Code, §81.090 (relating to Serologic Testing During pregnancy). The center shall ensure that the results of any HIV test are kept confidential pursuant to the Health and Safety Code, §81.103.(n) A center shall ensure that its birth attendants comply with the Health and Safety Code, §81.091, (relating to Ophthalmia Neonatorum Prevention; Criminal Penalty).(o) A center shall ensure that its birth attendants cause the newborn screening tests to be performed as required by:(1) the Health and Safety Code, §33.011 (relating to Test Requirement); and(2) Texas Occupations Code, §203.354 (relating to Newborn Screening).(p) A licensed birthing center shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §503.55 adopted to be effective December 2, 2007, 32 TexReg 8507; amended to be effective January 6, 2022,46 TexReg 9305; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9022. 1 HEALTH AND HUMAN SERVICES COMMISSION 503 BIRTHING CENTERS D OPERATIONAL AND CLINICAL STANDARDS FOR THE PROVISION AND COORDINATION OF TREATMENT AND SERVICES §503.55 Other State and Federal Compliance Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222822 03/12/2026 (a) Purpose. The purpose of this chapter is to implement the Texas Abortion Facility Reporting and Licensing Act, Health and Safety Code, Chapter 245, which provides the Department of State Health Services with the authority to establish rules governing the licensing and regulation of abortion facilities and to establish annual reporting requirements for each abortion performed. This chapter also implements the Woman's Right to Know Act, Health and Safety Code, Chapter 171.(b) Scope and applicability.(1) Licensing requirements.(A) A person may not establish or operate an abortion facility in Texas without a license issued under this chapter unless the person is exempt from licensing requirements.(B) The following need not be licensed under this chapter:(i) a hospital licensed under Health and Safety Code, Chapter 241;(ii) an ambulatory surgical center licensed under Health and Safety Code, Chapter 243; or(iii) the office of a physician licensed by the Texas Medical Board and authorized to practice medicine in the State of Texas, unless the office is used for the purpose of performing more than 50 abortions in any 12-month period.(2) Reporting requirements. All licensed abortion facilities and facilities and persons exempt from licensing shall comply with §139.5 of this title (relating to Additional Reporting Requirements). Source Note: The provisions of this §504.1 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; amended to be effective November 4, 2019, 44 TexReg 6540; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.1 Purpose and Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222823 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Abortion--The act of using or prescribing an instrument, a drug, a medicine, or any other substance, device, or means with the intent to cause the death of an unborn child of a woman known to be pregnant. The term does not include birth control devices or oral contraceptives. An act is not an abortion if the act is done with the intent to save the life or preserve the health of an unborn child; remove a dead, unborn child whose death was caused by spontaneous abortion; or remove an ectopic pregnancy.(2) Abortion complication or adverse event--Any harmful event or adverse outcome with respect to a patient related to an abortion that is performed on the patient or induced and that is diagnosed or treated by a health care practitioner or at a health care facility, including:(A) shock;(B) uterine perforation;(C) cervical laceration;(D) hemorrhage;(E) aspiration or allergic response;(F) infection;(G) sepsis;(H) death of the patient;(I) incomplete abortion;(J) damage to the uterus;(K) an infant born alive after the abortion;(L) blood clots resulting in pulmonary embolism or deep vein thrombosis;(M) failure to actually terminate the pregnancy;(N) pelvic inflammatory disease;(O) endometritis;(P) missed ectopic pregnancy;(Q) cardiac arrest;(R) respiratory arrest;(S) renal failure;(T) metabolic disorder;(U) embolism;(V) coma;(W) placenta previa in subsequent pregnancies;(X) preterm delivery in subsequent pregnancies;(Y) fluid accumulation in the abdomen;(Z) hemolytic reaction resulting from the administration of ABO-incompatible blood or blood products;(AA) adverse reactions to anesthesia or other drugs; or(BB) any other adverse event as defined by the United States Food and Drug Administration's criteria provided by MedWatch Reporting System.(3) Abortion facility--A place where abortions are performed or induced.(4) Abortion-inducing drug--A drug, medicine, or any other substance, including a regimen of two or more drugs, medicines, or substances, prescribed, dispensed, or administered with the intent of terminating a clinically diagnosable pregnancy of a woman and with knowledge that the termination will, with reasonable likelihood, cause the death of the woman's unborn child. The term includes off-label use of drugs, medicines, or other substances known to have abortion-inducing properties that are prescribed, dispensed, or administered with the intent of causing an abortion, including the Mifeprex regimen, misoprostol (Cytotec), and methotrexate. The term does not include a drug, medicine, or other substance that may be known to cause an abortion but is prescribed, dispensed, or administered for other medical reasons.(5) Act--Texas Abortion Facility Reporting and Licensing Act, Health and Safety Code Chapter 245.(6) Administrator--A person who:(A) is delegated the responsibility for the implementation and proper application of policies, programs, and services established for the licensed abortion facility; and(B) meets the qualifications established in §139.46(2) of this chapter (relating to Licensed Abortion Facility Staffing Requirements and Qualifications).(7) Advanced practice registered nurse (APRN)--A registered nurse approved by the Texas Board of Nursing to practice as an advanced practice registered nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner."(8) Affidavit--A written statement, sworn to or affirmed, and witnessed by a witness whose signature and printed name appears on the affidavit. "Notarized affidavit" in these rules means an affidavit in which the statement is witnessed by a notary acting pursuant to Government Code Chapter 406.(9) Affiliate--With respect to an applicant or owner which is:(A) a corporation--includes each officer, consultant, stockholder with a direct ownership of at least 5.0%, subsidiary, and parent company;(B) a limited liability company--includes each officer, member, and parent company;(C) an individual--includes:(i) the individual's spouse;(ii) each partnership and each partner thereof of which the individual or any affiliate of the individual is a partner; and(iii) each corporation in which the individual is an officer, consultant, or stockholder with a direct ownership of at least 5.0%;(D) a partnership--includes each partner and any parent company; and(E) a group of co-owners under any other business arrangement--includes each officer, consultant, or the equivalent under the specific business arrangement and each parent company.(10) Applicant--The owner of an abortion facility which is applying for a license under the Act. For the purpose of this chapter, the word "owner" includes nonprofit organization.(11) Certified registered nurse anesthetist (CRNA)--A registered nurse who has current certification from the Council on Certification of Nurse Anesthetists and who is currently authorized to practice as an advanced practice registered nurse by the Texas Board of Nursing.(12) Change of ownership--A sole proprietor who transfers all or part of the facility's ownership to another person or persons; the removal, addition, or substitution of a person or persons as a partner in a facility owned by a partnership; or a corporate sale, transfer, reorganization, or merger of the corporation which owns the facility if sale, transfer, reorganization, or merger causes a change in the facility's ownership to another person or persons.(13) Commission--The Texas Health and Human Services Commission.(14) Condition on discharge--A statement on the condition of the patient at the time of discharge.(15) Critical item--All surgical instruments and objects that are introduced directly into the bloodstream or into other normally sterile areas of the body.(16) Decontamination--The physical and chemical process that renders an inanimate object safe for further handling.(17) Department--The Department of State Health Services.(18) Director--The director of the Health Care Regulation Department of HHSC or their designee.(19) Disinfection--The destruction or removal of vegetative bacteria, fungi, and most viruses but not necessarily spores; the process does not remove all organisms but reduces them to a level that is not harmful to a person's health. There are three levels of disinfection:(A) high-level disinfection--kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the United States Food and Drug Administration;(B) intermediate-level disinfection--kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a "tuberculocide" by the United States Environmental Protection Agency (EPA); and(C) low-level disinfection--kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.(20) Ectopic pregnancy--The implantation of a fertilized egg or embryo outside of the uterus.(21) Education and information staff--A professional or nonprofessional person who is trained to provide information on abortion procedures, alternatives, informed consent, and family planning services.(22) Embryonic and fetal tissue remains--An embryo, a fetus, body parts, or organs from a pregnancy that terminates in the death of the embryo or fetus and for which the issuance of a fetal death certificate is not required by state law. The term does not include the umbilical cord, placenta, gestational sac, blood, or body fluids.(23) Executive Commissioner--The Executive Commissioner of the Texas Health and Human Services Commission.(24) Facility--A licensed abortion facility as defined in this section.(25) Fetus--An individual human organism from fertilization until birth.(26) Health care facility--Any type of facility or home and community support services agency licensed to provide health care in any state or is certified for Medicare (Title XVIII) or Medicaid (Title XIX) participation in any state.(27) Health care worker--Any person who furnishes health care services in a direct patient care situation under a license, certificate, or registration issued by the State of Texas or a person providing direct patient care in the course of a training or educational program.(28) Hospital--A facility that is licensed under the Texas Hospital Licensing Law, Health and Safety Code Chapter 241, or if exempt from licensure, certified by the United States Department of Health and Human Services as in compliance with the conditions of participation for hospitals in Title XVIII, Social Security Act (42 United States Code §§1395 et. seq.).(29) Immediate jeopardy to health and safety--A situation in which there is a high probability that serious harm or injury to patients could occur at any time or already has occurred and may well occur again, if patients are not protected effectively from the harm or if the threat is not removed.(30) Inspection--An on-site inspection by HHSC in which a standard-by-standard evaluation is conducted.(31) Licensed abortion facility--A place licensed by HHSC under Health and Safety Code Chapter 245, where abortions are performed or induced.(32) Licensed mental health practitioner--A person licensed in the State of Texas to provide counseling or psychotherapeutic services.(33) Licensed vocational nurse (LVN)--A person who is currently licensed by the Texas Board of Nursing as a licensed vocational nurse.(34) Licensee--A person or entity who is currently licensed as an abortion facility.(35) Medical abortion--The administration or use of an abortion-inducing drug to induce an abortion, and may also be referred to as a "medication abortion," a "chemical abortion," a "drug-induced abortion," "RU-486," or the "Mifeprex regimen."(36) Medical consultant--A physician who is designated to supervise the medical services of the facility.(37) Nonprofessional personnel--Personnel of the facility who are not licensed or certified under the laws of this state to provide a service and shall function under the delegated authority of a physician, registered nurse, or other licensed health professional who assumes responsibility for their performance in the licensed abortion facility.(38) Noncritical items--Items that come in contact with intact skin.(39) Notarized copy--A copy attached to a notarized affidavit which states that the attached copy(ies) are true and correct copies of the original documents.(40) Patient--A pregnant female on whom an abortion is performed or induced, but shall in no event be construed to include a fetus.(41) Person--Any individual, firm, partnership, corporation, or association.(42) Physician--An individual licensed by the Texas Medical Board and authorized to practice medicine in the State of Texas.(43) Physician assistant--A person licensed as a physician assistant by the Texas Physician Assistant Board.(44) Plan of correction--A written strategy for correcting a licensing violation. The plan of correction shall be developed by the facility, and shall address the systemic operation(s) of the facility as the systemic operation(s) apply to the deficiency.(45) Post-procedure infection--An infection acquired at or during an admission to a facility; there shall be no evidence that the infection was present or incubating at the time of admission to the facility. Post-procedure infections and their complications that may occur after an abortion include, but are not limited to, endometritis and other infections of the female reproductive tract, laboratory-confirmed or clinical sepsis, septic pelvic thrombophlebitis, and disseminated intravascular coagulopathy.(46) Pregnant unemancipated minor certification form--The document prepared by HHSC and used by physicians to certify the medical indications supporting the judgment for the immediate abortion of a pregnant minor.(47) Pre-inspection conference--A conference held with HHSC staff and the applicant or his or her representative to review licensure standards, inspection documents, and provide consultation prior to the on-site licensure inspection.(48) Professional personnel--Patient care personnel of the facility currently licensed or certified under the laws of this state to use a title and provide the type of service for which the patient care personnel are licensed or certified.(49) Quality assurance--An ongoing, objective, and systematic process of monitoring, evaluating, and improving the appropriateness, and effectiveness of care.(50) Quality improvement--An organized, structured process that selectively identifies improvement projects to achieve improvements in products or services.(51) Registered nurse (RN)--A person who is currently licensed by the Texas Board of Nursing as a registered nurse.(52) Semicritical items--Items that come in contact with nonintact skin or mucous membranes. Semicritical items may include respiratory therapy equipment, anesthesia equipment, bronchoscopes, and thermometers.(53) Standards--Minimum requirements under the Act and this chapter.(54) Sterile field--The operative area of the body and anything that directly contacts this area.(55) Sterilization--The use of a physical or chemical procedure to destroy all microbial life, including bacterial endospores.(56) Supervision--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity that includes initial direction and periodic inspection of the actual act of accomplishing the function or activity.(57) Surgical abortion--The use of instruments, aspiration, and/or suction to induce an abortion, with the purpose of terminating the pregnancy of a woman known to be pregnant.(58) Third trimester certification form--The document prepared by HHSC and used by physicians to certify the medical indications supporting the judgment for the abortion of a viable fetus during the third trimester of pregnancy.(59) Third trimester--A gestational period of not less than 26 weeks (following last-menstrual period (LMP)).(60) Unemancipated minor--A minor who is unmarried and has not had the disabilities of minority removed under Family Code Chapter 31. Source Note: The provisions of this §504.2 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; amended to be effective May 31, 2018, 43 TexReg 3361; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222824 03/12/2026 (a) If the Department of State Health Services (department) has reason to believe that a person or facility may be providing abortion services without a license as required by the Act and this chapter, the department shall notify the person or facility in writing by certified mail, return receipt requested. The person or facility shall submit to the department the following information within 10 days of receipt of the notice:(1) an application for a license and the license fee; or(2) a notarized affidavit to support exemption under Health and Safety Code, §245.004, including any and all documentation. The notarized affidavit shall attest to the fact that the person or facility is exempt from licensing as specified in §139.1(b) of this title (relating to Purpose and Scope). The form of notarized affidavit to support exemption shall be provided by the department.(b) If the person or facility has submitted an application for a license, the application shall be processed in accordance with §139.23 of this title (relating to Application Procedures and Issuance of Licenses).(c) If the person or facility fails to respond to the notice, either by submitting an application for a license or a notarized affidavit of exemption, the department may seek injunctive relief as prescribed in Health and Safety Code, Chapter 245. Source Note: The provisions of this §504.3 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.3 Unlicensed Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222825 03/12/2026 (a) The purpose of this section is to implement the monthly abortion reporting requirements under Health and Safety Code (HSC) §245.011 for physicians who perform or induce one or more abortions during the preceding calendar month. A report must be submitted for each abortion performed or induced.(b) The report may not identify by any means the patient.(c) The report must include:(1) whether the abortion facility at which the abortion is performed is licensed under this chapter;(2) the patient's year of birth, race, marital status, and state and county of residence;(3) the type of abortion procedure;(4) the date the abortion was performed;(5) whether the patient survived the abortion, and if the patient did not survive, the cause of death;(6) the probable post-fertilization age of the unborn child based on the best medical judgment of the attending physician at the time of the procedure;(7) the date, if known, of the patient's last menstrual cycle;(8) the number of previous live births of the patient;(9) the number of previous induced abortions of the patient;(10) whether the patient viewed the printed material provided under Health and Safety Code Chapter 171;(11) whether the sonogram image, verbal explanation of the image, and the audio of the heart sounds were made available to the patient;(12) whether the patient completed the "Abortion and Sonogram" election form;(13) the method used to dispose of embryonic and fetal tissue remains;(14) if the patient is younger than 18 years of age, as documented in the patient's medical record, whether authorization for the abortion was obtained by:(A) written consent of the patient's parent, managing conservator, or legal guardian under Occupations Code §164.052(a)(19) and whether the consent was given:(i) in person at the location where the abortion was performed; or(ii) at a place other than the location where the abortion was performed;(B) judicial authorization under Family Code §33.003 or §33.004 and:(i) if applicable, the process the physician or physician's agent used to inform the patient of the availability of petitioning for judicial authorization as an alternative to the written consent required by Occupations Code §164.052(a)(19);(ii) whether the court forms were provided to the patient by the physician or the physician's agent;(iii) whether the physician or the physician's agent made arrangements for the patient's court appearance; and(iv) if known, whether the patient became pregnant while in foster care or in the managing conservatorship of the Department of Family and Protective Services;(C) consent of the patient because the patient had the disabilities of minority removed; or(D) the physician's conclusion, documented in the patient's medical record, that on the basis of the physician's good-faith clinical judgment:(i) a condition existed that complicated the medical condition of the patient and necessitated the immediate abortion to avert the patient's death or to avoid a serious risk of substantial impairment of a major bodily function; and(ii) there was insufficient time to obtain the consent of the patient's parent, managing conservator, or legal guardian;(15) the method of pregnancy verification;(16) the type of anesthesia, if any, used in the procedure: intravenous sedation or general anesthesia;(17) whether the abortion was performed or induced because of a medical emergency and any medical condition of the pregnant woman that required the abortion;(18) if the abortion was performed or induced because of a medical emergency:(A) certification that the abortion was necessary due to a medical emergency; and(B) the woman's medical condition requiring the abortion;(19) if the abortion was performed or induced to preserve the health of the pregnant woman:(A) the medical condition the abortion was asserted to address; and(B) the medical rationale for the physician's conclusion that the abortion was necessary to address the medical condition; and(20) for an abortion other than an abortion described by subparagraph (19) of this subsection, that maternal health was not a purpose of the abortion.(d) Except as provided by HSC §245.023, all information and records held by HHSC under this chapter are confidential and are not open records for the purposes of Government Code Chapter 552. That information may not be released or made public on subpoena, or otherwise, except that release may be made:(1) for statistical purposes, but only if a person, patient, physician performing or inducing an abortion, the county in which a minor obtained judicial authorization for an abortion under Family Code Chapter 33, or abortion facility is not identified;(2) with the consent of each person, patient, physician, and abortion facility identified in the information released;(3) to medical personnel, appropriate state agencies, or county and district courts to enforce this chapter;(4) to appropriate state licensing boards to enforce state licensing laws; or(5) to licensed medical or health care personnel currently treating the patient.(e) The reporting period for each physician is the preceding calendar month in which the physician performed or induced one or more abortions. Each physician who performs or induces one or more abortions shall submit the abortion report(s) to HHSC no later than the 15th day of the subsequent month.(f) The abortion reports shall be submitted via the secure electronic reporting system established and maintained by HHSC.(g) Not later than the seventh day after the date the report required by this section is due, HHSC shall notify the Texas Medical Board of a violation of this section.(h) HHSC shall publish on its Internet website a monthly report containing aggregate data of the information in the reports submitted under this section. HHSC's monthly report may not identify by any means an abortion facility, a physician performing or inducing an abortion, the county in which a minor obtained judicial authorization for an abortion under Family Code Chapter 33, or a patient. Source Note: The provisions of this §504.4 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective December 31, 2012, 37 TexReg 9938; amended to be effective January 1, 2014, 38 TexReg 9577; amended to be effective May 31, 2018, 43 TexReg 3361; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.4 Monthly Reporting Requirements for All Abortions Performed or Induced https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222826 03/12/2026 In addition to the reporting required by §139.4 of this subchapter (relating to Monthly Reporting Requirements for All Abortions Performed or Induced), physicians and health care facilities subject to this chapter shall comply with this section when performing or inducing third trimester abortions, when performing or inducing emergency abortions, and when diagnosing or treating abortion complications.(1) Reporting requirements for third trimester abortions.(A) The purpose of this paragraph is to establish procedures for reporting third trimester abortions as required by the Medical Practice Act, Occupations Code Chapters 151 - 160 and 162 - 165.(B) A physician who performs or induces a third trimester abortion of a viable fetus with a biparietal diameter of 60 millimeters or greater shall certify in writing to the Texas Health and Human Services Commission (HHSC) the medical indications supporting the physician's judgment that the abortion is either necessary to prevent the death or a substantial risk of serious impairment to the physical or mental health of the woman, or the fetus has a severe and irreversible abnormality, as identified through reliable diagnostic procedures.(C) The certification shall be made on a form approved by HHSC.(D) The certification form and any supporting documents shall be submitted via the secure electronic reporting system established and maintained by HHSC.(E) HHSC shall retain the certification form and supporting documents as a cross-reference to the annual reporting requirements of the Act and this section. The certification form and supporting documents retained by HHSC are confidential. Any release of the documents shall be in accordance with the provisions of the Medical Practice Act, Occupations Code Chapters 151 - 160 and 162 - 165.(F) A physician performing or inducing abortions at a licensed abortion facility who fails to submit the certification form required under this paragraph may subject the licensed facility to denial, suspension, probation, or revocation of the license in accordance with §139.32 of this chapter (relating to License Denial, Suspension, Probation, or Revocation).(2) Reporting requirements for emergency abortions.(A) The purpose of this paragraph is to establish procedures for reporting emergency abortions performed or induced as required by Family Code §33.002(a)(3) (relating to Parental Notice), Health and Safety Code §171.0124 (relating to Exception for Medical Emergency), and Health and Safety Code §285.202 (relating to Use of Tax Revenue for Abortions; Exception for Medical Emergency).(B) A physician who performs or induces an emergency abortion under one of the three circumstances described in subparagraph (A) of this paragraph shall certify in writing to HHSC that a medical emergency exists.(C) The certification shall be made on a form approved by HHSC.(D) The certification form shall be submitted via the secure electronic reporting system established and maintained by HHSC.(E) A physician performing or inducing abortions at a licensed abortion facility who fails to submit the certification form required by this paragraph may subject the licensed facility to denial, suspension, probation, or revocation of the license in accordance with §139.32 of this chapter.(3) Reporting requirements for abortion complications.(A) Within three business days after the date the complication is diagnosed or treated, a physician shall submit to HHSC an abortion complication report.(B) Within 30 calendar days after the date the complication is diagnosed or treated, a hospital, abortion facility, freestanding emergency medical care facility, or health care facility that provides emergency medical care as defined by Health and Safety Code §773.003 shall submit to HHSC an abortion complication report.(C) The certification form shall be submitted via the secure electronic reporting system established and maintained by HHSC.(D) A report submitted under this paragraph may not identify the physician who performed or induced the abortion, other than the reporting physician, or the patient.(E) The report must identify the name of the physician submitting the report or the name and type of health care facility submitting the report, must include the most specific, accurate, and complete reporting for the highest level of specificity, and must include, if known:(i) the date of the abortion that caused or may have caused the complication;(ii) the type of abortion that caused or may have caused the complication;(iii) the name and type of facility where the abortion was performed;(iv) the name, date, and type of facility where the complication was diagnosed and treated;(v) description of complications;(vi) the number of weeks of gestation at which the abortion was performed;(vii) the number of previous live births of the patient;(viii) the number of previous induced abortions of the patient;(ix) the type of anesthesia, if any, used in the procedure: intravenous sedation or general anesthesia;(x) the patient's year of birth, race, marital status, and state and county of residence; and(xi) the date of the first day of the patient's last menstrual period that occurred before the date of the abortion that caused or may have caused the complication.(F) HHSC shall notify the Texas Medical Board of a violation of this paragraph by a physician.(G) HHSC shall publish on its Internet website an annual report containing aggregate data of the information in the reports submitted under this paragraph for the previous calendar year. The annual report may not include any duplicative data and may not identify by any means an abortion facility, a physician, or a patient.(H) The third separate violation of this paragraph by a facility required to report under subparagraph (B) of this paragraph constitutes cause for the revocation or suspension of the facility's license, permit, registration, certificate, or other authority or for other disciplinary action against the facility. Source Note: The provisions of this §504.5 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective December 31, 2012, 37 TexReg 9938; amended to be effective May 31, 2018, 43 TexReg 3361; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.5 Additional Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222827 03/12/2026 (a) An abortion facility shall provide to a woman, at the time the woman initially consults the facility, a written statement indicating the number of the toll-free telephone number maintained under subsection (d) of this section. The written statement shall be available in English and Spanish. (1) The following form is an example of the statement in English. Attached Graphic(2) The following form is an example of the statement in Spanish. Attached Graphic(b) The department on request shall make the following information available to the public: (1) the status of the license of any abortion facility; (2) the date of the last inspection of the facility, any violation discovered during that inspection that would pose a health risk to a patient at the facility, any challenge raised by the facility to the allegation that there was a violation, and any corrective action that is acceptable to the department and that is being undertaken by the facility with respect to the violation; and (3) an administrative or civil penalty imposed against the facility or a physician who provides services at the facility, professional discipline imposed against a physician who provides services at the facility, and any criminal conviction of the facility or a physician who provides services at the facility that is relevant to services provided at the facility. (c) Subsection (b) of this section does not require the department to provide information that is not in the possession of the department. In accordance with Health and Safety Code, §245.023(b), the Texas Medical Board (board) is required to provide to the department information in the possession of the board that the department is required to provide under subsection (b) of this section. (d) In accordance with Health and Safety Code, §245.023(c), the department shall maintain a toll-free telephone number that a person may call to obtain the information described by subsection (b) of this section. (e) This section does not authorize the department to the release of the name, address, or phone number of any employee or patient of an abortion facility or of a physician, advanced practice registered nurse, or physician assistant who provides services at an abortion facility. Source Note: The provisions of this §504.6 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.6 Public Information; Toll-Free Telephone Number https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222828 03/12/2026 (a) The department shall assign to each licensed abortion facility a unique license number that may not change during the period the facility is operating in this state.(b) A licensed abortion facility shall include the unique license number assigned to the facility by the department in any abortion advertisement directly relating to the provision of abortion services at the facility. If more than one location is advertised in a single advertisement, the license number(s) for each location shall be included in the advertisement. The facility shall document efforts to place the unique license number in advertisements within each specific deadline for each advertisement.(c) In this section, "abortion advertisement" means:(1) any communication that advertises the availability of abortion services at a licensed abortion facility and that is disseminated through a public medium, including an advertisement in a newspaper or other publication or an advertisement on television, radio, or any other electronic medium; or(2) any commercial use of the name of the licensed facility as a provider of abortion services, including the use of the name in a directory, listing, or pamphlet. Source Note: The provisions of this §504.7 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.7 Unique Identifying Number; Disclosure in Advertisement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222829 03/12/2026 (a) Quality Assurance (QA) Program. A licensed abortion facility shall maintain a QA program in the facility which shall be implemented by a QA committee. The QA program shall be ongoing and have a written plan of implementation. This plan shall be reviewed and updated or revised at least annually by the QA Committee. The QA program shall include measures for quality improvement in the measurement of the facility's delivery of service. Quality assurance documents pertinent to the facility shall be kept within the facility.(b) QA committee membership. At a minimum, the QA committee shall consist of at least:(1) the medical consultant designated by the facility;(2) an advanced practice registered nurse, a physician assistant, a registered nurse, or a licensed vocational nurse; and(3) at least two other members of the facility's staff.(c) Frequency of QA committee meetings. The QA committee, by consensus, shall meet at least quarterly to identify issues with respect to which quality assurance activities are necessary.(d) Minimum responsibilities. The QA committee shall:(1) evaluate all organized services related to patient care, including services furnished by contract;(2) ensure that there is a review of any abortion procedure complication(s), and shall make use of the findings in the development and revision of facility policies;(3) address issues of unprofessional conduct by any member of the facility's staff (including contract staff);(4) monitor infection control as outlined in §139.49 of this title (relating to Infection Control Standards) and post-procedure infections as outlined in §139.41 of this title (relating to Policy Development and Review);(5) address medication therapy practices;(6) address the integrity of surgical instruments, medical equipment, and patient supplies; and(7) address services performed in the facility as they relate to appropriateness of diagnosis and treatment.(e) Patient care and service issues. The QA committee shall identify and address patient care services and information issues and implement corrective action plans as necessary.(1) Identifying issues that necessitate corrective action. The QA committee shall be responsible for identifying issues that necessitate corrective action by the committee, such as issues which negatively affect care or services provided to patients.(2) Plan of corrective action. The QA committee shall develop and implement plans of action to correct identified deficiencies.(3) Remedial action. The QA committee shall take and document remedial action to address deficiencies found through the QA program. The facility shall document the outcome of the remedial action.(f) Departmental review.(1) The department shall not use good faith efforts by the QA committee to identify and correct deficiencies as a basis for deficiency(ies), citation(s), or sanction(s).(2) Department surveyors shall verify that:(A) the facility has a QA committee which addresses concerns; and(B) the facility staff know how to access that process. Source Note: The provisions of this §504.8 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.8 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222830 03/12/2026 (a) The 83rd Legislature, in enacting House Bill 2 during its Second Session (2013), confirmed its intent that the provisions and the applications of the Health and Safety Code relating to the licensure and operation of abortion facilities were intended to be separately enforceable, if any of these separate provisions or the application of those provisions was determined unconstitutional, invalid, or unenforceable.(b) Consistent with the intent of the Legislature, the department intends, that with respect to the application of this chapter to each woman who seeks or obtains services from a facility licensed under this chapter, every provision, section, subsection, sentence, clause, phrase, or word in this chapter and each application of the provisions of this chapter remain severable from every other provision, section, subsection, sentence, clause, phrase, word, or application of this chapter.(c) The department further intends that if the application of any provision of this chapter is determined by a court of competent jurisdiction to impose an impermissible or undue burden on any pregnant woman or group of pregnant women, the application of the chapter to those women will be severed from the remaining applications of the chapter that do not impose an undue burden, and those remaining applications of this chapter will remain in force and unaffected, consistent with the intent of the Legislature.(d) Accordingly, to the extent that any parts or applications of this chapter or this section are enjoined, the department may enforce the parts and applications of this chapter that do not violate the Constitution or impose an undue burden on women seeking abortions. Source Note: The provisions of this §504.9 adopted to be effective January 1, 2014, 38 TexReg 9577; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING A GENERAL PROVISIONS §504.9 Severability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222831 03/12/2026 An applicant for an abortion facility license shall meet the following requirements.(1) If the applicant for a license is an individual, the applicant shall be at least 18 years of age.(2) An abortion facility is required to apply for a separate license for each place of business.(3) An abortion facility may not admit a patient for an abortion procedure until it has received an initial license.(4) The licensed location shall be in Texas.(5) The licensee of the abortion facility is responsible for ensuring the facility's compliance with the Act and this chapter.(6) Renewal licenses shall expire in two years.(7) An abortion facility shall prominently and conspicuously post the license issued under the Act for display in a public area of the facility that is readily accessible to patients, employees, and visitors.(8) An abortion facility license shall not be transferred or assigned from one person to another person or from one physical location to another physical location.(9) A licensed abortion facility shall have the financial ability to carry out its functions under the Act and this chapter. Source Note: The provisions of this §504.21 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING B LICENSING PROCEDURES §504.21 General Requirements for Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222832 03/12/2026 (a) Fees for an abortion facility license for all initial, change of ownership, change of physical location, and renewal applications are $5,000.(b) The commission shall not consider an application as officially submitted until the applicant pays the applicable licensing fee. The fee shall accompany the application form.(c) A license fee paid to the commission is not refundable.(d) Any remittance submitted to the commission in payment of a required license fee shall be in the form of a certified check, money order, or personal check made payable to the Texas Health and Human Services Commission.(e) For all applications, the commission is authorized to collect subscription and convenience fees, in amounts determined by the TexasOnline Authority, to recover costs associated with application and renewal application processing through TexasOnline, in accordance with Government Code, §2054.111.(f) The commission may make periodic reviews of its license fee schedule to ensure that the fees imposed are in amounts reasonable and necessary to defray the cost to the commission of administering the Act.(g) The commission shall impose an annual assessment as follows.(1) In addition to application fees, the commission shall impose on each facility an annual assessment in amounts reasonable and necessary to defray costs.(2) The annual assessment shall fall into one of three categories based on the facility's three-year history:(A) Facilities for which the annual average of reported abortions is less than 1,000 or facilities applying for an initial license;(B) Facilities for which the annual average of reported abortions is from 1,000 to 2,999;(C) Facilities for which the annual average of reported abortions is 3,000 or more.(3) Facilities identified in each category shall be assessed a proportionate share of the costs.(4) Facilities applying for an initial license shall submit the assessment at the same time as the application fee.(5) The commission shall notify each licensee of the amount of the annual assessment by the first day of April for each year.(6) The annual assessment shall be received by the commission no later than the first day of June for each year.(7) A licensee who fails to pay the annual assessment fee shall be subject to denial, revocation, probation, or suspension of a license as prescribed in §139.32 of this title (relating to License Denial, Suspension, Probation, or Revocation). Source Note: The provisions of this §504.22 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING B LICENSING PROCEDURES §504.22 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222833 03/12/2026 (a) Purpose. This section establishes the application procedures that an abortion facility shall follow to obtain a license to operate as a licensed abortion facility in Texas.(b) Definitions. The following terms when used in this section shall have the following meaning.(1) Initial license--A license which is issued by the commission to a first-time applicant for an abortion facility license, including an unlicensed abortion facility, to a licensed facility for which a change of ownership is anticipated, and to a licensed facility for which a change of physical location will occur, that meets the requirements of the Act and this chapter and has successfully completed the application procedures for an initial license as set out in subsection (c) of this section. Initial licenses shall expire in two years.(2) Renewal license--A license issued by the commission to a licensed abortion facility that meets all requirements of the Act and this chapter and has completed the application procedures for obtaining a renewal license as set out in subsection (d) of this section. Renewal licenses shall expire in two years.(c) Application procedures for an initial license. This subsection establishes the application procedures for obtaining an initial license.(1) Request for an application. Upon request for an abortion facility license, the commission shall furnish a person with an application packet. Applications may also be obtained and submitted through the commission's web site.(2) Application requirements. The applicant shall submit the information listed in subparagraph (C) of this paragraph to the commission.(A) An applicant shall not misstate a material fact on any documents required to be submitted under this subsection.(B) The application form shall be accurate and complete and shall contain original signatures. The initial license fee shall accompany the application.(C) The following documents shall be submitted with the original application form prescribed by the commission and shall be originals or notarized copies:(i) information on the applicant including name, street address, mailing address, social security number or franchise tax identification number, date of birth, and driver's license number;(ii) the name, mailing address, and street address of the abortion facility. The street address provided on the application shall be the physical location from which the abortion facility will be operating and providing services;(iii) the telephone number of the facility, the telephone number where the administrator can usually be reached when the facility is closed, and if the facility has a fax machine, the fax number;(iv) a list of names and business addresses of all persons who own any percentage interest in the applicant including:(I) each limited partner and general partner if the applicant is a partnership; and(II) each shareholder, member, director, and officer if the applicant is a corporation, limited liability company, or other business entity;(v) a list of any businesses with which the applicant subcontracts and in which the persons listed under clause (iv) of this subparagraph hold any percentage of the ownership;(vi) if the applicant has held or holds an abortion facility license or has been or is an affiliate of another licensed facility, the relationship, including the name and current or last mailing address and physical location of the other facility, and the date such relationship commenced and, if applicable, the date it was terminated;(vii) if the facility is operated by or proposed to be operated under a management contract, the names and addresses of any person and organization having an ownership interest of any percentage in the management company;(viii) a notarized affidavit attesting that the applicant is capable of meeting the requirements of this chapter;(ix) an organizational structure of the staffing for the abortion facility. The organizational structure shall include full disclosure in writing of the names and addresses of all owners and persons controlling any ownership interest in the abortion facility. In the case of corporations, holding companies, partnerships, and similar organizations, the names and addresses of officers, directors, and stockholders, both beneficial and of record, when holding any percent, shall be disclosed. In the case of a nonprofit corporation, the names and addresses of the officers and directors shall be disclosed;(x) the name(s), address(es), and Texas physician license number(s) of the physician(s) (including the facility's designated medical consultant), and all advanced practice registered nurse(s) and physician assistant(s) who will provide services at the abortion facility;(xi) the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(I) denial, suspension, probation, or revocation of an abortion facility license in any state, a license for any health care facility or a license for a home and community support services agency (agency) in any state or any other enforcement action, such as (but not limited to) court civil or criminal action in any state;(II) denial, suspension, probation, or revocation of or other enforcement action against an abortion facility license in any state, a license for any health care facility in any state, or a license for an agency in any state which is or was proposed by the licensing agency and the status of the proposal;(III) surrendering a license before expiration of the license or allowing a license to expire in lieu of the commission proceeding with enforcement action;(IV) federal or state (any state) criminal felony arrests or convictions;(V) Medicare or Medicaid sanctions or penalties relating to the operation of a health care facility or agency;(VI) operation of a health care facility or agency that has been decertified or terminated from participation in any state under Medicare or Medicaid; or(VII) debarment, exclusion, or contract cancellation in any state from Medicare or Medicaid; and(xii) for the two-year period preceding the application date, the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(I) federal or state (any state) criminal misdemeanor arrests or convictions;(II) federal or state (any state) tax liens;(III) unsatisfied final judgments;(IV) eviction involving any property or space used as an abortion facility or health care facility in any state;(V) injunctive orders from any court; or(VI) unresolved final Medicare or Medicaid audit exceptions.(3) Applicant copy. The applicant shall retain a copy of all documentation that is submitted to the commission.(4) Application processing. Upon the commission's receipt of the application form, the required information described in paragraph (2)(C) of this subsection, and the initial license fee from an applicant, the commission shall review the material to determine whether it is complete and correct.(A) The time periods for reviewing the material shall be in accordance with §139.25 of this title (relating to Time Periods for Processing and Issuing a License).(B) If an abortion facility receives a notice from the commission that some or all of the information required under paragraph (2)(C) of this subsection is deficient, the facility shall submit the required information no later than six months from the date of the notice.(i) A facility which fails to submit the required information within six months from the notice date is considered to have withdrawn its application for an initial license. The license fee shall not be refunded.(ii) A facility which has withdrawn its application shall reapply for a license in accordance with this subsection, if it wishes to continue the application process. A new license fee is required.(5) Withdrawal from the application process. If an applicant decides at any time not to continue the application process for an initial license, the application shall be withdrawn upon written request from the applicant.(6) Issuance of an initial license.(A) Time periods for processing. The time periods for processing an initial application shall be in accordance with §139.25 of this title.(B) Effective period of an initial license. The initial license is valid for two years. The initial license expires on the last day of the month ending the licensure period.(C) Pre-licensing Inspection. Once the commission has determined that the application form, the information required to accompany the application form, and the initial license fee are complete and correct, the commission shall conduct an on-site pre-licensing inspection of the physical location.(D) After the on-site pre-licensing inspection has been completed, the commission shall:(i) issue an initial license to the owner of a facility, if the facility is found to be in compliance with the commission's requirements for initial licensure; or(ii) deny the application, if the facility has not complied with the commission's requirements for issuing an initial license. The procedure for denial of a license shall be in accordance with §139.32 of this title (relating to License Denial, Suspension, Probation, or Revocation).(7) A commission representative shall inspect the abortion facility in accordance with §139.31 of this title (relating to On-Site Inspections and Complaint Investigations of a Licensed Abortion Facility) within 60 days after the issuance of an initial license. If the commission determines that a facility is not in compliance with the provisions of the Act or this chapter after the initial on-site inspection, the commission shall notify the facility. Notification shall be in accordance with §139.32 of this title.(8) If for any reason, an applicant decides not to continue the application process, the applicant shall submit to the commission a written request to withdraw its application. If an initial license has been issued, the applicant shall cease providing abortion services and return the initial license to the commission with its written request to withdraw. The commission shall acknowledge receipt of the request to withdraw. The license fee shall not be refunded.(9) Continuing compliance by the licensed abortion facility with the provisions of the Act and this chapter is required.(d) Application procedures for renewal of a license.(1) The commission shall send notice of expiration of a license to the licensee at least 60 days before the expiration date of the license. If the licensee has not received notice of expiration from the commission 45 days prior to the expiration date, it is the duty of the licensee to notify the commission and request an application for a renewal license.(2) The licensee shall submit the following items to the commission by certified mail, marked confidential, and postmarked no later than 30 days prior to the expiration date of the license:(A) a complete and accurate renewal application form;(B) current updated documents containing all the information required in subsection (c)(2)(C) of this section; and(C) the renewal license fee.(3) A facility shall not misstate a material fact on any documents required to be submitted to the commission or required to be maintained by the facility in accordance with the provisions of the Act and this chapter.(4) A commission surveyor shall inspect a licensed abortion facility in accordance with §139.31(b) of this title.(5) If a licensee makes timely and sufficient application for renewal, the license shall not expire until the commission issues the renewal license or until the commission denies renewal of the license.(A) The commission shall issue a renewal license to a licensee who meets the minimum standards for a license in accordance with the provisions of the Act and this chapter.(B) The commission may propose to deny the issuance of a renewal license if:(i) based on the inspection report, the commission determines that the abortion facility does not meet or is in violation of any of the provisions of the Act or this chapter;(ii) renewal is prohibited by the Education Code, §57.491, relating to defaults on guaranteed student loans;(iii) a facility discloses any of the actions or offenses listed in subsection (c)(2)(C)(xi) and (xii) of this section; and(iv) a facility fails to file abortion reports or fails to ensure that a physician's report is filed in accordance with §139.5 of this title (relating to Additional Reporting Requirements).(6) If a licensee makes a timely application for renewal of a license, and action to revoke, suspend, place on probation, or deny renewal of the license is pending, the license does not expire but does extend until the application for renewal is granted or denied after the opportunity for a formal hearing. A renewal license shall not be issued unless the commission has determined the reason for the proposed action no longer exists.(7) If a suspension of a license overlaps a renewal date, the suspended license holder shall comply with the renewal procedures in this subsection; however, the commission may not renew the license until the commission determines that the reason for suspension no longer exists.(8) If the commission revokes or does not renew a license, a person may apply for an initial license by complying with the requirements of the Act and this chapter at the time of reapplication. The commission may refuse to issue a license, if the reason for revocation or non-renewal continues to exist.(9) Upon revocation or non-renewal, a license holder shall return the original license to the commission.(10) The procedures for revocation, suspension, probation, or denial of a license shall be in accordance with §139.32 of this title.(e) Failure to timely renew a license.(1) If a licensee fails to timely renew a license in accordance with subsection (d) of this section, the commission shall notify the licensee that the facility shall cease operation on the expiration date of the license.(2) To continue providing services at the abortion facility after the expiration of the license, the owner shall apply for an initial license in accordance with subsection (c) of this section.(f) Frequency of inspections. Inspections of the abortion facility shall be performed at a frequency prescribed by and in accordance with §139.31 of this title. Source Note: The provisions of this §504.23 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING B LICENSING PROCEDURES §504.23 Application Procedures and Issuance of Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222834 03/12/2026 (a) The following provisions apply to change of ownership of the licensed abortion facility and affect the condition of a license.(1) A licensee shall not transfer or assign its license from one person to another person.(2) The licensed abortion facility shall not materially alter any license issued by the commission.(3) A person who desires to receive a license in its name for a facility licensed under the name of another person or to change the ownership of any facility shall submit an initial license application and the initial license fee at least 60 calendar days prior to the desired date of the change of ownership. The application shall be in accordance with §139.23(c) of this title (relating to Application Procedures and Issuance of Licenses).(4) An application for a change of ownership shall include a notarized affidavit signed by the previous owner acknowledging agreement with the change of ownership. If the applicant is a corporation, the application shall include a copy of the applicant's articles of incorporation. If the applicant is a business entity other than a corporation, the applicant shall include a copy of the sales agreement.(5) The commission shall conduct an on-site inspection prior to the issuance of an initial license to the new owner of the facility, in accordance with §139.23(c) of this title.(6) The previous owner's license shall be void on the effective date of the change of ownership.(7) This subsection does not apply if a licensee is simply revising its name as allowed by law (i.e., a corporation is amending the articles of incorporation to revise its name).(8) The sale of stock of a corporate licensee does not cause this subsection to apply.(b) The following provisions apply to a change of physical location of the licensed abortion facility and affect the condition of a license.(1) A facility that intends to move its operations to a different physical location shall notify the commission at least 60 days in advance of the relocation.(2) A facility must apply for an initial license for the new physical location, submit the required initial license fee, and meet all requirements for an initial license in accordance with §139.23(c) of this title.(c) The following business changes affect the condition of a license and shall be reported to the commission.(1) If a licensed abortion facility changes its business name, business mailing address, telephone number of the facility, administrator's telephone number, or fax number (if available), the administrator shall notify the commission in writing within 15 calendar days after the effective date of the change.(2) If a licensed abortion facility changes its administrator, the facility shall provide the name of the new administrator and effective date to the commission in writing no later than 15 calendar days following such change.(d) The licensee shall notify the commission at least 30 days in advance of a relocation.(e) The licensee shall notify the commission in writing within 15 calendar days when a licensed abortion facility ceases operation. The licensee shall return the original license to the commission.(f) A licensed abortion facility shall have a written policy for the preservation and release of active and inactive medical records in the event the facility closes. Source Note: The provisions of this §504.24 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING B LICENSING PROCEDURES §504.24 Change of Ownership or Services, Change of Physical Location, and Closure of a Licensed Abortion Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222835 03/12/2026 (a) General.(1) The date a license application is received is the date the application reaches Health Facility Licensing (commission).(2) An application for an initial license is complete when the commission has received, reviewed, and found acceptable the information described in §139.23(c)(2)(C) of this title (relating to Application Procedures and Issuance of Licenses).(3) An application for a renewal license is complete when the commission has received, reviewed, and found acceptable the information described in §139.23(d)(2) of this title.(4) An application for a change of ownership or change of physical location license is complete when the requirements of §139.24 of this title (relating to Change of Ownership or Services, Change of Physical Location, and Closure of a Licensed Abortion Facility) have been met.(b) Time periods. An application from an abortion facility for an initial license, renewal license, change of physical location license, or change of ownership license shall be processed in accordance with the following time periods.(1) The first time period begins on the date the commission receives the application, and ends on the date the license is issued, or if the application is received incomplete, the period ends on the date the facility is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 45 days for initial, renewal, change of physical location, and change of ownership applications.(2) The second time period begins on the date the last item necessary to complete the application is received and ends on the date the license is issued. The second time period is 45 days for initial, renewal and change of ownership applications.(c) Reimbursement of fees.(1) In the event the application is not processed in the time periods stated in subsection (b) of this section, the applicant has the right to request that the commission reimburse in full the fee paid in that particular application process. If the commission does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request shall be denied.(2) Good cause for exceeding the period established is considered to exist if:(A) the number of applications for licenses to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;(B) another public or private entity utilized in the application process caused the delay; or(C) other conditions existed giving good cause for exceeding the established periods.(d) Appeal. If the request for reimbursement as authorized by subsection (c) of this section is denied, the applicant may then appeal to the executive commissioner for a resolution of the dispute. The applicant shall give written notice to the executive commissioner requesting reimbursement of the fee paid because the application was not processed within the established time period. The commission shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The executive commissioner shall make the final decision and provide written notification of the decision to the applicant and the commission. Source Note: The provisions of this §504.25 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING B LICENSING PROCEDURES §504.25 Time Periods for Processing and Issuing a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222836 03/12/2026 (a) General. An on-site inspection shall determine if the requirements of the Act and this chapter are being met.(1) An authorized representative of the commission (surveyor) may enter the premises of a licensed abortion facility at reasonable times during business hours and at other times as it considers necessary to ensure compliance with:(A) the Act and this chapter;(B) an order of the executive commissioner;(C) a court order granting injunctive relief; or(D) other enforcement actions.(2) The surveyor is entitled to access all books, records, or other documents maintained by or on behalf of the facility to the extent necessary to ensure compliance with the Act, this chapter, an order of the executive commissioner, a court order granting injunctive relief, or other enforcement action. The commission shall maintain the confidentiality of facility records as applicable under federal or state law. Ensuring compliance includes permitting photocopying by a department surveyor or providing photocopies to a commission surveyor of any records or other information by or on behalf of the commission as necessary to determine or verify compliance with the Act or this chapter.(3) By applying for or holding a license, the facility consents to entry and inspection of the facility by the commission or representative of the commission in accordance with the Act and this chapter.(b) Inspection procedures.(1) Except for purposes of an initial license application, all on-site inspections shall be unannounced and conducted at least annually. An on-site inspection for an initial license application, in accordance with §139.23(c) of this title (relating to Application Procedures and Issuance of Licenses), shall be scheduled with the applicant.(2) The commission's surveyor shall hold a conference with the person who is in charge of a licensed abortion facility or a facility subject to an application prior to commencing the inspection for the purpose of explaining the nature and scope of the inspection. The surveyor shall hold an exit conference with the person who is in charge of the facility when the inspection is completed, and the surveyor shall identify any records that were duplicated. Any original facility records that are removed from a facility shall be removed only with the consent of the facility.(3) The commission's authorized representative shall hold an exit conference and fully inform the person who is in charge of the facility of the preliminary finding(s) of the inspection, and shall give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings. The response shall be made a part of the inspection for all purposes, and shall be received by the commission within 14 calendar days of receipt of the preliminary findings of the inspection by the facility.(4) After the inspection is completed, the commission shall provide the administrator of the facility specific and timely written notice of the findings of the inspection in accordance with paragraph (7) of this subsection.(5) If the commission determines that the facility is in compliance with minimum standards at the time of the on-site inspection, the commission shall issue a license to the facility, if applicable.(6) If the surveyor finds there are deficiencies, the commission shall provide the facility with a statement of the deficiencies; the surveyor's recommendation for further action; or if there are no deficiencies found, a statement indicating this fact.(7) If the commission representative finds there are deficiencies, the facility and the commission shall comply with the following procedure.The commission shall determine if the written plan of correction is acceptable. If the plan of correction(s) is not acceptable to the commission, the commission shall notify the facility and request that the plan of correction be modified by telephone or resubmitted no later than 14 calendar days from receipt of such request by the facility.(A) The commission shall provide the facility with a statement of deficiencies on site at the time of the exit conference or within 14 calendar days of the exit conference.(B) The facility administrator or person in charge shall sign the written statement of deficiencies and return it to the commission with its plan of correction(s) for each deficiency within 14 calendar days of its receipt of the statement of deficiencies. The signature does not indicate the person's agreement with deficiencies stated on the form.(C) The facility shall have the option to challenge any deficiency cited after receipt of the statement of deficiencies. A challenge to a deficiency(ies) shall be in accordance with this subparagraph.(i) An initial challenge to a deficiency(ies) shall be submitted in writing no later than 14 calendar days from the facility's receipt of the statement of deficiencies to the Manager, Health Care Quality, Health Facility Compliance Texas Health and Human Services Commission, Post Office Box 149347, Austin, Texas 78714-9347. The initial written challenge shall include any and all documents supporting the facility's position.(ii) If the initial challenge is favorable to the commission, the facility may request a review of the initial challenge by submitting a written request to the Director, Health Care Quality, Texas Health and Human Services Commission, Post Office Box 149347, Austin, Texas 78714-9347. The facility shall submit its written request for review of the initial challenge no later than 14 calendar days of its receipt of the commission's response to the initial challenge. The commission shall not accept or review any documents that were not submitted with the initial challenge. A determination by the Director of Health Care Quality, relating to a challenge to a deficiency(ies) shall be considered the final determination by the commission.(iii) The commission shall respond to any written challenge submitted under clauses (i) or (ii) of this subparagraph no later than 14 calendar days from its receipt.(D) (E) If the facility does not come into compliance by the required date of correction, the commission may propose to deny, suspend, place on probation, or revoke the license in accordance with §139.32 of this title (relating to License Denial, Suspension, Probation, or Revocation).(F) Acceptance of a plan of correction by the commission does not preclude the commission from taking enforcement action as appropriate under §139.32 of this title.(8) The commission shall refer issues and complaints relating to the conduct or action(s) by licensed health care professionals to their appropriate licensing boards.(c) Complaints.(1) In accordance with §139.50 of this title (relating to Disclosure Requirements), all licensed abortion facilities are required to provide the woman on whom the abortion is to be performed and her guardian, if present, if the patient is a minor at time of the initial visit or if guardianship is required, with a written statement that complaints relating to the abortion facility may be registered with the Manager, Health Care Quality, Health Facility Compliance, Texas Health and Human Services Commission, Post Office Box 149347, Austin, Texas 78714-9347, (888) 973-0022.(2) The commission shall evaluate all complaints against licensed abortion facilities. All complaints submitted to the commission shall be in writing and signed by the complainant. Only those allegations determined to be relevant to the Act or this chapter shall be authorized for investigation. All information pertaining to a complaint is strictly confidential.(3) The commission or its authorized representative may enter the premises of an abortion facility during normal business hours as necessary to assure compliance with the Act and this chapter. The investigation may be conducted on site, by phone or by mail.(4) Conduct of the on-site investigation of a licensed abortion facility shall include, but not be limited to:(A) a conference prior to commencing the on-site investigation for the purpose of explaining the nature and scope of the investigation between the commission's authorized representative and the administrator of the abortion facility, or his or her designee;(B) an inspection of the facility;(C) an inspection of medical records, personnel records, administrative files, reports, other records, and/or working papers;(D) an interview with any physician or other health care practitioner, including abortion facility personnel who care for the recipient of abortion services;(E) a conference at the conclusion of the inspection between the commission's representative and the administrator, or his or her designee of the facility; and(F) identification by the commission's representative of any facility documents that have been reproduced.(5) If the commission finds that there are deficiencies following the on-site inspection, the provisions of subsection (b)(6) and (7) of this section shall apply.(6) The commission shall review the report of the investigation and determine the validity of the complaint. Source Note: The provisions of this §504.31 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective March 26, 2019, 44 TexReg 1532; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING C ENFORCEMENT §504.31 On-site Inspections and Complaint Investigations of a Licensed Abortion Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222837 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may refuse to issue or renew a license for a facility if the facility fails to comply with any provisions of the Act, this chapter, or Health and Safety Code Chapter 171.(b) Notwithstanding any other part of this chapter, HHSC is prohibited under Health and Safety Code §171.005 and §171.207 from enforcing Health and Safety Code Chapter 171, Subchapter H (relating to Detection of Fetal Heartbeat).(c) HHSC may suspend, place on probation, or revoke the license of a facility for one or more of the following reasons:(1) the facility commits fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to HHSC or required to be maintained by the facility pursuant to the Act;(2) the facility or any of its employees materially alters any license issued by HHSC;(3) the facility or its employees commits an act which causes immediate jeopardy to the health and safety of a patient;(4) the facility is cited for deficiencies and fails to submit an acceptable plan of correction in accordance with this chapter;(5) the facility has been cited for deficiencies and fails to timely comply with minimum standards for licensure within the dates designated in the plan of correction;(6) the facility or any of its employees has aided, abetted, or permitted the commission of an illegal act;(7) the facility or any of its employees fails to comply with any provisions of the Act or this chapter;(8) the facility is not in compliance with minimum standards for licensure;(9) the facility fails to provide the required application or renewal information;(10) the facility fails to comply with an order of the commissioner or another enforcement procedure under the Act;(11) the facility discloses an action described in §139.23(c)(2)(C)(xi) and (xii) of this chapter (relating to Application Procedures and Issuance of Licenses);(12) the facility knowingly employs as the facility administrator or chief financial officer an individual who was convicted of a felony or misdemeanor listed in subsection (d) of this section; or(13) the facility has a history of failure to comply with the rules adopted under this chapter.(d) HHSC may deny a person a license or suspend or revoke an existing license on the grounds that the person has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility.(1) In determining whether a criminal conviction directly relates to the duties and responsibilities of the ownership or operation of a licensed abortion facility, and in determining the fitness of a person who has been convicted of a crime to perform such duties and responsibilities, HHSC shall consider the provisions of Occupations Code Chapter 53.(2) HHSC is entitled to obtain criminal history information maintained by the Texas Department of Public Safety (Government Code §411.122), the Federal Bureau of Investigation (Government Code §411.087), or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.(3) The following felonies and misdemeanors directly relate to the duties and responsibilities of the ownership or operation of a licensed abortion facility because these criminal offenses demonstrate impaired ability to own or operate a facility:(A) a misdemeanor violation of Health and Safety Code Chapter 171 or Chapter 245;(B) a misdemeanor or felony involving moral turpitude;(C) a misdemeanor or felony relating to deceptive business practices;(D) a misdemeanor or felony of practicing any health-related profession without a required license;(E) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(F) a misdemeanor or felony under the Penal Code, Title 5, involving a patient or client of any health care facility, a home and community support services agency, or a health care professional; or(G) a misdemeanor or felony under the Penal Code:(i) Title 4--offenses of attempting or conspiring to commit any of the offenses in this clause;(ii) Title 5--offenses against the person;(iii) Title 7--offenses against property;(iv) Title 8--offenses against public administration;(v) Title 9--offenses against public order and decency;(vi) Title 10--offenses against public health, safety or morals; or(vii) Title 11--offenses involving organized crime.(4) Offenses listed in paragraph (3) of this subsection are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign or military jurisdictions which indicate an impaired ability or tendency for the person to be unable to own or operate a facility.(5) A license holder's license shall be revoked on the license holder's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(e) All proceedings for the denial, suspension, probation, or revocation of a license under this section shall be conducted at the State Office of Administrative Hearings, and in accordance with Health and Safety Code Chapter 245; Government Code Chapter 2001; and Chapter 1, Subchapter B of this title (relating to Formal Hearing Procedures).(f) A person who has had a facility license revoked under this section may not apply for a license under this chapter for one year following the date of revocation.(g) After an on-site inspection in which deficiencies were cited by the surveyor, a facility may surrender its license before expiration or allow its license to expire in lieu of HHSC proceeding with enforcement action. HHSC may accept such submission, or reject it and proceed with an enforcement action. The facility, its owner(s), and its affiliates may not reapply for a license for six months from the date of the surrender or expiration.(h) If HHSC suspends a license, the suspension shall remain in effect until HHSC determines that the reason for suspension no longer exists. An HHSC surveyor shall conduct an inspection of the facility prior to making a determination.(1) During the time of suspension, the suspended license holder shall return the original license certificate to HHSC.(2) If a suspension overlaps a renewal date, the suspended license holder shall comply with the renewal procedures in this chapter; however, HHSC may not renew the license until HHSC determines that the reason for suspension no longer exists.(3) If suspension is for more than one year, the suspended license holder may apply to HHSC for cancellation of the suspension only after one year following the initial date of the suspension.(i) If HHSC revokes or does not renew a license, a person may reapply for a license (subject to subsection (e) of this section), by complying with the requirements and procedures in this chapter at the time of reapplication. HHSC may refuse to issue a license, if the reason for revocation or non-renewal continues to exist, and may consider the enforcement history of the applicant, administrator, or clinical director in making such a determination.(j) Upon revocation or non-renewal, a license holder shall return the original license certificate to HHSC.(k) Upon a licensee's felony conviction, felony probation revocation, revocation of parole, or revocation of mandatory supervision, the license shall be revoked.(l) If HHSC finds that a licensed abortion facility is in repeated noncompliance with Health and Safety Code Chapter 171 or Chapter 245, or rules adopted under this chapter, but the noncompliance does not in any way involve the health and safety of the public or an individual, HHSC may schedule the facility for probation rather than suspending or revoking the facility's license.(m) HHSC may suspend or revoke the license of a licensed abortion facility that does not correct items that were in noncompliance or that does not comply with Health and Safety Code Chapter 171 or Chapter 245, or rules adopted under this chapter within the applicable probation period.(n) HHSC may suspend or revoke a license to be effective immediately when a situation(s) is identified that poses immediate jeopardy to the health and safety of person(s) at the facility.(1) HHSC shall immediately give the licensee adequate notice of the action taken, the legal grounds for the action, and the procedure governing appeal of the action.(2) HHSC shall set a hearing date not later than the 14th day after the effective date of the suspension or revocation.(3) HHSC shall also notify the facility in writing of the emergency action, the legal grounds for the action, the effective date of the emergency action, the procedure governing appeal of the action, and the date set for the hearing. This notice shall be sent by certified mail, return receipt requested, or by personal delivery. The hearing shall be conducted at the State Office of Administrative Hearings, and pursuant to Health and Safety Code Chapter 245; Government Code Chapter 2001; and the formal hearing procedures set out in Chapter 1, Subchapter B of this title.(o) If a person violates the licensing requirements of the Act or rules adopted under the Act, HHSC may petition the district court for a temporary restraining order to restrain the person from continuing the violation or operating without a license.(p) If a person operates a facility without a license as required by this chapter and the Act, the person is liable for a civil penalty of not less than $1,000 nor more than $2,500 for each day of violation.(q) If a facility has had enforcement action taken by HHSC against it, the facility, its owner(s), or its affiliate(s) may not apply for a facility license for one year following the effective date of the enforcement action. For purposes of this subsection only, the term "enforcement action" means license revocation, suspension, emergency suspension, or denial or injunctive action, but does not include administrative penalties or civil penalties. If HHSC prevails in one enforcement action (e.g., injunctive action) against the facility but also proceeds with another enforcement action (e.g., revocation) based on some or all of the same violations, but HHSC does not prevail in the second enforcement action (e.g., the facility prevails), the prohibition in this paragraph does not apply.(r) If HHSC revokes or does not renew a license and the one-year period described in subsection (q) of this section has passed, a person may reapply for a license by complying with the requirements and procedures in this chapter at the time of reapplication. HHSC may refuse to issue a license, if the reason for revocation or non-renewal continues to exist.(s) Upon revocation or non-renewal, a license holder shall return the license to HHSC. Source Note: The provisions of this §504.32 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING C ENFORCEMENT §504.32 License Denial, Suspension, Probation, or Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222838 03/12/2026 (a) Administrative penalties.(1) The department may assess an administrative penalty against a person who violates the Act or this chapter.(2) The penalty may not exceed $1,000 for each violation. Each day of a continuing violation constitutes a separate violation.(3) In determining the amount of an administrative penalty assessed under this section, the department shall consider:(A) the seriousness of the violation;(B) the history of previous violations;(C) the amount necessary to deter future violations;(D) efforts made to correct the violation; and(E) any other matters that justice may require.(4) All proceedings for the assessment of an administrative penalty under this section shall be conducted at the State Office of Administrative Hearings, and pursuant to the Health and Safety Code, Chapter 245; the Government Code, Chapter 2001; and the department's formal hearing procedures set out in §§1.21, 1.23, 1.25, and 1.27 of this title.(5) The department may assess costs against facilities in administrative proceedings in accordance with Health and Safety Code, Chapter 245.(b) Injunction, criminal penalties, and civil penalties. In addition to administrative penalties, the Health and Safety Code, Chapter 245, provides for injunctive relief and civil penalties for violations of that chapter and violations of these rules and also provides for criminal penalties for certain violations described therein. Source Note: The provisions of this §504.33 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING C ENFORCEMENT §504.33 Administrative Penalties, Injunction, Criminal Penalties, and Civil Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222839 03/12/2026 (a) Effective September 1, 2014, the department adopts by reference the following sections of Chapter 135 of this title (relating to Ambulatory Surgical Centers) that were in effect on January 1, 2014:(1) Subchapter A (relating to Operating Requirements for Ambulatory Surgical Centers):(A) The following definitions are incorporated by reference:(i) §135.2(2) (defining "Action plan");(ii) §135.2(6) (defining "Autologous blood units");(iii) §135.2(7) (defining "Available");(iv) §135.2(10) (defining "Dentist");(v) §135.2(12) (defining "Disposal");(vi) §135.2(13) (defining "Extended observation");(vii) §135.2(14) (defining "Health care practitioners");(viii) §135.2(16) (defining "Medicare");(ix) §135.2(21) (defining "Surgical technologist");(x) §135.2(22) (defining "Title XVIII");(B) The following sections relating to ambulatory surgical centers operating requirements:(i) §135.4 (relating to Ambulatory Surgical Center (ASC) Operation), except as specifically noted in subsection (d)(2) of this section;(ii) §135.5 (relating to Patient Rights);(iii) §135.6 (relating to Administration);(iv) §135.7 (relating to Quality of Care);(v) §135.8 (relating to Quality Assurance);(vi) §135.9 (relating to Medical Records);(vii) §135.10 (relating to Facilities and Environment);(viii) §135.11(a) and (b)(1) - (18) (relating to Anesthesia and Surgical Services);(ix) §135.12 (relating to Pharmaceutical Services);(x) §135.13 (relating to Pathology and Medical Laboratory Services);(xi) §135.14 (relating to Radiology Services);(xii) §135.15 (relating to Facility Staffing and Training);(xiii) §135.16 (relating to Teaching and Publication);(xiv) §135.17 (relating to Research Activities);(xv) §135.26 (relating to Reporting Requirements); and(xvi) §135.27 (relating to a Patient Safety Program);(2) Subchapter B (relating to Fire Prevention and Safety Requirements):(A) §135.41 (relating to Fire Prevention and Protection);(B) §135.42 (relating to General Safety); and(C) §135.43 (relating to Handling and Storage of Gases, Anesthetics, and Flammable Liquids); and(3) Subchapter C (relating to Physical Plant and Construction Requirements):(A) §135.51 (relating to Construction Requirements for an Existing Ambulatory Surgical Center), except as specifically noted in subsection (d)(3) of this section;(B) §135.52 (relating to Construction Requirements for a New Ambulatory Surgical Center);(C) §135.53 (relating to Elevators, Escalators, and Conveyors);(D) §135.54 (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records);(E) §135.55 (relating to Construction, Inspections, and Approval of Project); and(F) §135.56 (relating to Construction Tables).(b) As required by §4 of House Bill 2, passed in the Second Session, 83rd Legislature, 2013, the department intends by this adoption of rules to impose minimum standards for the health and safety of a patient of a licensed abortion facility, and that those minimum standards be equivalent to the minimum standards adopted under Health and Safety Code, §243.010, for ambulatory surgical centers.(c) The minimum standards adopted by reference under this section are not applicable to a licensed abortion facility before September 1, 2014.(d) Interpretive conventions. For purposes of this chapter:(1) The words "ambulatory surgical center" and "ASC" and their plural forms in the rules that are adopted by reference in subsection (a) of this section are understood to mean "licensed abortion facility" or "licensed abortion facilities," as appropriate, for purposes of this chapter.(2) The text of §135.4(c)(11)(B) that reads "or all physicians performing surgery at the ASC shall have admitting privileges at a local hospital" is not adopted by reference into this chapter.(3) The text of §135.51(a)(1) and the portion of the text of §135.51(a)(2) that reads, "In lieu of meeting the requirements in paragraph (1) of this subsection," are not adopted by reference into this chapter.(e) If the application of any particular rule that is incorporated by reference from Chapter 135 of this title is found by a state or federal court to violate the Constitution or impose an "undue burden" on women seeking abortions, the department shall continue to enforce the remaining incorporated rules that do not violate the Constitution or impose an "undue burden" on women seeking abortions, and shall continue to enforce all rules incorporated by reference from Chapter 135 of this title against abortion facilities for whom the application of such rules does not violate the Constitution or impose an "undue burden" on women seeking abortions. Source Note: The provisions of this §504.40 adopted to be effective January 1, 2014, 38 TexReg 9577; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.40 Adoption by Reference of Ambulatory Surgical Centers Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222840 03/12/2026 (a) The licensee shall be responsible for the conduct of the licensed abortion facility and shall assume full legal responsibility for developing, implementing, enforcing, and monitoring written policies governing the facility's total operation, and for ensuring that these policies comply with the Act and the applicable provisions of this chapter and are administered so as to provide health care in a safe and professionally acceptable environment. These written policies shall include at a minimum the following: (1) administrative policies governing the administration of the facility, covering at a minimum: (A) personnel; (B) employee orientation, training, and evaluation; (C) employee and patient record system; (D) auditing system for monitoring state or federal funds; (E) advertisements for the facility; (F) accuracy of public education information materials and activities in relation to abortion, birth control, and sexually-transmitted diseases; (G) patient education/information services and referral services; (H) reporting requirements; and (I) procedures for the resolution of complaints regarding care or services rendered by licensed health professionals and other members of the facility staff, including contract services or staff. The facility shall document the receipt and the disposition of the complaint. The investigation and documentation shall be completed within 30 calendar days after the facility receives the complaint, unless the facility has and documents reasonable cause for a delay. (2) clinical policies governing medical and clinical practices and procedures of the facility, covering at a minimum: (A) the provision of medical and clinical services; (B) the provision of laboratory services; (C) examination of fetal tissue; (D) disposition of medical waste; (E) emergency services; (F) condition on discharge procedures; (G) clinical records; (H) reporting and filing requirements; and (I) monitoring post-procedure infection(s). (3) a policy to ensure that the facility is in compliance with fire safety provisions as required by the local codes; (4) policies on decontamination, disinfection, and sterilization, and storage of sterile supplies; (5) policies for parental notice for unemancipated pregnant minors as stipulated in Family Code, Chapter 33; (6) policies for informed consent as stipulated in Health and Safety Code, Chapter 171, the Woman's Right to Know Act; (7) policies for reporting suspected abuse or neglect as stipulated in Family Code, Chapter 261; and (8) policies to ensure all women who present to obtain an abortion provide identification that includes the woman's date of birth. (A) If the woman does not have identification stating her date of birth, she shall be required to execute an affidavit on a form published by the department indicating that she does not have appropriate identification and indicating her date of birth on the affidavit. Attached Graphic(B) The facility shall keep a copy of the identification presented or the affidavit in its files. (b) The licensee, in fulfilling its responsibility under subsection (a) of this section, shall review the facility's written policies and procedures periodically, but no less than once every two years; date to indicate time of last review; revise as necessary; and enforce. Source Note: The provisions of this §504.41 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.41 Policy Development and Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222841 03/12/2026 (a) Delegation of authority.(1) The licensee shall appoint a medical consultant who shall be responsible for:(A) implementing and enforcing the clinical policies of the facility; and(B) supervising all medical services provided at the facility, such as medical, nursing, clinical, laboratory, and information/education services.(2) The licensee shall appoint an administrator who shall be responsible for implementing and supervising the administrative policies of the facility.(3) The licensee shall designate in writing a person who meets the qualifications of an administrator to act in the absence of the administrator.(b) Organizational structure. The licensee shall develop a written organizational structure which shall be in a chart format or a narrative explanation that provides a description of the structure of the licensed abortion facility and defines the lines of authority.(1) The written organizational structure shall include, at a minimum, the identification of the licensee, medical consultant, administrator, and clinical staff.(2) The written organizational structure shall clearly define the lines of authority and the delegation of responsibility for professional and nonprofessional staff (including the medical consultant, the administrator, the medical and clinical staff, and ancillary staff). Source Note: The provisions of this §504.42 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.42 Delegation of Authority and Organizational Structure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222842 03/12/2026 The licensee shall develop, implement and enforce policies which shall govern all personnel staffed by the facility using the following minimum criteria:(1) job descriptions, including qualifications for all personnel providing direct or indirect patient care;(2) a requirement for orientation of all employees, volunteers, students and contractors to the policies and objectives of the facility and participation by all personnel in employee training specific to their job;(3) job-related training for each position;(4) a requirement for an annual evaluation of employee performance;(5) in-service and continuing education requirements;(6) a requirement that all personnel providing direct patient care be currently certified in basic life support by the American Heart Association, the American Red Cross, or the American Safety and Health Institute, or in accordance with their individual professional licensure requirements, and if required in their job description or job responsibilities;(7) a requirement that all personnel having direct contact with patients (employed or contracting with the facility) sign a statement that they have read, understand, and shall respect the rights of all patients as established in §139.51 of this title (relating to Patient Rights at the Facility); and(8) a requirement that all personnel complete a training program developed jointly by the department and the Department of Family and Protective Services (DFPS) concerning their individual duties to report child abuse, how to identify and recognize abuse, and the jurisdiction of DFPS and local law enforcement over child abuse. Source Note: The provisions of this §504.43 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.43 Personnel Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222843 03/12/2026 (a) A licensed abortion facility shall develop and implement a written orientation and training program to familiarize all employees (including office staff) with the facility's policies, philosophy, job responsibilities of all staff, and emergency procedures.(b) In implementing the orientation and training program, a licensed abortion facility shall orient and train each employee to ensure, through demonstrated competency, that:(1) the employee understands his or her specific job description;(2) the employee understands the facility's policy and procedure manual, including protocols and description of the roles and responsibilities of all personnel;(3) the employee understands, at a minimum but not limited to, the following:(A) coordination and treatment of patient care;(B) sterilization and infection control policies;(C) patient education/information;(D) informed consent policies;(E) abortion techniques provided at that facility;(F) care of the patient before, during, and after an abortion procedure;(G) patient rights;(H) possible complications of the abortion procedure; and(I) prevention of infectious diseases.(c) The facility shall ensure that staff responsible for sterilization of critical surgical instruments are trained by the facility to meet the requirements of §139.49(d) of this title (relating to Infection Control Standards) and demonstrate competency in performing the sterilization procedures at the facility.(d) The facility shall ensure that all staff are aware of the reporting requirements for child abuse or neglect under Family Code, §261.101; and reporting requirements for family violence under Family Code, §91.002 and §91.003.(e) The facility shall document in each employee's personnel record evidence of all training and orientation received. Source Note: The provisions of this §504.44 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.44 Orientation, Training, and Demonstrated Competency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222844 03/12/2026 An individual personnel record shall be maintained on each person employed by the licensed abortion facility which shall include, but not be limited to, the following:(1) current job description for the employee, which is reviewed and revised as needed;(2) verification of current license and certification of personnel required to have a license and or certification;(3) clinical laboratory tests results and vaccinations if required by law (e.g., Mycobacterium tuberculosis, hepatitis B virus);(4) documentation of the education, training, and experience of the employee, in addition to a copy or verification of the employee's current license or certification credentials, or both; and(5) documentation of the employee's orientation, in-service, and other educational programs provided by the licensed abortion facility (training), and employee evaluation. Source Note: The provisions of this §504.45 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.45 Personnel Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222845 03/12/2026 A licensed abortion facility shall have an adequate number of personnel qualified under this section available to provide direct patient care as needed by all patients; and administrative and nonclinical services needed to maintain the operation of the facility in accordance with the provisions of the Act and this chapter.(1) Medical consultant. The medical consultant shall be a physician.(2) Administrator.(A) The administrator shall be at least 18 years of age, and shall meet at least one of the following qualifications:(i) be a licensed health care professional;(ii) have a baccalaureate degree, a postgraduate degree, or a professional degree and one year administrative experience in a health care or health-related field; or(iii) have a minimum of two years of administrative experience in a health care or health-related facility.(B) The administrator shall not have been employed in the last year as an administrator with another abortion facility or health-related facility at the time the facility was cited for violations of a licensing law or rule which resulted in enforcement action taken against the abortion facility or health-related facility. For purposes of this subparagraph only, the term "enforcement action" means license revocation, suspension, emergency suspension, probation, denial or injunctive action, but does not include administrative penalties or civil penalties. If the department prevails in one enforcement action (e.g., injunctive action) against the facility but also proceeds with another enforcement action (e.g., revocation) based on some or all of the same violations, but the department does not prevail in the second enforcement action (e.g., the facility prevails), the prohibition in this paragraph does not apply.(C) The administrator shall not have been convicted of a felony or misdemeanor listed in §139.32 of this title (relating to License Denial, Suspension, Probation, or Revocation).(3) Direct patient care staff.(A) Medical staff. The medical staff shall include a physician and may include an advanced practice registered nurse or a physician assistant.(B) Nursing staff. The nursing staff shall include a registered nurse(s) or a licensed vocational nurse(s).(C) Education and information staff. Staff providing education and information services at the facility shall be a person(s) who is trained to provide information on surgical abortion procedures, medical abortions, alternatives to abortion, consent form, and family planning services, and meets at least one of the following additional qualifications:(i) has one year experience in a health care facility;(ii) has a baccalaureate degree; or(iii) is a licensed professional mental health practitioner who provides therapeutic intervention.(D) Laboratory staff. The laboratory staff shall include a person(s) who is trained to provide the laboratory services for the facility as determined by the medical consultant.(4) Ancillary staff. Ancillary staff may include professional or nonprofessional staff who shall have training and experience to perform duties as prescribed by the administrator and the medical consultant as needed. Source Note: The provisions of this §504.46 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.46 Licensed Abortion Facility Staffing Requirements and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222846 03/12/2026 (a) The administrator shall be responsible for implementing and supervising the administrative policies of the facility.(b) The administrator shall:(1) employ a qualified staff adequate in number to:(A) provide the medical and clinical services;(B) provide the nonclinical services; and(C) maintain the abortion facility;(2) ensure that employment of personnel is without regard to age, race, color, religion, national origin, sex, or disability;(3) ensure that all medical and clinical personnel hold current Texas licenses to practice their respective disciplines/professions, if applicable;(4) develop and make available to all staff and the department, a policy and procedure manual including protocols and description of the roles and responsibilities of all personnel;(5) ensure that assignment of duties and functions to each employee are commensurate with his/her licensure, certification, and experience and competence;(6) ensure that staff receive training, education, and orientation to their specific job description, facility personnel policies, philosophy, and emergency procedures in accordance with this section;(7) schedule employee evaluations;(8) maintain employee and patient records;(9) ensure the accuracy of public education information materials and activities in relation to abortion, birth control, and sexually-transmitted diseases. The department shall be the primary resource for human immunodeficiency virus (HIV) education, prevention, risk reduction materials, policies, and information. Educational materials may be obtained by writing or calling the Department of State Health Services Warehouse, Literature and Forms, 1100 West 49th Street Austin, Texas 78756, (512) 458-7761;(10) implement an effective budgeting, accounting, and auditing system for receipt of state or federal funds;(11) ensure that all advertisements for the facility include the unique identifying license number assigned by the department in accordance with §139.7 of this title (relating to Unique Identifying Number; Disclosure in Advertisement);(12) ensure that a woman on whom the abortion is to be performed, at the time of initial on-site consultation, receives the information required to be disclosed under §139.50 of this title (relating to Disclosure Requirements); and(13) ensure that the reporting requirements of §139.4 of this title (relating to Annual Reporting Requirements for All Abortions Performed) are performed.(c) A licensed abortion facility shall report violations of practice acts and conditions of license for its licensed health care professional(s) to the appropriate licensing board. If the patient is unsatisfied with the facility's findings, the facility shall provide the complainant with the name, address, and telephone number of the appropriate licensing board. The facility shall document the review and action taken by the facility. Source Note: The provisions of this §504.47 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.47 Licensed Abortion Facility Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222847 03/12/2026 The physical and environmental requirements for a licensed abortion facility are as follows.(1) A facility shall:(A) have a safe and sanitary environment, properly constructed, equipped, and maintained to protect the health and safety of patients and staff at all times;(B) equip each procedure room so that procedures can be performed in a manner that assures the physical safety of all individuals in the area;(C) have a separate recovery room if moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia are administered at the facility;(D) have a written protocol for emergency evacuation for fire and other disasters tailored to the facility's geographic location. Each staff member employed by or under contract with the facility shall be able to demonstrate their role or responsibility to implement the facility's emergency evacuation protocol required by this subparagraph;(E) store hazardous cleaning solutions and compounds in a secure manner and label substances;(F) have the capacity to provide patients with liquids. The facility may provide commercially packaged food to patients in individual servings. If other food is provided by the facility, it shall be subject to the requirements of Chapter 228 of this title (relating to Retail Food);(G) provide clean hand washing facilities for patients and staff including running water, and soap;(H) have two functioning sinks and a functioning toilet; and(I) have equipment available to sterilize instruments, equipment, and supplies in accordance with §139.49(d) of this title (relating to Infection Control Standards) before use in the facility.(2) The equipment for vacuum aspiration shall be electrically safe and designed to prevent reverse pump action in facilities that provide vacuum aspiration.(3) Projects involving alterations of and additions to existing buildings shall be programmed and phased so that on-site construction shall minimize disruptions of existing functions. Access, exit ways, and fire protection shall be maintained so that the safety of the occupants shall not be jeopardized during construction. Source Note: The provisions of this §504.48 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective February 18, 2018, 43 TexReg 577; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.48 Physical and Environmental Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222848 03/12/2026 (a) Written policies. A licensed abortion facility shall develop, implement, and enforce infection control policies and procedures to minimize the transmission of post-procedure infections. These policies shall include, but not be limited to, the prevention of the transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), Mycobacterium tuberculosis (TB), and Streptococcus species (S. spp.); educational course requirements; cleaning and laundry requirements; and decontamination, disinfection, sterilization, and storage of sterile supplies.(b) Prevention and control of the transmission of HIV, HBV, HCV, TB, and S. spp.(1) Universal/standard precautions.(A) An abortion facility shall ensure that all staff comply with universal/standard precautions as defined in this paragraph.(i) Universal/standard precautions includes procedures for disinfection and sterilization of reusable medical devices and the appropriate use of infection control, including hand washing, the use of protective barriers, and the use and disposal of needles and other sharp instruments.(ii) Universal/standard precautions synthesize the major points of universal precautions with the points of body substance precautions and apply them to all patients receiving care in facilities, regardless of their diagnosis or presumed infection status.(I) Universal/standard precautions apply to:(-a-) blood;(-b-) body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood;(-c-) nonintact skin; and(-d-) mucous membranes.(II) Universal/standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in facilities.(B) A licensed abortion facility shall establish procedures for monitoring compliance with universal/standard precautions described in subparagraph (A) of this paragraph.(2) Health care workers infected with the HIV or HBV. A licensed abortion facility shall adopt, implement, and enforce a written policy to ensure compliance of the facility and all of the health care workers within the facility with the Health and Safety Code, Chapter 85, Subchapter I, concerning the prevention of the transmission of HIV and HBV by infected health care workers.(3) Educational course work and training. A licensed abortion facility shall require its health care workers to complete educational course work or training in infection control and barrier precautions, including basic concepts of disease transmission, scientifically accepted principles and practices for infection control and engineering and work practice controls. To fulfill the requirements of this paragraph, course work and training may include formal education courses or in-house training or workshops provided by the facility. The course work and training shall include, but not be limited to:(A) HIV infection prevention; and(B) HBV, HCV, TB, and S. spp. infection prevention based on universal/standard precautions as defined in paragraph (1) of this subsection;(C) bidirectional aspect of disease transmission; and(D) epidemic control.(c) Cleaning and laundry policies and procedures.(1) A licensed abortion facility shall develop, implement, and enforce written policies and procedures on cleaning the procedure room(s).(2) A licensed abortion facility shall develop, implement, and enforce written policies and procedures for the handling, processing, storing, and transporting of clean and dirty laundry.(3) A licensed abortion facility may provide cleaning and laundry services directly or by contract in accordance with Occupational Safety and Health Administration's Standards, 29 Code of Federal Regulations, Subpart Z. Bloodborne Pathogens.(d) Policies and procedures for decontamination, disinfection, sterilization, and storage of sterile supplies. A licensed abortion facility shall have written policies covering its procedures for the decontamination and sterilization activities performed. Policies shall include, but not be limited to, the receiving, cleaning, decontaminating, disinfecting, preparing and sterilization of critical items (reusable items), as well as those for the assembly, wrapping, storage, distribution, and the monitoring and control of sterile items and equipment.(1) Supervision. The decontamination, disinfection, and sterilization of all supplies and equipment shall be under the supervision of a person qualified by education, training, or experience.(2) Quantity of sterile surgical instruments. The facility shall ensure that surgical instruments are sufficient in number to permit sterilization of the instrument(s) used for each procedure and adequate to perform conventional cervical dilatation and curettage if this procedure is available at the facility.(3) Inspection of surgical instruments.(A) All instruments shall undergo inspection before being packaged for reuse or storage. Routine inspection of instruments shall be made to assure clean locks, crevices, and serrations.(B) Inspection procedures shall be thorough and include visual and manual inspection for condition and function.(i) Cutting edges shall be checked for sharpness; tips shall be properly aligned, and box locks shall be clean and free from buildup of soap, detergent, dried blood, or tissue.(ii) There shall be no evident cracks or fissures in the box locks, and the hinges shall work freely.(iii) Ratchets shall hold and be routinely tested.(iv) There shall be no corrosion or pitting of the finish.(C) Instruments needing maintenance shall be taken out of service and repaired by someone qualified to repair surgical instruments.(D) To protect the instrument and its protective finish, impact markers or electric engravers shall not be used for instrument identification. Instrument identification shall be accomplished by the instrument manufacturer, employing methods which shall not damage the instrument or its protective finish.(4) Items to be disinfected and sterilized.(A) Critical items.(i) Critical items include all surgical instruments and objects that are introduced directly into the bloodstream or into other normally sterile areas of the body and shall be sterilized in accordance with this subsection.(ii) All items that come in contact with the sterile field during the operative procedure shall be sterile.(B) Semicritical items.(i) Semicritical items include items that come in contact with nonintact skin or mucous membranes. Semicritical items shall be free of microorganisms, except bacterial spores. Semicritical items may include respiratory therapy equipment, anesthesia equipment, bronchoscopes, and thermometers.(ii) High-level disinfection shall be used for semicritical items.(C) Noncritical items.(i) Noncritical items include items that come in contact with intact skin.(ii) Intermediate-level or low-level disinfection shall be used for noncritical items.(5) Equipment and sterilization procedures. Effective sterilization of instruments depends on performing correct methods of cleaning, packaging, arrangement of items in the sterilizer, and storage. The following procedures shall be included in the written policies as required in this subsection to provide effective sterilization measures.(A) Equipment. A licensed abortion facility shall provide sterilization equipment adequate to meet the requirements of this paragraph for sterilization of critical items. Equipment shall be maintained and operated to perform, with accuracy, the sterilization of critical items.(B) Environmental requirements. Where cleaning, preparation, and sterilization functions are performed in the same room or unit, the physical facilities, equipment, and the written policies and procedures for their use shall be such as to effectively separate soiled or contaminated supplies and equipment from the clean or sterilized supplies and equipment.(i) A facility shall have a sink for hand washing. This sink shall not be used for cleaning instruments or disposal of liquid waste.(ii) A facility shall have a separate sink for cleaning instruments and disposal of liquid waste. Hand washing shall only be performed at this sink after it has been disinfected.(C) Preparation for sterilization.(i) All items to be sterilized shall be prepared to reduce the bioburden. All items shall be thoroughly cleaned, decontaminated and prepared in a clean, controlled environment. Cleaning is the removal of all adherent visible soil from the surfaces, crevices, joints, and lumens of instruments. Decontamination is the physical/chemical process that renders an inanimate object safe for further handling.(ii) One of the following methods of cleaning and decontamination shall be used as appropriate.(I) Manual cleaning. Manual cleaning of instruments at the sink is permitted.(II) Ultrasonic cleaning. Ultrasonic cleaning of instruments cleans by cavitation and reduces the need for hand scrubbing. When grossly soiled items are placed in the ultrasonic cleaner the water shall be changed more than once a shift. If using this method for cleaning, chambers shall be covered to prevent potential hazards to personnel from aerosolization of the contents.(III) Washer-sterilizers. Washer-sterilizers clean by using rotating spray arms to create water jets that clean by impingement and appropriate soap and disinfectant. These machines shall reach a temperature of 140 degrees Celsius (285 degrees Fahrenheit).(IV) Washer-decontaminator machines. Washer-decontaminator machines clean by numerous water jets and a high pH of detergent even if instruments are grossly soiled. The thorough cleaning is followed by a neutralizing rinse to quickly restore the pH to neutral.(iii) All articles to be sterilized shall be arranged so all surfaces shall be directly exposed to the sterilizing agent for the prescribed time and temperature.(D) Packaging.(i) All wrapped articles to be sterilized shall be packaged in materials recommended for the specific type of sterilizer and material to be sterilized, and to provide an effective barrier to microorganisms. Acceptable packaging includes peel pouches, perforated metal trays, or rigid trays. Muslin packs shall be limited in size to 12 inches by 12 inches by 20 inches with a maximum weight of 12 pounds. Wrapped instrument trays shall not exceed 17 pounds.(ii) All items shall be labeled for each sterilizer load as to the date and time of sterilization, the sterilizing load number, and the autoclave.(E) External chemical indicators.(i) External chemical indicators, also known as sterilization process indicators, shall be used on each package to be sterilized, including items being flash sterilized to indicate that items have been exposed to the sterilization process.(ii) The indicator results shall be interpreted according to the manufacturer's written instructions and indicator reaction specifications.(F) Biological indicators.(i) The efficacy of the sterilizing process shall be monitored with reliable biological indicators appropriate for the type of sterilizer used (e.g., Bacillus stearothermophilus for steam sterilizers).(ii) Biological indicators shall be included in at least one run each day of use for steam sterilizers.(iii) A log shall be maintained with the load identification, biological indicator results, and identification of the contents of the load.(iv) If a test is positive, the sterilizer shall immediately be taken out of service. A malfunctioning sterilizer shall not be put back into use until it has been serviced and successfully tested according to the manufacturer's recommendations.(v) All available items shall be recalled and reprocessed if a sterilizer malfunction is found. A list of all items which were used after the last negative biological indicator test shall be submitted to the administrator.(G) Sterilizers.(i) Steam sterilizers (saturated steam under pressure) shall be utilized for sterilization of heat and moisture stable items. Steam sterilizers shall be used according to manufacturer's written instructions.(ii) Other sterilizers shall be used in accordance with the manufacturer's instructions.(H) Maintenance of sterility.(i) Items that are properly packaged and sterilized shall remain sterile indefinitely unless the package becomes wet or torn, has a broken seal, is damaged in some way, or is suspected of being compromised.(ii) Medication or materials within a package that deteriorate with the passage of time shall be dated according to the manufacturer's recommendations.(iii) All packages shall be inspected before use. If a package is torn, wet, discolored, has a broken seal, or is damaged, the item may not be used. The item shall be returned to sterile processing for reprocessing.(I) Commercially packaged items. Commercially packaged items are considered sterile according to the manufacturer's instructions.(J) Storage of sterilized items. The loss of sterility is event related, not time related. The facility shall ensure proper storage and handling of items in a manner that does not compromise the packaging of the product.(i) Sterilized items shall be transported so as to maintain cleanliness and sterility and to prevent physical damage.(ii) Sterilized items shall be stored in well-ventilated, limited access areas with controlled temperature and humidity.(iii) Sterilized items shall be positioned so that the packaging is not crushed, bent, compressed, or punctured so that their sterility is not compromised.(iv) Storage of supplies shall be in areas that are designated for storage.(K) Disinfection.(i) The manufacturer's written instructions for the use of disinfectants shall be followed.(ii) An expiration date, determined according to manufacturer's written recommendations, shall be marked on the container of disinfection solution currently in use.(iii) Disinfectant solutions shall be kept covered and used in well-ventilated areas.(L) Performance records.(i) Performance records for all sterilizers shall be maintained for each cycle. These records shall be retained and available for review for a minimum of two years.(ii) Each sterilizer shall be monitored during operation for pressure, temperature, and time at desired temperature and pressure. A record shall be maintained either manually or machine generated and shall include:(I) the sterilizer identification;(II) sterilization date and time;(III) load number;(IV) duration and temperature of exposure phase (if not provided on sterilizer recording charts);(V) identification of operator(s);(VI) results of biological tests and dates performed; and(VII) time-temperature recording charts from each sterilizer (if not provided on sterilizer recording charts).(M) Preventive maintenance. Preventive maintenance of all sterilizers shall be performed according to individual policy on a scheduled basis by qualified personnel, using the sterilizer manufacturer's service manual as a reference. A preventive maintenance record shall be maintained for each sterilizer. These records shall be retained at least two years and shall be available for review to the facility within two hours of request by the department. Source Note: The provisions of this §504.49 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.49 Infection Control Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222849 03/12/2026 (a) At the time a woman on whom the abortion is to be performed or induced initially consults with a licensed abortion facility, the facility shall comply with the following.(1) Provide the woman with a written statement indicating the number of the toll-free telephone line which is maintained by the Texas Health and Human Services Commission (HHSC) to provide specific information relating to licensed abortion facilities in Texas. The statement shall be in accordance with §139.6 of this chapter (relating to Public Information; Toll-Free Telephone Number).(2) Provide the woman with a written statement identifying HHSC as the responsible agency for facility complaint investigations. The statement shall indicate that a person may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC. All complaints are confidential.(3) Provide the woman with a copy of HHSC's "A Woman's Right to Know" booklet created for women seeking an abortion, if the woman chooses to view it.(4) Provide the woman with a copy of HHSC's "A Woman's Right to Know" resource directory (required by Health and Safety Code §171.015), if the woman chooses to view it.(5) Inform the woman of her option to view HHSC's "A Woman's Right to Know" booklet and resource directory on HHSC's Internet website and provide her with the Internet address for obtaining the information.(6) Provide the woman with a written statement that she may call HHSC at (888) 973-0022, if the facility does not provide her with the information required in paragraphs (3) and (4) of this subsection.(b) The facility shall ensure that the woman on whom the abortion is to be performed or induced receives all information required for voluntary and informed consent, in accordance with Health and Safety Code §171.012 at least 24 hours prior to the abortion procedure.(c) The facility shall initiate a clinical record for the woman on whom the abortion is to be performed or induced at the time of the initial consultation. The following information pertaining to disclosure, as described in this section, shall be documented in the clinical record:(1) the date and time of the initial consultation;(2) the method by the which the information required under subsections (a) and (b) of this section was provided; and(3) the name and title of individual(s) who provided or verified the information required under subsections (a) and (b) of this section. Source Note: The provisions of this §504.50 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.50 Disclosure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222850 03/12/2026 A licensed abortion facility shall ensure that all women on whom the abortion is to be performed:(1) be allowed to make her own choice and self-determination;(2) are ensured the right to personal privacy and confidentiality of her choices and decisions;(3) are ensured the right to voluntary and informed consent as defined in Health and Safety Code, §171.012, without paying a fee for the informational materials;(4) are ensured individual counseling concerning private medical information and to be given a private opportunity to ask questions;(5) be allowed to view their medical record, including the sonogram, if one has been performed, at any time as provided by law;(6) have access to care and treatment consistent with available resources and generally accepted standards regardless of race, color, national origin, age, sex, religion or disability;(7) are allowed to ask additional questions after giving consent and to withdraw consent while still medically safe to do so;(8) are provided freedom from abuse, neglect, or exploitation as those terms are defined in §1.204 of this title (relating to Abuse, Neglect, and Exploitation Defined); and(9) be allowed to review the department's informational materials as described in Health and Safety Code, §171.014 and §171.015. Source Note: The provisions of this §504.51 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.51 Patient Rights at the Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222851 03/12/2026 (a) A licensed abortion facility shall ensure patient education/information services are provided to each woman on whom the abortion is to be performed or induced to:(1) ensure compliance with Health and Safety Code §171.011 (relating to Informed Consent Required), and §171.012 (relating to Voluntary Informed Consent) concerning informed consent by utilizing the sonogram and election form as set out in Health and Safety Code §171.012, signed by the woman prior to an abortion procedure, and maintained in the patient's clinical record;(2) prepare the patient for surgery in a manner that facilitates her safety and comfort;(3) assist the patient in reaching a decision about the method of post-procedure birth control she will use, if any, and respect her choices; and(4) ensure, when medically appropriate, the patient is advised of the physician's obligation to take all reasonable steps to maintain the life and health of a child who is born alive.(b) A licensed abortion facility shall, if needed, refer a patient to a licensed mental health practitioner who provides therapeutic intervention. Source Note: The provisions of this §504.52 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.52 Patient Education/Information Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222852 03/12/2026 (a) Surgical abortion.(1) The medical consultant shall be responsible for implementing and supervising the medical and clinical policies of the facility.(2) All medical and clinical services of the facility, with the exception of the abortion procedure, shall be provided under the direction of a physician or registered nurse who assumes responsibility for the clinical employees' performance in the facility.(3) A licensed abortion facility shall ensure that a surgical consent form is signed by the patient prior to the procedure being started, that the patient is informed of the risks and the benefits of the procedure, and that the patient recognizes the alternatives to abortion. Informed consent shall be in accordance with rules adopted by the Texas Medical Disclosure Panel under §601.2 of this title (relating to Procedures Requiring Full Disclosure of Specific Risks and Hazards--List A), §601.4 of this title (relating to Disclosure and Consent Form), and Health and Safety Code §171.011 (relating to Informed Consent Required), and §171.012 (relating to Voluntary Informed Consent).(4) A licensed abortion facility shall ensure that the attending physician, advanced practice registered nurse, or physician assistant has obtained and documented a preoperative history, physical exam, and laboratory studies, including verification of pregnancy.(5) A licensed abortion facility shall ensure that:(A) the attending physician examines each patient immediately prior to surgery to evaluate the risk to the procedure; and(B) the person administering the anesthetic agent(s) examines the patient immediately prior to surgery to evaluate the risk of anesthesia.(6) The administration of anesthesia shall be in accordance with §139.59 of this subchapter (relating to Anesthesia Services).(7) A surgical abortion shall be performed only by a physician.(8) A physician, advanced practice registered nurse, physician assistant, registered nurse, or licensed vocational nurse shall be in the facility whenever there is a patient in the procedure room or recovery room. While a patient is in the procedure room or recovery room she shall not be left unattended.(9) The recovery room(s) at the facility shall be supervised by a physician, advanced practice registered nurse, physician assistant, or registered nurse. This supervisor shall be available for recovery room staff within a recommended 10 minutes with a maximum required 15 minutes while any patient is in the recovery room.(10) A physician shall be available for the facility while any patient is in the recovery room within a recommended 10 minutes and a maximum required 15 minutes.(11) The facility shall ensure that a patient is fully reactive and her vital signs are stable before discharging the patient from the facility upon written order by the attending physician.(12) All fetal tissue shall be examined grossly at the time of the procedure. In the absence of visible fetal parts or placenta, the tissue may be examined by magnification for the detection of villi. If this examination is inconclusive, the tissue shall be sent to a pathology lab. The results of the tissue examination shall be recorded in the patient's clinical record.(13) A facility shall meet the requirements set forth by the department in §§1.131 - 1.137 of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(b) Medical abortion.(1) The medical consultant shall be responsible for implementing and supervising the medical and clinical policies of the facility.(2) All medical and clinical services of the facility, with the exception of the abortion procedure, shall be provided under the direction of a physician or registered nurse who assumes responsibility for the clinical employees' performance in the facility.(3) A licensed abortion facility shall ensure:(A) the physician(s) providing medical abortion is able to accurately date a pregnancy;(B) the physician(s) is able to determine that the pregnancy is not an ectopic gestation;(C) the physician(s) is able to provide surgical intervention or provide for the patient to receive a surgical abortion if necessary; and(D) patients have access to medical facilities equipped to provide blood transfusion and patient resuscitation, if necessary.(4) A licensed abortion facility shall ensure follow-up examination and services are provided to patients requesting medical abortion.(5) A licensed abortion facility shall ensure that the attending physician, advanced practice registered nurse, or physician assistant has obtained and documented a pre-procedure history, physical exam, and laboratory studies, including verification of pregnancy.(6) A licensed abortion facility shall ensure:(A) written consent is obtained from the patient prior to the commencement of the abortion procedure in accordance with §139.50 of this chapter (relating to Disclosure Requirements);(B) the patient is informed of the risks and benefits of the procedure;(C) the patient is informed of the possibility that a surgical abortion may be required;(D) the patient is informed of the alternatives to abortion; and(E) informed consent is in accordance with rules adopted by the Texas Medical Disclosure Panel under §601.2 of this title, §601.4 of this title, and Health and Safety Code §171.011 and §171.012.(7) A licensed abortion facility shall provide the patient with written discharge instructions including a direct referral to a physician who shall accept the patient for surgical abortion.(8) A medical abortion shall be performed only by a physician.(c) Requirements of a physician. A physician performing or inducing an abortion must, on the date the abortion is performed or induced, have active admitting privileges at a hospital that:(1) is located not further than 30 miles from the location at which the abortion is performed or induced; and(2) provides obstetrical or gynecological health care services. Source Note: The provisions of this §504.53 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.53 Medical and Clinical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222853 03/12/2026 (a) Definition. For the purposes of this section, the term "health care professional" includes:(1) a physician;(2) an advanced practice registered nurse;(3) a physician assistant;(4) a registered nurse;(5) a licensed vocational nurse; or(6) a licensed mental health practitioner.(b) Licensed health care professionals.(1) A licensed abortion facility shall ensure that its licensed health care professionals practice within the scope of their practice and within the constraints of applicable state laws and regulations governing their practice and follow the facility's written policies and procedures.(2) A licensed abortion facility may allow physicians to train nonlicensed personnel, age 18 years or above, to extract blood for laboratory testing and to administer intravenous fluids.(c) Student health care professionals. If the facility has a contract or agreement with an accredited school of health care to use their facility for a portion of the students' clinical experience, those students may provide care under the following conditions.(1) Students may be used in facilities, provided the instructor gives class supervision and assumes responsibility for all student activities occurring within the facility. If the student is licensed, such as a licensed vocational nurse attending a registered nurse program for licensure as a registered nurse, the facility shall ensure that the administration of any medication(s) is within the student's licensed scope of practice.(2) All instruction shall be provided by the school's instructor or his or her designee.(3) A student may administer medications only if:(A) on assignment as a student of their school of health care; and(B) the instructor is on the premises and directly supervises the administration of medication by an unlicensed student, and the administration of such medication is within the instructor's licensed scope of practice.(4) Students shall not be used to fulfill the requirement for administration of medications by licensed personnel.(5) Students shall not be considered when determining staffing needs required by the facility. Source Note: The provisions of this §504.54 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.54 Health Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222854 03/12/2026 (a) A licensed abortion facility shall maintain a daily patient roster of all patients receiving abortion services. This daily patient roster shall be retained for a period of five years.(b) A licensed abortion facility shall establish and maintain a clinical record for each patient. A licensed abortion facility shall maintain the record to assure that the care and services provided to each patient is completely and accurately documented, and readily and systematically organized to facilitate the compilation and retrieval of information.(1) The facility shall have written procedures which are adopted, implemented, and enforced regarding the removal of records and the release of information. A facility shall not release any portion of a patient record to anyone other than the patient except as allowed by law.(2) All information regarding the care and services shall be centralized in the record and be protected against loss or damage and unofficial use.(3) The facility shall establish an area for patient record storage. The patient records shall be retrievable within two hours by the facility for patients whose date of the last visit is less than twelve months. For patients whose date of the last visit is greater than twelve months, records shall be retrievable within ten days.(4) The facility shall ensure that each record is treated with confidentiality.(5) The clinical record shall be an original, a microfilmed copy, an optical disc imaging system or other electronic means, or a certified copy. An original record includes manually signed paper records or electronically signed computer records. Computerized records shall meet all requirements of paper records including protection from unofficial use and retention for the period specified in subsection (d) of this section. Systems shall assure that entries regarding the delivery of care or services are not altered without evidence and explanation of such alteration.(6) A facility shall maintain clinical records in their original state. Each entry shall be accurate, dated with the date of entry, and signed by the individual making the entry. Correction fluid or tape shall not be used in the record. Corrections shall be made by striking through the error with a single line, and shall include the date the correction was made and the initials of the person making the correction.(c) The clinical record shall contain:(1) patient identifying information;(2) name of physician;(3) diagnosis;(4) history and physical;(5) a preanesthesia evaluation performed by personnel approved by the facility to provide anesthesia services;(6) laboratory reports;(7) report of gross and/or microscopic examination of tissue obtained during a surgical abortion;(8) allergies/drug reactions;(9) physician's orders;(10) progress notes to include at a minimum notations of vital signs; signs and symptoms; response to medication(s) and treatment(s); and any changes in physical or emotional condition(s). These notations shall be written, dated, and signed by the individual(s) delivering patient care no later than 10 days from the day the patient is discharged from the facility;(11) education/information and referral notes;(12) signed patient consent form;(13) medication administration records. Notations of all pharmaceutical agents shall include the time and date administered, the name of the individual administering the agent, and the signature of the person making the notation if different than the individual administering the agent;(14) condition on discharge;(15) the medical examination or written referral, if obtained;(16) physician documentation of viability or nonviability of fetus(es) at a gestational age greater than 26 weeks;(17) for patients receiving moderate sedation/analgesia or deep sedation/analgesia:(A) a minimum of blood pressure, pulse, and respirations shall be obtained and recorded before sedation, during sedation, during the procedure, during the initial recovery period, and before discharge from the facility; and(B) the patient's blood oxygenation shall be assessed and recorded, a minimum of at the time of sedation, during the procedure, and after the procedure;(18) for an abortion performed or induced because of a medical emergency, a written document executed by the physician certifying the abortion is necessary due to a medical emergency and specifying the medical condition requiring the abortion;(19) for an abortion performed or induced to preserve the health of the patient, a written document executed by the physician specifying the medical condition the abortion is asserted to address and providing the medical rationale for the physician's conclusion that the abortion is necessary to address the medical condition; and(20) for an abortion performed or induced for a reason other than an abortion described by paragraph (19) of this subsection, a written document executed by the physician specifying that maternal health is not a purpose of the abortion.(d) A licensed abortion facility shall retain clinical records for adults for seven years from the time of discharge and clinical records for minors for five years past the age the patient reaches majority.(e) A licensed abortion facility may not destroy patient records that relate to any matter that is involved in litigation if the facility knows the litigation has not been finally resolved.(f) If a licensed abortion facility closes, there shall be an arrangement for the preservation of inactive records to ensure compliance with this section. The facility shall send the Texas Health and Human Services Commission written notification of the reason for closure, the location of the patient records, and the name and address of the patient record custodian. If a facility closes with an active patient roster, a copy of the active patient record shall be transferred with the patient to the receiving facility or other health care facility in order to assure continuity of care and services to the patient. Source Note: The provisions of this §504.55 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective November 24, 2022, 47 TexReg 7696; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.55 Clinical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222855 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222855 03/12/2026 (a) A licensed abortion facility shall have a readily accessible written protocol for managing medical emergencies and the transfer of patients requiring further emergency care to a hospital. The facility shall ensure that the physicians who practice at the facility:(1) have active admitting privileges at a hospital that provides obstetrical or gynecological health care services and is located not further than 30 miles from the abortion facility;(2) provide the pregnant woman with:(A) a telephone number by which the pregnant woman may reach the physician, or other health care personnel employed by the physician or the facility at which the abortion was performed or induced with access to the woman's relevant medical records, 24 hours a day to request assistance for any complications that arise from the performance or induction of the abortion or ask health-related questions regarding the abortion; and(B) the name and telephone number of the nearest hospital to the home of the pregnant woman at which an emergency arising from the abortion would be treated.(b) The facility shall have the necessary equipment and personnel for cardiopulmonary resuscitation as described in §139.59 of this title (relating to Anesthesia Services).(c) Personnel providing direct patient care shall be currently certified in basic life support by the American Heart Association, the American Red Cross, or the American Safety and Health Institute, or in accordance with their individual professional licensure requirements, and if required in their job description or job responsibilities. Source Note: The provisions of this §504.56 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.56 Emergency Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222856 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222856 03/12/2026 (a) A licensed abortion facility shall develop and implement written discharge instructions which shall include:(1) a list of complications (developed by the facility in conjunction with a physician who practices in the facility) that warrant the patient contacting the facility, which shall include, but not be limited to:(A) pain;(B) fever; and(C) bleeding;(2) a statement of the facility's plan to respond to the patient in the event the patient experiences any of the complications listed in the discharge instructions to include:(A) a telephone number by which the patient may reach the physician, or other health care personnel employed by the physician or by the facility at which the abortion was performed or induced with access to the woman's relevant medical records, 24 hours a day to request assistance for any complications that arise from the performance or induction of the abortion or ask health-related questions regarding the abortion;(B) the name and telephone number of the nearest hospital to the home of the patient at which an emergency arising from the abortion would be treated;(C) assurance that the responding individual shall be a physician, advanced practice registered nurse, physician assistant, registered nurse, or licensed vocational nurse; and(D) information that the patient may also contact the emergency medical service or present for care at the emergency room of a hospital in addition to contacting the facility; and(3) information concerning the need for a post-abortion examination.(b) A facility shall provide a patient with a copy of the written discharge instructions described in subsection (a) of this section.(c) The facility shall develop and implement written policies and procedures for:(1) examination or referral of all patients who report complications, as identified in the list required by subsection (a)(1) of this section, to the facility after an abortion procedure. The written policy and procedure shall require:(A) the facility to maintain a written system of documentation of patients who report post-abortion complications within 14 days of the procedure date;(B) documentation of the facility's action following a patient's reporting of post-abortion complications to be placed in the patient's record; and(C) the patients' records to be maintained for adults for seven years and for minors five years past the age the patient reaches majority; and(2) periodic review of the record keeping system for post-abortion complications to identify problems and potential problems and to make changes in order to resolve the problems. Source Note: The provisions of this §504.57 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective January 1, 2014, 38 TexReg 9577; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.57 Discharge and Follow-up Referrals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222857 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222857 03/12/2026 A licensed abortion facility shall report a woman's death if it results from a complication(s) of an abortion. The report shall be made by phone or fax within one business day after the facility is notified of the death to the Manager, Facility Licensing Group, Department of State Health Services, Post Office Box 149347, Austin, Texas 78714-9347, telephone (512) 834-6646, or fax (512) 834-4514 or (512) 834-6709. Source Note: The provisions of this §504.58 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.58 Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222858 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222858 03/12/2026 (a) Anesthesia services, when provided in the abortion facility, shall be limited to those that are approved by the governing body, which may include the following:(1) Topical anesthesia--An anesthetic agent applied directly or by spray to the skin or mucous membranes, intended to produce transient and reversible loss of sensation to the circumscribed area.(2) Local anesthesia--Administration of an agent that produces a transient and reversible loss of sensation to a circumscribed portion of the body.(3) Regional anesthesia--Anesthetic injected around a single nerve, a network of nerves, or vein that serves the area involved in a surgical procedure to block pain.(4) Minimal sedation (anxiolysis)--A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(5) Moderate sedation/analgesia ("conscious sedation")--A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)(6) Deep sedation/analgesia--A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)(7) General anesthesia--A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.(b) An anesthesia department shall be required if moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia are administered at the facility and shall be under the medical direction of a physician approved by the governing body upon the recommendation of the abortion facility medical staff.(c) The medical staff shall develop written policies and practice guidelines for the anesthesia service, which shall be approved, implemented and enforced by the governing body. The policies and guidelines shall include consideration of the applicable practice standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the licensing rules and standards applicable to those categories of licensed professionals qualified to administer anesthesia.(d) Only personnel who have been approved by the facility to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. A qualified registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA), in accordance with the orders of the operating surgeon, anesthesiologist, or CRNA may administer topical anesthesia, local anesthesia, minimal sedation and moderate sedation, in accordance with all applicable rules, polices, directives and guidelines issued by the Texas Board of Nursing. When an RN who is not a CRNA administers sedation, as permitted in this paragraph, the facility shall:(1) verify that the registered nurse has the requisite training, education, and experience;(2) maintain documentation to support that the registered nurse has demonstrated competency in the administration of sedation;(3) with input from the facility's qualified anesthesia providers, develop, implement and enforce detailed, written policies and procedures to guide the registered nurse; and(4) ensure that, when administering moderate sedation during a procedure, the registered nurse has no other duties except to monitor the patient.(e) Anesthesia shall not be administered unless the operating surgeon has evaluated the patient immediately prior to the procedure to assess the risk of the anesthesia and of the procedure to be performed.(f) The CRNA, the anesthesiologist, or the operating surgeon shall be available until all of his or her patients operated on that day have been discharged from the recovery room.(g) Patients who have received anesthesia shall be evaluated for proper anesthesia recovery by the operating surgeon or the person administering the anesthesia prior to discharge from the recovery room using criteria approved by the medical staff.(h) Patients who remain in the facility for extended observation following discharge from the recovery room shall be evaluated immediately prior to leaving the facility by a physician, the person administering the anesthesia, or a registered nurse acting in accordance with physician's orders and written policies, procedures and criteria developed by the medical staff.(i) A physician shall be on call and able to respond physically or by telephone within 30 minutes until all patients have been discharged from the abortion facility.(j) Emergency equipment and supplies appropriate for the type of anesthesia services provided shall be maintained and accessible to staff at all times.(1) Functioning equipment and supplies which are required for all facilities include:(A) suctioning equipment, including a source of suction and suction catheters in appropriate sizes for the population being served;(B) source of compressed oxygen;(C) basic airway management equipment, including oral and nasal airways, face masks, and self-inflating breathing bag valve set;(D) blood pressure monitoring equipment; and(E) emergency medications specified by the medical staff and appropriate to the type of surgical procedures and anesthesia services provided by the facility.(2) In addition to the equipment and supplies required under paragraph (1) of this subsection, facilities which provide moderate sedation/analgesia, deep sedation/analgesia, regional analgesia and/or general anesthesia shall provide the following:(A) intravenous equipment, including catheters, tubing, fluids, dressing supplies, and appropriately sized needles and syringes;(B) advanced airway management equipment, including laryngoscopes and an assortment of blades, endotracheal tubes and stylets in appropriate sizes for the population being served;(C) a mechanism for monitoring blood oxygenation, such as pulse oximetry;(D) electrocardiographic monitoring equipment;(E) cardiac defibrillator; and(F) pharmacologic antagonists as specified by the medical staff and appropriate to the type of anesthesia services provided. Source Note: The provisions of this §504.59 adopted to be effective June 28, 2009, 34 TexReg 4125; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.59 Anesthesia Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222859 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222859 03/12/2026 (a) A licensed abortion facility shall be in compliance with all state and federal laws pertaining to handling of drugs.(b) A licensed abortion facility that provides laboratory services shall meet the Clinical Laboratory Improvement Amendments of 1988, 42 United States Code §263a, Certification of Laboratories (CLIA 1988). CLIA 1988 applies to all facilities with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.(c) A licensed abortion facility shall ensure that its physicians comply with the Medical Practice Act, Texas Occupations Code Chapters 151 - 160 and 162 - 165, while functioning in his or her capacity at or for the facility.(d) A licensed abortion facility utilizing physician assistant services shall ensure that its physician assistants comply with the Physician Assistant Licensing Act, Texas Occupations Code Chapter 204, while functioning in his or her capacity at or for the facility.(e) A licensed abortion facility utilizing registered nurse services shall ensure that its registered nurses comply with the Nursing Practice Act, Texas Occupations Code Chapters 301 and 304, while functioning in his or her capacity at or for the facility.(f) A licensed abortion facility utilizing licensed vocational nurse services shall ensure that its vocational nurses comply with the Nursing Practice Act, Texas Occupations Code Chapters 301 and 304, while functioning in his or her capacity at or for the facility.(g) A licensed abortion facility that provides pharmacy services shall obtain a license as a pharmacy if required by the Texas Pharmacy Act, Texas Occupations Code Chapters 551 - 569.(h) A licensed abortion facility shall comply with the following federal Occupational Safety and Health Administration requirements:(1) 29 Code of Federal Regulations (CFR), Subpart E, §1910.38 and §1910.39;(2) 29 CFR, Subpart I, §1910.132;(3) 29 CFR, Subpart I, §1910.133;(4) 29 CFR, Subpart I, §1910.138;(5) 29 CFR, Subpart K, §1910.151;(6) 29 CFR, Subpart L, §1910.157;(7) 29 CFR, Subpart Z, §1910.1030; and(8) 29 CFR, Subpart Z, §1910.1200, Appendices A - E.(i) A licensed abortion facility shall not use adulterated or misbranded drugs or devices in violation of the Texas Health and Safety Code §431.021. Adulterated drugs and devices are described in Texas Health and Safety Code §431.111. Misbranded drugs or devices are described in Texas Health and Safety Code §431.112.(j) A licensed abortion facility shall not commit a false, misleading, or deceptive act or practice as that term is defined in the Deceptive Trade Practices-Consumer Protection Act, Business and Commerce Code §17.46.(k) A licensed abortion facility shall comply with the requirements of the Texas Family Code §33.002.(l) A licensed abortion facility shall comply with the requirements of Texas Health and Safety Code Chapter 171.(m) A licensed abortion facility shall comply with the requirements of Texas Occupations Code Chapter 102.(n) A licensed abortion facility shall comply with the following balance billing requirements.(1) A licensed abortion facility may not violate a law that prohibits the licensed abortion facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A licensed abortion facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the licensed abortion facility.(o) A licensed abortion facility shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002.(p) A licensed abortion facility shall comply with human trafficking signage requirements in accordance with Texas Health and Safety Code §245.025.(q) A licensed abortion facility shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S. Source Note: The provisions of this §504.60 adopted to be effective June 28, 2009, 34 TexReg 4125; amended to be effective April 15, 2021, 46 TexReg 2423; amended to be effective January 6, 2022, 46 Texreg 9306; amended to be effective August 18, 2024, 49 TexReg 6217; transferred effective December 31, 2024, as published in the December 13, 2024, issue of the Texas Register, 49 TexReg 10119. 1 HEALTH AND HUMAN SERVICES COMMISSION 504 ABORTION FACILITY REPORTING AND LICENSING D MINIMUM STANDARDS FOR LICENSED ABORTION FACILITIES §504.60 Other State and Federal Compliance Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223744 03/12/2026 (a) The purpose of this chapter is to implement the Health and Safety Code, Chapter 241, which requires general and special hospitals to be licensed by the Department of State Health Services.(b) This chapter provides procedures for obtaining a hospital license; minimum standards for hospital functions and services; patient rights standards; discrimination or retaliation standards; patient transfer and other policy and protocol requirements; reporting, posting and training requirements relating to abuse and neglect; standards for voluntary agreements; waiver provisions; inspection and investigation procedures; enforcement standards; fire prevention and protection requirements; general safety standards; physical plant and construction requirements for existing and new hospitals, and mobile transportable and relocatable units; and standards for the preparation, submittal, review and approval of construction documents.(c) Compliance with this chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, rules, regulations and ordinances. This chapter must be followed where it exceeds other codes and ordinances. Source Note: The provisions of this §505.1 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING A GENERAL PROVISIONS §505.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223745 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Act--The Texas Hospital Licensing Law, Health and Safety Code (HSC), Chapter 241.(2) Action plan--A written document that includes specific measures to correct identified problems or areas of concern; identifies strategies for implementing system improvements; and includes outcome measures to indicate the effectiveness of system improvements in reducing, controlling or eliminating identified problem areas.(3) Advanced practice registered nurse (APRN)--A registered nurse who is currently licensed and authorized by the Texas Board of Nursing to practice as a nurse practitioner, nurse-midwife, nurse anesthetist, or clinical nurse specialist.(4) Adverse event--An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.(5) Applicant--The person legally responsible for the operation of the hospital, whether by lease or ownership, who seeks a hospital license from the department.(6) Attending physician--A physician selected by or assigned to a patient who has primary responsibility for a patient's treatment and care.(7) Available--When referring to on-site personnel, on the premises and able to rapidly perform hands-on care in an emergency situation.(8) Cardiopulmonary resuscitation--Any medical intervention used to restore circulatory or respiratory function that has ceased.(9) Chemical dependency services--A planned, structured, and organized program designed to initiate and promote a person's chemical-free status or to maintain the person free of illegal drugs. It includes, but is not limited to, the application of planned procedures to identify and change patterns of behavior related to or resulting from chemical dependency that are maladaptive, destructive, or injurious to health, or to restore appropriate levels of physical, psychological, or social functioning lost due to chemical dependency.(10) Competent--Possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.(11) Comprehensive medical rehabilitation--The provision of rehabilitation services that are designed to improve or minimize a person's physical or cognitive disabilities, maximize a person's functional ability, or restore a person's lost functional capacity through close coordination of services, communication, interaction, and integration among several professions that share responsibility to achieve team treatment goals for the person.(12) Comprehensive medical rehabilitation hospital--A general hospital that specializes in providing comprehensive medical rehabilitation services, including surgery and related ancillary services.(13) Comprehensive medical rehabilitation unit--An identifiable part of a hospital which provides comprehensive medical rehabilitation services to patients admitted to the unit.(14) Cooperative agreement--An agreement among two or more hospitals for the allocation or sharing of health care equipment, facilities, personnel, or services.(15) Dentist--A person licensed to practice dentistry by the Texas State Board of Dental Examiners. This includes a doctor of dental surgery or a doctor of dental medicine.(16) Department--The Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.(17) Dietitian--A person who is currently licensed by the Texas State Board of Examiners of Dietitians as a licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with the American Dietetic Association.(18) Director--The hospital licensing director, Department of State Health Services.(19) Do Not Resuscitate (DNR) order--An order issued in a hospital under Health and Safety Code, Chapter 166, Subchapter E (relating to Health Care Facility Do-Not-Resuscitate Orders), instructing a health care professional not to attempt cardiopulmonary resuscitation on a patient whose circulatory or respiratory function ceases.(20) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in one or all of the following:(A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;(B) serious impairment to bodily functions;(C) serious dysfunction of any bodily organ or part; or(D) with respect to a pregnant woman who is having contractions:(i) that there is inadequate time to effect a safe transfer to another hospital before delivery; or(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.(21) Freestanding emergency medical care facility--A facility that is structurally separate and distinct from a hospital and receives individuals for the provision of emergency care. The facility is owned and operated by the hospital, and is exempt from the licensing requirements of Texas Health and Safety Code, Chapter 254, under §254.052(7) or (8).(22) General hospital--An establishment that:(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and(B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.(23) Governing body--The governing authority of a hospital which is responsible for a hospital's organization, management, control, and operation, including appointment of the medical staff; includes the owner or partners for hospitals owned or operated by an individual or partners.(24) Governmental unit--A political subdivision of the state, including a hospital district, county, or municipality, and any department, division, board, or other agency of a political subdivision.(25) Hospital--A general hospital or a special hospital.(26) Hospital administration--Administrative body of a hospital headed by an individual who has the authority to represent the hospital and who is responsible for the operation of the hospital according to the policies and procedures of the hospital's governing body.(27) Incompetent--Lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.(28) Inpatient--An individual admitted for an intended length of stay of 24 hours or greater.(29) Inpatient services--Services provided to an individual admitted to a hospital for an intended length of stay of 24 hours or greater.(30) Intellectual Disability--Significantly sub-average general intellectual functioning that is concurrent with deficits in adaptive behavior and originates during the developmental period.(31) Licensed vocational nurse (LVN)--A person who is currently licensed under the Nursing Practice Act by the Texas Board of Nursing for the State of Texas as a licensed vocational nurse or who holds a valid vocational nursing license with multi-state licensure privilege from another compact state.(32) Licensee--The person or governmental unit named in the application for issuance of a hospital license.(33) Medical staff--A physician or group of physicians and a podiatrist or group of podiatrists who by action of the governing body of a hospital are privileged to work in and use the facilities of a hospital for or in connection with the observation, care, diagnosis, or treatment of an individual who is, or may be, suffering from a mental or physical disease or disorder or a physical deformity or injury.(34) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate persons who have a mental disorder or disability, including persons whose mental disorders or disabilities result from alcoholism or drug addiction.(35) Niche hospital--A hospital that:(A) classifies at least two-thirds of the hospital's Medicare patients or, if data is available, all patients:(i) in not more than two major diagnosis-related groups; or(ii) in surgical diagnosis-related groups.(B) specializes in one or more of the following areas:(i) cardiac;(ii) orthopedics;(iii) surgery; or(iv) women's health; and(C) is not:(i) a public hospital;(ii) a hospital for which the majority of inpatient claims are for major diagnosis-related groups relating to rehabilitation, psychiatry, alcohol and drug treatment, or children or newborns; or(iii) a hospital with fewer than 10 claims per bed per year.(36) Nurse--A registered, vocational, or advanced practice registered nurse licensed by the Texas Board of Nursing or entitled to practice in this state under Occupations Code, Chapters 301, 304, or 305.(37) Outpatient--An individual who presents for diagnostic or treatment services for an intended length of stay of less than 24 hours; provided, however, that an individual who requires continued observation may be considered as an outpatient for a period of time not to exceed a total of 48 hours.(38) Outpatient services--Services provided to patients whose medical needs can be met in less than 24 hours and are provided within the hospital; provided, however, that services that require continued observation may be considered as outpatient services for a period of time not to exceed a total of 48 hours.(39) Owner--One of the following persons or governmental unit which will hold or does hold a license issued under the statute in the person's name or the person's assumed name:(A) a corporation;(B) a governmental unit;(C) a limited liability company;(D) an individual;(E) a partnership if a partnership name is stated in a written partnership agreement or an assumed name certificate;(F) all partners in a partnership if a partnership name is not stated in a written partnership agreement or an assumed name certificate; or(G) all co-owners under any other business arrangement.(40) Patient--An individual who presents for diagnosis or treatment.(41) Pediatric and adolescent hospital--A general hospital that specializes in providing services to children and adolescents, including surgery and related ancillary services.(42) Person--An individual, firm, partnership, corporation, association, or joint stock company, and includes a receiver, trustee, assignee, or other similar representative of those entities.(43) Physician--A physician licensed by the Texas Medical Board.(44) Physician assistant--A person licensed as a physician assistant by the Texas Physician Assistant Board.(45) Podiatrist--A podiatrist licensed by the Texas State Board of Podiatric Medical Examiners.(46) Practitioner--A health care professional licensed in the State of Texas, other than a physician, podiatrist, or dentist. A practitioner shall practice in a manner consistent with their underlying practice act.(47) Premises--A premises may be any of the following:(A) a single building where inpatients receive hospital services; or(B) multiple buildings where inpatients receive hospital services provided that the following criteria are met:(i) all buildings in which inpatients receive hospital services are subject to the control and direction of the same governing body;(ii) all buildings in which inpatients receive hospital services are within a 30-mile radius of the primary hospital location;(iii) there is integration of the organized medical staff of each of the hospital locations to be included under the single license;(iv) there is a single chief executive officer for all of the hospital locations included under the license who reports directly to the governing body and through whom all administrative authority flows and who exercises control and surveillance over all administrative activities of the hospital;(v) there is a single chief medical officer for all of the hospital locations under the license who reports directly to the governing body and who is responsible for all medical staff activities of the hospital;(vi) each hospital location to be included under the license that is geographically separate from the other hospital locations contains at least one nursing unit for inpatients which is staffed and maintains an active inpatient census, unless providing only diagnostic or laboratory services, or a combination of diagnostic or laboratory services, in the building for hospital inpatients; and(vii) each hospital that is to be included in the license complies with the emergency services standards:(I) for a general hospital, if the hospital provides surgery or obstetrical care or both; or(II) for a special hospital, if the hospital does not provide surgery or obstetrical care.(48) Presurvey conference--A conference held with department staff and the applicant or the applicant's representative to review licensure rules and survey documents and provide consultation prior to the on-site licensure inspection.(49) Psychiatric disorder--A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful syndrome (distress) or impairment in one or more important areas of behavioral, psychological, or biological function and is more than a disturbance in the relationship between the individual and society.(50) Quality improvement--A method of evaluating and improving processes of patient care which emphasizes a multidisciplinary approach to problem solving, and focuses not on individuals, but systems of patient care which might be the cause of variations.(51) Registered nurse (RN)--A person who is currently licensed by the Texas Board of Nursing for the State of Texas as a registered nurse or who holds a valid registered nursing license with multi-state licensure privilege from another compact state.(52) SAFE-ready facility--A facility designated by the Health and Human Services Commission as a sexual assault forensic exam-ready facility.(53) Sexual assault forensic examiner--A certified sexual assault nurse examiner or a physician with specialized training on conducting a forensic medical examination.(54) Sexual assault survivor--An individual who is a victim of a sexual assault, regardless of whether a report is made or a conviction is obtained in the incident.(55) Special hospital--An establishment that:(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals who are regularly admitted, treated, and discharged and who require services more intensive than room, board, personal services, and general nursing care;(B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities, or other definitive medical treatment;(C) has a medical staff in regular attendance; and(D) maintains records of the clinical work performed for each patient.(56) Stabilize--With respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or that the woman has delivered the child and the placenta.(57) Surgical technologist--A person who practices surgical technology as defined in Health and Safety Code, Chapter 259.(58) Transfer--The movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who has been declared dead, or leaves the facility without the permission of any such person.(59) Universal precautions--Procedures for disinfection and sterilization of reusable medical devices and the appropriate use of infection control, including hand washing, the use of protective barriers, and the use and disposal of needles and other sharp instruments as those procedures are defined by the Centers for Disease Control and Prevention (CDC) of the Department of Health and Human Services. This term includes standard precautions as defined by CDC which are designed to reduce the risk of transmission of blood borne and other pathogens in hospitals.(60) Violation--Failure to comply with the licensing statute, a rule or standard, special license provision, or an order issued by the executive commissioner of health and human services (executive commissioner) or the executive commissioner's designee, adopted or enforced under the licensing statute. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty. Source Note: The provisions of this §505.2 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective December 9, 2010, 35 TexReg 10716; amended to be effective November 11, 2012, 37 TexReg 8809; amended to be effective September 14, 2014, 39 TexReg 7140; amended to be effective September 20, 2018, 43 TexReg 5952; amended to be effective February 2, 2020, 45 TexReg 555; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING A GENERAL PROVISIONS §505.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223746 03/12/2026 (a) License required.(1) A hospital shall obtain a license prior to admitting patients.(2) Upon written request, the Department of State Health Services (department) shall furnish a person with an application for a hospital license.(3) The license application shall be submitted in accordance with §133.22 of this title (relating to Application and Issuance of Initial License). The applicant shall retain copies of all application documents submitted to the department.(b) Compliance. A hospital shall comply with the provisions of the Act and this chapter during the licensing period.(c) Scope of hospital license.(1) A hospital license is issued for the premises and person or governmental unit named in the application.(2) A hospital license shall not include off-site outpatient facilities.(3) Multiple hospitals may share one building.(A) Each hospital shall be licensed separately.(B) No part of the building may be dually licensed by more than one hospital; and(C) Each hospital in the building shall comply with the requirements of §133.165 of this title (relating to Building with Multiple Occupancies).(4) Multiple hospitals may be licensed under one license provided the following conditions are met.(A) The hospitals must comply with the requirements for multiple hospitals under a single license as specified under §133.2(41) of this title (relating to Definitions).(B) Each hospital location under the hospital license must;(i) provide emergency services in compliance with §133.41(e) of this title (relating to Hospital Functions and Services); and(ii) meet the requirements as an existing hospital in accordance with §133.161 of this title (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located) as determined by the department; or(iii) meet the requirements of a new hospital in accordance with §133.162 of this title (relating to New Construction Requirements) as determined by the department.(C) The administration of the primary hospital location must submit to the department the following:(i) a complete and accurate multiple-location application;(ii) a licensing fee for the number of design beds at the multiple-location hospital in accordance with §133.26(b) of this title (relating to Fees);(iii) a copy of a hospital fire safety survey of the multiple-location hospital indicating approval by the local fire authority in whose jurisdiction the hospital is based that is dated no earlier than one year prior to the multiple-location application; and(iv) if the main hospital is accredited by a Centers for Medicare and Medicaid Services-approved organization, a letter extending the accreditation of the main hospital to the multiple location.(D) If a change of ownership is concurrent with the request for a hospital to become a multiple location of another, the department will require the new owners to submit the documents in subparagraph (C) of this paragraph and a signed copy of the bill of sale or lease agreement that reflects the effective date of the sale or lease. No change of ownership application will be required.(5) A hospital license and an ambulatory surgical center license shall not be issued for the same premises.(d) Display. A hospital shall prominently and conspicuously display the hospital license in a public area of the licensed premises that is readily visible to patients, employees, and visitors.(e) Alteration. A hospital license shall not be altered.(f) Transfer or assignment prohibited. A hospital license shall not be transferred or assigned. The hospital shall comply with the provisions of §133.24 of this title (relating to Change of Ownership) in the event of a change in the ownership of a hospital.(g) Changes which affect the license.(1) A hospital shall notify the department in writing prior to the occurrence of any of the following:(A) addition or deletion of those services indicated on the license application;(B) changes in design bed capacity as the phrase is used in §133.26(b)(1)(A) - (C) of this title;(C) request to change license classification; and(D) any construction, renovation, or modification of the hospital buildings.(2) A hospital shall notify the department in writing at the time of the occurrence of any of the following:(A) cessation of operation of the hospital. The hospital shall include in the written notice the location where the medical records will be stored and the identity and telephone number of the custodian of the medical records;(B) change in certification or accreditation status;(C) change in hospital name, telephone number or administrator; and(D) change in the emergency contact name and phone number. Source Note: The provisions of this §505.21 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.21 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223747 03/12/2026 (a) Application submittal. The applicant shall submit the following documents to the Department of State Health Services (department) no earlier than 60 calendar days prior to the projected opening date of the hospital:(1) an accurate and complete application form;(2) a copy of the hospital's patient transfer policy which is developed in accordance with §133.44 of this title (relating to Hospital Patient Transfer Policy) and is signed by both the chairman and secretary of the governing body attesting to the date the policy was adopted by the governing body and the effective date of the policy;(3) a copy of the hospital's memorandum of transfer form which contains at a minimum the information described in §133.44(c)(10)(B) of this title;(4) if the application is for a special hospital license, a copy of a written agreement the special hospital has entered into with a general hospital which provides for the prompt transfer to and the admission by the general hospital of any patient when special services are needed but are unavailable at the special hospital. This agreement is required and is separate from any voluntary patient transfer agreements the hospital may enter into in accordance with §133.61 of this title (relating to Hospital Patient Transfer Agreements);(5) copies of any patient transfer agreements entered into between the hospital and another hospital in accordance with §133.61 of this title;(6) for existing facilities, a copy of a hospital fire safety survey indicating approval by the local fire authority in whose jurisdiction the hospital is based that is dated no earlier than one year prior to the hospital opening date. For new construction, addition, and renovation projects, written approval by the local building department and local fire authority shall be submitted during the final construction inspection by the department;(7) the appropriate license fee as required in §133.26 of this title (relating to Fees); and(8) the following ownership information:(A) the name and social security number of the sole proprietor, if the applicant is a sole proprietor;(B) the name and social security number of each general partner who is an individual, if the applicant is a partnership;(C) the name and social security number of any individual who has an ownership interest of more than 25% in the corporation, if the applicant is a corporation; and(D) if the applicant is a niche hospital, the names and license numbers of any physicians licensed by the Texas Medical Board who have a financial interest in the applicant or any entity which has an ownership interest in the applicant.(b) Additional documentation for new hospitals or conversions from nonhospital buildings. In addition to the document submittal requirements in subsection (a) of this section, the following shall be completed prior to the issuance of a hospital license to newly constructed hospitals or hospitals from conversions of nonhospital buildings.(1) Final construction documents shall be reviewed and approved by the department in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans and Retention of Records).(2) For new construction, necessary intermediate inspections and final construction inspections shall be conducted by the department in accordance with §133.168(b) of this title (relating to Construction, Inspections, and Approval of Project) to determine that the hospital was constructed or remodeled in accordance with this chapter.(3) When an applicant intends to reopen and relicense a building formerly licensed as a hospital, an on-site inspection shall be conducted by the department in accordance with §133.168 of this title to determine compliance with applicable construction and fire safety requirements.(4) All plan review and construction inspection fees shall be paid to the department.(5) A certificate of occupancy approved by the local fire authority, and issued by the city building inspector, if applicable, shall be obtained and a copy submitted to the department.(6) A complete and accurate Final Construction Approval form shall be submitted to the department.(c) Presurvey conference. The applicant or the applicant's representative shall attend a presurvey conference at the office designated by the department. The designated survey office may waive the presurvey conference requirement. (d) Issuance of license. When it is determined that the hospital has complied with subsections (a) - (c) of this section, the department shall issue the license to the applicant.(1) Effective date. The license shall be effective on the date the hospital is determined to be in compliance with subsections (a) - (c) of this section. The effective date shall not be prior to the date of the final construction inspection conducted by the department. (2) Expiration date.(A) If the effective date of the license is the first day of a month, the license expires on the last day of the 23rd month after issuance.(B) If the effective date of the license is the second or any subsequent day of a month, the license expires on the last day of the 24th month after issuance.(e) Withdrawal of application. If an applicant decides not to continue the application process for a license or renewal of a license, the application may be withdrawn. If a license has been issued, the applicant shall return the license to the department with its written request to withdraw. The department shall acknowledge receipt of the request to withdraw.(f) Denial of a license. Denial of a license shall be governed by §133.121 of this title (relating to Enforcement Action).(g) Inspection. During the licensing period, the department shall conduct an inspection of the hospital to ascertain compliance with the provisions of the Act and this chapter.(1) If a hospital has applied to participate in the federal Medicare program, the inspection may be conducted in conjunction with the inspection to determine compliance with 42 Code of Federal Regulations, Part 482 (relating to Conditions of Participation for Hospitals).(2) A hospital shall have admitted and be providing services to at least one inpatient in the hospital at the time of the inspection. Source Note: The provisions of this §505.22 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.22 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223748 03/12/2026 (a) Renewal notice. The Department of State Health Services (department) shall send a renewal notice to a hospital at least 60 calendar days before the expiration date of a license.(1) If the hospital has not received the renewal notice from the department within 45 calendar days prior to the expiration date, it is the duty of the hospital to notify the department and request a renewal application for a license.(2) If the hospital fails to submit the application and fee within 15 calendar days prior to the expiration date of the license, the department shall send by certified mail to the hospital a letter advising that unless the license is renewed, the hospital must cease operations upon the expiration of the hospital's license.(b) Renewal license. The department shall issue a renewal license to a hospital which meets the minimum requirements for a license. (1) The hospital shall submit the following to the department prior to the expiration date of the license:(A) a complete and accurate application form;(B) a copy of a hospital fire safety survey indicating approval by the local fire authority in whose jurisdiction the hospital is based. The hospital fire safety survey shall be conducted annually and both surveys shall be submitted.(C) the renewal license fee;(D) if the applicant is accredited by a Centers for Medicare and Medicaid Services-approved organization, a copy of documentation from the accrediting body showing the current accreditation status of the hospital; and(E) the following ownership information:(i) the name and social security number of the sole proprietor, if the applicant is a sole proprietor;(ii) the name and social security number of each partner who is an individual, if the applicant is a partnership;(iii) the name and social security number of any individual who has an ownership interest of more than 25% in the corporation, if the applicant is a corporation; and(iv) if the applicant is a niche hospital, the names and license numbers of any physicians licensed by the Texas Medical Board who have a financial interest in the applicant or any entity which has an ownership interest in the applicant.(2) The department may conduct an inspection prior to issuing a renewal license in accordance with §133.101 of this title (relating to Inspection and Investigation Procedures).(3) Renewal licenses will be valid for 24 months.(c) Notice to cease operation and return license. If a hospital fails to submit the application, documents, and fee by the expiration date of the hospital's license, the department shall notify the hospital by certified mail that it must cease operation and immediately return the license by certified mail to the department. If the hospital wishes to provide services after the expiration date of the license, it shall apply for a license under §133.22 of this title (relating to Application and Issuance of Initial License). Source Note: The provisions of this §505.23 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.23 Application and Issuance of Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223749 03/12/2026 (a) Change of ownership defined. A change of ownership of a hospital occurs when there is a change in the person legally responsible for the operation of the hospital, whether by lease or by ownership.(1) If a corporate licensee amends its articles of incorporation to revise its name and the tax identification number does not change, this subsection does not apply, except that the corporation must notify the department within 10 calendar days after the effective date of the name change.(2) The sale of stock of a corporate licensee does not cause this subsection to apply.(b) License application required. The new owner shall submit an application for an initial license to the Department of State Health Services (department) prior to the date of the change of ownership or not later than 10 calendar days following the date of a change of ownership. The application shall be in accordance with §133.22 of this title (relating to the Application and Issuance of Initial License) except that the applicant need not submit any transfer agreements previously approved by the department and the current applicant has affirmatively indicated it has adopted the transfer agreement. In addition to the documents required in §133.22 of this title, the applicant shall include a copy of the signed bill of sale or lease agreement that reflects the effective date of the sale or lease.(c) Inspections. The on-site construction and health inspections required by §133.22 of this title may be waived by the department.(d) Issuance of license. When the new owner has complied with the provisions of §133.22 of this title, the department shall issue a license which shall be effective the date of the change of ownership.(e) Expiration of license. The expiration date of the license shall be in accordance with §133.22(d)(2) of this title.(f) License void. The previous owner's license shall be void on the effective date of the new owner's license. Source Note: The provisions of this §505.24 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.24 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223750 03/12/2026 (a) General.(1) The receipt date for an application for an initial license or a renewal license is the date the application is received by the Facility Licensing Group, Department of State Health Services (department).(2) An application for an initial license is complete when the department has received, reviewed, and found acceptable the information described in §133.22(a) - (b) of this title (relating to Application and Issuance of Initial License).(3) An application for a renewal license is complete when the department has received, reviewed, and found acceptable the information described in §133.23(b) of this title (relating to Application and Issuance of Renewal License).(b) Time periods. An application for a hospital initial license or renewal license shall be processed in accordance with the following time periods.(1) The first time period begins on the date the department receives the application and ends on the date the hospital license is issued, or, if the application is received incomplete, the period ends on the date the hospital is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 20 working days.(2) The second time period begins on the date the department receives the last item necessary to complete the application and ends on the date the hospital license is issued. The second time period is 20 working days.(c) Reimbursement of fees.(1) In the event the application is not processed in the time periods as stated in subsection (b) of this section, the applicant has the right to request the department to reimburse in full the fee paid in that particular application process. If the department does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request shall be denied.(2) Good cause for exceeding the period established is considered to exist if:(A) the number of applications for licenses to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;(B) another public or private entity utilized in the application process caused the delay; or(C) other conditions existed which gave good cause for exceeding the established periods.(d) Appeal. If the request for full reimbursement authorized by subsection (c) of this section is denied, the applicant may then appeal to the commissioner of state health services (commissioner) for a resolution of the dispute. The applicant shall give written notice to the commissioner requesting full reimbursement of all filing fees paid because the application was not processed within the adopted time period. The department shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The commissioner shall make the final decision and provide written notification of the decision to the applicant and the department. Source Note: The provisions of this §505.25 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.25 Time Periods for Processing and Issuing Hospital Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223751 03/12/2026 (a) General.(1) All fees paid to the Department of State Health Services (department) are nonrefundable with the exception of inspection fees for inspections that were not conducted.(2) All fees shall be paid by check or money order made payable to the Department of State Health Services.(b) License fees.(1) The fee for an initial license or a renewal license is $39 per bed based upon the design bed capacity of the hospital. The design bed capacity of a hospital is determined as follows.(A) The design bed capacity is the maximum number of patient beds that a hospital can accommodate in rooms that comply with the requirements for patient room suites in §133.163 of this title (relating to Spatial Requirements for New Construction) including beds, bassinets or cribs in critical care units (including neonatal nurseries), continuing care nursery beds, hospital-based skilled nursing units, medical nursing units, mental health and chemical dependency nursing units, pediatric and adolescent nursing units, obstetrical suites (including labor/delivery/recovery/postpartum (LDRP) beds), intermediate care beds, universal care beds, antepartum beds and postpartum beds. The design bed capacity does not include labor/delivery/recovery (LDR) beds, newborn nursery bassinets, or recovery beds.(B) The maximum design bed capacity includes beds that comply with the requirements in §133.163 of this title even if the beds are unoccupied or the space is used for other purposes such as offices or storage rooms, provided such rooms can readily be returned to patient use. All required support and service areas must be maintained in place. For example, the removal of a nurse station in an unused patient bedroom wing of 20 beds would effectively eliminate those 20 beds from the design capacity. Eliminating access to the medical gas outlets and nurse call would also remove bed(s) from the design capacity.(C) The number of licensed beds in a multiple-occupancy room shall be determined by the design even if the number of beds actually placed in the room is less than the design capacity.(2) A hospital shall submit a license fee for each design bed added as a result of adding a multiple-location hospital to its license. The fee is $39 per bed, regardless of the number of months remaining in the license period.(3) A hospital shall submit an additional license fee with the Final Construction Approval form for each new design bed resulting from an approved construction project. The fee is $39 per bed, regardless of the number of months remaining in the license period. The hospital shall also submit an additional plan review fee if the construction cost increases to the next higher fee schedule according to subsection (c)(4) of this section.(4) A hospital will not receive a refund of previously submitted fees should the hospital's design capacity decrease as a result of an approved construction project.(c) Plan review fees. This subsection outlines the fees which must accompany the application for plan review and all proposed plans and specifications covering the construction of new buildings or alterations to existing buildings which must be submitted for review and approval by the department in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(1) Construction plans will not be reviewed or approved until the required fee and an application for plan review are received by the department.(2) Plan review fees are based upon the estimated construction project costs which are the total expenditures required for a proposed project from initiation to completion, including at least the following items.(A) Construction project costs shall include expenditures for physical assets such as:(i) site acquisition;(ii) soil tests and site preparation;(iii) construction and improvements required as a result of the project;(iv) building, structure, or office space acquisition;(v) renovation;(vi) fixed equipment; and(vii) energy provisions and alternatives.(B) Construction project costs shall include expenditures for professional services including:(i) planning consultants;(ii) architectural fees;(iii) fees for cost estimation;(iv) legal fees;(v) management fees; and(vi) feasibility study.(C) Construction project costs shall include expenditures or costs associated with financing, excluding long-term interest, but including:(i) financial advisor;(ii) fund-raising expenses;(iii) lender's or investment banker's fee; and(iv) interest on interim financing.(D) Construction project costs shall include expenditure allowances for contingencies including:(i) inflation;(ii) inaccurate estimates;(iii) unforeseen fluctuations in the money market; and(iv) other unforeseen expenditures.(3) Regarding purchases, donations, gifts, transfers, and other comparable arrangements whereby the acquisition is to be made for no consideration or at less than the fair market value, the project cost shall be determined by the fair market value of the item to be acquired as a result of the purchase, donation, gift, transfer, or other comparable arrangement.(4) The plan review fee schedule based on cost of construction is:(A) $100,000 or less--$300;(B) $100,001 to $600,000--$850;(C) $600,001 to $2,000,000--$2,000;(D) $2,000,001 to $5,000,000--$3,000;(E) $5,000,001 to $10,000,000--$4,000; and(F) $10,000,001 and over--$5,000.(5) If an estimated construction cost cannot be established, the estimated cost shall be based on $225 per square foot. No construction project shall be increased in size, scope, or cost unless the appropriate fees are submitted with the proposed changes.(d) Construction inspection fees. A fee of $500 and an application for construction inspection for each inspection shall be submitted to the department at least three weeks prior to the anticipated inspection date. Construction inspections will not be conducted until all required fees are received by the department. If additional construction inspections of the proposed project are requested by the hospital, the appropriate additional fees shall be submitted prior to any inspections conducted by the staff of the department. When follow-up construction inspections are performed to verify plans of correction, the fee shall be submitted upon completion of the inspection.(e) Cooperative agreement application fee. The application fee for a cooperative agreement is $10,000. The application fee shall be submitted with an application for a cooperative agreement and other documents in accordance with §133.62 of this title (relating to Cooperative Agreements).(f) Subscription and convenience fee. The department is authorized to collect subscription and convenience fees, in amounts determined by the TexasOnline Authority, to recover costs associated with application and renewal application processing through TexasOnline, in accordance with Texas Government Code, §2054.111. At each renewal application, in addition to the license fee, there shall be a $20 TexasOnline subscription fee. Source Note: The provisions of this §505.26 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING B HOSPITAL LICENSE §505.26 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223754 03/12/2026 (a) Anesthesia services. If the hospital furnishes anesthesia services, these services shall be provided in a well-organized manner under the direction of a qualified physician in accordance with the Texas Occupations Code Subtitle B and the Texas Occupations Code Chapter 301. The hospital is responsible for and shall document all anesthesia services administered in the hospital. (1) Organization and staffing. The organization of anesthesia services shall be appropriate to the scope of the services offered. Only personnel who have been approved by the facility to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. (2) Delivery of services. Anesthesia services shall be consistent with needs and resources. Policies on anesthesia procedure shall include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies shall ensure that the following are provided for each patient. (A) A pre-anesthesia evaluation by an individual qualified to administer anesthesia under paragraph (1) of this subsection shall be performed within 48 hours before surgery. (B) An intraoperative anesthesia record shall be provided. The record shall include any complications or problems occurring during the anesthesia including time, description of symptoms, review of affected systems, and treatments rendered. The record shall correlate with the controlled substance administration record. (C) A post-anesthesia follow-up report shall be written by the person administering the anesthesia before transferring the patient from the post-anesthesia care unit and shall include evaluation for recovery from anesthesia, level of activity, respiration, blood pressure, level of consciousness, and patient's oxygen saturation level. (i) With respect to inpatients, a post-anesthesia evaluation for proper anesthesia recovery shall be performed after transfer from the post-anesthesia care unit and within 48 hours after surgery by the person administering the anesthesia, registered nurse (RN), or physician in accordance with policies and procedures approved by the medical staff and using criteria written in the medical staff bylaws for postoperative monitoring of anesthesia. (ii) With respect to outpatients, immediately before discharge, a post-anesthesia evaluation for proper anesthesia recovery shall be performed by the person administering the anesthesia, RN, or physician in accordance with policies and procedures approved by the medical staff and using criteria written in the medical staff bylaws for postoperative monitoring of anesthesia. (b) Chemical dependency services. (1) Chemical dependency unit. A hospital may not admit patients to a chemical dependency services unit unless the unit is approved by the Texas Health and Human Services Commission (HHSC) as meeting the requirements of §133.163(q) of this title (relating to Spatial Requirements for New Construction). (2) Admission criteria. A hospital providing chemical dependency services shall have written admission criteria that are applied uniformly to all patients who are admitted to the chemical dependency unit. (A) The hospital's admission criteria shall include procedures to prevent the admission of minors for a condition which is not generally recognized as responsive to treatment in an inpatient setting for chemical dependency services. (i) The following conditions are not generally recognized as responsive to treatment in a treatment facility for chemical dependency unless the minor to be admitted is qualified because of other disabilities, such as: (I) cognitive disabilities due to intellectual disability; (II) learning disabilities; or (III) psychiatric disorders. (ii) A minor may be qualified for admission based on other disabilities which would be responsive to chemical dependency services. (iii) A minor patient shall be separated from adult patients. (B) The hospital shall have a preadmission examination procedure under which each patient's condition and medical history are reviewed by a member of the medical staff to determine whether the patient is likely to benefit significantly from an intensive inpatient program or assessment. (C) A voluntarily admitted patient shall sign an admission consent form before admission to a chemical dependency unit which includes verification that the patient has been informed of the services to be provided and the estimated charges. (3) Compliance. A hospital providing chemical dependency services in an identifiable unit within the hospital shall comply with Chapter 448, Subchapter B of this title (relating to Standard of Care Applicable to All Providers). (c) Comprehensive medical rehabilitation services. (1) Rehabilitation units. A hospital may not admit patients to a comprehensive medical rehabilitation services unit unless the unit is approved by HHSC as meeting the requirements of §133.163(z) of this title. (2) Equipment and space. The hospital shall have the necessary equipment and sufficient space to implement the treatment plan described in paragraph (7)(C) of this subsection and allow for adequate care. Necessary equipment is all equipment necessary to comply with all parts of the written treatment plan. The equipment shall be on-site or available through an arrangement with another provider. Sufficient space is the physical area of a hospital which in the aggregate, constitutes the total amount of the space necessary to comply with the written treatment plan. (3) Emergency requirements. Emergency personnel, equipment, supplies and medications for hospitals providing comprehensive medical rehabilitation services shall be as follows. (A) A hospital that provides comprehensive medical rehabilitation services shall have emergency equipment, supplies, medications, and designated personnel assigned for providing emergency care to patients and visitors. (B) The emergency equipment, supplies, and medications shall be properly maintained and immediately accessible to all areas of the hospital. The emergency equipment shall be periodically tested according to the policy adopted, implemented, and enforced by the hospital. (C) At a minimum, the emergency equipment and supplies shall include those specified in subsection (e)(4) of this section. (D) The personnel providing emergency care in accordance with this subsection shall be staffed for 24-hour coverage and accessible to all patients receiving comprehensive medical rehabilitation services. At least one person who is qualified by training to perform advanced cardiac life support and administer emergency drugs shall be on duty each shift. (E) All direct patient care licensed personnel shall maintain current certification in cardiopulmonary resuscitation (CPR). (4) Medications. A rehabilitation hospital's governing body shall adopt, implement, and enforce policies and procedures that require all medications to be administered by licensed nurses, physicians, or other licensed professionals authorized by law to administer medications. (5) Organization and Staffing. (A) A hospital providing comprehensive medical rehabilitation services shall be organized and staffed to ensure the health and safety of the patients. (i) All provided services shall be consistent with accepted professional standards and practice. (ii) The organization of the services shall be appropriate to the scope of the services offered. (iii) The hospital shall adopt, implement, and enforce written patient care policies that govern the services it furnishes. (B) The provision of comprehensive medical rehabilitation services in a hospital shall be under the medical supervision of a physician who is on duty and available, or who is on-call 24 hours each day. (C) A hospital providing comprehensive medical rehabilitation services shall have a medical director or clinical director who supervises and administers the provision of comprehensive medical rehabilitation services. (i) The medical director or clinical director shall be a physician who is board certified or eligible for board certification in physical medicine and rehabilitation, orthopedics, neurology, neurosurgery, internal medicine, or rheumatology as appropriate for the rehabilitation program. (ii) The medical director or clinical director shall be qualified by training or at least two years training and experience to serve as medical director or clinical director. A person is qualified under this subsection if the person has training and experience in the treatment of rehabilitation patients in a rehabilitation setting. (6) Admission criteria. A hospital providing comprehensive medical rehabilitation services shall have written admission criteria that are applied uniformly to all patients who are admitted to the comprehensive medical rehabilitation unit. (A) The hospital's admission criteria shall include procedures to prevent the admission of a minor for a condition which is not generally recognized as responsive to treatment in an inpatient setting for comprehensive medical rehabilitation services. (i) The following conditions are not generally recognized as responsive to treatment in an inpatient setting for comprehensive medical rehabilitation services unless the minor to be admitted is qualified because of other disabilities, such as: (I) cognitive disabilities due to intellectual disability; (II) learning disabilities; or (III) psychiatric disorders. (ii) A minor may be qualified for admission based on other disabilities which would be responsive to comprehensive medical rehabilitation services. (B) The hospital shall have a preadmission examination procedure under which each patient's condition and medical history are reviewed by a member of the medical staff to determine whether the patient is likely to benefit significantly from an intensive inpatient program or assessment. (7) Care and services. (A) A hospital providing comprehensive medical rehabilitation services shall use a coordinated interdisciplinary team which is directed by a physician and which works in collaboration to develop and implement the patient's treatment plan. (i) The interdisciplinary team for comprehensive medical rehabilitation services shall have available to it, at the hospital at which the services are provided or by contract, members of the following professions as necessary to meet the treatment needs of the patient: (I) physical therapy; (II) occupational therapy; (III) speech-language pathology; (IV) therapeutic recreation; (V) social services and case management; (VI) dietetics; (VII) psychology; (VIII) respiratory therapy; (IX) rehabilitative nursing; (X) certified orthotics; (XI) certified prosthetics; (XII) pharmaceutical care; and (XIII) in the case of a minor patient, persons who have specialized education and training in emotional, mental health, or chemical dependency problems, as well as the treatment of minors. (ii) The coordinated interdisciplinary team approach used in the rehabilitation of each patient shall be documented by periodic entries made in the patient's medical record to denote: (I) the patient's status in relationship to goal attainment; and (II) that team conferences are held at least every two weeks to determine the appropriateness of treatment. (B) An initial assessment and preliminary treatment plan shall be performed or established by the physician within 24 hours of admission. (C) The physician in coordination with the interdisciplinary team shall establish a written treatment plan for the patient within seven working days of the date of admission. (i) Comprehensive medical rehabilitation services shall be provided in accordance with the written treatment plan. (ii) The treatment provided under the written treatment plan shall be provided by staff who are qualified to provide services under state law. The hospital shall establish written qualifications for services provided by each discipline for which there is no applicable state statute for professional licensure or certification. (iii) Services provided under the written treatment plan shall be given in accordance with the orders of physicians, dentists, podiatrists, or practitioners who are authorized by the governing body, hospital administration, and medical staff to order the services, and the orders shall be incorporated in the patient's record. (iv) The written treatment plan shall delineate anticipated goals and specify the type, amount, frequency, and anticipated duration of service to be provided. (v) Within 10 working days after the date of admission, the written treatment plan shall be provided. It shall be in the person's primary language, if practicable. What is or would have been practicable shall be determined by the facts and circumstances of each case. The written treatment plan shall be provided to: (I) the patient; (II) a person designated by the patient; and (III) upon request, a family member, guardian, or individual who has demonstrated on a routine basis responsibility and participation in the patient's care or treatment, but only with the patient's consent unless such consent is not required by law. (vi) The written treatment plan shall be reviewed by the interdisciplinary team at least every two weeks. (vii) The written treatment plan shall be revised by the interdisciplinary team if a comprehensive reassessment of the patient's status or the results of a patient case review conference indicates the need for revision. (viii) The revision shall be incorporated into the patient's record within seven working days after the revision. (ix) The revised treatment plan shall be reduced to writing in the person's primary language, if practicable, and provided to: (I) the patient; (II) a person designated by the patient; and (III) upon request, a family member, guardian, or individual who has demonstrated on a routine basis responsibility and participation in the patient's care or treatment, but only with the patient's consent unless such consent is not required by law. (8) Discharge and continuing care plan. The patient's interdisciplinary team shall prepare a written continuing care plan that addresses the patient's needs for care after discharge. (A) The continuing care plan for the patient shall include recommendations for treatment and care and information about the availability of resources for treatment or care. (B) If the patient's interdisciplinary team deems it impracticable to provide a written continuing care plan before discharge, the patient's interdisciplinary team shall provide the written continuing care plan to the patient within two working days after the date of discharge. (C) Before discharge or within two working days after the date of discharge, the written continuing care plan shall be provided in the person's primary language, if practicable, to: (i) the patient; (ii) a person designated by the patient; and (iii) upon request, to a family member, guardian, or individual who has demonstrated on a routine basis responsibility and participation in the patient's care or treatment, but only with the patient's consent unless such consent is not required by law. (d) Dietary services. The hospital shall have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company or an arrangement with another hospital may meet this requirement if the company or other hospital has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company or other hospital maintains at least the minimum requirements specified in this section, and provides for the frequent and systematic liaison with the hospital medical staff for recommendations of dietetic policies affecting patient treatment. The hospital shall ensure that there are sufficient personnel to respond to the dietary needs of the patient population being served. (1) Organization. (A) The hospital shall have a full-time employee who is qualified by experience or training to serve as director of the food and dietetic service, and be responsible for the daily management of the dietary services. (B) There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If by consultation, such services shall occur at least once per month for not less than eight hours. The dietitian shall: (i) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian; (ii) maintain standards for professional practice; (iii) supervise the nutritional aspects of patient care; (iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as appropriate; (v) provide diet counseling and teaching, as appropriate; (vi) document nutritional status and pertinent information in patient medical records, as appropriate; (vii) approve menus; and (viii) approve menu substitutions. (C) There shall be administrative and technical personnel competent in their respective duties. The administrative and technical personnel shall: (i) participate in established departmental or hospital training pertinent to assigned duties; (ii) conform to food handling techniques in accordance with paragraph (2)(E)(viii) of this subsection; (iii) adhere to clearly defined work schedules and assignment sheets; and (iv) comply with position descriptions which are job specific. (2) Director. The director shall: (A) comply with a position description which is job specific; (B) clearly delineate responsibility and authority; (C) participate in conferences with administration and department heads; (D) establish, implement, and enforce policies and procedures for the overall operational components of the department to include: (i) quality assessment and performance improvement program; (ii) frequency of meals served; (iii) nonroutine occurrences; and (iv) identification of patient trays; and (E) maintain authority and responsibility for the following: (i) orientation and training; (ii) performance evaluations; (iii) work assignments; (iv) supervision of work and food handling techniques; (v) procurement of food, paper, chemical, and other supplies, to include implementation of first-in first-out rotation system for all food items; (vi) ensuring there is a four-day food supply on hand at all times; (vii) menu planning; and (viii) ensuring compliance with Chapter 228 of this title (relating to Retail Food Establishments). (3) Diets. Menus shall meet the needs of the patients. (A) Therapeutic diets shall be prescribed by the physicians responsible for the care of the patients. The dietary department of the hospital shall: (i) establish procedures for the processing of therapeutic diets to include: (I) accurate patient identification; (II) transcription from nursing to dietary services; (III) diet planning by a dietitian; (IV) regular review and updating of diet when necessary; and (V) written and verbal instruction to patient and family. It shall be in the patient's primary language, if practicable, before discharge. What is or would be practicable shall be determined by the facts and circumstances of each case; (ii) ensure that therapeutic diets are planned in writing by a qualified dietitian; (iii) ensure that menu substitutions are approved by a qualified dietitian; (iv) document pertinent information about the patient's response to a therapeutic diet in the medical record; and (v) evaluate therapeutic diets for nutritional adequacy. (B) Nutritional needs shall be met in accordance with recognized dietary practices and in accordance with orders of the physicians or appropriately credentialed practitioners responsible for the care of the patients. The following requirements shall be met. (i) Menus shall provide a sufficient variety of foods served in adequate amounts at each meal according to the guidance provided in the Recommended Dietary Allowances (RDA), as published by the Food and Nutrition Board, Commission on Life Sciences, National Research Council, Tenth edition, 1989. (ii) A maximum of 15 hours shall not be exceeded between the last meal of the day (i.e., supper) and the breakfast meal, unless a substantial snack is provided. The hospital shall adopt, implement, and enforce a policy on the definition of "substantial" to meet each patient's varied nutritional needs. (C) A current therapeutic diet manual approved by the dietitian and medical staff shall be readily available to all medical, nursing, and food service personnel. The therapeutic manual shall: (i) be revised as needed, not to exceed 5 years; (ii) be appropriate for the diets routinely ordered in the hospital; (iii) have standards in compliance with the RDA; (iv) contain specific diets which are not in compliance with RDA; and (v) be used as a guide for ordering and serving diets. (e) Emergency services. All licensed hospital locations, including multiple-location sites, shall have an emergency suite that complies with §133.161(a)(1)(A) of this chapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals Are Located) or §133.163(f) of this title, and the following. (1) Organization. The organization of the emergency services shall be appropriate to the scope of the services offered. (A) The services shall be organized under the direction of a qualified member of the medical staff who is the medical director or clinical director. (B) The services shall be integrated with other departments of the hospital. (C) The policies and procedures governing medical care provided in the emergency suite shall be established by and shall be a continuing responsibility of the medical staff. (D) Medical records indicating patient identification, complaint, physician, nurse, time admitted to the emergency suite, treatment, time discharged, and disposition shall be maintained for all emergency patients. (E) Each freestanding emergency medical care facility shall advertise as an emergency room. The facility shall display notice that it functions as an emergency room. (i) The notice shall explain that patients who receive medical services will be billed according to comparable rates for hospital emergency room services in the same region. (ii) The notice shall be prominently and conspicuously posted for display in a public area of the facility that is readily available to each patient, managing conservator, or guardian. The postings shall be easily readable and consumer-friendly. The notice shall be in English and in a second language appropriate to the demographic makeup of the community served. (2) Personnel. (A) There shall be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the hospital. (B) Except for comprehensive medical rehabilitation hospitals and pediatric and adolescent hospitals that generally provide care that is not administered for or in expectation of compensation: (i) there shall be on duty and available at all times at least one person qualified as determined by the medical staff to initiate immediate appropriate lifesaving measures; and (ii) in general hospitals where the emergency treatment area is not contiguous with other areas of the hospital that maintain 24-hour staffing by qualified staff (including separation by one or more floors in multiple-occupancy buildings), qualified personnel must be physically present in the emergency treatment area at all times. (C) Except for comprehensive medical rehabilitation hospitals and pediatric and adolescent hospitals that generally provide care that is not administered for or in expectation of compensation, the hospital shall provide that one or more physicians shall be available at all times for emergencies, as follows. (i) General hospitals, except for hospitals designated as critical access hospitals (CAHs) by the Centers for Medicare & Medicaid Services (CMS), located in counties with a population of 100,000 or more shall have a physician qualified to provide emergency medical care on duty in the emergency treatment area at all times. (ii) Special hospitals, hospitals designated as CAHs by the CMS, and general hospitals located in counties with a population of less than 100,000 shall have a physician on-call and able to respond in person, or by radio or telephone within 30 minutes. (D) Schedules, names, and telephone numbers of all physicians and others on emergency call duty, including alternates, shall be maintained. Schedules shall be retained for no less than one year. (3) Supplies and equipment. Adequate age-appropriate supplies and equipment shall be available and in readiness for use. Equipment and supplies shall be available for the administration of intravenous medications as well as facilities for the control of bleeding and emergency splinting of fractures. Provision shall be made for the storage of blood and blood products as needed. The emergency equipment shall be periodically tested according to the policy adopted, implemented, and enforced by the hospital. (4) Required emergency equipment. At a minimum, the age-appropriate emergency equipment and supplies shall include the following: (A) emergency call system; (B) oxygen; (C) mechanical ventilatory assistance equipment, including airways, manual breathing bag, and mask; (D) cardiac defibrillator; (E) cardiac monitoring equipment; (F) laryngoscopes and endotracheal tubes; (G) suction equipment; (H) emergency drugs and supplies specified by the medical staff; (I) stabilization devices for cervical injuries; (J) blood pressure monitoring equipment; and (K) pulse oximeter or similar medical device to measure blood oxygenation. (5) Participation in local emergency medical service (EMS) system. (A) General hospitals shall participate in the local EMS system, based on the hospital's capabilities and capacity, and the locale's existing EMS plan and protocols. (B) The provisions of subparagraph (A) of this paragraph do not apply to a comprehensive medical rehabilitation hospital or a pediatric and adolescent hospital that generally provides care that is not administered for or in expectation of compensation. (6) Emergency services for sexual assault survivors. This section does not affect the duty of a health care facility to comply with the requirements of the federal Emergency Medical Treatment and Active Labor Act of 1986 (42 U.S.C. §1395dd) that are applicable to the facility. The hospital shall develop, implement, and enforce policies and procedures to ensure that after a sexual assault survivor presents to the hospital following a sexual assault, the hospital shall provide the care specified under Texas Health and Safety Code (HSC) Chapter 323. (f) Governing body. (1) Legal responsibility. There shall be a governing body responsible for the organization, management, control, and operation of the hospital, including appointment of the medical staff. For hospitals owned and operated by an individual or by partners, the individual or partners shall be considered the governing body. (2) Organization. The governing body shall be formally organized in accordance with a written constitution and bylaws which clearly set forth the organizational structure and responsibilities. (3) Meeting records. Records of governing body meetings shall be maintained. (4) Responsibilities relating to the medical staff. (A) The governing body shall ensure that the medical staff has current bylaws, rules, and regulations which are implemented and enforced. (B) The governing body shall approve medical staff bylaws and other medical staff rules and regulations. (C) In hospitals that provide obstetrical services, the governing body shall ensure that the hospital collaborates with physicians providing services at the hospital to develop quality initiatives, through the adoption, implementation, and enforcement of appropriate hospital policies and procedures, to reduce the number of elective or nonmedically indicated induced deliveries or cesarean sections performed at the hospital on a woman before the 39th week of gestation. (D) In hospitals that provide obstetrical services, the governing body shall ensure that the hospital implements a newborn audiological screening program, consistent with the requirements of HSC Chapter 47, and performs, either directly or through a referral to another program, audiological screenings for the identification of hearing loss on each newborn or infant born at the facility before the newborn or infant is discharged. These audiological screenings are required to be performed on all newborns or infants before discharge from the facility unless: (i) a parent or legal guardian of the newborn or infant declines the screening; (ii) the newborn or infant requires emergency transfer to a tertiary care facility before the completion of the screening; (iii) the screening previously has been completed; or (iv) the newborn was discharged from the facility not more than 10 hours after birth and a referral for the newborn was made to another program. (E) In hospitals that provide obstetrical services, the governing body shall adopt, implement, and enforce policies and procedures related to the testing of any newborn for critical congenital heart disease (CCHD) that may present themselves at birth. The facility shall implement testing programs for all infants born at the facility for CCHD. In the event that a newborn is presented at the emergency room following delivery at a birthing center or a home birth that may or may not have been assisted by a midwife, the facility shall ascertain if any testing for CCHD had occurred and, if not, shall provide the testing necessary to make such determination. The rules concerning the CCHD procedures and requirements are described in Chapter 37, Subchapter E of this title (relating to Newborn Screening for Critical Congenital Heart Disease). (F) The governing body shall determine, in accordance with state law and with the advice of the medical staff, which categories of practitioners are eligible candidates for appointment to the medical staff. (i) In considering applications for medical staff membership and privileges or the renewal, modification, or revocation of medical staff membership and privileges, the governing body must ensure that each physician, podiatrist, and dentist is afforded procedural due process. (I) If a hospital's credentials committee has failed to take action on a completed application as required by subclause (VIII) of this clause, or a physician, podiatrist, or dentist is subject to a professional review action that may adversely affect his medical staff membership or privileges, and the physician, podiatrist, or dentist believes that mediation of the dispute is desirable, the physician, podiatrist, or dentist may require the hospital to participate in mediation as provided in Texas Civil Practice and Remedies Code (CPRC) Chapter 154. The mediation shall be conducted by a person meeting the qualifications required by CPRC §154.052 and within a reasonable period of time. (II) Subclause (I) of this clause does not authorize a cause of action by a physician, podiatrist, or dentist against the hospital other than an action to require a hospital to participate in mediation. (III) An applicant for medical staff membership or privileges may not be denied membership or privileges on any ground that is otherwise prohibited by law. (IV) A hospital's bylaw requirements for staff privileges may require a physician, podiatrist, or dentist to document the person's current clinical competency and professional training and experience in the medical procedures for which privileges are requested. (V) In granting or refusing medical staff membership or privileges, a hospital may not differentiate on the basis of the academic medical degree held by a physician. (VI) Graduate medical education may be used as a standard or qualification for medical staff membership or privileges for a physician, if that equal recognition is given to training programs accredited by the Accreditation Council for Graduate Medical Education and by the American Osteopathic Association. (VII) Board certification may be used as a standard or qualification for medical staff membership or privileges for a physician, provided that equal recognition is given to certification programs approved by the American Board of Medical Specialties and the Bureau of Osteopathic Specialists. (VIII) A hospital's credentials committee shall act expeditiously and without unnecessary delay when a licensed physician, podiatrist, or dentist submits a completed application for medical staff membership or privileges. The hospital's credentials committee shall take action on the completed application not later than the 90th day after the date on which the application is received. The governing body of the hospital shall take final action on the application for medical staff membership or privileges not later than the 60th day after the date on which the recommendation of the credentials committee is received. The hospital must notify the applicant in writing of the hospital's final action, including a reason for denial or restriction of privileges, not later than the 20th day after the date on which final action is taken. (ii) The governing body is authorized to adopt, implement and enforce policies concerning the granting of clinical privileges to advanced practice registered nurses (APRNs) and physician assistants, including policies relating to the application process, reasonable qualifications for privileges, and the process for renewal, modification, or revocation of privileges. (I) If the governing body of a hospital has adopted, implemented and enforced a policy of granting clinical privileges to APRNs or physician assistants, an individual APRN or physician assistant who qualifies for privileges under that policy shall be entitled to certain procedural rights to provide fairness of process, as determined by the governing body of the hospital, when an application for privileges is submitted to the hospital. At a minimum, any policy adopted shall specify a reasonable period for the processing and consideration of the application and shall provide for written notification to the applicant of any final action on the application by the hospital, including any reason for denial or restriction of the privileges requested. (II) If an APRN or physician assistant has been granted clinical privileges by a hospital, the hospital may not modify or revoke those privileges without providing certain procedural rights to provide fairness of process, as determined by the governing body of the hospital, to the APRN or physician assistant. At a minimum, the hospital shall provide the APRN or physician assistant written reasons for the modification or revocation of privileges and a mechanism for appeal to the appropriate committee or body within the hospital, as determined by the governing body of the hospital. (III) If a hospital extends clinical privileges to an APRN or physician assistant conditioned on the APRN or physician assistant having a sponsoring or collaborating relationship with a physician and that relationship ceases to exist, the APRN or physician assistant and the physician shall provide written notification to the hospital that the relationship no longer exists. Once the hospital receives such notice from an APRN or physician assistant and the physician, the hospital shall be deemed to have met its obligations under this section by notifying the APRN or physician assistant in writing that the APRN's or physician assistant's clinical privileges no longer exist at that hospital. (IV) Nothing in this clause shall be construed as modifying Texas Occupations Code Chapter 204 or 301, or any other law relating to the scope of practice of physicians, APRNs, or physician assistants. (V) This clause does not apply to an employer-employee relationship between an APRN or physician assistant and a hospital. (G) The governing body shall ensure that the hospital complies with the requirements concerning physician communication and contracts as set out in HSC §241.1015. (H) The governing body shall ensure the hospital complies with the requirements for reporting to the Texas Medical Board the results and circumstances of any professional review action in accordance with Texas Occupations Code §160.002 and §160.003. (I) The governing body shall be responsible for and ensure that any policies and procedures adopted by the governing body to implement the requirements of this chapter shall be implemented and enforced. (5) Hospital administration. The governing body shall appoint a chief executive officer or administrator who is responsible for managing the hospital. (6) Patient care. In accordance with hospital policy adopted, implemented, and enforced, the governing body shall ensure that: (A) every patient is under the care of: (i) a physician; this provision is not to be construed to limit the authority of a physician to delegate tasks to other qualified health care personnel to the extent recognized under state law or the state's regulatory mechanism; (ii) a dentist who is legally authorized to practice dentistry by the state and who is acting within the scope of his or her license; or (iii) a podiatrist, but only with respect to functions which he or she is legally authorized by the state to perform. (B) patients are admitted to the hospital only by members of the medical staff who have been granted admitting privileges; (C) a physician is on duty or on-call at all times; (D) specific colored condition alert wrist bands that have been standardized for all hospitals licensed under HSC Chapter 241, are used as follows: (i) red wrist bands for allergies; (ii) yellow wrist bands for fall risks; and (iii) purple wrist bands for do not resuscitate status; (E) the governing body shall consider the addition of the following optional condition alert wrist bands and document in the minutes of the meeting of the governing body in which the discussion was held: (i) green wrist bands for latex allergy; and (ii) pink wrist bands for restricted extremity; (F) the governing body shall adopt, implement, and enforce a policy and procedure regarding the removal of personal wrist bands and bracelets as well as a patient's right to refuse to wear condition alert wrist bands; and (G) the governing body shall adopt, implement, and enforce policies and procedures regarding do-not-resuscitate (DNR) orders issued in the hospital by the attending physician that comply with HSC Chapter 166, Subchapter E , including policies and procedures regarding the rights of a patient and person authorized to make treatment decisions regarding the patient's DNR status; notice and medical record requirements for DNR orders and revocations; and actions the attending physician and hospital must take pursuant to HSC §166.206 when the physician or hospital and the patient or person authorized to make treatment decisions regarding the patient's DNR status are in disagreement about the execution of, or compliance with, a DNR order. The policies and procedures shall include the following: (i) Except in circumstances described by HSC §166.203(a)(2) and (3), a DNR order issued for a patient is valid only if a physician providing direct care to the patient issues the order, the order is dated, and the order is issued in compliance with: (I) the written and dated directions of a patient who was competent at the time the patient wrote the directions; (II) the oral directions of a competent patient delivered to or observed by two competent adult witnesses, at least one of whom must be a person not listed under HSC §166.003(2)(E) or (F); (III) the directions in an advance directive enforceable under HSC §166.005 or executed in accordance with HSC §§166.032, 166.034, 166.035, 166.082, 166.084, or 166.085; (IV) the directions of a patient's:(-a-) legal guardian; (-b-) agent under a medical power of attorney acting in accordance with HSC Chapter 166, Subchapter D; or (-c-) proxy as designated and authorized by a directive executed in accordance with HSC Chapter 166, Subchapter B to make a treatment decision for the patient if the patient becomes incompetent or otherwise mentally or physically incapable of communication; or(V) a treatment decision made in accordance with HSC §166.039. (ii) A DNR order that is not issued in accordance with HSC §166.203(a)(1) is valid only if: (I) the patient's attending physician issues the order, the order is dated; and (-a-) the order is not contrary to the directions of a patient who was competent at the time the patient conveyed the directions; (-b-) in the reasonable medical judgment of the patient's attending physician, the patient's death is imminent, within minutes to hours, regardless of the provision of cardiopulmonary resuscitation; and (-c-) in the reasonable medical judgment of the patient's attending physician, the DNR order is medically appropriate; or (II) the patient's attending physician issues the order for a patient who is incompetent or otherwise mentally or physically incapable of communication and the order is in compliance with a decision: (-a-) agreed upon by the attending physician and the person responsible for the patient's health care decisions; and(-b-) concurred in by another physician who is not involved in the direct treatment of the patient or who is a representative of an ethics or medical committee of the health care facility in which the person is a patient.(iii) A DNR order takes effect at the time the order is issued, as provided by HSC §166.203(b), provided the order is placed in the patient's medical record as soon as practicable, and may be issued and entered in a format acceptable under the policies of the hospital. (iv) Unless notice is provided in accordance with HSC §166.204(a), before placing in a patient's medical record a DNR order described by HSC §166.203(a)(2), a physician, physician assistant, nurse, or other person acting on behalf of the hospital shall: (I) notify the patient of the order's issuance; or (II) if the patient is incompetent, make a reasonably diligent effort to contact or cause to be contacted and notify of the order's issuance:(-a-) the patient's known agent under a medical power of attorney or legal guardian; or (-b-) for a patient who does not have a known agent under a medical power of attorney or legal guardian, a person described by HSC §166.039(b)(1), (2), or (3). (v) In accordance with HSC §166.205(a), a physician providing direct care to a patient for whom a DNR order is issued shall revoke the patient's DNR order if: (I) an advance directive that serves as the basis of the DNR order is properly revoked in accordance with HSC Chapter 166; (II) the patient expresses to any person providing direct care to the patient a revocation of consent to or intent to revoke a DNR order issued under HSC §166.203(a); or(III) the DNR order was issued under HSC §166.203(a)(1)(D) or (E) or §166.203(a)(3) and the person responsible for the patient's health care decisions expresses to any person providing direct care to the patient a revocation of consent to or intent to revoke the DNR order.(vi) A person providing direct care to a patient under the supervision of a physician shall notify the physician of a request to revoke a DNR order or the revocation of an advance directive under HSC §166.205(a). (vii) A patient's attending physician may at any time revoke a DNR order executed under: (I) HSC §166.203(a)(1)(A), (B), or (C), provided that:(-a-) the order is for a patient who is incompetent or otherwise mentally or physically incapable of communication; and(-b-) the decision to revoke the order is:(-1-) agreed on by the attending physician and the person responsible for the patient's health care decisions; and(-2-) concurred in by another physician who is not involved in the direct treatment of the patient or who is a representative of an ethics or medical committee of the health care facility in which the person is a patient;(II) HSC §166.203(a)(1)(E), provided that the order's issuance was based on a treatment decision made in accordance with HSC §166.039(e);(III) HSC §166.203(a)(2); or(IV) HSC §166.203(a)(3).(viii) A patient's attending physician shall revoke a DNR order issued for the patient under HSC §166.203(a)(2) if, in the attending physician's reasonable medical judgment, the condition described by HSC §166.203(a)(2)(B)(i) is no longer satisfied.(ix) For a patient who was incompetent at the time notice otherwise would have been provided to the patient under HSC §166.203(c)(1) and if a physician providing direct care to the patient later determines that, based on the physician's reasonable medical judgment, the patient has become competent, a physician, physician assistant, or nurse providing direct care to the patient shall disclose the order to the patient, provided that the physician, physician assistant, or nurse has actual knowledge:(I) of the order; and(II) that a physician providing direct care to the patient has determined that the patient has become competent.(x) On admission to the hospital, the hospital shall provide to the patient or person authorized to make treatment decisions regarding the patient's DNR status notice of the policies and procedures adopted under this subparagraph. (7) Services. The governing body shall be responsible for all services furnished in the hospital, whether furnished directly or under contract. The governing body shall ensure that services are provided in a safe and effective manner that permits the hospital to comply with applicable rules and standards. At hospitals that have a mental health service unit, the governing body shall adopt, implement, and enforce procedures for the completion of criminal background checks on all prospective employees that would be considered for assignment to that unit, except for persons currently licensed by this state as health professionals. (8) Nurse Staffing. The governing body shall adopt, implement, and enforce a written nurse staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The governing body policy shall require that hospital administration adopt, implement, and enforce a nurse staffing plan and policies that: (A) require significant consideration be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan; (B) are based on the needs of each patient care unit and shift and on evidence relating to patient care needs; (C) ensure that all nursing assignments consider client safety, and are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability; (D) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget; (E) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns; (F) protect from retaliation nurses who provide input to the nurse staffing committee; and (G) comply with subsection (o) of this section. (9) Photo identification badge. The governing body shall adopt a policy requiring employees, physicians, contracted employees, and individuals in training who provide direct patient care at the hospital to wear a photo identification badge during all patient encounters, unless precluded by adopted isolation or sterilization protocols. The badge must be of sufficient size and worn in a manner to be visible and must clearly state: (A) at minimum the individual's first or last name; (B) the department of the hospital with which the individual is associated; (C) the type of license held by the individual, if applicable under Texas Occupations Code Title 3; and (D) the provider's status as a student, intern, trainee, or resident, if applicable. (g) Infection control. The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and surveillance of infections and communicable diseases. (1) Organization and policies. A person shall be designated as infection control professional. The hospital shall ensure that policies governing prevention, control and surveillance of infections and communicable diseases are developed, implemented and enforced. (A) There shall be a system for identifying, reporting, investigating, and controlling health care associated infections and communicable diseases between patients and personnel. (B) The infection control professional shall maintain a log of all reportable diseases and health care associated infections designated as epidemiologically significant according to the hospital's infection control policies. (C) A written policy shall be adopted, implemented, and enforced for reporting all reportable diseases to the local health authority and the Texas Department of State Health Services (DSHS) in accordance with Chapter 97 of this title (relating to Communicable Diseases) and HSC §98.103 and §98.1045. (D) The infection control program shall include active participation by the pharmacist. (2) Responsibilities of the chief executive officer (CEO), medical staff, and chief nursing officer (CNO). The CEO, the medical staff, and the CNO shall be responsible for the following. (A) The hospital-wide quality assessment and performance improvement program and training programs shall address problems identified by the infection control professional. (B) Successful corrective action plans in affected problem areas shall be implemented. (3) Universal precautions. The hospital shall adopt, implement, and enforce a written policy to monitor compliance of the hospital and its personnel and medical staff with universal precautions in accordance with HSC Chapter 85. (h) Laboratory services. The hospital shall maintain directly or have available adequate laboratory services to meet the needs of its patients. (1) Hospital laboratory services. A hospital that provides laboratory services shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the requirements specified in 42 Code of Federal Regulations (CFR) §§493.1 - 493.1780. CLIA 1988 applies to all hospitals with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. (2) Contracted laboratory services. The hospital shall ensure that all laboratory services provided to its patients through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR Part 493 to comply with CLIA 1988. (3) Adequacy of laboratory services. The hospital shall ensure the following. (A) Emergency laboratory services shall be available 24 hours a day. (B) A written description of services provided shall be available to the medical staff. (C) The laboratory shall make provision for proper receipt and reporting of tissue specimens. (D) The medical staff and a pathologist shall determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examination. (E) When blood and blood components are stored, there shall be written procedures readily available containing directions on how to maintain them within permissible temperatures and including instructions to be followed in the event of a power failure or other disruption of refrigeration. A label or tray with the recipient's first and last names and identification number, donor unit number and interpretation of compatibility, if performed, shall be attached securely to the blood container. (F) The hospital shall establish a mechanism for ensuring that the patient's physician or other licensed health care professional is made aware of critical value lab results, as established by the medical staff, before or after the patient is discharged. (4) Chemical hygiene. A hospital that provides laboratory services shall adopt, implement, and enforce written policies and procedures to manage, minimize, or eliminate the risks to laboratory personnel of exposure to potentially hazardous chemicals in the laboratory which may occur during the normal course of job performance. (i) Linen and laundry services. The hospital shall provide sufficient clean linen to ensure the comfort of the patient. (1) For purposes of this subsection, contaminated linen is linen which has been soiled with blood or other potentially infectious materials or may contain sharps. Other potentially infectious materials means: (A) human body fluids such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (B) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (C) Human Immunodeficiency Virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV)-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. (2) The hospital, whether it operates its own laundry or uses commercial service, shall ensure the following. (A) Employees of a hospital involved in transporting, processing, or otherwise handling clean or soiled linen shall be given initial and follow-up in-service training to ensure a safe product for patients and to safeguard employees in their work. (B) Clean linen shall be handled, transported, and stored by methods that will ensure its cleanliness. (C) All contaminated linen shall be placed and transported in bags or containers labeled or color-coded. (D) Employees who have contact with contaminated linen shall wear gloves and other appropriate personal protective equipment. (E) Contaminated linen shall be handled as little as possible and with a minimum of agitation. Contaminated linen shall not be sorted or rinsed in patient care areas. (F) All contaminated linen shall be bagged or put into carts at the location where it was used. (i) Bags containing contaminated linen shall be closed before transport to the laundry. (ii) Whenever contaminated linen is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the linen shall be deposited and transported in bags that prevent leakage of fluids to the exterior. (iii) All linen placed in chutes shall be bagged. (iv) If chutes are not used to convey linen to a central receiving or sorting room, then adequate space shall be allocated on the various nursing units for holding the bagged contaminated linen. (G) Linen shall be processed as follows. (i) If hot water is used, linen shall be washed with detergent in water with a temperature of at least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes. Hot water requirements specified in Table 5 of §133.169(e) of this chapter (relating to Tables) shall be met. (ii) If low-temperature (less than or equal to 70 degrees Centigrade) (158 degrees Fahrenheit) laundry cycles are used, chemicals suitable for low-temperature washing at proper use concentration shall be used. (iii) Commercial dry cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission. (H) Flammable liquids shall not be used to process laundry but may be used for equipment maintenance. (j) Medical record services. The hospital shall have a medical record service that has administrative responsibility for medical records. A medical record shall be maintained for every individual who presents to the hospital for evaluation or treatment. (1) The organization of the medical record service shall be appropriate to the scope and complexity of the services performed. The hospital shall employ or contract with adequate personnel to ensure prompt completion, filing, and retrieval of records. (2) The hospital shall have a system of coding and indexing medical records. The system shall allow for timely retrieval by diagnosis and procedure, to support medical care evaluation studies. (3) The hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with HSC Chapter 241, Subchapters G and E, §241.103, and §241.1031 . (4) The medical record shall contain information to justify admission and continued hospitalization, support the diagnosis, reflect significant changes in the patient's condition, and describe the patient's progress and response to medications and services. Medical records shall be accurately written, promptly completed, properly filed and retained, and accessible. (5) If an attending physician issues a DNR order for a patient under HSC Chapter 166, Subchapter E, that order shall be entered into the patient medical record as soon as practicable. In the event a physician revokes a DNR order under HSC Chapter 166, Subchapter E, that revocation shall be entered into the patient medical record as soon as practicable. To the extent this paragraph conflicts with requirements elsewhere in this subsection, this paragraph prevails. (6) Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. (7) All orders (except verbal orders) must be dated, timed, and authenticated the next time the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders provides care to the patient, assesses the patient, or documents information in the patient's medical record. (8) All verbal orders must be dated, timed, and authenticated within 96 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders. (A) Use of signature stamps by physicians and other licensed practitioners credentialed by the medical staff may be allowed in hospitals when the signature stamp is authorized by the individual whose signature the stamp represents. The administrative offices of the hospital shall have on file a signed statement to the effect that he or she is the only one who has the stamp and uses it. The use of a signature stamp by any other person is prohibited. (B) A list of computer codes and written signatures shall be readily available and shall be maintained under adequate safeguards. (C) Signatures by facsimile shall be acceptable. If received on a thermal machine, the facsimile document shall be copied onto regular paper. (9) Medical records (reports and printouts) shall be retained by the hospital in their original or legally reproduced form for a period of at least ten years. A legally reproduced form is a medical record retained in hard copy, microform (microfilm or microfiche), or other electronic medium. Films, scans, and other image records shall be retained for a period of at least five years. For retention purposes, medical records that shall be preserved for ten years include: (A) identification data; (B) the medical history of the patient; (C) evidence of a physical examination, including a health history, performed no more than 30 days before admission or within 24 hours after admission, which shall be placed in the patient's medical record within 24 hours after admission; (D) an updated medical record entry documenting an examination, completed and documented in the patient's medical record within 24 hours after admission, for any changes in the patient's condition when the medical history and physical examination are completed within 30 days before admission; (E) admitting diagnosis; (F) diagnostic and therapeutic orders; (G) properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state laws if applicable, to require written patient consent; (H) clinical observations, including the results of therapy and treatment, all orders, nursing notes, medication records, vital signs, and other information necessary to monitor the patient's condition; (I) reports of procedures, tests, and their results, including laboratory, pathology, and radiology reports; (J) results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient; (K) discharge summary with outcome of hospitalization, disposition of care, and provisions for follow-up care; and (L) final diagnosis with completion of medical records within 30 calendar days following discharge. (10) A hospital may not destroy a medical record from the forensic medical examination of a sexual assault victim until the 20th anniversary of the date the record was created, in accordance with HSC Chapter 241, Subchapter E, §241.1031. (11) If a patient was less than 18 years of age at the time the patient was last treated, the hospital may authorize the disposal of those medical records relating to the patient on or after the date of the patient's 20th birthday or on or after the 10th anniversary of the date on which the patient was last treated, whichever date is later. (12) The hospital shall not destroy medical records that relate to any matter that is involved in litigation if the hospital knows the litigation has not been finally resolved. (13) The hospital shall provide written notice to a patient, or a patient's legally authorized representative, that the hospital may authorize the disposal of medical records relating to the patient on or after the periods specified in this section. The notice shall be provided to the patient or the patient's legally authorized representative not later than the date on which the patient who is or will be the subject of a medical record is treated, except in an emergency treatment situation. In an emergency treatment situation, the notice shall be provided to the patient or the patient's legally authorized representative as soon as is reasonably practicable following the emergency treatment situation. (14) If a licensed hospital should close, the hospital shall notify HHSC at the time of closure the disposition of the medical records, including the location of where the medical records will be stored and the identity and telephone number of the custodian of the records. (k) Medical staff. (1) The medical staff shall be composed of physicians and may also be composed of podiatrists, dentists and other practitioners appointed by the governing body. (A) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws. (B) The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidate. (2) The medical staff shall be well-organized and accountable to the governing body for the quality of the medical care provided to patients. (A) The medical staff shall be organized in a manner approved by the governing body. (B) If the medical staff has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy. (C) Records of medical staff meetings shall be maintained. (D) The responsibility for organization and conduct of the medical staff shall be assigned only to an individual physician. (E) Each medical staff member shall sign a statement signifying they will abide by medical staff and hospital policies. (3) The medical staff shall adopt, implement, and enforce bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall: (A) be approved by the governing body; (B) include a statement of the duties and privileges of each category of medical staff (for example, active, courtesy, consultant); (C) describe the organization of the medical staff; (D) describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body; (E) include criteria for determining the privileges to be granted and a procedure for applying the criteria to individuals requesting privileges; (F) include a requirement that a physical examination and medical history be done no more than 30 days before or 24 hours after an admission for each patient by a physician or other qualified practitioner who has been granted these privileges by the medical staff: (i) the medical history and physical examination shall be placed in the patient's medical record within 24 hours after admission; (ii) when the medical history and physical examination are completed within the 30 days before admission, an updated examination for any changes in the patient's condition must be completed and documented in the patient's medical record within 24 hours after admission; and (G) include procedures regarding DNR orders issued in the hospital by an attending physician that comply with HSC Chapter 166, Subchapter E , including policies and procedures regarding the rights of a patient and person authorized to make treatment decisions regarding the patient's DNR status; notice and medical record requirements for DNR orders and revocations; and actions the attending physician and hospital must take pursuant to HSC §166.206 when the physician or hospital and the patient or person authorized to make treatment decisions regarding the patient's DNR status are in disagreement about the execution of, or compliance with, a DNR order. (i) Except in circumstances described by HSC §166.203(a)(2) and (3), the procedures shall include that a DNR order issued for a patient is valid only if a physician providing direct care to the patient issues the order, the order is dated, and the order is issued in compliance with: (I) the written and dated directions of a patient who was competent at the time the patient wrote the directions; (II) the oral directions of a competent patient delivered to or observed by two competent adult witnesses, at least one of whom must be a person not listed under HSC §166.003(2)(E) or (F); (III) the directions in an advance directive enforceable under HSC §166.005 or executed in accordance with HSC §§166.032, 166.034, 166.035, 166.082, 166.084, or 166.085; (IV) the directions of a patient's:(-a-) legal guardian;(-b-) agent under a medical power of attorney acting in accordance with HSC Chapter 166, Subchapter D; or (-c-) proxy as designated and authorized by a directive executed in accordance with HSC Chapter 166, Subchapter B to make a treatment decision for the patient if the patient becomes incompetent or otherwise mentally or physically incapable of communication; or(V) a treatment decision made in accordance with HSC §166.039. (ii) The procedures shall include that a DNR order that is not issued in accordance with HSC §166.203(a)(1) is valid only if: (I) the patient's attending physician issues the order, the order is dated; and (-a-) the order is not contrary to the directions of a patient who was competent at the time the patient conveyed the directions; (-b-) in the reasonable medical judgment of the patient's attending physician, the patient's death is imminent, within minutes to hours, regardless of the provision of cardiopulmonary resuscitation; and (-c-) in the reasonable medical judgment of the patient's attending physician, the DNR order is medically appropriate; or (II) the patient's attending physician issues the order for a patient who is incompetent or otherwise mentally or physically incapable of communication, and the order is in compliance with a decision:(-a-) agreed upon by the attending physician and the person responsible for the patient's health care decisions; and(-b-) concurred in by another physician, who is not involved in the direct treatment of the patient or who is a representative of an ethics or medical committee of the health care facility in which the person is a patient.(iii) The procedures shall include that a DNR order takes effect at the time the order is issued, as provided by HSC §166.203(b), provided the order is placed in the patient's medical record as soon as practicable, and may be issued and entered in a format acceptable under the policies of the hospital. (iv) The procedures shall include that unless notice is provided in accordance with HSC §166.204(a), before placing in a patient's medical record a DNR order described by HSC §166.203(a)(2), a physician, physician assistant, nurse, or other person acting on behalf of the hospital shall: (I) notify the patient of the order's issuance; or (II) if the patient is incompetent, make a reasonably diligent effort to contact or cause to be contacted and inform of the order's issuance:(-a-) the patient's known agent under a medical power of attorney or legal guardian; or (-b-) for a patient who does not have a known agent under a medical power of attorney or legal guardian, a person described by HSC §166.039(b)(1), (2), or (3). (v) The procedures shall include that in accordance with HSC §166.205(a), a physician providing direct care to a patient for whom a DNR order is issued shall revoke the patient's DNR order if:(I) an advance directive that serves as the basis of the DNR order is properly revoked in accordance with HSC Chapter 166; (II) the patient expresses to any person providing direct care to the patient a revocation of consent to or intent to revoke a DNR order issued under HSC §166.203(a); or(III) the DNR order was issued under HSC §166.203(a)(1)(D) or (E) or §166.203(a)(3), and the person responsible for the patient's health care decisions expresses to any person providing direct care to the patient a revocation of consent to or intent to revoke the DNR order. (vi) The procedures shall include that a person providing direct care to a patient under the supervision of a physician shall notify the physician of the request to revoke a DNR order or the revocation of an advance directive under HSC §166.205(a). (vii) The procedures shall include that a patient's attending physician may at any time revoke a DNR order executed under: (I) HSC §166.203(a)(1)(A), (B), or (C), provided that:(-a-) the order is for a patient who is incompetent or otherwise mentally or physically incapable of communication; and(-b-) the decision to revoke the order is:(-1-) agreed on by the attending physician and the person responsible for the patient's health care decisions; and(-2-) concurred in by another physician who is not involved in the direct treatment of the patient or who is a representative of an ethics or medical committee of the health care facility in which the person is a patient;(II) HSC §166.203(a)(1)(E), provided that the order's issuance was based on a treatment decision made in accordance with HSC §166.039(e);(III) HSC §166.203(a)(2); or(IV) HSC §166.203(a)(3).(viii) The procedures shall include that a patient's attending physician shall revoke a DNR order issued for the patient under HSC §166.203(a)(2) if, in the attending physician's reasonable medical judgment, the condition described by HSC §166.203(a)(2)(B)(i) is no longer satisfied.(ix) The procedures shall include that for a patient who was incompetent at the time notice otherwise would have been provided to the patient under HSC §166.203(c)(1) and if a physician providing direct care to the patient later determines that, based on the physician's reasonable medical judgment, the patient has become competent, a physician, physician assistant, or nurse providing direct care to the patient shall disclose the order to the patient, provided that the physician, physician assistant, or nurse has actual knowledge:(I) of the order; and(II) that a physician providing direct care to the patient has determined that the patient has become competent.(l) Mental health services. (1) Mental health services unit. A hospital may not admit patients to a mental health services unit unless the unit is approved by HHSC as meeting the requirements of §133.163(q) of this title. (2) Admission criteria. A hospital providing mental health services shall have written admission criteria that are applied uniformly to all patients who are admitted to the service. (A) The hospital's admission criteria shall include procedures to prevent the admission of minors for a condition which is not generally recognized as responsive to treatment in an inpatient setting for mental health services. (i) The following conditions are not generally recognized as responsive to treatment in a hospital unless the minor to be admitted is qualified because of other disabilities, such as: (I) cognitive disabilities due to intellectual disability; or (II) learning disabilities. (ii) A minor may be qualified for admission based on other disabilities which would be responsive to mental health services. (B) The medical record shall contain evidence that admission consent was given by the patient, the patient's legal guardian, or the managing conservator, if applicable. (C) The hospital shall have a preadmission examination procedure under which each patient's condition and medical history are reviewed by a member of the medical staff to determine whether the patient is likely to benefit significantly from an intensive inpatient program or assessment. (D) A voluntarily admitted patient shall sign an admission consent form before admission to a mental health unit which includes verification that the patient has been informed of the services to be provided and the estimated charges. (3) Compliance. A hospital providing mental health services shall comply with the following rules: (A) 26 TAC Chapter 568 (relating to Standards of Care and Treatment in Psychiatric Hospitals); (B) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services); (C) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT)); (D) Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services); and (E) Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs). (m) Mobile, transportable, and relocatable units. The hospital shall adopt, implement, and enforce procedures which address the potential emergency needs for those inpatients who are taken to mobile units on the hospital's premises for diagnostic procedures or treatment. (n) Nuclear medicine services. If the hospital provides nuclear medicine services, these services shall meet the needs of the patients in accordance with acceptable standards of practice and be licensed in accordance with §289.256 of this title (relating to Medical and Veterinary Use of Radioactive Material). (1) Policies and procedures. Policies and procedures shall be adopted, implemented, and enforced which will describe the services nuclear medicine provides in the hospital and how employee and patient safety will be maintained. (2) Organization and staffing. The organization of the nuclear medicine services shall be appropriate to the scope and complexity of the services offered. (A) There shall be a medical director or clinical director who is a physician qualified in nuclear medicine. (B) The qualifications, training, functions, and responsibilities of nuclear medicine personnel shall be specified by the medical director or clinical director and approved by the medical staff. (3) Delivery of services. Radioactive materials shall be prepared, labeled, used, transported, stored, and disposed of in accordance with acceptable standards of practice and in accordance with §289.256 of this title. (A) In-house preparation of radiopharmaceuticals shall be by, or under, the direct supervision of an appropriately trained licensed pharmacist or physician. (B) There shall be proper storage and disposal of radioactive materials. (C) If clinical laboratory tests are performed by the nuclear medicine services staff, the nuclear medicine staff shall comply with CLIA 1988 in accordance with the requirements specified in 42 CFR Part 493. (D) Nuclear medicine workers shall be provided personnel monitoring dosimeters to measure their radiation exposure. Exposure reports and documentation shall be available for review. (4) Equipment and supplies. Equipment and supplies shall be appropriate for the types of nuclear medicine services offered and shall be maintained for safe and efficient performance. The equipment shall be inspected, tested, and calibrated at least annually by qualified personnel. (5) Records. The hospital shall maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures. (A) The physician approved by the medical staff to interpret diagnostic procedures shall sign and date the interpretations of these tests. (B) The hospital shall maintain records of the receipt and disposition of radiopharmaceuticals until disposal is authorized by DSHS' in accordance with §289.256 of this title. (C) Nuclear medicine services shall be ordered only by an individual whose scope of state licensure and whose defined staff privileges allow such referrals. (o) Nursing services. The hospital shall have an organized nursing service that provides 24-hour nursing services as needed. (1) Organization. The hospital shall have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. (A) Nursing services shall be under the administrative authority of a chief nursing officer (CNO) who shall be an RN and comply with one of the following: (i) possess a master's degree in nursing; (ii) possess a master's degree in health care administration or business administration; (iii) possess a master's degree in a health-related field obtained through a curriculum that included courses in administration and management; or (iv) be progressing under a written plan to obtain the nursing administration qualifications associated with a master's degree in nursing, which shall: (I) describe efforts to obtain the knowledge associated with graduate education and to increase administrative and management skills and experience; (II) include courses related to leadership, administration, management, performance improvement and theoretical approaches to delivering nursing care; and (III) provide a time-line for accomplishing skills. (B) The CNO in hospitals with 100 or fewer licensed beds and located in counties with a population of less than 50,000, or in hospitals that have been certified by the Centers for Medicare and Medicaid Services as critical access hospitals in accordance with the 42 CFR Part 485, Subpart F, §485.606(b), shall be exempted from the requirements in subparagraph (A)(i) - (iv) of this paragraph. (C) The CNO shall be responsible for the operation of the services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. (D) The CNO shall report directly to the individual who has authority to represent the hospital and who is responsible for the operation of the hospital according to the policies and procedures of the hospital's governing board. (E) The CNO shall participate with leadership from the governing body, medical staff, and clinical areas, in planning, promoting and conducting performance improvement activities. (2) Staffing and delivery of care. (A) The nursing services shall adopt, implement and enforce a procedure to verify that hospital nursing personnel for whom licensure is required have valid and current licensure. (B) There shall be adequate numbers of RNs, licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients as needed. (C) There shall be supervisory and staff personnel for each department or nursing unit to provide, when needed, the immediate availability of an RN to provide care for any patient. (D) An RN shall be on duty in each building of a licensed hospital that contains at least one nursing unit where patients are present. The RN shall supervise and evaluate the nursing care for each patient and assign the nursing care to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. (E) The nursing staff shall develop and keep current a nursing plan of care for each patient which addresses the patient's needs. (F) The hospital shall establish a nurse staffing committee as a standing committee of the hospital. The committee shall be established in accordance with HSC §§161.031 - 161.033, to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. As provided by HSC, §161.032, the hospital's records and review relating to evaluation of these outcomes and indicators are confidential and not subject to disclosure under Texas Government Code Chapter 552 and not subject to disclosure, discovery, subpoena or other means of legal compulsion for their release. As used in this subsection, "committee" or "staffing committee" means a nurse staffing committee established under this subparagraph. (i) The committee shall be composed of: (I) at least 60 percent registered nurses who are involved in direct patient care at least 50 percent of their work time and selected by their peers who provide direct care during at least 50 percent of their work time; (II) at least one representative from either infection control, quality assessment and performance improvement or risk management; (III) members who are representative of the types of nursing services provided at the hospital; and (IV) the chief nursing officer of the hospital who is a voting member. (ii) Participation on the committee by a hospital employee as a committee member shall be part of the employee's work time and the hospital shall compensate that member for that time accordingly. The hospital shall relieve the committee member of other work duties during committee meetings. (iii) The committee shall meet at least quarterly. (iv) The responsibilities of the committee shall be to: (I) develop and recommend to the hospital's governing body a nurse staffing plan that meets the requirements of subparagraph (G) of this paragraph; (II) review, assess and respond to staffing concerns expressed to the committee; (III) identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse services staffing plan; (IV) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan and variations between the plan and the actual staffing; and (V) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing. (G) The hospital shall adopt, implement, and enforce a written official nurse services staffing plan. As used in this subsection, "patient care unit" means a unit or area of a hospital in which registered nurses provide patient care. (i) The official nurse services staffing plan and policies shall: (I) require significant consideration to be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan; (II) be based on the needs of each patient care unit and shift and on evidence relating to patient care needs; (III) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget; (IV) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns; (V) protect from retaliation nurses who provide input to the nurse staffing committee; and (VI) comply with subsection (o) of this section. (ii) The plan shall: (I) set minimum staffing levels for patient care units that are: (-a-) based on multiple nurse and patient considerations including: (-1-) patient characteristics and number of patients for whom care is being provided, including number of admissions, discharges and transfers on a unit; (-2-) intensity of patient care being provided and variability of patient care across a nursing unit; (-3-) scope of services provided; (-4-) context within which care is provided, including architecture and geography of the environment, and the availability of technology; and (-5-) nursing staff characteristics, including staff consistency and tenure, preparation and experience, and the number and competencies of clinical and non-clinical support staff the nurse must collaborate with or supervise. (-b-) determined by the nursing assessment and in accordance with evidence-based safe nursing standards; and (-c-) recalculated at least annually, or as necessary; (II) include a method for adjusting the staffing plan shift to shift for each patient care unit based on factors, such as, the intensity of patient care to provide staffing flexibility to meet patient needs; (III) include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources; (IV) include how on-call time will be used; (V) reflect current standards established by private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations and should be developed based upon a review of the codes of ethics developed by the nursing profession through national nursing organizations; (VI) include a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs, nursing sensitive quality indicators, nurse satisfaction measures collected by the hospital and evidence based nurse staffing standards. At least one from each of the following three types of outcomes shall be correlated to the adequacy of staffing: (-a-) nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions; (-b-) operational outcomes, such as, work-related injury or illness, vacancy and turnover rates, nursing care hours per patient day, on-call use, or overtime rates; and (-c-) substantiated patient complaints related to staffing levels; (VII) incorporate a process that facilitates the timely and effective identification of concerns about the adequacy of the staffing plan by the nurse staffing committee established pursuant to subparagraph (F) of this paragraph. This process shall include: (-a-) a prohibition on retaliation for reporting concerns; (-b-) a requirement that nurses report concerns timely through appropriate channels within the hospital; (-c-) orientation of nurses on how to report concerns and to whom; (-d-) encouraging nurses to provide input to the committee relating to nurse staffing concerns; (-e-) review, assessment, and response by the committee to staffing concerns expressed to the committee; (-f-) a process for providing feedback during the committee meeting on how concerns are addressed by the committee established under subparagraph (F) of this paragraph; and (-g-) use of the nurse safe harbor peer review process pursuant to Texas Occupations Code §303.005; (VIII) include policies and procedures that require: (-a-) orientation of nurses and other personnel who provide nursing care to all patient care units to which they are assigned on either a temporary or permanent basis; (-b-) that the orientation of nurses and other personnel and the competency to perform nursing services is documented in accordance with hospital policy; (-c-) that nursing assignments be congruent with documented competency; and (IX) be used by the hospital as a component in setting the nurse staffing budget and guiding the hospital in assigning nurses hospital wide. (iii) The hospital shall make readily available to nurses on each patient care unit at the beginning of each shift the official nurse services staffing plan levels and current staffing levels for that unit and that shift. (iv) There shall be a semiannual evaluation by the staffing committee of the effectiveness of the official nurse services staffing plan and variations between the staffing plan and actual staffing. The evaluation shall consider the outcomes and nursing-sensitive indicators as set out in clause (ii)(VI) of this subparagraph, patient needs, nurse satisfaction measures collected by the hospital, and evidence based nurse staffing standards. This evaluation shall be documented in the minutes of the committee established under subparagraph (F) of this paragraph and presented to the hospital's governing body. Hospitals may determine whether this evaluation is done on a unit or facility level basis. To assist the committee with the semiannual evaluation, the hospital shall report to the committee the variations between the staffing plan and actual staffing. This report of variations shall be confidential and not subject to disclosure under Texas Government Code Chapter 552 and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release. (v) The staffing plan shall be retained for a period of two years. (H) Nonemployee licensed nurses who are working in the hospital shall adhere to the policies and procedures of the hospital. The CNO shall provide for the adequate orientation, supervision, and evaluation of the clinical activities of nonemployee nursing personnel which occur within the responsibility of the nursing services. (I) The hospital shall annually report to DSHS on: (i) whether the hospital's governing body has adopted a nurse staffing policy; (ii) whether the hospital has established a nurse staffing committee that meets the membership requirements of subparagraph (F) of this paragraph; (iii) whether the nurse staffing committee has evaluated the hospital's official nurse services staffing plan and has reported the results of the evaluation to the hospital's governing body; and (iv) the nurse-sensitive outcome measures the committee adopted for use in evaluating the hospital's official nurse services staffing plan. (3) Mandatory overtime. The hospital shall adopt, implement, and enforce policies on use of mandatory overtime. (A) As used in this subsection: (i) "on-call time" means time spent by a nurse who is not working but who is compensated for availability; and (ii) "mandatory overtime" means a requirement that a nurse work hours or days that are in addition to the hours or days scheduled, regardless of the length of a scheduled shift or the number of scheduled shifts each week. Mandatory overtime does not include prescheduled on-call time or time immediately before or after a scheduled shift necessary to document or communicate patient status to ensure patient safety. (B) A hospital may not require a nurse to work mandatory overtime, and a nurse may refuse to work mandatory overtime. (C) This section does not prohibit a nurse from volunteering to work overtime. (D) A hospital may not use on-call time as a substitute for mandatory overtime. (E) The prohibitions on mandatory overtime do not apply if: (i) a health care disaster, such as a natural or other type of disaster that increases the need for health care personnel, unexpectedly affects the county in which the nurse is employed or affects a contiguous county; (ii) a federal, state, or county declaration of emergency is in effect in the county in which the nurse is employed or is in effect in a contiguous county; (iii) there is an emergency or unforeseen event of a kind that: (I) does not regularly occur; (II) increases the need for health care personnel at the hospital to provide safe patient care; and (III) could not prudently be anticipated by the hospital; or (iv) the nurse is actively engaged in an ongoing medical or surgical procedure and the continued presence of the nurse through the completion of the procedure is necessary to ensure the health and safety of the patient. The nurse staffing committee shall ensure that scheduling a nurse for a procedure that could be anticipated to require the nurse to stay beyond the end of his or her scheduled shift does not constitute mandatory overtime. (F) If a hospital determines that an exception exists under subparagraph (E) of this paragraph, the hospital shall, to the extent possible, make and document a good faith effort to meet the staffing need through voluntary overtime, including calling per diems and agency nurses, assigning floats, or requesting an additional day of work from off-duty employees. (G) A hospital may not suspend, terminate, or otherwise discipline or discriminate against a nurse who refuses to work mandatory overtime. (4) Drugs and biologicals. Drugs and biologicals shall be prepared and administered in accordance with federal and state laws, the orders of the individuals granted privileges by the medical staff, and accepted standards of practice. (A) All drugs and biologicals shall be administered by, or under supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing rules, and in accordance with the approved medical staff policies and procedures. (B) All orders for drugs and biologicals shall be in writing, dated, timed, and signed by the individual responsible for the care of the patient as specified under subsection (f)(6)(A) of this section. When telephone or verbal orders must be used, they shall be: (i) accepted only by personnel who are authorized to do so by the medical staff policies and procedures, consistent with federal and state laws; (ii) dated, timed, and authenticated within 96 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges which are consistent with the written orders; and (iii) used infrequently. (C) There shall be a hospital procedure for immediately reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs to the attending physician and, if appropriate, to the hospital-wide quality assessment and performance improvement program. (5) Blood transfusions. (A) Transfusions shall be prescribed in accordance with hospital policy and administered in accordance with a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment. (B) Personnel administering blood transfusions and intravenous medications shall have special training for this duty according to written, adopted, implemented, and enforced hospital policy. (C) Blood and blood components shall be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient. (D) The patient must be observed during the transfusion and for an appropriate time thereafter for suspected adverse reactions. (E) Pretransfusion and posttransfusion vital signs shall be recorded. (F) When warming of blood is indicated, this shall be accomplished during its passage through the transfusion set. The warming system shall be equipped with a visible thermometer and may have an audible warning system. Blood shall not be warmed above 42 degrees Celsius. (G) Drugs or medications, including those intended for intravenous use, shall not be added to blood or blood components. A 0.9 percent sodium chloride injection, United States Pharmacopeia, may be added to blood or blood components. Other solutions intended for intravenous use may be used in an administration set or added to blood or blood components under either of the following conditions: (i) they have been approved for this use by the Federal Drug Administration; or (ii) there is documentation available to show that addition to the component involved is safe and efficacious. (H) There shall be a system for detection, reporting and evaluation of suspected complications of transfusion. Any adverse event experienced by a patient in association with a transfusion is to be regarded as a suspected transfusion complication. In the event of a suspected transfusion complication, the personnel attending the patient shall notify immediately a responsible physician and the transfusion service and document the complication in the patient's medical record. All suspected transfusion complications shall be evaluated promptly according to an established procedure. (I) Following the transfusion, the blood transfusion record or a copy shall be made a part of the patient's medical record. (6) Reporting and peer review of a vocational or registered nurse. A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with the Texas Occupations Code §§301.401 - 301.403, 301.405, and Chapter 303, and with the rules adopted by the Texas Board of Nursing in 22 TAC §217.16 (relating to Minor Incidents), §217.19 (relating to Incident-Based Nursing Peer Review and Whistleblower Protections), and §217.20 (relating to Safe Harbor Nursing Peer Review and Whistleblower Protections). (7) Policies and procedures related to workplace safety. (A) The hospital shall adopt, implement, and enforce policies and procedures related to the work environment for nurses which: (i) improve workplace safety and reduce the risk of injury, occupational illness, and violence; and (ii) increase the use of ergonomic principles and ergonomically designed devices to reduce injury and fatigue. (B) The policies and procedures adopted under subparagraph (A) of this paragraph, at a minimum, must include: (i) evaluating new products and technology that incorporate ergonomic principles; (ii) educating nurses in the application of ergonomic practices; (iii) conducting workplace audits to identify areas of risk of injury, occupational illness, or violence and recommending ways to reduce those risks; (iv) controlling access to those areas identified as having a high risk of violence; and (v) promptly reporting crimes committed against nurses to appropriate law enforcement agencies. (8) Safe patient handling and movement practices. (A) The hospital shall adopt, implement, and enforce policies and procedures to identify, assess, and develop strategies to control risk of injury to patients and nurses associated with the lifting, transferring, repositioning, or movement of a patient. (B) The policies and procedures shall establish a process that, at a minimum, includes the following: (i) analysis of the risk of injury to both patients and nurses posed by the patient handling needs of the patient populations served by the hospital and the physical environment in which patient handling and movement occurs; (ii) education of nurses in the identification, assessment, and control of risks of injury to patients and nurses during patient handling; (iii) evaluation of alternative ways to reduce risks associated with patient handling, including evaluation of equipment and the environment; (iv) restriction, to the extent feasible with existing equipment and aids, of manual patient handling or movement of all or most of a patient's weight to emergency, life-threatening, or otherwise exceptional circumstances; (v) collaboration with and annual report to the nurse staffing committee; (vi) procedures for nurses to refuse to perform or be involved in patient handling or movement that the nurse believes in good faith will expose a patient or a nurse to an unacceptable risk of injury; (vii) submission of an annual report to the governing body on activities related to the identification, assessment, and development of strategies to control risk of injury to patients and nurses associated with the lifting, transferring, repositioning, or movement of a patient; and (viii) development of architectural plans for constructing or remodeling a hospital or a unit of a hospital in which patient handling and movement occurs, with consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment at a later date. (p) Outpatient services. If the hospital provides outpatient services, the services shall meet the needs of the patients in accordance with acceptable standards of practice. (1) Organization. Outpatient services shall be appropriately organized and integrated with inpatient services. (2) Personnel. (A) The hospital shall assign an individual to be responsible for outpatient services. (B) The hospital shall have appropriate physicians on staff and other professional and nonprofessional personnel available. (q) Pharmacy services. The hospital shall provide pharmaceutical services that meet the needs of the patients. (1) Compliance. The hospital shall provide a pharmacy which is licensed, as required, by the Texas State Board of Pharmacy. Pharmacy services shall comply with all applicable statutes and rules. (2) Organization. The hospital shall have a pharmacy directed by a licensed pharmacist. (3) Medical staff. The medical staff shall be responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital's organized pharmaceutical services. (4) Pharmacy management and administration. The pharmacy or drug storage area shall be administered in accordance with accepted professional principles. (A) Standards of practice as defined by state law shall be followed regarding the provision of pharmacy services. (B) The pharmaceutical services shall have an adequate number of personnel to ensure quality pharmaceutical services including emergency services. (i) The staff shall be sufficient in number and training to respond to the pharmaceutical needs of the patient population being served. There shall be an arrangement for emergency services. (ii) Employees shall provide pharmaceutical services within the scope of their license and education. (C) Drugs and biologicals shall be properly stored to ensure ventilation, light, security, and temperature controls. (D) Records shall have sufficient detail to follow the flow of drugs from entry through dispensation. (E) There shall be adequate controls over all drugs and medications including the floor stock. Drug storage areas shall be approved by the pharmacist, and floor stock lists shall be established. (F) Inspections of drug storage areas shall be conducted throughout the hospital under pharmacist supervision. (G) There shall be a drug recall procedure. (H) A full-time, part-time, or consulting pharmacist shall be responsible for developing, supervising, and coordinating all the activities of the pharmacy services. (i) Direction of pharmaceutical services may not require on-premises supervision but may be accomplished through regularly scheduled visits in accordance with state law. (ii) A job description or other written agreement shall clearly define the responsibilities of the pharmacist. (I) Current and accurate records shall be kept of the receipt and disposition of all scheduled drugs. (i) There shall be a record system in place that provides the information on controlled substances in a readily retrievable manner which is separate from the patient record. (ii) Records shall trace the movement of scheduled drugs throughout the services, documenting utilization or wastage. (iii) The pharmacist shall be responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and reconciled with written orders. (5) Delivery of services. To provide patient safety, drugs and biologicals shall be controlled and distributed in accordance with applicable standards of practice, consistent with federal and state laws. (A) All compounding, packaging, and dispensing of drugs and biologicals shall be under the supervision of a pharmacist and performed consistent with federal and state laws. (B) All drugs and biologicals shall be kept in a secure area, and locked when appropriate. (i) A policy shall be adopted, implemented, and enforced to ensure the safeguarding, transferring, and availability of keys to the locked storage area. (ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be kept locked within a secure area. (C) Outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for patient use. (D) When a pharmacist is not available, drugs and biologicals shall be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with federal and state laws. (i) There shall be a current list of individuals identified by name and qualifications who are designated to remove drugs from the pharmacy. (ii) Only amounts sufficient for immediate therapeutic needs shall be removed. (E) Drugs and biologicals not specifically prescribed as to time or number of doses shall automatically be stopped after a reasonable time that is predetermined by the medical staff. (i) Stop order policies and procedures shall be consistent with those of the nursing staff and the medical staff rules and regulations. (ii) A protocol shall be established by the medical staff for the implementation of the stop order policy, in order that drugs shall be reviewed and renewed, or automatically stopped. (iii) A system shall be in place to determine compliance with the stop order policy. (F) Drug administration errors, adverse drug reactions, and incompatibilities shall be immediately reported to the attending physician and, if appropriate, to the hospital-wide quality assessment and performance improvement program. There shall be a mechanism in place for capturing, reviewing, and tracking medication errors and adverse drug reactions. (G) Abuses and losses of controlled substances shall be reported, in accordance with applicable federal and state laws, to the individual responsible for the pharmaceutical services, and to the chief executive officer, as appropriate. (H) Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage, indications for use, and routes of administration shall be immediately available to the professional staff. (i) A pharmacist shall be readily accessible by telephone or other means to discuss drug therapy, interactions, side effects, dosage, assist in drug selection, and assist in the identification of drug induced problems. (ii) There shall be staff development programs on drug therapy available to facility staff to cover such topics as new drugs added to the formulary, how to resolve drug therapy problems, and other general information as the need arises. (I) A formulary system shall be established by the medical staff to ensure quality pharmaceuticals at reasonable costs. (r) Quality assessment and performance improvement. The governing body shall ensure that there is an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care. (1) Program scope. The hospital-wide QAPI program shall reflect the complexity of the hospital's organization and services and have a written plan of implementation. The program must include an ongoing program that shows measurable improvements in the indicators for which there is evidence that they will improve health outcomes and identify and reduce medical errors. (A) All hospital departments and services, including services furnished under contract or arrangement shall be evaluated. (B) Health care associated infections shall be evaluated. (C) Medication therapy shall be evaluated. (D) All medical and surgical services performed in the hospital shall be evaluated as they relate to appropriateness of diagnosis and treatment. (E) The program must measure, analyze, and track quality indicators, including adverse patients' events, and other aspects of performance that assess processes of care, hospital services and operations. (F) Data collected must be used to monitor the effectiveness and safety of service and quality of care, and to identify opportunities for changes that will lead to improvement. (G) Priorities must be established for performance improvement activities that focus on high-risk, high-volume, or problem-prone areas, taking into consideration the incidence, prevalence, and severity of problems in those areas, and how health outcomes and quality of care may be affected. (H) Performance improvement activities which affect patient safety, including analysis of medical errors and adverse patient events, must be established, and preventive actions implemented. (I) Success of actions implemented as a result of performance improvement activities must be measured, and ongoing performance must be tracked to ensure improvements are sustained. (2) Responsibility and accountability. The hospital's governing body, medical staff and administrative staff are responsible and accountable for ensuring that: (A) an ongoing program for quality improvement is defined, implemented and maintained, and that program requirements are met; (B) an ongoing program for patient safety, including reduction of medical errors, is defined, implemented and maintained; (C) the hospital-wide QAPI efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated; and (D) adequate resources are allocated for measuring, assessing, improving, and sustaining the hospital's resources, and for reducing risk to patients. (3) Medically-related patient care services. The hospital shall have an ongoing plan, consistent with available community and hospital resources, to provide or make available social work, psychological, and educational services to meet the medically-related needs of its patients. The hospital also shall have an effective, ongoing discharge planning program that facilitates the provision of follow-up care. (A) Discharge planning shall be completed before discharge. (B) Patients, along with necessary medical information, shall be transferred or referred to appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care. (C) Screening and evaluation before patient discharge from hospital. In accordance with 42 CFR Part 483, Subpart C and the HHSC rules set forth in 26 TAC Chapter 303 (relating to Preadmission Screening and Resident Review (PASRR)), all patients who are being considered for discharge from the hospital to a nursing facility shall be screened, and if appropriate, evaluated, before discharge by the hospital and admission to the nursing facility to determine whether the patient may have a mental illness, intellectual disability or developmental disability. (i) If the screening indicates that the patient has a mental illness, intellectual disability or developmental disability, the hospital shall contact and arrange for the local mental health authority designated pursuant to HSC §533.035, to conduct before hospital discharge an evaluation of the patient in accordance with the applicable provisions of the PASRR rules. (ii) The purpose of PASRR is: (I) to ensure that placement of the patient in a nursing facility is necessary; (II) to identify alternate placement options when applicable; and (III) to identify specialized services that may benefit the person with a diagnosis of mental illness, intellectual disability, or developmental disability. (4) Implementation. The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. (s) Radiology services. The hospital shall maintain, or have available, diagnostic radiologic services according to needs of the patients. All radiology equipment, including X-ray equipment, mammography equipment and laser equipment, shall be licensed and registered as required under Chapter 289 of this title (relating to Radiation Control). If therapeutic services are also provided, the services, as well as the diagnostic services, shall meet professionally approved standards for safety and personnel qualifications as required in §289.227 of this title (relating to Use of Radiation Machines in the Healing Arts); §289.229 of this title (relating to Radiation Safety Requirements for Accelerators, Therapeutic Radiation Machines, Simulators, and Electronic Brachytherapy Devices); §289.230 of this title (relating to Certification of Mammography Systems and Mammography Machines Used for Interventional Breast Radiography); and §289.231 of this title (relating to General Provisions and Standards for Protection Against Machine-Produced Radiation) . In a special hospital, portable X-ray equipment may be acceptable as a minimum requirement. (1) Policies and procedures. Policies and procedures shall be adopted, implemented, and enforced which will describe the radiology services provided in the hospital and how employee and patient safety will be maintained. (2) Safety for patients and personnel. The radiology services, particularly ionizing radiology procedures, shall minimize hazards to patients and personnel. (A) Proper safety precautions shall be maintained against radiation hazards. This includes adequate radiation shielding, safety procedures and equipment maintenance and testing. (B) Inspection of equipment shall be made by or under the supervision of a licensed medical physicist in accordance with §289.227(o) of this title. Defective equipment shall be promptly repaired or replaced. (C) Radiation workers shall be provided personnel monitoring dosimeters to measure the amount of radiation exposure they receive. Exposure reports and documentation shall be available for review. (D) Radiology services shall be provided only on the order of individuals granted privileges by the medical staff. (3) Personnel. (A) A qualified full-time, part-time, or consulting radiologist shall supervise the ionizing radiology services and shall interpret only those radiology tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section a radiologist is a physician who is qualified by education and experience in radiology in accordance with medical staff bylaws. (B) Only personnel designated as qualified by the medical staff shall use the radiology equipment and administer procedures. (4) Records. Records of radiology services shall be maintained. The radiologist or other individuals who have been granted privileges to perform radiology services shall sign reports of his or her interpretations. (t) Renal dialysis services. (1) Hospitals may provide inpatient dialysis services without an additional license under HSC Chapter 251. Hospitals providing outpatient dialysis services shall be licensed under HSC Chapter 251. (2) Hospitals may provide outpatient dialysis services when the governor or the president of the United States declares a disaster in this state or another state. The hospital may provide outpatient dialysis only during the term of the disaster declaration. (3) Equipment. (A) Maintenance and repair. All equipment used by a facility, including backup equipment, shall be operated within manufacturer's specifications, and maintained free of defects which could be a potential hazard to patients, staff, or visitors. Maintenance and repair of all equipment shall be performed by qualified staff or contract personnel. (i) Staff shall be able to identify malfunctioning equipment and report such equipment to the appropriate staff for immediate repair. (ii) Medical equipment that malfunctions must be clearly labeled and immediately removed from service until the malfunction is identified and corrected. (iii) Written evidence of all maintenance and repairs shall be maintained. (iv) After repairs or alterations are made to any equipment or system, the equipment or system shall be thoroughly tested for proper operation before returning to service. This testing must be documented. (v) A facility shall comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code (USC) §360i(b), concerning reporting when a medical device as defined in 21 USC §321(h) has or may have caused or contributed to the injury or death of a patient of the facility. (B) Preventive maintenance. A facility shall develop, implement, and enforce a written preventive maintenance program to ensure patient care related equipment used in a facility receives electrical safety inspections, if appropriate, and maintenance at least annually or more frequently as recommended by the manufacturer. The preventive maintenance may be provided by facility staff or by contract. (C) Backup machine. At least one complete dialysis machine shall be available on site as backup for every ten dialysis machines in use. At least one of these backup machines must be completely operational during hours of treatment. Machines not in use during a patient shift may be counted as backup except at the time of an initial or an expansion survey. (D) Pediatric patients. If pediatric patients are treated, a facility shall use equipment and supplies, to include blood pressure cuffs, dialyzers, and blood tubing, appropriate for this special population. (E) Emergency equipment and supplies. A facility shall have emergency equipment and supplies immediately accessible in the treatment area. (i) At a minimum, the emergency equipment and supplies shall include the following: (I) oxygen; (II) mechanical ventilatory assistance equipment, to include airways, manual breathing bag, and mask; (III) suction equipment; (IV) supplies specified by the medical director; (V) electrocardiograph; and (VI) automated external defibrillator or defibrillator. (ii) If pediatric patients are treated, the facility shall have the appropriate type and size emergency equipment and supplies listed in clause (i) of this subparagraph for this special population. (iii) A facility shall establish, implement, and enforce a policy for the periodic testing and maintenance of the emergency equipment. Staff shall properly maintain and test the emergency equipment and supplies and document the testing and maintenance. (F) Transducer protector. A transducer protector shall be replaced when wetted during a dialysis treatment and shall be used for one treatment only. (4) Water treatment and dialysate concentrates. (A) Compliance required. A facility shall meet the requirements of this section. A facility may follow more stringent requirements than the minimum standards required by this section. (i) The facility administrator and medical director shall each demonstrate responsibility for the water treatment and dialysate supply systems to protect hemodialysis patients from adverse effects arising from known chemical and microbial contaminates that may be found in improperly prepared dialysate, to ensure that the dialysate is correctly formulated and meets the requirements of all applicable quality standards. (ii) The facility administrator and medical director must assure that policies and procedures related to water treatment and dialysate are understandable and accessible to the operator and that the training program includes quality testing, risks and hazards of improperly prepared concentrate and bacterial issues. (iii) The facility administrator and medical director must be informed before any alteration of, or any device being added to, the water system. (B) Water treatment. These requirements apply to water intended for use in the delivery of hemodialysis, including the preparation of concentrates from powder at a dialysis facility and dialysate. (i) The design for the water treatment system in a facility shall be based on considerations of the source water for the facility and designed by a water quality professional with education, training, or experience in dialysis system design. (ii) When a public water system supply is not used by a facility, the source water shall be tested by the facility at monthly intervals in the same manner as a public water system as described in 30 TAC §290.104 (relating to Summary of Maximum Contaminant Levels, Maximum Residual Disinfectant Levels, Treatment Techniques, and Action Levels), and 30 TAC §290.109 (relating to Microbial Contaminants) as adopted by the Texas Commission on Environmental Quality (TCEQ). (iii) The physical space in which the water treatment system is located must be adequate to allow for maintenance, testing, and repair of equipment. If mixing of dialysate is performed in the same area, the physical space must also be adequate to house and allow for the maintenance, testing, and repair of the mixing equipment and for performing the mixing procedure. (iv) The water treatment system components shall be arranged and maintained so that bacterial and chemical contaminant levels in the product water do not exceed the standards for hemodialysis water quality described in §4.2.1 (concerning Water Bacteriology) and §4.2.2 (concerning Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the Association for the Advancement of Medical Instrumentation (AAMI). (v) Written policies and procedures for the operation of the water treatment system must be developed and implemented. Parameters for the operation of each component of the water treatment system must be developed in writing and known to the operator. Each major water system component shall be labeled in a manner that identifies the device; describes its function, how performance is verified and actions to take in the event performance is not within an acceptable range. (vi) The materials of any components of water treatment systems (including piping, storage, filters, and distribution systems) that contact the purified water shall not interact chemically or physically so as to affect the purity or quality of the product water adversely. Such components shall be fabricated from unreactive materials (e.g., plastics) or appropriate stainless steel. The use of materials that are known to cause toxicity in hemodialysis, such as copper, brass, galvanized material, or aluminum, is prohibited. (vii) Chemicals infused into the water such as iodine, acid, flocculants, and complexing agents shall be shown to be nondialyzable or shall be adequately removed from product water. Monitors or specific test procedures to verify removal of additives shall be provided and documented. (viii) Each water treatment system shall include reverse osmosis membranes or deionization tanks and a minimum of two carbon tanks in series. If the source water is from a private supply which does not use chlorine/chloramine, the water treatment system shall include reverse osmosis membranes or deionization tanks and a minimum of one carbon tank. (I) Reverse osmosis membranes. Reverse osmosis membranes, if used, shall meet the standards in §4.3.7 (concerning Reverse Osmosis) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the AAMI. (II) Deionization systems. (-a-) Deionization systems, if used, shall be monitored continuously to produce water of one megohm-centimeter (cm) or greater specific resistivity (or conductivity of one microsiemen/cm or less) at 25 degrees Celsius. An audible and visual alarm shall be activated when the product water resistivity falls below this level and the product water stream shall be prevented from reaching any point of use. (-b-) Patients shall not be dialyzed on deionized water with a resistivity less than 1.0 megohm-cm measured at the output of the deionizer. (-c-) A minimum of two deionization (DI) tanks in series shall be used with resistivity monitors including audible and visual alarms placed pre and post the final DI tank in the system. The alarms must be audible in the patient care area. (-d-) Feed water for deionization systems shall be pretreated with activated carbon adsorption, or a comparable alternative, to prevent nitrosamine formation. (-e-) If a deionization system is the last process in a water treatment system, it shall be followed by an ultrafilter or other bacteria and endotoxin reducing device. (III) Carbon tanks. (-a-) The carbon tanks must contain acid washed carbon, 30-mesh or smaller with a minimum iodine number of 900. (-b-) A minimum of two carbon adsorption beds shall be installed in a series configuration. (-c-) The total empty bed contact time (EBCT) shall be at least ten minutes, with the final tank providing at least five minutes EBCT. Carbon adsorption systems used to prepare water for portable dialysis systems are exempt from the requirement for the second carbon and a ten-minute EBCT if removal of chloramines to below 0.1 milligram (mg)/1 is verified before each treatment. (-d-) A means shall be provided to sample the product water immediately prior to the final bed(s). Water from this port(s) must be tested for chlorine/chloramine levels immediately prior to each patient shift. (-e-) All samples for chlorine or chloramine testing must be drawn when the water treatment system has been operating for at least 15 minutes. (-f-) Tests for total chlorine, which include both free and combined forms of chlorine, may be used as a single analysis with the maximum allowable concentration of 0.1 mg/liter (L). Test results of greater than 0.5 parts per million (ppm) for chlorine or 0.1 ppm for chloramine from the port between the initial tank(s) and final tank(s) shall require testing to be performed at the final exit and replacement of the initial tank(s). (-g-) In a system without a holding tank, if test results at the exit of the final tank(s) are greater than the parameters for chlorine or chloramine described in this subclause, dialysis treatment shall be immediately terminated to protect patients from exposure to chlorine or chloramine and the medical director shall be notified. In systems with holding tanks, if the holding tank tests <1 mg/L for total chlorine, the reverse osmosis (RO) may be turned off and the product water in the holding tank may be used to finish treatments in process. The medical director shall be notified. (-h-) If means other than granulated carbon are used to remove chlorine/chloramine, the facility's governing body must approve such use in writing after review of the safety of the intended method for use in hemodialysis applications. If such methods include the use of additives, there must be evidence the product water does not contain unsafe levels of these additives. (ix) Water softeners, if used, shall be tested at the end of the treatment day to verify their capacity to treat a sufficient volume of water to supply the facility for the entire treatment day and shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. (x) If used, the face of a timer used to control any component of the water treatment or dialysate delivery system shall be visible to the operator at all times. Written evidence that timers are checked for operation and accuracy each day of operation must be maintained. (xi) Filter housings, if used during disinfectant procedures, shall include a means to clear the lower portion of the housing of the disinfecting agents. Filter housings shall be opaque. (xii) Ultrafilters, or other bacterial reducing filters, if used, shall be fitted with pressure gauges on the inlet and outlet water lines to monitor the pressure drop across the membrane. Ultrafilters shall be included in routine disinfection procedures. (xiii) If used, storage tanks shall have a conical or bowl-shaped base and shall drain from the lowest point of the base. Storage tanks shall have a tight-fitting lid and be vented through a hydrophobic 0.2 micron air filter. Means shall be provided to effectively disinfect any storage tank installed in a water distribution system. (xiv) Ultraviolet (UV) lights, if used, shall be monitored at the frequency recommended by the manufacturer. A log sheet shall be used to record monitoring. (xv) Water treatment system piping shall be labeled to indicate the contents of the pipe and direction of flow. (xvi) The water treatment system must be continuously monitored during patient treatment and be guarded by audible and visual alarms which can be seen and heard in the dialysis treatment area should water quality drop below specific parameters. Quality monitor sensing cells shall be located as the last component of the water treatment system and at the beginning of the distribution system. No water treatment components that could affect the quality of the product water as measured by this device shall be located after the sensing cell. (xvii) When deionization tanks do not follow a reverse osmosis system, parameters for the rejection rate of the membranes must assure that the lowest rate accepted would provide product water in compliance with §4.2.2 (concerning Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition published by the AAMI. (xviii) A facility shall maintain written logs of the operation of the water treatment system for each treatment day. The log-book shall include each component's operating parameter and the action taken when a component is not within the facility's set parameters. (xix) Microbiological testing of product water shall be conducted. (I) Frequency. Microbiological testing shall be conducted monthly and following any repair or change to the water treatment system. For a newly installed water distribution system, or when a change has been made to an existing system, weekly testing shall be conducted for one month to verify that bacteria and endotoxin levels are consistently within the allowed limits. (II) Sample sites. At a minimum, sample sites chosen for the testing shall include the beginning of the distribution piping, at any site of dialysate mixing, and the end of the distribution piping. (III) Technique. Samples shall be collected before sanitizing or disinfecting the water treatment system and dialysis machines. Water testing results shall be routinely trended and reviewed by the medical director to determine if results seem questionable or if there is an opportunity for improvement. The medical director shall determine if there is a need for retesting. Repeated results of "no growth" shall be validated via an outside laboratory. A calibrated loop may not be used in microbiological testing of water samples. Colonies shall be counted using a magnifying device. (IV) Expected results. Product water used to prepare dialysate, concentrates from powder, or to reprocess dialyzers for multiple use, shall contain a total viable microbial count less than 200 colony forming units (CFU)/millimeter (ml) and an endotoxin concentration less than 2 endotoxin units (EU)/ml. The action level for the total viable microbial count in the product water shall be 50 CFU/ml and the action level for the endotoxin concentration shall be 1 EU/ml. (V) Required action for unacceptable results. If the action levels described at subclause (IV) of this clause are observed in the product water, corrective measures shall be taken promptly to reduce the levels into an acceptable range. (VI) Records. All bacteria and endotoxin results shall be recorded on a log sheet to identify trends that may indicate the need for corrective action. (xx) If ozone generators are used to disinfect any portion of the water or dialysate delivery system, testing based on the manufacturer's direction shall be used to measure the ozone concentration each time disinfection is performed, to include testing for safe levels of residual ozone at the end of the disinfection cycle. Testing for ozone in the ambient air shall be conducted on a periodic basis as recommended by the manufacturer. Records of all testing must be maintained in a log. (xxi) If used, hot water disinfection systems shall be monitored for temperature and time of exposure to hot water as specified by the manufacturer. Temperature of the water shall be recorded at a point furthest from the water heater, where the lowest water temperature is likely to occur. The water temperature shall be measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection shall be maintained. (xxii) After chemical disinfection, means shall be provided to restore the equipment and the system in which it is installed to a safe condition relative to residual disinfectant before the product water being used for dialysis applications. (xxiii) Samples of product water must be submitted for chemical analysis every six months and must demonstrate that the quality of the product water used to prepare dialysate or concentrates from powder, meets §4.2.2 (concerning Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the AAMI. (I) Samples for chemical analysis shall be collected at the end of the water treatment components and at the most distal point in each water distribution loop, if applicable. All other outlets from the distribution loops shall be inspected to ensure that the outlets are fabricated from compatible materials. Appropriate containers and pH adjustments shall be used to ensure accurate determinations. New facilities or facilities that add or change the configuration of the water distribution system must draw samples at the most distal point for each water distribution loop, if applicable, on a one-time basis. (II) Additional chemical analysis shall be submitted if substantial changes are made to the water treatment system or if the percent rejection of a reverse osmosis system decreased 5.0 percent or more from the percent rejection measured at the time the water sample for the preceding chemical analysis was taken. (xxiv) Facility records must include all test results and evidence that the medical director has reviewed the results of the water quality testing and directed corrective action when indicated. (xxv) Only persons qualified by the education or experience may operate, repair, or replace components of the water treatment system. (C) Dialysate. (i) Quality control procedures shall be established to ensure ongoing conformance to policies and procedures regarding dialysate quality. (ii) Each facility shall set all hemodialysis machines to use only one family of concentrates. When new machines are put into service or the concentrate family or concentrate manufacturer is changed, samples shall be sent to a laboratory for verification. (iii) Before each patient treatment, staff shall verify the dialysate conductivity and pH of each machine with an independent device. (iv) Bacteriological testing shall be conducted. (I) Frequency. Responsible facility staff shall develop a schedule to ensure each hemodialysis machine is tested quarterly for bacterial growth and the presence of endotoxins. Hemodialysis machines of home patients shall be cultured monthly until results not exceeding 200 CFU/ml are obtained for three consecutive months, then quarterly samples shall be cultured. (II) Acceptable limits. Dialysate shall contain less than 200 CFU/ml and an endotoxin concentration of less than 2 EU/ml. The action level for total viable microbial count shall be 50 CFU/ml and the action level for endotoxin concentration shall be 1 EU/ml. (III) Action to be taken. Disinfection and retesting shall be done when bacterial or endotoxin counts exceed the action levels. Additional samples shall be collected when there is a clinical indication of a pyrogenic reaction and/or septicemia. (v) Only a licensed nurse may use an additive to increase concentrations of specific electrolytes in the acid concentrate. Mixing procedures shall be followed as specified by the additive manufacturer. When additives are prescribed for a specific patient, the container holding the prescribed acid concentrate shall be labeled with the name of the patient, the final concentration of the added electrolyte, the date the prescribed concentrate was made, and the name of the person who mixed the additive. (vi) All components used in concentrate preparation systems (including mixing and storage tanks, pumps, valves, and piping) shall be fabricated from materials (e.g., plastics or appropriate stainless steel) that do not interact chemically or physically with the concentrate so as to affect its purity, or with the germicides used to disinfect the equipment. The use of materials that are known to cause toxicity in hemodialysis such as copper, brass, galvanized material, and aluminum is prohibited. (vii) Facility policies shall address means to protect stored acid concentrates from tampering or from degeneration due to exposure to extreme heat or cold. (viii) Procedures to control the transfer of acid concentrates from the delivery container to the storage tank and prevent the inadvertent mixing of different concentrate formulations shall be developed, implemented, and enforced. The storage tanks shall be clearly labeled. (ix) Concentrate mixing systems shall include a purified water source, a suitable drain, and a ground fault protected electrical outlet. (I) Operators of mixing systems shall use personal protective equipment as specified by the manufacturer during all mixing processes. (II) The manufacturer's instructions for use of a concentrate mixing system shall be followed, including instructions for mixing the powder with the correct amount of water. The number of bags or weight of powder added shall be determined and recorded. (III) The mixing tank shall be clearly labeled to indicate the fill and final volumes required to correctly dilute the powder. (IV) Systems for preparing either bicarbonate or acid concentrate from powder shall be monitored according to the manufacturer's instructions. (V) Concentrates shall not be used, or transferred to holding tanks or distribution systems, until all tests are completed. (VI) If a facility designs its own system for mixing concentrates, procedures shall be developed and validated using an independent laboratory to ensure proper mixing. (x) Acid concentrate mixing tanks shall be designed to allow the inside of the tank to be rinsed when changing concentrate formulas. (I) Acid mixing systems shall be designed and maintained to prevent rust and corrosion. (II) Acid concentrate mixing tanks shall be emptied completely and rinsed with product water before mixing another batch of concentrate to prevent cross contamination between different batches. (III) Acid concentrate mixing equipment shall be disinfected as specified by the equipment manufacturer or in the case where no specifications are given, as defined by facility policy. (IV) Records of disinfection and rinsing of disinfectants to safe residual levels shall be maintained. (xi) Bicarbonate concentrate mixing tanks shall have conical or bowl-shaped bottoms and shall drain from the lowest point of the base. The tank design shall allow all internal surfaces to be disinfected and rinsed. (I) Bicarbonate concentrate mixing tanks shall not be prefilled the night before use. (II) If disinfectant remains in the mixing tank overnight, this solution must be completely drained, the tank rinsed and tested for residual disinfectant before preparing the first batch of that day of bicarbonate concentrate. (III) Unused portions of bicarbonate concentrate shall not be mixed with fresh concentrate. (IV) At a minimum, bicarbonate distribution systems shall be disinfected weekly. More frequent disinfection shall be done if required by the manufacturer, or if dialysate culture results are above the action level. (V) If jugs are reused to deliver bicarbonate concentrate to individual hemodialysis machines: (-a-) jugs shall be emptied of concentrate, rinsed and inverted to drain at the end of each treatment day; (-b-) at a minimum, jugs shall be disinfected weekly, more frequent disinfection shall be considered by the medical director if dialysate culture results are above the action level; and (-c-) following disinfection, jugs shall be drained, rinsed free of residual disinfectant, and inverted to dry and testing for residual disinfectant shall be done and documented. (xii) All mixing tanks, bulk storage tanks, dispensing tanks and containers for single hemodialysis treatments shall be labeled as to the contents. (I) Mixing tanks. Before batch preparation, a label shall be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling shall remain on the mixing tank until the tank has been emptied. (II) Bulk storage or dispensing tanks. These tanks shall be permanently labeled to identify the chemical composition or formulation of their contents. (III) Single machine containers. At a minimum, single machine containers shall be labeled with sufficient information to differentiate the contents from other concentrate formulations used in the facility and permit positive identification by users of container contents. (xiii) Permanent records of batches produced shall be maintained to include the concentrate formula produced, the volume of the batch, lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date (if applicable). (xiv) If dialysate concentrates are prepared in the facility, the manufacturers' recommendations shall be followed regarding any preventive maintenance. Records shall be maintained indicating the date, time, person performing the procedure, and the results (if applicable). (5) Prevention requirements concerning patients. (A) Hepatitis B vaccination. (i) With the advice and consent of a patient's attending nephrologist, facility staff shall make the hepatitis B vaccine available to a patient who is susceptible to hepatitis B, provided that the patient has coverage or is willing to pay for vaccination. (ii) The facility shall make available to patients literature describing the risks and benefits of the hepatitis B vaccination. (B) Serologic screening of patients. (i) A patient new to dialysis shall have been screened for hepatitis B surface antigen (HBsAg) within one month before or at the time of admission to the facility or have a known hepatitis B surface antibody (anti-HBs) status of at least 10 milli-international units per milliliter no more than 12 months before admission. The facility shall document how this screening requirement is met. (ii) Repeated serologic screening shall be based on the antigen or antibody status of the patient. (I) Monthly screening for HBsAg is required for patients whose previous test results are negative for HBsAg. (II) Screening of HBsAg-positive or anti-HBs-positive patients may be performed on a less frequent basis, provided that the facility's policy on this subject remains congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Disease in the United States, 2000, published by the United States Department of Health and Human Services. (C) Isolation procedures for the HBsAg-positive patient. (i) The facility shall treat patients positive for HBsAg in a segregated treatment area which includes a hand washing sink, a work area, patient care supplies and equipment, and sufficient space to prevent cross-contamination to other patients. (ii) A patient who tests positive for HBsAg shall be dialyzed on equipment reserved and maintained for the HBsAg-positive patient's use only. (iii) When a caregiver is assigned to both HBsAg-negative and HBsAg-positive patients, the HBsAg-negative patients assigned to this grouping must be Hepatitis B antibody positive. Hepatitis B antibody positive patients are to be seated at the treatment stations nearest the isolation station and be assigned to the same staff member who is caring for the HBsAg-positive patient. (iv) If an HBsAg-positive patient is discharged, the equipment which had been reserved for that patient shall be given intermediate level disinfection before use for a patient testing negative for HBsAg. (v) In the case of patients new to dialysis, if these patients are admitted for treatment before results of HBsAg or anti-HBs testing are known, these patients shall undergo treatment as if the HBsAg test results were potentially positive, except that they shall not be treated in the HBsAg isolation room, area, or machine. (I) The facility shall treat potentially HBsAg-positive patients in a location in the treatment area which is outside of traffic patterns until the HBsAg test results are known. (II) The dialysis machine used by this patient shall be given intermediate level disinfection before its use by another patient. (III) The facility shall obtain HBsAg status results of the patient no later than three days from admission. (u) Respiratory care services. The hospital shall meet the needs of the patients in accordance with acceptable standards of practice. (1) Policies and procedures shall be adopted, implemented, and enforced which describe the provision of respiratory care services in the hospital. (2) The organization of the respiratory care services shall be appropriate to the scope and complexity of the services offered. (3) There shall be a medical director or clinical director of respiratory care services who is a physician with the knowledge, experience, and capabilities to supervise and administer the services properly. The medical director or clinical director may serve on either a full-time or part-time basis. (4) There shall be adequate numbers of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with the state law. (5) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures shall be designated in writing. (6) If blood gases or other clinical laboratory tests are performed by the respiratory care services staff, the respiratory care staff shall comply with CLIA 1988 in accordance with the requirements specified in 42 CFR Part 493. (7) Services shall be provided only on, and in accordance with, the orders of a physician. (v) Sterilization and sterile supplies. (1) Supervision. The sterilization of all supplies and equipment shall be under the supervision of a person qualified by education, training, and experience. Staff responsible for the sterilization of supplies and equipment shall participate in a documented continuing education program; new employees shall receive initial orientation and on-the-job training. (2) Equipment and procedures. (A) Sterilization. Every hospital shall provide equipment adequate for sterilization of supplies and equipment as needed. Equipment shall be maintained and operated to perform, with accuracy, the sterilization of the various materials required. (B) Written policy. Written policies and procedures for the decontamination and sterilization activities performed shall be adopted, implemented, and enforced. Policies shall include the receiving, cleaning, decontaminating, disinfecting, preparing and sterilization of reusable items, as well as those for the assembly, wrapping, storage, distribution and quality control of sterile items and equipment. These written policies shall be reviewed at least every other year and approved by the infection control practitioner or committee. (C) Separation. Where cleaning, preparation, and sterilization functions are performed in the same room or unit, the physical facilities, equipment, and the policies and procedures for their use, shall be such as to effectively separate soiled or contaminated supplies and equipment from the clean or sterilized supplies and equipment. Hand washing facilities shall be provided and a separate sink shall be provided for safe disposal of liquid waste. (D) Labeling. All containers for solutions, drugs, flammable solvents, ether, alcohol, and medicated supplies shall be clearly labeled to indicate contents. Those which are sterilized by the hospital shall be labeled so as to be identifiable both before and after sterilization. Sterilized items shall have a load control identification that indicates the sterilizer used, the cycle or load number, and the date of sterilization. (E) Preparation for sterilization. (i) All items to be sterilized shall be prepared to reduce the bioburden. All items shall be thoroughly cleaned, decontaminated, and prepared in a clean, controlled environment. (ii) All articles to be sterilized shall be arranged so all surfaces will be directly exposed to the sterilizing agent for the prescribed time and temperature. (F) Packaging. All wrapped articles to be sterilized shall be packaged in materials recommended for the specific type of sterilizer and material to be sterilized. (G) External chemical indicators. (i) External chemical indicators, also known as sterilization process indicators, shall be used on each package to be sterilized, including items being flash sterilized to indicate that items have been exposed to the sterilization process. (ii) The indicator results shall be interpreted according to manufacturer's written instructions and indicator reaction specifications. (iii) A log shall be maintained with the load identification, indicator results, and identification of the contents of the load. (H) Biological indicators. Biological indicators are commercially-available microorganisms (e.g., United States Food and Drug Administration (FDA) approved strips or vials of Bacillus species endospores) which can be used to verify the performance of waste treatment equipment and processes (or sterilization equipment and processes). (i) The efficacy of the sterilizing process shall be monitored with reliable biological indicators appropriate for the type of sterilizer used. (ii) Biological indicators shall be included in at least one run each week of use for steam sterilizers, at least one run each day of use for low-temperature hydrogen peroxide gas sterilizers, and every load for ethylene oxide (EO) sterilizers. (iii) Biological indicators shall be included in every load that contains implantable objects. (iv) A log shall be maintained with the load identification, biological indicator results, and identification of the contents of the load. (v) If a test is positive, the sterilizer shall immediately be taken out of service. (I) Implantable items shall be recalled and reprocessed if a biological indicator test (spore test) is positive. (II) All available items shall be recalled and reprocessed if a sterilizer malfunction is found and a list of those items not retrieved in the recall shall be submitted to infection control. (III) A malfunctioning sterilizer shall not be put back into use until it has been serviced and successfully tested according to the manufacturer's recommendations. (I) Sterilizers. (i) Steam sterilizers (saturated steam under pressure) shall be utilized for sterilization of heat and moisture stable items. Steam sterilizers shall be used according to manufacturer's written instructions. (ii) EO sterilizers shall be used for processing heat and moisture sensitive items. EO sterilizers and aerators shall be used and vented according to the manufacturer's written instructions. (iii) Flash sterilizers shall be used for emergency sterilization of clean, unwrapped instruments and porous items only. (J) Disinfection. (i) Written policies, approved by the infection control committee, shall be adopted, implemented, and enforced for the use of chemical disinfectants. (ii) The manufacturer's written instructions for the use of disinfectants shall be followed. (iii) An expiration date, determined according to manufacturer's written recommendations, shall be marked on the container of disinfection solution currently in use. (iv) Disinfectant solutions shall be kept covered and used in well-ventilated areas. (v) Chemical germicides that are registered with the United States Environmental Protection Agency as "sterilants" may be used either for sterilization or high-level disinfection. (vi) All staff personnel using chemical disinfectants shall have received training on their use. (K) Performance records. (i) Performance records for all sterilizers shall be maintained for each cycle. These records shall be retained and available for review for a minimum of five years. (ii) Each sterilizer shall be monitored continuously during operation for pressure, temperature, and time at desired temperature and pressure. A record shall be maintained and shall include: (I) the sterilizer identification; (II) sterilization date; (III) cycle number; (IV) contents of each load; (V) duration and temperature of exposure phase (if not provided on sterilizer recording charts); (VI) identification of operators; (VII) results of biological tests and dates performed; (VIII) time-temperature recording charts from each sterilizer; (IX) gas concentration and relative humidity (if applicable); and (X) any other test results. (L) Storage of sterilized items. (i) Sterilized items shall be transported so as to maintain cleanliness and sterility and to prevent physical damage. (ii) Sterilized items shall be stored in well-ventilated, limited access areas with controlled temperature and humidity. (iii) The hospital shall adopt, implement, and enforce a policy which describes the mechanism used to determine the shelf life of sterilized packages. (M) Preventive maintenance. Preventive maintenance of all sterilizers shall be performed according to individual adopted, implemented, and enforced policy on a scheduled basis by qualified personnel, using the sterilizer manufacturer's service manual as a reference. A preventive maintenance record shall be maintained for each sterilizer. These records shall be retained at least two years and shall be available for review. (w) Surgical services. If a hospital provides surgical services, the services shall be well-organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered, the services shall be consistent in quality with inpatient care in accordance with the complexity of services offered. A special hospital may not offer surgical services. (1) Organization and staffing. The organization of the surgical services shall be appropriate for the scope of the services offered. (A) The operating rooms shall be supervised by an experienced RN or physician. (B) Licensed vocational nurses (LVNs) and surgical technologists (operating room technicians) may serve as scrub nurses or technologists under the supervision of an RN. (C) Circulating duties in the operating room must be performed by qualified RNs. In accordance with approved medical staff policies and procedures, LVNs and surgical technologists may assist in circulatory duties under the direct supervision of a qualified RN circulator. (D) Surgical privileges shall be delineated for all physicians, podiatrists, and dentists performing surgery in accordance with the competencies of each. The surgical services shall maintain a roster specifying the surgical privileges of each. (E) If the facility employs surgical technologists, the facility shall adopt, implement, and enforce policies and procedures to comply with HSC Chapter 259. (2) Delivery of service. Surgical services shall be consistent with needs and resources. Written policies governing surgical care which are designed to ensure the achievement and maintenance of high standards of medical practice and patient care shall be adopted, implemented, and enforced. (A) There shall be a complete medical history and physical examination, as required under subsection (k)(3)(F) of this section, in the medical record of every patient before surgery, except in emergencies. If this has been dictated, but not yet recorded in the patient's medical record, there shall be a statement to that effect and an admission note in the record by the individual who admitted the patient. (B) A properly executed informed consent form for the operation shall be in the patient's medical record before surgery, except in emergencies. (C) The following equipment shall be available in the operating room suites: (i) communication system; (ii) cardiac monitor; (iii) resuscitator; (iv) defibrillator; (v) aspirator; and (vi) tracheotomy set. (D) There shall be adequate provisions for immediate postoperative care. (E) The operating room register shall be complete and up-to-date and it shall contain the following: (i) patient's name and hospital identification number; (ii) date of operation; (iii) operation performed; (iv) operating surgeon and assistants; (v) type of anesthesia used and name of person administering it; (vi) time operation began and ended; (vii) time anesthesia began and ended; (viii) disposition of specimens; (ix) names of scrub and circulating personnel; (x) unusual occurrences; and (xi) disposition of the patient. (F) An operative report describing techniques, findings, and tissue removed or altered shall be written or dictated immediately following surgery and signed by the surgeon. (x) Therapy services. If the hospital provides physical therapy, occupational therapy, audiology, or speech pathology services, the services shall be organized and staffed to ensure the health and safety of patients. (1) Organization and staffing. The organization of the services shall be appropriate to the scope of the services offered. (A) The director of the services shall have the necessary knowledge, experience, and capabilities to properly supervise and administer the services. (B) Physical therapy, occupational therapy, speech therapy, or audiology services, if provided, shall be provided by staff who meet the qualifications specified by the medical staff, consistent with state law. (2) Delivery of services. Services shall be furnished in accordance with a written plan of treatment. Services to be provided shall be consistent with applicable state laws and regulations, and in accordance with orders of the physician, podiatrist, dentist or other licensed practitioner who is authorized by the medical staff to order the services. Therapy orders shall be incorporated in the patient's medical record. (y) Waste and waste disposal. (1) Special waste and liquid/sewage waste management. (A) The hospital shall comply with the requirements set forth by DSHS in Chapter 1, Subchapter K of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities) and the TCEQ requirements in 30 TAC Chapter 326, Subchapter B (relating to Packaging, Labeling and Shipping Requirements) and §326.31 (relating to Exempt Medical Waste Operations). (B) All sewage and liquid wastes shall be disposed of in a municipal sewerage system or a septic tank system permitted by the TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site Sewage Facilities). (2) Waste receptacles. (A) Waste receptacles shall be conveniently available in all toilet rooms, patient areas, staff work areas, and waiting rooms. Receptacles shall be routinely emptied of their contents at a central location into closed containers. (B) Waste receptacles shall be properly cleaned with soap and hot water, followed by treatment of inside surfaces of the receptacles with a germicidal agent. (C) All containers for other municipal solid waste shall be leak-resistant, have tight-fitting covers, and be rodent-proof. (D) Nonreusable containers shall be of suitable strength to minimize animal scavenging or rupture during collection operations. Source Note: The provisions of this §505.41 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective December 9, 2010, 35 TexReg 10716; amended to be effective November 11, 2012, 37 TexReg 8809; amended to be effective May 24, 2013, 38 TexReg 3001; amended to be effective September 14, 2014, 39 TexReg 7140; amended to be effective February 18, 2018, 43 TexReg 575; amended to be effective September 20, 2018, 43 TexReg 5952; amended to be effective February 2, 2020, 45 TexReg 555; amended to be effective November 1, 2024, 49 TexReg 8582; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.41 Hospital Functions and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223755 03/12/2026 (a) Patient rights requirements for all hospitals. (1) A hospital shall adopt, implement, and enforce a policy to ensure patients' rights. The written policy shall include: (A) the right of the patient to the hospital's reasonable response to his or her requests and needs for treatment or service, within the hospital's capacity, its stated mission, and applicable law and regulation; (B) the right of the patient to considerate and respectful care: (i) the care of the patient includes consideration of the psychosocial, spiritual, and cultural variables that influence the perceptions of illness; (ii) the care of the dying patient optimizes the comfort and dignity of the patient through: (I) treating primary and secondary symptoms that respond to treatment as desired by the patient or surrogate decision maker; (II) effectively managing pain; and (III) acknowledging the psychosocial and spiritual concerns of the patient and the family regarding dying and the expression of grief by the patient and family; (C) the right of the patient, in collaboration with his or her physician, to make decisions involving his or her health care, to include the following: (i) the right of the patient to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal; and (ii) the right of the patient to formulate advance directives and to appoint a surrogate to make health care decisions on his or her behalf to the extent permitted by law. Advance directives are written instructions recognized under state law relating to the provision of health care when individuals are unable to communicate their wishes regarding medical treatment. The advance directive may be a written document authorizing an agent or surrogate to make decisions on an individual's behalf (a medical power of attorney for health care), a written or verbal statement (a living will), or some other form of instruction recognized under state law specifically addressing the provisions of health care; (I) a hospital shall have in place a mechanism to ascertain the existence of, and, as appropriate, assist in the development of advance directives at the time of the patient's admission; (II) the provision of care shall not be conditioned on the existence of an advance directive; and (III) an advance directive(s) shall be in the patient's medical record and shall be reviewed periodically with the patient or surrogate decision maker if the patient has executed an advance directive; (D) the right of the patient to the information necessary to enable him or her to make treatment decisions that reflect his or her wishes; a policy on informed decision making shall be adopted, implemented and enforced by the medical staff and governing body and shall be consistent with any legal requirements; (E) the right of the patient to receive, at the time of admission, information about the hospital's patient rights policy(ies) and the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care; (F) the right of the patient or the patient's designated representative to participate in the consideration of ethical issues that arise in the care of the patient. The hospital shall have a mechanism for the consideration of ethical issues arising in the care of patients and to provide education to care givers and patients on ethical issues in health care; (G) the right of the patient to be informed of any human experimentation or other research or educational projects affecting his or her care or treatment; (H) the right of the patient, within the limits of law, to personal privacy and confidentiality of information; (I) the right of the patient or the patient's legally designated representative access to the information contained in the patient's medical record, within the limits of the law; and (J) the right of the patient's guardian, next of kin, or legally authorized responsible person to exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient: (i) has been adjudicated incompetent in accordance with the law; (ii) is found by his or her physician to be medically incapable of understanding the proposed treatment or procedure; (iii) is unable to communicate his or her wishes regarding treatment; or (iv) is a minor. (2) The hospital patient's bill of rights shall be prominently and conspicuously posted for display in a public area of the facility that is readily available to patients, residents, employees, and visitors. (b) Additional patient bill of rights requirements for hospitals providing comprehensive medical rehabilitation services. A hospital that provides comprehensive medical rehabilitation services shall comply with subsection (a) of this section and with the following additional provisions applicable to patients who receive such services. (1) The patient's bill of rights shall address the rights of minors and provide that a minor is entitled to: (A) appropriate treatment in the least restrictive setting available; (B) not receive unnecessary or excessive medication; (C) an individualized treatment plan and to participate in the development of the plan; (D) a humane treatment environment that provides reasonable protection from harm and appropriate privacy for personal needs; (E) separation from adult patients; and (F) regular communication between the minor patient and the patient's family. (2) Prior to admission or acceptance for evaluation, a written copy of the patient's bill of rights in the patient's primary language, if possible, shall be given to each patient, and, as appropriate, to the patient's parent, managing conservator, or guardian. (3) The hospital shall ensure that within 24 hours after the patient is admitted to the hospital, the rights described in this subsection are explained to the patient and, if appropriate, to the patient's parent, managing conservator, or guardian in the following manner: (A) orally, in simple, nontechnical terms in the person's primary language, if possible; or (B) other reasonable means calculated to communicate with a person who has an impairment of vision or hearing, if applicable. (4) If the patient cannot comprehend the information because of illness, age, or other factors, or an emergency exists that precludes immediate presentation of the information, or the patient refused to sign the written copy of the patient's bill of rights as provided for in paragraph (5) of this subsection, the presentation of the document shall be witnessed by two members of the hospital staff, and the unsigned patient's bill of rights shall be placed in the clinical record along with a note signed by the witnesses indicating the reasons for their signatures. (5) The hospital shall obtain a signed copy of the patient's bill of rights from each patient, or, if appropriate, from the patient's parent, managing conservator, or guardian. The signed copy shall include a statement that the patient, patient's parent, managing conservator, or guardian has read the document and understands the rights specified in the document. The signed copy shall be made a part of the patient's medical record. (c) Additional patient bill of rights requirements for hospitals providing chemical dependency services. A hospital that provides chemical dependency services shall comply with subsection (a) of this section and with §448.701 of this title (relating to Client Bill of Rights) applicable to patients who receive such services. (d) Additional patient bill of rights requirements for hospitals providing mental health services. A hospital that provides mental health services shall comply with subsection (a) of this section and Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services) applicable to patients who receive such services. (e) Posting requirements for patient bill of rights for hospitals providing comprehensive medical rehabilitation services, chemical dependency services, or mental health services. The hospital shall prominently and conspicuously post for display a copy of the patient's bill of rights in a public area of the hospital that is readily visible to patients, residents, employees, and visitors. The patient bill of rights posted for display shall be in English and in a second language appropriate to the demographic makeup of the community served. Source Note: The provisions of this §505.42 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.42 Patient Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223756 03/12/2026 (a) Posting requirements for reporting a violation of law. In accordance with Health and Safety Code (HSC), §161.134(j) and §161.135(h), each hospital shall prominently and conspicuously post for display in a public area of the hospital that is readily visible to patients, residents, employees, and visitors a statement that nonemployees, employees and staff are protected from discrimination or retaliation for reporting a violation of law. The statement shall be in English and in a second language appropriate to the demographic makeup of the community served. (b) Discrimination relating to employee reporting a violation of law. In accordance with HSC, §161.134(a), and §133.41(o)(2)(I)(i)(III) of this title (relating to Hospital Functions and Services), a hospital may not suspend or terminate the employment of, discipline, or otherwise discriminate against an employee for reporting in good faith to the employee's supervisor, an administrator of the hospital, a state or federal regulatory agency, a national accrediting organization or a law enforcement agency a violation of law, including a violation of the Act or this chapter. For purposes of this subsection, a report is not made in good faith if there is not a reasonable factual or legal basis for making the report. (c) Retaliation relating to nonemployee reporting a violation of law. In accordance with HSC, §161.135(a), a hospital may not retaliate against a person who is not an employee for reporting a violation of law, including a violation of the Act or this chapter. Source Note: The provisions of this §505.43 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.43 Discrimination or Retaliation Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223757 03/12/2026 (a) Definitions. (1) Designated provider--A provider of health care services, selected by a health maintenance organization, a self-insured business corporation, a beneficial society, the Veterans Administration, CHAMPUS, a business corporation, an employee organization, a county, a public hospital, a hospital district, or any other entity to provide health care services to a patient with whom the entity has a contractual, statutory, or regulatory relationship that creates an obligation for the entity to provide the services to the patient. (2) Mandated provider--A person who provides health care services, is selected by a county, public hospital, or hospital district, and agrees to provide health care services to eligible residents. (b) General. (1) The governing body of each hospital shall adopt, implement, and enforce a policy relating to patient transfers that is consistent with this section and contains each of the requirements in subsection (c) of this section. The policies shall identify hospital staff who have the authority to represent the hospital and the physician with regard to the transfer from or receipt of patients into the hospital. (2) The transfer policy shall be adopted by the governing body of the hospital after consultation with the medical staff and shall apply to transfers between hospitals licensed under the Health and Safety Code, Chapters 241 and 577, as well as transfers to hospitals which are exempt from licensing. (3) The policy shall govern transfers not covered by a transfer agreement. (4) The movement of a stable patient from a hospital to another hospital is not considered to be a transfer under this section if it is the understanding and intent of both hospitals that the patient is going to the second hospital only for tests, the patient will not remain overnight at the second hospital, and the patient will return to the first hospital. This paragraph applies only when a patient remains stable during transport to and from hospitals and during testing. (5) The hospital's transfer policy shall include a written operational plan to provide for patient transfer transportation services if the hospital does not provide its own patient transfer transportation services. (6) If possible, each governing body, after consultation with the medical staff, shall implement its transfer policy by adopting transfer agreements with other hospitals in accordance with §133.61 of this title (relating to Hospital Patient Transfer Agreements). (7) A public hospital or a hospital district shall accept the transfer of its eligible residents if the public hospital or hospital district has appropriate facilities, services, and staff available for providing care to the patient. (8) The hospital's policy shall recognize and comply with the requirements of the Indigent Health Care and Treatment Act, Health and Safety Code (HSC), §§61.030 - 61.032 and §§61.057 - 61.059 (Mandated Providers) since those requirements may apply to a patient. (9) The hospital's policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations which may exist concerning a patient and a designated provider. (10) The hospital's policy shall require that all reasonable steps are taken to secure the written informed consent of a patient, or of a person acting on a patient's behalf, when refusing a transfer or related examination and treatment. Reasonable steps include: (A) a factual explanation of the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring hospital; (B) a factual explanation of any increased risks to the patient from not effecting the transfer; and (C) a factual explanation of the medical benefits reasonably expected from the provision of appropriate treatment at another hospital. (D) The informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation or transfer shall be documented and signed if possible by the patient or by a person acting on the patient's behalf, dated and witnessed by the attending physician or hospital employee, and placed in the patient's medical record. (11) The hospital's policy shall recognize the right of an individual to request a transfer into the care of a physician and a hospital of the individual's own choosing. (12) Transfer of patients may occur routinely or as part of a regionalized plan for obtaining optimal care for patients at a more appropriate or specialized facility. (c) Requirements for transfer of patients between hospitals. (1) Discrimination. Except as is specifically provided in subsection (b)(8) and (9) of this section, relating, respectively, to mandated providers and designated providers, the hospital policy shall provide that the transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status or ability to pay. (2) Disclosure. The hospital's policy shall recognize the right of an individual to request transfer into the care of a physician and a hospital of his own choosing; however, if a patient requests or consents to transfer for economic reasons and the patient's choice is predicated upon or influenced by representations made by the transferring physician or hospital administration regarding the availability of medical care and hospital services at a reduced cost or no cost to the patient, the physician or hospital administration shall fully disclose to the patient the eligibility requirements established by the patient's chosen physician or hospital. (3) Patient. A patient is an individual: (A) seeking medical treatment who may or may not be under the immediate supervision of a personal attending physician, has one or more undiagnosed or diagnosed medical conditions, and who, within reasonable medical probability, requires immediate or continuing hospital services and medical care; or (B) admitted to the hospital as a patient. (4) Patient evaluation. The hospital's policy shall provide that each patient who arrives at the hospital is: (A) evaluated by a physician who is present in the hospital at the time the patient presents or is presented or evaluated by a physician on-call who is: (i) physically able to reach the patient within 30 minutes after being informed that a patient is present at the hospital who requires immediate medical attention; or (ii) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant or other qualified medical personnel as established by the governing body at the hospital under orders to assess and report the patient's condition to the physician; and (B) personally examined and evaluated by the physician before an attempt to transfer is made; however: (i) after receiving a report on the patient's condition from the hospital's registered nurse, physician assistant or other qualified medical personnel as established by the governing body by telephone or radio, if the physician on-call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on-call may order the transfer by telephone or radio; and (ii) physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient's medical record, signed by the registered nurse, physician assistant or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. The patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to paragraph (8) of this subsection. (5) Hospital personnel, written protocols, standing delegation orders, eligibility and payment information. The policy of the transferring and receiving hospital shall provide that licensed nurses and other qualified personnel are available and on duty to assist with patient transfers and to provide accurate information regarding eligibility and payment practices. The policy shall provide that written protocols or standing delegation orders are in place to guide hospital personnel when a patient requires transfer to another hospital. (6) Special requirements related to the transfer of patients who have emergency medical conditions. (A) If a patient at a hospital has an emergency medical condition which has not been stabilized or when stabilization of the patient's vital signs is not possible because the hospital or emergency treatment area does not have the appropriate equipment or personnel to correct the underlying process (e.g. children's hospitals, thoracic surgeon on staff, or cardiopulmonary bypass capability), evaluation and treatment shall be performed and transfer shall be carried out as quickly as possible. (B) The hospital's policy shall provide that the hospital may not transfer a patient with an emergency medical condition which has not been stabilized unless: (i) the individual (or a legally responsible person acting on the individual's behalf), after being informed of the hospital's obligations under this section and of the risk of transfer, requests the transfer, in writing and indicates the reasons for the request, as well as that he or she is aware of the risks and benefits of the transfer; (ii) a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer; or (iii) if the physician who made the determination to transfer a patient with an emergency condition is not physically present in the emergency treatment area at the time of transfer, a qualified medical person may sign a certification described in clause (ii) of this subparagraph after consultation with the physician. The physician shall countersign the physician certification within a reasonable period of time. (C) Except as is specifically provided in subsection (b)(8) and (9) of this section, the hospital's policy shall provide that the transfer of patients who have emergency medical conditions, as determined by a physician, shall be undertaken for medical reasons only. The hospital must provide medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child. (D) A hospital that has specialized capabilities or facilities (including, but not limited to such facilities as burn units, shock-trauma units, neonatal intensive care units, or, with respect to rural areas, regional referral centers) may not refuse to accept from a referring hospital an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. Except as expressly permitted in clauses (i) and (ii) of this subparagraph, a hospital's policy shall provide for the receipt of patients who have an emergency medical condition from other hospitals so that upon notification from a transferring physician or a transferring hospital prior to transfer, the receiving hospital shall respond to the transferring hospital and transferring physician with the status of the transfer request within 30 minutes and either accept or refuse the transfer. The time period begins to run at the time a member of the staff of the receiving hospital receives the call initiating the request to transfer. (i) The receiving hospital's policy may permit response to the transferring hospital and transferring physician within a period of time in excess of 30 minutes but no longer than one hour if there are extenuating circumstances for the delay. If the transfer is accepted, the reason for the delay shall be documented on the memorandum of transfer. (ii) The response time may be extended before the expiration of the initial 30 minutes period by agreement among the transferring hospital and transferring physician and the receiving hospital and receiving physician. If the transfer is accepted, the agreed extension shall be documented in the memorandum of transfer. (7) Physician's duties and standard of care. (A) The policy shall provide that the transferring physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer. (B) The policy shall provide that the transferring physician shall determine and order the utilization of appropriate personnel and equipment for the transfer. (C) The policy shall provide that in determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer. (D) The policy shall provide that except as allowed under paragraph (4)(B) of this subsection, prior to each patient transfer, the physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used. (E) The policy shall provide that prior to transfer, the transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the patient have accepted responsibility for the patient's medical treatment and hospital care. (8) Record review for standard of care. The hospital's policy shall provide that the hospital's medical staff review appropriate records of patients transferred from the hospital to determine that the appropriate standard of care has been met. (9) Medical record. (A) The hospital's policy shall provide that a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient be forwarded to the receiving physician and receiving hospital with the patient. If all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the records shall be forwarded to the receiving physician and hospital as soon as possible. (B) The medical record shall contain at a minimum: (i) a brief description of the patient's medical history and physical examination; (ii) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer; (iii) the reason for the transfer; (iv) the results of all diagnostic tests, such as laboratory tests; (v) pertinent X-ray films and reports; and (vi) any other pertinent information. (10) Memorandum of transfer. (A) The hospital's policy shall provide that a memorandum of transfer be completed for every patient who is transferred. (B) The memorandum shall contain the following information: (i) the patient's full name, if known; (ii) the patient's race, religion, national origin, age, sex, physical handicap, if known; (iii) the patient's address and next of kin, address, and phone number if known; (iv) the names, telephone numbers and addresses of the transferring and receiving physicians; (v) the names, addresses, and telephone numbers of the transferring and receiving hospitals; (vi) the time and date on which the patient first presented or was presented to the transferring physician and transferring hospital; (vii) the time and date on which the transferring physician secured a receiving physician; (viii) the name, date, and time hospital administration was contacted in the receiving hospital; (ix) signature, time, and title of the transferring hospital administration who contacted the receiving hospital; (x) the certification required by paragraph (6)(B)(ii) of this subsection, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form); (xi) the time and date on which the receiving physician assumed responsibility for the patient; (xii) the time and date on which the patient arrived at the receiving hospital; (xiii) signature and date of receiving hospital administration; (xiv) type of vehicle and company used; (xv) type of equipment and personnel needed in transfers; (xvi) name and city of hospital to which patient was transported; (xvii) diagnosis by transferring physician; and (xviii) attachments by transferring hospital. (C) The receipt of the memorandum of transfer shall be acknowledged in writing by the receiving hospital administration and receiving physician. (D) A copy of the memorandum of transfer shall be retained by the transferring and receiving hospitals. The memorandum shall be filed separately from the patient's medical record and in a manner which will facilitate its inspection by the department. All memorandum of transfer forms filed separately shall be retained for five years. A copy of the memorandum of transfer may also be filed with the patient's medical record. (d) Violations. A hospital violates the Act and this section if: (1) the hospital fails to comply with the requirements of this section; or (2) the governing body fails or refuses to: (A) adopt a transfer policy which is consistent with this section and contains each of the requirements in subsection (c) of this section; (B) adopt a memorandum of transfer form which meets the minimum requirements for content contained in this section; or (C) enforce its transfer policy and the use of the memorandum of transfer. Source Note: The provisions of this §505.44 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.44 Hospital Patient Transfer Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223758 03/12/2026 (a) Determination of death and autopsy reports. The hospital shall adopt, implement, and enforce protocols to be used in determining death and for filing autopsy reports which comply with Texas Health and Safety Code (HSC) Chapter 671.(b) Organ and tissue donors. The hospital shall adopt, implement, and enforce a written protocol to identify potential organ and tissue donors which complies with HSC Chapter 692A. The hospital shall make its protocol available to the public during the hospital's normal business hours.(1) The hospital's protocol shall include all requirements in HSC §692A.015.(2) A hospital which performs organ transplants shall be a member of the Organ Procurement and Transplantation Network in accordance with 42 United States Code §274.(c) Discrimination prohibited. A licensed hospital shall not discriminate based on a patient's disability and shall comply with HSC Chapter 161, Subchapter S.(d) All-hazard disaster preparedness.(1) Definitions.(A) Adult intensive care unit (ICU)--Can support critically ill or injured patients, including ventilator support.(B) Burn or burn ICU--Either approved by the American Burn Association or self-designated. (These beds should not be included in other ICU bed counts.)(C) Medical/surgical--Also thought of as "ward" beds.(D) Negative pressure/isolation--Beds provided with negative airflow, providing respiratory isolation. Note: This value may represent available beds included in the counts of other types.(E) Operating rooms--An operating room that is equipped and staffed and could be made available for patient care in a short period.(F) Pediatric ICU--The same as adult ICU, but for patients 17 years and younger.(G) Pediatrics--Ward medical/surgical beds for patients 17 years and younger.(H) Physically available beds--Beds that are licensed, physically set up, and available for use. These are beds regularly maintained in the hospital for the use of patients, which furnish accommodations with supporting services (such as food, laundry, and housekeeping). These beds may or may not be staffed but are physically available.(I) Psychiatric--Ward beds on a closed or locked psychiatric unit or ward beds where a patient will be attended by a sitter.(J) Staffed beds--Beds that are licensed and physically available for which staff members are available to attend to the patient who occupies the bed. Staffed beds include those that are occupied and those that are vacant.(K) Vacant/available beds--Beds that are vacant and to which patients can be transported immediately. These must include supporting space, equipment, medical material, ancillary and support services, and staff to operate under normal circumstances. These beds are licensed, physically available, and have staff on hand to attend to the patient who occupies the bed.(2) A hospital shall adopt, implement, and enforce a written plan for all-hazard, natural or man-made, disaster preparedness for effective preparedness, mitigation, response, and recovery from disasters.(3) The plan, which may be subject to review and approval by the Texas Health and Human Services Commission (HHSC), shall be sent to the local disaster management authority.(4) The plan shall:(A) be developed through a joint effort of the hospital governing body, administration, medical staff, hospital personnel and emergency medical services partners;(B) include the applicable information contained in the:(i) National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition, Chapter 12, published by the National Fire Protection Association; and(ii) the State of Texas Emergency Management Plan, which is available from the city or county emergency management coordinator; (C) contain the names and contact numbers of city and county emergency management officers and the hospital water supplier;(D) be exercised at least annually and in conjunction with state and local exercises;(E) include the methodology for notifying the hospital personnel and the local disaster management authority of an event that will significantly impact hospital operations;(F) include evidence that the hospital has communicated prospectively with the local utility and phone companies regarding the need for the hospital to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly;(G) include the use of a Texas Department of State Health Services (DSHS) approved process to update bed availability, as follows:(i) as requested by DSHS during a public health emergency or state declared disaster; and(ii) for the physically available beds and staffed beds that are vacant/available beds for the following bed types:(I) adult ICU;(II) burn or burn ICU;(III) medical/surgical;(IV) negative pressure/isolation;(V) operating rooms;(VI) pediatric ICU;(VII) pediatrics; and(VIII) psychiatric;(iii) for emergency department divert status;(iv) for decontamination facility available; and(v) for ventilators available;(H) include at a minimum:(i) a component for the reception, treatment, and disposition of casualties that can be used in the event that a disaster situation requires the hospital to accept multiple patients, which shall include at a minimum:(I) process, developed in conjunction with appropriate agencies, to allow essential healthcare workers and personnel to safely access their delivery care sites;(II) procedures for the appropriate provision of personal protection equipment for and appropriate immunization of staff, volunteers, and staff families; and(III) plan to provide food and shelter for staff and volunteers as needed throughout the duration of response;(ii) an evacuation component that can be engaged in any emergency situation necessitating either a full or partial evacuation of the hospital, which shall address at a minimum:(I) activation, including who makes the decision to activate and how it is activated;(II) when within control of the hospital, patient evacuation destination, including protocol to ensure that the patient destination is compatible to patient acuity and health care needs, plan for the order of removal of patients and planned route of movement, train and drill staff on the traffic flow and the movement of patients to a staging area, and room evacuation protocol;(III) family or responsible party notification, including the procedure to notify patient emergency contacts of an evacuation and the patient's destination; and(IV) transport of records and supplies, including the protocol for the transfer of patient specific medications and records to the receiving facility, which shall include at a minimum:(-a-) the patient's most recent physician's assessment;(-b-) order sheet;(-c-) medication administration record (MAR);(-d-) patient history with physical documentation; and(-e-) a weather-proof patient identification wrist band (or equivalent identification), which must be intact on all patients. (5) Hospitals participating in an exercise or responding to a real-life event under paragraph (4)(D) of this subsection shall develop an after-action report (AAR) within 60 days. The hospital shall retain the AARs for at least three years and make them available for review by the local emergency management authority and HHSC.(e) Voluntary paternity establishment services. A hospital that handles the birth of newborns must provide voluntary paternity establishment services in accordance with:(1) HSC §192.012; and(2) the rules of the Office of the Attorney General found at 1 Texas Administrative Code Chapter 55, Subchapter J (relating to Voluntary Paternity Acknowledgment Process).(f) Harassment and abuse. A hospital shall adopt, implement, and enforce a written policy for identifying and addressing instances of alleged verbal or physical abuse or harassment of hospital employees or contracted personnel by other hospital employees or contracted personnel or by a health care provider who has clinical privileges at the hospital.(g) Information for parents of newborn children. A hospital that provides prenatal care to a pregnant woman during gestation or at delivery of an infant, shall adopt, implement, and enforce written policies to ensure compliance with HSC §161.501.(1) The policy shall require that the woman and the father of the infant, if possible, or another adult caregiver for the infant, be provided with a resource pamphlet which includes:(A) a list of the names, addresses, and phone numbers of professional organizations providing counseling and assistance relating to postpartum depression and other emotional trauma associated with pregnancy and parenting;(B) information regarding the prevention of shaken baby syndrome, as specified under HSC §161.507(a)(1)(B)(i) - (iv);(C) a list of diseases for which a child is required by state law to be immunized and the appropriate schedule for the administration of those immunizations;(D) the appropriate schedule for follow-up procedure for newborn screening;(E) information regarding sudden infant death syndrome, including current recommendations for infant sleeping conditions to lower the risk of sudden infant death syndrome;(F) educational information in both English and Spanish on:(i) pertussis disease and the availability of a vaccine to protect against pertussis, including information on the Centers for Disease Control and Prevention recommendation that parents receive Tdap during the postpartum period to protect newborns from the transmission of pertussis; and(ii) the incidence of cytomegalovirus, birth defects caused by congenital cytomegalovirus, and available resources for the family of an infant born with congenital cytomegalovirus; and(G) the danger of heatstroke for a child left unattended in a motor vehicle.(2) If the woman is a recipient of medical assistance under Texas Human Resources Code Chapter 32, the policy must require the hospital to provide the woman and the father of the infant, if possible, or another adult caregiver with a resource guide that includes information in both English and Spanish relating to the development, health, and safety of a child from birth until age five, including information relating to:(A) selecting and interacting with a primary health care practitioner and establishing a "medical home" for the child;(B) dental care;(C) effective parenting;(D) child safety;(E) the importance of reading to a child;(F) expected developmental milestones;(G) health care resources available in the state;(H) selecting appropriate child care; and(I) other resources available in the state;(3) The policy shall include a requirement that it be documented in the woman's record that the information was provided, and that the documentation be maintained for at least five years.(h) Abortion. A hospital that performs abortions shall adopt, implement, and enforce policies to:(1) ensure compliance with HSC Chapter 171;(2) ensure compliance with Texas Occupations Code §164.052(a)(19). (i) Influenza and pneumococcal vaccine for elderly persons. The hospital shall adopt, implement, and enforce a policy for providing influenza and pneumococcal vaccines for elderly persons. The policy shall:(1) establish that an elderly person, defined as 65 years of age older, who is admitted to the hospital for a period of 24 hours or more, is informed of the availability of the influenza and pneumococcal vaccines, and, if they request the vaccine, is assessed to determine if receipt of the vaccine is in their best interest; and(2) include provisions that if the vaccines requested by the elderly person under paragraph (1) of this subsection are determined appropriate by the physician or other qualified medical personnel, the elderly person shall receive the vaccines prior to discharge from the hospital;(3) include provisions that the influenza vaccine shall be made available in October and November, and if available, December, and pneumococcal vaccine shall be made available throughout the year;(4) require that the person administering the vaccine ask the elderly patient if they are currently vaccinated against influenza or pneumococcal disease, assess potential contraindications, and then, if appropriate, administer the vaccine under approved hospital protocols; and(5) address required documentation of the vaccination in the patient medical record.(6) HHSC may waive requirements related to the administration of the vaccines based on established shortages of the vaccines.(j) Human trafficking signage required. A licensed hospital shall comply with human trafficking signage requirements in accordance with HSC §241.011.(k) Prohibited discharge of patients to certain group-centered facilities. A hospital shall comply with HSC §256.003.(1) Except as provided by paragraph (2) of this subsection, a hospital may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility only if the person operating the group-centered facility holds a license or permit issued in accordance with applicable state law.(2) A hospital may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility operated by a person who does not hold a license or permit issued in accordance with applicable state law only if:(A) there is no group-centered facility operated in the county where the patient is discharged that is operated by a person holding the applicable license or permit; or(B) the patient voluntarily chooses to reside in the group-centered facility operated by an unlicensed or unpermitted person.(l) Basic sexual assault forensic evidence collection training. A hospital shall develop, implement, and enforce policies and procedures to ensure a person who performs a forensic medical examination on a survivor of sexual assault completes the required forensic evidence collection training or equivalent education required by HSC §323.0045.(m) Basic sexual assault response policy and training. A hospital shall develop, implement, and enforce policies and procedures to provide basic sexual assault response training that meets the requirements under HSC §323.0046 to facility employees who provide patient admission functions, patient-related administrative support functions, or direct patient care. Source Note: The provisions of this §505.45 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective September 14, 2014, 39 TexReg 7140; amended to be effective January 6, 2022, 46 TexReg 9304; amended to be effective December 31, 2024, 49 TexReg 10647; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.45 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223759 03/12/2026 (a) Itemized statements. (1) A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with Texas Health and Safety Code (HSC) §311.002. (2) A hospital shall comply with the itemized bill requirements under HSC §185.002.(b) Audits of billing. A hospital shall adopt, implement, and enforce a policy to ensure that the hospital complies with HSC §311.0025(a). (c) Balance billing. (1) A hospital may not violate a law that prohibits the hospital from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition. (2) A hospital shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the hospital. (d) Complaint investigation procedures. (1) A complaint submitted to the Texas Health and Human Services Commission's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted. (2) Upon receiving a complaint warranting an investigation, Texas Health and Human Services Commission (HHSC) shall send the complaint to the hospital requesting the hospital to conduct an internal investigation. Within 30 days of the hospital's receipt of the complaint, the hospital shall submit to HHSC: (A) a report outlining the hospital's investigative process; (B) the resolution or conclusions reached by the hospital with the patient, third party payor or complainant; and (C) corrections, if any, in the hospital's policies or protocols which were made as a result of its investigative findings. (3) In addition to the hospital's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the hospital. (4) HHSC shall inform in writing a complainant who identifies himself by name and address: (A) of the receipt of the complaint; (B) if the complainant's allegations are potential violations of the Act or this chapter warranting an investigation; (C) whether the complaint will be investigated by HHSC; (D) if the complaint was referred to the hospital for internal investigation; (E) whether and to whom the complaint will be referred; (F) of the results of the hospital's investigation and the hospital's resolution with the complainant; and (G) of HHSC's findings if an on-site audit investigation was conducted. (5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments which were not provided to the appropriate licensing agency. Source Note: The provisions of this §505.46 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective April 15, 2021, 46 TexReg 2421; amended to be effective August 18, 2024, 49 TexReg 6216; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.46 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223760 03/12/2026 (a) Reporting. Incidents of abuse, neglect, exploitation, or illegal, unethical or unprofessional conduct as those terms are defined in subsections (b) and (c) of this section shall be reported to the Texas Health and Human Services Commission (HHSC) as provided in subsections (b) and (c)(3) of this section.(b) Abuse or neglect of a child, and abuse, neglect, or exploitation of an elderly or disabled person. The following definitions apply only to this subsection.(1) Abuse or neglect of a child, as defined in §1.204(a) and (b) of this title (relating to Abuse, Neglect, or Exploitation Defined).(2) Abuse, neglect, or exploitation of an elderly or disabled person, as defined in §1.204(a) - (c) of this title.(c) Abuse and neglect of individuals with mental illness, and illegal, unethical, and unprofessional conduct. The requirements of this subsection are in addition to the requirements of subsection (b) of this section.(1) Definitions. The following definitions are in accordance with Texas Health and Safety Code (HSC) §161.131 and apply only to this subsection.(A) Abuse--(i) Abuse (as the term is defined in United States Code Title 42 (42 USC) Chapter 114 (relating to Protection and Advocacy for Individuals with Mental Illness) is any act or failure to act by an employee of a facility rendering care or treatment which was performed, or which was failed to be performed, knowingly, recklessly, or intentionally, and which caused, or may have caused, injury or death to an individual with mental illness, and includes acts such as:(I) the rape or sexual assault of an individual with mental illness;(II) the striking of an individual with mental illness;(III) the use of excessive force when placing an individual with mental illness in bodily restraints; and (IV) the use of bodily or chemical restraints on an individual with mental illness which is not in compliance with federal and state laws and regulations.(ii) In accordance with HSC §161.132(j), abuse also includes coercive or restrictive actions that are illegal or not justified by the patient's condition and that are in response to the patient's request for discharge or refusal of medication, therapy or treatment.(B) Illegal conduct--Illegal conduct (as the term is defined in HSC §161.131(4)) is conduct prohibited by law.(C) Neglect--Neglect (as the term is defined in 42 USC §10801 et seq.) is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriately trained staff.(D) Unethical conduct--Unethical conduct (as the term is defined in HSC §161.131(11)) is conduct prohibited by the ethical standards adopted by state or national professional organizations for their respective professions or by rules established by the state licensing agency for the respective profession.(E) Unprofessional conduct--Unprofessional conduct (as the term is defined in HSC §161.131(12)) is conduct prohibited under rules adopted by the state licensing agency for the respective profession.(2) Posting requirements. A hospital shall prominently and conspicuously post for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors a statement of the duty to report abuse and neglect, or illegal, unethical, or unprofessional conduct in accordance with HSC §161.132(e). The statement shall be in English and in a second language appropriate to the demographic makeup of the community served and contain the current toll-free telephone number for submitting a complaint to HHSC as specified on the HHSC website.(3) Reporting responsibility.(A) Reporting abuse and neglect. A person, including an employee, volunteer, or other person associated with the hospital who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the hospital who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect (as those terms are defined in this subsection) by any person shall as soon as possible report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency in accordance with HSC §161.132(a).(B) Reporting illegal, unprofessional, or unethical conduct. An employee of or other person associated with a hospital, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the hospital or an employee or health care professional associated with the hospital, has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the hospital or mental health or chemical dependency services provided in the hospital shall as soon as possible report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency in accordance with HSC §161.132(b). (4) Training requirements. A hospital that provides comprehensive medical rehabilitation, mental health, or substance use services shall annually provide as a condition of continued licensure a minimum of eight hours of in-service training designed to assist employees and health care professionals associated with the hospital in identifying patient abuse or neglect and illegal, unprofessional, or unethical conduct by or in the hospital and establish a means for monitoring compliance with the requirement.(d) Investigations. A complaint under this subsection will be investigated or referred by HHSC as follows.(1) Allegations under subsection (b) of this section will be investigated in accordance with §1.205 of this title (relating to Reports and Investigations) and §1.206 of this title (relating to Completion of Investigation).(2) Allegations under subsection (c) of this section will be investigated in accordance with §133.103 of this chapter (relating to Complaint Investigations). Allegations concerning a health care professional's failure to report abuse and neglect or illegal, unprofessional, or unethical conduct will not be investigated by HHSC but will be referred to the individual's licensing board for appropriate disciplinary action.(3) Allegations under both subsections (b) and (c) will be investigated in accordance with §1.205 and §1.206 of this title except as noted in paragraph (2) of this subsection concerning a health care professional's failure to report.(e) Submission of complaints. A complaint made under this section may be submitted in writing or verbally to HHSC. (f) Notification.(1) For complaints under subsection (b) of this section, HHSC shall provide notification according to the following.(A) HHSC shall notify the reporter, if known, in writing of the outcome of the completed investigation.(B) HHSC shall notify the alleged victim, and the alleged victim's parent or guardian if a minor, in writing of the outcome of the completed investigation.(2) For complaints under subsection (c) of this section, HHSC informs, in writing, the complainant who identifies themselves by name and address of the following:(A) the receipt of the complaint;(B) if the complainant's allegations are potential violations of this chapter warranting an investigation;(C) whether the complaint will be investigated by HHSC;(D) whether and to whom the complaint will be referred; and(E) the findings of the complaint investigation.(g) HHSC reporting and referral.(1) Reporting health care professional to licensing board.(A) In cases of abuse, neglect, or exploitation, as those terms are defined in subsection (b) of this section, by a licensed, certified, or registered health care professional, HHSC may forward a copy of the completed investigative report to the state agency that licenses, certifies, or registers the health care professional. Any information which might reveal the identity of the reporter or any other patients of the hospital must be blacked out or deidentified.(B) A health care professional who fails to report abuse and neglect or illegal, unprofessional, or unethical conduct as required by subsection (c)(3) of this section may be referred by HHSC to the individual's licensing board for appropriate disciplinary action.(2) Sexual exploitation reporting requirements. In addition to the reporting requirements described in subsection (c)(3) of this section, a mental health services provider must report suspected sexual exploitation in accordance with Texas Civil Practice and Remedies Code §81.006.(3) Referral follow-up. HHSC shall request a report from each referral agency of the action taken by the agency six months after the referral.(4) Referral of complaints. A complaint containing allegations which are not a violation of HSC Chapter 241 or this chapter will not be investigated by HHSC but shall be referred to law enforcement agencies or other agencies, as appropriate. Source Note: The provisions of this §505.47 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.47 Abuse and Neglect Issues https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223761 03/12/2026 (a) A hospital shall submit reports to the Texas Department of State Health Services (DSHS) in accordance with the reporting requirements in Texas Health and Safety Code (HSC) §98.103 and §98.1045. (b) A hospital that donates human fetal tissue under HSC Chapter 173 shall submit an annual report to the Texas Health and Human Services Commission (HHSC) that includes for each donation the specific type of fetal tissue donated and the accredited public or private institution of higher learning that received the donation. The hospital shall submit the annual report no later than January 31st of the subsequent year. (c) A hospital that diagnoses or treats an abortion complication, as defined in §139.2 of this title (relating to Definitions), shall comply with §139.5 of this title (relating to Additional Reporting Requirements).(d) Pursuant to HSC §166.054, a hospital shall complete and submit to HHSC the Ethics or Medical Committee Reporting Form, which is located on the HHSC website, no later than the 180th day after the hospital provides written notice under HSC §166.046(b)(1). The Ethics or Medical Committee Reporting Form collects the following information:(1) the number of days that elapsed from the patient's admission to the hospital to the date notice was provided under HSC §166.046(b)(1); (2) whether the ethics or medical committee met to review the case under HSC §166.046 and, if the committee did meet, the number of days that elapsed from the date notice was provided under HSC §166.046(b)(1) to the date the meeting was held;(3) whether the patient was:(A) transferred to a physician within the same hospital who was willing to comply with the patient's advance directive or a health care or treatment decision made by or on behalf of the patient;(B) transferred to a different health care facility; or(C) discharged from the hospital to a private residence or other setting that is not a health care facility;(4) whether the patient died while receiving life-sustaining treatment at the hospital;(5) whether life-sustaining treatment was withheld or withdrawn from the patient at the hospital after expiration of the time period described by HSC §166.046(e) and, if so, the disposition of the patient after the withholding or withdrawal of life-sustaining treatment at the hospital, as selected from the following categories:(A) the patient died at the hospital;(B) the patient is currently a patient at the hospital;(C) the patient was transferred to a different health care facility; or(D) the patient was discharged from the facility to a private residence or other setting that is not a health care facility;(6) the age group of the patient selected from the following categories:(A) 17 years of age or younger;(B) 18 years of age or older and younger than 66 years of age; or(C) 66 years of age or older;(7) the health insurance coverage status of the patient selected from the following categories:(A) private health insurance coverage;(B) public health plan coverage; or(C) uninsured;(8) the patient's sex;(9) the patient's race;(10) whether the hospital was notified of and able to reasonably verify any public disclosure of the contact information for the hospital's personnel, physicians or health care professionals who provide care at the hospital, or members of the ethics or medical committee in connection with the patient's stay at the hospital; and(11) whether the hospital was notified of and able to reasonably verify any public disclosure by hospital personnel of the contact information for the patient's immediate family members or the person responsible for the patient's health care decisions in connection with the patient's stay at the hospital.(e) In accordance with HSC §166.054(c)-(e), HHSC publishes on its website an aggregate report of information submitted under subsection (d) of this section in the preceding year by April 1st of each year.(f) Pursuant to HSC §166.054(g), information collected or submitted under subsection (d) of this section:(1) is not admissible in a civil or criminal proceeding in which a physician, health care professional acting under the direction of a physician, or health care facility is a defendant;(2) may not be used in relation to any disciplinary action by a licensing or regulatory agency with oversight over a physician, health care professional acting under the direction of a physician, or health care facility; and(3) is not public information or subject to disclosure under Texas Government Code Chapter 552, except as permitted by Texas Government Code §552.008. Source Note: The provisions of this §505.49 adopted to be effective December 9, 2010, 35 TexReg 10716; amended to be effective September 30, 2018, 43 TexReg 6287; amended to be effective November 1, 2024, 49 TexReg 8582; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.49 Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223762 03/12/2026 (a) Definitions. The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Aftercare--Assistance provided by a designated caregiver to a person after that person's discharge from a hospital, as described by Health and Safety Code, chapter 317, and this section. (2) Designated caregiver--An individual designated by a patient, including a relative, partner, friend, or neighbor, who:(A) is at least 18 years of age;(B) has a significant relationship with the patient; and(C) will provide aftercare to the patient.(3) Surrogate decision-maker--An individual with decision-making capacity who is identified as the person who has authority to consent to medical treatment on behalf of an incapacitated patient in need of medical treatment.(b) The hospital shall provide a patient who is at least 18 years of age, a patient who is younger than 18 years of age who has had the disabilities of minority removed, the patient's legal guardian, or the patient's surrogate decision-maker the opportunity to designate a caregiver for receipt of aftercare instructions. (c) The hospital shall provide the opportunity to designate a caregiver on admission of the patient or before the patient is discharged or transferred to another facility.(d) If the patient, the patient's legal guardian, or the patient's surrogate decision-maker declines to designate a caregiver, the hospital shall note the fact in the patient's medical record. (e) If the patient, the patient's legal guardian, or the patient's surrogate decision-maker designates a caregiver, the hospital shall:(1) document in the patient's medical record the designated caregiver's name, telephone number, address, and relationship to the patient; and(2) request written authorization to disclose health care information to the designated caregiver.(f) If written authorization to disclose health care information to the designated caregiver is obtained, the hospital shall:(1) as soon as possible before the patient's discharge or transfer, notify the designated caregiver of this fact;(2) if the hospital is unable to contact the designated caregiver before the patient's discharge or transfer, note this in the patient's medical record;(3) before the patient's discharge, provide the designated caregiver a written discharge plan that describes the patient's aftercare needs that includes:(A) the designated caregiver's name, contact information, and relationship to the patient;(B) a description of the aftercare tasks that the patient requires, written in a culturally competent manner; and(C) the contact information for any health care resources necessary to meet the patient's aftercare needs; (4) before the patient's discharge to any setting in which health care services are not regularly provided to others, provide the designated caregiver instruction and training as necessary for the caregiver to perform aftercare tasks, including the opportunity to ask follow-up questions.(g) The patient, the patient's legal guardian, or the patient's surrogate decision-maker may change the designated caregiver at any time and the hospital shall note the change in the patient's medical record.(h) This section may not be construed to interfere with, delay, or otherwise affect any medical care provided to the patient or the discharge or transfer of the patient. Source Note: The provisions of this §505.50 adopted to be effective July 23, 2019, 44 TexReg 3635; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.50 Caregiver Designation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223763 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Public health emergency--A state of disaster or local disaster declared under Texas Government Code Chapter 418 or a public health disaster as defined by Texas Health and Safety Code (HSC) §81.003.(2) Qualifying official disaster order--An order, proclamation, or other instrument issued by the Governor, another official of this state, or the governing body or an official of a political subdivision of this state declaring a disaster that has infectious disease as the basis for the declared disaster.(3) Qualifying period of disaster--The period of time the area in which a hospital is located is declared to be a disaster area by a qualifying official disaster order.(4) Religious counselor--An individual acting substantially in a pastoral or religious capacity to provide spiritual counsel to other individuals.(b) In accordance with HSC §260C.002 (relating to In-Person Visitation with Religious Counselor), except as provided by subsections (c) and (d) of this section, a hospital may not prohibit a patient from receiving in-person visitation with a religious counselor during a public health emergency upon the request of the patient or, if the patient is incapacitated, upon the request of the patient's legally authorized representative, including a family member of the patient.(c) A hospital may prohibit in-person visitation with a religious counselor during a public health emergency if federal law or a federal agency requires the hospital to prohibit in-person visitation during that period.(d) To the extent that hospital establishes policies and procedures for in-person religious counselor visitation during a public health emergency, these policies and procedures shall comply with the following:(1) The policies and procedures shall establish minimum health and safety requirements for in-person visitation with religious counselors consistent with:(A) state, local, and federal directives and guidance regarding the public health emergency;(B) public health emergency and disaster preparedness plans; and(C) other policies adopted by the hospital, including the hospital's general visitation policy and infection control policy.(2) The policies and procedures shall address considerations for patients who are receiving end-of-life care.(3) The policies and procedures may contain reasonable time, place, and manner restrictions on in-person visitation with religious counselors to mitigate the spread of a communicable disease or address a patient's medical condition.(4) The policies and procedures may condition in-person visitation with religious counselors on the counselor's compliance with guidelines, policies, and procedures established under this subsection. (e) In accordance with HSC §241.012 (relating to In-Person Hospital Visitation During Period of Disaster), a hospital may not, during a qualifying period of disaster prohibit in-person visitation with a patient receiving care or treatment at the hospital unless federal law or a federal agency requires the hospital to prohibit in-person visitation during that period.(f) Notwithstanding subsection (e) of this section, a hospital may, during a qualifying period of disaster:(1) restrict the number of visitors a patient receiving care or treatment at the hospital may receive to not fewer than one, except for religious counselors visiting under subsection (b) of this section;(2) require a visitor, including a religious counselor visiting under subsection (b) of this section, to:(A) complete a health screening before entering the hospital; and(B) wear personal protective equipment at all times while visiting a patient at the hospital; and(3) deny entry to or remove from the hospital's premises a visitor, including a religious counselor visiting under subsection (b) of this section, who fails or refuses to:(A) submit to or meet the requirements of a health screening administered by the hospital; or(B) wear personal protective equipment that meets the hospital's infection control and safety requirements in the manner prescribed by the hospital.(g) A health screening administered by a hospital under this section must be conducted in a manner that, at a minimum, complies with:(1) hospital policy; and(2) if applicable, guidance or directives issued by the Texas Health and Human Services Commission, the Centers for Medicare and Medicaid Services, or another agency with regulatory authority over the hospital.(h) This section does not require a hospital to:(1) provide a specific type of personal protective equipment to a visitor, including a religious counselor visiting under subsection (b) of this section; or(2) except for a religious counselor visiting under subsection (b) of this section, allow in-person visitation with a patient receiving care or treatment at the hospital if an attending physician determines and documents in the patient's medical record that in-person visitation with that patient may lead to the transmission of an infectious agent that poses a serious community health risk.(i) A determination made by an attending physician under subsection (h) of this section is valid for not more than five days after the date the determination is made unless renewed by an attending physician.(j) If a visitor to a hospital is denied in-person visitation with a patient receiving care or treatment at a hospital because of a determination made by an attending physician under subsection (h) of this section, the hospital shall:(1) provide each day a written or oral update of the patient's condition to the visitor if the visitor:(A) is authorized by the patient to receive relevant health information regarding the patient;(B) has authority to receive the patient's health information under an advance directive or medical power of attorney; or(C) is otherwise the patient's surrogate decision-maker regarding the patient's health care needs under hospital policy and other applicable law; and(2) notify the person who receives the daily update required under paragraph (1) of this subsection of the estimated date and time at which the patient will be discharged from the hospital. Source Note: The provisions of this §505.51 adopted to be effective September 29, 2022, 47 TexReg 6197; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.51 In-Person Visitation During a Public Health Emergency or Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223764 03/12/2026 (a) This section applies only to a freestanding emergency medical care (FEMC) facility, as that term is defined by Texas Health and Safety Code (HSC) §254.001 (relating to Definitions), that is:(1) exempt from the licensing requirements of HSC Chapter 254 (relating to Freestanding Emergency Medical Care Facilities) under HSC §254.052(5), (7), or (8); and(2) associated with a hospital licensed under HSC Chapter 241 (relating to Hospitals) and this chapter that does not meet the conditions of participation for certification under Title XVIII of the Social Security Act (42 U.S.C. §1395 et seq. ).(b) This section does not apply to an FEMC facility associated with a hospital licensed under HSC Chapter 241 and this chapter that:(1) has been operating as a hospital for less than one year;(2) has submitted an application to a federally recognized accreditation program for certification under Title XVIII of the Social Security Act (42 U.S.C. §1395 et seq. ); and(3) has not failed an accreditation for certification.(c) In this section, "unconscionable price" means a price that is more than 200 percent of the average price for the same or a substantially similar product or service provided to other individuals by health care facilities located in the same or nearest county to the county in which the FEMC facility is located, as applicable, according to data collected by the Texas Department of State Health Services under HSC Chapter 108 (relating to Health Care Data Collection). (d) In accordance with HSC §241.222 (relating to Certain Fees Prohibited), an FEMC facility that provides a health care service, including testing or vaccination, to an individual accessing the service from the individual's vehicle may not charge the individual or a third-party payor a facility or observation fee.(e) In accordance with HSC §241.223 (relating to Disclosure of Certain Prices and Fees During Declared Disaster; Construction), an FEMC facility that provides testing or vaccination for an infectious disease for which a state of disaster has been declared under Texas Government Code Chapter 418 (relating to Emergency Management), shall disclose to each patient the prices the facility charges for the test or vaccine and any facility fees, supply costs, and other costs associated with the test or vaccine in accordance with the disclosure requirements described by HSC §254.156 (relating to Disclosure Statement Required).(f) In accordance with HSC §241.224 (relating to Prohibited Pricing Practices During Declared State of Disaster), during a state of disaster declared by the Governor under Texas Government Code Chapter 418, an FEMC facility may not:(1) charge an individual an unconscionable price for a product or service provided at the facility; or(2) knowingly or intentionally charge a third-party payor, including a health benefit plan insurer, a price higher than the price charged to an individual for the same product or service based on the payor's liability for payment or partial payment of the product or service.(g) Subsection (f)(2) of this section does not prohibit an FEMC facility from:(1) offering an uninsured individual a cash discount for a particular product or service; or(2) accepting directly from an individual full payment for a health care product or service in lieu of submitting a claim to the individual's health benefit plan.(h) This section may not be construed as expanding the type of health care services an FEMC facility is authorized to provide under HSC Chapter 241 or this chapter.(i) Pursuant to HSC §241.225 (relating to Enforcement), and except for good cause shown, the Texas Health and Human Services Commission shall impose the following applicable penalty on a hospital licensed under this chapter and HSC Chapter 241 that violates subsection (f) of this section or HSC §241.224:(1) for the first violation, an administrative penalty of $10,000;(2) for the second violation:(A) an administrative penalty of $50,000; and(B) a suspension of the hospital's license for 30 days; and(3) for the third violation, a permanent revocation of the hospital's license. Source Note: The provisions of this §505.52 adopted to be effective November 10, 2022, 47 TexReg 7422; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.52 Hospital-Owned or Hospital-Operated Freestanding Emergency Medical Care Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223765 03/12/2026 (a) A hospital shall comply with the disclosure and reporting requirements of Texas Health and Safety Code (HSC) Chapter 327 (relating to Disclosure of Prices) as described in this section.(b) In this section, "prominent location" or "prominently displayed" means a size and font at least as large as that of surrounding text, links, or buttons, distinct from the background of the website, immediately viewable upon accessing the home page of the hospital's publicly accessible website without having to scroll.(c) A hospital shall make the information required by HSC Chapter 327 available in a prominent location on the home page of its publicly accessible website or accessible by selecting a dedicated link that is prominently displayed on the home page of its publicly accessible website. If the facility operates multiple locations and maintains a single website, the homepage must contain a link to the list containing the links to each location the facility operates in a manner that clearly associates the list with the applicable location of the facility.(d) Each time a hospital updates a list as required by HSC §327.003 and §327.004, it shall submit the updated list to the Texas Health and Human Services Commission (HHSC) in the manner specified by HHSC on its website.(e) HHSC has jurisdiction to impose an administrative penalty against a hospital licensed under this chapter for violations of HSC Chapter 327 and this section. An administrative penalty imposed under this section shall be in accordance with the provisions of HSC §327.008. (f) In determining the amount of any penalty sought pursuant to HSC §327.008, HHSC shall consider:(1) previous violations by the hospital's operator;(2) the seriousness of the violation;(3) the demonstrated good faith of the hospital's operator; and(4) any other matters that justice may require.(g) For purposes of calculating any penalty sought pursuant to HSC §327.008, the penalty imposed by HHSC for a hospital with one of the following total gross revenues, as reported to the Centers for Medicare and Medicaid Services, in the year preceding the year in which a penalty is imposed, may not exceed:(1) $10 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is less than $10,000,000;(2) $100 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is $10,000,000 or more and less than $100,000,000; and(3) $1,000 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is $100,000,000 or more.(h) Each day a violation continues is considered a separate violation.(1) The administrative penalties for each day of a continuing violation cease on the date the violation is corrected. A violation that is the subject of a penalty is presumed to continue on each successive day until it is corrected. The date of correction alleged by the hospital in its written plan of correction or corrective action plan will be presumed to be the actual date of correction, unless HHSC later determines that the correction was not made by that date or was not satisfactory.(2) For continuing violations pursuant to HSC Chapter 327, penalties are cumulative as demonstrated in Figure: 25 TAC §133.53(h)(2). The penalty amount is multiplied by the number of days the violation continues. The penalty amount for each day of the continuing violation is then added to the running total of the previous day's penalties according to the formula in subparagraph (A) of this paragraph. Attached Graphic(A) Cumulative administrative penalty = [penalty for each day of violation + (penalty for each day of violation x number of days of violation)]/2 x (number of days of violation). (B) The cumulative amounts are not subject to the per day penalty cap in subsection (g) of this section. Source Note: The provisions of this §505.53 adopted to be effective February 26, 2023, 48 TexReg 895; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.53 Hospital Price Transparency Reporting and Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223766 03/12/2026 (a) As defined by Texas Health and Safety Code §241.401, and when used in this subchapter, the following words and terms have the following meanings.(1) "Acute hospital care at home waiver program" means:(A) the program established by the Centers for Medicare and Medicaid Services under United States Code Title 42 Section 1320b-5 that waives the requirements of 42 CFR Sections 482.23(b) and (b)(1); and(B) a successor program to the program described by subparagraph (A) of this paragraph that is established by the United States Congress or the Centers for Medicare & Medicaid Services.(2) "Hospital at home program" means a program operated by a hospital to provide in a home setting health care services that are considered to be acute hospital care for purposes of the acute hospital care at home waiver program.(b) Notwithstanding hospital functions and services requirements in §133.41 of this subchapter (relating to Hospital Functions and Services) and hospital physical plant and construction requirements in Subchapter I of this chapter (relating to Physical Plant and Construction Requirements), a hospital may operate a hospital at home program and treat an eligible patient at that patient's home if the hospital:(1) obtains approval from the Centers for Medicare & Medicaid Services (CMS) to participate in the acute hospital care at home waiver program; and(2) receives written approval from the Texas Health and Human Services Commission (HHSC) to operate a hospital at home program.(c) To apply for HHSC approval to operate a hospital at home program, an applicant shall submit the following to HHSC:(1) a complete application to operate the program as indicated on the HHSC website;(2) a nonrefundable application fee of $350;(3) a copy of the CMS approval to participate in the acute hospital care at home waiver program; and(4) any additional information requested by HHSC.(d) A hospital shall reapply for HHSC approval to operate the hospital's hospital at home program when applying to renew the hospital's license under §133.23 of this chapter (relating to Application and Issuance of Renewal License).(e) A hospital shall pay a nonrefundable renewal application fee of $390 per 10 beds the hospital designates for the hospital at home program in the renewal application. This fee is in addition to the hospital's license renewal fee.(f) When a hospital increases the number of beds designated for its hospital at home program between license renewal periods, the hospital shall notify HHSC and pay a nonrefundable fee of $390 per block of 10 beds the hospital adds to their program.(g) A hospital that is approved by HHSC to operate a hospital at home program shall:(1) maintain CMS approval to participate in the acute hospital care at home waiver program;(2) comply with the CMS acute hospital care at home waiver program requirements and all other applicable statutes and regulations;(3) develop, implement, and enforce policies and procedures to ensure:(A) the patient's health and safety;(B) the safety of hospital staff entering the patient's home; and(C) the safety of the patient's home;(4) ensure the hospital's policies and procedures adopted under paragraph (3) of this subsection at a minimum:(A) require the patient's home to:(i) be located at a physical address;(ii) allow hospital staff entry into the home as needed;(iii) have animals separated securely away from the patient care area while hospital staff is on site, except for service animals as allowed by the Americans with Disabilities Act of 1990; and(iv) maintain a safe route from the entrance and exit to the patient area within in the home;(B) require the patient's home maintain electricity, water, and wastewater service and identify how the hospital addresses any disruptions in these services in an emergency; and(C) require the patient maintain access to telephone service;(5) obtain a patient's written and informed consent to participate before the patient participates in the hospital's hospital at home program, including notice that HHSC may request to accompany hospital staff when entering the patient's home to ensure a hospital's compliance with this rule; and(6) notify HHSC in writing no later than five business days if the hospital:(A) chooses to no longer operate a hospital at home program; or(B) loses CMS approval to participate in the acute hospital care at home waiver program.(h) At any time, HHSC may withdraw its approval for a hospital to operate a hospital at home program if HHSC finds a threat to patient health or safety. Any patient being treated under the hospital at home program at the time HHSC withdraws its approval shall be safely relocated as soon as practicable and according to the hospital's policies and procedures.(i) To the extent this section may conflict with a requirement in §133.21(c)(4)(B) or (C) of this chapter (relating to General), this section controls. Source Note: The provisions of this §505.54 adopted to be effective January 25, 2024, 49 TexReg 247; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.54 Hospital at Home Program Application and Operational Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223767 03/12/2026 (a) In accordance with Texas Health and Safety Code (HSC) §331.002, a hospital shall establish a workplace violence prevention committee or authorize an existing hospital committee to develop a workplace violence prevention plan.(b) A hospital shall ensure the committee includes at least:(1) one registered nurse who provides direct care to the hospital's patients;(2) one physician licensed to practice medicine in Texas who provides direct care to the hospital's patients; and(3) one hospital employee who provides security services for the hospital if any and if practicable.(c) A health care system that owns or operates more than one facility, as that term is defined by HSC §331.001, which includes a hospital, may establish a single workplace violence prevention committee for all of the system's facilities if:(1) the committee develops a violence prevention plan for implementation at each facility in the system; and(2) data related to violence prevention remains distinctly identifiable for each facility in the system.(d) A hospital shall adopt, implement, and enforce a written workplace violence prevention policy to protect health care providers and employees from violent behavior and threats of violent behavior occurring at the hospital. In accordance with HSC §331.003, the policy shall:(1) require the hospital to:(A) provide significant consideration of the violence prevention plan recommended by the hospital's committee; and(B) evaluate any existing hospital violence prevention plan;(2) encourage health care providers and employees to provide confidential information on workplace violence to the committee;(3) include a process to protect from retaliation health care providers or employees who provide information to the committee; and(4) comply with HHSC rules relating to workplace violence. (e) A hospital shall adopt, implement, and enforce a written workplace violence prevention plan developed by the committee. In accordance with HSC §331.004, the plan shall:(1) be based on a hospital setting;(2) adopt a definition of "workplace violence" that includes:(A) an act or threat of physical force against a health care provider or employee that results in, or is likely to result in, physical injury or psychological trauma; and(B) an incident involving the use of a firearm or other dangerous weapon, regardless of whether a health care provider or employee is injured by the weapon;(3) require the hospital to at least annually provide workplace violence prevention training or education that may be included in other required training or education provided to the health care providers and employees who provide direct patient care;(4) prescribe a system for responding to and investigating violent incidents or potentially violent incidents at the hospital;(5) address physical security and safety;(6) require the hospital to solicit information from the health care providers and employees when developing and implementing a workplace violence prevention plan;(7) allow health care providers and employees to report workplace violence incidents through the hospital's existing occurrence reporting systems; and(8) require the hospital to adjust patient care assignments, to the extent practicable, to prevent a health care provider or employee from treating or providing services to a patient who has intentionally physically abused or threatened the provider or employee.(f) The written workplace violence prevention plan may satisfy the requirements of subsection (e) of this section by referencing other internal hospital policies and documents.(g) At least annually after the date a hospital adopts a written workplace violence prevention plan required by subsection (e) of this section, the committee shall:(1) review and evaluate the workplace violence prevention plan; and(2) report the results of the evaluation to the hospital's governing body.(h) Each hospital shall make available on request an electronic or printed copy of the hospital's workplace violence prevention plan to each health care provider or employee. If the committee determines the plan contains information that would pose a security threat if made public, the committee may redact that information before providing the plan.(i) In accordance with HSC §331.005, after an incident of workplace violence occurs, a hospital shall offer immediate post-incident services, including any necessary acute medical treatment for each hospital health care provider or employee who is directly involved in the incident.(j) In accordance with HSC §331.005, a hospital may not discourage a health care provider or employee from exercising the provider's or employee's right to contact or file a report with law enforcement regarding a workplace violence incident.(k) In accordance with HSC §331.005, a hospital shall prohibit hospital personnel from disciplining, including by suspension or termination of employment, discriminating against, or retaliating against another person who:(1) in good faith reports a workplace violence incident; or(2) advises a health care provider or employee of the provider's or employee's right to report a workplace violence incident. Source Note: The provisions of this §505.55 adopted to be effective October 21, 2024, 49 TexReg 8379; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING C OPERATIONAL REQUIREMENTS §505.55 Workplace Violence Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223752 03/12/2026 (a) General provisions.(1) Transfer agreements between hospitals are voluntary.(2) Transfer agreements must comply with the transfer policies required under §133.44 of this title (relating to Hospital Patient Transfer Policy).(3) The transfer agreement shall be submitted to the Department of State Health Services (department) for review to determine if the agreement meets the requirements of subsection (b) of this section.(4) Multiple transfer agreements may be entered into by a hospital based upon the type or level of medical services available at other hospitals.(b) Minimum requirements for hospital patient transfer agreements. Patient transfer agreements must include specific language consistent with the following requirements:(1) §133.44(c)(1) of this title (relating to prohibiting discrimination);(2) §133.44(c)(6)(A) - (B) of this title (relating to the transfer of patients with emergency medical conditions);(3) §133.44(b)(8) of this title (relating to compliance with the Indigent Health Care and Treatment Act);(4) §133.44(b)(11) of this title (relating to the patient's right to request transfer);(5) §133.44(c)(7) of this title (relating to the physician's duties and standard of care); and(6) §133.44(c)(9) and (10) of this title (relating to medical record and memorandum of transfer).(c) Review of transfer agreements.(1) In order that the department may review the transfer agreements for compliance with the minimum requirements, each party to the transfer agreement shall jointly submit the following documents to the department:(A) a copy of the current or proposed agreement signed by each hospital's representative;(B) the date of the adoption of the agreement; and(C) the effective date of the agreement.(2) The department may waive the submittal of the documents required under paragraph (1) of this subsection to avoid the repetitious submission of required documentation and approved agreements.(3) If a governing body or a governing body's designee executes a transfer agreement and the entire text of that agreement consists of the entire text of an agreement that has been previously approved by the department, the governing body or the governing body's designee is not required to submit the later agreement for review. On the date the later agreement is fully executed and before the later agreement is implemented, the governing body or the governing body's designee must give adequate notice to the department that the later agreement has been executed.(4) The department shall review the agreement within 30 calendar days after the department's receipt of the agreement to determine if the agreement is consistent with the requirements of this section.(5) After the department's review of the agreement, if the department determines that the agreement is consistent with the requirements contained in this section, the department shall notify the hospital administration that the agreement has been approved.(6) If the department determines that the agreement is not consistent with the requirements contained in this section, the department shall give notice to the hospital administration that the agreement is deficient and provide recommendations for correction.(7) A transfer agreement will be considered in compliance if it is consistent with the rules that were in effect at the time the transfer agreement was executed and approved by the department.(d) Appeals.(1) If the department rejects a patient transfer agreement, the hospitals that are parties to the agreement may jointly request reconsideration of the department's decision.(2) A hospital that is party to a rejected agreement shall appeal the rejection jointly with an appeal by other appealing parties or waive that hospital's opportunity to appeal.(3) To initiate the appeal process, the party hospitals shall notify the department, in writing, that each party hospital requests formal reconsideration of the department's decision.(4) The request must be received by the department within 20 calendar days from the receipt of the department's rejection notice by the hospital that submitted the proposed agreement for review and approval.(5) Failure of the party hospitals to provide a written request for appeal shall be deemed a waiver of the opportunity for an internal reconsideration by the department, and the rejection shall become final.(6) An internal review of a rejection shall consist of a review of the actions taken to-date concerning the rejection of the agreement.(7) The review shall be conducted by a three member panel. The members shall be appointed by the commissioner of state health services. The panel members shall not have participated in the department's decision.(A) The panel shall meet as necessary.(B) The panel shall review all agreement submissions for which an appeal has been requested.(C) The review shall be based primarily on the documentation provided with the request for an appeal, but the party requesting the appeal may appear before the panel, if they desire.(D) The panel's decision is binding on the department and the hospital(s).(e) Amendments to an agreement.(1) The governing body of a hospital or governing body's designee may adopt proposed amendments to a transfer agreement which has been approved by the department. However, before the amendments are implemented, the governing body or the governing body's designee shall submit the proposed amendments to the department for review in the same manner as the agreement to be amended was submitted.(2) The department shall review the amendments and shall approve or reject them in the same manner as provided for the review of the agreement to be amended.(f) Complaints. Complaints alleging a violation of a transfer agreement shall be treated in the same manner as complaints alleging violations of the Act or this chapter. Source Note: The provisions of this §505.61 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING D VOLUNTARY AGREEMENTS §505.61 Hospital Patient Transfer Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223753 03/12/2026 (a) A cooperative agreement is an agreement among two or more hospitals for the allocation or sharing of health care equipment, facilities, personnel, or services, and may be established in accordance with Health and Safety Code (HSC), Chapter 314.(b) For purposes of this section only, the term hospital is limited to a general or special hospital licensed under HSC, Chapter 241, or a private mental hospital licensed under HSC, Chapter 577.(c) A hospital may negotiate and enter into cooperative agreements with other hospitals in the state if the likely benefits resulting from the agreement outweigh any disadvantages attributable to a reduction in competition that may result from the agreements. Acting through their boards of directors, a group of hospitals may conduct discussions or negotiations concerning cooperative agreements, provided that the discussions or negotiations do not involve price fixing or predatory pricing.(d) Parties to a cooperative agreement may apply to the department for a certification of public advantage governing the cooperative agreement. The application must include the application fee in accordance with §133.26(e) of this title (relating to Fees), and a written copy of the cooperative agreement that describes the nature and scope of the cooperation in the agreement and any consideration passing to any party under the agreement. A copy of the application and copies of all additional related materials must be submitted to the attorney general and to the department at the same time. Source Note: The provisions of this §505.62 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING D VOLUNTARY AGREEMENTS §505.62 Cooperative Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223768 03/12/2026 (a) Request for a waiver. A hospital may submit a written request to the director for a waiver or modification of a particular provision of the Texas Hospital Licensing Act (Act) or a minimum standard in this chapter, except fire safety requirements. The written request shall specify the section(s) of the Act or this chapter for which a waiver is requested.(b) Waiver request requirements. In requesting the waiver, the hospital must address each of the following points and provide documentation as necessary to support their position. The hospital must:(1) provide evidence to support why the requested waiver will not adversely affect the health and safety of the hospital patients, employees, or the general public;(2) indicate how it was determined that granting the waiver would not adversely impact the hospital's participation in the federal Medicare program or accreditation by a Centers for Medicare and Medicaid Services-approved organization;(3) describe how not granting the waiver would impose an unreasonable hardship on the hospital in providing adequate care for patients;(4) describe how the waiver would facilitate the creation or operation of the hospital; and(5) explain why the waiver would be appropriate when balanced against the best interests of the individuals served or to be served by the hospital.(c) Supporting documentation. The hospital should submit supporting documentation with the waiver request. The department may request additional written documentation from the hospital to support the waiver or modification.(d) Written recommendation. The director shall submit a written recommendation for granting or denying the waiver to the commissioner of state health services (commissioner).(e) Granting order. If the director recommends that the waiver or modification be granted, the commissioner may issue a written order granting the waiver or modification.(f) Denial of order. If the director recommends that the waiver or modification be denied, the commissioner may issue a written order denying the waiver or modification.(g) File documentation. The licensing file for the hospital maintained by the Department of State Health Services shall contain a copy of the request, any supporting documents which were provided, the written recommendation of the director, and the order. The hospital is to maintain the original order in their permanent records. Source Note: The provisions of this §505.81 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING E WAIVER PROVISIONS §505.81 Waiver Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223769 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission's (HHSC's) inspection and investigation process, a hospital:(1) may not record, listen to, or eavesdrop on any HHSC interview with hospital staff or patients that the hospital staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) may not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of hospital staff when HHSC has requested a private room or office or distanced themselves from hospital staff unless the hospital first informs HHSC and the hospital obtains HHSC's written approval before beginning to record or listen to the discussion.(b) A hospital shall inform HHSC when security cameras or other existing recording devices in the hospital are in operation during any internal discussion by or among HHSC staff.(c) When HHSC by words or actions permits hospital staff to be present, an interview or conversation for which hospital staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §505.101 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.101 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223770 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an inspection of each hospital prior to the issuance or renewal of a license.(1) A hospital is not subject to additional annual licensing inspections subsequent to the issuance of the initial license while the hospital maintains:(A) certification under Title XVIII of the Social Security Act, 42 United States Code (USC), §§1395 et seq.; or(B) accreditation from The Joint Commission, the American Osteopathic Association, or other national accreditation organization for the offered services.(2) HHSC may conduct an inspection of a hospital exempt from an annual licensing inspection under paragraph (1) of this subsection before issuing a renewal license to the hospital if the certification or accreditation body has not conducted an on-site inspection of the hospital in the preceding three years and HHSC determines that an inspection of the hospital by the certification or accreditation body is not scheduled within 60 days of the license expiration date.(b) HHSC may conduct an unannounced, on-site inspection of a hospital at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) a hospital's plan of correction;(3) an order or special order of the HHSC executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the hospital.(c) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its hospitals by HHSC.(d) HHSC inspections to evaluate a hospital's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or bed numbers;(3) routine inspections, which may be conducted without notice and at HHSC's discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies; (5) inspections to determine if an unlicensed hospital is offering or providing, or purporting to offer or provide, treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(e) A hospital shall cooperate with any HHSC inspection and shall permit HHSC to examine the hospital's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the hospital, unless prohibited by law.(f) A hospital shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(g) A hospital shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the hospital, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(h) Upon entry, HHSC holds an entrance conference with the hospital's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the hospital representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the hospital representative to inform the hospital representative of any preliminary findings of the inspection, including possible health and safety concerns. The hospital may provide any final documentation regarding compliance during the exit conference.(k) HHSC shall maintain the confidentiality of hospital records as applicable under state or federal law. Except as provided by subsection (l) of this section, all information and materials in the possession of or obtained or compiled by HHSC in connection with an inspection are confidential and not subject to disclosure under Texas Government Code Chapter 552 (relating to Public Information), and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the hospital;(2) the hospital that is the subject of the enforcement action, or the hospital's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate hospital services;(4) law enforcement agencies as allowed by law; and(5) persons engaged in bona fide research, if all individual-identifying and hospital-identifying information has been deleted.(l) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552, only to the extent that all personally identifiable information of a patient or health care provider is omitted from the information:(1) a notice of the hospital's alleged violation, which must include the provisions of law the hospital is alleged to have violated, and a general statement of the nature of the alleged violation; (2) the number of investigations HHSC conducted of the hospital;(3) the pleadings in any administrative proceeding to impose a penalty against the hospital for the alleged violation;(4) the outcome of each investigation HHSC conducted of the hospital, including:(A) reprimand issuance;(B) license denial or revocation;(C) corrective action plan adoption; or(D) administrative penalty imposition and the penalty amount;(5) a final decision, investigative report, or order issued by HHSC to address the alleged violation; and(6) any other information required by law to be disclosed under public information laws.(m) Within 90 days after the date HHSC issues a final decision, investigative report, or order to address a hospital's alleged violation, HHSC posts certain information on the HHSC website in accordance with Texas Health and Safety Code §241.051. Source Note: The provisions of this §505.102 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.102 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223771 03/12/2026 (a) A hospital shall provide each patient and applicable legally authorized representative at the time of admission with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the hospital.(1) The statement shall inform persons that they may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The hospital shall prominently and conspicuously post this statement in patient common areas and in visitor's areas and waiting rooms so that it is readily visible to patients, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A complaint must be submitted using HHSC's current CII contact information for that purpose, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints directed to HHSC CII based on the seriousness of the alleged violation and the level of risk to patients, personnel, and the public.(1) Allegations determined to be within HHSC's regulatory jurisdiction relating to a hospital may be investigated under this chapter.(2) HHSC may refer complaints outside HHSC's jurisdiction to an appropriate agency, as applicable.(d) HHSC conducts investigations to evaluate a hospital's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of patients. Complaint investigations may be coordinated with the federal Centers for Medicare & Medicaid Services and its agents responsible for the inspection of hospitals to determine compliance with the Conditions of Participation under Title XVIII of the Social Security Act, (42 USC, §§1395 et seq.), so as to avoid duplicate investigations.(e) HHSC may conduct an unannounced, on-site investigation of a hospital at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) a hospital's compliance with any applicable statute or rule;(2) a hospital's plan of correction;(3) a hospital's compliance with an order of the HHSC executive commissioner or the executive commissioner's designee;(4) a hospital's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the hospital.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its facilities by HHSC.(g) A hospital shall cooperate with any HHSC investigation and shall permit HHSC to examine the hospital's grounds, buildings, books, records, video surveillance, and other documents and information maintained by, or on behalf of, the hospital, unless prohibited by law.(h) A hospital shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(i) A hospital shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the hospital, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(j) Upon entry, the HHSC representative holds an entrance conference with the hospital's designated representative to explain the nature, scope, and estimated duration of the investigation.(k) The HHSC representative holds an exit conference with the hospital representative to inform the hospital representative of any preliminary findings of the investigation. The hospital may provide any final documentation regarding compliance during the exit conference.(l) Once an investigation is complete, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint.(m) HHSC shall maintain the confidentiality of hospital records as applicable under state or federal law. Except as provided by subsection (n) of this section , all information and materials in the possession of or obtained or compiled by HHSC in connection with an investigation are confidential and not subject to disclosure under Texas Government Code Chapter 552, and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the hospital;(2) the hospital that is the subject of the enforcement action, or the hospital's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate hospital services;(4) law enforcement agencies as allowed by law; and(5) persons engaged in bona fide research, if all individual-identifying and hospital-identifying information has been deleted.(n) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552, only to the extent that all personally identifiable information of a patient or health care provider is omitted from the information:(1) a notice of the hospital's alleged violation, which must include the provisions of law the hospital is alleged to have violated, and a general statement of the nature of the alleged violation; (2) the number of investigations HHSC conducted of the hospital;(3) the pleadings in any administrative proceeding to impose a penalty against the hospital for the alleged violation;(4) the outcome of each investigation HHSC conducted of the hospital, including:(A) reprimand issuance;(B) license denial or revocation;(C) corrective action plan adoption; or(D) administrative penalty imposition and the penalty amount;(5) a final decision, investigative report, or order issued by HHSC to address the alleged violation; and(6) any other information required by law to be disclosed under public information laws.(o) Within 90 days after the date HHSC issues a final decision, investigative report, or order to address a hospital's alleged violation, HHSC posts certain information on the HHSC website in accordance with Texas Health and Safety Code Section 241.051 (relating to Inspections). (p) HHSC notifies complainants regarding the investigation's outcome within 10 business days after completing the investigation. Source Note: The provisions of this §505.103 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.103 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223772 03/12/2026 (a) A hospital is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after mailing, whichever is earlier.(b) When HHSC finds deficiencies:(1) HHSC provides the hospital with a written Statement of Deficiencies (SOD) within 10 business days after the exit conference via U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the hospital's receipt of the SOD, the hospital shall return to HHSC a written Plan of Correction (POC) that addresses each cited deficiency, including timeframes for corrections, together with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the hospital in writing.(B) If HHSC does not accept the POC, HHSC notifies the hospital in writing and requests the hospital submit to HHSC a modified POC and any additional evidence of compliance no later than 10 business days after HHSC notifies the hospital in writing.(C) The hospital shall correct the identified deficiencies and submit to HHSC evidence verifying implementation of corrective action within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of a hospital's compliance with this subsection or HHSC's acceptance of a hospital's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter. Source Note: The provisions of this §505.104 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.104 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223773 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission reports, in writing, to the appropriate licensing board any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure. Source Note: The provisions of this §505.105 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.105 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223774 03/12/2026 A hospital may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by following the procedure listed on the HHSC website. Source Note: The provisions of this §505.106 adopted to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING F INSPECTION AND INVESTIGATION PROCEDURES §505.106 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223775 03/12/2026 Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, and orders.(1) Denial, suspension or revocation of a license or imposition of an administrative penalty. HHSC has jurisdiction to enforce violations of the Act or the rules adopted under this chapter. HHSC may deny, suspend, or revoke a license or impose an administrative penalty for the following:(A) failure to comply with any applicable provision of the Texas Health and Safety Code (HSC), including Chapters 241, 311, and 327;(B) failure to comply with any provision of this chapter or any other applicable laws;(C) the hospital, or any of its employees, committing an act which causes actual harm or risk of harm to the health or safety of a patient;(D) the hospital, or any of its employees, materially altering any license issued by HHSC;(E) failure to comply with minimum standards for licensure; (F) failure to provide a complete license application;(G) failure to comply with an order of the HHSC executive commissioner or another enforcement procedure under HSC Chapters 241, 311, or 327;(H) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights that reflect more than nominal noncompliance;(I) the hospital aiding, committing, abetting, or permitting the commission of an illegal act;(J) the hospital, or any of its employees, committing fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to HHSC or required to be maintained by the hospital pursuant to HSC Chapter 241 and the provisions of this chapter;(K) failure to comply with other state and federal laws affecting the health, safety, and rights of hospital patients;(L) failure to timely pay an assessed administrative penalty as required by HHSC;(M) failure to submit an acceptable plan of correction for cited deficiencies within the timeframe required by HHSC;(N) failure to timely implement plans of corrections to deficiencies cited by HHSC within the dates designated in the plan of correction;(O) failure to comply with applicable requirements within a designated probation period; or(P) if the hospital is participating under Title XVIII of the Social Security Act, 42 United States Code (USC), §1395 et seq, the Centers for Medicare & Medicaid Services terminating the hospital's Medicare provider agreement.(2) Denial of a license. HHSC has jurisdiction to enforce violations of HSC Chapters 241, 311, and 327 and this chapter. HHSC may deny a license if the applicant:(A) fails to provide timely and sufficient information required by HHSC that is directly related to the application; or(B) has had the following actions taken against the applicant within the two-year period preceding the application:(i) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;(ii) federal Medicare or state Medicaid sanctions or penalties;(iii) unsatisfied federal or state tax liens;(iv) unsatisfied final judgments;(v) eviction involving any property or space used as a hospital in any state;(vi) unresolved federal Medicare or state Medicaid audit exceptions;(vii) denial, suspension, or revocation of a hospital license, a private psychiatric hospital license, or a license for any health care facility in any state; or(viii) a court injunction prohibiting ownership or operation of a facility.(3) Emergency suspension. Following notice and opportunity for hearing, the executive commissioner of HHSC or a person designated by the executive commissioner may issue an emergency order in relation to the operation of a hospital licensed under this chapter if the executive commissioner or the executive commissioner's designee determines that the hospital is violating this chapter, a rule adopted pursuant to this chapter, a special license provision, injunctive relief, an order of the executive commissioner or the executive commissioner's designee, or another enforcement procedure permitted under this chapter and the provision, rule, license provision, injunctive relief, order, or enforcement procedure relates to the health or safety of the hospital's patients.(A) HHSC shall send written notice of the hearing and shall include within the notice the time and place of the hearing. The hearing must be held within 10 days after the date of the hospital's receipt of the notice.(B) The hearing shall be held in accordance with HHSC's informal hearing rules.(C) The order shall be effective on delivery to the hospital or at a later date specified in the order.(4) Probation. In lieu of denying, suspending, or revoking the license, HHSC may place the hospital on probation for a period of not less than 30 days, if HHSC finds that the hospital is in repeated noncompliance with these rules or HSC Chapter 241, and the hospital's noncompliance does not endanger the public's health and safety.(A) HHSC shall provide notice to the hospital of the probation and of the items of noncompliance not later than the 10th day before the probation period begins.(B) During the probation period, the hospital shall correct the items of noncompliance and report the corrections to HHSC for approval.(5) Administrative penalty. HHSC has jurisdiction to impose an administrative penalty against a hospital licensed or regulated under this chapter for violations of HSC Chapters 241, 311, and 327 and this chapter. The imposition of an administrative penalty shall be in accordance with the provisions of HSC §241.059, §241.060, and §327.008.(6) Licensure of persons or entities with criminal backgrounds. HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a hospital. HHSC shall apply the requirements of Texas Occupations Code Chapter 53.(A) HHSC is entitled under Texas Government Code Chapter 411 to obtain criminal history information maintained by the Texas Department of Public Safety, the Federal Bureau of Investigation, or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.(B) In determining whether a criminal conviction directly relates, HHSC shall apply the requirements and consider the provisions of Texas Occupations Code Chapter 53.(C) The following felonies and misdemeanors directly relate to the duties and responsibilities of the ownership or operation of a health care facility because these criminal offenses indicate an ability or a tendency for the person to be unable to own or operate a hospital:(i) a misdemeanor violation of HSC Chapter 241;(ii) a misdemeanor or felony involving moral turpitude;(iii) a misdemeanor or felony relating to deceptive business practices;(iv) a misdemeanor or felony of practicing any health-related profession without a required license;(v) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(vi) a misdemeanor or felony under Texas Penal Code (TPC), Title 5, involving a patient, resident, or a client of any health care facility, a home and community support services agency or a health care professional; or(vii) a misdemeanor or felony under the TPC:(I) Title 4;(II) Title 5;(III) Title 7;(IV) Title 8;(V) Title 9;(VI) Title 10; or(VII) Title 11.(7) Offenses listed in paragraph (6)(C) of this subsection are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign, or military jurisdictions that indicate an inability or tendency for the person or entity to own or operate a hospital.(8) HHSC shall revoke a license on the licensee's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(9) Notice. If HHSC proposes to deny, suspend, or revoke a license, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC or HHSC may personally deliver the notice. The notice to deny, suspend, or revoke a license, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.(10) Acceptance. Within 20 calendar days after receipt of the notice, the applicant or licensee may notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing.(11) Hearing request.(A) A request for a hearing by the applicant or licensee shall be in writing and submitted to HHSC within 20 calendar days of receipt of the notice of the proposed action described in paragraph (9) of this subsection. Receipt of the notice is presumed to occur on the third day after the date HHSC mails the notice to the last known address of the applicant or licensee.(B) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001, and Title 1, Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act).(12) No response to notice. If an applicant or licensee does not request a hearing in writing within 20 calendar days after receiving the notice of the proposed action, the case shall be set for a hearing.(13) Notification of HHSC's final decision. HHSC shall send the licensee or applicant a copy of HHSC's decision for denial, suspension or revocation of a license or imposition of an administrative penalty by certified mail, which shall include the findings of fact and conclusions of law on which HHSC based its decision.(14) Admission of new patients upon suspension or revocation. Upon HHSC's determination to suspend or revoke a license, the license holder may not admit new patients until HHSC reissues the license.(15) Decision to suspend or revoke. When HHSC's decision to suspend or revoke a license is final, the licensee must immediately cease operation, unless the district court issues a stay of such action.(16) Return of original license. Upon suspension, revocation or non-renewal of the license, the original license shall be returned to HHSC within 30 calendar days of HHSC's notification.(17) Reapplication following denial or revocation.(A) One year after HHSC's decision to deny or revoke, or the voluntary surrender of a license by a hospital while enforcement action is pending, a hospital may petition HHSC, in writing, for a license. Expiration of a license prior to HHSC's decision becoming final shall not affect the one-year waiting period required before a petition can be submitted.(B) HHSC may allow a reapplication for licensure if there is proof that the reasons for the original action no longer exist.(C) HHSC may deny reapplication for licensure if HHSC determines that:(i) the reasons for the original action continues;(ii) the petitioner has failed to offer sufficient proof that conditions have changed; or(iii) the petitioner has demonstrated a repeated history of failure to provide patients a safe environment or has violated patient rights.(D) If HHSC allows a reapplication for licensure, the petitioner shall be required to meet the requirements as described in §133.22 of this chapter (relating to Application and Issuance of Initial License).(18) Expiration of a license during suspension. A hospital whose license expires during a suspension period may not reapply for license renewal until the end of the suspension period.(19) Surrender of a license. In the event that enforcement, as defined in this subsection, is pending or reasonably imminent, the surrender of a hospital license shall not deprive HHSC of jurisdiction in regard to enforcement against the hospital. Source Note: The provisions of this §505.121 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective November 21, 2024, 49 TexReg 9227; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING G ENFORCEMENT §505.121 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223776 03/12/2026 (a) Fire inspections.(1) Annual inspection. Approval of the fire protection of a hospital by the local fire department shall be a prerequisite for licensure.(2) Purpose of inspection. The purpose of these inspections shall be to ascertain and to cause to be corrected any conditions liable to cause fire or violations of any of the provisions or intent of these rules, or of any other applicable ordinances, which affect fire safety in any way.(3) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the fire department or bureau of fire prevention find in any building or upon any premises dangerous or hazardous conditions or materials, removal or remedy of dangerous conditions or materials shall be carried out in a manner specified by the head of the local fire department.(4) Access for inspection. At all reasonable hours, the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors may enter any building or premises for the purpose of making an inspection or investigation which may be deemed necessary under the provisions of these rules.(b) Fire reporting. All occurrences of fire shall be reported to the local fire authority and shall be reported in writing to the hospital licensing director as soon as possible but not later than 10 calendar days following the occurrence.(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), §18.7, and §133.161(a)(1) of this title (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located), and §133.162(a)(1) and (d) of this title (relating to New Construction Requirements). When required or installed, sprinkler systems for exterior fire exposures shall comply with National Fire Protection Association 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 2001 edition. All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.(d) Smoking rules. Each hospital shall adopt, implement and enforce a smoking policy. The policy shall include the minimal provisions of NFPA 101, §18.7.4.(e) Fire extinguishing systems. Inspection, testing, and maintenance of fire-fighting equipment shall be conducted by each hospital.(1) Water-based fire protection systems. All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested and maintained in accordance with National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2002 edition.(2) Range hood extinguishers. Fire extinguishing systems for commercial cooking equipment, such as at range hoods, shall be inspected and maintained in accordance with National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 2001 edition.(3) Portable fire extinguishers. Every portable fire extinguisher located in a hospital or upon hospital property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 edition.(f) Fire protection and evacuation plan. A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §18.7. Copies of the plan shall be available to all staff.(1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the hospital in public areas that are readily visible to patients, residents, employees, and visitors.(2) Annual training. Each hospital shall conduct an annual training program for instruction of all personnel in the location and use of fire-fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(g) Fire drills. The hospital shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment.(h) Fire alarm system. Every hospital and building used for patient care shall have an approved fire alarm system. Each fire alarm system shall be installed and tested in accordance with §133.161(a)(1)(A) of this title for existing hospitals, and §133.162(d)(5)(N) of this title for new construction.(i) System for communicating an alarm of fire. A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101, §18.3.4.3.2.(j) Fire department access. As an aid to fire department services, every hospital shall provide the following.(1) Driveways. The hospital shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Submission of plans. Upon request, the hospital shall submit a copy of the floor plans of the building to the local fire department officials.(3) Outside identification. The hospital shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(k) Fire department protection. When a hospital is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire. Source Note: The provisions of this §505.141 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING H FIRE PREVENTION AND SAFETY REQUIREMENTS §505.141 Fire Prevention and Protection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223777 03/12/2026 (a) Safety committee. Each hospital shall have a multidisciplinary safety committee. The hospital chief executive officer (CEO) shall appoint the chairman and members of the safety committee.(1) Safety officer. The CEO shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall be a member of the safety committee, and shall carry out the functions of the safety program.(2) Safety committee meetings. The safety committee shall meet as required by the chairman, but not less than quarterly. Written minutes of each meeting shall be retained for at least one year.(3) Safety activities.(A) Incident reports. The safety committee shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded in safety committee minutes are evaluated, and documentation is provided to show follow-up and corrective actions.(B) Safety policies and procedures. Safety policies and procedures for each department or service shall be developed, implemented and enforced.(C) Safety training and continuing education. Safety training shall be established as part of new employee orientation and in the continuing education of all employees.(4) Written authority. The authority of the safety committee to take action when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.(b) Safety manual. Each department or service shall have a safety policy and procedure manual within their own area that becomes a part of the overall facility safety manual.(c) Emergency communication system. An emergency communication system shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments. Source Note: The provisions of this §505.142 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING H FIRE PREVENTION AND SAFETY REQUIREMENTS §505.142 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223778 03/12/2026 (a) Flammable germicides. If flammable germicides, including alcohol-based products, are used for preoperative surgical skin preparation, the facility must:(1) use only self-contained, single-use, pre-measured applicators to apply the surgical skin preparations;(2) follow all manufacturer product safety warnings and guidelines;(3) develop, implement and enforce written policies and procedures outlining the safety precautions required related to the use of the products, which, at a minimum, must include minimum drying times, prevention and management of product pooling, parameters related to draping and the use of ignition sources, staff responsibilities related to ensuring safe use of the product, and documentation requirements sufficient to evaluate compliance with the written policies and procedures;(4) ensure that all staff working in the surgical environment where flammable surgical skin preparation products are in use have received training on product safety and the facility policies and procedures related to the use of the product;(5) develop, implement and enforce an interdisciplinary team process for the investigation and analysis of all surgical suite fires and alleged violations of the policies; and(6) report all occurrences of surgical suite fires to the department in care of the Facility Licensing Group within two business days, and complete an investigation of the occurrence and develop and implement a corrective action plan within 30 days.(b) Flammable and nonflammable gases and liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association 329, Handling Releases of Flammable and Combustible Liquids and Gases, 1999 edition. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.(1) Nonflammable gases (examples include, but are not limited to, oxygen and nitrous oxide) shall be stored and distributed in accordance with Chapter 5 of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99).(A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99, Chapter 9.(B) Oxygen shall be administered in accordance with NFPA 99, §9.6.(2) Piped flammable gas systems intended for use in laboratories and piping systems for fuel gases shall comply with requirements of NFPA 99, §11.11.(3) Flammable gases shall be stored in accordance with NFPA 99, §11.10.(4) Flammable and combustible liquids used in laboratories shall be handled and stored in accordance with NFPA 99, §11.7, and National Fire Protection Association 101, Life Safety Code, 2003 edition, §18.3.2.2.(5) Other flammable agents shall be stored in accordance with NFPA 99, Chapter 7.(c) Gasoline and gasoline powered equipment. No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the hospital building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the hospital building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.(d) Gas fired appliances. The installation, use and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2002 edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §505.143 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING H FIRE PREVENTION AND SAFETY REQUIREMENTS §505.143 Handling and Storage of Gases, Anesthetics, and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223779 03/12/2026 (a) Compliance. All buildings in which existing hospitals licensed by the Department of State Health Services (department) are located shall comply with this subsection. (1) Minimum fire safety and construction requirements. (A) Existing licensed hospitals shall meet the requirements for health care occupancies contained in the 1967, 1973, 1981, 1985, 1991, 1997, 2000, or 2003 editions of the National Fire Protection Association 101, Life Safety Code, (NFPA 101), the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and the hospital licensing rules under which the buildings or sections of buildings were constructed. All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. (B) Existing hospitals or portions of existing hospitals constructed prior to the adoption of any of the editions of NFPA 101, the Hospital Licensing Standards, and the hospital licensing rules listed in subparagraph (A) of this paragraph, shall comply with this section and Chapter 19, NFPA 101, 2003 edition. (C) Compliance with the requirements of Chapter 4 of the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 edition, (relating to Fire Safety Evaluation System for Health Care Occupancies) will be acceptable in lieu of complying with the requirements of Chapter 19, NFPA 101, 2003 edition. (2) Remodeling of existing facilities. All requirements listed in this chapter relating to new construction are applicable to renovations, additions and alterations unless stated otherwise. (A) Alteration or installation of new equipment. Any alteration or any installation of new equipment shall be accomplished as nearly as practicable with the requirements for new construction, except that when existing conditions make changes impractical to accomplish, minor deviations from functional requirements may be permitted if the intent of the requirements is met and if the care and safety of patients will not be jeopardized. (B) Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system may be replaced, materially altered or extended in an existing building licensed as a hospital, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records). (C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the hospital is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes in accordance with §133.167(f)(3) of this title. (D) Major remodeling or alterations. Plans shall be submitted in accordance with §133.167 of this title for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or add beds or services over those for which the hospital is licensed are considered as major remodeling and alterations. (E) Phasing of construction in existing facilities. (i) Projects involving alterations of and additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions. (ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants will not be jeopardized during construction. (iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day. (iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior. (v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present. (vi) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building. (F) Nonconforming conditions. When doing renovation work, if it is found to be infeasible to correct all of the nonconforming conditions in the existing hospital in accordance with these rules, a conditional approval may be granted by the department if the operation of the hospital, necessary access by the handicapped, and safety of the patients are not jeopardized by the nonconforming condition. (b) Previously licensed hospitals. Buildings which have been licensed previously as hospitals but have been vacated or used for purposes other than as hospitals and which are not in compliance with the 1967, 1973, 1981, 1985, 1991, 1997, 2000, or 2003 editions of the NFPA 101, the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and hospital licensing rules under which the building or sections of buildings were constructed shall comply with the requirements of §133.162 of this title (relating to New Construction Requirements), §133.163 of this title (relating to Spatial Requirements for New Construction), §133.165 of this title (relating to Building with Multiple Occupancies), §133.167 of this title, and §133.168 of this title (relating to Construction, Inspections, and Approval of Project). Source Note: The provisions of this §505.161 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.161 Requirements for Buildings in Which Existing Licensed Hospitals Are Located https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223780 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223780 03/12/2026 (a) Hospital location. Any proposed new hospital shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as a hospital which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients. (1) Hazardous locations. (A) Underground and above ground hazards. New hospitals or additions to existing hospitals shall not be constructed within 150 feet of easement boundaries or setbacks of hazardous underground locations including but not limited to liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not within the easement of high voltage electrical lines. (B) Fire hazards. New hospitals and additions to existing hospitals shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants. (2) Undesirable locations. (A) Nuisance producing sites. New hospitals shall not be located near nuisance producing industrial sites, feed lots, sanitary landfills, or manufacturing plants producing excessive noise or air pollution. (B) Cemeteries. New hospitals shall not be located near a cemetery in a manner that allows direct view of the cemetery from patient windows. (C) Flood plains. (i) New construction. Construction of a new hospital is prohibited in a designated 100-year flood plain. (ii) Previously licensed hospital. An existing building or a portion of an existing building located in a designated 100-year flood plain which was previously licensed as a hospital but has been vacated or used for purposes other than a hospital, will not be licensed as a hospital. (iii) Existing hospital. Access and required functional hospital components shall be constructed above the designated flood plain in a new addition to an existing hospital located in a designated 100-year flood plain. (D) Airports. Construction of new hospitals shall be avoided in close proximity to airports. When hospitals are proposed to be located near airports, recommendations of the Texas Aviation Authority and the Federal Aviation Authority shall apply. A hospital may not be constructed within a rectangular area formed by lines perpendicular to and two miles (10,560 feet) from each end of any runway and by lines parallel to and one-half mile (2,640 feet) from each side of any runway. (b) Environmental considerations. Development of a hospital site and hospital construction shall be governed by state and local regulations and requirements with respect to the effect of noise and traffic on the community and the environmental impact on air and water. (c) Hospital site. (1) Paved roads and walkways. Paved roads shall be provided within the lot lines to provide access from public roads to the main entrance, emergency entrance, entrances serving community activities, and to service entrances, including loading and unloading docks for delivery trucks. (A) Emergency entrance. Hospitals having an organized emergency services department shall have the emergency entrance well-marked to facilitate entry from the public roads or streets serving the site. (B) Access to emergency department. Access to the emergency entrance shall not conflict with other vehicular traffic or pedestrian traffic and shall be located so as not to be compromised by floods. (C) Pedestrian traffic. Finished surface walkways shall be provided for pedestrians. (2) Parking. Off-street parking shall be available for visitors, employees, and staff. Parking structures directly accessible from a hospital shall be separated with two-hour fire rated noncombustible construction. When used as required means of egress for hospital occupants, parking structures shall comply with National Fire Protection Association 88A, Standard for Parking Structures, 2002 edition. This requirement does not apply to freestanding parking structures. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. (A) Number of parking places. In the absence of a formal parking study, one parking space shall be provided for each day shift employee plus one space for each patient bed. This ratio may be reduced in an area convenient to a public transportation system or to public parking facilities on the basis of a formal parking study. Parking facilities shall be increased accordingly when the size of existing facilities is increased. (B) Additional parking. Additional parking shall be required to accommodate medical staff, outpatient and other services when such services are provided. (C) Emergency and delivery parking. Separate parking facilities shall be provided for ambulances and delivery vehicles. (d) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, the hospital shall be constructed in accordance with the International Building Code, 2003 edition, published by the International Code Council, 5203 Leesburg Pike, Falls Church, VA 22041, telephone (800) 786-4452. (1) General architectural requirements. All new construction, including conversion of an existing building to a hospital, and establishing a separately licensed hospital in a building with an existing licensed hospital, shall comply with Chapter 18 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), and Subchapters H and I of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Construction documents shall be submitted to the department in accordance with §133.167 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records). (A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each hospital. The physical premises of the hospital and those areas of the hospital's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and Subchapters H and I of this chapter. (B) Construction type. A hospital may occupy an entire building or a portion of a building, provided the hospital portion of the building is separated from the rest of the building in accordance with subparagraph (C) of this paragraph and the entire building or the hospital portion of the building complies with new construction requirements (type of construction permitted for hospitals by NFPA 101, §18.1.6.2), and the entire building is protected with a fire sprinkler system conforming with requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13). (C) Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls which are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies. (D) Design for the handicapped. Special considerations benefiting handicapped staff, visitors, and patients shall be provided. Each hospital shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities, or 16 TAC Chapter 68, Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Texas Government Code, Chapter 469. (E) Patient safety. In developing construction documents for submission to the department in accordance with §133.167 of this title, the owner shall comply with the requirements of Health and Safety Code, Chapter 256, Safe Patient Handling and Movement Practices. Section 256.002(b)(8) requires a hospital's governing body to consider the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment at a later date. (F) Other regulations. The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists. (G) Exceeding minimum requirements. Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter. (H) Equivalency. Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this subchapter, providing technical documentation which demonstrates equivalency is submitted to the department for approval. (I) Freestanding buildings (not for patient use). Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed in accordance with other occupancy classifications requirements listed in NFPA 101. (J) Freestanding buildings (for patient use other than sleeping). Buildings containing areas for patient use which do not contain patient sleeping areas and in which care or treatment is rendered to ambulatory inpatients who are capable of judgment and appropriate physical action for self-preservation under emergency conditions, may be classified as business or ambulatory care occupancies as listed in NFPA 101, Chapters 20 and 38, respectively, instead of hospital occupancy. (K) Energy conservation. In new construction and in major alterations and additions to existing buildings and in new buildings, electrical and mechanical components shall be selected for efficient utilization of energy. Hospital construction shall be in accordance with the provisions of the Texas Building Energy Performance Standards, Health and Safety Code, Chapter 388. (L) Heliports. Heliports located on hospital buildings or land used or intended to be used for landing and take off of helicopters shall comply with National Fire Protection Association 418, Standard for Heliports, and 2001 edition. (2) General detail and finish requirements. Details and finishes in new construction projects, including additions and alterations, shall be in compliance with this paragraph, with NFPA 101, Chapter 18, with local building codes, and with any specific detail and finish requirements for the particular unit as contained in §133.163 of this title (relating to Spatial Requirements for New Construction). (A) General detail requirements. (i) Fire safety. Fire safety features, including compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with §133.161 of this title (relating to Requirements for Buildings in Which Existing Licensed Hospitals Are Located), and NFPA 101, Chapter 18 requirements for hospitals. The Fire Safety Evaluation System for Health Care Occupancies contained in the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 edition, Chapter 3, shall not be used in new building construction, renovations or additions to existing hospitals. (ii) Access to exits. Corridors providing access to all patient, diagnostic, treatment, and sleeping rooms and exits shall be at least eight feet in clear and unobstructed width (except as allowed by NFPA 101, §18.2.3.4, Exceptions 1 and 2), not less than seven feet six inches in height, and constructed in accordance with requirements listed in NFPA 101, §18.3.6. (iii) Corridors in other occupancies. Public corridors in outpatient, administrative, and service areas which are designed to other than hospital requirements and are the required means of egress from the hospital shall be not less than five feet in width. (iv) Encroachment into the means of egress. Items such as drinking fountains, telephone booths or stations, and vending machines shall be so located as to not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment shall not be stored so as to project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. (v) Doors in means of egress. All door leaves in the means of egress shall be not less than 44 inches wide or as otherwise permitted for hospitals by NFPA 101, §18.2.3.6. (vi) Sliding doors. Horizontal sliding doors serving an occupant load of fewer than 10 shall be permitted. The area served by the door has no high hazard contents. The door is readily operable from either side without special knowledge or effort. The force required to operate the door in the direction of door travel is not more than 30 pounds per foot to set the door in motion and is not more than 15 pounds per foot to close the door or open in the minimum required width. The door assembly complies with any required fire protection rating, and, where rated, is self-closing or automatic closing. The sliding doors opening to the egress corridor doors shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. The sliding doors may have breakaway provisions and shall be installed to resist passage of smoke. The latching sliding panel shall have a minimum clear opening of 41.5 inches in the fully open position. The fixed panels may have recessed tracks. (vii) Control doors. Designs that include cross-corridor control doors should be avoided. When unavoidable, cross-corridor control doors shall consist of two 44-inch wide leaves which swing in a direction opposite from the other, or of the double acting type. Each door leaf shall be provided with a view window. (viii) Emergency access. Rooms containing bathtubs, showers, and water closets, intended for patient use shall be provided with at least one door having hardware which will permit access from the outside in any emergency. Door leaf width of such doors shall not be less than 36 inches. (ix) Obstruction of corridors. All doors which swing towards the corridor must be recessed. Corridor doors to rooms not subject to occupancy (any room that you can walk into and close the door behind you is considered occupiable) may swing into the corridor, provided that such doors comply with the requirements of NFPA 101, §7.2.1.4.4. (x) Stair landing. Doors shall not open immediately onto a stair without a landing. The landing shall be 44 inches deep or have a depth at least equal to the door width, whichever is greater. (xi) Doors to rooms subject to occupancy. All doors to rooms subject to occupancy shall be of the swing type except that horizontal sliding doors complying with the requirements of NFPA 101, §18.2.2.2.9 are permitted. Door leaves to rooms subject to occupancy shall not be less than 36 inches wide. (xii) Operable windows and exterior doors. Windows that can be opened without tools or keys and outer doors without automatic closing devices shall be provided with insect screens. (xiii) Glazing. Glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101, §18.3.3. (xiv) Fire doors. All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 edition. Reference to a labeled door shall be construed to include labeled frame and hardware. (xv) Grab bars. Grab bars shall be provided at patient toilets, showers and tubs. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars are not permitted at bathing and toilet fixtures in mental health and chemical dependency units unless designed and installed to eliminate the possibility of patients harming themselves. Grab bars intended for use by the disabled shall also comply with ADA requirements. (xvi) Soap dishes. Soap dishes shall be provided at all showers and bathtubs. (xvii) Hand washing facilities. Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free operable controls shall be provided within each workroom, examination, and treatment room. Hands-free includes blade-type handles, and foot, knee, or sensor operated controls. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be provided and conveniently located for staff use throughout the hospital where patient care contact occurs and services are provided. (xviii) Soap dispensers. A liquid or foam soap dispenser shall be located at each hand washing facility. (xix) Alcohol-based hand rubs. Alcohol-based hand rubs (ABHRs) are considered flammable. When used, the ABHRs shall meet the following requirements: (I) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart. (II) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms. (III) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches. (IV) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments. (V) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage. (xx) Hand drying. Provisions for hand drying shall be included at all hand washing facilities except scrub sinks. There shall be hot air dryers or individual paper or cloth units enclosed in such a way as to provide protection against dust or soil and ensure single-unit dispensing. (xxi) Mirrors. Mirrors shall not be installed at hand washing fixtures where asepsis control and sanitation requirements would be lessened by hair combing. Mirrors may be installed in patient rooms, patient toilet rooms, lockers, and public toilet rooms. (xxii) Ceiling heights. The minimum ceiling height shall be seven feet six inches with the following exceptions. (I) Boiler rooms. Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping. (II) Rooms with ceiling-mounted equipment. Rooms containing ceiling-mounted equipment shall have the ceiling height clearance increased to accommodate the equipment or fixtures. (III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor. (xxiii) Areas producing impact noises. Recreation rooms, exercise rooms, and similar spaces where impact noises may be generated shall not be located directly over patient bed area or operating rooms unless special provisions are made to minimize noise. (xxiv) Noise reduction. Noise reduction criteria in accordance with the Table 1 in §133.169(a) of this title (relating to Tables) shall apply to partitions, floor, and ceiling construction in patient areas. (xxv) Rooms with heat-producing equipment. Rooms containing heat-producing equipment such as heater rooms, laundries, etc. shall be insulated and ventilated to prevent any occupied floor surface above from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature. (xxvi) Chutes. Linen and refuse chutes shall comply with the requirements of National Fire Protection Association 82, Standard on Incinerators, Waste and Linen Handling Systems and Equipment, 2004 edition, and NFPA 101, §18.5.4. (xxvii) Thresholds and expansion joint covers. Thresholds and expansion joint covers shall be flush or not more than one-half inch above the floor surface to facilitate the use of wheelchairs and carts. Expansion and seismic joints shall be constructed to restrict the passage of smoke and fire and shall be listed by a nationally recognized testing laboratory. (xxviii) Housekeeping room. (I) In addition to the housekeeping room(s) required in certain departments, sufficient housekeeping rooms shall be provided throughout the hospital as required to maintain a clean and sanitary environment. (II) Each housekeeping room shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies. (B) General finish requirements. (i) Cubicle curtains and draperies. (I) Cubicle curtains, draperies and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small scale and the large-scale tests of National Fire Protection Association 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition. Copies of laboratory test reports for installed materials shall be submitted to the department at the time of the final construction inspection. (II) Cubicle curtains shall be provided to assure patient privacy. (ii) Flame spread, smoke development and noxious gases. Flame spread and smoke developed limitations of interior finishes shall comply with Table 2 of §133.169(b) of this title and NFPA 101, §10.2. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition, and National Fire Protection Association 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 2001 edition, shall be provided. (iii) Floor finishes. Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet (such as shower and bath areas, kitchens, and similar work areas) shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes: (I) painted concrete; (II) vinyl and vinyl composition tiles and sheets; (III) monolithic or seamless flooring. Where required, seamless flooring shall be impervious to water, coved and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles. The base shall not be less then six inches in height. Welded joint flooring is acceptable; (IV) ceramic and quarry tile; (V) wood floors. Wood floors subject to frequent cleaning methods shall be avoided. When wood floors are used, the floor shall be tightly sealed, without voids and the joints shall be impervious to water; (VI) carpet flooring. Carpeting installed in intensive care units, nurseries, patient rooms and similar patient care areas shall be treated to prevent bacterial and fungal growth; (VII) terrazzo; and (VIII) poured in place floors. (iv) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall comply with requirements contained in Table 2 of §133.169(b) of this title, and NFPA 101, §18.3.3. (I) Wall finishes shall be water-resistant in the immediate area of plumbing fixtures. (II) Wall finishes subject to frequent wet cleaning methods shall be impervious to water, tightly sealed and without voids. (v) Floor, wall and ceiling penetrations. Floor, wall and ceiling penetrations by pipes, ducts, and conduits or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents and insects. Joints of structural elements shall be similarly sealed. (vi) Ceiling types. Ceilings which are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing. Three types of ceilings that are required in various areas of the hospital are: (I) Ordinary ceilings. Ceilings such as acoustical tiles installed in a metal grid which are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners. (II) Washable ceilings. Ceilings that are made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid. (III) Monolithic ceilings. Ceilings which are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish. (vii) Special construction. Special conditions may require special wall and ceiling construction for security in areas such as storage of controlled substances and areas where patients are likely to attempt suicide or escape. (viii) Flammable anesthetizing locations. Flammable anesthetic locations in which flammable anesthetic agents are stored or administered shall comply with Annex E of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99). (ix) Materials finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes. (x) Signage. A sign shall be posted at the entrance to each toilet/restroom to identify the facility for public, staff or patient use. Signs are not required for patient room bathrooms. (3) General mechanical requirements. This paragraph contains common requirements for mechanical systems; steam and hot and cold water systems; air conditioning, heating and ventilating systems; plumbing fixtures; piping systems; and thermal and acoustical insulation. The hospital shall comply with the requirements of this paragraph and any specific mechanical requirements for the particular unit of the hospital in accordance with §133.163 of this title. (A) Equipment location. When mechanical equipment is exposed to weather, it shall be protected by weatherproof construction or weather protected. (B) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators. (C) Performance and acceptance. Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or his representative that the installation and performance of these systems conform to the requirements of the plans and specifications. (i) Material lists. Upon completion of the contract, the owner shall be provided with parts lists and procurement information with numbers and description for each piece of equipment. (ii) Instructions. Upon completion of the contract, the owner shall be provided with instructions in the operational use of systems and equipment as required. (D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition, (NFPA 90A), NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §133.163 of this title. (i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior. (I) Cost reduction methods. To reduce utility costs, facility design may utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shutdown or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied. In no case shall patient care be jeopardized. (II) Economizer cycle. Mechanical systems shall be arranged to take advantage of outside air conditions by using an economizer cycle when appropriate to reduce heating and cooling systems loads. Innovative design that provides for additional energy conservation while meeting the intent of this section for acceptable patient care may be presented to the department for consideration. (III) Outside air intake locations. Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet. (IV) Low air intake location limit. The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level. (V) Contaminated air exhaust outlets. Exhaust outlets from areas (kitchen hoods, etc.) that exhaust contaminated air shall be above the roof and be arranged to exhaust upward unless the air has been treated by an appropriate means where sidewall exhaust will be allowed. Ethylene oxide sterilizers shall be terminated above the roof and be arranged to exhaust upward. (VI) Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of §133.169(c) of this title. For reductions and shutdown of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 3 of §133.169(c) of this title shall be followed. (VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food preparation areas, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted. (VIII) Ventilation start-up requirements. Air handling systems shall not be started or operated without the filters installed in place. This includes the 90% and 99.97% efficiency filters where required. Ducts shall be cleaned thoroughly and throughout by a certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, the department will require a written report assuring cleanliness of duct and clean air quality. (IX) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used. (ii) Filtration requirements. All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of §133.169(d) of this title. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. All documents published by ASHRAE as referenced in this section may be obtained by writing or calling the ASHRAE, Inc. at the following address or telephone number: ASHRAE, Inc., 1791 Tullie Circle, N. E., Atlanta, GA 30329; telephone (404) 636-8400. (I) Filtration requirements for air handling units serving single rooms requiring asepsis control. Dedicated air handlers serving only one room where asepsis control is required, such as, but not limited to, operating rooms, delivery rooms, special procedure rooms, and nurseries shall be equipped with filters having efficiencies equal to, or greater than, those specified for patient care areas in Table 4 of §133.169(d) of this title. (II) Filtration requirements for air handling units serving other single rooms. Dedicated air handlers serving all other single rooms shall be equipped with nominal filters installed at the return air system. (III) Location of multiple filters. Where two filter beds are required by Table 4 of §133.169(d) of this title, filter bed number one shall be located upstream of the air conditioning equipment, and filter bed number two shall be downstream of the supply air blowers and cooling and heating coils. (IV) Location of single filters. Where only one filter bed is required by Table 4 of §133.169(d) of this title, it shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork. (V) Pressure monitoring devices. A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters. (iii) Thermal and acoustical insulation for air handling systems. Asbestos insulation shall not be used. (I) Thermal duct insulation. Air ducts and casings with outside surface temperature below ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation. (II) Insulation in air plenums and ducts. Linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories (UL), Inc., Standard Number 181 (relating to Factory-Made Duct Materials and Air Duct Connectors), April 4, 1996 edition. This document may be obtained from the Underwriters Laboratories, Inc., 333 Pfingsten Road, Northbrook, IL 60062-2096. (III) Insulation flame spread and smoke developed ratings. Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A, Chapters 4 and 5. (IV) Linings and acoustical traps. Duct lining and acoustical traps exposed to air movement shall not be used in ducts serving critical care areas. This requirement shall not apply to mixing boxes and acoustical traps that have approved nonabrasive coverings over such linings. (V) Frangible insulation. Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem. (VI) Existing duct linings. Internal linings shall not be used in ducts, terminal boxes, or other air system components supplying operating rooms, delivery rooms, birthing rooms, labor rooms, recovery rooms, nurseries, trauma rooms, isolation rooms, and intensive care units unless terminal filters of at least 90% efficiency are installed downstream of linings. (iv) Ventilation for anesthetizing locations. Ventilation for anesthetizing locations, as defined in NFPA 99, §3.3, shall comply with NFPA 99, §13.4.1.2, and any specific ventilation requirements for the particular unit in accordance with §133.163 of this title. (I) Smoke removal systems for windowless anesthetizing locations. Smoke removal systems shall be provided in all windowless anesthetizing locations in accordance with NFPA 99, §6.4.1.2. (II) Smoke removal systems for surgical suites. Smoke removal systems shall be provided in all surgical suites in accordance with NFPA 99, §6.4.1.3. (III) Smoke exhaust grilles. Exhaust grilles for smoke evacuation systems shall be ceiling-mounted or wall-mounted within 12 inches of the ceiling. (v) Location of return and exhaust air devices. The bottoms of wall-mounted return and exhaust air openings shall be at least four inches above the floor. Return air openings located less than six inches above the floor shall be provided with nominal filters. All exhaust air openings and return air openings located higher than six inches but less than seven feet above the floor shall be protected with grilles or screens having openings through which a one-half inch sphere will not pass. (vi) Ray protection. Ducts which penetrate construction intended for X-ray or other ray protection shall not impair the effectiveness of the protection. (vii) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a required two-hour or higher fire rated wall or floor in accordance with the requirements of NFPA 101, §18.5.2. (viii) Smoke damper requirements. Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101, §18.3.7.3, and NFPA 90A, Chapter 5. (I) Fail-safe installation. Smoke dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by National Fire Protection Association 72, National Fire Alarm Code, 2002 edition (NFPA 72), Chapter 8; NFPA 90A, Chapter 6; and NFPA 101, §18.3.7; the fire sprinkler system; and upon loss of power. Smoke dampers shall not close by fan shutdown alone unless it is a part of an engineered smoke removal system. (II) Interconnection of air handling fans and smoke dampers. Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts. (III) Frangible devices. Use of frangible devices for shutting smoke dampers is not permitted. (ix) Acceptable damper assemblies. Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose shall be acceptable. (x) Duct access doors. Unobstructed access to duct openings in accordance with NFPA 90A, §4.3.4, shall be provided in ducts within reach and sight of every fire damper, smoke damper and smoke detector. Each opening shall be protected by an internally insulated door which shall be labeled externally to indicate the fire protection device located within. (xi) Restarting controls. Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided that provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices. (xii) Make-up air. If air supply requirements in Table 3 of §133.169(c) of this title do not provide sufficient air for use by exhaust hoods and safety cabinets, filtered make-up air shall be ducted to maintain the required air flow direction in that room. Make-up systems for hoods shall be arranged to minimize short circuiting of air and to avoid reduction in air velocity at the point of contaminant capture. (4) General piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code Illustrated published by the National Association of Plumbing-Heating-Cooling Contractors (PHCC), 2003 edition, and this paragraph. The National Standard Plumbing Code may be obtained by writing or calling the PHCC at the following address or telephone number: Plumbing-Heating-Cooling Contractors, P.O. Box 6808, Falls Church, VA 22046; telephone (800) 533-7694. (A) Piping systems. (i) Water supply systems. Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Domestic water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand. (I) Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture. (II) Backflow preventers. Backflow preventers (vacuum breakers) shall be installed on hose bibbs, laboratory sinks, janitor sinks, bedpan-flushing attachments, autopsy tables, and on all other fixtures to which hoses or tubing can be attached. (III) Flushing valves. Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers. (IV) Capacity of water heating equipment. Water heating equipment shall have sufficient capacity to supply water for clinical, dietary and laundry use at the temperatures and amounts specified in Table 5 of §133.169(e) of this title. (V) Water temperature measurements. Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment. (VI) Water storage tanks. Domestic water storage tank(s) shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. When potable water storage tanks (hot and cold) are used, the water shall be used and replenished. Water shall not be stored in tanks for future use unless the water is tested weekly for contaminates/bacteria. (VII) Hot water distribution. Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times. (VIII) Emergency water supply. Emergency potable water storage facilities shall be provided. The storage capacity shall not be less than 500 gallons or 12 gallons per licensed patient bed, whichever is greater. Capacity of hot water storage tanks may be included as part of the required emergency water capacity when valves and piping systems are arranged to make this water available at all times. When bottle water is used in lieu of water storage facilities, the hospital shall maintain and ensure the required amount of bottled water supply on hand at all times, maintain an inventory record which reflects the rotation and replacement of expired bottled water, and have adequate storage space on site that is readily accessible by staff in the event of an emergency. The hospital shall ensure the continued availability and delivery of bottled water until the emergency situation has concluded. (IX) Purified water supply system. Purified water distribution system piping shall be task specific and include, but not necessarily be limited to, Polypropylene (PP), Polyvinylidene fluoride (PVDF) or Polyvinyl Chloride (PVC) pipe. Final installed purified water system piping assemblies shall be UL approved and fully comply with applicable American Society for Testing and Materials (ASTM) Fire Resistant/Smoke Density requirements. The applicable documents are available from ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA, 19428-2959. (X) Dead-end piping. Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In any renovation work, dead-end piping shall be removed. Empty risers, mains and branches installed for future use are permitted. (ii) Fire sprinkler systems. Fire sprinkler systems shall be provided in hospitals as required by NFPA 101, §18.3.5. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, and shall be certified as required by §133.168(c)(1)(C) of this title (relating to Construction, Inspections, and Approval of Project). (iii) Nonflammable medical gas and clinical vacuum systems. Nonflammable medical gas and clinical vacuum system installations shall be designed, installed and certified in accordance with the requirements of NFPA 99, §5.1 for Level I systems and the requirements of this clause. (I) Outlets. Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 6 of §133.169(f) of this title. (II) Installer qualifications. All installations of the medical gas piping systems shall be done only by, or under the direct supervision of a holder of a master plumber license or a journeyman plumber license with a medical gas piping installation endorsement issued by the Texas State Board of Plumbing Examiners. (III) Installer tests. Prior to closing of walls, the installer shall perform an initial pressure test, a blowdown test, a secondary pressure test, a cross-connection test, and a purge of the piping system as required by NFPA 99. (IV) Qualifications for conducting verification tests and inspections. Verification testing shall be performed and inspected by a party, other than the installer, installing contractor, or material vendor. Testing shall be conducted by a registered medical gas system verifier and technically competent and experienced in the field of medical gas and vacuum pipeline testing and meeting the requirements of the American Society of Safety Engineers (ASSE) Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems. The document published by ASSE Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems as referenced in this rule may be obtained by writing or calling The American Society of Safety Engineers (ASSE) at ASSE International Office, 901 Canterbury, Suite A, Westlake, Ohio 44145, telephone (440) 885-3040. (V) Verification tests. Upon completion of the installer inspections and tests and after closing of walls, verification tests of the medical gas piping systems, the warning system, and the gas supply source shall be conducted. The verification tests shall include a cross-connection test, valve test, flow test, piping purge test, piping purity test, final tie-in test, operational pressure tests, and medical gas concentration test. (VI) Verification test requirements. Verification tests of the medical gas piping system and the warning system shall be performed on all new piped medical gas systems, additions, renovations, or repaired portions of an existing system. All systems that are breached and components that are added, renovated, or replaced shall be inspected and appropriately tested. The breached portions of the systems subject to inspection and testing shall be all of the new and existing components in the immediate zone or area located upstream of the point or area of intrusion and downstream to the end of the system or a properly installed isolation valve. (VII) Warning system verification tests. Verification tests of piped medical gas systems shall include tests of the source alarms and monitoring safeguards, master alarm systems, and the area alarm systems. (VIII) Source equipment verification tests. Source equipment verification tests shall include medical gas supply sources (bulk and manifold) and the compressed air source systems (compressors, dryers, filters, and regulators). (IX) Hospital responsibility. Before new piped medical gas systems, additions, renovations, or repaired portions of an existing system are put into use, the hospital shall be responsible for ensuring that the gas delivered at the outlet is the gas shown on the outlet label and that the proper connecting fittings are checked against their labels. (X) Written certification. Upon successful completion of all verification tests, written certification for affected piped medical gas systems and piped medical vacuum systems including the supply sources and warning systems shall be provided by a party technically competent and experienced in the field of medical gas pipeline testing stating that the provisions of NFPA 99 have been adhered to and systems integrity has been achieved. The written certification shall be submitted directly to the hospital and the installer. A copy shall be forwarded to the department by the hospital. (XI) Documentation of medical gas and clinical vacuum outlets. Documentation of the installed, modified, extended or repaired medical gas piping system shall be submitted to the department by the same party certifying the piped medical gas systems. The number and type of medical gas outlets (oxygen, vacuum, medical air, nitrogen, nitrous oxide, etc.) shall be documented and arranged tabularly by room numbers and room types. (iv) Medical gas storage facilities. Main storage of medical gases may be outside or inside the hospital in accordance with NFPA 99, §5.1. Provision shall be made for additional separate storage of reserve gas cylinders necessary to complete at least one day's procedures. (v) Multiple gas outlets on one medical gas outlet. Y-connections, "twinning," or other similar devices shall not be used on any medical gas outlet. (vi) Waste anesthetic gas disposal (WAGD) systems. Each space routinely used for administering inhalation anesthesia shall be provided with a WAGD system as required by NFPA 99, §5.1.3.7. (vii) Steam and hot water systems. (I) Boilers. Boilers shall have the capacity, based upon the net ratings as published in The I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of GAMA, to supply the normal requirements of all systems and equipment. The number and arrangement of boilers shall be such that, when one boiler breaks down or routine maintenance requires that one boiler be temporarily taken out of service, the capacity of the remaining boiler(s) shall be sufficient to provide hot water service for clinical, dietary, and patient use, steam for sterilization and dietary purposes, and heating for operating, delivery, emergency, labor, recovery, intensive care, nursery, treatment, and general patient rooms. However, reserve capacity for space heating of noncritical care areas (e.g. general patient rooms and administrative areas) is not required in geographical areas where a design dry bulb temperature equals 25 degrees Fahrenheit or higher as based on the 99% design value shown in the Handbook of Fundamentals, 2005 edition, published by ASHRAE, Inc. The document published by the Hydronics Institute Division of GAMA as referenced in this rule may be obtained by writing or calling the Hydronics Institute Division of GAMA at 35 Russo Place, P.O. Box 218, Berkeley Heights, N.J. 07922, telephone (908) 464-8200. (II) Boiler accessories. Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service. (III) Valves. Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment. (IV) Hot water distribution systems. Hot water distribution systems for patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet. Nonrecirculated fixtures branch piping shall not exceed 25 feet in length. Water temperature is measured at the point of use or inlet to the equipment. Tankless water system may be used at point of use. (V) Domestic hot water system. The domestic hot water system shall make provisions to limit the amount of Legionella bacteria and opportunistic waterborne pathogens. (viii) Drainage systems. (I) Above ground piping. Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe. (II) Underground piping. All underground building drains shall be: cast iron soil pipe, hard temper copper tube (DWV or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), polyvinyl chloride (PVC) plastic pipe (DWV Schedule 40 or heavier), or extra strength vitrified clay pipe (VCP) with compression joints or couplings with at least 12 inches of earth cover. (III) Drains for chemical wastes. Separate drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant glass pipe, high silicone content cast iron pipe, VCP, plastic pipe, or plastic lined pipe. (ix) Thermal insulation for piping systems and equipment. Insulation shall be provided for the following: (I) boilers, smoke breeching, and stacks; (II) steam supply and condensate return piping; (III) hot water piping and all hot water heaters, generators, converters, and storage tanks; (IV) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; (V) other piping, ducts, and equipment as necessary to maintain the efficiency of the system. (x) Pipe and equipment insulation rating. Flame spread shall not exceed 25 and smoke development rating shall not exceed 150 for pipe insulation as determined by an independent testing laboratory in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition. Smoke development rating for pipe insulation located in environmental air areas shall not exceed 50. (xi) Asbestos insulation. Asbestos insulation shall not be used. (B) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive acid-resistant materials and shall comply with the recommendations of the National Standard Plumbing Code and this paragraph. (i) Sink and lavatory controls. All fixtures used by medical and nursing staff and all lavatories used by patients and food handlers shall be trimmed with valves which can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may be used. (ii) Clinical sink traps. Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface. (iii) Sinks for disposal of plaster of paris. Sinks used for the disposal of plaster of paris shall have a plaster trap. (iv) Back-flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized. (v) Drinking fountain. Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination. (vi) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent not only the contamination of the water supply but also the entrance of contaminating materials into the sterilizing units. (vii) Hose attachment. No hose shall be affixed to any faucet if the end of the hose can become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker. (viii) Bedpan washers and sterilizers. Bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level. (ix) Flood level rim clearance. The water supply spout for lavatories and sinks required in patient care areas shall be mounted so that its discharge point is a minimum of five inches above the rim of the fixture. (x) Scrub sink controls. Scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or ultrasonic controls. Single lever wrist blades are not acceptable at scrub sinks. (xi) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to grilled drain cover to prevent entry of large particles of waste which might cause stoppages. (xii) Under-counter piping. Under-counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of floor below the equipment. (xiii) Ice machines. All ice-making machines used for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines. (xiv) Food disposal units. A food disposal unit shall only be permitted in the dietary department (§133.163(e) of this title). (5) General electrical requirements. This paragraph contains common electrical requirements. The hospital shall comply with the requirements of this paragraph and with any specific electrical requirements for the particular unit of the hospital in accordance with §133.163 of this title. (A) Electrical installations. All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the National Fire Protection Association 70, National Electrical Code, 1999 edition (NFPA 70), and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturers' instructions. (i) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition. (ii) Extension cords and cables shall not be used for permanent wiring. (iii) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater. (iv) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70. (v) Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of floor below the equipment. (B) Installation testing and certification. (i) Installation testing. The electrical installations, including alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional. (ii) Grounding system testing. The grounding system shall be tested as described in NFPA 99, 4.3.3, for patient care areas in new or renovated work. The testing shall be performed by a qualified electrician or their qualified electrical testing agent. The electrical contractor shall provide a letter stating that the grounding system has been tested in accordance with NFPA 99, the testing device use complies with NFPA 99, and whether the grounding system passed the test. The letter shall be signed by the qualified electrical contractor, or their designated qualified electrical testing agent, certifying that the system has been tested and the results of the test are indicated. (C) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment. (D) Services and switchboards. Electrical service and switchboards serving the required hospital components shall be installed above the designated 100-year flood plain. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures. (E) Panelboards. Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits shall be located on each floor that has major users (operating rooms, delivery suites, intensive care, etc.) and may also serve the floor above and the floor below. Panelboards serving life safety branch circuits may serve three floors, the floor where the panelboard is located, and the floors above and below. (F) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300. (G) Lighting. (i) Lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IESNA) Handbook, 2000 edition, published by the IESNA, 120 Wall Street, Floor 17, New York, New York 10005. (I) Consideration should be given to controlling intensity and wavelength to prevent harm to the patient's eyes (i.e., retina damage to premature infants and cataracts due to ultraviolet light). (II) Approaches to buildings and parking lots, shall be illuminated. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all parts of these spaces shall be clearly visible. (III) Consideration should be given to the special needs of the elderly. Excessive contrast in lighting levels that makes effective sight adaptation difficult shall be minimized. (ii) Means of egress and exit sign lighting intensity shall comply with NFPA 101, §§7.8 - 7.10. (iii) Electric lamps which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields. (iv) Ceiling-mounted surgical and examination light fixtures shall be suspended from rigid support structures mounted above the ceiling. (H) Receptacles. Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in all patient care areas. This does not apply to special purpose receptacles. (i) Installations of multiple-ganged receptacles shall not be permitted in patient care areas. (ii) Electrical outlets powered from the critical branch shall be provided in all patient care, procedure and treatment locations in accordance with NFPA 99, §4.4.2.2.2.3. At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel. (iii) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be accomplished with receptacles of the same distinct color as the existing receptacles. (iv) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use. (v) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor. (vi) All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number. (I) Equipment. (i) Equipment required for safe operation of the hospital shall be powered from the equipment system in accordance with the requirements contained in NFPA 99, §4.4.2.2.3. (ii) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected and installed to provide both normal and standby service. (iii) Laser equipment shall be installed according to manufacturer recommendations and shall be registered with the Radiation Branch, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756. (J) Ground fault circuit interrupters (GFCI). GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle. (K) Grounding requirements. In areas such as critical care units and special nurseries where a patient may be treated with an internal probe or catheter connected to the heart, the ground system shall comply with applicable sections of NFPA 99 and NFPA 70. (L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a hospital: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with §133.163 and Table 7 of §133.169(g) of this title. Where required in this subparagraph, a distinct visible signal is provided when a colored dome light lamp, or particular combination of colored lamps is used for only one type of call. Different flash rates do not meet this requirement. (i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signal(s) in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. An alarm shall activate at the nurses station when the call cable is unplugged. (ii) A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §133.169(g) of this title. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement. (iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit's nurses station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of §133.169(g) of this title. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided via automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit's nurse station. (M) Emergency electric service. A type I essential electrical system shall be provided in each hospital in accordance with requirements of NFPA 99; NFPA 101, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 edition. (i) When the emergency and standby power systems require a fuel source with tank, the fuel storage capacity tank shall have enough fuel for a period of 24 hours. (ii) When a vapor liquefied petroleum gas (LPG) systems (natural gas) system is used, the 24-hour fuel capacity on-site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply. (iii) When the emergency generator(s) and electrical transformer(s) are located within the same area, they shall be located at least 10 feet apart. (N) Fire alarm system. A fire alarm system which complies with NFPA 101, §18.3.4, and with NFPA 72, Chapter 6 requirements, shall be provided in each facility. The required fire alarm system components are as follows: (i) A fire alarm control panel (FACP) shall be installed at a continuously attended (24 hour) location. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and is capable of indicating both visual and audible alarm, trouble and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP. (ii) Manual fire alarm pull stations shall be installed in accordance with NFPA 101, §18.3.4. (iii) Smoke detectors for door release service shall be installed on the ceiling at each door opening in the smoke partition in accordance with NFPA 72, §6.15.6, where the doors are held open with electromagnetic devices conforming with NFPA 101, §18.2.2.6. (iv) Ceiling-mounted smoke detector(s) shall be installed in room containing the FACP when this room is not attended continuously by staff as required by NFPA 72, §4.4.5. (v) Smoke detectors shall be installed in air ducts in accordance with NFPA 72, §5.14.4.2 and §5.14.5 and NFPA 90A, §6.4.2. (vi) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A, §6.4.2.2. (vii) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101, §9.6.2; NFPA 13, §6.9; and NFPA 72, §8.5.3.3.3.4. (viii) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72, §6.8.5.5. (ix) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §18.3.4, and NFPA 72, §7.4. (x) Visual fire alarm indicating devices which comply with the requirements of paragraph (1)(D) of this subsection and NFPA 72, §7.5, shall be provided. (xi) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72. (xii) A smoke detection system for spaces open to corridor(s) shall be provided when required by NFPA 101, §18.3.6.1. (xiii) A fire alarm signal notification which complies with NFPA 101, §9.6.3, shall be provided to alert occupants of fire or other emergency. (xiv) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70, Article 760. (xv) A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72, §6.15.3.10. (I) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 2000 edition. The publications of the ASME/ANSI referenced in this section may be obtained by writing ASME/ANSI, United Engineering Center, 345 East 47th Street, New York, N.Y. 10017. (II) The elevator recall smoke detection system in existing hospitals shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2002 edition. (xvi) Smoke detectors for initiating smoke removal from windowless anesthetizing areas shall be provided in accordance with NFPA 99, §6.4.1.2. (xvii) Smoke detectors for initiating smoke removal from surgical suites shall be provided in accordance with NFPA 99, §6.4.1.3. (xviii) A smoke detection system for initiating smoke removal from atriums shall be located above the highest floor level of the atrium and at return intakes from the atrium in accordance with National Fire Protection Association 92B, Guide for Smoke Management Systems in Malls, Atria, and Large Areas, 2000 edition. (xix) Smoke detector(s) for shutdown of air handling units shall be provided. The detectors shall be installed in accordance with NFPA 90A, §6.4.3. (O) Telecommunications and information systems. Telecommunications and information systems central equipment shall be installed in a separate location designed for the intended purpose. Special air conditioning and voltage regulation shall be provided as recommended by the manufacturer. (P) Lightning protection systems. When installed, lightning protection systems shall comply with National Fire Protection Association 780, Standard for the Installation of Lightning Protection Systems, 2000 edition. Source Note: The provisions of this §505.162 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.162 New Construction Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223781 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223781 03/12/2026 (a) Administration and public suite.(1) Architectural requirements. The following rooms or areas shall be provided.(A) Primary entrance. An entrance at grade level shall be accessible and protected from inclement weather with a drive under canopy for loading and unloading passengers.(B) Lobby. A main lobby shall be located at the primary entrance and shall include a reception and information counter or desk, waiting space(s), public toilet facilities, public telephones, drinking fountain(s), and storage room or alcove for wheelchairs.(C) Admissions area. An admissions area shall include a waiting area, work counters or desk, private interview spaces, and storage room or alcove for wheelchairs. The waiting area and wheelchair storage may be shared with similar areas located in the main lobby. The admission area may be omitted if exclusive bedside registration is used.(D) General or individual office(s). Office space shall be provided for business transactions, medical and financial records, and administrative and professional staffs.(E) Multipurpose room(s). Room(s) shall be provided for conferences, meetings, and health education purposes including provisions for showing visual aids.(F) Storage. Storage for office equipment and supplies shall be provided. The construction protection for the storage room or area shall be in accordance with the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), §18.3.2. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555; the NFPA website address is http://catalog.nfpa.org.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title (relating to New Construction Requirements).(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(b) Cart cleaning and sanitizing unit.(1) Architectural requirements.(A) Cart cleaning, sanitizing and storage facilities shall be provided for carts serving central services, dietary services, and linen services.(B) Cart facilities may be provided for each service or be centrally located.(C) Hand washing fixtures shall be provided in cart cleaning, sanitizing and storage areas.(2) Details and finishes. When interior cart cleaning facilities are provided, details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph.(A) Flooring in the cart cleaning and sanitizing unit shall be of the seamless type, or ceramic or quarry tile as required by §133.162(d)(2)(B)(iii)(III) or (IV) of this title.(B) Ceilings in the cart cleaning and sanitizing unit shall be the monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) Hand washing fixtures shall be provided with hot and cold water. Hot and cold water fixtures shall be provided in cart cleaning and sanitizing locations regardless of whether or not they are interior or exterior.(B) Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages. Floor drains and floor sinks shall be located to avoid conditions where removal of covers for cleaning is difficult.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(c) Central sterile supply suite.(1) Architectural requirements.(A) General. When obstetrical or surgical services are provided, the following rooms or areas shall be provided.(i) Decontamination room. This room shall be physically separated from all other areas of the suite. The room shall include work counters or tables, flush type utility sink, equipment for initial disinfection, and hand washing facilities with hands-free operable controls. Materials shall be transferred from the decontamination room to the clean assembly room by way of pass-through doors, windows or washer equipment. The dirty side of the decontamination room may be combined with a soiled utility room if all functions for each space are provided within the room.(ii) Clean and assembly room. The room shall include counters or tables, equipment for sterilizing and hand washing facilities with hands-free operable controls. Clean and soiled work areas shall be physically separated.(iii) Breakdown storage room. A storage room for breakdown of supplies shall be provided. The storage room shall have adequate areas and counters for breakdown of prepackaged supplies.(iv) Sterile and clean supply room. A sterile and clean supply room shall be provided. Storage of sterile and clean supplies shall not occur within the breakdown room.(v) Equipment storage. An equipment storage room shall be provided.(vi) Cart storage room. The storage room for distribution carts shall be adjacent to clean and sterile storage and close to main distribution points.(vii) Multipurpose room. The equipment storage and cart storage room can be combined into a multipurpose room.(B) Service areas. The central supply suite shall provide the following.(i) Office space. Office space for director of central services.(ii) Staff toilets. Facilities may be outside the unit but must be convenient for staff use and shall contain hand washing fixtures with hands-free operable controls.(iii) Locker room. When provided, the locker room for staff shall include lockers, toilets, lavatories, showers, and male and female dressing rooms or cubicles. A central changing locker room may be shared and made available within the immediate area of the central sterile supply suite.(iv) Housekeeping room. A housekeeping room shall be provided and contain a floor receptor or service sink and storage space for housekeeping supplies and equipment. The housekeeping room shall be located on the decontamination/soiled side of the central sterile supply suite. (2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details. Mirrors shall not be installed at hand washing fixtures in clean and sterile supply areas.(B) Finishes.(i) Flooring used in the decontamination room and the clean assembly room shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceilings in the decontamination room, clean assembly room, and supply storage room shall be the monolithic type in accordance with §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) The sterile supply room and the clean and assembly room shall include provisions for ventilation, humidity, and temperature control.(B) When provided, installations of ethylene oxide (EO) sterilizers shall comply with the requirements of 30 TAC §106.417 (relating to Ethylene Oxide Sterilizers), administered by the Texas Commission on Environmental Quality (TCEQ), and the following requirements. (i) All source areas shall be exhausted, including the sterilizer equipment room, service and aeration areas, over sterilizer door, and the aerator. If the EO cylinders are not located in a well-ventilated unoccupied equipment space, an exhaust hood shall be provided over the cylinders. The relief valve shall be terminated in a well-ventilated, unoccupied equipment space, or outside the building.(ii) General airflow shall be away from sterilizer operators and towards the sterilizers.(iii) A dedicated exhaust fan and an exhaust duct system shall be provided for EO sterilizers. The exhaust outlet to the atmosphere shall be located on the highest roof, directed upward, and not less than 25 feet from any air intake. A legible warning sign shall be provided to identify the exhaust stack on the roof.(iv) An audible and visual alarm located in sterilizer work area and a 24-hour staffed location shall be activated upon loss of airflow in the exhaust system.(C) Filtration requirements for air handling units serving the central sterile supply suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title (relating to Tables).(D) Duct linings exposed to air movement shall not be used in ducts serving the central sterile supply suite unless terminal filters of at least 90% efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title. When medical gas systems are provided, the systems shall comply with §133.162(d)(4) of this title and this paragraph.(A) Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in sterile areas unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(B) No plumbing lines may be exposed or on walls where possible leaks would create a potential of contamination of the sterile areas.(C) The compressed air required for the decontamination room shall not be connected to the medical air piping distribution system such as supporting breathable air for respiratory assistance needs, anesthesia machines, intermittent positive pressure breathing machine (IPPB), etc. A separate compressed air supply source shall be provided for maintenance and equipment needs for facility support use.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. Electrical circuit(s) to equipment in wet areas shall be provided with ground fault circuit interrupters (GFCIs).(d) Critical care unit.(1) Architectural requirements.(A) General. When a critical care unit(s) (CCU) (also known as intensive care unit) is provided, the unit(s) may be classified as general CCU, coronary CCU (CCCU) or pediatric CCU (PCCU). Requirements for neonatal intensive care units (NCCU) are stated in subsection (u) of this section.(i) The CCU(s) shall be a separate suite(s) operated separately from other units of the hospital. The location shall be arranged to eliminate the need for through traffic.(ii) When elevator transport is required for critically ill patients, the size of the elevator cab, mechanisms and controls shall meet the specialized needs. (B) CCU services and facilities. The following services and facilities shall apply to all classifications of CCUs unless otherwise noted.(i) The patient area (whether separate rooms, cubicles, or multiple-bed space) shall have a minimum clear floor area of 200 square feet per bed exclusive of anterooms, vestibules, toilet rooms, closets, lockers, wardrobes, and/or alcoves. A minimum of 13 feet width shall be provided for the head wall for each bed.(ii) When an open ward plan is used, at least one private room for every six ward beds shall be provided for medical isolation or psychological needs.(iii) A minimum of one airborne infection isolation room shall be provided for each type of CCU suite. The number of airborne infection isolation rooms shall be determined based on an infection control risk assessment. Each room shall comply with requirements of subsection (t)(1)(C)(iii) and (iv) of this section. In addition, the isolation room shall comply with clause (i) of this subparagraph.(iv) When private rooms or cubicles are provided, view panels in the door or walls of these rooms are required. Curtains or other means shall be provided to cover the viewing panels when visual privacy is required.(v) For open ward environments in adult and pediatric units, the clearance between a bed and a wall/partition shall be a minimum of five feet. The clearance between sides of beds shall be a minimum of eight feet. The minimum distance at the foot of the bed shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space requirement at the foot of the bed may be shared between two beds. The multiple-bed CCU wards shall contain cabinets, work counters, and hand washing fixtures with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagrams A and B of §133.169(h) of this title.(vi) Each room and ward shall be located on an exterior wall and shall have a window. In a ward, one window may serve more than one patient. The window sill height shall not exceed five feet above the floor. Patient beds shall not be located more than 50 feet from an exterior window. Patients' views to outside windows shall be direct. When partitions are used, the patient's view to the outside window(s) may be through no more than two separate clear vision panels. Windows shall be in accordance with subsection (t)(2)(A)(v) of this section.(vii) Hand washing fixtures with hands-free operable controls shall be located in or adjacent to the nurse station, inside of each room at the entrance of the room, and at a ratio of one fixture to each three beds for an open ward layout. Hand washing fixtures shall be sized to contain splashing and conveniently distributed throughout the ward. When a combination modular swivel/fixed toilet and hand washing fixture is provided, hospital administration shall provide a letter (on hospital letterhead) indicating if the toilet is for staff convenience (bed pan washing) or for patient use.(I) If the toilet is for patient use, an additional hand washing fixture shall be provided in each room at the entrance of the room. If the modular toilet/hand washing unit is for patient use, provision shall be made for patient privacy and odor control. The toilet room exhaust shall be in accordance with Table 3 of §133.169(c) of this title.(II) When the modular toilet/hand washing unit is for staff use, it shall be near the entrance to the room.(viii) The nurse station shall be located to permit direct visual observation of each patient served. Video cameras or mirrors shall not be substituted for direct visual observation. The nurse station shall have space for counters and storage. The counter height shall not exceed 42 inches. The nurse station may be combined with or include centers for reception and communication.(ix) When individual nurse substations are provided and located at each patient room(s), they shall be located to permit direct visual observation of each patient served. The nurse substation shall have space for a counter, storage space and a recessed sitting space. The substation shall, at a minimum, be recessed one foot six inches from the egress corridor.(x) Storage and preparation of medication may be done from a room, alcove area or from a self-contained dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks are not acceptable for hand washing.(xi) An intravenous solution support shall be provided at each patient crib, bed or bassinet. The intravenous solution shall not be suspended directly over the patient.(xii) Storage space shall be provided for emergency equipment in the unit.(C) CCCU. When a CCCU is provided, the CCCU shall comply with the requirements contained in subparagraph (B) of this paragraph and the following.(i) Each CCCU bed shall be in a separate room. Equipment for monitoring cardiac patients shall be provided by visual display both at the bed location and at the nurse station.(ii) Each coronary patient shall have direct access to a toilet room and a hand washing fixture. Swivel type commodes may be utilized in lieu of individual toilet rooms, but provision must be made for patient privacy and odor control. The toilet room exhaust rate shall be in accordance with Table 3 of §133.169(c) of this title.(iii) When medical, surgical, and coronary critical care services are combined in one CCU suite, at least 50% of the beds shall be located in private rooms. (Note: Medical/surgical patients may utilize open areas or private critical care rooms as needed and available but, insofar as possible, coronary patients should not be accommodated in open ward areas.)(D) PCCU. When a PCCU is provided, the unit shall comply with the requirements contained in subparagraph (B) of this paragraph and the following.(i) The PCCU may be an open ward, private rooms, or combination of both. When an open ward plan is used, one private room is required for each 10 beds or fraction thereof.(ii) In a multiple-bassinet/crib (sleeping unit) room/ward the clearance between the side of the sleeping unit and a wall/partition shall be a minimum of five feet. The clearance between sides of sleeping units shall be a minimum of eight feet. The minimum distance at the foot of the bassinet shall not be less than ten feet for single load area/room or sixteen feet for double load area/room. Four feet of the passage space requirement at the foot of the bassinet may be shared between two bassinets. The fixed and moveable cabinets and shelves shall not encroach upon the bassinet/crib clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram K of §133.169(h) of this title.(iii) A sleeping space shall be provided for parents who spend long hours with the patient. This space may be within the patient room or separate from the patient area but shall be in communication with the PCCU staff.(iv) Hand washing fixtures with hands-free operable controls shall be provided in each room near the entrance of the room, and in open wards at a minimum ratio of one fixture to each three cribs, beds or bassinets. Hand washing fixtures shall be sized to contain splashing.(v) A room shall be provided for private discussions and shall be located within, or convenient to, the PCCU. The multipurpose room noted in subparagraph (F)(v) of this paragraph will meet this requirement if conveniently located.(vi) Storage space for infant formula shall be provided. This functional space may be outside the PCCU but shall be available for use at all times.(vii) Storage cabinets or closets for toys and games shall be provided within the unit.(viii) Storage area for cots, bed linens, and other items needed for overnight accommodation of parents shall be provided in the general location of sleeping accommodations.(ix) An examination/treatment room with a minimum of 120 square feet of clear floor area shall be located in or near the PCCU suite. The room shall contain a hand washing fixture with hands-free operable controls, storage facilities, counter, or shelf space for writing. This requirement does not apply when all patient rooms are private rooms.(E) Additional service spaces. The following additional service spaces shall be immediately available within each type of CCU(s). These may be shared by more than one CCU (unless otherwise noted) provided that direct access is available from each.(i) Securable closets. Securable closets or cabinet compartments for the personal effects of nursing personnel, located in or near the nurse station, shall be provided. At a minimum, these shall be large enough for purses and billfolds. Coats may be stored in closets or cabinets on each floor or in a central staff locker area.(ii) Charting and dictation area(s) for physicians. Space for recording, record storage and reviews shall be provided near cribs, beds or bassinets. Dictation space may be in a separate room or alcove. Suitable space shall be provided when computers are used for the clinical records.(iii) X-ray viewing area. Each type of CCU shall be provided with an X-ray viewing area and film illuminators for handling at least four films simultaneously. When the entire CCU suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the suite.(iv) Nourishment station. The nourishment station shall contain a sink with hands-free operable controls, work counter, refrigerator, cabinets, and not be located in the medication room or the clean workroom. Space shall be included for temporary holding of unused or soiled dietary trays.(v) Ice machine. The ice machine shall provide ice for treatment and patient use. Ice-making equipment for treatment may be in the clean workroom or the nourishment station.(vi) Equipment storage. In addition to above, twenty square feet of equipment storage shall be provided for each patient station. These storage areas shall be out of the way of the corridor traffic.(vii) Stretcher storage alcove. The alcove provided for stretcher or bassinet storage shall be located out of direct line of traffic.(viii) Clean workroom. The room shall contain a work counter, a hand washing fixture with hands-free operable controls, and storage facilities for clean and sterile supplies.(ix) Clean linen storage. There shall be a designated area for clean linen storage. This may be within a clean workroom, a separate closet, or an approved distribution system. If a closed cart system is used, storage of the cart may be in an alcove.(x) Soiled workroom. The soiled workroom shall contain a work counter, a clinical sink with hands-free operable controls or equivalent flushing rim type fixture with hot and cold mixing faucet, separate hand washing facilities, and separate waste and soiled linen receptacles.(xi) Soiled holding room. When provided, soiled holding rooms used only for temporary holding of soiled material may omit the clinical sink and work counter.(xii) Housekeeping room. A housekeeping room shall be provided within or immediately adjacent to the CCU. It shall not be shared with other nursing units or departments.(F) Other required areas/rooms. The following areas/rooms shall be provided and may be located outside the unit if conveniently accessible.(i) Waiting space. A visitors' waiting space shall be provided with toilet facility(ies), public telephone(s), and drinking fountain(s). One waiting space may serve other CCUs.(ii) Offices. Room(s) shall be provided for critical care medical and nursing management and administrative personnel. The offices shall be large enough to permit consulting with members of the critical care team and visitors. The offices shall be linked with the unit by telephone or an intercommunications system.(iii) Staff lounge. A staff lounge shall include toilet facilities with a hand washing fixture with hands-free operable controls. The lounge(s) shall be located so that staff may be recalled quickly to the patient area in emergencies. One lounge may serve multiple CCUs when the lounge is adjacent to the units. Toilet facilities may be shared as long as privacy is maintained for changing areas.(iv) On-call rooms. Physicians and other staff on 24-hour on-call work schedules shall be provided with sleeping rooms with access to a shower(s), toilet(s), and lavatory(ies). If on-call room(s) are not within the CCU served, a dedicated telephone or intercom system shall connect the on-call room(s) to the CCU(s).(v) Multipurpose room(s). A multipurpose room for staff, patients, and patients' families for patient conferences, reports, education, and training sessions shall be provided. This room(s) must be accessible to each nursing unit.(vi) A consultation room shall be provided, if not provided elsewhere in the unit.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) At least one door to a CCU room shall be not less than four feet wide (41.5 inches clear width) and arranged to minimize interference with movement of beds and large equipment.(ii) Sliding doors in CCUs shall not have floor tracks at the latch side of the sliding panel, have hardware that minimizes jamming possibilities, and be in accordance with §133.162(d)(2)(A)(vi) of this title.(iii) Glazing in viewing panels shall be safety glass, wire glass, or clear plastic.(iv) Noise control and sound attenuation in an open ward environment shall be a design factor and meet the requirements contained in Table 1 of §133.169(a) of this title.(v) Recreation rooms, exercise rooms, equipment rooms, and similar spaces where impact noises may be generated shall not be located directly over CCU(s), unless special provisions are made to minimize such noise.(B) Finishes.(i) Flooring used in soiled workrooms shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceilings in the soiled workroom shall be monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Room recirculating units shall not be used.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Receptacles at each bed location in a CCU(s) shall be served by two branch circuits, one or more from the critical branch panel of the emergency electrical system and one or more from the normal system. One critical branch circuit shall serve only one bed location. All branch circuits from the normal system shall be from a single panelboard. All branch circuits from the emergency electrical system shall be from a single panelboard.(ii) A minimum of seven hospital grade duplex outlets shall be conveniently located at the head of each bed, crib or bassinet. At least three of these duplex outlets shall be on the critical branch of the emergency electrical system.(iii) Hospital grade receptacles in the PCCU shall be tamper-resistant or provided with GFCIs.(B) Nurses calling systems. The nurse call system shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(e) Dietary suite.(1) Architectural requirements.(A) General. Construction, equipment, and installation shall comply with Chapter 228 of this title (relating to Retail Food).(B) Food service facilities. Food services shall be provided by an on-site food preparation system or an off-site food service system or a combination of the two. The following minimum functional elements shall be provided on site regardless of the type of dietary services.(i) Dining area. Provide dining space(s) for ambulatory patients, staff, and visitors. These spaces shall be separate from the food preparation and distribution areas.(ii) Receiving area. This receiving area shall have direct access to the outside for incoming dietary supplies or off-site food preparation service and shall be separate from the general receiving area. The receiving area shall contain a control station and an area for breakout for loading, unloading, uncrating, and weighing supplies. The entrance area to the receiving area shall be covered from the weather.(iii) Storage spaces. Storage spaces shall be convenient to receiving area and food preparation area and shall be located to exclude traffic through the food preparation area. Regardless of the type of food services provided, the facility shall provide storage of food for emergency use for a minimum of four calendar days.(I) Storage space(s). Storage space(s) shall be provided for bulk, refrigerated, and frozen foods.(II) Cleaning supply storage. This room or closet shall be used to store nonfood items that might contaminate edibles. This storage area may be combined with the housekeeping room.(iv) Food preparation area. Counter space shall be provided for food prep work, equipment, and an area to assemble trays for distribution for patient meals.(v) Ice-making equipment. Ice-making equipment shall be provided for both drinks and food products (self-dispensing equipment) and for general use (storage-bin type equipment).(vi) Hand washing. Hand washing fixtures with hands-free operable controls shall be conveniently located at all food preparation areas and serving areas.(vii) Food service carts. When a cart distribution system is provided, space shall be provided for storage, loading, distribution, receiving, and sanitizing of the food service carts. The cart traffic shall be designed to eliminate any danger of cross-circulation between outgoing food carts and incoming soiled carts, and the cleaning and sanitizing process. Cart circulation shall not be through food processing areas.(viii) Ware washing room. A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross-traffic between "dirty side" and "clean side" of the dish wash areas shall be provided.(ix) Pot washing facilities. A three compartmented sink of adequate size for intended use shall be provided convenient to the food preparation area. Supplemental heat for hot water to clean pots and pans shall be by booster heater or by steam jet.(x) Waste storage room. A food waste storage room shall be conveniently located to the food preparation and ware washing areas but not within the food preparation area. It shall have direct access to the hospital's waste collection and disposal facilities.(xi) Sanitizing facilities. Storage areas and sanitizing facilities for garbage or refuse cans, carts, and mobile tray conveyors shall be provided. All containers for trash storage shall have tight-fitting lids.(xii) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the dietary department. Where hot water or steam is used for general cleaning, additional space within the room shall be provided for the storage of hoses and nozzles.(xiii) Office spaces. An office shall be provided for the use of the food service manager or the dietary service manager. In smaller facilities, a designated alcove may be located in an area that is part of the food preparation area.(xiv) Toilets and locker spaces. A toilet room(s) with a hand washing fixture(s) with hands-free operable controls shall be provided for the exclusive use of the dietary staff. Toilet room(s) shall not open directly into the food preparation areas, but must be in close proximity to them. For larger facilities, a locker room or space for lockers shall be provided for staff belongings.(C) Additional service areas, rooms and facilities. When an on-site food preparation system is used, in addition to the items required in subparagraph (B) of this paragraph, the following service areas, rooms and facilities shall be provided.(i) Food preparation facilities. When food preparation systems are provided, there shall be space and equipment for preparing, cooking, and baking.(ii) Tray assembly line. A patient tray assembly and distribution area shall be located within close proximity to the food preparation and distribution areas.(iii) Food storage. When food is prepared on site, the storage room shall be adequate to accommodate food for a seven calendar day menu cycle.(iv) Additional storage room(s). An additional room(s) shall be provided for the storage of cooking wares, extra trays, flatware, plastic and paper products, and portable equipment.(v) Drying storage area. Provisions shall be made for drying and storage of pots and pans from the pot washing room.(D) Equipment. Equipment for use in the dietary suite shall meet the following requirements.(i) Mechanical devices shall be heavy duty, suitable for the use intended, and easily cleaned. Where equipment is movable, provide heavy duty locking casters. Equipment with fixed utility connections shall not be equipped with casters.(ii) Floor, wall, and top panels of walk-in coolers, refrigerators, and freezers shall be insulated. Coolers and refrigerators shall be capable of maintaining a temperature down to freezing. Freezers shall be capable of maintaining a temperature of 20 degrees below 0 degrees Fahrenheit. Coolers, refrigerators, and freezers shall be thermostatically controlled to maintain desired temperature settings in increments of two degrees or less. Interior temperatures shall be indicated digitally and visible from the exterior. Controls shall include audible and visible high and low-temperature alarm. The time of alarm shall be automatically recorded.(iii) Walk-in units may be lockable from the outside but must have a release mechanism for exit from inside at all times. The interior shall be lighted. All shelving shall be corrosion-resistant, easily cleaned, and constructed and anchored to support a loading of at least 100 pounds per linear foot.(iv) All cooking equipment shall be equipped with automatic shutoff devices to prevent excessive heat buildup.(E) Vending services. When vending machines are provided, a dedicated room or an alcove shall be located so that access is available at all times.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Food storage shelves shall not be less than four inches above the finished floor and the space below the bottom shelf shall be closed in and sealed tight for ease of cleaning.(ii) Operable windows and doors not equipped with automatic closing devices shall be equipped with insect screens.(iii) Food processing areas in the central dietary kitchen shall have ceiling heights not less than nine feet. Ceiling-mounted equipment shall be supported from rigid structures located above the finished ceiling.(iv) Mirrors shall not be installed at hand washing fixtures in the food preparation areas.(B) Finishes. (i) Floors in areas used for food preparation, food assembly, soiled and clean ware cleaning shall be water-resistant and grease-proof. Floor surfaces, including tile joints, shall be resistant to food acids.(ii) Wall bases in food preparation, food assembly, soiled and clean ware cleaning and other areas which are frequently subject to wet cleaning methods shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and be impervious to water.(iii) In the dietary and food preparation areas, the wall construction, finishes, and trim, including the joints between the walls and the floors, shall be free of voids, cracks, and crevices.(iv) The ceiling in food preparation and food assembly areas shall be washable as required by §133.162(d)(2)(B)(vi)(II) of this title.(v) The ceiling in the soiled and clean ware cleaning area shall be of the monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Exhaust hoods handling grease-laden vapors in food preparation centers shall comply with National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2001 edition. All hoods over cooking ranges shall be equipped with grease filters, fire extinguishing systems, and heat-actuated fan controls. Clean out openings shall be provided every 20 feet and at any changes in direction in the horizontal exhaust duct systems serving these hoods. (Horizontal runs of ducts serving range hoods should be kept to a minimum.)(B) When air change standards in Table 3 of §133.169(c) of this title do not provide sufficient air for proper operation of exhaust hoods (when in use), supplementary filtered make-up air shall be provided in these rooms to maintain the required airflow direction and exhaust velocity. Make-up systems for hoods shall be arranged to minimize "short circuiting" of air and to avoid reduction in air velocity at the point of contaminant capture.(C) Air handling units serving the dietary suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) The kitchen grease traps shall be located and arranged to permit easy access without the need to enter food preparation or storage areas. Grease traps shall be of capacity required and shall be accessible from outside of the building without need to interrupt any services.(B) Grease traps or grease interceptors shall be located outside the food preparation area and shall comply with the requirements in the National Association of Plumbing-Heating-Cooling Contractors (PHCC), National Standard Plumbing Code, 2000 edition. This publication may be obtained from the National Association of Plumbing-Heating-Cooling Contractors, 180 South Washington Street, Falls Church, VA 22046; telephone (703) 237-8100.(C) The material used for plumbing fixtures shall be nonabsorptive and acid-resistant.(D) Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and containers.(E) Hand washing fixtures used by food handlers shall be trimmed with valves that can be operated without hands. Single lever or wrist blade devices may be used. Blade handles used for this purpose shall not be less than four inches in length.(F) Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in food preparation centers, food serving facilities and food storage areas unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(G) No plumbing lines may be exposed overhead or on walls where possible leaks would create a potential for food contamination. (5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(B) The electrical circuit(s) to equipment in wet areas shall be provided with five milliampere GFCI.(f) Emergency suite. This subsection applies to all hospitals (general or special) included under the hospital license, including those licensed as a multiple-location hospital.(1) Architectural requirements.(A) Emergency treatment area.(i) Emergency treatment room. As a minimum requirement, all hospitals shall provide at least one emergency treatment room and facilities to handle emergencies. The room(s) and facilities shall meet the following requirements.(I) The emergency treatment room for a single patient shall have a minimum clear area of 120 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 10 feet. The emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls.(II) When a multiple-bed emergency treatment room is provided, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of four feet. The clearance between the sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this subclause are illustrated in Table 8, Diagram C of §133.169(h) of this title.(III) One hand washing fixture with hands-free operable controls shall be provided for each bed/gurney location. One hand washing fixture may serve two beds/gurneys if distributed appropriately between the two.(IV) Storage space shall be provided within the room or suite and be under staff control for general medical-surgical emergency supplies and medications. Adequate space shall be provided for emergency equipment such as emergency treatment trays, ventilator, defibrillator, splints, cardiac monitor, etc.(V) Locked storage space shall be provided for drugs and an area for preparation of medication with a work counter, refrigerator, and hand washing fixture with hands-free operable controls.(VI) An alcove shall be provided for stretcher and wheelchair storage. The storage shall be located out of the line of traffic.(VII) Patient toilet room(s) shall be provided and shall be convenient to treatment rooms, examination rooms, and holding rooms, and a hand washing fixture with hands-free operable controls.(VIII) In a special hospital, comprehensive medical rehabilitation hospital, or pediatric and adolescent hospital, the emergency treatment room and facilities may be located anywhere in the hospital.(ii) Additional requirements for a general hospital. Except for comprehensive medical rehabilitation hospitals and pediatric and adolescent hospitals that generally provide care that is not administered for or in expectation of compensation, a general hospital shall also meet the following requirements.(I) Emergency entry signage. An emergency sign shall be provided at the entry from the public road(s) or street(s) serving the site. The emergency sign at the entry to the site shall be illuminated and connected to the emergency essential electrical system. Additional sign(s) on-site may be required to direct patients to the emergency treatment area entrance when the emergency treatment area is not visible from the site entry. The letters on the entry sign shall be red with a contrasting background, all capitalized, at least eight inches in height, and an arrow indicating direction.(II) Entrances. Separate ambulance and pedestrian entrances at grade level shall be well-illuminated, identified by signs, and protected from inclement weather. The ambulance entry shall have a drive under canopy for protection from inclement weather. The emergency access to permit discharge of patients from automobile and ambulances shall be paved. Parking shall be provided near and convenient to the pedestrian entrance.(III) Control station. A registration, reception, discharge or control station shall be located to permit staff observation and control of access to treatment room(s), pedestrian and ambulance entrances, and public waiting area(s). When a dedicated triage space is provided, it shall include a counter with a hand washing fixture with hands-free operable controls.(IV) Public waiting room. A public waiting room shall be provided.(V) Public facilities. Toilet facilities, public telephone(s), and drinking fountain(s) shall be provided for the exclusive use of the waiting room.(VI) Diagnostic radiographic (X-ray) room. Imaging facilities for diagnostic services shall be readily available to the emergency suite. If a separate radiographic (X-ray) room is installed within the emergency suite, it shall comply with the requirements in subsection (l)(1)(A) of this section. When the diagnostic X-ray room is exclusively used for the emergency treatment area, the dressing rooms may be omitted.(VII) Laboratory unit. Laboratory services shall be made available to the emergency suite. If a separate laboratory workroom is installed within the emergency suite, it shall comply with the requirements in subsection (n)(1)(C)(i) of this section. All laboratory services provided on site or by contractual arrangement shall comply with §133.41(h) of this title (relating to Hospital Functions and Services).(VIII) Medical staff work area and charting area(s). A medical staff work area and charting area(s) shall be provided. The area may be combined with the reception and control area.(IX) Clean storage room. A clean storage room shall be provided for clean supplies, linens and medications as needed. A hand washing fixture shall be provided with hands-free operable controls.(X) Soiled workroom. The workroom shall contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles.(XI) Housekeeping room. The housekeeping room shall contain a floor receptor or service sink, storage space for housekeeping supplies and equipment, and be located within the suite. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided.(XII) Staff toilets. Toilets may be outside the suite but shall be convenient for staff use and include hand washing fixtures with hands-free operable controls. When a department has four or more treatment or examination rooms, toilet facilities shall be in the suite.(iii) Other rooms. If a hospital provides the following rooms, the rooms shall meet these requirements.(I) Examination room. When provided, the examination room for a single patient shall have a minimum clear area of 100 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 9 feet. The examination room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls.(II) Multi-bed examination room. In a multiple-bed examination room the clearance between the side of the bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of the beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed examination room shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. One hand washing fixture shall be provided for every four beds/gurneys or fraction thereof. Fixtures shall be uniformly distributed. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area.(III) Isolation room. The need for an airborne infection isolation room in the emergency suite shall be determined by the hospital and the infection risk assessment. When the hospital provides treatment rooms to perform procedures on persons who are known or suspected of having an airborne infectious disease, these procedures shall be performed in a designated treatment room meeting airborne infection isolation ventilation requirements. The isolation room shall have functional space in accordance with clause (i)(I) of this subparagraph, and meet the ventilation requirements contained in Table 3 of §133.169(c) of this title.(IV) Secured holding room. When provided, this room shall be constructed to allow for security, patient and staff safety, patient observation, and sound mitigation. The secure holding room shall have a minimum clear area of 100 square feet clear floor area exclusive of fixed cabinets. The minimum clear room dimension exclusive of fixed cabinets shall be 10 feet.(V) Orthopedic and cast room. The room(s) may be in separate room(s) or in the trauma room. The room(s) shall contain a work counter, storage for splints and orthopedic supplies, traction hooks, medication storage, examination light, and a hand washing fixture with hands-free operable controls. When a cast room is provided it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures.(VI) Film processing room. When a radiographic (X-ray) room is provided, a darkroom for processing film shall be provided unless the processing equipment does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the darkroom.(VII) Decontamination room. A decontamination room shall have an exterior entry point and as far as practical from any other entry point to the emergency treatment area. The internal door from the decontamination room shall open directly to the corridor into the emergency treatment area. The door shall swing into the room and be lockable against ingress from the corridor. The room shall be a minimum of 80 square feet of clear floor area with a hand washing fixture with hands-free operable controls.(B) Holding or observation room/area.(i) When a holding or observation room/area is provided within or adjacent to the emergency suite, it shall comply with the following.(I) A single holding/observation room shall have a minimum clear area of 100 square feet exclusive of fixed and movable cabinets and shelves. The holding/observation room shall contain a work counter and hand washing fixture with hands-free operable controls.(II) The single holding/observation room shall be near the nurses station and near a patient toilet room which contains a hand washing fixture with hands-free operable controls.(III) In a multiple-bed holding/observation room/area, the clearance between the side of the bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of the beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed holding/observation room/area shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. One hand washing fixture shall be provided for every four holding/observation beds or fraction thereof. Fixtures shall be uniformly distributed. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this subclause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(IV) In a multiple-bed holding/observation room/area, a patient toilet room with a hand washing fixture with hands-free operable controls shall be provided within the room or area.(ii) When a multiple-bed gurney holding or observation room is not within or adjacent to the emergency suite, the following additional spaces shall be provided:(I) stretcher and wheelchair storage alcove. The alcove provided for stretcher and wheelchair storage shall be located out of the line of traffic;(II) clean storage room. A clean storage room shall be provided within or adjacent to the holding or observation room. The clean storage room shall be provided for clean supplies, linen and medication as needed. A hand washing fixture shall be provided with hands-free operable controls;(III) soiled workroom. A soiled workroom shall be provided within or adjacent to the holding or observation room. The workroom shall contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles; and(IV) housekeeping room. A housekeeping room shall be provided within or near the holding or observation room. The housekeeping room shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment.(C) Trauma center. When provided, a trauma center shall comply with subparagraph (B) of this paragraph and in addition contain the following.(i) Trauma room. A minimum of one trauma room shall be provided with 250 square feet of clear floor area exclusive of aisles and fixed and moveable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 12 feet. The trauma room shall contain a work counter, cabinets, medication storage, and examination light.(ii) Multiple-station trauma room. When multiple-patient stations are provided, the clearance between the head of the bed/gurney to the wall/partition shall be a minimum of three feet. The clearance between the side of a bed/gurney and a wall/partition shall be a minimum of six feet. The clearance between the sides of beds/gurneys shall be a minimum of twelve feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed trauma room shall contain cabinets, medication storage, work counter, examination light, and scrub sink with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagrams E of §133.169(h) of this title. Provisions shall be made for visual privacy between multiple stations.(iii) Scrub facilities. A scrub station shall be located at the entrance to each trauma room either inside or outside of the room. One scrub station may serve two trauma beds/gurneys. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts. The scrub sinks shall be recessed out of the main line of traffic.(iv) Doorways. All doorways openings from the ambulance entrance to the trauma room shall be a minimum of five feet wide.(D) Emergency clinic. When an emergency clinic (which may also be referred to as "urgent care", "fast track", "express care", "minor care", etc.) is provided, the clinic shall be separate and distinct from the emergency treatment area and trauma center and shall meet all the requirements of subparagraph (A) of this paragraph. All facilities required by subparagraph (A) of this paragraph may be shared with the emergency treatment area and trauma center except for the emergency treatment room. The emergency treatment room(s) in the emergency clinic shall not be less than 100 square feet. The emergency exam room(s) in the emergency clinic shall not be less than 80 square feet.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Trauma rooms shall have ceiling heights not less than nine feet. (ii) The decontamination room shall be equipped with two hand-held showerheads with temperature controls and a dedicated holding tank with a floor drain.(B) Finishes.(i) Flooring used in a trauma room, treatment room, examination room, holding area, and soiled workroom shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title. Seamless type flooring is not required in the examination room in the emergency clinic.(ii) Ceilings in soiled workrooms, isolation rooms, and trauma rooms shall be of the monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(iii) The decontamination room floor shall be self-coved to a height of six inches. The room shall have all smooth, nonporous, scrubable, nonabsorbent and nonperforated surfaces.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Duct linings exposed to air movement shall not be used in ducts serving any trauma rooms, treatment rooms, examination rooms, holding areas, and clean room. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(B) When a trauma room is provided under paragraph (1)(C)(i) of this subsection, the air supply for the trauma/surgical room shall be from ceiling outlets that are as near the work centers as possible, and a minimum of two low return inlets shall be located diagonally opposite from one another.(C) Return air inlets shall be not lower than four inches nor higher than 12 inches from floor level.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) Medical gas systems. Medical gas systems shall be provided in accordance with §133.162(d)(4)(A)(iii) of this title.(B) Ice machine. An ice machine shall be provided for therapeutic purposes and shall be located in the clean utility room. A self-dispensing ice machine shall be provided for ice for human consumption.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Each treatment and examination room in the emergency treatment area and trauma center shall have a minimum of six duplex electrical receptacles located convenient to the head of each bed.(ii) Each treatment and examination room in the emergency clinic suite shall have a minimum of four duplex electrical receptacles located convenient to the head of each bed/table.(iii) Each work counter and table shall have access to at least one duplex receptacle connected to the critical branch of the emergency electrical system.(iv) The hospital shall provide X-ray film illuminators for handling at least four films simultaneously in all treatment, examination, and trauma rooms in the emergency treatment area. When the entire emergency treatment area is provided with digital imaging, a minimum of two X-ray film illuminators shall be provided within a central location within the emergency treatment area.(B) Nurses calling systems. The nurse call system shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(g) Employees suite.(1) Architectural requirements.(A) Architectural requirements shall be in accordance with §133.162(d)(1) of this title and this paragraph.(B) Lockers, lounges, toilets and showers shall be provided within the hospital for employees and volunteers. These facilities are in addition to, and separate from, those required for the medical staff and the public.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(h) Engineering suite and equipment areas.(1) Architectural requirements. Architectural requirements shall be in accordance with §133.162(d)(1) of this title and this paragraph.(A) General. The following facilities shall be provided:(i) an engineer's office with file space and provisions for protected storage of facility drawings, records, manuals, etc.;(ii) a general maintenance shop(s) for repair and maintenance; (iii) a separate room(s) for building maintenance supplies and equipment. Storage of bulk solvents and flammable liquids shall be in a separate building and not within the hospital building;(iv) a medical equipment room which includes provisions for the storage, repair, and testing of electronic and other medical equipment;(v) a separate room or building for yard maintenance equipment and supplies. When a separate room is within the physical plant the room shall be located so that equipment may be moved directly to the exterior. Yard equipment or vehicles using flammable liquid fuels shall not be stored or housed within the general hospital building; and(vi) sufficient space in all mechanical and electrical equipment rooms for proper maintenance of equipment. Provisions shall also be made for removal and replacement of equipment.(B) Additional areas or room(s). Additional areas or room(s) for mechanical, and electrical equipment shall be provided within the physical plant or installed in separate buildings or weatherproof enclosures with the following exceptions.(i) An area shall be provided for cooling towers and heat rejection equipment when such equipment is used.(ii) An area for the medical gas park and equipment shall be provided. For smaller medical gas systems, the equipment may be housed in a room within the physical plant in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99), Chapters 4 and 8.(iii) When provided, compactors, dumpsters, and incinerators shall be located in an area remote from public entrances.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(i) General stores.(1) Architectural requirements. Architectural requirements shall be in accordance with §133.162(d)(1) of this title and this paragraph.(A) General. In addition to storage facilities in individual departments, a central storage room shall be provided. General stores may be located in a separate building on-site with provisions for protection against inclement weather during transfer of supplies.(B) Receiving. Facilities for central storage areas shall be provided with an off-street unloading and receiving area protected from inclement weather.(C) General storage room. General storage room with a total area of not less than 20 square feet per inpatient bed shall be provided. The storage room may be within the facility, or separate building on-site. Fifty percent of the storage may be provided off-premises. When additional inpatient beds are constructed, additional general storage shall be provided.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(j) Hospital-based skilled nursing units.(1) Architectural requirements. When a hospital-based skilled nursing unit is provided, each unit shall comply with the requirements contained in subsection (t)(1) of this section and the requirements listed below. The skilled nursing unit may be separated from the rest of the hospital with two-hour fire protection rated construction in order to define areas for certification inspections.(A) At least 50% of patient rooms and bathrooms and all public and common use areas in a newly constructed, or reconstructed hospital-based skilled nursing unit, are required to be handicapped accessible in accordance with §133.162(d)(1)(D) of this title.(B) At least 10% of patient rooms and bathrooms and all public and common use areas shall be made handicapped accessible in accordance with §133.162(d)(1)(D) of this title when remodeling a hospital-based skilled nursing unit or remodeling an existing nursing unit to a hospital-based skilled nursing unit.(C) Activity and dining space shall be part of the unit. It may be located in a separate room or open to the corridor and shall be convenient to the unit. The floor area of this space shall provide at least 30 square feet per patient bed with a minimum of 160 square feet. Additional space shall be required if this space is also used for other programs.(D) When physical and occupational therapy services are provided for rehabilitating patients, spaces and equipment that conform to program intent shall be provided. These spaces may be located in the unit or elsewhere in the hospital.(E) Each unit shall have at least one assisted bathing wheelchair shower or tub room per floor or nursing unit. The bathtub shall be accessible to patients in wheelchairs or the shower shall accommodate a gurney. The room shall be centrally located, convenient to the units and shall be directly accessible from the corridor. The room shall have space for drying and dressing and provided with hand washing fixture with hands-free operable controls and toilet training facilities with three feet of clear space on sides and front of the water closet.(F) A housekeeping room shall be provided for the exclusive use of the unit. The housekeeping room shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment. (2) Details and finishes. Each unit shall comply with the requirements contained in subsection (t)(2) of this section and this paragraph.(A) All portions of corridor walls in the unit with an uninterrupted length of two feet or more shall have graspable handrails. The handrails shall comply with NFPA 101, §7.2.2.4, and the provisions found in 16 TAC Chapter 68, Texas Accessibility Standards, April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Texas Government Code, Chapter 469. No handrail shall protrude more than three and one-half inches into the egress corridor. All handrail ends shall be returned to the wall.(B) Floor finishes shall comply with the requirements of §133.162(d)(2)(B)(iii) of this title.(3) Mechanical requirements. Mechanical requirements in each unit shall be in accordance with subsection (t)(3) of this section.(4) Plumbing fixtures and piping systems. The plumbing fixtures and piping systems shall be in accordance with subsection (t)(4) of this section.(5) Electrical Requirements. Electrical requirements shall be in accordance with subsection (t)(5) of this section. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(k) Hyperbaric suite.(1) Architectural requirements. When a hyperbaric suite is provided, it shall meet the requirements of Chapter 20, NFPA 99, and Chapter 18, NFPA 101.(A) Hyperbaric chamber clearances. Multiple occupancy chambers (Class A) shall be in accordance with NFPA 99, Chapter 20. The minimum clearances for individual (Class B) hyperbaric chambers and the side of a chamber and a wall/partition shall be a minimum of three feet. The clearance between sides of chambers shall be a minimum of six feet. The minimum distance at the chamber entry shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the chamber entry may be shared between two chambers. The chamber room shall contain cabinets, medication storage, work counter and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the chamber clear floor space/area. The requirements of this subparagraph are illustrated in Table 8, Diagram F of §133.169(h) of this title.(B) Service areas. The following minimum service areas and facilities shall be provided convenient to the hyperbaric chamber suite.(i) Patient waiting area. The area shall be out of traffic, under staff control, and shall have seating capacity in accordance with the functional program. Outpatients and inpatients shall be provided with separate waiting areas with screening for visual privacy between the waiting areas. Patient waiting areas may be omitted for two or less individual hyperbaric chamber units.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Holding area. A holding area under staff control shall accommodate inpatients on stretchers or beds. Stretcher patients shall be out of the direct line of normal traffic. The patient holding area may be omitted for two or less individual hyperbaric chamber units. (iv) Patient toilet rooms. Toilet rooms shall be provided with hand washing fixtures with hands-free operable controls and with direct access from the hyperbaric suite.(v) Patient dressing room(s). A dressing room(s) for outpatients shall be provided and shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate wheelchair patients.(vi) Staff facilities. Toilets with hand washing fixtures with hands-free operable controls may be outside the suite but shall be convenient for staff use. These facilities may be shared with an adjacent suite.(vii) Consultation room. An appropriate consultation room for individual consultation with referring clinicians shall be provided for outpatients. This room may be shared with an adjacent suite.(viii) Storage space. A clean storage space shall be provided for clean supplies and linens. The space shall contain a hand washing fixture with hands-free operable controls. The storage room may be shared with another department if convenient to both.(ix) Soiled holding room. A soiled holding room shall be provided with waste receptacles and soiled linen receptacles. This room may be shared with an adjacent suite.(x) Hand washing. A lavatory equipped for hand washing with hands-free operable controls shall be located in the room where the hyperbaric chambers are located.(xi) Housekeeping room. The housekeeping room shall contain a floor receptor or service sink, storage space for housekeeping supplies and equipment, and be located nearby.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) Grounding of hyperbaric chambers shall be connected only to the equipment ground in accordance with NFPA 99, §3-3.2.1.2, and National Fire Protection Association 70, National Electrical Code, 1999 edition, (NFPA 70), Article 250 (A) - (C), and Article 517.(B) Additional grounds such as earth or driven grounds shall not be permitted.(C) The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(l) Imaging suite.(1) Architectural requirements.(A) General. Each hospital shall have a diagnostic radiographic (X-ray) room convenient to emergency, surgery, cystoscopy, and outpatient suites.(i) All diagnostic imaging room sizes shall be in compliance with the manufacturer's recommendations for the specific equipment. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(ii) When radiation protection is required for any diagnostic imaging room, a medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602, shall specify the type, location, and amount of radiation protection to be installed for the layout and equipment selections.(iii) Each room where radiation protection is required shall include a shielded control alcove. The control alcove shall be provided with a view window designed to permit full view of the examination table and the patient at all times.(iv) Warning signs capable of indicating that the equipment is in use shall be provided.(v) Diagnostic and procedure room intended for patients with airborne infectious diseases shall meet the ventilation requirements as contained in Table 3 of §133.169(c) of this title.(B) Diagnostic X-ray and radiographic and fluoroscopy (R&F) rooms. X-ray and R&F rooms shall be in compliance with the manufacturer's recommendations for the specific equipment. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(i) A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) A toilet room shall be provided including a hand washing fixture with hands-free operable controls and have direct access to each R&F room and a corridor.(C) Noninvasive angiography imaging room. When noninvasive angiography imaging is provided, the room shall have minimum clear floor area of 250 square feet exclusive of built-in shelves or cabinets. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(i) A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) A viewing room or area shall be provided and shall be a minimum of 10 feet in length. The viewing room or area may be provided in combination with the control room.(iii) A scrub sink shall be near the entrance to each angiographic room and shall be recessed out of the main traffic areas or corridor. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts.(iv) Storage space for portable equipment and supplies shall be provided.(D) Computerized tomography (CT) scanning. When CT services are provided, the CT room(s) size shall be in compliance with the manufacturer's recommendations and shall contain the following.(i) A control room shall be provided with a view window permitting view of the patient. The control room shall be located to allow convenient film processing.(ii) A patient toilet shall be provided conveniently to the procedure room. When directly accessible to the scan room, the toilet shall be arranged so that a patient may leave the toilet room without having to reenter the scan room. The toilet room shall have a hand washing fixture with hands-free operable controls.(E) Mammography. When mammography services are provided, the room(s) shall have a minimum clear floor area of 100 square feet exclusive of built-in shelves or cabinets.(i) A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) When mammography machines with built-in shielding for the operator are provided, the alcove may be omitted when approved by a medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602.(F) Magnetic resonance imaging (MRI). When MRI services are provided, the room shall be of sufficient size to house equipment but no less than 325 square feet of clear floor area exclusive of built-in shelves or cabinets.(i) A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) A separate computer room shall be provided to accommodate the equipment.(iii) When cryogen is provided, a storage room or closet shall have a minimum clear floor area of 50 square feet for two large dewars of cryogen. A storage room or closet shall be required in areas where service to replenish supplies is not readily available.(iv) When a darkroom is provided, the room shall be located near the required control room and shall be outside the 10-gauss field.(v) When spectroscopy is provided, caution should be exercised in locating it in relation to the magnetic fringe fields.(vi) Magnetic shielding may be required to restrict the magnetic field plot. Radio frequency shielding is required to attenuate stray radio frequencies.(vii) A patient holding area shall be provided and shall be located near the MRI unit and be large enough to accommodate stretchers.(viii) A hand washing fixture with hands-free controls shall be provided near the entrance to the MRI room and shall be recessed out of the main traffic areas or corridor.(ix) A 3T or larger magnetic strength MRI shall be secured behind locked doors. The patient and staff entrance to the MRI shall have a traffic pattern from the waiting, dressing, holding and work areas through a lockable control station before entering the MRI. At no time shall patients or nonpatients be allowed to enter this restricted area without MRI staff present when the magnet is active.(G) Ultrasound room. When ultrasound services are provided, the room(s) size shall be in compliance with the manufacturer's recommendations. A patient toilet room shall be provided convenient to the procedure room and a corridor. The toilet room shall have a hand washing fixture with hands-free operable controls.(H) Cardiac catheterization laboratory. The cardiac catheterization laboratory is normally a separate suite, but may be within the imaging suite. If provided, a cardiac catheterization laboratory shall comply with the requirements of subsection (dd)(1)(C) of this section.(I) Service areas. The following common service areas shall be provided.(i) Patient waiting area. The area shall be out of traffic and under direct staff visual control. When the waiting area serves both outpatient and inpatients, separate areas shall be provided and include visual privacy between the waiting areas.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Holding area. The holding area shall be out of direct traffic patterns and under visual control by staff. A minimum of one stretcher station shall be provided for each three diagnostic and procedure rooms or fraction thereof. The minimum clear floor space in the holding area shall be 80 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The area shall contain cabinets, a work counter, and a hand washing fixture with hands-free operable controls. The holding area may be reduced to 50 square feet exclusive of aisles and fixed and moveable cabinets and shelves for mammography, bone density and other similar procedures.(iv) Post-procedure observation room. When invasive diagnostic X-ray services for outpatients are provided with anesthesia, a room for extended post-procedure observation of patients shall be provided. The minimum clear floor space for the observation space shall be 100 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The room shall contain cabinets, a work counter, and a hand washing fixture with hands-free operable controls.(v) Patient toilet rooms. Toilet room(s) with hand washing facilities shall be located convenient to the waiting area.(vi) Patient dressing rooms or cubicles. Dressing rooms or cubicles shall be convenient to the waiting areas and X-ray rooms. Each room shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate wheelchair patients.(vii) Hand washing facilities. A hand washing fixture with hands-free controls shall be provided in or near the entrance to each diagnostic and procedure room unless noted otherwise. When a hand washing fixture is provided in the room, the fixture shall be located near the entrance to the room or near the staff entrance. When a hand washing fixture is located outside the room, the fixture shall be recessed in the egress corridor and located within five feet of the entrance to the room. Hand washing facilities shall be arranged to minimize any incidental splatter on nearby personnel or equipment.(viii) Staff facilities. Toilets may be outside the suite and may be shared with other departments but shall be convenient for staff use. When four or more diagnostic or procedure imaging rooms are provided, a staff toilet is required with a hand washing fixture with hands-free controls.(ix) X-ray film illuminator viewers. When all the diagnostic and imaging procedures are provided with digital imaging, two mounted X-ray film illuminator viewers shall be provided in the central viewing area/room.(x) Contrast media preparation. This room shall include a work counter, a sink with hands-free operable controls, and storage. One preparation room may serve any number of rooms. When prepared media is used, this area may be omitted, but storage shall be provided for the media.(xi) Film processing room. A darkroom shall be provided for processing film unless the processing equipment normally used does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the procedure rooms and to the quality control area.(xii) Quality control area or room. An area or room for film viewing shall be located near the film processor. All view boxes shall be illuminated to provide light of the same color value and intensity.(xiii) Film storage (active). When X-ray film is used, it shall be stored in a room with a cabinet or shelves for filing patient film for immediate retrieval.(xiv) Film storage (inactive). When X-ray film is used, a room for inactive film storage shall be provided. It may be outside the imaging suite, but must be under the administrative control of imaging suite personnel and be properly secured to protect films against loss or damage.(xv) Storage for unexposed film. When X-ray film is used, storage facilities for unexposed film shall include protection of film against exposure or damage.(xvi) Storage of cellulose nitre film. When used, cellulose nitrate film shall be stored in accordance with the requirements of National Fire Protection Association 40, Standard for the Storage and Handling of Cellulose Nitrate Motion Picture Film, 1994 edition.(xvii) Additional spaces. When four or more diagnostic or procedure rooms are provided in the hospital, the following shall be required:(I) office(s) for radiologist(s) and assistant(s);(II) clerical office spaces, as necessary for the functional program;(III) consultation area/room;(IV) medication station. Storage and preparation of medication shall be done from a room, alcove area, or from a self-contained dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks are not acceptable for hand washing;(V) clean storage room. Clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls. When conveniently located, the clean storage room may be shared with another department; and(VI) soiled workroom. The soiled workroom shall not have direct connection to the diagnostic and procedure rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and soiled linen receptacle. When contaminated soiled material or fluid waste is not handled, only a soiled holding room shall be required.(xviii) Housekeeping room. The room may serve multiple departments when conveniently located.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Radiation protection shall be designed, tested and approved by a medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602.(I) Room shielding calculations for linear accelerators, teletherapy units and remote control brachytherapy units must be submitted to the Department of State Health Services' Radiation Control (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by RC inspectors, in the field, subsequent to use. Any changes in design or shielding which affects radiation exposure levels adjacent to those rooms, requires prior approval by RC. The RC mailing address is: Radiation Control, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756.(II) Facility design and environmental controls associated with licensable quantities of radioactive material in laboratories and/or imaging rooms shall be approved by RC prior to licensed authorizations. (ii) Where protected alcoves with view windows are required, provide a minimum of one foot six inches from the edge where the glazing and the frame connect and the outside partition edge.(iii) Imaging procedure rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(B) Finishes.(i) Flooring used in contrast media preparation and soiled workroom shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) A lay-in type ceiling is acceptable for the diagnostic and procedure rooms.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) The cryogen gas venting from the MRI unit shall be exhausted to the exterior. When a cryogen storage room is provided to replenish supplies, the storage room shall be vented and exhausted to the exterior.(B) Self-contained air conditioning to supplement the cooling capacity in computer rooms is permitted.(C) Air handling units serving the imaging suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Each imaging procedure room shall have at least four duplex electrical receptacles.(ii) A special grounding system in areas such as imaging procedures rooms where a patient may be treated with an internal probe or catheter shall comply with Chapter 9 of NFPA 99, and Article 517 of NFPA 70.(iii) General lighting with at least one light fixture powered from a normal circuit shall be provided in imaging procedures rooms in addition to special lighting units at the procedure or diagnostic tables.(B) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(m) Intermediate care suite (Step down suite).(1) Architectural requirements.(A) General. The requirements in this subsection apply to intermediate care units for acute care patients who require frequent monitoring that exceed the level of care for nursing units and less than that provided in critical care units. The suite may share services with an adjacent suite.(B) Intermediate care services and facilities. The following services and facilities shall apply to all classifications of intermediate care unless otherwise noted.(i) In a single-bed patient room, the minimum clear floor area shall be 150 square feet exclusive of anterooms, vestibules, toilet rooms, closets, lockers, wardrobes, and/or alcoves. A minimum of 12 feet width shall be provided for the head wall for each bed. A hand washing fixture with hands-free operable controls shall be located in the patient room and in the patient bathroom.(ii) In a multi-bed intermediate care patient room the maximum capacity shall be no more than four patients per room. In a multiple-bed open ward patient room, the clearance between the side of a bed and a wall/partition shall be a minimum of four feet. The clearance between sides of beds shall be a minimum of eight feet. The minimum distance at the foot of the bed shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds. The ward shall contain cabinets, work counter, and washing fixture with hands-free operable controls located centrally to the beds. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram P of §133.169(h) of this title.(iii) Each single-bed or multi-bed open ward patient room shall have access to a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet, a hand washing fixture with hands-free operable controls, bathing facilities, and a storage shelf or cabinet.(iv) Each single and open ward patient room shall be located on an exterior wall and shall have a window. In a ward, one window may serve more than one patient. The window sill height shall not exceed three feet above the floor. Patient beds shall not be located more than 50 feet from an exterior window. Patients' views to outside windows shall be direct and not through other clear vision panels. Windows shall be in accordance with subsection (t)(2)(A)(iv) and (v) of this section.(v) The nurse station shall be located to permit direct visual observation of each patient served. Video cameras or mirrors shall not be substituted for direct visual observation. The nurse station shall have space for counters and storage. The counter height shall not exceed 42 inches. The nurse station may be combined with or include centers for reception and communication. In multi-bed intermediate care patient room the nurse station shall be located within the room and have space for counters and storage.(vi) When individual nurse substations are provided and located at each patient room(s), they shall be located to permit direct visual observation of each patient served. The nurse substation shall have space for counter, storage space and a recessed sitting space. The substation shall be at a minimum recessed from the egress corridor one foot six inches.(vii) Visual privacy shall be provided each patient in multi-bed rooms. Design for privacy shall not restrict independent patient access to the corridor, lavatory, or bathroom.(viii) Each patient shall have a separate wardrobe, locker, or closet that is suitable for hanging full-length garments and for storing personal effects. A minimum of 12 lineal inches of hanging space shall be provided per patient.(C) Service areas. Service areas shall be located in, adjacent to, or readily available to, each nursing unit. Each service area may be arranged and located to serve more than one nursing unit. The following service areas shall be provided.(i) A visitors' waiting space shall be provided with a toilet facility(ies), public telephone(s), and drinking fountain(s). One waiting space may serve other units on the floor.(ii) A nurses station with a hand washing fixture with hands-free operable controls and an adjacent but separate dictation space shall be provided when the single-bed intermediate care patient rooms concept is used. An adjacent nurse station may be used and shared when feasible.(iii) Storage space shall be provided for emergency equipment in the suite.(iv) Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be located with the clean work room.(v) A soiled workroom shall be provided. The room shall contain a clinical sink or equivalent flushing rim type fixture with hot and cold mixing faucet, separate hand washing facilities with hands-free operable controls, and separate waste and soiled linen receptacles. When facilities for cleaning bedpans are provided elsewhere, the flushing rim clinical sink may be omitted.(vi) A clean workroom or clean supply room shall be provided. A clean workroom when used for preparing patient care items shall contain a work counter, hand washing facilities with hands-free operable controls, and storage facilities for clean and sterile supplies. When used only for storage and holding as part of a distribution system of clean and sterile supplies, the work counter and hand washing facilities may be omitted.(vii) A nourishment station containing a work counter with sink, microwave, refrigerator and storage cabinets and not located in the clean workroom shall be provided.(viii) A conveniently located examination room shall be provided and have a minimum clear floor area of 100 square feet and contain a counter for writing and hand washing facilities with hands-free operable controls. This room may be omitted if all patient rooms on the floor are single-bed patient rooms.(ix) A housekeeping room shall be provided and contain a service sink, and storage for housekeeping supplies and equipment. A shared nursing unit housekeeping room that is adjacent to the intermediate care suite is acceptable.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) At least one door to an intermediate care multi-bed open ward patient room shall be not less than four feet wide and arranged to minimize interference with movement of beds and large equipment. (ii) Sliding doors in intermediate care rooms shall not have floor tracks and shall have hardware that minimizes jamming possibilities and break-away feature from any position and be in accordance with §133.162(d)(2)(A)(vi) of this title.(B) Finishes.(i) Flooring used in soiled workrooms shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceilings in the soiled workroom shall be monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Room recirculating units shall not be used.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Receptacles at each bed location shall be served by two branch circuits, one or more from the critical branch panel of the emergency electrical system and one or more from the normal system. One critical branch circuit shall serve only one bed location. All branch circuits from the normal system shall be from a single panelboard. All branch circuits from the emergency electrical system shall be from a single panelboard.(ii) A minimum of three hospital grade duplex outlets shall be conveniently located at the head of each bed. At least two of these duplex outlets shall be on the critical branch of the emergency electrical system.(iii) One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location.(B) Illumination requirements.(i) Each single patient room and multi-patient wards shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system.(ii) A reading light shall be provided over each patient bed. Reading light control shall be readily accessible from each patient bed. Flexible light arms, if used, shall be mechanically controlled to prevent the bulb from coming in contact with bed linen. High heat-producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered with a diffuser or a lens.(iii) A wall or ceiling-mounted lighting fixture shall be provided above each lavatory.(iv) A ceiling-mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch.(C) Nurses calling systems. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(n) Laboratory suite.(1) Architectural requirements.(A) General.(i) Laboratory facilities and services shall be provided by the hospital such as hematology, clinical chemistry, urinalysis, cytology, anatomic pathology, immunohematology, microbiology, bacteriology and others.(ii) Each laboratory unit shall meet the requirements of Chapter 11 of NFPA 99 (relating to Laboratories), and Chapter 18 of NFPA 101 (relating to New Health Care Occupancies).(B) Minimum laboratory facilities. When laboratory services are provided off site by contract, the following minimum facilities shall be provided within the hospital.(i) Laboratory work room. The laboratory workroom shall include a counter and a sink with hands-free operable controls.(ii) General storage. Cabinets or closets shall be provided for supplies and equipment used in obtaining samples for testing. A refrigerator or other similar equipment shall be provided for specimen storage waiting for transfer to off-site testing.(iii) Blood storage facilities. Refrigerated blood storage facilities for transfusions shall be provided. The blood storage refrigerator shall be equipped with temperature monitoring and alarm signals.(iv) Specimen collection facilities. A blood collection area shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands-free operable controls shall be provided for specimen collection. This facility may be outside the laboratory suite if conveniently located.(C) On-site laboratory facilities. When the hospital provides on-site laboratory services, the following facilities shall be provided in addition to the requirements in subparagraphs (A) and (B) of this paragraph.(i) Laboratory workroom(s). The laboratory work room shall include counter(s), space appropriately designed for laboratory equipment and sink(s) with hands-free operable controls.(ii) General storage. Storage, including refrigeration for reagents, standards, supplies, and stained specimen microscope slides, etc. shall be provided. Separate facilities shall be provided for such incompatible materials as acids and bases, and vented storage shall be provided for volatile solvents. (iii) Chemical safety facilities. When chemical safety is a requirement, provisions shall be made for an emergency shower and eye flushing devices.(iv) Flammable liquids. When flammable or combustible liquids are used, the liquids shall be stored in approved containers, in accordance with National Fire Protection Association 30, Flammable and Combustible Liquids Code, 2003 edition.(v) Radioactive materials. When radioactive materials are employed, storage facilities shall be provided.(D) Bone marrow laboratory. A cryopreservation laboratory and a human leukocyte antigen laboratory shall be provided in hospitals providing bone marrow transplantation services.(E) Service areas and facilities. The following service areas and facilities shall be provided.(i) Hand washing facilities. Each laboratory room or work area shall be provided with a hand washing fixture(s) with hands-free operable controls.(ii) Office spaces. The scope of laboratory services shall determine the size and quantity for administrative areas including offices as well as space for clerical work, filing, and record maintenance. At a minimum, an office space shall be provided for the use of the laboratory service director.(iii) Staff facilities. Lounge, locker, and toilet facilities shall be conveniently located for male and female laboratory staff. These may be outside the laboratory area and shared with other departments.(iv) Housekeeping room. A housekeeping room shall be located within the suite or conveniently located nearby.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title. Floors in laboratories shall comply with the requirements of §133.162(d)(2)(B)(iii) of this title except that carpet flooring shall not be used.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) No air from the laboratory areas shall be recirculated to other parts of the facility. Recirculation of air within the laboratory suite is allowed.(B) When laboratory hoods are provided, they shall meet the following general requirements.(i) The average face velocity of each exhaust hood shall be at least 75 feet per minute.(ii) The exhaust shall be connected to an exhaust system to the exterior which is separate from the building exhaust system. Biological safety cabinets with HEPA filters and alarms to alert staff do not have to be exhausted to the exterior. If the air changes for biological safety cabinets as provided in Table 3 of §133.169(c) of this title do not provide sufficient air for proper operation of the safety cabinets (when in use), supplementary make-up air (filtered and preheated) shall be provided around these units to maintain the required airflow direction and exhaust velocity. Make-up air system for safety cabinets shall be arranged to minimize "short circuiting" of air and to avoid reduction in air velocity at the point of contaminant capture.(iii) The exhaust fan shall be located at the discharge end of the system.(iv) The exhaust duct system shall be of noncombustible and corrosion-resistant material.(v) Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(C) When special laboratory hoods are provided, they shall meet the following special standards for these types of hoods.(i) Fume hoods, and their associated equipment in the air stream, intended for use with perchloric acid and other strong oxidants, shall be constructed of stainless steel or other material consistent with special exposures, and be provided with a water wash and drain system to permit periodic flushing of duct and hood. Electrical equipment intended for installation within such ducts shall be designed and constructed to resist penetration by water. Duct systems serving these hoods shall be constructed of acid-resistant stainless steel for at least 10 feet from the hood. Lubricants and seals shall not contain organic materials. When perchloric acid or other strong oxidants are only transferred from one container to another, standard laboratory fume hoods and the associated equipment may be used in lieu of stainless steel construction.(ii) Each laboratory hood used to process infectious or radioactive materials shall have a minimum face velocity of 90-110 feet per minute, be connected to an independent exhaust system, with suitable pressure-independent air modulating devices and alarms to alert staff of fan shutdown or loss of airflow. Each hood shall also have filters with a 99.97% efficiency (based on the dioctyl-phthalate (DOP) test method) in the exhaust stream, and be designed and equipped to permit the safe removal, disposal, and replacement of contaminated filters. Filters shall be as close to the hood as practical to minimize duct contamination.(iii) Fume hoods intended for use with radioactive isotopes shall be constructed of stainless steel or other material suitable for the particular exposure and shall comply with National Fire Protection Association 801, Standard for Facilities Handling Radioactive Materials, 2003 edition and NFPA 99, §11.3.5.(iv) Each laboratory hood shall have a suitable pressure-independent air modulating device and alarm to alert staff of fan shutdown or loss of airflow. The alarm shall be audible within the laboratory and at a 24-hour manned location.(D) Filtration requirements for air handling units serving the laboratory suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title.(E) Duct linings exposed to air movement shall not be used in ducts serving any laboratory room and clean room unless terminal filters of at least 80% efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) General.(i) Faucet spouts at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of beakers, test tubes, etc.(ii) Drain lines from sinks used for acid waste disposal shall be made of acid-resistant material.(iii) Drain lines serving some types of automatic blood-cell counters must be of carefully selected material that will eliminate potential for undesirable chemical reactions (and/or explosions) between sodium azide wastes and copper, lead, brass, and solder, etc.(B) Medical gas systems. When provided, medical gas systems shall comply with §133.162(d)(4)(A)(iii) and (iv) of this title. The number of outlets in the laboratory for vacuum, gases, and air shall be determined by the functional program requirements.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(A) The blood storage refrigerator shall have an alarm device to indicate a temperature increase or malfunction and indicate an audible warning at a 24-hour manned location.(B) The blood storage refrigerator shall be connected to the critical branch of the emergency essential electrical system.(C) All exhausts hoods shall be connected to the emergency essential electrical system.(o) Laundry suite. Laundry facilities shall be provided on site or off site. On-site laundry services may be within the hospital or in a separate building on-site. The laundry facilities shall be separated from patient rooms, areas of food preparation and storage, and areas in which clean supplies and equipment are stored.(1) Architectural requirements.(A) When laundry service is provided on site, it shall comply with the following. (i) Soiled and clean linen processing rooms shall be provided. When the soiled and clean linen processing are combined in a single room, each process shall be physically separated within the room.(ii) Adequate hand washing facilities shall be provided in both the soiled and clean processing areas.(iii) A receiving, holding, and sorting room for control and distribution of soiled linen shall be provided. This area may be combined with the soiled linens processing room. Discharge from soiled linen chutes may be received in the soiled room/area or in a separate dedicated room.(iv) A laundry processing room shall be provided with a commercial washer(s) and dryer(s) capable of processing at least a seven-day laundry supply within the regular scheduled work week.(v) A clean linen processing room/area shall be provided with folding counters or tables. This area shall have provisions for inspections, folding, packing and mending of linen.(vi) A holding room or area for storage and issuing of clean linen shall be provided but may be combined with clean linen processing room.(vii) Storage space and cabinets for soaps, stain removers, and other laundry processing agents shall be located in the soiled and clean processing room/areas.(viii) Laundry equipment shall be arranged so that the processing of laundry is an orderly work flow from soiled to clean operations. Cross-traffic shall be held to a minimum to prevent contamination. (B) When laundry service is provided off site, the following minimum requirements shall be provided on site:(i) a service entrance which shall have a drive under canopy for protection from inclement weather, for loading and unloading of linen;(ii) a control station for pickup and receiving. This may be a room at the common loading dock, in the soiled linen holding room, or the central clean linen storage room;(iii) a soiled linen holding room; and(iv) a central clean linen storage/issuing room in addition to linen storage required at the individual patient units.(C) The following areas/rooms shall be provided regardless of delivery type of laundry service:(i) office space for the director of laundry services;(ii) cart storage rooms for clean and soiled linen. The cart storage areas may be provided within the clean and soiled rooms. Carts may not be parked or stored in the egress corridor;(iii) cart sanitizing facilities which comply with subsection (b) of this section;(iv) staff toilet in the laundry suite or convenient for staff use and with a hand washing fixture with hands-free operable controls;(v) lockers for staff use may be in laundry suite or part of a central locker room when convenient to the laundry; and(vi) housekeeping room within the laundry suite or available near by.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) The ventilation system shall include adequate intake, filtration, exchange rate, and exhaust in accordance with Table 3 and Table 4 of §133.169(c) and (d) of this title, respectively.(B) Filtration requirements for air handling units serving the laundry suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title.(C) Direction of air flow of the HVAC systems shall be from clean to soiled areas.(D) The ventilation system for soiled processing area shall have negative air pressure while the clean processing area shall have positive pressure.(E) Lint interceptors shall be located outside the laundry area. Drainage piping that serves laundry equipment shall employ suds-control features.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(p) Medical records suite.(1) Architectural requirements. The following rooms, areas, or offices shall be provided in the medical records suite:(A) medical records administrator or technician office;(B) review and dictating rooms or spaces;(C) work area which includes provisions for sorting, recording, scanning, or microfilming records; and(D) file room. When nondigital files are stored on site, the room shall be considered as hazardous. The construction protection for the storage room or area shall comply with Chapter 18 of NFPA 101, §18.3.2.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(q) Mental health and chemical dependency nursing suite.(1) Architectural requirements. When mental health and chemical dependency patient care services are provided, the suite shall comply with the requirements contained in subsection (t)(1) of this section and the requirements of this paragraph.(A) A minimum of two separate social spaces, one appropriate for noisy activities and the other for quiet activities, shall be provided. The combined total area shall be not less than 40 square feet per bed with not less than 120 square feet for each of the two spaces, whichever is greater.(B) A room for group therapy shall be provided. The room shall not be less than 250 square feet. The group therapy room may be combined with the quiet space required in subparagraph (A) of this paragraph when the unit accommodates not more than 12 patients.(C) Space shall be provided for occupational therapy at the rate of 15 square feet per bed with a minimum total area of 200 square feet, whichever is greater. Space shall include hand washing, work counters, storage, and displays. When the mental health and chemical dependency nursing unit contains less than 12 beds, the occupational therapy functions may be performed within the noisy activities area, if at least 10 additional square feet per patient served is included.(D) A consultation room for each 12 beds or any portion thereof shall be provided. Each consultation room shall have a minimum floor space of 100 square feet. Each room shall be designed for acoustical and visual privacy.(E) There shall be a suite in each nursing unit for mental health and chemical dependency patients intended for short-term occupancy by a single person requiring security and protection from self or others. The seclusion suite shall consist of seclusion room(s), an anteroom or a vestibule, and a toilet.(i) Each seclusion room shall be located and designed in a manner affording direct visual supervision by nursing staff and shall be constructed to prevent patient hiding, escape, injury, or suicide. There shall be a minimum of one seclusion room for each 24 beds or any portion thereof.(I) The floor area of each seclusion room shall be not less than 60 square feet. The minimum room dimension shall be 6 feet.(II) The seclusion room shall have a minimum ceiling height of 9 feet.(III) The door to each seclusion room shall have no hardware on the room side and shall open out. A vision panel shall be provided in each door to permit staff observation of the entire room while maintaining privacy from the public and other patients.(IV) Each seclusion room shall have natural light (skylight or window) in order to maintain a therapeutic environment. Skylight wells or windows shall be not less than 400 square inches in area.(ii) Access to the seclusion room from any public space such as a corridor shall be through an anteroom. When the seclusion suite is directly accessible from the nurse station, a vestibule may be provided in place of an anteroom. A cased opening to the vestibule in lieu of a door may be provided as long as the arrangement assures privacy from the public and other patients.(I) At least one dimension of the anteroom or vestibule shall be 8 feet.(II) The door to the anteroom shall swing out.(iii) There shall be at least one toilet room directly accessible from the anteroom or vestibule.(I) The toilet room shall be a minimum of 50 square feet.(II) The toilet room door shall swing out into the anteroom or vestibule.(III) A water closet and hand washing facilities shall be provided in the toilet room. An unbreakable wall hung mirror may be provided.(F) When a smoking room is provided, all air shall have a dedicated exhaust system to the exterior.(G) Service areas shall be provided in accordance with the requirements of subsection (t)(1)(F) of this section and the following additional requirements.(i) Nurses and doctor's charting areas shall be provided with separation needed for acoustical privacy as well as space required for the function. A view window to permit observation of patient area by the charting nurse or physician may be used provided that it is located so that patient files cannot be read from outside the charting space.(ii) A small kitchen for patient use shall be provided. It shall contain a sink, refrigerator, kitchen cabinets, ice dispenser, and a microwave. This kitchen may serve as a nourishment center for patients between meals. It may be located in the noisy activity area.(iii) Patient laundry facilities with automatic washer and an electric dryer shall be provided. This requirement may be omitted in nursing units intended only for adolescent and gero-psychiatric patients.(2) Details and finishes. Details and finishes in each mental health and chemical dependancy nursing unit shall comply with the requirements contained in subsection (t)(2) of this section and this paragraph.(A) Details.(i) The type and degree of security and patient safety required in the suite shall be determined by hospital administration and described in the hospital's functional program narrative, unless stated otherwise within these rules.(ii) All areas of the mental health suite, including entrances to patient rooms, shall be visible from the nurse station(s). Observation by video cameras of seclusion rooms, entrances, hallways, and activity areas shall be acceptable.(iii) All exposed and accessible fasteners shall be tamper-resistant.(iv) Suitable hardware shall be provided on doors to toilet rooms so that access to these rooms can be controlled by staff. Hardware shall be utilized which is appropriate to prevent patient injury.(v) Only breakaway or collapsible clothes bars in wardrobes, lockers, and closets and shower curtain rods shall be permitted in nursing units for mental health and chemical dependency patients.(vi) Wire coat hangers shall not be permitted in the suite.(vii) Special fixtures, hardware, and tamper-proof screws are required throughout the suite.(viii) Horizontal grab bars shall be constructed to prevent looping or tying of cords, ropes, etc.(ix) Where glass fragments may create a hazard, safety glazing or other appropriate security features shall be incorporated.(B) Finishes. Patient sleeping rooms, patient toilet rooms and seclusion rooms shall have monolithic ceilings and bonded walls for patient safety and security measures. The ceiling in the soiled workroom shall be monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title. Gero-psychiatric patient rooms and toilet rooms may omit the monolithic ceiling requirement when hospital administration provides a written statement (on hospital letterhead) that the type and degree of security is appropriate for the patient areas.(3) Mechanical requirements. Mechanical requirements shall be in accordance with subsection (t)(3) of this section and this paragraph.(A) Special consideration shall be given to the type of heating and cooling units, ventilation outlets, and appurtenance installed in patient-occupied areas of mental health nursing units. The following shall apply:(B) All air grilles and diffusers shall be of a type that prevents the insertion of foreign objects.(C) All convector or HVAC enclosures exposed in the room shall be constructed with rounded corners and shall have enclosures fastened with tamper-resistant fasteners.(D) HVAC equipment shall be of a type that minimizes the need for maintenance within the room.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with subsection (t)(4) of this section and this paragraph.(A) Piping systems.(i) Piped medical gas systems are not required.(ii) Only tamper-proof sprinkler and tamper-proof showerheads from which it is not possible to suspend any objects shall be installed.(B) Plumbing fixtures.(i) Faucet controls shall not be equipped with handles that may be easily broken off.(ii) Bedpan washers are not required in patient bathrooms. (5) Electrical requirements. Electrical requirements shall be in accordance with subsection (t)(5) of this section and this paragraph.(A) A nurses calling system is not required in patient rooms. However, when a nurses calling system is provided, the system shall meet the requirements of §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title. Pull cords shall not exceed 18 inches in length, and provisions shall be made to permit removal of call buttons and use of blank plates as required for security.(B) Each patient room shall have duplex grounded receptacles. There shall be one receptacle at each side of the head of each bed and one on every other wall. Receptacles in areas intended for mental health and chemical dependency patients of all ages shall be protected by GFCI breakers installed in distribution panel enclosures serving the unit.(C) Fifteen-ampere and 20-ampere, 125-volt receptacles intended to supply patient care areas shall be tamper-resistant as permitted by NFPA 70, §517-18, or shall be protected by GFCI breakers. A tamper-resistant receptacle is one that is constructed to limit improper access to its energized contacts.(r) Morgue.(1) Architectural requirements.(A) General. When a morgue or body-holding room is provided, it shall be located to avoid the need for transporting bodies of deceased patients through public areas. A body-holding room shall be provided as a minimum for a general hospital.(B) Autopsy performed within hospital. When autopsies are performed within the hospital, the following rooms, areas, and equipment shall be provided.(i) Refrigerated facilities shall be provided for body-holding. (ii) The autopsy room shall contain work counters, hand washing facilities with hands-free operable controls, autopsy table and storage space for supplies, equipment and specimens.(iii) A deep sink shall be provided for washing specimens. (iv) A clothing change area shall be provided with shower, toilet, hand washing facilities and lockers.(C) Service areas. The following service areas shall be provided:(i) a pathologist office;(ii) staff toilets. Toilets may be outside the suite but be convenient for staff use with hand washing fixture(s) with hands-free operable controls; and(iii) a housekeeping room. A housekeeping room which meets the requirements of §133.162(d)(2)(A)(xxviii) of this title shall be provided for the exclusive use of the morgue when autopsies are performed.(D) Minimum requirements. If autopsies are performed outside the hospital, a well-ventilated, temperature-controlled, nonrefrigerated body-holding room shall be provided.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Flooring used in the autopsy room shall be the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(B) Ceilings in the autopsy rooms shall be monolithic as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) The autopsy room shall be equipped with low exhaust grilles.(B) The body-holding room shall be ventilated in accordance with Table 3 of §133.169(c) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. Refrigerators for body-holding in the autopsy room shall be connected to the equipment branch of the essential electrical distribution system.(s) Nuclear medicine suite.(1) Architectural requirements.(A) General. When nuclear medicine services are provided, the facilities may be in a separate suite or combined with an imaging suite.(i) When nuclear medicine requires radiation protection, a medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602, shall specify the type, location, and amount of radiation protection to be installed for the layout, equipment selections and storage, handling and disposal of radioactive material.(ii) The nuclear medicine room shall be sufficiently sized to house all fixed and moveable equipment and allow a minimum of three feet of clear and unobstructed working space on all sides of equipment accessible to staff and patient.(B) Radioisotope room (Hot lab). When radiopharmaceutical preparation is performed on site, the room shall include sufficient space for equipment, storage of radionuclides, chemicals for preparation, dose calibrators, and record keeping. When preprepared materials are used, storage and calculation area may be smaller than for on-site preparation.(i) The room and isotope handling areas within the room shall have appropriate radiation shielding.(ii) There shall be a shielded area or enclosed shielded cabinet for long-term storage of decaying radioisotopes.(iii) When venting of radioactive gases is required, a hood shall exhaust to the exterior.(C) Positron emission tomography (PET). When PET services are provided, scanner and cyclotron rooms shall be in compliance with the manufacturer's recommendations and provide a minimum of three feet of clear and unobstructed working space on all sides of equipment accessible to staff and patient.(i) A control alcove shall be provided with a view window permitting view of the patient.(ii) An equipment area large enough to contain necessary electronic and electrical gear shall be provided.(iii) A dose administration room(s) with radiation shielding shall be located near the treatment room. Patients in route to procedure rooms shall not pass through public corridors and waiting rooms after injection with radioisotope.(iv) A patient toilet with radiation shielding shall be provided with or adjacent to dose administration room(s). The patient toilet room shall contain a hand washing fixture with hands-free operable controls.(D) Service areas.(i) Patient waiting area. The area shall be out of traffic and under direct staff visual control. When the waiting area serves both outpatients and inpatients, separate areas shall be provided and include visual privacy between the waiting areas.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Dictation and report preparation area. The dictation and report preparation area may be incorporated with the control station. (iv) Holding area. The holding area shall be under direct staff control, out of the direct line of traffic, and have space for stretchers. The holding area shall accommodate two stretchers for the first procedure room with one additional station for each additional procedure room.(v) Patient toilet facilities. A toilet room with a hand washing fixture with hands-free operable controls shall be provided convenient to the waiting room and procedure room.(vi) Staff toilet facilities. Toilets and hand washing fixtures with hands-free operable controls may be outside the suite but shall be convenient for staff use.(vii) Patient dressing rooms or cubicles. Dressing rooms or cubicles shall be provided convenient to the waiting areas and procedure rooms. Each room or cubicle shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate wheelchair patients.(viii) Exam room(s). When examination rooms are provided, each room shall have a minimum of 100 square feet of clear floor area exclusive of built-in shelves or cabinets. Each exam room shall be equipped with a work counter and a hand washing fixture with hands-free operable controls.(ix) Dose administration area. When a dose administration area is provided, the area shall be located near the preparation area and include visual privacy for the patients.(x) Computer control area/room. Computer control area shall be located within or adjacent to the treatment room(s). When a centralized computer area is provided, it shall be a separate room with access terminals available within the treatment rooms.(xi) Film processing room. A darkroom shall be provided for film processing unless the processing equipment normally used does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the treatment room(s) and to the quality control area.(xii) Quality control area or room. A quality control area shall include view boxes illuminated with light of the same color value and intensity.(xiii) Film storage room (active). A room with cabinet or shelves for filing patient film for immediate retrieval shall be provided.(xiv) Film storage room (inactive). A room for inactive film storage may be located outside the nuclear medicine suite, but must be under the administrative control of nuclear medicine personnel and properly secured to protect films against loss or damage.(xv) If digital imaging is utilized throughout the suite, the darkroom film processing area and film viewers may be omitted. (xvi) Storage for unexposed film. Storage facilities for unexposed film shall include protection of film against exposure or damage.(xvii) Offices for physicians, oncologist, physicists, and assistants. Offices shall include provisions for individual consultation, viewing, and charting of film.(xviii) Clerical office(s) spaces. Clerical office(s) spaces shall be provided.(xix) Consultation room. A consultation room shall be provided.(xx) Clean storage room. A clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls. When conveniently located, the clean storage room may be shared with another department.(xxi) Soiled workroom. The soiled workroom shall not have direct connection to the nuclear medicine procedure or diagnostic rooms or sterile activity rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and soiled linen receptacle. When contaminated soiled material or fluid waste is not handled, only a soiled holding room is required.(xxii) Housekeeping room. The housekeeping room shall be located within the suite.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Radiation protection shall be designed, tested and approved by a medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602.(I) Room shielding calculations for the stipulated rooms within the nuclear medicine suite must be submitted to the Department of State Health Services, Radiation Control (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by RC inspectors, in the field, subsequent to use. Any changes in design or shielding which affects radiation exposure levels adjacent to those rooms, requires prior approval by RC.(II) Facility design and environmental controls associated with licensable quantities of radioactive material in laboratories or procedure rooms must be approved by RC prior to licensed authorizations. (ii) The nuclear medicine treatment rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(B) Finishes.(i) Flooring used in the nuclear medicine procedure room, any work or treatment areas where radioactive material is handled, and soiled workroom shall be of the seamless monolithic type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceilings in radiopharmacy, hot laboratory, and soiled workrooms shall be monolithic as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) When radiopharmaceutical preparations are performed, vents and traps for radioactive gases shall be provided.(B) Direction of air flow of the HVAC system shall be from nonradioactive spaces into the radioactive spaces. A minimum of two return air inlets located diagonally opposite from one another and near floor level shall be provided.(C) In the PET suite, special ventilation systems together with monitors, sensors, and alarm systems shall be required to vent gases and chemicals. The ventilation shall be directly to the exterior.(D) Filtration requirements for air handling units serving the nuclear medicine suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title.(E) Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood. Fume hoods shall be exhausted directly to the exterior.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Each nuclear medicine procedure room shall have at least four duplex electrical hospital grade receptacles.(ii) Nuclear medicine procedures rooms shall have general lighting in addition to that provided by special lighting units at the procedure tables.(B) Nurses calling systems. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(t) Nursing unit. The requirements in this subsection apply to nursing units in hospitals for all types of inpatient care. Facilities providing care to less than 15 pediatric inpatients may be included with an adult nursing unit. Additional requirements for a nursing unit providing care to 15 or more pediatric patients are contained in subsection (w) of this section.(1) Architectural requirements. Architectural requirements shall be in accordance with §133.162(d)(1) of this title and this paragraph.(A) Handicapped accessibility requirements. At least 10% of each patient room type, isolation room, bathing units and toilets in medical/surgical, intermediate care, universal care, antepartum, postpartum, mental health, chemical dependency, and pediatric nursing units and all public and common use areas shall be designed and constructed to be handicapped accessible. These requirements shall apply in all new construction and when an existing nursing unit or a portion thereof is converted from one service to another, i.e. mental health care to medical or surgical nursing care.(B) Patient room suites. A patient room suite shall consist of the patient room and a bathroom. Patient room suites shall comply with the following requirements.(i) Maximum patient room capacity. The maximum patient room capacity shall be two patients. In existing facilities where renovation work is undertaken and the present capacity is more than two patients, the maximum room capacity shall be no more than the present capacity with a maximum of four patients. (ii) Single-bed patient room. In a single-bed patient room, the minimum clear floor area shall be 120 square feet.(iii) Multi-bed (two) patient room. The clearance between the side of a bed and a wall/partition shall be a minimum of three feet. The clearance between sides of beds shall be a minimum of five feet. The minimum distance at the foot of the bed shall not be less than four feet for a single load area/room or seven feet for a double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds. The requirements of this clause are illustrated in Table 8, Diagram G of §133.169(h) of this title.(iv) Multi-bed (two) accessible patient room. The clearance between the side of a bed and a wall/partition shall be a minimum of five feet. The clearance between sides of beds shall be a minimum of four feet. The minimum distance at the foot of the bed shall not be less than four feet for a single load area/room or seven feet for a double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds. The requirements of this clause are illustrated in Table 8, Diagram H of §133.169(h) of this title.(v) Arrangement of patient rooms. Minor encroachments including columns and wall hung lavatories that do not interfere with functions may be ignored when determining space requirements for patient rooms.(I) Required clear floor space in patient rooms shall be exclusive of toilet rooms, closets, lockers, built-in cabinets, wardrobes, alcoves, or vestibules.(II) Visual privacy shall be provided each patient in multi-bed rooms. Design for privacy shall not restrict independent patient access to the corridor, lavatory, or bathroom.(vi) Patient bathroom. Each patient shall have access to a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet with bed pan washers, hand washing fixture with hands-free operable controls, bathing facilities, and storage shelf or cabinet and serve not more than two patient rooms. Hand washing facilities shall be located in the patient room and in the patient bathroom. The hand washing fixture in the room shall be located outside of the patient's cubicle curtain in multi-bed patient room.(vii) Patient storage. Each patient shall have a separate wardrobe, locker, or closet that is suitable for hanging full-length garments and for storing personal effects. A minimum of 12 lineal inches of hanging space shall be provided per patient.(C) Airborne infection isolation suites. A minimum of one isolation suite shall be provided for each 30 acute care beds or fraction thereof. The suite may be located within a nursing unit or in a separate isolation unit. When a pediatric patient suite is located in an adult nursing unit and is not part of a pediatric or adolescent nursing unit, a minimum of one isolation room shall be designated for pediatric patient care. Each airborne infection isolation suite shall consist of a work area, a patient room, and a patient bathroom.(i) The work area may be a separately enclosed anteroom or a vestibule that is open to and is located immediately inside the door to the patient room. It shall have facilities for hand washing, gowning, and storage of clean and soiled materials. One enclosed anteroom may serve multiple isolation rooms.(ii) Each patient room shall have a clear floor area of 120 square feet exclusive of the work area and shall contain only one bed. A patient bathroom shall be provided in accordance with subparagraph (B)(vi) of this paragraph.(iii) At least one airborne infection isolation suite with an enclosed anteroom shall be provided.(iv) A door(s) from an anteroom to an airborne infection isolation room(s) and a door(s) from an egress corridor into an anteroom shall be provided with a self-closing device(s). When an isolation room does not have an anteroom, the door from the egress corridor into the isolation room shall be provided with a self-closing device. When sliding doors are used in isolation rooms in CCU suites and in surgical suite post-anesthesia care units, the self-closing device may not be required as long as assurances of negative air pressure are met when sliding doors are opened.(v) Pressure differential monitors or air flow devices shall be installed outside the isolation room and anteroom. Devices shall be installed in corridors, passageways, etc.(D) Protective environment suite. When specialized services for patients with extreme susceptibility to infection are provided, spatial requirements for the suite shall be identical to those for airborne infection isolation suites contained in subparagraph (C) of this paragraph with the exception that an enclosed anteroom shall be provided.(E) Room for disturbed medical patients. Each general hospital shall provide at least one private patient room for patients needing close supervision for medical and/or psychiatric care. The room may be part of the mental health and chemical dependency nursing suite described in subsection (q) of this section. If the room is part of a nursing suite, the provisions of subparagraph (B)(ii) of this paragraph shall apply. Each room shall be designed in accordance with subsection (q)(2)(A) and (B) of this section.(F) Service areas. Service areas shall be located in, or readily available to, each nursing unit. Each service area may be arranged and located to serve more than one nursing unit, but at least one service area shall be provided on each nursing floor. The following service areas shall be provided:(i) an administrative center or nurses station with an adjacent but separate dictation space;(ii) a nurses office;(iii) an area for charting. The area may be combined with the nurses station when adequate space is provided for both;(iv) a medication room, medicine alcove area, or a self-contained medicine dispensing unit under visual control of nursing staff. The medication alcove area may be located in the clean workroom. The self-contained medicine dispensing unit may be located in an alcove at the nurse station. The room, area or unit shall contain a work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances. Standard cup-sinks provided in many self-contained units are not adequate for hand washing;(v) a nourishment station containing a work counter with sink, microwave, refrigerator and storage cabinets and not located in the clean workroom;(vi) a multipurpose room for staff and patient conferences, education, demonstrations, and consultation. The room shall be conveniently accessible to each nursing unit and may serve several nursing units or departments. The room may be located on another floor if convenient for regular use;(vii) a conveniently located examination/treatment room which may serve several nursing units located on the same floor. The room shall have a minimum clear floor area of 100 square feet and contain a counter for writing and hand washing facilities with hands-free operable controls. This room may be omitted if all patient rooms on the floor are single-bed patient rooms;(viii) special assisted bathing facilities, including space for attendant, for patients on stretchers, carts, and wheelchairs at the ratio of one per 100 beds or a fraction thereof. This may be on another floor if convenient for use. The central bathing room shall contain a bathtub which is accessible to a patient in a wheelchair or a shower that can accommodate a gurney. The room shall have space for drying and dressing and be provided with a hand washing fixture with hands-free operable controls and a toilet with three feet of clear space on sides and front of the water closet;(ix) staff lounge with unisex dressing cubicles, lockers, toilets and hand washing facilities. These facilities may be on another floor;(x) securable closets or cabinet compartments for personal articles of nursing unit staff. The closets or lockers shall be located at or near the nurse station. At a minimum, these shall be large enough for purses and billfolds. Coats may be stored in closets or cabinets on each floor or in a central staff locker area;(xi) clean workroom or clean supply room. When used for preparing patient care items, it shall contain a work counter, hand washing facilities with hands-free operable controls, and storage facilities for clean and sterile supplies. When used only for storage and holding as part of a distribution system of clean and sterile supplies, the work counter and hand washing facilities may be omitted;(xii) clean linen storage for each nursing unit. This may be within a clean workroom, a separate closet, or an approved distribution system on each floor. If a closed cart system is used, storage may be in an alcove, but must be out of the path of normal traffic and under staff control;(xiii) a soiled workroom or soiled holding room. The room shall contain a clinical sink or equivalent flushing rim fixture, hand washing facilities with hands-free operable controls, both with hot and cold water. The room shall have a work counter and space for separate covered containers for soiled linen and waste. When facilities for cleaning bedpans are provided elsewhere, the flushing rim clinical sink may be omitted;(xiv) an equipment storage room or alcove. The room(s) or alcove(s) shall be located on the patient floor to keep the corridor width free of all equipment and supplies. Ten square feet of equipment storage or supplies shall be provided for each patient bed. Combustible supplies shall not be stored in an alcove in the egress corridors;(xv) an emergency equipment storage room or alcove under direct visual control of the nursing staff;(xvi) a housekeeping room which may also serve adjacent nursing units;(xvii) stretcher and wheelchair storage space which is located without restricting normal traffic;(xviii) public toilets with hand washing facilities. The toilets shall be located on each floor containing a nursing unit;(xix) staff toilet conveniently located to each nursing unit. At least one staff toilet shall be located on each patient sleeping floor. Toilet may be unisex; and(xx) an ice dispensing machine for each nursing unit which is located at the nourishment station or the clean work room.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Egress. Means of egress from each patient suite shall comply with the requirements of NFPA 101, §18.2.(ii) Patient bathroom and toilet room doors. Door leaves to all patient bathrooms and toilet rooms shall be at least 36 inches wide and shall swing outward or be double acting so that nursing staff may gain access to a patient who has collapsed against the door. Doors lockable from the inside shall have hardware that allows staff to open the door from the outside.(iii) Vision panels. Vision panels shall be provided in the door between an anteroom and an airborne infection isolation room or a protective environment room.(iv) Patient room windows. Each patient sleeping room shall have an outside door or an outside window. When operable windows are provided and the operation of windows requires the use of tools or keys, the tools or keys shall be located at each nurses station, on the same floor, and easily accessible to staff. The allowable window sill height shall not exceed 36 inches above the floor.(v) Location of patient room windows. Windows in patient sleeping rooms shall be located on an outside wall. These windows may face an atrium, an inner court, or an outer court provided the following requirements are met.(I) Patient room atria windows. When patient room windows face an atrium, the atrium shall comply with the requirements of NFPA 101, §8.6.7. When windows are operable, an engineered smoke control system shall be provided in accordance with National Fire Protection Association 92B, Guide for Smoke Management Systems in Malls, Atria, and Large Areas, 2000 edition.(II) Outer courts. Outer court (not enclosed by building on one side) onto which the required windows open shall have a minimum width, at all levels, of not less than three inches for each foot, or fraction thereof, of the height (average height of enclosing walls) of such court, but in no case shall the width be less than five feet. An outer court shall have a horizontal cross-sectional area not greater than four times the square of its width.(III) Inner courts. Inner court (enclosed by building on all sides) onto which the required windows open shall have minimum width, at all levels, of not less than one foot for each foot, or fraction thereof, of the height (average height of enclosing walls) of such courts, but in no case shall the width be less than 10 feet. When operable windows are provided, a horizontal, unobstructed, and permanently open air intake or passage having a cross-sectional area of not less than 21 square feet shall be provided at or near the bottom of the court. Metal decorative grilles not effectively reducing the open area by more than 5.0% shall be permitted at the ends. Walls, partitions, floor, and floor-ceiling assemblies forming intakes or passages shall be noncombustible and shall be constructed in accordance with NFPA 101, §18.3.1.1. An inner court shall have a horizontal cross-sectional area of not less than one and one-half times the square of its width.(vi) Hand washing facilities. Hand washing facilities shall be conveniently located near the nurses station and in the medication area. One lavatory in an open medication area can meet this requirement.(vii) Elevator lobbies. Elevator lobbies shall be provided in accordance with §133.164 of this title (relating to Elevators, Escalators, and Conveyors).(viii) Patient's privacy. Cubicle curtains to assure privacy for each patient shall be provided in all multi-bed patient rooms.(ix) Telephone access. Each patient shall have access to a telephone directly from each bed.(B) Finishes.(i) Seamless floors with coved wall bases described in §133.162(d)(2)(B)(iii)(III) of this title shall be provided in soiled workrooms.(ii) Wall bases in the soiled workroom shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and impervious to water.(iii) Monolithic ceilings described in §133.162(d)(2)(B)(vi)(III) of this title shall be provided in airborne infection isolation rooms, protective environment rooms, and soiled workrooms.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Outside air shall be supplied to each patient room by a central air handling unit to provide make-up air for air exhausted from the bathroom in accordance with Note 3 of Table 3 of §133.169(c) of this title.(B) Each patient room bathroom shall be exhausted continuously to the exterior in accordance with Table 3 of §133.169(c) of this title.(C) The isolation room exhaust shall be a dedicated system which exhausts all air continuously to the exterior in accordance with Table 3 of §133.169(c) of this title. Multiple isolation rooms may be interconnected to the same exhaust system.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph. Each patient bathroom shall contain a water closet with a bedpan washer, bathtub or shower and a lavatory.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) Electric receptacles in nursing units.(i) Each receptacle shall be grounded to the reference grounding point by means of an insulated copper grounding conductor.(ii) Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, §3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard.(iii) One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location.(iv) Each examination table shall have access to two duplex receptacles.(v) Each work table or counter shall have access to one duplex receptacle for every six feet of table or counter space or fraction thereof.(vi) One duplex receptacle protected with a GFCI shall be installed in the bathroom to permit the use of electrical appliances in front of the mirror.(vii) Duplex receptacles shall be installed not more than 50 feet apart in corridors and within 25 feet of corridor ends.(viii) The isolation exhaust system shall be connected to the emergency essential electrical system.(B) Nurses calling systems. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(C) Illumination requirements.(i) General illumination requirements. Nursing unit corridors shall have general illumination with provisions for reducing light levels at night. Illumination of corridors for egress purposes shall comply with NFPA 101, §18.2.8 and §18.2.9.(ii) Illumination of the nurses station. Illumination of the nurses station and all nursing support areas shall include fixtures powered from the critical branch of the emergency electrical system NFPA 99, §4.4.2.2.2.3(3)(d).(iii) Patient suite lighting.(I) Each patient room shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system.(II) A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. Flexible light arms, if used, shall be mechanically controlled to prevent the bulb from coming in contact with bed linen. High heat-producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens.(III) A wall or ceiling-mounted lighting fixture shall be provided above each lavatory.(IV) A ceiling-mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch.(u) Obstetrical suite.(1) Architectural requirements.(A) General. When obstetrical services are provided, the obstetrical suite shall be located and arranged to preclude unrelated traffic through the suite. Regardless of the clinical model used for labor, delivery, recovery and postpartum, a hospital offering such services shall be able to demonstrate the availability of one room designed, equipped and held in reserve for emergency, caesarean section deliveries. This room shall be located either in the labor and delivery suite or surgical suite.(B) Caesarean section (c-section) operating room(s). A minimum of one dedicated c-section operating room shall be located in either the obstetrical or surgical suite. This room shall have a minimum clear floor area of 360 square feet with a minimum dimension of 18 feet exclusive of built-in shelves or cabinets. There shall be no direct access between operating rooms.(C) Delivery room(s). A minimum of one delivery room shall be provided in every obstetrical suite. The delivery room shall have a minimum clear floor area of 300 square feet with a minimum dimension of 16 feet exclusive of fixed and moveable cabinets and built-in shelves. In facilities having only one c-section operating room, the delivery room shall be designed to function as an emergency c-section operating room. When two c-section operating rooms are provided, the delivery room requirement may be omitted.(D) Infant resuscitation area. An infant resuscitation space shall be provided within the c-section operating room; delivery room; labor, delivery, and recovery room (LDR); and labor, delivery, recovery and postpartum room (LDRP) with a minimum clear floor area of 40 square feet in addition to the required area of each room or may be provided in a separate but immediately accessible room with a clear floor area of 150 square feet.(E) Labor room(s). A minimum of two labor beds shall be provided for each delivery room. Each labor room shall be designed for one or two beds with a minimum clear floor area of 120 square feet per bed.(i) An LDR or LDRP may be substituted for a labor room.(ii) In facilities having only one delivery room, one of the two required labor beds shall be in a separate room with a minimum clear floor area of 160 square feet to serve as an emergency vaginal delivery room. Medical gas outlets shall be the same as for delivery room.(iii) Each labor room shall contain a lavatory equipped with hands-free operable controls. Each labor room shall have direct access to a toilet room. One toilet room may serve two labor rooms.(iv) Labor rooms shall be arranged so that doors are visible from a nurses work station.(v) A minimum of one shower shall be provided for each four labor beds. Each shower room shall contain a toilet and hand washing fixture with hands-free operable controls.(F) Recovery room(s). Recovery room(s) shall contain not less than two beds. There shall be enough space for baby and crib and a chair for the support person. Visual privacy of the new family shall be provided. LDRs or LDRPs may be substituted for recovery rooms.(i) In multiple recovery patient stations, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of five feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than eight feet for single load area/room or twelve feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram N of §133.169(h) of this title.(ii) A nurse station and charting area shall be provided and arranged to permit staff visual observation of recovery beds.(iii) A work counter, facilities for dispensing medicine, storage for supplies and equipment, and a clinical sink with bedpan-flushing device shall be provided.(iv) One hand washing fixture with hands-free operable controls shall be provided for every three recovery beds or fraction thereof. Fixtures shall be uniformly distributed.(v) There shall be cubicle curtains at each station for patient privacy.(G) Postpartum and antepartum suite. Postpartum and antepartum patient suites shall be provided in accordance with subsection (t)(1)(B) of this section.(H) LDR.(i) When provided, each LDR room shall have controlled access and shall be located so that a patient may be transported to the c-section operating room without the need to pass through other functional areas.(ii) Each LDR room shall be designed for single occupancy and have a minimum clear floor area of 200 square feet exclusive of the infant resuscitation area, built-in shelves or cabinets, alcove, vestibule or other adjoining rooms. The minimum clear room dimension shall not be less than 11 feet.(iii) A hand washing fixture with hands-free operable controls shall be provided in each LDR room.(iv) Each LDR shall have direct access to and exclusive use of a bathroom with a shower, or tub with shower, hand washing fixture with hands-free operable controls and a toilet.(I) LDRP. When provided, each LDRP room shall have controlled access and shall be located on an exterior wall and have a window in accordance with subsection (t)(2)(A)(iv) and (v) of this section.(i) Each room shall be designated for single occupancy and have a minimum clear floor area of 260 square feet exclusive of the infant resuscitation area, built-in shelves or cabinets, alcove, vestibules, or other adjoining rooms. The minimum clear room dimension shall not be less than 11 feet.(ii) A hand washing fixture with hands-free operable controls shall be provided in each LDRP room.(iii) Each LDRP shall have direct access to and exclusive use of a bathroom with a shower, or tub with shower, hand washing fixture with hands-free operable controls and a toilet.(J) Isolation rooms. When patients who have airborne infectious diseases are treated, an isolation room shall be provided in the obstetrical suite which complies with the functional space requirements as specified in subparagraphs (G) - (I) of this paragraph, and with the ventilation requirements for infection isolation rooms in Table 3 of §133.169(c) of this title.(K) Nursery suite. One infant station for each LDRP and each postpartum bed shall be provided in the nursery. Nurseries shall be located and arranged convenient to the postpartum nursing unit and near or part of the obstetrical suite. The nurseries shall be located and arranged to preclude the need for nonrelated pedestrian traffic. Each nursery unit shall meet the following requirements.(L) Full-term nursery. A full-term nursery shall have a maximum of 16 infant stations. The clearance between the side of a bassinet and a wall/partition shall be a minimum of two feet six inches. The clearance between sides of bassinets shall be a minimum of four feet. The minimum distance at the foot of the bassinet shall not be less than five feet for single load area/room or seven feet for double load area/room. Three feet of the passage space at the foot of the bassinet may be shared between two bassinets. The requirements of this subparagraph are illustrated in Table 8, Diagram I of §133.169(h) of this title. Additional area shall be provided to accommodate workroom functions if these are located within the nursery area as specified in subparagraph (N)(iv) of this paragraph.(i) When a rooming-in program is used, the total number of bassinets in full-term nursery units shall be not less than one bassinet for every two LDRP and postpartum beds.(ii) When a rooming-in program is used but all infants are returned to the nursery at night, a reduction in bassinets shall not be allowed.(iii) There shall be one lavatory with hands-free operable controls for each six infant stations or fraction thereof. Fixtures shall be uniformly distributed but not in the clear floor area of the infant stations.(iv) An observation window to permit the viewing of infants from public areas shall be provided. The public viewing areas shall not encroach into the egress corridor.(M) Continuing care nursery suite. Hospitals with 25 or more maternity beds shall provide a continuing care nursery for infants requiring close observation. The suite shall have a maximum of 16 infant stations. The clearance between the side of the bassinet and a wall/partition shall be a minimum of three feet. The clearance between sides of bassinets shall be a minimum of six feet. The minimum distance at the foot of the bassinet shall not be less than six feet for single load area/room or nine feet for double load area/room. Three feet of the passage space at the foot of the bassinet may be shared between two bassinets. The requirements of this subparagraph are illustrated in Table 8, Diagram J of §133.169(h) of this title. Additional area shall be provided to accommodate workroom functions if these are located within the nursery area as specified in subparagraph (N)(iv) of this paragraph.(i) The continuing care nursery shall be located on an exterior wall and shall have a window(s). In the nursery, one window may serve more than one bassinet. The window sill height shall not exceed five feet above the floor. Bassinets shall not be located more than 50 feet from an exterior window. A newborn's view to outside windows shall be direct. When partitions are used, the newborn's view to the outside windows may be through no more than two separate clear vision panels.(ii) The continuing care nursery shall not be located within a full-term nursery.(iii) There shall be a minimum of one lavatory with hands-free operable controls for each four infant stations or fraction thereof. Fixtures shall be uniformly distributed but not in the clear floor area of the infant stations.(N) General requirements for nurseries. Each nursery regardless of type shall meet the following requirements:(i) Observation windows to permit the viewing of infants from public areas for full-term nurseries and from workroom(s) into adjacent nurseries shall be provided. Windows between nurseries may be provided for the convenience of staff observation.(ii) Ten square feet per bassinet shall be provided for convenient, accessible storage for linens, infant supplies, and equipment.(iii) A room for consultation, demonstration, breast feeding or breast pumping shall be provided convenient to the unit. A counter with sink with hands-free operable controls, refrigeration and freezer, storage for pump and attachments, and educational materials shall be provided in or convenient to the room.(iv) Each nursery room shall be served by a connecting workroom(s). The workroom shall contain scrubbing and gowning facilities at the entrance for staff and housekeeping personnel, work counter, refrigerator, storage for supplies, and hand washing fixture with hands-free operable controls. One workroom may serve no more than two nursery rooms provided that required services are convenient to each. No nursery shall open directly into another nursery.(v) The workroom serving the full-term and continuing care nurseries may be omitted if equivalent work and storage areas and facilities, including those for scrubbing and gowning, are provided within that nursery at the entrance. Space required for work areas located within the nursery is in addition to the area required for infant care. Adequate provisions shall be made for storage of emergency carts and equipment, and for sanitary storage and disposal of soiled waste for the nursery.(vi) Charting and dictation facilities shall be provided for physicians and nurses. This may be in a separate room or part of the workroom.(vii) An examination/treatment room or space shall be provided and shall contain a work counter, storage, and lavatory equipped for hand washing with hands-free operable controls. The examination/treatment room or space shall have a minimum clear area of 80 square feet in addition to the required area of each workroom exclusive of fixed and movable cabinets and shelves. The examination treatment space shall be located within the nursery.(viii) An airborne infection isolation room is required in at least one level of nursery care and the neonatal critical care unit. The isolation room shall be enclosed and separated from the nursery unit with provisions for observation of the infant from adjacent nurseries or control area(s). The minimum size of the room shall be 120 square feet of clear floor area. The isolation room shall contain cabinets, a work counter, and a hand washing fixture with hands-free operable controls. Fixed and moveable cabinets and shelves shall not encroach upon bed/gurney clear floor space/area. The isolation room shall comply with the ventilation requirements in Table 3 of §133.169(c) of this title.(ix) A housekeeping room shall be provided for the exclusive use of the nursery. (O) Neonatal critical care unit (NCCU). When an NCCU is provided, the unit shall comply with the following.(i) The NCCU shall be conveniently located near the obstetrical suite and be arranged to preclude unrelated traffic.(ii) Each room and ward shall be located on an exterior wall and shall have a window. In a ward, one window may serve more than one patient. The window sill height shall not exceed five feet above the floor. Patient beds shall not be located more than 50 feet from an exterior window. Patients' views to outside windows shall be direct. When partitions are used, the patient's direct view to the exterior may be through no more than two separate clear vision panels. Window shall be in accordance with subsection (t)(2)(A)(v) of this section.(iii) The NCCU shall have a clearly identified public entrance and reception area arranged to permit visual observation and contact with all traffic entering the unit. Gowning facilities, lockers, and scrub area shall be provided at each public entrance to the patient care area(s) of the NCCU. All scrub sinks shall be provided with hands-free operable controls and large enough to contain splashing.(iv) A control station shall be provided in a central area and shall have space for counters and storage, and shall have convenient access to a hand washing fixture with hands-free operable controls. The control station may be combined with or include centers for reception, communication and patient monitoring.(v) NCCU patients may be housed in private rooms or a room with multiple bassinets or cribs. Each unit shall not exceed 24 bassinets or cribs. There shall be at least one enclosed private room for every six bassinets or cribs.(vi) A single-bassinet/crib patient NCC room shall have a minimum clear floor area of 120 square feet per bassinet/crib exclusive of work counter, vestibule, sink and aisle. A minimum of 12 feet width shall be provided for the head wall for each bed.(vii) In a multiple-bassinet/crib room/ward the clearance between the side of a sleeping unit and a wall/partition shall be a minimum of five feet. The clearance between sides of sleeping units shall be a minimum of eight feet. The minimum distance at the foot of the bassinet shall not be less than ten feet for single load area/room or sixteen feet for double load area/room. Four feet of the passage space at the foot of the bassinet may be shared between two bassinets. The fixed and moveable cabinets and shelves shall not encroach upon the bassinet/crib clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram K of §133.169(h) of this title.(viii) A minimum of one isolation room shall be provided with a minimum clear floor area of 120 square feet per bassinet/crib exclusive of work counter, vestibule, sink and aisle. A minimum of 12 feet width shall be provided for the head wall for each bed. A toilet room is not required.(ix) A lavatory equipped for hand washing with hands-free operable controls shall be provided in each single-bed room. In rooms with multiple beds, one lavatory with hands-free operable controls for each four patient stations or fraction thereof shall be provided. These lavatories shall be located convenient to infant stations.(x) Each NCCU shall be served by a connecting workroom containing gowning facilities at the entrance for staff and housekeeping personnel, a work space with counter, storage facilities, a lavatory or sink equipped for hand washing with hands-free operable controls, and individual closet or lockers for personal effects of nursing personnel. One workroom may serve not more than two NCCUs.(xi) A storage space for infant formula shall be provided. This functional space may be outside the NCCU but shall be available for use at all times.(xii) A breast feeding or pump room shall be provided convenient to the unit. Provision shall be made, either within the room or conveniently located nearby, for a sink with hands-free operable controls, counter, refrigeration and freezer, storage for pump and attachments, and educational materials.(xiii) A room(s) shall be provided within the NCCU for parents and infants for extended private time together and the room is not considered a patient room. The room(s) shall have direct access to toilet facilities and a hand washing fixture with hands-free operable controls. The room(s) shall have a sleeping area for at least one parent, and sufficient space for the infant's bassinet/crib and equipment. The room(s) shall have electrical and medical gas outlets as specified for NCCU bassinet/cribs. This room(s) shall have direct communication with the NCCU staff.(xiv) Twenty square feet of equipment storage shall be provided for each patient station. The storage areas shall be out of the way of the corridor traffic.(xv) Charting and dictation space shall be provided for physicians and nurses.(xvi) A respiratory therapy work area and storage room shall be provided.(xvii) Blood gas lab facilities shall be immediately accessible to the NCCU.(xviii) A staff lounge shall include toilet facilities with a hand washing fixture with hands-free operable controls. The lounge(s) shall be located so that staff may be recalled quickly to the patient area in emergencies. Toilet facilities may be shared as long as privacy is maintained for changing areas.(xix) Physicians and other staff on 24-hour on-call work schedules shall be provided with sleeping rooms with access to a shower(s), toilet(s), and lavatory(ies). If on-call room(s) are not within the NCCU served, a dedicated telephone or intercom system shall connect the on-call room(s) to the NCCU.(xx) A waiting room/area shall be provided and contain toilet room(s) with hand washing facilities. Waiting room/area maybe shared with other waiting room/areas if conveniently located.(xxi) A consultation room shall be provided, if not provided elsewhere in the suite.(xxii) A housekeeping room shall be provided exclusively within or immediately adjacent to the NCCU. It shall not be shared with other nursing units or departments.(P) Infant formula facilities. Infant formula facilities shall meet the following requirements.(i) When infant formula is prepared on site, the infant formula preparation room shall contain a lavatory equipped for hand washing with hands-free operable controls, warming facilities, refrigerator, work counter, formula sterilizer, and storage facilities. The formula room may be located near the nurseries or at another appropriate place within the hospital. Direct access from the formula preparation room to any nursery room is prohibited.(ii) An infant formula clean-up room shall be provided and include a hand washing fixture with hands-free operable controls, facilities for bottle washing, a work counter, and sterilization equipment. (iii) When commercial infant formula is used, the separate clean-up and formula preparation rooms may be omitted. The storage and handling may be done in the nursery workroom or in another appropriate room in the hospital that is conveniently accessible at all hours.(iv) A refrigerated storage and warming facilities for infant formula shall be provided and be accessible for use by nursery personnel at all times.(Q) Service areas. The following service areas shall be provided to support an obstetrical suite unless otherwise noted.(i) Control station. The control station shall be located to permit direct visual surveillance of all traffic which enters the obstetrical suite.(ii) Office. A supervisor's office shall be provided.(iii) Waiting room/area. A waiting room/area shall be provided and contain toilet room(s) with hand washing facilities, public telephone(s), and drinking fountain(s).(iv) Scrub facilities. Two scrub stations shall be within 5 feet of the entrance to each c-section operating room and delivery room. Two scrub stations may serve two c-section operating rooms or delivery rooms if the scrub stations are located adjacent to the entrance of each c-section operating room or delivery room. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts. Viewing panels shall be provided for observation of c-section operating rooms and delivery rooms from the scrub area.(v) Sterilizing facilities. Sterilizing facilities with high speed sterilizers shall be conveniently located to serve all c-section operating rooms and delivery rooms. A work space and a hand washing fixture with hands-free operable controls shall be included. High speed autoclaves should only be used in an emergency situation (e.g. replacements unavailable for dropped instruments). Sterilization facilities would not be necessary when spare instruments are available.(vi) Anesthesia workroom. An anesthesia workroom shall be provided with work counter, sink with hands-free operable controls, and storage space for small style D or E medical gas cylinders and other anesthesia equipment.(vii) Medication station. Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not adequate for hand washing. The medication station may be shared with the clean work room.(viii) Nourishment station. The nourishment station shall contain sink with hands-free operable controls, work counter, self-dispensing ice machine, refrigerator, cabinets, and not located in the clean work room. Space shall be included for temporary holding of unused or soiled dietary trays. A nourishment station is not required in the nursery suite.(ix) General storage room(s). A minimum of 50 square feet per operating room is required for general storage space(s). The storage space is exclusive of soiled holding, sterile supplies, clean storage, drug storage, locker rooms. In addition to general storage, equipment storage shall be provided for labor, LDR and LDRP rooms.(x) Emergency storage. Equipment used for emergencies shall be stored in a room or alcove under direct visual control of the nursing staff.(xi) Storage alcove. The alcove provided for stretcher storage, portable X-ray equipment, warming devices, auxiliary lamps, etc. shall be located out of direct line of traffic.(xii) Obstetrical suite staff clothing change rooms. Appropriately sized areas shall be provided for male and female personnel working within the obstetrical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker/changing rooms shall be provided for male and female staff. The shower and toilet room(s) may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the obstetrical suite can shower, change, and move directly into the restricted areas of the obstetrical suite.(xiii) Lounge. A lounge shall be provided in hospitals with four or more obstetrical surgical and delivery rooms. The lounge shall permit staff use without leaving the obstetrical surgical suite or delivery suite and may be accessed from the obstetrical suite staff clothing change rooms or staff changing room for delivery suite. The lounge shall not have direct access from outside the surgical suite. When the lounge is remote from the clothing change rooms, toilet facilities and a hand washing fixture with hands-free operable controls accessible from the lounge shall be provided.(xiv) Staff toilet facilities. Toilet facilities located in the obstetrical suite for exclusive staff use shall be provided and contain hand washing facilities with hands-free operable controls. The toilet room may be accessible from a staff lounge, when provided.(xv) Nurses' toilet. A nurses' toilet room shall be provided at the labor and recovery area(s) and shall include hand washing fixture with hands-free operable controls.(xvi) Dictation and report preparation area. This may be accessible from the lounge area.(xvii) On-call rooms. Physicians and staff on 24-hour on-call work schedules shall be provided with sleeping rooms with access to a toilet, lavatory and shower. If not contained within the unit itself, the area shall have a telephone or intercom connection to the obstetrical suite(s).(xviii) Clean workroom or clean supply room. A clean workroom is required. It shall contain a work counter, a hand washing fixture with hands-free operable controls, storage facilities for clean supplies, and a space to package reusable items. The storage for sterile supplies must be in a separated room. When the room is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and hand washing fixture may be omitted.(xix) Soiled workroom. The soiled workroom shall be for the exclusive use of the obstetrical suite and shall be in addition to the soiled workroom required for the obstetrical surgical suite. The soiled workroom for the obstetrical c-section operating room or delivery room suite shall not have direct connection with operating rooms or other sterile activity rooms. The soiled workroom shall contain a clinical sink with hands-free operable controls or equivalent flushing type fixture, work counter, sink equipped for hand washing, waste receptacle, and linen receptacle. There shall be a designated soiled workroom for the exclusive use of the NCCU.(xx) Housekeeping rooms. A separate housekeeping room containing a floor receptor or service sink and storage space for housekeeping supplies and equipment shall be provided for the exclusive use of the obstetrical suite, the c-section operating room, and nurseries (one for each).(xxi) Triage room. When triage services are provided, there shall be a minimum of one triage room in the obstetrical suite.(I) An obstetrical triage room shall be a minimum clear floor area of 100 square feet with a minimum dimension of nine feet. The obstetrical triage room shall contain cabinets, work counter, examination light, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area.(II) When a multiple-bed/gurney triage patient station is provided, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed/gurney triage room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. Privacy shall be provided for each patient with cubicle curtains or movable screens. The requirements of this subclause are illustrated in Table 8, Diagram D of §133.169(h) of this title. (III) A patient in a triage bed shall have access to a patient toilet room without entering the corridor.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) C-section operating rooms and delivery rooms shall have ceiling heights not less than nine feet.(ii) Recreation rooms, exercise rooms, equipment rooms, and similar spaces where impact noises may be generated shall not be located directly over operating rooms or delivery rooms, unless special provisions are made to minimize such noise as contained in Table 1 of §133.169(a) of this title.(iii) When vision panels are provided in labor rooms, LDRs, and LDRPs, the windows shall be located, draped, or otherwise arranged to preserve patient privacy from casual observation from outside the labor room.(iv) Shower controls shall be outside the wet area for use by nursing staff for labor room showers. In the LDRP rooms shower control outside of the wet area may be omitted.(v) When viewing windows are provided in a NCCU, provision shall be made to control casual viewing of infants.(vi) Noise control and sound attenuation in a NCCU shall be a design factor and meet the requirements contained in Table 1 of §133.169(a) of this title.(B) Finishes.(i) Finishes for LDR and LDRP rooms shall be selected for ease of cleaning and resistance to strong detergents.(ii) Flooring in c-section operating rooms, delivery rooms, labor rooms, isolation room, and soiled workroom shall be of the seamless type in accordance with the requirements of §133.162(d)(2)(B)(iii)(III) of this title. LDR and LDRP rooms shall have seamless type flooring below the bed and four feet at each side of the bed and foot of the bed.(iii) Ceilings and walls in c-section operating rooms, delivery rooms, soiled workroom, isolation and anteroom, and sterile processing room shall be of the monolithic type in accordance with §133.162(d)(2)(B)(vi)(III) of this title. Acoustic lay-in ceiling is permissible in the LDR and LDRP rooms.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) The air supply for the c-section operating room and delivery room shall be from ceiling outlets near the center of the work area. Return air shall be from near the floor level. Each c-section operating room and delivery room shall have at least two return air inlets located as remotely from each other as practical. (Design should consider turbulence and other factors of air movement to minimize fall of particulate into a wound site).(B) Air supply for LDRs, LDRPs, and nurseries shall be from ceiling outlets or high wall outlets. Return air shall be from near the floor level. Each LDR, LDRP, and nursery shall have at least two return air inlets located diagonally opposite from each other.(C) The ventilation system for anesthesia storage rooms shall conform to the requirements of NFPA 99, §4-3.1.1.2.(D) Each c-section operating room, delivery room and nursery shall have temperature and humidity indicating devices mounted at eye level.(E) Air handling units serving the obstetrical and surgical suite shall be equipped with filter having efficiencies equal to, or greater than specified in Table 4 of §133.169(d) of this title. (4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) General.(i) Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in c-section operating rooms and delivery rooms unless special precautions are taken to protect the spaces below from leakage and condensation from necessary overhead piping systems. Any required secondary protection shall be labeled every 20 feet "code required secondary drain system." The labeling shall be in highly visible print.(ii) Floor drains shall not be installed in c-section rooms and delivery rooms.(iii) Bedpan-flushing devices shall be installed in all patient toilet rooms serving LDRs and LDRPs.(B) Medical gas systems. Medical gas systems shall be provided in accordance with §133.162(d)(4)(A)(iii)-(vi) of this title.(i) Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 6 of §133.169(f) of this title.(ii) Nonflammable medical gas and clinical vacuum outlets for the infant resuscitation area or room shall be provided in addition to the required medical gas and vacuum for the mother in accordance with Table 6 of §133.169(f) of this title.(iii) When a labor room is intended to function as an emergency delivery room the nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 6 of §133.169(f) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) X-ray film illuminators for handling at least four films simultaneously shall be provided in each c-section operating room, labor, and delivery room. When the entire obstetrical suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the suite.(ii) Each c-section operating room shall have at least eight duplex hospital grade receptacles. (iii) Each delivery room, LDR and LDRP shall have at least six duplex hospital grade receptacles.(iv) Operating rooms and delivery rooms shall have at least three of the required duplex hospital grade receptacles located convenient to the head of the procedure table.(v) Newborn and continuing care nurseries shall have one normal and one critical duplex outlet for every two bassinets.(vi) In the infant resuscitation area or room, three duplex hospital grade receptacles shall be provided for the infant in addition to those required for the mother.(vii) The electrical circuit(s) to equipment in wet areas shall be provided with five milliampere GFCI. GFCI circuits shall not be used in c-section operating rooms and delivery rooms. When GFCIs are used in critical areas, provisions shall be made to ensure that other essential equipment is not affected by activation of one interrupter.(viii) C-section operating rooms and delivery rooms shall have general lighting in addition to that provided by special lighting units at the surgical and obstetrical tables. Each fixed special lighting unit at the operating or delivery table shall be connected to an independent circuit powered by the critical branch of the essential electrical system. Portable units may share circuits.(ix) Indirect lighting and high-intensity lighting shall be provided in the NCCU(s). The lighting shall be able to be adjusted over individual patient care spaces. No direct ambient lighting shall be permitted in the infant care spaces, and any direct ambient lighting used outside the infant care area shall be located or framed so as to avoid any infant's direct line of sight to the fixture. This does not exclude the use of direct procedure lighting.(x) Receptacles at each bed location in a NCCU shall be served by two branch circuits, one or more from the critical branch panel of the emergency electrical system and one or more from the normal system. One critical branch circuit shall serve only one bed location. All branch circuits from the normal system shall be from a single panelboard. All branch circuits from the emergency electrical system shall be from a single panelboard.(xi) A minimum of seven hospital grade duplex outlets shall be conveniently located at the head of each NCCU bed, crib or bassinet. At least three of these duplex outlets shall be on the critical branch of the emergency electrical system.(B) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(v) Outpatient suite.(1) Architectural requirements.(A) General. Outpatient services that the hospital provides to patients under the hospital license shall be within the hospital. Outpatient services and facilities (diagnostics, imaging, surgical, etc.) may be provided throughout the hospital within other suites, departments or units within the hospital. When an organized outpatient suite is provided for the hospital, it shall be in one identifiable contiguous location within the hospital and meet all the elements described in this subsection. To be included in the hospital license, an outpatient suite located in an office building or other building shall be physically connected to the hospital and become contiguous to the hospital. In no case may one leave the hospital, traverse the other occupancies, and then reenter the hospital to access the remaining portion of the hospital. A hospital may not occupy two or more noncontiguous areas of nonhospital occupancies, which contain intervening space of the nonhospital occupancies even if on the same floor or other floors. Outpatient facilities physically connected to the hospital with a common wall or an enclosed connection shall comply with the requirements of NFPA 101, Chapter 18.(B) Site, administration and public areas. The following shall be provided. (i) Parking. When an outpatient suite is provided, four parking spaces shall be required for each surgical procedure room, treatment room, and diagnostic room, plus additional spaces for each staff member.(ii) Entrance. When an established outpatient suite in one identifiable location provides surgical services, an illuminated covered drive through entrance shall be provided.(iii) Public waiting area. Toilet facilities, public telephone, and drinking fountain shall be provided. When pediatric services are provided, pediatric and adult patients waiting areas shall be separate.(iv) Control station. A control station shall be located to permit staff observation of waiting area and control of access to treatment rooms, procedure rooms, diagnostic rooms, and the surgical suite.(v) Wheelchair storage alcove. The alcove provided for wheelchair storage shall be located out of line of traffic.(vi) Interview space. Interview spaces shall be provided for social services, credit, and admissions. Provisions shall be made for privacy and dignity of the patient during interview, examination, and treatment.(vii) Offices. General or individual offices shall be provided for business transaction, records, and administrative and professional staff.(viii) Multipurpose rooms. Multipurpose rooms for conferences, meetings, and health education purposes shall be provided.(C) Examination, treatment, and observation rooms. When examination, treatment, or observation facilities are provided, the following shall be included.(i) Examination room. The room shall have a minimum clear floor area of 100 square feet exclusive of fixed cabinets and shelves. Each examination room shall contain a work counter, cabinets, examination light and hand washing fixture with hands-free operable controls. A clearance of three feet shall be provided at each side and the foot of the examination table.(ii) Special purpose examination rooms. The special purpose examination room shall comply with the requirements of an examination room as described in clause (i) of this subparagraph, but room size and configuration may be modified for specialized equipment. (iii) Treatment room. The room shall have a minimum clear floor area of 120 square feet exclusive of fixed and movable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 10 feet. The treatment room shall contain a work counter, cabinets, medication storage, examination light and a hand washing fixture with hands-free operable controls. (iv) Observation room. The room shall be located to permit close observation from either a nurse station or the control station. The room shall have a minimum clear area of 80 square feet exclusive of fixed and movable cabinets and shelves. Patients shall have access to a toilet room without entering the general corridor area.(v) Multiple-bed holding/observation room/area. In a multiple-bed holding/observation room/area, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed holding/observation room/area shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(D) Diagnostic facilities. Services shall be available to the outpatient suite. When separate radiology units are located within the outpatient suite, the requirements in subsection (l) of this section shall be met.(E) Laboratory. Services shall be made available to the outpatient suite. When a separate laboratory unit is installed within the outpatient suite, the requirements in subsection (n) of this section shall be met. All laboratory services provided within the outpatient suite or by a written contractual arrangement shall comply with the requirements of §133.41(h) of this title.(F) Surgical facilities. Outpatient surgical facilities may be provided separately or may be shared with the inpatient facilities. (i) When a separate outpatient surgery suite is provided, it shall meet the requirements in subsection (ee) of this section.(ii) The following additional rooms and areas shall be provided in each surgical suite wherever outpatient surgical procedures are performed. A preoperative area for outpatient use shall be provided. The area shall include a waiting room, public toilet facilities, sitting space for ambulatory patients, and at least one or more of the following: a single patient preoperative room, multiple-bed/gurney preoperative patient stations, single patient preoperative/recovery room, or multiple-bed/gurney preoperative/recovery patient stations. Traffic patterns shall be arranged for patients to enter the preoperative area from outside the surgical suite, prepare for surgical procedure and then move directly into the restricted corridor of the operating suite. (I) When a single patient preoperative room is provided the minimum clear area is 100 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The room shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls.(II) When a multiple-bed/gurney preoperative patient station is provided, the clearance between the side of the bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed/gurney preoperative patient room shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. One hand washing fixture with hands-free operable controls shall be provided for every four stations or fraction thereof. Privacy shall be provided for each patient with cubicle curtains or movable screens. The requirements of this subclause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(III) When a single patient preoperative/recovery room is provided the minimum clear area is 120 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The room shall contain cabinets, work counter, and hand washing fixture with hands-free operable controls.(IV) When a multiple-bed/gurney preoperative/recovery patient station is provided, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of four feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than eight feet for single load area/room or twelve feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed/gurney preoperative/recovery patient station shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. One hand washing fixture with hands-free operable controls shall be provided for every four stations or fraction thereof. Privacy shall be provided for each patient with cubicle curtains or movable screens. The requirements of this subclause are illustrated in Table 8, Diagram M of §133.169(h) of this title.(iii) A secondary recovery lounge (for outpatients requiring additional observation) with a nurse's station and a hand washing fixture with hands-free operable controls shall be provided. One hand washing fixture with hands-free operable controls shall be provided for every four secondary recovery stations or fraction thereof. In each secondary recovery station, the clearance between a side of lounger/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of lounger/gurney shall be a minimum of six feet. The minimum distance at the foot of the lounger/gurney shall not be less than six feet for single load area/room or nine feet for double load area/room. Three feet of passage space requirement at the foot of the lounger/gurney may be shared between two loungers/gurneys. The fixed and movable cabinets and shelves shall not encroach upon the lounger/gurney clear floor space/area. Privacy shall be provided for each patient with cubicle curtains or movable screens. The requirements of this clause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(iv) A toilet room for use by outpatients shall be provided directly accessible from the outpatient preoperative, recovery and secondary recovery lounge areas. The toilet room shall contain a water closet and a hand washing fixture with hands-free operable controls. There shall be one outpatient toilet room for every ten patient stations or fraction thereof. Toilet rooms may be shared if convenient to the outpatient preoperative, recovery and secondary recovery lounge areas.(G) Special procedure room(s). When outpatient special procedures services are provided within the outpatient suite, the special procedure room(s) shall comply with the requirements in subsection (dd) of this section.(H) Service areas. The following service areas and facilities shall be provided within the outpatient suite unless noted otherwise.(i) Nurse station(s). The nurse station shall contain a work counter, communication system, space for supplies, and provisions for charting.(ii) Hand washing fixtures. Hand washing fixtures with hands-free operable controls shall be available at all patient care areas.(iii) Patient toilet room(s). Toilet room(s) shall be conveniently located to treatment room(s), examination room(s), and diagnostic room(s) and shall include hand washing fixture(s) with hands-free operable controls.(iv) Staff toilet facilities. Toilet rooms equipped with hand washing fixtures with hands-free operable controls shall be provided for the exclusive staff use. Toilet facilities may be provided in conjunction with the staff lounge.(v) Staff lounge. A staff lounge with separate male and female staff clothing change rooms and toilets with hand washing fixtures with hands-free operable controls shall be provided in hospitals having a total of six or more diagnostic and treatment rooms.(vi) Medication station. Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, a hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean workroom.(vii) Dictation and report preparation area. This area may be accessible from the lounge.(viii) Cast room. When a cast room is provided, it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures.(ix) Wheelchair and stretcher storage. Wheelchair and stretcher storage space or alcove shall be provided and located out of direct line of traffic.(x) Storage. Storage facilities shall be provided for office supplies, sterile supplies, pharmaceutical supplies, splints and other orthopedic supplies, and housekeeping supplies and equipment.(xi) Ice machine. A self-dispensing ice machine shall be provided.(xii) Clean workroom. A clean workroom or clean supply room shall be provided.(xiii) Storage room. A storage room for the outpatient services shall be provided at least equal to 5.0% of the total area of the outpatient suite. This required storage room area may be combined with general stores.(xiv) Soiled workroom. A soiled workroom shall be provided. It shall not have direct access to any patient treatment, examination, diagnostic rooms, or sterile rooms. The room shall contain a clinical sink or equivalent flushing rim fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle.(xv) Housekeeping room. The housekeeping room shall be located within the suite. The room may be shared with an adjacent emergency suite when directly accessible from both sides.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. Treatment rooms shall be provided with seamless flooring in accordance with requirements contained in §133.162(d)(2)(B)(iii)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Filtration requirements for air handling units serving the outpatient and surgical suite shall be equipped with filters having efficiencies equal to, or greater than specified for patient care areas in Table 4 of §133.169(d) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph. Sinks used for the disposal of plaster of paris shall have a plaster trap.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(w) Pediatric and adolescent nursing unit.(1) Architectural requirements. When a facility offers pediatric care services and the nursing unit contains a total of 15 or more patient beds, cribs or bassinets, the unit shall meet the requirements contained in this subsection. Units containing less than 15 beds, cribs or bassinets, may be a part of the medical/surgical nursing unit. Each pediatric and adolescent nursing unit shall comply with the requirements contained in subsection (t)(1) of this section and the following requirements.(A) Patient rooms. Patient rooms in a pediatric and adolescent nursing unit containing hospital beds or cribs shall comply with subsection (t)(1)(B) of this section with the following exceptions: (i) The minimum clear floor space in a private patient room within a dedicated pediatric unit intended for a crib shall be 100 square feet exclusive of toilet room, closet, built-in cabinets, wardrobe, alcove, or vestibules. Minor encroachments including columns and wall hung lavatories that do not interfere with functions may be ignored.(ii) Patient rooms used for multiple cribs shall have no more than six cribs in a room. The clearance between the side of a crib and a wall/partition shall be a minimum of three feet six inches. The clearance between sides of crib shall be a minimum of six feet. The minimum distance at the foot of the crib shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the crib may be shared between two cribs. The fixed and moveable cabinets and shelves shall not encroach upon the crib clear floor space/area. One hand washing fixture with hands-free operable controls shall be provided for every three patients cribs. The requirements of this clause are illustrated in Table 8, Diagram L of §133.169(h) of this title.(B) Airborne infection isolation suites and protective environment suites. (i) Airborne infection isolation suites shall comply with the requirements contained in subsection (t)(1)(C) of this section and shall be located within the pediatric and adolescent nursing unit.(ii) Protective environment suites shall comply with the requirements contained in subsection (t)(1)(D) of this section and shall be located within the pediatric and adolescent nursing unit.(C) Pediatric nursery suite. When provided, the pediatric nursery suite shall be located in the pediatric nursing unit and shall consist of a nursery, examination/treatment room, workroom, and formula preparation room and contain the following elements.(i) Nursery. Each pediatric nursery shall contain not more than eight bassinets. The clearance between the side of bassinet and a wall/partition shall be a minimum of three feet. The clearance between sides of bassinets shall be a minimum of six feet. The minimum distance at the foot of the bassinet shall not be less than six feet for single load area/room or nine feet for double load area/room. Four feet of the passage space at the foot of the bassinet may be shared between two bassinets. The fixed and moveable cabinets and shelves shall not encroach upon the bassinet clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram J of §133.169(h) of this title. Additional area shall be provided to accommodate workroom functions if these are located within the nursery area as specified in clauses (ii) and (iii) of this subparagraph. (I) One hand washing fixture with hands-free operable controls shall be provided for every four patients bassinets in each pediatric nursery.(II) Each pediatric nursery shall be provided with viewing windows for observing infants from public areas and workroom(s).(ii) Nursery workroom. A connecting workroom shall be provided which shall contain gowning facilities at the entrance for staff, visitors, and housekeeping personnel, work space with counter, refrigerator, lavatory or sink equipped for hand washing, and storage. One workroom shall serve no more than two nurseries provided that required services are convenient to each. The workroom may be omitted if only one nursery is provided and the equivalent work area and facilities are provided within the nursery in which case the gowning facilities shall be located near the entrance to the nursery and shall be separated from the work area.(iii) Examination/treatment room or area. An examination/treatment room or area shall be provided. The examination/treatment area may be located in a separate room or a designated part of the nursery. It shall contain a work counter, storage facilities, and a lavatory for hand washing.(iv) On-site formula preparation. Where infant formula is prepared on the hospital site, the hospital shall provide cleanup facilities for washing and sterilizing supplies. These shall consist of a lavatory or sink equipped for hand washing, a bottle washer, work counter space, and an equipment sterilizer. A separate room for preparing infant formula shall be provided. The room shall contain a lavatory or sink equipped for hand washing, hot plate, refrigerator, work counter, formula sterilizer, and storage facilities. It may be located in the pediatric nursery or in another appropriate place within the hospital. There shall be no direct access from the formula room to a nursery.(v) Commercially prepared formula. If a commercial infant formula is used, the storage and handling may be done in the nursery workroom or in another appropriate room elsewhere in the hospital which has a work counter, sink equipped for hand washing, and storage facilities.(vi) Housekeeping room. A housekeeping room shall be located in the pediatric nursery suite.(D) Service areas. The service areas in the pediatric and adolescent nursing unit shall comply with the requirements listed in subsection (t)(1)(F) of this section and the following requirements.(i) Multipurpose or individual room(s) shall be provided for dining, educational, and play purposes. Special provision shall be made to minimize the impact noise transmission through the floor of the multipurpose room(s) to occupied spaces below. Requirements in Table 1 of §133.169(a) of this title shall be met.(ii) Patient toilet room(s) shall be provided convenient to multipurpose room(s) and central bathing facilities.(iii) Storage closets or cabinets for toys and educational and recreational equipment shall be provided.(iv) Storage space shall be provided for replacement of cribs and adult beds to provide flexibility for interchange of patient accommodations.(2) Details and finishes. Each pediatric and adolescent nursing unit shall comply with the requirements contained in subsection (t)(2) of this section.(3) requirements. Mechanical requirements in each pediatric and adolescent nursing unit shall comply with the requirements contained in subsection (t)(3) of this section and this paragraph.(A) Special consideration for safety shall be given to the type of heating and cooling units, ventilation outlets, and appurtenances installed in patient areas of pediatric and adolescent nursing units.(B) All air grilles and diffusers shall be of a type that prevents the insertion of foreign objects.(C) All convector or HVAC enclosures exposed in the room shall be constructed with rounded corners and shall have enclosures fastened with tamper-resistant fasteners.(4) Plumbing fixtures and piping systems. Plumbing fixtures and piping systems shall be in accordance with subsection (t)(4) of this section.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(x) Pharmacy suite.(1) Architectural requirements.(A) General. The pharmacy room or suite shall be located for convenient access, staff control, and security for drugs and personnel. (B) Dispensing area. The pharmacy room or suite shall include the following functional spaces and facilities:(i) area(s) for pickup, receiving, reviewing and recording; (ii) extemporaneous compounding area with sufficient counter space for drug preparation and sink with hands-free operable controls;(iii) work counter space for automated and manual dispensing activities;(iv) storage or areas for temporary storage, exchange, and restocking of carts; and(v) security provisions for drugs and personnel in the dispensing counter area.(C) Manufacturing. The pharmacy room or suite shall provide the following functional spaces and facilities for the manufacturing area(s):(i) bulk compounding area with work space and counters; and(ii) area(s) for packaging, labeling and quality control.(D) Storage. The following spaces shall be provided in cabinets, shelves, and/or separate rooms or closets:(i) space for bulk storage, active storage, and refrigerated storage;(ii) storage in a fire safety cabinet or storage room that is constructed under the requirements for protection from hazardous areas in accordance with NFPA 101, Chapter 12, for alcohol or other volatile fluids, when used;(iii) storage in a secure vault, safe, or double locking wall cabinet for narcotics and controlled drugs; and(iv) storage space for general supplies and equipment not in use.(E) Intravenous (IV) solutions area. When IV solutions are prepared in a pharmacy, a sterile work area shall be provided and be in compliance with 22 TAC §291.26 (relating to Pharmacies Compounding Sterile Pharmaceuticals) and the United States Pharmacopoeia, Chapter 797, Pharmaceutical Compounding-Sterile Preparations.(i) The IV work area shall consist of a preparation room, hood room and, if provided, a separate chemo-hood room. Access to the preparation room shall be through the pharmacy only, access to the hood room or chemo-hood room shall be through the preparation room only.(ii) The preparation room shall contain a work counter, gowning area and shelving.(iii) A hand washing fixture with hands-free operable controls shall be in the preparation room and within five feet of each entrance to the hood room or chemo-hood room. Hand washing fixtures and floor drains are not allowed inside the hood room or chemo-hood room.(iv) Laminar-flow hoods/work stations shall be located inside the hood room.(F) Compounding aseptic isolator (CAI). When a CAI is used for compounding, in lieu of the IV solutions area, it may be done within the pharmacy provided it complies with the following.(i) The CAI shall provide isolation from the room and maintain the International Organization for Standardization (ISO) Class 5 (100 particles greater than or equal to 0.5 microns per cubic foot) levels during dynamic operating conditions including transferring ingredients, components, and devices into and out of the isolator and during preparation of compounded sterile preparations.(ii) The particle counts sampled shall be 6 to 12 inches upstream of the critical exposure site within the CAI and maintain ISO Class 5 levels during compounding operations.(iii) The facility shall obtain documentation from the manufacturer that the CAI will meet this standard when located in worse than ISO Class 7 (10,000 particles greater than or equal to 0.5 microns per cubic foot environments).(G) Administrative area(s). The following functional spaces and facilities shall be included for the administrative area(s):(i) office area for the chief pharmacist and any other offices areas required for records, reports, accounting activities, and patients profiles;(ii) poison control center with storage facilities for reaction data and drug information centers; and(iii) a room or area for counseling and instruction when individual medication pick-up is available for inpatients or outpatients.(H) Satellite pharmacy facilities. When provided, the room(s) shall include a work counter, a sink with hands-free operable controls, storage facilities, and refrigerator for medications. As applicable, items required in subparagraphs (B) and (C) of this paragraph may be incorporated into the satellite pharmacy.(I) Service areas and facilities. The following service areas and facilities shall be provided.(i) Hand washing facilities. A hand washing fixture with hands-free operable controls shall be located in each room where open medication is handled except for IV prepared chemo-hood rooms.(ii) Staff facilities. Toilet rooms with hand washing fixture with hands-free operable controls may be outside the suite but shall be convenient for staff use.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Flooring in the IV solutions area for the preparation room, hood room and chemo-hood room shall be seamless and coved to the wall.(B) IV solutions area ceiling and wall finishes for the preparation room, hood room and chemo-hood room shall be interlocking monolithic panels and sealed together or monolithic epoxy-painted gypsum board. The ceiling shall be coved to the wall.(C) All penetrations in the walls and ceilings shall be sealed.(D) The door from hood room shall swing into the preparation room. The door from preparation room shall swing into the chemo room. The door from preparation room shall swing into pharmacy.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) When IV solutions are prepared, the required laminar-flow system shall include a nonhygroscopic filter rated at 99.97% (HEPA). A pressure gauge shall be installed for detection of filter leaks or defects.(B) When fume hoods are used for chemotherapy, the air/fumes shall be exhausted directly to the exterior. The hood exhaust shall not use the building exhaust system. When more than one fume hood is in the same hood room and the work stations face each other, at least six feet must separate work area openings.(C) When fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(D) All air entering the IV solutions area for the preparation room, hood room and chemo-hood room shall be HEPA filtered.(E) In the IV solutions area the air pressure in the preparation room shall be positive to the pharmacy, the hood room shall be positive to the preparation room and the chemo-hood room shall be negative to the preparation room.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) Material used for plumbing fixtures shall be nonabsorptive and acid-resistant. (B) Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of carafes, etc. (5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of the floor below or of the equipment.(B) Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(C) Electrical circuit(s) to equipment in wet areas shall be provided with five milliampere GFCI.(y) Radiotherapy suite. When radiotherapy services are provided, the suite may contain equipment for electron beam therapy, radiation therapy, or both. The following facilities shall be provided.(1) Architectural requirements.(A) Cobalt, linear accelerators, and simulation rooms require radiation protection. A medical physicist licensed under the Texas Medical Physics Practice Act, Occupations Code, Chapter 602, shall specify the type, location, and amount of radiation protection to be installed for the layout and equipment selections. Room layouts and construction shall prevent the escape of radioactive particles. Openings into the room, including doors, ductwork, vents, and electrical raceways and conduits, shall be baffled to prevent direct exposure to other areas of the facility.(B) Cobalt, linear accelerator, and simulator rooms shall be sized in accordance with the installed equipment requirements, patient access on a stretcher, medical staff access to the equipment and patient, and access for servicing the equipment.(C) When a mold room is provided, it shall contain a ventilation hood exhausted to the exterior and a hand washing fixture with hands-free operable controls.(D) A block room with storage for the linear accelerator may be combined with the mold room.(E) A hot laboratory in support of cobalt therapy shall be provided.(F) The following service areas shall be provided unless these are accessible from other departments such as imaging or outpatient areas:(i) a stretcher hold area adjacent to the treatment rooms, screened for privacy, and combined with a seating area for outpatients(ii) exam rooms for each treatment room. The rooms shall be a minimum of 100 square feet and shall be provided with hand washing facilities;(iii) a patient gowning area with provisions for safe storage of valuables and clothing. At least one space shall be sized to allow for staff-assisted dressing;(iv) convenient access to a housekeeping room;(v) film file area;(vi) film storage area for unprocessed film; and(vii) a radioisotope decay room. This room may be combined with the hot lab.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Radiation protection shall be designed, tested and approved by a medical physicist licensed under the Texas Civil Statutes, Occupations Code, Chapter 602.(ii) Room shielding calculations for linear accelerators, cobalt and simulation rooms shall be submitted to the Department of State Health Services' Radiation Control (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by inspectors, in the field, subsequent to use. Any changes in design or shielding, which affects radiation exposure levels adjacent to those rooms, requires prior approval by RC.(iii) The cobalt, simulation and linear accelerator rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(iv) Properly designed rigid support structures for ceiling-mounted equipment shall be located above the finished ceiling.(B) Finishes.(i) Flooring in the soiled workroom and any work or treatment areas in the radiotherapy suite where radioactive materials are handled shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Walls shall be constructed of materials that are easily decontaminated from accidental radioactive spills and finished in accordance with §133.162(d)(2)(B)(iv) of this title.(iii) Ceilings in the hot laboratory and soiled workroom shall be monolithic as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(B) Each hood used to process radioactive materials shall have a minimum face velocity of 90-110 feet per minute, be connected to an independent exhaust system, with suitable pressure-independent air modulating devices and alarms to alert staff of fan shutdown or loss of airflow. Each hood shall also have filters with a 99.97% efficiency (based on the dioctyl-phthalate (DOP) test method) in the exhaust stream, and be designed and equipped to permit the safe removal, disposal, and replacement of contaminated filters. Filters shall be as close to the hood as practical to minimize duct contamination.(4) Plumbing fixtures and piping systems. Piping systems and plumbing fixtures shall comply with the requirements of §133.162(d)(4) of this title.(5) Electrical requirements. Each radiotherapy suite shall comply with the requirements of §133.162(d)(5) of this title and this paragraph.(A) Each radiotherapy procedure room shall have at least four electrical receptacles.(B) Ground fault circuit interrupters shall not be used in radiotherapy procedure rooms.(C) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(z) Rehabilitation nursing unit.(1) Architectural requirements. When provided, each rehabilitation nursing unit shall comply with the requirements contained in subsection (t)(1) of this section and the following requirements.(A) Accessibility requirements. All patient rooms, bathing units and toilets in each rehabilitation nursing unit and all public and common use areas shall be designed and constructed to be handicapped accessible in accordance with §133.162(d)(1)(D) of this title. These requirements shall apply in all new construction and when an existing nursing unit or a portion thereof is converted to rehabilitation nursing care from other nursing care, e.g. mental health care to rehabilitation care.(B) Patient room suites. Patient room suites shall comply with the requirements of subsection (t)(1)(B) and the following requirements.(i) Multi-bed patient room. The clearance between the side of a bed and a wall/partition shall be a minimum of five feet. The clearance between sides of beds shall be a minimum of four feet. The minimum distance at the foot of the bed shall not be less than four feet for single load area/room or seven feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds. The fixed and moveable cabinets and shelves shall not encroach upon the bed clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram H of §133.169(h) of this title.(ii) Training toilet room. When a training toilet room is provided, there shall be three feet of clearance on both sides and front of the water closet fixture. The room shall be designed to comply with accessibility requirements of §133.162(d)(1)(D) of this title.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with subsection (t)(4) of this section. All plumbing fixtures shall comply with the requirements for the handicapped in accordance with §133.162(d)(1)(D) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(aa) Rehabilitation therapy suite. Rehabilitation therapy may include one or more categories of services. Where two or more rehabilitation services are provided, the services may share common areas when appropriate.(1) Architectural requirements.(A) Occupational therapy. When occupational therapy services are provided, the following rooms or areas shall be included:(i) an activity area with work areas, counters and a hand washing fixture with hands-free operable controls. Work areas and counters shall be suitable for wheel chairs;(ii) an area for teaching daily living activities with space for a bed, kitchen counter with appliances and sink, bathroom, and a table and chair. The daily living activities area may be combined with the activity area;(iii) an office for the occupational therapist; and(iv) a storage room for supplies and equipment.(B) Physical therapy. When physical therapy services are provided, the following rooms or areas shall be included.(i) Provisions shall be made for thermotherapy, diathermy, ultrasonics, and hydrotherapy when required by the functional program.(ii) Treatment area(s) shall be provided with a minimum of 70 square feet of clear floor area for each patient station, exclusive of four foot aisle space. Privacy screens or curtains shall be provided at each treatment station.(iii) A hand washing fixture with hands-free operable controls shall be provided in each treatment room/space. One hand washing fixture may serve up to four patient stations when cubicles or open room concepts are used and when the fixture is conveniently located. (iv) An area shall be provided for exercise and may be combined with treatment areas in open plan concepts.(v) An office shall be provided for the physical therapist. (vi) Separate storage shall be provided for soiled linen, towels, and supplies.(vii) A storage area or room for equipment, clean linen, and supplies shall be provided.(viii) When outpatient physical therapy services are provided, the suite shall have as a minimum patient dressing areas, showers and lockers. These shall be accessible and usable by the disabled. (C) Prosthetics and orthotics. When prosthetics and orthotics services are provided, the following rooms or areas shall be included:(i) work space with counters and shelves for technicians;(ii) a treatment space for evaluating and fitting with privacy screens or curtains; and(iii) a storage area or room for equipment and supplies.(D) Speech and hearing. When speech and hearing services are provided, the following rooms or areas shall be included:(i) a space for evaluating and treatment with privacy screens or curtains; and(ii) a storage area or room for equipment and supplies.(E) Service areas. The following areas or items shall be provided in a rehabilitation therapy suite, but may be shared when multiple rehabilitation services are offered:(i) patient waiting area(s) out of traffic with space for wheelchairs; (ii) patient toilet facilities containing hand washing fixtures, with hands-free operable controls;(iii) reception and control station(s). The reception and control station shall be located to provide supervision of activities areas. The control station may be combined with office and clerical spaces;(iv) office and clerical space;(v) wheelchair and stretcher storage room or alcove which shall be in addition to other storage requirements;(vi) lockable closets, lockers or cabinets for securing staff personal effects;(vii) staff toilets. The toilets may be outside the suite but shall be convenient for staff use and contain hand washing fixtures with hands-free operable controls;(viii) soiled holding room; and(ix) housekeeping room with service sink, conveniently accessible.(2) Details and finishes.(A) Details. Details shall be in accordance with §133.162(d)(2)(A) of this title.(B) Finishes. Finishes shall be in accordance with §133.162(d)(2)(B) of this title and this paragraph.(i) Flooring in a treatment room and soiled workroom shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Wall finishes shall be in accordance with the requirements of §133.162(d)(2)(B)(iv) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Air handling units serving the rehabilitation therapy suite shall be equipped with filters having efficiencies equal to, or greater than specified for patient care areas in Table 4 of §133.169(d) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(bb) Renal dialysis suite. Outpatient renal dialysis shall not be performed in the hospital's inpatient renal dialysis suite unless authorized under §133.41(t) of this title. When outpatient renal dialysis is provided within a hospital building, the service and facilities shall be separated from the hospital with a two-hour fire rated partition. The owner of the outpatient renal dialysis facility must obtain a separate license under Texas Health and Safety Code, Chapter 251, End Stage Renal Disease Facilities. Mechanical, electrical and plumbing services may be contracted from the hospital and the hospital shall maintain all rights and controls of all systems. When inpatient renal dialysis services are provided, the following rooms or areas shall be included.(1) Architectural requirements.(A) Dialysis services (acute). Dialysis services (acute) may be performed in critical care units and designated areas in the hospital, with appropriate equipment and space.(B) Treatment area(s). The treatment area(s) shall be separate from the administrative area(s).(i) Individual patient treatment room(s) shall have a minimum of 120 square feet of clear floor area exclusive of fixed and movable cabinets and shelves. The patient treatment room shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls.(ii) In multiple-treatment stations, the clearance between the side of a station and a wall/partition shall be a minimum of three feet. The clearance between sides of stations shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-treatment stations shall contain cabinets, work counters, and hand washing fixtures with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the patient treatment station clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(iii) A nurse station shall be located within the dialysis treatment area(s) and designed to provide visual observation of all patient stations. The nurse station shall have counters for storage and access to a hand washing fixture(s) with hands-free operable controls. (iv) Privacy shall be provided for each patient in the open treatment area with cubicle curtains or moveable screens.(v) Storage and preparation of medication may be done from a medicine preparation room, medicine alcove or from a self-contained medicine dispensing unit and shall be under visual control of nursing staff. A work counter, a hand washing fixture that is operable without the use of hands, a refrigerator, and double-locked storage for controlled substances shall be provided. (Standard cup-sinks provided in many self-contained units are not adequate for hand washing.)(C) Home training room. When home training is provided in the unit, a private treatment area of at least 120 square feet exclusive of fixed and movable cabinets and shelves shall be provided. This room shall contain a work counter, a hand washing fixture with hands-free operable controls, and a separate drain for fluid disposal.(D) Isolation rooms.(i) When renal dialysis treatment is provided for persons who are known or suspected of having airborne infectious disease, these procedures shall be performed in a designated treatment room of not less than 120 square feet of floor area meeting airborne infection isolation ventilation requirements as contained in Table 3 of §133.169(c) of this title. Bathing facilities are not required.(ii) When medical isolation for hepatitis B surface antigen (HbsAg) is provided, it shall be in a separate dedicated treatment room for a single patient with a minimum of 100 square feet clear area exclusive of fixed and movable cabinets and shelves. The treatment room shall include a work counter and a hand washing fixture with hands-free operable controls, and space for patient care supplies and equipment. The dialyzed equipment shall be designated and reserved for individual renal dialysis patients. The equipment shall be disinfected after each use. Disinfection of equipment shall occur in the treatment room.(E) Service areas and facilities.(i) Patient toilet(s). Patient toilet rooms shall be convenient to the treatment area(s) and include hand washing fixture(s) with hands-free operable controls.(ii) Storage space. A storage space shall be available for wheelchairs, supply carts and stretchers. This storage shall be located out of the direct line of traffic and in addition to other storage requirements.(iii) Water treatment room. The water treatment and equipment for the dialysis shall be located in a dedicated enclosed room.(iv) Mixing room. Dialysis solutions may be processed from a central batch delivery system or prepared in an on-site mixing room. When provided, a mixing room shall include a work counter, sink with hands-free operable controls, storage space, and holding tanks.(v) Dialyzers reprocessing room. When provided, the room shall be arranged for the separation and one-way movement of soiled and clean materials. This room shall include a work counter, service sink, separate hand washing fixture with hands-free operable controls, refrigerator and storage space.(vi) Breakdown room. When provided, the room shall include a work counter, service sink, separate hand washing fixture with hands-free operable controls, and storage space. This function may be included as part of the soiled processing area of the dialyzers reprocessing room.(vii) Nourishment station. When provided, the nourishment station shall include a work counter, a sink with hands-free operable controls, refrigerator, microwave, and storage cabinets.(viii) Hand washing facilities. Hand washing facilities shall be provided in each examination room and treatment room. In an open multiple-treatment area one hand washing fixture shall be provided for every four treatment stations or fraction thereof.(ix) Dictation and report preparation area. This area may be incorporated with the nurse station if adequate work space is provided.(x) Staff facilities. Toilets may be outside the suite but shall be convenient for staff use.(xi) Offices work area. Office space and clinical work area shall include space for records storage and report preparation.(xii) Clean workroom. When the functional program dictates preparing patient care items, a clean workroom shall be provided and contain a work counter, a hand washing fixture with hands-free operable controls, and storage facilities for clean and sterile supplies. This function may be within the mixing room. (xiii) Clean linen storage. There shall be a designated area for clean linen storage. This may be within a clean workroom, a mixing room, a separate closet, or an approved distribution system. If a closed cart system is used, storage of the cart shall be in an alcove.(xiv) Soiled workroom. The soiled workroom shall contain a work counter, a clinical sink with hands-free operable controls or equivalent flushing type fixture, separate hand washing facilities, and separate waste and linen receptacles.(xv) Housekeeping room. A housekeeping room for the exclusive use of the unit shall contain a service sink and storage for housekeeping supplies and equipment.(2) Details and finishes.(A) Details. Details shall be in accordance with §133.162(d)(2)(A) of this title.(B) Finishes. Finishes shall be in accordance with §133.162(d)(2)(B) of this title and this paragraph.(i) Flooring in a treatment room and soiled workroom shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Wall finishes shall be in accordance with the requirements of §133.162(d)(2)(B)(iv) of this title.(iii) Ceilings in the isolation and hepatitis B rooms shall be of the monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Air handling units serving the renal dialysis suite shall be equipped with filters having efficiencies equal to, or greater than specified for patient care areas in Table 4 of §133.169(d) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph. The dialysis water treatment shall meet the standards as described in the American National Standard, Hemodialysis Systems, July 2003 edition, published by the American Association for the Advancement of Medical Instrumentation (AAMI), 1110 North Glebe Road, Suite 220, Arlington, Virginia 22201, telephone (703) 525-4890.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General. Each treatment area and treatment room shall have at least two duplex electrical receptacles located on each side of a patient bed or lounge chair.(B) Grounding. All equipment and appliances shall be properly grounded in accordance with the National Fire Protection Association 99, Standard for Health Care Facilities, §§3-3.2.1.2(a)(2) and 7-5.1, 2002 Edition (NFPA 99), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Post Office Box 9101, Quincy, Massachusetts 02269-9101, 1-800-344-3555.(C) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title. (cc) Respiratory therapy suite. The type and extent of respiratory therapy services vary greatly in each hospital. Therapy can be delivered from a large centralized area or basic services can be provided at the patient bedside.(1) Architectural requirements.(A) Respiratory therapy suite. When respiratory services are provided from a centralized area, the following rooms or areas shall be included:(i) an office for the respiratory therapist;(ii) office and clerical space with provision for filing and retrieval of patient records;(iii) receiving/decontamination workroom with work counter or table, a deep sink, and a hand washing fixture with hands-free operable controls; and(iv) a storage room for clean and sterile supplies which is separate from the receiving/decontamination workroom.(v) When a blood gas analyzer is provided, it shall be located in a room and contain a counter and hand washing sink. When a portable blood gas analyzer is used, it may be used in rooms which have a work counter and hand washing facilities with hands-free operable controls. Storage of the unit may occur in an alcove or equipment storage room.(B) Outpatient respiratory therapy services. When respiratory therapy services are provided for outpatients, the following additional areas and facilities shall be included in the centralized respiratory therapy suite:(i) patient waiting area with space for wheelchairs;(ii) reception and control station(s) with visual control of waiting and activities areas;(iii) patient toilet facilities which include hand washing fixtures with hands-free operable controls;(iv) office and clerical space; and(v) consultation/education room.(C) Cough-inducing and aerosol-generating procedures. All cough-inducing procedures performed on patients who may have infectious Mycobacterium tuberculosis shall be performed in rooms, booths or special enclosures using local exhaust ventilation devices with HEPA filters located at the discharge end and exhaust directly to the outside. (D) Service areas. The following areas and facilities shall be provided for the respiratory therapy suite but may be shared with other departments when conveniently located:(i) wheelchair and stretcher storage room or alcove which is in addition to other storage requirements;(ii) lockable closets, lockers or cabinets for securing staff personal effects; (iii) staff toilets which include a hand washing fixture with hands-free operable controls. Staff toilets may be located outside suite if location is near and convenient; and(iv) housekeeping room. The housekeeping room shall be located within the suite or nearby, and shall contain a service sink and storage space for housekeeping supplies and equipment. (2) Details and finishes.(A) Details. Details shall be in accordance with §133.162(d)(2)(A) of this title. (B) Finishes. Finishes shall be in accordance with §133.162(d)(2)(B) of this title and this paragraph.(i) Flooring in a decontamination room shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Wall finishes shall be in accordance with the requirements of §133.162(d)(2)(B)(iv) of this title.(iii) Ceilings shall be in accordance with §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title.(dd) Special procedure suite.(1) Architectural requirements.(A) General. When special procedures such as endoscopy, bronchoscopy, and cardiac catheterization and other similar special procedures are provided, procedure rooms may be in a separate suite or may be part of the surgical suite.(i) Special procedure rooms may be incorporated in an outpatient suite. (ii) When special procedure rooms are part of the surgical suite and noninvasive procedures are performed, these rooms are not required to be part of the sterile environment.(iii) Nonsurgical or noninvasive procedure rooms shall have a minimum clear floor area of 250 square feet, and a minimum clear dimension between fixed cabinets and built-in shelves shall be 14 feet.(iv) A hand washing fixture or a scrub sink with hands-free controls shall be located within five feet of the entrance to each nonsurgical procedure room either in the room or outside. Hand washing facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts and recessed out of the main traffic areas.(v) When general anesthesia or inhalation anesthetizing agents are used during special procedures, these rooms shall comply with the detail, finish, mechanical and electrical requirements for an operating room contained in subsection (ee) of this section.(B) Special procedure rooms for surgical cystoscopic and other endourologic procedures.(i) The procedure room shall have a minimum clear floor area of 350 square feet exclusive of fixed cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 15 feet.(ii) Procedure rooms shall be designed for visual and acoustical privacy for the patient.(iii) One scrub station shall be located within five feet of the outside entrance of each special procedure surgical room. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment or supply carts. The scrub sinks shall be recessed out of the main traffic areas. The scrub sink shall be located off the restricted areas of the special procedure surgical procedure rooms. Scrub sinks or sinks shall not be located inside the sterile area.(iv) Appropriately sized areas shall be provided for male and female changing rooms within the special procedure surgical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker/changing rooms shall be provided for male and female staff. The shower and toilet room(s) may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the special procedure surgical suite can shower, change, and move into the restricted portions of special procedure surgical suite.(C) Catheterization laboratory. A catheterization procedure room may be in a separate suite, part of a special procedure suite, surgical suite, or in the imaging suite. The following items and facilities shall be provided.(i) The room(s) shall be located in an area restricted to authorized personnel.(ii) The procedure room shall be a minimum of 400 square feet of clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 18 feet.(iii) A control room shall have a view window which permits complete observation of the patient from the control console. The control room shall be large enough to contain the efficient functioning of the X-ray and image recording equipment.(iv) An area for viewing images and film file room shall be provided. When digital imaging is provided throughout the suite, a minimum of two X-ray film illuminators shall be provided within a central location within the catheterization laboratory and the film file room may be omitted. (v) An equipment room large enough to contain X-ray transformers, power modules, and necessary electronics and electrical gear shall be provided.(vi) Appropriately sized areas shall be provided for male and female changing rooms within the catheterization laboratory suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker/changing rooms shall be provided for male and female staff. The shower and toilet room(s) may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the catheterization laboratory can shower, change, and move into the restricted portions of catheterization laboratory.(vii) One scrub station shall be located within five feet of the outside entrance of each cardiac catheterization laboratory procedure room. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment or supply carts. The scrub sinks shall be recessed out of the main traffic areas. The scrub sink shall be located off the restricted areas of the cardiac catheterization laboratory. Scrub sinks or sinks shall not be located inside the sterile area.(viii) Sterilizing facilities for immediate or emergency use shall be provided unless instruments are all disposable. A work space and hand washing fixture with hands-free operable controls shall be included.(D) Patient holding and preparation area. In suites with two or more special procedure rooms, a patient holding and preparation area shall be provided to accommodate ambulatory and stretcher patients and meet the following requirements:(i) two-stretcher stations shall be provided for first procedure room with one additional station for each additional procedure room;(ii) the minimum clear floor space in a private holding and preparation room shall be 100 square feet exclusive of toilet room, built-in cabinets, work counter, alcove, or vestibules. A hand washing fixture with hands-free operable controls shall be provided. A minimum of 10 feet width shall be provided for the head wall;(iii) in a multiple-bed holding and preparation area, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram D of §133.169(h) of this title;(iv) a control station and charting area arranged to permit staff visual observation of holding and preparation area;(v) a work counter and a hand washing fixture with hands-free operable controls for every four beds/gurneys located in the preparation area; and(vi) cubicle curtains at each station for patient privacy. (E) Recovery room or area. In suites with two or more special procedure rooms, a recovery room or area shall be provided to accommodate ambulatory and stretcher patients and meet the following requirements:(i) a minimum of one patient recovery station shall be provided for each special procedure room;(ii) in a single patient recovery room, there shall be a minimum clear area of 130 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of 10 feet width shall be provided for the head wall. The room shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area;(iii) when multiple-bed/gurney recovery patient stations are provided, the clearance between side of bed/gurney and a wall/partition shall be a minimum of four feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than eight feet for single load area/room or twelve feet for double load area/room. Four feet of passage space requirement at the foot of the bed may be shared between two beds/gurneys. The multiple-bed/gurney recovery patient station shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. One hand washing fixture with hands-free operable controls shall be provided for every four stations or fraction thereof. The requirements of this clause are illustrated in Table 8, Diagram M of §133.169(h) of this title;(iv) a nurse station with a hand washing fixture with hands-free operable controls and charting area shall be provided and arranged to provide visual observation of recovery room area;(v) a staff toilet room with a hand washing fixture with hands-free operable controls shall be provided and located within the working area to maintain staff availability to patients;(vi) cubicle curtains shall be provided at each station for patient privacy; and(vii) the recovery room or area may be within the patient holding area.(F) Instrument processing room. When instruments and equipment are processed, cleaned and disinfected within the suite, dedicated rooms shall be provided. The room may serve multiple procedure rooms. The following rooms shall be included.(i) A decontamination room shall be provided and equipped with work counters, two sinks remote from each other and a hand washing fixture with hands-free operable controls. One of the sinks shall be utility type.(ii) A clean room shall be provided and the process of cleaning the instruments or equipment shall flow from the contaminated area to the clean area, and finally, to storage. The room shall include a work counter and a hand washing sink fixture with hands-free operable controls. Instruments and equipment shall be protected from contamination. (iii) When endoscopy scope wash rooms are provided, cleaning, washing and drying may occur in the same room. The room shall contain two sinks.(G) Service areas. The following services shall be provided for all types of special procedure rooms unless noted otherwise. (i) Control station. In facilities with two or more special procedure rooms in a suite, a nurse station shall be provided and located to permit visual surveillance of all traffic which enters the special procedure rooms suite.(ii) Dictation and report preparation area. This area may be incorporated with the control station.(iii) Medication station. Provision shall be made for the storage and distribution of medication to be administered to patients. This may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit. The medicine preparation room, medicine alcove area or self-contained medicine dispensing unit shall be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean work room.(iv) Outpatient services. When outpatient services are provided in the special procedure suite, a separate waiting/change area shall include waiting room, dressing/gowning area, and toilet facilities and a hand washing fixture with hands-free operable controls.(v) Patient toilet room(s). Toilet room(s) shall be conveniently located to special procedure rooms and patient changing areas and shall include hand washing fixture(s) with hands-free operable controls.(vi) Staff toilet facilities. Facilities shall be provided for exclusive staff use and include a hand washing fixture with hands-free operable controls. The toilet may be accessible from a staff lounge, when a staff lounge is provided.(vii) Storage. A storage room(s) shall be provided for equipment and supplies used in the special procedure suite. Each special procedure suite shall provide a minimum of 150 square feet of storage area or 50 square feet per procedure room, whichever is greater.(viii) Wheelchair and stretcher storage. Wheelchair and stretcher storage space/alcove shall be provided and located out of direct line of traffic.(ix) Staff storage. Storage space for employees' personal effects shall be provided.(x) Ice machine. An ice machine shall be provided.(xi) Clean storage room. A clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls.(xii) Soiled workroom. The soiled workroom shall not have direct connection to the special procedure or diagnostic rooms or other sterile or clean activity rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle.(xiii) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the special procedure suite. It shall be directly accessible from the suite and shall contain a floor receptor or service sink and storage for supplies and housekeeping equipment.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details. Special procedure rooms shall have ceiling heights not less than nine feet.(B) Finishes.(i) Flooring used in special procedure rooms, decontamination room, and in the soiled workroom shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceiling finishes in special surgical procedure rooms and isolation rooms, soiled workroom and sterile processing rooms shall be monolithic as required by §133.162(d)(2)(B)(vi)(III) of this title.(iii) A lay-in type ceiling is acceptable in nonsurgical special procedure rooms.(iv) A nonsurgical or noninvasive catheterization lab shall have a washable ceiling.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Air supply for the special procedure rooms shall be from ceiling outlets that are as near the work centers as possible. A minimum of two low return inlets shall be located diagonally opposite from one another.(B) Return air inlets shall be not lower than four inches nor higher than 12 inches from floor level.(C) Smoke removal systems shall be provided in accordance with §133.162(d)(3)(D)(iv)(II) of this title, for special procedure rooms that have piped-in nitrous oxide medical gas or where anesthesia is administered to patients.(D) The decontamination room shall meet the ventilation requirements that are contained in Table 3 of §133.169(c) of this title.(E) Each special procedure room and recovery room shall have wall-mounted temperature and humidity indicating devices.(F) When patients with airborne infectious disease are treated, the room shall meet requirements for airborne infection ventilation for patient care areas in accordance with Table 3 of §133.169(c) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in special procedure rooms and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(B) A medical gas system shall be provided in accordance with §133.162(d)(4)(A)(iii) and (iv) and Table 6 of §133.169(f) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) X-ray film illuminators for handling at least four films simultaneously shall be provided in a central location. When the entire special procedure suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminators viewers shall be provided.(ii) Each special procedure room shall have at least six duplex electrical hospital grade receptacles.(iii) In locations where mobile X-ray, laser, or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(iv) The electrical circuit(s) to equipment in wet areas shall be provided with GFCIs. GFCI circuits shall not be used in special procedure rooms. When ground fault circuit interrupters are used in critical areas, provisions shall be made to ensure that other essential equipment is not affected by activation of one interrupter. (v) Special grounding system in areas such as special procedure rooms where a patient may be treated with an internal probe or catheter the ground system shall comply with Chapter 10, NFPA 99 and Article 517, NFPA 70. (vi) Special procedures rooms shall have general lighting in addition to that provided by special lighting units at the procedure tables.(B) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(ee) Surgical suite.(1) Architectural requirements.(A) General.(i) A public waiting room shall be provided.(ii) Toilet facilities, public telephone(s), and drinking fountain(s) shall be provided within or nearby.(iii) The surgical suite shall be located and arranged to preclude unrelated traffic through the suite.(iv) When outpatient surgery is provided within the surgical suite additional requirements in subsection (v)(1)(F) of this section shall be provided.(B) General operating room(s). A minimum of one operating room shall be provided and shall have a minimum clear floor area of 400 square feet exclusive of fixed and movable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 20 feet. There shall be no direct access between operating rooms.(C) Operating rooms for cardiovascular, orthopedic, neurological, and other special surgical procedures that require additional personnel and large equipment.(i) When provided, these rooms shall have a minimum clear floor area of 600 square feet, with a minimum of 20 feet clear dimension exclusive of fixed or wall-mounted cabinets and built-in shelves.(ii) An additional room shall be provided in the restricted area of the surgical suite, preferably adjoining this operating room, where extra corporeal pump(s), supplies and accessories can be stored and serviced.(iii) When complex orthopedic surgery and neurosurgery are performed, additional rooms shall be provided in the restricted area of the surgical suite, preferably adjoining the specialty operating rooms, for storage of equipment used during these procedures.(D) Preoperative patient holding area(s) or room(s). In facilities with two or more operating rooms, a patient holding area or rooms shall be provided. The preoperative patient holding area may be used for secondary recovery. The area shall meet the following requirements.(i) The minimum clear floor space in a private preoperative holding room shall be 100 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of nine feet width shall be provided for the head wall.(ii) In a multiple-bed preoperative holding area, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram D of §133.169(h) of this title.(iii) A control station and charting area shall be provided and arranged to permit staff visual observation of holding and preparation area.(iv) A work counter with hand washing fixture with hands-free operable controls shall be provided and located in the preparation area.(v) Cubicle curtains shall be provided at each station for patient privacy.(vi) One hand washing fixture with hands-free operable controls shall be provided for every four preoperative holding beds or fraction thereof. Fixtures shall be uniformly distributed. One hand washing fixture with hands-free operable controls shall be provided within each single-bed preoperative holding room.(E) Post-anesthesia care units.(i) Post-anesthesia care units (PACU) for surgical patients shall contain a medication distribution station, nurse station with charting facilities, clinical sink provisions for bedpan cleaning, and storage space for stretchers, supplies and equipment. The nurse station shall be arranged to permit the staff to have full visual control of the PACU area.(ii) A minimum of one and a half patient stations per operating room shall be provided for post-anesthesia care or fraction thereof. A minimum of two stations shall be provided when there is only one operating room.(iii) The minimum clear floor space in a private recovery room shall be 130 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of 10 feet width shall be provided for the head wall. The room shall contain cabinets, work counter, and hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area.(iv) In multiple-bed/gurney recovery patient stations, the clearance between the side of bed/gurney and a wall/partition shall be a minimum of five feet. The clearance between sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than eight feet for single load area/room or twelve feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multi-bed/gurney recovery patient station shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 8, Diagram N of §133.169(h) of this title.(v) Special provisions shall be made to keep medical isolation infectious patients separate during surgical recovery. An isolation room meeting the requirements in subsection (t)(1)(C) of this section may meet this requirement if conveniently located near the surgical suite and otherwise complies with requirements for a PACU except that a patient toilet room is not required. The recovery isolation room shall have a minimum clear floor area of 120 square feet. In addition, the recovery isolation room medical gas system outlet requirements shall be in accordance with Table 6 of §133.169(f) of this title for recovery room(s). (vi) Cubicle curtains shall be provided for patient privacy.(vii) At least one door to the PACU room shall be within the surgical suite.(viii) Staff toilet facilities and a hand washing fixture with hands-free operable controls shall be located within or immediately adjacent to the PACU.(ix) One hand washing fixture shall be provided for every four recovery beds or fraction thereof in open wards. Fixtures shall be uniformly distributed. One hand washing fixture shall be provided within each single-bed recovery room.(F) Separation of recovery patients. Provisions shall be made for separating all patients subject to general anesthesia from those who did not receive general anesthesia. This requirement may be satisfied by providing separate recovery rooms, cubicles, secondary recovery rooms or scheduling of procedures.(G) Service areas. Services, except for the enclosed soiled workroom and the housekeeping room, may be shared with the obstetrical facilities if the functional program reflects this concept. Service areas, when shared with delivery rooms, shall be designed to avoid the passing of patients or staff between the operating room and the delivery room areas.(i) Control station. A control station located to permit visual surveillance of all traffic entering the surgical suite shall be provided.(ii) Office. A supervisor's office or station shall be provided.(iii) Scrub facilities. Two scrub stations shall be located in the restricted corridor within five feet of the entrance of each operating room. Two scrub stations may serve two operating rooms if the scrub stations are located adjacent to the entrance of both operating rooms. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment, or supply carts. Viewing panels shall be provided for observation of the surgical room interior. The scrub sinks shall be recessed out of the main traffic areas. The alcove shall be located within the restricted areas of the surgical suite. Scrub sinks shall not be located inside the sterile area.(iv) Substerile facilities. Sterilizing facilities located conveniently to the operating rooms for immediate or emergency use with work counter shall be provided.(v) Anesthesia workroom. The anesthesia workroom shall contain a work counter, sink with hands-free operable controls and storage space for medical gas cylinders and other anesthesia equipment.(vi) Medication station. Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean work room.(vii) General storage room(s). A minimum of 50 square feet per operating room is required for general storage space(s). The minimum requirement for three operating rooms or less is 150 square feet. This storage room is exclusive of soiled holding, sterile supplies, clean storage, drug storage, locker rooms and storage alcoves.(viii) Orthopedic surgery storage. Splints and traction equipment shall be stored in an enclosed storage room. Storage shall be outside the operating room but must be conveniently located.(ix) Storage alcove. An alcove(s) located out of the direct line of traffic shall be provided for the storage of stretchers, portable X-ray equipment, fracture tables, warming devices, auxiliary lamps, etc.(x) Surgical suite staff clothing change rooms. Appropriately sized areas shall be provided for male and female personnel working within the surgical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker/changing rooms shall be provided for male and female staff. The shower and toilet room(s) may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the surgical suite can shower, change, and move directly into the restricted areas of the surgical suite.(xi) Lounge. A lounge shall be provided in hospitals with three or more operating rooms. The lounge shall permit staff use without leaving the surgical suite and may be accessed from the clothing changing rooms. The lounge shall not have direct access from outside the surgical suite. When the lounge is remote from the clothing change rooms, toilet facilities and a hand washing fixture with hands-free operable controls accessible from the lounge shall be provided.(xii) Staff toilet facilities. Toilet facilities located in the surgical suite for exclusive staff use shall be provided and contain a hand washing fixture with hands-free operable controls. The toilet room may be accessible from a staff lounge, when provided.(xiii) Dictation and report preparation area. This may be accessible from the lounge area.(xiv) Cast room. When a cast room is provided it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures. This room may be located in the emergency room.(xv) Ice machines. An ice machine shall be provided for therapeutic purposes. A self-dispensing ice machine shall be provided for human consumption.(xvi) Clean workroom or clean supply room. A clean workroom is required when clean materials are assembled within the surgical suite prior to use or following the decontamination cycle. It shall contain a work counter, a hand washing fixture with hands-free operable controls, storage facilities for clean supplies, and a space to package reusable items. The storage for sterile supplies must be in a separate room. When the room is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and hand washing fixture may be omitted.(xvii) Sterile core. When a surgical suite contains a sterile core, it shall be free of any cross-traffic of staff and supplies from the soiled/decontaminated areas to the sterile/clean areas. The use of facilities outside the operating room for soiled/decontaminated processing, clean assembly and sterile processing shall be designed to move the flow of goods and personnel from dirty to clean without compromising universal precautions or aseptic techniques in both departments. (xviii) Soiled workroom. The soiled workroom shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle. The clinical sink and work counter may be eliminated if the room is used only for temporary holding of soiled material and cleaning of equipment/instruments and sterilization is provided outside the surgical suite. Provisions shall be made for the disposal of liquid waste. The soiled workroom shall be provided for the exclusive use of the surgical suite, shall be located in the restricted area of the surgical suite, and shall not have direct connection with operating rooms, delivery rooms or other sterile activity rooms.(xix) Housekeeping room. A housekeeping room containing a floor receptor or service sink and storage space for housekeeping supplies and equipment shall be provided for the exclusive use of the surgical suite and shall be directly accessible from the surgical suite.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) Operating rooms shall have ceiling heights not less than nine feet. (ii) Recreation rooms, exercise rooms, equipment rooms, and similar spaces where impact noises may be generated shall not be located directly over operating suites, unless special provisions are made to minimize such noise.(B) Finishes.(i) Flooring within operating rooms, soiled workrooms and sterile processing rooms shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Walls in operating rooms, special procedures rooms, and soiled workrooms shall comply with the requirements of §133.162(d)(2)(B)(iv)(II)of this title.(iii) Ceilings in operating rooms, isolation rooms, soiled workroom and sterile processing rooms shall be monolithic as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph.(A) Air supply for the operating rooms shall be from ceiling outlets near the center of the work area to efficiently control air movement. A minimum of two return air inlets located diagonally opposite from one another and near floor level shall be provided. Design should consider turbulence and other factors of air movement to minimize airborne particulate matter. Where extraordinary procedures require special designs, the installation shall be reviewed on a case by case basis.(B) Smoke removal systems shall be provided in accordance with §133.162(d)(3)(D)(iv)(II) of this title.(C) The ventilation system for anesthesia storage rooms and medical gases storage shall conform to the requirements of Chapter 5, NFPA 99, §5.1.3.3.3.(D) Each operating room, PACU, and recovery room shall be provided with conveniently mounted temperature and humidity indicating devices.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title and this paragraph.(A) General.(i) Drainage and waste piping shall not be installed above or below ceilings in operating rooms, and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(ii) Floor drains shall not be installed in operating rooms. Flushing rim type floor drains may be installed in cystoscopic operating rooms. If a floor drain is installed in cystoscopy, it shall contain a nonsplash, horizontal-flow flushing bowl beneath the drain plate.(iii) Sinks used for the disposal of plaster of paris shall have plaster trap.(B) Medical gas systems. Medical gas systems and outlets shall be provided in accordance with §133.162(d)(4)(A)(iii) and Table 6 of §133.169(f) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) X-ray film illuminators for handling at least four films simultaneously shall be provided in each operating room. When the entire surgical suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the suite.(ii) Each operating room shall have at least eight duplex electrical hospital grade receptacles of which three shall be located convenient to the head of the procedure table. Each PACU recovery station shall have a minimum of seven receptacles at the head of each bed.(iii) Special grounding system for critical care areas such as operating rooms, and special procedure rooms where patients are subjected to invasive procedures and connected to line-operated, electromedical devices shall comply with NFPA 99, Chapter 9, and NFPA 70, Article 517.(iv) Operating rooms and special procedure rooms shall have general lighting in addition to that provided by special lighting units at the surgical tables. Each fixed special lighting unit at the operating or delivery table shall be connected to an independent circuit powered by the critical branch of the essential electrical system. Portable units may share circuits. At least one general lighting fixture shall be served from a normal branch panel.(v) Operating rooms shall be provided with one or more battery-powered emergency lighting units as required by NFPA 99, §13.4.1.2.6(E). (vi) Operating rooms shall be provided with at least one receptacle powered from a normal power panel. Receptacle shall be labeled, "Normal power receptacle, use only in the event of loss of critical system."(B) Nurses calling system. The nurse call shall be in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title.(ff) Universal care suite.(1) Architectural requirements. Architectural requirements shall be in accordance with §133.162(d)(1) of this title and this paragraph.(A) General. When a universal care suite is provided, the universal care suite shall be a separate suite(s) operated separately from other suites in the hospital.(i) All universal care suite patient rooms shall be single patient rooms and have a minimum clear floor area of 200 square feet per bed exclusive of anterooms, vestibules, toilet rooms, closets, lockers, wardrobes, and/or alcoves. A minimum of 13 feet width shall be provided for the head wall. (ii) Minor encroachments including columns and wall hung lavatories that do not interfere with functions may be ignored when determining space requirements for patient rooms. Required clear floor space for patient rooms shall be exclusive of toilet rooms, closets, lockers, built-in cabinets, wardrobes, alcoves, or vestibules.(iii) Each universal care suite patient room shall be located on an exterior wall and shall have a window. Windows shall be in accordance with subsection (t)(2)(A)(iv) and (v) of this section.(iv) Each universal care suite patient room shall have access to a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet, a hand washing fixture with hands-free operable controls and bathing facilities, and storage shelf or cabinet.(v) A hand washing fixture with hands-free operable controls shall be located in each patient room near the entrance of the room and in the patient bathroom.(vi) A minimum of one airborne infection isolation room and patient bathroom shall be provided in accordance with subsection (t)(1)(C)(iii), (iv) and (v) of this section. The universal care suite infection isolation room shall have a minimum clear floor area of 200 square feet per bed exclusive of anterooms, vestibules, toilet rooms, closets, lockers, wardrobes, and/or alcoves. A minimum of 13 feet width shall be provided for the head wall. The universal care suite isolation patient room shall have a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet, a hand washing fixture with hands-free operable controls and bathing facilities, and storage shelf or cabinet.(vii) Viewing panels in the door or walls of these rooms are required. Curtains or other means shall be provided to cover the viewing panels when visual privacy is required.(viii) Each patient shall have a wardrobe, locker, or closet that is suitable for hanging full-length garments and for storing personal effects. A minimum of 12 lineal inches of hanging space shall be provided per patient.(ix) Each universal care room shall be provided with X-ray film illuminators for handling at least two films simultaneously. When the entire universal care suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the suite.(B) Pediatrics. When a universal care suite is provided for pediatrics, the suite shall comply with the requirements contained in this paragraph and the following.(i) A sleeping space shall be provided for parents who spend long hours with the patient. This space may be within the patient room or separate from the patient area but shall be in communication with the universal care suite staff.(ii) A room shall be provided for private consultation and shall be located within, or convenient to, the universal care suite. The multipurpose room noted in subparagraph (D)(iv) of this paragraph will meet this requirement if conveniently located.(iii) Storage space for infant formula shall be provided. This functional space may be outside the universal care suite but shall be available for use at all times.(iv) Storage cabinets or closets for toys and games shall be provided within the room.(v) Storage closet for cots, bed linens, and other items needed for overnight accommodation of parents shall be provided in the general location of sleeping accommodations.(C) Universal care suite services and facilities. The following services and facilities shall be provided.(i) A visitors' waiting space shall be provided with toilet facility(ies), public telephone(s), and drinking fountain(s). One waiting space may serve other units.(ii) The nurse station shall be located to permit direct visual observation of each patient served. Video cameras or mirrors shall not be substituted for direct visual observation. The nurse station shall have space for counters and storage. The counter height shall not exceed 42 inches. The nurse station may be combined with or include centers for reception and communication.(iii) When individual nurse substations are provided and located at each patient room(s), they shall be located to permit direct visual observation of each patient served. The nurse substation shall have space for counter, storage space and a recessed sitting space. The substation shall be at a minimum recessed from the egress corridor one foot six inches.(iv) Charting and dictation area(s) for physicians for recording, record storage and reviews shall be provided. Dictation space may be in a separate room or alcove. Suitable space shall be provided when computers are used for the clinical records.(v) Storage space shall be provided for emergency equipment in the unit.(vi) Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be located with the clean work room.(vii) A soiled workroom shall be provided and contain a clinical sink or equivalent flushing rim type fixture with hot and cold mixing faucet, separate hand washing facilities with hands-free operable controls, and separate waste and soiled linen receptacles.(viii) A soiled holding room may be provided when all the universal care suite patient toilet rooms have bedpan washers. The soiled holding room shall contain a hand washing fixture with hands-free operable controls and separate waste and soiled linen receptacles. (ix) A clean workroom or clean supply room shall be provided. A clean workroom when used for preparing patient care items shall contain a work counter, hand washing facilities, and storage facilities for clean and sterile supplies. When a clean supply room is used only for storage and holding as part of a distribution system of clean and sterile supplies, the work counter and hand washing facilities may be omitted.(x) A nourishment station shall contain a work counter, a sink with hands-free operable controls, refrigerator, cabinets, and not be located in the medication room or the clean workroom. Space shall be included for temporary holding of unused or soiled dietary trays.(xi) An ice machine shall be provided for ice for treatment and patient use. Ice-making equipment for treatment may be in the clean workroom or the nourishment station.(xii) An intravenous solution support shall be provided at each patient bed. The intravenous solution shall not be suspended directly over the patient.(xiii) The stretcher storage alcove provided for stretcher or bassinet storage shall be located out of direct line of traffic.(xiv) Securable closets or cabinet compartments for the personal effects of nursing personnel, located in or near the nurse station, shall be provided. At a minimum, these shall be large enough for purses and billfolds. Coats may be stored in closets or cabinets on each floor or in a central staff locker area.(xv) Twenty square feet of equipment storage shall be provided for each patient station. These storage areas shall be out of the way of the corridor traffic.(xvi) A housekeeping room shall be provided and contain a service sink, storage for housekeeping supplies, and equipment. A shared nursing unit housekeeping room that is adjacent to the universal care suite is acceptable.(D) Other required areas/rooms. The following areas/rooms shall be provided and may be located outside the unit if conveniently accessible.(i) Offices. Room(s) shall be provided for the universal care suite medical staff, nursing management and administrative personnel. The offices shall be large enough to permit consulting with members of the universal care suite staff and visitors. The offices shall be linked with the unit by telephone or an intercommunications system.(ii) Staff lounge. A staff lounge shall include toilet facilities with a hand washing fixture with hands-free operable controls. The lounge(s) shall be located so that staff may be recalled quickly to the patient area in emergencies. One lounge may serve multiple units when the lounge is adjacent to the units.(iii) On-call rooms. Physicians and other staff on 24-hour on-call work schedules shall be provided with sleeping rooms with access to a shower(s), toilet(s), and lavatory(ies). If an on-call room(s) is not within the universal care suite served, a dedicated telephone or intercom system shall connect the on-call room(s) to the universal care suite.(iv) Multipurpose room(s). A multipurpose room shall be provided for patient conferences, reports, education, training sessions, and consultation. This room(s) must be accessible to the universal care suite.(2) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title and this paragraph. (A) Details.(i) At least one door to a universal care suite room shall be not less than four feet wide and arranged to minimize interference with movement of beds and large equipment.(ii) Sliding doors in the universal care suite shall not have floor tracks and shall have hardware that minimizes jamming possibilities, in accordance with §133.162(d)(2)(A)(vi) of this title.(iii) Glazing in viewing panels shall be safety glass, wire glass, or clear plastic.(iv) Recreation rooms, exercise rooms, equipment rooms, and similar spaces where impact noises may be generated shall not be located directly over the universal care suite, unless special provisions are made to minimize such noise.(v) Each patient shall have access to a telephone directly from each bed. The telephone may be omitted at a pediatric universal care suite bed.(B) Finishes.(i) Flooring used in universal care suite patient rooms, patient toilet rooms, and soiled workrooms shall be of the seamless type as required by §133.162(d)(2)(B)(iii)(III) of this title.(ii) Ceilings in the soiled workroom shall be monolithic type as required by §133.162(d)(2)(B)(vi)(III) of this title.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title and this paragraph. Room recirculating units shall not be used.(A) Outside air shall be supplied to each patient room by a central air handling unit to provide make-up air for air exhausted from the bathroom in accordance with Note 3, Table 3 of §133.169(c) of this title.(B) Each patient room bathroom shall be exhausted continuously to the exterior in accordance with Table 3 of §133.169(c) of this title.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title.(5) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title and this paragraph.(A) General.(i) Receptacles at each bed location in a universal care suite shall be served by two branch circuits, one or more from the critical branch panel of the emergency electrical system and one or more from the normal system. One critical branch circuit shall serve only one bed location. All branch circuits from the normal system shall be from a single panelboard. All branch circuits from the emergency electrical system shall be from a single panelboard.(ii) A minimum of seven hospital grade duplex outlets shall be conveniently located at the head of each bed. At least three of these duplex outlets shall be on the critical branch of the emergency electrical system.(iii) One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location.(iv) Hospital grade receptacles in the pediatric universal care suite shall be tamper-resistant or provided with GFCIs.(B) Illumination requirements.(i) Each single patient room and multi-patient wards shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system.(ii) A reading light shall be provided over each patient bed. Reading light control shall be readily accessible from each patient bed. Flexible light arms, if used, shall be mechanically controlled to prevent the bulb from coming in contact with bed linen. High heat-producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered with a diffuser or a lens.(iii) A wall or ceiling-mounted lighting fixture shall be provided above each lavatory.(iv) A ceiling-mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch.(C) Nurses calling systems. The nurse call shall be in accordance with §133.162(d)(5)(L). Source Note: The provisions of this §505.163 adopted to be effective June 21, 2007, 32 TexReg 3587; amended to be effective December 9, 2010, 35 TexReg 10716; amended to be effective February18, 2018, 43 TexReg 576; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.163 Spatial Requirements for New Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223782 03/12/2026 (a) General. All hospitals with two or more floor levels shall have at least one electrical or electrical hydraulic elevator. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §18.3 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555. (b) Requirements for new elevators, escalators, and conveyors. New elevators, escalators and conveyors shall be installed in accordance with the requirements of A17.1 Safety Code for Elevators and Escalators, 2000 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI). All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, United Engineering Center, 345 East 47th Street, New York, N.Y. 10017. (1) Elevator lobby. An elevator lobby shall be provided. The elevator lobby shall have at least 10 feet of clear floor space in front of each elevator door. (2) Elevator shaft openings. When elevator shaft openings occur in a smoke compartment with patient sleeping rooms or occur in a smoke compartment adjacent to the patient sleeping rooms, the elevator shaft openings shall resist the passage of smoke by one of the following means. (A) Provide a lobby with separation partitions to resist the passage of smoke from the means of egress. When elevator lobby space extends into the egress corridor, the means of egress from one side of the egress corridor through the lobby to the other side of the egress corridor is not permitted during emergency conditions. (B) Provide a mechanical means of exhausting smoke from the elevator shaft. The smoke removal exhaust system for the elevator shaft shall operate automatically upon the initiation of the activation of the smoke detectors located in each elevator lobby, which also initiates automatic recall of the elevator cabs to the designated level of discharge. The activation of the smoke exhaust system shall provide a negative pressure at each level. (C) Provide swinging doors that are held open by magnetic hold open devices and close the doors at the elevator door opening upon activation of the fire alarm system. (D) Provide a horizontal automated moving door like a "Won-Door" two feet or more from the elevator door opening that will close automatically by the activation of the fire alarm system and have emergency capabilities of opening and closing. (E) The elevator shaft opening protection shall not be required at the elevator main level of recall. (3) Cars and doors. (A) Cars of hospital type elevators for patient transport shall not be less than five feet eight inches wide and not less than eight feet six inches deep inside the cab. (B) The car door opening shall be not less than four feet wide and seven feet high. (C) Elevator doors shall be B-labeled one-hour fire protection rated doors in buildings less than four stories; and one and one-half hour fire protection rated doors in buildings four or more stories. (4) Type of controls and alarms. Elevator cab lighting, control, communication and signal systems shall be connected in accordance with NFPA 99, §4.4.2.2.2.2. (5) Location. Conveyors, elevators, dumbwaiters, and pneumatic conveyors serving various stories of a building shall not open to an exit. (6) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems required to maintain temperature during fire fighters' service operation for elevator operation. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power. (c) Requirements for existing elevators, escalators, and conveyors. Existing elevators, escalators, and conveyors shall comply with ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 1996 edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3 as required by NFPA 101, §9.4.3. (d) Testing. All elevators and escalators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 2000 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101, §9.4.6. (e) Certification. A certificate of inspection evidencing that the elevators, escalators, and related equipment were inspected in accordance with the requirements in Health and Safety Code (HSC), Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under HSC, §754.014, administered by the Texas Department of Licensing and Regulation, shall be on record in each hospital. (f) Requirements for new hospitals. All new hospitals having patient facilities (such as patient sleeping rooms, dining rooms, or recreation areas) or critical services (such as operating, delivery, diagnostic, or therapy) on floors other than on the main entrance floor shall have the following number of hospital type elevators: (1) at least one hospital type elevator for the first 59 beds; (2) at least two elevators for the first 60 to 200 patient bed spaces. One elevator shall be the hospital type; (3) at least three elevators for 201 to 350 patient bed spaces. Two elevators shall be hospital type; or (4) for hospitals with over 350 patient beds, as determined from a study of the hospital plan and the estimated vertical transportation requirements for the facility. Source Note: The provisions of this §505.164 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.164 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223783 03/12/2026 (a) Multiple hospitals located within one building. (1) Identifiable location. Each hospital shall conform with all the requirements contained in Chapter 18 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), relating to New Health Care Occupancies. All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. (A) The guest hospital shall be in one separately contiguous location. (B) In no case may a person leave the guest hospital, traverse the host hospital, and then reenter the guest hospital to access the remaining portion of the guest hospital. (C) A connecting stair within the host hospital may be used to connect the vertical contiguous areas of the guest hospital. (D) A guest hospital may not occupy two or more noncontiguous areas of a host hospital which contain intervening space of the host hospital even if on the same floor. (E) Construction of the host hospital building shall conform to the requirements of NFPA 101, Chapter 18, and the building shall be fully sprinklered. (2) Separate facilities. Each hospital shall provide the following separate facilities: (A) a nursing unit in accordance with the requirements of §133.163(t) of this title (relating to Spatial Requirements for New Construction); (B) an administration office with an adjacent waiting room or waiting area; (C) a medical records room which conforms with the requirements of §133.163(p) of this title; (D) a pharmacy suite in accordance with §133.163(x) of this title; (E) employee locker facilities which comply with requirements of §133.163(g)(1) of this title; (F) a housekeeping room in accordance with the requirements of §133.162(d)(2)(A)(xxviii) of this title (relating to New Construction Requirements); (G) emergency facilities. Each hospital shall provide emergency facilities as required by §133.163(f)(1)(A) of this title. When general hospitals share a building, each general hospital shall provide emergency facilities as required by §133.163(f)(1)(A)(i) and (ii) of this title; (H) imaging and other diagnostic services and facilities, in accordance with §133.41(s) of this title (relating to Hospital Functions and Services) and §133.163(l) of this title respectively; (I) laboratory services and a laboratory suite which comply with §133.41(h) of this title, and §133.163(n)(1)(B) of this title respectively; (J) surgical or obstetrical facilities for each general hospital, in accordance with §133.163(u) and §133.163(ee) of this title; (K) dietary services and dietary suite, including staff dining facilities, which comply with §133.41(d) of this title and §133.163(e) of this title respectively; (L) external signage at the building entrance which identifies each hospital; and (M) internal signage which provides directions to each hospital. (3) Means of egress. Means of egress from the host or guest hospital shall not be through a psychiatric hospital or a crisis stabilization unit or other area subject to locking. Means of egress may traverse through a hospital which conforms with the requirements of §133.161 of this title (relating to Requirements for Buildings in which Existing Licensed Hospitals are Located) or §133.162 of this title. Stairs must have guardrails from the floor of the guest hospital to the level of exit discharge in accordance with NFPA 101, §7.2.2.4.5. (4) Additional services and facilities. Additional services and facilities when required in each licensed hospital may be provided by contractual agreement with the other hospital when the services and facilities comply with the specific requirements of §133.41 of this title and §133.163 of this title. Some services may be provided by contractual agreement with a commercial contractor; however, the following minimal facilities shall be provided on site by the host hospital and be located in one of the hospitals. If the host hospital fails to provide the facilities and services, the guest hospital shall describe to the department how it plans to provide services: (A) cart cleaning and sanitizing services and facilities which comply with §133.163(b) of this title; (B) general stores services and facilities which comply with §133.163(i) of this title; (C) housekeeping rooms as required in §133.162(d)(2)(A)(xxviii) of this title; (D) parking facilities, in accordance with §133.162(c)(2) of this title; (E) physical and/or occupational therapy services and facilities, in accordance with §133.41(x) of this title, and §133.163(aa) of this title respectively; (F) patient activity facilities. The patient activity facilities shall comply with the requirements for the specific service in accordance with §133.163 of this title as follows: hospital-based skilled units §133.163(j)(1)(C); mental health and chemical dependency nursing units §133.163(q)(1)(B); pediatric and adolescent nursing unit §133.163(w)(1)(D)(i); and rehabilitation therapy suite §133.163(aa)(1)(A)(i) and (ii); (G) respiratory care services and respiratory therapy suite which comply with §133.41(u) of this title and §133.163(cc) of this title respectively; (H) body-holding room which complies with §133.163(r)(1)(D) of this title; (I) central sterile supply which complies with §133.41(v)(2)(L) of this title and §133.163(c) of this title respectively; (J) waste and waste disposal services, and waste processing and storage units shall comply with §133.41(y) of this title; and (K) emergency water storage requirement of §133.162(d)(4)(A)(i)(VIII) shall be required for each the hospital and be located in one of the hospitals. (5) Building systems and equipment. (A) The following systems shall be provided separately in each hospital at a 24-hour staffed location. (i) Nurses calling systems shall be provided separately in each hospital in accordance with §133.162(d)(5)(L) and Table 7 of §133.169(g) of this title (relating to Tables). (ii) Medical gas alarms shall be provided in each hospital. (iii) Fire alarm annunciator panels shall be provided in each hospital so that each hospital can monitor the other. (iv) An emergency generator annunciator panel shall be provided in each hospital. (B) Where applicable, the following systems may serve more than one hospital provided the systems meet the new construction requirements of §133.162 of this title: (i) air conditioning, heating and ventilating systems; (ii) drainage systems; (iii) elevators; (iv) fire sprinkler systems. The guest hospital may not be constructed in a host hospital when the host hospital is not fully sprinklered. The host and guest hospitals shall be fully sprinklered; (v) medical piping systems; (vi) stand pipe systems; (vii) steam systems; (viii) water supply systems, hot and cold (including emergency water storage); and (ix) electrical service and equipment. (I) Where applicable, the building electrical service, lighting, essential electrical system, and fire alarm system, may be a part of or extension of those in the existing hospital, provided the existing systems meet these requirements. The host hospital shall be responsible for maintenance, testing and upkeep of the essential electrical system. Power and lighting distribution panels shall be within each hospital served and comply with the requirements of §133.162(d)(5)(E). Electrical installation details shall conform with all requirements contained in §133.162(d)(5)(A). (II) When the existing essential electrical system is nonconforming, the following options are available: (-a-) a separate conforming essential electrical system shall be provided in the guest hospital; or (-b-) separate transfer switches connected to the existing on-site generator(s) shall be provided when adequate capacity is available and the host hospital existing nonconforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by the department. (b) Hospitals located in buildings with licensed health care facilities other than hospitals. (1) Before a hospital is licensed in a building containing other licensed health care facilities, all the requirements of this chapter and the following requirements shall be met. (A) Construction of the building shall conform to the requirements of NFPA 101, Chapter 18, and the building shall be fully sprinklered. (B) The hospital shall be in one identifiable contiguous location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other licensed health care facility and comply with the requirements of this chapter. (i) In no case may a person leave the hospital, traverse other licensed healthcare facilities, and then reenter the hospital to access the remaining portion of the hospital. (ii) A connecting stair(s) and elevator(s) within the building shall be provided to connect the vertical contiguous areas of the hospital. (iii) A hospital may not occupy two or more noncontiguous areas of other licensed healthcare facilities which contain intervening space of the other licensed healthcare facilities even if on the same floor. (iv) Access to the hospital shall be directly from a main lobby or an elevator lobby, if on an upper floor. The required means of egress from the hospital may be through the other licensed health care facility except not through a psychiatric hospital or a crisis stabilization unit or other area subject to locking. (I) Each licensed facility shall be identified with external signage at the building entrance. (II) Internal signage shall provide direction to the hospital. (v) The hospital shall have services and facilities separate from the other licensed health care facility. The required facilities shall be located within the proposed hospital proper. (vi) Common use of facilities using time-sharing concepts may be permitted on a case by case basis when the other health care facilities comply with the requirements contained in NFPA 101, Chapter 18, and §133.163 of this title, and provided this chapter and the other health care facility licensing regulations allow. (C) The equipment and systems required in each new hospital may be provided exclusively for the hospital or by contractual agreement with a licensed health care facility. The equipment and systems shall be in accordance with §133.162 of this title. (i) The following equipment and systems shall be provided for the exclusive use of the hospital, except where noted otherwise: (I) breaker serving the hospital. Where the hospital is served by the building's normal electrical system, the breaker serving the hospital shall originate in the main switchboard and shall be labeled, "Hospital Service - Contact Hospital Representative Prior to Opening Breaker"; (II) electrical service for power and lighting. The hospital distribution panel board(s) shall be within the hospital; (III) type I essential electrical system. An electrical room for the distribution of type I essential electrical system shall be provided separate from the building electrical room. The hospital staff shall have access at all times to the essential electrical system room and the building's electrical room(s). The hospital shall be responsible for maintenance, testing and upkeep of the essential electrical system. When the existing essential electrical system owned and operated by the other licensed health care facility is nonconforming, the following options are available: (-a-) a separate conforming essential electrical system shall be provided in the new hospital; or (-b-) separate transfer switches connected to the existing on-site generator(s) shall be provided when adequate capacity is available and the other health care facility existing nonconforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by the department; (IV) an emergency generator. An emergency generator may be shared when adequate capacity is available. Separate transfer switches shall be provided to serve the hospital and other licensed health care facilities. The hospital shall be the owner of the generator, have access to the generator at all times, and shall be responsible for maintenance, testing and upkeep of the generator; (V) emergency water storage requirement of §133.162(d)(4)(A)(i)(VIII) of this title shall be located within the hospital; (VI) a fire alarm system. When the other licensed health care facilities have a fire alarm control center or a main building alarm panel at the main lobby entrance, the hospital shall have an annunciator panel at a 24-hour staffed location. The hospital staff shall have access at all times to the main building fire alarm system panels and shall be responsible for verifying the maintenance and upkeep of such system; (VII) fireman's test valve for the fire sprinkler system; (VIII) air conditioning, heating and ventilating systems; (IX) medical piping systems with alarm. The medical gas supply sources may be shared provided the hospital is owner of the medical gas system source and is responsible for maintenance, testing and upkeep of the supply sources. The hospital and other occupancies shall have separate main supply shutoff valves. The hospital shall be provided with an alarm panel within the hospital that monitors the medical gas system supply source serving the other licensed health care facilities; (X) medical vacuum and medical air; and (XI) nurses calling systems. (ii) Where applicable, the following systems may be a part or extension of those in the existing licensed health care facility, provided the existing systems meet the requirements of this chapter for new construction: (I) drainage systems; (II) elevators. The hospital shall be served by the number and size of elevators cabs in accordance with §133.164 of this title (relating to Elevators, Escalators, and Conveyors). The elevators cab lighting, control, communication, and signal systems shall be connected to the life safety panel of the essential electrical system; (III) fire sprinkler systems. The new hospital may not be constructed in the other health care facility when the other health care facility is not fully sprinklered. The new hospital and the other health care facility shall be fully sprinklered; (IV) stand pipe systems; (V) steam systems. The hospital is responsible for providing all backup systems (such as boilers) as required in this chapter; (VI) domestic water supply systems, hot and cold; and (VII) mechanical chilled and hot water systems. (2) When hospitals and psychiatric hospitals share one building, the building systems and equipment may be shared in accordance with subsection (a)(5)(B) of this section, or be provided separately. (c) Hospitals in buildings with nonhealth care occupancies. (1) General. Before a hospital is licensed in a building also containing occupancies other than health care occupancies, all requirements of this chapter and the following requirements shall be met. (A) Construction of the building shall conform to the requirements of NFPA 101, Chapter 18, and the building shall be fully sprinklered. (B) The hospital shall be in one identifiable contiguous location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other occupancies. (i) In no case may a person leave the hospital, traverse other occupancies, and then reenter the hospital to access the remaining portion of the hospital. (ii) A connecting stair(s) and elevator(s) within the building shall be provided to connect the vertical contiguous areas of the hospital. (iii) A hospital may not occupy two or more noncontiguous areas of other occupancies which contain intervening space of the other occupancies even if on the same floor. (C) Access to the hospital shall be through a dedicated hospital lobby or from the building's main lobby. The building's main lobby shall be part of the hospital and shall comply with the requirements of §133.162 of this title. (i) External signage shall be provided at the building entrance which identifies the hospital. (ii) Internal signage shall be provided to give directions to the hospital. (D) The required means of egress from the hospital shall be independent of and shall not traverse through the other occupancies. (E) Stairs shall have guardrails and handrails from the floor of the hospital to the level of exit discharge in accordance with NFPA 101, §7.2.2.4.5. (2) Services and facilities. Services and facilities shall be provided exclusively for the hospital in accordance with subchapters C, H, and I of this title (relating to Operational Requirements, Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Required services and facilities shall not be shared with the other occupancies except as noted in paragraph (3) of this subsection. (3) Building equipment and facilities. The equipment and systems shall be in accordance with §133.162 of this title. (A) The following equipment and systems shall be provided for the exclusive use of the hospital except where noted otherwise: (i) type I essential electrical system. An electrical room for the distribution of type I essential electrical system shall be provided separate from the building electrical room. The hospital staff shall have access at all times to the essential electrical system room and the building's electrical room(s). The hospital shall be responsible for maintenance, testing and upkeep of the essential electrical system; (ii) emergency generator. An emergency generator may be shared when adequate capacity is available. Separate transfer switches shall be provided to serve the hospital and other building occupancies. The hospital shall be the owner of the generator, have access to the generator at all times, and shall be responsible for maintenance, testing and upkeep of the generator; (iii) emergency water storage located within the hospital; (iv) fire alarm system. When the building has a fire alarm control center or a main building alarm panel at the main lobby entrance, the hospital shall have an annunciator panel at a 24-hour staffed location. The hospital staff shall have access at all times to the main building fire alarm system panels and shall be responsible for verifying the maintenance and upkeep of such system; (v) fireman's test valve for the fire sprinkler system; (vi) medical gas systems. The medical gas supply sources may be shared provided the hospital is owner of the medical gas system supply source and is responsible for maintenance, testing and upkeep of the supply sources. The hospital and other occupancies shall have separate main supply shutoff valves. The hospital shall be provided with an alarm panel within the hospital that monitors the medical gas system serving the other occupancies; (vii) medical vacuum and medical air; (viii) air conditioning, heating and ventilating systems. Air handling units of other occupancies may not be used for the hospital. The hospital air handling units may share the supply source for other occupancies but shall not return air from the other occupancies back to the air handling unit(s); and (ix) nurses calling systems. (B) Where applicable, the following systems may be a part or extension of those in the existing building occupancies provided the existing systems meet the requirements of this chapter for new construction: (i) breaker serving the hospital. Where the hospital is served by the building's normal electrical system, the breaker serving the hospital shall originate in the main switchboard and shall be labeled, "Hospital Service - Contact Hospital Representative Prior to Opening Breaker"; (ii) electrical service for power and lighting. The hospital's distribution panelboard(s) shall be within the hospital; (iii) drainage systems; (iv) elevators. The hospital shall be served by the number and size of elevators cabs in accordance with §133.164 of this title. The elevators cab lighting, control, communication, and signal systems shall be connected to the life safety panel of the essential electrical system; (v) fire sprinkler systems. The hospital may not be constructed in the other type of building occupancies when the other types of occupancies are not fully sprinklered. The hospital and the other occupancies shall be fully sprinklered; (vi) stand pipe systems; (vii) fire pump, where applicable; The hospital staff shall have access at all times to the location of the fire pump to verify compliance and maintenance; (viii) steam systems. The hospital is responsible for providing all backup systems (such as boilers) that are required in this chapter; and (ix) domestic water supply systems, hot and cold. Source Note: The provisions of this §505.165 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025,issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.165 Building with Multiple Occupancies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223784 03/12/2026 (a) Definitions. (1) Mobile unit--Any pre-manufactured structure, trailer, or self-propelled unit equipped with a chassis on wheels and intended to provide shared medical services to the community on a temporary basis. Some of these units are equipped with expanding walls and designed to be moved on a daily basis. (2) Relocatable unit--Any structure, not on wheels, that is built to be relocated at any time and provide medical services. These structures vary in size. (3) Transportable unit--Any pre-manufactured structure or trailer, equipped with a chassis on wheels, intended to provide shared medical services to the community on an extended temporary basis. These units are designed to be moved periodically, depending on need. (b) General. When mobile, transportable and relocatable units are utilized to provide patient treatment services on the hospital premises, these units shall be treated as buildings and constructed to the required occupancy as follows. (1) When such units are provided for diagnostic, treatment or procedural services to patients who are litter borne, under general anesthesia, or incapable of self-preservation, the unit shall be constructed in accordance with Chapter 18 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), relating to health care occupancy, published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555. (2) When such units provide diagnostic, treatment, or procedural services to patients who are not litter borne, not under general anesthesia, and are capable of self-preservation, the unit may be constructed in accordance with Chapter 38 of NFPA 101 (relating to Business Occupancy). (c) Common elements. (1) Site requirements. (A) Sites shall have a level concrete or asphalt pad and be designed for the structural loads of the unit. (B) The sites shall provide hazard-free drop-off zones and adequate parking for patients. The site and location of the unit shall not restrict access for fire or emergency vehicles. (C) Each site shall provide access to the unit for the handicapped, and wheelchair and stretcher patients. (D) When a mobile, transportable, or relocatable unit is not physically attached to the hospital and provides inpatient services, a covered walkway or enclosure from the hospital to the unit shall be provided to ensure patient safety from the outside elements. (E) The location of the unit shall be such that engine exhaust fumes from the unit are kept away from any fresh air intake of the hospital. (F) When a mobile, transportable, or relocatable unit is permanently connected appropriately for the climate to the hospital or the unit does not move on a regular basis, i.e. every 90 days or less, the units shall be provided with the following equipment and systems connected to the hospital: (i) fire alarm system; (ii) sprinkler system; (iii) electrical system and the essential electrical system; (iv) water and waste water system; (v) medical gas systems; and (vi) nurses calling systems. (2) Support services. Support services shall meet the requirements of this chapter for new construction. These support services and areas shall be provided either within the mobile, transportable, or relocatable unit or located within the hospital adjacent to the unit served. (3) Details and finishes. Details and finishes shall be in accordance with §133.162(d)(2) of this title (relating to New Construction Requirements). (4) Mechanical requirements. Mechanical requirements shall be in accordance with §133.162(d)(3) of this title. (5) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §133.162(d)(4) of this title. (6) Electrical requirements. Electrical requirements shall be in accordance with §133.162(d)(5) of this title. Source Note: The provisions of this §505.166 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.166 Mobile, Transportable, and Relocatable Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223785 03/12/2026 (a) General. (1) Hospital owners/operators may not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents. (2) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter. (3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents and specifications shall be consistent with the names of the spaces used in this chapter. (4) The department shall notify the hospital owner/operator of the result of its review of each type of submission discussed in this section. (5) The hospital owner/operator shall respond to all department requests for additional information, including providing a plan of correction for deficiencies cited by the department. (6) Once final construction documents are approved, the hospital owner/operator shall request inspections in accordance with §133.168 of this title (relating to Construction, Inspections, and Approval of Project). (7) When construction is delayed for longer than one year from the plan approval or self-certification approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new Application for Plan Review, plan review fee, and functional program narrative. (8) The hospital owner/operator shall provide written notification to the department when a project has been placed on hold, canceled or abandoned. (9) The department may close a project file after one year of assigning an application number to a project if the project has been placed on hold. Plan review fees are nonrefundable. (b) Submission of projects and assignment of application number. (1) The hospital owner/operator or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the Application for Plan Review: (A) a completed and signed Application for Plan Review. The Application for Plan Review may be obtained by calling the department's Architectural Review Group, telephone (512) 834-6649; (B) the applicable plan review fee in accordance with §133.26 of this title (relating to Fees); (C) a functional program narrative in accordance with subsection (d) of this section; and (D) final construction documents in accordance with subsection (f) of this section. (2) The cost of submitting documents/plans and specifications shall be borne by the sender. (3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department will assign an application number to the project that must be referenced on all documents and correspondence related to the project. Final construction documents will be reviewed in the chronological order received. (4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted. (5) Construction shall not begin until the hospital owner/operator of the facility receives written notification from the department that the final construction documents have been approved. (c) Feasibility conference. A hospital owner/operator or representative may request a feasibility conference. A feasibility conference is an informal meeting between a member of the department's Architectural Review Group staff and the hospital owner/operator or representative to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes. (1) A feasibility conference is not a substitute for plan review. (2) A hospital owner/operator or representative may schedule a feasibility conference by calling the department's Architectural Review Group, telephone number (512) 834-6649. (3) The hospital owner/operator or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents. (4) The hospital owner/operator or representative is responsible for recording conference notes and shall submit the notes to the department. (d) Functional program narrative. The hospital owner/operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(C) of this section. The functional program narrative shall be presented on facility letterhead, signed by hospital administration, include the functional description of each space, and the following: (1) departmental relationships, number of patient beds in each category, and other basic information relating to the fulfillment of the facility's objectives; (2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features; (3) energy conservation measures, included in building, mechanical and electrical designs; (4) a description of the type of asepsis control in diagnostic and treatment areas; and (5) the type of construction (existing or proposed) as stated in Table 18.1.6.2 of National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555. (e) Preliminary documents. The department may request preliminary documents. If requested by the department, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, bed count and services, and the usage of all spaces, areas, and rooms on every floor level. (f) Final construction documents. Final construction documents and specifications shall be submitted to the department for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the project registered architect and professional engineer(s) licensed by the state of Texas. (1) Submission of final construction documents. The hospital owner/operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings. (2) Preparation of final construction documents. Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, and shall include all necessary explanatory notes, schedules, and legends and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work. (A) Architectural plans. Architectural drawings shall include the following: (i) a map of the area within a two-mile radius of the facility site shall be provided and any hazardous and undesirable location noted in §133.162(a) of this title (relating to New Construction Requirements) shall be identified; (ii) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided; (iii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces; (iv) schedules of doors, windows, and finishes; (v) elevations of each facade; (vi) sections through building; and (vii) scaled details as necessary. (B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information: (i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways); (I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided; (II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided; (ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper; (iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and (iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers. (C) Equipment drawings. Equipment drawings shall include the following: (i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility; (ii) fixed equipment (equipment which is permanently affixed to the building or which must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term "fixed equipment" includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets); (iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term "moveable equipment" includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and (iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction. (D) Structural drawings. Structural drawings shall include: (i) plans for foundations, floors, roofs, and all intermediate levels; (ii) a complete design with sizes, sections, and the relative location of the various members; (iii) a schedule of beams, girders, and columns; (iv) dimensioned floor levels, column centers, and offsets; (v) details of all special connections, assemblies, and expansion joints; and (vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference. (E) Mechanical drawings. Mechanical drawings shall include: (i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g. corridor, patient room, operating room); (ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps; (iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water; (iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, gas outlets; (v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems); (vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment); (vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and (viii) laboratory exhaust and safety cabinets. (F) Electrical drawings. Electrical drawings shall include: (i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections; (ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches and equipment which require permanent electrical connections, on plans of each building level: (I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and (II) outlets marked distinctly to indicate connection to critical, life safety or normal power circuits; (iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment; (iv) nurses calling system showing all stations, signals, and annunciators on the plans; (v) in addition to electrical plans, single line diagrams prepared for: (I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generator(s), transfer switch(es), emergency system (life safety branch and critical branch), equipment system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches; (II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses regular calling system, nurses emergency calling system, or staff emergency assistance calling system); (III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices and the room number where each device is located; and (vi) schedules of all panels indicating connection to life safety branch, critical branch, equipment system or normal system, and connected load at each panel. (3) Construction document changes. Any changes to the final construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications. (g) Special submittals. (1) Self-certification. (A) In an effort to shorten the plan review and approval process, the hospital owner/operator or representative may request approval of final construction documents under the self-certification review process. (i) The owner/operator shall submit the items in subsection (b)(1)(A) - (D) of this section and a completed self-certification form, signed by the hospital owner/operator, architect of record, and engineer(s) of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter. (ii) By signing and submitting the self-certification form, the hospital owner/operator accepts the following conditions. (I) The department retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval. (II) The hospital owner/operator has a continuing obligation to make any changes the department requires to comply with the licensing rules whether or not physical plant construction or alterations have been completed. (III) The hospital owner/operator is ultimately responsible for compliance with the Texas Hospital Licensing Law (Health and Safety Code, Chapter 241) and this chapter. (B) The department will review the request for self-certification and notify the hospital owner/operator if the request is approved or denied. If denied, the department will review the final construction documents in the chronological order in which the documents were received. Construction may not begin until the final construction documents have been reviewed and approved. (2) Fast-track project. At the discretion of the department, projects for new hospitals or major new additions may be allowed to submitted under the fast-track project in not more than three separate packages. A fast-track project shall be requested in writing on facility letterhead, signed by hospital administration, with a brief written description and narrative of the proposed project. Construction may not begin until the first package has been approved by the department. (A) First package. The first package shall include: (i) the items in subsection (b)(1)(A) - (C) of this section; (ii) a map showing the location of the proposed facility site and adjacent surrounding area at least two miles in radius identifying any hazardous and undesirable location noted in §133.162(a) of this title; (iii) preliminary architectural plans and a detailed building site plan showing all adjacent streets, site work, underslab mechanical, electrical, and plumbing work, and related specifications; and (iv) foundation and structural plans. (B) Second package. The second package shall include complete architectural plans and details with specifications and fire safety plans as described in subsection (f)(1) and (2)(A) - (D) of this section. (C) Third package. The third package shall include complete mechanical, electrical, equipment and furnishings, and plumbing plans and specifications, as described in subsection (f)(1) and (2)(E) and (F) of this section. Package three may be submitted with the second package. (3) Minor project. If a hospital owner/operator believes that a proposed project is a minor project as described in §133.161(a)(2)(C) of this title (relating to Requirements for Buildings in which Existing Licensed Hospitals are Located), the hospital owner/operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work. (A) If it is determined that the proposed project is a minor project, the department will notify the hospital owner/operator of the approval, and state the number of inspections that will be required. A minimum of one inspection will be conducted. (B) The department will notify the hospital owner/operator that a proposed project is not approved as a minor project if the project involves any of the following: (i) remodeling or alterations which involve alterations to load bearing members or partitions; (ii) a change in functional operation; (iii) affects fire safety (e.g. modifications to the fire, smoke, and corridor walls); (iv) adds beds or services for which the hospital is not currently licensed; and (v) significantly changes the mechanical, electrical, plumbing, fire protection, or piped medical system. (C) The hospital owner/operator shall submit final construction documents in accordance with subsection (f) of this section if the department determines the project is not a minor project. (4) Fire sprinkler systems. (A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the hospital owner/operator shall submit to the department for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents. (B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler systems, 2002 edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty. (i) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§14.1, 14.2 and 14.3, for new fire sprinkler systems, alterations of and additions to existing ones. (ii) One set of fire sprinkler working plans, calculations and water supply information shall be forwarded to the department together with the professional engineer's (P.E. licensed in the state of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation. (iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project. (h) Retention of drawings, manuals and design data. (1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the hospital's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built. (2) Manuals. Upon completion of the contract, the owner shall retain as part of the hospital's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations. (3) Design data. The owner shall retain in the hospital's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation. Source Note: The provisions of this §505.167 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.167 Preparation, Submittal, Review and Approval of Plans, and Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223786 03/12/2026 (a) Construction. (1) Major construction. Construction, of other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate plan review fee according to the plan review schedule in §133.26 of this title (relating to Fees) has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants. (2) Construction commencement notification. The architect of record or the hospital owner/operator shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules. (3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project. (b) Construction inspections. All hospitals including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §1395 et seq), and those which maintain accreditation by a Centers for Medicare and Medicaid Services-approved organization are subject to construction inspections. (1) Number of construction inspections. A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with subchapters H and I of this chapter and the approved plans and specifications. The final plan approval letter will inform the architect of record and the owner as to the minimum number of inspections required for the project. (2) Requesting an inspection. The architect of record or the hospital owner/operator shall request an inspection by submitting, at least three weeks in advance of the requested inspection date, an Application for Inspection and the construction inspection fee in accordance with §133.26(d) of this title for each intermediate inspection, final inspection, and reinspection requested. Inspection requests by contractors will not be honored. (A) The architect of record or the hospital owner/operator shall request an intermediate construction inspection to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate inspection, however ceilings shall not be installed. (B) The architect of record or the hospital owner/operator shall request a final construction inspection at 100% completion. One hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project. (3) Reinspections. Depending upon the number and nature of the deficiencies cited during the final inspection, the inspector may require that a reinspection be conducted to confirm correction of all deficiencies cited. The inspector may also require a reinspection if he determines that the project was not sufficiently complete to warrant a final inspection. The request for reinspection shall be submitted in accordance with paragraph (2) of this subsection. (c) Approval of project. Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department. (1) Documentation requirements. The hospital owner/operator shall submit the following documents to the department before the project will be approved: (A) written approval of the project by the fire authority; (B) a certificate of occupancy for the project issued by the local building authority; (C) a copy of a letter or certification from a professional engineer (P.E.) licensed in the state of Texas indicating the fire sprinkler working plans, hydraulic calculation, the testing and field inspection of the installation of the new or modified sprinkler system is in compliance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 edition, if applicable. A copy of a letter or certification of changes in existing fire sprinkler system is not required when relocation of not more than twenty sprinkler heads and hydraulic calculation is not involved; (D) fire alarm system certification (form FML-009 040392 of the Office of the State Fire Marshal), if applicable; (E) a signed copy of a letter of certification from a qualified certification agency or individual for the piped-in medical gas system that was installed or modified and verification inspection testing in this project in accordance with §133.162 (d)(4)(A)(iii)(IV), (X) and (XI) of this title (relating to New Construction Requirements), if applicable; (F) a copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2002 edition, §4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project; (G) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. Provide a signed letter or statement corroborating the installation of the product in the project; (H) a copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition as required by NFPA 101, §18-7.5, and provide a signed letter or statement corroborating the installation of the product in the project; (I) a written plan of correction signed by the hospital owner/operator for any deficiencies noted during the final inspection; (J) a Final Construction Approval form signed by the hospital owner/operator; and (K) any other documentation or information required or requested due to the type of the project. (2) Temporary occupancy approval. (A) If, during the final inspection, the inspector finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the inspector may grant temporary approval for occupancy contingent upon the documents listed in paragraph (1)(A) - (E) of this subsection being provided to and approved by the inspector at the time of the final inspection. (B) Temporary approval for occupancy allows the hospital owner/operator to occupy the project. However, the hospital owner/operator must submit the documents required in paragraph (1)(F) - (K) of this subsection before the project receives final approval. (3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, the department will issue written final approval of the project. Source Note: The provisions of this §505.168 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.168 Construction, Inspections, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223787 03/12/2026 (a) Table 1. Sound transmission limitations in hospitals. Attached Graphic(b) Table 2. Flame spread and smoke production limitations for interior finishes. Attached Graphic(c) Table 3. Ventilation requirements for hospitals and outpatient facilities. Attached Graphic(d) Table 4. Filter efficiencies for central ventilation and air conditioning systems. Attached Graphic(e) Table 5. Hot water use. Attached Graphic(f) Table 6. Station outlets for oxygen, vacuum, and medical air systems. Attached Graphic(g) Table 7. Nurses Calling Systems. Attached Graphic(h) Table 8. Multiple Bed Room Configurations. Attached Graphic Source Note: The provisions of this §505.169 adopted to be effective June 21, 2007, 32 TexReg 3587; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 429. 1 HEALTH AND HUMAN SERVICES COMMISSION 505 HOSPITAL LICENSING I PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §505.169 Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195318 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195318 03/12/2026 The purpose of this chapter is to implement the Texas Special Care Facility Licensing Act as authorized under the Health and Safety Code, Chapter 248, and provide minimum standards for the licensing of special care facilities. Source Note: The provisions of this §506.1 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES A GENERAL PROVISIONS §506.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195319 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195319 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Advanced practice nurse--A registered nurse approved by the Texas Board of Nurse Examiners to practice as an advanced practice nurse. The term includes a nurse practitioner, nurse-midwife, nurse anesthetist, and a clinical nurse specialist.(2) Applicant--The person legally responsible for the operation of the facility, whether by lease or ownership, who seeks a license from the department.(3) Administration of medication--The direct application of any medication by injection, inhalation, ingestion, or any other means to the body of a patient. The preparation of medication is part of the administration of medication and is the act or process of making ready a medication for administration, including the calculation of a resident's medication dosage; altering the form of the medication by crushing, dissolving, or any other method; pouring a quantity of a liquid to be ingested; reconstitution of an injectable medication; drawing an injectable medication into a syringe; preparing an intravenous admixture; or any other act required to render the medication ready for administration.(4) AIDS--Acquired immune deficiency syndrome.(5) Assistance with medication or treatment regimen--Aid provided to a resident who self-administers their own medication or treatment, such as reminding a resident to take a medication at the prescribed time, opening and closing a medication container, returning a medication to the proper storage area, and assisting in reordering medications from a pharmacy. Such ancillary aid shall not include administration of any medication.(6) Bereavement--The process by which a survivor of a deceased person mourns and experiences grief.(7) Bereavement services--Support services offered to a family during bereavement. Family includes a significant other(s).(8) Board--The Texas Board of Health or its successor.(9) Controlled substance--A drug, controlled substance, or immediate precursor as defined in the Texas Controlled Substance Act, Health and Safety Code, §481.002, or the Federal Controlled Substance Act of 1970, Public Law 91-513.(10) Dangerous drugs--Any dangerous drug as defined in the Texas Dangerous Drug Act, Health and Safety Code, §483.001.(11) Department--The Texas Department of Health or its successor.(12) Dietitian--A person who is currently licensed by the Texas State Board of Examiners of Dietitians.(13) Director--The director of the Health Facility Licensing and Compliance Division of the Texas Department of Health or his or her designee.(14) Facility--A special care facility.(15) Fast-track project--A construction project in which it is necessary to begin initial phases of construction before later phases of the construction documents are fully completed in order to establish other design conditions or because of time constraints such as mandated deadlines.(16) Hospice services--Services, including services provided by unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to a resident or resident's family as part of a coordinated program which includes palliative care for terminally ill residents and support services for a resident and a resident's family that are available 24 hours a day, seven days a week, during the last stages of illness, during death, and during bereavement; and are provided by a medically directed interdisciplinary team.(17) Incident--An unusual or abnormal event or occurrence in, at, or affecting the facility or the residents of the facility.(18) Licensed vocational nurse--An individual who is currently licensed as a licensed vocational nurse (LVN) by the Board of Nurse Examiners in accordance with Texas Occupations Code, Chapter 301.(19) Local health authority--The physician having local jurisdiction to administer state and local laws or ordinances relating to public health as defined in the Health and Safety Code, Chapter 121, Subchapter B.(20) Medical care--Care that is:(A) required for improving life span and quality of life, for comfort, for prevention and treatment of illness, and for maintenance of bodily and mental function;(B) under the continued supervision of a physician; and(C) provided by a registered nurse or licensed vocational nurse available to carry out a physician's plan of care for a resident.(21) Nursing care--Services provided by nursing personnel as prescribed by a physician, including services to:(A) promote and maintain health;(B) prevent illness and disability;(C) manage health care during acute and chronic phases of illness, including end of life care;(D) provide guidance and counseling of individuals and families; and(E) provide referrals to physicians, other health care providers, and community resources when appropriate.(22) Palliative care--Services that focus primarily on the reduction or abatement of physical, psychosocial, and spiritual symptoms of a terminal illness.(23) Pharmacist--A person who is licensed to practice pharmacy by the Texas Board of Pharmacy in accordance with Texas Occupations Code, Chapter 558.(24) Physician--An individual who is:(A) licensed as a physician by the Texas State Board of Medical Examiners in accordance with Texas Occupations Code, Chapter 155; or(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas State Board of Medical Examiners.(25) Practitioner--A physician, podiatrist, dentist, or an advanced practice nurse or physician assistant to whom a physician has delegated authority to sign a prescription order, when relating to pharmacy services.(26) Presurvey conference--A conference held with department staff and the applicant and/or his or her representative to review licensure standards, survey documents, and facility policies and procedures and provide consultation prior to issuance of a license and the on-site licensure inspection.(27) Registered nurse (RN)--An individual who is licensed as a registered nurse by the Board of Nurse Examiners in accordance with Texas Occupations Code, Chapter 301.(28) Resident--An individual accepted for care in a special care facility.(29) Residential AIDS hospice--A special care facility licensed and designated as a residential AIDS hospice in accordance with §125.35 of this title (relating to Residential AIDS Hospice Designation).(30) Social worker--A person who is currently licensed as a social worker in accordance with Texas Occupations Code, Chapter 505.(31) Special care facility--An institution or establishment that provides a continuum of nursing or medical care or services primarily to persons with acquired immune deficiency syndrome or other terminal illnesses. The term includes a special residential care facility.(32) Violation--Failure to comply with the licensing statute, a rule or standard, special license provision, or an order issued by the commissioner of health or the commissioner's designee, adopted or enforced under the licensing statute. Source Note: The provisions of this §506.2 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES A GENERAL PROVISIONS §506.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195320 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195320 03/12/2026 (a) The level of care that the resident requires determines the facility's occupancy classification.(b) A new facility shall be classified into one of the following two occupancy classifications:(1) Limited care facility (LCF). A LCF provides medical and nursing care, treatment and other services to residents who require staff attendance and supervision, including staff assistance to evacuate the facility. These residents are not able to participate in fire drills because they are either physically unable to respond to the fire alarm or they are incapable of following directions under emergency conditions.(2) Residential board and care facility (RBCF). A RBCF provides medical and nursing care, treatment and other services for residents who do not require routine or continuous staff attendance and supervision, and are physically and mentally able to evacuate the facility. These residents must be able to participate in fire drills, be able to transfer and evacuate themselves and be capable of following directions under emergency conditions. A RBCF is further classified as either small or large.(A) A small RBCF provides sleeping accommodations for up to 16 residents.(B) A large RBCF provides sleeping accommodations for more than 16 residents.(c) New applicants shall identify the classification of the facility at the time the license application is submitted.(d) A licensed special care facility which was licensed prior to the effective date of these rules is considered to be an existing facility and is not required to identify or specify their occupancy classification. Source Note: The provisions of this §506.3 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES A GENERAL PROVISIONS §506.3 Occupancy Classification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195321 03/12/2026 (a) License required.(1) A facility shall obtain a license prior to admitting patients.(2) A facility shall only admit and provide services for the number of residents which may be accommodated based on the approved number of licensed beds.(3) All residents receiving services under the license must be admitted for 24-hour residential care.(b) Display. A facility shall prominently and conspicuously display the license in a public area of the licensed premises that is readily visible to patients, employees, and visitors.(c) Alteration. A facility license shall not be altered.(d) Transfer or assignment prohibited. A facility license shall not be transferred or assigned. The facility shall comply with the provisions of §125.12(h) of this title (relating to Application and Issuance of Initial License) in the event of a change in the ownership.(e) Changes which affect the license. A facility shall notify the department in writing prior to the occurrence of any of the following:(1) any construction, renovation, or modification of the facility buildings;(2) changes in designed bed capacity;(3) cessation of operation of the facility; and(4) change in facility name, telephone number or administrator. Source Note: The provisions of this §506.11 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES B FACILITY LICENSING §506.11 General Licensing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195322 03/12/2026 (a) Application submittal. The applicant shall submit the following documents to the department no earlier than 60 calendar days prior to the projected opening date of the facility:(1) an accurate and complete application form;(2) evidence of project and occupancy approval under local codes, if applicable, or in accordance with §125.95 of this title (relating to Construction, Inspections, and Approval of Projects for New or Existing Facilities in the Absence of Local Codes and Regulations).(3) the appropriate license fee as required in §125.15 of this title (relating to Fees).(b) Presurvey conference. The applicant or the applicant's representative shall attend a presurvey conference at the office designated by the department. The purpose of the presurvey conference, which is conducted by department staff, is to review licensure rules, survey documents and facility policies and procedures, and provide consultation prior to the on-site licensure survey. The department staff conducting the presurvey conference is responsible for making a recommendation regarding the issuance of the initial license. The department may waive the presurvey conference requirement.(c) Residential AIDS hospice designation. The designation must be requested at the time of license application. The facility shall provide evidence of compliance with §125.35 of this title (relating to Residential AIDS Hospice Designation) at the time of the presurvey conference.(d) Issuance of license. When it is determined that the facility has complied with subsections (a) and (b) of this section and, if applicable, subsection (c) of this section, the department shall issue the license to the applicant.(1) Effective date. The license shall be effective on the date the facility is determined to be in compliance with subsections (a) and (b) of this section, and, if applicable subsection (c) of this section.(2) Expiration date.(A) For initial licenses issued prior to January 1, 2005.(i) If the effective date of the license is the first day of a month, the license expires on the last day of the 11th month after issuance.(ii) If the effective date of the license is the second or any subsequent day of a month, the license expires on the last day of the 12th month after issuance.(B) For initial licenses issued January 1, 2005, or after.(i) If the effective date of the license is the first day of a month, the license expires on the last day of the 23rd month after issuance.(ii) If the effective date of the license is the second or any subsequent day of a month, the license expires on the last day of the 24th month after issuance.(e) Withdrawal of application. If an applicant decides not to continue the application process for a license or renewal of a license, the application may be withdrawn. The department shall acknowledge receipt of the request to withdraw.(f) Denial of a license. Denial of a license shall be governed by §125.71 of this title (relating to License Denial, Suspension, Revocation and Probation).(g) Survey. During the initial licensing period, the department shall conduct a survey of the facility to ascertain compliance with the provisions of the Health and Safety Code, Chapter 248, and this chapter.(1) A facility shall request an on-site survey to be conducted after one inpatient has been admitted and provided services.(2) A facility shall be providing services to at least one inpatient in the facility at the time of the survey.(h) Change of ownership. A change of ownership occurs when there is a change in the person legally responsible for the operation of the facility, whether by lease or by ownership. If a corporate licensee amends its articles of incorporation to revise its name and the tax identification number does not change, this subsection does not apply, except that the corporation must notify the department within 10 calendar days after the effective date of the name change. The sale of stock of a corporate licensee does not cause this subsection to apply. A change of ownership requires submission of an initial license application.(1) The new owner shall submit an application for an initial license to the department prior to the date of the change of ownership or not later than 10 calendar days following the date of a change of ownership. The application shall be in accordance with subsection (a) of this section. In addition to the documents required in subsection (a) of this section, the applicant shall include the effective date of the change of ownership.(2) Surveys. The on-site construction and health surveys required by subsection (g) of this section, and §125.61 of this title (relating to Inspection and Investigation Procedures) may be waived by the department.(3) Issuance of license. When the new owner has complied with the provisions of subsection (a) of this section, the department shall issue a license which shall be effective the date of the change of ownership.(4) Expiration of license. The expiration date of the license shall be in accordance with subsection (d)(2) of this section.(5) License void. The previous owner's license shall be void on the effective date of the new owner's license. Source Note: The provisions of this §506.12 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES B FACILITY LICENSING §506.12 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195323 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195323 03/12/2026 (a) Renewal notice. The department may send a renewal notice to a facility up to 60 calendar days before the expiration date of a license.(1) If the facility has not received the renewal notice from the department within 30 calendar days prior to the expiration date, it is the duty of the facility to notify the department and request a renewal application for a license.(2) If the facility fails to submit the application and fee within 15 calendar days prior to the expiration date of the license, the department shall send to the facility a letter advising that unless the license is renewed, the facility must cease operations upon the expiration of the license.(b) Renewal license. The department shall issue a renewal license to a facility that meets the minimum requirements for a license.(1) The facility shall submit the following to the department prior to the expiration date of the license:(A) a complete and accurate application form;(B) a copy of a fire safety survey indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year prior to the application date;(C) the renewal license fee;(2) The department may conduct a survey prior to issuing a renewal license in accordance with §125.61 of this title (relating to Inspection and Investigation Procedures).(3) Renewal licenses issued prior to January 1, 2005, will be valid for 12 months.(4) Renewal licenses issued January 1, 2005, through December 31, 2005, will be valid for either 12 or 24 months, to be determined by the department prior to the time of license renewal.(5) Renewal licenses issued January 1, 2006, or after will be valid for 24 months.(c) Notice to cease operation and return license. If a facility fails to submit the application, documents, and fee by the expiration date of the license, the department shall notify the facility by certified mail that it must cease operation and immediately return the license by certified mail to the department. If the facility wishes to provide services after the expiration date of the license, it shall apply for a license under §125.12 of this title (relating to Application and Issuance of Initial License). Source Note: The provisions of this §506.13 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES B FACILITY LICENSING §506.13 Application and Issuance of Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195324 03/12/2026 (a) General.(1) The receipt date for an application for an initial license or a renewal license is the date the application is received by the division.(2) An application for an initial license is complete when the division has received, reviewed, and found acceptable the information described in §125.12(a) of this title (relating to Application and Issuance of Initial License).(3) An application for a renewal license is complete when the division has received, reviewed, and found acceptable the information described in §125.13(b) of this title (relating to Application and Issuance of Renewal License).(b) Time periods. An application for an initial license or renewal license shall be processed in accordance with the following time periods.(1) The first time period begins on the date the division receives the application and ends on the date the license is issued, or, if the application is received incomplete, the period ends on the date the facility is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 20 working days.(2) The second time period begins on the date the division receives the last item necessary to complete the application and ends on the date the license is issued. The second time period is 20 working days.(c) Reimbursement of fees.(1) In the event the application is not processed in the time periods as stated in subsection (b) of this section, the applicant has the right to request the division to reimburse in full the fee paid in that particular application process. If the division does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request shall be denied.(2) Good cause for exceeding the period established is considered to exist if:(A) the number of applications for licenses to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;(B) another public or private entity utilized in the application process caused the delay; or(C) other conditions existed which gave good cause for exceeding the established periods.(d) Appeal. If the request for full reimbursement authorized by subsection (c) of this section is denied, the applicant may then appeal to the commissioner of health (commissioner) for a resolution of the dispute. The applicant shall give written notice to the commissioner requesting full reimbursement of all filing fees paid because the application was not processed within the adopted time period. The division shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The commissioner shall make the final decision and provide written notification of the decision to the applicant and the division.(e) Contested case hearings. The procedures set out in §1.21 of this title (relating to Formal Hearing Procedures) apply to all hearings requested under this chapter. Source Note: The provisions of this §506.14 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES B FACILITY LICENSING §506.14 Time Periods for Processing and Issuing Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195325 03/12/2026 (a) General.(1) All fees paid to the department are nonrefundable with the exception of fees for surveys that were not conducted.(2) All fees shall be paid to the department.(b) License fees. The fee for an initial license or a renewal license is $35 per bed per 12 months based upon the designed bed capacity. The total fee may not be less than $300 or more than $2,500.(c) Plan review fees. This subsection outlines the fees that must accompany the application for plan review.(1) Construction plans will not be reviewed or approved until the required fee and an application for plan review are received by the department.(2) Plan review fees are based upon the estimated construction project costs which are the total expenditures required for a proposed project from initiation to completion. The plan review schedule is as follows:(A) $150,000 or less--$200;(B) $150,001 to $600,000--$500;(C) $600,001 to $2,000,000--$850;(D) $2,000,001 to $5,000,000--$1,500;(E) $5,000,001 to $10,000,000--$2,000; and(F) $10,000,001 and over--$3,000.(3) If an estimated construction cost cannot be established, the estimated cost shall be based on $105 per square foot. No construction project shall be increased in size, scope, or cost unless the appropriate fees are submitted with the proposed changes.(d) Construction survey fees. A fee of $500 and an Application for Survey form for each survey shall be submitted to the department at least three weeks prior to the anticipated survey date. Construction surveys will not be conducted until all required fees are received by the department. If additional construction surveys of the proposed project are requested, or if follow-up construction surveys are required to verify plans of correction, the appropriate additional fees shall be submitted to the department.(e) Other fees. For all applications and renewal applications, the department is authorized to collect subscription and convenience fees, in amounts determined by the Texas Online Authority, to recover costs associated with application and renewal application processing through Texas Online, in accordance with Texas Government Code, §2054.111. Source Note: The provisions of this §506.15 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES B FACILITY LICENSING §506.15 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195326 03/12/2026 (a) Administration and staffing.(1) Legal responsibility. There shall be an individual or individuals that assume(s) full legal responsibility for the overall conduct of the facility and are responsible for compliance with all applicable laws and rules of the department.(2) Facility director.(A) The facility director, who is to be accountable for the overall management of the facility, shall be named in writing.(B) The director's responsibilities shall be defined in writing.(C) If the facility can be successfully managed with less than the director's full-time management, the director may be less than full-time. In such instances, the director shall assign another responsible individual who can perform management tasks so that there is administrative management essentially for the usual and customary 40-hours-per-week business operations.(D) There shall be a competent individual authorized to be in charge of the facility when the director is absent.(E) The director shall be at least 18 years of age and shall be qualified by education or training to perform the duties required to manage the facility.(F) The director shall be responsible for coordinating the provision of all services.(3) Personnel requirements.(A) The facility shall have written personnel policies and procedures for paid staff and volunteer staff which include at a minimum:(i) written position descriptions that include responsibilities for all positions in the facility;(ii) qualifications for employment for all positions in the facility; and(iii) the process for filling a position, evaluating performance and termination.(B) The facility shall maintain personnel records which contain sufficient information to support appropriate placement of an individual in a position. The file shall include a copy of the individual's current license or certification, if applicable, or other evidence that license or certification status was verified.(C) The facility shall be staffed at all times with sufficient qualified personnel to meet the needs of residents and maintain a clean and safe environment. A minimum of one staff person shall be on duty at all times. A qualified staff person will be designated as in charge on each shift.(4) Contracted services. If a facility does not employ a person qualified to provide a required or needed service, it shall have a contract with an outside resource to provide the service directly to residents or to act as a consultant to the facility. The facility maintains responsibility for ensuring that contract staff is qualified to perform the services to be provided and that they are appropriately supervised.(5) Volunteer services. Volunteer staff may be placed in any position for which they are qualified. Requirements in paragraph (6) of this subsection shall apply to all volunteer staff.(6) Staff development and training.(A) All staff shall receive orientation training prior to being allowed to work with residents. Orientation shall include information pertaining to the facility's mission and philosophy, position specific responsibilities and all operational policies and procedures.(B) All staff must participate in periodic staff development training designed to update their knowledge and skills in providing care to residents. Training will also include a review of operational policies and procedures.(C) The facility shall maintain documentation which verifies each staff person's participation in the orientation training program and staff development training.(b) Policies and procedures. The facility shall adopt, implement and enforce written policies and procedures detailing the operations of the facility. The policies shall be reviewed and updated annually. In addition to describing the operations of the facility and the manner in which care and services will be provided, the policies and procedures shall include:(1) Resident admission.(A) Admission policies shall include qualifications and criteria for admission based on the mission and philosophy of the facility.(B) Policies may include restriction of admission and retention of individuals with regard to illegal drug use, alcohol abuse, or actions that pose a threat to the health and safety of other residents or staff.(C) Policies shall require a written admission agreement between the resident and the facility that addresses the care and services to be provided and the method of payment for services.(D) The facility policy shall require that a chronological register of all residents admitted to and discharged from the facility be maintained. The register shall contain at least the name of the resident, date of birth, date of admission, date of discharge or death, and disposition.(2) Infection control and universal precautions. There shall be written policies and procedures providing for a safe and sanitary environment, and the control of communicable diseases and infections in staff, residents, and visitors. The policy shall also provide for monitoring compliance of the facility and its staff with universal precautions in accordance with the Health and Safety Code (HSC), Chapter 85, Subchapter I, (relating to the Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis B Virus by Infected Health Care Workers).(3) Determination of death. If applicable, there shall be a written policy with protocols to be used in determining death that complies with HSC, Title 8, Subtitle A, Chapter 671, Subchapter A (relating to Determination of Death).(4) Special waste. The facility shall comply with the requirements set forth by the department in §1.131-1.137 of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care Related Facilities), and the Texas Commission on Environmental Quality requirements in Title 30, Texas Administrative Code, Subchapter Y, §330.1004 (relating to Generators of Medical Waste).(5) Confidentiality of records. There shall be a written policy that addresses the confidentiality of resident information.(6) Advance directives. There shall be policies and procedures regarding the use of advance directives in the facility. These policies and procedures shall be in accordance with the Advance Directives Act, HSC, Chapter 166. Violations of §166.004 may result in the assessment of administrative penalties, in accordance with HSC, §248.0545 (relating to Violation of Law Relating to Advance Directives). Source Note: The provisions of this §506.31 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.31 General Functions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195327 03/12/2026 (a) Physician services.(1) Each resident shall have an attending physician who is charge of the resident's medical care.(2) The facility shall make a reasonable effort to contact the resident's physician within 72 hours after admission to obtain any information relating to the care of the resident. Any relevant information obtained from the physician will be recorded in the resident's care document.(3) In the event of an acute illness, condition, or accident requiring medical and/or nursing care beyond the capabilities of the facility, the resident shall be transferred, in a medically appropriate manner, to a hospital or other health care facility as appropriate where needed services and facilities are available.(b) Nursing services.(1) Licensed nurses shall function consistent with the nursing practices recognized and authorized by Texas Board of Nurse Examiners.(2) When nursing services are provided, nursing personnel are responsible for ensuring that residents receive treatments, medications, and diets as prescribed; receive preventive care to prevent and minimize the incidence of skin breakdown; are kept comfortable with personal hygiene needs met; are protected from accident and injury through the initiation of appropriate safety measures; and are treated with kindness and respect.(3) Nursing or attendant personnel on duty shall be responsible for obtaining emergency medical care when a resident's condition so requires and shall be responsible for notifying the attending physician.(c) Medications.(1) Medications shall be provided as required for those residents on a physician or practitioner-ordered medication therapy regimen.(2) Upon admission, and as part of the plan of care, the admitting physician shall determine whether a resident can self-administer his or her medications or will require administration by qualified personnel in accordance with paragraph (7) of this subsection.(3) Each resident's health status shall be reviewed at least quarterly, or more often if indicated, to determine if any changes are necessary in the medication administration procedures.(A) The appropriateness for a resident to self-administer medications shall be reviewed by facility staff and the attending physician or an advanced practice nurse working in collaboration with the attending physician.(B) A resident's drug regimen review shall be incorporated into the individual's plan of care.(4) Medications must be kept secured at all times. Only the resident and authorized facility staff shall have access to the secured medications. Residents self-administering their medications may:(A) keep medications in their possession at all times;(B) secure their medications within their locked room if the room is not shared with others, or in a locked cabinet in their room; or(C) allow the facility to keep residents' medications in a central medication storage area under control of facility staff.(5) The central medication storage shall be kept locked when facility staff is not actually in or at the storage area.(6) Residents may be permitted entrance or access to the storage area for the purpose of self-administering their medications or treatments or receiving assistance with their medication or treatment regimen. A facility staff member shall remain in or at the storage area the entire time any resident is in the storage area.(7) Medications that are administered to a resident shall be administered only by a registered professional nurse, licensed vocational nurse, or an individual under direct delegation orders by a physician and in conformance with all laws, rules, and recognized professional standards of practice. A home health agency who is providing services within a special care facility may use a home health medication aide in accordance with 40 Texas Administrative Code, §95.128 (relating to Home Health Medication Aides).(A) The person administering medications shall properly record the medications administered. This record will be retained in the resident file.(B) Medications classified as dangerous drugs or controlled substances may not be taken by or administered to residents unless the medication was obtained directly from or under a valid prescription or order of a physician or practitioner. If facility staff administer the medications, they shall only be administered under written orders, or verbal orders which are subsequently verified in writing by the treating physician or practitioner.(C) All injectable medication, intravenous solutions, or medications administered by way of a tube inserted in a cavity of the body shall be administered under physician's or practitioner's orders by a physician, registered professional nurse, licensed vocational nurse, or other individual qualified under state law.(D) If administration of medications to residents is performed by a registered professional nurse or licensed vocational nurse the following shall apply.(i) There shall be a specific area designated for medication that is:(I) sufficient in size and/or space for the storage of all medications that are being administered to residents and for the preparation of medications for administration to residents;(II) lockable and shall be maintained locked at all times when not occupied;(III) accessible only to persons authorized to administer medications to residents;(IV) equipped with a sink having hot and cold water available at all times; and(V) adequately ventilated and temperature controlled.(ii) A medication storage cart may be used in addition to the medication room for the storage of residents' medications. When not in use, the medication storage cart must be kept locked in the locked medication room or in the designated locked storage room that shall be used only for the storage of the cart.(8) When a resident needs assistance with taking oral medication, only those individuals approved in writing by the director of the facility may provide that assistance.(A) A mechanism will be developed, implemented and monitored by the facility director to insure that the resident is given only those medications that have been prescribed by the resident's physician or practitioner at the intervals detailed on the resident's medication container.(B) When assistance with taking oral medication is provided, the facility will maintain a medication record which documents the medication, date, and time taken. The name of the individual who assisted the resident taking the oral medication shall also be documented.(C) The facility director or designee will monitor the medication records daily to insure accuracy.(9) Medication requiring refrigeration shall be stored in a separate refrigerator designated for medications which is kept in the secured medication storage area. Medications may be stored in an area within the common refrigerator if they are stored in a manner that prevents contamination of the medications, and allows for the security of the medication to be maintained.(10) Medication under storage control of the facility shall be returned to the resident upon dismissal from the facility, or as directed by the physician.(11) Medications of a resident shall not be used for another resident. When a resident is dismissed from or otherwise leaves the facility for a period of time greater than 48 hours, medications which had been under the control of the resident and left in the facility shall be secured under locked storage control of the facility until reclaimed by the resident and no longer than 90 days. Medications of deceased residents shall not remain in the facility for more than 7 days after the resident's death. Medications of deceased residents and medications which have been left unclaimed in the facility for more than 90 days shall be handled in one of the following manners.(A) Medications may be returned to any licensed pharmacy for destruction in accordance with regulations of the Texas Board of Pharmacy governing the destruction of dangerous drugs or controlled substances. A record shall be maintained by the facility which itemizes the quantity and strength of each medication returned to a pharmacy for destruction. Such record shall be signed by the director of the facility and the pharmacist accepting the drugs for destruction and shall be retained in the resident's file.(B) Medications may be destroyed beyond reclamation on site by the facility director. Drugs should be destroyed by incineration, if possible. Small amounts of drugs may be flushed into the sewer system unless prohibited by local ordinance. Large quantities of drugs may be destroyed by removing the drugs from the prescription containers, placing them in a strong plastic container, and adulterating the drugs with water or bleach.(i) A record of the destruction shall be maintained by the facility and include:(I) the name, strength, and quantity of the drug;(II) the method of destruction; and(III) the signature of the facility director who destroyed the drugs and signatures of two other individuals who witnessed the destruction.(ii) This record shall be retained in the resident's file.(12) Controlled substances and drugs under storage control of the facility shall be kept separately locked in a permanently affixed compartment within the medicine room or medication storage cart.(A) A separate record must be maintained for each controlled substance and drug.(B) The record shall include, but not be limited to, prescription number, name and strength of drug, date received by the facility, date and time each dose is provided, signature of person providing the dose, name of resident, and the original amount received with the balance verifiable by drug inventory at least daily.(13) All residents' medications shall be properly labeled in accordance with applicable laws and regulations.(d) Dietary services.(1) A dining room, rooms, or space with appropriate furnishings shall be provided. The dining space and furnishings should allow the residents who can come to the dining room to dine at one sitting. Where alternate or second meal services are employed, quantity and quality shall be maintained.(2) The facility shall have a kitchen or dietary area to meet the food service needs of the residents. It shall include provisions for the storage, refrigeration, preparation, and serving of food; for dish and utensil cleaning; and for refuse storage and removal.(3) Meal service at intervals of at least three meals per day, seven days per week, shall be provided or arranged to be commensurate with the needs of the residents. Meals shall be palatable and meet the nutritional needs of the residents.(4) Procedures to prevent cross contamination shall be observed in the storage, preparation, and distribution of food; in the cleaning of dishes, equipment, and work area; and in the storage and disposal of waste. The facility shall provide storage of food for emergency use for a minimum of four calendar days.(5) All dishes and utensils shall be washed in an automatic dishwasher or by the use of manual dishwashing procedures.(A) A three-compartment sink shall be used if washing, rinsing and sanitizing of utensils and equipment is done manually; or a two-compartment sink may be utilized if single service tableware is provided, or when an approved detergent sanitizer is used.(B) Cleaning and sanitizing may be done by spray-type or immersion dishwashing machines or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils either by chemical or mechanical sanitization.(6) Sanitary hand washing and drying provisions shall be provided in the kitchen area and shall include soap, water and individual disposable towels.(e) Social services/pastoral care. Services to meet identified social, spiritual, and emotional needs shall be offered to the resident. Services may also be available to the resident's family, responsible party, and significant other persons. Acceptance of these services will be at the option of the resident.(f) Personal care services.(1) The facility shall provide personal care services in accordance with the individualized needs of each resident.(2) Personal care services shall include normal activities of daily, and may include:(A) assistance with their medications;(B) assistance with hygiene;(C) assistance with dressing;(D) assistance with ambulation; and(E) emotional support.(g) Laboratory services.(1) A facility that provides laboratory services shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the requirements specified in 42 Code of Federal Regulations (CFR), Chapter IV, Part 493, §§493.1-493.1780. CLIA 1988 applies to all facilities with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.(2) The facility shall ensure that all laboratory services provided to its residents through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR, Chapter IV, Part 493 to comply with CLIA 1988. Source Note: The provisions of this §506.32 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.32 Resident Care and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195328 03/12/2026 (a) General. The facility shall promote and protect the rights of all residents. Policies that ensure resident rights shall be adopted, implemented and enforced. The policies shall include:(1) the right of the resident to considerate and respectful care:(A) the care of the resident includes consideration of the psychosocial, spiritual, and cultural variables that influence the perceptions of illness; and(B) the care of the dying resident optimizes the comfort and dignity of the patient;(2) the right of the patient, in collaboration with his or her physician, to make decisions involving his or her health care;(3) the right of the resident to formulate advance directives and to appoint a surrogate to make health care decisions on his or her behalf to the extent permitted by law:(A) a facility shall have in place a mechanism to ascertain the existence of, and, as appropriate, assist in the development of advance directives at the time of the resident's admission;(B) the provision of care shall not be conditioned on the existence of an advance directive; and(C) an advance directive(s) shall be in the resident's record and shall be reviewed periodically with the patient or surrogate decision maker if the patient has executed an advance directive;(4) the right of the resident, within the limits of law, to personal privacy and confidentiality of information;(5) the right to receive care in a safe setting:(A) all accidents, whether or not they result in injury, and any unusual incidents or abnormal events, including allegations of mistreatment of residents by staff, personnel, or visitors, shall be investigated by the facility; and(B) documentation shall be maintained in separate administrative records, to be filed in the facility director's office.(6) the right to have unlimited freedom to move to and from the facility;(7) the right to only be discharged from the facility for reasons specified in the admission policies and to have due notification;(8) the right to keep and maintain his or her personal belongings in his or her possession:(A) within 72 hours of admission, the facility must prepare a written inventory of the personal property a resident brings to the facility (inventory of the resident's clothing is not required);(B) if requested by the resident or responsible party, the inventory shall be updated; and(C) the facility shall have a mechanism to protect resident clothing.(9) the right to keep and maintain his or her own finances;(10) the right to participate in, or abstain from, religious observances;(11) the right to receive and send mail unopened and without undue delay; and(12) the right to receive visitors at reasonable hours, within reasonable limitations, as may be required by the facility in its operation policies.(b) Rights of the elderly. Rights of the elderly specified in Human Resources Code, Title 6, Chapter 102, shall apply to residents 60 years of age or older.(c) Abuse, neglect and exploitation. The facility shall adopt, implement and enforce policies which ensure that residents are protected from abuse, neglect and exploitation.(1) Reporting requirements.(A) Abuse or neglect of a child, as defined in §1.204(a) and (b) of this title (relating to Investigations of Abuse, Neglect, or Exploitation of Children or Elderly or Disabled Persons), which occurs in a facility shall be reported to the Texas Department of Health (department).(B) Abuse, neglect or exploitation of an elderly or disabled person, as defined in §1.204(a) and (b) of this title, which occurs in a facility shall be reported to the department.(2) Investigations.(A) Submission of complaints. A complaint alleging abuse, neglect or exploitation may be submitted in writing or verbally to the Health Facility Licensing and Compliance Division, Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756-3199, telephone, (888) 973-0022.(B) Investigations by the department. A complaint containing allegations of abuse, neglect or exploitation as defined in §1.204(a) and (b) of this title shall be investigated by the department.(C) Allegations of abuse, neglect or exploitation which are not under the jurisdiction of the department will be referred to law enforcement agencies or other agencies, as appropriate. Source Note: The provisions of this §506.33 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.33 Resident Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195329 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195329 03/12/2026 (a) The facility shall maintain for each resident admitted, a separate record with all entries kept current, dated and signed by the recorder. The record shall be accurately written, promptly completed, properly stored and filed, and accessible. At a minimum, the record shall include:(1) identification data. The facility shall secure at the time of admission appropriate identifying information, including full name; sex; date of birth; usual occupation; social security number; family/friend name, address, and telephone number; and physician names and telephone numbers including emergency numbers;(2) medical history and physical exam reports, if available;(3) any physician orders and progress notes, if available;(4) any documentation of the resident's change in health condition requiring emergency procedures, and health services provided by facility personnel;(5) other documents or reports related to the care of the resident as required by facility policy;(6) if appropriate, documentation of nursing services provided and nursing staff observation as required by facility policy; and(7) a list of medications the resident is taking.(b) The facility director shall be responsible for the organization and management of the resident file.(c) The facility will protect the resident file against loss, damage, destruction, and unauthorized use by:(1) safeguarding the confidentiality of the resident file and allowing access or release only as specifically allowed by federal or state laws;(2) maintaining files in an organized manner and filing them using an organized system;(3) recording entries in ink, computer, or typewritten format and keeping original reports and records; and(4) storing files in a lockable area during non-use and after resident's discharge.(d) Resident files must be retained for at least five years after services end. In the case of a minor, the resident file must be retained for at least three years after the minor reaches majority under state law.(e) The facility may not destroy resident files that relate to any matter that is involved in litigation if the facility knows the litigation has not been finally resolved. Source Note: The provisions of this §506.34 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.34 Resident Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195330 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195330 03/12/2026 (a) General. A special care facility designated as a residential AIDS hospice shall meet the standards of this section. These standards are in addition to the other standards described in this chapter that apply to special care facilities.(b) Service requirements.(1) Palliative care. The facility shall provide palliative care that is reasonable and necessary to meet the needs of a resident and the management of the resident's terminal illness and related conditions.(2) Support services. Support services shall be available to both the resident and the family. Support services shall:(A) include social, spiritual and emotional care provided to a resident and the family; and(B) be under the supervision of a qualified individual who may be a person with a master's degree in social work, an accredited or ordained member of the clergy, or other individual with appropriate training and experience.(3) Counseling services. Counseling services shall be available to the resident and the family. If provided, counseling services shall be identified as a need in the resident's plan of care described in subsection (c) of this section.(4) Bereavement services. Bereavement services shall be available to the family. The provision of bereavement services shall be:(A) provided in an organized program under the supervision of a qualified person who may be a person with a master's in social work, an accredited or ordained member of the clergy, or other individual with appropriate training and experience;(B) available to families for up to one year following the death of the resident; and(C) identified as a need for the family in the resident's plan of care described in subsection (c) of this section.(c) Plan of care.(1) An interdisciplinary team shall develop an individual plan of care for each resident receiving hospice services.(A) The interdisciplinary team shall consist of the resident, a physician, a registered nurse and other appropriate members who are involved with the resident's care.(B) Members of the interdisciplinary team may also include a volunteer, an employee of the facility, an individual under contract with facility, or an employee or representative of a home and community support services agency employed by the resident to provide services.(C) The interdisciplinary team shall review and revise the resident's plan of care as needed based on changes in the resident's needs, but not less than once a month.(2) The plan of care shall identify the need for counseling and bereavement services, as appropriate.(3) A physician shall conduct a clinical and medical review of the care and services provided to a resident receiving hospice services. The physician conducting the review shall serve as a member of the interdisciplinary team described in paragraph (1) of this subsection. The physician may be an employee, a volunteer, or a contracted consultant to the facility.(d) Designation process. The department must approve a special care facility's designation as a residential AIDS hospice prior to the facility's implementation of hospice services.(1) A special care facility may request designation as a residential AIDS hospice on the initial application form, or by submitting a written request to the department at any time during the licensing period.(2) The department will evaluate the facility's compliance with subsections (a) - (c) of this section prior to approving the residential AIDS hospice designation. This evaluation may be accomplished through a presurvey conference with review of required policies and documents or by means of an onsite inspection.(3) The department will send a written notice to the facility regarding the approval or denial of the residential AIDS hospice designation. If denied, the written notice will state the deficient items that resulted in the denial of the application. The facility may submit additional information and request reconsideration of the application.(4) The facility may withdraw the residential AIDS hospice designation by submitting a written request to the department. The request shall include the effective date of withdrawal. Source Note: The provisions of this §506.35 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.35 Residential AIDS Hospice Designation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195331 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195331 03/12/2026 (a) As used in this section, an unlicensed applicant or employee excludes licensed health professionals. A licensed health professional is an individual who is authorized and holds a license issued by the State of Texas to practice in the health care field. This term "licensed health professional" includes, but is not limited to, a physician, physician assistant, advanced practice registered nurse, registered nurse, licensed vocational nurse, social worker, counselor, dietitian, pharmacist, or psychologist.(b) Each facility shall comply with the provisions of Health and Safety Code, Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illnesses).(c) The facility shall obtain criminal history record information from the Department of Public Safety (DPS) for all unlicensed applicants for employment.(1) A facility shall obtain the information directly from the DPS or by paying a private agency to obtain criminal history record information directly from the DPS.(2) If an applicant has been convicted of an offense under Health and Safety Code, §250.006 (relating to Convictions Barring Employment), the facility shall determine whether the conviction bars the applicant from employment or whether the conviction is a contraindication to employment with the patients the facility serves.(3) If a facility determines that a conviction bars an applicant from employment in a facility, or is a contraindication to employment, the facility shall notify the applicant.(4) A facility shall not employ an unlicensed applicant who has been convicted of an offense listed in Health and Safety Code, §250.006, if the facility determines that the conviction bars employment or is a contraindication to employment with the patients the facility serves.(d) Before a facility employs any unlicensed applicant, the facility shall search the nurse aide registry (NAR) and the employee misconduct registry (EMR) by calling the toll-free number, 1-(800) 452-3934, or by using the Employability Status Search website at http://www.dads.state.tx.us/providers/employability/esearch.cfm.(1) The facility shall receive the search results and verify that an unlicensed applicant is not designated in the NAR or the EMR as having a finding concerning abuse, neglect, or mistreatment of a patient, or misappropriation of a patient's property before employing the applicant.(2) A facility shall not employ a nurse aide until the facility verifies that the applicant is listed in the NAR and verifies that the applicant is not designated in the NAR or the EMR as having a finding concerning abuse, neglect, or mistreatment of a patient of a facility, or misappropriation of a patient's property.(e) In addition to the initial verification of employability, a facility shall comply with the following requirements for all unlicensed employees:(1) conduct criminal history checks;(2) if the employee is a nurse aide, search the NAR annually as set forth in subsection (c) of this section to determine whether the employee is listed in the NAR;(3) search the NAR and the EMR annually as set forth in subsection (d) of this section to determine whether any employee is designated in the NAR or the EMR as having a finding concerning abuse, neglect, or mistreatment of a patient, or misappropriation of a patient's property;(4) maintain in each unlicensed employee's personnel file a copy of the results of the search conducted under this subsection; and(5) provide written information about the EMR to all unlicensed employees, including information that a person may not be employed if the person is listed in the EMR.(f) A facility shall notify any employee if the facility determines that a conviction bars the employee from employment in a facility under Health and Safety Code, §250.006, or is a contraindication to employment.(g) A facility shall immediately discharge any employee who is designated in the NAR and the EMR as having committed an act of abuse, neglect, or mistreatment of a patient of a facility, or misappropriation of a patient's property.(h) A facility shall immediately discharge any employee whose criminal history check reveals conviction of a crime that bars employment under Health and Safety Code, §250.006, or that the facility determines is a contraindication to employment.(i) In an emergency that requires immediate employment, a facility may hire an applicant on a temporary or interim basis before obtaining the results of a criminal conviction check.(1) The facility shall justify and document the emergency.(2) The facility shall verify that the applicant is not designated in the NAR or the EMR as having a finding concerning abuse, neglect, or mistreatment of a patient of a facility, or misappropriation of a patient's property.(3) The facility shall verify that a nurse aid applicant is listed in the NAR.(4) The facility shall request the DPS criminal conviction check within 72 hours of employment.(5) The facility shall ensure that the applicant/employee has no direct contact with a patient until the facility obtains the person's criminal history record information and verifies the person's employability.(j) The facility shall ensure that the criminal history records are used exclusively by the facility on behalf of the applicant or employee who is the subject of the records.(1) All criminal records and reports and the information they contain are privileged information.(2) The facility shall ensure that this information is not released or otherwise disclosed to any person or agency except on court order or with the written consent of the person being investigated.(k) A person commits an offense if the person releases or otherwise discloses any information received under this chapter except as allowed in subsection (j) of this section. An offense under this section is a Class A misdemeanor.(l) A facility or an officer or employee of a facility is not civilly liable for failure to comply with this chapter if the facility makes a good faith effort to comply. Source Note: The provisions of this §506.36 adopted to be effective March 20, 2011, 36 TexReg 1672; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.36 Criminal History and Nurse Aide Registry Checks of Employees and Applicants for Employment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220245 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220245 03/12/2026 (a) A facility shall comply with the following balance billing requirements.(1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility.(b) A facility shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §506.37 adopted to be effective April 15, 2021, 46 TexReg 2425; amended to be effective August 18, 2024, 49 TexReg 6218. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.37 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207480 03/12/2026 A facility shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §506.38 adopted to be effective January 6, 2022, 46 TexReg 9398. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.38 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210221 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Public health emergency--A state of disaster or local disaster declared under Texas Government Code Chapter 418 or a public health disaster as defined by Texas Health and Safety Code (HSC) §81.003.(2) Religious counselor--An individual acting substantially in a pastoral or religious capacity to provide spiritual counsel to other individuals.(b) In accordance with HSC §260C.002 (relating to In-Person Visitation with Religious Counselor), except as provided by subsections (c) and (d) of this section, a facility may not prohibit a resident from receiving in-person visitation with a religious counselor during a public health emergency upon the request of the resident or, if the resident is incapacitated, upon the request of the resident's legally authorized representative, including a family member of the resident.(c) A facility may prohibit in-person visitation with a religious counselor during a public health emergency if federal law or a federal agency requires the facility to prohibit in-person visitation during that period.(d) To the extent that facility establishes policies and procedures for in-person religious counselor visitation during a public health emergency, these policies and procedures shall comply with the following:(1) The policies and procedures shall establish minimum health and safety requirements for in-person visitation with religious counselors consistent with:(A) state, local and federal directives and guidance regarding the public health emergency;(B) public health emergency and disaster preparedness plans; and(C) other policies adopted by the facility, including the facility's general visitation policy and infection control policy.(2) The policies and procedures shall address considerations for residents who are receiving end-of-life care.(3) The policies and procedures may contain reasonable time, place, and manner restrictions on in-person visitation with religious counselors to mitigate the spread of a communicable disease or address a resident's medical condition.(4) The policies and procedures may condition in-person visitation with religious counselors on the counselor's compliance with guidelines, policies, and procedures established under this subsection. Source Note: The provisions of this §506.39 adopted to be effective September 29, 2022, 47 TexReg 6200. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.39 In-Person Visitation During a Public Health Emergency or Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221281 03/12/2026 (a) Pursuant to Texas Health and Safety Code (HSC) §166.054, a facility shall complete and submit to the Texas Health and Human Services Commission (HHSC) the Ethics or Medical Committee Reporting Form, which is located on the Texas HHSC website, no later than the 180th day after the facility provides written notice under HSC §166.046(b)(1). The Ethics or Medical Committee Reporting Form collects the following information:(1) the number of days that elapsed from the patient's admission to the facility to the date notice was provided under HSC §166.046(b)(1);(2) whether the ethics or medical committee met to review the case under HSC §166.046 and, if the committee did meet, the number of days that elapsed from the date notice was provided under HSC §166.046(b)(1) to the date the meeting was held;(3) whether the patient was:(A) transferred to a physician within the same facility who was willing to comply with the patient's advance directive or a health care or treatment decision made by or on behalf of the patient;(B) transferred to a different health care facility; or(C) discharged from the facility to a private residence or other setting that is not a health care facility;(4) whether the patient died while receiving life-sustaining treatment at the facility;(5) whether life-sustaining treatment was withheld or withdrawn from the patient at the facility after expiration of the time period described by HSC §166.046(e) and, if so, the disposition of the patient after the withholding or withdrawal of life-sustaining treatment at the facility, as selected from the following categories:(A) the patient died at the facility;(B) the patient is currently a patient at the facility;(C) the patient was transferred to a different health care facility; or(D) the patient was discharged from the facility to a private residence or other setting that is not a health care facility;(6) the age group of the patient selected from the following categories:(A) 17 years of age or younger;(B) 18 years of age or older and younger than 66 years of age; or(C) 66 years of age or older;(7) the health insurance coverage status of the patient selected from the following categories:(A) private health insurance coverage;(B) public health plan coverage; or(C) uninsured;(8) the patient's sex;(9) the patient's race;(10) whether the facility was notified of and able to reasonably verify any public disclosure of the contact information for the facility's personnel, physicians or health care professionals who provide care at the facility, or members of the ethics or medical committee in connection with the patient's stay at the facility; and(11) whether the facility was notified of and able to reasonably verify any public disclosure by facility personnel of the contact information for the patient's immediate family members or the person responsible for the patient's health care decisions in connection with the patient's stay at the facility.(b) In accordance with HSC §166.054(c)-(e), HHSC publishes on its website an aggregate report of information submitted under subsection (a) of this section in the preceding year by April 1 of each year.(c) Pursuant to HSC §166.054(g), information collected or submitted under subsection (a) of this section:(1) is not admissible in a civil or criminal proceeding in which a physician, health care professional acting under the direction of a physician, or health care facility is a defendant;(2) may not be used in relation to any disciplinary action by a licensing or regulatory agency with oversight over a physician, health care professional acting under the direction of a physician, or health care facility; and(3) is not public information or subject to disclosure under Texas Government Code Chapter 552, except as permitted by Texas Government Code §552.008. Source Note: The provisions of this §506.40 adopted to be effective November 1, 2024, 49 TexReg 8585. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §506.40 Advance Directives Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195332 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195332 03/12/2026 (a) Physical plant waiver. On the request of the facility, the department may grant a waiver or modification for certain provisions of the physical plant and environment that, in the opinion of the department, would be impractical for the facility to meet. Waivers will not be granted for fire safety requirements required by the National Fire Protection Association (NFPA). The facility's written request must specify the specific provision for which waiver is requested.(b) Facility operation waiver. On the request of the facility, the department may grant a waiver or approve a variation for certain provisions of facility operation that, in the opinion of the department, would be impractical or inappropriate for the facility to meet. The facility's written request must specify the specific provision for which waiver is requested.(c) Consideration. In considering the waiver or modification request, the department shall consider information submitted by the facility and whether the waiver or modification:(1) will adversely affect the health and safety of the facility patients, employees, or the general public;(2) if not granted, would impose an unreasonable hardship on the facility in providing adequate care for patients;(3) will facilitate the creation or operation of the facility; and(4) is appropriate when balanced against the best interests of the individuals served or to be served by the facility.(d) Supporting documentation. The department may request written documentation from the facility to support the waiver or modification including, but not limited to:(1) a statement addressing each of the criteria in subsection (c) of this section;(2) evidence of approval by the local building and fire authorities;(3) evidence of provisions in the Act or this chapter which will mitigate any adverse effect of the waiver or modification; and(4) evidence of any mitigating act in excess of the Act or this chapter which will be used by the hospital to offset any adverse effect of the waiver or modification.(e) Written recommendation. The director shall submit a written recommendation for granting or denying the waiver to the commissioner of health (commissioner).(f) Granting order. If the director recommends that the waiver or modification be granted, the commissioner may issue a written order granting the waiver or modification.(g) Denial of order. If the director recommends that the waiver or modification be denied, the commissioner may issue a written order denying the waiver or modification.(h) File documentation. The licensing file for the facility maintained by the Texas Department of Health shall contain a copy of the request, the written recommendation of the director, and the order of the commissioner. The facility shall also maintain a copy of the order. Source Note: The provisions of this §506.51 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES D WAIVERS §506.51 Waivers, Modifications, and Variations to Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222038 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission's (HHSC's) inspection and investigation process, a facility:(1) may not record, listen to, or eavesdrop on any HHSC interview with facility staff or residents that the facility staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) may not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of facility staff when HHSC has requested a private room or office or distanced themselves from facility staff unless the facility first informs HHSC and the facility obtains HHSC's written approval before beginning to record or listen to the discussion.(b) A facility shall inform HHSC when security cameras or other existing recording devices in the facility are in operation during any internal discussion by or among HHSC staff.(c) When HHSC by words or actions permits facility staff to be present, an interview or conversation for which facility staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §506.61 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.61 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222039 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an unannounced, on-site inspection of a facility at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) a facility's plan of correction;(3) an order or special order of the HHSC executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(b) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its facilities by HHSC.(c) HHSC inspections to evaluate a facility's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or bed numbers;(3) routine inspections, which may be conducted without notice and at HHSC's discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies;(5) inspections to determine if an unlicensed facility is offering or providing, or purporting to offer or provide treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(d) A facility shall cooperate with any HHSC inspection and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the facility, unless prohibited by law.(e) A facility shall permit HHSC access to interview members of the governing body, personnel, and residents, including the opportunity to request a written statement.(f) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(g) HHSC shall maintain the confidentiality of facility records as applicable under state and federal law.(h) Upon entry, HHSC holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the facility representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the inspection, including possible health and safety concerns. The facility may provide any final documentation regarding compliance during the exit conference. Source Note: The provisions of this §506.62 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.62 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222040 03/12/2026 (a) A facility shall provide each resident and applicable legally authorized representative at the time of admission with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the facility.(1) The statement shall inform persons that they may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The facility shall prominently and conspicuously post this statement in resident common areas and in visitor's areas and waiting rooms so that it is readily visible to residents, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A complaint must be submitted using HHSC's current CII contact information for that purpose, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints directed to HHSC CII based on the seriousness of the alleged violation and the level of risk to residents, personnel, and the public.(1) Allegations determined to be within HHSC's regulatory jurisdiction relating to health care facilities may be investigated under this chapter.(2) HHSC may refer complaints outside HHSC's jurisdiction to an appropriate agency, as applicable.(d) HHSC shall conduct investigations to evaluate a facility's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of residents.(e) HHSC may conduct an unannounced, on-site investigation of a facility at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) a facility's compliance with any applicable statute or rule;(2) a facility's plan of correction;(3) a facility's compliance with an order of the executive commissioner or the executive commissioner's designee;(4) a facility's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its facilities by HHSC.(g) A facility shall cooperate with any HHSC investigation and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by, or on behalf of, the facility, unless prohibited by law.(h) A facility shall permit HHSC access to interview members of the governing body, personnel, and residents, including the opportunity to request a written statement.(i) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(j) HHSC shall maintain the confidentiality of facility records as applicable under state and federal law.(k) Upon entry, the HHSC representative holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the investigation.(l) The HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the investigation. The facility may provide any final documentation regarding compliance during the exit conference.(m) Once an investigation is complete, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint.(n) HHSC notifies complainants regarding the investigation's outcome within 10 business days after completing the investigation. Source Note: The provisions of this §506.63 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.63 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222041 03/12/2026 (a) A facility is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after mailing, whichever is earlier.(b) When HHSC finds deficiencies:(1) HHSC provides the facility with a written Statement of Deficiencies (SOD) within 10 business days after the exit conference via U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the facility's receipt of the SOD, the facility shall return to HHSC a written Plan of Correction (POC) that addresses each cited deficiency, including timeframes for corrections, together with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the facility in writing.(B) If HHSC does not accept the POC, HHSC notifies the facility in writing and requests the facility submit a modified POC and any additional evidence of compliance no later than 10 business days after HHSC notifies the facility in writing.(C) The facility shall correct the identified deficiencies and submit to HHSC evidence verifying implementation of corrective action within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of a facility's compliance with this subsection or HHSC's acceptance of a facility's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter. Source Note: The provisions of this §506.64 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.64 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222043 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission reports, in writing, to the appropriate licensing board any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure. Source Note: The provisions of this §506.65 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.65 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222042 03/12/2026 A facility may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by following the procedure listed on the HHSC website. Source Note: The provisions of this §506.66 adopted to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES E INSPECTIONS AND INVESTIGATIONS §506.66 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222044 03/12/2026 (a) Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, and orders.(b) Denial, suspension or revocation of a license or imposition of an administrative penalty. HHSC has jurisdiction to enforce violations of Health and Safety Code (HSC) Chapter 248 (relating to Special Care Facilities) and this chapter. HHSC may deny, suspend, or revoke a license or impose an administrative penalty for:(1) failure to comply with any applicable provision of the HSC, including Chapter 248;(2) failure to comply with any provision of this chapter or any other applicable laws;(3) the facility, or any of its employees, committing an act which causes actual harm or risk of harm to the health or safety of a resident;(4) the facility, or any of its employees, materially altering any license issued by HHSC;(5) failure to comply with minimum standards for licensure;(6) failure to provide a complete license application;(7) failure to comply with an order of the HHSC executive commissioner or another enforcement procedure under HSC Chapter 248;(8) a history of failure to comply with the applicable rules relating to resident environment, health, safety, and rights;(9) the facility aiding, committing, abetting, or permitting the commission of an illegal act;(10) the facility, or any of its employees, committing fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to HHSC or required to be maintained by the facility pursuant to HSC Chapter 248 and the provisions of this chapter;(11) failure to timely pay an assessed administrative penalty as required by HHSC;(12) failure to submit an acceptable plan of correction for cited deficiencies within the timeframe required by HHSC;(13) failure to timely implement plans of corrections to deficiencies cited by HHSC within the dates designated in the plan of correction; or(14) failure to comply with applicable requirements within a designated probation period.(c) HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility.(1) In determining whether a criminal conviction directly relates, HHSC shall apply the requirements and consider the provisions of Texas Occupations Code Chapter 53.(2) The following felonies and misdemeanors directly relate to the duties and responsibilities of the ownership or operation of a health care facility because these criminal offenses indicate an ability or a tendency for the person to be unable to own or operate a facility:(A) a misdemeanor violation of HSC Chapter 248;(B) a misdemeanor or felony involving moral turpitude;(C) a misdemeanor or felony relating to deceptive business practice;(D) a misdemeanor or felony of practicing any health-related profession without a required license;(E) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(F) a misdemeanor or felony under Texas Penal Code (TPC) Title 5, involving a patient, resident, or client of any health care facility, a home and community support services agency, or a health care professional;(G) a misdemeanor or felony under TPC:(i) Title 4;(ii) Title 5;(iii) Title 7;(iv) Title 8;(v) Title 9;(vi) Title 10; or(vii) Title 11.(3) Offenses listed in paragraph (2) of this subsection are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign or military jurisdictions that indicate an inability or tendency for the person to be unable to own or operate a facility.(d) HHSC shall revoke a license on the licensee's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(e) If HHSC proposes to deny, suspend, or revoke a license, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC, or HHSC may personally deliver the notice. The notice to deny, suspend, or revoke a license, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.(f) Within 20 calendar days after receipt of the notice, the applicant or licensee may notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing.(g) A request for a hearing by the applicant or licensee shall be in writing and submitted to HHSC within 20 calendar days after receipt of the notice. Receipt of the notice is presumed to occur on the third day after the date HHSC mails the notice to the last known address of the applicant or licensee.(1) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001 and Texas Administrative Code Title 1 Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(2) If an applicant or licensee does not request a hearing in writing within 20 calendar days after receiving the notice of the proposed action described in subsection (e) of this section, the applicant or licensee is deemed to have waived the opportunity for a hearing and HHSC shall take the proposed action.(h) HHSC may issue an emergency order to suspend a license effective immediately when HHSC has reasonable cause to believe that the conduct of a license holder creates an immediate danger to public health and safety. HHSC shall notify the facility of the emergency action by mail or personal delivery of the notice. On written request of the license holder to HHSC for a hearing, HHSC refers the matter to the State Office of Administrative Hearings.(i) In lieu of denying, suspending, or revoking the license, HHSC may place the facility on probation for a period of not less than 30 days, if HHSC finds that the facility is in repeated non-compliance with this chapter or HSC Chapter 248, and the facility's noncompliance does not endanger the public's health and safety. Source Note: The provisions of this §506.71 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467; amended to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES F ENFORCEMENT §506.71 License Denial, Suspension, Revocation and Probation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195336 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195336 03/12/2026 (a) A license holder or person who violates the Act or any rule adopted by the board under the Act is liable for a civil penalty, to be imposed by a district court, of not more than $1,000 for each day of violation.(b) A person who knowingly establishes or operates a special care facility without a license issued under this Act commits an offense. An offense under this section is a Class B misdemeanor. Each day of a continuing violation constitutes a separate offense. Source Note: The provisions of this §506.72 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES F ENFORCEMENT §506.72 Civil and Criminal Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222045 03/12/2026 (a) Imposition of penalty. The Texas Health and Human Services Commission (HHSC) may impose an administrative penalty on a person licensed under this chapter who violates the Act, this chapter, or an order adopted under this chapter.(b) Deposit of penalty. A penalty collected under this section shall be deposited in the state treasury in the general revenue fund.(c) Contested case. A proceeding to impose the penalty is considered to be a contested case under Texas Government Code Chapter 2001.(d) Amount of penalty.(1) The amount of the penalty may not exceed $1,000 for each violation, except for violations of §506.31(b)(6) of this chapter (relating to General Functions), which are limited to $500. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty. The total amount of the penalty assessed for a violation continuing or occurring on separate days under this paragraph may not exceed $5,000.(2) In determining the amount of an administrative penalty assessed under this section, HHSC shall consider:(A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(B) the threat to health or safety caused by the violation;(C) the history of previous violations;(D) the amount necessary to deter a future violation;(E) whether the violator demonstrated good faith, including when applicable whether the violator made good faith efforts to correct the violation; and(F) any other matter that justice may require.(e) Report and notice of violation and penalty.(1) If HHSC initially determines that a violation occurred, HHSC sends written notice of the report by certified mail to the person alleged to have committed the violation following the exit conference date.(2) The notice must include:(A) a brief summary of the alleged violation;(B) a statement of the amount of the recommended penalty based on the factors listed in subsection (d)(2) of this section; and(C) a statement of the person's right to a hearing on the occurrence of the violation, the amount of the penalty, or both.(f) Penalty to be paid or hearing requested.(1) Within 20 calendar days after the date the person receives the notice sent under subsection (e) of this section, the person in writing may:(A) accept HHSC's determination and recommended penalty; or(B) request a hearing on the occurrence of the violation, the amount of the penalty, or both.(2) If the person accepts the determination and recommended penalty or if the person fails to respond to the notice, the HHSC executive commissioner or the commissioner's designee by order shall approve the determination and impose the recommended penalty.(g) Hearing.(1) If the person requests a hearing, the HHSC executive commissioner or the commissioner's designee shall refer the matter to the State Office of Administrative Hearings (SOAH). The hearing shall be conducted in accordance with Texas Government Code Chapter 2001 and all applicable SOAH and HHSC rules.(2) As mandated by Health and Safety Code (HSC) §248.105(a), SOAH shall promptly set a hearing date and give written notice of the time and place of the hearing to the person.(A) An administrative law judge of the SOAH shall conduct the hearing.(B) The administrative law judge shall make findings of fact and conclusions of law and promptly issue to the HHSC executive commissioner a proposal for a decision about the occurrence of the violation and the amount of a proposed penalty.(h) Decision by HHSC executive commissioner.(1) Based on the findings of fact, conclusions of law, and proposal for a decision made by the administrative law judge under subsection (g)(2) of this section, the HHSC executive commissioner or the commissioner's designee by order may find that a violation has occurred and may impose a penalty or may find that no violation has occurred.(2) The HHSC executive commissioner or the executive commissioner's designee shall give notice of the executive commissioner's order under paragraph (1) of this subsection to the person alleged to have committed the violation in accordance with Texas Government Code Chapter 2001. The notice must include:(A) a statement of the right of the person to judicial review of the order;(B) separate statements of the findings of fact and conclusions of law; and(C) the amount of any penalty assessed.(i) Options following decision. Within 30 calendar days after the date the order of the HHSC executive commissioner under subsection (h) of this section that imposes an administrative penalty becomes final, the person shall:(1) pay the penalty; or(2) appeal the penalty by filing a petition for judicial review of the HHSC executive commissioner's order contesting the occurrence of the violation, the amount of the penalty, or both.(j) Stay of enforcement of penalty.(1) Within the 30-day period prescribed by subsection (i) of this section, a person who files a petition for judicial review in accordance with subsection (i)(2) of this section may:(A) stay enforcement of the penalty by:(i) paying the penalty to the court for placement in an escrow account; or(ii) giving to the court a supersedeas bond that is approved by the court for the amount of the penalty and that is effective until all judicial review of the HHSC executive commissioner's order is final; or(B) request the court to stay enforcement of the penalty by:(i) filing with the court a sworn affidavit of the person stating that the person is financially unable to pay the penalty and is financially unable to give the supersedeas bond; and(ii) sending a copy of the affidavit to the HHSC executive commissioner by certified mail.(2) If the HHSC executive commissioner receives a copy of an affidavit under paragraph (1)(B) of this subsection, the executive commissioner may file with the court, within five days after the date the copy is received, a contest to the affidavit. In accordance with §248.108(b), the court shall hold a hearing on the facts alleged in the affidavit as soon as practicable and shall stay the enforcement of the penalty on finding that the alleged facts are true. The person who files an affidavit has the burden of proving that the person is financially unable to pay the penalty or to give a supersedeas bond.(k) Collection of penalty.(1) If the person does not pay the penalty and the enforcement of the penalty is not stayed, HHSC may refer the matter to the attorney general for collection of the penalty.(2) As provided by HSC §248.109(b), the attorney general may sue to collect the penalty.(l) Decision by court. A decision by the court is governed by HSC §248.110 and provides the following.(1) If the court sustains the finding that a violation occurred, the court may uphold or reduce the amount of the penalty and order the person to pay the full or reduced amount of the penalty.(2) If the court does not sustain the finding that a violation occurred, the court shall order that no penalty is owed.(m) Remittance of penalty and interest and release of supersedeas bond. The remittance of penalty and interest is governed by HSC §248.111 and provides the following.(1) If the person paid the penalty and if the amount of the penalty is reduced or the penalty is not upheld by the court, the court shall order, when the court's judgment becomes final, that the appropriate amount plus accrued interest be remitted to the person within 30 days after the date that the judgment of the court becomes final.(2) The interest accrues at the rate charged on loans to depository institutions by the New York Federal Reserve Bank.(3) The interest shall be paid for the period beginning on the date the penalty is paid and ending on the date the penalty is remitted.(n) Release of bond. The release of supersedeas bond is governed by HSC §248.112 and provides the following.(1) If the person gave a supersedeas bond and the penalty is not upheld by the court, the court shall order, when the court's judgment becomes final, the release of the bond.(2) If the person gave a supersedeas bond and the amount of the penalty is reduced, the court shall order the release of the bond after the person pays the reduced amount. Source Note: The provisions of this §506.73 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467; amended to be effective November 21, 2024, 49 TexReg 9278. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES F ENFORCEMENT §506.73 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195338 03/12/2026 (a) The building must be kept in good repair. Electrical, heating and cooling must be maintained in a safe manner. The department may require the licensee to submit evidence to this effect, consisting of a report from the fire marshal, city or county building official having jurisdiction, licensed electrician, or a registered professional engineer.(b) Use of electrical appliances, devices, and lamps, must be such as not to overload circuits or cause excessive lengths of extension cords.(c) In facilities of 16 beds or less, all draperies and other window coverings in public or common areas, and in bedrooms and living units shall be flame resistant. In facilities of 17 beds or more, draperies shall be flame resistant, where smoking is permitted.(d) In facilities of 17 beds or more, all floor carpet installed in public or common spaces shall be Class I or II based on the "Critical Radiant Flux" ratings. Proper documentation must be provided.(e) Open flame heating devices are prohibited. All fuel burning heating devices must be vented. Working fireplaces are accepted if of safe design and construction and if screened or otherwise enclosed.(f) There must be a least one telephone in the facility available to both staff and residents for use in case of an emergency. Emergency telephone numbers, including at least fire, police, ambulances, EMS, and poison control center, must be posted conspicuously at or near the telephone.(g) An initial pressure test of facility gas lines from the meter must be provided. Additional pressure tests will be required when the facility has major renovations or additions where the gas service is interrupted. All gas heating systems must be checked prior to the heating season for proper operation and safety by persons who are licensed or approved by the State of Texas to inspect such equipment. A record of this service must be maintained by the facility. Any unsatisfactory conditions must be corrected promptly.(h) Exterior and interior stairs must have handrails that are firmly secured to prevent falls.(i) Cooling and heating must be provided for occupant comfort. Conditioning systems must be capable of maintaining the comfort ranges of 68 degrees Fahrenheit to 82 degrees Fahrenheit in resident-use areas. Heating, ventilating, and air conditioning (HVAC) equipment must comply with the provisions of National Fire Protection Association (NFPA) 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 1999 edition, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air Conditioning Systems, 1999, as applicable. NFPA 90A requires automatic shut down upon activation of the fire alarm in HVAC systems of over 2,000 cubic feet per minute (CFM) capacity. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169-7471 or (800) 344-3555.(j) For existing facilities which were licensed prior to the effective date of these rules, illumination shall be provided to meet the needs of the residents and staff without eye strain or glare. Each resident bedroom shall have sufficient illumination for reading and general use. For new facilities, minimum illumination must be 10 foot-candles in resident rooms during the day and 20 foot-candles in corridors, staff stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways and elevators during the day. Illumination requirements for these areas apply to lighting throughout the space and should be measured at approximately 30 inches above the floor anywhere in the room. Minimum illumination for medication preparation or storage areas, kitchen, and staff station desks must be 50 foot-candles during the day. Illumination requirements for these areas apply to the task performed and should be measured on the tasks.(k) All buildings three floors or higher and in facilities that provide services, treatment, or social activities of floors above or below the level of discharge shall have a passenger elevator. The lowest level of discharge will be the first floor for determining floor level.(l) Floor, ceiling, and wall finish materials must be complete and in place to provide a sanitary and structurally safe environment.(m) All equipment requiring periodic maintenance, testing, and servicing must be reasonably accessible. Necessary equipment to conduct these services, such as ladders, specific tools, and keys, must be readily available on site. Access panels (20 inches x 20 inches minimum) must be provided for building maintenance and must be located for reasonable access to equipment or barriers installed in the attic or other concealed spaces.(n) The facility shall implement procedures, in accordance with the standards and recommendations of Compressed Gas Association in its publication, Safe Handling of Compressed Gases in Containers, 1991 edition, that assure safe and sanitary use and storage of oxygen. Liquid oxygen containers must be certified by Underwriters Laboratory (UL) or other approved testing laboratory for compliance with NFPA 50, Standard for Bulk Oxygen Systems of Consumer Sites, 1996 edition. The facility is responsible for defining all potential hazards both graphically and verbally to all persons involved in the use of liquid oxygen and ensuring the liquid oxygen provider does also. Source Note: The provisions of this §506.81 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES G SAFETY REQUIREMENTS AND FIRE PROTECTION §506.81 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195339 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195339 03/12/2026 (a) Each SCF shall develop written plans for effective preparedness, mitigation, response, and recovery from disasters.(b) The administration must have in effect and available to all personnel written copies of a plan for the protection of all persons in the event of fire and for their remaining in place, for their evacuation to areas of refuge, and from the building when necessary. The plan must include special staff actions including fire protection procedure needed to ensure the safety of any resident and must be amended or revised when needed. All employees must be periodically instructed and kept informed with respect to their duties and responsibilities under the plan. A copy of the plan must be readily available at all times within the facility. This written plan must reflect the current evacuation capabilities of the resident or patient.(c) The SCF must have written preparedness and response plan. Procedures to be followed in an internal or external disaster should be attached to the plan. The plan must address, at a minimum, the eight core functions of emergency management, which are: direction and control; warning (how the facility will be notified of emergencies and who they will notify); communication (with whom and by what mechanism); sheltering arrangements; evacuation (destinations, routes); transportation; health and medical needs; and resource management (supplies, staffing, emergency equipment, records). A copy of the plan must be provided to the local emergency management coordinator and should address those emergencies that could affect the facility. Information about the local emergency management coordinator may be obtained from the office of the local mayor or county judge. Source Note: The provisions of this §506.82 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES G SAFETY REQUIREMENTS AND FIRE PROTECTION §506.82 Emergency Preparedness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195340 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195340 03/12/2026 (a) Fire evacuation classification rating and National Fire Protection Association (NFPA) compliance. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471 or (800) 344-3555.(1) An existing special care facility, which was licensed prior to the effective date of the rules, shall:(A) comply, at a minimum, with the edition of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), under which it was initially licensed, or(B) if classified as a health care occupancy, with NFPA 101, Chapter 19, 2000 edition; or(C) if classified as an occupancy other than a health care occupancy, NFPA 101, Chapter 33; or(D) if classified as an occupancy other than a health care occupancy, the applicable code as determined by the local fire authority.(2) A new special care facility shall be classified as a Limited Care Facility (LCF) or a Residential Board and Care Facility (RBCF).(A) A LCF, as the term is defined in §125.3(b)(1) of this title (relating to Occupancy Classification), shall be classified as a health care occupancy and shall comply with NFPA 101, Chapter 18.(B) For an RBCF, as the term is defined in §125.3(b)(2) of this title, the fire evacuation classification rating shall be determined based on the evacuation capability of the residents. A RBCF shall be designated as having an evacuation capability of prompt or impractical.(i) To be designated as prompt, all residents must be able to travel from their living unit to a central location, such as a lobby, living room or dining room area, on the level of the building where the fire exit to the outside of the facility is located, within a 13 minute period without continuous staff assistance. Elevators cannot be used as an evacuation route.(ii) A RBCF that is not able to meet all criteria specified in clause (i) of this subparagraph will be designated as impractical.(C) A RBCF with an evacuation capability of prompt shall be classified as a residential board and care occupancy, and must comply with NFPA 101, Chapter 32.(D) A RBCF with an evacuation capability rating of impractical shall be classified as a health care occupancy and must comply with subparagraph (A) of this paragraph.(b) Fire protection. Fire protection shall be provided in accordance with the requirements of NFPA 101, §12-7, and §125.91 of this title (relating to Construction Requirements). When required or installed, sprinkler systems for exterior fire exposures shall comply with NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 1996 edition.(c) Fire inspections.(1) Annual inspection. Approval of the fire protection of a SCF by the local fire department shall be a prerequisite for licensure.(2) Purpose of inspection. The purpose of these inspections shall be to ascertain and to cause to be corrected any conditions liable to cause fire or violations of any of the provisions or intent of these rules, or of any other applicable ordinances, which affect fire safety in any way.(3) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the fire department or bureau of fire prevention find in any building or upon any premises dangerous or hazardous conditions or materials, removal or remedy of dangerous conditions or materials shall be carried out in a manner specified by the head of the local fire department.(4) Access for inspection. At all reasonable hours, the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors may enter any building or premises for the purpose of making an inspection or investigation which may be deemed necessary under the provisions of these rules.(d) Fire reporting. All occurrences of fire shall be reported to the local fire authority and shall be reported in writing to the director as soon as possible but not later than 10 calendar days following the occurrence. Any fire causing injury or death to a resident shall be reported within 24 hours of incident.(e) Smoking rules. Each SCF shall adopt, implement and enforce a smoking policy. The policy shall include the minimal provisions of NFPA 101, §18.7.4, or §32.7.4.(f) Fire extinguishing systems. Inspection, testing, and maintenance of fire-fighting equipment shall be conducted by each SCF.(1) Water-based fire protection systems. All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested and maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1998 edition.(2) Range hood extinguishers. Fire extinguishing systems for commercial cooking equipment, such as at range hoods, shall be inspected and maintained in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 1998 edition.(3) Portable fire extinguishers. Every portable fire extinguisher located in a SCF or upon SCF property shall be installed, tagged, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition.(A) Extinguishers in resident corridors must be spaced so that travel distance is not more than 75 feet. The minimum size of extinguishers must be either 2 1/2 gallon for water type of five pounds for ABC type. In large facilities, at least one portable Underwriters Laboratory or Factory Mutual-approved five-pound Class B:C dry chemical fire extinguisher, rechargeable type, is required in each laundry, kitchen and walk-in mechanical room.(B) Extinguishers must be surface wall-mounted or recessed in an approved cabinet where they are not subject to physical damage or dislodgement.(g) Fire protection and evacuation plan. A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §18.7, or §32.7. Copies of the plan shall be available to all staff.(1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the SCF in public areas that are readily visible to patients, residents, employees, and visitors.(2) Annual training. Each SCF shall conduct an annual training program for instruction of all personnel in the location and use of fire-fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(h) Fire drills. The SCF shall conduct fire drills on a regular basis.(1) For existing facilities which were licensed prior to the effective date of these rules, fire drills shall be conducted at least quarterly.(2) New facilities shall conduct fire drills as follows:(A) A LCF shall conduct fire drills quarterly for each shift.(B) A RBCF shall conduct fire drills quarterly with not less than two drills conducted during the night when residents are sleeping.(i) The drills may be announced in advance to the residents.(ii) The drills shall involve the residents, family, and staff in accordance with the emergency plan.(iii) Residents shall be informed of evacuation procedures and locations of exits.(3) All fire drills shall be documented on a form. There shall be an evaluation of each drill with respect to the fire plan.(4) The fire drill for a new facility classified as a LCF or a RBCF shall include communication of alarms, and use of fire-fighting equipments. The LCF drill may include simulation of evacuation of patients.(5) When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms in a LCF.(i) Fire alarm system.(1) For existing facilities which were licensed prior to the effective date of these rules, a fire alarm system must be provided only if required by local code, or under the applicable NFPA 101 occupancy category under which the facility was initially licensed.(2) For new facilities, all buildings used for resident care shall have an approved fire alarm system. Each fire alarm system shall be installed and tested in accordance with NFPA 101, §9.6, 1999 edition.(j) System for communicating an alarm of fire. A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department, required by NFPA 101, §§18.3.4.3, 32.2.3.4, or 32.3.3.4.(k) Fire department access. As an aid to fire department services, every SCF shall provide the following.(1) Driveways. The SCF shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Submission of plans. Upon request, the SCF shall submit a copy of the floor plans of the building to the local fire department officials.(3) Outside identification. The SCF shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(l) Fire department protection. When a SCF is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire. Source Note: The provisions of this §506.83 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES G SAFETY REQUIREMENTS AND FIRE PROTECTION §506.83 Fire Safety Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195341 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195341 03/12/2026 (a) General. When local regulations are in effect and enforced governing the construction of a SCF, the SCF shall be constructed in accordance with the local regulations. An existing SCF may voluntarily comply with any of the following requirements. (b) Existing special care facilities. In the absence of local regulations, an existing SCF shall comply with the following sections. (1) Compliance. (A) A licensed SCF which is licensed prior to the effective date of these rules is considered to be an existing licensed SCF and shall continue, at a minimum, to meet the licensing requirements under which it was originally licensed. (B) In lieu of meeting the requirements in subparagraph (A) of this paragraph, an existing licensed SCF may, instead, comply with National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), Chapter 33, Existing Residential Board and Care Facilities, or Chapter 19, Existing Health Care Occupancies. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471, or (800) 344-3555. (2) Remodeling and additions. All remodeling, renovations, additions and alterations to or relocation of an existing SCF shall be done in accordance with the requirements for new construction in subsection (c) of this section. When existing conditions make such changes impractical, the department may grant a conditional approval of minor deviations from the requirements of subsection (c) of this section, if the intent of the requirements is met and if the care, safety and welfare of residents will not be jeopardized. The operation of the SCF, accessibility of individuals with disabilities, and safety of the residents shall not be compromised by a condition(s) that is not in compliance with this chapter. (A) Building equipment alterations or installations. Any alteration or any installation of new building equipment, such as mechanical, electrical, plumbing, fire protection, or piped medical gas system shall comply with the requirements for new construction and may not be replaced, materially altered, or extended in an existing SCF until complete plans and specifications have been submitted to the department, and the department has reviewed and approved the plans and specifications in accordance with §125.94 of this title (relating to Preparation, Submittal, Review and Approval of Plans). (B) Minor remodeling or alterations. Minor remodeling or alterations within an existing SCF which do not involve alterations to load bearing members and partitions, change functional operation, affect fire safety, add or subtract services, or involve any of the major changes listed in subparagraph of this paragraph are considered to be minor projects and require evaluation and approval by the department. An SCF shall submit a written request for evaluation, a brief description of the proposed changes, and sketches of the area being remodeled or altered. Based on such submittal, the department will evaluate and determine whether any additional submittals or inspections are required. The department will notify the SCF of its decision.(C) Major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety, or add or delete services, are considered major projects. A SCF shall comply with this subparagraph prior to beginning construction of major projects. (i) Submittal of plans. Plans shall be submitted in accordance with §125.94 of this title for all major remodeling or alterations. (ii) Phasing of construction in existing facilities. Projects involving alterations of or additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions. (I) Access, exit access, fire protection and all necessary functions shall be maintained so that the safety of the occupants will not be jeopardized during construction. (II) Construction, dust, objectionable fumes and vapor barriers shall be provided to separate areas undergoing demolition and construction from occupied areas. (III) Temporary sound barriers shall be provided where intense, prolonged construction noises will disturb patients, residents or staff in the occupied portions of the building. (3) Previously licensed SCF. A previously licensed SCF that has been vacated for 12 months or longer or used for other purposes shall comply with all the requirements for new construction contained in subsection (c) of this section in order to be licensed. (c) Construction requirements for new SCFs. (1) SCF location. A SCF may be a distinct separate part of an existing hospital. It may occupy an entire separate independent structure, or it may be located within another building such as an office building or commercial building. (A) Accessibility to facility. The location of a proposed new SCF shall be easily accessible to service vehicles and fire protection apparatus. (B) Means of egress. A SCF shall have at least two exits remotely located in accordance with NFPA 101, §§18.2.4.1, 32.2.2.1, and 32.3.2.4. When a required means of egress from the SCF is through another portion of the building, that means of egress shall comply with the requirements of NFPA 101 which are applicable to the occupancy of the other building. Such means of egress shall be open, available, unlocked, unrestricted, and lighted at all times during the SCF hours of operation. (C) Hazardous locations. (i) Underground and above ground hazards. A new SCF or an addition(s) to an existing SCF shall not be constructed within 125 feet of a hazardous location or easement. Hazardous locations include underground liquid butane or propane, liquid petroleum or natural gas transmission lines, high-pressure lines, or under high voltage electrical lines. (ii) Fire hazards. A new SCF shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing areas. (iii) Health and safety hazards. A new SCF shall not be located in a building which, because of its location, physical condition, state of repair, or arrangement of facilities, would be determined hazardous to the health or safety of the resident. (D) Undesirable locations. (i) Nuisance producing sites. A new SCF shall not be located near nuisance producing sites such as industrial sites, feed lots, sanitary landfills, or manufacturing plants which produce excessive noise or air pollution. (ii) Flood plains. Construction of a new SCF shall be avoided in designated flood plains. Where such is unavoidable, access and required SCF components shall be constructed at least one foot above the designated flood plain. This requirement also applies to new additions to an existing SCF or a portion of facility which has been licensed previously as a SCF, but which has been vacated or used for other purposes. This requirement does not apply to remodeling of an existing licensed SCF. (iii) Cemeteries. A new SCF shall not be located near a cemetery in a manner that allows direct views of the cemetery from resident rooms, dining area, living areas or front entry of the facility. (2) SCF site. The SCF site shall include paved roads, walkways, and parking in accordance with the requirements set out in this paragraph. (A) Paved roads and walkways. (i) Paved roads shall be provided within lot lines for access from public roads to the main entrance and to service entrances. Gravel-based roads are permitted in rural areas. (ii) Finished surface walkways shall be provided for pedestrians. When public transportation or walkways serve the site, finished surface walkways or paved roads shall extend from the public conveyance to the building entrance. (B) Parking. (i) Off street parking shall be provided at the minimum ratio of one space for each four resident beds, one space for each daytime staff member, and one visitor space for every four resident beds, or per local code, whichever is more stringent. (ii) Handicapped parking. Parking spaces for handicapped persons shall be provided in accordance with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities. (3) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and local governing building codes. Where there is no local governing building code, the International Building Code (IBC), 2000 edition, or the International Residential Code (IRC) shall govern: The IBC and IRC are published by the International Code Council, 5203 Leesburg Pike, Suite 600, Falls Church, VA 22041, telephone (703) 931-4533. (A) General architectural requirements. All new construction, including conversion of an existing building to a SCF or establishing a separately licensed SCF within another existing building, shall comply with NFPA 101, Chapter 32, New Residential Board and Care Occupancies, or Chapter 18, New Health Care Occupancies, and this subchapter. (i) Construction types for multiple building occupancy. (I) Mixed occupancies. When a SCF is part of another occupancy, the SCF shall be separated from the other occupancy with a minimum of 2-hour fire rated construction, in accordance with NFPA 101, §18.1.2.3, and §32.1.2. (II) Small facility. When a SCF is classified as a small facility for residential board and care occupancy, the SCF shall comply with NFPA 101, §32.2.1.3, Minimum Construction Requirements. (III) Large facility. When a SCF is classified as a large facility for residential board and care occupancy, the SCF shall comply with NFPA 101, §32.3.1.3, Minimum Construction Requirements. (IV) Multistory buildings. When a SCF is located in a multistory building of two or more stories, the entire building shall meet the construction requirements of NFPA 101, §32.3.1.3, or §18.1.6.2. A SCF shall not be located in a multistory building that does not comply with the minimum construction requirements of NFPA 101, §18.1.6.2. or §32.3.1.3. (V) Single story buildings. When a SCF is part of a one-story building that does not comply with the construction requirements of NFPA 101, §§18.1.6.1, 32.2.1.3, or 32.3.1.3. The SCF must be separated from the remainder of the building with a 2-hour fire rated construction. The designated SCF portion shall have the construction type upgraded to comply with NFPA 101, §§18.1.6.1, 32.2.1.3, or 32.3.3.1.3, as applicable. (ii) Special design provisions. Special provisions shall be made in the design of a facility if located in a region where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, or floods. (iii) Foundations. Foundations shall rest on natural solid bearing if satisfactory bearing is available. Proper soil-bearing values shall be established in accordance with nationally recognized requirements. If solid bearing is not encountered at practical depths, the structure shall be supported on driven piles or drilled piers designed to support the intended load without detrimental settlement, except that one-story buildings may rest on a fill designed by a soils engineer. When engineered fill is used, site preparation and placement of fill shall be done under the direct full-time supervision of the soils engineer. The soils engineer shall issue a final report on the compacted fill operation and certification of compliance with the job specifications. (iv) Physical environment. A physical environment that protects the health and safety of resident, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the residents (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and the requirements of this chapter. (v) Handicapped requirements. Special considerations that benefit handicapped residents, staff, and visitors shall be provided. Each SCF shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36, Code of Federal Regulations, Chapter XI, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities. (vi) Other regulations. Certain projects may be subject to other regulations, including those of federal, state, and local authorities. The more stringent standard or requirement shall apply when a difference in requirements exists. (vii) Exceeding minimum requirements. Nothing in these sections shall be construed to prohibit a better type of building construction or otherwise safer conditions than the minimum requirements specified in these sections. (viii) Equivalency. Nothing in these sections is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, performance and safety to those prescribed by these sections, provided technical documentation which demonstrates equivalency is submitted to the department for approval. (ix) Separate freestanding buildings (not for resident use). Separate freestanding buildings for non-patient use which are located at least 20 feet from the SCF building such as the heating plant, boiler plant, repair workshops, or general storage may be designed and constructed in accordance with other applicable occupancy classification requirements listed in NFPA 101. (B) General detail requirements. (i) Corridors. The minimum clear and unobstructed width of a public corridor shall be at least four feet in a RBCF. In a LCF, the minimum clear and unobstructed width of public corridor shall be at least eight feet. (ii) Doors and windows. (I) Door types. Doors at all openings between corridors and rooms or spaces subject to occupancy shall be swing type. Elevator doors are excluded from this requirement. (II) Door swing. Doors, except doors to spaces such as small closets that are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the required corridor width. Large walk-in type closets are considered as occupied spaces. (III) Labeled doors. Labeled fire doors shall be listed by an independent testing laboratory and shall meet the construction requirement for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition. Reference to a labeled door shall be construed to include labeled frame and hardware. (IV) Glazing. Glass doors, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches above the finished floor shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings unless otherwise required for fire safety. Safety glass, tempered glass, or plastic glazing materials shall be used for shower doors, bath enclosures, interior windows, and doors (which have glazing). (V) Operable windows. All operable windows shall be insect screened. (iii) Ceiling heights. The minimum ceiling height shall be eight feet with the following exceptions. Ceilings in storage rooms, toilet rooms, and other minor rooms not meant for resident of public use shall be not less than seven feet six inches. (iv) Toilet room accessories. Grab bars shall be provided at resident showers and tubs. The bars shall be one and one-half inches in diameter, shall have one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars intended for use by the disabled shall also comply with ADA requirements. (v) Hand drying. Provisions for hand drying shall be included at all hand washing facilities. Hot air dryers or individual paper units shall be provided and must be enclosed in such a way as to provide protection against dust or soil. (vi) Rooms with heat producing equipment. Rooms containing heat producing equipment such as mechanical and electrical equipment and laundry rooms shall be insulated and ventilated to prevent floors of any occupied room located above it from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature. (C) General finish requirements. (i) Floor finishes. (I) General. Floor materials shall be easily cleanable, wear resistant, and appropriate for the location involved. In areas subject to frequent wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. Floors that are subject to traffic while wet, such as shower areas, shall have non-slip surfaces. (II) Threshold and expansion joint covers. Thresholds at doorways may not exceed 3/4 inch in height for exterior sliding doors or 1/2 inch for other type doors. Raised thresholds and floor level changes at accessible doorways shall be beveled with a slope no greater than 1:2. Expansion joint covers may not exceed 1/2 inch in height and shall have beveled edges with a slope no greater than 1:2. (ii) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall be in compliance with the requirements of NFPA 101, §18.3.3, and §32.3.3.3, relating to flame spread. (I) Finishes at plumbing fixtures. Wall finishes shall be water resistant in the immediate area of plumbing fixtures. (II) Wet cleaning methods. Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed; and without voids. (iii) Ceiling finishes. (I) General. All occupied rooms and spaces shall be provided with finished ceilings, unless otherwise noted. Ceilings that are a part of a rated roof and ceiling assembly or a floor-ceiling assembly shall be constructed of listed components (by a nationally recognized testing laboratory) and installed in accordance with the listing. (II) Special requirements. Finished ceilings may be omitted in mechanical and equipment spaces, shops, and similar spaces unless required for fire-resistive purposes. (iv) Floor, wall, and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed. (v) Cubicle curtains, draperies, and other hanging fabrics. Cubicle curtains, draperies, and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small scale and large scale test of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1996 edition. Copies of laboratory test reports for installed materials shall be submitted to the department at the time of the final construction inspection. (D) General mechanical requirements. This subparagraph contains requirements for mechanical systems; air-conditioning, heating and ventilating systems; steam and hot and cold water systems; plumbing fixtures; piping systems; and thermal and acoustical insulation. (i) Cost. All mechanical systems shall be designed for overall efficiency and life cycle costing, including operational costs. Recognized engineering practices shall be followed to achieve the most economical and effective results except that in no case shall patient care or safety be sacrificed for conservation. (ii) Equipment location. Mechanical equipment may be located indoors or outdoors (when in a weatherproof enclosure), or in a separate building(s). (iii) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc., connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators. (iv) Performance and acceptance. Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or his representative that the installation and performance of these systems conform to the requirements of the plans and specifications. (I) Material lists. Upon completion of the contract, the owner shall obtain from the construction contractor parts lists and procurement information with numbers and description for each piece of equipment. (II) Instructions. Upon completion of the contract, the owner shall obtain from the construction contractor instructions in the operational use and maintenance of systems and equipment as required. (v) Heating, ventilating, and air conditioning (HVAC) systems. (I) Code requirements. All central HVAC systems shall comply with and shall be installed in accordance with the requirements of NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 1999 edition, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, 1999 edition, as applicable and the requirements contained in this clause. Air handling units serving two or more rooms are considered to be central units. (-a-) Temperature and humidity. The indoor design temperature shall be 75 degrees Fahrenheit with relative humidity of not less than 30 percent. (-b-) Thermostat gauges. Thermostats shall be provided for all heating and cooling systems with an on and off switch. (-c-) Air handling duct requirements. Fully ducted supply, return and exhaust air systems shall be provided for all resident care areas. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted. (-1-) Protection of ducts penetrating fire and smoke partitions. Combination fire and smoke leakage limiting dampers (Class II) shall be installed in accordance with manufacturer's instructions for all ducts penetrating 1 and 2-hour rated fire and smoke partitions required by NFPA 101, §12-6.3.7, Subdivision of Building Space, (not required in SCFs meeting the provisions of NFPA 101, §12-6.3.7.3, Exception). (-2-) Fail-safe installation. Combination smoke and fire dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by NFPA 72, Chapter 5, National Fire Alarm Code, 1996 edition; NFPA 90A, Chapter 4; and NFPA 101, §12-6.3.7; by activation of the fire sprinkler system; and upon loss of electrical power. Smoke dampers shall not close by fan shut-down alone. This requirement applies to all existing and new installations. (-3-) Interconnection of air handling fans and smoke dampers. Air handling fans and smoke damper controls shall be interlocked so that closing of smoke dampers will not damage the ducts. (-4-) Frangible devices. The use of frangible (non-resetting) devices for shutting smoke dampers shall not be permitted. (-d-) Outside air intake locations. Outside air intakes shall be located at least 10 feet from exhaust outlets of ventilating systems, combustion equipment stacks, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require other arrangements). (-e-) Pressure relationship. Ventilation systems for a LCF shall be designed and balanced to provide pressure relationships contained in Table 1 of this title. For reductions and shut down of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 1 of this title shall be followed. (-f-) Duct linings. Friable internal linings shall not be used in ducts, air terminal units, or other air system components. This requirement shall not apply to air terminal units and sound attenuators that have approved nonfriable coverings, e.g., foil facing, over such linings. (II) Thermal and acoustical insulation for air handling systems. Asbestos containing insulation materials shall not be used. (-a-) Thermal duct insulation. Air ducts and casings with outside surface temperature below the ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation. (-b-) Insulation in air plenums and ducts. When installed, linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters' Laboratories, Inc., Standard 181, Factory-Made Duct Materials and Air Duct Connectors. This document may be obtained from the Underwriters' Laboratories, Inc., 333 Pfingsten Road, Northbrook, IL 60062-2096. (-c-) Insulation flame spread and smoke developed ratings. Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A, Chapters 2 and 3 and as determined by an independent testing laboratory in accordance with NFPA 255, A Standard Method of Test of Surface Burning Characteristics of Building Materials, 1999 edition. (-d-) Friable insulation. Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem or occupant discomfort. (vi) Piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the International Plumbing Code (IPC), 2000 edition. The IPC is published by the International Code Council, 5203 Leesburg Pike, Suite 600, Falls Church, VA 22041, telephone (703) 931-4533. (I) Water supply piping systems. Water supply piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand. (-a-) Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall be valved. Stop valves shall be provided at each fixture. (-b-) Backflow preventers. Backflow preventers (vacuum breakers) shall be installed on hose bibs, laboratory sinks, janitor sinks, bedpan-flushing attachments, and on all other fixtures to which hoses or tubing can be attached. Connections to high hazard sources, e.g., x-ray film processors, shall be from a cold-water hose bibb through a reduced pressure principle type backflow preventer (RPBFP). (-c-) Flushing valves. Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers. (-d-) Water storage tanks. Water storage tanks shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. (II) Fire sprinkler systems. When provided, fire sprinkler systems shall comply with the requirements of NFPA 101, §7-7, Automatic Sprinklers and Other Extinguishing Equipment, and the requirements of this subclause. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 edition, and shall be certified as required by §125.94 of this title (relating to Preparation, Submittal, Review and Approval of Plans). (vii) Steam and hot water systems. (I) Boilers. When provided, boilers shall have the capacity, based upon the net ratings published by the Hydronics Institute or another acceptable national standard, to supply the normal heating, hot water, and steam requirements of all systems and equipment. (-a-) Valves. Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment. (-b-) Boiler certification. When required, the SCF shall ensure compliance with Texas Department of Licensing and Regulation, Boiler Section, Texas Boiler Law, 1995 (Health and Safety Code, Chapter 755, Boilers), which requires certification documentation for boilers to be posted on site at each boiler installation. (II) Domestic hot water system. Hot water distribution system serving all resident care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet. (-a-) Capacity of water heating equipment. Water heating equipment shall have sufficient capacity to supply water for all residents' needs based on accepted engineering practices using actual number and type of fixtures and for heating, when applicable. (-b-) Water temperature measurements. Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment. Hot water temperature at point of use for residents, staff and visitors shall not exceed 110 degrees Fahrenheit. (viii) Drainage systems. Building sewers shall discharge into a community sewage system. Where such a system is not available, a facility providing sewage treatment must conform to applicable local and state regulations. (I) Above ground piping. Soil stacks and roof drains installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or Schedule 40 polyvinyl chloride (PVC) pipe. In LCF schedule 40 polyvinylchloride (PVC) pipe is not permitted. (II) Underground piping. All underground building drains shall be cast iron soil pipe, hard temper copper tube (DWV or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), or PVC pipe (DWV Schedule 40 or heavier. Underground piping shall have at least 12 inches of earth cover or comply with local codes. (ix) Thermal insulation for piping systems and equipment. Asbestos containing insulation materials shall not be used. (I) Insulation. Insulation shall be provided for the following: (-a-) boilers, smoke breeching, and stacks; (-b-) steam supply and condensate return piping; (-c-) hot water piping and all hot water heaters, generators, converters, and storage tanks; (-d-) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; and (-e-) other piping, ducts, and equipment as necessary to maintain the efficiency of the system. (II) Flame spread. Flame spread shall not exceed 25 and smoke development rating shall not exceed 50 for pipe insulation as determined by an independent testing laboratory in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 1996 edition. (x) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive, acid resistant materials and shall comply with the requirements of the International Plumbing Code, 2000 edition, and this clause. (I) Sink and lavatory controls. All lavatories used by residents and staff shall be trimmed with valves or electronic controls. (II) Back flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized. (III) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages. (IV) Under counter piping. Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of the floor below the equipment. (E) General electrical requirements. All electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the NFPA 70, National Electrical Code, 1999 edition, NFPA 99, 1999 edition, the requirements of this subparagraph; and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturer's instructions. (i) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition. (ii) Extension cords and cables shall not be used for permanent wiring. (iii) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater. (iv) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70. (v) Under-counter electrical installations shall be arranged (raised) to not interfere with cleaning of the floor below the equipment. (vi) Installation testing and certification. The electrical installations, including grounding continuity, fire alarm, and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional. A written record of performance tests on special electrical systems and equipment must show compliance with applicable codes and standards and shall be available to the department upon request. (vii) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment. (viii) Services and switchboards. Main switchboards shall be located in an area separate from plumbing and mechanical equipment and shall be accessible to authorized persons only. Switchboards shall be convenient for use, readily accessible for maintenance, away from traffic lanes, and located in dry, ventilated spaces free of corrosive or explosive fumes, gases, or any flammable material. Overload protective devices must operate properly in ambient temperatures. (ix) Panelboard. Distribution panels containing circuit breakers that control lighting and power to essential and normal electrical circuits shall be located within the SCF. (x) Wiring. When a SCF provides an essential electrical system all conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in metal or metallic raceways in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300. (xi) Lighting. (I) In LCF lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IES) Handbook published by the Illuminating Engineering Society of North America, 120 Wall Street, New York, NY 10025-4001. (-a-) Consideration should be given to controlling light intensity and wavelength to prevent harm to the patient's eyes. (-b-) Approaches to buildings and parking lots, and all spaces within buildings shall have fixtures that can be illuminated as necessary. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all spaces shall be clearly visible. (II) Means of egress and exit sign lighting intensity shall comply with NFPA 101, §§5-8, 5-9 and 5-10. (III) Electric lamps which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields. (xii) Receptacles. (I) Appliances shall be grounded in accordance with NFPA 99, Chapter 9. (II) A minimum of one duplex receptacle in each wall shall be installed in each work area or room other than storage or lockers. Each examination and work table shall have access to a minimum of two duplex receptacles. (xiii) Grounding requirements. Fixed electrical equipment shall be grounded in accordance with the requirements of NFPA 99, §3-3.1.2, and NFPA 70, Article 517-13. (xiv) Nurses calling systems. (I) An audible voice two way communication nurse call system shall be provided in a SCF when it is classified as a LCF. The audible signal shall sound at a nurse station or similar control station. (II) Distinct visible and audible signals shall be activated in the nurse's duty station, lounge, and workroom, soiled workroom and clean workroom. (xv) Essential electrical system (EES). When SCF provides or requires an essential electrical system, the EES system shall comply with the requirements of NFPA 99, §3-5. A Type I EES shall be provided for LCF when patients require the use of life-support systems. (xvi) Fire alarm system. A fire alarm system which complies with the requirements of NFPA 101, §§12-6.3.4, 32.2.3.4.1, 32.3.3.4.1, NFPA 70, Article 760; and NFPA 72, Chapter 3, shall be provided in each facility. (I) Fire alarm system shall be installed by or under direct supervision of a fire alarm installer licensed by the State Fire Marshal. (II) The SCF shall submit a copy of the Fire Alarm Installation Certificate (State Fire Marshal's form FML 009 040392) to the department for all new installations and for any material changes to the existing systems. Source Note: The provisions of this §506.91 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.91 Construction Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195342 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195342 03/12/2026 (a) Administration and public suite.(1) Entrance. Entrances shall be located at grade level, be accessible to individuals with disabilities, and protected against inclement weather. When an SCF is located on a floor above grade level, elevators shall be accessible and shall meet the requirements of §125.93 of this title (relating to Elevators).(2) Waiting area. A waiting area or foyer shall be provided which includes having access to the following rooms and items:(A) public toilet facilities; and(B) telephone(s) for public use.(3) General or individual office(s). An office(s) shall be provided for business transactions, records, and administrative and professional staff.(4) Resident records area. Resident record storage space shall be located within a secure designated area under direct visual supervision of administrative staff.(b) Dietary suite. In addition to the requirements of §125.32(d) of this title (relating to Resident Care and Services), the facility shall provide the following.(1) Dining area for ambulatory patients, staff, and visitors. A dining area for ambulatory patients, staff, and visitors with a minimum floor space of 15 square feet per person to be seated shall be provided. The footage requirement does not include serving area. The dining area and service areas shall be separate from the food preparation and distribution area.(2) Food service for a 50-bed residence or more. The food service for a 50-bed residence or more shall be provided by an on-site food preparation system or an off-site food service system or a combination of the two. The following minimum functional elements shall be provided on-site regardless of the type of dietary services.(A) Receiving area. A receiving area shall be provided and shall have direct access to the outside for incoming dietary supplies or off-site food preparation service and shall be separate from the general receiving area. The receiving area shall contain a control station and an area for breakout for loading, unloading, uncrating, and weighing supplies. The entrance area to the receiving area shall be covered from the weather.(B) Storage spaces. Storage spaces shall be convenient to receiving area and food preparation area and shall be located to exclude traffic through the food preparation area. Regardless of the type of food services provided, the facility shall provide storage of food for emergency use for a minimum of four calendar days.(i) Storage space(s) shall be provided for bulk, refrigerated, and frozen foods.(ii) A cleaning supply storage room or closet shall be provided to store non-food items that might contaminate edibles. This storage area may be combined with the housekeeping room.(C) Counter space. Counter space shall be provided for food prep work, equipment, and an area to assemble trays for distribution for patient meals.(D) Hand washing fixtures. Hand washing fixtures with hands-free operable controls shall be conveniently located at all food preparation area and serving areas.(E) Cart distribution system. When a cart distribution system is provided, space shall be provided for storage, loading, distribution, receiving, and sanitizing of the food service carts. The cart traffic shall be designed to eliminate any danger of cross-circulation between outgoing food carts and incoming soiled carts, and the cleaning and sanitizing process. Cart circulation shall not be through food processing areas.(F) Ware washing room. A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross traffic between "dirty side and "clean side" of the dish wash areas shall be provided.(G) Three-compartmented sink. A three-compartmented sink of adequate size for pot washing shall be provided convenient to the food preparation area. It shall have direct access to the SCF waste collection and disposal facilities.(H) Food waste storage room. A food waste storage room shall be conveniently located to the food preparation and ware washing areas but not within the food preparation area. It shall have direct access to the SCF waste collection and disposal facilities.(I) Storage areas and sanitizing facilities. Storage areas and sanitizing facilities for garbage or refuse cans, carts, and mobile tray conveyors shall be provided. All containers for trash storage shall have tight-fitting lids.(J) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the dietary department. Where hot water or steam is used for general cleaning, additional space within the room shall be provided for the storage of hoses and nozzles.(K) Dietary office. An office shall be provided for the use of the food service manager or the dietary service manager. In smaller facilities, a designated alcove may be located in an area that is part of the food preparation area.(L) Toilet room. A toilet room shall be provided for the exclusive use of the dietary staff. Toilets shall not open directly into the food preparation areas, but must be in a close proximity to them. For larger facilities, a locker room or space for lockers shall be provided for staff belongings.(M) Additional service areas, rooms and facilities. When an on-site food preparation system is used, in addition to the items required in subparagraphs (A) - (L) of this paragraph, the following service areas, rooms, and facilities shall be provided.(i) When food preparation systems are provided, there shall be space and equipment for preparing, cooking, and baking.(ii) A patient tray assembly and distribution area shall be located within close proximity to the food preparation and distribution areas.(iii) When food is prepared on-site, the storage room shall be adequate to accommodate food for a seven-calendar day menu cycle.(iv) An additional room(s) shall be provided for the storage of clean cooking wares, extra trays, flatware, plastic and paper products, and portable equipment.(v) Provisions shall be made for drying and storage of pots and pans from the pot washing room or area.(N) Details.(i) Food storage shelves shall not be less than four inches above the finished floor and the space below the bottom shelf shall be closed in and sealed tight for ease of cleaning.(ii) Operable windows and doors not equipped with automatic closing devices shall be equipped with insect screens.(iii) Food processing areas in the central dietary kitchen shall have ceilings height not less than nine feet. In a facility classified as a RBCF, ceiling height shall not be less then eight feet. Ceiling mounted equipment shall be supported from rigid structures located above the finished ceilings.(iv) Mirrors shall not be installed at hand washing fixtures in the food preparation areas.(O) Finishes.(i) Floors in areas used for food preparations, food assembly, and soiled and clean ware cleaning shall be water-resistance and greaseproof. Floor surfaces, including tile joints, shall be resistant to food acids.(ii) Wall bases in food preparation, food assembly, soiled and clean ware cleaning and other areas which are frequently subject to wet cleaning methods shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and be impervious to water.(iii) In the dietary and food preparation areas, the wall construction, finishes, and trims, including the joints between the wall and the floor, shall be free of voids, cracks, and crevices.(iv) The ceiling in food preparation and food assembly areas shall be washable. Smooth moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid.(v) The ceiling in the soiled and clean ware cleaning area shall be monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish.(c) Laboratory suite. When a laboratory is located on-site the following minimum items shall be provided:(1) a room with work counter, utility sink, and storage cabinets or closet(s); and(2) specimen collection facilities. For dip stick urinalysis, urine collection rooms shall be equipped with water closet and lavatory. Blood collection facilities shall have space for a chair, work counter and hand washing facilities.(d) Laundry and linen storage and processing suite. Clean linen shall be available in a quantity sufficient to meet the needs of the residents. Clean linens shall be stored in clean linen storage areas.(1) The SCF shall provide an area or room with a washer and dryer for resident use.(2) In a facility classified as a large RBCF or a LCF, soiled and clean processing operations shall be separated and arranged to provide a one-way traffic pattern from soiled to clean areas. The following rooms and items shall be provided:(A) a soiled linen processing room which includes areas for receiving, holding, sorting, and washing;(B) a clean linen processing room which includes areas for drying, sorting, folding, and holding prior to distribution;(C) supply storage cabinets in the soiled and clean linen processing rooms;(D) hand washing facilities within the soiled linen processing room; and(e) Medication room. The medication room shall be in compliance with the spatial and security requirements under §125.32(c)(7)(D) of this title.(f) Resident bedroom suite.(1) Bedrooms shall be arranged and equipped for adequate delivery of services and for comfort and privacy.(2) Useable bedroom clear floor space shall be not less than 80 square feet for a one-bed room and not less than 60 square feet (40 square feet where bassinets or cribs are used) per bed for a multiple-bed room. Larger rooms are recommended for those residents needing nursing care. A bedroom shall be not less than eight feet in the smallest dimension.(3) No more than four beds shall be in any bedroom.(4) In the bedrooms and for each resident there shall be a bed, chair, table, dresser, and closet space or wardrobe providing security and privacy for clothing and personal belongings.(5) Each resident bedroom shall have at least one operable outside window that can be readily opened from the inside without the use of tools. The height of the windowsill shall not exceed 36 inches from the floor. Operable window sections may be restricted for security or safety reasons, but the required one operable section shall not be restricted to less than six inches. Each window shall be provided with a flame-retardant shade, curtain, or blind.(6) All resident rooms shall open upon an egress corridor leading to an exterior exit either by stairway or a door opening to the exterior.(7) All resident rooms shall be arranged for convenient and sheltered resident access to living or public areas, restrooms, and dining facilities.(g) Resident toilet and bathing facilities.(1) If the SCF houses both male and female residents, all bedrooms shall have separate private, connecting, or general toilet rooms for each sex. The general toilet room or bathing room shall be accessible from a corridor or public space. A lavatory shall be readily accessible to each water closet. The facility shall provide at least one full bath on each resident sleeping floor.(2) One water closet and one lavatory shall be provided for each four residents or fraction thereof. One tub or one shower shall be provided for each six residents or fraction thereof.(3) Privacy partitions and shields shall be provided at water closets and bathing units in rooms for multi-resident use.(4) A public or staff toilet, commode and lavatory, complying with accessibility standards, is required for every facility up to and including 50 beds. Facilities over 50 beds must have separate public toilets and staff toilets (this is in addition to the staff toilet(s) required for the dietary staff).(5) All bathrooms, toilet rooms, and other odor-producing rooms shall be ventilated with operable windows or powered exhaust to the exterior for order control.(6) Soap and towel dispensers shall be provided at all hand washing facilities.(h) Recreation, living, or day room.(1) Recreation, living, or day room space and furniture shall be provided to allow seating of residents. Each facility shall have at least one space of not less than 144 square feet. A facility with a capacity of nine or more residents shall provide a space of 10 square feet more per resident in addition to the 144 square feet minimum.(2) At least one of the recreation, living, or day room areas shall have exterior windows providing a view to the outside.(i) Additional service areas.(1) Janitor's closet. A sufficient number of janitor closets shall be provided throughout the facility to maintain a clean and sanitary environment. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment.(2) Storage room. A resident storage room shall be a minimum of 50 square feet per six resident beds or fraction thereof.(3) Medical gas storage room. When provided or required by National Fire Protection Association 101, (NFPA 101), Code for Safety to Life from Fire in Buildings and Structures, 2000 edition, a medical gas storage room shall comply with the requirements of NFPA 99, Chapter 4-4, Gas and Vacuum Systems. All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, 25 West 43rd Street, New York, N.Y. 10036. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471, or (800) 344-3555.(4) Area for emergency crash cart, if provided. An area or alcove located out of traffic and conveniently located near medication room or similar staff control room shall be provided for an emergency crash cart.(5) Medical waste processing. Space and facilities shall be provided for the safe storage and disposal of waste as appropriate for the material being handled and in compliance with all applicable rules and regulations. Source Note: The provisions of this §506.92 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.92 Minimum Spatial Requirements for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195343 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195343 03/12/2026 (a) General. All buildings that have resident services located on other than the main entrance floor shall have electric or electro hydraulic elevators. The elevators shall be installed in sufficient quantity, capacity, and speed to ensure that the average interval of dispatch time will not exceed one minute, and average peak loading can be accommodated.(b) Requirements for new elevators. New elevators shall be installed in accordance with the requirements of Health and Safety Code (HSC), Chapter 754, Elevators, Escalators, and Related Equipment, and ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 1996 edition, published by the American Society of Mechanical Engineers and the American National Standards Institute. All new elevators shall conform to the Fire Fighters' Service Requirements of ASME/ANSI A17.1, in accordance with National Fire Protection Association 101, (NFPA 101), Code for Safety to Life from Fire in Buildings and Structures, 2000 edition, §7-4.4. All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, 25 West 43rd Street, New York, N.Y. 10036. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471, or (800) 344-3555.(c) Requirements for existing elevators. Existing elevators shall comply with the ASME/ANSI A17.1, Part XII, Alterations, Repair, Replacements, and Maintenance, and ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, current edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3, as required by NFPA 101, §7-4.5.(d) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air-conditioning systems with the capability to maintain an operating temperature during fire fighter service operations. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall also be connected to standby power. These requirements are not applicable to existing elevators.(e) Elevator car size. Minimum elevator car size shall be five feet wide and five feet deep. A minimum LCF elevator car size shall be five feet wide and eight feet deep.(f) Elevator and elevator shaft doors. When light beams are used for operating door-opening devices, the beams shall be used in combination with door edge devices and shall be interconnected with a system of smoke detectors. The light control feature shall be disengaged when smoke is detected in any elevator lobby.(1) The smallest elevator car door opening shall be at least three feet wide and seven feet high.(2) The elevator car door opening for a LCF elevator shall be at least four feet wide and seven feet high.(3) The elevator cars for LCF shall be at least five feet by eight inches wide by eight feet six inches deep.(g) Type of controls and alarms. Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.(h) Leveling. All elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of one-half inch.(i) Operation. All elevators, except freight elevators, shall be equipped with a two-way key operated service switch permitting cars to bypass all landing button calls and be dispatched directly to any floor.(j) Accessibility of controls and alarms. Elevator controls, alarm buttons, and telephones shall be accessible to wheelchair occupants in accordance with the Americans with Disabilities Act.(k) Location. Elevators shall not open to an exit.(l) Testing. An SCF shall have all elevators and escalators routinely and periodically inspected and tested in accordance with ASME/ANSI A17.1. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101, §7-4.8, Elevator Testing.(m) Certification. An SCF shall obtain a certificate of inspection evidencing that the elevators and related equipment were inspected in accordance with the requirements in HSC, Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under HSC, §754.014, administered by the Texas Department of Licensing and Regulation. The certificate of inspection shall be on record in each center. Source Note: The provisions of this §506.93 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.93 Elevators https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195344 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195344 03/12/2026 (a) Compliance.(1) When local regulations are in effect and enforced governing the construction of a new SCF or the renovation or modification of an existing SCF, the SCF shall be constructed in accordance with the local regulations and submission of construction documents to the department is not required. An SCF may voluntarily submit construction documents to the department.(2) In the absence of local regulations, a new or existing SCF shall comply with the following subparagraphs (A) - (E) of this paragraph, and subsections (b) - (e) of this section.(A) Facility owners or operators may not begin construction of a new building or additions to or renovations or conversions of existing buildings until final construction documents are reviewed and approved by the department.(B) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers.(C) A program narrative shall be prepared in accordance with subsection (b) of this section and submitted to the department at the time of the submission of the Application for Plan Review.(D) Preliminary plans shall be prepared and submitted in accordance with subsection (c) of this section.(E) Final plans and specifications shall be prepared and submitted in accordance with subsection (d) of this section.(b) Functional program narrative. The facility shall provide a functional program narrative presented on facility letterhead and signed by facility administration. The narrative shall include the functional description of each space and the following:(1) departmental relationships, number of patient beds in each category, and other basic information relating to the fulfillment of the facility's objectives;(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, types of equipment required, interrelationship of various functions and spaces;(3) energy conservation measures, included in building, mechanical and electrical designs; and(4) the type of construction (existing or proposed) as stated in §18-1.6.2, or §32.1.1.3, National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, (800) 344-3555.(c) Preliminary documents. Preliminary documents shall consist of a functional program narrative, preliminary plans, and outline specifications. These documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, bed count and services, and the usage of all spaces, areas, and rooms on every floor level.(1) Preparation of preliminary plans. Preliminary plans shall be of a sufficiently large scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. Preliminary plans shall provide the following information.(A) Floor area and bed distribution. The total floor area on each level involved in construction, together with the proposed bed distribution, shall be shown on the drawings.(B) Floor plan. Each floor plan shall indicate and identify all individual spaces, doors, windows and means of egress.(C) Existing floor plan. An overall floor plan showing existing spaces, smoke partitions, smoke compartments, and exits and their relationship to the new construction shall be submitted on all renovations or additions to an existing facility. Plans for remodeling of spaces above or below the level of discharge shall include the level of discharge floor plan, showing all exits at that level. When there are two different levels of discharge, plans for both levels shall be submitted.(D) Construction type and fire rating. Building sections shall be provided to illustrate construction type and fire protection rating. Section(s) shall be drawn at a scale sufficiently large to clearly present the proposed construction system.(E) Area map. A map of the area within a two mile radius of the facility site shall be provided and any hazardous and undesirable location noted in §125.91(c) of this title (relating to Construction Requirements) shall be identified.(F) Site plan. A site plan shall be submitted and shall indicate the location of the proposed building(s) in relation to property lines, existing buildings or structures, access and approach roads, and parking areas and drives. Any overhead or underground utilities or service lines shall also be indicated.(G) Outline specifications. Outline specifications shall provide a general description of the construction, materials, and finishes that are not shown on the drawings.(2) Submission of preliminary plans. One set of preliminary plans, outline specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings, a functional program narrative, a completed and signed Application for Plan Review, and the applicable plan review fee in accordance with §125.15 of this title (relating to Fees) shall be submitted to the Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756, for review and approval. For convenience, preliminary plans may be reduced for preliminary submittal. The cost of submitting plans and specifications shall be borne by the sender.(3) Preliminary plan review. All deficiencies noted in the preliminary plan review shall be satisfactorily resolved.(d) Construction documents. Construction documents or final plans and specifications shall be submitted to the department for review and approval prior to start of construction. All final plans and specifications shall be appropriately sealed and signed by a registered architect and a professional engineer licensed by the State of Texas.(1) Preparation of construction documents. Construction documents shall be well prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, and shall include all necessary explanatory notes, schedules, and legends and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All rooms shall be identified by usage on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural plans. Architectural drawings shall include the following:(i) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, walks, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided;(ii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces;(iii) schedules of doors, windows, and finishes;(iv) elevations of each facade;(v) sections through building; and(vi) scaled details as necessary.(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways):(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.(C) Equipment drawings. Equipment drawings shall include the following:(i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility;(ii) fixed equipment (equipment which is permanently affixed to the building or which must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term "fixed equipment" includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets);(iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term "moveable equipment" includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and(iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings. Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings. Documentation for selection of the type of heating and cooling system based on requirements contained in §125.91(c)(3)(D) of this title shall be included with the mechanical plans. Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g. corridor, patient room, operating room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) drain piping systems (waste and soiled piping systems, roof drain systems);(v) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment); and(vi) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct mounted smoke detectors.(F) Electrical drawings. Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections;(ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches and equipment which require permanent electrical connections, on plans of each building level;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;(II) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices and the room number where each device is located; and(vi) schedules of all panels indicating connected load at each panel.(2) Final plan review. All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.(3) Construction approval. Construction shall not begin until written approval by the department is received by the owner of the facility.(4) Construction document changes. Any changes to construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications.(e) Special submittals.(1) Designer certified construction documents. In an effort to shorten the plan review and approval process, design professionals may submit, at the discretion of the department, a set of final construction documents, the department's completed checklist of licensing requirements and a certification letter which states that the plans and specifications, based on the department's checklist comply with the requirements of this chapter. Project certification forms shall be signed by the licensee or applicant and the architect(s) and engineer(s) of record.(2) Fast-track projects. Submittal of fast-track projects shall be at the discretion of the department and shall be submitted in not more than three separate packages.(A) First package. The first package shall include:(i) a map showing the location of the proposed facility site and adjacent surrounding area at least two miles in radius identifying any hazardous and undesirable location noted in §125.91(c) of this title;(ii) preliminary architectural plans and a detailed building site plan showing all adjacent streets, site work, underslab mechanical, electrical, and plumbing work, and related specifications; and(iii) foundation and structural plans.(B) Second package. The second package shall include complete architectural plans and details with specifications and fire safety plans as described in subsection (c) of this section.(C) Third package. The third package shall include complete mechanical, electrical, equipment and furnishings, and plumbing plans and specifications, as described in subsection (c) of this section.(3) Fire sprinkler systems. Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler systems, 1999 edition. Fire sprinkler systems shall be designed or reviewed by an engineer who is registered by the Texas State Board of Registration for Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(A) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§8-1, 8-2 and 8-3, for new fire sprinkler systems, alterations of and additions to existing ones.(B) Certification of changes in an existing system is not required when relocation of not more than twenty sprinkler heads is involved.(C) One set of fire sprinkler working plans (sealed by the engineer), calculations and water supply information shall be forwarded to the department together with the engineer's certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation.(D) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(f) Resubmittal of construction documents. When construction is delayed for longer than one year from the plan approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new Application for Plan Review and a plan review fee.(g) Project delay or cancellation. The licensee or owner shall provide written notification to the department when a project has been placed on hold, canceled or abandoned.(h) On-hold projects. The department may close a project file after one year of its receipt of an Application for Plan Review for projects that have been placed on hold. Source Note: The provisions of this §506.94 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.94 Preparation, Submittal, Review and Approval of Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195345 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195345 03/12/2026 (a) Construction.(1) Major construction. Construction, of other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate plan review fee, according to the plan review schedule in §125.15 of this title (relating to Fees), has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) Construction commencement notification. The architect of record or the licensee or applicant shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules.(3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) Construction inspections. All facilities including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §1395 et seq.), are subject to construction inspections.(1) Number of construction inspections. A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with subchapters G and H of this chapter and the approved plans and specifications. The final plan approval letter will inform the architect of record and the owner as to the minimum number of inspections required for the project.(2) Requesting an inspection. The architect of record or the licensee shall request a inspection by submitting an Application for Inspection and the construction inspection fee in accordance with §125.15(d) of this title for each intermediate inspection, final inspection, and reinspection requested. Inspection requests by contractors will not be honored.(A) The architect of record or the licensee shall request an intermediate construction inspection to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate inspection, however ceilings should not be installed.(B) The architect of record or the licensee shall request a final construction inspection at 100% completion. One-hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Reinspection. Depending upon the number and nature of the deficiencies cited during the final inspection, the surveyor may require that an inspection be conducted to confirm correction of all deficiencies cited. The request for re-inspection shall be submitted in accordance with paragraph (2) of this subsection.(c) Approval of project. Patients shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.(1) Documentation requirements. The licensee shall submit the following documents to the department before the project will be approved:(A) written approval of the project by the fire authority;(B) a certificate of occupancy for the project issued by the local building authority;(C) written certification by the engineer, stating that the fire sprinkler system is installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 edition, if applicable;(D) fire alarm system certification (form FML-009 040392 of the Office of the State Fire Marshal), if applicable;(E) a written plan of correction signed by the licensee for any deficiencies noted during the final inspection;(F) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. Provide a signed letter or statement corroborating the installation of the product in the project;(G) a copy of documentation indicating that draperies, curtains, and other similar loosely hanging furnishings and decorations are flame resistant as demonstrated by passing both the small and large-scale tests of National Fire Protection Association (NFPA) 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition, as required by NFPA 101, Code for Safety to Life from Fire in Buildings and Structures, §18-7.5, and provide a signed letter or statement corroborating the installation of the product in the project. All documents published by NFPA as referenced in these rules may be obtained by writing or calling the NFPA, 1 Batterymarch Park, Quincy, MA 02169-7471, or (800) 344-3555.(H) a Final Construction Approval form signed by the licensee; and(I) any other documentation or information required due to the type of the project.(2) Verbal occupancy approval.(A) If, during the final inspection, the surveyor finds only a few minor deficiencies that do not jeopardize resident health, safety and welfare, the surveyor may grant verbal approval for occupancy contingent upon the documents listed in paragraph (1)(A)-(E) of this subsection being provided to and approved by the surveyor at the time of the final inspection.(B) Verbal occupancy approval allows the licensee to occupy the project. However, the licensee must submit the documents required in paragraph (1)(F)-(I) of this subsection before the project receives final approval.(3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, the department will issue final approval of the project. Source Note: The provisions of this §506.95 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.95 Construction, Inspections, and Approval of Projects for New or Existing Facilities in the Absence of Local Codes and Regulations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195346 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195346 03/12/2026 Table 1. Ventilation Requirements for LCF Facilities.Attached Graphic Source Note: The provisions of this §506.96 adopted to be effective July 25, 2004, 29 TexReg 6911; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2467. 1 HEALTH AND HUMAN SERVICES COMMISSION 506 SPECIAL CARE FACILITIES H PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §506.96 Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227170 03/12/2026 (a) The chapter's purpose is to implement Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities), which requires an end stage renal disease facility providing routine, repetitive, outpatient dialysis to be licensed by the Texas Health and Human Services Commission.(b) This chapter provides minimum standards for:(1) equipment used by the facility;(2) water treatment and reuse;(3) sanitary and hygienic conditions;(4) quality assessment and performance improvement;(5) indicators of quality of care;(6) provision and coordination of treatment and services;(7) professional staff qualifications and supervision, including physicians and other personnel;(8) clinical records, curricula, and instructors used to train dialysis technicians;(9) competency evaluation of dialysis technicians;(10) enforcement standards;(11) fire prevention and safety requirements; and(12) physical plant and construction requirements.(c) Compliance with this chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, standards, rules, regulations, and ordinances. The more stringent standard, code, or requirement shall apply when a difference in requirements exists. Source Note: The provisions of this §507.1 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES A GENERAL PROVISIONS §507.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227171 03/12/2026 The following words and terms when used in this chapter have the following meanings, unless the context clearly indicates otherwise.(1) Action level--The point at which end stage renal disease (ESRD) facility staff shall take steps to interrupt the trend towards unacceptable levels.(2) Administrator--An individual responsible for implementation and proper application of policies, programs, and services established for the ESRD facility.(3) Advanced practice registered nurse (APRN)--A registered nurse authorized by the Texas Board of Nursing to practice as an advanced practice registered nurse in Texas. The term includes a nurse practitioner and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner" and "advanced practice nurse."(4) Adverse event--An event that results in unintended harm to the patient because of an act of commission or omission by the ESRD facility or ESRD facility staff rather than by the patient's underlying disease or condition or those events affecting patient's family members, visitors, or staff.(5) Applicant--The person who seeks an ESRD facility license from the Texas Health and Human Services Commission (HHSC) and is legally responsible for the ESRD facility's operation, whether by lease or ownership.(6) Architectural inspection--An inspection HHSC conducts to ensure compliance with all applicable federal and state regulations relating to the ESRD facility physical plant and to verify project construction aligns with submitted contract construction documents.(7) Audio-only telecommunication--An interactive, two-way audio communication that uses only sound and that meets the privacy requirements of the federal Health Insurance Portability and Accountability Act. Audio-only includes the use of telephonic communication.(8) Biofilm--A coating on surfaces consisting of microcolonies of bacteria embedded in a protective extracellular matrix. The matrix, a slimy material secreted by the cells, protects the bacteria from antibiotics and disinfectants.(9) Business day--Any weekday from Monday through Friday that is not a state or national holiday listed in Texas Government Code §662.003.(10) Calendar day--All days, including weekends and holidays.(11) Caregiver--A person trained, qualified, and competent in using a device for the selected modality prescribed to the patient.(12) Charge nurse--A practicing licensed registered nurse in accordance with applicable provisions of law who is responsible for making daily staff assignments based on patient needs, providing immediate supervision and support of patient care, monitoring patients for changes in condition, and communicating with the physician, dietitian, and social worker regarding patient needs.(13) Closed system--A dialysis system for hemodialysis or peritoneal dialysis, that uses sterile manufactured bagged dialysate or dialysate solution.(14) CMS--Centers for Medicare and Medicaid Services.(15) Competency--Demonstrated ability to carry out specified tasks or activities with reasonable skill and safety that adheres to the prevailing standard of practice.(16) Conditions for Coverage (CfCs)--The minimum health and safety rules that all Medicare and Medicaid participating ESRD facilities must meet. The basic health and safety requirements that an ESRD facility must meet to receive payment from the Medicare program.(17) Conventional dialysis system--The ESRD facility's water treatment components and single pass dialysis machines.(18) Core staff members--The ESRD facility's medical director, supervising nurse, dietitian, social worker, administrator, and approved biomedical representative.(19) Corrective action plan--An alternative to enforcement action, as outlined in Texas Health and Safety Code §251.061 (relating to Corrective Action Plan).(20) Delegation--Transfer of the authority to perform a selected task or activity in a selected situation to a qualified and properly trained individual.(21) Dialysate--An aqueous fluid made from water and concentrate, containing electrolytes and usually dextrose that exchanges solutes with blood during hemodialysis that is delivered to the dialyzer by the dialysate supply system. This term does not include peritoneal dialysis fluid.(22) Dialysate supply system--Devices that prepare dialysate on line from water and concentrates, or store and distribute premixed dialysate; circulate the dialysate through the dialyzer; monitor the dialysate for temperature, conductivity, pressure, flow, and blood leaks; and prevent dialysis during disinfection or cleaning modes. The term "devices" as used in this definition includes reservoirs; conduits; proportioning devices for the dialysate; monitors and associated alarms; and controls assembled as a dialysate supply system. The dialysate supply system is often an integral part of single patient dialysis machines.(23) Dialysis--A process to remove dissolved substances from a patient's body by diffusion, osmosis, and convection (ultrafiltration) from one fluid compartment to another across a semipermeable membrane.(24) Dialysis technician--An individual who is not a registered nurse or physician and provides dialysis care under the supervision of a registered nurse or physician. This individual may also be known as a Patient Care Technician (PCT) or Certified Clinical Hemodialysis Technician (CCHT).(25) Dietitian--An individual who:(A) is currently licensed by the Texas Department of Licensing and Regulation under the laws of this state as a licensed dietitian;(B) is a registered dietitian; and(C) has one year of experience in clinical dietetics after becoming a registered dietitian.(26) Direct care staff--Staff who provide hands-on dialysis care to specifically assigned patients during their dialysis treatment (e.g., registered nurse, licensed vocational nurse, patient care technician). These staff members fulfill the patient to staff ratio requirement. (27) Education--Presenting and teaching informative materials, including to licensed ESRD facility's patients, about treatment modalities, options, and overall health literacy. An ESRD facility may conduct education individually or in a group setting.(28) Empty bed contact time (EBCT)--A measure of how much contact occurs between particles, such as activated carbon, and water as the water flows through a bed of the particles. EBCT = (7.48 x V)/Q where V is the volume of particles in the bed (feet), Q is the flow rate of the water through the bed (gallon/minute), and 7.48 is the conversion factor for gallons to feet.(29) End stage renal disease--The stage of renal impairment that appears irreversible and permanent and that requires a regular course of dialysis or kidney transplantation to maintain life (also known as chronic kidney disease stage V).(30) End stage renal disease (ESRD) facility--A facility that provides dialysis treatment or dialysis training and support to individuals with end stage renal disease.(31) ESRD Network--An organization consisting of all Medicare-approved ESRD facilities in the designated geographic area specified by CMS. The network is operated by a corporation that functions under a federal government contract. The network organization is the administrative governing body to the network and acts as a liaison to the Federal government. The network helps ensure quality of care and coordinated delivery of end stage renal disease services.(32) Endotoxin--Lipopolysaccharides consisting of a polysaccharide chain covalently bound to lipid A and the major component of the outer cell wall of gram-negative bacteria.(33) Endotoxin-retentive filter--Membrane filter specifically proven to remove bacteria and endotoxins.(34) Executive commissioner--The executive commissioner of the Texas Health and Human Services Commission.(35) Facility--A contiguous, identifiable location HHSC approved for use as a licensed ESRD facility that is either a freestanding building or a single, distinct, contiguous space in a multi-tenant building.(36) Full-time--The time period established by an ESRD facility as a full working week, as defined and specified in the facility's policies and procedures.(37) Full-time equivalent--Work time equivalent to 2,080 hours per 12 consecutive months.(38) Governing body--The governing authority of a licensed ESRD facility responsible for organization, management, control, operation, and appointment of medical staff. The governing body includes the medical director and representatives of the ESRD facility's owner. The governing body has the overall legal responsibility for the ESRD facility's governance and operation.(39) Health care facility--Any type of facility or home and community support services agency licensed to provide health care in any state or certified for Medicare (Title XVIII) or Medicaid (Title XIX) participation in any state.(40) Home dialysis service--Dialysis performed at home by an end stage renal disease patient or caregiver who has completed an appropriate course of training, as described in §507.53 of this chapter (relating to Home Dialysis Service).(41) Hospital--A entity licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals), or when exempt from licensure, certified by the United States Department of Health and Human Services as in compliance with conditions of participation for hospitals in Title XVIII, Social Security Act (42 United States Code §1395 et seq.).(42) In-center dialysis--Dialysis provided within the ESRD facility's licensed patient care area.(43) Inspection--A survey conducted by a representative of HHSC to determine whether an applicant or licensee is in compliance with this chapter and Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities).(44) Integrated hemodialysis system--A preconfigured hemodialysis system, as designated by the United States Food and Drug Administration (FDA), in which dialysis-quality water and concentrate is prepared and used at the patient's station in the approved and licensed dialysis unit. In licensed facilities that use this modality of delivery of dialysis services, the conventional water distribution system may not be necessary, as each unit contains its own water purification system, produces dialysate, and makes individualized adjustments as needed.(45) Interdisciplinary team (IDT)--A group composed of the primary dialysis physician, registered nurse, dietitian, and social worker who are responsible for planning care for the patient.(46) Intermediate-level disinfection--A surface treatment using chemical germicides or disinfectants that are capable of inactivating various classes of microorganisms including viruses (primarily medium to large viruses and lipid-containing viruses), fungi, and actively growing bacteria (including tubercle bacteria) when such chemical germicides or disinfectants are used in accordance with the manufacturer's directions for use or per established guidelines. Intermediate-level disinfection is generally not effective in inactivating or eliminating bacterial endospores. Examples of intermediate-level disinfectants include bleach, 70 - 90 percent ethanol or isopropanol, and certain phenolic or iodophor preparations.(47) Licensed nurse--A registered nurse or licensed vocational nurse.(48) Licensed vocational nurse (LVN)--An individual who is currently licensed under Texas Occupations Code Chapter 301 (relating to Nurses) by the Texas Board of Nursing as a licensed vocational nurse, or who holds a valid vocational nursing license with multi-state licensure privilege from another compact state. An LVN may act in the capacity of a dialysis technician after meeting the competency requirements specified in §507.48(o) of this chapter (relating to Nursing Services).(49) Medical director--A physician who:(A) is board certified in internal medicine by the American Board of Internal Medicine or in pediatrics by the American Board of Pediatrics; has completed a board-approved training program in nephrology; and has at least 12 months of experience providing care to patients receiving dialysis; or(B) is board certified in nephrology or pediatric nephrology and has at least 12 months of experience providing care to patients receiving dialysis.(50) Medical review board--A review board appointed by the ESRD Network that has a contract with CMS.(51) Modality--A particular treatment option and settings for a patient with end stage renal disease, for example, in-center hemodialysis, home hemodialysis, home peritoneal dialysis, self-care dialysis, nocturnal dialysis, or transplantation.(52) Owner--The legal or governmental entity that holds or will hold a license issued under this chapter and Texas Health and Safety Code Chapter 251.(53) Patient--An individual receiving dialysis treatment or training from an ESRD facility.(54) Patient plan of care--Documentation of the interactive process by which the interdisciplinary team and the patient and family members or guardian develop and implement a plan, based on the assessments performed by the interdisciplinary team members, to assist the end stage renal disease patient in managing the disease and its complications. (55) Pediatric patient--An individual under 18 years of age.(56) Person--An individual, corporation, or other legal entity.(57) Physician--An individual who is licensed by the Texas Medical Board to practice medicine under Texas Occupations Code, Subtitle B, Title 3.(58) Physician assistant--An individual licensed as a physician assistant by the Texas Physician Assistant Board.(59) Plan of Correction (POC)--A written plan developed by the ESRD facility that lists specific actions the ESRD facility will take to correct specific deficiencies of state licensing regulations. (60) Prelicensure conference--A meeting between HHSC staff and the administrator or licensed professional listed on the license application to review licensure standards and provide consultation before HHSC issues a license. The prelicensure conference is not an architectural review feasibility conference.(61) Product water--Water produced by a water treatment system or by an individual component of a system.(62) Progress note--A physical or electronic record of an event dated and signed by facility staff, which summarizes facts about the patient's care and the patient's response during a given time period.(63) Pyrogen--A fever producing substance. Pyrogens are most often lipopolysaccharides of gram-negative bacterial origin.(64) Quality assessment and performance improvement (QAPI)--An ongoing program that measures, analyzes, and tracks quality indicators related to improving health outcomes. The program implements improvement plans and evaluates the implementation until resolution is achieved.(65) Registered nurse (RN)--An individual currently licensed by the Texas Board of Nursing as a registered nurse, or who holds a valid registered nursing license with multi-state licensure privilege from another compact state.(66) Second-chance patient--A patient voluntarily or involuntarily discharged from a facility, or pending involuntary discharge due to behavioral or compliance issues, chosen by the ESRD Network to participate in the second chance program set forth by the ESRD Network who agrees to receive treatment at another licensed ESRD facility. The patient will have specific behavioral expectations compliance expectations, or both, that shall be achieved and maintained to successfully participate in the second chance program and remain a patient at the accepting facility.(67) Self-care patient--An in-center patient who performs all or part of their dialysis treatment, including, at a minimum, set up and tear down of machinery, holding their own site at termination of treatment, and taking and recording their own vital signs.(68) Self-care service--A service where patients participate in their self-care with supervision by a qualified registered nurse as approved and delegated by the medical director.(69) Single patient device--A dialysis machine, as designated by the FDA, assigned to a patient for individual use at home.(70) Social worker--An individual who:(A) is currently licensed by the Texas Behavioral Health Executive Council as a social worker under Texas Occupations Code Chapter 505 (relating to Social Workers), and holds a master's degree from a graduate school of social work accredited by the Council on Social Work Education; or(B) has at least two years of work experience as a social worker, one year of which was in a dialysis facility or transplantation program before September 1, 1976, and has established a consultative relationship with a social worker who has a master's degree from a graduate school of social work accredited by the Council on Social Work Education.(71) Sorbent regeneration system--A system that regenerates dialysate by passing the dialysate through substances that restore the dialysate to a condition comparable to fresh dialysate.(72) Station--An area in the ESRD facility in which a patient receives in-center hemodialysis treatment, or dialysis instruction, such as home hemodialysis training or home peritoneal dialysis training.(73) Supervising nurse (Director of Nursing)--A registered nurse who has:(A) clinical experience including:(i) at least 12 months of clinical nursing experience as an RN, and(ii) an additional 6 months of experience in dialysis obtained within the last 24 months, or(B) at least 18 months experience as an RN and holds a current certification from a nationally recognized board in nephrology nursing or hemodialysis.(74) Supervision--Authoritative procedural guidance by a qualified individual for accomplishing a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity.(A) Immediate supervision--The supervisor is observing the task or activity as it is performed.(B) Direct supervision--The supervisor is at the licensed ESRD facility site but not necessarily immediately physically present where the task or activity is being performed.(C) Indirect supervision--The supervisor is not at the licensed ESRD facility site but is accessible by two-way communication, able to respond to an inquiry when made, and readily available for consultation.(75) Technical supervisor--The supervisor of the ESRD facility's mechanical, reuse, and water treatment systems.(76) Telehealth or telehealth service--A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology, in accordance with Texas Occupations Code Chapter 111 (relating to Telemedicine, Teledentistry, and Telehealth).(77) Telemedicine or telemedicine medical service--A health care service delivered by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state, and acting within the scope of the physician's or health professional's license to a patient at a different physical location than the physician or health professional using telecommunications or information technology, in accordance with Texas Occupations Code Chapter 111.(78) Training (Patient)--The process of developing, practicing, and maintaining specific skills of an individual patient related to the patient's home dialysis treatment modality, including self-care, home hemodialysis, peritoneal dialysis, and other modalities. Patient training must meet the requirements in §507.53 of this chapter.(79) Training (Staff)--The process of teaching tasks through on-the-job experience or instruction from an individual who has the capacity through education or experience to perform the delegated task or activity.(80) Transitional care--Services to transition a patient from a current modality to a self-care modality in-center or at home.(81) Transitional services--In-center dialysis intended to transition a patient from a current modality to a self-care modality whether in-center or at home.(82) Ultrafilter--A membrane filter with a pore size in the range of 0.001 to 0.05 micrometer. Performance is usually rated in terms of a nominal molecular weight cut off (MWCO), which is defined as the smallest molecular weight species for which the filter membrane has more than 90 percent rejection.(83) Water distribution system--Storage tanks and piping used to distribute the product water from the purification cascade to or from its point of use, including individual hemodialysis machines, dialyzer reprocessing equipment, and dialysate concentrate preparation systems.(84) Water treatment system--A collection of water purification devices and associated piping, pumps, valves, gauges, and other related components that together produce purified water for hemodialysis applications and deliver it to the point of use. Source Note: The provisions of this §507.2 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES A GENERAL PROVISIONS §507.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227172 03/12/2026 (a) All facilities that provide dialysis services, regardless of affiliation or modality, shall be licensed as an end stage renal disease (ESRD) facility. A patient of an ESRD facility receiving home dialysis services, as defined in §507.2 of this chapter (relating to Definitions), shall receive the services under the purview of a licensed ESRD facility.(b) A facility shall obtain a license before admitting patients.(c) A facility shall prominently and conspicuously display the license in a public area of the facility that is readily visible to patients, employees, and visitors.(d) A facility shall not alter the ESRD facility license.(e) An ESRD facility license is nontransferable. The facility shall comply with the provisions of §507.12 of this subchapter (relating to Application and Issuance of Initial License) in the event of a change in the ownership.(f) The Texas Health and Human Services Commission (HHSC) issues an ESRD facility license for the facility site and person named in the application.(g) An ESRD facility may share a building with other licensed health care facilities.(1) The ESRD facility shall be licensed separately from the other licensed facilities.(2) No identifiable part of the building may be dually licensed by more than one person.(h) The following facilities are not required to be licensed under this chapter:(1) a home and community support services agency licensed under Texas Health and Safety Code Chapter 142 (relating to Home and Community Support Services), with a home dialysis designation;(2) a hospital licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals) that provides dialysis only to individuals receiving:(A) inpatient services from the hospital; or(B) outpatient services due to a disaster declared by the governor or a federal disaster declared by the president of the United States occurring in this state or another state during the term of the disaster declaration;(3) a hospital operated by, or on behalf of, the state as part of the managed health care provider network established under Texas Government Code Chapter 501 (relating to Inmate Welfare) that provides dialysis only to individuals receiving:(A) inpatient services from the hospital; or(B) outpatient services while the individual is serving a term of confinement in a facility operated by, or under contract with, the Texas Department of Criminal Justice;(4) an ESRD facility operated by, or on behalf of, the state as part of the managed health care provider network established under Texas Government Code Chapter 501 that provides dialysis only to individuals receiving those services while serving a term of confinement in a facility operated by, or under contract with, the Texas Department of Criminal Justice; or(5) the office of a physician unless the office is used primarily as an ESRD facility. Source Note: The provisions of this §507.11 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.11 General Requirements for a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227173 03/12/2026 (a) An applicant shall comply with this subsection before receiving an initial license.(1) The applicant shall submit an accurate and complete application form to the Texas Health and Human Services Commission (HHSC) in accordance with HHSC instructions, including evidence that:(A) the facility has at least one qualified physician on staff; and(B) each dialysis technician on staff completed the training program requirements as required by §507.72 of this chapter (relating to Training Curricula and Instructors).(2) The applicant shall submit the appropriate license fee, as required in §507.20 of this subchapter (relating to Fees).(3) The applicant for a new or existing facility that is increasing the number of in-center dialysis treatment stations shall have an isolation room, as specified in the current CMS Conditions for Coverage or shall provide a CMS waiver.(4) The applicant shall attend a prelicensure conference conducted by HHSC to review facility staff qualifications and licensure rules, and to receive consultation before the on-site licensure inspection. HHSC may waive the prelicensure conference requirement at its discretion. (5) The applicant shall submit a copy of a fire safety inspection that:(A) indicates approval by an individual certified by the Texas Commission on Fire Protection; and(B) is dated no earlier than 12 months before the facility licensure date.(6) The facility physical plant shall meet the requirements set forth in Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements) before HHSC issues an end stage renal disease (ESRD) facility license for a newly constructed ESRD facility or an ESRD facility converted from a non-ESRD facility building.(7) The applicant shall submit to HHSC, in accordance with HHSC instructions, a complete chemical analysis of the product water and reports to verify that bacteriological and endotoxin levels of product water and dialysate are compliant with §507.33 of this chapter (relating to Water Treatment) and §507.34 of this chapter (relating to Dialysate). The facility shall keep the reports on file at the facility and make the reports available to HHSC staff during an on-site inspection or when requested by HHSC.(b) When HHSC determines the applicant has complied with subsection (a) of this section, HHSC issues the license to the applicant.(1) The license is effective on the issue date.(2) The license expires on the last day of the month two years after the issue date.(c) HHSC will not process an application until HHSC receives the fee required in subsection (a)(2) of this section.(d) An applicant may withdraw their application by notifying HHSC in accordance with HHSC instructions.(e) If the applicant does not complete all requirements of subsection (a) of this section within six months after the date HHSC receives the license application and appropriate fee, HHSC will consider the application withdrawn. The applicant must reapply for an initial license in accordance with this section.(f) Any fee paid for a withdrawn application is nonrefundable, as indicated by §507.20(a) of this subchapter.(g) Denial of a license is governed by §507.90 of this chapter (relating to Enforcement).(h) Within the first two years of licensure, HHSC inspects the facility to determine the facility's compliance with the provisions of Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) and this chapter.(1) HHSC may conduct this inspection at the same time as the inspection to determine compliance with Code of Federal Regulations Title 42, Part 494 (relating to Conditions for Coverage for End-Stage Renal Disease Facilities).(2) After the facility admits and provides services to at least one patient, the facility shall request an on-site inspection in accordance with HHSC instructions. An HHSC representative will conduct the inspection while patients are in the facility being dialyzed. (3) At the time of inspection, the facility shall provide services to at least one patient in each modality the facility requested in their application. An HHSC representative may interview patients at the time of the inspection, either in the patient's home or at the facility. An HHSC representative may interview peritoneal and home hemodialysis patients trained or retrained at the facility as part of the inspection. Source Note: The provisions of this §507.12 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.12 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227174 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) sends written notice of license expiration to a facility at least 90 calendar days before the expiration date of a license. If the facility does not receive the notice, it is the facility's duty to notify HHSC and request a renewal notice.(b) HHSC renews the license of a facility that meets the minimum requirements for a license.(c) The facility shall submit to HHSC before the license expiration date:(1) a complete and accurate renewal application form;(2) a copy of two fire safety inspections indicating approval by an individual certified by the Texas Commission on Fire Protection, which includes:(A) one approved within the 12 months before the submission date or the license expiration date, whichever is earlier, and(B) one approved within the last 13 - 24 months before the submission date or the license expiration date, whichever is earlier; and(3) the license renewal fee.(d) HHSC may conduct an inspection before issuing a renewal license in accordance with §507.82 of this chapter (relating to Inspections).(e) A renewal license is valid for two years from the previous expiration date.(f) A facility must submit a complete renewal application, including all required documents and the fee, at least 30 days before the license expiration date.(1) If the facility does not submit the completed renewal application, required documents, and license renewal fee until after the license expiration date, the facility must pay a late fee of half of the renewal fee based on the facility's number of stations, as listed in §507.20(c) of this subchapter (Relating to Fees).(2) If the facility does not submit the completed renewal application, required documents, license renewal fee, and late fee within 30 days after the expiration date, HHSC notifies the facility to immediately cease operation. (A) If HHSC notifies a facility to immediately cease operation, the facility must apply for and receive an initial license under §507.12 of this subchapter (relating to Application and Issuance of Initial License) to resume services. (B) If HHSC requires the facility to apply for an initial license, the facility shall not provide services until HHSC issues the initial license.(3) HHSC issues a renewal license only after the facility submits the renewal application, required documents, license renewal fee and any applicable late fee.(g) If the facility does not wish to provide services after the license expiration date, the facility must close in accordance with §507.18 of this subchapter (relating to Closure).(h) After the license expiration date, if the facility does not correct a deficiency in the renewal application within 15 business days after being notified, HHSC may assess a late fee as described in subsection (f)(1) of this section or deny the license. If HHSC denies the license, any license fee paid is nonrefundable, as indicated by §507.20(a) of this subchapter.(i) Denial of a license is governed by §507.90 of this chapter (relating to Enforcement). Source Note: The provisions of this §507.13 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.13 License Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227175 03/12/2026 (a) A change of ownership occurs when there is a change in the person legally responsible for the facility's operation, whether by lease or ownership.(1) If a corporate licensee amends its articles of incorporation to revise its name and the tax identification number does not change, this subsection does not apply, except for the following notification requirement. The corporation shall notify the Texas Health and Human Services Commission (HHSC) within 10 calendar days after the effective date of the name change.(2) The sale of stock of a corporate licensee does not cause this subsection to apply.(3) The new owner shall submit a license application, documents, and fee in accordance with §507.12 of this subchapter (relating to Application and Issuance of Initial License) to HHSC before the date of the change of ownership or within 10 calendar days after the change of ownership date.(4) HHSC may waive the inspection required by subsection (d) of this section.(5) When HHSC determines the new owner complied with provisions of §507.12 of this subchapter, HHSC issues a license, which is effective on the date of the change of ownership.(6) The license expiration date shall be in accordance with §507.12(b)(2) of this subchapter.(7) The previous owner's license shall be void on the effective date of the new owner's license, and the facility shall return the voided license to HHSC.(b) The facility shall comply with §507.12(a)(7) of this subchapter.(c) Applications under this section are subject to §507.12(d) and (e) of this subchapter.(d) Within the first two years of licensure, HHSC may inspect the facility to determine the facility's compliance with the provisions of Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) and this chapter in accordance with §507.12(h) of this subchapter. Source Note: The provisions of this §507.14 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.14 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227176 03/12/2026 (a) A facility planning to relocate shall notify the Texas Health and Human Services Commission (HHSC) in accordance with HHSC instructions at least 90 calendar days before the planned relocation. Relocations shall be within the state of Texas.(1) The facility shall submit a license application in accordance with §507.12 of this subchapter (relating to Application and Issuance of Initial License) to HHSC before relocation.(2) HHSC may waive the inspection required by §507.12 of this subchapter.(3) The license is effective on the issue date.(4) The license expires on the last day of the month two years after the issue date.(5) The previous facility license is void once the relocation is effective and after the facility ceases all services at the previous location. The facility must return the voided license to HHSC.(b) The facility shall comply with §507.12(a)(7) of this subchapter.(c) When HHSC determines the facility complied with this section, HHSC issues a new license to the applicant, when applicable. (d) Applications under this subsection are subject to §507.12(d) and (e) of this subchapter.(e) Within the first two years of licensure after relocation, HHSC may inspect the facility to determine the facility's compliance with the provisions of Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) and this chapter in accordance with §507.12(h) of this subchapter. Source Note: The provisions of this §507.15 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.15 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227177 03/12/2026 (a) A facility shall notify the Texas Health and Human Services Commission (HHSC) in writing in accordance with HHSC instructions at least 30 calendar days before:(1) any construction;(2) addition, alteration, renovation, or remodeling;(3) equipment and finish upgrade;(4) conversion of a licensed or previously licensed facility to an ESRD license designation;(5) demolition;(6) retrofitting a function, such as changing end stage renal disease treatment modality or training station designations; or(7) change of services, including change in treatment modality, station type, and station number.(b) A facility shall notify HHSC in writing and in accordance with HHSC instructions within 10 calendar days following:(1) a change in the facility name, mailing address, facility administrator email address, telephone number, or fax number;(2) a change of administrator; or(3) the facility ceasing operation.(c) A facility shall request and receive HHSC written approval in accordance with HHSC instructions before changes in services or the number of stations.(1) The facility shall request HHSC approval at least 90 calendar days before the planned change and must receive HHSC approval before implementing the changes.(2) The change shall comply with Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(3) For an additional service or increase in stations, HHSC may require the facility to provide evidence of appropriate staffing, policies and procedures, or any other documentation it determines is necessary to evaluate the request.(4) For an increase in stations, the facility shall also submit written evidence that the water treatment system is of sufficient size to accommodate the increase and maintain a safe water supply.(5) HHSC may conduct an on-site inspection before acting on the requested changes.(6) The facility shall comply with §507.12(a)(7) of this subchapter (relating to Application and Issuance of Initial License).(7) HHSC sends the facility written notice of HHSC approval or denial of the requested change.(8) All existing facilities increasing the number of in-center dialysis treatment stations shall have an isolation room, as specified in the current CMS Conditions for Coverage, or shall provide a waiver. Refer to isolation room requirements in Subchapter Z of this chapter. Source Note: The provisions of this §507.16 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.16 Change in Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227178 03/12/2026 A facility that stops offering services under its license shall first ensure the safety of the facility's patients, staff, and visitors, then inform the Texas Health and Human Services Commission (HHSC) and request inactive status within five calendar days of ceasing operations, in accordance with HHSC instructions. HHSC may close a license if the facility does not offer services for more than 90 calendar days unless the facility sends a written request to place the license on inactive status.(1) To be eligible for inactive status, a facility must be in good standing with no pending legal action or investigation.(2) The facility is responsible for any license renewal requirements or fees, and for proper maintenance of patient records, while the license is inactive.(3) A license may not remain inactive for more than 90 calendar days without an approved extension from HHSC.(4) A facility that does not reactivate its license within 90 calendar days after it stopped offering services may request a single 90-day renewal period of the inactive status from HHSC through a written request in accordance with HHSC instructions. (5) A facility may request HHSC to place the license on inactive status once during each two-year licensing period.(6) If the facility does not reactivate its license or request a renewal for inactive status by the 90th calendar day after the facility stopped offering services, HHSC may consider the facility closed and the license invalid.(7) If the facility does not resume patient services within 10 calendar days after the date the facility's license is placed on inactive status:(A) the facility shall submit to HHSC an application for inspection and water culture testing results;(B) the facility's water culture testing results submitted to HHSC with the application shall meet the requirements of §507.33 of this chapter (relating to Water Treatment); and(C) the facility shall not resume providing patient services until after HHSC inspects the facility. Source Note: The provisions of this §507.17 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.17 Inactive Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227179 03/12/2026 A license becomes invalid when a facility closes. A facility shall notify the Texas Health and Human Services Commission (HHSC) in writing in accordance with HHSC instructions before or immediately upon facility closure.(1) The facility shall discharge or transfer all patients before the facility closes.(2) The facility shall dispose of or store medical records in compliance with federal and state law as well as HHSC rules. (3) When notifying HHSC of the facility closure, the facility shall inform HHSC how the facility disposed of or stored patient records.(4) The facility shall return the license certificate to HHSC immediately after the facility closes. Source Note: The provisions of this §507.18 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.18 Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227180 03/12/2026 (a) The application receipt date for an initial license or a renewal license is the date the Texas Health and Human Services Commission (HHSC) receives the application and fee.(b) An initial license application is complete when HHSC receives, reviews, and finds acceptable the information described in §507.12 of this subchapter (relating to Application and Issuance of Initial License).(c) A renewal license application is complete when HHSC receives, reviews, and finds acceptable the information described in §507.13 of this subchapter (relating to License Renewal).(d) An application for a change of ownership or relocation is complete when HHSC receives, reviews, and finds acceptable the information described in §507.14 of this subchapter (relating to Change of Ownership) or §507.15 of this subchapter (relating to Relocation).(e) An application for a request in change in services or number of stations is complete when HHSC receives, reviews, and finds acceptable the information described in §507.16 of this subchapter (relating to Change in Status). HHSC acknowledges receipt of a request for change in services or number of stations within 15 calendar days after receipt.(f) HHSC processes an end stage renal disease (ESRD) facility initial license or a renewal license in accordance with the following time periods.(1) After receiving an application, HHSC takes one of the following actions within 45 calendar days:(A) issues a license for a complete and approved application; or(B) for an incomplete application, sends a written notice to the applicant describing the documents or information required to complete the application.(2) After HHSC determines an application is complete per subsections (b) - (e) of this section, HHSC issues a license for an approved application within 45 calendar days.(g) If HHSC does not process an application in the time periods stated in subsection (f) of this section, the applicant has the right to request HHSC to fully reimburse the fee paid. If HHSC does not agree that the established periods have been violated or finds good cause, in accordance with subsection (h) of this section, existed for exceeding the established periods, HHSC denies the request.(h) The following circumstances are good cause for HHSC exceeding the established time period:(1) the number of applications for licenses to be processed exceeds by 15 percent, or more, the number processed in the same calendar quarter the preceding year;(2) another public or private entity utilized in the application process caused the delay; or(3) other conditions existed which gave good cause for HHSC exceeding the established periods.(i) If HHSC denies the request for full reimbursement authorized by subsection (g) of this section, the applicant may appeal the decision to the executive commissioner. The applicant may request reimbursement in writing to the executive commissioner of up to the amount of all filing fees paid to HHSC. The executive commissioner shall make a final decision based on facts related to the application processing and good cause and provide written notification of the decision to the applicant. Source Note: The provisions of this §507.19 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.19 Time Periods for Processing and Issuing a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227181 03/12/2026 (a) All fees paid to the Texas Health and Human Services Commission (HHSC) are nonrefundable.(b) All fees shall be paid by check or money order made payable to HHSC.(c) The fees for both initial and renewal license applications are:(1) $3,500 for facilities licensed for 1 to 10 dialysis stations;(2) $4,300 for facilities licensed for 11 to 20 dialysis stations;(3) $5,100 for facilities licensed for 21 to 30 dialysis stations;(4) $5,900 for facilities licensed for 31 to 40 dialysis stations; and(5) $6,700 for facilities licensed for 41 or more dialysis stations.(d) All licenses are valid for 24 months.(e) HHSC collects subscription and convenience fees, in amounts determined by the Texas Online Authority, to recover costs associated with application and renewal application processing through Texas Online, in accordance with Texas Government Code §2054.111 (relating to Use of State Electronic Internet Portal Project) and §2054.252 (relating to State Electronic Internet Portal Project).(f) If the Texas Comptroller of Public Accounts notifies HHSC that a fee payment in connection with a license application did not clear, HHSC informs the applicant and stops processing that license application until the payment clears. Source Note: The provisions of this §507.20 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.20 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227182 03/12/2026 (a) An end stage renal disease (ESRD) facility may request the following types of exceptions from a requirement in this chapter.(1) An ESRD facility may request a temporary exception related to alternative concepts, methods, procedures, or techniques, or for conducting pilot projects or research.(2) An ESRD facility may request a permanent exception related to United States Food and Drug Administration-approved equipment. (b) Exceptions related to operating a facility during an emergency or disaster situation are governed by §507.22 of this subchapter (relating to Exceptions During Emergency or Disaster Situations).(c) To request an exception to a requirement in this chapter, a facility shall submit a form to the Texas Health and Human Services Commission (HHSC) that includes:(1) the specific rule for which the facility requests an exception;(2) a detailed description of the specific circumstances the facility administration believe justify the exception;(3) a detailed description of what alternatives the facility considered, if any, and why the facility did not select any of the identified alternatives, including compliance with the rule;(4) a detailed description of how the proposed exception is desirable to maintain or improve the health and safety of the patients, will not jeopardize patient health and safety, and will maintain patient access to care; and(5) the proposed duration of the exception, if the facility submits a request for a temporary exception.(d) HHSC may conduct an inspection and may consult with the medical review board before approving an exception.(e) HHSC responds to an exception request within 90 calendar days after the date HHSC receives the request. On finding that the facility satisfied the conditions of this section, HHSC may grant a temporary or permanent exception and shall specify the exception duration when notifying the facility that HHSC granted the exception.(f) The facility may implement an exception only after the date the facility receives written approval from HHSC.(g) Granting of an exception is public information, is subject to disclosure, and may be posted on the HHSC website. Source Note: The provisions of this §507.21 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.21 Exceptions to These Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227183 03/12/2026 (a) An end stage renal disease facility shall submit a request for an exception during an emergency or disaster situation to the Texas Health and Human Services Commission (HHSC). To request an exception during an emergency or disaster situation, a facility:(1) shall make the request in accordance with HHSC instructions;(2) shall develop an action plan to resolve the situation, including any staffing crisis;(3) shall submit the action plan to HHSC within 60 calendar days after HHSC grants the exception;(4) shall monitor outcome data related to quality of care and report these outcomes monthly to HHSC during the granted exception period, including granted exception periods for staffing requirements; and(5) may request an exemption from clinical records for evacuees, except that the facility shall assess and document the hepatitis and tuberculosis status of the affected patients. (b) If the facility requests an exemption under subsection (a)(5) of this section, at minimum, the facility must obtain:(1) the patient's name, address, date of birth, and payor information, if available; and(2) the name, address, and telephone number of the patient's usual dialysis facility.(c) HHSC may only grant a temporary exception in an emergency for a maximum of 120 calendar days, with a single renewal period for an additional 120 calendar days. Source Note: The provisions of this §507.22 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.22 Exceptions During Emergency or Disaster Situations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227184 03/12/2026 (a) This section applies only to an end stage renal disease (ESRD) facility located in a county for which:(1) the governor declared a state of disaster due to a pandemic or epidemic pursuant to Texas Government Code Chapter 418 (relating to Emergency Management);(2) the commissioner of the Texas Department of State Health Services determined that a public health disaster exists, pursuant to Texas Health and Safety Code Chapter 81 (relating to Communicable Diseases; Public Health Disasters; Public Health Emergencies); and(3) the Texas Health and Human Services Commission (HHSC) designated this section as applicable, pursuant to paragraphs (1) and (2) of this subsection.(b) Notwithstanding §507.13 of this subchapter (relating to License Renewal), an ESRD facility applying for a renewal license may request an exemption for the current fire safety survey requirement by providing evidence to HHSC that the local fire authority is not performing fire inspections. Source Note: The provisions of this §507.23 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.23 License Renewal During a Public Health Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227185 03/12/2026 (a) This section applies only to an end stage renal disease (ESRD) facility located in a county for which:(1) the governor declared a state of disaster due to a pandemic or epidemic pursuant to Texas Government Code Chapter 418 (relating to Emergency Management);(2) the commissioner of the Texas Department of State Health Services determined that a public health disaster exists, pursuant to Texas Health and Safety Code Chapter 81 (relating to Communicable Diseases; Public Health Disasters; Public Health Emergencies); and(3) the Texas Health and Human Services Commission (HHSC) designated this section as applicable, pursuant to paragraphs (1) and (2) of this subsection.(b) An ESRD facility licensed under Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) that meets the requirements of this section may apply to HHSC to temporarily use an off-site facility under its current license for added services or an increased number of stations to meet patient needs for the public health disaster's duration.(c) The ESRD facility may only use the off-site facility after HHSC approves the off-site facility and when the off-site facility is:(1) an ESRD facility no longer licensed under Texas Health and Safety Code Chapter 251 that closed within the past 36 months, or a facility with a pending application for such a license that has passed its final architectural review inspection that:(A) can meet the current licensing requirements at §507.33 of this chapter (relating to Water Treatment) and §507.34 of this chapter (relating to Dialysate); or(B) shall provide integrated hemodialysis machines, which incorporate water treatment and dialysis preparation and delivery into one system;(2) a mobile, transportable, or relocatable medical unit using integrated dialysis systems, defined as any trailer or self-propelled unit:(A) equipped with a chassis on wheels;(B) without a permanent foundation; and(C) intended for provision of medical services on a temporary basis; (3) a physician's office built after January 1, 2015, that is currently in use, which a facility may use for home training of dialysis patients;(4) a physician's office built after January 1, 2015, that has closed within the past 12 months, which a facility may use for home training of dialysis patients and:(A) is well maintained with all building systems in good working condition; and(B) has manual fire extinguishers in accordance with the latest National Fire Protection Association (NFPA) code and standard; (5) an ambulatory surgical center no longer licensed under Texas Health and Safety Code Chapter 243 (relating to Ambulatory Surgical Centers) that closed within the past 36 months, which an ESRD facility may use for either home training or providing in-center dialysis treatment where:(A) the ESRD facility only provides integrated hemodialysis machines; and(B) the building layout provides a direct view of all patient stations from a nurse's station; (6) a freestanding emergency medical care facility no longer licensed under Texas Health and Safety Code Chapter 254 (relating to Freestanding Emergency Medical Care Facilities) that closed within the past 36 months, which an ESRD facility may use for either home training services or providing in-center dialysis treatment where:(A) the ESRD facility only provides integrated hemodialysis machines; and(B) the building layout provides a direct view of all patient stations from a nurse's station; (7) a hospital or portion of a hospital currently licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals); or(8) a building or structure of opportunity temporarily converted for health care use, including an alternate care site, that is created or maintained by the ESRD facility in partnership with or under the supervision of the health authority, local health department, public health district, or public health consortium that has jurisdiction over the site location.(d) To request approval for an off-site facility under this section, the ESRD facility must submit in accordance with HHSC instructions:(1) an application to use an off-site facility for the addition of services or increased number of stations; and(2) water culture testing results that meet the requirements of §507.33 of this chapter (relating to Water Treatment).(e) HHSC may approve or deny an ESRD facility application to use an off-site facility under this section. HHSC may require an off-site facility inspection or additional documentation before considering an application.(f) To protect the health, safety, and welfare of patients and the public, HHSC may withdraw its approval for an ESRD facility to use the off-site facility under this section at any time. The facility shall safely relocate any patients being treated in the off-site facility at the time HHSC withdraws its approval as soon as practicable according to the ESRD facility's policies and procedures. Source Note: The provisions of this §507.24 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES B LICENSING REQUIREMENTS §507.24 Use of Off-Site Facility During a Public Health Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227186 03/12/2026 An end stage renal disease (ESRD) facility must comply with all applicable technical standards, including those listed below.(1) American National Standards Institute (ANSI)/Association for the Advancement of Medical Instrumentation (AAMI)/International Organization for Standardization (ISO) 23500-1:2019, Preparation and quality management of fluids for haemodialysis and related therapies - Part 1: General requirements.(2) ANSI/AAMI/ISO 23500-2:2019, Preparation and quality management of fluids for haemodialysis and related therapies - Part 2: Water treatment equipment for haemodialysis applications and related therapies.(3) ANSI/AAMI/ISO 23500-3:2019, Preparation and quality management of fluids for haemodialysis and related therapies - Part 3: Water for haemodialysis and related therapies.(4) ANSI/AAMI/ISO 23500-4:2019, Preparation and quality management of fluids for haemodialysis and related therapies - Part 4: Concentrates for haemodialysis and related therapies.(5) ANSI/AAMI/ISO 23500-5:2019, Preparation and quality management of fluids for haemodialysis and related therapies - Part 5: Quality of dialysis fluid for haemodialysis and related therapies.(6) ANSI/AAMI/ISO 8637-1:2017, Extracorporeal systems for blood purification - Part 1: Haemodialysers, haemodiafilters, haemofilters and haemoconcentrators.(7) ANSI/AAMI/ISO 8637-2:2018, Extracorporeal systems for blood purification - Part 2: Extracorporeal blood circuit for haemodialysers, haemodiafilters and haemofilters.(8) ANSI/AAMI/ International Electrotechnical Commission (IEC) 8637-3:2018, Extracorporeal systems for blood purification - Part 3: Plasmafilters.(9) ANSI/AAMI/IEC 60601-2-16:2018, Medical electrical equipment - Part 2 - 16: Particular requirements for basic safety and essential performance of haemodialysis, haemodiafiltration and haemofiltration equipment.(10) ANSI/AAMI/IEC 60601-2-39:2018, Medical electrical equipment - Part 2 - 39: Particular requirements for basic safety and essential performance of peritoneal dialysis equipment.(11) AAMI Technical Information Report (TIR)72:2017, Dialysis fluid chemical composition.(12) AAMI TIR58:2021/(R)2025, Water testing methodologies. (13) AAMI TIR43:2021/(R)2025, Ultrapure dialysis fluid for hemodialysis and related therapies.(14) AAMI TIR77:2018, Sorbent-based regenerative hemodialysis systems.(15) ANSI/AAMI Renal Disease (RD)47:2020, Reprocessing of hemodialyzers.(16) Acute Dialysis: Survey Readiness Handbook, 2nd edition, 2021. Source Note: The provisions of this §507.30 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.30 Technical Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227187 03/12/2026 (a) All equipment used by a facility, including backup equipment, shall be approved by the United States Food and Drug Administration (FDA), operated in accordance with the manufacturer's direction for use, and maintained free of defects that could be a potential hazard to patients, staff, or visitors. Qualified staff or contract personnel shall perform maintenance and repair of all equipment.(1) Staff shall be able to identify malfunctioning equipment and immediately report such equipment to the appropriate staff for repair.(2) Staff shall clearly and immediately label medical equipment that malfunctions and promptly remove the equipment from service until the facility ensures identification and correction of the malfunction.(3) A facility shall maintain a record of all maintenance and repairs.(4) After the facility ensures necessary repair or alteration to any equipment or system, the facility shall thoroughly test the equipment or system for proper operation and disinfect the equipment or system before returning the equipment or system to service.(5) A facility shall comply with the Federal Food, Drug, and Cosmetic Act, 21 United States Code (USC) §360i(b) (relating to Records and Reports on Devices), concerning reporting when a medical device, as defined in 21 USC §321(h) (relating to Definitions; Generally), has or may have caused or contributed to the injury or death of a patient of the facility.(6) A facility shall document completion of the requirements listed in paragraphs (1) - (5) of this subsection on the facility's equipment or system repair log (electronic or paper).(b) A facility shall develop, implement, and enforce a written preventive maintenance program to ensure patient care related equipment used in the facility, or provided by the facility for use by a patient in the patient's home, receives electrical safety inspections, when appropriate, and maintenance at least annually, or more frequently in accordance with the manufacturer's direction for use. Facility staff or contract personnel may provide the preventive maintenance.(c) At least one complete dialysis machine shall be available on site as backup for every 10 machines in use. At least one of these backup machines shall be completely operational during hours of treatment. Machines not in use during a patient shift may be counted as backup except at the time of an initial or an expansion survey.(d) A facility shall annually inspect equipment with internal transducer protectors to ensure the equipment is not contaminated. If the transducer protector is wetted or fluid or blood is visible, the facility must follow instructions as described in §507.36 of this subchapter (relating to Infection Control).(e) If a facility treats pediatric patients, the facility shall use equipment and supplies, to include blood pressure cuffs, dialyzers, and blood tubing, appropriate for this special population.(f) All equipment and appliances shall be properly grounded in accordance with the National Fire Protection Association (NFPA 99), Standard for Health Care Facilities, §4.3.2.2.2, 2002 Edition.(g) A facility shall have emergency equipment and supplies immediately accessible in the treatment area.(1) At a minimum, the emergency equipment and supplies shall include:(A) oxygen;(B) ventilatory assistance equipment, to include airways, manual breathing bag, and mask;(C) suction equipment;(D) supplies specified by the medical director; and(E) automated external defibrillator.(2) If a facility treats pediatric patients, the facility shall have the appropriate type and size emergency equipment and supplies listed in paragraph (1) of this subsection for this special population.(3) A facility shall establish, implement, and enforce a policy for periodic testing and maintenance of the emergency equipment. Staff shall properly maintain and test the emergency equipment and supplies and document the testing and maintenance. Source Note: The provisions of this §507.31 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.31 Equipment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227188 03/12/2026 (a) A facility shall meet the requirements of this subchapter and Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements). A facility may follow more stringent requirements than the minimum standards required by this subchapter.(b) The facility medical director and biomedical technical staff shall each demonstrate responsibility for the water treatment and dialysate supply systems to protect hemodialysis patients from adverse effects arising from known chemical and microbial contaminates that may be found in water and improperly prepared dialysate and ensure the dialysate is correctly formulated and meets the requirements of all applicable quality standards.(c) The facility medical director and biomedical technical staff shall each ensure that policies and procedures related to water treatment, dialysate, and reuse are understandable and accessible to the operators, and the training program includes quality testing, risks, and hazards of improperly prepared concentrate and bacterial issues.(d) Facility staff shall inform the facility owner, medical director, biomedical technical staff, and any other staff members as required by facility policy before any alteration of, or any device being added to, the water system. Source Note: The provisions of this §507.32 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.32 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227189 03/12/2026 The requirements in this section apply to water used for hemodialysis, including preparation of concentrates from powder at a dialysis facility and dialysate, and reprocessing dialyzers for multiple use.(1) The design for the water treatment system in a facility shall be based on considerations of the source water for the facility and designed by a water quality professional with education, training, or experience in dialysis system design.(2) When a facility does not use a public water system supply, the facility shall test the source water monthly in the same manner as a public water system, as required by the Texas Commission on Environmental Quality (TCEQ) under Texas Administrative Code, Title 30, Chapter 290, Subchapter F (relating to Drinking Water Standards Governing Drinking Water Quality and Reporting Requirements for Public Water Systems).(3) The physical space in which the water treatment system is located shall be adequate to allow for maintenance, testing, and repair of equipment. If facility staff mixes concentrates in the same area, the physical space shall also be adequate to house and allow for maintenance, testing, and repair of the mixing equipment and for performing the mixing procedure. When a facility uses a water distribution system, the system shall be configured as a continuous recirculation loop. To minimize biofilm formation, there shall always be flow in a piping system, except during the backwash cycle of the carbon tanks for direct feed systems.(A) For direct and indirect feed systems, the water flow rate shall comply with the standards listed in §507.30 of this subchapter (relating to Technical Standards).(B) This section shall not apply to facilities providing only home training and services utilizing single patient devices. Devices used in the facility for training and support services shall be compliant with the United States Food and Drug Administration (FDA) and Underwriters' Laboratories (UL) requirements.(C) The water treatment and distribution system shall include appropriate pressure gauges, flow meters, sample ports, and other ancillary equipment necessary to allow monitoring of the performance of individual system components and the system as a whole, as determined by the facility medical director.(4) The water treatment system components shall be arranged and maintained so that bacterial and chemical contaminant levels in the product water do not exceed the standards for hemodialysis water quality described by the standards listed in §507.30 of this subchapter.(A) Direct feed systems shall include a means of verifiably preventing retrograde flow of water into the distribution loop from the feed side of the reverse osmosis unit.(B) Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In any renovation work, dead-end piping shall be removed.(5) The facility shall develop written policies and procedures for operating the water treatment system, receiving approval from the medical director, and implementing and enforcing the approved policies and procedures. The facility shall develop written parameters for operating each water treatment system component and ensuring the operator is trained and knowledgeable on these parameters. Each major water system component shall be labeled in a manner that identifies the device, describing its function, how performance is verified, and actions to take in the event performance is not within an acceptable range. The facility's policies and procedures for the bypass valves for the carbon tanks, and any other bypass valves considered to be critical by the medical director, shall have a means to minimize the likelihood the device will be inadvertently bypassed during the normal operation of the system.(6) The materials of any components of water treatment systems (including piping, storage, filters, and distribution systems) that contact the product water shall not interact chemically or physically to adversely affect the product water purity or quality. Such components shall be fabricated from unreactive materials (e.g., plastics) or appropriate stainless steel. The use of materials that are known to cause toxicity in hemodialysis, such as copper, brass, galvanized material, or aluminum, is prohibited at any point beyond the water treatment component used to remove contaminating metal ions (e.g., reverse osmosis system or deionizer).(7) Chemicals infused into the water such as iodine, acid, flocculants, and complexing agents shall be shown to be nondialyzable or shall be adequately removed from product water. Systems shall be monitored in accordance with the manufacturer's direction for use, and specific test procedures to verify removal of additives shall be provided and documented. Chemical injection systems shall include a means of regulating the metering pump to control the addition of a chemical. This control system shall be designed to tightly control addition of the chemical. This control system shall ensure the chemical is added only when the water is flowing through the pre-treatment cascade and in fixed proportion to the water flow. If an automated control system is used to inject the chemical, there shall be an independent monitor of the controlling parameter.(8) Each water treatment system shall include reverse osmosis membranes or deionization tanks and a minimum of two carbon tanks in series. If the source water is from a private supply that does not use chlorine or chloramine, the water treatment system shall include reverse osmosis membranes or deionization tanks and a minimum of one carbon tank.(A) Reverse osmosis systems, if used, shall meet the standards set forth by the CMS Conditions for Coverage.(B) Single patient devices used in a dialysis facility shall meet the appropriate standards set forth in the CMS Conditions for Coverage to provide dialysis-quality water. Once the designated patient no longer needs the single patient device, the facility may process, disinfect, and prepare the device for another designated patient's use, per manufacturer's directions for use.(C) A facility shall meet the following requirements for deionization systems.(i) Deionization systems, if used, shall be monitored continuously to produce water of one megohm-centimeter or greater specific resistivity (or conductivity of 1.0 microsiemens/centimeter or less) at 25 degrees Celsius. The system shall have an audible and visual alarm which activates in the facility to include the patient care area when the product water resistivity falls below this level, and the product water stream shall be prevented from reaching any point of use.(ii) A facility shall not dialyze patients on deionized water with a resistivity less than 1.0 megohm-centimeter measured at the output of the final deionizer.(iii) Deionization tanks, if used, shall be a minimum of two mixed beds in series and shall be used with resistivity monitors including audible and visual alarms placed pre and post the final deionization tank in the system and audible in the patient care area.(iv) Feed water for deionization systems shall be pretreated with activated carbon adsorption, or a comparable alternative, to prevent nitrosamine formation.(v) If a deionization system is the last process in a water treatment system, it shall be followed by an ultrafilter or other bacteria and endotoxin reducing device.(vi) Facilities shall ensure all devices that are regenerated or reconstituted off site, such as deionizers, shall be disinfected at the time of regeneration or reconstitution, so contaminated water is not reintroduced into the system after regeneration or reconstitution. (D) A facility shall meet the following requirements for carbon tanks.(i) The carbon tanks shall contain granular activated carbon, with a minimum iodine number of 900 or equivalent, as indicated by the medical device manufacturer. The facility shall not use previously used carbon.(ii) A minimum of two carbon adsorption beds shall be installed in series with a sample port following the first bed. A sample port shall also be installed following the second bed for use in the event of total chlorine (the sum of free chlorine and chloramine) breaking through the first bed.(iii) The total empty bed contact time (EBCT) shall be at least 10 minutes, with the final tank providing at least five minutes EBCT at the maximum flow rate through the bed. Carbon adsorption systems used to prepare water for home dialysis or for portable dialysis systems are exempt from the requirement for the second carbon and a 10-minute EBCT, if removal of total chlorine to below 0.1 milligram/liter (mg/L) is verified before each treatment.(iv) Water from the sample ports following the first carbon bed shall be tested for total chlorine levels at the beginning of each treatment day, before patients initiate treatment, before reprocessing of dialyzers, and again before the beginning of each patient shift. If there are no set patient shifts, testing shall be performed every four hours until all activities that require use of dialysis-quality water are completed.(v) If used, an automated chlorine monitoring system will provide, at minimum, the equivalent frequencies of testing as required in clause (iv) of this subparagraph and used in accordance with the manufacturer's direction for use. Facility staff shall manually test the automated chlorine monitoring system before the first patient treatment every morning to verify that the device is functioning within manufacturer's specifications to ensure water quality. If a breakdown in the system occurs at any time before or during the treatment day, the facility shall return to manually testing the system every four hours during the treatment day and maintain the appropriate records for manual monitoring.(vi) Carbon beds are sometimes arranged as series-connected pairs of beds so that they need not be overly large. The beds within each pair are of equal size and water flows through them are parallel. In this situation, each pair of beds shall have a minimum empty bed contact time of five minutes at the maximum flow rate through the bed. When series connected pairs of beds are used, the piping shall be designed to minimize differences in the resistance to flow from inlet and outlet between each parallel series of beds, to ensure an equal volume of water flows through all beds.(vii) All samples for total chlorine testing shall be drawn when the water treatment system has been operating for at least 15 minutes.(viii) A facility may use tests for total chlorine, which include both free and combined forms of chlorine, as a single analysis with the maximum allowable concentration of 0.1 mg/L. Test results of greater than 0.5 parts per million (ppm) for chlorine or 0.1 ppm for chloramine from the port between the initial tanks and final tanks shall require testing to be performed at the final exit and replacement of the initial tanks. A facility shall use testing equipment, supplies, and procedures in accordance with the manufacturer's directions for use.(ix) In a system without a holding tank, if test results at the exit of the final tanks are greater than the parameters for total chlorine described in this subparagraph, dialysis treatment shall be immediately terminated to protect patients from exposure to chlorine or chloramines, and the medical director shall be notified. In systems with holding tanks, if the holding tank tests less than 0.1 mg/L for total chlorine, the reverse osmosis may be turned off and the product water in the holding tank may be used to finish treatments in process. The medical director shall be notified.(x) If means other than granulated carbon is used to remove chlorine or chloramine, the facility governing body shall approve such use, in writing, after reviewing the intended method's safety for use in hemodialysis applications. If such methods include the use of additives, there shall be evidence the product water does not contain unsafe levels of these additives.(9) Water softeners, if used, shall be tested at the end of the treatment day to verify their capacity to treat a sufficient volume of water to supply the facility for the entire treatment day and shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration.(10) If used, the faces of timers used to control any component of the water treatment or dialysate delivery system shall always be visible to the operator. The facility shall maintain written evidence that staff checked timers for operation and accuracy each day of operation.(11) Filter housings, if used during disinfectant procedures, shall include a means to clear the lower portion of the housing of the disinfecting agents. Filter housings shall be opaque.(12) Ultrafilters, or other bacterial reducing filters, if used, shall be fitted with pressure gauges on the inlet and outlet water lines to monitor the pressure drop across the membrane. Ultrafilters shall be included in routine disinfection procedures. Ultrafilters with a nominal molecular weight cut off (MWCO) of 20,000 or less are generally adequate for endotoxin removal.(13) If used, storage tanks shall have a conical or bowl-shaped base and drain from the lowest point of the base. Storage tanks shall have a tight-fitting lid and be vented through a hydrophobic 0.2-micron air filter. A means shall be provided to effectively disinfect any storage tank installed in a water distribution system.(14) Ultraviolet (UV) lights, if used, shall be monitored at the frequency in accordance with the manufacturer's direction for use and have an endotoxin-reducing filter located downstream of the device. Records shall be maintained for monitoring, as outlined by the manufacturer's directions for use. Monitoring of all water system components shall be maintained on water system logs (electronic or paper).(15) Water treatment system piping shall be labeled to indicate the pipe contents and direction of flow.(16) The water treatment system shall be continuously monitored during patient treatment and guarded by audible and visual alarms, which can be seen and heard in the dialysis treatment area should water quality drop below specific parameters. Quality monitor sensing cells shall be located at the last component of the water treatment system and at the beginning of the distribution system. No water treatment components that could affect the product water quality, as measured by this device, shall be located after the sensing cell.(17) When deionization tanks do not follow a reverse osmosis system, the facility shall ensure the parameters for the rejection rate of the membranes assure that the lowest rate accepted would provide product water with a level of chemical contaminants in compliance with the standards listed in §507.30 of this subchapter.(18) A facility shall maintain water treatment system operation records for each treatment day. The logbook (electronic or paper) shall include each component's operating parameter and the action taken when a component is not within the facility's set parameters.(19) Microbiological testing of product water shall be conducted.(A) Routine microbiological testing shall be conducted on a quarterly, or more frequent basis as needed, or required by the standards listed in §507.30 of this subchapter. Routine microbiological testing shall ensure the water and dialysate bacteria and endotoxin levels are within the limits described in the standards listed in §507.30 of this subchapter. For a newly installed water distribution system, or when any repairs, modifications, or changes to the configuration have been made to an existing system, weekly testing shall be conducted for four weeks to verify that bacteria and endotoxin levels are consistently within the allowed limits. Changes to components that are designed to be replaced on a routine schedule such as filters, ultrafilters, and ultraviolet lamps do not require a period of more frequent testing.(B) At a minimum, sample sites chosen for testing shall include the beginning of the distribution piping, product water in the reuse room at any site of concentrate mixing, and end of the distribution piping.(C) Samples shall be collected before sanitizing or disinfecting the water treatment system and dialysis machines. Water testing results shall be routinely trended and reviewed by the medical director to determine if results seem questionable or if there is an opportunity for improvement. The medical director shall determine if there is a need for retesting. (D) Product water used to prepare dialysate, concentrates from powder, or to reprocess dialyzers for multiple use shall contain a total viable microbial count of less than 100 colony forming units/milliliter (CFU/ml) and an endotoxin concentration of less than 0.25 endotoxin units (EU)/ml. The action level for the total viable microbial count in the product water shall be consistent with the standards listed in §507.30 of this subchapter.(E) If the action levels described at subparagraph (D) of this paragraph are observed in the product water, the medical director shall be notified, and corrective measures shall be taken promptly to reduce the levels into an acceptable range.(F) All bacteria and endotoxin results shall be recorded to identify trends that may indicate the need for corrective action.(20) If ozone generators are used to disinfect any portion of the water or dialysate delivery system, the ozone generator shall be capable of delivering ozone at the concentration and for the exposure time specified and in accordance with the manufacturer's direction for use. Testing based on the manufacturer's direction shall be used to measure the ozone concentration each time disinfection is performed, to include testing for safe levels of residual ozone at the end of the disinfection cycle. Testing for ozone in the ambient air shall be conducted on a periodic basis as recommended by the manufacturer. The records of all testing shall be maintained in a log (electronic or paper). The frequency of disinfection shall be performed at least monthly.(21) If used, hot water disinfection systems shall use water that meets the standards listed in §507.30 of this subchapter, which must be capable of delivering hot water at the temperature and for the exposure time specified and in accordance with the manufacturer's direction for use, and be monitored for temperature and time of exposure to hot water, as specified by the manufacturer. Water temperature shall be monitored at a point furthest from the water heater, where the lowest water temperature is likely to occur. The water temperature shall be measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection shall be maintained. The frequency of disinfection shall be performed at least monthly or more frequently, as needed or required by the standards listed in §507.30 of this subchapter.(22) After chemical disinfection, a mechanism shall be incorporated to ensure that the equipment and system are restored to a safe condition before using the equipment and product water being used for dialysis applications. The results of all absence testing shall be documented. The frequency of disinfection shall be performed at least monthly. A mechanism shall be incorporated in the distribution system to ensure disinfectant does not drain from pipes during the disinfection period.(23) Users shall establish and implement a procedure for regular disinfection of the line between the outlet from the water distribution system and the back of the dialysis machine.(24) Samples of product water used for dialysis shall be submitted for chemical analysis every six months, after a change of the reverse osmosis membranes, and demonstrate that the quality and level of chemical contaminants of the product water used to prepare dialysate, concentrates from powder, or to reprocess dialyzers for multiple use meets the standards listed in §507.30 of this subchapter. (A) Samples for chemical analysis shall be collected at the most distal point in each water distribution loop. All other outlets from the distribution loops shall be inspected to ensure that the outlets are fabricated from compatible materials. Appropriate containers and pH adjustments shall be used to ensure accurate determinations. New facilities, or facilities that add or change the water distribution system configuration, shall draw samples at the most distal point for each water distribution loop and then every six months thereafter.(B) Additional chemical analysis shall be submitted when any modification or change to the existing system configuration is made to the water treatment system, or if the percent rejection of a reverse osmosis system decreased 5.0 percent or more from the percent rejection measured at the time the water sample for the preceding chemical analysis was taken.(25) Facility records shall include all test results and provide evidence the medical director has reviewed the water quality testing results and directed corrective action when indicated.(26) Only individuals qualified by the education or experience described in §507.54 of this chapter (relating to Staff Qualifications) may operate, repair, or replace water treatment system components. Source Note: The provisions of this §507.33 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.33 Water Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227190 03/12/2026 (a) The facility shall develop, implement, maintain, and evaluate quality assessment and performance improvement (QAPI) procedures to ensure ongoing conformance to policies and procedures regarding dialysate quality.(b) Each facility shall set all hemodialysis machines to use only one family of concentrates. When new machines are put into service, the concentrate family changes, or the concentrate manufacturer changes, dialysate samples shall be taken from each machine and sent to a laboratory for verification of the dialysate electrolyte values.(c) Before each patient treatment, facility staff shall verify the dialysate conductivity and pH of each machine with an independent method, following the manufacturer's guidance.(d) For machines with internal independent conductivity and pH testing, the staff must verify and document that the machine conducted internal testing before each patient treatment. The facility shall test the machine's calibration every six months and maintain logs of the calibration testing.(e) Bacteriological testing shall be conducted, and bacteriological levels shall meet the hemodialysis dialysate quality required by the standards listed in §507.30 of this subchapter (relating to Technical Standards).(f) Only a qualified, licensed nurse may use an additive to increase concentrations of specific electrolytes in the acid concentrate. The nurse shall follow mixing procedures, as specified by the additive manufacturer. For additives prescribed for a specific patient, the nurse shall label the container holding the prescribed acid concentrate with the patient name, final concentration of the added electrolyte, date the prescribed concentrate was made, and the facility staff name who mixed the additive. Facility staff may use additives only:(1) when other interventions were not effective;(2) per physician order; and(3) when the additive is reviewed by the governing body.(g) A facility shall ensure all components used in concentrate preparation systems (including mixing and storage tanks, pumps, valves, and piping) are only made from materials (e.g., plastics or appropriate stainless steel) that do not interact chemically or physically with the concentrate to affect its purity, or with the germicides used to disinfect the equipment. The facility shall ensure components are not made of or use materials known to cause toxicity in hemodialysis such as copper, brass, galvanized material, and aluminum. (h) Facility policies shall address means to protect stored dialysate components (acid concentrates, bicarbonate concentrates, or bulk storage of dialysate components) from tampering or degeneration due to exposure to extreme heat or cold.(i) The facility shall develop, implement, and enforce procedures to:(1) control the transfer of acid concentrates from the delivery container to the clearly labeled storage tank and prevent the inadvertent mixing of different concentrate formulations;(2) form an integral system of the tank and associated plumbing to prevent contamination of the acid concentrate; and(3) secure and clearly label the storage tank and inlet and outlet connections, if remote from the tank.(j) Concentrate mixing systems shall include a purified water source, a suitable drain, and an acceptable electrical outlet, as specified by the manufacturer's recommendations, directions, or instructions.(1) Mixing system operators shall use personal protective equipment as specified and in accordance with the manufacturer's direction for use during all mixing processes.(2) Operators shall follow the manufacturer's directions for use of a concentrate mixing system, including instructions for mixing the powder with the correct amount of water, and determine and record the number of bags or weight of powder added.(3) The facility shall use clear mixing tank labeling to indicate the fill and final volumes required to correctly dilute the powder.(4) The facility shall monitor systems for preparing either bicarbonate or acid concentrate from powder according to the manufacturer's directions for use to ensure compliance with subsection (k)(1) of this section.(5) Facility staff shall not use or transfer concentrates to holding tanks or distribution systems until staff complete all tests per the manufacturer's specifications and in accordance with the manufacturer's directions for use. Facility staff shall document the test results and include the facility staff signature who completed the tests.(6) Where a facility designs its own system for mixing concentrates, the facility shall develop and validate procedures using an independent laboratory to ensure proper concentrate mixing, including establishing acceptable limits for proper concentration tests.(k) The facility shall ensure the design of acid concentrate mixing tanks allow the inside of the tank to be rinsed when changing concentrate formulas.(1) The facility shall ensure that the design and maintenance of acid mixing systems prevent rust and corrosion.(2) Facility staff shall empty acid concentrate mixing tanks completely and rinse with dialysis-quality water before mixing another batch of concentrate to prevent cross-contamination between different batches.(3) Facility staff shall disinfect acid concentrate mixing equipment, as specified by the equipment manufacturer or, in the case where no specifications are given, as defined by facility policy.(4) The facility shall maintain records of disinfecting and rinsing disinfectants to safe residual levels.(l) Bicarbonate concentrate mixing tanks shall have conical or bowl-shaped bottoms and shall drain from the lowest point of the base. The tank design shall allow disinfection and rinsing of all internal surfaces.(1) Facility staff shall not pre-fill bicarbonate concentrate mixing tanks the night before use, and mixed solution shall not remain in mixing or holding tanks overnight.(2) If disinfectant remains in the mixing tank overnight, facility staff shall completely drain this solution, rinse the tank and test for residual disinfectant before preparing the first batch of that day of bicarbonate concentrate.(3) Facility staff shall empty the container and rinse with dialysis-quality water before mixing a new batch of bicarbonate solution, and staff shall not mix unused portions of bicarbonate concentrate with fresh concentrate.(4) At a minimum, facility staff shall disinfect bicarbonate distribution systems weekly. Facility staff shall disinfect the bicarbonate distribution systems more frequently if required by the manufacturer's directions for use, or if dialysate culture results comply with §507.30 of this subchapter.(5) If facility staff reuse jugs to deliver bicarbonate concentrate to individual hemodialysis machines, staff shall:(A) empty jugs of concentrate, rinse jugs with dialysis-quality water, and invert jugs to drain at the end of each treatment day;(B) rinse pick-up tubes with dialysis-quality water and allow tubes to air dry at the end of each treatment day;(C) at a minimum, disinfect jugs and pick-up tubes weekly, and the facility QAPI committee shall consider more frequent jug and pick-up tube disinfection if dialysate culture results comply with §507.30 of this subchapter; and(D) following disinfection:(i) drain jugs, rinse jugs using dialysis-quality water to ensure jugs are free of residual disinfectant, and invert jugs to dry;(ii) rinse pick-up tubes using dialysis-quality water to ensure tubes are free of residual disinfectant, and allow the tubes to air dry; and(iii) test jugs and pick-up tubes for residual disinfectant and document the test results.(m) The facility shall label all mixing tanks, bulk storage tanks, dispensing tanks, and containers for single hemodialysis treatments to indicate the contents of the tank or container.(1) Before batch preparation, facility staff shall affix a label to the mixing tank that includes the date of preparation, tank contents, and chemical composition or formulation of the concentrate being prepared. This labeling shall remain on the mixing tank until the tank has been emptied.(2) A facility shall permanently label bulk storage and dispensing tanks to identify the chemical composition or formulation of their contents.(3) A facility shall, at a minimum, sufficiently label single-machine containers to differentiate the contents from other concentrate formulations used in the facility and permit positive identification by users of container contents.(n) A facility shall maintain permanent records of batches produced to include the concentrate formula produced, volume of the batch, lot numbers of powdered concentrate packages, manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date, if applicable.(o) If facility staff prepare acid and bicarbonate concentrates in the facility, the facility shall ensure completion of preventive maintenance in accordance with the manufacturer's direction for use. The facility shall maintain records indicating the date, time, facility staff performing the procedure, and results, if applicable. Source Note: The provisions of this §507.34 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.34 Dialysate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227191 03/12/2026 (a) Reuse practice in a facility shall comply with the standards listed in §507.30 of this subchapter (relating to Technical Standards) and the CMS Conditions for Coverage.(b) Facility staff shall review the dialyzer manufacturer's labeling to determine whether a specific dialyzer requires special considerations.(c) Facility staff shall reuse arterial lines only when the arterial lines are labeled for reuse by the manufacturer, and the manufacturer-established protocols for the specific line are approved by the United States Food and Drug Administration.(d) The water supply in the reuse room shall incorporate a check valve to prevent chemical agents used from inadvertently back flowing into the water distribution system.(e) Ventilation systems in the reuse room shall meet the requirements of Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements) and be connected to an exhaust system to the outside that is separate from the building exhaust system, have an exhaust fan located at the discharge end of the system, and have an exhaust duct system of noncombustible corrosion-resistant material, as needed to meet the planned usage of the system. Exhaust outlets shall be above the roof-level and arranged to minimize recirculation of exhaust air into the building.(f) A facility shall establish, implement, and enforce a policy for dialyzer reuse criteria (including any facility-set number of reuses allowed) that is included in patient education materials and posted in the waiting room and patient treatment areas. A dialyzer may be reused only if the dialyzer's original volume is measured and recorded before its first use, and the volume of that dialyzer is used as the basis for discard for that dialyzer.(g) A facility shall consider and address the health and safety of patients sensitive to disinfectant solution residuals.(h) A facility shall provide each patient with information regarding the reuse practices at the facility and the opportunity to have questions answered.(i) A facility shall restrict the reprocessing room to authorized personnel during the reprocessing of dialyzers.(j) If a facility participates in centralized reprocessing at a different location, in which dialyzers from multiple facilities are reprocessed at one site, the facility shall:(1) ensure direct communication with the medical director at the centralized reprocessing center and the facility medical director; (2) require the use of an automated reprocessing facility; (3) maintain responsibility and accountability for the entire reuse process;(4) adopt, implement, and enforce policies to ensure the transfer and transport of used and reprocessed dialyzers to and from the off-site location does not increase contamination of the dialyzers or the environment;(5) ensure that each dialyzer is returned to the appropriate facility or patient home, and a system shall be established to verify that the correct dialyzers are being returned to each patient's home in the case of home patients who participate in a dialyzer reprocessing program; and(6) provide Texas Health and Human Services Commission staff access to the off-site reprocessing site as part of a facility inspection. Source Note: The provisions of this §507.35 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.35 Reuse of Hemodialyzers and Related Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227192 03/12/2026 (a) A facility shall follow Standard Precautions for all patient care activities in accordance with Code of Federal Regulations, Title 29 §1910.1030(d)(1) - (3) (relating to Bloodborne Pathogens) and Texas Health and Safety Code Chapter 85, Subchapter I (relating to Prevention of Transmission of HIV and Hepatitis B Virus by Infected Health Care Workers).(1) The facility shall demonstrate that it follows standard infection control precautions by implementing the most current Recommended Infection Control Practices for Hemodialysis Units developed by the Centers for Disease Control and Prevention, to prevent and control cross-contamination and the spread of infectious agents.(2) The facility and facility staff shall take infection control precautions for all patients.(A) Facility staff shall wear disposable gloves when caring for a patient or touching the patient's equipment or bloodlines at the dialysis station.(B) Facility staff shall remove gloves and clean hands between each patient contact, and after touching blood, body fluids, secretions, excretions, and contaminated items or station. (C) Enough sinks, with water and soap shall be available to facilitate handwashing. Sink faucets shall have hands-free operable controls to activate the water flow, which may include a single-lever, wrist blade lever, electronic sensor faucet, or an elbow or wrist action faucet. Provisions for hand drying shall be included at each handwashing sink.(D) If hands are not visibly soiled, staff may substitute use of a waterless antiseptic hand rub for handwashing. Staff shall wash with soap and water when hands are visibly soiled.(E) Facility staff shall wear gowns, eye protection, and, where applicable, masks to protect themselves and prevent soiling clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning dialyzers, and centrifuging blood). If visibly soiled, gowns shall be changed and discarded immediately.(F) Facility staff shall not eat, drink, or smoke in the dialysis treatment area or laboratory.(G) For an item taken to the dialysis station, facility staff shall:(i) dispose of the item; (ii) dedicate the item for use only on a single patient; or(iii) clean and disinfect the item before taking the item to a common clean area or using the item on another patient.(H) Facility staff shall dedicate non-disposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) for use on only a single patient.(I) Facility staff shall use unused medications or supplies (syringes, alcohol swabs, etc.) taken to the patient's station for only that patient and not return the medications or supplies to a common clean area or use the medications or supplies on other patients.(J) A facility shall clearly designate clean areas for preparing, handling, and storing medications and unused supplies and equipment. Facility staff shall not handle or store medications or clean supplies in the same or an immediately adjacent area where facility staff handle used supplies, equipment, or blood samples.(K) A facility shall clearly designate contaminated areas where staff handle used supplies, equipment, or blood samples.(L) When facility staff use multiple dose medication vials (including vials containing diluents), staff shall prepare individual patient doses in a clean, centralized area away from dialysis stations and deliver the medication separately to each patient.(M) Facility staff shall not carry multiple dose medication vials from station to station.(N) Facility staff shall not use common medication carts to deliver medications to patients. If facility staff use trays to deliver medications to individual patients, staff shall clean and disinfect the trays after delivering medications to each patient.(O) If facility staff use a common supply cart to store clean supplies in the patient treatment area, this cart shall remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Staff shall not move such carts between stations to distribute supplies.(P) Facility staff shall not carry medication vials, syringes, alcohol swabs, or supplies in their pockets.(3) The facility shall ensure the location and arrangement of handwashing sinks permit ease of access and proper use.(4) Facility staff shall explain the potential risks associated with blood and blood products to patients and family members and provide the indicated personal protective equipment to a patient or family member, if the patient or family member assists in procedures that could result in contact with blood or body fluids. Facility staff shall encourage patients to clean their access sites before each treatment and their hands following their treatment.(b) A facility shall designate a staff member to monitor and coordinate infection control activities.(c) A facility shall develop, maintain, and enforce a system to identify and track infections to allow identification of trends or patterns. This activity shall be reviewed as a part of the facility's quality assessment and performance improvement (QAPI) program described in §507.43 of this chapter (relating to Quality Assessment and Performance Improvement). The record shall include trends, corrective actions, and improvement actions taken.(d) Facility staff shall replace a transducer protector when wetted during a dialysis treatment and use a transducer protector for only one treatment. If fluid or blood is visible on the side of the transducer protector that faces the machine, the machine must be opened by qualified personnel after the dialysis treatment to allow the internal transducer to be inspected for contamination, including inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. Source Note: The provisions of this §507.36 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.36 Infection Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227193 03/12/2026 (a) A facility shall comply with Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(b) Facility staff shall clean blood spills immediately, as required by the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standards.(1) The facility must follow all appropriate requirements in the OSHA Bloodborne Pathogens Standards.(2) Facility staff shall ensure the surface is subjected to intermediate-level disinfection in accordance with the manufacturer's directions for use if a facility uses commercial liquid chemical disinfectant. (3) If using a solution of chlorine bleach (sodium hypochlorite), facility staff shall ensure the solution is at least 1:100 sodium hypochlorite and water. Facility staff shall mix the solution in accordance with the manufacturer's directions for use. Facility staff shall ensure the surface being treated is compatible with this type of chemical treatment. Facility staff shall label the solution with the date and time the staff mixed the solution. Facility staff shall only use the solution for 24 hours after being mixed.(c) The facility shall adhere to the following procedures for equipment and dialysis machines.(1) The facility shall routinely disinfect active and backup dialysis machines according to facility defined protocol, accomplishing at least intermediate-level disinfection, per Centers for Disease Control and Prevention (CDC) guidelines. The facility staff responsible for disinfecting the dialysis machines shall document the date and the time they disinfected the dialysis machines, verified facility staff rinsed the dialysis machines, and verified facility staff removed the disinfectant.(2) Between patient shifts, facility staff shall clean machine exteriors, treatment chairs, tourniquets, blood pressure cuffs, facility individual television sets at each treatment station, and hemostats. Facility staff shall remove blood pressure cuffs that become contaminated with blood from service, disinfect the cuffs, and allow the cuffs to dry before using the cuffs, per CDC recommendations.(d) The facility shall comply with the requirements set forth by the Texas Health and Human Services Commission in Texas Administrative Code, Title 25 (25 TAC) Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities); the Texas Commission on Environmental Quality (TCEQ) requirements in 30 TAC Chapter 326 (relating to Medical Waste Management); and Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(e) The facility shall dispose all sewage and liquid wastes in a municipal sewerage system or a septic tank system permitted by the TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site Sewage Facilities).(f) Waste containers shall comply with Subchapter Z of this chapter. Source Note: The provisions of this §507.37 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.37 Environmental. https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227194 03/12/2026 (a) The facility shall take the following measures for Hepatitis B prevention.(1) The facility shall offer Hepatitis B vaccination to all previously unvaccinated, susceptible new staff members in accordance with Code of Federal Regulations, Title 29 §1910.1030(f)(1) - (2) (relating to Bloodborne Pathogens). Staff vaccination records shall be maintained in each staff member's health record.(2) With an order from the patient's nephrologist, facility staff shall make the Hepatitis B vaccine available to a patient who is susceptible to Hepatitis B, provided that the patient has coverage or is willing to pay for the vaccination.(3) The facility shall ensure the most recent Centers for Disease Control and Preventions (CDC) Hepatitis B Vaccine Information Statement is available to patients.(4) The facility shall ensure serologic screening of patients.(A) The facility must record the Hepatitis B virus (HBV) serological status to include Hepatitis B surface antigen (HbsAg), total anti-Hepatitis B core antibody (anti-HBc), and antibody to Hepatitis B surface antigen (anti-HBs) of all patients before admission to the hemodialysis unit. The facility shall maintain the anti-HBc results obtained previously or on admission in the clinical record and repeated only if clinically indicated.(B) A patient returning to a facility after extended hospitalization or absence of 30 calendar days or longer shall have been screened for HbsAg within one month before or at the time of admission to the facility or have a known anti-HBs status of at least 10 milli-international units per milliliter no more than 12 months before admission. The facility shall document how this screening requirement is met.(C) Repeated serologic screening shall be based on the patient's antigen or antibody status.(i) Monthly screening for HbsAg is required for patients whose previous test results are negative for anti-HBs.(ii) Screening of HbsAg-positive or anti-HBs-positive patients may be performed on a less frequent basis but shall be performed at least annually.(5) The facility shall follow appropriate isolation procedures for an HBsAg-positive patient.(A) An end stage renal disease (ESRD) facility licensed before February 9, 2009, shall comply with §507.16(c)(8) of this chapter (relating to Change in Status). An ESRD facility licensed after February 9, 2009, shall treat patients positive for HBsAg in a separate treatment room that complies with Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(B) Separate dedicated supplies and equipment, including blood glucose monitors, shall be used to provide care to the Hepatitis B positive patients. All supplies used in the isolation area or room, such as clamps, blood pressure cuffs, testing reagents, etc., shall be labeled "isolation" and not routinely removed from the isolation area or room.(C) Refillable concentrate containers shall be surface disinfected at the completion of each treatment. Refillable acid concentrate containers shall be kept in the isolation area or room and refilled at the door. Refillable bicarbonate concentrate containers shall be removed for cleaning and disinfection. In the disinfection area, containers labeled "isolation" containers and pick-up tubes shall be segregated in a dedicated, designated area away from all other containers and pick-up tubes.(D) Separate gowns shall be used in the isolation area or room and removed before leaving the isolation area or room. Anyone entering the isolation area or room during the patient's treatment shall wear a protective gown. Gowns used in the isolation area or room shall be discarded at the end of each treatment day. If visibly soiled, gowns shall be changed and discarded immediately.(E) Dedicated cleaning supplies (such as a mop and bucket) for cleaning the isolation area or room and blood spills shall be used and labeled "isolation."(F) A patient who tests positive for HBsAg shall be dialyzed on equipment reserved and maintained for an HBsAg-positive patient's use only.(G) When a direct patient care staff member is assigned to both HBsAg-negative and HBsAg-positive patients, the HBsAg-negative patients assigned to this grouping shall be Hepatitis B antibody positive. Hepatitis B antibody positive patients are to be seated at the treatment stations nearest the isolation station and assigned to the same staff member who is caring for the HBsAg-positive patient.(H) If an HBsAg-positive patient is discharged, the equipment that had been reserved for that patient shall be given intermediate-level disinfection before use for a patient testing negative for HBsAg.(I) In the case of patients new to dialysis or a patient returning to a facility after extended hospitalization or absence of 30 calendar days or longer, if these patients are admitted for treatment before results of HBsAg or anti-HBs testing are known, these patients shall undergo treatment as if the HBsAg test results were potentially positive, except that they shall not be treated in the HBsAg isolation room, area, or machine.(i) The facility shall treat potentially HBsAg-positive patients in a location in the treatment area that is outside of traffic patterns and shall not reuse the dialyzer until the HBsAg test results are known.(ii) The dialysis machine used by the HBsAg-positive patient shall be given intermediate-level disinfection before its use by another patient.(iii) The facility shall obtain the patient's HBsAg status results within three calendar days of admission.(b) The facility shall take the following measures for tuberculosis prevention.(1) The facility direct care staff shall be screened for tuberculosis upon employment before patient contact, or provide documentation of negative tuberculosis status, per current CDC recommendations. (2) Subsequent screening of facility staff shall be performed after any potential exposure to laryngeal or pulmonary tuberculosis, per current CDC recommendations.(3) Facility staff shall follow the facility's respiratory isolation procedures and precautions when providing treatment to patients with pulmonary tuberculosis.(4) The facility shall screen patients for tuberculosis when indicated by the presence of risk factors for, or the signs and symptoms of tuberculosis. Screening shall be performed after potential exposure to active laryngeal or pulmonary tuberculosis, per current CDC recommendation.(c) The facility shall adopt, implement, and enforce a policy for offering and providing pneumococcal and influenza vaccines. The policy shall:(1) include provisions that the influenza vaccine shall be offered according to the CDC annual recommendations, and the pneumococcal vaccine shall be offered throughout the year;(2) require the facility staff administering the vaccine to ask the patient if they are currently vaccinated against influenza or pneumococcal disease, assess potential contraindications, and then, if appropriate, administer the vaccine under approved facility protocols; (3) address required vaccination documentation in the patient clinical record; and(4) include that the Texas Health and Human Services Commission may waive vaccine administration requirements based on established vaccine shortages. Source Note: The provisions of this §507.38 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES C OPERATIONAL REQUIREMENTS FOR EQUIPMENT, WATER TREATMENT AND REUSE, AND SANITARY AND HYGIENIC CONDITIONS §507.38 Disease Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227195 03/12/2026 (a) The facility shall have an identified governing body responsible for the facility's organization, management, control, and operation, including appointing the facility's medical director as defined in §507.2 of this chapter (relating to Definitions). (b) A facility may request in writing a waiver to appoint or retain as medical director a physician who does not meet one or more of the qualifications in §507.2(49)(B) of this chapter. The request shall explain why a physician meeting the board certification requirement is not available and include the physician's resume for the physician the facility seeks to appoint or retain. The facility shall make the request through the Texas Health and Human Services Commission (HHSC) Health Facility Licensing Unit, for transmission to the CMS. The facility may not appoint or retain as medical director a physician who does not meet one or more of the qualifications in §507.2(49)(B) of this chapter until the facility receives approval from CMS.(c) The governing body shall develop, implement, and enforce policies and procedures for all services provided by the facility. (d) The governing body shall adopt, implement, and enforce policies and procedures to ensure compliance with current laws, rules, and regulations pertaining to medical staff.(e) The governing body shall implement and annually review current and effective administrative rules, regulations, and policies designed to protect patient health and safety.(f) The governing body shall ensure there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care. The governing body shall review and monitor QAPI activities at least biannually.(g) The governing body shall ensure all facility staff, including advanced practice registered nurses (APRN), physician assistants (PAs), registered nurses, licensed vocational nurses, licensed master social workers, registered dietitians, patient care technicians, and other technical staff, are qualified to serve the complex needs of dialysis patients and deliver dialysis services. APRNs, PAs, registered nurses, licensed vocational nurses, licensed master social workers, registered dietitians, patient care technicians, and other technical staff shall demonstrate and sustain the skills and any professional licensures required to perform the specific duties of their positions.(h) The governing body shall ensure adequate numbers of qualified personnel are present whenever patients are undergoing dialysis so that the patient to staff ratio is appropriate to the level of dialysis care given and meets the needs of patients, including meeting the minimum staffing requirements demonstrated in §507.60 of this chapter (relating to Staffing Table).(i) The governing body shall review, approve, and implement the facility's training program for staff, patients, and caregivers. (j) The governing body shall develop, implement, and enforce policies and procedures relating to the facility's emergency preparedness plan to meet the requirements of §507.46 of this subchapter (relating to Emergency Preparedness). The plan shall address the continuity of essential building systems including emergency power and water, or a contract with another licensed end stage renal disease (ESRD) facility to provide emergency contingency care to patients to meet the requirements of Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(k) The governing body shall ensure all equipment used by facility staff or patients is properly maintained in accordance with the manufacturer's directions.(l) The governing body shall ensure the facility's physical environment protects the health and safety of patients, personnel, and the public. The licensed facility site and the facility's surrounding physical structure used by the patients (including stairwells, corridors, and passageways) shall meet the local building and fire safety codes and standards as they relate to design and space requirements for safe access and patient privacy.(m) The governing body shall develop, implement, and enforce policies and procedures regarding disruptive patients or family members to ensure the health and safety of patients, personnel, and the public.(n) The governing body shall ensure that all facility staff members have access to the most current version of all applicable laws, rules, and regulations. Source Note: The provisions of this §507.41 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.41 Governing Body https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227196 03/12/2026 (a) Each facility shall adopt, implement, and enforce policies and procedures appropriate to the patient population served to ensure each patient is:(1) treated with respect, dignity, and full recognition of the patient's individuality and personal needs;(2) provided privacy and confidentiality for the patient and the patient's clinical record;(3) provided a safe, sanitary, and comfortable treatment environment;(4) provided information in a manner to facilitate understanding by the patient and the patient's legal representative, family member, or significant other, as applicable, including patient information materials available in the appropriate language;(5) provided an interpreter, interpreter service, or visual and hearing assistance if written materials in the patient's primary language are not available or not appropriate for the patient's needs;(6) informed by a physician of the patient's medical status;(7) informed of and provided education regarding all treatment modalities and settings, including self-care and transplant, for the treatment of end stage renal disease upon initiating treatment and an annual basis thereafter;(8) informed about and provided the opportunity to participate in all aspects of care, including plan of care meetings, the right to refuse treatment, and the medical consequences of such refusal;(9) informed of all services available in the facility and all charges for services provided;(10) informed about the facility's reuse of dialysis supplies, including hemodialyzers, and if printed materials such as brochures are used to describe a facility and its services the brochures shall contain a statement describing the methods and procedures used when such supplies are reused;(11) assured of a reasonable response by the facility to the patient's requests and needs for treatment or service, within the facility's capacity, the facility's stated mission, and applicable law and regulation;(12) provided hours of dialysis that are scheduled for patient convenience whenever feasible or possible, with consideration is given to the patient's work or school schedule;(13) transferred or discharged only for medical reasons, for the patient's welfare or that of other patients or staff members, or for nonpayment of fees; and given 30 calendar days advance notice in the event of a transfer or discharge, except in cases where the patient presents an immediate risk to others;(14) given an opportunity and assistance to improve problematic behavior before dismissal from the facility;(15) protected from abuse, neglect, or exploitation;(16) provided information regarding advance directives and allowed to formulate such directives to the extent permitted by law, including documents executed under Texas Health and Safety Code Chapter 166 (relating to Advance Directives);(17) fully informed on how to file a complaint against the facility without fear of reprisal or denial of services, including a written statement provided at the time of admission informing patients of their rights to make a complaint directly to Texas Health and Human Services Commission (HHSC) Complaint and Incident Intake;(18) fully informed of the rights listed in this section, the responsibilities established by the facility, and all rules and regulations governing patient conduct and responsibilities, including a written copy of the patient's rights and responsibilities provided upon admission to each patient or the patient's legally authorized representative; and(19) fully informed of the patient plan of care process, including the necessary services outlined in the patient plan of care.(b) A facility shall prominently and conspicuously post a legible and current copy of the patient rights and facility license certificate in one or more public areas of the facility, so that the posting is readily available and observable to all facility patients, staff, and visitors.(c) A facility shall obtain written informed consent for dialysis services from the patient or the patient's legally authorized representative.(d) A facility shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §507.42 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.42 Patient Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227197 03/12/2026 (a) A facility shall develop, implement, maintain, and evaluate an effective, ongoing, facility-wide, data-driven, interdisciplinary quality assessment and performance improvement (QAPI) program. The program shall be individualized to the facility and meet the criteria and standards described in this section.(b) The program shall reflect the complexity of the facility's organization and services involved. All facility services (including services furnished under contract or arrangement), shall focus on indicators related to improved health outcomes and prevention and reduction of medical errors.(c) The program shall include an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with identification and reduction of medical errors.(d) The facility shall demonstrate that facility staff evaluate the provision of dialysis care and patient services, set treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until resolution is achieved.(e) The facility shall measure, analyze, and track quality indicators or other aspects of performance it adopts or develops that reflect processes of care and facility operations. The facility shall provide evidence to show that it continuously reviews aggregate patient data, including identifying and tracking patient infections for trends.(f) Core staff members shall actively participate in the QAPI activities, including QAPI meetings.(1) A facility shall hold QAPI meetings monthly, or more often as necessary, to identify or correct problems.(2) A facility shall conduct QAPI meetings separately from a patient plan of care conference.(3) A facility shall document QAPI meetings.(4) A facility shall invite and encourage the facility patient representatives to attend QAPI meetings.(g) The facility's QAPI program shall include:(1) an ongoing review of key elements of care using comparative and trend data to include aggregate patient data;(2) identifying areas where performance measures or outcomes indicate an opportunity for improvement, including review of the progress of End Stage Renal Disease (ESRD) Network Program and CMS assigned activities;(3) appointing interdisciplinary improvement teams to:(A) identify, measure, analyze, and track indicators for variation from desired outcomes;(B) create and implement improvement plans;(C) evaluate improvement plan implementation; and(D) continue monitoring and improvement activities until the improvement plan resolution; and(4) establishing and monitoring quality indicators related to improved health outcomes.(h) For each quality assessment indicator, the facility shall establish and monitor a level of performance consistent with current professional knowledge. These performance components shall influence or relate to the desired outcomes themselves. At a minimum, the facility shall measure, analyze, and track monthly:(1) water quality (chemical, bacteriological analysis, and other indicators specific to the facility's water treatment system);(2) equipment preventive maintenance and repair;(3) reprocessing of hemodialyzers (dialyzer performance measures, labeling, and disinfection);(4) infection control (staff and patient screening; standard precautions; bacteriological monitoring of dialyzers, water, machines, and dialysate; pyrogen reactions; sepsis episodes; patient infections; and peritonitis rate);(5) adverse events;(6) vascular access;(7) reportable incidents as required to be reported under §507.56 of this subchapter (relating to Incident Reports);(8) mortality (review of each death and monitoring modality specific mortality rates);(A) complaints and suggestions (from patients, family, or staff);(B) staffing to include orientation, training, delegation, licensing and certification, and non-adherence to policies and procedures by facility staff;(C) safety (fire and emergency preparedness, use of a Texas Health and Human Services Commission (HHSC) approved reporting system, and disposal of special waste);(D) clinical records review to include dialysis treatment errors, and medication errors;(E) clinical outcomes (laboratory indicators, hospitalizations, vascular access complications, intradialytic complications, fluid management, patient no-shows, patient non-adherence to the dialysis prescription, and transplantation);(F) patient's health-related quality of life surveys; and(G) involuntary transfer or discharge of a patient.(9) The dialysis facility shall continuously monitor performance, take actions that result in performance improvement, and track performance to ensure that improvements are sustained over time. The facility shall immediately correct any identified problems that threaten health and safety of patients.(i) HHSC may review a facility's QAPI activities to determine compliance with this section.(1) An HHSC inspector shall verify the facility has a QAPI program that addresses concerns relating to quality of care provided to its patients and the core staff members have knowledge of and the ability to access the facility's QAPI program.(2) HHSC requires disclosure of QAPI program records when disclosure is necessary to determine compliance with this section. Source Note: The provisions of this §507.43 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.43 Quality Assessment and Performance Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227198 03/12/2026 (a) The facility shall regularly review the facility's data to identify opportunities to improve care. Assistance in improving care from the Texas Health and Human Services Commission (HHSC) or HHSC designee may include feedback of comparative data, a plan of correction, or an on-site inspection.(b) The facility shall adopt, implement, and enforce procedures for resolution of complaints relevant to quality of care or services rendered by licensed health care professionals and other facility staff members, including contract services or staff. (c) The facility shall document complaint receipt and the disposition. The investigation and documentation shall be completed within 30 calendar days after the facility receives the complaint unless the facility has and documents reasonable cause for a delay. Source Note: The provisions of this §507.44 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.44 Indicators of Quality of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227199 03/12/2026 (a) A facility shall develop, implement, and enforce policies and procedures regarding the patient's plan of care process, which specifies the services necessary to address the patient's comorbid conditions and other needs based on the patient's interdisciplinary assessment. The facility shall coordinate patient services using an interdisciplinary team approach, per CMS guidance. The interdisciplinary team shall consist of the patient, the patient's primary dialysis physician, registered nurse, social worker, and dietitian.(b) The interdisciplinary team shall engage in an interactive conference to develop a written, individualized, comprehensive patient plan of care that specifies the services necessary to address the patient's medical, psychological, social, and functional needs, and includes treatment goals.(c) The patient plan of care shall include measurable and expected outcomes and estimated timetables to achieve these outcomes. The patient plan of care shall include the patient's current dose of dialysis, dialysis adequacy, other medical comorbidity issues, nutritional status, mineral metabolism, anemia, vascular access, psychosocial status, modality, transplantation status, rehabilitation status, goals, and education and training.(d) The patient plan of care shall include evidence of coordination with other service providers (e.g., hospitals, long term care facilities, home and community support services agencies, and transportation providers) as needed to ensure continuity of safe care.(e) The patient plan of care shall include evidence of the patient's (or patient's legal representative's) input and participation unless they refuse to participate. If the patient refuses to participate, the facility shall document the patient refusal in the patient's record. At a minimum, the patient plan of care shall demonstrate an interdisciplinary team member discussed the content with the patient or the patient's legal representative.(f) Facility staff shall develop and implement the patient plan of care within 30 calendar days, or 13 outpatient dialysis treatments from the patient's admission to the facility, whichever occurs later. Facility staff shall revise the patient plan of care due to changes in the patient's personal treatment goals, lack of progress towards the patient's plan of care goals, marked deterioration in health status, significant changes in the patient's psychosocial needs, or changes in the patient's nutritional condition, as needed, but no less than annually after the date of the patient's last plan of care.(g) The facility shall monitor the patient plan of care at least monthly to recognize and address any deviations from the patient plan of care by:(1) implementing changes in interventions due to the lack of progress toward the patient's plan of care goals;(2) documenting the reasons why the patient was unable to achieve the goals; and(3) implementing changes to address the revised patient plan of care.(h) Facility staff may conduct an interdisciplinary team conference via telehealth or telemedicine, which may include audio-only telecommunications. A telehealth or telemedicine patient plan of care conference conducted with the interdisciplinary team and the patient (or their legally authorized representative) shall be documented as such.(i) In the case of disruptive patients or family members or patients who do not conform to the treatment plan, the facility shall develop, implement, and enforce a process for more intensive interdisciplinary team intervention with this patient to include assessment of needs and planned interventions to assist the patient in adjusting to the requirements for safe care.(1) The facility shall contact the End Stage Renal Disease Network for assistance with these patients before considering an involuntary discharge of the disruptive patient.(2) The facility shall establish, implement, and enforce a policy allowing a disruptive or noncompliant patient or family member the opportunity and assistance to improve any problematic behavior before their dismissal from the facility, in accordance with the requirements of this section.(j) A facility shall not violate Texas Occupations Code Chapter 102 (relating to Solicitation of Patients). Source Note: The provisions of this §507.45 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.45 Patient Assessment and Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227200 03/12/2026 (a) In this section, unless the context clearly indicates otherwise, "emergency" means an incident likely to threaten the health, welfare, or safety of a facility's patients, facility staff, or the public, including a fire, equipment failure, power outage, flood, interruption in utility service, medical emergency, or natural or other disaster.(b) In accordance with Texas Health and Safety Code §251.016 (relating to Emergency Preparedness and Contingency Operations Planning), a facility shall implement a written emergency preparedness and contingency operations plan that describes staff and patient actions to manage potential medical and nonmedical emergencies, including fire, equipment failure, power outages, medical emergencies, and natural or other disasters that are likely to threaten the health, welfare, or safety of the facility patients, staff, or public. The plan shall comply with the following requirements.(1) The facility shall update the plan at least annually.(2) The facility's leadership shall approve the plan each time the facility updates the plan.(3) The plan shall include:(A) procedures for notifying each of the following entities, as soon as practicable, regarding facility closure or reduction in hours of operation due to an emergency:(i) the Texas Health and Human Services Commission (HHSC);(ii) each hospital with which the facility has a transfer agreement in accordance with subsection (j) of this section;(iii) the trauma service area regional advisory council that serves the geographic area in which the facility is located; and(iv) each applicable local emergency management agency;(B) a documented patient communications plan that includes procedures for notifying a patient when that patient's scheduled dialysis treatment is interrupted;(C) a continuity of care plan for the provision of dialysis treatment to facility patients during an emergency that meets the requirements under subsection (d) of this section; and(D) a disaster preparedness plan for natural and other disasters that:(i) is specific to the facility based on an assessment of the probability and type of disaster in the region and the local resources available to the facility;(ii) incorporates the use of the HHSC-approved reporting system and participation in the End Stage Renal Disease (ESRD) Network disaster preparedness activities;(iii) includes procedures designed to minimize harm to patients and staff along with ensuring safe facility operations;(iv) along with in-service programs for patients and staff, includes provisions or procedures for responsibility of direction and control, communications, alerting and warning systems, evacuation, and closure;(v) requires each staff member employed by or under contract with the facility to be able to demonstrate their role or responsibility to implement the facility's disaster preparedness plan.(vi) designates a staff member in each facility to monitor and coordinate disaster preparedness activities;(vii) maintains in each facility documentation of the monitoring and coordination of disaster preparedness activities; and(viii) addresses the continuity of essential building systems, including emergency power and water, or a contract with another licensed ESRD facility to provide emergency contingency care to patients to meet the requirements of §507.501(i) of this chapter (relating to Fire Prevention, Protection, and Emergency Contingency Plan); and(4) except as provided by subsection (c) of this section, requires a facility to execute a contract with another ESRD facility located within a 100-mile radius of the facility stipulating that the other ESRD facility will provide dialysis treatment to facility patients who are unable to receive scheduled dialysis treatment due to the facility's closure or reduction in hours.(c) A facility is not required to contract with another ESRD facility under subsection (b)(4) of this section if:(1) no other ESRD facility is located within a 100-mile radius of the facility; and(2) the facility obtains written approval from HHSC exempting the facility from that requirement.(d) A facility shall develop a continuity of care plan for provision of dialysis treatment to facility patients during an emergency that:(1) includes procedures for distributing written materials to facility patients that specifically describe the facility's emergency preparedness and contingency operations plan;(2) includes detailed procedures on the facility's continency plans, based on the facility's patient population, including transportation options, for patients to access dialysis treatment at each ESRD facility with which the facility has an agreement or made advance preparations to ensure that the facility's patients have the option to receive dialysis treatment and procedures for notifying a patient when that patient's scheduled dialysis treatment is interrupted;(3) is approved by the facility's leadership; and(4) is provided by the facility to each patient before providing or scheduling dialysis treatment.(e) On request, a facility shall provide the facility's emergency preparedness and contingency operations plan adopted under subsection (b) of this section to:(1) HHSC;(2) each hospital with which the facility has a transfer agreement in accordance with subsection (j) of this section;(3) the trauma service area regional advisory council that serves the geographic area in which the facility is located; and(4) each applicable local emergency management agency.(f) A facility shall provide annual training to facility staff on the facility's emergency preparedness and contingency operations plan required by subsection (b) of this section.(g) A facility shall annually contact a local and state disaster management representative, an emergency operations center in its local jurisdiction, and a trauma service area regional advisory council to:(1) request comments on whether the emergency preparedness and contingency plan adopted by the facility under subsection (b) of this section should be modified; and(2) ensure that local agencies, regional agencies, state agencies, and hospitals are aware of the facility, the facility's policy on provision of life saving treatment, the facility's patient population and potential transportation needs, and the anticipated number of patients affected.(h) A facility shall have a functional plan to access emergency medical services.(i) A facility shall have personnel qualified to operate emergency equipment and provide emergency care to patients on site and available during all treatment times. A charge nurse qualified to provide basic cardiopulmonary life support (BCLS) shall be on site and available to the treatment area whenever patients are present. All direct care staff members shall maintain current certification and competency in BCLS.(j) A facility shall have a transfer agreement with one or more hospitals that provide acute dialysis service for provision of inpatient care and other hospital services to the facility's patients. The facility shall have documentation from the hospital to the effect that patients from the facility shall be accepted and treated in emergencies. There shall be reasonable assurances in the transfer agreement that:(1) whenever a transfer or referral is deemed medically appropriate by the attending physician, the hospital and facility shall coordinate the patient's transfer or referral to ensure timely acceptance and admission;(2) the interchange of medical and other information necessary or useful in the transferred patient's care and treatment shall occur within one business day; and(3) the facility shall ensure the security and accountability of the transferred patient's personal effects.(k) A facility shall post a telephone number specific to the facility's equipment and locale to assist staff in contacting mechanical and technical support in the event of an emergency.(l) The facility shall maintain information on the HHSC-approved reporting system and update online monthly. Source Note: The provisions of this §507.46 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.46 Emergency Preparedness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227201 03/12/2026 (a) The facility shall provide pharmaceutical and therapeutic items in accordance with accepted professional principles and federal and state laws and regulations.(b) Facility staff shall administer medications only when the patient's physician, attending physician, physician assistant (PA) or an advanced practice registered nurse (APRN) orders the medication. Facility staff shall administer medication as ordered.(c) The sponsoring physician shall document and authenticate or countersign all physician, PA, or APRN orders within 15 calendar days from the date the physician, PA or APRN gave the order.(d) The facility shall properly store and safeguard medications maintained in the facility in enclosures of sufficient size, which are not accessible to unauthorized individuals. The facility shall maintain refrigerators used for medication storage with documentation of the appropriate temperatures for such storage.(e) A facility shall maintain emergency medications, as specified by the medical director, to treat the emergency needs of patients.(f) Facility staff shall not prepare medications for administration in the patient's immediate treatment area. The medication preparation area shall include a work counter and a sink in an area to prevent contamination of medicines being prepared for administration.(g) Facility staff shall not take medication vials to a patient station. Facility staff shall not puncture more than once intravenous medication vials labeled for single use.(h) Facility staff shall label medications not given immediately with the patient's name, medication name, dosage prepared, and initials of the staff member preparing the medication. Facility staff shall protect medications not given immediately to prevent contamination and casual access of the prepared medications to unauthorized individuals. The facility staff who prepared the medication shall administer the medication.(i) Facility staff shall not draw saline from the IV bag or tubing in use for the patient and shall prepare saline in a clean medication preparation area separate from potentially contaminated items and surfaces.(j) Licensed nurses, physician assistants, or physicians shall administer all medications except intravenous normal saline, intravenous heparin, subcutaneous lidocaine, topical lidocaine, and oxygen, which may be administered as part of a routine hemodialysis treatment by dialysis technicians qualified according to §507.72 of this chapter (relating to Training Curricula and Instructors) and §507.73 of this chapter (relating to Competency Evaluation). Such administration by dialysis technicians shall comply with Texas Occupations Code Chapter 157 (relating to Authority of Physician to Delegate Certain Medical Acts). Source Note: The provisions of this §507.47 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.47 Medication Storage and Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227202 03/12/2026 (a) The facility shall provide nursing services to prevent or reduce complications, maximize the patient's functional status, and educate the end stage renal disease patient, patient's family, patient's caregiver, or significant other.(b) The facility shall employ a full-time supervising nurse to supervise and manage the provision of safe patient care. A facility shall not use contract staff as a full-time supervising nurse.(c) The facility shall ensure a registered nurse is in the facility when patients are present in the facility.(1) The facility's governing body shall develop policies and procedures for allowing patients in the building when a registered nurse is not present and inclement weather or safety concerns exist. The policies and procedures shall require a review of any occurrence when patients are allowed in the building when a registered nurse is not present. Facility staff shall present the date of the incident, reasons, patients affected, and staff present to the facility's quality assessment and performance improvement (QAPI) committee and governing body for review and development of an appropriate plan.(2) In inclement weather or due to safety concerns, when two or more basic cardiopulmonary life support-trained staff members are in the facility, patients may enter the facility lobby in accordance with the facility's policies and procedures.(d) A registered nurse shall conduct:(1) admission nursing assessments;(2) assessments of a patient upon a change in the patient's status, extended or frequent hospitalizations, or at the patient's request;(3) dialysis assessments on all patients within the first hour of treatment each time the patient receives treatment; and(4) immediate assessments if an abnormal finding or change of condition is identified pre-dialysis, intradialytic, or post-dialysis.(e) A registered nurse shall participate in the interdisciplinary team review of a patient's progress and recommend changes in treatment based on the patient's current needs and facilitate communication between the patient, patient's family, and the patient's significant other, as applicable, and other interdisciplinary members, to ensure the facility delivers the necessary care.(f) A registered nurse shall provide oversight and direction to dialysis technicians and licensed vocational nurses.(g) A registered nurse shall participate in the facility's QAPI activities.(h) A registered nurse functioning in the charge role shall be present during all dialysis treatments.(i) If the facility provides pediatric dialysis, a registered nurse with experience or training in pediatric dialysis shall be available to provide care for pediatric dialysis patients smaller than 35 kilograms in weight.(j) The facility shall ensure sufficient direct care staff, as defined in §507.2(26) of this chapter (relating to Definitions), are on site to meet the needs of the patients, and at least one licensed nurse is available on site for every 12 patients or portion thereof, as demonstrated in §507.60 of this subchapter (relating to Staffing Table). The nurse can be either a registered nurse (RN) or licensed vocational nurse (LVN). A registered nurse functioning in the charge role shall be present during all dialysis treatments. Each direct care staff shall only be assigned a maximum of four patients.(1) During treatment of seven or fewer patients, direct care staff shall consist of at least one registered nurse and one direct care staff, as demonstrated in §507.60 of this subchapter.(2) For one to seven patients, the direct care staff may be assigned a maximum of four patients and the charge nurse may be assigned a maximum of three patients.(3) During treatment of 8-12 patients, the registered nurse functioning as charge nurse shall not be assigned as direct care staff, as demonstrated in §507.60 of this subchapter.(4) For pediatric dialysis patients, one registered nurse shall be provided on site for each patient weighing less than 10 kilograms and one registered nurse provided on site for every two patients weighing from 10 to 20 kilograms.(k) A facility shall ensure patients are in view of staff during hemodialysis treatments, and staff shall observe the patient, their access site, and their bloodline connections during the dialysis treatment.(l) The facility shall include documentation in the patient's record verifying the patient was educated during treatment, upon admission, and annually on the importance of leaving their access sites uncovered.(m) A licensed nurse or dialysis technician shall collect and document objective and subjective data for each patient before and after treatment, according to facility policy and the staff member's level of training.(1) The facility shall have written policies and procedures specific to the facility to guide nursing staff actions in the event a patient's condition deteriorates during treatment to identify parameters which would require a patient be referred to a nurse for evaluation.(2) A registered nurse shall conduct a patient assessment when indicated by a question relating to a change in the patient's status or at the patient's request.(n) A registered nurse shall conduct the initial patient assessment before the patient's first dialysis treatment by the facility.(o) This chapter does not preclude a licensed vocational nurse (LVN) from practicing in accordance with the rules adopted by the Texas Board of Nursing. If the LVN is acting in the capacity of a dialysis technician, the facility shall determine that the LVN has passed a training and competency evaluation curriculum that meets the requirements in §507.72 of this chapter (relating to Training Curricula and Instructors) and §507.73 of this chapter (relating to Competency Evaluation).(p) A dialysis technician providing direct patient care shall demonstrate knowledge and competency for the responsibilities specified in §507.72 and §507.73 of this chapter. Source Note: The provisions of this §507.48 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.48 Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227203 03/12/2026 (a) A facility shall provide nutrition services to a patient and the patient's caregivers to maximize the patient's nutritional status.(b) The dietitian shall be responsible for:(1) conducting a nutrition assessment of a patient;(2) participating in an interdisciplinary team review of a patient's progress;(3) recommending therapeutic diets in consideration of cultural preferences and changes in treatment based on the patient's nutritional needs in consultation with the patient's physician;(4) counseling a patient, a patient's family, and a patient's significant other, as applicable, on prescribed diets and monitoring adherence and response to diet therapy;(5) referring a patient for assistance with nutrition resources such as financial assistance, community resources, or in-home assistance;(6) participating in the facility's quality assessment and performance improvement (QAPI) activities; and(7) providing ongoing monitoring of subjective and objective data to determine the need for timely intervention and follow-up, including weight changes, blood chemistries, adequacy of dialysis, and medication changes that affect nutrition status and potentially cause adverse nutrient interactions.(c) The dietitian shall contact the patient to document and complete the patient's comprehensive nutrition assessment with an educational component no later than 30 calendar days or 13 treatments after the patient's admission to the facility, whichever occurs later.(d) The dietitian shall conduct a nutrition reassessment no less than annually or upon a change in the patient's status, extended or frequent hospitalizations, a change in the patient's modality, or at the patient's request.(e) Each facility shall employ or contract with a dietitian to provide clinical nutrition services for each patient. (1) The maximum caseload for a full-time equivalent dietitian is 125 patients. The caseload is cumulative across all modalities and facilities where the dietitian is employed. A facility shall employ or contract a second dietitian for a patient caseload over 125 patients.(2) The governing body shall ensure the facility assigns personnel to assist dietitians with ancillary tasks when the patient load, including all modalities, exceeds 100 patients per facility.(f) The facility shall ensure nutrition services are available at the facility during scheduled patient treatment times. A patient may need an appointment to access nutritional services.(g) A facility shall have written physician standing orders specific to that facility authorizing delegation of responsibilities for the facility dietitian, as determined by the medical director and the facility.(1) The medical director shall review and approve the standing orders at least annually.(2) The standing orders shall be consistent with the statutes and rules of the Texas Medical Board, Texas Board of Nursing, and Texas Department of Licensing and Regulation.(h) When the facility uses a medication algorithm or protocol for managing renal bone disease, the nutritional care for each patient shall be individualized. Source Note: The provisions of this §507.49 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.49 Nutrition Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220246 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220246 03/12/2026 (a) A facility shall comply with the following balance billing requirements.(1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility.(b) A facility shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §507.50 adopted to be effective April 15, 2021, 46 TexReg 2426; amended to be effective August 18, 2024, 49 TexReg 6219. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.50 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227204 03/12/2026 (a) A facility shall provide social services to patients and their families that are directed at supporting and maximizing the patient's adjustment, social functioning, and rehabilitation.(b) The social worker is responsible for:(1) conducting psychosocial evaluations, which include health-related quality of life surveys;(2) participating in the interdisciplinary team review of a patient's progress;(3) providing an ongoing assessment and recommend changes in treatment based on the patient's current psychosocial needs;(4) providing social work interventions including counseling, case work, and group work services to patients and their families experiencing special problems associated with end stage renal disease;(5) identifying community social agencies and other community resources, and assisting patients and families to use them;(6) participating in the facility's quality assessment and performance Improvement (QAPI) activities; and(7) assisting patients to achieve optimum levels of productive activity and making rehabilitation referrals as appropriate.(c) The facility shall ensure the social worker initially contacts the patient and documents the initial contact no later than 30 calendar days or 13 treatments from the patient's admission, whichever occurs later. Qualified facility staff shall complete comprehensive psychosocial assessment no later than 30 calendar days or 13 treatments from the patient's admission to the facility, whichever occurs later.(d) Qualified facility staff shall conduct a governing-body-approved psychosocial and quality of life reassessment as needed, but no later than 90 calendar days after the initial assessment and at least annually thereafter, and when there is:(1) a significant change to the patient's psychosocial needs;(2) extended or frequent hospitalizations;(3) any event that would interfere with the patient's ability to follow aspects of the plan of care;(4) a change in the patient's modality; or(5) at the patient's request.(e) Each facility shall employ or contract with a social worker to meet the psychosocial needs of the patients.(1) The facility shall ensure one full-time equivalent of qualified social worker time is available for up to 125 patients per facility, which is the maximum case load for all modalities available in the facility. The caseload is cumulative across all modalities and facilities where the social worker is employed. The facility shall employ or contract a second social worker for a patient caseload over 125.(2) The governing body shall ensure the facility assigns personnel to assist social workers with ancillary tasks, such as assistance with financial services, transportation, and administrative and clerical duties, when the patient load, including all modalities, exceeds 100 patients per facility. (f) The facility shall ensure social services are available at the facility during scheduled patient treatment times. A patient may need an appointment to access social services. Source Note: The provisions of this §507.51 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.51 Social Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227205 03/12/2026 (a) The medical director shall meet the requirements set forth in the CMS Conditions for Coverage and is responsible for:(1) developing facility treatment goals that are based on review of aggregate data assessed through quality assessment and performance improvement (QAPI) activities;(2) ensuring adequate training of licensed nurses and dialysis technicians;(3) adequate monitoring of patients and the dialysis process;(4) developing, implementing, and enforcing all policies required by this chapter;(5) ensuring the facility's attending physicians follow the facility's policies and procedures, and the physicians follow the facility's established treatment and clinical standards, including quality, safety, and infection control standards; and(6) ensuring all facility care staff, including nurses, patient care technicians, social workers, dietitians, physicians, and other ancillary staff receive annual training in all modalities, including transplant.(b) The facility shall meet the following requirements regarding medical staff responsibilities.(1) Each patient shall be under the care of a licensed and qualified nephrologist on the medical staff, or a physician on the medical staff who has demonstrated experience treating dialysis patients for at least 18 months.(2) Each pediatric dialysis patient shall be under the care of a pediatric nephrologist or under the care of an adult nephrologist with direct patient evaluation by a pediatric nephrologist as follows:(A) for patients two years of age or younger, monthly (two of three evaluations may be conducted by phone);(B) for patients 3-12 years of age, quarterly; and(C) for patients 13-18 years of age, semiannually.(3) For each patient receiving dialysis in the facility, a physician on the facility's medical staff shall see the patient at least twice a month. The physician shall conduct the first visit in person. The second visit is required unless the patient is stable, as justified in the patient record by the physician. If the second visit is necessary, it shall be separated from the first visit by at least 10 calendar days and may be conducted in person or using telemedicine. Additional visits conducted in the same month by a physician may be conducted using telemedicine.(4) Home dialysis patients shall be seen by a physician, an advanced practice registered nurse (APRN), or a physician assistant (PA) no less than once a month. (A) The physician shall see the patient in person at least once every three months.(B) The physician shall conduct physician visits required by subparagraph (A) of this paragraph in person and may conduct the visit in the dialysis facility, at the physician's office, or in the patient's home. The physician may conduct additional visits in the same month using telemedicine.(C) An APRN or a PA may conduct the visits required by this paragraph using telemedicine. (D) The record of these contacts shall include evidence of assessment for new and recurrent problems and review of dialysis adequacy each month.(5) The facility shall ensure a physician on the medical staff is on call and available 24 hours a day (in person or by telecommunication) to patients and staff. (6) The physician shall verify and sign all orders for treatment. Facility staff shall update routine orders for treatment at least annually. Any changes in patient treatment shall be per physician's order.(A) Orders for hemodialysis treatment shall include length of treatment, dialyzer, blood flow rate, dialysate composition, target weight, all medications administered during or needed for treatment, and specific infection control measures, as needed.(B) Orders for peritoneal dialysis treatment shall include fill volumes, number of exchanges, dialysate concentrations, catheter care, medications, and specific infection control measures, as needed.(c) If the facility uses APRNs or PAs:(1) the facility shall ensure documented evidence of communication with the treating physician whenever the APRN or PA changes treatment orders;(2) the APRN or (PA) shall not replace the physician in participating in patient care planning or in QAPI activities;(3) the APRN or PA shall not replace the physician for the completion of assessments, as defined by the CMS Conditions for Coverage, or for the twice monthly evaluation of the in-center dialysis patient;(4) the APRN or PA shall notify the treating physician of patient medical emergencies;(5) the APRN or PA shall meet the requirements established by the Texas Board of Nursing (for an APRN) or the Texas Physician Assistant Board (for a PA); and(6) the APRN or PA shall use mechanisms that provide authority for that care, which shall include protocols or other written authorization:(A) reviewed and approved by the APRN or PA and the appropriate physician;(B) signed by both the APRN or PA and the physician;(C) reviewed and re-signed at least annually;(D) maintained in the practice setting of the APRN or PA; and(E) made available as necessary to the Texas Health and Human Services Commission (HHSC) to verify authority to provide medical aspects of care.(d) The facility shall comply with Texas Health and Safety Code Chapter 166 (relating to Advance Directives) concerning out-of-hospital do-not-resuscitate orders.(e) If the facility has a contract or agreement with an accredited school of health care for the school to use their facility for a portion of the students' clinical experience, those students may provide care under the following conditions.(1) The facility may offer clinical experience to students, provided the instructor is present at the facility, provides direct supervision to the student, and assumes responsibility for all student activities occurring within the facility.(2) A student may administer medications only if:(A) on assignment as a student at their school of health care; and(B) under the immediate supervision of a qualified registered nurse on staff at the facility.(3) A facility shall not use a student to fulfill the requirement for administration of medications by licensed personnel.(4) A facility shall not consider a student when determining staffing levels required by the facility.(5) A student shall not mix concentrate or test water quality.(6) A student shall not accept or transcribe physician orders.(7) A student shall not conduct the assessments of new or unstable patients.(8) A qualified registered nurse shall directly supervise the students to protect the students and facility patients. Source Note: The provisions of this §507.52 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.52 Medical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227206 03/12/2026 (a) A facility that provides home dialysis training, and support shall ensure through its interdisciplinary team that home dialysis services are at least equivalent to those provided to in-facility patients and meet all applicable licensure rules.(b) A facility shall provide a separate room for home dialysis services, as defined in §507.2 of this chapter (relating to Definitions).(1) The room shall include a handwashing sink with water and soap available to facilitate handwashing. Sink faucets shall have a hands-free operation to activate the water flow, which may include a single-lever, wrist blade lever, electronic sensor faucet, or an elbow or wrist action faucet. Provisions for hand drying shall be included at each handwashing sink.(2) The facility shall clearly designate clean areas for preparing, handling, and storing medications and unused supplies and equipment. Facility staff shall not handle or store medications or clean supplies in the same or an immediately adjacent area where facility staff handle used supplies, equipment, or blood samples.(3) The facility shall have a designated area with a separate sink for disposal of blood or body fluids. The facility shall clearly designate contaminated areas where staff handle used supplies, equipment, or blood samples.(c) Patients may receive Training (Patient), as defined in §507.2 of this chapter (relating to Definitions), individually or in a small group setting. A facility must offer patients a choice of an individual or small group training setting and ensure the facility meets each patient's preferences and individual needs. Patient training must take place in person. (d) When a patient completes home dialysis training, the facility shall assign each individual home dialysis patient, regardless of modality, one machine for the patient's exclusive use in the home. A facility shall not assign multiple home dialysis patients to the same machine.(e) For home dialysis patients, including all modalities, a facility shall maintain a staffing level of one full-time equivalent registered nurse for every group of 25 patients. For 21 - 25 patients, the facility shall assign a licensed vocational nurse or a dialysis technician to assist the registered nurse.(f) A registered nurse shall conduct home dialysis training. Before permitting a registered nurse to provide home dialysis training to a patient and a patient's caregiver, the facility shall:(1) verify the registered nurse has:(A) at least 12 months clinical nursing experience; and(B) a minimum of three months experience, occurring within the last 24 months, in the specific modality with the responsibility for training the patient and the patient's caregiver; (2) evaluate and document the nurse's ability to independently provide home dialysis training;(3) document the nurse's competency to provide home dialysis training three months after passing the initial competency exam; and (4) ensure all competency evaluations administered under this subsection contain the facility staff's signature evaluating the nurse's competency to provide home dialysis training. (g) A facility's medical director shall develop and approve the home dialysis training curriculum. The home dialysis training curriculum shall comply with the following requirements.(1) Training for each home dialysis patient shall address the patient's specific needs in the nature and management of end stage renal disease in a manner that complies with all patient privacy and infection control requirements.(2) Training shall include the full range of techniques associated with the treatment modality selected, including the effective use of dialysis supplies and equipment in achieving and delivering the physician's prescription.(3) Training of the patient and caregiver, as applicable, shall include:(A) effective and safe administration of erythropoiesis-stimulating agents (if prescribed) to achieve and maintain a target level hemoglobin, hematocrit, and blood pressure levels, or hematocrit, as written in the patient's plan of care;(B) how to detect, report, and manage potential dialysis complications, including water treatment problems;(C) availability of support resources and how to access and use resources;(D) how to self-monitor health status and record and report health status information;(E) how to handle medical and nonmedical emergencies;(F) infection control precautions;(G) proper waste storage and disposal procedures;(H) how to order supplies on an ongoing basis;(I) not using non-medical electrical equipment within six feet of the home hemodialysis machine; and(J) notifying the facility of any change in machinery used in home dialysis.(4) Staff shall include documentation in the clinical record that the patient, the caregiver, or both, received and demonstrated adequate comprehension of the training.(h) The interdisciplinary team shall oversee training of a home dialysis patient and the designated caregiver before the initiation of home dialysis, and when the home dialysis caregiver or home dialysis modality changes.(i) A home dialysis training facility shall retrieve and review complete self-monitoring data and other information from the home dialysis self-care patient, or their designated caregiver, at least every two months, and maintain this information in the patient's clinical record in the facility.(j) If a facility is unable to obtain a patient's self-monitoring data after an appropriate number of attempts, the physician must refer the case to the medical director for a determination about a potential modality change for the patient.(k) A home dialysis training facility shall furnish home dialysis support services, regardless of whether dialysis supplies may be provided by the dialysis facility or a durable medical equipment company.(l) A home dialysis training facility shall provide services as follows.(1) The facility shall complete an initial monitoring visit of the patient's home adaptation by facility personnel (including the registered nurse responsible for training the patient in the chosen modality and technical staff as appropriate) in accordance with the patient's plan of care, before the patient begins training for the selected home modality, and periodically thereafter. (2) The facility must make a monitoring visit to the patient's home in case of:(A) patient's change of address,(B) change in the patient's primary caregiver,(C) disaster that impacts the patient's home,(D) major renovation, or(E) any other event that may impact the patient's care.(3) A physician, an advanced practice registered nurse, or a physician assistant shall see a home dialysis patient in accordance with §507.52(b)(4) of this subchapter (relating to Medical Services). (4) The interdisciplinary team shall develop and periodically review an individualized and comprehensive plan of care for the patient. The plan of care shall specify the services necessary to address the patient's needs and meet the measurable and expected outcomes, which meet a hemodialysis Kt/Vurea (Kt/V) of at least 1.2 (three times a week), or standard Kt/V of 2.0 (four to six times a week), or a peritoneal dialysis weekly Kt/V of at least 1.7, or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.(5) The facility shall provide patient consultation with interdisciplinary team members as needed.(m) A home dialysis training facility shall monitor the quality of water and dialysate used by a home hemodialysis patient, including an initial on-site evaluation and testing of the water and dialysate system, and any time facility staff repairs or exchanges the water treatment equipment.(1) A home dialysis training facility shall annually analyze the product water used for dialysate preparation to ensure the water meets the standards listed in §507.30 of this chapter (relating to Technical Standards).(2) A home dialysis training facility shall test the water and dialysate system in accordance with the manufacturer's direction for use.(3) A home dialysis training facility shall test the water and dialysate system in accordance with the system's United States Food and Drug Administration (FDA) approved labeling, for integrated hemodialysis system designed, tested, and validated to meet the quality (including standards for chemical and total chlorine testing) water and dialysate required by standards listed in §507.30 of this chapter. The facility shall meet testing and other requirements of the standards listed in §507.30 of this chapter, when using an integrated water and dialysate system, which is designed and validated to meet the standards listed in §507.30 of this chapter.(4) A home dialysis training facility shall perform bacteriological and endotoxin testing of water used for dialysate preparation and dialysate monthly and ensure the results are within the limits allowed by the standards listed in §507.30 of this chapter.(n) The dialysis facility shall correct any water and dialysate quality problem for the home hemodialysis patient, and if necessary, arrange for backup dialysis until the facility corrects the problem if:(1) an analysis of the water and dialysate quality indicates contamination; or(2) the home hemodialysis patient demonstrates clinical symptoms associated with water and dialysate contamination.(o) The dialysis facility shall be responsible for arranging the purchase, lease, or rental of medically necessary home dialysis supplies and equipment, and the delivery, installation, repair, and maintenance of these supplies and equipment (including supportive equipment), as prescribed by the attending physician. If the patient purchases, leases or rents dialysis equipment, the facility shall ensure the equipment's installation, repair, and maintenance in accordance with the manufacturer's directions for use.(p) The dialysis facility shall identify a plan and arrange for emergency backup dialysis services when needed.(q) The dialysis facility shall maintain a recordkeeping system that ensures continuity of care and patient privacy.(r) The dialysis facility, or the patient or patient's caregiver with facility oversight, shall culture and measure the hemodialysis machines of home patients for colony forming units and endotoxins before disinfection, at least quarterly or more frequently, as needed, or required by the standards listed in §507.30 of this chapter. The facility shall follow the manufacturer's recommendations regarding the proper procedure for disinfection. For integrated hemodialysis system devices, facility staff shall follow the device's FDA labeling and manufacturer's recommendations.(s) As applicable, the facility shall maintain maintenance records for all dialysis machines and dialysis equipment at the licensed facility site.(t) If required, the electrical connection for the home hemodialysis machines shall be connected to a ground-fault circuit interrupter (GFCI) receptacle in accordance with Subchapter Z of this chapter (relating to Physical Plant and Construction Requirements).(u) The dialysis machine shall comply with the requirements of §507.33 of this chapter (relating to Water Treatment). The facility shall ensure that the water pressure in the patient's home meets the minimum requirement specified by the water treatment system's manufacturer.(1) The facility shall meet the following requirements for an integrated hemodialysis system.(A) The facility shall analyze the source water used for dialysate annually or if there is a change in the source water, to ensure the water quality meets the manufacturer's guidelines for source water purity.(B) The facility shall obtain the product water chemical quality every six months before replacing the water purification disposable component, or when any modifications are made to the integrated hemodialysis system to ensure that the product water meets the current CMS guidelines. (C) The facility shall provide a means for the patient or patient's caregiver to sample the product water to test for total chlorine levels immediately before using the dialysate. The total chlorine level shall comply with the standards listed in §507.30 of this chapter, and the results shall be documented by the patient or the patient's caregiver.(D) If applicable, the facility, or the patient or patient's caregiver with facility oversight, shall obtain the microbiological quality of the dialysate at the end of a prepared dialysate bag, with the requirements at §507.33 of this chapter and §507.34 of this chapter (relating to Dialysate).(2) If using a dialysis system that uses manufactured dialysate solution in its existing form, the facility shall use the system according to manufacturer's directions. The facility shall ensure patients receive necessary training and can demonstrate competencies to follow the manufacturer's directions for use.(3) If using a peritoneal dialysis system that uses manufactured dialysis solution the facility shall use the system according to manufacturer's directions. The facility shall ensure that patients are trained and can demonstrate competencies to follow the manufacturer's directions for use.(4) If using sorbent technology, the patient or facility staff shall test the sorbent regeneration dialysis system (machine) before each treatment with the manufacturer's self-test method, and the patient or facility staff shall document evidence of the self-test. The facility shall analyze the source water used for dialysate to ensure the water quality meets the manufacturer's guidelines for source water purity annually or if there is a change in the source water. Source Note: The provisions of this §507.53 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.53 Home Dialysis Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227207 03/12/2026 (a) Facility staff (whether employees or contractors) shall meet the personnel qualifications and demonstrated competencies necessary to serve the needs of the patients. Facility staff shall demonstrate and sustain the skills needed to perform the specific duties of their positions.(1) The facility shall develop and implement a written orientation program to familiarize all new employees (including office staff) with the facility, its policies, and their job responsibilities. The facility shall ensure that each new direct care staff member (whether employee or contractor) receives sufficient time to become familiar with the facility.(A) The orientation program shall meet the following minimum time requirements.(i) For individuals with previous dialysis experience, the orientation program shall be two weeks.(ii) For new direct care staff members with no previous dialysis experience, the orientation program shall be two weeks plus additional time as determined by the facility.(B) In facilities with similar policies and equipment, staff with dialysis experience oriented to one facility may be shared with another facility after a shorter orientation period. Each facility where a shared employee works shall keep documentation on file of the shared staff's current competency and tasks delegated by that facility's medical director to unlicensed technicians.(C) A facility shall provide registered nurses with no previous dialysis experience an orientation program of a minimum of seven weeks. The seven-week orientation program shall contain content specific to end stage renal disease patient management and appropriate to the population served by the facility, including at least:(i) fluid, electrolyte, and acid-base balance;(ii) kidney disease and treatment;(iii) dietary management of kidney disease;(iv) principles of dialysis;(v) dialysis technology;(vi) venipuncture technique;(vii) care of the dialysis patient;(viii) psychological, social, financial, and physical complications of long-term dialysis;(ix) prevention of hepatitis and other infectious diseases; (x) risks and benefits of reuse (if reuse is practiced); and(xi) all available treatment modalities, including the availability of kidney transplantation.(2) A facility shall ensure each licensed nurse and dialysis technician demonstrates competency through written and skills testing after they complete the orientation program and annually thereafter. The facility shall maintain documented evidence of competency in writing in personnel files. Current certification by a nationally recognized board may substitute for the annual written test. The facility shall ensure all dialysis technicians receive certification from a national commercially available certification program within 18 months of being hired as a dialysis technician.(b) A facility shall ensure medical staff meet the following requirements.(1) Each physician on the medical staff shall have a current license to practice medicine in the state of Texas.(2) If a facility uses an advanced practice registered nurse, that individual shall meet the requirements established by the Texas Board of Nursing in Texas Administrative Code, Title 22 (22 TAC), Chapter 221 (relating to Advanced Practice Nurses).(3) If a facility uses a physician assistant, that individual shall meet the requirements established by the Texas Medical Board in 22 TAC Chapter 185 (relating to Physician Assistants).(c) A facility shall ensure nursing staff meet the following requirements.(1) Each individual licensed as a nurse shall have a current Texas license to practice nursing in accordance with the statutes and rules of the Texas Board of Nursing, or a current license from another state in the Nurse Licensure Compact (NLC).(2) Each registered nurse assigned charge nurse responsibilities shall have at least 12 months of clinical experience and six months experience in hemodialysis after completing the facility's training program.(A) For a newly licensed registered nurse, the last six months of clinical experience may run concurrently with the six months of dialysis experience.(B) The hemodialysis experience shall be within the last 24 months.(C) A registered nurse who holds a current certification from a nationally recognized board in nephrology nursing or hemodialysis may substitute the certification for the six months experience in dialysis obtained within the last 24 months.(3) The facility shall document written physician standing orders, specific to the facility, in the patient's clinical record to guide nursing staff actions in the event a patient's condition deteriorates during treatment. The medical director shall review and approve these standing orders at least annually, consistent with the Texas Medical Board statutes and rules and the Texas Board of Nursing statutes, rules, and policy statements for registered nurses and licensed vocational nurses.(4) If a facility provides patient self-care training, either in-center or at home, a registered nurse with at least 12 months clinical experience and three months experience in the specific modality, shall be responsible for providing self-care training to the patient or caregiver in that modality.(5) When other facility staff assist in the self-care training in-center, the qualified registered nurse shall supervise the self-care training. When other facility staff assist in training a patient or the patient's caregiver in self-care training, the facility shall document in the employee's personnel record that the employee is qualified, as approved by the medical director, to assist in the self-care training.(6) The facility shall establish a nursing peer review committee to conduct nursing peer review, as required by Texas Occupations Code Chapter 303 (relating to Nursing Peer Review).(d) Each dietitian shall have a current Texas license, be a registered dietitian, and have a minimum of one year of professional work experience in clinical dietetics after becoming a registered dietitian.(e) Each social worker shall:(1) hold a current license as a social worker under Texas Occupations Code Chapter 505 (relating to Social Workers) and hold a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education; or(2) have at least two years of work experience as a social worker, one year of which was in a dialysis facility or transplantation program before September 1, 1976, and have an established consultative relationship with a social worker who has a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education.(f) A facility shall ensure biomedical technical staff meet the following requirements.(1) The facility's biomedical technical staff may be one or more individuals (including nursing staff) employed by or under contract with the facility as long as the individual meets the minimum qualifications for each required level of responsibility, as described in this subsection.(2) Only individuals qualified by training, education, or experience may operate, repair, or replace components of the systems used in providing dialysis treatment or reprocessing dialyzers.(A) Technical staff shall have minimum education, training, and experience documented and maintained on file in the facility, which includes:(i) a high school diploma or equivalent, except for technical staff employed by the facility for two or more years before April 11, 1999, who are exempt from this requirement; and(ii) training or experience, in one or more of the following:(I) completion of a college-based technical dialysis program;(II) completion of the didactic training and education requirement for patient care technicians set out in §507.72(a) and (b) of this chapter (relating to Training Curricula and Instructors); (III) current certification in technical aspects of dialysis by a nationally recognized testing organization; or(IV) 12 months experience in dialysis within the last two years.(B) Any staff member assigned responsibilities in the technical area shall pass an annual written competency examination, demonstrate skills related to the required level of responsibility, and be certified by the facility's medical director as competent to perform their assigned duties. Current certification by a national board in dialysis technology may substitute for the written test.(C) The technical staff shall annually complete a minimum of five hours of continuing education with a technical or end stage renal disease focus. Facility staff may provide continuing education. Continuing education documentation shall include the continuing education course title, duration, and author or instructor.(3) The technical supervisor is responsible for supervision of technical services. The technical supervisor shall meet the education, training, and experience requirements described in this paragraph.(A) The technical supervisor shall meet the requirements in paragraph (3) of this subsection.(B) The technical supervisor shall ensure technical staff demonstrate competency in equipment maintenance and repair, mechanical service, water treatment systems, and reprocessing of hemodialyzers, if applicable.(i) Before assuming technical supervisory responsibility, a technical supervisor trainee shall successfully complete the facility's orientation and training courses as established for each technical area.(ii) The medical director shall approve the training courses. The training courses shall follow a written curriculum with stated objectives. The curriculum shall include all items noted in this clause and paragraph (4)(B) of this subsection.(4) Facility staff responsible for the water treatment and dialysate systems shall demonstrate understanding of the risks to patients of exposure to water that has not been treated to remove contaminants and impurities.(A) The facility shall maintain training documentation for each individual who operates (regularly or intermittently) these systems to ensure safe operation of the water treatment and dialysate systems.(B) The staff responsible for water treatment and dialysate systems shall meet the education, training, and experience requirements described in paragraph (2) of this subsection and shall demonstrate competency by:(i) successful completion of the facility training course specific to water treatment, dialysate preparation, and related tasks, which must be approved by the medical director and follow a written curriculum with state objectives;(ii) completion of a training curriculum that includes(I) introduction to end stage renal disease;(II) principles of hemodialysis;(III) principles of infection control and basic microbiology for water treatment systems, machines, and sampling techniques;(IV) rationale for water treatment for dialysis;(V) risks and hazards of using unsafe water for dialysis;(VI) current water standards;(VII) source water characteristics;(VIII) communication with source water agencies and water treatment vendors;(IX) selection of water treatment equipment;(X) water purification equipment, to include filtration, carbon adsorption, and reverse osmosis;(XI) ion exchange to include softeners and deionizers;(XII) water distribution system and other equipment specific to the facility;(XIII) monitoring system performance, to include online and offline monitoring, aseptic sample collection, incubation of samples, and interpretation of results;(XIV) evaluation of water treatment component performance, to include filters, activated carbon adsorption beds, reverse osmosis, and ion exchange;(XV) evaluation of system performance, to include monitoring schedules and review of system failures;(XVI) purpose of each component of dialysate, to include electrolytes, glucose, acid, and buffer;(XVII) hazards of exposure of patients to a dialysate containing a different concentration of electrolytes than prescribed;(XVIII) testing methods in use to verify expected concentrations in any reconstituted components of the dialysate are achieved;(XIX) action to take in the event testing of a mixed batch of dialysate concentrate does not meet the expected parameters;(XX) labeling employed to positively identify each concentrate; and(XXI) procedures to ensure the proper transfer of concentrates from the manufacturer's drums to the holding tanks;(iii) confirmation of the ability to distinguish all primary colors; and(iv) successful completion of the facility's orientation and training course as established for the water treatment and dialysate preparation systems technician trainee before the trainee's initial assumption of responsibility.(5) The staff responsible for equipment maintenance and repair shall meet the education, training, and experience requirements described in paragraph (2) of this subsection and shall demonstrate competency by:(A) successful completion of the facility training course outlined in paragraph (2) of this subsection, relating to water treatment systems;(B) successful completion of a training curriculum, which includes:(i) prevention of transmission of hepatitis through dialysis equipment;(ii) safety requirements of dialysate delivery systems;(iii) repair and maintenance of dialysis and other equipment specific to the facility;(iv) electrical safety, including lockout or tagout;(v) emergency equipment maintenance;(vi) building maintenance;(vii) fire safety and prevention requirements; and(viii) emergency response procedures; and(C) successful completion of a written competency exam and demonstration of skills specific to the facility's mechanical and equipment service and water treatment and distribution systems.(6) The staff responsible for reprocessing hemodialyzers and other supplies shall meet the education, training, and experience requirements described in paragraph (2) of this subsection and shall demonstrate competency by:(A) successful completion of a training curriculum that includes the components of the standards for reuse of hemodialyzers listed in §507.30 of this chapter (relating to Technical Standards); and(B) successful completion of a written competency exam that includes return demonstration of skills specific to reprocessing of hemodialyzers and other dialysis supplies. Source Note: The provisions of this §507.54 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.54 Staff Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227208 03/12/2026 (a) A facility shall develop, implement, and enforce policies and procedures for a clinical record system to ensure complete and accurate documentation of care provided to each patient. The clinical record system shall make documentation readily available and systematically organized to facilitate the compilation and retrieval of information.(1) The facility shall centralize all information in the patient's clinical record and protect the record against loss or damage in accordance with state and federal regulations.(2) The facility shall provide an area for clinical records storage that is separate from all patient treatment areas and secured from unauthorized access. The facility shall store the active clinical record of each patient currently treated by the facility on site.(3) The facility shall maintain the confidentiality of each patient's personal and clinical records.(4) The facility shall not use signature stamps to authenticate clinical record entries.(5) The facility may preserve clinical records electronically. Electronic records shall meet all requirements of paper records, including protection from casual access and retention for the specified period. Systems shall ensure that facility staff may not alter entries regarding the delivery of care without evidence and explanation of such alteration. (6) The facility shall preserve inactive clinical records by electronic means and may store inactive records off site, as long as the facility maintains security, and ensures the record is readily retrievable for review by the Texas Health and Human Services Commission (HHSC) or HHSC designee.(7) Each patient's clinical record, whether hard copy, electronic, or a combination of both, shall include complete and pertinent information about the patient's condition, assessments by the interdisciplinary team, updated plans of care, all interventions and treatments prescribed and delivered, and details of any events occurring with the patient during treatment. The record of care shall be readily accessible to every authorized interdisciplinary team member so that safe care can be coordinated to best meet the patient's needs.(8) Each clinical record shall include:(A) identifying information;(B) consents and notifications;(C) if the patient requires an accommodation, details on how staff explained consent forms for treatment, whether staff obtained the patient's consent, and how staff explained to the patient the patient's rights and responsibilities;(D) documentation that the physician explained the treatment risks, benefits, and complications to the patient before the patient's first treatment;(E) documentation that a licensed registered nurse witnessed the patient signing the consent forms before the patient's first treatment;(F) physician orders;(G) progress notes;(H) problem list;(I) medical history and physical examination;(J) professional assessments by the registered nurse, social worker, and dietitian;(K) medications given during treatment, which may be listed on the treatment record; and a list of medications the patient takes at home;(L) transfusion records;(M) laboratory reports;(N) diagnostic studies;(O) hospitalization records;(P) consultations;(Q) records of creation and revision of access for dialysis;(R) plans of care, including evidence of interdisciplinary team review and adjustment;(S) evidence of patient education;(T) daily treatment records; and(U) discharge summary, if applicable.(b) A facility physician shall complete a comprehensive medical history and physical examination no later than 30 calendar days from the patient's admission to the facility and at least annually thereafter.(1) For a patient new to dialysis, the physician responsible for the dialysis care shall complete the history and examination.(2) For an established dialysis patient, the history and examination may be completed by an advanced practice registered nurse or physician assistant.(3) Before the first treatment in the facility, the physician shall inform the registered nurse functioning in the charge role of at least the patient's diagnoses, medications, hepatitis status, allergies, and dialysis prescription. The patient's clinical record shall include this data.(c) The patient's clinical record shall provide an ongoing and accurate report of the patient's progress, reflecting changes in patient status, plans for and results of changes in treatment, diagnostic testing, consultations, and unusual events. Each interdisciplinary team member shall record the patient's progress as indicated by any change in the patient's medical, nutritional, or psychosocial condition.(d) Facility staff shall note the patient's condition and response to treatment on the daily treatment record.(e) A facility shall ensure care for transient patients meets the following requirements.(1) Except as provided by paragraph (2)(B) of this subsection, before providing dialysis treatment to a transient patient the facility shall obtain and include, at a minimum:(A) orders for treatment in this facility;(B) a list of medications and allergies;(C) laboratory testing results no earlier than one month before treatment, which include screening for Hepatitis B status;(D) the most current plan of care;(E) the most current treatment records from the home facility; and(F) records of care and treatment at this facility.(2) If a facility dialyzes a patient who is normally dialyzed in another facility, the facility shall meet the following requirements.(A) The facility shall continuously evaluate staffing levels and use this information in determining whether to accept a transient patient for treatment.(B) If a transient patient arrives unannounced, the facility may provide dialysis after obtaining, at a minimum, from the patient records:(i) orders for treatment;(ii) Hepatitis B status; and(iii) medical justification by the physician ordering treatment that the patient's need for dialysis outweighs the need for the additional clinical information set out in this subsection.(3) In the event a transient patient's hepatitis status is unknown, the patient may undergo treatment as if the Hepatitis B surface antigen (HbsAg) test results were potentially positive, except that the facility shall not treat such a patient in the HBsAg isolation room, area, or machine.(f) Facility staff shall complete clinical records within 30 days after discharge. The discharge summary shall clearly identify the patient's disposition and include the diagnosis or cause of death, date of discharge or death, location of death, transplant, or relocation information when appropriate, and reason for discharge if not for transplantation or death.(g) Clinical records are the facility's property, and the facility shall safeguard clinical records against loss, destruction, or unauthorized use.(h) The facility shall provide copies of pertinent portions of a patient's record when the patient is transferred. The records provided shall include, at a minimum, the most current orders for dialysis treatment, last three treatment records, he current hepatitis status, and current plan of care. If the facility transfers the patient to another outpatient facility, the facility shall provide copies of the most recent history and physical and assessment of each interdisciplinary team member.(i) The facility shall retain records for a minimum of five years after the patient's discharge and in accordance with state and federal regulations. The facility shall not destroy clinical records that relate to any matter that is involved in litigation, unless the litigation has been finally resolved.(j) If a facility ceases operation, it shall arrange for the preservation of records to ensure compliance with this section. The facility shall notify HHSC in writing of the location of the clinical records and the clinical records custodian's name and address. Source Note: The provisions of this §507.55 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.55 Clinical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227209 03/12/2026 (a) A facility shall report only the following incidents to the Texas Health and Human Services Commission (HHSC). The facility shall report these incidents to HHSC within 10 business days after the facility being informed or possessing knowledge of:(1) the death of a dialysis patient that occurs in the facility;(2) the death of a dialysis patient that occurs within 24 hours after the patient's last dialysis treatment, unless the death is related to:(A) an accident unrelated to dialysis care and services;(B) a pre-scheduled elective surgery;(C) a previously executed do-not-resuscitate order or advance directive;(D) a hospice patient; or (E) a patient who withdraws from dialysis;(3) emergent hospital transfers from the dialysis facility; (4) the confirmed conversion of staff or a patient to Hepatitis B surface antigen (HbsAg) positive, unless it is a verified false positive;(5) the involuntary transfer or discharge of a patient, unless the involuntary transfer or discharge is due to nonpayment or the patient was a participant in the ESRD Network's Second Chance program, in which case there is no incident report required if the patient is involuntarily discharged within the first 90 days of placement;(6) a fire in the facility; or (7) a generator out of operation.(b) The facility shall report an incident listed in subsection (a) of this section to HHSC Complaint and Incident Intake through the HHSC online portal. Source Note: The provisions of this §507.56 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.56 Incident Reports https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227210 03/12/2026 (a) A facility shall meet the following requirements for in-center self-care.(1) If a licensed dialysis facility offers in-center self-care in addition to conventional hemodialysis, the facility shall develop, implement, and maintain policies and procedures related to self-care, including policies regarding staffing levels in the self-care milieu.(2) While nurse to patient ratios must remain the same, the facility may reduce the number of patient care technicians from a 4:1 ratio to a 6:1 ratio if:(A) the self-care area is separated from the conventional dialysis area, such as in a separate bay or room within the facility; and(B) self-care patients can, at a minimum, demonstrate the ability to:(i) set up and tear down the machinery used in their treatment;(ii) hold their own sites at termination of treatment, except for a catheter patient; and(iii) monitor and record their own vital signs before beginning and ending the day's treatment.(3) A licensed facility that offers the option of in-center self-care shall ensure that all assessments, evaluations, history and physicals, treatment plans, modality options education, and similar documents and activities are completed before starting or moving to self-care.(4) Before a patient moves from conventional dialysis to self-care in a licensed dialysis facility, the patient shall demonstrate verbal understanding of competencies in the self-care areas, as determined by the facility staff.(5) The facility shall maintain written documentation of self-care competencies via checklists and competency testing in the patient's medical record.(6) The facility shall annually evaluate a patient's competency and skills to verify the patient maintains the abilities and knowledge to continue self-care. The facility shall document the annual evaluation in the patient's medical record. A patient may take on additional aspects of self-care. Before the patient may independently complete the additional self-care aspects, the facility shall evaluate the patient's competency to perform the self-care aspects and document the evaluation for additional self-care aspects in the patient's medical record. The facility shall annually re-evaluate the patient's competency to perform the additional self-care aspects.(b) A facility shall meet the following requirements for transitional care services.(1) A facility offering transitional services shall develop, implement, and enforce policies and procedures specific to operation of transitional services.(2) Licensed dialysis facilities that offer transitional care shall ensure that all assessments, evaluations, history and physicals, treatment plans and similar documents and activities are completed before beginning treatment.(3) A facility offering transitional services shall provide the patient with appropriate education regarding end-stage renal disease, its treatment and treatment availability, and advisability of all modalities to include renal transplant, dietary concerns and needs, and social services.(4) A facility offering transitional services shall ensure the patient retains all rights applicable to treatment in a licensed dialysis facility. The interdisciplinary treatment team shall assess a patient for transitioning services no later than 30 calendar days after entry into the program. If the team determines a patient requires continued services only available in a conventional dialysis setting, the facility shall consider the patient for transfer to a conventional setting to continue the benefits of dialysis. The facility shall not consider this transfer as an involuntary discharge from the transitional facility.(5) Transitional direct care staff shall receive equivalent training to both in-center and home hemodialysis staff, including training to the manufacturer's specifications of the hemodialysis machine being used. The facility shall keep available upon request documentation of the transitional direct care staff's: (A) training and skills, and(B) competencies as approved by the medical director.(c) A facility shall meet the following requirements for integrated hemodialysis systems.(1) A licensed facility offering the use of self-contained or integrated hemodialysis systems shall develop, implement, and enforce policies and procedures related to these systems and staff shall have verification of competency for each type of machine they perform or monitor treatments on.(2) If the licensed dialysis facility uses self-contained or integrated hemodialysis systems along with conventional hemodialysis machines, the facility shall separate the self-contained units or integrated hemodialysis systems from the conventional machines.(3) Each patient shall receive education on the self-contained unit's use and efficacy.(4) A facility using solely self-contained or integrated hemodialysis systems shall follow the manufacturer's recommendations and instructions for the use of the machines.(5) A licensed facility offering the use of self-contained or integrated hemodialysis systems shall maintain a copy of the manufacturer's instructions on each type of unit used in the facility. The facility shall provide inspectors with a copy of the manufacturer's instructions and recommendations upon request.(6) A facility shall ensure a registered nurse is present in the integrated hemodialysis systems treatment area, and the facility shall maintain the same staffing ratios as for conventional dialysis. Source Note: The provisions of this §507.57 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.57 Nonconventional Dialysis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227211 03/12/2026 (a) This section applies only to an end stage renal disease (ESRD) facility located in a county for which:(1) the governor declared a state of disaster due to a pandemic or epidemic, pursuant to Texas Government Code Chapter 418 (relating to Emergency Management);(2) the commissioner of the Texas Department of State Health Services determined that a public health disaster exists, pursuant to Texas Health and Safety Code Chapter 81 (relating to Communicable Diseases; Public Health Disasters; Public Health Emergencies); and(3) the Texas Health and Human Services Commission (HHSC) designated this section as applicable, pursuant to paragraphs (1) and (2) of this subsection.(b) An ESRD facility that is experiencing a documented, significant staffing shortage may temporarily adopt the accommodations under this section to meet patient needs for the duration of the public health disaster.(c) Subject to HHSC approval, an ESRD facility may request a temporary exemption from staffing requirements:(1) for nursing services, as specified in §507.48 of this subchapter (relating to Nursing Services);(2) for nutrition services, as specified in §507.49 of this subchapter (relating to Nutrition Services);(3) for social services, as specified §507.51 of this subchapter (relating to Social Services); and(4) for staffing levels of direct care staff, as specified in §507.60 of this subchapter (relating to Staffing Table).(d) Notwithstanding §507.43(e) of this subchapter (relating to Quality Assessment and Performance Improvement), core staff members shall actively participate in quality assessment and performance improvement (QAPI) activities and attend meetings every other month.(e) Notwithstanding §507.47 of this subchapter (relating to Medication Storage and Administration), all verbal or telephone physician orders shall be documented and authenticated or countersigned by the physician not more than 30 calendar days from the date the order was given.(f) Notwithstanding §507.53 of this subchapter (relating to Home Dialysis Service), the staffing level for home dialysis patients, including all modalities, shall be one full-time equivalent registered nurse per 25 patients, or portion thereof.(g) Notwithstanding §507.54(d)(2) of this subchapter (relating to Staff Qualifications), each registered nurse who is assigned charge nurse responsibilities shall have at least 12 months of clinical experience and have three months of experience in hemodialysis after completion of the facility's training program. In addition:(1) the registered nurse shall be able to demonstrate competency for the required level of responsibility and the facility shall maintain documentation of that competency;(2) the registered nurse shall be certified by the facility's medical director and governing body;(3) the hemodialysis experience shall be within the last 24 months; and(4) a registered nurse who holds a current certification from a nationally recognized board in nephrology nursing or hemodialysis may substitute the certification for the three months experience in dialysis obtained within the last 24 months.(h) Notwithstanding §507.54(d)(4) of this subchapter, if patient self-care training is provided, a registered nurse who has at least 12 months of clinical experience and three months of experience in the specific modality shall be responsible for training the patient or family in that modality. When other personnel assist in the training, supervision by the qualified registered nurse shall be demonstrated.(i) Notwithstanding the deadline provision of §507.56(a) of this subchapter (relating to Incident Reports), a facility shall report an incident listed in §507.56(a)(1) - (5) of this subchapter to HHSC within 20 business days of the incident.(j) Notwithstanding §507.72(i) of this chapter (relating to Training Curricula and Instructors), for individuals with no previous experience in direct patient care, a minimum of 80 clock hours of classroom education and 200 clock hours of supervised clinical training shall be required for dialysis technicians. Training programs for dialysis technician trainees who have confirmed previous direct patient care experience may be shortened to a total of 40 clock hours of combined classroom education and clinical training if they demonstrate competency with the required knowledge and skills and there has not been more than a year of time elapsed since they provided patient care in a licensed ESRD facility setting. Source Note: The provisions of this §507.58 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.58 Staffing and Reporting Requirements During a Public Health Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227212 03/12/2026 (a) This section applies only to an end stage renal disease (ESRD) facility located in a county for which:(1) the governor declared a state of disaster due to a pandemic or epidemic, pursuant to Texas Government Code Chapter 418 (relating to Emergency Management);(2) the commissioner of the Texas Department of State Health Services determined that a public health disaster exists, pursuant to Texas Health and Safety Code Chapter 81 (relating to Communicable Diseases; Public Health Disasters; Public Health Emergencies); and(3) the Texas Health and Human Services Commission (HHSC) designated this section as applicable, pursuant to paragraphs (1) and (2) of this subsection.(b) An ESRD facility may temporarily adopt accommodations under this section to meet patient needs, support infection control procedures, and maintain necessary social distancing in response to a public health disaster.(c) Notwithstanding §507.52(b)(3) of this subchapter (relating to Medical Services), at a minimum, each patient receiving dialysis in the facility shall be seen by a physician on the medical staff once a month during the patient's treatment time.(d) Notwithstanding §507.52(b)(4) of this subchapter, home dialysis patients shall be seen by a physician, an advanced practice registered nurse (APRN), or a physician assistant (PA) no less than once a month. This visit by a physician, an APRN, or a PA may be conducted using telemedicine medical services.(e) Notwithstanding §507.53(l)(1) of this subchapter (relating to Home Dialysis Service), a registered nurse may conduct an initial monitoring visit of a patient's home adaptation before the patient beginning training for the selected home modality from outside the patient's home if the nurse performs the visit using a synchronous audiovisual interaction between the registered nurse and the patient while the patient is at home.(1) The nurse shall conduct the visit to the same review standards as a normal face-to-face visit.(2) If the nurse cannot perform the visit using a synchronous audiovisual interaction between the nurse and the patient, the nurse must conduct the visit in the patient's home. Source Note: The provisions of this §507.59 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.59 Medical Services and Home Dialysis During a Public Health Disaster https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227213 03/12/2026 The attached graphic sets out minimum staffing levels for nursing staff, direct care staff, and total clinical staff.Attached Graphic Source Note: The provisions of this §507.60 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES D OPERATIONAL REQUIREMENTS FOR PATIENT CARE AND TREATMENT §507.60 Staffing Table https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227214 03/12/2026 (a) An individual shall not act as a dialysis technician unless that individual is trained and competent as described in this subchapter.(b) A trainee shall identify themselves as a trainee during any time spent in the patient treatment area.(c) Until a trainee successfully completes the competency evaluation, a trainee may provide patient care only as part of a training program and under the immediate supervision of a registered nurse or an assigned preceptor. A preceptor shall be a licensed nurse or dialysis technician who has one year of experience in hemodialysis obtained within the last 24 months, a recommendation by the supervising nurse to be a preceptor, and a current competency skills checklist on file in the facility.(d) A facility shall have written physician standing orders specific to that facility authorizing delegation of responsibilities for a dialysis technician, as determined by the medical director and the facility.(e) A facility allowing a dialysis technician who is not a licensed vocational nurse to initiate or discontinue dialysis via a central venous catheter or manipulate a central venous catheter shall adopt, implement, and enforce policies and procedures that require: (1) the dialysis technician to be certified as a Certified Clinical Hemodialysis Technician (CCHT);(2) the dialysis technician to take the training described in §507.72(c)(3) of this subchapter (relating to Training Curricula and Instructors);(3) the dialysis technician to pass the competency evaluation described in §507.72(f) of this subchapter; and(4) a nurse to supervise the dialysis technician and ensure the dialysis technician follows all facility policies and procedures. Source Note: The provisions of this §507.71 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES E REQUIREMENTS FOR DIALYSIS TECHNICIANS §507.71 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227215 03/12/2026 (a) Each training program for dialysis technicians shall develop a written curriculum with objectives specified for each section.(b) The training curriculum for dialysis technicians shall include:(1) an introduction to dialytic therapies, history, and major issues to include:(A) a history of dialysis;(B) definitions and terminology;(C) communication skills;(D) ethics and confidentiality;(E) multidisciplinary process;(F) roles of other team members; and(G) information about renal organizations and resources;(2) the principles of hemodialysis to include:(A) principles of dialysis;(B) access to the circulatory system; and(C) anticoagulation, local anesthetics, and normal saline;(3) understanding the individual with kidney failure to include:(A) basic renal anatomy, physiology, and pathophysiology;(B) the effect of renal failure on other body systems;(C) symptoms and findings related to the uremic state;(D) modes of renal replacement therapy, including transplantation; (E) basic renal nutrition;(F) basic psychosocial aspects of end stage renal disease; (G) medications commonly administered to patients with end stage renal disease;(H) confidentiality of patient personal and clinical records;(I) professional conduct;(J) patient rights and responsibilities; and(K) rehabilitation;(4) dialysis procedures to include:(A) using aseptic technique;(B) technical aspects of dialysis, operation and monitoring of equipment, initiation and termination of dialysis;(C) delivering an adequate dialysis treatment and factors that may result in inadequate treatment;(D) observing and reporting patient reactions to treatment; (E) glucose monitoring and hemoglobin and hematocrit monitoring;(F) emergency procedures and responses, such as cardiopulmonary resuscitation, air embolism management, and response to line separation and hemolysis;(G) external and internal disasters, fire, natural disasters, and emergency preparedness; and(H) safety and quality assurance and performance improvement (QAPI);(5) hemodialysis devices to include:(A) theory and practice of conventional, high efficiency, and high flux dialysis;(B) dialysate composition, options, indications, complications, and safety;(C) monitoring and safety; and(D) disinfection of equipment;(6) water treatment to include:(A) standards for water treatment used for dialysis listed in §507.30 of this chapter (relating to Technical Standards); (B) systems and devices;(C) monitoring; and(D) risks to patients of unsafe water;(7) reprocessing, if the facility practices reuse, to include:(A) principles of reuse;(B) safety, QAPI, universal precautions, and water treatment; and(C) standards for reuse in the standards listed in §507.30 of this chapter;(8) patient teaching to include:(A) the technician's role in supporting patient education goals; and(B) adult education principles;(9) infection control and safety to include:(A) risks to patients of nosocomial infections, accidents, and errors in treatment;(B) universal precautions, aseptic technique, sterile technique, and specimen handling;(C) basic bacteriology and epidemiology;(D) risks to employees of blood and chemical exposure; and(E) electrical, fire, disaster, environmental safety, and hazardous substances; and(10) QAPI to include:(A) the technician's role in QAPI activities;(B) principles of QAPI; and(C) the importance of ongoing QAPI activities in ensuring the facility provides safe dialysis treatments to patients.(c) The facility's training curricula shall comply with the following requirements related to a dialysis technician's additional responsibilities.(1) If a dialysis technician is to assist with training or treatment of peritoneal dialysis patients, the facility's training curricula shall include:(A) principles of peritoneal dialysis;(B) sterile technique;(C) peritoneal dialysis delivery systems;(D) symptoms of peritonitis; and(E) other complications of peritoneal dialysis.(2) If a dialysis technician, other than a licensed vocational nurse (LVN), is to cannulate access or administer intravenous normal saline, intravenous heparin, subcutaneous lidocaine, topical lidocaine, or oxygen, the facility's training curricula shall include:(A) access to the circulation to include:(i) for a fistula, creation, development, needle placement, and prevention of complications;(ii) for a graft, creation, materials, needle placement, and prevention of complications; and(iii) symptoms to report;(B) safe administration of medications to include:(i) identifying the correct patient;(ii) ensuring the appropriate medication;(iii) measuring the appropriate dose;(iv) determining the appropriate route; and(v) checking the appropriate time for administration;(C) administration of normal saline to include:(i) reasons for administration;(ii) potential risks and complications;(iii) administration limits; and(iv) information to report and record;(D) administration of heparin to include:(i) reasons for administration;(ii) methods of administration;(iii) preparation of ordered dose;(iv) potential risks and complications; and(v) information to report and record;(E) administration of lidocaine to include:(i) reasons for administration;(ii) method of administration;(iii) preparation of ordered dose;(iv) potential complications and risks; and(v) information to report and record; and(F) administration of oxygen to include:(i) reasons for administration;(ii) method of administration;(iii) delivery of the ordered flow rate;(iv) potential complications and risks; and(v) information to report and record.(3) If a dialysis technician, other than a licensed vocational nurse, is to initiate or discontinue dialysis via a central venous catheter or manipulate a central venous catheter, the facility's training curricula shall include:(A) patient assessment;(B) infection control and aseptic technique;(C) materials used and prevention of complications;(D) observing and reporting patient reactions to treatment; (E) safety checks, potential complications, and risks; and(F) information to report and record.(d) The instructor shall maintain a roster of attendance for each training class.(e) The instructor shall evaluate each trainee weekly during the training program to determine the trainee's progress.(f) The facility shall administer a written examination encompassing the required content. The dialysis technician trainee shall pass the exam with a score of at least 80 percent before the trainee's release from orientation.(1) The examination shall encompass the content required in subsection (b) of this section.(2) When the dialysis technician trainee cannulates access, administers medications, initiates or discontinues dialysis via a central venous catheter, or manipulates a central venous catheter, the examination shall encompass the content required in subsection (c) of this section.(3) Other than the first examination for a specific responsibility in a facility, current certification as a dialysis technician by a nationally recognized testing organization may be substituted for the written examination.(g) An instructor for the course to train an individual as a dialysis technician shall be:(1) a physician who qualifies as a medical director;(2) a registered nurse with at least 12 months of experience in hemodialysis obtained within the last 24 months and a current competency skills checklist on file in the facility, or a registered nurse instructor of a dialysis technician training course of an accredited college or university;(3) a qualified dietitian or social worker providing training only within the individual's area of expertise; or(4) a technician with at least 12 months experience, qualified by training and experience in water treatment, dialysate preparation, reprocessing, or other technical aspects of dialysis providing training only within their area of expertise.(h) Licensed nurses and patient care technicians who have at least one year of experience in hemodialysis and a current competency skills checklist on file in the facility may assist in didactic sessions and serve as preceptors.(i) For an individual with no previous experience in direct patient care, a minimum of 80 clock hours of classroom education and 200 clock hours of supervised clinical training shall be required. Training programs for dialysis technician trainees who have previous direct patient care experience may be shortened if they demonstrate competency with the required knowledge and skills but may not be less than a total of 80 clock hours of combined classroom education and clinical training. Source Note: The provisions of this §507.72 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES E REQUIREMENTS FOR DIALYSIS TECHNICIANS §507.72 Training Curricula and Instructors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227216 03/12/2026 (a) The governing body shall ensure the facility's core staff members review the training records of each trainee, including tests and skills checklists, hear comments from the training instructors and preceptors, and validate that the trainee has successfully completed the training program and is competent to perform their job duties and tasks.(b) An individual who completes the facility's orientation and training program and the facility determines is qualified to deliver dialysis patient care may qualify as a dialysis technician by passing the written examination described in §507.72(f) of this subchapter (relating to Training Curricula and Instructors) and demonstrating competency by completing the skills checklist described in subsection (c) of this section.(c) The supervising nurse or a registered nurse who qualifies as an instructor under §507.72(g)(2) of this subchapter shall complete a competency skills checklist to document each dialysis technician trainee's knowledge and skills for:(1) assembling necessary supplies;(2) preparing dialysate according to procedure and dialysis prescription;(3) assembling and preparing the dialysis extracorporeal circuit correctly;(4) securing the correct dialyzer for the specific patient;(5) installing and rinsing dialyzer and all necessary tubing;(6) testing monitors and alarms, conductivity, and presence and absence of residual sterilants, if applicable;(7) setting monitors and alarms according to facility and manufacturer protocols;(8) obtaining pre-dialysis evaluation to include vital signs, weight, and temperature according to facility protocol and informing the registered nurse of unusual findings;(9) inspecting access for patency and, after cannulation is performed and heparin administered, initiating dialysis according to the patient's prescription, observing universal precautions, and reporting unusual findings to the registered nurse;(10) adjusting blood flow rates according to established protocols and the patient's prescription;(11) calculating and setting the dialysis machine to allow fluid removal rates according to established protocols and the patient's prescription;(12) monitoring the patient and equipment during treatment, responding appropriately to patient needs and machine alarms, and reporting unusual occurrences to the registered nurse;(13) changing fluid removal rate, placing patient in Trendelenburg position, and administering replacement normal saline as directed by the registered nurse, physician order, or facility protocol;(14) documenting findings and actions per facility protocol;(15) describing appropriate response to dialysis-related emergencies such as cardiac or respiratory arrest, needle displacement or infiltration, clotting, blood leaks, or air emboli, and nonmedical emergencies such as power outages or equipment failure;(16) discontinuing dialysis and establishing hemostasis by:(A) inspecting, cleaning, and dressing access according to facility protocol; and(B) reporting unusual findings and occurrences to the registered nurse;(17) obtaining and recording post-dialysis vital signs, temperature, and weight and reporting unusual findings to the registered nurse;(18) discarding supplies and sanitizing equipment and treatment chair according to facility protocol;(19) communicating the patient's emotional, medical, psychological, and nutritional concerns to the registered nurse;(20) maintaining current certification in cardiopulmonary resuscitation; and(21) maintaining professional conduct, good communication skills, and confidentiality in the care of patients.(d) For dialysis technician trainees who will be assisting with training or treatment of peritoneal dialysis patients, each trainee shall satisfactorily:(1) assist patients in ordering supplies;(2) make a dialysate exchange (draining and refilling the peritoneal space with dialysate) to include continuous ambulatory peritoneal dialysis exchange procedures, and initiation or discontinuation of continuous cycling peritoneal dialysis;(3) observe peritoneal effluent;(4) know what observations to report;(5) collect dialysate specimen; and(6) set up and operating continuous cycling peritoneal dialysis equipment.(e) For dialysis technician trainees who will be cannulating dialysis access and administering intravenous normal saline, intravenous heparin, subcutaneous lidocaine, topical lidocaine, or oxygen, each trainee shall satisfactorily:(1) cannulate to include:(A) inspecting the access for patency;(B) preparing the skin;(C) using aseptic technique;(D) placing needles correctly;(E) establishing blood access;(F) replacing needles;(G) knowing when to call for assistance;(H) securing needles; and(I) removing needles;(2) administer intravenous heparin to include:(A) checking the patient's individual prescription;(B) preparing the dose;(C) labeling the prepared syringe;(D) administering the dose; and(E) observing for complications;(3) administer normal saline to include:(A) understanding unit protocol;(B) checking the patient's prescription;(C) recognizing signs of hypotension;(D) notifying the registered nurse;(E) administering normal saline; and(F) rechecking vital signs;(4) administer subcutaneous or topical lidocaine to include:(A) checking the patient's prescription;(B) identifying the correct medication;(C) preparing the dose;(D) administering the dose; and(E) observing for complications; and(5) administer oxygen to include:(A) verifying the ordered flow rate from the nurse functioning in the charge role;(B) setting up the equipment; and(C) connecting the tubing for the patient.(f) For dialysis technician trainees who will be initiating or discontinuing dialysis via a central venous catheter or manipulating a central venous catheter, each trainee shall satisfactorily:(1) use aseptic technique;(2) establish blood access;(3) observe for complications;(4) document findings and actions per facility protocol;(5) know when to call for assistance and reporting unusual findings and occurrences to the registered nurse; and(6) administer intravenous heparin to include:(A) checking the patient's individual prescription;(B) preparing the dose;(C) labeling the prepared syringe;(D) administering the dose; and(E) observing for complications.(g) If a dialysis technician is to cannulate a dialysis access, initiate or discontinue dialysis via a central venous catheter, manipulate a central venous catheter, administer intravenous normal saline, intravenous heparin, subcutaneous lidocaine, topical lidocaine, or oxygen, the medical director shall verify and document the dialysis technician's competency to perform these tasks and delegate authority to the technician in accordance with Texas Occupations Code Chapter 157 (relating to Authority of Physician to Delegate Certain Medical Acts). Source Note: The provisions of this §507.73 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES E REQUIREMENTS FOR DIALYSIS TECHNICIANS §507.73 Competency Evaluation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227217 03/12/2026 (a) A facility's training program shall provide a certification or verification document to the dialysis technician trainee, documenting their successful completion of the training program and competency evaluation. This document shall indicate that the training program the trainee completed meets the requirements of this subchapter.(b) Another facility that may later employ the dialysis technician may accept the document described in subsection (a) of this section. Each employing facility shall have each newly hired experienced dialysis technician complete a written test and competency checklist in accordance with §507.73(c) - (e) of this subchapter (relating to Competency Evaluation) within a minimum 80 work hours after hire. Source Note: The provisions of this §507.74 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES E REQUIREMENTS FOR DIALYSIS TECHNICIANS §507.74 Documentation of Competency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227218 03/12/2026 The facility shall ensure a dialysis technician does not:(1) initiate patient education;(2) alter ordered treatment, including shortening the treatment time;(3) change central venous catheter dressings;(4) administer any medications other than intravenous normal saline, intravenous heparin, subcutaneous lidocaine, topical lidocaine, or oxygen, which may only be administered during a routine dialysis treatment;(5) administer blood or blood products;(6) perform nonaccess site arterial puncture;(7) accept physician orders;(8) provide hemodialysis treatment to pediatric patients under the age of 18 who weigh less than 35 kilograms; or(9) alter the level of electrolytes in dialysate through use of additives ("spiking"). Source Note: The provisions of this §507.75 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES E REQUIREMENTS FOR DIALYSIS TECHNICIANS §507.75 Prohibited Acts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227219 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission (HHSC) inspection and investigation process, an end stage renal disease (ESRD) facility:(1) may not record, listen to, or eavesdrop on any HHSC interview with facility staff or patients that the facility staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) may not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of facility staff when HHSC has requested a private room or office or distanced themselves from facility staff unless the facility first informs HHSC and the facility obtains written approval from HHSC before beginning to record or listen to the discussion.(b) A facility shall inform HHSC when security cameras or other existing recording devices in the facility are in operation during any internal discussion by or among HHSC staff.(c) When HHSC by words or actions permits facility staff to be present, an interview or conversation for which facility staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §507.81 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.81 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227220 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an inspection of each end stage renal disease (ESRD) facility prior to the issuance or renewal of a license.(1) A facility is not subject to additional annual licensing inspections subsequent to the issuance of the initial license while the facility maintains: (A) certification under Title XVIII of the Social Security Act, 42 United States Code §§1395 et seq.; or (B) accreditation from a national accreditation organization for the offered services.(2) HHSC may conduct an inspection of a facility exempt from an annual licensing inspection under paragraph (1) of this subsection before issuing a renewal license to the facility if the certification or accreditation organization has not conducted an on-site inspection of the facility in the preceding three years and HHSC determines that an inspection of the facility by the certification or accreditation body is not scheduled within 60 days of the license expiration date.(b) HHSC may conduct an unannounced, on-site inspection of a facility at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) a facility's plan of correction;(3) an order or special order of the HHSC executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(c) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its facilities by HHSC.(d) HHSC inspections to evaluate a facility's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or licensed station numbers;(3) routine inspections, which may be conducted without notice and at HHSC discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies; (5) inspections to determine if an unlicensed facility is offering or providing, or purporting to offer or provide, treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(e) A facility shall cooperate with any HHSC inspection and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the facility, unless prohibited by law.(f) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(g) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(h) Upon entry, HHSC holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the facility representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the inspection, including possible health and safety concerns. The facility may provide any final documentation regarding compliance during the exit conference.(k) HHSC maintains the confidentiality of facility records as applicable under state or federal law. Source Note: The provisions of this §507.82 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.82 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227221 03/12/2026 (a) A facility shall provide each patient and applicable legally authorized representative at the time of admission with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the facility.(1) The statement shall inform persons that they may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The facility shall prominently and conspicuously post this statement in patient common areas and in visitor's areas and waiting rooms so that it is readily visible to patients, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A complaint must be submitted using HHSC current CII contact information for that purpose, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints directed to HHSC CII based on the seriousness of the alleged violation and the level of risk to patients, personnel, and the public.(1) Allegations determined to be within HHSC regulatory jurisdiction relating to health care facilities may be investigated under this chapter.(2) HHSC may refer complaints outside HHSC jurisdiction to an appropriate agency, as applicable.(d) HHSC conducts investigations to evaluate a facility's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of patients. Complaint investigations may be coordinated with the federal Centers for Medicare & Medicaid Services and its agents responsible for the inspection of ESRD facilities to determine compliance with the Conditions of Participation under Title XVIII of the Social Security Act, (42 United States Code, §§1395 et seq.), to avoid duplicate investigations.(e) HHSC may conduct an unannounced, on-site investigation of a facility at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) a facility's compliance with any applicable statute or rule;(2) a facility's plan of correction;(3) a facility's compliance with an order of the HHSC executive commissioner or the executive commissioner's designee; (4) a facility's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its facilities by HHSC.(g) A facility shall cooperate with any HHSC investigation and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by, or on behalf of, the facility, unless prohibited by law.(h) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(i) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(j) Upon entry, the HHSC representative holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the investigation.(k) The HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the investigation. The facility may provide any final documentation regarding compliance during the exit conference.(l) Once an investigation is complete, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint.(m) HHSC maintains the confidentiality of facility records as applicable under state or federal law.(n) HHSC notifies complainants regarding the investigation's outcome within 10 business days after completing the investigation. Source Note: The provisions of this §507.83 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.83 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227222 03/12/2026 (a) A facility is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after mailing, whichever is earlier.(b) When HHSC finds deficiencies:(1) HHSC provides the facility with a written Statement of Deficiencies (SOD) within 10 business days after the exit conference via U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the facility's receipt of the SOD, the facility shall return to HHSC a written Plan of Correction (POC) that addresses each cited deficiency, including timeframes for corrections, together with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the facility in writing.(B) If HHSC does not accept the POC, HHSC notifies the facility in writing and requests the facility submit to HHSC a modified POC and any additional evidence of compliance no later than 10 business days after HHSC notifies the facility in writing.(C) The facility shall correct the identified deficiencies and submit to HHSC evidence verifying implementation of corrective action within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of a facility's compliance with this subsection or HHSC acceptance of a facility's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter. Source Note: The provisions of this §507.84 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.84 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227223 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227223 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission reports, in writing, to the appropriate licensing board any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure. Source Note: The provisions of this §507.85 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.85 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227224 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227224 03/12/2026 A facility may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by following the procedure listed on the HHSC website. Source Note: The provisions of this §507.86 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.86 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227225 03/12/2026 (a) The medical review board (MRB) may assist the Texas Health and Human Services Commission (HHSC) in determining the corrective action required when the results of an inspection or an annual report indicate significant problems potentially impacting patient outcomes exist. At the conclusion of an on-site inspection, HHSC may refer an end stage renal disease facility to the MRB if the results of the inspection present concerns related to patient outcomes. These facilities may be requested to provide additional information, or may be subject to an on-site inspection, corrective action plan, or enforcement action.(b) A corrective action plan may be used in accordance with Texas Health and Safety Code §251.061 (relating to Corrective Action Plan).(1) HHSC may use a corrective action plan as an alternative to enforcement action under Texas Health and Safety Code §251.061.(2) Before taking enforcement action, HHSC considers whether the use of a corrective action plan is appropriate. In determining whether to use a corrective action plan, HHSC considers whether:(A) the facility has violated Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities), or this chapter, and the violation has resulted in an adverse patient result;(B) the facility has a previous history of lack of compliance with the statute, this chapter, or a previously executed corrective action plan; or(C) the facility fails to agree to a corrective action plan.(c) HHSC may use a level one, level two, or level three corrective action plan, as determined by HHSC in accordance with this subsection, after inspection of the facility.(1) A level one corrective action plan is appropriate if HHSC finds the facility is not in compliance with Texas Health and Safety Code Chapter 251 or this chapter, but the circumstances are not serious or life-threatening. HHSC or a monitor may supervise the implementation of the plan.(2) A level two corrective action plan is appropriate if HHSC finds the facility is not in compliance with Texas Health and Safety Code Chapter 251 or this chapter and the circumstances are potentially serious or life-threatening, or if HHSC finds that the facility failed to implement or comply with a level one corrective action plan. HHSC or a monitor shall supervise the implementation of the plan. Supervision of the plan's implementation may include on-site supervision, observation, and direction. The facility is expected to comply with all HHSC requests, including supervision, observation, and direction, as requested by HHSC.(3) A level three corrective action plan is appropriate if HHSC finds that the facility is not in compliance with Texas Health and Safety Code Chapter 251 or this chapter and the circumstances are serious or life-threatening, or if HHSC finds that the facility failed to comply with a level two corrective action plan or cooperate with HHSC in connection with that plan. HHSC may require the appointment of a monitor to supervise the implementation of the plan, appointment of a temporary manager, or appointment of a monitor and temporary manager. Appointment of a temporary manager by agreement shall be in accordance with §507.88 of this subchapter (relating to Voluntary Appointment of a Temporary Manager). Involuntary appointment of a temporary manager shall be in accordance with §507.89 of this subchapter (relating to Involuntary Appointment of a Temporary Manager).(4) A corrective action plan is not confidential. Information contained in the plan may be exempted from required disclosure under Texas Government Code Chapter 552 (relating to Public Information) or other applicable law.(5) HHSC approves the monitor for a corrective action plan. The monitor shall be an individual or team of individuals and may include a professional with end stage renal disease experience or a MRB member.(A) The monitor shall not be a current employee or former employee within the past two years of the dialysis organization or an affiliated facility.(B) The monitor's purpose is to observe, supervise, consult, and educate the facility and the facility's employees under a corrective action plan and bring the facility into substantial compliance with the regulations of this chapter and all other state and federal laws and regulations in as short a time as practicable.(C) The monitor shall report their findings no less than once a month to facility management, administrators, and HHSC to report goals and accomplishments and set forth further improvements needed in the facility. Monitors shall reduce their time spent in the facility to allow staff to practice what they have learned, to the point that continued monitoring is no longer necessary nor desired.(D) HHSC may conduct an on-site inspection to determine the facility's progress under the monitor's direction. HHSC staff inspects monitored facilities within six months after imposing a facility monitor to determine whether the facility must maintain the corrective action plan under which the monitor was placed.(E) The facility shall pay the cost of the monitor.(F) A facility shall not use a monitor who is currently acting as a full-time monitor for another facility under a corrective action plan.(G) A facility shall select a monitor and submit the monitor's resume for HHSC approval of the monitor. Once the facility selects and HHSC approves a monitor, the facility shall ensure only the approved monitor is used. The facility shall not allow a subcontractor to take the place of the approved monitor. Source Note: The provisions of this §507.87 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.87 Corrective Action Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227226 03/12/2026 (a) A person holding a controlling interest in a facility may, at any time, request the Texas Health and Human Services Commission (HHSC) to assume the facility's management by appointing a temporary manager in accordance with Texas Health and Safety Code §251.091 (relating to Appointment by Agreement).(b) After receiving the request, HHSC may enter into an agreement providing for the appointment of a temporary manager to manage the facility under conditions considered appropriate by both parties, if HHSC considers the appointment desirable.(c) An agreement under this section shall:(1) specify all terms and conditions of the temporary manager's appointment and authority; and(2) preserve all rights of individuals served by the facility granted by law.(d) The temporary manager's primary duty is to ensure adequate and safe services are provided to patients until temporary management ceases.(e) The appointment terminates at the time specified by the agreement. Source Note: The provisions of this §507.88 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.88 Voluntary Appointment of a Temporary Manager https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227227 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227227 03/12/2026 (a) Under Texas Health and Safety Code §251.092 (relating to Involuntary Appointment), the Texas Health and Human Services Commission (HHSC) may request the attorney general to bring an action in the name and on behalf of the state to appoint a temporary manager to manage a facility if:(1) the facility is operating without a license;(2) HHSC has denied, suspended, or revoked the facility's license but the facility continues to operate;(3) license denial, suspension, or revocation proceedings against the facility are pending, and HHSC determines that an imminent or reasonably foreseeable threat to the health and safety of a facility's patient exists;(4) HHSC determines that an emergency exists that presents an immediate threat to the facility's patient's health and safety;(5) the facility is closing and arrangements for the care of patients by other licensed facilities have not been made before closure; or(6) HHSC determines a level three corrective action plan, under §507.87(c)(3) of this subchapter (relating to Corrective Action Plan) that includes appointment of an involuntary temporary manager, is necessary to address serious or life-threatening conditions at the facility.(b) After a hearing under Texas Health and Safety Code §251.092, a court appoints a temporary manager to manage a facility, if the court finds appointing the manager is necessary.(1) The court order addresses the temporary manager's duties and authority, which may include facility management and providing dialysis services to facility patients until specified circumstances occur, such as new facility ownership, compliance with the statute or this chapter, or facility closure.(2) If possible, the court appoints as temporary manager an individual whose background includes administration of end stage renal disease facilities or similar facilities.(3) The venue for an action under this section is in Travis County.(c) A temporary manager appointed under this section is entitled to a reasonable fee, as determined by the court in accordance with Texas Health and Safety Code §251.093 (relating to Fee; Release of Funds).(1) The facility shall pay the fee.(2) The temporary manager may petition the court to order the release of any payment owed to the manager for care and services provided to facility patients if the facility withholds payment. (3) Withheld payments that may be released may include payments withheld by a governmental agency or other entity before or during the temporary manager's appointment, including:(A) Medicaid, Medicare, or insurance payments; or(B) payments from another third party. Source Note: The provisions of this §507.89 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.89 Involuntary Appointment of a Temporary Manager https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227228 03/12/2026 (a) Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, or orders.(b) HHSC has jurisdiction to enforce violations of Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) and this chapter. HHSC may deny, suspend, or revoke a license or impose an administrative penalty for:(1) failure to comply with any applicable provision of Texas Health and Safety Code, including Chapter 251;(2) failure to comply with any provision of this chapter or any other applicable laws;(3) the facility, or any of its employees, committing an act that causes actual harm or risk of harm to the health or safety of a patient;(4) the facility, or any of its employees, materially altering any license issued by HHSC;(5) failure to comply with minimum standards for licensure; (6) failure to provide a complete license application;(7) failure to comply with an order of the executive commissioner or another enforcement procedure under Texas Health and Safety Code Chapter 251;(8) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights that reflects more than nominal noncompliance;(9) the facility aiding, committing, abetting, or permitting the commission of an illegal act;(10) the facility, or any of its employees, committing fraud, misrepresentation, or concealment of a material fact on any documents a facility is required to submit to HHSC or required to maintain pursuant to Texas Health and Safety Code Chapter 251, and the provisions of this chapter;(11) failure to comply with other state and federal laws affecting the health, safety, and rights of facility patients;(12) failure to timely pay an assessed administrative penalty as required by HHSC;(13) failure to submit an acceptable plan of correction (POC) for cited deficiencies within the timeframe required by HHSC;(14) failure to timely implement a POC for deficiencies cited by HHSC within the dates designated in the POC;(15) failure to comply with applicable requirements within a designated probation period; or(16) if the facility is participating under Title XVIII, and the CMS terminates the facility's Medicare provider agreement.(c) HHSC has jurisdiction to enforce violations of Texas Health and Safety Code Chapter 251 and this chapter. HHSC may deny a license if the applicant:(1) fails to provide timely and sufficient information or fees required by HHSC that is directly related to the application;(2) has had the following actions taken against the applicant within the two-year period preceding the application:(A) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;(B) federal Medicare or state Medicaid sanctions or penalties;(C) unsatisfied federal or state tax liens;(D) unsatisfied final judgments;(E) eviction involving any property or space used as an end stage renal disease (ESRD) facility or health care facility in any state;(F) unresolved federal Medicare or state Medicaid audit exceptions;(G) denial, suspension, or revocation of an ESRD facility license, a private psychiatric hospital license, or a license for any health care facility in any state; or(H) a court injunction prohibiting ownership or operation of an ESRD facility.(d) HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility. HHSC applies the requirements of Texas Occupations Code Chapter 53 (relating to Consequences of Criminal Conviction).(1) In determining whether a criminal conviction directly relates, HHSC considers the provisions of Texas Occupations Code §53.022 (relating to Factors in Determining Whether Conviction Directly Relates to Occupation) and Texas Occupations Code §53.023 (relating to Additional Factors for Licensing Authority to Consider After Determining Conviction Directly Relates to Occupation).(2) The following felonies and misdemeanors directly relate to the duties and responsibilities of a licensed facility because these criminal offenses indicate an inability or a tendency for the person to be unable to own or operate a facility:(A) a misdemeanor violation of Texas Health and Safety Code Chapter 251;(B) a misdemeanor or felony involving moral turpitude;(C) a misdemeanor or felony relating to deceptive business practices;(D) a misdemeanor or felony of practicing any health-related profession without a required license;(E) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(F) a misdemeanor or felony under Texas Penal Code (TPC) Title 5 (relating to Offenses Against the Person), involving a patient, resident, or client of any health care facility, a home and community support services agency, or a health care professional; or(G) a misdemeanor or felony under TPC:(i) Title 4 (relating to Inchoate Offenses);(ii) Title 7 (relating to Offenses Against Property);(iii) Title 8 (relating to Offenses Against Public Administration);(iv) Title 9 (relating to Offenses Against Public Order and Decency);(v) Title 10 (relating to Offenses Against Public Health, Safety, and Morals); or(vi) Title 11 (relating to Organized Crime).(H) Offenses listed in this paragraph are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign, or military jurisdictions that indicate an inability or tendency for the person or entity to be unable to own or operate a facility.(3) HHSC revokes a license on the licensee's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(e) If HHSC proposes to deny, suspend, or revoke a license, HHSC sends a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC or HHSC may personally deliver the notice. The notice to deny, suspend, or revoke a license, or impose an administrative penalty, states the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and states that the applicant or license holder has an opportunity for a hearing before taking the action.(1) The facility must request a hearing within 30 calendar days after receipt of the notice. Receipt of the notice is presumed to occur on the third business day after the notice is mailed by HHSC to the applicant's or licensee's last known address.(2) The request for a hearing shall be in writing and submitted to the Texas Health and Human Services Commission, Enforcement Unit, Regulatory Services Division.(3) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001 (relating to Administrative Procedure) and Texas Administrative Code, Title 1 Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(4) If the facility does not request a hearing in writing within 30 calendar days after receiving the notice, the facility is deemed to have waived the opportunity for hearing, and the proposed action shall be taken.(5) If the facility fails to appear or be represented at the scheduled hearing, the facility has waived the right to a hearing, and the proposed action shall be taken.(f) If HHSC suspends a license, the suspension shall remain in effect until HHSC determines that the reason for suspension no longer exists. An authorized representative of HHSC investigates before making a determination.(1) During the time of suspension, the suspended license holder shall return the license to HHSC.(2) If a suspension overlaps a renewal date, the suspended license holder shall comply with the renewal procedures in this chapter; however, HHSC may not renew the license until HHSC determines that the reason for suspension no longer exists.(g) If HHSC revokes or does not renew a license, a person may reapply for a license by complying with the requirements and procedures in this chapter at the time of reapplication. HHSC may refuse to issue a license if the reason for revocation or nonrenewal continues to exist.(h) Upon revocation or nonrenewal, a license holder shall return the license to HHSC within 30 calendar days after notification from HHSC.(i) In lieu of denying, suspending, or revoking the license, HHSC may place the facility on probation for a period of not less than 30 calendar days if the facility is found in repeated noncompliance and the facility's noncompliance does not endanger the public's health and safety.(1) HHSC provides the facility notice of probation and the items of noncompliance at least 10 calendar days before the probation period begins.(2) During the probation period, the facility must correct the items of noncompliance and report corrections to HHSC for approval. Source Note: The provisions of this §507.90 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.90 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227229 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227229 03/12/2026 The Texas Health and Human Services Commission (HHSC) may issue an emergency order to suspend a license issued under this chapter, if HHSC has reasonable cause to believe that the conduct of a license holder creates an immediate danger to the public health and safety.(1) An emergency suspension is effective immediately without a hearing or notice to the license holder.(2) On the license holder's written request, HHSC refers the matter to the State Office of Administrative Hearings and an administrative law judge of that office is required to conduct a hearing, not earlier than the 10th day or later than the 30th day after the date the hearing request is received, to determine if the emergency suspension is to be continued, modified, or rescinded. The hearing and any appeal are governed by HHSC rules for a contested case hearing and Texas Government Code Chapter 2001 (relating to Administrative Procedure). Source Note: The provisions of this §507.91 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.91 Emergency Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227230 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may assess an administrative penalty against a person who violates Texas Health and Safety Code Chapter 251 (relating to End Stage Renal Disease Facilities) or this chapter, under:(1) Texas Health and Safety Code (HSC) §251.066 (relating to Administrative Penalty),(2) HSC §251.067 (relating to Report Recommending Administrative Penalty),(3) HSC §251.068 (relating to Hearing; Order), (4) HSC §251.069 (relating to Notice and Payment of Administrative Penalty; Judicial Review; Refund), (5) HSC §251.070 (relating to Penalty Deposited to State Treasury), and (6) HSC §251.071 (relating to Recovery of Costs).(b) The penalty may not exceed $1,000 for each violation. Each day of a continuing violation constitutes a separate violation.(c) In determining the amount of an administrative penalty assessed under this section, HHSC considers:(1) the violation's seriousness;(2) the history of previous violations;(3) the amount necessary to deter future violations;(4) efforts made to correct the violation; and(5) any other matters that justice may require.(d) All proceedings for the assessment of an administrative penalty are subject to Texas Government Code Chapter 2001 (relating to Administrative Procedure).(e) If after investigation of a possible violation and the facts surrounding that possible violation, HHSC determines that a violation has occurred, HHSC gives written notice of the violation to the person alleged to have committed the violation. The notice will include:(1) the alleged violation's summary;(2) a statement of the proposed penalty amount, based on the factors listed in subsection (c) of this section; and(3) a statement of the person's right to a hearing on the violation's occurrence, the penalty amount, or both the violation's occurrence and the penalty amount.(f) Within 20 calendar days after receiving the notice, the person notified may accept the determination of HHSC made under this section, including the recommended penalty, or make a written request for a hearing on that determination.(g) If the person notified of the violation accepts the determination of HHSC, the executive commissioner issues an order approving the determination and ordering that the person pay the recommended penalty.(h) If the person notified fails to respond in a timely manner to the notice or if the person requests a hearing, the executive commissioner's designee:(1) refers the matter to the State Office of Administrative Hearings for an administrative law judge of that office to conduct a hearing; and(2) gives written notice of the hearing to the person.(i) At the hearing, the administrative law judge makes findings of fact and conclusions of law and promptly issues the executive commissioner a decision proposal regarding the violation's occurrence and the recommended proposed penalty amount, if the judge determines a penalty is warranted.(j) Based on the findings of fact and conclusions of law and the administrative law judge's recommendation, the executive commissioner by order may find that a violation has occurred and may assess a penalty or may find that no violation has occurred. The executive commissioner or the executive commissioner's designee gives notice of the executive commissioner's order to the person notified. The notice includes:(1) separate statements of the findings of fact and conclusions of law;(2) the amount of any penalty assessed; and(3) a statement regarding the person's right to judicial review of the executive commissioner's order.(k) Within 30 calendar days after the date the decision is final, the person shall:(1) pay the penalty in full;(2) pay the penalty amount and file a petition for judicial review contesting the violation's occurrence, the penalty amount, or both the violation's occurrence and the penalty amount; or(3) without paying the penalty amount, file a petition for judicial review contesting the violation's occurrence, the penalty amount, or both the violation's occurrence and the penalty amount. Within the 30-day period, a person who acts under this paragraph may:(A) stay the penalty's enforcement by:(i) paying the penalty amount to the court for placement in an escrow account; or(ii) giving to the court a supersedeas bond that is approved by the court for the penalty amount and that is effective until all judicial review of the executive commissioner's order is final; or(B) request the court to stay the penalty's enforcement by:(i) filing with the court a person's affidavit stating that the person is financially unable to pay the penalty amount and give the supersedeas bond; and(ii) giving a copy of the affidavit to HHSC by certified mail.(l) If HHSC receives a copy of an affidavit under subsection (k)(3)(B) of this section, HHSC may file with the court, within five calendar days after the date the copy is received, a contest to the affidavit. Source Note: The provisions of this §507.92 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.92 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227231 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may assess reasonable expenses and costs against a person in an administrative hearing if, as a result of the hearing, the person's license is denied, suspended, or revoked, or if administrative penalties are assessed against the person.(b) The person shall pay expenses and costs assessed under this section within 30 calendar days after the date of an order requiring the payment of expenses and costs is final.(c) HHSC may refer the matter to the attorney general for collection of the expenses and costs.(d) If the attorney general brings an action against a person under Texas Health and Safety Code §251.063 (relating to Injunction) or §251.065 (relating to Civil Penalty), or to enforce an administrative penalty assessed, and an injunction is granted against the person or the person is found liable for a civil or administrative penalty, the attorney general may recover, on behalf of the attorney general and HHSC, reasonable expenses and costs.(e) For purposes of this section, "reasonable expenses and costs" include expenses incurred by HHSC and the attorney general in the investigation, initiation, or prosecution of any actions, including reasonable investigative costs, court costs, attorney's fees, witness fees, and deposition expenses. Source Note: The provisions of this §507.93 adopted to be effective December 23, 2025, 50 TexReg 8289. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES F INSPECTIONS, INVESTIGATIONS, AND ENFORCEMENT §507.93 Recovery of Costs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225021 03/12/2026 (a) An end stage renal disease (ESRD) facility shall comply with the provisions of this section with respect to fire prevention and protection.(1) The facility shall comply with local fire codes.(2) The facility shall report all incidents of fire to the local fire authority and to Texas Health and Human Services Commission Complaint and Incident Intake as soon as possible, but not later than 10 calendar days following the incident. Any fire incident causing injury to a person shall be reported within one business day.(3) The facility shall adopt, implement, and enforce a written smoking policy.(b) The facility shall adopt, implement, and enforce a written policy for periodic inspection, testing, and maintenance of fire fighting equipment, portable fire extinguishers, and when installed sprinkler systems. If installed, fire sprinkler systems shall comply with National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13).(1) All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested, and maintained in accordance with National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2002 Edition.(2) Every portable fire extinguisher located in or upon the facility's property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 Edition.(c) A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §21.7.1.1. Copies of the plan shall be available to all staff.(1) An evacuation floor plan shall be prominently and conspicuously posted for display throughout the facility in public areas that are readily visible to patients, employees, and visitors.(2) Each facility shall conduct an annual training program for instruction of all personnel in the location and use of fire fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(3) The facility shall conduct one fire drill per shift per quarter, which shall include the transmission of the fire alarm signal and simulation of the emergency fire condition, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment. Written reports shall be maintained to include evidence of patient and staff participation. Fire exit drills shall incorporate the minimum requirements of NFPA 101, §§21.7.1.2 - 21.7.2.3.(4) All staff shall be familiar with the locations of fire fighting equipment. Fire fighting equipment shall be located so that a person shall not have to travel more than 75 feet from any point to reach the equipment.(d) A fire alarm system shall be installed, maintained, and tested, in accordance with National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72) and NFPA 101, §21.3.4. (e) A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101, §21.3.4.4.(f) As an aid to fire department services, every ESRD facility shall provide the following:(1) The facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Upon request, the facility shall submit a copy of the floor plans of the building to the local fire department officials. (3) The facility shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(g) When the facility is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire.(h) In this subsection, unless the context clearly indicates otherwise, "emergency" means an incident likely to threaten the health, welfare, or safety of a facility's patients, facility staff, or the public, including a fire, equipment failure, power outage, flood, interruption in utility service, medical emergency, or natural or other disaster.(1) In accordance with Texas Health and Safety Code §251.017, the facility shall adopt an emergency contingency plan for the continuity of emergency essential building systems that meets the requirements described by paragraph (2), (3), or (4) of this subsection.(2) The facility shall have an onsite permanent emergency generator affixed to a generator pad with a Type 2 essential electrical distribution system in accordance with National Fire Protection Association (NFPA) 99: Health Care Facilities Code, 2002 Edition, §4.5, and NFPA 110: Standard for Emergency and Standby Power Systems, 2002 Edition.(A) The emergency generator shall require an onsite fuel source and enough fuel capacity in the tank for a period of 24 hours or more, as determined by the electrical load demand on the emergency generator for that period. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the 24-hour fuel capacity on site is not required. The vapor liquified petroleum gas system shall require a dedicated fuel supply.(B) The facility shall install, test, and maintain the onsite emergency generator in accordance with NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.4, and NFPA 110 Standard for Emergency and Standby Power Systems.(C) The facility shall always keep the emergency generator not less than 10 feet from any electrical transformer.(D) The facility shall maintain on-site a sufficient quantity of potable water supply for the operation of the water treatment system for at least 24 hours.(E) The facility shall provide and maintain a water valve connection that allows an outside vendor to provide potable water to operate the facility's water treatment system.(3) The facility shall:(A) maintain sufficient resources to provide on demand or to execute a contract with an outside supplier or vendor to provide on demand:(i) a portable emergency generator that:(I) has an electrical transfer switch with a plug-in device sized to provide emergency power for patient care areas and complies with NFPA 99: Health Care Facilities Code, 2002 Edition, §4.5.2.2.2; and(II) has a water valve connection that allows for the use of potable water to operate the facility's water treatment system; and(ii) an alternate power source for light, including battery-powered light, that:(I) is separate and independent from the normal electrical power source;(II) can provide light for at least one-and-a-half hours;(III) can provide enough light to allow for safe evacuation of the building; and(IV) is maintained and tested at least four times each year; and(iii) potable water;(B) implement the emergency contingency plan when the facility loses of electrical power due to a natural or man-made event during which the electrical power may not be restored within 24 hours; and(C) contact the outside supplier or vendor with which the facility contracts under subparagraph (A) of this subsection, if applicable, within 36 hours after the facility loses electrical power.(4) The facility shall execute a contract with another licensed ESRD facility located within a 100-mile radius of the facility stipulating that the other ESRD facility will provide emergency contingency care to the facility's patients. The other ESRD facility with which the facility contracts must have an alternate power source for light, including battery-powered light, that:(A) is separate and independent from the normal electric power source;(B) can provide light for at least one-and-a-half hours;(C) can provide enough light to allow for safe evacuation of the building; and(D) is maintained and tested at least four times each year. Source Note: The provisions of this §507.501 adopted to be effective July 6, 2010, 35 TexReg 5835; amended to be effective February 21, 2023, 48 TexReg 893; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Y FIRE PREVENTION AND SAFETY REQUIREMENTS §507.501 Fire Prevention, Protection, and Emergency Contingency Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225022 03/12/2026 (a) An ESRD facility shall provide a physical environment that protects the health, safety, and welfare of patients, personnel, and the public. The physical premises and the physical environment of the facility and those areas of the facility's surrounding physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes as they relate to safe access and patient privacy.(b) An emergency communication system, such as radio-frequency communication devices, battery operated emergency phone, or facility cellular telephones, shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments.(c) No portable or ceiling fans shall be utilized in patient treatment areas, or in the reprocessing room.(d) Electrical extension cords and cables shall not be used for permanent wiring. When temporary electrical cords or cables are used, they shall be secured and protected to prevent tripping.(e) A nurses emergency calling system shall be installed in the patient waiting areas, all individual treatment rooms, exam rooms, isolation hepatitis B rooms, and toilet rooms used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in all areas. The visible and audible signals shall be cancelable only at the patient calling station. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.(f) Doors to an isolation or home dialysis training room shall not be lockable from inside the room.(g) When construction takes place during dialysis treatments, adequate provision shall be made for the safety and comfort of patients. Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.(h) When construction is done after hours or on weekends, the facility shall assure that all areas of construction are cleaned thoroughly and a clean safe environment is provided before patients are treated. Source Note: The provisions of this §507.502 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Y FIRE PREVENTION AND SAFETY REQUIREMENTS §507.502 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225023 03/12/2026 (a) An ESRD facility shall comply with the requirements of this section for handling and storage of gas and flammable liquids. The ESRD facility premises shall be kept free from accumulations of combustible materials not necessary for immediate operation of the facility.(1) Flammability of liquids and gases shall be determined by National Fire Protection Association 329, Handling Releases of Flammable and Combustible Liquids and Gases, 2002 Edition. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555.(2) Nonflammable gases shall be stored and distributed in accordance with Chapter 5 of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99).(3) Oxygen shall be administered in accordance with NFPA 99, §9.6.(b) Alcohol-based hand rubs (ABHRs) are considered flammable. When used, the ABHRs shall meet the following requirements:(1) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart.(2) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms.(3) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches.(4) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.(5) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage.(c) No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the ESRD facility building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the ESRD facility building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.(d) The installation, use, and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2002 Edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §507.503 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Y FIRE PREVENTION AND SAFETY REQUIREMENTS §507.503 Handling and Storage of Gases and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225024 03/12/2026 (a) All buildings in which existing ESRD facilities licensed by the department are located shall comply with this subsection. (1) A licensed ESRD facility which is licensed prior to the effective date of these rules is considered to be an existing licensed ESRD facility and shall continue, at a minimum, to meet the licensing requirements under which it was originally licensed.(2) Existing licensed ESRD facilities shall meet the requirements for Existing Ambulatory Health Care Occupancies contained in Chapter 21 of the 2000 edition of the National Fire Protection Association 101, Life Safety Code, (NFPA 101), the ESRD Standards/Rules (1996, 1999, or 2006 editions as amended), and the ESRD rules under which the buildings or sections of buildings were constructed. All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.(3) In lieu of meeting the requirements in paragraph (1) of this subsection, an existing licensed ESRD facility may, instead, comply with National Fire Protection Association (NFPA) 101, Life Safety Code 2003 Edition (NFPA 101) Chapter 21, Existing Ambulatory Health Care Occupancies.(b) All major remodeling, renovations, additions and alterations to an existing ESRD facility shall be done in accordance with the requirements for new construction in §117.102 of this title (relating to Construction Requirements for a New End Stage Renal Disease Facility). All areas of an existing ESRD facility that are not part of a major remodel, renovation, addition or alteration to the ESRD facility, are not required to meet these new construction requirements as long as the existing portion of the facility met the rules and codes that were in effect when it was originally constructed and licensed. When existing conditions make such changes impractical, the department may grant a conditional approval of minor deviations from the requirements of §117.102 of this title, if the intent of the requirements is met and if the care, safety and welfare of patients will not be jeopardized. The operation of the ESRD facility, accessibility of individuals with disabilities, and safety of the patients shall not be jeopardized by a condition(s) which is not in compliance with §117.102 of this title and this section.(1) Any alteration, modification, replacement, or any installation of new building equipment, such as mechanical, electrical, emergency power equipment, energy/utility management, conveying systems, plumbing, fire protection, or other equipment with a primary function of building service that affects life safety, infection control, changes the functional operation, or the health, safety and welfare of patients or staff shall comply with the requirements for new construction and shall not be replaced, materially altered, or extended in an existing ESRD facility until complete plans and specifications have been submitted to the department, and the department has reviewed and approved the plans and specifications in accordance with §117.104 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(2) Minor remodeling or alterations within an existing ESRD facility which do not involve alterations to load bearing members and partitions, change functional operation, affect fire safety, or involve any of the major changes listed in paragraph (1) of this subsection are considered to be minor projects and require evaluation and approval by the department. An ESRD facility shall submit by mail or fax a written request and floor plan for evaluation, a brief description of the proposed changes, and sketches of the area being remodeled. Based on such submittal, the department shall evaluate and determine whether any additional submittals or inspections are required. The department shall notify the ESRD facility of its decision. The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition would not require submission to the department for approval.(3) All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, add treatment stations, or affect fire safety are considered major projects. An ESRD facility shall comply with this section prior to beginning construction of major projects.(A) Plans shall be submitted in accordance with §117.104 of this title for all major remodeling or alterations.(B) As of February 9, 2009, all new facilities or increasing the number of in-center dialysis treatment stations in existing facilities shall have an isolation room or be granted a waiver by Center for Medicare and Medicaid Services. The waiver shall demonstrate that there is sufficient capacity in the geographic area for isolation rooms for hepatitis B positive patients. A written request for waiver shall be made through the Texas Department of State Health Services, Health Facility Compliance Group, Mail Code 1979, P.O. Box 149347, Austin, Texas, 78714-9347 for transmission to CMS.(C) Phasing of construction in existing facilities.(i) Projects involving alterations of or additions to existing buildings shall be programmed and phased so that on-site construction shall minimize disruptions of existing functions.(ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants shall not be jeopardized during construction.(iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.(iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.(v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present.(vi) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.(vii) When construction is done after hours or on weekends, the facility shall assure that all areas of construction are cleaned thoroughly and a clean safe environment is provided before patients are treated. All fire safety protection and building systems are in place and working properly.(c) A previously licensed ESRD facility which has been vacated or used for other purposes shall comply with all the requirements for new construction contained in §117.102 of this title in order to be licensed. Source Note: The provisions of this §507.511 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Z PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §507.511 Construction Requirements for an Existing End Stage Renal Disease Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225025 03/12/2026 (a) Any proposed new ESRD facility shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as an ESRD facility which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients.(1) An ESRD facility shall have at least two exits remotely located in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2003 Edition (NFPA 101), §20.2.4.1. When a required means of egress from the ESRD facility is through another portion of the building, that means of egress shall comply with the requirements of NFPA 101 which are applicable to the occupancy of that other building. Such means of egress shall be open, available, unlocked, unrestricted, and lighted at all times during the ESRD facility hours of operation. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555.(2) Hazardous locations.(A) A new ESRD facility or an addition to an existing ESRD facility shall not be constructed within 150 feet of easement boundaries or setbacks of hazardous underground locations including but not limited to liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not within the easement of high voltage electrical lines. Municipality's main natural gas lines in right-of-ways serving dwellings and gas lines on property servicing gas meter(s) under this provision are not consider natural high pressure lines.(B) A new ESRD facility and an addition to an existing ESRD facility shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants.(3) Undesirable locations.(A) In lieu of local codes, a new ESRD facility shall not be located closer than 1500 feet to nuisance producing industrial sites, feed lots, sanitary landfills, or manufacturing plants producing excessive noise or air pollution.(B) Flood plains.(i) When a new ESRD facility is constructed in a designated 100-year flood plain, the building finished floor elevation shall be one foot above the set base flood plain elevation. The building shall meet all local flood code ordinances and local flood control requirements.(ii) To obtain a license as an ESRD facility, a previously licensed ESRD facility and an existing building or a portion of an existing building located in a designated 100-year flood plain shall meet the requirement of clause (i) of this subparagraph.(iii) ESRD facility required functional components shall be constructed above the designated flood plain in a new addition to an existing ESRD facility located in a designated 100-year flood plain. The new addition shall meet the requirement of clause (i) of this subparagraph.(iv) Currently licensed ESRD facilities located within a designated 100-year flood plain are exempt from these requirements for renovations and repairs.(b) The ESRD facility site shall include paved roads, walkways, and parking in accordance with the requirements set out in this subsection.(1) Paved roads and walkways.(A) Paved roads shall be provided within lot lines for access from public roads to the main entrance and to service entrances. (B) Finished surface walkways shall be provided for pedestrians. When public transportation or walkways serve the site, finished surface walkways or paved roads shall extend from the public conveyance to the building entrance.(2) Parking and disability requirements.(A) Off-street parking shall be available for visitors, employees, and staff. Parking structures directly accessible from an ESRD facility shall be separated with two-hour fire rated noncombustible construction. When used as required means of egress for ESRD facility occupants, parking structures shall comply with National Fire Protection Association 88A, Standard for Parking Structures, 2002 edition. This requirement does not apply to freestanding parking structures. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.(B) In the absence of local code, one parking space shall be provided for each staff member on duty, plus one space for each four treatment stations, and one visitor's space for every five treatment stations. This ratio may be reduced in an area convenient to a public transportation system or to public parking facilities. Parking facilities shall be increased accordingly when the size of existing facilities is increased.(C) When on-street parking is available and acceptable to the local authorities having jurisdiction, the numbers of parking spaces may be reduced accordingly and shall meet the requirement of subparagraph (B) of this paragraph.(D) Special considerations benefiting disabled staff, visitors, and patients shall be provided. Each ESRD facility shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101 - 336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities or 16 Texas Administrative Code, Part 4, Chapter 68, §68.20 (relating to Buildings and Facilities Subject to Compliance with the Texas Accessibility Standards), Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Texas Government Code, Chapter 469.(c) Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, the ESRD facility shall be constructed in accordance with the International Building Code, 2003 edition, published by the International Code Council, 500 New Jersey Avenue, Northwest, 6th Floor, Washington, District of Columbia 20001-2070, (800) 344-3555.(1) All new construction, including conversion of an existing building to an ESRD facility or establishing a separately licensed ESRD facility within another existing building, shall comply with NFPA 101, Chapter 20, New Ambulatory Health Care Occupancies, of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), and subchapters G and H of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Construction documents shall be submitted to the department in accordance with §117.104 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(A) Construction types for multiple building occupancy.(i) When an ESRD facility is part of a larger building which complies with NFPA 101, §20.1.6, Minimum Construction Requirements for (fire resistance) construction type, the designated ESRD facility shall be separated from the remainder of the building with a minimum of one-hour fire rated construction.(ii) When an ESRD facility is located in a multistory building of two or more stories, the entire building shall meet the construction requirements of NFPA 101, §20.1.6.3. An ESRD facility shall not be located in a multistory building which does not comply with the minimum construction requirements of NFPA 101, §20.1.6.3.(iii) When an ESRD facility is part of a one-story building that does not comply with the construction requirements of NFPA 101, §20.1.6.2, the ESRD facility shall be separated from the remainder of the building with a 2-hour fire rated construction. The designated ESRD facility portion shall have the construction type upgraded to comply with NFPA 101, §20.1.6.2.(B) Special provisions shall be made in the design of a facility if located in a region where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, or floods.(2) A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and the requirements of this chapter.(3) The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists.(4) Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter. (5) Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, safety to health and welfare of individuals, and safety to those prescribed by this subchapter, provided technical documentation which demonstrates equivalency is submitted to the department for approval.(6) Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed and constructed in accordance with other occupancy classifications requirements listed in NFPA 101.(d) Spatial requirements.(1) Administration and public areas.(A) Patient entrances shall be located at grade level, be accessible to individuals with disabilities, and provide exterior covered protection against inclement weather. The minimum exterior protection covering shall be no smaller than 4 feet by 6 feet wide. A covered area for patients in wheelchairs shall be provided next to the opening area of the door swing and door swing shall not interfere within this area. When an ESRD is located on a floor above grade level, elevators shall be accessible and shall meet the requirements of §117.103 of this title (relating to Elevators, Escalators, and Conveyors).(B) A waiting area or lobby shall be provided within the ESRD facility and include having the following rooms and items:(i) public toilet facilities; and(ii) telephone(s) for public use.(C) A designated reception area with desk or counter shall be provided.(D) Space shall be provided for private interviews for family members relating to social services, credit, or admission.(E) An office(s) shall be provided for business transactions, records, and administrative and professional staff.(F) The facility shall provide an area for storage of clinical records which is separate from all patient treatment areas, and shall be secured from unauthorized access. The facility shall store the active clinical record of each patient currently treated by the facility on site.(G) A general storage room with a minimum of 2 square feet per treatment station shall be provided. General storage may be located in one or more rooms or closets, and shall be located outside of the patient treatment areas.(H) Storage space for wheelchairs shall be provided, and shall be out of the direct line of traffic.(2) Equipment rooms with adequate space shall be provided for mechanical and electrical equipment. These areas shall be separate from public, patient, and staff areas.(3) An exam room shall be provided for medical examinations. The room shall have a minimum clear floor space of 80 square feet area exclusive of fixed cabinets and shelves and contain a counter for writing and a hand washing sink with hands-free operable controls.(4) When a patient is hepatitis B positive, the treatment shall be in a separated dedicated isolation room. All treatment in the isolation room shall be for hepatitis B patients only.(A) A single hepatitis B patient isolation room shall be a minimum of 120 square feet clear area exclusive of fixed and movable cabinets and shelves.(B) When multiple-treatment stations for hepatitis B patients are treated in a single isolation room, each individual patient treatment area shall be 80 square feet with a minimum of 8 feet clear dimension exclusive of fixed or wall mounted cabinets and built-in shelves. The clearance between the side of a station/chair and a wall/partition shall be a minimum of 3 feet. The clearance between sides of stations/chairs shall be a minimum of 4 feet.(C) The isolation treatment room shall include a work counter and a hand washing sink with hands-free operable controls, and space for patient care supplies and equipment. The fixed and moveable cabinets and shelves shall not encroach upon the patient treatment station/chair clear floor space/area.(D) The isolation treatment room shall have viewing panels in doors and/or walls for continuous direct visual monitoring of the patient in the room.(E) The dialysis equipment shall be designated, reserved, and used for hepatitis B positive patients only.(F) Disinfection of dialysis equipment shall occur in the hepatitis B treatment isolation room and shall meet the requirements of §117.33(d)(2)(C) of this title (relating to Sanitary Conditions and Hygienic Practices).(G) As of February 9, 2009, all new facilities or increasing the number of in-center dialysis treatment stations in existing facilities shall have an isolation room or be granted a waiver by Centers for Medicare and Medicaid Services. The waiver shall demonstrate that there is sufficient capacity in the geographic area for isolation rooms for hepatitis B positive patients. A written request for waiver shall be made through the Texas Department of State Health Services, Health Facility Compliance Group, Mail Code 1979, P.O. Box 149347, Austin, Texas, 78714-9347 for transmission to CMS.(5) When home training is provided in the facility, a private treatment area of at least 120 square feet exclusive of fixed and movable cabinets and shelves shall be provided. This room shall contain a work counter, a hand washing sink with hands-free operable controls, and a separate drain for fluid disposal.(6) A sufficient number of janitor's closets shall be provided throughout the facility to maintain a clean and sanitary environment. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment.(7) When laboratory services are provided on site the following shall be provided and meet the requirements of §117.45(l) of this title (relating to Provision and Coordination of Treatment and Services).(A) The laboratory workroom/area shall include a counter and a sink with hands-free operable controls. Laboratory services and medication preparation and dispensing shall not be done within the same designated space.(B) Cabinets or closets shall be provided for supplies and equipment used in obtaining samples for testing.(C) Refrigerated specimen storage shall be provided for specimens waiting for transfer to off-site testing. The refrigerators shall be maintained with documentation of the appropriate temperature for such storage.(8) When laundry and linen is provided, processing may be done within the center or off site at a commercial laundry.(A) When on-site linen processing is provided, soiled and clean processing operations shall be separated and arranged to provide a one-way traffic pattern from soiled to clean areas. The following rooms and items shall be provided:(i) a soiled linen processing room which includes areas for receiving, holding, sorting, and washing;(ii) a clean linen processing room which includes areas for drying, sorting, folding, and holding prior to distribution;(iii) supply storage cabinets in the soiled and clean linen processing rooms;(iv) hand washing sink within the soiled linen processing room; and(v) a storage room for clean linen. Clean linen storage may be combined with the clean work room.(B) When linen is processed off site, the following areas shall be provided:(i) clean linen shall be stored within the clean supply area; and(ii) soiled linen shall be stored in a designated space in the facility.(9) Space shall be provided for the safe storage and disposal of waste as appropriate for the material being handled and in compliance with all applicable rules and regulations.(10) At a minimum, the medication area shall include a counter, a refrigerator, and a hand washing sink with hands-free operable controls. Storage and preparation of medication shall be done from a medication area and shall be under visual control of nursing staff. Medication preparation, dispensing and laboratory services shall not be done within the same designated areas. The refrigerators used for storage of medications shall be maintained with documentation of the appropriate temperatures for such storage.(11) When peritoneal dialysis (PD) training is provided within the ESRD facility, a patient treatment training room shall have a minimum of 120 square feet of clear floor area exclusive of fixed and movable cabinets and shelves.(A) The PD treatment room shall contain cabinets, a work counter, and a hand washing sink with hands-free operable controls.(B) An additional clinical sink or equivalent flushing rim sink with hands-free operable controls shall be provided. The clinical sink or equivalent flushing rim sink and the hand washing sink shall have a minimum separation of 6 feet.(C) A physical partition between the clinical sink or equivalent flushing rim sink and the hand washing sink may be constructed in-lieu-of the 6 foot separation. The partition shall be a minimum of 5 feet in height from the finished floor and 2 feet in width from the wall or from the wall to the front edge of the countertop whichever is greater.(12) When a reuse room is provided, the room shall be sufficiently sized to house dialyzers reprocessing area, breakdown area, a storage area/room and work area. All fixed and moveable equipment shall require a minimum of three feet of clear and unobstructed working space on all sides of fixed or moveable equipment that require access for staff. The reuse room shall include a work counter, deep utility service sink and separate hand washing sink with hands-free operable controls, refrigerator and storage space and shall meet the requirements of §117.32(d) of this title (relating to Water Treatment, Dialysate Concentrates, and Reuse).(A) Dialyzers reprocessing area shall be arranged for the one-way movement from soiled dialyzers and materials to cleaning and storage.(B) Breakdown of dialyzers shall be processed in the soiled processing area of the reprocessing area. The deep utility service sink with hands-free operable controls shall be located within the soiled processing area. There shall be adequate storage space to store the soiled/used dialyzers before processing occurs. The minimum depth of the utility sink shall not be less than 14 inches.(C) The reuse room shall provide either a separate storage room or within the reuse room storage space to store all reprocessed cleaned dialyzers. There shall be a definitive separation between storing used and reprocessed dialyzers, and the temperature in the storage areas shall be maintained in accordance with the manufacturer's direction for use.(13) The treatment area(s) or rooms shall be separate from the administrative area(s).(A) When individual hemodialysis patient treatment room(s) is provided, the room shall have a minimum of 120 square feet of clear floor area exclusive of fixed and movable cabinets and shelves. The patient treatment room shall contain cabinets, work counter, and a hand washing sink with hands-free operable controls.(B) In multiple-treatment stations, each individual patient treatment area shall be 80 square feet exclusive of fixed or wall mounted cabinets and built-in shelves. A minimum of 8 feet width shall be provided for the head wall for each station. The clearance between the side of a chair and a wall shall be a minimum of 3 feet, and the back of the extended chair and a wall shall be a minimum of 1 foot. A clear unobstructed width of 3 feet 8 inches shall be available at the foot of each treatment area(s) outside of the 80 square feet treatment area for passage of equipment, gurneys, and personnel.(C) The multiple-treatment station area shall contain cabinets, work counters, and hand washing sinks with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the patient treatment station.(D) A nurse station shall be located within the dialysis treatment area(s) and designed to provide visual observation of all patient stations. The nurse station shall have counters for storage and access to a hand washing sink(s) with hands-free operable controls.(E) One hand washing sink with hands-free operable controls shall be provided for every six stations. Sinks shall be uniformly distributed.(F) When required or requested, privacy shall be provided for each patient in the open treatment area with portable moveable screens.(e) Service areas.(1) A clean storage room or closet shall be provided for patient care items, clean and sterile supplies.(2) Emergency eyewash shall be provided conveniently for staff use and comply with ANSI Z358.1.(3) Dialysis solutions may be processed from a central batch delivery system or prepared in an on-site mixing room. When provided, a mixing room shall include a sink, storage space, and holding tanks.(4) Patient toilet rooms shall be located within the treatment area(s) and include hand washing sink(s) with hands-free operable controls. Patient toilet room shall be at a ratio of 1 toilet room for every 40 treatment stations or fraction thereof.(5) Staff toilet room(s) shall be provided and include hand washing sink(s) with hands-free operable controls. The toilet room shall be outside the treatment area but convenient for staff use only.(6) The water treatment and equipment for the dialysis shall be located in a room not accessible to unauthorized persons. The water room shall be designed and house the water treatment system and meet the requirements of §117.32(b) of this title.(f) Details and finishes in new construction projects, including additions and alterations, shall be in compliance with this subsection, with NFPA 101, Chapter 20, and with local building codes.(1) General detail requirements.(A) Fire safety features, including compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with §117.101 of this title (relating to Construction Requirements for an Existing End Stage Renal Disease Facility), and NFPA 101, Chapter 20. The Fire Safety Evaluation System for Health Care Occupancies contained in the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 Edition, Chapter 4, shall not be used in new building construction, renovations or additions to existing ESRD facilities.(B) Exits, corridors and doors.(i) A facility shall provide two exits remote from each other in accordance with NFPA 101, §20.2.4.1. At least one exit door shall be accessible by an ambulance from the outside. This door may also serve as an entry for loading or receiving goods.(ii) Corridors providing access to all patient treatment area(s) and exits shall be at least three feet eight inches in clear and unobstructed width, not less than seven feet six inches in height, and constructed in accordance with requirements listed in NFPA 101, §20.2.1. (iii) Items such as drinking fountains and vending machines shall be so located as to not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment shall not be stored so as to project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(iv) Doors at all openings between corridors and rooms or spaces subject to occupancy shall be swing type. Elevator doors are excluded from this requirement.(v) Doors, except doors to spaces such as small closets which are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the required corridor width. Large walk-in type closets are considered as occupiable spaces.(vi) All doors in the means of egress shall be not less than 36 inches in clear width.(vii) The minimum width of doors for patient access to treatment, examination, and consultation areas/rooms shall be 36 inches in clear width.(viii) Rooms containing a toilet, intended for patient use, shall be provided with at least one door having hardware which will permit access from the outside in any emergency.(ix) Horizontal sliding doors serving an occupant load of fewer than 10 shall be permitted. The area served by the door shall have no high hazard contents. The door shall be readily operable from either side without special knowledge or effort. The force required to operate the door in the direction of door travel shall be not more than 30 pounds per foot to set the door in motion, and shall be not more than 15 pounds per foot to close the door or open in the minimum required width. The door assembly shall comply with any required fire protection rating, and, where rated, shall be self-closing or automatic closing. The sliding doors opening to the egress corridor doors shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. The sliding doors may have breakaway provisions and shall be installed to resist passage of smoke. The latching sliding panel shall have a minimum clear opening of 36 inches in the fully open position. The fixed panels may have recessed tracks.(x) Doors shall not open immediately onto a stair without a landing. The landing shall be 44 inches deep or have a depth at least equal to the door width, whichever is greater.(xi) All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 Edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(C) Glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101, §18.3.3.(D) Grab bars shall be provided at patient toilets and at the weight scales. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars intended for use by the disabled shall also comply with ADA requirements.(E) Location and arrangement of fittings for hand washing sinks shall permit their proper use and operation. Hand washing sinks with hands-free operable controls shall be provided within each workroom, examination, treatment room, and toilet room. Hands-free includes blade-type handles, and foot, knee, or sensor operated controls. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing sinks shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the sink. In addition to the specific areas noted, hand washing sinks shall be provided and conveniently located for staff use throughout the ESRD facility where patient care contact occurs and services are provided.(F) A liquid or foam soap dispenser shall be located at each hand washing sink.(G) Provisions for hand drying shall be included at all hand washing sinks. There shall be hot air dryers or individual paper towel dispensers enclosed in such a way as to provide protection against dust or soil and ensure single-unit dispensing.(H) The minimum ceiling height shall be eight feet with the following exceptions.(i) Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.(ii) Rooms containing ceiling-mounted equipment shall have the ceiling height clearance increased to accommodate the equipment or fixtures.(iii) Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.(I) The dialysis facility shall not be located directly under recreation rooms, exercise rooms, and similar spaces where impact noises may be generated unless special provisions are made to minimize noise.(J) Rooms containing heat-producing equipment such as heater rooms, laundries, etc. shall be insulated and ventilated to prevent any occupied floor surface above from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature. (K) Thresholds and expansion joint covers shall be flush or not more than one-half inch above the floor surface to facilitate the use of wheelchairs and carts. Expansion and seismic joints shall be constructed to restrict the passage of smoke and fire and shall be listed by a nationally recognized testing laboratory.(2) General finish requirements.(A) Portable privacy screens shall be provided to assure patient privacy when required or requested by a patient. When not in use the screens shall be stored conveniently within the treatment area for immediate use.(B) Flame spread and smoke developed limitations of interior finishes shall comply with NFPA 101, §10.2. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition, and National Fire Protection Association 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 2001 Edition, shall be provided.(C) Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes:(i) painted concrete for water treatment areas, mechanical, electrical, janitor's closets and general storage;(ii) exposed concrete shall be sealed for water treatment areas, mechanical, electrical, janitor's closets and general storage;(iii) vinyl sheets and vinyl composition tiles for offices, lobbies, administrative areas, storage, toilet rooms, treatment areas/rooms, isolation treatment room, exam rooms, training room, reprocessing rooms, support spaces and nontreatment areas;(iv) when monolithic or seamless flooring is installed it shall be impervious to water, coved and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles. The base shall not be less than six inches in height. Welded joint flooring is acceptable;(v) marble, ceramic and quarry tile for offices, lobbies, waiting, toilet rooms, administrative areas, wet areas, and similar spaces;(vi) carpet flooring for offices, administrative areas, and similar spaces; and(vii) terrazzo for offices, lobbies, administrative areas, and similar spaces.(D) Wall finishes shall be smooth, washable, moisture resistant, and cleanable.(i) Wall finishes shall be water-resistant in the immediate area of plumbing fixtures.(ii) Wall finishes subject to frequent wet cleaning methods shall be impervious to water, tightly sealed and without voids.(E) Ceilings which are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing. Three types of ceilings that are required in various areas of the ESRD facility are:(i) ordinary ceilings are required in all areas or rooms in the ESRD facility unless a requirement requires a specific type of ceiling for such space. This includes ceilings such as acoustical tiles installed in a metal grid which are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners; (ii) washable ceilings are ceilings that are made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid when installed in the water treatment room and reuse room;(iii) monolithic ceilings which are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish shall be provided for the isolation room and reuse room; and(iv) no finished ceiling is required in mechanical, electrical, general storage, and water treatment rooms.(F) Floor, wall and ceiling penetrations by pipes, ducts, and conduits, or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents and insects. Joints of structural elements shall be similarly sealed.(G) Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(H) A sign shall be posted at the entrance to each toilet/restroom to identify the facility for public, staff or patient use.(I) When vinyl sheets and vinyl composition tiles are used for toilet rooms, treatment areas/rooms, isolation treatment rooms, exam rooms, training rooms, and reprocessing rooms the joints shall be sealed to prevent moisture and blood from seeping into the joints and under the tile.(g) This subsection contains common requirements for mechanical systems; steam and hot and cold water systems; air conditioning, heating and ventilating systems; and thermal and acoustical insulation.(1) When mechanical equipment is exposed to weather, it shall be protected by weatherproof construction or weather protected.(2) Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators. (3) Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or his representative that the installation and performance of these systems conform to the requirements of the plans and specifications.(A) Upon acceptance of the mechanical system, the owner shall be provided with parts lists and procurement information with numbers and description for each piece of equipment.(B) Upon acceptance of the mechanical system, the owner shall be provided with instructions in the operational use of systems and equipment as required.(4) All heating, ventilating and air conditioning (HVAC) systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition (NFPA 90A), NFPA 99, Chapter 6 and the requirements contained in this subsection.(5) All rooms and areas in the ESRD facility shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.(A) The systems serving all treatment areas/rooms, exam rooms, and isolation rooms, shall be capable of maintaining a temperature range between 68 and 78 degrees Fahrenheit and a relative humidity range between 45% and 60%.(B) The indoor design temperature in all other areas shall be between 68 and 75 degrees Fahrenheit with relative humidity of not less than 30%.(6) Ventilation systems for the reuse room and airborne isolation room shall be connected to an air exhaust system to the outdoors which is separate from the building exhaust system, have an exhaust fan located at the discharge end of the system, and have an exhaust duct system of noncombustible corrosion-resistant material as needed to meet the planned usage of the system.(A) The bottoms of wall-mounted return and exhaust air openings shall be at least six inches above the floor. All exhaust air openings and return air openings located higher than six inches but less than seven feet above the floor shall be protected with grilles or screens having openings through which a one-half inch sphere will not pass.(B) Exhaust outlets shall be above the roof level and arranged to minimize recirculation of exhaust air into the building. Exhaust outlets shall be located at least 25 feet from any fresh air intake of ventilating systems. (Prevailing winds and proximity to other structures may require more stringent requirements.) Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.(C) If applicable, the reuse room and the airborne isolation room exhaust systems shall be connected to the emergency electrical system and shall meet the requirements of paragraph (10) of this subsection.(7) All toilet exhaust ventilation shall be exhausted to the outdoors. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. (8) To reduce utility costs, facility design may utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shutdown, or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied. In no case shall patient care be jeopardized.(9) Mechanical systems shall be arranged to take advantage of outside air conditions by using an economizer cycle when appropriate to reduce heating and cooling systems loads. Innovative design that provides for additional energy conservation while meeting the intent of this subsection for acceptable patient care may be presented to the department for consideration.(10) Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.(11) Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all patient treatment care areas, storage rooms, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas, shall not be permitted.(12) Air handling systems shall not be started or operated without 30% or equal minimum efficient rating value (merv) of 8 and the filters installed in place. Ducts shall be cleaned thoroughly and throughout by a certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, the department shall require a written report assuring cleanliness of duct and clean air quality.(13) Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs shall be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used.(14) All central air handling systems shall be equipped with filters having efficiencies 30% or equal to 8 merv. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. All documents published by ASHRAE as referenced in this section may be obtained by writing or calling the ASHRAE, Inc. at the following address or telephone number: ASHRAE, Inc., 1791 Tullie Circle, Northeast, Atlanta, Georgia 30329; telephone (404) 636-8400.(A) Filtration requirements for air handling units serving single rooms. Dedicated air handlers serving single rooms shall be equipped with nominal filters installed at the return air system.(B) A filter bed shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork.(15) Thermal and acoustical insulation for air handling systems. Asbestos insulation shall not be used.(A) Air ducts and casings with outside surface temperature below ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation.(B) Linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories (UL), Inc., Standard Number 181 (relating to Factory-Made Duct Materials and Air Duct Connectors), April 4, 1996 edition. This document may be obtained from the Underwriters Laboratories, Inc., 333 Pfingsten Road, Northbrook, Illinois 60062-2096.(C) Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A, Chapters 4 and 5.(D) Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem.(16) Fire dampers shall be located and installed in all ducts at the point of penetration of a required two-hour or higher fire rated wall or floor in accordance with the requirements of NFPA 101, §20.1.(17) Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101, and NFPA 90A, Chapter 5.(A) Smoke dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72), Chapter 8; NFPA 90A, Chapter 6; and NFPA 101, §18.3.7; the fire sprinkler system; and upon loss of power. Smoke dampers shall not close by fan shutdown alone unless it is a part of an engineered smoke removal system.(B) Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts.(C) Use of frangible devices for shutting smoke dampers is not permitted.(18) Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose shall be acceptable.(19) Unobstructed access to duct openings in accordance with NFPA 90A, §4.3.4, shall be provided in ducts within reach and sight of every fire damper, smoke damper and smoke detector. Each opening shall be protected by an internally insulated door which shall be labeled externally to indicate the fire protection device located within.(20) Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided that provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices.(h) All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code Illustrated published by the National Association of Plumbing-Heating-Cooling Contractors (PHCC), 2003 edition, and this paragraph. The National Standard Plumbing Code may be obtained by writing or calling the PHCC at the following address or telephone number: Plumbing-Heating-Cooling Contractors, Post Office Box 6808, Falls Church, Virginia 22046; telephone (800) 533-7694.(1) Piping systems.(A) Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Domestic water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(i) Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture.(ii) Backflow preventers (vacuum breakers) shall be installed on hose bibbs, laboratory sinks, janitor sinks, and on all other fixtures to which hoses or tubing can be attached. Backflow preventers are not required for hoses that are directly connected to the dialysis machines.(iii) Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.(iv) Hot water distribution systems for patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet. Nonrecirculated fixtures branch piping shall not exceed 25 feet in length. Tankless water system may be used at point of use.(v) Water heating equipment shall have sufficient capacity to supply water for clinical, use.(vi) Water temperatures shall be measured at hot water point of use, and shall be between 105 - 120 degrees Fahrenheit.(vii) The domestic hot water system shall make provisions to limit the amount of Legionella bacteria and opportunistic waterborne pathogens.(viii) Domestic water storage tank(s) shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. When potable water storage tanks (hot and cold) are used, the water shall be used and replenished. Water shall not be stored in tanks for future use unless the water is tested weekly for contaminates/bacteria. (ix) Purified water distribution system piping shall be task specific and include, but not necessarily be limited to, polypropylene (PP), polyvinylidene fluoride (PVDF) or polyvinyl chloride (PVC) pipe. Final installed purified water system piping assemblies shall be UL approved and fully comply with applicable American Society for Testing and Materials (ASTM) Fire Resistant/Smoke Density requirements. The applicable documents are available from ASTM International, 100 Barr Harbor Drive, Post Office Box C700, West Conshohocken, Pennsylvania 19428-2959.(B) When fire sprinkler systems are required and provided in an ESRD facility, the fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, and shall be certified as required by §117.105(c)(1)(C) of this title (relating to Construction, Inspections, and Approval of Project).(C) Main storage of medical gases may be outside or inside the ESRD facility in accordance with NFPA 99, §5.1.(D) Steam and hot water systems.(i) When boilers are used the boilers shall have the capacity, based upon the net ratings as published in The I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of GAMA, to supply the normal requirements of all systems and equipment. The document published by the Hydronics Institute Division of GAMA as referenced in this rule may be obtained by writing or calling the Hydronics Institute Division of GAMA at 35 Russo Place, P.O. Box 218, Berkeley Heights, New Jersey 07922, telephone (908) 464-8200.(ii) Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.(iii) Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment.(E) Drainage systems.(i) All underground building drains shall be: cast iron soil pipe, hard temper copper tube (drain-waste-vent (DWV) or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), polyvinyl chloride (PVC) plastic pipe (DWV Schedule 40 or heavier), or extra strength vitrified clay pipe (VCP) with compression joints or couplings with at least 12 inches of earth cover.(ii) Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be DWV weight or heavier and shall be: copper pipe, copper tube, plastic pipe (DWV scheduled 40 or heavier) cast iron pipe, or galvanized iron pipe.(iii) Drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant glass pipe, high silicone content cast iron pipe, VCP, CPVC plastic pipe, or plastic lined pipe.(iv) Thermal insulation for piping systems and equipment shall be provided for the following:(I) boilers, smoke breeching, and stacks;(II) steam supply and condensate return piping;(III) hot water piping and all hot water heaters, generators, converters, and storage tanks;(IV) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; and(V) other piping, ducts, and equipment as necessary to maintain the efficiency of the system.(v) Flame spread shall not exceed 25 and smoke development rating shall not exceed 50 for pipe insulation as determined by an independent testing laboratory in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition. Smoke development rating for pipe insulation located in environmental air areas shall not exceed 50.(vi) Asbestos insulation shall not be used.(2) Plumbing fixtures shall be made of nonabsorptive acid-resistant materials and shall comply with the recommendations of the National Standard Plumbing Code and this paragraph.(A) All sinks used by medical and nursing staff and all lavatories used by patients shall be trimmed with valves which can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may be used.(B) Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.(C) All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(D) Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination.(E) All sterilizing equipment shall be designed and installed to prevent not only the contamination of the water supply but also the entrance of contaminating materials into the sterilizing units. Sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(F) No hose shall be affixed to any faucet if the end of the hose can become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker.(G) The water supply spout for lavatories and sinks required in patient care areas shall be mounted so that its discharge point is a minimum of five inches above the rim of the sink.(H) Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to grilled drain cover to prevent entry of large particles of waste which might cause stoppages.(I) Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of floor below the equipment.(J) All ice-making machines used for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines.(i) This subsection contains common electrical requirements. The ESRD facility shall comply with the requirements of this subsection.(1) All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the National Fire Protection Association 70, National Electrical Code, 2002 Edition (NFPA 70), and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and with the manufacturer's direction for use.(A) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(B) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(C) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70 and NFPA 99, §4.3.2.2.2. (D) Under counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of floor below the equipment.(2) Installation testing and certification.(A) The electrical installations, including alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional.(B) The grounding system shall be tested as described in NFPA 99, 4.3.3, for patient care areas in new or renovated work. The testing shall be performed by a qualified electrician or their qualified electrical testing agent. The electrical contractor shall provide a letter stating that the grounding system has been tested in accordance with NFPA 99, the testing device use complies with NFPA 99, and whether the grounding system passed the test. The letter shall be signed by the qualified electrical contractor, or their designated qualified electrical testing agent, certifying that the system has been tested and the results of the test are indicated.(3) Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(4) Electrical service and switchboards serving the required ESRD facility components shall be installed above the designated 100-year flood plain. Main switchboards shall be located in a permanently dry location and the electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms or spaces shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. When switchboards are installed in a damp or wet location the enclosure shall be installed in a waterproof cabinet. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 408. Overload protective devices shall operate properly in ambient temperatures.(5) Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits shall be located on each floor that has major users and may also serve the floor above and the floor below. Panelboards serving life safety branch circuits may serve three floors, the floor where the panelboard is located, and the floors above and below.(6) All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300.(7) The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways in accordance with NFPA 70, §517.30(C)(3).(8) Lighting and receptacles.(A) Lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IESNA) Handbook, 2000 edition, published by the IESNA, 120 Wall Street, Floor 17, New York, New York 10005.(i) Consideration shall be given to controlling intensity and wavelength to prevent harm to the patient's eyes (i.e., retina damage to cataracts due to ultraviolet light).(ii) Approaches to buildings and parking lots shall be illuminated. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all parts of these spaces shall be clearly visible.(iii) Consideration shall be given to the special needs of the elderly. Excessive contrast in lighting levels that makes effective sight adaptation difficult shall be minimized.(B) Means of egress and exit sign lighting intensity shall comply with NFPA 101, §§7.8 - 7.10.(C) Electric lamps, which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(D) Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in all patient care areas. This does not apply to special purpose receptacles.(i) Installations of multiple-ganged receptacles shall not be permitted in patient care areas.(ii) Electrical outlets powered from the emergency system shall be provided in all patient care, procedure, and treatment locations in accordance with NFPA 99, §4.4.2.2.2.3. At least one receptacle at each patient treatment station/room, exam room, or procedure location shall be powered from the emergency electrical system power panel. At least one receptacle at each patient treatment station/room, exam room, or procedure location shall be powered from the normal power panel.(iii) Replacement of malfunctioning receptacles and installation of new receptacles powered from the emergency system in existing facilities shall be accomplished with receptacles of the same distinct color as the existing receptacles.(iv) In locations where other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(v) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor.(vi) All emergency system receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.(E) Equipment.(i) Equipment required for safe operation of the ESRD facility shall be powered from the critical system in accordance with the requirements contained in NFPA 99, §4.5.2.2.3.(ii) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected and installed to provide both normal and standby service.(F) Ground fault circuit interrupters (GFCI) receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle. (9) A nurses emergency calling system shall be installed in the patient waiting area, all individual treatment rooms, exam rooms, isolation rooms, hepatitis B rooms, and toilet rooms used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in all areas. The visible and audible signals shall be cancelable only at the patient calling station. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.(10) The ESRD facility shall provide, at submission of construction documents/plans a letter on facility letterhead indicating the method the ESRD facility has chosen for implementation of the emergency contingency plan for the continuity of emergency essential building systems (emergency generator). The contingency plan shall consist of one of the three options as described as follows.(A) An onsite emergency generator shall be provided with a Type II essential electrical distribution system in accordance with requirements of NFPA 99, §4.5, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(i) An emergency generator standby power system(s) shall require an onsite fuel source and enough fuel capacity in the tank for a period of twenty-four hours or more. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the twenty-four hour fuel capacity on site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(ii) The emergency generator shall be installed, tested and maintained in accordance with the National Fire Protection Association 99, §4.5.4, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(iii) When the emergency generator(s) and electrical transformer(s) are located within the same area, they shall be located at least 10 feet apart.(iv) Sufficient quantity of potable water supply shall be on site for the operation of the water treatment system for at least twenty-four hours. A water valve connection shall be provided to allow hook-up for potable water from an outside vendor to supply the water treatment system.(B) A executed contract with an outside supplier/vendor(s) that will provide a portable emergency generator(s) and potable water on demand.(i) An electrical transfer switch with plug-in device sized to provide emergency power for the patient care areas and the provisions in NFPA 99, §4.5.2.2.2.(ii) A water valve connection to allow hook-up for potable water from an outside vendor to supply the water treatment system.(iii) An alternate source of power (battery power lighting) shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of 1-1/2 hours after loss of the electrical power. The emergency lighting system shall be capable of providing sufficient illumination to allow safe evacuation from the building. The battery pack systems shall be maintained and tested quarterly.(iv) The facility shall implement the emergency contingency plan upon the loss of electrical power following a natural weather or man-made event when the electrical power may not be restored within 24 hours. The facility shall exercise the contract(s) with the supplier/vendor(s) in order to have portable emergency generator(s) and potable water available within 36 hours after the loss of electrical power.(C) An executed contract with another licensed ESRD facility within a 100 mile radius to provide emergency contingency care for the patients.(i) The accepting licensed ESRD facility shall meet the requirements of paragraph (1) of this subsection.(ii) An alternate source of power shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of 1-1/2 hours after loss of the electrical power. The emergency lighting system shall be capable of providing sufficient illumination to allow safe evacuation from the building. The battery pack systems shall be maintained and tested quarterly.(11) A fire alarm system, which complies with NFPA 101, §18.3.4, and with NFPA 72, Chapter 6 requirements, shall be provided in each facility. The required fire alarm system components are as follows:(A) A fire alarm control panel (FACP) shall be installed at a visible central location.(B) Manual fire alarm pull stations shall be installed in accordance with NFPA 101, §18.3.4.(C) Smoke detectors for door release service shall be installed on the ceiling at each door opening in the smoke partition in accordance with NFPA 72, §6.15.6, where the doors are held open with electromagnetic devices conforming with NFPA 101, §18.2.2.6. (D) Smoke detectors shall be installed in air ducts in accordance with NFPA 72, §5.14.4.2 and §5.14.5 and NFPA 90A, §6.4.2.(E) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A, §6.4.2.2.(F) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101, §9.6.2; NFPA 13, §6.9; and NFPA 72, §8.5.3.3.3.4.(G) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72, §6.8.5.5. (H) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §18.3.4, and NFPA 72, §7.4.(I) Visual fire alarm indicating devices, which comply with the requirements of NFPA 72, §7.5, shall be provided.(J) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72.(K) A fire alarm signal notification, which complies with NFPA 101, §9.6.3, shall be provided to alert occupants of fire or other emergency.(L) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70, Article 760.(M) Smoke detector(s) for shutdown of air handling units shall be provided. The detectors shall be installed in accordance with NFPA 90A, §6.4.3.(N) Telecommunications and information systems central equipment shall be installed in a separate location designed for the intended purpose. Special air conditioning and voltage regulation shall be provided as recommended by the manufacturer.(O) When installed, lightning protection systems shall comply with National Fire Protection Association 780, Standard for the Installation of Lightning Protection Systems, 2000 Edition. Source Note: The provisions of this §507.512 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Z PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §507.512 Construction Requirements for a New End Stage Renal Disease Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225026 03/12/2026 (a) All buildings that have patient services located on other than the main entrance floor shall have electric or electrohydraulic elevators. The elevators shall be installed in sufficient quantity, capacity, and speed to ensure that the average interval of dispatch time will not exceed one minute, and average peak loading can be accommodated. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §20.3 of the National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(b) New elevators, escalators and conveyors shall be installed in accordance with the requirements of Health and Safety Code, Chapter 754, Elevators, Escalators, and Related Equipment, and A17.1 Safety Code for Elevators and Escalators, 2000 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI). All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(1) Elevators shall not open to an exit or exit passageway. (2) A facility located above the ground floor shall have an elevator of sufficient size to accommodate a gurney available at all times. Minimum elevator car size shall be five feet wide and seven feet deep.(3) The smallest elevator car door opening shall be at least three feet wide and seven feet high.(4) When light beams are used for operating door opening devices, the beams shall be used in combination with door edge devices and shall be interconnected with a system of smoke detectors. The light control feature shall be disengaged when smoke is detected in any elevator lobby.(5) Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.(6) All elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of one-half inch.(7) All elevators, except freight elevators, shall be equipped with a two-way key operated service switch permitting cars to bypass all landing button calls and be dispatched directly to any floor.(8) Elevator controls, alarm buttons, and telephones shall be accessible to wheelchair occupants in accordance with the Americans with Disabilities Act.(9) A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72, §6.15.3.10.(A) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 2000 edition. The publications of the ASME/ANSI referenced in this section may be obtained by writing ASME/ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(B) The elevator recall smoke detection system in existing ESRD facilities shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2002 edition.(10) Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems with the capability to maintain an operating temperature during fire fighter service operations. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power. These requirements are not applicable to existing elevators.(11) An ESRD facility shall have all elevators and escalators routinely and periodically inspected and tested as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 2000 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101, §9.4.6.(12) An ESRD facility shall obtain a certificate of inspection evidencing that the elevators, escalators, and conveyors and related equipment were inspected in accordance with the requirements in Health and Safety Code (HSC), Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under HSC, §754.014, administered by the Texas Department of Licensing and Regulation. The certificate of inspection shall be on record in each center.(c) Existing elevators and escalators shall comply with the ASME/ANSI A17.3, Safety Code for Elevators and Escalators, 1996 edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3 as required by NFPA 101, §9.4.3. Source Note: The provisions of this §507.513 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Z PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §507.513 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225027 03/12/2026 (a) General.(1) ESRD facility owners or operators shall not begin construction of a new building, additions to, or renovations, or conversions of existing buildings until the department approves final construction documents.(2) Plans and specifications describing the construction of new buildings, and additions to, or renovations, and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter.(3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents, and specifications shall be consistent with the names of the spaces used in this chapter.(4) The department shall notify the ESRD facility owner or operator of the result of its review of each type of submission discussed in this section.(5) The ESRD facility owner or operator shall respond to all department requests for additional information, including providing a plan of correction for deficiencies cited by the department.(6) Once final construction documents are approved, the ESRD facility owner or operator shall request inspections in accordance with §117.105 of this title (relating to Construction, Inspections, and Approval of Project).(7) When construction is delayed or put on hold for longer than one year from the plan approval or self-certification approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new application for plan review and functional program narrative.(8) The ESRD facility owner or operator shall provide written notification to the department when a project has been placed on hold, canceled, or abandoned.(9) The department may close a project file after one year of assigning an application number to a project if the project has been placed on hold.(b) Submission of projects and assignment of application number.(1) The ESRD facility owner, operator, or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the application for plan review:(A) a completed and signed application for plan review. The application for plan review may be obtained by calling the department or by visiting the department's website at www.dshs.state.tx.us/hfp; (B) a functional program narrative in accordance with subsection (d) of this section;(C) final construction documents in accordance with subsection (f) of this section; and(D) a letter on facility letterhead indicating the determination of the emergency contingency plan for the continuity of emergency essential building systems as noted in §117.102(i)(10) of this title (relating to Construction Requirements for a New End Stage Renal Disease Facility).(2) The cost of submitting documents/plans and specifications shall be borne by the sender.(3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department shall assign an application number to the project that shall be referenced on all documents and correspondence related to the project. Final construction documents shall be reviewed in the chronological order received.(4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.(5) Construction shall not begin until the ESRD facility owner or operator of the facility receives written notification from the department that the final construction documents have been approved.(c) An ESRD facility owner, operator, or representative may request a feasibility conference. A feasibility conference is an informal meeting between a member of the department's architectural review group staff and the ESRD facility owner, operator, or representative to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes.(1) A feasibility conference is not a substitute for plan review.(2) An ESRD facility owner, operator, or representative may schedule a feasibility conference by calling the department.(3) The ESRD facility owner, operator, or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents.(4) The ESRD facility owner, operator, or representative is responsible for recording conference notes and shall submit the notes to the department.(d) The ESRD facility owner or operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(B) of this section. The functional program narrative shall be presented on facility letterhead, signed by ESRD facility administration, include the functional description of each space, and the following:(1) departmental relationships, number of patient stations, and other basic information relating to the fulfillment of the facility's objectives;(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features;(3) energy conservation measures, included in building, mechanical, and electrical designs;(4) a description of the type of asepsis control in diagnostic and treatment areas; and(5) the type of construction (existing or proposed) as stated in §20.1.6 of National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, (800) 344-3555.(e) The department may request preliminary documents. If requested by the department, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, and the usage of all spaces, areas, and rooms on every floor level.(f) Final construction documents and specifications shall be submitted to the department for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the project registered architect and professional engineer(s) licensed by the State of Texas.(1) The ESRD facility owner or operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.(2) Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, shall include all necessary explanatory notes, schedules, and legends, and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 Edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural drawings shall include the following:(i) a map of the area within a 500 foot radius of the facility site shall be provided and any hazardous and undesirable location noted in §117.102(a) of this title shall be identified;(ii) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided;(iii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces;(iv) schedules of doors, windows, and finishes;(v) elevations of each facade;(vi) sections through building; and(vii) scaled details as necessary.(B) Fire safety plan drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plan drawings shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire-resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways); (I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced, and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location and fire-resistance rating (one or two-hour) of each smoke partition, location, type and fire-resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.(C) Equipment drawings shall include the following:(i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility;(ii) fixed equipment (equipment which is permanently affixed to the building or which shall be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term fixed equipment includes items such as laundry extractors, communication systems, and built-in casework (cabinets);(iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term moveable equipment includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and(iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g., corridor, patient room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, gas outlets;(v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems);(vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment);(vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and(viii) laboratory exhaust and safety cabinets.(F) Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections; (ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches and equipment which require permanent electrical connections, on plans of each building level:(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and(II) outlets marked distinctly to indicate connection to critical, life safety, or normal power circuits;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generator(s), transfer switch(es), emergency system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses emergency calling system, or staff emergency assistance calling system);(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices, and the room number where each device is located; and(vi) schedules of all panels indicating connection to emergency system or normal system, and connected load at each panel.(3) Any changes to the final construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications.(g) Special submittals.(1) Self-certification.(A) In an effort to shorten the plan review and approval process, the ESRD facility owner, operator, or representative may request approval of final construction documents under the self-certification review process.(i) The owner or operator shall submit the items in subsection (b)(1)(A) - (C) of this section and a completed self-certification form, signed by the ESRD facility owner or operator, architect of record, and engineer(s) of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter.(ii) By signing and submitting the self-certification form, the ESRD facility owner or operator accepts the following conditions. (I) The department retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval.(II) The ESRD facility owner or operator has a continuing obligation to make any changes the department requires to comply with the licensing rules, whether or not physical plant construction or alterations have been completed.(III) The ESRD facility owner or operator is ultimately responsible for compliance with Health and Safety Code, Chapter 251, End Stage Renal Disease Facilities, and this chapter.(B) The department shall review the request for self-certification and notify the ESRD facility owner or operator if the request is approved or denied. If denied, the department shall review the final construction documents in the chronological order in which the documents were received. Construction shall not begin until the final construction documents have been reviewed and approved.(2) If an ESRD facility owner or operator believes that a proposed project is a minor project, the ESRD facility owner or operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work. The minor project request shall be mailed or faxed.(A) If it is determined that the proposed project is a minor project, the department shall notify the ESRD facility owner or operator of the approval, and state the number of inspections that shall be required. A minimum of one inspection shall be conducted.(B) The department shall notify the ESRD facility owner or operator that a proposed project is not approved as a minor project, if the project involves any of the following:(i) remodeling or alterations which involve alterations to load bearing members or partitions;(ii) a change in functional operation;(iii) affects fire safety (e.g., modifications to the fire, smoke, and corridor walls);(iv) adds services for which the ESRD facility is not currently licensed; and(v) significantly changes the mechanical, electrical, plumbing, or fire protection.(C) The ESRD facility owner or operator shall submit final construction documents in accordance with subsection (f) of this section if the department determines the project is not a minor project.(3) Fire sprinkler systems.(A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the ESRD facility owner or operator shall submit to the department for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents.(B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(i) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§14.1, 14.2 and 14.3, for new fire sprinkler systems, alterations of and additions to existing ones.(ii) One set of fire sprinkler working plans, calculations, and water supply information shall be forwarded to the department together with the professional engineer's (P.E. licensed in the State of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation. (iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(h) Retention of drawings, manuals, and design data.(1) Upon occupancy of the building or portion thereof, the owner shall retain as part of the ESRD facility's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.(2) Upon completion of the contract, the owner shall retain as part of the ESRD facility's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.(3) The owner shall retain in the ESRD facility's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation. Source Note: The provisions of this §507.514 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Z PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §507.514 Preparation, Submittal, Review and Approval of Plans, and Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225028 03/12/2026 (a) Construction.(1) Construction, other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate licensing fee has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) The architect of record or the ESRD facility owner or operator shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules.(3) Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) All ESRD facilities, including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §§1395 et seq.), are subject to construction inspections.(1) A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with subchapters G and H of this chapter and the approved plans and specifications. The final plan approval letter shall inform the architect of record and the owner as to the minimum number of inspections required for the project.(2) The architect of record or the ESRD facility owner or operator shall request an inspection by submitting, at least three weeks in advance of the requested inspection date, an application for inspection for each intermediate inspection, final inspection, and reinspection requested. Inspection requests by contractors shall not be honored.(A) The architect of record or the ESRD facility owner or operator shall request an intermediate construction inspection to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate inspection, however, ceilings shall not be installed.(B) The architect of record or the ESRD facility owner or operator shall request a final construction inspection at 100% completion. One hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Depending upon the number and nature of the deficiencies cited during the final inspection, the inspector may require that a reinspection be conducted to confirm correction of all deficiencies cited. The inspector may also require a reinspection, if he determines that the project was not sufficiently complete to warrant a final inspection. The request for reinspection shall be submitted in accordance with paragraph (2) of this subsection.(c) Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.(1) The ESRD facility owner or operator shall submit the following documents to the department before the project will be approved:(A) written approval of the project by the fire authority; (B) a certificate of occupancy for the project issued by the local building authority;(C) a copy of a letter or certification from a professional engineer (P.E.) licensed in the State of Texas indicating the fire sprinkler working plans, hydraulic calculation, the testing, and field inspection of the installation of the new or modified sprinkler system is in compliance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, if applicable. A copy of a letter or certification of changes in existing fire sprinkler system is not required, when relocation of not more than twenty sprinkler heads and hydraulic calculation is not involved;(D) fire alarm system certification (form FML-009A of the State Fire Marshal's Office), if applicable;(E) a copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2002 Edition, §4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project;(F) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. A signed letter or statement corroborating the installation of the product in the project shall be provided;(G) a copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 Edition, as required by NFPA 101, §20-7.5, and a signed letter or statement corroborating the installation of the product in the project;(H) a written plan of correction signed by the ESRD facility owner or operator for any deficiencies noted during the final inspection; and(I) any other documentation or information required or requested due to the type of the project.(2) Architectural approval.(A) If, during the final inspection, the inspector finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the inspector may grant architectural approval contingent upon the documents listed in paragraph (1)(A) - (D) of this subsection being provided to and approved by the inspector at the time of the final inspection.(B) Architectural approval allows the ESRD facility owner or operator to proceed with licensing. Patients may not be admitted nor patient services provided until a license or modified license has been issued to the facility by the department. However, the ESRD facility owner or operator shall submit the documents required in paragraph (1)(E) - (I) of this subsection before the project receives final approval.(3) Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection and receipt of an acceptable Plan of Correction of the final inspection report, the department shall issue written final approval of the project. Source Note: The provisions of this §507.515 adopted to be effective July 6, 2010, 35 TexReg 5835; transferred effective May 30, 2025, as published in the May 9, 2025, issue of the Texas Register, 50 TexReg 2817. 1 HEALTH AND HUMAN SERVICES COMMISSION 507 END STAGE RENAL DISEASE FACILITIES Z PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §507.515 Construction, Inspections, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223705 03/12/2026 (a) The purpose of these sections is to implement Health and Safety Code, Chapter 243, which requires ambulatory surgical centers to be licensed by the Department of State Health Services.(b) These sections provide minimum standards for ambulatory surgical center licenses and procedures for granting, denying, suspending, and revoking a license and licensure fees. The sections under this subchapter primarily cover the licensing procedures and standards for operation, and the remaining sections of this chapter primarily cover the requirements concerning construction design and the life safety code.(c) The standards pertaining to the construction and design, the qualifications of the professional staff and other personnel, the equipment essential to the health and welfare of the patients, sanitary and hygienic conditions, and the quality assurance program may not exceed the minimum standards for certification under the Social Security Act, Title XVIII, 42 United States Code (USC), §§1395 et seq. Source Note: The provisions of this §508.1 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.1 Scope and Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223706 03/12/2026 The following words and terms, when used in these sections, shall have the following meanings, unless the context clearly indicates otherwise.(1) Act--Texas Ambulatory Surgical Center Licensing Act, Health and Safety Code, Chapter 243.(2) Action plan--A written document that includes specific measures to correct identified problems or areas of concern; identifies strategies for implementing system improvements; and includes outcome measures to indicate the effectiveness of system improvements in reducing, controlling or eliminating identified problem areas.(3) Administrator--A person who is a physician, is a registered nurse, has a baccalaureate or postgraduate degree in administration or a health-related field, or has one year of administrative experience in a health care setting.(4) Advanced practice registered nurse (APRN)--A registered nurse approved by the Texas Board of Nursing to practice as an advanced practice registered nurse in Texas. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner."(5) Ambulatory Surgical Center (ASC)--A facility that primarily provides surgical services to patients who do not require overnight hospitalization or extensive recovery, convalescent time or observation. The planned total length of stay for an ASC patient shall not exceed 23 hours. Patient stays of greater than 23 hours shall be the result of an unanticipated medical condition and shall occur infrequently. The 23-hour period begins with the induction of anesthesia.(6) Autologous blood units--Units of blood or blood products derived from the recipient.(7) Available--Able to be physically present in the facility to assume responsibility for the delivery of patient care services within five minutes.(8) Certified registered nurse anesthetist (CRNA)--A registered nurse who has current certification from the Council on Certification of Nurse Anesthetists and who is currently authorized to practice as an advanced practice registered nurse by the Texas Board of Nursing.(9) Change of ownership--(A) a sole proprietor who transfers all or part of the ASC's ownership to another person or persons;(B) the removal, addition, or substitution of a person or persons as a general, managing, or controlling partner in an ASC owned by a partnership and the tax identification number of that ownership changes; or(C) a corporation that transfers all or part of the corporate stock which represents the ASC's ownership to another person or persons and the tax identification number of that ownership changes.(10) Dentist--A person who is currently licensed under the laws of this state to practice dentistry.(11) Department--The Department of State Health Services.(12) Disposal--The discharge, deposit, injection, dumping, spilling, leaking, or placing of any solid waste or hazardous waste (whether containerized or uncontainerized) into or on any land or water so that such solid waste or hazardous waste or any constituent thereof may enter the environment or be emitted into the air or discharge into any waters, including ground waters.(13) Extended observation--The period of time that a patient remains in the facility following recovery from anesthesia and discharge from the postanesthesia care unit, during which additional comfort measures or observation may be provided.(14) Health care practitioners (qualified medical personnel)--Individuals currently licensed under the laws of this state who are authorized to provide services in an ASC.(15) Licensed vocational nurse (LVN)--A person who is currently licensed by the Texas Board of Nursing as a licensed vocational nurse.(16) Medicare-approved reference laboratory--A facility that has been certified and found eligible for Medicare reimbursement, and includes hospital laboratories which may be Joint Commission or American Osteopathic Association accredited or nonaccredited Medicare approved hospitals, and Medicare certified independent laboratories.(17) Person--Any individual, firm, partnership, corporation, or association.(18) Physician--An individual licensed by the Texas Medical Board and authorized to practice medicine in the State of Texas.(19) Premises--A building where patients receive outpatient surgical services.(20) Registered nurse (RN)--A person who is currently licensed by the Texas Board of Nursing as a registered nurse.(21) Surgical technologist--A person who practices surgical technology as defined in Health and Safety Code, Chapter 259.(22) Title XVIII--Title XVIII of the United States Social Security Act, 42 United States Code (USC), §§1395 et seq. Source Note: The provisions of this §508.2 adopted to be effective June 18, 2009, 34 TexReg 3948; amended to be effective November 25, 2010, 35 TexReg 10232; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223707 03/12/2026 (a) Initial license fee. The fee for an initial license (includes change of ownership or relocation) is $5,200. The license term is two years.(b) Renewal license fee. The fee for a renewal license is $5,200. The license term is two years.(c) Official submission. The department shall not consider an application as officially submitted until the applicant pays the application fee and submits the application form.(d) Nonrefundable. Fees paid to the department are not refundable.(e) Payment of fees. All fees shall be paid to the Department of State Health Services.(f) Fee schedule review. The department shall make periodic reviews of its fee schedule and make any adjustments necessary to provide funds to meet its expenses without creating an unnecessary surplus. Such adjustments shall be through section amendments.(g) Other fees. The department is authorized to collect subscription and convenience fees, in amounts determined by the TexasOnline Authority, to recover costs associated with application and renewal application processing through TexasOnline, in accordance with Government Code, §2054.111. Source Note: The provisions of this §508.3 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.3 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223708 03/12/2026 (a) The ASC shall have a governing body that sets policy and assumes full legal responsibility for the total operation of the ASC.(b) The governing body shall be responsible for assuring that medical staff bylaws are current and on file.(c) The governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for the operation and performance of the ASC. Governing body responsibilities include:(1) determining the mission, goals, and objectives of the ASC;(2) assuring that facilities and personnel are adequate and appropriate to carry out the mission;(3) establishing an organizational structure and specifying functional relationships among the various components of the ASC;(4) adopting bylaws or similar rules and regulations for the orderly development and management of the ASC;(5) adopting policies or procedures necessary for the orderly conduct of the ASC;(6) assuring that the quality of care is evaluated and that identified problems are addressed;(7) reviewing all legal and ethical matters concerning the ASC and its staff and, when necessary, responding appropriately;(8) maintaining effective communication throughout the ASC;(9) establishing a system of financial management and accountability that includes an audit appropriate to the ASC;(10) developing, implementing, and enforcing a policy on the rights of patients;(11) approving all major contracts or arrangements affecting the medical care provided under its auspices, including those concerning:(A) the employment of health care practitioners;(B) an effective procedure for the immediate transfer to a hospital of patients requiring emergency care beyond the capabilities of the ASC;(i) the ASC shall have a written transfer agreement with a hospital; or(ii) all physicians performing surgery at the ASC shall have admitting privileges at a local hospital;(C) the use of external laboratories;(D) an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services if laboratory, X-ray, and pharmacy services are not provided on site; and(E) the provision of education to students and postgraduate trainees if the ASC participates in such programs;(12) formulating long-range plans in accordance with the mission, goals, and objectives of the ASC;(13) operating the ASC without limitation because of race, creed, sex, or national origin;(14) assuring that all marketing and advertising concerning the ASC does not imply that it provides care or services which it is not capable of providing; and(15) developing a system of risk management appropriate to the ASC including:(A) periodic review of all litigation involving the ASC, its staff, and health care practitioners regarding activities in the ASC;(B) periodic review of all incidents reported by staff and patients;(C) review of all deaths, trauma, or adverse reactions occurring on premises; and(D) evaluation of patient complaints.(d) The governing body shall provide for full disclosure of ownership to the department.(e) The governing body shall meet at least annually and keep such minutes or other records as may be necessary for the orderly conduct of the ASC.(f) If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the authority, responsibility, and functions of all such positions shall be defined.(g) When a majority of its members are physicians, the governing body, either directly or by delegation, shall make (in a manner consistent with state law and based on evidence of the education, training, and current competence of the physician) initial appointments, reappointments, and assignment or curtailment of medical privileges. When a majority of the members of the governing body are not physicians, the ASC's bylaws or similar rules and regulations shall specify a procedure for establishing medical review for the purpose of making (in a manner consistent with state law and based on evidence of the education, training, and current competence of the physician) initial appointments, reappointments, and assignment or curtailment of medical privileges.(h) The governing body shall provide (in a manner consistent with state law and based on evidence of education, training, and current competence) for the initial appointment, reappointment, and assignment or curtailment of privileges and practice for nonphysician health care personnel and practitioners.(i) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the ASC.(j) The governing body shall adopt, implement, and enforce written policies to ensure compliance with Texas Health and Safety Code Chapter 324.(k) The governing body shall adopt, implement, and enforce written policies to ensure compliance with applicable state laws.(l) An ASC that performs abortions shall adopt, implement, and enforce a policy to ensure compliance with Texas Health and Safety Code Chapters 245 and 171, Subchapters A and B.(m) An ASC shall comply with the following balance billing requirements.(1) An ASC may not violate a law that prohibits the ASC from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) An ASC shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the ASC.(n) An ASC shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §508.4 adopted to be effective June 18, 2009, 34 TexReg 3948; amended to be effective April 15, 2021, 46 TexReg 2422; amended to be effective August 18, 2024, 49 TexReg 6216; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.4 Ambulatory Surgical Center (ASC) Operation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223709 03/12/2026 (a) Patients shall be treated with respect, consideration, and dignity.(b) Patients shall be provided appropriate privacy.(c) Patient records shall be treated confidentially and, except when authorized by law, patients shall be given the opportunity to approve or refuse their release.(d) Patients shall be provided, to the degree known, appropriate information concerning their diagnosis, treatment, and prognosis. When it is medically inadvisable to give such information to a patient, the information shall be provided to a person designated by the patient or to a legally authorized person.(e) Patients shall be given the opportunity to participate in decisions involving their health care, except when such participation is contraindicated for medical reasons.(f) Information shall be available to patients and staff concerning:(1) patient rights, including those specified in subsections (a) - (e) of this section;(2) patient conduct and responsibilities;(3) services available at the ambulatory surgical center (ASC);(4) provisions for after-hours and emergency care;(5) fees for services;(6) payment policies;(7) patient's right to refuse to participate in experimental research; and(8) methods for expressing complaints and suggestions to the ASC.(g) Marketing or advertising regarding the competence and/or capabilities of the organization shall not be misleading to patients. Source Note: The provisions of this §508.5 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.5 Patient Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223710 03/12/2026 (a) Administrative policies, procedures, and controls shall be established and implemented to assure the orderly and efficient management of the ambulatory surgical center (ASC). Administrative responsibilities shall include, but are not limited to:(1) enforcing policies delegated by the governing body;(2) employing qualified management personnel;(3) long-range and short-range planning for the needs of the ASC, as determined by the governing body;(4) using methods of communicating and reporting, designed to assure the orderly flow of information within the ASC;(5) controlling the purchase, maintenance, and distribution of the equipment, materials, and facilities of the ASC;(6) establishing lines of authority, accountability, and supervision of personnel;(7) establishing controls relating to the custody of the official documents of the ASC; and(8) maintaining the confidentiality, security, and physical safety of data on patients and staff.(b) Personnel policies shall be established and implemented to facilitate attainment of the mission, goals, and objectives of the ASC. Personnel policies shall:(1) define and delineate functional responsibilities and authority;(2) require the employment of personnel with qualifications commensurate with job responsibilities and authority, including appropriate licensure or certification;(3) require periodic appraisal of each person's job performance;(4) specify responsibilities and privileges of employment;(5) be made known to employees at the time of employment; and(6) provide adequate orientation and training to familiarize all personnel with the ASC's policies, procedures, and facilities.(c) The ASC shall periodically assess patient satisfaction with services and facilities provided by the ASC. The findings shall be reviewed by the governing body.(d) When students and postgraduate trainees are present, their status shall be defined in the ASC's personnel policies.(e) All employee categories shall be included in personnel policies and appropriate job descriptions shall be developed. Source Note: The provisions of this §508.6 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.6 Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223711 03/12/2026 (a) All health care practitioners shall have the necessary and appropriate training and skills to deliver the services provided by the ambulatory surgical center (ASC).(b) Health care practitioners shall practice in accordance with applicable state law and conform to the standards and ethics of their professions.(c) Patient care responsibilities shall be delineated in accordance with recognized standards of practice.(d) There shall be qualified medical personnel available for emergency treatment whenever there is a patient in the ASC who has received services.(e) The provision of quality health care services shall be demonstrated by at least the following:(1) accessible and available health services;(2) appropriate and timely diagnostic procedures;(3) treatment that is consistent with clinical impression or working diagnosis;(4) appropriate and timely consultation;(5) absence of clinically unnecessary diagnostic or therapeutic procedures;(6) provision for services when the ASC is not open;(7) appropriate, accurate, and complete medical record entries; and(8) adequate transfer of information when patients are transferred to and from other health care providers.(f) When clinically indicated, patients shall be contacted as quickly as possible for follow-up regarding significant problems and/or abnormal laboratory or radiologic findings that have been identified.(g) When the need arises, patients shall be transferred from the care of one health care practitioner to another.(1) Adequate specialty consultation services shall be made available by prior arrangement.(2) Referral to another health care practitioner shall be clearly outlined to the patient and arranged with the accepting health care practitioner prior to transfer.(h) Concern for the appropriateness of care shall be governed by the following:(1) the relevance of health care services to the needs of the patients;(2) the absence of duplicative diagnostic procedures;(3) the appropriateness of treatment frequency; and(4) the use of ancillary services that is consistent with patients' needs.(i) Education activities shall relate, in part, to the findings as quality assurance activities and shall include cardiopulmonary resuscitation training. Source Note: The provisions of this §508.7 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.7 Quality of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223712 03/12/2026 (a) Quality assurance includes the selection of professional personnel prior to engagement for service, ongoing review of clinical responsibilities and authority, and peer review and supervision of all professional and technical activities of personnel.(b) The professional and administrative staff shall understand, support, and participate in the quality assurance program.(c) The quality assurance program shall address clinical, administrative, and cost effective issues. Exclusive concentration on administrative cost effective issues does not fulfill this requirement.(d) Quality assurance activities shall be conducted by the quality assurance committee, which is composed of specific clinical disciplines within the ambulatory surgical center (ASC) (individual medical specialties, nursing, etc.), and shall be consistent with the characteristics of the overall quality assurance program and the services provided by the ASC.(e) Problem identification and resolution activities shall be conducted as part of an ongoing, organized quality assurance program in which all practitioners in all clinical disciplines have an opportunity to participate. A variety of self-assessment methodologies may be used to implement the quality assurance program. Assessment techniques shall examine the structure, process, or outcome of care, and shall be assessed prospectively, concurrently, or retrospectively.(f) Quality assurance activities shall address the following.(1) Important problems or concerns in the care of patients shall be identified. Although the medical record is an important data source for identifying previously unrecognized problems, any sources may be used. Problems concerning accessibility, medical-legal issues, and wasteful practices shall be considered, as well as concerns previously recognized by patients and staff but inadequately addressed.(2) The frequency, severity, and source of suspected problems or concerns shall be assessed.(A) Health care practitioners shall participate in the development and application of the criteria used to evaluate the care they provide.(B) Health care practitioners shall participate in the evaluation of the problems or concerns identified.(C) A record shall be maintained of all fires, patient deaths, and all transfers from the ASC to the hospital.(3) Measures shall be implemented to resolve important problems or concerns that have been identified. Health care practitioners as well as administrative staff shall participate in the resolution of the problems or concerns that are identified.(4) The problems or concerns shall be reassessed to determine objectively whether or not the measures have achieved and sustained the desired result, and if not, why not.(5) Through the ASC's designated mechanisms, quality assurance activities shall be reported, as appropriate, to the proper personnel and the governing body.(g) Quality assurance activities described in subsection (f) of this section shall encompass, but are not limited to:(1) the clinical performance of health care practitioners;(2) the standards for medical records;(3) quality controls for and the use of radiology, pathology, and medical laboratory services;(4) other professional and technical services provided; and(5) studies of patient satisfaction.(h) The quality assurance program shall be a well-defined organized program designed to enhance patient care through the ongoing objective assessment of important aspects of patient care and the associated or identified problems. The responsibilities for quality assurance activities shall be clearly delineated.(1) Qualified medical staff shall participate in assessment of medical services by health care practitioners and shall be accomplished by a specified member(s) of the medical staff or by staff as a group.(2) Nursing service shall be represented by one or more qualified registered nurses in quality assurance activities. Source Note: The provisions of this §508.8 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.8 Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223713 03/12/2026 (a) The ambulatory surgical center (ASC) shall develop and maintain a system for the collection, processing, maintenance, storage, retrieval, and distribution of patient's medical records.(b) An individual medical record shall be established for each person receiving care.(c) All clinical information relevant to a patient shall be readily available to health care practitioners involved in the care of that patient.(d) Except when otherwise required by law, any record that contains clinical, social, financial, or other data on a patient shall be strictly confidential and shall be protected from loss, tampering, alteration, destruction, and unauthorized or inadvertent disclosure.(e) A person shall be designated to be in charge of medical records whose responsibilities include, but are not limited to:(1) the confidentiality, security, and safe storage of medical records;(2) the timely retrieval of individual medical records upon request;(3) the specific identification of each patient's medical record;(4) the supervision of the collection, processing, maintenance, storage, retrieval, and distribution of medical records; and(5) the maintenance of a predetermined organized medical record format.(f) Policies concerning medical records shall follow current statute in regard to retention of active records, retirement of inactive records, and the release of information contained in the record.(g) Except when otherwise required by law, the content and format of medical records, including the sequence of information, shall be uniform.(h) Reports, histories and physicals, progress notes, and other patient information (such as laboratory reports, X-ray readings, and consultation) shall be incorporated into the medical record in a timely manner.(i) Medical records shall be available to authorized health care practitioners any time the ASC is open to patients.(j) The ASC shall include the following in patients' medical records:(1) patient identification;(2) allergies and untoward reactions to drugs recorded in a prominent and uniform location;(3) all preoperative, postoperative medications administered and drug/dose/route/frequency/quantity of all postoperative drugs dispensed to the patient by the ASC and entered on the patient's record;(4) significant medical history and results of physical examination;(5) a preanesthesia evaluation by an individual qualified to administer anesthesia;(6) preoperative diagnostic studies entered before surgery, if required by policy or ordered by a physician, podiatrist, dentist, or advanced practice registered nurse;(7) findings and techniques of the operation (operative report);(8) pathology report on all tissues removed during surgery, except those exempted by the governing body;(9) anesthesia administration record;(10) documentation of a properly executed informed consent;(11) evidence of evaluation of the patient by a physician or advanced practice registered nurse prior to dismissal;(12) evidence that the patient left the facility in the company of a responsible adult, unless the operating surgeon or advanced practice registered nurse writes an order that the patient may leave the facility without the company of a responsible adult; and(13) for patients with a length of stay greater than eight hours, an evaluation of nutritional needs and evidence of how identified needs were met.(k) Appropriate medical advice given to a patient by telephone shall be entered in the patient's medical record and appropriately signed or initialed.(l) Entries in patients' medical records shall be legible to clinical personnel, and shall be accurate and completed promptly.(m) Any notation in a patient's medical record indicating diagnostic or therapeutic intervention as part of clinical research shall be clearly contrasted with entries regarding the provision of nonresearch-related care.(n) When necessary for assuring continuity of care, summaries of records of a patient who was treated elsewhere (such as by another physician, hospital, ambulatory surgical center, nursing home, or consultant) shall be obtained.(o) When necessary for assuring continuity of care, summaries or photocopies of the patient's record shall be transferred to the health care practitioner to whom the patient was referred and, if appropriate, to the facility where future care will be rendered.(p) Certain repetitive procedures are suitable for pre-printed operative notes. These operative notes are suitable as long as they are approved by the governing body, are signed by the surgeon, and transmit to a knowledgeable reader the events of the surgical procedure.(q) All final tissue and abnormal cytology reports from the Medicare-approved reference laboratory shall be signed by a pathologist. Source Note: The provisions of this §508.9 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.9 Medical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223714 03/12/2026 (a) The ambulatory surgical center (ASC) shall have the necessary personnel, equipment, and procedures to handle medical emergencies that may arise in connection with services sought or provided. At a minimum, the ASC shall provide:(1) periodic instruction of all personnel in the proper use of safety, emergency, and fire-extinguishing equipment;(2) procedures, including adequate surveillance techniques, that minimize sources and transmission of infections;(3) a comprehensive emergency plan to address internal and external emergencies, including:(A) a provision for the safe evacuation of patients during an internal emergency, especially patients who have difficulty walking;(B) a provision for the most efficient use of available facilities and services during an external emergency; and(C) a requirement for at least four drills a year of the internal emergency plan.(b) Hazards that might lead to slipping, falling, electrical shock, burns, poisoning, or other trauma shall be eliminated.(c) Facilities shall be clean and properly maintained.(d) An emergency call system shall be provided and readily accessible to staff and patients in all areas of the facility.(e) All equipment, including emergency equipment, shall be properly maintained and periodically tested.(f) There shall be a system for the proper identification, management, handling, transport, treatment, and disposition of hazardous materials and wastes whether solid, liquid, or gas.(1) This system shall include, but is not limited to, infectious, radioactive, chemical, and physical hazards.(2) The system shall provide for the protection of patients, staff, and the environment.(g) An ambulatory surgical center shall meet the requirements set forth by the department in §§1.131 et seq. of this title (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(h) Sufficient space, equipment, and supplies shall be provided to perform the volume of work with optimal accuracy, precision, efficiency, and safety in the laboratory and x-ray. The ASC shall furnish equipment for basic diagnostic purposes, depending on the extent of services provided. Dressing area(s) shall be required, depending on services provided, with convenient access to toilets, and may be shared with patient changing/preoperative rooms. Source Note: The provisions of this §508.10 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.10 Facilities and Environment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223715 03/12/2026 (a) Anesthesia services.(1) Anesthesia services provided in the ambulatory surgical center (ASC) shall be limited to those that are approved by the governing body, which may include the following.(A) Topical anesthesia--An anesthetic agent applied directly or by spray to the skin or mucous membranes, intended to produce transient and reversible loss of sensation to the circumscribed area.(B) Local anesthesia--Administration of an agent that produces a transient and reversible loss of sensation to a circumscribed portion of the body.(C) Regional anesthesia--Anesthetic injected around a single nerve, a network of nerves, or vein that serves the area involved in a surgical procedure to block pain.(D) Minimal sedation (anxiolysis)--A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(E) Moderate sedation/analgesia ("conscious sedation")--A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)(F) Deep sedation/analgesia--A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)(G) General anesthesia--A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.(2) The anesthesia department shall be under the medical direction of a physician approved by the governing body upon the recommendation of the ASC medical staff.(3) The medical staff shall develop written policies and practice guidelines for the anesthesia service, which shall be approved, implemented and enforced by the governing body. The policies and guidelines shall include consideration of the applicable practice standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the licensing rules and standards applicable to those categories of licensed professionals qualified to administer anesthesia.(4) Only personnel who have been approved by the facility to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. A qualified registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA), in accordance with the orders of the operating surgeon, anesthesiologist, or CRNA, may administer topical anesthesia, local anesthesia, minimal sedation and moderate sedation, in accordance with all applicable rules, polices, directives and guidelines issued by the Texas Board of Nursing. When an RN who is not a CRNA administers sedation, as permitted in this paragraph, the facility shall:(A) verify that the registered nurse has the requisite training, education, and experience;(B) maintain documentation to support that the registered nurse has demonstrated competency in the administration of sedation;(C) with input from the facility's qualified anesthesia providers, develop, implement and enforce detailed, written policies and procedures to guide the registered nurse; and(D) ensure that, when administering sedation during a procedure, the registered nurse has no other duties except to monitor the patient.(5) Anesthesia shall not be administered unless the operating surgeon has evaluated the patient immediately prior to the procedure to assess the risk of the anesthesia and of the procedure to be performed.(6) The advanced practice registered nurse, the anesthesiologist, or the operating surgeon shall be available until all of his or her patients operated on that day have been discharged from the postanesthesia care unit.(7) Patients who have received anesthesia shall be evaluated for proper anesthesia recovery by the operating surgeon or the person administering the anesthesia prior to discharge from the postanesthesia care unit using criteria approved by the medical staff.(8) Patients who remain in the facility for extended observation following discharge from the postanesthesia care unit shall be evaluated immediately prior to leaving the facility by a physician, the person administering the anesthesia, or a registered nurse acting in accordance with physician's orders and written policies, procedures, and criteria developed by the medical staff.(9) A physician shall be on call and able to respond physically or by telephone within 30 minutes until all patients have been discharged from the ASC.(10) Emergency equipment and supplies appropriate for the type of anesthesia services provided shall be maintained and accessible to staff at all times.(A) Functioning equipment and supplies which are required for all facilities include:(i) suctioning equipment, including a source of suction and suction catheters in appropriate sizes for the population being served;(ii) source of compressed oxygen;(iii) basic airway management equipment, including oral and nasal airways, face masks, and self-inflating breathing bag valve set;(iv) blood pressure monitoring equipment; and(v) emergency medications specified by the medical staff and appropriate to the type of surgical procedures and anesthesia services provided by the facility.(B) In addition to the equipment and supplies required under subparagraph (A) of this paragraph, facilities which provide moderate sedation/analgesia, deep sedation/analgesia, regional analgesia and/or general anesthesia shall provide the following:(i) intravenous equipment, including catheters, tubing, fluids, dressing supplies, and appropriately sized needles and syringes;(ii) advanced airway management equipment, including laryngoscopes and an assortment of blades, endotracheal tubes and stylets in appropriate sizes for the population being served;(iii) a mechanism for monitoring blood oxygenation, such as pulse oximetry;(iv) electrocardiographic monitoring equipment;(v) cardiovertor-defibrillator; and(vi) pharmacologic antagonists as specified by the medical staff and appropriate to the type of anesthesia services provided.(b) Surgical services.(1) Surgical procedures performed in the ASC shall be limited to those procedures that are approved by the governing body upon the recommendation of qualified medical personnel.(2) Adequate supervision of surgery conducted in the ASC shall be a responsibility of the governing body, shall be recommended by qualified medical personnel, and shall be provided by appropriate personnel.(3) Surgical procedures shall be performed only by health care practitioners who are licensed to perform such procedures within Texas and who have been granted privileges to perform those procedures by the governing body of the ASC, upon the recommendation of qualified medical personnel and after medical review of the practitioner's documented education, training, experience, and current competence.(4) Surgical procedures to be performed in the ASC shall be reviewed periodically as part of the peer review portion of the ASC's quality assurance program.(5) An appropriate history, physical examination, and pertinent preoperative diagnostic studies shall be incorporated into the patient's medical record prior to surgery.(6) The necessity or appropriateness of the proposed surgery, as well as any available alternative treatment techniques, shall be discussed with the patient prior to scheduling the patient for surgery.(7) Licensed nurses and other personnel assisting in the provision of surgical services shall be appropriately trained and supervised and shall be available in sufficient numbers for the surgical care provided.(8) Each operating room shall be designed and equipped so that the types of surgery conducted can be performed in a manner that protects the lives and assures the physical safety of all persons in the area.(A) If flammable agents are present in an operating room the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Annex 2, Flammable Anesthetizing Locations, 1999) and with applicable state and local fire codes.(B) If nonflammable agents are present in an operating room the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Chapters 4 and 8, 1999) and with applicable state and local fire codes.(9) With the exception of those tissues exempted by the governing body after medical review, tissues removed during surgery shall be examined by a pathologist, whose signed report of the examination shall be made a part of the patient's medical record.(10) A description of the findings and techniques of an operation shall be accurately and completely written or dictated immediately after the procedure by the health care practitioner who performed the operation. If the description is dictated, an accurate written summary shall be immediately available to the health care practitioners providing patient care and shall become part of the patient's medical record. Refer to §135.9(p) of this title (relating to Medical Records).(11) A safe environment for treating surgical patients, including adequate safeguards to protect the patient from cross infection, shall be assured through the provision of adequate space, equipment, and personnel.(A) Provisions shall be made for the isolation or immediate transfer of patients with communicable diseases.(B) All persons entering operating rooms shall be properly attired.(C) Acceptable aseptic techniques shall be used by all persons in the surgical area.(D) Only authorized persons shall be allowed in the surgical area.(E) Suitable equipment for rapid and routine sterilization shall be available to assure that operating room materials are sterile.(F) Environmental controls shall be implemented to assure a safe and sanitary environment.(G) Operating rooms shall be appropriately cleaned before each operation.(12) Written policies and procedures for decontamination, disinfection, sterilization, and storage of sterile supplies shall be developed, implemented and enforced. Policies shall include, but not be limited to, the receiving, cleaning, decontaminating, disinfecting, preparing, and sterilization of critical items (reusable items), as well as for the assembly, wrapping, storage, distribution, and the monitoring and control of sterile items and equipment.(A) Policies and procedures shall be developed following standards, guidelines, and recommendations issued by the Association of periOperative Registered Nurses (AORN), the Association for Professionals in Infection Control and Epidemiology (APIC), the Centers for Disease Control and Prevention (CDC) and, if applicable, the Society of Gastroenterology Nurses and Associates (SGNA). Standards, guidelines, and recommendations of these organizations are available for review at the Department of State Health Services, Exchange Building, 8407 Wall Street, Austin, Texas. Copies may also be obtained directly from each organization, as follows: AORN, 2170 South Parker Road, Suite 300, Denver Colorado, 80231, (800) 755-2676; APIC, 1275 K Street, Northwest, Suite 1000, Washington, District of Columbia, 20005-4006, (202) 789-1890; CDC, 1600 Clifton Road, Atlanta, Georgia, 30333, (800) 311-3435; SGNA, 401 North Michigan Avenue, Chicago, Illinois, 60611-4267, (312) 321-5165.(B) Policies and procedures shall also address proper use of external chemical indicators and biological indicators.(C) Performance records for all sterilizers shall be maintained for a period of six months.(D) Preventive maintenance of all sterilizers shall be completed according to manufacturer's recommendations on a scheduled basis. A preventive maintenance record shall be maintained for each sterilizer. These records shall be retained at least one year and shall be available for review to the facility within two hours of request by the department.(13) Emergency power adequate for the type of surgery performed shall be available in the operative and postoperative recovery areas.(14) Periodic calibration and/or preventive maintenance of all equipment shall be provided in accordance with manufacturer's guidelines.(15) The informed consent of the patient or, if applicable, of the patient's legal representative shall be obtained before an operation is performed.(16) A written procedure shall be established for observation and care of the patient during the preoperative preparation and postoperative recovery period.(17) Written protocols shall be established for instructing patients in self-care after surgery, including written instructions to be given to patients who receive conscious sedation, regional, and general anesthesia.(18) Patients who have received anesthesia shall only be allowed to leave the facility in the company of a responsible adult, unless the operating surgeon or an advanced practice registered nurse writes an order that the patient may leave without the company of a responsible adult.(19) An effective written procedure for the immediate transfer to a hospital of patients requiring emergency care beyond the capabilities of the ASC shall be developed. The ASC shall have a written transfer agreement with a hospital, or all physicians on staff at the ASC shall have admitting privileges at a local hospital. Source Note: The provisions of this §508.11 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.11 Anesthesia and Surgical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223716 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223716 03/12/2026 (a) The ambulatory surgical center (ASC) shall provide drugs and biologicals in a safe and effective manner in accordance with professional practices and shall be in compliance with all state and federal laws and regulations. The ASC shall be licensed as required by the Texas State Board of Pharmacy and comply with 22 Texas Administrative Code, §291.76 (relating to Class C Pharmacies Located in a Freestanding Ambulatory Surgical Center).(b) Pharmaceutical services may be made available by the ASC through a contractual agreement and shall be provided in accordance with the same ethical and professional practices and legal requirements that would be required if such services were provided directly by the ASC. Source Note: The provisions of this §508.12 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.12 Pharmaceutical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223717 03/12/2026 Pathological and clinical services shall be provided or made available when appropriate to meet the needs of the patients and adequately support the ambulatory surgical center's (ASC's) clinical capabilities.(1) Pathology and clinical laboratory services shall include, but are not limited to:(A) conducting laboratory procedures that are appropriate to the needs of the patients;(B) performing tests in a timely manner;(C) distributing test results within 24 hours after completion of a test and maintaining a copy of the results in the laboratory; and(D) performing and documenting appropriate quality assurance procedures, including, but not limited to, calibrating equipment periodically and validating test results through use of standardized control specimens or laboratories.(2) Preoperative laboratory procedures may be required as follows.(A) It shall be at the discretion of the governing body upon the recommendation of the medical staff to require preoperative laboratory orders.(B) If specific preoperative laboratory work is required, the medical staff shall approve them in accordance with the medical staff bylaws. Other laboratory work shall be performed only on the order of a physician, podiatrist, dentist, or advanced practice registered nurse and written on the patient's chart.(C) These services shall be provided either directly within or through an effective contract arrangement with a Medicare-approved reference laboratory.(D) The contractual agreement with the Medicare-approved reference laboratory shall provide for routine and stat work to include pathology, clinical, and blood bank services, if blood is authorized by the ASC, and shall be available for review.(3) The patient may be instructed to go directly to the Medicare-approved reference laboratory, or the specimen may be collected on the ambulatory surgical center's premises and then referred to the Medicare-approved reference laboratory.(4) If the specimens are collected on the premises only, the following shall be maintained:(A) procedures and policies governing the Medicare-approved reference laboratory specimen requirements; identification, collection, labeling, storage, and transportation of the specimen, and preventive maintenance of equipment used in processing and storage of specimen;(B) a log book which shall include patient name and identification number, doctor's name, date the specimen was drawn and sent to the Medicare-approved reference laboratory, laboratory tests ordered, date the final report came back from the reference laboratory, and condition of the specimen. The final report shall be on the patient's chart, with copies kept in the ASC's laboratory.(5) If laboratory tests are performed on the premises, the following shall be maintained:(A) procedures governing identification, collection, labeling, and storage of specimens;(B) a log book, which shall include patient name and identification number, practitioner's name, date the specimen was drawn, test ordered, and results;(C) procedures for each test procedure performed by the laboratory, including source of reagents, standards, and calibration procedures, and information concerning the basis for the tested normal ranges;(D) procedures and documentation of performed maintenance on equipment used to process laboratory work;(E) dated reports of all examinations performed and made a part of the patient's medical record; and(F) proficiency testing.(6) Quality control of the laboratory shall be monitored through the quality assurance committee.(7) If the ASC designates its laboratory to perform as an independent laboratory, it shall be surveyed according to 42 Code of Federal Regulations, §§493.1 - 493.1780.(8) The ASC can allow laboratory work to be performed and brought in from other Medicare-approved reference laboratories or practitioners' offices, and the reports shall be on the patient's charts before surgery.(A) Written criteria describing the length of time tests can be done prior to surgery shall be developed by the medical staff and approved by the governing body.(B) Laboratory work shall be performed in a Medicare-approved reference laboratory or in the patient's healthcare practitioner's office. This shall be written in a policy accepted by the medical staff and governing body.(9) If it is the ASC's policy to administer blood, policies shall be developed on administration of blood transfusions to include autologous blood units in accordance with the ASC's operative procedures. If the operative procedure(s) performed in the ASC requires or may require the necessity for transfusions, policies and procedures shall include provisions for stat and routine transfusions. These policies and procedures shall include, but are not limited to, collection, labeling, and transportation of specimen in accordance with the ASC or contract service policies. All patient results shall appear in the patient's chart.(10) If the ASC performs surgery which incorporates the removal of a tissue specimen or the freezing of a tissue specimen, the specimen shall be submitted to a Medicare-approved reference laboratory. The following shall be maintained:(A) procedures governing the Medicare-approved reference laboratory specimen requirements, identification, collection, labeling, storage, and transportation of the specimen;(B) documentation to include patient name and identification number, practitioner's name, date the tissue specimen was collected and referred to the Medicare-approved reference laboratory, and date the final report came back from the Medicare-approved reference laboratory. Final copies shall be placed in the patient's chart, with copies kept in the ASC; and(C) the medical staff bylaws may exempt tissue specimens from pathology examination, and the list of exemptions shall be available for review.(11) The medical staff bylaws shall define those specimens for macroscopic pathology examination only and both macroscopic and microscopic pathology examinations.(12) The original pathology report shall be included in the patient's chart.(13) Pathology tissue reports and positive cytology reports shall have the authorized signature of the pathologist interpreting the report. Source Note: The provisions of this §508.13 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.13 Pathology and Medical Laboratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223718 03/12/2026 (a) Radiology services shall be provided or made available when appropriate to meet the needs of the patients and adequately support the ambulatory surgical center's (ASC's) clinical capabilities. Policy and procedures shall be available for emergency and/or routine radiological procedures.(b) A radiologist shall authenticate all examination reports, except reports of specific procedures that may be authenticated by physicians who are not radiologists, but who have been granted privileges by the governing body or its designee to authenticate such reports.(c) Services shall be provided either directly within or through a Medicare-approved facility, and the contracts shall be available for review.(d) If X-ray services are performed within the ASC, the X-ray department shall be surveyed according to 42 Code of Federal Regulations §482.26 or §§486.100 - 486.110.(e) Procedure manuals shall include procedures for all examinations performed, infection control in the ASC and operating rooms to include dress code of personnel and cleaning of equipment.(f) Policies shall address the quality aspects of radiology services, including, but not limited to:(1) performing radiology services only upon the written order of a physician, dentist, advanced practice registered nurse, or other authorized health care practitioner (such orders shall be accompanied by a concise statement of the reason for the examination); and(2) limiting the use of any radioactive sources in the ASC to physicians who have been granted privileges for such use on the basis of their training, experience, and current competence.(g) Policies shall address the safety aspects of radiology services, including, but not limited to:(1) regulation of the use, removal, handling, and storage of any radioactive material which is required to be licensed by the Department of State Health Services, Radiation Safety Licensing Branch;(2) precautions against electrical, mechanical, and radiation hazards;(3) proper shielding where radiation sources are used;(4) acceptable monitoring devices for all personnel who might be exposed to radiation (monitoring devices shall be worn by such personnel in any area with a radiation hazard);(5) maintenance of radiation exposure records on personnel; and(6) authenticated, dated reports of all examinations performed shall be made a part of the patient's medical record.(h) Laser equipment shall be licensed as required by the Department of State Health Services, Radiation Safety Licensing Branch. Policies and procedures shall be established and implemented for laser technology which include laser safety programs, education and training of laser personnel, credentialing for each specific laser, and a requirement for all personnel working with lasers to be adequately trained in the safety and use of each type of laser utilized. Source Note: The provisions of this §508.14 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.14 Radiology Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223719 03/12/2026 (a) Nursing services.(1) There shall be an organized nursing service under the direction of a qualified registered nurse (RN). The ambulatory surgical center (ASC) shall be staffed to assure that the nursing needs of all patients are met.(2) There shall be a written plan of administrative authority for all nursing services with responsibilities and duties of each category of nursing personnel delineated and a written job description for each category. The scope of nursing service shall include, but is not limited to, nursing care rendered to patients preoperatively, intraoperatively, and postoperatively.(A) The responsible individual for nursing services shall be a qualified registered nurse (RN) whose responsibility and authority for nursing service shall be clearly defined and includes supervision of both personnel performance and patient care.(B) There shall be a written delineation of functions, qualifications, and patient care responsibilities for all categories of nursing personnel.(C) Surgical technicians and licensed vocational nurses may be permitted to serve in the scrub nurse role under the direct supervision of an RN; they shall not be permitted to function as circulating nurses in the operating rooms. Licensed vocational nurses and surgical technicians may assist in circulatory duties under the direct supervision of a qualified RN.(D) Nursing services shall be provided in accordance with current recognized standards or recommended practices.(E) The facility shall adopt, implement and enforce policies and procedures to comply with Health and Safety Code, Chapter 259 (relating to Surgical Technologists at Health Care Facilities).(3) There shall be an adequate number of RNs on duty to meet the following minimum staff requirements: director of the department (or designee), and supervisory and staff personnel for each service area to assure the immediate availability of an RN for emergency care or for any patient when needed.(A) An RN shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and qualifications of the nursing staff available.(B) There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the service of an RN.(4) An RN qualified, at a minimum, with current certification in basic cardiac life support shall be on duty and on the premises at all times whenever patients are present in the facility.(b) Additional staffing requirements. In addition to meeting the requirements for nursing staff under subsection (a) of this section, facilities shall comply with the following minimum staffing requirements.(1) Facilities that provide only topical anesthesia, local anesthesia and/or minimal sedation are required to have a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility.(2) Facilities that provide moderate sedation/analgesia are required to have the following additional staff:(A) a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility; and(B) an individual trained and currently certified in advanced cardiac life support and, if surgery is performed on pediatric patients, pediatric advanced life support shall be available until all patients have been discharged from the postanesthesia care unit.(3) Facilities that provide deep sedation/analgesia, general anesthesia, and/or regional anesthesia shall have the following additional staff:(A) a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility; and(B) an individual who is trained and currently certified in advanced cardiac life support and, if surgery is performed on pediatric patients, pediatric advanced life support shall be on duty on the premises and sufficiently free of other duties to enable the individual to respond rapidly to emergency situations until all patients have been discharged from the postanesthesia care unit.(c) Nursing peer review committees. The facility shall establish a nursing peer review committee to conduct nursing peer review, as required by Texas Occupations Code, Chapter 303. Source Note: The provisions of this §508.15 adopted to be effective June 18, 2009, 34 TexReg 3948; amended to be effective November 25, 2010, 35 TexReg 10232; amended to be effective January 26, 2020, 45 TexReg 578; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.15 Facility Staffing and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223720 03/12/2026 (a) Policies concerning teaching activities shall be developed, implemented, and enforced which address:(1) the terms and conditions of reimbursement or other compensation;(2) the reasonableness of the time spent away from direct patient care and administrative activities; and(3) the training of all students and postgraduate trainees, including the extent of their involvement in patient care activities.(b) A policy concerning the provision of health care by personnel in any student or postgraduate trainee status shall be developed, implemented, and enforced, and provide for close and adequate supervision and for informing the patient of the status of the provider.(c) A policy shall be developed, implemented, and enforced concerning publishing activities. The policy shall address:(1) the need for governing body approval when the views, policies, and procedures expressed in the publication are attributed to the ASC; and(2) the terms and conditions of compensation from publication and the cost of publication. Source Note: The provisions of this §508.16 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.16 Teaching and Publication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223721 03/12/2026 (a) Research activities shall be performed in accordance with ethical and professional practices and legal requirements, and these activities shall be periodically monitored by the governing body.(b) The protocols for conducting research shall be approved by the governing body or its designee after medical and legal review.(c) Any research activities carried out within the ambulatory surgical center (ASC) shall be appropriate to the expertise of staff and the resources in the ASC.(d) Individuals engaged in research shall be provided with adequate facilities.(e) Provisions shall be made to assure that the rights and welfare of all research subjects are adequately protected and that the informed consent of the subject, in the language spoken by him or her, is obtained by adequate and appropriate methods.(f) All professional staff shall be informed of the ASC's research policies. Source Note: The provisions of this §508.17 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.17 Research Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223722 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223722 03/12/2026 (a) If the department has reason to believe that a person or facility may be providing ambulatory surgical services without a license as required by the Act, the person or facility shall be so notified in writing by certified mail, return receipt requested, and shall submit to the department the following information within 20 days of receipt of the notice:(1) an application for a license and the license fee, which is nonrefundable;(2) a claim for exemption under §135.19 of this title (relating to Exemptions); or(3) any and all documentation necessary to establish that ambulatory surgical services are not being provided. Documentation shall include a notarized statement attesting to the fact that ambulatory surgical services are not provided and a statement of the type(s) of service(s) that are provided.(b) If the person or facility has submitted an application for a license, the application shall be processed in accordance with §135.20 of this title (relating to Initial Application and Issuance of License).(c) If the person or facility submits a claim for exemption, the exemption claim shall be processed in accordance with §135.19 of this title.(d) If the person or facility submits sufficient documentation to establish that ambulatory surgical services are not provided, the department shall so notify the person or facility in writing within 30 days that no license is required. If the documentation submitted is determined to be insufficient by the department, the person or facility shall be so notified in writing and shall have 10 days to respond. Following receipt of the response, if any, the department shall then notify the person or facility in writing within 10 days of the determination. Source Note: The provisions of this §508.18 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.18 Unlicensed Ambulatory Surgical Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223723 03/12/2026 (a) The following facilities are not required to be licensed under the Act:(1) an office or clinic of a licensed physician, dentist, or podiatrist;(2) a licensed nursing home; or(3) a licensed hospital.(b) If a person or facility is uncertain about whether or not licensing under the Act is required, a written claim for exemption, including all documentation supporting the exemption claim, may be submitted to the department.(c) The department shall evaluate the claim for exemption and notify the person or facility in writing of the proposed decision within 30 days following receipt of the claim for exemption.(d) If the proposed decision is to grant the claim for exemption, the department shall provide written notice according to subsection (c) of this section.(e) If the claim for exemption is proposed to be denied, the person or facility so affected shall have the right to appeal the determination to the department by written letter with the reasons supporting exemption within 10 days following receipt of the proposed denial.(f) If the person or facility does not request an appeal as provided in subsection (e) of this section, the right to appeal is deemed to be waived and the denial of the exemption becomes final 30 days following the person or facility's receipt of the proposed denial.(g) The person or facility shall submit a completed application and nonrefundable licensing fee to the department within 20 days following the final denial of exemption. Source Note: The provisions of this §508.19 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.19 Exemptions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223724 03/12/2026 (a) All first-time applications for licensing, including those from unlicensed operating ambulatory surgical centers (ASCs) and licensed ASCs for which a change of ownership or relocation is anticipated, are applications for an initial license.(b) Upon written or verbal request, the department shall furnish a person with an application form for an ASC license. The applicant shall submit to the department a completed original application and the nonrefundable license fee.(1) The applicant shall provide:(A) the name and address of the owner of the ASC, or a list of names and addresses of persons who own an interest in the ASC;(B) the name, Texas license number, and license expiration date of the medical chief of staff;(C) the number of physicians, dentists, podiatrists and advanced practice registered nurses on staff at the ASC;(D) the name, Texas license number, and license expiration date of the director of nursing of the ASC;(E) whether the ASC has applied for certification under Title XVIII of the Social Security Act; and(F) number of surgery suites.(G) the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(i) denial, suspension, probation, or revocation of an ambulatory surgical center license in any state, a license for any health care facility or a license for a home and community support services agency (agency) in any state; or any other enforcement action, such as (but not limited to) court civil or criminal action in any state;(ii) denial, suspension, probation, or revocation of or other enforcement action against an ambulatory surgical center license in any state, a license for any health care facility in any state, or a license for an agency in any state which is or was proposed by the licensing agency and the status of the proposal;(iii) surrendering a license before expiration of the license or allowing a license to expire in lieu of the department proceeding with enforcement action;(iv) federal or state (any state) criminal felony arrests or convictions;(v) Medicare or Medicaid sanctions or penalties relating to the operation of a health care facility or agency;(vi) operation of a health care facility or agency that has been decertified or terminated from participation in any state under Medicare or Medicaid; or(vii) debarment, exclusion, or contract cancellation in any state from Medicare or Medicaid; and(H) for the two-year period preceding the application date, the following data concerning the applicant, the applicant's affiliates, and the managers of the applicant:(i) federal or state (any state) criminal misdemeanor arrests or convictions;(ii) federal or state (any state) tax liens;(iii) unsatisfied final judgments;(iv) eviction involving any property or space used as an ambulatory surgical center or health care facility in any state;(v) injunctive orders from any court; or(vi) unresolved final federal or state (any state) Medicare or Medicaid audit exceptions.(2) Upon receipt of the application, the department shall review the application to determine whether it is complete. All documents submitted to the department shall be originals. The address provided on the application shall be the address at which the ASC is operating.(3) If the department determines that the application for an unlicensed ASC is complete and correct, a representative of the department shall schedule a pre-survey conference with the applicant in order to inform the applicant of the standards for the operation of the ASC. A pre-survey conference may, at the department's discretion, be waived for an applicant of a licensed ASC for which a change of ownership is anticipated.(4) After a pre-survey conference has been held or waived at the department's discretion and the facility has received an approved architectural inspection conducted by the department, the department may issue a license to an ASC to provide ambulatory surgical services in accordance with these sections.(c) When it is determined that the facility is in compliance with subsection (b) of this section, the department shall issue the license to the applicant.(1) Effective date. The license shall be effective on the date the facility is determined to be in compliance with subsection (b) of this section.(2) Expiration date.(A) If the effective date of the license is the first day of a month, the license expires on the last day of the 23rd month after issuance.(B) If the effective date of the license is the second or any subsequent day of a month, the license expires on the last day of the 24th month after issuance.(d) If an applicant decides not to continue the application process for a license, the application may be withdrawn. The applicant shall submit a written request to withdraw to the department. The department shall acknowledge receipt of the request to withdraw.(e) During the initial licensing period, the department shall conduct a survey of the ASC to ascertain compliance with the provisions of the Health and Safety Code, Chapter 243, and this chapter.(1) The ASC shall request that an on-site survey be conducted after the ASC has provided services to a minimum of one patient.(2) The ASC shall be providing services at the time of the survey.(3) If the ASC has applied to participate in the federal Medicare program, the Medicare survey may be conducted in conjunction with the licensing survey.(4) The initial licensing survey may be waived if the ASC provides documented evidence of accreditation by the Joint Commission, the Accreditation Association for Ambulatory Health Care, or the American Association for Accreditation of Ambulatory Surgery Facilities and Medicare deemed status. Source Note: The provisions of this §508.20 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.20 Initial Application and Issuance of License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223725 03/12/2026 (a) The department shall conduct an on-site inspection to evaluate the ambulatory surgical center's (ASC's) compliance with the standards for licensing set forth in these sections.(1) The department shall evaluate the ASC on a standard-by-standard basis before the first renewal license is issued, unless waived in accordance with §135.20(e)(4) of this title (relating to Initial Application and Issuance of License).(2) An on-site licensing inspection may be conducted once every three years.(3) The department may make any survey or investigation that it considers necessary. A department representative(s) may enter the premises of a facility at any reasonable time to make a survey or an investigation to ensure compliance with or prevent a violation of Health and Safety Code, Chapter 243, an order or special order of the commissioner, a special license provision, a court order granting injunctive relief, or other enforcement procedures. Ensuring compliance includes permitting photocopying of any records or other information by or on behalf of the department as necessary to determine or verify compliance with the statute or rules adopted under the statute, except that the department may not photocopy, reproduce, remove or dictate from any part of the root cause analysis or action plan required in §135.27 of this title (relating to Patient Safety Program).(b) If an on-site inspection is conducted at an ASC and deficiencies are cited, the surveyor shall request the applicant or person in charge to sign the statement of deficiencies as an acknowledgment of receipt of a copy of the statement of deficiencies. Signing the statement of deficiencies does not indicate agreement with any deficiencies. If the applicant or person in charge declines to sign the form, the surveyor shall note the declination on the statement of deficiencies and the name of the person so declining. The surveyor shall leave a copy of the statement of deficiencies at the ASC and, if the person in charge is not the applicant, mail a copy of the statement of deficiencies to the applicant.(c) After an inspection is completed, the surveyor shall prepare a survey report which contains the following:(1) a completed survey report form;(2) a statement of which standards were evaluated;(3) a statement of deficiencies, if any, and the signature of the applicant or person in charge;(4) a plan of correction which has been provided by the ASC and the date(s) by which correction(s) will be made; and(5) any comments by the applicant or person in charge concerning the survey.(d) The survey report form shall be submitted as follows.(1) The surveyor shall submit the survey report to their supervisor for evaluation and decision.(2) A license shall be issued to an ASC that is in compliance with minimum standards in accordance with these sections at the time of the on-site inspection.(3) If deficiencies are cited and the plan of correction is acceptable, written notice shall be sent to the applicant acknowledging same.(4) If deficiencies are cited and the plan of correction is not acceptable, the department shall notify the applicant in writing and request that the plan of correction be resubmitted. Upon resubmission of the acceptable plan of correction, written notice shall be sent to the applicant acknowledging same.(5) The ASC shall come into compliance at least 30 days prior to the expiration date of the license.(6) The department shall verify the correction of deficiencies by mail or by an on-site inspection.(7) If the ASC does not timely come into compliance, the department may take action in accordance with §135.24 of this title (relating to Enforcement). Source Note: The provisions of this §508.21 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.21 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223726 03/12/2026 (a) The department shall send written notice of expiration of a license to an ambulatory surgical center (ASC) at least 60 days before the expiration date. If the applicant has not received notice, it is the duty of the ASC to notify the department and request a renewal application.(b) The department shall issue a renewal license to an ASC that meets the minimum standards for a license set forth in these sections.(1) The ASC shall submit the following to the department no later than 30 days prior to the expiration date of the license:(A) a completed renewal application form;(B) a nonrefundable license fee; and(C) if the ASC is accredited by the Joint Commission, the Accreditation Association for Ambulatory Health Care, or the American Association for Accreditation of Ambulatory Surgery Facilities, documented evidence of current accreditation status.(2) Renewal licenses shall be valid for two years.(c) If the applicant fails to timely submit an application and fee in accordance with subsection (b) of this section, the department shall notify the applicant that the ASC shall cease providing ambulatory surgical services. If the ASC can provide the department with sufficient evidence that the submission was completed in a timely manner and all dates were adhered to, the cease to perform shall be dismissed. If the ASC cannot provide sufficient evidence, the ASC shall immediately thereafter return the license by certified mail. If the applicant wishes to provide ambulatory surgical services after the expiration date of the license, the applicant shall reapply for a license under §135.20 of this title (relating to Initial Application and Issuance of License). Source Note: The provisions of this §508.22 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.22 Renewal of License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223727 03/12/2026 (a) An ambulatory surgical center (ASC) license is issued only for the premises and person or governmental unit named on the application.(b) An ASC license is issued for a single physical location, and shall not include multiple buildings or offsite locations.(c) Multiple ASCs may share a single building, provided that:(1) each ASC is separately licensed; and(2) no part of the building may be dually licensed by more than one ASC.(d) No license may be transferred or assigned from one person to another person. If a change of ownership of a licensed ASC is anticipated, in order to ensure continuity of patient services, the department shall be informed in writing and the applicant shall submit a license application and nonrefundable fee at least 30 days prior to the change of ownership of each ASC. The procedure shall be handled in accordance with §135.20 of this title (relating to Initial Application and Issuance of License), with the exception of the presurvey conference and the on-site inspection, unless deemed necessary by the department. A license shall be issued for the newly acquired ASC effective on the date the ownership changed. The previous license shall be void on the date of acquisition.(e) No license may be transferred from one ASC location to another. If an ASC is relocating, the ASC shall complete and submit a license application and nonrefundable fee at least 30 days prior to the relocation of the ASC. The procedure shall be handled in accordance with §135.20 of this title, with the exception of the pre-survey conference, unless deemed necessary by the department. An initial license shall be issued for the relocated ASC effective on the date the relocation occurred. The previous license shall be void on the date of relocation.(f) Written notice to the department of any change in telephone number shall be received within 30 days after the number has changed.(g) If the name of an ASC is changed, the department shall be notified in writing within 30 days after the effective date of the name change. Source Note: The provisions of this §508.23 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.23 Conditions of Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223728 03/12/2026 (a) Reasons for enforcement action.(1) The Department of State Health Services (department) may deny, suspend, or revoke an ambulatory surgical center's (ASC's) license in accordance with Health and Safety Code (HSC), §243.011 if the applicant or licensee:(A) fails to comply with any provision of the Act;(B) fails to comply with any provision of this chapter or any other applicable laws;(C) fails to comply with a special license condition;(D) fails to comply with an order of the commissioner or another enforcement procedure under the statute;(E) has a history of noncompliance with the rules adopted under this chapter relating to patient health, safety, and rights which reflects more than nominal noncompliance;(F) has aided, committed, abetted, or permitted the commission of an illegal act;(G) fails to provide an adequate application or renewal information;(H) fails to timely pay assessed administrative penalties in accordance with the Act;(I) fails to comply with applicable requirements within a designated probation period;(J) fails to submit an acceptable plan of correction for cited deficiencies; or(K) if the facility is participating under Title XVIII, and the Centers for Medicare and Medicare Services terminates the ASC's Medicare provider agreement.(2) The department may suspend or revoke an existing valid license or disqualify a person from receiving a license because of a person's conviction of a felony or misdemeanor, if the crime directly relates to the duties and responsibilities of the ownership or operation of an ambulatory surgical center.(A) In determining whether a criminal conviction directly relates, the department shall consider the provisions of Occupations Code, Chapter 53.(B) The following felonies and misdemeanors directly relate because these criminal offenses indicate an ability or a tendency for the person to be unable to own or operate an ambulatory surgical center:(i) a misdemeanor violation of the statute;(ii) a misdemeanor or felony involving moral turpitude;(iii) a conviction relating to deceptive business practices;(iv) a misdemeanor of practicing any health-related profession without a required license;(v) a conviction under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(vi) an offense under the Penal Code, Title 5, involving a patient or a client of any health care facility, a home and community support services agency, or a health care professional;(vii) a misdemeanor or felony offense under various titles of the Penal Code, as follows:(I) Title 4 concerning offenses of attempting or conspiring to commit any of the offenses in this subsection;(II) Title 5 concerning offenses against the person;(III) Title 7 concerning offenses against property;(IV) Title 9 concerning offenses against public order and decency; or(V) Title 10 concerning offenses against public health, safety, and morals; and(viii) other misdemeanors and felonies which indicate an inability or tendency for the person to be unable to own or operate an ambulatory surgical center.(C) Upon a licensee's felony conviction, felony probation revocation, revocation of parole, or revocation of mandatory supervision, the license shall be revoked.(3) If the department proposes to deny, suspend, or revoke a license, the department shall give the applicant written notification of the reasons for the proposed action and offer the applicant an opportunity for a hearing. The applicant may request a hearing within 30 days after the date the applicant receives notice. The request shall be in writing and submitted to the department as instructed in the notice of violation letter. A hearing shall be conducted pursuant to the Government Code, Chapter 2001, Administrative Procedure Act, and §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures). If a hearing is not requested in writing within 30 days after receiving notice of the proposed action, the applicant is deemed to have waived the opportunity for a hearing and the proposed action shall be taken.(4) If the department finds that a violation of the standards or licensing requirements prescribed by the Act creates an immediate threat to the health and safety of patients of an ASC, the department may petition the district court for a temporary restraining order to restrain continuing violations.(5) The provisions of Occupations Code, Chapter 53, Consequences of Criminal Conviction, apply to an ASC.(6) If a person violates the licensing requirements or the standards prescribed by the Act, the department may petition the district court for an injunction to prohibit the person from continuing the violation or to restrain or prevent the establishment or operation of an ASC without a license issued under the Act.(b) Emergency suspension of a license. The department may issue an emergency order to suspend a license issued under this chapter, if the department has reasonable cause to believe that the conduct of a license holder creates an immediate danger to the public health and safety.(1) An emergency suspension is effective immediately without a hearing on notice to the license holder.(2) On written request of the license holder, the department shall conduct a hearing not earlier than the 10th day or later than the 30th day after the date the hearing request is received to determine if the emergency suspension is to be continued, modified, or rescinded. The hearing and any appeal are governed by the department's rules for a contested case hearing and Government Code, Chapter 2001.(c) Probation. In lieu of denying, suspending or revoking the license under subsection (a) of this section, the department may schedule the ASC for a probation period of not less than thirty days, if the ASC's noncompliance does not endanger the health and safety of the public.(1) The department shall provide notice of the probation to the ASC not later than the 10th day before the date the probation begins. The notice shall include the items of noncompliance that resulted in placing the ASC on probation, and shall designate the period of the probation.(2) During the probationary period, the ASC shall correct the items of noncompliance and provide a written report to the department that describes the corrective actions taken.(3) The department may verify the corrective actions through an on-site inspection.(d) Administrative penalty. The department may impose an administrative penalty on a person licensed under this chapter who violates the Act, this chapter, or order adopted under this chapter.(1) A penalty collected under this section shall be deposited in the state treasury in the general revenue fund.(2) A proceeding to impose the penalty is considered to be a contested case under Government Code, Chapter 2001.(3) The amount of the penalty may not exceed $1,000 for each violation, and each day a violation continues or occurs is a separate violation for purposes of imposing a penalty. The total amount of the penalty assessed for a violation continuing or occurring on separate days under this paragraph may not exceed $5,000.(4) In determining the amount of an administrative penalty assessed under this section, the department shall consider:(A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(B) the threat to health or safety caused by the violation;(C) the history of previous violations;(D) the amount necessary to deter a future violation;(E) whether the violator demonstrated good faith, including when applicable whether the violator made good faith efforts to correct the violation; and(F) any other matter that justice may require.(5) If the department initially determines that a violation occurred, the department shall give written notice of the report by certified mail to the person alleged to have committed the violation following the survey exit date. The notice shall include:(A) a brief summary of the alleged violation;(B) a statement of the amount of the recommended penalty; and(C) a statement of the person's right to a hearing on the occurrence of the violation, the amount of the penalty, or both.(6) Within 20 days after the date the person receives the notice under paragraph (5) of this subsection, the person in writing may:(A) accept the determination and recommended penalty of the department; or(B) make a request for a hearing on the occurrence of the violation, the amount of the penalty, or both.(7) If the person accepts the determination and recommended penalty or if the person fails to respond to the notice, the commissioner or the commissioner's designee by order shall approve the determination and impose the recommended penalty.(8) If the person requests a hearing, the commissioner shall refer the matter to the State Office of Administrative Hearings (SOAH). The hearing shall be conducted in accordance with Government Code, Chapter 2001, and all applicable SOAH and department rules.(9) Based on the proposal for decision made by the administrative law judge under paragraph (8) of this subsection, the commissioner by order may find that a violation occurred and impose a penalty, or may find that a violation did not occur. The commissioner or the commissioner's designee shall give notice of the commissioner's order under paragraph (7) of this subsection to the person alleged to have committed the violation in accordance with Government Code, Chapter 2001. The notice shall include:(A) a statement of the right of the person to judicial review of the order;(B) separate statements of the findings of fact and conclusions of law; and(C) the amount of any penalty assessed.(10) Within 30 days after the date an order of the commissioner under paragraph (7) of this subsection that imposes an administrative penalty becomes final, the person shall:(A) pay the penalty; or(B) appeal the penalty by filing a petition for judicial review of the commissioner's order contesting the occurrence of the violation, the amount of the penalty, or both.(11) Within the 30-day period prescribed by paragraph (10) of this subsection, a person who files a petition for judicial review may:(A) stay enforcement of the penalty by:(i) paying the penalty to the court for placement in an escrow account; or(ii) giving the court a supersedeas bond that is approved by the court for the amount of the penalty, and that is effective until all judicial review of the commissioner's order is final; or(B) request the court to stay enforcement of the penalty by:(i) filing with the court a sworn affidavit of the person stating that the person is financially unable to pay the penalty and is financially unable to give the supersedeas bond; and(ii) sending a copy of the affidavit to the commissioner by certified mail.(C) If the commissioner receives a copy of an affidavit under subparagraph (B) of this paragraph, the commissioner may file with the court, within five days after the date the copy is received, a contest to the affidavit. In accordance with Health and Safety Code, §243.016(c), the court shall hold a hearing on the facts alleged in the affidavit as soon as practicable and shall stay the enforcement of the penalty on finding that the alleged facts are true. The person who files an affidavit has the burden of proving that the person is financially unable to pay the penalty or to give a supersedeas bond.(12) If the person does not pay the penalty and the enforcement of the penalty is not stayed, the department may refer the matter to the attorney general for collection of the penalty. As provided by the Health and Safety Code, §243.016(d), the attorney general may sue to collect the penalty.(13) A decision by the court is governed by Health and Safety Code, §243.016(e) and (f), and provides the following.(A) If the court sustains the finding that a violation occurred, the court may uphold or reduce the amount of the penalty and order the person to pay the full or reduced amount of the penalty.(B) If the court does not sustain the finding that a violation occurred, the court shall order that a penalty is not owed.(14) The remittance of penalty and interest is governed by Health and Safety Code, §243.016(g) and provides the following. (A) If the person paid the penalty and if the amount of the penalty is reduced or the penalty is not upheld by the court, the court shall order, when the court's judgment becomes final, that the appropriate amount plus accrued interest be remitted to the person within 30 days after the date that the judgment of the court becomes final.(B) The interest accrues at the rate charged on loans to depository institutions by the New York Federal Reserve Bank.(C) The interest shall be paid for the period beginning on the date the penalty is paid and ending on the date the penalty is remitted.(15) The release of supersedeas bond is governed by Health and Safety Code, §243.016(h), and provides the following.(A) If the person gave a supersedeas bond and the court does not uphold the penalty, the court shall order, when the court's judgment becomes final, the release of the bond.(B) If the person gave a supersedeas bond and the amount of the penalty is reduced, the court shall order the release of the bond after the person pays the reduced amount. Source Note: The provisions of this §508.24 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.24 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223729 03/12/2026 (a) In response to a complaint, the department or its authorized representative may enter the premises of an ambulatory surgical center (ASC) during normal business hours as necessary to assure compliance with the Act and these sections. The investigation may be conducted on-site, unannounced or announced, or may be investigated by phone or mail.(b) All licensed ambulatory surgical centers are required to provide the patient and his/her guardian at time of admission a written statement identifying the department as the responsible agency for ambulatory surgical centers complaint investigations. The statement shall inform persons to direct complaint to the Department of State Health Services, Manager, Health Facility Compliance Group, Post Office Box 149347, Austin, Texas 78714-9347, (888) 973-0022. This information shall also be prominently and conspicuously posted for display in an area of the facility that is readily available to patients, families and visitors. Complaints may be registered with the department by phone or in writing. A complainant may provide his/her name, address, and phone number to the department. Anonymous complaints may be registered. All complaints are confidential.(c) The department shall evaluate all complaints against all ambulatory surgical centers. Only those allegations determined to be relevant to the Act shall be authorized for investigation.(d) Conduct of the investigation shall include, but is not limited to:(1) a conference prior to commencing the on-site inspection for the purpose of explaining the nature and scope of the inspection between the department's authorized representative and the person who is in charge of the ASC;(2) inspection of the ASC;(3) inspection of medical and personnel records, including administrative files, reports, records, or working papers;(4) an interview with any willing recipient of ambulatory surgical center services at the ASC or in the recipient's home if the recipient grants permission in writing;(5) an interview with any health care practitioner or ambulatory surgical center personnel who care for the recipient of ambulatory surgical services; and(6) a conference at the conclusion of the inspection between the department's representative and the person who is in charge of the ASC.(A) The department's representative shall identify any records that have been reproduced.(B) Any records that are removed from an ASC (other than those reproduced) shall be removed only with the consent of the ASC. The ASC shall furnish copies of all records pertinent to the investigation at the department's request.(e) The department shall review the report of the investigation and determine the validity of the complaint. Source Note: The provisions of this §508.25 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.25 Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223730 03/12/2026 (a) The ambulatory surgical center (ASC) shall make a report of the following incidents to the Texas Health and Human Services Commission (HHSC). An incident report form shall be submitted to HHSC Complaint and Incident Intake within 10 business days of the incident.(1) The death of a patient while under the care of the ASC;(2) The transfer of a patient to a hospital;(3) Patient development of complications within 24 hours of discharge from the ASC resulting in admission to a hospital; and(4) A patient stay exceeding 23 hours.(b) On an annual basis, the ASC shall report the types and numbers of procedures performed and the average length of stay during the previous 12-month period. The report shall be made using a form to be prescribed by the department.(c) Any theft of drugs and/or diversion of controlled drugs shall be reported to the local police agency, the Texas State Board of Pharmacy, the Texas Department of Public Safety, and/or the Drug Enforcement Administration, and HHSC.(d) An ASC that performs abortions shall comply with the reporting requirements specified in the Texas Health and Safety Code, Chapters 171 and 245, and Chapter 139 of this title.(e) The ASC shall submit reports to the Department of State Health Services in accordance with the reporting requirements in Texas Health and Safety Code, §98.103 and §98.1045 (relating to Reportable Infections and Reporting of Preventable Adverse Events), and associated rules.(f) Occurrences of fire in the ASC shall be reported as specified under §135.41(a)(2) of this title (relating to Fire Prevention and Protection) and §135.43(b)(6) of this title (relating to Handling and Storage of Gases, Anesthetics, and Flammable Liquids).(g) An ASC that donates human fetal tissue under Texas Health and Safety Code, Chapter 173, shall submit an annual report to the Health and Human Services Commission that includes, for each donation, the specific type of fetal tissue donated and the accredited public or private institution of higher learning that received the donation. The ASC shall submit the annual report no later than January 31st of the subsequent year. Source Note: The provisions of this §508.26 adopted to be effective June 18, 2009, 34 TexReg 3948; amended to be effective November 25, 2010, 35 TexReg 10232; amended to be effective September 30, 2018, 43 TexReg 6288; amended to be effective April 1, 2021, 46 TexReg 2024; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.26 Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223731 03/12/2026 Request for information and access to records are governed by the Texas Public Information Act, Government Code, Chapter 552.(1) A written request for information is required. The request shall sufficiently identify the information requested.(2) The department may ask for a clarification if it cannot reasonably understand a particular request. Source Note: The provisions of this §508.28 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.28 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223732 03/12/2026 (a) General.(1) The date a license application is received is the date the application reaches the Department of State Health Services (department).(2) An application for an initial license is complete when the department has received, reviewed, and found acceptable the information described in §135.20 of this title (relating to Initial Application and Issuance of License).(3) An application for a renewal license is complete when the department has received, reviewed, and found acceptable the information described in §135.22 of this title (relating to Renewal of License).(b) Time Periods. An application from a facility for an initial license or a renewal license shall be processed in accordance with the following time periods.(1) The first time period begins on the date the department receives the application and ends on the date the license is issued, or if the application is received incomplete, the period ends on the date the facility is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 45 calendar days.(2) The second time period begins on the date the last item necessary to complete the application is received and ends on the date the license is issued. The second time period is 45 calendar days.(c) Reimbursement of fees.(1) In the event the application is not processed in the time periods stated in subsection (b) of this section, the applicant has the right to request that the department reimburse in full the fee paid in that particular application process. If the department does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request shall be denied.(2) Good cause for exceeding the period established is considered to exist if:(A) the number of applications for licenses to be processed exceeds by 15% or more the number processed in the same calendar quarter the preceding year;(B) another public or private entity utilized in the application process caused the delay; or(C) other conditions existed giving good cause for exceeding the established periods.(d) Appeal. If the request for reimbursement as authorized by subsection (c) of this section is denied, the applicant may then appeal to the commissioner for a resolution of the dispute. The applicant shall give written notice to the commissioner requesting reimbursement of the fee paid because the application was not processed within the established time period. The department shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The commissioner shall make the final decision and provide written notification of the decision to the applicant and the department.(e) Hearings. If a hearing is proposed during the processing of the application, the hearing shall be conducted pursuant to the Government Code, Chapter 2001, Administrative Procedure Act (APA), the hearing procedures of the State Office of Administrative Hearings (Texas Government Code, Chapter 2003 and 1 Texas Administrative Code, Chapter 155, Rules of Procedures). Source Note: The provisions of this §508.29 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.29 Time Periods for Processing and Issuing a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223733 03/12/2026 A licensed ambulatory surgical center shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §508.30 adopted to be effective January 6, 2022, 46 TexReg 9305; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.30 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223734 03/12/2026 (a) In accordance with Texas Health and Safety Code (HSC) §331.002, an ambulatory surgical center (ASC) shall establish a workplace violence prevention committee or authorize an existing ASC committee to develop a workplace violence prevention plan.(b) An ASC shall ensure the committee includes at least:(1) one registered nurse who provides direct care to the ASC's patients;(2) one physician licensed to practice medicine in Texas who provides direct care to the ASC's patients; and(3) one ASC employee who provides security services for the ASC if any and if practicable.(c) A health care system that owns or operates more than one facility, as that term is defined by HSC §331.001, which includes an ASC, may establish a single workplace violence prevention committee for all of the system's facilities if:(1) the committee develops a violence prevention plan for implementation at each facility in the system; and(2) data related to violence prevention remains distinctly identifiable for each facility in the system.(d) An ASC shall adopt, implement, and enforce a written workplace violence prevention policy to protect health care providers and employees from violent behavior and threats of violent behavior occurring at the ASC. In accordance with HSC §331.003, the policy shall:(1) require the ASC to:(A) provide significant consideration of the violence prevention plan recommended by the ASC's committee; and(B) evaluate any existing ASC violence prevention plan;(2) encourage health care providers and employees to provide confidential information on workplace violence to the committee;(3) include a process to protect from retaliation health care providers or employees who provide information to the committee; and(4) comply with HHSC rules relating to workplace violence. (e) An ASC shall adopt, implement, and enforce a written workplace violence prevention plan developed by the committee. In accordance with HSC 331.004, the plan shall:(1) be based on an ASC setting;(2) adopt a definition of "workplace violence" that includes:(A) an act or threat of physical force against a health care provider or employee that results in, or is likely to result in, physical injury or psychological trauma; and(B) an incident involving the use of a firearm or other dangerous weapon, regardless of whether a health care provider or employee is injured by the weapon;(3) require the ASC to at least annually provide workplace violence prevention training or education that may be included in other required training or education provided to the ASC's health care providers and employees who provide direct patient care;(4) prescribe a system for responding to and investigating violent incidents or potentially violent incidents at the ASC;(5) address physical security and safety;(6) require the ASC to solicit information from health care providers and employees when developing and implementing a workplace violence prevention plan;(7) allow health care providers and employees to report workplace violence incidents through the ASC's existing occurrence reporting systems; and(8) require the ASC to adjust patient care assignments, to the extent practicable, to prevent a health care provider or employee from treating or providing services to a patient who has intentionally physically abused or threatened the provider or employee.(f) The written workplace violence prevention plan may satisfy the requirements of subsection (e) of this section by referencing other internal ASC policies and documents.(g) At least annually after the date an ASC adopts a written workplace violence prevention plan required by subsection (e) of this section, the committee shall:(1) review and evaluate the workplace violence prevention plan; and(2) report the results of the evaluation to the ASC's governing body.(h) Each ASC shall make available on request an electronic or printed copy of the ASC's workplace violence prevention plan to each health care provider or ASC employee. If the committee determines the plan contains information that would pose a security threat if made public, the committee may redact that information before providing the plan.(i) In accordance with HSC §331.005, after an incident of workplace violence occurs, an ASC shall offer immediate post-incident services, including any necessary acute medical treatment for each ASC health care provider or employee who is directly involved in the incident.(j) In accordance with HSC §331.005, an ASC may not discourage a health care provider or employee from exercising the provider's or employee's right to contact or file a report with law enforcement regarding a workplace violence incident.(k) In accordance with HSC §331.005, an ASC shall prohibit ASC personnel from disciplining, including by suspension or termination of employment, discriminating against, or retaliating against another person who:(1) in good faith reports a workplace violence incident; or(2) advises a health care provider or employee of the provider's or employee's right to report a workplace violence incident. Source Note: The provisions of this §508.31 adopted to be effective October 21, 2024, 49 TexReg 8381; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS A OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS §508.31 Workplace Violence Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223735 03/12/2026 (a) Compliance. An ambulatory surgical center (ASC) shall comply with the provisions of this section with respect to fire prevention and protection.(1) Fire inspections. An ASC shall comply with local fire codes.(2) Fire reporting. Except as required under §135.43(b)(6) of this title (relating to Handling and Storage of Gases, Anesthetics, and Flammable Liquids), an ASC shall report all occurrences of fire to the local fire authority and in writing to the department's facility licensing group manager as soon as possible but not later than 10 calendar days following the occurrence. Any fire occurrence causing injury to a person shall be reported no later than the next business day to the facility licensing group manager by fax, (512) 834-4514, or overnight mail to Department of State Health Services, Facility Licensing Group Manager, Post Office Box 149347, Austin, Texas 78714-9347.(3) Smoking policy. An ASC shall adopt, implement and enforce a written smoking policy. The policy shall include the minimum provisions of National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), §20.7.4. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555.(b) Fire extinguishing systems. An ASC shall adopt, implement, and enforce a written policy for periodic inspection, testing and maintenance of fire-fighting equipment, portable fire extinguishers, and when installed sprinkler systems. If installed, fire sprinkler systems shall comply with National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13).(1) Water-based fire protection systems. All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested and maintained in accordance with National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2002 Edition.(2) Portable fire extinguishers. Every portable fire extinguisher located in an ASC or upon ASC property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 Edition.(c) Fire protection and evacuation plan. A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §20.7. Copies of the plan shall be available to all staff.(1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the ASC in public areas that are readily visible to patients, employees, and visitors.(2) Annual training. Each ASC shall conduct an annual training program for instruction of all personnel in the location and use of fire-fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(3) Fire drills. The ASC shall conduct at least one fire drill per shift, per quarter. Each drill shall include the use of communication of alarms, use of fire-fighting equipment, simulation of evacuation of patients, discussion with patients, visitors, other occupants, employees and staff about the evacuation plan. Written reports shall be maintained to include evidence of staff and patient participation. Fire exit drills shall incorporate the minimum requirements of NFPA 101, §§20.7.1.2 through 20.7.2.3.(4) Fire-fighting equipment. All staff shall be familiar with the locations of fire-fighting equipment. Fire-fighting equipment shall be located so that a person shall not have to travel more than 75 feet from any point to reach the equipment.(d) Fire alarm system. A fire alarm system shall be installed, maintained and tested, in accordance with National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72) and NFPA 101, §20.3.4.(e) System for communicating an alarm of fire. A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101, §20.3.4.4.(f) Fire department access. As an aid to fire department services, every ASC shall provide the following.(1) Driveways. The ASC shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Submission of plans. Upon request, the ASC shall submit a copy of the floor plans of the building to the local fire department officials.(3) Outside identification. The ASC shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(g) Fire department protection. When an ASC is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire.(h) Physical environment. A facility shall provide a physical environment that protects the health, welfare, and safety of patients, personnel and the public. The physical premises of the facility and those areas of the facility's surrounding physical structure that are used by the patients (including all stairwells, corridors and passageways) must meet the local building and fire safety codes as they relate to safe access and patient privacy. Source Note: The provisions of this §508.41 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS B FIRE PREVENTION AND SAFETY REQUIREMENTS §508.41 Fire Prevention and Protection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223736 03/12/2026 (a) Safety officer. The governing body shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall carry out the functions of the safety program.(b) Safety activities.(1) Incident reports. The safety officer shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded are evaluated, and documentation is provided to show follow-up and corrective actions.(2) Safety policies and procedures. Safety policies and procedures for each department or service shall be developed, implemented, and enforced.(3) Safety training and continuing education. Safety training shall be established as part of new employee orientation and in the continuing education of all employees.(c) Written authority. The authority of the safety officer to take action, when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.(d) Safety manual. Each department or service shall have a safety policy and procedure manual within its own area that becomes a part of the overall facility safety manual.(e) Emergency communication system. An emergency communication system shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments.(f) Fans. All portable fans and ceiling fans shall not be utilized in any patient treatment areas/rooms.(g) Electrical extension cords and cables. Electrical extension cords and cables shall not be used for permanent wiring. Temporary electrical cords or cables shall be secured and protected to prevent tripping. Source Note: The provisions of this §508.42 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS B FIRE PREVENTION AND SAFETY REQUIREMENTS §508.42 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223737 03/12/2026 (a) An ambulatory surgical center (ASC) shall comply with the requirements of this section for handling and storage of gases, anesthetics, and flammable liquids. The ASC premises shall be kept free from accumulations of combustible materials not necessary for immediate operation of the facility.(b) Flammable germicides. If flammable germicides, including alcohol-based products, are used for preoperative surgical skin preparation, the facility shall:(1) use only self-contained, single-use, pre-measured applicators to apply the surgical skin preparations;(2) follow all manufacturer product safety warnings and guidelines;(3) develop, implement, and enforce written policies and procedures outlining the safety precautions required related to the use of the products, which, at a minimum, shall include minimum drying times, prevention and management of product pooling, parameters related to draping and the use of ignition sources, staff responsibilities related to ensuring safe use of the product, and documentation requirements sufficient to evaluate compliance with the written policies and procedures;(4) ensure that all staff working in the surgical environment where flammable surgical skin preparation products are in use have received training on product safety and the facility policies and procedures related to the use of the product;(5) develop, implement and enforce an interdisciplinary team process for the investigation and analysis of all surgical suite fires and alleged violations of the policies; and(6) provide a written report of all occurrences of surgical suite fires within two business days to the department in care of the facility licensing group, and complete an investigation of the occurrence and develop and implement a corrective action plan within 30 days.(c) Flammable and nonflammable gases and liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association 329, Handling Releases of Flammable and Combustible Liquids and Gases, 2002 Edition. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555.(1) Nonflammable gases (examples include, but are not limited to, oxygen and nitrous oxide) shall be stored and distributed in accordance with Chapter 5 of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 Edition (NFPA 99).(A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99, Chapter 9.(B) Oxygen shall be administered in accordance with NFPA 99, §9.6.(2) Piped flammable gas systems intended for use in laboratories and piping systems for fuel gases shall comply with requirements of NFPA 99, §11.11.(3) Flammable gases shall be stored in accordance with NFPA 99, §11.10.(4) Flammable and combustible liquids used in laboratories shall be handled and stored in accordance with NFPA 99, §11.7, and National Fire Protection Association 101, Life Safety Code, 2003 Edition, §20.3.2.2.(5) Other flammable agents shall be stored in accordance with NFPA 99, Chapter 7, Materials.(d) Alcohol-based hand rubs. Alcohol-based hand rubs (ABHRs) are considered flammable. When used, the ABHRs shall meet the following requirements.(1) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart.(2) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms.(3) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches.(4) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.(5) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage.(e) Gasoline and gasoline powered equipment. No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the ASC building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the ASC building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.(f) Gas fired appliances. The installation, use, and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2002 Edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §508.43 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS B FIRE PREVENTION AND SAFETY REQUIREMENTS §508.43 Handling and Storage of Gases, Anesthetics, and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223738 03/12/2026 (a) Compliance.(1) A licensed ambulatory surgical center (ASC) which is licensed prior to the effective date of these rules is considered to be an existing licensed ASC and shall continue, at a minimum, to meet the licensing requirements under which it was originally licensed.(2) In lieu of meeting the requirements in paragraph (1) of this subsection, an existing licensed ASC may, instead, comply with National Fire Protection Association (NFPA) 101, Life Safety Code 2003 Edition (NFPA 101), Chapter 21, Existing Ambulatory Health Care Occupancies. All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555.(b) Remodeling and additions. All remodeling, renovations, additions and alterations to, or relocation of an existing ASC shall be done in accordance with the requirements for new construction in §135.52 of this title (relating to Construction Requirements for a New Ambulatory Surgical Center). When existing conditions make such changes impractical, the department may grant a conditional approval of minor deviations from the requirements of §135.52 of this title (relating to Construction Requirements for a New Ambulatory Surgical Center), if the intent of the requirements is met and if the care, safety, and welfare of patients will not be jeopardized. The operation of the ASC, accessibility of individuals with disabilities, and safety of the patients shall not be jeopardized by a condition(s) which is not in compliance with these sections.(1) Building equipment alterations or installations. Any alteration or any installation of new building equipment, such as mechanical, electrical, plumbing, fire protection, or piped medical gas system, shall comply with the requirements for new construction and shall not be replaced, materially altered, or extended in an existing ASC until complete plans and specifications have been submitted to the department, and the department has reviewed and approved the plans and specifications in accordance with §135.54 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(2) Minor remodeling or alterations. Minor remodeling or alterations within an existing ASC which do not involve alterations to load bearing members and partitions, change functional operation, affect fire safety, add or subtract services, or involve any of the major changes listed in paragraph (3) of this subsection are considered to be minor projects and require evaluation and approval by the department. An ASC shall submit a written request for evaluation, a brief description of the proposed changes, and sketches of the area being remodeled. Based on such submittal, the department shall evaluate and determine whether any additional submittals or inspections are required. The department shall notify the ASC of its decision.(3) Major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety, or add or delete services are considered major projects. An ASC shall comply with this paragraph prior to beginning construction of major projects.(A) Submittal of plans. Plans shall be submitted in accordance with §135.54 of this title for all major remodeling or alterations.(B) Phasing of construction in existing facilities.(i) Projects involving alterations of or additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions.(ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants will not be jeopardized during construction.(iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.(iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.(v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present.(vi) Temporary sound barriers shall be provided where intense, prolonged construction noises will disturb patients or staff in the occupied portions of the building.(c) Previously licensed ASCs. A previously licensed ASC which has been vacated or used for other purposes shall comply with all the requirements for new construction contained in §135.52 of this title in order to be licensed. Source Note: The provisions of this §508.51 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.51 Construction Requirements for an Existing Ambulatory Surgical Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223739 03/12/2026 (a) Ambulatory surgical center (ASC) location. Any proposed new ASC shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as an ASC which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients. An ASC may be a distinct separate part of an existing hospital, it may occupy an entire separate independent structure, or it may be located within another building such as an office building or commercial building.(1) Means of egress. An ASC shall have at least two exits remotely located in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2003 Edition (NFPA 101), §20.2.4.1. When a required means of egress from the ASC is through another portion of the building, that means of egress shall comply with the requirements of NFPA 101 which are applicable to the occupancy of that other building. Such means of egress shall be open, available, unlocked, unrestricted, and lighted at all times during the ASC hours of operation. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or 800-344-3555.(2) Hazardous location.(A) Underground and above ground hazards. A new ASC or an addition(s) to an existing ASC shall not be constructed within 150 feet of easement boundaries or setbacks of hazardous underground locations including but not limited to liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not within the easement of high voltage electrical lines.(B) Fire hazards. A new ASC and an addition to an existing ASC shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants.(3) Undesirable locations.(A) Nuisance producing sites. A new ASC shall not be located near nuisance producing sites such as industrial sites, feed lots, sanitary landfills, or manufacturing plants which produce excessive noise or air pollution.(B) Flood plains.(i) New construction. When a new ASC is constructed in a designated 100-year flood plain, the building finished floor elevation shall be one foot above the set base flood plain elevation. The building shall meet all local flood code ordinances and local flood control requirements.(ii) Previously licensed ASC. To obtain a license as an ASC, a previously licensed ASC and an existing building or a portion of an existing building located in a designated 100-year flood plain shall meet the requirement of subparagraph (B)(i) of this paragraph.(iii) Existing ASC. ASC required functional components shall be constructed above the designated flood plain in a new addition to an existing ASC located in a designated 100-year flood plain. The new addition shall meet the requirement of subparagraph (B)(i) of this paragraph.(b) ASC site. The ASC site shall include paved roads, walkways, and parking in accordance with the requirements set out in this subsection.(1) Paved roads and walkways.(A) Paved roads shall be provided within lot lines for access from public roads to the main entrance and to service entrances.(B) Finished surface walkways shall be provided for pedestrians. When public transportation or walkways serve the site, finished surface walkways or paved roads shall extend from the public conveyance to the building entrance.(2) Parking and disability requirements.(A) Parking requirements. Off-street parking shall be provided at the minimum ratio of two spaces for each operating room, one space for each staff member, and one visitor's space for each operating room.(B) Design for the handicapped. Special considerations benefiting handicapped staff, visitors, and patients shall be provided. Each ASC shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101 - 336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities or 16 Texas Administrative Code, §68.20 (relating to Buildings and Facilities Subject to Compliance with the Texas Accessibility Standards), Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Texas Government Code, Chapter 469.(c) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and local governing building codes. Where there is no local governing building code, the ASC shall be constructed in accordance with the International Building Code, 2003 edition, published by the International Code Council, 500 New Jersey Avenue, Northwest, 6th Floor, Washington, District of Columbia 20001-2070, (888) 422-7233.(1) General architectural requirements. All new construction, including conversion of an existing building to an ASC or establishing a separately licensed ASC within another existing building, shall comply with NFPA 101, Chapter 20, New Ambulatory Health Care Occupancies, of the National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), and Subchapters B and C of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Construction documents shall be submitted to the department in accordance with §135.54 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(A) Construction types for multiple building occupancy.(i) When an ASC is part of a larger building which complies with NFPA 101, §20.1.6, Minimum Construction Requirements for (fire resistance) construction type, the designated ASC shall be separated from the remainder of the building with a minimum of one-hour fire-rated construction.(ii) When an ASC is located in a multistory building of two or more stories, the entire building shall meet the construction requirements of NFPA 101, §20.1.6.3. An ASC shall not be located in a multistory building which does not comply with the minimum construction requirements of NFPA 101, §20.1.6.3.(iii) When an ASC is part of a one-story building that does not comply with the construction requirements of NFPA 101, §20.1.6.2, the ASC shall be separated from the remainder of the building with a two-hour fire-rated construction. The designated ASC portion shall have the construction type upgraded to comply with NFPA 101, §20.1.6.2.(B) Special design provisions. Special provisions shall be made in the design of a facility if located in a region where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, or floods.(2) Physical environment. A physical environment that protects the health, welfare, and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and the requirements of this chapter.(3) Other regulations. The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists.(4) Exceeding minimum requirements. Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter.(5) Equivalency. Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this subchapter, provided technical documentation which demonstrates equivalency is submitted to the department for approval.(6) Freestanding buildings (not for patient use). Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed and constructed in accordance with other occupancy classifications requirements listed in NFPA 101.(d) Spatial requirements.(1) Administration and public areas.(A) Entrance. Entrances shall be located at grade level, be accessible to individuals with disabilities, and be protected against inclement weather from the point of passenger loading/unloading to the building entrance. When an ASC is located on a floor above grade level, elevators shall be accessible and shall meet the requirements of §135.53 of this title (relating to Elevators, Escalators, and Conveyors).(B) Waiting area. A waiting area or lobby shall be provided within the ASC and include having the following rooms and items:(i) public toilet facilities;(ii) telephone(s) for public use; and(iii) access to potable drinking water.(C) Reception area. A designated reception area with desk or counter shall be provided.(D) Interview space(s). Space shall be provided for private interviews or family members, relating to social services, credit, or admission.(E) General or individual office(s). An office(s) shall be provided for business transactions, records, and administrative and professional staff.(F) Medical records area. The medical records area shall have adequate space for reviewing, dictating, sorting, or recording records. If electronic imaging devices are employed (i.e., microfilm, digital, or optical disc), the medical records area shall have adequate space for transcribing records in the electronic format. Medical record storage space shall be located within a secure designated area under direct visual supervision of administrative staff.(G) General storage room.(i) A minimum of 30 square feet per operating room shall be provided exclusive of soiled holding, sterile supplies, clean storage, drug storage, locker rooms, and surgical equipment storage. General storage may be located in one or more rooms or closets, and shall be located outside of the patient treatment areas.(ii) General storage room(s) shall be separated from adjacent areas by fire-rated construction in accordance with the NFPA 101, §38.3.2.1 and §38.3.2.2.(H) Wheelchair storage space or alcove. Storage space for wheelchairs shall be provided and shall be out of the direct line of traffic.(2) Engineering services and equipment areas. Equipment rooms with adequate space shall be provided for mechanical and electrical equipment. These areas shall be separate from public, patient, and staff areas.(3) Examination room. An examination room is not required, but when provided, the room shall have:(A) a minimum clear floor area of at least 80 square feet exclusive of fixed or moveable cabinets, counters, or shelves; and(B) a work counter with space for writing and a hand washing fixture with hands-free operable controls.(4) Janitor's closet. In addition to the janitor's closet exclusive to the surgery suite, a sufficient number of janitor's closets shall be provided throughout the facility to maintain a clean and sanitary environment. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment.(5) Laboratory.(A) General. Laboratory services shall be provided within the ASC or through a contract or other arrangement with a hospital or accredited laboratory.(B) Special requirements. When the laboratory is located on site the following minimum items shall be provided:(i) a room with work counter, utility sink, and storage cabinets or closet(s); and(ii) specimen collection facilities. For dip stick urinalysis, urine collection rooms shall be equipped with a water closet and lavatory. Blood collection facilities shall have space for a chair, work counter, and a hand washing fixture with hands-free operable controls.(C) Code compliance. An on-site laboratory shall comply with the following codes.(i) Construction for fire protection in laboratories employing quantities of flammable, combustible, or other hazardous material shall be in accordance with the National Fire Protection Association 99, Health Care Facilities, 2002 Edition, (NFPA 99).(ii) Laboratories shall comply with the requirements of NFPA 99, Health Care Facilities, 2002 Edition, Chapter 11, as applicable and the requirements of NFPA 45, Standards on Fire Protection for Laboratories Using Chemicals, 2000 Edition, as applicable.(6) Laundry and linen processing area(s). Laundry and linen processing may be done within the center or off site at a commercial laundry.(A) On-site linen processing. When on-site linen processing is provided, soiled and clean processing operations shall be separated and arranged to provide a one-way traffic pattern from soiled to clean areas. The following rooms and items shall be provided:(i) a soiled linen processing room which includes areas for receiving, holding, sorting, and washing;(ii) a clean linen processing room which includes areas for drying, sorting, folding, and holding prior to distribution;(iii) supply storage cabinets in the soiled and clean linen processing rooms;(iv) a hand washing fixture with hands-free operable controls within the soiled linen processing room; and(v) a storage room for clean linen located within the surgical suite. Clean linen storage may be combined with the clean work room.(B) Off-site linen processing. When linen is processed off site, the following rooms or items shall be provided:(i) a storage room for clean linen located within the surgical suite. Clean linen storage may be combined with the clean work room; and(ii) a soiled linen holding room or area located within the surgical suite. Soiled linen holding may be combined with the soiled workroom.(7) Medical waste processing. Space and facilities shall be provided for the safe storage and disposal of waste as appropriate for the material being handled and in compliance with all applicable rules and regulations.(8) Pharmacy. A pharmacy work room or alcove shall be provided and located separate from patient and public areas and under the direct supervision of staff. A work counter, refrigerator, medication storage, and locked storage for biologicals and drugs shall be provided. A hand washing fixture with hands-free operable controls shall be located in the pharmacy room or alcove.(9) Postoperative recovery suite.(A) General. A postoperative recovery suite shall be distinct and separate from preoperative areas. The postoperative recovery suite shall be arranged to provide a one-way traffic pattern from the restricted surgical corridor to the postoperative recovery suite, and then to the extended observation rooms or discharge.(B) Postanesthesia care unit. A minimum of one patient station per operating room, plus one additional station, shall be provided.(i) In a multiple-bed postoperative recovery area, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of three feet. The clearance between sides of beds/gurneys shall be a minimum of four feet six inches. The minimum distance at the foot of the bed/gurney shall not be less than six feet for single load area/room or nine feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area.(ii) The minimum clear floor space in a private postoperative recovery room shall be 100 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of nine feet width shall be provided for the head wall.(C) Patient toilet. A toilet room with a water closet and a hand washing fixture with hands-free operable controls shall be provided. The toilet room may be shared with the preoperative patient holding area, if located conveniently between both areas.(D) Hand washing fixture. One hand washing fixture with hands-free operable controls shall be provided for every four recovery beds or fraction thereof in open wards. Fixtures shall be uniformly distributed. One hand washing fixture shall be provided within each single-bed recovery room.(E) Extended observation rooms. Separate supervised rooms or areas may be provided for patients who are sufficiently stabilized to leave the postanesthesia care unit, but require additional time in the facility for observation or comfort measures prior to being discharged.(i) When individual rooms are provided for extended observation, the rooms shall have an area of at least 60 square feet. When such rooms include a bed or recliner, a minimum clearance of three feet at the foot and on each side of the bed or recliner shall be provided.(ii) When an open or ward area for extended observation is provided, the minimum clearance from the bed or recliner to the side wall shall not be less than three feet; and a space of four feet shall be provided at the foot of each bed or recliner. The minimum clearance between beds or recliners shall not be less than three feet.(iii) A toilet room with a water closet and a hand washing fixture with hands-free operable controls shall be provided. The toilet room may be shared with the postoperative recovery area, if located conveniently between both areas.(10) Preoperative patient holding room.(A) General. A preoperative holding area shall be provided and arranged in a one-way traffic pattern so that patients entering from outside the surgical suite can change, gown, and move directly into the restricted corridor of the surgical suite. The holding area shall be separate from the postoperative recovery suite and the restricted corridor.(B) Patient station. A minimum of one patient station per operating room shall be provided.(i) When individual rooms are provided, the minimum clear floor space in a private preoperative holding room shall be 80 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The rooms shall include a bed or recliner with a minimum clearance of three feet at the foot and on each side of the bed or recliner.(ii) In a multiple-bed preoperative holding area, a minimum area of 60 square feet shall be provided for each patient station. The minimum clearance from the gurney or bed to a sidewall shall not be less than three feet. A space of four feet shall be provided at the foot of the gurney or bed and the minimum clearance between gurneys or beds shall not be less than four feet six inches.(iii) Space shall be made available for storing and securing patient's personal effects.(iv) One hand washing fixture with hands-free operable controls shall be provided for every four preoperative beds or fraction thereof in open wards. Fixtures shall be uniformly distributed. One hand washing fixture shall be provided within each single-bed preoperative holding room.(C) Patient toilet. A toilet room with handicapped accessible water closet and hand washing facilities shall be provided. The toilet room may be shared with the postoperative recovery suite, if located conveniently between both areas.(D) Duty station. A hand washing fixture with hands-free operable controls and a counter or shelf space for writing shall be provided for staff use within or convenient to the preoperative area. The staff hand washing fixture with hands-free operable controls shall be separate from and in addition to patient toilet accommodations.(11) Radiology.(A) Special requirements. When radiology services are provided on site, the following minimum facilities shall be provided:(i) film processing facilities, if used;(ii) viewing capabilities;(iii) storage facilities for exposed film, if used, located in rooms or areas constructed in accordance with the NFPA 101, §38.3.2.1 and §38.3.2.2; and(iv) dressing area(s) shall be required, depending on services provided, with convenient access to toilets, and may be shared with patient changing/preoperative rooms.(B) Fluoroscopy room. When fluoroscopy services are provided on site in a dedicated fluoroscopy room, a toilet room with a water closet and a hand washing fixture with hands-free operable controls shall be directly accessible to the room.(12) Soiled workroom. In addition to the soiled workroom provided in the surgical suite, a separate soiled workroom(s) shall be required when a treatment room is provided, except as allowed in subparagraph (B) of this paragraph.(A) Special requirements. The workroom(s) shall contain a clinical sink or equivalent flushing type fixture, work counter, designated space for waste and linen receptacles, and a hand washing fixture with hands-free operable controls.(B) Shared functions. The soiled workroom required in support of a treatment room may be combined with a surgical suite soiled work room with two means of entry. A separate door into the soiled workroom shall serve a treatment room located outside the surgical suite.(13) Surgical staff clothing change area.(A) Surgical staff changing rooms. Appropriately sized areas shall be provided for male and female personnel working within the surgical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker/changing rooms shall be provided for male and female staff. The shower and toilet room(s) may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the surgical suite can shower, change, and move directly into the restricted areas of the surgical suite.(B) Surgical staff lounge. When a surgical staff lounge is provided, the lounge shall be located to permit the use without leaving the surgical suite and may be accessed from the clothing changing rooms. The surgical staff lounge shall not have direct access from outside the surgical suite. When the lounge is remote from the clothing change rooms, toilet facilities and a hand washing fixture with hands-free operable controls accessible from the lounge shall be provided.(14) Sterilizing facilities. A system for sterilizing equipment and supplies shall be provided. Sterilizing procedures may be done on site or off site, or disposables may be used to satisfy functional needs.(A) Off-site sterilizing. When sterilizing is provided off site and disposables and prepackage surgical supplies are used, the following rooms shall be provided near the operating room.(i) Soiled holding room. A room for receiving contaminated/soiled material and equipment from the operating room shall be provided. The room shall be physically separate from all other areas of the suite. The room shall include a work counter(s) or a table(s), clinical sink or equivalent flushing type fixture, equipment for initial disinfection and preparation for transport to off-site sterilizing, and a hand washing fixture with hands-free operable controls. The soiled holding room may be combined with the surgical suite soiled workroom.(ii) Clean workroom. A clean workroom shall be provided for the exclusive use of the surgical suite. The workroom shall contain a work counter with space for receiving, disassembling and organizing clean supplies, storage cabinets or shelving, and a hand washing fixture with hands-free operable controls.(iii) Sterilizer equipment. Sterilizer equipment shall be located in a separate room convenient to the operating room(s), in an alcove adjacent to the restricted corridor, or in the clean workroom.(B) On-site sterilizing facilities. When sterilizing facilities are provided on site they shall be located near the operating room and provide the following rooms.(i) Receiving/decontamination room. The receiving/decontamination room shall be physically separate from all other areas of the surgical suite. The room shall include a work counter(s) or table(s), clinical sink or equivalent flushing type fixture, equipment for initial washing/disinfection, and a hand washing fixture with hands-free operable controls. Pass-through dutch doors, windows, and washer/sterilizer decontaminators shall serve in delivering material to the clean workroom. The receiving/decontamination room may be combined with the surgical suite soiled workroom.(ii) Clean/assembly workroom. The clean/assembly workroom shall include a counter(s) or table(s) with space for organizing, assembling, and packaging of medical/surgical supplies and equipment, equipment for terminal sterilizing, and a hand washing fixture with hands-free operable controls. Clean and soiled work areas shall be physically separated.(iii) Sterile storage. A storage room for clean and sterile supplies shall be provided. The storage room shall have adequate areas and counters for breakdown of manufacturers' clean/sterile medical/surgical supplies. This room may be combined with the clean assembly/workroom.(iv) Cart storage room or alcove. The storage space for distribution carts shall be adjacent to clean and sterile storage area(s) and close to main distribution points.(15) Surgical suite. The surgical suite shall be arranged to preclude unrelated traffic through the suite. The surgical suite shall contain at least one operating room and all surgical service areas required under subparagraph (B) of this paragraph.(A) Operating room. The operating room(s) shall have a clear floor area of at least 240 square feet exclusive of fixed or moveable cabinets, counters, or shelves. The minimum clear dimension between built-in cabinets, counters, and shelves shall be 14 feet.(B) Surgical service areas.(i) Restricted corridor. The restricted corridor shall serve as the primary passageway for staff and patients within the surgical suite. The following rooms and areas shall have direct access to the restricted corridor:(I) preoperative patient holding area;(II) operating room(s);(III) postoperative recovery suite;(IV) soiled workroom;(V) clean workroom;(VI) janitor's closet;(VII) equipment storage;(VIII) sterilizing facilities;(IX) anesthesia workroom when provided; and(X) area for emergency crash cart.(ii) Soiled workroom. A soiled workroom shall be provided for the exclusive use of the surgical suite staff. The workroom shall contain a clinical sink or equivalent flushing type fixture, work counter, designated space for waste and linen receptacles, and a hand washing fixture with hands-free operable controls. The soiled workroom shall not have direct connection with operating room(s) or other sterile activity room(s).(iii) Clean linen storage. A storage room or alcove shall be provided for storing clean linen.(iv) Scrub facilities. A scrub station shall be located in the restricted corridor within five feet of the entrance of each operating room. One scrub station with dual faucets with hands free operable controls may serve two operating rooms if the scrub stations are located adjacent to the entrance of both operating rooms. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment, or supply carts. Viewing panels shall be provided for observation of the surgical room interior. The scrub sinks shall be recessed out of the main traffic areas. The scrub sink alcove shall be located within the restricted areas of the surgical suite. Scrub sinks shall not be located inside the sterile area.(v) Janitor's closet. A janitor's closet shall be provided for the exclusive use of the surgical suite. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment.(vi) Equipment storage. A room, alcove, or designated area shall be provided for storing equipment and supplies used in the surgical suite. The storage room or area shall be a minimum of 50 square feet per operating room.(vii) Medical gas storage room. When provided or required by NFPA 101, a medical gas storage room shall comply with the requirements of NFPA 99, 2002, Chapter 5, Gas and Vacuum Systems.(viii) Area for emergency crash cart. An area or alcove located out of traffic and convenient to the operating room(s) shall be provided for an emergency crash cart.(ix) Stretcher storage area. An area or alcove shall be located convenient for use and out of the direct line of traffic for the storage of stretchers as required. Stored stretchers shall not encroach on corridor widths.(16) Treatment room.(A) A treatment room is not required, but when provided, it shall be used only for minor procedures.(B) If inhalation anesthesia is administered in the treatment room, the room shall comply with NFPA 99, §14.4.1 requirements for an anesthetizing location.(C) The treatment room shall have a clear floor area of at least 120 square feet exclusive of fixed or moveable cabinets, counters, or shelves.(D) The treatment room shall contain an examination table, a counter for writing, and a hand washing fixture with hands-free operable controls.(e) General detail and finish requirements. Details and finishes in new construction projects, including additions and alterations, shall be in compliance with this subsection, with NFPA 101, Chapter 20, and with local building codes.(1) General detail requirements.(A) Fire safety. Fire safety features, including smoke compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with NFPA 101, Chapter 20. The Fire Safety Evaluation System for Health Care Occupancies contained in the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 Edition, Chapter 3, shall not be used in new building construction, renovations, or additions to existing ASCs.(B) Exits, corridors and doors.(i) Number of exits. A facility shall provide two exits remote from each other in accordance with NFPA 101, §20.2.4.1. At least one exit door shall be accessible by an ambulance from the outside. This door may also serve as an entry for loading or receiving goods.(ii) Encroachment into the means of egress. Items such as drinking fountains, telephone booths or stations, and vending machines shall be so located as to not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment shall not be stored so as to project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(iii) Corridors.(I) Public corridor. The minimum clear and unobstructed width of a public corridor shall be at least four feet.(II) Communicating corridor. The communicating corridor shall be used to convey patients by stretcher, gurney, or bed.(III) The communicating corridor shall link the preoperative holding area, operating room(s), and postoperative recovery suite, and shall be continuous to at least one exit.(IV) The minimum clear and unobstructed width of the communicating corridor shall be eight feet.(iv) Door types. Doors at all openings between corridors and rooms or spaces subject to occupancy shall be swing type. Elevator doors are excluded from this requirement.(v) Door swing. Doors, except doors to spaces such as small closets which are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the required corridor width. Large walk-in type closets are considered as occupiable spaces.(vi) Patient access doors. The minimum width of doors for patient access to examination and consultation rooms shall be three feet. The minimum width of doors requiring access for beds and gurneys (preoperative holding area, operating room, postoperative recovery suite, treatment rooms) shall be three feet eight inches.(vii) Emergency access. Rooms containing a water closet, intended for patient use, shall be provided with at least one door having hardware which will permit access from the outside in any emergency. Door leaf width of such doors shall not be less than 36 inches.(viii) Sliding doors. Horizontal sliding doors serving an occupant load of fewer than 10 shall be permitted. The area served by the door shall have no high hazard contents. The door shall be readily operable from either side without special knowledge or effort. The force required to operate the door in the direction of door travel shall be not more than 30 pounds per foot to set the door in motion, and shall be not more than 15 pounds per foot to close the door or open in the minimum required width. The door assembly shall comply with any required fire protection rating, and, where rated, shall be self-closing or automatic closing. The sliding doors opening to the egress corridor doors shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. The sliding doors may have breakaway provisions and shall be installed to resist passage of smoke. The latching sliding panel shall have a minimum clear opening of 36 inches in the fully open position. The fixed panels may have recessed tracks.(ix) Fire doors. All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 Edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(C) Glazing. Glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101, §18.3.3.(D) Grab bars. Grab bars shall be provided at patient toilets and showers. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars intended for use by the disabled shall also comply with ADA requirements.(E) Hand washing facilities. Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free controls shall be provided in each examination room, treatment room, preoperative area, postoperative recovery suite, extended observation room or area, soiled utility room, fluoroscopy room, clean work room, and toilet room. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be conveniently located for staff use in rooms and areas noted under spatial requirements in subsection (d) of this section and throughout the center where patient care services are provided.(F) Soap dispensers. A liquid or foam soap dispenser shall be located at each hand washing facility.(G) Hand drying. Provisions for hand drying shall be included at all hand washing facilities. There shall be hot air dryers or individual paper or cloth units enclosed in such a way as to provide protection against dust or soil and ensure single-unit dispensing.(H) Signage. A sign shall be posted at the entrance to each toilet/restroom to identify the facility for public, staff, or patient use.(I) Ceiling heights. The minimum ceiling height shall be eight feet six inches with the following exceptions.(i) Rooms containing ceiling-mounted light fixtures or equipment. Operating rooms or other rooms containing ceiling-mounted light fixtures or equipment shall have ceiling heights of not less than nine feet. Additional ceiling height may be required to accommodate special fixtures or equipment.(ii) Minor rooms. Ceilings in storage rooms, toilet rooms, and other minor rooms shall be not less than seven feet six inches(iii) Boiler rooms. Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.(iv) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.(J) Areas producing impact noises. Recreation rooms, exercise rooms, and similar spaces where impact noises may be generated shall not be located directly over operating rooms or special procedure rooms unless special provisions are made to minimize noise.(K) Rooms with heat-producing equipment. Rooms containing heat-producing equipment, such as mechanical and electrical equipment and laundry rooms, shall be insulated and ventilated to prevent floors of any occupied room located above it from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature.(L) Radiation protection. Shielding shall be designed, tested, and approved by a medical physicist licensed under the Medical Physics Practice Act, Occupations Code, Chapter 602. The ASC shall obtain a certificate of registration issued by the Radiation Safety Licensing Branch to use radiation machines.(f) General finishes requirements.(1) Privacy screens, cubicle curtains, and draperies.(A) Cubicle curtains or privacy screens shall be provided to assure patient privacy when required or requested by a patient.(B) Cubicle curtains, draperies and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small-scale and the large-scale tests of National Fire Protection Association 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 Edition. Copies of laboratory test reports for installed materials shall be submitted to the department at the time of the final construction inspection.(2) Flame spread, smoke development and noxious gases. Flame spread and smoke developed limitations of interior finishes shall comply with Table 4 of §135.56(d) of this title (relating to Construction Tables) and NFPA 101, §10.2. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition, and National Fire Protection Association 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 2001 Edition, shall be provided.(3) Floor finishes.(A) Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet (such as shower and bath areas, and similar work areas) shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes:(i) painted concrete for mechanical, electrical, communication rooms, and janitor's closets;(ii) vinyl and vinyl composition tiles and sheets tiles for offices, lobbies, administrative areas, storage, staff and public toilet rooms, examination rooms, support spaces, and nontreatment areas;(iii) monolithic or seamless flooring shall be provided for all operating rooms, special procedure rooms, treatment rooms, patient toilet rooms, soiled workrooms, and sterilizing facility(ies). Seamless flooring shall be impervious to water, coved and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles. The base shall not be less then six inches in height. Welded joint flooring is acceptable;(iv) marble, ceramic and quarry tile for offices, lobbies, staff and public toilet rooms, administrative areas, wet areas, and similar spaces;(v) carpet flooring for offices, lobbies, and administrative areas. Carpeting shall not be installed in any preoperative holding, toilet rooms, treatment rooms, examination rooms, and similar spaces; and(vi) terrazzo for offices, lobbies, administrative areas, and similar spaces.(B) Threshold and expansion joint covers. Thresholds at doorways shall not exceed 3/4 inch in height for exterior sliding doors or 1/2 inch for other type doors. Raised thresholds and floor level changes at accessible doorways shall be beveled with a slope no greater than 1:2. Expansion joint covers shall not exceed 1/2 inch in height and shall have beveled edges with a slope no greater than 1:2.(4) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall be in compliance with the requirements of NFPA 101, §38.3.3, relating to flame spread.(A) Finishes at plumbing fixtures. Wall finishes shall be water-resistant in the immediate area of plumbing fixtures.(B) Wet cleaning methods. Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed, and without voids.(5) Ceiling finishes. All occupied rooms and spaces shall be provided with finished ceilings, unless otherwise noted. Ceilings which are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing. Three types of ceilings that are required in various areas of the ASC are:(A) ordinary ceilings. Ceilings are required in all areas or rooms in the ASC unless otherwise noted. This includes ceilings such as acoustical tiles installed in a metal grid which are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners;(B) washable ceilings. When ceilings that dictate this type of cleaning or protection for these spaces such as soil utility or soil workroom, the ceilings shall be made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid; and(C) monolithic ceilings. Ceilings which are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish shall be provided in the operating rooms, special procedure rooms, and sterilizing facilities.(D) Nonceiling requirements. Finished ceilings may be omitted in mechanical, electrical, communication rooms and equipment spaces, shops, and similar spaces unless required for fire-resistive purposes.(6) Floor, wall, and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits, or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed.(7) Materials finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(g) General mechanical requirements. This subsection contains requirements for mechanical systems; air conditioning, heating and ventilating systems; steam and hot and cold water systems; and thermal and acoustical insulation.(1) Cost. All mechanical systems shall be designed for overall efficiency and life cycle costing, including operational costs. Recognized engineering practices shall be followed to achieve the most economical and effective results except that in no case shall patient care or safety be sacrificed for conservation.(2) Equipment location. Mechanical equipment may be located indoors or outdoors (when in a weatherproof enclosure), or in a separate building(s).(3) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators.(4) Performance and acceptance. Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or his representative that the installation and performance of these systems conform to the requirements of the plans and specifications.(A) Material lists. Upon completion of the contract, the owner shall obtain from the construction contractor parts lists and procurement information with numbers and descriptions for each piece of equipment.(B) Instructions. Upon completion of the contract, the owner shall obtain from the construction contractor instructions in the operational use and maintenance of systems and equipment as required.(5) Heating, ventilating, and air conditioning (HVAC) systems.(A) All central HVAC systems shall comply with and shall be installed in accordance with the requirements of NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 Edition, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, 2002 Edition, as applicable and the requirements contained in this paragraph. Air handling units serving two or more rooms are considered to be central units.(B) Noncentral air handling systems, i.e., individual room units that are used for heating and cooling purposes (e.g., fan-coil units, heat pump units, and packaged terminal air conditioning units) shall be equipped with permanent (cleanable) or replaceable filters. The filters shall have an average efficiency of 25 - 30% and an average arrestance of 85% based on American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air Cleaning Devices for Removal Efficiency by Particle Size. These units shall be used as air recirculating units only. All outdoor air requirements shall be met by a separate central air handling system with the proper filtration, as required in Table 1 of §135.56(a) of this title.(C) General ventilation requirements. All rooms and areas in the ASC shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 1 of §135.56(a) of this title shall be used only as minimum requirements, since they do not preclude the use of higher rates that may be appropriate.(i) Cost reduction methods. To reduce utility costs, facility design may utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shutdown, or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied. In no case shall patient care be jeopardized.(ii) Economizer cycle. Mechanical systems shall be arranged to take advantage of outside air conditions by using an economizer cycle when appropriate to reduce heating and cooling systems loads. Innovative design that provides for additional energy conservation while meeting the intent of this section for acceptable patient care may be presented to the department for consideration.(iii) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, clean storage rooms, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas, shall not be permitted. Ductwork access panels shall be labeled.(iv) Temperatures and humidities. The designed capacity of the systems shall be capable of providing the ranges of temperatures and humidities as shown in Table 1 of §135.56(a) of this title.(v) Thermometers and humidity gauges. Each operating room, special procedure room, and postoperative recovery suite shall have temperature and humidity indicating devices mounted at eye level.(vi) Outside air intake locations.(I) Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum system outlets, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require other arrangements).(II) Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet to the air intake.(III) The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level.(vii) Contaminated air exhaust outlets. Exhaust outlets from areas (laboratory hoods, etc.) that exhaust contaminated air shall be above the roof and be arranged to exhaust upward unless the air has been treated by an appropriate means where sidewall exhaust will be allowed. Exhaust outlets from areas containing ethylene oxide sterilizers and other contaminants, e.g., glutaraldehyde, shall terminate not less than eight feet above the roof level (or be appropriately labeled as "hazardous exhaust") and arranged to exhaust upward.(viii) Directional air flow. Ventilation systems shall be designed and balanced to provide pressure relationships contained in Table 1 of §135.56(a) of this title. For reductions and shut down of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 1 of §135.56(a) of this title shall be followed.(ix) Air distribution devices. Design shall consider turbulence and other factors of air movement to minimize airborne particulate matter. Where extraordinary procedures require special designs, the installation shall be reviewed on a case-by-case basis.(I) All supply diffusers grilles shall be located on the ceiling or on a wall near the ceiling.(II) Air supply for the operating rooms and special procedure rooms shall be from ceiling outlets near the center of the work area to efficiently control air movement.(III) A minimum of two return air inlets located diagonally opposite from one another and near floor level shall be provided. Bottoms of return air grilles in operating rooms and other anesthetizing locations shall be located not more than 12 inches above the finished floor nor less than six inches above the finished floor.(x) Ventilation start-up requirements. Air handling systems shall not be started or operated without the filters installed in place. This includes the 90% and 99.97% efficiency filters where required. This includes during construction operations. Ducts shall be cleaned thoroughly and throughout by a National Air Duct Cleaners Association (NADCA) certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, the department shall require a written report assuring cleanliness of duct and clean air quality.(xi) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Duct work with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct takeoffs shall be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used.(xii) Filtration requirements. All air handling units shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 2 of §135.56(b) of this title. Filter efficiencies shall be average dust spot efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. All documents published by ASHRAE as referenced in this section may be obtained by writing or calling the ASHRAE, Inc. at the following address or telephone number: ASHRAE, 1791 Tullie Circle, Northeast, Atlanta, Georgia 30329; telephone (404) 636-8400.(I) Filtration requirements for air handling units serving single rooms requiring asepsis control. Dedicated air handlers serving only one room where asepsis control is required, such as, but not limited to, operating rooms, special procedure rooms, and treatment rooms shall be equipped with filters having efficiencies equal to, or greater than, those specified for patient care areas in Table 2 of §135.56(b) of this title.(II) Filtration requirements for air handling units serving other single rooms. Dedicated air handlers serving all other single rooms shall be equipped with nominal filters installed at the return air system.(III) Location of multiple filters. Where two filter beds are required by Table 2 of §135.56(b) of this title, filter bed number one shall be located upstream of the air conditioning equipment, and filter bed number two shall be downstream of the supply air blowers, cooling and heating coils.(IV) Location of single filters. Where only one filter bed is required by Table 2 of §135.56(b) of this title, it shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork.(V) Pressure monitoring devices. A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more, including laboratory hoods requiring high efficiency particulate air (HEPA) filters. The pressure monitoring device shall be mounted below the ceiling line within the ASC such that it can be observed by staff.(D) Thermal and acoustical insulation for air handling systems. Asbestos containing insulation materials shall not be used.(i) Thermal duct insulation. Air ducts and casings with outside surface temperature below the ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation.(ii) Insulation in air plenums and ducts. When installed, linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories (UL), Standard 181, relating to Factory-Made Duct Materials and Air Duct Connectors, April 4, 1996 edition. This document may be obtained from the Underwriters Laboratories, 333 Pfingsten Road, Northbrook, Illinois 60062-2096.(iii) Insulation flame spread and smoke developed ratings. Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A, Chapters 4 and 5 and as determined by an independent testing laboratory in accordance with NFPA 255, A Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition.(iv) Linings and acoustical traps. Duct lining and acoustical traps exposed to air movement shall not be used in ducts serving critical care areas. This requirement shall not apply to mixing boxes and acoustical traps that have approved nonabrasive coverings over such linings.(v) Frangible insulation. Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem or occupant discomfort.(vi) Existing duct linings. Internal linings shall not be used in ducts, terminal boxes, or other air system components supplying operating rooms and the postoperative recovery suite, unless terminal filters of at least 90% efficiency are installed downstream of linings.(E) Ventilation for anesthetizing locations. When anesthesia is administered, ventilation for anesthetizing locations, as defined in NFPA 99, §3-3, shall comply with NFPA 99, §13.4.1.2 and any specific ventilation requirements of clauses (i) - (iii) of this subparagraph.(i) Smoke removal systems for anesthetizing locations. Smoke removal systems shall be provided in all windowless anesthetizing locations in accordance with NFPA 99, §6.4.1.2. Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically exhaust smoke and products of combustion, prevent recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intakes, without in either case interfering with the exhaust function of the system.(ii) Smoke removal systems for surgical suites. Smoke removal systems shall be provided in all surgical suites in accordance with NFPA 99, §6.4.1.3.(iii) Smoke exhaust grilles. Exhaust grilles for smoke evacuation systems shall be ceiling-mounted or wall-mounted within 12 inches of the ceiling.(F) Location of return and exhaust air devices. The bottoms of wall-mounted return and exhaust air openings shall be at least four inches above the floor. Return air openings located less than six inches above the floor shall be provided with nominal filters. All exhaust air openings and return air openings located higher than six inches but less than seven feet above the floor shall be protected with grilles or screens having openings through which a one-half inch sphere will not pass.(G) Ray protection. Ducts which penetrate construction intended for X-ray or other ray protection shall not impair the effectiveness of the protection.(H) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a required two-hour or higher fire-rated wall or floor in accordance with the requirements of NFPA 101, §18.5.2.(I) Smoke damper requirements. Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101, §20.3.7.3, and NFPA 90A, Chapter 5.(i) Protection of ducts penetrating fire and smoke partitions. Combination fire and smoke leakage limiting dampers (Class II) shall be installed in accordance with manufacturer's instructions for all ducts penetrating one and two-hour rated fire and smoke partitions required by NFPA 101, §20.3.7, Subdivision of Building Space (not required in ASCs meeting the provisions of NFPA 101, §20.3.7.2, Exception Number 1).(ii) Fail-safe installation. Combination smoke and fire dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72), Chapter 8; NFPA 90A, Chapter 6; and NFPA 101, §20.3.5; the fire sprinkler system; and upon loss of power. Smoke dampers shall not close by fan shutdown alone unless it is a part of an engineered smoke removal system.(iii) Interconnection of air handling fans and smoke dampers. Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts.(iv) Frangible devices. Use of frangible devices for shutting smoke dampers is not permitted.(J) Acceptable damper assemblies. Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose shall be acceptable.(K) Duct access doors. Unobstructed access to duct openings in accordance with NFPA 90A, §4.3, shall be provided in ducts within reach and sight of every fire damper, smoke damper and smoke detector. Each opening shall be protected by an internally insulated door which shall be labeled externally to indicate the fire protection device located within.(L) Restarting controls. Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided that provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices.(M) Make-up air. If air supply requirements in Table 2 of §135.56(b) of this title do not provide sufficient air for use by exhaust hoods and safety cabinets, filtered make-up air shall be ducted to maintain the required air flow direction in that room. Make-up systems for hoods shall be arranged to minimize short circuiting of air and to avoid reduction in air velocity at the point of contaminant capture.(h) Piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code Illustrated published by the National Association of Plumbing-Heating-Cooling Contractors (PHCC), 2003 edition, and this paragraph. The National Standard Plumbing Code may be obtained by writing or calling the PHCC at the following address or telephone number: Plumbing-Heating-Cooling Contractors, Post Office Box 6808, Falls Church, Virginia 22046; telephone (800) 533-7694.(1) Piping systems.(A) Water supply piping systems. Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Domestic water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(i) Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture.(ii) Backflow preventers. Backflow preventers (vacuum breakers) shall be installed on hose bibs, laboratory sinks, janitor sinks, bedpan flushing attachments, and all other fixtures to which hoses or tubing can be attached. Connections to high hazard sources, e.g., X-ray film processors, shall be from a cold water hose bib through a reduced pressure principle type backflow preventer (RPBFP).(iii) Flushing valves. Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.(iv) Capacity of water heating equipment. Water heating equipment shall have sufficient capacity to supply water for all clinical needs based on accepted engineering practices using actual number and type of fixtures and for heating, when applicable.(v) Domestic hot water system. Hot water distribution system serving all patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet.(vi) Water temperature measurements. Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment. Hot water temperature at point of use for patients, staff, and visitors shall be in the range of 105 to 120 degrees Fahrenheit.(vii) Water storage tanks. Domestic water storage tank(s) shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. When potable water storage tanks (hot and cold) are used, the water shall be used and replenished. Water shall not be stored in tanks for future use unless the water is tested weekly for contaminates/bacteria.(viii) Purified water supply system. Purified water distribution system piping shall be task specific and include, but not necessarily be limited to, polypropylene (PP), polyvinylidene fluoride (PVDF) or polyvinyl chloride (PVC) pipe. Final installed purified water system piping assemblies shall be UL approved and fully comply with applicable American Society for Testing and Materials (ASTM) Fire Resistant/Smoke Density requirements. The applicable documents are available from ASTM International, 100 Barr Harbor Drive, Post Office Box C700, West Conshohocken, Pennsylvania 19428-2959.(ix) Dead-end piping. Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In any renovation work, dead-end piping shall be removed. Empty risers, mains and branches installed for future use are permitted.(B) Fire sprinkler systems. When provided, fire sprinkler systems shall comply with the requirements of NFPA 101, §9.7, Automatic Sprinklers and Other Extinguishing Equipment, and the requirements of this subparagraph. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, and shall be certified as required by §135.55(c)(1)(C) of this title (relating to Construction, Inspections, and Approval of Project).(C) Piped nonflammable medical gas and clinical vacuum systems. When provided, piped nonflammable medical gas and clinical vacuum system installations shall be designed, installed, and certified in accordance with the requirements of NFPA 99, §5.1 for Level 1 Piped Systems and the requirements of this subparagraph.(i) Outlets. Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 3 of §135.56(c) of this title.(ii) Installer qualifications. All installations of the medical gas piping systems including source tanks and related piping shall be done only by, or under the direct supervision of, a holder of a master plumber license or a journeyman plumber license with a medical gas piping installation endorsement issued by the Texas State Board of Plumbing Examiners.(iii) Installer tests. Prior to closing of walls, the installer shall perform an initial pressure test, a blowdown test, a secondary pressure test, a cross-connection test, and a purge of the piping system as required by NFPA 99.(iv) Qualifications for conducting verification tests and inspections. Verification testing shall be performed and inspected by a party, other than the installer, installing contractor, or material vendor. Testing shall be conducted by a medical gas system verifier registered with an acceptable organization by this department and is technically competent and experienced in the field of medical gas and vacuum pipeline testing and meets the requirements of The American Society of Safety Engineers (ASSE) Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems. The document published by ASSE Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems as referenced in this rule may be obtained by writing or calling The American Society of Safety Engineers (ASSE) at ASSE International Office, 901 Canterbury, Suite A, Westlake, Ohio 44145, telephone (440) 885-3040.(v) Verification tests. Upon completion of the installer inspections and tests and after closing of walls, verification tests of the medical gas piping systems, the warning system, and the gas supply source shall be conducted. The verification tests shall include a cross-connection test, valve test, flow test, piping purge test, piping purity test, final tie-in test, operational pressure tests, and medical gas concentration test.(vi) Verification test requirements. Verification tests of the medical gas piping system and the warning system shall be performed on all new piped medical gas systems, additions, renovations, or repaired portions of an existing system. All systems that are breached and components that are added, renovated, or replaced shall be inspected and appropriately tested. The breached portions of the systems subject to inspection and testing shall be all of the new and existing components in the immediate zone or area located upstream of the point or area of intrusion and downstream to the end of the system or a properly installed isolation valve.(vii) Warning system verification tests. Verification tests of piped medical gas systems shall include tests of the source alarms and monitoring safeguards, master alarm systems, and the area alarm systems.(viii) Source equipment verification tests. Source equipment verification tests shall include medical gas supply sources (bulk and manifold) and the compressed air source systems (compressors, dryers, filters, and regulators).(ix) ASC responsibility. Before new piped medical gas systems, additions, renovations, or repaired portions of an existing system are put into use, ASC medical personnel shall be responsible for ensuring that the gas delivered at the outlet is the gas shown on the outlet label and that the proper connecting fittings are checked against their labels.(x) Written certification. Upon successful completion of all verification tests, written certification for affected piped medical gas systems and piped medical vacuum systems including the supply sources and warning systems shall be provided by a party technically competent and experienced in the field of medical gas pipeline testing stating that the provisions of NFPA 99 have been adhered to and systems integrity has been achieved. The written certification shall be submitted directly to the ASC and the installer. A copy shall be available at final department construction inspection.(xi) Documentation of medical gas and clinical vacuum outlets. Documentation of the installed, modified, extended or repaired medical gas piping system shall be submitted to the department by the same party certifying the piped medical gas systems. The number and type of medical gas outlets (e.g., oxygen, vacuum, medical air, nitrogen, nitrous oxide) shall be documented and arranged tabularly by room numbers and room types.(D) Medical gas storage facilities. Main storage of medical gases may be outside or inside the ASC in accordance with NFPA 99, §5.1. Provision shall be made for additional separate storage of reserve gas cylinders necessary to complete at least one day's procedures.(E) Multiple gas outlets on one medical gas outlet. Y-connections, "twinning", or other similar devices shall not be used on any medical gas outlet.(F) Waste anesthetic gas disposal (WAGD) systems. Each space routinely used for administering inhalation anesthesia shall be provided with a WAGD system as required by NFPA 99, §5.1.3.7.(2) Steam and hot water systems.(A) Boilers. When provided, the boilers shall have the capacity, based upon the net ratings as published in The I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of GAMA, to supply the normal heating, hot water, and steam requirements of all systems and equipment. The document published by the Hydronics Institute Division of GAMA as referenced in this rule may be obtained by writing or calling the Hydronics Institute Division of GAMA at 35 Russo Place, Post Office Box 218, Berkeley Heights, New Jersey 07922, telephone (908) 464-8200.(i) Boiler accessories. Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.(ii) Valves. Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment.(B) Boiler certification. When required, the ASC shall ensure compliance with Texas Department of Licensing and Regulation, Boiler Section, Texas Boiler Law, (Health and Safety Code, Chapter 755, Boilers), which requires certification documentation for boilers to be posted on site at each boiler installation.(3) Drainage systems. Building sewers shall discharge into a community sewage system. Where such a system is not available, a facility providing sewage treatment shall conform to applicable local and state regulations.(A) Above ground piping. Soil stacks and roof drains installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or Schedule 40 polyvinyl chloride (PVC) pipe. Buildings or portions of buildings remodeled to an ASC need not comply with this requirement.(B) Underground piping. All underground building drains shall be cast iron soil pipe, hard temper copper tube (DWV or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), or PVC pipe (DWV Schedule 40 or heavier. Underground piping shall have at least 12 inches of earth cover or comply with local codes. Existing buildings or portions of buildings that are being remodeled need not comply with this subparagraph.(C) Drains for chemical wastes. Separate drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant borosilicate glass pipe, high silicone content cast iron pipe, polypropylene plastic pipe, or plastic lined pipe.(D) Drainage and waste piping. Drainage and waste piping shall not be installed above or below ceilings in operating rooms, special procedure rooms, and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Secondary protection shall be required to drain. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(4) Thermal insulation for piping systems and equipment. Asbestos containing insulation materials shall not be used.(A) Insulation. Insulation shall be provided for the following:(i) boilers, smoke breeching, and stacks;(ii) steam supply and condensate return piping;(iii) hot water piping and all hot water heaters, generators, converters, and storage tanks;(iv) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; and(v) other piping, ducts, and equipment as necessary to maintain the efficiency of the system.(B) Insulation flame spread. Flame spread shall not exceed 25 and smoke development rating shall not exceed 50 for pipe insulation as determined by an independent testing laboratory in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition.(5) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive, acid-resistant materials and shall comply with the requirements of the National Standard Plumbing Code, and this paragraph.(A) Sink and lavatory controls. All lavatories used by medical and nursing staff and by patients shall be trimmed with valves or electronic controls which can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may also be used.(B) Clinical sink traps. Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.(C) Sinks for disposal of plaster of paris. Sinks that are used for the disposal of plaster of paris shall have a plaster trap.(D) Back-flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(E) Drinking fountain. Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination.(F) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent not only the contamination of the water supply but also the entrance of contaminating materials into the sterilizing units.(G) Hose attachment. No hose shall be affixed to any faucet if the end of the hose can become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker.(H) Bedpan washers and sterilizers. When provided, bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(I) Flood level rim clearance. The water supply spouts for lavatories and sinks required in patient care areas shall be mounted so that their discharge points are a minimum of five inches above the rim of the fixture.(J) Scrub sink controls. Freestanding scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or electronic hands-free controls. Single lever wrist blades are not acceptable at scrub sinks.(K) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages.(L) Under counter piping. Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of the floor below the equipment.(M) Ice machines. All ice-making machines used for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines.(i) General electrical requirements. This paragraph contains common electrical and essential emergency system requirements.(1) Electrical requirements. All electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the NFPA 70, National Electrical Code, 2002 Edition, §517; NFPA 99, Chapter 14; the requirements of this subsection; and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturer's instructions.(A) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(B) Extension cords and cables shall not be used for permanent wiring.(C) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(D) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70.(E) Under counter electrical installations shall be arranged (raised) to not interfere with cleaning of the floor below the equipment.(2) Installation testing and certification.(A) Installation testing. The electrical installations, including grounding continuity, fire alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional. A written record of performance tests on special electrical systems and equipment shall show compliance with applicable codes and standards and shall be available to the department upon request.(B) Grounding system testing. The grounding system shall be tested as described in NFPA 99, §4.3.3, for patient care areas in new or renovated work. The testing shall be performed by a qualified electrician or their qualified electrical testing agent. The electrical contractor shall provide a letter stating that the grounding system has been tested in accordance with NFPA 99, the testing device use complies with NFPA 99, and whether the grounding system passed the test. The letter shall be signed by the qualified electrical contractor, or their designated qualified electrical testing agent, certifying that the system has been tested and the results of the test are indicated.(3) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(4) Services and switchboards. Electrical service and switchboards serving the required ASC components shall be installed above the designated 100-year flood plain. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire-rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures.(5) Panelboard. Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits shall be located on each floor that has major users (operating rooms, special procedure room, etc.) and may also serve the floor above and the floor below. Panelboards serving life safety branch circuits may serve three floors, the floor where the panelboard is located, and the floors above and below.(6) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in metal or metallic raceways in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300.(7) Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways in accordance with NFPA 70, §517.30(C)(3).(8) Lighting.(A) Lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IESNA) Handbook, 2000 edition, published by the IESNA, 120 Wall Street, Floor 17, New York, New York 10005.(i) Consideration shall be given to controlling light intensity and wavelength to prevent harm to the patient's eyes.(ii) Approaches to buildings and parking lots, and all spaces within buildings shall have fixtures that can be illuminated as necessary. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all spaces shall be clearly visible.(iii) Consideration shall be given to the special needs of the elderly. Excessive contrast in lighting levels that makes effective sight adaptation difficult shall be minimized.(B) Means of egress and exit sign lighting intensity shall comply with NFPA 101, §§7.8, 7.9, and 7.10.(C) Electric lamps, which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(D) Ceiling mounted surgical and examination light fixtures shall be suspended from rigid support structures mounted above the ceiling.(E) Operating rooms shall have general lighting in addition to local lighting provided by special lighting units at the surgical tables. Each fixed special lighting unit at the tables, except for portable units, shall be connected to an independent circuit.(F) X-ray film illuminators for handling at least two films simultaneously shall be provided in each operating room and special procedure room. When the entire surgical suite is provided with digital imaging system capabilities the film illuminators may be omitted.(9) Receptacles. Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in the operating rooms, special procedure rooms, postoperative recovery suite, and all patient care areas. This does not apply to special purpose receptacles.(A) Installations of multiple-ganged receptacles shall not be permitted in patient care areas.(B) Electrical outlets powered from the critical branch shall be provided in all patient care, procedure and treatment locations in accordance with NFPA 99, §4.4.2.2.2.3. At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel. All receptacles powered from the critical branch shall be colored red.(C) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be accomplished with receptacles of the same distinct color as the existing receptacles.(D) All critical care area receptacles shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.(E) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(F) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor in accordance with NFPA 70, §517-13.(G) Each operating room and special procedure room shall have at least four duplex receptacles located convenient to the head of the procedure table and one receptacle on the other walls.(H) Each work table or counter shall have access to one duplex receptacle for every six feet of table or counter space or fraction thereof.(I) A minimum of one duplex receptacle in each wall shall be installed in each work area or room other than storage or lockers.(J) Appliances shall be grounded in accordance with NFPA 99, Chapter 9.(K) Ground fault circuit interrupters (GFCI) receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70, §§517.20 and 517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.(10) Equipment.(A) The following shall be powered from the Type I essential electrical system in accordance with the requirements of NFPA 99, §§3-4.2.2.3, when such a system is required for safe operation of the ASC referenced in paragraph (14) of this subsection.(i) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected to the equipment system.(ii) Ventilating system serving preoperative areas, operating rooms, and the postoperative recovery suite shall be connected to the equipment system in accordance with the requirements of NFPA 99, Chapter 3.(B) Laser equipment shall be installed according to manufacturer recommendations and shall be registered with Department of State Health Services, Radiation Safety Licensing Branch, Post Office Box 149347, Austin, Texas 78714-9347.(C) A "kill switch" shall be provided for disconnection of each HVAC serving the building in accordance with the requirements of NFPA 90A, §6.2.1.(11) Wet patient care location. Wet patient care locations shall be protected against shock in accordance with the requirements of NFPA 99, §4.3.2.2.9.1.(12) Grounding requirements. Fixed electrical equipment shall be grounded in accordance with the requirements of NFPA 99, §4.3.3.1, and NFPA 70, Article 517.(13) Nurses calling systems.(A) A nurse emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound an audible signal which repeats every five seconds at a staffed location, and shall activate a distinct visible signal outside of toilet room where the call originated. The visible and audible signals shall be cancelable only at the patient calling station. Activation of the system shall also activate distinct visible signals in the clean workroom, in the soiled workroom, and if provided, in the nourishment station.(B) A staff emergency assistance calling system station shall be located in each operating room, treatment room, examination room, postoperative recovery, and preoperative holding area to be used by staff to summon additional help in an emergency. Activation of the system shall sound an audible signal at a staffed location, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the door. Additional visible signals shall be installed at corridor intersections in multi-corridor facilities. Distinct visible and audible signals shall be activated in the clean workroom, in soiled workroom, sterile processing room, equipment storage, and if provided, in the nourishment station.(14) Essential electrical system. The essential electrical system shall comply with the requirements of NFPA 99, §4.4.(A) A Type 1 essential electrical system shall be installed, maintained and tested in each ASC in accordance with requirements of NFPA 99, §4.4; NFPA 101, §20.2.9; and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(i) At least one autoclaving/sterilizing equipment shall be connected to the emergency electrical essential power system.(ii) One electrical outlet connected to the life safety branch of the electrical system shall be provided adjacent to (or on) the emergency generator.(iii) The battery charger for emergency lighting at the emergency generator shall be connected to the life safety branch of the electrical system.(B) Fuel storage capacity for an on-site generator for a Type 1 essential electrical system shall allow continuous operation, under full load for eight hours of testing as required by NFPA 99, §4.4.4.1.1.2.(C) When a vapor liquefied petroleum gas (LPG - natural gas) system is used, the 24-hour fuel capacity on-site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(D) When the emergency generator(s) and electrical transformer(s) are located within the same area, they shall be located at least 10 feet apart.(15) Fire alarm system. A fire alarm system which complies with NFPA 101, §20.3.4, and with NFPA 72, Chapter 6 requirements, shall be provided in each facility. The required fire alarm system components are as follows.(A) A fire alarm control panel (FACP) shall be installed at a visual location such as the main lobby. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and capable of indicating both visual and audible alarm, trouble, and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.(B) Manual fire alarm pull stations shall be installed in accordance with NFPA 101, §20.3.4.(C) Ceiling-mounted smoke detector(s) shall be installed in room containing the FACP when this room is not attended continuously by staff as required by NFPA 72, §4.4.5.(D) Smoke detectors shall be installed in air ducts in accordance with NFPA 72, §5.14.4.2 and §5.14.5 and NFPA 90A, §6.4.2.(E) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A, §6.4.2.2.(F) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101, §9.6.2; NFPA 13, §6.9; and NFPA 72, §8.5.3.3.3.4.(G) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72, §6.8.5.5.(H) A fire alarm signal notification which complies with NFPA 101, §9.6.3, shall be provided to alert occupants of fire or other emergency.(I) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §20.3.4, and NFPA 72, §7.4.(J) Visual fire alarm indicating devices which comply in accordance with the requirements of NFPA 72, §7.5, shall be provided.(K) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72.(L) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70, Article 760. Source Note: The provisions of this §508.52 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.52 Construction Requirements for a New Ambulatory Surgical Center https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223740 03/12/2026 (a) Elevators. All buildings that have patient services located on other than the main entrance floor shall have electric or electrohydraulic elevators. The elevators shall be installed in sufficient quantity, capacity, and speed to ensure that the average interval of dispatch time will not exceed one minute, and average peak loading can be accommodated. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §20.3 of the National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(b) Requirements for new elevators, escalators, and conveyors. New elevators, escalators and conveyors shall be installed in accordance with the requirements of Health and Safety Code, Chapter 754, Elevators, Escalators, and Related Equipment, and A17.1 Safety Code for Elevators and Escalators, 2000 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI). All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(1) Location. Elevators shall not open to an exit.(2) Elevator car size. A facility located above the ground floor must have an elevator of sufficient size to accommodate a gurney available at all times. Minimum elevator car size shall be five feet wide and seven feet deep. When an operating room(s) is located on a different floor than the preoperative area or the postoperative recovery suite, a hospital-type elevator shall be provided. Cars of hospital-type elevators shall be at least five feet eight inches wide by eight feet six inches deep.(3) Car door opening. The smallest elevator car door opening shall be at least three feet wide and seven feet high.(4) Elevator and elevator shaft doors. When light beams are used for operating door opening devices, the beams shall be used in combination with door edge devices and shall be interconnected with a system of smoke detectors. The light control feature shall be disengaged when smoke is detected in any elevator lobby.(5) Type of controls and alarms. Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.(6) Leveling. All elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of one-half inch.(7) Operation. All elevators, except freight elevators, shall be equipped with a two-way key operated service switch permitting cars to bypass all landing button calls and be dispatched directly to any floor.(8) Accessibility of controls and alarms. Elevator controls, alarm buttons, and telephones shall be accessible to wheelchair occupants in accordance with the Americans with Disabilities Act.(9) Smoke detection system. A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72, §6.15.3.10.(A) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 2000 edition. The publications of the ASME/ANSI referenced in this section may be obtained by writing ASME/ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(B) The elevator recall smoke detection system in existing ambulatory surgical centers (ASCs) shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2002 edition.(10) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems with the capability to maintain an operating temperature during fire fighter service operations. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power. These requirements are not applicable to existing elevators.(11) Testing. An ASC shall have all elevators and escalators routinely and periodically inspected and tested as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 2000 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101, §9.4.6.(12) Certification. An ASC shall obtain a certificate of inspection evidencing that the elevators, escalators, conveyors, and related equipment were inspected in accordance with the requirements in Health and Safety Code (HSC), Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under HSC, §754.014, administered by the Texas Department of Licensing and Regulation. The certificate of inspection shall be on record in each ASC.(c) Requirements for existing elevators, escalators, and conveyors. Existing elevators and escalators shall comply with the ASME/ANSI A17.3, Safety Code for Elevators and Escalators, 1996 edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3 as required by NFPA 101, §9.4.3. Source Note: The provisions of this §508.53 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.53 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223741 03/12/2026 (a) General.(1) Ambulatory surgical center (ASC) owners/operators shall not begin construction of a new building, additions to or renovations or conversions of existing buildings until the department approves final construction documents.(2) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter.(3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents and specifications shall be consistent with the names of the spaces used in this chapter.(4) The department shall notify the ASC owner/operator of the result of its review of each type of submission discussed in this section.(5) The ASC owner/operator shall respond to all department requests for additional information, including providing a plan of correction for deficiencies cited by the department.(6) Once final construction documents are approved, the ASC owner/operator shall request inspections in accordance with §135.55 of this title (relating to Construction, Inspections, and Approval of Project).(7) When construction is delayed for longer than one year from the plan approval or self-certification approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new application for plan review and functional program narrative.(8) The ASC owner/operator shall provide written notification to the department when a project has been placed on hold, canceled, or abandoned.(9) The department may close a project file after one year of assigning an application number to a project if the project has been placed on hold.(b) Submission of projects and assignment of application number.(1) The ASC owner/operator or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the application for plan review:(A) a completed and signed application for plan review. The application for plan review may be obtained by calling the department's architectural review group by telephone at (512) 834-6649 or visit the Architectural Review at www.dshs.state.tx.us/hfp;(B) a functional program narrative in accordance with subsection (d) of this section; and(C) final construction documents in accordance with subsection (f) of this section.(2) The cost of submitting documents/plans and specifications shall be borne by the sender.(3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department shall assign an application number to the project that shall be referenced on all documents and correspondence related to the project. Final construction documents shall be reviewed in the chronological order received.(4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.(5) Construction shall not begin until the ASC owner/operator of the facility receives written notification from the department that the final construction documents have been approved.(c) Feasibility conference. An ASC owner/operator or representative may request a feasibility conference. A feasibility conference is an informal meeting between a member of the department's architectural review group staff and the ASC owner/operator or representative to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes.(1) A feasibility conference is not a substitute for plan review.(2) An ASC owner/operator or representative may schedule a feasibility conference by calling the department's architectural review group by telephone number (512) 834-6649.(3) The ASC owner/operator or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents.(4) The ASC owner/operator or representative is responsible for recording conference notes and shall submit the notes to the department.(d) Functional program narrative. The ASC owner/operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(B) of this section. The functional program narrative shall be presented on facility letterhead, signed by ASC administration, include the functional description of each space, and the following:(1) departmental relationships and other basic information relating to the fulfillment of the facility's objectives;(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features;(3) energy conservation measures, included in building, mechanical, and electrical designs;(4) a description of the type of asepsis control in diagnostic and treatment areas; and(5) the type of construction (existing or proposed) as stated in §20.1.6 of National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, (800) 344-3555.(e) Preliminary documents. The department may request preliminary documents. If requested by the department, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, and the usage of all spaces, areas, and rooms on every floor level.(f) Final construction documents. Final construction documents and specifications shall be submitted to the department for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the projects's registered architect and professional engineer(s) licensed by the State of Texas.(1) Submission of final construction documents. The ASC owner/operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.(2) Preparation of final construction documents. Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, shall include all necessary explanatory notes, schedules, and legends, and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 Edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural plans. Architectural drawings shall include the following:(i) a map of the area within a 500 foot radius of the facility site shall be provided and any hazardous and undesirable location noted in §135.52(a) of this title (relating to Construction Requirements for a New Ambulatory Surgical Center) shall be identified;(ii) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided;(iii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces;(iv) schedules of doors, windows, and finishes;(v) elevations of each facade;(vi) sections through building; and(vii) scaled details as necessary.(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced, and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location, and fire resistance rating (one or two hour) of each smoke partition, location, type, and fire resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches, and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.(C) Equipment drawings. Equipment drawings shall include the following:(i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility;(ii) fixed equipment (equipment which is permanently affixed to the building or which must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term "fixed equipment" includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets);(iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term "moveable equipment" includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and(iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings. Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings. Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g., corridor, patient room, operating room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, gas outlets;(v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems);(vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment);(vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and(viii) laboratory exhaust and safety cabinets.(F) Electrical drawings. Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections;(ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches, and equipment which require permanent electrical connections, on plans of each building level:(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and(II) outlets marked distinctly to indicate connection to critical, life safety, or normal power circuits;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generator(s), transfer switch(es), emergency system (life safety branch and critical branch), equipment system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses regular calling system, nurses emergency calling system, or staff emergency assistance calling system);(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices and the room number where each device is located; and(vi) schedules of all panels indicating connection to life safety branch, critical branch, equipment system or normal system, and connected load at each panel.(3) Construction document changes. Any changes to the final construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications.(g) Special submittals.(1) Self-certification.(A) In an effort to shorten the plan review and approval process, the ASC owner/operator or representative may request approval of final construction documents under the self-certification review process.(i) The owner/operator shall submit the items in subsection (b)(1)(A) - (C) of this section and a completed self-certification form, signed by the ASC owner/operator, architect of record, and engineer(s) of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter.(ii) By signing and submitting the self-certification form, the ASC owner/operator accepts the following conditions.(I) The department retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval.(II) The ASC owner/operator has a continuing obligation to make any changes the department requires to comply with the licensing rules whether or not physical plant construction or alterations have been completed.(III) The ASC owner/operator is ultimately responsible for compliance with Health and Safety Code, Chapter 243, Texas Ambulatory Surgical Center Licensing Act, and this chapter.(B) The department shall review the request for self-certification and notify the ASC owner/operator if the request is approved or denied. If denied, the department shall review the final construction documents in the chronological order in which the documents were received. Construction shall not begin until the final construction documents have been reviewed and approved.(2) Minor project. If a ASC owner/operator believes that a proposed project is a minor project, the ASC owner/operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work. The minor project request shall be mailed or faxed.(A) If it is determined that the proposed project is a minor project, the department shall notify the ASC owner/operator of the approval, and state the number of inspections that shall be required. A minimum of one inspection shall be conducted.(B) The department shall notify the ASC owner/operator that a proposed project is not approved as a minor project, if the project involves any of the following:(i) remodeling or alterations which involve alterations to load bearing members or partitions;(ii) a change in functional operation;(iii) a change that affects fire safety (e.g., modifications to the fire, smoke, and corridor walls);(iv) additional services for which the ASC is not currently licensed; and(v) a significant change to the mechanical, electrical, plumbing, fire protection, or piped medical system.(C) The ASC owner/operator shall submit final construction documents in accordance with subsection (f) of this section if the department determines the project is not a minor project.(3) Fire sprinkler systems.(A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the ASC owner/operator shall submit to the department for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents.(B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(i) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§14.1, 14.2 and 14.3, for new fire sprinkler systems, alterations of and additions to existing ones.(ii) One set of fire sprinkler working plans, calculations, and water supply information shall be forwarded to the department together with the professional engineer's (P.E. licensed in the State of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation.(iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(h) Retention of drawings, manuals, and design data.(1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the ASC's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.(2) Manuals. Upon completion of the contract, the owner shall retain as part of the ASC's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.(3) Design data. The owner shall retain in the ASC's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation. Source Note: The provisions of this §508.54 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.54 Preparation, Submittal, Review and Approval of Plans, and Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223742 03/12/2026 (a) Construction.(1) Major construction. Construction, of other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate licensing fee has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) Construction commencement notification. The architect of record or the ambulatory surgical center (ASC) owner/operator shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules.(3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) Construction inspections. All ASCs including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §§1395 et seq.), and those which maintain accreditation by a Centers for Medicare and Medicaid Services-approved organization are subject to construction inspections.(1) Number of construction inspections. A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with subchapters B and C of this chapter and the approved plans and specifications. The final plan approval letter or the self-certification approval letter shall inform the architect of record and the owner as to the minimum number of inspections required for the project.(2) Requesting an inspection. The architect of record or the ASC owner/operator shall request an inspection by submitting, at least three weeks in advance of the requested inspection date, an application for inspection for each intermediate inspection, final inspection, and reinspection requested. Inspection requests by contractors shall not be honored.(A) The architect of record or the ASC owner/operator shall request an intermediate construction inspection to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate inspection; however, ceilings shall not be installed.(B) The architect of record or the ASC owner/operator shall request a final construction inspection at 100% completion. One hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Reinspections. Depending upon the number and nature of the deficiencies cited during the final inspection, the inspector may require that a reinspection be conducted to confirm correction of all deficiencies cited. The inspector may also require a reinspection, if he determines that the project was not sufficiently complete to warrant a final inspection. The request for reinspection shall be submitted in accordance with paragraph (2) of this subsection.(c) Approval of project. Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.(1) Documentation requirements. The ASC owner/operator shall submit the following documents to the department before the project will be approved:(A) written approval of the project by the fire authority;(B) a certificate of occupancy for the project issued by the local building authority;(C) a copy of a letter or certification from a professional engineer (P.E.) licensed in the State of Texas indicating the fire sprinkler working plans, hydraulic calculation, the testing, and field inspection of the installation of the new or modified sprinkler system is in compliance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, if applicable. A copy of a letter or certification of changes in existing fire sprinkler system is not required, when relocation of not more than twenty sprinkler heads and hydraulic calculation is involved;(D) fire alarm system certification (form FML-009A of the State Fire Marshal's Office), if applicable;(E) a signed copy of a letter of certification from a qualified certification agency or individual for the piped-in medical gas system that was installed or modified and verification inspection testing in this project in accordance with §135.52(h)(1)(C)(iv), (x) and (xi) of this title (relating to Construction Requirements for a New Ambulatory Surgical Center), if applicable;(F) a copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2002 Edition, §4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project;(G) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. A signed letter or statement corroborating the installation of the product in the project shall be provided;(H) a copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 Edition, as required by NFPA 101, §18-7.5, and a signed letter or statement corroborating the installation of the product in the project;(I) a written plan of correction signed by the ASC owner/operator for any deficiencies noted during the final inspection; and(J) any other documentation or information required or requested due to the type of the project.(2) Temporary occupancy approval(A) If, during the final inspection, the inspector finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the inspector may grant temporary approval for occupancy by staff only contingent upon the documents listed in paragraph (1)(A) - (E) of this subsection being provided to and approved by the inspector at the time of the final inspection. The inspector shall issue a completed signed final architectural inspection form as testament for temporary approval for occupancy by staff only. The ASC shall complete the licensing process and receive a license before patients may be admitted or treated.(B) Temporary approval for occupancy allows the ASC owner/operator to occupy the project. However, the ASC owner/operator shall submit the documents required in paragraph (1)(F) - (J) of this subsection before the project receives final approval.(3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, the department shall issue written final approval of the project. Source Note: The provisions of this §508.55 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.55 Construction, Inspections, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223743 03/12/2026 (a) Table 1. Ventilation requirements for ambulatory surgical centers. Attached Graphic(b) Table 2. Filter efficiencies for central ventilation and air conditioning systems. Attached Graphic(c) Table 3. Station outlets for oxygen, vacuum, and medical air systems. Attached Graphic(d) Table 4. Flame spread and smoke production limitations for interior finishes. Attached Graphic Source Note: The provisions of this §508.56 adopted to be effective June 18, 2009, 34 TexReg 3948; transferred effective January 31, 2025, as published in the January 3, 2025, issue of the Texas Register, 50 TexReg 193. 1 HEALTH AND HUMAN SERVICES COMMISSION 508 AMBULATORY SURGICAL CENTERS C PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §508.56 Construction Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215704 03/12/2026 (a) The purpose of this chapter is to implement Texas Health and Safety Code Chapter 254, referred to as "the Act" throughout this chapter, which requires freestanding emergency medical care facilities to be licensed by the Texas Health and Human Services Commission.(b) This chapter provides:(1) procedures for obtaining a freestanding emergency medical care facility license;(2) minimum standards for freestanding emergency medical care facility functions and services;(3) patient rights standards; discrimination or retaliation standards;(4) patient transfer and other policy and protocol requirements;(5) reporting, posting, and training requirements relating to abuse and neglect;(6) standards for voluntary agreements;(7) inspection and investigation procedures;(8) enforcement standards; fire prevention and protection requirements;(9) general safety standards;(10) physical plant and construction requirements; and(11) standards for preparing, submitting, reviewing, and approval of construction documents.(c) Compliance with this chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, rules, regulations, and ordinances. This chapter must be followed where it exceeds other requirements. Source Note: The provisions of this §509.1 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES A GENERAL PROVISIONS §509.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215705 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Act--Texas Health and Safety Code Chapter 254, titled Freestanding Emergency Medical Care Facilities.(2) Action plan--A written document that includes specific measures to correct identified problems or areas of concern; identifies strategies for implementing system improvements; and includes outcome measures to indicate the effectiveness of system improvements in reducing, controlling, or eliminating identified problem areas.(3) Administrator--A person who is a physician, is a registered nurse, has a baccalaureate or postgraduate degree in administration or a health-related field, or has one year of administrative experience in a health-care setting.(4) Advanced practice registered nurse (APRN)--A registered nurse authorized by the Texas Board of Nursing to practice as an advanced practice registered nurse in Texas. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner."(5) Adverse event--An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.(6) Applicant--A person who seeks a freestanding emergency medical care facility license from the Texas Health and Human Services Commission (HHSC) and who is legally responsible for operation of the freestanding emergency medical care facility, whether by lease or ownership.(7) Certified registered nurse anesthetist (CRNA)--A registered nurse who has current certification from the Council on Certification of Nurse Anesthetists and is currently authorized to practice as an advanced practice registered nurse by the Texas Board of Nursing.(8) Change of ownership--Change in the person legally responsible for operation of the facility, whether by lease or by ownership.(9) Designated provider--A provider of health care services selected by a health maintenance organization, a self-insured business corporation, a beneficial society, the Veterans Administration, TRICARE, a business corporation, an employee organization, a county, a public hospital, a hospital district, or any other entity to provide health care services to a patient with whom the entity has a contractual, statutory, or regulatory relationship that creates an obligation for the entity to provide the services to the patient.(10) Disposal--Discharge, deposit, injection, dumping, spilling, leaking, or placing any solid waste or hazardous waste (containerized or uncontainerized) into or on any land or water so that solid waste or hazardous waste, or any constituent thereof, may enter the environment or be emitted into the air or discharge into any waters, including groundwaters.(11) Emergency care--Health care services provided in a freestanding emergency medical care facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the person's condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in:(A) placing the person's health in serious jeopardy;(B) serious impairment to bodily functions;(C) serious dysfunction of a bodily organ or part;(D) serious disfigurement; or(E) in the case of a pregnant woman, serious jeopardy to the health of the woman or fetus.(12) Facility--A freestanding emergency medical care facility.(13) Freestanding emergency medical care facility--A facility that is structurally separate and distinct from a hospital and which receives an individual and provides emergency care as defined in this section.(14) Freestanding emergency medical care facility administration--The administrative body of a freestanding emergency medical care facility headed by an individual who has the authority to represent the facility and who is responsible for operation of the facility according to the policies and procedures of the facility's governing body.(15) Governing body--The governing authority of a freestanding emergency medical care facility that is responsible for a facility's organization, management, control, and operation, including appointment of the medical staff; and includes the owner or partners for a freestanding emergency medical care facility owned or operated by an individual or partners or corporation.(16) HHSC--Texas Health and Human Services Commission.(17) Legally authorized representative (LAR)--Means:(A) a parent or legal guardian if the patient is a minor;(B) a legal guardian if the patient has been adjudicated incapacitated to manage the patient's personal affairs;(C) an agent of the patient authorized under a medical power of attorney;(D) an attorney ad litem appointed for the patient;(E) a person authorized to consent to medical treatment on behalf of the patient under Texas Health and Safety Code Chapter 313;(F) a guardian ad litem appointed for the patient;(G) a personal representative or heir of the patient, as defined by Texas Estates Code Chapter 22, if the patient is deceased;(H) an attorney retained by the patient or by the patient's legally authorized representative; or(I) a person exercising a power granted to the person in the person's capacity as an attorney-in-fact or agent of the patient by a statutory durable power of attorney that is signed by the patient as principal.(18) Licensed vocational nurse (LVN)--A person who is currently licensed by the Texas Board of Nursing as a licensed vocational nurse.(19) Licensee--The person or governmental unit named in the application for issuance of a facility license.(20) Medical director--A physician who is board certified or board eligible in emergency medicine, or board certified in primary care with a minimum of two years of emergency care experience.(21) Medical staff--A physician or group of physicians, podiatrist or group of podiatrists, and dentist or group of dentists who by action of the governing body of a facility are privileged to work in and use the facility.(22) Owner--One of the following persons or governmental unit that will hold, or does hold, a license issued under the Act in the person's name or the person's assumed name:(A) a corporation;(B) a governmental unit;(C) a limited liability company;(D) an individual;(E) a partnership, if a partnership name is stated in a written partnership agreement, or an assumed name certificate;(F) all partners in a partnership if a partnership name is not stated in a written partnership agreement, or an assumed name certificate; or(G) all co-owners under any other business arrangement.(23) Patient--An individual who presents for diagnosis or treatment.(24) Person--An individual, firm, partnership, corporation, association, or joint stock company, including a receiver, trustee, assignee, or other similar representative of such an entity.(25) Physician--An individual licensed by the Texas Medical Board and authorized to practice medicine in the state of Texas.(26) Physician assistant--An individual licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners.(27) Practitioner--A health care professional licensed in the state of Texas, other than a physician, podiatrist, or dentist. A practitioner shall practice in a manner consistent with their underlying practice act.(28) Prelicensure conference--A conference held between HHSC staff and the applicant or the applicant's representative to review licensure rules and survey documents and provide consultation before the on-site licensure inspection.(29) Premises--A building where patients receive emergency services from a freestanding emergency medical care facility.(30) Quality assessment and performance improvement (QAPI)--An ongoing program that measures, analyzes, and tracks quality indicators related to improving health outcomes and patient care emphasizing a multidisciplinary approach. The program implements improvement plans and evaluates the implementation until resolution is achieved.(31) Registered nurse (RN)--An individual who is currently licensed by the Texas Board of Nursing as a registered nurse.(32) Sexual assault survivor--An individual who is a victim of a sexual assault, regardless of whether a report is made, or a conviction is obtained in the incident.(33) Stabilize--To provide necessary medical treatment of an emergency medical condition to ensure, within reasonable medical probability, that the condition is not likely to deteriorate materially from or during the transfer of the individual from a facility.(34) Transfer--Movement (including the discharge) of an individual outside a facility at the direction of and after personal examination and evaluation by the facility physician. Transfer does not include movement outside a facility of an individual who has been declared dead or who leaves the facility against the advice of a physician.(35) Transfer agreement--A referral, transmission, or admission agreement with a hospital.(36) Universal precautions--Procedures for disinfecting and sterilizing reusable medical devices and appropriate use of infection control, including hand washing, use of protective barriers, and use and disposal of needles and other sharp instruments, as those procedures are defined by the Centers for Disease Control and Prevention (CDC) of the United States Department of Health and Human Services. This term includes standard precautions as defined by CDC, which are designed to reduce the risk of transmission of bloodborne and other pathogens in healthcare facilities.(37) Violation--Failure to comply with the Act, another statute relating to the licensure or operation of a freestanding emergency medical care facility, a rule or standard, or an order issued by the executive commissioner of HHSC or the executive commissioner's designee, adopted or enforced under the Act. Source Note: The provisions of this §509.2 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES A GENERAL PROVISIONS §509.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215706 03/12/2026 (a) License required.(1) Except as provided in §509.22 of this subchapter (related to Exemptions from Licensure), a person may not establish or operate a freestanding emergency medical care facility in this state without a license issued by the Texas Health and Human Services Commission (HHSC).(2) A facility or person shall not hold itself out to the public as a freestanding emergency medical care facility or advertise, market, or otherwise promote the services using the terms "emergency," "ER," or any similar term that would give the impression that the facility or person is providing emergency care.(3) An applicant shall submit a license application in accordance with §509.24 of this subchapter (relating to Application and Issuance of Initial License). The applicant shall retain copies of all application documents submitted to HHSC.(b) Compliance requirements. A facility shall comply with the provisions of the Act and this chapter during the licensing period.(c) Scope of facility license.(1) Each separate facility location shall have a separate license.(2) HHSC issues a facility license for the premises and person or governmental unit named in the application.(3) A facility shall not have more than one health facility license for the same physical address. The premises of a facility license shall be separated from any other occupancy or licensed health facility by a minimum of a one-hour fire rated wall.(4) A facility license authorizes only emergency care services and procedures that are related to providing emergency care.(d) License display requirements. A facility shall prominently and conspicuously display the facility license in a public area of the licensed premises that is readily visible to patients, employees, and visitors.(e) License alterations prohibited. A facility license shall not be altered.(f) License transfer prohibited. A facility license shall not be transferred or assigned. The facility shall comply with the provisions of §509.27 of this subchapter (relating to Change of Ownership) in the event of a change in the ownership of a facility.(g) Changes that affect the license.(1) A facility shall notify HHSC in writing before:(A) any construction, renovation, or modification of the facility buildings as described in 25 TAC Chapter 131, Subchapter G (relating to Physical Plant and Construction Requirements); or(B) facility operations cease.(2) A facility shall notify HHSC in writing not later than the third calendar day after:(A) a facility modifies its evacuation or smoke compartment relocation plans in accordance with the requirements of NFPA 101: Life Safety Code (2018); or(B) a facility's fire alarm system or sprinkler system becomes non-operational.(3) A facility shall notify HHSC in writing not later than the 10th calendar day after the effective date of:(A) a change in certification or accreditation status; or(B) a change in facility name, mailing address, telephone number, or administrator.(4) A facility that becomes inactive or closes shall meet the requirements in §509.26 of this subchapter (relating to Inactive Status and Closure). Source Note: The provisions of this §509.21 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.21 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215707 03/12/2026 The following facilities are not required to be licensed under this chapter:(1) an office or clinic owned and operated by a manufacturing facility solely for the purposes of treating its employees and contractors;(2) a temporary emergency clinic in a disaster area;(3) an office or clinic of a licensed physician, dentist, optometrist, or podiatrist;(4) a licensed nursing home;(5) a licensed hospital;(6) a hospital that is owned and operated by this state;(7) a facility located within or connected to a licensed hospital or a hospital that is owned and operated by this state;(8) a facility that is owned or operated by a licensed hospital or a hospital that is owned and operated by this state and is:(A) surveyed as a service of the hospital by an organization that has been granted deeming authority as a national accreditation program for hospitals by the Centers for Medicare and Medicaid Services (CMS); or(B) granted provider-based status by CMS; or(9) a licensed ambulatory surgical center. Source Note: The provisions of this §509.22 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.22 Exemptions from Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215708 03/12/2026 (a) If the Texas Health and Human Services Commission (HHSC) has reason to believe that a person or facility may be providing emergency medical care services as defined in this chapter without a license, HHSC will notify the person or facility in writing by certified mail, return receipt requested. Not later than 20 calendar days after the date the person or facility receives the notice, the person or facility shall submit to HHSC either:(1) an application for a license and the nonrefundable license fee;(2) a claim for exemption under §509.22 of this subchapter (relating to Exemptions from Licensure); or(3) documentation sufficient to establish that freestanding emergency medical care services are not being provided, including a notarized statement that freestanding emergency medical care services are not being provided and listing the types of services that are provided.(b) If a person or facility submits an application for a license, HHSC will process the application in accordance with §509.25 of this subchapter (relating to Application and Issuance of Initial License).(c) If the person or facility submits a claim for exemption, HHSC shall evaluate the claim for exemption and notify the person or facility in writing of the proposed decision within 30 calendar days following receipt of the claim for exemption.(d) If the person or facility submits sufficient documentation, under subsection (a)(3) of this section, to establish that the facility does not provide freestanding emergency medical services, HHSC shall notify the person or facility in writing that no license is required not later than 30 calendar days after HHSC receives the documentation.(e) If HHSC determines the documentation submitted under subsection (a)(3) of this section is insufficient, HHSC shall notify the person or facility in writing not later than 30 calendar days after HHSC received the documentation. The person or facility shall have the opportunity to respond not later than 10 calendar days after the date the facility receives the notice. Not later than 10 calendar days after the date HHSC receives the facility's response, HHSC shall notify the person or facility in writing of HHSC's determination. Source Note: The provisions of this §509.23 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.23 Unlicensed Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215709 03/12/2026 (a) All first-time applications for licensing are applications for an initial license, including applications from unlicensed operational facilities and licensed facilities for which a change of ownership or relocation is anticipated.(b) The applicant shall submit the completed application, the information required in subsection (d) of this section, and the nonrefundable license fee to the Texas Health and Human Services Commission (HHSC) 90 days before the projected opening date of the facility.(c) The applicant shall disclose to HHSC, if applicable:(1) the name, address, and social security number of the owner or sole proprietor, if the owner of the facility is a sole proprietor;(2) the name, address, and social security number of each general partner who is an individual, if the facility is a partnership;(3) the name, address, and social security number of any individual who has an ownership interest of more than 25 percent in the corporation, if the facility is a corporation;(4) the name, medical license number, and medical license expiration date of any physician licensed by the Texas Medical Board who has a financial interest in the facility or in any entity that has an ownership interest in the facility;(5) the name, medical license number, and medical license expiration date of the medical chief of staff;(6) the name, nursing license number, and nursing license expiration date of the director of nursing;(7) affirmation that at least one physician licensed in the state of Texas and at least one registered nurse licensed in the state of Texas will be on site during all hours of operation;(8) information concerning the applicant and the applicant's affiliates and managers, as applicable:(A) denial, suspension, probation, or revocation of a facility license in any state or any other enforcement action, such as court civil or criminal action in any state;(B) surrendering a license before expiration of the license or allowing a license to expire in lieu of HHSC proceeding with enforcement action;(C) federal or state (any state) criminal felony arrests or convictions;(D) Medicare or Medicaid sanctions or penalties relating to operation of a health care facility or home and community support services agency;(E) operation of a health care facility or home and community support services agency that has been decertified or terminated from participation in any state under Medicare or Medicaid; or(F) debarment, exclusion, or contract cancellation in any state from Medicare or Medicaid;(9) for the two-year period preceding the application date, information concerning the applicant and the applicant's affiliates and managers, as applicable:(A) federal or state (any state) criminal misdemeanor arrests or convictions;(B) federal, state (any state), or local tax liens;(C) unsatisfied final judgments;(D) eviction involving any property or space used as a health care facility in any state;(E) injunctive orders from any court; or(F) unresolved final federal or state (any state) Medicare or Medicaid audit exceptions;(10) the number of emergency treatment stations;(11) a copy of the facility's patient transfer policy and procedure for the immediate transfer to a hospital of patients requiring emergency care beyond the capabilities of the facility developed in accordance with §509.65 of this chapter (relating to Patient Transfer Policy) and signed by the chairman and the secretary of the governing body that attests the date the policy was adopted by the governing body and its effective date;(12) a copy of the facility's memorandum of transfer form, which contains at a minimum the information described in §509.65 of this chapter;(13) a copy of a written agreement the facility has with a hospital, which provides for the prompt transfer to and the admission by the hospital of any patient when services are needed but are unavailable or beyond the capabilities of the facility in accordance with §509.66 of this chapter (relating to Patient Transfer Agreements); and(14) a copy of a passing fire inspection report indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year before the opening date of the facility.(d) The address provided on the application shall be the physical location at which the facility is or will be operating.(e) Upon receipt of the application, HHSC shall review the application to determine whether it is complete. If HHSC determines that the application is not complete, HHSC shall notify the facility in writing.(f) The applicant or the applicant's representative shall attend a prelicensure conference at the office designated by HHSC. HHSC may waive the prelicensure conference requirement.(g) After the facility has participated in a prelicensure conference or the prelicensure conference has been waived at HHSC's discretion, the facility has received an approved architectural inspection conducted by HHSC, and HHSC has determined the facility is in compliance with subsections (c) - (e) of this section, HHSC shall issue a license to the facility to provide freestanding emergency medical care services in accordance with this chapter.(h) The license shall be effective on the date the facility is determined to be in compliance with subsections (c) - (g) of this section.(i) The license expires on the last day of the 24th month after issuance.(j) If an applicant decides not to continue the application process for a license, the applicant may withdraw its application. The applicant shall submit to HHSC a written request to withdraw. HHSC shall acknowledge receipt of the request to withdraw.(k) If the applicant does not complete all requirements of subsections (b) - (d) and (f) of this section within six months after the date HHSC's health care facility licensing unit receives confirmation that HHSC received the application and payment, HHSC will consider the application to be withdrawn. Any fee paid for a withdrawn application is nonrefundable, as indicated by §509.30(d) of this subchapter (relating to Fees).(l) During the initial licensing period, HHSC shall conduct an inspection of the facility to ascertain compliance with the provisions of the Act and this chapter.(1) The facility shall request HHSC conduct an on-site inspection after the facility provides services to at least one patient.(2) The facility shall be providing services at the time of the inspection. Source Note: The provisions of this §509.24 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.24 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215710 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may send written notice of expiration of a license to a facility no later than 60 calendar days before the expiration date. If the applicant has not received notice, it is the duty of the applicant to notify HHSC and request a renewal application.(b) The facility shall submit to HHSC no later than 30 calendar days before the expiration date of the license:(1) a completed renewal application form;(2) a nonrefundable license fee;(3) a copy of a passing fire inspection report conducted within the last 12 months and one from the year prior indicating approval by the local fire authority in whose jurisdiction the facility is based, as HHSC requires annual fire safety inspections for a facility's continued licensure status; and(4) if the facility is accredited by the Joint Commission or other accrediting organization, documented evidence of current accreditation status.(c) HHSC shall issue a renewal license to a facility that submits a renewal application in accordance with subsection (b) of this section and meets the minimum standards for a license set forth in this chapter.(d) Renewal licenses shall be valid for two years from the previous expiration date.(e) If a facility fails to timely submit a complete application and fee in accordance with subsection (b) of this section, HHSC shall notify the facility that the facility shall cease providing freestanding emergency medical care (FEMC) services. If the facility provides HHSC with sufficient evidence the facility submitted a complete application and fee in a timely manner and the facility adhered to all required dates, HHSC will dismiss the cessation notice prohibiting the facility from providing FEMC services. If the facility does not provide sufficient evidence, the facility shall immediately return the license to HHSC within 30 days of HHSC's notification.(f) If a facility does not correct a deficiency in the renewal application within 10 business days after the date HHSC notifies the facility of the deficiency, HHSC may deny the renewal application. Any fee paid for a denied renewal application is nonrefundable, as indicated by §509.30(d) of this subchapter (relating to Fees).(g) If a license expires and a facility wishes to provide FEMC services after the expiration date of the license, the facility shall reapply for a license under §509.24 of this subchapter (relating to Application and Issuance of Initial License). Source Note: The provisions of this §509.25 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.25 Application and Issuance of Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215711 03/12/2026 (a) A facility that is not staffed and open for more than five calendar days shall inform the Texas Health and Human Services Commission (HHSC), and HHSC will change the status of the facility license to inactive.(1) To be eligible for inactive status, a facility must be in good standing with no pending enforcement action or investigation.(2) The licensee is responsible for any license renewal requirements or fees, and for proper maintenance of patient records, while the license is inactive.(3) A license may not remain inactive for more than 60 calendar days.(4) To reactivate the license, the facility must inform HHSC no later than 60 calendar days after the facility stopped providing services under its license.(5) A facility that does not reactivate its license by the 60th calendar day after it stopped providing services has constructively surrendered its license, and HHSC will consider the facility closed.(b) A facility shall notify HHSC in writing before closure of the facility.(1) The facility shall dispose of medical records in accordance with §509.54 of this chapter (relating to Medical Records).(2) The facility shall appropriately discharge or transfer all patients before the facility closes.(3) A license becomes invalid when a facility closes. The facility shall return the licensure certificate to HHSC not later than 30 calendar days after the facility closes.(c) A facility that closes, or for which a license issued under this chapter expires or is suspended or revoked, shall immediately remove or cause to be removed any signs within view of the general public indicating that the facility is in operation as required under Texas Health and Safety Code §254.158 (relating to Removal of Signs). Source Note: The provisions of this §509.26 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.26 Inactive Status and Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215712 03/12/2026 (a) When a facility plans to change its ownership, the new owner shall submit:(1) an application for an initial license and nonrefundable fee to the Texas Health and Human Services Commission (HHSC) no later than 30 calendar days before the date of the change of ownership in accordance with §509.24 of this subchapter (relating to Application and Issuance of Initial License); and(2) notwithstanding §509.24(c)(14) of this subchapter, a copy of a passing fire inspection report conducted within the last 12 months and one from the year prior indicating approval by the local fire authority in whose jurisdiction the facility is based. Annual fire safety inspections are required for continued licensure status.(b) In addition to the documents required in §509.24 of this subchapter, the applicant shall submit a copy of the signed bill of sale or lease agreement that reflects the effective date of the change of ownership.(c) The applicant is not required to submit a transfer agreement that HHSC has previously approved if the applicant notifies HHSC in writing that it has adopted the transfer agreement.(d) A facility is not required to submit an application for change of ownership if the facility changes only its name. If a facility changes its name, the facility must notify HHSC no later than 10 calendar days after the effective date of the change.(e) For a change of ownership, HHSC may waive the initial licensure on-site health inspection required by §509.24(l) of this subchapter and the initial on-site construction inspection required by 25 TAC Chapter 131, Subchapter G (relating to Physical Plant and Construction Requirements).(f) If the applicant does not complete all requirements of subsection (a) and (b) of this section within six months after the date HHSC's health facility licensing unit receives confirmation that HHSC received the application and payment, HHSC will withdraw the application. Any fee paid for a withdrawn application is nonrefundable, as indicated by §509.30(d) of this subchapter (relating to Fees).(g) When the new owner has complied with the provisions of §509.24 of this subchapter, HHSC shall issue a license that is effective as of the date of the change of ownership.(h) HHSC shall set the expiration date of the license in accordance with §509.24 of this subchapter.(i) The previous owner's license becomes void as of the effective date of the new owner's license. Source Note: The provisions of this §509.27 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.27 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215713 03/12/2026 (a) A facility license is issued only for the premises and person or governmental unit named on the application.(b) A facility license is issued for a single physical location and shall not include multiple buildings or offsite locations.(c) A license shall not be transferred or assigned from one person or governmental unit to another person or governmental unit.(d) A license shall not be transferred from one facility location to another.(e) If a facility is relocating, the facility shall complete and submit a license application and nonrefundable fee no later than 30 calendar days before facility relocation. The Texas Health and Human Services Commission (HHSC) shall process the application in accordance with §509.24 of this subchapter (relating to Application and Issuance of Initial License). An initial license for the relocated facility is effective on the date the relocation occurred. The previous license is void on the date of relocation.(f) A facility that changes its telephone number shall send HHSC written notice of the change no later than 30 calendar days after the number has changed.(g) If a facility's name changes, the facility shall notify HHSC in writing no later than 30 calendar days after the effective date of the name change. Source Note: The provisions of this §509.28 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.28 Conditions of Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215714 03/12/2026 (a) The date a license application is received is the date the application reaches the Texas Health and Human Services Commission (HHSC).(b) An application for an initial license is complete when HHSC has received the application fee and received, reviewed, and found acceptable the information described in §509.24 of this subchapter (relating to Application and Issuance of Initial License).(c) An application for a renewal license is complete when HHSC has received the application fee and received, reviewed, and found acceptable the information described in §509.25 of this subchapter (relating to Application and Issuance of Renewal License).(d) HHSC shall process an application from an applicant for an initial license or a facility for a renewal license in accordance with the following time periods.(1) The first time period begins on the date HHSC receives the complete application and ends on the date HHSC issues the license. The first time period is 45 calendar days.(2) If HHSC receives an incomplete application, the first time period ends on the date HHSC issues a written notice to the applicant or facility that the application is incomplete. The written notice shall describe the specific information HHSC requires before HHSC considers the application complete.(3) For incomplete applications, the second time period begins on the date HHSC receives the last item necessary to complete the application and ends on the date HHSC issues the license. The second time period is 45 calendar days.(e) In the event HHSC does not process the application in the time periods stated in subsection (d) of this section, the applicant has the right to request that HHSC reimburse in full the fee paid in that particular application process. If HHSC does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, HHSC shall deny the request.(f) Good cause for exceeding the period established is considered to exist if:(1) the number of applications for licenses to be processed exceeds by 15 percent or more the number processed in the same calendar quarter the preceding year;(2) another public or private entity used in the application process caused the delay; or(3) other conditions existed giving good cause for exceeding the established periods.(g) If the request for reimbursement as authorized by subsection (e) of this section is denied, the applicant may then appeal to the HHSC Executive Commissioner (executive commissioner) for a resolution of the dispute. The applicant shall give written notice to the executive commissioner requesting reimbursement of the fee paid because the application was not processed within the established time period. HHSC shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. HHSC shall make the final decision and provide written notification of the decision to the applicant and HHSC.(h) If a hearing is proposed during the processing of the application, the hearing shall be conducted under Texas Government Code Chapter 2001 (relating to Administrative Procedure); 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act); and 1 TAC Chapter 155 (relating to Rules of Procedure). Source Note: The provisions of this §509.29 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.29 Time Periods for Processing and Issuing Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215715 03/12/2026 (a) The fee for an initial license (includes change of ownership or relocation) is $14,820. The license term is two years.(b) The fee for a renewal license is $6,070. The license term is two years.(c) An application is not complete until the applicant pays the entire application fee and submits the application form.(d) Fees paid to the Texas Health and Human Services Commission (HHSC) are not refundable, except as indicated in §509.29 of this subchapter (relating to Time Periods for Processing and Issuing Licenses).(e) All fees shall be paid to HHSC.(f) HHSC collects subscription and convenience fees, in amounts determined by the Texas Online Authority, to recover costs associated with application and renewal application processing through Texas Online, in accordance with Texas Government Code §2054.111 (relating to Use of State Electronic Internet Portal Project) and §2054.252 (State Electronic Internet Portal Project). Source Note: The provisions of this §509.30 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES B LICENSING REQUIREMENTS §509.30 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215723 03/12/2026 (a) A facility shall have an identified governing body fully responsible for organization, management, control, and operation of the facility, including the appointment of the facility's medical director. The medical director shall be board certified or board eligible in emergency medicine, or board certified in primary care with at least two years emergency care experience.(b) The governing body shall adopt, implement, and enforce written policies and procedures for the total operation and all services provided by the facility.(c) The governing body is responsible for all services furnished in the facility, whether furnished directly or under contract. The governing body shall ensure services are provided in a safe and effective manner that permits the facility to comply with all applicable rules and standards.(d) The governing body shall ensure the medical staff has on file current written bylaws, rules, and regulations that are adopted, implemented, and enforced.(e) The governing body shall disclose all owners of the facility to the Texas Health and Human Services Commission (HHSC).(f) The governing body shall meet at least annually and keep minutes or other records necessary for orderly conduct of the facility. Each meeting held by the facility governing body shall be a separate meeting with separate minutes from any other governing body meeting.(g) If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the governing body shall define the authority, responsibility, and functions of all such positions.(h) The governing body shall develop a process for appointing or reappointing medical staff, and for assigning or curtailing medical privileges.(i) The governing body shall provide (in a manner consistent with state law and based on evidence of education, training, and current competence) for the initial appointment, reappointment, and assignment or curtailment of privileges and practice for non-physician health care personnel and practitioners.(j) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the facility.(k) The governing body shall adopt, implement, and enforce written policies to ensure compliance with applicable state and federal laws.(l) In accordance with Texas Health and Safety Code §254.157 (relating to Certain Advertising Prohibited), a facility may not advertise or hold itself out as a network provider, including by stating that the facility "takes" or "accepts" any insurer, health maintenance organization, health benefit plan, or health benefit plan network, unless the facility is a network provider of a health benefit plan issuer.(m) A facility may not post the name or logo of a health benefit plan issuer in any signage or marketing materials if the facility is an out-of-network provider for all of the issuer's health benefit plans.(n) A facility shall assess, and the governing body shall review, patient satisfaction with services and environment no less than annually. Source Note: The provisions of this §509.41 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.41 Operational Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215724 03/12/2026 The governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for operation and performance of the facility. Governing body responsibilities include:(1) determining the mission, goals, and objectives of the facility;(2) ensuring that facilities and personnel are adequate and appropriate to carry out the mission;(3) ensuring a physical environment that protects the health and safety of patients, personnel, and the public;(4) establishing an organizational structure and specifying functional relationships among the various components of the facility;(5) adopting, implementing, and enforcing bylaws or similar rules and regulations for the orderly development and management of the facility;(6) adopting, implementing, and enforcing policies or procedures necessary for orderly conduct of the facility;(7) reviewing and approving the facility's training program for staff;(8) ensuring that all equipment used by facility staff or patients is properly used and maintained per manufacturer recommendations;(9) adopting, implementing, and enforcing policies or procedures related to emergency planning and disaster preparedness, including reviewing the facility's disaster preparedness plan at least annually;(10) ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care, including quarterly review and monitoring of QAPI activities;(11) reviewing legal and ethical matters concerning the facility and its staff, when necessary, and responding appropriately;(12) maintaining effective communication throughout the facility;(13) establishing a system of financial management and accountability that includes an audit or financial review appropriate to the facility;(14) adopting, implementing, and enforcing policies for provision of radiological services;(15) adopting, implementing, and enforcing policies for provision of laboratory services;(16) adopting, implementing, and enforcing policies for provision of pharmacy services;(17) adopting, implementing, and enforcing policies for collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records and reports;(18) adopting, implementing, and enforcing a policy on the rights of patients and complying with all state and federal patient rights requirements;(19) adopting, implementing, and enforcing policies for provision of an effective procedure for the immediate transfer to a licensed hospital of patients requiring emergency care beyond the capabilities of the facility, including a transfer agreement with a hospital licensed in this state in accordance with §509.66 of this subchapter (relating to Patient Transfer Agreements);(20) adopting, implementing, and enforcing policies for all individuals that arrive at the facility to ensure they are provided an appropriate medical screening examination within the capability of the facility, including ancillary services routinely available to determine whether or not the individual needs emergency care as defined in §509.2 of this chapter (relating to Definitions), and that if emergency care is determined to be needed, the facility shall provide any necessary stabilizing treatment or arrange an appropriate transfer the individual as defined in §509.65 of this subchapter (relating to Patient Transfer Policy);(21) adopting, implementing, and enforcing protocols to be used in determining death and for filing autopsy reports that comply with Texas Health and Safety Code Chapter 671 (relating to Determination of Death and Autopsy Reports);(22) approving all major contracts or arrangements affecting the medical care provided under its auspices, including those concerning:(A) services of physicians and practitioners;(B) use of external laboratories; and(C) an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure;(23) formulating long-range plans in accordance with the mission, goals, and objectives of the facility;(24) operating the facility without limitation because of color, race, age, sex, religion, national origin, or disability;(25) ensuring that all marketing and advertising concerning the facility does not imply that it provides care or services that the facility is not capable of providing; and(26) developing a system of risk management appropriate to the facility, including:(A) periodic review of all litigation involving the facility, its staff, physicians, and practitioners regarding activities in the facility;(B) periodic review of all incidents reported by staff and patients;(C) review of all deaths, trauma, or adverse reactions occurring on premises; and(D) evaluation of patient complaints. Source Note: The provisions of this §509.42 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.42 Governing Body Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215725 03/12/2026 (a) The facility administration shall adopt, implement, and enforce administrative policies, procedures, and controls to ensure orderly and efficient management of the facility. Administrative responsibilities shall include:(1) enforcing policies delegated by the governing body;(2) employing qualified management personnel;(3) long- and short-range planning for the needs of the facility, as determined by the governing body;(4) using methods of communicating and reporting, designed to ensure orderly flow of information within the facility;(5) controlling purchase, maintenance, and distribution of the equipment, materials, and facilities of the facility;(6) establishing lines of authority, accountability, and supervision of personnel;(7) establishing controls relating to custody of the official documents of the facility; and(8) maintaining confidentiality, security, and physical safety of data on patients and staff.(b) The facility administration shall adopt, implement, and enforce personnel policies to facilitate attainment of the mission, goals, and objectives of the facility. Personnel policies shall:(1) define and delineate functional responsibilities and authority;(2) require employment of personnel with qualifications commensurate with job responsibilities and authority, including appropriate licensure or certification;(3) require documented periodic appraisal of each person's job performance;(4) specify responsibilities and privileges of employment;(5) be made known to employees at the time of employment; and(6) provide and document adequate orientation and training to familiarize all personnel with the facility's policies, procedures, equipment, and facilities.(c) A facility shall adopt, implement, and enforce personnel policies that address and are relevant to all employees and contractors.(d) A facility shall develop appropriate job descriptions for each employee position. Source Note: The provisions of this §509.43 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.43 Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215726 03/12/2026 (a) The medical director shall be on-site at the facility when necessary to fulfill the responsibilities of the position, as described by this chapter and the governing body.(b) Notwithstanding subsection (a) of this section, each facility's medical director shall be on-site at the facility for at least 12 hours per month.(c) The medical director's responsibilities shall include:(1) organizing the emergency services to be provided at the facility;(2) supervising and overseeing the infection control program and quality assessment and performance improvement (QAPI) program; and(3) regularly attending meetings of the infection control program and QAPI program.(d) The medical director shall have the authority to contract with outside persons for performance of the facility's peer review activities, as necessary. Source Note: The provisions of this §509.44 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.44 Medical Director https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215727 03/12/2026 (a) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws.(b) The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidate.(c) The medical staff shall be well-organized and accountable to the governing body for the quality of the medical care provided to patients.(1) The medical staff shall be organized in a manner approved by the governing body.(2) If the medical staff has an executive committee, the members of the committee shall be doctors of medicine or osteopathy.(3) The facility shall maintain records of medical staff meetings.(4) The governing body shall assign responsibility for organization and conduct of the medical staff only to an individual physician.(5) Each medical staff member shall sign a statement signifying they will abide by medical staff and facility policies.(d) The medical staff shall adopt, implement, and enforce written bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall:(1) be approved by the governing body;(2) include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, consultant);(3) describe the organization of the medical staff;(4) describe the qualifications a candidate must meet for the medical staff to recommend the governing body appoint the candidate; and(5) include criteria for determining the privileges to be granted and a procedure for applying the criteria to individuals requesting privileges. To be privileged, a physician must have at least one year of experience in emergency services, and current certification in advanced cardiac life support, pediatric advanced life support, and advanced trauma life support. Source Note: The provisions of this §509.45 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.45 Medical Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215728 03/12/2026 (a) A facility shall have personnel qualified to operate emergency equipment and to provide emergency care to patients that is on site and available at all times.(b) A facility shall comply with the following nursing services staffing and training requirements.(1) There shall be an organized nursing service under the direction of a qualified registered nurse (RN). The facility shall be staffed to ensure the nursing needs of all patients are met.(2) There shall be a written plan of administrative authority for all nursing services with responsibilities and duties of each category of nursing personnel delineated and a written job description for each category. The scope of nursing services shall be limited to nursing care rendered to patients as authorized by Texas Occupations Code Chapter 301 (relating to Nurses).(A) The responsible individual for nursing services shall be a qualified RN whose responsibility and authority shall be clearly defined and shall include supervision of both personnel performance and patient care.(B) There shall be a written delineation of functions, qualifications, and patient care responsibilities for all categories of nursing personnel.(C) Nursing services shall be provided in accordance with current recognized standards or recommended practices.(3) There shall be an adequate number of RNs on duty to meet minimum staff requirements, including supervisory and staff RNs, to ensure the immediate availability of an RN for emergency care or for any patient when needed.(4) There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the service of an RN. An RN shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and qualifications of the nursing staff available.(5) An RN qualified, at a minimum, with current certification in advanced cardiac life support and pediatric advanced life support shall be on duty at the facility at all times whenever patients are present in the facility.(6) All direct care staff members shall maintain current certification and competency in basic cardiac life support.(7) The facility shall establish a nursing peer review committee to conduct nursing peer review, to the extent required by Texas Occupations Code Chapter 303 (relating to Nursing Peer Review).(c) In addition to meeting the requirements for nursing staff under subsection (b) of this section, a facility shall comply with the following minimum staffing requirements:(1) A facility that provides only topical anesthesia, local anesthesia, or minimal sedation shall have a second individual, who is trained and currently certified in basic cardiac life support, on duty at the facility until all patients have been discharged from the facility.(2) A facility that provides moderate sedation or analgesia shall have the following additional staff:(A) a second individual, who is trained and currently certified in basic cardiac life support, on duty at the facility until all patients have been discharged from the facility; and(B) an individual trained and currently certified in advanced cardiac life support and pediatric advanced life support, until all patients have been discharged.(3) A facility that provides deep sedation or analgesia or regional anesthesia shall have the following additional staff:(A) a second individual, who is trained and currently certified in basic cardiac life support, on duty at the facility until all patients have been discharged from the facility; and(B) an individual who is trained and currently certified in advanced cardiac life support and pediatric advanced life support, on duty and sufficiently free of other duties to enable the individual to respond rapidly to emergency situations, until all patients have been discharged. Source Note: The provisions of this §509.46 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.46 Facility Staffing and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222885 03/12/2026 (a) A facility shall provide to each patient, without regard to the individual's ability to pay, an appropriate medical screening, examination, and stabilization within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists, and any necessary stabilizing treatment.(b) The organization of emergency services shall be appropriate to the scope of the services offered. The services shall be organized under the direction of a qualified physician member of the medical staff who is the medical director or clinical director.(c) A facility shall maintain patient medical records for all emergency patients. The medical records shall contain patient identification, complaints, name of physician, name of nurse, time admitted to the emergency suite, treatment, time discharged, and disposition.(d) A facility shall comply with the following personnel requirements.(1) There shall be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.(2) As determined by the medical staff, there must always be at least one person qualified and at least one nurse with current advanced cardiac life support and pediatric advanced life support certification on duty and on-site to initiate immediate appropriate lifesaving measures.(3) Qualified personnel shall always be physically present in the emergency treatment area.(4) One or more physicians shall always be on-site during facility hours of operation.(5) A facility shall maintain schedules, names, and telephone numbers of all physicians and others on emergency call duty, including alternates. The facility shall retain the schedules for at least one year.(e) Adequate age-appropriate supplies and equipment shall be available and in readiness for use. Equipment and supplies shall be available for the administration of intravenous medications as well as facilities for the control of bleeding and emergency splinting of fractures. The facility shall periodically test the emergency equipment according to its policy.(f) Age-appropriate emergency equipment and supplies shall include:(1) emergency call system;(2) oxygen;(3) mechanical ventilatory assistance equipment, including airways, manual breathing bag, and mask;(4) cardiac defibrillator;(5) cardiac monitoring equipment;(6) laryngoscopes and endotracheal tubes;(7) suction equipment;(8) emergency drugs and supplies specified by the medical staff;(9) stabilization devices for cervical injuries;(10) blood pressure monitoring equipment; and(11) pulse oximeter or similar medical device to measure blood oxygenation.(g) A facility shall participate in the local Emergency Medical Service (EMS) system, based on the facility's capabilities and capacity, and the locale's existing EMS plan and protocols.(h) A facility shall comply with the following emergency services requirements for survivors of sexual assault.(1) This subsection does not affect the duty of a facility to comply with subsection (a) of this section.(2) The facility shall develop, implement, and enforce policies and procedures to ensure that after a survivor of sexual assault presents to the facility following a sexual assault, the facility shall provide the care specified under Texas Health and Safety Code Chapter 323, Subchapter A.(3) The facility shall develop, implement, and enforce policies and procedures to ensure a person who performs a forensic medical examination on a survivor of sexual assault completes the required forensic evidence collection training or equivalent education required by Texas Health and Safety Code §323.0045.(4) The facility shall develop, implement, and enforce policies and procedures to provide basic sexual assault response training that meets the requirements under Texas Health and Safety Code §323.0046 to facility employees who provide patient admission functions, patient-related administrative support functions, or direct patient care. Source Note: The provisions of this §509.47 adopted to be effective December 4, 2023, 48 TexReg 7064; amended to be effective December 31, 2024, 49 TexReg 10648. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.47 Emergency Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215730 03/12/2026 (a) If a facility furnishes anesthesia services, the facility shall provide these services in a well-organized manner under the medical direction of a physician approved by the governing body and qualified in accordance with Texas Occupations Code Title 3, Subtitle B (relating to Physicians) and Texas Occupations Code Chapter 301 (relating to Nurses), as appropriate.(b) A facility that furnishes anesthesia services shall comply with Texas Occupations Code Chapter 162, Subchapter C (relating to Anesthesia in Outpatient Setting), unless the facility is exempt under Texas Occupations Code §162.103 (relating to Applicability).(c) A facility is responsible for and shall document all anesthesia services administered in the facility.(d) Anesthesia services provided in the facility shall be limited to those that are recommended by the medical staff and approved by the governing body, which may include the following.(1) Topical anesthesia--An anesthetic agent applied directly or by spray to the skin or mucous membranes, intended to produce transient and reversible loss of sensation to the circumscribed area.(2) Local anesthesia--Administering an agent that produces a transient and reversible loss of sensation to a circumscribed portion of the body.(3) Regional anesthesia--Anesthetic injected around a single nerve, a network of nerves, or vein that serves the area involved in a surgical procedure to block pain.(4) Minimal sedation (anxiolysis)--A drug-induced state during which patients respond normally to oral commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(5) Moderate sedation or analgesia ("conscious sedation")--A drug-induced depression of consciousness during which patients respond purposefully to oral commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)(6) Deep sedation or analgesia--A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)(e) The medical staff shall develop written policies and practice guidelines for the anesthesia service, which the governing body shall adopt, implement, and enforce. The policies and guidelines shall include consideration of the applicable practice standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the licensing rules and standards applicable to those categories of licensed professionals qualified to administer anesthesia.(f) Only personnel who have been approved by the facility to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. On the order of a physician, podiatrist, dentist, or other practitioner practicing within the scope of their license and education, a qualified registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA) may administer topical anesthesia, local anesthesia, minimal sedation and moderate sedation, in accordance with all applicable rules, polices, directives, and guidelines issued by the Texas Board of Nursing. When an RN who is not a CRNA administers sedation, as permitted in this paragraph, the facility shall:(1) verify the RN has the requisite training, education, and experience;(2) maintain documentation to support that the RN has demonstrated competency in administering sedation;(3) with input from the facility's qualified anesthesia providers, develop, implement, and enforce detailed written policies and procedures to guide the RN; and(4) ensure that, when administering sedation during a procedure, the RN has no other duties except to monitor the patient.(g) Anesthesia shall not be administered unless the physician has evaluated the patient immediately before the procedure to assess the risk of the anesthesia and of the procedure to be performed.(h) A patient who has received anesthesia shall be evaluated for proper anesthesia recovery by the physician, or the person administering the anesthesia, before discharge using criteria approved by the medical staff.(i) A patient shall be evaluated immediately before leaving the facility by a physician, the person administering the anesthesia, or an RN acting in accordance with physician's orders and written policies, procedures, and criteria developed by the medical staff.(j) Emergency equipment and supplies appropriate for the type of anesthesia services provided shall always be maintained and accessible to staff.(k) All facilities shall provide at least the following functioning equipment and supplies:(1) suctioning equipment, including a source of suction and suction catheters in appropriate sizes for the population being served;(2) a source of compressed oxygen;(3) basic airway management equipment, including oral and nasal airways, face masks, and self-inflating breathing bag valve set;(4) blood pressure monitoring equipment; and(5) emergency medications specified by the medical staff and appropriate to the type of procedures and anesthesia services provided by the facility.(l) In addition to the equipment and supplies required under subsection (k) of this section, a facility that provides moderate sedation/analgesia, deep sedation/analgesia, or regional analgesia shall provide:(1) intravenous equipment, including catheters, tubing, fluids, dressing supplies, and appropriately sized needles and syringes;(2) advanced airway management equipment, including laryngoscopes and an assortment of blades, endotracheal tubes, and stylets in appropriate sizes for the population being served;(3) a mechanism for monitoring blood oxygenation, such as pulse oximetry;(4) electrocardiographic monitoring equipment;(5) cardiac defibrillator; and(6) pharmacologic antagonists, as specified by the medical staff and appropriate to the type of anesthesia services provided. Source Note: The provisions of this §509.48 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.48 Anesthesia https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215731 03/12/2026 (a) A facility shall maintain directly, or have immediately available on the premises, adequate laboratory services to meet the needs of its patients.(b) Laboratory services shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the requirements specified in Code of Federal Regulations, Title 42 (42 CFR), Part 493 (relating to Laboratory Requirements). CLIA 1988 applies to all facilities with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment, or for health assessment.(c) A facility shall ensure that all laboratory services provided to its patients through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR Part 493 to comply with CLIA 1988.(d) Emergency laboratory services shall be available on the premises during hours of operation, including:(1) assays for cardiac markers;(2) hematology;(3) chemistry; and(4) pregnancy testing.(e) A written description of services provided shall be available to the medical staff.(f) The laboratory shall ensure proper receipt and reporting of tissue specimens.(g) The medical staff and a pathologist shall determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examination.(h) When blood and blood components are stored, the facility shall have written procedures readily available containing directions on how to maintain the blood and blood components within permissible temperatures and including instructions to follow in the event of a power failure or other disruption of refrigeration.(1) Blood transfusions shall be prescribed in accordance with facility policy and administered in accordance with a written protocol for administering blood and blood components and using infusion devices and ancillary equipment.(2) Personnel administering blood transfusions and intravenous medications shall have special training for this duty according to adopted, implemented, and enforced facility policy.(3) Blood and blood components shall be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient.(4) Facility staff shall observe the patient for potential adverse reactions during the transfusion and for an appropriate time thereafter and document the observations and patient's response.(5) Pre-transfusion and post-transfusion vital signs shall be recorded.(6) Following the transfusion, the blood transfusion record or a copy shall be made a part of the patient's medical record.(i) The facility shall establish a mechanism for ensuring that the patient's physician or other licensed health care professional is made aware of critical value lab results, as established by the medical staff, before or after the patient is discharged. A physician shall read, date, sign, and authenticate all laboratory reports.(j) A facility that provides laboratory services shall adopt, implement, and enforce written policies and procedures to manage, minimize, or eliminate the risks to laboratory personnel of exposure to potentially hazardous chemicals in the laboratory. Source Note: The provisions of this §509.49 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.49 Laboratory and Pathology Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215732 03/12/2026 (a) The facility shall be licensed as required by the Texas State Board of Pharmacy.(b) The facility shall adopt, implement, and enforce policy and procedures for pharmaceutical services.(c) The facility shall provide drugs, controlled substances, and biologicals in a safe and effective manner in accordance with professional practices and comply with all state and federal laws and regulations regarding pharmaceutical services.(d) The facility may make pharmaceutical services available through contractual agreement. Pharmaceutical services provided under contract shall meet the same ethical practices, professional practices, and legal requirements that would be required if those services were provided directly by the facility. Source Note: The provisions of this §509.50 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.50 Pharmaceutical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215733 03/12/2026 (a) The facility shall adopt, implement, and enforce policies and procedures for emergency radiological procedures.(b) The facility shall provide radiological services that are immediately available on the premises to meet the emergency needs of patients and to adequately support the facility's clinical capabilities, including plain film X-ray.(c) The facility shall provide computed tomography (CT) scan services and ultrasound services that are immediately available on the premises.(d) A physician or other practitioner within the scope of their license and education shall read, date, sign, and authenticate all examination reports.(e) The radiology department shall meet all applicable federal, state, and local laws, codes, standards, rules, regulations, and ordinances.(f) Procedure manuals shall include procedures for all examinations performed, infection control in the facility, treatment and examination rooms, personnel dress code, and equipment cleaning.(g) Policies shall address the quality aspects of radiology services, including:(1) performing radiology services only on the written order of a physician, podiatrist, dentist, or other practitioner, who is practicing within the scope of their license and education, (such orders shall be accompanied by a concise statement of the reason for the examination); and(2) limiting the use of any radioactive sources in the facility to physicians who have been granted privileges for such use based on their training, experience, and current competence.(h) Policies shall address safety, including:(1) regulating use, removal, handling, and storage of any radioactive material that is required to be licensed by the Texas Department of State Health Services Radiation Control Program;(2) precautions against electrical, mechanical, and radiation hazards;(3) proper shielding where radiation sources are used;(4) acceptable monitoring devices for all personnel who might be exposed to radiation that shall be worn by such personnel in any area with a radiation hazard;(5) maintenance of radiation exposure records on personnel; and(6) authenticated dated reports of all examinations performed added to the patient's medical record. Source Note: The provisions of this §509.51 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.51 Radiology https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215734 03/12/2026 (a) The facility shall meet the respiratory needs of the patients in accordance with acceptable standards of practice.(b) The facility shall adopt, implement, and enforce policies and procedures that describe the provision of respiratory care services in the facility.(c) The organization of the respiratory care services shall be appropriate to the scope and complexity of the services offered.(d) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures shall be designated in writing.(e) If blood gases or other clinical laboratory tests are performed, staff shall comply with Clinical Laboratory Improvement Amendments of 1988 in accordance with the requirements specified in Code of Federal Regulations, Title 42, Part 493 (relating to Laboratory Services).(f) Respiratory services shall be provided only on, and in accordance with, the orders of a physician, or other practitioner practicing within the scope of their license. Source Note: The provisions of this §509.52 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.52 Respiratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215735 03/12/2026 (a) Surgical procedures performed in the facility shall be limited to those emergency procedures that are approved by the governing body on the recommendation of medical staff.(b) Adequate supervision of surgical procedures conducted in the facility shall be a responsibility of the governing body, recommended by medical staff, and provided by appropriate medical staff.(c) Surgical procedures shall be performed only by physicians, podiatrists, dentists, or other practitioners, who are practicing within the scope of their license and education, who are licensed to perform surgical procedures in Texas and who have been granted privileges to perform those procedures by the governing body, on the recommendation of the medical staff, and after medical review of the physician's, podiatrist's, dentist's, or practitioner's documented education, training, experience, and current competence.(d) Surgical procedures to be performed in the facility shall be reviewed periodically as part of the peer review portion of the facility's quality assessment and performance improvement program.(e) An appropriate history, physical examination, and pertinent preoperative diagnostic studies shall be incorporated into the patient's medical record before a surgical procedure.(f) Unless otherwise provided by law, the necessity or appropriateness of the proposed surgical procedure, as well as any available alternative treatment techniques, shall be discussed with the patient, or if applicable, with the patient's legal representative before the surgical procedure.(g) Licensed nurses and other personnel assisting in the provision of surgical services shall be appropriately trained and supervised and available in sufficient numbers for the surgical care provided.(h) Each treatment or examination room shall be designed and equipped so that the types of surgical procedures conducted can be performed in a manner that protects the lives and ensures the physical safety of all persons in the area.(1) If flammable agents are present in a treatment or examination room, the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Annex 2, Flammable Anesthetizing Locations, 1999) and with applicable state and local fire codes.(2) If nonflammable agents are present in a treatment or examination room, the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Chapters 4 and 8, 1999) and with applicable state and local fire codes.(i) With the exception of those tissues exempted by the governing body after medical review, tissues removed shall be examined by a pathologist, whose signed or authenticated report of the examination shall be made a part of the patient's medical record.(j) A description of the findings and techniques of surgical procedures shall be accurately and completely incorporated into the patient's medical record immediately after the procedure by the physician, podiatrist, dentist, or other practitioner, acting within the scope of their license and education, who performed the procedure. If the description is dictated, an accurate written summary shall be immediately available to the physicians and practitioners providing patient care and shall become a part of the patient's medical record.(k) The facility shall provide adequate space, equipment, and personnel to ensure a safe environment for treating patients during surgical procedures, including adequate safeguards to protect the patient from cross infection.(1) The facility shall isolate patients with communicable diseases.(2) Acceptable aseptic techniques shall be used by all persons.(3) Suitable equipment for rapid and routine sterilization shall be available.(4) The facility shall implement environmental controls that ensure a safe and sanitary environment.(l) Written policies and procedures for decontaminating, disinfecting, sterilizing, and storing sterile supplies shall be adopted, implemented, and enforced as described in §509.57 of this subchapter (relating to Sterilization).(m) Emergency power adequate for the type of surgical procedures performed shall be available.(n) Periodic calibration and preventive maintenance of all equipment shall be provided in accordance with manufacturer's guidelines.(o) Unless otherwise provided by law, the informed consent of the patient or, if applicable, of the patient's legal representative shall be obtained before a surgical procedure is performed.(p) The facility shall establish a written procedure for observing and caring for the patient during and after surgical procedures.(q) The facility shall establish written protocols for instructing patients in self-care after surgical procedures, including written instructions to be given to patients who receive conscious sedation or regional anesthesia.(r) Patients who have received anesthesia, other than solely topical anesthesia, shall be allowed to leave the facility only in the company of a responsible adult, unless the physician, physician assistant, or an advanced practice registered nurse writes an order that the patient may leave without the company of a responsible adult.(s) The facility shall develop an effective written procedure for the immediately transferring to a hospital patients requiring emergency care beyond the capabilities of the facility. The facility shall have a written transfer agreement with a hospital as set forth in §509.65 of this subchapter (relating to Patient Transfer Policy). Source Note: The provisions of this §509.53 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.53 Surgical Services within the Scope of the Practice of Emergency Medicine https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215736 03/12/2026 (a) The facility shall develop and maintain a system for collecting, processing, maintaining, storing, retrieving, authenticating, and distributing patient medical records.(b) The facility shall establish an individual medical record for each patient.(c) All clinical information relevant to a patient shall be readily available to physicians or practitioners involved in the care of that patient.(d) Except when otherwise required or permitted by law, any record that contains clinical, social, financial, or other data on a patient shall be strictly confidential and shall be protected from loss, tampering, alteration, improper destruction, and unauthorized or inadvertent disclosure.(e) The facility shall designate a person to be in charge of medical records. The person's responsibilities include:(1) confidential, secure, and safe storage of medical records;(2) timely retrieval of individual medical records on request;(3) specific identification of each patient's medical record;(4) supervision of collecting, processing, maintaining, storing, retrieving, and distributing medical records; and(5) maintenance of a predetermined organized medical record format.(f) The facility shall retain medical records in their original or legally reproduced form for a period of at least 10 years. A legally reproduced form is a medical record retained in hard copy, microform (microfilm or microfiche), or electronic medium. The facility shall retain films, scans, and other image records for a period of at least five years.(1) The facility shall not destroy medical records that relate to any matter that is involved in litigation if the facility knows the litigation has not been finally resolved.(2) For medical records of a patient less than 18 years of age at the time of last treatment, the facility may dispose of those medical records after the date of the patient's 20th birthday or after the 10th anniversary of the date on which the patient was last treated, whichever date is later, unless the records are related to a matter that is involved in litigation that the facility knows has not been finally resolved.(3) If a facility plans to close, the facility shall arrange for disposition of the medical records in accordance with applicable law. The facility shall notify the Texas Health and Human Services Commission at the time of closure of the disposition of the medical records, including where the medical records will be stored and the name, address, and phone number of the custodian of the records.(g) Except when otherwise required by law, the content and format of medical records, including the sequence of information, shall be uniform.(h) Medical records shall be available to authorized physicians and practitioners any time the facility is open to patients.(i) The facility shall include in patients' medical records:(1) complete patient identification;(2) date, time, and means of arrival and discharge;(3) allergies and untoward reactions to drugs recorded in a prominent and uniform location;(4) all medications administered and the drug dose, route of administration, frequency of administration, and quantity of all drugs administered or dispensed to the patient by the facility and entered on the patient's medical record;(5) significant medical history of illness and results of physical examination, including the patient's vital signs;(6) a description of any care given to the patient before the patient's arrival at the facility;(7) a complete detailed description of treatment and procedures performed in the facility;(8) clinical observations including the results of treatment, procedures, and tests;(9) diagnostic impression;(10) a pre-anesthesia evaluation by an individual qualified to administer anesthesia when administered;(11) a pathology report on all tissues removed, except those exempted by the governing body;(12) documentation of a properly executed informed consent when necessary;(13) for patients with a length of stay greater than eight hours, an evaluation of nutritional needs and evidence of how identified needs were met;(14) evidence of patient evaluation by a physician, physician assistant, or advanced practice registered nurse before dismissal; and(15) conclusion at the termination of evaluation or treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient or family for follow-up care.(j) Medical advice given to a patient by telephone shall be entered in the patient's medical record and dated, timed, and authenticated.(k) Entries in medical records shall be legible, accurate, complete, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided no later than 48 hours after discharge.(l) To ensure continuity of care, medical records shall be transferred to the physician, practitioner, or facility to whom the patient was referred, if applicable. Source Note: The provisions of this §509.54 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.54 Medical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215737 03/12/2026 (a) The facility shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility shall have an infection control program for prevention, control, and surveillance of infections and communicable diseases.(1) The facility shall designate an infection control professional. The facility shall adopt, implement, and enforce policies governing prevention, control, and surveillance of infections and communicable diseases.(2) The facility shall have a system for identifying, reporting, investigating, and controlling health care-associated infections and communicable diseases between patients and personnel.(3) The infection control professional shall maintain a log of all reportable diseases and health care-associated infections designated as epidemiologically significant according to the facility's infection control policies.(4) The facility shall adopt, implement, and enforce a written policy for reporting all reportable diseases to the local health authority and the Texas Department of State Health Services Infectious Disease Prevention Section, in accordance with 25 TAC Chapter 97 (relating to Communicable Diseases).(5) The infection control program shall include active participation by the medical staff, nursing staff, pharmacist, and other practitioners as appropriate.(b) The medical director is responsible for ensuring the facility-wide quality assessment and performance improvement program and training programs address problems identified by the infection control professional.(c) The medical director is responsible for ensuring that the facility implements successful corrective action plans in affected problem areas.(d) The facility shall adopt, implement, and enforce a written policy to monitor compliance of the facility and its personnel and medical staff with universal precautions in accordance with Texas Health and Safety Code Chapter 85 (relating to Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection). Source Note: The provisions of this §509.55 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.55 Infection Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215738 03/12/2026 (a) General infection control measures. Universal precautions shall be followed in the facility for all patient care activities in accordance with Code of Federal Regulations, Title 29 §1910.1030(d)(1) - (3) (relating to Bloodborne Pathogens) and Texas Health and Safety Code Chapter 85, Subchapter I (relating to Prevention of Transmission of HIV and Hepatitis B Virus by Infected Health Care Workers).(b) Physical environment.(1) A facility shall develop, implement, and enforce policies and procedures to provide and actively monitor a safe, functional, comfortable, and sanitary environment that minimizes or prevents transmission of infectious diseases for all patients and visitors and the public.(2) Blood spills shall be cleaned immediately or as soon as is practical with a disposable cloth and an appropriate chemical disinfectant.(A) If a commercial liquid chemical disinfectant is used, the surface shall be subjected to intermediate-level disinfection in accordance with the manufacturer's directions for use.(B) If a solution of chlorine bleach (sodium hypochlorite) is used, the solution shall be at least 1:100 sodium hypochlorite and mixed in accordance with the manufacturer's directions for use. The surface to be treated shall be compatible with this type of chemical treatment.(C) The facility shall use dedicated cleaning supplies (i.e., mop, bucket) for cleaning blood spills. Source Note: The provisions of this §509.56 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.56 Sanitary Conditions and Hygienic Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215739 03/12/2026 (a) A person qualified by education, training, and experience shall supervise the sterilization of all supplies and equipment. Staff responsible for sterilizing supplies and equipment shall participate in a documented continuing education program. New employees shall receive initial orientation and on-the-job training. Staff using chemical disinfectants shall have received training on their use.(b) The facility shall adopt, implement, and enforce written policies and procedures for decontamination and sterilization activities. Policies shall include receiving, cleaning, decontaminating, disinfecting, preparing, and sterilizing reusable items, as well as assembling, wrapping, storing, distributing, and quality control of sterile items and equipment. The infection control practitioner or committee shall review and approve these written policies at least every other year.(c) Every facility shall provide equipment adequate for sterilizing supplies and equipment, as needed. Equipment shall be maintained and operated to accurately sterilize the various materials required.(d) Where cleaning, preparation, and sterilization functions are performed in the same room or unit, the physical facilities, equipment, and policies and procedures for their use, shall effectively separate soiled or contaminated supplies and equipment from clean or sterilized supplies and equipment. Hand-washing facilities shall be provided, and a separate sink shall be provided for safe disposal of liquid waste.(e) All containers for solutions, drugs, flammable solvents, ether, alcohol, and medicated supplies shall be clearly labeled to indicate contents. Containers that are sterilized by the facility shall be labeled to be identifiable before and after sterilization. Sterilized items shall have a load control identification that indicates the sterilizer used, the cycle or load number, and the sterilization date.(f) A facility shall comply with the following sterilizer requirements.(1) Steam sterilizers (saturated steam under pressure) shall be used to sterilize heat- and moisture-stable items. Steam sterilizers shall be used according to manufacturer's written instructions.(2) Ethylene oxide (EO) sterilizers shall be used for processing heat- and moisture-sensitive items. EO sterilizers and aerators shall be used and vented according to the manufacturer's written instructions.(3) Flash sterilizers shall be used only for emergency sterilization of clean, unwrapped instruments and porous items.(g) A facility shall comply with the following sterilization preparation requirements.(1) All items to be sterilized shall be prepared to reduce the bioburden. All items shall be thoroughly cleaned, decontaminated, and prepared in a clean, controlled environment.(2) All articles to be sterilized shall be arranged so all surfaces will be directly exposed to the sterilizing agent for the prescribed time and temperature.(3) All wrapped articles to be sterilized shall be packaged in materials recommended for the specific type of sterilizer and material to be sterilized.(h) A facility shall comply with the following external chemical indicator requirements.(1) External chemical indicators, also known as sterilization process indicators, shall be used on each package to be sterilized, including items being flash sterilized to indicate that items have been exposed to the sterilization process.(2) The indicator results shall be interpreted according to manufacturer's written instructions and indicator reaction specifications.(3) A log shall be maintained with the load identification, indicator results, and identification of the contents of the load.(i) Biological indicators are commercially available microorganisms (e.g., United States Food and Drug Administration-approved strips or vials of Bacillus species endospores) that can be used to verify the performance of waste treatment equipment and processes or sterilization equipment and processes.(1) The efficacy of the sterilizing process shall be monitored with reliable biological indicators appropriate for the type of sterilizer used.(2) Biological indicators shall be included in at least one run each week of use for steam sterilizers, at least one run each day of use for low-temperature hydrogen peroxide gas sterilizers, and every load for EO sterilizers.(3) Biological indicators shall be included in every load that contains implantable objects.(4) A log shall be maintained with the load identification, biological indicator results, and identification of the contents of the load.(5) If a test is positive, the sterilizer shall immediately be taken out of service.(A) Implantable items shall be recalled and reprocessed if a biological indicator test (spore test) is positive.(B) All available items shall be recalled and reprocessed if a sterilizer malfunction is found, and a list of those items not retrieved in the recall shall be submitted to infection control.(C) A malfunctioning sterilizer shall not be put back into use until it has been serviced and successfully tested according to the manufacturer's recommendations.(j) A facility shall comply with the following disinfection requirements.(1) The facility shall adopt, implement, and enforce written policies, approved by the infection control committee, for the use of chemical disinfectants.(2) The manufacturer's written instructions for the use of disinfectants shall be followed.(3) An expiration date, determined according to manufacturer's written recommendations, shall be marked on the container of disinfection solution currently in use.(4) Disinfectant solutions shall be kept covered and used in well-ventilated areas.(5) Chemical germicides that are registered with the United States Environmental Protection Agency as "sterilants" may be used either for sterilization or high-level disinfection.(6) All staff personnel using chemical disinfectants shall receive training on their use.(k) A facility shall comply with the following performance record requirements.(1) Performance records for all sterilizers shall be maintained for each cycle. These records shall be retained and available for review for a minimum of five years.(2) Each sterilizer shall be monitored continuously during operation for pressure, temperature, and time at desired temperature and pressure. A record shall be maintained and shall include:(A) the sterilizer identification;(B) sterilization date;(C) cycle number;(D) contents of each load;(E) duration and temperature of exposure phase (if not provided on sterilizer recording charts);(F) identification of operator or operators;(G) results of biological tests and dates performed;(H) time-temperature recording charts from each sterilizer;(I) gas concentration and relative humidity (if applicable); and(J) any other test results.(l) Storage of sterilized items shall comply with the following requirements.(1) Sterilized items shall be transported to maintain cleanliness and sterility and to prevent physical damage.(2) Sterilized items shall be stored in well-ventilated, limited access areas with controlled temperature and humidity.(3) The facility shall adopt, implement, and enforce a policy that describes the mechanism used to determine the shelf life of sterilized packages.(m) Qualified personnel shall perform preventive maintenance of all sterilizers on a scheduled basis according to adopted, implemented, and enforced policy, using the sterilizer manufacturer's service manual as a reference. A preventive maintenance record shall be maintained for each sterilizer. These records shall be retained at least two years and shall be available for review at the facility within two hours of request by the Texas Health and Human Services Commission. Source Note: The provisions of this §509.57 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.57 Sterilization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215740 03/12/2026 (a) The facility shall adopt, implement, and enforce policies to provide sufficient clean linen to ensure the comfort of the patient.(b) For purposes of this subsection, contaminated linen is linen that has been soiled with blood or other potentially infectious materials or may contain sharps. Other potentially infectious materials means:(1) the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;(2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and(3) Human Immunodeficiency Virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV)-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.(c) The facility, whether it operates its own laundry or uses a commercial service, shall ensure that employees of a facility involved in transporting, processing, or otherwise handling clean or soiled linen shall be given initial and follow-up in-service training to ensure a safe product for patients and to safeguard employees in their work.(d) Employees who have contact with contaminated linen shall wear gloves and other appropriate personal protective equipment.(e) Clean linen shall be handled, transported, and stored by methods that will ensure its cleanliness.(f) Contaminated linen shall be handled as little as possible and with a minimum of agitation.(1) Contaminated linen shall not be sorted or rinsed in patient care areas.(2) Contaminated linen shall be bagged or put into carts at the location where it was used.(3) Contaminated linen shall be placed and transported in bags or containers that are labeled or color-coded.(4) Bags containing contaminated linen shall be closed before transport.(5) Whenever contaminated linen is wet and presents a reasonable likelihood of soak-through or leakage from the bag or container, the linen shall be deposited and transported in bags that prevent leakage of fluids to the exterior.(g) All linen placed in chutes shall be bagged.(h) If chutes are not used to convey linen to a central receiving or sorting room, adequate space shall be allocated in the facility for holding the bagged contaminated linen.(i) Linen shall be processed in the following manner.(1) If hot water is used, linen shall be washed with detergent in water with a temperature of at least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes.(2) If low-temperature (less than or equal to 70 degrees Centigrade, 158 degrees Fahrenheit) laundry cycles are used, chemicals suitable for low-temperature washing at proper use concentration shall be used.(3) Fabrics soiled with blood may be commercially dry cleaned (because dry cleaning eliminates the risk of pathogen transmission).(4) Flammable liquids shall not be used to process laundry but may be used for equipment maintenance. Source Note: The provisions of this §509.58 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.58 Linen and Laundry Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215741 03/12/2026 (a) Special waste and liquid or sewage waste management.(1) Facilities shall comply with the requirements set forth by the Texas Commission on Environmental Quality (TCEQ) in 30 TAC Chapter 326 (relating to Medical Waste Management).(2) All sewage and liquid wastes shall be disposed of in a municipal sewerage system or a septic tank system permitted by the TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site Sewage Facilities).(3) Facilities shall comply with the requirements set forth in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(b) Waste receptacles.(1) Waste receptacles shall be conveniently available in all toilet rooms, patient areas, staff work areas, and waiting rooms. Receptacles shall be routinely emptied of their contents at a central location into closed containers.(2) Waste receptacles shall be properly cleaned with soap and hot water, followed by treatment of inside surfaces of the receptacles with a germicidal agent.(3) All containers for other municipal solid waste shall be leak-resistant, have tight-fitting covers, and be rodent-proof.(4) Non-reusable containers shall be of suitable strength to minimize animal scavenging or rupture during collection operations. Source Note: The provisions of this §509.59 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.59 Waste and Waste Disposal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215716 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215716 03/12/2026 (a) Patients shall be treated with respect, consideration, and dignity.(b) Patients shall be provided appropriate privacy.(c) Patient records shall be treated confidentially. Patients shall be given the opportunity to approve or refuse release of patient records, except when release of the records is authorized by law.(d) Patients shall be provided, to the degree known, appropriate information concerning their diagnosis, treatment, and prognosis. When it is medically inadvisable to give such information to a patient, the information shall be provided to a person designated by the patient or a legally authorized person.(e) Patients shall be given the opportunity to participate in decisions involving their health care, except when the patient's participation is contraindicated for medical reasons.(f) The facility shall provide information to patients and staff concerning:(1) patient rights, including those specified in subsections (a) - (e) of this section;(2) patient conduct and responsibilities;(3) services available at the facility;(4) fees for services provided;(5) payment policies; and(6) methods for expressing complaints and suggestions to the facility.(g) Marketing or advertising shall not be misleading to patients.(h) A facility shall post a notice of fees in accordance with Texas Health and Safety Code §254.155 (relating to Notice of Fees).(i) A facility shall provide to a patient or a patient's legally authorized representative a written disclosure statement, detailing the facility's fees and health benefit plans, in accordance with Texas Health and Safety Code §254.156 (relating to Disclosure Statement Required).(j) A facility shall comply with Texas Health and Safety Code Chapter 324, Subchapter C (relating to Billing of Facility Services and Supplies). Source Note: The provisions of this §509.60 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.60 Patient Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215717 03/12/2026 (a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--The negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment, including pain or sexual abuse, that adversely affects the physical, mental, or emotional welfare of a patient.(2) Exploitation--The use of a patient's resources for monetary or personal benefit, profit, or gain without the informed consent of the patient.(3) Illegal conduct--Conduct prohibited by law.(4) Neglect--The failure to provide goods or services that are necessary to avoid adversely affecting the physical, mental, or emotional welfare of a patient.(5) Unethical conduct--Conduct prohibited by the ethical standards adopted by state or national professional organizations for their respective professions or by rules established by the state licensing agency for the respective profession.(6) Unprofessional conduct--Conduct prohibited under rules adopted by the state licensing agency for the respective profession.(b) The facility or a person associated with a facility, including an employee, volunteer, health care professional, or other person, shall immediately report all incidents of abuse, neglect, or exploitation to the Texas Health and Human Services Commission (HHSC) and any other appropriate regulatory agency. This includes any information that would reasonably cause a person to believe that an incident of abuse, neglect, or exploitation has occurred, is occurring, or will occur.(c) A person associated with a facility, including an employee, volunteer, health care professional, or other person, who reasonably believes or knows of information that would reasonably cause a person to believe the facility, a facility employee, or a health care professional associated with the facility, has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility shall report the information as soon as possible to HHSC or to the appropriate state health care regulatory agency.(d) A facility shall prominently and conspicuously post for display a statement of the duty to report abuse, neglect, exploitation, illegal conduct, unethical conduct, or unprofessional conduct.(1) The display shall be posted in a public area of the facility and shall be readily visible to patients, residents, volunteers, employees, and visitors.(2) The statement shall be in English and in a second language as appropriate to the demographic makeup of the community served.(3) The statement shall contain the contact information for HHSC Complaint and Incident Intake. Source Note: The provisions of this §509.61 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.61 Abuse and Neglect https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215718 03/12/2026 (a) A facility shall report the following incidents to the Texas Health and Human Services Commission (HHSC):(1) the death of a patient while under the care of the facility;(2) a patient stay exceeding 23 hours; and(3) 9-1-1 activation or the emergency transfer of a patient from the facility to a hospital by ambulance.(b) Reports under subsection (a) of this section shall be on a form provided by HHSC. The report shall contain a written explanation of the incident and the name of the individual responsible. The report shall be submitted online or through a telephone call to HHSC Complaint and Incident Intake not later than the 10th business day after the incident.(c) A facility shall report any abuse, theft, or diversion of controlled drugs in accordance with applicable federal and state laws and shall report the incident to the chief executive officer of the facility.(d) A facility shall report occurrences of fires in the facility as specified under 25 TAC Chapter 131, Subchapter F (relating to Fire Prevention Safety Requirements). Source Note: The provisions of this §509.62 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.62 Reporting Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215719 03/12/2026 (a) Each facility shall develop, implement, maintain, and evaluate an effective, ongoing, facility-wide, data-driven, interdisciplinary quality assessment and performance improvement (QAPI) program. The program shall be individualized to the facility and meet the criteria and standards described in this section.(b) The program shall reflect the complexity of the facility's organization and services involved. All facility services (including services furnished under contract or arrangement) shall focus on indicators related to improved health outcomes and prevention and reduction of medical errors.(c) The program shall include an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.(d) The facility shall demonstrate that facility staff, including the medical, nursing, and pharmacy staff, evaluate the provision of emergency care and patient services, set treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until resolution is achieved.(e) The facility shall measure, analyze, and track quality indicators, or other aspects of performance that the facility adopts or develops, that reflect processes of care and facility operations.(f) The facility shall provide evidence supporting that the facility continuously reviews aggregate patient data, including identification and tracking of patient infections, for trends.(g) Core staff members, including the medical, nursing, and pharmacy staff, shall actively participate in the QAPI activities, including QAPI meetings.(1) QAPI meetings shall be held monthly, or more often as necessary, to identify or correct problems.(2) QAPI meetings shall be documented.(h) The facility's QAPI program shall include:(1) an ongoing review of key elements of care using comparative and trend data to include aggregate patient data;(2) identification of areas where performance measures or outcomes indicate an opportunity for improvement;(3) appointment of interdisciplinary improvement teams to:(A) identify, measure, analyze, and track indicators for variation from desired outcomes;(B) create and implement improvement plans;(C) evaluate the implementation of the improvement plans; and(D) continue monitoring and improvement activities until resolution of the improvement plan;(4) establishing and monitoring quality indicators related to improved health outcomes, which includes establishing and monitoring a level of performance consistent with current professional knowledge for each quality assessment indicator that must influence or relate to the desired outcomes themselves;(5) monthly measurement, analysis, and tracking of at least the following indicators:(A) infection control (staff and patient screening; standard precautions);(B) adverse events;(C) mortality (review of each death and monitoring modality specific mortality rates);(D) complaints and suggestions (from patients, family, or staff);(E) staffing to include orientation, training, delegation, licensing and certification, and non-adherence to policies and procedures by facility staff;(F) safety (fire and disaster preparedness, use of the Texas Health and Human Services Commission (HHSC) emergency/disaster notification form, and disposal of special waste); and(G) clinical records review to include treatment errors and medication errors; and(6) the facility shall continuously monitor performance, take actions that result in performance improvement, and track performance to ensure that improvements are sustained over time. The facility shall immediately correct any identified problems that threaten the health and safety of patients.(i) HHSC may review a facility's QAPI activities to determine compliance with this section.(1) An HHSC inspector shall verify that the facility has a QAPI program, which addresses concerns relating to quality of care provided to its patients and that the core staff members have knowledge of and the ability to access the facility's QAPI program.(2) HHSC may not require disclosure of QAPI program records, except when disclosure is necessary for HHSC to determine compliance with this section. Source Note: The provisions of this §509.63 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.63 Quality Assessment and Performance Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215720 03/12/2026 (a) The facility shall follow the requirements in 25 TAC Chapter 131, Subchapter F (relating to Fire Prevention and Safety Requirements).(b) The facility shall submit emergency and disaster information to the Texas Health and Human Services Commission (HHSC) using the HHSC Emergency/Disaster Notification form located on HHSC's website.(c) The facility shall obtain an annual fire safety inspection from the local fire authority in whose jurisdiction the facility is based. Source Note: The provisions of this §509.64 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.64 Safety and Preparedness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215721 03/12/2026 (a) General.(1) The governing body of each facility shall adopt, implement, and enforce a policy relating to patient transfers that is consistent with this section and contains each of the requirements in subsection (b) of this section. The policies shall identify facility staff that has authority to represent the facility and the physician regarding transfers from the facility.(2) The governing body shall adopt the transfer policy after consultation with the medical staff, and the transfer policy shall apply to transfers to hospitals licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals) and Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities), as well as transfers to hospitals that are exempt from licensing.(3) The transfer policy shall govern transfers not covered by a transfer agreement.(4) The transfer policy shall include a written operational plan to provide for patient transfer transportation services if the facility does not provide its own patient transfer transportation services.(5) The governing body, after consultation with the medical staff, shall implement its transfer policy by adopting transfer agreements with hospitals in accordance with §509.66 of this subchapter (relating to Patient Transfer Agreements).(6) The transfer policy shall recognize and comply with the applicable requirements of Texas Health and Safety Code Chapter 61 (relating to Indigent Health Care and Treatment Act).(7) The transfer policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations that may exist concerning a patient and a designated provider.(8) The transfer policy shall require that all reasonable steps are taken to secure the written informed consent of a patient, or a person acting on a patient's behalf, when refusing a transfer or related examination and treatment. Reasonable steps include:(A) a factual explanation of the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring hospital;(B) a factual explanation of any increased risks to the patient from not effecting the transfer; and(C) a factual explanation of the medical benefits reasonably expected from the provision of appropriate treatment at another hospital.(9) The informed refusal of a patient, or a person acting on a patient's behalf, to examination, evaluation, or transfer shall be documented and signed if possible by the patient or by a person acting on the patient's behalf, dated and witnessed by the attending physician or facility employee, and placed in the patient's medical record.(10) The transfer policy shall recognize the right of an individual to request a transfer into the care of a physician and a hospital of the individual's own choosing.(b) Requirements for transfer of patients from facilities to hospitals.(1) The transfer policy shall provide that the transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status, or ability to pay.(2) The transfer policy shall recognize the right of an individual to request transfer into the care of a physician and hospital of the individual's own choosing; however, if a patient requests or consents to transfer for economic reasons and the patient's choice is predicated upon or influenced by representations made by the transferring physician or facility administration regarding the availability of medical care and hospital services at a reduced cost or no cost to the patient, physician or facility administration shall fully disclose to the patient the eligibility requirements established by the patient's chosen physician or hospital.(3) The transfer policy shall provide that each patient who arrives at the facility is:(A) evaluated by a physician at the time the patient presents; and(B) personally examined and evaluated by the physician before an attempt to transfer is made.(4) The policy of the transferring facility and receiving hospital shall provide that licensed nurses and other qualified personnel are available and on duty to assist with patient transfers. The policy shall provide that written protocols or standing delegation orders are in place to guide facility personnel when a patient requires transfer to another hospital.(5) Special requirements related to the transfer of patients who have emergency medical conditions:(A) If a patient at a facility has an emergency medical condition that has not been stabilized, or when stabilization of the patient's vital signs is not possible because the facility does not have the appropriate equipment or personnel to correct the underlying process, the facility shall evaluate and treat the patient and transfer the patient as quickly as possible.(B) The transfer policy shall provide that the facility may not transfer a patient with an emergency medical condition that has not been stabilized unless:(i) the individual or the individual's legally authorized representative, after being informed of the facility's obligations under this section and the risk of transfer, requests the transfer, in writing, and indicates the reasons for the request, as well as that he or she is aware of the risks and benefits of the transfer; or(ii) a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at a hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer.(C) Except as is specifically provided in subsection (a)(6) and (7) of this section, the transfer policy shall provide that the transfer of patients who have emergency medical conditions, as determined by a physician, shall be undertaken for medical reasons only. The facility must provide medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child.(6) The transfer policy shall provide for the following physician's duties and standard of care requirements.(A) The transferring physician shall determine and order life support measures that are medically appropriate to stabilize the patient before transfer and to sustain the patient during transfer.(B) The transferring physician shall determine and order the utilization of appropriate personnel and equipment for the transfer.(C) In determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care that a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer.(D) Except as allowed under paragraph (5)(B) of this subsection, before each patient transfer, the physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used.(E) Before transfer, the transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the patient have accepted responsibility for the patient's medical treatment and hospital care.(7) The facility's medical staff shall review appropriate records of patients transferred from the facility to determine that the appropriate standard of care has been met.(8) A facility shall comply with the following medical record requirements.(A) The facility's policy shall require that a copy of those portions of the patient's medical record that are available and relevant to the transfer and to the continuing care of the patient be forwarded to the receiving physician and receiving hospital with the patient. If all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the records shall be forwarded to the receiving physician and hospital as soon as possible.(B) The medical record shall contain at least:(i) a brief description of the patient's medical history and physical examination;(ii) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;(iii) the reason for the transfer;(iv) the results of all diagnostic tests, such as laboratory tests;(v) pertinent radiological films and reports; and(vi) any other pertinent information.(9) A facility shall comply with the following memorandum of transfer requirements.(A) The facility's policy shall require that a memorandum of transfer be completed for every patient who is transferred.(B) The memorandum shall contain the:(i) patient's full name, if known;(ii) patient's race, religion, national origin, age, sex, physical handicap, if known;(iii) patient's address and next of kin, address, and phone number, if known;(iv) names, telephone numbers, and addresses of the transferring and receiving physicians;(v) names, addresses, and telephone numbers of the transferring facility and receiving hospital;(vi) time and date on which the patient first presented or was presented to the transferring physician and transferring facility;(vii) time and date on which the transferring physician secured a receiving physician;(viii) name, date, and time hospital administration was contacted in the receiving hospital;(ix) signature, time, and title of the transferring facility administration who contacted the receiving hospital;(x) certification required by paragraph (5)(B)(ii) of this subsection, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form);(xi) time and date on which the receiving physician assumed responsibility for the patient;(xii) time and date on which the patient arrived at the receiving hospital;(xiii) signature and date of receiving hospital administration;(xiv) type of vehicle and company used to transport the patient;(xv) type of equipment and personnel needed in the transfer;(xvi) name and city of hospital to which patient was transported;(xvii) diagnosis by transferring physician; and(xviii) attachments by transferring facility.(C) A copy of the memorandum of transfer shall be retained by the transferring facility. The memorandum shall be filed separately from the patient's medical record and in a manner that will facilitate its inspection by HHSC. All memorandum of transfer forms filed separately shall be retained for at least five years.(c) Violations. A facility violates the Act and this section if:(1) the facility fails to comply with the requirements of this section; or(2) the governing body fails or refuses to:(A) adopt a transfer policy that is consistent with this section and contains each of the requirements in subsection (b) of this section;(B) adopt a memorandum of transfer form that meets the minimum requirements for content contained in this section; or(C) enforce its transfer policy and the use of the memorandum of transfer. Source Note: The provisions of this §509.65 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.65 Patient Transfer Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215722 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215722 03/12/2026 (a) General provisions.(1) Patient transfer agreements between a facility and hospitals are mandatory.(2) The facility shall submit the transfer agreement to the Texas Health and Human Services Commission (HHSC) for review to determine if the agreement meets the requirements of subsection (b) of this section.(3) Multiple transfer agreements may be entered into by a facility based upon the type or level of medical services available at other hospitals.(b) Minimum requirements for patient transfer agreements. Patient transfer agreements shall include specific language that is consistent with:(1) Texas Health and Safety Code Chapter 61 (relating to Indigent Health Care Treatment Act), in accordance with §509.65(a)(6) of this subchapter (relating to Patient Transfer Policy);(2) discrimination, in accordance with §509.65(b)(1) of this subchapter;(3) patient's right to request transfer, in accordance with §509.65(b)(2) of this subchapter;(4) transfer of patients with emergency medical conditions, in accordance with §509.65(b)(5) of this subchapter;(5) physician's duties and standard of care, in accordance with §509.65(b)(6) of this chapter;(6) medical records, in accordance with §509.65(b)(8) of this subchapter; and(7) memorandum of transfer, in accordance with §509.65(b)(9) of this chapter.(c) Review of transfer agreements.(1) The facility shall submit the following documents to HHSC for review so HHSC may determine whether the transfer agreements comply with this section's requirements:(A) a copy of the current or proposed agreement signed by the representatives of the facility and the hospital;(B) the date of the adoption of the agreement; and(C) the effective date of the agreement.(2) HHSC may waive the documents submission required under paragraph (1) of this subsection to avoid the repetitious submission of required documentation and approved agreements.(3) If a governing body or a governing body's designee executes a transfer agreement and the entire text of that agreement consists of the entire text of an agreement that has been previously approved by HHSC, the governing body or the governing body's designee is not required to submit the later agreement for review. On the date the later agreement is fully executed and before the later agreement is implemented, the governing body or the governing body's designee shall give notice to HHSC that the later agreement has been executed.(4) HHSC shall review the agreement not later than 30 calendar days after the date HHSC receives the agreement to determine if the agreement is consistent with the requirements of this section.(5) After HHSC review of the agreement, if HHSC determines that the agreement is consistent with the requirements contained in this section, HHSC shall notify the facility administration that the agreement has been approved.(6) If HHSC determines that the agreement is not consistent with the requirements contained in this section, HHSC shall give notice to the facility administration that the agreement is deficient and provide recommendations for correction.(7) A transfer agreement will be considered in compliance if it is consistent with the rules that were in effect at the time the transfer agreement was executed and approved by HHSC.(d) Amendments to an agreement.(1) The governing body of a facility or governing body's designee may adopt proposed amendments to a transfer agreement that has been approved by HHSC. Before the facility implements the amendments, the governing body or the governing body's designee shall submit the proposed amendments to HHSC for review in the same manner as the agreement was submitted.(2) HHSC shall review the amendments and approve or reject them in the same manner as provided for the review of the agreement.(e) Complaints. Complaints alleging a violation of a transfer agreement shall be treated in the same manner as complaints alleging violations of the Act or this chapter. Source Note: The provisions of this §509.66 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.66 Patient Transfer Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220247 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220247 03/12/2026 (a) A facility shall comply with the following balance billing requirements.(1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility.(b) A facility shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §509.67 adopted to be effective April 15, 2021, 46 TexReg 2426; amended to be effective August 18, 2024, 49 TexReg 6220. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.67 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207442 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207442 03/12/2026 A licensed freestanding emergency medical care facility shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §509.68 adopted to be effective January 6, 2022, 46 TexReg 9399. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.68 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210606 03/12/2026 (a) In this section, "unconscionable price" means a price that is more than 200 percent of the average price for the same or a substantially similar product or service provided to other individuals by health care facilities located in the same or nearest county to the county in which the freestanding emergency medical care facility is located, as applicable, according to data collected by the Texas Department of State Health Services under Texas Health and Safety Code (HSC) Chapter 108 (relating to Health Care Data Collection).(b) In accordance with HSC §254.160 (relating to Prohibited Practices During Declared State of Disaster), during a state of disaster declared by the Governor under Texas Government Code Chapter 418 (relating to Emergency Management), a facility may not:(1) charge an individual an unconscionable price for a product or service provided at the facility; or(2) knowingly or intentionally charge a third-party payor, including a health benefit plan insurer, a price higher than the price charged to an individual for the same product or service based on the payor's liability for payment or partial payment of the product or service.(c) Subsection (b)(2) of this section does not prohibit a facility from:(1) offering an uninsured individual a cash discount for a particular product or service; or(2) accepting directly from an individual full payment for a health care product or service in lieu of submitting a claim to the individual's health benefit plan.(d) In accordance with HSC §254.1556 (relating to Disclosure of Certain Prices and Fees During Declared Disaster; Construction), a facility that provides testing or vaccination for an infectious disease for which a state of disaster has been declared under Texas Government Code Chapter 418, shall disclose the price the facility charges for the test or vaccine and any facility fees, supply costs, and other costs associated with the test or vaccine in accordance with the disclosure requirements described by HSC §254.156 (relating to Disclosure Statement Required).(e) In accordance with HSC §254.1555 (relating to Certain Fees Prohibited), a facility that provides a health care service, including testing or vaccination, to an individual accessing the service from the individual's vehicle may not charge the individual or a third-party payor a facility or observation fee.(f) Pursuant to HSC §254.207 (relating to Enforcement), and except for good cause shown, the Texas Health and Human Services Commission shall impose the following applicable penalty on a facility licensed under this chapter and HSC Chapter 254 (relating to Freestanding Emergency Medical Care Facilities) that violates subsection (b) of this section or HSC §254.160:(1) for the first violation, an administrative penalty of $10,000;(2) for the second violation:(A) an administrative penalty of $50,000; and(B) a suspension of the facility's license for 30 days; and(3) for the third violation, a permanent revocation of the facility's license.(g) This section may not be construed as expanding the type of health care services a facility is authorized to provide under HSC Chapter 254 or this chapter. Source Note: The provisions of this §509.69 adopted to be effective November 10, 2022, 47 TexReg 7423. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.69 Fees and Prices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221157 03/12/2026 (a) In accordance with Texas Health and Safety Code (HSC) §331.002, a facility shall establish a workplace violence prevention committee or authorize an existing facility committee to develop a workplace violence prevention plan.(b) A facility shall ensure the committee includes at least:(1) one registered nurse who provides direct care to the facility's patients;(2) one physician licensed to practice medicine in this state who provides direct care to the facility's patients; and(3) one facility employee who provides security services for the facility if any and if practicable.(c) A health care system that owns or operates more than one facility, as that term is defined by HSC §331.001, may establish a single workplace violence prevention committee for all of the system's facilities if:(1) the committee develops a violence prevention plan for implementation at each facility in the system; and(2) data related to violence prevention remains distinctly identifiable for each facility in the system.(d) A facility shall adopt, implement, and enforce a written workplace violence prevention policy to protect health care providers and employees from violent behavior and threats of violent behavior occurring at the facility. In accordance with HSC §331.003, the policy shall:(1) require the facility to:(A) provide significant consideration of the violence prevention plan recommended by the facility's committee; and(B) evaluate any existing facility violence prevention plan;(2) encourage health care providers and facility employees to provide confidential information on workplace violence to the committee;(3) include a process to protect from retaliation facility health care providers or employees who provide information to the committee; and(4) comply with HHSC rules relating to workplace violence.(e) A facility shall adopt, implement, and enforce a written workplace violence prevention plan developed by the committee. In accordance with HSC §331.004, the plan shall:(1) be based on a facility setting;(2) adopt a definition of "workplace violence" that includes:(A) an act or threat of physical force against a health care provider or employee that results in, or is likely to result in, physical injury or psychological trauma; and(B) an incident involving the use of a firearm or other dangerous weapon, regardless of whether a health care provider or employee is injured by the weapon;(3) require the facility to at least annually provide workplace violence prevention training or education that may be included in other required training or education provided to the facility's health care providers and employees who provide direct patient care;(4) prescribe a system for responding to and investigating violent incidents or potentially violent incidents at the facility;(5) address physical security and safety;(6) require the facility to solicit information from health care providers and employees when developing and implementing a workplace violence prevention plan;(7) allow health care providers and employees to report workplace violence incidents through the facility's existing occurrence reporting systems; and(8) require the facility to adjust patient care assignments, to the extent practicable, to prevent a health care provider or facility employee from treating or providing services to a patient who has intentionally physically abused or threatened the provider or employee.(f) The written workplace violence prevention plan may satisfy the requirements of subsection (e) of this section by referencing other internal facility policies and documents.(g) At least annually after the date a facility adopts a written workplace violence prevention plan required by subsection (e) of this section, the committee shall:(1) review and evaluate the workplace violence prevention plan; and(2) report the results of the evaluation to the facility's governing body.(h) Each facility shall make available on request an electronic or printed copy of the facility's workplace violence prevention plan to each health care provider or facility employee. If the committee determines the plan contains information that would pose a security threat if made public, the committee may redact that information before providing the plan.(i) In accordance with HSC §331.005, after an incident of workplace violence occurs, a facility shall offer immediate post-incident services, including any necessary acute medical treatment for each facility health care provider or employee who is directly involved in the incident.(j) In accordance with HSC §331.005, a facility may not discourage a health care provider or employee from exercising the provider's or employee's right to contact or file a report with law enforcement regarding a workplace violence incident.(k) In accordance with HSC §331.005, a facility shall prohibit facility personnel from disciplining, including by suspension or termination of employment, discriminating against, or retaliating against another person who:(1) in good faith reports a workplace violence incident; or(2) advises a health care provider or employee of the provider's or employee's right to report a workplace violence incident. Source Note: The provisions of this §509.70 adopted to be effective October 21, 2024, 49 TexReg 8382. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES C OPERATIONAL REQUIREMENTS §509.70 Workplace Violence Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215742 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission's (HHSC's) inspection and investigation process, a facility:(1) shall not record, listen to, or eavesdrop on any HHSC interview with facility staff or patients that the facility staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) shall not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of facility staff when HHSC has requested a private room or office or distanced themselves from facility staff and the facility obtains HHSC' written approval before beginning to record or listen to the discussion.(b) A facility shall inform HHSC when security cameras or other existing recording devices in the facility are in operation during any internal discussion by or among HHSC staff.(c) When HHSC by words or actions permits facility staff to be present, an interview or conversation for which facility staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §509.81 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.81 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215743 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an unannounced, on-site inspection of a facility at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) a facility's plan of correction;(3) an order or special order of the executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(b) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its facilities by HHSC.(c) HHSC inspections to evaluate a facility's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or bed numbers;(3) routine inspections, which may be conducted without notice and at HHSC's discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies;(5) inspections to determine if an unlicensed facility is offering or providing, or purporting to offer or provide, treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(d) A facility shall cooperate with any HHSC inspection and shall permit HHSC to examine the facility's grounds, buildings, books, records, and other documents and information maintained by or on behalf of the facility, unless prohibited by law.(e) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(f) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(g) HHSC shall maintain the confidentiality of facility records as applicable under state and federal law.(h) Upon entry, HHSC holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the facility representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the inspection, including possible health and safety concerns. The facility may provide any final documentation regarding compliance during the exit conference. Source Note: The provisions of this §509.82 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.82 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215744 03/12/2026 (a) Upon initial triage, a facility shall provide each patient and applicable legally authorized representative with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the facility.(1) The statement shall inform persons that they may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The facility shall prominently and conspicuously post this statement in patient common areas and in visitor's areas and waiting rooms so that it is readily visible to patients, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A complaint must be submitted using HHSC's current CII contact information for that purpose, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints based on the seriousness of the alleged violation and the level of risk to patients, personnel, and the public.(1) Allegations determined to be within HHSC's regulatory jurisdiction relating to freestanding emergency medical care facilities may be investigated under this chapter.(2) HHSC may refer complaints outside HHSC's jurisdiction to an appropriate agency, as applicable.(d) HHSC shall conduct investigations to evaluate a facility's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of patients.(e) HHSC may conduct an unannounced, on-site investigation of a facility at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) a facility's compliance with any applicable statute or rule;(2) a facility's plan of correction;(3) a facility's compliance with an order of the executive commissioner or the executive commissioner's designee;(4) a facility's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its facilities by HHSC.(g) A facility shall cooperate with any HHSC investigation and shall permit HHSC to examine the facility's grounds, buildings, books, records, and other documents and information maintained by, or on behalf of, the facility, unless prohibited by law.(h) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(i) HHSC shall maintain the confidentiality of facility records as applicable under state and federal law.(j) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(k) Upon entry, the HHSC representative holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the investigation.(l) The HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the investigation. The facility may provide any final documentation regarding compliance during the exit conference.(m) Once an investigation is complete, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint. Source Note: The provisions of this §509.83 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.83 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215745 03/12/2026 (a) A facility is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after mailing, whichever is earlier.(b) When HHSC finds deficiencies:(1) HHSC provides the facility with a written Statement of Deficiencies (SOD) within 10 business days after the exit conference via U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the facility's receipt of the SOD, the facility shall return to HHSC a written Plan of Correction (POC) that addresses each cited deficiency, including timeframes for corrections, together with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the facility in writing.(B) If HHSC does not accept the POC, HHSC notifies the facility in writing and requests the facility submit a modified POC and any additional evidence no later than 10 business days after HHSC notifies the facility in writing.(C) The facility shall correct the identified deficiencies and submit to HHSC evidence verifying implementation of corrective action within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of the facility's compliance with this subsection or HHSC's acceptance of a facility's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter. Source Note: The provisions of this §509.84 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.84 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215746 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission reports, in writing, to the appropriate licensing board any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure. Source Note: The provisions of this §509.85 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.85 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215747 03/12/2026 A facility may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by following the procedure listed on the HHSC website. Source Note: The provisions of this §509.86 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES D INSPECTION AND INVESTIGATION PROCEDURES §509.86 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215749 03/12/2026 (a) Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, and orders.(b) HHSC has jurisdiction to enforce violations of the Act and this chapter.(c) HHSC may deny, suspend, or revoke a license or impose an administrative penalty for:(1) failure to comply with any applicable provision of Texas Health and Safety Code (HSC), including Chapter 254 (relating to Freestanding Emergency Medical Care Facilities);(2) failure to comply with any provision of this chapter or any other applicable laws;(3) the facility, or any of its employees, commits an act which causes actual harm or risk of harm to the health or safety of a patient;(4) the facility, or any of its employees, materially alters any license issued by HHSC;(5) failure to comply with minimum standards for licensure;(6) failure to provide a complete license application;(7) failure to comply with an order of the executive commissioner or another enforcement procedure under the Act;(8) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights;(9) the facility aiding, committing, abetting, or permitting the commission of an illegal act;(10) the facility, or any of its employees, committing fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to HHSC or required to be maintained by the facility pursuant to the Act and the provisions of this chapter;(11) failure to timely pay an assessed administrative penalty as required by HHSC;(12) failure to submit an acceptable plan of correction for cited deficiencies within the timeframe required by HHSC;(13) failure to timely implement plans of corrections to deficiencies cited by HHSC within the dates designated in the plan of correction; or(14) failure to comply with applicable requirements within a designated probation period.(d) If HHSC proposes to deny, suspend, revoke a license, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC, or HHSC may personally deliver the notice. The notice to deny, suspend, or revoke a license, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.(e) Within 20 calendar days after receipt of the notice, the applicant or licensee may notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing.(f) A request for a hearing by the applicant or licensee shall be in writing and submitted to HHSC within 20 calendar days after receipt of the notice. Receipt of the notice is presumed to occur on the third day after the date HHSC mails the notice to the last known address of the applicant or licensee.(1) A hearing shall be conducted pursuant to Government Code Chapter 2001 (relating to Administrative Procedure) and 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(2) If an applicant or licensee does not request a hearing in writing within 20 calendar days after receiving notice of the proposed action, the applicant or licensee is deemed to have waived the opportunity for a hearing and HHSC shall take the proposed action. Source Note: The provisions of this §509.101 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.101 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215748 03/12/2026 The Texas Health and Human Services Commission (HHSC) has jurisdiction to enforce violations of the Act and this chapter. HHSC may deny a license if the applicant:(1) fails to provide timely and sufficient information required by HHSC that is directly related to the application; or(2) has had the following actions taken against the applicant within the two-year period preceding the application:(A) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;(B) federal Medicare or state Medicaid sanctions or penalties;(C) unsatisfied federal or state tax liens;(D) unsatisfied final judgments;(E) eviction involving any property or space used as a freestanding emergency medical care (FEMC) facility in any state;(F) unresolved federal Medicare or state Medicaid audit exceptions;(G) denial, suspension, or revocation of an FEMC facility license, a hospital license, a private psychiatric hospital license, or a license for any health care facility in any state; or(H) a court injunction prohibiting ownership or operation of a facility. Source Note: The provisions of this §509.102 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.102 Denial of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215750 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility.(b) In determining whether a criminal conviction directly relates, HHSC shall apply the requirements and consider the provisions of Texas Occupations Code Chapter 53 (relating to Consequences of Criminal Conviction).(c) The following felonies and misdemeanors directly relate to the duties and responsibilities of the ownership or operation of a health care facility because these criminal offenses indicate an ability or a tendency for the person to be unable to own or operate a facility:(1) a misdemeanor violation of the Act;(2) a misdemeanor or felony involving moral turpitude;(3) a misdemeanor or felony relating to deceptive business practices;(4) a misdemeanor or felony of practicing any health-related profession without a required license;(5) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(6) a misdemeanor or felony under Texas Penal Code (TPC) Title 5, involving a patient or a client of any health care facility, a home and community support services agency or a health care professional;(7) a misdemeanor or felony under TPC:(A) Title 4, concerning offenses of attempting or conspiring to commit any of the offenses in this paragraph;(B) Title 5, concerning offenses against the person;(C) Title 7, concerning offenses against property;(D) Title 8, concerning offenses against public administration;(E) Title 9, concerning offenses against public order and decency;(F) Title 10, concerning offenses against public health, safety, and morals; or(G) Title 11, concerning offenses involving organized crime.(8) Offenses listed in this subsection are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign, or military jurisdictions that indicate an inability or tendency for the person or entity to be unable to own or operate a facility.(d) HHSC shall revoke a license on the licensee's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision. Source Note: The provisions of this §509.103 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.103 Suspension; Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215751 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may issue an emergency order to suspend a facility's license issued under this chapter, if HHSC has reasonable cause to believe that the conduct of a license holder creates an immediate danger to public health and safety.(b) An emergency suspension under this section is effective immediately without a hearing on notice to the license holder.(c) On written request of the license holder to HHSC for a hearing, HHSC shall refer the matter to the State Office of Administrative Hearings. An administrative law judge of the office shall conduct a hearing, not earlier than the 10th day or later than the 30th day after the date HHSC receives the hearing request, to determine if the emergency suspension is to be continued, modified, or rescinded.(d) A hearing and any appeal under this section are governed by HHSC rules for a contested case hearing and Texas Government Code Chapter 2001 (relating to Administrative Procedure). Source Note: The provisions of this §509.104 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.104 Emergency Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215752 03/12/2026 (a) If the Texas Health and Human Services Commission (HHSC) finds that a facility is in repeated noncompliance with the Act or this chapter but that the noncompliance does not endanger public health and safety, HHSC may place the facility on probation rather than suspending or revoking the facility's license.(b) HHSC shall provide notice to the facility of the probation and of the items of noncompliance not later than the 10th day before the date the probation period begins.(c) HHSC shall designate a period of not less than 30 days during which the facility remains under probation.(d) During the probation period, the facility shall correct the items of noncompliance and report the corrections to HHSC for approval.(e) HHSC may verify the corrective actions through an on-site inspection.(f) HHSC may suspend or revoke the license of a facility that does not correct items of noncompliance or that does not comply with the Act or this chapter within the applicable probation period. Source Note: The provisions of this §509.105 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.105 Probation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215753 03/12/2026 Pursuant to Texas Health and Safety Code §254.203 (relating to Injunction), the Texas Health and Human Services Commission (HHSC) may petition a district court for a temporary restraining order to restrain a continuing violation of the standards or licensing requirements provided under the Act or Texas Health and Safety Code Section 254.158 (relating to Removal of Signs) if HHSC finds that the violation creates an immediate threat to the health and safety of the patients of a facility or of the public. Source Note: The provisions of this §509.106 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.106 Injunction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215754 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may impose an administrative penalty on a person licensed under the Act who violates the Act, this chapter, or an order adopted under this chapter.(b) The amount of the penalty may not exceed $1,000 for each violation. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty.(c) The amount shall be based on:(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(2) the threat to health or safety caused by the violation;(3) the history of previous violations;(4) the amount necessary to deter a future violation;(5) whether the violator demonstrated good faith efforts to come into compliance; and(6) any other matter that justice may require.(d) If HHSC initially determines that a violation occurred, HHSC shall give written notice of the report by certified mail to the person.(e) The notice under subsection (d) of this section shall include:(1) a brief summary of the alleged violation;(2) a statement of the amount of the recommended penalty; and(3) a statement of the person's right to a hearing on the occurrence of the violation, the amount of the penalty, or both.(f) Within 20 calendar days after the date the person receives the notice under subsection (d) of this section, the person in writing may:(1) accept the determination and recommended penalty of HHSC; or(2) make a request for a hearing on the occurrence of the violation, the amount of the penalty, or both.(g) If the person accepts the determination and recommended penalty or if the person fails to respond to the notice, the executive commissioner or the executive commissioner's designee by order shall approve the determination and impose the recommended penalty.(h) If the person requests a hearing, the executive commissioner shall refer the matter to the State Office of Administrative Hearings (SOAH), which will set the hearing date. HHSC shall give written notice of the time and place of the hearing to the person. An administrative law judge with SOAH will conduct the hearing.(i) The administrative law judge will make findings of fact and conclusions of law and issue to the executive commissioner a proposal for a decision about the occurrence of the violation and the amount of a proposed penalty.(j) Based on the findings of fact, conclusions of law, and proposal for a decision, the executive commissioner by order may:(1) find that a violation occurred and impose a penalty; or(2) find that a violation did not occur.(k) The notice of the order under subsection (j) of this section that HHSC sends to the person in accordance with Texas Government Code Chapter 2001 (relating to Administrative Procedure) must include a statement of the right of the person to judicial review of the order. Source Note: The provisions of this §509.107 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.107 Administrative Penalty https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215755 03/12/2026 (a) Within 30 calendar days after the date an order of the executive commissioner under §509.107(k) of this subchapter (relating to Administrative Penalty) that imposes an administrative penalty becomes final, the person shall:(1) pay the penalty; or(2) pursuant to Texas Health and Safety Code (HSC) §254.206 (relating to Payment and Collection of Administrative Penalty; Judicial Review), file a petition for judicial review of the executive commissioner's order contesting the occurrence of the violation, the amount of the penalty, or both.(b) Within the 30-day period prescribed by subsection (a) of this section, a person who files a petition for judicial review may:(1) stay enforcement of the penalty by:(A) paying the penalty to the court for placement in an escrow account; or(B) giving the court a supersedeas bond that is approved by the court for the amount of the penalty, and that is effective until all judicial review of the commissioner's order is final; or(2) request the court to stay enforcement of the penalty by:(A) filing with the court a sworn affidavit of the person stating that the person is financially unable to pay the penalty and is financially unable to give the supersedeas bond; and(B) sending a copy of the affidavit to the executive commissioner by certified mail.(3) If the executive commissioner receives a copy of an affidavit under paragraph (2)(B) of this subsection, the executive commissioner may file with the court, within five days after the date the copy is received, a contest to the affidavit. In accordance with HSC §254.206(c), the court shall hold a hearing on the facts alleged in the affidavit as soon as practicable and shall stay the enforcement of the penalty on finding that the alleged facts are true. The person who files an affidavit has the burden of proving that the person is financially unable to pay the penalty or to give a supersedeas bond.(c) If the person does not pay the penalty and the enforcement of the penalty is not stayed, HHSC may refer the matter to the attorney general for collection of the penalty. As provided by HSC §254.206(d), the attorney general may sue to collect the penalty.(d) A decision by the court is governed by HSC §254.206(e) and (f) and provides the following.(1) If the court sustains the finding that a violation occurred, the court may uphold or reduce the amount of the penalty and order the person to pay the full or reduced amount of the penalty.(2) If the court does not sustain the finding that a violation occurred, the court shall order that a penalty is not owed.(e) The remittance of penalty and interest is governed by HSC §254.206(g) and provides the following.(1) If the person paid the penalty and if the amount of the penalty is reduced or the penalty is not upheld by the court, the court shall order, when the court's judgment becomes final, that the appropriate amount plus accrued interest be remitted to the person within 30 days after the date that the judgment of the court becomes final.(2) The interest accrues at the rate charged on loans to depository institutions by the New York Federal Reserve Bank.(3) The interest shall be paid for the period beginning on the date the penalty is paid and ending on the date the penalty is remitted.(f) The release of supersedeas bond is governed by HSC §254.206(h) and provides the following.(1) If the person gave a supersedeas bond and the court does not uphold the penalty, the court shall order, when the court's judgment becomes final, the release of the bond.(2) If the person gave a supersedeas bond and the amount of the penalty is reduced, the court shall order the release of the bond after the person pays the reduced amount. Source Note: The provisions of this §509.108 adopted to be effective December 4, 2023, 48 TexReg 7064. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES E ENFORCEMENT §509.108 Payment of Administrative Penalty; Judicial Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221880 03/12/2026 (a) A facility shall comply with the provisions of this section with respect to fire prevention and protection.(1) A facility shall comply with local fire codes.(2) All incidents of fire shall be reported to the local fire authority and shall be reported in writing to the Department of State Health Services, Facility Licensing Group, Mail Code 1979, P.O. Box 149347 Austin, Texas 78714-9347, as soon as possible, but not later than 10 calendar days following the incident. Any fire incident causing injury to a person shall be reported no later than the next business day.(3) A facility shall adopt, implement, and enforce a written smoking policy.(b) A facility shall adopt, implement, and enforce a written policy for periodic inspection, testing, and maintenance of fire fighting equipment, portable fire extinguishers, and when installed sprinkler systems. If installed, fire sprinkler systems shall comply with National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13). All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555. NFPA documents are also available for public inspection during regular working hours at the offices of Architectural Review Group, Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.(1) All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested, and maintained in accordance with National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2002 Edition.(2) Every portable fire extinguisher located in a facility or upon facility property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 2002 Edition.(c) A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §21.7.1.1 Copies of the plan shall be available to all staff.(1) An evacuation floor plan shall be prominently and conspicuously posted for display throughout the facility in public areas that are readily visible to patients, employees, and visitors.(2) Each facility shall conduct an annual training program for instruction of all personnel in the location and use of fire fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(3) The facility shall conduct one fire drill per shift per quarter. The governing body of the facility shall define working shifts for the facility. Fire drills shall include the transmission of the fire alarm signal and simulation of the emergency fire condition, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment. Written reports shall be maintained to include evidence of patient and staff participation. Fire exit drills shall incorporate the minimum requirements of NFPA 101, §§21.7.1.2 through 21.7.2.3.(4) All staff shall be familiar with the locations of fire fighting equipment. Fire fighting equipment shall be located so that a person shall not have to travel more than 75 feet from any point to reach the equipment.(d) A fire alarm system shall be installed, maintained, and tested, in accordance with National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72) and NFPA 101, §21.3.4.(e) A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101, §21.3.4.4.(f) As an aid to fire department services, every facility shall provide the following:(1) The facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Upon request, the facility shall submit a copy of the floor plans of the building to the local fire department officials.(3) The facility shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(g) When a facility is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire.(h) The facility shall provide an emergency contingency plan for the continuity of emergency essential building systems. The emergency contingency plan shall consist of one of the two options as described in paragraphs (1) and (2) of this subsection.(1) An onsite emergency generator shall be provided with a Type II essential electrical distribution system in accordance with requirements of NFPA 99, §4.5, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(A) The minimum electrical load connection shall be in accordance with NFPA 99 §4.5.2.(B) An emergency generator standby power system(s) shall require an onsite fuel source and enough fuel capacity in the tank for a period of twenty-four hours or more. The facility shall execute contract(s) with the supplier/vendor(s) for fuel on demand. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the twenty-four hour fuel capacity onsite is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(C) The emergency generator shall be installed, tested and maintained in accordance with the National Fire Protection Association 99, §4.5.4, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(2) An executed contract(s) with an outside supplier/vendor that will provide a portable emergency generator(s) and fuel.(A) An electrical transfer switch with plug-in device sized to provide emergency power for the patient care areas and the provisions in NFPA 99, §4.5.2.2.2.(B) An alternate source of power (battery power lighting) shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of one and one half hours after loss of the electrical power. The emergency lighting system shall be capable of providing sufficient illumination to allow safe evacuation from the building. The battery pack systems shall be maintained and tested quarterly.(C) The facility shall implement the emergency contingency plan upon the loss of electrical power following a natural weather or man-made event when the electrical power may not be restored within 24 hours. The facility shall exercise the contract(s) with the supplier/vendor(s) in order to have portable emergency generator(s) and potable water available within 36 hours after the loss of electrical power.(i) The facility premises shall be kept free from accumulations of combustible materials not necessary for immediate operation of the facility. Source Note: The provisions of this §509.121 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES F FIRE PREVENTION AND SAFETY REQUIREMENTS §509.121 Fire Prevention, Protection, and Emergency Contingency Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221881 03/12/2026 (a) The governing body shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall carry out the functions of the safety program.(b) Safety activities.(1) The safety officer shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded are evaluated, and documentation is provided to show follow-up and corrective actions.(2) Safety policies and procedures for the facility shall be developed, implemented, and enforced.(3) Safety training shall be established as part of new employee orientation and in the continuing education of all employees.(c) The authority of the safety officer to take action, when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.(d) Each department or service shall have a safety manual describing safety policies and procedures within their own areas and become part of the overall facility safety manual.(e) An emergency communication system, such as radio-frequency communication devices, battery operated emergency phone, or cellular telephones, shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments.(f) No portable or ceiling fans shall be utilized in any patient treatment areas, exam areas, holding areas, imaging areas, diagnostic areas, clean and sterile environments.(g) Electrical extension cords and cables shall not be used for permanent wiring. When temporary electrical cords or cables are used, they shall be secured and protected to prevent tripping.(h) A nurse's emergency calling system shall be installed in the all treatment room/area station(s), exam rooms/area station(s), isolation room(s), patient holding stations, imaging, diagnostic and patient toilet room(s) to summon nursing staff in an emergency. Activation of the system shall sound a distinct audible signal which repeats every five seconds or less at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in all areas. The activation of the system shall also activate distinct visible signals in the clean workroom, soiled workroom, and if provided, in the nourishment station. The visible and audible signals shall be cancelable only at the patient calling station. A nurse's emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.(i) A staff emergency assistance calling system station shall be located in each treatment room/area, examination room/area, trauma room/area, and holding room/area to be used by staff to summon additional help in an emergency. Activation of the system shall sound an audible signal at a staffed location, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the door. Additional visible signals shall be installed at corridor intersections in multi-corridor facilities. Distinct visible and audible signals shall be activated in the clean workroom, in soiled workroom, equipment storage, and if provided, in the nourishment station.(j) Doors to any treatment, exam, or isolation rooms shall not be lockable from inside the room.(k) When construction takes place during any treatments, exams, and diagnostics, adequate provision shall be made for the safety and comfort of patients. Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.(l) When construction occurs after hours or on weekends, the facility shall thoroughly clean all areas of construction and provide a clean safe environment before treating patients.(m) A facility shall provide a physical environment that protects the health, safety, and welfare of patients, personnel, and the public. The physical premises and the environment of the facility and those areas of the facility's surrounding physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes as they relate to safe access and patient privacy. Source Note: The provisions of this §509.122 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES F FIRE PREVENTION AND SAFETY REQUIREMENTS §509.122 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221882 03/12/2026 (a) If flammable germicides, including alcohol-based products, are used for surgical skin preparation, the facility must:(1) use only self-contained, single-use, pre-measured applicators to apply the surgical skin preparations;(2) follow all manufacturer product safety warnings and guidelines;(3) develop, implement and enforce written policies and procedures outlining the safety precautions required related to the use of the products, which, at a minimum, must include minimum drying times, prevention and management of product pooling, parameters related to draping and the use of ignition sources, staff responsibilities related to ensuring safe use of the product, and documentation requirements sufficient to evaluate compliance with the written policies and procedures;(4) ensure that all staff working in the surgical environment where flammable surgical skin preparation products are in use have received training on product safety and the facility policies and procedures related to the use of the product;(5) develop, implement and enforce an interdisciplinary team process for the investigation and analysis of all flammable germicides fires and alleged violations of the policies; and(6) report all occurrences of flammable germicide fires to the department in care of the Facility Licensing Group not later than the second business day after the fire, and complete an investigation of the occurrence and develop and implement a corrective action plan not later than the 30th day after the fire.(b) Alcohol-based hand rubs (ABHRs) are considered flammable. When used, the ABHRs shall meet the following requirements.(1) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart.(2) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms.(3) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches.(4) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.(5) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage.(c) An facility shall comply with the requirements of this section for handling and storage of gas and flammable liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association 329, Handling Releases of Flammable and Combustible Liquids and Gases, 2002 Edition.(1) Nonflammable gases, including but not limited to oxygen and nitrous oxide, shall be stored and distributed in accordance with Chapter 5 of the National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99). All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555. NFPA documents are also available for public inspection during regular working hours at the offices of Architectural Review Group, Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.(A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99, Chapter 9.(B) Oxygen shall be administered in accordance with NFPA 99, §9.6.(C) When inhalation anesthetic agents are used, the ventilation requirements shall be in accordance with the requirements of NFPA 99, §13.4.1.2.(2) Piped flammable gas systems intended for use in laboratories and piping systems for fuel gases shall comply with requirements of NFPA 99, §11.11.(3) Flammable gases shall be stored in accordance with NFPA 99, §11.10.(4) Flammable and combustible liquids used in laboratories shall be handled and stored in accordance with NFPA 99, §11.7, and National Fire Protection Association 101, Life Safety Code, 2003 edition, §18.3.2.2.(5) Other flammable agents shall be stored in accordance with NFPA 99, Chapter 7.(d) No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the facility building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the facility building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.(e) The installation, use, and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2002 Edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §509.123 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES F FIRE PREVENTION AND SAFETY REQUIREMENTS §509.123 Handling and Storage of Gases, Anesthetics, and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221883 03/12/2026 (a) A facility that is operating before the effective date of this chapter is considered to be a pre-existing facility and shall meet the physical plant and construction requirements under this chapter.(b) A pre-existing facility shall complete all major remodeling, renovations, additions, and alterations in accordance with the requirements for new construction in §131.143 of this title (relating to Construction Requirements for a New Facility). All areas of a pre-existing facility that are not part of a major remodel, renovation, addition or alteration to the facility, are not required to meet these new construction requirements as long as the existing portion met the codes that were in effect when it was originally constructed and licensed. When existing conditions make such changes impractical, the department may grant a conditional approval of minor deviations from the requirements of §131.143 of this title, if the intent of the requirements is met and if the care, safety and welfare of patients will not be jeopardized. The operation of the facility, accessibility of individuals with disabilities, and safety of the patients shall not be jeopardized by a condition(s) which is not in compliance with this subchapter.(1) Any alteration, modification, replacement, or installation of new building equipment (such as mechanical, electrical, emergency power equipment, energy/utility management, conveying systems, plumbing, fire protection, or other equipment), with a primary function of building service that affects life safety, infection control, functional operation, or the health, safety, and welfare of patients and staff shall comply with the requirements for new construction and shall not be replaced, materially altered, or extended in a pre-existing licensed facility until complete plans and specifications have been submitted to the department, and the department has reviewed and approved the plans and specifications in accordance with §131.146 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(2) Minor remodeling or alterations within an existing facility which do not involve alterations to load-bearing members and partitions, change functional operation, affect fire safety, or involve any of the major changes listed in paragraph (1) of this subsection are considered to be minor projects and require evaluation and approval by the department. A pre-existing licensed facility shall submit by mail or fax a written request and floor plan for evaluation, a brief description of the proposed changes, floor plan, and sketches of the area being remodeled. Based on such submittal, the department shall evaluate and determine whether any additional submittals or inspections are required. The department shall notify the facility of its decision. The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition would not require submission to the department for approval.(3) All remodeling or alterations which involve alterations to load-bearing members or partitions, change functional operation, or affect fire safety are considered major projects. A facility shall comply with this section before beginning construction of major projects.(A) Plans shall be submitted in accordance with this section for all major remodeling or alterations.(B) Construction projects involving alterations of or additions to existing buildings shall be programmed and phased so that on-site construction shall minimize disruptions of existing functions.(i) Access, exit access, and fire protection shall be maintained so that the safety of the occupants shall not be jeopardized during construction.(ii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.(iii) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.(iv) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present.(v) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.(vi) When construction occurs after hours or on weekends, the facility shall thoroughly clean all areas of construction and provide a clean safe environment before treating patients. The facility shall ensure that all fire safety protection and building systems are in place and working properly.(c) Pre-existing facilities shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus.(1) The facility site shall include paved roads, walkways, and parking in accordance with local building codes and ordinances.(2) Pre-existing licensed facilities shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101 - 336, 42 United States Code, Chapter 126, and Title 36, Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities or 16 TAC, §68.20 (relating to Buildings and Facilities Subject to Compliance with the Texas Accessibility Standards), Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Government Code, Chapter 469.(d) Spatial requirements.(1) Administration and public areas.(A) A primary entrance at grade level shall be accessible.(B) A main lobby shall be located at the primary entrance and shall include a reception and information counter or desk, waiting space(s), public toilet facilities located convenient to the lobby/waiting area, and storage room or alcove for wheelchairs. Private interview area may be omitted if all interviews occur in treatment or exam rooms.(2) Emergency Entrance and Signage.(A) An ambulance entrance at grade level shall be well-illuminated.(B) Emergency entry signage. An emergency sign shall be provided at the entry from the public road(s) or street(s) serving the site.(C) A facility that is not in continuous operation 24 hours per day and 7 days per week shall display clearly visible signage at the main entry and ambulance entry points of the facility. The signage letter size shall be readable and not smaller than half an inch in height. The signage shall provide the information required under §131.22(c) of this title (relating to Classifications of Facilities).(D) A facility that is not in continuous operation shall comply with the requirements under §133.22(d) of this title.(3) Emergency suite.(A) Control station/nurse station shall be located to permit staff observation and control of access to treatment room(s), exam rooms, pedestrian and ambulance entrances, and public waiting area(s). The nurse station shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls.(B) A medical staff work area and charting area(s) shall be provided. The area may be combined with the control station/nurse station.(C) As a minimum requirement, all pre-existing facilities shall provide at least one emergency treatment room to handle emergencies. The emergency treatment room shall contain cabinets, work counter, examination light, and a hand washing fixture with hands-free operable controls.(D) As a minimum requirement, all pre-existing facilities shall provide at least one exam room. The examination room shall contain cabinets, work counter, examination light, and a hand washing fixture with hands-free operable controls.(E) Storage space shall be provided within the room or suite and be under staff control for general medical-surgical emergency supplies and medications. Adequate space shall be provided for emergency equipment such as emergency treatment trays, ventilator, defibrillator, splints, cardiac monitor, etc.(F) An area or alcove located out of traffic and convenient to the treatment and exam room(s) shall be provided for an emergency crash cart.(G) An alcove shall be provided for stretcher and wheelchair storage. The storage for stretchers and wheelchairs shall be located out of the line of traffic.(H) A nourishment station shall be provided containing a work counter with sink, microwave, refrigerator and storage cabinets and not located in the clean workroom. When the patient nourishment refrigerator is located in the staff lounge, the refrigerator shall be labeled "patient refrigerator."(I) An ice machine supplying ice for therapeutic purposes, when provided, shall be located in the clean utility room or similar clean space. A self-dispensing ice machine shall be provided for ice for human consumption.(J) Patient toilet room(s) shall be provided and shall be convenient to treatment rooms, examination rooms, and trauma rooms a hand washing fixture with hands-free operable controls.(K) Staff toilets shall be provided and may be outside the suite but shall be convenient for staff use and include hand washing fixtures with hands-free operable controls.(L) A clean storage room shall be provided for clean supplies, linens and medications as needed. A hand washing fixture shall be provided within the room with hands-free operable controls.(M) Soiled workroom shall be provided and contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles.(4) Medication storage. A medication work room or alcove shall be provided and located separate from patient and public areas and under the direct supervision of staff. A work counter, refrigerator, medication storage, and locked storage for biologicals and drugs shall be provided. A hand washing fixture with hands-free operable controls shall be located in the medication storage room or alcove.(A) Functional space shall be provided and areas required for records, reports, and accounting activities.(B) Space for the poison control center shall be provided with storage facilities for reaction data and drug information centers.(5) Diagnostic radiographic (X-ray). A diagnostic radiographic (X-ray) room shall be provided and be readily available to the emergency suite.(A) Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(B) When the facility is equipped with digital imaging system capabilities, a minimum of two X-ray film illuminators viewers shall be provided and mounted in a central location.(6) Computed tomography (CT) scanning. A CT room shall be provided and be readily available to the emergency suite. Clearance and unobstructed space shall be not less than three feet on each side of the diagnostic table.(A) A control room shall be provided with a view window permitting view of the patient. The control room shall be located to allow convenient film processing.(B) A patient toilet shall be provided convenient to the CT room. The toilet room shall have a hand washing fixture with hands-free operable controls.(7) Laboratory services. Laboratory room or work area shall be provided with the following minimum facilities.(A) The laboratory work room(s) shall include counter(s), space appropriately designed for laboratory equipment, and sink(s) with hands-free operable controls.(B) Each laboratory room or work area shall be provided with a hand washing fixture(s) with hands-free operable controls.(C) General storage, including refrigeration for reagents, standards, supplies, and stained specimen microscope slides, etc. shall be provided. Separate facilities shall be provided for such incompatible materials as acids and bases, and vented storage shall be provided for volatile solvents.(D) A refrigerator and other necessary equipment shall be provided for specimen storage waiting for transfer to off-site testing.(E) Specimen room/area for blood collection shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands-free operable controls shall be provided for specimen collection. This facility may be outside the laboratory area if conveniently located.(F) When chemical safety is a requirement, an emergency shower and eye flushing devices shall be provided.(G) Flammable or combustible liquids, when used, shall be stored in approved containers, in accordance with National Fire Protection Association 30, Flammable and Combustible Liquids Code, 2003 edition.(H) Radioactive materials, when employed, shall be stored in safe storage facilities.(I) Each laboratory unit shall meet the requirements of Chapter 11 of NFPA 99 (relating to Laboratories), and Chapter 20 of NFPA 101 (relating to New Ambulatory Health Care Occupancies).(8) Housekeeping room. A sufficient number of janitor's closets shall be provided throughout the facility to maintain a clean and sanitary environment. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment. When there is only one housekeeping room for the entire facility there shall be policies and procedures in place, as described in §131.55 of this title (relating to Sanitary Conditions and Hygienic Practices) for proper use of cleaning body fluids versus general cleaning, and the use of separate equipment and supplies.(9) Medical waste. Space and facilities shall be provided for the safe storage and disposal of medical waste as appropriate for the material being handled and in compliance with all applicable federal, state, or local laws, codes, rules, regulations and ordinances.(10) Supply rooms.(A) A storage room/area for breakdown of supplies shall be provided. The storage room/area shall have adequate space for breakdown of prepackaged supplies to be loaded on cart(s) to transport to the appropriate storage spaces. The breakdown area shall not reduce the clear unobstructive width in the egress corridor.(B) Sterile/clean supply room. A sterile/clean supply room shall be provided. Storage of sterile/clean supplies shall not occur within the breakdown room.(C) An equipment storage room shall be provided. The equipment room may be in the emergency suite.(11) Employee facilities. A lounge, lockers and staff toilets shall be provided for employees and volunteers. The toilet room(s) may be unisex.(12) Engineering suite and equipment areas shall be provided.(A) Provisions shall be made for protected storage of facility drawings, records, manuals, etc.(B) All mechanical and electrical equipment rooms shall provide sufficient space for proper maintenance of equipment. Provisions shall be made for removal and replacement of equipment.(C) Additional areas or room(s) for mechanical and electrical equipment shall be provided within the physical plant or installed in separate buildings or weatherproof enclosures with the following exceptions.(i) An area shall be provided for cooling towers and heat rejection equipment when such equipment is used.(ii) Medical gas systems shall be housed in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99), Chapters 4 and 8.(iii) When provided, compactors, dumpsters, and incinerators shall be located in an area remote from public entrances.(e) General detail requirements. Details in pre-existing facilities shall comply with this subsection, local building codes, and local ordinances.(1) Exits, corridors and doors.(A) A facility shall provide two exits remote from each other. At least one exit door shall be accessible by an ambulance from the outside.(B) Encroachment into the means of egress. Such items as drinking fountains, telephone booths or stations, and vending machines shall not project into or restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment, when stored, shall not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(C) The unobstructed width of a corridor shall be at least four feet.(D) Doors at all openings between corridors and rooms or spaces subject to occupancy shall be swing type. Elevator doors are excluded from this requirement.(E) The minimum width of doors for patient access to treatment, examination, diagnostic, and imaging rooms requiring access for beds and gurneys shall be three feet.(F) All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 Edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(2) Glazing for glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101, §18.3.3.(3) Grab bars shall be provided at patient toilets and showers. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars intended for use by the disabled shall also comply with ADA requirements.(4) Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free controls shall be provided in each examination, treatment, trauma, diagnostic, imaging, holding/observation room/area, soiled utility room, clean work room, and toilet room. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be conveniently located for staff use in rooms and areas noted under spatial requirements in subsection (c) of this section and throughout the center where patient care services are provided.(5) A liquid or foam soap dispenser shall be located at each hand washing facility.(6) Provisions for hand drying shall be included at all hand washing facilities. Hot air dryers or individual paper or cloth units shall be enclosed to provide protection against dust or soil and shall provide single-unit dispensing.(7) A sign shall be posted at the entrance to each toilet/restroom to identify the facility for public, staff, or patient use.(8) Emergency eyewash shall be provided conveniently located within the emergency suite for staff use and comply with ANSI Z358.1.(9) The minimum ceiling height shall be eight feet six inches with the following exceptions.(A) Ceilings in storage rooms, toilet rooms, and other minor rooms shall be not less than seven feet six inches.(B) Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.(C) Overhead clearance for suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.(10) Radiation shielding shall be designed, tested, and approved by a medical physicist licensed under the Medical Physics Practice Act, Occupations Code, Chapter 602. The facility shall obtain a certificate of registration issued by the Radiation Safety Licensing Branch to use radiation machines.(f) General finish requirements. Finishes in pre-existing facilities shall comply with this subsection, local building codes, and local ordinances.(1) Privacy screens, cubicle curtains, and draperies.(A) Cubicle curtains or privacy screens shall be provided to assure patient privacy when required or requested by a patient.(B) Cubicle curtains, draperies and other hanging fabrics shall be noncombustible or flame retardant.(2) Floor finishes.(A) Flooring shall be easy to clean and have wear resistance appropriate for the location involved. In all areas frequently subjected to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions.(B) Existing flooring in patient treatment/exam rooms in a pre-existing facility that has jointed or seamed flooring material may continue to be used provided there is assurance that no bodily fluids or moisture can harbor in the joints, seams or under the flooring material. If assurance of fluids harboring under the flooring material cannot be made, the flooring material must be sealed with a covering sealant material to prevent fluids from entering the seams and joints. When the existing flooring is replaced, the new flooring shall meet the requirements of §131.143(f)(3)(A)(iii) of this title (relating to Construction Requirements for a New Facility).(C) Thresholds at doorways shall not exceed 3/4 inch in height for exterior sliding doors or 1/2 inch for other type doors. Raised thresholds and floor level changes at accessible doorways shall be beveled with a slope no greater than 1:2. Expansion joint covers shall not exceed 1/2 inch in height and shall have beveled edges with a slope no greater than 1:2.(3) Wall finishes. Wall finishes shall be washable, moisture resistant, and cleanable by standard housekeeping practices.(A) Wall finishes shall be water-resistant in the immediate area of plumbing fixtures.(B) Wall finishes in areas subject to frequent, wet cleaning methods shall be impervious to water, tightly sealed, and without voids.(4) Ceiling finishes. All occupied rooms and spaces shall be provided with finished ceilings, unless otherwise noted. Ceilings which are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing.(5) Floor, wall, and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits, or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed.(6) Material finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(g) General mechanical requirements. Mechanical systems, air conditioning, heating, and ventilating systems shall meet the requirements of the local building codes, ordinances and this section.(1) Equipment location. Mechanical equipment may be located indoors, outdoors in a weatherproof enclosure, or in a separate building(s).(2) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators.(3) Heating, ventilating, and air conditioning (HVAC) systems.(A) All central HVAC systems shall comply with and shall be installed in accordance with required building codes, ordinances and NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 Edition, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, 2002 Edition, as applicable, and the requirements contained in this paragraph. Air handling units serving two or more rooms are considered to be central units.(B) Noncentral air handling systems, i.e., individual room units that are used for heating and cooling purposes (e.g., fan-coil units, heat pump units, and packaged terminal air conditioning units) shall be equipped with permanent (cleanable) or replaceable filters. The filters shall have an average efficiency of 25 - 30% and an average arrestance of 85% based on American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air Cleaning Devices for Removal Efficiency by Particle Size. These units shall be used as air recirculating units only.(C) General ventilation requirements. All rooms and areas in the facility shall have provision for positive ventilation.(i) All toilet exhaust ventilation shall be exhausted.(ii) Air distribution devices. Design shall consider turbulence and other factors of air movement to minimize airborne particulate matter.(I) All supply diffusers grilles shall be located on the ceiling or on a wall within four inches from the ceiling.(II) Air supply for the treatment rooms/areas, exam rooms/areas, and trauma rooms/areas shall be from ceiling outlets.(iii) Air handling units shall be equipped with filters having efficiencies of 25 - 30% and an average arrestance of 85% or greater based on American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage.(iv) Existing return air plenums in pre-existing facility may continue to be used as long as the following conditions are provided.(I) Final filters providing 90% efficiency shall be located downstream of the supply air blowers, cooling and heating coils.(II) The facility shall at all times have constant air changes throughout the facility and meet the ventilation requirements of Table 2 of §131.148(b) of this title (relating to Tables) during operational hours.(III) Provide Ultraviolet (UV) lighting apparatus in the central air handling unit.(D) Ray protection. Ducts which penetrate construction intended for X-ray or other ray protection shall not impair the effectiveness of the protection.(E) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a required two-hour or higher fire-rated wall or floor in accordance with the requirements of NFPA 101, §18.5.2.(h) Piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall meet the requirements of the local building codes, ordinances and this subchapter.(1) Piping systems.(A) Water supply piping systems. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(i) Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture.(ii) Backflow preventers (vacuum breakers) shall be installed on hose bibs, laboratory sinks, janitor sinks, bedpan flushing attachments, and all other fixtures to which hoses or tubing can be attached. Connections to high hazard sources, e.g., X-ray film processors, shall be from a cold water hose bib through a reduced pressure principle type backflow preventer (RPBFP).(iii) Flush valves installed on plumbing fixtures shall be a quiet operating type, equipped with silencers.(iv) Water heating equipment shall have sufficient capacity to supply water for all clinical needs based on accepted engineering practices using actual number and type of fixtures and for heating, when applicable.(v) Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment. Hot water temperature at point of use for patients, staff, and visitors shall be in the range of 105 to 120 degrees Fahrenheit.(vi) Dead-end piping (risers with no flow, branches with no fixture) shall not be allowed.(B) Fire sprinkler systems. When provided, fire sprinkler systems shall comply with the requirements of NFPA 101, §9.7, Automatic Sprinklers and Other Extinguishing Equipment, and the requirements of this subparagraph. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, and shall be certified as required by §131.147(c)(1)(C) of this title (relating to Construction, Inspection, and Approval of Project).(C) Piped nonflammable medical gas and clinical vacuum systems. Existing piped nonflammable medical gas and clinical vacuum systems shall be in accordance with NFPA 99, §5.1 for Level 1 Piped Systems.(D) Main storage of medical gases may be outside or inside the facility in accordance with NFPA 99, §5.1. Provision shall be made for additional separate storage of reserve gas cylinders necessary to complete at least one day's procedures.(2) Building sewers shall discharge into a community sewage system. Where such a system is not available, a facility providing sewage treatment shall conform to applicable local and state regulations.(3) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive, acid-resistant materials and shall comply with the requirements of the National Standard Plumbing Code, and this paragraph.(A) Sink and lavatory controls. All lavatories used by medical and nursing staff and by patients shall be trimmed with valves or electronic controls which can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may also be used.(B) Back-flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(C) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent the contamination of the water supply, and the entrance of contaminating materials into the sterilizing units.(D) Hose attachment. No hose shall be affixed to any faucet if the end of the hose may become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker.(E) Bedpan washers and sterilizers. When provided, bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(F) Flood level rim clearance. The water supply spouts for lavatories and sinks required in patient care areas shall be mounted so that their discharge points are a minimum of five inches above the rim of the fixture.(G) Scrub sink controls. Freestanding scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or electronic hands-free controls. Single lever wrist blades are not acceptable at scrub sinks.(H) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages.(I) Under counter piping. Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of the floor below the equipment.(J) Ice machines. All ice-making machines used for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines.(i) General electrical requirements. This subsection contains common electrical and essential emergency system requirements. All electrical installation and equipment shall meet the requirements of the local building codes, ordinances and this subsection.(1) Electrical requirements. All electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the NFPA 70, National Electrical Code, 2002 Edition, §517; NFPA 99, Chapter 14; the requirements of this subsection; and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturer's instructions.(A) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(B) Extension cords and cables shall not be used for permanent wiring.(C) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(D) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70.(E) Under counter electrical installations shall be arranged (raised) to not interfere with cleaning the floor below the equipment.(2) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(3) Services and switchboards. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire-rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures.(4) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in metal or metallic raceways in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300.(5) Lighting.(A) Consideration shall be given to controlling light intensity and wavelength to prevent harm to the patient's eyes.(B) Approaches to buildings and parking lots, and all spaces within buildings shall have fixtures that can be illuminated as necessary. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all spaces are clearly visible.(C) The special needs of the elderly shall be considered. The facility shall minimize excessive contrast in lighting levels that makes effective sight adaptation difficult.(D) Electric lamps, which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(E) Ceiling mounted surgical and examination light fixtures shall be suspended from rigid support structures mounted above the ceiling.(6) Receptacles. Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in the trauma, treatment, exam, diagnostic, imaging rooms, and all patient care areas. This does not apply to special purpose receptacles.(A) Electrical receptacles powered from the emergency generator shall be colored red.(B) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be installed or replaced with receptacles of the same distinct color as the existing receptacles.(C) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(D) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor in accordance with NFPA 70, §517-13.(E) Ground fault circuit interrupters (GFCI) receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip.(7) Nurse's calling systems.(A) A nurse's emergency calling system shall be installed in all treatment room/area station(s), exam rooms/area station(s), isolation room(s), patient holding stations, imaging, diagnostic and patient toilet room(s) to summon nursing staff in an emergency. Activation of the system shall sound a distinct audible signal which repeats every five seconds or less at the nurse station, indicate the type and location of call on the system monitor, and activate a distinct visible signal in all areas. The activation of the system shall also activate distinct visible signals in the clean workroom, soiled workroom, and if provided, in the nourishment station. The visible and audible signals shall be cancelable only at the patient calling station. A nurse's emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.(B) A staff emergency assistance calling system station shall be located in each treatment room/area, examination room/area, trauma room/area, and holding room/area to be used by staff to summon additional help in an emergency. Activation of the system shall sound an audible signal at a staffed location, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the door. Additional visible signals shall be installed at corridor intersections in multi-corridor facilities. Distinct visible and audible signals shall be activated in the clean workroom, in soiled workroom, equipment storage, and if provided, in the nourishment station.(8) The pre-existing facility shall have an emergency contingency plan for the continuity of emergency essential building systems. The emergency contingency plan shall consist of one of the two options in this paragraph.(A) An onsite emergency generator shall be provided with a Type II essential electrical distribution system in accordance with requirements of NFPA 99, §4.5 (2), and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(i) An emergency generator standby power system(s) shall require an onsite fuel source and enough fuel capacity in the tank for a period of 24 hours or more. The facility shall execute a contract with an outside supplier/vendor(s) that will provide fuel on demand. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the twenty-four hour fuel capacity on site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(ii) The emergency generator shall be installed, tested and maintained in accordance with the National Fire Protection Association 99, §4.5.4, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(B) An executed contract with an outside supplier/vendor(s) to provide a portable emergency generator(s) and fuel on demand.(i) An electrical transfer switch with plug-in device sized to provide emergency power for the patient care areas and the provisions in NFPA 99, §4.5.2.2.2.(ii) An alternate source of power (battery power lighting) shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of one and one-half hours after loss of electrical power. The emergency lighting system shall be capable of providing sufficient illumination to allow safe evacuation from the building. The battery pack systems shall be maintained and tested quarterly.(iii) The facility shall implement the emergency contingency plan upon the loss of electrical power following a natural weather or man-made event when the electrical power may not be restored within 24 hours. The facility shall exercise the contract(s) with the supplier/vendor(s) in order to have portable emergency generator(s) available within 36 hours after the loss of electrical power.(9) Fire alarm system. A fire alarm system which complies with NFPA 101, §20.3.4, and with NFPA 72, Chapter 6 requirements, shall be provided in pre-existing facilities. The required fire alarm system components are as follows.(A) A fire alarm control panel (FACP) shall be installed at a visual location such as the main lobby. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and capable of indicating both visual and audible alarm, trouble, and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.(B) Manual fire alarm pull stations shall be installed in accordance with NFPA 101, §20.3.4.(C) Smoke detectors shall be installed in supply and return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A, §6.4.2.2.(D) A fire alarm signal notification which complies with NFPA 101, §9.6.3, shall be provided to alert occupants of fire or other emergency.(E) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §20.3.4, and NFPA 72, §7.4.(F) Visual fire alarm indicating devices which comply with the requirements of NFPA 72, §7.5, shall be provided.(G) Devices for transmitting an alarm shall be provided to alert the local fire brigade or municipal fire department of a fire or other emergency. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72. Source Note: The provisions of this §509.141 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.141 Construction Requirements for a Pre-Existing Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221884 03/12/2026 (a) All buildings in which existing facilities licensed by the department are located shall comply with this subsection.(1) A facility that is licensed before the effective date of these rules is considered to be a pre-existing or existing facility and shall continue, at a minimum, to meet the licensing requirements under which it was originally licensed.(2) Existing licensed facilities shall meet the requirements for Existing Ambulatory Health Care Occupancies contained in Chapter 21 of the 2003 editions of the National Fire Protection Association 101, Life Safety Code, (NFPA 101). All documents published by NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. NFPA documents are also available for public inspection during regular working hours at the offices of Architectural Review Group, Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.(3) In lieu of meeting the requirements in paragraph (1) of this subsection, an existing licensed facility may, instead, comply with National Fire Protection Association (NFPA) 101, Life Safety Code, 2003 Edition (NFPA 101), Chapter 21, Existing Ambulatory Health Care Occupancies.(b) All major remodeling, renovations, additions and alterations to an existing facility shall be completed in accordance with the requirements for new construction in §131.143 of this title (relating to Construction Requirements for a New Facility). All areas of an existing facility that is not part of the a major remodel, renovation, addition or alteration to the facility, are not required to meet these new construction requirements as long as the existing portion met the rules and codes that were in effect when it was originally constructed and licensed. When existing conditions make such changes impractical, the department may grant a conditional approval of minor deviations from the requirements of §131.143 of this title, if the intent of the requirements is met and if the care, safety and welfare of patients will not be jeopardized. The operation of the facility, accessibility of individuals with disabilities, and safety of the patients shall not be jeopardized by a condition(s), which is not in compliance with this chapter.(1) Any alteration, modification, replacement, or installation of new building equipment (such as mechanical, electrical, emergency power equipment, energy/utility management, conveying systems, plumbing, fire protection, or other equipment) with a primary function of building service that affects life safety, infection control, changes the functional operation, or the health, safety, and welfare of patients and staff shall comply with the requirements for new construction and shall not be replaced, materially altered, or extended in an existing facility until complete plans and specifications have been submitted to the department, and the department has reviewed and approved the plans and specifications in accordance with §131.146 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(2) Minor remodeling or alterations within an existing facility which do not involve alterations to load bearing members and partitions, change functional operation, affect fire safety, or involve any of the major changes listed in paragraph (1) of this subsection are considered minor projects and require evaluation and approval by the department. A facility shall submit by mail or fax a written request and floor plan for evaluation, a brief description of the proposed changes, and sketches of the area being remodeled. Based on such submittal, the department shall evaluate and determine whether any additional submittals or inspections are required. The department shall notify the facility of its decision. Patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition would not require submission to the department for approval.(3) All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, or affect fire safety are considered major projects. A facility shall comply with this section before beginning construction of major projects.(A) Plans shall be submitted in accordance with this section for all major remodeling or alterations.(B) Phasing of construction in existing facilities.(i) Projects involving alterations of or additions to existing buildings shall be programmed and phased so that on-site construction shall minimize disruptions of existing functions.(ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants shall not be jeopardized during construction.(iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.(iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.(v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas which shall continue as long as construction dust and odors are present.(vi) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building during patient treatment times.(vii) When construction occurs after hours or on weekends, the facility shall thoroughly clean all areas of construction and provide a clean safe environment before treating patients. The facility shall ensure all fire safety protection and building systems are in place and working properly.(c) A previously licensed facility which has been vacated or used for other purposes shall comply with all the requirements for new construction contained in §131.143 of this title in order to be licensed. Source Note: The provisions of this §509.142 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.142 Construction Requirements for an Existing Facility for Construction Completed after September 1, 2010 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221885 03/12/2026 (a) Any proposed new facility shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as a facility which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients.(1) A facility shall have at least two exits remotely located in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2003 Edition (NFPA 101), §20.2.4.1. When a required means of egress from the facility is through another portion of the building, that means of egress shall comply with the requirements of NFPA 101 which are applicable to the occupancy of that other building. Such means of egress shall be open, available, unlocked, unrestricted, and lighted at all times during the facility hours of operation. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101 or (800) 344-3555. NFPA documents are also available for public inspection during regular working hours at the offices of Architectural Review Group, Texas Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199.(2) Hazardous locations.(A) A new facility or an addition to an existing facility shall not be constructed within 150 feet of easement boundaries or setbacks of hazardous underground locations including but not limited to liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not within the easement of high voltage electrical lines. Municipality's main natural gas lines in right-of ways serving dwellings and gas lines on property servicing gas meter(s) under this provision are not consider natural high pressure lines.(B) A new facility and an addition to an existing facility shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants.(3) Undesirable locations.(A) In lieu of local codes, a new facility shall not be located closer than 1500 feet to nuisance producing industrial sites, feed lots, sanitary landfills, or manufacturing plants producing excessive noise or air pollution.(B) Flood plains.(i) When a new facility is constructed in a designated 100-year flood plain, the building finished floor elevation shall be one foot above the set base flood plain elevation. The building shall meet all local flood code ordinances and local flood control requirements.(ii) To obtain a license as a facility, a previously licensed facility and an existing building or a portion of an existing building located in a designated 100-year flood plain shall meet the requirement of clause (i) of this subparagraph.(iii) Facility required functional components shall be constructed above the designated flood plain in a new addition to an existing facility located in a designated 100-year flood plain. The new addition shall meet the requirement of clause (i) of this subparagraph.(iv) Currently licensed facilities located within a designated 100-year flood plain are exempted from these requirements for renovations and repairs.(b) The facility site shall include paved roads, walkways, and parking in accordance with the requirements set out in this subsection.(1) Paved roads and walkways.(A) Paved roads shall be provided within lot lines for access from public roads to the main entrance and to service entrances.(B) Finished surface walkways shall be provided for pedestrians. When public transportation or walkways serve the site, finished surface walkways or paved roads shall extend from the public conveyance to the building entrance.(2) Parking and disability requirements.(A) Off-street parking shall be available for visitors, employees, and staff. Parking structures directly accessible from a facility shall be separated with two-hour fire rated noncombustible construction. When used as required means of egress for facility occupants, parking structures shall comply with National Fire Protection Association 88A, Standard for Parking Structures, 2002 edition. This requirement does not apply to freestanding parking structures.(B) In the absence of local code, one parking space shall be provided for each staff member on duty, plus one space for each three treatment or examination stations, one space for each three diagnostic rooms and one visitor's space for every five treatment/exam/diagnostic stations/rooms. Parking facilities shall be increased accordingly when the size of existing facilities is increased.(C) When on-street parking is available and acceptable to the local authorities having jurisdiction, the numbers of parking spaces may be reduced accordingly and shall meet the requirement of subparagraph (B) of this paragraph.(D) Special considerations benefiting disabled staff, visitors, and patients shall be provided. Each facility shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities or 16 TAC, §68.20 (relating to Buildings and Facilities Subject to Compliance with the Texas Accessibility Standards), Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under the Texas Architectural Barriers Act, Government Code, Chapter 469.(c) Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, the facility shall be constructed in accordance with the International Building Code, 2003 edition, published by the International Code Council, 500 New Jersey Avenue, Northwest, 6th Floor, Washington, District of Columbia 20001-2070, (888) 422-7233.(1) All new construction, including conversion of an existing building to a facility or establishing a separately licensed facility within another existing building, shall comply with NFPA 101, Chapter 20, New Ambulatory Health Care Occupancies, of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), and Subchapters F and G of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Construction documents shall be submitted to the department in accordance with §131.146 of this title (relating to Preparation, Submittal, Review and Approval of Plans, and Retention of Records).(A) Construction types for multiple building occupancy.(i) When a facility is part of a larger building which complies with NFPA 101, §20.1.6, Minimum Construction Requirements for (fire resistance) construction type, the designated facility shall be separated from the remainder of the building with a minimum of one-hour fire rated construction.(ii) When a facility is located in a multistory building of two or more stories, the entire building shall meet the construction requirements of NFPA 101, §20.1.6.3. A facility shall not be located in a multistory building which does not comply with the minimum construction requirements of NFPA 101, §20.1.6.3.(iii) When a facility is part of a one-story building that does not comply with the construction requirements of NFPA 101, §20.1.6.2, the facility shall be separated from the remainder of the building with a 2-hour fire rated construction. The designated facility portion shall have the construction type upgraded to comply with NFPA 101, §20.1.6.2.(B) Special provisions shall be made in the design of a facility if located in a region where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, or floods.(2) A facility shall provide a physical environment that protects the health, safety, and welfare of patients, personnel, and the public.(3) The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists.(4) Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter.(5) Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, safety to health and welfare of individuals, and safety to those prescribed by this subchapter, provided technical documentation which demonstrates equivalency is submitted to the department for approval.(6) Separate freestanding buildings for non-patient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed and constructed in accordance with other occupancy classifications requirements listed in NFPA 101.(d) Spatial requirements.(1) Administration and public areas.(A) A primary entrance shall be located at grade level and be accessible to individuals with disabilities, and protected against inclement weather with a canopy from the point of passenger loading and unloading to the building entrance. The canopy shall at least extend over the passenger side of the vehicle to minimally protect the patient from inclement weather.(B) A main lobby shall be located at the primary entrance and shall include a reception and information counter or desk, waiting space(s), private interview space/alcove, public toilet facilities located convenient to the lobby/waiting area, public telephones, drinking fountain(s), bottled water or water cooler, and storage room or alcove for wheelchairs. Private interview space/alcove may be omitted if all interviews are conducted in treatment or exam rooms.(C) General office(s) space shall be provided for business transactions, medical and financial records, and administrative and professional staff on site or off site.(D) Storage. Storage room or closet for office equipment and supplies shall be provided and located outside of the patient treatment areas.(E) When a facility is fully digitalized, an IT closet shall be provided for computer servers. When the facility is not fully digitalized, the facility shall provide an area for storage of clinical records which is separate from patient treatment and diagnostic areas, and shall be secured from unauthorized access.(2) Emergency entrance and signage.(A) A separate ambulance entrance at grade level shall be well-illuminated, identified by sign(s), and protected from inclement weather. The ambulance entry shall have a drive under canopy for protection from inclement weather. The primary and ambulance entry to permit discharge of patients from automobiles and ambulances shall be paved. Parking shall be provided near and convenient to the pedestrian primary entrance.(B) Emergency entry signage. An emergency sign shall be provided at the entry from the public road(s) or street(s) serving the site. The emergency sign at the entry to the site shall be illuminated and connected to the emergency essential electrical system. Additional sign(s) on-site may be required to direct patients to the emergency treatment area entrance when the emergency treatment area is not visible from the site entry. The letters on the entry sign shall be red or white with a contrasting background, all capitalized, at least eight inches in height, and include an arrow indicating direction.(C) A facility that is not in continuous operation 24 hours per day and 7 days per week shall display clearly visible signage at the main entry and ambulance entry points of the facility. The signage letter size shall be readable and not smaller than half an inch in height. The signage shall provide the information required under §131.22(c) of this title (relating to Classifications of Facilities).(D) A facility that is not in continuous operation shall comply with the requirements under §133.22(d) of this title.(3) Emergency suite.(A) Control station/nurse station shall be located to permit staff observation and control of access to treatment room(s), exam rooms, pedestrian and ambulance entrances, and public waiting area(s). Video cameras may be substituted for direct visual observation for pedestrian and ambulance entrances, and public waiting area(s). The nurse station shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls. The counter height shall not exceed 42 inches. The nurse station may be combined with or include centers for reception and communication.(B) When a dedicated triage space/room is provided, it shall include a counter with a hand washing fixture with hands-free operable controls.(C) Charting and dictation space for physician's space may be in a separate room or alcove or control station/nurse station. Suitable space shall be provided when computers are used for the clinical records.(D) As a minimum requirement, all facilities shall provide at least one emergency treatment room to handle emergencies. The room(s) and facilities shall meet the following requirements.(i) The emergency treatment room for a single patient shall have a minimum clear area of 120 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 10 feet. The emergency treatment room shall contain cabinets, work counter, examination light, and a hand washing fixture with hands-free operable controls.(ii) When a multiple-bed emergency treatment room is provided, the clearance between the side of a bed/gurney and a wall/partition shall be a minimum of four feet. The clearance between the sides of beds/gurneys shall be a minimum of six feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or ten feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between two beds/gurneys. The multiple-bed emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table (5), Diagram (A) of §131.148(e) of this title (relating to Tables).(iii) One hand washing fixture with hands-free operable controls shall be provided for each bed/gurney location. One hand washing fixture may serve two beds/gurneys if distributed appropriately between the two.(iv) Storage space shall be provided within the room or suite and be under staff control for general medical-surgical emergency supplies and medications. Adequate space shall be provided for emergency equipment such as emergency treatment trays, ventilator, defibrillator, splints, cardiac monitor, etc.(E) As a minimum requirement, all facilities shall provide at least one exam room. The room(s) and facilities shall meet the following requirements.(i) The exam room for a single patient shall have a minimum clear area of 100 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 9 feet. The examination room shall contain cabinets, work counter, examination light, and a hand washing fixture with hands-free operable controls.(ii) When a multiple-bed exam room is provided, the clearance between the side of the bed/gurney and a wall/partition shall be a minimum of 3 feet. The clearance between sides of the beds/gurneys shall be a minimum of 6 feet. The minimum distance at the foot of the bed/gurney shall not be less than seven feet for single load area/room or 10 feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between 2 beds/gurneys. The multiple-bed examination room shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 5, Diagram (B) of §131.148(e) of this title. Provisions shall be made for visual privacy between multiple stations.(iii) One hand washing fixture shall be provided for every four beds/gurneys or fraction thereof. Fixtures shall be uniformly distributed and not located within the exam area behind the curtains.(F) Storage space shall be provided within the emergency suite and be under staff control for general medical emergency supplies and medications. Adequate space shall be provided for emergency equipment such as emergency treatment trays, ventilator, defibrillator, splints, cardiac monitor, etc.(G) A medical staff work area and charting area(s) shall be provided. The area may be combined with the control station/nurse station.(H) An area or alcove located out of traffic and convenient to the treatment and exam room(s) shall be provided for an emergency crash cart.(I) An alcove shall be provided for stretcher and wheelchair storage. The storage shall be located out of the line of traffic.(J) A nourishment station shall be provided containing a work counter with sink, microwave, refrigerator and storage cabinets and not located in the clean workroom.(K) When provided, an ice machine supplying ice for therapeutic purposes shall be located in the clean utility room. A self-dispensing ice machine shall be provided for ice for human consumption and located in a clean utility room or the nurse station.(L) Patient toilet room(s) shall be provided and shall be convenient to treatment rooms, examination rooms, and trauma rooms a hand washing fixture with hands-free operable controls. Patient toilet room shall be at a ratio of 1 toilet room for every 5 treatment, exam, trauma stations or fraction thereof.(M) A clean storage room shall be provided for clean supplies and linens as needed. A hand washing fixture shall be provided within the room with hands-free operable controls.(N) Soiled workroom shall be provided and contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles.(O) A housekeeping room containing a floor receptor or service sink and storage space for housekeeping supplies and equipment shall be provided for the exclusive use of the emergency suite and shall be directly accessible from the emergency suite. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided. When there is only one housekeeping room for the entire facility there shall be policies and procedures in place, as describe in §131.55 of this title (relating to Sanitary Conditions and Hygienic Practices) for proper use of cleaning up body fluids versus general cleaning, and the use of separate equipment and supplies.(P) Staff toilets may be outside the suite but shall be convenient for staff use and include hand washing fixtures with hands-free operable controls. When a department has 4 or more treatment or examination rooms, toilet facilities shall be in the suite.(4) Trauma Treatment rooms. When provided, a trauma room it shall comply with the following.(A) A trauma room shall be 250 square feet of clear floor area exclusive of aisles and fixed and moveable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 12 feet. The trauma room shall contain a work counter, cabinets, and examination light.(B) When multiple-patient trauma stations are provided, the clearance between the head of the bed/gurney to the wall/partition shall be a minimum of 3 feet. The clearance between the side of a bed/gurney and a wall/partition shall be a minimum of 6 feet. The clearance between the sides of beds/gurneys shall be a minimum of 12 feet. The minimum distance at the foot of the bed/gurney shall not be less than 7 feet for single load area/room or 10 feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between 2 beds/gurneys. The multiple-bed trauma room shall contain cabinets, medication storage, work counter, examination light, and scrub sink with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this subparagraph are illustrated in Table 5, Diagram (C) of §131.148(e) of this title. Provisions shall be made for visual privacy between multiple stations.(C) A scrub station shall be located within five feet of the either inside or outside entrance to each trauma room. One scrub station may serve two trauma beds/gurneys. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts. The scrub sinks shall be recessed out of the main line of traffic.(D) All doorway openings from the ambulance entrance to the trauma room shall be a minimum of five feet wide.(5) Holding or observation room/area.(A) When a holding or observation room/area is provided within or adjacent to the emergency suite, it shall comply with the following.(B) A single holding/observation room shall have a minimum clear area of 100 square feet exclusive of fixed and movable cabinets and shelves. The holding/observation room shall contain a work counter and hand washing fixture with hands-free operable controls.(i) The single holding/observation room shall be near the nurse station and near a patient toilet room which contains a hand washing fixture with hands-free operable controls.(ii) In a multiple-bed holding/observation room/area, the clearance between the side of the bed/gurney and a wall/partition shall be a minimum of 3 feet. The clearance between sides of the beds/gurneys shall be a minimum of 6 feet. The minimum distance at the foot of the bed/gurney shall not be less than 7 feet for single load area/room or 10 feet for double load area/room. Four feet of the passage space at the foot of the bed may be shared between 2 beds/gurneys. The multiple-bed holding/observation room/area shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. One hand washing fixture shall be provided for every 4 holding/observation beds or fraction thereof. Fixtures shall be uniformly distributed. The fixed and moveable cabinets and shelves shall not encroach upon the bed/gurney clear floor space/area. The requirements of this clause are illustrated in Table 5, Diagram (B) of §131.148(e) of this title.(iii) In a multiple-bed holding/observation room/area, a patient toilet room with a hand washing fixture with hands-free operable controls shall be provided within the room or area.(C) When a multiple-bed gurney holding or observation room is not within or adjacent to the emergency suite, the following additional spaces shall be provided:(i) A stretcher and wheelchair storage alcove/room shall be provided. The alcove/room for stretcher and wheelchair storage shall be located out of the line of traffic.(ii) A clean storage room shall be provided within or adjacent to the holding or observation room. The clean storage room shall be provided for clean supplies and linen as needed. A hand washing fixture shall be provided with hands-free operable controls.(iii) Soiled workroom. A soiled workroom shall be provided within or adjacent to the holding or observation room. The workroom shall contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles. The soiled workroom required in support of a treatment/exam room may be combined with the holding or observation room/area if confidently located between the 2 areas.(6) Medication work room or alcove. A medication work room or alcove shall be provided and located separate from patient and public areas and under the direct supervision of staff. A work counter, refrigerator, medication storage, and locked storage for biologicals and drugs shall be provided. A hand washing fixture with hands-free operable controls shall be located in the medication work room or alcove. Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of carafes, etc.(A) Functional space shall be provided and areas required for records, reports, and accounting activities.(B) Space for the poison control center shall be provided with storage facilities for reaction data and drug information centers.(7) Diagnostic radiographic (X-ray). A diagnostic radiographic (X-ray) room shall be provided and be readily available to the emergency suite. The diagnostic radiographic (X-ray) room size shall be in compliance with the manufacturer's recommendations. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment. Dressing room(s) shall be provided and located near the X-ray room.(8) Computed tomography (CT) scanning. A CT room shall be provided and be readily available to the emergency suite. Clearance and unobstructed space shall not be less than three feet on each side of the diagnostic equipment. The CT room(s) size shall be in compliance with the manufacturer's recommendations and shall contain the following.(A) A control room shall be provided with a view window permitting view of the patient. The control room shall be located to allow convenient film processing.(B) A patient toilet room shall be provided conveniently to the procedure room. When directly accessible to the scan room, the toilet room shall be arranged so that a patient may leave the toilet room without having to reenter the scan room. The toilet room shall have a hand washing fixture with hands-free operable controls.(9) Laboratory services. Laboratory suite shall be provided with the following minimum facilities.(A) The laboratory work room(s) shall include counter(s), space appropriately designed for laboratory equipment, and sink(s) with hands-free operable controls.(B) Each laboratory room or work area shall be provided with a hand washing fixture(s) with hands-free operable controls.(C) General storage, including refrigeration for reagents, standards, supplies, and stained specimen microscope slides, etc. shall be provided. Separate facilities shall be provided for such incompatible materials as acids and bases, and vented storage shall be provided for volatile solvents.(D) A refrigerator or other similar equipment shall be provided for specimen storage waiting for transfer to off-site testing.(E) Specimen room/area for blood collection shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands-free operable controls shall be provided for specimen collection. This facility may be outside the laboratory suite if conveniently located.(F) When chemical safety is a requirement, an emergency shower and eye flushing devices shall be provided.(G) Flammable or combustible liquids, when used, shall be stored in approved containers, in accordance with National Fire Protection Association 30, Flammable and Combustible Liquids Code, 2003 edition.(H) When radioactive materials are employed, safe storage facilities shall be provided.(I) Each laboratory unit shall meet the requirements of Chapter 11 of NFPA 99 (relating to Laboratories), and Chapter 20 of NFPA 101 (relating to New Ambulatory Health Care Occupancies).(10) Isolation room. The need for an airborne infection isolation room in the emergency suite shall be determined by the governing body and the infection risk assessment.(A) When the facility provides treatment rooms to perform procedures on persons who are known or suspected of having an airborne infectious disease, these procedures shall be performed in a designated emergency airborne infection isolation treatment rooms and meeting airborne infection isolation ventilation requirements. The isolation room shall meet the ventilation requirements contained in Table 1 of §131.148(a) of this title.(B) The emergency airborne infection isolation treatment room for a single patient shall have a minimum clear area of 120 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 10 feet. The emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls.(C) The emergency airborne infection isolation room shall be provided with an enclosed anteroom. The enclosed anteroom shall open to directly into the emergency airborne infection isolation treatment room. The enclosed anteroom shall have facilities for hand washing, gowning, and storage of clean and soiled materials. One enclosed anteroom may serve multiple isolation rooms.(D) The door from the enclosed anteroom to the emergency airborne infection isolation room shall be provided with a self-closing device.(E) Pressure differential monitors or air flow devices shall be installed outside the isolation room and anteroom. Devices shall be installed in corridors, passageways, etc.(11) Secured holding room. When provided, this room shall be constructed to allow for security, patient and staff safety, patient observation, and sound mitigation. The secure holding room shall have a minimum clear area of 100 square feet clear floor area exclusive of fixed cabinets. The minimum clear room dimension exclusive of fixed cabinets shall be 10 feet.(12) Orthopedic and cast room. When provided, the room(s) may be in separate room(s) or in the trauma room. The room(s) shall contain a work counter, storage for splints and orthopedic supplies, traction hooks, medication storage, examination light, and a hand washing fixture with hands-free operable controls. When a cast room is provided it shall be equipped with hand washing facilities, storage, and other provisions required for cast procedures.(13) Film processing room. When a radiographic (X-ray) room is provided, a darkroom for processing film shall be provided unless the processing equipment does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the darkroom.(14) Housekeeping room. Sufficient number of janitor's closets shall be provided throughout the facility to maintain a clean and sanitary environment. The closet shall contain a floor receptor or service sink and storage space for housekeeping supplies and equipment. When there is only 1 housekeeping room for the entire facility there shall be policies and procedures in place, as describe in §131.55 of this title for proper use of cleaning up body fluids versus general cleaning, and the use of separate equipment and supplies.(15) Medical waste. Space and facilities shall be provided for the safe storage and disposal of medical waste as appropriate for the material being handled and in compliance with all applicable federal, state, or local laws, codes, rules, regulations and ordinances.(16) Decontamination room.(A) When a decontamination room is provided, the exterior entry point shall be far as practical from any other entry point to the emergency treatment area.(B) The internal door from the decontamination room shall open directly to the corridor into the emergency treatment area.(C) The door shall swing into the room and be lockable against ingress from the corridor.(D) The room shall be a minimum of 80 square feet of clear floor area with a hand washing fixture with hands-free operable controls.(E) The decontamination room shall be equipped with 2 hand-held showerheads with temperature controls and a dedicated holding tank with a floor drain.(F) The decontamination room floor shall be self-coved to a height of 6 inches. The room shall have all smooth, nonporous, scrubable, nonabsorbent and nonperforated surfaces.(17) Supply rooms.(A) A storage room/area for breakdown of supplies shall be provided. The storage room/area shall have adequate space for breakdown of prepackaged supplies to be loaded on cart(s) to transport to the appropriate storage spaces. The breakdown area shall not reduce the clear unobstructive width in the egress corridor.(B) Sterile/clean supply room. A sterile/clean supply room shall be provided. Storage of sterile/clean supplies shall not occur within the breakdown room.(C) An equipment storage room shall be provided. The equipment room may be in the emergency suite.(18) Laundry and linen may be processed within the facility or off site at a commercial laundry.(A) When on-site linen processing is provided, soiled and clean processing operations shall be separated and arranged to provide a one-way traffic pattern from soiled to clean areas. The following rooms and items shall be provided:(i) a soiled linen processing room that includes areas for receiving, holding, sorting, and washing;(ii) a clean linen processing room that includes areas for drying, sorting, folding, and holding before distribution;(iii) supply storage cabinets in the soiled and clean linen processing rooms;(iv) hand washing sink within the soiled linen processing room; and(v) a storage room for clean linen. Clean linen storage may be combined with the clean work room.(B) When linen is processed off site, the following areas shall be provided:(i) clean linen shall be stored within the clean supply area; and(ii) soiled linen shall be stored in a designated space in the facility.(19) Employee facilities. An employee suite shall be provided containing lockers, a lounge, and staff toilets for employees and volunteers. The toilet room(s) may be unisex.(20) Engineering suite and equipment areas shall be provided.(A) An engineer's office/area with file space and provisions for protected storage of facility drawings, records, manuals, etc. .(B) A general maintenance shop(s) for repair, maintenance, supplies and equipment. An area for medical equipment which includes provisions for the storage, repair, and testing of electronic and other medical equipment.(C) When necessary, a separate room or building for yard maintenance equipment and supplies. When a separate room is within the physical plant, the room shall be located so that equipment may be moved directly to the exterior. Yard equipment or vehicles using flammable liquid fuels shall not be stored or housed within the facility.(D) Sufficient space shall be provided in all mechanical and electrical equipment rooms for proper maintenance of equipment. Provisions shall also be made for removal and replacement of equipment.(E) Additional areas or room(s) for mechanical and electrical equipment shall be provided within the physical plant or installed in separate buildings or weatherproof enclosures with the following exceptions.(i) An area shall be provided for cooling towers and heat rejection equipment when such equipment is used.(ii) An area for the medical gas park and equipment shall be provided. For smaller medical gas systems, the equipment may be housed in a room within the physical plant in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, 2002 edition (NFPA 99), Chapters 4 and 8.(iii) When provided, compactors, dumpsters, and incinerators shall be located in an area remote from public entrances.(e) General detail requirements. Details in new construction projects, including additions and alterations, shall comply with this subsection, with NFPA 101, Chapter 20, and with local building codes.(1) Fire safety features, including smoke compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with NFPA 101, Chapter 20. The Fire Safety Evaluation System for Health Care Occupancies contained in the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 2001 Edition, Chapter 3, shall not be used in new building construction, renovations, or additions to existing facilities.(2) Exits, corridors and doors.(A) A facility shall provide 2 exits remote from each other in accordance with NFPA 101, §20.2.4.1. At least 1 exit door shall be accessible by an ambulance from the outside. This door may also serve as an entry for loading or receiving goods.(B) Encroachment into the means of egress. Such items as drinking fountains, telephone booths or stations, and vending machines shall not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment, when stored, shall not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(C) Corridors.(i) The minimum clear and unobstructed width of a public corridor shall be at least 4 feet.(ii) The communicating corridor shall be used to convey patients by stretcher, gurney, or bed.(iii) The communicating corridor shall link the treatment room/area, exam room/area, and holding room/area and shall be continuous to at least 1 exit.(iv) The minimum clear and unobstructed width of the communicating corridor shall be 6 feet.(D) Doors at all openings between corridors and rooms or spaces subject to occupancy shall be swing type. Elevator doors are excluded from this requirement.(E) Doors, except doors to spaces such as small closets which are not subject to occupancy, shall not swing into corridors in a manner that might obstruct traffic flow or reduce the required corridor width. Large walk-in type closets are considered as occupiable spaces.(F) The minimum width of doors for patient access to treatment, examination, diagnostic, and imaging rooms requiring access for beds and gurneys shall be 3 feet 8 inches.(G) Emergency access rooms containing a restroom, intended for patient use, shall be provided with at least one door having hardware which will permit access from the outside in any emergency. Door leaf width of such doors shall not be less than 36 inches.(H) Horizontal sliding doors serving an occupant load of fewer than 10 shall be permitted. The area served by the door shall have no high hazard contents. The door shall be readily operable from either side without special knowledge or effort. The force required to operate the door in the direction of door travel shall be not more than 30 pounds per foot to set the door in motion, and shall be not more than 15 pounds per foot to close the door or open in the minimum required width. The door assembly shall comply with any required fire protection rating, and, where rated, shall be self-closing or automatic closing. The sliding doors opening to the egress corridor doors shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. The sliding doors shall be installed to resist passage of smoke and may have breakaway provisions. The latching sliding panel shall have a minimum clear opening of 36 inches in the fully open position. The fixed panels may have recessed tracks.(I) All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 Edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(3) Glazing for glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101, §18.3.3.(4) Grab bars shall be provided at patient toilets and showers. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars intended for use by the disabled shall also comply with ADA requirements.(5) Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free controls shall be provided in each examination, treatment, trauma, diagnostic, imaging, holding/observation room/area, soiled utility room, clean work room, and toilet room. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be conveniently located for staff use in rooms and areas noted under spatial requirements in subsection (d) of this section and throughout the center where patient care services are provided.(6) A liquid or foam soap dispenser shall be located at each hand washing facility.(7) Provisions for hand drying shall be included at all hand washing facilities. Hot air dryers or individual paper or cloth units shall be enclosed to provide protection against dust or soil and shall provide single-unit dispensing.(8) A sign shall be posted at the entrance to each toilet/restroom to identify the facility for public, staff, or patient use.(9) Emergency eyewash shall be provided conveniently located within the emergency suite for staff use and comply with ANSI Z358.1.(10) The minimum ceiling height shall be eight feet six inches with the following exceptions.(A) Rooms containing ceiling-mounted light fixtures or equipment. Trauma rooms or other rooms containing ceiling-mounted light fixtures or equipment shall have a ceiling height of not less than 9 feet. Additional ceiling height may be required to accommodate special fixtures or equipment.(B) Ceilings in storage rooms, toilet rooms, and other minor rooms shall be not less than 7 feet 6 inches.(C) Boiler rooms shall have ceiling clearances not less than 2 feet 6 inches above the main boiler header and connecting piping.(D) Overhead clearance for suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.(11) Areas producing impact noises like recreation rooms, exercise rooms, and similar spaces shall not be located directly over trauma or treatment rooms/area unless special provisions are made to minimize noise.(12) Rooms containing heat-producing equipment, such as mechanical and electrical equipment and laundry rooms, shall be insulated and ventilated to prevent floors of any occupied room located above it from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature.(13) When the entire facility is provided with digital imaging system capabilities, a minimum of 2 X-ray film illuminators viewers shall be provided in a central location.(14) Radiation shielding shall be designed, tested, and approved by a medical physicist licensed under the Medical Physics Practice Act, Occupations Code, Chapter 602. The facility shall obtain a certificate of registration issued by the Radiation Safety Licensing Branch to use radiation machines.(f) General finish requirements. Finishes in new construction projects, including additions and alterations, shall comply with this subsection, with NFPA 101, Chapter 20, and with local building codes.(1) Privacy screens, cubicle curtains, and draperies.(A) Cubicle curtains or privacy screens shall be provided to assure patient privacy when required or requested by a patient.(B) Cubicle curtains, draperies and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small-scale and the large-scale tests of National Fire Protection Association 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 Edition. Copies of laboratory test reports for installed materials shall be submitted to the department at the time of the final construction inspection.(2) Flame spread, smoke development and noxious gases. Flame spread and smoke developed limitations of interior finishes shall comply with Table 4 of §131.148(d) of this title and NFPA 101, §10.2. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition, and National Fire Protection Association 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 2001 Edition, shall be provided.(3) Floor finishes.(A) Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet (such as shower and bath areas and similar work areas) shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes:(i) painted concrete for mechanical, electrical, communication rooms, and janitor's closets;(ii) vinyl and vinyl composition tiles and sheets tiles for offices, lobbies, administrative areas, storage, staff and public toilet rooms, support spaces, and non-treatment areas. The joints shall be sealed to prevent moisture penetration between the joints and under the tile;(iii) monolithic or seamless flooring shall be provided for all treatment rooms/areas, exam rooms/areas, patient toilet rooms, and soiled workrooms. Seamless flooring shall be impervious to water, coved and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles. The base shall not be less then six inches in height. Welded joint flooring is acceptable;(iv) marble, ceramic and quarry tile for offices, lobbies, staff and public toilet rooms, administrative areas, wet areas, and similar spaces;(v) carpet flooring for offices, lobbies, and administrative areas. Carpeting shall not be installed in any holding rooms, toilet rooms, treatment rooms, examination rooms, diagnostic, imaging, and similar spaces; and(vi) terrazzo for offices, lobbies, administrative areas, and similar spaces.(B) Thresholds at doorways shall not exceed 3/4-inch in height for exterior sliding doors or 1/2-inch for other type doors. Raised thresholds and floor level changes at accessible doorways shall be beveled with a slope no greater than 1:2. Expansion joint covers shall not exceed 1/2-inch in height and shall have beveled edges with a slope no greater than 1:2.(4) Wall finishes. Wall finishes in patient exam, treatment, or diagnostic rooms, toilet rooms, soiled work room, clean work/storage rooms, and laboratory, shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall be in compliance with the requirements of NFPA 101, §38.3.3, relating to flame spread.(A) Wall finishes shall be water-resistant in the immediate area of plumbing fixtures.(B) Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed, and without voids.(5) Ceiling finishes. All occupied rooms and spaces shall be provided with finished ceilings, unless otherwise noted. Ceilings which are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing. Three types of ceilings that are required in various areas of the facility are:(A) ordinary ceilings are required in all areas or rooms in the facility unless otherwise noted. This includes ceilings such as acoustical tiles installed in a metal grid which are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners;(B) washable ceilings that dictate this type of cleaning or protection for these spaces (such as soil utility or soil workroom). The ceilings shall be made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid; and(C) monolithic ceilings which are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices, and with a washable and moisture impervious finish shall be provided in the airborne isolation rooms, soiled workrooms, trauma rooms, and sterilizing facilities when provided.(D) Nonfinished ceilings may be omitted in mechanical, electrical, communication rooms, shops, and similar spaces unless required for fire-resistive purposes.(6) Floor, wall, and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits, or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed.(7) Material finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(g) General mechanical requirements. This subsection contains requirements for mechanical systems; air conditioning, heating and ventilating systems; steam and hot and cold water systems; and thermal and acoustical insulation.(1) Cost. All mechanical systems shall be designed for overall efficiency and life cycle costing, including operational costs. Recognized engineering practices shall be followed to achieve the most economical and effective results except that in no case shall patient care or safety be sacrificed for conservation.(2) Equipment location. Mechanical equipment may be located indoors, outdoors when in a weatherproof enclosure, or in a separate building(s).(3) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators.(4) Performance and acceptance. Prior to completion and acceptance of the facility to the owner/operator, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or their representative that the installation and performance of these systems conform to the requirements of the plans and specifications.(A) Upon completion of the contract, the facility owner/operator shall obtain from the construction contractor parts lists and procurement information with numbers and descriptions for each piece of equipment.(B) Upon completion of the contract, the facility owner/operator shall obtain from the construction contractor instructions in the operational use and maintenance of systems and equipment as required.(5) Heating, ventilating, and air conditioning (HVAC) systems.(A) All central HVAC systems shall comply with and shall be installed in accordance with the requirements of NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 Edition, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, 2002 Edition, as applicable and the requirements contained in this paragraph. Air handling units serving two or more rooms are considered to be central units.(B) Noncentral air handling systems, i.e., individual room units that are used for heating and cooling purposes (e.g., fan-coil units, heat pump units, and packaged terminal air conditioning units) shall be equipped with permanent (cleanable) or replaceable filters. The filters shall have an average efficiency of 25 - 30% and an average arrestance of 85% based on American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air Cleaning Devices for Removal Efficiency by Particle Size. These units shall be used as air recirculating units only. All outdoor air requirements shall be met by a separate central air handling system with the proper filtration, as required in Table 1 of §131.148(a) of this title.(C) General ventilation requirements. All rooms and areas in the facility shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 1of §131.148(a) of this title shall be used only as minimum requirements, since they do not preclude the use of higher rates that may be appropriate.(i) To reduce utility costs, facility design may utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shutdown, or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied. In no case shall patient care be jeopardized.(ii) Mechanical systems shall be arranged to take advantage of outside air conditions by using an economizer cycle when appropriate to reduce heating and cooling systems loads. Innovative design that provides for additional energy conservation while meeting the intent of this section for acceptable patient care may be presented to the department for consideration.(iii) Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all patient care areas, storage rooms, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas, shall not be permitted. All ductwork access panels shall be labeled.(iv) The designed capacity of the HVAC systems shall be capable of providing the ranges of temperatures and humidities as shown in Table 1 of §131.148(a) of this title. Where no values are noted or indicated, the indoor design temperature in all other areas shall be between 68 and 75 degrees Fahrenheit with relative humidity of not less than 30%.(v) Each trauma room shall have temperature and humidity indicating devices mounted at eye level.(vi) Outside air intake locations.(I) Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum system outlets, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require other arrangements.)(II) Plumbing and vacuum vents that terminate 5 feet above the level of the top of the air intake may be located as close as 10 feet to the air intake.(III) The bottom of outside air intakes serving central systems shall be located as high as practical but at least 6 feet above ground level, or if installed above the roof, 3 feet above the roof level.(vii) Contaminated air exhaust outlets from areas (laboratory hoods, etc.) that exhaust contaminated air shall be above the roof and be arranged to exhaust upward unless the air has been treated by an appropriate means where sidewall exhaust will be allowed.(viii) All toilet exhaust ventilation shall be exhausted to the exterior. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation.(ix) Directional air flow. Ventilation systems shall be designed and balanced to provide pressure relationships contained in Table 1 of §131.148(a) of this title. Provisions in Note 4 of Table 1 of §131.148(a) of this title shall be followed for the reductions and shut down of ventilation systems when a room is unoccupied.(x) Air distribution devices. Turbulence and other factors of air movement to minimize airborne particulate matter shall be considered in the design of air distribution devices. Where extraordinary procedures require special designs, the installation shall be reviewed on a case-by-case basis.(I) All supply diffusers grilles shall be located on the ceiling or on a wall within four inches from the ceiling.(II) Air supply for the treatment rooms/areas, exam rooms/areas, and trauma rooms/areas shall be from ceiling outlets near the center of the work area to efficiently control air movement.(III) A minimum of two return air inlets located diagonally opposite from one another and near floor level shall be provided. Bottoms of the wall mounted return air grilles in trauma and other anesthetizing locations shall be at least four inches above the floor.(xi) The air handling units (AHU) shall not be started or operated without the filters installed in place, including. This includes the 90% efficiency filters where required. This includes during construction operations. Ducts shall be cleaned thoroughly and throughout by a National Air Duct Cleaners Association (NADCA) certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, the department shall require a written report assuring cleanliness of duct and clean air quality.(xii) When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Duct work with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct takeoffs shall be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used.(xiii) All air handling units shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 2 of §131.148(b) of this title. Filter efficiencies shall be average dust spot efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers. All documents published by ASHRAE as referenced in this section may be obtained by writing or calling the ASHRAE, Inc. at the following address or telephone number: ASHRAE, 1791 Tullie Circle, Northeast, Atlanta, Georgia 30329; telephone (404) 636-8400.(I) Filtration for air handling units serving single rooms requiring asepsis control. Dedicated air handlers serving only one room where asepsis control is required (such as, but not limited to trauma rooms/areas, treatment rooms/areas, exam rooms/areas) shall be equipped with filters having efficiencies equal to, or greater than, those specified for patient care areas in Table 2 of §131.148(b) of this title.(II) Filtration requirements for air handling units serving other single rooms. Dedicated air handlers serving all other single rooms shall be equipped with nominal filters installed at the return air system.(III) Location of multiple filters. Where 2 filter beds are required by Table 2 of §131.148(b) of this title, filter bed number one shall be located upstream of the air conditioning equipment, and filter bed number 2 shall be downstream of the supply air blowers, cooling and heating coils.(IV) Where only 1 filter bed is required by Table 2 of §131.148(b) of this title, it shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork.(V) Pressure monitoring devices. A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more, including laboratory hoods requiring high efficiency particulate air (HEPA) filters. The pressure monitoring device shall be mounted below the ceiling line within the facility such that it can be observed by staff.(D) Thermal and acoustical insulation for air handling systems. Asbestos containing insulation materials shall not be used.(i) Air ducts and casings with outside surface temperature below the ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation.(ii) When installed, linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories (UL), Standard 181, relating to Factory-Made Duct Materials and Air Duct Connectors, April 4, 1996 edition. This document may be obtained from the Underwriters Laboratories, 333 Pfingsten Road, Northbrook, Illinois 60062-2096.(iii) Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A, Chapters 4 and 5 and as determined by an independent testing laboratory in accordance with NFPA 255, A Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition.(iv) Duct lining and acoustical traps exposed to air movement shall not be used in ducts serving any trauma rooms, treatment rooms, examination rooms, holding areas, clean room, and critical care areas. This requirement shall not apply to mixing boxes and acoustical traps that have approved nonabrasive coverings over such linings.(v) Insulation of soft and spray-on types shall not be used where subject to air currents or mechanical erosion or where loose particles may create a maintenance problem or occupant discomfort.(vi) Internal linings shall not be used in ducts, terminal boxes, or other air system components supplying all patient care areas. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(E) Ventilation for anesthetizing locations. When anesthesia is administered, ventilation for anesthetizing locations, as defined in NFPA 99, §3-3, shall comply with NFPA 99, §13.4.1.2 and any specific ventilation requirements of clauses (i) - (iii) of this subparagraph.(i) Smoke removal systems for anesthetizing locations. Smoke removal systems shall be provided in all windowless anesthetizing locations in accordance with NFPA 99, §6.4.1.2. Supply and exhaust systems for windowless anesthetizing locations shall be arranged to automatically exhaust smoke and products of combustion, prevent recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intakes, without in either case interfering with the exhaust function of the system.(ii) Smoke removal systems for surgical suites. Smoke removal systems shall be provided in all surgical suites in accordance with NFPA 99, §6.4.1.3.(iii) Smoke exhaust grilles. Exhaust grilles for smoke evacuation systems shall be ceiling-mounted or wall-mounted within 12 inches of the ceiling.(F) Location of return and exhaust air devices. The bottoms of wall-mounted return and exhaust air openings shall be at least 4 inches above the floor. Return air openings located less than 6 inches above the floor shall be provided with nominal filters. All exhaust air openings and return air openings located higher than 6 inches but less than 7 feet above the floor shall be protected with grilles or screens having openings through which a 1/2-inch sphere will not pass.(G) Ray protection. Ducts which penetrate construction intended for X-ray or other ray protection shall not impair the effectiveness of the protection.(H) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a required 2-hour or higher fire-rated wall or floor in accordance with the requirements of NFPA 101, §18.5.2.(I) Smoke damper requirements. Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101, §20.3.7.3, and NFPA 90A, Chapter 5.(i) Combination fire and smoke leakage limiting dampers (Class II) shall be installed in accordance with manufacturer's instructions for all ducts penetrating one and two-hour rated fire and smoke partitions required by NFPA 101, §20.3.7, Subdivision of Building Space (not required in facility meeting the provisions of NFPA 101, §20.3.7.2, Exception Number 1).(ii) Combination smoke and fire dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by National Fire Protection Association 72, National Fire Alarm Code, 2002 Edition (NFPA 72), Chapter 8; NFPA 90A, Chapter 6; and NFPA 101, §20.3.5; the fire sprinkler system; and upon loss of power. Smoke dampers shall not close by fan shutdown alone unless it is a part of an engineered smoke removal system.(iii) Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts.(iv) Use of frangible devices for shutting smoke dampers is not permitted.(J) Acceptable damper assemblies. Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose shall be acceptable.(K) Duct access doors. Unobstructed access to duct openings in accordance with NFPA 90A, §4.3, shall be provided in ducts within reach and sight of every fire damper, smoke damper and smoke detector. Each opening shall be protected by an internally insulated door which shall be labeled externally to indicate the fire protection device located within.(L) Restarting controls. Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided that provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices.(M) Make-up air. If air supply requirements in Table 1 of §131.148(a) of this title do not provide sufficient air for use by exhaust hoods and safety cabinets, filtered make-up air shall be ducted to maintain the required air flow direction in that room. Make-up systems for hoods shall be arranged to minimize short circuiting of air and to avoid reduction in air velocity at the point of contaminant capture.(h) Piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code Illustrated published by the National Association of Plumbing-Heating-Cooling Contractors (PHCC), 2003 edition, and this paragraph. The National Standard Plumbing Code may be obtained by writing or calling the PHCC at the following address or telephone number: Plumbing-Heating-Cooling Contractors, P.O. Box 6808, Falls Church, Virginia 22046; telephone (800) 533-7694.(1) Piping systems.(A) Water supply piping systems. Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Domestic water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(i) Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture.(ii) Backflow preventers (vacuum breakers) shall be installed on hose bibs, laboratory sinks, janitor sinks, bedpan flushing attachments, and all other fixtures to which hoses or tubing can be attached. Connections to high hazard sources, e.g., X-ray film processors, shall be from a cold water hose bib through a reduced pressure principle type backflow preventer (RPBFP).(iii) Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.(iv) Water heating equipment shall have sufficient capacity to supply water for all clinical needs based on accepted engineering practices using actual number and type of fixtures and for heating, when applicable.(v) Hot water distribution system serving all patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet.(vi) Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment. Hot water temperature at point of use for patients, staff, and visitors shall be in the range of 105 to 120 degrees Fahrenheit.(vii) When potable water storage tanks (hot and cold) are used, the water shall be used and replenished. Domestic water storage tank(s) shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. Water shall not be stored in tanks for future use unless the water is tested weekly for contaminates/bacteria.(viii) Purified water distribution system piping shall be task specific and include, but not necessarily be limited to, polypropylene (PP), polyvinylidene fluoride (PVDF) or polyvinyl chloride (PVC) pipe. Final installed purified water system piping assemblies shall be UL approved and fully comply with applicable American Society for Testing and Materials (ASTM) Fire Resistant/Smoke Density requirements. The applicable documents are available from ASTM International, 100 Barr Harbor Drive, P.O. Box C700, West Conshohocken, Pennsylvania 19428-2959.(ix) Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In any renovation work, dead-end piping shall be removed. Empty risers, mains and branches installed for future use are permitted.(B) Fire sprinkler systems. When provided, fire sprinkler systems shall comply with the requirements of NFPA 101, §9.7, Automatic Sprinklers and Other Extinguishing Equipment, and the requirements of this subparagraph. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, and shall be certified as required by §131.147(c)(1)(C) of this title (relating to Construction, Inspection, and Approval of Project).(C) Piped nonflammable medical gas and clinical vacuum systems. Piped nonflammable medical gas and clinical vacuum system shall be designed, installed, and certified in accordance with the requirements of NFPA 99, §5.1 for Level 1 Piped Systems and the requirements of this subparagraph.(i) Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 3 of §131.148(c) of this title.(ii) Medical gas piping systems including source tanks and related piping shall be installed only by, or under the direct supervision of, a holder of a master plumber license or a journeyman plumber license with a medical gas piping installation endorsement issued by the Texas State Board of Plumbing Examiners.(iii) Prior to closing of walls, the installer shall perform an initial pressure test, a blowdown test, a secondary pressure test, a cross-connection test, and a purge of the piping system as required by NFPA 99.(iv) Qualifications verification testing shall be performed and inspected by a party, other than the installer, installing contractor, or material vendor. Testing shall be conducted by a medical gas system verifier registered with an acceptable organization by this department and is technically competent and experienced in the field of medical gas and vacuum pipeline testing and meets the requirements of The American Society of Safety Engineers (ASSE) Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems. The document published by ASSE Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems as referenced in this rule may be obtained by writing or calling The American Society of Safety Engineers (ASSE) at ASSE International Office, 901 Canterbury, Suite A, Westlake, Ohio 44145, telephone (440) 885-3040.(v) Upon completion of the installer inspections and tests and after closing of walls, verification tests of the medical gas piping systems, the warning system, and the gas supply source shall be conducted. The verification tests shall include a cross-connection test, valve test, flow test, piping purge test, piping purity test, final tie-in test, operational pressure tests, and medical gas concentration test.(vi) Verification testing of the medical gas piping systems and the warning systems shall be performed on all new piped medical gas systems, additions, renovations, or repaired portions of an existing system. All systems that are breached and components that are added, renovated, or replaced shall be inspected and appropriately tested. The breached portions of the systems subject to inspection and testing shall all be of the new and existing components in the immediate zone or area located upstream of the point or area of intrusion and downstream to the end of the system or a properly installed isolation valve.(vii) Verification tests of piped medical gas systems shall include tests of the source alarms and monitoring safeguards, master alarm systems, and the area alarm systems.(viii) Source equipment verification tests. Source equipment verification tests shall include medical gas supply sources (bulk and manifold) and the compressed air source systems (compressors, dryers, filters, and regulators).(ix) Before new piped medical gas systems, additions, renovations, or repaired portions of an existing system are put into use, facility medical personnel shall be responsible for ensuring that the gas delivered at the outlet is the gas shown on the outlet label and that the proper connecting fittings are checked against their labels.(x) Upon successful completion of all verification tests, written certification for affected piped medical gas systems and piped medical vacuum systems including the supply sources and warning systems shall be provided by a party technically competent and experienced in the field of medical gas pipeline testing stating that the provisions of NFPA 99 have been adhered to and systems integrity has been achieved. The written certification shall be submitted directly to the facility and the installer. A copy shall be available at final department construction inspection.(xi) Documentation of the installed, modified, extended or repaired medical gas piping system shall be submitted to the department by the same party certifying the piped medical gas systems. The number and type of medical gas outlets (e.g., oxygen, vacuum, medical air, nitrogen, nitrous oxide) shall be documented and arranged tabularly by room numbers and room types.(D) Main storage of medical gases may be outside or inside the facility in accordance with NFPA 99, §5.1. Provision shall be made for additional separate storage of reserve gas cylinders necessary to complete at least one day's procedures.(E) Multiple gas outlets on one medical gas outlet. Y-connections, "twinning," or other similar devices shall not be used on any medical gas outlet.(2) Steam and hot water systems.(A) Boilers. When provided, the boilers shall have the capacity, based upon the net ratings as published in The I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of GAMA, to supply the normal heating, hot water, and steam requirements of all systems and equipment. The document published by the Hydronics Institute Division of GAMA as referenced in this rule may be obtained by writing or calling the Hydronics Institute Division of GAMA at 35 Russo Place, P.O. Box 218, Berkeley Heights, New Jersey 07922, telephone (908) 464-8200.(i) Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.(ii) Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment.(B) When required, the facility shall ensure compliance with Texas Department of Licensing and Regulation, Boiler Section, Texas Boiler Law (Health and Safety Code, Chapter 755, Boilers), which requires certification documentation for boilers to be posted on site at each boiler installation.(3) Building sewers shall discharge into a community sewage system. Where such a system is not available, a facility providing sewage treatment shall conform to applicable local and state regulations.(A) Above ground piping. Soil stacks and roof drains installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or Schedule 40 polyvinyl chloride (CPVC) pipe.(B) All underground building drains shall be cast iron soil pipe, hard temper copper tube (DWV schedule 40 or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe, or PVC, VCP, CPVC pipe. Underground piping shall have at least 12 inches of earth cover or comply with local codes. Existing buildings or portions of buildings that are being remodeled need not comply with this subparagraph.(C) Separate drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant borosilicate glass pipe, high silicone content cast iron pipe, polypropylene plastic pipe, or plastic lined pipe.(D) Drainage and waste piping shall not be installed above or below ceilings in trauma rooms/areas and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Secondary protection shall be required to drain. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(4) Thermal insulation for piping systems and equipment. Asbestos containing insulation materials shall not be used.(A) Insulation shall be provided for the following:(i) boilers, smoke breeching, and stacks;(ii) steam supply and condensate return piping;(iii) hot water piping and all hot water heaters, generators, converters, and storage tanks;(iv) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; and(v) other piping, ducts, and equipment as necessary to maintain the efficiency of the system.(B) Insulation flame spread. Flame spread shall not exceed 25 and smoke development rating shall not exceed 50 for pipe insulation as determined by an independent testing laboratory in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 Edition.(5) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive, acid-resistant materials and shall comply with the requirements of the National Standard Plumbing Code, and this paragraph.(A) Sink and lavatory controls. All lavatories used by medical and nursing staff and by patients shall be trimmed with valves or electronic controls which can be operated without the use of hands. Blade handles used for this purpose shall not be less than 4 inches in length. Single lever or wrist blade devices may also be used.(B) Clinical sink traps. Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.(C) Back-flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(D) Drinking fountain. Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination.(E) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent contamination of the water supply and the entrance of contaminating materials into the sterilizing units.(F) Hose attachment. No hose shall be affixed to any faucet if the end of the hose may become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker.(G) Bedpan washers and sterilizers. When provided, bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(H) Flood level rim clearance. The water supply spouts for lavatories and sinks required in patient care areas shall be mounted so that their discharge points are a minimum of 5 inches above the rim of the fixture.(I) Scrub sink controls. Freestanding scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or electronic hands-free controls. Single lever wrist blades are not acceptable at scrub sinks.(J) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages.(K) Under counter piping. Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of the floor below the equipment.(L) Ice machines. All ice-making machines used to provide ice for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines.(i) General electrical requirements. This subsection contains common electrical and essential emergency system requirements.(1) Electrical requirements. All electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the NFPA 70, National Electrical Code, 2002 Edition, §517; NFPA 99, Chapter 14; the requirements of this subsection, and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturer's instructions.(A) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(B) Extension cords and cables shall not be used for permanent wiring.(C) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(D) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70.(E) Under counter electrical installations shall be arranged (raised) to not interfere with floor cleaning below the equipment.(2) Installation testing and certification.(A) Installation testing. The electrical installations, including grounding continuity, fire alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional. A written record of performance tests on special electrical systems and equipment shall show compliance with applicable codes and standards and shall be available to the department upon request.(B) Grounding system testing. The grounding system shall be tested as described in NFPA 99, §4.3.3, for patient care areas in new or renovated work. The testing shall be performed by a qualified electrician or their qualified electrical testing agent. The electrical contractor shall provide a letter stating that the grounding system has been tested in accordance with NFPA 99, the testing device use complies with NFPA 99, and whether the grounding system passed the test. The letter shall be signed by the qualified electrical contractor, or their designated qualified electrical testing agent, certifying that the system has been tested and the results of the test are indicated.(3) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(4) Services and switchboards. Electrical service and switchboards serving the required facility components shall be installed above the designated 100-year flood plain. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire-rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures.(5) Panelboard. Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits shall be located on each floor that has major users (treatment rooms/areas, exam rooms/areas, trauma rooms/areas, etc.) and may also serve the floor above and the floor below. Panelboards serving life safety branch circuits may serve 3 floors, the floor where the panelboard is located, and the floors above and below.(6) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in metal or metallic raceways in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of 7 feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300.(7) Mechanical protection of the emergency system. The wiring of the emergency system shall be mechanically protected by installation in nonflexible metal raceways in accordance with NFPA 70, §517.30(C)(3).(8) Lighting.(A) Lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IESNA) Handbook, 2000 edition, published by the IESNA, 120 Wall Street, Floor 17, New York, New York 10005.(i) Light intensity and wavelength control to prevent harm to the patient's eyes shall be considered.(ii) Approaches to buildings and parking lots, and all spaces within buildings shall have fixtures that can be illuminated as necessary. All rooms and spaces including storerooms, electrical and mechanical equipment rooms, and attics shall have sufficient artificial lighting for clear visibility.(iii) The special needs of the elderly shall be considered. The facility shall minimize excessive contrast in lighting levels that makes effective sight adaptation difficult.(B) Means of egress and exit sign lighting intensity shall comply with NFPA 101, §§7.8, 7.9, and 7.10.(C) Electric lamps, which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(D) Ceiling mounted surgical and examination light fixtures shall be suspended from rigid support structures mounted above the ceiling.(E) Trauma rooms/areas shall have general lighting in addition to local lighting provided by special lighting units at the procedure tables. Each fixed special lighting unit at the tables, except for portable units, shall be connected to an independent circuit.(F) X-ray film illuminators for handling at least two films simultaneously shall be provided in each trauma room/area and treatment room/area. When the entire emergency suite is provided with digital imaging system capabilities, a minimum of two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the emergency suite.(9) Receptacles. Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in the trauma, treatment, exam, diagnostic, imaging rooms, and all patient care areas. This does not apply to special purpose receptacles.(A) Installations of multiple-ganged receptacles shall not be permitted in all patient care areas.(B) Electrical outlets powered from the critical branch shall be provided in all patient care areas, diagnostic, imaging, procedure and treatment locations in accordance with NFPA 99, §4.4.2.2.2.3. At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel. All receptacles powered from the critical branch shall be colored red.(C) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be replaced or installed with receptacles of the same distinct color as the existing receptacles.(D) All receptacles connected to the essential electrical system shall be identified. The face plate for the receptacle(s) shall have a nonremovable label or be engraved indicating the panel and circuit number.(E) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(F) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor in accordance with NFPA 70, §517-13.(G) Each treatment, examination, and trauma room in the emergency suite shall have a minimum of 6 duplex electrical receptacles located convenient to the head of each procedure table. All other walls shall have a minimum of at least 1 receptacle.(H) Each work table or counter shall have access to 1 duplex receptacle for every 6 feet of table or counter space or fraction thereof. Each work counter and table shall have at least 1 duplex receptacle connected to the critical branch of the emergency electrical system.(I) A minimum of one duplex receptacle in each wall shall be installed in each work area or room other than storage or lockers.(J) Appliances shall be grounded in accordance with NFPA 99, Chapter 9.(K) Ground fault circuit interrupters (GFCI) receptacles shall be provided for all general use receptacles located within 3 feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch used for equipment that should not be interrupted do not require GFCI protection. Receptacles in wet locations, as defined by NFPA 70, §§517.20 and 517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.(10) Equipment.(A) The following shall be powered from the Type II essential electrical system in accordance with the requirements of NFPA 99, §3.4.2.2.3, when such a system is required for safe operation of the facility referenced in paragraph (14) of this subsection.(i) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected to the equipment system.(ii) Ventilating system serving trauma, treatment and exam rooms, shall be connected to the equipment system in accordance with the requirements of NFPA 99, Chapter 3.(B) A "kill switch" shall be provided for disconnection of each HVAC serving the building in accordance with the requirements of NFPA 90A, §6.2.1.(11) Wet patient care location. Wet patient care locations shall be protected against shock in accordance with the requirements of NFPA 99, §4.3.2.2.9.1.(12) Grounding requirements. Fixed electrical equipment shall be grounded in accordance with the requirements of NFPA 99, §4.3.3.1, and NFPA 70, Article 517.(13) Nurses calling systems.(A) A nurse's emergency calling system shall be installed in the all treatment room/area station(s), exam rooms/area station(s), isolation room(s), patient holding stations, imaging, diagnostic and patient toilet room(s) to summon nursing staff in an emergency. Activation of the system shall sound a distinct audible signal which repeats every 5 seconds or less at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in all areas. The activation of the system shall also activate distinct visible signals in the clean workroom, soiled workroom, and if provided, in the nourishment station. The visible and audible signals shall be cancelable only at the patient calling station. A nurse's emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within 6 inches of the floor will satisfy this requirement.(B) A staff emergency assistance calling system station shall be located in each treatment room/area, examination room/area, trauma room/area, and holding room/area to be used by staff to summon additional help in an emergency. Activation of the system shall sound an audible signal at a staffed location, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the door. Additional visible signals shall be installed at corridor intersections in multi-corridor facilities. Distinct visible and audible signals shall be activated in the clean workroom, in the soiled workroom, equipment storage, and if provided, in the nourishment station.(14) Essential electrical system. The facility shall provide, at submission of construction documents/plans, a letter on facility letterhead indicating the method the facility has chosen for implementation of the emergency contingency plan for the continuity of emergency essential building systems (emergency generator). The contingency plan shall consist of one of the two options as described in subparagraphs (A) and (B) of this paragraph.(A) An onsite emergency generator shall be provided with a Type II essential electrical distribution system in accordance with requirements of NFPA 99, §4.5 (2), and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(i) An emergency generator standby power system(s) shall require an onsite fuel source and enough fuel capacity in the tank for a period of twenty-four hours or more. The facility shall execute a contract with an outside supplier/vendor(s) that will provide fuel on demand. When a vapor liquefied petroleum gas (LPG) (natural gas) system is used, the 24 hour fuel capacity on site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(ii) The emergency generator shall be installed, tested and maintained in accordance with the National Fire Protection Association 99, §4.5.4, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 2002 Edition.(iii) When the emergency generator(s) and electrical transformer(s) are located within the same area, they shall be located at least 10 feet apart.(iv) One electrical outlet connected to the life safety branch of the electrical system shall be provided adjacent to (or on) the emergency generator.(v) The battery charger for emergency lighting at the emergency generator shall be connected to the life safety branch of the electrical system.(B) An executed contract with an outside supplier/vendor(s) that will provide a portable emergency generator(s) and fuel on demand.(i) An electrical transfer switch with plug-in device sized to provide emergency power for the patient care areas and the provisions in NFPA 99, §4.5.2.2.2.(ii) An alternate source of power (battery power lighting) shall be provided separate and independent from the normal electrical power source that will be effective for a minimum of one and one half hours after loss of the electrical power. The emergency lighting system shall be capable of providing sufficient illumination to allow safe evacuation from the building. The battery pack systems shall be maintained and tested quarterly.(iii) The facility shall implement the emergency contingency plan upon the loss of electrical power following a natural weather or man-made event when the electrical power may not be restored within 24 hours. The facility shall exercise the contract(s) with the supplier/vendor(s) to have portable emergency generator(s) available within 36 hours after the loss of electrical power.(15) Fire alarm system. A fire alarm system which complies with NFPA 101, §20.3.4, and with NFPA 72, Chapter 6 requirements, shall be provided in each facility. The required fire alarm system components are as follows.(A) A fire alarm control panel (FACP) shall be installed at a visual location such as the main lobby. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and capable of indicating both visual and audible alarm, trouble, and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.(B) Manual fire alarm pull stations shall be installed in accordance with NFPA 101, §20.3.4.(C) Ceiling-mounted smoke detector(s) shall be installed in room containing the FACP when this room is not attended continuously by staff as required by NFPA 72, §4.4.5.(D) Smoke detectors shall be installed in air ducts in accordance with NFPA 72, §5.14.4.2 and §5.14.5 and NFPA 90A, §6.4.2.(E) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A, §6.4.2.2.(F) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101, §9.6.2; NFPA 13, §6.9; and NFPA 72, §8.5.3.3.3.4.(G) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72, §6.8.5.5.(H) A fire alarm signal notification which complies with NFPA 101, §9.6.3, shall be provided to alert occupants of fire or other emergency.(I) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §20.3.4, and NFPA 72, §7.4.(J) Visual fire alarm indicating devices which comply with the requirements of NFPA 72, §7.5, shall be provided.(K) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72.(L) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70, Article 760. Source Note: The provisions of this §509.143 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.143 Construction Requirements for a New Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221886 03/12/2026 (a) Elevators. All buildings that have patient services located on other than the main entrance floor shall have electric or electrohydraulic elevators. The elevators shall be installed in sufficient quantity, capacity, and speed to ensure that the average interval of dispatch time will not exceed 1 minute, and average peak loading can be accommodated. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §20.3 of the National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: P.O. Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(b) Requirements for new elevators, escalators, and conveyors. New elevators, escalators and conveyors shall be installed in accordance with the requirements of Health and Safety Code, Chapter 754, Elevators, Escalators, and Related Equipment, and A17.1 Safety Code for Elevators and Escalators, 2000 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI). All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(1) Location. Elevators shall not open to an exit.(2) Elevator car size. A facility located above the ground floor must have an elevator of sufficient size to accommodate a gurney available at all times. Minimum elevator car size shall at least 5 feet 8 inches wide by 8 feet 6 inches deep.(3) Car door opening. The smallest elevator car door opening shall be at least 3 feet wide and 7 feet high.(4) Elevator and elevator shaft doors. When light beams are used for operating door opening devices, the beams shall be used in combination with door edge devices and shall be interconnected with a system of smoke detectors. The light control feature shall be disengaged when smoke is detected in any elevator lobby.(5) Type of controls and alarms. Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.(6) Leveling. All elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of one-half inch.(7) Operation. All elevators, except freight elevators, shall be equipped with a two-way key operated service switch permitting cars to bypass all landing button calls and be dispatched directly to any floor.(8) Accessibility of controls and alarms. Elevator controls, alarm buttons, and telephones shall be accessible to wheelchair occupants in accordance with the Americans with Disabilities Act.(9) Smoke detection system. A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72, §6.15.3.10.(A) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 2000 edition. The publications of the ASME/ANSI referenced in this section may be obtained by writing ASME/ANSI, United Engineering Center, 345 East 47th Street, New York, New York 10017.(B) The elevator recall smoke detection system in existing facilities shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2002 edition.(10) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems with the capability to maintain an operating temperature during fire fighter service operations. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power. These requirements are not applicable to existing elevators.(11) Testing. A facility shall have all elevators and escalators routinely and periodically inspected and tested as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 2000 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101, §9.4.6.(12) Certification. A facility shall obtain a certificate of inspection evidencing that the elevators, escalators, conveyors, and related equipment were inspected in accordance with the requirements in Health and Safety Code, Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under Health and Safety Code, §754.014, administered by the Texas Department of Licensing and Regulation. The certificate of inspection shall be on record in each facility. Source Note: The provisions of this §509.144 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.144 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221876 03/12/2026 (a) Definitions. The following definitions apply in this section.(1) Mobile unit--Any pre-manufactured structure, trailer, or self-propelled unit equipped with a chassis on wheels and intended to provide shared medical services to the community on a temporary basis. Some of these units are equipped with expanding walls and designed to be moved on a daily basis.(2) Relocatable unit--Any structure, not on wheels, that is built to be relocated at any time and provide medical services. These structures vary in size.(3) Transportable unit--Any pre-manufactured structure or trailer, equipped with a chassis on wheels, intended to provide shared medical services to the community on an extended temporary basis. These units are designed to be moved periodically, depending on need.(b) General. When mobile, transportable and relocatable units are utilized to provide patient treatment services on the facility premises, these units shall be treated as buildings and constructed to the required occupancy as follows.(1) When such units are provided for diagnostic, imaging, treatment or procedural services to patients who are litter borne, under general anesthesia, or incapable of self-preservation, the unit shall be constructed in accordance with Chapter 20 of the National Fire Protection Association 101, Life Safety Code, 2003 edition (NFPA 101), relating to health care occupancy, published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: P.O. Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(2) When such units provide diagnostic, imaging, treatment, or procedural services to patients who are not litter borne, not under general anesthesia, and are capable of self-preservation, the unit may be constructed in accordance with Chapter 38 of NFPA 101 (relating to Business Occupancy).(c) Common elements.(1) Site requirements.(A) Sites shall have a level concrete or asphalt pad and be designed for the structural loads of the unit.(B) The sites shall provide hazard-free drop-off zones and adequate parking for patients. The site and location of the unit shall not restrict access for fire or emergency vehicles.(C) Each site shall provide access to the unit for the handicapped, and wheelchair and stretcher patients.(D) The location of the unit shall be such that engine exhaust fumes from the unit are kept away from any fresh air intake of the facility.(E) When a mobile, transportable, or relocatable unit does not move on a regular basis, i.e. every 90 days and the facility provides diagnostic and imaging services, the facility shall provide a permanent connected enclosure appropriately for the climate from the facility to the unit. These types of units shall be provided with the following equipment and systems physically connected to the facility:(i) fire alarm system;(ii) sprinkler system;(iii) electrical system and the essential electrical system;(iv) water and waste water system;(v) medical gas systems; and(vi) nurses calling systems.(2) Support services. Support services shall meet the requirements of this chapter for new construction. These support services and areas shall be provided either within the mobile, transportable, or relocatable unit or located within the facility adjacent to the unit served. Source Note: The provisions of this §509.145 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.145 Mobile, Transportable, and Relocatable Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221877 03/12/2026 (a) General.(1) Facility owners or operators shall not begin construction of a new building, additions to, or renovations, or conversions of existing buildings until the department approves final construction documents.(2) Plans and specifications describing the construction of new buildings, and additions to, or renovations, and conversions of existing buildings shall be prepared by registered architects and/or licensed professional engineers and meet the requirements of this subchapter.(3) The names of spaces used in the functional program narrative, preliminary documents, final construction documents, and specifications shall be consistent with the names of the spaces used in this chapter.(4) The department shall notify the facility owner or operator of the result of its review of each type of submission discussed in this section.(5) The facility owner or operator shall respond to all department requests for additional information, including providing a plan of correction for deficiencies cited by the department.(6) Once final construction documents are approved, the facility owner or operator shall request inspections in accordance with §131.147 of this title (relating to Construction, Inspection, and Approval of Project).(7) When construction is delayed or put on hold for longer than one year from the plan approval or self-certification approval date, construction documents shall be resubmitted to the department for review and approval. The plans shall be accompanied by a new application for plan review and functional program narrative.(8) The facility owner or operator shall provide written notification to the department when a project has been placed on hold, canceled, or abandoned.(9) The department may close a project file after one year of assigning an application number to a project if the project has been placed on hold.(b) Submission of projects and assignment of application number.(1) The facility owner, operator, or representative shall submit the following items to the department in care of the mailing or overnight delivery address that appears on the application for plan review:(A) a completed and signed application for plan review. The application for plan review may be obtained by calling the department or by visiting the department's website at www.dshs.state.tx.us/hfp;(B) a functional program narrative in accordance with subsection (d) of this section; and(C) final construction documents in accordance with subsection (f) of this section.(2) The cost of submitting documents/plans and specifications shall be borne by the sender.(3) Once the department has determined that the submission required in paragraph (1) of this subsection is complete, the department shall assign an application number to the project that shall be referenced on all documents and correspondence related to the project. Final construction documents shall be reviewed in the chronological order received.(4) All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.(5) Construction shall not begin until the facility owner or operator of the facility receives written notification from the department that the final construction documents have been approved.(c) A facility owner, operator, or representative may request a feasibility conference. A feasibility conference is an informal meeting between a member of the department's architectural review group staff and the facility owner, operator, or representative to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes.(1) A feasibility conference is not a substitute for plan review.(2) A facility owner, operator, or representative may schedule a feasibility conference by calling the department.(3) The facility owner, operator, or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents.(4) The facility owner, operator, or representative is responsible for recording conference notes and shall submit the notes to the department.(d) The facility owner or operator shall submit a functional program narrative to the department with each new project in accordance with subsection (b)(1)(B) of this section. The functional program narrative shall be presented on facility letterhead, signed by facility administration, include the functional description of each space, and the following:(1) departmental relationships, number of patient stations, and other basic information relating to the fulfillment of the facility's objectives;(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features;(3) energy conservation measures, included in building, mechanical, and electrical designs;(4) a description of the type of asepsis control in diagnostic and treatment areas; and(5) the type of construction (existing or proposed) as stated in §20.1.6 of National Fire Protection Association 101, Life Safety Code, 2003 Edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, (800) 344-3555.(e) The department may request preliminary documents. If requested by the department, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, and the usage of all spaces, areas, and rooms on every floor level.(f) Final construction documents and specifications shall be submitted to the department for review and approval before the start of construction. All final documents and specifications shall be appropriately sealed and signed by the project registered architect and professional engineer(s) licensed by the State of Texas.(1) The facility owner or operator shall submit to the department for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.(2) Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, shall include all necessary explanatory notes, schedules, and legends, and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 Edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than 1/8-inch equals 1 foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural drawings shall include the following:(i) a map of the area within a 500 foot radius of the facility site shall be provided and any hazardous and undesirable location noted in §131.143(a) of this title (relating to Construction Requirements for a New Facility) shall be identified;(ii) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided;(iii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces;(iv) schedules of doors, windows, and finishes;(v) elevations of each facade;(vi) sections through building; and(vii) scaled details as necessary.(B) Fire safety plan drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plan drawings shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than 1/16-sixteenth inch equals 1 foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire-resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided;(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced, and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location and fire-resistance rating (one or two-hour) of each smoke partition, location, type and fire-resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.(C) Equipment drawings shall include the following:(i) all equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility;(ii) fixed equipment (equipment which is permanently affixed to the building or which shall be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term fixed equipment includes items such as laundry extractors, communication systems, and built-in casework (cabinets);(iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term moveable equipment includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and(iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g., corridor, patient room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, gas outlets;(v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems);(vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment);(vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and(viii) laboratory exhaust and safety cabinets.(F) Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections;(ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches and equipment which require permanent electrical connections, on plans of each building level:(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and(II) outlets marked distinctly to indicate connection to critical, life safety, or normal power circuits;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generator(s), transfer switch(es), emergency system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities. Feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses emergency calling system, or staff emergency assistance calling system);(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices, and the room number where each device is located; and(vi) schedules of all panels indicating connection to emergency system or normal system, and connected load at each panel.(3) Any changes to the final construction documents which affect or change the function, design, or designated use of an area shall be submitted to the department for approval prior to authorization of the modifications.(g) Special submittals.(1) Self-certification.(A) In an effort to shorten the plan review and approval process, the facility owner, operator, or representative may request approval of final construction documents under the self-certification review process.(i) The owner or operator shall submit the items in subsection (b)(1)(A) - (C) of this section and a completed self-certification form, signed by the facility owner or operator, architect of record, and engineer(s) of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter.(ii) By signing and submitting the self-certification form, the facility owner or operator accepts the following conditions.(I) The department retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval.(II) The facility owner or operator has a continuing obligation to make any changes the department requires to comply with the licensing rules, whether or not physical plant construction or alterations have been completed.(III) The facility owner or operator is ultimately responsible for compliance with the Act and this chapter.(B) The department shall review the request for self-certification and notify the facility owner or operator if the request is approved or denied. If denied, the department shall review the final construction documents in the chronological order in which the documents were received. Construction shall not begin until the final construction documents have been reviewed and approved.(2) If a facility owner or operator believes that a proposed project is a minor project, the facility owner or operator shall provide to the department a brief written description of the proposed project and floor plans of the areas of work. The minor project request shall be mailed or faxed.(A) If it is determined that the proposed project is a minor project, the department shall notify the facility owner or operator of the approval, and state the number of inspections that shall be required. A minimum of one inspection shall be conducted.(B) The department shall notify the facility owner or operator that a proposed project is not approved as a minor project, if the project involves any of the following:(i) remodeling or alterations which involve alterations to load bearing members or partitions;(ii) a change in functional operation;(iii) affects fire safety (e.g., modifications to the fire, smoke, and corridor walls);(iv) adds services for which the facility is not currently licensed; and(v) significantly changes the mechanical, electrical, plumbing, or fire protection.(C) The facility owner or operator shall submit final construction documents in accordance with subsection (f) of this section if the department determines the project is not a minor project.(3) Fire sprinkler systems.(A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the facility owner or operator shall submit to the department for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents.(B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 2002 Edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(i) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13, §§14.1, 14.2 and 14.3, for new fire sprinkler systems, alterations of and additions to existing ones.(ii) One set of fire sprinkler working plans, calculations, and water supply information shall be forwarded to the department together with the professional engineer's (P.E. licensed in the State of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation.(iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(h) Retention of drawings, manuals, and design data.(1) Upon occupancy of the building or portion thereof, the owner shall retain as part of the facility's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.(2) Upon completion of the contract, the owner shall retain as part of the facility's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shal1 also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.(3) The owner shall retain in the facility's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation. Source Note: The provisions of this §509.146 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.146 Preparation, Submittal, Review and Approval of Plans, and Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221878 03/12/2026 (a) Construction.(1) Construction, other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate licensing fee has been paid, and the department has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) The architect of record or the facility owner or operator shall provide written notification to the department when construction will commence. The department shall be notified in writing of any change in the completion schedules.(3) Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) All facilities, including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code, §§1395 et seq.), are subject to construction inspections.(1) A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with Subchapters F and G of this chapter (relating to Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively) and the approved plans and specifications. The final plan approval letter shall inform the architect of record and the owner as to the minimum number of inspections required for the project.(2) The architect of record or the facility owner or operator shall request an inspection by submitting, at least three weeks in advance of the requested inspection date, an application for inspection for each intermediate inspection, final inspection, and re-inspection requested. Inspection requests by contractors shall not be honored.(A) The architect of record or the facility owner or operator shall request an intermediate construction inspection to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate inspection; however, ceilings shall not be installed.(B) The architect of record or the facility owner or operator shall request a final construction inspection at 100% completion. One hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Depending upon the number and nature of the deficiencies cited during the final inspection, the inspector may require that a re-inspection be conducted to confirm correction of all deficiencies cited. The inspector may also require a re-inspection, if he determines that the project was not sufficiently complete to warrant a final inspection. The request for reinspection shall be submitted in accordance with paragraph (2) of this subsection.(c) Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and the department.(1) The facility owner or operator shall submit the following documents to the department before the project will be approved:(A) written approval of the project by the fire authority;(B) a certificate of occupancy for the project issued by the local building authority;(C) a copy of a letter or certification from a professional engineer (P.E.) licensed in the State of Texas indicating the fire sprinkler working plans, hydraulic calculation, the testing, and field inspection of the installation of the new or modified sprinkler system is in compliance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 Edition, if applicable. A copy of a letter or certification of changes in existing fire sprinkler system is not required, when relocation of not more than twenty sprinkler heads and hydraulic calculation is not involved;(D) fire alarm system certification (form FML-009A of the State Fire Marshal's Office), if applicable;(E) a copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2002 Edition, §4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project;(F) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. A signed letter or statement corroborating the installation of the product in the project shall be provided;(G) a copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 Edition, as required by NFPA 101, §20-7.5, and a signed letter or statement corroborating the installation of the product in the project;(H) a written plan of correction signed by the facility owner or operator for any deficiencies noted during the final inspection; and(I) any other documentation or information required or requested due to the type of the project.(2) Architectural approval.(A) If, during the final inspection, the inspector finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the inspector may grant architectural approval contingent upon the documents listed in paragraph (1)(A) - (D) of this subsection being provided to and approved by the inspector at the time of the final inspection.(B) Architectural approval allows the facility owner or operator to proceed with licensing. Patients may not be admitted nor patient services provided until a license or modified license has been issued to the facility by the department. However, the facility owner or operator shall submit the documents required in paragraph (1)(E) - (I) of this subsection before the project receives final approval.(3) Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection and receipt of an acceptable Plan of Correction of the final inspection report, the department shall issue written final approval of the project. Source Note: The provisions of this §509.147 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.147 Construction, Inspection, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221879 03/12/2026 (a) Table 1. Ventilation requirements for freestanding emergency medical care facilities. Attached Graphic(b) Table 2. Filter efficiencies for central ventilation and air conditioning systems. Attached Graphic(c) Table 3. Medical gas and vacuum systems. Stations outlets for oxygen, vacuum, and medical air systems. Attached Graphic(d) Table 4. Flame spread and smoke production limitations for interior finishes. Attached Graphic(e) Table 5. Multiple bed room configurations. Attached Graphic Source Note: The provisions of this §509.148 adopted to be effective June 1, 2010, 35 TexReg 4400; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9021. 1 HEALTH AND HUMAN SERVICES COMMISSION 509 FREESTANDING EMERGENCY MEDICAL CARE FACILITIES G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §509.148 Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222046 03/12/2026 (a) The purpose of this chapter is to implement Texas Health and Safety Code Chapter 577, which requires psychiatric hospitals and mental health facilities that provide court-ordered mental health services to be licensed by the Texas Health and Human Services Commission.(b) This chapter provides definitions, and establishes licensing procedures, operational requirements, standards for voluntary agreements, enforcement procedures, fire prevention and safety requirements, and physical plant and construction requirements for private psychiatric hospitals and crisis stabilization units.(c) Compliance with this chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, rules, regulations and ordinances. This chapter must be followed where it exceeds other codes and ordinances. Source Note: The provisions of this §510.1 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS A GENERAL PROVISIONS §510.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222047 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Action plan--A written document that includes specific measures to correct identified problems or areas of concern; identifies strategies for implementing system improvements; and includes outcome measures to indicate the effectiveness of system improvements in reducing, controlling, or eliminating identified problem areas.(2) Adverse event--An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.(3) Applicant--A person who seeks a private psychiatric hospital license or crisis stabilization unit license from the Texas Health and Human Services Commission (HHSC) and who is legally responsible for the operation of the facility.(4) Community center--A center established under Texas Health and Safety Code Chapter 534, Subchapter A.(5) Contaminated linen--Linen soiled with blood or other potentially infectious materials or linen containing sharps. Other potentially infectious materials means:(A) human body fluids such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;(B) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and(C) Human Immunodeficiency Virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV) containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.(6) Crisis stabilization unit (CSU)--A mental health facility operated by a community center or other entity designated by the local mental health authority in accordance with Texas Health and Safety Code §534.054, that provides treatment to individuals who are the subject of a protective custody order issued in accordance with Texas Health and Safety Code §574.022.(7) Dentist--A person licensed to practice dentistry by the Texas State Board of Dental Examiners. This includes a doctor of dental surgery or a doctor of dental medicine.(8) Dietitian--A person who is currently licensed by the Texas Department of Licensing and Regulation as a licensed dietitian or provisional licensed dietitian or who is a registered dietitian with the American Dietetic Association.(9) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance use disorder) such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:(A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;(B) serious impairment to bodily functions;(C) serious dysfunction of any bodily organ or part; or(D) with respect to a pregnant woman who is having contractions:(i) that there is inadequate time to effect a safe transfer to another hospital before delivery; or(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.(10) Facility--A private psychiatric hospital or a crisis stabilization unit.(11) Facility administration--Administrative body of a facility headed by an individual who has the authority to represent the facility and who is responsible for the operation of the facility according to the policies and procedures of the facility governing body.(12) Fast-track project--A construction project for which it is necessary to begin initial phases of construction before later phases of the construction documents are fully completed in order to establish other design conditions or because of time constraints.(13) Governing body--The governing authority of a facility responsible for the facility's organization, management, control, and operation, including appointment of the medical staff. This term includes the owner or partners for facilities owned or operated by an individual or partners.(14) Governmental unit--A political subdivision of the state, including a hospital district, county, or municipality, and any department, division, board, or other agency of a political subdivision.(15) HHSC--The Texas Health and Human Services Commission.(16) Hospital--A private psychiatric hospital.(17) Inpatient services--Services provided to a patient admitted to a hospital for an intended length of stay of 24 hours or more.(18) Licensed vocational nurse--An individual who is currently licensed as a licensed vocational nurse (LVN) by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301.(19) Licensee--A person or governmental unit who has been granted a private psychiatric hospital license or crisis stabilization unit license.(20) Medical staff--Licensed physicians and other licensed practitioners permitted by law and by the facility to provide medical care independently in the facility.(21) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate persons who have a mental illness.(22) Mental illness--An illness, disease, or condition, other than epilepsy, dementia, substance use disorder, or intellectual disability that:(A) substantially impairs a person's thought, perception of reality, emotional process, or judgment; or(B) grossly impairs behavior as demonstrated by recent disturbed behavior.(23) Minor--A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.(24) Mobile unit--Any pre-manufactured structure, trailer, or self-propelled unit equipped with a chassis on wheels and intended to provide shared medical services to the community on a temporary basis. Some of these units are equipped with expanding walls and designed to be moved on a daily basis.(25) Outpatient services--Services provided to patients whose medical needs can be met in less than 24 hours and are provided within the facility.(26) Owner--One of the following persons who will hold or does hold a license issued under Texas Health and Safety Code Chapter 577, in the person's name or the person's assumed name:(A) a corporation;(B) a governmental unit;(C) a limited liability company;(D) an individual;(E) a partnership if a partnership name is stated in a written partnership agreement or an assumed name certificate;(F) all partners in a partnership if a partnership name is not stated in a written partnership agreement or an assumed name certificate; or(G) all co-owners under any other business arrangement.(27) Patient--An individual who is receiving mental health services under this chapter.(28) Person--An individual, firm, partnership, corporation, association, joint stock company, joint venture, or local authority, and includes a receiver, trustee, assignee, or other similar representative of those entities.(29) Pharmacist--A person who is licensed to practice pharmacy by the Texas State Board of Pharmacy in accordance with Texas Occupations Code Chapter 558.(30) Physician--An individual who is:(A) licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code Chapter 155; or(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board.(31) Plan of correction--A documented and directed response to any compliance issue identified in a report provided to the facility by HHSC staff after a facility inspection or investigation, which is required to state how and when any compliance issues identified in the report will be corrected.(32) Podiatrist--A podiatrist licensed by the Texas Department of Licensing and Regulation.(33) Political subdivision--A county, municipality, or hospital district in this state but does not include a department, board, or agency of the state that has statewide authority and responsibility.(34) Practitioner--A health care professional licensed in the state of Texas, other than a physician.(35) Premises--A premises is:(A) a single building where inpatients receive hospital services; or(B) multiple buildings where inpatients receive hospital services, provided that the following criteria are met:(i) all inpatient buildings and inpatient services are subject to the control and direction of the governing body of the hospital;(ii) all inpatient buildings are within a 30-mile radius of the main address of the licensee;(iii) there is integration of the organized medical staff of the hospital;(iv) there is a single chief executive officer who reports directly to the governing body and through whom all administrative authority flows and who exercises control and surveillance over all administrative activities of the hospital;(v) there is a single chief medical officer who reports directly to the governing body and who is responsible for all medical staff activities of the hospital; and(vi) each building that is geographically separate from other buildings contains at least one nursing unit for inpatients, unless providing only diagnostic or laboratory services, or a combination thereof, in the building for hospital inpatients.(36) Private psychiatric hospital--A hospital that provides inpatient mental health services to individuals with a mental illness or with a substance use disorder except that, at all times, a majority of the individuals admitted are individuals with a mental illness. Such services include psychiatric assessment and diagnostic services, physician services, professional nursing services, and monitoring for patient safety provided in a restricted environment.(37) Registered nurse--An individual who is licensed as a registered nurse by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301.(38) Relocatable unit--Any structure, not on wheels, built to be relocated at any time and provide medical services. These structures vary in size.(39) Stabilize--With respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or that the woman has delivered the child and the placenta.(40) Transfer--The movement (including the discharge) of an individual outside a facility at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the facility, but does not include such a movement of an individual who has been declared dead or leaves the facility without the permission of any such person.(41) Transportable unit--Any pre-manufactured structure or trailer, equipped with a chassis on wheels, intended to provide shared medical services to the community on an extended temporary basis. These units are designed to be moved periodically, depending on need.(42) Universal precautions--Procedures for disinfecting and sterilizing reusable medical devices and appropriate use of infection control, including hand washing, use of protective barriers, and use and disposal of needles and other sharp instruments as those procedures are defined by the Centers for Disease Control and Prevention (CDC) of the United States Department of Health and Human Services. This term includes standard precautions as defined by CDC which are designed to reduce the risk of transmission of blood borne and other pathogens in facilities.(43) Violation--Failure to comply with a licensing statute, rule or standard, special license provision, or order issued by HHSC adopted or enforced under the licensing statute. Each day a violation continues or occurs is a separate violation for purposes of imposing an administrative penalty. Source Note: The provisions of this §510.2 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective May 9, 2004, 29 TexReg 4159; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS A GENERAL PROVISIONS §510.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222048 03/12/2026 (a) License required.(1) A facility shall obtain a license prior to admitting patients.(2) Upon written request, the Texas Health and Human Services Commission (HHSC) shall furnish a person with an application for a private psychiatric hospital or a crisis stabilization unit license.(3) An applicant shall submit a license application in accordance with §510.22 of this subchapter (relating to Application and Issuance of Initial License). The applicant shall retain copies of all application documents submitted to HHSC.(b) Compliance.(1) A hospital shall comply with Texas Health and Safety Code (HSC) Chapter 577, this chapter, and the following rules:(A) 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(B) 25 TAC Chapter 405, Subchapter E (relating to Electroconvulsive Therapy (ECT));(C) 25 TAC Chapter 414, Subchapter I (relating to Consent to Treatment with Psychoactive Medication--Mental Health Services);(D) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services); and(E) Chapter 568 of this title (relating to Standards of Care and Treatment in Psychiatric Hospitals).(2) A Crisis stabilization unit (CSU) shall comply with HSC Chapter 577, this chapter, Chapter 306, Subchapter B of this title (relating to Standards of Care in Crisis Stabilization Units), and paragraph (1)(A)-(D) of this subsection.(c) Scope of facility license.(1) A facility license is issued for the premises and person or governmental unit named in the application.(2) A facility license shall not include outpatient services located apart from the licensed premises.(3) A facility license shall not include spaces licensed by another licensing agency.(4) Multiple facilities may share one building.(A) Each facility shall be licensed separately.(B) Spaces within the building may not be included under more than one facility license.(C) Each facility in the building shall comply with Subchapter G of this chapter (relating to Physical Plant and Construction Requirements).(5) Multiple hospitals may be licensed under one license number.(A) Hospitals must comply with the following in order to be licensed under a multiple hospital license:(i) meet the criteria for multiple buildings in the definition of premises in §510.2(35) (relating to Definitions); and(ii) when the multiple site location is a previously licensed hospital, the hospital must meet the architectural requirements contained in Subchapter G of this chapter and be approved for occupancy by HHSC's Architectural Review Unit.(B) HHSC will issue a license listing the primary hospital and all multiple location sites when the hospitals meet the requirements of subparagraph (A) of this paragraph, and the primary hospital has submitted:(i) a written request to HHSC for a multiple location application; and(ii) a completed application and licensing fee.(C) When HHSC receives a multiple location application and a change of ownership application simultaneously, HHSC will process the change of ownership application separately prior to the multiple location addendum.(d) Display. A facility shall prominently and conspicuously display the license in a public area of the licensed premises that is readily visible to patients, employees, and visitors.(e) Alteration. A facility license shall not be altered.(f) Transfer or assignment prohibited. A facility license shall not be transferred or assigned. The facility shall comply with the provisions of §510.24 of this subchapter (relating to Change of Ownership) in the event of a change in the ownership.(g) Changes which affect the license.(1) A facility shall notify HHSC in writing prior to the occurrence of any of the following:(A) addition or deletion of those services indicated on the license application;(B) changes in designed bed capacity as the phrase is used in §510.26(b)(1)(A) - (C) of this subchapter (relating to Fees);(C) request to change license classification; and(D) any construction, renovation, or modification of the facility buildings.(2) A facility shall notify HHSC in writing at the time of the occurrence of any of the following:(A) cessation of operation of the facility which shall include in the written notice the location where the medical records will be stored and the identity and telephone number of the custodian of the medical records;(B) change in certification or accreditation status; and(C) change in facility name, telephone number, or administrator. Source Note: The provisions of this §510.21 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.21 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222049 03/12/2026 (a) Application submittal. The applicant shall submit the following documents to the Texas Health and Human Services Commission (HHSC) no earlier than 60 calendar days prior to the projected opening date of the facility:(1) an accurate and complete application form;(2) a copy of the facility's patient transfer policy which is developed in accordance with §510.43 of this chapter (relating to Patient Transfer Policy) and is signed by both the chairman and secretary of the governing body attesting to the date the policy was adopted by the governing body and the effective date of the policy;(3) a copy of the facility's memorandum of transfer form which contains at a minimum the information described in §510.43(d)(10)(B) of this chapter;(4) for existing facilities, a copy of a fire safety inspection indicating approval by the local fire authority in whose jurisdiction the facility is based that is dated no earlier than one year prior to the opening date. For new construction, additions, and renovation projects, written approval by the local building department and local fire authority shall be submitted at the time of the final construction field survey by HHSC;(5) documentation of accreditation by an accrediting organization approved by the Centers for Medicare & Medicaid Services, if applicable;(6) the appropriate license fee as required in §510.26 of this subchapter (relating to Fees);(7) if the applicant is a sole proprietor, partnership with individuals as a partner, or a corporation in which an individual has an ownership interest of at least 25 percent of the business entity, the names and social security numbers of the individuals; and(8) a multiple hospital location application form for multiple hospitals to be licensed under a single license number, if applicable.(b) Additional documentation for new facilities or conversions from non-facility buildings. In addition to the document submittal requirements in subsection (a) of this section, an applicant shall complete the following prior to the issuance of a license.(1) The applicant shall submit preliminary and final architectural plans and specifications for review and approval by HHSC in accordance with Subchapter G of this chapter (relating to Physical Plant and Construction Requirements).(2) For new construction, HHSC shall conduct field surveys in accordance with Subchapter G of this chapter to determine that the facility was constructed or remodeled in accordance with this chapter.(3) When an applicant intends to reopen and license a building formerly licensed as a hospital or crisis stabilization unit, HHSC shall conduct an on-site field survey in accordance with Subchapter G of this chapter to determine compliance with applicable construction and fire safety requirements.(4) The applicant shall pay all plan review and construction field survey fees to HHSC.(5) The applicant shall obtain a certificate of occupancy approved by the local fire authority, and issued by the city building inspector, if applicable, and submit a copy to HHSC.(6) The applicant shall submit a complete and accurate Final Construction Approval form signed by facility administration to HHSC.(c) Prelicensure conference. The applicant or the applicant's representative shall attend a prelicensure conference at the office designated by HHSC. The purpose of the prelicensure conference that HHSC staff conducts is to review licensure rules and inspection documents and provide consultation before the on-site licensure inspection. HHSC may waive the prelicensure conference requirement.(d) Issuance of license. When HHSC determines the facility has complied with subsections (a)-(c) of this section, HHSC shall issue the license to the applicant.(1) Effective date. The license shall be effective on the date the facility is determined to be compliant with subsections (a)-(c) of this section. The effective date shall not be before the date of the final construction field survey conducted by HHSC.(2) Expiration date. For initial licenses issued:(A) If the effective date of the license is the first day of a month, the license expires on the last day of the 23rd month after issuance.(B) If the effective date of the license is the second or any subsequent day of a month, the license expires on the last day of the 24th month after issuance.(e) Withdrawal of application. If an applicant decides not to continue the application process for a license or renewal of a license, the applicant may withdraw the application. HHSC shall acknowledge receipt of the request to withdraw.(f) Denial of a license. Denial of a license shall be governed by §510.87 of this chapter (relating to Enforcement).(g) Inspection. During the initial licensing period, HHSC shall conduct an inspection of the facility to ascertain compliance with the provisions of Texas Health and Safety Code Chapter 577 and this chapter.(1) A facility shall request HHSC conduct an on-site inspection after the facility has admitted and provided services to one inpatient.(2) A facility shall be providing services to at least one inpatient in the facility at the time of the inspection.(3) If a hospital has applied to participate in the federal Medicare program, HHSC may conduct the inspection in conjunction with the licensing inspection to determine compliance with Code of Federal Regulations Title 42 Part 482. Source Note: The provisions of this §510.22 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective May 9, 2004, 29 TexReg 4159; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.22 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222050 03/12/2026 (a) Renewal notice. The Texas Health and Human Services Commission (HHSC) shall send a renewal notice to a facility at least 60 calendar days before the expiration date of a license.(1) If the facility has not received the renewal notice from HHSC within 45 calendar days before the expiration date, it is the duty of the facility to notify HHSC and request a renewal application for a license.(2) If the facility fails to submit the application and fee within 15 calendar days before the expiration date of the license, HHSC shall send by certified mail to the facility a letter advising that unless the license is renewed, the facility must cease operations upon the expiration of the license.(b) Renewal license. HHSC shall issue a renewal license to a facility which meets the minimum requirements for a license.(1) The facility shall submit the following to HHSC before the expiration date of the license:(A) a complete and accurate application form;(B) a copy of a passing fire safety inspection report conducted within the last 12 months and one from the year prior indicating approval by the local fire authority in whose jurisdiction the facility is based, as HHSC requires annual fire safety inspections for a facility's continued licensure;(C) the renewal license fee; and(D) documentation of accreditation by an accrediting organization approved by the Centers for Medicare & Medicaid Services, if applicable.(2) HHSC may conduct an inspection before issuing a renewal license in accordance with §510.82 of this chapter (relating to Inspections).(3) Renewal licenses are valid for 24 months.(c) Notice to cease operation and return license. If a facility fails to submit the complete and accurate application form, documents, and fee by the expiration date of the license, HHSC shall notify the facility by certified mail that it must cease operation and immediately return the license by certified mail to HHSC. If the facility wishes to provide services after the expiration date of the license, it shall apply for a license under §510.22 of this subchapter (relating to Application and Issuance of Initial License). Source Note: The provisions of this §510.23 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective May 9, 2004, 29 TexReg 4159; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.23 Application and Issuance of Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222051 03/12/2026 (a) Change of ownership defined. A change of ownership occurs when there is a change in the person legally responsible for the operation of the facility, whether by lease or by ownership.(1) If a corporate licensee amends its articles of incorporation to revise its name and the tax identification number does not change, this subsection does not apply, except that the corporation must notify the Texas Health and Human Services Commission (HHSC) within 10 calendar days after the effective date of the name change.(2) The sale of stock of a corporate licensee does not cause this subsection to apply.(b) License application required. The new owner shall submit an application for an initial license to HHSC before the date of the change of ownership or not later than 10 calendar days following the date of a change of ownership. The application shall be in accordance with §510.22 of this subchapter (relating to the Application and Issuance of Initial License). In addition to the documents required in §510.22 of this subchapter, the applicant shall include the effective date of the change of ownership.(c) Inspections. For a change of ownership, HHSC may waive the on-site construction field survey and health inspection required by §510.22 of this subchapter.(d) Issuance of license. When the new owner has complied with the provisions of §510.22 of this subchapter, HHSC shall issue a license which shall be effective the date of the change of ownership.(e) Expiration of license. The expiration date of the license shall be in accordance with §510.22(d)(2) of this subchapter.(f) License void. The previous owner's license shall be void on the effective date of the new owner's license. Source Note: The provisions of this §510.24 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.24 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222052 03/12/2026 (a) General.(1) The receipt date for an application for an initial license or a renewal license is the date the application is received by the Texas Health and Human Services Commission (HHSC).(2) An application for an initial license is complete when HHSC has received, reviewed, and found acceptable the information described in §510.22(a) and (b) of this subchapter (relating to Application and Issuance of Initial License).(3) An application for a renewal license is complete when HHSC has received, reviewed, and found acceptable the information described in §510.23(b) of this subchapter (relating to Application and Issuance of Renewal License).(b) Time periods. An application for an initial license or renewal license shall be processed in accordance with the following time periods.(1) The first time period begins on the date HHSC receives the application and ends on the date the license is issued, or, if the application is received incomplete, the period ends on the date the facility is issued a written notice that the application is incomplete. The written notice shall describe the specific information that is required before the application is considered complete. The first time period is 20 business days.(2) The second time period begins on the date HHSC receives the last item necessary to complete the application and ends on the date the license is issued. The second time period is 20 business days.(c) Reimbursement of fees.(1) In the event the application is not processed in the time periods stated in subsection (b) of this section, the applicant has the right to request HHSC reimburse in full the fee paid for that application process. If HHSC does not agree the established periods have been violated or finds good cause existed for exceeding the established periods, the request shall be denied.(2) Good cause for exceeding the period established exists if:(A) the number of applications for licenses to be processed exceeds by 15 percent or more the number processed in the same calendar quarter the preceding year;(B) another public or private entity utilized in the application process caused the delay; or(C) other conditions existed which gave good cause for exceeding the established periods.(d) Appeal. If the request for full reimbursement authorized by subsection (c) of this section is denied, the applicant may then appeal to the HHSC Executive Commissioner (commissioner) for a resolution of the dispute. The applicant shall give written notice to the commissioner requesting full reimbursement of all filing fees paid because the application was not processed within the adopted time period. HHSC shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The commissioner shall make the final decision and provide written notification of the decision to the applicant and HHSC.(e) Contested case hearings. The procedures set out in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) apply to all hearings requested under this chapter. Source Note: The provisions of this §510.25 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.25 Time Periods for Processing and Issuing Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222053 03/12/2026 (a) General.(1) All fees paid to the Texas Health and Human Services Commission (HHSC) are nonrefundable except for fees for field surveys that were not conducted.(2) All fees shall be paid to HHSC.(b) License fees.(1) The fee for an initial license or a renewal license is $200 per bed per 24 months based upon the designed bed capacity. The total fee may not be less than $6,000 per 24 months. The designed bed capacity is determined as follows.(A) The designed bed capacity is the maximum number of patient beds that can be accommodated in rooms that comply with the requirements for patient room suites in Subchapter G of this chapter (relating to Physical Plant and Construction Requirements).(B) The maximum designed bed capacity includes beds that comply with the requirements in Subchapter G of this chapter even if the beds are unoccupied or the space is used for other purposes such as offices or storage rooms, provided such rooms can readily be returned to patient use. All required support and service areas must be maintained in place. For example, the removal of a nurse station in an unused patient bedroom wing of 20 beds would effectively eliminate those 20 beds from the designed capacity.(C) The number of licensed beds in a multiple occupancy room shall be determined by the design even if the number of beds actually placed in the room is less than the designed capacity.(2) An additional fee shall be submitted with the Final Construction Approval form for an increase in the number of beds resulting from an approved construction project and an additional plan review fee if the construction cost increases to the next higher fee schedule according to subsection (c)(4) of this section.(3) A facility will not receive a refund of previously submitted fees should the designed bed capacity decrease as a result of an approved construction project.(c) Plan review fees. This subsection outlines the fees which must accompany the application for plan review and all proposed plans and specifications covering the construction of new buildings or alterations to existing buildings which must be submitted for review and approval by HHSC in accordance with Subchapter G of this chapter.(1) Construction plans will not be reviewed or approved until the required fee and an application for plan review are received by HHSC.(2) Plan review fees are based upon the estimated construction project costs which are the total expenditures required for a proposed project from initiation to completion, including at least the following items.(A) Construction project costs shall include expenditures for physical assets such as:(i) site acquisition;(ii) soil tests and site preparation;(iii) construction and improvements required as a result of the project;(iv) building, structure, or office space acquisition;(v) renovation;(vi) fixed equipment; and(vii) energy provisions and alternatives.(B) Construction project costs shall include expenditures for professional services including:(i) planning consultants;(ii) architectural fees;(iii) fees for cost estimation;(iv) legal fees;(v) management fees; and(vi) feasibility study.(C) Construction project costs shall include expenditures or costs associated with financing, excluding long-term interest, but including:(i) financial advisor;(ii) fund-raising expenses;(iii) lender's or investment banker's fee; and(iv) interest on interim financing.(D) Construction project costs shall include expenditure allowances for contingencies including:(i) inflation;(ii) inaccurate estimates;(iii) unforeseen fluctuations in the money market; and(iv) other unforeseen expenditures.(3) Regarding purchases, donations, gifts, transfers, and other comparable arrangements whereby the acquisition is to be made for no consideration or at less than the fair market value, the project cost shall be determined by the fair market value of the item to be acquired as a result of the purchase, donation, gift, transfer, or other comparable arrangement.(4) The plan review fee schedule based on cost of construction is:(A) $100,000 or less: $300;(B) $100,001 to $600,000: $850;(C) $600,001 to $2,000,000: $2,000;(D) $2,000,001 to $5,000,000: $3,000;(E) $5,000,001 to $10,000,000: $4,000; and(F) $10,000,001 and over: $5,000.(5) If an estimated construction cost cannot be established, the estimated cost shall be based on $105 per square foot. No construction project shall be increased in size, scope, or cost unless the appropriate fees are submitted with the proposed changes.(d) Construction field survey fees. A fee of $500 and an application form for each field survey shall be submitted to HHSC at least three weeks prior to the anticipated field survey date. Construction field surveys will not be conducted until all required fees are received by HHSC. If additional construction field surveys of the proposed project are requested, the appropriate additional fees shall be submitted before any field surveys conducted by HHSC staff. When follow up construction field surveys are performed to verify plans of correction, the fee shall be submitted upon completion of the field survey.(e) Cooperative agreement application fee. The application fee for a cooperative agreement, established under Texas Health and Safety Code Chapter 314 is $10,000. The application fee shall be submitted with an application for a cooperative agreement. Source Note: The provisions of this §510.26 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective May 9, 2004, 29 TexReg 4159; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS B APPLICATION AND ISSUANCE OF A LICENSE §510.26 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222054 03/12/2026 (a) Anesthesia services. If the hospital furnishes anesthesia services, these services shall be provided in a well-organized manner under the direction of a qualified physician. The anesthesia service is responsible for all anesthesia administered in the hospital.(1) Organization and staffing. The organization of anesthesia services shall be appropriate to the scope of the services offered. Anesthesia shall be administered only by:(A) a qualified anesthesiologist;(B) a physician (other than an anesthesiologist);(C) a dentist, oral surgeon (licensed by the State Board of Dental Examiners), or podiatrist who is qualified to administer anesthesia under state law; or(D) a certified registered nurse anesthetist who is under the supervision, as set forth in Texas Occupations Code Title 3, Subtitle B, and Texas Occupations Code Chapter 301, of the operating physician or of an anesthesiologist who is immediately available if needed.(2) Delivery of services. Anesthesia services shall be consistent with needs and resources. Policies on anesthesia procedures shall include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies shall ensure that the following are provided for each patient.(A) A pre-anesthesia evaluation by an individual qualified to administer anesthesia under paragraph (1) of this subsection shall be performed within 48 hours prior to the procedure.(B) An intraoperative anesthesia record shall be provided. The record shall include any complications or problems occurring during the anesthesia including time, description of symptoms, review of affected systems, and treatments rendered. The record shall correlate with the controlled substance administration record.(C) A post-anesthesia follow-up report shall be written by the person administering the anesthesia before transferring the patient from the recovery room and shall include evaluation for recovery from anesthesia, level of activity, respiration, blood pressure, level of consciousness, and patient color.(i) With respect to inpatients, a post-anesthesia evaluation for proper anesthesia recovery shall be performed after transfer from recovery and within 48 hours after the procedure by the person administering the anesthesia, registered nurse (RN), or physician in accordance with policies and procedures approved by the medical staff.(ii) With respect to outpatients, immediately prior to discharge, a post-anesthesia evaluation for proper anesthesia recovery shall be performed by the person administering the anesthesia, RN, or physician in accordance with policies and procedures approved by the medical staff.(b) Dietary services. The facility shall have organized dietary services that are directed and staffed by adequate qualified personnel. However, a facility that has a contract with an outside food management company or an arrangement with another facility may meet this requirement if the company or other facility has a dietitian who serves the facility on a full-time, part-time, or consultant basis, and if the company or other facility maintains at least the minimum requirements specified in this section, and provides for the frequent and systematic liaison with the facility medical staff for recommendations of dietetic policies affecting patient treatment. The facility shall ensure that there are sufficient personnel to respond to the dietary needs of the patient population being served.(1) Organization.(A) A facility shall have an employee who is qualified by experience or training to serve as director of the food and dietetic service and is responsible for the daily management of the dietary services. This employee shall be full-time in a hospital; the crisis stabilization unit employee does not have to be full-time.(B) There shall be a qualified dietitian who works full-time, part-time, or on a consultant basis. If by consultation, such services shall occur at least once per month for not less than eight hours. The dietitian shall:(i) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian;(ii) maintain standards for professional practice;(iii) supervise the nutritional aspects of patient care;(iv) make an assessment of the nutritional status and adequacy of nutritional regimen, as appropriate;(v) provide diet counseling and teaching, as appropriate;(vi) document nutritional status and pertinent information in patient medical records, as appropriate;(vii) approve menus; and(viii) approve menu substitutions.(C) There shall be administrative and technical personnel competent in their respective duties. The administrative and technical personnel shall:(i) participate in established departmental or facility training pertinent to assigned duties;(ii) conform to food handling techniques in accordance with paragraph (2)(E)(vii) of this subsection;(iii) adhere to clearly defined work schedules and assignment sheets; and(iv) comply with position descriptions which are job specific.(2) Director. The director shall:(A) comply with a position description which is job specific;(B) clearly delineate responsibility and authority;(C) participate in conferences with administration and department heads;(D) establish, implement, and enforce policies and procedures for the overall operational components of the department to include:(i) quality assurance;(ii) frequency of meals served;(iii) non-routine occurrences; and(iv) identification of patient trays;(E) maintain authority and responsibility for the following:(i) orientation and training;(ii) performance evaluations;(iii) work assignments;(iv) supervision of work and food handling techniques;(v) procurement of food, paper, chemical, and other supplies, to include implementation of first-in first-out rotation system for all food items;(vi) menu planning; and(vii) ensuring compliance with 25 TAC Chapter 228 (relating to Retail Food Establishments).(3) Diets. Menus shall meet the needs of the patients.(A) Therapeutic diets shall be prescribed by a physician responsible for the care of the patients. The dietary department of the facility shall:(i) establish procedures for the processing of therapeutic diets to include:(I) accurate patient identification;(II) transcription from nursing to dietary services;(III) diet planning by a dietitian;(IV) regular review and updating of diet when necessary; and(V) written and verbal instruction to patient and family. It shall be in the patient's primary language, if practicable, prior to discharge. What is or would have been practicable shall be determined by the facts and circumstances of each case;(ii) ensure that therapeutic diets are planned in writing by a qualified dietitian;(iii) ensure that menu substitutions are approved by a qualified dietitian;(iv) document pertinent information about the patient's response to a therapeutic diet in the medical record; and(v) evaluate therapeutic diets for nutritional adequacy.(B) Nutritional needs shall be met in accordance with recognized dietary practices and in accordance with orders of a physician responsible for the care of the patients. The following requirements shall be met.(i) Menus shall provide a sufficient variety of foods served in adequate amounts at each meal according to the guidance provided in the Recommended Dietary Allowances (RDA), as published by the Food and Nutrition Board, National Academy of Sciences, National Research Council, Tenth edition, 1989.(ii) A maximum of 15 hours shall not be exceeded between the last meal of the day (i.e. supper) and the breakfast meal, unless a substantial snack is provided. The facility shall adopt, implement, and enforce a policy on the definition of "substantial" to meet each patient's varied nutritional needs.(C) A current therapeutic diet manual approved by the dietitian and medical staff shall be readily available to all medical, nursing, and food service personnel. The therapeutic manual shall:(i) be revised as needed, not to exceed five years;(ii) be appropriate for the diets routinely ordered in the facility;(iii) have standards in compliance with the RDA;(iv) contain specific diets which are not in compliance with RDA; and(v) be used as a guide for ordering and serving diets.(c) Governing body.(1) Legal responsibility. There shall be a governing body responsible for the organization, management, control, and operation of the facility, including appointment of the medical staff. For facilities owned and operated by an individual or by partners, the individual or partners shall be considered the governing body.(2) Organization. The governing body shall be formally organized in accordance with a written constitution or bylaws which clearly set forth the organizational structure and responsibilities.(3) Meeting records. Records of governing body meetings shall be maintained.(4) Responsibilities relating to the medical staff. The governing body shall:(A) ensure that the medical staff has current bylaws, rules, and regulations which are implemented and enforced;(B) approve medical staff bylaws and other medical staff rules and regulations;(C) determine, in accordance with state law and with the advice of the medical staff, which categories of practitioners are eligible candidates for appointment to the medical staff;(D) ensure that criteria for selection include individual character, competence, training, experience, and judgment;(E) ensure that under no circumstances is the accordance of staff membership or professional privileges in the facility dependent solely upon certification, fellowship or membership in a specialty body or society;(F) ensure the process for considering applications for medical staff membership and privileges affords each candidate for appointment procedural due process;(G) ensure in granting or refusing medical staff membership or privileges, the facility does not differentiate on the basis of the academic medical degree;(H) ensure that equal recognition is given to training programs accredited by the Accreditation Council on Graduate Medical Education and by the American Osteopathic Association if graduate medical education is used as a standard or qualification for medical staff membership or privileges for a physician;(I) ensure that equal recognition is given to certification programs approved by the American Board of Medical Specialties and the Bureau of Osteopathic Specialists if board certification is used as a standard or qualification for medical staff membership or privileges for a physician;(J) ensure that the medical staff is accountable to the governing body for the quality of care provided to patients;(K) ensure that a facility's credentials committee acts expeditiously and without unnecessary delay when a candidate for appointment submits a completed application, as defined by each hospital, for medical staff membership or privileges, in accordance with the following:(i) the credentials committee shall take action on the completed application not later than the 90th day after the date on which the application is received;(ii) the governing body shall take final action on the application for medical staff membership or privileges not later than the 60th day after the date on which the recommendation of the credentials committee is received; and(iii) the facility must notify the applicant in writing of the facility's final action, including a reason for denial or restriction of privileges, not later than the 20th day after the date on which final action is taken;(L) ensure the facility complies with the requirements for reporting to the Texas Medical Board the results and circumstances of any professional review action in accordance with Texas Occupations Code §160.002 and §160.003.(5) Facility administration. The governing body shall appoint a chief executive officer or administrator who is responsible for managing the facility.(6) Patient care. In accordance with facility policy, the governing body shall ensure that:(A) every patient is under the care of a physician, but this provision is not to be construed to limit the authority of a physician to delegate tasks to other qualified health care personnel to the extent recognized under state law;(B) patients are admitted to the facility only by members of the medical staff who have been granted admitting privileges; and(C) a physician is on duty or on-call at all times.(7) Contracted services. The governing body shall be responsible for services furnished in the facility whether or not they are furnished directly or under contracts. The governing body shall ensure that a contractor of services (including one for shared services and joint ventures) furnishes services in a safe and effective manner that permits the facility to comply with all applicable rules and standards for contracted services.(8) Nurse staffing. The governing body shall adopt, implement, and enforce a written nurse staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed. The governing body policy shall require that hospital administration adopt, implement, and enforce a nurse staffing plan and policies that:(A) require significant consideration be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan;(B) are based on the needs of each patient care unit and shift and on evidence relating to patient care needs;(C) ensure that all nursing assignments consider client safety and are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability;(D) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget;(E) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns;(F) protect from retaliation nurses who provide input to the nurse staffing committee; and(G) comply with subsection (j) of this section.(d) Infection control. The facility shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and investigation of infections and communicable diseases.(1) Organization and policies. A person shall be designated as infection control coordinator. The facility shall ensure that policies governing prevention, control and surveillance of infections and communicable diseases are developed, implemented, and enforced.(A) There shall be a system for identifying, reporting, investigating, and controlling nosocomial infections and communicable diseases between patients and personnel.(B) The infection control coordinator shall maintain a log of all reportable diseases and nosocomial infections designated as epidemiologically significant according to the facility's infection control policies.(C) There shall be a written policy for reporting all reportable diseases to the local health authority or the Infectious Disease Epidemiology and Surveillance Division, Department of State Health Services in accordance with 25 TAC Chapter 97 (relating to Communicable Diseases).(2) Responsibilities of the chief executive officer (CEO), medical staff, and chief nursing officer (CNO). The CEO, the medical staff, and the CNO shall be responsible for the following.(A) The facility-wide quality assurance program and training programs shall address problems identified by the infection control coordinator.(B) Successful corrective action plans in affected problem areas shall be implemented.(3) Universal precautions. The facility shall adopt, implement, and enforce a written policy to monitor compliance of the facility and its personnel and medical staff with universal precautions in accordance with Texas Health and Safety Code Chapter 85, Subchapter I.(e) Laboratory services. The facility shall provide or have available, adequate laboratory services to meet the needs of its patients.(1) Facility laboratory services. A facility that provides laboratory services shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988), in accordance with the requirements specified in Code of Federal Regulations (CFR) Title 42 Part 493. CLIA 1988 applies to all facilities with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.(2) Contracted laboratory services. The facility shall ensure that all laboratory services provided to its patients through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR Part 493 to comply with CLIA 1988.(3) Adequacy of laboratory services. The facility shall ensure the following.(A) Emergency laboratory services shall be available 24 hours a day.(B) A written description of services provided shall be available to the medical staff.(C) The laboratory shall make provision for proper receipt and reporting of tissue specimens.(4) Chemical hygiene. A facility that provides laboratory services directly shall adopt, implement, and enforce written policies and procedures to manage, minimize, or eliminate the risks to laboratory personnel of exposure to potentially hazardous chemicals in the laboratory which may occur during the normal course of job performance.(f) Linen and laundry services. The facility shall provide sufficient clean linen to ensure the comfort of the patient. The facility, whether it operates its own laundry or uses commercial service, shall ensure the following.(1) Employees of a facility involved in transporting, processing, or otherwise handling clean or soiled linen shall be given initial and follow-up in-service training to ensure a safe product for patients and to safeguard employees in their work.(2) Clean linen shall be handled, transported, and stored by methods that will ensure its cleanliness.(3) All contaminated linen shall be placed and transported in bags or containers labeled or color-coded.(4) Employees who have contact with contaminated linen shall wear gloves and other appropriate personal protective equipment.(5) Contaminated linen shall be handled as little as possible and with minimum agitation. Contaminated linen shall not be sorted or rinsed in patient care areas.(6) All contaminated linen shall be bagged or put into carts at the location where it was used.(A) Bags containing contaminated linen shall be closed prior to transport to the laundry.(B) Whenever contaminated linen is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the linen shall be deposited and transported in bags that prevent leakage of fluids to the exterior.(C) All linen placed in chutes shall be bagged.(D) If chutes are not used to convey linen to a central receiving or sorting room, then adequate space shall be allocated on the various nursing units for holding the bagged contaminated linen.(7) Linen shall be processed as follows.(A) If hot water is used, linen shall be washed with detergent in water with a temperature of at least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes. Hot water requirements specified in Subchapter G of this chapter (relating to Physical Plant and Construction Requirements) shall be met.(B) If low temperature (less than or equal to 70 degrees Centigrade) (158 degrees Fahrenheit) laundry cycles are used, chemicals suitable for low-temperature washing at proper use concentration shall be used.(C) Commercial dry cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission.(8) Flammable liquids shall not be used in the laundry.(g) Medical record services. The facility shall have a medical record service that has administrative responsibility for medical records. A medical record shall be maintained for every individual who presents to the hospital for evaluation or treatment.(1) The organization of the medical record service shall be appropriate to the scope and complexity of the services performed. The facility shall employ adequate personnel to ensure prompt completion, filing, and retrieval of records.(2) The facility shall have a system of coding and indexing medical records. The system shall allow for timely retrieval by diagnosis and procedure, in order to support medical care evaluation studies.(3) The facility shall adopt, implement, and enforce a policy to ensure that the facility complies with Texas Health and Safety Code §576.005 and Texas Health and Safety Code Chapter 611.(4) The medical record shall contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. Medical records shall be accurately written, promptly completed, properly filed and retained, and accessible.(5) The facility shall use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all entries to the records.(A) The author of each entry shall be identified and shall authenticate the author's entry.(B) Authentication shall include signatures, written initials, or computer entry.(C) Use of signature stamps by physicians may be allowed in facilities when the signature stamp is authorized by the individual whose signature the stamp represents. The administrative offices of the facility shall have on file a signed statement to the effect that the individual is the only person who has and uses the stamp. Delegation of use to another individual shall not be acceptable.(D) A list of computer codes and written signatures shall be readily available and shall be maintained under adequate safeguards.(E) Signatures by facsimile shall be acceptable. If received on a thermal machine, the facsimile document shall be copied onto regular paper.(6) Medical records (reports and printouts) shall be retained by the facility in their original or legally reproduced form, which is a medical record retained in hard copy, microform (microfilm or microfiche), or another electronic medium, for a period of at least 10 years. Films, scans, and other image records shall be retained for a period of at least five years. For retention purposes, medical records that shall be preserved for ten years include:(A) identification data;(B) the medical history of the patient;(C) evidence of a physical examination and psychiatric evaluation;(D) admitting diagnosis;(E) diagnostic and therapeutic orders;(F) properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state laws if applicable, to require written patient consent;(G) treatment plans;(H) clinical observations, including the results of therapy and treatment, all orders, nursing notes, medication records, vital signs, and other information necessary to monitor the patient's condition;(I) reports of procedures, tests, and their results, including laboratory, pathology, and radiology reports;(J) results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient;(K) discharge summary with outcome of hospitalization, disposition of care, and provisions for follow-up are; and(L) final diagnosis with completion of medical records within 30 calendar days following discharge.(7) If a patient was younger than 18 years of age at the time the patient was last treated, the facility may authorize the disposal of those medical records relating to the patient on or after the date of the patient's 20th birthday or on or after the 10th anniversary of the date on which the patient was last treated, whichever date is later.(8) The facility shall not destroy medical records that relate to any matter that is involved in litigation if the facility knows the litigation has not been finally resolved.(9) If a licensed facility closes, the facility shall notify the Texas Health and Human Services Commission (HHSC) at the time of closure, the disposition of the medical records, including the location of where the medical records will be stored and the identity and telephone number of the custodian of the records.(h) Medical staff.(1) The medical staff shall be composed of physicians and may also be composed of podiatrists, dentists, and other practitioners appointed by the governing body.(A) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws.(B) The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidate.(2) The medical staff shall be well-organized and accountable to the governing body for the quality of the medical care provided to patients.(A) The medical staff shall be organized in a manner approved by the governing body.(B) If the medical staff has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy.(C) Records of medical staff meetings shall be maintained.(D) The responsibility for organization and conduct of the medical staff shall be assigned only to an individual physician.(E) Each medical staff member shall sign a statement signifying they will abide by medical staff and hospital policies.(3) The medical staff shall adopt, implement, and enforce bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall:(A) be approved by the governing body;(B) include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, consultant);(C) describe the organization of the medical staff;(D) describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body; and(E) include criteria for determining the privileges to be granted and a procedure for applying the criteria to individuals requesting privileges.(i) Mobile, transportable, and relocatable units. If the facility provides diagnostic procedures or treatments in mobile, transportable, or relocatable units, the facility shall adopt, implement, and enforce procedures which address the potential emergency needs for those inpatients who are taken to mobile units on the facility premises for diagnostic procedures or treatment.(j) Nurse staffing.(1) The hospital shall establish a nurse staffing committee as a standing committee of the hospital. As used in this subsection, "committee" or "staffing committee" means a nurse staffing committee established under this paragraph.(A) The committee shall be composed of:(i) at least 60 percent registered nurses who are involved in direct patient care at least 50 percent of their work time and selected by their peers who provide direct care during at least 50 percent of their work time;(ii) members who are representative of the types of nursing services provided at the hospital; and(iii) the chief nursing officer of the hospital who is a voting member.(B) Participation on the committee by a hospital employee as a committee member shall be part of the employee's work time and the hospital shall compensate that member for that time accordingly. The hospital shall relieve the committee member of other work duties during committee meetings.(C) The committee shall meet at least quarterly.(D) The responsibilities of the committee shall be to:(i) develop and recommend to the hospital's governing body a nurse staffing plan that meets the requirements of paragraph (2) of this subsection;(ii) review, assess, and respond to staffing concerns expressed to the committee;(iii) identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse services staffing plan;(iv) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan and variations between the plan and the actual staffing; and(v) submit to the hospital's governing body, at least semiannually, a report on nurse staffing and patient care outcomes, including the committee's evaluation of the effectiveness of the official nurse services staffing plan and aggregate variations between the staffing plan and actual staffing.(2) The hospital shall adopt, implement, and enforce a written official nurse services staffing plan. As used in this subsection, "patient care unit" means a unit or area of a hospital in which registered nurses provide patient care.(A) The official nurse services staffing plan and policies shall:(i) require significant consideration be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan;(ii) be based on the needs of each patient care unit and shift and on evidence relating to patient care needs;(iii) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget;(iv) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns;(v) protect nurses who provide input to the nurse staffing committee from retaliation; and(vi) comply with this subsection.(B) The plan shall:(i) set minimum staffing levels for patient care units that are:(I) based on multiple nurse and patient considerations; and(II) determined by the nursing assessment and in accordance with evidence-based safe nursing standards; and(ii) include a method for adjusting the staffing plan shift to shift for each patient care unit to provide staffing flexibility to meet patient needs;(iii) include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources;(iv) include how on-call time will be used;(v) reflect current standards established by private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations;(vi) include a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs, nursing-sensitive quality indicators, nurse satisfaction measures collected by the hospital, and evidence-based nurse staffing standards; and(vii) be used by the hospital as a component in setting the nurse staffing budget and guiding the hospital in assigning nurses hospital wide.(C) The hospital shall make readily available to nurses on each patient care unit at the beginning of each shift the official nurse services staffing plan levels and current staffing levels for that unit and that shift.(3) The hospital shall annually report to HHSC on:(A) whether the hospital's governing body has adopted a nurse staffing policy;(B) whether the hospital has established a nurse staffing committee that meets the membership requirements of paragraph (1) of this subsection;(C) whether the nurse staffing committee has evaluated the hospital's official nurse services staffing plan and has reported the results of the evaluation to the hospital's governing body; and(D) the nurse-sensitive outcome measures the committee adopted for use in evaluating the hospital's official nurse services staffing plan.(4) Mandatory overtime. The hospital shall adopt, implement, and enforce policies on use of mandatory overtime.(A) As used in this subsection:(i) "on-call time" means time spent by a nurse who is not working but who is compensated for availability; and(ii) "mandatory overtime" means a requirement that a nurse work hours or days that are in addition to the hours or days scheduled, regardless of the length of a scheduled shift or the number of scheduled shifts each week. Mandatory overtime does not include prescheduled on-call time or time immediately before or after a scheduled shift necessary to document or communicate patient status to ensure patient safety.(B) A hospital may not require a nurse to work mandatory overtime, and a nurse may refuse to work mandatory overtime.(C) This section does not prohibit a nurse from volunteering to work overtime.(D) A hospital may not use on-call time as a substitute for mandatory overtime.(E) The prohibitions on mandatory overtime do not apply if:(i) a health care disaster, such as a natural or other type of disaster that increases the need for health care personnel, unexpectedly affects the county in which the nurse is employed or affects a contiguous county;(ii) a federal, state, or county declaration of emergency is in effect in the county in which the nurse is employed or is in effect in a contiguous county;(iii) there is an emergency or unforeseen event of a kind that:(I) does not regularly occur(II) increases the need for health care personnel at the hospital to provide safe patient care; and(III) could not prudently be anticipated by the hospital; or(iv) the nurse is actively engaged in an ongoing medical or surgical procedure and the continued presence of the nurse through the completion of the procedure is necessary to ensure the health and safety of the patient. The nurse staffing committee shall ensure that scheduling a nurse for a procedure that could be anticipated to require the nurse to stay beyond the end of his or her scheduled shift does not constitute mandatory overtime.(F) If a hospital determines that an exception exists under subparagraph (E) of this paragraph, the hospital shall, to the extent possible, make and document a good faith effort to meet the staffing need through voluntary overtime, including calling per diems and agency nurses, assigning floats, or requesting an additional day of work from off-duty employees.(G) A hospital may not suspend, terminate, or otherwise discipline or discriminate against a nurse who refuses to work mandatory overtime.(k) Outpatient services. If the facility provides outpatient services within the facility, written policies and procedures describing the operation of the services shall be adopted, implemented, and enforced.(l) Pharmacy services. The facility shall provide pharmaceutical services that meet the needs of the patients.(1) License. A facility that stores and dispenses prescription drugs for administration to a patient by a person authorized by law to administer the drug, shall be licensed, as required, by the Texas State Board of Pharmacy.(2) Organization. The facility shall have a pharmacy directed by a licensed pharmacist.(3) Medical staff. The medical staff shall be responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the facility's organized pharmaceutical services.(4) Pharmacy management and administration. The pharmacy or drug storage area shall be administered in accordance with accepted professional principles.(A) Standards of practice as defined by state law shall be followed regarding the provision of pharmacy services.(B) The pharmaceutical services shall have an adequate number of personnel to ensure quality pharmaceutical services including emergency services.(i) The staff shall be sufficient in number and training to respond to the pharmaceutical needs of the patient population being served. There shall be an arrangement for emergency services.(ii) Employees shall provide pharmaceutical services within the scope of their license and education.(C) Drugs and biologicals shall be properly stored to ensure ventilation, light, security, and temperature controls.(D) Records shall have sufficient detail to follow the flow of drugs from entry through dispensation.(E) There shall be adequate controls over all drugs and medications including floor stock. Drug storage areas shall be approved by the pharmacist, and floor stock lists shall be established.(F) Inspections of drug storage areas shall be conducted throughout the hospital under pharmacist supervision.(G) There shall be a drug recall procedure.(H) A full-time, part-time, or consulting pharmacist shall be responsible for developing, supervising, and coordinating all the activities of the pharmacy services.(i) Direction of pharmaceutical services may not require on premises supervision but may be accomplished through regularly scheduled visits in accordance with state law.(ii) A job description or other written agreement shall clearly define the responsibilities of the pharmacist.(I) Current and accurate records shall be kept of the receipt and disposition of all scheduled drugs.(i) There shall be a record system in place that provides the information on controlled substances in a readily retrievable manner which is separate from the patient record.(ii) Records shall trace the movement of scheduled drugs throughout the services, documenting utilization or wastage.(iii) The pharmacist shall be responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and reconciled with written orders.(5) Delivery of services. In order to provide patient safety, drugs and biologicals shall be controlled and distributed in accordance with applicable standards of practice, consistent with federal and state laws.(A) All compounding, packaging, and dispensing of drugs and biologicals shall be under the supervision of a pharmacist and performed consistent with federal and state laws.(B) Drugs and biologicals shall be kept in a locked storage area.(i) A policy shall be adopted, implemented, and enforced to ensure the safeguarding, transferring, and availability of keys to the locked storage area.(ii) Dangerous drugs as well as controlled substances shall be secure from unauthorized use.(C) Outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for patient use.(D) When a pharmacist is not available, drugs and biologicals shall be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with federal and state laws.(i) There shall be a current list of individuals identified by name and qualifications who are designated to remove drugs from the pharmacy.(ii) Only amounts sufficient for immediate therapeutic needs shall be removed.(E) Drugs and biologicals not specifically prescribed as to time or number of doses shall automatically be stopped after a reasonable time that is predetermined by the medical staff.(i) Stop order policies and procedures shall be consistent with those of the nursing staff and the medical staff rules and regulations.(ii) A protocol shall be established by the medical staff for the implementation of the stop order policy, in order that drugs shall be reviewed and renewed, or automatically stopped.(iii) A system shall be in place to determine compliance with the stop order policy.(F) Drug administration errors, adverse drug reactions, and incompatibilities shall be immediately reported to the attending physician and, if appropriate, to the facility-wide quality assurance program. There shall be a mechanism in place for capturing, reviewing, and tracking medication errors and adverse drug reactions.(G) Abuses and losses of controlled substances shall be reported, in accordance with applicable federal and state laws, to the individual responsible for the pharmaceutical services, and to the chief executive officer, as appropriate.(H) Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage, indications for use, and routes of administration shall be immediately available to the professional staff.(i) A pharmacist shall be readily available by telephone or other means to discuss drug therapy, interactions, side effects, dosage, assist in drug selection, and assist in the identification of drug induced problems.(ii) There shall be staff development programs on drug therapy available to facility staff to cover such topics as new drugs added to the formulary, how to resolve drug therapy problems, and other general information as the need arises.(I) A formulary system shall be established by the medical staff to ensure quality pharmaceuticals at reasonable costs.(m) Quality assurance. The governing body shall ensure that there is an effective, ongoing, facility-wide, data-driven quality assurance (QA) program to evaluate the provision of patient care.(1) Implementation plan. The facility-wide QA program shall be on-going and have a written plan of implementation.(A) All organized services related to patient care, including services furnished by contract, shall be evaluated.(B) Nosocomial infections and medication therapy shall be evaluated.(C) All medical services performed in the facility shall be evaluated as they relate to appropriateness of diagnosis and treatment.(2) Implementation. The facility shall take and document appropriate remedial action to address deficiencies found through the QA program. The facility shall document the outcome of the remedial action.(3) Discharge planning. The facility shall have an effective, ongoing discharge planning program that facilitates the provision of follow-up care.(A) Discharge planning shall be completed prior to discharge.(B) Patients, along with necessary medical information, shall be transferred or referred to appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care.(C) Screening and evaluation before patient discharge from facility. In accordance with 42 CFR Part 483, Subpart C and the rules set forth in Chapter 303 of this title, (relating to Preadmission Screening and Resident Review (PASRR)), all patients who are being considered for discharge from the facility to a nursing facility shall be screened, and if appropriate, evaluated, prior to discharge by the facility and admission to the nursing facility to determine whether the patient may have a mental illness, intellectual disability or developmental disability.(i) If the screening indicates that the patient has a mental illness, intellectual disability or developmental disability, the facility shall contact and arrange for the local mental health authority designated pursuant to Texas Health and Safety Code §533.035 to conduct, prior to facility discharge, an evaluation of the patient in accordance with the applicable provisions of the PASRR rules.(ii) The purpose of PASRR is:(I) to ensure that placement of the patient in a nursing facility is necessary;(II) to identify alternate placement options when applicable; and(III) to identify specialized services that may benefit the person with a diagnosis of mental illness, intellectual disability, or developmental disability.(n) Radiology services. When radiology services are provided, written policies and procedures shall be adopted, implemented, and enforced which describe the radiology services provided in the facility and how employee and patient safety will be maintained.(1) Safety Precautions. Proper safety precautions shall be maintained against radiation hazards. This includes adequate shielding for patients, personnel, and facilities.(2) Equipment Inspections. Inspection of equipment shall be made periodically. Defective equipment shall be promptly repaired or replaced.(3) Radiation Exposure. Radiation workers shall be checked, by the use of exposure meters or badge tests, for amount of radiation exposure. Exposure reports and documentation shall be available for review.(4) Service Provision. Radiology services shall be provided only on the order of individuals with privileges granted by the medical staff and of other physicians or practitioners authorized by the medical staff and governing body to order such services.(5) Personnel.(A) A qualified full-time, part-time, or consulting radiologist shall supervise the ionizing radiology services and shall interpret only those radiology tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section a radiologist is a physician who is qualified by education and experience in radiology in accordance with medical staff bylaws.(B) Only personnel designated as qualified by the medical staff shall use the radiology equipment and administer procedures.(6) Records. Records of radiology services shall be maintained. The radiologist or other individuals who have been granted privileges to perform radiology services shall sign reports of his or her interpretations.(o) Respiratory care services. When respiratory care services are provided, written policies and procedures shall be adopted, implemented, and enforced which describe the provision of respiratory care services in the facility. Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures shall be designated in writing.(p) Waste and waste disposal.(1) Special waste and liquid or sewage waste management.(A) The hospital shall comply with the requirements set forth by the Texas Department of State Health Services in 25 TAC §§1.131 - 1.137 (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities) and the Texas Commission on Environmental Quality (TCEQ) requirements in 30 TAC Chapter 326 (relating to Medical Waste Management).(B) All sewage and liquid wastes shall be disposed of in a municipal sewerage system or a septic tank system permitted by the TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site Sewage Facilities).(2) Waste receptacles.(A) Waste receptacles shall be conveniently available in all toilet rooms, patient areas, staff work areas, and waiting rooms. Receptacles shall be routinely emptied of their contents at one or more central locations into closed containers.(B) Waste receptacles shall be properly cleaned with soap and hot water, followed by treatment of inside surfaces of the receptacles with a germicidal agent.(C) All containers for other municipal solid waste shall be leak-resistant, have tight-fitting covers, and be rodent-proof.(D) Non-reusable containers shall be of suitable strength to minimize animal scavenging or rupture during collection operations. Source Note: The provisions of this §510.41 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective December 9, 2010, 35 TexReg 10746; amended to be effective May 24, 2013, 38 TexReg 3027; amended to be effective February 18, 2018, 43 TexReg 576; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.41 Facility Functions and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222055 03/12/2026 (a) Posting requirements for reporting a violation of law. In accordance with Texas Health and Safety Code (HSC) §161.134(j) and §161.135(h), each facility shall prominently and conspicuously post for display in a public area of the facility that is readily visible to patients, residents, employees, and visitors a statement that employees, staff, and nonemployees are protected from discrimination or retaliation for reporting a violation of law. The statement shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) Discrimination relating to employee reporting a violation of law. In accordance with HSC §161.134(a), a facility may not suspend or terminate the employment of, discipline, or otherwise discriminate against an employee for reporting to the employee's supervisor, an administrator of the hospital, a state regulatory agency, or a law enforcement agency, a violation of law, including a violation of Texas Health and Safety Code Chapter 577 or this chapter.(c) Retaliation relating to nonemployee reporting a violation of law. In accordance with HSC §161.135(a), a facility may not retaliate against a person who is not an employee for reporting a violation of law, including a violation of Texas Health and Safety Code Chapter 577 or this chapter. Source Note: The provisions of this §510.42 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.42 Discrimination or Retaliation Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222056 03/12/2026 (a) Definitions.(1) For purposes of this section, a transferring facility is a private psychiatric hospital licensed under Texas Health and Safety Code (HSC) Chapter 577.(2) For purposes of this section, a receiving facility is one of the following:(A) a private psychiatric hospital licensed under HSC Chapter 577;(B) a general or special hospital licensed under HSC Chapter 241;(C) a hospital operated by HHSC;(D) a hospital operated by a federal agency; or(E) a chemical dependency treatment facility licensed under HSC Chapter 464.(3) For purposes of this section, patient is defined as an individual:(A) seeking treatment who may or may not be under the immediate supervision of a personal attending physician, and who, within reasonable medical probability, requires immediate or continuing services and medical care; or(B) admitted as a patient.(b) Applicability.(1) If a transferring facility or a receiving facility is licensed under HSC Chapter 577, it must comply with all requirements of this section.(2) Receiving facilities, other than those licensed under HSC Chapter 577, are not governed by these rules.(c) General.(1) The governing body of each transferring facility shall adopt, implement, and enforce a policy relating to patient transfers that is consistent with this section and contains each of the requirements in subsection (d) of this section. Facility administration has the authority to represent a facility during the transfer from or receipt of patients into the facility.(2) The transfer policy shall be adopted by the governing body of the facility after consultation with the medical staff.(3) The policy shall govern transfers not covered by a transfer agreement in accordance with §510.61 of this chapter (relating to Patient Transfer Agreements).(4) The movement of a stable patient from a transferring facility to a receiving facility is not considered to be a transfer under this section if it is the understanding and intent of both facilities that the patient is going to the receiving facility only for tests, the patient will not remain overnight at the receiving facility, and the patient will return to the transferring facility. This paragraph applies only when a patient remains stable during transport to and from the facilities and during testing.(5) The policy shall include a written operational plan to provide for patient transfer transportation services if the transferring facility does not provide its own patient transfer transportation services.(6) Each governing body, after consultation with the medical staff, may implement its transfer policy by adopting transfer agreements with other receiving facilities in accordance with §510.61 of this chapter.(d) Requirements for transfer of patients between facilities.(1) Discrimination. Except as is specifically provided in paragraphs (5)(E) and (5)(F) and (6)(A) and (6)(B) of this subsection, relating, respectively, to mandated providers and designated providers, the policy shall provide that the transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, or economic status.(2) Disclosure. The policy shall recognize the right of an individual to request transfer into the care of a physician and a receiving facility of the individual's own choosing; however, if a patient is transferred for economic reasons and the patient's choice is predicated upon or influenced by representations made by the transferring physician or transferring facility administration regarding the availability of medical care and services at a reduced cost or no cost to the patient, the physician or facility administration shall fully disclose to the patient the eligibility requirements established by the patient's chosen physician or receiving facility.(3) Patient evaluation. The policy shall provide that each patient who arrives at a transferring facility is evaluated in accordance with §568.41 of this title (relating to Responding to an Emergency Medical Condition).(A) After receiving a report on the patient's condition from the nursing staff by telephone or radio, if the physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on call may order the transfer by telephone or radio.(B) Physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient's medical record, signed by the staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible. The patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to paragraph (8) of this subsection.(4) Facility personnel, written protocols, standing delegation orders, eligibility, and payment information. The policy of the transferring facility and receiving facility shall provide that licensed nurses and other qualified personnel are available and on duty to assist with patient transfers and to provide accurate information regarding eligibility and payment practices. The policy shall provide that written protocols or standing delegation orders are in place to guide personnel when a patient requires transfer.(5) Transfer of patients who have emergency medical conditions.(A) If a patient has an emergency medical condition which has not been stabilized or when stabilization of the patient's vital signs is not possible because the transferring facility does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment shall be performed and transfer shall be carried out as quickly as possible.(B) The policy shall provide that the transferring facility may not transfer a patient with an emergency medical condition which has not been stabilized unless:(i) the patient or a legally responsible person acting on the patient's behalf, after being informed of the transferring facility's obligations under this section and of the risks and benefits of transfer, requests transfer in writing;(ii) a physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at a receiving facility outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer; or(iii) if the physician who made the determination to transfer a patient with an emergency condition is not physically present at the time of transfer, a qualified medical person, as designated by facility policy, may sign a certification described in clause (ii) of this subparagraph after consultation with the physician and the physician shall countersign the physician certification within a reasonable period of time.(C) Except as provided by subparagraphs (E) and (F) of this paragraph and paragraph (6)(A) and (6)(B) of this subsection, the policy shall provide that the transfer of patients who have emergency medical conditions, as determined by a physician, shall be undertaken for medical reasons only.(D) Except as expressly permitted in clauses (i) and (ii) of this subparagraph, the policy shall provide for the receipt of patients who have an emergency medical condition so that upon notification of and prior to a transfer, the receiving facility shall, after determining whether or not space, personnel and services necessary to provide appropriate care for the patient are available, respond to the transferring facility, within 30 minutes, either accepting or refusing the transfer. The 30-minute time period begins at the time a member of the staff of the receiving facility receives the call initiating the request to transfer.(i) The policy may permit response within a period of time in excess of 30 minutes but no longer than one hour if there are extenuating circumstances for the delay. If the transfer is accepted, the reason for the delay shall be documented on the memorandum of transfer.(ii) The response time may be extended before the expiration of the initial 30 minutes period by agreement among the parties to the transfer. If the transfer is accepted, the agreed extension shall be documented in the memorandum of transfer.(E) The policy shall recognize and comply with the requirements of HSC §§61.030-61.032 and §§61.057-61.059 since those requirements may apply to a patient.(F) The policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations which may exist concerning a patient and a designated provider.(G) The policy shall require that all reasonable steps are taken to secure the informed refusal of a patient refusing a transfer or a related examination and treatment or of a person acting on a patient's behalf refusing a transfer or a related examination and treatment. Reasonable steps include:(i) a factual explanation of the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring facility;(ii) a factual explanation of any increased risks to the patient from not effecting the transfer; and(iii) a factual explanation of the medical benefits reasonably expected from the provision of appropriate treatment at a receiving facility.(H) The informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation or transfer shall be documented and signed if possible by the patient or by a person acting on the patient's behalf, dated and witnessed by the attending physician or facility employee, and placed in the patient's medical record.(I) Transfer of patients may occur routinely or as part of a regionalized plan for obtaining optimal care for patients at a more appropriate or specialized health care entity.(6) Transfer of patients who do not have emergency medical conditions.(A) The policy shall recognize and comply with the requirements of HSC §§61.030-61.032 and §§61.057-61.059 as those requirements may apply to a patient.(B) The policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations which may exist concerning a patient and a designated provider.(C) The policy shall require that all reasonable steps are taken to secure the informed refusal of a patient refusing a transfer or a related examination and treatment or of a person acting on a patient's behalf refusing a transfer or a related examination and treatment. Reasonable steps include:(i) a factual explanation of the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring facility;(ii) a factual explanation of any increased risks to the patient from not effecting the transfer; and(iii) a factual explanation of the medical benefits reasonably expected from the provision of appropriate treatment at a receiving facility.(D) The informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation or transfer shall be documented and signed if possible by the patient or by a person acting on the patient's behalf, dated and witnessed by the attending physician or facility employee, and placed in the patient's medical record.(E) Transfer of patients may occur routinely or as part of a regionalized plan for obtaining optimal care for patients at a more appropriate or specialized health care entity.(F) The policy shall recognize the right of an individual to request a transfer into the care of a physician and a receiving facility of the individual's own choosing.(7) Physician's duties and standard of care.(A) The policy shall provide that the transferring physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer.(B) The policy shall provide that the transferring physician shall determine and order the utilization of appropriate personnel and equipment for the transfer.(C) The policy shall provide that in determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer.(D) The policy shall provide that except as allowed under paragraph (3)(B) of this subsection, prior to each patient transfer, the physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used.(E) The policy shall provide that prior to transfer, the transferring physician shall secure a receiving physician and a receiving facility that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and care.(8) Record review for standard of care. The policy shall provide that the medical staff review appropriate records of patients transferred to determine that the appropriate standard of care has been met.(9) Medical record.(A) The policy shall provide that a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient be forwarded to the receiving physician and receiving facility with the patient. If all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the records shall be forwarded to the receiving physician and receiving facility as soon as possible.(B) The medical record shall contain at a minimum:(i) a brief description of the patient's medical history and physical examination;(ii) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;(iii) the reason for the transfer;(iv) the results of all diagnostic tests, such as laboratory tests;(v) pertinent X-ray films and reports; and(vi) any other pertinent information.(10) Memorandum of transfer.(A) The policy shall provide that a memorandum of transfer be completed for every patient who is transferred.(B) The memorandum shall contain the following information:(i) the patient's full name, if known;(ii) the patient's race, religion, national origin, age, sex, physical disability, if known;(iii) the patient's address and next of kin, address, and phone number if known;(iv) the names, telephone numbers and addresses of the transferring and receiving physicians;(v) the names, addresses, and telephone numbers of the transferring and receiving facilities;(vi) the time and date on which the patient first presented or was presented to the transferring physician and transferring facility;(vii) the time and date on which the transferring physician secured a receiving physician;(viii) the name, date, and time administration was contacted in the receiving facility;(ix) signature, time, and title of the transferring facility administration who contacted the receiving facility;(x) the certification required by paragraph (5)(B)(ii) of this subsection, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form);(xi) the time and date on which the receiving physician assumed responsibility for the patient;(xii) the time and date on which the patient arrived at the receiving facility;(xiii) signature and date of receiving administration;(xiv) type of vehicle and company used;(xv) type of equipment and personnel needed in transfers;(xvi) name and city of facility to which patient was transported;(xvii) diagnosis by transferring physician; and(xviii) attachments by transferring facility.(C) A copy of the memorandum of transfer shall be retained by the transferring and receiving facilities. The memorandum shall be filed separately from the patient's medical record and in a manner that facilitates its inspection by HHSC. All memorandum of transfer forms filed separately shall be retained for five years.(e) Violations. A facility violates HSC Chapter 577 and this section if:(1) the facility fails to comply with the requirements of this section; or(2) the governing body fails or refuses to:(A) adopt a transfer policy which is consistent with this section and contains each of the requirements in subsection (d) of this section;(B) adopt a memorandum of transfer form which meets the minimum requirements for content contained in this section; or(C) enforce its transfer policy and the use of the memorandum of transfer. Source Note: The provisions of this §510.43 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.43 Patient Transfer Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222886 03/12/2026 (a) Determination of death. The facility shall adopt, implement, and enforce protocols to be used in determining death which comply with Texas Health and Safety Code (HSC) Chapter 671, Subchapter A.(b) Organ and tissue donors. The facility shall adopt, implement, and enforce a written protocol to identify potential organ and tissue donors which complies with the HSC Chapter 692A. The facility shall make its protocol available to the public during the facility's normal business hours. The facility's protocol shall include all requirements in HSC §692A.015.(c) Professional nurse reporting and peer review. A facility shall adopt, implement, and enforce a policy to ensure that the facility complies with Texas Occupations Code Chapter 301, Subchapter I and Texas Occupations Code Chapter 303, and with the rules adopted by the Texas Board of Nursing at Texas Administrative Code, Title 22 §217.16 (relating to Minor Incidents), §217.19 (relating to Incident-Based Nursing Peer Review and Whistleblower Protections) and §217.20 (relating to Safe Harbor Nursing Peer Review and Whistleblower Protections).(d) Discrimination prohibited. A facility shall not discriminate based on a patient's disability and shall comply with HSC Code Chapter 161, Subchapter S.(e) Prohibited discharge of a patient to certain group-centered facilities. A facility shall comply with HSC §256.003.(1) Except as provided by paragraph (2) of this subsection, a facility may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility only if the person operating the group-centered facility holds a license or permit issued in accordance with applicable state law.(2) A facility may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility operated by a person who does not hold a license or permit issued in accordance with applicable state law only if:(A) there is no group-centered facility operated in the county where the patient is discharged that is operated by a person holding the applicable license or permit; or(B) the patient voluntarily chooses to reside in the group-centered facility operated by an unlicensed or unpermitted person. Source Note: The provisions of this §510.44 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective January 6, 2022, 46 TexReg 9399; amended to be effective December 31, 2024, 49 TexReg 10649. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.44 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220248 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220248 03/12/2026 (a) Itemized statements.(1) A facility shall adopt, implement, and enforce a policy to ensure that the facility complies with Texas Health and Safety Code (HSC) §311.002.(2) A facility shall comply with the itemized bill requirements under HSC §185.002.(b) Audits of billing. A facility shall adopt, implement, and enforce a policy to ensure that the facility complies with HSC §311.0025(a).(c) Complaint investigation procedures.(1) A complaint submitted to the Texas Health and Human Services Commission's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted.(2) Upon receiving a complaint warranting an investigation, Texas Health and Human Services Commission (HHSC) shall send the complaint to the facility requesting the facility to conduct an internal investigation. Within 30 days of the facility's receipt of the complaint, the facility shall submit to HHSC:(A) a report outlining the facility's investigative process;(B) the resolution or conclusions reached by the facility with the patient, third party payor, or complainant; and(C) corrections, if any, in the policies or protocols which were made as a result of its investigative findings.(3) In addition to the facility's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the facility.(4) HHSC may inform a complainant who identifies themselves by name and address in writing of the receipt and disposition of the complaint.(5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments which were not provided to the appropriate licensing agency.(d) Balance billing.(1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility. Source Note: The provisions of this §510.45 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective April 15, 2021, 46 TexReg 2427; amended to be effective August 18, 2024, 49 TexReg 6220. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.45 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222057 03/12/2026 (a) Reporting. Incidents of abuse, neglect, exploitation, or illegal, unethical or unprofessional conduct shall be reported to Texas Health and Human Services Commission (HHSC) Complaint and Incident Intake as provided in subsections (b) and (c) of this section.(b) Abuse or neglect of a child, and abuse, neglect, or exploitation of an elderly or disabled person. The following definitions apply only to this subsection.(1) Abuse or neglect of a child, as defined in 25 TAC §1.204(a) and (b) (relating to Abuse, Neglect, and Exploitation Defined).(2) Abuse, neglect, or exploitation of an elderly or disabled person, as defined in 25 TAC §1.204(a) - (c).(c) Abuse and neglect of individuals with mental illness, and illegal, unethical, and unprofessional conduct. The requirements of this subsection are in addition to the requirements of subsection (b) of this section.(1) Definitions. The following definitions are in accordance with Texas Health and Safety Code (HSC) §161.131 and apply only to this subsection.(A) Abuse--(i) Abuse (as the term is defined in United States Code (USC) Title 42 Chapter 114 is any act or failure to act by an employee of a facility rendering care or treatment which was performed, or which was failed to be performed, knowingly, recklessly, or intentionally, and which caused, or may have caused, injury or death to an individual with mental illness, and includes acts such as:(I) the rape or sexual assault of an individual with mental illness;(II) the striking of an individual with mental illness;(III) the use of excessive force when placing an individual with mental illness in bodily restraints; and(IV) the use of bodily or chemical restraints on an individual with mental illness which is not in compliance with federal and state laws and regulations.(ii) In accordance with HSC §161.132(j), abuse also includes coercive or restrictive actions that are illegal or not justified by the patient's condition and that are in response to the patient's request for discharge or refusal of medication, therapy, or treatment.(B) Illegal conduct--Illegal conduct (as the term is defined in HSC §161.131(4)) is conduct prohibited by law.(C) Neglect--Neglect (as the term is defined in 42 USC §10801 et seq.) is a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness, the failure to provide adequate nutrition, clothing, or health care to an individual with mental illness, or the failure to provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriately trained staff.(D) Unethical conduct--Unethical conduct (as the term is defined in HSC §161.131(11)) is conduct prohibited by the ethical standards adopted by state or national professional organizations for their respective professions or by rules established by the state licensing agency for the respective profession.(E) Unprofessional conduct--Unprofessional conduct (as the term is defined in HSC §161.131(12)) is conduct prohibited under rules adopted by the state licensing agency for the respective profession.(2) Posting requirements. A facility shall prominently and conspicuously post for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with HSC §161.132(e). The statement shall be in English and in a second language appropriate to the demographic makeup of the community served and contain the number of the current toll-free telephone number for submitting a complaint to HHSC as specified on the HHSC website.(3) Reporting responsibility.(A) Reporting abuse and neglect. A person, including an employee, volunteer, or other person associated with the facility who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the facility who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect (as those terms are defined in this subsection) by any person shall as soon as possible, report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency in accordance with HSC §161.132(a).(B) Reporting illegal, unprofessional, or unethical conduct. An employee of or other person associated with a facility including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe that the facility or an employee or health care professional associated with the facility, has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the facility or mental health or chemical dependency services provided in the facility shall as soon as possible, report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency in accordance with HSC §161.132(b).(4) Training requirements. A facility providing mental health or substance use services shall comply with §568.121 of this title (relating to Staff Member Training) to all employees and associated health care professionals who are assigned to or who provide services in the facility.(d) Investigations. A complaint under this subsection will be investigated or referred by HHSC as follows.(1) Allegations under subsection (b) of this section will be investigated in accordance with 25 TAC §1.205 (relating to Reports and Investigations) and 25 TAC §1.206 (relating to Completion of Investigation).(2) Allegations under subsection (c) of this section will be investigated in accordance with §510.83 of this chapter (relating to Complaint Investigations). Allegations concerning a health care professional's failure to report abuse and neglect or illegal, unprofessional, or unethical conduct will not be investigated by HHSC but will be referred to the individual's licensing board for appropriate disciplinary action.(3) Allegations under both subsections (b) and (c) will be investigated in accordance with 25 TAC §§1.205 and 1.206 except as noted in paragraph (2) of this subsection concerning a health care professional's failure to report.(e) Submission of complaints. A complaint made under this section shall be submitted in writing or orally to HHSC.(f) Notification.(1) For complaints under subsection (b) of this section, HHSC shall provide notification according to the following:(A) HHSC shall notify the reporter, if known, in writing of the outcome of the complete investigation.(B) HHSC shall notify the alleged victim, and the alleged victim's parent or guardian if a minor, in writing of the outcome of the completed investigation.(2) For complaints under subsection (c) of this section, HHSC shall inform, in writing, the complainant who identifies themselves by name and address of the following:(A) the receipt of the complaint;(B) if the complainant's allegations are potential violations of this chapter warranting an investigation;(C) whether the complaint will be investigated by HHSC;(D) whether and to whom the complaint will be referred; and(E) the findings of the complaint investigation.(g) HHSC reporting and referral.(1) Reporting health care professional to licensing board.(A) In cases of abuse, neglect, or exploitation, as those terms are defined in subsection (b), by a licensed, certified, or registered health care professional, HHSC may forward a copy of the completed investigative report to the state agency which licenses, certifies or registers the health care professional. Any information which might reveal the identity of the reporter or any other patients or clients of the facility must be blacked out or deidentified.(B) A health care professional who fails to report abuse and neglect or illegal, unprofessional, or unethical conduct as required by subsection (c)(3) of this section may be referred by HHSC to the individual's licensing board for appropriate disciplinary action.(2) Sexual exploitation reporting requirements. In addition to the reporting requirements described in subsection (c)(3) of this section, a mental health services provider must report suspected sexual exploitation in accordance with Texas Civil Practice and Remedies Code §81.006.(3) Referral follow-up. HHSC shall request a report from each referral agency of the action taken by the agency six months after the referral.(4) Referral of complaints. A complaint containing allegations which are not a violation of HSC Chapters 571 through 577 or this chapter will not be investigated by HHSC but shall be referred to law enforcement agencies or other agencies, as appropriate. Source Note: The provisions of this §510.46 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.46 Abuse and Neglect Issues https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221158 03/12/2026 (a) In accordance with Texas Health and Safety Code (HSC) §331.002, a hospital shall establish a workplace violence prevention committee or authorize an existing hospital committee to develop a workplace violence prevention plan.(b) A hospital shall ensure the committee includes at least:(1) one registered nurse who provides direct care to the hospital's patients;(2) one physician licensed to practice medicine in this state who provides direct care to the hospital's patients; and(3) one hospital employee who provides security services for the hospital if any and if practicable.(c) A health care system that owns or operates more than one facility, as that term is defined by HSC §331.001, which includes a hospital, may establish a single workplace violence prevention committee for all of the system's facilities if:(1) the committee develops a violence prevention plan for implementation at each facility in the system; and(2) data related to violence prevention remains distinctly identifiable for each facility in the system.(d) A hospital shall adopt, implement, and enforce a written workplace violence prevention policy to protect health care providers and employees from violent behavior and threats of violent behavior occurring at the hospital. In accordance with HSC §331.003, the policy shall:(1) require the hospital to:(A) provide significant consideration of the violence prevention plan recommended by the hospital's committee; and(B) evaluate any existing hospital violence prevention plan;(2) encourage health care providers and employees to provide confidential information on workplace violence to the committee;(3) include a process to protect from retaliation health care providers or employees who provide information to the committee; and(4) comply with HHSC rules relating to workplace violence.(e) A hospital shall adopt, implement, and enforce a written workplace violence prevention plan developed by the committee. In accordance with HSC §331.004, the plan shall:(1) be based on a hospital setting;(2) adopt a definition of "workplace violence" that includes:(A) an act or threat of physical force against a health care provider or employee that results in, or is likely to result in, physical injury or psychological trauma; and(B) an incident involving the use of a firearm or other dangerous weapon, regardless of whether a health care provider or employee is injured by the weapon;(3) require the hospital to at least annually provide workplace violence prevention training or education that may be included in other required training or education provided to the health care providers and employees who provide direct patient care;(4) prescribe a system for responding to and investigating violent incidents or potentially violent incidents at the hospital;(5) address physical security and safety;(6) require the hospital to solicit information from the health care providers and employees when developing and implementing a workplace violence prevention plan;(7) allow health care providers and employees to report workplace violence incidents through the hospital's existing occurrence reporting systems; and(8) require the hospital to adjust patient care assignments, to the extent practicable, to prevent a health care provider or employee from treating or providing services to a patient who has intentionally physically abused or threatened the provider or employee.(f) The written workplace violence prevention plan may satisfy the requirements of subsection (e) of this section by referencing other internal hospital policies and documents.(g) At least annually after the date a hospital adopts a written workplace violence prevention plan required by subsection (e) of this section, the committee shall:(1) review and evaluate the workplace violence prevention plan; and(2) report the results of the evaluation to the hospital's governing body.(h) Each hospital shall make available on request an electronic or printed copy of the hospital's workplace violence prevention plan to each health care provider or hospital employee. If the committee determines the plan contains information that would pose a security threat if made public, the committee may redact that information before providing the plan.(i) In accordance with HSC §331.005, after an incident of workplace violence occurs, a hospital shall offer immediate post-incident services, including any necessary acute medical treatment for each hospital health care provider or employee who is directly involved in the incident.(j) In accordance with HSC §331.005, a hospital may not discourage a health care provider or employee from exercising the provider's or employee's right to contact or file a report with law enforcement regarding a workplace violence incident.(k) In accordance with HSC §331.005, a hospital shall prohibit hospital personnel from disciplining, including by suspension or termination of employment, discriminating against, or retaliating against another person who:(1) in good faith reports a workplace violence incident; or(2) advises a health care provider or employee of the provider's or employee's right to report a workplace violence incident. Source Note: The provisions of this §510.47 adopted to be effective October 21, 2024, 49 TexReg 8384. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS C OPERATIONAL REQUIREMENTS §510.47 Workplace Violence Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222058 03/12/2026 (a) General provisions.(1) Transfer agreements between transferring facilities and receiving facilities as those terms are defined in §510.43 of this chapter (relating to Patient Transfer Policy) are voluntary.(2) If transfer agreements are executed that are consistent with the requirements of subsection (b) of this section, any patient transfers shall be governed by the agreement. The memorandum of transfer described in §510.43(d)(10) of this chapter is not required for transfers governed by an agreement.(3) Multiple transfer agreements may be entered into based upon the type or level of medical services available at other facilities.(b) Rules for patient transfer agreements.(1) A patient transfer agreement shall contain the following.(A) Except as specifically provided in paragraph (4) of this subsection, relating to mandated providers, the transfer of a patient shall not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, or economic status.(B) The transfer or receipt of patients in need of emergency care shall not be based upon the individual's inability to pay for the services rendered.(2) The patient transfer agreement shall require that patient transfers be accomplished in a medically appropriate manner by determining the availability of appropriate facilities, services, and staff for providing care to the patient and by providing:(A) medically appropriate life support measures which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use to stabilize the patient prior to transfer and to sustain the patient during the transfer;(B) appropriate personnel and equipment which a reasonable and prudent physician in the same or similar locality exercising ordinary care would use for the transfer; and(C) all necessary records for continuing the care for the patient.(3) The facility shall recognize the right of an individual to request transfer into the care of a physician and facility of the individual's own choosing.(4) The facility shall recognize and comply with the requirements of Texas Health and Safety Code §61.030 through §61.032 and §61.057 through §61.059.(5) The patient transfer agreement shall provide that a patient with an emergency medical condition which has not been stabilized shall not be transferred unless the following occurs.(A) The patient, or a legally responsible person acting on the patient's behalf, after being informed of the facility's obligations under this section and of the risk of transfer, has requested transfer to another facility in writing.(B) A physician has signed a certification, which includes a summary of the risks and benefits, that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer.(C) If a physician is not physically present at the time a patient is transferred, a qualified medical person has signed a certification described in subparagraph (B) of this paragraph after consultation with a physician who has made the determination described in subparagraph (B) of this paragraph and who will subsequently countersign the certification within a reasonable period of time. Source Note: The provisions of this §510.61 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS D VOLUNTARY AGREEMENTS §510.61 Patient Transfer Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222059 03/12/2026 (a) A cooperative agreement is an agreement among two or more hospitals for the allocation or sharing of health care equipment, facilities, personnel, or services, and may be established in accordance with Texas Health and Safety Code (HSC) Chapter 314.(b) For purposes of this section only, a hospital is a private psychiatric hospital licensed under HSC Chapter 577, or a general or special hospital licensed under HSC Chapter 241.(c) A hospital may negotiate and enter into cooperative agreements with other hospitals in the state if the likely benefits resulting from the agreement outweigh any disadvantages attributable to a reduction in competition that may result from the agreements. Acting through their boards of directors, a group of hospitals may conduct discussions or negotiations concerning cooperative agreements, provided that the discussions or negotiations do not involve price fixing or predatory pricing.(d) Parties to a cooperative agreement may apply to HHSC for a certification of public advantage governing the cooperative agreement. The application must include the application fee in accordance with §510.26(e) of this chapter (relating to Fees), and a written copy of the cooperative agreement that describes the nature and scope of the cooperation in the agreement and any consideration passing to any party under the agreement. A copy of the application and copies of all additional related materials must be submitted to the attorney general and to HHSC at the same time. Source Note: The provisions of this §510.62 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS D VOLUNTARY AGREEMENTS §510.62 Cooperative Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222061 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission's (HHSC's) inspection and investigation process, a facility:(1) shall not record, listen to, or eavesdrop on any HHSC interview with facility staff or patients that the facility staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) shall not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of facility staff when HHSC has requested a private room or office or distanced themselves from facility staff unless the facility first informs HHSC and the facility obtains HHSC's written approval before beginning to record or listen to the discussion.(b) A facility shall inform HHSC when security cameras or other existing recording devices in the facility are in operation during any internal discussion by or among HHSC staff.(c) When HHSC by words or actions permits facility staff to be present, an interview or conversation for which facility staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §510.81 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.81 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222062 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an inspection of a facility prior to the issuance or renewal of a license.(1) A hospital is not subject to additional annual licensing inspections subsequent to the issuance of the initial license while the hospital maintains:(A) certification under Title XVIII of the Social Security Act, 42 United States Code (USC) §1395 et seq.; or(B) accreditation from The Joint Commission, the American Osteopathic Association, or other national accreditation organization for the offered services.(2) HHSC may conduct an inspection of a hospital exempt from an annual licensing inspection under paragraph (1) of this subsection before issuing a renewal license to the hospital if the certification or accreditation body has not conducted an on-site inspection of the hospital in the preceding three years and HHSC determines that an inspection of the hospital by the certification or accreditation body is not scheduled within 60 days of the license expiration date.(b) HHSC may conduct an unannounced, on-site inspection of a facility at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) a facility's plan of correction;(3) an order or special order of the HHSC executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(c) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its facilities by HHSC.(d) HHSC inspections to evaluate a facility's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or bed numbers;(3) routine inspections, which may be conducted without notice and at HHSC's discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies;(5) inspections to determine if an unlicensed facility is offering or providing, or purporting to offer or provide, treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(e) A facility shall cooperate with any HHSC inspection and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the facility, unless prohibited by law.(f) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(g) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(h) Upon entry, HHSC holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the facility representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the inspection, including any possible health and safety concerns. The facility may provide any final documentation regarding compliance during the exit conference.(k) HHSC shall maintain the confidentiality of facility records as applicable under state or federal law. Except as provided by subsection (l) of this section, all information and materials in the possession of or obtained or compiled by HHSC in connection with an inspection are confidential and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the facility;(2) the facility that is the subject of the enforcement action, or the facility's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate licensed mental health facility services;(4) law enforcement agencies as allowed by law; and(5) persons engaged in bona fide research, if all individual-identifying information and information identifying the facility has been deleted.(l) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552, only to the extent that all personally identifiable information of a patient or health care provider is omitted from the information:(1) a notice of the facility's alleged violation, which must include the provisions of law the facility is alleged to have violated, and a general statement of the nature of the alleged violation;(2) the number of investigations HHSC conducted of the facility;(3) the pleadings in any administrative proceeding to impose a penalty against the facility for the alleged violation;(4) the outcome of each investigation HHSC conducted of the facility, including:(A) reprimand issuance;(B) license denial or revocation;(C) corrective action plan adoption; or(D) administrative penalty imposition and the penalty amount;(5) a final decision, investigative report, or order issued by HHSC to address the alleged violation; and(6) any other information required by law to be disclosed under public information laws.(m) Within 90 days after the date HHSC issues a final decision, investigative report, or order to address a facility's alleged violation, HHSC posts certain information on the HHSC website in accordance with Texas Health and Safety Code §577.013. Source Note: The provisions of this §510.82 adopted to be effective November 21, 2024, 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.82 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222063 03/12/2026 (a) A facility shall provide each patient and applicable legally authorized representative at the time of admission with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the facility.(1) The statement shall inform persons that they may direct a complaint to HHSC Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The facility shall prominently and conspicuously post this statement in patient common areas and in visitor's areas and waiting rooms so that it is readily visible to patients, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A complaint must be submitted using HHSC's current CII contact information for that purpose, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints directed to HHSC CII based on the seriousness of the alleged violation and the level of risk to patients, personnel, and the public.(1) Allegations determined to be within HHSC's regulatory jurisdiction relating to health care facilities may be investigated under this chapter.(2) HHSC may refer complaints outside HHSC's jurisdiction to an appropriate agency, as applicable.(d) HHSC conducts investigations to evaluate a facility's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of patients. Complaint investigations may be coordinated with the federal Centers for Medicare & Medicaid Services and its agents responsible for the inspection of hospitals to determine compliance with the Conditions of Participation under Title XVIII of the Social Security Act, (42 USC, §1395 et seq.), so as to avoid duplicate investigations.(e) HHSC may conduct an unannounced, on-site investigation of a facility at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) a facility's compliance with any applicable statute or rule;(2) a facility's plan of correction;(3) a facility's compliance with an order of the HHSC executive commissioner or the executive commissioner's designee;(4) a facility's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the facility.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its facilities by HHSC.(g) A facility shall cooperate with any HHSC investigation and shall permit HHSC to examine the facility's grounds, buildings, books, records, video surveillance, and other documents and information maintained by, or on behalf of, the facility, unless prohibited by law.(h) A facility shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(i) A facility shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the facility, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(j) Upon entry, the HHSC representative holds an entrance conference with the facility's designated representative to explain the nature, scope, and estimated duration of the investigation.(k) The HHSC representative holds an exit conference with the facility representative to inform the facility representative of any preliminary findings of the investigation. The facility may provide any final documentation regarding compliance during the exit conference.(l) Once an investigation is complete, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint.(m) HHSC shall maintain the confidentiality of facility records as applicable under state or federal law. Except as provided by (n) of this subsection, all information and materials in the possession of or obtained or compiled by HHSC in connection with an investigation are confidential and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the facility;(2) the facility that is the subject of the enforcement action, or the facility's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate licensed mental health facility services;(4) law enforcement agencies as allowed by law; and(5) persons engaged in bona fide research, if all individual-identifying information and information identifying the facility has been deleted.(n) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552, only to the extent that all personally identifiable information of a patient or health care provider is omitted from the information:(1) a notice of the facility's alleged violation, which must include the provisions of law the facility is alleged to have violated, and a general statement of the nature of the alleged violation;(2) the number of investigations HHSC has conducted of the facility;(3) the pleadings in any administrative proceeding to impose a penalty against the facility for the alleged violation;(4) the outcome of each investigation HHSC conducted of the facility, including:(A) reprimand issuance;(B) license denial or revocation;(C) corrective action plan adoption; or(D) administrative penalty imposition and the penalty amount;(5) a final decision investigative report, or order issued by HHSC to address the alleged violation; and(6) any other information required by law to be disclosed under public information laws.(o) Within 90 days after the date HHSC issues a final decision, investigative report, or order to address a facility's alleged violation, HHSC posts certain information on the HHSC website in accordance with Texas Health and Safety Code §577.013.(p) HHSC notifies complainants regarding the investigation's outcome within 10 business days after completing the investigation. Source Note: The provisions of this §510.83 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.83 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222064 03/12/2026 (a) A facility is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after mailing, whichever is earlier.(b) When HHSC finds deficiencies:(1) HHSC provides the facility with a written Statement of Deficiencies (SOD) within 10 business days after the exit conference via U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the facility's receipt of the SOD, the facility shall return to HHSC a written Plan of Correction (POC) that addresses each cited deficiency, including timeframes for corrections, together with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the facility in writing.(B) If HHSC does not accept the POC, HHSC notifies the facility in writing and requests the facility submit a modified POC and any additional evidence of compliance no later than 10 business days after HHSC notifies the facility in writing.(C) The facility shall correct the identified deficiencies and submit to HHSC evidence verifying implementation of corrective action within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of a facility's compliance with this subsection or HHSC's acceptance of a facility's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter. Source Note: The provisions of this §510.84 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.84 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222065 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission reports, in writing, to the appropriate licensing board any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure. Source Note: The provisions of this §510.85 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.85 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222066 03/12/2026 A facility may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by following the procedure listed on the HHSC website. Source Note: The provisions of this §510.86 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.86 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222067 03/12/2026 Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, and orders.(1) Denial, suspension or revocation of a license or imposition of an administrative penalty. HHSC has jurisdiction to enforce violations of Texas Health and Safety Code (HSC) Chapters 571 through 578 or the rules adopted under these chapters. HHSC may deny, suspend, or revoke a license or impose an administrative penalty for:(A) failure to comply with any applicable provision of the HSC, including Chapters 161, 321, 322, and 571 through 578;(B) failure to comply with any provision of this chapter or any other applicable laws;(C) the facility, or any of its employees, committing an act which causes actual harm or risk of harm to the health or safety of a patient;(D) the facility, or any of its employees, materially altering any license issued by HHSC;(E) failure to comply with minimum standards for licensure;(F) failure to provide a complete license application;(G) failure to comply with an order of the executive commissioner or another enforcement procedure under HSC Chapters 571 through 578;(H) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights;(I) the facility aiding, committing, abetting, or permitting the commission of an illegal act;(J) the facility, or any of its employees, committing fraud, misrepresentation, or concealment of a material fact on any documents required to be submitted to HHSC or required to be maintained by the facility pursuant to HSC Chapters 571 through 578 and the provisions of this chapter;(K) failure to timely pay an assessed administrative penalty as required by HHSC;(L) failure to submit an acceptable plan of correction for cited deficiencies within the timeframe required by HHSC;(M) failure to timely implement plans of corrections to deficiencies cited by HHSC within the dates designated in the plan of correction;(N) failure to comply with applicable requirements within a designated probation period; or(O) if the facility is participating under Title XVIII of the Social Security Act, 42 United States Code (USC), §1395 et seq., the Centers for Medicare & Medicaid Services terminating the facility's Medicare provider agreement.(2) Denial of a license. HHSC has jurisdiction to enforce violations of HSC Chapters 571 through 578 or the rules adopted under this chapter. HHSC may deny a license if the applicant:(A) fails to provide timely and sufficient information required by HHSC that is directly related to the license application; or(B) has had the following actions taken against the applicant within the two-year period preceding the license application:(i) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;(ii) federal Medicare or state Medicaid sanctions or penalties;(iii) unsatisfied federal or state tax liens;(iv) unsatisfied final judgments;(v) eviction involving any property or space used as a hospital in any state;(vi) unresolved federal Medicare or state Medicaid audit exceptions;(vii) denial, suspension, or revocation of a hospital license, a private psychiatric hospital license, or a license for any health care facility in any state; or(viii) a court injunction prohibiting ownership or operation of a facility.(3) Order for immediate license suspension. HHSC may suspend a license for 10 days pending a hearing if after an investigation HHSC finds that there is an immediate threat to the health or safety of the patients or employees of a licensed facility. HHSC may issue necessary orders for the patients' welfare.(4) Probation. In lieu of denying, suspending, or revoking a license, HHSC may place a facility on probation for a period of not less than 30 days, if HHSC finds that the facility is in repeated non-compliance with this chapter or HSC Chapters 571 through 578 and the facility's noncompliance does not endanger the public's health and safety.(A) HHSC shall provide notice to the facility of the probation and of the items of noncompliance not later than the 10th day before the date the probation period begins.(B) During the probation period, the facility shall correct the items of noncompliance and report the corrections to HHSC for approval.(5) Administrative penalty. HHSC has jurisdiction to impose an administrative penalty against a person licensed or regulated under this chapter for violations of applicable chapters of the HSC or this chapter. The imposition of an administrative penalty shall be in accordance with the provisions of HSC §571.025.(6) Licensure of persons or entities with criminal backgrounds. HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of a facility. HHSC shall apply the requirements of Texas Occupations Code Chapter 53.(A) HHSC is entitled under Texas Government Code Chapter 411 to obtain criminal history information maintained by the Texas Department of Public Safety, the Federal Bureau of Investigation, or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.(B) In determining whether a criminal conviction directly relates, HHSC shall apply the requirements and consider the provisions of Texas Occupations Code Chapter 53 (relating to Consequences of Criminal Conviction).(C) The following felonies and misdemeanors directly relate to the duties and responsibilities of the ownership or operation of a health care facility because these criminal offenses indicate an ability or a tendency for the person to be unable to own or operate a facility:(i) a misdemeanor violation of HSC Chapter 571;(ii) a misdemeanor or felony involving moral turpitude;(iii) a misdemeanor or felony relating to deceptive business practices;(iv) a misdemeanor or felony of practicing any health-related profession without a required license;(v) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(vi) a misdemeanor or felony under Texas Penal Code (TPC), Title 5, involving a patient or a client of any health care facility, a home and community support services agency, or a health care professional; or(vii) a misdemeanor or felony under TPC:(I) Title 4;(II) Title 5;(III) Title 7;(IV) Title 8;(V) Title 9;(VI) Title 10; or(VII) Title 11.(7) Offenses listed in paragraph (6)(C) of this section are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign or military jurisdictions that indicate an inability or tendency for the person or entity to be unable to own or operate a facility.(8) HHSC shall revoke a license on the licensee's imprisonment following a felony conviction, felony community supervision revocation, revocation of parole, or revocation of mandatory supervision.(9) Notice. If HHSC proposes to deny, suspend, or revoke a license, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC or HHSC may personally deliver the notice. The notice to deny, suspend, or revoke a license, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.(10) Acceptance. Within 20 calendar days after receipt of the notice described in paragraph (9) of this section, the applicant or licensee shall notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing.(11) Hearing request.(A) A request for a hearing by the applicant or licensee shall be in writing and submitted to HHSC within 20 calendar days after receipt of the notice described in paragraph (9) of this section. Receipt of the notice is presumed to occur on the third day after the date HHSC mails the notice to the last known address of the applicant or licensee.(B) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001, and Texas Administrative Code Title 1 Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act).(12) No response to notice. If an applicant or licensee does not request a hearing in writing within 20 calendar days after receiving notice of the proposed action, the applicant or licensee is deemed to have waived the opportunity for a hearing and HHSC takes the proposed action.(13) Notification of HHSC's final decision. HHSC shall send the licensee or applicant a copy of HHSC's decision for denial, suspension or revocation of license or imposition of an administrative penalty by certified mail, which shall include the findings of fact and conclusions of law on which HHSC based its decision.(14) Admission of new patients upon suspension or revocation. Upon HHSC's determination to suspend or revoke a license, the license holder may not admit new patients until the license is reissued.(15) Decision to suspend or revoke. When HHSC's decision to suspend or revoke a license is final, the licensee must immediately cease operation, unless a stay of such action is issued by the district court.(16) Return of original license. Upon suspension, revocation or non-renewal of the license, the original license shall be returned to HHSC within 30 calendar days of HHSC's notification.(17) Reapplication following denial or revocation.(A) One year after HHSC's decision to deny or revoke, or the voluntary surrender of a license by a facility while enforcement action is pending, a facility may petition HHSC, in writing, for a license. Expiration of a license prior to HHSC's decision becoming final shall not affect the one-year waiting period required before a petition can be submitted.(B) HHSC may allow a reapplication for licensure if there is proof that the reasons for the original action no longer exist.(C) HHSC may deny reapplication for licensure if HHSC determines that:(i) the reasons for the original action continues;(ii) the petitioner has failed to offer sufficient proof that conditions have changed; or(iii) the petitioner has demonstrated a repeated history of failure to provide patients a safe environment or has violated patient rights.(D) If HHSC allows a reapplication for licensure, the petitioner shall be required to meet the requirements as described in §510.22 of this chapter (relating to Application and Issuance of Initial License).(18) Expiration of a license during suspension. A facility whose license expires during a suspension period may not reapply for license renewal until the end of the suspension period.(19) Surrender of a license. In the event that enforcement, as defined in this subsection, is pending or reasonably imminent, the surrender of a facility license shall not deprive HHSC of jurisdiction in regard to enforcement against the facility. Source Note: The provisions of this §510.87 adopted to be effective November 21, 2024 49 TexReg 9311. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS E ENFORCEMENT §510.87 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222060 03/12/2026 (a) Fire inspections.(1) Annual inspection. Approval of the fire protection of a facility by the local fire department or State Fire Marshall's Office shall be a prerequisite for licensure.(2) Purpose of inspection. The purpose of these inspections shall be to ascertain and to cause to be corrected any conditions liable to cause fire or violations of any of the provisions or intent of these rules, or of any other applicable ordinances, which affect fire safety in any way.(3) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the fire department or bureau of fire prevention find in any building or upon any premises dangerous or hazardous conditions or materials, removal or remedy of dangerous conditions or materials shall be carried out in a manner specified by the inspector or officer.(4) Access for inspection. At all reasonable hours, the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors may enter any building or premises for the purpose of making an inspection or investigation which may be deemed necessary under the provisions of these rules.(b) Fire reporting. All occurrences of fire shall be reported to the local fire authority and shall be reported in writing to the Texas Health and Human Services Commission, as soon as possible but not later than 10 calendar days following the occurrence.(1) The fire incident report shall indicate as a minimum the following information:(A) the fire origin and area or location;(B) amount of damage;(C) were patients or employees or staff injured;(D) was the fire department notified and did they respond;(E) how was the fire detected;(F) how was the fire extinguished;(G) what caused the fire;(H) was there a general evacuation or just area evacuation; and(I) has the fire area or location been reoccupied.(2) The fire incident report shall be provided on facility letterhead and signed by hospital administration.(3) A copy of the fire marshal incident report shall be provided if the fire marshal wrote an incident report.(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), §18-7, and §510.121(a)(1) of this chapter (relating to Requirements for Buildings in which Existing Licensed Facilities are Located), and §510.122(a)(1) and (d) of this chapter (relating to New Construction Requirements). When required or installed, sprinkler systems for exterior fire exposures shall comply with National Fire Protection Association 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 1999 edition.(d) Smoking rules. Each facility shall adopt, implement, and enforce a smoking policy. The policy shall include the minimal provisions of NFPA 101 §18-7.4.(e) Fire extinguishing systems. Inspection, testing, and maintenance of fire-fighting equipment shall be conducted by each facility.(1) Water-based fire protection systems. All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks, and valves and fire department connections shall be inspected, tested and maintained in accordance with National Fire Protection Association 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1995 edition.(2) Range hood extinguishers. Fire extinguishing systems for commercial cooking equipment, such as at range hoods, shall be inspected and maintained in accordance with National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 1998 edition.(3) Portable fire extinguishers. Every portable fire extinguisher located in a facility or upon facility property shall be installed, tagged, and maintained in accordance with National Fire Protection Association 10, Standard for Portable Fire Extinguishers, 1998 edition.(f) Fire protection and evacuation plan. A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101 §18-7. Copies of the plan shall be available to all staff.(1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the facility in public areas that are readily visible to patients, residents, employees, and visitors.(2) Annual training. Each facility shall conduct an annual training program for instruction of all personnel in the location and use of fire-fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(g) Fire drills. The facility shall conduct at least one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment. Documentation of the drills shall be maintained for a period of not less than one year.(h) Fire alarm system. Every facility and building used for patient care shall have an approved fire alarm system. Each fire alarm system shall be installed and tested in accordance with §510.121(a)(1)(A) of this chapter for existing facilities, and §510.122(d)(5)(M) of this chapter for new construction.(i) System for communicating an alarm of fire. A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101 §18-3.4.3.2.(j) Fire department access. As an aid to fire department services, every facility shall provide the following.(1) Driveways. The facility shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Floor plans. Upon request, the facility shall submit a copy of the floor plans of the building to the local fire department officials.(3) Outside identification. The facility shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(k) Fire department protection. When a facility is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire. Source Note: The provisions of this §510.101 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS F FIRE PREVENTION AND SAFETY REQUIREMENTS §510.101 Fire Prevention and Protection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195305 03/12/2026 (a) Safety committee. Each facility shall have a multi-disciplinary safety committee. The facility chief executive officer (CEO) shall appoint the chairman and members of the safety committee.(1) Safety officer. The CEO shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall be a member of the safety committee, and shall carry out the functions of the safety program.(2) Safety committee meetings. The safety committee shall meet as required by the chairman, but not less than quarterly. Written minutes of each meeting shall be retained for a period of not less than one year.(3) Safety activities.(A) Incident reports. The safety committee shall establish an incident reporting system which includes a mechanism to ensure that all incidents recorded in safety committee minutes are evaluated, and documentation is provided to show follow-up and corrective actions.(B) Safety policies and procedures. The facility shall develop, implement and enforce safety policies and procedures for each department or service which are integrated within the overall plan. Unit specific policies and procedures shall be maintained within each department or service.(C) Safety training and continuing education. Safety training shall be established as part of new employee orientation and in the continuing education of all employees.(4) Written authority. The authority of the safety committee to take action when conditions exist that are a possible threat to life, health, or building damage, shall be defined in writing and approved by the governing body.(b) Emergency preparedness.(1) Disaster management. Each facility shall develop plans for effective preparedness, mitigation, response, and recovery from disasters.(2) Disaster preparedness. Each facility shall develop a written policy and procedures for the following:(A) notification of personnel and patients;(B) the receipt, treatment and disposition of casualties;(C) the identification of appropriate community resources; and(D) evacuation procedures.(3) Disaster plans. National Fire Protection Association 99, Standard for Health Care Facilities, 1999 edition, Chapter 11, and the State of Texas Emergency Management Planshall be used as references to plan and establish the disaster plans. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, Post Office Box 9101, Quincy, MA 02269-9101 or (800) 344-3555. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator.(4) Annual rehearsal. The facility shall practice the disaster plans at least one time per year and shall document the rehearsal of the plans. Documentation of rehearsals for the last three years shall be retained.(c) Emergency communication system. An emergency communication system shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments. Source Note: The provisions of this §510.102 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS F FIRE PREVENTION AND SAFETY REQUIREMENTS §510.102 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195306 03/12/2026 (a) Flammable and nonflammable gases and liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association 325, Guide to Fire Hazard Properties of Flammable Liquids, Gases, and Volatile Solids, 1994 edition. All documents published by National Fire Protection Association (NFPA) as referenced in this section may be obtained by writing or calling the NFPA at the following address or telephone number: National Fire Protection Association, 1 Batterymarch Park, P.O. Box 9101, Quincy, MA 02269-9101 or (800) 344-3555.(1) Nonflammable gases shall be stored and distributed in accordance with Chapter 4 of the National Fire Protection Association 99, Standard for Health Care Facilities, 1999 edition (NFPA 99).(A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99, Chapter 8.(B) Oxygen shall be administered in accordance with NFPA 99 §8-6.(2) Flammable gases shall be stored in accordance with NFPA 99, §4-6.1.1.(3) Other flammable agents shall be stored in accordance with NFPA 99, Chapter 6.(b) Gasoline and gasoline powered equipment. No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the facility building. Other devices which may cause or communicate fire, and which are not necessary for patient treatment or care, shall not be stored within the facility building. All such devices and materials which are necessary shall be used within the building only with precautions which ensure a reasonable degree of safety from fire.(c) Gas fired appliances. The installation, use and maintenance of gas fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 1999 edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §510.103 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS F FIRE PREVENTION AND SAFETY REQUIREMENTS §510.103 Handling and Storage of Gases and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222068 03/12/2026 (a) Compliance. All buildings in which existing facilities licensed by the Texas Health and Human Services Commission (HHSC) are located shall comply with this subsection.(1) Minimum fire safety and construction requirements.(A) Existing licensed facilities shall meet the requirements for health care occupancies contained in the 1985, 1988, 1991 or 2000 editions of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, (NFPA 101), and the facility licensing rules (1988, 1989 or 1994) under which the buildings or sections of buildings were constructed or last modified.(B) Existing facilities or portions of existing facilities constructed prior to the adoption of any of the editions of NFPA 101, the Facility Licensing Standards, and the facility licensing rules listed in subparagraph (A) of this paragraph, shall comply with this section and Chapter 19, NFPA 101, 2000 edition.(C) Compliance with the requirements of Chapter 3 of the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 1998 edition, (relating to Fire Safety Evaluation System for Health Care Occupancies) will be acceptable in lieu of complying with the requirements of Chapter 19, NFPA 101, 2000 edition.(2) Remodeling of existing facilities. All requirements listed in this chapter relating to new construction are applicable to renovations, additions and alterations unless stated otherwise.(A) Alteration or installation of new equipment. Any alteration or any installation of new equipment shall be accomplished as nearly as practicable with the requirements for new construction, except that when existing conditions make changes impractical to accomplish, minor deviations from functional requirements may be permitted if the intent of the requirements is met and if the care and safety of patients will not be jeopardized. A request for deviation must be submitted in writing to HHSC.(B) Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system be replaced, materially altered or extended in an existing building licensed as a facility, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to HHSC, reviewed and approved in accordance with §510.127 of this subchapter (relating to Preparation, Submittal, Review and Approval of Plans).(C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the facility is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes and a simple floor plan for evaluation and determination of disposition.(D) Major remodeling or alterations. Plans shall be submitted in accordance with §510.127 of this subchapter for all major remodeling or alterations. All remodeling or alterations which involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), or change the designed bed capacity or services over those for which the facility is licensed are considered as major remodeling and alterations.(E) Phasing of construction in existing facilities. Projects involving alterations of and additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions. Access, exit access, and fire protection shall be maintained so that the safety of the occupants will not be jeopardized during construction. Dust and vapor barriers shall be provided to separate areas undergoing demolition and construction from occupied areas. Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building.(F) Nonconforming conditions. When doing renovation work, if it is found to be infeasible to correct all of the nonconforming conditions in the existing facility in accordance with these rules, a conditional approval may be granted by HHSC if the operation of the facility, necessary access by the handicapped, and safety of the patients are not jeopardized by the nonconforming condition.(b) Previously licensed facilities. Buildings which have been licensed previously as facilities but have been vacated or used for purposes other than as facilities and which are not in compliance with the 1985, 1988, 1991 or 2000 editions of the NFPA 101, and facility licensing rules (1988, 1989 or 1994) under which the building or sections of buildings were constructed shall comply with the requirements of §510.122 of this subchapter (relating to New Construction Requirements), §510.123 of this subchapter (relating to Spatial Requirements for New Construction), §510.125 of this subchapter (relating to Building with Multiple Occupancies), §510.127 of this subchapter, and §510.130 of this subchapter (relating to Record Drawings, Manuals and Design Data), inclusively. Source Note: The provisions of this §510.121 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.121 Requirements for Buildings in which Existing Licensed Facilities are Located https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222069 03/12/2026 (a) Facility location. Any proposed new facility shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as a facility which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients.(1) Hazardous locations.(A) Underground and above ground hazards. New facilities or additions to existing facilities shall not be built within 125 feet of right away/easement of hazardous locations including underground liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not under high voltage electrical lines.(B) Fire hazards. New facilities shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants.(2) Undesirable locations.(A) Nuisance producing sites. New facilities shall not be located near nuisance producing industrial sites, feed lots, sanitary landfills, or manufacturing plants producing excessive noise or air pollution.(B) Cemeteries. New facilities shall not be located near a cemetery in a manner that allows direct view of the cemetery from patient windows.(C) Flood plains. Construction of new facilities shall be avoided in designated flood plains. Where such is unavoidable, access and required functional facility components shall be constructed above the designated flood plain. This requirement also applies to new additions to existing facilities or portions of facilities which have been licensed previously as facilities but which have been vacated or used for purposes other than facilities. This requirement does not apply to remodeling of existing licensed facilities.(D) Airports. Construction of new facilities shall be avoided in close proximity to airports. When facilities are proposed to be located near airports, recommendations of the Texas Aviation Authority and the Federal Aviation Authority shall apply. A facility may not be constructed within a rectangular area formed by lines perpendicular to and two miles (10,560 feet) from each end of any runway and by lines parallel to and one-half mile (2,640 feet) from each side of any runway.(b) Environmental considerations. Development of a facility site and facility construction shall be governed by state and local regulations and requirements with respect to the effect of noise and traffic on the community and the environmental impact on air and water.(c) Facility site.(1) Paved roads and walkways. Paved roads shall be provided within the lot lines to provide access from public roads to the main entrance, entrances serving community activities, and to service entrances, including loading and unloading docks for delivery trucks. Finished surface walkways shall be provided for pedestrians.(2) Parking. Off-street parking shall be available for visitors, employees, and staff. Parking structures directly accessible from a facility shall be separated with two-hour fire rated noncombustible construction. When used as required means of egress for facility occupants, parking structures shall comply with National Fire Protection Association 88A, Standard for Parking Structures, 1998 edition. This requirement does not apply to freestanding parking structures.(A) Number of parking places. In the absence of a formal parking study, one parking space shall be provided for each day shift employee plus one space for one and one-half patient beds. This ratio may be reduced in an area convenient to a public transportation system or to public parking facilities on the basis of a formal parking study. Parking shall be increased accordingly when the size of an existing facility is increased.(B) Additional parking. Additional parking shall be required to accommodate medical staff, outpatient and other services when such services are provided.(C) Delivery parking. Separate parking facilities shall be provided for delivery vehicles.(D) Accessible parking. Parking spaces for persons with disabilities shall be provided in accordance with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities.(d) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, one of the following codes shall be adhered to: Uniform Building Code, 1999 edition, published by the International Conference of Building Officials.(1) General architectural requirements. All new construction, including conversion of an existing building to a facility, establishing a separately licensed facility in a building with an existing licensed health care occupancy, and establishing a licensed facility in a non-health care occupancy shall comply with Chapter 18 of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), and Subchapters F and G of this chapter (relating to Fire Prevention and Safety Requirements and Physical Plant and Construction Requirements, respectively). The facility shall comply with the requirements of this paragraph and any specific architectural requirements for the particular unit or suite of the facility in accordance with §510.123 of this subchapter (relating to Spatial Requirements for New Construction).(A) Special design provisions. Special provisions shall be made in the design of a facility in regions where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, or floods.(B) Foundations. Foundations shall rest on natural solid bearing if satisfactory bearing is available. Proper soil-bearing values shall be established in accordance with recognized requirements. If solid bearing is not encountered at practical depths, the structure shall be supported on driven piles or drilled piers designed to support the intended load without detrimental settlement, except that one-story buildings may rest on a fill designed by a soils engineer. When engineered fill is used, site preparation and placement of fill shall be done under the direct full-time supervision of the soils engineer. The soils engineer shall issue a final report on the compacted fill operation and certification of compliance with the job specifications. All footings shall extend to a depth not less than one foot below the estimated maximum frost line.(C) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each facility. The physical premises of the facility and those areas of the facility's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes and subchapters F and G of this chapter.(D) Construction type. A facility may occupy an entire building or a portion of a building, provided the facility portion of the building is separated from the rest of the building in accordance with subparagraph (E) of this paragraph and the entire building or the facility portion of the building complies with new construction requirements (type of construction permitted for facilities by NFPA 101, §18-1.6.2), and the entire building is protected with a fire sprinkler system conforming with requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler Systems, 1999 Edition (NFPA 13).(E) Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls which are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies.(F) Design for people with disabilities. Special considerations benefiting staff, visitors, and patients with disabilities shall be provided. Each facility shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A, Accessibility Guidelines for Buildings and Facilities.(G) Other regulations. Certain projects may be subject to other regulations, including those of federal, state, and local authorities. The more stringent standard or requirement shall apply when a difference in requirements for construction exists.(H) Exceeding minimum requirements. Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter.(I) Equivalency. Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this subchapter, providing technical documentation which demonstrates equivalency is submitted to the department for approval.(J) Freestanding buildings (not for patient use). Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected non-combustible construction, protected non-combustible construction, or fire-resistive construction and be designed in accordance with other occupancy classifications requirements listed in NFPA 101.(K) Freestanding buildings (for patient use other than sleeping). Buildings containing areas for patient use which do not contain patient sleeping areas and in which care or treatment is rendered to ambulatory inpatients who are capable of judgment and appropriate physical action for self-preservation under emergency conditions, may be classified as ambulatory health care occupancies or business occupancies as listed in NFPA 101 Chapters 20 and 38, respectively, instead of facility occupancy. Such buildings shall be located at least 20 feet from the facility unless protected by an approved automatic sprinkler system.(L) Energy conservation. In new construction and in major alterations and additions to existing buildings and in new buildings, electrical and mechanical components shall be selected for efficient utilization of energy.(2) General detail and finish requirements. Details and finishes in new construction projects, including additions and alterations, shall be in compliance with this paragraph, with NFPA 101, Chapter 18, with local building codes, and with any specific detail and finish requirements for the particular unit or suite as contained in §510.123 of this subchapter.(A) General detail requirements.(i) Fire safety. Fire safety features, including compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with §510.121 of this subchapter (relating to Requirements for Buildings in which Existing Licensed Facilities are Located), and NFPA 101 Chapter 18 requirements for facilities. The Fire Safety Evaluation System for Health Care Occupancies contained in the National Fire Protection Association 101A, Alternative Approaches to Life Safety, 1998 edition, Chapter 3, shall not be used in new building construction, renovations, or additions to existing facilities.(ii) Access to exits. Corridors providing access to all patient, diagnostic, treatment, and sleeping rooms and exits shall be at least six feet in clear and unobstructed width (except as allowed by NFPA 101, §18-2.3.3, Exceptions 1 and 2), not less than 7 feet 6 inches in height, and constructed in accordance with requirements listed in NFPA 101 §18-3.6.(iii) Corridors in other occupancies. Public corridors in outpatient, administrative, and service areas which are designed to other than facility requirements and are the required means of egress from the facility shall be not less than five feet in width.(iv) Encroachment into the means of egress. Items such as drinking fountains, telephone booths or stations, and vending machines shall be so located as to not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment shall not be stored so as to project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(v) Doors in means of egress. All door leaves in the means of egress shall be not less than 36 inches wide or as otherwise permitted for facilities by NFPA 101 §18-2.3.5.(vi) Sliding doors. When sliding doors are provided to a means of egress corridor, the sliding doors shall have break-away provisions, positive latching devices, and shall be installed to resist passage of smoke.(vii) Control doors. Designs that include cross-corridor control doors should be avoided. When unavoidable, cross-corridor control doors shall consist of two 32-inch wide leaves which swing in a direction opposite from the other, or of the double acting type, and be provided with view panels.(viii) Emergency access. Rooms containing bathtubs, showers, or water closets, intended for patient use shall be provided with at least one outswinging door or special frame and hardware which will permit the door to swing out for staff access to a patient who may have collapsed against the door. The width of such doors shall not be less than 36 inches.(ix) Obstruction of corridors. All doors which swing towards the corridor must be recessed. Corridor doors to rooms not subject to occupancy (any room that you can walk into and close the door behind you is considered occupiable) may swing into the corridor, provided that such doors comply with the requirements of NFPA 101 §7-2.1.4.3.(x) Stair landing. Doors shall not open immediately onto a stair without a landing. The landing shall be 44 inches deep or have a depth at least equal to the door width, whichever is greater.(xi) Doors to rooms subject to occupancy. All doors to rooms subject to occupancy shall be of the swing type except that horizontal sliding doors complying with the requirements of NFPA 101 §18-2.2.2.9 are permitted. Door leaves to rooms subject to occupancy shall not be less than 36 inches wide unless noted otherwise.(xii) Operable windows and exterior doors. Windows that can be opened without tools or keys and outer doors without automatic closing devices shall be provided with insect screens.(xiii) Glazing. Glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor which may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame-spread ratings of NFPA 101 §18-3.3.(xiv) Fire doors. All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in National Fire Protection Association 80, Standard for Fire Doors and Fire Windows, 1999 edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(xv) Elevator doors. Elevator shaft openings shall be protected with a B labeled one-hour fire protection rated doors in buildings less than four stories; and one and one-half hour fire protection rated doors in buildings four or more stories.(xvi) Elevator lobbies. Elevator lobbies shall have at least 10 feet of clear floor space in front of the elevator doors.(xvii) Grab bars. Grab bars shall be provided at patient toilets, showers and tubs. The bars shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars are not permitted at bathing and toilet fixtures unless designed and installed to eliminate the possibility of patients harming themselves. Grab bars intended for use by persons with a disability shall also comply with ADA requirements.(xviii) Soap dishes. Recessed soap dishes shall be provided at all showers and bathtubs.(xix) Hand washing facilities. Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free operable controls shall be provided within each procedure room, workroom, examination and treatment room and all toilet rooms unless noted otherwise. Hands-free includes blade-type handles, and foot, knee, or sensor operated controls. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be provided and conveniently located for staff use throughout the facility where patient care and services are provided.(xx) Hand drying. Provisions for hand drying shall be included at all hand washing facilities except scrub sinks. There shall be hot air dryers or individual paper or cloth units enclosed in such a way as to provide protection against dust or soil and ensure single unit dispensing.(xxi) Mirrors. Mirrors shall not be installed at hand washing fixtures where asepsis control and sanitation requirements would be lessened by hair combing.(xxii) Ceiling heights. The minimum ceiling height shall be eight feet with the following exceptions.(I) Minor rooms. Ceilings in storage rooms, toilet rooms, and other minor rooms shall be not less than 7 feet 6 inches.(II) Boiler rooms. Boiler rooms shall have ceiling clearances not less than 2 feet 6 inches above the main boiler header and connecting piping.(III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than 6 feet 8 inches above the finished floor.(xxiii) Areas producing impact noises. Recreation rooms, exercise rooms, and similar spaces where impact noises may be generated shall not be located directly over patient bed area unless special provisions are made to minimize noise.(xxiv) Noise reduction. Noise reduction criteria in accordance with the Table 1 in §510.131(a) of this subchapter (relating to Tables) shall apply to partitions, floor, and ceiling construction in patient areas.(xxv) Rooms with heat producing equipment. Rooms containing heat-producing equipment such as heater rooms, laundries, etc. shall be insulated and ventilated to prevent any occupied floor surface above from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature.(xxvi) Chutes. Linen and refuse chutes shall comply with the requirements of National Fire Protection Association 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, 1999 edition, and NFPA 101 §18-5.4.(xxvii) Thresholds and expansion joint covers. Thresholds and expansion joint covers shall be flush with the floor surface to facilitate the use of wheelchairs and carts. Expansion and seismic joints shall be constructed to restrict the passage of smoke and fire and shall be listed by a nationally recognized testing laboratory.(xxviii) Housekeeping room.(I) In addition to the housekeeping rooms required in certain suites, sufficient housekeeping rooms shall be provided throughout the facility as required to maintain a clean and sanitary environment.(II) Each housekeeping room shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.(xxix) Public toilets. In addition to the public toilets required for the main lobby, a public toilet shall be provided convenient to each public and visitor waiting area. This may be a single unisex toilet for small waiting areas.(B) General finish requirements.(i) Cubicle curtains and draperies.(I) Cubicle curtains, draperies and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small scale and the large scale tests of National Fire Protection Association 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition. Copies of laboratory test reports for installed materials shall be submitted to the Texas Health and Human Services Commission at the time of the final construction inspection.(II) Cubicle curtains shall be provided to assure patient privacy.(ii) Flame spread, smoke development and noxious gases. Flame spread and smoke developed limitations of interior finishes shall comply with Table 2 of §510.131(b) of this subchapter and NFPA 101 §10-2.1. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition, and National Fire Protection Association 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 1997 edition, shall be provided.(iii) Floor finishes. Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet (such as shower and bath areas, kitchens, and similar work areas) shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes:(I) painted concrete;(II) vinyl and vinyl composition tiles and sheets;(III) monolithic or seamless flooring:(-a-) where required, seamless flooring shall be impervious to water, coved, and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles; and(-b-) welded joint flooring is acceptable;(IV) ceramic and quarry tile;(V) wood floors;(VI) carpet flooring, which if installed in patient rooms and similar patient care areas, shall be treated to prevent bacterial and fungal growth;(VII) terrazzo; and(VIII) poured in place floors.(iv) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall comply with requirements contained in Table 2 of §510.131(b) of this subchapter and NFPA 101 §18-3.3.(I) Wall finishes shall be water resistant in the immediate area of plumbing fixtures.(II) Wall finishes in areas subject to frequent wet cleaning methods shall be impervious to water, tightly sealed and without voids.(v) Floor, wall and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed.(vi) Ceiling types. All occupied rooms and spaces shall be provided with finished ceilings. Ceilings which are a part of a rated roof or ceiling assembly or a floor or ceiling assembly shall be constructed of listed components and installed in accordance with the listing. Three types of ceilings that are required in various areas of the facility are the following.(I) Ordinary ceilings. Ceilings such as acoustical tiles installed in a metal grid which are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners.(II) Washable ceilings. Ceilings that are made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid.(III) Monolithic ceilings. Ceilings which are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish.(vii) Special construction. Special conditions may require special wall and ceiling construction for security in areas such as storage of controlled substances and areas where patients are likely to attempt suicide or escape.(viii) Materials finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(3) General mechanical requirements. This paragraph contains common requirements for mechanical systems; steam and hot and cold water systems; air-conditioning, heating and ventilating systems; plumbing fixtures; piping systems; and thermal and acoustical insulation. The facility shall comply with the requirements of this paragraph and any specific mechanical requirements for the particular unit or suite of the facility in accordance with §510.123 of this subchapter.(A) Cost. All mechanical systems shall be designed for overall efficiency and life cycle costing, including operational costs. Recognized engineering procedures shall be followed to achieve the most economical and effective results. In no case shall patient care or safety be sacrificed for conservation.(B) Equipment location. Mechanical equipment may be located indoors or outdoors (when in a weatherproof enclosure), or in separate buildings.(C) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment which is a source of vibration shall be isolated from the equipment with vibration isolators.(D) Performance and acceptance. Prior to completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or the design engineer's representative that the installation and performance of these systems conform to the requirements of the plans and specifications.(i) Material lists. Upon completion of the contract, the owner shall be provided with parts lists and procurement information with numbers and description for each piece of equipment.(ii) Instructions. Upon completion of the contract, the owner shall be provided with instructions in the operational use of systems and equipment as required.(E) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 1999 edition, (NFPA 90A), NFPA 99, Chapter 5, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §510.123 of this subchapter.(i) General ventilation requirements. All rooms and areas in the facility listed in Table 3 of §510.131(c) of this subchapter shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §510.131(c) of this subchapter shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.(I) Cost reduction methods. To reduce utility costs, the building design and systems proposed shall utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shut down or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied, insofar as patient care is not jeopardized.(II) Economizer cycle. Mechanical ventilation shall be arranged to take advantage of outside air supply by using an economizer cycle when appropriate to reduce heating and cooling systems loads. Innovative design that provides for additional energy conservation while meeting the intent of this section for acceptable patient care will be considered.(III) Outside air intake locations. Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas which may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require other arrangements.) Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.(IV) Low air intake location limit. The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level.(V) Contaminated air exhaust outlets. Exhaust outlets from areas (kitchen hoods, ethylene oxide sterilizers, etc.) that exhaust contaminated air shall be above the roof level and arranged to exhaust upward.(VI) Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of §510.131(c) of this subchapter. For reductions and shut down of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 3 of §510.131(c) of this subchapter shall be followed.(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all general patient care areas and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted. Such areas include isolation rooms and food preparation areas.(VIII) Ventilation start-up requirements. Air handling systems shall not be started up and operated without the filters installed in place. This includes the 90% efficiency filters where required. Ducts shall be cleaned thoroughly by an air duct cleaning contractor when the air handling systems have been operating without the required filters in place.(IX) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used.(ii) Filtration requirements. All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified for those types of areas in Table 4 of §510.131(d) of this subchapter. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-conditioning Engineers (ASHRAE), Inc., Standard 52, 1999 edition. All joints between filter segments and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers.(I) Filtration requirements for air handling units serving single rooms requiring asepsis control. Dedicated air handlers serving only one room where asepsis control is required, including operating rooms, delivery rooms, special procedure rooms, and nurseries shall be equipped with filters having efficiencies equal to, or greater than, those specified for patient care areas in Table 4 of §510.131(d) of this subchapter.(II) Filtration requirements for air handling units serving other single rooms. Dedicated air handlers serving all other single rooms shall be equipped with nominal filters installed at the return air grille.(III) Location of multiple filters. Where two filter beds are required by Table 4 of §510.131(d) of this subchapter, filter bed number one shall be located upstream of the air-conditioning equipment and filter bed number two shall be downstream of the supply fan or blowers.(IV) Location of single filters. Where only one filter bed is required by Table 4 of §510.131(d) of this subchapter, it shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork.(V) Pressure monitoring devices. A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75% or more including hoods requiring high efficiency particulate air (HEPA) filters.(iii) Thermal and acoustical insulation for air handling systems. Asbestos insulation shall not be used.(I) Thermal duct insulation. Air ducts and casings with outside surface temperature below ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation.(II) Insulation in air plenums and ducts. Linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories, Inc., Standard Number 181.(III) Insulation flame spread and smoke developed ratings. Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A Chapters 2 and 3.(IV) Linings and acoustical traps. Duct lining and acoustical traps exposed to air movement shall not be used in ducts serving critical care areas. This requirement shall not apply to mixing boxes and acoustical traps that have approved nonabrasive coverings over such linings.(V) Frangible insulation. Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem.(VI) Existing duct linings. Internal linings shall not be used in ducts, terminal boxes, or other air system components supplying operating rooms, delivery rooms, birthing rooms, labor rooms, recovery rooms, nurseries, trauma rooms, isolation rooms, and intensive care units unless terminal filters of at least 90% efficiency are installed downstream of linings.(iv) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a two-hour or higher fire rated wall or floor in accordance with the requirements of NFPA 101 §18-5.2.(v) Smoke damper requirements. Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101 §18-3.7.3, and NFPA 90A Chapter 3.(I) Fail-safe installation. Smoke dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by National Fire Protection Association 72, National Fire Alarm Code, 1999 edition (NFPA 72), Chapter 5; NFPA 90A, Chapter 4; and NFPA 101, §18-3.7; the fire sprinkler system; and upon loss of power. Smoke dampers shall not close by fan shut-down alone.(II) Interconnection of air handling fans and smoke dampers. Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts.(III) Frangible devices. Use of frangible devices for shutting smoke dampers is not permitted.(vi) Acceptable damper assemblies. Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose shall be acceptable.(vii) Duct access doors. Unobstructed access to duct openings in accordance with NFPA 90A §2-3.4, shall be provided in ducts within reach and sight of every fire damper, smoke damper and smoke detector. Each opening shall be protected by an internally insulated door which shall be labeled externally to indicate the fire protection device located within.(viii) Restarting controls. Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided that provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices.(ix) Make-up air. If air supply requirements in Table 3 of §510.131(c) of this subchapter do not provide sufficient air for use by exhaust hoods and safety cabinets, filtered make-up air shall be ducted to maintain the required air flow direction in that room. Make-up systems for hoods shall be arranged to minimize short circuiting of air and to avoid reduction in air velocity at the point of contaminant capture.(4) General piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code, published by the International Association of Plumbing and Mechanical Officials, 2000 edition, and this paragraph.(A) Piping systems.(i) Water supply systems. Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(I) Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall be valved. Stop valves shall be provided at each fixture.(II) Backflow preventers. Backflow preventers (vacuum breakers) shall be installed on hose bibbs, laboratory sinks, janitor sinks, bedpan flushing attachments, and on all other fixtures to which hoses or tubing can be attached.(III) Flushing valves. Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.(IV) Capacity of water heating equipment. Water heating equipment shall have sufficient capacity to supply water for clinical, dietary and laundry use at the temperatures and amounts specified in Table 5 of §510.131(e) of this subchapter.(V) Water temperature measurements. Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment.(VI) Water storage tanks. Water storage tanks shall be fabricated of corrosion-resistant metal or lined with noncorrosive material.(VII) Hot water distribution. Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times.(VIII) Emergency water supply. Emergency potable water storage shall be provided. The storage capacity shall not be less than 500 gallons or 12 gallons per patient bed, whichever is greater. Capacity of hot water storage tanks may be included as part of the required emergency water capacity when valves and piping systems are arranged to make this water available at all times.(ii) Fire sprinkler systems. Fire sprinkler systems shall be provided in facilities as required by NFPA 101, §18-3.5. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA13, and shall be certified as required by §510.127(d)(3)(C) of this subchapter (relating to Preparation, Submittal, Review and Approval of Plans).(iii) Nonflammable medical gas and clinical vacuum systems. Nonflammable medical gas and clinical vacuum system installations shall be designed, installed and certified in accordance with the requirements of NFPA 99, §4-3 for Level I systems and the requirements of this clause.(I) Outlets. Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 6 of §510.131(f) of this subchapter.(II) Installer qualifications. All installations of the medical gas piping systems shall be done only by, or under the direct supervision of a holder of a master plumber license or a journeyman plumber license with a medical gas piping installation endorsement issued by the Texas State Board of Plumbing Examiners.(III) Installer tests. Prior to closing of walls, the installer shall perform an initial pressure test, a blowdown test, a secondary pressure test, a cross-connection test, and a purge of the piping system as required by NFPA 99.(IV) Qualifications for conducting verification tests and inspections. Verification tests and inspections by a party, other than the installer, shall be conducted by individuals who are technically competent and experienced in the field of piped medical gas systems.(V) Verification tests. Upon completion of the installer inspections and tests and after closing of walls, verification tests of the medical gas piping systems, the warning system, and the gas supply source shall be conducted. The verification tests shall include a cross-connection test, valve test, flow test, piping purge test, piping purity test, final tie-in test, operational pressure tests, and medical gas concentration test.(VI) Verification test requirements. Verification tests of the medical gas piping system, the warning system, shall be performed on all new piped medical gas systems, additions, renovations, or repaired portions of an existing system. All systems that are breached and components that are added, renovated, or replaced shall be inspected and appropriately tested. The breached portions of the systems subject to inspection and testing shall be all of the new and existing components in the immediate zone or area located upstream of the point or area of intrusion and downstream to the end of the system or a properly installed isolation valve.(VII) Warning system verification tests. Verification tests of piped medical gas systems shall include tests of the source alarms and monitoring safeguards, master alarm systems, and the area alarm systems.(VIII) Source equipment verification tests. Source equipment verification tests shall include medical gas supply sources (bulk and manifold) and the compressed air source systems (compressors, dryers, filters, and regulators).(IX) Written certification. Upon successful completion of all verification tests, written certification for affected piped medical gas systems and piped medical vacuum systems including the supply sources and warning systems shall be provided by a party technically competent and experienced in the field of medical gas pipeline testing stating that the provisions of NFPA 99 have been adhered to and systems integrity has been achieved. The written certification shall be submitted directly to the facility and the installer. A copy shall be forwarded to HHSC by the facility.(X) Facility responsibility. Before new piped medical gas systems, additions, renovations, or repaired portions of an existing system are put into use, the facility shall be responsible for ensuring that the gas delivered at the outlet is the gas shown on the outlet label and that the proper connecting fittings are checked against their labels.(XI) Documentation of medical gas and clinical vacuum outlets. Documentation of the installed, modified, extended, or repaired medical gas piping system shall be submitted to HHSC by the same party certifying the piped medical gas systems. The number and type of medical gas outlets (oxygen, vacuum, medical air, nitrogen, nitrous oxide, etc.) shall be documented and arranged tabularly by room numbers and room types.(iv) Steam and hot water systems.(I) Boilers. Boilers shall have the capacity, based upon the net ratings as published in The I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of GAMA, to supply the normal requirements of all systems and equipment. The number and arrangement of boilers shall be such that, when one boiler breaks down or routine maintenance requires that one boiler be temporarily taken out of service, the capacity of the remaining boilers shall be sufficient to provide hot water service for clinical, dietary, and patient use, steam for sterilization and dietary purposes, and heating for emergency, recovery, treatment, and general patient rooms. However, reserve capacity for space heating of noncritical care areas (e.g. general patient rooms and administrative areas) is not required in geographical areas where a design dry bulb temperature equals 25 degrees Fahrenheit or higher as based on the 99% design value shown in the Handbook of Fundamentals, 1999 edition, published by ASHRAE, Inc.(II) Boiler accessories. Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.(III) Valves. Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment.(v) Drainage systems.(I) Above ground piping. Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be copper pipe, copper tube, cast iron pipe, or galvanized iron pipe.(II) Underground piping. All underground building drains shall be cast iron soil pipe, hard temper copper tube (DWV or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), polyvinyl chloride (PVC) plastic pipe (DWV Schedule 40 or heavier), or extra strength vitrified clay pipe (VCP) with compression joints or couplings with at least 12 inches of earth cover.(III) Drains for chemical wastes. Separate drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant glass pipe, high silicone content cast iron pipe, VCP, plastic pipe, or plastic lined pipe.(IV) Drains above sensitive areas. Drainage pipes shall not be located above sensitive clean or sterile areas such as sterile processing, storage of food or of food preparation and serving areas, etc. unless protected from leaks or condensation by an approved method such as drip pans.(V) Sewers. Building sewers shall discharge into a community sewerage system. Where such a system is not available, a facility providing sewage treatment must conform to applicable local and state regulations.(vi) Thermal insulation for piping systems and equipment. Insulation shall be provided for the following:(I) boilers, smoke breeching, and stacks;(II) steam supply and condensate return piping;(III) hot water piping and all hot water heaters, generators, converters, and storage tanks;(IV) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur and insulation on cold surfaces shall include an exterior vapor barrier; and(V) other piping, ducts, and equipment as necessary to maintain the efficiency of the system.(vii) Pipe and equipment insulation rating. Flame spread shall not exceed 25 and smoke development rating shall not exceed 150 for pipe insulation as determined by an independent testing laboratory in accordance with National Fire Protection Association 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition. Smoke development rating for pipe insulation located in environmental air areas shall not exceed 50.(viii) Identification. All piping including heating, ventilating, air-conditioning (HVAC) shall be color coded or otherwise marked for easy identification.(ix) Asbestos insulation. Asbestos insulation shall not be used.(B) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive acid-resistant materials and shall comply with the recommendations of the National Standard Plumbing Code, and this paragraph.(i) Sink and lavatory controls. All fixtures used by medical and nursing staff and all lavatories used by patients and food handlers shall be trimmed with valves which can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may be used.(ii) Clinical sink traps. Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.(iii) Back flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(iv) Drinking fountain. Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination.(v) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent not only the contamination of the water supply but also the entrance of contaminating materials into the sterilizing units.(vi) Hose attachment. No hose shall be affixed to any faucet if the end of the hose can become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum-breaker.(vii) Bedpan washers and sterilizers. Bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(viii) Flood level rim clearance. The water supply spout for lavatories and sinks required in patient care areas shall be mounted so that its discharge point is a minimum of five inches above the rim of the fixture.(ix) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to grilled drain cover to prevent entry of large particles of waste which might cause stoppages.(x) Under counter piping. Under counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of floor below the equipment.(xi) Ice machines. All ice making machines shall be of the self-dispensing type, unless otherwise specified.(5) General electrical requirements. This paragraph contains common electrical requirements. The facility shall comply with the requirements of this paragraph and with any specific electrical requirements for the particular unit or suite of the facility in accordance with §510.123 of this subchapter. Electrical systems shall comply with NFPA 99 Chapter 3.(A) Electrical installations. All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of the National Fire Protection Association 70, National Electrical Code, 1999 edition (NFPA 70), and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturers' instructions.(i) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(ii) Extension cords and cables shall not be used for permanent wiring.(iii) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(iv) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70.(v) Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of floor below the equipment.(B) Installation testing and certification.(i) Installation testing. The electrical installations, including alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional.(I) Grounding continuity shall be tested as described in NFPA 99 for new or existing work.(II) A written record of performance tests on special electrical systems and equipment shall show compliance with applicable codes and standards.(ii) Installation certification. Certifications in affidavit form signed by a registered electrical engineer attesting that the electrical service, electrical equipment, and electrical appliances have been installed in compliance with the approved plans, applicable standards, or both shall be submitted to HHSC when requested.(C) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(D) Services and switchboards. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70, Article 384. Overload protective devices shall operate properly in ambient temperatures.(E) Panelboards. Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits may serve three floors, the floor where the panelboard is located, the floor above and the floor below. Panelboards serving life safety branch circuits may serve three floors, the floor where the panelboard is located, and the floors above and below.(i) Circuiting shall minimize the number of receptacles on a single branch circuit, in order to limit the effects of a branch circuit outage, caused by one faulted device. Any life-support equipment on that circuit would be lost.(ii) Loading of branch circuits is limited by NFPA 70, Articles 210, 220, and 384.(F) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in accordance with the requirements of NFPA 70, Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70, Article 300.(G) Lighting.(i) Lighting intensity for staff and patient needs shall comply with Chapter 17, Institution and Public Building Lighting, Health Care Facilities, of the Illuminating Engineering Society of North America (IES) Lighting Handbook, published by the IES.(I) Consideration should be given to controlling intensity and wavelength to prevent harm to the patient's eyes (i.e., cataracts due to ultraviolet light).(II) Approaches to buildings and parking lots, and all spaces within buildings shall have fixtures that can be illuminated as necessary. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so that all parts of these spaces shall be clearly visible.(III) Consideration should be given to the special needs of the elderly. Excessive contrast in lighting levels that makes effective sight adaptation difficult shall be minimized.(ii) Means of egress and exit sign lighting intensity shall comply with NFPA 101 §§7-8, 7-9 and 7-10.(iii) Electric lamps which may be subject to breakage or which are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(iv) Ceiling mounted examination light fixtures shall be suspended from rigid support structures mounted above the ceiling.(H) Receptacles. Only listed "hospital" grade single-grounding or duplex-grounding receptacles shall be used in all patient care areas. This does not apply to special purpose receptacles.(i) Installations of multiple ganged receptacles shall be permitted in patient care areas.(ii) Electrical outlets powered from the critical branch shall be provided in all patient care, procedure and treatment locations in accordance with NFPA 99 §3-4.2.2.2(c). At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel.(iii) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be accomplished with receptacles of the same distinct color as the existing receptacles.(iv) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(v) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor.(I) Equipment.(i) Equipment required for safe operation of the facility shall be powered from the equipment system in accordance with the requirements contained in NFPA 99 §3-4.2.2.3.(ii) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected and installed to provide both normal and standby service.(J) Ground fault circuit interrupters (GFCI). GFCIs shall comply with NFPA 70. When GFCIs are used in critical areas, provisions shall be made to ensure that other essential equipment is not affected by activation of one interrupter.(K) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a facility: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The facility shall comply with the requirements of this paragraph and any specific requirements for nurses calling systems for the particular unit of the facility in accordance with §510.123 of this subchapter.(i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds) audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signals in the corridor shall be canceled upon termination of the call. An alarm shall activate at the nurses station when the call cable is unplugged.(ii) A nurses emergency calling system shall be installed in all toilets used by all patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds) audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Activation of the system shall also activate distinct visible signals in the clean workroom, in the soiled workroom, medication, charting, clean linen storage, nourishment, nurse lounge and equipment storage. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor.(iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each bed and in each individual room. The emergency assistance calling device can be shared between two beds if conveniently located. Activation of the system will sound an audible signal at the nursing unit's nurses station, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Activation of the system shall also activate visible and audible signals in the clean workroom, in the soiled workroom, medication, charting, clean linen storage, nourishment, equipment storage, and examination or treatment rooms with back up to a continuously staffed area (other than the nurse station or an administrative center) from which assistance can be summoned. The system shall have voice communication capabilities so that the type of emergency or help required may be specified.(L) Emergency electric service. A Type I essential electrical system shall be provided in each facility in accordance with requirements of NFPA 99, NFPA 101, and National Fire Protection Association 110, Standard for Emergency and Standby Power Systems, 1999 edition. Exception: Crisis stabilization units have the option of providing a Type II essential electrical system in accordance with the requirements of NFPA 99 and NFPA 101.(i) The number of transfer switches to be used shall be based on reliability, design and load considerations.(ii) All wiring installation of the emergency system of the essential electrical system shall be mechanically protected in nonflexible metal raceways in compliance with NFPA 70 §517-30(c)(3).(iii) The stored fuel capacity for emergency generators shall be sufficient to permit continuous operation for at least 24 hours at full load.(M) Fire alarm system. A fire alarm system which complies with NFPA 101 §18-3.4, and with NFPA 72 Chapter 3 requirements, shall be provided in each facility. The required fire alarm system components are as follows.(i) A fire alarm control panel (FACP) shall be installed at a continuously attended (24 hour) location. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and is capable of indicating both visual and audible alarm, trouble and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.(ii) Manual fire alarm pull stations shall be installed in accordance with NFPA 101 §18-3.4.(iii) Smoke detectors for door release service shall be installed on the ceiling at each door opening in the smoke partition in accordance with NFPA 72 §2-10.6, where the doors are held open with electromagnetic devices conforming with NFPA 101 §18-2.2.6.(iv) Ceiling mounted smoke detectors shall be installed in room containing the FACP when this room is not attended continuously by staff as required by NFPA 72 §1-5.6.(v) Smoke detectors shall be installed in supply air ducts in accordance with NFPA 72 §2-10.4.2 and §2-10.5, and with NFPA 90A §4-4.2.(vi) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §2-10.4.2.2 and §2-10.5, and NFPA 90A §4-4.2(2).(vii) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101 §9-6.2; NFPA 13 §3-10; and NFPA 72 §3-8.5.(viii) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72 §3-8.6.(ix) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101, §18-3.4., and NFPA 72 §6-3.(x) Visual fire alarm indicating devices which comply with the requirements of §510.122(d)(1)(F) of this subchapter (relating to New Construction Requirements) and NFPA 72 §6-4 shall be provided.(xi) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory and be installed in accordance with such listing and the requirements of NFPA 72.(xii) A smoke detection system for spaces open to corridor(s) shall be provided when required by NFPA 101 §18-3.6.1.(xiii) A fire alarm signal notification which complies with NFPA 101 §9-6.3, shall be provided to alert occupants of fire or other emergency.(xiv) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70, Article 760.(xv) A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72 §3-9.3.7.(I) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 1996 edition.(II) The elevator recall smoke detection system in existing facilities shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 1995 edition.(xvi) A smoke detection system for initiating smoke removal from atriums shall be located above the highest floor level of the atrium and at return intakes from the atrium in accordance with National Fire Protection Association 92B, Guide for Smoke Management Systems in Malls, Atria, and Large Areas, 1995 edition.(xvii) Smoke detectors for shut-down of air handling units shall be provided. The detectors shall be installed in accordance with NFPA 90A §4-4.2.(xviii) New or modified fire alarm systems shall be certified as meeting applicable NFPA standards such as NFPA 101, 72A, 72E, etc. on form FML-009 040392 of the Office of the State Fire Marshal. A copy of the fire alarm system certification shall be submitted to HHSC.(N) Telecommunications and information systems. Telecommunications and information systems central equipment shall be installed in a separate location designed for the intended purpose. Special air conditioning and voltage regulation shall be provided as recommended by the manufacturer.(O) Lightning protection systems. When installed, lightning protection systems shall comply with National Fire Protection Association 780, Standard for the Installation of Lightning Protection Systems, 1997 edition. Source Note: The provisions of this §510.122 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.122 New Construction Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222070 03/12/2026 (a) Administration and public suite. The following rooms or areas shall be provided.(1) Primary entrance. An entrance at grade level shall be accessible and protected from inclement weather with a drive-under canopy for loading and unloading passengers.(2) Lobby. A main lobby shall be located at the primary entrance and shall include a reception and information counter or desk, waiting spaces, public toilet facilities, public telephones, drinking fountains, and storage room or alcove for wheelchairs.(3) Admissions area. An admissions area shall include a waiting area, work counters or desk, private interview spaces, and storage room or alcove for wheelchairs. The waiting area and wheelchair storage may be shared with similar areas located in the main lobby.(4) General or individual offices. Office space shall be provided for business transactions, medical and financial records, and administrative and professional staffs.(5) Multipurpose rooms. Rooms shall be provided for conferences, meetings, and health education purposes including provisions for showing visual aids.(6) Storage. Storage for office equipment and supplies shall be provided. The construction protection for the storage room or area shall be in accordance with the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 1997 edition (NFPA 101) §18-3.1.(b) Cart cleaning and sanitizing unit. A cart cleaning and sanitizing unit is optional for crisis stabilization units.(1) Architectural requirements.(A) Cart cleaning, sanitizing and storage shall be provided for carts serving dietary services and linen services.(B) Cart facilities may be provided for each service or be centrally located.(C) Hand washing fixtures shall be provided in cart cleaning, sanitizing and storage areas.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter (relating to New Construction Requirements) and this paragraph.(A) Flooring in the cart cleaning and sanitizing unit shall be of the seamless type, or ceramic or quarry tile as required by §510.122(d)(2)(B)(iii)(III) or (IV) of this subchapter.(B) Ceilings in the cart cleaning and sanitizing unit shall be the monolithic type as required by §510.122(d)(2)(B)(vi)(III) of this subchapter.(3) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph.(A) Hand washing fixtures shall be provided with hot and cold water. Hot and cold water fixtures shall be provided in cart cleaning and sanitizing locations.(B) Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste which might cause stoppages. Floor drains and floor sinks shall be located to avoid conditions where removal of covers for cleaning is difficult.(c) Central sterile supply suite. A central sterile supply suite is optional for crisis stabilization units.(1) Architectural requirements.(A) Supply storage. A storage room for clean and sterile supplies shall be provided. The storage room shall have adequate areas and counters for breakdown of prepackaged supplies.(B) Equipment storage. An equipment storage room shall be provided.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter and this paragraph. Ceilings in supply storage room shall be monolithic type in accordance with §510.122(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph.(A) The sterile supply room shall include provisions for ventilation, humidity, and temperature control.(B) Filtration requirements for air handling units serving the central sterile supply suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §510.131(d) of this subchapter (relating to Tables).(C) Duct linings exposed to air movement shall not be used in ducts serving the central sterile supply suite unless terminal filters of at least 90% efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(d) Dietary suite.(1) Architectural requirements.(A) General. Construction, equipment, and installation shall comply with the standards specified in 25 TAC Chapter 228 (relating to Retail Food Establishments).(B) Food service facilities. Food services shall be provided by an on-site food preparation system or an off-site food service system or a combination of the two. The following minimum functional elements shall be provided on-site regardless of the type of dietary services.(i) Dining area. Provide dining space for ambulatory patients, staff, and visitors with a minimum floor space of 15 square feet per person to be seated. The footage requirement does not include serving areas. The dining area and service areas shall be separate from the food preparation and distribution areas.(ii) Receiving area. This receiving area shall have direct access to the outside for incoming dietary supplies or off-site food preparation service and shall be separate from the general receiving area. The receiving area shall contain a control station and an area for breakout for loading, unloading, uncrating, and weighing supplies. The entrance area to the receiving area shall be covered from the weather.(iii) Storage spaces. Storage spaces shall be convenient to receiving area and food preparation area and shall be located to exclude traffic through the food preparation area. Regardless of the type of food services provided, the facility shall provide storage of food for emergency use for a minimum of four calendar days.(I) Storage space. Storage space shall be provided for bulk, refrigerated, and frozen foods.(II) Cleaning supply storage. This room or closet shall be used to store non-food items that might contaminate edibles. This storage area may be combined with the housekeeping room.(iv) Food preparation area. Counter space shall be provided for food prep work, equipment, and an area to assemble trays for distribution for patient meals.(v) Ice making equipment. Ice making equipment shall be provided for both drinks and food products (self-dispensing equipment) and for general use (storage-bin type equipment).(vi) Hand washing. Hand washing fixtures with hands-free operable controls shall be conveniently located at all food preparation areas and serving areas.(vii) Food service carts. When a cart distribution system is provided, space shall be provided for storage, loading, distribution, receiving, and sanitizing of the food service carts. The cart traffic shall be designed to eliminate any danger of cross-circulation between outgoing food carts and incoming soiled carts, and the cleaning and sanitizing process. Cart circulation shall not be through food processing areas.(viii) Ware washing room. A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross traffic between the dirty side and clean side of the dish wash areas shall be provided.(ix) Pot washing facilities. A three compartmented sink of adequate size for intended use shall be provided convenient to the food preparation area. Supplemental heat for hot water to clean pots and pans shall be by booster heater or by steam jet.(x) Waste storage room. A food waste storage room shall be conveniently located to the food preparation and ware washing areas but not within the food preparation area. It shall have direct access to the facility's waste collection and disposal facilities. A waste storage room is optional for crisis stabilization units.(xi) Sanitizing facilities. Storage areas and sanitizing facilities for garbage or refuse cans, carts, and mobile tray conveyors shall be provided. All containers for trash storage shall have tight-fitting lids.(xii) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the dietary department. Where hot water or steam is used for general cleaning, additional space within the room shall be provided for the storage of hoses and nozzles.(xiii) Office spaces. An office shall be provided for the use of the food service manager or the dietary service manager. In smaller facilities, a designated alcove may be located in an area that is part of the food preparation area.(xiv) Toilets and locker spaces. A toilet room shall be provided for the exclusive use of the dietary staff. Toilets shall not open directly into the food preparation areas but must be in close proximity to them. For larger facilities, a locker room or space for lockers shall be provided for staff belongings.(C) Additional service areas, rooms, and facilities. When an on-site food preparation system is used, in addition to the items required in subparagraph (B), the following service areas, rooms, and facilities shall be provided.(i) Food preparation facilities. When food preparation systems are provided, there shall be space and equipment for preparing, cooking, and baking.(ii) Tray assembly line. A patient tray assembly and distribution area shall be located within close proximity to the food preparation and distribution areas.(iii) Food storage. The food storage room shall be adequate in size to accommodate food for a seven calendar day menu cycle.(iv) Additional storage areas. Additional areas shall be provided for the storage of cooking wares, extra trays, flatware, plastic and paper products, and portable equipment.(v) Drying storage area. Provisions shall be made for drying and storage of pots and pans from the pot washing room.(D) Equipment. Equipment for use in the dietary suite shall meet the following requirements.(i) Mechanical devices shall be heavy duty, suitable for the use intended, and easily cleaned. Where equipment is movable, provide heavy duty locking casters. Equipment with fixed utility connections shall not be equipped with casters.(ii) Floor, wall, and top panels of walk-in coolers, refrigerators, and freezers shall be insulated. Coolers and refrigerators shall be capable of maintaining a temperature down to freezing. Freezers shall be capable of maintaining a temperature of 20 degrees below 0 degrees Fahrenheit. Coolers, refrigerators, and freezers shall be thermostatically controlled to maintain desired temperature settings in increments of two degrees or less. Interior temperatures shall be indicated digitally and visible from the exterior. Controls shall include audible and visible high and low temperature alarm. The time of alarm shall be automatically recorded.(iii) Walk-in units may be lockable from the outside but must have a release mechanism for exit from inside at all times. The interior shall be lighted. All shelving shall be corrosion resistant, easily cleaned, and constructed and anchored to support a loading of at least 100 pounds per linear foot.(iv) All cooking equipment shall be equipped with automatic shut-off devices to prevent excessive heat buildup.(E) Vending services. When vending machines are provided, a dedicated room or an alcove shall be located so that access is available at all times.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter and this paragraph.(A) Details.(i) Food storage shelves shall not be less than six inches above the finished floor and the space below the bottom shelf shall be closed in and sealed tight for ease of cleaning.(ii) Operable windows and doors not equipped with automatic closing devices shall be equipped with insect screens.(iii) Food processing areas in the central dietary kitchen shall have ceiling heights not less than nine feet. Ceiling mounted equipment shall be supported from rigid structures located above the finished ceiling.(iv) Mirrors shall not be installed at hand washing fixtures in the food preparation areas.(B) Finishes.(i) Floors in areas used for food preparation, food assembly, soiled and clean ware cleaning shall be water-resistant and grease-proof. Floor surfaces, including tile joints, shall be resistant to food acids.(ii) Wall bases in food preparation, food assembly, soiled and clean ware cleaning and other areas which are frequently subject to wet cleaning methods shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and be impervious to water.(iii) In the dietary and food preparation areas, the wall construction, finishes, and trim, including the joints between the walls and the floors, shall be free of voids, cracks, and crevices.(iv) The ceiling in food preparation and food assembly areas shall be washable as required by §510.122(d)(2)(B)(vi)(II) of this subchapter.(v) The ceiling in the food storage room and soiled and clean ware cleaning area shall be of the monolithic type as required by §510.122(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical Requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph.(A) Exhaust hoods handling grease-laden vapors in food preparation centers shall comply with National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. All hoods over cooking ranges shall be equipped with grease filters, fire extinguishing systems, and heat-actuated fan controls. Clean out openings shall be provided every 20 feet and at any changes in direction in the horizontal exhaust duct systems serving these hoods. (Horizontal runs of ducts serving range hoods should be kept to a minimum.)(B) When air change standards in Table 3 of §510.131(c) of this subchapter do not provide sufficient air for proper operation of exhaust hoods (when in use), supplementary filtered makeup air shall be provided in these rooms to maintain the required airflow direction and exhaust velocity. Makeup systems for hoods shall be arranged to minimize "short circuiting" of air and to avoid reduction in air velocity at the point of contaminant capture.(C) Air handling units serving the dietary suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §510.131(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph.(A) The kitchen grease traps shall be located and arranged to permit easy access without the need to enter food preparation or storage areas. Grease traps shall be of capacity required and shall be accessible from outside of the building without need to interrupt any services.(B) Grease traps or grease interceptors shall be located outside the food preparation area and shall comply with the requirements in the International Association of Plumbing and Mechanical Officials National Standard Plumbing Code, 2000 edition.(C) The material used for plumbing fixtures shall be non-absorptive and acid-resistant.(D) Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and containers.(E) Hand washing fixtures used by food handlers shall be trimmed with valves that can be operated without hands. Single lever or wrist blade devices may be used. Blade handles used for this purpose shall not be less than four inches in length.(F) Drainage and waste piping shall not be installed in the space above the ceiling or installed in an exposed location in food preparation centers, food serving facilities and food storage areas unless special precautions are taken to protect the space below from leakage and condensation from necessary overhead piping.(G) No plumbing lines may be exposed overhead or on walls where possible leaks would create a potential for food contamination.(5) Electrical requirements. Electrical requirements shall be in accordance with §510.122(d)(5) of this subchapter and this paragraph.(A) Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(B) The electrical circuits to equipment in wet areas shall be provided with five milliampere GFCI.(e) Emergency treatment room.(1) Architectural requirements.(A) Emergency treatment room. As a minimum requirement, a facility shall provide at least one emergency treatment room to handle emergencies. The emergency treatment room may be located anywhere in the facility and shall meet the following requirements.(i) The emergency treatment room shall have a minimum clear area of 120 square feet clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 10 feet. The emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and hand washing fixtures with hands-free operable controls. Exception: Crisis stabilization units are not required to have medication storage in the emergency treatment room.(ii) Storage space shall be provided within the room or on an emergency cart and be under staff control for general medical emergency supplies and medications. Adequate space shall be provided for emergency equipment.(B) Secured holding room. When provided, this room shall be constructed to allow for security, patient and staff safety, patient observation, and sound proofing.(C) Service areas. The following service areas shall be provided.(i) Soiled workroom. The workroom shall contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles. The soiled workroom in the nursing suite may be shared with the emergency treatment room if it is located conveniently nearby.(ii) Housekeeping room. The housekeeping room shall be located nearby.(iii) Patient toilet. A toilet room shall be provided and located nearby.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter and this paragraph.(A) Flooring used in the treatment room, secure holding area, and soiled workroom shall be of the seamless type as required by §510.122(d)(2)(B)(iii)(III) of this subchapter.(B) Ceilings in soiled workrooms and secure holding rooms shall be of the monolithic type as required by §510.122(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph. Duct linings exposed to air movement shall not be used in ducts serving any treatment rooms and secure holding rooms. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter. When provided, medical gas systems shall be in accordance with §510.122(d)(4)(A)(iii) of this subchapter.(5) Electrical requirements. Electrical requirements shall be in accordance with §510.122(d)(5) of this subchapter and this paragraph.(A) General.(i) Each treatment room shall have a minimum of six duplex electrical receptacles. Two duplex electrical receptacles shall be located convenient to the head of the bed.(ii) Each work counter and table shall have access to two duplex receptacles connected to the critical branch of the emergency electrical system and be labeled with panel and circuit number.(B) Nurses calling systems. A nurses regular calling system shall be provided for the treatment room in accordance with §510.122(d)(5)(K)(i) of this subchapter.(f) Employees suite. Lockers, lounges, toilets, and other amenities as determined by the facility shall be provided throughout the facility for employees and volunteers. These amenities are in addition to, and separate from, those required for the medical staff and the public.(g) Engineering suite and equipment areas.(1) General. The following areas or rooms shall be provided:(A) an engineer's office with file space and provisions for protected storage of facility drawings, records, manuals, etc.;(B) a general maintenance shop for repair and maintenance;(C) a separate room for building maintenance supplies and equipment and storage of bulk solvents and flammable liquids shall be in a separate building and not within the facility building;(D) a medical equipment room which includes provisions for the storage, repair, and testing of electronic and other medical equipment;(E) a separate room or building for yard maintenance equipment and supplies. When a separate room is within the physical plant the room shall be located so that equipment may be moved directly to the exterior. Yard equipment or vehicles using flammable liquid fuels shall not be stored or housed within the facility building; and(F) sufficient space in all mechanical and electrical equipment rooms for proper maintenance of equipment. Provisions shall also be made for removal and replacement of equipment.(2) Additional areas or rooms. Additional areas or rooms for mechanical, and electrical equipment shall be provided within the physical plant or installed in separate buildings or weatherproof enclosures with the following exceptions.(A) An area shall be provided for cooling towers and heat rejection equipment when such equipment is used.(B) An area for the medical gas park and equipment shall be provided. For smaller medical gas systems, the equipment may be housed in a room within the physical plant in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, 1999 edition (NFPA 99), Chapters 4 and 8.(C) When provided, compactors, dumpsters, and incinerators shall be located in an area remote from public entrances.(h) General stores.(1) General. In addition to storage rooms in individual departments, a central storage room shall also be provided. General stores may be located in a separate building on-site with provisions for protection against inclement weather during transfer of supplies.(2) Receiving. Central storage areas shall be provided with an off-street unloading and receiving area protected from inclement weather.(3) General storage room. General storage room with a total area of not less than 12 square feet per inpatient bed shall be provided. The storage room may be within the facility, or separate building on-site. A portion of the storage may be provided off-site.(4) Outpatient suite storage room. A storage room for the outpatient services shall be provided at least equal to five percent of the total area of the outpatient suite. This required storage room area may be combined with general stores.(i) Geriatric, Alzheimer, and other dementia nursing suites. When geriatric, Alzheimer, or other dementia nursing suites are provided, the nursing suite shall comply with the requirements in subsection (o) of this section with the following exceptions.(1) A patient bedroom suite shall be 120 square feet in a single patient bedroom suite and 200 square feet in multiple-bed room suites.(2) Each patient bedroom shall have storage for extra blankets, pillows, and linen.(3) Patient bedroom doors shall be a minimum of three feet eight inches in width.(4) Patients shall have access to at least one bathtub in each nursing suite.(5) A minimum of two separate social spaces, one appropriate for noisy activities and the other for quiet activities, shall be provided. The combined total area shall be not less than 30 square feet per bed space with not less than 140 square feet for each of the two spaces, whichever is greater. This space may be shared with the dining area or room.(6) Storage space for wheelchairs shall be provided in the nursing unit.(j) Imaging suite.(1) Architectural requirements.(A) General. When diagnostic imaging services are provided, the minimum the facility shall provide is a diagnostic radiographic (X-ray) room.(i) Diagnostic radiographic (x-ray) room sizes shall be in compliance with manufacturer's recommendation. When portable x-ray equipment is used, the portable unit shall be stored in a secured room.(ii) When radiation protection is required for any diagnostic imaging room, a medical physicist licensed under Texas Occupations Code Chapter 602, shall specify the type, location, and amount of radiation protection to be installed for the layout and equipment selections.(iii) Each X-ray room shall include a shielded control alcove. The control alcove shall be provided with a view window designed to permit full view of the examination table and the patient at all times.(iv) Warning signs capable of indicating that the equipment is in use shall be provided.(B) Service areas. The following service areas shall be provided.(i) Patient waiting area. The area shall be out of traffic and under direct staff visual control.(ii) Patient toilet rooms. Toilet rooms with hand washing amenities shall be located convenient to the waiting area.(iii) Patient dressing rooms. Dressing rooms shall be convenient to the waiting areas and X-ray rooms.(iv) Hand washing facilities. A freestanding hand washing fixture with hands-free controls shall be provided in or near the entrance to each diagnostic and procedure room unless noted otherwise. Hand washing facilities shall be arranged to minimize any incidental splatter on nearby personnel or equipment.(v) Contrast media preparation. This room shall include a work counter, a sink with hands-free operable controls, and storage. One preparation room may serve any number of rooms. When prepared media is used, this area may be omitted, but storage shall be provided for the media.(vi) Film processing room. A darkroom shall be provided for processing film unless the processing equipment normally used does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the procedure rooms and to the quality control area.(vii) Quality control area or room. An area or room for film viewing shall be located near the film processor. All view boxes shall be illuminated to provide light of the same color value and intensity.(viii) Film storage (active). A room shall include a cabinet or shelves for filing patient film for immediate retrieval.(ix) Film storage (inactive). A room for inactive film storage shall be provided. It may be outside the imaging suite but must be under the administrative control of imaging suite personnel and be properly secured to protect films against loss or damage.(x) Storage for unexposed film. Storage amenities for unexposed film shall include protection of film against exposure or damage.(xi) Storage of cellulose nitrate film. When used, cellulose nitrate film shall be stored in accordance with the requirements of National Fire Protection Association 40, Standard for the Storage and Handling of Cellulose Nitrate Motion Picture Film, 1994 edition.(xii) Housekeeping room. The room may serve multiple departments when conveniently located.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter and this paragraph.(A) Details.(i) Radiation protection shall be designed, tested, and approved by a medical physicist licensed under Texas Occupations Code Chapter 602.(ii) The design and environmental controls associated with licensable quantities of radioactive material in laboratories, imaging rooms, or both shall be approved by the Texas Department of State Health Services Radiation Control Program prior to licensed authorizations.(iii) Where protected alcoves with view windows are required, provide a minimum of 1 foot 6 inches between the view window edge or frame and the outside partition edge.(iv) Imaging procedure rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(B) Finishes.(i) Flooring used in contrast media preparation and soiled workroom shall be of the seamless type as required by §510.122(d)(2)(B)(iii)(III) of this subchapter.(ii) A lay-in type ceiling is acceptable for the diagnostic room.(3) Mechanical Requirements.(A) Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph.(B) Air handling units serving the imaging suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §510.131(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided.(5) Electrical requirements. Electrical requirements shall be in accordance with §510.122(d)(5) of this subchapter and this paragraph.(A) General.(i) Each imaging procedure room shall have at least four duplex electrical receptacles.(ii) A special grounding system in areas such as imaging procedures rooms where a patient may be treated with an internal probe or catheter shall comply with Chapter 9 of NFPA 99 and Article 517 of NFPA 70.(iii) General lighting with at least one light fixture powered from a normal circuit shall be provided in imaging procedures rooms in addition to special lighting units at the procedure or diagnostic tables.(B) Nurses calling system.(i) Nurses regular calling system. The nurses regular calling system shall be provided for patient dressing rooms in accordance with §510.122(d)(5)(K)(i) of this subchapter.(ii) Nurses emergency calling system. In toilet rooms used by inpatients and outpatients, a nurses emergency call station shall be provided in accordance with §510.122(d)(5)(K)(ii) of this subchapter.(iii) Staff emergency assistance calling system. A staff emergency assistance calling system (code blue) shall be provided for staff to summon additional assistance for each imaging procedure room in accordance with §510.122(d)(5)(K)(iii) of this subchapter.(k) Laboratory suite.(1) Architectural requirements.(A) General. The required laboratory testing shall be performed on-site or provided through a contractual arrangement with a laboratory service.(i) Provisions for laboratory services shall be provided within the facility for urinalysis, blood glucose and electrolytes.(ii) Each laboratory unit shall meet the requirements of Chapter 10 of NFPA 99 and Chapter 18 of NFPA 101.(B) Minimum laboratory. When laboratory services are provided off-site by contract, the following minimum areas or rooms shall be provided within the facility.(i) Laboratory work room. The laboratory workroom shall include a counter and a sink with hands-free operable controls.(ii) General storage. Cabinets or closets shall be provided for supplies and equipment used in obtaining samples for testing. A refrigerator or other similar equipment shall be provided for specimen storage waiting for transfer to off-site testing.(iii) Specimen collection room. A blood collection room shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands-free operable controls shall be provided for specimen collection. This room may be outside the laboratory suite if conveniently located.(C) On-site laboratory. When the facility provides on-site laboratory services, the following areas or rooms shall be provided in addition to the requirements in paragraph (1)(A) and (1)(B) of this subsection.(i) Laboratory workrooms. The laboratory work room shall include counters, space appropriately designed for laboratory equipment, sinks with hands-free operable controls, vacuum, gases, air, and electrical services as needed.(ii) General storage. Storage, including refrigeration for reagents, standards, supplies, and stained specimen microscope slides, etc. shall be provided. Separate spaces shall be provided for such incompatible materials as acids and bases, and vented storage shall be provided for volatile solvents.(iii) Chemical safety. When chemical safety is a requirement, provisions shall be made for an emergency shower and eye flushing devices.(iv) Flammable liquids. When flammable or combustible liquids are used, the liquids shall be stored in approved containers, in accordance with National Fire Protection Association 30, Flammable and Combustible Liquids Code, 1996 edition.(v) Radioactive materials. When radioactive materials are employed, storage amenities shall be provided.(D) Service areas or rooms. The following service areas or rooms shall be provided.(i) Hand washing amenities. Each laboratory room or work area shall be provided with a hand washing fixture with hands-free operable controls.(ii) Office spaces. The scope of laboratory services shall determine the size and quantity for administrative areas including offices as well as space for clerical work, filing, and record maintenance. At a minimum, an office space shall be provided for the use of the laboratory service director.(iii) Staff facilities. Lounge, locker, and toilet amenities shall be conveniently located for male and female laboratory staff. These may be outside the laboratory area and shared with other departments.(iv) Housekeeping room. A housekeeping room shall be located nearby.(2) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this subchapter. Floors in laboratories shall comply with the requirements of §510.122(d)(2)(B)(iii) of this subchapter except that carpet flooring shall not be used.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph.(A) No air from the laboratory areas shall be recirculated to other parts of the facility. Recirculation of air within the laboratory suite is allowed.(B) When laboratory hoods are provided, they shall meet the following general requirements.(i) The average face velocity of each exhaust hood shall be at least 75 feet per minute.(ii) The exhaust shall be connected to an exhaust system to the outside which is separate from the building exhaust system.(iii) The exhaust fan shall be located at the discharge end of the system.(iv) The exhaust duct system shall be of noncombustible and corrosion resistant material.(C) Filtration requirements for air handling units serving the laboratory suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §510.131(d) of this subchapter.(D) Duct linings exposed to air movement shall not be used in ducts serving any laboratory room and clean room unless terminal filters of at least 80% efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph.(A) General.(i) Faucet spouts at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of beakers, test tubes, etc.(ii) Drain lines from sinks used for acid waste disposal shall be made of acid-resistant material.(iii) Drain lines serving some types of automatic blood-cell counters must be of carefully selected material that will eliminate potential for undesirable chemical reactions (or explosions) between sodium azide wastes and copper, lead, brass, and solder, etc.(B) Medical gas systems. When provided, medical gas systems shall comply with §510.122(d)(4)(A)(iii) of this subchapter. The number of outlets in the laboratory for vacuum, gases, and air shall be determined by the functional program requirements.(l) Laundry suite. Laundry amenities may be provided on-site or off-site. On-site laundry services may be within the facility or in a separate building.(1) Architectural requirements.(A) General. The following amenities are required for both on-site or off-site commercial laundry services.(i) The laundry room shall be equipped and ventilated so as to minimize the dissemination of contaminants.(ii) Soiled and clean linen processing areas shall be physically separated.(iii) An adequate amount of hand washing fixtures shall be provided in both the soiled and clean processing areas.(B) On-site laundry processing. When linen is processed within the facility or in a separate building located on-site, the following minimum requirements shall be provided.(i) A receiving, holding, and sorting room for control and distribution of soiled linen shall be provided. This area may be combined with the soiled linens processing room. Discharge from soiled linen chutes may be received within this room or in a separate dedicated room.(ii) A laundry processing room shall be provided which shall contain commercial type equipment capable of processing at least a seven-day laundry supply within the regular scheduled work week.(iii) A clean linen processing room shall be provided and shall include built-in dryers and folding counters or tables. This area shall have provisions for inspections, folding, packing, and mending of linen.(iv) A holding room or area for storage and issuing of clean linen shall be provided but may be combined with clean linen processing room.(C) Off-site laundry processing. When linen is processed off the facility site, the following minimum requirements shall be provided on-site:(i) a service entrance which shall have protection from inclement weather, for loading and unloading of linen;(ii) control station for pickup and receiving;(iii) soiled linen holding room;(iv) a central clean linen storage room and issuing room in addition to linen storage required at the individual patient suites. This central holding area shall include provisions for inspecting, sorting, and mending; and(v) cart storage areas, which shall be located out of pedestrian traffic and shall be provided separately for clean and soiled linen.(D) Service areas for on-site laundry processing. The laundry shall be separated from patient rooms, areas of food preparation and storage, and areas in which clean supplies and equipment are stored. An on-site laundry shall have the following services areas and facilities.(i) Office space. Office space for director of laundry services.(ii) Equipment layout for soiled and clean linen. The laundry equipment processing shall be arranged to permit an orderly work flow and minimize cross-traffic that might mix clean and soiled operations.(iii) Storage. Storage space and cabinets for soaps, stain removers, and other laundry processing agents shall be located in the soiled and clean processing rooms.(iv) Cart sanitizing. Cart sanitizing shall comply with subsection (b) of this section.(v) Staff toilets. Toilets may be outside the unit but shall be convenient for staff use and shall contain hand washing fixtures with hands-free operable controls.(vi) Staff lockers. Lockers may be in laundry suite or part of a central locker area when convenient to the laundry.(vii) Housekeeping room.(2) Mechanical Requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this chapter and this paragraph.(A) The ventilation system shall include adequate intake, filtration, exchange rate, and exhaust in accordance with Table 3 and Table 4 of §510.131(c) and (d) of this subchapter.(B) Filtration requirements for air handling units serving the laundry suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §510.131(d) of this subchapter.(C) Direction of air flow of the HVAC systems shall be from clean to soiled areas.(D) The ventilation system for soiled processing area shall have negative air pressure while the clean processing area shall have positive pressure.(m) Medical records suite. The following rooms, areas, or offices shall be provided in the medical records suite:(1) medical records administrator or technician office;(2) review and dictating rooms or spaces;(3) work area which includes provisions for sorting, recording, or microfilming records; and(4) file storage room. Rooms containing open file systems or moveable filing storage systems shall be considered as hazardous. The construction protection for the storage room or area shall comply with NFPA 101 §18-3.2.(n) Nursing suite. The nursing suite shall be designed to facilitate care of ambulatory and non-ambulatory inpatients.(1) Physical environment. A nursing suite shall provide a safe environment for patients and staff.(A) The environment of the unit shall be characterized by a feeling of openness with emphasis on natural light and exterior views and with the organization of various functions accessible to common spaces while not jeopardizing desirable levels of patient privacy.(B) Interior finishes, lighting, and furnishings shall present an atmosphere which is as noninstitutional as possible, consistent with applicable fire safety requirements. Security and safety devices should not be present in a manner to attract or challenge tampering by patients.(2) Architectural requirements. Architectural requirements shall be in accordance with §510.122(d)(1) of this subchapter and this paragraph.(A) Handicapped accessibility requirements. At least 10 percent of patient room suites, bathing units and toilets, and all public and common use areas shall be designed and constructed to be handicapped accessible. These requirements shall apply in all new construction and when an existing nursing suite or a portion thereof is converted from one service to another.(B) Patient room suites. A patient room suite shall consist of the patient room and a toilet room or bathroom. Patient room suites shall comply with the following requirements.(i) Maximum patient room capacity. The maximum patient room capacity shall be two patients. In existing facilities where renovation work is undertaken and the present capacity is more than two patients, the maximum room capacity shall be no more than the present capacity with a maximum of four patients.(ii) Single-bed patient room. In a single-bed patient room, the minimum clear floor area shall be 100 square feet. The minimum clear floor area in an accessible private patient room shall be 120 square feet. The minimum room dimension shall be not less than 10 feet.(iii) Multi-bed patient room. In a multi-bed patient room, the minimum clear floor area shall be 80 square feet per bed. Minimum clear floor space in an accessible multi-bed room shall be 110 square feet per bed. Design of multi-bed patient rooms shall not restrict independent patient access to the corridor, lavatory, or bathroom.(iv) Arrangement of patient rooms. Minor encroachments including columns and wall hung lavatories that do not interfere with functions may be ignored when determining space requirements for patient rooms.(I) Required clear floor space in patient rooms shall be exclusive of toilet rooms, closets, lockers, built-in cabinets, wardrobes, alcoves, or vestibules.(II) A clearance of 3 feet 8 inches shall be available at the foot of each bed in multi-bed patient rooms to permit the passage of equipment and beds. A minimum distance of three feet between a wall and the side of a bed and four feet between beds shall be provided. A minimum distance of five feet between a wall and the side of a bed and four feet between beds shall be provided in an accessible semi-private room or one intended for rehabilitation patients. Arrangement of beds shall be such that sufficient space is provided for a bed and maneuvering space for a wheelchair.(III) Sleeping areas shall have doors for privacy. Design for visual privacy in multi-bed rooms shall not restrict patient access to the room, toilet, or observation by staff.(v) Patient bathroom. Each patient shall have access to a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet, hand washing fixtures, and storage shelf or cabinet and serve not more than four patient beds or two patient rooms. Hand washing fixtures may be located in the patient room.(vi) Bathing rooms. One bathtub or shower shall be provided for each four patient beds or space which is not otherwise served by bathing rooms within patients' rooms. Each tub or shower shall be in an individual room or enclosure which provides space for the private use of the bathing fixture and for drying and dressing.(vii) Patient storage. Each patient shall have a separate wardrobe, locker, or closet that is suitable for hanging full-length garments and for storing personal effects. A minimum of 12 lineal inches of hanging space shall be provided per patient.(C) Security rooms. When security rooms are provided by the treatment program narrative, the security rooms shall be single patient suite rooms designed to minimize potential for escape, hiding, injury to self or others, or suicide. Access to toilets, showers, and wardrobes shall be restricted. The patient room suite shall be in accordance with subparagraph (B)(ii) of this paragraph. Security rooms may be centralized on one unit or decentralized among units.(D) Seclusion suite. There shall be a seclusion suite in each nursing suite intended for short-term occupancy by a single person requiring security and protection from self or others. The seclusion suite shall consist of seclusion rooms, an anteroom or a vestibule, a toilet, and hand washing fixtures.(i) Each seclusion room shall be located and designed in a manner affording direct visual supervision by nursing staff and shall be constructed to prevent patient hiding, escape, injury, or suicide. There shall be a minimum of one seclusion room for each 24 beds or any portion thereof.(I) The floor area of each seclusion room shall be not less than 60 square feet. The minimum room dimension shall be six feet.(II) The seclusion room shall have a minimum ceiling height of nine feet.(III) The door to each seclusion room shall have no hardware on the room side and shall open out. A vision panel shall be provided in each door to permit staff observation of the entire room while maintaining privacy from the public and other patients. The seclusion room door shall swing out.(IV) Each seclusion room shall have natural light (skylight or window) in order to maintain a therapeutic environment. Skylight wells or windows shall be not less than 400 square inches in area.(ii) Access to the seclusion room from any public space such as a corridor shall be through an anteroom. When the seclusion suite is directly accessible from the nurse station, a vestibule may be provided in place of an anteroom. A cased opening to the vestibule in lieu of a door may be provided as long as the arrangement assures privacy from the public and other patients.(I) The minimum dimension of the anteroom or vestibule shall be eight feet.(II) The door to the anteroom shall swing in.(iii) There shall be at least one toilet room directly accessible from the anteroom or vestibule.(I) The toilet room shall be large enough to safely manage the patient.(II) The toilet room door shall swing out into the anteroom or vestibule.(III) A water closet and hand washing fixtures shall be provided in the toilet room. An unbreakable wall hung mirror may be provided.(IV) Doors for the seclusion room and anteroom shall be not less than 3 feet 8 inches in width.(V) When the interior of the seclusion room is padded, the padding shall be a Class "A." The flame spread rating shall be 0-25 and the smoke development rating shall be 0-450 in accordance with NFPA 101 Chapter 8.(E) Airborne infection isolation suites. When an isolation suite is provided, the suite may be located within a nursing suite or in a separate isolation unit. Each airborne infection isolation suite shall consist of a work area, a patient room, and a patient bathroom.(i) The work area may be a separately enclosed anteroom or a vestibule that is open to and is located immediately inside the door to the patient room. It shall have amenities for hand washing, gowning, and storage of clean and soiled materials. One enclosed anteroom may serve multiple isolation rooms.(ii) Each patient room shall have a clear floor area of 120 square feet exclusive of the work area and shall contain only one bed.(iii) Each bathroom shall be designed for the use of the handicapped and shall contain bathing fixtures, toilet fixtures and hand washing fixtures. Each bathroom shall be arranged to provide access from the patient room without entering or passing through the work area.(iv) At least one airborne infection isolation suite with an enclosed anteroom shall be provided.(v) Ventilation requirements for the isolation rooms shall be in accordance with Table 3 of §510.131(c) of this subchapter.(vi) Doors to airborne infection isolation rooms shall be provided with self-closing devices.(F) Social spaces. A minimum of two separate social spaces, one appropriate for noisy activities and the other for quiet activities, shall be provided. The combined total area shall be not less than 40 square feet per bed space with not less than 160 square feet for each of the two spaces, whichever is greater. This space may be shared with the dining area or room.(G) Group therapy room. A room for group therapy shall be included. The room shall not be less than 250 square feet. The group therapy room may be combined with the quiet space required in subparagraph (F) of this paragraph provided that a space of not less than 370 square feet is available for both the quiet activity room and group therapy activities.(H) Activity service space. Space for activity services (e.g., music therapy, recreational therapy, art, dance, vocational therapy, educational therapy, etc.) shall be provided at the rate of 15 square feet per occupant of the room and a minimum area of not less than 375 square feet, whichever is greater. Space shall include provisions for hand washing, work counters, storage and displays. Where facilities contain less than 25 beds, the activity services therapy functions may be provided within the noisy activities area as required in subparagraph (F) of this paragraph if a space of not less than 485 square feet is available for both the noisy activity area and activity services area.(I) Service areas. Service areas shall be located in, or readily available to, each nursing suite. Each service area may be arranged and located to serve more than one nursing suite but at least one service area shall be provided on each nursing floor. A service area is composed of the following.(i) An administrative center or nurses station with an adjacent but separate dictation space.(ii) A nurses office.(iii) An area for charting. The charting area shall be provided with separation needed for acoustical privacy as well as space required for the function. A view window to permit observation of the patient area by the charting nurse or physician may be used provided that it is so located that patient files cannot be read from outside the charting space.(iv) A medication room, medicine alcove area, or a self-contained medicine dispensing unit under visual control of nursing staff. The room shall have a minimum area of 30 square feet under direct control of the nursing or pharmacy staff. The room, area or unit shall contain a work counter, hand washing fixture with hands-free operable controls, and refrigerator. Provisions for security against unauthorized access shall be assured. Standard cup-sinks provided in many self-contained units are not adequate for hand washing.(v) A small kitchen for patient use. The room shall contain a sink, refrigerator, ice dispenser, microwave, and storage cabinets. This room is to provide nourishment for patients between scheduled meals.(vi) A multipurpose room for staff and patient conferences, education and demonstrations. The room shall be conveniently accessible to each nursing suite and may serve several nursing suites or departments. The room may be located on another floor if convenient for regular use.(vii) An examination or treatment room. The room shall have a minimum floor area of 120 square feet excluding space for vestibule, toilet, and closets. The minimum room dimension shall be 10 feet. The room shall contain a lavatory or sink equipped for hand washing, work counter, storage facilities, and a desk, counter, or shelf space for writing. The emergency treatment room may be used for this purpose if it is conveniently located on the same floor as the patient rooms.(viii) Patient laundry facilities. An automatic washer and an electric dryer shall be provided. This requirement may be omitted in nursing units intended only for adolescents and gero-psychiatric patients.(ix) Staff lounge with separate female and male dressing areas containing lockers, showers, toilets, and hand washing facilities. These facilities may be on another floor.(x) Securable closets or cabinet compartments for personal articles of nursing unit staff. The closets or lockers shall be located at or near the nurse station. At a minimum, these shall be large enough for purses and billfolds. Coats may be stored in closets or cabinets on each floor or in a central staff locker area.(xi) Secured storage area for patients' effects determined potentially harmful (razors, nail files, cigarette lighters, etc.). This area shall be controlled by staff.(xii) Clean workroom or clean supply room. When used for preparing patient care items, it shall contain a work counter, hand washing facilities, and storage facilities for clean and sterile supplies. When used only for storage and holding as part of a distribution system of clean and sterile supplies, the work counter and hand washing facilities may be omitted.(xiii) Clean linen storage for each nursing unit. The clean linen area shall contain a work counter and storage space for clean linen. The area shall be a part of the storage and distribution of clean linen. Minimum area for clean linen shall be three square feet of room area per patient bed space. The required area may be concentrated in one central room or divided in several rooms throughout the facility.(xiv) A soiled workroom or soiled holding room. The room shall contain a clinical sink or equivalent flushing rim fixture, hand washing facilities, both with hot and cold water. The room shall have a work counter and space for separate covered containers for soiled linen and waste. Minimum area for soiled linen shall be three square feet of room area per patient bed space.(xv) An equipment storage room and storage room for administrative supplies located on each floor which may serve multiple nursing suites.(xvi) An emergency equipment storage room or alcove under direct visual control of the nursing staff and out of normal traffic.(xvii) A housekeeping room which may also serve adjacent nursing suites.(xviii) Stretcher and wheelchair storage space which is located without restricting normal traffic. The space may be located outside the nursing suite.(xix) An accessible public toilet with hand washing fixtures. The toilets shall be located on each floor containing a nursing suite.(xx) Staff toilet conveniently located to each nursing suite. At least one staff toilet shall be located on each patient sleeping floor. Toilet may be unisex.(xxi) An ice dispensing machine for each nursing suite which is located at the nourishment station or the clean work room.(xxii) Adequate number of drinking fountain fixtures.(xxiii) Adequate number of telephones available for patients' private conversations.(xxiv) A visitor room for patients to meet with friends or family with a minimum floor space of 100 square feet.(xxv) A quiet room for a patient who needs to be alone for a short period of time but does not require a seclusion room. Each quite room shall be not less than 80 square feet. The visitor room may serve this purpose.(xxvi) Separate consultation room. The room shall have a minimum floor space of 100 square feet, and provided at a room-to-bed ratio of one consultation room for each 12 patient beds. The room(s) shall be designed for acoustical and visual privacy and constructed to achieve a level of voice privacy of 50 STC (which in terms of vocal privacy means that some loud or raised speech is heard only by straining, but is not intelligible).(xxvii) A conference and treatment planning room for use for patient care planning. This room may be combined with the charting room or use of the multipurpose room.(3) Details and finishes. Details and finishes shall be in accordance with §510.122(d)(2) of this chapter and this paragraph.(A) Details.(i) Egress. Means of egress from each patient suite shall comply with the requirements of NFPA 101 §18-2.(ii) Patient bathroom and toilet room doors. Door leaves to all patient bathrooms and toilet rooms shall be at least 36 inches wide and shall swing outward or be double acting so that nursing staff may gain access to a patient. Doors lockable from the inside shall have hardware that allows staff to open the door from the outside.(iii) Vision panels. Vision panels shall be provided in the door between an anteroom and an airborne infection isolation room.(iv) Windows. Each patient sleeping room shall have an outside window. The windows shall be restricted. Where the operation of windows requires the use of tools or keys, the tools or keys shall be located at each nurses station, on the same floor, and easily accessible to staff. The bottom of the window opening shall not exceed 36 inches above the floor.(v) Location of patient room windows. Windows shall be located on an outside wall. Windows may face an atrium, an inner court, or an outer court provided the following requirements are met.(I) Atria windows. Atria onto which the required windows face shall comply with the requirements of NFPA 101 §8-2.5.6.(II) Outer courts. Outer court (not enclosed by building on one side) onto which the required windows face shall have a minimum width, at all levels, of not less than three inches for each foot, or fraction thereof, of the height (average height of enclosing walls) of such court, but in no case shall the width be less than five feet. An outer court shall have a horizontal cross sectional area not greater than four times the square of its width.(III) Inner courts. Inner court (enclosed by building on all sides) onto which the required windows open shall have minimum width, at all levels, of not less than one foot for each foot, or fraction thereof, of the height (average height of enclosing walls) of such courts, but in no case shall the width be less than 10 feet. If operable windows are provided, a horizontal, unobstructed, and permanently open air intake or passage having a cross-sectional area of not less than 21 square feet shall be provided at or near the bottom of the court. Metal decorative grilles not effectively reducing the open area by more than five percent shall be permitted at the ends. Walls, partitions, floor, and floor-ceiling assemblies forming intakes or passages shall be noncombustible and shall be constructed in accordance with NFPA 101 §18-3.1(b) and (c). An inner court shall have a horizontal cross sectional area of not less than one and one-half times the square of its width.(vi) Visibility. All areas of the nursing suite, including entrances to patient rooms, shall be visible from the nurse station. Observation by video cameras of seclusion rooms, entrances, hallways, and activity areas shall be acceptable.(vii) Special fixtures, hardware, and tamper-proof screws. Special fixtures, hardware, and tamper-proof screws shall be used throughout the patient nursing suites.(I) All exposed and accessible fasteners shall be tamper-resistant.(II) Suitable hardware shall be provided on doors to toilet rooms so that access to these rooms can be controlled by staff. Hardware shall be utilized which is appropriate to prevent patient injury.(III) Only break-away or collapsible clothes bars in wardrobes, lockers, towel bars, and closets and shower curtain rods shall be permitted. Wire coat hangers shall not be permitted in nursing suites.(IV) When grab bars are provided, the space between the grab bar and the wall should be filled to prevent a cord being tied around it for hanging. Bars, including those which are part of such fixtures as soap dishes, shall be sufficiently anchored to sustain a concentrated load of 250 pounds.(viii) Detention screens.(I) When operable windows are provided in patient sleeping rooms, it may be necessary to provide detention screens on windows or limit the amount of window operation in order to inhibit possible tendency for suicide or elopement. The type and the degree of security required shall be determined by the facility administration.(II) When detention screens are provided, windows shall be capable of opening with the screens in place. Where glass fragments may create a hazard, safety glazing or other appropriate security features shall be incorporated.(III) In building housing for certain types of patients, detention rooms, or a security section, the facility shall provide detention screens to confine or protect building inhabitants, when necessary.(ix) Hand washing amenities. Hand washing amenities shall be conveniently located near the nurses station and in the medication area. One lavatory in an open medication area can meet this requirement.(x) Elevator lobbies. Elevator lobbies shall be physically separated from the required means of egress with one hour fire rated construction which resist the passage of smoke on all floors containing patient rooms.(B) Finishes.(i) Seamless floors with coved wall bases described in §510.122(d)(2)(B)(iii)(III) of this subchapter shall be provided in soiled workrooms.(ii) Wall bases in the soiled workroom shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and impervious to water.(iii) Monolithic ceilings described in §510.122(d)(2)(B)(vi)(III) of this subchapter shall be provided in airborne infection isolation rooms, seclusion rooms, and security rooms.(iv) Ceilings of patient rooms may be acoustically treated; however, they shall be monolithic as described in §510.122(d)(2)(B)(vi)(III) of this subchapter.(v) Acoustical ceilings shall be provided for corridors in patient areas, nurses' stations, dayrooms, recreation rooms, dining areas, and waiting areas.(4) Mechanical requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph.(A) Special consideration shall be given to the type of heating and cooling units, ventilations outlets, and appurtenances installed in patient-occupied areas of nursing suites. The following shall apply.(B) All air grilles and diffusers shall be of a type that prevents the insertion of foreign objects.(C) All convector or HVAC enclosures exposed in the room shall be constructed with rounded corners and shall have enclosures fastened with tamper-resistant fasteners.(D) HVAC equipment shall be of a type that minimizes the need for maintenance within the room.(E) Outside air shall be supplied to each patient room by a central air handling unit to provide make-up air for air exhausted from the bathroom in accordance with Note 3 of Table 3 of §510.131(c) of this subchapter.(F) Each patient room bathroom shall be exhausted continuously to the exterior in accordance with Table 3 of §510.131(c) of this subchapter.(5) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph.(A) Each patient bathroom shall contain a water closet and a lavatory. The lavatory may be located in a single bed patient room instead of in the bathroom.(B) An additional lavatory shall be placed in each patient room proper where the bathroom serves more than two beds.(C) Hand washing fixtures shall be located near the nurses' station and the drug distribution station. One lavatory may serve both areas.(D) Faucet controls shall not be equipped with handles that may be easily broken off in the patient care areas.(E) Bedpan washers are not required in patient bathrooms.(F) Piped medical gas systems are not required unless otherwise noted.(G) Only special, tamper proof sprinkler heads from which it is not possible to suspend any objects shall be installed.(6) Electrical requirements. Electrical requirements shall be in accordance with §510.122(d)(5) of this subchapter and this paragraph.(A) Electric receptacles in nursing units.(i) Each receptacle shall be grounded to the reference grounding point by means of an insulated copper grounding conductor.(ii) Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, §3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard.(iii) One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location.(iv) Each examination table shall have access to two duplex receptacles.(v) Each work table or counter shall have access to two duplex receptacles.(vi) One duplex receptacle shall be installed in the bathroom to permit the use of electrical appliances in front of the mirror.(vii) Receptacles shall be protected by GFCI breakers installed in distribution panel enclosures serving the nursing suite.(viii) Duplex receptacles shall be installed not more than 50 feet apart in corridors and within 25 feet of corridor ends.(ix) When mobile x-ray equipment is provided, special receptacles marked for X-ray use shall be installed in corridors so that mobile equipment may be used anywhere within a patient room using a cord length of 50 feet or less. Where capacitive discharge or battery powered X-ray units are used, special X-ray receptacles will not be required in corridors.(x) Additional duplex receptacles shall be installed as required to satisfy operational needs of the nursing unit.(B) Nurses calling systems. When a nurses calling system is provided in a nursing suite, a nurses regular calling system, nurses emergency calling system, and a staff emergency assistance calling system shall comply with §510.122(d)(5)(K) of this subchapter. Provisions shall be made for easy removal of all call buttons or for covering call buttons as required for security. Pull cords shall not exceed 18 inches in length.(i) Each patient room shall be served by at least one nurses regular calling station for two-way voice communication. Each patient bed shall be provided with a call button. Two call buttons serving adjacent beds may be served by one calling station. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses calling systems shall be equipped with an indicating light at each calling station which remains lighted as long as the voice circuit is operating.(ii) A nurses emergency calling system shall be provided at each inpatient water closet, bathtub and shower in accordance with §510.122(d)(5)(K)(ii) of this subchapter. When conveniently located one emergency call station may serve one bathroom.(iii) A staff emergency assistance calling system for staff to summon additional assistance shall be provided in central bathing facility rooms and exam or treatment rooms in accordance with §510.122(d)(5)(K)(iii) of this subchapter.(iv) All nurse call hardware shall have tamper resistant fasteners.(v) A call system shall be provided at all seclusion anterooms.(C) Illumination requirements.(i) General illumination requirements. Nursing suite corridors shall have general illumination with provisions for reducing light levels at night. Illumination of corridors for egress purposes shall comply with NFPA 101 §§18-2.8 and 18-2.9.(ii) Illumination of the nurses station. Illumination of the nurses station and all nursing support areas shall be with fixtures powered from the critical branch of the emergency electrical system NFPA 99 §3-4.2.2.2(c).(iii) Patient suite lighting.(I) Each patient room shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system.(II) A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. High heat producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens.(III) A wall or ceiling mounted lighting fixture shall be provided above each lavatory.(IV) A ceiling mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch.(o) Pharmacy suite.(1) Architectural requirements.(A) General. The pharmacy room or suite shall be located for convenient access, staff control, and security for drugs and personnel.(B) Dispensing area. The pharmacy room or suite shall include the following functional spaces and facilities:(i) area for pickup, receiving, reviewing and recording;(ii) extemporaneous compounding area with sufficient counter space for drug preparation and sink with hands-free operable controls;(iii) work counter space for automated and manual dispensing activities;(iv) storage or areas for temporary storage, exchange, and restocking of carts; and(v) security provisions for drugs and personnel in the dispensing counter area.(C) Manufacturing. The pharmacy room or suite shall provide the following functional spaces and facilities.(i) When bulk compounding area is required, work space and counters shall be provided.(ii) When packaging, labeling and quality control is required, an area(s) shall be provided.(D) Storage. The following spaces shall be provided in cabinets, shelves, and/or separate rooms or closets:(i) space for bulk storage, active storage, and refrigerated storage;(ii) storage in a fire safety cabinet or storage room that is constructed under the requirements for protection from hazardous areas in accordance with NFPA 101 Chapter 12, for alcohol or other volatile fluids, when used; and(iii) storage space for general supplies and equipment not in use.(E) Administrative area. An administrative area for the pharmacy is optional for crisis stabilization units. The following functional spaces and facilities shall be included for the administrative area.(i) Office area for the chief pharmacist and any other offices areas required for records, reports, accounting activities, and patients profiles.(ii) Poison control center with storage facilities for reaction data and drug information centers.(iii) A room or area for counseling and instruction when individual medication pick-up is available for inpatients or outpatients.(F) Service areas. The following service areas and items shall be provided.(i) Intravenous (IV) solutions area. When IV solutions are prepared in a pharmacy, a sterile work area with a laminar-flow workstation designed for product protection shall be provided.(ii) Satellite pharmacy. When provided, the room shall include a work counter, a sink with hands-free operable controls, storage facilities, and refrigerator for medications.(iii) Hand washing amenities. A hand washing fixture with hands-free operable controls shall be located in each room where open medication is handled.(iv) Staff toilets. Toilets may be outside the suite but shall be convenient for staff use.(2) Mechanical Requirements. Mechanical requirements shall be in accordance with §510.122(d)(3) of this subchapter and this paragraph. When IV solutions are prepared, the required laminar-flow system shall include a non-hygroscopic filter rated at 99.97% (HEPA). A pressure gauge shall be installed for detection of filter leaks or defects.(3) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §510.122(d)(4) of this subchapter and this paragraph.(A) Material used for plumbing fixtures shall be non-absorptive and acid-resistant.(B) Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of carafes, etc.(4) Electrical requirements. Electrical requirements shall be in accordance with §510.122(d)(5) of this subchapter and this paragraph.(A) Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of the floor below or of the equipment.(B) Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(C) Electrical circuits to equipment in wet areas shall be provided with five milliampere GFCI.(p) Rehabilitation therapy suite.(1) Occupational therapy. When occupational therapy services are provided, the following shall be included:(A) an activity room with work areas, counters and a hand washing fixture. Counters shall be wheel chair accessible;(B) a storage room for supplies and equipment;(C) secured storage for potential harmful supplies and equipment; and(D) remote electrical switching for potentially harmful equipment.(2) Physical therapy. When physical therapy services are provided, the following rooms shall be included.(A) When services required by the narrative program for thermotherapy, diathermy, ultrasonics, and hydrotherapy, individual treatment areas shall be provided.(B) An individual treatment area shall be a minimum of 70 square feet of clear floor area exclusive of four foot aisle space. Privacy screens or curtains shall be provided at each treatment station.(C) A hand washing fixture with hands-free operable controls shall be provided in each treatment room or space. A hand washing fixture may serve several patient stations when cubicles or open room concepts are used and when the fixture is conveniently located.(D) An area shall be provided for exercise and may be combined with treatment areas in open plan concepts.(E) Provisions for the collection and storage of wet and soiled linen shall be provided.(F) A storage area or room for equipment, clean linen, and supplies shall be provided.(G) When outpatient physical therapy services are provided, the suite shall have as a minimum patient dressing areas, showers, and lockers.(3) Service areas. The following areas or items shall be provided in a rehabilitative therapy suite but may be shared when multiple rehabilitation services are offered:(A) patient waiting area with space for wheelchairs;(B) patient toilet facilities containing hand washing fixtures with hands-free operable controls;(C) reception and control stations shall be located to provide supervision of activities areas and the control station may be combined with office and clerical spaces;(D) office and clerical space;(E) wheelchair and stretcher storage room or alcove which shall be in addition to other storage requirements;(F) lockable closets, lockers or cabinets for securing staff personal effects;(G) staff toilets may be outside the suite but shall be convenient for staff use and contain hand washing fixtures with hands-free operable controls; and(H) housekeeping room, conveniently accessible. Source Note: The provisions of this §510.123 adopted to be effective January 1, 2004, 28 TexReg 5154; amended to be effective February 18, 2018, 43 TexReg 576; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.123 Spatial Requirements for New Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195310 03/12/2026 (a) General. All facilities with two or more floor levels shall have at least one electrical or electrical hydraulic elevator. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §18-3 of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(b) Requirements for new elevators, escalators, and conveyors. New elevators, escalators and conveyors shall be installed in accordance with the requirements of A17.1, Safety Code for Elevators and Escalators, 1996 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI). All documents published by the ASME/ANSI as referenced in this section may be obtained by writing the ANSI, United Engineering Center, 345 East 47th Street, New York, N.Y. 10017.(1) Cars and doors. Cars of "hospital type" elevators shall be at least 5 feet 8 inches wide by 8 feet, 6 inches deep. The car door opening shall be not less than 4 feet wide and 7 feet high.(2) Leveling. All elevators shall be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of one-half inch.(3) Operation. All elevators, except freight elevators, shall be equipped with a two-way service key-operated switch to permit cars to bypass all landing button calls and be dispatched directly to any floor.(4) Accessibility of controls and alarms. Elevator controls, alarm buttons, and telephones shall be accessible to wheelchair occupants.(5) Type of controls and alarms. Elevator call buttons, controls, and door safety stops shall be of a type that will not be activated by heat or smoke.(6) Location. Conveyors, elevators, dumbwaiters, and pneumatic conveyors serving various stories of a building shall not open to an exit.(7) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems required to maintain temperature during fire fighters' service operation for elevator operation. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power.(c) Requirements for existing elevators, escalators, and conveyors. Existing elevators, escalators, and conveyors shall comply with ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 1995 edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3 as required by NFPA 101, §9-4.3.2.(d) Testing. All elevators and escalators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 1996 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA101, §9-4.6.(e) Certification. A certificate of inspection evidencing that the elevators, escalators, and related equipment were inspected in accordance with the requirements in Health and Safety Code (HSC), Chapter 754, Subchapter B, and determined to be in compliance with the safety standards adopted under HSC, §754.014, administered by the Texas Department of Licensing and Regulation, shall be on record in each facility.(f) Requirements for new facilities. All new facilities having patient facilities (such as patient sleeping rooms, dining rooms, diagnostic, therapy or recreation areas) on floors other than on the main entrance floor shall have the following number of elevators:(1) two elevators for the first 200 bed spaces; or(2) three elevators for 201 to 350 bed spaces; Source Note: The provisions of this §510.124 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.124 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222071 03/12/2026 (a) Multiple facilities located within one building.(1) Identifiable location. Each facility shall be in one separately identifiable location and conform with all the requirements contained in Chapter 18 of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101).(2) Separate licensed facilities. Each facility shall provide the following separate services and amenities:(A) a nursing suite in accordance with the requirements of §510.123(n) of this subchapter (relating to Spatial Requirements for New Construction);(B) an administration office with an adjacent waiting room or waiting area;(C) a medical records room which conforms with the requirements of §510.123(m) of this subchapter;(D) a pharmacy suite in accordance with §510.123(o) of this subchapter;(E) employee locker facilities which comply with requirements of §510.123(f) of this subchapter;(F) a housekeeping room in accordance with the requirements of §510.122(d)(2)(A)(xxviii) of this subchapter (relating to New Construction Requirements);(G) an emergency treatment room as required by §510.123(e)(1)(A) of this subchapter;(H) external signage at the building entrance which identifies each facility; and(I) internal signage which provides directions to each facility.(3) Means of egress. Means of egress from the facility shall not be through another facility or other areas subject to locking.(4) Additional services and amenities. Additional services and amenities when required in each licensed facility may be provided by contractual agreement with the other facility when the services and amenities comply with the specific requirements of §510.41 of this chapter (relating to Facility Functions and Services) and §510.123 of this subchapter. Some services may be provided by contractual agreement with a commercial contractor; however, the following minimal services and amenities shall be provided on site:(A) dietary services and dietary suite which comply with §510.41(b) of this chapter and §510.123(d) of this subchapter respectively;(B) cart cleaning and sanitizing services and facilities which comply with §510.123(b) of this subchapter;(C) general stores services and facilities which comply with §510.123(h) of this subchapter;(D) laboratory services and a laboratory suite which comply with §510.41(e) of this chapter, and §510.123(k) of this subchapter, respectively;(E) housekeeping rooms as required in §510.122(d)(2)(A)(xxviii) of this subchapter;(F) parking, in accordance with §510.122(c)(2) of this subchapter;(G) physical therapy services and amenities, occupational therapy services and amenities, or both in accordance with §510.123(p) of this subchapter;(H) imaging services in accordance with §510.123(j) of this subchapter;(I) central sterile supply which complies with §510.123(c) of this subchapter; and(J) waste and waste disposal services, and waste processing and storage units shall comply with §510.41(o) of this chapter.(5) Building systems and equipment.(A) The following systems shall be provided separately in each facility.(i) Nurses calling systems shall be provided separately in each facility in accordance with §510.122(d)(5)(K) of this subchapter.(ii) When medical gas systems are provided, medical gas alarms shall be provided in each facility.(iii) A fire alarm system in accordance with §510.122(d)(5)(M) of this subchapter shall be provided.(B) Where applicable, the following systems may serve more than one facility provided the systems meet the new construction requirements of §510.122 of this subchapter:(i) air-conditioning, heating and ventilating systems;(ii) drainage systems;(iii) elevators;(iv) fire sprinkler systems;(v) medical piping systems;(vi) stand pipe systems;(vii) steam systems;(viii) water supply systems, hot and cold (including emergency water storage); and(ix) electrical service and equipment.(I) Where applicable, the building electrical service, lighting, essential electrical system, and fire alarm system, may be a part of or extension of those in the existing host facility, provided the existing systems meet these requirements. Power and lighting distribution panels shall be within the facility served and comply with the requirements of §510.122(d)(5)(E) of this subchapter. Electrical installation details shall conform with all requirements contained in §510.122(d)(5)(A) of this subchapter.(II) When the existing essential electrical system is non-conforming, the following options are available:(-a-) a separate conforming essential electrical system shall be provided in the new facility; or(-b-) separate transfer switches connected to the existing on-site generator(s) shall be provided when adequate capacity is available and the existing non-conforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by HHSC.(b) Facilities located in buildings with hospitals licensed under Texas Health and Safety Code Chapter 241. Before a facility is licensed in a building containing a hospital licensed under Texas Health and Safety Code Chapter 241 (241 hospital), the following requirements shall be met.(1) The facility shall be in one identifiable location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the 241 hospital and comply with the requirements of this chapter.(A) Access to the facility shall be directly from a main lobby or an elevator lobby, if on an upper floor. The required means of egress from the facility shall not be through the 241 hospital.(i) Each facility and 241 hospital shall be identified with external signage at the building entrance.(ii) Internal signage shall provide direction to the facility and to the 241 hospital.(B) Common use of services and amenities using time-sharing concepts may be permitted on a case by case basis when the 241 hospital complies with the requirements contained in NFPA 101 Chapter 18, and §510.123 of this subchapter, and provided this chapter and the 241 hospital licensing rules allow.(2) The facility and the 241 hospital shall provide services and amenities in accordance with their respective licensing requirements.(3) Additional services and amenities when required in the facility or 241 hospital may be provided by contractual agreement with either entity. Shared services and amenities shall meet the most stringent entity licensing standard or rule. Some services may be provided by contractual agreement with a commercial contractor; however, the following minimal services and amenities shall be provided on-site:(A) dietary services and dietary suite, including staff dining amenities;(B) cart cleaning and sanitizing services;(C) general stores services;(D) laboratory services and a laboratory suite;(E) housekeeping rooms;(F) parking;(G) physical or occupational therapy services and amenities;(H) imaging and other diagnostic services and amenities;(I) respiratory care services and respiratory therapy suite;(J) body holding room;(K) central sterile supply; and(L) waste and waste disposal services, and waste processing and storage units.(4) The equipment and systems required in the facility or 241 hospital may be provided exclusively for the facility or by contractual agreement with a 241 hospital. Equipment and systems provided shall be in accordance with the most stringent entity standard or rule.(A) The following equipment and systems shall be provided for the exclusive use of the facility:(i) a fire alarm system; and(ii) nurses calling systems.(B) Where applicable, the following systems may serve more than one facility or 241 hospital:(i) air-conditioning, heating, and ventilating systems;(ii) drainage systems;(iii) elevators;(iv) fire sprinkler systems.(v) medical piping systems;(vi) stand pipe systems;(vii) steam systems;(viii) water supply systems, hot and cold (including emergency water storage); and(ix) electrical service and equipment.(I) Where applicable, the building electrical service, lighting, essential electrical system, and fire alarm system, may be a part of or extension of those in the existing 241 hospital, provided the existing systems meet these requirements. Power and lighting distribution panels shall be within the facility served and comply with the requirements of §510.122(d)(5)(E) of this subchapter. Electrical installation details shall conform with all requirements contained in §510.122(d)(5)(A) of this subchapter.(II) When the existing essential electrical system is nonconforming, the following options are available:(-a-) a separate conforming essential electrical system shall be provided in the new facility; or(-b-) separate transfer switches connected to the existing on-site generator shall be provided when adequate capacity is available and the existing nonconforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by the department.(c) Facilities located in buildings with other licensed health care entities.(1) Before a facility is licensed in a building containing other licensed health care entities, the following requirements shall be met.(A) The facility shall be in one identifiable location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other licensed health care entity and comply with the requirements of this chapter.(i) Access to the facility shall be directly from a main lobby or an elevator lobby, if on an upper floor. The required means of egress from the facility shall not be through the other licensed health care entity.(I) Each facility and licensed entity shall be identified with external signage at the building entrance.(II) Internal signage shall provide direction to the facility and to the licensed entity.(ii) The facility shall have services and amenities separate from the other health care entity. The required services and amenities shall be located within the proposed facility.(iii) Common use of services and amenities using time-sharing concepts may be permitted on a case-by-case basis when the other health care entities comply with the requirements contained in NFPA 101 Chapter 18, and §510.123 of this subchapter, and provided this chapter and the other health care entity licensing rules allow.(B) The equipment and systems required in each facility may be provided exclusively for the facility or by contractual agreement with a licensed health care entity. The equipment and systems provided shall be in accordance with §510.122 of this subchapter.(i) The following equipment and systems shall be provided for the exclusive use of the facility:(I) electrical service for power and lighting and the essential electrical system;(II) emergency water storage located with the facility;(III) a fire alarm system;(IV) air-conditioning, heating and ventilating systems;(V) medical piping systems with alarm; and(VI) nurses calling systems.(ii) Where applicable, the following systems may be a part or extension of those in the existing licensed health care entity, provided the existing systems meet the requirements of this chapter for new construction:(I) drainage systems;(II) elevators;(III) fire sprinkler systems.(IV) stand pipe systems;(V) steam systems; and(VI) water supply systems, hot and cold.(2) When a facility and other licensed health care entities share one building, the building systems and equipment may be shared in accordance with subsection (a)(5)(B) of this section or be provided separately. The shared systems and equipment shall meet the requirements of this subchapter and be under the control of the licensed health care entity.(d) Facilities in buildings with non-health care occupancies. Before a facility is licensed in a building also containing occupancies other than health care occupancies, all requirements of this chapter and the following requirements shall be met.(1) Construction. Construction of the building shall conform to the requirements of NFPA 101 Chapter 18 and the facility shall be in one identifiable location.(A) The facility shall be in one identifiable location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other non-health care occupancies and comply with the requirements of this chapter.(B) Access to the facility shall be through a dedicated facility lobby or from the building's main lobby. The building's main lobby shall be part of the facility and shall comply with the requirements of §510.122 of this subchapter.(C) The required means of egress from the facility shall be independent of and shall not traverse through the other occupancies.(2) Services and amenities. Services and amenities shall be provided exclusively for the facility in accordance with Subchapters C, F, and G of this chapter (relating to Operational Requirements, Fire Prevention and Safety Requirements, and Physical Plant and Construction Requirements, respectively). Required services and amenities shall not be shared with the other occupancies.(3) Building equipment and amenities. The equipment and amenities shall be provided for the exclusive use of a facility in accordance with this subchapter. Source Note: The provisions of this §510.125 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.125 Building with Multiple Occupancies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195312 03/12/2026 (a) General. When mobile, transportable and relocatable units are utilized to provide patient treatment services on the facility premises, these units shall be treated as buildings and constructed to the required occupancy as follows:(1) When such units are provided for diagnostic, treatment or procedural services to patients that are litter borne or incapable of self-preservation, the unit shall be constructed in accordance with Chapter 18 of the National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), relating to health care occupancy, published by the National Fire Protection Association. All documents published by the NFPA as referenced in this section may be obtained by writing or calling the NFPA at the following address and telephone number: Post Office Box 9101, 1 Batterymarch Park, Quincy, Massachusetts 02269-9101, (800) 344-3555.(2) When such units provide diagnostic, treatment, or procedural services to patients, or types of services that are not litter borne and are capable of self-preservation, the unit may be constructed in accordance with Chapter 38 of NFPA 101 (relating to Business Occupancy).(b) Common elements.(1) Site requirements.(A) Sites shall be designed for the structural loads of the unit.(B) The sites shall provide hazard-free drop-off zones and adequate parking for patients. The site and location of the unit shall not restrict access for fire or emergency vehicles.(C) Each site shall provide access to the unit for the handicapped, and wheelchair and stretcher patients.(D) The location of the unit shall be such that engine exhaust fumes from the unit are kept away from any fresh air intake of the facility.(E) Each unit shall be provided with approved fire alarm connections. Properly sized power, including emergency power, water, waste, and telephone services shall be provided as necessary.(2) Support services. Support services such as waiting areas, toilet facilities, and storage spaces shall be provided either within the unit or located within the facility adjacent to the site unit for convenient use. Source Note: The provisions of this §510.126 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.126 Mobile, Transportable, and Relocatable Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222072 03/12/2026 (a) General.(1) Facility owners or operators may not begin construction of a new building or additions to or renovations or conversions of existing buildings until final construction documents are reviewed and approved by the Texas Health and Human Services Commission (HHSC).(2) Plans and specifications describing the construction of new buildings and additions to or renovations and conversions of existing buildings shall be prepared by registered architects, licensed professional engineers, or both.(3) Preliminary plans shall be prepared and submitted in accordance with subsection (b) of this section.(4) Final plans and specifications shall be prepared and submitted in accordance with subsection (c) of this section.(b) Preliminary documents. Preliminary documents shall consist of a functional program narrative, preliminary plans, and outline specifications. These documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, bed count and services, and the usage of all spaces, areas, and rooms on every floor level.(1) Preparation of preliminary plans. Preliminary plans shall be of a sufficiently large scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. Preliminary plans shall provide the following information.(A) Floor area and bed distribution. The total floor area on each level involved in construction, together with the proposed bed distribution, shall be shown on the drawings.(B) Floor plan. Each floor plan shall indicate and identify all individual spaces, doors, windows and means of egress.(C) Existing floor plan. An overall floor plan showing existing spaces, smoke partitions, smoke compartments, and exits and their relationship to the new construction shall be submitted on all renovations or additions to an existing facility. Plans for remodeling of spaces above or below the level of discharge shall include the level of discharge floor plan, showing all exits at that level. When there are two different levels of discharge, plans for both levels shall be submitted.(D) Construction type and fire rating. Building sections shall be provided to illustrate construction type and fire protection rating. Sections shall be drawn at a scale sufficiently large to clearly present the proposed construction system.(E) Area map. A map of the area within a two-mile radius of the facility site shall be provided and any hazardous and undesirable location noted in §510.122(a) of this subchapter (relating to New Construction Requirements) shall be identified.(F) Site plan. A site plan shall be submitted and shall indicate the location of the proposed buildings in relation to property lines, existing buildings or structures, access and approach roads, and parking areas and drives. Any overhead or underground utilities or service lines shall also be indicated.(G) Outline specifications. Outline specifications shall provide a general description of the construction, materials, and finishes that are not shown on the drawings.(2) Functional program narrative. The facility shall provide a functional program narrative presented on facility letterhead and signed by facility administration. The narrative program shall be submitted to HHSC at the preliminary plan (stage 1) review and be approved by HHSC. The narrative shall include the functional description of each space and the following:(A) departmental relationships, number of patient beds in each category, and other basic information relating to the fulfillment of the facility's objectives;(B) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, types of equipment required, interrelationship of various functions and spaces;(C) energy conservation measures, included in building, mechanical, and electrical designs; and(D) the type of construction (existing or proposed) as stated in Table 18-1.6.2 of National Fire Protection Association 101, Code for Safety to Life from Fire in Buildings and Structures, 2000 edition (NFPA 101), published by the National Fire Protection Association.(3) Submission of preliminary plans. One set of preliminary plans, outline specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings, a functional program narrative, a completed and signed Application for Plan Review, and the applicable plan review fee in accordance with §510.26(c) of this chapter (relating to Fees) shall be submitted to HHSC for review and approval. For convenience, preliminary plans may be reduced for preliminary submittal. The cost of submitting plans and specifications shall be borne by the sender.(4) Preliminary plan review. All deficiencies noted in the preliminary plan review shall be satisfactorily resolved. Written HHSC approval of preliminary plans must be obtained prior to proceeding with final plans and specifications. This requirement also applies to fast-track projects.(c) Construction documents. Construction documents or final plans and specifications shall be submitted to HHSC for review and approval prior to start of construction. All final plans and specifications shall be appropriately sealed and signed by a registered architect and a professional engineer licensed by the State of Texas.(1) Preparation of construction documents. Construction documents shall be well prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, and shall include all necessary explanatory notes, schedules, and legends and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 1999 edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All rooms shall be identified by usage on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural plans. Architectural drawings shall include the following:(i) site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, walks, and the extent of the areas to be landscaped. All structures which are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided, which includes a:(ii) plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces;(iii) schedules of doors, windows, and finishes;(iv) elevations of each facade;(v) sections through building; and(vi) scaled details as necessary.(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided; and(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, location, type and fire resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, location and type of portable fire extinguishers.(C) Equipment drawings. Equipment drawings shall include the following:(i) all equipment necessary for the operation of the facility as planned, and the design shall indicate provisions for the installation of large and special items of equipment and for service accessibility;(ii) fixed equipment (equipment which is permanently affixed to the building or which must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment), which includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets);(iii) movable equipment (equipment not described in clause (ii) of this subparagraph as fixed), which includes wheeled equipment, plug-in type monitoring equipment, and relocatable items; and(iv) equipment which is not included in the construction contract but which requires mechanical or electrical service connections or construction modifications, and this shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings. Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings. Documentation for selection of the type of heating and cooling system based on requirements contained in §510.122(d)(3)(A) of this subchapter shall be included with the mechanical plans. Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g. corridor, patient room, operating room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) non-flammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shut-off valves, pressure gages, alarm modules, gas outlets;(v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems);(vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment);(vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct mounted smoke detectors; and(viii) laboratory exhaust and safety cabinets.(F) Electrical drawings. Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections;(ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches and equipment which require permanent electrical connections, on plans of each building level:(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and(II) outlets marked distinctly to indicate connection to critical, life safety or normal power circuits;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system and the essential electrical system including the on-site generators, transfer switches, emergency system (life safety branch and critical branch), equipment system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities, and feeder and conduit sizes shall be shown with schedule of feeder breakers or switches;(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses regular calling system, nurses emergency calling system, or staff emergency assistance calling system); and(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices and the room number where each device is located; and(vi) schedules of all panels indicating connection to life safety branch, critical branch, equipment system or normal system, and connected load at each panel.(2) Final plan review. All deficiencies noted in the final plan review shall be satisfactorily resolved before approval of project for construction will be granted.(3) Construction approval. Construction shall not begin until written approval by HHSC is received by the owner of the facility.(4) Construction document changes. Any changes to construction documents which affect or change the function, design, or designated use of an area shall be submitted to HHSC for approval prior to authorization of the modifications.(d) Special submittals.(1) Designer certified construction documents. In an effort to shorten the plan review and approval process, design professionals may submit, at the discretion of HHSC, a set of final construction documents, HHSC's completed checklist of licensing requirements and a certification letter which states that the plans and specifications, based on HHSC's checklist comply with the requirements of this chapter. Project certification forms shall be signed by the licensee or applicant and all architects and engineers of record.(2) Fast-track projects. Submittal of fast-track projects shall be at the discretion of HHSC and shall be submitted in not more than three separate packages.(A) First package. The first package shall include:(i) a map showing the location of the proposed facility site and adjacent surrounding area at least two miles in radius identifying any hazardous and undesirable location noted in §510.122(a) of this subchapter;(ii) preliminary architectural plans and a detailed building site plan showing all adjacent streets, site work, underslab mechanical, electrical, and plumbing work, and related specifications; and(iii) foundation and structural plans.(B) Second package. The second package shall include complete architectural plans and details with specifications and fire safety plans as described in subsection (c) of this section.(C) Third package. The third package shall include complete mechanical, electrical, equipment and furnishings, and plumbing plans and specifications, as described in subsection (c) of this section.(3) Fire sprinkler systems. Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler systems, 1999 edition (NFPA 13). Fire sprinkler systems shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(A) Fire sprinkler working plans, complete hydraulic calculations and water supply information shall be prepared in accordance with NFPA 13 §§8-1, 8-2 and 8-3, for new fire sprinkler systems, alterations of and additions to existing ones.(B) Certification of changes in an existing system is not required when relocation of not more than twenty sprinkler heads is involved.(C) One set of fire sprinkler working plans (sealed by the engineer), calculations and water supply information shall be forwarded to HHSC together with the engineer's certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation.(D) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(e) Resubmittal of construction documents. When construction is delayed for longer than one year from the plan approval date, construction documents shall be resubmitted to HHSC for review and approval. The plans shall be accompanied by a new Application for Plan Review and a plan review fee.(f) Project delay or cancellation. The licensee or owner shall provide written notification to HHSC when a project has been placed on hold, canceled or abandoned.(g) On-hold projects. HHSC may close a project file after one year of its receipt of an Application for Plan Review for projects that have been placed on hold. Source Note: The provisions of this §510.127 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.127 Preparation, Submittal, Review and Approval of Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222073 03/12/2026 (a) Construction.(1) Major construction. Construction, of other than minor alterations, shall not commence until the final plan review deficiencies have been satisfactorily resolved, the appropriate plan review fee according to the plan review schedule in §510.26 of this chapter (relating to Fees) has been paid, and the Texas Health and Human Services Commission (HHSC) has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) Construction commencement notification. The architect of record or the licensee or applicant shall provide written notification to HHSC when construction will commence. HHSC shall be notified in writing of any change in the completion schedules.(3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) Construction surveys. All facilities including those which maintain certification under Title XVIII of the Social Security Act (42 United States Code §1395 et seq.), and those which maintain accreditation by the Joint Commission, or by the American Osteopathic Association (AOA) are subject to construction surveys.(1) Number of construction surveys. A minimum of two construction surveys of the project is generally required for the purpose of verifying compliance with Subchapters F and G of this chapter and the approved plans and specifications. The final plan approval letter will inform the architect of record and the owner as to the minimum number of surveys required for the project.(2) Requesting a survey. The architect of record or the licensee shall request a survey by submitting an Application for Survey and the construction survey fee in accordance with §510.26(d) of this chapter for each intermediate survey, final survey, and resurvey requested. Survey requests by contractors will not be honored.(A) The architect of record or the licensee shall request an intermediate construction survey to occur at approximately 80% completion. All major work above the ceiling shall be completed at the time of the intermediate survey, however ceilings should not be installed.(B) The architect of record or the licensee shall request a final construction survey at 100 percent completion. One-hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Resurveys. Depending upon the number and nature of the deficiencies cited during the final inspection, the surveyor may require that a resurvey be conducted to confirm correction of all deficiencies cited. The request for resurvey shall be submitted in accordance with paragraph (2) of this subsection.(c) Approval of project. Patients shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and HHSC.(1) Documentation requirements. The licensee shall submit the following documents to HHSC before the project will be approved:(A) written approval of the project by the fire authority;(B) a certificate of occupancy for the project issued by the local building authority;(C) written certification by the engineer, stating that the fire sprinkler system is installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 edition, if applicable;(D) fire alarm system certification (form FML-009 040392 of the Office of the State Fire Marshal), if applicable;(E) a copy of a letter from a qualified certification agency for the piped-in medical gas system installed in the project, if applicable;(F) a written plan of correction signed by the licensee for any deficiencies noted during the final inspection;(G) a copy of a letter from a registered electrical engineer stating the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 1999 edition, §3-3.2.1.2(e) (Special Grounding) and §3-3.3.2.1 (Grounding System Testing), if applicable to the project;(H) a copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project, including a signed letter or statement corroborating the installation of the product in the project;(I) a copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 1999 edition as required by NFPA 101 §18-7.5, and provide a signed letter or statement corroborating the installation of the product in the project;(J) a Final Construction Approval form signed by the licensee; and(K) any other documentation or information required due to the type of the project.(2) Verbal occupancy approval.(A) If, during the final survey, the surveyor finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the surveyor may grant verbal approval for occupancy contingent upon the documents listed in paragraph (1)(A)-(E) of this subsection being provided to and approved by the surveyor at the time of the final survey.(B) Verbal occupancy approval allows the licensee to occupy the project. However, the licensee must submit the documents required in paragraph (1)(F)-(K) before the project receives final approval.(3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, HHSC will issue final approval of the project. Source Note: The provisions of this §510.128 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.128 Construction, Surveys, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222074 03/12/2026 (a) Request for a waiver. A facility may submit a written request to the Texas Health and Human Services Commission (HHSC) for a waiver or modification of a particular provision of §510.122 or §510.123 of this subchapter (relating to New Construction Requirements and Spatial Requirements for New Construction). Waivers will not be granted for fire safety requirements required by the National Fire Protection Association (NFPA). The written request shall specify the specific provision for which a waiver is requested.(b) Consideration. In considering the waiver or modification request, HHSC shall consider whether the waiver or modification:(1) will adversely affect the health and safety of the facility patients, employees, or the general public;(2) will adversely impact the hospital's participation in the federal Medicare program or accreditation by the Joint Commission or the American Osteopathic Association;(3) if not granted, would impose an unreasonable hardship on the facility in providing adequate care for patients;(4) will facilitate the creation or operation of the facility; and(5) is appropriate when balanced against the best interests of the individuals served or to be served by the facility.(c) Supporting documentation. HHSC may request written documentation from the facility to support the waiver or modification, including:(1) a statement addressing each of the criteria in subsection (b) of this section;(2) evidence of approval by the local building and fire authorities;(3) evidence of provisions in Texas Health and Safety Code Chapter 577 or this chapter which will mitigate any adverse effect of the waiver or modification; and(4) evidence of any mitigating act in excess of the Act or this chapter which will be used by the hospital to offset any adverse effect of the waiver or modification.(d) Written recommendation. HHSC shall submit a written recommendation for granting or denying the waiver to the executive commissioner. The recommendation shall address each of the criteria in subsection (b) of this section.(e) Granting order. If HHSC recommends that the waiver or modification be granted, the executive commissioner may issue a written order granting the waiver or modification.(f) Denial of order. If HHSC recommends that the waiver or modification be denied, the executive commissioner may issue a written order denying the waiver or modification.(g) File documentation. The licensing file for the facility maintained by HHSC shall contain a copy of the request, the documents requested in subsection (c) of this section (if applicable), HHSC's written recommendation, and the order. Source Note: The provisions of this §510.129 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.129 Waiver Requests https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195316 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195316 03/12/2026 (a) Manuals. Upon completion of the contract, the owner shall be furnished with a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions;parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shal1 also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.(b) Design data. The owners shall be provided with complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, but not limited to, energy audits and retrofit for energy conservation. Source Note: The provisions of this §510.130 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.130 Record Drawings, Manuals and Design Data https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222075 03/12/2026 (a) Table 1. Sound transmission limitations in facilities. Attached Graphic(b) Table 2. Flame spread and smoke production limitations for interior finishes.Attached Graphic(c) Table 3. Ventilation requirements for facilities.Attached Graphic(d) Table 4. Filter efficiencies for central ventilation and air conditioning systems.Attached Graphic(e) Table 5. Hot water use.Attached Graphic(f) Table 6. Station outlets for oxygen, vacuum, and medical air systems.Attached Graphic Source Note: The provisions of this §510.131 adopted to be effective January 1, 2004, 28 TexReg 5154; transferred effective June 1, 2019, as published in the Texas Register May 17, 2019, 44 TexReg 2469; amended to be effective November 21, 2024, 49 TexReg 9283. 1 HEALTH AND HUMAN SERVICES COMMISSION 510 PRIVATE PSYCHIATRIC HOSPITALS AND CRISIS STABILIZATION UNITS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §510.131 Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215179 03/12/2026 (a) The purpose of this chapter is to implement Texas Health and Safety Code Chapter 241, Subchapter K for Limited Services Rural Hospitals licensed by the Texas Health and Human Services Commission.(b) This chapter provides:(1) procedures for obtaining a limited services rural hospital (LSRH) license;(2) standards for LSRH functions and services;(3) patient rights;(4) discrimination or retaliation prohibitions;(5) patient transfer and other policy and protocol requirements;(6) reporting, posting, and training requirements relating to abuse and neglect;(7) standards for voluntary agreements;(8) inspection and investigation procedures;(9) enforcement standards;(10) fire prevention and protection requirements;(11) general safety standards;(12) physical plant and construction requirements; and(13) standards for the preparation, submittal, review, and approval of construction documents.(c) An LSRH shall comply with the Conditions of Participation for Rural Emergency Hospitals at Code of Federal Regulations Title 42 Part 485, Subpart E (relating to Conditions of Participation: Rural Emergency Hospitals (REHs)). To the extent the conditions of participation conflict with Texas law and this chapter, Texas law and this chapter shall prevail.(d) Compliance with this chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, rules, regulations, and ordinances. This chapter must be followed where it exceeds other requirements. Source Note: The provisions of this §511.1 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS A GENERAL PROVISIONS §511.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226327 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings.(1) Act--The Texas Hospital Licensing Law, Texas Health and Safety Code (HSC) Chapter 241.(2) Actual harm--A negative outcome that compromises a patient's physical, mental, or emotional well-being.(3) Advance directive--A directive, as that term is defined by HSC §166.031 (relating to Definitions), an out-of-hospital do not resuscitate (DNR) order as that term is defined by HSC §166.081 (relating to Definitions), or a medical power of attorney under HSC Chapter 166, Subchapter D (relating to Medical Power of Attorney).(4) Advanced practice registered nurse (APRN)--A registered nurse authorized by the Texas Board of Nursing to practice as an advanced practice registered nurse in Texas. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with "advanced nurse practitioner."(5) Adverse event--An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.(6) Applicant--A person who seeks a limited services rural hospital (LSRH) license from the Texas Health and Human Services Commission (HHSC) and is legally responsible for the operation of the LSRH, whether by lease or ownership.(7) Attending physician--A physician selected by or assigned to a patient who has primary responsibility for a patient's treatment and care.(8) Available--When referring to on-site personnel, on the premises and able to rapidly perform hands-on care in an emergency situation.(9) Biological indicators--Commercially available microorganisms (e.g., United States Food and Drug Administration approved strips or vials of Bacillus species endospores).(10) Cardiopulmonary resuscitation--Any medical intervention used to restore circulatory or respiratory function that has ceased.(11) Chemical dependency services--A planned, structured, and organized program designed to initiate and promote a person's chemical-free status or to maintain the person free of illegal drugs. It includes the application of planned procedures to identify and change patterns of behavior related to or resulting from chemical dependency that are maladaptive, destructive, or injurious to health, or to restore appropriate levels of physical, psychological, or social functioning lost due to chemical dependency.(12) Competent--Possessing the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.(13) Comprehensive medical rehabilitation--The provision of rehabilitation services that are designed to improve or minimize a person's physical or cognitive disabilities, maximize a person's functional ability, or restore a person's lost functional capacity through close coordination of services, communication, interaction, and integration among several professions that share responsibility to achieve team treatment goals for the person.(14) Contaminated linen--Linen that has been soiled with blood or other potentially infectious materials or may contain sharps.(15) Dentist--A person licensed to practice dentistry by the Texas State Board of Dental Examiners. This includes a doctor of dental surgery or a doctor of dental medicine.(16) Dietitian--A person who is currently licensed by the Texas Department of Licensing and Regulation as a licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with the Academy of Nutrition and Dietetics.(17) Do not resuscitate (DNR) order--An order issued under HSC Chapter 166, Subchapter E (relating to Health Care Facility Do-Not-Resuscitate Orders), instructing a health care professional not to attempt cardiopulmonary resuscitation on a patient whose circulatory or respiratory function ceases.(18) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in one or all of the following:(A) placing the health of the individual (or with respect to a pregnant individual, the health of the pregnant individual or her unborn child) in serious jeopardy;(B) serious impairment to bodily functions;(C) serious dysfunction of any bodily organ or part; or(D) with respect to a pregnant individual who is having contractions:(i) that there is inadequate time to safely transfer to another hospital before delivery; or(ii) that transfer may pose a threat to the health or safety of the pregnant individual or the unborn child.(19) Facility--A limited services rural hospital as defined at paragraph (29) of this section unless context clearly indicates otherwise.(20) General hospital--An establishment that:(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals requiring diagnosis, treatment, or care for illness, injury, deformity, abnormality, or pregnancy; and(B) regularly maintains, at a minimum, clinical laboratory services, diagnostic X-ray services, treatment facilities, including surgery or obstetrical care or both, and other definitive medical or surgical treatment of similar extent.(21) Governing body--The governing authority of an LSRH that is responsible for the LSRH's organization, management, control, and operation, including appointment of medical staff. This term includes the owner or partners for an LSRH owned or operated by an individual or partners.(22) Governmental unit--A political subdivision of the state, including a hospital district, county, or municipality, and any department, division, board, or other agency of a political subdivision.(23) Incompetent--Lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision.(24) Inpatient--An individual admitted to a facility for an intended length of stay of 24 hours or greater.(25) Inpatient services--Services provided to an individual admitted to an LSRH for an intended length of stay of 24 hours or greater.(26) Legally authorized representative (LAR)--A person authorized by law to act on behalf of another person with regard to a matter described in this chapter, including:(A) a parent, guardian, or managing conservator of a minor;(B) the guardian of an adult;(C) an agent to whom authority to make health care decisions is delegated under a medical power of attorney or durable power of attorney in accordance with state law; or(D) the representative of a deceased person.(27) Licensed vocational nurse (LVN)--A person who is currently licensed by the Texas Board of Nursing as a licensed vocational nurse or who holds a valid vocational nursing license with multi-state licensure privilege from another compact state.(28) Licensee--The person or governmental unit named in the application for issuance of an LSRH license.(29) Limited services rural hospital (LSRH)--A general or special hospital that is or was licensed under HSC Chapter 241 and that:(A) is:(i) located in a rural area, as defined by:(I) Texas Health and Human Services Commission rule; or(II) 42 United States Code (U.S.C.) Section 1395ww(d)(2)(D); or(ii) designated by the Centers for Medicare & Medicaid Services as a critical access hospital, rural referral center, or sole community hospital; and(B) otherwise meets the requirements to be designated as to be designated as a rural emergency hospital under Code of Federal Regulations Title 42 (42 CFR) Part 485, Subpart E.(30) Limited services rural hospital (LSRH) administration--Administrative body of an LSRH headed by an individual who has the authority to represent the LSRH and who is responsible for the operation of the LSRH according to the policies and procedures of the LSRH's governing body.(31) Medical staff--A physician or group of physicians and a podiatrist or group of podiatrists who by action of the governing body of an LSRH are privileged to work in and use the facilities of an LSRH for or in connection with the observation, care, diagnosis, or treatment of an individual who is, or may be, suffering from a mental or physical disease or disorder or a physical deformity or injury.(32) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate persons who have a mental illness.(33) Nurse--A registered, vocational, or advanced practice registered nurse licensed by the Texas Board of Nursing or entitled to practice in this state under Texas Occupations Code Title 3, Subtitle E.(34) Other potentially infectious materials--Any of the following materials.(A) The following human body fluids:(i) semen;(ii) vaginal secretions;(iii) cerebrospinal fluid;(iv) synovial fluid;(v) pleural fluid;(vi) pericardial fluid;(vii) peritoneal fluid;(viii) amniotic fluid;(ix) saliva in dental procedures;(x) any body fluid that is visibly contaminated with blood; and(xi) all body fluids in situations where it is difficult or impossible to differentiate between body fluids;(B) any unfixed tissue or organ (other than intact skin) from a human (living or dead); or(C) human immunodeficiency virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or hepatitis B virus (HBV)-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.(35) Outpatient--An individual who presents for diagnostic or treatment services for an intended length of stay of less than 24 hours. An individual who requires continued observation may be considered as an outpatient for up to 48 hours.(36) Outpatient services--Services provided to patients whose medical needs can be met in less than 24 hours and are provided within the LSRH. Services that require continued observation may be considered as outpatient services for up to 48 hours.(37) Owner--One of the following persons or governmental unit which will hold or does hold a license issued under the statute in the person's name or the person's assumed name:(A) a corporation;(B) a governmental unit;(C) a limited liability company;(D) an individual;(E) a partnership if a partnership name is stated in a written partnership agreement or an assumed name certificate;(F) all partners in a partnership if a partnership name is not stated in a written partnership agreement or an assumed name certificate; or(G) all co-owners under any other business arrangement.(38) Patient--An individual who presents for diagnosis or treatment.(39) Person--An individual, firm, partnership, corporation, association, or joint stock company, and includes a receiver, trustee, assignee, or other similar representative of those entities.(40) Physician--An individual licensed by the Texas Medical Board and authorized to practice medicine in the state of Texas.(41) Physician assistant--A person licensed as a physician assistant by the Texas Physician Assistant Board.(42) Podiatrist--A podiatrist licensed by the Texas Department of Licensing and Regulation.(43) Practitioner--A health care professional licensed in the state of Texas, other than a physician, podiatrist, or dentist.(44) Prelicensure conference--A conference held with HHSC staff and the applicant or the applicant's representative to review licensure rules and survey documents and provide consultation prior to the on-site licensure inspection.(45) Premises--A building where patients receive LSRH services.(46) Prominent location--A size and font at least as large as that of surrounding text, links, or buttons, distinct from the background of the website, immediately viewable upon accessing the home page of the hospital's publicly accessible website without having to scroll.(47) Prominently displayed--Refer to "prominent location." (48) Public health emergency--A state of disaster or local disaster declared under Texas Government Code Chapter 418 or a public health disaster as defined by HSC §81.003.(49) Qualified rural hospital--A general or special hospital licensed under HSC Chapter 241 (relating to Hospitals) on December 27, 2020, that meets the requirements to be designated as a rural emergency hospital under 42 CFR §485.502 (relating to Definitions), and §485.506 (relating to Designation and Certification of REHs) and is:(A) located in a rural area, as defined by 42 U.S.C. §1395ww(d)(2)(D); or(B) designated by the Centers for Medicare & Medicaid Services as a critical access hospital, rural referral center, or sole community hospital.(50) Qualifying official disaster order--An order, proclamation, or other instrument issued by the Governor, another official of this state, or the governing body or an official of a political subdivision of this state declaring a disaster that has infectious disease as the basis for the declared disaster.(51) Qualifying period of disaster--The period of time the area in which a LSRH is located is declared to be a disaster area by a qualifying official disaster order.(52) Quality improvement--A method of evaluating and improving processes of patient care that emphasizes a multidisciplinary approach to problem solving, and focuses not on individuals, but systems of patient care which might be the cause of variations.(53) Quality improvement organization--An organization that has a contract with the Centers for Medicare & Medicaid Services, under Title XI Part B of the Social Security Act, to perform utilization and quality control review of the health care furnished, or to be furnished, to Medicare beneficiaries.(54) Religious counselor--An individual acting substantially in a pastoral or religious capacity to provide spiritual counsel to other individuals.(55) Registered nurse (RN)--A person who is currently licensed by the Texas Board of Nursing as a registered nurse or who holds a valid registered nursing license with multi-state licensure privilege from another compact state.(56) Restraint--A restraint is:(A) any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move their arms, legs, body, or head freely; or(B) a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition and does not include:(i) devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests; or(ii) devices to protect the patient from falling out of bed, off of a stretcher, or out of a chair, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort).(57) Seclusion--The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving.(58) Special hospital--An establishment that:(A) offers services, facilities, and beds for use for more than 24 hours for two or more unrelated individuals who are regularly admitted, treated, and discharged and who require services more intensive than room, board, personal services, and general nursing care;(B) has clinical laboratory facilities, diagnostic X-ray facilities, treatment facilities, or other definitive medical treatment;(C) has a medical staff in regular attendance; and(D) maintains records of the clinical work performed for each patient.(59) Stabilize--With respect to an emergency medical condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or that the woman has delivered the child and the placenta.(60) Surgical technologist--A person who practices surgical technology as defined in HSC Chapter 259.(61) Telemedicine--A health care service that is initiated by a physician or provided by a licensed health professional acting under appropriate physician delegation and supervision that is provided for purposes of client assessment by a health professional, diagnosis or consultation by a physician, or treatment, or for the transfer of medical data, and that requires the use of advanced telecommunications technology, other than telephone or facsimile technology, including:(A) compressed digital interactive video, audio, or data transmission;(B) clinical data transmission using computer imaging by way of still-image capture and store and forward; and(C) other technology that facilitates access to health care services or medical specialty expertise.(62) Transfer--The movement (including the discharge) of an individual outside an LSRH's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the LSRH, but does not include such a movement of an individual who has been declared dead, or leaves the facility without the permission of any such person.(63) Universal precautions--Procedures for disinfection and sterilization of reusable medical devices and the appropriate use of infection control, including hand washing, the use of protective barriers, and the use and disposal of needles and other sharp instruments as those procedures are defined by the Centers for Disease Control and Prevention (CDC) of the United States Department of Health and Human Services. This term includes standard precautions as defined by the CDC that are designed to reduce the risk of transmission of blood borne and other pathogens in hospitals.(64) Violation--Failure to comply with the licensing statute, a rule or standard, special license provision, or an order issued by the HHSC executive commissioner (executive commissioner) or the executive commissioner's designee, adopted or enforced under the licensing statute. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty. Source Note: The provisions of this §511.2 adopted to be effective October 5, 2023, 48 TexReg 5668; amended to be effective October 9, 2025, 50 TexReg 6495. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS A GENERAL PROVISIONS §511.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215181 03/12/2026 (a) A limited services rural hospital (LSRH) may submit a written request to the Texas Health and Human Services Commission (HHSC) for a waiver or modification of a particular provision of Texas Health and Safety Code (HSC) Chapter 241 (relating to Hospitals) or a standard in this chapter, except fire safety requirements. The written request shall specify the section or sections of HSC Chapter 241 or this chapter for which the LSRH is requesting a waiver.(b) In requesting the waiver, the LSRH must address each of the following requirements and provide documentation as necessary to support its position. The LSRH must:(1) provide evidence to support why the requested waiver will not adversely affect the health and safety of the hospital patients, employees, or the general public;(2) indicate how the LSRH determined that granting the waiver would not adversely impact the LSRH's participation in the federal Medicare program or accreditation by a Centers for Medicare & Medicaid Services-approved organization;(3) describe how not granting the waiver would impose an unreasonable hardship on the LSRH in providing adequate care for patients;(4) describe how the waiver would facilitate creating or operating the LSRH; and(5) explain why the waiver would be appropriate when balanced against the best interests of the individuals served or to be served by the LSRH.(c) The LSRH must submit supporting documentation with the waiver request. HHSC may request additional written documentation from the LSRH to support the waiver or modification.(d) In accordance with HSC §241.302(f) (relating to License Required), HHSC may grant a waiver under this section if HHSC determines the waiver or modification will facilitate creating or operating the LSRH and that the waiver or modification is in the best interests of the individuals served or to be served by the LSRH.(e) The HHSC Health Care Regulation licensing director ("licensing director") shall submit a written recommendation for granting or denying the waiver to the HHSC executive commissioner or designee.(f) If the licensing director recommends that the waiver or modification be granted, the executive commissioner may issue a written order granting the waiver or modification.(g) If the licensing director recommends that the waiver or modification be denied, the executive commissioner may issue a written order denying the waiver or modification.(h) The LSRH's licensing file maintained by HHSC shall contain a copy of the request, any supporting documents the LSRH provided, and the order. The LSRH shall maintain the original order in their permanent records. Source Note: The provisions of this §511.3 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS A GENERAL PROVISIONS §511.3 Waiver Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215182 03/12/2026 (a) A limited services rural hospital (LSRH) shall obtain a license before admitting patients.(b) An applicant for an LSRH license shall submit a license application to the Texas Health and Human Services Commission (HHSC) in a form and manner prescribed by HHSC.(c) An applicant shall submit a license application in accordance with §511.12 of this subchapter (relating to Application and Issuance of Initial License). The applicant shall retain copies of all application documents submitted to HHSC.(d) During the licensing period, an LSRH shall comply with the other provisions of Texas Health and Safety Code Chapter 241 (relating to Hospitals), to the extent they do not conflict with Subchapter K (relating to Limited Services Rural Hospitals), and Code of Federal Regulations Title 42 Part 485 Subpart E (relating to Conditions of Participation: Rural Emergency Hospitals (REHs)) and this chapter.(e) HHSC issues an LSRH license for the premises and person named in the application.(1) An LSRH license shall not include off-site outpatient facilities.(2) An LSRH may share a building with other licensed facilities.(A) The LSRH must be licensed separately from the other licensed facilities.(B) No identifiable part of the building may be dually licensed by more than one facility.(C) Each licensed facility in the building shall comply with the requirements of §511.165 of this chapter (relating to Building with Multiple Occupancies).(3) A licensed LSRH shall not hold or pursue dual licensure as any other facility type.(f) An LSRH shall prominently and conspicuously display the LSRH license in a public area of the licensed premises that is readily visible to patients, employees, and visitors.(g) An LSRH shall not alter the LSRH license.(h) An LSRH license is nontransferable. The LSRH shall comply with the provisions of §511.15 of this subchapter (relating to Change of Ownership) in the event of a change in the ownership of an LSRH.(i) An LSRH shall notify HHSC in writing and in accordance with HHSC instructions, of any changes affecting the LSRH's license before the change occurs. Changes may include:(1) addition or deletion of services indicated on the license application; or(2) any construction, renovation, or modification of the hospital buildings.(j) An LSRH shall notify HHSC, in writing and in accordance with HHSC instructions, at the time of the occurrence of any of the following:(1) cessation of operation of the LSRH, whether temporary or permanent;(2) change in certification or accreditation status;(3) change in the LSRH name, telephone number, or administrator; or(4) change in the emergency contact name or emergency contact phone number.(k) A written notice of cessation of operation under subsection (j)(1) of this section shall include the location where the LSRH will store medical records and the identity and telephone number of the custodian of the medical records. Source Note: The provisions of this §511.11 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.11 General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226328 03/12/2026 (a) An applicant who meets the definition of a qualified rural hospital under §511.2(49) of this chapter (relating to Definitions) and is seeking a limited services rural hospital (LSRH) license shall submit the following documents to the Texas Health and Human Services Commission (HHSC) within 60 calendar days before the projected opening date of the LSRH:(1) an accurate and complete application form;(2) a copy of the LSRH's patient transfer policy, developed in accordance with §511.65 of this chapter (relating to Patient Transfer Policy) and signed by both the chairman and secretary of the LSRH's governing body attesting to the date the governing body adopted the policy and the policy's effective date;(3) a copy of the LSRH's memorandum of transfer form that contains at least the information described in §511.65 of this chapter;(4) a copy of a patient transfer agreement entered into between the LSRH and at least one hospital certified by the Centers for Medicare & Medicaid Services that is designated as a level I or level II trauma center in accordance with §511.66 of this chapter (relating to Patient Transfer Agreements);(5) a copy of a fire inspection approved by an individual certified by the Texas Commission on Fire Protection that is dated no earlier than one year before the application submission date; and(6) the appropriate license fee as required in §511.17 of this subchapter (relating to Fees).(b) In addition to the document submittal requirements in subsection (a) of this section, the applicant must complete the following before HHSC will issue an LSRH license.(1) When HHSC requires an architectural inspection, per HHSC instructions, submit written approval from HHSC confirming compliance with Subchapters F and G of this chapter (relating to Fire Prevention and Safety and Physical Plant and Construction Requirements, respectively).(A) HHSC requires an architectural inspection when a qualifying rural hospital that has closed subsequently applies for an LSRH license.(B) A hospital applying for an LSRH license after being closed for 90 days or fewer shall inform HHSC of the entity maintaining the facility during the closure period, if any, and provide maintenance and facility condition documentation, such as logbooks and photographs. HHSC may waive the architectural inspection if HHSC determines the documentation indicates an acceptable maintenance history and facility condition.(C) HHSC may waive the architectural inspection for a currently operating qualifying rural hospital that applies for an LSRH license.(2) If the applicant intends to add on any new services as an LSRH that the applicant did not offer while licensed as a general or special hospital, the applicant must comply with Subchapter G of this chapter as applicable.(3) The applicant or the applicant's representative shall attend a prelicensure conference conducted by HHSC. HHSC may waive the prelicensure conference requirement at its discretion.(c) Subject to subsection (g) of this section, when HHSC determines the applicant has complied with subsections (a) and (b) of this section, HHSC shall issue the LSRH license to the applicant.(1) The license is effective on the issue date.(2) The license expires on the last day of the month two years after the issue date.(d) If an applicant decides not to continue the application process for a license, the applicant may withdraw the application. The applicant shall submit a written withdrawal request to HHSC. HHSC shall acknowledge receipt of the application withdrawal request.(e) If the applicant does not complete all requirements of subsections (a) and (b) of this section within six months after the date HHSC receives the application and payment, HHSC may deny the application.(f) Any fee paid for a withdrawn application under subsection (d) or (e) of this section is nonrefundable, as indicated by §511.17(a) of this subchapter.(g) Denial of a license shall be governed by §511.121 of this chapter (relating to Enforcement).(h) Once the LSRH is operational and providing services, HHSC shall conduct an inspection of the LSRH to ascertain compliance with the provisions of Texas Health and Safety Code Chapter 241 to the extent it does not conflict with HSC Subchapter K and this chapter. This inspection may be conducted at the same time as the inspection to determine compliance with Code of Federal Regulations Title 42, Part 482 (relating to Conditions of Participation for Hospitals).(i) An LSRH seeking relocation shall comply with all requirements of this section, except the prelicensure conference required under subsection (b)(3) of this section. An initial license for the relocated facility is effective on the issue date. The previous license is void on the date the previous location closes. The facility must notify HHSC once the previous location has closed. Source Note: The provisions of this §511.12 adopted to be effective October 5, 2023, 48 TexReg 5668; amended to be effective October 9, 2025, 50 TexReg 6495. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.12 Application and Issuance of Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215184 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) shall send written notice of license expiration to a limited services rural hospital (LSRH) at least 60 calendar days before the expiration date of the license. If the LSRH has not received notice, it is the LSRH's duty to notify HHSC and request a renewal notice.(b) The LSRH shall submit the following to HHSC before the license expiration date:(1) a complete and accurate application;(2) a copy of two fire inspections that are conducted and approved by an individual certified by the Texas Commission on Fire Protection to conduct fire inspections and meet the requirements of §511.141 of this chapter (relating to Fire Prevention and Protection), one from within the last 12 months and one from the year before, as the LSRH must obtain an approved fire inspection annually;(3) the renewal license fee; and(4) if the applicant is accredited by a Centers for Medicare & Medicaid Services-approved organization, a copy of documentation from the accrediting body showing the current accreditation status of the hospital.(c) HHSC may conduct an inspection before issuing a renewal license in accordance with §511.112 of this chapter (relating to Inspections).(d) Subject to subsection (g) of this section, HHSC shall issue a renewal license to an LSRH that meets the requirements for a license.(e) Renewal licenses will be valid for two years from the previous expiration date.(f) If an LSRH fails to submit the application, documents, and fee by the expiration date of the LSRH's license, HHSC shall notify the LSRH that it must cease operation and immediately return the license to HHSC. If the LSRH intends to provide services after the expiration date of the license, HHSC may require the LSRH to apply for a license under §511.12 of this subchapter (relating to Application and Issuance of Initial License).(g) Denial of a renewal license shall be governed by §511.121 of this chapter (relating to Enforcement). Source Note: The provisions of this §511.13 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.13 Application and Issuance of Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215185 03/12/2026 (a) A limited services rural hospital (LSRH) that is not offering services under its license shall immediately inform the Texas Health and Human Services Commission (HHSC). HHSC may automatically close an LSRH facility if the facility does not offer services for more than 60 days, unless the facility sends a written request to place the license on inactive status.(1) To be eligible for inactive status, an LSRH must be in good standing with no pending enforcement action or investigation.(2) The licensee is responsible for any license renewal requirements or fees, and for proper maintenance of patient records, while the license is inactive.(3) A license may not remain inactive for more than 60 calendar days without an approved extension from HHSC.(4) To reactivate the license, the LSRH must inform HHSC no later than 60 calendar days after the LSRH stopped offering services under its license.(5) An LSRH that does not reactivate its license by the 60th calendar day may request an extension of the inactive status from HHSC through a written request.(6) If by the 60th calendar day after it stopped offering services, the LSRH does not reactivate its license or request an extension for inactive status, HHSC may consider the facility closed.(b) An LSRH shall notify HHSC, in writing in accordance with HHSC instructions, before closure of the facility.(1) The LSRH shall dispose of medical records in accordance with §511.67 of this chapter (relating to Medical Records).(2) The LSRH shall appropriately discharge or transfer all patients before the facility closes.(3) A license becomes invalid when an LSRH closes. The facility shall return the licensure certificate to HHSC immediately after the LSRH closes.(c) An LSRH that closes, or for which a license issued under this chapter expires or is suspended or revoked, shall immediately remove or cause to be removed any signs within view of the general public indicating that the facility is in operation. Source Note: The provisions of this §511.14 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.14 Inactive Status and Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215186 03/12/2026 (a) A change of ownership of a limited services rural hospital (LSRH) occurs when there is a change in the person or governmental entity legally responsible for the operation of the LSRH, whether by lease or by ownership.(1) If a licensee amends its articles of incorporation to revise its name and the tax identification number does not change, this section does not apply, except that the corporation must notify the Texas Health and Human Services Commission (HHSC) within 10 calendar days after the effective date of the name change.(2) The sale of stock of a licensee does not cause this section to apply.(b) The new owner shall submit a license application to HHSC before the date of the change of ownership or not later than 10 calendar days after the date of a change of ownership. The application shall be in accordance with §511.12 of this subchapter (relating to the Application and Issuance of Initial License) except the applicant does not need to submit any transfer agreements previously approved by HHSC if the current applicant affirmatively indicates adoption of the HHSC-approved transfer agreement. In addition to the documents required in §511.12 of this subchapter, the applicant shall include a legal document reflecting the change of ownership, such as a copy of the signed bill of sale, or lease agreement, that reflects the effective date of the sale or lease and has been executed by both parties.(c) HHSC may waive the on-site construction and health inspections required by §511.12 of this subchapter.(d) When HHSC determines the new owner has complied with the provisions of §511.12 of this subchapter, HHSC shall issue a new license which shall be effective the date of the change of ownership.(e) The expiration date of the license shall be in accordance with §511.12 of this subchapter.(f) The previous owner's license shall be void on the effective date of the new owner's license. Source Note: The provisions of this §511.15 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.15 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215187 03/12/2026 (a) The application receipt date for an initial license or a renewal license is the date the Texas Health and Human Services Commission (HHSC) receives the application and fee.(b) An initial license application is complete when HHSC receives, reviews, and finds acceptable the information described in §511.12(a) - (b) of this subchapter (relating to Application and Issuance of Initial License).(c) A renewal license application is complete when HHSC receives, reviews, and finds acceptable the information described in §511.13(b) of this subchapter (relating to Application and Issuance of Renewal License).(d) HHSC shall process a limited services rural hospital (LSRH) initial or renewal license in accordance with the following time periods.(1) The first time period begins on the date HHSC receives the application and supporting documents and ends on the date HHSC issues the LSRH license. If HHSC receives an incomplete application, the time period ends on the date HHSC issues a written notice to the applicant that the application is incomplete. The written notice shall describe the specific documents or information required to complete the application. The first time period is 45 calendar days.(2) For incomplete applications, the second time period begins on the date HHSC determines the application is complete and ends on the date HHSC issues the LSRH license. The second time period is 45 calendar days.(e) If the application is not processed in the time periods as stated in subsection (d) of this section, the applicant has the right to request HHSC to fully reimburse the fee paid in that particular application process. If HHSC does not agree the established periods have been violated or finds good cause existed for exceeding the established periods, HHSC shall deny the request.(f) The following circumstances are good cause for HHSC exceeding the established time period:(1) the number of applications for licenses exceeds by 15 percent or more the number processed in the same calendar quarter the preceding year;(2) another public or private entity utilized in the application process caused the delay; or(3) other conditions existed which gave good cause for exceeding the established time periods.(g) If HHSC denies the request for full reimbursement authorized by subsection (e) of this section, the applicant may then appeal to the HHSC executive commissioner for a resolution of the dispute. The applicant shall give written notice to the executive commissioner requesting full reimbursement of all filing fees paid because HHSC did not process the application within the adopted time period. HHSC shall submit a written report of the facts related to the processing of the application and good cause for exceeding the established time periods. The executive commissioner shall make the final decision and provide written notification of the decision to the applicant and HHSC. Source Note: The provisions of this §511.16 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.16 Time Periods for Processing and Issuing Limited Services Rural Hospital Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215188 03/12/2026 (a) All fees paid to the Texas Health and Human Services Commission (HHSC) are nonrefundable with the exception of inspection fees for inspections that were not conducted.(b) All fees shall be paid by check or money order made payable to HHSC.(c) The license application fee for an initial license or a renewal license is $350.00.(d) A limited services rural hospital (LSRH) shall submit a license fee regardless of the number of months remaining in the license period.(e) An LSRH will not receive a refund of previously submitted fees should the LSRH's design capacity decrease as a result of an approved construction project.(f) This subsection outlines the fees that must accompany the application for plan review and all proposed plans and specifications covering the alterations to existing buildings which the LSRH must submit for review and approval by HHSC in accordance with §511.167 of this chapter (relating to Preparation, Submittal, Review, and Approval of Plans, and Retention of Records).(1) HHSC will not review or approve construction plans until HHSC receives the required fee and an application for plan review.(2) HHSC bases plan review fees on the estimated construction project costs that are the total expenditures required for a proposed project from initiation to completion, including at least the following items.(A) Construction project costs shall include expenditures for physical assets, such as:(i) site acquisition;(ii) soil tests and site preparation;(iii) construction and improvements required as a result of the project;(iv) building, structure, or office space acquisition;(v) renovation;(vi) fixed equipment; and(vii) energy provisions and alternatives.(B) Construction project costs shall include expenditures for professional services, including:(i) planning consultants;(ii) architectural fees;(iii) fees for cost estimation;(iv) legal fees;(v) management fees; and(vi) feasibility study.(C) Construction project costs shall include expenditures or costs associated with financing, excluding long-term interest, but including:(i) financial advisor;(ii) fund-raising expenses;(iii) lender's or investment banker's fee; and(iv) interest on interim financing.(D) Construction project costs shall include expenditure allowances for contingencies, including:(i) inflation;(ii) inaccurate estimates;(iii) unforeseen fluctuations in the money market; and(iv) other unforeseen expenditures.(3) Regarding purchases, donations, gifts, transfers, and other comparable arrangements whereby the acquisition is to be made for no consideration or at less than the fair market value, HHSC shall determine project cost by the fair market value of the item to be acquired as a result of the purchase, donation, gift, transfer, or other comparable arrangement.(A) The plan review fee schedule based on cost of construction is:(i) $100,000 or less--$300;(ii) $100,001 to $600,000--$850;(iii) $600,001 to $2,000,000--$2,000;(iv) $2,000,001 to $5,000,000--$3,000;(v) $5,000,001 to $10,000,000--$4,000; and(vi) $10,000,001 and over--$5,000.(B) If an estimated construction cost cannot be established, the estimated cost shall be based on $225 per square foot. No construction project shall be increased in size, scope, or cost unless the LSRH submits appropriate fees with the proposed changes.(g) An LSRH shall submit a fee of $500 and a construction inspection application for each inspection to HHSC at least three weeks before the anticipated inspection date. HHSC will not conduct construction inspections until HHSC receives all required fees. If the LSRH requests additional construction inspections of the proposed project, the LSRH shall submit appropriate additional fees before HHSC conducts any inspections. When HHSC performs follow-up construction inspections to verify plans of correction, the LSRH shall submit the fee when HHSC completes the inspection.(h) HHSC collects subscription and convenience fees, in amounts determined by the TexasOnline Authority, to recover costs associated with application and renewal application processing through TexasOnline, in accordance with Texas Government Code §2054.111 (relating to Use of State Electronic Internet Portal Project) and §2054.252 (State Electronic Internet Portal Project). Source Note: The provisions of this §511.17 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS B LICENSING REQUIREMENTS §511.17 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215191 03/12/2026 (a) A limited services rural hospital (LSRH) shall have an identified governing body responsible for the LSRH's organization, management, control, and operation, including the appointment of the LSRH's medical staff. For LSRHs owned and operated by an individual or by partners, the individual or partners are the governing body.(b) An LSRH shall formally organize its governing body in accordance with a written constitution and bylaws, which clearly set forth the organizational structure and responsibilities. Source Note: The provisions of this §511.41 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.41 Governing Body Organization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215192 03/12/2026 (a) A limited services rural hospital's (LSRH's) governing body shall address and is fully responsible, either directly or by appropriate professional delegation, for the operation and performance of the LSRH.(b) The governing body is responsible for all services furnished in the LSRH, whether furnished directly or under contract. The governing body shall ensure:(1) services, including any contracted services, are provided in a safe and effective manner that permits the LSRH to comply with all applicable rules and standards, including the federal conditions of participation at Code of Federal Regulations Title 42 (42 CFR) Part 485, Subchapter E and this chapter;(2) the LSRH maintains a list of all contracted services, including the scope and nature of the services provided;(3) the medical staff is accountable to the governing body for the quality of care provided to patients as required by 42 CFR §485.510; and(4) the provision of education to students and postgraduate trainees if the LSRH participates in such programs.(c) An LSRH's governing body shall adopt, implement, and enforce written policies and procedures for the total operation and all services the LSRH provides, with the policies for the LSRH's services being developed, reviewed, and updated in accordance with §511.51 of this subchapter (relating to Provision of Services). The policies and procedures shall include at least the following:(1) bylaws or similar rules and regulations for the orderly development and management of the LSRH;(2) policies or procedures necessary for the orderly conduct of the LSRH;(3) policies or procedures related to emergency planning and disaster preparedness that shall require the governing body to review the LSRH's disaster preparedness plan at least annually;(4) policies for the provision of the following services:(A) emergency services;(B) radiological services;(C) laboratory services;(D) pharmacy services; and(E) any outpatient services the LSRH provides;(5) policies for the collection, processing, maintenance, storage, retrieval, authentication, and distribution of patient medical records and reports;(6) policy on the rights of patients and complying with all state and federal patient rights requirements;(7) policies for the provision of an effective procedure for the immediate transfer to a licensed hospital of patients requiring emergency care beyond the capabilities of the LSRH, including a transfer agreement with a hospital licensed in this state as defined in §511.66 of this subchapter (relating to Patient Transfer Agreements);(8) policies for all individuals that arrive at the LSRH to ensure they are provided an appropriate medical screening examination within the capability of the LSRH, including:(A) ancillary services routinely available to determine whether or not the individual needs emergency care as defined in §511.2 of this chapter (relating to Definitions); and(B) if emergency care is determined to be needed, the LSRH shall provide any necessary stabilizing treatment or arrange an appropriate transfer for the individual as defined in §511.65 of this subchapter (relating to Patient Transfer Policy);(9) a policy that complies with the requirements under Texas Health and Safety Code §241.009 to require employees, physicians, contracted employees, and individuals in training who provide direct patient care at the LSRH to wear a photo identification badge during all patient encounters, unless precluded by adopted isolation or sterilization protocols; and(10) policies to ensure compliance with applicable state and federal laws.(d) The governing body's responsibilities shall include:(1) determining the LSRH's mission, goals, and objectives;(2) ensuring that facilities and personnel are sufficient and appropriate to carry out the LSRH's mission;(3) determining, in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff;(4) appointing members of the medical staff after considering the recommendations of the existing members of the medical staff;(5) ensuring that the medical staff is accountable to the governing body for the quality of care provided to patients;(6) ensuring the criteria for medical staff selection are individual character, competence, training, experience, and judgment;(7) ensuring a physical environment that protects the health and safety of patients, personnel, and the public;(8) establishing an organizational structure and specifying functional relationships among the various components of the LSRH;(9) reviewing and approving the LSRH's training program for staff;(10) ensuring all equipment utilized by LSRH staff or by patients is properly used and maintained per manufacturer recommendations;(11) ensuring there is a quality assessment and performance improvement (QAPI) program to evaluate the provision of patient care;(12) reviewing and monitoring QAPI activities quarterly;(13) consulting directly at least periodically throughout the fiscal or calendar with medical director or their designee, and include discussion of matters related to the quality of medical care provided to patients of the LSRH;(14) consulting directly with the individual responsible for the organized medical staff (or their designee) of each hospital or LSRH within its system as applicable for a multi-facility system, including a multi-hospital or multi-LSRH system, using a single governing body;(15) reviewing legal and ethical matters concerning the LSRH and its staff when necessary and responding appropriately;(16) ensuring that under no circumstances is the accordance of staff membership or professional privileges in the LSRH dependent solely upon certification, fellowship, or membership in a specialty body or society;(17) maintaining effective communication throughout the LSRH;(18) establishing a system of financial management and accountability that includes an audit or financial review appropriate to the LSRH;(19) formulating long-range plans in accordance with the mission, goals, and objectives of the LSRH;(20) operating the LSRH without limitation because of color, race, age, sex, religion, national origin, or disability;(21) ensuring that all marketing and advertising concerning the LSRH does not imply that it provides care or services that the LSRH is not capable of providing;(22) developing a system of risk management appropriate to the LSRH, including:(A) periodic review of all litigation involving the LSRH, its staff, physicians, and practitioners regarding activities in the LSRH;(B) periodic review of all incidents reported by staff and patients;(C) review of all deaths, trauma, or adverse reactions occurring on premises; and(D) evaluation of patient complaints;(23) ensuring that when telemedicine services are furnished to the LSRH's patients through an agreement with a distant-site hospital, the agreement meets the requirements of 42 CFR §485.510; and(24) ensuring that when telemedicine services are furnished the services meet all federal and state laws, rules, and regulations.(e) The governing body shall ensure the medical staff has current written bylaws, rules, and regulations that are adopted, implemented, and enforced by the LSRH on file.(f) The governing body shall approve medical staff bylaws and other medical staff rules and regulations.(g) The governing body, with input from the medical staff, shall periodically review the scope of procedures performed in the LSRH and amend as appropriate.(h) The governing body shall provide for full disclosure of ownership to the Texas Health and Human Services Commission.(i) The governing body shall meet at least annually and maintain minutes or other records necessary for the orderly conduct of the LSRH. Meetings the LSRH's governing body holds shall be separate meetings with separate minutes from any other governing body meeting.(j) If the governing body elects, appoints, or employs officers and administrators to carry out its directives, the governing body shall define the authority, responsibility, and functions of all such positions.(k) The governing body shall provide (in a manner consistent with state law and based on evidence of education, training, and current competence) for the initial appointment, reappointment, and assignment or curtailment of privileges and practice for non-physician health care personnel and practitioners.(l) The governing body shall develop a process for appointing or reappointing medical staff, and for assigning or curtailing medical privileges and shall periodically reappraise medical staff privileges.(m) The governing body shall encourage personnel to participate in continuing education that is relevant to their responsibilities within the LSRH.(n) The governing body shall review patient satisfaction with services and environment at least annually. Source Note: The provisions of this §511.42 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.42 Governing Body Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215193 03/12/2026 (a) A limited services rural hospital (LSRH) shall adopt, implement, and enforce administrative policies and procedures to ensure the orderly and efficient management of the LSRH. An LSRH's administrative policies and procedures shall include the following administrative responsibilities:(1) enforcing policies delegated by the governing body;(2) employing qualified management personnel;(3) long-range and short-range planning for the LSRH's needs, as determined by the governing body;(4) using methods of communicating and reporting, designed to ensure the orderly flow of information within the LSRH;(5) controlling the purchase, maintenance, and distribution of the LSRH's equipment, materials, and facilities;(6) establishing lines of authority, accountability, and personnel supervision;(7) establishing controls relating to the custody of the LSRH's official documents; and(8) maintaining the confidentiality, security, and physical safety of data on patients and staff.(b) The LSRH shall adopt, implement, and enforce personnel policies to facilitate the LSRH attaining its mission, goals, and objectives. The LSRH's personnel policies shall:(1) define and delineate functional responsibilities and authority;(2) require LSRH personnel to have qualifications commensurate with their job responsibilities and authority, including appropriate licensure or certification;(3) require documented periodic appraisal of each person's job performance;(4) specify employment responsibilities and privileges;(5) be made known to employees at the time of employment; and(6) provide and document adequate orientation and training to familiarize all personnel with the LSRH's policies, procedures, equipment, and facilities.(c) An LSRH shall include all employee categories in personnel policies and shall develop appropriate job descriptions for each position. Source Note: The provisions of this §511.43 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.43 Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215194 03/12/2026 (a) A limited services rural hospital (LSRH) shall provide the emergency care necessary to meet the needs of its patients in accordance with acceptable standards of practice.(b) An LSRH shall provide to each patient, without regard to the individual's ability to pay, an appropriate medical screening, examination, and stabilization within the facility's capability, including ancillary services routinely available to the hospital, to determine whether an emergency medical condition exists and shall provide any necessary stabilizing treatment.(c) An LSRH shall have an emergency suite that complies with §511.163(e) of this chapter (relating to Spatial Requirements).(d) The organization of the LSRH's emergency services must be appropriate to the scope of the services offered.(e) Emergency services must be organized under the direction of a qualified physician member of the LSRH's medical staff who is the medical director or clinical director.(f) Emergency services must be integrated with other LSRH departments.(g) The LSRH must maintain patient medical records for all emergency patients. The medical records shall contain patient identification, the reason for the visit, name of physician, name of nurse, time admitted to the emergency suite, treatment, time discharged, and disposition.(h) The policies and procedures governing medical care provided in the emergency suite must be established by and must be a continued responsibility of the medical staff.(i) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the LSRH.(j) There must be on-duty and on-site 24 hours a day, seven days a week at least one person qualified, as determined by the medical staff, to initiate immediate appropriate lifesaving measures and at least one nurse with current advanced cardiac life support and pediatric advanced life support certification. This individual or individuals must be able to receive patients and activate the appropriate medical resources to meet the care needed by the patient.(k) Qualified personnel must be physically present in the emergency treatment area at all times.(l) An LSRH must maintain schedules, names, and phone numbers of all physicians and others on emergency call duty, including alternates. The LSRH must maintain the schedules for at least one year.(m) In accordance with Code of Federal Regulations Title 42 (42 CFR) §485.516(c)(4), there must be a physician, a physician assistant, or an advanced practice registered nurse, with training or experience in emergency care, on call and immediately available by telephone or radio contact, and available on-site at the LSRH within 30 minutes, on a 24-hour a day basis, if the LSRH is located in an area other than an area described in 42 CFR §485.618(d)(1)(ii).(n) Emergency services must be available 24-hours per day.(o) An LSRH shall keep adequate age-appropriate equipment, supplies, and medication used in treating emergency cases and make this equipment, supplies, and medication readily available for treating emergency cases.(p) The age-appropriate emergency equipment and supplies available at the LSRH shall include at least the following:(1) emergency call system;(2) oxygen;(3) mechanical ventilatory assistance equipment, including airways, manual breathing bag, endotracheal tubes, ambu bag/valve/mask;(4) cardiac defibrillator;(5) cardiac monitoring equipment;(6) laryngoscopes and endotracheal tubes;(7) suction equipment;(8) stabilization devices for cervical injuries;(9) blood pressure monitoring equipment;(10) pulse oximeter or similar medical device to measure blood oxygenation;(11) tourniquets;(12) immobilization devices;(13) nasogastric tubes;(14) splints;(15) Intravenous (IV) therapy supplies;(16) suction machine;(17) chest tubes;(18) indwelling urinary catheters; and(19) drugs and biologicals commonly used in life-saving procedures as specified by the medical staff, which shall include:(A) analgesics,(B) local anesthetics,(C) antibiotics,(D) anticonvulsants,(E) antidotes and emetics,(F) serums and toxoids,(G) antiarrhythmics,(H) cardiac glycosides,(I) antihypertensives,(J) diuretics, and(K) electrolytes and replacement solutions.(q) Equipment and supplies must be available at the LSRH for administering intravenous medications as well as facilities for bleeding control and emergency splinting of fractures.(r) The LSRH shall periodically test emergency equipment according to the LSRH's adopted policy.(s) An LSRH shall provide, either directly or under arrangements, services for the procurement, safekeeping, and transfusion of blood, including the availability of blood products needed for emergencies on a 24-hour a day basis.(t) Provision for the storage of blood and blood products must be made as needed. If blood banking services are provided under an arrangement, the arrangement is approved by the LSRH's medical staff and by the persons directly responsible for the operation of the LSRH. An LSRH shall ensure all blood and blood components are stored in accordance with §511.45(h) of this subchapter (relating to Laboratory Services).(u) An LSRH shall, in coordination with emergency response systems in the area, establish procedures under which a physician is immediately available by telephone or radio contact on a 24-hour a day basis to receive emergency calls, provide information on treatment of emergency patients, and refer patients to the LSRH or other appropriate locations for treatment. Source Note: The provisions of this §511.44 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.44 Emergency Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215195 03/12/2026 (a) A limited services rural hospital (LSRH) shall provide basic laboratory services essential to the immediate diagnosis and treatment of the patient consistent with nationally recognized standards of care for emergency services, patient population, and services offered.(b) The LSRH must ensure laboratory services are available, either directly or through a contractual agreement with a certified laboratory that complies with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988) in accordance with the requirements specified in Code of Federal Regulations Title 42 (42 CFR) Part 493 (relating to Laboratory Requirements). CLIA 1988 applies to all hospitals with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.(c) The LSRH shall ensure that all laboratory services provided to its patients through a contractual agreement are performed in a facility certified in the appropriate specialties and subspecialties of service in accordance with the requirements specified in 42 CFR Part 493 to comply with CLIA 1988.(d) Emergency laboratory services shall be available on the premises, including at least the following:(1) assays for cardiac markers;(2) hematology;(3) chemistry; and(4) pregnancy testing.(e) A written description of services provided shall be available to the medical staff.(f) The laboratory shall ensure proper receipt and reporting of tissue specimens.(g) The medical staff and a pathologist shall determine which tissue specimens require a macroscopic (gross) examination and which require both macroscopic and microscopic examination.(h) When blood and blood components are stored, the LSRH shall have written procedures readily available containing directions on how to maintain the blood and blood components within permissible temperatures and include instructions to follow in the event of a power failure or other disruption of refrigeration.(1) Blood transfusions shall be prescribed in accordance with LSRH policy and administered in accordance with a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment.(2) A label or tray with the recipient's first and last names and identification number, donor unit number and interpretation of compatibility, if performed, shall be attached securely to the blood container.(3) Personnel administering blood transfusions and intravenous medications shall have special training for this duty according to adopted, implemented, and enforced LSRH policy.(4) Blood and blood components shall be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient.(5) LSRH staff must observe the patient for potential adverse reactions during the transfusion and for an appropriate time thereafter, and document the observations and patient's response as defined in the LSRH's blood transfusion policy.(6) Pretransfusion and posttransfusion vital signs shall be recorded.(7) Following the transfusion, the blood transfusion record or a copy shall be made a part of the patient's medical record.(i) The LSRH shall establish a mechanism for ensuring that the patient's physician or other licensed health care professional is made aware of critical value lab results, as established by the medical staff, before or after the patient is discharged.(j) An LSRH that provides laboratory services shall adopt, implement, and enforce written policies and procedures to manage, minimize, or eliminate the risks to laboratory personnel of exposure to potentially hazardous chemicals in the laboratory that may occur during the normal course of job performance.(k) Pathology and clinical laboratory services shall include at least the following:(1) conducting laboratory procedures that are appropriate to the needs of the patients;(2) performing tests in a timely manner;(3) distributing test results within 24 hours after completion of a test and maintaining a copy of the results in the laboratory; and(4) performing and documenting appropriate quality assurance procedures, including calibrating equipment periodically and validating test results through use of standardized control specimens or laboratories.(l) Preoperative laboratory procedures may be required as follows.(1) It shall be at the discretion of the governing body upon the recommendation of the medical staff to require preoperative laboratory orders.(2) If specific preoperative laboratory work is required, the medical staff shall approve them in accordance with the medical staff bylaws. Other laboratory work shall be performed only on the order of a physician, podiatrist, dentist, or other practitioner, practicing within the scope of their license and education, and written on the patient's chart.(3) These services shall be provided either directly within or through an effective contract arrangement with a Medicare-approved reference laboratory.(4) The contractual agreement with the Medicare-approved reference laboratory shall provide for routine and stat work to include pathology, clinical, and blood bank services, if blood is authorized by the LSRH, and shall be available for review. Source Note: The provisions of this §511.45 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.45 Laboratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215196 03/12/2026 (a) A limited services rural hospital (LSRH) shall maintain, or have available, diagnostic radiologic services according to needs of the patients. All radiology equipment, including X-ray equipment, mammography equipment and laser equipment, shall be licensed and registered as required under Texas Administrative Code Title 25 (25 TAC) Chapter 289 (relating to Radiation Control). When therapeutic services are also provided, the services, as well as the diagnostic services, shall meet professionally approved standards for safety and personnel qualifications as required in 25 TAC §§289.227, 289.229, 289.230, and 289.231 (relating to Use of Radiation Machines in the Healing Arts; Radiation Safety Requirements for Accelerators, Therapeutic Radiation Machines, Simulators, and Electronic Brachytherapy Devices; Certification of Mammography Systems and Mammography Machines Used for Interventional Breast Radiography; and General Provisions and Standards for Protection Against Machine-Produced Radiation, respectively). Portable X-ray equipment may be acceptable as a minimum requirement.(b) An LSRH shall adopt, implement, and enforce policies and procedures describing the radiologic services provided in the LSRH and how the LSRH maintains employee and patient safety.(c) LSRH policies shall address the quality aspects of radiologic services by:(1) performing radiologic services only upon the written order of a physician, podiatrist, dentist, or other practitioner, who is practicing within the scope of their license and education, and a concise statement of the reason for the examination; and(2) limiting the use of any radioactive sources in the facility to physicians who have been granted privileges for such use based on their training, experience, and current competence.(d) An LSRH shall minimize hazards to patients and personnel when providing radiologic services, particularly ionizing radiology procedures.(e) An LSRH shall adopt, implement, and enforce policies and procedures to address safety including:(1) regulation of the use, removal, handling, and storage of any radioactive material that is required to be licensed by the Texas Department of State Health Services (DSHS);(2) precautions against electrical, mechanical, and radiation hazards;(3) proper shielding where radiation sources are used;(4) acceptable monitoring devices for all personnel who might be exposed to radiation, including requiring monitoring devices be worn by all personnel in any area with a radiation hazard;(5) personnel monitoring dosimeters for nuclear medicine workers to measure their radiation exposure;(6) maintenance of radiation exposure records on personnel;(7) authenticated dated reports of all examinations performed shall be made a part of the patient's medical record;(8) inspection of equipment shall be made by or under the supervision of a licensed medical physicist in accordance with 25 TAC §289.227(o) (relating to Use of Radiation Machines in the Healing Arts). Defective equipment shall be promptly repaired or replaced; and(9) exposure reports and documentation shall be available for review.(f) Only personnel designated as qualified by the medical staff shall use the radiology equipment and administer procedures.(g) LSRH personnel shall provide radiologic services only on the order of individuals granted privileges by the medical staff.(h) A qualified full-time, part-time, or consulting radiologist shall supervise the ionizing radiologic services and shall interpret radiology tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section a radiologist is a physician who is qualified by education and experience in radiology in accordance with medical staff bylaws.(i) An LSRH shall maintain records of radiologic services. The radiologist or other individuals in accordance with subsections (f) and (h) of this section shall sign reports of their interpretations.(j) A physician or other practitioner within the scope of their license and education shall read, date, sign, and authenticate all examination reports.(k) The radiology department shall meet all applicable federal, state, and local laws, codes, rules, regulations, and ordinances.(l) Procedure manuals shall include procedures for all examinations performed, infection control in the facility, treatment or examination rooms, dress code of personnel, and cleaning of equipment.(m) When the LSRH provides nuclear medicine services, these services shall meet the needs of the patients in accordance with acceptable standards of practice and be licensed in accordance with 25 TAC §289.256 (relating to Medical and Veterinary Use of Radioactive Material).(1) The LSRH shall adopt, implement, and enforce policies and procedures describing the LSRH's nuclear medicine services and how the LSRH maintains employee and patient safety with regard to these services.(2) The organization of the nuclear medicine services shall be appropriate to the scope and complexity of the services offered.(3) The LSRH shall have a medical director or clinical director who is a physician qualified in nuclear medicine.(4) The medical director or clinical director shall specify the qualifications, training, functions, and responsibilities of nuclear medicine personnel and the medical staff shall approve them.(5) Radioactive materials shall be prepared, labeled, used, transported, stored, and disposed of in accordance with acceptable standards of practice and in accordance with 25 TAC §289.256.(6) In-house preparation of radiopharmaceuticals shall be by, or under, the direct supervision of an appropriately trained licensed pharmacist or physician.(7) There shall be proper storage and disposal of radioactive materials.(8) When nuclear medicine services staff perform clinical laboratory tests, the nuclear medicine staff shall comply with CLIA 1988 in accordance with the requirements specified in 42 CFR Part 493.(9) Equipment and supplies shall be appropriate for the types of nuclear medicine services offered and shall be maintained for safe and efficient performance. Qualified personnel shall inspect, test, and calibrate the equipment at least annually.(10) The LSRH shall maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures.(11) The physician approved by the medical staff to interpret diagnostic procedures shall sign and date the interpretations of these tests.(12) The LSRH shall maintain records of the receipt and disposition of radiopharmaceuticals until disposal is authorized by DSHS in accordance with 25 TAC §289.256.(13) Only an individual whose scope of state licensure and whose defined staff privileges allow referrals to nuclear medicine services shall order such services. Source Note: The provisions of this §511.46 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.46 Radiologic Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215197 03/12/2026 (a) A limited services rural hospital (LSRH) shall provide pharmaceutical services that meet the needs of the patients. The LSRH shall provide a pharmacy that is licensed, as required, by the Texas State Board of Pharmacy. Pharmacy services shall comply with all applicable statutes and rules.(b) The LSRH pharmacy shall be directed by a licensed pharmacist.(c) The LSRH medical staff shall develop policies and procedures that minimize drug errors. This function may be delegated to the LSRH's organized pharmaceutical services.(d) The LSRH pharmacy or drug storage area shall be administered in accordance with accepted professional principles.(e) Standards of practice as defined by state law shall be followed regarding the provision of pharmacy services.(f) The pharmaceutical services shall have an adequate number of personnel to ensure quality pharmaceutical services, including emergency services.(1) The staff shall be sufficient in number and training to respond to the pharmaceutical needs of the patient population being served. There shall be an arrangement for emergency services.(2) Employees shall provide pharmaceutical services within the scope of their license and education.(g) Drugs and biologicals shall be properly stored to ensure ventilation, light, security, and temperature controls.(h) Records shall have sufficient detail to follow the flow of drugs from entry through dispensation.(i) There shall be adequate controls over all drugs and medications, including the floor stock. Drug storage areas shall be approved by the pharmacist, and floor stock lists shall be established.(j) Inspections of drug storage areas shall be conducted throughout the LSRH under pharmacist supervision.(k) The LSRH shall have a drug recall procedure.(l) A full-time, part-time, or consulting pharmacist shall be responsible for developing, supervising, and coordinating all the activities of the pharmacy services.(1) Direction of pharmaceutical services may not require on-premises supervision but may be accomplished through regularly scheduled visits in accordance with state law.(2) A job description or other written agreement shall clearly define the responsibilities of the pharmacist.(m) The LSRH shall keep current and accurate records of the receipt and disposition of all scheduled drugs.(1) There shall be a record system in place that provides the information on controlled substances in a readily retrievable manner that is separate from the patient record.(2) Records shall trace the movement of scheduled drugs throughout the services, documenting utilization or wastage.(3) The pharmacist shall be responsible for determining that all drug records are in order and that an account of all scheduled drugs is maintained and reconciled with written orders.(n) In order to provide patient safety, drugs and biologicals shall be controlled and distributed in accordance with applicable standards of practice, consistent with federal and state laws.(o) All compounding, packaging, and dispensing of drugs and biologicals shall be under the supervision of a pharmacist and performed consistent with federal and state laws.(p) All drugs and biologicals shall be kept in a secure area and locked when appropriate.(1) The LSRH shall adopt, implement, and enforce a policy to ensure the safeguarding, transferring, and availability of keys to the locked storage area.(2) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970, Pub. L. 91-513, 84 Stat. 1236 (21 USC Ch. 13 § 801 et seq.), shall be kept locked within a secure area.(q) Outdated, mislabeled, or otherwise unusable drugs and biologicals shall not be available for patient use.(r) When a pharmacist is not available, drugs and biologicals shall be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with federal and state laws.(1) There shall be a current list of individuals identified by name and qualifications who are designated to remove drugs from the pharmacy.(2) Only amounts sufficient for immediate therapeutic needs shall be removed.(s) Drugs and biologicals not specifically prescribed as to time or number of doses shall automatically be stopped after a reasonable time that is predetermined by the medical staff.(1) Stop order policies and procedures shall be consistent with those of the nursing staff and the medical staff rules and regulations.(2) A protocol shall be established by the medical staff for the implementation of the stop order policy, in order that drugs shall be reviewed and renewed, or automatically stopped.(3) A system shall be in place to determine compliance with the stop order policy.(t) Drug administration errors, adverse drug reactions, and incompatibilities shall be immediately reported to the attending physician and, if appropriate, to the LSRH-wide quality assessment and performance improvement program. There shall be a mechanism in place for capturing, reviewing, and tracking medication errors and adverse drug reactions.(u) Abuses and losses of controlled substances shall be reported, in accordance with applicable federal and state laws, to the individual responsible for the pharmaceutical services, and to the chief executive officer, as appropriate.(v) Information relating to drug interactions and information on drug therapy, side effects, toxicology, dosage, indications for use, and routes of administration shall be immediately available to the professional staff.(1) A pharmacist shall be readily accessible by telephone or other means to discuss drug therapy, interactions, side effects, dosage, assist in drug selection, and assist in the identification of drug induced problems.(2) There shall be staff development programs on drug therapy available to facility staff to cover such topics as new drugs added to the formulary, how to resolve drug therapy problems, and other general information as the need arises.(3) The medical staff shall establish a formulary system to ensure quality pharmaceuticals at reasonable costs.(w) Blood transfusions, blood products, and intravenous medications must be administered in accordance with state law and approved medical staff policies and procedures.(x) Orders given orally for drugs and biologicals must be followed by a written order, signed by the prescribing physician or other authorized prescriber.(y) The LSRH shall have a procedure for reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs. Source Note: The provisions of this §511.47 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.47 Pharmaceutical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215198 03/12/2026 (a) A limited services rural hospital (LSRH) shall report to the Texas Health and Human Services Commission (HHSC) incidents of abuse, neglect, exploitation, or illegal, unethical, or unprofessional conduct as those terms are defined in subsection (b) of this section.(b) The following definitions apply only to this subsection.(1) Abuse of a child--includes the following acts or omissions by any person:(A) mental or emotional injury to a child that results in an observable and material impairment in the child's growth, development, or psychological functioning;(B) causing or permitting the child to be in a situation in which the child sustains a mental or emotional injury that results in an observable and material impairment in the child's growth, development, or psychological functioning;(C) physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from physical injury to the child, including an injury that is at variance with the history or explanation given and excluding an accident (an unforeseen event that causes or threatens physical injury despite prudent efforts to avoid the risk of injury) or reasonable discipline (correction of behavior that does not result in or risk substantial harm from physical injury) by a parent, guardian, or managing or possessory conservator that does not expose the child to a substantial risk of harm;(D) failure to make a reasonable effort to prevent an action (effort that an ordinary and prudent person would take to stop an action from occurring) by another person that results in physical injury that results in substantial harm to the child;(E) sexual conduct harmful to a child's mental, emotional, or physical welfare;(F) failure to make a reasonable effort to prevent sexual conduct harmful to a child;(G) compelling or encouraging the child to engage in sexual conduct as defined by the Texas Penal Code §43.01 (this is met whether the child actually engages in sexual conduct or simply faces a substantial risk of doing so);(H) causing, permitting, encouraging, engaging in, or allowing the photographing, filming, or depicting of the child if the person knew or should have known that the resulting photograph, film, or depiction of the child is obscene (as defined by the Texas Penal Code) or pornographic (this is met whether or not the child voluntarily participates);(I) the current use by a person of a controlled substance as defined by the Texas Health and Safety Code (HSC) Chapter 481, in a manner or to the extent that the use results in physical, mental, or emotional injury to a child; or(J) causing, expressly permitting, or encouraging a child to use a controlled substance as defined by HSC Chapter 481.(2) Abuse of an elderly or disabled person--means:(A) the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain by the person's caretaker, family member, or other individual who has an ongoing relationship with the person; or(B) sexual abuse by the persons, caretaker, family member, or other individual who has an ongoing relationship with the person, but does not include:(i) the proper use of restraints or seclusion in accordance with federal or state laws or regulations or court order;(ii) other actions taken in accordance with federal or state laws or regulations or court order;(iii) actions an employee may reasonably believe to be immediately necessary to avoid imminent harm to self, patients or clients, or other individuals if such actions are limited only to those actions reasonably believed to be necessary under the existing circumstances. Such actions do not include acts of unnecessary force or the inappropriate use of restraints or seclusion; or(iv) complaints related to the daily administrative operations of a facility (e.g., staffing ratios).(3) Abuse of an individual with mental illness--Has the following meanings:(A) In accordance with 42 United States Code (USC) §10802(1) (relating to Definitions), any act or failure to act by an employee of a facility rendering care or treatment that was performed, or that was failed to be performed, knowingly, recklessly, or intentionally, and that caused, or may have caused, injury or death to an individual with mental illness, and includes acts such as:(i) the rape or sexual assault of an individual with mental illness;(ii) the striking of an individual with mental illness;(iii) the use of excessive force when placing an individual with mental illness in bodily restraints; and(iv) the use of bodily or chemical restraints on an individual with mental illness that is not in compliance with federal and state laws and regulations.(B) In accordance with HSC §161.132(j) (relating to Reports of Abuse and Neglect or of Illegal, Unprofessional, or Unethical Conduct), abuse also includes coercive or restrictive actions that are illegal or not justified by the patient's condition and that are in response to the patient's request for discharge or refusal of medication, therapy, or treatment.(4) Exploitation of an elderly or disabled person--means the illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with the elderly or disabled person using the resources of an elderly or disabled person for monetary or personal benefit, profit, or gain without the informed consent of the elderly or disabled person.(5) Illegal conduct--Conduct prohibited by law.(6) Neglect of a child--includes:(A) the leaving of a child in a situation where the child would be exposed to a substantial risk of physical or mental harm, without arranging for necessary care for the child, and a demonstration of an intent not to return by a parent, guardian, or managing or possessory conservator of a child;(B) the following acts or omissions by any person:(i) placing the child in or failing to remove the child from a situation that a reasonable person would realize requires judgment or actions beyond the child's level of maturity, physical condition, or mental abilities and that results in bodily injury or a substantial risk of immediate harm to the child;(ii) the failure to seek, obtain, or follow through with medical care for the child, with the failure resulting in or presenting a substantial risk of death, disfigurement, or bodily injury or with the failure resulting in an observable and material impairment to the growth, development, or functioning of the child;(iii) the failure to provide the child with food, clothing, or shelter necessary to sustain the life or health of the child (if the failure results in an observable and material impairment to the child's growth, development, or functioning or in a substantial risk of such an observable or material impairment), excluding failure caused primarily by financial inability unless relief services had been offered and refused; or(iv) placing a child in or failing to remove the child from a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child; or(C) the failure by the person responsible for a child's care, custody, or welfare to permit the child to return to the child's home without arranging for the necessary care for the child after the child has been absent from the home for any reason, including having been in residential placement or having run away.(7) Neglect of an elderly or disabled person--means the failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services.(8) Neglect of an individual with mental illness--In accordance with 42 USC §10802(5), a negligent act or omission by any individual responsible for providing services in a facility rendering care or treatment that:(A) caused or may have caused injury or death to an individual with mental illness, or(B) placed an individual with mental illness at risk of injury or death, and includes an act or omission such as the failure to:(i) establish or carry out an appropriate individual program plan or treatment plan for an individual with mental illness,(ii) provide adequate nutrition, clothing, or health care to an individual with mental illness, or(iii) provide a safe environment for an individual with mental illness, including the failure to maintain adequate numbers of appropriately trained staff.(9) Unethical conduct--Conduct prohibited by the ethical standards adopted by state or national professional organizations for their respective professions or by rules established by the state licensing agency for the respective profession.(10) Unprofessional conduct--Conduct prohibited under rules adopted by the state licensing agency for the respective profession.(c) An LSRH shall prominently and conspicuously post for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with HSC §161.132(e). The statement shall be in English and in a second language appropriate to the demographic makeup of the community served and contain the current HHSC patient information and complaint line phone number. The LSRH shall ensure the following individuals are aware of the reporting requirements required under HSC §161.132.(1) In accordance with HSC §161.132(a), a person, including an employee, volunteer, or other person associated with the LSRH who reasonably believes or who knows of information that would reasonably cause a person to believe that the physical or mental health or welfare of a patient of the facility who is receiving mental health or chemical dependency services has been, is, or will be adversely affected by abuse or neglect (as those terms are defined in subsection (b) of this section) by any person, shall as soon as possible report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency.(2) In accordance with HSC §161.132(b), an LSRH employee or other person associated with the LSRH, including a health care professional, who reasonably believes or who knows of information that would reasonably cause a person to believe the LSRH, an employee, or health care professional associated with the LSRH, has, is, or will be engaged in conduct that is or might be illegal, unprofessional, or unethical and that relates to the operation of the LSRH or mental health or chemical dependency services provided in the LSRH, shall as soon as possible report the information supporting the belief to HHSC or to the appropriate state health care regulatory agency.(d) In accordance with HSC §161.133 (relating to Inservice Training), an LSRH providing comprehensive medical rehabilitation, mental health or substance use services shall annually provide, as a condition of continued licensure, a minimum of eight hours of in-service training designed to assist employees and health care professionals associated with the facility in identifying patient abuse or neglect and illegal, unprofessional, or unethical conduct by or in the LSRH and establish a means for monitoring compliance with the requirement.(e) A health care professional who fails to report abuse and neglect or illegal, unprofessional, or unethical conduct as required by subsection (c)(2) of this section shall be referred by HHSC to the individual's licensing board for appropriate disciplinary action.(f) In addition to the reporting requirements described in subsection (c)(2) of this section, a mental health services provider must report suspected sexual exploitation in accordance with Texas Civil Practice and Remedies Code §81.006 (relating to Duty to Report). Source Note: The provisions of this §511.48 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.48 Abuse and Neglect Issues https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215199 03/12/2026 (a) The medical director shall be on-site at the limited services rural hospital (LSRH) when necessary to fulfill the responsibilities of the position, as described by this chapter and the LSRH's governing body.(b) Notwithstanding subsection (a) of this section, each LSRH's medical director shall be on-site at the LSRH for at least 12 hours per month.(c) The medical director's responsibilities shall include:(1) organizing the emergency services to be provided at the LSRH;(2) supervising and overseeing the infection control program, quality assessment and performance improvement program, and patient safety program; and(3) regularly attending meetings of the infection control program, quality assessment and performance improvement program, and patient safety program.(d) The medical director shall have the authority to contract with outside persons for the performance of the LSRH's peer review activities as necessary.(e) The medical director shall be a physician licensed to practice medicine in Texas. Source Note: The provisions of this §511.49 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.49 Medical Director https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215204 03/12/2026 (a) A limited services rural hospital (LSRH) shall have an organized medical staff that operates under bylaws approved by the LSRH's governing body, and which is responsible for the quality of medical care provided to patients by the LSRH.(b) The medical staff shall be composed of physicians and may also include podiatrists, dentists, and other practitioners appointed by the LSRH's governing body.(c) The medical staff shall be well-organized, in a manner approved by the LSRH's governing body, and accountable to the governing body for the quality of the medical care provided to patients.(d) The responsibility for organization and conduct of the medical staff must be assigned to a physician.(e) When an LSRH is part of a system consisting of multiple separately certified hospitals, critical access hospitals, or LSRHs, and the system elects to have a unified and integrated medical staff, each separately certified LSRH must demonstrate:(1) the decision to have a unified and integrated medical staff is in accordance with all applicable state and local laws;(2) the medical staff members of each separately certified LSRH in the system (that is, all medical staff members who hold specific privileges to practice at that LSRH) have voted by majority, in accordance with medical staff bylaws, either to accept a unified and integrated medical staff structure or to opt out of such a structure and to maintain a separate and distinct medical staff for their respective LSRH;(3) the unified and integrated medical staff has bylaws, rules, and requirements describing:(A) its processes for self-governance, appointment, credentialing, privileging, and oversight;(B) its peer review policies and due process rights guarantees; and(C) a process to advise the members of the medical staff of each separately certified LSRH (that is, all medical staff members who hold specific privileges to practice at that LSRH) of their right to opt out of the unified and integrated medical staff structure in accordance with paragraph (2) of this subsection;(4) the unified and integrated medical staff is established in a manner that considers each member LSRH's unique circumstances and any significant differences in patient populations and services offered in each hospital, critical access hospital (CAH), and LSRH;(5) the unified and integrated medical staff establishes and implements policies and procedures to ensure that the needs and concerns expressed by members of the medical staff, at each of its separately certified hospitals, CAHs, and LSRHs, regardless of practice or location, are given due consideration; and(6) the unified and integrated medical staff has mechanisms in place to ensure that issues localized to particular hospitals, CAHs, and LSRHs are duly considered and addressed.(f) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws.(g) The medical staff shall examine credentials of a candidate for medical staff membership and make a recommendation to the LSRH's governing body on the candidate's appointment.(h) When the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.(i) An LSRH shall maintain records of medical staff meetings.(j) The medical staff shall adopt, implement, and enforce written bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall:(1) be approved by the governing body;(2) include a statement of the duties and privileges of each category of medical staff (for example, active, courtesy, etc.);(3) describe the organization of the medical staff;(4) describe the candidate qualifications needed for the medical staff to recommend the candidate's appointment by the governing body; and(5) include criteria for granting privileges to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to provide telemedicine services under an agreement with the LSRH, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in the Code of Federal Regulations Title 42 (42 CFR) §485.510(a)(8) and §485.512(a)(9).(k) To be privileged as an emergency room physician, the physician shall:(1) be currently board certified in emergency medicine; or(2) have a minimum of one year experience in emergency services and current certification in advanced cardiac life support, pediatric advanced life support, and advanced trauma life support.(l) The LSRH shall comply with applicable telemedicine requirements in 42 CFR §485.512. Source Note: The provisions of this §511.50 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.50 Medical Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215205 03/12/2026 (a) The limited services rural hospital (LSRH) shall adopt, implement, train, and enforce written policies to ensure all provided services are consistent with accepted professional standards and practice and compliance in accordance with applicable federal and state law.(b) The LSRH must develop policies with the advice of members of the LSRH's professional health care staff, including:(1) one or more physicians; and(2) one or more of the following if they are on staff under the provisions of Code of Federal Regulations Title 42 (42 CFR) §485.528(b)(1):(A) physician assistants; or(B) advanced practice registered nurses.(c) The policies must include:(1) a description of the services the LSRH provides, including those provided through agreement or arrangement;(2) policies and procedures for emergency medical services;(3) guidelines for the medical management of health problems, including:(A) conditions requiring medical consultation or patient referral;(B) maintenance of health care records; and(C) procedures for the periodic review and evaluation of LSRH services; and(4) policies and procedures that address the post-acute care needs of patients receiving services in the LSRH.(d) The group of professional personnel described in subsection (b) of this section must review and update the policies as necessary, but at least biennially. Source Note: The provisions of this §511.51 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.51 Provision of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215189 03/12/2026 (a) A limited services rural hospital (LSRH) shall limit the surgical procedures performed at the LSRH to procedures the governing body approved upon the medical staff's recommendation.(b) Adequate supervision of surgical procedures conducted in the LSRH shall be:(1) a responsibility of the governing body;(2) recommended by medical staff; and(3) provided by appropriate medical staff.(c) An LSRH shall only perform surgical procedures when:(1) a physician, dentist, podiatrist, or other practitioner licensed to perform surgical procedures in Texas performs the procedure;(2) the governing body granted privileges to the physician, dentist, podiatrist, or other practitioner, practicing within the scope of their license and education, to perform surgical procedures;(3) the LSRH's medical staff recommended the surgical procedure; and(4) the governing body has medically reviewed the physician's, dentist's, podiatrist's, or other practitioner's documented education, training, experience, and current competence.(d) An LSRH shall periodically review surgical procedures to be performed in the LSRH as part of the peer review portion of the LSRH's quality assessment and performance improvement program by physically observing planned surgical procedures.(e) An LSRH shall incorporate an appropriate patient history, physical examination, and pertinent preoperative diagnostic studies into the patient's medical record before surgical procedures.(f) Unless otherwise provided by law, the LSRH shall discuss the proposed surgical procedure's necessity or appropriateness, as well as any available alternative treatment techniques, with the patient or the patient's legally authorized representative, as applicable, before the surgical procedure.(g) Unless otherwise provided by law, the LSRH shall obtain the informed consent of the patient or, if applicable, of the patient's legally authorized representative before a surgical procedure is performed. When the LSRH is unable to obtain informed consent before an emergency surgery, the LSRH shall document in the patient's medical record the reason or reasons why the LSRH was unable to obtain the informed consent.(h) With the exception of those tissues exempted by the governing body after medical review, a pathologist shall examine tissues removed and sign or authenticate the report of the examination for the patient's medical record.(i) A description of the findings and techniques of surgical procedures shall be accurately and completely incorporated into the patient's medical record immediately after the procedure by the physician or practitioner who performed the procedure. If the description is dictated, an accurate written summary shall be immediately available to the physicians and practitioners providing patient care and shall become a part of the patient's medical record.(j) The LSRH shall allow patients who have received anesthesia, other than solely topical anesthesia, to leave the facility only in the company of a responsible adult, unless the physician, physician assistant, or an advanced practice registered nurse writes an order that the patient may leave without the company of a responsible adult. Source Note: The provisions of this §511.52 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.52 Surgical Services within the Scope of the Practice of Emergency Medicine https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215190 03/12/2026 (a) A limited services rural hospital (LSRH) shall have organized dietary services that are directed and staffed by adequate qualified personnel.(1) An LSRH that has a contract with an outside food management company or an arrangement with another hospital may meet this requirement if the food management company or other hospital:(A) has a dietitian who serves the LSRH on a full-time, part-time, or consultant basis;(B) maintains at least the minimum requirements specified in this section; and(C) provides for the frequent and systematic liaison with the LSRH medical staff for recommendations of dietetic policies affecting patient treatment.(2) The LSRH shall ensure that there are sufficient personnel to respond to the dietary needs of the patient population being served.(b) The LSRH shall employ a full-time staff who is qualified by experience or training to serve as director of the food and dietetic service and is responsible for the daily management of the dietary services. The director shall:(1) comply with a job-specific position description;(2) clearly delineate responsibility and authority;(3) participate in conferences with administration and department heads;(4) establish, implement, and enforce policies and procedures for the overall operational components of the LSRH's dietary department that include:(A) integration of the food and dietetic service into the LSRH-wide quality assessment and performance improvement program and infection control program;(B) the frequency of meals served;(C) nonroutine occurrences; and(D) identification of patient trays; and(5) maintain authority and responsibility for at least the following:(A) providing orientation and training;(B) evaluating staff performance;(C) providing work assignments;(D) supervising work and food handling techniques including kitchen sanitation and acceptable hygiene practices of food service personnel;(E) procuring food, paper, chemical, and other supplies, including implementing a first-in first-out rotation system for all food items;(F) ensuring there is a four-day food supply on hand at all times;(G) planning the menu; and(H) ensuring compliance with Texas Administrative Code Title 25 Chapter 228 (relating to Retail Food Establishments).(c) The LSRH shall employ a qualified dietitian who works full-time, part-time, or on a consultant basis. If the LSRH chooses to employ the dietician on a consultant basis, such services shall occur at least once per month for not less than eight hours. The dietitian shall:(1) be currently licensed under the laws of this state to use the titles of licensed dietitian or provisional licensed dietitian, or be a registered dietitian;(2) maintain professional practice standards;(3) supervise the nutritional aspects of patient care;(4) assess the nutritional status and nutritional regimen adequacy, as appropriate;(5) provide diet counseling and teaching, as appropriate;(6) document nutritional status and pertinent information in patient medical records, as appropriate;(7) approve menus; and(8) approve menu substitutions.(d) The LSRH shall employ administrative and technical personnel competent in their respective duties. The administrative and technical personnel shall:(1) participate in established departmental or LSRH training pertinent to assigned duties;(2) conform to food handling techniques in accordance with subsection (b)(5)(D) of this section;(3) adhere to clearly defined work schedules and assignment sheets; and(4) comply with job-specific position descriptions.(e) An LSRH shall ensure menus meet the needs of the patients.(f) A physician responsible for the care of the patients shall prescribe therapeutic diets. The LSRH's dietary department shall:(1) establish procedures for processing therapeutic diets, including:(A) accurate patient identification;(B) transcription from nursing to dietary services;(C) diet planning by a dietitian;(D) regular review and updating of diet when necessary; and(E) written and verbal instruction to patient and family, which shall be in the patient's primary language, if practicable, prior to discharge;(2) ensure a qualified dietitian plans therapeutic diets in writing;(3) ensure a qualified dietitian approves menu substitutions;(4) document pertinent information about the patient's response to a therapeutic diet in the patient's medical record; and(5) evaluate therapeutic diets for nutritional adequacy.(g) An LSRH shall meet patient nutritional needs in accordance with recognized dietary practices and in accordance with orders of a physician or appropriately credentialed practitioner responsible for the care of the patients. The LSRH shall meet the following requirements.(1) Menus shall provide a sufficient variety of foods served in adequate amounts at each meal according to the guidance provided in the Recommended Dietary Allowances (RDA), as published by the National Research Council.(2) The LSRH shall not exceed 15 hours between providing the last meal of the day (i.e., dinner) and the breakfast meal, unless a substantial snack is provided. The LSRH shall adopt, implement, and enforce a policy on the definition of "substantial" to meet each patient's varied nutritional needs.(h) An LSRH shall have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel. The LSRH shall:(1) revise the therapeutic manual as needed and at least every five years;(2) ensure the therapeutic manual:(A) is appropriate for the diets routinely ordered in the LSRH;(B) has standards in compliance with the RDA; and(C) contains specific diets which are not in compliance with RDA; and(3) ensure staff use the therapeutic manual as a guide for ordering and serving diets. Source Note: The provisions of this §511.53 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.53 Dietary Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215200 03/12/2026 (a) In addition to providing emergency services and observation care, a limited services rural hospital (LSRH) may provide outpatient and medical health diagnostic and therapeutic items and services that are commonly furnished in a physician's office or at another entry point into the health care delivery system that include: radiology, laboratory, outpatient rehabilitation, surgical, maternal health, and behavioral health services. If an LSRH provides additional outpatient and medical health diagnostic and therapeutic items and services, the LSRH shall comply with the requirements of this section.(b) The outpatient and medical health diagnostic and therapeutic items and services the LSRH provides shall:(1) align with the health needs of the community served by the LSRH; and(2) be appropriately organized and meet the needs of the patients in accordance with acceptable standards of practice.(c) The LSRH shall:(1) provide items and services based on nationally recognized guidelines and standards of practice;(2) have a system in place for referral from the LSRH to different levels of care, including follow-up care, as appropriate;(3) have effective communication systems in place between the LSRH and the patient (or responsible individual) and their family, ensuring that the LSRH is responsive to their needs and preferences;(4) have established relationships with hospitals that have the resources and capacity available to deliver care that is beyond the scope of care delivered at the LSRH; and(5) have personnel providing these services who meet the requirements in subsection (d) of this section.(d) The LSRH shall meet the following personnel requirements for outpatient services.(1) The LSRH shall assign one or more individuals to be responsible for outpatient services.(2) The LSRH shall have appropriate professional and nonprofessional personnel available at each location where outpatient services are offered, based on the scope and complexity of outpatient services.(3) For any specialty services offered at the LSRH, the LSRH shall have a physician, advanced practice registered nurse, or physician assistant providing services with experience and training in the specialty service area and in accordance with their scope of practice.(e) Outpatient medical and health services shall be ordered by a practitioner who is:(1) responsible for the care of the patient for whom the practitioner is ordering the services;(2) licensed in the state of Texas;(3) acting within their scope of practice under state law;(4) authorized, in accordance with state law and policies adopted by the medical staff; and(5) approved by the governing body, to order the applicable outpatient services and either:(A) appointed to the LSRH's medical staff and who have been granted privileges to order the applicable outpatient services; or(B) not appointed to the medical staff, but who satisfy the requirements for authorization by the medical staff and the LSRH for ordering the applicable outpatient services for their patients. Source Note: The provisions of this §511.54 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.54 General Outpatient Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215201 03/12/2026 (a) If a limited services rural hospital (LSRH) performs outpatient surgical services, emergency surgical services, or both, the LSRH shall comply with this section.(b) The LSRH's governing body, on recommendation of the LSRH's medical staff, shall approve surgical procedures performed in the LSRH.(c) Surgical services shall be well-organized and provided in accordance with acceptable standards of practice.(d) An LSRH shall provide adequate space, equipment, and personnel to ensure a safe environment for treating patients during surgical procedures, including adequate safeguards to protect the patient from cross infection.(e) The organization of the surgical services shall be appropriate for the scope of the services offered.(f) The LSRH shall periodically review surgical procedures performed in the LSRH as part of the LSRH's quality assessment and performance improvement program.(g) Appropriate medical staff shall provide adequate supervision of surgical procedures conducted in the LSRH under the recommendation of medical staff and approval of the governing body.(h) The LSRH shall establish a written procedure for observation and care of the patient during and after surgical procedures.(i) The LSRH shall establish written protocols for instructing patients in self-care after surgical procedures, including written instructions to be given to patients who receive conscious sedation, regional anesthesia, or both.(j) The LSRH shall develop an effective written procedure for the immediate transfer to a hospital of patients requiring emergency care beyond the capabilities of the LSRH. The LSRH shall have a written transfer agreement with a hospital as set forth in §511.65 of this subchapter (relating to Patient Transfer Policy).(k) Surgical procedures shall be performed only by a physician, dentist, podiatrist, or practitioner, practicing within the scope of their license and education, who:(1) is licensed to perform surgical procedures in Texas; and(2) has been granted privileges to perform those procedures by the governing body, upon the recommendation of the medical staff, and after medical review of the physician's, dentist's, podiatrist's, or practitioner's documented education, training, experience, and current competence.(l) The LSRH shall designate the practitioners who are allowed to perform surgery for LSRH patients, in accordance with its approved policies and procedures, and with state scope of practice laws.(m) The LSRH shall provide adequate staff during surgical procedures.(1) The operating rooms shall be supervised by an experienced registered nurse (RN) or physician.(2) Licensed vocational nurses (LVNs) and surgical technologists (operating room technicians) may serve as scrub nurses or technologists only under the supervision of an RN.(3) Circulating duties in the operating room must be performed by qualified RNs. In accordance with approved medical staff policies and procedures, LVNs and surgical technologists may assist in circulatory duties only under the direct supervision of a qualified RN circulator.(4) The LSRH shall delineate surgical privileges for all physicians, podiatrists, and dentists performing surgery in accordance with the competencies of each. The surgical services department shall maintain a roster specifying the surgical privileges of each.(5) If the LSRH employs surgical technologists, the LSRH shall adopt, implement, and enforce policies and procedures to comply with Texas Health and Safety Code Chapter 259 (relating to Surgical Technologists at Health Care Facilities).(6) Licensed nurses and other personnel assisting in the provision of surgical services shall be appropriately trained and supervised and shall be available in sufficient numbers for the surgical care provided.(n) Preoperative laboratory procedures may be required as follows.(1) It shall be at the discretion of the governing body and the medical staff to require preoperative laboratory orders.(2) If specific preoperative laboratory work is required, the medical staff shall approve them in accordance with the medical staff bylaws. Specific preoperative laboratory work shall be performed only on the order of a physician, podiatrist, dentist, or other practitioner, who is practicing within the scope of their license and education, and written on the patient's chart.(3) These services shall be provided either directly within or through an effective contract arrangement with a Medicare-approved reference laboratory.(4) The contractual agreement with the Medicare-approved reference laboratory shall provide for routine and stat work to include pathology, clinical, and blood bank services, and shall be available for review.(o) Surgical services shall be consistent with needs and resources. Written policies governing surgical care that are designed to ensure the achievement and maintenance of high standards of medical practice and patient care shall be adopted, implemented, and enforced.(p) There shall be a complete medical history and physical examination, as required under subsections (s) and (t) of this section, in the medical record of every patient prior to surgery, except in emergencies. If this has been dictated verbally, but not yet transcribed in the patient's medical record, there shall be a statement to that effect and an admission note in the record by the individual who admitted the patient.(q) A properly executed informed consent form for the operation shall be in the patient's medical record before surgery, except in emergencies.(r) A "time out" shall be conducted before starting the procedure to confirm that the correct patient, site, and procedure have been identified, and that all required documents and equipment are available and ready for use.(s) A qualified practitioner, as specified in subsection (k) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed.(t) A qualified practitioner, as specified in subsection (k) of this section, must examine each patient before surgery to evaluate the risk of anesthesia.(u) All persons shall use acceptable aseptic techniques in accordance with the LSRH's chosen infection control standards.(v) Each treatment or examination room shall be designed and equipped so that the types of surgical procedures conducted can be performed in a manner that protects the lives and ensures the physical safety of all persons in the area.(w) The facility shall implement environmental controls that ensure a safe and sanitary environment.(x) Written policies and procedures for decontamination, disinfection, sterilization, and storage of sterile supplies shall be adopted, implemented, and enforced as described in §511.73 of this subchapter (relating to Sterilization).(1) Performance records for all sterilizers shall be maintained for a period of six months.(2) The LSRH shall maintain appropriate supplies to prevent immediate use sterilization.(3) Preventive maintenance of all sterilizers shall be completed according to manufacturer's recommendations on a scheduled basis. A preventive maintenance record shall be maintained for each sterilizer. An LSRH shall retain these records for at least one year and shall ensure their availability for review at the facility within two hours of HHSC's request.(y) Emergency power adequate for the type of surgical procedures performed shall be available.(z) Periodic calibration and preventive maintenance of all equipment shall be provided in accordance with manufacturer's guidelines.(aa) The following equipment shall be available in the operating room suites:(1) communication system;(2) cardiac monitor;(3) resuscitator;(4) defibrillator;(5) aspirator; and(6) tracheotomy set.(bb) If flammable agents are present in a treatment/examination room, the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Annex 2, Flammable Anesthetizing Locations, 1999) and with applicable state and local fire codes.(cc) If nonflammable agents are present in a treatment/examination room, the room shall be constructed and equipped in compliance with standards established by the National Fire Protection Association (NFPA 99, Chapters 4 and 8, 1999) and with applicable state and local fire codes.(dd) There shall be adequate provisions for immediate postoperative care.(ee) The operating room register shall be complete and up-to-date. The register shall contain, but not be limited to, the following:(1) patient's name and hospital identification number;(2) date of operation;(3) operation performed;(4) operating surgeon and assistant(s);(5) type of anesthesia used and name of person administering it;(6) time operation began and ended;(7) time anesthesia began and ended;(8) disposition of specimens;(9) names of scrub and circulating personnel;(10) unusual occurrences; and(11) disposition of the patient.(ff) An operative report describing techniques, findings, and tissue removed or altered shall be written or dictated immediately following surgery and signed by the surgeon.(gg) Before discharge from the LSRH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in subsection (k) of this section, as applicable.(hh) All patients are discharged in the company of a responsible adult, except those exempted by the practitioner who performed the surgical procedure. Source Note: The provisions of this §511.55 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.55 Surgical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215202 03/12/2026 (a) The anesthesia services must be provided:(1) in a well-organized manner;(2) under the direction of a qualified physician approved by the governing body; and(3) in accordance with Texas Occupations Code Title 3, Subtitle B (relating to Physicians) and Texas Occupations Code Chapter 301 (relating to Nurses).(b) The LSRH is responsible for and shall document all anesthesia services administered in the LSRH.(c) The organization of anesthesia services shall be appropriate to the scope of the services offered.(d) Only personnel who have been approved by the LSRH to provide anesthesia services shall administer anesthesia. All approvals or delegations of anesthesia services as authorized by law shall be documented and include the training, experience, and qualifications of the person who provided the service. On the order of a physician, podiatrist, dentist, or other authorized practitioner practicing within the scope of their license and education, a qualified registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA), may administer topical anesthesia, local anesthesia, minimal sedation, and moderate sedation, in accordance with all applicable rules, polices, directives, and guidelines issued by the Texas Board of Nursing. When an RN who is not a CRNA administers sedation, as permitted in this subsection, the LSRH shall:(1) verify that the RN has the requisite training, education, and experience;(2) maintain documentation to support that the RN has demonstrated competency in the administration of sedation;(3) with input from the facility's qualified anesthesia providers, develop, implement, and enforce detailed written policies and procedures to guide the RN; and(4) ensure that, when administering sedation during a procedure, the RN has no other duties except to monitor the patient.(e) Anesthesia shall not be administered unless the physician has evaluated the patient immediately before the procedure to assess the risk of the anesthesia and of the procedure to be performed.(f) The medical staff shall develop written policies and practice guidelines for the anesthesia service, which shall be adopted, implemented, and enforced by the governing body. The policies and guidelines shall include consideration of the applicable practice standards and guidelines of the American Society of Anesthesiologists, the American Association of Nurse Anesthetists, and the licensing rules and standards applicable to those categories of licensed professionals qualified to administer anesthesia.(g) Anesthesia services shall be consistent with needs and resources. Policies on anesthesia procedures shall include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies shall ensure that the following are provided for each patient.(1) A pre-anesthesia evaluation by an individual qualified to administer anesthesia under subsection (e) of this section shall be performed within 48 hours before surgery.(2) An intraoperative anesthesia record shall be provided. The record shall include any complications or problems occurring during the anesthesia, including time, description of symptoms, review of affected systems, and treatments rendered. The record shall correlate with the controlled substance administration record.(3) A post-anesthesia follow-up report shall be written by the person administering the anesthesia before transferring the patient from the post-anesthesia care unit and shall include evaluation for recovery from anesthesia, level of activity, respiration, blood pressure, level of consciousness, and patient's oxygen saturation level.(4) Immediately prior to discharge, a post-anesthesia evaluation for proper anesthesia recovery shall be performed by the person administering the anesthesia, by an RN, within the scope of their license and education, or physician in accordance with policies and procedures approved by the medical staff and using criteria written in the medical staff bylaws for postoperative monitoring of anesthesia.(h) Anesthesia services provided in the LSRH shall be limited to those that are recommended by the medical staff and approved by the governing body, which may include the following.(1) Topical anesthesia--An anesthetic agent applied directly or by spray to the skin or mucous membranes, intended to produce transient and reversible loss of sensation to the circumscribed area.(2) Local anesthesia--Administration of an agent that produces a transient and reversible loss of sensation to a circumscribed portion of the body.(3) Regional anesthesia--Anesthetic injected around a single nerve, a network of nerves, or vein that serves the area involved in a surgical procedure to block pain.(4) Minimal sedation (anxiolysis)--A drug-induced state during which patients respond normally to oral commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.(5) Moderate sedation/analgesia ("conscious sedation")--A drug-induced depression of consciousness during which patients respond purposefully to oral commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)(6) Deep sedation/analgesia--A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. (Reflex withdrawal from a painful stimulus is not considered a purposeful response.)(i) Patients who have received anesthesia shall be evaluated for proper anesthesia recovery by the physician or the person administering the anesthesia before discharge using criteria approved by the medical staff.(j) Patients shall be evaluated immediately before leaving the facility by a physician, the person administering the anesthesia, or an RN acting in accordance with physician's orders and written policies, procedures, and criteria developed by the medical staff.(k) Emergency equipment and supplies appropriate for the type of anesthesia services provided shall be maintained and accessible to staff at all times. Functioning equipment and supplies that are required for all LSRHs include the following:(1) suctioning equipment, including a source of suction and suction catheters in appropriate sizes for the population being served;(2) source of compressed oxygen;(3) basic airway management equipment, including oral and nasal airways, face masks, and self-inflating breathing bag valve set;(4) blood pressure monitoring equipment; and(5) emergency medications specified by the medical staff and appropriate to the type of procedures and anesthesia services provided by the facility.(l) In addition to the equipment and supplies required under subsection (l) of this section, an LSRH that provides moderate sedation/analgesia, deep sedation/analgesia, or regional analgesia shall provide the following:(1) intravenous equipment, including catheters, tubing, fluids, dressing supplies, and appropriately sized needles and syringes;(2) advanced airway management equipment, including laryngoscopes and an assortment of blades, endotracheal tubes, and stylets in appropriate sizes for the population being served;(3) a mechanism for monitoring blood oxygenation, such as pulse oximetry;(4) electrocardiographic monitoring equipment;(5) cardiac defibrillator; and(6) pharmacologic antagonists as specified by the medical staff and appropriate to the type of anesthesia services provided.(m) The advanced practice registered nurse, the anesthesiologist, or the operating surgeon shall be available until the surgeon's patients operated on that day have been discharged from the post-anesthesia care unit.(n) Patients who have received anesthesia shall be evaluated for proper anesthesia recovery in accordance with subsection (g) of this section prior to discharge from the post-anesthesia care unit using criteria approved by the medical staff.(o) Patients who remain in the facility for extended observation following discharge from the post-anesthesia care unit shall be evaluated immediately prior to leaving the facility by a physician, the person administering the anesthesia, or a registered nurse acting in accordance with physician's orders and written policies, procedures, and criteria developed by the medical staff.(p) A physician shall be on call and able to respond physically or by telephone within 30 minutes until all patients have been discharged from the LSRH. Source Note: The provisions of this §511.56 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.56 Anesthesia Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215203 03/12/2026 (a) If a limited services rural hospital (LSRH) provides physical therapy, occupational therapy, audiology, or speech pathology services as outpatient services, the services shall be organized and staffed to ensure the health and safety of patients.(b) The organization of the services shall be appropriate to the scope of the services offered.(c) The director of the services shall have the necessary knowledge, experience, and capabilities to properly supervise and administer the services.(d) Physical therapy, occupational therapy, speech therapy, or audiology services, if provided, shall be provided by staff who meet the qualifications specified by the medical staff, consistent with state law.(e) Services shall be furnished in accordance with a written plan of treatment. Services to be provided shall be consistent with applicable state laws and regulations, and in accordance with orders of the physician, podiatrist, dentist, or other licensed practitioner who is authorized by the medical staff to order the services. Therapy orders shall be incorporated in the patient's medical record. Source Note: The provisions of this §511.57 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.57 Therapy Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215206 03/12/2026 (a) A limited services rural hospital (LSRH) may provide dialysis services as a patient medical service in an emergency or to stabilize a patient without an additional license under Texas Health and Safety Code (HSC) Chapter 251. An LSRH may not provide outpatient dialysis services or seek licensure under HSC Chapter 251 except if providing services during a state of disaster as allowed by HSC §251.012(2)(B) (relating to Exemptions from Licensing Requirement) and subsection (b) of this section.(b) An LSRH may provide outpatient dialysis services when the governor declares a state of disaster or the president of the United States declares a federal disaster in this state or another state. The LSRH may provide outpatient dialysis only during the term of the disaster declaration.(c) All equipment used in the process for providing dialysis, including backup equipment, shall be operated within manufacturer's specifications, and maintained free of defects that could be a potential hazard to patients, staff, or visitors. Maintenance and repair of all equipment shall be performed by qualified staff or contract personnel.(d) Staff shall be able to identify malfunctioning equipment used in the process for providing dialysis and report such equipment to the appropriate staff for immediate repair.(e) Medical equipment used in the process for providing dialysis that malfunctions must be clearly labeled and immediately removed from service until the malfunction is identified and corrected. Written evidence of all maintenance and repairs shall be maintained.(f) After repairs or alterations are made to any equipment or system used in the process for providing dialysis, the equipment or system shall be thoroughly tested for proper operation before returning to service. This testing must be documented.(g) An LSRH shall comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code (USC), §360i(b), relating to reporting when a medical device as defined in 21 USC §321(h) has or may have caused or contributed to the injury or death of a patient of the facility.(h) An LSRH shall develop, implement, and enforce a written preventive maintenance program to ensure patient care related equipment used in a facility receives electrical safety inspections, if appropriate, and maintenance at least annually or more frequently as recommended by the manufacturer. The preventive maintenance may be provided by LSRH staff or by contract.(i) At least one complete dialysis machine shall be available on site as backup for every 10 dialysis machines in use. At least one of these backup machines must be completely operational during hours of treatment. Machines not in use during a patient shift may be counted as backup except at the time of an initial or an expansion survey.(j) An LSRH shall have emergency equipment and supplies immediately accessible in the treatment area. The emergency equipment and supplies shall include at least the following:(1) oxygen;(2) mechanical ventilatory assistance equipment, to include airways, manual breathing bag, and mask;(3) suction equipment;(4) supplies specified by the medical director;(5) electrocardiograph; and(6) automated external defibrillator or defibrillator.(k) If pediatric patients are treated, the LSRH shall have the appropriate type and size emergency equipment and supplies listed in subsection (j) of this section for this special population.(l) If pediatric patients are treated, an LSRH shall use equipment and supplies, to include blood pressure cuffs, dialyzers, and blood tubing, appropriate for this special population.(m) An LSRH shall establish, implement, and enforce a policy for the periodic testing and maintenance of the emergency equipment. Staff shall properly maintain and test the emergency equipment and supplies and document the testing and maintenance.(n) A transducer protector shall be replaced when wetted during a dialysis treatment and shall be used for one treatment only.(o) Water treatment and dialysate supply systems shall meet the requirements of this subsection. An LSRH may follow more stringent requirements than the standards required by this subsection.(1) The LSRH administrator and medical director shall each demonstrate responsibility for the water treatment and dialysate supply systems to protect hemodialysis patients from adverse effects arising from known chemical and microbial contaminates that may be found in improperly prepared dialysate, to ensure that the dialysate is correctly formulated and meets the requirements of all applicable quality standards.(2) The LSRH administrator and medical director must assure that policies and procedures related to water treatment and dialysate are understandable and accessible to the operator and that the training program includes quality testing, risks and hazards of improperly prepared concentrate and bacterial issues.(3) The LSRH administrator and medical director must be informed before any alteration of, or any device being added to, the water system.(4) These requirements apply to water intended for use in the delivery of hemodialysis, including the preparation of concentrates from powder at a dialysis facility and dialysate.(5) The design for the water treatment system in an LSRH shall be based on considerations of the source water for the LSRH and designed by a water quality professional with education, training, or experience in dialysis system design.(6) When an LSRH does not use a public water system supply, the LSRH shall test the source water at monthly intervals in the same manner as a public water system as described in Texas Administrative Code Title 30 §290.104 (relating to Summary of Maximum Contaminant Levels, Maximum Residual Disinfectant Levels, Treatment Techniques, and Action Levels), and §290.109 (relating to Microbial Contaminants) as adopted by the Texas Commission on Environmental Quality (TCEQ).(7) The physical space in which the water treatment system is located must be adequate to allow for maintenance, testing, and repair of equipment. If mixing of dialysate is performed in the same area, the physical space must also be adequate to house and allow for the maintenance, testing, and repair of the mixing equipment and for performing the mixing procedure.(8) The water treatment system components shall be arranged and maintained so that bacterial and chemical contaminant levels in the product water do not exceed the standards for hemodialysis water quality described in §4.2.1 (relating to Water Bacteriology) and §4.2.2 (relating to Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the Association for the Advancement of Medical Instrumentation (AAMI).(9) Written policies and procedures for the operation of the water treatment system must be developed and implemented. Parameters for the operation of each component of the water treatment system must be developed, in writing, and known to the operator. Each major water system component shall be labeled in a manner that identifies the device, describes its function, how performance is verified and actions to take in the event performance is not within an acceptable range.(10) The materials of any components of water treatment systems (including piping, storage, filters and distribution systems) that contact the purified water shall not interact chemically or physically so as to affect the purity or quality of the product water adversely. Such components shall be fabricated from unreactive materials (e.g., plastics) or appropriate stainless steel. The use of materials that are known to cause toxicity in hemodialysis, such as copper, brass, galvanized material, or aluminum, is prohibited.(11) Chemicals infused into the water such as iodine, acid, flocculants, and complexing agents shall be shown to be nondialyzable or shall be adequately removed from product water. Monitors or specific test procedures to verify removal of additives shall be provided and documented.(12) Each water treatment system shall include reverse osmosis (RO) membranes or deionization (DI) tanks and a minimum of two carbon tanks in series. If the source water is from a private supply that does not use chlorine/chloramine, the water treatment system shall include RO membranes or deionization tanks and a minimum of one carbon tank.(13) Reverse osmosis membranes, if used, shall meet the standards in §4.3.7 (relating to Reverse Osmosis) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the AAMI.(14) Deionization systems, if used, shall be monitored continuously to produce water of one megohm-centimeter (cm) or greater specific resistivity (or conductivity of one microsiemen/cm or less) at 25 degrees Centigrade. An audible and visual alarm shall be activated when the product water resistivity falls below this level and the product water stream shall be prevented from reaching any point of use.(15) Patients shall not be dialyzed on deionized water with a resistivity less than 1.0 megohm-cm measured at the output of the deionizer.(16) A minimum of two DI tanks in series shall be used with resistivity monitors including audible and visual alarms placed pre and post the final DI tank in the system. The alarms must be audible in the patient care area.(17) Feed water for deionization systems shall be pretreated with activated carbon adsorption, or a comparable alternative, to prevent nitrosamine formation.(18) If a deionization system is the last process in a water treatment system, it shall be followed by an ultrafilter or other bacteria and endotoxin reducing device.(19) The carbon tanks must contain acid washed carbon, 30-mesh or smaller with a minimum iodine number of 900.(20) A minimum of two carbon adsorption beds shall be installed in a series configuration.(21) The total empty bed contact time (EBCT) shall be at least 10 minutes, with the final tank providing at least five minutes EBCT. Carbon adsorption systems used to prepare water for portable dialysis systems are exempt from the requirement for the second carbon and a 10-minute EBCT if removal of chloramines to below 0.1 milligram (mg)/1 is verified before each treatment.(22) A means shall be provided to sample the product water immediately prior to the final bed(s). Water from this port(s) must be tested for chlorine/chloramine levels immediately prior to each patient shift.(23) All samples for chlorine/chloramine testing must be drawn when the water treatment system has been operating for at least 15 minutes.(24) Tests for total chlorine, which include both free and combined forms of chlorine, may be used as a single analysis with the maximum allowable concentration of 0.1 mg/liter (L). Test results of greater than 0.5 parts per million (ppm) for chlorine or 0.1 ppm for chloramine from the port between the initial tank(s) and final tank(s) shall require testing to be performed at the final exit and replacement of the initial tank(s).(25) In a system without a holding tank, if test results at the exit of the final tank(s) are greater than the parameters for chlorine or chloramine described in this subclause, dialysis treatment shall be immediately terminated to protect patients from exposure to chlorine/chloramine and the medical director shall be notified. In systems with holding tanks, if the holding tank tests <1 mg/L for total chlorine, the RO may be turned off and the product water in the holding tank may be used to finish treatments in process. The medical director shall be notified.(26) If means other than granulated carbon are used to remove chlorine/chloramine, the facility's governing body must approve such use, in writing, after review of the safety of the intended method for use in hemodialysis applications. If such methods include the use of additives, there must be evidence the product water does not contain unsafe levels of these additives.(27) Water softeners, if used, shall be tested at the end of the treatment day to verify their capacity to treat a sufficient volume of water to supply the facility for the entire treatment day and shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration.(28) If used, the face(s) of timer(s) used to control any component of the water treatment or dialysate delivery system shall be visible to the operator at all times. Written evidence that timers are checked for operation and accuracy each day of operation must be maintained.(29) Filter housings, if used during disinfectant procedures, shall include a means to clear the lower portion of the housing of the disinfecting agents. Filter housings shall be opaque.(30) Ultrafilters, or other bacterial reducing filters, if used, shall be fitted with pressure gauges on the inlet and outlet water lines to monitor the pressure drop across the membrane. Ultrafilters shall be included in routine disinfection procedures.(31) If used, storage tanks shall have a conical or bowl-shaped base and shall drain from the lowest point of the base. Storage tanks shall have a tight-fitting lid and be vented through a hydrophobic 0.2 micron air filter. Means shall be provided to effectively disinfect any storage tank installed in a water distribution system.(32) Ultraviolet (UV) lights, if used, shall be monitored at the frequency recommended by the manufacturer. A log sheet shall be used to record monitoring.(33) Water treatment system piping shall be labeled to indicate the contents of the pipe and direction of flow.(34) The water treatment system must be continuously monitored during patient treatment and be guarded by audible and visual alarms that can be seen and heard in the dialysis treatment area should water quality drop below specific parameters. Quality monitor sensing cells shall be located as the last component of the water treatment system and at the beginning of the distribution system. No water treatment components that could affect the quality of the product water as measured by this device shall be located after the sensing cell.(35) When deionization tanks do not follow an RO system, parameters for the rejection rate of the membranes must assure that the lowest rate accepted would provide product water in compliance with §4.2.2 (relating to Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition published by the AAMI.(36) An LSRH shall maintain written logs of the operation of the water treatment system for each treatment day. The log book shall include each component's operating parameter and the action taken when a component is not within the facility's set parameters.(37) Microbiological testing of product water shall be conducted.(A) Microbiological testing shall be conducted monthly and following any repair or change to the water treatment system. For a newly installed water distribution system, or when a change has been made to an existing system, weekly testing shall be conducted for one month to verify that bacteria and endotoxin levels are consistently within the allowed limits.(B) At a minimum, sample sites chosen for the testing shall include the beginning of the distribution piping, at any site of dialysate mixing, and the end of the distribution piping.(C) Samples shall be collected immediately before sanitization/disinfection of the water treatment system and dialysis machines. Water testing results shall be routinely trended and reviewed by the medical director in order to determine if results seem questionable or if there is an opportunity for improvement. The medical director shall determine if there is a need for retesting. Repeated results of "no growth" shall be validated via an outside laboratory. A calibrated loop may not be used in microbiological testing of water samples. Colonies shall be counted using a magnifying device.(38) Product water used to prepare dialysate, concentrates from powder, or to reprocess dialyzers for multiple use, shall contain a total viable microbial count less than 200 colony forming units (CFU)/millimeter (ml) and an endotoxin concentration less than 2 endotoxin units (EU)/ml. The action level for the total viable microbial count in the product water shall be 50 CFU/ml and the action level for the endotoxin concentration shall be 1 EU/ml.(39) Required action for unacceptable results. If the action levels described at paragraph (6) of this subsection are observed in the product water, corrective measures shall be taken promptly to reduce the levels into an acceptable range.(40) All bacteria and endotoxin results shall be recorded on a log sheet in order to identify trends that may indicate the need for corrective action.(41) If ozone generators are used to disinfect any portion of the water or dialysate delivery system, testing based on the manufacturer's direction shall be used to measure the ozone concentration each time disinfection is performed, to include testing for safe levels of residual ozone at the end of the disinfection cycle. Testing for ozone in the ambient air shall be conducted on a periodic basis as recommended by the manufacturer. Records of all testing must be maintained in a log.(42) If used, hot water disinfection systems shall be monitored for temperature and time of exposure to hot water as specified by the manufacturer. Temperature of the water shall be recorded at a point furthest from the water heater, where the lowest water temperature is likely to occur. The water temperature shall be measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection shall be maintained.(43) After chemical disinfection, means shall be provided to restore the equipment and the system in which it is installed to a safe condition relative to residual disinfectant prior to the product water being used for dialysis applications.(44) Samples of product water must be submitted for chemical analysis every six months and must demonstrate that the quality of the product water used to prepare dialysate or concentrates from powder, meets §4.2.2 (relating to Maximum Level of Chemical Contaminants) of the American National Standard, Water Treatment Equipment for Hemodialysis Applications, August 2001 Edition, published by the AAMI.(45) Samples for chemical analysis shall be collected at the end of the water treatment components and at the most distal point in each water distribution loop, if applicable. All other outlets from the distribution loops shall be inspected to ensure that the outlets are fabricated from compatible materials. Appropriate containers and pH adjustments shall be used to ensure accurate determinations. New LSRHs or LSRHs that add or change the configuration of the water distribution system must draw samples at the most distal point for each water distribution loop, if applicable, on a one time basis.(46) Additional chemical analysis shall be submitted if substantial changes are made to the water treatment system or if the percent rejection of an RO system decreased 5.0% or more from the percent rejection measured at the time the water sample for the preceding chemical analysis was taken.(47) LSRH records must include all test results and evidence that the medical director has reviewed the results of the water quality testing and directed corrective action when indicated.(48) Only persons qualified by the education or experience may operate, repair, or replace components of the water treatment system.(49) Quality control procedures shall be established to ensure ongoing conformance to policies and procedures regarding dialysate quality.(p) Each LSRH shall set all hemodialysis machines to use only one family of concentrates. When new machines are put into service or the concentrate family or concentrate manufacturer is changed, samples shall be sent to a laboratory for verification.(q) Prior to each patient treatment, LSRH staff shall verify the dialysate conductivity and pH of each machine with an independent device.(r) The LSRH shall conduct bacteriological testing.(s) Responsible LSRH staff shall develop a schedule to ensure each hemodialysis machine is tested quarterly for bacterial growth and the presence of endotoxins. Hemodialysis machines of home patients shall be cultured monthly until results not exceeding 200 CFU/ml are obtained for three consecutive months, then quarterly samples shall be cultured.(t) Dialysate shall contain less than 200 CFU/ml and an endotoxin concentration of less than 2 EU/ml. The action level for total viable microbial count shall be 50 CFU/ml and the action level for endotoxin concentration shall be 1 EU/ml.(u) Disinfection and retesting shall be done when bacterial or endotoxin counts exceed the action levels. Additional samples shall be collected when there is a clinical indication of a pyrogenic reaction and/or septicemia.(v) Only a licensed nurse may use an additive to increase concentrations of specific electrolytes in the acid concentrate. Mixing procedures shall be followed as specified by the additive manufacturer. When additives are prescribed for a specific patient, the container holding the prescribed acid concentrate shall be labeled with the name of the patient, the final concentration of the added electrolyte, the date the prescribed concentrate was made, and the name of the person who mixed the additive.(w) All components used in concentrate preparation systems (including mixing and storage tanks, pumps, valves, and piping) shall be fabricated from materials (e.g., plastics or appropriate stainless steel) that do not interact chemically or physically with the concentrate so as to affect its purity, or with the germicides used to disinfect the equipment. The use of materials that are known to cause toxicity in hemodialysis such as copper, brass, galvanized material, and aluminum is prohibited.(x) LSRH policies shall address means to protect stored acid concentrates from tampering or from degeneration due to exposure to extreme heat or cold.(y) Procedures to control the transfer of acid concentrates from the delivery container to the storage tank and prevent the inadvertent mixing of different concentrate formulations shall be developed, implemented, and enforced. The storage tanks shall be clearly labeled.(z) Concentrate mixing systems shall include a purified water source, a suitable drain, and a ground fault-protected electrical outlet.(aa) Operators of mixing systems shall use personal protective equipment as specified by the manufacturer during all mixing processes.(bb) The manufacturer's instructions for use of a concentrate mixing system shall be followed, including instructions for mixing the powder with the correct amount of water. The number of bags or weight of powder added shall be determined and recorded.(1) The mixing tank shall be clearly labeled to indicate the fill and final volumes required to correctly dilute the powder.(2) Systems for preparing either bicarbonate or acid concentrate from powder shall be monitored according to the manufacturer's instructions.(3) Concentrates shall not be used, or transferred to holding tanks or distribution systems, until all tests are completed.(4) If an LSRH designs its own system for mixing concentrates, procedures shall be developed and validated using an independent laboratory to ensure proper mixing.(5) Acid concentrate mixing tanks shall be designed to allow the inside of the tank to be rinsed when changing concentrate formulas.(6) Acid mixing systems shall be designed and maintained to prevent rust and corrosion.(7) Acid concentrate mixing tanks shall be emptied completely and rinsed with product water before mixing another batch of concentrate to prevent cross contamination between different batches.(8) Acid concentrate mixing equipment shall be disinfected as specified by the equipment manufacturer or in the case where no specifications are given, as defined by LSRH policy.(9) Records of disinfection and rinsing of disinfectants to safe residual levels shall be maintained.(10) Bicarbonate concentrate mixing tanks shall have conical or bowl-shaped bottoms and shall drain from the lowest point of the base. The tank design shall allow all internal surfaces to be disinfected and rinsed.(11) Bicarbonate concentrate mixing tanks shall not be prefilled the night before use.(12) If disinfectant remains in the mixing tank overnight, this solution must be completely drained and the tank must be rinsed and tested for residual disinfectant prior to preparing the first batch of that day of bicarbonate concentrate.(13) Unused portions of bicarbonate concentrate shall not be mixed with fresh concentrate.(14) At a minimum, bicarbonate distribution systems shall be disinfected weekly. More frequent disinfection shall be done if required by the manufacturer, or if dialysate culture results are above the action level.(15) If jugs are reused to deliver bicarbonate concentrate to individual hemodialysis machines:(A) jugs shall be emptied of concentrate, rinsed, and inverted to drain at the end of each treatment day;(B) at a minimum, jugs shall be disinfected weekly, and more frequent disinfection shall be considered by the medical director if dialysate culture results are above the action level; and(C) following disinfection, jugs shall be drained, rinsed free of residual disinfectant, and inverted to dry. Testing for residual disinfectant shall be done and documented.(16) All mixing tanks, bulk storage tanks, dispensing tanks, and containers for single hemodialysis treatments shall be labeled as to the contents.(17) Prior to batch preparation, a label shall be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling shall remain on the mixing tank until the tank has been emptied.(18) Mixing tanks shall be permanently labeled to identify the chemical composition or formulation of their contents.(19) At a minimum, single machine containers shall be labeled with sufficient information to differentiate the contents from other concentrate formulations used in the LSRH and permit positive identification by users of container contents.(20) Permanent records of batches produced shall be maintained to include the concentrate formula produced, the volume of the batch, lot number(s) of powdered concentrate packages, the manufacturer of the powdered concentrate, date and time of mixing, test results, person performing mixing, and expiration date (if applicable).(21) If dialysate concentrates are prepared in the facility, the manufacturers' recommendations shall be followed regarding any preventive maintenance. Records shall be maintained indicating the date, time, person performing the procedure, and the results (if applicable).(cc) With the advice and consent of a patient's attending nephrologist, facility staff shall make the hepatitis B vaccine available to a patient who is susceptible to hepatitis B, provided that the patient has coverage or is willing to pay for vaccination.(dd) The LSRH shall make available to patients literature describing the risks and benefits of the hepatitis B vaccination.(ee) A patient new to dialysis shall have been screened for hepatitis B surface antigen (HBsAg) within one month before or at the time of admission to the facility or have a known hepatitis B surface antibody (anti-HBs) status of at least 10 milli-international units per milliliter no more than 12 months prior to admission. The LSRH shall document how this screening requirement is met.(1) Repeated serologic screening shall be based on the antigen or antibody status of the patient.(2) Monthly screening for HBsAg is required for patients whose previous test results are negative for HBsAg.(3) Screening of HBsAg-positive or anti-HBs-positive patients may be performed on a less frequent basis, provided that the LSRH's policy on this subject remains congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Disease in the United States, 2000, published by the United States Department of Health and Human Services.(ff) The LSRH shall treat patients positive for HBsAg in a segregated treatment area that includes a hand washing sink, a work area, patient care supplies and equipment, and sufficient space to prevent cross-contamination to other patients.(1) A patient who tests positive for HBsAg shall be dialyzed on equipment reserved and maintained for the HBsAg-positive patient's use only.(2) When a caregiver is assigned to both HBsAg-negative and HBsAg-positive patients, the HBsAg-negative patients assigned to this grouping must be hepatitis B antibody positive. Hepatitis B antibody positive patients are to be seated at the treatment stations nearest the isolation station and be assigned to the same staff member who is caring for the HBsAg-positive patient.(3) If an HBsAg-positive patient is discharged, the equipment that had been reserved for that patient shall be given intermediate level disinfection prior to use for a patient testing negative for HBsAg.(4) In the case of patients new to dialysis, if these patients are admitted for treatment before results of HBsAg or anti-HBs testing are known, these patients shall undergo treatment as if the HBsAg test results were potentially positive, except that they shall not be treated in the HBsAg isolation room, area, or machine.(A) The LSRH shall treat potentially HBsAg-positive patients in a location in the treatment area that is outside of traffic patterns until the HBsAg test results are known.(B) The dialysis machine used by this patient shall be given intermediate level disinfection prior to its use by another patient.(C) The LSRH shall obtain HBsAg status results of the patient no later than three days from admission. Source Note: The provisions of this §511.58 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.58 Renal Dialysis Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215207 03/12/2026 (a) A limited services rural hospital (LSRH) shall have an infection prevention and control and antibiotic stewardship program that complies with Code of Federal Regulations Title 42 §485.528 to the extent it does not conflict with this chapter and state law.(b) The facility shall isolate patients with communicable diseases. Source Note: The provisions of this §511.59 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.59 Infection Prevention and Control and Antibiotic Stewardship Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215208 03/12/2026 (a) The LSRH must have a professional health care staff that includes one or more physicians, and may include one or more physician assistants, or advanced practice registered nurses (APRN).(b) Any ancillary personnel are supervised by the professional staff.(c) There shall be a written delineation of functions, qualifications, and patient care responsibilities for all categories of personnel.(d) The LSRH shall maintain documentation of evidence that all personnel are trained prior to treatment of services.(e) The staff shall be sufficient to provide the services essential to the operation of the LSRH.(f) A nurse shall be on duty whenever the LSRH has one or more patients receiving emergency care or observation care.(g) If the LSRH provides outpatient services, the services shall meet the needs of the patients in accordance with acceptable standards of practice.(1) The LSRH shall assign an individual to be responsible for outpatient services.(2) The LSRH shall have appropriate physicians on staff and other professional and nonprofessional personnel available.(3) The physician must:(A) provide medical direction for the LSRH's health care activities and consultation for, and medical supervision of, the health care staff;(B) participate, in conjunction with any physician assistant or nurse practitioner members, in developing, executing, and periodically reviewing the LSRH's written policies governing the services it furnishes;(C) review periodically, in conjunction with any physician assistant or nurse practitioner members, the LSRH patient records, provide medical orders, and provide medical care services to the patients of the LSRH; and(D) review periodically and sign a sample of outpatient records of patients cared for by APRN or physician assistants only to the extent where state law requires record reviews or co-signatures, or both, by a collaborating physician.(h) A physician must be present for sufficient periods of time to provide medical direction, consultation, and supervision for the services provided in the LSRH, and is available through direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral.(i) The physician assistant, the nurse practitioner, or clinical nurse specialist members of the LSRH staff shall:(1) participate in the development, execution and periodic review of the written policies governing the services the LSRH furnishes; and(2) participate with a physician in a periodic review of the patients' health records.(j) The physician assistant, nurse practitioner, or clinical nurse specialist shall perform the following functions to the extent they are not being performed by a physician:(1) provides services in accordance with the LSRH's policies; and(2) arranges for, or refers patients to, needed services that cannot be furnished at the LSRH, and assures that adequate patient health records are maintained and transferred as required when patients are referred.(k) Whenever a patient is placed in observation care at the LSRH by a nurse practitioner, physician assistant, or clinical nurse specialist, a physician on the staff of the LSRH is notified of the patient's status.(l) When required by law, the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists, and physician assistants at the LSRH must be evaluated by a member of the LSRH staff who is a physician or by another physician under contract with the LSRH.(m) The quality and appropriateness of the diagnosis and treatment provided by a physician at the LSRH must be evaluated by one of the following:(1) One Quality Improvement Organization (QIO) or equivalent entity;(2) in the case of distant-site physicians and practitioners providing telemedicine services to the LSRH's patient under an agreement between the LSRH and a distant-site hospital, the distant-site hospital; or(3) in the case of distant-site physicians and practitioners providing telemedicine services to the LSRH's patients under a written agreement between the LSRH and a distant-site telemedicine entity, one QIO or equivalent entity.(n) The LSRH staff shall consider the findings of the evaluation and make the necessary changes as specified in Code of Federal Regulations Title 42 §485.528 (b) - (d) (relating to Condition of participation: Staffing and staff responsibilities).(o) There shall be an organized nursing service under the direction of a qualified registered nurse (RN). The LSRH shall be staffed to assure that the nursing needs of all patients are met.(p) There shall be a written plan of administrative authority for all nursing services with responsibilities and duties of each category of nursing personnel delineated and a written job description for each category. The scope of nursing service shall include nursing care rendered to patients preoperatively, intraoperatively, and postoperatively.(1) The responsible individual for nursing services shall be a qualified RN whose responsibility and authority for nursing service shall be clearly defined and includes supervision of both personnel performance and patient care.(2) There shall be a written delineation of functions, qualifications, and patient care responsibilities for all categories of nursing personnel.(3) Surgical technicians and licensed vocational nurses may be permitted to serve in the scrub nurse role under the direct supervision of an RN; they shall not be permitted to function as circulating nurses in the operating rooms. Licensed vocational nurses and surgical technicians may assist in circulatory duties under the direct supervision of a qualified RN.(4) Nursing services shall be provided in accordance with current recognized standards or recommended practices.(5) The LSRH shall adopt, implement and enforce policies and procedures to comply with Texas Health and Safety Code Chapter 259 (relating to Surgical Technologists at Health Care Facilities).(6) There shall be an adequate number of RNs on duty to meet the following minimum staff requirements: director of the department (or designee), and supervisory and staff personnel for each service area to assure the immediate availability of an RN for emergency care or for any patient when needed.(7) An RN shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and qualifications of the nursing staff available.(8) There shall be other nursing personnel in sufficient numbers to provide nursing care not requiring the service of an RN.(9) An RN qualified, at a minimum, with current certification in advanced cardiac life support and pediatric advanced life support shall be on duty and on the premises at all times whenever patients are present in the LSRH.(q) All direct patient care staff must have current certification in basic cardiac life support.(r) In addition to meeting the requirements for nursing staff under subsections (p) and (q) of this section, LSRHs shall comply with the following staffing requirements.(1) LSRHs that provide only topical anesthesia, local anesthesia, or minimal sedation are required to have a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility.(2) LSRHs that provide moderate sedation/analgesia are required to have the following additional staff:(A) a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility; and(B) an individual trained and currently certified in advanced cardiac life support and, if surgery is performed on pediatric patients, pediatric advanced life support shall be available until all patients have been discharged from the post-anesthesia care unit.(s) LSRHs that provide deep sedation/analgesia, general anesthesia, or regional anesthesia shall have the following additional staff:(1) a second individual on duty on the premises who is trained and currently certified in basic cardiac life support until all patients have been discharged from the facility; and(2) an individual who is trained and currently certified in advanced cardiac life support and, if surgery is performed on pediatric patients, pediatric advanced life support shall be on duty on the premises and sufficiently free of other duties to enable the individual to respond rapidly to emergency situations until all patients have been discharged from the post-anesthesia care unit.(t) As applicable, the LSRH shall establish a nursing peer review committee to conduct nursing peer review, as required by Texas Occupations Code Chapter 303 (relating to Nursing Peer Review). Source Note: The provisions of this §511.60 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.60 Staffing and Staff Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215209 03/12/2026 (a) A limited services rural hospital (LSRH) shall have a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for patient care and provides 24-hour nursing services as needed.(b) An LSRH shall provide nursing services in accordance with current recognized standards or recommended practices.(c) Nursing services shall be under the administrative authority of a chief nursing officer (CNO) who is a registered nurse (RN).(1) The CNO shall be responsible for the operation of nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the LSRH.(2) The CNO shall report directly to the individual who has authority to represent the LSRH and who is responsible for the operation of the LSRH according to the policies and procedures of the LSRH's governing board.(3) The CNO shall participate with the governing body, medical staff, and clinical areas, in planning, promoting and conducting performance improvement activities.(d) An LSRH shall adopt, implement and enforce a procedure to verify nursing personnel for whom licensure is required have valid and current licensure.(e) An LSRH shall comply with the following nursing staff requirements.(1) The LSRH shall have adequate numbers of RNs, licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients as needed in accordance with subsection (f) of this section.(2) The LSRH shall have an adequate number of RNs on duty to meet the LSRH's minimum staff requirements in accordance with subsection (f)(2) of this section to include supervisory and staff RNs to ensure the immediate availability of an RN for emergency care or for any patient when needed.(3) The nursing staff shall develop and keep current a nursing plan of care for each patient which addresses the patient's needs.(4) The LSRH shall establish a nurse staffing committee as a standing committee of the LSRH. The committee shall be established in accordance with Texas Health and Safety Code (HSC) Chapter 161, Subchapter D (relating to Medical Committees, Medical Peer Review Committees, and Compliance Officers), to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. As used in this section, "committee" or "staffing committee" means a nurse staffing committee established under this paragraph.(f) An LSRH shall adopt, implement, and enforce a written official nurse services staffing plan. As used in this subsection, "patient care unit" means a unit or area of an LSRH in which registered nurses provide patient care.(1) The official nurse services staffing plan and policies shall:(A) require significant consideration to be given to the nurse staffing plan recommended by the LSRH's nurse staffing committee and the committee's evaluation of any existing plan;(B) be based on the needs of each patient care unit and shift and on evidence relating to patient care needs;(C) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget;(D) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns;(E) protect from retaliation nurses who provide input to the nurse staffing committee;(F) reflect current standards established by private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations and should be developed based upon a review of the codes of ethics developed by the nursing profession through national nursing organizations; and(G) comply with this section.(2) The plan shall set minimum staffing levels for patient care units that are:(A) based on multiple nurse and patient considerations including:(i) patient characteristics and number of patients for whom care is being provided, including number of admissions, discharges, and transfers on a unit;(ii) intensity of patient care being provided and variability of patient care across a nursing unit;(iii) scope of services provided;(iv) context within which care is provided, including architecture and geography of the environment, and the availability of technology; and(v) nursing staff characteristics, including staff consistency and tenure, preparation and experience, and the number and competencies of clinical and non-clinical support staff the nurse must collaborate with or supervise;(B) determined by the nursing assessment and in accordance with evidence-based safe nursing standards; and(C) recalculated at least annually, or as necessary.(3) The plan shall include:(A) a method for adjusting the staffing plan shift to shift for each patient care unit based on factors, such as, the intensity of patient care to provide staffing flexibility to meet patient needs;(B) a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources;(C) how on-call time will be used;(D) a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs, nursing sensitive quality indicators, nurse satisfaction measures collected by the LSRH, and evidence-based nurse staffing standards, which must include at least one from each of the following three types of outcomes shall be correlated to the adequacy of staffing:(i) nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions;(ii) operational outcomes, such as, work-related injury or illness, vacancy and turnover rates, nursing care hours per patient day, on-call use, or overtime rates; and(iii) substantiated patient complaints related to staffing levels;(E) a process that facilitates the timely and effective identification of concerns about the adequacy of the staffing plan by the nurse staffing committee, which includes:(i) a prohibition on retaliation for reporting concerns;(ii) a requirement that nurses report concerns timely through appropriate channels within the LSRH;(iii) orientation of nurses on how to report concerns and to whom;(iv) encouraging nurses to provide input to the committee relating to nurse staffing concerns;(v) review, assessment, and response by the committee to staffing concerns expressed to the committee;(vi) a process for providing feedback during the committee meeting on how concerns are addressed by the committee; and(vii) use of the nurse safe harbor peer review process pursuant to Texas Occupations Code §303.005 (relating to Request for Peer Review Committee Determination); and(F) policies and procedures that require:(i) orientation of nurses and other personnel who provide nursing care to all patient care units to which they are assigned on either a temporary or permanent basis;(ii) the orientation of nurses and other personnel and the competency to perform nursing services is documented in accordance with LSRH policy; and(iii) nursing assignments be congruent with documented competency.(g) The LSRH shall use the staffing plan required under subsection (f) of this section as a component in setting the nurse staffing budget and guiding the LSRH in assigning nurses LSRH wide.(h) The LSRH shall make readily available to nurses on each patient care unit at the beginning of each shift the official nurse services staffing plan levels and current staffing levels for that unit and that shift.(i) There shall be a semiannual evaluation by the staffing committee of the effectiveness of the official nurse services staffing plan and variations between the staffing plan and actual staffing.(1) The evaluation shall consider the outcomes and nursing-sensitive indicators as set out in subsection (f)(3)(D)(i) of this section, patient needs, nurse satisfaction measures collected by the LSRH, and evidence-based nurse staffing standards.(2) The evaluation shall be documented in the minutes of the committee and presented to the LSRH governing body.(3) The LSRH may determine whether the evaluation is done on a unit or facility level basis.(4) To assist the committee with the semiannual evaluation, the LSRH shall report to the committee the variations between the staffing plan and actual staffing. This report of variations shall be confidential.(j) The LSRH shall retain each staffing plan for a period of two years.(k) Nonemployee licensed nurses who are working in the LSRH shall adhere to the LSRH's policies and procedures. The LSRH's CNO shall provide for the adequate orientation, supervision, and evaluation of the clinical activities of nonemployee nursing personnel that occur within the responsibility of the nursing services.(l) The LSRH shall annually report to the Texas Health and Human Services Commission on:(1) whether the LSRH governing body has adopted a nurse staffing policy;(2) whether the LSRH has established a nurse staffing committee that meets the requirements of subsection (e)(4) of this section;(3) whether the nurse staffing committee has evaluated the LSRH official nurse services staffing plan and has reported the results of the evaluation to the LSRH's governing body; and(4) the nurse-sensitive outcome measures the committee adopted for use in evaluating the LSRH official nurse services staffing plan.(m) The LSRH shall adopt, implement and enforce policies on use of mandatory overtime. The policies shall comply with the following requirements.(1) As used in this subsection:(A) "on-call time" means time spent by a nurse who is not working but who is compensated for availability; and(B) "mandatory overtime" means a requirement that a nurse work hours or days that are in addition to the hours or days scheduled, regardless of the length of a scheduled shift or the number of scheduled shifts each week. Mandatory overtime does not include prescheduled on-call time or time immediately before or after a scheduled shift necessary to document or communicate patient status to ensure patient safety.(2) An LSRH may not require a nurse to work mandatory overtime, and a nurse may refuse to work mandatory overtime.(3) This subsection does not prohibit a nurse from volunteering to work overtime.(4) An LSRH may not use on-call time as a substitute for mandatory overtime.(5) The prohibitions on mandatory overtime do not apply if:(A) a health care disaster, such as a natural or other type of disaster that increases the need for health care personnel, unexpectedly affects the county in which the nurse is employed or affects a contiguous county;(B) a federal, state, or county declaration of emergency is in effect in the county in which the nurse is employed or is in effect in a contiguous county;(C) there is an emergency or unforeseen event of a kind that:(i) does not regularly occur;(ii) increases the need for health care personnel at the LSRH to provide safe patient care; and(iii) could not prudently be anticipated by the LSRH; or(D) the nurse is actively engaged in an ongoing medical or surgical procedure and the continued presence of the nurse through the completion of the procedure is necessary to ensure the health and safety of the patient. The nurse staffing committee shall ensure that scheduling a nurse for a procedure that could be anticipated to require the nurse to stay beyond the end of his or her scheduled shift does not constitute mandatory overtime.(6) If an LSRH determines that an exception exists under paragraph (5) of this subsection, the LSRH shall, to the extent possible, make and document a good faith effort to meet the staffing need through voluntary overtime, including calling per diems and agency nurses, assigning floats, or requesting an additional day of work from off-duty employees.(7) An LSRH may not suspend, terminate, or otherwise discipline or discriminate against a nurse who refuses to work mandatory overtime.(n) Drugs and biologicals shall be prepared and administered in accordance with federal and state laws, the orders of the individuals granted privileges by the medical staff, and accepted standards of practice.(o) All drugs and biologicals shall be administered by, or under supervision of, nursing or other personnel in accordance with federal and state laws and regulations, including applicable licensing rules, and in accordance with the approved medical staff policies and procedures.(p) All orders for drugs and biologicals shall be in writing, dated, timed, and signed by the individual responsible for the care of the patient as specified under §511.46(x) of this subchapter (relating to Radiologic Services). When telephone or verbal orders must be used, they shall be:(1) accepted only by personnel who are authorized to do so by the medical staff policies and procedures, consistent with federal and state laws;(2) dated, timed, and authenticated within 96 hours by the prescriber or another practitioner who is responsible for the care of the patient and has been credentialed by the medical staff and granted privileges that are consistent with the written orders; and(3) used infrequently.(q) There shall be an LSRH procedure for immediately reporting transfusion reactions, adverse drug reactions, and errors in administration of drugs to the attending physician and, if appropriate, to the LSRH-wide quality assessment and performance improvement program.(r) Blood transfusions shall be prescribed in accordance with LSRH policy and administered in accordance with a written protocol for the administration of blood and blood components and the use of infusion devices and ancillary equipment.(s) Personnel administering blood transfusions and intravenous medications shall have special training for this duty according to written, adopted, implemented, and enforced LSRH policy.(t) Blood and blood components shall be transfused through a sterile, pyrogen-free transfusion set that has a filter designed to retain particles potentially harmful to the recipient.(u) Nursing staff shall observe and monitor the patient during blood and blood component transfusions and for an appropriate time thereafter as required by the LSRH's blood transfusion policy for suspected adverse reactions.(v) Pretransfusion and posttransfusion vital signs shall be recorded.(w) When warming of blood is indicated, this shall be accomplished during its passage through the transfusion set. The warming system shall be equipped with a visible thermometer and may have an audible warning system. Blood shall not be warmed above 42 degrees Centigrade.(x) Drugs or medications, including those intended for intravenous use, shall not be added to blood or blood components. A 0.9% sodium chloride injection, United States Pharmacopeia, may be added to blood or blood components. Other solutions intended for intravenous use may be used in an administration set or added to blood or blood components under either of the following conditions:(1) they have been approved for this use by the U.S. Food and Drug Administration; or(2) there is documentation available to show that addition to the component involved is safe and efficacious.(y) There shall be a system for detection, reporting, and evaluation of suspected complications of transfusion. Any adverse event experienced by a patient in association with a transfusion is to be regarded as a suspected transfusion complication. In the event of a suspected transfusion complication, the personnel attending the patient shall notify immediately a responsible physician and the transfusion service and document the complication in the patient's medical record. All suspected transfusion complications shall be evaluated promptly according to an established procedure.(z) Following the transfusion, the blood transfusion record or a copy shall be made a part of the patient's medical record.(aa) An LSRH shall adopt, implement, and enforce a policy to ensure the LSRH complies with Texas Occupations Code Chapter 301, Subchapter I (relating to Reporting Violations and Patient Care Concerns), and Chapter 303 (relating to Nursing Peer Review), and with the rules adopted by the Texas Board of Nursing in Texas Administrative Code Title 22 §217.16 (relating to Minor Incidents), §217.19 (relating to Incident-Based Nursing Peer Review and Whistleblower Protections), and §217.20 (relating to Safe Harbor Peer Review for Nurses and Whistleblower Protections).(bb) The LSRH shall adopt, implement, and enforce policies and procedures related to the work environment for nurses which:(1) improve workplace safety and reduce the risk of injury, occupational illness, and violence; and(2) increase the use of ergonomic principles and ergonomically designed devices to reduce injury and fatigue.(cc) The policies and procedures adopted under subsection (bb) of this section must address at least the following:(1) evaluating new products and technology that incorporate ergonomic principles;(2) educating nurses in the application of ergonomic practices;(3) conducting workplace audits to identify areas of risk of injury, occupational illness, or violence and recommending ways to reduce those risks;(4) controlling access to those areas identified as having a high risk of violence; and(5) promptly reporting crimes committed against nurses to appropriate law enforcement agencies.(dd) The LSRH shall adopt, implement and enforce policies and procedures to identify, assess, and develop strategies to control risk of injury to patients and nurses associated with the lifting, transferring, repositioning, or movement of a patient. The policies and procedures shall establish a process that includes at least the following:(1) analysis of the risk of injury to both patients and nurses posed by the patient handling needs of the patient populations served by the LSRH and the physical environment in which patient handling and movement occurs;(2) education of nurses in the identification, assessment, and control of risks of injury to patients and nurses during patient handling;(3) evaluation of alternative ways to reduce risks associated with patient handling, including evaluation of equipment and the environment;(4) restriction, to the extent feasible with existing equipment and aids, of manual patient handling or movement of all or most of a patient's weight to emergency, life-threatening, or otherwise exceptional circumstances;(5) collaboration with and annual report to the nurse staffing committee;(6) procedures for nurses to refuse to perform or be involved in patient handling or movement that the nurse believes in good faith will expose a patient or a nurse to an unacceptable risk of injury;(7) submission of an annual report to the governing body on activities related to the identification, assessment, and development of strategies to control risk of injury to patients and nurses associated with the lifting, transferring, repositioning, or movement of a patient; and(8) development of architectural plans for constructing or remodeling a LSRH or a unit of an LSRH in which patient handling and movement occurs, with consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment at a later date. Source Note: The provisions of this §511.61 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.61 Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222887 03/12/2026 (a) A limited services rural hospital (LSRH) shall have an effective, ongoing, discharge planning process that facilitates the provision of follow-up care and focuses on the patient's goals and treatment preferences and includes the patient and their caregivers or support persons as active partners in the discharge planning for post-discharge care.(b) The discharge planning process and the discharge plan shall be consistent with the patient's goals for care and their treatment preferences, ensure an effective transition of the patient from the LSRH to post-discharge care, and reduce the factors leading to preventable LSRH admissions or readmissions.(c) An LSRH's discharge planning process shall identify, at an early stage of the provision of services, those patients who are likely to suffer adverse health consequences on discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's legally authorized representative, or patient's physician.(d) Any discharge planning evaluation must be made on a timely basis to ensure appropriate arrangements for post-LSRH care will be made before discharge and to avoid unnecessary delays in discharge.(e) A discharge planning evaluation must include:(1) an evaluation of a patient's likely need for appropriate services following those furnished by the LSRH, including:(A) hospice care services;(B) post-LSRH extended care services;(C) home health services;(D) non-health care services; and(E) community-based care providers;(2) a determination of the availability of the appropriate services; and(3) a determination of the patient's access to those services.(f) The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's legally authorized representative).(g) On the request of a patient's physician, the LSRH must arrange for the development and initial implementation of a discharge plan for the patient.(h) Any discharge planning evaluation or discharge plan required under this section must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel.(i) The LSRH's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.(j) The LSRH must assess its discharge planning process on a regular basis. The assessment must include ongoing periodic review of a representative sample of discharge plans.(k) The LSRH must assist patients, their families, or the patient's legally authorized representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, home health agency, skilled nursing facility (SNF), inpatient rehabilitation facility, or long-term care hospital data on quality measures and data on resource use measures. The LSRH must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences.(l) The LSRH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.(m) An LSRH shall comply with Texas Health and Safety Code §256.003.(1) Except as provided by paragraph (2) of this subsection, an LSRH may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility only if the person operating the group-centered facility holds a license or permit issued in accordance with applicable state law.(2) An LSRH may discharge or release a patient to a group home, boarding home facility, or similar group-centered facility operated by a person who does not hold a license or permit issued in accordance with applicable state law only if:(A) there is no group-centered facility operated in the county where the patient is discharged that is operated by a person holding the applicable license or permit; or(B) the patient voluntarily chooses to reside in the group-centered facility operated by an unlicensed or unpermitted person. Source Note: The provisions of this §511.62 adopted to be effective October 5, 2023, 48 TexReg 5668; amended to be effective December 31, 2024, 49 TexReg 10650. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.62 Discharge Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215211 03/12/2026 (a) A limited services rural hospital (LSRH) shall protect and promote each patient's rights.(b) An LSRH shall adopt, implement, and enforce a policy to ensure patients' rights are upheld within the limits of law. The LSRH's written patient's rights policy shall include the following:(1) the right to participate in the development and implementation of their plan of care;(2) the right to make informed decisions regarding their care, including being informed of their health status, and being able to request or refuse treatment;(3) the right to formulate advance directives and to have LSRH staff and practitioners who provide care in the LSRH comply with these directives, in accordance with Code of Federal Regulations Title 42 (42 CFR) §§489.100 (relating to Definitions), 489.102 (relating to Requirement for Providers), and 489.104 (relating to Effective Dates) and Texas Health and Safety Code Chapter 166 (relating to Advance Directives);(4) the right to have personal privacy;(5) the right to receive medical standard of care in a safe setting;(6) the right to be free from all forms of abuse, neglect, exploitation, and harassment;(7) the right to have confidentiality of their medical records;(8) the right to the LSRH's reasonable response to the patient's requests and needs for treatment or service, within the LSRH's capacity, stated mission, and applicable law and regulation;(9) the right to considerate and respectful care, which includes:(A) the care of the patient includes consideration of the psychosocial, spiritual, and cultural variables that influence perceptions of illness; and(B) the care of a dying patient optimizes the comfort and dignity of the patient through;(i) treating primary and secondary symptoms that respond to treatment as desired by the patient or surrogate decision maker;(ii) effectively managing pain; and(iii) acknowledging the psychosocial and spiritual concerns of the patient and the family regarding dying and the expression of grief by the patient and family;(10) the right of the patient or their legally authorized representative (LAR) to, in collaboration with the patient's physician, make decisions involving their health care, including:(A) the right to accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal; and(B) the right to formulate advance directives and to appoint a surrogate to make health care decisions on their behalf to the extent permitted by law;(11) a mechanism to ascertain the existence of, and, as appropriate, assist in the development of advance directives at the time of the patient's admission;(12) the right to not have the provision of care conditioned on the existence of an advance directive;(13) the right of a patient to the information necessary to enable them to make treatment decisions reflecting their wishes;(14) the right of a patient to receive at the time of admission information about the LSRH's patient rights policy or policies and the mechanism for the initiation, review, and, when possible, resolution of patient complaints concerning the quality of care;(15) the right to receive information about the patient's rights in advance of receiving or discontinuing patient care whenever possible;(16) the right of the patient or the patient's legally authorized representative to participate in the consideration of ethical issues that arise in the care of a patient;(17) a mechanism for the consideration of ethical issues arising in the care of patients and to provide education to care givers and patients on ethical issues in health care;(18) the right of the patient to be informed of and consent to any human experimentation or other research or educational projects affecting their care or treatment;(19) the right of the patient or the patient's legally authorized representative to access the information contained in the patient's medical record, on oral or written request; and(20) the right of the patient's guardian, next of kin, or LAR to exercise, to the extent permitted by law, the rights delineated on behalf of the patient if the patient:(A) has been adjudicated incompetent in accordance with the law;(B) is found by their physician to be medically incapable of understanding the proposed treatment or procedure;(C) is unable to communicate their wishes regarding treatment; or(D) is a minor.(c) An LSRH must post the patient bill of rights prominently and conspicuously for display in a public area of the LSRH that is readily available to patients, residents, employees, and visitors.(1) In addition to these patient bill of rights requirements, an LSRH that provides chemical dependency services shall comply with this section and Texas Administrative Code Title 25 (25 TAC) §448.701 (relating to Client Bill of Rights) applicable to patients who receive such services.(2) In addition to these patient bill of rights requirements, an LSRH that provides mental health services shall comply with this section and 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services) applicable to patients who receive such services.(3) The patient bill of rights posted for display shall be in English and in a second language appropriate to the demographic makeup of the community served.(d) An LSRH's medical staff and governing body shall adopt, implement, and enforce a policy on informed decision making that is consistent with any legal requirements.(e) An LSRH shall establish a process for prompt resolution of patient complaints and inform each patient whom to contact to file a complaint. The LSRH's governing body or responsible individual shall approve and be responsible for the effective operation of the complaint process and shall review and resolve complaints, unless it delegates the responsibility, in writing, to a complaint committee. The complaint process shall include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization.(1) The LSRH shall establish a clearly explained procedure for the submission of a patient's written or verbal complaint to the LSRH.(2) The complaint process shall specify timeframes for review of the complaint and the provision of a response.(3) In its resolution of the complaint, the LSRH shall provide the patient with written notice of its decision that contains the name of the LSRH contact person, the steps taken on behalf of the patient to investigate the complaint, the results of the complaint process, and the date of completion.(f) Notwithstanding subsection (b) of this section, an LSRH may deny treatment or services deemed medically unnecessary or inappropriate. Source Note: The provisions of this §511.63 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.63 Patient's Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215212 03/12/2026 (a) A limited services rural hospital (LSRH) shall develop, implement, and maintain an effective, ongoing, LSRH-wide, data-driven quality assessment and performance improvement (QAPI) program.(b) An LSRH's governing body shall ensure the QAPI program is individualized to ensure the LSRH complies with the requirements of this section, reflects the complexity of the LSRH's organization and services, involves all LSRH departments and services (including those services furnished under contract or arrangement), and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The LSRH must maintain and demonstrate evidence of its QAPI program.(c) The LSRH shall measure, analyze, and track quality indicators, including adverse patient events, staffing, and other aspects of performance to evaluate processes of care, including LSRH service and operations.(d) The QAPI program shall:(1) include an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors;(2) incorporate quality indicator data, including patient care data, and other relevant data, to achieve the goals of the QAPI program;(3) evaluate all LSRH departments and services, including services furnished under contract or arrangement;(4) evaluate health care associated infections;(5) evaluate medication therapy;(6) evaluate all medical and surgical services performed in the LSRH as they relate to appropriateness of diagnosis and treatment;(7) measure, analyze, and track quality indicators, including adverse patients' events, and other aspects of performance that assess processes of care, LSRH services, and operations; and(8) use the data collected to monitor the effectiveness and safety of service and quality of care, and to identify opportunities for changes that will lead to improvement.(e) For each quality assessment indicator, the LSRH shall establish and monitor a level of performance consistent with current professional knowledge. These performance components shall influence or relate to the desired outcomes. The LSRH shall measure, analyze, and track at least the following indicators on a monthly basis:(1) infection control, including staff and patient screening and standard precautions;(2) adverse events;(3) mortality, including review of each death and monitoring modality specific mortality rate;(4) complaints and suggestions from patients, family, or staff;(5) staffing, including orientation, training, delegation, licensing and certification, and non-adherence to policies and procedures by facility staff;(6) safety, including fire and disaster preparedness, use of a Texas Health and Human Services Commission-required reporting system, and disposal of special waste; and(7) clinical records review, including treatment errors and medication errors.(f) The LSRH shall establish priorities for performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care. Performance improvement activities shall:(1) track medical errors and adverse patient events;(2) analyze their causes; and(3) implement preventive actions and mechanisms that include feedback and learning throughout the LSRH.(g) The LSRH shall measure the success of actions implemented resulting from performance improvement activities and track ongoing performance to ensure sustained improvements.(h) The LSRH shall ensure staff, including the medical, nursing, and pharmacy staff, complete the following activities:(1) evaluate the provision of emergency care and patient services;(2) set treatment goals;(3) identify opportunities for improvement;(4) develop and implement improvement plans; and(5) evaluate the implementation until resolution is achieved.(i) The LSRH shall measure, analyze, and track quality indicators or other aspects of performance the LSRH adopts or develops that reflect processes of care and LSRH operations. The LSRH shall document evidence demonstrating the LSRH continuously reviews aggregate patient data, including identifying and tracking patient infections trends.(j) The LSRH shall hold QAPI meetings as necessary, but not less than quarterly. Core staff members, including the medical, nursing, and pharmacy staff, shall actively participate in QAPI activities and meetings to identify or correct problems. The LSRH shall document QAPI meetings.(k) The LSRH's governing body, medical staff, and administrative officials are responsible and accountable for ensuring:(1) the LSRH defines, implements, and maintains an ongoing quality improvement and patient safety program, including the reduction of medical errors;(2) the LSRH-wide QAPI efforts address priorities for improved quality of care and patient safety, and evaluates all improvement actions;(3) the LSRH establishes clear expectations for safety; and(4) the LSRH allocates adequate resources for measuring, assessing, improving, and sustaining the LSRH's performance and reducing risk to patients.(l) The LSRH shall have an ongoing plan, consistent with available community and LSRH resources, to provide or make available social work, psychological, and educational services to meet the medically related needs of its patients.(m) When an LSRH is part of a system consisting of multiple separately certified hospitals, critical access hospitals (CAHs), or LSRHs using a system governing body that is legally responsible for the conduct of two or more hospitals, CAHs, or LSRHs, the system governing body can elect to have a unified and integrated QAPI program for all of its member facilities after determining that such a decision is in accordance with all applicable state and local laws. The system governing body is responsible and accountable for ensuring that each of its separately certified LSRHs meets all of the requirements of this section. Each separately certified LSRH subject to the system governing body must demonstrate:(1) the unified and integrated QAPI program is established in a manner that takes into account each member LSRH's unique circumstances and any significant differences in patient populations and services offered in each LSRH; and(2) the unified and integrated QAPI program establishes and implements policies and procedures to ensure that the needs and concerns of each of its separately certified LSRHs, regardless of practice or location, are given due consideration, and the unified and integrated QAPI program has mechanisms in place to ensure that issues localized to particular LSRHs are duly considered and addressed. Source Note: The provisions of this §511.64 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.64 Quality Assessment and Performance Improvement Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215213 03/12/2026 (a) The governing body of each limited services rural hospital (LSRH) shall adopt, implement, and enforce a policy relating to patient transfers consistent with this section and contains each of the requirements in subsection (b) of this section. The policy shall identify LSRH staff that has authority to represent the LSRH and the physician regarding transfers from the LSRH.(b) The LSRH's governing body shall adopt the transfer policy after consultation with the medical staff. The policy shall apply to patient transfers to general and special hospitals licensed under Texas Health and Safety Code (HSC) Chapter 241 (relating to Hospitals) and private psychiatric hospitals licensed under HSC Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities), as well as transfers to general, special, and private psychiatric hospitals that are exempt from licensing.(c) The LSRH's transfer policy shall govern transfers not covered by a transfer agreement.(d) The LSRH's transfer policy shall include a written operational plan to provide for patient transfer transportation services if the LSRH does not provide its own patient transfer transportation services.(e) The LSRH's governing body, after consultation with the medical staff, shall implement its transfer policy by adopting transfer agreements with hospitals in accordance with this section.(f) The LSRH's transfer policy shall recognize and comply with the requirements HSC Chapter 61 §§61.030 - 61.032 and §§61.057 - 61.059 (relating to Indigent Health Care and Treatment Act).(g) The LSRH's transfer policy shall acknowledge contractual obligations and comply with statutory or regulatory obligations that may exist concerning a patient and a designated provider.(h) The LSRH's transfer policy shall require the LSRH to take all reasonable steps to secure the written informed consent of a patient, or a person acting on a patient's behalf, when refusing a transfer or related examination and treatment. Reasonable steps include:(1) providing a factual explanation regarding:(A) the increased medical risks to the patient reasonably expected from not being transferred, examined, or treated at the transferring hospital;(B) any increased risks to the patient from not effecting the transfer; and(C) the medical benefits reasonably expected from the provision of appropriate treatment at another hospital; and(2) documenting the informed refusal of a patient, or of a person acting on a patient's behalf, to examination, evaluation, or transfer and obtaining, if possible, the signature of the patient or the person acting on the patient's behalf, regarding the refusal that is dated and witnessed by the attending physician or facility employee, and placed in the patient's medical record.(i) The LSRH's transfer policy shall recognize an individual's right to request a transfer into the care of a physician and a hospital of the individual's own choosing.(j) The LSRH's transfer policy shall prohibit a patient transfer from being predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status, or ability to pay.(k) The LSRH's transfer policy shall require, when a patient requests or consents to transfer for economic reasons and the patient's choice is based on or influenced by representations made by the transferring physician or LSRH administration regarding the availability of medical care and hospital services at a reduced cost or no cost to the patient, the physician or facility administration to fully disclose to the patient the eligibility requirements established by the patient's chosen physician or hospital.(l) The LSRH's transfer policy shall provide that each patient who arrives at the facility is:(1) evaluated by a physician at the time the patient presents or is presented or evaluated by a physician on-call who is:(A) physically able to reach the patient within 30 minutes after being informed that a patient is present at the LSRH who requires immediate medical attention; or(B) accessible by direct, telephone, or radio communication within 30 minutes with a registered nurse, physician assistant, or other qualified medical personnel as established by the governing body at the LSRH under orders to assess and report the patient's condition to the physician; and(2) personally examined and evaluated by the physician before an attempt to transfer is made; however:(A) after receiving a report on the patient's condition from the LSRH's registered nurse, physician assistant, or other qualified medical personnel as established by the governing body by telephone or radio, if the physician on-call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of a patient will unnecessarily delay the transfer to the detriment of the patient, the physician on-call may order the transfer by telephone or radio;(B) physician orders for the transfer of a patient which are issued by telephone or radio shall be reduced to writing in the patient's medical record, signed by the registered nurse, physician assistant, or other qualified medical personnel as established by the governing body receiving the order, and countersigned by the physician authorizing the transfer as soon as possible; and(C) patient transfers resulting from physician orders issued by telephone or radio shall be subject to automatic review by the medical staff pursuant to subsection (q)(6) of this section.(m) The transfer policies of the transferring LSRH and receiving general or special hospital shall require the facilities to have licensed nurses and other qualified personnel available and on duty to assist with patient transfers. The policies shall require written protocols or standing delegation orders to be in place to guide facility personnel when a patient requires transfer to another hospital.(n) If a patient at an LSRH has an emergency medical condition that has not been stabilized, or when stabilization of the patient's vital signs is not possible because the LSRH does not have the appropriate equipment or personnel to correct the underlying process, the LSRH shall evaluate and treat the patient, then transfer the patient as quickly as possible.(o) The LSRH's transfer policy shall prohibit the LSRH from transferring a patient with an emergency medical condition that has not been stabilized unless:(1) the individual (or a legally responsible person acting on the individual's behalf), after being informed of the LSRH's obligations under this section and of the risk of transfer, requests the transfer in writing, indicates the reasons for the request, and states the individual is aware of the risks and benefits of the transfer; or(2) a physician signs a certification, which includes a summary of the risks and benefits based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another hospital outweigh the increased risks to the patient and, in the case of labor, to the unborn child from effecting the transfer.(p) except as specifically provided in subsection (o) of this section, the LSRH's policy shall provide that the transfer of patients who have emergency medical conditions, as determined by a physician, shall be undertaken for medical reasons only. The LSRH must provide medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child.(q) The LSRH's transfer policy shall include the following information related to physicians' duties and standard of care. The policy shall require:(1) the transferring physician to determine and order life support measures that are medically appropriate to stabilize the patient before transfer and to sustain the patient during transfer;(2) the transferring physician to determine and order the utilization of appropriate personnel and equipment for the transfer;(3) the transferring physician, in determining the use of medically appropriate life support measures, personnel, and equipment, to exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer;(4) except as allowed under subsection (o) of this section, before each patient transfer, the physician who authorizes the transfer to personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used;(5) before each patient transfer, the transferring physician to ensure the receiving general or special hospital and physician are appropriate to the patient's medical needs and have accepted responsibility for the patient's medical treatment and hospital care; and(6) the LSRH's medical staff review appropriate records of patients transferred from the LSRH to determine that the appropriate standard of care has been met.(r) The LSRH's transfer policy shall comply with the following requirements related to medical records.(1) The policy shall require the LSRH to forward a copy of the portions of the patient's medical record, which are available and relevant to the transfer and to the continuing care of the patient, to the receiving physician and receiving hospital with the patient. When all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the transferring LSRH shall forward the records to the receiving physician and hospital as soon as possible.(2) The patient's medical record shall contain at least the following:(A) a brief description of the patient's medical history and physical examination;(B) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;(C) the reason for the transfer;(D) the results of all diagnostic tests, such as laboratory tests;(E) relevant radiological films and reports; and(F) any other relevant information.(s) The LSRH's transfer policy shall require the LSRH to complete a memorandum of transfer for every transferred patient.(1) The memorandum shall contain the following information:(A) if known, the patient's:(i) full name;(ii) race, religion, national origin, age, sex, disability status;(iii) address and phone number; and(iv) next of kin address and phone number;(B) the transferring and receiving physicians' names, telephone numbers, and addresses;(C) the transferring LSRH's and receiving general or special hospital's names, addresses, and telephone numbers;(D) the time and date on which the patient first presented or was presented to the transferring physician and transferring LSRH;(E) the time and date on which the transferring physician secured a receiving physician;(F) the name of the hospital contact and date and time hospital administration was contacted in the receiving general or special hospital;(G) the transferring LSRH administrator's signature and title and time the administrator contacted the receiving hospital;(H) certification required by subsection (o)(2) of this section, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form);(I) the time and date the receiving physician assumed responsibility for the patient;(J) the time and date the patient arrived at the receiving general or special hospital;(K) the signature and date of receiving hospital administration;(L) the type of vehicle and company used to transport the patient;(M) the type of equipment and personnel needed in transfers;(N) the name and city of hospital where the patient was transported;(O) the patient's diagnosis by the transferring physician; and(P) the attachments by the transferring LSRH.(2) The transferring LSRH shall retain a copy of the memorandum of transfer for five years and file the memorandum separately from the patient's medical record and in a manner facilitating its inspection by the Texas Health and Human Services Commission.(t) An LSRH violates HSC Chapter 241 and this section if:(1) the LSRH fails to comply with the requirements of this section; or(2) the LSRH's governing body fails or refuses to:(A) adopt a transfer policy that complies with this section and contains all requirements listed in this section;(B) adopt a memorandum of transfer form that complies with the content requirements contained in this section; or(C) enforce its transfer policy and the use of the memorandum of transfer. Source Note: The provisions of this §511.65 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.65 Patient Transfer Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215214 03/12/2026 (a) A limited services rural hospital (LSRH) shall have in effect an agreement with at least one general hospital that is a level I or level II trauma center as designated by the Texas Department of State Health Services (DSHS), certified by the Centers for Medicare & Medicaid Services for the referral and transfer of patients requiring emergency medical care beyond the capabilities of the LSRH, and is:(1) licensed under Texas Health and Safety Code (HSC) Chapter 241;(2) maintained or operated by the state or an agency of the federal government and exempt from licensure under HSC Chapter 241; or(3) maintained or operated by the federal government or an agency of the federal government and exempt from licensure under HSC Chapter 241.(b) An LSRH shall submit the transfer agreement to the Texas Health and Human Services Commission (HHSC) for review to determine whether the agreement meets the requirements of subsection (a) of this section.(c) An LSRH may enter into multiple transfer agreements based on the type or level of medical services available at other hospitals.(d) A patient transfer agreement shall include specific language that is consistent with the following.(1) HSC Chapter 61 (relating to Indigent Health Care Treatment Act) in accordance with §511.65(f) of this subchapter (relating to Patient Transfer Policy);(2) discrimination in accordance with §511.65(j) of this subchapter;(3) patient's right to request a transfer in accordance with §511.65(k) of this subchapter;(4) transfer of patients with emergency medical conditions in accordance with §511.65(n) and (o) of this subchapter;(5) physician's duties and standard of care in accordance with §511.65(q) of this subchapter;(6) medical records in accordance with §511.65(r) of this subchapter; and(7) memorandum of transfer in accordance with §511.65(s) of this subchapter.(e) In order for HHSC to review the transfer agreements to determine compliance with the requirements of this section, an LSRH shall submit the following documents to HHSC:(1) a copy of the current or proposed agreement signed by the representatives of the LSRH and the general or special hospital subject to the agreement;(2) the agreement's adoption date; and(3) the agreement's effective date.(f) HHSC may waive the document submission requirements under subsection (e) of this section at its sole discretion to avoid the repetitious submission of required documentation and approved agreements.(g) When an LSRH's governing body or governing body's designee executes a transfer agreement and the text of that agreement is the same text of a previously HHSC-approved agreement, the governing body or the governing body's designee is not required to submit the later agreement for review.(h) HHSC shall review the patient transfer agreement not later than 45 calendar days after the date HHSC receives the agreement to determine whether the agreement complies with the requirements of this section.(1) After HHSC's review of the agreement, if HHSC determines the agreement complies with the requirements contained in this section, HHSC shall notify the LSRH's administration that HHSC has approved the agreement.(2) If after reviewing the agreement, HHSC determines the agreement is not consistent with the requirements contained in this section, HHSC shall give notice to the LSRH's administration that the agreement is deficient and provide recommendations for correction.(i) HHSC considers a transfer agreement in compliance with this section if the agreement complies with the rules in effect at the time the LSRH executed the transfer agreement and HHSC approved the agreement.(j) HHSC shall treat complaints alleging a transfer agreement violation in the same manner as complaints alleging violations of HSC Chapter 241, Subchapter K (relating to Limited Services Rural Hospitals) or this chapter. Source Note: The provisions of this §511.66 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.66 Patient Transfer Agreements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215215 03/12/2026 (a) A limited services rural hospital (LSRH) shall maintain a medical records system in accordance with the LSRH's written policies and procedures, which must:(1) contain procedures for collecting, processing, maintaining, storing, retrieving, authenticating, and distributing patient medical records; and(2) require the medical records to be:(A) legible;(B) completely and accurately documented, dated, and timed;(C) authenticated by the person responsible for providing or evaluating the service provided no later than 48 hours after the patient's discharge;(D) systematically organized according to a predetermined and uniform medical record format;(E) confidential, secure, and safely stored; and(F) readily accessible, including that all a patient's relevant clinical information is readily available to physicians or practitioners involved in that patient's care, and an individual's records are timely retrievable upon request.(b) An LSRH shall designate a member of the LSRH's professional staff who is responsible for maintaining the records and for ensuring the records comply with the LSRH's written policies and procedures under subsection (a) of this section.(c) An LSRH shall maintain a uniformly formatted and organized medical record for each patient receiving health care services at the LSRH. The record shall include the following, as applicable:(1) complete patient identification and social data, as described in Code of Federal Regulations Title 42 §485.540(a)(4)(i) (relating to Conditions of Participation: Medical Records);(2) date, time, and means of the patient's arrival and discharge;(3) evidence of properly executed informed consent forms;(4) allergies and untoward reactions to drugs recorded in a prominent and uniform location;(5) relevant medical history;(6) the patient's advance directive;(7) assessment of the patient's health status and health care needs;(8) a brief summary of the episode, any care given to the patient before the patient's arrival to the LSRH, the patient's disposition, and instructions given to the patient;(9) a complete detailed description of treatment and procedures performed in the LSRH;(10) clinical observations, diagnostic impression, and consultative findings, including results of:(A) physical examinations, including vital signs;(B) diagnostic and laboratory tests, including clinical laboratory services; and(C) treatment provided and procedures performed;(11) a pre-anesthesia evaluation by an individual qualified to administer anesthesia before and LSRH administers anesthesia to a patient;(12) pathology report on all tissues removed, except those exempted by the governing body;(13) for a patient with a length of stay greater than eight hours, an evaluation of nutritional needs and evidence of how the LSRH met the patient's identified needs;(14) all orders of physicians or another practitioner, who is practicing within the scope of their license and education;(15) all reports of treatments and medications, including all medications administered and the drug dose, route of administration, frequency of administration, and quantity of all drugs administered or dispensed to the patient by the facility;(16) nursing notes and documentation of complications;(17) other relevant information necessary to monitor the patient's progress, such as temperature graphics and progress notes describing the patient's response to treatment;(18) evidence of the patient's evaluation by a physician, podiatrist, dentist, or another practitioner, who is practicing within the scope of their license and education, before dismissal;(19) conclusion at the termination of evaluation and treatment, including final disposition, the patient's condition on discharge or transfer, and any instructions given to the patient or family for follow-up care;(20) medical advice given to a patient by telephone; and(21) dated signatures of the physician or other health care professional.(d) Except when otherwise required or permitted by law, an LSRH shall maintain the strict confidentiality of patient record information, including any record that contains clinical, social, financial, or other data on a patient, and provide safeguards against loss, tampering, altering, improper destruction, unauthorized use, or inadvertent disclosure.(e) An LSRH shall have written policies and procedures governing the use and removal of records from the LSRH and the conditions for the release of information. The written policies and procedures shall include all the following requirements.(1) An LSRH shall obtain a patient's or their legally authorized representative's written consent before releasing information not required by law.(2) An LSRH shall retain medical records until at least the 10th anniversary of the last entry date when the patient was last treated in the LSRH except as required in subparagraphs (A) and (B) of this paragraph.(A) If a patient was younger than 18 years of age when the LSRH last treated the patient, the LSRH shall retain the patient's medical records until on or after the date of the patient's 20th birthday or on or after the 10th anniversary of the last entry date when the LSRH last treated the patient, whichever date is later.(B) The LSRH shall not destroy medical records that relate to any matter that is involved in litigation if the LSRH knows the litigation has not been finally resolved.(3) If an LSRH plans to close, the LSRH shall arrange for disposition of the medical records in accordance with applicable law. The LSRH shall notify HHSC at the time of closure of the disposition of the medical records, including where the medical records will be stored and the name, address, and phone number of the custodian of the records.(f) An LSRH shall provide written notice to a patient, or a patient's legally authorized representative as defined in Texas Health and Safety Code §241.151, that the LSRH, unless the exception in subsection (e)(2)(B) of this section applies, may authorize the disposal of medical records relating to the patient on or after the periods specified in this section.(1) The LSRH shall provide the notice to the patient or the patient's legally authorized representative not later than the date on which the patient who is or will be the subject of a medical record is treated, except in an emergency treatment situation.(2) In an emergency treatment situation, the LSRH shall provide the notice to the patient or the patient's legally authorized representative as soon as is reasonably practicable following the emergency treatment situation.(g) When necessary for ensuring continuity of care, the LSRH shall transfer summaries or electronic copies of the patient's record to the physician or practitioner to whom the patient was referred and, if appropriate, to the facility where future care will be rendered.(h) When the LSRH utilizes an electronic medical records system or other electronic administrative system, which is conformant with the content exchange standard at Code of Federal Regulations Title 45 §170.205(d)(2) (relating to Content Exchange Standards and Implementation Specifications for Exchanging Electronic Health Information), then the LSRH must demonstrate:(1) the system's notification capacity is fully operational and the LSRH uses it in accordance with all state and federal laws and regulations applicable to the LSRH's exchange of patient health information;(2) the system sends notifications that must include at least patient name, treating practitioner name, and sending institution name;(3) to the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, at the time of the patient's registration in the LSRH's emergency department;(4) to the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, either immediately prior to, or at the time the patient's discharge or transfer from the LSRH's emergency department; and(5) the LSRH has made a reasonable effort to ensure the system sends the notifications to all applicable post-acute care services providers and suppliers, as well as to any of the following practitioners and entities, which need to receive notification of the patient's status for treatment, care coordination, or quality improvement purposes:(A) the patient's established primary care practitioner;(B) the patient's established primary care practice group or entity; or(C) other practitioner, or other practice group or entity, identified by the patient as the practitioner, or practice group or entity, primarily responsible for their care.(i) An LSRH shall provide medical records in the form and format requested by the individual or their legally authorized representative, if it is readily producible in such form and format. This includes in an electronic form or format when such medical records are maintained electronically or if not, in a readable hard copy form or such other form and format as agreed to by the LSRH and the individual.(j) An LSRH shall provide records within a reasonable timeframe. The LSRH must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits. Source Note: The provisions of this §511.67 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.67 Medical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215216 03/12/2026 (a) A limited services rural hospital (LSRH) shall develop, adopt, implement, enforce, and maintain a written emergency preparedness plan. The LSRH shall review and update the plan at least every two years. The plan shall:(1) be based on and include a documented, facility-based and community-based risk assessment, using an all-hazards approach;(2) include strategies for addressing emergency events identified by the risk assessment;(3) identify the services the LSRH has the ability to provide in an emergency and include strategies for addressing and serving the patient population;(4) include the use of a Texas Health and Human Services Commission (HHSC)-approved process to update patient station availability as requested by HHSC during a public health emergency or state-declared disaster;(5) include continuity of operations, including delegations of authority and succession plans;(6) include a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation; and(7) incorporate applicable information listed in subsection (e) of this section and the State of Texas Emergency Management Plan. Information regarding the State of Texas Emergency Management Plan is available from the city or county emergency management coordinator.(b) An LSRH shall send the plan, which may be subject to review and approval by HHSC, to the local disaster management authority.(c) The LSRH shall develop the plan through a joint effort of the LSRH governing body, administration, medical staff, LSRH personnel, and emergency medical services partners.(d) An LSRH shall have an effective procedure for obtaining emergency laboratory, radiology, and pharmaceutical services when these services are not immediately available due to system failure.(e) An LSRH shall develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in subsection (a) of this section, risk assessment at subsection (a)(1) of this section, and the communication plan at subsection (f) of this section. The LSRH shall review and update the policies and procedures at least every two years. The policies and procedures shall at least address the following:(1) reception, treatment, and disposition of casualties that can be used if a disaster situation requires the LSRH to accept multiple patients;(2) the process, developed in conjunction with appropriate agencies, for allowing essential health care workers and personnel to safely access their delivery care sites;(3) providing subsistence needs throughout the duration of the response for staff, volunteers, and patients, whether they evacuate or shelter in place, including:(A) food, water, medical and pharmaceutical supplies, personal protection equipment, and appropriate immunizations;(B) alternate sources of power to maintain:(i) temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;(ii) emergency lighting;(iii) fire detection, extinguishing, and alarm systems; and(iv) sewage and waste disposal; and(C) a system to track the location of on-duty staff and sheltered patients in the LSRH's care during an emergency, which also requires the LSRH to document the specific name and location of the receiving facility or other location when on-duty staff or sheltered patients are relocated during the emergency;(4) safe evacuation from the LSRH, which includes the following:(A) activation procedures, including who makes the decision to activate and how it is activated;(B) consideration of care and treatment needs of evacuees;(C) staff responsibilities;(D) plan for the order of removal of patients and planned route of movement;(E) transportation of staff, volunteers, and patients;(F) records and supplies transportation, including the protocol for transferring patient-specific medications and records to the receiving facility, which requires records to include at a minimum:(i) the patient's most recent physician assessment if seen by a physician;(ii) the most recent assessment if the patient was last assessed by a practitioner within the scope of their license and education;(iii) the order sheet;(iv) medication administration record (MAR); and(v) patient history with physical documentation;(G) a weather-proof patient identification wrist band (or equivalent identification) must be intact on all patients;(H) identification of any evacuation locations and destinations, including protocol to ensure the patient destination is compatible to patient acuity and health care needs; and(I) primary and alternate means of communication with external sources of assistance;(5) a means to shelter in place for patients, staff, and volunteers who remain in the LSRH;(6) a system of medical documentation that does the following:(A) preserves patient information;(B) protects confidentiality of patient information; and(C) secures and maintains the availability of records;(7) the use of volunteers in an emergency and other staffing strategies, including the process and role for integration of state and federally designated health care professionals to address surge needs during an emergency; and(8) An LSRH's emergency preparedness policies and procedures shall include the LSRH's role in providing care and treatment at an alternate care site identified by federal and local emergency management officials, in the event of a declared disaster or national emergency in accordance with federal rules, regulations, and associated waivers.(f) An LSRH must develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. The LSRH shall review and update the communication plan at least every two years. The communication plan shall include:(1) names and contact information for:(A) staff;(B) entities providing services under arrangement;(C) patients' physicians; and(D) volunteers;(2) contact information for:(A) federal, state, tribal, regional, and local emergency preparedness staff, including the city and county emergency management officers;(B) the LSRH water supplier; and(C) other sources of assistance;(3) primary and alternate means for communicating with:(A) LSRH staff; and(B) federal, state, tribal, regional, and local emergency management agencies;(4) procedures for notifying each of the following entities, as soon as practicable, regarding the closure or reduction in hours of operation of the LSRH due to an emergency:(A) HHSC;(B) each hospital with which the facility has a transfer agreement in accordance with §511.66 of this subchapter (relating to Patient Transfer Agreements);(C) the trauma service area regional advisory council that serves the geographic area in which the facility is located; and(D) each applicable local emergency management agency;(5) a method for sharing information and medical documentation for patients under the LSRH's care, as necessary, with other health care providers to maintain the continuity of care;(6) a means, in the event of an evacuation, to notify a patient's emergency contact or contacts of an evacuation and the patient's destination and release patient information as permitted under Code of Federal Regulations Title 45 (45 CFR) §164.510(b)(1)(ii) (relating to Uses and Disclosures Requiring an Opportunity for the Individual to Agree or to Object);(7) a means of providing information about the general condition and location of patients under the LSRH's care as permitted under 45 CFR §164.510(b)(4);(8) a means of providing information about the LSRH's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee; and(9) evidence that the LSRH has communicated prospectively with the local utility and phone companies regarding the need for the LSRH to be given priority for the restoration of utility and phone services and a process for testing internal and external communications systems regularly.(g) An LSRH shall post a phone number listing specific to the LSRH equipment and locale to assist staff in contacting mechanical and technical support in the event of an emergency.(h) An LSRH must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in subsection (a) of this section, risk assessment in subsection (a)(1) of this section, policies and procedures in subsection (E) of this section, and the communication plan in subsection (f) of this section. The LSRH shall review and update the training and testing program at least every two years.(1) The LSRH shall:(A) provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles;(B) provide emergency preparedness training at least every two years;(C) maintain documentation of all emergency preparedness training;(D) demonstrate staff knowledge of emergency procedures; and(E) conduct training on the updated policies and procedures if the LSRH significantly updates the emergency preparedness policies and procedures.(2) The LSRH shall conduct exercises to test the emergency plan at least annually. The LSRH shall comply with all of the following requirements.(A) The LSRH shall participate in a full-scale exercise that is community-based every two years.(i) When a community-based exercise is not accessible, the LSRH shall conduct an LSRH-based functional exercise every two years; or(ii) If the LSRH experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LSRH is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the emergency event.(B) The LSRH shall conduct an additional exercise at least every two years, opposite the year the LSRH conducts the full-scale or functional exercise under subparagraph (A) of this paragraph, that may include the following:(i) a second full-scale exercise that is community-based, or an individual, facility-based functional exercise;(ii) a mock disaster drill; or(iii) a tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.(C) The LSRH shall analyze the LSRH's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the LSRH's emergency plan, as needed.(3) An LSRH participating in an exercise or responding to a real-life event shall develop an after-action report (AAR) within 60 days after the exercise or event. The LSRH shall retain an AAR for at least three years and be available for review by the local emergency management authority and HHSC. The LSRH shall revise the LSRH's emergency plan, as needed, in response to the AAR.(i) An LSRH must implement emergency and standby power systems based on the emergency plan set forth in subsection (a) of this section.(1) The generator shall be located in accordance with the location requirements found in the Health Care Facilities Code (National Fire Protection Association (NFPA) 99 and Tentative Interim Amendments (TIA) 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated.(2) The LSRH shall implement emergency power system inspection and testing requirements found in the Health Care Facilities Code, NFPA 110, and the Life Safety Code.(3) An LSRH that maintains an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency unless it evacuates.(j) When an LSRH is part of a health care system consisting of multiple separately certified health care facilities that elects to have a unified and integrated emergency preparedness program, the LSRH may choose to participate in the health care system's coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program shall:(1) demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program;(2) be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered;(3) demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance;(4) include a unified and integrated emergency plan that meets the requirements of this section and include the following:(A) a documented community-based risk assessment, utilizing an all-hazards approach; and(B) a documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach; and(5) include integrated policies and procedures that meet the requirements set forth in subsection (e) of this section, and a coordinated communication plan and training and testing programs that meet the requirements of subsections (f) and (h) of this section, respectively.(k) The following material listed in this subsection is incorporated by reference into this section.(1) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.(2) TIA 12-2 to NFPA 99, issued August 11, 2011.(3) TIA 12-3 to NFPA 99, issued August 9, 2012.(4) TIA 12-4 to NFPA 99, issued March 7, 2013.(5) TIA 12-5 to NFPA 99, issued August 1, 2013.(6) TIA 12-6 to NFPA 99, issued March 3, 2014.(7) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011.(8) TIA 12-1 to NFPA 101, issued August 11, 2011.(9) TIA 12-2 to NFPA 101, issued October 30, 2012.(10) TIA 12-3 to NFPA 101, issued October 22, 2013.(11) TIA 12-4 to NFPA 101, issued October 22, 2013.(12) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009. Source Note: The provisions of this §511.68 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.68 Emergency Preparedness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215217 03/12/2026 When a limited services rural hospital provides skilled nursing facility services, the services shall be provided in a unit that is in a distinct part, according to Code of Federal Regulations Title 42 §485.546 (Relating to Skilled Nursing Facility Distinct Part Unit), that is separately licensed as a nursing facility under Texas Health and Safety Code Chapter 242 (relating to Convalescent and Nursing Facilities and Related Institutions), certified by the Centers for Medicaid & Medicare Services, and comply with the requirements of participation for long-term care facilities specified in the Code of Federal Regulations Title 42 Part 483, Subpart B (relating to Requirements for Long Term Care Facilities). Source Note: The provisions of this §511.69 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.69 Skilled Nursing Facility as a Distinct Unit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215218 03/12/2026 (a) If a limited services rural hospital (LSRH) provides respiratory care as an outpatient service, the services shall meet the needs of the patients in accordance with acceptable standards of practice and shall comply with this section.(b) The LSRH shall adopt, implement, and enforce policies and procedures that describe respiratory care services provision in the LSRH.(c) The LSRH shall provide respiratory care services only on, and in accordance with, a physician's orders.(d) The LSRH shall organize respiratory care services to ensure they are appropriate to the scope and complexity of the services offered.(e) The LSRH shall have a medical director or clinical director of respiratory care services who is a physician with the knowledge, experience, and capabilities to supervise and administer the services properly. The medical director or clinical director may serve on either a full-time or part-time basis.(f) The LSRH shall ensure the LSRH has an adequate number of respiratory therapists, respiratory therapy technicians, and other personnel who meet the qualifications specified by the medical staff, consistent with state law.(g) The LSRH shall designate, in writing, personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures.(h) When respiratory care services staff perform blood gases or other clinical laboratory tests, the respiratory care staff shall comply with the Clinical Laboratory Improvement Amendments of 1988 (CLIA 1988) and the CLIA 1988 regulations at Code of Federal Regulations Title 42 CFR Part 493 (relating to Laboratory Requirements). Source Note: The provisions of this §511.70 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.70 Respiratory Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215219 03/12/2026 (a) A limited services rural hospital (LSRH) shall comply with the requirements set forth by the Texas Commission on Environmental Quality (TCEQ) in Texas Administrative Code Title 30 (30 TAC) Chapter 326 (relating to Medical Waste Management).(b) An LSRH shall dispose of all sewage and liquid wastes in a municipal sewerage system or a septic tank system permitted by TCEQ in accordance with 30 TAC Chapter 285 (relating to On-Site Sewage Facilities).(c) An LSRH shall comply with 25 TAC Chapter 1, Subchapter K (relating to the Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(d) An LSRH shall make waste receptacles conveniently available in all toilet rooms, patient areas, staff work areas, and waiting rooms. The LSRH shall ensure receptacles are routinely emptied of their contents at a central location or locations into closed containers.(e) An LSRH shall properly clean waste receptacles with soap and hot water, followed by treatment of inside surfaces of the receptacles with a germicidal agent.(f) An LSRH shall ensure all containers for other municipal solid waste are leak-resistant, have tight-fitting covers, and are rodent-proof.(g) An LSRH shall ensure non-reusable containers are of suitable strength to minimize animal scavenging or rupture during collection operations. Source Note: The provisions of this §511.71 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.71 Waste and Waste Disposal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215220 03/12/2026 (a) A limited services rural hospital (LSRH) shall provide sufficient clean linen to ensure the patient's comfort.(b) An LSRH, whether it operates its own laundry or uses commercial service, shall ensure the following.(1) LSRH employees involved in transporting, processing, or otherwise handling clean or soiled linen are given initial and follow-up in-service training to ensure a safe product for patients and to safeguard employees in their work.(2) Clean linen is handled, transported, and stored by methods that will ensure its cleanliness.(3) All contaminated linen is placed and transported in bags or containers labeled or color-coded.(4) LSRH employees who have contact with contaminated linen wear gloves and other appropriate personal protective equipment.(5) Contaminated linen is handled as little as possible and with a minimum of agitation and is not sorted or rinsed in patient care areas.(6) All contaminated linen is bagged or put into carts at the location where it was used.(A) Bags containing contaminated linen are closed before transport to the laundry.(B) Whenever contaminated linen is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the linen is deposited and transported in bags that prevent leakage of fluids to the exterior.(C) All linen placed in chutes is bagged.(D) If chutes are not used to convey linen to a central receiving or sorting room, then adequate space is allocated on the various nursing units for holding the bagged contaminated linen.(7) Linen is processed as follows.(A) When using hot water, the LSRH shall wash the linen with detergent in the water with a temperature of at least 71 degrees Centigrade (160 degrees Fahrenheit) for 25 minutes. The LSRH shall meet the hot water requirements specified in Table 5 of §511.169(e) of this chapter (relating to Tables).(B) When using low-temperature (less than or equal to 70 degrees Centigrade) (158 degrees Fahrenheit) laundry cycles, the LSRH shall use chemicals suitable for low-temperature washing at proper use concentration.(C) Commercial dry cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission.(D) The LSRH shall not use flammable liquids to process laundry, but may use flammable liquids for equipment maintenance. Source Note: The provisions of this §511.72 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.72 Linen and Laundry Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215221 03/12/2026 (a) A limited services rural hospital (LSRH) staff qualified by education, training, and experience shall supervise all supplies and equipment sterilization in an LSRH. An LSRH shall ensure:(1) staff responsible for sterilizing supplies and equipment participate in a documented continuing education program;(2) new employees receive initial orientation and on-the-job training; and(3) staff using chemical disinfectants received training on their use.(b) An LSRH shall adopt, implement, and enforce written policies and procedures for performing decontamination and sterilization activities.(1) Policies shall include the receiving, cleaning, decontaminating, disinfecting, preparing, and sterilizing of reusable items, as well as the assembly, wrapping, storage, distribution, and quality control of sterile items and equipment.(2) The infection control program shall review and approve the written policies at least every other year.(c) An LSRH shall provide equipment adequate for supplies and equipment sterilization as needed. The LSRH shall maintain and operate sterilization equipment to accurately sterilize the various materials required for sterilization.(d) Where cleaning, preparation, and sterilization functions are performed in the same room or unit, the physical facilities, equipment, and policies and procedures for their use, shall effectively separate soiled or contaminated supplies and equipment from clean or sterilized supplies and equipment. An LSRH shall provide hand-washing facilities and a separate sink for safe disposal of liquid waste.(e) An LSRH shall clearly label all containers for solutions, drugs, flammable solvents, ether, alcohol, and medicated supplies to indicate contents.(1) Containers sterilized by the LSRH shall be labeled to be identifiable before and after sterilization.(2) Sterilized items shall have a load control identification that indicates the sterilizer used, the cycle or load number, and the date of sterilization.(f) An LSRH shall ensure staff use the appropriate sterilizer, as indicated in the following paragraphs, when sterilizing materials and items. An LSRH shall use:(1) steam sterilizers (saturated steam under pressure) to sterilize heat-and moisture-stable items according to the manufacturer's written instructions;(2) ethylene oxide (EO) sterilizers for processing heat and moisture sensitive items (the LSRH shall use and vent EO sterilizers and aerators according to the manufacturer's written instructions); and(3) flash sterilizers only for emergency sterilization of clean, unwrapped instruments approved by the manufacturer for flash sterilization and according to the manufacturer's written instructions.(g) Before sterilization, an LSRH shall reduce the bioburden by:(1) thoroughly cleaning, decontaminating, and preparing all items in a clean, controlled environment;(2) arranging all articles in preparation for sterilization so all surfaces will be directly exposed to the sterilizing agent for the prescribed time and temperature; and(3) packaging all wrapped articles in preparation for sterilization in materials recommended for the specific type of sterilizer and material to be sterilized.(h) An LSRH shall use external chemical indicators, also known as sterilization process indicators, on each package in preparation for sterilization, including items being flash sterilized to indicate that items have been exposed to the sterilization process.(1) The LSRH shall interpret indicator results according to manufacturer's written instructions and indicator reaction specifications.(2) The LSRH shall maintain a log with the load identification, indicator results, and identification of the contents of the load.(i) An LSRH shall use biological indicators to verify the performance of waste treatment equipment and processes (or sterilization equipment and processes). The LSRH shall:(1) monitor the sterilizing process efficacy using reliable biological indicators appropriate for the type of sterilizer used;(2) include biological indicators in at least one run each week of use for steam sterilizers, at least one run each day of use for low-temperature hydrogen peroxide gas sterilizers, and every load for EO sterilizers;(3) include biological indicators in every load that contains implantable objects;(4) maintain a log with the load identification, biological indicator results, and identification of the contents of the load; and(5) take a sterilizer out of service immediately if a test is positive and shall:(A) recall and reprocess implantable items if a biological indicator test (spore test) is positive;(B) recall and reprocess all available items when a sterilizer malfunction is found and submit a list of those items not retrieved in the recall to infection control; and(C) not put a malfunctioning sterilizer back into use until it has been serviced and successfully tested according to the manufacturer's recommendations.(j) An LSRH shall adopt, implement, and enforce written policies, approved by the infection control program, for the use of chemical disinfectants. The LSRH:(1) shall follow the manufacturer's written instructions for the use of disinfectants;(2) shall mark an expiration date, determined according to manufacturer's written recommendations, on the container of disinfection solution currently in use;(3) shall keep disinfectant solutions covered and used in well-ventilated areas;(4) may use chemical germicides that are registered with the United States Environmental Protection Agency as "sterilants" either for sterilization or high-level disinfection; and(5) shall provide training to all staff and personnel who use chemical disinfectants on their use.(k) The LSRH shall maintain performance records for all sterilizers for each cycle. The LSRH must retain and have these records available for review for at least five years.(l) The LSRH shall continuously monitor each sterilizer during operation for pressure, temperature, and time at desired temperature and pressure. A record shall be maintained and shall include:(1) the sterilizer identification;(2) sterilization date;(3) cycle number;(4) contents of each load;(5) duration and temperature of exposure phase (if not provided on sterilizer recording charts);(6) identification of operators;(7) results of biological tests and dates performed;(8) time-temperature recording charts from each sterilizer;(9) gas concentration and relative humidity (if applicable); and(10) any other test results.(m) An LSRH shall comply with the following requirements for storing sterilized items.(1) The LSRH shall transport sterilized items so as to maintain cleanliness and sterility and to prevent physical damage.(2) The LSRH shall store sterilized items in well-ventilated, limited access areas with controlled temperature and humidity.(3) The LSRH shall adopt, implement and enforce a policy that describes the mechanism used to determine the shelf life of sterilized packages.(n) Qualified personnel shall perform preventive maintenance of all sterilizers according to adopted, implemented, and enforced policy on a scheduled basis, using the sterilizer manufacturer's service manual as a reference. An LSRH shall:(1) maintain a preventive maintenance record for each sterilizer,(2) retain these records for at least two years, and(3) ensure their availability for review at the facility within two hours of request by HHSC. Source Note: The provisions of this §511.73 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.73 Sterilization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215222 03/12/2026 (a) A limited services rural hospital (LSRH) shall follow universal precautions for all patient care activities in accordance with Code of Federal Regulations Title 29 §1910.1030(d)(1)-(3) (relating to Bloodborne Pathogens) and Texas Health and Safety Code Chapter 85, Subchapter I (relating to Prevention of Transmission of HIV and Hepatitis B Virus by Infected Health Care Workers).(b) An LSRH shall develop, implement, and enforce policies and procedures to provide and actively monitor a safe, functional, comfortable, and sanitary environment that minimizes or prevents transmission of infectious diseases for all patients, visitors, and the public.(1) The LSRH shall clean blood spills immediately or as soon as is practical with a disposable cloth and an appropriate chemical disinfectant.(2) The surface shall be subjected to intermediate-level disinfection in accordance with the manufacturer's directions for use, if a commercial liquid chemical disinfectant is used.(3) When a solution of chlorine bleach (sodium hypochlorite) is used, the solution shall be at least 1:100 sodium hypochlorite and mixed in accordance with the manufacturer's directions for use. The surface to be treated shall be compatible with this type of chemical treatment.(4) The LSRH shall use dedicated cleaning supplies (i.e., mop, bucket) for the cleaning of blood spills. Source Note: The provisions of this §511.74 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.74 Sanitary Conditions and Hygienic Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220249 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220249 03/12/2026 (a) A limited services rural hospital (LSRH) shall adopt, implement, and enforce a policy to ensure that the hospital complies with Texas Health and Safety Code (HSC) §311.002.(b) An LSRH shall adopt, implement, and enforce a policy to ensure that the LSRH complies with HSC §311.0025.(c) An LSRH shall comply with the itemized bill requirements under HSC §185.002.(d) An LSRH shall comply with the following balance billing requirements.(1) An LSRH may not violate a law that prohibits the hospital from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) An LSRH shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO (relating to Disclosures by Out-of-Network Providers) to the extent that subchapter applies to the LSRH.(e) A complaint submitted to the Texas Health and Human Services Commission's Complaint and Incident Intake relating to billing must specify the patient for whom the bill was submitted.(1) Upon receiving a complaint warranting an investigation, the Texas Health and Human Services Commission (HHSC) shall send the complaint to the LSRH and request the LSRH to conduct an internal investigation.(2) Within 30 days of the LSRH's receipt of the complaint, the LSRH shall submit to HHSC:(A) a report outlining the LSRH's investigative process;(B) the resolution or conclusions reached by the LSRH with the patient, third party payor, or complainant; and(C) corrections, if any, in the LSRH's policies or protocols that were made as a result of its investigative findings.(3) In addition to the LSRH's internal investigation, HHSC may also conduct an investigation to audit any billing and patient records of the LSRH.(4) HHSC shall inform, in writing, a complainant who identifies him or herself by name and address:(A) of the receipt of the complaint;(B) if the complainant's allegations are potential violations of the Act or this chapter warranting an investigation;(C) whether the complaint will be investigated by HHSC;(D) if the complaint was referred to the LSRH for internal investigation;(E) whether and to whom the complaint will be referred;(F) of the results of the LSRH's investigation and the LSRH's resolution with the complainant; and(G) of HHSC's findings if an on-site audit investigation was conducted.(5) HHSC shall refer investigative reports of billing by health care professionals who have provided improper, unreasonable, or medically or clinically unnecessary treatments or billed for treatments that were not provided to the appropriate licensing agency. Source Note: The provisions of this §511.75 adopted to be effective October 5, 2023, 48 TexReg 5668; amended to be effective August 18, 2024, 49 TexReg 6221. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.75 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215224 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215224 03/12/2026 (a) A limited services rural hospital (LSRH) shall adopt, implement, and enforce written policies and procedures regarding patient visitation rights, including those setting forth any clinically necessary or reasonable restriction or limitation that the LSRH may need to place on such rights and the reasons for the clinical restriction or limitation.(b) An LSRH shall:(1) inform each patient (or support person, where appropriate) of their visitation rights, including any clinical restriction or limitation on such rights, when they are informed of their other rights under §511.63 of this subchapter (relating to Patient's Rights);(2) inform each patient of the LSRH's visitation policy;(3) inform each patient (or support person, where appropriate) of the right, subject to their consent, to receive the visitors whom they designate, including a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and their right to withdraw or deny such consent at any time;(4) not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability;(5) ensure all visitors enjoy full and equal visitation privileges consistent with patient preferences; and(6) record any clinically justified visitation restrictions in the patient's medical record.(c) In accordance with Texas Health and Safety Code (HSC) §260C.002 (relating to In-Person Visitation with Religious Counselor), except as provided by subsections (d) and (e) of this section, an LSRH may not prohibit a patient from receiving in-person visitation with a religious counselor during a public health emergency upon the request of the patient or, if the patient is incapacitated, upon the request of the patient's legally authorized representative, including a family member of the patient.(d) An LSRH may prohibit in-person visitation with a religious counselor during a public health emergency if federal law or a federal agency requires the LSRH to prohibit in-person visitation during that period.(e) To the extent that an LSRH establishes policies and procedures for in-person religious counselor visitation during a public health emergency, these policies and procedures shall comply with the following.(1) The policies and procedures shall establish minimum health and safety requirements for in-person visitation with religious counselors consistent with:(A) state, local, and federal directives and guidance regarding the public health emergency;(B) public health emergency and disaster preparedness plans; and(C) other policies adopted by the LSRH, including the LSRH's general visitation policy and infection control policy.(2) The policies and procedures shall address considerations for patients who are receiving end-of-life care.(3) The policies and procedures may contain reasonable time, place, and manner restrictions on in-person visitation with religious counselors to mitigate the spread of a communicable disease or address a patient's medical condition.(4) The policies and procedures may condition in-person visitation with religious counselors on the counselor's compliance with guidelines, policies, and procedures established under this subsection.(f) In accordance with HSC §241.012 (relating to In-Person Hospital Visitation During Period of Disaster), an LSRH may not, during a qualifying period of disaster prohibit in-person visitation with a patient receiving care or treatment at the LSRH unless federal law or a federal agency requires the LSRH to prohibit in-person visitation during that period.(g) Notwithstanding subsection (f) of this section, an LSRH may, during a qualifying period of disaster:(1) restrict the number of visitors a patient receiving care or treatment at the LSRH may receive to not fewer than one, except for religious counselors visiting under subsection (b) of this section;(2) require a visitor, including a religious counselor visiting under subsection (c) of this section, to:(A) complete a health screening before entering the LSRH; and(B) wear personal protective equipment at all times while visiting a patient at the LSRH; and(3) deny entry to or remove from the LSRH's premises a visitor, including a religious counselor visiting under subsection (c) of this section, who fails or refuses to:(A) submit to or meet the requirements of a health screening administered by the LSRH; or(B) wear personal protective equipment that meets the LSRH's infection control and safety requirements in the manner prescribed by the LSRH.(h) A health screening administered by an LSRH under this section and during a qualifying period of disaster must be conducted in a manner that, at a minimum, complies with:(1) LSRH policy; and(2) if applicable, guidance or directives issued by the Texas Health and Human Services Commission, the Centers for Medicare & Medicaid Services, or another agency with regulatory authority over the LSRH.(i) This section does not require an LSRH to:(1) provide a specific type of personal protective equipment to a visitor, including a religious counselor visiting under subsection (c) of this section; or(2) except for a religious counselor visiting under subsection (c) of this section, allow in-person visitation with a patient receiving care or treatment at the LSRH if an attending physician determines and documents in the patient's medical record that in-person visitation with that patient may lead to the transmission of an infectious agent that poses a serious community health risk during a qualifying period of disaster.(j) A determination made by an attending physician under subsection (h) of this section is valid for not more than five days after the date the determination is made unless renewed by an attending physician.(k) When a visitor to an LSRH is denied in-person visitation with a patient receiving care or treatment at a LSRH because of a determination made by an attending physician under subsection (i)(2) of this section, the LSRH shall:(1) provide each day a written or oral update of the patient's condition to the visitor if the visitor:(A) is authorized by the patient to receive relevant health information regarding the patient;(B) has authority to receive the patient's health information under an advance directive or medical power of attorney; or(C) is otherwise the patient's surrogate decision-maker regarding the patient's health care needs under LSRH policy and other applicable law; and(2) notify the person who receives the daily update required under paragraph (1) of this subsection of the estimated date and time at which the patient will be discharged from the LSRH. Source Note: The provisions of this §511.76 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.76 Patient Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215225 03/12/2026 (a) A limited services rural hospital (LSRH) shall comply with the disclosure and reporting requirements of Texas Health and Safety Code (HSC) Chapter 327 (relating to Disclosure of Prices) as described in this section.(b) An LSRH shall make the information required by HSC Chapter 327 available in a prominent location on the home page of its publicly accessible website or accessible by selecting a dedicated link that is prominently displayed on the home page of its publicly accessible website. If the LSRH operates multiple locations and maintains a single website, the homepage must contain a link to the list containing the links to each location the LSRH operates in a manner that clearly associates the list with the applicable location of the LSRH.(c) Each time an LSRH updates a list as required by HSC §327.003 and §327.004, it shall submit the updated list to the Texas Health and Human Services Commission (HHSC) in the manner specified by HHSC on its website.(d) HHSC has jurisdiction to impose an administrative penalty against a hospital licensed under this chapter for violations of HSC Chapter 327 and this section. An administrative penalty imposed under this section shall be in accordance with the provisions of HSC §327.008. (e) In determining the amount of any penalty sought pursuant to HSC §327.008, HHSC shall consider:(1) previous violations by the hospital's operator;(2) the seriousness of the violation;(3) the demonstrated good faith of the hospital's operator; and(4) any other matters that justice may require.(f) For purposes of calculating any penalty sought pursuant to HSC §327.008, the penalty imposed by HHSC for an LSRH with one of the following total gross revenues, as reported to the Centers for Medicare and Medicaid Services, in the year preceding the year in which a penalty is imposed, may not exceed:(1) $10 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is less than $10,000,000;(2) $100 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is $10,000,000 or more and less than $100,000,000; and(3) $1,000 for each day the hospital violated HSC Chapter 327, if the hospital's total gross revenue is $100,000,000 or more.(g) Each day a violation continues is considered a separate violation.(1) The administrative penalties for each day of a continuing violation cease on the date the violation is corrected. A violation that is the subject of a penalty is presumed to continue on each successive day until it is corrected. The date of correction alleged by the hospital in its written plan of correction or corrective action plan will be presumed to be the actual date of correction, unless HHSC later determines that the correction was not made by that date or was not satisfactory.(2) For continuing violations pursuant to HSC Chapter 327, penalties are cumulative as demonstrated in Figure: 26 TAC §511.77(g)(2)(B). The penalty amount is multiplied by the number of days the violation continues. The penalty amount for each day of the continuing violation is then added to the running total of the previous day's penalties according to the formula in subparagraph (A) of this paragraph.(A) Cumulative administrative penalty = [penalty for each day of violation + (penalty for each day of violation x number of days of violation)]/2 x (number of days of violation).(B) The cumulative amounts are not subject to the per day penalty cap in subsection (f) of this section.Attached Graphic Source Note: The provisions of this §511.77 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.77 Hospital Price Transparency Reporting and Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215226 03/12/2026 (a) All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.(b) A limited services rural hospital (LSRH) may only use restraint or seclusion when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm.(c) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm.(d) The LSRH shall have written policies and procedures regarding the use of restraint and seclusion that are consistent with current standards of practice.(e) An LSRH may only seclude a patient for the management of violent or self-destructive behavior.(f) The patient has the right to safe implementation of restraint or seclusion by trained staff.(1) The LSRH shall provide patient-centered competency-based training and education on the use of restraint and seclusion to LSRH personnel and staff, including medical staff and, as applicable, personnel providing contracted services in the LSRH.(2) The training must include de-escalation techniques and other alternatives to the use of restraint or seclusion.(g) An LSRH shall comply with the restraint and seclusion documentation and reporting requirements under Code of Federal Regulations Title 42 §485.534(g). Source Note: The provisions of this §511.78 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.78 Restraint and Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226329 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226329 03/12/2026 (a) In accordance with Texas Health and Safety Code (HSC) §331.002, an LSRH shall establish a workplace violence prevention committee or authorize an existing LSRH committee to develop a workplace violence prevention plan.(b) An LSRH shall ensure the committee includes at least:(1) one registered nurse who provides direct care to the LSRH's patients;(2) one physician licensed to practice medicine in this state who provides direct care to the LSRH's patients; and(3) one LSRH employee who provides security services for the LSRH if any and if practicable.(c) A health care system that owns or operates more than one facility, as that term is defined by HSC §331.001, which includes an LSRH, may establish a single workplace violence prevention committee for all of the system's facilities if:(1) the committee develops a violence prevention plan for implementation at each facility in the system; and(2) data related to violence prevention remains distinctly identifiable for each facility in the system.(d) An LSRH shall adopt, implement, and enforce a written workplace violence prevention policy to protect health care providers and employees from violent behavior and threats of violent behavior occurring at the LSRH. In accordance with HSC §331.003, the policy shall:(1) require the LSRH to:(A) provide significant consideration of the violence prevention plan recommended by the LSRH's committee; and(B) evaluate any existing LSRH violence prevention plan;(2) encourage health care providers and employees to provide confidential information on workplace violence to the committee;(3) include a process to protect from retaliation health care providers or employees who provide information to the committee; and(4) comply with HHSC rules relating to workplace violence. (e) An LSRH shall adopt, implement, and enforce a written workplace violence prevention plan developed by the committee. In accordance with HSC §331.004, the plan shall:(1) be based on an LSRH setting;(2) adopt a definition of "workplace violence" that includes:(A) an act or threat of physical force against a health care provider or employee that results in, or is likely to result in, physical injury or psychological trauma; and(B) an incident involving the use of a firearm or other dangerous weapon, regardless of whether a health care provider or employee is injured by the weapon;(3) require the LSRH to at least annually provide workplace violence prevention training or education that may be included in other required training or education provided to the health care providers and employees who provide direct patient care;(4) prescribe a system for responding to and investigating violent incidents or potentially violent incidents at the LSRH;(5) address physical security and safety;(6) require the LSRH to solicit information from the health care providers and employees when developing and implementing a workplace violence prevention plan;(7) allow health care providers and employees to report workplace violence incidents through the LSRH's existing occurrence reporting systems; and(8) require the LSRH to adjust patient care assignments, to the extent practicable, to prevent a health care provider or employee from treating or providing services to a patient who has intentionally physically abused or threatened the provider or employee.(f) The written workplace violence prevention plan may satisfy the requirements of subsection (e) of this section by referencing other internal LSRH policies and documents.(g) At least annually after the date an LSRH adopts a written workplace violence prevention plan required by subsection (e) of this section, the committee shall:(1) review and evaluate the workplace violence prevention plan; and(2) report the results of the evaluation to the LSRH's governing body.(h) Each LSRH shall make available on request an electronic or printed copy of the LSRH's workplace violence prevention plan to each health care provider or LSRH employee. If the committee determines the plan contains information that would pose a security threat if made public, the committee may redact that information before providing the plan.(i) In accordance with HSC §331.005, after an incident of workplace violence occurs, an LSRH shall offer immediate post-incident services, including any necessary acute medical treatment for each LSRH health care provider or employee who is directly involved in the incident.(j) In accordance with HSC §331.005, an LSRH may not discourage a health care provider or employee from exercising the provider's or employee's right to contact or file a report with law enforcement regarding a workplace violence incident.(k) In accordance with HSC §331.005, an LSRH shall prohibit LSRH personnel from disciplining, including by suspension or termination of employment, discriminating against, or retaliating against another person who:(1) in good faith reports a workplace violence incident; or(2) advises a health care provider or employee of the provider's or employee's right to report a workplace violence incident. Source Note: The provisions of this §511.79 adopted to be effective October 9, 2025, 50 TexReg 6495. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.79 Workplace Violence Prevention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227742 03/12/2026 A limited services rural hospital shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §511.85 adopted to be effective March 10, 2026, 51 TexReg 1417. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS C OPERATIONAL REQUIREMENTS §511.85 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215227 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215227 03/12/2026 (a) In order to preserve the integrity of the Texas Health and Human Services Commission's (HHSC's) inspection and investigation process, a limited services rural hospital (LSRH):(1) shall not record, listen to, or eavesdrop on any HHSC interview with LSRH staff or patients that the LSRH staff knows HHSC intends to keep confidential as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) shall not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of LSRH staff when HHSC has requested a private room or office or distanced themselves from LSRH staff and the LSRH obtains HHSC written approval before beginning to record or listen to the discussion.(b) An LSRH shall inform HHSC when security cameras or other existing recording devices in the LSRH are in operation during any internal discussion by or among HHSC staff.(c) When HHSC permits facility staff by words or actions to be present, an interview or conversation for which facility staff are present does not constitute a violation of this rule.(d) This section does not prohibit an individual from recording an HHSC interview with the individual. Source Note: The provisions of this §511.111 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.111 Integrity of Inspections and Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215228 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may inspect a limited services rural hospital (LSRH) before issuing or renewing an LSRH license.(1) An LSRH is not subject to additional annual licensing inspections after HHSC issues the initial license while the LSRH maintains:(A) certification under Title XVIII of the Social Security Act, 42 United States Code (USC), §§1395 et seq; or(B) accreditation from The Joint Commission, the American Osteopathic Association, or other national accreditation organization for the offered services.(2) HHSC may inspect an LSRH that is exempt from an annual licensing inspection under paragraph (1) of this subsection before issuing a renewal license to the LSRH if the certification or accreditation body has not conducted an on-site inspection of the LSRH in the preceding three years and HHSC determines an inspection of the LSRH by the certification or accreditation body is not scheduled within 60 days of the license expiration date.(b) HHSC may conduct an unannounced, on-site inspection of an LSRH at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of:(1) any applicable statute or rule;(2) an LSRH's plan of correction;(3) an order or special order of the executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the LSRH.(c) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its LSRHs by HHSC.(d) HHSC inspections to evaluate an LSRH's compliance may include:(1) initial, change of ownership, or relocation inspections, which HHSC may conduct when issuing a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or patient station numbers;(3) routine inspections, which HHSC may conduct without notice and at HHSC's discretion, or before HHSC renews an LSRH license;(4) follow-up on-site inspections, which HHSC may conduct to evaluate implementation of a plan of correction for previously cited deficiencies;(5) inspections to determine whether an unlicensed LSRH is offering or providing, or purporting to offer or provide, treatment or services; and(6) entry in conjunction with any other federal, state, or local agency's entry.(e) An LSRH shall cooperate with any HHSC inspection and shall permit HHSC to examine the LSRH's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the LSRH.(f) An LSRH shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(g) An LSRH shall permit HHSC to inspect and copy any requested information, unless prohibited by law.(h) HHSC shall maintain the confidentiality of LSRH records as applicable under state or federal law. All information and materials obtained or compiled by HHSC in connection with an inspection are confidential and not subject to disclosure under Texas Government Code Chapter 552 (relating to Public Information), and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the LSRH;(2) the LSRH that is the subject of the enforcement action, or the LSRH's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate LSRH services;(4) law enforcement agencies; and(5) persons engaged in bona fide research, if all individual-identifying and LSRH-identifying information has been deleted.(i) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552:(1) a notice of alleged violation against the LSRH, which notice shall include the provisions of law that the LSRH is alleged to have violated, and a general statement of the nature of the alleged violation;(2) the pleadings in the administrative proceeding;(3) a final decision or order by HHSC; and(4) any other information required by law to be disclosed under public information request laws. Source Note: The provisions of this §511.112 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.112 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215229 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215229 03/12/2026 (a) A limited services rural hospital (LSRH) shall provide each patient and applicable consenter at the time of admission with a written statement identifying the Texas Health and Human Services Commission (HHSC) as the agency responsible for investigating complaints against the LSRH.(1) The statement shall inform persons that they may direct a complaint to HHSC's Complaint and Incident Intake (CII) and include current CII contact information, as specified by HHSC.(2) The LSRH shall prominently and conspicuously post this information in each patient common area, visitor area, and waiting room so that it is readily visible to patients, employees, and visitors. The information shall be in English and in a second language appropriate to the demographic makeup of the community served.(b) HHSC evaluates all complaints. A person must submit a complaint using HHSC's current CII contact information for complaint submission, as described in subsection (a) of this section.(c) HHSC documents, evaluates, and prioritizes complaints based on the seriousness of the alleged violation and the level of risk to patients, personnel, and the public.(1) HHSC may investigate allegations determined to be within HHSC's regulatory jurisdiction relating to LSRH's under this chapter.(2) HHSC may refer complaints outside HHSC's jurisdiction to an appropriate agency, as applicable.(d) HHSC shall conduct an investigation to evaluate an LSRH's compliance following a complaint of abuse, neglect, or exploitation; or a complaint related to the health and safety of patients. HHSC may coordinate complaint investigations with the federal Centers for Medicare & Medicaid Services and its agents responsible for surveying LSRHs to determine compliance with the conditions of participation under Title XVIII of the Social Security Act, (42 USC, §§1395 et seq), to avoid duplicate investigations.(e) HHSC may conduct an unannounced, on-site investigation of an LSRH at any reasonable time, including when treatment services are provided, to inspect or investigate:(1) an LSRH's compliance with any applicable statute or rule;(2) an LSRH's plan of correction;(3) an LSRH's compliance with an order of the executive commissioner or the executive commissioner's designee;(4) an LSRH's compliance with a court order granting injunctive relief; or(5) for other purposes relating to regulation of the LSRH.(f) An applicant or licensee, by applying for or holding a license, consents to entry and investigation of any of its LSRHs by HHSC.(g) An LSRH shall cooperate with any HHSC investigation and shall permit HHSC to examine the LSRH's grounds, buildings, books, records, video surveillance, and other documents and information maintained by, or on behalf of, the LSRH.(h) An LSRH shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(i) An LSRH shall permit HHSC to inspect and copy any requested information. If it is necessary for HHSC to remove documents or other records from the LSRH, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(j) HHSC shall maintain the confidentiality of LSRH records as applicable under state or federal law. All information and materials obtained or compiled by HHSC in connection with an investigation are confidential and not subject to disclosure under Texas Government Code Chapter 552 (relating to Public Information), and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the LSRH;(2) the LSRH that is the subject of the enforcement action, or the LSRH's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate LSRH services;(4) law enforcement agencies; and(5) persons engaged in bona fide research, if all individual-identifying and LSRH-identifying information has been deleted.(k) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552:(1) a notice of alleged violation against the LSRH, which notice shall include the provisions of law that the LSRH is alleged to have violated, and a general statement of the nature of the alleged violation;(2) the pleadings in the administrative proceeding;(3) a final decision or order by HHSC; and(4) any other information required by law to be disclosed under public information request laws.(l) On entry, HHSC holds an entrance conference with the LSRH's designated representative to explain the nature, scope, and estimated duration of the investigation.(m) HHSC holds an exit conference with the LSRH representative to inform the LSRH representative of any preliminary findings of the investigation. The LSRH may provide any final documentation regarding compliance during the exit conference.(n) Once HHSC completes an investigation, HHSC reviews the evidence from the investigation to evaluate whether there is a preponderance of evidence supporting the allegations contained in the complaint. Source Note: The provisions of this §511.113 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.113 Complaint Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215230 03/12/2026 (a) A limited service rural hospital (LSRH) is deemed to have received any Texas Health and Human Services Commission (HHSC) correspondence on the date of receipt, or three business days after sending, whichever is earlier.(b) When deficiencies are found:(1) HHSC sends the LSRH a written Statement of Deficiencies (SOD) within 10 business days after the exit conference by U.S. Postal Service or electronic mail.(2) Within 10 calendar days after the LSRH receives the SOD, the LSRH shall return a written Plan of Correction (POC) to HHSC that addresses each cited deficiency, including timeframes for corrections, with any additional evidence of compliance.(A) HHSC determines if a POC and proposed timeframes are acceptable, and, if accepted, notifies the LSRH in writing.(B) If HHSC does not accept the POC, HHSC notifies the LSRH, in writing, and requests the LSRH submit a modified POC and any additional evidence no later than 10 business days after HHSC notifies the LSRH in writing.(C) The LSRH shall correct the identified deficiencies and submit evidence to HHSC verifying the LSRH implemented all corrective actions within the timeframes set forth in the POC, or as otherwise specified by HHSC.(3) Regardless of the LSRH's compliance with this subsection or HHSC's acceptance of an LSRH's POC, HHSC may, at any time, propose to take enforcement action as appropriate under this chapter in accordance with §511.121 of this chapter (relating Enforcement). Source Note: The provisions of this §511.114 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.114 Notice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215231 03/12/2026 In addition to any enforcement action under this chapter, the Texas Health and Human Services Commission refers, in writing, any issue or complaint relating to the conduct of a licensed professional, intern, or applicant for professional licensure to the appropriate licensing board. Source Note: The provisions of this §511.115 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.115 Professional Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215232 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215232 03/12/2026 (a) A limited services rural hospital (LSRH) may register a complaint against a Texas Health and Human Services Commission (HHSC) representative who conducts an inspection or investigation under this subchapter by contacting the HHSC Health Facility Compliance Regional Director for the region in which the LSRH is located.(b) HHSC shall register all complaints against an HHSC representative with HHSC leadership. Source Note: The provisions of this §511.116 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS D INSPECTIONS AND INVESTIGATIONS §511.116 Complaint Against an HHSC Representative https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215233 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215233 03/12/2026 (a) Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, or orders.(b) HHSC has jurisdiction to enforce violations of Texas Health and Safety Code (HSC) Chapter 241 (relating to Hospitals) and this chapter. HHSC may deny, suspend, or revoke a license or impose an administrative penalty on a limited services rural hospital (LSRH) for the following reasons:(1) failure to comply with any applicable provision of the HSC, including Chapters 241, 311 (relating to Powers and Duties of Hospitals), and 327 (relating to Disclosure of Prices);(2) failure to comply with any provision of this chapter or any other applicable laws;(3) the LSRH, or any of its employees, commits an act which causes actual harm or risk of harm to the health or safety of a patient;(4) the LSRH, or any of its employees, materially alters any license issued by HHSC;(5) failure to comply with minimum standards for licensure;(6) failure to provide a complete license application;(7) failure to comply with an order of the executive commissioner or another enforcement procedure under HSC Chapters 241, 311, or 327;(8) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights that reflects more than nominal noncompliance;(9) the LSRH has aided, committed, abetted or permitted the commission of an illegal act;(10) the LSRH, or any of its employees, commits fraud, misrepresentation, or concealment of a material fact on any documents an LSRH is required to submit to HHSC or required to maintain pursuant to HSC Chapter 241, 311, or 327, and the provisions of this chapter;(11) failure to comply with other state and federal laws affecting the health, safety, and rights of LSRH patients;(12) failure to timely pay an assessed administrative penalty as required by HHSC;(13) failure to submit an acceptable plan of correction (POC) for cited deficiencies within the timeframe required by HHSC;(14) failure to timely implement POCs for deficiencies cited by HHSC within the dates designated in the POC;(15) failure to comply with applicable requirements within a designated probation period; or(16) if the LSRH is participating under Title XVIII and the Centers for Medicare & Medicaid Services terminates the LSRH's Medicare provider agreement.(c) HHSC has jurisdiction to enforce violations of HSC Chapters 241, 311, and 327 and this chapter. HHSC may deny a license if the applicant:(1) fails to provide timely and sufficient information required by HHSC that is directly related to the application;(2) has had the following actions taken against the applicant within the two-year period preceding the application:(A) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;(B) federal Medicare or state Medicaid sanctions or penalties;(C) unsatisfied federal or state tax liens;(D) unsatisfied final judgments;(E) eviction involving any property or space used as an LSRH or health care facility in any state;(F) unresolved federal Medicare or state Medicaid audit exceptions;(G) denial, suspension, or revocation of an LSRH license, a private psychiatric hospital license, or a license for any health care facility in any state; or(H) a court injunction prohibiting ownership or operation of an LSRH.(d) Following notice and opportunity for hearing, the executive commissioner of HHSC or a person designated by the executive commissioner may issue an emergency order in relation to the operation of an LSRH licensed under this chapter if the executive commissioner or the executive commissioner's designee determines that the LSRH is violating this chapter, a rule adopted pursuant to this chapter, a special license provision, injunctive relief, an order of the executive commissioner or the executive commissioner's designee, or another enforcement procedure permitted under this chapter and the provision, rule, license provision, injunctive relief, order, or enforcement procedure relates to the health or safety of the LSRH's patients.(1) HHSC shall send written notice of the hearing and shall include within the notice the time and place of the hearing. The hearing must be held within 10 days after the date of the LSRH's receipt of the notice.(2) The hearing shall be held in accordance with HHSC's informal hearing rules.(3) The order shall be effective on delivery to the LSRH or at a later date specified in the order.(e) In lieu of denying, suspending, or revoking the license, HHSC may place the LSRH on probation for a period of not less than 30 days, if the LSRH is found in repeated noncompliance with these rules or HSC Chapter 241 and the LSRH's noncompliance does not endanger the health and safety of the public.(1) HHSC shall provide notice to the LSRH of the probation and of the items of noncompliance not later than the 10th day before the probation period begins.(2) During the probation period, the LSRH must correct the items that were in noncompliance and report the corrections to HHSC for approval.(3) HHSC has jurisdiction to impose an administrative penalty against an LSRH licensed or regulated under this chapter for violations of HSC Chapters 241, 311, and 327 and this chapter. The imposition of an administrative penalty shall be in accordance with the provisions of HSC §241.059 (relating to Administrative Penalty), §241.060 (relating to Administrative Penalty for Mental Health, Chemical Dependency, or Rehabilitation Services), and §327.008 (relating to Administrative Penalty).(f) HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of an LSRH. HHSC shall apply the requirements of Texas Occupations Code Chapter 53 (relating to Consequences of Criminal Conviction).(1) HHSC is entitled under Texas Government Code Chapter 411 (relating to Department of Public Safety of the State of Texas) to obtain criminal history information maintained by the Texas Department of Public Safety, the Federal Bureau of Investigation, or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.(2) The following felonies and misdemeanors directly relate because these criminal offenses indicate an inability or a tendency for the person to be unable to own or operate an LSRH:(A) a misdemeanor violation of HSC Chapter 241;(B) a misdemeanor or felony involving moral turpitude;(C) a misdemeanor or felony relating to deceptive business practices;(D) a misdemeanor or felony of practicing any health-related profession without a required license;(E) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;(F) a misdemeanor or felony under the Texas Penal Code (TPC) Title 5, involving a patient or a client of any health care facility, a home and community support services agency, or a health care professional; or(G) a misdemeanor or felony under the TPC:(i) Title 4, relating to offenses of attempting or conspiring to commit any of the offenses in this clause;(ii) Title 5, relating to offenses against the person;(iii) Title 7, relating to offenses against property;(iv) Title 8, relating to offenses against public administration;(v) Title 9, relating to offenses against public order and decency;(vi) Title 10, relating to offenses against public health, safety and morals; or(vii) Title 11, relating to offenses involving organized crime.(g) Offenses listed in subsection (f)(2) of this section are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign, or military jurisdictions that indicate an inability or tendency for the person or entity to be unable to own or operate an LSRH.(h) HHSC shall revoke a license on the licensee's conviction of a felony or revocation of community supervision.(i) If HHSC proposes to deny, suspend or revoke a license, place on probation, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC. The notice to deny, suspend, or revoke a license, place on probation, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.(j) Within 20 calendar days after receipt of the notice, the applicant or licensee may notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing. Receipt of the notice is presumed to occur on the third day after the date the notice is mailed by HHSC to the last known address of the applicant or licensee.(k) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001 and Texas Administrative Code Title 1 Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act).(l) If the applicant or licensee fails to timely respond to the notice or does not request a hearing, in writing, within 30 calendar days after receipt of the notice, HHSC shall refer the matter to the State Office of Administrative Hearings.(m) HHSC shall send the licensee or applicant a copy of HHSC's decision for denial, suspension, or revocation of license or imposition of an administrative penalty by certified mail, which shall include the findings of fact and conclusions of law on which HHSC based its decision.(n) On HHSC's determination to suspend or revoke a license, the license holder may not admit new patients until the license is reissued.(o) When HHSC's decision to suspend or revoke a license is final, the licensee shall immediately cease operation, unless a stay of such action is issued by the district court.(p) On suspension, revocation, or non-renewal of the license, the original license shall be returned to HHSC within 30 calendar days of HHSC's notification.(q) One year after HHSC's decision to deny or revoke, or the voluntary surrender of a license by an LSRH while enforcement action is pending, an LSRH may petition HHSC, in writing, for a license. Expiration of a license prior to HHSC's decision becoming final shall not affect the one-year waiting period required before a petition may be submitted.(1) HHSC may allow a reapplication for licensure if there is proof that the reasons for the original action no longer exist.(2) HHSC may deny reapplication for licensure if HHSC determines that:(A) the reasons for the original action continues;(B) the petitioner has failed to offer sufficient proof that conditions have changed; or(C) the petitioner has demonstrated a repeated history of failure to provide patients a safe environment or has violated patient rights.(3) If HHSC allows a reapplication for licensure, the petitioner shall be required to meet the requirements as described in §511.12 of this chapter (relating to Application and Issuance of Initial License).(r) An LSRH whose license expires during a suspension period may not reapply for license renewal until the end of the suspension period.(s) In the event that enforcement, as defined in this subsection, is pending or reasonably imminent, the surrender of an LSRH license shall not deprive HHSC of jurisdiction in regard to enforcement against the LSRH. Source Note: The provisions of this §511.121 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS E ENFORCEMENT §511.121 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215234 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215234 03/12/2026 (a) Fire inspections.(1) Annual inspection. A limited services rural hospital (LSRH) shall obtain approval of the fire protection of the LSRH by an individual certified by the Texas Commission on Fire Protection as a prerequisite for licensure.(2) Hazardous or dangerous conditions or materials. Whenever any of the officers, members, or inspectors of the Texas Commission on Fire Protection find in any building or upon any premises dangerous or hazardous conditions or materials, removal or remedy of dangerous conditions or materials shall be carried out in a manner specified by the head of the local fire department.(3) Access for inspection. At all reasonable hours, the LSRH shall allow the chief of the fire department, the chief of the bureau of fire prevention, or any of the fire inspectors to enter any LSRH building or premises for the purpose of making an inspection or investigation that may be deemed necessary under the provisions of these rules.(b) Fire reporting. All occurrences of fire shall be reported, in writing, to the Texas Health and Human Services Commission (HHSC) as soon as possible but not later than 10 calendar days after the occurrence.(c) Fire protection. Fire protection shall be provided in accordance with the requirements of National Fire Protection Association 101, Life Safety Code, 2012 edition (NFPA 101), §18.7, §511.161(a)(1) of this chapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located), and §511.162(a)(1) and (d) of this chapter (relating to General Construction Requirements). Sprinkler systems for exterior fire exposures shall comply with NFPA 80A, Recommended Practice for Protection of Buildings from Exterior Fire Exposures, 2001 edition.(d) Smoking rules. Each LSRH shall adopt, implement, and enforce a smoking policy. The policy shall include the minimal provisions of NFPA 101 §18.7.4.(e) Fire extinguishing systems. An LSRH shall conduct inspection, testing, and maintenance of fire-fighting equipment.(1) Water-based fire protection systems. All fire sprinkler systems, fire pumps, fire standpipe and hose systems, water storage tanks and valves, and fire department connections shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 2011 edition.(2) Range hood extinguishers. Fire extinguishing systems for commercial cooking equipment, such as at range hoods, shall be inspected and maintained in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Cooking Operations, 2011 edition.(3) Portable fire extinguishers. Every portable fire extinguisher located in an LSRH or on LSRH property shall be installed, tagged, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition.(f) Fire protection and evacuation plan. A plan for the protection of patients in the event of fire and their evacuation from the building when necessary shall be formulated according to NFPA 101, §18.7. Copies of the plan shall be available to all staff.(1) Posting requirements. An evacuation floor plan shall be prominently and conspicuously posted for display throughout the LSRH in public areas that are readily visible to patients, residents, employees, and visitors.(2) Annual training. The LSRH shall conduct an annual training program for instruction of all personnel in the LSRH location and use of fire-fighting equipment. All employees shall be instructed regarding their duties under the fire protection and evacuation plan.(g) Fire drills. An LSRH shall conduct at least 12 fire drills each year, one fire drill per shift per quarter, which shall include communication of alarms, simulation of evacuation of patients and other occupants, and use of fire-fighting equipment.(h) Fire alarm system. Every LSRH and building used for patient care shall have an approved fire alarm system. Each fire alarm system shall be installed and tested in accordance with §511.161(a)(1)(A) of this chapter for existing hospitals, and §511.162(d)(5)(N) of this chapter for new construction.(i) System for communicating an alarm of fire. A reliable communication system shall be provided as a means of reporting a fire to the fire department. This is in addition to the automatic alarm transmission to the fire department required by NFPA 101, §18.3.4.3.2.(j) Fire department access. As an aid to fire department services, an LSRH shall provide the following.(1) Driveways. The LSRH shall maintain driveways, free from all obstructions, to main buildings for fire department apparatus use.(2) Submission of plans. Upon request, the LSRH shall submit a copy of the floor plans of the building to the local fire department officials.(3) Outside identification. The LSRH shall place proper identification on the outside of the main building showing the locations of siamese connections and standpipes as required by the local fire department services.(k) Fire department protection. When an LSRH is located outside of the service area or range of the public fire protection, arrangements shall be made to have the nearest fire department respond in case of a fire. Source Note: The provisions of this §511.141 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS F FIRE PREVENTION AND SAFETY §511.141 Fire Prevention and Protection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215235 03/12/2026 (a) Safety committee. A limited services rural hospital (LSRH) shall have a multidisciplinary safety committee. The LSRH chief executive officer (CEO) shall appoint the chairman and members of the safety committee.(1) Safety officer. The CEO shall appoint a safety officer who is knowledgeable in safety practices in health care facilities. The safety officer shall be a member of the safety committee, and shall carry out the functions of the safety program.(2) Safety committee meetings. The safety committee shall meet as required by the chairman, but not less than quarterly. The committee shall retain written minutes for each meeting for at least one year.(3) Safety activities.(A) Incident reports. The safety committee shall establish an incident reporting system that includes a mechanism to ensure that all incidents recorded in safety committee minutes are evaluated, and documentation is provided to show follow-up and corrective actions.(B) Safety policies and procedures. Safety policies and procedures for each department or service shall be developed, implemented, and enforced.(C) Safety training and continuing education. Safety training shall be established as part of new employee orientation and in the continuing education of all employees.(4) Written authority. The authority of the safety committee to take action when conditions exist that are a possible threat to life, health, or building damage, shall be defined, in writing, and approved by the governing body.(b) Safety manual. Each department or service shall have a safety policy and procedure manual within their own area that becomes a part of the overall facility safety manual.(c) Emergency communication system. An emergency communication system shall be provided in each facility. The system shall be self-sufficient and capable of operating without reliance on the building's service or emergency power supply. Such system shall have the capability of communicating with the available community or state emergency networks, including police and fire departments. Source Note: The provisions of this §511.142 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS F FIRE PREVENTION AND SAFETY §511.142 General Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215236 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215236 03/12/2026 (a) Flammable germicides. If flammable germicides, including alcohol-based products, are used for preoperative surgical skin preparation in a limited services rural hospital (LSRH), the LSRH must:(1) use only self-contained, single-use, pre-measured applicators to apply the surgical skin preparations;(2) follow all manufacturer product safety warnings and guidelines;(3) develop, implement, and enforce written policies and procedures outlining the safety precautions required related to the use of the products, which, at a minimum, must include minimum drying times, prevention and management of product pooling, parameters related to draping and the use of ignition sources, staff responsibilities related to ensuring safe use of the product, and documentation requirements sufficient to evaluate compliance with the written policies and procedures;(4) ensure that all staff working in the surgical environment where flammable surgical skin preparation products are in use have received training on product safety and the facility policies and procedures related to the use of the product;(5) develop, implement, and enforce an interdisciplinary team process for the investigation and analysis of all surgical suite fires and alleged violations of the policies; and(6) report all occurrences of surgical suite fires to the Texas Health and Human Services Commission as soon as possible but not later than 10 calendar days after the occurrence, and complete an investigation of the occurrence and develop and implement a corrective action plan within 30 days after a surgical suite fire.(b) Flammable and nonflammable gases and liquids. Flammability of liquids and gases shall be determined by National Fire Protection Association (NFPA) 329, Recommended Practice for Handling Releases of Flammable and Combustible Liquids and Gases, 2010 edition.(1) Nonflammable gases (examples including oxygen and nitrous oxide) shall be stored and distributed in accordance with Chapter 5 of the NFPA 99, Standard for Health Care Facilities, 2012 edition.(A) Medical gases and liquefied medical gases shall be handled in accordance with the requirements of NFPA 99 Chapter 9.(B) Oxygen shall be administered in accordance with NFPA 99 §9.6.(2) Piped flammable gas systems intended for use in laboratories and piping systems for fuel gases shall comply with requirements of NFPA 99 §11.11.(3) Flammable gases shall be stored in accordance with NFPA 99 §11.10.(4) Flammable and combustible liquids used in laboratories shall be handled and stored in accordance with NFPA 99 §11.7, and National Fire Protection Association 101, Life Safety Code, 2012 edition, §18.3.2.2.(5) Other flammable agents shall be stored in accordance with NFPA 99 Chapter 7.(c) Gasoline and gasoline powered equipment. No motor vehicles including gasoline powered standby generators or any amount of gasoline shall be located within the LSRH building. Other devices that may cause or communicate fire, and that are not necessary for patient treatment or care, shall not be stored within the LSRH building. All such devices and materials when necessary shall be used within the building only with precautions ensuring a reasonable degree of safety from fire.(d) Gas-fired appliances. The installation, use, and maintenance of gas-fired appliances and gas piping installations shall comply with the National Fire Protection Association 54, National Fuel Gas Code, 2012 edition. The use of portable gas heaters and unvented open flame heaters is specifically prohibited. Source Note: The provisions of this §511.143 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS F FIRE PREVENTION AND SAFETY §511.143 Handling and Storage of Gases, Anesthetics, and Flammable Liquids https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215237 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215237 03/12/2026 (a) Compliance. All buildings in which existing hospitals licensed by the Texas Health and Human Services Commission (HHSC) are located shall comply with this subsection. This chapter shall not be applied retroactively to an operating hospital holding an active HHSC facility license before the effective date of this chapter that complies with the occupancy requirements in National Fire Protection Association 101, Life Safety Code, (NFPA 101), the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and the hospital licensing rules under which the buildings or sections of buildings were constructed.(1) Minimum fire safety and construction requirements.(A) Code requirements. A limited services rural hospital (LSRH) shall meet the requirements for health care occupancies contained in the 1967, 1973, 1981, 1985, 1991, 1997, 2000, 2003, or 2010 editions of the NFPA 101, Life Safety Code, the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and the hospital licensing rules under which the buildings or sections of buildings were constructed.(B) Existing construction requirements. Existing LSRHs or portions of existing LSRHs constructed before the adoption of any of the editions of NFPA 101, the Hospital Licensing Standards, and the hospital licensing rules listed in subparagraph (A) of this paragraph, shall comply with this section and Chapter 19, NFPA 101, 2012 edition.(2) Remodeling. All requirements listed in this chapter are applicable to renovations, additions and alterations unless stated otherwise.(A) Alteration or installation of new equipment. Any alteration or any installation of new equipment shall be accomplished as nearly as practicable with the subchapter requirements, except that when existing conditions make changes impractical to accomplish, minor deviations from functional requirements may be permitted if the intent of the requirements is met and if the care and safety of patients will not be jeopardized.(B) Installation, alteration, or extension approval. No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system may be replaced, materially altered or extended, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to HHSC, reviewed and approved in accordance with §511.167 of this subchapter (relating to Preparation, Submittal, Review, and Approval of Plans, and Retention of Records).(C) Minor remodeling or alterations. All remodeling or alterations that do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g., modifications to the fire, smoke, and corridor walls), add or subtract services for which the LSRH is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing, with a brief description of the proposed changes in accordance with §511.167(f)(3) of this subchapter.(D) Major remodeling or alterations. Plans shall be submitted in accordance with §511.167 of this subchapter for all major remodeling or alterations. All remodeling or alterations that involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g., modifications to the fire, smoke, and corridor walls), or add services over those for which the LSRH is licensed are considered as major remodeling and alterations.(E) Phasing of construction in existing facilities.(i) Projects involving alterations of and additions to existing buildings shall be programmed and phased so that on-site construction will minimize disruptions of existing functions.(ii) Access, exit access, and fire protection shall be maintained so that the safety of the occupants will not be jeopardized during construction.(iii) A noncombustible or limited combustible dust and vapor barrier shall be provided to separate areas undergoing demolition and construction from occupied areas. When a fire retardant plastic material is used for temporary daily usage, it shall be removed at the end of each day.(iv) The air inside the construction area shall be protected by mechanical filtration that recirculates inside the space or is exhausted directly to the exterior.(v) The area shall be properly ventilated and maintained. The area under construction shall have a negative air pressure differential to the adjoining areas and shall continue to operate as long as construction dust and odors are present.(vi) Temporary sound barriers shall be provided where intense prolonged construction noises will disturb patients or staff in the occupied portions of the building.(F) Nonconforming conditions. When doing renovation work, if it is found to be infeasible to correct all of the nonconforming conditions in the existing LSRH in accordance with these rules, HHSC may grant a conditional approval if the operation of the LSRH, Americans with Disabilities Act accessibility requirements, and safety of the patients are not jeopardized by the nonconforming condition.(b) Previously licensed hospitals. Buildings that have been licensed previously as general hospitals, special hospitals, or LSRHs but have been vacated or used for purposes other than as general hospitals, special hospitals, or LSRHs and that are not in compliance with the 1967, 1973, 1981, 1985, 1991, 1997, 2000, 2003, or 2010 editions of the NFPA 101, the Hospital Licensing Standards/Rules (1969, 1985, or 1998 editions as amended), and hospital licensing rules under which the building or sections of buildings were constructed shall comply with the requirements of §511.162 of this subchapter (relating to General Construction Requirements), §511.163 of this subchapter (relating to Spatial Requirements), §511.165 of this subchapter (relating to Building with Multiple Occupancies), §511.167 of this subchapter, and §511.168 of this subchapter (relating to Construction, Inspections, and Approval of Project).(c) Service removal. Where removal of a patient care service occurs in a patient care bedroom, patient treatment room, patient diagnostic room, patient therapy room, or any other similar location where patient services are provided and the area does not hold an Architectural Review Unit application number, the following systems and furnishing shall be removed from that room, rooms, or unit affected:(1) access to the nurse call system equipment, including nurse call activation devises, and dome lights;(2) access to the medical gases;(3) access to cubicle curtains and cubicle curtain tracks; and(4) access to patient reading lights. Source Note: The provisions of this §511.161 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.161 Requirements for Buildings in Which Existing Licensed Hospitals Are Located https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215238 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215238 03/12/2026 (a) Location. Any proposed limited services rural hospital (LSRH) shall be easily accessible to the community and to service vehicles such as delivery trucks, ambulances, and fire protection apparatus. No building may be converted for use as an LSRH which, because of its location, physical condition, state of repair, or arrangement of facilities, would be hazardous to the health and safety of the patients.(1) Hazardous locations.(A) Underground and above ground hazards. New LSRHs or additions to existing LSRHs shall not be constructed within 150 feet of easement boundaries or setbacks of hazardous underground locations including liquid butane or propane, liquid petroleum or natural gas transmission lines, high pressure lines, and not within the easement of high voltage electrical lines.(B) Fire hazards. New LSRHs and additions to existing LSRHs shall not be built within 300 feet of above ground or underground storage tanks containing liquid petroleum or other flammable liquids used in connection with a bulk plant, marine terminal, aircraft refueling, bottling plant of a liquefied petroleum gas installation, or near other hazardous or hazard producing plants.(2) Undesirable locations.(A) Nuisance producing sites. New LSRHs shall not be located near nuisance producing industrial sites, feed lots, sanitary landfills, or manufacturing plants producing excessive noise or air pollution.(B) Cemeteries. New LSRHs shall not be located near a cemetery in a manner that allows direct view of the cemetery from patient windows.(C) Flood plains.(i) Previously licensed eligible general or special hospital. An existing building or a portion of an existing building located in a designated 100-year flood plain that was previously licensed as a general or special hospital but has been vacated or used for purposes other than a hospital, will not be licensed as an LSRH.(ii) Existing LSRH. Access and required functional LSRH components shall be constructed above the designated flood plain in a new addition to an existing LSRH located in a designated 100-year flood plain.(D) Airports. Construction of new LSRHs shall be avoided in close proximity to airports. When LSRHs are proposed to be located near airports, recommendations of the Texas Aviation Authority and the Federal Aviation Authority shall apply. An LSRH may not be constructed within a rectangular area formed by lines perpendicular to and two miles (10,560 feet) from each end of any runway and by lines parallel to and one-half mile (2,640 feet) from each side of any runway.(b) Environmental considerations. Development of an LSRH site and LSRH construction shall be governed by state and local regulations and requirements with respect to the effect of noise and traffic on the community and the environmental impact on air and water.(c) LSRH site.(1) Paved roads and walkways. Paved roads shall be provided within the lot lines to provide access from public roads to the main entrance, emergency entrance, entrances serving community activities, and to service entrances, including loading and unloading docks for delivery trucks.(A) Emergency entrance. An LSRH shall have its emergency entrance well-marked to facilitate entry from the public roads or streets serving the site.(B) Access to emergency department. Access to the emergency entrance shall not conflict with other vehicular traffic or pedestrian traffic and shall be located so as not to be compromised by floods.(C) Pedestrian traffic. Finished surface walkways shall be provided for pedestrians.(2) Parking. Off-street parking shall be available for visitors, employees, and staff. Parking structures directly accessible from an LSRH shall be separated with two-hour fire rated noncombustible construction. When used as required means of egress for LSRH occupants, parking structures shall comply with National Fire Protection Association (NFPA) 88A, Standard for Parking Structures, 2011 edition. This requirement does not apply to freestanding parking structures.(A) Number of parking places. In the absence of a formal parking study, one parking space shall be provided for each day shift employee plus one space for each patient station. This ratio may be reduced in an area convenient to a public transportation system or to public parking facilities on the basis of a formal parking study. Parking facilities shall be increased accordingly when the size of existing facilities is increased.(B) Additional parking. Additional parking shall be required to accommodate medical staff, outpatient and other services when such services are provided.(C) Emergency and delivery parking. Separate parking facilities shall be provided for ambulances and delivery vehicles.(d) Building design and construction requirements. Every building and every portion thereof shall be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards and the local governing building codes. Where there is no local governing building code, the LSRH shall be constructed in accordance with the International Building Code, 2003 edition.(1) General architectural requirements. All new construction, including conversion of an existing building to an LSRH, and establishing a separately licensed LSRH in a building with an existing licensed LSRH, shall comply with Chapter 18 of the NFPA 101, Life Safety Code, 2012 edition (NFPA 101), Subchapter F of this chapter (relating to Fire Prevention and Safety), and this subchapter. An LSRH shall submit construction documents to the Texas Health and Human Services Commission (HHSC) in accordance with §511.167 of this subchapter (relating to Preparation, Submittal, Review, and Approval of Plans, and Retention of Records).(A) Physical environment. A physical environment that protects the health and safety of patients, personnel, and the public shall be provided in each LSRH. The physical premises of the LSRH and those areas of the LSRH's physical structure that are used by the patients (including all stairwells, corridors, and passageways) shall meet the local building and fire safety codes, Subchapter F of this chapter, and this subchapter.(B) Construction type. An LSRH may occupy an entire building or a portion of a building, provided the LSRH portion of the building is separated from the rest of the building in accordance with subparagraph (C) of this paragraph and the entire building or the LSRH portion of the building complies with this subchapter's requirements (type of construction permitted for hospitals by NFPA 101 §18.1.6.2), and the entire building is protected with a fire sprinkler system conforming with requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 edition.(C) Separate buildings. Portions of a building divided horizontally with two-hour fire rated walls that are continuous (without offsets) from the foundation to above the roof shall be considered as a separate building. Communicating openings in the two-hour wall shall be limited to public spaces such as lobbies and corridors. All such openings shall be protected with self-closing one and one-half hour, Class B fire door assemblies.(D) Design for the accessibility. Special considerations benefiting staff, visitors, and patients with disabilities shall be provided. An LSRH shall comply with the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, 42 United States Code, Chapter 126, and Title 36 Code of Federal Regulations, Part 1191, Appendix A (relating to Accessibility Guidelines for Buildings and Facilities) or 16 TAC Chapter 68 (relating to Elimination of Architectural Barriers), Texas Accessibility Standards (TAS), April 1, 1994 edition, issued by the Texas Department of Licensing and Regulation, under Texas Government Code Chapter 469 (relating to Elimination of Architectural Barriers).(E) Patient safety. In developing construction documents for submission to HHSC in accordance with §511.167 of this subchapter, the owner shall comply with the requirements of Texas Health and Safety Code Chapter 256 (relating to Safe Patient Handling and Movement Practices). Texas Health and Safety Code §256.002(b)(8) requires an LSRH's governing body to consider the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment at a later date.(F) Other regulations. The more stringent standard, code or requirement shall apply when a difference in requirements for construction exists.(G) Exceeding minimum requirements. Nothing in this subchapter shall be construed to prohibit a better type of building construction, more exits, or otherwise safer conditions than the minimum requirements specified in this subchapter.(H) Equivalency. Nothing in this subchapter is intended to prevent the use of systems, methods, or devices of equivalent or superior quality, strength, fire resistance, effectiveness, durability, and safety to those prescribed by this subchapter, providing technical documentation that demonstrates equivalency is submitted to HHSC for approval.(I) Freestanding buildings (not for patient use). Separate freestanding buildings for nonpatient use such as the heating plant, boiler plant, laundry, repair workshops, or general storage may be of unprotected noncombustible construction, protected noncombustible construction, or fire-resistive construction and be designed in accordance with other occupancy classifications requirements listed in NFPA 101.(J) Energy conservation. In new construction and in major alterations and additions to existing buildings and in new buildings, electrical and mechanical components shall be selected for efficient utilization of energy. LSRH construction shall be in accordance with the provisions of Texas Health and Safety Code Chapter 388 (relating to Texas Building Energy Performance Standards).(K) Heliports. Heliports located on LSRH buildings or land used or intended to be used for landing and takeoff of helicopters shall comply with National Fire Protection Association 418, Standard for Heliports, 2011 edition.(2) General detail and finish requirements. Details and finishes in new construction projects, including additions and alterations, shall be in compliance with this paragraph, with NFPA 101, Chapter 18, with local building codes, and with any specific detail and finish requirements for the particular unit as contained in §511.163 of this subchapter (relating to Spatial Requirements).(A) General detail requirements.(i) Fire safety. Fire safety features, including compartmentation, means of egress, automatic extinguishing systems, inspections, smoking regulations, and other details relating to fire prevention and fire protection shall comply with §511.161 of this subchapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals Are Located), and NFPA 101, Chapter 18 requirements for hospitals. The Fire Safety Evaluation System for Health Care Occupancies contained in the NFPA 101A, Alternative Approaches to Life Safety, 2010 edition, Chapter 3, shall not be used in new building construction, renovations, or additions to existing LSRHs.(ii) Access to exits. Corridors providing access to all patient, diagnostic, treatment, and patient therapy rooms and exits shall be at least eight feet in clear and unobstructed width, not less than seven feet six inches in height, and constructed in accordance with requirements listed in NFPA 101 §18.3.6.(iii) Corridors in other occupancies. Public corridors in administrative and service areas that are designed to requirements other than LSRH requirements and are the required means of egress from the LSRH shall be not less than five feet in width.(iv) Encroachment into the means of egress. Items such as drinking fountains, telephone booths or stations, and vending machines shall be so located as to not project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum. Portable equipment shall not be stored so as to project into and restrict exit corridor traffic or reduce the exit corridor width below the required minimum.(v) Doors in means of egress. All door leaves in the means of egress shall be not less than 44 inches wide or as otherwise permitted for hospitals by NFPA 101 §18.2.3.6.(vi) Sliding doors. Horizontal sliding doors serving an occupant load of fewer than 10 shall be permitted. The area served by the door has no high hazard contents. The door is readily operable from either side without special knowledge or effort. The force required to operate the door in the direction of door travel is not more than 30 pounds per foot to set the door in motion and is not more than 15 pounds per foot to close the door or open in the minimum required width. The door assembly complies with any required fire protection rating, and, where rated, is self-closing or automatic closing. The sliding doors opening to the egress corridor doors shall have a latch or other mechanism that ensures that the doors will not rebound into a partially open position if forcefully closed. The sliding doors may have breakaway provisions and shall be installed to resist passage of smoke. The latching sliding panel shall have a minimum clear opening of 41.5 inches in the fully open position. The fixed panels may have recessed tracks.(vii) Control doors. Designs that include cross-corridor control doors should be avoided. When unavoidable, cross-corridor control doors shall consist of two 44-inch wide leaves that swing in a direction opposite from the other, or of the double acting type. Each door leaf shall be provided with a view window.(viii) Emergency access. Rooms containing bathtubs, showers, and water closets, intended for patient use shall be provided with at least one door having hardware that will permit access from the outside in any emergency. Door leaf width of such doors shall not be less than 36 inches.(ix) Obstruction of corridors. All doors that swing towards the corridor must be recessed. Corridor doors to rooms not subject to occupancy (any room that you can walk into and close the door behind you is considered occupiable) may swing into the corridor, provided that such doors comply with the requirements of NFPA 101 §7.2.1.4.4.(x) Stair landing. Doors shall not open immediately onto a stair without a landing. The landing shall be 44 inches deep or have a depth at least equal to the door width, whichever is greater.(xi) Doors to rooms subject to occupancy. All doors to rooms subject to occupancy shall be of the swing type except that horizontal sliding doors complying with the requirements of NFPA 101 §18.2.2.2.9 are permitted. Door leaves to rooms subject to occupancy shall not be less than 36 inches wide.(xii) Operable windows and exterior doors. Windows that can be opened without tools or keys and outer doors without automatic closing devices shall be provided with insect screens.(xiii) Glazing. Glass doors, lights, sidelights, borrowed lights, and windows located within 12 inches of a door jamb or with a bottom-frame height of less than 18 inches and a top-frame height of more than 36 inches above the finished floor that may be broken accidentally by pedestrian traffic shall be glazed with safety glass or plastic glazing material that will resist breaking and will not create dangerous cutting edges when broken. Similar materials shall be used for wall openings in activity areas such as recreation and exercise rooms, unless otherwise required for fire safety. Safety glass, tempered, or plastic glazing materials shall be used for shower doors and bath enclosures, interior windows and doors. Plastic and similar materials used for glazing shall comply with the flame spread ratings of NFPA 101 §18.3.3.(xiv) Fire doors. All fire doors shall be listed by an independent testing laboratory and shall meet the construction requirements for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, 2010 edition. Reference to a labeled door shall be construed to include labeled frame and hardware.(xv) Grab bars. Grab bars shall be provided at patient toilets, showers and tubs. The bars shall be one and one-half inches in diameter, shall have either one and one-fourth or one and one-half inches clearance to walls, and shall have sufficient strength and anchorage to sustain a concentrated vertical or horizontal load of 250 pounds. Grab bars are not permitted at bathing and toilet fixtures in mental health and chemical dependency units unless designed and installed to eliminate the possibility of patients harming themselves. Grab bars intended for use by the disabled shall also comply with Americans with Disabilities Act of 1990 (ADA) requirements.(xvi) Soap dishes. Soap dishes shall be provided at all showers and bathtubs.(xvii) Hand washing facilities. Location and arrangement of fittings for hand washing facilities shall permit their proper use and operation. Hand washing fixtures with hands-free operable controls shall be provided within each workroom, examination, and treatment room. Hands-free includes blade-type handles, and foot, knee, or sensor operated controls. Particular care shall be given to the clearances required for blade-type operating handles. Lavatories and hand washing facilities shall be securely anchored to withstand an applied vertical load of not less than 250 pounds on the front of the fixture. In addition to the specific areas noted, hand washing facilities shall be provided and conveniently located for staff use throughout the LSRH where patient care contact occurs and services are provided.(xviii) Soap dispensers. A liquid or foam soap dispenser shall be located at each hand washing facility.(xix) Alcohol-based hand rubs. Alcohol-based hand rubs (ABHRs) are considered flammable. When used, ABHRs shall meet the following requirements.(I) The dispensers may be installed in a corridor so long as the corridor width is six feet or greater. The dispensers shall be installed at least four feet apart.(II) The maximum individual dispenser fluid capacity is 1.2 liters for dispensers in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms.(III) The dispensers shall not be installed over or directly adjacent to electrical outlets and switches.(IV) Dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.(V) Each smoke compartment may contain a maximum aggregate of 10 gallons of ABHR solution in dispensers and a maximum of five gallons in storage.(xx) Hand drying. Provisions for hand drying shall be included at all hand washing facilities except scrub sinks. There shall be hot air dryers or individual paper or cloth units enclosed in such a way as to provide protection against dust or soil and ensure single-unit dispensing.(xxi) Mirrors. Mirrors shall not be installed at hand washing fixtures where asepsis control and sanitation requirements would be lessened by hair combing. Mirrors may be installed in patient toilet rooms, lockers, and public toilet rooms.(xxii) Ceiling heights. The minimum ceiling height shall be seven feet six inches with the following exceptions.(I) Boiler rooms. Boiler rooms shall have ceiling clearances not less than two feet six inches above the main boiler header and connecting piping.(II) Rooms with ceiling-mounted equipment. Rooms containing ceiling-mounted equipment shall have the ceiling height clearance increased to accommodate the equipment or fixtures.(III) Overhead clearance. Suspended tracks, rails, pipes, signs, lights, door closers, exit signs, and other fixtures that protrude into the path of normal traffic shall not be less than six feet eight inches above the finished floor.(xxiii) Areas producing impact noises. Recreation rooms, exercise rooms, and similar spaces where impact noises may be generated shall not be located directly over patient bed area or operating rooms unless special provisions are made to minimize noise.(xxiv) Noise reduction. Noise reduction criteria in accordance with the Table 1 in §511.169(a) of this subchapter (relating to Tables) shall apply to partitions, floor, and ceiling construction in patient areas.(xxv) Rooms with heat-producing equipment. Rooms containing heat-producing equipment such as heater rooms, laundries, etc. shall be insulated and ventilated to prevent any occupied floor surface above from exceeding a temperature differential of 10 degrees Fahrenheit above the ambient room temperature.(xxvi) Chutes. Linen and refuse chutes shall comply with the requirements of NFPA 82, Standard on Incinerators, Waste and Linen Handling Systems and Equipment, 2009 edition, and NFPA 101 §18.5.4.(xxvii) Thresholds and expansion joint covers. Thresholds and expansion joint covers shall be flush or not more than one-half inch above the floor surface to facilitate the use of wheelchairs and carts. Expansion and seismic joints shall be constructed to restrict the passage of smoke and fire and shall be listed by a nationally recognized testing laboratory.(xxviii) Housekeeping room.(I) In addition to any housekeeping rooms required in certain departments, sufficient housekeeping rooms shall be provided throughout the LSRH as required to maintain a clean and sanitary environment.(II) Each housekeeping room shall contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.(B) General finish requirements.(i) Cubicle curtains and draperies.(I) Cubicle curtains, draperies, and other hanging fabrics shall be noncombustible or flame retardant and shall pass both the small scale and the large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 2010 edition. Copies of laboratory test reports for installed materials shall be submitted to HHSC at the time of the final construction inspection.(II) Cubicle curtains shall be provided to assure patient privacy.(ii) Flame spread, smoke development, and noxious gases. Flame spread and smoke developed limitations of interior finishes shall comply with Table 2 of §511.169(b) of this subchapter and NFPA 101 §10.2. The use of materials known to produce large or concentrated amounts of noxious or toxic gases shall not be used in exit accesses or in patient areas. Copies of laboratory test reports for installed materials tested in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition, and NFPA 258, Standard Research Test Method for Determining Smoke Generation of Solid Materials, 2001 edition, shall be provided.(iii) Floor finishes. Flooring shall be easy to clean and have wear resistance appropriate for the location involved. Floors that are subject to traffic while wet (such as shower and bath areas, kitchens, and similar work areas) shall have a nonslip surface. In all areas frequently subject to wet cleaning methods, floor materials shall not be physically affected by germicidal and cleaning solutions. The following are acceptable floor finishes:(I) painted concrete;(II) vinyl and vinyl composition tiles and sheets;(III) monolithic or seamless flooring. Where required, seamless flooring shall be impervious to water, coved and installed integral with the base, tightly sealed to the wall, and without voids that can harbor insects or retain dirt particles. The base shall not be less than six inches in height. Welded joint flooring is acceptable;(IV) ceramic and quarry tile;(V) wood floors. Wood floors subject to frequent cleaning methods shall be avoided. When wood floors are used, the floor shall be tightly sealed, without voids and the joints shall be impervious to water;(VI) carpet flooring. Carpeting installed in patient care areas shall be treated to prevent bacterial and fungal growth;(VII) terrazzo; and(VIII) poured in place floors.(iv) Wall finishes. Wall finishes shall be smooth, washable, moisture resistant, and cleanable by standard housekeeping practices. Wall finishes shall comply with requirements contained in Table 2 of §511.169(b) of this subchapter, and NFPA 101 §18.3.3.(I) Wall finishes shall be water-resistant in the immediate area of plumbing fixtures.(II) Wall finishes subject to frequent wet cleaning methods shall be impervious to water, tightly sealed, and without voids.(v) Floor, wall, and ceiling penetrations. Floor, wall, and ceiling penetrations by pipes, ducts, and conduits or any direct openings shall be tightly sealed to minimize entry of dirt particles, rodents, and insects. Joints of structural elements shall be similarly sealed.(vi) Ceiling types. Ceilings that are a part of a rated roof/ceiling assembly or a floor/ceiling assembly shall be constructed of listed components and installed in accordance with the listing. The following subclauses describe three types of ceilings that are required in various areas of the LSRH.(I) Ordinary ceilings. Ceilings such as acoustical tiles installed in a metal grid that are dry cleanable with equipment used in daily housekeeping activities such as dusters and vacuum cleaners.(II) Washable ceilings. Ceilings that are made of washable, smooth, moisture impervious materials such as painted lay-in gypsum wallboard or vinyl faced acoustic tile in a metal grid.(III) Monolithic ceilings. Ceilings that are monolithic from wall to wall (painted solid gypsum wallboard), smooth and without fissures, open joints, or crevices and with a washable and moisture impervious finish.(vii) Special construction. Special conditions may require special wall and ceiling construction for security in areas such as storage of controlled substances and areas where patients are likely to attempt suicide or escape.(viii) Flammable anesthetizing locations. Flammable anesthetic locations in which flammable anesthetic agents are stored or administered shall comply with Annex E of NFPA 99, Health Facilities Code, 2012 edition.(ix) Materials finishes. Materials known to produce noxious gases when burned shall not be used for mattresses, upholstery, and wall finishes.(x) Signage. A sign shall be posted at the entrance to each toilet or restroom to identify the facility for public, staff, or patient use. A sign is not required for patient room bathrooms.(3) General mechanical requirements. This paragraph contains common requirements for mechanical systems; steam and hot and cold water systems; air conditioning, heating and ventilating systems; plumbing fixtures; piping systems; and thermal and acoustical insulation. An LSRH shall comply with the requirements of this paragraph and any specific mechanical requirements for the particular unit of the LSRH as described in §511.163 of this subchapter.(A) Equipment location. When mechanical equipment is exposed to weather, it shall be weather protected or protected by weatherproof construction.(B) Vibration isolation. Mechanical equipment shall be mounted on vibration isolators as required to prevent unacceptable structure-borne vibration. Ducts, pipes, etc. connected to mechanical equipment that is a source of vibration shall be isolated from the equipment with vibration isolators.(C) Performance and acceptance. Before completion and acceptance of the facility, all mechanical systems shall be tested, balanced, and operated to demonstrate to the design engineer or their representative that the installation and performance of these systems conform to the requirements of the plans and specifications.(i) Material lists. On completion of the contract, the owner shall be provided with parts lists and procurement information with numbers and description for each piece of equipment.(ii) Instructions. On completion of the contract, the owner shall be provided with instructions in the operational use of systems and equipment as required.(D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2012 edition, NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §511.163 of this subchapter.(i) General ventilation requirements. All rooms and areas in the LSRH listed in Table 3 of §511.169(c) of this subchapter shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §511.169(c) of this subchapter shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.(I) Cost reduction methods. To reduce utility costs, facility design may utilize energy conserving procedures including recovery devices, variable air volume, load shedding, systems shutdown or reduction of ventilation rates (when specifically permitted) in certain areas when unoccupied. In no case shall patient care be jeopardized.(II) Economizer cycle. Mechanical systems shall be arranged to take advantage of outside air conditions by using an economizer cycle when appropriate to reduce heating and cooling systems loads. An LSRH may present to HHSC for consideration an innovative design that provides for additional energy conservation while meeting the intent of this section for acceptable patient care.(III) Outside air intake locations. Outside air intakes shall be located at least 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes. (Prevailing winds and proximity to other structures may require more stringent requirements). Plumbing and vacuum vents that terminate five feet above the level of the top of the air intake may be located as close as 10 feet.(IV) Low air intake location limit. The bottom of outside air intakes serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level.(V) Contaminated air exhaust outlets. Exhaust outlets from areas (kitchen hoods, etc.) that exhaust contaminated air shall be above the roof and be arranged to exhaust upward unless the air has been treated by an appropriate means where sidewall exhaust will be allowed. Ethylene oxide sterilizers shall be terminated above the roof and be arranged to exhaust upward. Each patient room bathroom shall be exhausted continuously to the exterior in accordance with Table 3 of §511.169(c) of this subchapter.(VI) Directional air flow. Ventilation systems shall be designed and balanced to provide directional flow as shown in Table 3 of §511.169(c) of this subchapter. For reductions and shutdown of ventilation systems when a room is unoccupied, the provisions in Note 4 of Table 3 of §511.169(c) of this subchapter shall be followed.(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food preparation areas, and where required for fire safety purposes. Combination systems, utilizing both ducts and plenums for movement of air in these areas shall not be permitted.(VIII) Ventilation start-up requirements. Air handling systems shall not be started or operated without the filters installed in place. This includes the 90 percent and 99.97 percent efficiency filters where required. Ducts shall be cleaned thoroughly and throughout by a certified air duct cleaning contractor when the air handling systems have been operating without the required filters in place. When ducts are determined to be dirty or dusty, HHSC will require a written report assuring cleanliness of duct and clean air quality.(IX) Humidifier location. When duct humidifiers are located upstream of the final filters, they shall be located at least 15 feet from the filters. Ductwork with duct-mounted humidifiers shall be provided with a means of removing water accumulation. An adjustable high-limit humidistat shall be located downstream of the humidifier to reduce the potential of condensation inside the duct. All duct take-offs should be sufficiently downstream of the humidifier to ensure complete moisture absorption. Reservoir-type water spray or evaporative pan humidifiers shall not be used.(ii) Filtration requirements. All central air handling systems serving patient care areas, including corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified in Table 4 of §511.169(d) of this subchapter. Filter efficiencies shall be average efficiencies tested in accordance with American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), Inc., Standard 52.2, 1999 edition, Method of Testing General Ventilation Air-Cleaning Devices for Removal Efficiency by Particle Size. All joints between filter segments, and between filter segments and the enclosing ductwork, shall have gaskets and seals to provide a positive seal against air leakage. Air handlers serving more than one room shall be considered as central air handlers.(I) Filtration requirements for air handling units serving single rooms requiring asepsis control. Dedicated air handlers serving only one room where asepsis control is required, including operating rooms and special procedure rooms shall be equipped with filters having efficiencies equal to, or greater than, those specified for patient care areas in Table 4 of §511.169(d) of this subchapter.(II) Filtration requirements for air handling units serving other single rooms. Dedicated air handlers serving all other single rooms shall be equipped with nominal filters installed at the return air system.(III) Location of multiple filters. Where two filter beds are required by Table 4 of §511.169(d) of this subchapter, filter bed number one shall be located upstream of the air conditioning equipment, and filter bed number two shall be downstream of the supply air blowers and cooling and heating coils.(IV) Location of single filters. Where only one filter bed is required by Table 4 of §511.169(d) of this subchapter, it shall be located upstream of the supply fan. Filter frames shall be durable and constructed to provide an airtight fit with the enclosing ductwork.(V) Pressure monitoring devices. A manometer or draft gauge shall be installed across each filter bed having a required efficiency of 75 percent or more including hoods requiring high efficiency particulate air (HEPA) filters.(iii) Thermal and acoustical insulation for air handling systems. Asbestos insulation shall not be used.(I) Thermal duct insulation. Air ducts and casings with outside surface temperature below ambient dew point or temperature above 80 degrees Fahrenheit shall be provided with thermal insulation.(II) Insulation in air plenums and ducts. Linings in air ducts and equipment shall meet the Erosion Test Method described in Underwriters Laboratories (UL), Inc., Standard Number 181 (relating to Factory-Made Duct Materials and Air Duct Connectors), April 4, 1996 edition.(III) Insulation flame spread and smoke developed ratings. Interior and exterior insulation, including finishes and adhesives on the exterior surfaces of ducts and equipment, shall have a flame spread rating of 25 or less and a smoke developed rating of 50 or less as required by NFPA 90A Chapters 4 and 5.(IV) Linings and acoustical traps. Duct lining and acoustical traps exposed to air movement shall not be used in ducts serving critical care areas. This requirement shall not apply to mixing boxes and acoustical traps that have approved nonabrasive coverings over such linings.(V) Frangible insulation. Insulation of soft and spray-on types shall not be used where it is subject to air currents or mechanical erosion or where loose particles may create a maintenance problem.(VI) Existing duct linings. Internal linings shall not be used in ducts, terminal boxes, or other air system components supplying operating rooms, delivery rooms, birthing rooms, labor rooms, recovery rooms, nurseries, trauma rooms, isolation rooms, and intensive care units unless terminal filters of at least 90 percent efficiency are installed downstream of linings.(iv) Ventilation for anesthetizing locations. Ventilation for anesthetizing locations, as defined in NFPA 99 §3.3, shall comply with NFPA 99 §13.4.1.2, and any specific ventilation requirements for the particular unit in accordance with §511.163 of this subchapter.(I) Smoke removal systems for windowless anesthetizing locations. Smoke removal systems shall be provided in all windowless anesthetizing locations in accordance with NFPA 99 §6.4.1.2.(II) Smoke removal systems for surgical suites. Smoke removal systems shall be provided in all surgical suites in accordance with NFPA 99 §6.4.1.3.(III) Smoke exhaust grilles. Exhaust grilles for smoke evacuation systems shall be ceiling-mounted or wall-mounted within 12 inches of the ceiling.(v) Location of return and exhaust air devices. The bottoms of wall-mounted return and exhaust air openings shall be at least four inches above the floor. Return air openings located less than six inches above the floor shall be provided with nominal filters. All exhaust air openings and return air openings located higher than six inches but less than seven feet above the floor shall be protected with grilles or screens having openings through which a one-half inch sphere will not pass.(vi) Ray protection. Ducts that penetrate construction intended for X-ray or other ray protection shall not impair the effectiveness of the protection.(vii) Fire damper requirements. Fire dampers shall be located and installed in all ducts at the point of penetration of a required two-hour or higher fire rated wall or floor in accordance with the requirements of NFPA 101 §18.5.2.(viii) Smoke damper requirements. Smoke dampers shall be located and installed in accordance with the requirements of NFPA 101 §18.3.7.3 and NFPA 90A Chapter 5.(I) Fail-safe installation. Smoke dampers shall close on activation of the fire alarm system by smoke detectors installed and located as required by NFPA 72, National Fire Alarm Code, 2010 edition, Chapter 8; NFPA 90A Chapter 6; and NFPA 101 §18.3.7; the fire sprinkler system; and on loss of power. Smoke dampers shall not close by fan shutdown alone unless it is a part of an engineered smoke removal system.(II) Interconnection of air handling fans and smoke dampers. Air handling fans and smoke damper controls may be interconnected so that closing of smoke dampers will not damage the ducts.(III) Frangible devices. Use of frangible devices for shutting smoke dampers is not permitted.(ix) Acceptable damper assemblies. Only fire damper and smoke damper assemblies integral with sleeves and listed for the intended purpose is acceptable.(x) Duct access doors. Unobstructed access to duct openings in accordance with NFPA 90A §4.3.4 shall be provided in ducts within reach and sight of every fire damper, smoke damper, and smoke detector. Each opening shall be protected by an internally insulated door that shall be labeled externally to indicate the fire protection device located within.(xi) Restarting controls. Controls for restarting fans may be installed for convenient fire department use to assist in evacuation of smoke after a fire is controlled, provided provisions are made to avoid possible damage to the system because of closed dampers. To accomplish this, smoke dampers shall be equipped with remote control devices.(xii) Make-up air. If air supply requirements in Table 3 of §511.169(c) of this subchapter do not provide sufficient air for use by exhaust hoods and safety cabinets, filtered make-up air shall be ducted to maintain the required air flow direction in that room. Make-up systems for hoods shall be arranged to minimize short circuiting of air and to avoid reduction in air velocity at the point of contaminant capture.(xiii) Isolation room exhaust. An isolation room exhaust shall be a dedicated system that exhausts all air continuously to the exterior in accordance with Table 3 of §511.169(c) of this subchapter. Multiple isolation rooms may be interconnected to the same exhaust system.(4) General piping systems and plumbing fixture requirements. All piping systems and plumbing fixtures shall be designed and installed in accordance with the requirements of the National Standard Plumbing Code Illustrated published by the National Association of Plumbing-Heating-Cooling Contractors (PHCC), 2003 edition, and this paragraph.(A) Piping systems.(i) Water supply systems. Water service pipe to point of entrance to the building shall be brass pipe, copper tube (not less than type M when buried directly), copper pipe, cast iron water pipe, galvanized steel pipe, or approved plastic pipe. Domestic water distribution system piping within buildings shall be brass pipe, copper pipe, copper tube, or galvanized steel pipe. Piping systems shall be designed to supply water at sufficient pressure to operate all fixtures and equipment during maximum demand.(I) Valves. Each water service main, branch main, riser, and branch to a group of fixtures shall be equipped with accessible and readily identifiable shutoff valves. Stop valves shall be provided at each fixture.(II) Backflow preventers. Backflow preventers (vacuum breakers) shall be installed on hose bibbs, laboratory sinks, janitor sinks, bedpan-flushing attachments, autopsy tables, and on all other fixtures to which hoses or tubing can be attached.(III) Flushing valves. Flush valves installed on plumbing fixtures shall be of a quiet operating type, equipped with silencers.(IV) Capacity of water heating equipment. Water heating equipment shall have sufficient capacity to supply water for clinical, dietary and laundry use at the temperatures and amounts specified in Table 5 of §511.169(e) of this subchapter.(V) Water temperature measurements. Water temperatures shall be measured at hot water point of use or at the inlet to processing equipment.(VI) Water storage tanks. Any domestic water storage tanks shall be fabricated of corrosion-resistant metal or lined with noncorrosive material. When potable water storage tanks (hot and cold) are used, the water shall be used and replenished. Water shall not be stored in tanks for future use unless the water is tested weekly for contaminates and bacteria.(VII) Hot water distribution. Water distribution systems shall be arranged to provide hot water at each hot water outlet at all times.(VIII) Purified water supply system. Purified water distribution system piping shall be task specific and include Polypropylene (PP), Polyvinylidene fluoride (PVDF) or Polyvinyl Chloride (PVC) pipe. Final installed purified water system piping assemblies shall be UL approved and fully comply with applicable American Society for Testing and Materials (ASTM) Fire Resistant/Smoke Density requirements.(IX) Dead-end piping. Dead-end piping (risers with no flow, branches with no fixture) shall not be installed. In any renovation work, dead-end piping shall be removed. Empty risers, mains and branches installed for future use are permitted.(ii) Fire sprinkler systems. Fire sprinkler systems shall be provided in an LSRH as required by NFPA 101 §18.3.5. All fire sprinkler systems shall be designed, installed, and maintained in accordance with the requirements of NFPA 13, and shall be certified as required by §511.168(c)(1)(C) of this subchapter (relating to Construction, Inspections, and Approval of Project).(iii) Nonflammable medical gas and clinical vacuum systems. Nonflammable medical gas and clinical vacuum system installations shall be designed, installed, and certified in accordance with the requirements of NFPA 99 §5.1 for Level I systems and the requirements of this clause.(I) Outlets. Nonflammable medical gas and clinical vacuum outlets shall be provided in accordance with Table 6 of §511.169(f) of this subchapter.(II) Installer qualifications. All installations of the medical gas piping systems shall be done only by, or under the direct supervision of, a holder of a master plumber license or a journeyman plumber license with a medical gas piping installation endorsement issued by the Texas State Board of Plumbing Examiners.(III) Installer tests. Prior to closing of walls, the installer shall perform an initial pressure test, a blowdown test, a secondary pressure test, a cross-connection test, and a purge of the piping system as required by NFPA 99.(IV) Qualifications for conducting verification tests and inspections. Verification testing shall be performed and inspected by a party, other than the installer, installing contractor, or material vendor. Testing shall be conducted by a registered medical gas system verifier and technically competent and experienced in the field of medical gas and vacuum pipeline testing and meeting the requirements of the American Society of Safety Engineers (ASSE) Personnel Standard 6030, Professional Qualifications Standard for Medical Gas Systems.(V) Verification tests. On completion of the installer inspections and tests and after closing of walls, verification tests of the medical gas piping systems, the warning system, and the gas supply source shall be conducted. The verification tests shall include a cross-connection test, valve test, flow test, piping purge test, piping purity test, final tie-in test, operational pressure tests, and medical gas concentration test.(VI) Verification test requirements. Verification tests of the medical gas piping system and the warning system shall be performed on all new piped medical gas systems, additions, renovations, or repaired portions of an existing system. All systems that are breached and components that are added, renovated, or replaced shall be inspected and appropriately tested. The breached portions of the systems subject to inspection and testing shall be all of the new and existing components in the immediate zone or area located upstream of the point or area of intrusion and downstream to the end of the system or a properly installed isolation valve.(VII) Warning system verification tests. Verification tests of piped medical gas systems shall include tests of the source alarms and monitoring safeguards, master alarm systems, and the area alarm systems.(VIII) Source equipment verification tests. Source equipment verification tests shall include medical gas supply sources (bulk and manifold) and the compressed air source systems (compressors, dryers, filters, and regulators).(IX) LSRH responsibility. Before new piped medical gas systems, additions, renovations, or repaired portions of an existing system are put into use, the LSRH is responsible for ensuring the gas delivered at the outlet is the gas shown on the outlet label and the proper connecting fittings are checked against their labels.(X) Written certification. On successful completion of all verification tests, written certification for affected piped medical gas systems and piped medical vacuum systems including the supply sources and warning systems shall be provided by a party technically competent and experienced in the field of medical gas pipeline testing stating the provisions of NFPA 99 have been adhered to and systems integrity has been achieved. The written certification shall be submitted directly to the LSRH and the installer. The LSRH shall forward a copy to HHSC.(XI) Documentation of medical gas and clinical vacuum outlets. The same party certifying the piped medical gas systems shall submit to HHSC documentation of the installed, modified, extended or repaired medical gas piping system. The number and type of medical gas outlets (oxygen, vacuum, medical air, nitrogen, nitrous oxide, etc.) shall be documented and arranged tabularly by room numbers and room types.(iv) Medical gas storage facilities. Main storage of medical gases may be outside or inside the LSRH in accordance with NFPA 99 §5.1. Provision shall be made for additional separate storage of reserve gas cylinders necessary to complete at least one day's procedures.(v) Multiple gas outlets on one medical gas outlet. Y-connections, "twinning," or other similar devices shall not be used on any medical gas outlet.(vi) Waste anesthetic gas disposal (WAGD) systems. Each space routinely used for administering inhalation anesthesia shall be provided with a WAGD system as required by NFPA 99 §5.1.3.7.(vii) Steam and hot water systems.(I) Boilers. Boilers shall have the capacity, based on the net ratings as published in the I-B-R Ratings Book for Boilers, Baseboard Radiation and Finned Tube (commercial) by the Hydronics Institute Division of Gas Appliance Manufacturers Association, to supply the normal requirements of all systems and equipment. The number and arrangement of boilers shall be such that, when one boiler breaks down or routine maintenance requires that one boiler be temporarily taken out of service, the capacity of the remaining boiler or boilers shall be sufficient to provide hot water service for clinical, dietary, and patient use, steam for sterilization and dietary purposes, and heating for operating, emergency, recovery, treatment, and general patient care rooms. However, reserve capacity for space heating of noncritical care areas (e.g., general patient care rooms and administrative areas) is not required in geographical areas where a design dry bulb temperature equals 25 degrees Fahrenheit or higher as based on the 99 percent design value shown in the Handbook of Fundamentals, 2005 edition, published by ASHRAE, Inc.(II) Boiler accessories. Boiler feed pumps, heating circulating pumps, condensate return pumps, and fuel oil pumps shall be connected and installed to provide normal and standby service.(III) Valves. Supply and return mains and risers of cooling, heating, and process steam systems shall be valved to isolate the various sections of each system. Each piece of equipment shall be valved at the supply and return ends except that vacuum condensate returns need not be valved at each piece of equipment.(IV) Hot water distribution systems. Hot water distribution systems for patient care areas shall be under constant recirculation to provide continuous hot water at each hot water outlet. Nonrecirculated fixtures branch piping shall not exceed 25 feet in length. Water temperature is measured at the point of use or inlet to the equipment. Tankless water system may be used at point of use.(V) Domestic hot water system. The domestic hot water system shall make provisions to limit the amount of Legionella bacteria and opportunistic waterborne pathogens.(viii) Drainage systems.(I) Above ground piping. Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waste-vent (DWV) weight or heavier and shall be copper pipe, copper tube, cast iron pipe, or galvanized iron pipe.(II) Underground piping. All underground building drains shall be cast iron soil pipe, hard temper copper tube (DWV or heavier), acrylonitrile-butodiene-styrene (ABS) plastic pipe (DWV Schedule 40 or heavier), polyvinyl chloride (PVC) plastic pipe (DWV Schedule 40 or heavier), or extra strength vitrified clay pipe (VCP) with compression joints or couplings with at least 12 inches of earth cover.(III) Drains for chemical wastes. Separate drainage systems for chemical wastes (acids and other corrosive materials) shall be provided. Materials acceptable for chemical waste drainage systems shall include chemically resistant glass pipe, high silicone content cast iron pipe, VCP, plastic pipe, or plastic lined pipe.(ix) Thermal insulation for piping systems and equipment. Insulation shall be provided for the following:(I) boilers, smoke breeching, and stacks;(II) steam supply and condensate return piping;(III) hot water piping and all hot water heaters, generators, converters, and storage tanks;(IV) chilled water, refrigerant, other process piping, equipment operating with fluid temperatures below ambient dew point, and water supply and drainage piping on which condensation may occur. Insulation on cold surfaces shall include an exterior vapor barrier; and(V) other piping, ducts, and equipment as necessary to maintain the efficiency of the system.(x) Pipe and equipment insulation rating. Flame spread shall not exceed 25 and smoke development rating shall not exceed 150 for pipe insulation as determined by an independent testing laboratory in accordance with NFPA 255, Standard Method of Test of Surface Burning Characteristics of Building Materials, 2000 edition. Smoke development rating for pipe insulation located in environmental air areas shall not exceed 50.(xi) Asbestos insulation. Asbestos insulation shall not be used.(B) Plumbing fixtures. Plumbing fixtures shall be made of nonabsorptive acid-resistant materials and shall comply with the recommendations of the National Standard Plumbing Code and this paragraph.(i) Sink and lavatory controls. All fixtures used by medical and nursing staff and all lavatories used by patients and food handlers shall be trimmed with valves that can be operated without the use of hands. Blade handles used for this purpose shall not be less than four inches in length. Single lever or wrist blade devices may be used.(ii) Clinical sink traps. Clinical sinks shall have an integral trap in which the upper portion of a visible trap seal provides a water surface.(iii) Sinks for disposal of plaster of paris. Sinks used for the disposal of plaster of paris shall have a plaster trap.(iv) Back-flow or siphoning. All plumbing fixtures and equipment shall be designed and installed to prevent the back-flow or back-siphonage of any material into the water supply. The over-the-rim type water inlet shall be used wherever possible. Vacuum-breaking devices shall be properly installed when an over-the-rim type water inlet cannot be utilized.(v) Drinking fountain. Each drinking fountain shall be designed so that the water issues at an angle from the vertical, the end of the water orifice is above the rim of the bowl, and a guard is located over the orifice to protect it from lip contamination.(vi) Sterilizing equipment. All sterilizing equipment shall be designed and installed to prevent not only the contamination of the water supply but also the entrance of contaminating materials into the sterilizing units.(vii) Hose attachment. No hose shall be affixed to any faucet if the end of the hose can become submerged in contaminated liquid unless the faucet is equipped with an approved, properly installed vacuum breaker.(viii) Bedpan washers and sterilizers. Bedpan washers and sterilizers shall be designed and installed so that both hot and cold water inlets shall be protected against back-siphonage at maximum water level.(ix) Flood level rim clearance. The water supply spout for lavatories and sinks required in patient care areas shall be mounted so that its discharge point is a minimum of five inches above the rim of the fixture.(x) Scrub sink controls. Scrub sinks and lavatories used for scrubbing in procedure rooms shall be trimmed with foot, knee, or ultrasonic controls. Single lever wrist blades are not acceptable at scrub sinks.(xi) Floor drains or floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to grilled drain cover to prevent entry of large particles of waste that might cause stoppages.(xii) Under-counter piping. Under-counter piping and above floor drains shall be arranged (raised) so as not to interfere with cleaning of floor below the equipment.(xiii) Ice machines. All ice-making machines used for human consumption shall be of the self-dispensing type. Copper tubing shall be provided for supply connections to ice machines.(xiv) Food disposal units. A food disposal unit shall only be permitted in the dietary department in accordance with §511.163(d) of this subchapter.(5) General electrical requirements. This paragraph contains common electrical requirements. The LSRH shall comply with the requirements of this paragraph and with any specific electrical requirements for the particular unit of the LSRH in accordance with §511.163 of this subchapter.(A) Electrical installations. All new electrical material and equipment, including conductors, controls, and signaling devices, shall be installed in compliance with applicable sections of NFPA 70, National Electrical Code, 2011 edition, and NFPA 99 and as necessary to provide a complete electrical system. Electrical systems and components shall be listed by nationally recognized listing agencies as complying with available standards and shall be installed in accordance with the listings and manufacturers' instructions.(i) All fixtures, switches, sockets, and other pieces of apparatus shall be maintained in a safe and working condition.(ii) Extension cords and cables shall not be used for permanent wiring.(iii) All electrical heating devices shall be equipped with a pilot light to indicate when the device is in service, unless equipped with a temperature limiting device integral with the heater.(iv) All equipment, fixtures, and appliances shall be properly grounded in accordance with NFPA 70.(v) Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of floor below the equipment.(B) Installation testing and certification.(i) Installation testing. The electrical installations, including alarm, nurses calling system and communication systems, shall be tested to demonstrate that equipment installation and operation is appropriate and functional.(ii) Grounding system testing. The grounding system shall be tested as described in NFPA 99 4.3.3, for patient care areas in new or renovated work. A qualified electrician or their qualified electrical testing agent shall perform the testing. The electrical contractor shall provide a letter stating the grounding system has been tested in accordance with NFPA 99, the testing device use complies with NFPA 99, and whether the grounding system passed the test. The qualified electrical contractor or their designated qualified electrical testing agent shall sign the letter, certifying the system has been tested and the results of the test are indicated.(C) Electrical safeguards. Shielded isolation transformers, voltage regulators, filters, surge suppressors, and other safeguards shall be provided as required where power line disturbances are likely to affect fire alarm components, data processing, equipment used for treatment, and automated laboratory diagnostic equipment.(D) Services and switchboards. Electrical service and switchboards serving the required LSRH components shall be installed above the designated 100-year flood plain. Main switchboards shall be located in separate rooms, separated from adjacent areas with one-hour fire rated enclosures containing only electrical switchgear and distribution panels and shall be accessible to authorized persons only. These rooms shall be ventilated to provide an environment free of corrosive or explosive fumes and gases, or any flammable and combustible materials. Switchboards shall be located convenient for use and readily accessible for maintenance as required by NFPA 70 Article 384. Overload protective devices shall operate properly in ambient temperatures.(E) Panelboards. Panelboards serving normal lighting and appliance circuits shall be located on the same floor as the circuits they serve. Panelboards serving critical branch emergency circuits shall be located on each floor that has major users (operating rooms, emergency department, etc.) and may also serve the floor above and the floor below. Panelboards serving life safety branch circuits may serve three floors, the floor where the panelboard is located and the floors above and below.(F) Wiring. All conductors for controls, equipment, lighting and power operating at 100 volts or higher shall be installed in accordance with the requirements of NFPA 70 Article 517. All surface mounted wiring operating at less than 100 volts shall be protected from mechanical injury with metal raceways to a height of seven feet above the floor. Conduits and cables shall be supported in accordance with NFPA 70 Article 300.(G) Lighting.(i) Lighting intensity for staff and patient needs shall comply with guidelines for health care facilities set forth in the Illuminating Engineering Society of North America (IESNA) Handbook, 2000 edition, published by the IESNA.(I) Consideration should be given to controlling intensity and wavelength to prevent harm to the patient's eyes (i.e., cataracts due to ultraviolet light).(II) Approaches to buildings and parking lots shall be illuminated. All rooms including storerooms, electrical and mechanical equipment rooms, and all attics shall have sufficient artificial lighting so all parts of these spaces are clearly visible.(III) Consideration should be given to the special needs of the elderly. Excessive contrast in lighting levels that makes effective sight adaptation difficult shall be minimized.(ii) Means of egress and exit sign lighting intensity shall comply with NFPA 101 §§7.8 - 7.10.(iii) Electric lamps that may be subject to breakage or that are installed in fixtures in confined locations when near woodwork, paper, clothing, or other combustible materials, shall be protected by wire guards, or plastic shields.(iv) Ceiling-mounted surgical and examination light fixtures shall be suspended from rigid support structures mounted above the ceiling.(H) Receptacles. Only listed hospital grade single-grounding or duplex-grounding receptacles shall be used in all patient care areas. This does not apply to special purpose receptacles.(i) Installations of multiple-ganged receptacles shall not be permitted in patient care areas.(ii) Electrical outlets powered from the critical branch shall be provided in all patient care, procedure and treatment locations in accordance with NFPA 99 §4.4.2.2.2.3. At least one receptacle at each patient treatment or procedure location shall be powered from the normal power panel.(iii) Replacement of malfunctioning receptacles and installation of new receptacles powered from the critical branch in existing facilities shall be accomplished with receptacles of the same distinct color as the existing receptacles.(iv) In locations where mobile X-ray or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(v) Each receptacle shall be grounded to the reference grounding point by means of a green insulated copper equipment grounding conductor.(vi) All critical care area receptacles shall be identified. The face plate for the receptacle or receptacles shall have a nonremovable label or be engraved indicating the panel and circuit number.(I) Equipment.(i) Equipment required for safe operation of the LSRH shall be powered from the equipment system in accordance with the requirements contained in NFPA 99 §4.4.2.2.3.(ii) Boiler accessories including feed pumps, heat-circulating pumps, condensate return pumps, fuel oil pumps, and waste heat boilers shall be connected and installed to provide both normal and standby service.(iii) Laser equipment shall be installed according to manufacturer recommendations and shall be registered with the Texas Department of State Health Services Radiation Control Program.(J) Ground fault circuit interrupters (GFCI). GFCI receptacles shall be provided for all general use receptacles located within three feet of a wash basin or sink. When GFCI receptacles are used, they shall be connected to not affect other devices connected to the circuit in the event of a trip. Receptacles connected to the critical branch that may be used for equipment that should not be interrupted do not have to be GFCI protected. Receptacles in wet locations, as defined by NFPA 70 §517.20 and §517.21, shall be GFCI protected regardless of the branch of the electrical system serving the receptacle.(K) Grounding requirements. In areas such as a critical care unit where a patient may be treated with an internal probe or catheter connected to the heart, the ground system shall comply with applicable sections of NFPA 99 and NFPA 70.(L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in an LSRH: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The LSRH shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the LSRH in accordance with §511.163 and Table 7 of §511.169(g) of this subchapter. When required in this subparagraph, when a colored dome light lamp or particular combination of colored lamps is used for only one type of call, a distinct visible signal shall be (used or provided). Different flash rates do not meet this requirement.(i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the call is answered by the nursing staff. The visible signal or signals in the corridor shall be canceled upon termination of the call. Calls shall activate visible signals in accordance with Table 7 of §511.169(g) of this subchapter. An alarm shall activate at the nurse station when the call cable is unplugged.(ii) A nurses emergency calling system shall be installed in all toilets used by patients to summon nursing staff in an emergency. Activation of the system shall sound a repeating (every 5 seconds or less) a distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The visible and audible signals shall be cancelable only at the patient calling station. Calls shall activate visible signals in accordance with Table 7 of §511.169(g) of this subchapter. When conveniently located and accessible from both the bathing and toilet fixtures, one emergency call station may serve one bathroom. A nurses emergency call system shall be accessible to a collapsed patient lying on the floor. Inclusion of a pull cord extending to within six inches of the floor will satisfy this requirement.(iii) A staff emergency assistance calling system (code blue) is intended to be used by staff to summon additional help in an emergency. In open suites, an emergency assistant call system device shall be located at the head of each patient station and in each individual room. The emergency assistance calling device can be shared between two patient stations if conveniently located. Activation of the system will sound a distinct audible signal at the nursing unit's nurse station or at a staffed control station of a suite, department or unit, indicate type and location of call on the system monitor and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. Calls shall activate audible and visible signals in accordance with Table 7 of §511.169(g) of this subchapter. A visible system shall clearly define the alarm location to a continuously staffed back up area (other than the nurse station or an administrative center) from which assistance can be summoned. Alternatively, back up may be provided by automatic annunciation from the staff emergency assistance calling system through wireless phones or pagers. The system shall have voice communication capability so that the type of emergency or help required may be specified between the point of alarm and the unit's nurse station.(M) Emergency electric service. A type I essential electrical system shall be provided in each LSRH in accordance with requirements of NFPA 99; NFPA 101; and NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.(i) When the emergency and standby power systems require a fuel source with tank, the fuel storage capacity tank shall have enough fuel for a 24-hour period.(ii) When a vapor liquefied petroleum gas (LPG) systems (natural gas) system is used, the 24-hour fuel capacity on-site is not required. The vapor withdrawal LPG system shall require a dedicated fuel supply.(iii) When the emergency generator or generators and electrical transformer or transformers are located within the same area, they shall be located at least 10 feet apart.(N) Fire alarm system. A fire alarm system that complies with NFPA 101 §18.3.4, and with NFPA 72 Chapter 6 requirements shall be provided in each LSRH. The required fire alarm system components are as follows.(i) A fire alarm control panel (FACP) shall be installed at a continuously attended (24 hour) location. A remote fire alarm annunciator listed for fire alarm service and installed at a continuously attended location and is capable of indicating both visual and audible alarm, trouble and supervisory signals in accordance with the requirements of NFPA 72 may be substituted for the FACP.(ii) Manual fire alarm pull stations shall be installed in accordance with NFPA 101 §18.3.4.(iii) Smoke detectors for door release service shall be installed on the ceiling at each door opening in the smoke partition in accordance with NFPA 72 §6.15.6, where the doors are held open with electromagnetic devices conforming with NFPA 101 §18.2.2.6.(iv) Ceiling-mounted smoke detector or detectors shall be installed in room containing the FACP when this room is not attended continuously by staff as required by NFPA 72 §4.4.5.(v) Smoke detectors shall be installed in air ducts in accordance with NFPA 72 §5.14.4.2 and §5.14.5 and NFPA 90A §6.4.2.(vi) Smoke detectors shall be installed in return air ducts in accordance with requirements of NFPA 72 §5.14.4.2.2 and §5.14.5 and NFPA 90A §6.4.2.2.(vii) Fire sprinkler system water flow switches shall be installed in accordance with requirements of NFPA 101 §9.6.2; NFPA 13 §6.9; and NFPA 72 §8.5.3.3.3.4.(viii) Sprinkler system valve supervisory switches shall be installed in accordance with the requirements of NFPA 72 §6.8.5.5.(ix) Audible alarm indicating devices shall be installed in accordance with the requirements of NFPA 101 §18.3.4 and NFPA 72 §7.4.(x) Visual fire alarm indicating devices that comply with the requirements of paragraph (1)(D) of this subsection and NFPA 72 §7.5 shall be provided.(xi) Devices for transmitting alarm for alerting the local fire brigade or municipal fire department of fire or other emergency shall be provided. The devices shall be listed for the fire alarm service by a nationally recognized laboratory, and be installed in accordance with such listing and the requirements of NFPA 72.(xii) A smoke detection system for spaces open to a corridor shall be provided when required by NFPA 101 §18.3.6.1.(xiii) A fire alarm signal notification that complies with NFPA 101 §9.6.3 shall be provided to alert occupants of fire or other emergency.(xiv) Wiring for fire alarm detection circuits and fire alarm notification circuits shall comply with requirements of NFPA 70 Article 760.(xv) A smoke detection system for elevator recall shall be located in elevator lobbies, elevator machine rooms and at the top of elevator hoist ways as required by NFPA 72 §6.15.3.10.(I) The elevator recall smoke detection system in new construction shall comply with requirements of American Society of Mechanical Engineers/American National Standards Institute (ASME/ANSI) A17.1, Safety Code for Elevators and Escalators, 2000 edition.(II) The elevator recall smoke detection system in existing hospitals shall comply with requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2002 edition.(xvi) Smoke detectors for initiating smoke removal from windowless anesthetizing areas shall be provided in accordance with NFPA 99 §6.4.1.2.(xvii) Smoke detectors for initiating smoke removal from surgical suites shall be provided in accordance with NFPA 99 §6.4.1.3.(xviii) A smoke detection system for initiating smoke removal from atriums shall be located above the highest floor level of the atrium and at return intakes from the atrium in accordance with NFPA 92B, Guide for Smoke Management Systems in Malls, Atria, and Large Areas, 2000 edition.(xix) A smoke detector or detectors for shutdown of air handling units shall be provided. The detectors shall be installed in accordance with NFPA 90A §6.4.3.(O) Telecommunications and information systems. Telecommunications and information systems central equipment shall be installed in a separate location designed for the intended purpose. Special air conditioning and voltage regulation shall be provided as recommended by the manufacturer.(P) Lightning protection systems. When installed, lightning protection systems shall comply with NFPA 780, Standard for the Installation of Lightning Protection Systems, 2000 edition.(6) General design requirements. Services that the LSRH provides to patients under the LSRH license shall be within the LSRH. The services may be provided throughout the LSRH within identifiable suites, departments or units within the LSRH however all required units in this chapter shall be in one identifiable contiguous location. To be included in the LSRH license, a required patient care unit or support areas shall be physically connected to the LSRH and become contiguous to the LSRH. In no case may one leave the LSRH, traverse the other occupancies, and then reenter the LSRH to access the remaining portion of the LSRH. An LSRH may not occupy two or more noncontiguous areas of non-LSRH occupancies that contain intervening space of the non-LSRH occupancies even if on the same floor or other floors. Source Note: The provisions of this §511.162 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.162 General Construction Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215239 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215239 03/12/2026 (a) Administration and public suite.(1) Architectural requirements. The following rooms or areas shall be provided.(A) Primary entrance. An entrance at grade level shall be accessible and protected from inclement weather with a drive under canopy for loading and unloading passengers.(B) Lobby. A main lobby shall be located at the primary entrance and shall include a reception and information counter or desk, waiting space, public toilet facilities, public telephones, drinking fountain, and storage room or alcove for wheelchairs.(C) Admissions area. An admissions area shall include a waiting area, work counters or desk, private interview spaces, and storage room or alcove for wheelchairs. The waiting area and wheelchair storage may be shared with similar areas located in the main lobby.(D) General or individual offices. Office space shall be provided for business transactions, medical and financial records, and administrative and professional staffs.(E) Multipurpose rooms. A multipurpose room or rooms shall be provided for conferences, meetings, and health education purposes including provisions for showing visual aids.(F) Storage. Storage for office equipment and supplies shall be provided. The construction protection for the storage room or area shall be in accordance with National Fire Protection Association 101, Life Safety Code, 2012 edition (NFPA 101) §18.3.2.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter (relating to General Construction Requirements).(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(b) Cart cleaning and sanitizing unit.(1) Architectural requirements.(A) Facilities. Cart cleaning, sanitizing, and storage facilities shall be provided for carts serving central services, dietary services, and linen services.(B) Location. Cart facilities may be provided for each service or be centrally located.(C) Hand washing fixtures. Hand washing fixtures shall be provided in cart cleaning, sanitizing, and storage areas.(2) Details and finishes. When interior cart cleaning facilities are provided, details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Flooring. Flooring in the cart cleaning and sanitizing unit shall be of the seamless type, or ceramic or quarry tile as required by §511.162(d)(2)(B)(iii)(III) or (IV) of this subchapter.(B) Ceilings. Ceilings in the cart cleaning and sanitizing unit shall be the monolithic type as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) Hand washing fixtures. Hand washing fixtures shall be provided with hot and cold water. Hot and cold water fixtures shall be provided in cart cleaning and sanitizing locations regardless of whether they are interior or exterior.(B) Floor drains and floor sinks. Where floor drains or floor sinks are installed, they shall be of a type that can be easily cleaned by removal of the cover. Removable stainless steel mesh shall be provided in addition to a grilled drain cover to prevent entry of large particles of waste that might cause stoppages. Floor drains and floor sinks shall be located to avoid conditions where removal of covers for cleaning is difficult.(5) Electrical requirements. Electrical requirements shall be in accordance with §511.162(d)(5) of this subchapter.(c) Central sterile supply suite.(1) Architectural requirements.(A) General. When surgical services are provided, the following rooms or areas shall be provided.(i) Decontamination room. This room shall be physically separated from all other areas of the suite. The room shall include work counters or tables, flush type utility sink, equipment for initial disinfection, and hand washing facilities with hands-free operable controls. Materials shall be transferred from the decontamination room to the clean assembly room by way of pass-through doors, windows, or washer equipment. The dirty side of the decontamination room may be combined with a soiled utility room if all functions for each space are provided within the room.(ii) Clean and assembly room. The room shall include counters or tables, equipment for sterilizing, and hand washing facilities with hands-free operable controls. Clean and soiled work areas shall be physically separated.(iii) Breakdown storage room. A storage room for breakdown of supplies shall be provided. The storage room shall have adequate areas and counters for breakdown of prepackaged supplies.(iv) Sterile and clean supply room. A sterile and clean supply room shall be provided. Storage of sterile and clean supplies shall not occur within the breakdown room.(v) Equipment storage. An equipment storage room shall be provided.(vi) Cart storage room. The storage room for distribution carts shall be adjacent to clean and sterile storage and close to main distribution points.(vii) Multipurpose room. The equipment storage and cart storage room may be combined into a multipurpose room.(B) Service areas. The central supply suite shall provide the following service areas.(i) Office space. Office space for director of central services.(ii) Staff toilets. Facilities may be outside the unit but must be convenient for staff use and shall contain hand washing fixtures with hands-free operable controls.(iii) Locker room. When provided, the locker room for staff shall include lockers, toilets, lavatories, showers, and male and female dressing rooms or cubicles. A central changing locker room may be shared and made available within the immediate area of the central sterile supply suite.(iv) Housekeeping room. A housekeeping room shall be provided and contain a floor receptor or service sink and storage space for housekeeping supplies and equipment. The housekeeping room shall be located on the decontamination or soiled side of the central sterile supply suite.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details. Mirrors shall not be installed at hand washing fixtures in clean and sterile supply areas.(B) Finishes.(i) Flooring. Flooring used in the decontamination room and the clean assembly room shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Ceilings. Ceilings in the decontamination room, clean assembly room, and supply storage room shall be the monolithic type as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical Requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Ventilation, humidity, and temperature control. The sterile supply room and the clean and assembly room shall include provisions for ventilation, humidity, and temperature control.(B) Ethylene oxide (EO) sterilizers. When provided, installations of EO sterilizers shall comply with the requirements of 30 TAC §106.417 (relating to Ethylene Oxide Sterilizers) administered by the Texas Commission on Environmental Quality (TCEQ), and the following requirements.(i) EO sterilizer requirements. All source areas shall be exhausted, including the sterilizer equipment room, service and aeration areas, over sterilizer door, and the aerator. If the EO cylinders are not located in a well-ventilated unoccupied equipment space, an exhaust hood shall be provided over the cylinders. The relief valve shall be terminated in a well-ventilated, unoccupied equipment space, or outside the building.(ii) Airflow. General airflow shall be away from sterilizer operators and towards the sterilizers.(iii) Exhaust. A dedicated exhaust fan and an exhaust duct system shall be provided for EO sterilizers. The exhaust outlet to the atmosphere shall be located on the highest roof, directed upward, and not less than 25 feet from any air intake. A legible warning sign shall be provided to identify the exhaust stack on the roof.(iv) Alarm. An audible and visual alarm located in sterilizer work area and a 24-hour staffed location shall be activated upon loss of airflow in the exhaust system.(C) Filtration. Filtration requirements for air handling units serving the central sterile supply suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter (relating to Tables).(D) Ducts. Duct linings exposed to air movement shall not be used in ducts serving the central sterile supply suite unless terminal filters of at least 90 percent efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter. When medical gas systems are provided, the systems shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) Drainage and waste piping. Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in sterile areas unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(B) Plumbing lines. No plumbing lines may be exposed or on walls where possible leaks would create a potential of contamination of the sterile areas.(C) Compressed air requirements. The compressed air required for the decontamination room shall not be connected to the medical air piping distribution system such as supporting breathable air for respiratory assistance needs, anesthesia machines, intermittent positive pressure breathing machine (IPPB), etc. A separate compressed air supply source shall be provided for maintenance and equipment needs for facility support use.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph. An electrical circuit or circuits to equipment in wet areas shall be provided with ground fault circuit interrupters (GFCIs).(d) Dietary suite.(1) Architectural requirements.(A) General. Construction, equipment, and installation shall comply with all applicable local and state requirements for food safety and handling and food service.(B) Food service facilities. Food services shall be provided by an on-site food preparation system or an off-site food service system or a combination of the two. The following minimum functional elements shall be provided on site regardless of the type of dietary services.(i) Dining area. Provide dining space for ambulatory patients, staff, and visitors. These spaces shall be separate from the food preparation and distribution areas.(ii) Receiving area. This receiving area shall have direct access to the outside for incoming dietary supplies or off-site food preparation service and shall be separate from the general receiving area. The receiving area shall contain a control station and an area for breakout for loading, unloading, uncrating, and weighing supplies. The entrance area to the receiving area shall be covered from the weather.(iii) Storage spaces. Storage spaces shall be convenient to receiving area and food preparation area and shall be located to exclude traffic through the food preparation area. Regardless of the type of food services provided, the facility shall provide storage of food for emergency use for a minimum of four calendar days.(I) Storage space. Storage space shall be provided for bulk, refrigerated, and frozen foods.(II) Cleaning supply storage. This room or closet shall be used to store nonfood items that might contaminate edibles. This storage area may be combined with the housekeeping room.(iv) Food preparation area. Counter space shall be provided for food preparation work, equipment, and an area to assemble trays for distribution for patient meals.(v) Ice-making equipment. Ice-making equipment shall be provided for both drinks and food products (self-dispensing equipment) and for general use (storage-bin type equipment).(vi) Hand washing. Hand washing fixtures with hands-free operable controls shall be conveniently located at all food preparation areas and serving areas.(vii) Food service carts. When a cart distribution system is provided, space shall be provided for storage, loading, distribution, receiving, and sanitizing of the food service carts. The cart traffic shall be designed to eliminate any danger of cross-circulation between outgoing food carts and incoming soiled carts, and the cleaning and sanitizing process. Cart circulation shall not be through food processing areas.(viii) Ware washing room. A ware washing room equipped with commercial type dishwasher equipment shall be located separate from the food preparation and serving areas. Space shall be provided for receiving, scraping, sorting, and stacking soiled tableware and for transferring clean tableware to the using areas. Hand washing facilities with hands-free operable controls shall be located within the soiled dish wash area. A physical separation to prevent cross-traffic between "dirty side" and "clean side" of the dish wash areas shall be provided.(ix) Pot washing facilities. A three compartmented sink of adequate size for intended use shall be provided convenient to the food preparation area. Supplemental heat for hot water to clean pots and pans shall be by booster heater or by steam jet.(x) Waste storage room. A food waste storage room shall be conveniently located to the food preparation and ware washing areas but not within the food preparation area. It shall have direct access to the LSRH's waste collection and disposal facilities.(xi) Sanitizing facilities. Storage areas and sanitizing facilities for garbage or refuse cans, carts, and mobile tray conveyors shall be provided. All containers for trash storage shall have tight-fitting lids.(xii) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the dietary department. Where hot water or steam is used for general cleaning, additional space within the room shall be provided for the storage of hoses and nozzles.(xiii) Office spaces. An office shall be provided for the use of the food service manager or the dietary service manager. In smaller LSRHs, a designated alcove may be located in an area that is part of the food preparation area.(xiv) Toilets and locker spaces. A toilet room with at least one hand washing fixture with hands-free operable controls shall be provided for the exclusive use of the dietary staff. A toilet room shall not open directly into the food preparation areas, but must be in close proximity to them. For larger LSRHs, a locker room or space for lockers shall be provided for staff belongings.(C) Additional service areas, rooms, and facilities. When an on-site food preparation system is used, in addition to the items required in subparagraph (B) of this paragraph, the following service areas, rooms and facilities shall be provided.(i) Food preparation facilities. When food preparation systems are provided, there shall be space and equipment for preparing, cooking, and baking.(ii) Tray assembly line. A patient tray assembly and distribution area shall be located within close proximity to the food preparation and distribution areas.(iii) Food storage. When food is prepared on site, the storage room shall be adequate to accommodate food for a seven calendar day menu cycle.(iv) Additional storage rooms. An additional room or rooms shall be provided for the storage of cooking wares, extra trays, flatware, plastic and paper products, and portable equipment.(v) Drying storage area. Provisions shall be made for drying and storage of pots and pans from the pot washing room.(D) Equipment. Equipment for use in the dietary suite shall meet the following requirements.(i) Mechanical devices. Mechanical devices shall be heavy duty, suitable for the use intended, and easily cleaned. Where equipment is movable, provide heavy duty locking casters. Equipment with fixed utility connections shall not be equipped with casters.(ii) Panels. Floor, wall, and top panels of walk-in coolers, refrigerators, and freezers shall be insulated. Coolers and refrigerators shall be capable of maintaining a temperature down to freezing. Freezers shall be capable of maintaining a temperature of 20 degrees below 0 degrees Fahrenheit. Coolers, refrigerators, and freezers shall be thermostatically controlled to maintain desired temperature settings in increments of two degrees or less. Interior temperatures shall be indicated digitally and visible from the exterior. Controls shall include audible and visible high and low-temperature alarm. The time of alarm shall be automatically recorded.(iii) Walk-in units. Walk-in units may be lockable from the outside but must have a release mechanism for exit from inside at all times. The interior shall be lighted. All shelving shall be corrosion-resistant, easily cleaned, and constructed and anchored to support a load of at least 100 pounds per linear foot.(iv) Cooking equipment. All cooking equipment shall be equipped with automatic shutoff devices to prevent excessive heat buildup.(E) Vending services. When vending machines are provided, a dedicated room or an alcove shall be located so that access is available at all times.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Food storage. Food storage shelves shall not be less than four inches above the finished floor and the space below the bottom shelf shall be closed in and sealed tight for ease of cleaning.(ii) Windows. Operable windows and doors not equipped with automatic closing devices shall be equipped with insect screens.(iii) Food processing areas. Food processing areas in the central dietary kitchen shall have ceiling heights not less than nine feet. Ceiling-mounted equipment shall be supported from rigid structures located above the finished ceiling.(iv) Mirrors. Mirrors shall not be installed at hand washing fixtures in the food preparation areas.(B) Finishes.(i) Flooring. Floors in areas used for food preparation, food assembly, soiled and clean ware cleaning shall be water-resistant and grease-proof. Floor surfaces, including tile joints, shall be resistant to food acids.(ii) Wall bases. Wall bases in food preparation, food assembly, soiled and clean ware cleaning, and other areas that are frequently subject to wet cleaning methods shall be made integral and coved with the floor, tightly sealed to the wall, constructed without voids that can harbor insects, retain dirt particles, and be impervious to water.(iii) Wall construction, finishes, and trim. In the dietary and food preparation areas, the wall construction, finishes, and trim, including the joints between the walls and the floors, shall be free of voids, cracks, and crevices.(iv) Food preparation and food assembly area ceiling. The ceiling in food preparation and food assembly areas shall be washable as required by §511.162(d)(2)(B)(vi)(II) of this subchapter.(v) Soiled and clean ware cleaning area ceiling. The ceiling in the soiled and clean ware cleaning area shall be of the monolithic type as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical Requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Exhaust hood requirements. Exhaust hoods handling grease-laden vapors in food preparation centers shall comply with National Fire Protection Association 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition. All hoods over cooking ranges shall be equipped with grease filters, fire extinguishing systems, and heat-actuated fan controls. Clean out openings shall be provided every 20 feet and at any changes in direction in the horizontal exhaust duct systems serving these hoods. (Horizontal runs of ducts serving range hoods should be kept to a minimum.)(B) Air change standards. When air change standards in Table 3 of §511.169(c) of this subchapter do not provide sufficient air for proper operation of exhaust hoods (when in use), supplementary filtered make-up air shall be provided in these rooms to maintain the required airflow direction and exhaust velocity. Make-up systems for hoods shall be arranged to minimize "short circuiting" of air and to avoid reduction in air velocity at the point of contaminant capture.(C) Air handling units. Air handling units serving the dietary suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §511.162(d)(4) of this subchapter and this paragraph.(A) Grease trap location. The kitchen grease traps shall be located and arranged to permit easy access without the need to enter food preparation or storage areas. Grease traps shall be of capacity required and shall be accessible from outside of the building without need to interrupt any services.(B) Grease traps or grease interceptors. Grease traps or grease interceptors shall be located outside the food preparation area and shall comply with the requirements in the National Association of Plumbing-Heating-Cooling Contractors (PHCC), National Standard Plumbing Code, 2000 edition.(C) Plumbing fixtures. The material used for plumbing fixtures shall be nonabsorptive and acid-resistant.(D) Water spouts. Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and containers.(E) Food handler hand washing fixtures. Hand washing fixtures used by food handlers shall be trimmed with valves that can be operated without hands. Single lever or wrist blade devices may be used. Blade handles used for this purpose shall not be less than four inches in length.(F) Drainage and waste piping. Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in food preparation centers, food serving facilities and food storage areas unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(G) Plumbing lines. No plumbing lines may be exposed overhead or on walls where possible leaks would create a potential for food contamination.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) Exhaust hoods. Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(B) Electrical circuits. The electrical circuit or circuits to equipment in wet areas shall be provided with five milliampere GFCI.(e) Emergency suite. This subsection applies to all LSRHs included under the LSRH license.(1) Architectural requirements.(A) Emergency treatment area.(i) Emergency treatment room. An LSRH shall provide at least one emergency treatment room and facilities to handle emergencies. The room and facilities shall meet the following requirements.(I) Single patient room area requirements. The emergency treatment room for a single patient shall have a minimum clear floor area of 120 square feet exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be 10 feet. The emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls.(II) Multiple-patient room area requirements. When a multiple-patient station emergency treatment room is provided, the clearance between the side of a gurney and a wall or partition shall be a minimum of four feet. The clearance between the sides of gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurney shall not be less than seven feet for single load area or room or ten feet for double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The multiple-patient station emergency treatment room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(III) Hand washing fixtures. One hand washing fixture with hands-free operable controls shall be provided for each gurney location. One hand washing fixture may serve two gurneys if distributed appropriately between the two.(IV) Storage space. Storage space shall be provided within the room or suite and be under staff control for general medical-surgical emergency supplies and medications. Adequate space shall be provided for emergency equipment such as emergency treatment trays, ventilator, defibrillator, splints, cardiac monitor, etc.(V) Medication preparation storage. Locked storage space shall be provided for drugs and an area for preparation of medication with a work counter, refrigerator, and hand washing fixture with hands-free operable controls.(VI) Stretcher and wheelchair storage. An alcove shall be provided for stretcher and wheelchair storage. The storage shall be located out of the line of traffic.(VII) Patient toilet room. At least one patient toilet room shall be provided and shall be convenient to treatment rooms, examination rooms, and holding rooms, and a hand washing fixture with hands-free operable controls.(VIII) Emergency entry signage. An emergency sign shall be provided at the entry from the public roads or streets serving the site. The emergency sign at the entry to the site shall be illuminated and connected to the emergency essential electrical system. Additional signs on-site may be required to direct patients to the emergency treatment area entrance when the emergency treatment area is not visible from the site entry. The letters on the entry sign shall be red with a contrasting background, all capitalized, at least eight inches in height, and an arrow indicating direction.(IX) Entrances. Separate ambulance and pedestrian entrances at grade level shall be well-illuminated, identified by signs, and protected from inclement weather. The ambulance entry shall have a drive under canopy for protection from inclement weather. The emergency access to permit discharge of patients from automobile and ambulances shall be paved. Parking shall be provided near and convenient to the pedestrian entrance.(X) Control station. A registration, reception, discharge or control station shall be located to permit staff observation and control of access to treatment rooms, pedestrian and ambulance entrances, and public waiting areas. When a dedicated triage space is provided, it shall include a counter with a hand washing fixture with hands-free operable controls.(XI) Public waiting room. A public waiting room shall be provided.(XII) Public facilities. Toilet facilities, public telephone, and drinking fountain shall be provided for the exclusive use of the waiting room.(XIII) Diagnostic radiographic (X-ray) room. Imaging facilities for diagnostic services shall be readily available to the emergency suite. If a separate radiographic (X-ray) room is installed within the emergency suite, it shall comply with the requirements in subsection (j)(1)(A) of this section. When the diagnostic X-ray room is exclusively used for the emergency treatment area, the dressing rooms may be omitted.(XIV) Laboratory unit. Laboratory services shall be made available to the emergency suite. If a separate laboratory workroom is installed within the emergency suite, it shall comply with the requirements in subsection (k)(1)(C)(i) of this section. All laboratory services provided on site or by contractual arrangement shall comply with §511.45 of this chapter (relating to Laboratory Services).(XV) Medical staff work area and charting areas. A medical staff work area and charting area shall be provided. The area may be combined with the reception and control area.(XVI) Clean storage room. A clean storage room shall be provided for clean supplies, linens, and medications as needed. A hand washing fixture shall be provided with hands-free operable controls.(XVII) Soiled workroom. The workroom shall contain a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles.(XVIII) Housekeeping room. The housekeeping room shall contain a floor receptor or service sink, storage space for housekeeping supplies and equipment, and be located within the suite. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided.(XIX) Staff toilets. Toilets may be outside the suite but shall be convenient for staff use and include hand washing fixtures with hands-free operable controls. When a department has four or more treatment or examination rooms, toilet facilities shall be in the suite.(ii) Other rooms. If an LSRH provides one or more of the following rooms, the room shall meet the applicable requirements in this clause.(I) Examination room. When provided, the examination room for a single patient shall have a minimum clear floor area of 100 square feet exclusive of fixed and movable cabinets and shelves. The minimum clear room dimension exclusive of fixed cabinets and built-in shelves shall be nine feet. The examination room shall contain cabinets, medication storage, work counter, examination light, and a hand washing fixture with hands-free operable controls.(II) Multi-bed examination room. When a multiple-patient station examination room is provided, the clearance between the side of the gurney and a wall or partition shall be a minimum of three feet. The clearance between sides of the gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurney shall not be less than seven feet for single load area or room or ten feet for double load area or room. Four feet of the passage space at the foot of the bed may be shared between two gurneys. The multiple-patient station examination room shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. One hand washing fixture shall be provided for every four gurneys or fraction thereof. Fixtures shall be uniformly distributed. The fixed and moveable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(III) Isolation room. The need for an airborne infection isolation room in the emergency suite shall be determined by the LSRH and the infection risk assessment. When an LSRH provides treatment rooms to perform procedures on persons who are known or suspected of having an airborne infectious disease, these procedures shall be performed in a designated treatment room meeting airborne infection isolation ventilation requirements. The isolation room shall have functional space in accordance with clause (i)(I) of this subparagraph, and meet the ventilation requirements contained in Table 3 of §511.169(c) of this subchapter.(IV) Secured holding room. When provided, this room shall be constructed to allow for security, patient and staff safety, patient observation, and sound mitigation. The secure holding room shall have a minimum clear floor area of 100 square feet exclusive of fixed cabinets. The minimum clear room dimension exclusive of fixed cabinets shall be 10 feet.(V) Orthopedic and cast room. When provided, the room may be in a separate room or in the trauma room. The room shall contain a work counter, storage for splints and orthopedic supplies, traction hooks, medication storage, examination light, and a hand washing fixture with hands-free operable controls. When a cast room is provided it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures.(VI) Film processing room. When a radiographic (X-ray) room is provided, a darkroom for processing film shall be provided unless the processing equipment does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the darkroom.(VII) Decontamination room. When provided, a decontamination room shall have an exterior entry point and as far as practical from any other entry point to the emergency treatment area. The internal door from the decontamination room shall open directly to the corridor into the emergency treatment area. The door shall swing into the room and be lockable against ingress from the corridor. The room shall have a minimum clear floor area of at least 80 square feet and a hand washing fixture with hands-free operable controls.(B) Holding or observation room area.(i) Location. When a holding or observation room or area is provided within or adjacent to the emergency suite, it shall comply with the following.(I) Single occupancy room area. A single occupancy holding or observation room shall have a minimum clear area of 100 square feet exclusive of fixed and movable cabinets and shelves. The holding or observation room shall contain a work counter and hand washing fixture with hands-free operable controls.(II) Single occupancy room location. The single occupancy holding or observation room shall be near the nurse station and near a patient toilet room that contains a hand washing fixture with hands-free operable controls.(III) Multiple occupancy room area. In a multiple occupancy holding or observation room or area, the clearance between the side of the gurney and a wall or partition shall be at least three feet. The clearance between sides of the gurneys shall be at least six feet. The minimum distance at the foot of the gurney shall not be less than seven feet for a single load area or room or ten feet for a double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The multiple occupancy holding or observation room or area shall contain cabinets, work counters, and a hand washing fixture with hands-free operable controls. One hand washing fixture shall be provided for every four holding or observation gurneys or fraction thereof. Fixtures shall be uniformly distributed. The fixed and moveable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(IV) Toilet room. In a multiple occupancy holding or observation room or area, a patient toilet room with a hand washing fixture with hands-free operable controls shall be provided within the room or area.(ii) Multiple occupancy room location. When a multiple occupancy holding or observation room is not within or adjacent to the emergency suite, the following additional spaces shall be provided:(I) a stretcher and wheelchair storage alcove, that shall be located out of the line of traffic;(II) a clean storage room for clean supplies, linen and medication as needed that is located within or adjacent to the holding or observation room and contains a hand washing fixture with hands-free operable controls;(III) a soiled workroom located within or adjacent to the holding or observation room and contains a work counter, a clinical sink or equivalent flushing type fixture, hand washing fixture with hands-free operable controls, waste receptacles, and soiled linen receptacles; and(IV) a housekeeping room located within or near the holding or observation room and contains a floor receptor or service sink and storage space for housekeeping supplies and equipment.(C) Trauma center. When provided, a trauma center shall comply with subparagraph (B) of this paragraph and the following requirements.(i) Trauma room. At least one trauma room shall be provided with 250 square feet of clear floor area exclusive of aisles and fixed and moveable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 12 feet. The trauma room shall contain a work counter, cabinets, medication storage, and examination light.(ii) Multiple-station trauma room. When multiple-patient stations are provided, the clearance between the head of the gurney to the wall or partition shall be at least three feet. The clearance between the side of a gurney and a wall or partition shall be at least six feet. The clearance between the sides of gurneys shall be at least twelve feet. The minimum distance at the foot of the gurney shall not be less than seven feet for a single load area or room or ten feet for a double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The multiple-station trauma room shall contain cabinets, medication storage, work counter, examination light, and scrub sink with hands-free operable controls. The fixed and moveable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(iii) Scrub facilities. A scrub station shall be located at the entrance to each trauma room either inside or outside of the room. One scrub station may serve two trauma gurneys. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts. The scrub sinks shall be recessed out of the main line of traffic.(iv) Doorways. All doorways openings from the ambulance entrance to the trauma room shall be at least five feet wide.(D) Emergency clinic. When an emergency clinic (that may also be referred to as "urgent care," "fast track," "express care," "minor care," etc.) is provided, the clinic shall be separate and distinct from the emergency treatment area and trauma center and shall meet all the requirements of subparagraph (A) of this paragraph. All facilities required by subparagraph (A) of this paragraph may be shared with the emergency treatment area and trauma center except for the emergency treatment room. An emergency treatment room in the emergency clinic shall not be less than 100 square feet. An emergency exam room in the emergency clinic shall not be less than 80 square feet.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Area. Trauma rooms shall have ceiling heights not less than nine feet.(ii) Fixtures. The decontamination room shall be equipped with two hand-held showerheads with temperature controls and a dedicated holding tank with a floor drain.(B) Finishes.(i) Flooring. Flooring used in a trauma room, treatment room, examination room, holding area, and soiled workroom shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter. Seamless type flooring is not required in the examination room in the emergency clinic.(ii) Ceiling. Ceilings in soiled workrooms, isolation rooms, and trauma rooms shall be of the monolithic type as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(iii) Surfaces. The decontamination room floor shall be self-coved to a height of six inches. The room shall have all smooth, nonporous, scrubbable, nonabsorbent and nonperforated surfaces.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Duct linings. Duct linings exposed to air movement shall not be used in ducts serving any trauma rooms, treatment rooms, examination rooms, holding areas, and clean room. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(B) Air supply. When a trauma room is provided under paragraph (1)(C)(i) of this subsection, the air supply for the trauma or surgical room shall be from ceiling outlets that are as near the work centers as possible, and a minimum of two low return inlets shall be located diagonally opposite from one another.(C) Return air inlets. Return air inlets shall be not lower than four inches nor higher than 12 inches from floor level.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) Medical gas systems. Medical gas systems shall be provided in accordance with §511.162(d)(4)(A)(iii) of this subchapter.(B) Ice machine. An ice machine shall be provided for therapeutic purposes and shall be located in the clean utility room. A self-dispensing ice machine shall be provided for ice for human consumption.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) General.(i) Examination room electrical receptacles. Each treatment and examination room in the emergency treatment area and trauma center shall have at least six duplex electrical receptacles located convenient to the head of each patient station.(ii) Emergency clinic suite electrical receptacles. Each treatment and examination room in the emergency clinic suite shall have a minimum of four duplex electrical receptacles located convenient to the head of each patient station.(iii) Work counter electrical receptacles. Each work counter and table shall have access to at least one duplex receptacle connected to the critical branch of the emergency electrical system.(iv) Film illuminators. The LSRH shall provide X-ray film illuminators for handling at least four films simultaneously in all treatment, examination, and trauma rooms in the emergency treatment area. When the entire emergency treatment area is provided with digital imaging, at least two X-ray film illuminators shall be provided within a central location within the emergency treatment area.(B) Nurses calling systems. The nurse call system shall comply with §511.162(d)(5)(L) of this subchapter and Table 7 of §511.169(g) of this subchapter.(f) Employees suite.(1) Architectural requirements.(A) Compliance. Architectural requirements shall comply with §511.162(d)(1) of this subchapter and this paragraph.(B) Lockers, lounges, toilets, and showers. Lockers, lounges, toilets, and showers shall be provided within the LSRH for employees and volunteers. These facilities are in addition to, and separate from, those required for the medical staff and the public.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this chapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(g) Engineering suite and equipment areas.(1) Architectural requirements. Architectural requirements comply with §511.162(d)(1) of this subchapter and this paragraph.(A) General. The following facilities shall be provided:(i) an engineer's office with file space and provisions for protected storage of facility drawings, records, manuals, etc.;(ii) a general maintenance shop or shops for repair and maintenance;(iii) a separate room for building maintenance supplies and equipment, and storage of bulk solvents and flammable liquids shall be in a separate building and not within the LSRH building;(iv) a medical equipment room that includes provisions for the storage, repair, and testing of electronic and other medical equipment;(v) a separate room or building for yard maintenance equipment and supplies. When a separate room is within the physical plant the room shall be located so that equipment may be moved directly to the exterior. Yard equipment or vehicles using flammable liquid fuels shall not be stored or housed within the LSRH building; and(vi) sufficient space in all mechanical and electrical equipment rooms for proper maintenance of equipment. Provisions shall also be made for removal and replacement of equipment.(B) Additional areas or rooms. Additional areas or rooms for mechanical, and electrical equipment shall be provided within the physical plant or installed in separate buildings or weatherproof enclosures with the following exceptions.(i) An area shall be provided for cooling towers and heat rejection equipment when such equipment is used.(ii) An area for the medical gas park and equipment shall be provided. For smaller medical gas systems, the equipment may be housed in a room within the physical plant in accordance with National Fire Protection Association 99, Standard for Health Care Facilities, 2012 edition (NFPA 99), Chapters 4 and 8.(iii) When provided, compactors, dumpsters, and incinerators shall be located in an area remote from public entrances.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(h) General storage. A general storage room shall be provided at least equal to five percent of the total area of the patient care units.(i) Hyperbaric suite.(1) Architectural requirements. When a hyperbaric suite is provided, it shall meet the requirements of NFPA 99 Chapter 20, and NFPA 101 Chapter 18.(A) Hyperbaric chamber clearances. Multiple occupancy chambers (Class A) shall comply with NFPA 99 Chapter 20. The minimum clearances for individual (Class B) hyperbaric chambers and the side of a chamber and a wall or partition shall be at least three feet. The clearance between sides of chambers shall be at least six feet. The minimum distance at the chamber entry shall not be less than seven feet for a single load area or room or ten feet for a double load area or room. Four feet of the passage space at the chamber entry may be shared between two chambers. The chamber room shall contain cabinets, medication storage, work counter and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the chamber clear floor space or area.(B) Service areas. The following minimum service areas and facilities shall be provided convenient to the hyperbaric chamber suite.(i) Patient waiting area. The area shall be out of traffic, under staff control, and shall have seating capacity in accordance with the LSRH's functional program. Patient waiting areas are not required where two or fewer individual hyperbaric chamber units are provided.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Holding area. A holding area under staff control shall accommodate patients on stretchers or beds. Stretcher patients shall be out of the direct line of normal traffic. The patient holding area is not required where two or fewer individual hyperbaric chamber units are provided.(iv) Patient toilet rooms. Toilet rooms shall be provided with hand washing fixtures with hands-free operable controls and with direct access from the hyperbaric suite.(v) Patient dressing room. A dressing room for outpatients shall be provided and shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate wheelchair patients.(vi) Staff facilities. Toilets with hand washing fixtures with hands-free operable controls may be outside the suite but shall be convenient for staff use. These facilities may be shared with an adjacent suite.(vii) Consultation room. An appropriate consultation room for individual consultation with referring clinicians shall be provided for outpatients. This room may be shared with an adjacent suite.(viii) Storage space. A clean storage space shall be provided for clean supplies and linens. The space shall contain a hand washing fixture with hands-free operable controls. The storage room may be shared with another department if convenient to both.(ix) Soiled holding room. A soiled holding room shall be provided with waste receptacles and soiled linen receptacles. This room may be shared with an adjacent suite.(x) Hand washing. A lavatory equipped for hand washing with hands-free operable controls shall be located in the room where the hyperbaric chambers are located.(xi) Housekeeping room. The housekeeping room shall contain a floor receptor or service sink, storage space for housekeeping supplies and equipment, and be located nearby.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) Grounding of hyperbaric chambers shall be connected only to the equipment ground in accordance with NFPA 99 §3-3.2.1.2, and National Fire Protection Association 70, National Electrical Code, 2011 edition (NFPA 70) Article 250 (A)-(C), and Article 517.(B) Additional grounds such as earth or driven grounds shall not be permitted.(C) The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(j) Imaging suite.(1) Architectural requirements.(A) General. An LSRH shall have a diagnostic radiographic (X-ray) room convenient to emergency suites, and where provided surgery suites.(i) Room size. All diagnostic imaging room sizes shall be in compliance with the manufacturer's recommendations for the specific equipment. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(ii) Radiation protection. When radiation protection is required for any diagnostic imaging room, a medical physicist licensed under the Texas Occupations Code Chapter 602 (relating to Medical Physicists), shall specify the type, location, and amount of radiation protection to be installed for the layout and equipment selections.(iii) Shielded control. Each room where radiation protection is required shall include a shielded control alcove. The control alcove shall be provided with a view window designed to permit full view of the examination table and the patient at all times.(iv) Warning signs. Warning signs capable of indicating that the equipment is in use shall be provided.(v) Ventilation requirements. Diagnostic and procedure room intended for patients with airborne infectious diseases shall meet the ventilation requirements as contained in Table 3 of §511.169(c) of this subchapter.(B) Diagnostic X-ray and radiographic and fluoroscopy (R&F) rooms. X-ray and R&F rooms shall comply with the manufacturer's recommendations for the specific equipment. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(i) Control alcove. A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) Toilet room. A toilet room shall be provided including a hand washing fixture with hands-free operable controls and have direct access to each R&F room and a corridor.(C) Noninvasive angiography imaging room. When noninvasive angiography imaging is provided, the room shall have a minimum clear floor area of 250 square feet exclusive of built-in shelves or cabinets. Clearance and unobstructed space shall not be less than three feet around the diagnostic equipment.(i) Control alcove. A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) Viewing room or area. A viewing room or area shall be provided and shall be at least 10 feet in length. The viewing room or area may be provided in combination with the control room.(iii) Scrub sink. A scrub sink shall be near the entrance to each angiographic room and shall be recessed out of the main traffic areas or corridor. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts.(iv) Storage space. Storage space for portable equipment and supplies shall be provided.(D) Computerized tomography (CT) scanning. When CT services are provided, the CT room's size shall comply with the manufacturer's recommendations and shall contain the following.(i) Control room. A control room shall be provided with a view window permitting view of the patient. The control room shall be located to allow convenient film processing.(ii) Patient toilet room. A patient toilet shall be provided conveniently to the procedure room. When directly accessible to the scan room, the toilet shall be arranged so that a patient may leave the toilet room without having to reenter the scan room. The toilet room shall have a hand washing fixture with hands-free operable controls.(E) Mammography. When mammography services are provided, the room shall have a minimum clear floor area of 100 square feet exclusive of built-in shelves or cabinets.(i) Control alcove. A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) Built-in shielding. When mammography machines with built-in shielding for the operator are provided, the alcove is not required when approved by a medical physicist licensed under Texas Occupations Code Chapter 602.(F) Magnetic resonance imaging (MRI). When MRI services are provided, the room shall be of sufficient size to house equipment but no less than 325 square feet of clear floor area exclusive of built-in shelves or cabinets.(i) Control alcove. A control alcove shall be provided with a view window designed to provide full view of the patient at all times.(ii) Computer room. A separate computer room shall be provided to accommodate the equipment.(iii) Cryogen storage requirements. When cryogen is provided, a storage room or closet shall have a minimum clear floor area of 50 square feet for two large dewars of cryogen. A storage room or closet is required in areas where service to replenish supplies is not readily available.(iv) Darkroom. When a darkroom is provided, the room shall be located near the required control room and shall be outside the 10-gauss field.(v) Spectroscopy. When spectroscopy is provided, caution should be exercised in locating it in relation to the magnetic fringe fields.(vi) Magnetic shielding. Magnetic shielding may be required to restrict the magnetic field plot. Radio frequency shielding is required to attenuate stray radio frequencies.(vii) Patient holding area. A patient holding area shall be provided and shall be located near the MRI unit and be large enough to accommodate stretchers.(viii) Hand washing fixture. A hand washing fixture with hands-free controls shall be provided near the entrance to the MRI room and shall be recessed out of the main traffic areas or corridor.(ix) 3T magnetic strength MRI. A 3T or larger magnetic strength MRI shall be secured behind locked doors. The patient and staff entrance to the MRI shall have a traffic pattern from the waiting, dressing, holding and work areas through a lockable control station before entering the MRI. At no time shall patients or nonpatients be allowed to enter this restricted area without MRI staff present when the magnet is active.(G) Ultrasound room. When ultrasound services are provided, the room's size shall comply with the manufacturer's recommendations. A patient toilet room shall be provided convenient to the procedure room and a corridor. The toilet room shall have a hand washing fixture with hands-free operable controls.(H) Cardiac catheterization laboratory. The cardiac catheterization laboratory is normally a separate suite, but may be within the imaging suite. If provided, a cardiac catheterization laboratory shall comply with the requirements of subsection (w)(1)(C) of this section.(I) Service areas. The following common service areas shall be provided.(i) Patient waiting area. The area shall be out of traffic and under direct staff visual control.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Holding area. The holding area shall be out of direct traffic patterns and under visual control by staff. At least one stretcher station shall be provided for each three diagnostic and procedure rooms or fraction thereof. The minimum clear floor space in the holding area shall be 80 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The area shall contain cabinets, a work counter, and a hand washing fixture with hands-free operable controls. The holding area may be reduced to 50 square feet exclusive of aisles and fixed and moveable cabinets and shelves for mammography, bone density, and other similar procedures.(iv) Post-procedure observation room. When invasive diagnostic X-ray services are provided with anesthesia, a room for extended post-procedure observation of patients shall be provided. The minimum clear floor space for the observation space shall be 100 square feet exclusive of aisles and fixed and moveable cabinets and shelves. The room shall contain cabinets, a work counter, and a hand washing fixture with hands-free operable controls.(v) Patient toilet rooms. A toilet room with hand washing facilities shall be located convenient to the waiting area.(vi) Patient dressing rooms or cubicles. Dressing rooms or cubicles shall be convenient to the waiting areas and X-ray rooms. Each room shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate wheelchair patients.(vii) Hand washing facilities. A hand washing fixture with hands-free controls shall be provided in or near the entrance to each diagnostic and procedure room unless noted otherwise. When a hand washing fixture is provided in the room, the fixture shall be located near the entrance to the room or near the staff entrance. When a hand washing fixture is located outside the room, the fixture shall be recessed in the egress corridor and located within five feet of the entrance to the room. Hand washing facilities shall be arranged to minimize any incidental splatter on nearby personnel or equipment.(viii) Staff facilities. Toilets may be outside the suite and may be shared with other departments but shall be convenient for staff use. When four or more diagnostic or procedure imaging rooms are provided, a staff toilet is required with a hand washing fixture with hands-free controls.(ix) X-ray film illuminator viewers. When all the diagnostic and imaging procedures are provided with digital imaging, two mounted X-ray film illuminator viewers shall be provided in the central viewing area or room.(x) Contrast media preparation. This room shall include a work counter, a sink with hands-free operable controls, and storage. One preparation room may serve any number of rooms. When prepared media is used, this area is not required, but storage shall be provided for the media.(xi) Film processing room. A darkroom shall be provided for processing film unless the processing equipment normally used does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the procedure rooms and to the quality control area.(xii) Quality control area or room. An area or room for film viewing shall be located near the film processor. All view boxes shall be illuminated to provide light of the same color value and intensity.(xiii) Film storage (active). When X-ray film is used, it shall be stored in a room with a cabinet or shelves for filing patient film for immediate retrieval.(xiv) Film storage (inactive). When X-ray film is used, a room for inactive film storage shall be provided. It may be outside the imaging suite, but must be under the administrative control of imaging suite personnel and be properly secured to protect films against loss or damage.(xv) Storage for unexposed film. When X-ray film is used, storage facilities for unexposed film shall include protection of film against exposure or damage.(xvi) Storage of cellulose nitrate film. When used, cellulose nitrate film shall be stored in accordance with the requirements of National Fire Protection Association 40, Standard for the Storage and Handling of Cellulose Nitrate Motion Picture Film, 2011 edition.(xvii) Additional spaces. When four or more diagnostic or procedure rooms are provided in the LSRH, the following shall be required:(I) an office for radiologists and assistants;(II) clerical office spaces, as necessary for the functional program;(III) consultation area or room;(IV) medication station. Storage and preparation of medication shall be done from a room, alcove area, or from a self-contained dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks are not acceptable for hand washing;(V) clean storage room. Clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls. When conveniently located, the clean storage room may be shared with another department; and(VI) soiled workroom. The soiled workroom shall not have direct connection to the diagnostic and procedure rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and soiled linen receptacle. When contaminated soiled material or fluid waste is not handled, only a soiled holding room shall be required.(xviii) Housekeeping room. The room may serve multiple departments when conveniently located.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Radiation protection. Radiation protection shall be designed, tested, and approved by a medical physicist licensed under Texas Occupations Code Chapter 602.(I) Room shielding. Room shielding calculations for linear accelerators, teletherapy units and remote control brachytherapy units must be submitted to the Department of State Health Services Radiation Control Program (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by RC inspectors, in the field, subsequent to use. Any changes in design or shielding that affects radiation exposure levels adjacent to those rooms requires prior approval by RC.(II) Facility design and environmental controls. Facility design and environmental controls associated with licensable quantities of radioactive material in laboratories, imaging rooms, or both shall be approved by RC prior to licensed authorizations.(ii) Protected alcoves. Where protected alcoves with view windows are required, provide a minimum of one foot six inches from the edge where the glazing and the frame connect and the outside partition edge.(iii) Ceilings. Imaging procedure rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(B) Finishes.(i) Flooring. Flooring used in contrast media preparation and soiled workroom shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Ceilings. A lay-in type ceiling is acceptable for the diagnostic and procedure rooms.(3) Mechanical Requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Cryogen gas venting and exhaust. The cryogen gas venting from the MRI unit shall be exhausted to the exterior. When a cryogen storage room is provided to replenish supplies, the storage room shall be vented and exhausted to the exterior.(B) Air conditioning. Self-contained air conditioning to supplement the cooling capacity in computer rooms is permitted.(C) Air handling units. Air handling units serving the imaging suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph. When automatic film processors are used, a receptacle of adequate size with hot and cold water for cleaning the processor racks shall be provided.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) General.(i) Each imaging procedure room shall have at least four duplex electrical receptacles.(ii) A special grounding system in areas such as imaging procedures rooms where a patient may be treated with an internal probe or catheter shall comply with NFPA 99 Chapter 9 and NFPA 70 Article 517.(iii) General lighting with at least one light fixture powered from a normal circuit shall be provided in imaging procedures rooms in addition to special lighting units at the procedure or diagnostic tables.(B) Nurses calling system. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(k) Laboratory suite.(1) Architectural requirements.(A) General.(i) Laboratory facilities. Laboratory facilities and services shall be provided by the LSRH such as hematology, clinical chemistry, urinalysis, cytology, anatomic pathology, immunohematology, microbiology, bacteriology and others.(ii) Code requirements. Each laboratory unit shall meet the requirements of NFPA 99 Chapter 11 (relating to Laboratories), and NFPA 101 Chapter 18 (relating to New Health Care Occupancies).(B) Minimum laboratory facilities. When laboratory services are provided off site by contract, the following minimum facilities shall be provided within the LSRH.(i) Laboratory work room. The laboratory workroom shall include a counter and a sink with hands-free operable controls.(ii) General storage. Cabinets or closets shall be provided for supplies and equipment used in obtaining samples for testing. A refrigerator or other similar equipment shall be provided for specimen storage waiting for transfer to off-site testing.(iii) Blood storage facilities. Refrigerated blood storage facilities for transfusions shall be provided. The blood storage refrigerator shall be equipped with temperature monitoring and alarm signals.(iv) Specimen collection facilities. A blood collection area shall be provided with a counter, space for seating, and hand washing fixture with hands-free operable controls. A toilet and lavatory with hands-free operable controls shall be provided for specimen collection. This facility may be outside the laboratory suite if conveniently located.(C) On-site laboratory facilities. When the LSRH provides on-site laboratory services, the following facilities shall be provided in addition to the requirements in subparagraphs (A) and (B) of this paragraph.(i) Laboratory workroom. The laboratory work room shall include a counter, space appropriately designed for laboratory equipment and a sink with hands-free operable controls.(ii) General storage. Storage, including refrigeration for reagents, standards, supplies, and stained specimen microscope slides, etc. shall be provided. Separate facilities shall be provided for such incompatible materials as acids and bases, and vented storage shall be provided for volatile solvents.(iii) Chemical safety facilities. When chemical safety is a requirement, provisions shall be made for an emergency shower and eye flushing devices.(iv) Flammable liquids. When flammable or combustible liquids are used, the liquids shall be stored in approved containers, in accordance with National Fire Protection Association 30, Flammable and Combustible Liquids Code, 2012 edition.(v) Radioactive materials. When radioactive materials are employed, storage facilities shall be provided.(D) Bone marrow laboratory. A cryopreservation laboratory and a human leukocyte antigen laboratory shall be provided in hospitals providing bone marrow transplantation services.(E) Service areas and facilities. The following service areas and facilities shall be provided.(i) Hand washing facilities. Each laboratory room or work area shall be provided with a hand washing fixture with hands-free operable controls.(ii) Office spaces. The scope of laboratory services shall determine the size and quantity for administrative areas including offices as well as space for clerical work, filing, and record maintenance. At a minimum, an office space shall be provided for the use of the laboratory service director.(iii) Staff facilities. Lounge, locker, and toilet facilities shall be conveniently located for male and female laboratory staff. These may be outside the laboratory area and shared with other departments.(iv) Housekeeping room. A housekeeping room shall be located within the suite or conveniently located nearby.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter. Floors in laboratories shall comply with the requirements of §511.162(d)(2)(B)(iii) of this subchapter except that carpet flooring shall not be used.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Air recirculation. No air from the laboratory areas shall be recirculated to other parts of the LSRH. Recirculation of air within the laboratory suite is allowed.(B) Laboratory hoods. When laboratory hoods are provided, they shall meet the following general requirements.(i) Face velocity. The average face velocity of each exhaust hood shall be at least 75 feet per minute.(ii) Exhaust system. The exhaust shall be connected to an exhaust system to the exterior that is separate from the building exhaust system. Biological safety cabinets with HEPA filters and alarms to alert staff do not have to be exhausted to the exterior. If the air changes for biological safety cabinets as provided in Table 3 of §511.169(c) of this subchapter do not provide sufficient air for proper operation of the safety cabinets (when in use), supplementary make-up air (filtered and preheated) shall be provided around these units to maintain the required airflow direction and exhaust velocity. Make-up air system for safety cabinets shall be arranged to minimize "short circuiting" of air and to avoid reduction in air velocity at the point of contaminant capture.(iii) Exhaust fan. The exhaust fan shall be located at the discharge end of the system.(iv) Exhaust duct system. The exhaust duct system shall be of noncombustible and corrosion- resistant material.(v) Fume hoods. Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(C) Special laboratory hoods. When special laboratory hoods are provided, they shall meet the following special standards for these types of hoods.(i) Associated equipment. Fume hoods, and their associated equipment in the air stream, intended for use with perchloric acid and other strong oxidants, shall be constructed of stainless steel or other material consistent with special exposures, and be provided with a water wash and drain system to permit periodic flushing of duct and hood. Electrical equipment intended for installation within such ducts shall be designed and constructed to resist penetration by water. Duct systems serving these hoods shall be constructed of acid-resistant stainless steel for at least 10 feet from the hood. Lubricants and seals shall not contain organic materials. When perchloric acid or other strong oxidants are only transferred from one container to another, standard laboratory fume hoods and the associated equipment may be used in lieu of stainless steel construction.(ii) Infectious or radioactive material laboratory hoods. Each laboratory hood used to process infectious or radioactive materials shall have a minimum face velocity of 90-110 feet per minute and be connected to an independent exhaust system, with suitable pressure-independent air modulating devices and alarms to alert staff of fan shutdown or loss of airflow. Each hood shall also have filters with a 99.97 percent efficiency (based on the dioctyl-phthalate (DOP) test method) in the exhaust stream, and be designed and equipped to permit the safe removal, disposal, and replacement of contaminated filters. Filters shall be as close to the hood as practical to minimize duct contamination.(iii) Radioactive isotope hoods. Fume hoods intended for use with radioactive isotopes shall be constructed of stainless steel or other material suitable for the particular exposure and shall comply with National Fire Protection Association 801, Standard for Facilities Handling Radioactive Materials, 2003 edition and NFPA 99 §11.3.5.(iv) Air modulating devices. Each laboratory hood shall have a suitable pressure-independent air modulating device and alarm to alert staff of fan shutdown or loss of airflow. The alarm shall be audible within the laboratory and at a 24-hour manned location.(D) Filtration requirements. Filtration requirements for air handling units serving the laboratory suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter.(E) Duct linings. Duct linings exposed to air movement shall not be used in ducts serving any laboratory room and clean room unless terminal filters of at least 80 percent efficiency are installed downstream of linings. This requirement shall not apply to mixing boxes and acoustical traps that have special coverings over such lining.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) General.(i) Faucet spouts. Faucet spouts at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of beakers, test tubes, etc.(ii) Sink drain lines. Drain lines from sinks used for acid waste disposal shall be made of acid-resistant material.(iii) Other drain lines. Drain lines serving some types of automatic blood-cell counters must be of carefully selected material that will eliminate potential for undesirable chemical reactions, explosions, or both between sodium azide wastes and copper, lead, brass, and solder, etc.(B) Medical gas systems. When provided, medical gas systems shall comply with §511.162(d)(4)(A)(iii) and (iv) of this subchapter. The number of outlets in the laboratory for vacuum, gases, and air shall be determined by the LSRH's functional program requirements.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(A) Blood storage refrigerator alarm. The blood storage refrigerator shall have an alarm device to indicate a temperature increase or malfunction and indicate an audible warning at a 24-hour manned location.(B) Blood storage refrigerator connection. The blood storage refrigerator shall be connected to the critical branch of the emergency essential electrical system.(C) Exhaust hoods. All exhausts hoods shall be connected to the emergency essential electrical system.(l) Laundry suite. Laundry facilities shall be provided on site or off site. On-site laundry services may be within the LSRH or in a separate building on-site. The laundry facilities shall be separated from a patient treatment room, patient examination room, and a patient diagnostic room, or areas of food preparation and storage, and areas in which clean supplies and equipment are stored.(1) Architectural requirements.(A) When laundry service is provided on site, it shall comply with the following.(i) Soiled and clean linen processing room. Soiled and clean linen processing rooms shall be provided. When the soiled and clean linen processing are combined in a single room, each process shall be physically separated within the room.(ii) Hand washing facilities. Adequate hand washing facilities shall be provided in both the soiled and clean processing areas.(iii) Receiving, holding, and sorting room. A receiving, holding, and sorting room for control and distribution of soiled linen shall be provided. This area may be combined with the soiled linens processing room. Discharge from soiled linen chutes may be received in the soiled room or area or in a separate dedicated room.(iv) Laundry processing room. A laundry processing room shall be provided with a commercial washer and dryer capable of processing at least a seven-day laundry supply within the regular scheduled work week.(v) Clean linen processing room. A clean linen processing room or area shall be provided with folding counters or tables. This area shall have provisions for inspections, folding, packing, and mending of linen.(vi) Storage room. A holding room or area for storage and issuing of clean linen shall be provided but may be combined with clean linen processing room.(vii) Storage space. Storage space and cabinets for soaps, stain removers, and other laundry processing agents shall be located in the soiled and clean processing room or areas.(viii) Laundry equipment. Laundry equipment shall be arranged so that the processing of laundry is an orderly work flow from soiled to clean operations. Cross-traffic shall be held to a minimum to prevent contamination.(B) Off-site laundry. When laundry service is provided off site, the following minimum requirements shall be provided on site:(i) a service entrance that shall have a drive under canopy for protection from inclement weather, for loading and unloading of linen;(ii) a control station for pickup and receiving. This may be a room at the common loading dock, in the soiled linen holding room, or the central clean linen storage room;(iii) a soiled linen holding room; and(iv) a central clean linen storage and issuing room in addition to linen storage required at the individual patient units.(C) Required areas or rooms. The following areas or rooms shall be provided regardless of delivery type of laundry service:(i) office space for the director of laundry services;(ii) cart storage rooms for clean and soiled linen. The cart storage areas may be provided within the clean and soiled rooms. Carts may not be parked or stored in the egress corridor;(iii) cart sanitizing facilities that comply with subsection (b) of this section;(iv) staff toilet in the laundry suite or convenient for staff use and with a hand washing fixture with hands-free operable controls;(v) lockers for staff use may be in laundry suite or part of a central locker room when convenient to the laundry; and(vi) housekeeping room within the laundry suite or available nearby.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter.(3) Mechanical Requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Ventilation system. The ventilation system shall include adequate intake, filtration, exchange rate, and exhaust in accordance with Table 3 and Table 4 of §511.169(c) and (d) of this subchapter, respectively.(B) Filtration. Filtration requirements for air handling units serving the laundry suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter.(C) Air flow. Direction of air flow of the HVAC systems shall be from clean to soiled areas.(D) Soiled processing ventilation. The ventilation system for soiled processing area shall have negative air pressure while the clean processing area shall have positive pressure.(E) Lint interceptors. Lint interceptors shall be located outside the laundry area. Drainage piping that serves laundry equipment shall employ suds-control features.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(m) Medical records suite.(1) Architectural requirements. The following rooms, areas, or offices shall be provided in the medical records suite:(A) medical records administrator or technician office;(B) review and dictating rooms or spaces;(C) work area that includes provisions for sorting, recording, scanning, or microfilming records; and(D) file room. When nondigital files are stored on site, the room shall be considered as hazardous. The construction protection for the storage room or area shall comply with Chapter 18 of NFPA 101 §18.3.2.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(n) Mental health and chemical dependency treatment.(1) General requirements. Areas that a patient receiving mental health or chemical dependency services at the LSRH may occupy shall comply with the requirements in this subsection.(2) Details and finishes.(A) Details.(i) Security. The type and degree of security and patient safety required in the suite shall be determined by LSRH administration and described in the LSRH's functional program narrative, unless stated otherwise within these rules.(ii) Visibility. All areas where a person receiving mental health services is located in the LSRH, including entrances to patient care rooms, shall be visible from the nurse station. Observation by video cameras of seclusion rooms, entrances, hallways, and activity areas shall be acceptable.(iii) Fasteners. All exposed and accessible fasteners shall be tamper-resistant.(iv) Hardware. Suitable hardware shall be provided on doors to toilet rooms so that access to these rooms can be controlled by staff. Hardware shall be utilized that is appropriate to prevent patient injury.(v) Breakaway fixtures. Only breakaway or collapsible clothes bars in wardrobes, lockers, and closets and shower curtain rods shall be permitted in areas that a patient receiving mental health or chemical dependency treatment services may occupy in the LSRH.(vi) Hangers. Wire coat hangers shall not be permitted in the suite.(vii) Special hardware. Special fixtures, hardware, and tamper-proof screws are required throughout the suite.(viii) Grab bars. Horizontal grab bars shall be constructed to prevent looping or tying of cords, ropes, etc.(ix) Safety glazing. Where glass fragments may create a hazard, safety glazing or other appropriate security features shall be incorporated.(B) Finishes. Patient sleeping rooms, patient toilet rooms and seclusion rooms shall have monolithic ceilings and bonded walls for patient safety and security measures. The ceiling in the soiled workroom shall be monolithic type as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall be in accordance with 25 TAC §133.163(t)(3) and this paragraph. Special consideration shall be given to the type of heating and cooling units, ventilation outlets, and appurtenance installed in patient-occupied areas of mental health nursing units. The following shall apply:(A) All air grilles and diffusers shall be of a type that prevents the insertion of foreign objects.(B) All convector or HVAC enclosures exposed in the room shall be constructed with rounded corners and shall have enclosures fastened with tamper-resistant fasteners.(C) HVAC equipment shall be of a type that minimizes the need for maintenance within the room.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with 25 TAC §133.163(t)(4) and this paragraph.(A) Piping systems.(i) Medical gas. Piped medical gas systems are not required.(ii) Sprinklers and showerheads. Only tamper-proof sprinkler and tamper-proof showerheads from which it is not possible to suspend any objects shall be installed.(B) Plumbing fixtures.(i) Faucet controls. Faucet controls shall not be equipped with handles that may be easily broken off.(ii) Bedpan washers. Bedpan washers are not allowed in patient bathrooms or toilet rooms.(5) Electrical requirements. Electrical requirements shall be in accordance with 25 TAC §133.163(t)(5) and this paragraph.(A) Nurse call. A nurse call system shall comply with the requirements of §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter. Pull cords shall not exceed 18 inches in length, and provisions shall be made to permit removal of call buttons and use of blank plates as required for security.(B) Each patient room shall have duplex grounded receptacles. There shall be one receptacle at each side of the head of each bed and one on every other wall. Receptacles in areas intended for mental health and chemical dependency patients of all ages shall be protected by GFCI breakers installed in distribution panel enclosures serving the unit.(C) Fifteen-ampere and 20-ampere, 125-volt receptacles intended to supply patient care areas shall be tamper-resistant as permitted by NFPA 70, §517-18, or shall be protected by GFCI breakers. A tamper-resistant receptacle is one that is constructed to limit improper access to its energized contacts.(o) Morgue.(1) Architectural requirements.(A) General. When a morgue or body-holding room is provided, it shall be located to avoid the need for transporting bodies of deceased patients through public areas. A body-holding room shall be provided.(B) Autopsy performed within LSRH. When autopsies are performed within the LSRH, the following rooms, areas, and equipment shall be provided.(i) Facilities. Refrigerated facilities shall be provided for body-holding.(ii) Room requirements. The autopsy room shall contain work counters, hand washing facilities with hands-free operable controls, autopsy table and storage space for supplies, equipment and specimens.(iii) Sink. A deep sink shall be provided for washing specimens.(iv) Change area. A clothing change area shall be provided with shower, toilet, hand washing facilities and lockers.(C) Service areas. The following service areas shall be provided:(i) a pathologist office;(ii) staff toilets may be outside the suite but be convenient for staff use with a hand washing fixture with hands-free operable controls; and(iii) a housekeeping room that meets the requirements of §511.162(d)(2)(A)(xxviii) of this subchapter shall be provided for the exclusive use of the morgue when autopsies are performed.(D) Minimum requirements. If autopsies are performed outside the LSRH, a well-ventilated, temperature-controlled, nonrefrigerated body-holding room shall be provided.(2) Details and finishes. Details and finishes shall be in accordance with §511.162(d)(2) of this subchapter and this paragraph.(A) Flooring used in the autopsy room shall be the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(B) Ceilings in the autopsy rooms shall be monolithic as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall be in accordance with §511.162(d)(3) of this subchapter and this paragraph.(A) The autopsy room shall be equipped with low exhaust grilles.(B) The body-holding room shall be ventilated in accordance with Table 3 of §511.169(c) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall be in accordance with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall be in accordance with §511.162(d)(5) of this subchapter and this paragraph. Refrigerators for body-holding in the autopsy room shall be connected to the equipment branch of the essential electrical distribution system.(p) Nuclear medicine suite.(1) Architectural requirements.(A) General. When nuclear medicine services are provided, the facilities may be in a separate suite or combined with an imaging suite.(i) Radiation protection. When nuclear medicine requires radiation protection, a medical physicist licensed under Texas Occupations Code Chapter 602 shall specify the type, location, and amount of radiation protection to be installed for the layout, equipment selections and storage, handling and disposal of radioactive material.(ii) Room size. The nuclear medicine room shall be sufficiently sized to house all fixed and moveable equipment and allow a minimum of three feet of clear and unobstructed working space on all sides of equipment accessible to staff and patient.(B) Radioisotope room (Hot lab). When radiopharmaceutical preparation is performed on site, the room shall include sufficient space for equipment, storage of radionuclides, chemicals for preparation, dose calibrators, and record keeping. When preprepared materials are used, storage and calculation area may be smaller than for on-site preparation.(i) Radiation shielding. The room and isotope handling areas within the room shall have appropriate radiation shielding.(ii) Radioisotope storage. There shall be a shielded area or enclosed shielded cabinet for long-term storage of decaying radioisotopes.(iii) Hood exhaust. When venting of radioactive gases is required, a hood shall exhaust to the exterior.(C) Positron emission tomography (PET). When PET services are provided, scanner and cyclotron rooms shall be in compliance with the manufacturer's recommendations and provide a minimum of three feet of clear and unobstructed working space on all sides of equipment accessible to staff and patient.(i) Control alcove. A control alcove shall be provided with a view window permitting view of the patient.(ii) Equipment area. An equipment area large enough to contain necessary electronic and electrical gear shall be provided.(iii) Dose administration room. A dose administration room with radiation shielding shall be located near the treatment room. Patients in route to procedure rooms shall not pass through public corridors and waiting rooms after injection with radioisotope.(iv) Patient toilet. A patient toilet with radiation shielding shall be provided with or adjacent to the dose administration room. The patient toilet room shall contain a hand washing fixture with hands-free operable controls.(D) Service areas.(i) Patient waiting area. The area shall be out of traffic and under direct staff visual control.(ii) Control desk and reception area. A control desk and reception area shall be provided.(iii) Dictation and report preparation area. The dictation and report preparation area may be incorporated with the control station.(iv) Holding area. The holding area shall be under direct staff control, out of the direct line of traffic, and have space for stretchers. The holding area shall accommodate two stretchers for the first procedure room with one additional station for each additional procedure room.(v) Patient toilet facilities. A toilet room with a hand washing fixture with hands-free operable controls shall be provided convenient to the waiting room and procedure room.(vi) Staff toilet facilities. Toilets and hand washing fixtures with hands-free operable controls may be outside the suite but shall be convenient for staff use.(vii) Patient dressing rooms or cubicles. Dressing rooms or cubicles shall be provided convenient to the waiting areas and procedure rooms. Each room or cubicle shall include a seat or bench, mirror, and provisions for hanging patients' clothing and for securing valuables. At least one dressing room shall be provided to accommodate patients using wheelchairs.(viii) Exam rooms. When examination rooms are provided, each room shall have a minimum of 100 square feet of clear floor area exclusive of built-in shelves or cabinets. Each exam room shall be equipped with a work counter and a hand washing fixture with hands-free operable controls.(ix) Dose administration area. When a dose administration area is provided, the area shall be located near the preparation area and include visual privacy for the patients.(x) Computer control area or room. Computer control area shall be located within or adjacent to the treatment room or rooms. When a centralized computer area is provided, it shall be a separate room with access terminals available within the treatment rooms.(xi) Film processing room. A darkroom shall be provided for film processing unless the processing equipment normally used does not require a darkroom for loading and transfer. When daylight processing is used, the darkroom may be minimal for emergency and special uses. Film processing shall be located convenient to the treatment room or rooms and to the quality control area.(xii) Quality control area or room. A quality control area shall include view boxes illuminated with light of the same color value and intensity.(xiii) Film storage room (active). A room with cabinet or shelves for filing patient film for immediate retrieval shall be provided.(xiv) Film storage room (inactive). A room for inactive film storage may be located outside the nuclear medicine suite, but must be under the administrative control of nuclear medicine personnel and properly secured to protect films against loss or damage.(xv) Digital imaging. If digital imaging is utilized throughout the suite, the darkroom film processing area and film viewers is not required.(xvi) Storage for unexposed film. Storage facilities for unexposed film shall include protection of film against exposure or damage.(xvii) Offices for physicians, oncologist, physicists, and assistants. Offices shall include provisions for individual consultation, viewing, and charting of film.(xviii) Clerical office spaces. Clerical office spaces shall be provided.(xix) Consultation room. A consultation room shall be provided.(xx) Clean storage room. A clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls. When conveniently located, the clean storage room may be shared with another department.(xxi) Soiled workroom. The soiled workroom shall not have direct connection to the nuclear medicine procedure or diagnostic rooms or sterile activity rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and soiled linen receptacle. When contaminated soiled material or fluid waste is not handled, only a soiled holding room is required.(xxii) Housekeeping room. The housekeeping room shall be located within the suite.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Radiation protection. Radiation protection shall be designed, tested and approved by a medical physicist licensed under Texas Occupations Code Chapter 602.(I) Room shielding. Room shielding calculations for the stipulated rooms within the nuclear medicine suite must be submitted to the Department of State Health Services Radiation Control Program (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by RC inspectors, in the field, subsequent to use. Any changes in design or shielding that affects radiation exposure levels adjacent to those rooms requires prior approval by RC.(II) Facility design and environmental controls associated with licensable quantities of radioactive material in laboratories or procedure rooms must be approved by RC prior to licensed authorizations.(ii) The nuclear medicine treatment rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(B) Finishes.(i) Flooring. Flooring used in the nuclear medicine procedure room, any work or treatment areas where radioactive material is handled, and soiled workroom shall be of the seamless monolithic type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Ceiling. Ceilings in radiopharmacy, hot laboratory, and soiled workrooms shall be monolithic as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Radiopharmaceutical preparations. When radiopharmaceutical preparations are performed, vents and traps for radioactive gases shall be provided.(B) Direction of air flow of the HVAC system shall be from nonradioactive spaces into the radioactive spaces. A minimum of two return air inlets located diagonally opposite from one another and near floor level shall be provided.(C) In the PET suite, special ventilation systems together with monitors, sensors, and alarm systems shall be required to vent gases and chemicals. The ventilation shall be directly to the exterior.(D) Filtration requirements for air handling units serving the nuclear medicine suite shall be equipped with filters having efficiencies equal to, or greater than specified in Table 4 of §511.169(d) of this subchapter.(E) Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood. Fume hoods shall be exhausted directly to the exterior.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) General.(i) Nuclear medicine procedure room. Each nuclear medicine procedure room shall have at least four duplex electrical hospital grade receptacles.(ii) Nuclear medicine procedures rooms shall have general lighting in addition to that provided by special lighting units at the procedure tables.(B) Nurses calling systems. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(q) Nursing unit. The requirements in this subsection apply to nursing units in LSRHs. Architectural requirements shall comply with §511.162(d)(1) of this subchapter and this subsection.(1) Accessibility requirements. At least 10 percent of each patient room type, isolation room, bathing units and toilets in medical/surgical, intermediate care, universal care, antepartum, postpartum, mental health, chemical dependency, and pediatric nursing units and all public and common use areas shall be designed and constructed to be Americans with Disabilities Act (ADA) accessible. These requirements shall apply in all new construction and when an existing nursing unit or a portion thereof is converted from one service to another (e.g., mental health care to medical or surgical nursing care).(2) Patient room suites. A patient room suite shall consist of the patient room and a bathroom. Patient room suites shall comply with the following requirements.(A) Maximum patient room capacity. The maximum patient room capacity shall be two patients. In existing facilities where renovation work is undertaken and the present capacity is more than two patients, the maximum room capacity shall be no more than the present capacity with a maximum of four patients.(B) Single-patient station room. In a single-patient station room, the minimum clear floor area shall be 120 square feet.(C) Multi (two)-patient station room. The clearance between the side of a station and a wall or partition shall be a minimum of three feet. The clearance between sides of stations shall be a minimum of five feet. The minimum distance at the foot of the station shall not be less than four feet for a single load area or room or seven feet for a double load area or room. Four feet of the passage space at the foot of the station may be shared between two stations.(D) Multi (two)-station accessible patient room. The clearance between the side of a station and a wall or partition shall be a minimum of five feet. The clearance between sides of stations shall be a minimum of four feet. The minimum distance at the foot of the station shall not be less than four feet for a single load area or room or seven feet for a double load area or room. Four feet of the passage space at the foot of the station may be shared between two stations.(E) Arrangement of patient rooms. Minor encroachments including columns and wall hung lavatories that do not interfere with functions may be ignored when determining space requirements for patient rooms.(i) Clear floor space. Required clear floor space in patient rooms shall be exclusive of toilet rooms, closets, lockers, built-in cabinets, wardrobes, alcoves, or vestibules.(ii) Visual privacy. Visual privacy shall be provided each patient in multi-station room. Design for privacy shall not restrict independent patient access to the corridor, lavatory, or bathroom.(F) Patient bathroom. Each patient shall have access to a bathroom without having to enter the general corridor area. Each bathroom shall contain a toilet with bed pan washers, hand washing fixture with hands-free operable controls, bathing facilities, and storage shelf or cabinet and serve not more than two patient rooms. Hand washing facilities shall be located in the patient room and in the patient bathroom. The hand washing fixture in the room shall be located outside of the patient's cubicle curtain in multi-station patient room.(G) Patient storage. Each patient shall have a separate wardrobe, locker, or closet that is suitable for hanging full-length garments and for storing personal effects. A minimum of 12 lineal inches of hanging space shall be provided per patient.(3) Airborne infection isolation suites. Where provided, a minimum of one isolation room shall be designated for pediatric patient care. Each airborne infection isolation suite shall consist of a work area, a patient room, and a patient bathroom.(A) The work area may be a separately enclosed anteroom or a vestibule that is open to and is located immediately inside the door to the patient room. It shall have facilities for hand washing, gowning, and storage of clean and soiled materials. One enclosed anteroom may serve multiple isolation rooms.(B) Each patient room shall have a clear floor area of 120 square feet exclusive of the work area and shall contain only one patient station. A patient bathroom shall be provided in accordance with paragraph (2)(F) of this subsection.(C) At least one airborne infection isolation suite with an enclosed anteroom shall be provided.(D) A door from an anteroom to an airborne infection isolation room and a door from an egress corridor into an anteroom shall be provided with a self-closing device. When an isolation room does not have an anteroom, the door from the egress corridor into the isolation room shall be provided with a self-closing device. When sliding doors are used in isolation rooms and in surgical suite post-anesthesia care units, the self-closing device may not be required as long as assurances of negative air pressure are met when sliding doors are opened.(E) Pressure differential monitors or air flow devices shall be installed outside the isolation room and anteroom. Devices shall be installed in corridors, passageways, etc.(F) Where a special assisted bathing facility is provided, it shall meet the requirements of this paragraph. including space for attendant, for patients on stretchers, carts, and wheelchairs. This may be on another floor if convenient for use. The central bathing room shall contain a bathtub that is accessible to a patient using a wheelchair or a shower that can accommodate a gurney. The room shall have space for drying and dressing and be provided with a hand washing fixture with hands-free operable controls and a toilet with three feet of clear space on sides and front of the water closet; The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(r) LSRH-based outpatient suite.(1) Architectural requirements.(A) Site, administration and public areas. The following areas shall be provided.(i) Public waiting area. Toilet facilities, public telephone, and drinking fountain shall be provided. When pediatric services are provided, pediatric and adult patients waiting areas shall be separate.(ii) Control station. A control station shall be located to permit staff observation of waiting area and control of access to LSRH-based outpatient clinical rooms.(iii) Wheelchair storage alcove. The alcove provided for wheelchair storage shall be located out of line of traffic.(iv) Interview space. Interview spaces shall be provided for social services, credit, and admissions. Provisions shall be made for privacy and dignity of the patient during interview, LSRH-based outpatient clinical services.(v) Office. At least one office shall be provided for business transaction, records, and administrative and professional staff.(B) LSRH-based outpatient room. The room shall have a minimum clear floor area of 100 square feet exclusive of fixed cabinets and shelves. Each examination room shall contain a work counter, cabinets, examination light and hand washing fixture with hands-free operable controls. A clearance of three feet shall be provided at each side and the foot of the examination table.(C) Service areas. The following service areas and facilities shall be provided within the outpatient suite unless noted otherwise.(i) Nurse stations. The nurse station shall contain a work counter, communication system, space for supplies, and provisions for charting.(ii) Hand washing fixtures. Hand washing fixtures with hands-free operable controls shall be available at all patient care areas.(iii) Patient toilet rooms. A toilet room shall be conveniently located to treatment rooms, examination rooms, and diagnostic rooms and shall include hand washing fixtures with hands-free operable controls.(iv) Staff toilet facilities. Toilet rooms equipped with hand washing fixtures with hands-free operable controls shall be provided for the exclusive staff use. Toilet facilities may be provided in conjunction with the staff lounge.(v) Staff lounge. A staff lounge with separate male and female staff clothing change rooms and toilets with hand washing fixtures with hands-free operable controls shall be provided in an LSRH having a total of six or more LSRH-based outpatient clinical rooms.(vi) Medication station. Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area, or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, a hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean workroom.(vii) Dictation and report preparation area. This area may be accessible from the lounge.(viii) Cast room. When a cast room is provided, it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures.(ix) Wheelchair and stretcher storage. Wheelchair and stretcher storage space or alcove shall be provided and located out of direct line of traffic.(x) Storage. Storage facilities shall be provided for office supplies, sterile supplies, pharmaceutical supplies, splints and other orthopedic supplies, and housekeeping supplies and equipment.(xi) Ice machine. A self-dispensing ice machine shall be provided.(xii) Clean workroom. A clean workroom or clean supply room shall be provided.(xiii) Storage room. A storage room for the outpatient services shall be provided at least equal to five percent of the total area of the outpatient suite. This required storage room area may be combined with general stores.(xiv) Soiled workroom. A soiled workroom shall be provided. It shall not have direct access to any patient treatment, examination, diagnostic rooms, or sterile rooms. The room shall contain a clinical sink or equivalent flushing rim fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle.(xv) Housekeeping room. The housekeeping room shall be located within the suite.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph. Treatment rooms shall be provided with seamless flooring in accordance with requirements contained in §511.162(d)(2)(B)(iii)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph. Filtration requirements for air handling units serving the outpatient and surgical suite shall be equipped with filters having efficiencies equal to, or greater than specified for patient care areas in Table 4 of §511.169(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph. Sinks used for the disposal of plaster of paris shall have a plaster trap.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(s) Pharmacy suite.(1) Architectural requirements.(A) General. The pharmacy room or suite shall be located for convenient access, staff control, and security for drugs and personnel.(B) Dispensing area. The pharmacy room or suite shall include the following functional spaces and facilities:(i) area for pickup, receiving, reviewing and recording;(ii) extemporaneous compounding area with sufficient counter space for drug preparation and sink with hands-free operable controls;(iii) work counter space for automated and manual dispensing activities;(iv) storage or areas for temporary storage, exchange, and restocking of carts; and(v) security provisions for drugs and personnel in the dispensing counter area.(C) Manufacturing. The pharmacy room or suite shall provide the following functional spaces and facilities for the manufacturing area:(i) bulk compounding area with work space and counters; and(ii) area for packaging, labeling and quality control.(D) Storage. The following spaces shall be provided in cabinets, shelves, or separate rooms or closets:(i) space for bulk storage, active storage, and refrigerated storage;(ii) storage in a fire safety cabinet or storage room that is constructed under the requirements for protection from hazardous areas in accordance with NFPA 101 Chapter 12, for alcohol or other volatile fluids, when used;(iii) storage in a secure vault, safe, or double locking wall cabinet for narcotics and controlled drugs; and(iv) storage space for general supplies and equipment not in use.(E) Intravenous (IV) solutions area. When IV solutions are prepared in a pharmacy, a sterile work area shall be provided and be in compliance with 22 TAC §291.133 (relating to Pharmacies Compounding Sterile Preparations) and the United States Pharmacopeia Chapter 797, Pharmaceutical Compounding-Sterile Preparations.(i) IV work area components. The IV work area shall consist of a preparation room, hood room and, if provided, a separate chemo-hood room. Access to the preparation room shall be through the pharmacy only, access to the hood room or chemo-hood room shall be through the preparation room only.(ii) Preparation room components. The preparation room shall contain a work counter, gowning area, and shelving.(iii) Hand washing fixtures. A hand washing fixture with hands-free operable controls shall be in the preparation room and within five feet of each entrance to the hood room or chemo-hood room. Hand washing fixtures and floor drains are not allowed inside the hood room or chemo-hood room.(iv) Laminar-flow hoods/work stations. Laminar-flow hoods/work stations shall be located inside the hood room.(F) Compounding aseptic isolator (CAI). When a CAI is used for compounding in lieu of the IV solutions area, it may be done within the pharmacy provided it complies with the following.(i) CAI requirements. The CAI shall provide isolation from the room and maintain the International Organization for Standardization (ISO) Class 5 (100 particles greater than or equal to 0.5 microns per cubic foot) levels during dynamic operating conditions including transferring ingredients, components, and devices into and out of the isolator and during preparation of compounded sterile preparations.(ii) Particle counts. The particle counts sampled shall be six to 12 inches upstream of the critical exposure site within the CAI and maintain ISO Class 5 levels during compounding operations.(iii) CAI documentation. The pharmacy shall obtain documentation from the manufacturer that the CAI will meet this standard when located in worse than ISO Class 7 (10,000 particles greater than or equal to 0.5 microns per cubic foot environments).(G) Administrative areas. The following functional spaces and facilities shall be included for the administrative areas:(i) office area for the chief pharmacist and any other offices areas required for records, reports, accounting activities, and patients profiles;(ii) poison control center with storage facilities for reaction data and drug information centers; and(iii) a room or area for counseling and instruction when individual medication pick-up is available for inpatients or outpatients.(H) Satellite pharmacy facilities. When provided, the room shall include a work counter, a sink with hands-free operable controls, storage facilities, and refrigerator for medications. As applicable, items required in subparagraphs (B) and (C) of this paragraph may be incorporated into the satellite pharmacy.(I) Service areas and facilities. The following service areas and facilities shall be provided.(i) Hand washing facilities. A hand washing fixture with hands-free operable controls shall be located in each room where open medication is handled except for IV prepared chemo-hood rooms.(ii) Staff facilities. Toilet rooms with hand washing fixture with hands-free operable controls may be outside the suite but shall be convenient for staff use.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Flooring. Flooring in the IV solutions area for the preparation room, hood room and chemo-hood room shall be seamless and coved to the wall.(B) Ceilings. IV solutions area ceiling and wall finishes for the preparation room, hood room and chemo-hood room shall be interlocking monolithic panels and sealed together or monolithic epoxy-painted gypsum board. The ceiling shall be coved to the wall.(C) Sealing requirements. All penetrations in the walls and ceilings shall be sealed.(D) Door requirements. The door from hood room shall swing into the preparation room. The door from preparation room shall swing into the chemo room. The door from preparation room shall swing into pharmacy.(3) Mechanical Requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Laminar-flow system. When IV solutions are prepared, the required laminar-flow system shall include a nonhygroscopic filter rated at 99.97 percent (HEPA). A pressure gauge shall be installed for detection of filter leaks or defects.(B) Fume hoods for chemotherapy. When fume hoods are used for chemotherapy, the air and fumes shall be exhausted directly to the exterior. The hood exhaust shall not use the building exhaust system. When more than one fume hood is in the same hood room and the work stations face each other, at least six feet must separate work area openings.(C) General fume hood requirements. When fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(D) Filtration. All air entering the IV solutions area for the preparation room, hood room and chemo-hood room shall be HEPA filtered.(E) Air pressure. In the IV solutions area the air pressure in the preparation room shall be positive to the pharmacy, the hood room shall be positive to the preparation room, and the chemo-hood room shall be negative to the preparation room.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) Material used for plumbing fixtures shall be nonabsorptive and acid-resistant.(B) Water spouts used at lavatories and sinks shall have clearances adequate to avoid contaminating utensils and the contents of carafes, etc.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) Under-counter receptacles. Under-counter receptacles and conduits shall be arranged (raised) to not interfere with cleaning of the floor below or of the equipment.(B) Exhaust hoods. Exhaust hoods shall have an indicator light indicating that the exhaust fan is in operation.(C) Electrical circuits. Electrical circuits to equipment in wet areas shall be provided with five milliampere GFCI.(t) Radiotherapy suite. When radiotherapy services are provided, the suite may contain equipment for electron beam therapy, radiation therapy, or both. The following facilities shall be provided.(1) Architectural requirements.(A) Radiation protection. Cobalt, linear accelerators, and simulation rooms require radiation protection. A medical physicist licensed under Texas Occupations Code Chapter 602, shall specify the type, location, and amount of radiation protection to be installed for the layout and equipment selections. Room layouts and construction shall prevent the escape of radioactive particles. Openings into the room, including doors, ductwork, vents, and electrical raceways and conduits, shall be baffled to prevent direct exposure to other areas of the facility.(B) Room size. Cobalt, linear accelerator, and simulator rooms shall be sized in accordance with the installed equipment requirements, patient access on a stretcher, medical staff access to the equipment and patient, and access for servicing the equipment.(C) Mold room. When a mold room is provided, it shall contain a ventilation hood exhausted to the exterior and a hand washing fixture with hands-free operable controls.(D) Block room. A block room with storage for the linear accelerator may be combined with the mold room.(E) Hot laboratory. A hot laboratory in support of cobalt therapy shall be provided.(F) Service areas. The following service areas shall be provided unless these are accessible from other departments such as imaging or outpatient areas:(i) a stretcher hold area adjacent to the treatment rooms, screened for privacy, and combined with a seating area for outpatients;(ii) exam rooms for each treatment room shall be at least 100 square feet and shall be provided with hand washing facilities;(iii) a patient gowning area with provisions for safe storage of valuables and clothing. At least one space shall be sized to allow for staff-assisted dressing;(iv) convenient access to a housekeeping room;(v) film file area;(vi) film storage area for unprocessed film; and(vii) a radioisotope decay room, that may be combined with the hot lab.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Radiation protection. Radiation protection shall be designed, tested, and approved by a medical physicist licensed under the Texas Occupations Code Chapter 602.(ii) Room shielding. Room shielding calculations for linear accelerators, cobalt, and simulation rooms shall be submitted to the Department of State Health Services Radiation Control Program (RC) for approval prior to use. Shielding in diagnostic radiographic rooms will be reviewed by inspectors, in the field, subsequent to use. Any changes in design or shielding that affects radiation exposure levels adjacent to those rooms requires prior approval by RC.(iii) Ceiling heights. The cobalt, simulation, and linear accelerator rooms shall have ceiling heights not less than nine feet. Ceilings containing ceiling-mounted equipment shall be of sufficient height to accommodate the equipment of fixtures and their normal movement.(iv) Ceiling-mounted equipment. Properly designed rigid support structures for ceiling-mounted equipment shall be located above the finished ceiling.(B) Finishes.(i) Flooring. Flooring in the soiled workroom and any work or treatment areas in the radiotherapy suite where radioactive materials are handled shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Walls. Walls shall be constructed of materials that are easily decontaminated from accidental radioactive spills and finished in accordance with §511.162(d)(2)(B)(iv) of this subchapter.(iii) Ceilings. Ceilings in the hot laboratory and soiled workroom shall be monolithic as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Fume hoods. Where fume hoods are used, the design should consider the placement and types of air distribution devices to avoid the disturbance of a uniform velocity across the face of the hood.(B) Radioactive material fume hoods. Each hood used to process radioactive materials shall have a minimum face velocity of 90-110 feet per minute, be connected to an independent exhaust system, with suitable pressure-independent air modulating devices and alarms to alert staff of fan shutdown or loss of airflow. Each hood shall also have filters with a 99.97 percent efficiency (based on the dioctyl-phthalate (DOP) test method) in the exhaust stream, and be designed and equipped to permit the safe removal, disposal, and replacement of contaminated filters. Filters shall be as close to the hood as practical to minimize duct contamination.(4) Plumbing fixtures and piping systems. Piping systems and plumbing fixtures shall comply with the requirements of §511.162(d)(4) of this subchapter.(5) Electrical requirements. Each radiotherapy suite shall comply with the requirements of §511.162(d)(5) of this subchapter and this paragraph.(A) Radiotherapy procedure room. Each radiotherapy procedure room shall have at least four electrical receptacles.(B) Ground fault circuit. Ground fault circuit interrupters shall not be used in radiotherapy procedure rooms.(C) Nurses calling system. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(u) Rehabilitation therapy suite. Rehabilitation therapy may include one or more categories of services. Where two or more rehabilitation services are provided, the services may share common areas when appropriate.(1) Architectural requirements.(A) Occupational therapy. When occupational therapy services are provided, the following rooms or areas shall be included:(i) an activity area with work areas, counters and a hand washing fixture with hands-free operable controls. Work areas and counters shall be suitable for wheel chairs;(ii) an area for teaching daily living activities with space for a bed, kitchen counter with appliances and sink, bathroom, and a table and chair. The daily living activities area may be combined with the activity area;(iii) an office for the occupational therapist; and(iv) a storage room for supplies and equipment.(B) Physical therapy. When physical therapy services are provided, the following rooms or areas shall be included.(i) Provisions shall be made for thermotherapy, diathermy, ultrasonics, and hydrotherapy when required by the LSRH's functional program.(ii) Treatment areas shall be provided with at least 70 square feet of clear floor area for each patient station, exclusive of four foot aisle space. Privacy screens or curtains shall be provided at each treatment station.(iii) A hand washing fixture with hands-free operable controls shall be provided in each treatment room or space. One hand washing fixture may serve up to four patient stations when cubicles or open room concepts are used and when the fixture is conveniently located.(iv) An area shall be provided for exercise and may be combined with treatment areas in open plan concepts.(v) An office shall be provided for the physical therapist.(vi) Separate storage shall be provided for soiled linen, towels, and supplies.(vii) A storage area or room for equipment, clean linen, and supplies shall be provided.(viii) When outpatient physical therapy services are provided, the suite shall have as a minimum patient dressing areas, showers and lockers. These shall be accessible and usable by people with disabilities.(C) Prosthetics and orthotics. When prosthetics and orthotics services are provided, the following rooms or areas shall be included:(i) work space with counters and shelves for technicians;(ii) a treatment space for evaluating and fitting with privacy screens or curtains; and(iii) a storage area or room for equipment and supplies.(D) Speech and hearing. When speech and hearing services are provided, the following rooms or areas shall be included:(i) a space for evaluating and treatment with privacy screens or curtains; and(ii) a storage area or room for equipment and supplies.(E) Service areas. The following areas or items shall be provided in a rehabilitation therapy suite, but may be shared when multiple rehabilitation services are offered:(i) patient waiting area out of traffic with space for wheelchairs;(ii) patient toilet facilities containing hand washing fixtures, with hands-free operable controls;(iii) reception and control stations shall be located to provide supervision of activities areas. The control station may be combined with office and clerical spaces;(iv) office and clerical space;(v) wheelchair and stretcher storage room or alcove that shall be in addition to other storage requirements;(vi) lockable closets, lockers or cabinets for securing staff personal effects;(vii) staff toilets may be outside the suite but shall be convenient for staff use and contain hand washing fixtures with hands-free operable controls;(viii) soiled holding room; and(ix) housekeeping room with service sink, conveniently accessible.(2) Details and finishes.(A) Details. Details shall comply with §511.162(d)(2)(A) of this subchapter.(B) Finishes. Finishes shall comply with §511.162(d)(2)(B) of this subchapter and this paragraph.(i) Flooring in a treatment room and soiled workroom shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Wall finishes shall comply with the requirements of §511.162(d)(2)(B)(iv) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph. Air handling units serving the rehabilitation therapy suite shall be equipped with filters having efficiencies equal to, or greater than specified for patient care areas in Table 4 of §511.169(d) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(v) Respiratory therapy suite. The type and extent of respiratory therapy services vary greatly in each LSRH.(1) Architectural requirements.(A) Respiratory therapy suite. When respiratory services are provided from a centralized area, the following rooms or areas shall be included:(i) an office for the respiratory therapist;(ii) office and clerical space with provision for filing and retrieval of patient records;(iii) receiving/decontamination workroom with work counter or table, a deep sink, and a hand washing fixture with hands-free operable controls;(iv) a storage room for clean and sterile supplies that is separate from the receiving/decontamination workroom;(v) when a blood gas analyzer is provided, it shall be located in a room and contain a counter and hand washing sink;(vi) when a portable blood gas analyzer is used, it may be used in rooms that have a work counter and hand washing facilities with hands-free operable controls and storage of the unit may occur in an alcove or equipment storage room;(vii) patient waiting area with space for wheelchairs;(viii) reception and control station with visual control of waiting and activities areas;(ix) patient toilet facilities that include hand washing fixtures with hands-free operable controls;(x) office and clerical space; and(xi) consultation/education room.(B) Cough-inducing and aerosol-generating procedures. All cough-inducing procedures performed on patients who may have infectious Mycobacterium tuberculosis shall be performed in rooms, booths or special enclosures using local exhaust ventilation devices with HEPA filters located at the discharge end and exhaust directly to the outside.(C) Service areas. The following areas and facilities shall be provided for the respiratory therapy suite but may be shared with other departments when conveniently located:(i) wheelchair and stretcher storage room or alcove that is in addition to other storage requirements;(ii) lockable closets, lockers or cabinets for securing staff personal effects;(iii) staff toilets that include a hand washing fixture with hands-free operable controls. Staff toilets may be located outside suite if location is near and convenient; and(iv) the housekeeping room shall be located within the suite or nearby, and shall contain a service sink and storage space for housekeeping supplies and equipment.(2) Details and finishes.(A) Details. Details shall comply with §511.162(d)(2)(A) of this subchapter.(B) Finishes. Finishes shall comply with §511.162(d)(2)(B) of this subchapter and this paragraph.(i) Flooring. Flooring in a decontamination room shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Wall finishes. Wall finishes shall comply with the requirements of §511.162(d)(2)(B)(iv) of this subchapter.(iii) Ceilings. Ceilings shall comply with §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter.(w) Special procedure suite.(1) Architectural requirements.(A) General. When special procedures such as endoscopy, bronchoscopy, and cardiac catheterization and other similar special procedures are provided, procedure rooms may be in a separate suite or may be part of the surgical suite.(i) When special procedure rooms are part of the surgical suite and noninvasive procedures are performed, these rooms are not required to be part of the sterile environment.(ii) Nonsurgical or noninvasive procedure rooms shall have a minimum clear floor area of 250 square feet, and a minimum clear dimension between fixed cabinets and built-in shelves shall be 14 feet.(iii) A hand washing fixture or a scrub sink with hands-free controls shall be located within five feet of the entrance to each nonsurgical procedure room either in the room or outside. Hand washing facilities shall be arranged to minimize any incidental splatter on nearby personnel or supply carts and recessed out of the main traffic areas.(iv) When general anesthesia or inhalation anesthetizing agents are used during special procedures, these rooms shall comply with the detail, finish, mechanical and electrical requirements for an operating room contained in subsection (x) of this section.(B) Special procedure room. Special procedure rooms for surgical cystoscopic and other endourologic procedures.(i) Room area. The procedure room shall have a minimum clear floor area of 350 square feet exclusive of fixed cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 15 feet.(ii) Room design. Procedure rooms shall be designed for visual and acoustical privacy for the patient.(iii) Scrub station. One scrub station shall be located within five feet of the outside entrance of each special procedure surgical room. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment, or supply carts. The scrub sinks shall be recessed out of the main traffic areas. The scrub sink shall be located off the restricted areas of the special procedure surgical procedure rooms. Scrub sinks or sinks shall not be located inside the sterile area.(iv) Changing rooms. Appropriately sized areas shall be provided for male and female changing rooms within the special procedure surgical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker or changing rooms shall be provided for male and female staff. The shower and toilet room may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the special procedure surgical suite can shower, change, and move into the restricted portions of special procedure surgical suite.(C) Catheterization laboratory. A catheterization procedure room may be in a separate suite, part of a special procedure suite, surgical suite, or in the imaging suite. The following items and facilities shall be provided.(i) The room shall be located in an area restricted to authorized personnel.(ii) The procedure room shall be a minimum of 400 square feet of clear floor area exclusive of fixed and movable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 18 feet.(iii) A control room shall have a view window that permits complete observation of the patient from the control console. The control room shall be large enough to contain the efficient functioning of the X-ray and image recording equipment.(iv) An area for viewing images and film file room shall be provided. When digital imaging is provided throughout the suite, at least two X-ray film illuminators shall be provided within a central location within the catheterization laboratory and the film file room is not required.(v) An equipment room large enough to contain X-ray transformers, power modules, and necessary electronics and electrical gear shall be provided.(vi) Appropriately sized areas shall be provided for male and female changing rooms within the catheterization laboratory suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate locker or changing rooms shall be provided for male and female staff. The shower and toilet rooms may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the catheterization laboratory can shower, change, and move into the restricted portions of catheterization laboratory.(vii) One scrub station shall be located within five feet of the outside entrance of each cardiac catheterization laboratory procedure room. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment, or supply carts. The scrub sinks shall be recessed out of the main traffic areas. The scrub sink shall be located off the restricted areas of the cardiac catheterization laboratory. Scrub sinks or sinks shall not be located inside the sterile area.(viii) Sterilizing facilities for immediate or emergency use shall be provided unless instruments are all disposable. A work space and hand washing fixture with hands-free operable controls shall be included.(D) Patient holding and preparation area. In suites with two or more special procedure rooms, a patient holding and preparation area shall be provided to accommodate ambulatory and stretcher patients and meet the following requirements:(i) two-stretcher stations shall be provided for first procedure room with one additional station for each additional procedure room;(ii) the minimum clear floor space in a private holding and preparation room shall be 100 square feet exclusive of toilet room, built-in cabinets, work counter, alcove, or vestibules. A hand washing fixture with hands-free operable controls shall be provided. A minimum of 10 feet width shall be provided for the head wall;(iii) in a multiple-station holding and preparation area, the clearance between the side of a gurney and a wall or partition shall be a minimum of three feet. The clearance between sides of gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurney shall not be less than seven feet for single load area or room or ten feet for double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The fixed and moveable cabinets and shelves shall not encroach upon the gurney clear floor space or area;(iv) a control station and charting area arranged to permit staff visual observation of holding and preparation area;(v) a work counter and a hand washing fixture with hands-free operable controls for every four gurneys located in the preparation area; and(vi) cubicle curtains at each station for patient privacy.(E) Recovery room or area. In suites with two or more special procedure rooms, a recovery room or area shall be provided to accommodate ambulatory and stretcher patients and meet the following requirements:(i) a minimum of one patient recovery station shall be provided for each special procedure room;(ii) in a single patient recovery room, there shall be a minimum clear area of 130 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of 10 feet width shall be provided for the head wall. The room shall contain cabinets, work counter, and a hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the gurney clear floor space or area;(iii) when multiple-gurney recovery patient stations are provided, the clearance between side of gurney and a wall or partition shall be a minimum of four feet. The clearance between sides of gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurneys shall not be less than eight feet for single load area or room or twelve feet for double load area or room. Four feet of passage space requirement at the foot of the gurney may be shared between two gurneys. The multiple-gurney recovery patient station shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the gurney clear floor space or area. One hand washing fixture with hands-free operable controls shall be provided for every four stations or fraction thereof;(iv) a nurse station with a hand washing fixture with hands-free operable controls and charting area shall be provided and arranged to provide visual observation of recovery room area;(v) a staff toilet room with a hand washing fixture with hands-free operable controls shall be provided and located within the working area to maintain staff availability to patients;(vi) cubicle curtains shall be provided at each station for patient privacy; and(vii) the recovery room or area may be within the patient holding area.(F) Instrument processing room. When instruments and equipment are processed, cleaned and disinfected within the suite, dedicated rooms shall be provided. The room may serve multiple procedure rooms. The following rooms shall be included.(i) A decontamination room shall be provided and equipped with work counters, two sinks remote from each other and a hand washing fixture with hands-free operable controls. One of the sinks shall be utility type.(ii) A clean room shall be provided and the process of cleaning the instruments or equipment shall flow from the contaminated area to the clean area, and finally, to storage. The room shall include a work counter and a hand washing sink fixture with hands-free operable controls. Instruments and equipment shall be protected from contamination.(iii) When endoscopy scope wash rooms are provided, cleaning, washing and drying may occur in the same room. The room shall contain two sinks.(G) Service areas. The following services shall be provided for all types of special procedure rooms unless noted otherwise.(i) Control station. In facilities with two or more special procedure rooms in a suite, a nurse station shall be provided and located to permit visual surveillance of all traffic that enters the special procedure rooms suite.(ii) Dictation and report preparation area. This area may be incorporated with the control station.(iii) Medication station. Provision shall be made for the storage and distribution of medication to be administered to patients. This may be done from a medicine preparation room, medicine alcove area or from a self-contained medicine dispensing unit. The medicine preparation room, medicine alcove area or self-contained medicine dispensing unit shall be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean work room.(iv) Patient toilet room. A toilet room shall be conveniently located to special procedure rooms and patient changing areas and shall include hand washing fixtures with hands-free operable controls.(v) Staff toilet facilities. Facilities shall be provided for exclusive staff use and include a hand washing fixture with hands-free operable controls. The toilet may be accessible from a staff lounge, when a staff lounge is provided.(vi) Storage. A storage room shall be provided for equipment and supplies used in the special procedure suite. Each special procedure suite shall provide at least 150 square feet of storage area or 50 square feet per procedure room, whichever is greater.(vii) Wheelchair and stretcher storage. A wheelchair and stretcher storage space or alcove shall be provided and located out of direct line of traffic.(viii) Staff storage. Storage space for employees' personal effects shall be provided.(ix) Ice machine. An ice machine shall be provided.(x) Clean storage room. A clean storage room shall be provided for clean supplies and linens. A hand washing fixture shall be provided with hands-free operable controls.(xi) Soiled workroom. The soiled workroom shall not have direct connection to the special procedure or diagnostic rooms or other sterile or clean activity rooms. The room shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle.(xii) Housekeeping room. A housekeeping room shall be provided for the exclusive use of the special procedure suite. It shall be directly accessible from the suite and shall contain a floor receptor or service sink and storage for supplies and housekeeping equipment.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details. Special procedure rooms shall have ceiling heights not less than nine feet.(B) Finishes.(i) Flooring. Flooring used in special procedure rooms, decontamination room, and in the soiled workroom shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Ceilings. Ceiling finishes in special surgical procedure rooms and isolation rooms, soiled workroom and sterile processing rooms shall be monolithic as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(iii) Nonsurgical special procedure room ceilings. A lay-in type ceiling is acceptable in nonsurgical special procedure rooms.(iv) Nonsurgical or noninvasive cauterization lab ceilings. A nonsurgical or noninvasive catheterization lab shall have a washable ceiling.(3) Mechanical Requirements. Mechanical requirements comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Air supply. Air supply for the special procedure rooms shall be from ceiling outlets that are as near the work centers as possible. At least two low return inlets shall be located diagonally opposite from one another.(B) Return air inlets. Return air inlets shall be not lower than four inches nor higher than 12 inches from floor level.(C) Smoke removal system. Smoke removal systems shall be provided in accordance with §511.162(d)(3)(D)(iv)(II) of this subchapter, for special procedure rooms that have piped-in nitrous oxide medical gas or where anesthesia is administered to patients.(D) Ventilation. The decontamination room shall meet the ventilation requirements that are contained in Table 3 of §511.169(c) of this subchapter.(E) Temperature and humidity indicating devices. Each special procedure room and recovery room shall have wall-mounted temperature and humidity indicating devices.(F) Airborne infection ventilation. When patients with airborne infectious disease are treated, the room shall meet requirements for airborne infection ventilation for patient care areas in accordance with Table 3 of §511.169(c) of this subchapter.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) Drainage and waste piping shall not be installed within the ceiling or installed in an exposed location in special procedure rooms and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(B) A medical gas system shall be provided in accordance with §511.162(d)(4)(A)(iii) and (iv), and Table 6 of §511.169(f) of this subchapter.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) General.(i) X-ray film illuminators. X-ray film illuminators for handling at least four films simultaneously shall be provided in a central location. When the entire special procedure suite is provided with digital imaging system capabilities, at least two X-ray film illuminators viewers shall be provided.(ii) Electrical receptacles. Each special procedure room shall have at least six duplex electrical hospital grade receptacles.(iii) Additional receptacles. In locations where mobile X-ray, laser, or other equipment requiring special electrical configuration is used, the additional receptacles shall be distinctively marked for the special use.(iv) GFCIs. The electrical circuits to equipment in wet areas shall be provided with GFCIs. GFCI circuits shall not be used in special procedure rooms. When ground fault circuit interrupters are used in critical areas, provisions shall be made to ensure that other essential equipment is not affected by activation of one interrupter.(v) Special grounding system. Special grounding system in areas such as special procedure rooms where a patient may be treated with an internal probe or catheter the ground system shall comply with NFPA 99 Chapter 10 and NFPA 70 Article 517.(vi) Lighting. Special procedures rooms shall have general lighting in addition to that provided by special lighting units at the procedure tables.(B) Nurses calling system. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(x) Surgical suite.(1) Architectural requirements.(A) General.(i) Waiting room. A public waiting room shall be provided.(ii) Toilet facilities. Toilet facilities, public telephone, and drinking fountains shall be provided within or nearby.(iii) Unrelated traffic. The surgical suite shall be located and arranged to preclude unrelated traffic through the suite.(B) General operating room. At least one operating room shall be provided and shall have a minimum clear floor area of 400 square feet exclusive of fixed and movable cabinets and shelves. The minimum clear dimension between fixed cabinets and built-in shelves shall be 20 feet. There shall be no direct access between operating rooms.(C) Operating rooms for cardiovascular, orthopedic, neurological, and other special surgical procedures that require additional personnel and large equipment.(i) When provided, these rooms shall have a minimum clear floor area of 600 square feet, with a minimum of 20 feet clear dimension exclusive of fixed or wall-mounted cabinets and built-in shelves.(ii) An additional room shall be provided in the restricted area of the surgical suite, preferably adjoining this operating room, where extra corporeal pumps, supplies and accessories can be stored and serviced.(iii) When complex orthopedic surgery and neurosurgery are performed, additional rooms shall be provided in the restricted area of the surgical suite, preferably adjoining the specialty operating rooms, for storage of equipment used during these procedures.(D) Preoperative patient holding areas or rooms. In facilities with two or more operating rooms, a patient holding area or rooms shall be provided. The preoperative patient holding area may be used for secondary recovery. The area shall meet the following requirements.(i) Clear floor space for private preoperative holding room. The minimum clear floor space in a private preoperative holding room shall be 100 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of nine feet width shall be provided for the head wall.(ii) Clear floor space for multiple-patient station preoperative holding area. In a multiple-patient station preoperative holding area, the clearance between the side of a gurney and a wall or partition shall be a minimum of three feet. The clearance between sides of gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurney shall not be less than seven feet for single load area or room or ten feet for double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The fixed and moveable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(iii) Control station. A control station and charting area shall be provided and arranged to permit staff visual observation of holding and preparation area.(iv) Work counter. A work counter with hand washing fixture with hands-free operable controls shall be provided and located in the preparation area.(v) Cubicle curtains. Cubicle curtains shall be provided at each station for patient privacy.(vi) Hand washing fixtures. One hand washing fixture with hands-free operable controls shall be provided for every four preoperative holding beds or fraction thereof. Fixtures shall be uniformly distributed. One hand washing fixture with hands-free operable controls shall be provided within each single-bed preoperative holding room.(E) Post-anesthesia care units.(i) Post-anesthesia care units (PACU) requirements. PACUs for surgical patients shall contain a medication distribution station, nurse station with charting facilities, clinical sink provisions for bedpan cleaning, and storage space for stretchers, supplies, and equipment. The nurse station shall be arranged to permit the staff to have full visual control of the PACU area.(ii) Patient station. At least one and a half patient stations per operating room shall be provided for post-anesthesia care or fraction thereof. At least two stations shall be provided when there is only one operating room.(iii) Private recovery room clear floor area. The minimum clear floor space in a private recovery room shall be 130 square feet exclusive of aisles and fixed and moveable cabinets and selves. A minimum of 10 feet width shall be provided for the head wall. The room shall contain cabinets, work counter, and hand washing fixture with hands-free operable controls. The fixed and movable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(iv) Multiple-gurney recovery patient station area. In multiple-gurney recovery patient stations, the clearance between the side of gurney and a wall or partition shall be a minimum of five feet. The clearance between sides of gurneys shall be a minimum of six feet. The minimum distance at the foot of the gurney shall not be less than eight feet for single load area or room or twelve feet for double load area or room. Four feet of the passage space at the foot of the gurney may be shared between two gurneys. The multi-gurney recovery patient station shall contain cabinets, medication storage, and work counter. The fixed and movable cabinets and shelves shall not encroach upon the gurney clear floor space or area.(v) Cubicle curtains. Cubicle curtains shall be provided for patient privacy.(vi) Doors. At least one door to the PACU room shall be within the surgical suite.(vii) Staff toilets. Staff toilet facilities and a hand washing fixture with hands-free operable controls shall be located within or immediately adjacent to the PACU.(viii) One hand washing fixture shall be provided for every four recovery beds or fraction thereof in open wards. Fixtures shall be uniformly distributed. One hand washing fixture shall be provided within each single-bed recovery room.(F) Separation of recovery patients. Provisions shall be made for separating all patients subject to general anesthesia from those who did not receive general anesthesia. This requirement may be satisfied by providing separate recovery rooms, cubicles, secondary recovery rooms, or scheduling of procedures.(G) Service areas. Services, except for the enclosed soiled workroom and the housekeeping room, may be shared with the obstetrical facilities if the LSRH's functional program reflects this concept. Service areas, when shared with delivery rooms, shall be designed to avoid the passing of patients or staff between the operating room and the delivery room areas.(i) Control station. A control station located to permit visual surveillance of all traffic entering the surgical suite shall be provided.(ii) Office. A supervisor's office or station shall be provided.(iii) Scrub facilities. Two scrub stations shall be located in the restricted corridor within five feet of the entrance of each operating room. Two scrub stations may serve two operating rooms if the scrub stations are located adjacent to the entrance of both operating rooms. Scrub facilities shall be arranged to minimize any incidental splatter on nearby personnel, medical equipment, or supply carts. Viewing panels shall be provided for observation of the surgical room interior. The scrub sinks shall be recessed out of the main traffic areas. The alcove shall be located within the restricted areas of the surgical suite. Scrub sinks shall not be located inside the sterile area.(iv) Substerile facilities. Sterilizing facilities located conveniently to the operating rooms for immediate or emergency use with work counter shall be provided.(v) Anesthesia workroom. The anesthesia workroom shall contain a work counter, sink with hands-free operable controls, and storage space for medical gas cylinders and other anesthesia equipment.(vi) Medication station. Storage and distribution of medication may be done from a medicine preparation room, medicine alcove area, or from a self-contained medicine dispensing unit but must be under visual control of nursing staff. A work counter, hand washing fixture with hands-free operable controls, refrigerator, and double-locked storage for controlled substances shall be provided. Standard cup-sinks provided in many self-contained units are not acceptable for hand washing. The medication station may be shared with the clean work room.(vii) General storage room. At least 50 square feet per operating room is required for general storage space. The minimum requirement for three operating rooms or less is 150 square feet. This storage room is exclusive of soiled holding, sterile supplies, clean storage, drug storage, locker rooms, and storage alcoves.(viii) Orthopedic surgery storage. Splints and traction equipment shall be stored in an enclosed storage room. Storage shall be outside the operating room but must be conveniently located.(ix) Storage alcove. An alcove or alcoves located out of the direct line of traffic shall be provided for the storage of stretchers, portable X-ray equipment, fracture tables, warming devices, auxiliary lamps, etc.(x) Surgical suite staff clothing change rooms. Appropriately sized areas shall be provided for male and female personnel working within the surgical suite. These areas shall contain lockers, showers, toilets, hand washing fixtures with hands-free operable controls, and space to change into scrub suits and boots. Separate changing rooms shall be provided for male and female staff. The shower and toilet room or rooms may be unisex. These areas shall be arranged to provide a traffic pattern so that personnel entering from outside the surgical suite can shower, change, and move directly into the restricted areas of the surgical suite.(xi) Lounge. A lounge shall be provided in an LSRH with three or more operating rooms. The lounge shall permit staff use without leaving the surgical suite and may be accessed from the clothing changing rooms. The lounge shall not have direct access from outside the surgical suite. When the lounge is remote from the clothing change rooms, toilet facilities and a hand washing fixture with hands-free operable controls accessible from the lounge shall be provided.(xii) Staff toilet facilities. Toilet facilities located in the surgical suite for exclusive staff use shall be provided and contain a hand washing fixture with hands-free operable controls. The toilet room may be accessible from a staff lounge, when provided.(xiii) Dictation and report preparation area. This may be accessible from the lounge area.(xiv) Cast room. When a cast room is provided, it shall be equipped with hand washing facilities, plaster sink, storage, and other provisions required for cast procedures. This room may be located in the emergency room.(xv) Ice machines. An ice machine shall be provided for therapeutic purposes. A self-dispensing ice machine shall be provided for human consumption.(xvi) Clean workroom or clean supply room. A clean workroom is required when clean materials are assembled within the surgical suite prior to use or following the decontamination cycle. It shall contain a work counter, a hand washing fixture with hands-free operable controls, storage facilities for clean supplies, and a space to package reusable items. The storage for sterile supplies must be in a separate room. When the room is used only for storage and holding as part of a system for distribution of clean and sterile supply materials, the work counter and hand washing fixture are not required.(xvii) Sterile core. When a surgical suite contains a sterile core, it shall be free of any cross-traffic of staff and supplies from the soiled or decontaminated areas to the sterile or clean areas. The use of facilities outside the operating room for soiled or decontaminated processing, clean assembly and sterile processing shall be designed to move the flow of goods and personnel from dirty to clean without compromising universal precautions or aseptic techniques in both departments.(xviii) Soiled workroom. The soiled workroom shall contain a clinical sink or equivalent flushing type fixture, work counter, hand washing fixture with hands-free operable controls, waste receptacle, and linen receptacle. The clinical sink and work counter may be eliminated if the room is used only for temporary holding of soiled material and cleaning of equipment and instruments and sterilization is provided outside the surgical suite. Provisions shall be made for the disposal of liquid waste. The soiled workroom shall be provided for the exclusive use of the surgical suite, shall be located in the restricted area of the surgical suite, and shall not have direct connection with operating rooms, delivery rooms, or other sterile activity rooms.(xix) Housekeeping room. A housekeeping room containing a floor receptor or service sink and storage space for housekeeping supplies and equipment shall be provided for the exclusive use of the surgical suite and shall be directly accessible from the surgical suite.(2) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter and this paragraph.(A) Details.(i) Ceiling height. Operating rooms shall have ceiling heights not less than nine feet.(ii) Noise minimization. Recreation rooms, exercise rooms, equipment rooms, and similar spaces where impact noises may be generated shall not be located directly over operating suites, unless special provisions are made to minimize such noise.(B) Finishes.(i) Flooring. Flooring within operating rooms, soiled workrooms and sterile processing rooms shall be of the seamless type as required by §511.162(d)(2)(B)(iii)(III) of this subchapter.(ii) Walls. Walls in operating rooms, special procedures rooms, and soiled workrooms shall comply with the requirements of §511.162(d)(2)(B)(iv)(II) of this subchapter.(iii) Ceilings. Ceilings in operating rooms, isolation rooms, soiled workroom, and sterile processing rooms shall be monolithic as required by §511.162(d)(2)(B)(vi)(III) of this subchapter.(3) Mechanical requirements. Mechanical requirements shall comply with §511.162(d)(3) of this subchapter and this paragraph.(A) Air supply for the operating rooms shall be from ceiling outlets near the center of the work area to efficiently control air movement. At least two return air inlets located diagonally opposite from one another and near floor level shall be provided. Design should consider turbulence and other factors of air movement to minimize airborne particulate matter. Where extraordinary procedures require special designs, the installation shall be reviewed on a case-by-case basis.(B) Smoke removal systems shall be provided in accordance with §511.162(d)(3)(D)(iv)(II) of this subchapter.(C) The ventilation system for anesthesia storage rooms and medical gases storage shall conform to the requirements of Chapter 5, NFPA 99 §5.1.3.3.3.(D) Each operating room, PACU, and recovery room shall be provided with conveniently mounted temperature and humidity indicating devices.(4) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter and this paragraph.(A) General.(i) Drainage and waste piping shall not be installed above or below ceilings in operating rooms, and sterile processing rooms unless precautions are taken to protect the space below from leakage and condensation from necessary overhead piping. Any required secondary protection shall be labeled, "code required secondary drain system" every 20 feet in a highly visible print or label.(ii) Floor drains shall not be installed in operating rooms. Flushing rim type floor drains may be installed in cystoscopic operating rooms. If a floor drain is installed in cystoscopy, it shall contain a nonsplash, horizontal-flow flushing bowl beneath the drain plate.(iii) Sinks used for the disposal of plaster of paris shall have plaster trap.(B) Medical gas systems. Medical gas systems and outlets that comply with §511.162(d)(4)(A)(iii) and Table 6 of §511.169(f) of this subchapter shall be provided.(5) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter and this paragraph.(A) General.(i) X-ray film illuminators for handling at least four films simultaneously shall be provided in each operating room. When the entire surgical suite is provided with digital imaging system capabilities, at least two X-ray film illuminator viewers shall be provided. The film illuminators shall be mounted within the central area of the suite.(ii) Each operating room shall have at least eight duplex electrical hospital grade receptacles of which three shall be located convenient to the head of the procedure table. Each PACU recovery station shall have at least seven receptacles at the head of each patient station.(iii) Special grounding system for critical care areas such as operating rooms, and special procedure rooms where patients are subjected to invasive procedures and connected to line-operated, electromedical devices shall comply with NFPA 99 Chapter 9 and NFPA 70 Article 517.(iv) Operating rooms and special procedure rooms shall have general lighting in addition to that provided by special lighting units at the surgical tables. Each fixed special lighting unit at the operating or delivery table shall be connected to an independent circuit powered by the critical branch of the essential electrical system. Portable units may share circuits. At least one general lighting fixture shall be served from a normal branch panel.(v) Operating rooms shall be provided with one or more battery-powered emergency lighting units as required by NFPA 99 §13.4.1.2.6(E).(vi) Operating rooms shall be provided with at least one receptacle powered from a normal power panel. Receptacle shall be labeled, "Normal power receptacle, use only in the event of loss of critical system."(B) Nurses calling system. The nurse call shall comply with §511.162(d)(5)(L) and Table 7 of §511.169(g) of this subchapter.(y) Labor, Delivery, and Recovery (LDR).(1) When provided, each LDR room shall have controlled access and shall be located so that a patient may be transported to the caesarean section operating room without the need to pass through other functional areas.(2) Each LDR room shall be designed for single occupancy and have a minimum clear floor area of 200 square feet exclusive of the infant resuscitation area, built-in shelves or cabinets, alcove, vestibule or other adjoining rooms. The minimum clear room dimension shall not be less than 11 feet.(3) A hand washing fixture with hands-free operable controls shall be provided in each LDR room.(4) Each LDR shall have direct access to and exclusive use of a bathroom with a shower, or tub with shower, hand washing fixture with hands-free operable controls and a toilet. Source Note: The provisions of this §511.163 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.163 Spatial Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215240 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215240 03/12/2026 (a) General. All limited services rural hospitals (LSRHs) with two or more floor levels shall have at least one electrical or electrical hydraulic elevator. Elevators shall also give access to all building levels normally used by the public. Escalators and conveyors are not required but, when provided, shall comply with these requirements and the requirement of §18.3 of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition.(b) Requirements for new elevators, escalators, and conveyors. New elevators, escalators and conveyors shall be installed in accordance with the requirements of A17.1 Safety Code for Elevators and Escalators, 2012 edition, published by the American Society of Mechanical Engineers (ASME) and the American National Standards Institute (ANSI).(1) Cars and doors.(A) Cars of hospital type elevators for patient transport shall not be less than five feet eight inches wide and not less than eight feet six inches deep inside the cab.(B) The car door opening shall not be less than four feet wide and seven feet high.(C) Elevator doors shall be B-labeled one-hour fire protection rated doors in buildings less than four stories, and one and one-half hour fire protection rated doors in buildings four or more stories.(2) Type of controls and alarms. Elevator cab lighting, control, communication, and signal systems shall be connected in accordance with NFPA 99 §4.4.2.2.2.2, 2012 edition.(3) Location. Conveyors, elevators, dumbwaiters, and pneumatic conveyors serving various stories of a building shall not open to an exit.(4) Elevator machine rooms. Elevator machine rooms that contain solid-state equipment for elevators having a travel distance of more than 50 feet above the level of exit discharge or more than 30 feet below the level of exit discharge shall be provided with independent ventilation or air conditioning systems required to maintain temperature during fire fighters' service operation for elevator operation. The operating temperature shall be established by the elevator equipment manufacturer's specifications and shall be posted in each such elevator machine room. When standby power is connected to the elevator, the machine room ventilation or air conditioning shall be connected to standby power.(c) Requirements for existing elevators, escalators, and conveyors. Existing elevators, escalators, and conveyors shall comply with ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators, 2008 edition. All existing elevators having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for fire-fighting or rescue purposes shall conform to Fire Fighters' Service Requirements of ASME/ANSI A17.3 as required by NFPA 101 §9.4.3.(d) Testing. All elevators and escalators shall be subject to routine and periodic inspections and tests as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators, 2007 edition. All elevators equipped with fire fighter service shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by NFPA 101 §9.4.6.(e) Certification. A certificate of inspection evidencing that the elevators, escalators, and related equipment were inspected in accordance with the requirements in Texas Health and Safety Code (HSC) Chapter 754 (relating to Elevators, Escalators, and Related Equipment), and determined to be in compliance with the safety standards adopted under HSC §754.014 and administered by the Texas Department of Licensing and Regulation shall be on record in each LSRH.(f) Where an LSRH has more than one floor, at least two elevators shall be provided. Source Note: The provisions of this §511.164 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.164 Elevators, Escalators, and Conveyors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215241 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215241 03/12/2026 (a) Multiple hospitals located within one building.(1) Identifiable location. Each hospital shall conform with all the requirements contained in Chapter 18 of the National Fire Protection Association 101, Life Safety Code, 2012 edition (NFPA 101), relating to New Health Care Occupancies.(A) The guest hospital shall be in one separately contiguous location.(B) In no case may a person leave the guest hospital, traverse the host hospital, and then reenter the guest hospital to access the remaining portion of the guest hospital.(C) A connecting stair within the host hospital may be used to connect the vertical contiguous areas of the guest hospital.(D) A guest hospital may not occupy two or more noncontiguous areas of a host hospital that contain intervening space of the host hospital even if on the same floor.(E) Construction of the host hospital building shall conform to the requirements of NFPA 101 Chapter 18, and the building shall be fully sprinklered.(2) Separate facilities. Each limited services rural hospital (LSRH) shall provide the following separate facilities:(A) a nursing unit in accordance with the requirements of §511.163(q) of this subchapter (relating to Spatial Requirements);(B) an administration office with an adjacent waiting room or waiting area;(C) a medical records room that conforms with the requirements of §511.163(m) of this subchapter;(D) a pharmacy suite that complies with §511.163(s) of this subchapter;(E) employee locker facilities that comply with requirements of §511.163(f)(1) of this subchapter;(F) a housekeeping room that complies with the requirements of §511.162(d)(2)(A)(xxviii) of this subchapter (relating to Construction Requirements);(G) emergency facilities as required by §511.163(e)(1)(A) of this subchapter;(H) imaging and other diagnostic services and facilities, in accordance with §511.46 of this chapter (relating to Radiologic Services) and §511.163(j) of this subchapter respectively;(I) laboratory services and a laboratory suite that comply with §511.163(k) of this subchapter, and §511.45 of this chapter (relating to Laboratory Services) of this chapter respectively;(J) where surgical services are provided, a surgical suite in accordance with §511.163(x) of this subchapter;(K) dietary services and dietary suite, including staff dining facilities, which comply with §511.53 of this chapter (relating to Dietary Services) and §511.163(d) of this subchapter respectively;(L) external signage at the building entrance that identifies each hospital; and(M) internal signage that provides directions to each hospital.(3) Means of egress. Means of egress from the host or guest hospital shall not be through a psychiatric hospital or a crisis stabilization unit or other area subject to locking. Means of egress may traverse through a hospital that conforms with the requirements of §511.161 of this subchapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located) or §511.162 of this subchapter. Stairs must have guardrails from the floor of the guest hospital to the level of exit discharge in accordance with NFPA 101 §7.2.2.4.5.(4) Additional services and facilities. Additional services and facilities when required in each licensed hospital may be provided by contractual agreement with the other hospital when the services and facilities comply with the specific requirements of Subchapter C of this chapter (relating to Operational Requirements) and §511.163 of this subchapter. Some services may be provided by contractual agreement with a commercial contractor; however, the following minimal facilities shall be provided on site by the host hospital and be located in one of the hospitals. If the host hospital fails to provide the facilities and services, the guest hospital shall describe to the Texas Health and Human Services Commission (HHSC) how it plans to provide services:(A) cart cleaning and sanitizing services and facilities that comply with §511.163(b) of this subchapter;(B) general storage services and facilities that comply with §511.163(h) of this subchapter;(C) housekeeping rooms as required in §511.162(d)(2)(A)(xxviii) of this subchapter;(D) parking facilities, in accordance with §511.162(c)(2) of this subchapter;(E) physical therapy, occupational therapy services and facilities, or both in accordance with §511.57 of this chapter (relating to Therapy Services), and §511.163(u) of this subchapter respectively;(F) patient activity facilities shall comply with the requirements for the specific service in accordance with §511.163 of this subchapter as follows: mental health and chemical dependency nursing units §511.163(n)(1) and rehabilitation therapy suite §511.163(u)(1)(A)(i) and (ii) of this subchapter;(G) respiratory care services and respiratory therapy suite that comply with §511.70 of this chapter (relating to Respiratory Care Services) and §511.163(v) of this subchapter respectively;(H) body-holding room that complies with §511.163(o)(1)(D) of this subchapter;(I) central sterile supply that complies with §511.163(c) of this subchapter respectively;(J) waste and waste disposal services and waste processing and storage units shall comply with §511.71 of this chapter (relating to Waste and Waste Disposal); and(K) emergency water storage requirement in Texas Administrative Code Title 25 §133.162(d)(4)(A)(i)(VIII) shall be required for the LSRH and the hospital and be located in either the LSRH or other hospital.(5) Building systems and equipment.(A) The following systems shall be provided separately in each hospital at a 24-hour staffed location.(i) Nurses calling systems shall be provided separately in each hospital in accordance with §511.162(d)(5)(L) and Table 7 in §511.169(g) of this subchapter (relating to Tables).(ii) Medical gas alarms shall be provided in each hospital.(iii) Fire alarm annunciator panels shall be provided in each hospital so that each hospital can monitor the other.(iv) An emergency generator annunciator panel shall be provided in each hospital.(B) Where applicable, the following systems may serve more than one hospital provided the systems meet the new construction requirements of §511.162 of this subchapter.(i) Air conditioning, heating, and ventilating systems.(ii) Drainage systems.(iii) Elevators.(iv) Fire sprinkler systems. The guest hospital may not be constructed in a host hospital when the host hospital is not fully sprinklered. The host and guest hospitals shall be fully sprinklered.(v) Medical piping systems.(vi) Stand pipe systems.(vii) Steam systems.(viii) Water supply systems, hot and cold (including emergency water storage).(ix) Electrical service and equipment.(I) Where applicable, the building electrical service, lighting, essential electrical system, and fire alarm system may be a part of or extension of those in the existing hospital, provided the existing systems meet these requirements. The host hospital shall be responsible for maintenance, testing and upkeep of the essential electrical system. Power and lighting distribution panels shall be within each hospital served and comply with the requirements of §511.162(d)(5)(E) of this subchapter. Electrical installation details shall conform with all requirements contained in §511.162(d)(5)(A) of this subchapter.(II) When the existing essential electrical system is nonconforming, the following options are available:(-a-) a separate conforming essential electrical system shall be provided in the guest hospital; or(-b-) separate transfer switches connected to the existing on-site generator(s) shall be provided when adequate capacity is available and the host hospital existing nonconforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by HHSC.(b) LSRHs located in buildings with licensed health care facilities other than hospitals.(1) Before an LSRH is licensed in a building containing other licensed health care facilities, all the requirements of this chapter and the following requirements shall be met.(A) Construction of the building shall conform to the requirements of NFPA 101 Chapter 18 and the building shall be fully sprinklered.(B) The LSRH shall be in one identifiable contiguous location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other licensed health care facility and comply with the requirements of this chapter.(i) In no case may a person leave the LSRH, traverse other licensed health care facilities, and then reenter the LSRH to access the remaining portion of the hospital.(ii) A connecting stair and elevator within the building shall be provided to connect the vertical contiguous areas of the LSRH.(iii) An LSRH may not occupy two or more noncontiguous areas of other licensed health care facilities that contain intervening space of the other licensed health care facilities even if on the same floor.(iv) Access to the LSRH shall be directly from a main lobby or an elevator lobby, if on an upper floor. The required means of egress from the LSRH may be through the other licensed health care facility except not through a psychiatric hospital or a crisis stabilization unit or other area subject to locking.(I) Each licensed facility shall be identified with external signage at the building entrance.(II) Internal signage shall provide direction to the LSRH.(v) The LSRH shall have services and facilities separate from the other licensed health care facility. The required facilities shall be located within the proposed LSRH proper.(vi) Common use of facilities using time-sharing concepts may be permitted on a case-by-case basis when the other health care facilities comply with the requirements contained in NFPA 101 Chapter 18 and §511.163 of this subchapter, and provided this chapter and the other health care facility licensing regulations allow.(C) The equipment and systems required in each new LSRH may be provided exclusively for the LSRH or by contractual agreement with a licensed health care facility. The equipment and systems shall comply with §511.162 of this subchapter.(i) The following equipment and systems shall be provided for the exclusive use of the LSRH, except where noted otherwise.(I) Where the LSRH is served by the building's normal electrical system, the breaker serving the LSRH shall originate in the main switchboard and shall be labeled, "Hospital Service - Contact Hospital Representative Prior to Opening Breaker".(II) The LSRH distribution panel board shall be within the LSRH.(III) An electrical room for the distribution of type I essential electrical system shall be provided separate from the building electrical room. The LSRH staff shall have access at all times to the essential electrical system room and the building's electrical room. The LSRH shall be responsible for maintenance, testing, and upkeep of the essential electrical system. When the existing essential electrical system owned and operated by the other licensed health care facility is nonconforming, the following options are available:(-a-) a separate conforming essential electrical system shall be provided in the new LSRH; or(-b-) separate transfer switches connected to the existing on-site generator shall be provided when adequate capacity is available and the other health care facility existing nonconforming system shall be corrected. Corrections shall be made in accordance with a plan of correction approved by HHSC.(IV) An emergency generator may be shared when adequate capacity is available. Separate transfer switches shall be provided to serve the LSRH and other licensed health care facilities. The LSRH shall be the owner of the generator, have access to the generator at all times, and shall be responsible for maintenance, testing and upkeep of the generator.(V) The LSRH shall meet the emergency water storage requirement under 25 TAC §133.162(d)(4)(A)(i)(VIII) and the storage shall be located within the LSRH.(VI) When the other licensed health care facilities have a fire alarm control center or a main building alarm panel at the main lobby entrance, the LSRH shall have an annunciator panel at a 24-hour staffed location. The LSRH staff shall have access at all times to the main building fire alarm system panels and shall be responsible for verifying the maintenance and upkeep of such system.(VII) Fireman's test valve for the fire sprinkler system.(VIII) Air conditioning, heating, and ventilating systems.(IX) The medical gas supply sources may be shared provided the LSRH is owner of the medical gas system source and is responsible for maintenance, testing and upkeep of the supply sources. The LSRH and other occupancies shall have separate main supply shutoff valves. The LSRH shall be provided with an alarm panel within the LSRH that monitors the medical gas system supply source serving the other licensed health care facilities.(X) Medical vacuum and medical air.(XI) Nurses calling systems.(ii) Where applicable, the following systems may be a part or extension of those in the existing licensed health care facility, provided the existing systems meet the requirements of this chapter for new construction.(I) Drainage systems.(II) The LSRH shall be served by the number and size of elevators cabs in accordance with §511.164 of this subchapter (relating to Elevators, Escalators, and Conveyors). The elevators cab lighting, control, communication, and signal systems shall be connected to the life safety panel of the essential electrical system.(III) The new LSRH may not be constructed in the other health care facility when the other health care facility is not fully sprinklered. The new LSRH and the other health care facility shall be fully sprinklered.(IV) Stand pipe systems.(V) The LSRH is responsible for providing all backup systems (such as boilers) as required in this chapter.(VI) Domestic water supply systems, hot and cold.(VII) Mechanical chilled and hot water systems.(2) When an LSRH and a psychiatric hospital share one building, the building systems and equipment may be shared in accordance with subsection (a)(5)(B) of this section, or be provided separately.(c) LSRHs in buildings with non-health care occupancies.(1) General. Before an LSRH is licensed in a building also containing occupancies other than health care occupancies, all requirements of this chapter and the following requirements shall be met.(A) Construction of the building shall conform to the requirements of NFPA 101 Chapter 18, and the building shall be fully sprinklered.(B) The LSRH shall be in one identifiable contiguous location and shall be separated (vertically and horizontally) with two-hour fire rated noncombustible construction from the other occupancies.(i) In no case may a person leave the LSRH, traverse other occupancies, and then reenter the LSRH to access the remaining portion of the LSRH.(ii) A connecting stair and elevator within the building shall be provided to connect the vertical contiguous areas of the LSRH.(iii) An LSRH may not occupy two or more noncontiguous areas of other occupancies that contain intervening space of the other occupancies even if on the same floor.(C) Access to the LSRH shall be through a dedicated LSRH lobby or from the building's main lobby. The building's main lobby shall be part of the LSRH and shall comply with the requirements of §511.162 of this subchapter.(i) External signage shall be provided at the building entrance that identifies the LSRH.(ii) Internal signage shall be provided to give directions to the LSRH.(D) The required means of egress from the LSRH shall be independent of and shall not traverse through the other occupancies.(E) Stairs shall have guardrails and handrails from the floor of the LSRH to the level of exit discharge in accordance with NFPA 101 §7.2.2.4.5.(2) Services and facilities. Services and facilities shall be provided exclusively for the LSRH in accordance with Subchapters C and F of this chapter (relating to Operational Requirements and Fire Prevention and Safety respectively) and this subchapter. Required services and facilities shall not be shared with the other occupancies except as noted in paragraph (3) of this subsection.(3) Building equipment and facilities. The equipment and systems shall comply with §511.162 of this subchapter.(A) The following equipment and systems shall be provided for the exclusive use of the LSRH except where noted otherwise.(i) An electrical room for the distribution of type I essential electrical system shall be provided separate from the building electrical room. LSRH staff shall have access at all times to the essential electrical system room and the building's electrical room or rooms. The LSRH is responsible for maintenance, testing and upkeep of the essential electrical system.(ii) An emergency generator may be shared when adequate capacity is available. Separate transfer switches shall be provided to serve the LSRH and other building occupancies. The LSRH shall be the owner of the generator, have access to the generator at all times, and shall be responsible for maintenance, testing and upkeep of the generator.(iii) Emergency water storage located within the LSRH.(iv) When the building has a fire alarm control center or a main building alarm panel at the main lobby entrance, the LSRH shall have an annunciator panel at a 24-hour staffed location. The LSRH staff shall have access at all times to the main building fire alarm system panels and shall be responsible for verifying the maintenance and upkeep of such system.(v) Fireman's test valve for the fire sprinkler system.(vi) The medical gas supply sources may be shared provided the LSRH is owner of the medical gas system supply source and is responsible for maintenance, testing, and upkeep of the supply sources. The LSRH and other occupancies shall have separate main supply shutoff valves. The LSRH shall be provided with an alarm panel within the LSRH that monitors the medical gas system serving the other occupancies.(vii) Medical vacuum and medical air.(viii) Air handling units of other occupancies may not be used for the LSRH. The LSRH air handling units may share the supply source for other occupancies but shall not return air from the other occupancies back to the air handling unit.(ix) Nurses calling systems.(B) Where applicable, the following systems may be a part or extension of those in the existing building occupancies provided the existing systems meet the requirements of this chapter for new construction.(i) Where the LSRH is served by the building's normal electrical system, the breaker serving the LSRH shall originate in the main switchboard and shall be labeled, "Hospital Service - Contact Hospital Representative Prior to Opening Breaker."(ii) The LSRH's distribution panelboard shall be within the LSRH.(iii) Drainage systems.(iv) The LSRH shall be served by the number and size of elevators cabs in accordance with §511.164 of this subchapter. The elevators cab lighting, control, communication, and signal systems shall be connected to the life safety panel of the essential electrical system.(v) The LSRH may not be constructed in the other type of building occupancies when the other types of occupancies are not fully sprinklered. The LSRH and the other occupancies shall be fully sprinklered.(vi) Stand pipe systems.(vii) Fire pump, where applicable; LSRH staff shall have access at all times to the location of the fire pump to verify compliance and maintenance.(viii) The LSRH is responsible for providing all backup systems (such as boilers) that are required in this chapter.(ix) Domestic water supply systems, hot and cold. Source Note: The provisions of this §511.165 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.165 Building with Multiple Occupancies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215242 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215242 03/12/2026 (a) Definitions. The following words and terms, when used in this Section, have the following meanings, unless the context clearly indicates otherwise.(1) Mobile unit--Any pre-manufactured structure, trailer, or self-propelled unit equipped with a chassis on wheels and intended to provide shared medical services to the community on a temporary basis. Some of these units are equipped with expanding walls and designed to be moved on a daily basis.(2) Relocatable unit--Any structure, not on wheels, that is built to be relocated at any time and provide medical services. These structures vary in size.(3) Transportable unit--Any pre-manufactured structure or trailer, equipped with a chassis on wheels, intended to provide shared medical services to the community on an extended temporary basis. These units are designed to be moved periodically, depending on need.(b) General. When mobile, transportable, and relocatable units are utilized to provide patient treatment services on the limited services rural hospital (LSRH) premises, these units shall be treated as buildings and constructed to the required occupancy as follows.(1) When such units are provided for diagnostic, treatment, or procedural services to patients who are litter borne, under general anesthesia, or incapable of self-preservation, the unit shall be constructed in accordance with Chapter 18 of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, relating to health care occupancy.(2) When such units provide diagnostic, treatment, or procedural services to patients who are not litter borne, not under general anesthesia, and are capable of self-preservation, the unit may be constructed in accordance with Chapter 38 of NFPA 101 (relating to Business Occupancy).(c) Common elements.(1) Site requirements.(A) Sites shall have a level concrete or asphalt pad and be designed for the structural loads of the unit.(B) The sites shall provide hazard-free drop-off zones and adequate parking for patients. The site and location of the unit shall not restrict access for fire or emergency vehicles.(C) Each site shall provide access to the unit for people with disabilities, and wheelchair and stretcher patients.(D) When a mobile, transportable, or relocatable unit is not physically attached to the LSRH and provides inpatient services, a covered walkway or enclosure from the LSRH to the unit shall be provided to ensure patient safety from the outside elements.(E) The location of the unit shall be such that engine exhaust fumes from the unit are kept away from any fresh air intake of the LSRH.(F) When a mobile, transportable, or relocatable unit is permanently connected appropriately for the climate to the LSRH or the unit does not move on a regular basis, e.g., every 90 days or less, the units shall be provided with the following equipment and systems connected to the LSRH:(i) fire alarm system;(ii) sprinkler system;(iii) electrical system and the essential electrical system;(iv) water and waste water system;(v) medical gas systems; and(vi) nurses calling systems.(2) Support services. Support services shall meet the requirements of this chapter for new construction. These support services and areas shall be provided either within the mobile, transportable, or relocatable unit or located within the LSRH adjacent to the unit served.(3) Details and finishes. Details and finishes shall comply with §511.162(d)(2) of this subchapter (relating to General Construction Requirements).(4) Mechanical requirements. Mechanical requirements comply with §511.162(d)(3) of this subchapter.(5) Piping systems and plumbing fixtures. Piping systems and plumbing fixtures shall comply with §511.162(d)(4) of this subchapter.(6) Electrical requirements. Electrical requirements shall comply with §511.162(d)(5) of this subchapter. Source Note: The provisions of this §511.166 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.166 Mobile, Transportable, and Relocatable Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215243 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215243 03/12/2026 (a) General.(1) A limited services rural hospital (LSRH) owner or operator may not begin construction of a new building, additions to or renovations, or conversions of existing buildings until the Texas Health and Human Services Commission (HHSC) approves final construction documents.(2) Plans and specifications describing the construction of new buildings and additions or renovations and conversions of existing buildings shall be prepared by a registered architect, a licensed professional engineer, or both, and meet the requirements of this subchapter.(3) The names of spaces used in the LSRH's functional program narrative, preliminary documents, final construction documents, and specifications shall be consistent with the names of the spaces used in this chapter.(4) HHSC shall notify the LSRH's owner or operator of the result of its review of each type of submission discussed in this section.(5) The LSRH owner or operator shall respond to all HHSC requests for additional information, including providing a plan of correction for deficiencies cited by HHSC.(6) Once final construction documents are approved, the LSRH owner or operator shall request inspections in accordance with §511.168 of this subchapter (relating to Construction, Inspections, and Approval of Project).(7) When construction is delayed for longer than one year from the plan approval or self-certification approval date, the LSRH shall resubmit construction documents to HHSC for review and approval. The plans shall be accompanied by a new Application for Plan Review, plan review fee, and functional program narrative.(8) The LSRH owner or operator shall provide written notification to HHSC when a project has been placed on hold, canceled, or abandoned.(9) HHSC may close a project file after one year of assigning an application number to a project if the LSRH has placed the project on hold. Plan review fees are nonrefundable.(b) Submission of projects and assignment of application number.(1) The LSRH owner or operator or representative shall submit the following items to HHSC in care of the mailing or overnight delivery address that appears on the Application for Plan Review.(A) A completed and signed Application for Plan Review. The Application for Plan Review may be obtained by contacting the HHSC Health Care Regulation Department Architectural Review Unit (ARU) using the contact information listed on the HHSC website.(B) The applicable plan review fee in accordance with §511.17 of this chapter (relating to Fees).(C) A functional program narrative in accordance with subsection (d) of this section.(D) Final construction documents in accordance with subsection (f) of this section.(2) The cost of submitting documents and plans and specifications shall be borne by the sender.(3) Once HHSC has determined that the submission required in paragraph (1) of this subsection is complete, HHSC will assign an application number to the project that must be referenced on all documents and correspondence related to the project. HHSC will review final construction documents in the chronological order received.(4) The LSRH shall satisfactorily resolve all deficiencies noted in the final plan review before HHSC will grant approval of the project for construction.(5) The LSRH shall not begin construction until the LSRH owner or operator receives written notification from HHSC that the final construction documents have been approved.(c) Feasibility conference. An LSRH owner or operator or representative may request a feasibility conference, which is an informal meeting between a member of ARU staff and the LSRH owner or operator or representative, to determine the feasibility of a project, for consultation and informational purposes, and to facilitate and establish understanding of compliance with the rules and codes.(1) A feasibility conference is not a substitute for plan review.(2) An LSRH owner or operator or representative may schedule a feasibility conference by contacting ARU using the contact information listed on the HHSC website.(3) The LSRH owner or operator or representative shall provide at the feasibility conference the items in subsection (b)(1)(A) - (C) of this section and a set of preliminary plans or final construction documents.(4) The LSRH owner or operator or representative is responsible for recording conference notes and shall submit the notes to HHSC.(d) Functional program narrative. The LSRH owner or operator or representative shall submit a functional program narrative to HHSC with each new project in accordance with subsection (b)(1)(C) of this section. The functional program narrative shall be presented on facility letterhead, signed by LSRH administration, include the functional description of each space, and the following:(1) departmental relationships, number of patient stations in each category, and other basic information relating to the fulfillment of the LSRH's objectives;(2) a description of each function to be performed, approximate space needed for these functions, occupants of the various spaces, projected occupant load, types of equipment required, interrelationship of various functions and spaces, and any special design features;(3) energy conservation measures, included in building, mechanical and electrical designs;(4) a description of the type of asepsis control in diagnostic and treatment areas; and(5) the type of construction (existing or proposed) as stated in Table 18.1.6.2 of National Fire Protection Association 101, Life Safety Code, 2012 edition (NFPA 101).(e) Preliminary documents. HHSC may request preliminary documents. If requested by HHSC, the submission shall consist of the items in subsection (b)(1)(A) - (C) of this section, preliminary plans, and outline specifications. The documents shall contain sufficient information to establish the project scope, description of functions to be performed, project location, required fire safety and exiting requirements, building construction type, compartmentation showing fire and smoke barriers, patient station count and services, and the usage of all spaces, areas, and rooms on every floor level.(f) Final construction documents. Final construction documents and specifications shall be submitted to HHSC for review and approval prior to start of construction. All final documents and specifications shall be appropriately sealed and signed by the project registered architect and professional engineer licensed by the state of Texas.(1) Submission of final construction documents. The LSRH owner or operator shall submit to HHSC for review and approval the items in subsection (b)(1)(A) - (C) of this section (if not previously submitted with preliminary documents) and one set of final construction documents and specifications covering the construction of new buildings or alterations, additions, conversions, modernizations, or renovations to existing buildings.(2) Preparation of final construction documents. Construction documents shall be well-prepared so that clear and distinct prints may be obtained, shall be accurately and adequately dimensioned, and shall include all necessary explanatory notes, schedules, and legends and shall be adequate for contract purposes. Compliance with model building codes and this chapter shall be indicated. The type of construction, as classified by National Fire Protection Association 220, Standard on Types of Building Construction, 2012 edition, shall be provided for existing and new facilities. Final plans shall be drawn to a sufficiently large-scale to clearly illustrate the proposed design but not less than one-eighth inch equals one foot. All spaces shall be identified by usage (using the names of spaces used in this chapter) on all plans (architectural, fire safety, mechanical, electrical, etc.) submitted. Separate drawings shall be prepared for each of the following branches of work.(A) Architectural plans. Architectural drawings shall include the following.(i) A map of the area within a two-mile radius of the facility site with any hazardous and undesirable location noted in §511.162(a) of this subchapter (relating to General Construction Requirements) identified.(ii) A site plan showing all new topography, newly established levels and grades, existing structures on the site (if any), new buildings and structures, roadways, parking, walks, easement, overhead or underground utilities or service lines, and the extent of the areas to be landscaped. All structures that are to be removed under the construction contract and improvements shall be shown. A general description of the immediate area surrounding the site shall be provided.(iii) A plan of each floor and roof to include fire and smoke separation, means of egress, and identification of all spaces.(iv) Schedules of doors, windows, and finishes.(v) Elevations of each facade.(vi) Sections through building.(vii) Scaled details as necessary.(B) Fire safety plans. These drawings shall be provided for all newly constructed buildings, conversions of existing buildings for facilities, additions to existing licensed facilities, and remodeled portions of existing buildings containing licensed facilities. Fire safety plans shall be of a sufficiently large-scale to clearly illustrate the proposed design but not less than one-sixteenth inch equals one foot and shall include the following information:(i) separate fire safety plans (preferably one floor plan per sheet) shall indicate location of fire protection-rated walls and partitions, location and fire resistance rating of each fire damper, and the required means of egress (corridors, stairs, exits, exit passageways);(I) when a new building is to contain a proposed facility, when an existing building is converted to a facility, or when an addition is made to an existing facility building, plans of each floor and roof shall be provided; and(II) when a portion of a building is remodeled or when a new service is added, only the plan of the floor where the remodeling will take place or new service will be introduced and the plan of the floor of discharge shall be provided;(ii) designated smoke compartments with floor areas of each compartment, location and fire resistance rating (one or two hour) of each smoke partition, and location, type, and fire resistance rating of each smoke damper;(iii) location of all required fire alarm devices, including all fire alarm control panels, manual pull stations, audible and visual fire alarm signaling devices, smoke detectors (ceiling and duct-mounted), fire alarm annunciators, fire alarm transmission devices, fire sprinkler flow switches and control valve supervisory switches on each of the floor plans; and(iv) areas protected with fire sprinkler systems (pendant, sidewall or upright, normal or quick response, and temperature rating shall be indicated), stand pipe system risers and sizes with valves and inside and outside fire department connections, fire sprinkler risers and sizes, and location and type of portable fire extinguishers.(C) Equipment drawings. Equipment drawings shall include the following.(i) All equipment necessary for the operation of the facility as planned. The design shall indicate provisions for the installation of large and special items of equipment and for service accessibility.(ii) Fixed equipment (equipment that is permanently affixed to the building or that must be permanently connected to a service distribution system designed and installed during construction for the specific use of the equipment). The term "fixed equipment" includes items such as laundry extractors, walk-in refrigerators, communication systems, and built-in casework (cabinets).(iii) Movable equipment (equipment not described in clause (ii) of this subparagraph as fixed). The term "moveable equipment" includes wheeled equipment, plug-in type monitoring equipment, and relocatable items.(iv) Equipment that is not included in the construction contract but that requires mechanical or electrical service connections or construction modifications. The equipment described in this clause shall be identified on the drawings to ensure its coordination with the architectural, mechanical, and electrical phases of construction.(D) Structural drawings. Structural drawings shall include:(i) plans for foundations, floors, roofs, and all intermediate levels;(ii) a complete design with sizes, sections, and the relative location of the various members;(iii) a schedule of beams, girders, and columns;(iv) dimensioned floor levels, column centers, and offsets;(v) details of all special connections, assemblies, and expansion joints; and(vi) special openings and pipe sleeves dimensioned or otherwise noted for easy reference.(E) Mechanical drawings. Mechanical drawings shall include:(i) complete ventilation systems (supply, return, exhaust), all fire and smoke partitions, locations of all dampers, registers, and grilles, air volume flow at each device, and identification of all spaces (e.g., corridor, patient room, operating room);(ii) boilers, chillers, heating and cooling piping systems (steam piping, hot water, chilled water), and associated pumps;(iii) cold and warm water supply systems, water heaters, storage tanks, circulating pumps, plumbing fixtures, emergency water storage tank(s) (if provided), and special piping systems such as for deionized water;(iv) nonflammable medical gas piping (oxygen, compressed medical air, vacuum systems, nitrous oxide), emergency shutoff valves, pressure gages, alarm modules, and gas outlets;(v) drain piping systems (waste and soiled piping systems, laboratory drain systems, roof drain systems);(vi) fire protection piping systems (sprinkler piping systems, fire standpipe systems, water or chemical extinguisher piping system for cooking equipment);(vii) piping riser diagrams, equipment schedules, control diagrams or narrative description of controls, filters, and location of all duct-mounted smoke detectors; and(viii) laboratory exhaust and safety cabinets.(F) Electrical drawings. Electrical drawings shall include:(i) electrical service entrance with service switches, service feeders to the public service feeders, and characteristics of the light and power current including transformers and their connections;(ii) location of all normal electrical system and essential electrical system conduits, wiring, receptacles, light fixtures, switches, and equipment that require permanent electrical connections, on plans of each building level:(I) light fixtures marked distinctly to indicate connection to critical or life safety branch circuits or to normal lighting circuits; and(II) outlets marked distinctly to indicate connection to critical, life safety, or normal power circuits;(iii) telephone and communication, fixed computers, terminals, connections, outlets, and equipment;(iv) nurses calling system showing all stations, signals, and annunciators on the plans;(v) in addition to electrical plans, single line diagrams prepared for:(I) complete electrical system consisting of the normal electrical system and the essential electrical system, including the on-site generator(s), transfer switch(es), emergency system (life safety branch and critical branch), equipment system, panels, subpanels, transformers, conduit, wire sizes, main switchboard, power panels, light panels, and equipment for additions to existing buildings, proposed new facilities, and remodeled portions of existing facilities (feeder and conduit sizes shall be shown with schedule of feeder breakers or switches);(II) complete nurses calling system with all stations, signals, annunciators, etc. with room number noted by each device and indicating the type of system (nurses regular calling system, nurses emergency calling system, or staff emergency assistance calling system);(III) a single line diagram of the complete fire alarm system showing all control panels, signaling and detection devices, and the room number where each device is located; and(vi) schedules of all panels indicating connection to life safety branch, critical branch, equipment system or normal system, and connected load at each panel.(3) Construction document changes. Any changes to the final construction documents that affect or change the function, design, or designated use of an area shall be submitted to HHSC for approval prior to authorization of the modifications.(g) Special submittals.(1) Self-certification.(A) In an effort to shorten the plan review and approval process, the LSRH owner or operator or representative may request approval of final construction documents under the self-certification review process.(i) The owner or operator shall submit the items in subsection (b)(1)(A) - (D) of this section and a completed self-certification form, signed by the LSRH owner or operator, architect of record, and engineer of record attesting that the plans and specifications are based upon and comply with the requirements of this chapter.(ii) By signing and submitting the self-certification form, the LSRH owner or operator accepts the following conditions.(I) HHSC retains the right to review the final construction documents, conduct inspections of the project, and withdraw its approval.(II) The LSRH owner or operator has a continuing obligation to make any changes HHSC requires to comply with the licensing rules whether physical plant construction or alterations have been completed.(III) The LSRH owner or operator is ultimately responsible for compliance with Texas Health and Safety Code Chapter 241 (relating to Hospitals) and this chapter.(B) HHSC will review the request for self-certification and notify the LSRH owner or operator if the request is approved or denied. If denied, HHSC will review the final construction documents in the chronological order in which the documents were received. Construction may not begin until HHSC has reviewed and approved the final construction documents.(2) Minor project. If an LSRH owner or operator believes that a proposed project is a minor project as described in §511.161(a)(2)(C) of this subchapter (relating to Requirements for Buildings in Which Existing Licensed Hospitals are Located), the LSRH owner or operator shall provide HHSC a brief written description of the proposed project and floor plans of the areas of work.(A) If HHSC determines the proposed project is a minor project, HHSC will notify the LSRH owner or operator of the approval, and state the number of inspections that will be required. HHSC will conduct a minimum of one inspection.(B) HHSC will notify the LSRH owner or operator that a proposed project is not approved as a minor project if the project involves any of the following:(i) remodeling or alterations that involve alterations to load bearing members or partitions;(ii) a change in functional operation;(iii) affects fire safety (e.g., modifications to the fire, smoke, and corridor walls);(iv) adds services for which the LSRH is not currently licensed; and(v) significantly changes the mechanical, electrical, plumbing, fire protection, or piped medical system.(C) The LSRH owner or operator shall submit final construction documents in accordance with subsection (f) of this section if HHSC determines the project is not a minor project.(3) Fire sprinkler systems.(A) When the sole purpose of a project is installation of a sprinkler system, whether a partial or complete system, the LSRH owner or operator shall submit to HHSC for approval the items in subsection (b)(1)(A) - (C) of this section and sprinkler documents.(B) Fire sprinkler systems shall comply with the requirements of National Fire Protection Association 13, Standard for the Installation of Sprinkler systems, 2010 edition (NFPA 13), and shall be designed or reviewed by an engineer who is registered by the Texas Board of Professional Engineers in fire protection specialty or is experienced in hydraulic design and fire sprinkler system installation. A short resume shall be submitted if registration is not in fire protection specialty.(i) Fire sprinkler working plans, complete hydraulic calculations, and water supply information shall be prepared in accordance with NFPA 13, §§14.1, 14.2 and 14.3, for new fire sprinkler systems and alterations of and additions to existing ones.(ii) One set of fire sprinkler working plans, calculations and water supply information shall be forwarded to HHSC together with the professional engineer's (professional engineer (P.E.) licensed in the state of Texas) certification letter stating that the sprinkler system design complies with the requirements of NFPA 13. Certification of the fire sprinkler system shall be submitted prior to system installation.(iii) Upon completion of the fire sprinkler system installation and any required corrections, written certification by the engineer, stating that the fire sprinkler system is installed in accordance with NFPA 13 requirements, shall be submitted prior to or with the written request for the final construction inspection of the project.(h) Retention of drawings, manuals and design data.(1) As built drawings. Upon occupancy of the building or portion thereof, the owner shall retain as part of the LSRH's permanent records, a complete set of legible architectural plans of each building level, fire safety plans as described in subsection (f)(2)(B) of this section for each floor reflecting fire safety requirements, and all single line diagrams described in subsection (f)(2)(F)(v) of this section, drawings for fixed equipment, and mechanical and electrical systems, as installed or built.(2) Manuals. Upon completion of the contract, the owner shall retain as part of the LSRH's permanent records a complete set of manufacturers' operating, maintenance, and preventive maintenance instructions; parts lists; and procurement information with numbers and a description for each piece of equipment. Facility staff shall also be provided with instructions on how to properly operate systems and equipment. Required information shall include energy ratings as needed for future conservation calculations.(3) Design data. The owner shall retain in the LSRH's permanent records complete design data for the facility. This shall include structural design loadings; summary of heat loss assumption and calculations; estimated water consumption; medical gas outlet listing; list of applicable codes; and electric power requirements of installed equipment. All such data shall be supplied to facilitate future alterations, additions, and changes, including, energy audits and retrofit for energy conservation. Source Note: The provisions of this §511.167 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.167 Preparation, Submittal, Review, and Approval of Plans, and Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215244 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215244 03/12/2026 (a) Construction.(1) Major construction. A limited services rural hospital (LSRH) shall not commence construction, other than minor alterations, until the LSRH has satisfactorily resolved final plan review deficiencies and paid the appropriate plan review fee according to the plan review schedule in §511.17 of this chapter (relating to Fees), and the Texas Health and Human Services Commission (HHSC) has issued a letter granting approval to begin construction. Such authorization does not constitute release from the requirements contained in this chapter. If the construction takes place in or near occupied areas, adequate provision shall be made for the safety and comfort of occupants.(2) Construction commencement notification. The architect of record or the LSRH owner or operator shall provide written notification to HHSC when construction will commence. HHSC shall be notified, in writing, of any change in the completion schedules.(3) Completion. Construction shall be completed in compliance with the construction documents including all addenda or modifications approved for the project.(b) Construction inspections. All LSRHs, including those that maintain certification under Title XVIII of the Social Security Act (42 United States Code, §1395 et seq), and those that maintain accreditation by a Centers for Medicare & Medicaid Services-approved organization, are subject to construction inspections.(1) Number of construction inspections. A minimum of two construction inspections of the project is generally required for the purpose of verifying compliance with Subchapter G of this chapter and this subchapter and the approved plans and specifications. The final plan approval letter will inform the architect of record and the owner or operator as to the minimum number of inspections required for the project.(2) Requesting an inspection. The architect of record or the LSRH owner or operator shall request an inspection by submitting, at least three weeks in advance of the requested inspection date, an Application for Inspection and the construction inspection fee in accordance with §511.17(g) of this chapter for each intermediate inspection, final inspection, and reinspection requested. Inspection requests by contractors will not be honored.(A) The architect of record or the LSRH owner or operator shall request an intermediate construction inspection to occur at approximately 80 percent completion. All major work above the ceiling shall be completed at the time of the intermediate inspection; however, ceilings shall not be installed.(B) The architect of record or the LSRH owner or operator shall request a final construction inspection at 100 percent completion. One hundred percent completion means that the project is completed to the extent that all equipment is operating in accordance with specifications, all necessary furnishings are in place, and patients could be admitted and treated in all areas of the project.(3) Reinspections. Depending upon the number and nature of the deficiencies cited during the final inspection, the inspector may require that a reinspection be conducted to confirm correction of all deficiencies cited. The inspector may also require a reinspection if they determine that the project was not sufficiently complete to warrant a final inspection. The request for reinspection shall be submitted in accordance with paragraph (2) of this subsection.(c) Approval of project. Patients and staff shall not occupy a new structure or remodeled or renovated space until approval has been received from the local building and fire authorities and HHSC.(1) Documentation requirements. The LSRH owner or operator shall submit the following documents to HHSC before the project will be approved.(A) Written approval of the project by the fire authority.(B) A certificate of occupancy for the project issued by the local building authority.(C) A copy of a letter or certification from a professional engineer (P.E.) licensed in the state of Texas indicating the fire sprinkler working plans, hydraulic calculation, the testing, and field inspection of the installation of the new or modified sprinkler system is in compliance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems, 2002 edition, if applicable. A copy of a letter or certification of changes in existing fire sprinkler system is not required when relocation of not more than twenty sprinkler heads and hydraulic calculation is not involved.(D) Fire alarm system certification (form FML-009 040392 of the Office of the State Fire Marshal), if applicable.(E) A signed copy of a letter of certification from a qualified certification agency or individual for the piped-in medical gas system that was installed or modified and verification inspection testing in this project in accordance with §511.162 (d)(4)(A)(iii)(IV), (X) and (XI) of this subchapter (relating to General Construction Requirements), if applicable.(F) A copy of the test and a letter from the electrical contractor certifying that the electrical system was tested and complies with the standards of NFPA 99, Health Care Facilities, 2012 edition, §4.3.2.2.8 (Special Grounding) and §4.3.3.1 (Grounding System Testing), if applicable to the project.(G) A copy of documentation indicating the flame spread rating and the smoke development rating of any wall covering installed in this project. Provide a signed letter or statement corroborating the installation of the product in the project.(H) A copy of documentation indicating that draperies, curtains (including cubicle curtains), and other similar loosely hanging furnishings and decorations are flame-resistant as demonstrated by passing both the small and large-scale tests of NFPA 701, Standard Methods of Fire Tests for Flame-Resistant Textiles and Films, 2010 edition as required by NFPA 101, §18-7.5, and provide a signed letter or statement corroborating the installation of the product in the project.(I) A written plan of correction signed by the LSRH owner/operator for any deficiencies noted during the final inspection.(J) A Final Construction Approval form signed by the LSRH owner/operator.(K) Any other documentation or information required or requested due to the type of the project.(2) Temporary occupancy approval.(A) If, during the final inspection, the inspector finds only a few minor deficiencies that do not jeopardize patient health, safety and welfare, the inspector may grant temporary approval for occupancy contingent upon the documents listed in paragraph (1)(A) - (E) of this subsection being provided to and approved by the inspector at the time of the final inspection.(B) Temporary approval for occupancy allows the LSRH owner or operator to occupy the project. However, the LSRH owner or operator must submit the documents required in paragraph (1)(F) - (K) of this subsection before the project receives final approval.(3) Final approval. Upon its receipt and acceptance of the documents required in paragraph (1) of this subsection, HHSC will issue written final approval of the project. Source Note: The provisions of this §511.168 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.168 Construction, Inspections, and Approval of Project https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215245 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215245 03/12/2026 (a) Table 1Attached Graphic(b) Table 2Attached Graphic(c) Table 3Attached Graphic(d) Table 4Attached Graphic(e) Table 5Attached Graphic(f) Table 6Attached Graphic(g) Table 7Attached Graphic Source Note: The provisions of this §511.169 adopted to be effective October 5, 2023, 48 TexReg 5668. 1 HEALTH AND HUMAN SERVICES COMMISSION 511 LIMITED SERVICES RURAL HOSPITALS G PHYSICAL PLANT AND CONSTRUCTION REQUIREMENTS §511.169 Tables https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221924 03/12/2026 The purpose of this chapter is to implement the Texas Health and Safety Code, Chapter 697, which requires the dignified disposition of embryonic and fetal tissue remains. Source Note: The provisions of this §512.1 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221925 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Burial--The act of depositing embryonic and fetal tissue remains in a grave, crypt, vault, or tomb, or at sea.(2) Burial park--A tract of land that is used or intended to be used for the interment of embryonic and fetal tissue remains in graves.(3) Cemetery--A tract of land that is used or intended to be used for the permanent interment of embryonic and fetal tissue remains, and includes:(A) a burial park for earth interments;(B) a mausoleum for crypt or vault interments;(C) a columbarium for cinerary interments; or(D) a combination of one or more of subparagraphs (A) - (C) of this paragraph.(4) Columbarium--A structure or room or other space in a building or structure of most durable and lasting fireproof construction; or a plot of earth, containing niches, used, or intended to be used, to contain cremated embryonic and fetal tissue remains.(5) HHSC--The Texas Health and Human Services Commission.(6) Cremation--The irreversible process of reducing tissue or remains to ashes or bone fragments through direct flame, extreme heat, and evaporation.(7) Crematory--A building or structure containing one or more furnaces used, or intended to be used, for the reduction (by burning) of human remains or embryonic and fetal tissue remains to cremated remains.(8) Crypt or vault--The chamber in a mausoleum of sufficient size to inter the uncremated embryonic and fetal tissue remains.(9) Entombment--The permanent interment of embryonic and fetal tissue remains in a crypt or vault.(10) Embryonic and fetal tissue remains--An embryo, a fetus, body parts, or organs from a pregnancy that terminates in the death of the embryo or fetus and for which the issuance of a fetal death certificate is not required by state law. The term does not include the umbilical cord, placenta, gestational sac, blood, or body fluids.(11) Executive Commissioner--The Executive Commissioner of the Health and Human Services Commission.(12) Grave--A space of ground in a burial park that is used, or intended to be used for the permanent interment in the ground of embryonic and fetal tissue remains.(13) Health care facility--Includes the following:(A) ambulatory surgical centers;(B) abortion clinics;(C) birthing centers;(D) medical clinics;(E) facilities that provide emergency medical services as defined by Texas Health and Safety Code, §773.003;(F) freestanding emergency medical care facilities;(G) hospitals;(H) professional offices, including the offices of physicians; and(I) other health care-related facilities that provide health or medical care to a pregnant woman.(14) Incineration--The process of burning embryonic and fetal tissue remains in an incinerator as defined in Title 30, Texas Administrative Code, Chapter 101 under conditions in conformance with standards prescribed in Title 30, Texas Administrative Code, Chapter 111 by the Texas Commission on Environmental Quality.(15) Interment--The disposition of embryonic and fetal tissue remains by entombment, burial, or placement in a niche.(16) Mausoleum--A structure or building of most durable and lasting fireproof construction used, or intended to be used, for the entombment of embryonic and fetal tissue remains.(17) Niche--A recess or space in a columbarium used, or intended to be used, for the permanent interment of the cremated remains of embryonic and fetal tissue remains.(18) Steam disinfection--The act of subjecting embryonic and fetal tissue remains to steam under pressure under those conditions which effect disinfection. Source Note: The provisions of this §512.2 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221926 03/12/2026 (a) Unless specifically exempted, all embryonic and fetal tissue remains from health care facilities must be treated as provided in this chapter.(b) To the extent this chapter conflicts with Title 25, Texas Administrative Code, Chapter 1, Subchapter K, this chapter prevails.(c) This chapter does not apply to:(1) placentas designated for sale and obtained from a licensed hospital or a licensed birthing center;(2) in vitro tissue cultures;(3) human fetal tissue donated in accordance with Texas Health and Safety Code, Chapter 173;(4) disposition of embryonic and fetal tissue remains of a single pregnancy, body parts, or tissue (including bulk blood), transferred for disposition to a licensed funeral director in accordance with Texas Health and Safety Code, Chapter 711, and Title 25, Texas Administrative Code Chapter 181 (relating to Vital Statistics), with the consent of the person or persons authorized to consent to the disposition of the fetal remains, body parts, or tissue (including bulk blood);(5) human tissue, including embryonic and fetal tissue, that is expelled or removed from the human body once the person is outside of a health care facility;(6) embryonic and fetal tissue required to be released to the parent of an unborn child pursuant to Texas Health and Safety Code, §241.010; and(7) a placenta removed from a hospital or birthing center pursuant to Texas Health and Safety Code, Chapter 172.(d) Notwithstanding any other law or rule, the umbilical cord, placenta, gestational sac, blood, or body fluids from a pregnancy terminating in the death of the embryo or fetus for which the issuance of a fetal death certificate is not required by state law may be disposed of in the same manner as and with the embryonic and fetal tissue remains from that same pregnancy as authorized by this chapter. Source Note: The provisions of this §512.3 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.3 Scope, Exemptions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221927 03/12/2026 (a) This chapter may not be used to require or authorize disclosure of confidential information, including personally identifiable or personally sensitive information, not permitted to be disclosed by state or federal privacy or confidentiality laws.(b) This chapter does not require the issuance of a birth or death certificate or a burial transit permit for the proper disposition of embryonic and fetal tissue remains from health care facilities.(c) This chapter does not extend or modify requirements of Texas Health and Safety Code, Chapters 711 and 716, or Texas Occupations Code, Chapter 651, to disposition of embryonic and fetal tissue remains.(d) This chapter applies to embryonic and fetal tissue remains from health care facilities. Source Note: The provisions of this §512.4 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.4 Application of this Chapter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221928 03/12/2026 (a) Embryonic and fetal tissue remains, regardless of the period of gestation, except as provided by §138.3 of this chapter (relating to Scope, Exemptions), must be subjected to one of the following methods of treatment and disposal:(1) interment;(2) cremation;(3) incineration followed by interment; or(4) steam disinfection followed by interment.(b) Embryonic and fetal tissue remains that undergo cremation must be placed in a cremation container that:(1) is made of combustible materials suitable for cremation;(2) provides a complete covering of the remains;(3) is resistant to leakage or spillage; and(4) protects the health and safety of crematory personnel.(c) The ashes resulting from the cremation or incineration of embryonic and fetal tissue remains:(1) may be interred or scattered in any manner authorized by law for human remains; and(2) may not be placed in a landfill or sewer system.(d) Any facility that receives embryonic and fetal tissue remains for treatment must maintain records to document the method and conditions of treatment in accordance with Title 30, Texas Administrative Code, Chapter 326.(e) Any facility that receives embryonic and fetal tissue remains for treatment is responsible for establishing the conditions necessary for operation of each method used at the facility to ensure the reduction of microbial activity of any embryonic and fetal tissue remains.(f) A health care facility responsible for disposing of embryonic and fetal tissue remains may coordinate with an entity in the registry established under §138.8 of this chapter (relating to Burial or Cremation Assistance Registry), in an effort to reduce the cost associated with transportation, burial, or cremation of the embryonic and fetal tissue remains. Source Note: The provisions of this §512.5 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.5 Approved Methods of Treatment and Disposition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221929 03/12/2026 (a) Any person or entity that is licensed, permitted or otherwise authorized by the Texas Funeral Services Commission to store, handle or transport human remains is authorized to store, handle or transport embryonic and fetal tissue remains in accordance with this chapter.(b) Any person or entity that is licensed, permitted or otherwise authorized by the Texas Commission on Environmental Quality to store, handle or transport special waste from health care facilities is authorized to store, handle or transport embryonic and fetal tissue remains in accordance with this chapter.(c) Any health care facility that generates embryonic and fetal tissue remains is authorized to store, handle, or transport embryonic and fetal tissue remains generated at that facility in accordance with this chapter. Source Note: The provisions of this §512.6 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.6 Storage, Handling, and Transport Authorization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221930 03/12/2026 (a) A container which contains untreated embryonic and fetal tissue remains must be placed in an outer container that is leak resistant, impervious to moisture, of sufficient strength to prevent tearing and bursting under normal conditions of use and handling, and sealed to prevent leakage.(b) The outer container holding untreated embryonic and fetal tissue remains must be labeled with a warning legend in English and in Spanish, along with the international symbol for biohazardous material on the sides of the container. The wording of the warning legend must be substantially similar to the following: "CAUTION, contains material which may be biohazardous" and "PRECAUCIÓN, contiene material que pueden ser peligro biológico."(c) Untreated embryonic and fetal tissue remains being transported for disposition in accordance with these rules shall be transported using units that:(1) have a fully enclosed, leak-proof remains storage area;(2) protect the remains from mechanical stress or compaction;(3) carry spill cleanup equipment; and(4) have a compartment where remains are transported that must:(A) be maintained in a sanitary condition;(B) be locked when the vehicle or trailer is in motion;(C) be locked or secured when remains are present in the compartment except during loading or unloading of remains;(D) have a floor and sides made of an impervious, nonporous material;(E) have all discharge openings securely closed during operation of the vehicle or trailer;(F) maintain a temperature of 45 degrees Fahrenheit or less for remains transported for longer than 72 hours during post-collection storage period; and(G) be disinfected before being used to transport any material other than remains or untreated medical waste.(d) Cremated embryonic and fetal tissue remains may be transported in any manner in this state and must be disposed of in accordance with this chapter. Source Note: The provisions of this §512.7 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.7 Storage, Handling, and Transport Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221931 03/12/2026 The registry is created to identify persons or entities who choose to provide financial or other assistance for the transportation, cremation, or burial of embryonic or fetal tissue remains.(1) The following persons or entities may apply for inclusion on the registry by submitting an application on a form prescribed by HHSC:(A) participating funeral homes and cemeteries willing to provide free common burials or free or low-cost private burials that certify that they will do so in compliance with applicable law; and(B) private nonprofit organizations that will provide financial assistance for the costs associated with burial or cremation of embryonic and fetal tissue remains.(2) An application will be approved if the applicant meets the requirements of paragraph (1) of this section.(3) An application will be disapproved if the applicant has:(A) not met the requirements in paragraph (1) of this section; or(B) failed or refused to properly complete or submit any application form, or deliberately presented false information on any form or document required by HHSC.(4) Upon approval of an application, the applicant's name will be placed on the registry. HHSC will provide notice of placement on the registry to each approved applicant.(5) A person or entity may be removed from the registry at the sole discretion of HHSC upon evidence that a registrant has failed to provide the services for which it was placed on the registry. HHSC will notify, in writing, a registrant of its removal from the registry. The denial or removal from the registry is not subject to Texas Government Code, Chapter 2001.(6) A request under this section will not be considered a petition for the adoption of rules.(7) Obtaining Registry Information.(A) HHSC will make the registry information available upon request to a physician, a health care facility, or the agent of a physician or health care facility.(B) A request from a physician, a health care facility, or the agent of a physician or health care facility must be submitted to HHSC on a form prescribed by HHSC. Source Note: The provisions of this §512.8 adopted to be effective February 1, 2018, 43 TexReg 465; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9025. 1 HEALTH AND HUMAN SERVICES COMMISSION 512 DISPOSITION OF EMBRYONIC AND FETAL TISSUE REMAINS §512.8 Burial or Cremation Assistance Registry https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220927 03/12/2026 (a) The purpose of this chapter is to implement THSC Chapter 248A, which directs the executive commissioner to adopt minimum standards that a person must meet to be licensed as a center.(b) Except as provided by THSC §248A.002, a person may not own or operate a center unless the person holds a license issued by HHSC under THSC Chapter 248A and this chapter.(c) An applicant may not provide services under a license for which an application has been submitted until HHSC issues the license. Source Note: The provisions of this §550.1 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective September 28, 2016, 41 TexReg 7512; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS A PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS §550.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194709 03/12/2026 (a) This chapter establishes the minimum standards necessary to promote the health, safety, and welfare of a minor served and to ensure that a center ensures the provision of medical, nursing, psychosocial, therapeutic, and developmental services to a minor, and meets the caregiver training needs of a minor's parent. The standards are the basis for inspection activities for licensure.(b) For purposes of this chapter, "at a center" and "at the center" includes the premises of the center and vehicles used for transportation, if transportation is provided by the center. Source Note: The provisions of this §550.2 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS A PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS §550.2 Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194710 03/12/2026 (a) Requirements established by private or public funding sources such as health maintenance organizations or other private third-party insurance, Medicaid (Title XIX of the Social Security Act), Medicare (Title XVIII of the Social Security Act), or state-sponsored funding programs are separate and apart from the requirements in this chapter for a center. Notwithstanding the funding source requirements that apply, a center must comply with the applicable provisions of THSC Chapter 248A and this chapter. A center is responsible for researching the availability of funding to pay for the services the center provides.(b) Admission to a center is not intended to supplant a minor's right to a Medicaid private duty nursing benefit when private duty nursing is medically necessary for the minor.(c) The services of a center must not supplant services afforded to a minor by the Individuals with Disabilities Education Act, United States Code, Title 20, §1400 et seq., and Section 504 of the Rehabilitation Act of 1973, United States Code, Title 29, §794. A center must not act as the primary education provider or accept a delegation of responsibility for the provision of a minor's education from an education provider, such as a local education agency. Source Note: The provisions of this §550.3 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS A PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS §550.3 Limitations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194711 03/12/2026 (a) A center must maintain satisfactory compliance with THSC Chapter 248A and this chapter to maintain licensure.(b) To the extent of any conflict between the standards in this chapter and a standard required in a local, county, or municipal ordinance, this chapter controls. Source Note: The provisions of this §550.4 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS A PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS §550.4 Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220928 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Active Play--Any physical activity from which a minor derives amusement, entertainment, enjoyment, or satisfaction by taking a participatory rather than a passive role. Active play includes various forms of activities, from the exploration of objects and toys to the structured play of formal games, sports, and hobbies.(2) Actual census--The number of minors at a center at any given time.(3) Administration of medication--The direct application of a medication to the body of a minor by any route. This includes removing an individual or unit dose from a previously dispensed, correctly labeled container, verifying it with the medication order, giving the correct medication and the correct dose to the correct minor at the correct time by the correct route, and accurately recording the time and dose given.(4) Administrator--The person who is responsible for implementing and supervising the administrative polices and operations of a center and for administratively supervising the provision of services to minors and their parents on a day-to-day basis.(5) Adult minor--A minor who is 18 years of age or older or is emancipated and has not been adjudged incompetent.(6) Affiliate--With respect to an applicant or license holder that is:(A) a corporation--means an officer, director, or stockholder with direct ownership or disclosable interest of at least five percent, a subsidiary, or a parent company;(B) a limited liability company--means an officer, member, or parent company;(C) an individual--means:(i) the individual's spouse;(ii) each partnership and each partner thereof of which an individual or any affiliate of an individual is a partner; and(iii) each corporation in which an individual is an officer, director, or stockholder with a direct ownership of at least five percent;(D) a partnership--means a partner or a parent company of the partnership; and(E) a group of co-owners under any other business arrangement means an officer, director, or the equivalent under the specific business arrangement or a parent company.(7) Applicant--A person who applies for a license to operate a center under THSC Chapter 248A and this chapter. The applicant is the person in whose name HHSC issues the license.(8) Audiologist--A person who has a valid license under Texas Occupations Code, Chapter 401, as an audiologist.(9) Basic services--Include:(A) the development, implementation, and monitoring of a comprehensive protocol of care that:(i) is provided to a medically dependent or technologically dependent minor;(ii) is developed in conjunction with the minor's parent; and(iii) specifies the medical, nursing, psychosocial, therapeutic, and developmental services required by the minor; and(B) the caregiver training needs of a medically dependent or technologically dependent minor's parent.(10) Behavioral emergency--A situation that occurs after which preventative or de-escalating techniques are attempted and determined to be ineffective and it is immediately necessary to restrain a minor to prevent immediate probable death or substantial bodily harm to the minor or to others because the minor is attempting serious bodily harm or immediate physical harm to the minor or to others.(11) Business day--Any day except a national or state holiday listed in Texas Government Code §662.003(a) or (b). The term includes Saturday or Sunday if the center is open on that day.(12) Center--A Prescribed Pediatric Extended Care Center. A facility operated for profit or on a nonprofit basis that provides nonresidential basic services to four or more medically dependent or technologically dependent minors who require the services of the center and who are not related by blood, marriage, or adoption to the owner or operator of the center.(13) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership.(14) Chemical restraint--The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, to restrict the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior and which is not a standard treatment for a minor's medical or psychosocial condition.(15) Chief financial officer--An individual who is responsible for supervising and managing all financial activities for a center.(16) Clinical note--A notation of a contact with a minor or a minor's family member that is written and dated by any staff providing services on behalf of a center and that describes signs and symptoms of the minor, and treatments and medications administered to the minor, including the minor's reaction or response, and any changes in physical, emotional, psychosocial, or spiritual condition of the minor during a given period of time.(17) Community disaster resources--A local, statewide, or nationwide emergency system that provides information and resources during a disaster, including weather information, transportation, evacuation and shelter information, disaster assistance and recovery efforts, evacuee and disaster victim resources, and resources for locating evacuated friends and relatives.(18) Complaint--An allegation against a center or involving services provided at a center that involves a violation of this chapter or THSC Chapter 248A.(19) Continuous face-to-face observation--Maintaining an in-person line of sight of a minor that is uninterrupted and free from distraction.(20) Contractor--An individual providing services ordered by a prescribing physician on behalf of a center that the center would otherwise provide by its employees.(21) Controlling person--A person who has the ability, acting alone or in concert with others, to directly or indirectly influence, direct, or cause the direction of the management of, expenditure of money for or policies of a center or other person.(A) A controlling person includes:(i) a management company, landlord, or other business entity that operates or contracts with another person for the operation of a center;(ii) any person who is a controlling person of a management company or other business entity that operates a center or that contracts with another person for the operation of a center; and(iii) any other person who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of a center, is in a position of actual control of or authority with respect to the center, regardless of whether the person is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the center.(B) Notwithstanding any other provision of this paragraph, a controlling person of a center or of a management company or other business entity described by subparagraph (A)(i) of this paragraph that is a publicly traded corporation or is controlled by a publicly traded corporation means an officer or director of the corporation. The term does not include a shareholder or lender of the publicly traded corporation.(C) A controlling person described by subparagraph (A)(iii) of this paragraph does not include a person, including an employee, lender, secured creditor, or landlord, who does not exercise any formal or actual influence or control over the operation of the center.(22) Conviction--An adjudication of guilt based on a finding of guilt, a plea of guilty, or a plea of nolo contendere.(23) Daily census--The number of minors served at a center during a center's hours of operation for a 24-hour period, starting at midnight.(24) Day--A calendar day, unless otherwise specified in the text. A calendar day includes Saturday, Sunday, and a holiday.(25) Dietitian--A person who has a valid license under the Licensed Dietitian Act, Texas Occupations Code, Chapter 701, as a licensed dietitian or provisional licensed dietitian, or who is registered as a dietitian by the Commission on Dietetic Registration of the American Dietetic Association.(26) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.(27) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.(28) Emergency situation--An impending or actual situation that:(A) interferes with normal activities of a center or minors at a center;(B) may:(i) cause injury or death to a minor or individual at the center; or(ii) cause damage to the center's property;(C) requires the center to respond immediately to mitigate or avoid injury, death, damage, or interference; and(D) does not include a situation that arises from the medical condition of a minor such as cardiac arrest, obstructed airway, or cerebrovascular accident.(29) Executive commissioner--The executive commissioner of the Texas Health and Human Services Commission.(30) Functional assessment--An evaluation of a minor's abilities, wants, interests, and needs related to self-care, communication skills, social skills, motor skills, play with toys or objects, growth, and development appropriate for age.(31) Health care provider--An individual or facility licensed, certified, or otherwise authorized to administer health care in the ordinary course of business or professional practice.(32) Health care setting--A location at which licensed, certified, or otherwise regulated health care is administered.(33) HHSC--The Texas Health and Human Services Commission.(34) IDT--Interdisciplinary team. Individuals who work together to meet the medical, nursing, psychosocial, and developmental needs of a minor and a minor's parent's training needs.(35) Immediate threat to the health or safety of a minor--A situation that causes, or is likely to cause, serious injury, harm, or impairment to, or the death of a minor.(36) Inactive medical record--A record for a minor who was admitted by a center to receive services and was subsequently discharged by the center.(37) Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder.(38) Inspection--An on-site examination or audit of a center by HHSC to determine compliance with THSC Chapter 248A and this chapter.(39) Isolation--The involuntary confinement of a minor in a room of a center for the purposes of infection control, assessment, and observation away from other minors in a room at the center. When in isolation, a minor is physically prevented from contact with other minors.(40) Joint training--Training provided by HHSC to service providers and HHSC inspectors on subjects that address the 10 most commonly cited violations of state law governing centers, as published in HHSC annual reports. HHSC determines the frequency of joint training.(41) License--A license to operate a center issued by HHSC under THSC, Chapter 248A, and this chapter. The term includes initial, renewal, and temporary licenses unless specifically stated otherwise.(42) Licensed assistant in speech-language pathology--A person who has a valid license under Texas Occupations Code, Chapter 401, as a licensed assistant in speech-language pathology and who provides speech language support services under the supervision of a licensed speech-language pathologist.(43) License holder--A person that holds a license to operate a center under THSC Chapter 248A and this chapter.(44) Life Safety Code--A publication of the National Fire Protection Association (NFPA), also known as NFPA 101, 2000 edition.(45) Local emergency management agencies--The local emergency management coordinator, fire, police, and emergency medical services.(46) Local emergency management coordinator--The person identified as the emergency management coordinator by the mayor or county judge for the geographical area in which a center is located.(47) LVN--Licensed vocational nurse. A person who has a valid license under Texas Occupations Code, Chapter 301, as a licensed vocational nurse.(48) Mechanical restraint--The use of any mechanical device, material, or equipment to restrict the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior.(49) Medical director--A physician who has the qualifications described in §550.307 of this chapter (relating to Medical Director Qualifications and Conditions) and has the responsibilities described in §550.308 of this chapter (relating to Medical Director Responsibilities).(50) Medical record--A record composed first-hand for a minor who has or is receiving services at a center.(51) Medically dependent or technologically dependent--The condition of an individual who, because of an acute, chronic, or intermittent medically complex or fragile condition or disability, requires ongoing, technology-based skilled nursing care prescribed by a physician to avert death or further disability, or the routine use of a medical device to compensate for a deficit in a life-sustaining body function. The term does not include a controlled or occasional medical condition that does not require continuous nursing care, including asthma or diabetes, or a condition that requires an epinephrine injection.(52) Medication administration record--A record used to document the administration of a minor's medications and pharmaceuticals.(53) Medication list--A list that includes all prescriptions, over-the-counter pharmaceuticals, and supplements that a minor is prescribed or taking, including the dosage, preparation, frequency, and the method of administration.(54) Minor--An individual younger than 21 years of age who is medically dependent or technologically dependent.(55) Mitigation--An action taken to eliminate or reduce the probability of an emergency or public health emergency or reduce an emergency's severity or consequences.(56) Nursing director--The individual responsible for supervising skilled services provided at a center and who has the qualifications described in §550.309 of this chapter (relating to Nursing Director and Alternate Nursing Director Qualifications and Conditions).(57) Nutritional counseling--Advising and assisting an adult minor or a minor's parent or family on appropriate nutritional intake by integrating information from a nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention, and nutrition education. The term includes:(A) dialogue with an adult minor or a minor's parent to discuss current eating habits, exercise habits, food budget, and problems with food preparation;(B) discussion of dietary needs to help an adult minor or the minor's parent understand why certain foods should be included or excluded from the minor's diet and to help with adjustment to the new or revised or existing diet plan;(C) a personalized written diet plan as ordered by the minor's prescribing physician, to include instructions for implementation;(D) providing the adult minor or the minor's parent with motivation to help them understand and appreciate the importance of the diet plan in getting and staying healthy; or(E) working with the adult minor or the minor's parent by recommending ideas for meal planning, food budget planning, and appropriate food gifts.(58) Occupational therapist--A person who has a valid license under Texas Occupations Code, Chapter 454, as an occupational therapist.(59) Occupational therapy assistant--A person who has a valid license under Texas Occupations Code, Chapter 454, as an occupational therapy assistant who assists in the practice of occupational therapy under the general supervision of an occupational therapist.(60) Online portal--A secure portal provided on the HHSC website for licensure activities, including for an applicant to submit licensure applications and information.(61) Operating hours--The days of the week and the hours of day a center is open for services to a minor as identified in a center's written policy as required by §550.201 of this chapter (relating to Operating Hours).(62) Overnight--The hours between 9:00 p.m. and 5:00 a.m. during the days of the week a center operates.(63) Over-the-counter pharmaceuticals--A drug or formulary for which a physician's prescription is not needed for purchase or administration.(64) Parent--A person authorized by law to act on behalf of a minor with regard to a matter described in this chapter. The term includes:(A) a biological, adoptive, or foster parent;(B) a guardian;(C) a managing conservator; and(D) a non-parent decision-maker as authorized by Texas Family Code §32.001.(65) Parent company--A person, other than an individual, who has a direct 100 percent ownership interest in the owner of a center.(66) Person--An individual, firm, partnership, corporation, association, or joint stock association, and the legal successor thereof.(67) Personal care services--Services required by a minor, including:(A) bathing;(B) maintaining personal hygiene;(C) routine hair and skin care;(D) grooming;(E) dressing;(F) feeding;(G) eating;(H) toileting;(I) maintaining continence;(J) positioning;(K) mobility and bed mobility;(L) transfer and ambulation;(M) range of motion;(N) exercise; and(O) use of durable medical equipment.(68) Pharmaceuticals--Of or pertaining to drugs, including over-the-counter drugs and those requiring a physician's prescription for purchase or administration.(69) Pharmacist--A person who is licensed to practice pharmacy under Texas Occupations Code, Chapter 558.(70) Pharmacy--A facility at which a prescription drug or medication order is received, processed, or dispensed as defined in Texas Occupations Code §551.003.(71) Physical restraint--The use of physical force, except for physical guidance or prompting of brief duration, that restricts the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior.(72) Physical therapist--A person who has a valid license under Texas Occupations Code, Chapter 453, as a physical therapist.(73) Physical therapist assistant--A person who has a valid license under Texas Occupations Code, Chapter 453, as a physical therapist assistant and:(A) who assists and is supervised by a physical therapist in the practice of physical therapy; and(B) whose activities require an understanding of physical therapy.(74) Physician--A person who:(A) has a valid license in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code, Chapter 155;(B) has a valid license in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of a minor, and orders services for the minor, in accordance with Texas Occupations Code, Chapter 151; or(C) is a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service if the person is not engaged in private practice, in accordance with Texas Occupations Code, Chapter 151.(75) Place of business--An office of a center where medical records are maintained and from which services are directed.(76) Plan of care--A protocol of care.(77) Positive intervention--An intervention that is based on or uses a minor's preferences as positive reinforcement, and focuses on positive outcomes and wellness for the minor.(78) Pre-licensing program training--Computer-based training, available on the HHSC website, designed to acquaint center staff with licensure standards.(79) Premises--The term includes the center, any lots on which the center is located, any outside ground areas, any outside play areas, and the parking lot.(80) Preparedness--Actions taken in anticipation of a disaster including a public health disaster.(81) Prescribing physician--A physician who is authorized to write and issue orders for services at a center.(82) Progress note--A dated and signed written notation summarizing facts about services provided to a minor and the minor's response during a given period of time.(83) Protective device--A mechanism or treatment, including sedation, that is:(A) used:(i) for body positioning;(ii) to immobilize a minor during a medical, dental, diagnostic, or nursing procedure;(iii) to permit wounds to heal; or(iv) for a medical condition diagnosed by a physician; and(B) not used as a restraint to modify or control behavior.(84) Protocol of care--A comprehensive, interdisciplinary plan of care that includes the medical physician's plan of care, nursing care plan and protocols, psychosocial needs, and therapeutic and developmental service needs required by a minor and family served.(85) Psychologist--A person who has a valid license under Texas Occupations Code, Chapter 501, as a psychologist.(86) Psychosocial treatment--The provision of skilled services to a minor under the direction of a physician that includes one or more of the following:(A) assessment of alterations in mental status or evidence of suicide ideation or tendencies;(B) teaching coping mechanisms or skills;(C) counseling activities; or(D) evaluation of a plan of care.(87) Quiet time--A behavior management technique used to provide a minor with an opportunity to regain self-control, where the minor enters and remains for a limited period of time in a designated area from which egress is not prevented.(88) Recovery--Activities implemented during and after a disaster response, including a public health disaster response, designed to return a center to its normal operations as quickly as possible.(89) Relocation--The closing of a center and the movement of its business operations to another location.(90) Respiratory therapist--A person who has a valid license under Texas Occupations Code, Chapter 604, as a respiratory care practitioner.(91) Response--Actions taken immediately before an impending disaster or during and after a disaster, including a public health disaster, to address the immediate and short-term effects of the disaster.(92) Restraint--Physical restraint, chemical restraint, or mechanical restraint.(93) RN--Registered nurse. A person who has a valid license under Texas Occupations Code, Chapter 301, to practice professional nursing.(94) RN delegation--Delegation of tasks by an RN in accordance with 22 Texas Administrative Code Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments).(95) Sedation--The act of allaying nervous excitement by administering medication that commonly induces the nervous system to calm. Sedation is a protective device.(96) Social worker--A person who has a valid license under Texas Occupations Code, Chapter 505, as a social worker.(97) Speech-language pathologist--A person who has a valid license under Texas Occupations Code, Chapter 401, as a speech-language pathologist.(98) Substantial compliance--A finding in which a center receives no recommendation for enforcement action after an inspection.(99) Supervision--Authoritative procedural guidance by a qualified person that instructs another person and assists in accomplishing a function or activity. Supervision includes initial direction and periodic inspection of the actual act of accomplishing the function or activity.(100) Support services--Social, spiritual, and emotional care provided to a minor and a minor's parent by a center.(101) THSC--Texas Health and Safety Code.(102) Total census--The total number of minors with active plans of care at a center.(103) Transition support--Planning, coordination, and assistance to move the location of services provided to a minor from a center to the least restrictive setting appropriate.(104) Violation--A finding of noncompliance with this chapter or THSC Chapter 248A resulting from an inspection.(105) Volunteer--An individual who provides assistance to a center without compensation other than reimbursement for actual expenses. Source Note: The provisions of this §550.5 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective September 28, 2016, 41 TexReg 7512; amended to be effective October 11, 2017, 42 TexReg 5492; amended to be effective October 28, 2018, 43 TexReg 7186; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective March 20, 2023, 48 TexReg 1564; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS A PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS §550.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220929 03/12/2026 (a) To obtain a license, a person must meet the application requirements in this subchapter and meet the criteria for a license.(b) A center must be located in Texas. The center must have a Texas mailing address.(c) A person may not operate a center on the same premises as:(1) a child-care center licensed in accordance with Texas Human Resource Code, Chapter 42; or(2) any other facility licensed by HHSC or the Texas Department of State Health Services.(d) A separate license is required for each center located on separate premises, regardless of whether the centers are owned or operated by the same person.(e) The actual census for a center must not exceed the capacity authorized by HHSC, as indicated on the license.(f) Before issuing a license, HHSC considers the background and qualifications of:(1) the applicant;(2) a controlling person of the applicant;(3) a person with a disclosable interest;(4) an affiliate of the applicant;(5) the administrator; and(6) the chief financial officer, if the center has a chief financial officer.(g) An applicant must affirmatively show that the center:(1) obtained approval of building plans through plan review by the HHSC Architectural Unit as required by Subchapter E of this chapter (relating to Building Requirements);(2) meets local building ordinances;(3) is approved by the local fire authority;(4) meets the standards of the Life Safety Code and the requirements in Subchapter E of this chapter; and(5) meets the requirements of this chapter based on an on-site health inspection by HHSC. Source Note: The provisions of this §550.101 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.101 Criteria and Eligibility for a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220930 03/12/2026 (a) An applicant may apply for a license for a center by submitting an application to the HHSC Licensing and Credentialing Unit through the online portal.(b) An applicant must complete the application in accordance with the instructions provided in the online portal.(c) An applicant must provide accurate and complete statements on the application and any attachments.(d) If an applicant decides not to continue the application process for a license after submitting an application and license fee, the applicant must submit a written request to HHSC to withdraw the application. HHSC does not refund the license fee for an application that is withdrawn, except as provided in §550.114 of this subchapter (relating to Time Periods for Processing All Types of License Applications). Source Note: The provisions of this §550.102 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.102 General Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220931 03/12/2026 (a) Fire authority. An applicant must receive approval from the local fire authority or, if the jurisdiction does not have a local fire authority, the state fire marshal, for an initial, renewal, change of ownership, relocation, or capacity increase license application. An applicant may submit a license application to HHSC through the online portal before receiving fire authority approval. An applicant must submit to HHSC a copy of a signed and dated written approval for occupancy by the local fire authority or state fire marshal that describes the center by name and address by uploading a copy through the online portal.(b) Local health authority. An applicant for an initial, change of ownership, relocation, or capacity increase license must submit to HHSC, by uploading through the online portal, a copy of a dated written notification to the local health authority that the applicant is submitting a license application to HHSC. A local health authority may provide an evaluation to HHSC regarding the status of the center's compliance with local codes, ordinances, or regulations. The local health authority may also recommend that HHSC issue or deny a license to the center, but HHSC makes the final decision regarding licensure of the center. Source Note: The provisions of this §550.103 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.103 Building Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220932 03/12/2026 (a) A person that submits an initial, renewal, change of ownership, relocation, or increase in capacity license application through the online portal must follow the instructions for that application; and(1) identify the location of the place of business for which the license is sought;(2) include documentation, signed by the appropriate local government official, stating that the center's place of business and the use of the center meet local zoning requirements;(3) provide the name, address, and social security number of, and background and criminal history check information for:(A) the applicant;(B) the administrator;(C) the financial officer; and(D) each controlling person of the applicant;(4) provide the federal employer identification number or taxpayer identification number of the applicant and of each controlling person, if an applicant or controlling person is not an individual;(5) state the assumed name under which the center will be doing business;(6) state the maximum capacity requested for the center; and(7) include a sworn affidavit that the applicant has complied with this chapter.(b) For an initial license and change of ownership application, an applicant must follow the instructions for that application; and(1) submit to HHSC evidence of the right to possess or occupy the center at the time the application is submitted, which may include:(A) a lease agreement; or(B) a deed; and(2) disclose to HHSC the name and address of the owner of the real property, including the owner of the buildings and grounds appurtenant to the center.(c) An applicant or license holder must provide to HHSC, through the online portal, any additional information requested by HHSC no later than 30 days after the date of the HHSC request.(d) HHSC may require an applicant to disclose information relating to the fiduciary-appointed administrator of the center. Source Note: The provisions of this §550.104 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.104 Applicant Disclosure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220933 03/12/2026 (a) The center's administrator must complete pre-licensing program training before an applicant may submit an initial application for a license.(b) An applicant for an initial license must submit to HHSC through the online portal:(1) a complete and correct application including all documents and information that HHSC requires as part of the application process;(2) the correct license fee established in §550.112 of this subchapter (relating to Licensing Fees);(3) a letter of credit for $250,000 from a bank that is insured by the Federal Deposit Insurance Corporation, or other documentation acceptable to HHSC, to demonstrate an applicant's financial viability; and(4) all other documents described in the instructions provided on the application and on the HHSC website.(c) After HHSC receives an application for an initial license and the correct license fee, HHSC reviews the application and notifies the applicant if additional information is needed to complete the application.(d) An applicant must submit written notice to HHSC that the center is ready for a Life Safety Code inspection by uploading the notification through the online portal.(1) The written notice must be submitted:(A) with the application; or(B) no later than 120 days after the HHSC Licensing and Credentialing Section receives the application.(2) After HHSC receives the written notice for a Life Safety Code inspection and an applicant has satisfied the application submission requirements, HHSC staff conducts an on-site Life Safety Code inspection.(e) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny the license application.(f) If a center meets the building requirements in Subchapter E of this chapter, the center may admit no more than three minors. After a center admits one minor, the applicant must send written notice to HHSC indicating the center is ready for a health inspection by uploading the notice through the online portal. The center must submit the request for the health inspection no later than 120 days after the date the center meets the building requirements.(1) After HHSC receives the request for the health inspection, HHSC conducts an on-site health inspection to determine compliance with this chapter.(2) If the center fails to comply with this chapter and fails to implement an approved written plan of correction no later than 120 days after the date of the initial health inspection, HHSC Licensing proposes to deny the license application.(g) If an applicant receives a notice from HHSC that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If the applicant fails to timely submit the requested information, HHSC Licensing proposes to deny the application. If HHSC Enforcement denies the application, HHSC does not refund the license fee.(h) HHSC issues an initial license if it determines that an applicant has met the provisions of this chapter and THSC Chapter 248A.(i) The issuance of an initial license constitutes notice from HHSC to the center of the approval of the application.(j) HHSC issues a center license to the license holder named on the license at the place of business listed on the license. The license is not transferable or assignable.(k) The license includes:(1) the license holder's name;(2) the name of the center;(3) the center's place of business;(4) the center's licensed capacity; and(5) the effective date of the license.(l) HHSC Licensing may propose to deny an application for an initial license if the applicant, a controlling person, or a person required to submit background and qualification information fails to meet the criteria for a license established in §550.101 of this subchapter (relating to Criteria and Eligibility for a License) or for any reason specified in §550.115 of this subchapter (relating to Criteria for Denial of a License).(m) If HHSC denies an application for an initial license, HHSC sends the applicant written notice of the denial and informs the applicant of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act).(n) An initial license expires on the third anniversary after the effective date of the initial license. Source Note: The provisions of this §550.105 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective October 29, 2018, 43 TexReg 7188; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.105 Initial License Application Procedures and Issuance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220934 03/12/2026 (a) A center license expires on the third anniversary after the effective date on the license. To renew a license, a license holder must submit a renewal application to HHSC through the online portal before the expiration date of the current license. HHSC sends written notice of expiration of a license to the license holder through the online portal at least 120 days before the expiration date of a license.(b) A license holder must comply with the requirements in §550.102 of this subchapter (relating to General Application Requirements) and §550.114 of this subchapter (relating to Time Periods for Processing All Types of License Applications) to renew a license.(c) In accordance with Texas Government Code, §2001.054, HHSC considers that a license holder meets the renewal application submission deadline if the license holder submits through the online portal:(1) no later than 60 days before the expiration date of the current license:(A) a complete application for renewal or an incomplete application for renewal with a letter explaining the circumstances that prevented the inclusion of the missing information; and(B) the correct license fee established in §550.112 of this subchapter (relating to Licensing Fees); or(2) during the 60-day period ending on the date the current license expires:(A) a complete application for renewal or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(B) the correct license fee established in §550.112 of this subchapter; and(C) the late fee established in §550.112 of this subchapter.(d) HHSC reviews a renewal application and notifies the license holder if additional information is needed to complete the application.(e) It is the license holder's responsibility to ensure that the application is timely received by HHSC. Failure to submit a timely and sufficient renewal application with the correct license fee through the online portal will result in the expiration of the license.(f) If a license holder submits a renewal application to HHSC through the online portal after the expiration date of the license, HHSC denies the renewal application and does not refund the renewal license fee. The license holder is not eligible to renew the license and must cease operation on the date the license expires. A license holder whose license expires must apply for an initial license in accordance with §550.105 of this subchapter (relating to Initial License Application Procedures and Issuance).(g) HHSC issues a renewal license after determining that an applicant and the center have met the provisions of THSC §248A.002 and this chapter.(h) The issuance of a renewal license constitutes notice from HHSC to the center that the application is approved.(i) A renewal license issued in accordance with this chapter expires on the third anniversary after the effective date on the license.(j) HHSC may pend action on an application for the renewal of a license for up to six months if the center is not in compliance with THSC §248A.002 and this chapter based on an on-site inspection.(k) HHSC Licensing may propose to deny an application for the renewal of a license if an applicant, controlling person, or any person required to submit background and qualification information fails to meet the criteria for a license established in §550.101 of this subchapter (relating to Criteria and Eligibility for a License) or for any reason specified in §550.115 of this subchapter (relating to Criteria for Denial of a License).(l) Before denying a license renewal application, HHSC Enforcement gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all the requirements of THSC Chapter 248A and this chapter to retain the license.(m) To request an opportunity to show compliance, the license holder must send a written request to HHSC. The request must:(1) be postmarked no later than 10 days after the date of notice from HHSC of the proposed action and received by HHSC no later than 10 days after the date of the postmark; and(2) contain documentation that refutes HHSC allegations specifically.(n) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action.(o) If HHSC Enforcement denies an application for a renewal license, HHSC sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC hearing rules found in Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §550.106 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective October 29, 2018, 43 TexReg 7188; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.106 Renewal License Application Procedures and Issuance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220935 03/12/2026 (a) For purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the new operator of a center that exists on the date the applicant submits a change of ownership license application.(b) A center license is not assignable or transferable. The applicant (prospective new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When HHSC approves the change of ownership by issuing a temporary change of ownership license to the applicant (prospective new license holder), the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the application. Between the effective date of the change of ownership and the issuance of the temporary change of ownership license, the current license holder remains responsible under its license; however, the applicant may operate a center on behalf of the current license holder during such period of time.(c) An applicant must submit to HHSC through the online portal:(1) a complete application for a license in accordance with HHSC instructions and §550.101 of this subchapter (relating to Criteria and Eligibility for a License) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) the application fee, in accordance with §550.112 of this subchapter (relating to Licensing Fees);(3) a letter of credit for $250,000 from a bank that is insured by the Federal Deposit Insurance Corporation, or other documentation acceptable to HHSC, to demonstrate the applicant's financial viability; and(4) a signed and notarized Change of Ownership Transfer Affidavit HHSC Form 1092 from the applicant and the center's current license holder of intent to transfer operation of the center from the current license holder to the applicant, beginning on the change of ownership effective date specified on the change of ownership application.(d) HHSC Licensing may propose to deny issuance of a change of ownership license if the applicant, a controlling person, or any person disclosed in the application fails to meet the criteria for a license established in §550.101 of this subchapter or for any reason specified in §550.115 of this subchapter (relating to Criteria for Denial of a License).(e) To avoid a center operating without a license, an applicant must submit all items in subsection (c) of this section in accordance with HHSC instructions at least 30 days before the anticipated date of the change of ownership specified on the change of ownership application, unless the 30-day notice requirement is waived in accordance with subsection (f) of this section.(f) HHSC may waive the 30-day notice required by subsection (e) of this section if:(1) the applicant presents evidence to HHSC demonstrating that an eviction of the center or a foreclosure of the property from which the center operates is imminent and that circumstances prevented the timely submission of the items specified in subsection (c) of this section; or(2) HHSC, in its sole discretion, determines that circumstances are present that threaten a minor's health, safety, or welfare and necessitate waiver of timely submission of the items specified in subsection (c) of this section.(g) Upon HHSC approval of the items specified in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all persons disclosed in the application satisfy the requirements in §§550.101(a) and (f) of this subchapter, 550.104 of this subchapter (relating to Applicant Disclosure Requirements), and 550.115 of this subchapter.(1) The issuance of a temporary change of ownership license constitutes official written notice by HHSC to the center of the approval of the application for a change of ownership.(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online portal.(h) A temporary change of ownership license expires on the earlier of:(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (i) of this section; or(2) the date HHSC issues a three-year license in accordance with subsection (l) of this section.(i) HHSC, in its sole discretion, may extend the term of a temporary change of ownership license by 90 days based upon extenuating circumstances.(j) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site health inspection after issuing a temporary change of ownership license if:(1) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or(2) every person with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(k) HHSC, in its sole discretion, may conduct an on-site Life Safety Code inspection after issuing a temporary change of ownership license.(l) If an applicant and all other persons disclosed in the application satisfy the requirements of §§550.101(a) and (f), 550.104, and 550.115 of this subchapter for a license, and the center passes the change of ownership health inspection as described in subsection (j) of this section, HHSC issues a three-year license. The effective date of the three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application for a license was received through the online portal.(m) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name.(n) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC of the addition no later than 30 days after the addition of the owner by submitting an application through the online portal. Source Note: The provisions of this §550.108 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective October 11, 2017, 42 TexReg 5492; amended to be effective October 29, 2018, 43 TexReg 7188; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 11, 2022, 47 TexRg 6588; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.108 Change of Ownership License Application Procedures and Issuance and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220936 03/12/2026 (a) A license holder must not increase a center's licensed capacity without approval from HHSC.(b) The license holder must submit an application for an increase in capacity in accordance with §550.102 of this subchapter (relating to General Application Requirements) and the correct fee required in §550.112 of this subchapter (relating to Licensing Fees) through the online portal.(c) The license holder must:(1) arrange for an inspection of the center by the local fire marshal or the state fire marshal; and(2) submit written evidence of the fire marshal's approval to HHSC that describes the center by name and address by uploading a copy through the online portal.(d) An applicant must send written notice to HHSC indicating that the center is ready for a Life Safety Code inspection by uploading the notice through the online portal.(1) The written notice must be submitted:(A) with the application; or(B) no later than 120 days after HHSC Licensing and Credentialing Unit receives the application.(2) After HHSC receives the written notice for a Life Safety Code inspection and an applicant has satisfied the application submission requirements, HHSC staff conducts an on-site Life Safety Code inspection.(e) If an applicant receives a notice from HHSC that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If an applicant fails to submit the requested information no later than 30 days after the notice date, HHSC considers the application incomplete and proposes to deny the application. If HHSC denies the application, HHSC does not refund the license fee.(f) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny the application for a license.(g) After a center has met Life Safety Code requirements, HHSC conducts an on-site health inspection.(h) HHSC issues a new license with an increased capacity if HHSC determines that the center is in compliance with this chapter.(i) If an applicant decides not to continue the application process after submitting the application and correct license fee, an applicant must submit to HHSC a written request to withdraw the application. HHSC does not refund the license fee.(j) Before denying an application for an increase in capacity, HHSC Enforcement gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all the requirements of the THSC Chapter 248A and this chapter to retain the license.(k) To request an opportunity to show compliance, the license holder must send a written request to HHSC. The request must:(1) be postmarked no later than 10 days after the date of the HHSC notice of proposed action and received by HHSC no later than 10 days after the date of the postmark; and(2) contain documentation that refutes the allegations.(l) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action.(m) If HHSC denies an application for an increase in capacity, HHSC sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC hearing rules found in Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §550.109 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.109 Increase in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220937 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220937 03/12/2026 (a) A license holder who wishes to decrease the licensed capacity of the center must provide written notification to HHSC by submitting a capacity change application through the online portal. The application must indicate the new licensed capacity for the center.(b) After HHSC receives the application, HHSC issues a new license with the new licensed capacity. Source Note: The provisions of this §550.110 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.110 Decrease in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220938 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220938 03/12/2026 (a) Relocation is the closing of a center and the movement of its business operations to another location.(b) A license holder must not relocate a center or provide services to a minor at a new location without prior approval from HHSC.(c) The license holder must continue to maintain the license at the current location and must continue to meet all requirements for operation of the center until HHSC approves the relocation.(d) Before a relocation, the license holder must submit a relocation application for the new location and the correct fee for a relocation required in §550.112 of this subchapter (relating to Licensing Fees) through the online portal.(e) The license holder must:(1) arrange for an inspection of the center by the local fire marshal or state fire marshal; and(2) submit written evidence of the fire marshal's approval to HHSC that describes the center by name and address by uploading a copy through the online portal.(f) An applicant must send written notice to HHSC indicating that the center is ready for a Life Safety Code inspection.(1) The written notice must be submitted through the online portal:(A) with the application; or(B) no later than 120 days after HHSC Licensing and Credentialing Unit receives the application.(2) After HHSC receives the written notice for a Life Safety Code inspection and an applicant has satisfied the application submission requirements, HHSC staff conducts an on-site Life Safety Code inspection.(g) If an applicant receives a notice from HHSC that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If an applicant fails to submit the requested information no later than 30 days after the notice date, HHSC Licensing considers the application incomplete and proposes to deny the application. If HHSC Enforcement denies the application, HHSC does not refund the license fee.(h) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny the application for a license.(i) Following Life Safety Code approval by HHSC, the license holder must notify HHSC of the date the business operations will be relocated.(j) HHSC issues a license for the new center if the new center meets the requirements in this chapter. The effective date of the license is the date all business operations are relocated.(k) The issuance of a license constitutes HHSC approval of the relocation.(l) The license for the current location becomes invalid upon issuance of the new license for the new location.(m) If an applicant decides not to continue the application process after submitting the application and correct license fee, an applicant must submit to HHSC a written request to withdraw the application. HHSC does not refund the license fee.(n) Before denying an application for relocation, HHSC Enforcement gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all the requirements of THSC Chapter 248A and the Chapter to retain the license.(o) To request an opportunity to show compliance, the license holder must send a written request to HHSC. The request must:(1) be postmarked no later than 10 days after the date of HHSC notice of proposed action and received by HHSC no later than 10 days after the date of the postmark; and(2) contain documentation that refutes HHSC allegations specifically.(p) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action.(q) If HHSC denies an application for relocation, HHSC sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with Texas Health and Human Services Commission rules found in 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC hearing rules found in Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §550.111 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.111 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220939 03/12/2026 (a) The schedule of fees for licensure of a center is as follows:(1) initial license fee (includes changes of ownership and relocation)--$2,625;(2) renewal license fee--$2,625; and(3) increase in capacity--$1,312.50.(b) HHSC does not waive the license fee for a change of ownership application despite a demonstration of the circumstances referenced in §550.108(f) of this subchapter (relating to Change of Ownership License Application Procedures and Issuance and Notice of Changes). HHSC may waive the timely submission of an application for a change of ownership in accordance with §550.108(f) of this subchapter.(c) The late fee established in §550.106 of this subchapter (relating to Renewal License Application Procedures and Issuance) is $50 per day to a license holder who submits a renewal application after the date as described at §550.106 of this subchapter, except that the total amount of a late fee may not exceed $500.00.(d) HHSC does not consider an application as submitted until an applicant pays the correct license fee as required in this section. The fee must accompany the application.(e) A fee paid to HHSC is not refundable, except as provided by §550.114 of this chapter (relating to Time Periods for Processing All Types of License Applications).(f) HHSC accepts payment according to methods described in the application instructions. Source Note: The provisions of this §550.112 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective October 29, 2018, 43 TexReg 7188; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.112 Licensing Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220940 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220940 03/12/2026 (a) A center must pay a fee to HHSC for its review of plans for new buildings, additions, conversion of buildings not licensed by HHSC, or remodeling of existing licensed facilities as described on the HHSC website.(b) The fee schedule follows:(1) facilities--new construction:(A) single-story facilities--$2,000; and(B) multiple-story facilities--$2,500; and(2) additions or remodeling of existing licensed facilities--2 percent of construction cost with a $500 minimum fee and a maximum not to exceed $2,000. Source Note: The provisions of this §550.113 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.113 Plan Review Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220941 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220941 03/12/2026 (a) The date of an application is the date the HHSC Licensing and Credentialing Unit receives the application and the correct license fee as required in §550.112 of this subchapter (relating to Licensing Fees).(b) HHSC considers an application for an initial license complete when HHSC accepts the information described in §550.105 of this subchapter (relating to Initial License Application Procedures and Issuance).(c) HHSC considers an application for a renewal license complete when HHSC accepts the information described in §550.106 of this subchapter (relating to Renewal License Application Procedures and Issuance). A center may continue to operate during the renewal application process in accordance with §550.106 of this subchapter.(d) HHSC considers an application for a change of ownership license complete when HHSC accepts the information described in §550.108 of this subchapter (relating to Change of Ownership License Application Procedures and Issuance and Notice of Changes).(e) HHSC reviews an application for a license no later than 45 days after the date the HHSC Licensing and Credentialing Unit receives the application.(f) If an applicant receives a notice through the online portal from HHSC that some or all of the information required by this chapter is missing or incomplete, an applicant must submit the required information through the online portal no later than 30 days after the date of the notice. If an applicant fails to submit the required information no later than 30 days after the notice date, HHSC Licensing considers the application incomplete and proposes to deny the application. If HHSC Enforcement denies the application, HHSC Licensing does not refund the license fee.(g) HHSC Licensing proposes to deny an application that remains incomplete 120 days after the date that the HHSC Licensing and Credentialing Unit receives the application.(h) HHSC issues a license no later than 30 days after HHSC determines that an applicant and the center have met all licensure requirements referenced in §550.105 and §550.106 of this subchapter, as applicable.(i) If HHSC does not process an application in the time period described in subsections (e) and (h) of this section, an applicant may request reimbursement of the license fee paid. The applicant must submit the reimbursement request through the online portal.(j) If HHSC does not agree that the established time period for processing an application described in subsection (e) of this section has been violated or finds that good cause existed for exceeding the established time period, HHSC denies the request.(k) Good cause for exceeding the established time period exists if:(1) the number of applications to be processed exceeds by 15 percent or more the number processed in the same fiscal quarter of the preceding year;(2) HHSC must rely on another public or private entity to process all or a part of the application received by HHSC, and the delay is caused by that entity; or(3) other conditions existed giving good cause for exceeding the established time period.(l) If HHSC denies the request for reimbursement, an applicant may request that the executive commissioner resolve the dispute. An applicant must send a written statement to the executive commissioner describing the request for reimbursement and the reason for the request. The executive commissioner reviews the request and notifies an applicant in writing of the decision. Source Note: The provisions of this §550.114 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.114 Time Periods for Processing All Types of License Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220942 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220942 03/12/2026 (a) HHSC may deny an application for an initial center license or for renewal of a license for:(1) a violation of the THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;(2) an intentional or negligent act by the center or an employee of the center that HHSC determines significantly affects the health or safety of a minor served at the center;(3) use of drugs or intoxicating liquors to an extent that affects the license holder's or applicant's professional competence;(4) a felony conviction, including a finding or verdict of guilty, an admission of guilt, or a plea of nolo contendere, in this state or in any other state of any person required by this chapter to undergo a background and criminal history;(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception, committed by any person listed on the application;(6) a license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed on the application;(7) criteria described in Chapter 560 of this title (relating to Denial or Refusal of License) that applies to any person required by this chapter to undergo a background and criminal history check;(8) aiding, abetting, or permitting a substantial violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;(9) a license holder or applicant's failure to provide the required information as requested on the application or in follow-up to the review of the application;(10) a license holder or applicant who knowingly:(A) submits false or intentionally misleading statements to HHSC on an application;(B) uses subterfuge or other evasive means of filing an application;(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or(D) conceals a material fact on an application;(11) a person listed on the application failing to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §550.112 of this subchapter (relating to Licensing Fees);(B) franchise taxes, if applicable; and(C) federal taxes, as applicable; or(12) a person listed on the application having a history of any of the following actions during the five-year period preceding the date of the application:(A) operation of a facility in Texas or another state or jurisdiction that has been decertified or had its contract canceled under the Medicare or Medicaid program;(B) federal or state Medicare or Medicaid sanctions or penalties;(C) an unsatisfied final court judgment;(D) eviction in Texas or another state or jurisdiction involving any property or space used as a center; or(E) suspension in Texas or another state or jurisdiction of a license to operate a health facility, long-term care facility, assisted living facility, or a similar facility, or a center.(b) HHSC:(1) denies a license to an applicant to operate a center if an applicant has on the date of the application:(A) a debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or(B) a court injunction prohibiting an applicant or manager from operating a center; and(2) may deny a license to an applicant to operate a new center if an applicant has a history of any of the following actions at any time preceding the date of the application:(A) revocation of a license to operate a health care facility, long-term care facility, assisted living facility or similar facility, or center in any state;(B) surrender of a license in lieu of revocation or while a revocation hearing is pending;(C) expiration of a license while a revocation action is pending and the license is surrendered without an appeal of the revocation or an appeal is withdrawn; or(D) probation period placed on a license to operate a center.(c) HHSC may consider exculpatory information provided by any person described in §550.101(f) of this subchapter (relating to Criteria and Eligibility for a License) and grant a license if HHSC finds that person able to comply with THSC Chapter 248A and this chapter.(d) In determining the denial of a license, HHSC considers all final actions taken against an applicant or license holder whether issued by HHSC or another state or federal agency. An action is final when administrative and judicial remedies are exhausted. All actions, whether pending or final, must be disclosed.(e) If an applicant owns multiple centers or other facility types, HHSC examines the overall record of compliance in all of the centers or other facilities and agencies. An overall record poor enough to deny issuance of a new license does not preclude the renewal of licenses of individual centers with satisfactory records.(f) If HHSC denies an application for a license, HHSC sends an applicant written notice of the denial and informs the applicant of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §550.115 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.115 Criteria for Denial of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194760 03/12/2026 A center must display the center's license in a conspicuous location readily visible to a person entering the center. Source Note: The provisions of this §550.116 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.116 Display of License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194761 03/12/2026 A center license may not be altered. Source Note: The provisions of this §550.117 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.117 License Alteration Prohibited https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220943 03/12/2026 If certain information provided on an initial or renewal application changes after HHSC issues the license, a center must report the change to HHSC by submitting a change application through the online portal. For requirements on reporting a change regarding:(1) the administrator, chief financial officer, and controlling person, a center must comply with §550.119 of this subchapter (relating to Notification Procedures for a Change in Administration and Management) and §559.302 of this chapter (relating to Organizational Structure and Lines of Authority);(2) the center's contact information, a center must comply with §550.120 of this subchapter (relating to Notification Procedures for a Change of Contact Information);(3) the center's operating hours, a center must comply with §550.121 of this subchapter (relating to Notification Procedures for a Change in Operating Hours); and(4) name (legal entity or doing business as), a center must comply with §550.122 of this subchapter (relating to Notification Procedures for a Name Change). Source Note: The provisions of this §550.118 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.118 Reporting Changes in Application Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220944 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220944 03/12/2026 (a) If a change occurs in the following management staff, a center must report the change to HHSC by submitting notification through the application in the online portal no later than seven days after the date of a change in:(1) administrator;(2) chief financial officer; or(3) controlling person, as defined in §550.5 of this chapter (relating to Definitions), including:(A) a change of five percent or more of the controlling interest of a limited partner in a limited partnership or the addition of a controlling person to the limited partnership; or(B) a change of five percent or more of the controlling interest in a for-profit corporation or limited liability company.(b) A change in the management staff listed in subsection (a) of this section requires HHSC review and approval. HHSC reviews the required documents and information submitted. HHSC provides notification to a center through the application in the online portal if a person listed in subsection (a) of this section does not meet the required qualifications described in §550.101 of this chapter (relating to Criteria and Eligibility for a License). Source Note: The provisions of this §550.119 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.119 Notification Procedures for a Change in Administration and Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220945 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220945 03/12/2026 A center must report a change in contact information to HHSC by submitting a change application through the online portal no later than seven days after a change in the center's:(1) telephone number; or(2) mailing address, if different from the physical location. Source Note: The provisions of this §550.120 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.120 Notification Procedures for a Change of Contact Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220946 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220946 03/12/2026 A center must report a change in operating hours to HHSC by submitting a change application through the online portal no later than seven days after a change in the center's operating hours. Source Note: The provisions of this §550.121 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.121 Notification Procedures for a Change in Operating Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220947 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220947 03/12/2026 (a) If a center intends to change the name of its legal entity or assumed name, but does not undergo a change of ownership as defined in §550.107 of this subchapter (relating to Change of Ownership), the center must report the name change to HHSC by submitting a change application through the online portal no later than seven days after the effective date of the name change.(b) If a center changes its name but does not undergo a change of ownership, the license holder must notify HHSC through submission of a change application through the online portal and submit a copy of a certificate of amendment from the Office of the Secretary of State. After HHSC receives the certificate of amendment and approves the change application, a license is issued in the license holder's new name. Source Note: The provisions of this §550.122 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.122 Notification Procedures for a Name Change https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220948 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220948 03/12/2026 (a) An applicant for an initial license under §550.105 of this subchapter (relating to Initial License Application Procedures and Issuance) may request that HHSC issue a temporary license pending review by HHSC of the applicant's application for an initial license.(b) To request a temporary license, the applicant must submit an application for a temporary license to the HHSC Licensing and Credentialing Unit through the online portal and upload a copy of the applicant's policies, procedures and staffing plans that demonstrate compliance with the licensing standards of this chapter.(c) HHSC issues a temporary license to an applicant who has requested a temporary license if HHSC:(1) determines that the applicant has submitted an application for an initial license in accordance with §550.105 of this subchapter;(2) determines that the applicant meets the building requirements of Subchapter E of this chapter; and(3) approves the applicant's policies, procedures and staffing plans submitted in accordance with subsection (b) of this section.(d) If HHSC issues a temporary license, the center may admit no more than six minors to the center until the temporary license expires or terminates.(e) The issuance of a temporary license constitutes HHSC notice to the applicant of the approval of the temporary license request.(f) A temporary license expires on the earlier of:(1) 90 days after HHSC issues the temporary license or the last day of any extension HHSC grants in accordance with subsection (g) of this section; or(2) the date HHSC issues an initial license.(g) A temporary license holder may request that HHSC extend the term of a temporary license by 90 days. To request an extension, the license holder must submit to the HHSC Provider License and Certification Unit, a request for an extension through the online portal. If HHSC receives the request at least 30 days before the date the temporary license expires, HHSC extends the term of the license for 90 days and notifies the temporary license holder of the extension in writing. HHSC grants an applicant only one temporary license extension for a center.(h) A temporary license holder must comply with the requirements of THSC Chapter 248A and the licensing standards of this chapter for the term of the temporary license. HHSC may take the enforcement action described in Subchapter G of this chapter (relating to Enforcement) if the temporary license holder does not comply with THSC Chapter 248A or this chapter.(i) HHSC may visit or conduct an investigation or inspection of a center owned or operated by a temporary license holder, as described in Subchapter F of this chapter (relating to Inspections and Visits). Source Note: The provisions of this §550.123 adopted to be effective September 28, 2016, 41 TexReg 7512; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS B LICENSING APPLICATION, MAINTENANCE, AND FEES §550.123 Request and Issuance of Temporary License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194738 03/12/2026 (a) A center must adopt and enforce a written policy identifying the center's operating hours. A center may not:(1) allow the provision of services to a minor at a center for more than 12 hours in any 24-hour period; or(2) allow the provision of services to a minor at a center overnight.(b) For the purposes of this section, the person in charge means the administrator, the alternate administrator, the nursing director, or the alternate nursing director.(c) If a center is closed during the center's operating hours, the person in charge must:(1) post a notice, in a location visible outside the center, that provides information regarding how to contact the person in charge by telephone; and(2) leave an outgoing message on the center's answering machine or similar electronic mechanism or with an answering service that provides information about how to contact the person in charge by telephone. Source Note: The provisions of this §550.201 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.201 Operating Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220949 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220949 03/12/2026 (a) Suspension of operations occurs when a center suspends its normal business operations for five or more consecutive days due to:(1) a scheduled closing of the center when a center has at least 45 days advance notice of the need to close the center; or(2) an unscheduled closing of the center when a center has less than 45 days but more than 15 days advance notice of the need to close the center.(b) A suspension of operations may not exceed the expiration date of the licensure period.(c) If a center suspends operations due to a scheduled closing of the center, the center must:(1) provide written notification to an adult minor or a minor's parent at least 30 days before the suspension of operations begins that includes:(A) the start and end date of the suspension;(B) instructions for obtaining a minor's medical records before and during the suspension for all services provided at the center; and(C) information about the available options to transfer, discharge, or put a minor's services on hold depending on the needs of the minor;(2) assist a parent or an adult minor with finding alternative services during the suspension;(3) discharge, transfer or put a minor's services on hold in accordance with §550.608 of this subchapter (relating to Discharge or Transfer Notification);(4) ensure coordination of services for the minor's other service providers;(5) notify the minor's physician at least 30 days before the suspension of operations begins;(6) provide written notification to HHSC through the online portal at least 30 days before the suspension of operations begins;(7) post a notice, in a location visible outside of the center for the duration of the suspension, that provides information about the suspension of operations, including:(A) the start and end date of the suspension; and(B) how to obtain a minor's records during the suspension;(8) leave an outgoing message, on the center's answering machine or other similar electronic mechanism or with an answering service, that provides the information in paragraph (7) of this subsection; and(9) notify HHSC in writing within seven days after resuming normal business operations.(d) If a center suspends operations due to an unscheduled closing of the center, the center must:(1) provide oral and written notification to a minor's parent no later than 15 days before the suspension of operations begins that includes:(A) the start and estimated end date of the suspension;(B) instructions for obtaining a minor's medical records before and during the suspension for all services provided at the center; and(C) information about the available options to transfer, discharge, or put a minor's services on hold depending on the needs of the minor;(2) assist a parent or an adult minor with finding alternative services during the suspension;(3) discharge, transfer or put the minor's services on hold in accordance with §550.608 of this subchapter;(4) ensure coordination of services with the minor's other service providers;(5) notify the minor's physician no later than 15 days before the suspension of operations begins;(6) provide written notification to HHSC no later than 15 days before the suspension of operations begins;(7) post a notice, in a location visible outside of the center, for the duration of the suspension that provides information about the suspension of operations, including:(A) the start and estimated end date of the suspension; and(B) how to obtain a minor's records during the suspension;(8) leave an outgoing message, on the center's answering machine or other similar electronic mechanism or with an answering service, that provides the information in paragraph (7) of this subsection; and(9) notify HHSC in writing within seven days after resuming normal business operations.(e) If the center must close with less than 15 days advance notice, the center must follow the requirements in §550.209 of this division (relating to Emergency Preparedness Planning and Implementation). Source Note: The provisions of this §550.202 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.202 Suspension of Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220950 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220950 03/12/2026 (a) A center must have the financial ability to carry out its functions.(b) A center must make available to HHSC, upon request, business records relating to its ability to carry out its functions. HHSC may conduct a more extensive review of the records if there is a question relating to the accuracy of the records or the center's financial ability to carry out its functions.(c) A center must maintain business records in their original state. Each entry must be accurate and include the date of entry. Correction fluid or tape may not be used in the record. Corrections must be made in accordance with standard accounting practices. Source Note: The provisions of this §550.203 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.203 Financial Solvency and Business Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194741 03/12/2026 A center must adopt and enforce a written policy that includes procedures:(1) to ensure that the center submits accurate billing and insurance claims; and(2) to prevent, detect, and report fraud, waste, and abuse. Source Note: The provisions of this §550.204 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.204 Billing and Insurance Claims https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220951 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220951 03/12/2026 (a) A center must ensure that the local fire marshal's office or the state fire marshal inspects the center annually. The center must keep a copy of the annual fire inspection report on file at the center for two years after the date of inspection.(b) A center must prepare a fire drill plan and conduct a fire drill at least once every month.(1) The center's administrator and nursing director must participate in the monthly fire drill.(2) The center must conduct fire drills at various times of the day.(3) The center must document a drill on the HHSC Fire Drill Report Form.(c) The center's administrator and nursing director must:(1) review the center's fire drill plan;(2) evaluate the effectiveness of the plan after each fire drill;(3) review any problems that occurred during each drill and take corrective action, if necessary; and(4) maintain documentation to support the requirements of this subsection.(d) A center must have a working telephone available at all times at the center. Coin operated telephones or cellular telephones are not acceptable for this purpose. If the center has multiple buildings, a working telephone must be located in each of the buildings.(e) A center must post at or near the immediate vicinity of all telephones:(1) emergency telephone numbers including:(A) the HHSC abuse, neglect, and exploitation hotline;(B) poison control;(C) 911 or the local fire department, ambulance, and police in communities where a 911 management system is unavailable; and(D) an emergency medical facility; and(2) the center's address.(f) A center must adopt and enforce written policies and procedures for a minor's medical emergency. The policy must include:(1) a requirement that each minor has an emergency plan, developed in collaboration with a minor's parent, that:(A) includes instructions from a minor's prescribing physician, as applicable;(B) includes coordination with other health care providers, including hospice; and(C) is updated and reviewed at least yearly or more often as necessary to meet the needs of a minor;(2) a requirement that staff receive training for medical emergencies;(3) a requirement that staff receive training in the use of emergency equipment; and(4) procedures that staff follow when a minor's parent cannot be contacted in an emergency.(g) If a minor must be transported to an emergency medical facility while at the center, the staff must immediately notify a minor's parent and hospice provider, if applicable. If a parent cannot be contacted, the center must ensure that an individual authorized by the parent or center staff meets a minor at the emergency facility.(h) The center must prepare a medical emergency transfer form to give to the emergency transportation provider when transporting a minor to an emergency medical facility. The transfer form must include:(1) the minor's name and age;(2) the minor's diagnoses, allergies, and medication;(3) the minor's parent name and contact information;(4) the minor's prescribing physician name and contact information;(5) the center's name and contact information; and(6) the name of the administrator or nursing director.(i) A center must maintain a first aid kit with unexpired supplies and an automated external defibrillator for minors served at the center that is easily accessible but not within reach of minors.(j) A center must adopt and enforce written policies and procedures for the verification and monitoring of visitors, including service providers at a center. The policies and procedures must include:(1) verification of a visitor's identity;(2) verification of a visitor's authorization to enter a center;(3) the recording of a visitor's name, organization, purpose of the visit, and the date and time a visitor entered and exited a center;(4) the center's awareness of a visitor while in a center; and(5) documentation of the requirements in this subsection.(k) A center must adopt and enforce written policies and procedures for the release of a minor. The policy must include:(1) procedures to verify the identity of a person authorized to pick up a minor from the center; and(2) procedures for the release of a minor when transported by the center in accordance with Subchapter D of this chapter (relating to Transportation).(l) A center must adopt and enforce written policies and procedures to ensure that no minor is left unattended at the center. The policy must include procedures for:(1) a minor who arrives at the center;(2) a minor who remains at the center during operating hours;(3) a minor who leaves the center; and(4) staff to conduct daily visual checks at the center at the close of business.(m) A center must maintain daily records and documentation of the visual check at the end of each day to ensure no minor is left at the center. The documentation must include:(1) the date and time; and(2) the signature of the staff member conducting the daily visual checks at the center at the close of business.(n) Except as otherwise provided in this section, a center must meet the provisions applicable to the health care occupancy chapters of the 2000 edition of the LSC of the National Fire Protection Association (NFPA) and the requirements in Subchapter E of this chapter (relating to Building Requirements). Roller latches are prohibited on corridor doors.(o) Notwithstanding any provisions of the 2000 edition of the Life Safety Code, NFPA 101, to the contrary, a center may place alcohol-based hand-rub dispensers at the center if:(1) use of alcohol-based hand-rub dispensers does not conflict with any state or local codes that prohibit or otherwise restrict the placement of such dispensers in health care facilities;(2) the dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;(3) the dispensers are installed in a manner or location out of reach of a minor; and(4) the dispensers are installed in accordance with Chapter 18.3.2.7 or Chapter 19.3.2.7 of the 2000 edition of the LSC, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004.(p) A center's environment must be free of health and safety hazards to reduce risks to minors. The center must:(1) use childproof electrical outlets or childproof covers on unused electrical outlets in all rooms to which minors have access at the center;(2) use safety precautions for strings and cords, including those used on window coverings, and keep them out of the reach of minors;(3) use safety precautions for all furnishings including cabinets, shelves, and other furniture items that are not permanently attached to the center; and(4) use play material and equipment that is safe and free from sharp or rough edges and toxic paints.(q) A center must adopt and enforce a written policy describing whether a center is a weapons-free location. A center must:(1) provide a copy of the policy to staff, individuals providing services on behalf of a center, an adult minor, and a minor's parent; and(2) provide a copy of the policy to any person who requests it.(r) If a center is weapons-free, a center must post a visible and readable sign at the entrance of the center indicating the center is a weapons-free location.(s) A center must adopt and enforce a written policy prohibiting the use of tobacco in any form, the use of alcohol, and the possession of illegal substances and potentially toxic substances at a center. Source Note: The provisions of this §550.205 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.205 Safety Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220952 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220952 03/12/2026 (a) A center must adopt and enforce written policies and procedures for the use of person-centered direction and guidance by individuals providing services to minors at the center. The policy must include:(1) the implementation of a system-wide, person-centered direction and guidance program for minors that includes:(A) the teaching of successful behavior and coping skills;(B) proactive strategies to identify and manage a minor's behaviors before they escalate; and(C) the monitoring and evaluation of the effectiveness of direction and guidance used with a minor by a committee as described in this section;(2) procedures for ensuring consistent language, practices, and application of direction and guidance by individuals providing services at a center; and(3) procedures for documenting and providing to a minor's parent a daily report of the minor's behavior.(b) A center must ensure that only person-centered strategies and techniques that encourage self-esteem, self-control, and self-direction are used for the purposes of direction and guidance of a minor at a center. A center must not use a restraint as part of person-centered direction and guidance.(c) Person-centered direction and guidance must be:(1) individualized and consistent for each minor;(2) differentiated in both nature and intensity based on a minor's level of behavior;(3) appropriate to the minor's level of understanding and functional or educational development; and(4) directed toward teaching the minor successful behavior, awareness of behavior triggers and self-control, including:(A) encouraging a minor to develop positive behavior in accordance with a minor's individualized psychosocial program;(B) redirecting behavior using positive statements; and(C) teaching the minor to use effective behavior management techniques.(d) A center must ensure that quiet time, if used, is:(1) in accordance with the minor's psychosocial program and plan of care;(2) brief and under continuous face-to-face observation by center staff;(3) appropriate for the minor's age and development;(4) limited to no more than one minute per year of the minor's developmental age; and(5) does not place a minor alone in a room.(e) A center must ensure the protection of minors at the center from harsh, cruel, or unusual treatment. Negative discipline is considered punishment and abuse and is prohibited at a center, including:(1) corporal punishment or threats of corporal punishment;(2) punishment associated with food, naps, or toilet training;(3) pinching, shaking, or biting a minor;(4) hitting a minor with a hand or object;(5) putting anything in or on a minor's mouth;(6) humiliating, ridiculing, rejecting, or yelling at a minor;(7) subjecting a minor to harsh, abusive, or profane language;(8) placing a minor alone in a locked or darkened room, bathroom, or closet without windows; and(9) requiring a minor to remain silent or inactive for inappropriately long periods of time for the minor's developmental age.(f) The center must establish a person-centered direction and guidance committee to review the techniques and strategies used at a center to:(1) determine whether the individualized direction and guidance used as established in a plan of care is consistently applied for each minor in accordance with center policy; and(2) evaluate the frequency and outcomes of strategies and techniques used with a minor to:(A) determine the impact of the direction and guidance on a minor's ability to achieve progress in goals;(B) determine effectiveness of the minor's program; and(C) recommend the use of new strategies and techniques when current strategies and techniques are determined to be ineffective.(g) The committee must include:(1) the center's administrator;(2) the center's nursing director or designee;(3) an individual providing psychosocial treatment and services on behalf of a center; and(4) a parent or an individual from a parent council or support group for minors receiving services at the center.(h) The center is not required to include a parent or individual from a parent council or support group if, after a good faith effort, the center is unable to include a parent or individual in a committee meeting. The center must document, for review by HHSC, a good faith effort to include a parent or individual from a parent council or support group at each meeting.(i) The center must adopt and enforce written policies and procedures for the frequency, format, and documentation of committee meetings.(j) A center must provide its written person-centered direction and guidance policy to all parents, employees, volunteers, and contractors. The center must maintain documentation of acknowledgment of the written policy from all employees, volunteers, and contractors. Source Note: The provisions of this §550.206 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.206 Person-Centered Direction and Guidance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220953 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220953 03/12/2026 (a) Protective Devices. A center must ensure that a protective device is used only as ordered by a minor's prescribing physician, as agreed to by an adult minor or a minor's parent, and in accordance with the minor's plan of care.(1) A center may use a protective device only in the following circumstances:(A) as part of a therapeutic regimen of basic services for a minor's physical health and development;(B) during medical, nursing, diagnostic, and dental procedures as prescribed by a physician's order and to protect the health and safety of a minor; or(C) in a medical emergency to protect the health and safety of a minor.(2) A center must adopt and enforce written policies and procedures requiring a protective device to be used as described in this subsection and in accordance with a minor's plan of care.(3) A center must not implement a physician's order for the use of a protective device on a pro re nata (PRN) or as-needed basis.(4) A center must ensure a physician's order is obtained before using a protective device at the center. The physician's order must include:(A) the circumstances under which a protective device may be used at the center;(B) instructions on how long a protective device may be used at the center; and(C) any individualized, less restrictive interventions described in the minor's plan of care that must be used before using a protective device.(5) A center must ensure that in implementing a physician's order for a protective device that an RN, with input from an adult minor, a minor's parent, and the IDT:(A) conducts an assessment of a minor's current and ongoing need for a protective device at a center;(B) reviews the physician's order for a protective device, as described in paragraph (4) of this subsection; and(C) obtains and documents in a minor's medical record the written consent of an adult minor or a minor's parent to use a protective device at the center.(6) Before using a protective device for the first time with a minor, the center must ensure an RN provides oral and written notification to the adult minor or the minor's parent of the right at any time to withdraw consent and discontinue use of a protective device at the center.(7) The center must ensure that a staff member who will apply a protective device has been properly trained in the use of a protective device, as ordered in the minor's plan of care, in accordance with this subsection, and in accordance with §550.415(b)(8)(F) of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training).(8) If a protective device is used for a minor, the center must ensure:(A) the minor is assessed by an RN, in accordance with the physician's order but no less than once every hour to determine if the protective device must be repositioned or discontinued;(B) except for sedation, the protective device is removed to conduct the RN assessment described in subparagraph (A) of this paragraph and removed more frequently as determined necessary by the RN's assessment;(C) center staff replaces the protective device, if necessary, after the assessment, in accordance with the physician's order;(D) a minor's physician is notified immediately if an assessment determines a change in the minor's condition or a negative reaction to the protective device has occurred, including notification of:(i) the minor's psychosocial condition;(ii) the minor's reaction to the protective device;(iii) the minor's medical condition; and(iv) the need to continue or discontinue the use of the protective device;(E) the type and frequency of use of the protective device is documented in the minor's medical record;(F) the effects of a protective device on the minor's health and welfare are evaluated and documented in the medical record; and(G) an RN, an adult minor, a minor's parent, and the IDT, at least every 180 days, or as the minor's needs change, review, with input and direction from the minor's prescribing physician, the use of a protective device to determine its effectiveness and the need to continue the use of the protective device.(b) Restraints. A center may use a restraint only in a behavioral emergency when the immediate health and safety of the minor or another minor are at risk. A center must not use a chemical or mechanical restraint.(1) The center must adopt and enforce a written policy and procedures regarding the use of restraints in a behavioral emergency, including whether a center is a restraint-free environment.(2) A center must ensure that the use of a restraint at a center must not be in a manner that:(A) obstructs a minor's airway, including the placement of anything in, on, or over the minor's mouth or nose;(B) impairs the minor's breathing by putting pressure on the minor's torso;(C) interferes with the minor's ability to communicate;(D) extends muscle groups away from each other;(E) uses hyperextension of joints; or(F) uses pressure points or pain.(3) A center must ensure that a restraint is not used for:(A) controlling a minor's behavior in a non-emergency;(B) negative discipline as described in §550.206 of this division (relating to Person-Centered Direction and Guidance);(C) convenience;(D) coercion or retaliation; or(E) as part of a behavior component of a minor's psychosocial program.(4) A center must not implement a physician's order for the use of a restraint on a pro re nata (PRN) or as-needed basis.(5) A center must ensure that a staff member whose job responsibilities will include the use or application of a restraint during a behavioral emergency has been properly trained in the use of a restraint for minors served at the center, in accordance with this section, and in accordance with §550.415(b)(8)(G) of this subchapter.(6) If a center restrains a minor due to a behavioral emergency, the center must ensure:(A) all less restrictive options available are exhausted before using a restraint;(B) the restraint is limited to the use of such reasonable force as is necessary to address the emergency;(C) the restraint is discontinued immediately at the point when the emergency no longer exists but no more than 15 minutes after the restraint was initiated;(D) the restraint is implemented in such a way as to protect the health and safety of the minor and others;(E) immediately after the restraint is discontinued, the minor is assessed by an RN;(F) immediately following an RN assessment, medical attention is provided for the minor if determined necessary by the RN assessment;(G) within three days after the use of the restraint, an assessment is conducted by an RN as described in §550.504 of this subchapter (relating to Psychosocial Treatment and Services) to determine if the development and implementation of a psychosocial treatment and services program is needed for the minor to address the minor's behavior and reduce the occurrence of future behavioral emergencies; and(H) within three days after the use of the restraint, an RN reviews and updates a minor's plan of care and psychosocial treatment and services program as determined appropriate.(7) If a center restrains a minor due to a behavioral emergency, the center must ensure the following documentation and notifications occur:(A) immediately after the restraint is discontinued, information about the restraint is documented, including:(i) the name of the individual who administered the restraint;(ii) the date and time the restraint began and ended;(iii) the location of the restraint;(iv) the nature of the restraint;(v) a description of the setting and activity in which the minor was engaged immediately preceding the use of the restraint;(vi) the behavior that prompted the restraint;(vii) the efforts made to de-escalate the situation and the less restrictive alternatives attempted before the restraint; and(viii) the minor's condition after the restraint was discontinued;(B) within 24 hours after the use of the restraint, written documentation regarding the use of the restraint and the RN assessment conducted immediately after the use of the restraint is included in a minor's medical record;(C) documentation of nursing director and administrator oral and written notifications as described in subparagraphs (E) and (I) of this paragraph, including nursing director and administrator signatures acknowledging receipt of notifications must be included in the minor's medical record;(D) documentation of parent oral and written notifications as described in subparagraphs (F) and (J) of this paragraph, including a parent signature acknowledging receipt of notifications must be included in the minor's medical record;(E) immediately after the restraint is used, the administrator and director of nursing are notified orally that the restraint occurred;(F) on the day the restraint is used, the minor's parent is notified orally that the restraint occurred;(G) on the day the restraint is used, the center's staff responsible for psychosocial treatment and services is notified orally that the restraint occurred;(H) immediately after the RN assessment is conducted in accordance with paragraph (6)(E) of this subsection, if the assessment determines a change in the minor's condition or a negative reaction to the restraint has occurred, the minor's physician is notified of the restraint and the minor's condition, including:(i) the minor's medical condition;(ii) the minor's reaction to the restraint; and(iii) the minor's psychosocial condition;(I) within one hour after the use of the restraint, the administrator and director of nursing are notified in writing of the restraint, including the information in subparagraph (A) of this paragraph; and(J) within one day after the use of the restraint, the minor's parent is notified in writing, in a language and format the parent understands, of the restraint, including the information in subparagraph (A) of this paragraph.(8) The IDT must review, on an annual basis or more frequently as needed, all behavioral emergencies that occurred at the center during the time period being reviewed to determine the appropriateness of the center's response and to identify strategies for reducing behavioral emergencies at the center.(9) A center must maintain documentation of compliance with this section. Source Note: The provisions of this §550.207 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.207 Protective Devices and Restraints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194745 03/12/2026 (a) A center, with input from the medical director, must determine the quantity and types including age and developmentally appropriate equipment, devices, and supplies that the center must keep on the premises to meet the needs of minors and for emergency purposes.(b) The center must coordinate with a minor, a minor's parent, and a minor's prescribing physician and other basic service providers, as applicable, to ensure that equipment, devices, and supplies used by a minor are available to a minor at the center.(c) The center must ensure the provision of necessary consumable supplies and resources, including diapers, if the center determines, after the minor's arrival at the center, that the minor's parent failed to provide an adequate amount of necessary consumable supplies and resources for the minor.(d) The center must adopt and enforce written preventive maintenance policies and procedures to ensure the center's equipment, devices, and supplies are inspected for safety purposes and maintained at least annually or more frequently if recommended by the manufacturer. Equipment, devices, and supplies must be maintained free of defects that could pose a potential hazard to a minor or an individual at the center. The staff may perform preventive maintenance if the staff are trained and experienced in maintaining the specific equipment.(e) The center must adopt and enforce written policies and procedures to ensure equipment used by a minor is cleaned and sanitized after each use.(f) A center must have clean storage areas for equipment, devices, and supplies. Source Note: The provisions of this §550.208 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.208 Equipment, Devices, and Supplies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212042 03/12/2026 (a) A center must have a written emergency preparedness and response plan that comprehensively describes its approach to an emergency situation, including a public health disaster that could affect the need for its services or its ability to provide those services.(b) Administration. A center must:(1) develop and implement a written plan as described in subsection (c) of this section;(2) maintain a current written copy of the plan in a central location that is accessible to all staff at all times and at a work station of each staff who has responsibilities under the plan;(3) evaluate the plan to determine if information in the plan must change:(A) no later than 30 days after an emergency situation;(B) as soon as possible after the remodeling or construction of an addition to the center; and(C) at least annually;(4) revise the plan no later than 30 days after information in the plan changes; and(5) maintain documentation of compliance with this section.(c) Emergency Preparedness and Response Plan. A center's plan must:(1) include a risk assessment of all potential external and internal emergency situations that pose a risk for harm to minors or property and are relevant to the provision of services at a center and the center's geographical area, such as fire, earthquake, hurricane, tornado, flood, extreme snow and ice conditions for the area, wildfire, terrorism, hazardous materials accident, thunderstorm, wind storm, wave action, oil spill or other water contamination, epidemic, air contamination, infestation, explosion, riot, hostile military or paramilitary action, energy emergency, water outage, failure of heating and cooling systems, power outage, bomb threat, and explosion;(2) include a description of minors served at the center;(3) include a description of the services and assistance needed by minors served at the center in an emergency situation;(4) include a section for each core function of emergency management, as described in subsection (d) of this section, that is based on the center's decision to either temporarily shelter-in-place or evacuate during an emergency situation; and(5) include a section for a fire safety plan that complies with §550.205 of this division (relating to Safety Provisions).(d) Plan Requirements Regarding Eight Core Functions of Emergency Management.(1) Direction and control. A center's plan must contain a section for direction and control that:(A) designates by name or title the emergency preparedness coordinator (EPC) who is the staff person with the authority to manage the center's response to an emergency situation in accordance with the plan, and includes the EPC's current phone number;(B) designates by name or title the alternate EPC who is the staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity, and includes the alternate EPC's current phone number;(C) documents the name and contact information for the local emergency management coordinator (EMC) for the area where the center is located, as identified by the office of the local mayor or county judge;(D) includes procedures for notifying the local EMC of the execution of the plan;(E) includes a plan for coordinating a staffing response to an emergency situation; and(F) includes a plan for relocating minors to a safe location that is based on the type of emergency situation occurring and a center's decision to either temporarily shelter-in-place or evacuate during an emergency situation.(2) Warning. A center's plan must contain a section for warning that:(A) describes how the EPC will be notified of an emergency situation;(B) identifies who the EPC will notify of an emergency situation and when the notification will occur, including during off hours, weekends, and holidays; and(C) addresses monitoring local news and weather reports regarding a disaster or potential disaster, taking into consideration factors such as geographic-specific natural disasters, whether a disaster is likely to be addressed or forecast in the reports, and the conditions, natural or otherwise, that would cause staff to monitor news and weather reports for a disaster.(3) Communication. A center's plan must contain a section for communication that:(A) identifies the center's primary mode of communication to be used during an emergency situation and the center's alternate mode of communication to be used in the event of power failure or the loss of the center's primary mode of communication in an emergency situation;(B) requires posting of the emergency contact number for the local fire department, ambulance, and police at or near each telephone at the center in communities where a 911 emergency management system is unavailable;(C) includes procedures for maintaining a current list of telephone numbers for:(i) minors' parents;(ii) safe locations; and(iii) center staff;(D) identifies the location of the lists described in subparagraph (C) of this paragraph;(E) includes procedures to notify:(i) center staff about an emergency situation;(ii) a contact person at a safe location about an impending or actual evacuation of minors; and(iii) a minor's parent about an impending or actual evacuation;(F) provides a method for staff to obtain a minor's emergency information during an emergency situation;(G) includes procedures for the center to maintain communication with:(i) center staff during an emergency situation;(ii) a contact person at a safe location; and(iii) the authorized driver of a vehicle transporting minors, medication, medical records, food, water, equipment, or supplies during an evacuation; and(H) includes procedures for reporting to the Texas Health and Human Services Commission (HHSC) an emergency situation that caused the death or serious injury of a minor as follows:(i) by telephone at 1-800-458-9858 or by using the HHSC website, no later than 24 hours after the death or serious injury of a minor; and(ii) in writing on the HHSC Provider Investigation Report Form no later than five days after the center makes the report.(4) Shelter-in-place. A center's plan must contain a section that includes procedures to temporarily shelter minors in place during an emergency situation.(5) Evacuation. A center's plan must contain a section for evacuation that:(A) requires posting center evacuation routes conspicuously throughout the center;(B) identifies evacuation destinations and routes for an authorized driver, and includes a map that shows the destinations and routes;(C) includes procedures for implementing a decision to evacuate minors to a safe location;(D) includes a current copy of an agreement with a pre-arranged safe location, outlining arrangements for receiving minors in the event of an evacuation, if the evacuation destination identified in accordance with subparagraph (B) of this paragraph is a prearranged safe location that is not owned by the same entity as the evacuating center;(E) includes procedures for:(i) ensuring that staff accompany evacuating minors;(ii) ensuring that minors and staff present at the center have been evacuated;(iii) ensuring that visitors, including parents and service providers, evacuate the center;(iv) accounting for minors and staff after they have been evacuated;(v) accounting for minors absent from the center at the time of the evacuation;(vi) releasing minor information in an emergency situation to promote continuity of a minor's care, in accordance with state law;(vii) notifying the local EMC regarding an evacuation of the center, if required by the local EMC guidelines;(viii) contacting the local EMC, if required by the local EMC guidelines, to find out if it is safe to return to the geographical area after an evacuation; and(ix) determining if it is safe to re-enter and occupy the center after an evacuation;(x) notifying HHSC by telephone, at 1-800-458-9858, no later than 24 hours after an evacuation that minors have been evacuated; and(xi) notifying HHSC Regulatory Services by telephone immediately after the EPC makes a decision to evacuate all minors from the center.(6) Transportation. A center's plan must contain a section for transportation that:(A) arranges for a sufficient number of vehicles to safely evacuate all minors;(B) identifies staff or contractors designated to drive a center owned, leased, or rented vehicle during an evacuation;(C) includes procedures for safely transporting minors and staff involved in an evacuation; and(D) includes procedures for safely transporting and having timely access to oxygen, medications, medical records, food, water, equipment, and supplies needed during an evacuation.(7) Health and Medical Needs. A center's plan must contain a section for health and special needs that:(A) identifies the types of services and medical equipment used by minors, including oxygen, respirator care, or hospice services; and(B) ensures that a minor's needs identified in subparagraph (A) of this paragraph are met during an emergency situation.(8) Resource Management. A center's plan must contain a section for resource management that:(A) includes a plan for identifying medications, medical records, food, water, equipment, and supplies needed during an emergency situation;(B) identifies staff who are assigned to locate the items in subparagraph (A) of this paragraph and who must ensure the transportation of the items during an emergency situation; and(C) includes procedures to ensure that medications are secure and maintained at the proper temperature during an emergency situation.(e) Training. A center must:(1) train staff on their responsibilities under the plan no later than 30 days from their hire date;(2) train staff on the staff responsibilities under the plan at least annually and when the staff member's responsibilities under the plan change; and(3) conduct one unannounced annual drill with staff for severe weather and other emergency situations identified by a center as likely to occur, based on the results of the risk assessment required by subsection (c) of this section.(f) Fire Emergency Response Plan.(1) The center must have a comprehensive written fire emergency response plan. Copies of the plan must be available to all staff. The center must periodically instruct and inform staff about the duties of their positions under the plan. The written fire emergency response plan must provide for the following:(A) use of alarms;(B) transmission of an alarm to a fire department;(C) response to alarms;(D) isolation of fire;(E) evacuation of the immediate area;(F) preparation of floors and building for evacuation; and(G) fire extinguishment;(2) The fire emergency response plan must include procedures to contact HHSC by telephone, at 1-800-458-9858, no later than 24 hours after activation of its Fire Emergency Response Plan.(3) The staff must conduct emergency egress and relocation drills as follows:(A) perform a monthly fire drill with all occupants of the building at expected and unexpected times and under varying conditions;(B) relocate, during the monthly drill, all occupants of the building to a predetermined location where occupants must remain until a recall or dismissal is given; and(C) complete the HHSC Fire Drill Report Form 4719 for each required drill.(4) The EPC or a designee must conduct fire prevention inspections on a monthly basis and prepare a report of the inspection results. The center must maintain copies of the fire prevention inspection report prepared by the center within the last 12 months. The center must post a copy of the most recent fire prevention inspection report in a conspicuous place at the center.(g) Emergency Response System.(1) The center administrator and alternate administrator must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The center must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §550.209 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective January 24, 2023, 48 TexReg 215. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.209 Emergency Preparedness Planning and Implementation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220954 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220954 03/12/2026 (a) A center must ensure a sanitary environment by following accepted standards of practice and maintain a safe physical environment free of hazards for minors, staff, and visitors.(b) A center must ensure that the following conditions are met.(1) Wastewater and sewage must be discharged into a state-approved municipal sewage system. An on-site sewage facility must be approved by the Texas Commission on Environmental Quality (TCEQ) or authorized agent.(2) The water supply must be from a system approved by the Public Drinking Water Section of the TCEQ, or from a system regulated by an entity responsible for water quality in the jurisdiction where the center is located as approved by the Public Drinking Water Section of the TCEQ.(3) Waste, trash, and garbage must be disposed of from the premises at regular intervals in accordance with state and local practices. Excessive accumulations are not permitted. Outside containers must have tight-fitting lids left in closed position. Containers must be maintained in a clean and serviceable condition.(4) Center grounds must be well kept and the exterior of the building, including sidewalks, steps, porches, ramps, and fences, must be in good repair.(5) The interior of the center's buildings including walls, ceilings, floors, windows, window coverings, doors, plumbing, and electrical fixtures must be in good repair.(6) Pest control must be provided by a licensed structural pest control applicator with a license category for pests. The center must maintain documented evidence of routine efforts to remove rodents and insects.(7) The center must be kept free of offensive odors, accumulations of dirt, rubbish, dust, and hazards. Storage areas, attics, and cellars must be free of refuse and extraneous materials.(c) A center must adopt and enforce a written work plan for housekeeping operations, with categorization of cleaning assignments as daily, weekly, monthly, or annually within each area of the center.(d) A center must ensure the provision of housekeeping and maintenance of the interior, exterior, and grounds of the center in a safe, clean, orderly, and attractive manner. The center must provide housekeeping and maintenance staff with equipment and supplies if needed. A center must designate staff to be responsible for overseeing the housekeeping services.(e) A center must develop procedures for the selection, use, and disposal of housekeeping and cleaning products and equipment. The center must ensure:(1) the use of Environmental Protection Agency-approved cleaning products appropriate for the application and materials to be sanitized;(2) the following of manufacturer instructions for use and disposal of cleaning products;(3) all bleaches, detergents, disinfectants, insecticides, and other poisonous substances are kept in a safe place accessible only to staff; and(4) all products are labeled.(f) A center must ensure a sufficient supply of clean linens is available to meet the needs of minors. Clean laundry must be provided in-house by the center, through a contract with another health care center, or with an outside commercial laundry service.(g) A center must ensure:(1) linens are handled, stored, and processed so as to control the spread of infection;(2) linens are maintained in good repair;(3) linens are washed, dried, stored, and transported in a manner which will produce hygienically clean linen;(4) the washing process has a mechanism for removing soil and killing bacteria;(5) clean linens are stored in a clean linen area easily accessible to the staff;(6) soiled linens and clothing are stored separately from clean linen and clothing;(7) soiled linens and clothing are stored in well-ventilated areas, and are not permitted to accumulate at the center;(8) soiled linens and clothing are transported in accordance with procedures consistent with universal precautions;(9) soiled linens are not sorted, laundered, rinsed, or stored in bathrooms, corridors, food preparation area, or food storage areas;(10) a minor's clothing stored at the center is cleaned after each use; and(11) staff wash their hands both after handling soiled linen and before handling clean linen. Source Note: The provisions of this §550.210 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.210 Sanitation, Housekeeping, and Linens https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220955 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220955 03/12/2026 (a) A center must establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment by preventing the development and transmission of disease and infection. Under the IPCP, the center must:(1) investigate, prevent, and control infections at the center;(2) decide what procedures, such as isolation, should be applied to an individual minor;(3) address vaccine preventable diseases in accordance with THSC, Chapter 224;(4) address hepatitis B vaccinations in accordance with Occupational Safety and Health Administration;(5) address tuberculosis requirements; and(6) maintain a record of incidents and corrective actions relating to infections.(b) A center must provide IPCP information to employees, contractors, volunteers, parents, health care providers, other service providers, and visitors.(c) A center's IPCP must include written policies and procedures for admissions and attendance of minors who are at risk for infections or present a significant risk to other minors. The policy must include that a minor is accepted only:(1) as authorized by a minor's prescribing physician:(2) as determined by the center's medical director's assessment of the risk;(3) as determined by the medical and nursing director review, on a case-by-case basis, to determine appropriateness of admission to or attendance at the center; and(4) in accordance with Centers for Disease Control (CDC) guidelines.(d) The center's IPCP must include written policies and procedures for preventing the spread of infection.(1) If the center determines, in accordance with its IPCP, that a minor must be isolated to prevent the spread of infection, the center must isolate a minor.(A) The center must maintain an isolation room with a glass window for observation of a minor. The isolation room must be equipped with emergency outlets and equipment as necessary to provide care to a minor. The isolation room must have a dedicated bathroom not accessible to the center's other rooms if appropriate to control the spread of infectious disease.(B) The center must ensure that all equipment is thoroughly cleaned and disinfected before being placed in the isolation room and before being removed from the room.(C) The center's procedures must address:(i) notification to a minor's parent of the minor's condition and the center's recommendation of isolation or removal based on the minor's risk assessment;(ii) the arrangement of transportation if the minor must be removed from the center; and(iii) the return of a minor to the center, as determined by a reassessment conducted by a nurse that the minor no longer poses a risk to other minors.(2) The center must prohibit employees, volunteers, and contractors with an infectious disease or infected skin lesions from direct contact with minors or food, if direct contact will transmit the disease.(3) The center's infection control policy must provide that staff, volunteers, and contractors wash their hands between each treatment and care interaction with a minor.(4) The center must immediately report the name of any minor with a reportable disease as specified in 25 Texas Administrative Code Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority or the Texas Department of State Health Services.(e) The center must assign a crib, bed, or sleep mat for a minor's exclusive use each day. A center must label cribs, beds, and sleep mats with the minor's name.(f) A center must place liquid soap, disposable paper towels, and trash containers at each sink.(g) The center must adopt and enforce written policies and procedures for the control of communicable diseases for employees, contractors, volunteers, parents, health care providers, other service providers, and visitors and must maintain evidence of compliance.(h) The center must adopt and enforce written policies and procedures for the control of an identified public health disaster.(1) If a center determines or suspects that an employee, volunteer, or contractor providing services has been exposed to, or has a positive screening for, a communicable disease, the center must respond according to current CDC guidelines and keep documentation of the action taken.(2) If the center determines that an employee, volunteer, or contractor providing services has been exposed to a communicable disease, the center must conduct and document a reassessment of the risk classification. The center must conduct and document subsequent screenings based upon the reassessed risk classification.(3) If the center determines that an employee, volunteer, or a contractor providing services at the center is suspected of having a communicable disease, the individual must not return to the center until the individual no longer poses a risk of transmission as documented by a written physician's statement.(i) The center must conduct and document an annual review that assesses the center's current risk classification according to the current CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings and 25 Texas Administrative Code Chapter 97, Subchapter A.(1) The center must have a system in place to screen all individuals providing services at the center.(2) The center must require employees, volunteers, and contractors providing services to provide evidence of current tuberculosis screening before providing services at the center. The center must maintain evidence of compliance.(3) Any employee, volunteer, or contractor providing services at a center with positive results must be referred to the person's personal physician, and if active tuberculosis is suspected or diagnosed, the person must be excluded from work until the physician provides written approval to return to work.(j) A center must adopt and enforce written policies and procedures to protect a minor from vaccine preventable diseases, in accordance with THSC Chapter 224.(1) The policy must:(A) require an employee, volunteer, or contractor providing direct care to receive vaccines for the vaccine preventable diseases specified by the center based on the level of risk the employee, volunteer, or contractor, presents to minors by the employee's, volunteer's, or contractor's routine and direct exposure to minors;(B) specify the vaccines an employee, volunteer, or contractor who provides direct care is required to receive in accordance with subsection (i) of this section;(C) include procedures for the center to verify that an employee, volunteer, or contractor who provides direct care has complied with the policy;(D) include procedures for the center to exempt an employee, volunteer, or contractor who provides direct care from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC;(E) include procedures, including using protective equipment such as gloves and masks, to protect minors from exposure to vaccine preventable diseases, based on the level of risk the employee, volunteer, or contractor presents to minors by the employee's, volunteer's, or contractor's routine and direct exposure to minors;(F) prohibit discrimination or retaliatory action against an employee, volunteer, or contractor who provides direct care and who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC, except that required use of protective medical equipment, such as gloves and masks, will not be considered retaliatory action;(G) require the center to maintain a written or electronic record of each employee's, volunteer's, or contractor's compliance with or exemption from the policy; and(H) include disciplinary actions the center may take against an employee, volunteer, or contractor providing direct care who fails to comply with the policy.(2) The center must have a written policy describing whether it will exempt an employee, volunteer, or contractor providing direct care:(A) from the required vaccines based on reasons of conscience, including a religious belief; and(B) prohibit an employee, volunteer, or contractor providing direct care who is exempt from the required vaccines from having contact with minors during a public health disaster.(k) The center must adopt and enforce written policies and procedures to identify employees, volunteers, or contractors at risk of directly contacting blood or other potentially infectious materials in accordance with the Occupational Safety and Health Standards in 29 Code of Federal Regulations §1910.1030 relating to Bloodborne pathogens.(l) A center must ensure that its employees, volunteers, and contractors comply with:(1) the center's IPCP;(2) the Communicable Disease Prevention and Control Act, THSC Chapter 81; and(3) THSC Chapter 85, Subchapter I, concerning the prevention of the transmission of human immunodeficiency virus and hepatitis B virus. Source Note: The provisions of this §550.211 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.211 Infection Prevention and Control Program and Vaccinations Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220956 03/12/2026 (a) The license holder is responsible for the conduct of the center and for the adoption, implementation, and enforcement of the written policies required throughout this chapter. The license holder is also responsible for ensuring that these policies comply with THSC Chapter 248A and the applicable provisions of this chapter and are administered to provide safe, professional, and quality health care.(b) The persons described in §550.101(f) of this chapter (relating to Criteria and Eligibility for a License) must not have been convicted of an offense described in §560.2 of this title (relating to Convictions Barring Licensure), during the time frames described in that chapter.(c) The license holder must ensure that all documents submitted to HHSC or maintained by the center as required by this chapter are accurate and do not misrepresent or conceal a material fact.(d) The license holder must comply with an order of the executive commissioner or other enforcement orders that may be imposed on the center in accordance with THSC Chapter 248A and this chapter.(e) The license holder of the center must have full legal authority and responsibility for the operation of the center.(f) A license holder must designate in writing an individual who meets the qualifications and conditions set out in §550.303 of this division (relating to Administrator and Alternate Administrator Qualifications and Conditions) to serve as the administrator of the center.(g) A license holder must designate in writing an alternate administrator who meets the qualifications and conditions of an administrator set out in §550.303 of this division to act in the absence of the administrator or when the administrator is unavailable to the staff during the center's operating hours.(h) A license holder must ensure the position and designation of an administrator or alternate administrator is filled with a qualified staff.(i) A license holder must ensure maintenance of documentation of efforts to ensure a vacancy in the position of an administrator or alternate administrator does not last more than 30 days.(j) A license holder must ensure all written notices to HHSC required by this chapter, unless otherwise specified in this chapter, are submitted through the online portal. Source Note: The provisions of this §550.301 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.301 License Holder's Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194769 03/12/2026 (a) A center must prepare and maintain a current written description of the center's organizational structure. The document may be either in the form of a chart or a narrative.(b) The description must include:(1) all services provided by the center;(2) if applicable to the center's organization structure and lines of authority, the governing body, board of directors, the administrator, alternate administrator, the medical director, the nursing director, the alternate nursing director, advisory committee, IDT, and staff, as appropriate, based on services provided by the center; and(3) the lines of authority and the delegation of responsibility down to and including the direct care level. Source Note: The provisions of this §550.302 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.302 Organizational Structure and Lines of Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220957 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220957 03/12/2026 (a) The administrator and alternate administrator of a center must have two years of experience in supervision and management in a pediatric health care setting and meet one of the following criteria:(1) be a physician licensed in Texas to practice medicine in accordance with Texas Occupations Code, Chapter 155;(2) be an RN with a master's or baccalaureate degree in nursing and be licensed under the Nursing Practice Act, Texas Occupations Code, Chapter 301, with no disciplinary actions;(3) be a college graduate with a bachelor's degree with one additional year of supervision or management experience in a health care setting;(4) have an associate degree in health care or administration with two additional years of supervision or management experience in a health care setting; or(5) have an associate degree in nursing and currently licensed under the Nursing Practice Act, Texas Occupations Code, Chapter 301, with no disciplinary action with two additional years of supervision or management experience in a health care setting.(b) The administrator and the alternate administrator of a center must be at least 25 years of age.(c) An administrator and alternate administrator of a center must meet the initial training requirements specified in §550.305 of this division (relating to Initial Training in Administration) and the continuing training requirements specified in §550.306 of this division (relating to Continuing Training in Administration).(d) A person is not eligible to be the administrator or alternate administrator of a center if the person was the administrator of a center cited with a violation that resulted in HHSC taking enforcement action against the center while the person was the administrator of the cited center.(1) This subsection applies for 12 months after the date of the enforcement action.(2) For purposes of this subsection, enforcement action means license suspension, licensure revocation, emergency suspension of a license, denial of an application for a license, or the issuance of an injunction. Enforcement action does not include administrative or civil penalties.(e) An administrator or alternate administrator must not be convicted of an offense described in §560.2 of this title (relating to Convictions Barring Licensure) during the time frames described in that chapter.(f) The designated administrator and alternate administrator of a center must be full-time employees of the center.(g) The designated administrator or alternate administrator may serve as the nursing director or alternate nursing director if the administrator or alternate administrator meets the nursing director qualifications as described in §550.309 of this division (relating to Nursing Director and Alternate Nursing Director Qualifications and Conditions).(h) The designated administrator or alternate administrator may be included in the center's staffing ratio if:(1) the administrator or alternate administrator is a licensed nurse or meets the qualifications in §550.409 of this subchapter (relating to Direct Care Staff Qualifications); and(2) the center's actual census is less than four minors.(i) The designated administrator or alternate administrator must not be included in the center's staffing ratios when functioning as the nursing director or alternate nursing director.(j) The designated administrator must manage only one center. Source Note: The provisions of this §550.303 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.303 Administrator and Alternate Administrator Qualifications and Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220958 03/12/2026 (a) An administrator of a center must be responsible for implementing and supervising the administrative policies and operations of the center and for administratively supervising the provision of all services to minors on a day-to-day basis.(b) A center's administrator must:(1) ensure that the center complies with applicable federal, state, and local laws, rules, and regulations;(2) manage the daily operations of the center;(3) organize and direct the center's ongoing functions;(4) ensure the availability of qualified staff and ancillary services to ensure the health, safety, and proper care of each minor;(5) ensure criminal history, employee misconduct registry, nurse aide registry, and medication aide registry checks are conducted for required staff before employment;(6) ensure the implementation of the center's training program policies and procedures;(7) familiarize staff with regulatory issues, as well as the center's policies and procedures;(8) ensure that the documentation of services provided is accurate and timely;(9) manage census records, including daily, actual, and total, in accordance with §550.803 of this chapter (relating to Census);(10) ensure that the center immediately notifies a minor's parent of any and all accidents or unusual incidents involving their minor or that had the potential to cause injury or harm to a minor;(11) ensure that the center provides written notice to the parent of accidents or unusual incidents involving their minor on the day of occurrence;(12) maintain a record of accidents or unusual incidents involving a minor or staff member that caused, or had the potential to cause, injury or harm to a person or property at the center;(13) maintain a copy of current contractor agreements with third party providers contracted by the center;(14) maintain a copy of current written agreements with each contractor;(15) ensure adequate staff education and evaluations according to requirements in §550.415 of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training);(16) maintain documented development programs for all staff;(17) ensure the accuracy of public information materials and activities made available and presented on behalf of the center;(18) ensure implementation of an effective budgeting and accounting system consistent with good business practice that promotes the health and safety of the center's minors; and(19) supervise the annual distribution and evaluation of the responses to the parent-satisfaction surveys on all minors served. Source Note: The provisions of this §550.304 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.304 Administrator Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220959 03/12/2026 (a) This section applies to an administrator and alternate administrator designated as an administrator or alternate administrator of a center.(b) Before designation, an administrator or alternate administrator must complete the HHSC pre-licensing program training titled Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas.(c) An administrator and alternate administrator of a center must complete a total of 12 clock hours of training in the administration of a center before the end of the first 12 months after designation to the position.(d) The initial 12 clock hours of training must address:(1) information on state and federal laws applicable to a center, including:(A) the Americans with Disabilities Act;(B) the Civil Rights Act of 1991;(C) the Rehabilitation Act of 1973;(D) the Family and Medical Leave Act of 1993;(E) Public Law 111-148 Patient Protection and Affordable Care Act; and(F) Occupational Safety and Health Administration requirements; and(2) information regarding the prevention, detection and reporting of fraud, waste, and abuse;(3) legal issues regarding advance directives;(4) infection control;(5) communicable disease reporting;(6) nutrition;(7) principles of person-centered direction and guidance; and(8) provision of services to a minor.(e) The 12-clock-hour training requirement described in subsection (d) of this section must be met through structured, formalized classes, correspondence courses, competency-based computer courses, training videos, distance learning programs, or off-site training courses. Subject matter that deals with the internal affairs of a center does not qualify for clock hours.(1) The training must be provided or produced by:(A) an academic institution;(B) a recognized state or national organization or association;(C) a consultant;(D) an accredited pediatric hospital; or(E) HHSC or other state agency.(2) If a consultant provides or produces the training, the training must be approved by a recognized state or national organization or association. The center must maintain documentation of this approval or recognition for review by HHSC inspectors.(3) An administrator and alternate administrator may apply joint training provided by HHSC toward the 12 clock hours of training required by this section if the joint training meets the training requirements described in subsection (d) of this section.(f) Documentation of administrator and alternate administrator training must:(1) be on file at the center; and(2) contain:(A) the name of the class or workshop;(B) course content, including the curriculum;(C) hours and dates of the training; and(D) name and contact information of the entity and trainer who provided the training.(g) An administrator and alternate administrator must not apply the pre-licensing program training as part of the 12 clock hours of training required in this section.(h) After completing 12 clock hours of initial training during the first 12 months after designation as an administrator and alternate administrator, an administrator and alternate administrator must complete the continuing training requirements as specified in §550.306 of this division (relating to Continuing Training in Administration) in each subsequent 12-month period after designation. Source Note: The provisions of this §550.305 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.305 Initial Training in Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220960 03/12/2026 (a) An administrator and alternate administrator must complete 12 clock hours of continuing training within each subsequent 12-month period beginning with the date of designation. The 12 clock hours of continuing training must include at least two of the following topics and may include other topics relating to the duties of an administrator:(1) any one of the training topics listed in §550.305(d) of this division (relating to Initial Training in Administration);(2) development and interpretation of the center policies;(3) basic principles of management in a licensed health care setting;(4) ethics;(5) quality improvement;(6) risk assessment and management;(7) financial management;(8) skills for working with minors, a minor's parent, and other professional service providers;(9) community resources;(10) communicable disease reporting; or(11) marketing.(b) In addition to the 12 clock hours of training required in this section, an administrator or alternate administrator must complete the Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas provided by HHSC every three years from the date of designation to the position.(c) The center must keep documentation of administrator and alternate administrator continuing training on file at the center and maintain:(1) the name of the class or workshop;(2) course content, including the curriculum;(3) hours and dates of the training; and(4) name and contact information of the entity and trainer who provided the training.(d) An administrator or alternate administrator must not apply the pre-licensing program training toward the continuing training requirements in this section. Source Note: The provisions of this §550.306 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.306 Continuing Training in Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194774 03/12/2026 (a) A center must designate a medical director who:(1) has a valid, unrestricted license to practice medicine or osteopathy in Texas in accordance with Texas Occupations Code Chapter 155; and(2) is board-certified in a pediatric specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association.(b) The medical director must be available in person or by phone for consultation or collaboration with prescribing physicians and the center's staff during the center's operating hours.(c) The medical director must not be included in the center's staffing ratios. Source Note: The provisions of this §550.307 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.307 Medical Director Qualifications and Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220961 03/12/2026 The medical director must:(1) review the services provided at the center to ensure a high quality of services;(2) maintain a liaison role with the medical community in the location of the center's place of business;(3) participate in the development and implementation of appropriate performance improvement and safety initiatives as directed by the Quality Assessment and Performance Improvement (QAPI) program;(4) participate in the development of new programs and modifications of existing programs at the center;(5) designate a physician as defined in §550.5 of this chapter (relating to Definitions) to provide medical consultation in the event the medical director is unavailable to the center's staff;(6) serve on committees as defined and required by this chapter and the center's polices;(7) consult with the center's administrator and nursing director on the health status of the center's staff as it relates to the center's IPCP and on a minor's health and safety or as threats to infection control arise;(8) review reports of accidents and unusual incidents occurring at the center and identify to the center's administrator hazards to health and safety as directed by the QAPI program;(9) participate in the development and implementation of policies and procedures for the delivery of emergency services for minors;(10) participate in the development and implementation of policies and procedures for the use of restraints; and(11) participate in the development and implementation of policies and procedures for the delivery of physician's services when a minor's prescribing physician or designated alternate is not available. Source Note: The provisions of this §550.308 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.308 Medical Director Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220962 03/12/2026 (a) A center must designate a nursing director and alternate nursing director who meet the qualifications and conditions set out in this section and who have completed the HHSC pre-licensing program training titled Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas.(b) The nursing director and alternate nursing director must have the following qualifications:(1) a valid RN license under Texas Occupations Code, Chapter 301, with no disciplinary action;(2) a valid certification in Pediatric Cardiopulmonary Resuscitation or Basic Cardiac Life Support; and(3) a minimum of two years of supervision and management in employment in a pediatric setting caring for a medically or technologically dependent minor or at least two years of supervision in one of the following specialty settings:(A) pediatric intensive care;(B) neonatal intensive care;(C) pediatric emergency care;(D) center;(E) home health or hospice agency specializing in pediatric care;(F) ambulatory surgical center specializing in pediatric care; or(G) have comparable pediatric unit experience in a hospital for two consecutive years before the person applies for the position of nursing director.(c) The nursing director and alternate nursing director must meet the requirements of this subsection.(1) The nursing director must be a full-time employee of the center.(2) The nursing director or alternate nursing director may serve as the administrator or alternate administrator of the center if the nursing director or alternate nursing director meets the administrator qualifications as described in §550.303 of this division (relating to Administrator and Alternate Administrator Qualifications and Conditions).(3) A center must designate an alternate nursing director who meets the qualifications as specified in this section who will assume the responsibilities of the nursing director when the nursing director is unavailable during the center's operating hours.(4) The nursing director must not be included in the center's staffing ratio when the center's actual census is less than four minors and the nursing director is also functioning as the administrator.(5) The designated alternate nursing director must not be included in the center's staffing ratio when functioning as the nursing director, administrator, or alternate administrator. Source Note: The provisions of this §550.309 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective March 20, 2023, 48 TexReg 1564; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.309 Nursing Director and Alternate Nursing Director Qualifications and Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220963 03/12/2026 The center's nursing director's responsibilities must include, but are not limited to:(1) supervising all aspects of a minor's plan of care to ensure the minor's plan of care is implemented as ordered;(2) supervising all activities of the center's professional nursing staff and direct care staff to ensure compliance with current standards of accepted nursing practice;(3) ensuring compliance with all federal and state laws, rules, and regulations in this chapter;(4) supervising the daily clinical operations of the center;(5) ensuring the documentation of the center's actual, daily, and total census in accordance with §550.803 of this subchapter (relating to Census) and §550.410 of this subchapter (relating to Nursing Services Staffing Ratio);(6) ensuring the documentation of the center's staffing ratios in accordance with §559.410 of this subchapter;(7) supervising the implementation of staffing policies to ensure that only qualified staff are hired by the center, including verification of licensure and certification before employment and annually thereafter;(8) ensuring the maintenance of records to support competency of the center's nursing and direct care staff;(9) ensuring the implementation of the center's policies and procedures that establish and support quality care to a minor;(10) providing orientation and in-service training to employees and providers of basic services to promote effective basic services and safety to a minor;(11) performing timely annual performance evaluations for the center's nursing and direct care staff;(12) ensuring participation in regularly scheduled continuing training for the center's nursing and direct care staff; and(13) ensuring that the care at the center promotes effective services and the safety of a minor. Source Note: The provisions of this §550.310 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.310 Nursing Director Responsibilities and Supervision Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220964 03/12/2026 (a) A center must adopt and enforce a written policy to ensure compliance of the center and its employees, volunteers, and contractors with Texas Occupations Code, Chapter 102.(b) HHSC may take enforcement action against a center in accordance with Subchapter G of this chapter (relating to Enforcement) if the center violates Texas Occupations Code, §102.001 or §102.006. Source Note: The provisions of this §550.311 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.311 Prohibition of Solicitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194779 03/12/2026 If nursing services are provided at a center, the center must ensure there are sufficient RNs and LVNs to ensure that the services provided to each minor are in accordance with the minor's plan of care. Source Note: The provisions of this §550.401 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.401 Nursing Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220965 03/12/2026 (a) An RN providing services on behalf of a center must have at least the following qualifications and experience:(1) a valid RN license under Texas Occupations Code, Chapter 301, with no disciplinary action;(2) valid certifications in Pediatric Cardiopulmonary Resuscitation and Basic First Aid; and(3) one of the following:(A) one year of pediatric specialty experience with emphasis on medically and technologically dependent minors, obtained within the previous five years; or(B) sufficient skills to meet the competency and training requirements described in subsection (b) of this section.(b) A center must adopt and enforce a written policy regarding an RN who qualifies to provide services at the center under subsection (a)(3)(B) of this section. The policy must:(1) require an RN qualified under subsection (a)(3)(B) of this section to complete a training program that is determined appropriate by the Director of Nursing and conducted by an RN on the RN responsibilities described in §550.403 of this division (relating to Registered Nurse Responsibilities) and that includes hands-on training;(2) require, before performing the RN responsibilities described in §550.403 of this division, an RN qualified under subsection (a)(3)(B) of this section to demonstrate competency in performing the responsibilities described in §550.403 of this division, as determined by an RN;(3) describe procedures for increased supervision of an RN qualified under subsection (a)(3)(B) of this section during the training program, competency evaluation, and for three months after completion of the competency evaluation to ensure the health and safety of minors; and(4) prohibit an RN qualified under subsection (a)(3)(B) of this section from performing the responsibilities in §550.403 of this division or being included in the nursing services staffing ratio as an RN, as described in §550.410 of this division (relating to Nursing Services Staffing Ratio), until the RN completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.(c) An RN qualified under subsection (a)(3)(B) of this section must meet the requirements in §550.415 of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 of this division (relating to Staff Development Program). Source Note: The provisions of this §550.402 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.402 Registered Nurse Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220966 03/12/2026 An RN providing services on behalf of a center must be responsible for the following:(1) maintaining compliance with the standards of nursing practice and delegation;(2) developing a minor's plan of care;(3) providing nursing interventions that includes parental training, information, and education to increase a parent's confidence and competence in caring for a minor;(4) coordinating services with other service providers;(5) monitoring the ongoing physical and developmental growth of a minor;(6) having knowledge of access to available community resources;(7) participating on the IDT and in the IDT meetings regarding a minor's plan of care and progress;(8) in accordance with accepted standards of professional practice:(A) administering medication, intravenous infusions, parenteral feeding, and other specialized treatments; and(B) monitoring and documenting the effect of medications, therapies, and progress;(9) communicating findings to a minor's prescribing physician and the center's nursing director; and(10) supervising the center's direct care staff. Source Note: The provisions of this §550.403 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.403 Registered Nurse Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220967 03/12/2026 (a) An LVN providing services on behalf of a center must have at least the following qualifications and experience:(1) a valid LVN license under Texas Occupations Code, Chapter 301, with no disciplinary action;(2) valid certifications in Pediatric Cardiopulmonary Resuscitation and Basic First Aid; and(3) one of the following:(A) one year of pediatric specialty experience with emphasis on medically and technologically dependent minors obtained within the last consecutive five years; or(B) sufficient skills to meet the competency and training requirements described in subsection (b) of this section.(b) A center must adopt and enforce a written policy regarding an LVN who qualifies to provide services at the center under subsection (a)(3)(B) of this section. The policy must:(1) require an LVN qualified under subsection (a)(3)(B) of this section to complete a training program that is determined appropriate by the Director of Nursing and conducted by an RN on the LVN responsibilities described in §550.405 of this division (relating to Licensed Vocational Nurse Responsibilities) and that includes hands-on training;(2) require, before performing the LVN responsibilities described in §550.405 of this division, an LVN qualified under subsection (a)(3)(B) of this section to demonstrate competency in performing the responsibilities described in §550.405 of this division, as determined by an RN;(3) describe procedures for increased supervision of an LVN qualified under subsection (a)(3)(B) of this section during the training program, competency evaluation, and for three months after completion of the competency evaluation to ensure the health and safety of minors; and(4) prohibit an LVN qualified under subsection (a)(3)(B) of this section from performing the responsibilities in §550.405 of this division or being included in the nursing services staffing ratio as an LVN, as described in §550.410 of this division (relating to Nursing Services Staffing Ratio), until the LVN completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.(c) An LVN must meet the requirements in §550.415 of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 of this division (relating to Staff Development Program). Source Note: The provisions of this §550.404 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.404 Licensed Vocational Nurse Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220968 03/12/2026 (a) An LVN providing services on behalf of a center must work under the supervision of an RN and is responsible to provide, within the LVN's level of competence and scope of practice, nursing care to the center's minors as ordered in the plan of care.(b) An LVN must be responsible for the following:(1) maintaining compliance with the standards of nursing practice;(2) providing nursing interventions that includes parental training, information, and education to increase a parent's confidence and competence in caring for a minor;(3) having knowledge of the availability of community resources;(4) participating on the IDT and in the IDT meetings regarding a minor's plan of care and progress;(5) communicating findings to a minor's prescribing physician and an RN; and(6) in accordance with accepted standards of professional practice:(A) administering medication, intravenous infusions, parenteral feeding, and other specialized treatments; and(B) monitoring and documenting the effect of medications, therapies, and progress. Source Note: The provisions of this §550.405 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.405 Licensed Vocational Nurse Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220969 03/12/2026 (a) If a center has an agreement with an accredited school of nursing to use the center for a portion of a student nurse's clinical experience, the student nurse may provide care under the following conditions:(1) the agreement ensures that criminal history checks are conducted for a student nurse in accordance with §550.418 of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry, and Employee Misconduct Registry Requirements) before a student nurse provides direct care;(2) a student nurse is not counted in the staffing ratio required in this chapter; and(3) one of the following:(A) an instructor from the school is onsite, provides class supervision, and assumes responsibility for all student nursing activities at the center; or(B) the center:(i) assumes responsibility for supervision of all student nurses and for all student nursing activities at the center; and(ii) meets the requirements described in subsection (b) of this section.(b) The center must adopt and enforce written policy and procedures describing whether the center will assume responsibility for supervision of all student nurses and for all student nursing activities at the center. If a center assumes responsibility for student nurse activity, the center must:(1) determine the appropriate level of student nurse interaction with a minor, based on the qualifications and experience of the student nurse;(2) assign an RN to supervise a student nurse;(3) limit RN supervision to no more than three student nurses at one time; and(4) based on the outcomes of paragraph (1) of this subsection, determine if it is appropriate to exclude from the staffing ratio the RN assigned to supervise the student nurse activities to ensure the health and safety of minors. Source Note: The provisions of this §550.406 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.406 Student Nurses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194785 03/12/2026 A center must adopt and enforce a written policy to ensure compliance with the rules of the Texas Board of Nursing adopted at 22 TAC Chapters 211, 213 - 217, and 219 - 226. Source Note: The provisions of this §550.407 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.407 Nursing Education, Licensure, and Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194786 03/12/2026 A center must adopt and enforce a written policy to ensure compliance with rules adopted by the Texas Board of Nursing as specified in 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments). Source Note: The provisions of this §550.408 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.408 Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel and Tasks Not Requiring Delegation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220970 03/12/2026 (a) Direct care staff providing services on behalf of a center, must have the following qualifications:(1) be 18 years of age or older;(2) a high school diploma or a general equivalency degree;(3) one of the following:(A) one year of experience employed in a health care setting providing direct care to minors who are medically or technologically dependent;(B) two years of experience employed in a health care, childcare, or school setting providing direct care to minors who are medically or technologically dependent;(C) two years of experience employed in a health care setting providing direct care to adults; or(D) sufficient skills to meet the competency and training requirements described in subsection (b) of this section; and(4) maintain current certification in Pediatric Cardiopulmonary Resuscitation and Basic First Aid.(b) A center must adopt and enforce written policies and procedures regarding direct care staff who qualify to provide services at the center under subsection (a)(3)(D) of this section. The policy must:(1) require direct care staff who qualify under subsection (a)(3)(D) of this section to complete a training program regarding the provision of direct care to minors that:(A) is determined appropriate by the nursing director;(B) is conducted by an RN or LVN; and(C) includes hands-on training;(2) require, before providing services to a minor, direct care staff who qualify under subsection (a)(3)(D) of this section to demonstrate competency in the provision of direct care to minors as determined by an RN;(3) describe procedures for increased supervision of direct care staff who qualify under subsection (a)(3)(D) of this section during the training program and the competency evaluation, and for six months after completion of the competency evaluation, to ensure the health and safety of minors; and(4) prohibit direct care staff who qualify under subsection (a)(3)(D) of this section from being assigned to a minor or being included in the nursing services staffing ratio as described in §550.410 of this division (relating to Nursing Services Staffing Ratio) until the direct care staff completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.(c) Direct care staff must meet the requirements in §550.415 of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 of this division (relating to Staff Development Program). Source Note: The provisions of this §550.409 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.409 Direct Care Staff Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220971 03/12/2026 (a) A center's total staffing for nursing services must be maintained, at a minimum, in the ratios described in subsection (d)(2) of this section. If only one staff member is on duty, that member must be an RN.(b) The staffing ratio is based on the number of minors on the center's actual census that are receiving nursing services from the center.(c) A center must not include direct care staff who qualify under §550.409(a)(3)(D) of this division (relating to Direct Care Staff Qualifications) in the staffing ratio until the staff complete the training program and demonstrate competency as described in §550.409(b)(1) and (2) of this division.(d) A center must maintain documentation to support compliance with this section and §550.803 of this subchapter (relating to Census). Documentation must include:(1) each change in the number of minors on the center's actual census that are receiving nursing services from the center; and(2) the increase or decrease in the number of RNs, LVNs, and direct care staff in accordance with this section as changes in the number of minors on the center's actual census that are receiving nursing services from the center occurs.Attached Graphic Source Note: The provisions of this §550.410 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.410 Nursing Services Staffing Ratio https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220972 03/12/2026 (a) If the following staff provide services on behalf of a center or supervise services at a center, the staff must have one year of experience in pediatric care in a health care setting. The staff may be:(1) an audiologist with a valid license under Texas Occupations Code, Chapter 401;(2) an occupational therapist with a valid license under Texas Occupations Code, Chapter 454;(3) an occupational therapist assistant with a valid license under Texas Occupations Code, Chapter 454;(4) a physical therapist with a valid license under Texas Occupations Code, Chapter 453;(5) a physical therapist assistant with a valid license under Texas Occupations Code, Chapter 453;(6) a respiratory therapist with a valid license under Texas Occupations Code, Chapter 604;(7) a speech-language pathologist with a valid license under Texas Occupations Code, Chapter 401;(8) a licensed assistant in speech-language pathology with a valid license under Texas Occupations Code, Chapter 401; or(9) a social worker with a valid license under Texas Occupation Code, Chapter 505.(b) A center must employ or contract with a qualified dietitian who has a valid license under the laws of the State of Texas to use the title of licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with one year of supervisory experience in dietetic service.(c) If a center has a qualified pharmacist on a full-time, part-time, or consultant basis, the pharmacist must have a valid license under Texas Occupations Code, Chapter 558.(d) A rehabilitative professional providing services on behalf of a center or supervising services at a center must be supervised by a center's qualified licensed person who practices under the center's policies and procedures.(e) A center must not include rehabilitative professionals in the staffing ratios. Source Note: The provisions of this §550.411 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.411 Rehabilitative and Ancillary Professional Staff and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194790 03/12/2026 A center must adopt and enforce written policies and procedures to ensure that all professional disciplines providing services on behalf of the center comply with their respective professional practice acts or title acts relating to reporting and peer review. Source Note: The provisions of this §550.412 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.412 Peer Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220973 03/12/2026 (a) If a center uses contractors, the center must enter into a contract with each contractor. The contract must be enforced by the center and clearly designate:(1) that minors are accepted for care only by the center;(2) the services to be provided by the contractor and how they will be provided, including per visit or per hour;(3) the necessity of the contractor to conform to all applicable center policies, including staff qualifications;(4) the contractor's responsibility for participating in developing the plan of care;(5) the manner in which services will be coordinated and evaluated by the center in accordance with §550.802 of this subchapter (relating to Coordination of Services); and(6) the procedures for:(A) submitting information and documentation by the contractor in accordance with the center's record policies;(B) scheduling of visits by the contractor or the center; and(C) periodic evaluation of the minor by the contractor.(b) A center must establish and maintain a contract management record system to ensure that services provided to each minor by a contractor at the center are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation, retrieval, and review of the information.(c) The center is not required to maintain a personnel record for contractors. Upon request by HHSC, a center must provide documentation at the site of a survey no later than eight working hours after the request to demonstrate:(1) that contractors meet the center's written job qualifications for the position and duties performed; and(2) the center is in compliance with §550.418 of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry, and Employee Misconduct Registry Requirements). Source Note: The provisions of this §550.413 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.413 Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194792 03/12/2026 (a) If a center uses volunteers, the center must use volunteers in defined roles under the supervision of a designated center staff.(b) A volunteer must meet the same qualifications, requirements and standards in this chapter that apply to center staff performing the same activities on behalf of the center.(c) A center must not include the volunteer in the center's staffing ratios. Source Note: The provisions of this §550.414 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.414 Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220974 03/12/2026 (a) A center must adopt and enforce written staffing policies and procedures that govern all staff providing services on behalf of the center, including employees, volunteers, and contractors.(b) A center's written staffing policies must include:(1) requirements for orientation to the policies, procedures, and objectives of the center;(2) requirements and procedures for processing criminal history checks;(3) requirements that staff are current on immunizations;(4) requirements that an applicant for employment provide written documentation to rule out communicable diseases, including but not limited to tuberculosis;(5) requirements for direct care staff to demonstrate the necessary skills and competency to meet the direct care needs of a minor to which he or she is assigned and as described in their job description;(6) requirements for staff to participate in appropriate employee development programs quarterly;(7) requirements for participation by all staff in job-specific training;(8) staff training policies that ensure:(A) staff are properly oriented to tasks performed;(B) demonstration of competency for tasks when competency cannot be determined through education, license, certification, or experience;(C) quarterly continuing systemic training for all staff who provide services, including training on infection prevention and control;(D) staff are informed of changes in techniques, philosophies, organization, minor's rights, ethics and confidentiality, medical record requirements, information relating to minor's development, goals, and products relating to a minor's care;(E) staff are properly oriented and trained in the proper use of person-centered direction and guidance as outlined in center policy and in accordance with §550.206 of this subchapter (relating to Person-Centered Direction and Guidance);(F) staff are properly oriented and trained in the proper use and application of protective devices; and(G) staff are properly oriented and trained in the proper use and application of restraints in accordance with the following requirements:(i) all center staff whose job responsibilities include the use of restraint during a behavioral emergency must be trained before assuming direct care responsibilities for a minor;(ii) all center staff must receive training and demonstrate competency in the following areas:(I) using any restraint techniques or procedures that are expected or anticipated to be employed;(II) identifying the underlying causes or functions of threatening behaviors;(III) understanding how the behavior of staff members affects the behavior of minors;(IV) using de-escalation, mediation, self-protection, and other techniques, such as quiet time, to prevent or reduce the use of restraint;(V) applying principles of trauma informed care; and(VI) recognizing and responding to signs of distress in a minor who is being restrained; and(iii) all center staff must complete training and demonstrate competence in the use of restraint in a behavioral emergency at least every 12 months following initial training; and(H) job-specific training is documented with the following information:(i) the name and qualifications of the trainer;(ii) the training topics and length; and(iii) a list of staff who completed the training and demonstrated competence;(9) a requirement to have a written job description that is a statement of the functions and responsibilities, and job qualifications, including the specific education and training requirements for each position at the center;(10) procedures for searching the nurse aide registry and the employee misconduct registry for staff in accordance with §550.418 of this division (relating to Criminal History Checks, Nurse Aid Registry, Medication Aide Registry, and Employee Misconduct Registry Requirements);(11) a requirement to have annual evaluation of employee and volunteer performance;(12) a description of employee and volunteer disciplinary action and procedures;(13) a policy regarding the use of volunteers that is in compliance with §550.414 of this division (relating to Volunteers); and(14) a requirement that all staff providing services on behalf of a center sign a statement that the staff have read, understand, and will comply with all applicable center policies.(c) A center must adopt and enforce written policies and procedures for parent orientation and training programs in accordance with §550.509 of this subchapter (relating to Parent Training). The policy must:(1) require orientation be provided to each parent of each minor admitted to the center; and(2) ensure that orientation includes:(A) the philosophy of the center;(B) the basic services as defined in §550.5 of this chapter (relating to Definitions);(C) on-going parent training needs as determined by the individual needs of the minor;(D) a minor's parent agreement and disclosure form;(E) the center attendance policy for minors; and(F) information about a minor's rights while receiving services at the center. Source Note: The provisions of this §550.415 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.415 Staffing Policies for Staff Orientation, Development, and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194794 03/12/2026 (a) A center's staff development programs must:(1) facilitate the ability of the staff to function as a member of an IDT that includes health professionals, an adult minor, and a minor's parent;(2) improve communication skills to:(A) facilitate a collaborative relationship between an adult minor, a minor's parent, and the staff;(B) focus on person-centered thinking;(C) facilitate positive behavior support; and(D) incorporate person-first language;(3) increase the understanding of childhood illness and the effects it has on a minor's development, a minor's parent, and a minor's family;(4) provide mechanisms and skills for coping with the effects of childhood illness;(5) develop case management skills to assist an adult minor and a minor's parent in setting priorities, planning, and implementing a minor's care at home;(6) facilitate staff implementation of life-sustaining and assistive technology, provided by the center or by durable medical equipment contractors, used in the care of a minor;(7) facilitate the ability of staff to develop an individualized comprehensive plan of care; and(8) prepare staff for the response to and management of emergency medical situations in a center.(b) A center must:(1) conduct quarterly staff development programs appropriate to the staff providing services to minors to maintain high quality care; and(2) ensure that all center staff providing basic services to minors maintain basic life support certification.(c) A center must document all staff development programs to include:(1) the title and a short summary of the training program;(2) date and time;(3) name of the trainer; and(4) certificate of completion.(d) A center must maintain the quarterly staff development training program documentation for a period of two years. If the staff development training is specific to services provided to a specific minor, reference to the training must be maintained as part of a minor's medical record. Source Note: The provisions of this §550.416 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.416 Staff Development Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220975 03/12/2026 (a) A center must maintain a personnel record for an employee and volunteer. A personnel record may be maintained electronically if it meets the same requirements as a paper record. All information must be kept current. A personnel record must include the following:(1) a signed job description and qualifications for each position accepted or a signed statement that the person read the job description and qualifications for each position accepted;(2) an application for employment or volunteer agreement;(3) a record of the immunizations requirements and evaluation of the tuberculosis results;(4) verification of references, job experience, and educational requirements as conducted by the center to verify qualifications for each position accepted;(5) verification of licenses, permits, and certifications before employment and annually;(6) annual performance evaluations and disciplinary actions;(7) the signed statement about compliance with center policies required by §550.415 of this division (relating to Staffing Policies for Staff Orientation, Development, and Training); and(8) for an employee and volunteer:(A) a printed copy of the results of the initial and annual searches of the nurse aide registry and employee misconduct registry obtained from the HHSC Internet website; and(B) documentation that the employee, volunteer, or contractor in accordance with §550.418 of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry, and Employee Misconduct Registry Requirements) received written information about the Employee Misconduct Registry.(b) A center must keep a complete and accurate personnel record for an employee and volunteer at its licensed location. Source Note: The provisions of this §550.417 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.417 Personnel Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220976 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Applicant means any individual applying for a position in a center.(2) Employee means an individual directly employed by a center, a volunteer, or a contractor.(b) The provisions in this subsection apply to an applicant and an employee.(1) A center must conduct a criminal history check authorized by, and in compliance with, THSC Chapter 250 for an applicant for employment and an employee.(2) A center must not employ an applicant whose criminal history check includes a conviction listed in THSC §250.006 that bars employment or a conviction the center has determined is a contraindication to employment. If an applicant's or employee's criminal history check includes a conviction of an offense that is not listed in THSC §250.006, the center must document its review of the conviction and its determination of whether the conviction is a contraindication to employment.(3) The center must immediately discharge an employee when the center becomes aware that the employee's criminal history check reveals conviction of a crime that bars employment or that the center has determined is a contraindication to employment.(c) The provisions in this subsection apply to an applicant and an employee.(1) Before a center hires an applicant, the center must search the Nurse Aide Registry (NAR), Medication Aide Registry (MAR), and Employee Misconduct Registry (EMR) using the HHSC website to determine if an applicant or employee is listed in any of these registries as unemployable. The center must not employ an applicant who is listed as unemployable in any of these registries.(2) The center must provide information about the EMR to an employee no later than five business days after hiring an employee. The information must:(A) be in writing;(B) state that a person listed in the EMR is not employable by the center; and(C) include a reference to Chapter 561 of this title (relating to Employee Misconduct Registry) and THSC Chapter 253.(3) In addition to the initial verification of employability, the center must search the NAR and the EMR to determine if the employee is listed as unemployable in either registry at least every 12 months.(4) A center must suspend the employment of an employee who HHSC finds has engaged in reportable conduct while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, in accordance with THSC §253.004 or §253.005, pending a final decision by an administrative law judge. A center must not reinstate the employee's employment or contract during the course of any applicable appeals process.(5) The center must immediately discharge an employee when the center becomes aware:(A) that the employee is designated in the NAR or the EMR as unemployable; or(B) that the employee's criminal history check reveals conviction of a crime that bars employment or that the center has determined is a contraindication to employment.(d) Upon request by HHSC, a center must provide documentation to demonstrate compliance with subsections (b) and (c) of this section. Source Note: The provisions of this §550.418 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.418 Criminal History Checks, Nurse Aide Registry, Medication Aide Registry, and Employee Misconduct Registry Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194797 03/12/2026 (a) A center must adopt and enforce a written policy describing whether it will conduct drug testing of its staff, volunteers, and contractors.(b) If a center conducts drug testing, the written policy must describe the method by which drug testing is conducted.(c) If a center does not practice drug testing, the written policy must state that the center does not conduct drug testing.(d) A center must provide a copy of the policy to anyone applying for services from the center and any person who requests a copy of the policy. Source Note: The provisions of this §550.419 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.419 Drug Testing Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194806 03/12/2026 (a) A center must ensure the provision of all basic services based on the needs of a minor and a minor's family in accordance with the plan of care.(b) A minor's parent is not required to accompany the minor when the minor receives services in the center, including therapeutic services provided in the center but billed separately. Source Note: The provisions of this §550.501 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective September 28, 2016, 41 TexReg 7512; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.501 Basic Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194807 03/12/2026 (a) A center must ensure the provision of medical services based on the needs of a minor, in accordance with a minor's plan of care and as ordered by a minor's prescribing physician.(b) A center must ensure that a minor's prescribing physician maintains responsibility for the overall medical therapeutic plan of a minor and consults and collaborates with the staff providing services in a center.(c) A center's nursing director or designee must communicate with each minor's prescribing physician at least every 90 days or more frequently when there is a health status or physical status change in a minor's condition.(d) A center must adopt and enforce a written policy requiring that therapists who provide services to a minor at the center consult with a minor's prescribing physician directly or coordinate with the clinical staff at least every 180 days or more frequently when there is a health status or physical status change in a minor's condition. Source Note: The provisions of this §550.502 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.502 Medical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194808 03/12/2026 (a) A center must ensure nursing services are provided based on the needs of a minor, in accordance with a minor's plan of care and as ordered by a minor's prescribing physician.(b) A center's nursing director or designee must participate in pre-admission planning along with other appropriate nursing staff.(c) The center's nursing director is responsible for:(1) ensuring the implementation of the nursing care plan;(2) monitoring and documenting the care and treatment according to a minor's plan of care;(3) ensuring that nurses providing services at the center participate in interdisciplinary team meetings regarding a minor's progress towards goals;(4) ensuring the maintenance of a minor's medical record in accordance with the center's policies and procedures; and(5) ensuring a minor's parent is instructed on how to provide the necessary care and treatment in the home. Source Note: The provisions of this §550.503 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.503 Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220981 03/12/2026 (a) A center must ensure the provision of psychosocial treatment based on the needs of a minor, in accordance with a minor's plan of care and as ordered by a minor's prescribing physician.(b) If psychosocial treatment and services are provided at the center, the center must ensure that the provision of psychosocial treatment and services complies with the requirements of this section, §550.206 of this subchapter (relating to Person-Centered Direction and Guidance) and §550.207 of this subchapter (relating to Protective Devices and Restraints) as applicable to a minor's plan of care and physician's order.(c) The center must ensure psychosocial treatments and services provided at a center are overseen by a physician, RN, or psychologist.(d) If psychosocial treatments and services are provided in a center, the center must adopt and enforce written policies and procedures relating to the provision of psychosocial treatments to a minor, including:(1) ensuring the development of interventions to foster normal development;(2) ensuring the development of interventions to foster psychosocial adaptations;(3) using person-centered direction and guidance in accordance with §550.206 of this chapter; and(4) using restraints in accordance with §550.207 of this subchapter.(e) If psychosocial treatments are provided in a center, the center must ensure the initial health assessment of a minor receiving psychosocial treatments includes:(1) mental status including psychological and behavioral status;(2) sensory and motor function;(3) cranial nerve function;(4) language function; and(5) any other criteria established by a center's policy.(f) The center must ensure that an individual providing psychosocial treatment and services in a center:(1) actively participates in the coordination of a minor's care, in accordance with accepted standards of practice;(2) participates in ongoing interdisciplinary comprehensive assessments and developing and evaluating the plan of care;(3) participate as a committee member in the continuous review of the center's person-centered direction and guidance program in accordance with §550.206 of this subchapter;(4) provides assistance to a minor's family with the effects of chronic illness and supporting effective relationships within a family; and(5) develops interventions to foster normal development and psychosocial adaptation. Source Note: The provisions of this §550.504 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.504 Psychosocial Treatment and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194810 03/12/2026 (a) A center must ensure the provision of social services based on the needs of a minor, in accordance with a minor's plan of care and as ordered by a minor's prescribing physician.(b) If social services are provided in a center, the services must be overseen by a social worker or RN.(c) The center must ensure that an individual providing social services in a center:(1) actively participates in the coordination of a minor's care, in accordance with accepted standards of practice; and(2) participates in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care.(d) The center must ensure that a minor's parent receives assistance in finding referrals to appropriate local community resources and is provided assistance to enhance coping skills in the parent's care of a minor. Source Note: The provisions of this §550.505 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.505 Social Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220982 03/12/2026 (a) A center must ensure the provision of rehabilitative services based on the needs of a minor, in accordance with a plan of care and as ordered by a minor's prescribing physician.(b) The center must ensure rehabilitative services provided at a center are overseen by a licensed or certified qualified professional staff as specified in §550.411 of this subchapter (relating to Rehabilitative and Ancillary Professional Staff and Qualifications).(c) The center must ensure that an individual providing rehabilitative services in a center:(1) actively participates in the coordination of a minor's care, in accordance with accepted standards of practice; and(2) participates in ongoing interdisciplinary comprehensive assessments, and in developing and evaluating the plan of care. Source Note: The provisions of this §550.506 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.506 Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220977 03/12/2026 (a) A center must ensure the provision of functional developmental services based on the needs of a minor, in accordance with the minor's plan of care and as ordered by a minor's prescribing physician.(b) A center must refer a minor to Early Childhood Intervention, within seven days after identification of a developmental delay or risk of developmental delay in accordance with 34 Code of Federal Regulations §303.303 Referral procedures.(c) A center must ensure that each minor has a functional assessment incorporated into the comprehensive assessment to include developmentally appropriate areas.(d) A minor's functional assessment must include:(1) measurable goals that enhance independent functioning in daily activities and to promote socialization;(2) a description of a minor's strengths and present performance level with respect to each goal;(3) skills areas in priority order; and(4) planning for specific areas identified as needing development. Source Note: The provisions of this §550.507 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.507 Functional Developmental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220978 03/12/2026 (a) The center must adopt and enforce written policies and procedures to facilitate each minor's access to available early intervention and educational services and programs delivered by an education provider, including a local education agency (LEA), as defined in United States Code, Title 20, §1401(19), early childhood intervention agency, or private school, in the least restrictive environment in the community where a minor resides and where the center is located. The center's educational policy must:(1) be person-centered and parent driven;(2) be collaborative with the education provider;(3) ensure that the center does not act as the primary education provider for a minor or accept a delegation of responsibility for the provision of a minor's education from an education provider; and(4) support a minor's education program as agreed to by a parent and education provider.(b) The center must not coerce or provide an incentive to an individual or education provider that would result in a minor's removal from a less restrictive educational environment.(c) The center must not be the primary location for the education provider to deliver services to a minor unless it is determined by the education provider, including the LEA's Admission, Review, and Dismissal (ARD) committee or committee required by Section 504 of the Rehabilitation Act of 1973, in collaboration with a minor's parent and a minor's prescribing physician that the center is the least restrictive environment for a minor to receive educational services.(d) For a minor who is not receiving services from an education provider, the center must provide a minor and a minor's parent contact information for the LEA where a minor resides.(e) For a minor receiving services from an education provider, the center must:(1) not duplicate or provide services that conflict with a minor's education program;(2) for a minor receiving services from an LEA, not interfere with the compulsory attendance requirements of Texas Education Code §25.085 and §25.086;(3) when requested by a parent, make available a minor's records to support the minor's education program;(4) request copies of a minor's education program records to support center care planning activities;(5) if requested by a parent, participate in planning activities for a minor conducted by the education provider, including an LEA's ARD committee or committee required by Section 504 of the Rehabilitation Act of 1973;(6) request that a minor's teacher, or other education provider representative, participate as part of the IDT to ensure coordination of a minor's services with the scheduled education component of activities; and(7) support a minor's education program activities at the center, if needed, by:(A) providing a well-lighted room, private space or other adequate workspace;(B) providing functional assistance to a minor;(C) coordinating with a minor and a minor's parent to ensure special and general supplies and equipment available for a minor if needed; and(D) providing an area to post education program calendars and information bulletins provided to the center for minors and parents to view. Source Note: The provisions of this §550.508 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.508 Educational Developmental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194814 03/12/2026 (a) A center must develop parent training for each minor's parent and family as identified in a minor's plan of care.(b) A center must identify the minimum frequency for parent training appropriate to a minor's plan of care to maintain high quality care at home and at the center.(c) A center must ensure that parent training includes the importance of basic life support certification and first aid training.(d) A center must document parent training in a minor's medical record, to include:(1) the title and a short summary of the training;(2) the date and time the training was conducted;(3) the name and title of the staff who provided the training; and(4) a copy of the training sign-in sheet or other attendance record.(e) A center's parent training program must:(1) facilitate the ability of a parent to be an active participant of an IDT in the development of an individualized comprehensive plan of care;(2) facilitate the ability of a parent to be an active participant in the development of a minor's emergency medical plan;(3) improve communication skills to facilitate a collaborative relationship between a minor's parent and providers of basic services;(4) increase the understanding of childhood illness and the effects it has on a minor's development and a minor's family;(5) provide mechanisms and skills for coping with the effects of childhood illness;(6) provide information on the importance of meeting a child's needs through a well-balanced and nutritional diet;(7) provide training regarding appropriate person-centered direction and guidance for effectively promoting successful behavioral and coping skills for a minor relating to a minor's medical conditions and treatment;(8) develop skills to determine and set priorities, and plan and implement a minor's care at home; and(9) provide training regarding the use, importance, and function of new technology used to provide care to a minor. Source Note: The provisions of this §550.509 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.509 Parent Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220979 03/12/2026 (a) A center must ensure the provision of nutritional counseling as defined in §550.5 of this chapter (relating to Definitions) based on the minor's needs and in accordance with the minor's plan of care.(b) Nutritional counseling must be overseen by a qualified individual including a dietitian, a nutritionist, or an RN. Source Note: The provisions of this §550.510 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.510 Nutritional Counseling https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220980 03/12/2026 (a) A center must adopt and enforce written policy and procedures to ensure that a minor, while at the center, receives:(1) a nourishing, well-balanced diet as recommended by the American Academy of Pediatrics or Food and Nutrition Board of the National Research Council, National Academy of Sciences; or(2) a diet ordered by a minor's prescribing physician.(b) If a minor's meals and snacks are supplied by an adult minor or a minor's parent, the center's written policy and procedures must:(1) include a written signed agreement between the center and the adult minor or minor's parent that includes:(A) a statement that the adult minor or minor's parent is responsible for providing the appropriate meals and snacks for the minor in accordance with this section;(B) the responsibilities of the center and the responsibilities of the adult minor or minor's parent concerning the provision of meals and snacks; and(C) actions that may be taken by the center if the adult minor or minor's parent fails to provide meals and snacks for the minor as agreed;(2) describe the actions that will occur if an adult minor or minor's parent fails to provide the minor's meals and snacks or fails to provide meals and snacks in accordance with the minor's prescribed diet, which must include that the center ensures that the minor receives the meals and snacks as required in this section while at the center; and(3) ensure an adult minor or minor's parent receives nutritional counseling as described in §550.510 of this division (relating to Nutritional Counseling).(c) If the center provides meals and snacks directly or under contract, the center must employ or contract with a dietitian as described in §550.411(b) of this subchapter (relating to Rehabilitative and Ancillary Professional Staff and Qualifications).(1) The dietitian is responsible for the overall operation of the dietary service.(2) The dietitian must participate in regular conferences with the administrator and nursing director to provide information about approaches to identified nutritional problems.(3) The dietitian must participate in the development of dietary support staff policies.(4) The center must employ sufficient dietary support staff who meet the qualifications to carry out the functions of the dietary service.(5) The dietitian must ensure that a minor has a diet:(A) that meets the daily nutritional and special dietary needs of a minor, based upon the acuity and clinical needs of a minor; or(B) as prescribed by a minor's prescribing physician.(6) The dietitian is required to review a minor's plan of care for any known food allergy and special diet ordered by a minor's prescribing physician as often as necessary for changes to a minor's dietary needs.(d) If a center provides meals and snacks directly or under contract:(1) a dietitian must develop a menu that:(A) is prepared at least one week in advance;(B) is written for each type of diet; and(C) varies from week to week, taking the general age-group of minors into consideration;(2) the center must post the current week's menu in a conspicuous location so an adult minor and a minor's parent may see it; and(3) the center must retain menus for 30 days.(e) If a center provides meals and snacks directly, the center must retain records of menus served and food purchased for 30 days. The center must keep a list of minors receiving special diets and a record of the diets in the minors' medical records for at least 30 days.(f) The center must:(1) provide tables that allow minors to eat together when possible;(2) provide assistance to minors, as needed;(3) serve food on appropriate tableware; and(4) ensure clean napkins, bibs, dishes, and utensils are available for each use.(g) A center must coordinate with an adult minor or a minor's parent to ensure special eating equipment and utensils are available for a minor at the center if needed.(h) An identification system, such as tray cards, must be available to ensure that all food is served in accordance with a minor's diet.(i) A center must monitor and record food intake of all minors as follows.(1) Deviations from normal food and fluid intake must be recorded in a minor's medical record.(2) In-between meal snacks, and supplementary feedings, either as a part of the overall plan of care or as ordered by a minor's prescribing physician, including special diets, must be documented using professional practice standards.(j) The center must serve a minor meals and snacks as specified in this section and as outlined in a minor's plan of care.(1) If breakfast is served, a morning snack is not required.(2) Notwithstanding the provisions of this section, a minor must not go more than three hours without a meal or snack being offered, unless a minor is sleeping.(3) The center must offer at least one snack to a minor who is served at the center for less than four hours.(4) The center must offer one meal, or one meal and one snack, equal to one third of a minor's daily food needs to a minor who is served at the center for four to seven hours.(5) The center must offer two meals and one snack, or two snacks and one meal, equal to one half of a minor's daily food needs to a minor who is served at the center for more than seven hours.(6) The center must ensure that a supply of drinking water is always available to each minor and is served at every snack, mealtime, and after active play.(k) The center must:(1) purchase food from sources approved or considered satisfactory by federal, state, and local authorities;(2) store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements; and(3) dispose of garbage and refuse properly.(l) The center must provide safe and proper storage and service of a minor's meals and snacks provided by an adult minor and a minor's parent.(m) Dietary service staff must be in good health and practice hygienic food-handling techniques. Staff with symptoms of communicable diseases or open, infected wounds may not work at the center until the center receives written documentation from a health care professional that the staff member is released to return to work or, the signs and symptoms which relate to the communicable disease are no longer evident.(n) Dietary service staff must wear clean, washable garments, wear hair coverings or clean caps, and have clean hands and fingernails.(o) Routine health examinations must meet all local, state, and federal codes for food service staff. Source Note: The provisions of this §550.511 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.511 Dietary Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220983 03/12/2026 (a) A center may admit a minor if:(1) the minor's prescribing physician, in consultation with the minor's parent and the minor, recommends admission to a center, taking into consideration the medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, education, and development needs of the minor in addition to the emotional, psychosocial, and environmental factors;(2) the minor's prescribing physician issues a prescription ordering care at a center;(3) the minor is stable for outpatient medical services and requires ongoing nursing care and other basic services;(4) the adult minor or the minor's parent signs a written agreement and disclosure form consenting to the adult minor's or minor's admission to a center; and(5) the admission is voluntary.(b) The center must ensure that its admission criteria are in accordance with §550.211 of this subchapter (relating to Infection Prevention and Control Program and Vaccinations Requirements). Source Note: The provisions of this §550.601 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.601 Admission Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220984 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220984 03/12/2026 (a) If a minor meets the criteria for admission into a center as described in §550.601 of this division (relating to Admission Criteria), the medical or nursing director must contact the minor's prescribing physician to schedule a pre-admission conference before the minor receives services at the center.(b) If a minor is hospitalized at the time of referral to a center, the pre-admission conference must include the minor's parent, the minor, the minor's prescribing physician, center staff, relevant hospital staff, including medical, nursing, social services, and developmental staff, and any other individuals requested by the adult minor or the minor's parent, to begin developing the plan of care.(c) If a minor is not hospitalized at the time of referral to a center, the pre-admission conference must include the minor's parent, the minor, the minor's prescribing physician, center staff, and any other individuals requested by the adult minor or the minor's parent to begin developing the plan of care.(d) A center must schedule a pre-admission conference no later than three days after the center receives a referral. The pre-admission conference must address a minor's:(1) medical history;(2) diagnosis;(3) mental and developmental status;(4) nutritional status;(5) dietary requirements;(6) functional abilities and limitations;(7) activities permitted and prohibited;(8) use of assistive devices;(9) treatment procedures;(10) use of restraints, if applicable;(11) medication;(12) safety measures to protect against injury;(13) education level and participation in an education program, if applicable;(14) immunization record;(15) receipt of services from other service providers; and(16) other appropriate information. Source Note: The provisions of this §550.602 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.602 Pre-admission Conference https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220985 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220985 03/12/2026 (a) A center must review a written agreement and disclosure form with a minor's parent or with an adult minor before services are provided at the center.(b) The agreement and disclosure form must include evidence or attestation that the parent of a minor has the legal authority to consent to the minor's medical care.(c) The agreement and disclosure form must document that a center obtained a minor's parent's or an adult minor's written informed consent specifying the services that may be provided on behalf of a center to a minor.(d) The agreement and disclosure form must document that the center provided the following information orally and in writing to a minor's parent or the minor, or an adult minor, in a language or format the minor understands:(1) the notice of rights and responsibilities described in §550.901 of this subchapter (relating to Rights and Responsibilities);(2) information on the Advance Directives Act, THSC, Chapter 166;(3) the extent to which payment for services provided on behalf of the center may be expected from any third-party payment source known to a center, the charges for services not covered by a third-party payment source and charges that a minor's parent or adult minor may have to pay;(4) a list of the staff who will provide services on behalf of the center;(5) a list of expected outcomes and any specific limitations or barriers to reaching the outcomes;(6) the method of supervision and oversight by a center of the services to be provided at the center;(7) the HHSC toll-free telephone number and its purpose;(8) the process for directing a grievance to the administrator about services provided at the center and the time frame in which the center must review and resolve a grievance;(9) the adult minor's and the minor's parent's responsibilities;(10) an emergency plan for a minor; and(11) notice of the center's policies regarding:(A) attendance requirements;(B) implementing an advance directive in accordance with §550.902 of this subchapter (relating to Advance Directives);(C) disclosure of the minor's medical record;(D) person-centered direction and guidance;(E) restraints;(F) reporting abuse, neglect, or exploitation of a minor by an employee, volunteer, or contractor;(G) drug testing of employees in direct contact with a minor in accordance with §550.419 of this subchapter (relating to Drug Testing Policy); and(H) management and disposal of medications in the center.(e) The agreement and disclosure form must be signed by a minor's parent or an adult minor.(f) A center must provide a signed copy of the agreement and disclosure form to the minor's parent or the adult minor.(g) The center must keep the signed written agreement and disclosure form in the minor's medical record.(h) The center must update the agreement and disclosure form if information in the form changes.(i) The center must comply with the terms of the agreement. Source Note: The provisions of this §550.603 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.603 Agreement and Disclosure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220986 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220986 03/12/2026 (a) A center's administrator, nursing director, or designee must conduct an interview with a minor's parent or an adult minor before or at a minor's admission to the center that addresses the following:(1) the adult minor's and minor's parent's rights and responsibilities;(2) the center's policies and procedures;(3) basic services;(4) the center's dietary services;(5) the center's transportation services;(6) the center's operating hours and contact information;(7) the center's infection prevention and control program;(8) the center's emergency preparedness plan;(9) the center's attendance policy;(10) services the minor is receiving at the center, but not provided by the center;(11) development of the minor's plan of care;(12) the minor's emergency plan and needs; and(13) the minor's transfer and discharge planning.(b) A center must request and keep a copy of a minor's medical history and documentation of a physical examination performed by the minor's prescribing physician within 30 days before or after the date of the minor's admission to the center.(c) A center must have a signed order from a minor's prescribing physician on the day of the minor's admission, as described in §550.701 of this subchapter (relating to Physician Orders). Source Note: The provisions of this §550.604 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.604 Admission Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220987 03/12/2026 (a) A center's RN must conduct and document a specific initial comprehensive assessment that identifies the minor's medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional abilities, educational, and developmental needs and the adult minor's or minor's parent's training needs.(b) The initial comprehensive assessment must include the minor's discharge planning, including transition support, self-advocacy guidance, and coordination of services required by the minor and the minor's parent.(c) The initial comprehensive assessment must be conducted in consultation with an adult minor and the minor's parent.(d) An RN must complete an initial comprehensive assessment no earlier than three business days before the minor is admitted to the center and no later than the date the minor is admitted to the center.(e) An RN must conduct, in consultation with a minor's parent or an adult minor, a comprehensive assessment of the minor at least once every 180 days after admitting the minor into the center. An RN must conduct a new comprehensive assessment on the minor when the minor has a change of condition or the minor's needs change.(f) The updated comprehensive assessment described in subsection (e) of this section must:(1) identify a minor's ongoing medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, educational, and developmental needs and the training needs of the adult minor or parents of the minor; and(2) include a minor's discharge planning, detailing transition support, if needed, self-advocacy guidance, and coordination with the minor's parent or the adult minor. Source Note: The provisions of this §550.605 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.605 Initial and Updated Comprehensive Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220988 03/12/2026 (a) A center must designate an IDT.(b) The IDT must monitor the services provided to a minor at the center.(c) A center must designate an RN to be a member of the IDT to:(1) provide coordination of care for the minor;(2) ensure continuous assessment of the minor's and the minor's parent's needs; and(3) implement the minor's interdisciplinary plan of care.(d) The IDT must prepare a written plan of care for the minor as described in §550.607 of this division (relating to Initial and Updated Plan of Care).(e) The IDT must include:(1) the minor's prescribing physician;(2) the center's nursing director or an RN designated by the nursing director;(3) the minor;(4) the minor's parent;(5) a social worker, if the minor is receiving social services at the center; and(6) another individual providing basic services to a minor if the minor is receiving basic services other than nursing services at the center.(f) The IDT must participate in the development of a plan of care with goals and objectives for a minor that includes discharge planning when goals and objectives are met. Source Note: The provisions of this §550.606 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.606 Interdisciplinary Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220989 03/12/2026 (a) A center must develop an individualized written plan of care for a minor. The plan of care must include:(1) the minor's and the minor's parent's goals and interventions based on the issues identified in the pre-admission conference and the initial and updated comprehensive assessments; and(2) measurable goals with interventions based on the minor's care needs and means of achieving each goal and must address, as appropriate, rehabilitative and restorative measures, preventive intervention and training, and teaching of personal care by the minor's parent.(b) An RN must address in the written interdisciplinary plan of care:(1) the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, educational, and developmental needs of the minor and the training needs of the minor's parent;(2) the minor's functional assessment;(3) the specific goals of care;(4) the time frame for achieving the goals and the schedule for evaluation of progress;(5) the orders for treatment, services, medications, medical equipment, diet, and restraints, if applicable;(6) specific criteria for transitioning from or discontinuing participation at the center; and(7) the minor's scheduled days of attendance.(c) In collaboration with the interdisciplinary team, an RN, a minor's parent, the minor, and an individual requested by the adult minor or the minor's parent must develop a plan of care based on the comprehensive assessment.(d) The RN, an adult minor, and a minor's parent must sign the plan of care within five days after initiation of the plan.(e) A minor's prescribing physician must review and sign the plan of care within 30 days after initiation of the plan.(f) The center must incorporate the plan of care into a minor's medical record no later than 10 days after receiving the signed plan from a minor's prescribing physician.(g) Copies of the plan of care must be given, in a language and format the recipient understands, to a minor's parent, an adult minor, the minor's prescribing physician, the center's staff, and other health care providers and providers of basic services as appropriate.(h) The center's IDT and an RN must review and update a minor's plan of care at least every 180 days, or more often, if there is a change in the minor's medical condition or changes in the minor's needs.(i) A minor's parent and an adult minor must review and sign the updated plan of care within five days before changes to the plan of care are implemented.(j) A minor's prescribing physician must review and sign the updated plan of care within 30 days after initiation of the updated plan.(k) The center must incorporate the updated plan of care into a minor's medical record no later than 10 days after receiving the signed plan from the minor's prescribing physician.(l) The center must adopt and enforce written policies and procedures regarding the communication and coordination of a minor's care with the minor's prescribing physician in accordance with the plan of care.(m) The policy described in subsection (l) of this section must ensure the communication between the center's staff and a minor's prescribing physician is conveyed to the minor's parent and the minor in a language and format that the adult minor and minor's parent understand.(n) The center's nursing director or designee must:(1) document communication with a minor's prescribing physician;(2) maintain the documentation in the minor's medical record; and(3) ensure that the communication is conveyed to the minor's parent and the adult minor in a language and format the adult minor and minor's parent understand.(o) The center staff must ensure the provision of services and treatments in accordance with the plan of care and as ordered by a minor's prescribing physician. Source Note: The provisions of this §550.607 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.607 Initial and Updated Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220990 03/12/2026 (a) A center intending to transfer or discharge a minor must provide both oral and written notification to the minor's parent and adult minor no later than 15 days before the date the minor will be transferred or discharged, if the notification is provided in person.(b) If the center does not provide the notice of transfer or discharge in person, the center must provide oral notification to a minor's parent and adult minor by telephone no later than 15 days before the date of transfer or discharge and mail the written notification no later than 15 days before the date of transfer or discharge.(c) A center that intends to transfer or discharge a minor must also notify the minor's prescribing physician no later than 15 days before the date the minor will be transferred or discharged.(d) A center may transfer or discharge a minor without providing the oral and written notification described in subsections (a) and (b) of this section:(1) if the minor's parent or adult minor requests the transfer or discharge;(2) if the minor's medical needs require transfer, including a medical emergency;(3) if the minor's health and safety is at risk due to an emergency and a transfer is made in accordance with §550.209 of this subchapter (relating to Emergency Preparedness Planning and Implementation);(4) for the protection of staff or a minor attending the center after the center makes a documented, reasonable effort to notify the minor's parent, the minor's prescribing physician, and appropriate state or local authorities of the center's concerns for the safety of staff or the minor, and in accordance with center policy;(5) according to the minor's prescribing physician's orders; or(6) if the minor's parent or an adult minor fails to pay for services, except as prohibited by state law.(e) A center must keep in a minor's medical record:(1) a copy of the written notification provided in accordance with subsection (a) or (b) of this section to the minor's parent or adult minor;(2) documentation of the personal contact with the minor's parent or adult minor in accordance with subsection (b) of this section; and(3) documentation that the minor's prescribing physician was notified of the date of transfer or discharge in accordance with subsection (c) of this section. Source Note: The provisions of this §550.608 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.608 Discharge or Transfer Notification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220991 03/12/2026 (a) A center must ensure that a minor admitted to the center is admitted under an order of the minor's prescribing physician and remains under the care of the prescribing physician for the duration of the minor's stay at the center. The minor's medical record must contain the written prescribing physician order used for admission as well as all subsequent prescribing physician orders.(b) The prescribing physician orders must include:(1) approval of a minor's admission to a center;(2) nursing services;(3) medication administration, if applicable;(4) dietary needs, if applicable;(5) permitted activities, if applicable;(6) therapy treatments, if applicable;(7) transportation authorization, if applicable; and(8) other services, if applicable. Source Note: The provisions of this §550.701 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.701 Physician Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194818 03/12/2026 (a) A center must adopt and enforce a written policy describing protocols and procedures the center must follow when receiving physician orders. A center's written policy must comply with this section. The center's written policy must ensure the center's compliance with THSC Chapter 248A, applicable rules in this chapter, and applicable state and federal regulations relating to receiving physician orders. If there is a conflict between this chapter and other applicable state and federal laws and regulations, a center must comply with the more stringent requirement.(b) A center's written policy describing protocols and procedures for receiving physician orders must address:(1) receipt of a physician order before providing basic services;(2) the licensed staff authorized to accept physician verbal orders;(3) the recording and signing of verbal physician orders by licensed staff;(4) the time frame for a physician to sign and date verbal orders; and(5) whether the center accepts an electronically signed physician order or a physician order submitted via a facsimile machine.(c) A center may accept signed facsimile copies of physician orders. A center must be able to obtain an original signature to verify a signature on a facsimile copy. If signed physician orders are accepted by this method, the written policy must describe:(1) safeguards to ensure that transmitted information is sent to the appropriate individual; and(2) the procedure to be followed in the case of misdirected transmission.(d) A center may accept electronically signed physician orders submitted electronically. If signed physician orders are accepted by this method, the written policy must describe the center's method for verifying that the system and software product the physician uses provides protection against:(1) modification of the physician order, including the physician's signature and date of signature; and(2) the unauthorized use of the physician's electronic signature. Source Note: The provisions of this §550.702 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.702 Receiving Physician Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220992 03/12/2026 (a) If a center administers or stores medication, the center must have a pharmacist or a qualified RN with education and training in drug management on a full-time, part-time, or on a consultant basis to provide consultation to the medical director, administrator, nursing director, and other center staff.(b) A center must consult with a pharmacist or qualified RN as needed on the following:(1) establishing written policies and procedures for the storage and administration of medications as described in §550.704 of this division (relating to Storage of Medication) and §550.705 of this division (relating to Administration of Medication);(2) reviewing medical records to ensure that the medication records are accurate, updated, and reflect that medications are administered in accordance with the orders of a minor's prescribing physician;(3) providing in-service training to staff on the storage and administration of medications; and(4) ensuring pharmaceutical compliance. Source Note: The provisions of this §550.703 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.703 Pharmacist Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194820 03/12/2026 (a) A center must adopt and enforce a written policy for the storage and administration of medication at the center. The policy must include protocols and procedures for:(1) labeling;(2) storage;(3) integrity;(4) control; and(5) accountability of all medications stored by a center;(b) A center must store over-the-counter (OTC) stock medications separately from medication brought to the center by an adult minor or a minor's parent. The OTC medication must include a medication label that includes:(1) the medication name;(2) strength;(3) manufacturer's name;(4) lot number;(5) expiration date;(6) recommended dosage for safe use; and(7) applicable cautionary or accessory labeling.(c) A center must only receive prescription medication from an adult minor or a minor's parent and in the original and labeled container issued by a pharmacy.(d) A center must store medication in a locked cabinet, located in or convenient to a nurse's station or other central location.(e) A center must keep Schedule II substances in separately locked, securely fixed boxes or drawers in the locked medication cabinet and under two locks.(f) A center must keep medications requiring refrigeration in a separate locked box in a separate refrigerator from the refrigerator the center uses to store food. Source Note: The provisions of this §550.704 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.704 Storage of Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220993 03/12/2026 (a) A center must adopt and enforce written policies and procedures for the administration of medication to a minor. The policies and procedures must address:(1) removing an individual dose from a previously dispensed, properly labeled container;(2) verifying the medication with the prescriber's orders;(3) verifying the order with the correct minor;(4) giving the correct medication dose to a minor;(5) giving the medication by the correct route;(6) observing that the medication is taken;(7) recording the required information, including the method of administration; and(8) documenting any medication not administered and the reason.(b) A center's written policy must ensure compliance with:(1) THSC Chapter 248A;(2) this chapter;(3) state law authorizing a person licensed under the Texas Occupations Code to administer medications;(4) rules adopted by the Texas Board of Nursing 22 Texas Administrative Code Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments) governing when an RN may delegate the administration of medication to an unlicensed person; and(5) any other applicable state and federal regulations relating to the administration of medication to a minor.(c) If there is a direct conflict between this chapter and other applicable state and federal laws and regulations, a center must comply with the more stringent requirements.(d) The administration of medication by center staff must be included in a minor's plan of care.(e) A center must adopt and enforce written policies and procedures for maintaining a current medication list and a current medication administration record.(f) A center's written policy must require center staff who supervise, assign, or delegate the administration of medication or administer medication to a minor to maintain a current medication list in the minor's medical record.(g) A center may incorporate a current medication list and medication administration record into one document.(h) An RN must review the medication list initially after a minor is admitted and update the list when necessary but at least every 90 days.(i) An RN must report significant findings from a review of the medication list to the minor's prescribing physician.(j) Review of the medication list includes evaluation of prescription and over-the-counter drugs, medication orders, and the medication list for:(1) known allergies;(2) rational drug therapy-contraindication;(3) reasonable dose and route of administration;(4) reasonable directions for use;(5) duplication of drug therapy;(6) drug-drug interaction;(7) drug-food interaction;(8) drug-disease interaction;(9) adverse drug reaction; and(10) proper use, including overuse or underuse.(k) A center must adopt and enforce written policies and procedures on medication errors. The policy must ensure that the nursing director, a minor's prescribing physician and the minor's parent are notified immediately after the discovery of a medication error or an adverse reaction. Source Note: The provisions of this §550.705 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.705 Administration of Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194822 03/12/2026 If a center provides laboratory services, then the center must adopt and enforce a written policy to ensure that the center meets the Clinical Laboratory Improvement Act, 42 United States Code Annotated, §263a (CLIA 1988). Source Note: The provisions of this §550.706 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.706 Laboratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220994 03/12/2026 (a) A center must adopt and enforce a written policy for the safe handling and disposal of special or medical waste and materials, including bio-hazardous waste and materials.(b) A center that generates special or medical waste while providing services must dispose of the waste according to the requirements issued by the Texas Department of State Health Services in 25 Texas Administrative Code Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities). Source Note: The provisions of this §550.707 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.707 Disposal of Special or Medical Waste https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194824 03/12/2026 A center must adopt and enforce a written policy for the safe and legal disposal and destruction of pharmaceuticals in accordance with all state, federal, and local laws. Source Note: The provisions of this §550.708 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.708 Disposal and Destruction of Pharmaceuticals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194825 03/12/2026 A center must adopt and enforce written policies and procedures that specify the center's care practices. The written care policies and procedures must address the following topics, as applicable:(1) initial and updated comprehensive assessment;(2) pre-admission, admission, placing a minor on hold, transfer, and discharge;(3) attendance requirements;(4) active play of a minor;(5) intravenous services;(6) safety of center staff;(7) safety of a minor;(8) the prevention, detection, and reporting of abuse, neglect, or exploitation;(9) nursing procedures relating to the care of a minor;(10) psychiatric nursing procedures;(11) person-centered direction and guidance;(12) restraints;(13) parent teaching;(14) care planning;(15) palliative care and management of a terminal illness;(16) performing waived laboratory testing;(17) medication administration;(18) emergency plans of care; and(19) any other care policies relating to the services provided on behalf of a center. Source Note: The provisions of this §550.801 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.801 Care Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220995 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220995&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220995 03/12/2026 (a) A center must adopt and enforce written policies and procedures regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of a minor's services:(1) among all staff providing services on behalf of a center; and(2) between the center and a provider of services to the minor that is not providing services on behalf of the center, if known by the center.(b) Documentation in a minor's medical records must demonstrate coordination of services as described in subsection (a) of this section.(c) For a minor receiving services from a provider that is not providing services on behalf of a center, the center must:(1) not duplicate or provide services that conflict with the minor's care plan or service plan with the provider;(2) when requested by an adult minor or parent, make available the minor's records to support the coordination of services between the center and the provider;(3) request copies of the minor's records with the provider to support center care planning activities;(4) if requested by an adult minor or parent, participate in planning activities for the adult minor or minor conducted by the provider;(5) request that the minor's provider participate as part of the center's interdisciplinary team and QAPI committee, as applicable; and(6) support the coordination of the minor's services by allowing the minor's provider to serve a minor at the center, if:(A) the center, the provider, the minor's parent or the adult minor agree that the provision of services to the minor by the provider at the center would be appropriate for the minor; and(B) the center and the provider establish a written agreement that includes the provider's agreement to comply with center policies and this chapter for the provision of the provider's services at the center. Source Note: The provisions of this §550.802 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.802 Coordination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220996 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220996 03/12/2026 (a) A center must adopt and enforce written policies and procedures for the development of the center's actual, daily, and total census lists.(b) A center's written policies and procedures must address:(1) developing and maintaining the census lists;(2) the staff responsible for maintaining the census lists; and(3) the retrieval of the census lists when requested by HHSC.(c) A center must maintain the following lists of minors receiving services:(1) actual census, which must be updated each time the number of minors at the center changes;(2) daily census; and(3) total census.(d) The actual and daily census must include:(1) the minor's name;(2) the services provided to the minor and the provider responsible for the delivery of each service; and(3) the time the minor entered and left the center.(e) The total census must include:(1) the minor's name;(2) the minor's diagnosis; and(3) the name and contact information of the minor's prescribing physician. Source Note: The provisions of this §550.803 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.803 Census https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220998 03/12/2026 (a) A center must adopt and enforce written policies to ensure a minor's legal rights are observed and protected and to ensure compliance with this section. The policies must comply with relevant law and ensure that the center considers a minor's age and legal status, including whether a guardian has been appointed or the disabilities of minority have been removed, to determine the minor's or other individual's authority to make decisions for the minor.(b) Before providing services to a minor, a center must provide an adult minor and a minor's parent with oral and written notification of the requirements of this section in a language and format that the minor and parent understand. The center must obtain the signature of the adult minor and minor's parent to confirm that the individual received the notice.(c) A center must:(1) ensure that a minor is free from abuse, neglect, and exploitation at the center, as described in §550.903 of this division (relating to Abuse, Neglect, or Exploitation Reportable to HHSC );(2) inform the minor and a minor's parent of the center's policy for reporting abuse, neglect, or exploitation of a minor;(3) ensure that the minor and the minor's property is treated with respect;(4) at the time of admission, inform the adult minor or the minor's parent, orally and in a written statement, that a complaint or question about the center may be directed to the HHSC Complaint and Incident Intake Section, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858, or through the online portal;(5) at the time of admission, inform the adult minor or the minor's parent, orally and in a written statement, that:(A) states that complaints about services at the center may be directed to the administrator who will address them promptly;(B) provides the time frame in which a center must review and resolve the complaint as described in §550.904 of this division (relating to Investigations of a Complaint and Grievance); and(C) does not include a statement that a complaint must be made to the center administrator before directing a complaint to HHSC;(6) ensure that the minor is not subjected to unlawful discrimination or retaliation;(7) ensure that the minor is treated appropriate to the minor's age and developmental status;(8) ensure that the minor is allowed to interact with other minors, including through planned and spontaneous active play, respective to a minor's condition and physician orders;(9) ensure that the adult minor or the minor's parent are informed in advance about the services to be provided, including:(A) staff who will provide the services and the proposed frequency of each service; and(B) any change in the plan of care before the change is made, except when a delay based on notification would compromise the health and safety of the minor;(10) ensure that the adult minor or the minor's parent are informed of the expected outcomes of services and any specific limitations or barriers to services;(11) ensure that the adult minor or the minor's parent are allowed and encouraged to participate in planning services and in planning changes to services and that the adult minor or the minor's parent consented to the changes before the changes are made, except when a delay based on participation in planning or obtaining consent would compromise the immediate health and safety of the minor;(12) ensure that the adult minor or the minor's parent are informed of the center's policies on implementing an advance directive in accordance with §550.902 of this division (relating to Advance Directives) and to receive information about executing an advance directive;(13) ensure that the adult minor or the minor's parent are allowed to refuse services;(14) ensure that the minor's medical record is kept confidential and the adult minor or the minor's parent are informed of the center's policies and procedures regarding disclosure of medical records;(15) ensure that the adult minor or the minor's parent are informed, before care is provided, of the:(A) extent to which payment for the center's services may be expected from Medicaid, or any other federally funded or aided program known to the center, or any other third-party payment source;(B) charges for services not covered by a third-party payment source; and(C) charges that the adult minor or minor's parent may have to pay;(16) inform the adult minor or the minor's parent of any changes in the information provided in accordance with paragraph (15) of this subsection as soon as possible after changes occur, but no later than 30 days after the date the center becomes aware of the change;(17) inform the adult minor or the minor's parent of the availability of other programs, including day care, early intervention programs, or school; and(18) ensure that the adult minor or the minor's parent are allowed to convene or participate in a council or support group for individuals receiving services at the center. Source Note: The provisions of this §550.901 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.901 Rights and Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220999 03/12/2026 (a) A center must adopt and enforce a written policy regarding implementation of advance directives. The policy must be in compliance with the Advance Directives Act, THSC, Chapter 166. The policy must include a clear and precise statement of any procedure the center is unwilling or unable to provide or withhold in accordance with an advance directive.(b) A center must provide written notice to a minor's parent or an adult minor of the written policy required by subsection (a) of this section. The notice must be provided at the earlier of:(1) the time the minor is admitted to receive services at the center; or(2) the time service provision begins for the minor.(c) HHSC assesses an administrative penalty of $500 against a center that violates this section. Source Note: The provisions of this §550.902 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.902 Advance Directives https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221000 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse, neglect, and exploitation of a minor have the meanings assigned in THSC Chapter 260A.(2) Employee means an individual directly employed by a center, a contractor, or a volunteer.(b) HHSC investigates a complaint or an incident of abuse, neglect, or exploitation when the act occurs at a center, a center employee is responsible for the care of the minor at the time the act occurs, or the alleged perpetrator is associated with the center. A complaint of abuse, neglect, or exploitation that does not meet these criteria must be referred to the Department of Family and Protective Services.(c) A center must adopt and enforce a written policy relating to the center's procedures for preventing, detecting, and reporting alleged acts of abuse, neglect, and exploitation of a minor.(d) A center's employee who has cause to believe that the physical or mental health or welfare of a minor has been or may be adversely affected by abuse, neglect, or exploitation must report the information immediately:(1) to the HHSC Complaint and Incident Intake Section at 1-800-458-9858, ciicomplaints@hhs.texas.gov, or via the online portal;(2) to one of the following law enforcement agencies in accordance with THSC Chapter 260A:(A) a municipal law enforcement agency, if the center is located in the territorial boundaries of a municipality; or(B) the sheriff's department of the county in which the center is located if a center is not located in the territorial boundaries of a municipality; and(3) in accordance with Texas Family Code, §261.101.(e) The following information must be reported to HHSC:(1) name, age, and address of the alleged victim;(2) name and address of the person responsible for the care of the alleged victim;(3) nature of the alleged act;(4) nature and extent of the alleged victim's condition;(5) identity of the alleged perpetrator; and(6) any other relevant information.(f) A center must investigate allegations of abuse, neglect, or exploitation immediately and send a written report of the investigation using the HHSC Provider Investigation Report form to the HHSC Complaint Intake Unit no later than five days after the initial report.(g) A center must complete the HHSC Provider Investigation Report form and include the following information:(1) incident date;(2) the alleged victim;(3) the alleged perpetrator;(4) any witnesses;(5) the allegation;(6) any injury or adverse effect;(7) any assessments made;(8) any treatment required;(9) the investigation summary; and(10) any action taken.(h) A center must require an employee, as a condition of employment with a center, to sign a statement indicating that the employee may be criminally liable for the failure to report abuse, neglect, or exploitation.(i) A center must prominently and conspicuously post a readable sign for display in a public area accessible to minors, minors' parents, employees, and visitors that reads: "Cases of Suspected Abuse, Neglect, or Exploitation Shall be Reported to HHSC by calling 1-800-458-9858." Source Note: The provisions of this §550.903 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.903 Abuse, Neglect, or Exploitation Reportable to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221001 03/12/2026 (a) HHSC investigates a complaint of non-compliance with THSC Chapter 248A or this chapter regarding:(1) treatment or care that was furnished at a center;(2) treatment or care that a center failed to furnish; or(3) a lack of respect for a minor's property by anyone furnishing services at the center.(b) A center must adopt and enforce a written policy relating to the center's procedures for prompt investigation of complaints, grievances, and reports of abuse, neglect, and exploitation.(c) A center must:(1) acknowledge receipt of a complaint or grievance;(2) document receipt of a complaint or grievance;(3) initiate an investigation no later than 10 days after a center receives a complaint or grievance; and(4) document all components of an investigation.(d) A center must retain all investigation documentation for a minimum of three years from the date a complaint or grievance was received.(e) A center must not retaliate against a person for filing a complaint, presenting a grievance, or providing in good faith information relating to services provided by a center.(1) A center may not retaliate against a minor or a minor's parent for filing a complaint, presenting a grievance, or providing, in good faith, information relating to services provided at the center.(2) A center is not prohibited from terminating an employee for a reason other than retaliation.(f) A center must not discharge or otherwise retaliate against a minor or a minor's parent for presenting a complaint or grievance against a center. Source Note: The provisions of this §550.904 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.904 Investigations of a Complaint and Grievance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221002 03/12/2026 (a) A center must report to HHSC the death of a minor at the center and those minors transferred from the center to a hospital who expire within 24 hours after the transfer.(b) A center must submit to the HHSC Complaint and Incident Intake Section an HHSC Provider Investigation Incident Report form no later than 10 days after the date a minor dies. A center must complete the HHSC Provider Investigation Incident Report form and include the following information:(1) name of a deceased minor;(2) social security number of a deceased minor;(3) date, time, place of death; and(4) name and address of a center. Source Note: The provisions of this §550.905 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.905 Reporting of a Minor's Death https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220997 03/12/2026 (a) A center must make available to any person on request a copy of each HHSC written notification of the inspection results pertaining to the center.(b) Before making the inspection results available under this subsection, the center must redact from the report any information that is confidential under other state or federal law. Source Note: The provisions of this §550.906 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.906 Examination of Inspection Results https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221003 03/12/2026 (a) In accordance with accepted principles of practice, a center must establish and maintain a medical record system to ensure that the services provided to a minor are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.(b) A center must establish a medical record for a minor and must maintain the record in accordance with and contain the information described in subsection (g) of this section.(c) A center must keep a single file for services provided to a minor and a minor's parent.(d) A center must adopt and enforce written procedures regarding the use and removal of records, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the medical record.(e) A center may not release any portion of a minor's medical record to anyone other than the adult minor or the minor's parent, except as allowed by law.(f) A center must establish a secure area for original active medical record storage at the center's place of business.(1) A center must ensure that a minor's medical record is treated as confidential, safeguarded against loss and unofficial use, and maintained according to professional standards of practice.(2) A center must keep a minor's medical record in original form, as a microfilmed copy, on an electronic system, or as a certified copy.(3) A medical record in its original form is a signed paper record or an electronically signed computer record.(4) A center must ensure that electronic medical records meet the requirements of paper records, including protection from unofficial use as specified in subsection (f)(1) of this section.(5) A center must ensure that an entry to a medical record regarding the delivery of services is not altered without evidence and explanation of the alteration.(6) A center must ensure that an entry to a minor's medical record is current, accurate, legible, clear, complete, and appropriately authenticated and dated with the date of entry by the individual making the entry. The record must document all services provided on behalf of the center. The center must not use correction fluid or tape in the record. The center must make corrections by striking through the error with a single line and including the date the correction was made and the initials of the person making the correction.(7) A center must store the record of an inactive minor's medical record on paper, microfilm, or electronically. The center must secure the medical record and ensure that it is readily retrievable by the center staff.(g) Each medical record must include the following information as applicable to the services provided on behalf of a center:(1) a minor's referral and application for services including, but not limited to:(A) the minor's full name;(B) the minor's sex and date of birth;(C) the name, address, and telephone number of the minor's parent, or others as identified by the minor's parent;(D) the minor's prescribing physician's name and telephone numbers, and an emergency contact number; and(E) the minor's prescribing physician's initial order for services;(2) comprehensive assessments, pertinent medical history including allergies and special precautions, and subsequent assessments;(3) plans of care, nursing care plans, and other plans as applicable;(4) verbal orders of a physician reduced to writing and signed by the physician in accordance with the center's policy as required by §550.702 of this subchapter (relating to Receiving Physician Orders);(5) documentation of nutritional counseling and special diets, as appropriate;(6) clinical and progress notes from all professionals providing services to the minor;(7) documentation of all known services and significant events;(8) current medication list;(9) medication administration record, if medication is administered by center staff;(10) current immunization record;(11) written acknowledgment of the adult minor's or the minor's parent's receipt of written notification of the requirements of §550.901 of this subchapter (relating to Rights and Responsibilities);(12) written acknowledgment of the adult minor's or the minor's parent's receipt of a center's policy relating to the reporting of abuse, neglect, or exploitation of a minor;(13) written acknowledgement of the adult minor's or the minor's parent's receipt of the notice of advance directives;(14) written acknowledgement of the adult minor's or the minor's parent's receipt of the center's policies relating to discipline and guidance;(15) documentation demonstrating that the adult minor or the minor's parent have been informed of how to register a complaint in accordance with §550.901 of this subchapter;(16) discharge summary, including the reason for discharge or transfer and a center's documented notice to the adult minor, the minor's parent, the minor's prescribing physician, and other individuals as required in §550.608 of this subchapter (relating to Discharge or Transfer Notification);(17) services provided to the minor's parent; and(18) all consent and election forms, as applicable.(h) A center must ensure that clinical and progress notes are written the day service is rendered and incorporated into the medical record no later than two business days after the services are rendered.(i) A center must ensure the retention of the medical record for a minor meets the requirements in §550.1004 of this division (relating to Retention of Records). Source Note: The provisions of this §550.1001 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.1001 Medical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221004 03/12/2026 (a) A center must develop, implement, and maintain a written quality assessment and performance improvement (QAPI) program.(b) A center must designate in writing the group or individuals, by title, responsible for ensuring that a center's written QAPI program is developed, implemented, and maintained in accordance with this section.(c) The center must implement the QAPI program using a QAPI Committee. The QAPI committee must be composed of the following persons based on the services provided at the center during the time period under review by the QAPI:(1) the administrator;(2) the medical director;(3) the nursing director;(4) a therapist from each therapy that provided services during the review period (e.g., if physical therapy was provided during the quarter being reviewed, a physical therapist must be on the QAPI committee);(5) a social worker that provided services during the review period; and(6) a supervisor of the direct care staff.(d) The QAPI program must evaluate all services including:(1) monitoring activities that have an impact on health and safety of minors;(2) monitoring and evaluating the quality of services;(3) improving measurable outcomes for minors, if applicable;(4) resolving problems identified by a center and raised by parents and adult minors; and(5) ensuring a center's compliance with THSC Chapter 248A and this chapter.(e) The QAPI program must be ongoing. Ongoing means there is a continuous and periodic collection and assessment of measurable care provided to minors and administrative quality data.(f) The written QAPI program must include the frequency and detail of data collection.(g) A center must collect quality data at least quarterly for all services provided to a minor.(h) The QAPI program must include a system that measures the quality, effectiveness, and safety of services provided to minors and identifies opportunities and priorities for performance improvement.(i) The system of measures must allow the QAPI Committee to collect and analyze services provided to minors and administrative quality data. The measures must include a review and analysis of the following, as applicable to the services provided at the center and the problems a center identifies:(1) a representative sample of active and closed medical records;(2) negative care outcomes to minors or adverse events;(3) complaints and grievances;(4) self-reported incidents alleging abuse, neglect, or exploitation by the center employees, volunteers, or contractors;(5) minor's parent satisfaction surveys;(6) infection control activities;(7) incident reports, including reports of medication errors and unprofessional conduct by licensed staff;(8) the accuracy and completeness of center personnel records;(9) the implementation and effectiveness of center policies;(10) the effectiveness and safety of all services provided, including:(A) competency and qualifications of staff;(B) the promptness, safety, and quality of services provided to minors;(C) the center's response to complaints and reports of abuse, neglect, or exploitation; and(D) a determination that services are provided as outlined in each minor's plan of care; and(11) an annual review and evaluation of a center's total operation.(j) The QAPI Committee must meet quarterly or more often if needed to analyze the data collected and to use the data to improve services. A center must immediately correct identified problems that directly or potentially threaten health and safety of minors. The QAPI Committee must:(1) plan and document actions taken to correct identified problems, and if necessary, to revise center policies;(2) measure and document the outcome of the corrective action taken; and(3) monitor and document the level of improvement over time to ensure sustained improvements.(k) The QAPI Committee must review and update or revise the written QAPI program at least annually, or more often if needed.(l) The center must document the ongoing implementation and annual review of the written QAPI program.(m) The center must keep QAPI documents confidential and make the documents readily available to HHSC upon request. Source Note: The provisions of this §550.1002 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.1002 Quality Assessment and Performance Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221005 03/12/2026 (a) A center must adopt and enforce a written policy that describes the center's written contingency plan for dissolution.(b) A center must implement the dissolution plan in the event of dissolution to ensure continuity of a minor's care.(c) The plan must include procedures for a center to:(1) notify each minor actively receiving services and the minor's parent of a center's dissolution; and(2) transfer or discharge minors actively receiving services consistent with §550.608 of this subchapter (relating to Discharge or Transfer Notification). Source Note: The provisions of this §550.1003 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.1003 Dissolution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194837 03/12/2026 A center, including a center that permanently closes must adopt and enforce a written policy relating to the retention of records in accordance with this section.(1) A center must retain original medical records for a minor until a minor's twenty-fourth birthday or five years from the date of service, whichever is later.(2) The center may not destroy medical records that relate to any matter that is involved in litigation if a center knows the litigation has not been finally resolved. Source Note: The provisions of this §550.1004 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS C GENERAL PROVISIONS §550.1004 Retention of Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221007 03/12/2026 (a) A center must ensure transportation services are provided for a minor, as authorized by an adult minor or the minor's parent and the minor's prescribing physician:(1) from the minor's home to the center;(2) from the center to the minor's home; and(3) to and from the center for services coordinated by the center.(b) A minor's parent is not required to accompany the minor when the center transports or provides for the transport of the minor.(c) A center must ensure that vehicles are accessible for a minor with disabilities and equipped to meet the needs of a minor during transport.(d) A minor's parent may decline a center's transportation services.(e) A center must adopt and enforce written policies and procedures describing the staff and equipment that will accompany a minor during transportation. The staff must include a driver and a direct care staff member, or a nurse, if necessary, depending on the acuity of the minors and as determined in coordination with the prescribing physician.(f) A center must ensure that:(1) a person transporting a minor on behalf of a center has a valid and appropriate Texas driver's license, a copy of which the center must keep on file;(2) a vehicle used to transport a minor has a current Texas safety inspection sticker and vehicle registration decal properly affixed to a vehicle;(3) the center maintains commercial insurance for the operation of a center's vehicles, including coverage for minors and staff in a center's vehicle in the event of accident or injury;(4) documentation of the insurance is maintained and includes:(A) the name of the insurance company;(B) the insurance policy number;(C) the period of coverage; and(D) an explanation of the coverage;(5) the center provides a driver and the center's staff riding in the vehicle with an up-to-date master transportation list that includes a minor's name, pick up and drop off locations, and authorized persons to whom a minor may be released;(6) the master transportation list is on file at the center;(7) the driver and the center's staff riding in the vehicle maintain a daily attendance record for each trip that includes the driver's name, the date, names of all passengers in the vehicle, the name of the person to whom a minor was released, and the time of release; and(8) the number of people in a vehicle used to transport minors does not exceed the manufacturer's recommended capacity for the vehicle. Source Note: The provisions of this §550.1101 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective September 28, 2016, 41 TexReg 7512; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS D TRANSPORTATION §550.1101 Transportation Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221006 03/12/2026 (a) A center must adopt and enforce written policies and procedures to ensure the care and safety of minors during transport.(b) A center must appropriately train staff on the needs of a minor being transported.(c) A center must properly restrain or secure a minor when the minor is transported by the center in a motor vehicle, in accordance with applicable federal motor vehicle safety standards, state law, THSC Chapter 248A, and this chapter.(d) A center must ensure that:(1) a minor boards and leaves the vehicle from the curbside of the street and is safely accompanied to the minor's destination;(2) there is a first aid kit with unexpired supplies, including oxygen, a pulse oximeter, and suction equipment in each center vehicle;(3) the center prohibits the use of tobacco in any form, electronic cigarettes, alcohol, possession of illegal substances or unauthorized potentially toxic substances, firearms, and pellet or BB guns, including loaded or unloaded BB guns, in any vehicle;(4) the driver does not use a hand-held wireless communication device while operating a center vehicle;(5) staff accompany a minor during transportation as described in §550.1101(e) of this subchapter (relating to Transportation Services) and paragraph (6) of this subsection;(6) at least one direct care staff member, or more depending on the acuity of the minors, accompanies every seven minors;(7) the driver or center's staff riding in the vehicle does not leave a minor unattended in the vehicle at any time;(8) the driver or the center's staff riding in the vehicle inspects the vehicle at the completion of each trip to ensure that no minor is left in the vehicle; and(9) the center maintains documentation that includes the signature of the individual conducting the inspection described in paragraph (8) of this subsection and the time of inspection.(e) A center must post near the emergency exit of each vehicle that transports a minor the following information in an easily readable font:(1) the name of the administrator;(2) the center's name;(3) the center's telephone number; and(4) the center's address.(f) The center must adopt and enforce a policy on emergencies while transporting a minor. The policy must include:(1) procedures for mechanical break downs;(2) procedures for vehicle accidents; and(3) procedures for a minor's emergency.(g) If a center conducts a field trip, the center must ensure that the driver or center's staff riding in the vehicle inspect the vehicle and account for each minor upon arrival and departure from each destination to ensure that no minor is left in the vehicle after reaching the vehicle's final destination.(1) A center must ensure that the driver or center's staff riding in the vehicle maintains a field trip record for each trip. The record must include the driver's name, the staff's name, the time and date, the vehicle's destinations, and names of all passengers in the vehicle.(2) A center must maintain documentation that includes the signature of the person conducting the inspection and the time of each inspection during the field trip.(3) Appropriate staff must be present when a minor is delivered to the center. Source Note: The provisions of this §550.1102 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective March 20, 2023, 48 TexReg 1564; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS D TRANSPORTATION §550.1102 Transportation Safety Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194840 03/12/2026 The standards in this subchapter apply to:(1) a newly constructed center;(2) alterations, additions, or renovations to an existing center;(3) an existing building renovated to create a center; and(4) a center's maintenance. Source Note: The provisions of this §550.1201 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1201 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221008 03/12/2026 (a) Plans for new buildings, additions, conversions of buildings not licensed by HHSC, and the remodeling of existing licensed facilities must be submitted to HHSC for review. No later than 30 days after receipt of the plans, HHSC informs an applicant in writing of the results of the review.(b) If the submitted plans comply with HHSC architectural requirements, HHSC may not subsequently change the architectural requirement that applies to the project unless the change is required by federal law or an applicant fails to complete the project no later than two years after submitting the plans to HHSC.(c) HHSC may grant a waiver of the two-year period for delays due to unusual circumstances.(d) HHSC may impose a deadline for completing a project using requirements that are revised after the project was reviewed.(e) Submittal of plans.(1) One copy of contract documents must be submitted to HHSC before construction begins. The documents must:(A) include working drawing and specifications;(B) have sufficient detail for HHSC to interpret compliance with this chapter and for a general contractor or builder to ensure proper construction; and(C) be prepared according to accepted architectural practice and include general construction, special conditions, and schedules.(2) Final copies of plans must be submitted to HHSC and include:(A) a title block that shows the name of the center;(B) the person or organization preparing the sheet;(C) sheet numbers;(D) the center's address; and(E) the drawing date.(3) Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a professional engineer licensed by the Texas Board of Professional Engineers.(4) The contract documents for additions, remodeling, and construction of a new center must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect.(5) A final plan for a major addition to a center must be submitted to HHSC and include a basic layout to scale of the entire building into which the addition will connect. North direction must be shown. The entire basic layout must be scaled to fit on a single 8 1/2-inch by 11-inch sheet.(6) Final plans and specifications for conversions or remodeling must be submitted to HHSC and include all parts and features involved.(7) Qualified staff must be employed to prepare the contract documents for construction. If the contract documents have errors or omissions to the extent that compliance with this chapter cannot be reasonably ensured or determined, HHSC may request a revised set of documents for review.(8) HHSC review of the plans and specifications is based on general utility and compliance with this chapter and the Life Safety Code. HHSC review is not an all-inclusive review of the structural, electrical, or mechanical components of a center. HHSC review does not include a review of building plans for compliance with the Texas Accessibility Standards as administered and enforced by the Texas Department of Licensing and Regulation.(9) Plan review fees must be submitted in accordance with §550.113 of this chapter (relating to Plan Review Fees).(f) Contract documents.(1) Site plan documents must be submitted to HHSC and include:(A) grade contours;(B) streets with names;(C) north arrow;(D) fire hydrants;(E) fire lanes;(F) public or private utilities;(G) fences; and(H) unusual site conditions, including:(i) ditches;(ii) low water levels;(iii) other buildings on-site; and(iv) indications of buildings five feet or less beyond site property lines.(2) Foundation plan documents must be submitted to HHSC and include general foundation design and details.(3) Floor plan documents must be submitted to HHSC and include:(A) room names, numbers, and usages;(B) numbered doors, including swing;(C) windows;(D) legend or clarification of wall types that include:(i) dimensions;(ii) fixed equipment;(iii) plumbing fixtures;(iv) basic layout of the food preparation area; and(v) identification of all smoke barrier walls from outside wall to outside wall or fire walls.(4) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building drawn or reduced to fit on a single 8 1/2-inch by 11-inch sheet must be submitted to HHSC.(5) Schedules must be submitted to HHSC and include:(A) door materials, widths, and types;(B) window materials, sizes, and types;(C) room finishes; and(D) special hardware.(6) Elevations and roof plans must be submitted to HHSC. Plans must include exterior elevations, including:(A) material note indications;(B) rooftop equipment;(C) roof slopes;(D) drains;(E) gas piping; and(F) interior elevations where needed for special conditions.(7) Contract document details must be submitted to HHSC and include:(A) wall sections as needed, especially for special conditions;(B) cabinet and built-in work, basic design only;(C) cross sections through buildings as needed; and(D) miscellaneous details and enlargements as needed.(8) Building structure documents must be submitted to HHSC and include:(A) structural framing layout and details used primarily for column, beam, joist, and structural building;(B) roof framing layout if it cannot be adequately shown on a cross section; and(C) cross sections in quantity and detail to show sufficient structural design and structural details as necessary to ensure adequate structural design and calculated design loads.(9) Electrical documents must be submitted to HHSC and include:(A) electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices;(B) service, circuiting, distribution, and panel diagrams;(C) exit light systems with exit signs and emergency egress lighting;(D) emergency electrical provisions, including generators and panels;(E) staff communication systems;(F) fire alarm and similar systems, including control panel, devices, and alarms; and(G) sizes and details sufficient to ensure safe and properly operating systems.(10) Plumbing documents must be submitted to HHSC and include:(A) plumbing layout with pipe sizes and details sufficient to ensure safe and properly operating systems;(B) water systems;(C) sanitary systems;(D) gas systems; and(E) other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(11) Heating, ventilation, and air-conditioning (HVAC) systems documents must be submitted to HHSC and include:(A) sufficient details of HVAC systems and components to ensure a safe and properly operating installation, including heating, ventilation, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke and fire dampers; and(B) equipment types, sizes, and locations.(12) Sprinkler system documents must be submitted to HHSC and include:(A) plans and details of National Fire Protection Association (NFPA) designed systems to meet the requirements of NFPA 13, Standard for the Installation of Sprinklers;(B) plans and details of partial systems provided only for hazardous areas; and(C) electrical devices interconnected to the alarm system.(13) Specifications must be submitted to HHSC that include:(A) installation techniques;(B) quality standards and manufacturers;(C) references to specific codes and standards;(D) design criteria;(E) special equipment;(F) hardware;(G) finishes; and(H) other specifications as needed to amplify drawings and notes.(14) Other layouts, plans or details must be submitted to HHSC as necessary for HHSC to obtain a clear understanding of the design and scope of the project. Plans covering private water or sewer systems that have been reviewed by the health or wastewater authority having appropriate jurisdiction must be submitted to HHSC.(g) Construction phase.(1) The HHSC Architectural Unit must be notified in writing before beginning construction of a new center or the remodeling of an existing center.(2) HHSC requires additional drawings if construction of the center is not performed in accordance with the completed plans and specifications as submitted to HHSC for review or as modified in accordance with HHSC review requirements, if the change is significant.(h) Initial inspection of completed construction.(1) After completion of construction, including grounds and basic equipment and furnishings, HHSC performs an initial architectural inspection of the center before the center admits a minor. HHSC schedules an initial architectural inspection after HHSC receives a licensure application, required fees, fire marshal approval, approval of local building authority, and a letter from an architect or engineer stating that, to the best of the architect or engineer's knowledge, the center meets the building requirements for licensure.(2) If HHSC Life Safety Code staff inspect the completed construction and find it in compliance with this chapter, the HHSC Architectural Unit forwards the information to the HHSC Licensing and Credentialing Unit as part of an applicant's license application. For additions to or remodeling of an existing center, HHSC may require an applicant to submit a revision or modification to an existing license. The building, including basic furnishings and operational needs, grades, drives, and parking, must be 100 percent complete at the time of the HHSC initial architectural inspection. A center may admit at least one but no more than three minors after it receives initial approval from HHSC but before a license is issued.(3) An applicant must make the following documents related to the completed building available to the HHSC architectural inspection surveyor at the time of the inspection:(A) written approval of the local authorities as required in paragraph (1) of this subsection;(B) for fire detection and alarm systems:(i) record drawings of the fire detection and alarm system as installed, signed by an alarm planning superintendent licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer;(ii) a sequence of operation, the owner's manuals and the manufacturer's published instructions covering all system equipment;(iii) a signed copy of the State Fire Marshal's Office Fire Alarm Installation Certificate; and(iv) for software-based systems, a record copy of the site-specific software, excluding the system executive software or external programmer software in non-volatile, non-erasable, non-rewritable memory;(C) documentation of materials used in the building that are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant rated ceilings and curtains, including cubicle curtains;(D) for carpeting that is required to have a specific limited fire or flame spread rating, a signed letter from the installer verifying that the carpeting installed is named in the laboratory test document; and(E) for fire sprinkler systems:(i) record drawings of the fire sprinkler system as installed, signed by a responsible managing employee, licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer;(ii) the hydraulic calculations;(iii) the alarm configuration;(iv) above ground and underground Contractor's Material and Test Certificate;(v) the literature and instructions provided by the manufacturer describing the proper operation and maintenance of all equipment and devices in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;(vi) service contracts for maintenance and testing of alarm systems and sprinkler systems;(vii) a copy of gas test results of the center's gas lines from the meter;(viii) a written statement from an architect or engineer stating, to the best of the architect or engineer's knowledge, the building was constructed in substantial compliance with the construction documents, the Life Safety Code, this chapter, and local codes; and(ix) any other such documentation as needed.(i) Non-approval of new construction.(1) If, during the initial on-site architectural inspection of completed construction, the HHSC Life Safety Code surveyor finds certain basic requirements are not met, the surveyor may recommend that the center not be licensed or approved for occupancy. Items that may result in this recommendation include:(A) substantial changes made during construction that were not submitted to HHSC for review and that may require revised "as-built" drawings to include the changes, including architectural, structural, mechanical, and electrical items as specified in this section;(B) construction that does not meet minimum code or licensure standards, including corridors that are less than the required width, ceilings installed at less than the minimum seven-foot, six-inch height, and other features that would disrupt or otherwise adversely affect minors and staff if corrected after occupancy;(C) lack of written approval by appropriate local authorities;(D) fire protection systems, including fire alarm systems, emergency power and lighting, and sprinkler systems, that are not completely installed or functioning properly;(E) required exits that not all usable according to NFPA 101 requirements;(F) telephones that are not installed or not working properly;(G) sufficient basic furnishings, essential appliances, and equipment that are not installed or functioning; and(H) other basic operational or safety feature that would preclude safe and normal occupancy by a minor on that day.(2) An applicant must submit copies of reduced-size floor plans on an 8 1/2-inch by 11-inch sheet, in duplicate, to HHSC for records and for the center's use for an evacuation plan, or fire alarm zone identification. The plan must contain basic legible information including scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information. Source Note: The provisions of this §550.1202 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1202 Plan Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221009 03/12/2026 (a) A center must be designed in accordance with:(1) the Health Care Occupancy chapter of the 2000 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code for newly constructed centers or centers converting an existing unlicensed building to a center; and(2) the requirements of Limited Care, as defined by NFPA 101.(b) An applicant for a center license must submit to HHSC site approval by the local building department and fire marshal having appropriate jurisdiction.(c) An applicant for a center license must meet applicable local, state, or national codes and ordinances as determined by the authority having appropriate jurisdiction for those codes and ordinances and by HHSC.(d) A center must meet the requirements of the International Plumbing Code or Uniform Plumbing Code, as adopted by the local municipality.(e) If conflicting codes apply to the construction of the center, the more stringent codes apply.(f) A center may not be built in an area designated as a floodplain of 100 years or less.(g) A center must comply with the accessibility requirements for individuals with disabilities as referenced in the revised regulations for Title II and III (2010 ADA Standards for Accessible Design) of the Americans with Disabilities Act of 1990 at Title 42, United States Code, Chapter 126; federal regulations at 28 Code of Federal Regulations Code of Federal Regulations, Part 35 and Part 36; Texas Accessibility Standards at Texas Government Code, Chapter 469; and Texas Department of Licensing and Regulation rules at 16 Texas Administrative Code Chapter 68 (relating to Elimination of Architectural Barriers). Source Note: The provisions of this §550.1203 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1203 Design Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221010 03/12/2026 (a) A center's construction type is limited to the building construction shown in the minimum construction requirements in the Life Safety Code chapter for New Health Care Occupancies.(b) A center must have a National Fire Protection Association (NFPA) 72 fire alarm system with initiation, notification, emergency forces notification, annunciation, emergency control and detection in accordance with the Life Safety Code. The center must have a written contract with a fire alarm firm that has been issued an Alarm Certificate of Registration number from the Texas State Fire Marshal's Office to inspect, test and maintain a fire alarm system to meet NFPA 72 requirements, semiannually. Inspections required in the contract must be performed. The person performing the semiannual service must have an individual fire alarm license from the Texas State Fire Marshal's Office.(c) A center must be protected throughout by an approved, supervised automatic sprinkler system installed in accordance with NFPA 13. The center must ensure that the sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The center must have a written contract with a fire protection sprinkler firm that has been issued a Sprinkler Certificate of Registration number from the Texas State Fire Marshal's Office to perform the required services, semiannually. The center must document and show to HHSC that all the requirements of NFPA 25 are met including the annual inspection, test, and maintenance performed by the registered fire sprinkler firm. The center must retain one set of the fire sprinkler system plans and hydraulic calculations on the property.(d) A center must distribute portable fire extinguishers throughout the center of size and type in accordance with NFPA 10.(e) A center must provide emergency power for emergency lighting, exit signs, and the fire alarm by a generator.(f) A center must ensure that the design, installation, and maintenance of emergency motor generators are in accordance with NFPA 37, NFPA 99, and NFPA 110.(g) A center must ensure that the generator is of sufficient size to maintain Life Safety Code requirements, medical equipment, and heating, ventilation, and air-conditioning systems to operate in designated core areas of the center in the event of power failure.(h) The center must ensure that emergency powered receptacles are used:(1) for a patient care-related electrical appliance, including a biological refrigerator;(2) at a nurse station; and(3) in a medication room.(i) The center must store and administer oxygen in accordance with NFPA 99. Source Note: The provisions of this §550.1204 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1204 Fire Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194844 03/12/2026 (a) A center must be physically and programmatically distinct from any business to which it is attached or of which it is a part.(b) If more than one business occupies the same building or physical location, the center must have its own entrance.(c) A center must be separated from other occupancies with construction having a fire resistance rating of not less than 2 hours.(d) A center's separate entrance must not be accessed solely through another business or health care provider.(e) A center's separate entrance must have appropriate signage and be clearly identified as belonging to the center.(f) A licensed center's space must be contiguous.(g) If a center has more than one building, the center must provide protection from inclement weather to minors, staff, contractors, volunteers and visitors who travel between the buildings. Source Note: The provisions of this §550.1205 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1205 Distinct Part Facilities and Physical and Programmatic Separation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221011 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221011 03/12/2026 (a) A center must have separate entrances for guests and minors.(b) A center must have a covered entry with a covered drop-off for family, emergency medical services (EMS), and the center's vehicles.(c) A center's roof overhang or canopy must extend as far as practicable to the face of the driveway or curb of the passenger access door of a passenger vehicle.(d) A center's roof overhang or cover must be of sufficient height to allow entry or departure from EMS vehicles.(e) A center must provide for an outdoor play space with a direct exit from the center into the outdoor play space. The outdoor play space should at least be 400 square feet in area with at least 20 percent of that area shaded.(f) A center's play yard must meet the requirements of the Texas Accessibility Standards.(g) A center must ensure that its structures and the grounds of the center that are used by minors are maintained in good repair and are free from hazards to health and safety.(h) A center must fence or ensure natural barriers are present to protect a minor from areas determined to be unsafe by HHSC, including steep grades, cliffs, open pits, swimming pools, high voltage boosters, high voltage equipment, and high speed roads.(i) A center must keep fences in good repair.(j) A center must store garbage, rubbish, and trash securely in outdoor, covered containers.(k) A center must keep trash collection receptacles and incinerators separated from outdoor recreational spaces and locate the receptacles and incinerators in a place to avoid being a nuisance. Source Note: The provisions of this §550.1206 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1206 Exterior Spaces https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221012 03/12/2026 (a) A center must consist of a building suitable for the purpose intended, and have a minimum of 50 square feet of space per minor exclusive of kitchen, toilet facilities, storage areas, hallways, stairways, basements, and attics.(b) If a center uses a room exclusively for dining or sleeping, the center must not count that space as part of the licensed capacity.(c) A center must have sufficient rooms to accommodate and segregate the different age groups of minors being served at the center.(d) A center must provide staff area and staff toilets.(e) A center must provide a reception area.(f) A center must provide an administrative office.(g) A center must provide quiet rooms based on the needs of minors.(h) A center's quiet room must contain a minimum of 100 square feet.(i) A center must provide indoor recreational exercise play area.(j) A center must provide a treatment room with a medication preparation area. The medication preparation area must contain a work counter, refrigerator, sink with hot and cold water, and locked storage for biologicals and drugs.(k) A center must develop isolation procedures to prevent cross-infection and provide an isolation room with at least one large glass area for observation of a minor in accordance with §550.211 of this chapter (relating to Infection Prevention and Control Program and Vaccination Requirements). The isolation room must contain a minimum of 100 square feet.(l) The center must make privacy accommodations available to attend to the personal care needs of a minor. Source Note: The provisions of this §550.1207 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1207 Interior Spaces https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213130 03/12/2026 A center must have a food preparation area designated for the preparation of meals, snacks, or prescribed nourishments. The meals, snacks, and nourishments must be maintained in accordance with state and local sanitation and safe food handling standards. If the center has a kitchen for cooking meals, or for providing meals and snacks directly or under contract, the center must be in compliance with Texas Department of State Health Services rules in 25 Texas Administrative Code Chapter 228 (relating to Retail Food Establishments). The center must also be in compliance with local health ordinances or requirements in the storage, preparation, and distribution of food; sanitation of dishes, equipment, and work area; and in the storage and disposal of waste. Source Note: The provisions of this §550.1208 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective March 20, 2023, 48 TexReg 1564. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1208 Food Preparation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194848 03/12/2026 (a) A center must provide toileting facilities appropriately accessible to persons with disabilities and age appropriate in design with hand-washing stations.(b) A center must have separate toilet facilities for minors, staff, and visitors.(c) A center must install a hand-washing station in each play area, classroom, and therapy room or area. Source Note: The provisions of this §550.1209 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1209 Toileting Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194849 03/12/2026 (a) A center must have a secure, individually labeled space available for each minor's personal belongings.(b) A center must provide locked storage for a minor's personal possessions as needed. Source Note: The provisions of this §550.1210 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1210 Minor's Personal Belongings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221013 03/12/2026 (a) A center must have a mechanical forced air exhaust system to the outside for soiled linen areas in accordance with §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens).(b) A center must have separate storage areas for clean and soiled linen in accordance with §550.210 of this chapter. Source Note: The provisions of this §550.1211 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1211 Linen Storage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194851 03/12/2026 (a) A center must have a secure room for the safe storage of janitorial supplies and equipment, poisonous materials, and toxic materials.(b) A center must label and identify poisonous and toxic substances and place them in locked cabinets that are used for no other purpose.(c) A center must provide a janitor's closet with mechanical forced air exhaust to the outside.(d) A center must install child proof latches onto closet and cabinet doors that are accessible to a minor. Source Note: The provisions of this §550.1212 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1212 Janitorial Supplies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194852 03/12/2026 A center must secure and lock any area the center determines is unsafe for a minor or minor's family. The center's door locking arrangement must meet Life Safety Code egress requirements from inside the room. An unsafe area includes high voltage areas and equipment rooms. Source Note: The provisions of this §550.1213 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1213 Locked Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194853 03/12/2026 A center must have an area for the safe and secure maintenance and storage of medical records and other center files, records, and manuals. If these areas are deemed hazardous storage in accordance with the Life Safety Code, the center must have rated doors with closers. Source Note: The provisions of this §550.1214 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1214 File Storage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221014 03/12/2026 (a) A center must store garbage, rubbish, and trash in an area separate from the areas used for the preparation and storage of food. A center must remove garbage, trash, and rubbish from the premises and sanitize the containers regularly.(b) A center must meet the sanitation requirements in §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens). Source Note: The provisions of this §550.1215 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1215 Garbage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194855 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194855 03/12/2026 (a) A center must secure clean storage areas for equipment, devices, and supplies including equipment supplied by the center for a minor's needs, including a wheelchair, a bed, and a mattress.(b) A center must maintain an age appropriate and developmentally appropriate environment in each of the areas where services are provided to a minor. Source Note: The provisions of this §550.1216 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1216 Furnishings and Equipment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221015 03/12/2026 (a) A center must have a supply of clean linen sufficient to meet the needs of a minor. Clean laundry must be provided by:(1) an in-house laundry service;(2) contract with another health care center; or(3) an outside commercial laundry service.(b) A center must handle, store, process, and transport laundry in a manner to prevent the spread of infection in accordance with §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens). Source Note: The provisions of this §550.1217 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1217 Laundry https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221016 03/12/2026 (a) A center must:(1) maintain a clean and safe environment;(2) be free of unpleasant odors; and(3) eliminate odors at the center at their source by prompt and thorough cleaning of commodes, urinals, bedpans, and other sources.(b) A center must meet the housekeeping requirements in §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens). Source Note: The provisions of this §550.1218 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1218 Housekeeping https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221017 03/12/2026 (a) A center must:(1) ensure that the grounds and the exterior of the building, including the sidewalks, steps, porches, ramps, and fences are in good repair;(2) keep equipment supplied by the center for a minor's needs in good repair, including wheelchairs, cribs, and mattresses;(3) keep the interior of the building including walls, ceilings, floors, windows, window coverings, doors, plumbing, and electrical fixtures in good repair; and(4) use pest control services provided by a licensed structural pest control applicator with a license category for pests.(b) A center must meet the requirements in §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens). Source Note: The provisions of this §550.1219 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1219 Maintenance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221018 03/12/2026 (a) A center must use a safe heating, ventilation, and air conditioning (HVAC) system that meets the requirements of the National Fire Protection Association (NFPA) 90A and is sufficient to maintain a comfortable temperature, with a minimum of 65 degrees and a maximum of 80 degrees Fahrenheit, in all public and private areas year round.(b) A center must ensure that during warm weather conditions, the temperature within the center does not exceed 80 degrees Fahrenheit. The center must ensure that the HVAC system operates in designated core areas of the center in the event of power failure.(c) A center must maintain the HVAC system in good repair.(d) A center must inspect gas-fired heating equipment before the cold weather season to ensure that the equipment operates properly and safely. The center must ensure that gas-fired heating equipment is inspected by a person licensed or approved by the State of Texas to inspect the equipment.(e) The center must maintain a record of the inspection conducted in accordance with subsection (d) of this section.(f) A center must correct any unsatisfactory condition or evacuate or relocate the minors.(g) A center must ensure that a gas heating unit and water heater are vented in accordance with NFPA 54 to carry the products of combustion to the outside atmosphere. The center must ensure that a vent is constructed and maintained to provide a continuous draft to the outside atmosphere in accordance with NFPA 54. The center must ensure that a heating unit is provided with a sufficient supply of outside combustion air in accordance with NFPA 54. A center must not use a portable heater within the center. Source Note: The provisions of this §550.1220 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1220 Heating, Ventilation, and Air Conditioning Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194860 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194860 03/12/2026 (a) A center must maintain an adequate supply of water, under pressure at all times. When a public water system is available, the center must ensure it is connected to the public water system. If the center uses water from a source other than a public water supply, the center must ensure that the water supply meets the rules issued by the Texas Commission on Environmental Quality.(b) A center must have a plan and policy for an alternative water supply in the event of interruption of water supply and the temporary loss of water to the center. Source Note: The provisions of this §550.1221 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1221 Water Supply https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221019 03/12/2026 A center must ensure that sewage is disposed of by a public system or an approved sewage disposal system constructed and operated to conform with the standards established for systems by the Texas Commission on Environmental Quality and in accordance with sanitation requirements in §550.210 of this chapter (relating to Sanitation, Housekeeping, and Linens). Source Note: The provisions of this §550.1222 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1222 Sewage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194862 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194862 03/12/2026 A center's address and name must be displayed so as to be easily visible from the street. Source Note: The provisions of this §550.1223 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1223 Signage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221020 03/12/2026 (a) HHSC may grant a waiver for certain provisions of the physical plant and environment requirements of HHSC licensure standards, which, in HHSC opinion, would be impractical for a center to meet. In granting the waiver, HHSC, on a case by case basis, determines if:(1) there are adverse effects on the health and safety of a minor if the center does not meet the licensure requirement; and(2) the center will experience an unreasonable hardship if the requirement is not waived.(b) HHSC may require a center to offset or comply with an equivalent provision if HHSC grants a waiver. A center must demonstrate an equivalent safety feature by utilizing the National Fire Protection Association 101A, Guide on Alternative Approaches to Life Safety, for waivers of the Life Safety Code.(c) An HHSC waiver is not transferable in a change of ownership and is subject to HHSC review or revocation upon any change in circumstances at the center. Source Note: The provisions of this §550.1224 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS E BUILDING REQUIREMENTS §550.1224 Waivers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221025 03/12/2026 (a) HHSC performs inspections, follow-up visits, compliance investigations, investigations of abuse, neglect and exploitation, and other contact visits at a center as deemed appropriate or as required to determine a center's compliance with this chapter.(b) An inspection may be conducted by an inspector or by a team depending on the purpose of the inspection, size of a center, and other factors.(c) HHSC does not announce inspections or visits.(d) HHSC conducts at least one unannounced licensing inspection annually after issuance of a license.(e) HHSC may visit a center for purposes other than the reasons described in subsection (a) of this section.(1) HHSC may visit a center to consult with a center's staff to determine how a center's physical space may be expanded or upgraded or determine the progress of a center's construction or repairs, equipment installation or repairs, systems installation or repairs, or when conditions or emergencies arise, including fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.(2) HHSC may announce visits that are not for a purpose described in subsection (a) of this section. Source Note: The provisions of this §550.1301 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS F INSPECTIONS AND VISITS §550.1301 Inspections and Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221021 03/12/2026 (a) HHSC investigates complaints of abuse, neglect, or exploitation if:(1) the act occurs at the center;(2) the center is responsible for the supervision of a minor at the time the act occurs;(3) the alleged perpetrator is associated with the center; or(4) the alleged perpetrator is present at the center.(b) HHSC refers complaints of abuse, neglect, or exploitation not meeting the criteria in subsection (a) of this section to the Department of Family and Protective Services.(c) HHSC conducts an investigation under this section in accordance with THSC §260A.007.(d) A center's investigation of complaints and self-reported incidents does not preclude HHSC from taking action in accordance with Subchapter G of this chapter (relating to Enforcement).(e) HHSC notifies the following individuals of the results of an HHSC investigation:(1) the individual who reported the allegation or complaint;(2) an adult minor;(3) a minor's parent;(4) any person designated by an adult minor or minor's parent to receive information concerning a minor; and(5) a center. Source Note: The provisions of this §550.1302 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective September 28, 2016, 41 TexReg 7512; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS F INSPECTIONS AND VISITS §550.1302 Investigation of Complaints and Self-Reported Incidents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221022 03/12/2026 (a) By applying for and holding a license, a license holder consents to entry or inspection of the center's premises by an HHSC representative to verify compliance with THSC Chapter 248A and this chapter.(b) A center must make all of its books, records, and other documents maintained by or on behalf of a center accessible to HHSC upon request.(1) HHSC is authorized to photocopy documents, photograph minors, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection or investigation that HHSC reasonably believes threaten the health and safety of a minor.(2) HHSC may request, photocopy, and otherwise reproduce records and documents including admission sheets, medication records, observation notes, medical records, clinical notes, and any other of a center's documents.(3) HHSC protects the copies for privacy and confidentially purposes in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.(c) During an inspection or investigation, a center's representative and staff must not:(1) make a false statement that a person knows or should know is false of a material fact about a matter under investigation by HHSC;(2) willfully interfere with the work of an HHSC representative;(3) willfully interfere with an HHSC representative in preserving evidence of a violation; or(4) refuse to allow an HHSC representative to inspect a book, record, or file required to be maintained by or on behalf of a center.(d) HHSC may assess an administrative penalty for a violation of provisions in this section, or may take other enforcement action to deny, revoke, or suspend a license, if a center does not cooperate with an inspection.(e) In order to preserve the integrity of the inspection and investigation process, a center must:(1) not record, listen to, or eavesdrop on any HHSC interview with center staff or minors that the center staff knows HHSC intends to keep confidential, as evidenced by HHSC taking reasonable measures to prevent from being overheard; or(2) not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of center staff when HHSC has requested a private room or office or distanced themselves from center staff, unless the center obtains HHSC written approval before beginning to record or listen to the discussion.(f) A center must inform HHSC when security cameras or other existing recording devices in the center are in operation during any internal discussion by or among HHSC staff.(g) When HHSC permits center staff by words or actions to be present, an interview or conversation for which center staff are present does not constitute a violation of this rule.(h) This section does not prohibit a minor or a minor's parents from recording an HHSC interview with the minor. Source Note: The provisions of this §550.1303 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS F INSPECTIONS AND VISITS §550.1303 Cooperation with an Inspection and Visit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221023 03/12/2026 (a) The center's administrator, alternate administrator, nursing director, or alternate nursing director must be present in person at the entrance and exit conferences of every HHSC inspection or visit and be available in person during the inspection.(b) If a required individual is not at the center when the inspector arrives and is unavailable during the inspection, the inspector will make reasonable attempts to contact the individual.(c) If an inspector arrives during regular business hours and the center is closed, an administrator, alternate administrator, nursing director, or alternate nursing director must provide the inspector entry to the center no later than two hours after the inspector's arrival at the center. The center must comply with the notice requirements described in §550.201 of this chapter (relating to Operating Hours). Source Note: The provisions of this §550.1304 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS F INSPECTIONS AND VISITS §550.1304 Staff Requirements for an Inspection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221024 03/12/2026 (a) HHSC determines if a center meets the requirements of THSC Chapter 248A and this chapter.(b) After an inspection is completed, the inspector holds an exit conference to inform a center of the preliminary findings.(c) A center may submit additional written documentation and facts after the exit conference only if the center describes the additional documentation and facts to the inspector during the exit conference.(1) A center must submit the additional written documentation and facts to the HHSC inspector or inspection team no later than two business days after the end of the exit conference.(2) If a center properly submits additional written documentation, the inspector may add the documentation to the record of the inspection.(d) HHSC provides a written notification of the inspection results to the center no later than 10 business days after the exit conference. The written notification includes a statement of violations and instructions for submitting an acceptable plan of correction and provides an opportunity for an informal dispute resolution (IDR).(e) If a center receives HHSC written notification of the inspection results indicating that the center is in violation of THSC Chapter 248A or this chapter, the center must follow HHSC instructions included with the notification for submitting an acceptable plan of correction.(f) If required, a center must submit an acceptable plan of correction that includes the corrective measures and time frame in which the center will comply to ensure correction of a violation. If a center fails to correct each violation by the date on the plan of correction, HHSC may take enforcement action against the center.(g) A center must submit an acceptable plan of correction for each violation no later than 10 calendar days after receipt of the written notification of the inspection results. An acceptable plan of correction must address:(1) how the center will accomplish corrective action for the minors affected by the violation;(2) how the center will identify other minors with the potential to be affected by the same violation;(3) the measures that the center will incorporate, or systemic changes the center made to ensure the violation will not recur;(4) how the center will monitor its corrective actions to ensure that the violation is corrected and will not recur; and(5) dates when the center's corrective action will be completed.(h) A center's acceptable plan of correction does not preclude HHSC from taking enforcement action against the center in accordance with Subchapter G of this chapter (relating to Enforcement).(i) A center must submit a plan of correction in response to the written notification of inspection results that specifies a violation even if the center disagrees with the inspection results.(j) If a center disagrees with the inspection results, the center may request an IDR. The center must submit a written request and all supporting documentation to HHSC no later than the 10th calendar day after the date the center receives HHSC statement of violations.(k) A center waives its right to an IDR if the center fails to submit the required information to the HHSC Regulatory Services, Survey and Certification Enforcement Unit, within the required time frames.(l) A center must make available to any person on request a copy of each HHSC inspection report. Before making an inspection report available under this subsection, the center must redact from the report any information that is confidential under other law.(m) A center must post the most recent inspection results in a conspicuous location at the center. Source Note: The provisions of this §550.1305 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS F INSPECTIONS AND VISITS §550.1305 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221026 03/12/2026 HHSC may deny a license application for the reasons described in §550.115 of this chapter (relating to Criteria for Denial of a License). Source Note: The provisions of this §550.1401 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1401 Denial of License Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221027 03/12/2026 (a) HHSC may suspend a center's license for:(1) a violation of THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;(2) an intentional or negligent act by a center or an employee of a center that HHSC determines significantly affects the health and safety of a minor served at a center;(3) use of drugs or intoxicating liquors to an extent that it affects the license holder's or applicant's professional competence;(4) a felony conviction, including a finding or verdict of guilty, an admission of guilt, or a plea of nolo contendere, in Texas or another state of any person required by this chapter to undergo a background and criminal history check;(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception committed by any person listed on the application;(6) license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed in the application;(7) criteria described in Chapter 560 of this title (relating to Denial or Refusal of License) that applies to any person required by this chapter to undergo a background and criminal history check;(8) aiding, abetting, or permitting a violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;(9) a license holder or applicant's failure to provide the required information, facts, or references;(10) a license holder or applicant who knowingly:(A) submits false or intentionally misleading statements to HHSC on an application;(B) uses subterfuge or other evasive means of filing an application;(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or(D) conceals a material fact on an application; or(11) a person listed on the application failing to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §550.112 of this chapter (relating to Licensing Fees);(B) plan review fees as described in §550.113 of this chapter (relating to Plan Review Fees); or(C) franchise taxes, if applicable.(b) HHSC may suspend a license simultaneously with any other enforcement action available to HHSC.(c) HHSC notifies the license holder by personal service, facsimile transmission, or registered or certified mail of its intent to suspend the license, including the facts or conduct alleged to warrant the suspension.(d) The license holder has an opportunity to show compliance with all requirements of law to retain the license, as provided in §550.1407 of this subchapter (relating to Opportunity to Show Compliance). If the license holder requests an opportunity to show compliance, HHSC gives the license holder a written affirmation or reversal of the proposed action.(e) HHSC notifies the license holder by personal services, facsimile transmission, or by registered or certified mail of its suspension of the center license. The license holder has 20 days after receipt of the notice to request a hearing in accordance with Texas Government Code, Chapter 2001, and the formal hearing procedures in 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). The license suspension takes effect when the deadline for an appeal of the suspension expires, unless the license holder appeals the suspension.(f) If a license holder appeals, the license remains valid until all administrative appeals are final, unless the license expires without a timely application for renewal submitted to HHSC. The license holder must continue to submit a renewal application in accordance with §550.106 of this chapter (relating to Renewal License Application Procedures and Issuance) until the action to suspend the license is completed. However, HHSC does not renew the license until it determines the reason for the proposed action no longer exists.(g) If a license holder appeals, the enforcement action takes effect when all administrative appeals are final and the proposed enforcement action is upheld. If the center wins the appeal, HHSC does not take the proposed action.(h) If HHSC suspends a license, the suspension remains in effect until HHSC determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC conducts an on-site investigation before making a determination. During the suspension, the license holder must return the license to HHSC. Source Note: The provisions of this §550.1402 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1402 License Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221028 03/12/2026 (a) HHSC may issue an emergency order to suspend a license, as authorized by THSC Chapter 248A, if HHSC has reasonable cause to believe that the conduct of a license holder creates an immediate danger to a minor served at the center or the public's health and safety.(1) If HHSC issues an order for emergency suspension of the center's license, HHSC provides immediate notice to the controlling person, administrator, or alternate administrator of the center by personal service, facsimile transmission, or registered or certified mail. The notice includes:(A) the action taken;(B) legal grounds for the action;(C) the procedure governing appeal of the action; and(D) the effective date of the order.(2) An order for emergency licensure suspension goes into effect immediately.(3) On written request of a license holder, HHSC conducts a hearing not earlier than the 10th day, or later than the 30th day after, the date HHSC receives the hearing request to determine if the emergency suspension should be continued, modified, or rescinded.(4) The hearing and any appeal are governed by HHSC rules for a contested case hearing and by Texas Government Code, Chapter 2001.(b) If HHSC suspends a license, the suspension remains in effect until HHSC determines that the reason for an emergency licensure suspension no longer exists. An emergency licensure suspension may last no longer than the term of the license. HHSC conducts an inspection of the center before making a determination to recommend cancellation of a suspension. During the suspension, the license holder must return the license to HHSC. Source Note: The provisions of this §550.1403 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1403 Emergency License Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221029 03/12/2026 (a) HHSC may revoke a center's license for:(1) a violation of THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;(2) an intentional or negligent act by a center or an employee of a center that HHSC determines significantly affects the health and safety of a minor served at a center;(3) use of drugs or intoxicating liquors to an extent that affects the license holder's or applicant's professional competence;(4) a felony conviction, including a finding or verdict of guilty, an admission of guilt, or a plea of nolo contendere, in Texas or another state of any person required by this chapter to undergo a background and criminal history check;(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception committed by any person listed on the application;(6) license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed in the application;(7) criteria described in Chapter 560 of this title (relating to Denial or Refusal of License) that applies to any person required by this chapter to undergo a background and criminal history check;(8) aiding, abetting, or permitting a violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;(9) a license holder or applicant's failure to provide the required information, facts, or references;(10) a license holder or applicant who knowingly:(A) submits false or intentionally misleading statements to HHSC on an application;(B) uses subterfuge or other evasive means of filing an application;(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or(D) conceals a material fact on an application;(11) a person listed on the application committing fraud; or(12) a person listed on the application failing to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §550.112 of this chapter (relating to Licensing Fees);(B) plan review fees as described in §550.113 of this chapter (relating to Plan Review Fees); and(C) franchise taxes, if applicable.(b) HHSC may revoke a license simultaneously with any other enforcement action available to HHSC.(c) HHSC notifies the license holder by personal service, facsimile transmission, registered or certified mail of its intent to revoke the license, including the facts or conduct alleged to warrant the revocation, and sends a copy to the center. The license holder has an opportunity to show compliance with all requirements of the law to retain the license, as provided in §550.1407 of this subchapter (relating to Opportunity to Show Compliance). If the license holder requests an opportunity to show compliance, HHSC gives the license holder a written affirmation or reversal of the proposed action.(d) HHSC notifies a license holder by personal service, facsimile transmission, or by registered or certified mail of its revocation of the center license and sends a copy to the center. The license holder has 20 days after receipt of the notice to request a hearing in accordance with the HHSC formal hearing procedures in 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and HHSC formal hearing procedures in Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). The revocation takes effect when the deadline for appeal of the revocation expires unless the license holder appeals the revocation.(e) If a license holder appeals, the license remains valid until all appeals are final, unless the license expires without a timely application for renewal submitted to HHSC. The license holder must continue to submit a renewal application in accordance with §550.106 of this chapter (relating to Renewal Application Procedures and Issuance) until the action to revoke the license is completed. However, HHSC does not renew the license until it determines the reason for the proposed action no longer exists.(f) If a license holder appeals, the enforcement action takes effect when all appeals are final and the proposed enforcement action is upheld. Upon revocation, the license must be returned to HHSC. If the license holder wins the appeal, HHSC does not take the proposed action. Source Note: The provisions of this §550.1404 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1404 License Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221030 03/12/2026 If HHSC finds that a center is in repeated noncompliance with THSC Chapter 248A, this chapter or a plan of correction, but the noncompliance does not endanger a minor served at a center or the public health and safety, HHSC may schedule the center for probation rather than suspending or revoking the center's license.(1) HHSC provides notice to the license holder of the probation and the items of noncompliance not later than the 10th day before the date the probation period begins.(2) HHSC designates a period of not less than 30 days during which the center remains on probation. During the probation period, the center must correct the items that were in noncompliance and report the corrections to HHSC for approval.(3) HHSC may suspend or revoke the license of a center that does not correct items that were in noncompliance or does not comply with THSC Chapter 248A or this chapter within the applicable probation period. Source Note: The provisions of this §550.1405 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1405 Probation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221031 03/12/2026 (a) HHSC may petition a district court for a temporary restraining order against a center to restrain a continuing violation of THSC Chapter 248A or standard in this chapter if HHSC finds that the violation creates an immediate threat to the health and safety of minors served at a center.(b) A district court, on petition of HHSC, and on a finding of the court that a person is violating THSC Chapter 248A or a standard in this chapter, may by injunction:(1) prohibit the person from continuing the violation;(2) restrain or prevent the establishment or operation of a center without a license under THSC Chapter 248A; or(3) grant any other injunctive relief warranted by the facts.(c) HHSC may request the attorney general to institute and conduct a suit authorized by this section.(d) HHSC may recover reasonable expenses incurred in obtaining relief under this section, including court costs, reasonable attorney's fees, investigation costs, witness fees, and deposition expenses.(e) Venue for a suit brought under this section is in the county in which the center is located or in Travis County.(f) If HHSC determines that a violation of THSC Chapter 248A or a standard in this chapter threatens the health and safety of a minor served at the center, HHSC may seek, against the person who violates THSC Chapter 248A, the requirements in this chapter, or fails to comply with a corrective action plan submitted in accordance with this chapter, a civil penalty of not more than $500 for each violation.(1) Each day a violation continues constitutes a separate violation for the purpose of this section.(2) HHSC may request the attorney general to sue to collect the penalty. HHSC may recover reasonable expenses incurred in obtaining relief under this section, including court costs, reasonable attorney fees, investigation costs, witness fees, and deposition expenses. Source Note: The provisions of this §550.1406 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1406 Injunctive Relief or Civil Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221032 03/12/2026 (a) Before revocation or suspension of a center's license or denial of an application for the renewal of a center's license, HHSC gives the license holder:(1) a notice by personal service, facsimile transmission, or by registered or certified mail of the facts or conduct alleged to warrant the proposed action, with a copy sent to the center; and(2) an opportunity to show compliance with all requirements of law to retain the license by sending HHSC a written request that must:(A) be postmarked no later than 10 days after the date of HHSC notice and be received in HHSC office no later than 10 days after the date of the postmark; and(B) contain specific documentation refuting HHSC allegations.(b) HHSC limits its review to the documentation submitted by the license holder and information HHSC used as the basis for its proposed action. A license holder or center representative may not attend the meeting to review the opportunity to show compliance documents. HHSC gives a license holder a written affirmation or reversal of the proposed action.(c) After an opportunity to show compliance, HHSC sends a license holder a written notice that:(1) informs the license holder of its decision; and(2) provides the license holder with an opportunity to appeal the decision through a formal hearing process, if HHSC affirms the proposed action. Source Note: The provisions of this §550.1407 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1407 Opportunity to Show Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221033 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings unless the context clearly indicates otherwise.(1) Actual harm--A negative outcome that compromises a minor's physical, mental, or emotional well-being.(2) Immediate threat to the health or safety of a minor--A situation that causes, or is likely to cause, serious injury, harm, or impairment to or the death of a minor.(3) Isolated--A very limited number of minors are affected and a very limited number of staff are involved, or the situation has occurred only occasionally.(4) Pattern of violation--Repeated, but not widespread in scope, failures of a center to comply with THSC Chapter 248A or a rule, standard, or order adopted under THSC Chapter 248A that:(A) result in a violation; and(B) are found throughout the services provided by the center or that affect or involve the same minor or center employees.(5) Potential for minimal harm--A violation that has the potential for causing no more than a minor negative impact on a minor.(6) Widespread in scope--A violation that:(A) is pervasive throughout the services provided by the center; or(B) represents a systemic failure by the center that affects or has the potential to affect a large portion of or all of the minors of the center.(b) Assessing penalties. HHSC may assess an administrative penalty against a person who violates:(1) THSC, Chapter 248A; or(2) a provision in this chapter for which a penalty may be assessed.(c) Criteria for assessing penalties. HHSC assesses an administrative penalty based on the scope and severity of a violation in accordance with the table in this section. Within an established range, HHSC determines the amount of an administrative penalty based on the following criteria:(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(2) the threat to the health or safety caused by the violation;(3) any previous violations;(4) the amount necessary to deter future violations;(5) efforts made by the violator to correct the violation; and(6) any other matters that justice may require.(d) Penalty calculation and assessment. The table in this section sets forth the ranges for administrative penalties that HHSC assesses, based on the scope and severity of a violation. An administrative penalty may not exceed $500 for each violation. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty.(e) Schedule of appropriate and graduated penalties.(f) The penalty range for a Severity Level A violation is $400 - $500 per violation.(g) A Severity Level A violation is a violation that results in immediate threat to a minor's health or safety.(h) The penalty range for a Severity Level B violation is $300 - $400 per violation.(i) A Severity Level B violation is a violation that results in actual harm that is not considered an immediate threat.(j) The penalty range for a Severity Level C violation is $200 - $300 per violation.(k) A Severity Level C violation is a violation with no actual harm with potential for more than minimal harm.(l) The penalty range for a Severity Level D violation is $100 - $200 per violation.(m) A Severity Level D violation is a violation with no actual harm with potential for minimal harm.Attached Graphic(n) Proposal of administrative penalties. If HHSC assesses an administrative penalty, HHSC provides a written notice of violation letter to a center. The notice includes:(1) a brief summary of the violation;(2) the amount of the proposed penalty; and(3) a statement of the center's right to a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both the occurrence of the violation and the amount of the penalty.(o) A center may accept the determination and recommended penalty not later than 20 days after the date on which the center receives the notice of violation letter, including the proposed penalty, or make a written request for a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both.(1) If a center that is notified of a violation accepts the determination and recommended penalty or fails to respond to the notice, the executive commissioner or designee issues an order approving the determination and ordering that the center pay the proposed penalty.(2) If a center that is notified of a violation does not accept the determination, the center must submit to HHSC a written request for a formal administrative hearing on the determination and must not pay the proposed penalty. Remittance of the penalty to HHSC is deemed acceptance by the center that the determination is final, and the center waives the center's right to a formal administrative hearing.(3) If a center requests a formal administrative hearing, the hearing is held in accordance with THSC §248A.255. Source Note: The provisions of this §550.1408 adopted to be effective September 1, 2014, 39 TexReg 6569; amended to be effective October 28, 2018, 43 TexReg 7186; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875; amended to be effective October 16, 2024, 49 TexReg 7929. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1408 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194877 03/12/2026 (a) If a person operates a center without a license issued in accordance with this chapter, the person is liable for a civil penalty of $500 for each day of violation.(b) A person commits an offense if the person knowingly establishes or operates a center without the appropriate license in accordance with this chapter.(c) An offense under this section is a Class B misdemeanor.(d) Each day a violation continues constitutes a separate offense. Source Note: The provisions of this §550.1409 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875. 1 HEALTH AND HUMAN SERVICES COMMISSION 550 LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS G ENFORCEMENT §550.1409 Operation of a Center without a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207869 03/12/2026 (a) The purpose of this chapter is to promote public health, safety, and welfare by providing for the development, establishment, and enforcement of standards for the provision of services to individuals residing in intermediate care facilities for persons with an intellectual disability or a related condition.(b) The term "facility serving persons with an intellectual disability or related conditions," when used in this chapter, means an establishment or home that provides food, shelter, and treatment or services to four or more persons who are unrelated to the owner; is primarily for the diagnosis, treatment, or rehabilitation of persons with an intellectual disability or related conditions; and provides in a protected setting continuous evaluation, planning, 24-hour supervision, and coordination and integration of health or rehabilitative services to help each resident function at the resident's greatest ability.(1) A person receiving services in a facility serving persons with an intellectual disability or related conditions must have a diagnosis of an intellectual disability or a related condition as defined under paragraph (2) of this subsection. Facilities serving persons with other developmental disabilities as a primary diagnosis do not fall under the scope of these standards.(2) The term "related condition" means a severe, chronic disability that meets all the following conditions:(A) a condition attributable to:(i) cerebral palsy or epilepsy; or(ii) any other condition including autism, but excluding mental illness, found to be closely related to an intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an intellectual disability and requires treatment or services similar to those required for these persons;(B) a condition manifested before the person reaches age 22 years;(C) a condition likely to continue indefinitely; and(D) a condition that results in substantial functional limitations in three or more of the following areas of major life activity:(i) self-care;(ii) understanding and use of language;(iii) learning;(iv) mobility;(v) self-direction; and(vi) capacity for independent living.(c) This chapter does not apply to an establishment that:(1) provides training, habilitation, rehabilitation, or education to individuals with an intellectual disability or a related condition; is operated under the jurisdiction of a state or federal agency; and is certified through inspection or evaluation as meeting the standards established by the state or federal agency; or(2) is conducted by or for the adherents of a well-recognized church or religious denomination for the purpose of providing facilities for the care or treatment of the sick who depend exclusively on prayer or spiritual means for healing, without the use of any drug or material remedy, if the establishment complies with safety, sanitary, and quarantine laws and rules. Source Note: The provisions of this §551.2 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS A INTRODUCTION §551.2 Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207870 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise. Individual subchapters may have definitions that are specific to the subchapter.(1) Active treatment--A continuous program, which includes aggressive, consistent implementation of specialized and generic training, treatment, health services, and related services, that is directed toward:(A) acquisition of the behaviors necessary for the resident to function with as much self-determination and independence as possible; and(B) prevention or deceleration of regression or loss of current optimal functional status.(2) Actual harm--A negative outcome that compromises a resident's physical, mental, or emotional well-being.(3) Addition--The addition of floor space to a facility.(4) Administrator--The administrator of a facility.(5) Administration of medication--Removing a unit or dose of medication from a previously dispensed, properly labeled container; verifying the medication with the medication order; giving the proper medication in the proper dosage to the proper resident at the proper time by the proper administration route; and recording the time of administration and dosage administered.(6) Advanced practice nurse--A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301, and authorized by the Texas Board of Nursing to practice as an advanced practice nurse.(7) Applicant--A person applying for a license under Texas Health and Safety Code, Chapter 252.(8) Administrative Procedure Act (APA)--Texas Government Code, Chapter 2001.(9) Behavioral emergency--A situation in which severely aggressive, destructive, violent, or self-injurious behavior exhibited by a resident:(A) poses a substantial risk of imminent probable death of, or substantial bodily harm to, the resident or others;(B) has not abated in response to attempted preventive de-escalatory or redirection techniques;(C) is not addressed in a behavior therapy program; and(D) does not occur during a medical or dental procedure.(10) Care and treatment--Services required to maximize resident independence, personal choice, participation, health, self-care, psychosocial functioning, and provide reasonable safety, all consistent with the preferences of the resident.(11) CDC--Centers for Disease Control and Prevention.(12) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership.(13) CFR--Code of Federal Regulations.(14) CMS--Centers for Medicare & Medicaid Services. The federal agency that provides funding and oversight for the Medicare and Medicaid programs.(15) Communicable disease--An illness due to an infectious agent or its toxic products that is transmitted directly to a well person from an infected person or animal, or indirectly through an intermediate plant or animal host, vector, or the inanimate environment.(16) Controlled substance--A drug, substance, or immediate precursor as defined in the Texas Controlled Substances Act, Texas Health and Safety Code, Chapter 481, as amended, or the Federal Controlled Substances Act, United States Code, Title 21, Chapter 13, as amended.(17) Controlling person of an applicant, license holder, or facility--A person who, acting alone or with others, has the ability to directly or indirectly influence or direct the management, expenditure of money, or policies of an applicant or license holder or of a facility owned by an applicant or license holder.(A) The term includes:(i) a spouse of the applicant or license holder;(ii) an officer or director, if the applicant or license holder is a corporation;(iii) a partner, if the applicant or license holder is a partnership;(iv) a trustee or trust manager, if the applicant or license holder is a trust;(v) a person who operates or contracts with others to operate the facility;(vi) a person who, because of a personal, familial, or other relationship is in a position of actual control or authority over the facility, without regard to whether the person is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the facility; and(vii) a person who would be a controlling person of an entity described in clauses (i) - (vi) of this subparagraph, if that entity were the applicant or license holder.(B) The term does not include an employee, lender, secured creditor, or other person who does not exercise formal or actual influence or control over the operation of a facility.(18) CPR--cardiopulmonary resuscitation.(19) Dangerous drug--Any drug as defined in the Texas Dangerous Drug Act, Texas Health and Safety Code, Chapter 483.(20) Designee--A state agency or entity with which HHSC contracts to perform specific, identified duties related to the fulfillment of a responsibility prescribed by this chapter.(21) DFPS--Texas Department of Family and Protective Services.(22) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.(23) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.(24) Drug (also referred to as medication)--A drug is:(A) any substance recognized as a drug in the official United States Pharmacopeia, official Homeopathic Pharmacopeia of the United States, or official National Formulary, or any supplement to any of them;(B) any substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in a person;(C) any substance (other than food) intended to affect the structure or any function of the human body; or(D) any substance intended for use as a component of any substance specified in subparagraphs (A) - (C) of this paragraph. It does not include devices or their components, parts, or accessories.(25) DSHS--Texas Department of State Health Services.(26) EMC--Emergency Management Coordinator.(27) EPC--Emergency Preparedness Coordinator.(28) Emergency situation--an impending or actual situation that:(A) may interfere with normal activities of a facility or its residents;(B) may cause:(i) injury or death to a resident or staff member of the facility; or(ii) damage to facility property;(C) requires the facility to respond immediately to mitigate or avoid injury, death, damage, or interference; and(D) does not include a situation that arises from the medical condition of a resident such as cardiac arrest, obstructed airway, or cerebrovascular accident.(29) EMR--Employee Misconduct Registry.(30) Establishment--A place of business or a place where business is conducted which includes staff, fixtures, and property.(31) Facility--A facility serving persons with an intellectual disability or related conditions licensed under this chapter as described in §551.2 of this chapter (relating to Scope) and required to be licensed under Texas Health and Safety Code, Chapter 252, or the entity that operates such a facility; or, in Subchapters C, D, and F of this chapter, a program provider that must comply with those subchapters in accordance with §261.212 of this title (relating to Non-licensed Providers Meeting Licensure Standards).(32) Governmental unit--A state or a political subdivision of the state, including a county or municipality.(33) Guardian--A person who is appointed guardian under Texas Estates Code, Chapter 1101.(34) Health authority--A physician designated to administer state and local laws relating to public health under the Local Public Health Reorganization Act, Texas Health and Safety Code, Chapter 121. The health authority may be:(A) a local health authority appointed by the local government jurisdiction; or(B) a regional director of DSHS if no physician has been appointed by the local government.(35) Health care professional--A person licensed, certified, or otherwise authorized to administer health care, for profit or otherwise. The term includes a physician, licensed nurse, physician assistant, podiatrist, dentist, physical therapist, speech therapist, and occupational therapist.(36) Hearing--A contested case hearing held in accordance with the APA and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I(relating to Hearings Under the Administrative Procedure Act).(37) HHSC--The Texas Health and Human Services Commission.(38) HVAC--Heating, ventilating, and air-conditioning system.(39) ICF/IID--An Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions.(40) IDT--Interdisciplinary Team.(41) Immediate jeopardy to health and safety of a resident--A situation in which immediate corrective action is necessary because the facility's noncompliance with one or more federal requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the certified facility.(42) Immediate threat to the health or safety of a resident--A situation that causes, or is likely to cause, serious injury, harm, or impairment or death of a resident because of the facility's noncompliance with one or more licensure requirements.(43) Incident--An unusual or abnormal event or occurrence in, at, or affecting the facility or the residents of the facility.(44) Indirect ownership interest--Any ownership or membership interest in a person who has a direct ownership interest in an applicant or license holder.(45) Inspection--Any on-site visit to or survey of a facility by HHSC for the purpose of inspection of care, licensing, monitoring, complaint investigation, architectural review, or similar purpose.(46) Individual program plan (IPP)--A plan developed by the interdisciplinary team of a facility resident that identifies the resident's training, treatment, and habilitation needs, and describes programs and services to meet those needs.(47) Isolated--A situation in which a very limited number of residents are affected and a very limited number of staff are involved, or the situation has occurred only occasionally.(48) Key infectious agents--Bacteria, viruses, and other microorganisms that cause the most common infections and infectious diseases in long-term care facilities, according to the CDC, and can be prevented by establishing, implementing, maintaining, and enforcing proper infection prevention and control policies and procedures.(49) Legally authorized representative (LAR)--A person authorized by law to act on behalf of a person regarding a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(50) Large facility--A facility with a capacity of 17 or more residents.(51) License--Approval from HHSC to establish or operate a facility.(52) License holder--A person who holds a license to operate a facility.(53) Licensed nurse--A licensed vocational nurse, registered nurse, or advanced practice nurse.(54) LIDDA--Local intellectual and developmental disability authority.(55) Life Safety Code--NFPA 101.(56) Life safety features--Fire safety components required by the Life Safety Code such as building construction, fire alarm systems, smoke detection systems, interior finishes, sizes and thicknesses of doors, exits, emergency electrical systems, and sprinkler systems.(57) Local authorities--A local health authority, fire marshal, building inspector, etc., who may be authorized by state law, county order, or municipal ordinance to perform certain inspections or certifications.(58) Local health authority--The physician having local jurisdiction to administer state and local laws or ordinances relating to public health, as described in the Texas Health and Safety Code, Chapter 121, Subchapter B.(59) Licensed vocational nurse(LVN)--A person licensed to practice vocational nursing in accordance with Texas Occupations Code, Chapter 301.(60) Metered dose inhaler--A device that delivers a measured amount of medication as a mist that can be inhaled.(61) Multidrug-resistant organisms--Bacteria and other microorganisms that have developed resistance to multiple types of medicine used to act against the microorganism.(62) NAR--Nurse Aide Registry.(63) NFPA--The National Fire Protection Association. If the term is immediately followed by a number, it is a reference to a publication of NFPA, as referenced in NFPA 101.(64) NFPA 10--NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition.(65) NFPA 13--NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition.(66) NFPA 13D--NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, 2010 Edition.(67) NFPA 13R--NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, 2010 Edition.(68) NFPA 25--NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.(69) NFPA 37--NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 2010 Edition.(70) NFPA 70--NFPA 70, National Electrical Code, 2011 Edition.(71) NFPA 72--NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.(72) NFPA 90A--NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition.(73) NFPA 90B--NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, 2012 Edition.(74) NFPA 99--NFPA 99, Health Care Facilities Code, 2012 Edition. A publication of the NFPA that provides minimum requirements for the installation, testing, maintenance, performance, and safe practices for health care facilities and for material, equipment, and appliances, used for patient care in health care facilities. CMS has incorporated NFPA 99, 2012 Edition, except Chapters 7, 8, 12, and 13, by reference as a Condition of Participation in the ICF/IID program for facilities that meet the definition of a health care occupancy. Copies of NFPA 99 may be obtained from NFPA, 1 Batterymarch Park, Quincy, MA 02169.(75) NFPA 101--NFPA 101, Life Safety Code, 2012 Edition. A publication of the NFPA that provides minimum requirements, with due regard to function, for the design, operation, and maintenance of buildings and structures for safety to life from fire. CMS has incorporated NFPA 101, 2012 Edition, by reference as a Condition of Participation in the ICF/IID program. Copies of NFPA 101 may be obtained from NFPA, 1 Batterymarch Park, Quincy, MA 02169.(76) NFPA 101A--NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 Edition.(77) NFPA 220--NFPA 220, Standard on Types of Building Construction, 2012 Edition.(78) NFPA 701--NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films, 2010 Edition.(79) Online Portal--Texas Unified Licensure Information Portal (TULIP).(80) Oral medication--Medication administered by way or through the mouth, not including sublingual or buccal.(81) Pattern of violation--Repeated, but not widespread in scope, failures of a facility to comply with Texas Health and Safety Code, Chapter 252, or a rule, standard or order adopted under Chapter 252 that:(A) result in a violation; and(B) are found throughout the services provided by the facility or that affect or involve the same residents or facility employees.(82) Person--An individual, firm, partnership, corporation, association, or joint stock company, and any legal successor of those entities.(83) Personal hold--(A) A manual method, except for physical guidance or prompting of brief duration, used to restrict:(i) free movement or normal functioning of all or a portion of a resident's body; or(ii) normal access by a resident to a portion of the resident's body.(B) Physical guidance or prompting of brief duration becomes a restraint if the resident resists the guidance or prompting.(84) Potential for minimal harm--A violation that has the potential for causing no more than a minor negative impact on a resident.(85) Potential for more than minimal harm--A violation that results in more than minimal physical, mental, or psychological discomfort to the resident or has the potential to compromise the resident's ability to reach and maintain the highest practicable physical, mental, and psychosocial well-being as defined for the resident.(86) Qualified intellectual disability professional (QIDP)--A person who has at least one year of experience working directly with persons with an intellectual disability or related conditions and is one of the following:(A) a doctor of medicine or osteopathy;(B) a registered nurse; or(C) an individual who holds at least a bachelor's degree in one of the following areas:(i) occupational therapy;(ii) physical therapy;(iii) social work;(iv) speech-language pathology or audiology;(v) recreation or a specialty area such as art, dance, music or physical education;(vi) dietetics; or(vii) human services, such as sociology, special education, rehabilitation counseling, or psychology (as specified in 42 CFR §483.430(b)(5)(x).(87) Rapid influenza diagnostic test--A test administered to a person with flu-like symptoms that can detect the influenza viral nucleoprotein antigen.(88) Receiving facility--A facility that has agreed to receive the residents of another facility who are evacuated due to an emergency.(89) Relocation--The new physical location of a facility.(90) Remodeling--The construction, removal, or relocation of walls and partitions, or construction of foundations, floors, or ceiling-roof assemblies, including expanding of safety systems (e.g.., sprinkler systems, fire alarm systems), that will change the existing plan and use areas of the facility.(91) Renovation--The restoration to a former better state by cleaning, repairing, or rebuilding (e.g., routine maintenance, repairs, equipment replacement, painting).(92) Resident--A person who resides in a facility.(93) Restraint--A manual method, or a physical or mechanical device, material, or equipment, attached or adjacent to the resident's body that the resident cannot remove easily, that restricts freedom of movement or normal access to the resident's body. This term includes a personal hold.(94) Registered nurse(RN)--A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301.(95) Seclusion--The involuntary separation of a resident away from other residents and the placement of the resident alone in an area from which the resident is prevented from leaving.(96) Small facility--A facility with a capacity of 16 or fewer residents.(97) Staff--Employee of an ICF/IID or a contracted staff working with residents living in an ICF/IID.(98) Standards--The minimum conditions, requirements, and criteria with which a facility will have to comply to be licensed under this chapter.(99) TIA--Tentative Interim Amendment.(100) TAC--Texas Administrative Code.(101) Topical medication--Medication applied to the skin, not including medication administered in the eyes.(102) Universal precautions--The use of barrier precautions by facility staff to prevent direct contact with blood or other body fluids that are visibly contaminated with blood.(103) Vaccine preventable diseases--The diseases included in the most current recommendations of the Advisory Committee on Immunization Practices of the CDC.(104) Violation--Any noncompliance with Texas Health and Safety Code, Chapter 252, or any rule under this chapter.(105) Well-recognized church or religious denomination--An organization which has been granted a tax-exempt status as a religious association from the state or federal government.(106) Widespread in scope--A violation that:(A) is pervasive throughout the services provided by the facility; or(B) that affects or has the potential to affect a large portion of or all the residents of the facility. Source Note: The provisions of this §551.3 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective June 1, 2006, 31 TexReg 4463; amended to be effective September 1, 2010, 35 TexReg 7876; amended to be effective June 1, 2012, 37 TexReg 3871; amended to be effective June 17, 2013, 38 TexReg 3806; amended tobe effective April 27, 2016, 41 TexReg 2971; amended to be effective October 11, 2017, 42 TexReg 5505; amended to be effective October 28, 2018, 43 TexReg 7191; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS A INTRODUCTION §551.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207879 03/12/2026 (a) A person or governmental unit, acting jointly or severally, must be licensed by the Texas Health and Human Services Commission (HHSC) to establish, conduct, or maintain a facility in this state.(b) An applicant for a license must submit a complete application form and license fee to HHSC through the online portal.(c) An applicant for a license must affirmatively show that:(1) the facility meets the standards of NFPA 101;(2) the facility meets the construction standards in Subchapter D of this chapter (relating to General Requirements for Facility Construction); and(3) the facility meets the standards for operation based on an on-site survey.(d) Before issuing a license, HHSC considers the background and qualifications of:(1) the applicant or license holder;(2) a controlling person of the applicant or license holder; and(3) an individual with five percent or more direct ownership interest in the applicant or license holder.(e) HHSC issues a license if it finds that the facility and any person described in subsection (d) of this section meets all requirements of this chapter. The license is valid for three years, as described in §551.15 of this subchapter (relating to Renewal Procedures and Qualifications). Each license specifies the maximum allowable number of residents to be cared for at any one time. The number of residents authorized by the license must not be exceeded. Source Note: The provisions of this §551.11 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective April 1, 1999, 24 TexReg 1816; amended to be effective May 1, 2002, 27 TexReg 3369; amended to be effective September 1, 2009, 34 TexReg 5139; amended to be effective September1,2010,35 TexReg 7876; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.11 Criteria for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207880 03/12/2026 (a) Local fire authority. All applications for licensure must include the written approval of the local fire authority having jurisdiction that the facility and its operation meet local fire ordinances.(b) Local health authority. The following procedures allow the local health authority to provide recommendations to HHSC concerning licensure of a facility.(1) New facility. The sponsor of a new facility under construction or a previously unlicensed facility must provide to HHSC a copy of a dated written notice to the local health authority that construction or modification has been or will be completed by a specific date. The sponsor must also provide a copy of a dated written notice of the approval for occupancy by the local fire marshal or local building code authority, if applicable. The local health authority may provide recommendations to HHSC regarding the status of compliance with local codes, ordinances, or regulations. An application for a new facility that was not included in the plan approved under Texas Health and Safety Code §533A.062 (relating to Plan on Long-Term Care for Persons with an Intellectual Disability) will not be approved by HHSC, as outlined under §551.14 of this subchapter (relating to Increase in Capacity).(2) Increase in capacity. The license holder must submit an application through the online portal for an increase in capacity from HHSC. The license holder must arrange for and have the inspection of the facility completed by the local fire marshal before the application is submitted. Upon completion of the inspection, the license holder must notify the local health authority and HHSC by uploading the letter with the application through the online portal if the facility meets local code requirements. HHSC approves the application only if the facility is found to be in compliance with the standards. Approval to occupy the increased capacity, which cannot exceed six total residents, may be granted by HHSC prior to the issuance of the license covering the increased capacity after inspection by HHSC if standards are met. An application for an increase in capacity that was not included in the plan approved under Texas Health and Safety Code §533A.062 (relating to Plan on Long-Term Care for Persons with an Intellectual Disability) will not be approved by HHSC, as outlined under §551.14 of this subchapter (Relating to Increase in Capacity).(3) Change of ownership. The applicant for a change of ownership license must provide to HHSC a copy of a letter notifying the local health authority of the request for a change of ownership by uploading the letter into the change of ownership application through the online portal.(4) Renewal. HHSC sends the local health authority a copy of HHSC's license renewal notice specifying the expiration date of the facility's current license. The local health authority may provide recommendations to HHSC regarding the status of compliance with local codes, ordinances, or regulations. The local authority may also recommend that a state license be issued or denied; however, the final decision on licensure status remains with HHSC.(5) Relocation. Prior to relocation of a facility, a program provider must receive HHSC approval of a facility relocation by following the application process through the online portal. If HHSC approves the application for relocation, HHSC will initiate licensure and certification action of the relocated facility. The facility must provide a copy of the letter notifying the local health authority of a change in location. Source Note: The provisions of this §551.12 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.12 Building Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207881 03/12/2026 (a) No person may apply for a license, change of ownership, increase in capacity, relocation, or renewal of a license to operate or maintain a facility without making a disclosure of information as required in this section.(b) All applications must be made on forms prescribed by and available from the Texas Health and Human Services Commission (HHSC) through the online portal. Each application must be completed in accordance with HHSC instructions. Any changes to the information on an initial, change of ownership, or renewal application must be reported to HHSC within 30 calendar days from the effective date of the change. Changes include:(1) persons with an ownership or control interest, as defined in 42 Code of Federal Regulations (CFR) §455.101 (relating to Definitions);(2) officers, directors, agents, or managing employees;(3) the corporation, association, or other company responsible for management of the facility;(4) the facility's administrator; or(5) a controlling person.(c) General information required. An applicant must submit to HHSC, through the online portal, an application that contains:(1) for initial applications, relocation, and change of ownership only, evidence of the right to possession of the facility at the time the application will be granted, which may be satisfied by the submission of applicable portions of a lease agreement, deed or trust, or appropriate legal document. The names and addresses of any persons or organizations listed as owner of record in the real estate, including the buildings and grounds and property documents, must be disclosed to HHSC; and(2) for initial applications and change of ownership tax ID documentation and a copy of the partnership agreement if a partnership exists. For other changes associated with tax ID, tax ID documentation must be provided. Source Note: The provisions of this §551.13 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2000, 25 TexReg 3557; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.13 Applicant Disclosure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207882 03/12/2026 (a) During the license term, a license holder may not increase capacity without approval from the Texas Health and Human Services Commission (HHSC). The license holder must submit to HHSC a complete application, through the online portal, for increase in capacity and the fee required in §551.19 of this subchapter (relating to License Fees).(b) An application for an increase in capacity that was not included in the plan approved under §533A.062 of Texas Health and Safety Code, Plan on Long-Term Care for Persons with an Intellectual Disability, will not be approved by HHSC .(c) Upon approval of an increase in capacity, HHSC will issue a new license. Source Note: The provisions of this §551.14 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective January 1, 1997, 21 TexReg 11290; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.14 Increase in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207871 03/12/2026 (a) A license expires three years after the date it is issued. The Texas Health and Human Services Commission does not automatically renew a license. For a license to remain in effect after its expiration date, a license holder must apply to renew the license in accordance with this section.(b) To renew a license, a license holder must submit to HHSC a timely and sufficient application to renew the license through the online portal. A license holder has submitted a timely and sufficient application to renew a license if:(1) the license holder submits the following to HHSC so HHSC receives it no later than the 45th day before the license expires:(A) the fee required by §551.19(a)(1) of this subchapter (relating to License Fees); and(B) one of the following:(i) a complete application; or(ii) an incomplete application with a letter explaining the circumstances that prevent the license holder from including the missing information; or(2) the license holder submits the following to HHSC so HHSC receives it during the 45-day period ending on the date the license expires:(A) the fee and documentation described in paragraph (1)(A) and (B) of this subsection; and(B) the late renewal fee described in §551.19(a)(4) of this subchapter.(c) If HHSC receives an application that is submitted before the submission deadline, the application is considered timely.(d) Regardless of whether HHSC sends advance notice that a license is expiring, providers are responsible for applying to renew their licenses in a timely manner. Furthermore, operating a facility without a license is a violation of state law. Source Note: The provisions of this §551.15 adopted to be effective October 29, 2018, 43 TexReg 7196; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.15 Renewal Procedures and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210350 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210350 03/12/2026 (a) For purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the new operator of a facility that exists on the date the application is submitted.(b) A license holder may not transfer its license. The applicant (new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When the Texas Health and Human Services Commission (HHSC) approves the change of ownership by issuing a temporary change of ownership license to the new license holder, the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the change of ownership application. Between the effective date of the change of ownership and the issuance of the temporary change of ownership license, the current license holder remains responsible under its license; however, the applicant may operate a facility on behalf of the current license holder during such period of time.(c) The applicant must submit to HHSC through the online portal:(1) a complete application for a license in accordance with HHSC instructions and §551.11 of this subchapter (relating to Criteria for Licensing) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) the application fee, in accordance with §551.19 of this subchapter (relating to License Fees); and(3) a signed and notarized Change of Ownership Transfer Affidavit HHSC Form 1092 from the applicant and the facility's current license holder of intent to transfer operation of the facility from the current license holder to the applicant beginning on the change of ownership effective date specified on the change of ownership, unless waived in accordance with subsection (d) of this section.(d) To avoid a facility operating without a license, an applicant must submit all items in subsection (c) of this section at least 30 days before the anticipated date of the change of ownership in accordance with HHSC instructions, unless the 30-day notice requirement is waived in accordance with subsection (e) of this section.(e) HHSC may waive the 30-day notice required by subsection (d) of this section if HHSC determines that the applicant presents evidence showing that circumstances prevented the submission of the items in subsection (c) of this section at least 30 days before the anticipated date of the change of ownership and that not waiving the 30-day requirement would create a threat to resident welfare or health and safety.(f) Upon HHSC approval of the items in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all person disclosed in the application satisfy the requirements in §§551.11(d) of this subchapter, 551.13 of this subchapter (relating to Applicant Disclosure Requirements), and 551.17 of this subchapter (relating to Criteria for Denying a License or Renewal of a License).(1) The issuance of a temporary change of ownership license constitutes HHSC's official written notice to the facility of the approval of the application for a change of ownership.(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online portal.(g) A temporary change of ownership license expires on the earlier of:(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (h) of this section; or(2) the date HHSC issues a three-year license in accordance with subsection (k) of this section.(h) HHSC, in its sole discretion, may extend the temporary change of ownership license for a term of 90 days at a time based on extenuating circumstances.(i) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site health inspection after issuing a temporary change of ownership license if:(1) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or(2) every owner with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(j) HHSC, in its sole discretion, may conduct an on-site Life Safety Code inspection after issuing a temporary change of ownership license.(k) If an applicant, all controlling persons, and all person disclosed in the application satisfy the requirements of §§551.11(d), 551.13, and 551.17 of this subchapter, and the facility passes the change of ownership health inspection as described in subsection (i) of this section, HHSC issues a three-year license. The effective date of the license is the same date as the effective date of the change of ownership and cannot precede the date the application was received by HHSC through the online portal.(l) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name.(m) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC of the addition no later than 30 days after the addition of the owner by submitting an application through the online portal. Source Note: The provisions of this §551.16 adopted to be effective July 30, 2012; 37 TexReg 5629; amended to be effective October 11, 2017, 42 TexReg 5505; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787; amended to be effective October 11, 2022, 47 TexReg 6588. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.16 Change of Ownership and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207873 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may deny an initial license or refuse to renew a license if any person described in §551.11(d) of this subchapter (relating to Criteria for Licensing):(1) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;(2) substantially fails to comply with the requirements described in §551.42 of this chapter (relating to Standards for a Facility), including:(A) noncompliance that poses a serious threat to health and safety, as described in Appendix Q of the State Operations Manual, "Core Guidelines for Determining Immediate Jeopardy"; or(B) a failure to maintain compliance on a continuous basis, including decertification, contract termination, denial of certification, or license revocation;(3) aids, abets, or permits a substantial violation described in paragraph (2) of this subsection about which the person had or should have had knowledge;(4) fails to provide the required information, facts, or references;(5) provides the following false or fraudulent information:(A) knowingly submits false or intentionally misleading statements to HHSC;(B) uses subterfuge or other evasive means of filing;(C) engages in subterfuge or other evasive means of filing on behalf of another who is unqualified for licensure;(D) knowingly conceals a material fact; or(E) is responsible for fraud;(6) fails to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §551.19 of this subchapter (relating to License Fees);(B) reimbursement of emergency assistance funds within one year after the date on which the funds were received by the trustee in accordance with the provisions of §551.238(e) of this chapter (relating to Involuntary Appointment of a Trustee);(C) administrative penalties within 60 days after the order assessing the penalties in accordance with §551.236 of this chapter (relating to Administrative Penalties); or(D) franchise taxes;(7) has a history of any of the following actions during the five-year period preceding the date of the application:(A) operation of a facility that has been decertified or had its contract cancelled under the Medicare or Medicaid program in any state;(B) federal or state long term care facility sanctions or penalties, including vendor holds, monetary penalties, downgrading the status of a facility license, proposals to decertify, directed plans of correction, or the denial of payment for new Medicaid admissions;(C) unsatisfied final judgments;(D) eviction involving any property or space used as a facility in any state; or(E) suspension of a license to operate a health care facility, long term care facility, assisted living facility, or a similar facility in any state.(b) Concerning subsection (a)(7) of this section, HHSC may consider exculpatory information provided by any person described in §551.11(d) of this subchapter and grant a license if HHSC finds that person able to comply with the rules in this chapter.(c) HHSC does not issue a license to an applicant to operate a new facility if the applicant has a history of any of the following actions during the five-year period preceding the date of the application:(1) revocation of a license to operate a health care facility, long term care facility, assisted living facility, or similar facility in any state;(2) debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state;(3) a court injunction prohibiting any person described in §551.11(d) of this subchapter from operating a facility; or(4) failure to comply with or breach of an administrative settlement agreement between the applicant and HHSC.(d) Only final actions are considered for purposes of subsections (a)(7) and (c) of this section. An action is final when routine administrative and judicial remedies are exhausted. All actions, whether pending or final, must be disclosed.(e) If an applicant for a new license owns multiple facilities, HHSC examines the overall record of compliance in all the applicant's facilities. Denial of a new license will not preclude the renewal of licenses for the applicant's other facilities with a history of compliance with licensing regulations.(f) HHSC does not approve as meeting licensing standards new beds or the expansion of a facility serving persons with an intellectual disability or related conditions that participates in the medical assistance program under Title XIX of the Social Security Act, as provided by the Texas Health and Safety Code §533A.062 (relating to Plan on Long-term Care for Persons with an Intellectual Disability) , unless the new beds or the expansion was included in the plan as well as the applicant including the approval letter to be approved by HHSC in accordance with Texas Health and Safety Code §533A.062.(g) If HHSC denies an application for a new license, the applicant may request an administrative hearing. If HHSC refuses to issue a renewal of a license, the licensee may request an informal reconsideration, as specified in §551.18 of this subchapter (relating to Informal Reconsideration) and an administrative hearing. An administrative hearing is held under HHSC's rules in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §551.17 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective June 1, 1994, 19 TexReg 3260; amended to be effective November 15, 1994, 19 TexReg 7927; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective September 1, 2009, 34 TexReg 5139; amended tobe effective September 1, 2010, 35 TexReg 7876; amended to be effective January 18, 2012, 37 TexReg 126; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.17 Criteria for Denying a License or Renewal of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207874 03/12/2026 (a) Before the institution of proceedings to revoke or suspend a license or deny an application for the renewal of a license, the Texas Health and Human Services Commission (HHSC) gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all requirements of law for the retention of the license by sending the director of HHSC a written request for an informal review. The request must:(A) be postmarked within ten days of the date of HHSC's notice and be received in the state office of the director of HHSC within ten days of the date of the postmark; and(B) contain specific documentation refuting HHSC's allegations.(b) HHSC's review will be limited to a review of documentation submitted by the license holder and information used by HHSC as the basis for its proposed action. HHSC's review will not be conducted as an adversarial hearing. HHSC will give the license holder a written affirmation or reversal of the proposed action. Source Note: The provisions of this §551.18 adopted to be effective May 1, 1995, 20 TexReg 1659; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.18 Informal Reconsideration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207875 03/12/2026 (a) Basic fees.(1) Initial and renewal license. The license fee for a three-year initial or renewal license is $225 plus $7.50 for each unit of capacity for which the license is sought.(2) Increase in capacity. If a license holder requests an increase in the capacity of its facility, the license holder must pay the Texas Health and Human Services Commission (HHSC) an additional fee of $7.50 for each unit of capacity approved.(3) Change of administrator. If a license holder hires a new administrator for a facility, the license holder must notify HHSC through the online portal not later than the 30th day after the date on which the change of administrator becomes effective and pay HHSC a $20 fee.(4) Late renewal fee. If a license holder submits an application for renewal during the 45-day period before a license expires, the license holder must pay a late renewal fee in an amount equal to one-half of the fee for a license renewal described in paragraph (1) of this subsection.(b) Emergency Assistance Fee.(1) HHSC may collect an annual fee to be used to make emergency assistance money available to a facility.(2) The fee collected under this subsection must be in the amount allowed by Texas Health and Safety Code §252.095(b), and must be deposited to the credit of the fund established under the Texas Health and Safety Code §242.096 (relating to Nursing and Convalescent Home Trust Fund and Emergency Assistance Funds).(3) HHSC disburses money to a trustee to alleviate an immediate threat to the health or safety of a facility's residents in accordance with Texas Health and Safety Code §252.095(c).(4) HHSC disburses emergency assistance money if a court order is issued in accordance with Texas Health and Safety Code §252.095(d).(c) Method of Payment. HHSC accepts the prescribed form of accepted payment through the online portal. HHSC does not refund a fee except as provided by Chapter 2005 of the Texas Government Code (relating to Miscellaneous Provisions Relating to State Licenses and Permits).(d) Quality Assurance Fee. HHSC collects a quality assurance fee from a license holder in accordance with 40 TAC Chapter 11 (relating to Quality Assurance Fee). Source Note: The provisions of this §551.19 adopted to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective June 1, 2002, 27 TexReg 4367; amended to be effective September 1, 2003, 28 TexReg 6953; amended to be effective January 15, 2009, 34 TexReg 238; amended to be effective October 29, 2018, 43 TexReg 7196; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.19 License Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207876 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) charges a fee to review plans for new buildings, additions, conversion of buildings not licensed by HHSC, and remodeling of existing licensed facilities.(b) The fee schedule is as follows.(1) New small facility (with a capacity of 4 to 16 based on NFPA 101, Chapter 32, New Residential Board and Care Occupancies:(A) single story--$1,100;(B) multiple story--$1,650; and(C) additions or remodeling--2 percent of construction cost with a $350 minimum fee and a maximum of 50 percent of the plan review fee for a new facility of the same type.(2) New large facility (with a capacity of 17 or more based on NFPA 101, Chapter 18, New Health Care Occupancies):(A) single story:(i) facilities with a capacity of 17-80--$1,600;(ii) facilities with a capacity of 81-120--$2,150; and(iii) facilities with a capacity of 121+--$18 per bed.(B) multiple story:(i) facilities with a capacity of 17-80--$2,100;(ii) facilities with a capacity of 81-120--$2,650; and(iii) facilities with a capacity of 121+--$22 per bed.(C) additions or remodeling--2 percent of construction cost with $500 minimum fee and a maximum of 50 percent of the plan review fee for a new facility of the same type. Source Note: The provisions of this §551.20 adopted to be effective April 1, 2002, 27 TexReg 2250; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.20 Plan Review Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207877 03/12/2026 (a) An application is complete when all requirements for licensing have been met, including compliance with standards. If an inspection for compliance is required, the application is not complete until the inspection has occurred, reports are reviewed, and the applicant complies with the standards.(b) If the application is submitted through the online portal by the filing deadline, the application is considered to be timely filed.(c) The Texas Health and Human Services Commission (HHSC) notifies applicants within 30 days of receipt of the application if any of the following applications are incomplete: initial application, change of ownership, renewal, and increase in capacity.(d) A license is issued or denied within 30 days of the receipt of a complete application or within 30 days before the expiration date of the license. HHSC may delay action on an application for renewal of a license for up to six months if the facility is subject to a proposed or pending licensure termination action on or within 30 days before the expiration date of the license. The issuance of the license constitutes HHSC's official written notice to the facility of the acceptance and filing of the application.(e) Reimbursement of fees.(1) In the event the application is not processed in the time periods as stated, the applicant has a right to request of the program director full reimbursement of all filing fees paid in that particular application process. If the program director does not agree the established periods have been violated or finds good cause existed for exceeding the established periods, the request will be denied. Good cause for exceeding the period established is considered to exist if:(A) the number of applications to be processed exceeds by 15 percent or more the number processed in the same calendar quarter of the preceding year;(B) another public or private entity used in the application process caused the delay; or(C) other conditions existed giving good cause for exceeding the established periods.(2) If the request for full reimbursement is denied, the applicant may appeal directly to the Commissioner of HHSC for resolution of the dispute. The applicant must send a written statement to the Commissioner that describes the request for reimbursement and the reasons for it. The program also may send a written statement to the Commissioner that describes the program's reasons for denying reimbursement. The Commissioner makes a timely decision concerning the appeal and notifies the applicant and the program in writing of the decision. Source Note: The provisions of this §551.21 adopted to be effective April 1, 2002, 27 TexReg 2250; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.21 Time Periods for Processing License Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207878 03/12/2026 (a) A license holder may not relocate a facility to another location without approval from the Texas Health and Human Services Commission (HHSC). The license holder must submit a complete application and the fee required under §551.19 of this subchapter (relating to License Fees) to HHSC, through the online portal, before the relocation.(b) Residents may not be relocated until the new building has been inspected and approved as meeting the standards of the Life Safety Code as applicable to intermediate care facilities serving persons with an intellectual disability or a related condition.(c) Following Life Safety Code approval by HHSC, the license holder must notify HHSC of the date residents will be relocated. If the new facility meets the standards for operation based on an on-site survey, a license will be issued.(d) The effective date of the license will be the date all residents are relocated.(e) The license holder must continue to maintain the license at the current location and must continue to meet all requirements for operation of the facility until the date of the relocation.(f) This section applies to relocation of a currently licensed facility, as described in §551.14 of this subchapter (relating to Increase in Capacity) for regulations governing capacity increases. Source Note: The provisions of this §551.22 adopted to be effective May 1, 2002, 27 TexReg 3369; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS B APPLICATION PROCEDURES §551.22 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207883 03/12/2026 (a) Purpose. The purpose of this section is to promote the public health, safety, and welfare by providing for the development, establishment, and enforcement of standards:(1) for the habilitation of residents based on an active treatment program in facilities governed by this chapter; and(2) for the establishment, construction, maintenance, and operation of such facilities that view an intellectual disability and related conditions within the context of a developmental model in accordance with the principle of normalization.(b) Active treatment. A facility regulated by the standards in this section is known as an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID). A resident living in a facility has the same civil rights, equal liberties, and due process of law as other individuals, plus the right to receive active treatment and habilitation. A facility must provide and promote services that enhance the development of each resident, maximize their achievement through an interdisciplinary approach, and create an environment, to the extent possible, that is normalized and normalizing. A facility must:(1) have the interdisciplinary team (IDT) prepare and implement, for each resident, an individual program plan (IPP) within 30 days after admission;(2) ensure each resident receives a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the IPP, as identified by the IDT; and(3) ensure each resident's IPP is reviewed at least annually by a qualified intellectual disability professional (QIDP) and revised as necessary, including situations in which a resident has successfully completed an objective identified in the IPP.(c) Standards. Each ICF/IID must comply with regulations promulgated by the United States Department of Health and Human Services in 42 CFR, Part 483, Subpart I §§483.400 - 483.480. Additionally, HHSC adopts by reference the federal regulations governing conditions of participation for the ICF/IID program as specified in 42 CFR Part 483, Subpart I §§483.410, 483.420, 483.430, 483.440, 483.450, 483.460, 483.470, 483.475, and 483.480 as licensing standards.(d) Precertification training conference for new providers of service. Each new provider must attend the precertification/prelicensure training conference prior to licensing by HHSC. The purpose of the training is to ensure that providers of services are familiar with the licensing requirements and to facilitate the delivery of quality services to residents in facilities serving persons with an intellectual disability or related conditions.(1) A new provider is an entity that has not had at least one year of administering services in a facility serving persons with an intellectual disability or related conditions in Texas. All new providers must attend a precertification training conference prior to the life safety code survey.(2) Each new provider must designate at least one individual who will be involved with the direct management of the facility to attend the training conference prior to a health survey being scheduled.(3) Each new provider will be responsible for taking the required training.(e) Additional requirements.(1) Abuse, neglect, and exploitation. A facility must develop and implement policies and procedures for reporting abuse, neglect, and exploitation, and other reportable incidents, to HHSC.(2) Cardiopulmonary resuscitation (CPR). A facility must ensure:(A) at least one staff person per shift and on duty is trained by a CPR instructor and certified by an organization, such as the American Heart Association or the Red Cross, whose training includes a hands-on in-person skills assessment; and(B) that staff members maintain their certification as recommended by the training organization.(3) Behavior management. Seclusion of residents may not be used.(4) Physical restraints.(A) A facility must not use a restraint:(i) in a manner that:(I) obstructs a resident's airway, including the placement of anything in, on, or over the resident's mouth or nose;(II) impairs a resident's breathing by putting pressure on the resident's torso;(III) interferes with a resident's ability to communicate;(IV) extends a resident's muscle groups away from each other;(V) uses hyperextension of joints on a resident; or(VI) uses pressure points or pain on a resident;(ii) for disciplinary purposes, that is, as retaliation or retribution;(iii) for the convenience of staff or other residents; or(iv) as a substitute for effective treatment or habilitation.(B) A facility may use a restraint:(i) in a behavioral emergency;(ii) as an intervention in a behavior therapy program that addresses inappropriate behavior exhibited voluntarily by a resident;(iii) during a medical or dental procedure if necessary to protect the resident or others and as a follow-up after a medical or dental procedure or following an injury to promote the healing of wounds;(iv) to protect the resident from involuntary self-injury; or(v) to provide postural support to the resident or to assist the resident in obtaining and maintaining normative bodily functioning.(C) In order to decrease the frequency of the use of restraint and to minimize the risk of harm to a resident, a facility must ensure that the IDT:(i) with the participation of a physician, or a physician assistant or an advanced practice nurse acting within the scope of his or her practice, identifies:(I) the resident's known physical or medical conditions that might constitute a risk to the resident during the use of restraint;(II) the resident's ability to communicate; and(III) other factors that must be taken into account if the use of restraint is considered, including the resident's:(-a-) cognitive functioning level;(-b-) height;(-c-) weight;(-d-) emotional condition (including whether a resident has a history of having been physically or sexually abused); and(-e-) age;(ii) documents the conditions and factors identified in accordance with clause (i) of this subparagraph, and, as applicable, limitations on specific restraint techniques or mechanical restraint devices in the resident's record; and(iii) reviews and updates with a physician, physician assistant, or licensed nurse, at least annually or when a condition or factor documented in accordance with clause (ii) of this subparagraph changes significantly, information in the resident's record related to the identified condition, factor, or limitation.(D) If a facility restrains a resident as provided in subparagraph (B) of this paragraph, the facility must:(i) take into account the conditions, factors, and limitations on specific restraint techniques or mechanical restraint devices documented in accordance with subparagraph (C)(ii) and (iii) of this paragraph;(ii) use the minimal amount of force or pressure that is reasonable and necessary to ensure the safety of the resident and others;(iii) safeguard the resident's dignity, privacy, and well-being; and(iv) not secure the resident to a stationary object while the resident is in a standing position.(E) If a facility uses a restraint in a circumstance described in subparagraph (B)(i) or (ii) of this paragraph:(i) the facility may only use a personal hold in which the resident's limbs are held close to the body to limit or prevent movement and that does not violate the provisions of subparagraph (A)(i) of this paragraph; and(ii) if a resident rolls into a prone or supine position during restraint, the facility must transition the resident to a side, sitting, or standing position as soon as possible. A facility may only use a prone or supine hold:(I) as a transitional hold, and only for the shortest period of time necessary to ensure the protection of the resident or others;(II) as a last resort, when other less restrictive interventions have proven to be ineffective; and(III) except in a small facility, when an observer who is trained to identify risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds is ensuring that the resident's breathing is not impaired.(F) A facility must release a resident from a restraint:(i) as soon as the resident no longer poses a risk of imminent physical harm to the resident or others; or(ii) if the resident in restraint experiences a medical emergency, as soon as possible as indicated by the medical emergency.(G) If a facility restrains a resident as provided in subparagraph (B)(i) of this paragraph, the facility must obtain a written order authorizing the restraint from a health care professional acting within his or her scope of practice by the end of the first business day after the use of a restraint.(H) A facility must ensure that each resident and the resident's legally authorized representative (LAR) are notified of HHSC rules and the facility's policies related to restraint and seclusion.(I) A facility may adopt policies that allow less use of restraint than allowed by the rules of this chapter.(5) Pharmacy services.(A) All pharmacy services must comply with the Texas State Board of Pharmacy requirements, the Texas Pharmacy Act, and rules adopted thereunder, the Texas Controlled Substances Act, and Texas Health and Safety Code, Chapter 483 (relating to Dangerous Drugs).(B) All medications must be ordered orally or in writing by a health care professional acting within the scope of his or her practice. Oral orders may be taken only by a licensed nurse, a pharmacist, physician assistant, or physician, and must be immediately transcribed and signed by the individual taking the order. Oral orders must be signed by the health care professional who ordered the medication within seven working days after issuing the order.(C) A facility, with input from the consultant pharmacist and a health care professional acting within the scope of his or her practice, must develop and implement procedures regarding automatic stop orders for medications. These procedures must be utilized when the order for a medication does not specify the number of doses to be given or the time for discontinuance or re-order.(6) Specialized nutrition support (delivery of parenteral nutrients and enteral feedings by nasogastric, gastrostomy, or jejunostomy tubes) must be given:(A) by a health care professional acting within the scope of his or her practice or by a person to whom a health care professional has properly delegated performance of the task; and(B) in accordance with an order issued by a health care professional acting within the scope of his or her practice.(7) Self-administration of medication and emergency medication kits.(A) A resident who has demonstrated the competency for self-administration of medication must have access to and maintain his or her own medication. The resident must have an individual storage space that permits him or her to store the medication under lock and key.(B) A resident may participate in a self-administration of medication training program if the IDT determines that self-administration of medication is an appropriate objective. A resident participating in a self-administration of medication training program must have training in coordination with and as part of the resident's total active treatment program. The resident's training plan must be evaluated as necessary by a licensed nurse. The supervision and implementation of a self-administration of medication training program may be conducted by staff described in §551.43(a)(1), (3), and (4) of this subchapter (relating to Administration of Medication).(C) A facility may maintain a supply of controlled substances in an emergency medication kit for a resident's emergency medication needs, as outlined under §551.324 and §551.325 of this chapter (relating to Emergency Medication Kit and Controlled Substances).(8) Infection prevention and control.(A) A facility must establish, implement, enforce, and maintain an infection prevention and control policy and procedure designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.(B) A facility must comply with rules regarding special waste in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health-Care Related Facilities).(C) A facility must immediately report the name of any resident of a facility with a reportable disease, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority.(D) A facility must have, implement, enforce, and maintain written policies for the control of communicable disease among employees and residents, which must address tuberculosis (TB) screening and the provision of a safe and sanitary environment for residents and employees.(i) If an employee contracts a communicable disease that is transmissible to residents through food handling or direct resident care, the facility must exclude the employee from providing these services for the applicable period of communicability.(ii) A facility must maintain evidence of compliance with local and state health codes or ordinances regarding employee and resident health status.(iii) A facility must screen all employees for TB within two weeks of employment and annually, according to the Centers for Disease Control and Prevention (CDC) screening guidelines. A person who provides services under an outside resource contract must, upon request of the facility, provide evidence of compliance with this requirement.(iv) A facility's policies and practices for resident TB screening must ensure compliance with the recommendations of a resident's attending physician and consistency with CDC guidelines.(E) A facility's infection prevention and control program established under subparagraph (A) of this subsection must include written policies and procedures for:(i) monitoring of key infectious agents, including multidrug-resistant organisms, as those terms are defined in §551.3 of this chapter (relating to Definitions);(ii) wearing personal protective equipment, such as gloves, a gown, or a mask based on anticipated exposure, and properly cleaning hands before and after touching another resident;(iii) cleaning and disinfecting environmental surfaces, including doorknobs, handrails, light switches, and handheld electronic control devices;(iv) using universal precautions for blood and bodily fluids; and(v) removing soiled items (such as used tissues, wound dressings, adult briefs, and soiled linens) from the environment at least once daily, or more often if an infection or infectious disease is present or suspected.(F) A facility must establish, implement, enforce, and maintain written policies and procedures for making a rapid influenza diagnostic test, as defined in §551.3 of this chapter (relating to Definitions), available to a resident who is exhibiting flu-like symptoms.(G) Staff must handle, store, process, and transport linens to prevent the spread of infection.(H) A facility must use universal precautions in the care of all residents.(9) Water activities. A facility must ensure the safety of all residents who participate in facility-sponsored events. For this section, a water activity is defined as an activity which occurs in or on water that is knee deep or deeper on the majority of residents participating in the event. To ensure the safety of all individuals who participate, the requirements in subparagraphs (A) - (F) of this paragraph apply.(A) A facility must develop a policy statement regarding the water sites utilized by the facility. Water sites include lakes, amusement parks, and pools.(B) A minimum of one staff person, who is certified and has demonstrated proficiency in CPR must be on duty and at the site when residents are involved in water activities.(C) A minimum of one person with demonstrated proficiency in water life-saving skills must be on duty and at the site when activities take place in or on water that is deep enough to require swimming for life-saving retrieval. This person must maintain supervision of the activity for its duration.(D) A sufficient number of staff or a combination of staff and volunteers must be available to meet the safety requirements of the group and specific residents.(E) Each resident's IPP must address each person's needs for safety when participating in water activities including medical conditions; physical disabilities and behavioral needs which could pose a threat to safety; the ability of residents to follow directions and instructions pertaining to water safety; the ability of residents to swim independently; and, when called for, special precautions.(F) If the IDT recommends the use of a flotation device as a precaution for any resident to engage in water activities, it must be identified and the precautions outlined in the IPP. The device must be approved by the United States Coast Guard or be a specialized therapy flotation device utilized in the individual's therapy program.(10) Communication. A facility may not prohibit a resident or employee from communicating in the person's native language with another resident or employee for acquiring or providing care, training, or treatment.(11) Physical exams. A facility must ensure that a resident is given at least one physical exam on a yearly basis by:(A) a person licensed to practice medicine in accordance with Texas Occupations Code, Chapter 155 (relating to License to Practice Medicine);(B) a person licensed as a physician assistant in accordance with Texas Occupations Code, Chapter 204 (relating to Physician Assistants); or(C) a person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301 (relating to Nurses), and authorized by the Texas Board of Nursing to practice as an advanced practice nurse.(f) Governing body and management. A facility must establish a governing body and the governing body must adopt, implement, and enforce the facility's policies and procedures. The governing body must review and update the facility policies and procedures at least annually.(g) Client protections. A facility must ensure the rights of a resident and through oversight, policy, and investigative procedures to ensure a resident is free from all abuse, neglect, and exploitation.(h) Facility staffing. A facility must ensure a resident receives professional and non-professional program services needed to implement the active treatment program defined by a resident's IPP.(i) Active treatment services. A facility must ensure a resident receives a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services in the IPP created by the IDT.(j) Client behavior and facility practices. A facility must develop and implement written policies and procedures for the management of conduct between staff and residents and the management of inappropriate resident behavior.(k) Health care services. A facility must provide or obtain preventative and general medical care for a resident and ensure a resident receives nursing services in accordance with the resident's needs.(l) Physical environment. A facility must provide sufficient space and equipment in dining, living, health services, recreation, and program areas to enable staff to provide a resident with needed services as required or identified in a resident's IPP. Additionally, a facility must ensure all fire safety and surrounding safety conditions are maintained in accordance with federal, state, and local regulations.(m) Emergency preparedness. A facility must establish and maintain an emergency preparedness program that meets all federal, state, and local emergency preparedness requirements.(n) Dietetic services. A facility must ensure a resident receives a nourishing, well-balanced diet including any modified or specifically prescribed diets. Source Note: The provisions of this §551.42 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective April 1, 1994, 19 TexReg 1832; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective June 1, 1995, 20 TexReg 3573; amended to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; amended tobe effective April 1, 1999, 24 TexReg 1816; amended to be effective May 1, 2000, 25TexReg 3557; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective June 1, 2006, 31 TexReg 4463; amended to be effective November 1, 2009, 34 TexReg 7654; amended to be effective June 1, 2010, 35 TexReg 4469; amended to be effective September 1, 2012, 37 TexReg 3871; amended to be effective June 17, 2013, 38 TexReg 3806; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS C STANDARDS FOR LICENSURE §551.42 Standards for a Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207884 03/12/2026 (a) Administration of medication to a resident of a facility may be performed only by:(1) a person who holds a license under state law that authorizes the person to administer medication;(2) in a facility, as defined in §557.101 of this title (relating to Introduction):(A) a person who holds a permit issued under Texas Health and Safety Code §242.610 (relating to Issuance and Renewal of Permit to Administer Medication) and acts under the authority of a person described in paragraph (1) of this subsection; or(B) a person who is exempt from licensure or permit requirements in accordance with Texas Health and Safety Code §242.607 (relating to Exemptions for Nursing Students and Medication Aide Trainees);(3) a person to whom an RN has delegated the administration of medication under 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments) or Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions); or(4) in a facility with a licensed or certified capacity of less than 14 residents, an unlicensed person who administers medication in accordance with Texas Human Resource Code, Chapter 161, Subchapter D-1 (relating to Administration of Medication for Clients with Intellectual and Developmental Disabilities).(b) An unlicensed person may administer medication without the requirement that an RN delegate or oversee each administration if:(1) the medication is:(A) an oral medication;(B) a topical medication; or(C) a metered dose inhaler;(2) the medication is administered to a resident for a stable or predictable condition;(3) the resident has been personally assessed by an RN initially and in response to significant changes in the resident's health status, and the RN has determined that the resident's health status permits the administration of medication by an unlicensed person; and(4) the unlicensed person has been:(A) trained by an RN or LVN under the direction of an RN regarding proper administration of medication; or(B) determined to be competent by an RN or LVN under the direction of an RN regarding proper administration of medication, including through a demonstration of proper technique by the unlicensed person.(c) An RN or an LVN under the supervision of an RN must review the administration of medication to a resident by a person described in subsection (a)(4) of this section at least annually and after any significant change in the resident's condition. Source Note: The provisions of this §551.43 adopted to be effective September 1, 2012, 37 TexReg 3871; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS C STANDARDS FOR LICENSURE §551.43 Administration of Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207885 03/12/2026 A facility must ensure that an employee who is hired by a facility on or after May 1, 2016, and whose duties will require the employee to work directly with a resident, completes trauma-informed care training before the employee works directly with a resident. For purposes of this section, "to work directly with a resident" means to serve on a resident's interdisciplinary team or otherwise work with a resident to implement the resident's individual program plan. Source Note: The provisions of this §551.44 adopted to be effective April 27, 2016, 41 TexReg 2971; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS C STANDARDS FOR LICENSURE §551.44 Trauma-Informed Care Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207886 03/12/2026 (a) For the purposes of this section, a "self-release seat belt" is a seat belt on a resident's wheelchair that the resident demonstrates the ability to fasten and release without assistance. A self-release seat belt is not a restraint.(b) Except as provided in subsection (c) of this section, a facility must allow a resident to use a self-release seat belt if:(1) the resident or the resident's legally authorized representative (LAR) requests that the resident use a self-release seat belt;(2) the resident consistently demonstrates the ability to fasten and release the self-release seat belt without assistance;(3) the use of the self-release seat belt is documented in and complies with the resident's individual program plan (IPP); and(4) the facility receives written authorization, signed by the resident or the resident's LAR, for the resident to use the self-release seat belt.(c) A facility that advertises as a restraint-free facility is not required to allow a resident to use a self-release seat belt if the facility:(1) provides a written statement to all residents that the facility is restraint-free and is not required to allow a resident to use a self-release seat belt; and(2) makes reasonable efforts to accommodate the concerns of a resident who requests a self-release seat belt in accordance with subsection (b) of this section.(d) A facility is not required to continue to allow a resident to use a self-release seat belt in accordance with subsection (b) of this section if:(1) the resident cannot consistently demonstrate the ability to fasten and release the seat belt without assistance;(2) the use of the self-release seat belt does not comply with the resident's IPP; or(3) the resident or the resident's LAR revokes in writing the authorization for the resident to use the self-release seat belt. Source Note: The provisions of this §551.45 adopted to be effective January 1, 2018, 42 TexReg 7727; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS C STANDARDS FOR LICENSURE §551.45 Wheelchair Self-Release Seat Belts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212043 03/12/2026 (a) Definitions. In this section, "plan" means a facility's emergency preparedness and response plan.(b) Administration. A facility must:(1) develop and implement a written plan as described in subsection (c) of this section;(2) maintain a current written copy of the plan that is accessible to all staff at all times;(3) evaluate the plan to determine if information in the plan needs to change:(A) within 30 days after an emergency situation;(B) due to remodeling or making an addition to the facility; and(C) at least every two years;(4) revise the plan within 30 days after information in the plan changes; and(5) maintain documentation of compliance with this section.(c) Emergency Preparedness and Response Plan. A facility's plan must:(1) include a risk assessment of potential internal and external emergency situations, including a fire, failure of heating and cooling systems, a power outage, an explosion, a hurricane, a tornado, a flood, extreme snow and ice conditions for the area, a wildfire, terrorism, or a hazardous materials accident;(2) include a description of the facility's resident population;(3) include a description of the services and assistance needed by the residents in an emergency situation;(4) include a section for each core function of emergency management that complies with subsection (d) of this section and is based on a facility's decision to either shelter-in-place or evacuate during an emergency situation; and(5) include a fire safety plan that complies with subsection (f) of this section.(d) Plan Requirements Regarding Eight Core Functions of Emergency Management.(1) Direction and control. A facility's plan must contain a section for direction and control that:(A) identifies the emergency preparedness coordinator (EPC), who is the facility staff person with the authority to manage the facility's response to an emergency situation in accordance with the plan;(B) identifies the alternate EPC, who is the facility staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity; and(C) documents the name and contact information for the local emergency management coordinator (EMC) for the area in which the facility is located, as identified by the office of the local mayor or county judge.(2) Warning. A facility's plan must contain a section for warning that:(A) describes how the EPC will be notified of an emergency situation;(B) identifies who the EPC will notify of an emergency situation and when the notification will occur, including during off hours, weekends, and holidays; and(C) ensures monitoring of local news and weather reports.(3) Communication. A facility's plan must contain a section for communication that:(A) identifies the facility's primary mode of communication and alternate mode of communication to be used in an emergency situation;(B) includes procedures for maintaining a current list of telephone numbers for residents' responsible parties;(C) includes procedures for maintaining a current list of telephone numbers for potential places to which to evacuate, such as hotels, motels, and other facilities licensed under this chapter or certified to participate in the Medicaid ICF/IID program;(D) includes procedures for maintaining a current list of telephone numbers for the facility's staff, by residence or unit, that identifies the facility's EPC and administrative staff;(E) identifies the location of the lists described in subparagraphs (B) - (D) of this paragraph, which must be a place where facility staff can obtain the information quickly;(F) includes procedures to notify:(i) facility staff about an emergency situation;(ii) a receiving facility about an impending or actual evacuation of residents; and(iii) residents, legally authorized representatives, and other persons about an impending or actual evacuation;(G) provides a method for persons to obtain resident information during an emergency situation; and(H) includes procedures for the facility to maintain communication with:(i) facility staff involved in an emergency situation;(ii) a receiving facility, if applicable; and(iii) the driver of a vehicle transporting residents, medications, records, food, water, equipment, or supplies during an evacuation.(4) Sheltering Arrangements. A facility's plan must contain a section for sheltering arrangements that:(A) includes procedures for implementing a decision to shelter-in-place that include:(i) having access to medications, records, food, water, equipment, and supplies; and(ii) sheltering facility staff involved in responding to an emergency situation, and their family members, if necessary;(B) includes procedures for notifying the HHSC regional office for the area in which the facility is located by telephone immediately after a decision to shelter-in-place has been made; and(C) includes procedures for accommodating evacuated residents, if the facility serves as a receiving facility for a facility that has evacuated.(5) Evacuation. A facility's plan must contain a section for evacuation that:(A) requires posting building evacuation routes prominently throughout the facility, except in small one-story buildings where all exits are obvious;(B) includes procedures for implementing a decision to evacuate residents to a receiving facility in an emergency situation, if applicable;(C) identifies evacuation destinations and routes and includes a map that shows the destinations and routes;(D) includes a current copy of the agreement with a receiving facility, if the evacuation destinations identified in accordance with subparagraph (C) of this paragraph include a receiving facility that is not owned by the same entity as the facility;(E) includes procedures for:(i) ensuring that facility staff accompany evacuating residents;(ii) ensuring that residents and facility staff present in the building have been evacuated;(iii) accounting for residents after they have been evacuated;(iv) accounting for residents absent from the facility at the time of the evacuation;(v) releasing resident information in an emergency situation to promote continuity of a resident's care;(vi) contacting the local EMC to find out if it is safe to return to the geographical area; and(vii) determining if it is safe to re-enter and occupy the building after an evacuation;(F) includes procedures for notifying the local EMC regarding an evacuation of the facility;(G) includes procedures for notifying the HHSC regional office for the area in which the facility is located by telephone immediately after a decision to evacuate is made; and(H) includes procedures for notifying the HHSC regional office for the area in which the facility is located by telephone that residents have returned to the facility, within 48 hours of their return to the facility after an evacuation.(6) Transportation. A facility's plan must contain a section for transportation that:(A) provides for a sufficient number of facility-owned vehicles to evacuate all residents and for alternate transportation arrangements if the facility-owned vehicles are not available;(B) includes procedures for safely transporting residents, facility staff involved in an evacuation and, if necessary, their family members, and the facility's and residents' pets during an evacuation; and(C) includes procedures to safely transport and have timely access to oxygen, medications, records, food, water, equipment, and supplies needed during an evacuation.(7) Health and Medical Needs. A facility's plan must contain a section for health and medical needs that:(A) identifies all the facility's residents with special medical needs; and(B) ensures that the needs of those residents are met during an emergency situation.(8) Resource Management. A facility's plan must contain a section for resource management that:(A) includes procedures for maintaining accurate and detailed checklists of medications, records, food, water, equipment and supplies needed during an emergency situation;(B) identifies facility staff who are assigned to locate and ensure the transportation of the items on the list described in subparagraph (A) of this paragraph during an emergency situation; and(C) includes procedures to ensure that medications are secure and stored at the proper temperatures during an emergency situation.(e) Training. A facility must:(1) inform a facility staff member of the staff member's responsibilities under the plan within five working days after assuming job duties;(2) re-train a facility staff member at least annually on the staff member's responsibilities under the plan and when the staff member's responsibilities under the plan change; and(3) conduct unannounced, annual drills with facility staff for severe weather and other emergency situations identified by the facility as likely to occur, based on the results of the risk assessment required by subsection (c)(1) of this section.(f) Fire Safety Plan. A facility's fire safety plan must:(1) for a large facility, include the provisions described in the Operating Features section of NFPA 101, Chapter 18 (for new healthcare occupancies) and Chapter 19 (for existing healthcare occupancies) concerning:(A) use of alarms;(B) transmission of alarms to fire department;(C) emergency phone calls to fire department;(D) response to alarms;(E) isolation of fire;(F) evacuation of immediate area;(G) evacuation of smoke compartment;(H) preparation of floors and building for evacuation; and(I) extinguishment of fire;(2) for a small facility, include the provisions described in the Operating Features section of NFPA 101, Chapter 32 (for new residential board and care occupancies) and Chapter 33 (for existing residential board and care occupancies) concerning:(A) use of alarms;(B) staff response in the event of a fire;(C) fire protection procedures for a resident;(D) actions to take if the primary escape route is blocked; and(E) specification of an assembly point after a resident evacuates from the facility; and(3) include procedures for:(A) rehearsing the fire safety plan at least once per quarter on each work shift;(B) evacuating residents as follows:(i) for a small facility that has a prompt or slow evacuation capability, during every fire drill; or(ii) for a large facility or facility with an impractical evacuation capability, during at least one fire drill each year on each work shift;(C) completing the HHSC form 4719 titled "Fire Drill Report" or a form containing, at a minimum, the information on the HHSC form; and(D) providing residents and facility staff with experience in egressing through all exits and means of escape.(g) Reporting Fires. A facility must report a fire at the facility to HHSC as follows:(1) by calling 1-800-458-9858 within 24 hours after the fire; and(2) by submitting a completed HHSC form 3707 titled "Fire Report for Long Term Care Facilities" within 15 days after the fire.(h) Emergency Response System.(1) The facility administrator and designee must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The facility must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §551.50 adopted to be effective March 21, 2011, 36 TexReg 1879; amended to be effective October 12, 2017, 42 TexReg 5508; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787; amended to be effective January 24, 2023, 48 TexReg 216. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS C STANDARDS FOR LICENSURE §551.50 Emergency Preparedness and Response https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207897 03/12/2026 (a) Construction phase.(1) The Texas Health and Human Services Commission (HHSC) in Austin, Texas, must be notified in writing of construction start.(2) All construction must be done in accordance with minimum licensing requirements. It is the sponsor's responsibility to employ qualified personnel to prepare the contract documents for construction of a new facility or remodeling of an existing facility. Contract documents for additions and remodeling and for the construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners (TBAE). Drawings must bear the seal of the architect. Certain parts of final plans, designs, and specifications must bear the seal of a registered professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. These certain parts include sheets and sections covering structural, electrical, mechanical, and sanitary engineering.(A) Remodeling is the construction, removal, or relocation of walls and partitions; the construction of foundations, floors, or ceiling-roof assemblies; the expanding or altering of safety systems (including sprinkler, fire alarm, and emergency systems); or the conversion of space in a facility to a different use.(B) General maintenance and repairs of existing material and equipment, repainting, applications of new floor, wall, or ceiling finishes, or similar projects are not included as remodeling, unless as a part of new construction. HHSC must be provided flame spread documentation for new materials applied as finishes.(b) Contract documents.(1) Site plan documents must include grade contours; streets (with names); north arrow; fire hydrants; fire lanes; utilities, public or private; fences; unusual site conditions, such as ditches, low water levels, other buildings on-site; and indications of buildings five feet or less beyond site property lines.(2) Foundation plan documents must include general foundation design and details.(3) Floor plan documents must include room names, numbers, and usages; doors (numbered) including swing; windows; legend or clarification of wall types; dimensions; fixed equipment; plumbing fixtures; and kitchen basic layout; and identification of all smoke barrier walls (outside wall to outside wall) or fire walls.(4) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2 inch by 11 inch sheet; submit two reduced plans for file record, as described in §551.60(c)(3) of this subchapter (relating to Construction and Initial Survey of Completed Construction).(5) Schedules must include door materials, widths, and types; window materials, sizes, and types; room finishes; and special hardware.(6) Elevations and roof plan must include exterior elevations, including material note indications and any roof top equipment; roof slopes, drains, and gas piping; and interior elevations where needed for special conditions.(7) Details must include wall sections as needed (especially for special conditions); cabinet and built-in work, basic design only; cross sections through buildings as needed; and miscellaneous details and enlargements as needed.(8) Building structure documents must include structural framing layout and details (primarily for column, beam, joist, and structural frame building); roof framing layout (when this cannot be adequately shown on cross section); cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design, also calculated design loads.(9) Electrical documents must include electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices; service, circuiting, distribution, and panel diagrams; exit light system (exit signs and emergency egress lighting); emergency electrical provisions (such as generators and panels); fire alarm and similar systems (such as control panel, devices, and alarms); sizes and details sufficient to assure safe and properly operating systems; and a staff communication system.(10) Plumbing documents must include plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems, water systems, sanitary systems, gas systems, other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(11) Heating, ventilation, and air-conditioning (HVAC) documents must include sufficient details of HVAC systems and components to assure a safe and properly operating installation including heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke or fire dampers; and equipment types, sizes, and locations.(12) Sprinkler system documents must include plans and details of NFPA designed systems; plans and details of partial systems provided only for hazardous areas; electrical devices interconnected to the alarm system.(13) Other layouts, plans, or details as may be necessary for a clear understanding of the design and scope of the project; including plans covering private water or sewer systems must be reviewed by the local health or wastewater authority having jurisdiction. If no local authority, then the plans will be reviewed by HHSC.(14) Specifications must include installation techniques, quality standards, manufacturers, references to specific codes and standards, design criteria, special equipment, hardware, painting, and any others as needed to amplify drawings and notes.(c) Initial survey of completed construction.(1) Upon completion of construction, including grounds and basic equipment and furnishings, a final construction inspection (initial survey) of the facility, including additions or remodeled areas, is required to be performed by HHSC prior to occupancy. The completed construction must have the written approval of the local authorities having jurisdiction, including the fire marshal, and building inspector.(2) After the completed construction has been surveyed by a representative of the architectural section of HHSC and found acceptable, this information will be conveyed to the licensing specialist as part of the information needed to issue a license to the facility. In the case of additions or remodeling of existing facilities, a revision or modification to an existing license may be necessary. Note that the building, grades, drives, parking and grounds must be essentially 100 percent complete at the time of this initial survey visit for occupancy approval and licensing, including basic furnishings and operational needs.(3) A copy of the following documents must be available to HHSC's surveyor at the time of the survey of the completed building:(A) written approval of local authorities as called for in paragraph (1) of this subsection;(B) written certification of the fire alarm system by the installing agent (Form FML-009A of the Texas State Fire Marshal);(C) documentation of materials used in the building which are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant curtains (including cubicle curtains), and rated ceilings. This must include a signed letter from the installer verifying that the material installed is the same material named in the laboratory test document;(D) approval of the completed sprinkler system installation by the designing engineer. A copy of the material list and test certification must be available;(E) service contracts for maintenance and testing of systems, including alarm systems and sprinkler systems;(F) a copy of gas test results of the facility's gas lines from the meter;(G) a written statement from an architect or engineer stating that he or she certifies that the building was constructed to meet NFPA 101 and all locally applicable codes, and that the facility is in substantial conformance with minimum licensing requirements; and(H) the contract documents specified in subsection (b) of this section.(d) Non-approval of new construction.(1) If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, he or she may recommend to HHSC that the facility not yet be licensed and approved for occupancy. Such basic items may include the following:(A) construction which does not meet minimum code or licensure standards for basic requirements such as corridor widths being less than eight feet clear width, ceilings installed at less than the minimum seven feet six inches height, resident bedroom dimensions less than required width, and other such features which would disrupt or otherwise adversely affect the residents and staff if corrected after occupancy;(B) no written approval by local authorities;(C) fire protection systems not completely installed or not functioning properly including fire alarm systems, emergency power and lighting, and sprinkler systems;(D) required exits are not all usable according to NFPA 101 requirements;(E) telephone not installed or not properly working;(F) sufficient basic furnishings, essential appliances and equipment are not installed or not functioning; and(G) any other basic operational or safety feature which the surveyor, as the authority having jurisdiction, encounters which in his or her judgment would preclude safe and normal occupancy by residents on that day.(2) If the surveyor encounters deficiencies that do not affect the health and safety of the residents, licensure may be recommended based on an approved written plan of correction by the facility's administrator.(3) Copies of reduced size floor plan on an 8 1/2 inch by 11 inch sheet must be submitted in duplicate to HHSC for record/file use and for such uses by the facility as evacuation planning and fire alarm zone identification. The plan must contain basic legible information such as overall dimensions, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information. Source Note: The provisions of this §551.60 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.60 Construction and Initial Survey of Completed Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207898 03/12/2026 (a) Scope. The requirements of this section are applicable to both new and existing facilities unless stated otherwise.(b) Purpose.(1) The concept of requirements for fire safety with regard to the residents is based on evacuation capability as published in NFPA 101. These standards are written with the premise that the residents will be capable of self-evacuation without continuous staff assistance. Residents that are not normally capable of self-evacuation nor capable of negotiating stairs unassisted must not be housed above or below the floor of exit discharge unless the facility meets the construction requirements of NFPA 101, Chapter 18, New Health Care Occupancies, or Chapter 19, Existing Health Care Occupancies, for large facilities, or the "impractical" requirements for small facilities as found in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, or Chapter 33, Existing Residential Board and Care Occupancies. Examples of residents who may not be capable of self-evacuation are as follows:(A) a person with a physical disability of a nature that he or she is not capable of maneuvering in a wheelchair, walker, or other assistive device unaided;(B) a person with an intellectual disability who will not take or cannot understand instructions from a staff member; or(C) a person that is taking medication before bedtime which will make it difficult for a staff member to arouse the person quickly.(2) The method of determining the evacuation capability of residents under NFPA 101, Chapter 32, New Residential Board and Care Occupancies or Chapter 33, Existing Residential Board and Care Occupancies, is by rating each resident and each staff member to determine an evacuation difficulty score (E-score). If the E-score is 1.5 or less, the evacuation capability of the facility is prompt, greater than 1.5 to five is slow, greater than five is impractical. The worksheets to be completed are located in NFPA 101A, Chapter 6, Evacuation Capability Determination for Board and Care Occupancies. Facilities with capacity for 16 residents or less must meet the evacuation requirement for their designated Chapter 32, New Residential Board and Care Occupancies or Chapter 33, Existing Residential Board and Care Occupancies rating. The ratings and their requirements are:(A) Impractical rating.(i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).(ii) The facility must actually evacuate residents once a year on each shift.(iii) All facility staff, including relief and substitute staff, must participate in drills as soon as possible after beginning employment on their shift.(iv) E-scores are not required for certification under this rating.(B) Slow rating.(i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).(ii) The facility must actually evacuate residents during all drills.(iii) Staff on each shift must participate in drills.(iv) New, relief, and substitute staff must participate in a drill within ten days of employment on their assigned shift.(v) E-scores must be calculated as soon as possible, but within ten calendar days of admission.(vi) Initial E-scores are based on four drills, as follows:(I) two conducted during the daytime; and(II) two conducted during the nighttime, after the first 30 minutes and within the first three hours of sleep.(vii) After the initial E-scores are obtained, a worksheet for rating residents must be completed for all newly admitted residents to obtain an E-score. The evacuation capability is calculated as described in clause (vi) of this subparagraph.(viii) E-scores must be updated annually or sooner if significant changes occur in any resident's evacuation capability. These updated scores are based on the group's overall performance during fire drills as they are conducted throughout the year. Scores do not have to be calculated in accordance with the drills required for newly admitted residents based on the requirements stated in clause (vi) of this subparagraph.(C) Prompt rating.(i) The facility must have one fire drill per shift each calendar quarter (minimum of 12 drills per year).(ii) The facility must actually evacuate residents during all drills.(iii) Staff on each shift must participate in drills.(iv) New, relief, and substitute staff must participate in a drill within ten days of employment on their assigned shift.(v) E-scores must be calculated as soon as possible, but within ten calendar days of admission.(vi) Initial E-scores are based on four drills, as follows:(I) two conducted during the daytime; and(II) two conducted during the nighttime, after the first 30 minutes and within the first three hours of sleep.(vii) After the initial E-scores are obtained, a worksheet for rating residents must be completed for all newly admitted residents to obtain an E-score. The evacuation capability is calculated as described in clause (vi) of this subparagraph.(viii) E-scores must be updated annually or sooner if significant changes occur that would affect a resident's evacuation capability. These updated scores are based on the group's overall performance during fire drills as they are conducted throughout the year. Scores do not have to be calculated in accordance with the drills required for newly admitted residents based on the requirements stated in clause (vi) of this subparagraph.(3) The "E" score will determine which NFPA 101 features are to be installed and maintained in the facility. These features include construction, fire alarm systems, smoke detector systems, interior finish, sprinkler systems, separation of bedrooms, and egress from the building.(c) Construction.(1) New construction is any construction work that began on or after July 5, 2016. The provisions of NFPA 101, Chapter 18, New Health Care Occupancies are applicable for large facilities, and Chapter 32, New Residential Board and Care Occupancies for small facilities.(2) An existing facility is one that was operating with a license as a facility for persons with an intellectual disability or related conditions before November 1, 2016, and has not subsequently become unlicensed. The provisions of NFPA 101, Chapter 19, Existing Health Care Occupancies are applicable for large facilities, and Chapter 33, Existing Residential Board and Care Occupancies for small facilities.(3) Alterations or new installations of building services equipment, such as mechanical and electrical systems, generators, fire alarm, and detection systems must be accomplished in conformance with the requirements for new construction as required by NFPA 101.(4) Site approval, as required by the local health officer, building department, or fire marshal having jurisdiction, must be obtained. Any conditions considered to be a fire, safety, or health hazard will be grounds for disapproval of the site by the Texas Health and Human Services Commission (HHSC) unless applied in an arbitrary or discriminating manner.(5) Facilities that renovate must provide documentation for the flame spread rate of any new materials applied as an interior finish.(6) Life safety features and equipment that have been installed in existing buildings and are now in excess of that required by NFPA 101 must continue to be maintained or must be removed at the direction of HHSC.(7) When an existing licensed facility plans building additions or remodeling, which includes construction of additional resident beds, then the ratio of bathing units must be reevaluated to meet minimum standards and the square footage of dining and living areas must be reevaluated by HHSC. Conversion of existing living, dining, or activity areas to resident bedrooms must not reduce these functions to an area less than required by minimum standards.(8) Buildings must be of recognized permanent type construction. They must be structurally sound with regard to actual or expected dead, live, and wind loads according to applicable building codes.(9) Each building must be classified as to the building construction type for fire resistance rating purposes in accordance with NFPA 220 and NFPA 101.(d) Applicable codes and standards. Except as provided in paragraph (9) of this subsection, a facility must comply with NFPA 101, NFPA 99, and a Tentative Interim Amendment (TIA) issued by the NFPA for NFPA 99 or NFPA 101, including the TIAs listed in paragraphs (1) and (2) of this subsection. A facility must also comply with other NFPA publications referenced in this chapter and a TIA issued for a publication referenced in this chapter, unless otherwise approved or required by HHSC.(1) The following TIAs have been issued for NFPA 101:(A) TIA 12-1 to NFPA 101, issued August 11, 2011;(B) TIA 12-2 to NFPA 101, issued October 30, 2012;(C) TIA 12-3 to NFPA 101, issued October 22, 2013; and(D) TIA 12-4 to NFPA 101, issued October 22, 2013.(2) The following TIAs have been issued for NFPA 99:(A) TIA 12-2 to NFPA 99, issued August 11, 2011;(B) TIA 12-3 to NFPA 99, issued August 9, 2012;(C) TIA 12-4 to NFPA 99, issued March 7, 2013;(D) TIA 12-5 to NFPA 99, issued August 1, 2013; and(E) TIA 12-6 to NFPA 99, issued March 3, 2014.(3) If the municipality has a building code and a plumbing code, then those codes must govern in those areas of construction. Where local codes or ordinances are applicable, the most restrictive parts concerning the same subject item must apply unless otherwise determined by the authority having jurisdiction for local codes and HHSC.(4) In the absence of such governing municipal codes, nationally recognized codes must be used, such as the Standard Building Code and the Standard Plumbing Code, both of the Southern Building Code Congress International, Inc. Such nationally recognized codes, when used, must all be publications of the same group or organization to assure the intended continuity.(5) Heating, ventilating, and air-conditioning systems must be designed and installed in accordance with NFPA 90A and NFPA 90B, as applicable, and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), except as may be modified in this subchapter.(6) Electrical and illumination system must be designed and installed in accordance with NFPA 70 and the Lighting Handbook of the Illuminating Engineering Society of North America (IES) except as may be modified in this subchapter.(7) The facility must meet all applicable provisions and requirements concerning accessibility for individuals with disabilities in the following laws and regulations: the Americans with Disabilities Act of 1990 (Title 42, United States Code, Chapter 126); 28 CFR Part 35, Nondiscrimination on the Basis of Disability in State and Local Government Services; Texas Government Code, Chapter 469, Elimination of Architectural Barriers; and 16 TAC , Chapter 68, Elimination of Architectural Barriers. Plans for new construction, substantial renovations, modifications, and alterations must be submitted to the Texas Department of Licensing and Regulation (Attention: Elimination of Architectural Barriers Program) for accessibility approval under Chapter 469.(8) A facility with a boiler must meet all applicable provisions and requirements of Texas Health and Safety Code, Chapter 755, Boilers.(9) A facility that is required to comply with NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, must be in compliance with Chapter 33.2.3.5.7.1 or 33.2.3.5.7.2 by July 5, 2019.(e) General requirements.(1) The facility must provide and maintain furnishings and decorations that meet the needs of the residents.(2) The building, grounds, and equipment must be maintained in good repair, operational, sanitary, and free of hazards.(3) There must be at least one telephone (other than a pay phone) in the facility, accessible to residents for use in making calls to summon help in case of emergency.(4) The facility must have:(A) floors that are free of irregularities and are substantially level (floor areas may be at different elevations with connecting stairs or ramps);(B) floors that have a resilient, nonabrasive, and slip-resistant surface;(C) nonabrasive carpeting, if the area used by residents is carpeted and serves residents who lie on the floor or ambulate with parts of their bodies, other than feet, touching the floor; and(D) exposed floor surfaces and floor coverings that promote mobility in areas used by residents and promote maintenance of sanitary conditions.(5) Walls and ceilings must be cleanable and in good repair.(6) Walls and floors must be kept free of cracks. The joint between the walls and floors is to be maintained so as to be free of spaces which might harbor insects, rodents, or vermin.(7) An adequate supply of hot water must be provided. The hot water system for resident use must be capable of being regulated to not exceed 110 degrees Fahrenheit at the fixtures.(8) Draperies, curtains (including cubicle curtains), and other similar furnishings and decorations must be flame resistant in accordance with NFPA 701. Documentation must be kept on file in the facility.(9) Wastebaskets must be of noncombustible material.(10) An initial pressure test of facility gas lines from the meter must be provided. Additional pressure tests will be required when the facility has major renovations or additions where the gas service is interrupted. All gas heating systems must be checked for proper operation and safety prior to the heating season. Any unsatisfactory conditions must be corrected promptly.(11) The IES recommendations must be followed to achieve proper illumination characteristics and lighting levels throughout the facility. Minimum illumination must be 10 footcandles in resident rooms during the day and 20 footcandles in corridors, staff stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways, and elevators during the day. Illumination requirements for these areas apply to lighting throughout the space and must be measured at approximately 30 inches above the floor anywhere in the room. Minimum illumination for medication preparation or storage areas, kitchens, and staff station desks must be 50 footcandles during the day. Illumination requirements for these areas apply to the task performed and must be measured on the tasks.(12) In addition to the required illumination (normal and emergency), the facility must keep on hand and readily available to night staff, no less than one working flashlight.(13) Combustible attic areas larger than 3,000 square feet must be divided into compartments not exceeding 3,000 square feet or the attic area must be sprinkled. The separating barrier must be at least one layer of 1/2-inch gypsum board on one side of support members. Source Note: The provisions of this §551.61 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective May 1, 2004, 29 TexReg 3237; amended to be effective July 30, 2012, 37 TexReg 5629; amended to be effective October 12, 2017, 42 TexReg 5508; transferred effective May 1, 2019, as published in the Texas Register April12,2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.61 Introduction, Application, and General Requirements for Facilities for Persons with an Intellectual Disability or Related Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207899 03/12/2026 (a) General (All Facilities).(1) Site grades must provide for positive surface water drainage so that there will be no ponding or standing water at or near the building such as would present a hazard to health or provide a breeding site or harborage for disease vectors.(2) Outdoor activity, recreational, and sitting spaces must be provided and be accessible to all residents.(3) Each facility must have parking space to satisfy the needs of residents, employees, staff, and visitors.(4) Protection must be provided for resident safety on facility grounds using appropriate methods, such as fences, hedges, retaining walls, railings, or other landscaping. Such protection must not inhibit the free emergency egress to a safe distance away from the building.(5) All outside areas, grounds, and adjacent buildings on the site must be maintained in good condition and kept free of rubbish, garbage, untended growth, and other conditions which may constitute a fire or health hazard.(b) Additional site conditions (large facilities only).(1) Auxiliary buildings located on the site within 20 feet of the main licensed structure and which contain hazardous operations or contents, such as laundries or storage buildings, must meet the same code requirements for safety as the main licensed structure, or the building must be moved to be 20 feet or farther away from the main building.(2) Other buildings on the site must meet the appropriate occupancy section or separation requirements of NFPA 101.(3) A new building (or addition) must be set back at least ten feet from the property lines except as otherwise approved by HHSC.(4) Exit doors from the building must not open directly onto a drive for vehicular traffic but must be set back at least six feet from the edge of such drive (measured from the end of building wall in the case of a recessed door) to prevent accidents due to lack of visual warning. These doors are to have automatic or self-closures.(5) Walks must be provided from all exits and must be of non-slip surfaces free of hazards. Walks must be at least 48 inches wide except as otherwise approved. Ramps must be used in lieu of steps where grade change is 21 inches or less, and where possible, for persons with physical disabilities or mobility impairment, and to facilitate bed or wheelchair removal in an emergency.(6) Open or enclosed courts with resident rooms or living areas opening upon them must not be less than 20 feet in the smallest dimension unless otherwise approved by HHSC.(7) There must be at least one approved readily accessible fire hydrant located within 300 feet of the building. The hydrant must be on a minimum six-inch service line, or else there must be an approved equivalent (such as a storage tank). The hydrant, its location, and service line, or equivalent must be approved by the local fire department and HHSC.(8) The building must have suitable fire lanes for access as required by local fire authorities and HHSC. Source Note: The provisions of this §551.62 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.62 Site and Grounds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207900 03/12/2026 (a) The facility must be served by a paid or volunteer fire department. The fire department must provide written assurance to the Texas Health and Human Services Commission that the fire department can respond to an emergency at the facility.(b) Water supply for firefighting purposes must be as required and approved by the firefighting unit.(c) The facility must have an annual inspection by the local fire marshal. Source Note: The provisions of this §551.63 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 2000, 25 TexReg 3557; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.63 Fire Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207901 03/12/2026 (a) Corridors and other means of egress must be kept clear of obstructions and must not be used for any purpose which would interfere with its use as an exit, such as for storage, vending machines, seating, or similar purposes. The corridor width must be maintained at all times.(b) Doors within the means of egress must not be equipped with a latch or lock which requires the use of a key or tool to open from the inside of the building. A latch or other fastening device on a door must be provided with a knob, handle, panic bar, or other simple type of releasing device, the method of operation of which is obvious, even in darkness. An exception is that large facilities are permitted to have doors which are locked, if residents can be rapidly removed using remote control of locks or by keying all locks to keys readily available to staff who are in constant attendance.(c) A hold-open device must be installed on each exit door of large facilities. Source Note: The provisions of this §551.64 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 2000, 25 TexReg 3557; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.64 Means of Egress https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207890 03/12/2026 (a) General. Fire alarms, detection systems, and sprinkler systems must be as required by NFPA 101, NFPA 72, NFPA 13, NFPA 13R, or NFPA 13D, as specified in NFPA 101, Chapter 32, New Residential Board and Care Occupancies and Chapter 33,Existing Residential Board and Care Occupancies, and as modified in this section.(1) Each building must have an approved fire alarm system.(2) Components must be compatible and laboratory listed for the use intended.(3) Wiring and circuitry for alarm systems must meet the applicable requirements of NFPA Codes, including NFPA 70, for such systems.(4) Fire alarm systems must be installed, maintained, and repaired by an agent having a current certificate of registration with the state fire marshal's office of the Texas Commission on Fire Protection, in accordance with the state law. A fire alarm system installation certificate must be provided as required by the State Fire Marshal's Office. An exception is that large facilities who have professional engineers on staff that are qualified in electrical and electronic installations are not required to have a certificate of registration with the State Fire Marshal's Office, provided they do not sell, install, or maintain fire alarm systems commercially.(5) Smoke detector sensitivity must be checked within one year after installation and every alternate year thereafter in accordance with NFPA 72. Documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation must be available for examination by HHSC.(b) Fire alarm and smoke detection and sprinkler systems for small facilities.(1) A manual alarm initiating system must be provided and must be supplemented by an automatic smoke detection and alarm initiation system in accordance with NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, Section 9-6, Fire Detection, Alarm, and Communications Systems.(2) Smoke detectors must be installed in resident bedrooms, corridors, hallways, and common living/dining areas. Service areas such as laundries and kitchens must have heat detectors in lieu of smoke detectors.(3) The fire alarm control panel must be located to be in view of staff. The primary power source for the complete fire alarm system must be commercial electric.(4) Emergency power source must be from storage batteries or on-site engine-driven generator set.(5) The operation of any alarm initiating device will sound an audible or visual alarm at the site.(6) The facility must have a written contract with a fire alarm company or person licensed by the State Fire Marshal's Office to maintain the fire alarm system semiannually, and the system will be inspected as specified in the contract.(7) Facilities classified as "impractical evacuation capability," must be protected by a sprinkler system in compliance with NFPA 13, NFPA 13R, or NFPA 13D with additional requirements for coverage in all dwelling areas and all closets as specified by NFPA 101, Chapter 32, New Residential Board and Care Occupancies, and Chapter 33, Existing Residential Board and Care Occupancies.(c) Fire alarm and emergency systems for large facilities.(1) The fire alarm system must be designed so that whenever the general alarm is sounded by activation of any device (manual pull, smoke sensor, sprinkler, kitchen range hood extinguisher, or other device) the following must occur automatically.(A) Smoke and fire doors which are held open by approved devices must be released to close.(B) Air handlers (air conditioning/heating distribution fans) serving three or more rooms or any means of egress must shut down immediately.(C) Smoke dampers must close.(D) The proper zone indicating lights must show on the fire alarm control panel, including auxiliary panels.(2) Fire alarm bells or horns must be located throughout the building for audible coverage. Flashing alarm lights (visual alarms) of proper intensity must be installed to be visible in corridors and public areas including dining rooms and living rooms.(3) A master control panel must be visible at the main staff station which has alarm and trouble conditions by zones, power-on lights, and required signal devices for trouble conditions. All control panels must be listed in accordance with the provisions of the Underwriters Laboratories, Inc. (UL) for the intended use, i.e., manual, automatic, and water flow activation. Alarm and trouble zoning must be by smoke compartments and by floors in multi-story facilities.(4) Remote annunciator panels equipped with alarm by zone and a common trouble signal (both audible and visual) must be located at auxiliary or secondary staff stations on each floor or major subdivisions of single story facilities, that will indicate the alarm condition of adjacent zones and the alarm conditions at all other staff stations.(5) Manual pull stations must be provided at all exits, living rooms, dining rooms, and at or near the staff stations.(6) The NFPA 13 sprinkler system must be interconnected with the fire alarm panel as a separate zone for alarm and trouble. Activation of the tamper switch will provide a trouble condition on the fire alarm panel that will not impair the operation of the alarm.(7) The kitchen range hood extinguisher must be interconnected with the fire alarm system. This interconnection may be a separate zone on the panel or combined with other initiating devices located in the same zone as the range hood is located.(8) The fire alarm system must be arranged to transmit an alarm automatically to the fire department legally committed to serve the area in which the facility is located by the most direct and reliable method allowed by NFPA 101.(9) Partial sprinkler systems (those provided only for hazardous areas) must be interconnected to the fire alarm system and comply with NFPA 101. Each partial system must have a valve with a supervisory switch to sound a supervisory signal, water flow switch to activate the fire alarm, and an end of line test drain.(10) Emergency electrical services must be provided to comply with the provisions of NFPA 70. This includes such items as emergency power provided by generator or batteries for fire alarm systems, emergency egress lighting, call systems, TV cameras and monitors (if used for corridor observation), life support systems, or designated wall receptacles. The system must comply with NFPA 99 and NFPA 37.(11) Elevators, escalators, and moving walks. Elevators must comply with the provisions of NFPA 101 and American National Standards Institute (ANSI) Safety Code for Elevators and Escalators (American Society of Mechanical Engineers (ASME)) A17.1. Elevators are required for buildings having resident facilities (such as bedrooms, dining, or recreation areas) or services (such as diagnostic or therapy) located on other than the main entrance floor. Passenger elevators, escalators, and walks must be inspected by a qualified agent at least every six months. Freight elevators and dumbwaiters must be inspected every 12 months. Source Note: The provisions of this §551.65 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective May 1, 2004, 29 TexReg 3237; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.65 Fire Alarms, Detection Systems, and Sprinkler Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207888 03/12/2026 (a) General. Portable fire extinguishers must be provided and maintained to comply with the provisions of NFPA 10. This includes such items as type of extinguishers (A, B, or C), location and spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent (with any necessary servicing), and hydrostatic testing as recommended by the manufacturer.(b) Types of extinguishers.(1) Extinguishers in resident corridors must be spaced so that travel distance is not more than 75 feet. The minimum size of extinguishers must be either 2 1/2 gallon (pressurized water) for water type or 2-A: 10-B: C (five-pound dry chemical) for ABC type.(2) Extinguishers must be installed on supplied hangers or brackets or be mounted in cabinets approved by the Texas Health and Human Services Commission (HHSC).(3) Extinguishers must be surface wall-mounted or recessed in cabinets where they are not subject to physical damage or dislodgement.(4) Extinguishers having a gross weight not exceeding 40 pounds must be installed so that the top of the extinguisher is not more than five feet above the floor. Extinguishers with a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than 3 1/2 feet above the floor. The clearance between the bottom of the extinguisher and the floor must not be less than four inches.(5) Portable extinguishers provided in hazardous rooms must be located as close as possible to the exit door opening and on the latch (knob) side.(6) Staff must be appropriately trained in the use of each type of extinguisher in the facility. Source Note: The provisions of this §551.66 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.66 Portable Fire Extinguishers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207889 03/12/2026 The physical plant must be designed for persons with physical disabilities or mobility impairments and must comply with applicable federal, state, and local requirements. Source Note: The provisions of this §551.67 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.67 Accessibility Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207891 03/12/2026 (a) Large facilities.(1) Ancillary resident space. The minimum total ancillary resident-use space must be not less than 35 square feet per resident. Ancillary space includes areas for living, dining, recreation, therapy, training, and other such program areas. It does not include bedrooms, passageways, offices, kitchens, or laundries (more than 35 square feet per resident is usually needed in facilities with less than 60 residents). A facility which has large proportions (approximately 65 percent or greater) of nonambulatory or bedfast residents must provide at least 50 square feet of ancillary space per resident unless otherwise approved by HHSC. An area providing less space than called for in this paragraph cannot be approved except on an individual basis where clearly justified.(2) Resident bedrooms. (A) A bedroom must be arranged and equipped for adequate personal care and for comfort and privacy. A bedroom must have full height walls that extend from floor to ceiling with doors. (Partial partitions or furnishings are not a substitute.) An exception is that an existing facility constructed prior to October 3, 1988, that has partial partitions in lieu of full-height walls, need not install the full-height walls unless there are major renovations or conversions.(B) A bedroom must provide at least 80 square feet for a single occupancy (one resident) and 60 square feet per resident for multiple occupancy. (Note: room configuration and usability are taken into consideration and there may be instances where the minimum square footage will not be acceptable.) The minimum room dimension must be at least eight feet for a single resident room and at least ten feet for a multiple-resident room, unless otherwise approved by HHSC. An exception is that a multi-occupancy bedroom for persons in wheelchairs must have 70 square feet per resident.(C) No more than four residents may be in any one bedroom. An exception is HHSC may grant a variance from the limit of four residents per room only if a physician who is a member of the IDT and who is a qualified intellectual disability professional (QIDP):(i) certifies that each resident to be placed in a bedroom accommodating more than four residents is so severely medically impaired as to require direct and continuous monitoring during sleeping hours; and(ii) documents the reasons why accommodating in a room of only four or fewer residents would not be medically feasible.(D) In the bedroom and for each resident there must be a bed with a comfortable mattress and appropriate bedding, functional furniture appropriate to residents' needs, and closet space providing security and privacy for clothing and personal belongings. Closet space must provide at least 24 inches of lineal hanging space per resident (in certain cases, such as for infants, exceptions may be made). Married couples may share a bed.(E) Each bedroom must have at least one outside wall with an operable window giving outside exposure. Unless approved otherwise by the HHSC, the window sill of the required window must be no higher than 44 inches from the floor and must be at or above outside grade level. Other window requirements must be as called for in NFPA 101. The window area for a bedroom must be equal to at least 10 percent of the total room floor area.(F) If a bedroom is below grade level, it must have a window that is usable as a second means of escape by a resident occupying the room. The window must be no more than 44 inches (measured to the window sill) above the floor.(G) A resident bedroom must open onto an exit corridor, living area, or public area and must be arranged for convenient resident access to dining, living, and bathing areas.(3) Social-diversional spaces.(A) A living room, a day room, a lounge, or other social-diversional space, must be provided on a sliding scale as follows (as part of the minimum required ancillary space): Attached Graphic(B) Where a required way of exit is through a living area, a pathway equal to the corridor width will normally be deducted from that area. Such exit pathways must be kept clear of obstructions.(C) Each living room and dining room must have at least one outside window. Normally, a resident classroom and a training area must also have an outside window unless otherwise approved by HHSC.(4) Dining space. Dining space must provide at least 15 square feet per resident for single-shift feeding. If procedure is approved for feeding in two shifts, at least eight square feet per resident must be provided.(5) Training spaces including academic, behavioral, occupational, physical, and speech therapy spaces. Classroom type space is anticipated for most training activities. The number and size of such spaces will be evaluated on an individual facility basis and according to program policies and procedures. Generally, a training room must provide at least 20 square feet per resident trainee within the room except that no training room may be less than 80 square feet. For purposes of calculation, space must be provided for at least one-third of the total population at any one time (i.e., plan space for 33 residents in a 100-resident facility).(6) Kitchens (main/dietary).(A) A kitchen must be evaluated based on its performance in the sanitary and efficient preparation and serving of meals to residents. Consideration must be given to planning for the type of meals served, the overall building design, the food service equipment, arrangement, and the work flow involved in the preparation and delivery of food. Plans for construction of new facilities must contain a detailed kitchen layout prepared by, or under the direction of, a registered or licensed dietitian.(B) A kitchen must be designed so that room temperature, at peak load, must not exceed an average temperature of 85 degrees Fahrenheit measured over the room at the five-foot level. The amount of supply air must take into account the large quantities of air exhausted at the range hood and dishwashing area.(C) A kitchen must be provided with operational equipment as planned and scheduled by the facility's consultants for preparing and serving meals and for refrigerating and freezing perishable foods, as well as equipment in, or adjacent to, the kitchen or dining area for producing ice.(D) A kitchen must be provided with facilities for washing and sanitizing dishes and cooking utensils. Such facilities will be provided for the number of meals served and the method of serving (permanent or disposable dishes, etc.). The kitchen must contain a compartmented sink large enough to immerse pots and pans. Separation of soiled and clean dish areas must be maintained, including air flow.(i) A mechanical dishwasher must be used to sanitize dishes and utensils and must meet the requirements specified under 25 TAC Chapter 228; or(ii) Dishes and utensils must be manually sanitized in accordance with 25 TAC Chapter 228 prior to placement in the dishwasher. (E) A kitchen must be provided with a supply of hot and cold water. Hot water for sanitizing purposes must be 180 degrees Fahrenheit or the manufacturer's suggested temperature for chemical sanitizers, as specified for the system in use. For a mechanical dishwasher, the temperature measurement is at the manifold.(F) A kitchen must be provided with at least one hand-washing lavatory or hand-sanitizing device. A hand-washing lavatory must be provided with hot and cold running water, soap, and individual towels, preferably paper towels; common use towels must not be used.(G) In new construction, a staff restroom facility with a lavatory must be accessible to kitchen staff without traversing resident use areas. The restroom door must not open directly into the kitchen, e.g., provide a vestibule.(H) In new construction, a janitorial facility must be provided exclusively for the kitchen and must be located in and entered from the kitchen.(I) Nonabsorbent smooth finishes or surfaces must be used on kitchen floors, walls, and ceilings. Such surfaces must be capable of being sanitized to maintain a healthful environment.(J) All operable window openings must be screened. A door opening to the outside of the building must have self-closing devices.(7) Food storage areas (main/kitchen).(A) In new construction, a food storage area must be planned based on the number and type of resident meals to be served. The size and layout of dry foods storage must be prepared by or designed under the direction of a licensed or registered dietitian.(B) Food storage areas must provide for storage of a four-day minimum supply of nonperishable foods at all times.(C) Shelves must be movable metal or sealed lumber, and walls must be finished with a nonabsorbent finish to provide a cleanable surface.(D) Dry food storage must have an approved venting system to provide for positive air circulation.(E) The maximum room temperature for food storage must not exceed 85 degrees Fahrenheit at all times. The measurement must be taken at the five-foot level.(F) Food storage areas may be located apart from the food preparation area as long as there is space adjacent to the kitchen for necessary daily stores.(8) Food services areas.(A) Where a service area other than the kitchen is used to dispense foods, this must be designated as a food service area and must have equipment for maintaining required food temperatures while serving.(B) A separate food service area must have hand-washing facilities as a part of the food service area. An employee toilet must be provided.(C) Finishes of all surfaces except ceilings must be the same as those required for dietary kitchens.(9) Other spaces.(A) A bathing unit (tubs or showers) must be provided at a minimum ratio of one per 15 residents. Toilets and sinks must be provided at a minimum ratio of one per eight residents. Bathing and toilet facilities must be of a type appropriate to the resident's varying needs and disabilities and designed for privacy within the bathroom.(B) Adequate storage space must be provided for equipment, carts, wheelchairs, etc., to eliminate the problem of such items being left or stored in corridors, or overcrowding bedroom space.(b) Small facilities.(1) Bedrooms.(A) A bedroom must be arranged and equipped for adequate personal care and for comfort and privacy. A bedroom must have full height walls that extend from floor to ceiling with doors. (Partial partitions or furnishings are not a substitute.) (B) A bedroom must provide at least 80 square feet for a single occupancy (one resident) and 60 square feet per resident for multiple occupancy. (Note: room configuration and usability are taken into consideration and there may be instances where the minimum square footage will not be acceptable.) The minimum room dimension must be at least eight feet for a single resident room and at least ten feet for a multiple-resident room, unless otherwise approved by the HHSC. An exception is that a multi-occupancy bedroom for residents in wheelchairs must have 70 square feet per resident.(C) No more than four residents may be in any one bedroom. An exception is that HHSC may grant a variance from the limit of four residents per room only if a physician who is a member of the IDT and who is a QIDP:(i) certifies that each resident to be placed in a bedroom accommodating more than four residents is so severely medically impaired as to require direct and continuous monitoring during sleeping hours; and (ii) documents the reasons why accommodating in a room of only four or fewer residents would not be medically feasible. (D) In the bedrooms and for each resident there must be a bed with a comfortable mattress and appropriate bedding, functional furniture appropriate to residents' needs, and closet space providing security for personal clothing and belongings. Closet space must provide at least 24 inches of lineal hanging space per resident (in certain cases, such as for infants, exceptions may be made). Married couples may share a bed.(E) Every bedroom must have at least one outside window that can be readily opened from the inside and provides a clear opening of at least 5.7 square feet (minimum width of 20 inches; minimum height of 24 inches). The bottom of the opening must be not more than 44 inches above the floor. Minimum dimensions for operable window section are 20 inches wide by 41.2 inches in height, or 24 inches in height by 34.2 inches wide to provide the minimum 5.7 feet of opening. If a bedroom has a second means of escape independent and remote from the primary means of escape, the bedroom must have a window with clear glass of area not less than 8 percent of the bedroom floor area. When opened, the window must have an open space of not less than 4 percent of the bedroom floor area.(F) A bedroom door must be 20-minute fire rated or 1 3/4-inch solid bonded core wood. This door must have automatic closures and latch in their frames. Exceptions are as follows.(i) A bedroom door only needs to be smoke resistant and does not need automatic closure if the building has an approved sprinkler system throughout.(ii) A bedroom door only needs to only be smoke resistant with automatic closures if the facility is classified "prompt" level of evacuation difficulty.(G) Each small facility must have at least two remotely located means of escape that do not involve windows. The arrangement must be such that there is a primary means of escape from each sleeping room that provides a path of travel to the outside without traversing any corridor or other space exposed to unprotected vertical openings or common living spaces, such as living rooms and kitchens. Exceptions are as follows:(i) A second means of escape or alternate protection is not required:(I) if the bedroom has a door leading directly to the outside of the building, at or to grade level; or(II) if the building is protected with an approved sprinkler system meeting NFPA 13, NFPA 13R, or NFPA 13D.(ii) Separated primary means of escape is not necessary if the building is single story; has 1 3/4-inch solid bonded core doors to bedrooms or smoke resistant doors with closures; 20-minute fire protection for the structure; Class A or B interior finish; bedroom windows of proper size; total smoke detection coverage of habitable spaces, including loft areas that are tied into the manual fire alarm system; and two remote means of escape.(2) Living room space. Living room space must provide at least 15 square feet per resident (with a minimum of 120 square feet regardless of number of residents). Living room space can include one or more rooms or areas provided that the first such area is at least 80 square feet each.(3) Dining space. Dining space must be large enough to accommodate all residents at one sitting and must provide at least 15 square feet per resident. Living and dining space may be in one room or area providing a combined total of 30 square feet per resident (15 square feet living plus 15 square feet dining per resident).(4) Bathrooms. Bathrooms must provide for individual privacy. Water closets and lavatories must be provided at a minimum ratio of one for each five residents. There must be at least one tub or shower for each eight residents. At least one bathroom (with water closets, lavatory, and tub or shower) must be provided on each sleeping floor accessible to the residents of that floor.(5) Kitchen. The facility must have a kitchen to meet the general food service needs of the residents. It must include provisions for the storage, refrigeration, preparation, and serving of food; for dish and utensil cleaning; and for refuse storage and removal. A mechanical dishwasher must be provided. (6) Office. An office or other space must be available for private individual counseling and for the safekeeping of files and records.(7) Stairs. Buildings of two or more stories require at least two separate approved exit stairs from the upper floors. Usable space under the stairs is not allowed unless fire separated or protected in accordance with NFPA 101. Open interior stairways which constitute an "unprotected vertical opening" to a required exit passageway on the upper floor must be provided with a barrier (wall and door) at either the lower or upper level to prevent the rapid rise of fire or smoke originating on the lower level from rendering the upstairs passageway to the second stair impassable.(8) Fire rating. Interior wall and ceiling surfaces must have, as the finished surface or a substrate or sheathing, a fire resistance of not less than 20 minutes, similar to that provided by 3/8-inch gypsum board. Source Note: The provisions of this §551.68 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2004, 29 TexReg 3237; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.68 Architectural Space Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207892 03/12/2026 (a) Bulk storage of hazardous items such as janitor supplies and equipment must be provided in closets or spaces separate from resident use areas. Closets or spaces must be maintained in a safe and sanitary condition and ventilated in a manner commensurate with the use of the closet or space.(b) There must be space for equipment for daily out-of-bed activity for all residents.(c) There must be suitable storage space accessible to the resident for personal possessions such as toys, televisions, radios, prosthetic equipment, and clothing.(d) Attics, mechanical rooms, boiler rooms, and other similar areas must not be used for storage purposes. Source Note: The provisions of this §551.69 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.69 Storage Requirements (All Facilities) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207893 03/12/2026 (a) Cooling and heating must be provided, as necessary, for resident comfort. Heating systems in resident use areas must be capable of maintaining a minimum temperature of 68 degrees Fahrenheit, and cooling of 81 degrees Fahrenheit maximum, with humidity in the normal comfort range.(b) The facility must be well ventilated using windows, mechanical ventilation, or a combination of both. Rooms and areas which do not have outside windows and which are used by residents or staff must be provided with functioning mechanical ventilation to change the air on a basis commensurate with the room usage.(c) Air systems must provide for the induction and mixing of at least 10 percent outside fresh air into the facility unless otherwise approved by the Texas Health and Human Services Commission (HHSC), that is, 100 percent continuous recirculation of interior air in most areas is not acceptable; or the system must be designed to meet the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) requirements.(d) Operable outside windows must be provided with insect screens that prevent insect entry.(e) Rooms such as baths, toilets, soiled linen, trash or garbage rooms, soiled utilities, janitor's closets, and other such areas which produce odors, fumes, excessive moisture, etc., must be provided with an exhaust system ducted to the exterior, meeting nationally recognized standards for capacity and function.(f) Electrical and mechanical systems must be safe and in working order. HHSC may require the facility sponsor or licensee to submit evidence to this effect, consisting of a written report by the local fire marshal, city/county building official having jurisdiction, or a registered professional engineer.(g) Use of electrical appliances, devices, and lamps must be such as not to overload circuits.(h) Portable heaters and open-flame heating devices are prohibited. All fuel burning devices must be vented. Working fireplaces are acceptable if of safe design and construction, and if screened or otherwise suitably enclosed. Source Note: The provisions of this §551.70 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.70 Electrical Systems and HVAC--All Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207894 03/12/2026 (a) The water supply must be of safe, sanitary quality, suitable for use, and adequate in quantity and pressure. The water must be obtained from a water supply system; the location, construction, and operation approved by the Texas Commission on Environmental Quality (TCEQ).(b) Sewage must be discharged into a state-approved sewerage system or septic system; otherwise, the sewage must be collected, treated, and disposed of in a manner approved by TCEQ. Source Note: The provisions of this §551.71 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.71 Plumbing (All Facilities) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207895 03/12/2026 (a) Walls, doors, and ceilings must be maintained free from holes, cracks, falling plaster or paint, and must be cleaned and painted.(b) Paint or plaster inside the building that contains lead must be removed or covered so that it is not accessible to the residents.(c) All abandoned utilities such as electrical wiring, ducts, and pipes must be removed from the facility when no longer usable. Source Note: The provisions of this §551.72 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.72 Maintenance (All Facilities) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207896 03/12/2026 (a) Pest control.(1) The facility must be kept free of insects, rodents, and vermin. The least toxic and least flammable effective chemicals must be used. Poisons must not be stored with food products and must be under lock.(2) Garbage and trash must be stored in an enclosed container, protected against leakage, contact with disease vectors, and access to animals. It must be stored in an area separate from those used for the preparation and storage of food and must be removed from the premises in conformity with state and local practices. A garbage or trash container must be maintained free of accumulations and coatings of garbage. A garbage storage area must be kept clean and in good repair.(b) Storage. Storage items must be neatly arranged and placed to minimize fire hazard. Gasoline, volatile materials, paint, and similar products, excluding personal items, must not be stored in the building accommodating residents except as may be approved by the local fire marshal. Accumulations of extraneous material and refuse must not be permitted.(c) Laundry.(1) There must be clean linen available at all times, and in a quantity to meet the needs of the residents.(2) Clean linen must be stored in a clean storage area, which is easily accessible to staff.(3) Soiled linen and clothing in a large facility must be transported or stored in approved containers or bags.(A) Soiled laundry storage must be in a separate, well ventilated area and must not be permitted to accumulate in other areas of the facility.(B) A soiled bag or container must not be used to convey clean linens.(C) Soiled linens must not be sorted, laundered, rinsed, or stored in bathrooms, resident rooms, corridors, kitchens, or food storage areas. Source Note: The provisions of this §551.73 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.73 Environmental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194618 03/12/2026 (a) The facility must have a program to inspect, test, and maintain the fire alarm system and must execute the program at least once every three months for large facilities and at least once every six months for small facilities.(1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.(2) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign, and date an inspection form similar to the inspection and testing form in NFPA 72 for a service provided under the contract.(3) The facility must ensure that fire alarm system components that require visual inspection are visually inspected in accordance with NFPA 72.(4) The facility must ensure that fire alarm system components that require testing are tested in accordance with NFPA 72.(5) The facility must ensure that fire alarm system components that require maintenance are maintained in accordance with NFPA 72.(6) The facility must ensure that smoke dampers are inspected and tested in accordance with NFPA 101.(7) The facility must maintain onsite documentation of compliance with this subsection.(b) The facility must have a program to inspect, test, and maintain the sprinkler system and must execute the program at least once every three months for large facilities and at least once every six months for small facilities.(1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.(2) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign, and date an inspection form similar to the inspection and testing form in NFPA 25 for a service provided under the contract.(3) The facility must ensure that sprinkler system components that require visual inspection are visually inspected in accordance with NFPA 13, NFPA 13D, or NFPA 13R and in accordance with NFPA 25.(4) The facility must ensure that sprinkler system components that require testing are tested in accordance with NFPA 13, NFPA 13D, or NFPA 13R and in accordance with NFPA 25.(5) The facility must ensure that sprinkler system components that require maintenance are maintained in accordance with NFPA 13, NFPA 13D, or NFPA 13R and in accordance with NFPA 25.(6) The facility must ensure that individual sprinkler heads are inspected and maintained in accordance with NFPA 13, NFPA 13D, or NFPA 13R and in accordance with NFPA 25.(7) The facility must maintain onsite documentation of compliance with this subsection.(c) The facility must formulate, adopt, and enforce smoking policies.(1) The facility's policies must comply with all applicable codes, regulations, and standards, including local ordinances.(2) The facility must inform residents, staff, visitors, and other affected parties of the facility's smoking policies.(3) The facility must prohibit smoking in any room, ward, or compartment where flammable liquids, combustible gas, or oxygen is used or stored and in any other hazardous location. The facility must post a "No Smoking" sign in these areas.(4) The facility must provide ashtrays of noncombustible material and safe design in all areas where smoking is permitted.(5) The facility must provide a metal container with a self-closing cover device into which ashtrays can be emptied in all areas where smoking is permitted. Source Note: The provisions of this §551.74 adopted to be effective March 21, 2011, 36 TexReg 1879; amended to be effective October 12, 2017, 42 TexReg 5508; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.74 Safety Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207902 03/12/2026 At the option of the applicant, the Texas Health and Human Services Commission (HHSC) will review plans for new buildings, additions, conversion of buildings not licensed by HHSC, or remodeling of existing licensed facilities. HHSC will, within 30 days, inform the applicant in writing of the results of the review. If the plans comply with HHSC's architectural requirements, HHSC may not subsequently change the architectural requirement applicable to the project unless the change is required by federal law or the applicant fails to complete the project within two years. HHSC may grant a waiver of this two-year period for delays due to unusual circumstances. There is no time limit to complete a project, only a time limit for completing a project using requirements that have been revised after the project was reviewed.(1) Submittal of plans.(A) For review of plans, submit one copy of working drawings and specifications (contract documents) before construction begins. Documents must be in sufficient detail to interpret compliance with these standards and assure proper construction. Documents must be prepared according to accepted architectural practice and must include general construction, special conditions, and schedules.(B) Final copies of plans must have (in the reproduction process by which plans are reproduced) a title block that shows name of facility, person, or organization preparing the sheet, sheet numbers, facility address, and drawing date. Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a registered professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. Contract documents for additions, remodeling, and construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners (TBAE). Drawings must bear the seal of the architect.(C) A final plan for a major addition to a facility must include a basic layout to scale of the entire building onto which the addition will connect. North direction must be shown. The entire basic layout usually can be to scale such as 1/16 inch per foot or 1/32 inch per foot for very large buildings.(D) Plans and specifications for conversions or remodeling must be complete for all parts and features involved.(E) The sponsor is responsible for employing qualified personnel to prepare the contract documents for construction. If the contract documents have errors or omissions to the extent that conformance with standards cannot be reasonably assured or determined, a revised set of documents for review may be requested.(F) The review of plans and specifications by HHSC is based on general utility, the minimum licensing standards, and conformance of the Life Safety Code, and is not to be construed as all-inclusive approval of the structural, electrical, or mechanical components, nor does it include a review of building plans for compliance with the Texas Accessibility Standards as administered and enforced by the Texas Department of Licensing and Regulation.(G) Fees for plan review will be required in accordance with §551.20 of this chapter (relating to Plan Review Fees).(2) Contract documents.(A) Site plan documents must include:(i) grade contours;(ii) streets (with names);(iii) north arrow;(iv) fire hydrants;(v) fire lanes;(vi) utilities, public or private;(vii) fences; and(viii) unusual site conditions, such as:(I) ditches;(II) low water levels;(III) other buildings on-site; and(IV) indications of buildings five feet or less beyond site property lines.(B) Foundation plan documents must include general foundation design and details.(C) Floor plan documents must include:(i) room names, numbers, and usages;(ii) doors (numbered), including swing;(iii) windows;(iv) legend or clarification of wall types;(v) dimensions;(vi) fixed equipment;(vii) plumbing fixtures;(viii) kitchen basic layout; and(ix) identification of all smoke barrier walls (outside wall to outside wall) or fire walls.(D) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2-inch by 11-inch sheet.(E) Schedules must include:(i) door materials, widths, and types;(ii) window materials, sizes, and types;(iii) room finishes; and(iv) special hardware.(F) Elevations and roof plan must include:(i) exterior elevations, including:(I) material note indications; and(II) any rooftop equipment;(ii) roof slopes;(iii) drains;(iv) gas piping, etc.; and(v) interior elevations where needed for special conditions.(G) Details must include:(i) wall sections as needed, especially for special conditions;(ii) cabinet and built-in work, basic design only;(iii) cross sections through buildings as needed; and(iv) miscellaneous details and enlargements as needed.(H) Building structure documents must include:(i) structural framing layout and details (primarily for column, beam, joist, and structural building);(ii) roof framing layout (when it cannot be adequately shown on cross section); and(iii) cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design and calculated design loads.(I) Electrical documents must include:(i) electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices;(ii) service, circuiting, distribution, and panel diagrams;(iii) exit light system (exit signs and emergency egress lighting);(iv) emergency electrical provisions (such as generators and panels);(v) staff communication system;(vi) fire alarm and similar systems (such as control panel, devices, and alarms); and(vii) sizes and details sufficient to assure safe and properly operating systems.(J) Plumbing documents must include:(i) plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems;(ii) water systems;(iii) sanitary systems;(iv) gas systems; and(v) other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(K) HVAC documents must include:(i) sufficient details of HVAC systems and components to assure a safe and properly operating installation, including, heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke or fire dampers; and(ii) equipment types, sizes, and locations.(L) Sprinkler system documents must include:(i) plans and details of NFPA designed systems;(ii) plans and details of partial systems provided only for hazardous areas; and(iii) electrical devices interconnected to the alarm system.(M) Specifications must include:(i) installation techniques;(ii) quality standards and manufacturers;(iii) references to specific codes and standards;(iv) design criteria;(v) special equipment;(vi) hardware;(vii) finishes; and(viii) any others as needed to amplify drawings and notes.(N) Other layouts, plans, or details as may be necessary for a clear understanding of the design and scope of the project, including plans covering private water or sewer systems, must be reviewed by local health or wastewater authority having jurisdiction.(3) Construction phase.(A) HHSC must be notified in writing before construction starts.(B) All construction not done in accordance with the completed plans and specifications as submitted for review and as modified in accordance with review requirements will require additional drawings if the change is significant.(4) Initial survey of completed construction.(A) Upon completion of construction, including grounds and basic equipment and furnishings, a final construction inspection (initial survey) of the facility must be performed by HHSC before admitting residents. An initial architectural inspection will be scheduled after HHSC receives a license application through the online portal, required fee, fire marshal approval, and a letter from an architect or engineer stating that to the best of their knowledge the facility meets the architectural requirements for licensure.(B) After the completed construction has been surveyed by HHSC and found acceptable, this information will be forwarded to HHSC as part of the information needed to issue a license to the facility. In the case of additions or remodeling of existing facilities, a revision or modification to an existing license may be necessary. The building, including basic furnishings and operational needs, grades, drives, and parking, must essentially be 100 percent complete at the time of this initial visit for occupancy approval and licensing. A facility may accept up to three residents between the time it receives initial approval from HHSC and the time the license is issued.(C) The following documents must be available to HHSC's architectural inspecting surveyor at the time of the survey of the completed building:(i) written approval of local authorities as required in subparagraph (A) of this paragraph;(ii) written certification of the fire alarm system by the installing agency (the Texas State Fire Marshal's Fire Alarm Installation Certificate);(iii) documentation of materials used in the building that are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant curtains (including cubicle curtains), rated ceilings, etc., and, in the case of carpeting, a signed letter from the installer verifying that the carpeting installed is named in the laboratory test document;(iv) approval of the completed sprinkler system installation by the Texas Department of Insurance or designing engineer. A copy of the material list and test certification must be available;(v) service contracts for maintenance and testing of alarm systems and sprinkler systems;(vi) a copy of gas test results of the facility's gas lines from the meter;(vii) a written statement from an architect or engineer stating, to the best of his or her knowledge, the building was constructed in substantial compliance with the construction documents, the Life Safety Code, HHSC licensure standards, and local codes; and(viii) any other such documentation as needed.(5) Non-approval of new construction.(A) If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, HHSC may recommend the facility not be licensed and approved for occupancy. Such items may include the following:(i) substantial changes made during construction that were not submitted to HHSC for review and that may require revised "as-built" drawings to cover the changes. This may include architectural, structural, mechanical, and electrical items as specified in paragraph (3)(B) of this section;(ii) construction that does not meet minimum code or licensure standards, such as corridors that are less than required width, ceilings installed at less than the minimum seven-foot six-inch height, resident bedroom dimensions less than required, and other such features that would disrupt or otherwise adversely affect the residents and staff if corrected after occupancy;(iii) no written approval by local authorities;(iv) fire protection systems, including fire alarm systems, emergency power and lighting, and sprinkler systems, not completely installed or not functioning properly;(v) required exits not all usable according to NFPA 101 requirements;(vi) telephone not installed or not properly working;(vii) sufficient basic furnishings, essential appliances, and equipment not installed or not functioning; and(viii) any other basic operational or safety feature that would preclude safe and normal occupancy by residents on that day.(B) If the surveyor encounters only minor deficiencies, licensure may be recommended based on an approved written plan of correction from the facility's administrator.(C) Copies of reduced-size floor plans on an 8 1/2-inch by 11-inch sheet must be submitted in duplicate to HHSC for record/file use and for the facility's use for evacuation plan, fire alarm zone identification, etc. The plan must contain basic legible information such as scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information. Source Note: The provisions of this §551.75 adopted to be effective April 1, 2002, 27 TexReg 2250; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS D GENERAL REQUIREMENTS FOR FACILITY CONSTRUCTION §551.75 Plans, Approvals, and Construction Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207903 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207903 03/12/2026 (a) Texas Health and Human Services Commission (HHSC) inspection and survey staff must perform inspections, surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits from time to time as HHSC deems appropriate or as required for carrying out the responsibilities of licensing.(b) A qualified surveyor or a team, of which one member is a specialized staff person who has expertise in developmental disabilities, conducts an inspection.(c) To determine standard compliance that cannot be determined during regular working hours, HHSC may conduct night or weekend inspections to cover specific segments of operation. HHSC completes the inspections with the least possible interference to staff and residents.(d) Generally, HHSC does not announce an inspection, survey, complaint investigation, or other visit, whether routine or non-routine, made for determining the appropriateness of resident care and day-to-day operations of a facility.(e) HHSC may announce certain visits, including:(1) an initial life safety code inspection;(2) a life safety code capacity increase inspection;(3) a final construction inspection;(4) a visit to determine the progress of physical plant construction or repairs, equipment installation or repairs, or systems installation or repairs; or(5) a visit resulting from an emergency, including a fire, a windstorm, or malfunctioning or nonfunctioning electrical or mechanical systems.(f) Persons authorized to receive advance notice of unannounced inspections include:(1) citizen advocates invited to attend inspections, as described in subsection (g) of this section;(2) representatives of the United States Department of Health and Human Services whose programs relate to the Medicare/Medicaid long-term care program; and(3) representatives of HHSC whose programs relate to the Medicare/Medicaid long-term care program.(g) HHSC conducts at least three unannounced inspections of a facility during a three-year licensing period.(1) HHSC conducts a sufficient number of inspections between the hours of 5:00 p.m. and 8:00 a.m. In randomly selected facilities, HHSC conducts a cursory after-hours inspection to determine staffing, emergency egress, resident care, medication security, food service or nourishments, sanitation, and other items determined necessary by HHSC. HHSC completes the inspections with minimal disruption to staff and residents.(2) For at least two unannounced inspections each licensing period, HHSC may invite to the inspections at least one person as a citizen advocate who has an interest in or who is employed by or affiliated with an organization or agency that represents or advocates for persons with an intellectual disability or a related condition. HHSC provides to these organizations basic licensing information and requirements for the organizations' dissemination to their members whom they engage to attend the inspections. Advocates participating in the inspections must follow all HHSC protocols. Advocates must provide their own transportation. The schedule of inspections in this category will be arranged confidentially in advance with the organizations. Participation by the advocates is not a condition precedent to conducting the inspection.(h) A facility must make all books, records, and other documents that are maintained by or on behalf of the facility accessible to HHSC on request.(1) HHSC may photocopy documents, photograph residents, and use any other available recording devices to preserve relevant evidence of conditions found during an inspection, survey, or investigation.(2) Examples of records that HHSC may request and photocopy or otherwise reproduce are resident medical records, including nursing notes, pharmacy records, medication records, and physician's orders.(3) When HHSC requests a facility furnish copies of documents, the facility may charge HHSC at a rate not to exceed the rate charged by HHSC for copies. The administrator or designee must ensure the documents are copied. If the documents must be removed from the facility to be copied, a representative of the facility must accompany the documents and ensure their order and preservation.(4) HHSC protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.(5) A facility must not falsify information contained in resident records.(i) HHSC may provide a special team to conduct validation surveys or to verify findings of previous licensure surveys.(1) At HHSC's discretion, based on record review, random sample, or any other determination, HHSC may assign a team to conduct a validation survey. HHSC may use the information to verify previous determinations or identify training needs to ensure consistency in deficiencies cited and in punitive actions recommended throughout the state.(2) A facility must correct any additional deficiencies cited by a validation team but is not subject to any new or additional punitive action as a result of those deficiencies.(j) During an investigation, survey, or inspection, HHSC may conduct an interview with a resident of a facility or staff employed by the facility in private. A facility must not retaliate against the resident or staff.(k) Facility staff must be available at the facility within 45 minutes of telephone contact by survey staff. Source Note: The provisions of this §551.191 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective October 29, 2018, 43 TexReg 7196; transferred effective May 1, 2019, as published in the Texas Register April12,2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS F INSPECTIONS, SURVEYS, AND VISITS §551.191 Procedural Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207904 03/12/2026 (a) Texas Health and Human Services Commission (HHSC) will determine if a facility meets licensure requirements through inspections, surveys, and investigations.(b) During an investigation resulting from a complaint, HHSC does not disclose the source of the complaint.(c) At the conclusion of an inspection, survey, or investigation, a representative of HHSC holds an exit conference with a representative of the facility and provides the facility representative a written list of preliminary findings.(d) If HHSC cites additional violations during a review of field notes or preparation of the official final statement of licensing violations, HHSC:(1) communicates the additional violations to the facility in writing within ten working days after the exit conference; and(2) gives the facility an additional face-to-face exit conference regarding the additional violations.(e) HHSC provides the facility with a clear and concise summary in nontechnical language of each licensure inspection or complaint investigation.(f) The facility must submit a plan to correct cited violations to the regional director of the area in which the facility is located no later than 10 working days after the date the facility receives the final, official statement of violations. To be accepted by HHSC, a plan to correct violations must state when the corrective action will be completed and must address:(1) how the facility will accomplish corrective action for residents directly affected by the cited violation;(2) how the facility will identify other residents who may be affected by the cited violation; and(3) how the facility will avoid having the violation recur.(g) If a facility fails to submit a plan to correct violations that meets the requirements of subsection (f) of this section, HHSC may assess an administrative penalty against the facility in accordance with §551.236(a)(7) of this chapter (relating to Administrative Penalties). Source Note: The provisions of this §551.192 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective April 1, 1999, 24 TexReg 1816; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective January 15, 2009, 34 TexReg 238; transferred effective May 1,2019,as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS F INSPECTIONS, SURVEYS, AND VISITS §551.192 Determinations and Actions Pursuant to Inspections, Surveys, or Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207905 03/12/2026 (a) A person, including a facility owner or employee, who has cause to believe that a resident of a facility has been or is being subjected to physical abuse, sexual abuse, sexual exploitation, verbal or emotional abuse, neglect, or exploitation, as those terms are defined in Chapter 711 of this title (relating to Investigations of Individuals Receiving Services from Certain Providers), by a person other than a resident of the facility, must report the alleged abuse, neglect, or exploitation to the Texas Department of Family and Protective Services (DFPS), as required by Chapter 711 of this title (relating to Investigations of Individuals Receiving Services from Certain Providers), by calling 1-800-647-7418.(b) If the person making the report is not an employee of the facility, such as a resident or visitor, facility staff must assist the person in making the report, if necessary.(c) The facility must assist an HHSC investigator by preserving and safeguarding evidence of the alleged abuse, neglect, or exploitation and by ensuring that facility employees are made available upon request by the investigator. Source Note: The provisions of this §551.212 adopted to be effective June 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS G ABUSE, NEGLECT, AND EXPLOITATION; COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §551.212 Reporting Abuse, Neglect, and Exploitation to DFPS https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207906 03/12/2026 (a) In this section, serious physical injury is defined as in Chapter 711 of this title (relating to Investigations of Individuals Receiving Services from Certain Providers).(b) A facility must report any of the following incidents to HHSC's Complaint and Incident Intake Section at 1-800-458-9858 within one hour after suspecting or learning of the incident:(1) alleged (Class I) physical abuse of a resident, as defined in Chapter 711 of this title, that caused or may have caused serious physical injury;(2) alleged (Class I) sexual abuse of a resident, as defined in Chapter 711 of this title;(3) sexual activity between residents resulting from coercion, physical force, or taking advantage of the disability of a resident;(4) sexual activity involving a resident less than 18 years of age;(5) the pregnancy of a resident;(6) resident-to-resident aggression that results in serious physical injury;(7) the death of a resident; and(8) a resident whose location has been unknown by the facility for more than eight hours or less than eight hours if there are circumstances that place the resident's health or safety at risk.(c) Within five working days after making a report described in subsection (b) of this section, the facility must ensure an investigation of the incident is conducted and send a written investigation report on Form 3613A, Provider Investigation Report, or a form containing, at a minimum, the information required by Form 3613A, to HHSC's Complaint and Incident Intake. Source Note: The provisions of this §551.213 adopted to be effective June 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS G ABUSE, NEGLECT, AND EXPLOITATION; COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §551.213 Reporting Incidents to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210351 03/12/2026 (a) A facility must ensure that physical and emotional care is provided to an alleged victim of abuse, neglect, or exploitation immediately but in no case more than one hour after the facility makes or learns of an allegation of abuse, neglect, or exploitation, and must ensure that such care is continued as needed.(b) The facility must take measures to protect the rights and safety of the alleged victim and other residents of the facility after the facility makes or learns of an allegation of abuse, neglect, or exploitation, including immediately preventing the alleged perpetrator from having contact with residents.(c) If the alleged perpetrator is not an employee of the facility and the alleged abuse, neglect, or exploitation occurred away from the facility premises, the facility must convene the interdisciplinary team (IDT) of the alleged victim to address the alleged perpetrator's access to the alleged victim while an investigation is being conducted. If the IDT recommends that a restriction be placed on an alleged perpetrator's access to the alleged victim, the facility's specially constituted committee must review and approve the restriction before it is implemented, and the facility must document the restriction in the alleged victim's record.(d) Within 24 hours of making or learning of an allegation of abuse, neglect, or exploitation, the facility must notify the alleged victim and the victim's legally authorized representative (LAR) that an allegation of abuse, neglect, or exploitation involving the victim has been made and reported. If the facility cannot notify the LAR in person or by phone, the facility must notify the LAR by certified mail with a return receipt requested.(e) If the Texas Health and Human Services Commission confirms an allegation of abuse, neglect, or exploitation against an employee of a facility, the facility must take prompt and appropriate disciplinary action against the employee. Source Note: The provisions of this §551.214 adopted to be effective June 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787; amended to be effective October 11, 2022, 47 TexReg 6588. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS G ABUSE, NEGLECT, AND EXPLOITATION; COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §551.214 Protection of Residents After Report of Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207908 03/12/2026 (a) A facility must require an employee of the facility to sign a statement:(1) acknowledging that the employee may be criminally liable for failure to report suspected abuse, neglect, or exploitation; and(2) acknowledging the employee's rights under Texas Health and Safety Code §252.132 (relating to Suit for Retaliation), which states that an employee has a cause of action against a facility, the owner of a facility, or another employee of a facility that suspends or terminates the employment of the employee or otherwise disciplines, discriminates against, or retaliates against the employee for:(A) reporting to the employee's supervisor, an administrator of the facility, a state regulatory agency, or a law enforcement agency, a violation of law, including a violation of Texas Health and Safety Code, Chapter 252, or a rule adopted under that chapter; or(B) initiating or cooperating in any investigation or proceeding of a governmental entity relating to the care, services, or conditions at the facility.(b) The facility must maintain as a part of its personnel records and make available to the Texas Health and Human Services Commission upon request the statement described in subsection (a) of this section. Source Note: The provisions of this §551.215 adopted to be effective June 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS G ABUSE, NEGLECT, AND EXPLOITATION; COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §551.215 Employee Statement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207909 03/12/2026 When Texas Health and Human Services Commission (HHSC) staff determine that a facility is out of compliance with licensure rules to a degree that places the facility at risk of the imposition of licensing actions, HHSC may send a warning letter to the facility. The warning letter notifies the facility that the violations of licensing rules must be corrected. Source Note: The provisions of this §551.231 adopted to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.231 Warning Letter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207910 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may suspend a facility's license when the facility's violation of the licensure rules threatens to jeopardize the health and safety of the residents.(b) Suspension of a license may occur simultaneously with any other enforcement provision available to HHSC.(c) The facility will be notified by certified mail of HHSC's intent to suspend the license, including the facts or conduct alleged to warrant the suspension. The facility has an opportunity to show compliance with all requirements of law for the retention of the license as provided in §551.18 of this chapter (relating to Informal Reconsideration). If the facility requests an informal reconsideration, HHSC will give the license holder a written affirmation or reversal of the proposed action.(d) The facility will be notified by certified mail of HHSC's suspension of the facility's license. The facility has 15 days from receipt of the certified mail notice to request a hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing). The suspension will take effect when the deadline for appeal of the suspension passes, unless the facility appeals the suspension. If the facility appeals the suspension, the status of the license holder is preserved until final disposition of the contested matter.(e) The suspension will remain in effect until HHSC determines that the reason for suspension no longer exists. HHSC will conduct an on-site investigation prior to making a determination. During the suspension, the license holder must return the license to HHSC. Source Note: The provisions of this §551.232 adopted to be effective May 1, 1995, 20 TexReg 1659; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.232 License Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207911 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may revoke a facility's license when:(1) the facility's violation of the licensure rules jeopardizes the health and safety of the residents; or(2) the facility has violated the requirements of Texas Health and Safety Code, Chapter 252, or the rules adopted under that chapter, in either a repeated or substantial manner.(b) In addition, HHSC may revoke a license if the license holder:(1) submitted false or misleading statements in the application for a license or any accompanying attachments;(2) used subterfuge or other evasive means to obtain the license;(3) concealed a material fact in the application for a license or failed to disclose information required in §551.13 of this chapter (relating to Applicant Disclosure Requirements) that would have been the basis to deny the license under §551.17 of this chapter (relating to Criteria for Denying a License or Renewal of a License); or(4) received monetary or other remuneration from a person or agency that furnishes services or materials to the facility or individuals for a fee.(c) Revocation of a license may occur simultaneously with any other enforcement provision available to HHSC.(d) The facility will be notified by certified mail of HHSC's intent to revoke the license, including the facts or conduct alleged to warrant the revocation. The facility has an opportunity to show compliance with all requirements of law for the retention of the license as provided in §551.18 of this chapter (relating to Informal Reconsideration). If the facility requests an informal reconsideration, HHSC will give the license holder a written affirmation or reversal of the proposed action.(e) The facility will be notified by certified mail of HHSC's intent to revoke the license, including the facts or conduct alleged to warrant the revocation. The facility has 15 days from receipt of the certified mail notice to request a hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing). The revocation will take effect when the deadline for appeal of the revocation passes, unless the facility appeals the revocation. If the facility appeals the revocation, the status of the license holder is preserved until final disposition of the contested matter. Upon revocation, the license must be returned to HHSC. Source Note: The provisions of this §551.233 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective February 1, 1999, 23 TexReg 11829; amended to be effective May 1, 2000, 25 TexReg 3557; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.233 Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207912 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may suspend a facility's license or order an immediate closing of part of the facility if:(1) HHSC finds that the facility is operating in violation of the licensure rules; and(2) the violation creates an immediate threat to the health and safety of a resident.(b) The order suspending a license or closing a part of a facility under this section is immediately effective on the date the license holder receives written notice or a later date specified in the order.(c) The order suspending a license or ordering an immediate closing of a part of the facility is valid for ten days after the effective date of the order.(d) When an emergency suspension has been ordered and the conditions in the facility indicate that residents need to be relocated, a facility must ensure:(1) A resident's rights or freedom of choice in selecting treatment facilities will be respected.(2) If a facility or part thereof is closed, the following rules apply.(A) HHSC will notify the local health department director, city or county health authority, and representatives of the appropriate state agencies of the closure.(B) Facility staff must notify each resident's legally authorized representative (LAR) and attending physician, advising them of the action in process.(C) The resident or the resident's LAR will have an opportunity to designate a preference for a specific facility or for other arrangements.(D) HHSC must contact the local intellectual and developmental disability authority (LIDDA) to arrange for resident relocation to other facilities in the area in accordance with the resident's preference. A facility chosen for relocation must be in good standing with HHSC and, if certified under Titles XVIII and XIX of the Social Security Act, must be in good standing under its contract. The facility chosen must be able to meet the needs of the resident.(E) If absolutely necessary, to prevent transport over substantial distances, HHSC will grant a waiver to a receiving facility to temporarily exceed its licensed capacity, provided the health and safety of residents is not compromised and the facility can meet the increased demands for direct care personnel and dietary services. A facility may exceed its licensed capacity under these circumstances, monitored by HHSC staff, until residents can be transferred to a permanent location.(F) With each resident transferred, the following reports, records, and supplies must be transmitted to the receiving institution:(i) a copy of the current physician's orders for medication, treatment, diet, and special services required;(ii) personal information, such as name and address of next of kin or LAR; attending physician; Medicare and Medicaid identification number; Social Security number; and other identification information as deemed necessary and available;(iii) all medication dispensed in the name of the resident for which physician's orders are current. The medication must be inventoried and transferred with the resident. Medications past an expiration date or discontinued by physician order must be inventoried for disposition in accordance with state law;(iv) the resident's personal belongings, clothing, and toilet articles. An inventory of personal property and valuables must be made by the closing facility; and(v) resident trust fund accounts maintained by the closing facility. All items must be properly inventoried, and receipts obtained for audit purposes by the appropriate state agency.(G) If the closed facility is allowed to reopen within 90 days, the relocated residents will have the first right to return to the facility. Relocated residents may choose to return, may stay in the receiving facility (if the facility is not exceeding its licensed capacity), or choose any other accommodations.(H) Any resident's return to the facility must be treated as a new admission, including exchange of medical information, medications, and completion of required forms.(e) A licensee whose facility is closed under this section is entitled to request an administrative hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing), but a hearing request does not suspend the effectiveness of the order. Source Note: The provisions of this §551.234 adopted to be effective May 1, 1995, 20 TexReg 1659; amended to be effective February 1, 1999, 23 TexReg 11829; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.234 Emergency License Suspension and Closing Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207913 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may petition a district court for a temporary restraining order to restrain a person from continuing a violation of the standards prescribed by this chapter if HHSC finds that the violation threatens the health and safety of a resident.(b) A district court, on petition by HHSC, may by injunction:(1) prohibit a person from continuing a violation of the standards or licensing requirements prescribed by this chapter;(2) restrain or prevent the establishment, conduct, management, or operation of a facility without a license issued under this chapter; or(3) grant the injunctive relief warranted by the facts on a finding by the court that a person is violating the standards or licensing requirements prescribed by this chapter.(c) HHSC may refer a facility to the Texas Office of the Attorney General for the assessment of civil penalties under the Texas Health and Safety Code §252.064 (relating to Civil Penalty), for a violation that threatens the health and safety of a resident. Source Note: The provisions of this §551.235 adopted to be effective May 1, 1995, 20 TexReg 1659; amended to be effective February 1, 1999, 23 TexReg 11829; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.235 Referral to the Attorney General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207914 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may assess an administrative penalty against a license holder if the license holder:(1) violates Texas Health and Safety Code, Chapter 252, or any rule, standard, or order adopted or a license issued under such chapter and the violation creates a potential for more than minimal harm, results in actual harm, or poses an immediate threat to the health or safety of a resident;(2) makes a false statement, that the person knows or should know is false, of a material fact:(A) on an application for issuance or renewal of a license or in documentation submitted to HHSC in support of the application; or(B) with respect to a matter under investigation by HHSC;(3) refuses to allow a representative of HHSC to inspect:(A) a book, record, or file required to be maintained by the person; or(B) any portion of the premises of a facility;(4) willfully interferes with the work of a representative of HHSC or the enforcement of Texas Health and Safety Code, Chapter 252;(5) willfully interferes with a representative of HHSC preserving evidence of a violation of Texas Health and Safety Code, Chapter 252, or a rule, standard, or order adopted or license issued under such chapter;(6) fails to pay a penalty assessed by HHSC under Texas Health and Safety Code, Chapter 252, not later than the 10th day after the date the assessment of the penalty becomes final;(7) fails to submit an acceptable plan of correction to HHSC within 10 working days after receiving the final statement of licensing violations; or(8) fails to notify HHSC of a change in ownership before the effective date of that change of ownership.(b) In determining if a violation described in subsection (a)(1) of this section warrants an administrative penalty, HHSC considers: (1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;(2) the hazard of the violation to the health and safety of a resident; and(3) whether the affected license holder had identified the violation as part of its internal quality assurance process and had made appropriate progress on correction.(c) HHSC does not assess an administrative penalty against a license holder because of a physician's or consultant's nonperformance beyond the license holder's control or if documentation clearly indicates the violation is beyond the license holder's control.(d) An administrative penalty assessed in accordance with subsection (a)(1) of this section begins on the first date HHSC establishes that the violation that caused the penalty to be assessed exists.(e) An administrative penalty assessed in accordance with subsection (a)(1) of this section ceases on the date the violation is corrected. A violation is corrected if the license holder:(1) notifies HHSC in writing that the violation has been corrected;(2) states the date of the correction in the notification; and(3) maintains evidence that the violation was corrected on the date in the notification.(f) An administrative penalty assessed in accordance with subsection (a)(1) of this section is determined based on the scope and severity of the violation, in accordance with the figures in this section.Attached Graphic(g) An administrative penalty assessed in accordance with subsection (a)(2) - (8) of this section is in the following amount:(1) for a facility with a licensed capacity of fewer than 60 residents:(A) $500 for the first violation of the paragraph;(B) $750 for the second violation of the same paragraph; and(C) $1000 for the third violation of the same paragraph; and(2) for a facility with a license capacity of 60 or more residents:(A) $500 for the first violation of the paragraph;(B) $3500 for the second violation of the same paragraph; and(C) $5000 for the third violation of the same paragraph.(h) Administrative penalties will be imposed on a per diem basis.(i) The total amount of penalties assessed under this subsection for an on-site regulatory visit or complaint investigation, regardless of the duration of any ongoing violations, may not exceed:(1) $5000 for a facility with a capacity of fewer than 60 residents; and(2) $25000 for a facility with a capacity of 60 residents or more.(j) If HHSC determines that a violation has occurred and that an administrative penalty is proposed, HHSC notifies the license holder of the proposal to assess an administrative penalty. The notification includes:(1) a brief summary of the alleged violation;(2) a statement of the amount of the proposed penalty; and(3) a statement of the license holder's right to request a hearing on the occurrence of the violation, the amount of the violation, the amount of the penalty, or both the occurrence of the violation and the amount of the penalty.(k) A license holder that is notified in accordance with subsection (j) of this section may file a request for a hearing with HHSC. To receive a hearing, a license holder must request a hearing in accordance with 1 TAC §357.484 (relating to Request for a Hearing) except, as provided by Texas Health and Safety Code §252.066 (relating to Notice; Request for Hearing), the license holder must make a written request for a hearing within 20 calendar days after the date on which the license holder receives written notice of the administrative penalty. A hearing requested under this section is governed by 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §551.236 adopted to be effective May 1, 1995, 20 TexReg 1659; amended to be effective February 1, 1999, 23 TexReg 11829; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective June 1, 2002, 27 TexReg 4367; amended to be effective January 15, 2009, 34 TexReg 238; amended to be effective October 28, 2018, 43 TexReg 7191; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.236 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207915 03/12/2026 (a) A person holding a controlling interest in a facility may, at any time, request that the Texas Health and Human Services Commission (HHSC) assume the operation of the facility through the appointment of a trustee.(b) If HHSC believes that the appointment of a trustee is desirable, HHSC may enter into an agreement with the person holding the controlling interest for the appointment of the trustee to take charge of the facility.(c) Any agreement entered into under this section must:(1) specify all terms and conditions of the trustee's appointment and authority; and(2) preserve all rights of the residents as granted by law.(d) The agreement will terminate either at a time specified in the agreement or upon receipt of notice of intent to terminate sent by either party.(e) If HHSC determines that termination of the agreement by the person holding a controlling interest in the facility would not be in the best interest of the residents, HHSC will petition a court for an involuntary appointment under the terms of §551.238 of this subchapter (relating to Involuntary Appointment of a Trustee).(f) The appointment of a trustee by agreement does not suspend the obligation of a facility to pay assessed civil money or administrative penalties. Source Note: The provisions of this §551.237 adopted to be effective February 1, 1999, 23 TexReg 11829; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.237 Appointment of a Trustee by Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207916 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may petition a court of competent jurisdiction for the involuntary appointment of a trustee to operate a facility if one or more of the following conditions exist:(1) the facility is operating without a license;(2) the facility's license has been suspended or revoked;(3) license suspension or revocation procedures against a facility are pending and an imminent threat to the health and safety of the residents exists;(4) an emergency exists that presents an immediate threat to the health and safety of the residents; or(5) the facility is closing (whether voluntarily or through an emergency closure order) and arrangements for relocation of the residents to other licensed facilities have not been made before closure.(b) A trustee appointed under this section is entitled to a reasonable fee as determined by the court to be paid from the Nursing and Convalescent Home trust fund.(c) The trustee may use the emergency assistance funds in the trust fund only to alleviate an immediate threat to the health and safety of the residents, through such disbursements as payments for food; medication; sanitation services; minor repairs; supplies necessary for personal hygiene; or services necessary for the personal care, health, and safety of the residents.(d) Before emergency assistance funds may be dispersed, a court order must be entered authorizing HHSC to disburse emergency assistance funds to the facility.(e) A facility that receives emergency assistance funds under this section must reimburse HHSC for the amounts received not later than one year after the date on which the funds were received by the trustee. The owner of the facility at the time the trustee was appointed is responsible for the reimbursement and must pay interest from the date the funds were disbursed on the amount outstanding at a rate equal to the rate of interest determined under Texas Finance Code, Chapter 302 (relating to Interest Rates), to be applicable to judgments rendered during the month in which the money was disbursed to the facility. HHSC will deposit the reimbursement and the interest received under this subsection to the credit of the Nursing and Convalescent Home Trust Fund.(f) Any amount remaining due at the end of one year becomes delinquent and will be referred to the attorney general.(g) HHSC may determine that the facility is ineligible for a Medicaid provider contract. Source Note: The provisions of this §551.238 adopted to be effective February 1, 1999, 23 TexReg 11829; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.238 Involuntary Appointment of a Trustee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207917 03/12/2026 (a) In this section, the terms "close" and "closure" refer to a facility ceasing to operate. The terms do not include temporarily relocating residents of a facility.(b) Except as provided in subsection (c) of this section, if a license holder intends to voluntarily close a facility, the license holder must, at least 60 days before the facility closes:(1) send written notice of the license holder's intent to close the facility, including the anticipated date of closure, to:(A) the Texas Health and Human Services Commission (HHSC); and(B) all residents; and(2) make reasonable efforts to send written notice of the license holder's intent to close the facility, including the anticipated date of closure to:(A) all residents' legally authorized representatives (LARs); or(B) if a resident does not have an LAR the resident's nearest relative.(c) If, for reasons beyond the license holder's control, the license holder cannot provide the notice required by subsection (b) of this section at least 60 days before the license holder anticipates closing the facility, the license holder must state in the notice the reason why a shorter time period is necessary.(d) If HHSC requires a facility to close or the facility's closure is in any other way involuntary, the license holder must, immediately after becoming aware that the facility is closing:(1) send written notice of the closure, including the anticipated date of closure, to:(A) HHSC, if HHSC is not requiring the facility to close; and(B) all residents; and(2) make reasonable efforts to send written notice of the closure, including the anticipated date of closure to:(A) all residents' LARs; or(B) if a resident does not have an LAR, the resident's nearest relative.(e) A license holder must submit the license of a closing facility to HHSC with the notice required by subsection (b)(1)(A) or (d)(1)(A) of this section. If notice is not provided in accordance with subsection (b)(1)(A) or (d)(1)(A) of this section because HHSC is requiring a facility to close, the license holder must submit the license to HHSC when the closure is final. Source Note: The provisions of this §551.239 adopted to be effective April 17, 2016, 41 TexReg 2602; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.239 Notification of Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207918 03/12/2026 (a) Except as provided in subsection (b) of this section, before imposing an administrative penalty, the Texas Health and Human Services Commission (HHSC) gives a reasonable period of time, not less than 45 days, to correct a violation if a plan of correction is implemented. A facility may request a shorter period of time to correct the violation by submitting a written request for an early inspection to clear the violation. If, during the requested early inspection, HHSC finds that the correction is not satisfactory, an administrative penalty may immediately be assessed from the first day of violation.(b) HHSC does not give a facility a period of time to correct a violation before assessing an administrative penalty if HHSC determines that the violation:(1) is a pattern of violation that results in actual harm;(2) is widespread in scope and results in actual harm;(3) is widespread in scope, creates a potential for more than minimal harm, and relates to:(A) staff treatment of a resident, as described in 42 Code of Federal Regulations (CFR) §483.420 (relating to Condition of Participation: Client Protections); §551.42(g) of this chapter (relating to Standards for a Facility); §551.212 of this chapter (relating to Reporting Abuse, Neglect, and Exploitation to HHSC Provider Investigations); §551.213 of this chapter (relating to Reporting Incidents to HHSC); or §551.214 of this chapter (relating to Protection of Residents After Report of Abuse, Neglect, and Exploitation);(B) active treatment, as described in 42 CFR §483.440 (relating to Condition of Participation: Active Treatment Services) and §551.42(i) of this chapter;(C) client behavior and facility practices, as described in 42 CFR §483.450 (relating to Condition of Participation: Client Behavior and Facility Practices) and §551.42(j) of this chapter;(D) health care services, as described in 42 CFR §483.460 (relating to Condition of Participation: Health Care Services) and §551.42(k) of this chapter;(E) drug administration, as described in 42 CFR §483.460(k) (relating to Standard: Drug Administration) and §551.43 of this chapter (relating to Administration of Medication);(F) infection control, as described in 42 CFR §483.470(l) (relating to Standard: Infection Control) and §551.42(l) of this chapter;(G) food and nutrition services, as described in 42 CFR §483.480 (relating to Condition of Participation: Dietetic Services) and §551.42(n) of this chapter; or(H) emergency preparedness and response, as described in 42 CFR §483.475 (relating to Condition of Participation: Emergency Preparedness) and §551.42(m) of this chapter;(4) constitutes an immediate threat to the health or safety of a resident;(5) substantially limits the facility's capacity to provide care; or(6) is described in §551.236(a)(2) - (8) of this subchapter (relating to Administrative Penalties).(c) HHSC may not assess an administrative penalty for a minor violation that HHSC gave the facility time to correct if the facility corrects the violation not later than the 46th day after the facility receives notice of the violation.(d) If the facility reports to HHSC that the violation has been corrected, HHSC inspects the facility or takes any other steps necessary to confirm that the violation has been corrected and notifies the facility that:(1) the correction is satisfactory and a penalty is not assessed; or(2) the correction is not satisfactory and a penalty is recommended.(e) If the facility wishes to appeal the administrative penalty, the facility must file a notice to request a hearing on the violation or penalty no later than the 20th calendar day after the date on which the facility received the notice to pay an administrative penalty. Source Note: The provisions of this §551.240 adopted to be effective May 1, 2000, 25 TexReg 3557; amended to be effective January 15, 2009, 34 TexReg 238; amended to be effective October 28, 2018, 43 TexReg 7191; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.240 Right to Correct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207919 03/12/2026 (a) In lieu of demanding payment of an administrative penalty, the Commissioner may allow the person to use, under the supervision of the Texas Health and Human Services Commission (HHSC), a portion of the penalty to ameliorate the violation or to improve services, other than administrative services, in the facility.(b) HHSC will offer amelioration to a person for a violation if HHSC determines that the violation does not constitute immediate jeopardy to the health and safety of a resident.(c) HHSC will not offer amelioration to a person if HHSC determines that the violation constitutes immediate jeopardy to the health and safety of a resident.(d) HHSC will offer amelioration to a person not later than the 10th day after the date the person receives from HHSC a final notification of assessment of administrative penalty that is sent to the person after an informal dispute resolution process but before an administrative hearing.(e) A person to whom amelioration has been offered must file a plan for amelioration not later than the 45th day after the date the person receives the offer of amelioration from HHSC. In submitting the plan, the person must agree to waive the person's right to an administrative hearing if HHSC approves the plan.(f) At a minimum, a plan for amelioration must:(1) propose changes to the management or operation of the facility that will improve services to or quality of care of residents;(2) identify, through measurable outcomes, the ways in which and the extent to which the proposed changes will improve services to or quality of care of residents;(3) establish clear goals to be achieved through the proposed changes;(4) establish a timeline for implementing the proposed changes; and(5) identify specific actions necessary to implement the proposed changes.(g) HHSC may require that an amelioration plan propose changes that would result in conditions that exceed the minimum requirements for facility licensure.(h) HHSC will approve or deny an amelioration plan not later than the 45th day after the date HHSC receives the plan. On approval of a person's plan, HHSC will deny a pending request for a hearing submitted by the person.(i) HHSC will not offer amelioration to a person:(1) more than three times in a two-year period; or(2) more than one time in a two-year period for the same or similar violation. Source Note: The provisions of this §551.241 adopted to be effective May 1, 2000, 25 TexReg 3557; amended to be effective June 1, 2002, 27 TexReg 4368; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS H ENFORCEMENT §551.241 Amelioration of Violation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207922 03/12/2026 RA facility licensed under this chapter may provide respite care for an individual who has a diagnosis of an intellectual disability or a related condition without regard to whether the individual is eligible to receive intermediate care services under federal law, according to a plan of care as provided under Texas Health and Safety Code, Chapter 252, Subchapter G (relating to Respite Care). Source Note: The provisions of this §551.281 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.281 Generally https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194649 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Plan of care--A written description of the care, training, and treatment needed by a person during respite care.(2) Respite care--The provision by a facility to a person, for not more than two weeks for each stay in the facility, of room, board, and care at the level ordinarily provided for permanent residents. Source Note: The provisions of this §551.282 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.282 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207924 03/12/2026 (a) The facility and the person arranging the care must agree on the plan of care and the plan must be filed at the facility before the facility admits the person for the care.(b) The plan of care must be signed by:(1) a licensed physician if the person for whom the care is arranged need medical care or treatment; or(2) the person arranging for the respite care if medical care or treatment is not needed.(c) The facility may keep an agreed plan of care for a person for not longer than six months from the date on which it is received. After each admission, the facility must review and update the plan of care. During that period, the facility may admit the person as frequently as is needed and as accommodations are available.(d) The clinical record of each respite care resident must contain:(1) general identifying information necessary to care for the resident and maintain his or her clinical record;(2) resident assessment according to facility policy and care plan according to this section;(3) progress notes or flow sheets which document care/services;(4) reports of diagnostic or lab studies done during resident stay;(5) any physician's orders given during resident stay; and(6) discharge and readmission information based on facility policy for respite care services. Source Note: The provisions of this §551.283 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.283 Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207923 03/12/2026 The Texas Health and Human Services Commission (HHSC), at the time of a licensing inspection or at other times HHSC determines necessary, inspects a facility's records of respite care services, physical accommodations available for respite care, and the plan of care records to ensure that the respite care services comply with the licensing standards of this chapter. Source Note: The provisions of this §551.285 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.285 Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207920 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may require a facility to cease providing respite care if HHSC determines that the respite care does not meet the standards required by this chapter and that the facility cannot comply with those standards in the respite care it provides.(b) HHSC may suspend the license of a facility that continues to provide respite care after receiving a written order from HHSC to cease, as set out in §551.232 of this chapter (relating to License Suspension). Source Note: The provisions of this §551.286 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1995, 20 TexReg 1659; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.286 Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207921 03/12/2026 When a facility provides respite care:(1) the total number of individuals receiving services in the facility must not exceed the licensed capacity of the facility; and(2) any required staff to resident ratio will include any individual receiving respite care services regardless of the number of hours in the facility. Source Note: The provisions of this §551.287 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS J RESPITE CARE §551.287 Licensed Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207925 03/12/2026 (a) A facility must comply with Texas Health and Safety Code, Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illnesses).(b) Before a facility hires an applicant for employment, the facility must search the employee misconduct registry (EMR) established under the Texas Health and Safety Code §253.007, and the nurse aide registry (NAR) established under Texas Health and Safety Code §253.008 (relating to Verification of Employability; Annual Search) to determine if the applicant is designated in the EMR or NAR as unemployable. The EMR and NAR may be accessed on the HHSC Internet website.(c) In addition to the initial search of the EMR and NAR, a facility must conduct a search of the EMR and NAR to determine if the employee is designated in either registry as unemployable, as follows:(1) for an employee most recently hired before September 1, 2009, by August 31, 2011, and at least every twelve months thereafter; and(2) for an employee most recently hired on or after September 1, 2009, at least every twelve months.(d) A facility must keep a copy of the results of the initial and annual searches of the EMR and NAR in the employee's personnel file and make it available to HHSC upon request.(e) A facility is prohibited from hiring or continuing to employ a person who is listed in the EMR or NAR as unemployable.(f) A facility must provide information about the EMR to an employee in accordance with 40 TAC §93.3 (relating to Employment and Registry Information). Source Note: The provisions of this §551.321 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective May 1, 2000, 25 TexReg 3557; amended to be effective September 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.321 Determination of Employability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207926 03/12/2026 (a) Procedures for inspection of public records will be in accordance with the Texas Government Code, Chapter 552 (relating to Public Information), and as further described in this section.(b) The Texas Health and Human Services Commission (HHSC) is responsible for the maintenance and release of records on licensed facilities, and other related records.(c) The application for inspection of public records is subject to the following criteria:(1) the application must be made to the HHSC Open Records Coordinator, by mail at 4900 N. Lamar Boulevard, MC-1070, Austin, TX 78751-2316, by fax 512-424-6586, or email at openrecordsrequest@hhsc.state.tx.us;(2) the requestor must identify himself;(3) the requestor must give reasonable prior notice of the time for inspection or copying of records;(4) the requestor must specify the records requested;(5) on a written application, if HHSC is unable to ascertain the records being requested, HHSC may return the written application to the requestor for clarification. HHSC will provide the requested records as soon as possible; however, if the records are in active use, or in storage, or time is needed for proper de-identification or preparation of the records for inspection, HHSC will so advise the requestor and set an hour and date within a reasonable time when the records will be available.(d) Original records may be inspected or copied, but in no instance will original records be removed from HHSC offices.(e) Records maintained by HHSC are open to the public, with the following exceptions.(1) Incomplete reports, audits, evaluations, and investigations made of, for, or by HHSC are confidential.(2) All reports, records, and working papers used or developed by HHSC in an investigation of reports of abuse and neglect are confidential, and may be released to the public only as follows.(A) Completed written investigation reports are open to the public, provided the report is de-identified. The process of de-identification means removing all names and other personally identifiable data, including any information from witnesses and others furnished to HHSC as part of the investigation.(B) If HHSC receives written authorization from a facility resident or the resident's legal representative regarding an investigation of abuse or neglect involving that resident, HHSC will release the completed investigation report without removing the resident's name. The authorization must:(i) be signed and dated within six months of the request or state a length of time the authorization is valid;(ii) detail the information to be released;(iii) identify to whom the information can be released; and(iv) release HHSC from all liability for complying with the authorization.(3) All names and related personal, medical, or other identifying information about a resident are confidential.(4) Information about any identifiable person which is defamatory or an invasion of privacy is confidential.(5) Information identifying complainants or informants is confidential.(6) Itineraries of surveys and inspections are confidential.(7) Other information that is excepted from release by the Government Code, Chapter 552 (relating to Public Information), is not available to the public.(8) To implement this subsection, HHSC may not alter or de-identify original records. Instead, HHSC will make available for public review or release only a properly de-identified copy of the original record.(f) HHSC will charge for copies of records upon request.(1) If the requestor wants to inspect records, the requestor will specify the records to be inspected. HHSC will make no charge for this service, unless HHSC determines a charge is appropriate based on the nature of the request.(2) If the requestor wants copies of a record, the requestor will specify in writing the records to be copied on an appropriate HHSC form, and HHSC will complete the form by specifying the charge for the records, which the requestor must pay in advance. Checks and other instruments of payment must be made payable to HHSC.(3) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requestor on a cost basis in accordance with costs established by the Office of the Attorney General or HHSC for office machine copies.(4) For documents that are mailed, HHSC will charge for the postage at the time it charges for the production. All applicable sales taxes will be added to the cost of copying records.(5) When a request involves more than one long-term care facility, each facility will be considered a separate request. Source Note: The provisions of this §551.323 adopted to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.323 Procedures for Inspection of Public Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207927 03/12/2026 Stocks of inventoried emergency medications may be kept in facilities.(1) Emergency medication kits must be maintained in compliance with the Texas State Board of Pharmacy rules in 22 TAC §291.121 (relating to Remote Pharmacy Services).(2) Facilities must have contracts with the provider pharmacy that provides the emergency medication kit. The contract must outline the services to be provided by the pharmacy and the responsibilities and accountabilities of each party in fulfilling the terms of the contract in compliance with federal and state laws and regulations. Source Note: The provisions of this §551.324 adopted to be effective July 1, 2002, 27 TexReg 5525; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.324 Emergency Medication Kit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194653 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194653 03/12/2026 The facility must adhere to the following procedures governing the use of drugs covered by the Controlled Substances Act.(1) A separate record must be maintained for each drug covered by Schedules II, III, and IV of the Controlled Substances Act, Health and Safety Code, Chapter 481.(2) The record for each drug must contain the prescription number, name, and strength of drug, date received by the facility, date and time administered, name of resident, dose, physician's name, signature of person administering dose, and original amount dispensed with the balance verifiable by drug inventory at every shift change.(3) Schedule V drugs are exempt from the requirements in paragraphs (1) and (2) of this section. Source Note: The provisions of this §551.325 adopted to be effective May 1, 1998, 23 TexReg 4060; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.325 Controlled Substances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207928 03/12/2026 A facility must prominently post for display in an area of the facility that is readily available to residents, employees, and visitors:(1) the license issued under this chapter;(2) a notice prescribed by the Texas Health and Human Services Commission (HHSC) describing complaint procedures;(3) a notice providing instructions for reporting an allegation of abuse, neglect, or exploitation to the Texas Department of Family and Protective Services Statewide Intake;(4) a notice in the form prescribed by HHSC stating that inspection and related reports are available at the facility for public inspection and providing HHSC's toll-free telephone number that may be used to obtain information concerning the facility;(5) a copy of the most recent inspection report relating to the facility; and(6) a notice, in English and Spanish, stating that employees, other staff, residents, volunteers, and family members and guardians of residents are protected from discrimination or retaliation as specified in the Texas Health and Safety Code §§252.132 - 252.133 (relating to Suit for Retaliation and Suit for Retaliation Against Volunteer, Resident, or Family Member or Guardian of Resident). Source Note: The provisions of this §551.326 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective June 1, 2010, 35 TexReg 4469; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.326 Required Postings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207929 03/12/2026 A facility must notify the department no later than 30 days after the date of hire of an administrator. Source Note: The provisions of this §551.327 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective July 1, 1996, 21 TexReg 5328; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.327 Notice of Changes in Key Personnel https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194656 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194656 03/12/2026 A facility must not discharge or otherwise retaliate against:(1) an employee, resident, or other person because the employee, resident, or other person files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of restraint or seclusion at the facility; or(2) a resident because someone on behalf of the resident files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of restraint or seclusion at the facility. Source Note: The provisions of this §551.328 adopted to be effective June 1, 2006, 31 TexReg 4463; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.328 Retaliation Prohibited https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194657 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=194657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 194657 03/12/2026 (a) Effective September 1, 2012, a facility must develop and implement a policy to protect a resident from vaccine preventable diseases in accordance with Texas Health and Safety Code, Chapter 224.(b) The policy must:(1) require an employee or a contractor providing direct care to a resident to receive vaccines for the vaccine preventable diseases specified by the facility based on the level of risk the employee or contractor presents to residents by the employee's or contractor's routine and direct exposure to residents;(2) specify the vaccines an employee or contractor is required to receive in accordance with paragraph (1) of this subsection;(3) include procedures for the facility to verify that an employee or contractor has complied with the policy;(4) include procedures for the facility to exempt an employee or contractor from the required vaccines for the medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention;(5) for an employee or contractor who is exempt from the required vaccines, include procedures the employee or contractor must follow to protect residents from exposure to disease, such as the use of protective equipment, such as gloves and masks, based on the level of risk the employee or contractor presents to residents by the employee's or contractor's routine and direct exposure to residents;(6) prohibit discrimination or retaliatory action against an employee or contractor who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention, except that required use of protective medical equipment, such as gloves and masks, may not be considered retaliatory action;(7) require the facility to maintain a written or electronic record of each employee's or contractor's compliance with or exemption from the policy;(8) include disciplinary actions the facility may take against an employee or contractor who fails to comply with the policy.(c) The policy may:(1) include procedures for an employee or contractor to be exempt from the required vaccines based on reasons of conscience, including religious beliefs; and(2) prohibit an employee or contractor who is exempt from the required vaccines from having contact with residents during a public health disaster, as defined in Texas Health and Safety Code, §81.003 (relating to Definitions). Source Note: The provisions of this §551.329 adopted to be effective June 1, 2012, 37 TexReg 3871; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883. 1 HEALTH AND HUMAN SERVICES COMMISSION 551 INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS L PROVISIONS APPLICABLE TO FACILITIES GENERALLY §551.329 Vaccine Preventable Diseases https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218916 03/12/2026 The purpose of this chapter is to establish the procedures and practices the Texas Department of Human Services uses in certifying, terminating certification, or taking action relating to long-term care facilities participating in Medicare and the Medical Assistance Program in the State of Texas under Titles XVIII and XIX of the United States Social Security Act. Source Note: The provisions of this §552.1 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218917 03/12/2026 Title XVIII of the Social Security Act creates the Medicare Program which is a health insurance program for the aged and disabled. Title XIX of the Social Security Act creates the Texas Medical Assistance Program, which is a state plan to provide care for the poor, the elderly, and the disabled. The Texas Department of Human Services, as the licensing agency for long-term care facilities, is required to determine whether facilities meet the requirements for participation in the Title XVIII and XIX programs. Source Note: The provisions of this §552.3 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.3 Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218918 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Certification--A determination by the department that a facility meets the requirements for participation of the Title XVIII Medicare Program or the Title XIX Medical Assistance Program.(2) Department--The Texas Department of Human Services.(3) Facility--A long-term care institution which has applied for participation or participates in the Title XVIII Medicare Program or the Title XIX Medical Assistance Program.(4) HCFA--Health Care Financing Administration of the United States Department of Health and Human Services.(5) Intermediate care facility for the mentally retarded--A facility that participates in the Title XIX Medicaid Program under the definition in 42 United States Code (USC) §1396(d).(6) Nursing facility--A facility that participates in the Title XIX Medicaid Program under the definition in 42 USC §1396(c).(7) Skilled nursing facility--A facility that participates in the Title XVIII Medicare Program under the definition in 42 USC §1395i-3(a).(8) Standards--The rules, requirements, and guidelines established by HCFA or the state Medicaid agency with which a facility must comply to participate in the Title XVIII Medicare Program or the Title XIX Medical Assistance Program.(9) State Medicaid agency--The state agency designated to administer the funds for the Title XIX Medical Assistance Program.(10) Title XVIII Medicare Program--The health insurance program for the aged and disabled authorized under Title XVIII of the Social Security Act.(11) Title XIX Medical Assistance Program--The medical assistance program in Texas authorized under Title XIX of the Social Security Act. Source Note: The provisions of this §552.5 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218919 03/12/2026 (a) The Texas Department of Human Services (department) will certify to the Health Care Financing Administration (HCFA) or to the state Medicaid agency by means of a survey report and related documentation the level of compliance of each facility with federal and state standards required for the facility classification (skilled nursing facility, nursing facility, intermediate care facility for the mentally retarded, or any other terminology additions or deletions in the Title XVIII Medicare or the Title XIX Medical Assistance Programs).(b) The department also will perform any and all other certification responsibilities as required by standards and the contract between the department and HCFA or the state Medicaid agency for the implementation of the state certification program.(c) The department will perform inspections, surveys, and on-site visits pursuant to the Texas Utilization Review/Quality Assurance Program. Source Note: The provisions of this §552.7 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.7 The Texas Department of Human Services' General Responsibilities under the Title XVIII Medicare Program and the Title XIX Medical Assistance Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218920 03/12/2026 (a) The Texas Department of Human Services (department) shall follow all requirements for the survey and certification of skilled nursing facilities, nursing facilities, and intermediate care facilities for the mentally retarded as provided in Title 42, Code of Federal Regulations, Part 488.(b) The department shall follow all instructions, guidelines, and interpretive memoranda issued by the Health Care Financing Administration (HCFA) that apply to the survey and certification agency under the Title XVIII Medicare Program and the Title XVIII Medicaid Program. The department shall use the survey methods, procedures, and forms prescribed by HCFA.(c) For a survey of an intermediate care facility for the mentally retarded, the department shall:(1) assign a qualified mental retardation professional as a survey team member;(2) require each survey team to conduct a final interview with the provider to ensure that the survey team informs the provider of survey findings and that the survey team has requested the necessary information from the provider; and(3) allow the provider to record any interview with the survey team and immediately provide the survey team with a copy of the recording. Source Note: The provisions of this §552.9 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.9 Survey Procedure and Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218921 03/12/2026 (a) General. The procedure in this section shall be utilized by providers when there is a disagreement with surveyors' findings and/or recommendations, when additional written information becomes available that was not shared with the survey team, or when a complaint is filed relating to the conduct of the survey. The provider may request a face-to-face, telephone, or paper review when one of the following termination actions is taken against the facility: 90-day termination, denial of certification, or when the automatic cancellation clause is invoked. If no action was taken against the facility but deficiencies were written, the provider will be given a paper review only. These procedures shall only be used if the deficiencies cited in the survey report do not pose an imminent threat or danger to the health and/or safety of a resident. Twenty-three day terminations are not entitled to utilize the Informal Review process.(b) Review process.(1) Exit conference.(A) At the time of the survey the provider will furnish any information requested by the surveyor. The facility staff must not wait until the exit conference to provide information requested earlier during the survey. Information needed to conduct the survey must be made available during the survey; however, additional information will be accepted for review at the time of the exit conference.(B) At the time of the exit conference, the facility will receive written notice from a member of the survey team of its right to an informal review.(C) If there are issues which are not resolved during the exit conference, the administrator or his designee may make a written or faxed request for an informal review with the associate commissioner for Long Term Care Regulatory or his state office designee. The request for the review and any additional information must be submitted and received in the associate commissioner's or his designee's office within ten calendar days after receipt of the official statement of deficiencies.(2) Associate commissioner's review. The associate commissioner for long term care regulatory or his state office designee:(A) will review all information and make an impartial decision as to whether deficiencies shall be sustained, altered, or reversed from the original findings of the survey team. The Texas Department of Human Services (DHS) will not accept additional information or schedule an informal review after ten calendar days following receipt of the official statement of deficiencies;(B) may conduct, at the request of the provider, a face-to-face, telephone, or paper review when one of the following actions was taken against the facility: 90-day termination, denial of certification, or when the automatic cancellation clause is invoked;(C) will conduct a paper review only, if no action was taken against the facility, but deficiencies were written;(D) may request additional information if necessary;(E) will determine a resolution and present the resolution to the associate commissioner for long term care regulatory for concurrence; and(F) will notify the provider of a decision before the forty-fifth day after the provider receives the official statement of deficiencies. Time frames for all certification actions must be adhered to by the facility and DHS. Source Note: The provisions of this §552.11 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective January 1, 1997, 21 TexReg 11291; amended to be effective September 1, 1997, 22 TexReg 7905; amended to be effective September 1, 1998, 23 TexReg 8186; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.11 Informal Review Process for Intermediate Care Facilities for Persons with Mental Retardation and Related Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218922 03/12/2026 (a) Informal reconsideration (IR) for intermediate care facilities for the mentally retarded. Prior to the effective date of any termination of certification, the Texas Department of Human Services (DHS) gives the facility an opportunity for an IR.(1) Elements of the informal reconsideration are as follows.(A) DHS gives the facility written notice of the proposed termination of certification and the findings upon which the action is based.(B) The facility will have the opportunity to refute DHS's findings in writing. If the facility does not respond during the specified period, the action will be taken. If there is no response by the facility, DHS is not required to take any other action on the appeals process prior to the proposed action.(C) If the facility does respond as required in subparagraph (B) of this paragraph, DHS will give the facility a written affirmation or reversal of the proposed action.(2) DHS will provide IRs for an immediate termination of certification as follows.(A) The facility must submit a written request for an IR and provide all supporting documentation within five calendar days after receipt of DHS's written notice of the proposed termination of certification. Long Term Care-Regulatory staff will provide a written response to the facility within seven calendar days after receipt of the request.(B) If, as a result of a credible allegation visit, the immediate termination is changed to a 90-day termination, an IR will be offered based on the findings of this visit. This second IR will follow the procedures in paragraph (4) of this subsection.(3) DHS will not provide an IR for an immediate termination of certification if, as a result of a credible allegation visit, DHS's proposal to immediately terminate the facility's certification is not changed.(4) DHS will provide IRs for a 90-day termination of certification as follows.(A) The facility must submit a written request for an IR and provide all supporting documentation within seven calendar days after receipt of DHS's written notice of the proposed termination of certification. Long Term Care-Regulatory staff will provide a written response to the facility within ten calendar days after receipt of the request.(B) After the 45-day visit, DHS will provide the following IRs for a 90-day termination of certification.(i) If DHS proposes to continue the 90-day termination based on new deficiencies, an IR will be offered on the new deficiencies only, following the procedure in paragraph (2)(A) of this subsection.(ii) If DHS proposes to continue the 90-day termination based only on uncorrected deficiencies, an IR will not be offered.(iii) If DHS proposes to change the 90-day termination to an immediate termination, an IR will be offered on the new deficiencies only, following the procedure in paragraph (2) of this subsection.(5) DHS will not provide an IR for a 90-day termination of certification if, as a result of a credible allegation visit, DHS's proposal to terminate the facility's certification in 90 days is not changed.(b) Formal hearing for all facilities.(1) The facility will have the opportunity for a formal hearing after the effective date of the termination of certification, denial of certification, or other adverse certification recommendation.(2) A facility desiring a formal hearing must make a request to DHS, in writing, within 15 calendar days after the facility receives DHS's official notice of the action. Upon receipt of the request, DHS's Office of General Counsel will institute formal hearing procedures. Failure of the facility to request a formal hearing within 15 calendar days constitutes a waiver of the right to a hearing.(3) The formal hearing will be conducted in accordance with DHS's formal hearing procedures in Chapter 79 of this title (relating to Legal Services). Source Note: The provisions of this §552.13 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective September 1, 1994, 19 TexReg 5736; amended to be effective March 1, 1995, 20 TexReg 353; amended to be effective July 31, 1995, 20 TexReg 5261; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.13 Appeals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=218923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 218923 03/12/2026 In all deliberations, the Texas Department of Human Services (department) will construe this chapter in order to assure quality-of-care standards for the long-term care facilities in the State of Texas and to enforce federal and state standards and regulations governing the Title XVIII Medicare Program and the Title XIX Medical Assistance Program. Source Note: The provisions of this §552.15 adopted to be effective August 31, 1993, 18 TexReg 2725; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; transferred effective June 30, 2024, as published in the May 31, 2024, issue of the Texas Register, 49 TexReg 3935. 1 HEALTH AND HUMAN SERVICES COMMISSION 552 CERTIFICATION OF LONG-TERM CARE FACILITIES §552.15 Construction of This Chapter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205791 03/12/2026 (a) The purpose of this chapter is to establish:(1) the criteria and application procedure for licensing an assisted living facility;(2) the licensing standards with which an assisted living facility must comply and that serve as a basis for licensure inspections, including:(A) operation and resident care standards; and(B) facility construction standards;(3) the inspections and investigations HHSC may conduct as a regulatory authority; and(4) enforcement actions HHSC may take against a facility.(b) This chapter applies to a facility licensed or subject to being licensed in accordance with Texas Health and Safety Code, Chapter 247. Assisted living services are driven by a philosophy that emphasizes personal dignity and autonomy to age in place in a residential setting while receiving increasing or decreasing levels of services as the person's needs change. Source Note: The provisions of this §553.1 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES A INTRODUCTION §553.1 Purpose and Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210897 03/12/2026 The following words and terms, when used in this chapter, have the following meaning, unless the context clearly indicates otherwise. (1) Abuse--(A) For a person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes, the term has the meaning in Texas Family Code §261.001(1), which is an intentional, knowing, or reckless act or omission by an employee, volunteer, or other individual working under the auspices of a facility or program that causes or may cause emotional harm or physical injury to, or the death of, a child served by the facility or program, as further described by rule or policy; and (B) For a person other than one described in subparagraph (A) of this paragraph, the term has the meaning in Texas Health and Safety Code §260A.001(1), which is: (i) the negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to a resident by the resident's caregiver, family member, or other individual who has an ongoing relationship with the resident; or (ii) sexual abuse of a resident, including any involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure), or Texas Penal Code, Chapter 22 (relating to Assaultive Offenses), committed by the resident's caregiver, family member, or other individual who has an ongoing relationship with the resident. (2) Accreditation commission--Has the meaning given in Texas Health and Safety Code §247.032. (3) Actual harm--A negative outcome that compromises a resident's physical, mental, or emotional well-being. (4) Advance directive--Has the meaning given in Texas Health and Safety Code §166.002. (5) Affiliate--With respect to: (A) a partnership, each partner thereof; (B) a corporation, each officer, director, principal stockholder, subsidiary, or person with a disclosable interest, as the term is defined in this section; and (C) a natural person: (i) said person's spouse; (ii) each partnership and each partner thereof, of which said person or any affiliate of said person is a partner; and (iii) each corporation in which said person is an officer, director, principal stockholder, or person with a disclosable interest. (6) Alzheimer's Assisted Living Disclosure Statement form--The HHSC-prescribed form a facility uses to describe the nature of care or treatment of residents with Alzheimer's disease and related disorders. (7) Alzheimer's disease and related disorders--Alzheimer's disease and any other irreversible dementia described by the Centers for Disease Control and Prevention (CDC), or the most current edition of the Diagnostic and Statistical Manual of Mental Disorders. (8) Alzheimer's facility--A Type B facility that is certified to provide specialized services to residents with Alzheimer's disease or a related condition. (9) Applicant--A person applying for a license to operate an assisted living facility under Texas Health and Safety Code, Chapter 247. (10) Assisted Living Facility Memory Care Disclosure Statement form--The HHSC-prescribed form that a facility uses when the facility advertises, markets, or otherwise promotes that it provides memory care services to residents with Alzheimer's disease and related disorders.(11) Attendant--A facility employee who provides direct care to residents. This employee may serve other functions, including cook, janitor, porter, maid, laundry worker, security personnel, bookkeeper, activity director, and manager. (12) Authorized electronic monitoring (AEM)--The placement of an electronic monitoring device in a resident's room and using the device to make tapes or recordings after making a request to the facility to allow electronic monitoring. (13) Behavioral emergency--Has the meaning given in §553.261(g)(2) of this chapter (relating to Coordination of Care). (14) Certified ombudsman--Has the meaning given in §88.2 of this title (relating to Definitions). (15) CFR--Code of Federal Regulations. (16) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership. (17) Commingles--The laundering of apparel or linens of two or more individuals together. (18) Controlling person--A person with the ability, acting alone or with others, to directly or indirectly influence, direct, or cause the direction of the management, expenditure of money, or policies of a facility or other person. A controlling person includes: (A) a management company, landlord, or other business entity that operates or contracts with others for the operation of a facility; (B) any person who is a controlling person of a management company or other business entity that operates a facility or that contracts with another person for the operation of an assisted living facility; (C) an officer or director of a publicly traded corporation that is, or that controls, a facility, management company, or other business entity described in subparagraph (A) of this paragraph but does not include a shareholder or lender of the publicly traded corporation; and (D) any other individual who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of a facility, is in a position of actual control or authority with respect to the facility, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the facility, except an employee, lender, secured creditor, landlord, or other person who does not exercise formal or actual influence or control over the operation of a facility. (19) Covert electronic monitoring--The placement and use of an electronic monitoring device that is not open and obvious, and about which the facility and HHSC have not been informed by the resident, by the person who placed the device in the room, or by a person who uses the device. (20) Delegation--In the assisted living facility context, written authorization by a registered nurse (RN) acting on behalf of the facility for personal care staff to perform tasks of nursing care in selected situations, where delegation criteria are met for the task. The delegation process includes nursing assessment of a resident in a specific situation, evaluation of the ability of the personal care staff, teaching the task to the personal care staff, ensuring supervision of the personal care staff in performing a delegated task, and re-evaluating the task at regular intervals. (21) Dietitian--A person who currently holds a license or provisional license issued by the Texas Department of Licensing and Regulation. (22) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder. (23) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder. (24) Disclosure statement--An HHSC form for prospective residents or their legally authorized representatives that a facility must complete. The form contains information regarding the preadmission, admission, and discharge process; resident assessment and service plans; staffing patterns; the physical environment of the facility; resident activities; and facility services. (25) Electronic monitoring device--Video surveillance cameras and audio devices installed in a resident's room, designed to acquire communications or other sounds that occur in the room. An electronic, mechanical, or other device used specifically for the nonconsensual interception of wire or electronic communication is excluded from this definition. (26) Exploitation-- (A) For a person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes, the term has the meaning in Texas Family Code §261.001(3), which is the illegal or improper use of a child or of the resources of a child for monetary or personal benefit, profit, or gain by an employee, volunteer, or other individual working under the auspices of a facility or program as further described by rule or policy; and (B) For a person other than one described in subparagraph (A) of this paragraph, the term has the meaning in Texas Health and Safety Code §260A.001(4), which is the illegal or improper act or process of a caregiver, family member, or other individual who has an ongoing relationship with the resident using the resources of a resident for monetary or personal benefit, profit, or gain without the informed consent of the resident. (27) Facility--An entity required to be licensed under the Assisted Living Facility Licensing Act, Texas Health and Safety Code, Chapter 247. (28) Fire suppression authority--The paid or volunteer fire-fighting organization or tactical unit that is responsible for fire suppression operations and related duties once a fire incident occurs within its jurisdiction. (29) Flame spread--The rate of fire travel along the surface of a material. This is different than other requirements for time-rated "burn through" resistance ratings, such as one-hour rated. Flame spread ratings are Class A (0-25), Class B (26-75), and Class C (76-200). (30) Functional disability--A mental, cognitive, or physical disability that precludes the physical performance of self-care tasks, including health maintenance activities and personal care. (31) Governmental unit--The state or any county, municipality, or other political subdivision, or any department, division, board, or other agency of any of the foregoing. (32) Health care professional--An individual licensed, certified, or otherwise authorized to administer health care, for profit or otherwise, in the ordinary course of business or professional practice. The term includes a physician, registered nurse, licensed vocational nurse, licensed dietitian, physical therapist, and occupational therapist. (33) Health maintenance activity (HMA)--Consistent with 22 TAC §225.4 (relating to Definitions), a task that: (A) may be exempt from delegation based on an RN's assessment in accordance with §553.263(c) of this chapter (relating to Health Maintenance Activities); and (B) requires a higher level of skill to perform than personal care services and, in the context of an ALF, excludes the following tasks: (i) intermittent catheterization; and (ii) subcutaneous, nasal, or insulin pump administration of insulin or other injectable medications prescribed in the treatment of diabetes mellitus. (34) HHSC--The Texas Health and Human Services Commission. (35) Immediate threat to the health or safety of a resident--A situation that causes, or is likely to cause, serious injury, harm, or impairment to or the death of a resident. (36) Immediately available--The capacity of facility staff to immediately respond to an emergency after being notified through a communication or alarm system. The staff are to be no more than 600 feet from the farthest resident and in the facility while on duty. (37) Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder. (38) Isolated--A very limited number of residents are affected, and a very limited number of staff are involved, or the situation has occurred only occasionally. (39) Key infectious agents--Bacteria, viruses, and other microorganisms which cause the most common infections and infectious diseases in long-term care facilities, and can be mitigated by establishing, implementing, maintaining, and enforcing proper infection, prevention, and control policies and procedures. (40) Large facility--A facility licensed for 17 or more residents. (41) Legally authorized representative--A person authorized by law to act on behalf of a person with regard to a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (42) License holder--A person that holds a license to operate a facility. (43) Listed--Equipment, materials, or services included in a list published by an organization concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets appropriate designated standards or has been tested and found suitable for a specified purpose. The listing organization must be acceptable to the authority having jurisdiction, including HHSC or any other state, federal, or local authority. (44) Local code--A model building code adopted by the local building authority where the facility is constructed or located. (45) Management services--Services provided under contract between the owner of a facility and a person to provide for the operation of a facility, including administration, staffing, maintenance, or delivery of resident services. Management services do not include contracts solely for maintenance, laundry, transportation, or food services. (46) Manager--The individual in charge of the day-to-day operation of the facility. (47) Managing local ombudsman--Has the meaning given in §88.2 of this title. (48) Medication-- (A) Medication is any substance: (i) recognized as a drug in the official United States Pharmacopoeia, Official Homeopathic Pharmacopoeia of the United States, Texas Drug Code Index or official National Formulary, or any supplement to any of these official documents; (ii) intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease; (iii) other than food intended to affect the structure or any function of the body; and (iv) intended for use as a component of any substance specified in this definition. (B) Medication includes both prescription and over-the-counter medication, unless otherwise specified. (C) Medication does not include devices or their components, parts, or accessories. (49) Medication administration--The direct application of a medication or drug to the body of a resident by an individual legally allowed to administer medication in the state of Texas. (50) Medication assistance or supervision--The assistance or supervision of the medication regimen by facility staff. Refer to §553.261(a) of this chapter. (51) Medication (self- or self-administration of)--The capability of a resident to administer the resident's own medication or treatments without assistance from the facility staff. (52) Memory care services--Services provided by an assisted living facility to meet the needs of residents with a diagnosis of Alzheimer's disease or related disorders or a diagnosis of dementia.(53) Multidrug-resistant organisms--Bacteria and other microorganisms that have developed resistance to multiple types of medicine used to act against the microorganism. (54) Neglect-- (A) For a person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes, the term has the meaning in Texas Family Code §261.001(4), which is a negligent act or omission by an employee, volunteer, or other individual working under the auspices of a facility or program, including failure to comply with an individual treatment plan, plan of care, or individualized service plan, that causes or may cause substantial emotional harm or physical injury to, or the death of, a child served by the facility or program as further described by rule or policy; and (B) For a person other than one described in subparagraph (A) of this paragraph, the term has the meaning in Texas Health and Safety Code §260A.001(6), which is the failure to provide for oneself the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services. (55) NFPA 101--The 2012 publication titled NFPA 101 Life Safety Code published by the National Fire Protection Association, Inc., 1 Batterymarch Park, Quincy, Massachusetts 02169. (56) Ombudsman intern--Has the meaning given in §88.2 of this title. (57) Ombudsman program--Has the meaning given in §88.2 of this title. (58) Online portal--A secure portal provided on the HHSC website for licensure activities, including for an assisted living facility applicant to submit licensure applications and information. (59) Pattern of violation--Repeated, but not widespread in scope, failures of a facility to comply with this chapter or a rule, standard, or order adopted under Texas Health and Safety Code, Chapter 247 that: (A) result in a violation; and (B) are found throughout the services provided by the facility or that affect or involve the same residents or facility employees. (60) Person--Any individual, firm, partnership, corporation, association, or joint stock association, and the legal successor thereof. (61) Personal care services--Assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in the facility or who needs assistance to manage his or her personal life, regardless of whether a guardian has been appointed for the person. (62) Personal care staff--An attendant whose primary employment function is to provide personal care services. (63) Physician--A practitioner licensed by the Texas Medical Board. (64) Potential for minimal harm--A violation that has the potential for causing no more than a minor negative impact on a resident. (65) Practitioner--An individual who is currently licensed in a state in which the individual practices as a physician, dentist, podiatrist, or a physician assistant; or a registered nurse approved by the Texas Board of Nursing to practice as an advanced practice registered nurse. (66) Private and unimpeded access--Access to enter a facility or communicate with a resident outside of the hearing and view of others, without interference or obstruction from facility employees, volunteers, or contractors. (67) Qualified medical personnel--An individual who is licensed, certified, or otherwise authorized to administer health care. The term includes a physician, registered nurse, and licensed vocational nurse. (68) Rapid influenza diagnostic test--A test administered to a person with flu-like symptoms that can detect the influenza viral nucleoprotein antigen. (69) Resident--An individual accepted for care in a facility. (70) Respite--The provision by a facility of room, board, and care at the level ordinarily provided for permanent residents of the facility to a person for not more than 60 days for each stay in the facility. (71) Restraint hold-- (A) A manual method, except for physical guidance or prompting of brief duration, used to restrict: (i) free movement or normal functioning of all or a portion of a resident's body; or (ii) normal access by a resident to a portion of the resident's body. (B) Physical guidance or prompting of brief duration becomes a restraint if the resident resists the guidance or prompting. (72) Restraints--Chemical restraints are psychoactive drugs administered for the purposes of discipline or convenience and are not required to treat the resident's medical symptoms. Physical restraints are any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident that restricts freedom of movement. Physical restraints include restraint holds. (73) RN (registered nurse)--A person who holds a current and active license from the Texas Board of Nursing to practice professional nursing, as defined in Texas Occupations Code §301.002(2). (74) Safety--Protection from injury or loss of life due to such conditions as fire, electrical hazard, unsafe building or site conditions, and the hazardous presence of toxic fumes and materials. (75) Seclusion--The involuntary separation of a resident from other residents and the placement of the resident alone in an area from which the resident is prevented from leaving. (76) Service plan--A written description of the medical care, supervision, or nonmedical care needed by a resident. (77) Short-term acute episode--An illness of less than 30 days' duration. (78) Small facility--A facility licensed for 16 or fewer residents. (79) Stable and predictable--A phrase describing the clinical and behavioral status of a resident that is non-fluctuating and consistent and does not require the regular presence of a registered or licensed vocational nurse. (A) The phrase does not include within its meaning a description of the clinical and behavioral status of a resident that is expected to change rapidly or needs continuous or continual nursing assessment and evaluation. (B) The phrase does include within its meaning a description of the condition of a resident receiving hospice care within a facility where deterioration is predictable. (80) Staff--Employees of an assisted living facility. (81) Standards--The minimum conditions, requirements, and criteria established in this chapter with which a facility must comply to be licensed under this chapter. (82) State Ombudsman--Has the meaning given in §88.2 of this title. (83) Terminal condition--A medical diagnosis, certified by a physician, of an illness that will result in death in six months or less. (84) Universal precautions--An approach to infection control in which blood, any body fluids visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids are treated as if known to be infectious for HIV, hepatitis B, and other blood-borne pathogens. (85) Vaccine Preventable Diseases--The diseases included in the most current recommendations of the Advisory Committee on Immunization Practices of the CDC. (86) Widespread in scope--A violation of Texas Health and Safety Code, Chapter 247 or a rule, standard, or order adopted under Chapter 247 that: (A) is pervasive throughout the services provided by the facility; or (B) represents a systemic failure by the facility that affects or has the potential to affect a large portion of or all of the residents of the facility. (87) Willfully interfere--To act or not act to intentionally prevent, interfere with, impeded, or to attempt to intentionally prevent, interfere with, or impede. (88) Working day--Any 24-hour period, Monday through Friday, excluding state and federal holidays. Source Note: The provisions of this §553.3 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective December 6, 2022, 47 TexReg 7705. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES A INTRODUCTION §553.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205793 03/12/2026 (a) Basis for licensure type. A facility must be licensed as a Type A or Type B facility. A facility's licensure type is based on the capability of the residents to evacuate the facility, as described in this section.(b) Type A. In a Type A facility, a resident:(1) must be physically and mentally capable of evacuating the facility without physical assistance from staff, which may include an individual who is mobile, although non-ambulatory, such as an individual who uses a wheelchair or an electric cart, and has the capacity to transfer and evacuate himself or herself in an emergency;(2) does not require routine attendance during nighttime sleeping hours;(3) must be capable of following directions under emergency conditions; and(4) must be able to demonstrate to HHSC that they can meet the evacuation requirements described in Subchapter D of this chapter (relating to Facility Construction).(c) Type B. In a Type B facility, a resident may:(1) require staff assistance to evacuate;(2) require attendance during nighttime sleeping hours;(3) be incapable of following directions under emergency conditions; and(4) require assistance in transferring to and from a wheelchair; but(5) must not be permanently bedfast.(d) Type C.(1) A Type C facility is a four-bed facility that was originally licensed by HHSC to provide adult foster care services as described in 40 TAC Chapter 48, Subchapter K (relating to Minimum Standards for Adult Foster Care).(2) HHSC no longer issues Type C licenses and Type C licensure is no longer a requirement to contract with HHSC to provide adult foster care services. In accordance with 40 TAC Chapter 48, Subchapter K, in order to contract with HHSC as a provider of adult foster care services, an applicant must have a current license for a Type A or Type B assisted living facility. Source Note: The provisions of this §553.5 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES A INTRODUCTION §553.5 Types of Assisted Living Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205794 03/12/2026 (a) An assisted living facility must:(1) furnish, in one or more facilities, food and shelter to four or more persons who are unrelated to the proprietor of the establishment; and(2) provide:(A) personal care services; or(B) medication administration by a person licensed or otherwise authorized in this state to administer the medication.(b) An assisted living facility establishment may provide:(1) assistance with or supervision of medication administration;(2) health maintenance activities in accordance with §553.263 of this chapter (relating to Health Maintenance Activities); and(3) skilled nursing services for the following limited purposes:(A) coordinate resident care with an outside home and community support services agency or other health care professional;(B) provision or delegation of personal care services and medication administration, as described in this chapter;(C) assessment of residents to determine the care required; and(D) delivery, for a period not to exceed 30 days, of temporary skilled nursing services for a minor illness, injury, or emergency. Source Note: The provisions of this §553.7 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES A INTRODUCTION §553.7 Assisted Living Facility Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205795 03/12/2026 This section describes some general characteristics of a resident in a facility. A resident may:(1) exhibit symptoms of mental or emotional disturbance, but is not considered at risk of imminent harm to self or others;(2) need assistance with movement;(3) require assistance with bathing, dressing, and grooming;(4) require assistance with routine skin care, such as application of lotions or treatment of minor cuts and burns;(5) need reminders to encourage toilet routine and prevent incontinence;(6) require temporary services by professional personnel;(7) need assistance with medication, supervision of self-medication, or medication administration;(8) require encouragement to eat, or monitoring due to social or psychological reasons of temporary illness;(9) be hearing impaired or speech impaired;(10) be incontinent without pressure sores;(11) require an established therapeutic diet;(12) require self-help devices; and(13) need assistance with meals, which may include feeding. Source Note: The provisions of this §553.9 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES A INTRODUCTION §553.9 General Characteristics of a Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220504 03/12/2026 (a) A person must be licensed to establish or operate an assisted living facility in Texas.(1) HHSC considers one or more facilities to be part of the same establishment and, therefore, subject to licensure as an assisted living facility, based on the following factors:(A) common ownership;(B) physical proximity;(C) shared services, personnel, or equipment in any part of the facilities' operations; and(D) any public appearance of joint operations or of a relationship between the facilities.(2) The presence or absence of any one factor in paragraph (1) of this subsection is not conclusive.(b) To obtain a license, a person must follow the application requirements in this subchapter and meet the criteria for a license.(c) An applicant must affirmatively show that the applicant, license holder, controlling person, and any person required to submit background and qualification information meet the criteria and eligibility for licensing, in accordance with this section; and(1) the building in which the facility is housed:(A) meets local fire ordinances;(B) is approved by the local fire authority;(C) meets HHSC licensing standards in accordance with Subchapter D of this chapter (relating to Facility Construction) based on an on-site inspection by HHSC or the standards for accreditation based on an on-site accreditation survey by an accreditation commission; and(D) if located in a county of more than 3.3 million residents for initial license applications submitted or issued on or after December 6, 2022, is not located in a 100-year floodplain; and(2) operation of the facility meets HHSC licensing standards based on an on-site health inspection by HHSC, which must include observation of the care of a resident; or(3) the facility meets the standards for accreditation based on an on-site accreditation survey by the accreditation commission.(d) An applicant who chooses the option authorized in subsection (c)(3) of this section must contact HHSC to determine which accreditation commissions are available to meet the requirements of that subsection. If a license holder uses an on-site accreditation survey by an accreditation commission, as provided in this subsection and §553.33(i) of this subchapter (relating to Renewal Procedures and Qualifications), the license holder must:(1) provide written notification to HHSC by submitting an updated application in the licensing system within five working days after the license holder receives a notice of change in accreditation status from the accreditation commission; and(2) include a copy of the notice of change with its written notification to HHSC.(e) HHSC issues a license to a facility meeting all requirements of this chapter. The facility must not exceed the maximum allowable number of residents specified on the license.(f) HHSC denies an application for an initial license or a renewal of a license if:(1) the applicant, license holder, controlling person, or any person required to be disclosed on the application for licensure has been debarred or excluded from the Medicare or Medicaid programs by the federal government or a state;(2) a court has issued an injunction prohibiting the applicant, license holder, controlling person, or any person required to be disclosed on the application for licensure from operating a facility; or(3) during the five years preceding the date of the application, a license to operate a health care facility, long-term care facility, assisted living facility, or similar facility in any state held by the applicant, license holder, controlling person, or any person required to be disclosed on the application for licensure has been revoked.(g) A license holder or controlling person who operates a nursing facility or an assisted living facility for which a trustee was appointed and for which emergency assistance funds, other than funds to pay the expenses of the trustee, were used is subject to exclusion from eligibility for:(1) the issuance of an initial license for a facility for which the person has not previously held a license; and(2) the renewal of the license of the facility for which the trustee was appointed.(h) HHSC may deny an application for an initial license or refuse to renew a license if an applicant, license holder, controlling person, or any person required to be disclosed on the application for licensure:(1) violates Texas Health and Safety Code, Chapter 247; a section, standard, or order adopted under Chapter 247; or a license issued under Chapter 247 in either a repeated or substantial manner;(2) commits an act described in §553.751(a)(2) - (9) of this chapter (relating to Administrative Penalties);(3) aids, abets, or permits a substantial violation described in paragraph (1) or (2) of this subsection about which the person had or should have had knowledge;(4) fails to provide the required information, facts, or references;(5) engages in the following:(A) knowingly submits false or intentionally misleading statements to HHSC;(B) uses subterfuge or other evasive means of filing an application for licensure;(C) engages in subterfuge or other evasive means of filing on behalf of another who is unqualified for licensure;(D) knowingly conceals a material fact related to licensure; or(E) is responsible for fraud;(6) fails to pay the following fees, taxes, and assessments when due:(A) license fees, as described in §553.47 of this subchapter (relating to License Fees); or(B) franchise taxes, if applicable;(7) during the five years preceding the date of the application, has a history in any state or other jurisdiction of any of the following:(A) operation of a facility that has been decertified or has had its contract canceled under the Medicare or Medicaid program;(B) federal or state long-term care facility, assisted living facility, or similar facility sanctions or penalties, including monetary penalties, involuntary downgrading of the status of a facility license, proposals to decertify, directed plans of correction, or the denial of payment for new Medicaid admissions;(C) unsatisfied final judgments, excluding judgments wholly unrelated to the provision of care rendered in long-term care facilities;(D) eviction involving any property or space used as a facility; or(E) suspension of a license to operate a health care facility, long-term care facility, assisted living facility, or a similar facility;(8) violates Texas Health and Safety Code §247.021 by operating a facility without a license; or(9) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter.(i) Without limitation, HHSC reviews all information provided by an applicant, a license holder, a person required to be disclosed on the application for licensure, or a manager when considering grounds for denial of an initial license application or a renewal application in accordance with subsection (h) of this section. HHSC may grant a license if HHSC finds the applicant, license holder, person required to be disclosed on the application for licensure, affiliate, or manager is able to comply with the rules in this chapter.(j) HHSC reviews final actions when considering the grounds for denial of an initial license application or renewal application in accordance with subsections (f) and (h) of this section. An action is final when routine administrative and judicial remedies are exhausted. An applicant must disclose all actions, whether pending or final.(k) If an applicant owns multiple facilities, HHSC examines the overall record of compliance in all of the applicant's facilities. An overall record poor enough to deny issuance of a new license does not preclude the renewal of a license of a facility with a satisfactory record. Source Note: The provisions of this §553.17 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective December 6, 2022, 47 TexReg 7705; amended to be effective September 12, 2024, 49 TexReg 7044. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.17 Criteria for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205800 03/12/2026 (a) An applicant must use the online portal and the forms prescribed by HHSC to submit a license application and for all licensure requirements and activities that can be met or conducted using the online portal.(b) An applicant must complete the application and furnish all documents and information that HHSC requests in accordance with the instructions provided with the application. An application must be complete, accurate, and submitted with full payment of applicable license fees described in §553.47 of this subchapter (relating to License Fees). If an applicant provides incorrect or false information, or withholds information, HHSC may deny the application as described in §553.17(h) of this subchapter (relating to Criteria for Licensing).(c) An application must include documentation from the local fire authority that the facility and its operations meet local fire ordinances.(d) If an applicant decides not to continue the application process for a license after submitting an application and license fee, the applicant must submit to HHSC a request to withdraw the application. HHSC does not refund the license fee for an application that is withdrawn, except as provided in §553.21(d) of this subchapter (relating to Time Periods for Processing All Types of License Applications). Source Note: The provisions of this §553.19 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.19 General Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205801 03/12/2026 (a) HHSC reviews an application for a license within 30 days after the date HHSC Licensing and Credentialing Section, Long-term Care Regulation, receives the application and notifies the applicant if additional information is needed to complete the application.(b) HHSC denies an application that remains incomplete 120 days after the date that HHSC Licensing and Credentialing Section, Long-term Care Regulation receives the application.(c) HHSC issues a license within 30 days after HHSC determines that the applicant and the facility have met all licensure requirements referenced in §553.23 of this subchapter (relating to Initial License Application Procedures and Requirements) or §553.33 of this subchapter (relating to Renewal Procedures and Qualifications), as applicable.(d) If HHSC does not process an application in the time period stated, the applicant has a right to make a request to the program director for reimbursement of the license fees paid with the application.(1) If the program director does not agree that the established time period has been violated or finds that good cause existed for exceeding the established time period, the program director denies the request.(2) Good cause for exceeding the established time period exists if:(A) the number of applications to be processed exceeds by 15 percent or more the number processed in the same calendar quarter of the preceding year;(B) HHSC must rely on another public or private entity to process all or a part of the application received by HHSC, and the delay is caused by that entity; or(C) other conditions existed giving good cause for exceeding the established time period.(3) If the request for reimbursement is denied, the applicant may appeal to the HHSC Executive Commissioner for resolution of the dispute. The applicant must send a written statement to the HHSC Executive Commissioner describing the request for reimbursement and the reason for the request. The HHSC Executive Commissioner will make a timely decision concerning the appeal and notify the applicant in writing of the decision. Source Note: The provisions of this §553.21 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.21 Time Periods for Processing All Types of License Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205802 03/12/2026 (a) An applicant must complete the HHSC pre-licensure training course before submitting an application for an initial license. An applicant that is currently licensed under Texas Health and Safety Code, Chapter 247 is exempt from this requirement.(b) An applicant for an initial license must submit an application in accordance with §553.19 of this subchapter (relating to General Application Requirements) and include full payment of the fees required in §553.47 of this subchapter (relating to License Fees).(c) HHSC reviews an application for an initial license within 30 days after the date HHSC Licensing and Credentialing Section, Long-term Care Regulation receives the application and notifies the applicant if additional information is needed to complete the application.(d) The applicant must notify HHSC via the online portal indicating that the facility is ready for a Life Safety Code (LSC) inspection. The notice must be submitted with the application or within 120 days after the HHSC Licensing and Credentialing Section, Long-term Care Regulation receives the application. After the applicant has satisfied the application submission requirements in §553.17 of this subchapter (relating to Criteria for Licensing) and §553.19 of this subchapter, HHSC staff conduct an on-site LSC inspection of the facility to determine if the facility meets the applicable NFPA 101 and other physical plant requirements in Subchapter D of this chapter (relating to Facility Construction).(e) If the facility fails to meet the licensure requirements within 120 days after the initial LSC inspection, HHSC denies the application for a license.(f) After a facility has met the licensure requirements in Subchapter D of this chapter and has admitted at least one but no more than three residents, the applicant must notify HHSC via the online portal that the facility is ready for a health inspection.(1) HHSC staff conduct an on-site health inspection to determine if the facility meets the licensure requirements for standards of operation and resident care in Subchapter E of this chapter (relating to Standards for Licensure).(2) If the facility fails to meet the licensure requirements for standards of operation and resident care within 120 days after the initial health inspection, HHSC denies the application for a license.(g) HHSC issues a license within 30 days after HHSC determines that the applicant and the facility have met the licensure requirements of this section. The issuance of a license constitutes HHSC's official written notice to the facility of the approval of the application.(h) HHSC may deny an application for an initial license if the applicant, controlling person, or any person required to submit background and qualification information fails to meet the criteria for a license established in §553.17 of this subchapter.(i) If HHSC denies an application for an initial license, HHSC sends the applicant a written notice of the denial and informs the applicant of the applicant's right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with Texas Health and Human Services Commission rules at Texas Administrative Code, Title 1, Part 15, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §553.23 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.23 Initial License Application Procedures and Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205803 03/12/2026 (a) An applicant may request that HHSC issue, before conducting an on-site health inspection, an initial license for a Type A or Type B facility. The applicant must request the license by submitting a form prescribed by HHSC via the online portal.(b) If an applicant makes a request in accordance with subsection (a) of this section, HHSC determines the applicant is in good standing, and the applicant complies with subsection (d) of this section, the applicant is not required to admit a resident to the facility or have the on-site health inspection described in §553.23(f) of this subchapter (relating to Initial License Application Procedures and Requirements) before HHSC issues an initial license.(c) For purposes of this section, an applicant is in good standing if:(1) one of the following conditions is met:(A) the applicant has operated or been a controlling person of a licensed Type A or Type B facility in Texas for at least six consecutive years; or(B) the applicant has not held a license for a Type A or Type B facility, but a controlling person of the applicant has operated or been a controlling person of a licensed Type A or Type B facility in Texas for at least six consecutive years; and(2) each licensed facility operated by the applicant or the controlling person described in paragraph (1)(A) or (B) of this subsection:(A) has not had a violation of a licensing rule:(i) that:(I) resulted in actual harm to a resident, which is defined as a negative outcome that compromises the resident's physical, mental or emotional well-being; or(II) posed an immediate threat of harm causing or likely to cause serious injury, impairment, or death to a resident; and(ii) that:(I) the facility did not challenge;(II) was affirmed; or(III) is pending a final determination; and(B) has not had a sanction imposed by HHSC against the facility during the six years before the date an application is submitted that resulted in:(i) a civil penalty;(ii) an administrative penalty;(iii) an injunction;(iv) the denial, suspension, or revocation of a license; or(v) an emergency closure.(d) An applicant that makes a request in accordance with subsection (a) of this section must:(1) submit to HHSC via the online portal:(A) the applicant's policies and procedures;(B) evidence that the applicant has complied with §553.257(b) of this chapter (relating to Human Resources); and(C) documentation that the applicant's employees have the credentials described in §553.253 of this chapter (relating to Employee Qualifications and Training); and(2) comply with §553.23(d) of this subchapter and §553.17 of this subchapter (relating to Criteria for Licensing).(e) HHSC issues an initial license to an applicant that makes a request in accordance with subsection (a) of this section if HHSC determines that an applicant:(1) is in good standing;(2) has submitted information in accordance with subsection (d)(1) of this section that complies with this chapter; and(3) is in compliance with applicable NFPA 101 and other physical plant requirements of Subchapter D of this chapter (relating to Facility Construction), including meeting the requirements of a Life Safety Code (LSC) inspection within 120 days after the date HHSC staff conduct the initial LSC inspection.(f) HHSC staff conduct an on-site health inspection within 90 days after the date HHSC issues a license in accordance with subsection (e) of this section. The on-site health inspection includes HHSC observation of the facility's provision of care to at least one resident.(g) Until a facility that is issued an initial license under this section meets the requirements of the on-site health inspection described in subsection (f) of this section, the facility must attach a written addendum to the disclosure statement required by §553.259(c)(1) of this chapter (relating to Admission Policies and Procedures) as notice to a resident or a prospective resident that the facility has not met the requirements of the on-site health inspection. At a minimum, the addendum must state that:(1) the facility has not met the requirements of an initial on-site health inspection for a license; and(2) HHSC staff conduct an on-site health inspection for licensure within 90 days after the date the license is issued. Source Note: The provisions of this §553.25 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.25 Initial License for a Type A or Type B Facility for an Applicant in Good Standing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205804 03/12/2026 (a) A facility that advertises, markets, or otherwise promotes that the facility or a distinct unit of the facility provides specialized care for persons with Alzheimer's disease or related disorders must be certified or have the unit certified under subsection (d) of this section or §553.29 of this subchapter (relating to Alzheimer's Certification of a Type B Facility for an Initial License Applicant in Good Standing). Certification under this section is not required for a facility to use advertising terms such as "medication reminders or assistance," "meal and activity reminders," "escort service," or "short-term memory loss, confusion, or forgetfulness."(b) To be certified under subsection (d) of this section, a facility must be licensed as a Type B facility.(c) A license holder must request certification of a facility or unit under subsection (d) of this section by submitting the forms prescribed by HHSC via the online portal and include full payment of applicable fees described in §553.47(c) of this subchapter (relating to License Fees).(d) After HHSC receives a request for certification in accordance with subsection (c) of this section, HHSC certifies a licensed Type B facility as a certified Alzheimer's facility or a unit of a licensed Type B facility as a certified Alzheimer's unit, if HHSC determines:(1) that the facility or unit is in compliance with §553.311 of this chapter (relating to Physical Plant Requirements for Alzheimer's Units) and Subchapter D of this chapter (relating to Facility Construction), including meeting the requirements of a Life Safety Code (LSC) inspection within 120 days after the date HHSC staff conduct an initial LSC inspection; and(2) that the facility or unit meets the requirements of Subchapter F of this chapter (relating to Additional Licensing Standards for Certified Alzheimer's Assisted Living Facilities) based on an on-site health inspection, during which HHSC observes the facility's or unit's provision of care to at least one resident who has been admitted to the Alzheimer's facility or unit.(e) A facility or unit may not exceed the maximum number of residents specified on the Alzheimer's certificate issued to the facility by HHSC.(f) A facility must post the facility's or unit's Alzheimer's certificate in a prominent location for public view.(g) An Alzheimer's certificate is valid for three years from the effective date of approval by HHSC.(h) HHSC cancels an Alzheimer's certificate if:(1) a certified facility, or the facility in which a certified unit is located, undergoes a change of ownership; or(2) HHSC determines that a certified facility or unit is not in compliance with applicable laws and rules.(i) A facility must remove a cancelled certificate from display and advertising and surrender the certificate to HHSC. Source Note: The provisions of this §553.27 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.27 Certification of a Type B Facility or Unit for Persons with Alzheimer's Disease and Related Disorders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205805 03/12/2026 (a) An applicant may request that HHSC, before conducting an on-site health inspection, issue an initial license for a Type B facility and an Alzheimer's certification for the facility or a distinct unit of the facility. The applicant must meet the requirements of §553.25 of this subchapter (relating to Initial License for a Type A or Type B Facility for an Applicant in Good Standing) for the initial license and the requirements of this section for certification of the facility or unit.(b) An applicant must request certification by submitting forms prescribed by HHSC via the online portal and include full payment of applicable fees described in §553.47 of this subchapter (relating to License Fees).(c) An applicant that makes a request in accordance with subsection (a) of this section is not required to admit a resident to the facility or unit or have the on-site health inspection described in §553.23(f) of this subchapter (relating to Initial License Application Procedures and Requirements) before HHSC certifies the facility or unit if HHSC determines that the applicant is in good standing:(1) for the issuance of an initial license of the facility in accordance with §553.25(c) of this subchapter; and(2) for certification of the facility or unit in accordance with subsection (d) of this section.(d) An applicant is in good standing to obtain certification of a facility or unit if:(1) for at least six consecutive years before applying for certification:(A) the applicant has been:(i) the license holder for an Alzheimer's certified facility in Texas or a facility in Texas that has an Alzheimer's certified unit; or(ii) a controlling person of the license holder for an Alzheimer's certified facility in Texas or a facility in Texas that has an Alzheimer's certified unit; or(B) a controlling person of the applicant has been:(i) the license holder for an Alzheimer's certified facility in Texas or a facility in Texas that has an Alzheimer's certified unit; or(ii) a controlling person of the license holder for an Alzheimer's certified facility in Texas or a facility in Texas that has an Alzheimer's certified unit;(2) each licensed facility operated by the applicant or the controlling person has not had a violation or sanction described in §553.25(c)(2) of this subchapter; and(3) each licensed facility operated by the applicant or the controlling person has had no more than two violations listed in §553.267(a) of this chapter (relating to Rights) during the six-year period immediately before the applicant applied for certification.(e) For purposes of subsection (d)(3) of this section, a facility has a violation if:(1) the applicant or controlling person operating the facility did not challenge the violation;(2) a final determination on the violation is pending; or(3) the violation was upheld.(f) An applicant that makes a request in accordance with subsection (a) of this section must submit to HHSC for approval via the online portal:(1) the applicant's policies and procedures required by Subchapter F of this chapter (relating to Additional Licensing Standards for Certified Alzheimer's Assisted Living Facilities); and(2) documentation demonstrating that the applicant is complying with Subchapter F of this chapter and §553.257(b)of this chapter (relating to Human Resources).(g) HHSC certifies a facility or unit after an applicant makes a request in accordance with subsection (a) of this section if HHSC determines that the applicant:(1) meets the good standing requirements described in §553.25(c) of this subchapter and subsection (d) of this section;(2) has submitted information in accordance with subsection (f) of this section; and(3) is in compliance with:(A) §553.27 of this subchapter (relating to Certification of a Type B Facility or Unit for Persons with Alzheimer's Disease and Related Disorders); and(B) §553.311 of this chapter (relating to Physical Plant Requirements for Alzheimer's Units).(h) HHSC conducts an on-site health inspection to determine if the facility or unit meets the requirements of Subchapter F of this chapter within 90 days after the date HHSC certifies a facility or unit in accordance with subsection (g) of this section. During each on-site health inspection, HHSC observes the provision of care to at least one resident who has been admitted to the facility or unit.(i) Until a facility or unit that is issued a certification under this section meets the requirements of the on-site health inspection described in subsection (h) of this section, the facility must attach a written addendum to the disclosure statement required by §553.307(a) of this chapter (relating to Admission Procedures, Assessment, and Service Plan) to notify a resident or a prospective resident that the facility or unit has not met the requirements of the on-site health inspection. At a minimum, the addendum must state that:(1) the facility or unit has not met the requirements of an initial on-site health inspection for Alzheimer's certification; and(2) HHSC conducts an on-site health inspection for Alzheimer's certification within 90 days after the date of certification.(j) To obtain certification of a unit in a Type B facility that is already licensed, a license holder must comply with §553.27 of this subchapter. Source Note: The provisions of this §553.29 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.29 Alzheimer's Certification of a Type B Facility for an Initial License Applicant in Good Standing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205806 03/12/2026 (a) HHSC may issue a six-month provisional license in the case of a corporate change of ownership.(b) HHSC issues a six-month provisional license for a newly constructed facility without conducting an NFPA 101 and physical plant inspection under Subchapter D of this chapter (relating to Facility Construction), and, as applicable §553.311, of this chapter (relating to Physical Plant Requirements for Alzheimer's Units), if:(1) an applicant requests in writing a provisional license;(2) the applicant submits working drawings and specifications to HHSC for review in accordance with applicable procedures for plan review, approval, and construction in Subchapter D of this chapter, before facility construction begins;(3) the applicant obtains all approvals, including a certificate of occupancy in a jurisdiction that requires one, from local authorities having jurisdiction in the area in which the facility is located, such as the fire marshal, health department, and building inspector;(4) the applicant submits a complete license application within 30 days after receipt of all local approvals described in paragraph (3) of this subsection;(5) the applicant pays in full the license fees required by §553.47 of this subchapter (relating to License Fees);(6) the applicant, or a person who is a controlling person and an owner of the applicant, has constructed another facility in this state that complies with applicable NFPA 101 and physical plant requirements in Subchapter D of this chapter, and, as applicable, §553.311 of this chapter; and(7) the applicant is in compliance with resident-care standards for licensure required by Subchapter E of this chapter (relating to Standards for Licensure) based on an on-site inspection conducted in accordance with §553.327 of this chapter (relating to Inspections, Investigations, and Other Visits).(c) HHSC considers the date facility construction begins to be the date the building construction permit for the facility was approved by local authorities.(d) A provisional license expires on the earlier of:(1) the 180th day after the effective date of the provisional license or the end of any extension period granted by HHSC; or(2) the date a three-year license is issued to the provisional license holder.(e) HHSC conducts an NFPA 101 and physical plant inspection of a facility as soon as reasonably possible after HHSC issues a provisional license to the facility.(f) After conducting an NFPA 101 and physical plant inspection, HHSC issues a license in accordance with Texas Health and Safety Code §247.023 to the provisional license holder if the facility passes the inspection and the applicant meets all requirements for a license. Source Note: The provisions of this §553.31 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.31 Provisional License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205807 03/12/2026 (a) The facility is responsible for submitting an application for license renewal via the online portal before the expiration date printed on the license. A license issued under this chapter:(1) expires three years after the date issued;(2) must be renewed before the license expiration date; and(3) is not automatically renewed.(b) An application for renewal must comply with the requirements of §553.19 of this subchapter (relating to General Application Requirements), and, as applicable, §553.21 of this subchapter (relating to Time Periods for Processing All Types of License Applications). The submission of a license fee alone does not constitute an application for renewal.(c) To renew a license, a license holder must submit an application for renewal with HHSC via the online portal before the expiration date of the license. For purposes of Texas Government Code §2001.054, HHSC considers a license holder to have submitted a timely and sufficient application for the renewal of a license, which continues the license in effect and permits the facility to continue operations while HHSC is processing the renewal application, if the license holder submits to HHSC the basic fee described in §553.47(a)(1) or (2) of this subchapter (relating to License Fees); and:(1) a complete application for renewal no later than 45 days before the expiration of the current license;(2) an incomplete application for renewal, with a letter explaining the circumstances that prevented the inclusion of the missing information no later than 45 days before the expiration of the current license; or(3) a complete application or an incomplete application, with a letter explaining the circumstances that prevented the inclusion of the missing information, and the late fee described in §553.47(b) of this chapter during the 45-day period ending on the date the current license expires.(d) HHSC may propose to deny, in accordance with subsection (m) of this section, a timely and sufficient, but incomplete, renewal application submitted in accordance with subsection (c) of this section if the license holder fails to complete the application by paying in full all fees due beyond the basic fee and late fee paid in accordance with §553.47(b) of this chapter, and by submitting all information and documentation required to complete the license holder's renewal application before the date that the current license expires. HHSC does not grant a license unless a renewal application is complete. It is the license holder's responsibility to ensure that the application is timely submitted to HHSC.(e) A license expires if the license holder fails to submit a timely and sufficient application in accordance with subsection (c) of this section before the expiration date of the license.(f) A person whose license has expired may not operate a facility without obtaining a license in accordance with the application requirements for an initial license in §553.23 of this subchapter (relating to Initial License Application Procedures and Requirements). Operating a facility without a license is subject to civil and administrative penalties and other authorized civil remedies.(g) HHSC reviews an application for a renewal license within 30 days after the date HHSC Licensing and Credentialing Section, Long-term Care Regulation receives the application and notifies the applicant if additional information is needed to complete the application.(h) A license holder applying for a renewal license must show that the facility meets HHSC licensing standards based on an on-site inspection by HHSC. The on-site inspection must include an observation of the care of a resident.(i) If an applicant is relying on meeting standards for accreditation in accordance with §553.17(c)(2) of this subchapter (relating to Criteria for Licensing) to show that it meets the requirements for licensure, the application for a renewal license must include a copy of the license holder's accreditation report from the accreditation commission with its application for renewal.(j) HHSC may pend action on an application for the renewal of a license for up to six months if the facility does not meet licensure requirements during an on-site inspection.(k) The issuance of a license constitutes official written notice from HHSC to the facility that its application is approved.(l) HHSC may deny an application for the renewal of a license if the applicant, controlling person, or any person required to submit background and qualification information fails to meet the criteria for a license established in §553.17 of this subchapter.(m) Before denying an application for renewal of a license, HHSC gives the license holder:(1) notice by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all requirements of law for the retention of the license.(n) To request an opportunity to show compliance, the license holder must send its written request to the Associate Commissioner of Long-term Care Regulation. The request must:(1) be postmarked no later than 10 days after the date of HHSC notice and be received in the office of the Associate Commissioner of Long-term Care Regulation no later than 10 days after the date of the postmark; and(2) contain specific documentation refuting HHSC allegations.(o) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC used as the basis for its proposed action and is not conducted as an adversary hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action.(p) If HHSC denies an application for the renewal of a license, the applicant may request:(1) an informal reconsideration by HHSC; and(2) an administrative hearing or binding arbitration to appeal the denial, as described in §553.801 of this chapter (relating to Arbitration). Source Note: The provisions of this §553.33 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.33 Renewal Procedures and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210352 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210352 03/12/2026 (a) For purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the new operator of a facility that exists on the date the application is submitted.(b) A license holder may not transfer its license. The applicant (new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When the Texas Health and Human Services Commission (HHSC) approves the change of ownership by issuing a temporary change of ownership license to the new license holder, the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the change of ownership application. Between the effective date of the change of ownership and the issuance of the temporary change of ownership license, the current license holder remains responsible under its license; however, the applicant may operate a facility on behalf of a current license holder during such period of time.(c) An applicant must submit to HHSC through the online portal:(1) a complete HHSC application for a license in accordance with HHSC instructions and §553.23 of this subchapter (relating to Initial Application Procedures and Requirements) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) full payment of the fees required in §553.47 of this subchapter (relating to License Fees); and(3) a signed and notarized Change of Ownership Transfer Affidavit HHSC Form 1092 from the applicant and the facility's current license holder of intent to transfer operation of the facility from the current license holder to the applicant, beginning on the change of ownership effective date specified on the change of ownership application.(d) To avoid a facility operating while unlicensed, an applicant must submit all items required by subsection (c) of this section at least 30 days before the anticipated date of the change of ownership, unless the 30-day notice requirement is waived in accordance with subsection (e) of this section.(e) HHSC may waive the 30-day notice required by subsection (d) of this section if HHSC determines that the applicant presents evidence showing that circumstances prevented the submission of the items specified in subsection (c) of this section and that not waiving the notice would create a threat to resident welfare or health and safety.(f) Upon HHSC approval of the items specified in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all persons disclosed in the application satisfy the requirements in §553.17 of this subchapter (relating to Criteria for Licensing), except for §553.17(c) and (d).(1) The issuance of a temporary change of ownership license constitutes HHSC's official written notice to the facility of the approval of the application for a change of ownership.(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online portal.(g) A temporary change of ownership license expires on the earlier of:(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (h) of this section; or(2) the date HHSC issues a three-year license in accordance with subsection (k) of this section.(h) HHSC, in its sole discretion, may extend a temporary change of ownership license for a term of 90 days at a time based upon extenuating circumstances.(i) HHSC staff conduct an on-site health inspection to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site health inspection after issuing a temporary change of ownership if:(1) less than 50 percent of the direct or indirect ownership interest in the former license holder differs from that of the new license holder; or(2) every owner with a disclosable interest in the new license holder has a disclosable interest in the former license holder.(j) HHSC, in its sole discretion, may conduct an on-site Life Safety Code inspection of the facility after issuing a temporary change of ownership license.(k) If the applicant, all controlling persons, and all persons disclosed in the application satisfy the requirements of §553.17 of this subchapter, except for §553.17(c)(1)(A) - (C), for a license, and the facility passes the change of ownership health inspection as described in subsection (i) of this section, HHSC issues a three-year license within 30 days after HHSC determines that the applicant and the facility have met the licensure requirements of this section. The effective date of the three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application was received by HHSC through the online portal.(l) HHSC may deny an application for a change of ownership if the applicant, controlling person, or any person disclosed in the application fails to meet the criteria for a license established in §553.17 of this subchapter.(m) If HHSC denies an application for a temporary change of ownership license or a three-year license, HHSC sends the applicant a written notice of the denial and informs the applicant of the applicant's right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with HHSC rules at 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(n) If a license holder that is not a publicly traded company adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC no later than 30 days after the addition of the owner by submitting an application through the online portal.(o) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name. Source Note: The provisions of this §553.35 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective October 11, 2022, 47 TexReg 6589. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.35 Change of Ownership and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205809 03/12/2026 (a) Relocation is the closing of a facility and the movement of its residents to another location for which the license holder does not hold a current license.(b) A license holder must not relocate a facility without a license from HHSC for the facility at the new location.(c) To apply for relocation, the license holder for the current location must submit an application via the online portal for an initial license for the new location in accordance with §553.23 of this subchapter (relating to Initial Application Procedures and Requirements) and full payment of the fees required in §553.47 of this subchapter (relating to License Fees). The applicant must enter the proposed date of relocation on the application, subject to issuance of a license.(d) Residents must not be relocated until the new building has been inspected and approved as meeting the Life Safety Code licensure requirements in Subchapter D of this chapter (relating to Facility Construction).(e) Following Life Safety Code approval by HHSC, the license holder must notify HHSC via the online portal of the date the residents will be relocated.(f) After a facility has met standards of operations in subsection (d) of this section, HHSC staff conduct an on-site health inspection if one was not conducted within the last licensure period, to determine if the facility meets the licensure requirements for standards of operation and resident care in Subchapter E of this chapter (relating to Standards for Licensure).(g) HHSC issues a license for the new facility if the new facility meets the standards of operations in subsections (d) and (e) of this section.(h) The license holder must continue to maintain the license at the current location and must continue to meet all requirements for operation of the facility until HHSC has approved the relocation. The issuance of a license constitutes HHSC approval of the relocation. The license for the current location becomes invalid upon issuance of the new license for the new location. The license from the other location must be returned to HHSC. Source Note: The provisions of this §553.37 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.37 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205810 03/12/2026 (a) A license holder must not increase a facility's licensed capacity without approval from HHSC.(b) The license holder must submit an application for an increase in capacity in accordance with §553.19 of this subchapter (relating to General Application Requirements) and the fee required in §553.47 of this subchapter (relating to License Fees).(c) The license holder must arrange for an inspection of the facility by the local fire marshal and provide the signed fire marshal approval to HHSC.(d) After HHSC's review of an application and after the applicant notifies HHSC via the online portal that the facility is ready for a Life Safety Code (LSC) inspection, HHSC staff conduct an on-site LSC inspection of the facility to determine if the facility meets the LSC licensure requirements in Subchapter D of this chapter (relating to Facility Construction).(e) If the facility fails to meet the LSC licensure requirements within 120 days after the LSC inspection, HHSC denies the application for an increase in capacity.(f) After a facility has met LSC licensure requirements, HHSC staff conduct an on-site health inspection, if one was not conducted within the last licensure period, to determine if the facility meets the licensure requirements for standards of operation and resident care in Subchapter E of this chapter (relating to Standards for Licensure).(g) HHSC issues a new license with an increased capacity within 30 days after HHSC determines that all licensure requirements have been met. HHSC may grant approval to occupy the increased capacity once HHSC determines that all licensure requirements have been met.(h) In order to meet the residents' health and safety needs in the event of a fire, natural disaster, or catastrophic event, HHSC may grant approval to temporarily exceed a facility's licensed capacity provided the health and safety of residents are not compromised and the facility can meet the required health care service needs of all residents. A facility may exceed its licensed capacity under this circumstance, monitored by HHSC, until residents can be transferred to a permanent location. HHSC issues authorization for the temporary increase in the facility's licensed capacity. The authorization to temporarily increase the capacity ends when the facility receives written notice from HHSC ending the authorization. Source Note: The provisions of this §553.39 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.39 Increase in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205811 03/12/2026 (a) A license holder that wishes to decrease the licensed capacity of the facility must provide notification via the online portal to HHSC's Licensing and Credentialing Section, Long-term Care Regulation. The notification must include the desired capacity for the new license.(b) Upon receipt of the notification, HHSC issues a new license with the desired capacity as indicated in the notification. Source Note: The provisions of this §553.41 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.41 Decrease in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205812 03/12/2026 A facility must use its state-issued facility identification number in all advertisements, solicitations, and promotional materials, including yellow pages, brochures, and business cards. Source Note: The provisions of this §553.43 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.43 Disclosure of Facility Identification Number https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205813 03/12/2026 (a) Basic fees.(1) Type A and Type B. The license fee is $300, plus $15 for each bed for which a license is sought, with a maximum of $2,250 for a three-year license. The fee must be paid with an initial application, change of ownership application, or renewal application.(2) Increase in capacity. An approved increase in capacity is subject to an additional fee of $15 for each bed.(b) Late renewal fee. An applicant that submits an application for license renewal later than the 45th day before the expiration date of the license must pay a late fee of an amount equal to one-half of the basic fee required in accordance with subsection (a)(1) and (2) of this section.(c) Alzheimer's certification. In addition to the basic license fee described in subsection (a) of this section, a facility that applies for certification as an Alzheimer's facility under Subchapter E of this chapter (relating to Standards for Licensure) must pay an additional license fee. For a three-year license issued in accordance with subsection (a)(1) of this section or §553.33(a)(1) of this subchapter, the additional fee is $300.(d) Trust fund fee.(1) If the amount in the facility trust fund, established under Texas Health and Safety Code, Chapter 242, Subchapter D, and Chapter 247 §247.003(b), is less than $500,000, HHSC collects an annual fee from each facility. The fee is based on a monetary amount specified for each licensed unit of capacity or bed space and is in an amount sufficient to provide not more than $500,000 in the trust fund. When the trust fund fee is collected, HHSC sends written notice to each facility stating the amount of the fee and the date the fee is due. A facility must pay the amount of the fee within 90 days after the date the fee is due.(2) HHSC may charge and collect a trust fund fee more than once a year if necessary to ensure that the amount in the facility trust fund is sufficient to make the disbursements required under Texas Health and Safety Code §242.0965. When this subsequent trust fund fee is collected, HHSC sends written notice to each facility stating the amount of the fee and the date the fee is due. A facility must pay the amount of the fee within 90 days after the date the fee is due.(3) Failure to pay the trust fund fee within 90 days after the date the fee is due as stated on the written notice described in paragraphs (1) and (2) of this subsection may result in an assessment of an administrative penalty under the administrative penalties described in Subchapter H, Division 9 of this chapter (relating to Administrative Penalties).(e) Plan review fee. An applicant may submit building plans for a new building, an addition, the conversion of a building not licensed, or for the remodeling of an existing licensed facility for review by HHSC architectural staff. If the applicant chooses to submit building plans for review, the applicant must pay a fee for the plan review according to the following schedule:Attached Graphic(f) Payment of fees. A facility or applicant must pay fees by check, cashier's check, money order, or credit card, made payable to HHSC. All fees are nonrefundable, except as provided in Texas Government Code, Chapter 2005, and in §553.21(d) of this chapter (relating to Time Periods for Processing All Types of License Applications).(g) Optional expedited inspection and associated fee.(1) An applicant for an assisted living facility license may obtain an expedited inspection described in subparagraph (A) or (B) of this paragraph if the applicant meets the requirements in both clauses of the applicable subparagraph.(A) A Life Safety Code (LSC) inspection conducted no later than the 15th day after the date HHSC receives a request for an expedited inspection, if the applicant:(i) meets the application requirements under this subchapter for the applicable license; and(ii) submits the applicable expedited LSC inspection fee in accordance with the fee schedule in paragraph (2) of this subsection; or(B) an on-site health inspection conducted no later than the 21st day after the date HHSC receives a request for an expedited inspection, if the applicant:(i) meets the application requirements under this subchapter for the applicable license; and(ii) submits the applicable expedited on-site health inspection fee in accordance with the fee schedule in paragraph (2) of this subsection.(2) An applicant requesting an expedited inspection must include the applicable fee from the following fee schedule with a request for an expedited inspection submitted in accordance with paragraph (1) of this subsection.Attached Graphic(h) If, after HHSC conducts two LSC inspections for a given application, the applicant requests an additional inspection, then the applicant must pay a fee of $25 per bed, with a minimum payment of $1,000 for the third and each subsequent inspection pertaining to the same application. Source Note: The provisions of this §553.47 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES B LICENSING §553.47 License Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206010 03/12/2026 (a) A building or structure used as a licensed assisted living facility, whether new or existing, must comply with these standards.(b) All assisted living facilities must comply with National Fire Protection Association Life Safety Code (NFPA 101) and any applicable Tentative Interim Amendment (TIA) issued by NFPA, except as otherwise stated in these standards.(c) All assisted living facilities must comply with other chapters, sections, subsections, and paragraphs of NFPA 101, as they relate to: Chapter 18, New Health Care Occupancies; Chapter 19, Existing Health Care Occupancies; Chapter 32, New Residential Board and Care Occupancies; and Chapter 33, Existing Residential Board and Care Occupancies, including:(1) Chapter 1, Administration;(2) Chapter 2, Referenced Publications;(3) Chapter 3, Definitions;(4) Chapter 4, General;(5) Chapter 5, Performance-Based Option;(6) Chapter 6, Classification of Occupancy and Hazard of Contents;(7) Chapter 7, Means of Egress;(8) Chapter 8, Features of Fire Protection;(9) Chapter 9, Building Service and Fire Protection Equipment;(10) Chapter 10, Interior Finish, Contents, and Furnishings;(11) Chapter 11, Special Structures and High-Rise Buildings; and(12) Chapter 43, Building Rehabilitation.(d) An assisted living facility that wishes to be reclassified from a small facility to a large facility, from a Type A facility to a Type B facility, or both, must meet the requirements for a new facility of the type and size specified in this subchapter to be reclassified.(e) The requirements of this subchapter apply to an assisted living facility as follows:(1) All assisted living facilities must comply with Division 1 of this subchapter (relating to General Provisions) and Division 2 of this subchapter (relating to Provisions Applicable to All Facilities).(2) An assisted living facility initially licensed before August 31, 2021, and continually operated under an assisted living license without interruption since then, is considered an existing assisted living facility and must comply with the following, as applicable:(A) An existing small Type A assisted living facility must comply with Division 4 of this subchapter (relating to Existing Small Type A Assisted Living Facilities).(B) An existing small Type B assisted living facility must comply with Division 5 of this subchapter (relating to Existing Small Type B Assisted Living Facilities).(C) An existing large Type A assisted living facility must comply with Division 6 of this subchapter (relating to Existing Large Type A Assisted Living Facilities).(D) An existing large Type B assisted living facility must comply with Division 7 of this subchapter (relating to Existing Large Type B Assisted Living Facilities).(3) An assisted living facility initially licensed on or after August 31, 2021, or any new building or building addition to a currently licensed assisted living facility constructed on or after August 31, 2021, is considered a new assisted living facility and must comply with the following:(A) A new small Type A assisted living facility must comply with Division 8 of this subchapter (relating to New Small Type A Assisted Living Facilities).(B) A new small Type B assisted living facility must comply with Division 9 of this subchapter (relating to New Small Type B Assisted Living Facilities).(C) A new large Type A assisted living facility must comply with Division 10 of this subchapter (relating to New Large Type A Assisted Living Facilities).(D) A new large Type B assisted living facility must comply with Division 11 of this subchapter (relating to New Large Type B Assisted Living Facilities).(f) An assisted living facility must comply with local codes and ordinances as follows:(1) An assisted living facility located within the jurisdiction of a local organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation, or a procedure that adopts codes or ordinances governing building construction or fire safety (Authority Having Jurisdiction or AHJ) must comply with applicable local codes and ordinances adopted by the AHJ, as interpreted and enforced by the AHJ. The description of the occupancy may vary with local codes.(2) An assisted living facility located where there is no local AHJ must be designed and constructed to meet a nationally-recognized building code and its referenced codes.(3) An existing building, either occupied as an assisted living facility at the time of initial inspection by HHSC or converted to occupancy as an assisted living facility prior to the initial inspection by HHSC, must meet all local requirements pertaining to that building for that occupancy as administered by the local AHJ for the adopted code or ordinance.(4) An assisted living facility must submit documentation from the local AHJ that local requirements are satisfied.(g) When local laws, codes, or ordinances are different from the standards for assisted living facilities set forth in this Subchapter D, an assisted living facility must comply with both local and HHSC requirements.(h) An assisted living facility must ensure building rehabilitation on existing buildings is classified according to NFPA 101 and that any rehabilitation complies with NFPA 101 and §553.107 of this subchapter (relating to Building Rehabilitation).(i) An assisted living facility must ensure buildings, or portions of buildings, are not occupied during construction, repair, alterations, or additions, except when required means of egress, required means of escape, and required fire protection features are in place and continuously maintained for the portion occupied. Alternative life safety measures may be put in place if prior approval is obtained from HHSC.(j) An assisted living facility must ensure no existing life safety feature is removed or reduced when the feature is a requirement for a new facility. Life safety features, and equipment not required by NFPA 101, that have been installed in existing buildings must continue to be maintained or be completely removed, if prior approval is obtained from HHSC.(k) An assisted living facility must comply with the plan review and inspection requirements of the Texas Accessibility Standards (TAS) adopted by the Texas Department of Licensing and Regulation (TDLR) rules in Texas Administrative Code, Title 16, Chapter 68, and must provide documentation demonstrating it has registered the facility with TDLR and obtained a plan review from a Registered Accessibility Specialist, if TDLR requires the facility to be registered and reviewed.(l) An assisted living facility must not segregate any area housing residents from other parts of the assisted living facility housing residents, except as permitted by §553.51 of this chapter (relating to Certification of a Facility or Unit for Persons with Alzheimer's Disease and Related Disorders). Source Note: The provisions of this §553.100 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.100 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206009 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. The definitions in §553.3 of this chapter (relating to Definitions) also apply to this subchapter.(1) Approved--Acceptable to the Texas Health and Human Services Commission.(2) Authority having jurisdiction (AHJ)--An organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation, or a procedure.(3) Auxiliary serving kitchen--An area that is not contiguous to a food preparation or serving area and that is for serving food but is not used for cooking or meal preparation.(4) Bedroom usable floor space--The floor area of a resident bedroom that may be considered toward meeting minimum requirements for a resident bedroom floor area.(5) Building rehabilitation--Any construction activity involving repair, modernization, reconfiguration, renovation, changes in occupancy or use, or installation of new fixed equipment, including:(A) the replacement of finishes, such as new flooring or wall finishes or the painting of walls and ceilings;(B) the construction, removal, or relocation of walls, partitions, floors, ceilings, doors, or windows;(C) the replacement of doors, windows, or roofing;(D) changes to the appearance of the exterior of a building, including new finish materials;(E) the installation, repair, replacement, or extension of fire protection systems, including fire sprinkler systems, fire alarm system, and fire suppression systems, at cooking operations;(F) the replacement of door hardware, plumbing fixtures, handrails in corridors, or grab rails in bathrooms and restrooms;(G) the repair, replacement, or extension of required communication systems;(H) the repair or replacement of emergency electrical system equipment and components, including generator sets, transfer switches, distribution panel boards, receptacles, switches, and light fixtures;(I) the change of a wing or area to a Certified Alzheimer's Disease Assisted Living Facility or unit;(J) the change of a Certified Alzheimer's Disease Assisted Living Facility or unit to ordinary resident-use;(K) a change in the use of space, including the change of resident bedrooms to other uses, such as offices, storage, or living or dining spaces; and(L) changes in locking arrangements, such as the installation of access control systems or the installation or removal of electronic locking devices, including electromagnetic locks, and other delayed-egress locking devices.(6) Co-mingles--The laundering of apparel or linens of two or more individuals together.(7) Conversion--Change of occupancy from an existing residential or health care occupancy to a residential board and care occupancy, including an assisted living facility located in a building that had been used as a residence or a health care facility such as a hospital or a nursing home.(8) Direct telephone--A telephone that automatically dials and connects to a fixed location when the caller takes the handset off-hook without requiring the caller to input a receiving telephone number. A direct telephone must ring at a location staffed 24-hours a day and may not be answered by an answering machine or voicemail system. A direct telephone may also function as a regular telephone when a receiving telephone number is entered.(9) Factory Mutual (FM)--An organization that certifies products and services for compliance with loss prevention standards. Also known as FM Approvals.(10) Finished ground level--The level of the finished ground (earth or other surface on ground).(11) Fuel-fired heating device--Any equipment, device, or apparatus, or any part thereof, which is installed for the purpose of combustion of fuel, including natural gas, liquid petroleum gas (propane), or solid fuel, to produce heat or energy used as a component of a heating system providing heat for any interior space or water source. Freestanding solid fuel- or pellet-fuel burning appliances such as freestanding wood-burning or pellet-burning stoves do not meet this definition.(12) Independent cooking equipment--An electric or gas stove or range with one or more burners, with or without an oven.(13) Living unit--A portion of a facility arranged as a separate unit providing one or more bedrooms, toilet and bathing facilities, and living or dining spaces, with or without facilities for cooking, exclusively for the use of the residents residing in the bedrooms.(14) Neighborhood or household--A portion of a large facility arranged as a unit providing bedrooms, toilet and bathing facilities, resident living areas, and kitchen facilities serving up to 16 residents.(15) NFPA--National Fire Protection Association.(16) NFPA 10--Standard for Portable Fire Extinguishers, 2010 edition.(17) NFPA 13--Standard for the Installation of Sprinkler Systems, 2010 edition.(18) NFPA 13D--Standard for the Installation of Sprinkler Systems in One-and Two-Family Dwellings and Manufactured Homes, 2010 edition.(19) NFPA 13R--Standard for the Installation of Sprinkler Systems in Residential Occupancies Up to and Including Four Stories in Height, 2010 edition.(20) NFPA 25--Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition.(21) NFPA 54--National Fuel Gas Code, 2012 edition.(22) NFPA 70--National Electrical Code, 2011 edition.(23) NFPA 72--National Fire Alarm and Signaling Code, 2010 edition.(24) NFPA 96--Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition.(25) NFPA 110--Standard for Emergency and Standby Power Systems, 2010 edition.(26) NFPA 211--Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances, 2010 edition.(27) NFPA 720--Standard for Installation of Carbon Monoxide (CO) Detection and Warning Equipment, 2012 edition.(28) Special Waste from Health Care-Related Facilities--Special waste from health care-related facilities as defined in Texas Administrative Code, Title 25, Part 1, Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(29) TCEQ--Texas Commission on Environmental Quality. Source Note: The provisions of this §553.101 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.101 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210899 03/12/2026 (a) Firefighting unit. An assisted living facility must be served by a professional or volunteer firefighting unit and must have a water supply that meets the firefighting unit's requirements and approval.(b) Correction of hazards. An assisted living facility must correct a site or building condition that HHSC staff identifies to be a fire, health, or physical hazard.(c) Parking.(1) An assisted living facility must provide or arrange for nearby parking spaces for the private vehicles of residents and visitors.(2) An assisted living facility must provide a minimum of one parking space for every four residents in its licensed capacity, and for any fraction thereof, or per local requirements, whichever is more stringent.(d) Ramps.(1) An assisted living facility must ensure a ramp, walk, or step is of slip-resistive texture and is uniform, without irregularities.(2) An assisted living facility must ensure a ramp does not exceed a slope of one foot in 12 feet.(3) An assisted living facility must ensure any new ramp has a clear width of at least 36 inches. A new ramp is one that was installed or constructed on or after August 31, 2021.(e) Site conditions. An assisted living facility must provide a guardrail, fence, or handrail where a grade makes an abrupt change in level.(f) Outside grounds. An assisted living facility must ensure that each outside area, grounds, and any adjacent buildings are maintained in good condition and kept free of rubbish, garbage, and untended growth that may constitute a fire or health hazard.(g) Drainage. An assisted living facility must ensure site grades provide for water drainage away from structures to prevent ponding or standing water at or near a building, unless the ponding or standing water is part of an approved drainage system intended to hold water for a period of time.(h) 100-year Floodplain. An assisted living facility that applies for an initial license or is initially licensed on or after December 6, 2022, must not be located in a 100-year floodplain, if the facility is located in a county of more than 3.3 million residents. Source Note: The provisions of this §553.103 adopted to be effective August 31, 2021, 46 TexReg 5189; amended to be effective December 6, 2022, 47 TexReg 7705. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.103 Site and Location for all Assisted Living Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206012 03/12/2026 (a) Local fire marshal inspection.(1) An assisted living facility must obtain an inspection at least once every 12 months, by the local fire marshal, or the Texas State Fire Marshal's Office in locations where there is no local fire marshal, and must correct any items cited by the local fire marshal, or the Texas State Fire Marshal's Office, to the satisfaction of those authorities.(2) An assisted living facility must maintain documentation at the facility reflecting the outcome of the most recent annual inspection.(b) Emergency evacuation floor plan. An assisted living facility, other than a one-story small Type A or a one-story small Type B assisted living facility, must post an emergency evacuation floor plan in a location visible to residents.(c) Fire safety plan. An assisted living facility must establish a fire safety plan for the protection of all persons in the facility in the event of fire.(1) An assisted living facility must ensure the fire safety plan is in effect at all times.(2) An assisted living facility must make written copies of the fire safety plan are available to all supervisory personnel.(3) An assisted living facility must ensure the fire safety plan addresses:(A) evacuation to an area of refuge;(B) evacuation from the building when necessary; and(C) special staff actions, including fire protection procedures necessary to ensure the safety of any resident.(4) If the facility is a large Type B assisted living facility:(A) An existing large Type B assisted living facility must ensure the fire safety plan includes the provisions described in 19.7.2, Procedure in Case of Fire, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(B) A new large Type B assisted living facility must ensure the fire safety plan includes the provisions described in 18.7.2, Procedure in Case of Fire, in NFPA 101, Chapter 18, New Health Care Occupancies.(5) An assisted living facility must ensure the fire safety plan is reviewed at least annually and revised, as needed, to address the changing needs of residents.(6) An assisted living facility must instruct and inform all employees of their duties and responsibilities under the fire safety plan at least annually, and when the fire safety plan is revised.(7) An assisted living facility must keep a copy of the fire safety plan readily available at all times within the facility.(8) An assisted living facility must ensure the fire safety plan reflects the current evacuation capabilities of the residents.(d) Fire drills. An assisted living facility must conduct at least one quarterly fire drill on each shift with at least one drill each month. Each drill must meet these requirements:(1) An assisted living facility must ensure staff take part in fire drills according to the assisted living facility's fire safety plan.(2) An assisted living facility must inform residents of evacuation procedures and locations of exits.(3) An assisted living facility must document every fire drill using the most current version of the required Texas Health and Human Services (HHSC) form titled "Fire Drill Report" available on the HHSC website.(4) A large Type B assisted living facility must activate the fire alarm signal during a fire drill conducted between 6:00 a.m. and 9:00 p.m.(5) An assisted living facility may announce a fire drill to residents in advance.(e) Reporting fires.(1) An assisted living facility must immediately report a fire causing injury or death to a resident.(2) An assisted living facility must report a fire causing damage to the facility or facility equipment to HHSC within 72 hours after the fire is extinguished.(3) After making a report by telephone or email, an assisted living facility must file a written report using the most current version of the required HHSC form titled "Fire Report for Long Term Care Facilities" available on the HHSC website.(f) Smoking policies. An assisted living facility must establish and enforce policies regarding smoking, even if the policy is that smoking will not be permitted. The policy must also address the use of e-cigarettes and vaping devices. If smoking will be permitted, the smoking policies must:(1) designate smoking areas for residents and staff; and(2) provide ashtrays of noncombustible material and safe design in smoking areas.(g) Fire alarm system. An assisted living facility must establish a program to inspect, test, and maintain the fire alarm system according to the requirements of NFPA 72, and according to the requirements of NFPA 720 where carbon monoxide detection is provided, and must execute the program at least once every six months.(1) An assisted living facility must contract with a company that holds an Alarm Certificate of Registration from the State Fire Marshal's Office to execute the program.(2) An assisted living facility must ensure a company that performs a service under the contract required under paragraph (1) of this subsection completes, signs, and dates an inspection form like the inspection and testing form in NFPA 72 for a service provided under the contract.(3) If a task required by NFPA 72 or NFPA 720 must occur at intervals other than during the contracted visits in this subsection, an assisted living facility must ensure the task is performed and documented by a knowledgeable individual.(4) An assisted living facility must ensure:(A) a fire alarm system component that requires visual inspection is visually inspected in accordance with NFPA 72;(B) a fire alarm system component that requires testing is tested in accordance with NFPA 72; and(C) a fire alarm system component that requires maintenance is maintained in accordance with NFPA 72.(5) An assisted living facility that provides carbon monoxide detection must ensure:(A) a carbon monoxide detection component that requires visual inspection is visually inspected in accordance with NFPA 720;(B) a carbon monoxide detection component that requires testing is tested in accordance with NFPA 720;(C) a carbon monoxide detection component that requires maintenance is maintained in accordance with NFPA 720; and(D) a facility with a carbon monoxide detection component installed before August 31, 2021, must perform visual inspection, testing, and maintenance of that component beginning no later than August 31, 2022.(6) A large assisted living facility containing smoke compartments must ensure each required smoke damper is inspected and tested in accordance with NFPA 101.(7) An assisted living facility must ensure smoke detector sensitivity is checked within one year after installation and every two years thereafter in accordance with test methods in NFPA 72.(8) An assisted living facility must maintain onsite documentation of compliance with this subsection and must maintain record copies of documents regarding the installation of a fire alarm system, including as-built installation drawings, operation and maintenance manuals, the installation certificate for the system, and written sequences for its operation.(9) An assisted living facility must make documentation described in paragraph (8) of this subsection available to HHSC on request.(h) Fire sprinkler system. An assisted living facility that is equipped with a fire sprinkler system, including a fire sprinkler system meeting NFPA 13D, must establish a program to inspect, test, and maintain the fire sprinkler system according to the requirements of NFPA 25, and must execute the program at least once every six months.(1) An assisted living facility must contract with a company that holds an appropriate Sprinkler Certificate of Registration from the State Fire Marshal's Office to execute the program.(2) An assisted living facility must ensure a company that performs a service under the contract required under paragraph (1) of this subsection completes, signs, and dates an inspection form like the inspection and testing form in NFPA 25 for a service provided under the contract.(3) If a task required by NFPA 25 must occur at intervals other than during the contracted visits in this subsection, an assisted living facility must ensure the task is performed and documented by knowledgeable individuals.(4) An assisted living facility must ensure that a sprinkler system component that requires visual inspection is visually inspected in accordance with NFPA 25.(5) An assisted living facility must ensure that a sprinkler system component that requires testing is tested in accordance with NFPA 25.(6) An assisted living facility must ensure that a sprinkler system component that requires maintenance is maintained in accordance with NFPA 25.(7) An assisted living facility must ensure that an individual sprinkler head is inspected and maintained in accordance with NFPA 25.(8) An assisted living facility must maintain onsite documentation of compliance with this subsection and must maintain record copies of documents regarding the installation of a fire sprinkler system, including as-built installation drawings, hydraulic calculations, proof of adequate fire sprinkler water supply, and installation certificates for the system.(9) An assisted living facility must make documentation described in paragraph (8) of this subsection available to HHSC on request.(i) Portable fire extinguishers.(1) An assisted living facility must ensure staff are appropriately trained in the use of each type of extinguisher in the facility.(2) An assisted living facility must inspect and maintain portable fire extinguishers and:(A) ensure that its staff perform regular monthly inspections or "quick checks" to ensure extinguishers are located in the designated place, extinguisher locations are not obstructed to access or visibility, and the pressure gauge reading or indicator on the extinguisher is in the operable range or position;(B) ensure annual maintenance and inspection or "thorough checks" are performed according to NFPA 10 by an individual employed by a company holding an appropriate Extinguisher Certificate of Registration from the State Fire Marshal's Office to perform inspection, testing, and maintenance of portable fire extinguishers;(C) maintain onsite, a record of all fire extinguisher inspections and maintenance performed; and(D) replace unserviceable fire extinguishers.(j) General facility condition and safety features.(1) An assisted living facility must ensure staff utilize procedures to avoid cross-contamination between clean and soiled processes, including the handling of linens and cooking utensils.(2) An assisted living facility must keep all buildings in good repair.(A) An assisted living facility must maintain electrical, heating, and cooling systems so these systems operate in a safe manner. As evidence that these systems operate in a safe manner, HHSC may require the facility to submit a report prepared by one of the following:(i) the fire marshal;(ii) the city or county building official having jurisdiction over the location of the facility;(iii) a licensed electrician; or(iv) a registered professional engineer.(B) An assisted living facility must ensure electrical appliances, devices, and lamps do not overload circuits or use extension cords of excessive length.(3) An assisted living facility must keep all buildings free of accumulations of dirt, rubbish, dust, and hazards.(4) An assisted living facility must maintain floors in good condition and clean floors regularly.(5) An assisted living facility must structurally maintain walls and ceilings and must repair, repaint, or clean walls and ceilings whenever needed.(6) An assisted living facility must keep storage areas and cellars organized and free from obstructions.(7) An assisted living facility must not store any items in attic spaces.(8) An assisted living facility must ensure all equipment requiring periodic maintenance, testing, and servicing is accessible.(A) An assisted living facility must ensure equipment that is necessary to conduct maintenance, testing, and services, including ladders, specific tools, and keys, is readily available to staff or maintenance personnel on site.(B) An assisted living facility must provide access panels, at least 20 inches wide by 20 inches long, for building maintenance and must ensure access panels are located for reasonable access to equipment and fire or smoke barrier walls installed in the attic or other concealed spaces.(k) Waste and storage containers.(1) An assisted living facility must provide metal waste baskets of substantial gauge or any UL- or FM-approved container in each area where smoking is permitted, if applicable, in accordance with the facility's smoking policies required in subsection (f) of this section.(2) An assisted living facility must provide one or more garbage, waste, or trash containers with close-fitting covers, made of metal or of any UL- or FM-approved material, for use in kitchens, janitor closets, laundry rooms, mechanical or boiler rooms, general storage rooms, and similar places. A facility may use disposable plastic liners in the containers for sanitation.(3) An assisted living facility must ensure waste, including waste classified as Special Waste from Health Care-Related Facilities, trash, and garbage are disposed of from the premises at regular intervals according to state and local requirements. The facility may not permit or allow an accumulation of waste on the facility premises, either inside or outside of facility buildings.(l) Pest control.(1) An assisted living facility must have an ongoing and effective pest control program executed by facility staff or by contract with a licensed pest control company.(2) An assisted living facility must ensure the chemicals used to control pests are the least toxic and least flammable chemicals that are effective.(3) An assisted living facility must ensure each operable window is provided with an insect screen.(m) Flammable or combustible liquids. An assisted living facility must not store flammable or combustible liquids, such as gasoline, oil-based paint, charcoal lighter fluid, or similar products in a building that houses residents.(n) Storage of oxygen. An assisted living facility must ensure sanitary use and storage of oxygen for the safety of all residents.(1) An assisted living facility must ensure oxygen cylinders in the possession and under the control of the facility are:(A) identified by attached labels or stencils naming the contents;(B) not stored with flammable or combustible materials;(C) protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device;(D) protected from tamper by unauthorized individuals;(E) if not supported in a proper cart or stand, properly chained or supported;(F) stored so the cylinders can be used in the order received from the supplier;(G) if empty and full cylinders are stored in the same enclosure or room, stored so that empty cylinders are separated from full cylinders; and(H) if empty, marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.(2) An assisted living facility must adopt, implement, and enforce procedures for resident use, storage, and handling of oxygen cylinders and liquid oxygen containers in the possession and under the control of residents, to ensure the safety of all residents.(o) Gas pressure test.(1) An assisted living facility must obtain an initial pressure test of facility gas lines from the gas meter or propane storage tank to all gas-fired appliances and equipment.(2) An assisted living facility must obtain an additional gas pressure test when the facility performs major renovations or additions to the gas piping or gas-fired equipment that interrupt gas service or replace gas-fired equipment.(p) Annual gas heating check.(1) An assisted living facility must ensure all gas heating systems are checked at least once per year, prior to the heating season for proper operation and safety by persons who are licensed or approved by the State of Texas to inspect the equipment.(2) An assisted living facility must maintain records of the testing of the gas heating system.(3) An assisted living facility must correct unsatisfactory conditions.(q) Emergency generator. A large assisted living facility that uses an emergency generator to provide power to emergency lighting systems must ensure the generator is tested and maintained according to Chapter 8, Routine Maintenance and Operational Testing, in NFPA 110. Routine maintenance and operational testing required by NFPA 110 includes the following procedures:(1) a readily available record of inspections, test, exercising, operation, and repairs;(2) monthly testing of cranking batteries;(3) weekly inspection of the generator set and other components that make up the emergency power system;(4) monthly exercise of the generator under load;(5) monthly test of transfer switches; and(6) a continuous operational test for at least 1-1/2 hours every three years. Source Note: The provisions of this §553.104 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.104 Safety Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206013 03/12/2026 (a) Prior to the start of building rehabilitation, other than that classified as repair in subsection (b) of this section, a facility must notify the Texas Health and Human Services commission (HHSC) in Austin, Texas, in writing.(b) Upon completion of building rehabilitation, other than that classified as repair or renovation in this section, a final construction inspection of the facility must be performed by HHSC prior to occupancy. The completed construction must have the written approval of the local authority having jurisdiction, including the fire marshal and building official. When construction or building rehabilitation does not alter the licensed capacity of a facility, based on submitted documentation and the scope of the performed building rehabilitation, HHSC may permit a facility to use the rehabilitated portion of a facility pending a final construction inspection or may determine a final construction inspection is not required.(c) An assisted living facility undergoing any building rehabilitation must meet the requirements of this section.(1) An assisted living facility must ensure the patching, restoration, or painting of materials, elements, equipment, or fixtures for maintaining such materials, elements, equipment, or fixtures in good or sound condition is classified as repair and must ensure the repair:(A) meets the applicable requirements of §553.100(e) of this subchapter (relating to General Requirements);(B) uses like materials, unless such materials are prohibited by NFPA 101, as modified by this subchapter; and(C) does not make a building less conforming with NFPA 101, as modified by this subchapter, with the applicable sections of this subchapter, or with any alternative arrangements previously approved by HHSC, than it was before the repair was undertaken.(2) An assisted living facility must ensure the replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures that does not result in a reconfiguration of the building spaces within is classified as renovation and must ensure:(A) any new work that is part of a renovation meets the applicable requirements of §553.100(e) of this subchapter;(B) any new interior or exterior finishes meet the applicable requirements of §553.100(e)(3) of this subchapter; and(C) does not make a building less conforming with NFPA 101, as modified by this subchapter, with the applicable sections of this subchapter, or with any alternative arrangements previously approved by HHSC, than it was before the renovation was undertaken.(3) An assisted living facility must ensure the reconfiguration of any space; addition, relocation, or elimination of any door or window; addition or elimination of load-bearing elements; reconfiguration or extension of any system; installation of any additional equipment; or changes in locking arrangements as defined in §553.101(6)(L) of this subchapter (relating to Definitions), is classified as modification and must ensure:(A) a newly constructed element, component, or system meets the applicable requirements of §553.100(e)(3) of this subchapter;(B) all other work in a modification meets, at a minimum, the requirements for a renovation according to paragraph (2) of this subsection; and(C) where the total rehabilitation work area classified as modification exceeds 50 percent of the total building area, the work is classified as reconstruction subject to paragraph (4) of this subsection.(4) An assisted living facility must ensure the reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space, or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress or fire protection systems are not in place or continuously maintained, is classified as reconstruction and must ensure:(A) reconstruction of components of the means of egress meets the applicable requirements of §553.100(e) of this subchapter, except for the following components, which must meet the specific requirements of §553.100(e)(3) of this subchapter:(i) illumination of means of egress;(ii) emergency lighting of means of egress; and(iii) marking of means of egress, including exit signs;(B) if the total rehabilitation work area classified as reconstruction on any one floor exceeds 50 percent of the total area of the floor, all means of egress components identified in paragraph (4)(A)(i) - (iii) of this subsection and located on that floor meet the specific requirements of §553.100(e)(3) of this subchapter;(C) if the total rehabilitation work area classified as reconstruction exceeds 50 percent of the total building area, all means of egress components identified in paragraph (4)(A)(i) - (iii) of this subsection and located in the building meet the specific requirements of §553.100(e)(3) of this subchapter; and(D) all other work classified as reconstruction meets, at a minimum, the requirements for modification according to paragraph (3) of this subsection and renovation according to paragraph (2) of this subsection.(5) An assisted living facility must ensure a change in the purpose or level of activity within a facility that involves a change in application of the requirements of this subchapter, including a change of a wing or area to a Certified Alzheimer's Disease Assisted Living Facility or unit, or a change of a Certified Alzheimer's Disease Assisted Living Facility or unit to ordinary resident-use, is classified as a change of use and meets the specific requirements of §553.100(e)(3) of this subchapter.(6) An assisted living facility must ensure a change in the use of a structure or portion of a structure is classified as a change of occupancy and meets the specific requirements of §553.100(e)(3) of this subchapter.(7) An assisted living facility must ensure an increase in the building area, aggregate floor area, building height, or number of stories of a structure is classified as an addition and meets the specific requirements of §553.100(e)(3) of this subchapter.(d) An assisted living facility undergoing rehabilitation must comply with the requirements of NFPA 101, as modified by this subchapter in accordance with the requirements of NFPA 101, Chapter 43, Building Rehabilitation.(e) An assisted living facility undergoing rehabilitation to an occupied building that involves means of escape, exit-ways, or exit doors must be accomplished without compromising the means of escape, means of egress, or exits or creating a dead-end situation at any time. HHSC may approve temporary exits or the facility must relocate residents until construction blocking the exit is completed. The facility must maintain other basic safety features, including fire alarm systems and fire sprinkler systems, in compliance with their relevant standards and must maintain required emergency power at all times during construction. Source Note: The provisions of this §553.107 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.107 Building Rehabilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206014 03/12/2026 An existing small Type A assisted living facility must comply with the requirements for a slow evacuation capability facility in 33.2, Small Facilities, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, where referenced by this division. Source Note: The provisions of this §553.110 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.110 General Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206015 03/12/2026 (a) Structurally sound. An existing small Type A assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads in accordance with applicable building codes.(b) Separation of occupancies. An existing small Type A assisted living facility must be separated from other occupancies by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards, unless otherwise permitted by paragraph (2) of this subsection.(1) An existing small Type A assisted living facility must be separated from other assisted living facilities, hospitals, or nursing facilities. Beginning August 31, 2021, an existing small Type A assisted living facility must be separated from any new occupancy or new use subject to the Texas Health and Human Services commission (HHSC) licensing.(2) An existing small Type A assisted living facility is not required to be separated from another occupancy not subject to HHSC licensing standards if the two occupancies are so intermingled that construction of a fire barrier having a 2-hour fire resistance rating is impractical and the following conditions are met.(A) The means of escape, construction, protection, and other safeguards for the entire building must comply with the NFPA 101 requirements for an existing small Type A assisted living facility.(B) HHSC must be given unrestricted and unannounced access at any reasonable time to inspect the other occupancy type for compliance with the NFPA 101 requirements for an existing small Type A assisted living facility.(c) Sheathing.(1) Except as provided in paragraph (3) of this subsection, an existing small Type A assisted living facility must ensure all buildings used by residents are sheathed with materials providing a fire resistance rating and ensure:(A) interior wall and ceiling surfaces have finished surfaces, substrates, or sheathing with a fire resistance rating of not less than 20 minutes; and(B) columns, beams, girders, or trusses that are not enclosed within walls or ceilings are encased in materials having a fire resistance rating of not less than 20 minutes.(2) A sprinkler system does not substitute for the minimum sheathing requirements under paragraph (1) of this subsection.(3) A building constructed to meet the minimum building construction type requirements of 19.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 19, Existing Health Care Occupancies, is not also required to be sheathed.(d) Interior finish. An existing small Type A assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 33.2.3.3.2, Interior Wall and Ceiling Finish, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(e) Vertical openings. An existing small Type A assisted living facility must ensure vertical openings are protected according to the requirements of 33.2.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies. Source Note: The provisions of this §553.111 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.111 Construction Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206016 03/12/2026 (a) Resident bedrooms.(1) An existing small Type A assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) An existing small Type A assisted living facility must ensure bedroom-usable floor space is not less than 80 square feet for a bedroom housing one resident and not less than 60 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than eight feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by HHSC.(3) An existing small Type A assisted living facility containing individual living units that include living space for the residents in addition to their bedrooms may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. An existing small Type A assisted living facility may not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(5) of this section.(4) An existing small Type A assisted living facility may house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. An existing small Type A assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by all residents occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space required by subsection (a)(2) of this section.(4) An existing bedroom window not meeting these requirements may be continued in service subject to approval by HHSC.(5) An existing small Type A assisted living facility that is not equipped with a fire sprinkler system meeting the requirements of §553.115 of this division (relating to Fire Protection Systems Requirements for an Existing Small Type A Assisted Living Facility) must provide at least one window in each bedroom in the facility that, in addition to meeting the requirements of paragraphs (1) - (4) of this subsection, meets the following requirements:(A) The bedroom window must meet the requirements of §553.113 of this division (relating to Means of Escape Requirements for an Existing Small Type A Assisted Living Facility) for use as a secondary means of escape from a resident sleeping room.(B) The bedroom window must not be blocked by bars, shrubs, or any obstacle that could impede evacuation.(C) The bedroom window must provide an operable section with a clear opening of not less than 5.7 square feet with a minimum width of 20 inches and a minimum height of 24 inches.(6) An existing small Type A assisted living facility that is protected by an automatic sprinkler system meeting the requirements of §553.115 of this division must provide an operable window in a bedroom. The window opening size may be smaller than the minimum size listed in paragraph (5) of this subsection but must be operable according to the requirements of paragraph (2) of this subsection.(c) Bedroom furnishings. When a resident does not provide their own furnishings, an existing small Type A assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) An existing small Type A assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) An existing small Type A assisted living facility must ensure all resident rooms are arranged for convenient resident access to dining and recreation areas.(e) Staff area. An existing small Type A assisted living facility must provide a staff area on each floor of an existing small Type A assisted living facility and in each separate building containing resident sleeping rooms, except as permitted under paragraph (1) of this subsection.(1) An existing small Type A assisted living facility that is not more than two-stories in height and is composed of separate buildings grouped together and connected by covered walks, is not required to provide a staff area on each floor or in each building, provided that a staff area is located not more than 200 feet walking distance from the farthest resident living unit.(2) An existing small Type A assisted living facility must provide the following at each staff area:(A) a desk or writing surface;(B) a telephone; and(C) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.115 of this division (relating to Fire Protection Systems Requirements for an Existing Small Type A Assisted Living Facility).(f) Resident toilet and bathing facilities. An existing small Type A assisted living facility must ensure each resident bedroom is served by a separate, private toilet room, a connecting toilet room, or a general toilet room.(1) An existing small Type A assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) An existing small Type A assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) An existing small Type A assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.117 of this division (relating to Mechanical Requirements for an Existing Small Type A Assisted Living Facility).(g) Resident living areas.(1) An existing small Type A assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) An existing small Type A assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) An existing small Type A assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) An existing small Type A assisted living facility must ensure the total space for social-diversional area provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(2) An existing small Type A assisted living facility must provide a dining area with appropriate furniture.(A) An existing small Type A assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) An existing small Type A assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) An existing small Type A assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) An existing small Type A assisted living facility must ensure the total space for dining areas provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(3) An existing small Type A assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) An existing small Type A assisted living facility must ensure an escape route through a resident living or dining area is kept clear of obstructions.(5) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, an existing small Type A assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) An existing small Type A assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. An existing small Type A assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) Kitchen.(1) An existing small Type A assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner.(2) An existing small Type A assisted living facility that prepares food on-site must provide a kitchen or dietary area meeting the general food service needs of the residents and must ensure that the kitchen:(A) is equipped to store, refrigerate, prepare, and serve food;(B) is equipped to clean and sterilize;(C) provides for refuse storage and removal; and(D) meets the requirements of the local fire, building, and health codes.(3) An existing small Type A assisted living facility must ensure a kitchen uses only residential cooking equipment or, if the kitchen uses commercial cooking equipment, that the facility protects the kitchen's cooking operations as required in §553.116 of this division (relating to Hazardous Area Requirements for an Existing Small Type A Assisted Living Facility). Source Note: The provisions of this §553.112 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.112 Space Planning and Utilization Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206017 03/12/2026 (a) The provisions of NFPA 101, Chapter 7, Means of Egress, do not apply to an existing small Type A assisted living facility unless explicitly referenced by this section or by NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing small Type A assisted living facility must meet the requirements of 33.2.2, Means of Escape, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, except as described in this section.(c) An existing small Type A assisted living facility must ensure doors meet the requirements of 33.2.2.5, Doors, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, and the additional requirements of this section.(1) A resident room door in an existing small Type A assisted living facility not protected throughout by an approved automatic fire sprinkler system complying with the requirements of §553.115 of this division (relating to Fire Protection Systems Requirements for an Existing Small Type A Assisted Living Facility) must meet one of the following options. A resident room door is not otherwise required to meet the requirements for doors in 33.2.3.6, Construction of Corridor Walls, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(A) The door must be a solid core wood door at least 1-3/4 inches thick or have a 20-minute opening protection rating and must latch in its frame to resist the passage of smoke; or(B) The door must be self-closing or automatic-closing and must latch in its frame to resist the passage of smoke.(2) A resident room door in an existing small Type A assisted living facility protected throughout by an approved automatic fire sprinkler system complying with the requirements of §553.115 of this division must latch in its frame to resist the passage of smoke.(3) In an existing small Type A assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(4) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) An existing small Type A assisted living facility providing a bedroom window used as a secondary means of escape must ensure the window meets the requirements for a bedroom window used as a secondary means of escape in §553.112 of this division (relating to Space Planning and Utilization Requirements for an Existing Small Type A Assisted Living Facility).(e) An existing small Type A assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs.(1) An existing stair may be continued in service, subject to approval by HHSC.(2) A stair used as means of escape must meet the requirements of 33.2.2.6, Stairs, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(3) Each stair must be arranged and located so that it is not necessary to go through another room, including a bedroom or bathroom, to reach the stair.(4) Each stair must be provided with handrails.(5) Each stair must be provided with normal lighting according to the requirements of §553.118 of this division (relating to Electrical Requirements for an Existing Small Type A Assisted Living Facility).(6) A stair in an existing building that became an assisted living through conversion must meet the dimensional criteria for existing stairs in 7.2.2.2, Dimensional Criteria, in NFPA 101, Chapter 7, Means of Egress.(7) An existing stair, previously approved by HHSC, may be rebuilt to the same dimensions but must meet all other requirements for stairs in NFPA 101. Source Note: The provisions of this §553.113 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.113 Means of Escape Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206018 03/12/2026 (a) Fire alarm and smoke detection system. An existing small Type A assisted living facility must provide a manual fire alarm system meeting the requirements of section 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. An existing small Type A assisted living facility must ensure the operation of any alarm initiating device automatically activates an audible or a visual alarm at the site.(2) Smoke detectors.(A) An existing small Type A assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) and (C) of this paragraph.(B) An existing small Type A assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) An existing small Type A assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 19, Existing Health Care Occupancies, may install a smoke detection system meeting the requirements of 19.3.4.5.1, Corridors, in NFPA 101, Chapter 19, Existing Health Care Occupancies, in lieu of the requirements in subparagraph (A) of this paragraph.(3) Alarm control panel.(A) An existing small Type A assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) An existing small Type A assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(4) Fire alarm power source.(A) An existing small Type A assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) An existing small Type A assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(b) Fire sprinkler system.(1) An existing small Type A assisted living facility may provide one of the following fire sprinkler systems according to the requirements of 33.2.3.5, Extinguishment Requirements, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(A) A fire sprinkler system meeting the requirements of NFPA 13 in accordance with 33.2.3.5.3.3;(B) A fire sprinkler system meeting the requirements of NFPA 13R in accordance with 33.2.3.5.3.4; or(C) A fire sprinkler system meeting the requirements of NFPA 13D in accordance with 33.2.3.5.3.2.(2) An existing small Type A assisted living facility must provide supervision of any fire sprinkler system where required by 33.2.3.5, Extinguishment Requirements, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(c) Protection of attics. An existing small Type A assisted living facility equipped with a fire sprinkler system must ensure an attic is protected according to the requirements of 33.2.3.5.7, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, not later than August 31, 2024.(d) Portable fire extinguishers. An existing small Type A assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) An existing small Type A assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) An existing small Type A assisted living facility must ensure portable fire extinguishers are located so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) An existing small Type A assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:5-B:C according to NFPA 10.(4) An existing small Type A assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) An existing small Type A assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) An existing small Type A assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.115 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.115 Fire Protection Systems Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206019 03/12/2026 (a) An existing small Type A assisted living facility must ensure any space where storage or an activity produces a greater potential for a fully involved fire than that found in a one- or two-family dwelling is protected according to the requirements of 33.2.3.2, Hazardous Areas, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing small Type A assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) An existing small Type A assisted living facility using commercial cooking equipment must protect the cooking operation according to the requirements of NFPA 96. Source Note: The provisions of this §553.116 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.116 Hazardous Area Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206020 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. An existing small Type A assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. An existing small Type A assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) An existing small Type A assisted living facility must provide at least one water closet and one lavatory for every six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) An existing small Type A assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) An existing small Type A assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) An existing small Type A assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, an existing small Type A assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) An existing small Type A assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. An existing small Type A assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. An existing small Type A assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Gas. An existing small Type A assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(d) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. An existing small Type A assisted living facility must ensure HVAC equipment meets the requirements of 33.2.5.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(2) Heating and cooling. An existing small Type A assisted living facility must provide heating and cooling for resident comfort.(A) An existing small Type A assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) An existing small Type A assisted living facility constructed or licensed after August 1, 2004, must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain the temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) An existing small Type A assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this section.(D) An existing small Type A assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(v) A fuel-fired heating device not meeting the requirements of clauses (i) - (iv) of this subparagraph may be continued in service, subject to approval by HHSC.(E) An existing small Type A assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A new working fireplace must be installed, maintained and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid fuel-burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(vii) An existing working fireplace not meeting the requirements of clauses (i) - (vi) of this subparagraph may be continued in service, subject to approval by HHSC.(3) Ventilation.(A) An existing small Type A assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) An existing small Type A assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust.(A) An existing small Type A assisted living facility must ensure bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control, unless otherwise permitted under subparagraph (B) of this paragraph.(B) An existing small Type A assisted living facility may provide exhaust into an attic where permitted by the local building code. Source Note: The provisions of this §553.117 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.117 Mechanical Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206021 03/12/2026 (a) Electrical system. An existing small Type A assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. An existing small Type A assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. An existing small Type A assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. An existing small Type A assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system, or intercom;(B) if it is an existing communication system, be approved by HHSC to be continued in service; and(C) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) An existing small Type A assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) An existing small Type A assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.118 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.118 Electrical Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206022 03/12/2026 An existing small Type A assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located. Source Note: The provisions of this §553.119 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.119 Miscellaneous Requirements for an Existing Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206023 03/12/2026 An existing small Type B assisted living facility must comply with the requirements for an impractical evacuation capability facility in 33.2, Small Facilities, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, where referenced by this division. Source Note: The provisions of this §553.120 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.120 General Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206024 03/12/2026 (a) Structurally sound. An existing small Type B assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads in accordance with applicable building codes.(b) Separation of occupancies. An existing small Type B assisted living facility must be separated from other occupancies by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards, unless otherwise permitted by paragraph (2) of this subsection.(1) An existing small Type B assisted living facility must be separated from other assisted living facilities, hospitals, or nursing facilities. Beginning August 31, 2021, an existing small Type A assisted living facility must be separated from any new occupancy or new use subject to HHSC licensing.(2) An existing small Type B assisted living facility is not required to be separated from another occupancy not subject to Texas Health and Human Services Commission (HHSC) licensing standards if the two occupancies are so intermingled that construction of a fire barrier having a 2-hour fire resistance rating is impractical and the following conditions are met.(A) The means of escape, construction, protection, and other safeguards for the entire building must comply with the NFPA 101 requirements for an existing small Type B assisted living facility.(B) HHSC must be given unrestricted and unannounced access at any reasonable time to inspect the other occupancy type for compliance with the NFPA 101 requirements for an existing small Type B assisted living facility.(c) Sheathing.(1) Except as provided in paragraph (3) of this subsection, an existing small Type B assisted living facility must ensure all buildings used by residents are sheathed with materials providing a fire resistance rating.(A) Interior wall and ceiling surfaces must have finished surfaces, substrates, or sheathing with a fire resistance rating of not less than 20 minutes.(B) Columns, beams, girders, or trusses that are not enclosed within walls or ceilings must be encased in materials having a fire resistance rating of not less than 20 minutes.(2) A sprinkler system does not substitute for the minimum sheathing requirements under paragraph (1) of this subsection.(3) A building constructed to meet the minimum building construction type requirements of 19.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 19, Existing Health Care Occupancies, is not also required to be sheathed.(d) Interior finish. An existing small Type B assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 33.2.3.3.2, Interior Wall and Ceiling Finish, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(e) Vertical openings. An existing small Type B assisted living facility must ensure vertical openings are protected according to the requirements of 33.2.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies. Source Note: The provisions of this §553.121 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.121 Construction Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206025 03/12/2026 (a) Resident bedrooms.(1) An existing small Type B assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) An existing small Type B assisted living facility must ensure bedroom-usable floor space is not less than 100 square feet for a bedroom housing one resident and not less than 80 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than 10 feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by the Texas Health and Human Services Commission (HHSC).(3) An existing small Type B assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. An existing small Type B assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(5) of this section.(4) An existing small Type B assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. An existing small Type B assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by all residents occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space required by subsection (a)(2) of this section.(4) An existing bedroom window not meeting these requirements may be continued in service subject to approval by HHSC.(c) Bedroom furnishings. When a resident does not provide their own furnishings, an existing small Type B assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must include closable door, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) An existing small Type B assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) An existing small Type B assisted living facility must ensure all resident rooms are arranged for convenient resident access to dining and recreation areas.(e) Staff area. An existing small Type B assisted living facility must provide a staff area on each floor of an existing small Type B assisted living facility and in each separate building containing resident sleeping rooms. An existing small Type B assisted living facility must provide the following at each staff area:(1) a desk or writing surface;(2) a telephone; and(3) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.125 of this division (relating to Fire Protection Systems Requirements for an Existing Small Type B Assisted Living Facility).(f) Resident toilet and bathing facilities. An existing small Type B assisted living facility must ensure each resident bedroom is served by a separate, private toilet room, a connecting toilet room, or a general toilet room.(1) An existing small Type B assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) An existing small Type B assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) An existing small Type B assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.127 of this division (relating to Mechanical Requirements for an Existing Small Type B Assisted Living Facility).(g) Resident living areas.(1) An existing small Type B assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) An existing small Type B assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) An existing small Type B assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) An existing small Type B assisted living facility must ensure the total space for social-diversional area provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(2) An existing small Type B assisted living facility must provide a dining area with appropriate furniture.(A) An existing small Type B assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) An existing small Type B assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) An existing small Type B assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) An existing small Type B assisted living facility must ensure the total space for dining areas provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(3) An existing small Type B assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) An existing small Type B assisted living facility must ensure an escape route through a resident living or dining area is kept clear of obstructions.(5) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, an existing small Type B assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) An existing small Type B assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. An existing small Type B assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) Kitchen.(1) An existing small Type B assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner.(2) An existing small Type B assisted living facility that prepares food on-site must provide a kitchen or dietary area meeting the general food service needs of the residents and must ensure that the kitchen:(A) is equipped to store, refrigerate, prepare, and serve food;(B) is equipped to clean and sterilize;(C) provides for refuse storage and removal; and(D) meets the requirements of the local fire, building, and health codes.(3) An existing small Type B assisted living facility must ensure a kitchen uses only residential cooking equipment or, if the kitchen uses commercial cooking equipment, that the facility protects the kitchen's cooking operations as required in §553.126 of this division (relating to Hazardous Area Requirements for an Existing Small Type B Assisted Living Facility). Source Note: The provisions of this §553.122 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.122 Space Planning and Utilization Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206026 03/12/2026 (a) The provisions of NFPA 101, Chapter 7, Means of Egress, do not apply to an existing small Type B assisted living facility, unless explicitly referenced by this section or by NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing small Type B assisted living facility must meet the requirements of 33.2.2, Means of Escape, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, except as described in this section.(c) An existing small Type B assisted living facility must ensure doors meet the requirements of 33.2.2.5, Doors, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, and the additional requirements of this section. A resident room door is not otherwise required to meet the requirements for doors in 33.2.3.6, Construction of Corridor Walls, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(1) A resident room door in an existing small Type B assisted living facility must latch in its frame to resist the passage of smoke.(2) In an existing small Type B assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) An existing small Type B assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs.(1) An existing stair may be continued in service, subject to approval by HHSC.(2) A stair used as means of escape must meet the requirements of 33.2.2.6, Stairs, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(3) Each stair must be arranged and located so that it is not necessary to go through another room, including a bedroom or bathroom, to reach the stair.(4) Each stair must be provided with handrails.(5) Each stair must be provided with normal lighting according to the requirements of §553.128 of this division (relating to Electrical Requirements for an Existing Small Type B Assisted Living Facility).(6) A stair in an existing building that became an assisted living through conversion must meet the dimensional criteria for existing stairs in 7.2.2.2, Dimensional Criteria, in NFPA 101, Chapter 7, Means of Egress.(7) An existing stair, previously approved by HHSC, may be rebuilt to the same dimensions but must meet all other requirements for stairs in NFPA 101. Source Note: The provisions of this §553.123 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.123 Means of Escape Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206027 03/12/2026 (a) Fire alarm and smoke detection system. An existing small Type B assisted living facility must provide a manual fire alarm system meeting the requirements of section 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. An existing small Type B assisted living facility must ensure the operation of any alarm initiating device automatically activates an audible or a visual alarm at the site.(2) Smoke detectors.(A) An existing small Type B assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) and (C) of this paragraph.(B) An existing small Type B assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) An existing small Type B assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 19, Existing Health Care Occupancies, may install a smoke detection system meeting the requirements of 19.3.4.5.1, Corridors, in NFPA 101, Chapter 19, Existing Health Care Occupancies, in lieu of the requirements in subparagraph (A) of this paragraph.(3) Alarm control panel.(A) An existing small Type B assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) An existing small Type B assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(4) Fire alarm power source.(A) An existing small Type B assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) An existing small Type B assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(b) Fire sprinkler system.(1) An existing small Type B assisted living facility must provide one of the following fire sprinkler systems according to the requirements of 33.2.3.5, Extinguishment Requirements, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(A) A fire sprinkler system meeting the requirements of NFPA 13 in accordance with 33.2.3.5.3.3;(B) A fire sprinkler system meeting the requirements of NFPA 13R in accordance with 33.2.3.5.3.4; or(C) A fire sprinkler system meeting the requirements of NFPA 13D in accordance with 33.2.3.5.3.2.(2) An existing small Type B assisted living facility must ensure a fire sprinkler system is supervised according to 9.7.2, Supervision, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(c) Protection of attics. An existing small Type B assisted living facility equipped with a fire sprinkler system must ensure an attic is protected according to the requirements of 33.2.3.5.7, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, not later than August 31, 2024.(d) Portable fire extinguishers. An existing small Type B assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) An existing small Type B assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) An existing small Type B assisted living facility must ensure portable fire extinguishers are located so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) An existing small Type B assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10; or(B) Other portable fire extinguishers must have a rating of at least 2-A:5-B:C according to NFPA 10.(4) An existing small Type B assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) An existing small Type B assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) An existing small Type B assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.125 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.125 Fire Protection Systems Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206028 03/12/2026 (a) An existing small Type B assisted living facility must ensure any space where storage or activity produces a greater potential for a fully involved fire than that found in a one- or two-family dwelling is protected according to the requirements of 33.2.3.2, Hazardous Areas, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing small Type B assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) An existing small Type B assisted living facility using commercial cooking equipment must protect the cooking operation according to the requirements of NFPA 96. Source Note: The provisions of this §553.126 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.126 Hazardous Area Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206029 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. An existing small Type B assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. An existing small Type B assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) An existing small Type B assisted living facility must provide at least one water closet and one lavatory for each six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) An existing small Type B assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) An existing small Type B assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) An existing small Type B assisted living facility must provide one tub or shower for every 10 residents, or for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, an existing small Type B assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) An existing small Type B assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. An existing small Type B assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. An existing small Type B assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Gas. An existing small Type B assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(d) Heating ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. An existing small Type B assisted living facility must ensure HVAC equipment meets the requirements of 33.2.5.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(2) Heating and cooling. An existing small Type B assisted living facility must provide heating and cooling for resident comfort.(A) An existing small Type B assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort ranges of 68 to 82 degrees Fahrenheit in resident-use areas.(B) An existing small Type B assisted living facility constructed or licensed after August 1, 2004, must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain a temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) An existing small Type B assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this section.(D) An existing small Type B assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(v) A fuel-fired heating device not meeting the requirements of clauses (i) - (iv) of this subparagraph may be continued in service, subject to approval by HHSC.(E) An existing small Type B assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A new working fireplace must be installed, maintained, and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.,(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(vii) An existing working fireplace not meeting the requirements of clauses (i) - (vi) of this subparagraph may be continued in service, subject to approval by HHSC.(3) Ventilation.(A) An existing small Type B assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) An existing small Type B assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust.(A) An existing small Type B assisted living facility must ensure bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control, unless otherwise permitted under subparagraph (B) of this paragraph.(B) An existing small Type B assisted living facility may provide exhaust into an attic where permitted by the local building code. Source Note: The provisions of this §553.127 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.127 Mechanical Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206030 03/12/2026 (a) Electrical system. An existing small Type B assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. An existing small Type B assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. An existing small Type B assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. An existing small Type B assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system or intercom;(B) if it is an existing communication system, be approved by the Texas Health and Human Services Commission to be continued in service;(C) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) An existing small Type B assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) An existing small Type B assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.128 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.128 Electrical Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206031 03/12/2026 An existing small Type B assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located. Source Note: The provisions of this §553.129 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.129 Miscellaneous Requirements for an Existing Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206032 03/12/2026 (a) An existing large Type A assisted living facility must comply with the requirements for a slow evacuation capability facility in 33.3, Large Facilities, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, where referenced by this division, except as permitted by subsection (b) of this section.(b) An existing large Type A assisted living facility campus comprised of multiple buildings providing sleeping rooms for no more than 16 residents in any one building may comply with other provision in NFPA 101, as follows.(1) Each individual building providing sleeping rooms on the campus may comply with the requirements for a slow evacuation capability facility in 33.2, Small Facilities, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(2) Other buildings on the campus that are part of the existing large Type A assisted living facility may be permitted to comply with the requirements for other occupancies in NFPA 101, subject to approval by the Texas Health and Human Services Commission (HHSC).(3) The provisions of this subsection do not apply where any building provides sleeping rooms for more than 16 residents. Source Note: The provisions of this §553.130 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.130 General Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206033 03/12/2026 (a) Structurally sound. An existing large Type A assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads in accordance with applicable building codes.(b) Separation of occupancies. An existing large Type A assisted living facility must be separated from other occupancies by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards, unless otherwise permitted by paragraphs (1) or (2) of this subsection.(1) An existing large Type A assisted living facility must be separated from other assisted living facilities, hospitals or nursing facilities. Beginning August 31, 2021, an existing large Type A assisted living facility must be separated from any new occupancy or new use subject to HHSC licensing.(2) An existing large Type A assisted living facility is not required to be separated from another occupancy not subject to HHSC licensing standards if the two occupancies are so intermingled that construction of a fire barrier having a 2-hour fire resistance rating is impractical and the following conditions are met.(A) The means of egress, construction, protection, and other safeguards for the entire building must comply with the NFPA 101 requirements for an existing large Type A assisted living facility.(B) HHSC must be given unrestricted and unannounced access at any reasonable time to inspect the other occupancy type for compliance with the NFPA 101 requirements for an existing large Type A assisted living facility.(c) Sheathing.(1) Except as provided in paragraph (3) of this subsection, an existing large Type A assisted living facility must ensure all buildings used by residents are sheathed with materials providing the following fire resistance ratings.(A) Interior wall and ceiling surfaces must have finished surfaces, substrates, or sheathing with a fire resistance rating of not less than 20 minutes.(B) Columns, beams, girders, or trusses that are not enclosed within walls or ceilings must be encased in materials having a fire resistance rating of not less than 20 minutes.(2) A sprinkler system does not substitute for this minimum sheathing requirement under paragraph (1) of this subsection.(3) A building constructed to meet the minimum building construction type requirements of 19.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 19, Existing Health Care Occupancies, is not also required to be sheathed.(d) Interior finish. An existing large Type A assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 33.3.3.3.2, Interior Wall and Ceiling Finish, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(e) Vertical openings. An existing large Type A assisted living facility must ensure vertical openings are protected according to the requirements of 33.3.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies. Source Note: The provisions of this §553.131 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.131 Construction Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206034 03/12/2026 (a) Resident bedrooms.(1) An existing large Type A assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) An existing large Type A assisted living facility must ensure bedroom usable floor space is not less than 80 square feet for a bedroom housing one resident and not less than 60 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than eight feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by the Texas Health and Human Services Commission (HHSC).(3) An existing large Type A assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. An existing large Type A assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(6) of this section.(4) An existing large Type A assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. An existing large Type A assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by a resident occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space according to the requirements of subsection (a)(2) of this section. (4) An existing bedroom window not meeting these requirements may be continued in service, subject to approval by HHSC.(c) Bedroom furnishings. When a resident does not provide their own furnishings, an existing large Type A assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) An existing large Type A assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) An existing large Type A assisted living facility must ensure a resident room is arranged for convenient resident access to dining and recreation areas.(e) Staff area. An existing large Type A assisted living facility must provide a staff area on each floor of an existing large Type A assisted living facility and in each separate building containing resident sleeping rooms, except as permitted under paragraph (1) of this subsection.(1) An existing large Type A assisted living facility that is not more than two stories in height and is composed of separate buildings grouped together and connected by covered walks, is not required to provide a staff area on each floor or in each building, provided that a staff area is located not more than 200 feet walking distance from the farthest resident living unit.(2) An existing large Type A assisted living facility must provide the following at each staff area:(A) a desk or writing surface;(B) a telephone; and(C) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.135 of this division (relating to Fire Protection Systems Requirements for an Existing Large Type A Assisted Living Facility).(f) Resident toilet and bathing facilities. An existing large Type A assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room.(1) An existing large Type A assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) An existing large Type A assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) An existing large Type A assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.137 of this division (relating to Mechanical Requirements for an Existing Large Type A Assisted Living Facility).(g) Resident living areas.(1) An existing large Type A assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) An existing large Type A assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) An existing large Type A assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) An existing large Type A assisted living facility must ensure the total space for social-diversional areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement. Attached Graphic(2) An existing large Type A assisted living facility must provide a dining area with appropriate furniture.(A) An existing large Type A assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) An existing large Type A assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) An existing large Type A assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) An existing large Type A assisted living facility must ensure the total space for dining areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement.Attached Graphic(3) An existing large Type A assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) For calculation purposes, where a means of egress passes through a living or dining area, an existing large Type A assisted living facility must deduct a pathway, equal to the minimum corridor width, according to §553.133 of this division (relating to Means of Egress Requirements for an Existing Large Type A Assisted Living Facility), from the measured area of the space.(5) An existing large Type A assisted living facility must ensure a means of egress through a resident living or dining area is kept clear of obstructions, except as permitted by NFPA 101.(6) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, an existing large Type A assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social-diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) An existing large Type A assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. An existing large Type A assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) General kitchen.(1) An existing large Type A assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner.(2) An existing large Type A assisted living facility must ensure a kitchen meets the requirements of the local fire, building, and health codes.(3) An existing large Type A assisted living facility that prepares food on-site must provide a kitchen or dietary area to meet the general food service needs of the residents and must include space for:(A) storage, refrigeration, preparation, and serving food;(B) dish and utensil cleaning, which includes:(i) a three-compartment sink large enough to immerse pots and pans; and(ii) a mechanical dishwasher for washing and sanitizing dishes;(C) a food preparation sink;(D) a handwashing station in every food preparation area with a supply of hot and cold water, soap, a towel dispenser and a waste receptacle;(E) a handwashing lavatory that is readily accessible to every dish room area;(F) refuse storage and removal;(G) floor drains in the kitchen and dishwashing areas, unless the facility was licensed before January 6, 2014, and the facility can keep the floor clean; and(H) a grease trap, if required by local authorities.(4) An existing large Type A assisted living facility must ensure a kitchen is designed so that room temperature, at peak load or in the summer, does not exceed 85 degrees Fahrenheit measured throughout the room at five feet above the floor.(5) An existing large Type A assisted living facility must ensure the volume of supply air provided takes into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(6) An existing large Type A assisted living facility must provide a supply of hot and cold water.(A) Hot water for sanitizing purposes must be 180 degrees Fahrenheit.(B) When chemical sanitizers are used, hot water must meet the manufacturer's suggested temperature.(7) An existing large Type A assisted living facility must maintain a separation between soiled and clean dish areas.(8) An existing large Type A assisted living facility must maintain a separation of air flow between soiled and clean dish areas.(j) Kitchen restrooms.(1) An existing large Type A assisted living facility must provide a restroom facility for kitchen staff, including a lavatory, except as described in paragraph (2) of this subsection.(A) The restroom facility must be directly accessible to kitchen staff without traversing resident-use areas. (B) The restroom must open into a service corridor or vestibule and not open directly into the kitchen. (2) An existing large Type A assisted living facility licensed before January 6, 2014, may provide a staff restroom that may be located outside the kitchen area.(k) Kitchen janitorial facility.(1) An existing large Type A assisted living facility must provide janitorial facilities exclusively for the kitchen and located in the kitchen area, except as described in paragraph (2) of this subsection.(2) An existing large Type A assisted living facility licensed before January 6, 2014, must provide a janitorial facility for the kitchen. The janitorial facility may be located outside the kitchen if sanitary procedures are used to reduce the possibility of cross-contamination.(3) An existing large Type A assisted living facility must provide a garbage can or cart washing area with a floor drain and a supply of hot water. The garbage can or cart washing area may be in the interior or on the exterior of the facility.(4) An existing large Type A assisted living facility must provide floor drains in the kitchen and dishwashing areas unless the facility was licensed before January 6, 2014, and the facility can keep the floors clean.(5) If required by local authorities, an existing large Type A assisted living facility must provide a grease trap.(l) Finishes.(1) An existing large Type A assisted living facility must provide non-absorbent, smooth finishes or surfaces on all kitchen floors, walls and ceilings. (2) An existing large Type A assisted living facility must provide non-absorbent, smooth, cleanable finishes on counter surfaces and all cabinet surfaces.(3) An existing large Type A assisted living facility must ensure surfaces are capable of being routinely cleaned and sanitized to maintain a healthful environment.(m) Vision panels in communicating doors.(1) An existing large Type A assisted living facility must ensure a door between a kitchen and a dining area, serving area, or resident-use area, is provided with a vision panel with fixed safety glass. Where the door is a required fire door or is located in a fire barrier or other fire resistance-rated enclosure, the vision panel, including the glazing and the frame, must meet the requirements of NFPA 101.(2) Existing doors between kitchens and adjacent spaces that are not provided with vision panels may be continued in service, subject to approval by HHSC.(n) Auxiliary serving kitchens.(1) An existing large Type A assisted living facility must ensure an auxiliary serving kitchen is equipped to maintain required food temperatures.(2) An existing large Type A assisted living facility must ensure an auxiliary serving kitchen is equipped with a handwashing lavatory meeting the requirements of this section.(3) An existing large Type A assisted living facility must ensure all surfaces in an auxiliary serving kitchen meet the requirements for finishes in this section.(o) Protection of cooking operations. (1) An existing large Type A assisted living facility must protect cooking facilities using commercial or residential cooking equipment for meal preparation as commercial cooking operations, according to the requirements for commercial cooking equipment in §553.136 of this division (relating to Hazardous Area Requirements for an Existing Large Type A Assisted Living Facility).(2) The following commercial or residential cooking equipment used only for reheating, and not for meal preparation, is not required to comply with the requirements of §553.136 of this division:(A) microwave ovens;(B) hot plates; or(C) toasters.(p) Food storage areas.(1) An existing large Type A assisted living facility must provide a food storage area large enough to consistently maintain a four-day minimum supply of non-perishable food. A food storage area may be located away from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(2) An existing large Type A assisted living facility must provide dollies, racks, pallets, wheeled containers, or shelving, so that food is not stored on the floor.(A) An existing large Type A assisted living facility must ensure shelves are adjustable wire type shelving.(B) An existing large Type A assisted living facility licensed before January 6, 2014, may use wood shelves provided the shelves are sealed and clean.(3) An existing large Type A assisted living facility must provide non-absorbent finishes or surfaces on all floors and walls in food storage areas.(4) An existing large Type A assisted living facility must provide effective ventilation in dry food storage areas to ensure positive air circulation. (5) An existing large Type A assisted living facility must ensure the maximum room temperature in a food storage area does not exceed 85 degrees Fahrenheit at any time, when measured at the highest food storage level, but not less than five feet above the floor.(q) Laundry and linen services.(1) An existing large Type A assisted living facility that co-mingles and processes laundry on-site in a central location, regardless of the type of laundry equipment used, must ensure a laundry area:(A) is separated from the assisted living building by a fire barrier having a one-hour fire resistance rating, and this separation must extend from the floor to the floor or roof above;(B) is protected throughout by a fire sprinkler system;(C) has access doors that open to the exterior or to an interior non-resident use area, such as a vestibule or service corridor; and(D) is provided with:(i) a soiled linen receiving, holding, and sorting room with a floor drain and forced exhaust to the exterior that;(I) must always operate when soiled linen is held in this area; and(II) may be combined with the washer section;(ii) a general laundry work area that is separated by partitioning a washer section and a dryer section;(iii) a storage area for laundry supplies;(iv) a folding area;(v) an adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire barrier separation required by subparagraph (1)(A) of this subsection; and(vi) provisions to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) If linen is processed off site, the facility must provide:(A) a soiled linen holding room with adequate forced exhaust ducted to the exterior; and(B) a clean linen receiving, holding, inspection, sorting or folding, and storage room.(3) An existing large Type A assisted living facility must ensure a laundry area for resident-use meets the following requirements. (A) An existing large Type A assisted living facility must ensure only residential type washers and dryers are provided in a laundry area for resident-use.(B) When more than three washers and three dryers are provided in one laundry area for resident use, the area must be:(i) protected throughout by a fire sprinkler system; or(ii) separated from the facility by a fire barrier having a one-hour fire resistance rating. Source Note: The provisions of this §553.132 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.132 Space Planning and Utilization Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206035 03/12/2026 (a) An existing large Type A assisted living facility must meet the requirements of 33.3.2, Means of Egress, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, except as described in this section.(b) The provisions of 33.3.2.11.2, Lockups, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, are not permitted.(c) An existing large Type A assisted living facility must ensure doors meet the requirements of 33.3.2.2.2, Doors, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, and the additional requirements of this section.(1) A resident room door in an existing large Type A assisted living facility must latch in its frame to resist the passage of smoke.(2) In an existing large Type A assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) An existing large Type A assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs and must ensure stairs used as a means of egress meet the requirements of 33.3.2.2.3, Stairs, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(e) An existing large Type A assisted living facility must ensure means of egress are marked according to the requirements of 33.3.2.10, Marking of Means of Egress, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(f) An existing large Type A assisted living facility containing more than 25 sleeping rooms must provide emergency lighting, according to the requirements of 33.3.2.9, Emergency Lighting, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, unless each sleeping room has a direct exit to the outside at the finished ground level. Source Note: The provisions of this §553.133 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.133 Means of Egress Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206036 03/12/2026 (a) An existing large Type A assisted living facility must meet the requirements of 33.3.3.6, Corridors and Separation of Sleeping Rooms, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing large Type A assisted living facility must meet the requirements of 33.3.3.7, Subdivision of Building Spaces, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies. Source Note: The provisions of this §553.134 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.134 Smoke Compartmentation for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206037 03/12/2026 (a) Fire alarm and smoke detection system. An existing large Type A assisted living facility must provide a manual fire alarm system meeting the requirements of 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. An existing large Type A assisted living facility must ensure the operation of any alarm initiating device automatically activates an audible or a visual alarm at the site.(2) Smoke detectors.(A) An existing large Type A assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) - (D) of this paragraph.(B) An existing large Type A assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) An existing large Type A assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 19, Existing Health Care Occupancies, may install a smoke detection system meeting the requirements of 19.3.4.5.1, Corridors, in NFPA 101, Chapter 19, Existing Health Care Occupancies, in lieu of the requirements found in subparagraphs (A) and (B) of this paragraph.(D) An existing large Type A assisted living facility comprised of buildings containing living units with independent cooking equipment must additionally have:(i) a smoke detector installed all in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens and laundries within the living unit, that sounds an alarm only within the living unit; and(ii) a heat detector installed in the kitchen within the living unit that activates the general alarm.(3) Alarm control panel.(A) An existing large Type A assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) An existing large Type A assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(C) An existing large Type A assisted living facility must ensure a fire alarm panel indicates each floor and smoke compartment, as applicable, as a separate zone. Each zone must provide an alarm and trouble indication. When all alarm initiating devices are addressable and the status of each device is identified on the fire alarm panel, zone indication is not required.(4) Fire alarm power source.(A) An existing large Type A assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) An existing large Type A assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(5) Emergency forces notification. An existing large Type A assisted living facility not equipped with a fire alarm system that automatically notifies emergency forces must immediately notify the fire department by telephone or other means.(b) Fire sprinkler system.(1) An existing large Type A assisted living facility may provide a fire sprinkler system meeting the requirements of NFPA 13 in accordance with 33.3.3.5.1, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(2) An existing large Type A assisted living facility located in a building that is four or fewer stories in height may provide a fire sprinkler system meeting the requirements of NFPA 13R in accordance with 33.3.3.5.1.1, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(3) An existing large Type A assisted living facility located in a high-rise building must be protected throughout by an approved, supervised automatic fire sprinkler system meeting the requirements of NFPA 13 according to 33.3.3.5.3, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(c) Protection of attics. An existing large Type A assisted living facility equipped with a fire sprinkler system must ensure an attic is protected according to the requirements of 33.3.3.5.4, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies, not later than August 31, 2024.(d) Portable fire extinguishers. An existing large Type A assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) An existing large Type A assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) An existing large Type A assisted living facility must ensure portable fire extinguishers are located in resident corridors so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) An existing large Type A assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:5-B:C according to NFPA 10.(C) A facility must provide at least one approved 20-B:C portable fire extinguisher in each laundry, kitchen and walk-in mechanical room.(4) An existing large Type A assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) An existing large Type A assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) An existing large Type A assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the exit access door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.135 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.135 Fire Protection Systems Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206038 03/12/2026 (a) An existing large Type A assisted living facility must meet the requirements of 33.3.3.2, Hazardous Areas, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(b) An existing large Type A assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) An existing large Type A assisted living facility using commercial cooking equipment must protect cooking facilities, other than those in individual resident living units, in accordance with the requirements of NFPA 96. Source Note: The provisions of this §553.136 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.136 Hazardous Area Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206039 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. An existing large Type A assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. An existing large Type A assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) An existing large Type A assisted living facility must provide at least one water closet and one lavatory for every six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) An existing large Type A assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) An existing large Type A assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) An existing large Type A assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, an existing large Type A assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) An existing large Type A assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. An existing large Type A assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. An existing large Type A assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Public and staff-use plumbing fixtures. In addition to the staff toilets required for the dietary staff according to §553.132(j) of this division (relating to Space Planning and Utilization Requirements for an Existing Large Type A Assisted Living Facility), an existing large Type A assisted living facility must provide toilets, including water closets and lavatories, for use by the public and by facility staff as follows:(1) if licensed for 60 or fewer residents, a toilet for use by the public and by facility staff; or(2) if licensed for more than 60 residents, a toilet for use by the public and a separate toilet for use by facility staff.(d) Gas. An existing large Type A assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(e) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. An existing large Type A assisted living facility must ensure HVAC equipment meets the requirements of 33.3.6.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 33, Existing Residential Board and Care Occupancies.(2) Heating and cooling. An existing large Type A assisted living facility must provide heating and cooling for resident comfort.(A) An existing large Type A assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) An existing large Type A assisted living facility constructed or licensed after August 1, 2004, must have a central air-conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain a temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) An existing large Type A assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this section.(D) An existing large Type A assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(v) A fuel-fired heating device not meeting the requirements of clauses (i) - (iv) of this subparagraph may be continued in service, subject to approval by HHSC.(E) An existing large Type A assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A new working fireplace must be installed, maintained and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and,(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material;(vii) An existing working fireplace not meeting the requirements of clauses (i) - (vi) of this subparagraph may be continued in service, subject to approval by HHSC.(3) Ventilation.(A) An existing large Type A assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) An existing large Type A assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. An existing large Type A assisted living facility must ensure bathrooms, toilet rooms, janitorial facilities, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.137 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.137 Mechanical Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206040 03/12/2026 (a) Electrical system. An existing large Type A assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. An existing large Type A assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. An existing large Type A assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. An existing large Type A assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system or intercom;(B) if it is an existing communication system, be approved by HHSC to be continued in service;(C) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) An existing large Type A assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) An existing large Type A assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.138 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.138 Electrical Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206041 03/12/2026 An existing large Type A assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located. Source Note: The provisions of this §553.139 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.139 Miscellaneous Requirements for an Existing Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206042 03/12/2026 An existing large Type B assisted living facility must comply with the requirements for a limited care facility in NFPA 101, Chapter 19, Existing Health Care Occupancies, except as modified by this division. Source Note: The provisions of this §553.140 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.140 General Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206043 03/12/2026 (a) Structurally sound. An existing large Type B assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads according to applicable building codes.(b) Separation of occupancies. An existing large Type B assisted living facility must be separated from other occupancies by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards, unless otherwise permitted by paragraphs (1) or (2) of this subsection.(1) An existing large Type B assisted living facility is not required to be separated from a hospital or nursing facility unless the separation is required by NFPA 101 or the standards for licensing the hospital or nursing facility. Beginning August 31, 2021, an existing large Type B assisted living facility must be separated from any new occupancy or new use subject to the Texas Health and Human Services Commission (HHSC) licensing.(2) An existing large Type B assisted living facility is not required to be separated from another occupancy not subject to HHSC licensing standards if the two occupancies are so intermingled that construction of a fire barrier having a 2-hour fire resistance rating is impractical and the following conditions are met.(A) The means of egress, construction, protection, and other safeguards for the entire building must comply with the NFPA 101 requirements for an existing large Type B assisted living facility.(B) HHSC must be given unrestricted and unannounced access at any reasonable time to inspect the other occupancy type for compliance with the NFPA 101 requirements for an existing large Type B assisted living facility.(c) Construction type. An existing large Type B assisted living facility must ensure a building housing the facility meets the requirements of 19.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(d) Interior finish. An existing Large Type B assisted living facility must ensure interior wall, ceiling and floor finish materials meet the requirements of 19.3.3, Interior Finish, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(e) Vertical openings. An existing large Type B assisted living facility must ensure vertical openings are protected according to the requirements of 19.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 19, Existing Health Care Occupancies. Source Note: The provisions of this §553.141 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.141 Construction Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206044 03/12/2026 (a) Resident bedrooms.(1) An existing large Type B assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) An existing large Type B assisted living facility must ensure bedroom usable floor space is not less than 100 square feet for a bedroom housing one resident and not less than 80 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than 10 feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by the Texas Health and Human Services Commission (HHSC).(3) An existing large Type B assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. An existing large Type B assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(6) of this section.(4) An existing large Type B assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. An existing large Type B assisted living facility must ensure each bedroom has at least one operable window, with outside exposure, that meets the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by a resident occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space required by subsection (a)(2) of this section.(4) An existing bedroom window that does not meet these requirements may be continued in service, subject to approval by HHSC.(c) Bedroom furnishings. When a resident does not provide their own furnishings, an existing large Type B assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) An existing large Type B assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) An existing large Type B assisted living facility must ensure all resident rooms are arranged for convenient resident access to dining and recreation areas.(e) Staff area. An existing large Type B assisted living facility must provide a staff area on each floor of an existing large Type B assisted living facility and in each separate building containing resident sleeping rooms. An existing large Type B assisted living facility must provide the following at each staff area:(1) a desk or writing surface;(2) a telephone; and(3) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.145 of this division (relating to Fire Protection Systems Requirements for an Existing Large Type B Assisted Living Facility).(f) Resident toilet and bathing facilities. An existing large Type B assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room.(1) An existing large Type B assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) An existing large Type B assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) An existing large Type B assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.147 of this division (relating to Mechanical Requirements for an Existing Large Type B Assisted Living Facility).(g) Resident living areas.(1) An existing large Type B assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) An existing large Type B assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) An existing large Type B assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) An existing large Type B assisted living facility must ensure the total space for social-diversional areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement. Attached Graphic(2) An existing large Type B assisted living facility must provide a dining area with appropriate furniture.(A) An existing large Type B assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) An existing large Type B assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) An existing large Type B assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) An existing large Type B assisted living facility must ensure the total space for dining areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement.Attached Graphic(3) An existing large Type B assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) For calculation purposes, where a means of egress passes through a living or dining area, an existing large Type B assisted living facility must deduct a pathway, equal to the minimum corridor width, according to §553.143 of this division (relating to Means of Egress Requirements for an Existing Large Type B Assisted Living Facility), from the measured area of the space. (5) An existing large Type B assisted living facility must ensure a means of egress through a resident living or dining area is kept clear of obstructions, except as permitted by NFPA 101.(6) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, an existing large Type B assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social-diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) An existing large Type B assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. An existing large Type B assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) General kitchen.(1) An existing large Type B assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner. (2) An existing large Type B assisted living facility must ensure a kitchen meets the requirements of the local fire, building, and health codes.(3) An existing large Type B assisted living facility that prepares food on-site must provide a kitchen or dietary area to meet the general food service needs of the residents and must include space for:(A) storage, refrigeration, preparation, and serving of food;(B) dish and utensil cleaning, which includes:(i) a three compartment sink large enough to immerse pots and pans; and(ii) a mechanical dishwasher for washing and sanitizing dishes;(C) a food preparation sink;(D) a handwashing station in every food preparation area with a supply of hot and cold water, soap, a towel dispenser, and a waste receptacle;(E) a handwashing lavatory that is readily accessible to every dish room area;(F) refuse storage and removal;(G) floor drains in the kitchen and dishwashing areas, unless the facility was licensed before January 6, 2014, and the facility can keep the floor clean; and(H) a grease trap, if required by local authorities.(4) An existing large Type B assisted living facility must ensure a kitchen is designed so that room temperature, at peak load or in the summer, does not exceed 85 degrees Fahrenheit, measured throughout the room at five feet above the floor.(5) An existing large Type B assisted living facility must ensure the volume of supply air provided takes into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(6) An existing large Type B assisted living facility must provide a supply of hot and cold water.(A) Hot water for sanitizing purposes must be 180 degrees Fahrenheit.(B) When chemical sanitizers are used, hot water must meet the manufacturer's suggested temperature.(7) An existing large Type B assisted living facility must maintain a separation between soiled and clean dish areas.(8) An existing large Type B assisted living facility must maintain a separation of air flow between soiled and clean dish areas.(j) Kitchen restrooms.(1) An existing large Type B assisted living facility must provide a restroom facility for kitchen staff, including a lavatory, except as described in paragraphs (2) and (3) of this subsection.(A) The restroom facility must be directly accessible to kitchen staff without traversing resident-use areas.(B) The restroom must open into a service corridor or vestibule and not open directly into the kitchen.(2) An existing large Type B assisted living facility licensed before January 6, 2014, may provide a staff restroom located outside the kitchen area.(3) An existing large Type B assisted living facility must ensure a kitchen serving a neighborhood or household provides a restroom accessible to kitchen staff that is in close proximity to the kitchen.(k) Kitchen janitorial facility.(1) An existing large Type B assisted living facility must provide janitorial facilities exclusively for the kitchen and located in the kitchen area, except as described in paragraphs (2) and (3) of this subsection.(2) An existing large Type B assisted living facility licensed before January 6, 2014, must provide a janitorial facility for the kitchen. The janitorial facility may be located outside the kitchen if sanitary procedures are used to reduce the possibility of cross-contamination.(3) An existing large Type B assisted living facility must ensure a kitchen serving a neighborhood or household provides a janitorial facility exclusively for the kitchen that is close to the kitchen.(4) An existing large Type B assisted living facility must provide a garbage can or cart washing area with a floor drain and a supply of hot water. The garbage can or cart washing area may be in the interior or on the exterior of the facility.(5) An existing large Type B assisted living facility must provide floor drains in the kitchen and dishwashing areas, unless the facility was licensed before January 6, 2014, and the facility can keep the floors clean.(6) If required by local authorities, an existing large Type B assisted living facility must provide a grease trap.(l) Finishes.(1) An existing large Type B assisted living facility must provide non-absorbent, smooth finishes or surfaces on all kitchen floors, walls, and ceilings.(2) An existing large Type B assisted living facility must provide non-absorbent, smooth, cleanable finishes on counter surfaces and all cabinet surfaces.(3) An existing large Type B assisted living facility must ensure surfaces are capable of being routinely cleaned and sanitized to maintain a healthful environment.(m) Vision panels in communicating doors.(1) An existing large Type B assisted living facility must ensure a door between a kitchen and a dining, serving, or resident-use area is provided with a vision panel with fixed safety glass. Where the door is a required fire door or is in a fire barrier or other fire resistance-rated enclosure, the vision panel, including the glazing and the frame, must meet the requirements of NFPA 101.(2) Existing doors between kitchens and adjacent spaces that are not provided with vision panels may be continued in service subject to approval by HHSC.(n) Auxiliary serving kitchens.(1) An existing large Type B assisted living facility must ensure an auxiliary serving kitchen is equipped to maintain required food temperatures.(2) An existing large Type B assisted living facility must ensure an auxiliary serving kitchen is equipped with a handwashing lavatory meeting the requirements of this section.(3) An existing large Type B assisted living facility must ensure all surfaces in an auxiliary serving kitchen meet the requirements for finishes in this section.(o) Protection of cooking operations. (1) An existing large Type B assisted living facility must protect cooking facilities according to the requirements in §553.146 of this division (relating to Hazardous Area Requirements for an Existing Large Type B Assisted Living Facility) except as provided for in paragraph (3) of this subsection.(2) The following commercial or residential cooking equipment used only for reheating, and not for meal preparation, is not required to comply with the requirements of §553.146 of this division:(A) microwave ovens;(B) hot plates; or(C) toasters.(3) A facility providing a kitchen serving a neighborhood or household may continue to operate the kitchen without modification subject to approval by HHSC.(p) Food storage areas.(1) An existing large Type B assisted living facility must provide a food storage area large enough to consistently maintain a four-day minimum supply of non-perishable food. A food storage area may be located away from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(2) An existing large Type B assisted living facility must provide dollies, racks, pallets, wheeled containers, or shelving so that food is not stored on the floor.(A) An existing large Type B assisted living facility must ensure shelves are adjustable wire type shelving.(B) An existing large Type B assisted living facility licensed before January 6, 2014, may use wood shelves provided the shelves are sealed and clean.(3) An existing large Type B assisted living facility must provide non-absorbent finishes or surfaces on all floors and walls in food storage areas.(4) An existing large Type B assisted living facility must provide effective ventilation in dry food storage areas to ensure positive air circulation.(5) An existing large Type B assisted living facility must ensure the maximum room temperature in a food storage area does not exceed 85 degrees Fahrenheit at any time when measured at the highest food storage level, but not less than five feet above the floor.(q) Laundry and linen services.(1) An existing large Type B assisted living facility that co-mingles and processes laundry on-site in a central location, regardless of the type of laundry equipment used, must ensure a laundry area:(A) is separated from the assisted living building by a fire barrier having a one-hour fire resistance rating, which must extend from the floor to the floor or roof above:(B) is protected throughout by a fire sprinkler system;(C) has access doors that open to the exterior or to an interior non-resident use area, such as a vestibule or service corridor; and(D) is provided with:(i) a soiled linen receiving, holding, and sorting room with a floor drain and forced exhaust to the exterior which;(I) must always operate when soiled linen is held in this area; and(II) may be combined with the washer section;(ii) a general laundry work area that is separated by partitioning a washer section and a dryer section with;(iii) a storage area for laundry supplies;(iv) a folding area;(v) an adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire barrier separation required by paragraph (1)(A) of this subsection; and(vi) provisions to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) If linen is processed off site, the facility must provide:(A) a soiled linen holding room with adequate forced exhaust ducted to the exterior; and(B) a clean linen receiving, holding, inspection, sorting or folding, and storage room.(3) An existing large Type B assisted living facility must ensure a laundry area for resident-use meets the following requirements. (A) An existing large Type B assisted living facility must ensure only residential type washers and dryers are provided in a laundry area for resident-use.(B) When more than three washers and three dryers are provided in one laundry area for resident-use, the area must be:(i) protected throughout by a fire sprinkler system; or(ii) separated from the facility by a fire barrier having a one-hour fire resistance rating. Source Note: The provisions of this §553.142 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.142 Space Planning and Utilization Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206045 03/12/2026 (a) An existing large Type B assisted living facility must meet the requirements of 19.2, Means of Egress, in NFPA 101, Chapter 19, Existing Health Care Occupancies, except as described in this section.(b) An existing large Type B assisted living facility must ensure doors meet the requirements of 19.2.2.2, Doors, in NFPA 101, Chapter 19, Existing Health Care Occupancies, and the additional requirements of this section.(1) A resident room door in an existing large Type B assisted living facility must latch in its frame to resist the passage of smoke.(2) In an existing large Type B assisted living facility comprised of buildings containing living units, with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(c) An existing large Type B assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs and must ensure stairs used as a means of egress meet the requirements of 19.2.2.3, Stairs, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(d) An existing large Type B assisted living facility must ensure means of egress are marked according to the requirements of 19.2.10, Marking of Means of Egress, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(e) An existing large Type B assisted living facility must provide emergency lighting according to the requirements of 19.2.9, Emergency Lighting, in NFPA 101, Chapter 19, Existing Health Care Occupancies. Source Note: The provisions of this §553.143 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.143 Means of Egress Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206046 03/12/2026 (a) An existing large Type B assisted living facility must meet the requirements of 19.3.6, Corridors, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(b) An existing large Type B assisted living facility must meet the requirements of 19.3.7, Subdivision of Building Spaces, in NFPA 101, Chapter 19, Existing Health Care Occupancies. Source Note: The provisions of this §553.144 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.144 Smoke Compartmentation for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206047 03/12/2026 (a) Fire alarm and smoke detection system. An existing large Type B assisted living facility must provide a fire alarm system meeting the requirements of 19.3.4, Detection, Alarm, and Communications Systems, in NFPA 101, Chapter 19, Existing Health Care Occupancies, as modified by this section.(1) General. An existing large Type B assisted living facility must ensure the operation of any alarm initiating device automatically activates an audible or a visual alarm at the site.(2) Smoke detectors.(A) An existing large Type B assisted living facility must install smoke detectors meeting the requirements of 19.3.4.5.1, Corridors, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(B) An existing large Type B assisted living facility comprised of buildings containing living units with independent cooking equipment must additionally have:(i) a smoke detector installed in all resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, and laundries within the living unit that sounds an alarm only within the living unit; and(ii) a heat detector installed in the kitchen within the living unit that activates the general alarm.(3) Alarm control panel.(A) An existing large Type B assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) An existing large Type B assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(C) An existing large Type B assisted living facility must ensure a fire alarm panel indicates each floor and smoke compartment, as applicable, as a separate zone. Each zone must provide an alarm and trouble indication. When all alarm initiating devices are addressable and the status of each device is identified on the fire alarm panel, zone indication is not required.(4) Fire alarm power source.(A) An existing large Type B assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) An existing large Type B assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(5) Emergency forces notification. An existing large Type B assisted living facility must ensure a fire alarm system automatically notifies emergency forces according to the requirements of 19.3.4.3.2, Emergency Forces Notification, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(b) Fire sprinkler system. An existing large Type B assisted living facility must provide a fire sprinkler system meeting the requirements of NFPA 13 in accordance with 19.3.5.3, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(c) Portable Fire Extinguishers. An existing large Type B assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) An existing large Type B assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) An existing large Type B assisted living facility must ensure portable fire extinguishers are located in resident corridors so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) An existing large Type B assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:5-B:C according to NFPA 10.(C) A facility must provide at least one approved 20-B:C portable fire extinguisher in each laundry, kitchen, and walk-in mechanical room.(4) An existing large Type B assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) An existing large Type B assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) An existing large Type B assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the exit access door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.145 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.145 Fire Protection Systems Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206048 03/12/2026 (a) An existing large Type B assisted living facility must meet the requirements of 19.3.2, Protection from Hazards, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(b) An existing large Type B assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) An existing large Type B assisted living facility must protect any cooking operation according to the requirements of 19.3.2.5, Cooking Facilities, in NFPA 101, Chapter 19, Existing Health Care Occupancies. Source Note: The provisions of this §553.146 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.146 Hazardous Area Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206049 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. An existing large Type B assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. An existing large Type B assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) An existing large Type B assisted living facility must provide at least one water closet and one lavatory for each six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) An existing large Type B assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) An existing large Type B assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) An existing large Type B assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, an existing large Type B assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) An existing large Type B assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. An existing large Type B assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. An existing large Type B assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Public and staff-use plumbing fixtures. In addition to the staff toilets required for the dietary staff according to §553.142(j) of this division (relating to Space Planning and Utilization Requirements for an Existing Large Type B Assisted Living Facility), a new large Type B assisted living facility must provide toilets, including water closets and lavatories, for use by the public and by facility staff, as follows:(1) if licensed for 60 or fewer residents, a toilet for use by the public and by facility staff; or(2) if licensed for more than 60 residents, a toilet for use by the public and a separate toilet for use by facility staff.(d) Gas. An existing large Type B assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(e) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. An existing large Type B assisted living facility must ensure HVAC equipment meets the requirements of 19.5.2, Heating, Ventilating and Air-Conditioning, in NFPA 101, Chapter 19, Existing Health Care Occupancies.(2) Heating and cooling. An existing large Type B assisted living facility must provide heating and cooling for resident comfort.(A) An existing large Type B assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) An existing large Type B assisted living facility constructed or licensed after August 1, 2004, must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain a temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) An existing large Type B assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this paragraph.(D) An existing large Type B assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(v) A fuel-fired heating device not meeting the requirements of clauses (i) - (iv) of this subparagraph may be continued in service, subject to approval by HHSC.(E) An existing large Type B assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A new working fireplace must be installed, maintained and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(vii) An existing working fireplace not meeting the requirements of clauses (i) - (vi) of this subparagraph may be continued in service, subject to approval by HHSC.(3) Ventilation.(A) An existing large Type B assisted living facility must be ventilated using windows or mechanical ventilation, or a combination of both.(B) An existing large Type B assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. An existing large Type B assisted living facility must ensure bathrooms, toilet rooms, janitorial facilities, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.147 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.147 Mechanical Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206050 03/12/2026 (a) Electrical system. An existing large Type B assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. An existing large Type B assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. An existing large Type B assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. An existing large Type B assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system, or intercom;(B) if it is an existing communication system, be approved by the Texas Health and Human Services Commission to be continued in service; and(C) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) An existing large Type B assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) An existing large Type B assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.148 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.148 Electrical Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206051 03/12/2026 An existing large Type B assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located. Source Note: The provisions of this §553.149 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.149 Miscellaneous Requirements for an Existing Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206052 03/12/2026 A new small Type A assisted living facility must comply with the requirements in 32.2, Small Facilities, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, where referenced by this division. Source Note: The provisions of this §553.210 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.210 General Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206053 03/12/2026 (a) Structurally sound. A new small Type A assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads according to applicable building codes.(b) Separation of occupancies. A new small Type A assisted living facility must be separated from other occupancies including other assisted living facilities, hospitals, or nursing facilities, by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards.(c) Sheathing.(1) Except as provided in paragraph (3) of this subsection a new small Type A assisted living facility must ensure all buildings used by residents are sheathed with materials providing a fire resistance rating as follows.(A) Interior wall and ceiling surfaces must have finished surfaces, substrates, or sheathing with a fire resistance rating of not less than 20 minutes.(B) Columns, beams, girders, or trusses that are not enclosed within walls or ceilings must be encased in materials having a fire resistance rating of not less than 20 minutes.(2) A sprinkler system does not substitute for the minimum sheathing requirements under paragraph (1) of this subsection.(3) A building constructed to meet the minimum building construction type requirements of 18.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 18, New Health Care Occupancies, is not also required to be sheathed.(d) Interior finish. A new small Type A assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 32.2.3.3.2, Interior Wall and Ceiling Finish, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(e) Vertical openings. A new small Type A assisted living facility must ensure vertical openings are protected according to the requirements of 32.2.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.211 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.211 Construction Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206054 03/12/2026 (a) Resident bedrooms.(1) A new small Type A assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) A new small Type A assisted living facility must ensure bedroom usable floor space is not less than 80 square feet for a bedroom housing one resident and not less than 60 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than eight feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by the Texas Health and Human Services Commission.(3) A new small Type A assisted living facility containing individual living units that include living space for the residents in addition to their bedrooms may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. A new small Type A assisted living facility may not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(5) of this section.(4) A new small Type A assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. A new small Type A assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by all residents occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space in subsection (a)(3) of this section.(c) Bedroom furnishings. When a resident does not provide their own furnishings, a new small Type A assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must include closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) A new small Type A assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) A new small Type A assisted living facility must ensure all resident rooms are arranged for convenient resident access to dining and recreation areas.(e) Staff area. A new small Type A assisted living facility must provide a staff area on each floor of a new small Type A assisted living facility and in each separate building containing resident sleeping rooms, except as permitted under paragraph (1) of this subsection.(1) A new small Type A assisted living facility that is not more than two stories in height and is composed of separate buildings grouped together and connected by covered walks, is not required to provide a staff area on each floor or in each building, provided that a staff area is located not more than 200 feet walking distance from the farthest resident living unit.(2) A new small Type A assisted living facility must provide the following at each staff area:(A) a desk or writing surface;(B) a telephone; and(C) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.215 of this division (relating to Fire Protection Systems Requirements for a New Small Type A Assisted Living Facility).(f) Resident toilet and bathing facilities. A new small Type A assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room.(1) A new small Type A assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) A new small Type A assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) A new small Type A assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.217 of this division (relating to Mechanical Requirements for a New Small Type A Assisted Living Facility).(g) Resident living areas.(1) A new small Type A assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) A new small Type A assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) A new small Type A assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) A new small Type A assisted living facility must ensure the total space for social-diversional area provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(2) A new small Type A assisted living facility must provide a dining area with appropriate furniture.(A) A new small Type A assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) A new small Type A assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) A new small Type A assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) A new small Type A assisted living facility must ensure the total space for dining areas provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(3) A new small Type A assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) A new small Type A assisted living facility must ensure an escape route through a resident living or dining area is kept clear of obstructions.(5) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, a new small Type A assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) A new small Type A assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. A new small Type A assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) Kitchen.(1) A new small Type A assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner.(2) A new small Type A assisted living facility that prepares food on-site must provide a kitchen or dietary area meeting the general food service needs of the residents and must ensure that the kitchen:(A) is equipped to store, refrigerate, prepare and serve food;(B) is equipped to clean and sterilize;(C) provides for refuse storage and removal; and(D) meets the requirements of the local fire, building, and health codes.(3) A new small Type A assisted living facility must ensure a kitchen uses only residential cooking equipment or, if the kitchen uses commercial cooking equipment, that the facility protects the kitchen's cooking operations as required in §553.216 of this division (relating to Hazardous Area Requirements for a New Small Type A Assisted Living Facility). Source Note: The provisions of this §553.212 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.212 Space Planning and Utilization Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206055 03/12/2026 (a) The provisions of NFPA 101, Chapter 7, Means of Egress, do not apply to a new small Type A assisted living facility, unless explicitly referenced by this section or by NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new small Type A assisted living facility must meet the requirements of 32.2.2, Means of Escape, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, except as described in this section.(c) A new small Type A assisted living facility must ensure doors meet the requirements of 32.2.2.5, Doors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, and the additional requirements of this section. A resident room door is not otherwise required to meet the requirements for doors in 32.2.3.6, Construction of Corridor Walls, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(1) A resident room door in a new small Type A assisted living facility must latch in its frame to resist the passage of smoke.(2) In a new small Type A assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) A new small Type A assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs.(1) A stair used as means of escape must meet the requirements of 32.2.2.6, Stairs, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Each stair must be arranged and located so that it is not necessary to go through another room, including a bedroom or bathroom, to reach the stair.(3) Each stair must be provided with handrails.(4) Each stair must be provided with normal lighting according to the requirements of §553.218 of this division (relating to Electrical Requirements for a New Small Type A Assisted Living Facility). Source Note: The provisions of this §553.213 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.213 Means of Escape Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206056 03/12/2026 (a) Fire alarm and smoke detection system. A new small Type A assisted living facility must provide a manual fire alarm system meeting the requirements of 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. A new small Type A assisted living facility must ensure the operation of any alarm initiating device automatically activates the manual fire alarm system evacuation alarm for the entire building.(2) Smoke detectors.(A) A new small Type A assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) and (C) of this paragraph.(B) A new small Type A assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) A new small Type A assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 18, New Health Care Occupancies, may install a smoke detection system meeting the requirements of 18.3.4.5.3, Nursing Homes, in NFPA 101, Chapter 18, New Health Care Occupancies, in lieu of the requirements found in subparagraph (A) of this paragraph.(3) Alarm control panel.(A) A new small Type A assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) A new small Type A assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(4) Fire alarm power source.(A) A new small Type A assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) A new small Type A assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(b) Fire sprinkler system.(1) A new small Type A assisted living facility must provide one of the following fire sprinkler systems according to the requirements of 32.2.3.5, Extinguishment Requirements, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(A) A fire sprinkler system meeting the requirements of NFPA 13 in accordance with 32.2.3.5.3;(B) A fire sprinkler system meeting the requirements of NFPA 13R in accordance with 32.2.3.5.3.1; or(C) A fire sprinkler system meeting the requirements of NFPA 13D in accordance with 32.2.3.5.3.2.(2) A new small Type A assisted living facility must provide electrical supervision of any fire sprinkler system according to the requirements of 32.2.3.5.4, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(c) Protection of attics. A new small Type A assisted living facility must ensure an attic is protected according to the requirements of 32.2.3.5.7, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(d) Portable fire extinguishers. A new small Type A assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) A new small Type A assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) A new small Type A assisted living facility must ensure portable fire extinguishers are located so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) A new small Type A assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:10-B:C according to NFPA 10.(4) A new small Type A assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) A new small Type A assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) A new small Type A assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.215 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.215 Fire Protection Systems Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206057 03/12/2026 (a) A new small Type A assisted living facility must ensure any space where storage or an activity produces a greater potential for a fully involved fire than that found in a one- or two-family dwelling is protected according to the requirements of 32.2.3.2, Hazardous Areas, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new small Type A assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) A new small Type A assisted living facility using commercial cooking equipment must protect the cooking operation according to the requirements of NFPA 96. Source Note: The provisions of this §553.216 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.216 Hazardous Area Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206058 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. A new small Type A assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. A new small Type A assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) A new small Type A assisted living facility must provide at least one water closet and one lavatory for every six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) A new small Type A assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) A new small Type A assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) A new small Type A assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, a new small Type A assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) A new small Type A assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. A new small Type A assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. A new small Type A assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Gas. A new small Type A assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(d) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. A new small Type A assisted living facility must ensure HVAC equipment meets the requirements of 32.2.5.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Heating and cooling. A new small Type A assisted living facility must provide heating and cooling for resident comfort.(A) A new small Type A assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) A new small Type A assisted living facility must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain the temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) A new small Type A assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this section.(D) A new small Type A assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(E) A new small Type A assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A working fireplace must be installed, maintained, and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(3) Ventilation.(A) A new small Type A assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) A new small Type A assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. A new small Type A assisted living facility must ensure bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.217 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.217 Mechanical Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206059 03/12/2026 (a) Electrical system. A new small Type A assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. A new small Type A assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. A new small Type A assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. A new small Type A assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system or intercom;(B) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) A new small Type A assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) A new small Type A assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.218 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.218 Electrical Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206060 03/12/2026 (a) A new small Type A assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located.(b) A new small Type A assisted living facility must ensure any new elevator, escalator, or conveyor meets the requirements of 32.2.5.3, Elevators, Escalators, and Conveyors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.219 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.219 Miscellaneous Requirements for a New Small Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206061 03/12/2026 A new small Type B assisted living facility must comply with the requirements in 32.2, Small Facilities, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, where referenced by this division. Source Note: The provisions of this §553.220 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.220 General Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206062 03/12/2026 (a) Structurally sound. A new small Type B assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads according to applicable building codes.(b) Separation of occupancies. A new small Type B assisted living facility must be separated from other occupancies, including other assisted living facilities, hospitals or nursing facilities, by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards.(c) Sheathing.(1) Except as provided in paragraph (3) of this subsection, a new small Type B assisted living facility must ensure all buildings used by residents are sheathed with materials providing a fire resistance rating as follows.(A) Interior wall and ceiling surfaces must have finished surfaces, substrates, or sheathing with a fire resistance rating of not less than 20 minutes.(B) Columns, beams, girders, or trusses that are not enclosed within walls or ceilings must be encased in materials having a fire resistance rating of not less than 20 minutes.(2) A sprinkler system does not substitute for the minimum sheathing requirements under paragraph (1) of this subsection.(3) A building constructed to meet the minimum building construction type requirements of 18.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 18, New Health Care Occupancies, is not also required to be sheathed.(d) Interior finish. A new small Type B assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 32.2.3.3.2, Interior Wall and Ceiling Finish, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(e) Vertical openings. A new small Type B assisted living facility must ensure vertical openings are protected according to the requirements of 32.2.3, Protection of Vertical Openings, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.221 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.221 Construction Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206063 03/12/2026 (a) Resident bedrooms.(1) A new small Type B assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) A new small Type B assisted living facility must ensure bedroom usable floor space is not less than 100 square feet for a bedroom housing one resident and not less than 80 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than 10 feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by the Texas Health and Human Services Commission.(3) A new small Type B assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. A new small Type B assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(5) of this section.(4) A new small Type B assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. A new small Type B assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by a resident occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space required by subsection (a)(3) of this section.(c) Bedroom furnishings. When a resident does not provide their own furnishings, a new small Type B assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms.(1) A new small Type B assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) A new small Type B assisted living facility must ensure all resident rooms are arranged for convenient resident access to dining and recreation areas.(e) Staff area. A new small Type B assisted living facility must provide a staff area on each floor of a new small Type B assisted living facility and in each separate building containing resident sleeping rooms. A new small Type B assisted living facility must provide the following at each staff area:(1) a desk or writing surface;(2) a telephone; and(3) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.225 of this division (relating to Fire Protection Systems Requirements for a New Small Type B Assisted Living Facility).(f) Resident toilet and bathing facilities. A new small Type B assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room.(1) A new small Type B assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) A new small Type B assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) A new small Type B assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.227 of this division (relating to Mechanical Requirements for a New Small Type B Assisted Living Facility).(g) Resident living areas.(1) A new small Type B assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms.(A) A new small Type B assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space.(B) A new small Type B assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside.(C) A new small Type B assisted living facility must ensure the total space for social-diversional area provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(2) A new small Type B assisted living facility must provide a dining area with appropriate furniture.(A) A new small Type B assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space.(B) A new small Type B assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) A new small Type B assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path.(D) A new small Type B assisted living facility must ensure the total space for dining areas provides an area of at least 15 square feet for each resident in the licensed capacity of the facility. No space smaller than 120 square feet in area can be counted toward meeting this requirement.(3) A new small Type B assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) A new small Type B assisted living facility must ensure an escape route through a resident living or dining area is kept clear of obstructions.(5) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, a new small Type B assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social-diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) A new small Type B assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. A new small Type B assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration;(2) medications and medical supplies;(3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses;(4) cleaning supplies, including for janitorial needs;(5) food;(6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) Kitchen.(1) A new small Type B assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner.(2) A new small Type B assisted living facility that prepares food on-site must provide a kitchen or dietary area meeting the general food service needs of the residents and must ensure that the kitchen:(A) is equipped to store, refrigerate, prepare, and serve food;(B) is equipped to clean and sterilize;(C) provides for refuse storage and removal; and(D) meets the requirements of the local fire, building, and health codes.(3) A new small Type B assisted living facility must ensure a kitchen uses only residential cooking equipment or, if the kitchen uses commercial cooking equipment, that the facility protects the kitchen's cooking operations, as required in §553.226 of this division (relating to Hazardous Area Requirements for a New Small Type B Assisted Living Facility). Source Note: The provisions of this §553.222 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.222 Space Planning and Utilization Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206064 03/12/2026 (a) The provisions of NFPA 101, Chapter 7, Means of Egress, do not apply to a new small Type B assisted living facility unless explicitly referenced by this section or by NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new small Type B assisted living facility must meet the requirements of 32.2.2, Means of Escape, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, except as described in this section.(c) A new small Type B assisted living facility must ensure doors meet the requirements of 32.2.2.5, Doors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, and the additional requirements of this section. A resident room door is not otherwise required to meet the requirements for doors in 32.2.3.6, Construction of Corridor Walls, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(1) A resident room door in a new small Type B assisted living facility must latch in its frame to resist the passage of smoke.(2) In a new small Type B assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) A new small Type B assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs.(1) A stair used as means of escape must meet the requirements of 32.2.2.6, Stairs, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Each stair must be arranged and located so that it is not necessary to go through another room, including a bedroom or bathroom, to reach the stair.(3) Each stair must be provided with handrails.(4) Each stair must be provided with normal lighting according to the requirements of §553.228 of this division (relating to Electrical Requirements for a New Small Type B Assisted Living Facility). Source Note: The provisions of this §553.223 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.223 Means of Escape Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206065 03/12/2026 (a) Fire alarm and smoke detection system. A new small Type B assisted living facility must provide a manual fire alarm system meeting the requirements of 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. A new small Type B assisted living facility must ensure the operation of any alarm initiating device automatically activates the manual fire alarm system evacuation alarm for the entire building.(2) Smoke detectors.(A) A new small Type B assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) and (C) of this paragraph.(B) A new small Type B assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) A new small Type B assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 18, New Health Care Occupancies, may install a smoke detection system meeting the requirements of 18.3.4.5.3, Nursing Homes, in NFPA 101, Chapter 18, New Health Care Occupancies, in lieu of the requirements found in subparagraph (A) of this paragraph.(3) Alarm control panel.(A) A new small Type B assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) A new small Type B assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(4) Fire alarm power source.(A) A new small Type B assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) A new small Type B assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(b) Fire sprinkler system.(1) A new small Type B assisted living facility must provide one of the following fire sprinkler systems according to the requirements of 32.2.3.5, Extinguishment Requirements, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(A) A fire sprinkler system meeting the requirements of NFPA 13 in accordance with 32.2.3.5.3;(B) A fire sprinkler system meeting the requirements of NFPA 13R in accordance with 32.2.3.5.3.1; or(C) A fire sprinkler system meeting the requirements of NFPA 13D in accordance with 32.2.3.5.3.2.(2) A new small Type B assisted living facility must provide electrical supervision of any fire sprinkler system according to the requirements of 32.2.3.5.4, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(c) Protection of attics. A new small Type B assisted living facility must ensure an attic is protected according to the requirements of 32.2.3.5.7, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(d) Portable fire extinguishers. A new small Type B assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) A new small Type B assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) A new small Type B assisted living facility must ensure portable fire extinguishers are located so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) A new small Type B assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:10-B:C according to NFPA 10.(4) A new small Type B assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) A new small Type B assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) A new small Type B assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.225 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.225 Fire Protection Systems Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206066 03/12/2026 (a) A new small Type B assisted living facility must ensure any space where storage or an activity produces a greater potential for a fully involved fire than that found in a one- or two-family dwelling is protected according to the requirements of 32.2.3.2, Hazardous Areas, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new small Type B assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) A new small Type B assisted living facility using commercial cooking equipment must protect the cooking operation according to the requirements of NFPA 96. Source Note: The provisions of this §553.226 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.226 Hazardous Area Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206067 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. A new small Type B assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of the Texas Commission on Environmental Quality (TCEQ), or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. A new small Type B assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) A new small Type B assisted living facility must provide at least one water closet and one lavatory for each six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) A new small Type B assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) A new small Type B assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) A new small Type B assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, a new small Type B assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) A new small Type B assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. A new small Type B assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. A new small Type B assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Gas. A new small Type B assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(d) Heating, ventilation, and air conditioning (HVAC) and exhaust systems.(1) General requirements. A new small Type B assisted living facility must ensure HVAC equipment meets the requirements of 32.2.5.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Heating and cooling. A new small Type B assisted living facility must provide heating and cooling for resident comfort.(A) A new small Type B assisted living facility must ensure air conditioning systems can maintain and do maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) A new small Type B assisted living facility must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain the temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) A new small Type B assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this section.(D) A new small Type B assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(E) A new small Type B assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A working fireplace must be installed, maintained and used according to NFPA 54 and NFPA 211.(iii) A working fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(3) Ventilation.(A) A new small Type B assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) A new small Type B assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. A new small Type B assisted living facility must ensure bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with operable windows or powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.227 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.227 Mechanical Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206068 03/12/2026 (a) Electrical system. A new small Type B assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. A new small Type B assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room.(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room.(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. A new small Type B assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. A new small Type B assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system, or intercom;(B) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) A new small Type B assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) A new small Type B assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit. Source Note: The provisions of this §553.228 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.228 Electrical Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206069 03/12/2026 (a) A new small Type B assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located.(b) A new small Type B assisted living facility must ensure any new elevator, escalator, or conveyor meets the requirements of 32.2.5.3, Elevators, Escalators, and Conveyors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.229 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.229 Miscellaneous Requirements for a New Small Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206079 03/12/2026 (a) A new large Type A assisted living facility must comply with the requirements of 32.3, Large Facilities, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, as modified by this division, except as permitted by subsection (b) of this section.(b) A new large Type A assisted living facility campus comprised of multiple buildings providing sleeping rooms for no more than 16 residents in any one building may comply with other provision in NFPA 101, as follows.(1) Each individual building providing sleeping rooms on the campus may comply with the requirements in 32.2, Small Facilities, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Other buildings on the campus that are part of the new large Type A assisted living facility may be permitted to comply with the requirements for other occupancies in NFPA 101, subject to approval by HHSC.(3) The provisions of this subsection do not apply where any building provides sleeping rooms for more than 16 residents.(c) All space planning and utilization requirements required by §553.232 of this division (relating to Space Planning and Utilization Requirements for a New Large Type A Assisted Living Facility) must be provided and located in the new residential board and care occupancy required by subsection (a) of this section. Source Note: The provisions of this §553.230 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.230 General Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206071 03/12/2026 (a) Structurally sound. A new large Type A assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads according to applicable building codes.(b) Separation of occupancies. A new large Type A assisted living facility must be separated from other occupancies, including other assisted living facilities, hospitals or nursing facilities, by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards.(c) Construction type. A new large Type A assisted living facility must ensure a building housing the facility meets the requirements of 32.3.1.3, Minimum Construction Requirements, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(d) Interior finish. A new large Type A assisted living facility must ensure interior wall and ceiling finish materials meet the requirements of 32.3.3.3, Interior Finish, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(e) Vertical openings. A new large Type A assisted living facility must ensure vertical openings are protected according to the requirements of 32.3.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.231 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.231 Construction Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206070 03/12/2026 (a) Resident bedrooms.(1) A new large Type A assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) A new large Type A assisted living facility must ensure bedroom usable floor space is not less than 80 square feet for a bedroom housing one resident and not less than 60 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted in paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than eight feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by HHSC.(3) A new large Type A assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. A new large Type A assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(6) of this section.(4) A new large Type A assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. A new large Type A assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by a resident occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space according to the requirements of subsection (a)(3) of this section. (c) Bedroom furnishings. When a resident does not provide their own furnishings, a new large Type A assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed, including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms. (1) A new large Type A assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) A new large Type A assisted living facility must ensure a resident room is arranged for convenient resident access to dining and recreation areas. (e) Staff area. A new large Type A assisted living facility must provide a staff area on each floor of a new large Type A assisted living facility and in each separate building containing resident sleeping rooms, except as permitted under paragraph (1) of this subsection.(1) A new large Type A assisted living facility that is not more than two stories in height and is composed of separate buildings grouped together and connected by covered walks, is not required to provide a staff area on each floor or in each building, provided that a staff area is located not more than 200 feet walking distance from the farthest resident living unit.(2) A new large Type A assisted living facility must provide the following at each staff area:(A) a desk or writing surface;(B) a telephone; and(C) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.235 of this division (relating to Fire Protection Systems Requirements for a New Large Type A Assisted Living Facility). (f) Resident toilet and bathing facilities. A new large Type A assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room. (1) A new large Type A assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) A new large Type A assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) A new large Type A assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.237 of this division (relating to Mechanical Requirements for a New Large Type A Assisted Living Facility).(g) Resident living areas. (1) A new large Type A assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms. (A) A new large Type A assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space. (B) A new large Type A assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside. (C) A new large Type A assisted living facility must ensure the total space for social-diversional areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement. Attached Graphic(2) A new large Type A assisted living facility must provide a dining area with appropriate furniture.(A) A new large Type A assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of the number of residents or other provisions of this section permitting a reduction in the total minimum dining space. (B) A new large Type A assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) A new large Type A assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path. (D) A new large Type A assisted living facility must ensure the total space for dining areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement.Attached Graphic(3) A new large Type A assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) For calculation purposes, where a means of egress passes through a living or dining area, a new large Type A assisted living facility must deduct a pathway, equal to the minimum corridor width according to §553.233 of this division (relating to Means of Egress Requirements for a New Large Type A Assisted Living Facility), from the measured area of the space.(5) A new large Type A assisted living facility must ensure a means of egress through a resident living or dining area is kept clear of obstructions, except as permitted by NFPA 101.(6) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, a new large Type A assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social-diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) A new large Type A assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. A new large Type A assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration; (2) medications and medical supplies; (3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses; (4) cleaning supplies including for janitorial needs; (5) food; (6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) General kitchen.(1) A new large Type A assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner. (2) A new large Type A assisted living facility must ensure a kitchen meets the requirements of the local fire, building, and health codes.(3) A new large Type A assisted living facility that prepares food on-site must provide a kitchen or dietary area to meet the general food service needs of the residents and must include space for the following:(A) storage, refrigeration, preparation, and serving food;(B) dish and utensil cleaning which includes:(i) a three-compartment sink large enough to immerse pots and pans; and(ii) a mechanical dishwasher for washing and sanitizing dishes;(C) a food preparation sink;(D) a handwashing station in every food preparation area with a supply of hot and cold water, soap, a towel dispenser and a waste receptacle;(E) a handwashing lavatory that is readily accessible to every dish room area; and(F) refuse storage and removal;(G) floor drains in the kitchen and dishwashing areas, unless the facility was created through conversion and the facility can keep the floor clean; and(H) a grease trap, if required by local authorities.(4) A new large Type A assisted living facility must ensure a kitchen is designed so that room temperature, at peak load or in the summer, does not exceed 85 degrees Fahrenheit measured throughout the room at five feet above the floor. (5) A new large Type A assisted living facility must ensure the volume of supply air provided takes into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(6) A new large Type A assisted living facility must provide a supply of hot and cold water.(A) Hot water for sanitizing purposes must be 180 degrees Fahrenheit.(B) When chemical sanitizers are used, hot water must meet the manufacturer's suggested temperature.(7) A new large Type A assisted living facility must maintain a separation between soiled and clean dish areas. (8) A new large Type A assisted living facility must maintain a separation of air flow between soiled and clean dish areas.(j) Kitchen restrooms.(1) A new large Type A assisted living facility must provide a restroom facility for kitchen staff, including a lavatory, except as described in paragraph (2) of this subsection.(A) The restroom facility must be directly accessible to kitchen staff without traversing resident use areas. (B) The restroom must open into a service corridor or vestibule and not open directly into the kitchen. (2) A new large Type A assisted living facility created through conversion may provide a staff restroom that may be located outside the kitchen area.(k) Kitchen janitorial facility. (1) A new large Type A assisted living facility must provide janitorial facilities exclusively for the kitchen and located in the kitchen area except as described in paragraph (2) of this subsection. (2) A new large Type A assisted living facility created through conversion must provide a janitorial facility for the kitchen. The janitorial facility may be located outside the kitchen if sanitary procedures are used to reduce the possibility of cross-contamination.(3) A new large Type A assisted living facility must provide a garbage can or cart washing area with a floor drain and a supply of hot water. The garbage can or cart washing area may be in the interior or on the exterior of the facility.(l) Finishes.(1) A new large Type A assisted living facility must provide non-absorbent, smooth finishes or surfaces on all kitchen floors, walls and ceilings. (2) A new large Type A assisted living facility must provide non-absorbent, smooth, cleanable finishes on counter surfaces and all cabinet surfaces.(3) A new large Type A assisted living facility must ensure surfaces are capable of being routinely cleaned and sanitized to maintain a healthful environment.(m) Vision panels in communicating doors. A new large Type A assisted living facility must ensure a door between a kitchen and a dining area, serving area, or resident-use area, is provided with a vision panel with fixed safety glass. Where the door is a required fire door or is located in a fire barrier or other fire resistance-rated enclosure, the vision panel, including the glazing and the frame, must meet the requirements of NFPA 101.(n) Auxiliary serving kitchens.(1) A new large Type A assisted living facility must ensure an auxiliary serving kitchen is equipped to maintain required food temperatures.(2) A new large Type A assisted living facility must ensure an auxiliary serving kitchen is equipped with a handwashing lavatory meeting the requirements of this section.(3) A new large Type A assisted living facility must ensure all surfaces in an auxiliary serving kitchen meet the requirements for finishes in this section.(o) Protection of cooking operations. (1) A new large Type A assisted living facility must protect cooking facilities according to the requirements in §553.236 of this division (relating to Hazardous Area Requirements for a New Large Type A Assisted Living Facility).(2) The following commercial or residential cooking equipment used only for reheating, and not for meal preparation, is not required to comply with the requirements of §553.236 of this division:(A) microwave ovens;(B) hot plates; or(C) toasters.(p) Food storage areas.(1) A new large Type A assisted living facility must provide a food storage area large enough to consistently maintain a four-day minimum supply of non-perishable food. A food storage area may be located away from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(2) A new large Type A assisted living facility must provide dollies, racks, pallets, wheeled containers, or shelving, so that food is not stored on the floor, and must ensure shelves are adjustable wire type shelving. (3) A new large Type A assisted living facility must provide non-absorbent finishes or surfaces on all floors and walls in food storage areas.(4) A new large Type A assisted living facility must provide effective ventilation in dry food storage areas to ensure positive air circulation.(5) A new large Type A assisted living facility must ensure the maximum room temperature in a food storage area does not exceed 85 degrees Fahrenheit at any time, when measured at the highest food storage level, but not less than five feet above the floor.(q) Laundry and linen services.(1) A new large Type A assisted living facility that co-mingles and processes laundry on-site in a central location, regardless of the type of laundry equipment used, must ensure a laundry area:(A) is separated from the assisted living building by a fire barrier having a one-hour fire resistance rating. This separation must extend from the floor to the floor or roof above;(B) is protected throughout by a fire sprinkler system; and(C) has access doors that open to the exterior or to an interior non-resident use area, such as a vestibule or service corridor; and(D) is provided with:(i) a soiled linen receiving, holding, and sorting room with a floor drain and forced exhaust to the exterior;(I) the exhaust must always operate when soiled linen is held in this area; and(II) the area may be combined with the washer section;(ii) a general laundry work area that is separated by partitioning a washer section and a dryer section;(iii) a storage area for laundry supplies;(iv) a folding area;(v) an adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire barrier separation required by subparagraph (A) of this paragraph; and(vi) provisions to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) If linen is processed off site, the facility must provide:(A) a soiled linen holding room with adequate forced exhaust ducted to the exterior; and(B) a clean linen receiving, holding, inspection, sorting or folding, and storage room.(3) A new large Type A assisted living facility must ensure a laundry area for resident-use meets the following requirements.(A) A new large Type A assisted living facility must ensure only residential type washers and dryers are provided in a laundry area for resident-use.(B) When more than three washers and three dryers are provided in one laundry area for resident-use, the area must be:(i) protected throughout by a fire sprinkler system; or(ii) separated from the facility by a fire barrier having a one-hour fire resistance rating. Source Note: The provisions of this §553.232 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.232 Space Planning and Utilization Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206072 03/12/2026 (a) A new large Type A assisted living facility must meet the requirements of 32.3.2, Means of Egress, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, except as described in this section.(b) The provisions of 32.3.2.11.2, Lockups, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, are not permitted.(c) A new large Type A assisted living facility must ensure doors meet the requirements of 32.3.2.2.2, Doors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, and the additional requirements of this section.(1) A resident room door in a new large Type A assisted living facility must latch in its frame to resist the passage of smoke.(2) In a new large Type A assisted living facility comprised of buildings that contain living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(d) A new large Type A assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs and must ensure stairs used as a means of egress meet the requirements of 32.3.2.2.3, Stairs, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(e) A new large Type A assisted living facility must ensure means of egress are marked according to the requirements of 32.3.2.10, Marking of Means of Egress, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(f) A new large Type A assisted living facility must provide emergency lighting according to the requirements of 32.3.2.9, Emergency Lighting, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, unless each sleeping room has a direct exit to the outside at the finished ground level. Source Note: The provisions of this §553.233 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.233 Means of Egress Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206073 03/12/2026 (a) A new large Type A assisted living facility must meet the requirements of 32.3.3.6, Corridors and Separation of Sleeping Rooms, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new large Type A assisted living facility must meet the requirements of 32.3.3.7, Subdivision of Building Spaces, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.234 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.234 Smoke Compartmentation for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206074 03/12/2026 (a) Fire alarm and smoke detection system. A new large Type A assisted living facility must provide a manual fire alarm system meeting the requirements of 9.6, Fire Detection, Alarm, and Communication Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment, as modified by this section.(1) General. A new large Type A assisted living facility must ensure the operation of any alarm initiating device automatically activates the manual fire alarm system evacuation alarm for the entire building.(2) Smoke detectors.(A) A new large Type A assisted living facility must install smoke detectors in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens, laundries, attached garages used for car parking, and public or common areas, except as permitted in subparagraphs (B) - (D) of this paragraph.(B) A new large Type A assisted living facility may install heat detectors in lieu of smoke detectors in kitchens, laundries, and attached garages used for car parking.(C) A new large Type A assisted living facility located in a building constructed to meet the requirements of NFPA 101, Chapter 18, New Health Care Occupancies, may install a smoke detection system meeting the requirements of 19.3.4.5.1, Corridors, in NFPA 101, Chapter 18, New Health Care Occupancies, in lieu of the requirements found in subparagraphs (A) and (B) of this paragraph.(D) A new large Type A assisted living facility comprised of buildings containing living units with independent cooking equipment must additionally have:(i) a smoke detector installed all in resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens and laundries within the living unit, that sounds an alarm only within the living unit; and(ii) a heat detector installed in the kitchen within the living unit that activates the general alarm.(E) A new large Type A assisted living facility is not required to install smoke alarms, as required by 32.3.4.7, Smoke Alarms, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, in addition to the smoke detectors required by subparagraphs (A) - (D) of this paragraph.(3) Alarm control panel.(A) A new large Type A assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) A new large Type A assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(C) A new large Type A assisted living facility must ensure a fire alarm panel indicates each floor and smoke compartment, as applicable, as a separate zone. Each zone must provide an alarm and trouble indication. When all alarm initiating devices are addressable and the status of each device is identified on the fire alarm panel, zone indication is not required.(4) Fire alarm power source.(A) A new large Type A assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) A new large Type A assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(5) Emergency forces notification. A new large Type A assisted living must ensure a fire alarm system provides emergency forces notification according to the requirements of 32.3.3.4.6, Emergency Forces Notification, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) Fire sprinkler system. A new large Type A assisted living facility must provide a fire sprinkler system meeting the requirements of NFPA 13 in accordance with 32.3.3.5, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(c) Portable Fire Extinguishers. A new large Type A assisted living facility must provide and maintain portable fire extinguishers according to the requirements of 32.3.3.5.7, Portable Fire Extinguishers, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies, and the additional requirements of this subsection.(1) A new large Type A assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) A new large Type A assisted living facility must ensure portable fire extinguishers are located in resident corridors so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) A new large Type A assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:10-B:C according to NFPA 10.(C) A facility must provide at least one approved 20-B:C portable fire extinguisher in each laundry, kitchen and walk-in mechanical room.(4) A new large Type A assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or is mounted in an approved cabinet.(5) A new large Type A assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) A new large Type A assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the exit access door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.235 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.235 Fire Protection Systems Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206075 03/12/2026 (a) A new large Type A assisted living facility must meet the requirements of 32.3.3.2, Protection from Hazards, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(b) A new large Type A assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) A new large Type A assisted living facility must protect cooking facilities, other than those in individual resident living units in accordance with the requirements of 32.3.3.8, Cooking Facilities, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.236 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.236 Hazardous Area Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206076 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. A new large Type A assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of TCEQ, or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. A new large Type A assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) A new large Type A assisted living facility must provide at least one water closet and one lavatory for every six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) A new large Type A assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) A new large Type A assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) A new large Type A assisted living facility must provide one tub or shower for every 10 residents, and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, a new large Type A assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) A new large Type A assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. A new large Type A assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. A new large Type A assisted living facility must supply towels, soap, and toilet tissue for individual resident use.(c) Public- and staff-use plumbing fixtures. In addition to the staff toilets required for the dietary staff according to §553.232(j) of this division (relating to Space Planning and Utilization Requirements for a New Large Type A Assisted Living Facility), an existing large Type A assisted living facility must provide toilets, including water closets and lavatories, for use by the public and by facility staff as follows:(1) if licensed for 60 or fewer residents, a new large Type A assisted living facility must provide a toilet for use by the public and by facility staff; or(2) if licensed for more than 60 residents, a new large Type A assisted living facility must provide a toilet for use by the public and a separate toilet for use by facility staff.(d) Gas. A new large Type A assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(e) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. A new large Type A assisted living facility must ensure HVAC equipment meets the requirements of 32.3.6.2, Heating, Ventilating, and Air-Conditioning, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies.(2) Heating and cooling. A new large Type A assisted living facility must provide heating and cooling for resident comfort.(A) A new large Type A assisted living facility must ensure air conditioning systems can maintain and does maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) A new large Type A assisted living facility must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain a temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) A new large Type A assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (E) of this paragraph.(D) A new large Type A assisted living facility must ensure a fuel-fired heating device, other than a working fireplace, meets the following requirements.(i) A fuel-fired heating device must be connected to a chimney or vent.(ii) A fuel-fired heating device must take air for combustion directly from outside.(iii) A fuel-fired heating device must be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area.(iv) A fuel-fired heating device must have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperatures or ignition failure.(E) A new large Type A assisted living facility must ensure a working fireplace meets the following requirements.(i) A building containing a working fireplace must be protected by an approved, supervised automatic sprinkler system with listed quick response or listed residential sprinklers.(ii) A working fireplace must be installed, maintained and used according to NFPA 54 and NFPA 211.(iii) A work fireplace may not be located in a resident sleeping room.(iv) The room where a working fireplace is located must be provided with electrically supervised carbon monoxide detection connected to the fire alarm system according to NFPA 720.(v) A direct-vent gas fireplace, as defined in NFPA 54, must meet the following requirements.(I) A direct-vent gas fireplace must include a sealed glass front with a wire mesh panel or screen.(II) The controls for a direct-vent gas fireplace must be locked or located in a restricted location.(vi) A solid-fuel burning fireplace must be equipped with:(I) a raised hearth at least four inches above the surrounding finished floor; and(II) a fireplace enclosure that is guaranteed against breakage up to a temperature of 650 degrees Fahrenheit and constructed of heat-tempered glass or other approved material.(3) Ventilation.(A) A new large Type A assisted living facility must be ventilated using windows, mechanical ventilation, or a combination of both.(B) A new large Type A assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. A new large Type A assisted living facility must ensure bathrooms, toilet rooms, janitorial facilities, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.237 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.237 Mechanical Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206077 03/12/2026 (a) Electrical system. A new large Type A assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. A new large Type A assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room;(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room; and(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. A new large Type A assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. A new large Type A assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system or intercom;(B) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) A new large Type A assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification station; or(B) additional call stations or devices in private or common resident areas.(3) A new large Type A assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit.(e) Generator.(1) A new large Type A assisted living facility that provides a system to supply, distribute, and control electricity for emergency lighting and illumination of exit signs required by NFPA 101, such as a system that uses a generator set as an alternate source of power, must comply with the requirements of Article 700, Emergency Systems, in NFPA 70, Chapter 7, Special Conditions.(A) The emergency system may not include any systems or equipment except:(i) emergency lighting, as required by NFPA 101;(ii) secondary power to ensure illumination of exit signs, as required by NFPA 101; and(iii) secondary power for detection, alarm, and communications systems, as required by NFPA 72.(B) A new large Type A assisted living facility must ensure wiring from an emergency source to emergency loads is kept entirely independent of all other wiring and equipment except as permitted by Article 700.10, Wiring, Emergency System, in NFPA 70. Two or more emergency circuits supplied from the same source may be routed in the same raceway, cable, box, or cabinet.(C) A new large Type A assisted living facility must ensure that transfer equipment for an emergency system does not serve another facility, including a hospital, a nursing facility, or an independent living facility.(2) A new large Type A assisted living facility that provides a system to supply, distribute, and control electricity for systems and equipment not identified in paragraph (1) of this subsection must comply with the requirements of Article 702, Optional Standby Systems, in NFPA 70.(3) The alternate power source for the emergency system may supply other emergency loads, legally required standby loads, and optional standby system loads where the source has adequate capacity to ensure adequate power to the different circuits in the following priority:(A) emergency circuits for the assisted living facility;(B) legally required standby circuits, if any; and(C) optional standby circuits, if any. Source Note: The provisions of this §553.238 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.238 Electrical Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206078 03/12/2026 (a) A new large Type A assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located.(b) A new large Type A assisted living facility must ensure an elevator, dumbwaiter, or vertical conveyor meets the requirements of 32.3.6.3, Elevators, Dumbwaiters, and Vertical Conveyors, in NFPA 101, Chapter 32, New Residential Board and Care Occupancies. Source Note: The provisions of this §553.239 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.239 Miscellaneous Requirements for a New Large Type A Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206080 03/12/2026 (a) A new large Type B assisted living facility must comply with the requirements for a limited care facility in NFPA 101, Chapter 18, New Health Care Occupancies, as modified by this division.(b) All space planning and utilization requirements required by §553.242 of this division (relating to Space Planning and Utilization Requirements for a New Large Type B Assisted Living Facility) must be provided and located in the new healthcare occupancy required by subsection (a) of this section. Source Note: The provisions of this §553.240 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.240 General Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206081 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206081 03/12/2026 (a) Structurally sound. A new large Type B assisted living facility must ensure any building is structurally sound regarding actual or expected dead, live, and wind loads according to applicable building codes.(b) Separation of occupancies.(1) A new large Type B assisted living facility must be separated from other occupancies by a fire barrier having at least a 2-hour fire resistance rating constructed according to the requirements of NFPA 101 and its referenced standards.(2) A large Type B assisted living facility is not required to be separated from a hospital or nursing facility unless the separation is required by NFPA 101 or the standards for licensing the hospital or nursing facility.(c) Construction type. A new large Type B assisted living facility must ensure a building housing the facility meets the requirements of 18.1.6, Minimum Construction Requirements, in NFPA 101, Chapter 18, New Health Care Occupancies.(d) Interior finish. A new Large Type B assisted living facility must ensure interior wall, ceiling and floor finish materials meet the requirements of 18.3.3, Interior Finish, in NFPA 101, Chapter 18, New Health Care Occupancies.(e) Vertical openings. A new large Type B assisted living facility must ensure vertical openings are protected according to the requirements of 18.3.1, Protection of Vertical Openings, in NFPA 101, Chapter 18, New Health Care Occupancies. Source Note: The provisions of this §553.241 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.241 Construction Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206082 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206082 03/12/2026 (a) Resident bedrooms.(1) A new large Type B assisted living facility must ensure a resident bedroom or living unit is not located on a floor that is below finished ground level.(2) A new large Type B assisted living facility must ensure bedroom usable floor space is not less than 100 square feet for a bedroom housing one resident and not less than 80 square feet per resident for a bedroom housing multiple residents, unless otherwise permitted by paragraphs (3) and (4) of this subsection. Portions of a bedroom that are less than 10 feet in the smallest dimension cannot be included in the measurement of bedroom usable floor space, unless approved by HHSC.(3) A new large Type B assisted living facility containing individual living units that include living space for the residents, in addition to their bedroom, may reduce the bedroom usable floor space for a bedroom housing multiple residents within a living unit by up to 10 percent of the required bedroom usable floor space, as long as the minimum dimensional criteria are maintained. A new large Type B assisted living facility must not use this provision in conjunction with the provision permitting the reduction of common social-diversional areas or common dining areas found in subsection (g)(6) of this section.(4) A new large Type B assisted living facility must house no more than 50 percent of its licensed resident capacity in bedrooms housing three or more residents. A bedroom must not house more than four residents.(b) Bedroom windows. A new large Type B assisted living facility must ensure each bedroom has at least one operable window with outside exposure and meeting the following requirements.(1) The window sill must be no higher than 44 inches above the floor.(2) The window must be operable by a resident occupying the bedroom, from the inside, without the use of tools or special devices.(3) The total area of all windows in a bedroom must not be less than eight percent of the minimum bedroom usable floor space required by subsection (a)(3) of this section. (c) Bedroom furnishings. When a resident does not provide their own furnishings, a new large Type B assisted living facility must provide the following furnishings for each resident, which must be maintained in good repair:(1) a bed including a mattress;(2) a chair;(3) a table or dresser; and(4) private clothes storage space, which must have closable doors, and drawer space for clothing and personal belongings.(d) Arrangement of resident living units or rooms. (1) A new large Type B assisted living facility must ensure all resident rooms open on an exit, corridor, living area, or public area.(2) A new large Type B assisted living facility must ensure a resident room is arranged for convenient resident access to dining and recreation areas. (e) Staff area. A new large Type B assisted living facility must provide a staff area on each floor of a new large Type B assisted living facility and in each separate building containing resident sleeping rooms. A new large Type B assisted living facility must provide the following at each staff area:(1) a desk or writing surface;(2) a telephone; and(3) a fire alarm control unit or a fire alarm annunciator panel meeting the requirements of §553.245 of this division (relating to Fire Protection Systems Requirements for a New Large Type B Assisted Living Facility). (f) Resident toilet and bathing facilities. A new large Type B assisted living facility must ensure each resident bedroom is served by a separate private toilet room, a connecting toilet room, or a general toilet room. (1) A new large Type B assisted living facility that houses individuals of more than one gender must provide toilet rooms for each gender, or individual single-occupant toilet rooms for use by any gender.(2) A new large Type B assisted living facility must ensure a general toilet room or bathing room is accessible from a corridor or public space.(3) A new large Type B assisted living facility must ensure resident toilet and bathing facilities comply with the requirements for resident-use plumbing fixtures according to §553.247 of this division (relating to Mechanical Requirements for a New Large Type B Assisted Living Facility).(g) Resident living areas. (1) A new large Type B assisted living facility must provide, in a common area of the facility, social-diversional spaces with appropriate furniture. Examples of social-diversional spaces include living rooms, day rooms, lounges, dens, game rooms, and sunrooms. (A) A new large Type B assisted living facility must provide a social-diversional space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of number of residents or other provisions of this section permitting a reduction in the total minimum social-diversional space. (B) A new large Type B assisted living facility must ensure a social-diversional space has one or more exterior windows providing a view of the outside. (C) A new large Type B assisted living facility must ensure the total space for social-diversional areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement. Attached Graphic(2) A new large Type B assisted living facility must provide a dining area with appropriate furniture. (A) A new large Type B assisted living facility must provide a dining space with a minimum area of 120 square feet in at least one space within a common area of the facility, regardless of number of residents or other provisions of this section permitting a reduction in the total minimum dining space. (B) A new large Type B assisted living facility must ensure a dining space has one or more exterior windows providing a view of the outside.(C) A new large Type B assisted living facility must ensure a dining area is accessible from resident living units or bedrooms via a covered path. (D) A new large Type B assisted living facility must ensure the total space for dining areas is provided on a sliding scale according to the following table. No space smaller than 120 square feet in area can be counted toward meeting this requirement.Attached Graphic(3) A new large Type B assisted living facility may provide a total living and dining area combined in a single or interconnecting space where the minimum area of the combined space is at least 240 square feet.(4) For calculation purposes, where a means of egress passes through a living or dining area, a new large Type B assisted living facility must deduct a pathway, equal to the minimum corridor width according to §553.243 of this division (relating to Means of Egress Requirements for a New Large Type B Assisted Living Facility), from the measured area of the space.(5) A new large Type B assisted living facility must ensure a means of egress through a resident living or dining area is kept clear of obstructions, except as permitted by NFPA 101.(6) Subject to the limitations of paragraphs (1)(A) and (2)(A) of this subsection and subparagraphs (A) and (B) of this paragraph, a new large Type B assisted living facility containing individual living units may reduce the minimum square footage required by paragraphs (1)(C) and (2)(D) of this subsection for total common social-diversional or common dining areas, respectively, by including up to 10 percent of the individual living unit area in the calculation of the total social-diversional area or total dining area.(A) The individual living unit area contributed toward total social-diversional space or total dining space must not be counted more than once per living unit but may be split between social-diversional and dining space calculations.(B) A new large Type B assisted living facility must not utilize both this paragraph and subsection (a)(3) of this section to reduce both the minimum square footage otherwise required for its common social-diversional or dining areas and the minimum square footage of usable floor space otherwise required in bedrooms housing multiple residents within a living unit.(h) Storage areas. A new large Type B assisted living facility must provide sufficient separate storage spaces or areas for at least:(1) administrative records, office supplies, and other storage needs related to administration; (2) medications and medical supplies; (3) equipment supplied by the facility for resident needs, including wheelchairs, walkers, beds, and mattresses; (4) cleaning supplies, including for janitorial needs; (5) food; (6) clean linens and towels, if the facility furnishes linen;(7) soiled linen, if the facility furnishes linen; and(8) lawn and maintenance equipment.(i) General kitchen.(1) A new large Type B assisted living facility that prepares food off-site or in a separate building must ensure food is served at the proper temperature and transported in a sanitary manner. (2) A new large Type B assisted living facility must ensure a kitchen meets the requirements of the local fire, building, and health codes.(3) A new large Type B assisted living facility that prepares food on-site must provide a kitchen or dietary area to meet the general food service needs of the residents and must include space for the following:(A) storage, refrigeration, preparation, and serving food;(B) dish and utensil cleaning which includes:(i) a three-compartment sink large enough to immerse pots and pans; and (ii) a mechanical dishwasher for washing and sanitizing dishes;(C) a food preparation sink;(D) a handwashing station in every food preparation area with a supply of hot and cold water, soap, a towel dispenser, and a waste receptacle;(E) a handwashing lavatory that is readily accessible to every dish room area;(F) refuse storage and removal;(G) floor drains in the kitchen and dishwashing areas; and(H) a grease trap, if required by local authorities.(4) A new large Type B assisted living facility must ensure a kitchen is designed so that room temperature, at peak load or in the summer, does not exceed 85 degrees Fahrenheit measured throughout the room at five feet above the floor. (5) A new large Type B assisted living facility must ensure the volume of supply air provided takes into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(6) A new large Type B assisted living facility must provide a supply of hot and cold water. (A) Hot water for sanitizing purposes must be 180 degrees Fahrenheit.(B) When chemical sanitizers are used, hot water must meet the manufacturer's suggested temperature.(7) A new large Type B assisted living facility must maintain a separation between soiled and clean dish areas.(8) A new large Type B assisted living facility must maintain a separation of air flow between soiled and clean dish areas.(j) Kitchen restrooms. (1) A new large Type B assisted living facility must provide a restroom facility for kitchen staff, including a lavatory, except as described in paragraph (2) of this subsection.(A) The restroom facility must be directly accessible to kitchen staff without traversing resident use areas. (B) The restroom must open into a service corridor or vestibule and not open directly into the kitchen. (2) A new large Type B facility must ensure a kitchen serving a neighborhood or household provides a restroom accessible to kitchen staff located in close proximity to the kitchen.(k) Kitchen janitorial facility.(1) A new large Type B assisted living facility must provide janitorial facilities exclusively for the kitchen and located in the kitchen area except as described in paragraph (2) of this subsection. (2) A new large Type B facility must ensure a kitchen serving a neighborhood or household provides a janitorial facility exclusively for the kitchen that is located in close proximity to the kitchen.(3) A new large Type B assisted living facility must provide a garbage can or cart washing area with a floor drain and a supply of hot water. The garbage can or cart washing area may be in the interior or on the exterior of the facility.(l) Finishes.(1) A new large Type B assisted living facility must provide non-absorbent, smooth finishes or surfaces on all kitchen floors, walls, and ceilings. (2) A new large Type B assisted living facility must provide non-absorbent, smooth, cleanable finishes on counter surfaces and all cabinet surfaces.(3) A new large Type B assisted living facility must ensure surfaces are capable of being routinely cleaned and sanitized to maintain a healthful environment.(m) Vision panels in communicating doors. A new large Type B assisted living facility must ensure a door between a kitchen and a dining area, serving area, or resident-use area, is provided with a vision panel with fixed safety glass. Where the door is a required fire door or is located in a fire barrier or other fire resistance-rated enclosure, the vision panel, including the glazing and the frame, must meet the requirements of NFPA 101.(n) Auxiliary serving kitchens.(1) A new large Type B assisted living facility must ensure an auxiliary serving kitchen is equipped to maintain required food temperatures.(2) A new large Type B assisted living facility must ensure an auxiliary serving kitchen is equipped with a handwashing lavatory meeting the requirements of this subsection.(3) A new large Type B assisted living facility must ensure all surfaces in an auxiliary serving kitchen meet the requirements for finishes in this section.(o) Protection of cooking operations. (1) A new large Type B assisted living facility must protect cooking facilities according to the requirements in §553.246 of this division (relating to Hazardous Area Requirements for a new Large Type B Assisted Living Facility).(2) The following commercial or residential cooking equipment used only for reheating, and not for meal preparation, is not required to comply with the requirements of §553.246 of this division:(A) microwave ovens;(B) hot plates; or(C) toasters.(p) Food storage areas.(1) A new large Type B assisted living facility must provide a food storage area large enough to consistently maintain a four-day minimum supply of non-perishable food. A food storage area may be located away from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(2) A new large Type B assisted living facility must provide dollies, racks, pallets, wheeled containers, or shelving so that food is not stored on the floor and must ensure shelves are adjustable wire type shelving.(3) A new large Type B assisted living facility must provide non-absorbent finishes or surfaces on all floors and walls in food storage areas.(4) A new large Type B assisted living facility must provide effective ventilation in dry food storage areas to ensure positive air circulation.(5) A new large Type B assisted living facility must ensure the maximum room temperature in a food storage area does not exceed 85 degrees Fahrenheit at any time when measured at the highest food storage level, but not less than five feet above the floor.(q) Laundry and linen services.(1) A new large Type B assisted living facility that co-mingles and processes laundry on-site in a central location, regardless of the type of laundry equipment used, must ensure a laundry area:(A) is separated from the assisted living building by a fire barrier having a one-hour fire resistance rating. This separation must extend from the floor to the floor or roof above;(B) is protected throughout by a fire sprinkler system;(C) has access doors that open to the exterior or to an interior non-resident use area, such as a vestibule or service corridor; and(D) is provided with:(i) a soiled linen receiving, holding, and sorting room with a floor drain and forced exhaust to the exterior;(I) The exhaust must always operate when soiled linen is held in this area; and(II) The area may be combined with the washer section;(ii) a general laundry work area that is separated by partitioning a washer section and a dryer section;(iii) a storage area for laundry supplies;(iv) a folding area;(v) an adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire barrier separation required by subparagraph (A) of this paragraph; and(vi) provisions to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) If linen is processed off site, the facility must provide:(A) a soiled linen holding room with adequate forced exhaust ducted to the exterior; and(B) a clean linen receiving, holding, inspection, sorting or folding, and storage room.(3) A new large Type B assisted living facility must ensure a laundry area for resident-use meets the following requirements.(A) A new large Type B assisted living facility must ensure only residential type washers and dryers are provided in a laundry area for resident-use.(B) When more than three washers and three dryers are provided in one laundry area for resident-use, the area must be:(i) protected throughout by a fire sprinkler system; or(ii) separated from the facility by a fire barrier having a one-hour fire resistance rating. Source Note: The provisions of this §553.242 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.242 Space Planning and Utilization Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206083 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206083 03/12/2026 (a) A new large Type B assisted living facility must meet the requirements of 18.2, Means of Egress, in NFPA 101, Chapter 18, New Health Care Occupancies, except as described in this section.(b) A new large Type B assisted living facility must ensure doors meet the requirements of 18.2.2.2, Doors, in NFPA 101, Chapter 18, New Health Care Occupancies, and the additional requirements of this section.(1) A resident room door in a new large Type B assisted living facility must latch in its frame to resist the passage of smoke.(2) In a new large Type B assisted living facility comprised of buildings containing living units with independent cooking equipment within the living unit, a door between the living unit and a corridor or hallway must:(A) be self-closing or automatic-closing; and(B) latch in its frame to resist the passage of smoke.(3) A resident room door or living unit door must not be arranged to prevent the occupant from closing the door.(c) A new large Type B assisted living facility providing spaces for use by residents on floors other than the ground floor must provide at least two separate approved stairs and must ensure stairs used as a means of egress meet the requirements of 18.2.2.3, Stairs, in NFPA 101, Chapter 18, New Health Care Occupancies.(d) A new large Type A assisted living facility must ensure means of egress are marked according to the requirements of 18.2.10, Marking of Means of Egress, in NFPA 101, Chapter 18, New Health Care Occupancies.(e) A new large Type B assisted living facility must provide emergency lighting according to the requirements of 18.2.9, Emergency Lighting, in NFPA 101, Chapter 18, New Health Care Occupancies. Source Note: The provisions of this §553.243 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.243 Means of Egress Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206084 03/12/2026 (a) A new large Type B assisted living facility must meet the requirements of 18.3.6, Corridors, in NFPA 101, Chapter 18, New Health Care Occupancies.(b) A new large Type B assisted living facility must meet the requirements of 18.3.7, Subdivision of Building Spaces, in NFPA 101, Chapter 18, New Health Care Occupancies. Source Note: The provisions of this §553.244 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.244 Smoke Compartmentation for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206085 03/12/2026 (a) Fire alarm and smoke detection system. A new large Type B assisted living facility must provide a fire alarm system meeting the requirements of 18.3.4, Detection, Alarm, and Communications Systems, in NFPA 101, Chapter 18, New Health Care Occupancies, as modified by this section.(1) General. A new large Type B assisted living facility must ensure the operation of any alarm initiating device automatically activates the manual fire alarm system evacuation alarm for the entire building.(2) Smoke detectors.(A) A new large Type B assisted living facility must install smoke detectors meeting the requirements of 18.3.4.5.1, Corridors, in NFPA 101, Chapter 18, New Health Care Occupancies.(B) A new large Type B assisted living facility comprised of buildings containing living units with independent cooking equipment within the living unit, must additionally have:(i) a smoke detector installed in all resident bedrooms, corridors, hallways, living rooms, dining rooms, offices, kitchens and laundries within the living unit, that sounds an alarm only within the living unit; and(ii) a heat detector installed in the kitchen within the living unit that activates the general alarm.(3) Alarm control panel.(A) A new large Type B assisted living facility must provide a fire alarm control unit, or a fire alarm annunciator providing annunciation of all fire alarm, supervisory, and trouble signals by audible and visible indicators, in a location visible to staff at or near the staff area that is attended 24 hours a day.(B) A new large Type B assisted living facility is not required to ensure a fire alarm control unit or fire alarm annunciator is visible to staff if the fire alarm is monitored by devices carried by all staff.(C) A new large Type B assisted living facility must ensure a fire alarm panel indicates each floor and smoke compartment, as applicable, as a separate zone. Each zone must provide an alarm and trouble indication. When all alarm initiating devices are addressable and the status of each device is identified on the fire alarm panel, zone indication is not required.(4) Fire alarm power source.(A) A new large Type B assisted living facility must ensure a fire alarm system is powered by a permanently-wired, dedicated branch circuit that is powered from a commercial power source in accordance with NFPA 70.(B) A new large Type B assisted living facility must provide a secondary, emergency power source meeting the requirements of NFPA 72.(5) Emergency forces notification. A new large Type B assisted living facility must ensure a fire alarm system automatically notifies emergency forces according to the requirements of 18.3.4.3.2, Emergency Forces Notification, in NFPA 101, Chapter 18, New Health Care Occupancies(b) Fire sprinkler system. A new large Type B assisted living facility must provide a fire sprinkler system meeting the requirements of NFPA 13 in accordance with 18.3.5, in NFPA 101, Chapter 18, New Health Care Occupancies.(c) Portable Fire Extinguishers. A new large Type B assisted living facility must provide and maintain portable fire extinguishers according to the requirements of NFPA 10.(1) A new large Type B assisted living facility must ensure all requirements of NFPA 10 are followed for all extinguisher types, including requirements for location, spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(2) A new large Type B assisted living facility must ensure portable fire extinguishers are located in resident corridors so the travel distance from any point in the facility to an extinguisher is no more than 75 feet.(3) A new large Type B assisted living facility must ensure the actual size of any portable fire extinguisher meets the requirements of NFPA 10 for maximum floor area per unit covered, but an extinguisher must be no smaller than the following.(A) A water-type portable fire extinguisher must have a rating of at least 1-A according to NFPA 10.(B) All other portable fire extinguishers must have a rating of at least 2-A:10-B:C according to NFPA 10.(C) A facility must provide at least one approved 20-B:C portable fire extinguisher in each laundry, kitchen, and walk-in mechanical room.(4) A new large Type B assisted living facility must ensure portable fire extinguishers are installed on hangers or brackets supplied with the extinguisher or mounted in an approved cabinet.(5) A new large Type B assisted living facility must ensure a portable fire extinguisher is protected from impact or dislodgement.(6) A new large Type B assisted living facility must ensure a portable fire extinguisher is installed at an appropriate height.(A) A portable fire extinguisher having a gross weight of up to 40 pounds must be installed so the top of the extinguisher is not more than five feet above the floor.(B) A portable fire extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than three and a half feet above the floor.(C) A portable fire extinguisher must be installed so the clearance between the bottom of the extinguisher and the floor is at least four inches.(7) A portable extinguisher provided in a hazardous room must be located as close as possible to the exit access door leading from the room and on the latch or knob side of the door. Source Note: The provisions of this §553.245 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.245 Fire Protection Systems Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206086 03/12/2026 (a) A new large Type B assisted living facility must meet the requirements of 19.3.2, Protection from Hazards, in NFPA 101, Chapter 19, New Health Care Occupancies.(b) A new large Type B assisted living facility must ensure flammable or combustible liquids, including gasoline, oil-based paint, charcoal lighter fluid, or similar products are not stored in a building housing residents.(c) A new large Type B assisted living facility must protect any cooking operation according to the requirements of 18.3.2.5, Cooking Facilities, in NFPA 101, Chapter 18, New Health Care Occupancies. Source Note: The provisions of this §553.246 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.246 Hazardous Area Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206087 03/12/2026 (a) Wastewater and water supply.(1) Wastewater. A new large Type B assisted living facility must ensure wastewater and sewage are discharged into a sewerage system or an onsite sewerage facility approved by the Water Quality Division of TCEQ, or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(2) Water supply. A new large Type B assisted living facility must ensure the water supply is of safe, sanitary quality, suitable for use, adequate in quantity and pressure, and obtained from a public or private water supply system or a private well.(b) Resident-use plumbing fixtures.(1) Water closets and lavatories.(A) A new large Type B assisted living facility must provide at least one water closet and one lavatory for each six residents and for each additional resident fewer than six. Multiple toilets in a single space must comply with paragraph (2)(B) of this subsection.(B) A new large Type B assisted living facility must ensure a lavatory is readily accessible to each water closet.(C) A new large Type B assisted living facility must provide at least one water closet, lavatory, and bathing unit, that are accessible to residents, on each floor containing resident sleeping rooms.(2) Bathing units.(A) A new large Type B assisted living facility must provide one tub or shower for every 10 residents and for any fraction thereof.(B) Where multiple water closets or bathing units are provided in a single space, a new large Type B assisted living facility must provide partitions or curtains to separate plumbing fixtures for resident privacy.(C) A new large Type B assisted living facility must ensure tubs and showers have non-slip bottoms or floor surfaces, either built-in or applied to the surfaces.(3) Hot water supply. A new large Type B assisted living facility must provide a supply of hot water for resident-use. Hot water for lavatories and bathing units accessible to residents must be maintained between 100 and 120 degrees Fahrenheit.(4) Supplies. A new large Type B assisted living facility must supply towels, soap, and toilet tissue for individual resident-use.(c) Public- and staff-use plumbing fixtures. In addition to the staff toilets required for the dietary staff according to §553.242(j) of this division (relating to Space Planning and Utilization Requirements for a New Large Type B Assisted Living Facility), a new large Type B assisted living facility must provide toilets, including water closets and lavatories, for use by the public and by facility staff as follows:(1) if licensed for 60 or fewer residents, a new large Type B assisted living facility must provide a toilet for use by the public and by facility staff; or(2) if licensed for more than 60 residents, a new large Type B assisted living facility must provide a toilet for use by the public and a separate toilet for use by facility staff.(d) Gas. A new large Type B assisted living facility must ensure equipment using natural gas or propane and related gas piping meets the requirements of 9.1.1, Gas, in NFPA, Chapter 9, Building Service and Fire Protection Equipment.(e) Heating, ventilation, and air-conditioning (HVAC) and exhaust systems.(1) General requirements. A new large Type B assisted living facility must ensure HVAC equipment meets the requirements of 18.5.2, Heating, Ventilating and Air-Conditioning, in NFPA 101, Chapter 18, New Health Care Occupancies.(2) Heating and cooling. A new large Type B assisted living facility must provide heating and cooling for resident comfort.(A) A new large Type B assisted living facility must ensure air conditioning systems can maintain and does maintain the comfort range of 68 to 82 degrees Fahrenheit in resident-use areas.(B) A new large Type B assisted living facility must have a central air conditioning system, or a substantially similar air conditioning system, that can maintain and does maintain a temperature range required under subparagraph (A) of this paragraph within areas used by residents.(C) A new large Type B assisted living facility may not use an open flame heating device in the facility, except as permitted by subparagraphs (D) - (F) of this paragraph.(D) A new large Type B assisted living facility must ensure any heating device, other than a central heating plant, suspended unit heater, or working fireplace, meets the requirements of 18.5.2.2, in NFPA 101, Chapter 18, New Health Care Occupancies.(E) A new large Type B assisted living facility must ensure a suspended unit heater meets the requirements of 18.5.2.3(1), in NFPA 101, Chapter 18, New Health Care Occupancies.(F) A new large Type B assisted living facility must ensure a working fireplace meets the following requirements.(i) A direct-vent gas fireplace must meet the requirements of 18.5.2.3(2), in NFPA 101, Chapter 18, New Health Care Occupancies.(ii) A solid fuel-burning fireplace must meet the requirements of 18.5.2.3(3), in NFPA 101, Chapter 18, New Health Care Occupancies.(3) Ventilation.(A) A new large Type B assisted living facility must be ventilated using mechanical ventilation.(B) A new large Type B assisted living facility with interior areas designated for smoking within the building must provide mechanical ventilation directed to the exterior to remove smoke at the rate of 10 air changes per hour.(4) Exhaust. A new large Type B assisted living facility must ensure bathrooms, toilet rooms, janitorial facilities, and other odor-producing rooms or areas for soiled or unsanitary operations are exhausted with powered exhaust vented to the exterior for odor control. Source Note: The provisions of this §553.247 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.247 Mechanical Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206088 03/12/2026 (a) Electrical system. A new large Type B assisted living facility must ensure an electrical system meets the requirements of 9.1.2, Electrical Systems, in NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Lighting. A new large Type B assisted living facility must provide illumination throughout the building. Minimum lighting levels must not be lower than:(1) 10 footcandles in resident rooms during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room.(2) 20 footcandles in each corridor, staff station, dining room, lobby, toilet room, bathroom, bathing facility, laundry room, stairway, and elevator during the day--illumination requirements for these areas apply to lighting throughout the space, as measured at 30 inches above the floor anywhere in the room.(3) 50 footcandles for each medication preparation or storage area, kitchen, and desk within a staff station. Illumination requirements apply when the area is in use for a task it supports, as measured where the task is being performed.(c) Telephone. A new large Type B assisted living facility must provide at least one telephone in the facility that is available to both staff and residents. Emergency telephone numbers must be posted conspicuously at or near the telephone, including fire, police, emergency medical services, and poison control center services.(d) Communication system. A new large Type B assisted living facility that consists of two or more floors or separate buildings must provide a communication system from each resident living unit to a central staff station.(1) The communication system must:(A) be a direct telephone, emergency call system, or intercom;(B) include at least:(i) one central notification station at a fixed location that receives all calls processed through the system; and(ii) one permanently fixed call station or device in every resident living unit.(2) A new large Type B assisted living facility may provide:(A) additional or portable notification stations or devices in addition to the central notification; or(B) additional call stations or devices in private or common resident areas.(3) A new large Type B assisted living facility may provide residents with portable, wireless call transmitters, such as pendants or wrist bands. However, a device may not be a substitute for a fixed call station in a resident living unit.(e) Generator.(1) A new large Type B assisted living facility that provides a system to supply, distribute, and control electricity for emergency lighting and illumination of exit signs required by NFPA 101, such as a system that uses a generator set as an alternate source of power, must comply with the requirements of Article 700, Emergency Systems, in NFPA 70, Chapter 7, Special Conditions.(A) The emergency system may not include any systems or equipment except:(i) emergency lighting, as required by NFPA 101;(ii) secondary power to ensure illumination of exit signs, as required by NFPA 101; and(iii) secondary power for detection, alarm, and communications systems, as required by NFPA 72.(B) A new large Type B assisted living facility must ensure wiring from an emergency source to emergency loads is kept entirely independent of all other wiring and equipment except as permitted by Article 700.10, Wiring, Emergency System, in NFPA 70. Two or more emergency circuits supplied from the same source may be routed in the same raceway, cable, box, or cabinet.(C) A new large Type B assisted living facility must ensure that transfer equipment for an emergency system does not serve another facility, including a hospital, a nursing facility or an independent living facility.(2) A new large Type B assisted living facility that provides a system to supply, distribute, and control electricity for systems and equipment not identified in paragraph (1) of this subsection must comply with the requirements of Article 702, Optional Standby Systems, in NFPA 70.(3) The alternate power source for the emergency system may supply other emergency loads, legally required standby loads, and optional standby system loads where the source has adequate capacity to ensure adequate power to the different circuits in the following priority:(A) emergency circuits for the assisted living facility(B) legally required standby circuits, if any; and(C) optional standby circuits, if any.(4) A new large Type B assisted living facility is not required to comply with the requirements of Article 517, Health Care Facilities, in NFPA 70. Source Note: The provisions of this §553.248 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.248 Electrical Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206089 03/12/2026 (a) A new large Type B assisted living facility must provide an elevator if:(1) the building in which the facility is located is three or more stories in height; or(2) the facility provides services or social activities to residents in spaces located on a floor other than the floor where the entrance to the facility is located.(b) A new large Type B assisted living facility must ensure an elevator meets the requirements of 18.5.3, Elevators, Escalators, and Conveyors, in NFPA 101, Chapter 18, New Health Care Occupancies. Source Note: The provisions of this §553.249 adopted to be effective August 31, 2021, 46 TexReg 5189. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES D FACILITY CONSTRUCTION §553.249 Miscellaneous Requirements for a New Large Type B Assisted Living Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220831 03/12/2026 (a) Manager qualifications. Each facility must designate, in writing, a manager to have authority over the operation.(1) Qualifications. In small facilities, the manager must have proof of graduation from an accredited high school or certification of equivalency of graduation. In large facilities, a manager must have:(A) an associate's degree in nursing, health care management, or a related field;(B) a bachelor's degree; or(C) proof of graduation from an accredited high school or certification of equivalency of graduation and at least one year of experience working in management or in health care industry management.(2) Training in management of assisted living facilities. A manager must complete at least one educational course on the management of assisted living facilities, which must include information on the assisted living standards; resident characteristics (including dementia), resident assessment and skills working with residents; basic principles of management; food and nutrition services; federal laws, with an emphasis on accessibility requirements under the Americans with Disabilities Act; community resources; ethics, and financial management.(A) The course must be at least 24 hours in length.(i) A manager must complete eight hours of training on the assisted living standards within the first three months of employment.(ii) The 24-hour training requirement may not be met through in-services at the facility, but may be met through structured, formalized classes, correspondence courses, training videos, distance learning programs, or off-site training courses. All training must be provided or produced by academic institutions, assisted living corporations, or recognized state or national organizations or associations. Subject matter that deals with the internal affairs of an organization will not qualify for credit.(iii) Evidence of training must be on file at the facility and must contain documentation of content, hours, dates, and provider.(B) A manager who can show documentation of a previously completed comparable course of study are exempt from the training requirements.(C) A manager must complete the training required by subparagraph (A) or (B) of this paragraph, as applicable, by the first anniversary of employment as manager.(D) An assisted living manager who was employed by a licensed assisted living facility as the manager and changes employment to another licensed assisted living facility as the manager, with a break in employment of no longer than 30 days, is exempt from the 24-hour training requirement.(3) Continuing education. All managers must show evidence of 12 hours of annual continuing education. This requirement will be met during the first year of employment by the 24-hour assisted living management course. The annual continuing education requirement must include at least two of the following areas:(A) resident and provider rights and responsibilities, abuse and neglect, and confidentiality;(B) basic principles of management;(C) skills for working with residents, families, and other professional service providers;(D) resident characteristics and needs;(E) community resources;(F) accounting and budgeting;(G) basic emergency first aid; or(H) federal laws, such as the Americans with Disabilities Act of 1990, as amended; the Civil Rights Act of 1991; the Rehabilitation Act of 1973, as amended; the Family and Medical Leave Act of 1993; and the Fair Housing Act, as amended.(4) Manager's responsibilities. The manager must be on duty 40 hours per week and may manage only one facility, except for managers of small Type A facilities, who may have responsibility for no more than 16 residents in no more than four facilities. The managers of small Type A facilities must be available by telephone or pager when conducting facility business off-site.(5) Manager's absence. An employee competent and authorized to act in the absence of the manager must be designated in writing.(b) Attendants. Full-time facility attendants must be at least 18 years old or a high-school graduate.(1) An attendant must be in the facility at all times when residents are in the facility.(2) Attendants are not precluded from performing other functions as required by the facility.(c) Staffing.(1) A facility must develop and implement staffing policies, which require staffing ratios based upon the needs of the residents, as identified in their service plans.(2) Prior to admission, a facility must disclose, to prospective residents and their families, the facility's normal 24-hour staffing pattern and post it monthly in accordance with §553.271 of this subchapter (relating to Postings).(3) A facility must have sufficient staff to:(A) maintain order, safety, and cleanliness;(B) assist with medication regimens;(C) prepare and serve meals that meet the daily nutritional and special dietary needs of each resident, in accordance with each resident's service plan;(D) assist with laundry;(E) assure that each resident receives the kind and amount of supervision and care required to meet his basic needs; and(F) ensure safe evacuation of the facility in the event of an emergency.(4) A facility must meet the staffing requirements described in this subparagraph.(A) Type A facility: Night shift staff in a small facility must be immediately available. In a large facility, the staff must be immediately available and awake.(B) Type B facility: Night shift staff must be immediately available and awake, regardless of the number of licensed beds.(d) Staff training. The facility must document that staff members are competent to provide personal care before assuming responsibilities and have received the following training.(1) All staff members must complete four hours of orientation before assuming any job responsibilities. Training must cover, at a minimum, the following topics:(A) reporting of abuse and neglect;(B) confidentiality of resident information;(C) universal precautions;(D) conditions about which they should notify the facility manager;(E) residents' rights; and(F) emergency and evacuation procedures.(2) Attendants must complete 16 hours of on-the-job supervision and training within the first 16 hours of employment following orientation. Training must include:(A) providing assistance with the activities of daily living;(B) resident's health conditions and how they may affect provision of tasks;(C) safety measures to prevent accidents and injuries;(D) emergency first aid procedures, such as the Heimlich maneuver and actions to take when a resident falls, suffers a laceration, or experiences a sudden change in physical or mental status;(E) managing disruptive behavior;(F) behavior management, for example, prevention of aggressive behavior and de-escalation techniques, practices to decrease the frequency of the use of restraint, and alternatives to restraints; and(G) fall prevention.(3) Direct care staff must complete six documented hours of education annually, based on each employee's hire date. Staff must complete one hour of annual training in fall prevention and one hour of training in behavior management, for example, prevention of aggressive behavior and de-escalation techniques, practices to decrease the frequency of the use of restraint, and alternatives to restraints. Training for these subjects must be competency-based. Subject matter must address the unique needs of the facility. Suggested topics include:(A) promoting resident dignity, independence, individuality, privacy, and choice;(B) resident rights and principles of self-determination;(C) communication techniques for working with residents with hearing, visual, or cognitive impairment;(D) communicating with families and other persons interested in the resident;(E) common physical, psychological, social, and emotional conditions and how these conditions affect residents' care;(F) essential facts about common physical and mental disorders, for example, arthritis, cancer, dementia, depression, heart and lung diseases, sensory problems, or stroke;(G) cardiopulmonary resuscitation;(H) common medications and side effects, including psychotropic medications, when appropriate;(I) understanding mental illness;(J) conflict resolution and de-escalation techniques; and(K) information regarding community resources.(4) Facilities that employ licensed nurses, certified nurse aides, or certified medication aides must provide annual in-service training, appropriate to their job responsibilities, from one or more of the following areas:(A) communication techniques and skills useful when providing geriatric care (skills for communicating with the hearing impaired, visually impaired and cognitively impaired; therapeutic touch; recognizing communication that indicates psychological abuse);(B) assessment and interventions related to the common physical and psychological changes of aging for each body system;(C) geriatric pharmacology, including treatment for pain management, food and drug interactions, and sleep disorders;(D) common emergencies of geriatric residents and how to prevent them, for example falls, choking on food or medicines, injuries from restraint use; recognizing sudden changes in physical condition, such as stroke, heart attack, acute abdomen, acute glaucoma; and obtaining emergency treatment;(E) common mental disorders with related nursing implications; and(F) ethical and legal issues regarding advance directives, abuse and neglect, guardianship, and confidentiality. Source Note: The provisions of this §553.253 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.253 Employee Qualifications and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220834 03/12/2026 (a) A facility that provides personal care services to a resident with Alzheimer's disease or a related disorder that is not an Alzheimer's certified facility must require a staff member to complete competency-based training and annual continuing education on Alzheimer's disease and related disorders in accordance with this section.(1) The training required in this section may be included as part of the initial training and continuing education required in §553.253 of this subchapter (relating to Employee Qualifications and Training).(2) The training required in this section may satisfy the training required by facility policy under §553.255 of this subchapter (relating to All Staff Policy for Residents with Alzheimer's Disease or a Related Disorder).(b) A facility must require a manager to:(1) complete four hours of training and pass a competency-based evaluation on:(A) Alzheimer's disease and related disorders;(B) provision of person-centered care;(C) assessment and care planning;(D) activities of daily living for a resident with Alzheimer's disease or a related disorder;(E) common behaviors and communications associated with residents with Alzheimer's disease or related disorders;(F) administrative support services related to information for:(i) comorbidities management;(ii) care planning;(iii) provision of medically appropriate education and support services and resources in the community; and(iv) including person-centered care to residents with Alzheimer's disease or related disorders and the resident's family;(G) staffing requirements that will:(i) facilitate collaboration and cooperation among facility staff members; and(ii) ensure each staff member obtains appropriate informational materials and training to properly care for and interact with a resident with Alzheimer's disease or a related disorder based on the staff member's position;(H) establishing a supportive and therapeutic environment for residents with Alzheimer's disease or related disorders to enhance the sense of community among the residents and within the facility; and(I) transitioning care and coordination of services for residents with Alzheimer's disease or related disorders; and(2) after the date of successfully completing the training and competency-based evaluation required in paragraph (1) of this subsection, complete two hours of annual continuing education on best practices related to treatment and provision of care to residents with Alzheimer's disease or related disorders.(c) A facility must require a staff member who provides personal care services to:(1) complete four hours of training and pass a competency-based evaluation on:(A) Alzheimer's disease and related disorders;(B) provision of person-centered care;(C) assessment and care planning;(D) activities of daily living for a resident with Alzheimer's disease or a related disorder; and(E) common behaviors and communications associated with a resident with Alzheimer's disease and related disorders;(2) complete the requirements in paragraph (1) of this subsection prior to performing personal care services; and(3) after successfully completing the training and competency-based evaluation required in paragraph (1) of this subsection, complete two hours of continuing education that includes best practices related to the treatment of and provision of care to residents with Alzheimer's disease or related disorders.(d) A facility must require each staff member who is not a direct service staff member, including housekeeping staff, front desk staff, maintenance staff, and other staff members with incidental but recurring contact with a resident with Alzheimer's disease or a related disorder, to complete training and pass a competency-based evaluation on:(1) Alzheimer's disease and related disorders;(2) provision of person-centered care; and(3) common behaviors and communications associated with a resident with Alzheimer's disease and related disorders.(e) A facility must:(1) provide the training completion certificate to the staff member, including the manager; and(2) maintain records of each certificate for all staff, including the manager, in accordance with the facility's records retention policies.(f) A facility staff member who successfully completes the training required by this section, passes the evaluation, and then transfers employment to another facility is not required to satisfy these requirements for the new facility if there is less than a two-year lapse of employment with a facility. Source Note: The provisions of this §553.254 adopted to be effective September 12, 2024, 49 TexReg 7044. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.254 Training Requirements for Staff Providing Personal Care Services to a Resident With Alzheimer's Disease or a Related Disorder in a Facility that is Not an Alzheimer's Certified Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220835 03/12/2026 (a) A facility must adopt, implement, and enforce a written policy that:(1) requires a facility employee who provides direct care to a resident with Alzheimer's disease or a related disorder to successfully complete training in the provision of care to residents with Alzheimer's disease and related disorders; and(2) ensures the care and services provided by a facility employee to a resident with Alzheimer's disease or a related disorder meet the specific identified needs of the resident relating to the diagnosis of Alzheimer's disease or a related disorder.(b) The training required for facility employees under subsection (a)(1) of this section may be satisfied by completing the training required under §553.254 of this subchapter (relating to Training Requirements for Staff Providing Personal Care Services to a Resident With Alzheimer's Disease or a Related Disorder in a Facility that is Not an Alzheimer's Certified Facility) or §553.303 of this chapter (relating to Staff Training) but must include information about:(1) symptoms of dementia;(2) stages of Alzheimer's disease;(3) person-centered behavioral interventions; and(4) communication with a resident with Alzheimer's disease or a related disorder. Source Note: The provisions of this §553.255 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective September 12, 2024, 49 TexReg 7044. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.255 All Staff Policy for Residents with Alzheimer's Disease or a Related Disorder https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220836 03/12/2026 (a) Personnel records. A facility must keep current and complete personnel records on a facility employee for review by HHSC staff including:(1) documentation that the facility performed a criminal history check;(2) an annual employee misconduct registry check;(3) an annual nurse aide registry check;(4) documentation of initial tuberculosis screenings referenced in §553.261(f) of this subchapter (relating to Coordination of Care);(5) documentation of the employee's compliance with or exemption from the facility vaccination policy referenced in §553.261(f) of this subchapter;(6) the signed statement from the employee referenced in §553.273 of this subchapter (relating to Abuse, Neglect, or Exploitation Reportable to HHSC by Facilities), acknowledging that the employee may be criminally liable for the failure to report abuse, neglect, and exploitation; and(7) a signed disclosure statement, indicating whether the employee:(A) has been convicted of an offense described in Texas Health and Safety Code §250.006; and(B) has lived in a state other than Texas within the past five years.(b) Investigation of facility employees.(1) A facility must comply with the provisions of Texas Health and Safety Code, Chapter 250.(2) Before a facility hires an employee, the facility must search the employee misconduct registry (EMR) established under §253.007, Texas Health and Safety Code, and the HHSC nurse aide registry (NAR) to determine if the individual is designated in either registry as unemployable based on employee misconduct. Both registries can be accessed on the HHSC Internet website.(3) A facility is prohibited from hiring or continuing to employ a person who is listed in the EMR or NAR as unemployable or who has been convicted of an offense listed in Texas Health and Safety Code §250.006 as a bar to employment or is a contraindication to employment with the facility.(4) A facility must provide notification about the EMR to an employee in accordance with §561.3 of this title (relating to Employment and Registry Information).(5) In addition to the initial search of the NAR and the EMR, a facility must conduct a search of the NAR and the EMR to determine if the employee is designated in either registry as unemployable at least every 12 months.(6) A facility must keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file.(7) If an applicant for employment indicates on the disclosure statement that he or she have lived in another state within the past five years, the facility must conduct a name-based criminal history check in each state in which the applicant previously resided within the five-year period. A facility may hire the applicant pending the results of the name-based criminal history check in each state, but the employee must not be in a position that has direct contact with residents.(8) If HHSC determines that a facility employee has engaged in reportable conduct, the facility must:(A) suspend the employment of the employee while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review conducted in accordance with Texas Health and Safety Code §253.004 or §253.005, pending a final decision by an administrative law judge; and(B) not reinstate the employee's employment during the course of any applicable appeals process.(9) For the purpose of paragraph (8) of this subsection, reportable conduct includes:(A) abuse or neglect that causes or may cause death or harm to a resident;(B) sexual abuse of a resident;(C) financial exploitation of a resident in an amount of $25 or more; and(D) emotional, verbal, or psychological abuse that causes harm to a resident. Source Note: The provisions of this §553.257 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective December 6, 2022, 47 TexReg 7705; amended to be effective September 12, 2024, 49 TexReg 7044. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.257 Human Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220820 03/12/2026 (a) Admission policies and disclosure statement.(1) A facility must not admit or retain a resident whose needs cannot be met by the facility and who cannot secure the necessary services from an outside resource. As part of the facility's general supervision and oversight of the physical and mental well-being of its residents, the facility remains responsible for all care provided at the facility. If the individual is appropriate for placement in a facility, then the decision that additional services are necessary and can be secured is the responsibility of facility management with written concurrence of the resident, resident's attending physician, or legal representative. Regardless of the possibility of "aging in place" or securing additional services, the facility must meet all NFPA 101 and physical plant requirements in Subchapter D of this chapter (relating to Facility Construction), and, as applicable, §553.311 (relating to Physical Plant Requirements for Alzheimer's Units), based on each resident's evacuation capabilities, except as provided in subsection (e) of this section.(2) There must be a written admission agreement between the facility and the resident. The agreement must specify such details as services to be provided and the charges for the services. If the facility provides services and supplies that could be a Medicare benefit, the facility must provide the resident a statement that such services and supplies could be a Medicare benefit.(3) A facility must share a copy of the facility disclosure statement, rate schedule, and individual resident service plan with outside resources that provide any additional services to a resident. Outside resources must provide facilities with a copy of their resident care plans and must document, at the facility, any services provided, on the day provided.(4) In addition to the facility disclosure statement, a facility that advertises, markets, or otherwise promotes that it provides services, including memory care services, to residents with Alzheimer's disease and related disorders, must provide to each resident the Assisted Living Facility Memory Care Disclosure Statement. The facility must disclose whether the facility is certified to provide specialized care to residents with Alzheimer's disease or related disorders.(A) A facility that is Alzheimer's certified and provides the Assisted Living Facility Memory Care Disclosure Statement to a resident, must also provide HHSC Form 3641, Alzheimer's Assisted Living Facility Disclosure Statement.(B) A facility that is not Alzheimer's certified and provides the Assisted Living Facility Memory Care Disclosure Statement, to a resident does not need to provide HHSC form 3641, Alzheimer's Assisted Living Disclosure Statement.(5) Each resident must have a health examination by a physician performed within 30 days before admission or 14 days after admission, unless a transferring hospital or facility has a physical examination in the medical record.(6) The facility must secure at the time of admission of a resident the following identifying information:(A) full name of resident;(B) social security number;(C) usual residence (where resident lived before admission);(D) sex;(E) marital status;(F) date of birth;(G) place of birth;(H) usual occupation (during most of working life);(I) family, other persons named by the resident, and physician for emergency notification;(J) pharmacy preference; and(K) Medicaid/Medicare number, if available.(b) Resident assessment and service plan. Within 14 days of admission, a resident comprehensive assessment and an individual service plan for providing care, which is based on the comprehensive assessment, must be completed. The comprehensive assessment must be completed by the appropriate staff and documented on a form developed by the facility. When a facility is unable to obtain information required for the comprehensive assessment, the facility should document its attempts to obtain the information.(1) The comprehensive assessment must include the following items:(A) the location from which the resident was admitted;(B) primary language;(C) sleep-cycle issues;(D) behavioral symptoms;(E) psychosocial issues (e.g., a psychosocial functioning assessment that includes an assessment of mental or psychosocial adjustment difficulty; a screening for signs of depression, such as withdrawal, anger or sad mood; assessment of the resident's level of anxiety; and determining if the resident has a history of psychiatric diagnosis that required in-patient treatment);(F) Alzheimer's disease/dementia history;(G) activities of daily living patterns (e.g., wakened to toilet all or most nights, bathed in morning/night, shower or bath);(H) involvement patterns and preferred activity pursuits (e.g., daily contact with relatives, friends, usually attended religious services, involved in group activities, preferred activity settings, general activity preferences);(I) cognitive skills for daily decision-making (e.g., independent, modified independence, moderately impaired, severely impaired);(J) communication (e.g, ability to communicate with others, communication devices);(K) physical functioning (e.g, transfer status; ambulation status; toilet use; personal hygiene; ability to dress, feed and groom self);(L) continence status;(M) nutritional status (e.g., weight changes, nutritional problems or approaches);(N) oral/dental status;(O) diagnoses;(P) medications (e.g., administered, supervised, self-administers);(Q) health conditions and possible medication side effects;(R) special treatments and procedures;(S) hospital admissions within the past six months or since last assessment; and(T) preventive health needs (e.g., blood pressure monitoring, hearing-vision assessment).(2) The service plan must be approved and signed by the resident or a person responsible for the resident's health care decisions. The facility must provide care according to the service plan. The service plan must be updated annually and upon a significant change in condition, based upon an assessment of the resident.(3) For respite clients, the facility may keep a service plan for six months from the date on which it is developed. During that period, the facility may admit the individual as frequently as needed.(4) Emergency admissions must be assessed and a service plan developed for them.(c) Resident policies.(1) Before admitting a resident, facility staff must explain and provide a copy of the disclosure statement to the resident, family, or responsible party. A facility that provides brain injury rehabilitation services must attach to its disclosure statement a specific statement that licensure as an assisted living facility does not indicate state review, approval, or endorsement of the facility's rehabilitative services. The facility must document receipt of the disclosure statement.(2) The facility must provide residents with a copy of the Resident's Bill of Rights.(3) When a resident is admitted, the facility must provide to the resident's immediate family, and document the family's receipt of, the HHSC telephone hotline number to report suspected abuse, neglect, or exploitation, as referenced in §553.273 of this subchapter (relating to Abuse, Neglect, or Exploitation Reportable to HHSC by Facilities).(4) The facility must have written policies regarding residents accepted, services provided, charges, refunds, responsibilities of facility and residents, privileges of residents, and other rules and regulations.(5) The facility must make available copies of the resident policies to staff and to residents or residents' responsible parties at time of admission. Documented notification of any changes to the policies must occur before the effective date of the changes.(6) Before or upon admission of a resident, a facility must notify the resident and, if applicable, the resident's legally authorized representative, of HHSC rules and the facility's policies related to restraint and seclusion.(7) The facility must provide a resident and the resident's legally authorized representative with a written copy of the facility's emergency preparedness plan or an evacuation summary, as required under §553.275(d) of this subchapter (relating to Emergency Preparedness and Response).(d) Advance directives.(1) The facility must maintain written policies regarding the implementation of advance directives. The policies must include a clear and precise statement of any procedure the facility is unwilling or unable to provide or withhold in accordance with an advance directive.(2) The facility must provide written notice of these policies to residents at the time they are admitted to receive services from the facility.(A) If, at the time notice is to be provided, the resident is incompetent or otherwise incapacitated and unable to receive the notice, the facility must provide the written notice, in the following order of preference, to:(i) the resident's legal guardian;(ii) a person responsible for the resident's health care decisions;(iii) the resident's spouse;(iv) the resident's adult child;(v) the resident's parents; or(vi) the person admitting the resident.(B) If the facility is unable, after diligent search, to locate an individual listed under subparagraph (A) of this paragraph, the facility is not required to give notice.(3) If a resident who was incompetent or otherwise incapacitated and unable to receive notice regarding the facility's advance directives policies later becomes able to receive the notice, the facility must provide the written notice at the time the resident becomes able to receive the notice.(4) HHSC imposes an administrative penalty of $500 for failure to inform the resident of facility policies regarding the implementation of advance directives.(A) HHSC sends a facility written notice of the recommendation for an administrative penalty.(B) Within 20 days after the date on which HHSC sends written notice to a facility, the facility must give written consent to the penalty or make written request to HHSC for an administrative hearing.(C) Hearings are held in accordance with the formal hearing procedures at 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedures Act).(e) Inappropriate placement in Type A or Type B facilities.(1) HHSC or a facility may determine that a resident is inappropriately placed in the facility if the resident experiences a change of condition but continues to meet the facility evacuation criteria.(A) If HHSC determines the resident is inappropriately placed and the facility is willing to retain the resident, the facility is not required to discharge the resident if, within 10 working days after receiving the Statement of Licensing Violations and Plan of Correction, Form 3724, and the Report of Contact, Form 3614-A, from HHSC, the facility submits the following to the HHSC regional office:(i) Physician's Assessment, Form 1126, indicating that the resident is appropriately placed and describing the resident's medical conditions and related nursing needs, ambulatory and transfer abilities, and mental status;(ii) Resident's Request to Remain in Facility, Form 1125, indicating that:(I) the resident wants to remain at the facility; or(II) if the resident lacks capacity to provide a written statement, the resident's family member or legally authorized representative wants the resident to remain at the facility; and(iii) Facility Request, Form 1124, indicating that the facility agrees that the resident may remain at the facility.(B) If the facility initiates the request for an inappropriately placed resident to remain in the facility, the facility must complete and date the forms described in subparagraph (A) of this paragraph and submit them to the HHSC regional office within 10 working days after the date the facility determines the resident is inappropriately placed, as indicated on the HHSC prescribed forms.(2) HHSC or a facility may determine that a resident is inappropriately placed in the facility if the facility does not meet all requirements for the evacuation of a designated resident referenced in §553.5 of this chapter (relating to Types of Assisted Living Facilities).(A) If, during a site visit, HHSC determines that a resident is inappropriately placed at the facility and the facility is willing to retain the resident, the facility must request an evacuation waiver, as described in subparagraph (C) of this paragraph, to the HHSC regional office within 10 working days after the date the facility receives the Statement of Licensing Violations and Plan of Correction, Form 3724, and the Report of Contact, Form 3614-A. If the facility is not willing to retain the resident, the facility must discharge the resident within 30 days after receiving the Statement of Licensing Violations and Plan of Correction and the Report of Contact.(B) If the facility initiates the request for a resident to remain in the facility, the facility must request an evacuation waiver, as described in subparagraph (C) of this paragraph, from the HHSC regional office within 10 working days after the date the facility determines the resident is inappropriately placed, as indicated on the HHSC prescribed forms.(C) To request an evacuation waiver for an inappropriately placed resident, a facility must submit to the HHSC regional office:(i) Physician's Assessment, Form 1126, indicating that the resident is appropriately placed and describing the resident's medical conditions and related nursing needs, ambulatory and transfer abilities, and mental status;(ii) Resident's Request to Remain in Facility, Form 1125, indicating that:(I) the resident wants to remain at the facility; or(II) if the resident lacks capacity to provide a written statement, the resident's family member or legally authorized representative wants the resident to remain at the facility;(iii) Facility Request, Form 1124, indicating that the facility agrees that the resident may remain at the facility;(iv) a detailed emergency plan that explains how the facility will meet the evacuation needs of the resident, including:(I) specific staff positions that will be on duty to assist with evacuation and their shift times;(II) specific staff positions that will be on duty and awake at night; and(III) specific staff training that relates to resident evacuation;(v) a copy of an accurate facility floor plan, to scale, that labels all rooms by use and indicates the specific resident's room;(vi) a copy of the facility's emergency evacuation plan;(vii) a copy of the facility fire drill records for the last 12 months;(viii) a copy of a completed Fire Marshal/State Fire Marshal Notification, Form 1127, signed by the fire authority having jurisdiction (either the local Fire Marshal or State Fire Marshal) as an acknowledgement that the fire authority has been notified that the resident's evacuation capability has changed;(ix) a copy of a completed Fire Suppression Authority Notification, Form 1129, signed by the local fire suppression authority as an acknowledgement that the fire suppression authority has been notified that the resident's evacuation capability has changed;(x) a copy of the resident's most recent comprehensive assessment that addresses the areas required by subsection (c) of this section and that was completed within 60 days, based on the date stated on the evacuation waiver form submitted to HHSC;(xi) the resident's service plan that addresses all aspects of the resident's care, particularly those areas identified by HHSC, including:(I) the resident's medical condition and related nursing needs;(II) hospitalizations within 60 days, based on the date stated on the evacuation waiver form submitted to HHSC;(III) any significant change in condition in the last 60 days, based on the date stated on the evacuation waiver form submitted to HHSC;(IV) specific staffing needs; and(V) services that are provided by an outside provider;(xii) any other information that relates to the required fire safety features of the facility that will ensure the evacuation capability of any resident; and(xiii) service plans of other residents, if requested by HHSC.(D) A facility must meet the following criteria to receive a waiver from HHSC:(i) The emergency plan submitted in accordance with subparagraph (C)(iv) of this paragraph must ensure that:(I) staff is adequately trained;(II) a sufficient number of staff are on all shifts to move all residents to a place of safety;(III) residents will be moved to appropriate locations, given health and safety issues;(IV) all possible locations of fire origin areas and the necessity for full evacuation of the building are addressed;(V) the fire alarm signal is adequate;(VI) there is an effective method for warning residents and staff during a malfunction of the building fire alarm system;(VII) there is a method to effectively communicate the actual location of the fire; and(VIII) the plan satisfies any other safety concerns that could have an effect on the residents' safety in the event of a fire; and(ii) the emergency plan will not have an adverse effect on other residents of the facility who have waivers of evacuation or who have special needs that require staff assistance.(E) HHSC reviews the documentation submitted under this subsection and notifies the facility in writing of its determination to grant or deny the waiver within 10 working days after the date the request is received in the HHSC regional office.(F) Upon notification that HHSC has granted the evacuation waiver, the facility must immediately initiate all provisions of the proposed emergency plan. If the facility does not follow the emergency plan, and there are health and safety concerns that are not addressed, HHSC may determine that there is an immediate threat to the health or safety of a resident.(G) HHSC reviews a waiver of evacuation during the facility's annual renewal licensing inspection.(3) If an HHSC surveyor determines that a resident is inappropriately placed at a facility and the facility either agrees with the determination or fails to obtain the written statements or waiver required in this subsection, the facility must discharge the resident.(A) The resident is allowed 30 days after the date of notice of discharge to move from the facility.(B) A discharge required under this subsection must be made notwithstanding:(i) any other law, including any law relating to the rights of residents and any obligations imposed under the Property Code; and(ii) the terms of any contract.(4) If a facility is required to discharge the resident because the facility has not submitted the written statements required by paragraph (1) of this subsection to the HHSC regional office, or HHSC denies the waiver as described in paragraph (2) of this subsection, HHSC may:(A) assess an administrative penalty if HHSC determines the facility has intentionally or repeatedly disregarded the waiver process because the resident is still residing in the facility when HHSC conducts a future onsite visit; or(B) seek other sanctions, including an emergency suspension or closing order, against the facility under Texas Health and Safety Code, Chapter 247, Subchapter C, if HHSC determines there is a significant risk and immediate threat to the health and safety of a resident of the facility.(5) The facility's disclosure statement must notify the resident and resident's legally authorized representative of the waiver process described in this section and the facility's policies and procedures for aging in place.(6) After the first year of employment and no later than the anniversary date of the facility manager's hire date, the manager must show evidence of annual completion of HHSC training on aging in place and retaliation. Source Note: The provisions of this §553.259 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective December 6, 2022, 47 TexReg 7705. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.259 Admission Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220821 03/12/2026 (a) Medications.(1) Administration. Medications must be administered according to physician's orders.(A) Residents who choose not to or cannot self-administer their medications must have their medications administered by a person who:(i) holds a current license under state law that authorizes the licensee to administer medication;(ii) holds a current medication aide permit and who:(I) acts under the authority of a person who holds a current nursing license under state law that authorizes the licensee to administer medication; and(II) functions under the direct supervision of a licensed nurse on duty or on call by the facility; or(iii) is an employee of the facility to whom medication administration has been delegated by a registered nurse, who has trained the employee to administer medications or verified their training. The delegation of the medication administration is governed by 22 TAC Chapter 225 (concerning RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions), which implements the Nursing Practice Act.(B) Each resident's prescribed medication must be dispensed through a pharmacy or by the resident's treating physician or dentist.(C) Physician sample medications may be given to a resident by the facility provided the medication has specific dosage instructions for the individual resident.(D) Each resident's medications must be listed on the individual resident's medication profile record. The recorded information obtained from the prescription label must include the medication:(i) name;(ii) strength;(iii) dosage;(iv) amount received;(v) directions for use;(vi) route of administration;(vii) prescription number;(viii) pharmacy name; and(ix) the date each medication was issued by the pharmacy.(2) Supervision. Supervision of a resident's medication regimen by facility staff may be provided to residents who are incapable of self-administering without assistance to include and be limited to:(A) reminders to take their medications at the prescribed time;(B) opening containers or packages and replacing lids;(C) pouring prescribed dosage according to medication profile record;(D) returning medications to the proper locked areas;(E) obtaining medications from a pharmacy; and(F) listing on an individual resident's medication profile record the medication:(i) name;(ii) strength;(iii) dosage;(iv) amount received;(v) directions for use;(vi) route of administration;(vii) prescription number;(viii) pharmacy name; and(ix) the date each medication was issued by the pharmacy.(3) Self-administration.(A) Residents who self-administer their own medications and keep them locked in their room must be counseled at least once a month by facility staff to ascertain if the residents continue to be capable of self-administering their medications or treatments and if security of medications can continue to be maintained. The facility must keep a written record of counseling.(B) Residents who choose to keep their medications locked in the central medication storage area may be permitted entrance or access to the area for the purpose of self-administering their own medication or treatment regimen. A facility staff member must remain in or at the storage area the entire time any resident is present.(4) General.(A) Facility staff will immediately report to the resident's physician and responsible party any unusual reactions to medications or treatments.(B) When the facility supervises or administers the medications, a written record must be kept when the resident does not receive or take his or her medications or treatments as prescribed. The documentation must include the date and time the dose should have been taken, and the name and strength of medication missed; however, the recording of missed doses of medication does not apply when the resident is away from the facility.(5) Storage.(A) The facility must provide a locked area for all medications. Examples of areas include:(i) central storage area;(ii) medication cart; and(iii) resident room.(B) Each resident's medication must be stored separately from other resident's medications within the storage area.(C) A refrigerator must have a designated and locked storage area for medications that require refrigeration, unless it is inside a locked medication room.(D) Poisonous substances and medications labeled for "external use only" must be stored separately within the locked medication area.(E) If facilities store controlled drugs, facility policies and procedures must address the prevention of the diversion of the controlled drugs.(6) Disposal.(A) Medications no longer being used by the resident for the following reasons are to be kept separate from current medications and are to be disposed of by a registered pharmacist licensed in the State of Texas:(i) medications discontinued by order of the physician;(ii) medications that remain after a resident is deceased; or(iii) medications that have passed the expiration date.(B) Needles and hypodermic syringes with needles attached must be disposed as required by 25 TAC §§1.131 - 1.137.(C) Medications kept in a central storage area are released to discharged residents when a receipt has been signed by the resident or responsible party.(b) Accident, injury, or acute illness.(1) In the event of accident or injury that requires emergency medical, dental or nursing care, or in the event of apparent death, the facility will(A) make arrangements for emergency care or transfer to an appropriate place for treatment, such as a physician's office, clinic, or hospital;(B) immediately notify the resident's physician and next of kin, responsible party, or agency who placed the resident in the facility; and(C) describe and document the injury, accident, or illness on a separate report. The report must contain a statement of final disposition and be maintained on file.(2) The facility must stock and maintain in a single location first aid supplies to treat burns, cuts, and poisoning.(3) Residents who need the services of professional nursing or medical personnel due to a temporary illness or injury may have those services delivered by persons qualified to deliver the necessary service.(c) Health Care Professional.(1) A health care professional may coordinate the provision of services to a resident within the professional's scope of practice and as authorized under Texas Health and Safety Code, Chapter 247, however, a facility must not provide ongoing services to a resident that are comparable to the services available in a nursing facility licensed under Texas Health and Safety Code, Chapter 242.(2) A resident may contract with a home and community support services agency licensed under Chapter 558 of this title, or with an independent health professional, to have health care services delivered to the resident at the facility.(d) Activities program. The facility must provide an activity or social program at least weekly for the residents.(e) Dietary services.(1) A person designated by the facility is responsible for the total food service of the facility.(2) At least three meals or their equivalent must be served daily, at regular times, with no more than a 16-hour span between a substantial evening meal and breakfast the following morning. All exceptions must be specifically approved by HHSC.(3) Menus must be planned one week in advance and must be followed. Variations from the posted menus must be documented. Menus must be prepared to provide a balanced and nutritious diet, such as that recommended by the National Food and Nutrition Board. Food must be palatable and varied. Records of menus as served must be filed and maintained for 30 days after the date of serving.(4) Therapeutic diets as ordered by the resident's physician must be provided according to the service plan. Therapeutic diets that cannot customarily be prepared by a layperson must be calculated by a qualified dietician. Therapeutic diets that can customarily be prepared by a person in a family setting may be served by the facility.(5) Supplies of staple foods for a minimum of a four-day period and perishable foods for a minimum of a one-day period must be maintained on the premises.(6) Food must be obtained from sources that comply with all laws relating to food and food labeling. If food subject to spoilage is removed from its original container, it must be kept sealed and labeled. Food subject to spoilage must also be dated.(7) Plastic containers with tight fitting lids are acceptable for storage of staple foods in the pantry.(8) Potentially hazardous food, such as meat and milk products, must be stored at 45 degrees Fahrenheit or below. Hot food must be kept at 140 degrees Fahrenheit or above during preparation and serving. Food that is reheated must be heated to a minimum of 165 degrees Fahrenheit.(9) Freezers must be kept at a temperature of 0 degrees Fahrenheit or below and refrigerators must be 41 degrees Fahrenheit or below. Thermometers must be placed in the warmest area of the refrigerator and freezer to assure proper temperature.(10) Food must be prepared and served with the least possible manual contact, with suitable utensils, and on surfaces that have been cleaned, rinsed, and sanitized before use to prevent cross-contamination.(11) Facilities must prepare food in accordance with established food preparation practices and safety techniques.(12) A food service employee, while infected with a communicable disease that can be transmitted by foods, or who is a carrier of organisms that cause such a disease or while afflicted with a boil, an infected wound, or an acute respiratory infection, must not work in the food service area in any capacity in which there is a likelihood of such person contaminating food or food-contact surfaces with pathogenic organisms or transmitting disease to other persons.(13) Effective hair restraints must be worn to prevent the contamination of food.(14) Tobacco products must not be used in the food preparation and service areas.(15) Kitchen employees must wash their hands before returning to work after using the lavatory.(16) Dishwashing chemicals used in the kitchen may be stored in plastic containers if they are the original containers in which the manufacturer packaged the chemicals.(17) Sanitary dishwashing procedures and techniques must be followed.(18) Facilities that house 17 or more residents must comply with 25 TAC Chapter 228 (relating to Retail Food) and local health ordinances or requirements must be observed in the storage, preparation, and distribution of food; in the cleaning of dishes, equipment, and work area; and in the storage and disposal of waste.(f) Infection prevention and control.(1) Each facility must establish, implement, enforce, and maintain an infection prevention and control policy and procedure designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.(2) The facility must comply with rules regarding special waste in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(3) The facility must immediately report the name of any resident of a facility with a reportable disease as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority.(4) The facility must have, implement, enforce, and maintain written policies for the control of communicable disease among employees and residents, which must address tuberculosis (TB) screening and provision of a safe and sanitary environment for residents and employees.(A) If an employee contracts a communicable disease that is transmissible to residents through food handling or direct resident care, the facility must exclude the employee from providing these services for the applicable period of communicability.(B) The facility must maintain evidence of compliance with local and state health codes or ordinances regarding employee and resident health status.(C) The facility must screen all employees for TB within two weeks of employment and annually, according to Centers for Disease Control and Prevention (CDC) screening guidelines. All persons who provide services under an outside resource contract must, upon request of the facility, provide evidence of compliance with this requirement.(D) The facility's policies and practices for resident TB screening must ensure compliance with the recommendations of a resident's attending physician and consistency with CDC guidelines.(5) The facility's infection prevention and control program established under paragraph (1) of this subsection must include written policies and procedures for:(A) monitoring key infectious agents, including multidrug-resistant organisms, as those terms are respectively defined in §553.3 of this chapter (relating to Definitions);(B) wearing personal protective equipment, such as gloves, a gown, or a mask when called on for anticipated exposure, and properly cleaning hands before and after touching another resident;(C) cleaning and disinfecting environmental surfaces, including door knobs, handrails, light switches, and hand held electronic control devices;(D) using universal precautions for blood and bodily fluids; and(E) removing soiled items (such as used tissues, wound dressings, incontinence briefs, and soiled linens) from the environment at least once daily, or more often if an infection or infectious disease is present or suspected.(6) The facility must establish, implement, enforce, and maintain a written policy and procedures for making a rapid influenza diagnostic test, as defined in §553.3 of this chapter, available to a resident who is exhibiting flu like symptoms.(7) Personnel must handle, store, process, and transport linens to prevent the spread of infection.(8) A facility must use universal precautions in the care of all residents.(9) A facility must establish, implement, enforce, and maintain a written policy to protect a resident from vaccine preventable diseases in accordance with Texas Health and Safety Code, Chapter 224.(A) The policy must:(i) require an employee or a contractor providing direct care to a resident to receive vaccines for the vaccine preventable diseases specified by the facility based on the level of risk the employee or contractor presents to residents by the employee's or contractor's routine and direct exposure to residents;(ii) specify the vaccines an employee or contractor is required to receive in accordance with clause (i) of this subparagraph;(iii) include procedures for the facility to verify that an employee or contractor has complied with the policy;(iv) include procedures for the facility to exempt an employee or contractor from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC;(v) include procedures the employee or contractor must follow to protect residents from exposure to disease for an employee or contractor who is exempt from the required vaccines, such as the use of protective equipment, like gloves and masks, based on the level of risk the employee or contractor presents to residents by the employee's or contractor's routine and direct exposure to residents;(vi) prohibit discrimination or retaliatory action against an employee or contractor who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC, except that required use of protective medical equipment, including gloves and masks, may not be considered retaliatory action;(vii) require the facility to maintain a written or electronic record of each employee's or contractor's compliance with or exemption from the policy; and(viii) include disciplinary actions the facility may take against an employee or contractor who fails to comply with the policy.(B) The policy may:(i) include procedures for an employee or contractor to be exempt from the required vaccines based on reasons of conscience, including religious beliefs; and(ii) prohibit an employee or contractor who is exempt from the required vaccines from having contact with residents during a public health disaster, as defined in Texas Health and Safety Code §81.003.(g) Restraints and seclusion. All restraints for purposes of behavioral management, staff convenience, or resident discipline are prohibited. Seclusion is prohibited.(1) As provided in §553.267(a)(3) of this subchapter (relating to Rights), a facility may use physical or chemical restraints only:(A) if the use is authorized in writing by a physician and specifies:(i) the circumstances under which a restraint may be used; and(ii) the duration for which the restraint may be used; or(B) if the use is necessary in an emergency to protect the resident or others from injury.(2) A behavioral emergency is a situation in which severely aggressive, destructive, violent, or self-injurious behavior exhibited by a resident:(A) poses a substantial risk of imminent probable death of, or substantial bodily harm to, the resident or others;(B) has not abated in response to attempted preventive de-escalatory or redirection techniques;(C) could not reasonably have been anticipated; and(D) is not addressed in the resident's service plan.(3) Except in a behavioral emergency, a restraint must be administered only by qualified medical personnel.(4) A restraint must not be administered under any circumstance if it:(A) obstructs the resident's airway, including a procedure that places anything in, on, or over the resident's mouth or nose;(B) impairs the resident's breathing by putting pressure on the resident's torso;(C) interferes with the resident's ability to communicate; or(D) places the resident in a prone or supine position.(5) If a facility uses a restraint hold in a circumstance described in paragraph (2) of this subsection, the facility must use an acceptable restraint hold.(A) An acceptable restraint hold is a hold in which the individual's limbs are held close to the body to limit or prevent movement and that does not violate the provisions of paragraph (4) of this subsection.(B) After the use of restraint, the facility must:(i) with the resident's consent, make an appointment with the resident's physician no later than the end of the first working day after the use of restraint and document in the resident's record that the appointment was made; or(ii) if the resident refuses to see the physician, document the refusal in the resident's record.(C) As soon as possible but no later than 24 hours after the use of restraint, the facility must notify one of the following persons, if there is such a person, that the resident has been restrained:(i) the resident's legally authorized representative; or(ii) an individual actively involved in the resident's care, unless the release of this information would violate other law.(D) If, under the Health Insurance Portability and Accountability Act, the facility is a "covered entity," as defined in 45 CFR §160.103, any notification provided under subparagraph (C)(ii) of this paragraph must be to a person to whom the facility is allowed to release information under 45 CFR §164.510.(6) In order to decrease the frequency of the use of restraint, facility staff must be aware of and adhere to the findings of the resident assessment required in §553.259(b) of this subchapter (relating to Admission Policies and Procedures) for each resident.(7) A facility may adopt policies that allow less use of restraint than allowed by the rules of this chapter.(8) A facility may not discharge or otherwise retaliate against:(A) an employee, resident, or other person because the employee, resident, or other person files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of restraint or seclusion at the facility; or(B) a resident because someone on behalf of the resident files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of restraint or seclusion at the facility.(h) Wheelchair self-release seat belts.(1) For the purposes of this section, a "self-release seat belt" is a seat belt on a resident's wheelchair that the resident demonstrates the ability to fasten and release without assistance. A self-release seat belt is not a restraint.(2) Except as provided in paragraph (3) of this subsection, a facility must allow a resident to use a self-release seat belt if:(A) the resident or the resident's legal guardian requests that the resident use a self-release seat belt;(B) the resident consistently demonstrates the ability to fasten and release the self-release seat belt without assistance;(C) the use of the self-release seat belt is documented in and complies with the resident's individual service plan; and(D) the facility receives written authorization, signed by the resident or the resident's legal guardian, for the resident to use the self-release seat belt.(3) A facility that advertises as a restraint-free facility is not required to allow a resident to use a self-release seat belt if the facility:(A) provides a written statement to all residents that the facility is restraint-free and is not required to allow a resident to use a self-release seat belt; and(B) makes reasonable efforts to accommodate the concerns of a resident who requests a self-release seat belt in accordance with paragraph (2) of this subsection.(4) A facility is not required to continue to allow a resident to use a self-release seat belt in accordance with paragraph (2) of this subsection if:(A) the resident cannot consistently demonstrate the ability to fasten and release the seat belt without assistance;(B) the use of the self-release seat belt does not comply with the resident's individual service plan; or(C) the resident or the resident's legal guardian revokes in writing the authorization for the resident to use the self-release seat belt. Source Note: The provisions of this §553.261 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.261 Coordination of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220822 03/12/2026 (a) A facility may allow personal care staff to perform a health maintenance activity (HMA) for a resident, without being delegated, only if:(1) the activity is performed for a person with a functional disability as defined in §553.3 of this chapter (relating to Definitions);(2) a registered nurse (RN) acting on behalf of the facility conducts and documents an assessment in accordance with subsection (b) of this section, and determines, based on the assessment, that the activity qualifies as an HMA not requiring delegation; and(3) the facility ensures and documents that all the conditions and requirements of subsection (c) of this section are met:(A) the resident, the resident's legally authorized representative, or other adult chosen by the resident, as applicable, is willing and able to direct personal care staff to perform the task without RN supervision; and(B) the resident, the resident's legally authorized representative, or other adult chosen by the resident, as applicable, is willing and able and has agreed in writing, to participate in directing the personal care staff's actions in carrying out the HMA;(4) the activity addresses a condition that is stable and predictable, as defined in §553.3 of this chapter; and(5) the activity is performed for a resident who could perform the task on his or her own but for a functional disability that prevents it.(b) The RN conducting an assessment for purposes of subsection (a)(1) of this section must conduct it in accordance with Board of Nursing rules at 22 TAC §225.6 (relating to RN Assessment of the Client).(1) The RN's assessment must consider each element listed in 22 TAC §225.6, and all relevant aspects of the resident's environment, to develop an overall understanding of the resident's health status.(2) In assessing each element required by paragraph (1) of this subsection, the RN may consider strength in one element to compensate for or offset a weakness in another element, as long as the RN determines that all required conditions in subsection (c) of this section are met.(3) The RN is not required to know the identity of the personal care staff member who will perform the activity or his or her specific qualifications. The RN is not required to determine the competency of the personal care staff who will perform the activity.(4) The RN must reassess a resident's status in accordance with this subsection any time there is a change in the resident's condition that may affect the resident's physical or cognitive abilities, or the stability or predictability of the resident's condition and, at a minimum, must reassess the resident's status:(A) at least once annually; or(B) at least once every six months if the resident has been diagnosed with Alzheimer's disease or a related disorder or resides in an Alzheimer's disease certified facility or unit.(c) To meet the condition of subsection (a)(2) of this section, the RN, in addition to conducting a resident assessment meeting the requirements of subsections (a)(1) and (b) of this section, must determine and document that all of the conditions listed in 22 TAC §225.8(a)(2) (relating to Health Maintenance Activities Not Requiring Delegation) exist.(d) If the RN determines under subsection (a)(1) of this section that an activity does not qualify as an HMA not requiring delegation, personal care staff may perform that activity for the resident only if:(1) the RN has determined in accordance with 22 Texas Administrative Code (TAC) Chapter 225 (relating to RN Delegation to Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions) that:(A) the activity can be delegated to a personal care staff member; and(B) the activity constitutes the medication administration;(2) the RN has properly delegated the task to the personal care staff member in accordance with 22 TAC Chapter 225 and §553.261(a)(1)(A)(iii) of this chapter (relating to Coordination of Care); and(3) the medication and medication administration requirements of §553.261(a) of this chapter are otherwise met. Source Note: The provisions of this §553.263 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.263 Health maintenance activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220823 03/12/2026 (a) Resident records.(1) Records that pertain to residents must be treated as confidential and properly safeguarded from unauthorized use, loss, or destruction.(2) Resident records must contain:(A) information contained in the facility's standard and customary admission form;(B) a record of the resident's assessments;(C) the resident's service plan;(D) physician's orders, if any;(E) any advance directives;(F) documentation of a health examination by a physician performed within 30 days before admission or 14 days after admission, unless:(i) a transferring hospital or facility has a physical examination in the medical record; or(ii) the resident is a Christian Scientist;(G) documentation by health care professionals of any services delivered in accordance with the licensing, certification, or other regulatory standards applicable to the health care professional under law; and(H) a copy of the most recent court order appointing a guardian of a resident or a resident's estate and letters of guardianship that the facility received in response to the request made in accordance with subsection (c) of this section.(3) Records must be available to residents, their legal representatives, and HHSC staff.(b) Resident finances. The facility must keep a simple financial record on all charges billed to the resident for care and these records must be available to HHSC. If the resident entrusts the handling of any personal finances to the facility, a simple financial record must be maintained to document accountability for receipts and expenditures, and these records must be available to HHSC. Receipts for payments from residents or family members must be issued upon request.(c) Guardianship Record Requirements.(1) A facility must request, from a resident's legally authorized representative or the person responsible for the resident's support, a copy of:(A) the current court order appointing a guardian for the resident or the resident's estate; and(B) current letters of guardianship for the resident.(2) A facility must request the court order and letters of guardianship:(A) when the facility admits an individual; and(B) when the facility becomes aware a guardian is appointed after the facility admits a resident.(3) A facility must request an updated copy of the court order and letters of guardianship at each annual assessment and retain documentation of any change.(4) A facility must make at least one follow-up request within 30 days after the facility makes a request in accordance with paragraphs (2) or (3) of this subsection if the facility has not received:(A) a copy of the court order and letters of guardianship; or(B) a response that there is no court order or letters of guardianship.(5) A facility must keep in the resident's record:(A) documentation of the results of the request for the court order and letters of guardianship; and(B) a copy of the court order and letters of guardianship. Source Note: The provisions of this §553.265 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.265 Resident Records and Retention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220824 03/12/2026 (a) Residents' Bill of Rights.(1) A facility must:(A) provide a copy of the Residents' Bill of Rights to each resident; and(B) post the Residents' Bill of Rights, as provided by HHSC, in a prominent place in the facility and written in the primary language of each resident.(2) A resident has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this state and the United States, except where lawfully restricted. The resident has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.(3) Each resident in the facility has the right to:(A) be free from physical and mental abuse, including corporal punishment or physical and chemical restraints that are administered for the purpose of discipline or convenience and not required to treat the resident's medical symptoms;(i) A provider may use physical or chemical restraints only if the use is authorized in writing by a physician or if the use is necessary in an emergency to protect the resident or others from injury.(ii) A physician's written authorization for the use of restraints must specify the circumstances under which the restraints may be used and the duration for which the restraints may be used.(iii) Except in an emergency, restraints may only be administered by qualified medical personnel.(B) participate in activities of social, religious, or community groups unless the participation interferes with the rights of others.(C) practice the religion of the resident's choice.(D) if intellectually disabled, with a court-appointed guardian of the person, participate in a behavior modification program involving use of restraints, consistent with subparagraph (A) of this paragraph, or adverse stimuli only with the informed consent of the guardian.(E) be treated with respect, consideration, and recognition of his or her dignity and individuality, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the resident:(i) has the right to make his or her own choices regarding personal affairs, care, benefits, and services;(ii) has the right to be free from abuse, neglect, and exploitation; and(iii) if protective measures are required, has the right to designate a guardian or representative to ensure the right to quality stewardship of his or her affairs.(F) a safe and decent living environment.(G) not be prohibited from communicating in his or her native language with other residents or employees for the purpose of acquiring or providing any type of treatment, care, or services.(H) complain about the resident's care or treatment. The complaint may be made anonymously or communicated by a person designated by the resident. The provider must promptly respond to resolve the complaint. The provider must not discriminate or take other punitive action against a resident who makes a complaint.(I) receive and send unopened mail, and the provider must ensure that the resident's mail is sent and delivered promptly.(J) unrestricted communication, including personal visitation with any person of the resident's choice, including family members and representatives of advocacy groups and community service organizations, at any reasonable hour.(K) make contacts with the community and to achieve the highest level of independence, autonomy, and interaction with the community of which the resident is capable.(L) manage his or her financial affairs.(i) The resident may authorize in writing another person to manage his or her money.(ii) The resident may choose the manner in which his or her money is managed, including a money management program, a representative payee program, a financial power of attorney, a trust, or a similar method, and the resident may choose the least restrictive of these methods.(iii) The resident must be given, upon request of the resident or the resident's representative, but at least quarterly, an accounting of financial transactions made on his or her behalf by the facility should the facility accept his or her written delegation of this responsibility to the facility in conformance with state law.(M) access the resident's records, which are confidential and may not be released without the resident's consent, except:(i) to another provider, if the resident transfers residence; or(ii) if the release is required by another law.(N) choose and retain a personal physician and to be fully informed in advance about treatment or care that may affect the resident's well-being.(O) participate in developing his or her individual service plan that describes the resident's medical, nursing, and psychological needs and how the needs will be met.(P) be given the opportunity to refuse medical treatment or services after the resident:(i) is advised by the person providing services of the possible consequences of refusing treatment or services; and(ii) acknowledges that he or she understands the consequences of refusing treatment or services.(Q) unaccompanied access to a telephone at a reasonable hour or in case of an emergency or personal crisis.(R) privacy, while attending to personal needs and a private place for receiving visitors or associating with other residents, unless providing privacy would infringe on the rights of other residents. (i) This right applies to medical treatment, written communications, telephone conversations, meeting with family, and access to resident councils.(ii) If a resident is married and the spouse is receiving similar services, the couple may share a room.(S) retain and use personal possessions, including clothing and furnishings, as space permits, and may be limited for the health and safety of other residents.(T) determine his or her dress, hair style, or other personal effects according to individual preference, except the resident has the responsibility to maintain personal hygiene.(U) retain and use personal property in his or her immediate living quarters and to have an individual locked area (cabinet, closet, drawer, footlocker, etc.) in which to keep personal property.(V) refuse to perform services for the facility, except as contracted for by the resident and operator.(W) be informed by the provider no later than the 30th day after admission:(i) whether the resident is entitled to benefits under Medicare or Medicaid; and(ii) which items and services are covered by these benefits, including items or services for which the resident may not be charged.(X) not be transferred or discharged unless:(i) the transfer is for the resident's welfare, and the resident's needs cannot be met by the facility;(ii) the resident's health is improved sufficiently so that services are no longer needed;(iii) the resident's health and safety or the health and safety of another resident would be endangered if the transfer or discharge was not made;(iv) the provider ceases to operate or to participate in the program that reimburses for the resident's treatment or care; or(v) the resident fails, after reasonable and appropriate notice, to pay for services.(Y) not be transferred or discharged, except in an emergency, until the 30th day after the date the facility provides written notice to the resident, the resident's legal representative, or a member of the resident's family, stating:(i) that the facility intends to transfer or discharge the resident;(ii) the reason for the transfer or discharge;(iii) the effective date of the transfer or discharge;(iv) if the resident is to be transferred, the location to which the resident will be transferred; and(v) any appeal rights available to the resident.(Z) leave the facility temporarily or permanently, subject to contractual or financial obligations.(AA) have access to the State Ombudsman and a certified ombudsman.(BB) execute an advance directive, under Texas Health and Safety Code, Chapter 166, or designate a guardian in advance of need to make decisions regarding the resident's health care should the resident become incapacitated.(b) Providers' Bill of Rights.(1) A facility must post a Providers' Bill of Rights in a prominent place in the facility.(2) The Providers' Bill of Rights must provide that a provider of assisted living services has the right to:(A) be shown consideration and respect that recognizes the dignity and individuality of the provider and the facility;(B) terminate a resident's contract for just cause after a written 30-day notice;(C) terminate a contract immediately, after notice to HHSC, if the provider finds that a resident creates a serious or immediate threat to the health, safety, or welfare of other residents of the facility, except during evening hours and on weekends or holidays, notice to HHSC must be made to 1-800-458-9858;(D) present grievances, file complaints, or provide information to state agencies or other persons without threat of reprisal or retaliation;(E) refuse to perform services for the resident or the resident's family other than those contracted for by the resident and the provider;(F) contract with the community to achieve the highest level of independence, autonomy, interaction, and services to residents; (G) access patient information concerning a client referred to the facility, which must remain confidential as provided by law;(H) refuse a person referred to the facility if the referral is inappropriate;(I) maintain an environment free of weapons and drugs; and(J) be made aware of a resident's problems, including self-abuse, violent behavior, alcoholism, or drug abuse.(c) Access to residents. The facility must allow an employee of HHSC or an employee of a local authority into the facility as necessary to provide services to a resident.(d) Authorized electronic monitoring (AEM).(1) A facility must permit a resident, or the resident's guardian or legal representative, to monitor the resident's room through the use of electronic monitoring devices.(2) A facility may not refuse to admit an individual and may not discharge a resident because of a request to conduct authorized electronic monitoring.(3) HHSC Information Regarding Authorized Electronic Monitoring form must be signed by or on behalf of all new residents upon admission. The form must be completed and signed by or on behalf of all current residents. A copy of the form must be maintained in the active portion of the resident's clinical record.Attached Graphic(4) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM must request AEM by giving a completed, signed, and dated HHSC Request for Authorized Electronic Monitoring form to the manager or designee. A copy of the form must be maintained in the active portion of the resident's clinical record.(A) If a resident has the capacity to request AEM and has not been judicially declared to lack the required capacity, only the resident may request AEM, notwithstanding the terms of any durable power of attorney or similar instrument.(B) If a resident has been judicially declared to lack the capacity required to request AEM, only the guardian of the resident may request AEM.(C) If a resident does not have the capacity to request AEM and has not been judicially declared to lack the required capacity, only the legal representative of the resident may request AEM.(i) A resident's physician makes the determination regarding the capacity to request AEM. Documentation of the determination must be made in the resident's clinical record.(ii) When a resident's physician determines the resident lacks the capacity to request AEM, a person from the following list, in order of priority, may act as the resident's legal representative for the limited purpose of requesting AEM:(I) a person named in the resident's medical power of attorney or other advance directive;(II) the resident's spouse;(III) an adult child of the resident who has the waiver and consent of all other qualified adult children of the resident to act as the sole decision-maker;(IV) a majority of the resident's reasonably available adult children;(V) the resident's parents; or(VI) the individual clearly identified to act for the resident by the resident before the resident became incapacitated or the resident's nearest living relative.(5) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM must also obtain the consent of other residents in the room, using the HHSC Consent to Authorized Electronic Monitoring form. When complete, the form must be given to the manager or designee. A copy of the form must be maintained in the active portion of the resident's clinical record. AEM cannot be conducted without the consent of other residents in the room.(A) Consent to AEM may be given only by:(i) the other resident or residents in the room;(ii) the guardian of the other resident, if the resident has been judicially declared to lack the required capacity; or(iii) the legal representative of the other resident, determined by following the same procedure established under paragraph (4)(C) of this subsection.(B) Another resident in the room may condition consent on:(i) pointing the camera away from the consenting resident, when the proposed electronic monitoring is a video surveillance camera; and(ii) limiting or prohibiting the use of an audio electronic monitoring device.(C) AEM must be conducted in accordance with any limitation placed on the monitoring as a condition of the consent given by or on behalf of another resident in the room. The resident's roommate, or the roommate's guardian or legal representative, assumes responsibility for assuring AEM is conducted according to the designated limitations.(D) If AEM is being conducted in a resident's room, and another resident is moved into the room who has not yet consented to AEM, the monitoring must cease until the new resident, or the resident's guardian or legal representative, consents.(6) When the completed HHSC Request for Authorized Electronic Monitoring form and the HHSC Consent to Authorized Electronic Monitoring form, if applicable, have been given to the manager or designee, AEM may begin.(A) Anyone conducting AEM must post and maintain a conspicuous notice at the entrance to the resident's room. The notice must state that the room is being monitored by an electronic monitoring device.(B) The resident, or the resident's guardian or legal representative, must pay for all costs associated with conducting AEM, including installation in compliance with life safety and electrical codes, maintenance, removal of the equipment, posting and removal of the notice, or repair following removal of the equipment and notice, other than the cost of electricity.(C) The facility must meet residents' requests to have a video camera obstructed to protect their dignity.(D) The facility must make reasonable physical accommodation for AEM, which includes providing:(i) a reasonably secure place to mount the video surveillance camera or other electronic monitoring device; and(ii) access to power sources for the video surveillance camera or other electronic monitoring device.(7) All facilities, regardless of whether AEM is being conducted, must post an 8 1/2-inch by 11-inch notice at the main facility entrance. The notice must be entitled "Electronic Monitoring" and must state, in large, easy-to-read type, "The rooms of some residents may be monitored electronically by or on behalf of the residents. Monitoring may not be open and obvious in all cases."(8) A facility may:(A) require an electronic monitoring device to be installed in a manner that is safe for residents, employees, or visitors who may be moving about the room, and meets all local and state regulations;(B) require AEM to be conducted in plain view; and(C) place a resident in a different room to accommodate a request for AEM.(9) A facility may not discharge a resident because covert electronic monitoring is being conducted by or on behalf of a resident. If a facility discovers a covert electronic monitoring device and it is no longer covert as defined in §553.3 of this chapter (relating to Definitions), the resident must meet all the requirements for AEM before monitoring is allowed to continue.(10) All instances of abuse or neglect must be reported to HHSC, as required by §553.273 of this subchapter (relating to Abuse, Neglect, or Exploitation Reportable to HHSC by Facilities). For purposes of the duty to report abuse or neglect, the following apply.(A) A person who is conducting electronic monitoring on behalf of a resident is considered to have viewed or listened to a recording made by the electronic monitoring device on or before the 14th day after the date the recording is made.(B) If a resident, who has capacity to determine that the resident has been abused or neglected and who is conducting electronic monitoring, gives a recording made by the electronic monitoring device to a person and directs the person to view or listen to the recording to determine whether abuse or neglect has occurred, the person to whom the resident gives the recording is considered to have viewed or listened to the recording on or before the seventh day after the date the person receives the recording.(C) A person is required to report abuse based on the person's viewing of or listening to a recording only if the incident of abuse is acquired on the recording. A person is required to report neglect based on the person's viewing of or listening to a recording only if it is clear from viewing or listening to the recording that neglect has occurred.(D) If abuse or neglect of the resident is reported to the facility and the facility requests a copy of any relevant recording made by an electronic monitoring device, the person who possesses the recording must provide the facility with a copy at the facility's expense. The cost of the copy must not exceed the community standard. If the contents of the recording are transferred from the original technological format, a qualified professional must do the transfer.(E) A person who sends more than one recording to HHSC must identify each recording on which the person believes an incident of abuse or evidence of neglect may be found. Tapes or recordings should identify the place on the recording that an incident of abuse or evidence of neglect may be found. Source Note: The provisions of this §553.267 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.267 Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220825 03/12/2026 (a) A resident has the right to be visited by the State Ombudsman, a certified ombudsman, or an ombudsman intern.(b) In accordance with 42 United States Code (U.S. Code) §3058g (b)(1)(A) and 45 CFR §1324.11(e)(2), a facility must allow:(1) the State Ombudsman, a certified ombudsman, and an ombudsman intern to have:(A) immediate, private, and unimpeded access to enter the facility at any time during the facility's regular business hours or regular visiting hours;(B) immediate, private, and unimpeded access to a resident; and(C) immediate and unimpeded access to the name and contact information of the resident's legally authorized representative, if the State Ombudsman, a certified ombudsman, or an ombudsman intern determines the information is needed to perform a function of the Ombudsman Program; and(2) the State Ombudsman and a certified ombudsman to have immediate, private, and unimpeded access to enter the facility at a time other than regular business hours or visiting hours, if the State Ombudsman or a certified ombudsman determines access may be required by the circumstances to be investigated.(c) A facility, in accordance with 42 U.S. Code §3058g (b)(1)(B) and 45 CFR §1324.11(e)(2), must allow the State Ombudsman and a certified ombudsman to have immediate access to:(1) all files, records, and other information concerning a resident, including an incident report involving the resident, if:(A) the State Ombudsman or certified ombudsman has the consent of the resident or legally authorized representative;(B) the resident is unable to communicate consent to access and has no legally authorized representative; or(C) such access is necessary to investigate a complaint and the following occurs:(i) the resident's legally authorized representative refuses to give consent to access to the records, files, and other information;(ii) the State Ombudsman or certified ombudsman has reasonable cause to believe that the legally authorized representative is not acting in the best interests of the resident; and(iii) if it is the certified ombudsman seeking access to the records, files, or other information, the certified ombudsman obtains the approval of the State Ombudsman to access the records, files, or other information without the legally authorized representative's consent; and(2) the administrative records, policies, and documents of the facility to which the residents or general public have access.(d) The rules adopted under the Health Insurance Portability and Accountability Act of 1996, 45 CFR part 164, subparts A and E, do not preclude a facility from releasing protected health information or other identifying information regarding a resident to the State Ombudsman or a certified ombudsman if the requirements of subsections (b)(1)(C) and (c)(1) of this section are otherwise met. The State Ombudsman and a certified ombudsman are each a "health oversight agency" as that phrase is defined in 45 CFR §164.501. Source Note: The provisions of this §553.269 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.269 Access to Residents and Records by the State Long-Term Care Ombudsman Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220826 03/12/2026 An assisted living facility must prominently and conspicuously post for display in a public area of the facility that is readily available to residents, employees, and visitors:(1) the license issued under this chapter;(2) a sign prescribed by HHSC that specifies complaint procedures established under these rules and specifies how complaints may be filed with HHSC;(3) a notice in the form prescribed by HHSC stating that inspection and related reports are available at the facility for public inspection and providing HHSC toll-free telephone number that may be used to obtain information concerning the facility;(4) a copy of the most recent inspection report relating to the facility;(5) Residents' Bill of Rights;(6) Providers' Bill of Rights;(7) the telephone number of the managing local ombudsman and the toll-free number of the Ombudsman Program, 1-800-252-2412;(8) the facility's normal 24-hour staffing patterns; and(9) a sign stating: "Cases of Suspected Abuse, Neglect, or Exploitation must be reported to HHSC by calling 1-800-458-9858." Source Note: The provisions of this §553.271 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.271 Postings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220827 03/12/2026 A facility must use its state-issued facility identification number in all advertisements, solicitations, and promotional materials, including yellow pages, brochures, and business cards. Source Note: The provisions of this §553.272 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.272 Advertisements, Solicitations, and Promotional Material https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220828 03/12/2026 (a) An assisted living facility staff who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation or that the resident has died due to abuse or neglect, must report the abuse, neglect, or exploitation to:(1) HHSC Consumer Rights and Services section at 1-800-458-9858 or via the HHSC website; and(2) one of the following law enforcement agencies:(A) a municipal law enforcement agency, if the facility is located within the territorial boundaries of a municipality; or(B) the sheriff's department of the county in which the facility is located if the facility is not located within the territorial boundaries of a municipality.(b) An assisted living facility must follow its internal policies regarding the prevention, detection, and reporting of abuse, neglect, or exploitation.(c) The following information must be reported to HHSC:(1) name, age, and address of the resident;(2) name and address of the person responsible for the care of the resident, if available;(3) nature and extent of the elderly or disabled person's condition;(4) basis of the reporter's knowledge; and(5) any other relevant information.(d) An assisted living facility must immediately make an oral report to HHSC of the alleged abuse, neglect, or exploitation and must investigate the allegation and send a written report of the investigation to HHSC state office no later than the fifth calendar day after the oral report.(e) An assisted living facility may not retaliate against a person for filing a complaint, presenting a grievance, or providing in good faith information relating to personal care services provided by the facility.(f) An assisted living facility must require facility staff, as a condition of employment with the facility, to sign a statement indicating that the employee may be criminally liable for the failure to report abuse, neglect, or exploitation. Source Note: The provisions of this §553.273 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.273 Abuse, Neglect, or Exploitation Reportable to HHSC by Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220829 03/12/2026 (a) Definitions. The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Designated emergency contact--A person that a resident, or a resident's legally authorized representative, identifies in writing for the facility to contact in the event of a disaster or emergency.(2) Disaster or emergency--An impending, emerging, or current situation that:(A) interferes with normal activities of a facility and its residents;(B) may:(i) cause injury or death to a resident or staff member of the facility; or(ii) cause damage to facility property;(C) requires the facility to respond immediately to mitigate or avoid the injury, death, damage, or interference; and(D) except as it relates to an epidemic or pandemic, or to the extent it is incident to another disaster or emergency, does not include a situation that arises from the medical condition of a resident, such as cardiac arrest, obstructed airway, or cerebrovascular accident.(3) Emergency management coordinator (EMC)--The person who is appointed by the local mayor or county judge to plan, coordinate, and implement public health emergency preparedness planning and response within the local jurisdiction.(4) Emergency preparedness coordinator (EPC)--The facility staff person with the responsibility and authority to direct, control, and manage the facility's response to a disaster or emergency.(5) Evacuation summary--A current summary of the facility's emergency preparedness and response plan that includes:(A) the name, address, and contact information for each receiving facility or pre-arranged evacuation destination identified by the facility under subsection (g)(3)(B) of this section;(B) the procedure for safely transporting residents and any other individuals evacuating a facility;(C) the name or title, and contact information, of the facility staff member to contact for evacuation information;(D) the facility's primary mode of communication to be used during a disaster or emergency and the facility's supplemental or alternate mode of communication;(E) the facility's procedure for notifying persons referenced in subsection (g)(5) of this section as soon as practicable about facility actions affecting residents during a disaster or emergency, including an impending or actual evacuation, and for maintaining ongoing communication with them for the duration of the disaster, emergency, or evacuation;(F) a statement about training that is available to a resident, the resident's legally authorized representative, and each designated emergency contact for the resident, on procedures under the facility's plan that involve or impact each of them, respectively; and(G) the facility's procedures for when a resident evacuates with a person other than a facility staff member.(6) Plan--A facility's emergency preparedness and response plan.(7) Receiving facility--A separate licensed assisted living facility:(A) from which a facility has documented acknowledgement, from an identified authorized representative, as described in subsection (i)(2)(C) of this section; and(B) to which the facility has arranged in advance of a disaster or emergency to evacuate some or all of a facility's residents, on a temporary basis due to a disaster or emergency, if, at the time of evacuation:(i) the receiving facility can safely receive and accommodate the residents; and(ii) the receiving facility has any necessary licensure or emergency authorization required to do so.(8) Risk assessment--The process of evaluating, documenting, and examining potential disasters or emergencies that pose the highest risk to a facility, and their foreseeable impacts, based on the facility's geographical location, structural conditions, resident needs and characteristics, and other influencing factors, in order to develop an effective emergency preparedness and response plan.(b) A facility must conduct and document a risk assessment that meets the definition in subsection (a)(8) of this section for potential internal and external emergencies or disasters relevant to the facility's operations and location, and that pose the highest risk to a facility, such as:(1) a fire or explosion;(2) a power, telecommunication, or water outage; contamination of a water source; or significant interruption in the normal supply of any essential, such as food or water;(3) a wildfire;(4) a hazardous materials accident;(5) an active or threatened terrorist or shooter, a detonated bomb or bomb threat, or a suspicious object or substance;(6) a flood or a mudslide;(7) a hurricane or other severe weather conditions;(8) an epidemic or pandemic;(9) a cyber attack; and(10) a loss of all or a portion of the facility.(c) A facility must develop and maintain a written emergency preparedness and response plan based on its risk assessment under subsection (b) of this section and that is adequate to protect facility residents and staff in a disaster or emergency.(1) The plan must address the eight core functions of emergency management, which are:(A) direction and control;(B) warning;(C) communication;(D) sheltering arrangements;(E) evacuation;(F) transportation;(G) health and medical needs; and(H) resource management.(2) The facility must prepare for a disaster or emergency based on its plan and follow each plan procedure and requirement, including contingency procedures, at the time it is called for in the event of a disaster or emergency. In addition to meeting the other requirements of this section, the emergency preparedness plan must:(A) document the contact information for the EMC for the area, as identified by the office of the local mayor or county judge;(B) include a process that ensures communication with the EMC, both as a preparedness measure and in anticipation of and during a developing and occurring disaster or emergency; and(C) include the location of a current list of the facility's resident population, which must be maintained as required under subsection (g)(3) of this section, that identifies:(i) residents with Alzheimer's disease or related disorders;(ii) residents who have an evacuation waiver approved under §553.259(e) of this chapter (relating to Admission Policies and Procedures; and(iii) residents with mobility limitations or other special needs who may need specialized assistance, either at the facility or in case of evacuation.(3) A facility must notify the EMC of the facility's emergency preparedness and response plan, take actions to coordinate its planning and emergency response with the EMC, and document communications with the EMC regarding plan coordination.(d) A facility must:(1) maintain a current printed copy of the plan in a central location that is accessible to all staff, residents, and residents' legally authorized representatives at all times;(2) at least annually and after an event described in subparagraphs (A)-(D) of this paragraph, review the plan, its evacuation summary, if any, and the contact lists described in subsection (g)(3) of this section, and update each:(A) to reflect changes in information, including when an evacuation waiver is approved under §553.259(e) of this chapter;(B) within 30 days or as soon as practicable following a disaster or emergency if a shortcoming is manifested or identified during the facility's response;(C) within 30 days after a drill, if, based on the drill, a shortcoming in the plan is identified; and(D) within 30 days after a change in a facility policy or HHSC rule that would impact the plan;(3) document reviews and updates conducted under paragraph (2) of this subsection, including the date of each review and dated documentation of changes made to the plan based on a review;(4) provide residents and the residents' legally authorized representatives with a written copy of the plan or an evacuation summary, as defined in subsection (a)(5) of this section, upon admission, on request, and when the facility makes a significant change to a copy of the plan or evacuation summary it has provided to a resident or a resident's legally authorized representative;(5) provide the information described in subsection (a)(5)(A) of this section to a resident or legally authorized representative who does not receive an evacuation summary under paragraph (4) of this subsection and requests that information;(6) notify each resident, next of kin, or legally authorized representative, in writing, how to register for evacuation assistance with the Texas Information and Referral Network (2-1-1 Texas); and(7) register as a provider with 2-1-1 Texas to assist the state in identifying persons who may need assistance in a disaster or emergency. In doing so, the facility is not required to identify or register individual residents for evacuation assistance.(e) Core Function One: Direction and Control. A facility's plan must contain a section for direction and control that:(1) designates the EPC, who is the facility staff person with the responsibility and authority to direct, control, and manage the facility's response to a disaster or emergency;(2) designates an alternate EPC, who is the facility staff person with the responsibility and authority to act as the EPC if the EPC is unable to serve in that capacity; and(3) assigns responsibilities to staff members by designated function or position and describes the facility's system for ensuring that each staff member clearly understands the staff member's own role and how to execute it, in the event of a disaster or emergency.(f) Core Function Two: Warning. A facility's plan must contain a section for warning that:(1) describes applicable procedures, methods, and responsibility for the facility and for the EMC and other outside organizations, based on facility coordination with them, to notify the EPC or alternate EPC, as applicable, of a disaster or emergency;(2) identifies who, including during off hours, weekends, and holidays, the EPC or alternate EPC, as applicable, will notify of a disaster or emergency, and the methods and procedures for notification;(3) describes a procedure for keeping all persons present in the facility informed of the facility's present plan for responding to a potential or current disaster or emergency that is impacting or threatening the area where the facility is located; and(4) addresses applicable procedures, methods, and responsibility for monitoring local news and weather reports regarding a disaster or potential disaster or emergency, taking into consideration factors such as:(A) location-specific natural disasters;(B) whether a disaster is likely to be addressed or forecast in the reports; and(C) the conditions, natural or otherwise, under which designated staff become responsible for monitoring news and weather reports for a disaster or emergency.(g) Core Function Three: Communication. A facility's plan must contain a section for communication that:(1) identifies the facility's primary mode of communication to be used during an emergency and the facility's supplemental or alternate mode of communication, and procedures for communication if telecommunication is affected by a disaster or emergency;(2) includes instructions on when to call 911;(3) includes the location of a list of current contact information, where it is easily accessible to staff, for each of the following:(A) the legally authorized representative and designated emergency contacts for each resident;(B) each receiving facility and pre-arranged evacuation destination, including alternate pre-arrangements, together with the written acknowledgement for each, as described and required in subsection (i)(2)(C) of this section;(C) home and community support services agencies and independent health care professionals that deliver health care services to residents in the facility;(D) personal contact information for facility staff, and(E) the facility's resident population, which must identify residents who may need specialized assistance at the facility or in case of evacuation, as described in subsection (c)(2)(C) of this section;(4) provides a method for the facility to communicate information to the public about its status during an emergency; and(5) describes the facility's procedure for notifying at least the following persons, as applicable and as soon as practicable, about facility actions affecting residents during an emergency, including an impending or actual evacuation, and for maintaining ongoing communication for the duration of the emergency or evacuation:(A) all facility staff members, including off-duty staff;(B) each facility resident;(C) any legally authorized representative of a resident;(D) each resident's designated emergency contacts;(E) each home and community support services agency or independent health care professional that delivers health care services to a facility resident;(F) each receiving facility or evacuation destination to be utilized, if there is an impending or actual evacuation, which, if utilized at the time of evacuation, must be utilized in accordance with the pre-arranged acknowledged procedures described in subsection (i)(2)(C) of this section, where applicable, and must verify with the applicable destination that it is available, ready, and legally authorized at the time to receive the evacuated residents and can safely do so;(G) the driver of a vehicle transporting residents or staff, medication, records, food, water, equipment, or supplies during an evacuation, and the employer of a driver who is not a facility staff person, and(H) the EMC.(h) Core Function Four: Sheltering Arrangements. A facility's plan must contain a section for sheltering arrangements that:(1) describes the procedure for making and implementing a decision to remain in the facility during a disaster or emergency, that includes:(A) the arrangements, staff responsibilities, and procedures for accessing and obtaining medication, records, equipment and supplies, water and food, including food to accommodate an individual who has a medical need for a special diet;(B) facility arrangements and procedures for providing, in areas used by residents during a disaster or emergency, power and ambient temperatures that are safe under the circumstances, but which may not be less than 68 degrees Fahrenheit or more than 82 degrees Fahrenheit; and(C) if necessary, sheltering facility staff or emergency staff involved in responding to an emergency and, as necessary and appropriate, their family members; and(2) includes a procedure for notifying HHSC Regulatory Services regional office for the area in which the facility is located and, in accordance with subsection (g)(5)(H) of this section, the EMC, immediately after the EPC or alternate EPC, as applicable, makes a decision to remain in the facility during a disaster or emergency.(i) Core Function Five: Evacuation.(1) A facility has the discretion to determine when an evacuation is necessary for the health and safety of residents and staff. However, a facility must evacuate if the county judge of the county in which the facility is located, the mayor of the municipality in which the facility is located mandates it by an evacuation order issued independently or concurrently with the governor.(2) A facility's plan must contain a section for evacuation that:(A) identifies evacuation destinations and routes, including at least each pre-arranged evacuation destination and receiving facility described in subparagraph (C) of this paragraph, and includes a map that shows each identified destination and route;(B) describes the procedure for making and implementing a decision to evacuate some or all residents to one or more receiving facilities or pre-arranged evacuation destinations, with contingency procedures, and a plan for any pets or service animals that reside in the facility;(C) includes the location of a current documented acknowledgment with an identified authorized representative of at least one receiving facility or pre-arranged evacuation destination, and at least one alternate. The documented acknowledgment must include acknowledgement by the receiving facility or pre-arranged evacuation destination of:(i) arrangements for the receiving facility or pre-arranged destination to receive an evacuating facility's residents; and(ii) the process for the facility to notify each applicable receiving facility or pre-arranged destination of the facility's plan to evacuate and to verify with the applicable destination that it is available, ready, and not legally restricted at the time from receiving the evacuated residents, and can do so safely;(D) includes the procedure and the staff responsible for:(i) notifying HHSC Regulatory Services regional office for the area in which the facility is located and, in accordance with subsection (g)(5)(H) of this section, the EMC, immediately after the EPC or alternate EPC, as applicable, makes a decision to evacuate, or as soon as feasible thereafter, if it is not safe to do so at the time of decision;(ii) ensuring that sufficient facility staff with qualifications necessary to meet resident needs accompany evacuating residents to the receiving facility, pre-arranged evacuation destination, or other destination to which the facility evacuates, and remain with the residents, providing any necessary care, for the duration of the residents' stay in the receiving facility or other destination to which the facility evacuates;(iii) ensuring that residents and facility staff present in the building have been evacuated;(iv) accounting for and tracking the location of residents, facility staff, and transport vehicles involved in the facility evacuation, both during and after the facility evacuation, through the time the residents and facility staff return to the evacuated facility;(v) accounting for residents absent from the facility at the time of the evacuation and residents who evacuate on their own or with a third party, and notifying them that the facility has been evacuated;(vi) overseeing the release of resident information to authorized persons in an emergency to promote continuity of a resident's care;(vii) contacting the EMC to find out if it is safe to return to the geographical area after an evacuation;(viii) making or obtaining, as appropriate, a comprehensive determination whether and when it is safe to re-enter and occupy the facility after an evacuation;(ix) returning evacuated residents to the facility and notifying persons listed in subsection (g)(5) of this section who were not involved in the return of the residents; and(x) notifying the HHSC Regulatory Services regional office for the area in which the facility is located immediately after each instance when some or all residents have returned to the facility after an evacuation.(j) Core Function Six: Transportation. A facility's plan must contain a section for transportation that:(1) identifies current arrangements for access to a sufficient number of vehicles to safely evacuate all residents;(2) identifies facility staff designated during an evacuation to drive a vehicle owned, leased, or rented by the facility; notification procedures to ensure designated staff's availability at the time of an evacuation; and methods for maintaining communication with vehicles, staff, and drivers transporting facility residents or staff during evacuation, in accordance with subsection (g)(5)(A) and (G) of this section;(3) includes procedures for safely transporting residents, facility staff, and any other individuals evacuating a facility; and(4) includes procedures for the safe and secure transport of, and staff's timely access to, the following resident items needed during an evacuation: oxygen, medications, records, food, water, equipment, and supplies.(k) Core Function Seven: Health and Medical Needs. A facility's plan must contain a section for health and medical needs that:(1) identifies special services that residents use, such as dialysis, oxygen, or hospice services;(2) identifies procedures to enable each resident, notwithstanding an emergency, to continue to receive from the appropriate provider the services identified under paragraph (1) of this subsection; and(3) identifies procedures for the facility to notify home and community support services agencies and independent health care professionals that deliver services to residents in the facility of an evacuation in accordance with subsection (g)(5)(E) of this section.(l) Core Function Eight: Resource Management. A facility's plan must contain a section for resource management that:(1) identifies a plan for identifying, obtaining, transporting, and storing medications, records, food, water, equipment, and supplies needed for both residents and evacuating staff during an emergency;(2) identifies facility staff, by position or function, who are assigned to access or obtain the items under paragraph (1) of this subsection and other necessary resources, and to ensure their delivery to the facility, as needed, or their transport in the event of an evacuation;(3) describes the procedure to ensure medications are secure and maintained at the proper temperature throughout an emergency; and(4) describes procedures and safeguards to protect the confidentiality, security, and integrity of resident records throughout an emergency and any evacuation of residents.(m) Receiving Facility. To act as a receiving facility, as defined in paragraph (a)(7) of this section, a facility's plan must include procedures for accommodating a temporary emergency placement of one or more residents from another assisted living facility, only in an emergency and only if:(1) the facility does not exceed its licensed capacity, unless pre-approved in writing by HHSC, and the excess is not more than 10 percent of the facility's licensed capacity;(2) the facility ensures that the temporary emergency placement of one or more residents evacuated from another assisted living facility does not compromise the health or safety of any evacuated or facility resident, facility staff, or any other individual;(3) the facility is able to meet the needs of all evacuated residents and any other persons it receives on a temporary emergency basis, in accordance with §553.18(h) of this chapter, while continuing to meet the needs of its own residents, and of any of its own staff or other individuals it is sheltering at the facility during an emergency, in accordance with its plan under subsection (h) of this section;(4) the facility maintains a log of each additional individual being housed in the facility that includes the individual's name, address, and the date of arrival and departure.(5) the receiving facility ensures that each temporarily placed resident has at arrival, or as soon after arrival as practicable and no later than necessary to protect the health of the resident, each of the following necessary to the resident's continuity of care:(A) necessary physician orders for care;(B) medications;(C) a service plan;(D) existing advance directives; and(E) contact information for each legally authorized representative and designated emergency contact of an evacuated resident, and a record of any notifications that have already occurred.(n) Emergency preparedness and response plan training. The facility must:(1) provide staff training on the emergency preparedness plan at least annually;(2) train a facility staff member on the staff member's responsibilities under the plan:(A) prior to the staff member assuming job responsibilities; and(B) when a staff member's responsibilities under the plan change;(3) conduct at least one unannounced annual drill with facility staff for severe weather or another emergency identified by the facility as likely to occur, based on the results of the risk assessment required by subsection (b) of this section;(4) offer training, and document, for each, the provision or refusal of such training, to each resident, legally authorized representative, if any, and each designated emergency contact, on procedures under the facility's plan that involve or impact each of them, respectively; and(5) document the facility's compliance with each paragraph of this subsection at the time it is completed.(o) Self-reported incidents related to a disaster or emergency.(1) A facility must report a fire to HHSC as follows:(A) by calling 1-800-458-9858 immediately after the fire or as soon as practicable during the course of an extended fire; and(B) by submitting a completed HHSC form titled "Fire Report for Long Term Care Facilities" within 15 calendar days after the fire.(2) A facility must report to HHSC a death or serious injury of a resident, or threat to resident health or safety, resulting from an emergency or disaster as follows:(A) by calling 1-800-458-9858 immediately after the incident, or, if the incident is of extended duration, as soon as practicable after the injury, death, or threat to the resident; and(B) by conducting an investigation of the emergency and resulting resident injury, death, or threat, and submitting a completed HHSC Form 3613-A titled "SNF, NF, ICF/IID, ALF, DAHS and PPECC Provider Investigation Report with Cover Sheet." The facility must submit the completed form within five working days after making the telephone report required by paragraph (2)(A) of this subsection.(p) Emergency Response System.(1) The facility administrator and designee must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The facility must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §553.275 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective January 24, 2023, 48 TexReg 216. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES E STANDARDS FOR LICENSURE §553.275 Emergency Preparedness and Response https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205847 03/12/2026 (a) The manager of the certified Alzheimer's facility or the supervisor of the certified Alzheimer's unit must be 21 years of age, and have:(1) an associate's degree in nursing or health care management;(2) a bachelor's degree in psychology, gerontology, nursing, or a related field; or(3) proof of graduation from an accredited high school or certification of equivalency of graduation and at least one year of experience working with persons with dementia.(b) The manager or supervisor must complete six hours of annual continuing education regarding dementia care. Source Note: The provisions of this §553.301 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.301 Manager Qualifications and Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205848 03/12/2026 (a) In addition to the staff training requirements under §553.253 of this chapter (relating to Employee Qualifications and Training), all staff members must receive four hours of dementia-specific orientation prior to assuming any job responsibilities. Training must cover, at a minimum, the following topics:(1) basic information about the causes, progression, and management of Alzheimer's disease;(2) managing dysfunctional behavior; and(3) identifying and alleviating safety risks to residents with Alzheimer's disease.(b) In addition to the staff training requirements under §553.253 of this chapter, attendants must receive 16 hours of on-the-job supervision and training within the first 16 hours of employment following orientation. Training must cover:(1) providing assistance with the activities of daily living;(2) emergency and evacuation procedures specific to the dementia population;(3) managing dysfunctional behavior; and(4) behavior management, including prevention of aggressive behavior and de-escalation techniques, fall prevention, or alternatives to restraints.(c) In addition to the staff training requirements under §553.253 of this chapter, attendants must annually complete 12 hours of in-service education regarding Alzheimer's disease. One hour of annual training must address behavior management, including prevention of aggressive behavior and de-escalation techniques, or fall prevention, or alternatives to restraints. Training for these subjects must be competency-based. Subject matter must address the unique needs of the facility. Additional suggested topics include:(1) assessing resident capabilities and developing and implementing service plans;(2) promoting resident dignity, independence, individuality, privacy, and choice;(3) planning and facilitating activities appropriate for the dementia resident;(4) communicating with families and other persons interested in the resident;(5) resident rights and principles of self-determination;(6) care of elderly persons with physical, cognitive, behavioral, and social disabilities;(7) medical and social needs of the resident;(8) common psychotropics and side effects; and(9) local community resources. Source Note: The provisions of this §553.303 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.303 Staff Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205849 03/12/2026 A facility must employ sufficient staff to provide services for and meet the needs of its Alzheimer's residents. In large facilities or units with 17 or more residents, two staff members must be immediately available when residents are present. Source Note: The provisions of this §553.305 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.305 Staffing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205846 03/12/2026 (a) Alzheimer's Assisted Living Disclosure Statement form. A facility must use the Alzheimer's Assisted Living Disclosure Statement form and amend the form if changes in the operation of the facility affect the information in the form.(b) Pre-admission. The facility must establish procedures, such as an application process, interviews, and home visits, to ensure that the placement of prospective residents is appropriate and that their needs can be met.(1) Prior to admitting a resident, facility staff must discuss and explain the Alzheimer's Assisted Living Disclosure Statement form with the family or responsible party.(2) The facility must give the Alzheimer's Assisted Living Disclosure Statement form to any individual seeking information about the facility's care or treatment of residents with Alzheimer's disease and related disorders.(c) Assessment. The facility must make a comprehensive assessment of each resident within 14 days after admission and annually. The assessment must include the items listed in §553.259(b)(1) of this chapter (relating to Admission Policies and Procedures).(d) Service plan. Facility staff, with input from the family, if available, must develop an individualized service plan for each resident, based upon the resident assessment, within 14 days after admission. The service plan must address the individual needs, preferences, and strengths of the resident. The service plan must be designed to help the resident maintain the highest possible level of physical, cognitive, and social functioning. The service plan must be updated annually and upon a significant change in condition, based on an assessment of the resident. Source Note: The provisions of this §553.307 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.307 Admission Procedures, Assessment, and Service Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205850 03/12/2026 (a) A facility must encourage socialization, cognitive awareness, self-expression, and physical activity in a planned and structured activities program. Activities must be individualized, based upon the resident assessment, and appropriate for each resident's abilities.(b) The activity program must contain a balanced mixture of activities addressing cognitive, recreational, and activity of daily living (ADL) needs.(1) Cognitive activities include arts, crafts, storytelling, poetry readings, writing, music, reading, discussion, reminiscences, and reviews of current events.(2) Recreational activities include all socially interactive activities, such as board games and cards, and physical exercise. Care of pets is encouraged.(3) Self-care ADLs include grooming, bathing, dressing, oral care, and eating. Occupational ADLs include cleaning, dusting, cooking, gardening, and yard work. Residents must be allowed to perform self-care ADLs as long as they are able, to promote independence and self-worth.(c) Residents must be encouraged, but never forced, to participate in activities. Residents who choose not to participate in a large group activity must be offered at least one small group or one-on-one activity per day.(d) Facilities must have an employee responsible for leading activities.(1) Facilities with 16 or fewer residents must designate an employee to plan, supply, implement, and record activities.(2) Facilities with 17 or more residents must employ, at a minimum, an activity director for 20 hours weekly. The activity director must be a qualified professional who:(A) is a qualified therapeutic recreation specialist or an activities professional who is eligible for certification as a therapeutic recreation specialist, a therapeutic recreation assistant, or an activities professional by a recognized accrediting body, such as the National Council for Therapeutic Recreation Certification, the National Certification Council for Activity Professionals, or the Consortium for Therapeutic Recreation/Activities Certification, Inc.;(B) has two years of experience in a social or recreational program within the last five years, one year of which was full-time in an activities program in a health care setting; or(C) has completed an activity director training course approved by the National Association for Activity Professionals or the National Therapeutic Recreation Society.(e) The activity director or designee must review each resident's medical and social history, preferences, and dislikes, in determining appropriate activities for the resident. Activities must be tailored to each resident's unique requirements and skills.(f) The activities program must provide opportunities for group and individual settings. On weekdays, each resident must be offered at least one cognitive activity, two recreational activities, and three ADL activities each day. The cognitive and recreational activities (structured activities) must be at least 30 minutes in duration, with a minimum of six and a half hours of structured activity for the entire week. At least an hour and a half of structured activities must be provided during the weekend and must include at least one cognitive activity and one physical activity.(g) The activity director or designee must create a monthly activities schedule. Structured activities should occur at the same time and place each week to ensure a consistent routine within the facility.(h) The activity director or designee must annually attend at least six hours of continuing education regarding Alzheimer's disease or related disorders.(i) Special equipment and supplies necessary to accommodate persons with a physical disability or other persons with special needs must be provided as appropriate. Source Note: The provisions of this §553.309 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.309 Activities Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205851 03/12/2026 Alzheimer's units, if segregated from other parts of the Type B facility with approved security devices, must meet the following requirements within the Alzheimer's unit:(1) Resident living areas must be in compliance with applicable requirements in Subchapter D of this chapter (relating to Facility Construction).(2) Resident dining areas must be in compliance with applicable requirements in Subchapter D of this chapter for resident dining areas.(3) Resident toilet and bathing facilities must be in compliance with applicable requirements in Subchapter D of this chapter for resident toilet and bathing facilities.(4) A monitoring station must be provided within the Alzheimer's unit with a writing surface such as a desk or counter, chair, task illumination, telephone or intercom, and lockable storage for resident records.(5) Access to at least two approved exits remote from each other must be provided in order to meet the NFPA 101 requirements.(6) In large facilities, cross corridor control doors, if used for the security of the residents, must be similar to smoke doors, which are each 34 inches in width and swing in opposite directions. A latch or other fastening device on a door must be provided with a knob, handle, panic bar, or other simple type of releasing device.(7) An outdoor area of at least 800 square feet must be provided in at least one contiguous space. This area must be connected to, be a part of, be controlled by, and be directly accessible from the facility.(A) Such areas must have walls or fencing that do not allow climbing or present a hazard and meet the following requirements. These minimum dimensions do not apply to additional fencing erected along property lines or building setback lines for privacy or to meet requirements of local building authorities.(i) Minimum distance of the enclosure fence from the building is 8 feet if the fence is parallel to the building and there are no window openings.(ii) Minimum distance of the enclosure fence (parallel with building walls) from bedroom windows is 20 feet if the fencing is solid and 15 feet from bedroom windows if the fencing is open.(iii) For unusual or unique site conditions, areas of enclosure may have alternate configurations with HHSC approval.(B) Access to at least two approved exits remote from each other must be provided from the enclosed area in order to meet the Life Safety Code requirements.(C) If the enclosed area involves a required exit from the building, the following additional requirements must be met:(i) A minimum of two gates must be remotely located from each other if only one exit is enclosed. If two or more exits are enclosed by the fencing and entry access can be made at each door, a minimum of one gate is required.(ii) The gates must be located to provide a continuous path of travel from the building exit to a public way, including walkways of concrete, asphalt, or other approved materials.(iii) If gates are locked, the gate nearest the exit from the building must be locked with an electronic lock that operates the same as electronic locks on control doors or exit doors and is in compliance with the National Electrical Code for exterior exposure. Additional gates may also have electronic locks or may have keyed locks provided staff carry the keys. All gates may have keyed locks, provided all staff carry the keys, and the outdoor area has an area of refuge which:(I) extends beyond a minimum of 30 feet from the building; and(II) the area of refuge allows at least 15 square feet per person (resident, staff, visitor) potentially present at the time of a fire.(8) Locking devices may be used on the control doors provided the following criteria are met:(A) The building must have an approved sprinkler system and an approved fire alarm system to meet the licensing standards.(B) The locking device must be electronic and must be released when any one of the following occurs:(i) activation of the fire alarm or sprinkler system;(ii) power failure to the facility; or(iii) activation of a switch or button located at the monitoring station and at the main staff station.(C) A key pad or buttons may be located at the control doors for routine use by staff.(9) Locking devices may be used on the exit doors provided:(A) the locking arrangements meet §7.2.1.6 of the NFPA 101; or(B) the following criteria are met:(i) the building must have an approved sprinkler system and an approved fire alarm system to meet the licensing standards;(ii) the locking device must be electro-magnetic; that is, no type of throw-bolt is to be used;(iii) the device must release when any one of the following occurs:(I) activation of the fire alarm or sprinkler system;(II) power failure to the facility; or(III) activation of a switch or button located at the monitoring station and at the main staff station;(iv) a key pad or buttons may be located at the control doors for routine use by staff;(v) a manual fire alarm pull must be located within five feet of each exit door with a sign stating, "Pull to release door in an emergency"; and(vi) staff must be trained in the methods of releasing the door device. Source Note: The provisions of this §553.311 adopted to be effective August 31, 2021, 46 TexReg 2017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES F ADDITIONAL LICENSING STANDARDS FOR CERTIFIED ALZHEIMER'S ASSISTED LIVING FACILITIES §553.311 Physical Plant Requirements for Alzheimer's Units https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205853 03/12/2026 (a) HHSC inspection and survey personnel perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits from time to time as they deem appropriate, or as required for carrying out the responsibilities of licensing.(b) In addition to the inspections required under Subchapter B of this chapter (relating to Licensing), HHSC inspects a facility at least once every two years after the initial inspection.(c) An inspection may be conducted by an individual surveyor or by a team, depending on the purpose of the inspection or survey, size of facility, and service provided by the facility, and other factors.(d) To determine standard compliance which cannot be verified during regular working hours, HHSC, with the least possible interference to staff and residents, may conduct night or weekend inspections to cover specific aspects of a facility's operation.(e) Generally, HHSC conducts routine and nonroutine inspections, surveys, complaint investigations and other visits made for the purpose of determining the appropriateness of resident care and day-to-day operations of a facility on an unannounced basis, unless there is justification for an exception.(f) Certain visits may be announced, including, but not limited to, conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.(g) When HHSC conducts a complaint investigation, HHSC notifies the facility of the complaint received and a summary of the complaint, without identifying the source of the complaint. A complaint is an allegation received by HHSC regarding:(1) abuse, neglect, or exploitation of a resident; or(2) a violation of state standards.(h) The facility must make all books, records, and other documents maintained by or on behalf of a facility accessible to HHSC upon request.(1) HHSC is authorized to photocopy documents, photograph residents, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection, survey, or investigation that HHSC reasonably believes threaten the health and safety of a resident.(2) Records and documents which may be requested and photocopied or otherwise reproduced include, but are not limited to, admission sheets, medication profiles, observation notes, medication refusal notes, and menu records.(3) When the facility is requested to furnish the copies, the facility may charge HHSC at the rate not to exceed the rate charged by HHSC for copies. Collection must be by billing HHSC. The procedure of copying is the responsibility of the administrator or his designee. If copying requires removal of the records from the facility, a representative of the facility will be expected to accompany the records and assure their order and preservation.(4) HHSC protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy. Source Note: The provisions of this §553.327 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.327 Inspections, Investigations, and Other Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220508 03/12/2026 (a) In accordance with the memorandum of understanding (relating to Memorandum of Understanding Concerning Protective Services for the Elderly), between HHSC and the Texas Department of Family and Protective Services (DFPS), HHSC receives and investigates reports of abuse, neglect, and exploitation of elderly and disabled persons or other residents living in facilities licensed under this chapter.(b) HHSC only investigates complaints of abuse, neglect, or exploitation when:(1) the act occurs in the facility;(2) the facility is responsible for the supervision of the resident at the time the act occurs; or(3) the alleged perpetrator is affiliated with the facility.(c) HHSC refers all other complaints of abuse, neglect, or exploitation not meeting subsection (b) of this section to DFPS.(d) HHSC must make an on-site visit to a facility to investigate complaints of abuse or neglect and all complaints involving unemancipated minors who have been inappropriately placed in the facility. During such on-site visits, HHSC must consult with persons thought to have knowledge of the circumstances. HHSC may make an on-site visit to a facility to investigate all other types of complaints.(e) If a facility fails to admit HHSC staff for an on-site investigation, HHSC may seek a court order for admission from a county, probate, or state district court. An HHSC investigator may ask the court to have a peace officer accompany them.(f) In cases concluded to be physical abuse, HHSC submits the written report of the HHSC investigation to the appropriate law enforcement agency. Source Note: The provisions of this §553.329 adopted to be effective August 31, 2021, 46 TexReg 5017; amended to be effective September 12, 2024, 49 TexReg 7044. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.329 HHSC Investigation of Allegations of Abuse, Neglect or Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205854 03/12/2026 (a) HHSC determines if a facility meets HHSC licensing rules, including physical plant and facility operation requirements, by conducting inspections, surveys, investigations, and on-site visits.(b) HHSC lists violations of licensing rules on a report of contact. The report of contact includes a specific reference to a licensing rule that has been violated.(c) At the conclusion of an inspection, survey, investigation, or on-site visit, an HHSC surveyor conducts an exit conference to advise the facility of the findings resulting from the inspection, survey, investigation, or on-site visit.(d) At the exit conference, the surveyor provides a copy of the report of contact described in subsection (b) of this section to the facility.(e) If, after the initial exit conference, an HHSC surveyor cites an additional licensing rule violation, the surveyor conducts another exit conference regarding the newly identified violations and updates the report of contact with a specific reference to the licensing rule that has been violated.(f) HHSC provides to the facility a written statement of violations from an inspection, survey, investigation, or on-site visit on HHSC Form 3724 within 10 days after the final exit conference. The statement of violations includes a clear and concise summary in nontechnical language of each licensing rule violation. The statement of violations does not include names of residents or staff, statements that identify a resident, or other prohibited information.(g) A facility must submit an acceptable plan of correction to the HHSC regional director for the HHSC surveyor within 10 working days after receiving the statement of violations described in subsection (f) of this section. An acceptable plan of correction must address:(1) how corrective action will be accomplished for a resident affected by a violation of a licensing rule;(2) how the facility will identify other residents who may be affected by the violation of the licensing rule;(3) how the corrective action the facility implements will ensure the violation does not reoccur;(4) how the facility will monitor its corrective action to ensure the violation is being corrected and will not reoccur; and(5) dates when corrective action will be completed. Source Note: The provisions of this §553.331 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.331 Determinations and Actions (Investigation Findings) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205855 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205855 03/12/2026 (a) If a facility disputes a violation of a licensing rule, which HHSC cites on a statement of violations in accordance with §553.331(f) of this subchapter (relating to Determinations and Actions (Investigation Findings)), the facility may request informal dispute resolution conducted in accordance with Texas Government Code §531.058 and Texas Health and Safety Code §247.051, and, to the extent consistent with those statutes, 1 TAC §393.2 (relating to Informal Dispute Resolution for Assisted Living Facilities).(b) To request informal dispute resolution, a facility must follow the informal dispute resolution process provided on the HHSC website and submit a completed Informal Dispute Resolution Request Form to HHSC in accordance with the form's instructions no later than 10 calendar days after the facility receives the statement of violations. The request form must summarize each violation that the facility disputes.(c) If a facility requests informal dispute resolution in accordance with subsection (b) of this section, HHSC sends to the facility a copy of all documents referenced in the disputed statement of violations or on which a cited licensure violation is based in connection with the survey, inspection, investigation, or other regulatory visit, including any notes taken by, or emails or messages sent by, an HHSC employee involved with the survey, inspection, investigation, or other regulatory visit, no later than 20 working days after HHSC receives the facility's request for informal dispute resolution. HHSC redacts or excludes the following information from the documents it sends to the facility:(1) the name of any complainant, witness, or informant;(2) information that would reasonably lead to the identification of a complainant, witness, or informant;(3) information obtained from or contained in the records of the facility;(4) information that is publicly available; and(5) information that is confidential by law.(d) HHSC may charge a facility $15 per hour for the time HHSC spends to redact the information described in subsection (c)(1) and (2) of this section. A facility must pay any amounts that HHSC charges it in accordance with this subsection.(e) If a facility requesting informal dispute resolution requests any documents other than documents which HHSC provides under subsection (c) of this section, it must reimburse HHSC for any costs associated with HHSC's preparation, copying, and delivery of information responsive to the facility's request. Source Note: The provisions of this §553.333 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.333 Informal Dispute Resolution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205856 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205856 03/12/2026 (a) Confidentiality. All reports, records, and working papers used or developed by HHSC in an investigation are confidential and may be released only as provided in this subsection.(1) Completed written investigation reports on cases concluded to be abuse or neglect must be furnished to the district attorney and appropriate law enforcement agency. HHSC also may release these reports to any other public agency HHSC deems appropriate to the investigation.(2) Completed written investigation reports are open to the public, provided the report is deidentified. The process of deidentification means removing all names and other personally identifiable data, including any information from witnesses and others furnished to HHSC as part of the investigation.(3) HHSC notifies the reporter and the facility of the results of the HHSC investigation of a reported case of abuse or neglect, whether HHSC concludes that abuse or neglect occurred or did not occur.(b) Immunity. A person who reports suspected instances of abuse or neglect, in the absence of bad faith or malicious conduct, is immune from civil or criminal liability which might have otherwise resulted from making the report. Such immunity extends to participation in any judicial proceeding resulting from the report.(c) Privileged communications. In a proceeding regarding a report or investigation conducted under this subchapter, evidence must not be excluded on a claim of privileged communication except in the case of a communication between an attorney and a client.(d) Central registry. HHSC maintains a central registry of reported cases of abuse and neglect at the central office in Austin.(e) Releasing Public Records.(1) As further described in this section, Texas Government Code, Chapter 552, governs procedures for inspection of public records.(2) Long-term Care Regulation, Regulatory Services Division is responsible for the maintenance and release of records on licensed facilities, and other related records.(3) The application for inspection of public records is subject to the following criteria.(A) The application must be made to Long-term Care Regulation, Regulatory Services Division, P.O. Box 149030 (E-349), Austin, Texas 78714-9030.(B) The requestor must identify himself or herself.(C) The requestor must give reasonable prior notice of the time for inspection and copying of records.(D) The requestor must specify the records requested.(E) On written applications, if HHSC is unable to ascertain the records being requested, HHSC may return the written application to the requestor for further specificity.(F) HHSC provides the requested records as soon as possible. However, if the records are in active use, or in storage, or time is needed for proper deidentification or preparation of the records for inspection, HHSC so advises the requestor and sets an hour and date within a reasonable time for records to be available.(4) Original records may be inspected or copied, but in no instance will original records be removed from HHSC offices.(5) Records maintained by HHSC are open to the public, except to the extent a record is made confidential by law or otherwise exempted from disclosure under Texas Government Code, Chapter 552. Without limitation:(A) incomplete reports, audits, evaluations, and investigations made of, for, or by HHSC are confidential;(B) reports of abuse and neglect are confidential;(C) all names and related personal, medical, or other identifying information about a resident are confidential;(D) information about any identifiable person that is defamatory, or an invasion of privacy is confidential;(E) information identifying complainants or informants is confidential;(F) itineraries of surveys and inspections are confidential; and(G) to implement this subsection, HHSC may not alter or deidentify original records. Instead, HHSC makes available for public review or release only a properly deidentified copy of the original record.(6) Charging for copies of records must be in accordance with the following criteria.(A) To inspect records without requesting copies, the requestor must specify the records to be inspected and HHSC does not charge for this service, except where HHSC determines that a charge is appropriate based on the nature of the request.(B) If the requestor wants to request copies of a record, the requestor will specify in writing the records to be copied, and HHSC notifies the requestor of the cost of the records, which the requestor must pay in advance. Checks and other instruments of payment must be made payable to the Texas Health and Human Services Commission.(C) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requestor on a cost basis in accordance with costs established by the Office of the Attorney General in 1 TAC Chapter 70 (relating to Costs of Copies of Public Information) or, where permitted by those rules, by HHSC for office machine copies.(D) For documents that are mailed, HHSC charges for the postage at the time it charges for the reproduction and adds applicable sales taxes to the cost of copying records.(7) HHSC makes a reasonable effort to furnish records promptly and will extend to the requestor all reasonable comfort and facility for the full exercise of the rights granted by Texas Government Code, Chapter 552. Source Note: The provisions of this §553.335 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.335 Confidentiality and Release of Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205857 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205857 03/12/2026 An HHSC employee must not retaliate against an assisted living facility, an employee of an assisted living facility, or a person in control of an assisted living facility for:(1) complaining about the conduct of an HHSC employee;(2) disagreeing with an HHSC employee about the existence of a violation of this chapter or a rule adopted under this chapter; or(3) asserting a right under state or federal law. Source Note: The provisions of this §553.337 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES G INSPECTIONS, INVESTIGATIONS, AND INFORMAL DISPUTE RESOLUTION §553.337 Retaliation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205858 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205858 03/12/2026 HHSC may take enforcement action when a facility is in violation of:(1) the sections of this chapter;(2) the Texas Health and Safety Code, Chapter 247;(3) an order adopted under Texas Health and Safety Code, Chapter 247; or(4) a license issued under Texas Health and Safety Code, Chapter 247. Source Note: The provisions of this §553.351 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.351 When may HHSC take an enforcement action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205859 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205859 03/12/2026 HHSC may:(1) suspend a license;(2) order immediate closing of all or part of the facility;(3) revoke a license;(4) refer the violation to the Office of the Attorney General for involuntary appointment of a trustee, injunction, or for the assessment of civil penalties; or(5) assess administrative penalties. Source Note: The provisions of this §553.353 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.353 What enforcement actions may HHSC take? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205860 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205860 03/12/2026 HHSC may suspend a facility's license when the applicant, license holder, or a controlling person violates:(1) the Texas Health and Safety Code, Chapter 247; a section, standard or order adopted under Texas Health and Safety Code, Chapter 247; or a license issued under Chapter 247 in a repeated or substantial manner; or(2) §553.751(a)(2) - (9) of this subchapter (relating to Administrative Penalties). Source Note: The provisions of this §553.401 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.401 When may HHSC suspend a facility's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205861 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205861 03/12/2026 Yes. Source Note: The provisions of this §553.403 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.403 Does HHSC provide notice of a license suspension and the opportunity for a hearing to the applicant, license holder, or a controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205862 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205862 03/12/2026 Yes. Source Note: The provisions of this §553.405 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.405 May HHSC suspend a license at the same time another enforcement action is occurring? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205863 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205863 03/12/2026 HHSC notifies a license holder by certified mail. Source Note: The provisions of this §553.407 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.407 How does HHSC notify a license holder of a proposed suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205864 03/12/2026 HHSC provides the license holder with the facts or conduct alleged to warrant the suspension. Source Note: The provisions of this §553.409 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.409 What information does HHSC provide the license holder concerning a proposed suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205865 03/12/2026 Yes. Source Note: The provisions of this §553.411 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.411 Does the license holder have an opportunity to show compliance with all requirements for keeping the license before HHSC begins proceedings to suspend a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205866 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205866 03/12/2026 A license holder must send a written request for an opportunity to show compliance to the Associate Commissioner of Long-term Care Regulation. Source Note: The provisions of this §553.413 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.413 How does a license holder request an opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205867 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205867 03/12/2026 A request for an opportunity to show compliance must be postmarked within 10 calendar days of the date of HHSC notice and must be received in the office of the Associate Commissioner of Long-term Care Regulation within 10 calendar days after the postmark. Source Note: The provisions of this §553.415 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.415 How much time does a license holder have to request an opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205868 03/12/2026 The request must contain specific documentation showing how the facts or conduct that support the proposed suspension are incorrect. Source Note: The provisions of this §553.417 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.417 What must the request for an opportunity to show compliance contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205869 03/12/2026 HHSC review is limited to documentation submitted by the license holder and information used by HHSC as the basis for its proposed action. The review is not conducted as an adversary hearing. Source Note: The provisions of this §553.419 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.419 How does HHSC conduct the opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205870 03/12/2026 Yes. Source Note: The provisions of this §553.421 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.421 Does HHSC give the license holder a written affirmation or reversal of the proposed action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205871 03/12/2026 HHSC notifies the facility by certified mail. Source Note: The provisions of this §553.423 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.423 How does HHSC notify a license holder of its final decision to suspend a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205872 03/12/2026 Yes. Source Note: The provisions of this §553.425 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.425 May the facility request a formal hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205873 03/12/2026 The license holder has 15 calendar days from receipt of the certified mail notice to request a hearing. Source Note: The provisions of this §553.427 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.427 How long does a license holder have to request a formal hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205874 03/12/2026 The suspension takes effect after the deadline for an appeal passes. Source Note: The provisions of this §553.429 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.429 If a license holder does not appeal, when does the suspension take effect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205875 03/12/2026 The status of the license remains in effect until after the appeal is complete. Source Note: The provisions of this §553.431 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.431 If a license holder appeals, when does the suspension take effect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205876 03/12/2026 A facility may continue to operate as long as the suspension is under appeal. Source Note: The provisions of this §553.433 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.433 May a facility operate during a suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205877 03/12/2026 The suspension remains in effect until HHSC determines that the reason for the suspension no longer exists, but no longer than the license expiration date. Source Note: The provisions of this §553.435 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.435 How long is the suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205878 03/12/2026 HHSC conducts an on-site inspection. Source Note: The provisions of this §553.437 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.437 How does HHSC decide to remove the suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205879 03/12/2026 Yes. Source Note: The provisions of this §553.439 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.439 Must the license be returned to HHSC during a license suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205880 03/12/2026 HHSC may revoke a license when the applicant, license holder, or a controlling person:(1) violates section §553.751(a)(2) - (9) of this subchapter (relating to Administrative penalties);(2) violates the Texas Health and Safety Code, Chapter 247; a section, standard or order adopted under Texas Health and Safety Code, Chapter 247; or a license issued under Texas Health and Safety Code, Chapter 247 in a repeated or substantial manner;(3) submits false statements on a license application;(4) submits false statements on license application attachments;(5) submits misleading statements on a license application;(6) submits misleading statements on license application attachments;(7) uses subterfuge or other evasive means to obtain a license;(8) conceals a material fact on a license application that would have been the basis for denying a license under §553.17 of this chapter (relating to Criteria for Licensing);(9) fails to disclose information, as required by Subchapter B of this chapter (relating to Licensing) that would have been the basis to deny a license under §553.17 of this chapter; or(10) violates the Texas Health and Safety Code §247.021. Source Note: The provisions of this §553.451 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.451 When may HHSC revoke a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205881 03/12/2026 Yes. Source Note: The provisions of this §553.453 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.453 Does HHSC provide notice of a license revocation and opportunity for a hearing to the applicant, license holder, or controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205882 03/12/2026 Yes. Source Note: The provisions of this §553.455 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.455 May HHSC take more than one enforcement action at a time against a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205883 03/12/2026 HHSC notifies a license holder by certified mail. Source Note: The provisions of this §553.457 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.457 How does HHSC notify a license holder of a proposed revocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205884 03/12/2026 HHSC provides the license holder with the facts or conduct alleged to warrant the revocation. Source Note: The provisions of this §553.459 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.459 What information does HHSC provide the license holder concerning a proposed revocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205885 03/12/2026 Yes. Source Note: The provisions of this §553.461 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.461 Does the license holder have an opportunity to show compliance with all requirements for keeping the license before HHSC begins proceedings to revoke a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205886 03/12/2026 A license holder must send a written request for an opportunity to show compliance to the Associate Commissioner of Long-term Care Regulation. Source Note: The provisions of this §553.463 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.463 How does a license holder request an opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205887 03/12/2026 A request for an opportunity to show compliance must be postmarked within 10 calendar days of the date of HHSC notice and must be received in the office of the Associate Commissioner of Long-term Care Regulation within 10 calendar days of the postmark. Source Note: The provisions of this §553.465 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.465 How much time does a license holder have to request an opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205888 03/12/2026 The request must contain specific documentation showing how the facts or conduct that support the proposed revocation are incorrect. Source Note: The provisions of this §553.467 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.467 What must the request for the opportunity to show compliance contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205889 03/12/2026 HHSC review is limited to documentation submitted by the license holder and information used by HHSC as the basis for its proposed action. The review is not conducted as an adversary hearing. Source Note: The provisions of this §553.469 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.469 How does HHSC conduct the opportunity to show compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205890 03/12/2026 Yes. Source Note: The provisions of this §553.471 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.471 Does HHSC give the license holder a written affirmation or reversal of the proposed action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205891 03/12/2026 Yes. Source Note: The provisions of this §553.473 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.473 Does the license holder have an opportunity for a formal hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205892 03/12/2026 The license holder has 15 calendar days from receipt of the certified mail notice to request a hearing. Source Note: The provisions of this §553.475 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.475 How long does a license holder have to request a formal hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205893 03/12/2026 The revocation takes effect after the deadline for an appeal passes. Source Note: The provisions of this §553.477 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.477 When does the revocation take effect if the license holder does not appeal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205894 03/12/2026 The status of the license remains in effect until after the appeal is complete. Source Note: The provisions of this §553.479 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.479 When does the revocation take effect if the license holder appeals the revocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205895 03/12/2026 A facility may continue to operate, as long as the revocation is under appeal. Source Note: The provisions of this §553.481 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.481 May a facility operate during a revocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205896 03/12/2026 If revoked, the license must be returned to HHSC. Source Note: The provisions of this §553.483 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.483 What happens to a license if it is revoked? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205897 03/12/2026 HHSC refers a facility to the Office of the Attorney General or local prosecuting authority for a temporary restraining order or an injunction when:(1) a violation creates an immediate threat or threat to the health and safety of residents;(2) a facility is operating without a license; or(3) HHSC is denied entry to a facility that is alleged to be operating without a license. Source Note: The provisions of this §553.501 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.501 Why does HHSC refer a facility to the Office of the Attorney General or local prosecuting authority for a temporary restraining order or an injunction? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205898 03/12/2026 HHSC refers a facility that is operating without a license to the:(1) district attorney;(2) county attorney;(3) city attorney; or(4) Attorney General. Source Note: The provisions of this §553.503 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.503 To whom does HHSC refer a facility that is operating without a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205925 03/12/2026 HHSC may suspend a license or order an immediate closing of all or part of a facility when:(1) the facility is operating in violation of the licensure rules; and(2) the violation creates an immediate threat to the health and safety of a resident. Source Note: The provisions of this §553.551 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.551 When may HHSC suspend a license or order an immediate closing of all or part of a facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205926 03/12/2026 A notice is hand-delivered to a facility staff member. Source Note: The provisions of this §553.553 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.553 How does HHSC notify a facility of a license suspension or immediate closing of all or part of a facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205904 03/12/2026 The order goes into effect immediately upon receipt of the hand-delivered written notice or on a later date specified in the order. Source Note: The provisions of this §553.555 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.555 When does an order suspending a license or closing all or part of a facility go into effect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205905 03/12/2026 An order is valid for 10 calendar days after the effective date of the order. Source Note: The provisions of this §553.557 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.557 How long is an order suspending a license or closing all or part of a facility valid? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205906 03/12/2026 Yes. Source Note: The provisions of this §553.559 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.559 May a license holder request a hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205907 03/12/2026 Information about administrative hearings is located in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), Texas Government Code, Chapter 2001, and 1 TAC Chapter 155 (relating to Rules of Procedure). Source Note: The provisions of this §553.561 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.561 Where can a license holder find information about administrative hearings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205903 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205903 03/12/2026 No. Source Note: The provisions of this §553.563 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.563 Does a request for an administrative hearing suspend the effectiveness of the order? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205908 03/12/2026 No. Source Note: The provisions of this §553.565 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.565 Does anything happen to a resident's rights or freedom of choice during an emergency relocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205909 03/12/2026 If all or part of a facility is closed, HHSC notifies:(1) the local health department director;(2) the city or county health authority; and(3) representatives of the appropriate state agencies. Source Note: The provisions of this §553.567 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.567 Who does HHSC notify if all or part of a facility is closed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205910 03/12/2026 A facility must notify each resident's:(1) guardian or responsible party; and(2) attending physician. Source Note: The provisions of this §553.569 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.569 Who must a facility notify if all or part of the facility is closed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205911 03/12/2026 The resident, the resident's guardian, or the resident's responsible person may designate a preference for a specific facility or for other arrangements. Source Note: The provisions of this §553.571 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.571 Who decides where to relocate a resident? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205912 03/12/2026 HHSC arranges to relocate residents to other facilities in the area. Source Note: The provisions of this §553.573 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.573 Who arranges the relocation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205913 03/12/2026 Yes. Source Note: The provisions of this §553.575 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.575 Is a resident's preference considered? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205914 03/12/2026 The following apply when a resident chooses a facility for relocation:(1) The facility must be in good standing with HHSC.(2) If the facility is certified under 42 United States Code, Chapter 7, Subchapters XVIII and XIX, it must be in good standing under its contract.(3) The facility must be able to meet the needs of the resident. Source Note: The provisions of this §553.577 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.577 What requirements must the facility a resident chooses for relocation meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205915 03/12/2026 Yes. Source Note: The provisions of this §553.579 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.579 Is a receiving facility allowed to temporarily exceed its licensed capacity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205916 03/12/2026 HHSC may grant a waiver to a receiving facility to temporarily exceed its licensed capacity to prevent substantial transportation of a resident. Source Note: The provisions of this §553.581 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.581 Under what conditions is a receiving facility allowed to temporarily exceed its licensed capacity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205917 03/12/2026 To be eligible for a temporary waiver to exceed its licensed capacity, a facility must:(1) not compromise the health and safety of residents; and(2) meet the increased demands for direct care personnel and dietary services. Source Note: The provisions of this §553.583 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.583 What requirements must a facility meet to obtain a temporary waiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205918 03/12/2026 A facility may have a temporary waiver until residents can be transferred to a permanent location. Source Note: The provisions of this §553.585 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.585 How long can a facility have a temporary waiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205919 03/12/2026 Yes. Source Note: The provisions of this §553.587 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.587 Does HHSC monitor a facility with a temporary waiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205920 03/12/2026 The following reports, records, and supplies must be sent to the receiving institution for each transferred resident:(1) a copy of the current physician's orders for:(A) medication;(B) treatment;(C) diet; and(D) special services required;(2) personal information, such as name and address of next of kin, guardian, or responsible party;(3) attending physician;(4) Medicare and Medicaid identification number, if applicable;(5) social security number;(6) other identification information as deemed necessary and available;(7) a copy of the resident's current comprehensive assessment and service plan;(8) all medications dispensed in the resident's name that have current physician's orders. Medications must be inventoried and transferred with the resident. Medications past expiration date or discontinued by physician order must be inventoried for disposition in accordance with state law. Only current prescription medications taken on a regular or as-needed basis may be transferred with the resident;(9) the resident's personal belongings, clothing, and toilet articles. The closing facility must make an inventory of personal property and valuables; and(10) resident trust fund accounts maintained by the closing facility. All items must be properly inventoried, and receipts obtained for audit purposes by the appropriate state agency. Source Note: The provisions of this §553.589 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.589 What records, reports, and supplies are sent to the receiving facility for transferred residents? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205921 03/12/2026 Yes. Source Note: The provisions of this §553.591 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.591 May a resident return to the closed facility if it reopens within 90 calendar days? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205922 03/12/2026 If the closed facility is allowed to reopen within 90 calendar days, the relocated residents have the first right to return to the facility. Source Note: The provisions of this §553.593 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.593 Do the relocated residents have any special admission rights at the closed facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205923 03/12/2026 Relocated residents may choose to:(1) return to the reopened facility;(2) stay in the receiving facility, if the facility is not exceeding its licensed capacity; or(3) choose other accommodations. Source Note: The provisions of this §553.595 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.595 What options does a relocated resident have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205924 03/12/2026 Yes. Any relocated resident who returns to the facility must be treated as a new admission. All procedures regarding new admissions apply. Source Note: The provisions of this §553.597 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.597 Are relocated residents who return to the facility considered new admissions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205901 03/12/2026 HHSC may refer a facility for a violation that threatens the health and safety of a resident. Source Note: The provisions of this §553.601 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.601 When may HHSC refer a facility to the Office of the Attorney General for assessment of civil penalties? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205902 03/12/2026 A civil penalty of $1,000 to $10,000 per day may be assessed for operating without a license. Source Note: The provisions of this §553.603 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.603 What is the amount of the civil penalty that can be assessed for operating without a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205927 03/12/2026 HHSC may petition a court for the involuntary appointment of a trustee to operate a facility when one or more of the following conditions exist:(1) the facility is operating without a license;(2) the facility's license has been suspended or revoked;(3) an imminent threat to the health and safety of the residents exists, and license suspension or revocation procedures are pending against the facility;(4) an emergency exists that presents an immediate threat to the health and safety of the residents; or(5) the facility is closing, whether voluntarily or through an emergency closure order, and arrangements for relocation of the residents to other licensed institutions have not been made before closure. Source Note: The provisions of this §55.651 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.651 When may HHSC petition a court for the involuntary appointment of a trustee to operate a facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205928 03/12/2026 HHSC may disburse emergency assistance funds when a court order is given. Source Note: The provisions of this §55.653 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.653 When may HHSC disburse emergency assistance funds? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205929 03/12/2026 Yes. Source Note: The provisions of this §55.655 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.655 Must a facility reimburse HHSC for emergency assistance funds? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205930 03/12/2026 Reimbursement is due not later than one year after the date the trustee received the funds. Source Note: The provisions of this §55.657 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.657 When is reimbursement for emergency assistance funds due to HHSC? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205931 03/12/2026 The owner of the facility at the time the trustee was appointed is responsible for reimbursement. Source Note: The provisions of this §55.659 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.659 Who is responsible for reimbursement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205932 03/12/2026 A license holder is referred to the Office of the Attorney General. HHSC also may decide the facility is not eligible for a Medicaid provider contract. Source Note: The provisions of this §55.661 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.661 What happens if a facility does not reimburse HHSC in one year? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205939 03/12/2026 Yes. Source Note: The provisions of this §553.701 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.701 May a facility request the appointment of a trustee to assume operation of a facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205940 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205940 03/12/2026 A person holding a controlling interest in a facility may request that HHSC assume the operation of the facility through the appointment of a trustee. Source Note: The provisions of this §553.703 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.703 Who may make the request? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205941 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205941 03/12/2026 An agreement must:(1) specify all terms and conditions of the trustee's appointment and authority; and(2) preserve all legal rights of the residents. Source Note: The provisions of this §553.705 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.705 What are the requirements for a trustee agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205942 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205942 03/12/2026 An agreement for a trustee terminates at a time specified in the agreement or upon receipt of notice of intent to terminate sent by HHSC or by the person holding a controlling interest in the facility. Source Note: The provisions of this §553.707 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.707 When does an agreement for a trustee terminate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205943 03/12/2026 HHSC petitions a court for an involuntary appointment of a trustee under the terms of §553.651 of this subchapter (relating to When may HHSC petition a court for the involuntary appointment of a trustee to operate a facility?). Source Note: The provisions of this §553.709 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.709 What happens if the controlling person wants to terminate the agreement, but HHSC determines termination of the agreement is not in the best interest of the residents? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205944 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205944 03/12/2026 Yes. Source Note: The provisions of this §553.711 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.711 When HHSC appoints a trustee, is the facility always required to pay assessed civil money penalties? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205900 03/12/2026 (a) Assessment of an administrative penalty. HHSC may assess an administrative penalty if a license holder:(1) violates:(A) Texas Health and Safety Code, Chapter 247;(B) a rule, standard, or order adopted under Texas Health and Safety Code, Chapter 247; or(C) a term of a license issued under Texas Health and Safety Code, Chapter 247;(2) makes a false statement of material fact that the license holder knows or should know is false:(A) on an application for issuance or renewal of a license;(B) in an attachment to the application; or(C) with respect to a matter under investigation by HHSC;(3) refuses to allow an HHSC representative to inspect:(A) a book, record, or file that a facility must maintain; or(B) any portion of the premises of a facility;(4) willfully interferes with the work of, or retaliates against, an HHSC representative or the enforcement of this chapter;(5) willfully interferes with, or retaliates against, an HHSC representative preserving evidence of a violation of Texas Health and Safety Code, Chapter 247; a rule, standard, or order adopted under Texas Health and Safety Code, Chapter 247; or a term of a license issued under Texas Health and Safety Code, Chapter 247;(6) fails to pay an administrative penalty not later than the 30th calendar day after the penalty assessment becomes final;(7) fails to notify HHSC of a change of ownership before the effective date of the change of ownership;(8) willfully interferes with the State Ombudsman, a certified ombudsman, or an ombudsman intern performing the functions of the Ombudsman Program as described in Chapter 88 of this title (relating to State Long-Term Care Ombudsman Program); or(9) retaliates against the State Ombudsman, a certified ombudsman, or an ombudsman intern:(A) with respect to a resident, employee of a facility, or other person filing a complaint with, providing information to, or otherwise cooperating with the State Ombudsman, a certified ombudsman, or an ombudsman intern; or(B) for performing the functions of the Ombudsman Program as described in Chapter 88 of this title.(b) Criteria for assessing an administrative penalty. HHSC considers the following in determining the amount of an administrative penalty:(1) the gradations of penalties established in subsection (d) of this section;(2) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the situation, and the hazard or potential hazard created by the situation to the health or safety of the public;(3) the history of previous violations;(4) deterrence of future violations;(5) the license holder's efforts to correct the violation; (6) the size of the facility and of the business entity that owns the facility; and(7) any other matter that justice may require.(c) Late payment of an administrative penalty. A license holder must pay an administrative penalty within 30 calendar days after the penalty assessment becomes final. If a license holder fails to timely pay the administrative penalty, HHSC may assess an administrative penalty under subsection (a)(6) of this section, which is in addition to the penalty that was previously assessed and not timely paid.(d) Administrative penalty schedule. HHSC uses the schedule of appropriate and graduated administrative penalties in this subsection to determine which violations warrant an administrative penalty.Attached Graphic(e) Administrative penalty assessed against a resident. HHSC does not assess an administrative penalty against a resident, unless the resident is also an employee of the facility or a controlling person.(f) Proposal of administrative penalties.(1) HHSC issues a preliminary report stating the facts on which HHSC concludes that a violation has occurred after HHSC has:(A) examined the possible violation and facts surrounding the possible violation; and(B) concluded that a violation has occurred.(2) HHSC may recommend in the preliminary report the assessment of an administrative penalty for each violation and the amount of the administrative penalty.(3) HHSC provides a written notice of the preliminary report to the license holder not later than 10 calendar days after the date on which the preliminary report is issued. The written notice includes:(A) a brief summary of the violation;(B) the amount of the recommended administrative penalty; (C) a statement of whether the violation is subject to correction in accordance with subsection (g) of this section and, if the violation is subject to correction, a statement of:(i) the date on which the license holder must file with HHSC a plan of correction for approval by HHSC; and(ii) the date on which the license holder must complete the plan of correction to avoid assessment of the administrative penalty; and(D) a statement that the license holder has a right to an administrative hearing on the occurrence of the violation, the amount of the penalty, or both.(4) Not later than 20 calendar days after the date on which a license holder receives a written notice of the preliminary report, the license holder may:(A) give HHSC written consent to the preliminary report, including the recommended administrative penalty; or(B) make a written request to HHSC for an administrative hearing.(5) If a violation is subject to correction under subsection (g) of this section, the license holder must submit a plan of correction to HHSC for approval not later than 10 calendar days after the date on which the license holder receives the written notice described in paragraph (3) of this subsection.(6) If a violation is subject to correction under subsection (g) of this section, and after the license holder reports to HHSC that the violation has been corrected, HHSC inspects the correction or takes any other step necessary to confirm the correction and notifies the facility that:(A) the correction is satisfactory and HHSC is not assessing an administrative penalty; or(B) the correction is not satisfactory, and a penalty is recommended.(7) Not later than 20 calendar days after the date on which a license holder receives a notice that the correction is not satisfactory and that a penalty is recommended under paragraph (6)(B) of this subsection, the license holder may:(A) give HHSC written consent to HHSC report, including the recommended administrative penalty; or(B) make a written request to HHSC for an administrative hearing.(8) If a license holder consents to the recommended administrative penalty or does not timely respond to a notice sent under paragraph (3) of this subsection (written notice of the preliminary report) or paragraph (6)(B) of this subsection (notice that the correction is not satisfactory and recommendation of a penalty):(A) HHSC assesses the recommended administrative penalty;(B) HHSC gives written notice of the decision to the license holder; and(C) the license holder must pay the penalty not later than 30 calendar days after the written notice given in subparagraph (B) of this paragraph.(g) Opportunity to correct.(1) HHSC allows a license holder to correct a violation before assessing an administrative penalty, except a violation described in paragraph (2) of this subsection. To avoid assessment of a penalty, a license holder must correct a violation not later than 45 calendar days after the date the facility receives the written notice described in subsection (f)(3) of this section.(2) HHSC does not allow a license holder to avoid a penalty assessment based on its correction of a violation:(A) described by subsection (a)(2)-(9) of this section;(B) of Texas Health and Safety Code §260A.014 or §260A.015;(C) related to advance directives as described in §553.259(d) of this chapter (relating to Admission Policies and Procedures);(D) that is the second or subsequent violation of:(i) a right of the same resident under §553.267 of this chapter (relating to Rights);(ii) the same right of all residents under §553.267 of this chapter; or(iii) §553.255 of this chapter (relating to All Staff Policy for Residents with Alzheimer's Disease or a Related Disorder) that occurs before the second anniversary of the date of a previous violation of §553.255 of this chapter;(E) that is written because of an inappropriately placed resident, except as described in §553.259(e) of this chapter;(F) that is a pattern of violation that results in actual harm;(G) that is widespread in scope and results in actual harm;(H) that is widespread in scope, constitutes a potential for more than minimal harm, and relates to:(i) resident assessment as described in §553.259(b) of this chapter;(ii) staffing, including staff training, as described in §553.253 of this chapter (relating to Employee Qualifications and Training);(iii) medication administration as described in §553.261(a) of this chapter (relating to Coordination of Care);(iv) infection control as described in §553.261(f) of this chapter;(v) restraints as described in §553.261(g) of this chapter; or(vi) emergency preparedness and response as described in §553.275 of this chapter (relating to Emergency Preparedness and Response); or(I) is an immediate threat to the health or safety of a resident.(3) Maintenance of violation correction.(A) A license holder that corrects a violation must maintain the correction. If the license holder fails to maintain the correction until at least the first anniversary of the date the correction was made, HHSC may assess and collect an administrative penalty for the subsequent violation.(B) An administrative penalty assessed under this paragraph is equal to three times the amount of the original administrative penalty that was assessed but not collected.(C) HHSC is not required to offer the license holder an opportunity to correct the subsequent violation.(h) Hearing on an administrative penalty. If a license holder timely requests an administrative hearing as described in subsection (f)(3) or (7) of this section, the administrative hearing is held in accordance with HHSC rules at 1 TAC Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act).(i) HHSC may charge interest on an administrative penalty. The interest begins the day after the date the penalty becomes due and ends on the date the penalty is paid in accordance with Texas Health and Safety Code §247.0455(e).(j) Amelioration of a violation.(1) In lieu of demanding payment of an administrative penalty, the commissioner may allow a license holder to use, under HHSC supervision, any portion of the administrative penalty to ameliorate the violation or to improve services, other than administrative services, in the facility affected by the violation. Amelioration is an alternate form of payment of an administrative penalty, not an appeal, and does not remove a violation or an assessed administrative penalty from a facility's history.(2) A license holder cannot ameliorate a violation that HHSC determines constitutes immediate jeopardy to the health or safety of a resident.(3) HHSC offers amelioration to a license holder not later than 10 calendar days after the date a license holder receives a final notification of the recommended assessment of an administrative penalty that is sent to the license holder after an informal dispute resolution process but before an administrative hearing.(4) A license holder to whom amelioration has been offered must:(A) submit a plan for amelioration not later than 45 calendar days after the date the license holder receives the offer of amelioration from HHSC; and(B) agree to waive the license holder's right to an administrative hearing if HHSC approves the plan for amelioration.(5) A license holder's plan for amelioration must:(A) propose changes to the management or operation of the facility that will improve services to or quality of care of residents;(B) identify, through measurable outcomes, the ways in which and the extent to which the proposed changes will improve services to or quality of care of residents;(C) establish clear goals to be achieved through the proposed changes;(D) establish a time line for implementing the proposed changes; and(E) identify specific actions the license holder will take to implement the proposed changes.(6) A license holder's plan for amelioration may include proposed changes to:(A) improve staff recruitment and retention;(B) offer or improve dental services for residents; and(C) improve the overall quality of life for residents.(7) HHSC may require that an amelioration plan propose changes that would result in conditions that exceed the requirements of this chapter.(8) HHSC approves or denies a license holder's amelioration plan not later than 45 calendar days after the date HHSC receives the plan. If HHSC approves the amelioration plan, any pending request the license holder has submitted for an administrative hearing must be withdrawn by the license holder.(9) HHSC does not offer amelioration to a license holder:(A) more than three times in a two-year period; or(B) more than one time in a two-year period for the same or a similar violation. Source Note: The provisions of this §553.751 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.751 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205899 03/12/2026 A facility may elect binding arbitration in accordance with Texas Health and Safety Code §247.082. Arbitration is conducted in accordance with §§247.083 - 247.098 and may be used to resolve a dispute between the facility and HHSC relating to:(1) renewal of a license;(2) suspension, revocation, or denial of a license;(3) assessment of a civil penalty; or(4) assessment of an administrative penalty. Source Note: The provisions of this §553.801 adopted to be effective August 31, 2021, 46 TexReg 5017. 1 HEALTH AND HUMAN SERVICES COMMISSION 553 LICENSING STANDARDS FOR ASSISTED LIVING FACILITIES H ENFORCEMENT §553.801 Arbitration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203000 03/12/2026 (a) Basis in legislation. The Nursing Facility Requirements for Licensure and Medicaid Certification implement the requirements of federal and state laws and regulations governing licensed nursing facilities and nursing facilities participating in the Medicaid program administered by HHSC in cooperation with other federal and state agencies. If there is a conflict between material in these requirements and the laws or regulations governing the Medicaid program, the Medicaid laws and regulations are controlling. It is the intent of the Texas Legislature that rules adopted under Chapter 242 of the Texas Health and Safety Code may be more stringent than the standards imposed by federal law for certification for participation in the state Medicaid program. The rules and standards may not be less stringent than the Medicaid certification standards imposed under the Omnibus Budget Reconciliation Act of 1987.(b) Scope. The Nursing Facility Requirements for Licensure and Medicaid Certification contain the requirements that an institution must meet in order to be licensed as a nursing facility and also to qualify to participate in the Medicaid program. The requirements serve as a basis for survey activities for licensure and certification.(1) Certain requirements are specific to Medicaid-certified facilities and are so designated. The Medicaid-specific requirements apply to all residents, including private pay, Medicaid applicants and recipients, U.S. Department of Veteran's Affairs patients, and Medicare recipients, who are admitted to and reside in a Medicaid-certified facility or a Medicaid-certified distinct part of a facility.(2) Additional requirements for facilities or distinct parts of facilities that are certified for Medicare-only participation are in 42 CFR §§483.5-483.95.(3) These requirements do not apply to skilled nursing facilities licensed under the Texas Health and Safety Code, Chapter 241, participating only in the Medicare program. Source Note: The provisions of this §554.1 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION A BASIS AND SCOPE §554.1 Basis and Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203327 03/12/2026 (a) A facility provides, under the terms of the contract, for the total medical, nursing, and psychosocial needs of each recipient.(b) The daily rate is compatible with reasonable charges consistent with efficiency, economy, and quality of total care. The facility must ensure that care meets the health needs and promotes the maximum well-being of recipients. The following items and services are included in the payment rate made to the facility by the Department of Aging and Disability Services (DADS) and, therefore, the facility must provide:(1) nursing care;(2) social services;(3) regular, special, and supplemental diets, including tube feedings;(4) nonlegend drugs, with the exception of insulin, and alcoholic beverages unless prescribed for medicinal purposes. Alcoholic beverages:(A) prescribed for medicinal purposes must include the dosage and frequency of the alcohol; and(B) not prescribed for medicinal purposes are at the expense of the recipient or family;(5) for a recipient who is not eligible for Medicare Part D benefits, legend drugs that are not covered by the Medicaid Vendor Drug Program;(6) for a recipient who is eligible for Medicare Part D benefits, legend drugs in a category that is not covered by Medicare Part D and that are not covered by the Medicaid Vendor Drug Program;(7) regular laundry services, except dry cleaning;(8) medical accessories, such as canulas, tubes, masks, catheters, ostomy bags and supplies, IV fluids, IV equipment, and equipment that can be used by more than one person, such as wheelchairs, adjustable chairs, crutches, canes, mattresses, hospital-type beds, enteral pumps, trapeze bars, walkers, and oxygen equipment, such as tanks, concentrators, tubing, masks, valves, and regulators.(A) Facilities are required to maintain, in good repair, equipment necessary to meet the needs of the recipient.(B) If a recipient desires equipment for exclusive use, its purchase is the responsibility of the recipient:(i) Only the recipient can use the equipment, and it must be identified as the personal property of the recipient.(ii) Upon discharge from the facility, the recipient retains the equipment he purchased. If the recipient dies, the purchased equipment must be transferred to the estate. If it is donated or sold to the facility by the recipient or the estate, the transaction must be documented. (See §19.416 of this title (relating to Personal Property)).(C) If a recipient owns a piece of equipment that is medically necessary, the facility must maintain and repair the equipment.(D) When Part B Medicare benefits are accessed to pay for equipment and accessories, the recipient or family may not be charged by the facility or supply company for any portion of these items;(9) medical supplies, including, but not limited to tongue depressors, swabs, bandaids, cotton balls, and alcohol; and(10) basic personal hygiene items and services to meet the needs of the residents (See §19.405(h) of this title (relating to Additional Requirements for Trust Funds in Medicaid-Certified Facilities) for a list of such items and services). The specific type or brand of personal hygiene items used by the facility must be disclosed to the recipient; then, if a recipient prefers to use a specific type or brand of a personal hygiene item(s) rather than the item(s) furnished by the facility, he may use his personal funds to purchase the item(s).(A) Before purchasing or charging for the preferred item(s), the facility must secure written authorization from the recipient or family indicating his desired preference, the date, and signature of the person requesting the preferred item(s). The signature may not be that of an employee of the facility.(B) If the recipient's personal funds are used to purchase an item(s), the item(s) is for his sole use.(C) When the facility purchases personal hygiene item(s) with the recipient's personal funds, the facility must ensure that the item(s) is in an individual container or package that is labeled with the recipient's name. The facility is not held responsible for labeling personal hygiene items brought into the facility and not reported to the management.(c) Facilities are not required to provide any particular brand of non-legend drug, medical accessory, equipment, or supply, but only those items necessary to ensure appropriate recipient care.(1) Unless the physician orders a specific type or brand, the facility may choose the type or brand.(2) If the recipient or family prefers a specific type or brand of item rather than the one furnished by the facility, the recipient, responsible party, or family may be billed for the item, or the recipient's personal funds may be used to purchase the item, or both.(3) Before purchasing or charging for the preferred item, the facility must secure written authorization from the recipient or family indicating his desired preference, the date, and signature of the person requesting the preferred item. The signature may not be that of an employee of the facility.(d) If a resident has requested and freely chosen to participate in an activity, or to have an item or service provided that is not included, or is different than that provided, in the daily vendor rate, then the resident may be charged for the activity, item, or service.(1) When documentation is present that supports the above criteria, and that is required by §19.405(d)(5) of this title, the amount may be paid from the resident's trust fund.(2) When the facility acts as a collection agent for any item, service, or activity not included in the daily rate, the facility must be able to provide documentation that clearly indicates that any charges made to the recipient or his trust fund are pass-through costs only. The facility may not charge any fees, including handling fees, for these types of transactions.(e) Except as described in paragraphs (1) and (2) of this subsection, DADS makes vendor payments to Nursing Facilities for the day a recipient enters a nursing facility, but not for the day a recipient leaves a facility. The two exceptions are as follows.(1) If entrance and departure are on the same day, and the recipient does not enter another Title XIX facility on that day, DADS pays for the entire day.(2) If departure is because of the recipient's death and the deceased recipient is not sent to another Title XIX facility for legal procedures necessary upon the death of the recipient, DADS pays for the entire day.(f) Vendor payments are made to Medicaid Nursing Facilities that comply with the PASARR requirements. Source Note: The provisions of this §554.2601 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective December 1, 2000, 25 TexReg 11665; amended to be effective January 1, 2006, 30 TexReg 7890; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2601 Vendor Payment (Items and Services Included) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203313 03/12/2026 (a) The Texas Department of Human Services (DHS) does not make vendor payments when a Title XIX recipient is absent from the facility because of:(1) therapeutic home visits that extend beyond three days; or(2) hospital inpatient services. However, DHS makes vendor payments for periods when a recipient is a hospital outpatient subject to the following limitations.(A) DHS makes vendor payments when a Title XIX recipient is absent from the nursing facility past midnight for outpatient hospital services, including services resulting from hospital outpatient observation. In these cases the facility must document in the clinical record that the recipient was not admitted as an inpatient in the hospital.(B) If the recipient is admitted to the hospital for inpatient services anytime during a hospital outpatient observation period, a patient transaction notice showing discharge must be submitted effective the date the recipient left the nursing facility.(b) The facility may enter into a written agreement with the recipient or responsible party to reserve a bed, according to the specifications of §19.503 of this title (relating to Notice of Bed-hold Policy and Readmission in Medicaid-Certified Facilities).(c) The facility may charge for transportation beyond normal transportation as defined in §19.2320 of this title (relating to Medical Transportation).(d) The billing of flu shots to recipients by the nursing facility is not allowed.(e) A facility must bill for charges not covered by Medicaid at least once a month. Each bill must itemize all extra charges by general category. Source Note: The provisions of this §554.2602 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2602 Additional Charges (Items and Services Excluded from Vendor Payment) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203314 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203314 03/12/2026 (a) The facility must have written policies and procedures governing recipient therapeutic home visits away from the facility for the purpose of visiting with relatives and friends.(b) The following conditions must be met for the facility to receive vendor payment:(1) the recipient's plan of care provides for physician-authorized therapeutic visits;(2) the facility must provide equipment and supplies necessary to meet the needs of the recipient, including, but not limited to, medication and oxygen and supplies for its administration;(3) if a visit exceeds three days, the facility submits a discharge form effective the first day. Days are defined as 24-hour periods extending from midnight to midnight. In determining days of absence from a facility, the first day is the first 24-hour period beginning at midnight after the recipient's departure. Situations that require a discharge form effective the first day include:(A) alternate care living arrangements, including at home;(B) transfer or discharge to other medical care or living arrangements covered under Title XIX; and(C) therapeutic visits that are over three days (one night must be spent in the facility between therapeutic home visits if vendor payment is to be made);(4) the facility must maintain a record of each therapeutic visit away from the facility. Verification that therapeutic visits took place and were documented is a part of the audit procedures during the DHS audit of the facility. DHS does not pay for therapeutic visits which were not documented.(c) Before a resident goes on therapeutic leave, the facility must provide written notification to the recipient, and, if known, a responsible party, or family or legal representative, regarding the three-day time limit for a home visit, as specified in subsection (b)(3) of this section. Source Note: The provisions of this §554.2603 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2603 Therapeutic Home Visits Away from the Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203315 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203315 03/12/2026 (a) Vendor payment will be made based upon the nursing facility administrator's or the administrative designee's approval of the Nursing Care Statement.(b) Vendor payment will be made at periodic intervals but not less than once per month for services rendered during the previous billing period.(c) The vendor payment for an entire month will be in accordance with the number of calendar days in the month.(d) Vendor payment for time periods of less than an entire calendar month shall be made in accordance with the number of days care was provided beginning with the effective date on the Notification of Recipient Medical Necessity Determination and/or Vendor Payment Plan.(e) Days are defined as 24-hour periods extending from midnight to midnight. Payment is computed in terms of whole days, even though the recipient may have been in a nursing facility only a fractional part of the day of entrance. (See §19.2601(e) of this title (relating to Vendor Payment (Items and Services Included)).(f) Vendor payment will be made in terms of daily rates.(g) The recipient must have the status of a certified recipient, must have been determined to be in need of nursing facility care, and must be physically located in a Medicaid-certified bed of a facility at the time the service is rendered in order for the facility to receive payment for the service.(h) The Texas Department of Human Services (DHS) will owe the facility no interest on payments not made within the time limits provided in these rules, the provider contract, or Chapter 2251 of the Government Code when the delay is the result of a bona fide dispute between DHS and the facility over compliance with the terms and conditions of the Medicaid program or is the result of other rules, laws or contract terms authorizing the withholding or nonpayment. Source Note: The provisions of this §554.2604 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2604 Vendor Payment Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203316 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203316 03/12/2026 If an applicant is determined to be eligible and in need of nursing facility care, the effective date of vendor coverage is either the date the individual entered the facility, the date of application, or the date the need for nursing facility care was established, whichever date is the latest.(1) Once the effective date is established, the Texas Department of Human Services (DHS), through the contract agreement with the facility, sets the acceptable rates for services.(2) If the facility charges the applicant an amount over the recognized monthly rate set by DHS, the difference must be refunded to the recipient or the responsible party.(3) Private pay individuals living in Medicaid certified nursing facilities, or distinct parts, who do not receive SSI cash benefits may be eligible for "Three months prior" vendor payments. (See §19.2408 of this title (relating to Retroactive Medical Necessity Determinations)). Source Note: The provisions of this §554.2605 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2605 Effective Date of Vendor Coverage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203317 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203317 03/12/2026 (a) Facilities must abide by Public Law 95-142 related to Medicare/Medicaid antifraud and abuse amendments.(b) Participation will be limited to providers of services who accept, as payment in full, the amounts paid in accordance with the fee structure approved by the Texas Department of Human Services (DHS).(c) Providers who have a contract with DHS and who solicit contributions, donations, or gifts from Medicaid recipients or family members will be in noncompliance with federal requirements.(d) The facility must inform Medicaid recipients and their families that their right to nursing facility services is not contingent upon contributions. The facility must give copies of this notice to the recipient, and either the responsible party or family representative.(e) If a recipient, family member, guardian, or other interested party does make a free-will contribution, the nursing facility administrator executes a statement for signature by both the contributor and the administrator. It will state that the services provided to any Medicaid recipient in the nursing facility are not predicated upon contributions and that the gifts are free-will contributions.(f) When a provider accepts federal and/or state funds for items or services delivered which are not reimbursed within the per diem, the facility must document:(1) that the type of item or service is ordered by the physician;(2) that the item or service has not been billed to more than one payor source; and(3) that the recipient actually received the item or service. Source Note: The provisions of this §554.2606 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2606 Supplementation of Vendor Payments https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203318 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203318 03/12/2026 A felony conviction with a fine of not more than $25,000 or imprisonment for not more than five years or both can be imposed on anyone in the facility who knowingly and willfully:(1) accepts, from the recipient, money or other considerations in excess of rates established by the state for services provided under a state plan approved under Title XIX;(2) charges, solicits, accepts, or receives any gifts, money, donation, or other consideration in addition to amounts required to be paid under a state plan approved under Title XIX (other than charitable donations from an organization or a person unrelated to the recipient) as a precondition for admitting or keeping a recipient in the nursing facility; or(3) accepts reimbursement from more than one source (including per diem reimbursement) for the same item or service. Source Note: The provisions of this §554.2607 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2607 Penalties for Supplementation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203319 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203319 03/12/2026 A provider of Medicaid (Title XIX) services may neither charge nor take other recourse against Medicaid applicants or recipients, their family members, or their representatives for any claim denied or reduced by the Texas Department of Human Services (DHS) because of the provider's failure to comply with any DHS rule, regulation, or procedure. Source Note: The provisions of this §554.2608 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2608 Limitations on Provider Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203320 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203320 03/12/2026 To receive payment for a service, a nursing facility must submit a complete and accurate claim to the state Medicaid claims administrator so that it is received within 12 months after the date of service. In this section, the date of service is the last day of the month in which the service was provided.(1) All payments are subject to availability of funds as provided by law.(2) For purposes of this section, third party means an individual, entity, or program other than DADS or the program provider that is or may be liable to pay all or part of the expenditures for nursing facility services, including:(A) A commercial insurance company offering health or casualty insurance to individuals or groups (including both experience-rated insurance contracts and indemnity contracts);(B) A profit or nonprofit prepaid plan offering either medical services or full or partial payment for services; and(C) An organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments or services, including self-insured and self-funded plans.(3) If DADS has established the probable existence of a third-party liability for nursing facility services at the time the claim is filed, DADS rejects the claim and returns it to the nursing facility for a determination of the amount of liability. When the amount of liability is determined, DADS pays the claim to the extent that payment allowed under the HHSC rate payment schedule exceeds the amount of the third party's payment.(4) If a claim is returned to a nursing facility provider for a determination of liability in accordance with paragraph (3) of this section, the nursing facility must:(A) submit the claim to the identified third-party for a determination of the amount of liability;(B) keep all documentation of actions taken to determine the amount of liability by the third-party; and(C) certify to DADS the actions the nursing facility has taken to determine the liability of the third-party in accordance with instructions from DADS.(5) A nursing facility must submit claims and adjustments rejected or denied to the state Medicaid claims administrator within 12 months after the date of service. DADS may pay for claims and adjustments rejected or denied during the 12-month period through no fault of the nursing facility.(6) If a nursing facility submits a claim to a third party, the requirement to submit the claim to the state Medicaid claims administrator in accordance with paragraph (5) of this section is not affected. In addition, the nursing facility must allow 110 days to elapse after the date the claim was submitted to the third-party before submitting the claim to the state Medicaid claims administrator.(7) A nursing facility may resubmit a claim after the 12-month period in the case of state-generated retroactive payments.(8) The provisions of §19.2413 of this chapter (relating to Determination of Payment Rate Based on the MDS Assessment Submission) apply to this section.(9) DADS recoups any inadvertent payments made to a facility. Source Note: The provisions of this §554.2609 adopted to be effective July 1, 1999, 24 TexReg 4833; amended to be effective November 1, 2002, 27 TexReg 9387; amended to be effective September 3, 2008, 33 TexReg 7264; amended to be effective July 1, 2012, 37 TexReg 4612; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2609 Payment of Claims https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203321 03/12/2026 When the Texas Department of Human Services (DHS) receives valid Medicare claims, DHS pays a portion of the Medicare Part A skilled nursing facility (SNF) deductible and coinsurance. When Medicare changes its daily interim payment, DHS adjusts the Medicaid payment on the Part A SNF coinsurance amount if necessary. The adjustment is effective on the first day of the month following the Medicare change. Source Note: The provisions of this §554.2610 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2610 Medicare Part A Skilled Nursing Facility Deductible and Coinsurance Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203322 03/12/2026 (a) In this section, retroactive vendor payment is payment DADS makes retroactively to a nursing facility for services the nursing facility provided to an individual who was eligible for, but had not yet applied for, Medicaid. A nursing facility is eligible for up to three months retroactive vendor payment for services it provided, if:(1) the individual resided in a Medicaid-certified nursing facility, or a distinct part, during the time services were provided;(2) the individual did not receive Supplemental Security Income cash benefits;(3) the individual met Medicaid financial eligibility requirements;(4) the state Medicaid claims administrator has a current MDS assessment for the individual that the facility submitted in compliance with the federal MDS submission requirements; and(5) the nursing facility met physician certification and plan of care requirements during the time services were provided.(b) After receipt of an application for Medicaid, Texas Health and Human Services Commission (HHSC) Medicaid eligibility staff notify the applicant whether the applicant meets financial eligibility. The state Medicaid claims administrator uses the applicant's current MDS assessment to make the MN determination and determine the effective date of the MN determination. For the purpose of establishing three months prior eligibility, the effective date of the MN determination for a new recipient is the first day of the month in which the recipient qualified for MN.(c) If the requirements in subsection (a) of this section are met, DADS makes a retroactive vendor payment based on the recipient's calculated RUG rate for the period covered by the retroactive vendor payment.(d) DADS or HHSC may verify that the recipient's record includes the required physician's certification, recertification, and plans of care, and that the plans were reviewed as required during the applicable periods.(e) If a recipient paid the nursing facility for services for which the facility later receives retroactive vendor payment, the facility must reimburse the recipient the full amount the recipient paid, beginning with the effective date of Medicaid eligibility, minus any applied income or co-payment as determined by HHSC Medicaid eligibility staff. Source Note: The provisions of this §554.2611 adopted to be September 3, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2611 Retroactive Vendor Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203323 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203323 03/12/2026 For services delivered after September 1, 1999, the Texas Department of Human Services (DHS) may make Quality Incentive payments to facilities according to reimbursement rules developed by the Health and Human Services Commission. DHS will determine the qualifying facilities.(1) The Texas Board of Human Services will review the adopted plan at least biennially.(2) Incentive payments will be based on:(A) specific resident care domains selected from the Center for Health Systems Research and Analysis (CHSRA) Quality Indicators; and(B) regulatory compliance.(3) The incentive payment is in addition to the daily vendor rate paid to the provider. Source Note: The provisions of this §554.2612 adopted to be effective January 1, 2000, 24 TexReg 10578; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2612 Quality Incentive Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203324 03/12/2026 (a) A specialized augmentative communication device system (ACD), also referred to as a speech-generating device system, is reimbursable if purchased by a facility for a Medicaid recipient and all criteria defined in this section are met. A physician and a licensed speech therapist must determine a recipient needs the ACD, and the facility must obtain DADS' approval of the request for reimbursement.(b) A facility must request and receive prior authorization from DADS before purchasing the ACD. The request for prior authorization must include:(1) an evaluation and recommendation from a licensed speech therapist to purchase the ACD;(2) an attestation from the recipient's attending physician that the ACD is medically necessary for the recipient to maximize his functional communication within the facility's environment; and(3) a minimum of two bids for the ACD or a request for an exception to the two-bid minimum if the recommended ACD is only available through one vendor.(c) The evaluation from the licensed speech therapist must include:(1) a description of how the ACD will specifically meet the need of the recipient;(2) detailed instructions for training on the use of the ACD for the recipient, facility staff, and family (if applicable);(3) a diagnosis relevant to the need for the ACD; and(4) the specific ACD being recommended.(d) If an ACD costs more than $10,000, DADS will facilitate an independent speech language review, at DADS' expense, to determine necessity for the ACD.(e) After receiving prior authorization from DADS, the facility must purchase the ACD.(f) To obtain reimbursement from DADS, a facility must submit to DADS the receipt for payment for the ACD and a copy of the approved prior authorization.(1) A facility must fully explore and use other funding sources to pay for an ACD before submitting the request for reimbursement to DADS. If another funding source will pay for part of the ACD expense, the facility may request reimbursement for the balance if the requirements in subsections (b) and (c) of this section are met. If another funding source is available, DADS reimburses only up to the remaining balance after other sources are fully utilized.(2) A facility must submit the request for reimbursement within one year after the date of purchase.(3) DADS reimburses the amount of the authorized bid or the remaining balance after all other sources are fully utilized.(g) If DADS denies a request for reimbursement because the facility failed to obtain prior authorization or submit the necessary documentation for the ACD, the facility is responsible for the cost of the ACD.(h) If DADS denies a prior authorization request, the recipient may request a Medicaid fair hearing in accordance with 1 TAC Chapter 357, Subchapter A.(i) Only the recipient can use the ACD, and it must be identified as the personal property of the recipient.(1) Upon discharge from the facility, the recipient retains the ACD. If the recipient dies, the ACD must be transferred to the recipient's estate. If it is donated or sold to the facility by the recipient or the recipient's estate, the transaction must be documented. (See §19.416 of this title (relating to Personal Property)).(2) The facility is responsible for the repair and maintenance of the ACD while the recipient resides in the facility. Source Note: The provisions of this §554.2613 adopted to be effective July 1, 2007, 32 TexReg 3857; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2613 Augmentative Communication Device Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203325 03/12/2026 (a) Customized power wheelchairs (CPWCs) are a service in the nursing facility Medicaid program for Medicaid-eligible nursing facility residents when medically necessary and prior authorized by the Health and Human Services Commission (HHSC) or its designee.(b) A CPWC is a wheelchair that consists of a power mobility base and customized seating system.(1) The power mobility base may include programmable electronics and may utilize alternate input devices.(2) The wheelchair must be medically necessary, adapted, and fabricated to meet the individualized needs of the resident, and intended for the exclusive and ongoing use of the resident.(3) Components of the customized seating system must be in part or entirely usable only by the resident for whom the power wheelchair is adapted and fabricated.(c) When requested by a resident or the resident's legal representative, the nursing facility must procure an evaluation for a CPWC from a licensed physical or occupational therapist. If the evaluation recommends a CPWC, the nursing facility must submit all required forms to HHSC or its designee for prior authorization.(d) After receiving prior authorization from HHSC or its designee, the facility must purchase the CPWC.(e) To be eligible for reimbursement, the nursing facility must request and receive prior authorization from HHSC or its designee before purchasing a CPWC. The prior authorization request must include:(1) a completed CPWC order form;(2) an occupational or physical therapy evaluation of the resident;(3) a statement signed by the resident's attending physician that the CPWC is medically necessary; and(4) a detailed breakdown of proposed CPWC specifications from the customized power wheelchair supplier.(f) To be eligible for reimbursement for a CPWC, the nursing facility must obtain an evaluation of the resident by an occupational or physical therapist licensed in the state of Texas prior to purchase of the CPWC. The occupational or physical therapy evaluation must include:(1) a diagnosis relevant to the need for a CPWC;(2) the specific CPWC and adaptations being recommended;(3) a description of how the CPWC will meet the specific needs of the resident;(4) a description of specific training needs for use of this device including training needs of the resident, nursing facility staff, and family (when applicable); and(5) written documentation from the therapist indicating that the resident is physically and cognitively capable of independently managing a power wheelchair.(g) Payment for physical or occupational therapy evaluations may be obtained for eligible residents in the same manner as payment for physical or occupational therapy evaluations is obtained in the Specialized and Rehabilitative Services programs, as described in §19.1306 of this chapter (relating to Payment for Specialized and Rehabilitative Services).(h) Following a review of the prior authorization request by HHSC or its designee, the nursing facility and resident will receive a written approval or denial of the request. If the request is approved, the nursing facility will promptly make arrangements to purchase the CPWC. If the request is denied, HHSC or its designee will send a notice of denial to the nursing facility resident informing the resident of the right to request a Medicaid fair hearing in accordance with 1 TAC Chapter 357, Subchapter A.(i) A facility must submit the request for reimbursement to DADS within one year after the date of purchase of the CPWC. If DADS denies a request for reimbursement because the facility failed to obtain prior authorization or submit the necessary documentation for the CPWC to HHSC or its designee, the facility is responsible for the cost of the CPWC and may not charge the cost to the resident or family.(j) A facility must fully explore and use other funding sources to pay for a CPWC before submitting the request for reimbursement to DADS. If another funding source will pay for part of the CPWC expense, the facility may request reimbursement for the balance if the requirements in subsections (d) - (f) of this section are met. If another funding source is available, DADS reimburses only up to the remaining balance after other sources are fully utilized.(k) Only the resident can use the CPWC, and it must be identified as the personal property of the resident.(l) The resident's comprehensive care plan must document that the CPWC is medically necessary.(m) Upon discharge from the facility, the resident retains the CPWC. If the resident dies, the CPWC becomes property of the resident's estate. As part of the estate, the CPWC is subject to all applicable Medicaid Estate Recovery Program (MERP) requirements, as detailed in 1 TAC Chapter 373. If the CPWC is donated or sold to the facility by the resident or executor of the resident's estate, the transaction must be documented in accordance with §19.416 of this chapter (relating to Personal Property).(n) As required by §19.2601(b)(8)(C) of this chapter (relating to Vendor Payment (Items and Services Included)), the nursing facility is required to maintain and repair all medically necessary equipment for its residents, including CPWCs obtained under this section.(o) Requests for replacement of a CPWC must be submitted in the same manner as the original prior authorization of the CPWC outlined in this section. A replacement CPWC may be requested no earlier than five years after the original date of purchase, unless the request includes an order from the prescribing physician familiar with the resident and an assessment by a physician or a licensed occupational or physical therapist with documentation supporting why the current CPWC no longer meets the resident's needs. DADS does not authorize replacement in situations where the CPWC has been abused or neglected. Source Note: The provisions of this §554.2614 adopted to be effective May 1, 2008, 33 TexReg 3301; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2614 Customized Power Wheelchairs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203326 03/12/2026 A nursing facility must electronically submit to the state Medicaid claims administrator a resident transaction notice within 72 hours after a recipient's admission or discharge from the Medicaid nursing facility vendor payment system. The nursing facility administrator must sign the resident transaction notice. Source Note: The provisions of this §554.2615 adopted to be September 3, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION AA VENDOR PAYMENT §554.2615 Resident Transaction Notices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220621 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise. (1) Abuse--Negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure) or Texas Penal Code, Chapter 22 (relating to Assaultive Offenses), sexual harassment, sexual coercion, or sexual assault. (2) Act--Chapter 242 of the Texas Health and Safety Code. (3) Activities assessment--See Comprehensive Assessment and Comprehensive Care Plan. (4) Activity director--The qualified individual appointed by the facility to direct the activities program as described in §554.702 of this chapter (relating to Activities).(5) Addition--The addition of floor space to an institution. (6) Administrator--A person currently licensed in accordance with Chapter 555 of this title (relating to Nursing Facility Administrators). (7) Admission MDS assessment--An MDS assessment that determines a recipient's initial determination of eligibility for medical necessity for admission into the Texas Medicaid Nursing Facility Program.(8) Advanced practice registered nurse--A person licensed as a registered nurse and approved to practice as an advanced practice registered nurse by the Texas Board of Nursing.(9) Adverse event--An untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk of death or serious injury.(10) Alzheimer's Disclosure Statement for Nursing Facilities--The HHSC-prescribed form a facility uses to describe the nature of care or treatment of residents with Alzheimer's disease and related disorders. (11) Alzheimer's disease and related disorders--Alzheimer's disease and any other irreversible dementia described by the Centers for Disease Control and Prevention or the most current edition of the Diagnostic and Statistical Manual of Mental Disorders.(12) Applicant--A person or governmental unit, as those terms are defined in the Texas Health and Safety Code, Chapter 242, applying for a license under that chapter.(13) Attending physician--A physician, currently licensed by the Texas Medical Board, who is designated by the resident or resident representative as having primary responsibility for the treatment and care of the resident.(14) Authorized electronic monitoring--The placement of an electronic monitoring device in a resident's room and using the device to make tapes or recordings after making a request to the facility to allow electronic monitoring.(15) Barrier precautions--Precautions including the use of gloves, masks, gowns, resuscitation equipment, eye protectors, aprons, face shields, and protective clothing for purposes of infection control. (16) Care and treatment--Services required to maximize resident independence, personal choice, participation, health, self-care, psychosocial functioning, and reasonable safety, all consistent with the preferences of the resident.(17) Certification--The determination by HHSC that a nursing facility meets all the requirements of the Medicaid or Medicare programs.(18) Certified facility--A facility that meets the requirements of the Medicare program, the Medicaid program, or both.(19) Certified Ombudsman--Has the meaning given in §88.2 of this title (relating to Definitions).(20) CFR--Code of Federal Regulations.(21) Change of ownership-- An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership.(22) Chemical restraints--Any drug administered for the purpose of discipline or convenience, and not required to treat the resident's medical symptoms.(23) CMS--Centers for Medicare & Medicaid Services.(24) Complaint--Any allegation received by HHSC other than an incident reported by the facility. Such allegations include, but are not limited to, abuse, neglect, exploitation, or violation of state or federal standards.(25) Completion date--The date an RN assessment coordinator signs an MDS assessment as complete. (26) Comprehensive assessment--An interdisciplinary description of a resident's needs and capabilities including daily life functions and significant impairments of functional capacity, as described in §554.801(2) of this chapter (relating to Resident Assessment). (27) Comprehensive care plan--A plan of care prepared by an interdisciplinary team that includes measurable short-term and long-term objectives and timetables to meet the resident's needs developed for each resident after admission. The plan addresses at least the following needs: medical, nursing, rehabilitative, psychosocial, dietary, activity, and resident's rights. The plan includes strategies developed by the team, as described in §554.802(c)(2) of this chapter (relating to Comprehensive Person-Centered Care Planning), consistent with the physician's prescribed plan of care, to assist the resident in eliminating, managing, or alleviating health or psychosocial problems identified through assessment. Planning includes: (A) goal setting; (B) establishing priorities for management of care; (C) making decisions about specific measures to be used to resolve the resident's problems; and (D) assisting in the development of appropriate coping mechanisms. (28) Controlling person--A person with the ability, acting alone or in concert with others, to directly or indirectly, influence, direct, or cause the direction of the management, expenditure of money, or policies of a nursing facility or other person. A controlling person does not include a person, such as an employee, lender, secured creditor, or landlord, who does not exercise any influence or control, whether formal or actual, over the operation of a facility. A controlling person includes: (A) a management company, landlord, or other business entity that operates or contracts with others for the operation of a nursing facility; (B) any person who is a controlling person of a management company or other business entity that operates a nursing facility or that contracts with another person for the operation of a nursing facility; (C) an officer or director of a publicly traded corporation that is, or that controls, a facility, management company, or other business entity described in subparagraph (A) of this paragraph but does not include a shareholder or lender of the publicly traded corporation; and (D) any other individual who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of a nursing facility, is in a position of actual control or authority with respect to the nursing facility, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the facility. (29) Covert electronic monitoring--The placement and use of an electronic monitoring device that is not open and obvious, and the facility and HHSC have not been informed about the device by the resident, by a person who placed the device in the room, or by a person who uses the device. (30) DADS--The term referred to the Department of Aging and Disability Services; it now refers to HHSC. (31) Dentist--A practitioner licensed to practice dentistry by the Texas State Board of Dental Examiners. (32) DHS--This term referred to the Texas Department of Human Services; it now refers to HHSC. (33) Dietitian--A qualified dietitian is one who is qualified based upon either: (A) registration by the Commission on Dietetic Registration of the Academy of Nutrition and Dietetics; or (B) licensure, or provisional licensure, as a dietitian under Texas Occupations Code, Chapter 701 and one year of supervisory experience in dietetic service of a health care facility. (34) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder. (35) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder. (36) Distinct part--That portion of a facility certified to participate in the Medicaid Nursing Facility program or as a SNF in the Medicare program. (37) Drug (also referred to as medication)--Any of the following: (A) any substance recognized as a drug in the official United States Pharmacopoeia, official Homeopathic Pharmacopoeia of the United States, or official National Formulary, or any supplement to any of them; (B) any substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans; (C) any substance (other than food) intended to affect the structure or any function of the body of a human; and (D) any substance intended for use as a component of any substance specified in subparagraphs (A) - (C) of this paragraph. It does not include devices or their components, parts, or accessories. (38) Electronic monitoring device--Video surveillance cameras and audio devices installed in a resident's room, designed to acquire communications or other sounds that occur in the room. An electronic, mechanical, or other device used specifically for the nonconsensual interception of wire or electronic communication is excluded from this definition. (39) Emergency--A sudden change in a resident's condition requiring immediate medical intervention. (40) Essential Caregiver--A family member, friend, guardian, volunteer, or other person designated for in-person visits by an individual, resident, or client or the individual's, resident's, or client's guardian or legally authorized representative (LAR) during a public health emergency or disaster. In case of conflict between an individual's, resident's, or client's selection and a guardian's selection on behalf of the individual, resident, or client, the guardian's selection prevails, in accordance with the terms of the guardianship. If an individual, resident, or client has no guardian and is unable to select an essential caregiver, the individual's, resident's, or client's LAR may select the essential caregiver. (41) Executive Commissioner--The executive commissioner of the Texas Health and Human Services Commission. (42) Exploitation--The illegal or improper act or process of a caregiver, family member, or other individual who has an ongoing relationship with a resident using the resources of the resident for monetary or personal benefit, profit, or gain without the informed consent of the resident. (43) Facility--Unless otherwise indicated, a facility is an institution that provides organized and structured nursing care and service and is subject to licensure under Texas Health and Safety Code, Chapter 242. (A) For Medicaid, a facility is a nursing facility that meets the requirements of §1919(a) - (d) of the Social Security Act (42 United States Code §1396r(a) - (d)). A facility may not include any institution that is for the care and treatment of mental diseases except for services furnished to individuals age 65 and over and who are eligible as defined in Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)). (B) For Medicare and Medicaid purposes (including eligibility, coverage, certification, and payment), the "facility" is always the entity which participates in the program, whether that entity is comprised of all, or a distinct part of, a larger institution. (C) "Facility" is also referred to as a nursing home or nursing facility. Depending on context, these terms are used to represent the management, administrator, or other persons or groups involved in the provision of care of the resident; or to represent the physical building, which may consist of one or more floors or one or more units, or which may be a distinct part of a licensed hospital. (44) Family council--A group of family members, friends, or legal guardians of residents, who organize and meet privately or openly. (45) Family representative--An individual appointed by the resident to represent the resident and other family members, by formal or informal arrangement. (46) Fiduciary agent--An individual who holds in trust another's monies. (47) Goals--Long-term: general statements of desired outcomes. Short-term: measurable, time-limited, expected results that provide the means to evaluate the resident's progress toward achieving long-term goals. (48) Governmental unit--A state or a political subdivision of the state, including a county or municipality. (49) Health care provider--An individual, including a physician, or facility licensed, certified, or otherwise authorized to administer health care, in the ordinary course of business or professional practice. (50) Hearing--A contested case hearing held in accordance with the Administrative Procedure Act, Texas Government Code, Chapter 2001, and the formal hearing procedures in 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and 40 TAC Chapter 91 (relating to Hearings Under the Administrative Procedure Act). (51) HHSC--The Texas Health and Human Services Commission. (52) HIV--Human Immunodeficiency Virus. (53) Incident--An abnormal event, including accidents or injury to staff or residents, which is documented in facility reports. An occurrence in which a resident may have been subject to abuse, neglect, or exploitation must also be reported to HHSC. (54) Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder. (55) Infection control--A program designed to prevent the transmission of disease and infection in order to provide a safe and sanitary environment. (56) Inspection--Any on-site visit to or survey of an institution by HHSC for the purpose of licensing, monitoring, complaint investigation, architectural review, or similar purpose. (57) Involuntary seclusion--Separation of a resident from others or from the resident's room or confinement to the resident's room, against the resident's will or the will of a person who is legally authorized to act on behalf of the resident. Monitored separation from other residents is not involuntary seclusion if the separation is a therapeutic intervention that uses the least restrictive approach for the minimum amount of time, not to exceed 24 hours, until professional staff can develop a care plan to meet the resident's needs. (58) IV--Intravenous. (59) Legend drug or prescription drug--Any drug that requires a written or telephonic order of a practitioner before it may be dispensed by a pharmacist, or that may be delivered to a particular resident by a practitioner in the course of the practitioner's practice. (60) License holder--A person that holds a license to operate a facility. (61) Licensed health professional--A physician; physician assistant; advanced practice registered nurse; physical, speech, or occupational therapist; pharmacist; physical therapist assistant occupational therapy assistant; registered professional nurse; licensed vocational nurse; licensed dietitian; licensed social worker; or certified respiratory care practitioner. (62) Licensed vocational nurse (LVN)--A nurse who is currently licensed by the Texas Board of Nursing as a licensed vocational nurse. (63) Life Safety Code--NFPA 101. (64) Life safety features--Fire safety components required by NFPA 101, including building construction, fire alarm systems, smoke detection systems, interior finishes, sizes and thicknesses of doors, exits, emergency electrical systems, and sprinkler systems. (65) Life support--Use of any technique, therapy, or device to assist in sustaining life. (See §554.419 of this chapter (relating to Advance Directives)). (66) Local authorities--Persons, including, but not limited to, local health authority, fire marshal, and building inspector, who may be authorized by state law, county order, or municipal ordinance to perform certain inspections or certifications. (67) Local health authority--The physician appointed by the governing body of a municipality or the commissioner's court of the county to administer state and local laws relating to public health in the municipality's or county's jurisdiction as defined in Texas Health and Safety Code §121.021. (68) Long-term care-regulatory--HHSC Regulatory Services Division, which is responsible for surveying nursing facilities to determine compliance with regulations for licensure and certification for Medicaid participation. (69) Major injury--An injury that qualifies as a major injury under NFPA 99. (70) Management services--Services provided under contract between the owner of a facility and a person to provide for the operation of a facility, including administration, staffing, maintenance, or delivery of resident services. Management services do not include contracts solely for maintenance, laundry, or food service. (71) Manager--A person, other than a licensed nursing home administrator, having a contractual relationship to provide management services to a facility. (72) Managing local ombudsman--Has the meaning given in §88.2 of this title. (73) MDS--Minimum data set. See RAI. (74) MDS nurse reviewer--A registered nurse employed by HHSC to monitor the accuracy of the MDS assessment submitted by a Medicaid-certified nursing facility. (75) Medicaid applicant--A person who requests the determination of eligibility to become a Medicaid recipient. (76) Medicaid nursing facility vendor payment system--Electronic billing and payment system for reimbursement to nursing facilities for services provided to eligible Medicaid recipients. (77) Medicaid recipient--A person who meets the eligibility requirements of the Title XIX Medicaid program, is eligible for nursing facility services, and resides in a Medicaid-participating facility. (78) Medical director--A physician licensed by the Texas Medical Board, who is engaged by the nursing home to assist in and advise regarding the provision of nursing and health care. (79) Medical power of attorney--The legal document that designates an agent to make treatment decisions if the individual designator becomes incapable. (80) Medication aide--A person who holds a current permit issued under the Medication Aide Training Program as described in Chapter 557 of this title (relating to Medication Aides--Program Requirements) and acts under the authority of a person who holds a current license under state law which authorizes the licensee to administer medication. (81) Memory Care Disclosure Statement for Nursing Facilities--The HHSC-prescribed form a facility uses when the facility advertises, markets, or otherwise promotes that it provides services to residents with Alzheimer's disease and related disorders. (82) Memory care services--Services provided by a nursing facility that meet the needs of residents with a diagnosis of Alzheimer's disease or related disorders or a diagnosis of dementia. (83) Misappropriation--The taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real or personal, or anything of value belonging to or under the legal control of a resident without the effective consent of the resident or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct relating to the custody or disposition of property of a resident. (84) MN--Medical necessity. A determination, made by physicians and registered nurses who are employed by or contract with the state Medicaid claims administrator, that a recipient requires the services of a licensed nurse in an institutional setting to carry out a physician's planned regimen for total care. A recipient's need for custodial care in a 24-hour institutional setting does not constitute medical necessity. (85) Neglect--The failure to provide goods or services, including medical services, that are necessary to avoid physical or emotional harm, pain, or mental illness. (86) NFPA--National Fire Protection Association. (87) NFPA 99--NFPA 99, Health Care Facilities Code, 2012 Edition. (88) NFPA 101--NFPA 101, Life Safety Code, 2012 Edition. (89) Nurse aide--An individual who provides nursing or nursing-related services to residents in a facility under the supervision of a licensed nurse. This term may include an individual who provides these services through an agency or under a contract with the facility. This definition does not include an individual who is a licensed health professional, a registered dietitian, or someone who volunteers such services without pay. A nurse aide is not authorized to provide nursing or nursing-related services for which a license or registration is required under state law. Nurse aides do not include those individuals who furnish services to residents only as paid feeding assistants. (90) Nurse practitioner--An advanced practice registered nurse licensed by the Texas Board of Nursing in the role of Nurse Practitioner. (91) Nurses' station--A nurses' station is an area designated as the focal point on all shifts for the administration and supervision of resident-care activities for a designated number of resident bedrooms. (92) Nursing care--Services provided by nursing personnel which include, but are not limited to, observation; promotion and maintenance of health; prevention of illness and disability; management of health care during acute and chronic phases of illness; guidance and counseling of individuals and families; and referral to physicians, other health care providers, and community resources when appropriate. (93) Nursing facility or nursing home--See definition of "facility." (94) Nursing personnel--Persons assigned to give direct personal and nursing services to residents, including registered nurses, licensed vocational nurses, nurse aides, and medication aides. Unlicensed personnel function under the authority of licensed personnel. (95) Objectives--See definition of "goals." (96) OBRA--Omnibus Budget Reconciliation Act of 1987, which includes provisions relating to nursing home reform. (97) Ombudsman intern--Has the meaning given in §88.2 of this title. (98) Ombudsman Program--Has the meaning given in §88.2 of this title. (99) Paid feeding assistant--An individual who meets the requirements of §554.1113 of this chapter (relating to Paid Feeding Assistants) and who is paid to feed residents by a facility or who is used under an arrangement with another agency or organization. (100) Palliative Plan of Care--Appropriate medical and nursing care for residents with advanced and progressive diseases for whom the focus of care is controlling pain and symptoms while maintaining optimum quality of life. (101) PASARR or PASRR--Preadmission Screening and Resident Review. (102) Patient care-related electrical appliance--An electrical appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in a patient care area, as defined in Standard 99 of the National Fire Protection Association. (103) Person--An individual, firm, partnership, corporation, association, joint stock company, limited partnership, limited liability company, or any other legal entity, including a legal successor of those entities. (104) Person-centered care--To focus on the resident as the locus of control, and to support the resident in making choices and having control over the resident's daily life. (105) Pharmacist--An individual, licensed by the Texas State Board of Pharmacy to practice pharmacy, who prepares and dispenses medications prescribed by a practitioner. (106) Physical restraint--Any manual method, or physical or mechanical device, material or equipment attached, or adjacent to the resident's body, that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The term includes a restraint hold. (107) Physician--A doctor of medicine or osteopathy currently licensed by the Texas Medical Board to practice medicine. (108) Physician assistant (PA)--An individual who is licensed as a physician assistant under Texas Occupations Code, Chapter 204. (109) Podiatrist--A practitioner whose profession encompasses the care and treatment of feet who is licensed to practice podiatry by the Texas State Board of Podiatric Medical Examiners. (110) Poison--Any substance that federal or state regulations require the manufacturer to label as a poison and is to be used externally by the consumer from the original manufacturer's container. Drugs to be taken internally that contain the manufacturer's poison label, but are dispensed by a pharmacist only by or on the prescription order of a practitioner, are not considered a poison, unless regulations specifically require poison labeling by the pharmacist. (111) Practitioner--A physician, podiatrist, dentist, or an advanced practice registered nurse or physician assistant to whom a physician has delegated authority to sign a prescription order, when relating to pharmacy services. (112) Private and unimpeded access--Access to enter a facility, or communicate with a resident outside of the hearing or view of others, without interference or obstruction from facility employees, volunteers, or contractors. (113) PRN (pro re nata)--As needed. (114) Provider--The individual or legal business entity that is contractually responsible for providing Medicaid services under an agreement with HHSC. (115) Qualified mental health professional - community services--Has the meaning given in §301.303 of this title (relating to Definitions). (116) Qualified surveyor--An employee of HHSC who has completed state and federal training on the survey process and passed a federal standardized exam. (117) Quality assessment and assurance committee--A group of health care professionals in a facility who develop and implement appropriate action to identify and rectify substandard care and deficient facility practice. (118) Quality measure report--A report that provides information derived from an MDS that provides a numeric value to quality indicators. This data is available to the public as part of the Nursing Home Quality Initiative (NHQI), and is intended to provide objective measures for consumers to make informed decisions about the quality of care in a nursing facility. (119) Quality-of-care monitor--A registered nurse, pharmacist, or dietitian employed by HHSC who is trained and experienced in long-term care facility regulation, standards of practice in long-term care, and evaluation of resident care, and functions independently of HHSC Regulatory Services Division. (120) RAI--Resident Assessment Instrument. An assessment tool used to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity as specified by the Secretary of the U. S. Department of Health and Human Services. At a minimum, this instrument must consist of the MDS core elements as specified by CMS; utilization guidelines; and Care Area Assessment process. (121) Recipient--Any individual residing in a Medicaid certified facility or a Medicaid certified distinct part of a facility whose daily vendor rate is paid by Medicaid. (122) Rehabilitative services--Rehabilitative therapies and devices provided to help a person regain, maintain, or prevent deterioration of a skill or function that has been acquired but then lost or impaired due to illness, injury, or disabling condition. The term includes physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services. (123) Reportable conduct--Conduct subject to reporting to the Employee Misconduct Registry (EMR) established under Texas Health and Safety Code, Chapter 253, including:(A) abuse or neglect that causes or may cause death or harm to a resident;(B) sexual abuse of a resident;(C) financial exploitation of a resident in an amount of $25 or more; and(D) emotional, verbal, or psychological abuse that causes harm to a resident.(124) Representative payee--A person designated by the Social Security Administration to receive and disburse benefits, act in the best interest of the beneficiary, and ensure that benefits will be used according to the beneficiary's needs. (125) Resident--Any individual residing in a nursing facility. (126) Resident group--A group or council of residents who meet regularly. (127) Resident representative-- (A) Any of the following: (i) an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; (ii) a person authorized by state or federal law (including agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage financial matters; or receive notifications; (iii) legal representative, as used in Section 712 of the Older Americans Act (40 U.S.C. §3058g); or (iv) the court-appointed guardian of a resident. (B) This definition is not intended to expand the scope of authority of any resident representative beyond that authority specifically authorized by the resident, state or federal law, or a court of competent jurisdiction. (128) Responsible party--An individual authorized by the resident to act for him as an official delegate or agent. Responsible party is usually a family member or relative, but may be a legal guardian or other individual. Authorization may be in writing or may be given orally. (129) Restraint--A chemical or physical restraint. (130) Restraint hold-- (A) A manual method, except for physical guidance or prompting of brief duration, used to restrict: (i) free movement or normal functioning of all or a portion of a resident's body; or (ii) normal access by a resident to a portion of the resident's body. (B) Physical guidance or prompting of brief duration becomes a restraint if the resident resists the guidance or prompting. (131) RN--Registered nurse. An individual currently licensed by the Texas Board of Nursing as a registered nurse. (132) RN assessment coordinator--A registered nurse who signs and certifies a comprehensive assessment of a resident's needs, using the RAI, including the MDS, as specified by HHSC. (133) RUG--Resource Utilization Group. A categorization method, consisting of 34 categories based on the MDS, that is used to determine a recipient's service and care requirements and to determine the daily rate HHSC pays a nursing facility for services provided to the recipient. (134) Secretary--Secretary of the U.S. Department of Health and Human Services. (135) Services required on a regular basis--Services which are provided at fixed or recurring intervals and are needed so frequently that it would be impractical to provide the services in a home or family setting. Services required on a regular basis include continuous or periodic nursing observation, assessment, and intervention in all areas of resident care. (136) SNF--A skilled nursing facility or distinct part of a facility that participates in the Medicare program. SNF requirements apply when a certified facility is billing Medicare for a resident's per diem rate. (137) Social Security Administration--Federal agency for administration of social security benefits. Local social security administration offices take applications for Medicare, assist beneficiaries file claims, and provide information about the Medicare program. (138) Social worker--A qualified social worker is an individual who is licensed, or provisionally licensed, by the Texas State Board of Social Work Examiners as prescribed by the Texas Occupations Code, Chapter 505, and who has at least: (A) a bachelor's degree in social work; or (B) similar professional qualifications, which include a minimum educational requirement of a bachelor's degree and one year experience met by supervised employment providing social services in a health care setting. (139) Standards--The minimum conditions, requirements, and criteria established in this chapter with which an institution must comply to be licensed under this chapter. (140) State Medicaid claims administrator--The entity under contract with HHSC to process Medicaid claims in Texas. (141) State Ombudsman--Has the meaning given in §88.2 of this title. (142) State plan--A formal plan for the medical assistance program, submitted to CMS, in which the State of Texas agrees to administer the program in accordance with the provisions of the State Plan, the requirements of Titles XVIII and XIX, and all applicable federal regulations and other official issuances of the U.S. Department of Health and Human Services. (143) Stay agreement--An agreement between a license holder and the executive commissioner that sets forth all requirements necessary to lift a stay and rescind a license revocation proposed under §554.2107 of this chapter (relating to Revocation of a License by the HHSC Executive Commissioner). (144) Substandard quality of care violation--A violation of §554.401(a) or (b) of this chapter (relating to Introduction); §554.402(b) or (c) of this chapter (relating to Exercise of Rights); §554.406(d) - (h) of this chapter (relating to Free Choice); §554.417 of this chapter (relating to Married Couples); §554.504(a) of this chapter (relating to Equal Access to Quality Care in Medicaid-certified Facilities); §554.601 of this chapter (relating to Freedom from Abuse, Neglect and Exploitation); §554.602 of this chapter (relating to Incidents of Abuse, Neglect, and Exploitation Reportable to the Texas Health and Human Services Commission and Law Enforcement Agencies by Facilities); §554.701 of this chapter (relating to Quality of Life); §554.703 of this chapter (relating to Social Services General Requirements); §554.706(a), (c), (d)(1) - (5), or (e)(7) of this chapter (relating to Resident Group and Family Council); §554.801 of this chapter (relating to Resident Assessment); §554.901 of this chapter (relating to Quality of Care); §554.904(2) or (4) of this chapter (relating to Behavioral Health Services); §554.1501(5), (6), or (7) of this chapter (relating to Pharmacy Services); or §554.1601(e)(2) of this chapter (relating to Infection Control) that constitutes: (A) an immediate threat to resident health or safety; (B) a pattern of or actual harm that is not an immediate threat; or (C) a widespread potential for more than minimal harm, but less than an immediate threat, with no actual harm. (145) Supervision--General supervision, unless otherwise identified. (146) Supervision (direct)--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity within the qualified person's sphere of competence. If the person being supervised does not meet assistant-level qualifications specified in this chapter and in federal regulations, the supervisor must be on the premises and directly supervising. (147) Supervision (general)--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity within the qualified person's sphere of competence. The person being supervised must have access to the qualified person providing the supervision. (148) Survey agency--HHSC is the agency that, through contractual agreement with CMS, is responsible for Title XIX (Medicaid) survey and certification of nursing facilities. (149) Texas Register --A publication of the Texas Register Publications Section of the Office of the Secretary of State that contains emergency, proposed, withdrawn, and adopted rules issued by Texas state agencies. (150) Therapeutic diet--A diet ordered by a physician as part of treatment for a disease or clinical condition, in order to eliminate, decrease, or increase certain substances in the diet or to provide food which has been altered to make it easier for the resident to eat. (151) Threatened violation--A situation that, unless immediate steps are taken to correct, may cause injury or harm to a resident's health and safety. (152) Title II--Federal Old-Age, Survivors, and Disability Insurance Benefits of the Social Security Act (42 U.S.C. §§401 - 434). (153) Title XVI--Supplemental Security Income (SSI) of the Social Security Act (42 U.S.C. §§1381 - 1385). (154) Title XVIII--Medicare provisions of the Social Security Act (42 U.S.C. §§1390 - 1395lll). (155) Title XIX--Medicaid provisions of the Social Security Act (42 U.S.C. §§1396 - 1396w-5). (156) Total health status--Includes functional status, medical care, nursing care, nutritional status, rehabilitation and restorative potential, activities potential, cognitive status, oral health status, psychosocial status, and sensory and physical impairments. (157) Universal precautions--The use of barrier precautions and other precautions to prevent the spread of blood-borne diseases. (158) Unreasonable confinement--Involuntary seclusion. (159) Vaccine preventable diseases--The diseases included in the most current recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. (160) Vendor payment--Payment made by HHSC on a daily-rate basis for services delivered to recipients in Medicaid-certified nursing facilities. Vendor payment is based on the nursing facility's approved-to-pay claim processed by the state Medicaid claims administrator. The Nursing Facility Billing Statement, subject to adjustments and corrections, is prepared from information submitted by the nursing facility, which is currently on file in the computer system as of the billing date. Vendor payment is made at periodic intervals, but not less than once per month for services rendered during the previous billing cycle. (161) Widespread--When the problem causing a violation is pervasive in a facility or represents systemic failure that affected or has the potential to affect a large portion or all facility residents. (162) Willfully interfere--To act or not act to intentionally prevent, interfere with, or impede or to attempt to intentionally prevent, interfere with, or impede. (163) Working day--Any 24-hour period, Monday through Friday, excluding state and federal holidays. Source Note: The provisions of this §19.101 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective January 15, 1997, 21 TexReg 11970; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective June 1, 2001, 26 TexReg 3824; amended to be effective May 1, 2002, 27 TexReg 3207; amended to be effective June 1, 2004, 29 TexReg 5416; amended to be effective June 1, 2006, 31 TexReg 4449; amended to be effective September 1, 2008, 33 TexReg 6151; amended to be effective September 1, 2008, 33 TexReg 7264; amended to be effectiveJune1,2010, 35 TexReg 4465; amended to be effective June 1, 2012, 37 TexReg 3862; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective July 21, 2016, 41 TexReg 5203; amended to be effective March 27, 2017, 42 TexReg 1574; amended to be effective September 10, 2017, 42 TexReg 4468; amended to be effective October 11, 2017, 42 TexReg 5498; amended to be effective March 22, 2018, 43 TexReg 1646; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712; amended to be effective September 18, 2024, 49 TexReg 7331. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION B DEFINITIONS §554.101 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203297 03/12/2026 The purpose of this subchapter is to:(1) describe the requirements of a nursing facility related to preadmission screening and resident review (PASRR), which is a federal requirement in Code of Federal Regulations, Title 42, Part 483, Subpart C to ensure that:(A) an individual seeking admission to a nursing facility or a resident of a nursing facility receives a PASRR Level I screening (PL1) to identify whether the individual or resident is suspected of having mental illness (MI), an intellectual disability (ID), or a developmental disability (DD); and(B) an individual or resident suspected of having MI, ID, or DD receives a PASRR Level II evaluation (PE) to confirm MI, ID, or DD and, if confirmed, to evaluate whether the individual or resident needs nursing facility care and specialized services;(2) describe the requirements of a nursing facility related to a designated resident who receives service planning and transition planning; and(3) describe the requirements of a nursing facility related to nursing facility specialized services. Source Note: The provisions of this §554.2701 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2701 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203298 03/12/2026 A nursing facility must comply with this subchapter to receive payment for services provided to a Medicaid-eligible resident. Source Note: The provisions of this §554.2702 adopted to be effective July 7, 2015, 40 TexReg 4373; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2702 Limitation on Charges for Nursing Facility Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203299 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:(1) Alternate placement assistance--Assistance provided to a resident to locate and secure services chosen by the resident or LAR that meet the resident's basic needs in a setting other than a nursing facility. Assistance includes the identification of specific services and supports available through alternate resources for which the resident may be eligible and an explanation of the possible benefits and consequences of selecting a setting other than a nursing facility.(2) Coma--A state of unconsciousness characterized by the inability to respond to sensory stimuli as documented by a physician.(3) Comprehensive care plan--A plan, defined in §19.101 of this chapter (relating to Definitions), that includes, for a designated resident, nursing facility specialized services and nursing facility PASRR support activities.(4) Convalescent care--A type of care provided after an individual's release from an acute care hospital that is part of a medically prescribed period of recovery.(5) CMWC--Customized manual wheelchair. A wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of a designated resident.(6) DADS--Department of Aging and Disability Services or HHSC, as its successor agency. For purposes of the PASRR process, HHSC is the state authority for intellectual and developmental disabilities.(7) DD--Developmental disability. A disability that meets the criteria described in the definition of "persons with related conditions" in Code of Federal Regulations (CFR) Title 42, §435.1010.(8) Delirium--A serious disturbance in an individual's mental abilities that results in a decreased awareness of the individual's environment and confused thinking.(9) Designated resident--A Medicaid recipient with ID or DD who is 21 years of age or older and who is a resident.(10) DME--Durable medical equipment. The following items, including any accessories and adaptations needed to operate or access the item:(A) a gait trainer;(B) a standing board;(C) a special needs car seat or travel restraint;(D) a specialized or treated pressure-reducing support surface mattress;(E) a positioning wedge;(F) a prosthetic device; and(G) an orthotic device.(11) DSHS--Department of State Health Services. For purposes of the PASRR process, DSHS is the state mental health authority.(12) Emergency protective services--Services that are furnished by the Department of Family and Protective Services to an elderly or disabled individual who has been determined to be in a state of abuse, neglect, or exploitation.(13) Exempted hospital discharge--A category of nursing facility admission that occurs when a physician has certified that an individual who is being discharged from a hospital is likely to require less than 30 days of nursing facility services for the condition for which the individual was hospitalized.(14) Expedited admission--A category of nursing facility admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite, or coma.(15) HHSC--Health and Human Services Commission or its designee.(16) ID--Intellectual disability. Mental retardation, as described in CFR Title 42, §483.102(b)(3)(i).(17) IDT--Interdisciplinary team. A team consisting of:(A) a resident with MI, ID, or DD;(B) the resident's LAR, if any;(C) a registered nurse from the nursing facility with responsibility for the resident;(D) a representative of a LIDDA or LMHA, or if the resident has MI and DD or MI and ID, a representative of the LIDDA and LMHA; and(E) other persons, as follows:(i) a concerned person whose inclusion is requested by the resident or LAR;(ii) a person specified by the resident or LAR, nursing facility, or LIDDA or LMHA, as applicable, who is professionally qualified or certified or licensed with special training and experience in the diagnosis, management, needs and treatment of people with MI, ID, or DD; and(iii) a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.(18) Individual--A person seeking admission to a nursing facility.(19) ISP--Individual service plan. A service plan developed by the service planning team for a designated resident in accordance with §17.502(2) of this title (relating to Service Planning Team (SPT) Responsibilities for a Designated Resident).(20) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual or resident with regard to a matter described by this subchapter, and who may be the parent of a minor child, the legal guardian, or the surrogate decision maker.(21) LIDDA--Local intellectual and developmental disabilities authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533A.035.(22) LIDDA specialized services--Support services, other than nursing facility services, that are identified through the PE or resident review and may be provided to a resident who has ID or DD. LIDDA specialized services are:(A) service coordination, which includes alternate placement assistance;(B) employment assistance;(C) supported employment;(D) day habilitation;(E) independent living skills training; and(F) behavioral support.(23) LMHA--Local mental health authority. An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code §533.035. For the purposes of this subchapter, LMHA includes an entity designated by DSHS as the entity to perform PASRR functions.(24) LMHA specialized services--Support services, other than nursing facility services, that are identified through the PE or resident review and may be provided to a resident who has MI. LMHA specialized services are defined in Title 25, Texas Administrative Code (TAC), Chapter 412, Subchapter I (relating to MH Case Management), including alternate placement, and 25 TAC Chapter 416, Subchapter A (relating to Mental Health Rehabilitative Services).(25) LTC Online Portal--Long Term Care Online Portal. A web-based application used by Medicaid providers to submit forms, screenings, evaluations, and the long term services and supports Medicaid identification section of the MDS assessment.(26) MDS assessment--Minimum data set assessment. A standardized collection of demographic and clinical information that describes a resident's overall condition, which a nursing facility in Texas is required to submit for a resident of the facility.(27) MI--Mental illness. Serious mental illness, as defined in 42 CFR §483.102(b)(1).(28) Nursing facility--A Medicaid-certified facility that is licensed in accordance with Texas Health and Safety Code, Chapter 242.(29) Nursing facility PASRR support activities--Actions a nursing facility takes in coordination with a LIDDA or LMHA to facilitate the successful provision of LIDDA specialized services or LMHA specialized services, including:(A) arranging transportation for a designated resident to participate in a LIDDA specialized service or a LMHA specialized service outside the nursing facility;(B) sending a resident to a scheduled LIDDA specialized service or a LMHA specialized service with food and medications required by the resident; and(C) including in the comprehensive care plan an agreement to avoid, when possible, scheduling nursing facility services at times that conflict with LIDDA specialized services or LMHA specialized services.(30) Nursing facility specialized services--Support services, other than nursing facility services, that are identified through the PE and may be provided to a designated resident. Nursing facility specialized services are:(A) therapy services;(B) CMWC; and(C) DME.(31) PASRR--Preadmission screening and resident review.(32) PASRR determination--A decision made by DADS, DSHS, or their designee regarding an individual's need for nursing facility specialized services, LIDDA specialized services, and LMHA specialized services, based on information in the PE; and, in accordance with Subchapter Y of this chapter (relating to Medical Necessity Determinations), whether the individual requires the level of care provided in a nursing facility. A report documenting the determination is sent to the individual and LAR.(33) PE--PASRR Level II evaluation. A face-to-face evaluation of an individual suspected of having MI, ID, or DD performed by a LIDDA or an LMHA to determine if the individual has MI, ID, or DD, and if so to:(A) assess the individual's need for care in a nursing facility;(B) assess the individual's need for nursing facility specialized services, LIDDA specialized services and LMHA specialized services; and(C) identify alternate placement options.(34) PL1--PASRR Level I screening. The process of screening an individual to identify whether the individual is suspected of having MI, ID, or DD.(35) Pre-admission--A category of nursing facility admission from a community setting that is not an expedited admission or an exempted hospital discharge.(36) Referring entity--The entity that refers an individual to a nursing facility, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.(37) Resident--An individual who resides in a nursing facility and receives services provided by professional nursing personnel of the facility.(38) Resident review--A face-to-face evaluation of a resident performed by a LIDDA or LMHA:(A) for a resident with MI, ID, or DD who experienced a significant change in status, to:(i) assess the resident's need for continued care in a nursing facility;(ii) assess the resident's need for nursing facility specialized services, LIDDA specialized services and LMHA specialized services; and(iii) identify alternate placement options; and(B) for a resident suspected of having MI, ID, or DD, to determine whether the resident has MI, ID, or DD and, if so:(i) assess the resident's need for continued care in a nursing facility;(ii) assess the resident's need for nursing facility specialized services, LIDDA specialized services, and LMHA specialized services; and(iii) identify alternate placement options.(39) Respite--Services provided on a short-term basis to an individual because of the absence of or the need for relief by the individual's unpaid caregiver for a period not to exceed 14 days.(40) Service coordination--As defined in §2.553 of this title (relating to Definitions), assistance in accessing medical, social, educational, and other appropriate services and supports that will help an individual achieve a quality of life and community participation acceptable to the person and LAR on the individual's behalf.(41) Service coordinator--An employee of a LIDDA who provides service coordination.(42) Severe physical illness--An illness resulting in ventilator dependence or diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, or congestive heart failure, that results in a level of impairment so severe that the individual could not be expected to benefit from nursing facility specialized services, LIDDA specialized services or LMHA specialized services.(43) SPT--Service planning team. A team that develops, reviews, and revises the ISP for a designated resident.(A) The SPT always includes:(i) the designated resident;(ii) the designated resident's LAR, if any;(iii) the service coordinator;(iv) nursing facility staff familiar with the designated resident's needs;(v) persons providing nursing facility specialized services and LIDDA specialized services for the designated resident;(vi) a representative from a community provider, if one has been selected; and(vii) a representative from the LMHA, if the designated resident has MI.(B) Other participants on the SPT may include:(i) a concerned person whose inclusion is requested by the designated resident or the LAR; and(ii) at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.(44) Surrogate decision maker--An actively involved family member of a resident who has been identified by an IDT in accordance with Texas Health and Safety Code §313.004 and who is available and willing to consent on behalf of the resident.(45) Terminal illness--A medical prognosis that an individual's life expectancy is six months or less if the illness runs its normal course, which is documented by a physician's certification in the individual's medical record maintained by a nursing facility.(46) Therapy services--Assessment and treatment to help a designated resident learn, keep, or improve skills and functioning of daily living affected by a disabling condition. Therapy services are referred to as habilitative therapy services. Therapy services are limited to:(A) physical therapy;(B) occupational therapy; and(C) speech therapy.(47) Transition plan--A plan developed by the SPT that describes the activities, timetable, responsibilities, services, and supports involved in assisting a designated resident to transition from the nursing facility to the community. Source Note: The provisions of this §554.2703 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2703 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203300 03/12/2026 (a) If an individual seeks admission to a nursing facility, the nursing facility:(1) must coordinate with the referring entity to ensure the referring entity conducts a PL1; and(2) may provide assistance in completing the PL1, if the referring entity is a family member, LAR, other personal representative selected by the individual, or a representative from an emergency placement source and requests assistance in completing the PL1.(b) A nursing facility must not admit an individual who has not had a PL1 conducted before the individual is admitted to the facility.(c) If an individual's PL1 indicates the individual is not suspected of having MI, ID, or DD, a nursing facility must enter the PL1 from the referring entity into the LTC Online Portal. The nursing facility may admit the individual into the facility through the routine admission process.(d) For an individual whose PL1 indicates the individual is suspected of having MI, ID, or DD, a nursing facility:(1) must enter the PL1 into the LTC Online Portal if the individual's admission category is:(A) expedited admission; or(B) exempted hospital discharge; and(2) must not enter the PL1 into the LTC Online Portal if the individual's admission category is pre-admission.(e) Except as provided by subsection (f) of this section, a nursing facility must not admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination.(f) A nursing facility may admit an individual whose PL1 indicates a suspicion of MI, ID, or DD without a complete PE and PASRR determination only if the individual:(1) is admitted as an expedited admission;(2) is admitted as an exempted hospital discharge; or(3) has not had an interruption in continuous nursing facility residence other than for acute care lasting fewer than 30 days and is returning to the same nursing facility.(g) A nursing facility must check the LTC Online Portal daily for messages related to admissions and directives related to the PASRR process.(h) Within seven calendar days after the LIDDA or LMHA has entered a PE or resident review into the LTC Online Portal for an individual or resident who has MI, ID, or DD, a nursing facility must:(1) review the recommended list of nursing facility specialized services, LIDDA specialized services, and LMHA specialized services; and(2) certify in the LTC Online Portal whether the individual's or resident's needs can be met in the nursing facility.(i) After an individual or resident who is determined to have MI, ID, or DD from a PE or resident review has been admitted to a nursing facility, the facility must:(1) contact the LIDDA or LMHA within two calendar days after the individual's admission or, for a resident, within two calendar days after the LTC Online Portal generated an automated notification to the LIDDA or LMHA, to schedule an IDT meeting to discuss nursing facility specialized services, LIDDA specialized services, and LMHA specialized services;(2) convene the IDT meeting within 14 calendar days after admission or, for a resident review, within 14 calendar days after the LTC Online Portal generated an automated notification to the LIDDA or LMHA;(3) participate in the IDT meeting to:(A) identify which of the nursing facility specialized services, LIDDA specialized services, and LMHA specialized services recommended for the resident that the resident, or LAR on the resident's behalf, wants to receive; and(B) determine whether the resident is best served in a facility or community setting.(4) provide staff from the LIDDA and LMHA access to the resident and the resident's clinical facility records upon request from the LIDDA or LMHA;(5) enter into the LTC Online Portal within 3 business days after the IDT meeting for a resident:(A) the date of the IDT meeting;(B) the name of the persons who participated in the IDT meeting;(C) the nursing facility specialized services, LIDDA specialized services, and LMHA specialized services that were agreed to in the IDT meeting; and(D) the determination of whether the resident is best served in a facility or community setting;(6) include in the comprehensive care plan:(A) the nursing facility specialized services agreed to by the resident or LAR; and(B) the nursing facility PASRR support activities;(7) submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the IDT meeting;(8) start providing a therapy service within three business days after receiving approval from HHSC in the LTC Online Portal;(9) order DME or CMWC in accordance with §19.2754(e) of this subchapter (relating to Requesting Authorization to Provide Durable Medical Equipment and Customized Manual Wheelchairs);(10) provide on-going therapy services as approved by HHSC;(11) for a designated resident, annually document in the LTC Online Portal all nursing facility specialized services, LIDDA specialized services, and LMHA specialized services being provided to the designated resident; and(12) promptly report a significant change in the mental or physical condition of a resident by submitting a MDS Significant Change in Status Assessment Form in the LTC Online Portal. Source Note: The provisions of this §554.2704 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2704 Nursing Facility Responsibilities Related to PASRR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203301 03/12/2026 An individual or the individual's LAR or responsible party who is not in agreement with a PASRR determination that the individual does or does not require a nursing facility level of care may request a fair hearing to appeal the determination in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules).(1) If the hearing officer finds that the individual requires a nursing facility level of care, a nursing facility may admit the individual immediately. The individual must meet other eligibility requirements for the facility to receive payment for services provided to the individual.(2) If the hearing officer finds that the individual does not require a nursing facility level of care, the nursing facility must not admit the individual. Source Note: The provisions of this §554.2705 adopted to be effective July 7, 2015, 40 TexReg 4373; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2705 Nursing Facility Responsibilities Related to the Fair Hearing Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203302 03/12/2026 (a) A nursing facility employee, nursing facility contractor, or nursing facility specialized services provider must report to the LIDDA the identity of any designated resident who expresses an interest in transitioning to the community.(b) For a designated resident, a nursing facility must designate staff and necessary contractors to be members of the resident's SPT.(c) A nursing facility must ensure its staff and contractors who are members of a designated resident's SPT:(1) attend and participate in the designated resident's SPT meetings as scheduled and convened by the service coordinator;(2) contribute to the development of the designated resident's ISP; and(3) assist the SPT by:(A) monitoring all nursing facility specialized services, LIDDA specialized services and LMHA specialized services, if applicable, provided to the designated resident to ensure the designated resident's needs are being met;(B) making timely referrals, service changes, and amendments to the ISP as needed;(C) ensuring that the designated resident's ISP, including nursing facility specialized services, nursing facility PASRR support activities, and LIDDA specialized services, is coordinated with the nursing facility's comprehensive care plan;(D) if the designated resident has expressed interest in community living:(i) developing a transition plan for the designated resident to live in the community; or(ii) identifying the action the SPT will take to address concerns and remove barriers to the designated resident living in the community; and(E) reviewing and discussing the information included in the ISP and transition plan with key nursing facility staff who work with the resident.(d) A nursing facility must allow a service coordinator access to:(1) a designated resident on a monthly basis, or more frequently if needed; and(2) the designated resident's clinical facility records. Source Note: The provisions of this §554.2706 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2706 Nursing Facility Responsibilities Related to a Designated Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203303 03/12/2026 (a) A nursing facility must participate in implementing the transition plan developed by an SPT for a designated resident.(b) A nursing facility must document in the comprehensive care plan for a designated resident any nursing facility responsibilities to support the implementation of the resident's transition plan. Source Note: The provisions of this §554.2707 adopted to be effective July 7, 2015, 40 TexReg 4373; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2707 Transition Activities Related to Designated Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203304 03/12/2026 A nursing facility must:(1) allow access to residents by the State Ombudsman, a certified ombudsman, an ombudsman intern, and representatives of the protection and advocacy system in the state for individuals with mental illness or individuals with intellectual or developmental disabilities to educate and inform them of their rights and options related to PASRR;(2) allow access to designated residents to support educational activities about community living options arranged by the LIDDA; and(3) provide a designated resident with adequate notice and assistance to be prepared for and participate in scheduled community visits. Source Note: The provisions of this §554.2708 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2708 Educational and Informational Activities for Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203305 03/12/2026 In addition to reporting incidents and complaints, including abuse and neglect, to DADS as required by §19.602 of this chapter (relating to Incidents of Abuse and Neglect Reportable to the Texas Department of Aging and Disability Services (DADS) and Law Enforcement Agencies by Facilities) and §19.2006 of this chapter (relating to Reporting Incidents and Complaints), a nursing facility must report the information by making a telephone report immediately after learning of the incident or complaint:(1) to the service coordinator, if it involves a designated resident; and(2) to the LMHA representative, if it involves a designated resident with MI receiving LMHA specialized services. Source Note: The provisions of this §554.2709 adopted to be effective July 7, 2015, 40 TexReg 4373; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2709 Incident and Complaint Reporting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203306 03/12/2026 (a) A nursing facility must request authorization from HHSC to provide a nursing facility specialized service to a designated resident if the service is agreed to by the designated resident's IDT in accordance with §19.2704 of this subchapter (relating to Nursing Facility Responsibilities Related to PASRR) or the designated resident's SPT in accordance with §17.502(2) of this title (relating to Service Planning Team (SPT) Responsibilities for a Designated Resident).(b) Before providing a nursing facility specialized service, a nursing facility must request and receive authorization from HHSC through the LTC Online Portal to provide the service. Source Note: The provisions of this §554.2750 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2750 Nursing Facility Specialized Services for Designated Residents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203307 03/12/2026 (a) Before requesting authorization to provide a therapy service to a designated resident, a nursing facility must ensure that:(1) the therapy service is required by the designated resident's comprehensive care plan;(2) the designated resident has a diagnosis relevant to the need for the therapy service;(3) the therapy service is ordered by the designated resident's attending physician; and(4) a therapy provider who meets the qualifications in §19.2752 of this division (relating to Qualifications of a Provider of Therapy Services) completes an assessment within 30 days before the nursing facility request for authorization to provide the therapy service.(b) After a nursing facility submits a request for authorization to provide a therapy service to a designated resident:(1) the nursing facility receives a written approval or denial of its request through the LTC Online Portal; and(2) HHSC notifies the designated resident or the designated resident's LAR that the request has been approved or denied.(c) If HHSC denies a request for authorization to provide therapy services to a designated resident, the designated resident may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), to appeal the denial. Source Note: The provisions of this §554.2751 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2751 Requesting Authorization to Provide Therapy Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203308 03/12/2026 A nursing facility must ensure that therapy services are provided to a designated resident by:(1) a person who:(A) is a speech-language pathologist licensed by the Texas Department of Licensing and Regulation; or(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as a speech-language pathologist;(2) an occupational therapist licensed by the Texas Board of Occupational Therapy Examiners;(3) an occupational therapy assistant licensed by the Texas Board of Occupational Therapy Examiners;(4) a physical therapist licensed by the Texas Board of Physical Therapy Examiners; or(5) a physical therapist assistant licensed by the Texas Board of Physical Therapy Examiners. Source Note: The provisions of this §554.2752 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2752 Qualifications of a Provider of Therapy Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203309 03/12/2026 (a) HHSC pays a nursing facility for therapy services provided to a designated resident based on fees determined in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).(b) A therapy session is one hour of therapy provided to one resident.(c) An assessment is reimbursed at the same rate as a therapy session.(d) An occupational therapist or physical therapist may assess a designated resident at any time to evaluate the needs of the designated resident for a therapy service, but HHSC does not pay for an assessment of a designated resident conducted within 180 days after the previous assessment of the designated resident.(e) A nursing facility must submit a complete and accurate claim for a therapy service within 12 months after the last day of an authorization from HHSC to provide the service. Source Note: The provisions of this §554.2753 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2753 Payment for Therapy Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203310 03/12/2026 (a) To request authorization to provide DME or a CMWC to a designated resident, a nursing facility must ensure that a physical therapist or occupational therapist licensed in Texas assesses the designated resident for the DME or CMWC. If, based on the assessment, the physical or occupational therapist recommends DME or a CMWC, the nursing facility must request authorization to provide the DME or CMWC through the LTC Online Portal. The assessment required by this subsection must be completed within 30 days before the nursing facility requests authorization through the LTC Online Portal.(b) The request for authorization to provide DME or a CMWC made through the LTC Online Portal must include:(1) the assessment of the designated resident described in subsection (a) of this section;(2) a statement signed by the designated resident's attending physician that the DME or CMWC is medically necessary; and(3) detailed specifications of the DME or CMWC from a DME supplier.(c) The documentation of the physical or occupational therapy assessment required by subsection (a) of this section must include:(1) a diagnosis of the designated resident relevant to the need for DME or a CMWC;(2) the specific DME or CMWC, including any adaptations recommended for the designated resident; and(3) a description of how the DME or CMWC will meet the specific needs of the designated resident.(d) After a nursing facility submits a request for authorization to provide DME or a CMWC to a designated resident:(1) the nursing facility receives a written approval or denial of its request through the LTC Online Portal; and(2) HHSC notifies the designated resident or the designated resident's LAR that the request has been approved or denied.(e) If HHSC approves a request to provide DME or a CMWC to a designated resident, the nursing facility must order the DME or CMWC from a DME supplier within 5 business days after receiving notification of the approval through the LTC Online Portal.(f) If HHSC denies a request to provide DME or a CMWC to a designated resident, the designated resident may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules), to appeal the denial. Source Note: The provisions of this §554.2754 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2754 Requesting Authorization to Provide Durable Medical Equipment and Customized Manual Wheelchairs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203311 03/12/2026 (a) A nursing facility must fully explore and use other sources to pay for DME or a CMWC before requesting payment from HHSC. If another funding source is available, HHSC pays no more than the remaining balance after other sources have paid.(b) HHSC pays a nursing facility for an assessment for DME or a CMWC for a designated resident based on fees determined in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).(1) HHSC pays for a DME or CMWC assessment at the same rate as a therapy session.(2) An occupational therapist or physical therapist may assess a designated resident at any time to evaluate the needs of the designated resident for DME or a CMWC, but HHSC does not pay for an assessment of a designated resident conducted within 180 days after the previous assessment of the designated resident.(c) A complete and accurate claim for DME or a CMWC must be received by HHSC within 12 months after the day the DME or CMWC is purchased.(d) A nursing facility must not submit a claim for payment for DME or a CMWC to HHSC before:(1) an occupational therapist or physical therapist licensed in Texas verifies that the DME or CMWC meets the original specifications and the needs of the designated resident; and(2) the nursing facility documents the verification in the LTC Online Portal.(e) If HHSC denies a request for payment for DME or a CMWC because a nursing facility did not obtain authorization before purchasing the DME or CMWC or did not submit necessary documentation to HHSC, the facility may not charge the designated resident or family for the DME or CMWC. Source Note: The provisions of this §554.2755 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2755 Payment for Durable Medical Equipment and Customized Manual Wheelchairs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203312 03/12/2026 (a) A nursing facility must ensure that only the designated resident to whom DME or a CMWC belongs uses the DME or CMWC. A nursing facility must identify the DME or CMWC as the personal property of the designated resident.(b) If the designated resident who was provided DME or a CMWC is discharged from a nursing facility, the designated resident retains the DME or CMWC.(c) If a designated resident who was provided DME or a CMWC dies, the DME or CMWC becomes property of the designated resident's estate. As part of the estate, the DME or CMWC is subject to the Medicaid Estate Recovery Program requirements in 1 TAC Chapter 373 (relating to Medicaid Estate Recovery Program).(d) If DME or a CMWC is donated or sold to a nursing facility by a designated resident or the personal representative of a designated resident's estate, the transaction must be documented in accordance with §19.416 of this chapter (relating to Personal Property).(e) A modification, adjustment, or repair to DME or a CMWC required within the first six months after delivery of the DME or CMWC is the responsibility of the DME supplier. More than six months after delivery of DME or a CMWC, a nursing facility must maintain and repair all medically necessary equipment for a designated resident, including DME or a CMWC obtained under this division, as required by §19.2601(b)(8)(C) of this chapter (relating to Vendor Payment (Items and Services Included)).(f) A nursing facility must submit a request to replace DME or a CMWC of a designated resident in the same manner as a request for the authorization to provide DME or a CMWC to a designated resident. HHSC does not approve a request to replace a CMWC made within five years after a CMWC was purchased for the designated resident, unless the request includes:(1) an order from the designated resident's attending physician; and(2) an assessment by an occupational therapist or physical therapist licensed in Texas, with documentation explaining why the designated resident's current CMWC no longer meets the designated resident's needs. Source Note: The provisions of this §554.2756 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION BB NURSING FACILITY RESPONSIBILITIES RELATED TO PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) §554.2756 Administrative Requirements for Durable Medical Equipment and Customized Manual Wheelchairs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203009 03/12/2026 (a) A person or governmental unit, acting jointly or severally, must be licensed by DADS to establish, conduct, or maintain a facility.(b) An applicant for a license must submit a complete application form and license fee to DADS.(c) No person may apply for a probationary license, a license, change of ownership, increase in capacity, or renewal of a nursing facility license without making a disclosure of information as required in this section.(d) An applicant for a license must affirmatively show that:(1) the applicant or license holder has the ability to comply with:(A) minimum standards of medical care, nursing care and financial condition; and(B) any other applicable state or federal standard;(2) the facility meets the standards of the Life Safety Code;(3) the facility meets the construction standards in Subchapter D of this chapter (relating to Facility Construction); and(4) the facility meets the standards for operation based on an on-site survey.(e) Before issuing a license, DADS considers the background and qualifications of:(1) the applicant or license holder;(2) a partner, officer, director, or managing employee of the applicant or license holder;(3) a person who owns or who controls the owner of the physical plant of a facility in which the nursing facility operates or is to operate; and(4) a controlling person with respect to the nursing facility for which a license or license renewal is requested.(f) An applicant or license holder must submit to DADS a sworn affidavit of a satisfactory compliance history and any other information required by DADS to substantiate a satisfactory compliance history in each state or other jurisdiction for any time period during which persons described in subsection (e) of this section operated a long-term care facility. For purposes of the sworn affidavit of a satisfactory compliance history, the applicant will be considered to have complied with the submission requirement (but not necessarily be entitled to a license) if the applicant swears or affirms that all the information disclosed in the application concerning previous state and federal nursing facility sanctions and penalties and related information are true and correct. The affidavit of compliance history is contained in DADS application form.(g) A license is issued if, after inspection and investigation, DADS finds that the persons described in subsection (e) of this section meet all requirements of this chapter. Except as provided in §19.205 of this subchapter (relating to Probationary License) and §19.208(b)(2) of this subchapter (relating to Renewal Procedures and Qualifications), the license is valid for three years. Each license specifies the maximum allowable number of residents. The number of residents authorized by the license must not be exceeded.(h) In making a determination whether to grant a nursing facility license, DADS reviews:(1) the information contained in the application;(2) the criminal history information of the persons described in subsection (e) of this section; and(3) other documents DADS deems relevant, including survey and complaint investigation findings in each facility with which the applicant or any other person named in subsection (e) of this section has been affiliated at any time. Source Note: The provisions of this §554.201 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective March 15, 1999, 24 TexReg 994; amended to be effective October 1, 1999, 24 TexReg 8314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2002, 27 TexReg 3369; amended to be effective September 1, 2007, 32 TexReg 4231; amended to be effective September 1, 2009, 34 TexReg 5138; amended to be effective December 2,2012, 37 TexReg 9525; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.201 Criteria for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203010 03/12/2026 All applications for license must include written approval of the local fire authority that the facility and its operation meet local fire ordinances.(1) New facility. The sponsor of a new facility under construction or a previously unlicensed facility will provide to the Texas Department of Human Services (DHS) a copy of a dated, written notice to the local health authority that construction or modification has been or will be completed by a specific date. The local health authority may provide recommendations to DHS regarding the status of compliance with local codes, ordinances, or regulations. The sponsor must also provide a copy of a dated, written notice of the approval for occupancy by the local building code authority, if applicable.(2) Increase in capacity. The license holder must request an application for increase in capacity from DHS. DHS provides the license holder with the application form, and DHS notifies the local fire marshal and the local health authority of the request. The license holder must arrange for the inspection of the facility by the local fire marshal. Upon completion of the inspection, the license holder must notify the local health authority and DHS in writing if the facility meets local code requirements. DHS approves the application only if the facility is found to be in compliance with the standards. Approval to occupy the increased capacity may be granted by DHS prior to the issuance of the license covering the increased capacity after inspection by DHS if standards are met.(3) Change of ownership. The applicant for a change of ownership license must provide to DHS a copy of a letter notifying the local health authority of the request for a change of ownership. The local health authority may provide recommendations to DHS regarding the status of compliance with local codes, ordinances, or regulations.(4) Renewal. DHS sends the local health authority a copy of DHS's license renewal notice specifying the expiration date of the facility's current license. The local health authority may provide recommendations to DHS regarding the status of compliance with local codes, ordinances, or regulations. The local authority may also recommend that a state license be issued or denied; however, the final decision on licensure status remains with DHS. Source Note: The provisions of this §554.202 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.202 Building Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210956 03/12/2026 (a) Applications. All applications must be made on forms prescribed by and available from the Texas Health and Human Services Commission (HHSC). All applications must be submitted through the licensure system.(1) Each application must be completed in accordance with HHSC instructions.(2) Changes to information required in the application must be reported to HHSC by submitting a change application in the licensure system, as required by §554.1918 of this chapter (relating to Disclosure of Ownership).(b) General information required. An applicant for an initial application or change of ownership, must file with HHSC an application in the licensure system that contains evidence of the right to possession of the facility at the time the application will be granted, which may be satisfied by the submission of applicable portions of a lease agreement, deed or trust, or appropriate legal document. The names and addresses of any persons or organizations listed as owner of record in the real estate, including the buildings and grounds, must be disclosed to HHSC.(c) Requested information. An applicant or license holder must provide any information HHSC requests within 30 days after the request.(d) Exemptions. The provisions of this section do not apply to a bank, trust company, financial institution, title insurer, escrow company, or underwriter title company to which a license is issued in a fiduciary capacity. Source Note: The provisions of this §554.204 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective September 1, 1996, 21 TexReg 7859; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective September 1, 2007, 32 TexReg 4231; amended to be effective July 21, 2016, 41 TexReg 5203; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6,2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.204 Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203012 03/12/2026 The initial license issued to a license holder who has not previously held a license is a probationary license and is effective for one year. A permanent license may be issued only after DHS finds that the license holder and any other person listed in §19.201(f) of this title (relating to Criteria for Licensing) continues to meet the nursing facility requirements and submits an application requesting a permanent license with the applicable license fee. The facility must also be able to pass an inspection unless an inspection is not required as provided by §242.047, Health and Safety Code. Source Note: The provisions of this §554.205 adopted to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.205 Probationary License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203013 03/12/2026 (a) During the license term, a license holder may not increase capacity without approval from the Texas Department of Human Services (DHS). The license holder must submit to DHS a complete application for increase in capacity and the fee required in §19.216 of this title (relating to License Fees).(b) Upon approval of an increase in capacity, DHS will issue a new license. Source Note: The provisions of this §554.206 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.206 Increase in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203014 03/12/2026 (a) A license issued under this chapter is not automatically renewed. Each license expires three years from the date issued, except as provided in §19.205 of this subchapter (relating to Probationary Licenses) and subsection (b)(2) of this section.(b) For a license that expires during the period September 1, 2013, through August 31, 2014, DADS:(1) issues a three-year renewal license to a facility with a facility identification number ending in an odd digit; and(2) issues a two-year renewal license to a facility with a facility identification number ending in an even digit.(c) The license fee for renewal licenses issued in accordance with subsection (b)(2) of this section is two-thirds of the amount referenced in §19.216(a)(2) of this subchapter (relating to License Fees).(d) For a license that expires after August 31, 2014, DADS issues a three-year renewal license.(e) Each license holder must, no later than the 45th day before the expiration of the current license, submit an application for renewal with DADS. DADS considers that an individual has submitted a timely and sufficient application for the renewal of a license if the license holder submits:(1) a complete application to DADS, and DADS receives the complete application no later than the 45th day before the expiration date of the current license;(2) an incomplete application to DADS with a letter explaining the circumstances which prevented the inclusion of the missing information, and DADS receives the incomplete application and letter no later than the 45th day before the expiration date of the current license; or(3) a complete application or an incomplete application with a letter explaining the circumstances which prevented the inclusion of the missing information to DADS, DADS receives the application during the 45-day period ending on the date the current license expires, and the license holder pays the late fee established in §19.216(a)(6) of this subchapter in addition to the basic renewal fee.(f) If the application is postmarked by the submission deadline, the application will be considered timely if received in DADS Licensing and Credentialing Section, Regulatory Services Division within 15 days after the postmark.(g) The appropriate license fee must be paid upon submission of the renewal application.(h) The renewal of a license may be denied for the same reasons an original application for a license may be denied. See §19.214 of this subchapter (relating to Criteria for Denying a License or Renewal of a License). Source Note: The provisions of this §554.208 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective April 1, 2001, 26 TexReg 1547; amended to be effective May 4, 2008, 33 TexReg 3446; amended to be effective January 15, 2009, 34 TexReg 237; amended to be effective December 2, 2012, 37 TexReg 9525; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.208 Renewal Procedures and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203015 03/12/2026 (a) DADS, after providing notice and opportunity for a hearing, may exclude a person from eligibility for a license if the person or any person described in §19.201(e) of this subchapter (relating to Criteria for Licensing) has substantially failed to comply with the rules in this chapter. During the period of exclusion, the excluded person is not eligible to be a license holder or a controlling person of a license holder. The period of exclusion:(1) must be for at least two years; and(2) may be:(A) for no more than ten years if the exclusion is based on conduct that occurred before September 1, 2011; or(B) throughout the person's lifetime or existence if the exclusion is based on conduct that occurred on or after September 1, 2011.(b) A license holder or controlling person who operates a nursing facility or an assisted living facility for which a trustee was appointed and for which emergency assistance funds, other than funds to pay the expenses of the trustee, were used is subject to exclusion from eligibility for the:(1) issuance of an original license for a facility for which the person has not previously held a license; or(2) renewal of the license of the facility for which the trustee was appointed. Source Note: The provisions of this §554.209 adopted to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective September 1, 2007, 32 TexReg 4231; amended to be effective December 2, 2012, 37 TexReg 9525; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.209 Exclusion from Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203016 03/12/2026 (a) A license holder may not transfer its license. If there is a change of ownership, the license holder's license becomes invalid on the date of the change of ownership. The new owner must obtain a change of ownership license in accordance with subsection (b) of this section. The license holder and new license applicant must notify DADS before a change of ownership occurs.(b) The applicant must submit to DADS:(1) a complete application for a change of ownership license under §19.201 of this subchapter (relating to Criteria for Licensing) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) the application fee, in accordance with §19.216 of this subchapter (relating to License Fees); and(3) signed, written notice from the facility's existing license holder of his intent to transfer operation of the facility to the applicant beginning on a date specified by the applicant.(c) To avoid a facility operating while unlicensed, an applicant must submit all items in subsection (b) of this section at least 30 days before the anticipated date of the change of ownership. DADS considers an application as submitted timely if the application is postmarked at least 30 days before the anticipated date of the change of ownership and received in DADS Licensing and Credentialing Section, Regulatory Services Division, within 15 days after the date of the postmark.(d) The 30-day notification from the applicant or the 30-day notification from the existing license holder or both may be waived if DADS determines that the applicant presented evidence showing that circumstances prevented the submission of the 30-day notice and if DADS determines that not waiving the 30-day notification would create a threat to resident welfare or health and safety. If the applicant submits a timely and sufficient application for a change of ownership license and meets all requirements for a license, DADS issues a change of ownership license effective on the date requested by the applicant.(e) A change of ownership license is a 90-day temporary license issued to an applicant who proposes to become the new operator of a nursing facility that exists on the date the application is submitted. Upon receipt of a complete application, fee, and signed, written notice from the facility's existing license holder of the intent to transfer the operation of the facility to the applicant beginning on a date specified by the applicant, DADS issues a change of ownership license to the applicant if DADS finds that the applicant and any other persons listed in §19.201(e) of this subchapter meet the requirements in §19.201(d)(1) and (f) of this subchapter.(1) All applications must be made on forms prescribed by and available from DADS. Each application must be completed in accordance with DADS instructions, signed, and notarized, and must contain all forms required by DADS.(2) DADS approves or denies an application for a change of ownership license not later than the 31st day after the date of receipt of the complete application, fee, and signed, written notice from the facility's existing license holder of his intent to transfer the operation of the facility to the applicant beginning on a date specified by the applicant. The effective date of the license is the later of the date requested in the application or the 31st day after the date DADS receives the application, fee, and signed, written notice from the existing license holder, unless waived in accordance with subsection (d) of this section. The effective date of the change of ownership license cannot precede the date the application is received in DADS Licensing and Credentialing Section, Regulatory Services Division.(3) If the applicant meets the requirements of §19.201 of this subchapter and passes an initial inspection, desk review, or a subsequent inspection before the change of ownership license expires, a regular three-year license is issued. The effective date of the regular three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application is received by DADS Licensing and Credentialing Section, Regulatory Services Division.(4) When an applicant has not previously held a license in Texas, a probationary license is issued following the change of ownership license. The effective date of the probationary one-year license is the same date as the change of ownership license and cannot precede the date the application is received in DADS Licensing and Credentialing Section, Regulatory Services Division.(5) A change of ownership license expires on the 90th day after its effective date.(6) DADS conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a change of ownership license. DADS may conduct a desk review instead of an on-site health inspection after issuing a change of ownership license if:(A) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or(B) every owner with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(7) DADS, in its sole discretion, may conduct an on-site Life Safety Code inspection after issuing a change of ownership license.(f) A license holder may be eligible to acquire, on an expedited basis, a license to operate another existing nursing facility. A license holder that appears on the expedited change of ownership list may be granted expedited approval in obtaining a change of ownership license to operate another existing nursing facility in Texas.(1) DADS maintains and keeps current a list of nursing facility license holders that operate an institution in Texas and that have met the criteria to qualify for an expedited change of ownership according to the information available to DADS.(2) In order to establish and maintain the expedited change of ownership list, DADS uses the criteria found in §19.2322(e) of this chapter (relating to Medicaid Bed Allocation Requirements). A license holder meeting these criteria appears on the list and is eligible to be issued, on an expedited basis, a change of ownership license to operate another existing institution in Texas.(3) A license holder appearing on the list must submit an affidavit that demonstrates the license holder continues to meet the criteria established for being listed on the expedited change of ownership list, and continues to meet the requirements in §19.201(d)(1) and (f) of this subchapter.(4) DADS processes a change of ownership license application on an expedited basis for a license holder on the list if DADS finds that the license holder and any other persons listed in §19.201(e) of this subchapter meet the requirements in §19.201(d)(1) and (f) of this subchapter.(5) If the license holder requesting a change of ownership license on an expedited basis complies with subsections (b) - (e) of this section, DADS approves or denies the application for a change of ownership license not later than the 15th day after the date of receipt of the complete application, fee, and signed, written notice from the facility's existing license holder of the intent to transfer the operation of the facility to the applicant beginning on a date requested in the application. The effective date of the license is the later of the date requested in the application or the 31st day after the date DADS receives the application fee, and signed, written notice from the existing license holder, unless waived in accordance with subsection (d) of this section. The effective date of the change of ownership license cannot precede the date the application is received in DADS Licensing and Credentialing Section, Regulatory Services Division.(6) An applicant for a change of ownership license on an expedited basis must meet all applicable requirements that an applicant for renewal of a license must meet. Any requirement relating to inspections or to an accreditation review applies only to institutions operated by the license holder at the time the application is made for the change of ownership license.(g) If a license holder changes its name, but does not undergo a change of ownership, the license holder must notify DADS and submit documentation evidencing a legal name change. On receipt of the notice and documentation, DADS re-issues the current license in the license holder's new name.(h) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify DADS no later than 30 days after the addition of the owner. Source Note: The provisions of this §554.210 adopted to be effective December 1, 2008, 33 TexReg 9713; amended to be effective September 1, 2009, 34 TexReg 5138; amended to be effective December 2, 2012, 37 TexReg 9525; amended to be effective October 11, 2017, 42 TexReg 5498; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.210 Change of Ownership and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203017 03/12/2026 (a) A license holder may not relocate a facility to another location without approval from the Texas Department of Human Services (DHS). The license holder must submit a complete application and the fee required under §19.216 of this title (relating to License Fees) to DHS before the relocation.(b) Residents may not be relocated until the new building has been inspected and approved as meeting the standards of the Life Safety Code as applicable to nursing facilities.(c) Following Life Safety Code approval by DHS, the license holder must notify DHS of the date residents will be relocated. If the new facility meets the standards for operation based on an on-site survey, a license will be issued.(d) The effective date of the license will be the date all residents are relocated.(e) The license holder must continue to maintain the license at the current location and must continue to meet all requirements for operation of the facility until the date of the relocation.(f) This section applies to relocation of a currently licensed facility, and does not govern the relocation of Medicaid-certified beds. See §19.2322 of this title (relating to Medicaid Bed Allocation Requirements) for guidelines on relocation of Medicaid-certified beds. Source Note: The provisions of this §554.211 adopted to be effective May 1, 2002, 27 TexReg 3369; amended to be effective November 1, 2002, 27 TexReg 9154; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.211 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203002 03/12/2026 (a) The Health and Human Services Commission (HHSC) will process only applications received within 60 days prior to the requested date of the issuance of the license.(b) An application is complete when all requirements for licensing have been met, including compliance with standards. If an inspection for compliance is required, the application is not complete until the inspection has occurred, reports have been reviewed, and the applicant complies with the standards.(c) If the application is postmarked by the filing deadline and received by HHSC within 15 days of the postmark, the application is considered to be timely filed.(d) HHSC notifies a facility within 30 days of receipt of the application if any of the following applications are incomplete:(1) initial application;(2) change of ownership;(3) renewal; and(4) increase in capacity.(e) A license will be issued or denied within 30 days of the receipt of a complete application or within 30 days prior to the expiration date of the license.(f) HHSC may pend action for up to six months on an application:(1) of any type listed in subsection (d) of this section to give an applicant time to comply with licensure requirements imposed by HHSC; or(2) for renewal of the license if the facility is subject to a proposed denial or pending licensure revocation action.(g) Criteria for reimbursement of fees are as follows.(1) In the event the application is not processed in the time periods as stated, the applicant has a right to request of the program director full reimbursement of all filing fees paid in that particular application process. If the program director does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request will be denied. Good cause for exceeding the period established is considered to exist if:(A) the number of applications to be processed exceeds by 15% or more the number processed in the same calendar quarter of the preceding year;(B) another public or private entity used in the application process caused the delay; or(C) other conditions existed giving good cause for exceeding the established periods.(2) If the request for full reimbursement is denied, the applicant may appeal directly to the executive commissioner for resolution of the dispute. The applicant must send a written statement to the executive commissioner describing the request for reimbursement and the reasons for it. The program also may send a written statement to the executive commissioner describing the program's reasons for denying reimbursement. The executive commissioner makes a timely decision concerning the appeal and notifies the applicant and the program in writing of the decision. Source Note: The provisions of this §554.212 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective February 20, 2018, 43 TexReg 900; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.212 Time Periods for Processing License Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203003 03/12/2026 (a) DADS may deny an initial license or refuse to renew a license if any person described in §19.201(e) of this subchapter (relating to Criteria for Licensing):(1) is subject to denial or refusal as described in Chapter 99 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;(2) does not have a satisfactory history of compliance with state and federal nursing home regulations. In determining whether there is a history of satisfactory compliance with federal or state regulations, DADS at a minimum may consider:(A) whether any violation resulted in significant harm or a serious and immediate threat to the health, safety, or welfare of any resident;(B) whether the person promptly investigated the circumstances surrounding any violation and took steps to correct and prevent a recurrence of a violation;(C) the history of surveys and complaint investigation findings and any resulting enforcement actions;(D) a repeated failure to comply with regulation;(E) an inability to attain compliance with cited deficiencies within an acceptable period of time as specified in the plan of correction or credible allegation of compliance, whichever is appropriate;(F) the number of violations relative to the number of facilities the applicant or any other person named in §19.201(e) of this subchapter has been affiliated with at any time; and(G) any exculpatory information deemed relevant by DADS;(3) has committed any act described in §19.2112(a)(2) - (7) of this chapter (relating to Administrative Penalties);(4) violated Chapter 242 of the Texas Health and Safety Code in either a repeated or substantial manner;(5) aids, abets, or permits a substantial violation described in paragraph (4) of this subsection about which the person had or should have had knowledge;(6) fails to provide the required information and facts and/or references;(7) fails to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §19.216 of this subchapter (relating to License Fees);(B) reimbursement of emergency assistance funds within one year after the date on which the funds were received by the trustee in accordance with the provisions of §19.2116(e) and (f) of this chapter (relating to Involuntary Appointment of a Trustee); or(C) franchise taxes;(8) has a history of any of the following actions at any time preceding the date of the application:(A) operation of a facility that has been decertified or had its contract canceled under the Medicare or Medicaid program in any state or both;(B) federal or state nursing facility sanctions or penalties, including, but not limited to, monetary penalties, downgrading the status of a facility license, proposals to decertify, directed plans of correction or the denial of payment for new Medicaid admissions;(C) unsatisfied final judgments;(D) eviction involving any property or space used as a facility in any state;(E) suspension of a license to operate a health care facility, long-term care facility, assisted living facility, or a similar facility in any state;(F) revocation of a license to operate a health care facility, long-term care facility, assisted living facility, or similar facility in any state;(G) surrender of a license in lieu of revocation or while a revocation hearing is pending; or(H) expiration of a license while a revocation action is pending and the license is surrendered without an appeal of the revocation or an appeal is withdrawn;(9) fails to meet minimum standards of financial condition as described in §19.201(d)(1)(A) of this subchapter and §19.1925(a) of this chapter (relating to Financial Condition); or(10) fails to notify DADS of a significant adverse change in financial condition as required under §19.1925 of this chapter.(b) DADS:(1) denies a license to an applicant to operate a facility if the applicant has on the date of the application:(A) a debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or(B) a court injunction prohibiting the applicant or manager from operating a facility; or(2) may deny a license to an applicant to operate a new facility if the applicant has a history of any of the following actions at any time preceding the date of the application:(A) revocation of a license to operate a health care facility, long-term care facility, assisted living facility, or similar facility in any state;(B) surrender of a license in lieu of revocation or while a revocation hearing is pending;(C) expiration of a license while a revocation action is pending and the license is surrendered without an appeal of the revocation or an appeal is withdrawn;(D) debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or(E) a court injunction prohibiting the applicant or manager from operating a facility.(c) Only final actions are considered for purposes of subsections (a)(8) and (b) of this section. An action is final when routine administrative and judicial remedies are exhausted. All actions, whether pending or final, must be disclosed.(d) If an applicant for a new license owns multiple facilities, DADS examines the overall record of compliance in all of the applicant's facilities. Denial of an application for a new license will not preclude the renewal of licenses for the applicant's other facilities with satisfactory records.(e) If DADS denies a license or refuses to issue a renewal of a license, the applicant or license holder may request an administrative hearing. Administrative hearings are held under the Health and Human Services Commission's hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and Chapter 91 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §554.214 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 1, 1999, 24 TexReg 8314; amended to be effective April 1, 2001, 26 TexReg 1547; amended to be effective September 1, 2007, 32 TexReg 4231; amended to be effective May 4, 2008, 33 TexReg 3446; amended to be effective September 1, 2009, 34 TexReg 5138; amended to be effective January 18, 2012, 37 TexReg 125; amended to be effective December 2, 2012, 37 TexReg 9525;transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.214 Criteria for Denying a License or Renewal of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203004 03/12/2026 (a) Before the institution of proceedings to revoke or suspend a license or deny an application for the renewal of a license, the Texas Department of Human Services (DHS) gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action, with a copy being sent to the facility; and(2) an opportunity to show compliance with all requirements of law for the retention of the license by sending the director of Long Term Care-Regulatory a written request. The request must:(A) be postmarked within 10 days of the date of DHS's notice and be received in the state office of the director of Long-Term Care-Regulatory within 10 days of the date of the postmark; and(B) contain specific documentation refuting DHS's allegations.(b) DHS's review will be limited to a review of documentation submitted by the license holder and information DHS used as the basis for its proposed action and will not be conducted as an adversary hearing. DHS will give the license holder a written affirmation or reversal of the proposed action. Source Note: The provisions of this §554.215 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 1, 2001, 26 TexReg 3824; amended to be effective May 1, 2003, 28 TexReg 2619; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.215 Opportunity to Show Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203005 03/12/2026 (a) Basic fees.(1) Probationary license. The license fee is $125 plus $5 for each unit of capacity or bed space for which a license is sought.(2) Initial and renewal license. The license fee is $375 plus $15 for each unit of capacity or bed space for which a license is sought. The fee must be paid with each initial and renewal of license application.(3) Increase in bed space. An approved increase in bed space is subject to an additional fee of $15 for each unit of capacity or bed space.(4) Change of administrator. A facility must report a change of administrator within 30 days of the effective date of the change by submitting a change of administrator notice and a $20 fee to DADS Licensing and Credentialing Section, Regulatory Services Division. If DADS Licensing and Credentialing Section, Regulatory Services Division does not receive the notice within 30 days of the effective date of the change, DADS may impose a $500 administrative penalty. If the notice is postmarked within the 30-day period, 15 days will be added to the time period to receive the notice.(5) Background information fee. The background information fee is $50.(6) Late renewal fee. An applicant for license renewal that submits an application during the 45-day period ending on the date the current license expires must pay a late fee of an amount equal to one-half of the total basic renewal fee in subsection (a)(2) of this section. The late fee for a two-year renewal license issued in accordance with §19.208(b)(2) of this subchapter (relating to Renewal Procedures and Qualifications) is one half of the total two-year renewal fee calculated in accordance with §19.208(c) of this subchapter.(b) Trust fund fee.(1) In addition to the basic license fee described in subsection (a) of this section, DADS has established a trust fund for the use of a court-appointed trustee as described in the Texas Health and Safety Code, Chapter 242, Subchapter D.(2) DADS charges and collects an annual fee from each facility licensed under the Texas Health and Safety Code, Chapter 242 each calendar year if the amount of the nursing and convalescent trust fund is less than $10,000,000. The fee is based on a monetary amount specified for each licensed unit of capacity or bed space, not to exceed $20 annually, and is in an amount sufficient to provide not more than $10,000,000 in the trust fund. In calculating the fee, the amount will be rounded to the next whole cent.(3) Veterans homes (as defined in the Texas Natural Resources Code, §164.002) are exempt from paying a trust fund fee.(4) DADS may charge and collect a fee more than once a year only if necessary to ensure that the amount in the nursing and convalescent trust fund is sufficient to allow required disbursements.(c) Alzheimer's certification. In addition to the basic license fee described in subsection (a) of this section, a facility that applies for certification to provide specialized services to persons with Alzheimer's disease or related conditions under Subchapter W of this chapter (relating to Certification of Facilities for Care of Persons with Alzheimer's Disease and Related Disorders) must pay with each initial and renewal certification application a fee of $300 for the three-year certification. Source Note: The provisions of this §554.216 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective January 1, 2000, 24 TexReg 11781; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective April 1, 2001, 26 TexReg 1547; amended to be effective September 1, 2003, 28 TexReg 6939; amended to be effective January 15, 2009, 34 TexReg 237; amended to be effective December 2, 2012, 37 TexReg 9525; amended to be effective January 1, 2014, 38 TexReg 9629; transferred effective January 15, 2021, aspublished in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.216 License Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203006 03/12/2026 Payment of fees must be by check or money order made payable to the Texas Department of Human Services. All fees are nonrefundable except as provided by the Government Code, Chapter 2005. Source Note: The provisions of this §554.218 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.218 Method of Payment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203007 03/12/2026 (a) The Texas Department of Human Services (DHS) charges a fee to review plans for new buildings, additions, conversion of buildings not licensed by DHS, or remodeling of existing licensed facilities.(b) The fee schedule follows:(1) Facilities--new construction:(A) single-story facilities--$20 per bed, $2,000 minimum; and(B) multiple-story facilities--$24 per bed, $2,500 minimum.(2) Additions or remodeling of existing licensed facilities--2% of construction cost with $500 minimum fee and a maximum not to exceed $2,000.(3) Alzheimer's certification--$550 in addition to the fees specified in paragraphs (1) - (2) of this subsection. Source Note: The provisions of this §554.219 adopted to be effective April 1, 2002, 27 TexReg 2249; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.219 Plan Review Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203008 03/12/2026 (a) DADS charges a fee for expedited Life Safety Code and physical plant inspections for new buildings, additions, conversion of buildings not licensed by DADS, or remodeling of existing licensed facilities. (b) Table of Expedited Life Safety Code and Physical Plant Inspection Fees. Attached Graphic Source Note: The provisions of this §554.220 adopted to be effective June 1, 2010, 35 TexReg 4465; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION C NURSING FACILITY LICENSURE APPLICATION PROCESS §554.220 Expedited Life Safety Code and Physical Plant Inspection Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207283 03/12/2026 (a) The facility must be designed, constructed, equipped, and maintained to protect the health and ensure the safety of residents, personnel, and the public.(b) If children are admitted to the facility, accommodations, furnishings, and equipment appropriate to children must be provided, including the following;(1) The facility must provide indoor and outdoor recreation areas designed to encourage exploration within the children's capabilities.(2) The facility must provide pediatric equipment and supplies in appropriate sizes for the age and development level of the children. Pediatric emergency supplies and equipment must be readily available for use.(3) The environment must be the least restrictive allowable while remaining within the parameters of safety. All areas of the facility accessible to children must be "child proof" for safety hazards. This type of safety proofing is above the normal level of hazard control maintained for adult residents and includes the addition of safety covers on electrical outlets not in use that are accessible to children.(4) Pediatric resident's rooms must be decorated and furnished in accordance with the age and developmental level of the children and as an expression of their individual preferences.(c) HHSC may grant a waiver for certain provisions regarding the physical plant and environment that, in the opinion of HHSC, would be impractical for the facility to meet. In granting the waiver, HHSC must determine that granting the waiver has no adverse effect on resident health and safety and the requirement, if not waived, would impose an unreasonable hardship on the facility. HHSC may require offsetting or equivalent provisions in granting a waiver.(d) The requirements of this subchapter are applicable to nursing facilities as follows:(1) All nursing facilities must comply with division 3 of this subchapter (relating to Provisions Applicable to All Facilities).(2) A nursing facility or a portion of a nursing facility licensed before September 11, 2003, and continually operated as a licensed nursing facility, must comply with division 2 of this subchapter (relating to Facilities Licensed Before September 11, 2003).(3) A nursing facility or a portion of a nursing facility licensed or constructed, on or after September 11, 2003, but before April 2, 2018, and continuously operated as a licensed nursing facility, must comply with division 5 of this subchapter (relating to Facilities Licensed On or After September 11, 2003 and Before April 2, 2018).(4) A nursing facility or a portion of a nursing facility licensed or constructed on or after April 2, 2018, must comply with division 9 of this subchapter (relating to Facilities Licensed On or After April 2, 2018).(5) A small house or household facility is a facility that is designed to provide a non-institutional environment to promote resident-centered care and that meets the requirements of §554.345 of this subchapter (relating to Small House and Household Facilities). New construction of a small house or household facility must meet the requirements of §554.345 of this subchapter.(e) A facility must comply with NFPA 101; NFPA 99, except Chapters 7, 8, 12, and 13; and a Tentative Interim Amendment (TIA) issued by NFPA, including the TIAs listed in paragraphs (1) and (2) of this subsection. A facility must also comply with other NFPA publications referenced in NFPA 101 or in this chapter, unless otherwise approved by HHSC.(1) The following TIAs have been issued for NFPA 101:(A) TIA 12-1, issued August 11, 2011;(B) TIA 12-2, issued October 30, 2012;(C) TIA 12-3, issued October 22, 2013; and(D) TIA 12-4, issued October 22, 2013.(2) The following TIAs have been issued for NFPA 99:(A) TIA 12-2, issued August 11, 2011;(B) TIA 12-3, issued August 9, 2012;(C) TIA 12-4, issued March 7, 2013;(D) TIA 12-5, issued August 1, 2013;(E) TIA 12-6, issued March 3, 2014;(F) TIA 12-7, issued December 1, 2016; and(G) TIA 12-8, issued April 10, 2018.(f) Building rehabilitation on existing buildings shall be classified in accordance with NFPA 101 and shall comply with NFPA 101 and §554.350 of this subchapter (relating to Building Rehabilitation).(g) Buildings, or portions of buildings, may be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied, or when alternative life safety measures acceptable to HHSC are in place.(h) No existing life safety feature shall be removed or reduced when the feature is a requirement for new construction. Life safety features and equipment that have been installed in existing buildings, if not required by NFPA 101, must continue to be maintained or may be completely removed if prior approval is obtained from HHSC.(i) The facility must perform a risk assessment in accordance with NFPA 99.(1) The risk assessment must follow and document the defined risk assessment procedure used.(2) The results of the assessment procedure must be documented and records retained.(3) A building system required by NFPA 99 shall be designed to meet the risk categories determined for each system as part of this assessment. At a minimum, any new systems or equipment must be designed to meet the requirements for Category 2 risk, as defined in NFPA 99.(4) The assessment must be reviewed and a new assessment performed, if necessary, on an annual basis and when the facility identifies changes in resident care needs that cannot be met by the currently installed systems and equipment.(5) In addition to the requirements of NFPA 99 based on the risk assessment, a facility must also meet all applicable requirements of this subchapter.(j) A wing or area that is separated from the rest of the facility by locked doors, or a facility that is locked in its entirety, for the purpose of securing residents must meet the requirements of §554.2208(a)(6) and (c)(1) - (10) of this chapter (relating to Standards for Certified Alzheimer's Facilities). Source Note: The provisions of this §554.300 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.300 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207284 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise. The definitions listed in §554.101 of this chapter (relating to Definitions) also apply to this subchapter.(1) Alarm Planning Superintendent--Fire Alarm Planning Superintendent. A person licensed by the State Fire Marshal's Office to plan, install, certify, inspect, test, service, monitor, and maintain fire alarm or fire detection devices.(2) ANSI--American National Standards Institute.(3) ASHRAE--Formerly American Society of Heating, Refrigerating and Air-Conditioning Engineers. A global society focusing on building systems, energy efficiency, indoor air quality, refrigeration, and sustainability.(4) ASME--The American Society of Mechanical Engineers, a developer of codes and standards associated with the art, science, and practice of mechanical engineering.(5) ASME A17.1--Safety Code for Elevators and Escalators, 2007 edition, published by ASME.(6) ASME A17.3--Safety Code for Existing Elevators and Escalators, 2008 edition, published by ASME.(7) ASTM--ASTM International, a not-for-profit, voluntary standards developing organization that develops and publishes international voluntary consensus standards for materials, products, systems, and services.(8) ASTM E84--Standard Test Method for Surface Burning Characteristics of Building Materials, 2010, published by ASTM.(9) ASTM E90--Standard Test Method for Laboratory Measurement of Airborne Sound Transmission Loss of Building Partitions and Elements, published by ASTM.(10) ASTM E108--Standard Test Methods for Fire Tests of Roof Coverings, published by ASTM.(11) ASTM E662--Standard Test Method for Specific Optical Density of Smoke Generated by Solid Materials, 2017, published by ASTM.(12) Building Rehabilitation--Any construction activity involving repair, modernization, reconfiguration, renovation, changes in occupancy or use, or installation of new fixed equipment, including, the following:(A) the replacement of finishes, such as new flooring or wall finishes or the painting of walls and ceilings;(B) the construction, removal, or relocation of walls, partitions, floors, ceilings, doors, or windows;(C) the replacement of doors, windows, or roofing;(D) changes to the appearance of the exterior of a building, including new finish materials;(E) the repair, replacement, or extension of fire protection systems, including fire sprinkler systems, fire alarm system, and fire suppression systems at cooking operations;(F) the replacement of door hardware, plumbing fixtures, handrails in corridors, or grab rails in bathrooms and restrooms;(G) the repair, replacement, or extension of nurse call systems;(H) the repair or replacement of emergency electrical system equipment and components, including generator sets, transfer switches, distribution panel boards, receptacles, switches, and light fixtures;(I) the change of a wing or area to a secured wing or unit;(J) the change of a secured wing or unit to ordinary resident-use;(K) a change in the use of space, including the change of resident bedrooms to other uses, such as offices, storage, or living or dining spaces; and,(L) changes in locking arrangements, such as the installation of access control systems or the installation or removal of electronic locking devices, including electromagnetic locks, and other delayed-egress locking devices.(13) NFPA 10--Standard for Portable Fire Extinguishers, 2010 edition.(14) NFPA 13--Standard for the Installation of Sprinkler Systems, 2010 edition.(15) NFPA 25--Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition.(16) NFPA 37--Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 2010 edition.(17) NFPA 54--National Fuel Gas Code, 2012 edition.(18) NFPA 55--Compressed Gases and Cryogenic Fluids Code, 2010 edition.(19) NFPA 58--Liquefied Petroleum Gas Code, 2011 edition.(20) NFPA 70--National Electrical Code, 2011 edition.(21) NFPA 72--National Fire Alarm and Signaling Code, 2010 edition.(22) NFPA 90A--Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 edition.(23) NFPA 96--Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition.(24) NFPA 110--Standard for Emergency and Standby Power Systems, 2010 edition.(25) NFPA 220--Standard on Types of Building Construction, 2012 edition.(26) NFPA 255--Standard Method of Test of Surface Burning Characteristics of Building Materials. This document was withdrawn by NFPA in 2009 in lieu of ASTM E84 and UL 723.(27) NFPA 258--Recommended Practice for Determining Smoke Generation of Solid Materials. This document was withdrawn by NFPA in 2006 in lieu of ASTM E662.(28) Patient care vicinity--A space extending 6 ft. (1.8 m) horizontally in all directions around the resident bed and extending vertically to 7 ft. 6 in. (2.3 m) above the floor. If the dimension between the bed and a wall or partition is less than 6 ft. (1.8 m), the limit of the patient care vicinity is at the wall or partition.(29) RME--Responsible Managing Employee. A person licensed by the State Fire Marshal's Office who is designated by a registered fire sprinkler firm to ensure that any fire protection sprinkler system, as planned, installed, maintained, or serviced, meets the standards provided by law. The type of RME license issued determines the type of fire sprinkler services the fire sprinkler firm may perform.(30) TAS--Texas Accessibility Standards.(31) TCEQ--Texas Commission on Environmental Quality.(32) UL--UL LLC, formerly Underwriters' Laboratory.(33) UL 723--Standard for Test for Surface Burnings Characteristics of Building Materials.(34) UL 790--Standard Test Methods for Fire Tests of Roof Coverings.(35) UL 1069--Standard for Hospital Signaling and Nurse Call Equipment. Source Note: The provisions of this §554.301 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.301 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203022 03/12/2026 (a) The facility must meet the provisions of the Existing Health Care Occupancies chapter of NFPA 101.(b) The following codes, standards, or guidelines govern their subject areas for existing construction:(1) If the municipality has a building code and a plumbing code, those codes govern.(2) In the absence of municipal codes, nationally recognized codes must be used. To ensure continuity, all nationally recognized codes, when used, must be publications of the same group or organization.(3) Heating, ventilating, and air-conditioning systems must be designed and installed in accordance with NFPA 90A and the ASHRAE Handbook, except as may be modified in this subchapter.(4) Electrical and illumination systems must be designed and installed in accordance with NFPA 70 and the Lighting Handbook of the Illuminating Engineering Society of North America, except as may be modified in this subchapter.(5) The facility must comply with accessibility requirements for individuals with disabilities in the revised regulations for Title II and III of the Americans with Disabilities Act at 28 CFR Part 35 and Part 36, also known as the 2010 ADA Standards for Accessible Design, and the TAS adopted by the Texas Department of Licensing and Regulation (TDLR) at 16 TAC Chapter 68. A facility must register plans for new construction, substantial renovations, modifications, and alterations with TDLR, Attn: Elimination of Architectural Barriers Program, and comply with TAS.(6) Every building and portion of a building must be capable of sustaining all dead and live loads in accordance with accepted engineering practices and standards.(7) Each building must be classified as to building construction type for fire resistance rating purposes in accordance with NFPA 220 and NFPA 101.(8) Building insulation materials, unless sealed on all sides and edges in an approved manner with noncombustible material, must have a flame-spread rating of 25 or less when tested in accordance with ASTM E84, UL723, or ASTM E662.(9) A facility with a boiler must meet all applicable requirements of Texas Health and Safety Code, Chapter 755. Source Note: The provisions of this §554.302 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.302 Applicable Codes and Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203023 03/12/2026 (a) Emergency power systems must meet the requirements of NFPA 99 applicable to existing facilities, for the risk category determined by the requirements of §19.300(i) of this subchapter (relating to General Requirements), and the requirements of this section. Rehabilitation or modernization of an existing emergency power system must be based on the assessed risk category and according to the requirements of NFPA 99 for new health care facilities.(b) An emergency electrical power system must supply power adequate at least for lighting all entrances and exits, equipment to maintain the fire detection, alarm, and extinguishing systems, and any systems or equipment whose failure is likely to cause major injury or death to a resident if the normal electrical supply is interrupted. Emergency electrical services by generator or battery must be provided to comply with the provisions of NFPA 70. Battery systems must be capable of sustaining power for a duration of at least one and one-half hours.(1) The emergency electrical power system must supply the following systems:(A) illumination for means of egress, nurses' stations, medication rooms, dining and living rooms, and areas immediately outside of exit doors;(B) exit signs and exit directional signs required by NFPA 101;(C) alarm systems, including fire alarms activated by manual stations, water flow alarm devices of sprinkler systems, fire and smoke detecting systems, and alarms required for nonflammable medical gas systems if installed;(D) task illumination and selected receptacles at any required or provided generator set location;(E) selected duplex receptacles, including receptacles in resident corridors, each resident-bed location where systems or equipment is used whose failure is likely to cause major injury or death to a resident, nurses' stations, medication rooms, including biological refrigerator, if a generator is required or provided;(F) nurse call systems;(G) resident room night lights when provided;(H) elevator cab lighting, control, and communication systems;(I) all facility telephone equipment; and(J) those paging or speaker systems that are necessary for the communication plan for an emergency. Radio transceivers that are necessary for emergency use must be capable of operating for at least one hour upon total failure of both normal and emergency power.(2) If the emergency electrical power system supplies other systems the facility considers critical to operation, the transfer to the emergency power source must be by delayed automatic connection.(3) The emergency lighting must be automatically in operation within 10 seconds after the interruption of normal electrical power supply. Emergency service to receptacles and equipment may be a delayed automatic connection. Receptacles connected to emergency power must be of a uniform and distinctive color. Stored fuel capacity must be sufficient for not less than four hours of required generator operation.(4) An emergency motor generator, if provided, must meet the following standards:(A) any emergency generator must be installed in accordance with NFPA 37, NFPA 110 and NFPA 99;(B) generators located on the exterior of the building must be provided with a noncombustible protective cover or be protected as per manufacturer's recommendations; and(C) motor generators fueled by public utility natural gas must have the capacity to be manually or automatically switched to an alternate fuel source, as specified in NFPA 70.(5) Wiring for the emergency system must be in accordance with NFPA 70.(c) When the failure of systems or equipment is likely to cause major injury or death to a resident, such as the failure of a mechanical ventilator used to support or completely control breathing, the facility must provide emergency electrical power with an emergency generator as, defined in NFPA 99, located on the premises. Source Note: The provisions of this §554.303 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 1, 2001, 26 TexReg 1171; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.303 Emergency Power https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203024 03/12/2026 The facility must:(1) provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident's plan of care; and(2) maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Source Note: The provisions of this §554.304 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.304 Space and Equipment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203025 03/12/2026 Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.(1) Bedrooms must:(A) accommodate no more than four residents. The total number of beds in ward rooms with three or more beds must not exceed 50% of the total facility capacity in existing facilities unless approved by HHSC.(B) measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms.(C) have direct access to an exit corridor.(D) be designed or equipped to ensure full visual privacy for each resident. A facility must take appropriate measures to protect the privacy and dignity of the residents through the use of cubicle curtains, screens, or procedures. Curtains and screens must be rendered and maintained flame-retardant.(E) in facilities initially certified after March 31, 1992, except in private rooms, have ceiling-suspended curtains for each bed, which extend around the bed to provide total visual privacy, in combination with adjacent walls and curtain (see paragraph (4) of this section).(F) have at least one operable window to the outside which can readily be opened from the inside without the use of tools. The height of the window sill must not exceed 36 inches above the floor. The minimum area of windows in each bedroom must equal at least 8.0% of the room area. Operable window sections may be restricted to not more than six nor less than four inches for security or safety reasons. Each window must be provided with a flame-retardant shade, curtain, or blind.(G) have a floor at or above grade level.(2) The facility must provide each resident with:(A) a separate bed of proper size and height for the convenience of the resident. The bed will be a minimum of 36 inches wide with a headboard of sturdy construction. The facility must provide each bed with suitable bedspreads and blankets to ensure the comfort and warmth of each resident, and must not pass bedspreads and blankets from resident to resident without first being laundered. The bed of each resident with physician's orders for bedrails must have bedrails affixed to both sides of the bed:(B) a clean, comfortable mattress with a moisture-proof cover, and a comfortable pillow;(C) bedding appropriate to the weather and climate; and(D) functional furniture appropriate to the resident's needs including a comfortable chair, bedside cabinet, and individual closet space in the resident bedroom with at least 16 inches of hanging space, shelves for personal belongings accessible to the resident, and closeable doors. Each bedroom must be provided with at least one noncombustible wastebasket.(3) HHSC may permit variations in requirements specified in paragraph (1)(A) and (B) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations:(A) are required by the special needs of the residents; and(B) will not adversely affect residents' health and safety.(4) The width and length of bedrooms and the arrangement of furniture must ensure appropriate resident circulation, especially in relation to emergency evacuation and to usual wheelchair movement. Bedrooms should not be less than 10 feet in the smallest dimension. There must be at least 36 inches between beds and should be at least 18 inches between any bed and the adjacent parallel wall that restricts access by the resident, that is, bed sides should not have to be placed against a wall to meet other spacing requirements. Beds must not extend into the bedroom door opening, nor must any other piece of furnishing or equipment be located where it might preclude or inhibit the removal of any bed or closing and latching of the bedroom door in an emergency.(5) Each bed must have access to a nurse call device that is part of an electrical nurse call system.(6) Each bed must be provided with an appropriate, safe, durable, non-glare, permanently bed-mounted or wall-mounted reading-light fixture. The fixture must be wired in accordance with NFPA 70. These fixtures should be mounted at least five feet, six inches above the floor. The switch must be within reach of a resident in the bed.(7) At least one duplex receptacle must be provided for each bed. Other duplex receptacles must be provided as needed or as required by NFPA 70.(8) Each bedroom must be ensured of having general lighting, either by means of appropriate combination reading light or by means of separate fixture.(9) For emergency separation from fire and smoke, bedroom doors must be maintained to close completely without dragging or binding, to latch securely, and to fit reasonably tight in the frame. The gap between the floor and the bottom of the closed door must not exceed 3/4 inch.(10) Vacant bedrooms may not be used for hazardous activities or hazardous storage, unless specifically approved by HHSC in writing.(11) Bedrooms must be identified with a raised or recessed unique number placed on or near the door. Refer to §19.319(c) of this title (relating to Provisions for Persons with Disabilities) and §19.302(b)(5) of this title (relating to Applicable Codes and Standards).(12) Residents must be permitted and encouraged to have personal possessions in their rooms that do not interfere with their care, treatment, or well-being, or that of other residents.(13) Locks on bedroom doors are permitted when they meet definite resident needs, including the following situations:(A) married couples whose rights of privacy could be infringed upon unless bedroom door locks are permitted; and(B) residents for whom the attending physician wants bedroom door locks to enhance their sense of security.(14) In situations such as those listed in paragraph (13) of this section, the following guidelines must be met:(A) bedroom door locks must be of the type which the occupant can unlock at will from inside the room;(B) all bedroom door locks must be of the type which can be unlocked from the corridor side;(C) attendants must carry keys which will permit ready accessibility to the locked bedrooms when entrance becomes necessary; and(D) locking of bedroom doors by residents for privacy or security will not be permitted except when specifically included in the attending physician's written orders or authorized by the nursing facility administrator. Source Note: The provisions of this §554.305 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.305 Resident Rooms https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203026 03/12/2026 Each resident room must be equipped with or located near toilet and bathing facilities.(1) Bedrooms not provided with their own (or shared) direct-access toilets and baths must have general-use baths and toilets conveniently located for each sex.(2) Bathtubs or showers must be provided at minimum rate of one for each 20 beds which are not otherwise served by bathing facilities directly accessible from resident bedrooms.(3) In toilet facilities designed for multi-resident use, water closets must be separated in such a manner that they can be used independently and afford privacy. Toilet paper in a suitable dispenser must be provided within reach of each toilet.(4) Water closets and lavatories must be provided at a minimum rate of one for each eight beds which are not otherwise served by fixtures directly accessible from resident bedrooms. A lavatory must be provided in or adjacent to each area having a water closet.(5) Lavatories must be equipped with a mixer faucet and hot and cold water. Resident-use hot water must be provided within the temperature guidelines specified in §19.322(g) of this title (relating to Plumbing).(6) There must be a sufficient number of toilet rooms and bathing areas designed to accommodate residents in wheelchairs, including sufficient space in or around fixtures. Proper heights, locations, and installations must be made for grab bars, and any mirrors and accessories provided.(7) Grab bars and lavatories must be substantially anchored to withstand sustained and repeated downward and outward pressure. Grab bars must be provided at all resident water closets and bathing fixtures. New grab bar installations must meet the requirements of the Texas Department of Licensing and Regulation, Elimination of Architectural Barriers Section.(8) Floors, walls, and ceilings must have a nonabsorbent, cleanable surface. Floors and tub or shower standing surfaces must be slip resistant.(9) Doors to bathing and toilet facilities must be wide enough for safe and easy passage of residents in wheelchairs. Folding or sliding doors must not be used unless it can be established that no safety hazard exists.(10) Keys to resident baths or toilets with privacy locks must be kept readily available to staff.(11) Provision must be made for sanitary hand washing and drying by staff, visitors, or residents at each lavatory.(12) Bathrooms and toilets rooms must have a negative air pressure in relation to adjacent areas with air exhausted through ducts to the exterior.(13) Bathing areas must be provided with safe heating.(14) Bathtubs, showers, and lavatories must be kept clean and in proper working order. They must not be used for laundering or for storage of soiled materials or for the cleaning of mops or brooms.(15) Nurse-call devices must be provided at resident-use baths and toilets and be within easy reach of residents.(16) Electrical outlets in wet areas must be provided with ground fault interrupters, excluding toilet rooms where there are no bathing units. Source Note: The provisions of this §554.306 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.306 Toilet Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203027 03/12/2026 (a) The nurse's station must be equipped to receive resident calls through a communication system from:(1) resident rooms; and(2) toilet and bathing facilities.(b) The call cord does not have to be accessible in all parts of the room, but must be accessible to the resident. The system must be connected to on and off switches operable at each bed, toilet unit, and bathing unit.(c) Each call entered into the system must activate a corridor dome light above the bedroom, bathroom, or toilet corridor door that opens onto a corridor.(d) A visual signal at the nurses station must indicate the room from which the call was placed with an audible signal of sufficient amplitude to be clearly heard by nursing staff. The amplitude or pitch of the audible signal must not be irritating to residents or visitors.(e) The system must be designed so calls entered into the system may be canceled only at the calling station. Intercom-type systems which meet this requirement are acceptable. Source Note: The provisions of this §554.307 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.307 Resident Call System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203028 03/12/2026 (a) Requirements. The facility must provide one or more rooms designated for resident dining and activities. These rooms must be:(1) well-lighted;(2) well ventilated, with nonsmoking areas identified;(3) adequately furnished; and(4) sufficiently spacious to accommodate all activities.(b) Resident living areas.(1) Resident living areas such as living rooms, dayrooms, lounges, recreation rooms, and sunrooms must be provided to meet the needs of the residents' comfort. Combined living and dining areas should be not less than 19 square feet per bed, but must not be less than ten square feet per bed.(2) No single room less than 100 square feet will be included as part of the acceptable total area required.(3) At least one living area must have an outside window.(4) Living areas must be provided with comfortable furniture of substantial construction and be appropriately decorated to provide a pleasant and comfortable environment for residents and visitors. Furnishings and decorations must not obstruct exits or ways of egress.(5) Nonsmoking areas must be provided and identified.(c) Dining areas. Dining space must be provided to adequately serve needs of the residents and provide an efficient, sanitary, and pleasant environment for dining. Source Note: The provisions of this §554.308 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.308 Dining and Resident Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203029 03/12/2026 The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.(1) The facility must:(A) establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply;(B) have adequate outside ventilation by means of windows, mechanical ventilation, or a combination of the two;(C) maintain an effective pest control program so that the facility is free of pests and rodents; and(D) equip corridors with firmly secured handrails on each side on all wall segments 18 inches in length or longer. These rails must be substantially anchored to withstand downward force and must be mounted 33 to 36 inches from the floor.(2) No occupancies or activities undesirable to the health, safety, or well-being of residents will be located in the facility.(3) An electric water cooler or water fountain must be accessible to residents. When new drinking fountains are provided, at least one must be installed to be accessible to persons in wheelchairs.(4) Public toilets with sanitary hand-washing and drying provisions must be provided or designated.(5) If deodorant is used for air-freshening purposes, the following procedures must apply:(A) deodorants or air fresheners are permitted provided the dispensing device is located where it is inaccessible to residents;(B) these products are not used to cover odors resulting from poor housekeeping practices or unsanitary conditions;(C) these products are not used in excess;(D) there is no contra-indication on the label of the product indicating that the product should not be used in the presence of persons who are older or ill; and(E) devices, such as ozone generators, ultra-violet generators, and smoke eliminators, must be approved by HHSC.(6) Permanently mounted hold-open devices to expedite emergency egress and prevent accidental lock-out must be provided for exterior doors. Source Note: The provisions of this §554.309 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.309 Other Environmental Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207285 03/12/2026 (a) Site grades must provide for positive surface water drainage so that there will be no ponding or standing water at or near the building that would present a hazard to health or provide a breeding site or harborage for carriers of disease.(b) Outdoor activity, recreational, and sitting spaces must be provided for residents as space permits.(c) Each facility must have parking spaces to satisfy the needs of residents, employees, staff, and visitors. Provisions must be made for handicapped parking and access into the building.(d) Protection must be provided for resident safety from traffic or other site hazards by the use of appropriate methods, such as fences, hedges, retaining walls, railings, or other landscaping. This protection must not inhibit the free emergency egress to a safe distance away from the building.(e) Auxiliary buildings located on the site within 20 feet of the main licensed structure and which contain hazardous operations or contents, such as laundries or storage buildings, must meet the same code requirements for safety as the main licensed structure.(f) Other buildings on the site must meet the appropriate occupancy section or separation requirements of NFPA 101.(g) All outside areas, grounds, and adjacent buildings on the site must be maintained in good condition and kept free of rubbish, garbage, and untended growth that may constitute a fire or health hazard.(h) Enclosed exterior spaces, such as fenced areas, that are in a means of egress to a public way must meet the requirements of §554.2208(a)(6) of this chapter (relating to Standards for Certified Alzheimer's Facilities). Source Note: The provisions of this §554.310 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.310 Site and Grounds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207287 03/12/2026 (a) The facility must be served by a paid or volunteer fire department. The fire department must provide written assurance to the licensing agency that the fire department can respond to an emergency at the facility within an appropriately prompt time for the travel conditions.(b) The facility must be served by an adequate water supply that is satisfactory and accessible for fire department use as determined by the fire department serving the facility and by HHSC.(c) There must be at least one approved, readily accessible fire hydrant located within 300 feet of the building. The hydrant must be on a minimum six-inch service line, or else there must be an approved equivalent, such as a storage tank. The hydrant, its location, and service line, or equivalent must be approved by the local fire department and HHSC.(d) The building must have suitable fire lanes for access as required by local fire authorities and HHSC. Source Note: The provisions of this §554.311 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.311 Fire Service and Access https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207286 03/12/2026 Interior finishes of walls and ceilings must have limited flame-spread rating as required by NFPA 101. Where new interior finishes of walls, ceilings, or floors are applied to existing facilities, the new finishes must meet the requirements for flame-spread ratings for new construction. Fire retardant paints or solutions must not be applied to new materials in an effort to meet flame-spread requirements for new construction. This description of interior finishes does not apply to furniture or accessories. Source Note: The provisions of this §554.313 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.313 Interior Finishes--Walls, Ceilings, and Floors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207288 03/12/2026 Fire alarms, detection systems, and sprinkler systems must be as required by NFPA 101, NFPA 72, and NFPA 13.(1) Components must be compatible and laboratory listed for the use intended.(2) Wiring and circuitry for alarm systems must meet the applicable requirements for NFPA standards, including NFPA 70, for these systems.(3) Fire alarm systems must be installed, maintained, and repaired by an agent having a current certificate of registration with the State Fire Marshal's Office, in accordance with state law. A fire alarm installation certificate must be provided as required by the Office of the State Fire Marshal.(4) Smoke detector sensitivity must be checked within one year after installation and every alternate year thereafter in accordance with NFPA 72. Documentation, including as-built installation drawings, operation and maintenance manuals, and a written sequence of operation for systems installed after July 1, 2000, must be available for examination by HHSC.(5) The fire alarm system must be designed so that whenever the general alarm is sounded by activation of any device (such as manual pull, smoke sensor, sprinkler, or kitchen range hood extinguisher) the following will occur automatically:(A) smoke and fire doors which are held open by an approved device must be released to close;(B) air handlers (air conditioning/heating distribution fans) serving three or more rooms or any means of egress must shut down immediately;(C) smoke dampers must close; and(D) the alarm-initiating location must be clearly indicated on the fire alarm control panel(s) and all auxiliary panels.(6) Consistent fire alarm bells or horns must be located throughout the building for audible coverage. Flashing alarm lights (visual alarms) must be installed to be visible in corridors and public areas including dining rooms and living rooms.(7) A master control panel which indicates location of alarm and trouble conditions (by zone or device) must be visible at the main nurse station. All control panels must be listed for intended use, such as manual, automatic, and water-flow activation. Alarm and trouble zoning must be by smoke compartments and by floors in multi-story facilities.(8) Remote annunciator panels, indicating location of alarm initiation by zone or device and common trouble signals, must be located at auxiliary or secondary nurses stations on each floor or major subdivision of single story facilities and indicate the alarm condition of adjacent zones and the alarm conditions at all other nurse stations.(9) Manual pull stations must be provided at all exits, living rooms, dining rooms, and at or near the nurse stations.(10) The NFPA 13 sprinkler system must be monitored for flow and tamper conditions by the fire alarm system.(11) The kitchen range hood extinguisher must be interconnected with the fire alarm system. This interconnection may be a separate zone on the panel or combined with other initiating devices located in the same zone as the range hood is located.(12) Partial sprinkler systems provided only for hazardous areas must be interconnected to the fire alarm system and comply with NFPA 101. Each partial system must have a valve with a supervisory switch to sound a supervisory signal, water-flow switch to activate the fire alarm, and an end-of-line test drain. Source Note: The provisions of this §554.314 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.314 Fire Alarms, Detection Systems, and Sprinkler Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207289 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207289 03/12/2026 Portable fire extinguishers must be provided and maintained to comply with the provisions of NFPA 10. This includes type of extinguishers (A, B, or C), location and spacing, mounting heights, monthly inspections by staff, yearly inspections by a licensed agent, any necessary servicing, and hydrostatic testing as recommended by the manufacturer.(1) Extinguishers in resident corridors must be spaced so that travel distance is not more than 75 feet. The minimum size of extinguishers must be either 2 1/2 gallon for water type or five pound for ABC type.(2) Extinguishers must be installed on supplied hangers or brackets or be mounted in cabinets approved by HHSC.(3) Extinguishers must be surface wall-mounted or recessed in cabinets where they are not subject to physical damage or dislodgement.(4) Extinguishers having a gross weight not exceeding 40 pounds must be installed so that the top of the extinguisher is not more than five feet above the floor. Extinguishers with a gross weight greater than 40 pounds must be installed so the top of the extinguisher is not more than 3-1/2 feet above the floor. The clearance between the bottom of the extinguisher and the floor must not be less than four inches.(5) Portable extinguishers provided in hazardous rooms must be located as close as possible to the exit door opening and on the latch (knob) side.(6) Staff must be appropriately trained in the use of each type of extinguisher in the facility. Source Note: The provisions of this §554.315 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.315 Portable Fire Extinguishers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207290 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207290 03/12/2026 (a) Subdivision of building spaces must be as required by NFPA 101.(b) The facility must maintain the integrity of smoke barrier walls, including those parts of walls in attics and other concealed spaces.(c) The facility must maintain the integrity of smoke dampers in air ducts.(d) Ducts with smoke dampers must have maintenance panels for inspection. The maintenance panels must be removable without tools. Means of access must also be provided in the ceiling or side wall to facilitate smoke damper inspection readily and without obstruction. Location of dampers must be identified on the wall or ceiling of the occupied area below. Source Note: The provisions of this §554.316 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.316 Subdivision of Building Spaces--Smoke Barriers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207291 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207291 03/12/2026 Elevators must comply with the provisions of NFPA 101 and ASME A17.3. Elevators are required for buildings having residents' facilities, such as bedrooms, dining, or recreation areas; or services, such as diagnostic or therapy, located on other than the main entrance floor. Passenger elevators and escalators must be inspected by a qualified agent at least every six months. Freight elevators must be inspected every 12 months. Source Note: The provisions of this §554.317 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.317 Elevators and Escalators https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203037 03/12/2026 (a) Nurses' station.(1) All resident bedroom corridors must be observable by direct line of sight or by mechanical means from a designated nurses' station or auxiliary station. There must be at least one nurses' station per floor in multi-story buildings.(2) If all resident bedroom corridors are observable by direct line of sight from inside the nurses' station or from within 24 inches of the counter or hall of the nurses' station, no auxiliary stations are required, even if resident bedrooms are more than 150 feet from the nurses' station.(3) When resident bedrooms are more than 150 feet from the nurses' station and the adjacent corridors are not observable from the station by direct line of sight, an auxiliary station must be established and used.(4) All corridors adjacent to resident bedrooms that are more than 150 feet from a designated nurses' station or auxiliary station must be observable by direct line of sight from the designated nurses' station or auxiliary station. Corridors located in the service area of an auxiliary station must be observable, as described in paragraphs (2) and (3) of this subsection, at the auxiliary station.(5) The 150-foot limitation described in paragraphs (2) - (4) of this subsection may be increased to 165 feet in facilities or additions to facilities completed before August 10, 1983.(6) In addition to the required normal and emergency illumination, the facility must keep on hand and readily available to night staff no less than one working flashlight at each nurses' station.(b) Auxiliary station. Each auxiliary station must include a work area in which nursing personnel can document and maintain resident data, even if the facility's initial decision is to maintain clinical records at the nurses' station.(1) Auxiliary stations must be staffed by nursing personnel during all shifts.(2) More than one auxiliary station may be assigned to a designated nurses' station, regardless of the distance between stations. More than one corridor may be observed by mechanical means from a designated nurses' station or auxiliary station.(3) A nurse call system for resident corridors monitored by an auxiliary station must register calls at the auxiliary station.(4) Each auxiliary station must have an emergency electrical source adequate to power lights at the station.(5) Medications and clinical records may be maintained at an auxiliary station.(6) If a required auxiliary station does not already exist and the facility must establish a new auxiliary station, all applicable standards, particularly those pertaining to the physical plant and NFPA 101, must be observed. All renovations and structural changes require prior approval from HHSC.(7) All new construction completed after August 10, 1983, must allow direct line-of-sight observation of all resident bedroom corridors from the nurses' station or auxiliary station.(c) Mechanical means for resident observation.(1) The nursing facility may use closed-circuit television or mirrors to observe residents in the facility.(2) Closed-circuit television monitoring systems must meet the following criteria:(A) The camera must be placed to view the entire corridor length, without any "blind spots."(B) The camera must be capable of providing recognizable images, in minimum and maximum light levels, for the complete viewing area.(C) The monitor must be installed and be clearly visible to persons in the nurses' station or auxiliary station who are assigned to the area monitored by the camera.(D) The system must be supplied with emergency power that enables the system to function during electrical service failures.(E) Each camera must have its own separate monitor.(F) If the system performs the minimum basic functions specified in subparagraphs (A) - (D) of this paragraph, television monitoring systems installed before March 1984 may remain in service until the equipment is replaced or the system is expanded. Replacement systems or new component equipment must satisfy subparagraphs (A) - (E) of this paragraph.(3) Mirrors must meet the following criteria:(A) The mounting height of the mirror must be no less than six feet and eight inches from the floor to the bottom of the mirror.(B) The mirror must not extend more than 3-1/2 inches from the face of the corridor wall, unless the bottom of the mirror is more than seven feet and six inches above the floor.(C) The mirror image must be clear enough that individuals can be recognized, in minimum and maximum light levels, throughout the viewing area.(4) The monitoring systems described in this section must not be used to deny privacy to staff or residents.(d) Nurse call system. Each nurses' station must be equipped to register residents' calls through a communication system from resident areas.(e) Medication storage area. A medication storage area must include a sufficient, lockable, enclosed medicine storage spaces, medicine room, or medication cart. The medication storage area must be furnished with a refrigerator. There must be sufficient space available for a medication preparation area equipped with a sink having hot and cold water. When not in use, a medication cart must be secured in a designated area. Only authorized personnel must have access to the lockable, enclosed medicine storage area, medication room, or the medication cart. Medication storage areas and preparation areas must be adequately ventilated and temperature controlled.(f) Clean utility room. A clean utility room must be provided and must contain a sink with hot and cold water. It must be part of a system for storage and distribution of clean and sterile supply materials and equipment.(g) Soiled utility room. A soiled utility room must be provided and contain a flushing fixture and a sink with hot and cold water. It must be part of a system for collection and cleaning or disposal of soiled utensils or materials.(h) Soiled linen room. A soiled linen room must be provided as needed commensurate with the type of laundry system used. In relation to adjacent areas, a negative air pressure must be provided with air exhausted through ducts to the exterior. Air must be exhausted continually whenever there are soiled linens in the room. A soiled linen room may be combined with a soiled utility room.(i) Clean linen storage. Clean linen storage must be provided, conveniently located to resident bedroom areas.(j) Kitchens.(1) Nursing facility kitchens will be evaluated on the basis of their performance in the sanitary and efficient preparation and serving of meals. Consideration will be given to planning for the type of meals served, the overall building design, the food service equipment, arrangement, and the work flow involved in the preparation and delivery of food. Evaluation will be based on the number of meals served.(2) Kitchen temperature, at peak load, must not exceed a temperature of 85 degrees Fahrenheit measured at the five foot level. The facility must provide sufficient heating to maintain an average temperature of not less than 70 degrees Fahrenheit in winter, with exhausts operating, at the five-foot level.(3) The kitchen must have operational equipment for preparing and serving meals and for refrigerating and freezing of perishable foods, as well as equipment in, or adjacent to, the kitchen or dining area for producing ice.(4) The kitchen must have facilities for washing and sanitizing dishes and cooking utensils. These facilities must be adequate for the number of meals served and the method of serving, such as use of permanent or disposable dishes. The kitchen must contain a multi-compartment sink large enough to immerse pots and pans. In all facilities, a mechanical dishwasher is required for sanitizing dishes. The facility must maintain separation of soiled and clean dish areas, including air flow and traffic flow.(5) The kitchen must have an adequate supply of hot and cold water. Hot water for sanitizing purposes must be 180 degrees Fahrenheit or the manufacturer's suggested temperature for chemical sanitizers, as specified for the system in use. For mechanical dishwashers, the temperature measurement is at the manifold. Hot water for general kitchen use must be 140 degrees Fahrenheit.(6) A kitchen must have at least one hand-washing lavatory in the food-preparation area. The dish washing area must have ready access to a hand-washing lavatory or hand sanitizing device. Hand-washing lavatories must be provided with hot and cold running water, a sanitary soap dispenser, and paper towel dispenser or hot air dryer.(7) Nonabsorbent smooth finishes or surfaces must be used on kitchen floors, walls, and ceilings. These surfaces must be capable of being routinely sanitized to maintain a healthful environment.(8) A janitor's closet with service sink must be easily and readily accessible to the kitchen.(9) The kitchen exhaust hood at cooking equipment and its attached automatic chemical extinguisher must comply with NFPA 96. HHSC may waive certain details of NFPA 96 for existing kitchen exhausts at cooking equipment provided that basic function and safety are not compromised.(k) Food storage areas.(1) Food storage areas must provide for storage of a seven-day minimum supply of nonperishable staple foods and a two-day supply of perishable foods at all times.(2) Shelves and pallets must be moveable wire, metal, or sealed lumber, and walls must be finished with a nonabsorbent finish to provide a cleanable surface.(3) Dry food storage must have a venting system to provide for reliable positive air circulation.(4) The maximum room temperature for food storage must not exceed 85 degrees Fahrenheit. The measurement must be taken at the five-foot level.(5) Foods must not be stored on the floor. Dunnage carts or pallets may be used to elevate foods not stored on shelving.(6) Sealed containers must be provided for storing dry foods after the package seal has been broken.(7) Food storage areas may be located apart from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(l) Auxiliary serving kitchens not contiguous to food preparation and serving areas.(1) When service areas other than the kitchen are used to dispense foods, the facility must designate these service areas as food service areas and must have equipment for maintaining required food temperatures while serving.(2) Separate food service areas must have hand-washing facilities as a part of the food service area.(3) Finishes of all surfaces except ceilings must be the same as those required for dietary kitchens.(m) Administrative and public areas. Facilities must have administrative areas for normal business transactions and maintenance of records.(n) Laundry.(1) Laundry facilities must be located in areas separate from resident rooms. The laundry must be designed, constructed, and equipped and appropriate procedures must be utilized to ensure that laundry is handled, cleaned, and stored in a sanitary manner.(2) Laundry for general linen and clothing must be arranged so as to separate soiled and clean operations as they relate to traffic, handling, and air currents. Suitable exhaust and ventilation must be provided to prevent air flow from soiled to clean areas.(3) Floors, walls, and ceilings must be nonabsorbing and easily cleanable.(4) Soiled linen must be stored and transported in closed or covered containers. Soiled linen storage or holding rooms must have a negative air pressure in relation to adjacent areas with air exhausted through ducts to the exterior.(5) Laundry areas must have air supply and ventilation to minimize mildew and odors. Doors must not remain open, for sanitation and safety reasons.(6) Room size, and number and type of appliances must provide efficient, sanitary, and timely laundry processing to meet the needs of the facility.(7) The laundry, if located in the facility, must meet NFPA 101 requirements for separation and construction for hazardous areas.(o) Resident-use laundry. This service, if provided, must be limited to not more than one residential type washer and dryer per laundry room. This room must be classified as a hazardous area according to NFPA 101.(p) Personal grooming area. Space and equipment must be provided for the hair care and grooming needs of the residents. Hair care and grooming service will be provided in resident bedrooms or in designated areas which are not in a way of egress.(q) Storage rooms. General and specific storage areas must be provided as needed and required for safe and efficient operation of the facility. Items must not be stored in inappropriate places such as corridors or rooms which are not equipped for special hazard protection.(r) Janitor closets. In addition to the janitors' closet called for in certain departments, other janitors' closets must be provided throughout the facility to maintain a clean and sanitary environment. All janitor closets must have a negative air pressure in relation to adjacent areas with air exhausted through ducts to the exterior.(s) Disposal facilities. A policy and procedure for the safe and sanitary disposal of special waste must be provided. Space and facilities must be provided for the sanitary storage and disposal of waste, not classified as special, by incineration, mechanical destruction, compaction, containerization, removal, or contract with outside resources, or by a combination of these techniques(t) Maintenance, engineering service, and equipment areas.(1) The facility must provide storage for building equipment, supplies, tools, parts, and yard maintenance equipment.(2) Volatile liquids and supplies must not be kept within the main building housing residents.(3) All equipment requiring periodic maintenance, testing, and servicing must be reasonably accessible. Necessary equipment to conduct these services, such as ladders, specific tools, and keys, must be readily available on site.(u) Oxygen.(1) The facility must implement procedures that ensure the safe and sanitary use and storage of oxygen. Such procedures must be in compliance with all applicable NFPA standards, including NFPA 99.(2) Oxygen cylinders and containers must be in compliance with NFPA 99. Liquid oxygen containers must be certified by UL or another approved testing laboratory for compliance with NFPA 55 requirements. The storage, handling, assembly, and testing must be in compliance with all applicable NFPA standards, including NFPA 99 and NFPA 55 requirements. The facility is responsible for defining all potential hazards both graphically and verbally to all persons involved in the use of liquid oxygen and ensuring that the liquid-oxygen provider does also. Source Note: The provisions of this §554.318 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.318 Other Rooms and Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203038 03/12/2026 New facilities and additions must meet the requirements of the Texas Department of Licensing and Regulation, Elimination of Architectural Barriers Section. Existing facilities must meet the requirements of the Americans with Disabilities Act and must, at a minimum, comply with the following:(1) The facility must provide and mark at least one parking space for persons with disabilities.(2) The facility must provide wheelchair access into the building by use of ramps and curb breaks. Ramps must not slope more than 1:12 (one unit of rise to 12 units of run).(3) Room identification signs or letters must be installed four feet six inches to five feet above finished floor and located on the corridor walls adjacent to the latch side of the door jamb. Letters or numbers on signs must be raised or recessed at least 1/32 inch minimum. Characters must be at least 5/8 inch in height and no higher than two inches.(4) Grab bars at toilet and bathing units must be 1-1/4 inch to 1-1/2 inch in diameter.(5) Toilet facilities must be available and of sufficient size to accommodate wheelchairs. There must be at least one public wheelchair-accessible restroom.(6) Water closet seat height in toilet facilities for persons with disabilities must be 17 to 19 inches from floor.(7) Mirrors and dispensers for persons with disabilities must be no higher than 40 inches above the floor.(8) Drinking fountains or coolers must meet American National Standards Institute (ANSI) A117.1 (that is, up front spout and controls no more than 36 inches from floor maximum). Fountains existing at the time of this publication do not have to be altered.(9) Public telephones, if provided, must meet ANSI A117.1. Mounting height must not exceed 48 inches to coin slot. Source Note: The provisions of this §554.319 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.319 Provisions for Persons with Disabilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203039 03/12/2026 Current recommendations of the Illumination Engineering Society of North America must be followed to achieve proper illumination characteristics and lighting levels throughout the facility. Minimum illumination must be ten foot candles in resident rooms and 20 foot candles in corridors, nurses stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways, and elevators. Illumination requirements for these areas apply to lighting throughout the space and should be measured at approximately 30 inches above the floor anywhere in the room. Minimum illumination for overbed reading lamps, medication preparation or storage areas, kitchens, and nurse's station desks must be 50 foot candles. Illumination requirements for these areas apply to the task performed and should be measured on the task. Source Note: The provisions of this §554.320 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.320 Lighting and Illumination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207292 03/12/2026 (a) The heating system must maintain a temperature of not less than 71 degrees Fahrenheit at the resident level in all resident-use areas. Auxiliary heating devices permanently installed, such as heat strips in ducts, electric ceiling-mounted heating units, and electric baseboards, may be used to augment a central heating system as approved by HHSC.(b) The cooling system must be capable of maintaining a temperature suitable for the comfort of the residents in resident-use areas to an upper limit of 81 degrees.(c) Air flow must be directed or adjusted so that a resident is not in direct drafts that could be harmful to the health and comfort of the resident.(d) Unvented heating units and portable heaters are prohibited.(e) The facility must be well ventilated through the use of windows, mechanical ventilation, or a combination of both. Rooms and areas which do not have outside windows and which are used by residents or personnel must be provided with functioning mechanical ventilation to change the air on a basis commensurate with the room usage. Air systems must provide for the induction and mixing of at least 10 percent outside fresh air into the facility unless otherwise approved by HHSC; that is, 100 percent continuous recirculation of interior air in most areas is not acceptable. When certain rooms or areas are dependent on a central air system for proper ventilation, including exhaust, that central air system fan must run continuously.(f) Operable outside windows must be provided with insect screens. Outside doors must be self-closing to control entry of insects. All exterior doors must be effectively weather stripped.(g) Heating and air conditioning systems must be provided with clean and effective air filters.(h) Ducts and piping subject to surface condensation must be insulated to prevent condensation at least in areas which may affect sanitation or cause building deterioration.(i) A comfortable temperature for residents when bathing must be provided.(j) Heating, ventilating, and air conditioning systems must comply with the provisions of applicable National Fire Prevention Association (NFPA) standards. Ducts are to be of a Class A material (noncombustible). Combustion air for gas-fired equipment must be ducted from the exterior.(k) Air flow must be designed to prevent cross contamination within any area where applicable, such as laundries and kitchens, as well as the system or facility as a whole.(l) In relation to adjacent areas, a positive air pressure must be provided for clean utility rooms, clean linen rooms, and medication rooms. Conditioned supply air must be introduced into these rooms.(m) In relation to adjacent areas, a negative air pressure must be provided for soiled utility rooms, soiled laundry rooms, bathrooms, toilets, and other odor-producing rooms. Air from these rooms must not be recirculated, but instead must be exhausted through ducts to the exterior by effective means.(n) Facility temperature must be maintained for the comfort of residents. Source Note: The provisions of this §554.321 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.321 Heating, Ventilating, and Air-conditioning Systems (HVAC) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207293 03/12/2026 (a) If the municipality has a plumbing code, that code must be used as a basis for determining the correctness of plumbing installation. In the absence of a municipal code, a nationally recognized plumbing code must be used.(b) The water supply must be of safe, sanitary quality, suitable for use, and adequate in quantity and pressure. The water must be obtained from a water supply system, the location, construction, and operation of which are approved by TCEQ.(c) Sewage must be discharged into a state-approved sewerage system or the sewage must be collected, treated, and disposed of in accordance with applicable TCEQ rules and regulations.(d) The wastewater drainage and sewage system must assure that sanitation is maintained for residents. Wastewater or sewage must not be discharged on the surface of the ground. Traps must not be allowed to lose their seal. Appliances must have air gaps as required for connections to the sewerage system. Venting must assure a rapid flow of wastewater in the sewage system.(e) The interior cold water supply system and piping must be so placed or so insulated as to prevent condensation drip in habitable areas and in storage areas.(f) Backflow preventers or vacuum breakers must be installed with any water supply fixture where the outlet or attachments may be submerged.(g) Resident-use hot water must be reliably controlled, such as by thermostatic or mixing valves, to not exceed 110 degrees Fahrenheit and not less than 100 degrees Fahrenheit at each fixture.(h) Hot water for other usages must be provided at the temperatures required for the appliance or fixture or for the operation involved, such as dishwashing and laundry.(i) The supply quantity of hot water must be adequate for normal peak load usage. Facilities which continue to experience a shortage of hot water must remedy the situation by such means as adding storage tanks, adding or increasing the size of water heaters, or other approved means.(j) Water heaters must be equipped with pressure temperature relief valves. Source Note: The provisions of this §554.322 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.322 Plumbing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203040 03/12/2026 (a) The facility must provide sufficient housekeeping and maintenance personnel, equipment, and supplies to maintain the interior, exterior, and grounds of the facility in a safe, clean, orderly, and attractive manner. In a nursing facility, an employee must be designated as responsible for housekeeping services.(b) Occupied resident rooms must be cleaned and put in order at least daily.(c) Storage areas must be kept safe and free from accumulations of extraneous materials such as refuse, discarded furniture, and newspapers. Combustibles, such as cleaning rags and compounds, must be kept in closed metal containers and labeled.(d) Attics, mechanical rooms, boiler rooms, and other similar areas must not be used for storage purposes.(e) All bleaches, detergents, disinfectants, insecticides, and other poisonous substances must be kept in a safe place accessible only to employees. They must not be kept in containers previously containing food or medicine. Containers must be labeled. Source Note: The provisions of this §554.323 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.323 Housekeeping Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203041 03/12/2026 (a) An effective, safe, and continuing pest control system against insects, rodents, and vermin must be in operation in the facility. Pest control services must be provided by nursing facility personnel or by contract with a licensed pest control company. Care must be taken to use the least toxic and least flammable effective insecticides and rodenticides. These compounds must be stored in nonfood preparation and storage areas. Poisons must be under lock.(b) The facility must protect against harborages and entrances for insects, rodents, and vermin. Outside doors must be self-closing to control entry of pests.(c) Garbage and trash must be stored in enclosed containers, protected against leakage, contact with disease carriers, and access to animals. It must be stored in areas separate from those used for the preparation and storage of food and must be removed from the premises in conformity with state and local practices. Garbage and trash containers must be maintained free of accumulations and coatings of garbage. Garbage storage areas must be kept clean and in a state of good repair. Source Note: The provisions of this §554.324 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.324 Pest Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203042 03/12/2026 (a) The nursing facility must have available at all times a quantity of linen essential for the proper care and comfort of residents. Linens must be handled, stored, and processed so as to control the spread of infection.(b) Linen will be maintained in good repair.(c) Linen must be washed, dried, stored, and transported in a manner which will produce hygienically clean linen. The washing process must have a mechanism for soil removal and bacteria kill.(d) Clean linen must be stored in a clean linen area easily accessible to the personnel.(e) Clean towels and washcloths must be provided to each resident as needed or desired. Towels and washcloths must be stored in a sanitary manner between uses by the resident and must not be used by more than one resident between launderings.(f) Soiled linen and clothing must be stored separately from clean linen and clothing. Soiled linen and clothing must be stored in well ventilated areas, and must not be permitted to accumulate in the facility. Soiled linen and clothing must be transported in accordance with procedures consistent with universal precautions. Bags or containers must not be reused to transport or store clean items.(g) Soiled linen must not be sorted, laundered, rinsed, or stored in bathrooms, resident rooms, corridors, kitchens, or food storage areas, except soiled linen and clothing which is not contaminated with blood may be rinsed in a resident's bathroom water closet.(h) Resident's personal clothing that is not soiled with body wastes may be stored in a closed container in the resident's closet. The clothing must be collected and cleaned at least weekly.(i) Facility staff must wash their hands both after handling soiled linen and before handling clean linen. Source Note: The provisions of this §554.325 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.325 Linen https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207294 03/12/2026 (a) The facility must have a program to inspect, test, and maintain the fire alarm system and must execute the program at least once every three months.(1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.(2) A person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign and date an inspection form similar to the inspection and testing form in NFPA 72 for a service provided under the contract.(3) The facility must ensure fire alarm system components that require visual inspection are visually inspected in accordance with NFPA 72.(4) The facility must ensure fire alarm system components that require testing are tested in accordance with NFPA 72.(5) The facility must ensure fire alarm system components that require maintenance are maintained in accordance with NFPA 72.(6) The facility must ensure smoke dampers are inspected and tested in accordance with NFPA 101.(7) The facility must maintain onsite documentation of compliance with this subsection.(b) A facility must have a program to inspect, test and maintain the sprinkler system and must execute the program at least once every three months.(1) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program.(2) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign and date an inspection form similar to the inspection and testing form in NFPA 25 for a service provided under the contract.(3) The facility must ensure sprinkler system components that require visual inspection are visually inspected in accordance with NFPA 13 and 25.(4) The facility must ensure sprinkler system components that require testing are tested in accordance with the NFPA 13 and 25.(5) The facility must ensure sprinkler system components that require maintenance are maintained in accordance with NFPA 13 and 25.(6) The facility must ensure that individual sprinkler heads are inspected and maintained in accordance with NFPA 13 and 25.(7) The facility must maintain onsite documentation of compliance with this subsection.(c) If facility staff verify or suspect a malfunction of the fire alarm, emergency electrical, or sprinkler system, the facility must immediately investigate and correct the condition. In addition, the facility must immediately report the failure of the fire alarm, emergency electrical, or sprinkler system to all facility staff and the local fire authority.(d) If emergency generators are required or provided, a facility must have a program to maintain, operate, and test all emergency generators, including all appurtenant components, and must execute the program at least once every week.(1) The facility must use a properly instructed person to oversee and execute the program.(2) The facility must ensure generator components are inspected, tested, and maintained in accordance with NFPA 37, 70, 99, and 110.(3) The facility must ensure all generators are operated, under load, for at least 30 minutes each week.(4) The person who executes the program must maintain a signed and dated record or log of inspections, tests and maintenance performed.(5) For each required operation of the generator under the program, the record or log must include the information necessary to verify:(A) the total time taken to transfer the load to emergency power;(B) the total time the generator operated under load;(C) the total time the facility's emergency system remained on generator power after restoration of normal utility power; and(D) the total time the generator operated without load after the facility's return to normal utility power.(6) The facility must ensure the condition and proper operation of all emergency lighting is inspected and tested at least once every week.(7) The facility must maintain onsite documentation of compliance with this subsection.(e) Duplex receptacles powered through the emergency electrical system must be installed at each resident bed location where resident-care-related electrical appliances are in use, unless a facility can demonstrate that it can provide the diagnostic, therapeutic, or monitoring benefits of the resident-care-related electrical appliances through acceptable alternative means in the event of a power outage.(f) A facility must conduct a functional test on every required battery emergency lighting system at 30-day intervals for a minimum of 30 seconds. The facility must also conduct an annual test for a minimum of 1 1/2 hours. The lighting system must be fully operational for the duration of the testing. The facility must maintain an onsite written record of all tests performed and make those records available to the authority having jurisdiction during an inspection.(g) A facility must ensure that a person licensed by the State Fire Marshal's Office inspects and services automatic fixed fire extinguishment systems mounted in kitchen range hoods at least once every six months in accordance with NFPA 96. The facility must maintain, onsite, a written and signed report of the inspection and service performed. The facility must keep the hood, exhaust ducts, and filters clean and free of accumulated grease.(h) A facility must inspect and maintain portable fire extinguishers.(1) Facility staff must visually inspect portable fire extinguishers monthly. Facility staff conducting the monthly visual inspection must ensure portable extinguishers are protected from damage, kept on their mounting brackets or in cabinets at all times, and kept in the proper condition and working order.(2) A facility must ensure that a person licensed by the State Fire Marshal's Office inspects and maintains portable fire extinguishers at least once every 12 months in accordance with NFPA 10.(3) The facility must maintain, onsite, a record of all fire extinguisher inspections and maintenance performed.(i) A facility using gas must have the gas piping lines between the meter and appliances tested for leaks annually by a person licensed by the State Board of Plumbing Examiners. The facility must maintain, onsite, a written and signed report of these tests. The facility must note and correct any unsatisfactory conditions immediately.(j) A facility must formulate, adopt, and enforce policies regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents.(1) The facility's policies must comply with all applicable federal, state, and local laws and regulations.(2) The facility is responsible for informing residents, staff, visitors, and other affected parties of smoking policies through the distribution and posting of policies.(3) A facility must prohibit smoking in any room, ward, or compartment where flammable liquids, combustible gas, or oxygen are used or stored and in any other hazardous locations. These areas must be posted with "No Smoking" signs.(4) A facility must provide ashtrays of noncombustible material and safe design in all areas where smoking is permitted.(5) A facility must provide a metal container with a self-closing cover device into which ashtrays can be emptied in all areas where smoking is permitted.(k) A facility must not allow storage of combustible products in facility rooms with gas-fired equipment.(l) A facility must not allow storage of volatile or flammable liquids or materials anywhere within the facility building.(m) A facility may install alcohol-based hand rub dispensers if the dispensers are:(1) installed in a manner that:(A) does not conflict with any state or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;(B) minimizes leaks and spills that could lead to falls;(C) adequately protects against access by vulnerable populations; and(D) complies with NFPA 101; and(2) maintained in accordance with dispenser manufacturer guidelines.(n) A facility must not store or leave unattended medical equipment, carts, wheelchairs, tables, furniture, dispensing machines, or similar physical objects in corridors or other ways of egress, except as permitted by NFPA 101.(o) A facility must keep smoke doors, fire doors, and doors to hazardous rooms in the facility closed and not prop or wedge a door open. The facility may use only approved devices to hold open a door, such as alarm-activated electromagnetic hold-open devices, as permitted by NFPA 101.(p) The facility must post building evacuation routes at prominent locations throughout the facility.(q) A facility must provide approved electrical receptacles in quantity and location for the normal use of appliances in the facility.(r) A facility must not use electrical extension cords or multi-receptacle plug-in adaptors as a substitute for approved wiring methods in the facility.(s) A facility may use a listed and approved surge-protection device for equipment for which the manufacturer recommends surge protection, but in no case may the facility use a surge-protection device to increase the number of existing electrical outlets in a room.(t) A facility must remove all abandoned utilities, such as electrical wiring, ducts, and pipes, from the facility when no longer in use. The facility may, however, leave an existing damper that is no longer required by NFPA 101 in-place and inoperable, if the damper is in a duct penetration of a smoke barrier in a fully ducted heating, ventilating, and air conditioning system; the damper is permanently secured in the open position; and quick-response sprinklers have been provided for the smoke compartments on both sides of the smoke barrier.(u) In operations where there is a chance of cross-contamination, clean and soiled operations must be separated to lessen the chance of cross-contamination by facility employees, residents, and others. This separation must be in relation to traffic flow, air currents, air exhaust, water flow, vapors, and other conditions.(v) A facility must have and implement as necessary a fire safety plan that:(1) includes the provisions described in the Operating Features section of NFPA 101, Chapter 18 New Health Care Occupancies and Chapter 19, Existing Health Care Occupancies and concerning:(A) use of alarms;(B) transmission of alarms to fire department;(C) emergency phone call to fire department;(D) response to alarms;(E) isolation of fire;(F) evacuation of immediate area;(G) evacuation of smoke compartment;(H) preparation of floors and building for evacuation; and(I) extinguishment of fire;(2) includes procedures for:(A) conducting a fire drill on each work shift at least once per quarter with at least one fire drill conducted each month; and(B) completing the most current version of the required HHSC form titled "Fire Drill Report" available on the HHSC website for each fire drill conducted.(w) Floors, walls, and ceilings.(1) Floors of the facility must be level, smooth, and free of any irregularities that might affect safety.(2) Walls and ceilings not specifically described elsewhere in this chapter must be cleanable, maintained attractively, and in good repair.(3) Walls and floors must be kept free of cracks. The joint between the walls and floors is to be maintained so as to be free of spaces that might harbor insects, rodents, or vermin.(x) All gas heating systems must be checked annually for proper operation and safety by persons who are licensed or approved by the State of Texas to inspect such equipment. A record of this service must be maintained by the facility. Any unsatisfactory condition must be corrected promptly.(y) A facility must have an annual inspection by the local fire marshal and maintain documentation of such an inspection at the facility. Source Note: The provisions of this §554.326 adopted to be effective August 1, 2011, 36 TexReg 4668; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.326 Safety Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207295 03/12/2026 (a) Construction phase.(1) Prior to the start of construction of a new facility or of building rehabilitation other than that classified as repair in §554.350 of this subchapter (relating to Building Rehabilitation), a facility must notify HHSC in Austin, Texas, in writing.(2) All construction must be done according to the minimum licensing requirements in this subchapter. It is a facility's responsibility to employ qualified personnel to prepare the contract documents for construction of a new facility or rehabilitation of an existing facility. Contract documents for additions and rehabilitation other than that classified as repair or renovation in §554.350 of this subchapter and for the construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect. Certain parts of contract documents, including final plans, designs, and specifications, must bear the seal of a licensed professional engineer approved by the Texas Board of Professional Engineers to operate in Texas or, as permitted by subsections (b)(12) and (15) of this section, signed by a Responsible Managing Employee or Alarm Planning Superintendent licensed by the State Fire Marshal's Office. These certain parts include sheets and sections covering structural, electrical, mechanical, sanitary, and civil engineering.(b) Contract documents.(1) Site plan documents must include grade contours; streets, with names; a north arrow; fire hydrant locations; fire lanes; utilities, public or private; fences; unusual site conditions, such as ditches, low water levels, and other buildings on-site; and indications of buildings located five feet or less beyond site property lines. Site plan documents for nursing facilities may include the developed landscaping plan for resident use.(2) Foundation plan documents must include the general foundation design and details.(3) Floor plan documents must include room names, numbers, and usages; resident care areas; numbered doors, including swing; windows; a legend or clarification of wall types; dimensions; fixed equipment; plumbing fixtures; kitchen basic layout; and identification of all smoke barrier walls and fire walls, outside wall to outside wall.(4) For new construction, additions to or rehabilitation of an existing building, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2-inch by 11-inch sheet.(5) Schedules must include door materials, sizes, and types; window materials, sizes, and types; room finishes; and special hardware.(6) Elevations must include exterior elevations with material note indications, and interior elevations, where needed for special conditions.(7) Roof plans must include any roof top equipment, roof slopes, drain locations, and gas piping.(8) Details must include wall sections as needed, especially for special conditions; cabinets and built-in work, basic design only; cross sections through buildings as needed; and miscellaneous details and enlargements as needed.(9) Building structure documents must include structural framing layout and details, primarily for columns, beams, joists, and structural frames; roof framing layout, when this cannot be adequately shown on cross section; cross sections in quantity and detail to show sufficient structural design; and structural details as necessary to ensure adequate structural design.(10) Electrical documents must include electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices; service, circuiting, distribution, and panel diagrams; exit signs and emergency egress lighting; emergency electrical provisions, such as generators and panelboards; fire alarms and similar systems, such as control panels, devices, and alarms; staff communication systems, including a nurse call system; and sizes and details sufficient to ensure safe and properly operating systems.(11) Plumbing documents must include plumbing layout with pipe sizes and details sufficient to ensure safe and properly operating systems, water systems, sanitary systems, gas systems, other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(12) Heating, ventilation, and air-conditioning (HVAC) documents must include sufficient details of HVAC systems and components to ensure a safe and properly operating installation including, heating, ventilating, and air-conditioning layout; ducts; protection of duct inlets and outlets; combustion air; piping; exhausts; duct smoke detectors; fire dampers; and equipment types, sizes, and locations.(13) Fire sprinkler system plans and hydraulic calculations must be designed in accordance with the applicable sections of NFPA 13, and signed by a Responsible Managing Employee, licensed by the State Fire Marshal's Office, or sealed by a licensed professional engineer.(14) Other layouts, plans, or details that are necessary to convey a clear understanding of the design and scope of the project, including plans covering private water or sewer systems, which must be reviewed by the local health or wastewater authority having jurisdiction.(15) Specifications must include installation techniques, quality standards, manufacturers, references to specific codes and standards, design criteria, special equipment, hardware, finishes, and any other information needed to amplify drawings and notes.(16) Fire detection and alarm system working plans must be designed according to the applicable sections of NFPA 72 and NFPA 70 and signed by an Alarm Planning Superintendent licensed by the State Fire Marshal's Office, or sealed by a licensed professional engineer.(c) Initial survey of completed construction.(1) Upon completion of construction of a new facility, or building rehabilitation other than that classified as repair or renovation in §554.350 of this subchapter, a final construction inspection of the facility, including grounds, basic equipment and furnishings, must be performed by HHSC prior to occupancy. The completed construction must have the written approval of the local authorities having jurisdiction, including the fire marshal and building official. When construction or building rehabilitation does not alter the licensed capacity of a facility, based on submitted documentation and the scope of the performed building rehabilitation, HHSC may permit a facility to use the rehabilitated portion of a facility pending a final construction inspection or may determine a final construction inspection is not required.(2) An applicant may obtain the inspection described in paragraph (1) of this subsection on an expedited basis. An applicant may obtain a Life Safety Code inspection within 15 business days after HHSC receives a written request if the applicant submits:(A) a complete application as required in §554.201(b) of this chapter (relating to Criteria for Licensing) and §554.204 of this chapter (relating to Application Requirements); and(B) the appropriate Life Safety Code fee listed in §554.220 of this chapter (relating to Expedited Life Safety Code and Physical Plant Inspection Fees).(3) After the completed construction is surveyed and found acceptable by HHSC, this information is conveyed to the licensing officer as part of the information needed to issue a license to the facility. Additions to or rehabilitation of existing facilities may require a revision or modification to an existing license. The building, including basic furnishings and operational needs, grades, drives, parking, and grounds must be 100 percent complete at the time of this initial survey visit for HHSC to approve occupancy and licensing. A facility may accept up to three residents between the time it receives initial approval from HHSC and the time the license is issued.(4) A copy of the following documents must be provided to HHSC at the time of the survey of the completed building. HHSC may request some or all of these documents prior to scheduling the initial survey:(A) written approval of local authorities as called for in paragraph (1) of this subsection;(B) record drawings of the fire detection and alarm system as installed, signed by an Alarm Planning Superintendent licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer, including a sequence of operation, the owner's manuals and the manufacturer's published instructions covering all system equipment, a signed copy of the State Fire Marshal's Office Fire Alarm Installation Certificate, and, for software-based systems, a record copy of the site-specific software, excluding the system executive software or external programmer software, in a non-volatile, non-erasable, non-rewritable memory;(C) documentation of materials used in the building that are required to have a specific limited fire resistance or flame spread rating, including special wall finishes or floor coverings; flame retardant curtains, including cubicle curtains; and fire resistance-rated ceilings. This documentation must include a signed letter from the installer verifying the material installed, such as carpeting, is the same material named in the documented fire test;(D) record drawings of the fire sprinkler system as installed, signed by a Responsible Managing Employee licensed by the State Fire Marshal's Office, or sealed by a licensed professional engineer, including the hydraulic calculations, alarm configuration, Contractor's Material and Test Certificates for Aboveground and Underground Piping, and all literature and instructions provided by the manufacturer describing the proper operation and maintenance of all equipment and devices in accordance with NFPA 25;(E) service contracts for maintenance and testing of systems, including alarm systems and sprinkler systems;(F) a copy of gas pressure test results of all facility gas lines from the meter to gas-fired equipment and appliances;(G) a written statement from an architect or engineer certifying the building was constructed to meet NFPA 101 all locally applicable codes, and that the facility substantially conforms to the minimum licensing requirements;(H) the contract documents specified in subsection (b) of this section; and(I) copies of reduced size floor plans on 8 1/2 by 11 inch sheets for record and file use by HHSC and for the facility to use in evacuation planning and fire alarm zone identification containing basic legible information such as overall dimensions, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information.(d) Non-approval of new construction.(1) If, during the survey of completed construction, the surveyor finds basic requirements not met, HHSC will not license the facility or approve it for occupancy. Such basic items may include the following:(A) construction that does not meet minimum code or licensure standards for basic requirements such as corridor widths that are less than eight feet clear width, ceilings installed at less than the minimum seven feet six inches height above the floor, resident bedroom dimensions less than the required minimum dimensions, and other similar features that would disrupt or otherwise adversely affect the residents and staff if corrected after occupancy;(B) absence of written approval by local authorities;(C) fire protection systems that are not completely installed or not functioning properly, including fire alarm systems, emergency power and lighting, and sprinkler systems;(D) required exits that are not usable according to NFPA 101 requirements;(E) telephones that are not installed or not working properly;(F) sufficient basic furnishings, essential appliances and equipment that are not installed or are not functioning; and(G) any other basic operational or safety feature that the surveyor, as the authority having jurisdiction, encounters that in his judgment would preclude safe and normal occupancy by residents on that day.(2) If the surveyor encounters deficiencies that do not affect the health and safety of the residents, licensure may be recommended based on an approved written plan of correction by the facility's administrator. Source Note: The provisions of this §554.330 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective June 1, 2010, 35 TexReg 4465; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.330 Construction Procedures and Initial Survey of Completed Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203045 03/12/2026 (a) This section applies to a facility constructed or licensed on or after September 11, 2003, but before April 2, 2018. The requirements of NFPA 101 and other applicable NFPA codes and standards referenced in NFPA 101 will apply unless otherwise noted or modified in this section:(1) Buildings that were constructed or that received design approval or building permits before July 5, 2016, must comply with the Existing Health Care Occupancies chapter of NFPA 101. All other buildings covered by this section must comply with the New Health Care Occupancies chapter of NFPA 101.(2) In addition to NFPA 101 and the standards referenced therein, a facility covered by this division is subject to the codes, standards, and requirements established by the following: UL; ASHRAE; and ASTM.(b) All applicable local, state, or national codes and ordinances must be met as determined by the authority having jurisdiction for those codes and ordinances and by HHSC. Any conflicts must be made known to HHSC for appropriate resolution.(c) The design of structural systems must be done by or under the direction of a professional engineer who is currently licensed by the Texas Board of Professional Engineers.(d) Nothing in this division may be construed as prohibiting a better type of building or construction, more space, services, features, or greater degree of safety than the minimum requirements. Source Note: The provisions of this §554.331 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.331 Construction Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207297 03/12/2026 (a) Any conditions considered to be a fire, safety, or health hazard will be grounds for disapproval of a site by HHSC.(b) Site grades must provide for positive surface water drainage so that there will be no ponding or standing water on the designated site. This does not apply to local government requirements for engineered controlled run-off holding ponds.(c) Exit doors from the building must not open directly onto a drive for vehicular traffic, but must be set back at least six feet from the edge of the drive, measured from the end of the building wall in the case of a recessed door, to prevent accidents due to lack of visual warning.(d) Walks must be provided as required from all exits and must be of non-slip surfaces free of hazards. Walks must be at least 48 inches wide except as otherwise approved. Ramps should be used in lieu of steps where possible for individuals with a disability and to facilitate bed or wheelchair removal in an emergency.(e) Outdoor activity, recreational, and sitting spaces must be provided and appropriately designed, landscaped, and equipped. Some shaded or covered outside areas are needed. These areas must be designed to accommodate residents in wheelchairs.(f) Each facility must have parking space to satisfy the needs of residents, employees, staff, and visitors. In the absence of a formal parking study, each facility must provide for a ratio of at least one parking space for every four beds in the facility. This ratio may be reduced slightly in areas convenient to public parking facilities. Space must be provided for emergency and delivery vehicles. No parking space may block or inhibit egress from the outside exit doors. Parking spaces and drives must be at least ten feet away from windows in bedrooms, dining, and living areas.(g) Barriers must be provided for resident safety from traffic or other site hazards by the use of appropriate methods such as fences, hedges, retaining walls, railings, or other landscaping. These barriers must not inhibit the free emergency egress to a safe distance away from the building.(h) Auxiliary buildings located within 20 feet of the main building must meet the applicable NFPA 101 requirements for separation and construction.(i) Other buildings on the site must meet the appropriate occupancy section or separation requirements of NFPA 101.(j) Fire service and access must be as follows:(1) The facility must be served by a paid or volunteer fire department. The fire department must provide written assurance to HHSC that the fire department can respond to an emergency at the facility within an appropriately prompt time for the travel conditions involved.(2) The facility must be served by an adequate water supply that is satisfactory and accessible for fire department use as determined by the fire department serving the facility and by HHSC.(3) There must be at least one readily accessible fire hydrant located within 300 feet of the building. The hydrant must be on a minimum six inch service line, or else there must be an approved equivalent, such as a storage tank. The hydrant, its location, and service line, or equivalent must be as approved by the local fire department and HHSC.(4) The building must have suitable all-weather fire lanes for access as required by local fire authorities and HHSC. As a minimum, there must be access to two sides of the building by an all-weather lane.(k) Enclosed exterior spaces, such as fenced areas, that are in a means of egress to a public way must meet the requirements of §554.2208(a)(6) of this chapter (relating to Standards for Certified Alzheimer's Facilities). Source Note: The provisions of this §554.332 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.332 Location and Site https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203047 03/12/2026 (a) Services. Nursing facilities must either contain the elements described in this section or the facility must indicate the manner in which the needed services are to be made available. Appropriate modifications or deletions in space requirements may be made when services are shared or purchased.(b) Sizes. The sizes of the various departments will depend upon program requirements and organization of services within the facility. Some functions requiring separate spaces or rooms in these minimum requirements may be combined provided that the resulting plan will not compromise the best standards of safety and of medical and nursing practices.(c) Shared or combined services. Nursing facilities may be operated together with hospitals and may share administration, food service, recreation, janitor service, and physical therapy facilities, but must have clearly identifiable physical separations such as a separate wing or floor. Nursing facilities with different levels of care will require identifiable physical separations. Combined attendant or nurses' stations and medication room areas will require some separating construction features.(d) Exterior finishes. Unless otherwise approved by HHSC, the exterior finish material of buildings classified as fire resistive or protected noncombustible construction, per NFPA 220, must have a flame spread index no greater than 25 and a smoke developed index no greater than 450, when tested in accordance with ASTM E84 or UL 723. All other exterior materials must have a flame spread index no greater than 75 and a smoke developed index no greater than 450. Items of trim may be of combustible material subject to approval by HHSC. Roof covering assemblies must have a Class A or Class B rating, when tested in accordance with ASTM E108 or UL 790.(e) Accessibility for individuals with disabilities. The facility must comply with accessibility requirements for individuals with disabilities in the revised regulations for Title II and III of the Americans with Disabilities Act at CFR Part 35 and Part 36, also known as the 2010 ADA Standards for Accessible Design and the TAS adopted by the Texas Department of Licensing and Regulation (TDLR) rules at 16 TAC Chapter 68. A facility must register plans for new construction, substantial renovations, modifications, and alterations with TDLR, Attn: Elimination of Architectural Barriers Program, and comply with TAS. Source Note: The provisions of this §554.333 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.333 General Considerations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203048 03/12/2026 (a) Resident bedrooms. Each resident bedroom must meet the following requirements:(1) The maximum room capacity must be four residents.(2) No more than 25% of the total licensed beds may be in bedrooms with more than two beds each.(3) Minimum bedroom area, excluding toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules, must be 100 square feet in single occupancy rooms and 80 square feet per bed in multi-bed rooms.(4) The minimum allowable room dimension is ten feet. The room must be designed to provide at least 36 inches between beds and 24 inches between any bed and the adjacent wall.(5) Each room must have at least one operable outside window arranged and located so that it can be easily opened from the inside without the use of tools or keys. The maximum allowable sill height must not exceed 36 inches above the floor. All operable windows must have insect screens. The minimum area of a window in each bedroom must equal at least 16 square feet or 8.0% of the room area, whichever is larger. Operable window sections may be restricted to not more than six nor less than four inches for security or safety reasons.(6) Each room must have general lighting, wall-mounted bed reading lights, and night lighting. The night light must be switched just inside the entrance to each resident room with a silent type switch unless otherwise approved by HHSC. The light providing general illumination must be switchable at the door of the resident room for use of staff and residents. A durable non-glare reading light with an opaque front panel securely anchored to the wall, integrally wired, must be provided for each resident bed. The switch must be within reach of a resident in the bed.(7) Two duplex or a fourplex grounding type receptacles must be provided beside the head of each bed. Other walls must have duplex receptacles to accommodate items such as TV, radio, razors, hairdryers, clocks, and as required by NFPA 70.(8) Each resident must have access to a toilet room without entering the general corridor area. One toilet room must serve no more than two resident rooms. The toilet room must contain a water closet and a lavatory. The lavatory may be omitted from a toilet room which serves two bedrooms if each resident room contains a lavatory. (9) Each resident must have a bed with a comfortable mattress, a bedside stand with at least two enclosed storage spaces, a dresser, and closet or wardrobe space providing privacy for clothing and personal belongings. Clothes storage space must provide at least 22 inches of lineal hanging space per bed and have closable doors. Chairs and space must be provided for use by residents and visitors.(10) Each room must open onto an exit corridor and must be arranged for convenient resident access to dining, living, and bathing areas.(11) Visual privacy such as cubicle curtains must be available for each resident in multi-bed rooms. Design for privacy must not restrict resident access to entry, lavatory, or toilet, nor may it restrict bed evacuation or obstruct sprinkler flow coverage.(12) At least one noncombustible wastebasket must be provided in each bedroom.(13) See the requirements in §19.341(d)(4) of this subchapter (relating to Electrical Requirements) for nurse call systems.(14) Bedrooms must be identified with a raised or recessed unique number placed on or near the door. Refer to §19.333(g) of this subchapter (relating to General Considerations).(15) Locks on bedroom doors are permitted when they meet definite resident needs. (A) Situations in which locking may be necessary include the following:(i) married couples whose rights of privacy could be infringed upon unless bedroom door locks are permitted; and(ii) residents for whom the attending physician wants bedroom door locks to enhance the residents' sense of security. (B) In situations such as those listed in subparagraph (A) of this paragraph, the following guidelines must be met:(i) bedroom door locks must be of the type which the occupant can unlock at will from inside the room;(ii) all bedroom door locks must be of the type which can be unlocked from the corridor side;(iii) attendants must carry keys which will permit ready access to the locked bedrooms when entrance becomes necessary; and(iv) locking of bedroom doors by residents for privacy or security will not be permitted except when specifically included in the attending physician's written orders or authorized by the nursing facility administrator. (16) Vacant bedrooms must not be used for hazardous activities or hazardous storage, unless specifically approved by HHSC in writing. (b) Nursing service areas. The service areas described in this subsection must be located in or readily available to each nursing unit. The size and disposition of each service area will depend upon the number and types of beds to be served. Each service area may be arranged and located to serve more than one nursing unit, but at least one service area must be provided on each nursing floor. The maximum allowable distance from a resident room door to a nurses' station is 150 feet. The following requirements are applicable to services areas:(1) Nurses' stations must be provided with space for nurses' charting, doctors' charting, and storage for administrative supplies. Nurses' stations must be located to provide a direct view of resident corridors. A direct view of resident corridors is acceptable if a person can see down the corridors from a point within 24 inches of the outside of the nurses' station counter or wall. When a nurses' station does not provide a direct view of resident corridors, an auxiliary station complying with the following guidelines must be provided.(A) The auxiliary station must be staffed by nursing personnel during all shifts.(i) More than one auxiliary station may be assigned to a designated nurses' station, regardless of the distance between stations. (ii) The nurse call system for resident corridors monitored by the auxiliary station must report to the auxiliary station.(iii) Each auxiliary station must meet the emergency electrical requirements for a nurses' station, including electrical receptacles and emergency lighting.(iv) If a required auxiliary station does not already exist and the facility must establish a new auxiliary station, all applicable standards, particularly those pertaining to the physical plant and NFPA 101, must be observed.(B) In addition to the required normal and emergency illumination, the facility must keep on hand and readily available to night staff no less than one working flashlight at each nurses' station.(2) Lounge and toilet room must be provided for nursing staff.(3) Lockers or security compartments must be provided for the safekeeping of personal effects of staff. These must be located convenient to the duty station of personnel or in a central location.(4) Clean utility room must contain a work counter, sink with high-neck faucet with lever controls, and storage facilities and must be part of a system for storage and distribution of clean and sterile supply materials.(5) Soiled utility room must contain a water closet or equivalent flushing rim fixture, a sink large enough to submerge a bedpan with spray hose and high-neck faucet with lever controls, work counter, waste receptacle, and linen receptacle. These utility rooms must be part of a system for collection and cleaning or disposal of soiled utensils or materials. A separate hand-wash sink must be provided if the bedpan disinfecting sink cannot normally be used for hand-washing.(6) Provision must be made for convenient and prompt 24-hour distribution of medication to residents. The medication preparation room must be under the nursing staff's visual control and contain a work counter, refrigerator, sink with hot and cold water, and locked storage for biologicals and drugs and must have a minimum area of 50 square feet. The minimum dimension allowed is five feet six inches. An appropriate air supply must be provided to maintain adequate temperature and ventilation for safe storage of medications. For purposes of storage of unrefrigerated medications, the room temperature must be maintained between 59 degrees and 86 degrees Fahrenheit.(7) Provision must be made for separate closets or room for clean linens. Corridors must not be used for folding or cart storage. Storage rooms must be located and distributed in the building for efficient access to bedrooms.(8) Soiled linen rooms must be provided as required in subsection (l) of this section.(9) Nourishment stations are usually required in all but the smaller facilities and must contain a sink equipped for hand-washing, equipment for serving nourishment between scheduled meals, refrigerator, and storage cabinets. Ice for residents' service and treatment must be provided only by icemaker units. This station may be furnished in a clean utility room.(10) An equipment storage room must be provided for equipment such as intravenous stands, inhalators, air mattresses, and walkers.(11) Parking spaces for stretchers and wheelchairs must be located out of the path of normal traffic.(c) Residents' bathing and toilet facilities. The following requirements are applicable to bathing and toilet facilities:(1) Bathtubs or showers must be provided at the rate of one for each 20 beds which are not otherwise served by bathing facilities within residents' rooms. At least one bathing unit must be provided in each nursing unit. Each tub or shower must be in an individual room or enclosure which provides space for the private use of the bathing fixture, for drying and dressing, and for a wheelchair and an attendant. Each general-use bathing room must be provided with at least one water closet, in a stall, room, or area for privacy, and one lavatory. A bathing room must be located conveniently to the bedroom area it serves and must not be more than 100 feet from the farthest bedroom. See requirements in subsection (a)(8) of this section for resident toilets at bedrooms.(2) At least 50% of bathrooms and toilet rooms, fixtures, and accessories must be designed and provided to meet criteria under the Americans with Disabilities Act for individuals with disabilities unless otherwise approved by HHSC.(3) All rooms containing bathtubs, sitz baths, showers, and water closets, subject to occupancy by residents, must be equipped with swinging doors and hardware which will permit access from the outside in any emergency.(4) Bathing areas must be provided with safe and effective auxiliary or supplementary heating. Bathing areas must be free of drafts and must have adequate exhaust ducted to the outside to minimize excess moisture retention and resulting mold and mildew problems.(5) Tubs and showers must be provided with slip-proof bottoms.(6) Lavatories and hand-washing facilities must be securely anchored to withstand an applied downward load of not less than 250 pounds on the front of the fixtures.(7) Provision must be made for sanitary hand drying and toothbrush storage at lavatories. There must be paper towel dispensers or separate towel racks and separate toothbrush holders.(8) Mirrors must be arranged for convenient use by residents in wheelchairs as well as by residents in a standing position, and the minimum size must be 15 inches in width by 30 inches in height, or tilt type.(9) Rooms with toilets must be provided with effective forced air exhaust ducted to the exterior to help remove odors. Ducted manifold systems are recommended for some multiple-type installations.(10) Floors, walls, and ceilings must have nonabsorbent surfaces, be smooth, and easily cleanable.(d) Disposal facilities. A policy and procedure for the safe and sanitary disposal of special waste must be provided. Space and facilities must be provided for the sanitary storage of waste by incineration, mechanical destruction, compaction, containerization, removal, or by a combination of these techniques.(e) Resident living areas. The following requirements are applicable to resident living areas:(1) Social-diversional spaces such as living rooms, dayrooms, lounges, sunrooms, must be provided on a sliding scale as follows:Attached Graphic(2) Where a required way of exit or a service way is through a living or dining area, a pathway equal to the corridor width will normally be deducted for calculation purposes and discounted from that area. These exit pathways must be kept clear of obstructions.(3) Each resident living room and dining room must have at least one outside window. The window area must be equal to at least 8.0% of the total room floor area. Sky-lighting may be used to fulfill one-half of the 8.0% minimum area.(4) Open or enclosed seating space must be provided within view of the main nurse station that will allow furniture or wheelchair parking that does not obstruct the corridor way of egress.(f) Dining space. Dining space must be adequate for the number of residents served, but not less than ten square feet per resident bed.(g) Dietary facilities. The following requirements are applicable to dietary facilities:(1) Main or dietary kitchens must be as follows:(A) Kitchens will be evaluated on the basis of their performance in the sanitary and efficient preparation and serving of meals to residents. Consideration will be given to planning for the type of meals served, the overall building design, the food service equipment, arrangement, and the work flow involved in the preparation and delivery of food. Plans must include a large-scale detailed kitchen layout designed by a registered or licensed dietitian or architect having knowledge in the design of food service operations.(B) Kitchens must be designed so that room temperature at summertime peak load will not exceed a temperature of 85 degrees Fahrenheit measured over the room at the five-foot level. The amount of supply air must take into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(C) Operational equipment must be provided as planned and scheduled by the facility consultants for preparing and serving meals and for refrigerating and freezing of perishable foods, as well as equipment in, or adjacent to, the kitchen or dining area for producing ice.(D) Facilities for washing and sanitizing dishes and cooking utensils must be provided. These facilities must be designed based on the number of meals served and the method of serving, that is, use of permanent or disposable dishes. As a minimum, the kitchen must contain a multi-compartment sink large enough to immerse pots and pans. In all facilities, a mechanical dishwasher is required for washing and sanitizing dishes. Separation of soiled and clean dish areas must be maintained, including air flow.(E) A vegetable preparation sink must be provided, and it must be separate from the pot sinks.(F) A supply of hot and cold water must be provided. Hot water for sanitizing purposes must be 180 degrees Fahrenheit or the manufacturer's suggested temperature for chemical sanitizers. For mechanical dishwashers the temperature measurement is at the manifold. (G) A kitchen must be provided with a hand-washing lavatory in the food preparation area with hot and cold water, soap, paper towel dispenser, and waste receptacle. The dish room area must have ready access to a hand-washing lavatory.(H) Staff rest room facilities with lavatory must be directly accessible to kitchen staff without traversing resident use areas. The rest room door must not open directly into the kitchen, that is, provide a vestibule. (I) Janitorial facilities must be provided exclusively for the kitchen and must be located in the kitchen area.(J) Nonabsorbent smooth finishes or surfaces must be used on kitchen floors, walls, and ceilings. These surfaces must be capable of being routinely cleaned and sanitized to maintain a healthful environment. Counter and cabinet surfaces, inside and outside, must also have smooth, cleanable, relatively nonporous finishes.(K) Operable windows must have insect screens provided.(L) Doors between kitchen and dining or serving areas must have a safety glass view panel.(M) A garbage can or cart washing area with drain and hot water must be provided.(N) Floor drains must be provided in the kitchen and dishwashing areas.(O) Vapor removal from cooking equipment must be designed and installed in accordance with NFPA 96.(P) Grease traps must be provided in compliance with local plumbing code or other nationally recognized plumbing code.(2) Food storage areas must be as follows:(A) Food storage areas must provide for storage of a seven-day minimum supply of nonperishable foods at all times.(B) Shelves must be adjustable wire type. Walls and floors must have a nonabsorbent finish to provide a cleanable surface. No foods may be stored on the floor; dollies, racks, or pallets may be used to elevate foods not stored on shelving.(C) Dry foods storage must have an effective venting system to provide for positive air circulation.(D) The maximum room temperature for food storage must not exceed 85 degrees F at any time. The measurement must be taken at the highest food storage level but not less than five feet from the floor.(E) Food storage areas may be located apart from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(3) Auxiliary serving kitchens not contiguous to food preparation or serving area must be as follows:(A) Where service areas other than the kitchen are used to dispense foods, these must be designated as food service areas and must have equipment for maintaining required food temperatures while serving.(B) Separate food service areas must have hand-washing facilities as a part of the food service area.(C) Finishes of all surfaces, except ceilings, must be the same as those required for dietary kitchens or comparable areas. See paragraph (1)(J) of this subsection.(h) Administrative and public areas.(1) The following elements must be provided in the public area:(A) The entrance must be at grade level, sheltered from the weather, and able to accommodate wheelchairs. A drive-under canopy must be provided for the protection of residents or visitors entering or leaving a vehicle. The latter may be a secondary entrance.(B) The lobby must include:(i) storage space for wheelchairs if more than one is kept available;(ii) a reception or information area, which may be adjacent to the lobby if location is obvious;(iii) waiting space;(iv) public toilet facilities for individuals with disabilities, which may be adjacent to lobby;(v) at least one public access telephone, installed to meet standards under the Americans with Disabilities Act; and(vi) drinking fountains. These may be provided in a common public area and at least one must be installed to meet standards under the Americans with Disabilities Act; and(C) A lobby may also be use-designed to satisfy a portion of the minimum area required for resident living room space.(2) The following must be provided in the administrative area:(A) General or individual offices for business transactions, medical and financial records, administrative and professional staff, and for private interviews relating to social service, credit, and admissions.(B) A multipurpose room for conferences, meetings, and health education purposes including facilities for showing visual aids.(C) Storage and work area for office equipment and supplies must be provided and accessible to the staff using such items.(3) Toilet facilities for the disabled must be available in the building.(i) Physical therapy facilities.(1) Physical therapy facilities must be provided if required by the treatment program. The facilities stated in subparagraph (B) of this paragraph and paragraph (2)(C) - (E) of this subsection may be planned and arranged for shared use by occupational therapy residents and staff if the treatment program reflects this sharing concept. Physical therapy facilities must include the following:(A) Provision for privacy at each individual treatment area. (B) Hand-washing facilities and one lavatory or sink may serve more than one cubicle. (C) Facilities for the collection of soiled linen and other material that may be used in the therapy.(D) Residents' dressing areas, showers, lockers, and toilet rooms, if the therapy is such that these would be needed at the area.(2) Physical therapy facilities may also include the following:(A) treatment areas with space and equipment for the therapies provided;(B) an exercise area;(C) storage for clean linen, supplies, and equipment used in therapy;(D) service sink located near therapy area; and(E) wheelchair and stretcher storage.(j) Occupational therapy. Occupational therapy facilities must be provided if required by the treatment program.(1) An activities area with a sink or lavatory and facilities for collection of waste products prior to disposal must be provided.(2) Storage for supplies and equipment used in the therapy must be provided.(k) Personal grooming area, such as a barber or beauty shop. A separate room with appropriate equipment must be provided for hair care and grooming needs of residents in facilities with over 60 beds.(l) Laundry and linen services.(1) On-site processing must be as follows:(A) Because of the high incidence of fires in laundries, it is highly recommended that the laundry be in a separate building 20 feet or more from the main building. If the laundry is located within the main building it must be separated by minimum one-hour fire construction to structure above, and sprinklered, and must be located in a remote area away from resident sleeping areas. Access doors must be from an interior nonresident use area, such as a service corridor, that is separated from the resident area, or from the exterior. (B) If linen is to be processed on the site, the following must be provided:(i) A soiled linen receiving, holding, and sorting room with a rinse sink. This area must have a floor drain and forced exhaust to the exterior which must operate at all times there is soiled linen being held in the area.(ii) A laundry processing room with equipment which can process seven days needs within a regularly scheduled work week. Hand-washing facilities must be provided. The washer area must have:(I) a floor drain;(II) storage for laundry supplies;(III) a clean linen inspection and mending room or area and a folding area;(IV) a clean linen storage, issuing, or holding room or area;(V) a janitors' closet containing a floor receptor or service sink and storage space for housekeeping equipment and supplies; and(VI) sanitizing and washing facilities and a storage area for carts.(C) Soiled and clean operations must be planned to maintain sanitary flow of functions as well as air flow. If carts containing soiled linens from resident rooms are not taken directly to the laundry area, intermediate holding rooms must be provided and located convenient to resident bedroom areas.(D) Laundry areas must have adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire wall separation.(E) Provisions must be made to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) For off-site linen processing, the following must be provided on the premises:(A) a soiled linen holding room provided with adequate forced exhaust ducted to the exterior;(B) clean linen receiving, holding, inspection, sorting or folding, and storage rooms; and(C) sanitizing facilities and storage area for carts.(3) Resident-use laundry, if provided, must be limited to not more than one residential type washer and dryer per laundry room. This room must be classified as a hazardous area according to NFPA 101.(m) General storage. The following requirements are applicable to general storage facilities:(1) A general storage room must be provided as needed to accommodate the facility's needs. It is recommended that a general storage area provide at least two square feet per resident bed. This area would be for items such as extra beds, mattresses, appliances, and other furnishing and supplies.(2) Storage space with provisions for locking and security control should be provided for residents' personal effects which are not kept in their rooms.(n) Janitors' closet. In addition to the janitors' closet called for in certain departments, a sufficient number of janitors' closets must be provided throughout the facility to maintain a clean and sanitary environment. These must contain a floor receptor or service sink and storage space for housekeeping equipment and supplies. (o) Maintenance, engineering service, and equipment areas. Space and facilities for adequate preventive maintenance and repair service must be provided. The following spaces are needed and it is suggested that these be part of a separate laundry building or area:(1) A storage area for building and equipment maintenance supplies, tools, and parts must be provided.(2) A space for storage of yard maintenance equipment and supplies, including flammable liquids bulk storage, must be provided separate from the resident-occupied facility.(3) A maintenance and repair workshop of at least 120 square feet and equipment to support usual functions is recommended.(4) A suitable office or desk space for the maintenance staff is recommended, possibly located within the repair shop area, with space for catalogs, files, and records.(p) Oxygen. The storage and use of oxygen and equipment must meet applicable NFPA standards for oxygen, including NFPA 99. Source Note: The provisions of this §554.334 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective May 1, 2004, 29 TexReg 3235; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.334 Architectural Space Planning and Utilization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203049 03/12/2026 Exit provisions, including doors, corridors, stairways, and other exit-ways, locks, and other applicable items must conform to the requirements of NFPA 101 concerning means of egress and of this section in order to ensure that residents can be rapidly and easily evacuated from the building at all times, or from one part of the building to a safe area of refuge in another part of the building. Exit provisions are as follows:(1) Bedroom space arrangement and doors and corridors must be designed for evacuation of bedfast residents by means of rolling the bed to a safe place in the building or to the outside.(2) Public assembly, common living rooms, dining rooms, and other rooms with a capacity of 50 or more persons or greater than 1,000 square feet must have two means of exit remote from each other. Out-swinging doors with panic hardware must be provided for these exits.(3) Exit doors and ways of egress must be maintained clear and free for use at all times, except as permitted by NPFA 101. Furnishings, equipment, carts, and other obstacles must not be left to block egress at any time.(4) Steps in interior ways of egress are prohibited. If changes of elevation are necessary within ways of egress, approved ramps with maximum slope of one unit of rise to 12 units of run must be used.(5) Doors in means of egress must be as follows:(A) Locking hardware or devices which are capable of preventing or inhibiting immediate egress must not be used in any room or area that can be occupied.(B) A latch or other fastening device on an exit door must be provided with a knob, handle, panic bar, or similar releasing device. The method of operation must be obvious in the dark, without use of a key, and operable by a well known one-action operation that will easily operate with normal pressure applied to the door or to the device toward the exterior. Locking hardware which prevents unauthorized entry from the outside is permissible. Self-closing devices and permanently mounted hold-open devices to expedite emergency egress and prevent accidental lock-out must be provided for exterior exit doors.(C) No screen or storm door may swing against the direction of exit travel where main doors are required to swing out.(D) To aid in control of wandering residents, buzzers or other sounding devices may be used to announce the unauthorized use of an exit door. Other methods include approved emergency exit door locks or fencing with a gate outside of exit doors which enclose a space large enough to allow the space to be an exterior area of egress and refuge away from the building.(E) Inactive leaves of double doors may have easily accessible and easily operable bolts if the active leaf is 44 inches wide, where permitted by NFPA 101. Center mullions are prohibited.(F) Resident baths or toilets having privacy locks will require that keys or devices for opening the doors are kept readily available to the staff.(G) Folding doors must not be used in exit corridors or exit-ways. Sliding doors, where permitted by NFPA 101, may be used as secondary doors from residents' bedrooms to grade or to a balcony, or in certain other areas, where permitted by NFPA 101. Corridor doors to rooms must swing into the room or be recessed so as not to extend into the corridor when open; however, doors ordinarily kept closed may be excepted.(6) Horizontal exits, if provided, must be according to NFPA 101.(7) Areas outside of exterior exit doors must be as follows:(A) Provision must be made to accommodate and facilitate continuation of emergency egress away from a building for a reasonable distance beyond the outside exit door, especially for movement of non-ambulatory residents in wheelchairs and beds. Any condition which may retard or halt free movement and progress outside the exit doors will not be allowed. Ramps must be used outside the exit doors in lieu of steps whenever possible.(B) The landing outside of each exit door must be essentially the same elevation as the interior floor and level for a distance equal to the door width plus at least four feet. Generally, the difference in floor elevation at an exterior door must not be over 1/2 inch with the outside slope not to exceed 1/4 inch per foot sloping away from the door for drainage on the exterior. In locations north of the +20 Fahrenheit Isothermal Line as defined in the ASHRAE Handbook of Fundamentals, the landing outside of all exit doors must be protected from ice build-up which would prohibit the door from opening or would be a slip hazard.(C) Emergency egress lighting immediately outside of exit doors is required as a part of the building emergency lighting system. Photocell devices may be used to turn lights off during daylight hours.(8) The requirements of an emergency lighting system must be in accordance with §19.341 of this division (relating to Electrical Requirements). Source Note: The provisions of this §554.335 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.335 Exit Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207296 03/12/2026 (a) Smoke compartmentation must be as described in NFPA 101 and in this section.(b) An exit sign must be provided on each side of corridor smoke doors unless otherwise directed by HHSC.(c) The metal frames for the wire glass view panels in smoke doors must be steel, unless otherwise approved by HHSC. The bottom of the view panel must not be higher than 54 inches above the floor. Pairs of opposite (double egress) swinging smoke doors in corridors must have push/pull hardware. The door leaves must align in the closed position.(d) Smoke barrier walls in concealed spaces such as attics, must have prominent signs on each side that read: "Warning: Smoke/fire barrier. Properly seal all openings."(e) Provisions must be made for reasonable access to concealed smoke barrier walls for maintaining smoke dampers and so that walls and dampers can be visually checked periodically for conformance by facility staff, service persons, and inspectors. Access must provide for visual inspection of both sides of the wall, and of all parts (end-to-end and top-to-bottom). Ceiling access panels must be prefabricated metal panel, or its equivalent, and be at least 20 inches by 20 inches with no obstructions above (such as ducts) to hamper entrance, and it must be fire rated if required to maintain ceiling-roof or ceiling-floor fire rating. Access must be provided for both sides of the wall.(f) Air systems should be designed to avoid having ducts which penetrate smoke barrier walls, thus eliminating the need for smoke dampers which are often a problem to maintain in proper working condition. Source Note: The provisions of this §554.336 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.336 Smoke Compartmentation (Subdivision of Building Spaces) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207298 03/12/2026 (a) Fire protection systems include detection, alarm, and communication systems; fixed automatic extinguishment systems; and portable extinguishers. These systems must meet the requirements of NFPA 101, and of this section. Components must be compatible and laboratory listed for the use intended.(b) Fire protection systems must meet the requirements of all applicable NFPA standards, such as NFPA 72 for alarm systems, as referenced in NFPA 101. Wiring and circuitry for alarm systems must meet the applicable requirements of NFPA standards including the NFPA 70 for these systems.(c) Requirements of emergency electrical systems must be in accordance with §554.341 of this chapter (relating to Electrical Requirements). Requirements for sprinkler systems must be in accordance with §554.340(4) of this chapter (relating to Mechanical Requirements).(d) Partial sprinkler systems (those provided only for hazardous areas) must be interconnected with the fire alarm and comply with NFPA 101. Each partial system must have a valve with a supervisory switch to sound a trouble signal, water flow switch to activate the fire alarm, and an end-of-line test drain.(e) Fire alarm systems must be installed, maintained, and repaired by an agent having a current certificate of registration with the State Fire Marshal's office, in accordance with state law. A fire alarm installation certificate must be provided as required by the Office of the State Fire Marshal.(f) The fire alarm system must be designed so that whenever the general alarm is sounded by activation of any device (such as manual pull, smoke sensor, sprinkler, or kitchen range hood extinguisher), the following must occur automatically:(1) smoke and fire doors which are held open by approved devices must be released to close;(2) air handlers (air conditioning or heating distribution fans) serving three or more rooms or any means of egress must shut down immediately;(3) smoke dampers must close; and(4) the alarm-initiating-device location must be clearly indicated on the fire alarm control panel(s) and all auxiliary panels.(g) Fire alarm bells or horns must be located throughout the building for audible coverage. Flashing alarm lights (visual alarms) must be installed to be visible in corridors and public areas including dining rooms and living rooms in a manner that will identify exit routes.(h) A master control panel indicating the location of all alarm, trouble, and supervisory signals, by zone or device, must be visible at the main nurse station. Fire alarm system components must be laboratory-listed as compatible. Alarm and trouble zoning must be by smoke compartments and by floors in multi-story facilities.(i) Remote annunciator panels, indicating location of alarm initiation, by zone or device, and trouble indication, must be located at auxiliary or secondary nurse stations on each floor, and will indicate the alarm condition of adjacent zones and the alarm conditions at all other nurse stations.(j) Manual pull stations must be provided at all exits, living rooms, dining rooms, and at or near the nurse stations.(k) The sprinkler system must be monitored for flow and tamper conditions by the fire alarm system.(l) The kitchen range hood extinguisher must be interconnected with the fire alarm system. This interconnection may be a separate zone on the panel or combined with other initiating devices located in the same zone as the range hood is located.(m) Portable fire extinguishers must be provided throughout the facility as required by NFPA Standard 10 and as determined by the local fire department and the Texas Department of Human Services. The following requirements are applicable to fire extinguishers:(1) Extinguishers in resident corridors must be spaced so that travel distance is not more than 75 feet. The minimum size of extinguishers must be either 2 1/2 gallon for water type or 5 pound for ABC type.(2) Extinguishers must be installed on hangers or brackets supplied or mounted in approved cabinets. Recessed cabinets are required for extinguishers located in corridors.(3) Extinguishers installed under conditions where they are subject to physical damage must be protected from impact or dislodgement.(4) Extinguishers having a gross weight not exceeding 40 pounds must be installed so that the top of the extinguisher is not more than five feet above the floor. Extinguishers having a gross weight greater than 40 pounds must be installed so that the top of the extinguisher is not more than 3-1/2 feet above the floor. In no case may the clearance between the bottom of the extinguisher and the floor be less than four inches.(5) Portable extinguishers provided in hazardous rooms should be located as close as possible to the exit door opening and nearest the latch (knob) side. Source Note: The provisions of this §554.337 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective July 1, 2002, 27 TexReg 5245; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.337 Fire Protection Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203052 03/12/2026 (a) Protection from hazardous areas must be as required in NFPA 101, except as required or modified in this section. Gas-fired equipment must not be located in attic spaces, except under the following conditions:(1) the area around the units must be constructed to be one-hour fire rated;(2) the enclosure must have sprinkler protection; and(3) combustion and venting air must be ducted from the exterior in properly sized metal ducts.(b) Laboratories must be protected according to NFPA 99.(c) Cooking equipment must be protected according to NFPA 101.(d) Doors to hazardous areas must have closers and be kept closed unless provided with an approved hold-open device such as an alarm activated magnetic hold-open device, as permitted by NFPA 101. Doors must be single-swing type with positive latching hardware. View panels at laundry entrances must be provided and be of materials adequate to maintain the integrity of the door as allowed by NFPA 101. Source Note: The provisions of this §554.338 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.338 Hazardous Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207299 03/12/2026 (a) Every building and every portion thereof must be designed and constructed to sustain all dead and live loads in accordance with accepted engineering practices and standards.(b) Special provisions must be made in the design of buildings in regions where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, earthquakes, or floods.(c) The sponsor is responsible for employing qualified personnel in the preparation of plan designs and engineering and in the construction of the facility to assure that all structural components are adequate, safe, and meet the applicable construction requirements.(d) The design of the structural system must be done by or under the direction of a professional structural engineer who is currently registered by the Texas Board of Professional Engineers and Land Surveyors in accordance with state law.(e) The parts of the plans, details, and specifications covering the structural design must bear the legible seal of the engineer on the original drawings from which the prints are made.(f) If the municipality has a building code, that code must govern the building requirements for the construction involved. NFPA 101 must be used for fire safety requirements. Should discrepancies between the codes arise, they must be called to the attention of HHSC.(g) In the absence of a local building code, a nationally recognized building code must be used with regard to the construction integrity of the building. NFPA 101 must be used for fire safety requirements.(h) Each building must be classified as to building construction type for fire resistance rating purposes in accordance with NFPA 220 and NFPA 101.(i) Enclosures of vertical openings between floors must meet NFPA 101.(j) All interior walls, partitions, and roof structure in buildings of fire resistive and noncombustible construction must be of noncombustible or limited combustible materials.(k) Building insulation materials, unless sealed on all sides and edges in an approved manner, must have a flame spread rating of 25 or less when tested in accordance with NFPA 255 and NFPA 258. Source Note: The provisions of this §554.339 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.339 Structural Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207300 03/12/2026 The design of the mechanical systems must be done by or under the direction of a registered professional (mechanical) engineer approved by the Texas Board of Professional Engineers and Land Surveyors to operate in Texas, and the parts of the plans and specifications covering mechanical design must bear the legible seal of the engineer. Building services pertaining to utilities; heating, ventilating, and air-conditioning systems; vertical conveyors; and chutes must be in accordance with NFPA 101. Required plumbing fixtures must be in accordance with NFPA 101 and §554.334 of this chapter (relating to Architectural Space Planning and Utilization) in specific use areas.(1) Plumbing. (A) All plumbing systems must be designed and installed in accordance with the requirements of the plumbing code of the municipality. In the absence of a municipal code, a nationally recognized plumbing code must be used. Any discrepancy between an applicable code and these requirements must be called to the attention of HHSC.(B) Supply systems must assure an adequacy of hot and cold water. An average rule-of-thumb design for hot water for resident usage (at 110 degrees Fahrenheit) is to provide 6-1/2 gallons per hour per resident in addition to kitchen and laundry use.(C) Water supply must be from a system approved by TCEQ, or from a system regulated by an entity responsible for water quality in that jurisdiction as approved by TCEQ.(D) The sewage system must connect to a system permitted by TCEQ, or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by TCEQ.(E) The minimum ratio of fixtures to residents shall be as required in §554.334(c) of this chapter.(F) For design calculation purposes, resident-use hot water must not exceed 110 degrees Fahrenheit at the fixture. For purposes of conforming to licensure requirements, an operating system providing water from 100 degrees Fahrenheit to 115 degrees Fahrenheit is acceptable. Hot water for laundry and kitchen use must be normally 140 degrees Fahrenheit except that dish sanitizing, if done by hot water, must be 180 degrees Fahrenheit.(G) Water closets raised to provide a seat height 17 inches to 19 inches from the floor is required for persons with disabilities. (H) Showers for wheelchair residents must not have curbs. Tub and shower bottoms must have a slip-resistant surface. Shower and tub enclosures, other than curtains, must be of tempered glass, plastic, and other safe materials.(I) Drinking fountains must not extend into exit corridors. (J) Fixture controls easily operable by residents must be provided (such as lever type).(K) Plumbing fixtures for residents must be vitreous china or porcelain finished cast iron or steel unless otherwise approved by HHSC. Bathing units constructed of class B fire rated fiberglass are acceptable for use.(L) Hand-washing sinks for staff use are required in many areas throughout the facility in accordance with §554.334 of this chapter (relating to Architectural Space Planning and Utilization). Lavatories are required to be provided adjacent to water closets in each area.(M) The soiled utility room must be provided with a flushing device such as a water closet with bedpan lugs, a spray hose with a siphon breaker or similar device, such as a high neck faucet with lever controls and a deep sink that is large enough to submerse a bedpan. A sterilizer for sanitizing may be used in place of a deep sink.(N) Siphon breakers or back-flow preventers must be installed with any water supply fixture where the outlet or attachments may be submerged.(O) Clean-outs for waste piping lines must be provided and located so that there is the least physical and sanitary hazard to residents. Where possible, clean-outs must open to the exterior or areas which would not spread contamination during clean-out procedures. (P) All boilers not exempted by the Texas Health and Safety Code §755.022 must be inspected and certified for operation by The Texas Department of Licensing and Regulation.(2) Heating, ventilating, and air-conditioning systems.(A) Heating, ventilating, and air-conditioning systems must be designed and installed in accordance with the Heating, Ventilating, and Air-Conditioning Guide of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), except as may be modified by this section.(B) Heating, ventilating, and air-conditioning systems must meet the requirements of NFPA 101 and NFPA 90A. The plans must have a statement verifying that the systems are designed to conform to NFPA 90A. Requirements for conditions related to smoke compartmentation must be in accordance with §554.336 of this chapter (relating to Smoke Compartmentation (Subdivision of Building Spaces)).(C) Systems using liquefied petroleum gas fuel must meet the requirements of the Railroad Commission of Texas and NFPA 58.(D) The heating system must be designed, installed, and functioning to be able to maintain a temperature of at least 75 degrees Fahrenheit for all areas occupied by residents. For all other occupied areas, the indoor design temperature must be at least 72 degrees Fahrenheit. The cooling system must be designed, installed, and functioning to be able to maintain a temperature of not more than 78 degrees Fahrenheit. A facility constructed or licensed after January 1, 2004, must have a central air conditioning system, or a substantially similar air conditioning system, that is capable of maintaining a temperature suitable for resident comfort within areas used by residents. Occupied areas generating high heat, such as kitchens, must be provided with a sufficient cool air supply to maintain a temperature not exceeding 85 degrees Fahrenheit at the five-foot level. Supply air volume must be approximately equal to the air volume exhausted to the exterior for these areas.(E) Air systems must provide for mixing at least 10 percent outside air for the supply distribution. Blowers for central heating and cooling systems must be designed so that they may run continuously.(F) Floor furnaces, unvented space heaters, and portable heating units must not be used. Heating devices or appliances must not be a burn hazard (to touch) to residents.(G) A combustion fresh air inlet must be provided to all gas or fossil fuel operated equipment in steel ducts or passages from outside the building in accordance with NFPA 54. Rooms must also be vented to the exterior to exhaust heated ambient air in the room. Combustion air will require one vent within 12 inches of the floor and one vent within 12 inches of the ceiling.(H) The location and design of air diffusers, registers, and return air grilles, must ensure that residents are not in harmful or excessive drafts in their normal usage of the room.(I) In areas requiring control of sanitation, the air flow must be from the clean area to the dirty area. Air supply to food preparation areas must not be from air which has circulated places such as resident bedrooms and baths.(J) Air from unsanitary areas such as janitors closets, soiled linen areas, utility areas, and soiled area of laundry rooms, must not be returned and recirculated to other areas.(K) Intakes for fresh outside air must be located sufficiently distant from exhaust outlets or other areas or conditions which may contaminate or otherwise pollute the incoming fresh air. Fresh air inlets must be appropriately screened to prevent entry of debris, rodents, and animals. Provision must be made for access to such screens for periodic inspection and cleaning to eliminate clogging or air stoppage (see paragraph (3)(C)(i) of this subsection).(L) Systems must be designed as much as possible to avoid having ducts passing through fire walls or smoke barrier walls. All openings or duct penetrations in these walls must be provided with approved automatic dampers. Smoke dampers at smoke partitions must close automatically upon activation of the fire alarm system to prevent the flow of air or smoke in either direction.(M) Ducts with smoke dampers must have maintenance panels for inspections. The maintenance panels must be removable without tools. Means of access must also be provided in the ceiling or side wall to facilitate smoke damper inspection readily and without obstruction. Location of dampers must be identified on the wall or ceiling of the occupied area below.(N) Fusible links are not approved for smoke dampers.(O) Central air supply systems and/or systems serving means of egress must automatically and immediately shut down upon activation of the fire alarm system. (An exception must be approved, engineered smoke-removal systems.)(P) Ducts must be of metal or other approved noncombustible material. Cooling ducts must be insulated against condensation drip.(3) Ventilating and exhaust.(A) General ventilating systems must be in accordance with paragraph (2) of this subsection.(B) Provisions for natural ventilation using windows or louvers must be incorporated into the building design where possible and practical. These windows or louvers must have insect screens.(C) All air-supply and air-exhaust systems must be mechanically-operated. The ventilation rates shown in the table in clause (xi) of this subparagraph must be considered as minimum acceptable rates and must not be construed as precluding the use of higher ventilation rates.(i) Outdoor air intakes must be located as far as practical (but normally not less than 10 feet) from exhaust outlets or ventilating systems, combustion equipment stacks, medical vacuum systems, plumbing vent stacks, or from areas which may collect vehicular exhaust and other noxious fumes.(ii) The ventilation systems must be designed and balanced to provide the pressure relationship as shown in the table in clause (xi) of this subparagraph. A final engineered system air balance report will be required for the completed system to be furnished and certified by the installer.(iii) The bottoms of ventilation openings must be not less than three inches above the floor of any room.(iv) Doors protecting corridors or ways of egress must not have air transfer grilles or louvers. Corridors must not be used to supply air to or exhaust air from any room except that air from corridors may be used as make-up air to ventilate small toilet rooms, janitor's closets, and small electrical or telephone closets opening directly on corridors, provided that the ventilation can be accomplished by door undercuts not exceeding 3/4 inches.(v) All exhausts must be continuously ducted to the exterior. Exhausting air into attics or other spaces is not permitted. Duct material must be metal.(vi) All central ventilation or air-conditioning systems must be equipped with filters of sufficient efficiency to minimize dust and lint accumulations throughout the system and building including supply and return plenums and ductwork. Filters with efficiency rating of 80 percent or greater (based on ASHRAE) are recommended. Filters for individual room units must be as recommended by the equipment manufacturer. Filters must be easily accessible for routine changing or cleaning.(vii) Static pressures of systems must be within limits recommended by ASHRAE and the equipment manufacturer (upstream and downstream).(viii) In geographic locations or interior room areas where extreme humidity levels are likely to occur for extended periods of time, apparatus for controlling humidity levels (preferably between 40-60 percent) are recommended to be installed as a part of central systems and with automatic humidistat controls.(ix) Exhaust hoods, ducts, and automatic extinguishers for kitchen cooking equipment must be in accordance with NFPA 96.(x) Forced air exhaust must be provided in laundries, kitchens, and dishwashing areas to remove excess heat and moisture and to maintain air flow in the direction of clean to soiled areas.(xi) Ventilation requirements for nursing areas must be according to the following table:Attached Graphic(xii) With relationship to adjacent areas, a positive air pressure must be provided for clean utility rooms, clean linen rooms, and medication rooms. Conditioned supply air must be introduced into these rooms.(4) Sprinkler systems. The following requirements are applicable to sprinkler systems:(A) Sprinkler systems must be in accordance with NFPA 13 and this subchapter.(B) The design and installation of sprinkler systems must meet any applicable state laws pertaining to these systems and one of the following criteria:(i) The sprinkler system must be designed by a qualified registered professional engineer approved by the Texas Board of Professional Engineers and Land Surveyors to operate in Texas. The engineer must supervise the installation and provide written approval of the completed installation.(ii) The sprinkler system must be planned and installed in accordance with NFPA 13 by firms with certificates of registration issued by the office of the state fire marshal that have at least one full-time licensed responsible managing employee (RME). The RME's license number and signature must be included on the prepared sprinkler drawings.(C) Particular attention should be paid to adequate, safe, and reasonable freeze protection for all piping. The design of freeze protection should minimize the need for dependence on staff action or intervention to provide protection. Source Note: The provisions of this §554.340 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2004, 29 TexReg 3235; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.340 Mechanical Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203055 03/12/2026 (a) The design of the electrical systems must be done by or under the direction of a licensed professional electrical engineer approved by the Texas Board of Professional Engineers to operate in Texas, and the parts of the plans and specifications covering electrical design must bear the legible seal of the engineer. Utilities; heating, ventilating, and air-conditioning systems; vertical conveyors, and chutes must meet the requirements of NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(b) Fire protection systems must meet the requirements of §19.337 of this division (relating to Fire Protection Systems).(c) Electrical systems must meet the requirements of NFPA 70.(d) Specific requirements for lighting and outlets at resident bedrooms must meet the requirements of §19.334 of this division (relating to Architectural Space Planning and Utilization).(1) Emergency electrical service.(A) To provide electricity during an interruption of the normal electric supply, an emergency source of electricity must be provided and connected to certain circuits for lighting and power. Facilities that were constructed or received design approval or building permits before July 5, 2016, may comply with the emergency electrical system requirements for existing health care facilities in NFPA 99. All other facilities covered by this section must comply with the emergency electrical system requirements for new health care facilities in NFPA 99.(B) Emergency electrical connection service must be provided to the distribution systems as required by NPFA 101 and NFPA 99. Rehabilitation or modernization of an existing emergency power system must be based on the assessed risk category and according to the requirements of NFPA 99 for new health care facilities.(i) The following systems must be arranged for automatic connection to the alternate power source, without delay:(I) illumination for means of egress, nurse stations', medication rooms, dining and living rooms, group bathing rooms not directly connected to resident bedrooms, and areas immediately outside of exit doors;(II) exit signs and exit directional signs as required by NFPA 101;(III) alarm systems including fire alarms activated by manual stations, water flow alarm devices of sprinkler systems, fire and smoke detecting systems, and alarms required for nonflammable medical gas systems, if installed;(IV) task illumination and selected receptacles at the generator set location;(V) selected duplex receptacles including such areas as resident corridors, each bed location where patient care-related electrical appliances are utilized, nurse stations, and medication rooms including biologicals refrigerator;(VI) nurse call systems;(VII) resident room night lights;(VIII) a light and receptacle in an electrical room or a boiler room;(IX) elevator cab lighting, control, and communication systems;(X) all facility telephone equipment; and(XI) paging or speaker systems, if intended for communication during emergency. Radio transceivers where installed for emergency use must be capable of operating for at least one hour upon total failure of both normal and emergency power.(ii) The following systems must be arranged for delayed automatic or manual connection to the alternate power source:(I) Heating equipment must provide heating for general resident rooms. This will not be required if:(-a-) the outside design temperature is higher than 20 degrees Fahrenheit (-6.7 degrees Celsius);(-b-) the outside design temperature is lower than 20 degrees Fahrenheit (-6.7 degrees Celsius) and, when selected rooms are provided for the needs of all confined residents, then only those rooms need to be heated; or(-c-) the facility is served by a dual source of normal power.(II) In instances when interruptions of power would result in elevators stopping between floors, throw-over facilities must be provided to allow the temporary operation of any elevator for the release of passengers.(C) The emergency lighting must be automatically in operation within ten seconds after the interruption of normal electric power supply. Emergency egress lighting must not be switched.(D) Emergency service to receptacles and equipment may be delayed automatic or manually connected. Receptacles connected to emergency power must have red faceplates.(E) The design and installation of emergency motor generators must be in accordance with NFPA 37, NFPA 99, and NFPA 110.(i) Generators must be located a minimum of three feet from a combustible exterior building finish and a minimum of five feet from a building opening, if located on the exterior of the building.(ii) Generators located on the exterior of the building must be provided with a noncombustible protective cover or be protected as per manufacturer's recommendations.(iii) Motor generators fueled by public utility natural gas must have the capability to be switched to an alternate fuel source in accordance with NFPA 70.(iv) Stored fuel capacity must be sufficient for not less than four hours of required generator operation.(F) The normal wiring circuits for the emergency system must be kept entirely independent of all other wiring and must not enter the same race-ways, boxes, or cabinets according to NFPA 70.(2) General Lighting Requirements. General lighting requirements are as follows:(A) All spaces occupied by people, machinery, equipment, approaches to buildings, and parking lots must have lighting.(B) All quality, intensity, and type of lighting must be adequate and appropriate to the space and all functions within the space.(C) Minimum lighting levels can be found in the Illuminating Engineering Society (IES) Lighting Handbook, latest edition. Minimum illumination must be 20-foot candles in resident rooms, corridors, nurses' stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways, and elevators. Illumination requirements for these areas apply to lighting throughout the space and are measured at approximately 30 inches above the floor anywhere in the room. Minimum illumination for over-bed reading lamps, medication-preparation or storage areas, kitchens, and nurses' station desks must be 50 foot candles. Illumination requirements for these areas apply to the task performed and are measured on the task.(D) Nursing unit corridors must have general illumination with provisions for reduction of light levels at night.(E) Exposed incandescent light bulbs or other high heat generating lamps in closets or other similar spaces must be provided with basket wire guards or other suitable shield to prevent contact of combustible materials with the hot bulb and to help prevent breakage.(F) Exposed incandescent or fluorescent bulbs are not permitted in food service or other areas where glass fragments from breakage may get into food, medications, linens, or utensils. All fluorescent bulbs will be protected with a shield or catcher to prevent bulb drop-out.(3) Receptacles or convenience outlets.(A) Receptacles at bedrooms must be according to §19.334(a)(7) of this division (relating to Architectural Space Planning and Utilization).(B) Duplex receptacles for general use must be installed in corridors spaced not more than 50 feet apart and within 25 feet of ends of corridors. At least one duplex receptacle in each resident corridor must be provided with emergency electrical service.(C) Receptacles must be provided for essential needs such as medication refrigerators and systems or equipment whose failure is likely to cause major injury or death to a resident. All receptacles on emergency circuits must be clearly, distinctly, and permanently identified, such as using a red faceplate or a small label that says "Emergency."(D) Receptacles in the remainder of the building must be sufficient to serve the present and future needs of the residents and equipment.(E) Location of receptacles, horizontally and vertically, should be carefully planned and coordinated with the expected designed use of furnishings and equipment to maximize their accessibility and to minimize conditions such as beds or furniture being jammed against plugs used in the outlets.(F) Exterior receptacles must be an approved waterproof type.(G) Ground fault interruption protection must be provided at appropriate locations such as at whirlpools and other wet areas according to the NFPA 70.(4) Nurse call systems.(A) A nurse call system consists of power units, annunciator control units, corridor dome stations, emergency call stations, bedside call stations, and activating devices. The units must be compatible and listed by a nationally recognized testing laboratory for the system and use intended.(B) Each resident bedroom must be served by at least one call station and each bed must be provided with a call switch. Two call switches serving adjacent beds may be served by one calling station. Each call entered into the system must activate a corridor dome light above the bedroom, bathroom, or toilet corridor door, a visual signal at the nurses' station which indicates the room from which the call was placed, and a continuous or intermittent continuous audible signal of sufficient amplitude to be clearly heard by nursing staff. The amplitude or pitch of the audible signal must not be such that it is irritating to residents or visitors. The system must be designed so that calls entered into the system may be canceled only at the call station. Intercom-type systems which meet this requirement are acceptable.(C) A nurse call system that provides two-way voice communication must be equipped with an indicating light at each call station which lights and remains lighted as long as the voice circuit is operating.(D) A nurse call emergency switch must be provided for resident use at each resident's toilet, bath, and shower. These switches must be usable by residents using the fixtures and by a collapsed resident lying on the floor. Source Note: The provisions of this §554.341 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective May 1, 2004, 29 TexReg 3235; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.341 Electrical Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203056 03/12/2026 (a) Safety related details. A high degree of safety for the occupants is needed to minimize accidents more apt to occur with the elderly and/or infirm residents in a nursing facility. Consideration must be given to the fact that many have impaired vision, hearing, spatial perception, and ambulation.(1) Hazards such as sharp corners and edges and unexpected steps must be avoided.(2) Items such as drinking fountains, telephone booths, vending machines, and portable equipment must be located so as not to restrict corridor traffic or reduce corridor width.(3) Windows must be designed to prevent residents from accidentally falling through the windows.(4) Doors that normally stay open or are frequently used must not swing out into the corridor unless otherwise needed or required. Alcoves may be provided for doors that must swing outward toward a corridor or way of egress.(5) The proper use of safety glass must be adhered to in applicable locations and conditions.(6) Thresholds and expansion joint covers must be made essentially flush with the floor surface to facilitate use of wheelchairs and carts. See §19.340(a)(8) of this title (relating to Mechanical Requirements) for requirements for such items as shower curbs, surfaces, and doors.(7) Grab bars must be provided at all residents' toilets, showers, tubs, and sitz baths. The bars must be 1-1/4 to 1-1/2 inches in diameter and must have 1-1/2 inch clearance to walls. Bars must have sufficient strength and anchorage to sustain a concentrated load of 250 pounds. Grab bar standards must comply with standards adopted under the Americans with Disabilities Act of 1990.(8) Handrails must be provided on both sides of corridors used by residents. A clear distance of 1-1/2 inches must be provided between the handrail and the wall. Handrails must be securely mounted to withstand downward forces of 250 pounds. Handrails may be omitted on wall segments less than 18 inches. Handrails must be mounted 33 inches to 36 inches above the floor, and must comply with standards adopted under the Americans with Disabilities Act and the Texas Accessibility Standards.(9) Ends of handrails and grab bars must be constructed to prevent snagging the clothes of residents (that is, return ends to wall).(10) Ceiling fan blades must be at least seven feet above the floor and be located so as not to interfere with the operation of any ceiling-mounted smoke detectors.(b) General details.(1) Concrete floors, whether finished by sealant, or similar product, must not be used as the finished floor unless specifically approved in writing by the Texas Department of Human Services. An exception is mechanical equipment rooms and maintenance or similar areas.(2) Sound separation must be provided in corridor walls and resident room party walls; Minimum Sound Transmission Coefficient 30 per American Society for Testing Material E-90.(3) Illumination and a safe platform in the attic must be provided at all attic access panels.(4) Attic access must be provided for building maintenance. Access panels must be prime coated steel flush panels where required to maintain fire rating of ceiling-roof/ceiling-floor assemblies. Source Note: The provisions of this §554.342 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective July 1, 2002, 27 TexReg 5245; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.342 Miscellaneous Details https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203057 03/12/2026 All buildings having residents' facilities (such as bedrooms, dining rooms, or recreation areas) or resident services (such as diagnostic or therapy) located on other than the main entrance floor must have at least one electric or electrohydraulic elevator and must comply with standards adopted under the American National Standards Institute (ANSI) Code, §A17.1.(1) Number of elevators.(A) At least one hospital-type elevator must be installed where one to 60 resident beds are located on any floor other than the main entrance floor.(B) At least two (one of which must be hospital-type) elevators must be installed where 61 to 200 resident beds are located on floors other than the main entrance floor, or where the major inpatient services are located on a floor other than those containing resident beds. Elevator service may be reduced for those floors which provide only partial inpatient services.(C) At least three (one of which must be hospital-type) elevators must be installed where 201 to 350 resident beds are located on floors other than the main entrance floor or where the major inpatient services are located on a floor other than those containing resident beds. Elevator service may be reduced for those floors which provide only partial inpatient services.(D) For facilities with more than 350 resident beds, the number of elevators must be determined from a study of the facility plan and the estimated vertical transportation requirements.(2) Cars and platforms. Cars of hospital-type elevators must have inside dimensions that will accommodate a resident bed and attendants and must be at least five feet wide by seven feet six inches deep. The car door must have a clear opening of not less than three feet eight inches.(3) Leveling. Elevators must be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of 1/2 inch.(4) Operation. Elevators, except freight elevators, must be equipped with a two-way special service switch to permit cars to bypass all landing button calls and be dispatched directly to any floor.(5) Accessibility provisions. Elevator controls, alarm buttons, and telephones, must be accessible to and usable by individuals with disabilities as required under the Americans with Disabilities Act of 1990.(6) Protection from fire. Elevator call buttons, controls, and door safety stops must be of a type that will not be activated by heat or smoke. Door openings must meet the requirements of the Life Safety Code for protection of vertical openings.(7) Field inspection and tests. Inspections and tests must be made and the owner must be furnished written certification that the installation meets the requirements set forth in this section and all applicable safety regulations and codes. Source Note: The provisions of this §554.343 adopted to be effective July 1, 1996, 21 TexReg 4408; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.343 Elevators https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203058 03/12/2026 At the option of the applicant, HHSC will review plans for a new building, an addition to a building, a conversion of a building not licensed by HHSC, or rehabilitation of an existing licensed facility. HHSC will, within 30 days, inform the applicant in writing of the results of the review. If the plans comply with HHSC's architectural requirements, HHSC may not subsequently change the architectural requirement applicable to the project unless the change is required by federal law or the applicant fails to complete the project within two years. HHSC may grant a waiver of this two-year period for delays due to unusual circumstances. There is no time limit to complete a project, only a time limit for completing a project using requirements that have been revised after the project was reviewed.(1) Submittal of plans.(A) For review of plans, submit one copy of contract documents described in paragraph (2) of this subsection before construction begins. Documents must be in sufficient detail to demonstrate compliance with this subchapter and ensure proper construction. Documents must be prepared according to accepted architectural practice and must include general construction, special conditions, and schedules.(B) Final copies of plans must include a title block that shows name of facility, person, or organization preparing the sheet, sheet numbers, facility address, and drawing date. Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a licensed professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. Contract documents for additions, rehabilitation of, or construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect.(C) A final plan for a major addition to a facility must include a basic layout to scale of the entire building onto which the addition will connect. North direction must be shown. The entire basic layout may be to a scale such as 1/16 inch per foot or 1/32 inch per foot for very large buildings.(D) Plans and specifications for the conversion of a building not licensed by HHSC or rehabilitation of an existing building must be complete for all parts and features involved.(E) The facility is responsible for employing qualified personnel to prepare the contract documents for construction. If the contract documents contain errors or omissions to the extent that conformance with standards cannot be reasonably ensured or determined, HHSC may request a revised set of documents for review.(F) The review of plans and specifications by HHSC is based on general utility, the minimum licensing standards, and conformance with NFPA 101. This review must not to be construed as an all-inclusive approval of the structural, electrical, or mechanical components, nor does it constitute the review of required building plans for compliance with TAS as administered and enforced by the Texas Department of Licensing and Regulation.(G) Fees for plan review will be required according to §19.219 of this chapter (relating to Plan Review Fees).(2) Contract documents.(A) Code compliance documents must include:(i) A life safety floor plan that includes the following information:(I) a building layout, depicted at an identified drawing scale;(II) the location of any changes in construction type;(III) occupant loads, according to NFPA 101;(IV) egress capacity, according to NFPA 101;(V) egress routes from spaces in the building to the public way, including travel distances;(VI) areas in buildings which use provisions for suites, per NFPA 101;(VII) provisions for the protection of vertical openings;(VIII) the locations of doors that use special locking arrangements;(IX) the relationship of the subject building to any adjacent buildings on the same property, including dimensions between buildings;(X) the size and location of smoke compartments, and the tested fire resistance-rated assemblies proposed for the construction of smoke barriers defining the compartments;(XI) the location of any fire barriers or fire walls, and the tested fire resistance-rated assemblies proposed for the construction of those barriers or walls; and(XII) the location of egress signage.(ii) documentation, published by a nationally recognized testing laboratory, describing any proposed fire resistance-rated assemblies, including the following:(I) fire resistance-rated wall assemblies;(II) fire resistance-rated floor-ceiling assemblies;(III) fire resistance-rated roof-ceiling assemblies;(IV) fire resistance-rated joint systems;(V) fire resistance-rated systems for protection of penetrations into or through other fire resistance-rated construction and assemblies; and(VI) fire resistance-rated assemblies for protection of structural columns and beams.(iii) for projects involving building rehabilitation, provide a diagram outlining each area undergoing rehabilitation identifying the classification of the rehabilitation work according to §19.350 of this subchapter (relating to Building Rehabilitation), and identifying the total floor area of each rehabilitation work area by rehabilitation classification.(B) Site plan documents must include:(i) grade contours;(ii) streets with names;(iii) a north arrow;(iv) fire hydrant locations;(v) fire lanes;(vi) utilities, public or private;(vii) fences; and(viii) unusual site conditions, such as(I) ditches;(II) low water levels;(III) other buildings on-site; and(IV) indications of buildings located five feet or less beyond site property lines.(C) Foundation plan documents must include the general foundation design and details.(D) Floor plan documents must include:(i) room names, numbers, and usages;(ii) numbered doors, including swing;(iii) windows;(iv) a legend or clarification of wall types;(v) dimensions;(vi) fixed equipment;(vii) plumbing fixtures;(viii) kitchen basic layout; and(ix) identification of all smoke barrier walls and fire walls, outside wall to outside wall.(E) For new construction, additions to or rehabilitation of an existing building, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2-inch by 11-inch sheet.(F) Schedules must include:(i) door materials, sizes, and types;(ii) window materials, sizes, and types;(iii) room finishes; and(iv) special hardware.(G) Elevations must include:(i) exterior elevations with material note; and(ii) interior elevations, where needed for special conditions.(H) Roof plans must include:(i) any roof top equipment;(ii) roof slopes;(iii) drain locations; and(iv) gas pipes.(I) Details must include:(i) wall sections as needed, especially for special conditions;(ii) cabinets and built-in work, basic design only;(iii) cross sections through buildings as needed; and(iv) miscellaneous details and enlargements as needed.(J) Building structure documents must include:(i) structural framing layouts and details;(ii) roof framing layout, when this cannot be adequately shown on cross section;(iii) cross sections in quantity and detail to show sufficient structural design; and(iv) structural details as necessary to ensure adequate structural design.(K) Electrical documents must include:(i) electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices;(ii) service, circuiting, distribution, and panel diagrams;(iii) exit signs and emergency egress lighting;(iv) emergency electrical provisions, such as generators and panelboards;(v) staff communication systems, including a nurse call system;(vi) fire alarm and similar systems, such as control panels, devices, and alarms; and(vii) sizes and details sufficient to ensure safe and properly operating systems.(L) Plumbing documents must include:(i) plumbing layout with pipe sizes and details sufficient to ensure safe and properly operating systems;(ii) water systems;(iii) sanitary systems;(iv) gas systems; and(v) other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(M) Heating, ventilating, and air-conditioning systems (HVAC) documents must include:(i) sufficient details of HVAC systems and components to ensure a safe and properly operating installation, including heating, ventilating, and air-conditioning layout; ducts; protection of duct inlets and outlets; combustion air; piping; exhausts; duct smoke detectors; and fire dampers; and(ii) equipment types, sizes, and locations.(N) Sprinkler system documents must include:(i) plans and details of systems designed according to NPFA 13; and(ii) electrical devices interconnected to the alarm system.(O) Specifications must include:(i) installation techniques;(ii) quality standards;(iii) manufacturers;(iv) references to specific codes and standards;(v) design criteria;(vi) special equipment;(vii) hardware;(viii) finishes; and(ix) any other information as needed to amplify drawings and notes.(P) Other layouts, plans, or details that are necessary to convey a clear understanding of the design and scope of the project, including plans covering private water or sewer systems, which must be reviewed by the local health or wastewater authority having jurisdiction. Source Note: The provisions of this §554.344 adopted to be effective April 1, 2002, 27 TexReg 2249; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.344 Plan Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207301 03/12/2026 (a) This section applies to a small house or household facility that is designed to provide a non-institutional environment to promote resident-centered care. New construction of a small house or household facility, including a conversion of an existing facility, an addition to an existing facility, or rehabilitation of an existing facility, must meet the requirements of this section.(b) A small house or household facility must comply with this chapter, except it is not required to comply with a requirement in Division 9 of this subchapter (relating to Facilities Licensed On or After April 2, 2018) if HHSC waives the requirement in accordance with subsection (c) of this section or if the requirement is modified by subsection (g) of this section.(c) HHSC may waive a requirement in Division 9 of this subchapter if HHSC determines a waiver of the requirement would facilitate the implementation of resident-centered care. To request a waiver of a requirement, a facility must submit plans to HHSC according to §554.344 of this subchapter (relating to Plan Review). The plans must include a statement from an architect identifying which requirements the facility is requesting to be waived and explaining how the waiver would contribute to the goals of resident-centered care.(d) A small house or household facility must be designed and equipped to provide a homelike environment that promotes resident-centered care.(e) A small house or a household within a facility must:(1) have no more than 16 bedrooms as described in subsection (g)(2) of this section;(2) have living, dining, social, and staffing areas exclusively within and for the house or household; and(3) have a kitchen that meets the requirements in §554.354(g)(1) of this subchapter (relating to Architectural Space Planning and Utilization for New Facilities) or a food service area that meets the requirements of an auxiliary serving kitchen in §554.354(g)(3) of this subchapter, exclusively within and for the house or household.(f) A small house or household facility must be:(1) a single small house model, which is a single licensed building having no more than 16 residents that meets the licensing requirements for architectural spaces provided within the same licensed building;(2) a multiple small house model, which is a single licensed group of two or more small houses located in close proximity to each other on a single contiguous property that meets the licensing requirements for architectural spaces in each house and that may include a stand-alone central building that provides social-diversional space, a treatment area, or an administrative area; or(3) a household model, which is a single licensed building that contains one or more households having no more than 16 residents each; that may include a central area that provides social-diversional space, a treatment area, or an administrative area; and that must be arranged to avoid travel through the household by persons who are not residing in, visiting, or providing services for the household.(g) A small house or household facility must comply with the requirements in this section and is not required to request a waiver for an exception described in this subsection.(1) The outdoor activity, recreational, and sitting spaces required in §554.352(f) of this subchapter (relating to Location and Site for New Facilities) must include a porch area under a roof with suitable furniture for sitting and space for wheelchairs.(2) The resident bedroom requirements in §554.354(a) of this subchapter must be met, except:(A) a bedroom must be occupied:(i) by only one resident; or(ii) by two residents, if they are members of the same family and the bedroom size, furniture, and headboard wall requirements for double occupancy are met;(B) the toilet requirements in §554.354(a)(7) of this subchapter must be met, except a bathroom must serve no more than one resident room and must include a lavatory, toilet, and a shower or bathing unit;(C) the night lighting requirement in §554.354(a)(5) of this subchapter must be met, except it must be a recessed wall mounted fixture just inside the entry door to the room and must not be obstructed by the door or furniture; and(D) the electrical receptacle requirements in §554.354(a)(6) of this subchapter must be met and additional receptacles must be provided to meet the requirements for Dwelling Unit Receptacle Outlets in NFPA 70.(3) The nursing service area requirements in §554.354(b) of this subchapter must be met, except:(A) a nursing staff lounge is not required in a small house facility;(B) the nursing staff toilet room may also be a toilet room for:(i) kitchen staff;(ii) the public; or(iii) a general bathing room, if the toilet room opens into the general bathing room and common areas; and(C) the nourishment station may be part of the residential kitchen area.(4) Resident bathing and toilet facility requirements in §554.354(c) of this subchapter must be met, except the door between a bathroom and a resident bedroom:(A) is not required to be a side-hinged swinging door;(B) may be an externally mounted by-pass door;(C) must have substantial hardware;(D) must not be equipped with a bottom door track that is a tripping hazard; and(E) if it swings open into the bedroom, must not interfere with the swing of any other door that opens into the bedroom.(5) The living area requirements in §554.354(e) of this subchapter and dining room requirements in §554.354(f) of this subchapter must be met, except the distance between the floor and the window sill of a window in the living or dining room must not exceed 36 inches, to allow a view to the outside from a seated position.(6) The dietary facility requirements in §554.354(g) of this subchapter must be met, except a kitchen serving 16 or fewer non-employees per meal:(A) may be open to the facility in compliance with NFPA 101;(B) must meet the general food service needs of the residents;(C) must provide for the storage, refrigeration, preparation, and serving of food; for dish and utensil cleaning; and for refuse storage and removal;(D) must contain a multi-compartment sink, vegetable sink, and hand washing sink;(E) must provide a supply of hot water that, if used for sanitizing purposes is 180 degrees Fahrenheit or at the manufacturer's suggested temperature for chemical sanitizers;(F) must provide a supply of cold water;(G) must have janitorial facilities exclusively for the kitchen and located in close proximity to the kitchen;(H) must have kitchen floors, walls, and ceilings with nonabsorbent smooth finishes or surfaces that are capable of being routinely cleaned and sanitized to maintain a healthful environment;(I) must have counter and cabinet surfaces, inside and outside, with smooth, cleanable, relatively nonporous finishes; and(J) must have a toilet for the kitchen staff that is in close proximity to the kitchen and that may also be a toilet room for the public or the general bathing room.(7) The exit requirements in §554.355(3) of this subchapter (relating to Exit Provisions for New Facilities) must be met except for fixed furniture and wheeled equipment as permitted by NFPA 101. Source Note: The provisions of this §554.345 adopted to be effective April 1, 2014, 39 TexReg 2313; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.345 Small House and Household Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203060 03/12/2026 (a) This section applies to facilities undergoing rehabilitation.(b) Rehabilitation work is classified as follows:(1) The patching, restoration, or painting of materials, elements, equipment, or fixtures for the purpose of maintaining such materials, elements, equipment, or fixtures in good or sound condition must be classified as repair and must meet the following requirements:(A) A repair must meet the applicable requirements of §19.300(d) of this subchapter (relating to General Requirements);(B) A repair must be done using like materials, unless such materials are prohibited by NFPA 101; and(C) A repair must not make a building less conforming with NFPA 101 or the applicable sections of this subchapter, or with any alternative arrangements previously approved by HHSC, than it was before the repair was undertaken, unless approved by HHSC.(2) The replacement in kind, strengthening, or upgrading of building elements, materials, equipment, or fixtures, that does not result in a reconfiguration of the building spaces within, must be classified as renovation and must meet the following requirements:(A) Any new work that is part of a renovation must comply with the applicable requirements of §19.300(d) of this subchapter;(B) Any new interior or exterior finishes must meet the requirements of division 9 of this subchapter (relating to Facilities Licensed On or After April 2, 2018).(C) A renovation must not make a building less conforming with NFPA 101 or the applicable sections of this subchapter, or with any alternative arrangements previously approved by HHSC, than it was before the renovation was undertaken, unless approved by HHSC; and(D) The reconfiguration or extension of any system, or the installation of any additional equipment, must be classified as modification according to paragraph (3) of this subsection.(3) The reconfiguration of any space; the addition, relocation, or elimination of any door or window; the addition or elimination of load-bearing elements; the reconfiguration or extension of any system; or the installation of any additional equipment, must be classified as modification and must meet the following requirements:(A) A newly constructed element, component, or system must comply with division 9 of this subchapter;(B) All other work in a modification must meet, at a minimum, the requirements for a renovation according to paragraph (2) of this subsection; and,(C) If the total rehabilitation work area classified as modification exceeds 50 percent of the total building area, the work must be classified as reconstruction according to paragraph (4) of this subsection.(4) The reconfiguration of a space that affects an exit or a corridor shared by more than one occupant space; or the reconfiguration of a space such that the rehabilitation work area is not permitted to be occupied because existing means of egress and fire protection systems, or their equivalent, are not in place or continuously maintained, must be classified as reconstruction and must meet the following requirements:(A) Any reconstruction of components of the means of egress must comply with the applicable requirements of §19.300(d) of this subchapter, except for the following components, which must comply with division 9 of this subchapter.(i) illumination of means of egress;(ii) emergency lighting of means of egress; or(iii) marking of means of egress, including exit signs.(B) If the total rehabilitation work area classified as reconstruction on any one floor exceeds 50 percent of the total area of the floor, all means of egress components on that floor identified in paragraph (4)(A)(i) - (iii) of this subsection must comply with division 9 of this subchapter.(C) If the total rehabilitation work area classified as reconstruction exceeds 50 percent of the total building area, all means of egress components in the building identified in paragraph (4)(A)(i) - (iii) of this subsection must comply with division 9 of this subchapter.(D) All other work classified as reconstruction must meet, at a minimum, the requirements for modification according to paragraph (3) of this subsection and renovation according to paragraph (2) of this subsection.(5) A change in the purpose or level of activity within a facility that involves a change in application of the requirements of this subchapter must be classified as a change of use and must comply with division 9 of this subchapter.(6) A change in the use of a structure or portion of a structure must comply with division 9 of this subchapter.(7) An increase in the building area, aggregate floor area, building height, or number of stories of a structure must be classified as an addition and must comply with division 9 of this subchapter.(c) If an existing licensed facility plans a building rehabilitation that includes a change in the facility capacity, HHSC must reevaluate the ratio of bathing units to meet minimum standards and the square footage of dining and living areas to meet a minimum of 19 square feet per bed. Conversion of existing living, dining, or activity areas to resident bedrooms must not reduce these functions to a total area of less than 19 square feet per bed. The facility's registered or licensed dietitian or architect having knowledge in the design of food service operations must reevaluate the dietary department. This reevaluation must be provided to HHSC.(d) A rehabilitation to an occupied building that involves exit-ways or exit doors must be accomplished without compromising the exits or creating a dead end situation at any time. HHSC may approve temporary exits, or the facility must relocate residents until construction blocking the exit is completed. The facility must maintain other basic safety features such as fire alarms, sprinkler systems, and emergency power. Source Note: The provisions of this §554.350 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.350 Building Rehabilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203061 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203061&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203061 03/12/2026 (a) This section applies to a facility licensed on or after April 2, 2018. The requirements of NFPA 101 and other applicable NFPA codes and standards referenced in NFPA 101 will apply unless otherwise noted or modified in this section:(1) Buildings covered by this section must comply with the New Health Care Occupancies chapter of NFPA 101.(2) In addition to NFPA 101 and the standards referenced therein, a facility covered by this division is subject to the codes, standards, and requirements established by the following: UL; ASHRAE; and ASTM.(b) All applicable local, state, or national codes and ordinances must be met as determined by the authority having jurisdiction for those codes and ordinances and by HHSC. Any conflicts must be made known to HHSC for appropriate resolution.(c) The design of structural systems must be done by or under the direction of a professional engineer who is currently licensed by the Texas Board of Professional Engineers.(d) Nothing in this division may be construed as prohibiting a better type of building or construction, more space, services, features, or greater degree of safety than the minimum requirements. Source Note: The provisions of this §554.351 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.351 Construction Standards for New Nursing Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203062 03/12/2026 (a) Any conditions considered to be a fire, safety, or health hazard will be grounds for disapproval of a site by HHSC. A new facility may not be built in an area designated as a floodplain of 100 years or less.(b) Site grades must provide for positive surface water drainage so that there will be no ponding or standing water on the designated site. This does not apply to local government requirements for engineered controlled run-off holding ponds.(c) A new building or addition must be set back at least 10 feet from the property lines except as otherwise approved by HHSC.(d) Exit doors from the building must not open directly onto a drive for vehicular traffic, but must be set back at least six feet from the edge of the drive, measured from the end of the building wall in the case of a recessed door, to prevent accidents due to lack of visual warning.(e) Walks must be provided as required from all exits and must be of non-slip surfaces free of hazards. Walks must be at least 48 inches wide except as otherwise approved. Ramps must be used in lieu of steps where possible for the individuals with a disability and to facilitate bed or wheelchair removal in an emergency.(f) Outdoor activity, recreational, and sitting spaces must be provided and appropriately designed, landscaped, and equipped. Some shaded or covered outside areas are needed. These areas must be designed to accommodate residents in wheelchairs.(g) Each facility must have parking space to satisfy the needs of residents, employees, staff, and visitors. In the absence of a formal parking study, each facility must provide for a ratio of at least one parking space for every four beds in the facility. This ratio may be reduced slightly in areas convenient to public parking facilities. Space must be provided for emergency and delivery vehicles. A parking space must not block or inhibit egress from the outside exit doors. Parking spaces and drives must be at least ten feet away from windows in bedrooms, dining areas, and living areas.(h) Barriers must be provided for resident safety from traffic or other site hazards by the use of appropriate methods such as fences, hedges, retaining walls, railings, or other landscaping. These barriers must not inhibit emergency egress to a safe distance away from the building.(i) Open or enclosed courts with resident rooms or living areas opening upon them must not be less than 20 feet in the smallest dimension unless otherwise approved by HHSC. Nonparallel wings forming an acute angle may have a maximum of two windows in each wing that are separated by a distance less than 20 feet, but not less than ten feet, when measured between the nearest edges of the opposing openings.(j) Auxiliary buildings located within 20 feet of the main building must meet the applicable requirements in NFPA 101 for separation and construction.(k) Other buildings on the site must meet the appropriate occupancy section or separation requirements in NFPA 101.(l) Fire service and access must be as follows:(1) The facility must be served by a paid or volunteer fire department. The fire department must provide written assurance to HHSC that the fire department can respond to an emergency at the facility within an appropriately prompt time for the travel conditions involved.(2) The facility must be served by an adequate water supply that is satisfactory and accessible for fire department use as determined by the fire department serving the facility and by HHSC.(3) There must be at least one readily accessible fire hydrant located within 300 feet of the building. The hydrant must be on a minimum six inch service line. The hydrant, its location, and service line, or equivalent must be as approved by the local fire department and HHSC.(4) The building must have suitable all-weather fire lanes as required by local fire authorities or, if no local fire authority has jurisdiction, by HHSC. As a minimum, the fire department must be able to access two sides of the building.(m) Enclosed exterior spaces, such as fenced areas, that are in a means of egress to a public way must meet the requirements of §19.2208(a)(6) of this chapter (relating to Standards for Certified Alzheimer's Facilities). Source Note: The provisions of this §554.352 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.352 Location and Site for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203063 03/12/2026 (a) Services. A nursing facility must either contain the elements described in this section or the facility must indicate the manner in which the needed services are to be made available.(b) Sizes. The sizes of the various departments will depend upon program requirements and the organization of services within the facility. Some functions requiring separate spaces or rooms in these minimum requirements may be combined, provided that the resulting plan will not compromise the best standards of safety and of medical and nursing practices.(c) Shared or combined services. A nursing facility may be operated together with a hospital and may share administration, food service, recreation, janitor service, and physical therapy facilities, but must have clearly identifiable physical separations, such as a separate wing or floor. A nursing facility with different levels of care will require identifiable physical separations. Combined attendant or nurses' stations and medication room areas will require some separating construction features. An assisted living facility may be operated together with a nursing facility and may share food and laundry service, but must have clearly identifiable physical separations such as a separate wing, or floor, and each facility must independently meet all other requirements within their licensed areas.(d) Exterior finishes. Unless otherwise approved by HHSC, the exterior finish material of a building classified as fire resistive or protected noncombustible construction, per NFPA 220, must have a flame spread index no greater than 25 and a smoke developed index no greater than 450, when tested according to ASTM E84 or UL 723. All others exterior materials must have a flame spread index no greater than 75 and a smoke developed index no greater than 450. Items of trim may be of combustible material subject to approval by HHSC. Roof covering assemblies must have a Class A or Class B rating, when tested according to ASTM E108 or UL 790.(e) Accessibility requirements. The facility must comply with accessibility requirements for individuals with disabilities in the revised regulations for Title II and III of the Americans with Disabilities Act of 1990 at 28 CFR Part 35 and Part 36, also known as the 2010 ADA Standards for Accessible Design, and the TAS adopted by the Texas Department of Licensing and Regulation (TDLR) at 16 TAC Chapter 68. A facility must register plans for new construction, substantial renovations, modifications, and alterations with TDLR, Attn: Elimination of Architectural Barriers Program, and comply with the TAS. Source Note: The provisions of this §554.353 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.353 General Considerations for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203064 03/12/2026 (a) Resident bedrooms. Each resident bedroom must meet the following requirements:(1) The maximum room capacity must be two residents.(2) Minimum bedroom area, excluding toilet rooms, closets, lockers, wardrobes, alcoves, or vestibules, must be 100 square feet in single occupancy rooms and 80 square feet per bed in multi-bed rooms.(3) The minimum allowable room dimension is ten feet. The room must be designed to provide at least 36 inches between beds and 24 inches between any bed and the adjacent wall.(4) Each room must have at least one operable outside window arranged and located so that it can be easily opened from the inside without the use of tools or keys. The maximum allowable sill height must not exceed 36 inches above the floor. All operable windows must have insect screens. The minimum area of window in each bedroom must equal at least 16 square feet or 8.0% of the gross floor area of the room, whichever is larger. Operable window sections may be restricted to not more than six nor less than four inches for security or safety reasons.(5) Each room must have general lighting, wall-mounted bed reading lights, and night lighting. The night light must be switched just inside the entrance to each resident room with a silent type switch, must be a recessed wall mounted fixture just inside the entry door to the room and must not be obstructed by the door or furniture, unless otherwise approved by HHSC. The light providing general illumination must be switchable at the door of the resident room for use of staff and residents. A durable non-glare reading light with an opaque front panel securely anchored to the wall, integrally wired, must be provided above each resident bed. The switch for this reading light must be within reach of a resident in the bed.(6) The minimum number of power receptacles at a resident bed location shall be determined based on the risk assessment required by NFPA 99 and §19.300(i) of this subchapter (relating to General Requirements), as follows:(A) All receptacles must be listed and identified as "hospital grade";(B) Four of the required receptacles must be provided beside the head of each bed;(C) No fewer than eight receptacles must be provided within the patient care vicinity, as defined in NFPA 99;(D) If the failure of patient-care-related electrical equipment is likely to cause major injury or death to a resident, no fewer than fourteen receptacles must be provided within the patient care vicinity.(E) Additional receptacles, beyond the minimum quantities above, must be provided to ensure the electrical needs of all residents living in the bedroom are met, including power for TV, radio, razors, hairdryers, clocks, or as required by NFPA 99 and NFPA 70.(7) Each resident bedroom must have direct access to a bathroom without entering the general corridor area. The bathroom must serve no more than one resident room and must include, at least, a lavatory and toilet. (8) Each resident must have a bed with a comfortable mattress, a bedside stand with at least two enclosed storage spaces, a dresser, and closet or wardrobe space providing privacy for clothing and personal belongings. Private clothes storage space must provide at least 22 inches of lineal hanging space per bed and have closable doors. Chairs and space must be provided for use by residents and visitors.(9) Each room must open onto an exit corridor and must be arranged for convenient resident access to dining, living, and bathing areas. To ensure a direct view from nurses' stations, resident room doors must not be recessed into the corridor wall more than four feet. Alcoves must meet applicable accessibility standards for a front approach to the door, and handrails must be provided in the alcove. If an alcove exceeds four feet in depth, it is a corridor and must meet all requirements for corridors, including direct view from a nurses' station, minimum width of the corridor, and provisions for handrails.(10) Visual privacy, such as cubicle curtains, must be available for each resident in multi-bed bedrooms. Design for privacy must not restrict resident access to the entry, lavatory, or toilet, nor may it restrict bed evacuation or obstruct sprinkler flow coverage. (11) At least one noncombustible wastebasket must be provided in each bedroom.(12) See the requirements in §19.361(d)(4) of this subchapter (relating to Electrical Requirements for New Facilities) for nurse call systems.(13) Bedrooms must be identified with a raised or recessed unique number placed on or near the door. Refer to TAS for information about signs. (14) Locks on bedroom doors are permitted when they meet definite resident needs. (A) Situations in which locks may be necessary include the following:(i) married couples whose rights of privacy could be infringed upon unless bedroom door locks are permitted; and(ii) residents for whom the attending physician wants bedroom door locks to enhance the residents' sense of security.(B) In situations such as those listed in subparagraph (A) of this paragraph, the following guidelines must be met:(i) bedroom door locks must be of the type which the occupant can unlock at will from inside the room;(ii) all bedroom door locks must be of the type which can be unlocked from the corridor side;(iii) attendants must carry keys which will permit ready access to the locked bedrooms when entrance becomes necessary;(iv) locking of bedroom doors by residents for privacy or security will not be permitted except when specifically included in the attending physician's written orders or authorized by the nursing facility administrator. (15) Vacant bedrooms must not be used for hazardous activities or hazardous storage, unless specifically approved by HHSC in writing. (b) Nursing service areas. A nursing service area includes a nurses' station and other areas described in this subsection and must be located in or readily available to each nursing unit. The size and disposition of each service area will depend upon the number and types of beds to be served. Each service area may be arranged and located to serve more than one nursing unit, but at least one service area must be provided on each nursing floor. The maximum allowable distance from a resident room door to a nurses' station is 150 feet. The following requirements are applicable to services areas:(1) Nurses' stations must be provided with space for nurses' charting, doctors' charting, and storage for administrative supplies. Nurses' stations must be located to provide a direct view of resident corridors. A nurses' station has a direct view of a resident corridor if a person can see down the corridor from a point within 24 inches of the outside of the nurses' station counter or wall. When a nurses' station does not provide a direct view of a resident corridor, an auxiliary station complying with the following guidelines must be provided.(A) The auxiliary station must be staffed by nursing personnel during all shifts.(i) More than one auxiliary station may be assigned to a designated nurses' station, regardless of the distance between stations. (ii) The nurse call system for resident corridors monitored by the auxiliary station must report to the auxiliary station.(iii) Each auxiliary station must meet the emergency electrical requirements for a nurse's station, including electrical receptacles and emergency lighting.(iv) If a required auxiliary station does not already exist and the facility must establish a new auxiliary station, all applicable standards, particularly those pertaining to the physical plant and NFPA 101, must be observed.(B) In addition to the required normal and emergency illumination, the facility must keep on hand and readily available to night staff no less than one working flashlight at each nurses' station. (2) Lounge and toilet room must be provided for nursing staff.(3) Lockers or security compartments must be provided for the safekeeping of personal effects of staff. These must be located convenient to the duty station of personnel or in a central location.(4) A clean utility room must contain a work counter, sink with high-neck faucet with lever controls, and storage facilities and must be part of a system for storage and distribution of clean and sterile supply materials.(5) A soiled utility room must contain a water closet or equivalent flushing rim fixture, a sink large enough to submerge a bedpan with spray hose and high-neck faucet with lever controls, work counter, waste receptacle, and linen receptacle. A soiled utility room must be part of a system for collection and cleaning or disposal of soiled utensils or materials. A separate hand-washing sink must be provided if the bedpan disinfecting sink cannot normally be used for hand-washing.(6) Provision must be made for convenient and prompt 24-hour distribution of medication to residents. The medication preparation room must be under the nursing staff's visual control and contain a work counter, refrigerator, sink with hot and cold water, and locked storage for biologicals and drugs and must have a minimum area of 50 square feet. The minimum dimension allowed is five feet six inches. An appropriate air supply must be provided to maintain adequate temperature and ventilation for safe storage of medications. For purposes of storage of unrefrigerated medications, the room temperature must be maintained between 59 degrees and 86 degrees Fahrenheit.(7) Provision must be made for separate closets or room for clean linens. Corridors must not be used for folding or cart storage. Storage rooms must be located and distributed in the building for efficient access to bedrooms.(8) A soiled linen rooms must meet the requirements in subsection (l)(2)(A) of this section.(9) A nourishment station is required and must contain a sink equipped for hand-washing, equipment for serving nourishment between scheduled meals, refrigerator, and storage cabinets. Ice for residents' service and treatment must be provided only by icemaker units. This station may be furnished in a clean utility room.(10) An equipment storage room must be provided for equipment such as intravenous stands, inhalators, air mattresses, and walkers.(11) Parking spaces for stretchers and wheelchairs must be located out of the path of normal traffic.(c) Residents' bathing and toilet facilities. The following requirements are applicable to bathing and toilet facilities:(1) Bathtubs or showers must be provided at the rate of one for each 20 beds which are not otherwise served by bathing facilities within residents' rooms. At least one bathing unit must be provided in each nursing unit. Each tub or shower must be in an individual room or enclosure which provides space for the private use of the bathing fixture, for drying and dressing, including an accessible dressing bench, and for a wheelchair and an attendant. Each general-use bathing room must be provided with at least one water closet in a stall, room, or area for privacy, and one lavatory. A bathing room must be located conveniently to the bedroom area it serves and must not be more than 100 feet from the farthest bedroom. (2) At least 50% of bathrooms and toilet rooms, fixtures, and accessories must be designed and provided to meet criteria under the Americans with Disabilities Act for individuals with disabilities, unless otherwise approved by HHSC.(3) All rooms containing bathtubs, sitz baths, showers, and water closets, used by residents must be equipped with doors and hardware that permits access from the outside in any emergency.(4) Bathing areas must be provided with safe and effective auxiliary or supplementary heating. Bathing areas must be free of drafts and must have adequate exhaust ducted to the outside to minimize excess moisture retention and resulting mold and mildew problems.(5) Tubs and showers must be provided with slip-proof bottoms.(6) Lavatories and hand-washing facilities must be securely anchored to withstand an applied downward load of not less than 250 pounds on the front of the fixtures.(7) Provision must be made for sanitary hand drying and toothbrush storage at lavatories. There must be paper towel dispensers or separate towel racks and separate toothbrush holders.(8) Mirrors must be arranged for convenient use by residents in wheelchairs as well as by residents in a standing position, and the minimum size must be 15 inches in width by 30 inches in height, or tilt type.(9) Rooms with toilets must be provided with effective forced air exhaust ducted to the exterior to remove odors. Ducted manifold systems are recommended.(10) Floors, walls, and ceilings must have nonabsorbent surfaces, be smooth, and be easily cleanable.(d) Disposal facilities. A policy and procedure for the safe and sanitary disposal of special waste must be provided. Space and facilities must be provided for the sanitary storage of waste by incineration, mechanical destruction, compaction, containerization, removal, or by a combination of these techniques.(e) Resident living areas. The following requirements are applicable to resident living areas:(1) Social-diversional spaces such as living rooms, dayrooms, lounges, and sunrooms, must be provided on a sliding scale as follows:Attached Graphic(2) If a required way of exit, or a service way, is through a living or dining area, a pathway equal to the corridor width must be deducted for calculation purposes and discounted from that area. These exit pathways must be kept clear of obstructions.(3) Each resident living room and dining room must have at least one outside window. The window area must be equal to at least 8.0% of the total room floor area. Sky-lighting may be used to fulfill one-half of the 8.0% minimum area.(4) Open or enclosed seating space must be provided within view of the main nurses' station that will allow furniture or wheelchair parking that does not obstruct the corridor way of egress.(f) Dining space. Dining space must be adequate for the number of residents served, but no less than ten square feet per resident bed. (g) Dietary facilities. The following requirements are applicable to dietary facilities:(1) A main or dietary kitchen must be as follows:(A) A kitchen will be evaluated on the basis of its performance in the sanitary and efficient preparation and serving of meals to residents. Consideration will be given to planning for the type of meals served, the overall building design, the food service equipment, the arrangement, and the work flow involved in the preparation and delivery of food. Plans must include a large-scale detailed kitchen layout designed by a registered or licensed dietitian or architect having knowledge in the design of food service operations.(B) Kitchens must be designed so that room temperature at summertime peak load will not exceed a temperature of 85 degrees Fahrenheit measured at the five-foot level. The amount of supply air must take into account the large quantities of air that may be exhausted at the range hood and dishwashing area.(C) Operational equipment must be provided as planned and scheduled by the facility consultants for preparing and serving meals and for refrigerating and freezing of perishable foods, as well as equipment in, or adjacent to, the kitchen or dining area for producing ice.(D) Facilities for washing and sanitizing dishes and cooking utensils must be provided. These facilities must be designed based on the number of meals served and the method of serving, that is, use of permanent or disposable dishes. The kitchen must contain a multi-compartment sink large enough to immerse pots and pans. A mechanical dishwasher is required for washing and sanitizing dishes. Separation of soiled and clean dish areas must be maintained, including air flow.(E) A vegetable preparation sink must be provided, and it must be separate from the pot sinks.(F) A supply of hot and cold water must be provided. Hot water for sanitizing purposes must be 180 degrees Fahrenheit or the manufacturer's suggested temperature for chemical sanitizers. For mechanical dishwashers, the temperature measurement is at the manifold.(G) A kitchen must be provided with a hand-washing lavatory in the food preparation area with hot and cold water, soap, paper towel dispenser, and waste receptacle. The dish room area must have ready access to a hand-washing lavatory.(H) Staff rest room facilities with lavatory must be directly accessible to kitchen staff without traversing resident use areas. A facility must provide a vestibule so the rest room door does not open directly into the kitchen.(I) Janitorial facilities must be provided exclusively for the kitchen and must be located in the kitchen area.(J) Nonabsorbent smooth finishes or surfaces must be used on kitchen floors, walls, and ceilings. These surfaces must be capable of being routinely cleaned and sanitized to maintain a healthful environment. Counter and cabinet surfaces, inside and outside, must also have smooth, cleanable, relatively nonporous finishes.(K) Operable windows must have insect screens provided.(L) Doors between kitchen and dining or serving areas must have a safety glass view panel.(M) A garbage can or cart washing area with drain and hot water must be provided.(N) Floor drains must be provided in the kitchen and dishwashing areas.(O) Vapor removal from cooking equipment must be designed and installed in accordance with NFPA 101.(P) Grease traps must be provided in compliance with local plumbing code or other nationally recognized plumbing code.(2) Food storage areas must be as follows:(A) Food storage areas must provide for storage of a seven-day minimum supply of nonperishable foods at all times.(B) Shelves must be adjustable wire type. Walls and floors must have a nonabsorbent finish to provide a cleanable surface. No foods may be stored on the floor; dollies, racks, or pallets may be used to elevate foods not stored on shelving.(C) Dry food storage must have an effective venting system to provide for positive air circulation.(D) The maximum room temperature for food storage must not exceed 85 degrees Fahrenheit at any time. The measurement must be taken at the highest food storage level but not less than five feet from the floor.(E) Food storage areas may be located apart from the food preparation area as long as there is space adjacent to the kitchen for necessary daily usage.(3) An auxiliary serving kitchen not contiguous to a food preparation or serving area must be as follows:(A) If a service area other than the kitchen is used to dispense food, it must be designated as a food service area and must have equipment for maintaining required food temperatures while serving.(B) Separate food service areas must have hand-washing facilities as a part of the food service area.(C) Finishes of all surfaces, except ceilings, must be the same as those required for dietary kitchens or comparable areas. See paragraph (1)(J) of this subsection.(h) Administrative and public areas.(1) The following elements must be provided in the public area:(A) The entrance must be at grade level, sheltered from the weather, and able to accommodate wheelchairs. A drive-under canopy must be provided for the protection of residents or visitors entering or leaving a vehicle. The drive-under canopy may be a secondary entrance.(B) The lobby, which may also be designed to satisfy a portion of the minimum area required for resident living room space, must include:(i) storage space for wheelchairs if more than one is kept available;(ii) a reception or information area, which may be adjacent to the lobby if the location is obvious;(iii) waiting space;(iv) public toilet facilities for individuals with disabilities, which may be adjacent to the lobby;(v) at least one public access telephone, installed to meet standards under the Americans with Disabilities Act; and(vi) a drinking fountain, which may be provided in a common public area and at least one of which must be installed to meet standards under the Americans with Disabilities Act.(2) The following must be provided in the administrative area:(A) General or individual offices must be provided for business transactions, medical and financial records, administrative and professional staff, and for private interviews relating to social service, credit, and admissions.(B) A multipurpose room must be provided for conferences, meetings, and health education purposes including facilities for showing visual aids.(C) Storage and work area for office equipment and supplies must be provided and accessible to the staff using such items.(3) Toilet facilities for the disabled must be available in the building.(i) Physical therapy facilities.(1) Physical therapy facilities must be provided if required by the treatment program. The facilities stated in subparagraph (B) of this paragraph and paragraph (2)(C) - (E) of this subsection may be planned and arranged for shared use by occupational therapy residents and staff if the treatment program reflects this sharing concept. Physical therapy facilities must include the following:(A) Provision for privacy at each individual treatment area; hand-washing facilities, one lavatory or sink may serve more than one cubicle; and facilities for the collection of soiled linen and other material that may be used in the therapy. (B) Residents' dressing areas with accessible benches, showers, lockers, and toilet rooms if the therapy is such that these would be needed at the area.(2) Physical therapy facilities may also include the following:(A) treatment areas with space and equipment for the therapies provided;(B) an exercise area;(C) storage for clean linen, supplies, and equipment used in therapy;(D) service sink located near therapy area; and(E) wheelchair and stretcher storage.(j) Occupational therapy facilities. Occupational therapy facilities must be provided if required by the treatment program.(1) An activities area with a sink or lavatory and facilities for collection of waste products prior to disposal must be provided.(2) Storage for supplies and equipment used in the therapy must be provided.(k) Personal grooming area, such as a barber or beauty shop. A separate room with appropriate equipment must be provided for hair care and grooming needs of residents in facilities with over 60 beds.(l) Laundry and linen services.(1) On-site processing must be as follows:(A) Because of the high incidence of fires in laundries, it is highly recommended that the laundry be in a separate building 20 feet or more from the main building. If the laundry is located within the main building it must be separated by minimum one-hour fire resistance-rated construction to structure above, and sprinklered, and must be located in a remote area away from resident sleeping areas. Access doors must be from the exterior or interior nonresident use area, such as a service corridor, that is separated from the resident area.(B) If linen is to be processed on the site, the following must be provided:(i) A soiled linen receiving, holding, and sorting room with a rinse sink. This area must have a floor drain and forced exhaust to the exterior which must operate at all times there is soiled linen being held in the area.(ii) A laundry processing room with equipment which can process seven days' worth of laundry within a regularly scheduled work week. Hand-washing facilities must be provided. The washer area must have:(I) a floor drain;(II) storage for laundry supplies;(III) a clean linen inspection and mending room or area and a folding area;(IV) a clean linen storage, issuing, or holding room or area;(V) a janitors' closet containing a floor receptor or service sink and storage space for housekeeping equipment and supplies; and(VI) sanitizing and washing facilities and a storage area for carts.(C) Soiled and clean operations must be planned to maintain sanitary flow of functions as well as air flow. If carts containing soiled linens from resident rooms are not taken directly to the laundry area, intermediate holding rooms must be provided and located convenient to resident bedroom areas.(D) Laundry areas must have adequate air supply and ventilation for staff comfort without having to rely on opening a door that is part of the fire wall separation.(E) Provisions must be made to exhaust heat from dryers and to separate dryer make-up air from the habitable work areas of the laundry.(2) For off-site linen processing, the following must be provided on the premises:(A) a soiled linen holding room with adequate forced exhaust ducted to the exterior;(B) clean linen receiving, holding, inspection, sorting or folding, and storage rooms; and(C) sanitizing facilities and storage area for carts.(3) Resident-use laundry, if provided, must be limited to not more than one residential type washer and dryer per laundry room. This room must be classified as a hazardous area according to NFPA 101.(m) General storage. The following requirements are applicable to general storage facilities:(1) A general storage room must be provided as needed to accommodate the facility's needs. It is recommended that a general storage area provide at least two square feet per resident bed. This area would be for items such as extra beds, mattresses, appliances, and other furnishing and supplies.(2) Storage space with provisions for locking and security control must be provided for residents' personal effects which are not kept in their rooms.(n) Janitors' closet. In addition to the janitors' closet called for in certain departments, a sufficient number of janitors' closets must be provided throughout the facility to maintain a clean and sanitary environment. These must contain a floor receptor or service sink and storage space for housekeeping equipment and supplies.(o) Maintenance, engineering service, and equipment areas. Space and facilities for adequate preventive maintenance and repair service must be provided. The following spaces are needed and it is suggested that these be part of a separate laundry building or area:(1) A storage area for building and equipment maintenance supplies, tools, and parts must be provided.(2) A space for storage of yard maintenance equipment and supplies, including flammable liquids bulk storage, must be provided separate from the resident-occupied facility.(3) A maintenance and repair workshop of at least 120 square feet and equipment to support usual functions is recommended.(4) A suitable office or desk space for the maintenance staff is recommended. This space may be located within the repair shop area with space for catalogs, files, and records.(p) Oxygen. The storage and use of oxygen and oxygen equipment must meet applicable NFPA standards for gas equipment, including NFPA 99. Piped medical gas and vacuum systems must comply with §19.360(e) of this subchapter (relating to Mechanical Requirements for New Facilities). Source Note: The provisions of this §554.354 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.354 Architectural Space Planning and Utilization for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203065 03/12/2026 Exit provisions, including doors, corridors, stairways, other exit-ways, locks, and other applicable items must conform to the requirements of NFPA 101 concerning means of egress and to this section to ensure that residents can be rapidly and easily evacuated from the building at all times, or from one part of the building to a safe area of refuge in another part of the building. Exit provisions are as follows:(1) Bedroom space arrangement and doors and corridors must be designed for evacuation of bedfast residents by means of rolling the bed to a safe place in the building or to the outside.(2) Public assembly rooms, common living rooms, dining rooms, and other rooms with a capacity of 50 or more persons or greater than 1,000 square feet in area must have two means of egress remote from each other. Out-swinging doors with panic hardware must be provided for these egress doors.(3) Exit doors and ways of egress must be maintained clear and free for use at all times, except as permitted by NFPA 101. Furnishings, equipment, carts, and other obstacles must not be left to block egress at any time, except as permitted by NFPA 101.(4) Steps in interior ways of egress are prohibited. If changes of elevation are necessary within ways of egress, approved ramps with a maximum slope of one unit of rise to 12 units of run must be provided.(5) Doors in means of egress must be as follows:(A) Locking hardware or devices which are capable of preventing or inhibiting immediate egress must not be used in any room or area that can be occupied.(B) A latch or other fastening device on an exit door must be provided with a knob, handle, panic bar, or similar releasing device. The method of operation must be obvious in the dark, without use of a key, and operable by a well-known, one-action operation that will easily operate with normal pressure applied to the door or to the device toward the exterior. Locking hardware which prevents unauthorized entry from the outside is permissible. Self-closing devices and permanently mounted hold-open devices to expedite emergency egress and prevent accidental lock-out must be provided for exterior exit doors.(C) No screen or storm door may swing against the direction of exit travel when main doors are required to swing out.(D) To aid in control of wandering residents, buzzers or other sounding devices may be used to announce the unauthorized use of an exit door. Other methods include approved emergency exit door locks or fencing with a gate outside of exit doors which enclose a space large enough to allow the space to be an exterior area of egress and refuge away from the building.(E) Inactive leaves of double doors may have easily accessible and easily operable bolts if the active leaf is 44 inches wide, where permitted by NFPA 101. Center mullions are prohibited.(F) Resident baths or toilets having privacy locks will require that keys or devices for opening the doors are kept readily available to the staff.(G) Folding doors must not be used in exit corridors or other means of egress. Sliding doors, when permitted by NFPA 101, may be used as secondary doors from residents' bedrooms to grade or to a balcony, or in certain other areas, when permitted by NFPA 101. Corridor doors to rooms must swing into the room or be recessed so as not to extend into the corridor when open; however, doors ordinarily kept closed may be excepted.(6) Horizontal exits, if provided, must be according to NFPA 101.(7) Areas outside of exterior exit or discharge doors must be as follows:(A) Provision must be made to facilitate continuation of emergency egress away from a building for a reasonable distance beyond the outside exit door, especially for movement of non-ambulatory residents in wheelchairs and beds. Any condition which may retard or halt free movement and progress outside the exit doors will not be allowed. Ramps must be used outside the exit doors in lieu of steps whenever possible.(B) The landing outside of each exit door must be essentially the same elevation as the interior floor and level for a distance equal to the door width plus at least four feet. Generally, the difference in floor elevation at an exterior door must not be over 1/2 inch with the outside slope not to exceed 1/4 inch per foot sloping away from the door for drainage on the exterior. In locations north of the +20 Fahrenheit Isothermal Line as defined in the ASHRAE Handbook of Fundamentals, the landing outside of all exit doors must be protected from ice build-up which would prohibit the door from opening or would be a slip hazard.(C) Emergency egress lighting immediately outside of exit doors is required as a part of the building emergency lighting system. Photocell devices may be used to turn lights off during daylight hours.(8) The requirements of an emergency lighting system must be in accordance with §19.361 of this division (relating to Electrical Requirements for New Facilities). Source Note: The provisions of this §554.355 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.355 Exit Provisions for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203066 03/12/2026 (a) Smoke compartments must be as described in NFPA 101 and in this section.(b) A facility must provide an exit sign on each side of corridor smoke barrier doors, unless otherwise directed by HHSC.(c) The metal frame for a vision panel in a smoke barrier door must be steel, unless otherwise approved by HHSC. The bottom of a vision panel must be located no more than 43 inches above the floor. A facility must provide push or pull hardware on pairs of opposite swinging, double egress smoke barrier doors in corridors. Door leaves must align in the closed position.(d) A facility must provide prominent signs on each side of smoke barrier walls in concealed spaces such as attics. The signs must state: "Warning: Smoke/fire barrier. Properly seal all openings."(e) A facility must provide reasonable access to concealed smoke barrier walls for maintaining smoke dampers, where provided, so that walls and dampers can periodically be visually checked for conformance by facility staff, service personnel, and inspectors. A facility must provide access to both sides of the wall, and to all parts, end-to-end and top-to-bottom. A facility must provide prefabricated metal ceiling access panels, or their equivalent, that are at least 20 inches wide by 20 inches long. Ceiling access panels must be fire resistance-rated if required to maintain the fire resistance rating of a roof-ceiling or floor-ceiling assembly.(f) A facility should design air systems to avoid ducts that penetrate smoke barrier walls, thus eliminating the need for smoke dampers which are often a problem to maintain in proper working condition. Source Note: The provisions of this §554.356 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.356 Smoke Compartments (Subdivision of Building Spaces) for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203067 03/12/2026 (a) Fire protection systems include detection, alarm, and communication systems; fixed automatic extinguishment systems; and portable extinguishers. These systems must meet the requirements of NFPA 101, and of this section. Components must be compatible and listed by a nationally recognized testing laboratory for the intended use.(b) Fire protection systems must meet the requirements of all applicable NFPA standards, such as NFPA 72 for alarm systems, as referenced in NFPA 101. Wiring and circuitry for alarm systems must meet the applicable requirements of NFPA standards, including NFPA 70.(c) Emergency electrical systems must meet the requirements of this division.(d) A fire alarm system must be installed, maintained, and repaired by an agent having a current certificate of registration from the State Fire Marshal's Office, according to state law. The agent must provide a Fire Alarm Installation Certificate to the facility as required by the State Fire Marshal's Office.(e) A fire alarm system must be designed so that whenever a general alarm is sounded by activation of any device, such as a manual pull, smoke detector, fire sprinkler, or kitchen range hood extinguisher, the following must occur automatically:(1) smoke and fire doors which are held open by approved devices must be released to close;(2) air conditioning or heating distribution fans serving three or more rooms, or any means of egress, must shut down immediately;(3) smoke dampers must close; and(4) the location of an alarm-initiating device must be clearly indicated on the fire alarm control panel and all auxiliary panels.(f) Fire alarm bells or horns must be located throughout the building for audible coverage. Flashing visual alarm lights must be installed to be visible in corridors and public areas, including dining rooms and living rooms, in a manner that will identify exit routes.(g) A master control panel, or a fire alarm annunciator panel providing annunciation of all fire alarm signals, that annunciates the location of all alarm, trouble, and supervisory signals, by zone or device, must be visible at the main nurses' station. Fire alarm system components must be listed as compatible by a nationally recognized testing laboratory. In a zone-based fire alarm system alarm and trouble zones must align with smoke compartments and with floors in multi-story buildings.(h) A remote annunciator panel, indicating location of alarm initiation and trouble indication, by zone or device, must be located at auxiliary or secondary nurses' stations on each floor, and must indicate the alarm condition of adjacent zones and the alarm conditions at all other nurses' stations.(i) A manual pull station must be provided at all exits, in living rooms and dining rooms, and at or near a nurses' station.(j) The flow and tamper conditions of a sprinkler system must be monitored by the fire alarm system.(k) A kitchen range hood extinguisher, if required by NFPA 101 and this subchapter, must be interconnected with the fire alarm system. This interconnection may report as a separate zone on the fire alarm control panel or may be combined with other initiating devices located in the same zone as the range hood is located.(l) Portable fire extinguishers must be provided throughout the facility as required by NFPA 10 and as determined by the local fire department and HHSC. The following requirements are applicable to fire extinguishers:(1) Extinguishers in resident corridors must be located so the travel distance from any point to an extinguisher does not exceed 75 feet. Water-type extinguishers must have a capacity of at least 2 1/2 gallons. Dry chemical-type extinguishers must be at least 5 pound ABC extinguishers.(2) An extinguisher must be installed on a hanger or bracket supplied with the extinguisher or mounted in an approved cabinet. A recessed cabinet is required for an extinguisher located in a corridor.(3) An extinguisher must be protected from impact or dislodgement.(4) An extinguisher having a gross weight not exceeding 40 pounds must be installed so the top of the extinguisher is located no more than five feet above the floor. An extinguisher having a gross weight greater than 40 pounds must be installed so the top of the extinguisher is located no more than 3-1/2 feet above the floor. In no case may the clearance between the bottom of an extinguisher and the floor be less than four inches.(5) A portable extinguisher provided in a hazardous room must be located as close as possible to the exit door opening and on the latch side. Source Note: The provisions of this §554.357 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.357 Fire Protection Systems for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203068 03/12/2026 (a) Protection from hazardous areas must be as required in NFPA 101, except as required or modified in this section. Gas-fired equipment must not be located in attic spaces, except under the following conditions:(1) the area around the units must have a one-hour fire resistance rating;(2) the enclosure must have sprinkler protection; and(3) combustion and venting air must be ducted from the exterior in properly sized metal ducts.(b) Laboratories must be protected according to NFPA 99.(c) Cooking equipment must be protected according to NFPA 101.(d) Doors to hazardous areas must have closers and must be kept closed unless provided with an approved hold-open device such as an alarm activated magnetic hold-open device, as permitted by NFPA 101. Doors must be single-swing type with positive latching hardware. View panels at laundry entrances must be provided and be of materials adequate to maintain the integrity of the door as allowed by NFPA 101. Source Note: The provisions of this §554.358 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.358 Hazardous Areas for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203069 03/12/2026 (a) Every building and portion of a building must be capable of sustaining all dead and live loads in accordance with accepted engineering practices and standards.(b) Special provisions must be made in the design of buildings in regions where local experience shows loss of life or extensive damage to buildings resulting from hurricanes, tornadoes, earthquakes, or floods.(c) The facility is responsible for employing qualified personnel in the preparation of plan designs and engineering and in the construction of the facility to ensure that all structural components are adequate, safe, and meet the applicable construction requirements.(d) The design of the structural system must be done by or under the direction of a professional structural engineer who is currently licensed by the Texas Board of Professional Engineers according to state law.(e) The parts of the plans, details, and specifications covering the structural design must bear the legible seal of the engineer on the original drawings from which the prints are made.(f) A building must be constructed according to the locally adopted building code. NFPA 101 must be used for fire safety requirements. Discrepancies between the codes must be called to the attention of HHSC for resolution.(g) In the absence of a locally-adopted building code, a building must meet the requirements of a nationally recognized model building code. NFPA 101 must be used for fire safety requirements.(h) Each building must be classified as to building construction type for fire resistance rating purposes according to NFPA 220 and NFPA 101.(i) Enclosures of vertical openings between floors must meet NFPA 101.(j) All interior walls, partitions, and roof structure in buildings of fire resistive and noncombustible construction must be according to NFPA 101.(k) Building insulation materials, unless sealed on all sides and edges in an approved manner, must have a flame spread rating of 25 or less when tested according to ASTM E84 or UL 723. Source Note: The provisions of this §554.359 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.359 Structural Requirements for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203070 03/12/2026 (a) The design of the mechanical systems must be done by or under the direction of a licensed professional mechanical engineer approved by the Texas Board of Professional Engineers to operate in Texas, and the parts of the plans and specifications covering mechanical design must bear the legible seal of the engineer.(1) Building services pertaining to utilities; heating, ventilating, and air-conditioning systems; vertical conveyors; and chutes must be according to NFPA 101.(2) Required plumbing fixtures must be according to NFPA 101 and §19.354 of this division (relating to Architectural Space Planning and Utilization for New Facilities) in specific use areas.(b) Plumbing.(1) All plumbing systems must be designed and installed according to the requirements of the locally adopted plumbing code. In the absence of a locally-adopted plumbing code, a nationally recognized model plumbing code must be used. Any discrepancy between an applicable code and the requirements of this section must be called to the attention of HHSC for resolution.(2) Supply systems must ensure adequate hot and cold water. In addition to hot water for kitchen and laundry use, a rule-of-thumb for hot water for resident use at 110 degrees Fahrenheit is to provide 6-1/2 gallons per hour per resident.(3) Water must be supplied from a system approved by the Water Supply Division of TCEQ, or from a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Supply Division of TCEQ.(4) The sewage system must connect to a system permitted by the Water Quality Division of TCEQ, or to a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Water Quality Division of TCEQ.(5) The minimum ratio of fixtures to residents shall be as required in §19.354(c) of this division.(6) For design calculation purposes, resident-use hot water must not exceed 110 degrees Fahrenheit at the fixture. For purposes of conforming to licensure requirements, an operating system providing water from 100 degrees Fahrenheit to 115 degrees Fahrenheit is acceptable. Hot water for laundry and kitchen use must be normally 140 degrees Fahrenheit. Hot water for dish sanitizing must be 180 degrees Fahrenheit.(7) A facility must provide water closets with a seat height 17 inches to 19 inches from the floor for persons with disabilities.(8) Showers for wheelchair residents must not have curbs. Tub and shower bottoms must have a slip-resistant surface. Shower and tub enclosures, other than curtains, must be of tempered glass, plastic, or other safe material.(9) Drinking fountains must not extend into exit corridors.(10) A facility must provide fixture controls easily operable by residents, such as lever-type controls.(11) Plumbing fixtures for residents must be vitreous china or porcelain finished cast iron or steel unless otherwise approved by HHSC. Fiberglass bathing units are acceptable if they have a Class B flame spread rating when tested according to ASTM E84.(12) Hand-washing sinks for staff use must be according to §19.354 of this division. A facility must provide lavatories adjacent to all water closets.(13) A soiled utility room must be provided with a flushing device, such as a water closet with bedpan lugs; a spray hose with a siphon breaker or similar device, such as a high neck faucet with lever controls; and a deep sink that is large enough to submerse a bedpan. A sterilizer may be used for sanitizing in place of a deep sink.(14) A facility must install a siphon breaker or back-flow preventer with any water supply fixture if the outlet or attachments may be submerged.(15) A facility must provide clean-outs for waste piping lines located so there is the least physical and sanitary hazard to residents. To avoid contamination, clean-outs must open to the exterior, where possible.(16) A facility with a boiler must meet all applicable requirements of Texas Health and Safety Code Chapter 755.(c) Heating, Ventilating, and Air-Conditioning (HVAC) and Exhaust Systems(1) General Requirements.(A) HVAC systems must be designed and installed in accordance with ASHRAE standards, except as may be modified by this section.(B) HVAC systems serving spaces or providing health functions covered by NFPA 99 must be commissioned as required by NFPA 99.(C) HVAC systems must meet the requirements of NFPA 90A and NFPA 99.(D) Mechanical plans must bear a statement verifying that the systems are designed according to NFPA 90A and NFPA 99.(E) All air-supply and air-exhaust systems must be mechanically-operated.(F) Ducts must be of metal or other approved noncombustible material. Cooling ducts must be insulated against condensation.(G) Static pressures of systems must be within limits recommended by ASHRAE and the equipment manufacturer, both upstream and downstream.(2) Heating and Cooling.(A) A facility must provide heating and cooling by a central air conditioning system, or a substantially similar air conditioning system. Air conditioning systems must be designed, installed and functioning to maintain temperatures suitable for resident comfort within all areas used by residents.(B) Design temperatures for heating and cooling must be as required by NFPA 99.(C) A heating system must be able to maintain a temperature of at least 75 degrees Fahrenheit for all areas occupied by residents. For all other occupied areas, a heating system must be able to maintain a temperature of at least 72 degrees Fahrenheit.(D) A cooling system must be able to maintain a temperature of not more than 78 degrees Fahrenheit.(E) Occupied areas generating high heat, such as kitchens, must be provided with a sufficient cool air supply to maintain a temperature not exceeding 85 degrees Fahrenheit at the five-foot level. Supply air volume must be approximately equal to the air volume exhausted to the exterior for these areas.(F) The location and design of air diffusers, registers, and return air grilles must ensure that residents are not in harmful or excessive drafts in their normal usage of the room.(G) In geographic locations or interior room areas where extreme humidity levels are likely to occur for extended periods of time, apparatus for controlling humidity levels with automatic humidistat controls, preferably at 40-60% relative humidity, are recommended as part of central systems.(H) Unvented space heaters and portable heating units must not be used. Heating devices or appliances must not be a burn hazard to residents.(I) Gas-fired Heating Equipment.(i) Systems using liquefied petroleum gas fuel must meet the requirements of the Railroad Commission of Texas and NFPA 58.(ii) A combustion fresh air inlet must be provided to all gas or fossil fuel operated equipment in steel ducts or passages from outside the building according to NFPA 54. Combustion air must be provided through two permanent openings, one commencing within 12 inches of the floor and one commencing within 12 inches of the ceiling.(iii) A room where gas-fired heating equipment is located must be vented to the exterior to exhaust heated ambient air in the room.(3) Ventilation.(A) Air systems must provide for mixing at least 10% outside air for the supply distribution. Blowers for central heating and cooling systems must be designed so that they may run continuously.(B) A facility must locate an outdoor air intake according to NFPA 99 and as far as practical, but not less than 10 feet, from exhaust outlets or ventilating systems, combustion equipment stacks, medical vacuum systems, plumbing vent stacks, or areas which may collect vehicular exhaust and other noxious fumes.(C) Fresh air inlets must be appropriately screened to prevent entry of debris, rodents, and animals. A facility must provide access to such screens for periodic inspection and cleaning to eliminate clogging or air stoppage.(D) A facility must incorporate natural ventilation using windows or louvers, if possible and practical. Windows or louvers must have insect screens.(E) The design of ventilation systems must provide air movement that is from clean to less clean areas. The ventilation systems must be designed and balanced to provide the pressure relationships to adjacent spaces as required by NFPA 99. The installer must furnish and certify a final engineered system air balance report for the completed system. The report must demonstrate the pressure relationships required by NFPA 99.(F) Air supply to food preparation areas must not be from air that has circulated through places such as resident bedrooms and baths.(G) Ventilation rates for all areas of a facility must be as required by NFPA 99. These rates are the minimum acceptable rates, but do not preclude the use of higher ventilation rates.(H) The bottoms of ventilation openings must be at least three inches above the floor of any room.(I) A door protecting a corridor or way of egress must not include an air transfer grille or louver. A corridor must not be used to supply air to or exhaust air from any room except that air from a corridor may be used as make-up air to ventilate a small toilet room, a janitor's closet, or a small electrical or telephone closet opening directly on a corridor, provided the ventilation can be accomplished by door undercuts not exceeding 3/4 inches.(4) Exhaust.(A) A facility must provide forced air exhaust of all room air directly to the outdoors according to NFPA 99.(i) Areas such as laundries, kitchens, and dishwashing areas must exhaust all room air to the outdoors to remove excess heat and moisture and to maintain air flow in the direction of clean to soiled areas.(ii) Unsanitary areas, including janitor's closets, soiled linen areas, soiled workroom and utility areas, and soiled areas of laundry rooms, must exhaust all room air outdoors.(B) All exhaust must be continuously ducted to the exterior. Exhausting air into attics or other spaces is not permitted. Exhaust duct material must be metal.(C) Exhaust hoods, ducts, and automatic extinguishers for kitchen cooking equipment must be according to NFPA 96, when required by NFPA 101.(5) Integration with Building Construction.(A) Smoke compartmentation must meet the requirements of §19.356 of this division (relating to Smoke Compartments (Subdivision of Building Spaces) for New Facilities).(B) An air system must be designed as much as possible to avoid having ducts passing through fire walls or smoke barrier walls. All openings or duct penetrations in these walls must be according to NFPA 101.(C) A smoke damper at a smoke barrier must close automatically upon activation of the fire alarm system to prevent the flow of air or smoke in either direction, when required by NFPA 101.(D) A duct with a smoke damper must have maintenance panels for inspection. A maintenance panel must be removable without tools. A facility must provide access in the ceiling or side wall to facilitate smoke damper inspection. A facility must identify the location of dampers on the wall or ceiling of the occupied area below.(E) A central air supply system or a system serving a means of egress must automatically and immediately shut down upon activation of the fire alarm system, except when such a system is part of an engineered smoke-removal system approved by HHSC.(6) All ventilation or air-conditioning systems must be equipped with filters as required by NFPA 99. Filters must be of sufficient efficiency to minimize dust and lint accumulations throughout the system and building, including in supply and return plenums and ductwork. Filters must be easily accessible for routine changing or cleaning.(d) Sprinkler systems. The following requirements are applicable to sprinkler systems:(1) Sprinkler systems must be according to NFPA 13 and this subchapter.(2) The design and installation of sprinkler systems must meet any applicable state laws pertaining to these systems and one of the following criteria:(A) A sprinkler system must be designed by a qualified licensed professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. The engineer must supervise the installation and provide written approval of the completed installation.(B) A sprinkler system must be planned and installed according to NFPA 13 by a firm with a certificate of registration issued by the State Fire Marshal's Office. The RME's license number and signature must be included on the prepared sprinkler drawings.(3) A facility must ensure all sprinkler piping is protected against freezing. The design of freeze protection must minimize the need for dependence on staff action or intervention to provide protection.(e) Piped gas and vacuum systems. A piped medical gas or medical vacuum system, including a piped oxygen system, a vacuum system, or a drive gas system such as a compressed air system, must be designed, installed, operated and managed according to the requirements of NFPA 99 for new health care facilities, and based on the risk category determined by the assessment required by §19.300(i) of this subchapter (relating to General Requirements). Source Note: The provisions of this §554.360 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.360 Mechanical Requirements for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207302 03/12/2026 (a) The design of the electrical systems must be done by or under the direction of a licensed professional electrical engineer approved by the Texas Board of Professional Engineers and Land Surveyors to operate in Texas, and the parts of the plans and specifications covering electrical design must bear the legible seal of the engineer.(1) Utilities; heating, ventilating, and air-conditioning systems; vertical conveyors; and chutes must meet the requirements of NFPA 101, Chapter 9, Building Service and Fire Protection Equipment.(2) Fire protection systems, including fire alarms, must meet the requirements of §554.357 of this division (relating to Fire Protection Systems for New Facilities).(3) Lighting and outlets at resident bedrooms must meet the requirements of §554.354 of this division (relating to Architectural Space Planning and Utilization for New Facilities).(b) Electrical systems.(1) Electrical systems must meet the installation requirements of NFPA 70.(2) Electrical systems must meet the performance requirements of NFPA 99.(3) Branch circuits serving resident bedrooms must meet the requirements of NFPA 99.(4) Essential Electrical System (EES).(A) To provide electricity during an interruption of the normal electric supply, an emergency source of electricity must be provided and connected to certain circuits for lighting and power. All facilities covered by this section must comply with the EES requirements for new health care facilities in NFPA 99, based on the risk category determined by the assessment required by §554.300(i) of this subchapter (relating to General Requirements).(i) If the determined risk category is Category 2, as defined in NFPA 99, the EES must meet the requirements for a Type II EES according to NFPA 99.(ii) If the determined risk category is Category 1, as defined in NFPA 99, the EES must meet the requirements for a Type I EES according to NFPA 99.(iii) A Type I EES serving a portion of a facility categorized as Category 1 risk is permitted to also serve a portion of the same facility categorized as Category 2 risk.(iv) Distribution requirements for Type I or Type II EES must be according to NFPA 99.(B) In addition to systems and devices required for the type of EES installed, the following systems and devices must be connected to the appropriate branches of the EES, according to NFPA 99:(i) illumination for the following areas:(I) means of egress, including areas immediately outside of exit doors;(II) nurses' stations;(III) medication rooms;(IV) dining, living, and recreation rooms, including activity rooms;(V) bathing rooms not directly connected to resident bedrooms;(ii) exit signs and exit directional signs as required by NFPA 101;(iii) alarm systems, including fire alarms and alarms required for nonflammable medical gas systems, if installed;(iv) task illumination and selected receptacles at the generator set location;(v) selected duplex receptacles including receptacles in such areas in resident corridors, at each resident bed location, in nurses' stations, and in medication rooms, including biologicals refrigerator;(vi) nurse call systems;(vii) resident room night lights;(viii) a light and receptacle in an electrical room or a boiler room;(ix) elevator cab lighting, control, and communication systems;(x) all facility telephone equipment;(xi) paging or speaker systems, if intended for communication during an emergency. Radio transceivers installed for emergency use must be capable of operating for at least one hour upon total failure of both normal and emergency power.(xii) Heating Equipment to Provide Heating for Resident Bedrooms. A facility must provide heating in resident bedrooms during disruption of the normal power source unless one of the following conditions applies:(I) The outside design temperature is higher than 20 degrees Fahrenheit (-6.7 degrees Celsius);(II) The outside design temperature is lower than 20 degrees Fahrenheit (-6.7 degrees Celsius) and, when selected rooms are provided for the needs of all residents, then only such rooms need be heated.(III) The facility is served by a dual source of normal power.(xiii) A facility must provide throw-over facilities to allow the temporary operation of any elevator for the release of passengers in instances when an interruption of power would result in elevators stopping between floors.(C) The emergency lighting must be automatically in operation within ten seconds after the interruption of the normal power supply. Emergency egress lighting must not be switched.(D) Receptacles and switches connected to emergency power must have red faceplates.(E) The design and installation of emergency motor generators must be according to NFPA 37, NFPA 99, and NFPA 110.(i) Nursing facilities and contiguous or same-site facilities, such as hospitals and assisted living facilities, may be served by the same generating equipment so long as the integrity of the individual facilities' emergency or back-up power systems is not compromised. This permission applies only to the generating equipment and not to automatic or manual transfer switches or to distribution systems.(ii) Generators must be located a minimum of three feet from a combustible exterior building finish and a minimum of five feet from a building opening, if located on the exterior of the building.(iii) A facility must provide a noncombustible protective cover or the protection recommended by the manufacturer when a generator is located on the exterior of the building.(iv) Stored fuel capacity must be sufficient for not less than four hours of required generator operation.(v) Motor generators fueled by public utility natural gas must have the capability to be switched to an alternate fuel source according to NFPA 70.(F) The wiring circuits for the EES must be kept entirely independent of all other wiring and must not enter the same race-ways, boxes, or cabinets according to NFPA 70.(G) A facility must meet the requirements for the administration of the EES, including maintenance and testing of the EES, according to the requirements of NFPA 99 for the type of EES installed, and the requirements of §554.326(d) of this subchapter (relating to Safety Operations).(5) General Lighting Requirements. General lighting requirements are as follows:(A) All spaces occupied by people, machinery, equipment, approaches to buildings, and parking lots must have lighting.(B) All quality, intensity, and type of lighting must be adequate and appropriate to the space and all functions within the space.(C) Minimum lighting levels can be found in the Illuminating Engineering Society Lighting Handbook, latest edition, but must not be lower than the following.(i) Minimum illumination must be 20 footcandles in resident rooms, corridors, nurses' stations, dining rooms, lobbies, toilets, bathing facilities, laundries, stairways, and elevators. Illumination requirements for these areas apply to lighting throughout the space and are measured at approximately 30 inches above the floor anywhere in the room.(ii) Minimum illumination for over-bed reading lamps, medication-preparation or storage area, kitchens, and nurses' station desks must be 50 footcandles. Illumination requirements for these areas apply to the task performed and are measured on the task.(D) A facility must provide general illumination, with provisions for reduction of light levels at night, in a nursing unit corridor.(E) A facility must provide a basket wire guard or other suitable shield to prevent breakage or contact between combustible materials and exposed incandescent light bulbs, or other high-heat generating lamps, in closets or other similar spaces.(F) Exposed incandescent or fluorescent bulbs are not permitted in food service or other areas where glass fragments from breakage may get into food, medications, linens, or utensils. A facility must protect all fluorescent bulbs with a shield or catcher to prevent bulb drop-out.(6) Receptacles or convenience outlets.(A) Receptacles in bedrooms must meet the requirements in §554.354(a)(6) of this division (relating to Architectural Space Planning and Utilization for New Facilities).(B) Duplex receptacles for general use must be installed in corridors spaced not more than 50 feet apart and within 25 feet of ends of corridors. A facility must provide at least one duplex receptacle with emergency electrical service in each resident corridor.(C) Receptacles must be provided with emergency electrical service for essential needs such as medication refrigerators and systems or equipment whose failure is likely to result in major injury or death to a resident.(D) Receptacles in the remainder of the building must be sufficient to serve the present and future needs of residents and equipment.(E) Location of receptacles, horizontally and vertically, should be carefully planned and coordinated with the expected designed use of furnishings and equipment to maximize their accessibility and to minimize conditions such as beds or furniture being jammed against plugs used in the outlets.(F) Exterior receptacles must be an approved waterproof type.(G) A facility must provide ground fault interruption protection at appropriate locations such as at whirlpools and other wet areas according to the NFPA 70.(c) Nurse call systems.(1) A nurse call system consists of power units, annunciator control units, corridor dome stations, emergency call stations, bedside call stations, and activating devices. The units must be compatible and laboratory listed by a nationally recognized testing laboratory for the system and use intended.(2) Each resident bedroom must be served by at least one call station and each bed must be provided with a call switch. Two call switches serving adjacent beds may be served by one call station. Each call entered into the system must activate a corridor dome light above the bedroom, bathroom, or toilet room corridor door, a visual signal at the nurses' station which indicates the room from which the call was placed, and a continuous or intermittent continuous audible signal of sufficient amplitude to be clearly heard by nursing staff. The amplitude or pitch of the audible signal must not be such that it is irritating to residents or visitors. The system must be designed so that calls entered into the system may be canceled only at the call station. Intercom-type systems which meet this requirement are acceptable.(3) A nurse call system that provides two-way voice communication must be equipped with an indicating light at each call station which lights and remains lighted as long as the voice circuit is operating.(4) A nurse call emergency switch must be provided for resident use at each resident's toilet, bath, and shower. These switches must be usable by residents using the fixtures and by a collapsed resident lying on the floor.(5) A nurse call system must meet UL 1069 for the core system of power units, annunciator control units, corridor dome lights, emergency call stations, bedside call stations, and activating devices; and(6) An ancillary or supplemental device, including a pocket pager or other portable device, is not required to meet UL 1069. Source Note: The provisions of this §554.361 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.361 Electrical Requirements for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203072 03/12/2026 (a) Safety related details. A high degree of safety for the occupants is needed to minimize accidents more apt to occur with the residents in a nursing facility. Consideration must be given to the fact that many have impaired vision, hearing, spatial perception, and ambulation.(1) Hazards such as sharp corners, edges, or unexpected steps must be avoided.(2) Drinking fountains, telephone booths, vending machines, and portable equipment must not restrict corridor traffic or reduce corridor width.(3) Windows must be designed to prevent residents from accidentally falling through the windows.(4) Doors that normally stay open or are frequently used must not swing out into the corridor unless required by NFPA 101 or another provision of this subchapter. Alcoves must be provided for doors that must swing outward toward a corridor or way of egress.(5) Safety glass must be used where required by local building codes or NFPA 101.(6) Thresholds and expansion joint covers must be flush with the floor surface to facilitate use of wheelchairs and carts.(7) A facility must provide grab bars at all residents' toilets, showers, tubs, and sitz baths. The bars must be 1-1/4 to 1-1/2 inches in diameter and must have 1-1/2 inch clearance to walls. Bars must have sufficient strength and anchorage to sustain a concentrated load of 250 pounds. Grab bar standards must comply with standards adopted under the Americans with Disabilities Act.(8) Handrails must be provided on both sides of corridors used by residents, and must meet the following:(A) A clear distance of 1-1/2 inches must be provided between the handrail and the wall;(B) Handrails must be securely mounted to withstand downward forces of 250 pounds;(C) Handrails may be omitted on wall segments less than 18 inches in length;(D) A window must be considered part of the wall segment in which it is installed and must not interrupt the continuity of the handrail;(E) Handrails must be mounted 33 inches to 36 inches above the floor, and must comply with standards adopted under the Americans with Disabilities Act and with TAS.(F) Where fixed furniture is provided in corridors, as permitted by NFPA 101 and §19.326(n) of this subchapter (relating to Safety Operations), the handrail may be omitted, provided the handrail terminates no more than 18 inches from the fixed furniture.(9) Ends of handrails and grab bars must be constructed with return ends to walls to prevent snagging the clothes of residents.(10) Ceiling fan blades must be at least seven feet above the floor and be located so as not to interfere with the operation of any ceiling-mounted smoke detectors.(b) General details.(1) Concrete floors, whether finished by sealant, or similar product, must not be used as the finished floor unless specifically approved in writing by HHSC. An exception is mechanical equipment rooms and maintenance or similar areas.(2) Sound separation must be provided in corridor walls and resident room party walls. Provide a minimum Sound Transmission Class of 30 per ASTM E90.(3) A facility must provide attic access for building maintenance and inspection.(4) A facility must provide illumination and a safe platform in the attic at all attic access locations. Source Note: The provisions of this §554.362 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.362 Miscellaneous Details for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203073 03/12/2026 A facility providing resident-use areas, such as bedrooms, dining rooms, or recreation areas, or resident services, such as diagnostic services or therapy services, located on other than the main entrance floor must provide at least one elevator that complies with the requirements of ASME A17.1.(1) Number of elevators.(A) When one to 60 resident beds are located on any floor other than the main entrance floor, a facility must provide at least one hospital-type elevator.(B) When 61 to 200 resident beds are located on any floor other than the main entrance floor or when major inpatient services are located on a floor other than those containing resident beds, a facility must provide at least two elevators, one of which must be hospital-type.(C) When 201 to 350 resident beds are located on any floor other than the main entrance floor, or when major inpatient services are located on a floor other than those containing resident beds, a facility must provide at least three elevators, one of which must be hospital-type.(D) A facility with a capacity of more than 350 resident beds must determine the number of elevators required from a study of the facility plan and the estimated vertical transportation requirements.(E) Elevator service may be reduced, with the approval of HHSC, for those floors that provide only partial inpatient services.(2) Cars and platforms. Cars of hospital-type elevators must have inside dimensions that will accommodate a resident bed and attendants and must be at least five feet wide by seven feet six inches deep. The car door must have a clear opening of not less than three feet eight inches.(3) Leveling. Elevators must be equipped with an automatic leveling device of the two-way automatic maintaining type with an accuracy of 1/2 inch.(4) Operation. Elevators, except freight elevators, must be equipped with a two-way special service switch to permit cars to bypass all landing button calls and be dispatched directly to any floor.(5) Accessibility provisions. Elevator controls, alarm buttons, and telephones must be accessible to and usable by individuals with disabilities as required by the Americans with Disabilities Act.(6) Protection from fire. Elevator call buttons, controls, and door safety stops must be of a type that will not be activated by heat or smoke. Door openings must meet the requirements of the NFPA 101 for protection of vertical openings.(7) Field inspection and tests. Inspections and tests must be made and the facility must be furnished written certification that the installation meets the requirements set forth in this section and all applicable safety regulations and codes. Source Note: The provisions of this §554.363 adopted to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION D FACILITY CONSTRUCTION §554.363 Elevators for New Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203108 03/12/2026 (a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident.(b) HHSC adopts by reference as a requirement for obtaining a license under Texas Health and Safety Code Chapter 242 the Centers for Medicare and Medicaid Services rule regarding resident rights, 42 CFR §483.10, adopted to be effective November 28, 2016. The adopted rule was published in the October 4, 2016, issue of the Federal Register (81 Fed. Reg. 68688, 68849).(c) HHSC has developed the following statement of the rights of a resident.Attached Graphic(d) The facility must give a copy of the Statement of Resident Rights to each resident, next of kin or guardian, and facility staff member. The facility must maintain a copy of the statement, signed by the resident or the resident's next of kin or guardian, in the facility records.(e) The Statement of Resident Rights must be posted in accordance with §19.1921 of this chapter (relating to General Requirements for a Nursing Facility). Source Note: The provisions of this §554.401 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective July 1, 2002, 27 TexReg 4362; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.401 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203109 03/12/2026 (a) The resident has the right to exercise the resident's rights as a resident at the facility and as a citizen or resident of the United States.(b) The resident has the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising the resident's rights.(c) In the case of a resident found to lack capacity under the laws of the State of Texas by a court of competent jurisdiction, the rights of the resident are exercised by the resident representative appointed under Texas law to act on the resident's behalf.(d) The facility must comply with all applicable provisions of the Texas Human Resources Code, Title 6, Chapter 102. An individual may not be denied appropriate care on the basis of the individual's race, religion, color, national origin, sex, age, disability, marital status, or source of payment.(e) The facility must allow the resident the right to observe the resident's religious beliefs. The facility must respect the religious beliefs of the resident in accordance with 42 United States Code §1396f.(f) Competent adults may issue directives or durable powers of attorney for health care, subject to the requirements of §19.419 of this subchapter (relating to Advance Directives).(g) In the case of a resident who has not been found to lack capacity by a state court, any legal surrogate designated in accordance with state law may exercise the resident's rights to the extent provided by state law. Source Note: The provisions of this §554.402 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.402 Exercise of Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210957 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210957 03/12/2026 (a) The facility must inform the resident, both orally and in writing, in a language that the resident understands, of the resident's rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. This notification must be made prior to or upon admission and during the resident's stay if changed.(b) The facility must also inform the resident, upon admission and during the stay, in a language the resident understands, of the following:(1) facility admission policies;(2) a description of the protection of personal funds as described in §554.404 of this subchapter (relating to Protection of Resident Funds);(3) the Texas Human Resources Code, Title 6, Chapter 102; or a written list of the rights and responsibilities contained in the Texas Human Resources Code, Title 6, Chapter 102;(4) a written description of the services available through the Ombudsman Program. This information must be made available to each facility by the ombudsman program. Facilities are responsible for reproducing this information and making it available to residents, their families, and resident representatives;(5) a written statement to the resident, the resident's next of kin, or guardian describing the facility's policy for:(A) the drug testing of employees who have direct contact with residents; and(B) the criminal history checks of employees and applicants for employment;(6) HHSC rules and the facility's policies related to the use of restraint and involuntary seclusion. This information must also be given to the resident's legally authorized representative, if the resident has one; and(7) facility essential caregiver policies and procedures during a public health emergency or disaster, and this information must also be given to the resident's legally authorized representative, if the resident has one.(c) Upon admission of a resident, a facility must:(1) provide written information to the resident's family representative, in a language the representative understands, of the right to form a family council; or(2) inform the resident's family representative, in writing, if a family council exists, of the council's meeting time, date, location and contact person.(d) Receipt of information in subsections (b) - (d) of this section, and any amendments to it, must be acknowledged in writing by all parties receiving the information.(e) The facility must post a copy of the documents specified in subsections (a) and (b) of this section in a conspicuous location.(f) The resident or the resident's legal representative has the following rights:(1) upon an oral or written request to the facility, to access all records pertaining to the resident, including clinical records, within 24 hours (excluding weekends and holidays); and(2) to purchase photocopies of all or any portion of the records upon request and two workdays advance notice to the facility.(g) The resident has the right to be fully informed in language the resident understands of the resident's total health status, including the resident's medical condition.(h) The resident has the right to refuse treatment, to formulate an advance directive (as specified in §554.419 of this subchapter (relating to Advance Directives), and to refuse to participate in experimental research.(1) If the resident refuses treatment, the resident must be informed of the possible consequences.(2) If the resident chooses to participate in experimental research, the resident must be fully notified of the research and possible effects of the research. The research may be carried on only with the full written consent of the resident's physician, and the resident.(3) Experimental research must comply with Federal Drug Administration regulations on human research as found in 45 CFR, Part 46.(i) The facility must inform a resident before, or at the time of admission, and periodically during the resident's stay (if there are any changes), of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.(j) The facility must provide a written description of a resident's legal rights, which includes:(1) a description of the manner of protecting personal funds, described in §554.404 of this subchapter;(2) a posting of names, addresses, and telephone numbers of all pertinent state client advocacy groups such as HHSC, the Ombudsman Program, the protection and advocacy network, and, in Medicaid-certified facilities, the Medicaid fraud control unit; and(3) a statement that the resident may file a complaint with HHSC concerning resident abuse, neglect, and misappropriation of resident property in the facility.(k) The facility must inform a resident of the name, specialty, and way of contacting the physician responsible for the resident's care.(l) Notification of changes.(1) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with the representative's authority, the resident representative when there is:(A) an accident involving the resident that results in injury and has the potential for requiring physician intervention;(B) a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);(C) a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or(D) a decision to transfer or discharge the resident from the facility.(2) The facility also must promptly notify the resident and the resident representative, if any, when there is:(A) a change in room or roommate assignment with the reason for the change provided in writing; or(B) a change in resident rights under federal or state law or regulations as described in subsection (b) of this section.(3) The facility must record and periodically update the address and phone number of the resident.(m) Additional requirements for Medicaid-certified facilities. Medicaid-certified facilities must:(1) provide the resident with the state-developed notice of rights under §1919(e)(6) of the Social Security Act (42 U.S.C. §1396r(e)(6));(2) inform a resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of:(A) the items and services that are included in nursing facility services provided under the State Plan and for which the resident may not be charged;(B) those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services;(3) inform each resident when changes are made to the items and services specified in paragraph (2)(A) and (B) of this subsection;(4) provide a written description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under §1924(c) of the Social Security Act (42 U.S.C. §1396r-5(c)), which:(A) is used to determine the extent of a couple's nonexempt resources at the time of institutionalization; and(B) attributes to the community spouse an equitable share of resources that cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in the process of spending down to Medicaid eligibility levels; and(5) prominently display in the facility written information, and provide to residents and potential residents oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.(n) Additional requirements for certain facilities related to memory care and Alzheimer's disease and related disorders. Facilities must provide the following HHSC forms:(1) for a facility that advertises, markets, or otherwise promotes that it provides memory care services to residents, the Memory Care Disclosure Statement for Nursing Facilities, to each resident, disclosing as required by the Texas Health and Safety Code §242.0405 whether the facility is certified to provide specialized care and treatment for a resident with Alzheimer's disease and related disorders, to:(A) each resident or resident representative; and(B) each person seeking information about the facility's care and treatment of residents with Alzheimer's disease or related disorders or dementia; or(2) for a facility that advertises, markets, or otherwise promotes that it provides services to residents with Alzheimer's disease and related disorders, HHSC Form 3641-A, Alzheimer's Disclosure Statement for Nursing Facilities, disclosing as required by the Texas Health and Safety Code §242.202 whether the facility is certified to provide specialized care and treatment for a resident with Alzheimer's disease and related disorders to:(A) each resident or resident representative;(B) each person seeking to become a resident of the facility or that person's representative; and(C) a person seeking information about the facility's care and treatment of residents with Alzheimer's disease and related disorders.(o) Amended disclosure statement. A facility must provide an amended disclosure statement required by subsection (n)(1) and (2) of this section, to a resident, responsible party, or legal guardian at least 30 days before the change in the operation of the facility reflected in the amended disclosure statement is effective. Source Note: The provisions of this §554.403 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective July 1, 2001, 26 TexReg 3824; amended to be effective May 1, 2002, 27 TexReg 3207; amended to be effective August 1, 2002, 27 TexReg 6052; amended to be effective June 1, 2006, 31 TexReg 4449; amended to be effective September 1, 2008, 33 TexReg 6151; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferredeffective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.403 Notice of Rights and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203111 03/12/2026 (a) Management of financial affairs. The resident has the right to manage the resident's financial affairs and the facility may not require a resident to deposit their personal funds with the facility. A resident may designate another person to manage the resident's financial affairs.(b) Management of personal funds.(1) Licensed-only facilities. Upon written authorization of a resident, the facility may hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility will act as a fiduciary agent if the facility holds, safeguards, and accounts for the resident's personal funds.(2) Medicaid-certified facilities. Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as described in §19.405 of this subchapter (relating to Additional Requirements for Trust Funds in Medicaid-certified Facilities). The facility will act as a fiduciary agent if the facility holds, safeguards, and accounts for the resident's personal funds.(c) Statement of resident rights and responsibilities. The facility must provide each resident and resident representative with a written statement at the time of admission that meets the following requirements:(1) the statement describes the resident's rights to select how personal funds will be handled. The following alternatives must be included:(A) the resident has the right to manage the resident's financial affairs;(B) the facility may not require a resident to deposit the resident's personal funds with the facility;(C) the facility has an obligation, upon written authorization of a resident, to hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility;(D) the resident has a right to apply to the Social Security Administration to have a representative payee designated for federal or state benefits to which the resident may be entitled; and(E) except when subparagraph (D) of this paragraph applies, the resident has a right to designate in writing another person to manage the resident's personal funds;(2) the statement notes, when applicable, that any charge for the facility handling a Medicaid recipient's personal funds is included in the facility's basic rate; and(3) the statement advises the resident that the facility must have written permission from the resident, or resident representative to handle the resident's personal funds. Source Note: The provisions of this §554.404 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.404 Protection of Resident Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220622 03/12/2026 (a) Deposit of funds. The facility must keep funds received from a resident for holding, safeguarding, and accounting, separate from the facility's funds.(1) This separate account must be identified "(Name of Facility), Resident's Trust Fund Account," or by a similar designation that shows a fiduciary relationship exists between a resident and the facility.(2) A facility may commingle the trust funds of Medicaid residents and private-pay residents.(3) If the funds are commingled, the facility must provide, upon request, the following records to HHSC, the Texas Office of the Attorney General Medicaid Fraud Control Unit, and the U.S. Department of Health and Human Services:(A) copies of release forms signed and dated by each private-pay resident or resident representative whose funds are commingled; and(B) legible copies of the trust fund records of private-pay residents whose funds are commingled.(4) The facility must maintain the forms and records described in paragraph (3) of this subsection in the same manner as the financial records of Medicaid residents as specified in this section.(5) A facility must ensure that a release form described in paragraph (3)(A) of this subsection:(A) includes permission for the facility to maintain trust fund records of private-pay residents in the same manner as those of Medicaid residents;(B) is obtained from a private-pay resident upon admission or at the time of request for trust fund services; and(C) includes a provision allowing inspection of the private-pay resident's trust fund records by the agencies described in paragraph (3) of this subsection.(b) Funds in excess of $50. The facility must deposit any residents' personal funds in excess of $50 in an interest-bearing account (or accounts) that is separate from any of the facility's operating accounts and that credits all interest earned on the residents' funds to that account. In pooled accounts, there must be a separate accounting for each resident's share.(c) Funds less than $50. The facility may maintain a resident's personal funds that do not exceed $50 in a noninterest-bearing account, interest-bearing account, or petty cash fund.(d) Accounting and records.(1) The facility must:(A) establish and maintain current, written, individual records of all financial transactions involving a resident's personal funds that the facility is holding, safeguarding, and accounting;(B) keep these records in accordance with:(i) the American Institute of Certified Public Accountants' Generally Accepted Accounting Principles; and(ii) the requirements of law for a fiduciary relationship; and(C) include at least the following in these records:(i) resident's name;(ii) identification of the resident's representative payee and resident representative, and payor source;(iii) valid letter of guardianship, if any;(iv) valid power of attorney, if any;(v) resident's admission and discharge dates;(vi) resident's trust fund ledger containing the following:(I) description of each transaction;(II) the date and amount of each deposit and withdrawal;(III) the name of the person who accepted any withdrawn funds;(IV) the balance after each transaction; and(V) amount of interest earned, posted at least quarterly;(vii) receipts for purchases and payments, including cash-register tapes or sales statements from a seller;(viii) written requests for personal funds from the trust fund account; and(ix) written requests for specific brands, items, or services.(2) The facility must maintain the following as general trust fund records:(A) valid trust fund trial balance;(B) petty cash logs;(C) bank statements for trust fund and operating accounts;(D) trust fund checkbook and register;(E) trust fund account monthly reconciliations;(F) trust fund bank account agreement form;(G) applied income ledgers;(H) applied income payment plans from HHSC;(I) proof of surety bond;(J) written agreements (e.g., bed hold, private room); and(K) facility census, admission, discharge, and leave records.(3) A resident must approve a withdrawal from the resident's personal funds by signing a document that shows the resident's approval and the date of the approval.(4) Except as provided in subparagraph (B) of this paragraph, a facility must obtain a receipt for the purchase of an item or service.(A) The receipt must contain:(i) the resident's name;(ii) the date the receipt was written or created;(iii) the amount of funds spent;(iv) the specific item or service purchased;(v) the name of the business from which the purchase was made; and(vi) the signature of the resident.(B) A receipt is not required if:(i) a purchase is made with funds withdrawn in accordance with paragraph (3) of this subsection;(ii) a purchase is made by the resident, a resident representative, or an individual, other than facility personnel, authorized in writing by the resident; or(iii) the item purchased costs one dollar or less.(5) If a facility cannot obtain the signature of a resident as required by paragraph (3) or (4)(A)(vi) of this subsection, the facility must obtain the signature of a witness. The witness may not be the person responsible for accounting for the resident's trust funds, that person's supervisor, or the person who accepts the withdrawn funds or who sells the item being purchased. The facility and HHSC staff must be able to identify the witness's name, address, and relationship to the resident or facility.(e) Notice of certain balances. The facility must notify each resident that receives Medicaid benefits:(1) if the amount in the resident's account reaches $200 less than Supplemental Security Income (SSI) resource limit for one person, specified in §1611(a)(3)(B) of the Social Security Act; and(2) that, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.(f) Conveyance upon death.(1) Upon the death of a resident with a personal fund deposited with the facility, the facility must convey, within 30 days after the date of the death, the resident's funds and a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate, or make a bona fide effort to locate the resident representative or heir to the estate.(2) If a facility is not able to convey funds in accordance with paragraph (1) of this subsection, the facility must, within 30 days after the resident's death;(A) hold the funds by depositing them in a separate account or maintaining them in an existing account, designating on the account records that the resident is deceased; or(B) submit funds to HHSC in accordance with paragraph (4) of this subsection.(3) If the facility holds funds in accordance with paragraph (2)(A) of this subsection:(A) the facility must provide HHSC with a notarized affidavit that contains:(i) the resident's name;(ii) the amount of funds being held;(iii) a description of the facility's efforts to locate a resident representative or heir;(iv) a statement acknowledging that the funds are not the property of the facility, but the property of the deceased resident's estate; and(v) a statement that the facility will hold the funds until they are conveyed to a resident representative or heir or submitted to HHSC in accordance with paragraph (4) of this subsection;(B) the facility must submit the funds to HHSC in accordance with paragraph (4) of this subsection within 180 days after the resident's death; and(C) funds held by a facility in accordance with this paragraph may be monitored or reviewed by HHSC or the Office of Inspector General.(4) A facility must submit unclaimed funds to HHSC, Accounts Receivable.(A) The funds must be identified as money that will escheat to the state.(B) If the facility held the funds in accordance with paragraph (3) of this subsection, the facility must include the notarized affidavit described in paragraph (3)(A) of this subsection.(g) Assurance of financial security. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary of Health and Human Services to ensure the security of all personal funds of residents deposited with the facility.(1) The amount of a surety bond must equal the average monthly balance of all the facility's resident trust fund accounts for the 12-month period preceding the bond issuance or renewal date.(2) Resident trust fund accounts are specific only to the single facility purchasing a resident trust fund surety bond.(3) If a facility employee is responsible for the loss of funds in a resident's trust fund account, the resident, the resident's family, and the resident representative are not obligated to make any payments to the facility that would have been made out of the trust fund had the loss not occurred.(h) Items and services that may not be charged to a resident's personal funds.(1) The facility may not impose a charge against the personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare.(2) Items or services included in Medicare or Medicaid payment that may not be billed to the resident's personal funds by the facility include:(A) nursing services as required in §554.1001 of this chapter (relating to Nursing Services);(B) dietary services as required in §554.1101 of this chapter (relating to Food and Nutrition Services);(C) an activities program as required in §554.702 of this chapter (relating to Activities);(D) room and bed maintenance services;(E) routine personal hygiene items and services as required to meet the needs of the resident, including:(i) hair hygiene supplies, including shampoo, comb, and brush;(ii) bath soaps, disinfecting soaps, or specialized cleansing agents when indicated to treat special skin problems or to fight infection;(iii) razor and shaving cream;(iv) toothbrush, toothpaste, and dental floss;(v) denture adhesive and denture cleanser;(vi) moisturizing lotion;(vii) tissues, cotton balls, and cotton swabs;(viii) deodorant;(ix) incontinent care and supplies, to include cloth or disposable incontinent briefs;(x) sanitary napkins and related supplies;(xi) towels and washcloths;(xii) hospital gowns;(xiii) over-the-counter drugs;(xiv) hair and nail hygiene services; and(xv) personal laundry; and(F) medically-related social services as required in §554.703 of this chapter (relating to Social Services General Requirements).(3) A facility must base necessity for, and type of incontinent brief described in paragraph (2)(E)(ix) of this subsection on an assessment of the resident's medical and psychosocial condition and resulting determination.(i) Items and services that may be charged to a resident's personal funds. The facility may charge a resident for requested services that are more expensive than or in excess of covered services in accordance with §554.2601 of this chapter (relating to Vendor Payment (Items and Services Included)). The following list contains general categories and examples of items and services that the facility may charge to a resident's personal funds if they are requested by a resident, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid:(1) telephone;(2) television or radio for personal use;(3) personal comfort items, including smoking materials, notions and novelties, and confections;(4) cosmetics and grooming items and services in excess of those for which payment is made under Medicare or Medicaid;(5) personal clothing;(6) personal reading material;(7) gifts purchased on behalf of a resident;(8) flowers and plants;(9) social events and entertainment offered outside the scope of the activities program, provided under §554.702 of this chapter;(10) noncovered special care services, such as privately hired nurses and aides;(11) private room, except when therapeutically required, such as isolation for infection control;(12) specially-prepared or alternative food requested instead of the food generally prepared by the facility, as required in §554.1101 of this chapter; and(13) incontinent briefs if the resident representative submits a written request to the facility and the attending physician and director of nurses (DON) determine and document in the clinical record that there is no medical or psychosocial need for supplies.(j) Request for items or services that may be charged to a resident's personal funds.(1) The facility can only charge a resident for an item or service not included under §554.2601 of this chapter if the resident or the resident representative specifically requests the item or service.(2) The facility must not require a resident or resident representative to request any item or service as a condition of admission or continued stay.(3) The facility must inform, orally and in writing, the resident or resident representative, when the resident or resident representative requests an item or service for which a charge will be made, that there will be a charge for the item or service and the amount of the charge.(k) Access to financial record. The individual financial record must be available on request to the resident, resident representative, and representative.(l) Quarterly statement.(1) The individual financial record must be available, through quarterly statements and on request, to the resident, representative payee, and resident representative.(2) The statement must reflect any resident's funds that the facility has deposited in an account as well as any resident's funds held by the facility in a petty cash account.(3) The statement must include at least the following:(A) balance at the beginning of the statement period;(B) total deposits and withdrawals;(C) interest earned, if any;(D) bank name and location of any account in which the resident's personal funds have been deposited; and(E) ending balance.(m) Banking charges.(1) Charges for checks, deposit slips, and services for pooled checking accounts are the responsibility of the facility and may not be charged to the resident or resident representative.(2) Bank service charges and charges for checks and deposit slips may be deducted from the individual checking accounts if it is the resident's written, individual choice to have this type of account.(3) Bank fees on individual accounts established solely for the convenience of the facility are the responsibility of the facility and may not be charged to the resident or resident representative.(4) The facility may not charge the resident or resident for the administrative handling of either type of account.(5) If the facility places any part of the resident's funds in savings accounts, certificates of deposit, or any other plan whereby interest or other benefits are accrued, the facility must distribute the interest or benefit to participating residents on an equitable basis. If pooled accounts are used, interest must be prorated on the basis of actual earnings or end-of-quarter balances.(n) Access to funds.(1) Disbursements from the trust fund.(A) A request for funds from the trust fund or trust fund petty cash box may be made, either orally or in writing, by the resident, or resident representative to cover a resident's expenses.(B) The facility must respond to a request received during normal business hours at the time of the request.(C) The facility must respond to a request received during hours other than normal business hours immediately at the beginning of the next normal business hours.(2) Discontinuing trust fund participation.(A) If a resident or resident representative requests that the facility discontinue managing the resident's personal funds, the facility must return to the resident or resident representative all the resident's personal funds held by the facility, including any interest accrued.(B) If the request is made during normal business hours, the facility must immediately return the funds.(C) If the request is made during hours other than normal business hours, the facility must return the funds immediately during the next normal business hours.(3) Transfer or discharge. If a resident is transferred or discharged from a facility, the facility must, within five working days after the transfer or discharge, return to the resident or resident representative all the resident's personal funds held by the facility, including any interest accrued.(4) For purposes of this subsection, normal business hours are 8:00 a.m. to 5:00 p.m., Monday through Friday, excluding national holidays.(o) Handling of monthly benefits. If the Social Security Administration has determined that a Title II and Title XVI SSI benefit to which the resident is entitled should be paid through a representative payee, the provisions in 20 CFR §§404.2001- 404.2065, for Old Age, Survivors, and Disability Insurance benefits and 20 CFR §§416.601 - 416.665, for SSI benefits apply.(p) Change of ownership. If the ownership of a facility changes, the former owner must transfer the bank balances or trust funds to the new owner with a list of the residents and their balances. The former owner must get a receipt from the new owner for the transfer of these funds. The former owner must keep this receipt for monitoring or audit purposes.(q) Alternate forms of documentation. Without HHSC's prior written approval, a facility may not submit alternate forms of documentation, including affidavits, to verify a resident's personal fund expenditures or as proof of compliance with any requirements specified in these requirements for the resident's personal funds.(r) Limitation on certain charges. A nursing facility may not impose charges for certain Medicaid-eligible individuals, for nursing facility services that exceed the per diem amount established by HHSC for such services. "Certain Medicaid-eligible individuals" means an individual who is entitled to medical assistance for nursing facility services, but for whom such benefits are not being paid because, in determining the individual's income to be applied monthly to the payment for the costs of nursing facility services, the amount of such income exceeds the payment amounts established by HHSC.(s) Trust fund monitoring and audits.(1) HHSC may periodically monitor all trust fund accounts to ensure compliance with this section. HHSC notifies a facility of monitoring plans and gives a report of the findings to the facility.(2) HHSC may, as a result of monitoring, refer a facility to the Office of Inspector General (OIG) for an audit.(3) The facility must provide all records and other documents required by subsection (d) of this section to HHSC upon request.(4) HHSC provides the facility with a report of the findings, which may include corrective actions that the facility must take and internal control recommendations that the facility may follow.(5) The facility may request an informal review in accordance with subsection (t) of this section or a formal hearing in accordance with subsection (u) of this section to dispute the report of findings.(6) If the facility does not request an informal review or a formal hearing and the report of findings requires corrective actions, the facility must complete corrective actions within 60 days after receiving the report of findings.(7) If the facility does not complete corrective actions required by HHSC within 60 days after receiving the report of findings, HHSC may impose a vendor hold on payments due to the facility under the provider agreement until the facility completes corrective actions.(8) If HHSC imposes a vendor hold in accordance with paragraph (7) of this subsection, the facility may request a formal hearing in accordance with subsection (u)(5) of this section. If the failure to correct is upheld, HHSC continues the vendor hold until the facility completes the corrective actions.(t) Informal review.(1) A facility that disputes the report of findings described in subsection (s)(4) of this section may request an informal review under this section. The purpose of an informal review is to provide for the informal and efficient resolution of the matters in dispute and is conducted according to the following procedures.(A) HHSC must receive a written request for an informal review by United States mail, hand delivery, special mail delivery, or fax no later than 15 days after the date on the written notification of the report of findings described in subsection (s)(4) of this section. If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first day following the 15th day is the final day the written request will be accepted. A request for an informal review that is not received by the stated deadline is not granted.(B) A facility must submit a written request for an informal review to the HHSC Trust Fund Monitoring Unit.(C) A facility must, with its request for an informal review:(i) submit a concise statement of the specific findings it disputes;(ii) specify the procedures or rules that were not followed;(iii) identify the affected cases;(iv) describe the reason the findings are being disputed; and(v) include supporting information and documentation that directly demonstrates that each disputed finding is not correct.(D) HHSC does not grant a request for an informal review that does not meet the requirements of this subsection.(2) Informal review process. Upon receipt of a request for an informal review, the Trust Fund Monitoring Unit Manager coordinates the review of the information submitted.(A) Additional information may be requested by HHSC and must be received in writing no later than 15 days after the date the facility receives the written request for additional information. If the 15th day is a Saturday, Sunday, national holiday, or state holiday, then the first day following the 15th day is the final day the additional information will be accepted.(B) HHSC sends its written decision to the facility by certified mail, return receipt requested.(i) If the original findings are upheld, HHSC continues the schedule of deficiencies and requirement for corrective action.(ii) If the original findings are reversed, HHSC issues a corrected schedule of deficiencies with the written decision.(iii) If the original findings are revised, HHSC issues a revised schedule of deficiencies including any revised corrective action.(iv) If the original findings are upheld or revised, the facility may request a formal hearing in accordance with subsection (u) of this section.(v) If the original findings are upheld or revised and the facility does not request a formal hearing, the facility has 60 days from the date of receipt of the written decision to complete the corrective actions. If the facility does not complete the corrective actions by that date, HHSC may impose a vendor hold. If HHSC imposes a vendor hold, the facility may request a formal hearing in accordance with subsection (u)(5) of this section. If the failure to correct is upheld, HHSC continues the vendor hold until the facility completes the corrective action.(u) Formal hearing.(1) The facility must submit a written request for a formal hearing under this section to the HHSC Appeals Division.(2) The written request for a formal hearing must be received within 15 days after:(A) the date on the written notification of the report of findings described in subsection (s)(4) of this section; or(B) the facility receives the written decision sent as described in subsection (t)(2)(B) of this section.(3) A formal hearing is conducted in accordance with Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(4) No later than 60 days after a final determination is issued as a result of a formal hearing requested by a facility under subsection (s)(8) or (t)(2)(B)(iv) of this section, the facility must complete any corrective action required by HHSC or be subject to a vendor hold on payments due to the facility under the provider agreement until the facility completes corrective action. If HHSC imposes a vendor hold, the facility may request a formal hearing in accordance with paragraph (5) of this subsection. If the failure to correct is upheld, HHSC continues the vendor hold until the facility completes the corrective action.(5) If HHSC imposes a vendor hold under subsections (s)(7), (t)(2)(B)(v), or (u)(4) of this section, the facility may request a formal hearing within 15 days after receiving notice of the correction failure and the vendor hold. The formal hearing is limited to the issue of whether the facility completed the corrective action. Source Note: The provisions of this §554.405 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 1, 2003, 28 TexReg 6941; amended to be effective August 31, 2004, 29 TexReg 8140; amended to be effective November 20, 2012, 37 TexReg 9112; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective September 18, 2024, 49 TexReg 7331. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.405 Additional Requirements for Trust Funds in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203113 03/12/2026 (a) Resident rights. The resident has the right to:(1) choose and retain a personal attending physician, subject to that physician's compliance with the facility's standard operating procedures for physician practices in the facility;(2) be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; and(3) participate in planning care and treatment or changes in care and treatment, to the extent practicable. See §19.419 of this title (relating to Advance Directives).(b) Licensed-only facilities. The resident must be allowed complete freedom of choice to obtain pharmacy services from any pharmacy that is qualified to perform the services. A facility must not require residents to purchase pharmaceutical supplies or services from the facility itself or from any particular vendor. The resident has the right to be informed of prices before purchasing any pharmaceutical item or service from the facility, except in an emergency.(c) Additional requirements regarding freedom of choice for Medicaid recipients. The recipient must be allowed complete freedom of choice to obtain any Medicaid services from any institution, agency, pharmacy, person, or organization that is qualified to perform the services, unless the provider causes the facility to be out of compliance with the requirements specified in this chapter.(1) A facility must not require recipients to purchase supplies or services, including pharmaceutical supplies or services, from the facility itself or from any particular vendor. The recipient has the right to be informed of prices before purchasing any item or services from the facility, except in an emergency.(2) The facility must furnish Medicaid recipients with complete information about available Medicaid services, how to obtain these services, their rights to freely choose service providers as specified in this subsection and the right to request a hearing before HHSC if the right to freely choose providers has been abridged without due process. Source Note: The provisions of this §554.406 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.406 Free Choice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203114 03/12/2026 The resident has the right to personal privacy and confidentiality of the resident's personal and clinical records.(1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.(2) Except as provided in paragraph (3)(B) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside of the facility.(3) The resident's right to refuse release of personal and clinical records does not apply:(A) when the resident is transferred to another health care institution;(B) when the record release is required by law or permitted under §19.1910(d) of this chapter (relating to Clinical Records); or(C) during surveys.(4) The facility must ensure the resident's right to privacy in the following areas:(A) accommodations as described in §19.1701 of this chapter (relating to Physical Environment);(B) medical treatment, including during examinations, treatment, case discussions, and consultations;(C) personal care;(D) access and visitation as described in §19.413 of this subchapter (relating to Access and Visitation Rights); and(E) meetings with family and resident groups.(5) Governmental searches are permitted only if there exists probable cause to believe an illegal substance or activity is being concealed. Administrative searches by the appropriate entity, such as the fire inspector, are allowed only for limited purposes, but such searches would not ordinarily extend to the resident's personal belongings. HHSC and the nursing facility must provide for and allow residents their individual freedoms. State statutes authorize inspections of the nursing facility but do not authorize inspection of those areas in which an individual has a reasonable expectation of privacy. Any direct participation by HHSC personnel in an inspection of "the contents of residents' personal drawers and possessions," is in violation of federal and state law; and(6) All information that contains personal identification or descriptions which would uniquely identify an individual resident is considered to be personal and private and will be kept confidential. Source Note: The provisions of this §554.407 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.407 Privacy and Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203115 03/12/2026 (a) A resident has the right to:(1) voice grievances without discrimination or reprisal including grievances regarding treatment that has been furnished as well as treatment that has not been furnished;(2) prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents; and(3) notify state agencies of complaints against a facility. Complaints will be acknowledged by the staff of the agency that receives the complaint. All complaints will be investigated, whether oral or written.(b) A nursing facility may not retaliate or discriminate against a resident, a resident representative, or a volunteer because the resident, the resident representative, a volunteer, or any other person:(1) makes a complaint or files a grievance concerning the facility;(2) reports a violation of law, including a violation of laws or regulations regarding nursing facilities; or(3) initiates or cooperates in an investigation or proceeding of a governmental entity relating to care, services, or conditions at the nursing facility.(c) A facility may not discharge or otherwise retaliate against:(1) an employee, resident, or other person because the employee, resident, or other person files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of a restraint or involuntary seclusion at the facility; or(2) a resident because someone on behalf of the resident files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of a restraint or involuntary seclusion at the facility. Source Note: The provisions of this §554.408 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2002, 27 TexReg 2832; amended to be effective June 1, 2006, 31 TexReg 4449; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.408 Grievances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203116 03/12/2026 (a) The resident has the right to:(1) examine the results of the most recent survey of the facility conducted by federal or state surveyors and any plan of correction in effect with respect to the facility; and(2) receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.(b) The facility must make the survey results available for examination in a place readily accessible to residents and must post a notice of their availability. Source Note: The provisions of this §554.409 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.409 Examination of Survey Results https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203117 03/12/2026 (a) The nursing facility must refund private funds paid to the facility for periods covered by Medicaid, including retroactive periods of Medicaid coverage, when:(1) the Medicaid vendor payment has been accepted by the nursing facility; or(2) the nursing facility has been notified by HHSC about an individual's eligibility for Medicaid.(b) The nursing facility must make the refund within 30 days of:(1) notification of eligibility for nursing home coverage;(2) notification of correction of applied income; or(3) receipt of any vendor payment from HHSC for any covered period.(c) When the facility becomes aware of the need for a refund as indicated in subsection (a) of this section, facility staff must write to the resident or resident representative, notifying the resident about the right to a refund and the amount due. Source Note: The provisions of this §554.410 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.410 Refunds in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203118 03/12/2026 The resident has the right to:(1) refuse to perform services for the facility; and(2) perform services for the facility, if the resident chooses, when:(A) the facility has documented the resident's need or desire for work in the care plan;(B) the care plan specifies the nature of the services performed and whether the services are voluntary or paid;(C) compensation for paid services is at or above prevailing rates; and(D) the resident agrees to the work arrangement described in the care plan. Source Note: The provisions of this §554.411 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.411 Work https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203119 03/12/2026 The resident has the right to privacy in written communications, including the right to:(1) send and receive mail promptly that is unopened;(2) request facility staff to help open and read incoming mail and help address and post outgoing mail;(3) have access to stationery, postage, and writing implements at the resident's own expense. Source Note: The provisions of this §554.412 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.412 Mail https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203120 03/12/2026 (a) A resident has the right to have access to, and the facility must provide immediate access to a resident to, the following:(1) in Medicaid-certified facilities, any representative of the Secretary of Health and Human Services;(2) any representative of the State of Texas;(3) the resident's individual physician;(4) the State Ombudsman;(5) a certified ombudsman;(6) any representative of the protection and advocacy system for individuals with intellectual or developmental disabilities established under the Developmental Disabilities Assistance and Bill of Rights Act, 42 USC Chapter 144, Subchapter I, Part C;(7) any representative of the protection and advocacy system for individuals with mental illness established under the Protection and Advocacy for Mentally Ill Individuals Act, 42 USC Chapter 114, Subchapter I;(8) subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident;(9) subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; and(10) the resident representative.(b) A facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.(c) In accordance with the Older Americans Act, §712(b)(1)(A) and 45 CFR §1324.11(e)(2), a facility must allow:(1) the State Ombudsman, a certified ombudsman, and an ombudsman intern to have:(A) immediate, private, and unimpeded access to enter the facility at any time during the facility's regular business hours or regular visiting hours;(B) immediate, private, and unimpeded access to a resident; and(C) immediate and unimpeded access to the name and contact information of a resident representative if the State Ombudsman, a certified ombudsman, or an ombudsman intern determines the information is needed to perform a function of the Ombudsman Program; and(2) the State Ombudsman and a certified ombudsman to have immediate, private, and unimpeded access to enter the facility at a time other than regular business hours or visiting hours, if the State Ombudsman or a certified ombudsman determines access may be required by the circumstances to be investigated.(d) A facility, in accordance with the Older American Act, §712(b)(1)(B) and 45 CFR §1324.11(e)(2), must allow the State Ombudsman and a certified ombudsman immediate access to:(1) all files, records, and other information concerning a resident, including an incident report involving the resident, if:(A) the State Ombudsman or certified ombudsman has the consent of the resident or resident representative;(B) the resident is unable to communicate consent to access and has no resident representative; or(C) such access is necessary to investigate a complaint and the following occurs:(i) the resident representative refuses to give consent to access to the records, files and other information;(ii) the State Ombudsman or certified ombudsman has reasonable cause to believe that the resident representative is not acting in the best interest of the resident; and(iii) if it is a certified ombudsman seeking access to the records, files, or other information, the certified ombudsman obtains the approval of the State Ombudsman to access the records, files, or other information without the resident representative's consent; and(2) the administrative records, policies, and documents of the facility to which the residents or general public have access.(e) The rules adopted under the Health Insurance Portability and Accountability Act of 1996, 45 CFR Part 164, Subparts A and E, do not preclude a facility from releasing protected health information or other identifying information regarding a resident to the State Ombudsman or a certified ombudsman if the requirements of subsections (c)(1)(C) and (d)(1)(A), (B), or (C) of this section are met. The State Ombudsman and a certified ombudsman are each a "health oversight agency" as that phrase is defined in 45 CFR §164.501. Source Note: The provisions of this §554.413 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 1, 2008, 33 TexReg 7280; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.413 Access and Visitation Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203121 03/12/2026 (a) The resident has the right to have reasonable access to the use of a telephone, other than a pay phone, where calls can be made without being overheard, and which can also be used for making calls to summon help in case of emergency.(b) The facility must permit residents to contract for private telephones at their own expense. Source Note: The provisions of this §554.414 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.414 Telephone https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203122 03/12/2026 The facility must have policies regarding postmortem procedures, including soliciting and meeting the resident's or families' requests regarding notification of a death, disposition of possessions or personal property, and choice of funeral homes. Source Note: The provisions of this §554.415 adopted to be effective March 1, 1998, 23 TexReg 1314; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.415 Postmortem Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203123 03/12/2026 The resident has the right to retain and use personal possessions, including some furnishings, and appropriate clothing as space permits, unless to do so would infringe upon the rights or health and safety of other residents. Reasons for any limitations are documented in the resident's clinical record.(1) If the resident dies, personal property must be transferred to the estate or the person designated by the resident.(2) If it is donated or sold to the facility by the resident or estate, the transaction must be documented.(3) If the resident dies and there is no resident representative or family and no arrangements have been made for the disposition of property, the facility must dispose of property according to the Texas Property Code, Title 6, Chapter 71 (concerning Escheat of Property) and according to the Texas Estates Code, Chapter 551 (concerning Payment of Certain Estates to State). Source Note: The provisions of this §554.416 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.416 Personal Property https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203124 03/12/2026 A resident must be ensured privacy for visits with the resident's spouse. The resident has the right to share a room with the resident's spouse when married residents live in the same facility and both spouses consent to the arrangement. Source Note: The provisions of this §554.417 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.417 Married Couples https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203102 03/12/2026 (a) Competent adults may issue advance directives in accordance with applicable laws. An advance directive has the meaning as defined in Texas Health and Safety Code, §166.002.(b) A facility must maintain policies and procedures implementing the following with respect to all adult residents:(1) The facility must:(A) maintain written policies regarding the implementation of advance directives; and(B) include a clear and precise statement of any procedure the facility is unwilling or unable to provide or withhold in accordance with an advance directive.(2) The facility must:(A) when a resident is admitted, provide the resident or the appropriate person referenced in paragraph (8) of this subsection with a copy of:(i) the advance care planning educational material provided by DADS;(ii) the resident's rights under Texas law (whether statutory or as recognized by the courts of the state) to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives; and(iii) the facility's policies respecting the implementation of these rights, including the written policies regarding the implementation of advance directives;(B) within 14 days after the resident is admitted, orally review and discuss the information provided in accordance with subparagraph (A) of this paragraph and the importance of planning for end-of-life care with the resident or with the appropriate person referenced in paragraph (8) of this subsection; and(C) annually and when there is a significant positive change or a significant deterioration in the resident's clinical condition, provide, review, and discuss the written information regarding advance directives listed in subparagraph (A) of this paragraph with the resident or with the appropriate person referenced in paragraph (8) of this subsection.(3) The facility must document the oral discussion and the provision of the written information in the resident's clinical record. The facility must document in the resident's clinical record whether or not the resident has executed an advance directive.(4) The facility must not condition the provision of care or otherwise discriminate against a resident based on whether or not the resident has executed an advance directive.(5) The facility must ensure compliance with the requirements of Texas law, whether statutory or as recognized by the courts of Texas, respecting advance directives.(6) The facility must provide, individually or with others, education for staff and the community on issues concerning advance directives. For the community, this may include newsletters, newspaper articles, local news reports, or commercials. For educating staff, this may include in-service programs.(7) The facility must provide the attending physician, emergency medical technician, and hospital personnel with any information relating to a resident's known existing advance directive and assist with coordinating physicians' orders with the resident's known existing advance directive.(8) Except as provided in paragraph (9) of this subsection, if a resident is in a comatose or otherwise incapacitated state, and therefore is unable to receive information or articulate whether the resident has executed an advance directive, the facility must provide, review, and discuss written information regarding advance directives, including advance care planning educational material provided by DADS and facility policies regarding the implementation of advance directives, in the following order of preference, to:(A) the resident's legal guardian;(B) a person responsible for the resident's health care decisions;(C) the resident's spouse;(D) the resident's adult child;(E) the resident's parents; or(F) the person admitting the resident.(9) If a resident is in a comatose or otherwise incapacitated state, and therefore is unable to receive information or articulate whether the resident has executed an advance directive, and if the facility is unable, after diligent search, to locate a person listed under paragraph (8) of this subsection, the facility is not required to provide written information regarding advance directives. The facility must document in the resident's clinical record its attempts to make a diligent search.(10) If a resident, who was incompetent or otherwise incapacitated and was unable to receive information regarding advance directives, including written policies regarding the implementation of advance directives, later becomes able to receive the information, the facility must provide, review, and discuss the written information at the time the resident becomes able to receive the information.(11) If the resident or a relative, surrogate, or other concerned or related person presents the facility with a copy of the resident's advance directive, the facility must comply with the advance directive, including recognition of a Medical Power of Attorney, to the extent allowed under state law. If no one comes forward with a previously executed advance directive and the resident is incapacitated or otherwise unable to receive information or articulate whether he has executed an advance directive, the facility must document in the resident's clinical record that the resident was not able to receive information and was unable to communicate whether an advance directive existed.(c) Failure to provide the facility's written policies as required in subsection (b)(2)(A)(iii) of this section when a resident is admitted will result in an administrative penalty of $500.(d) A facility that provides services to children must ensure that:(1) prior to admission to the facility, the primary physician, who has been providing care to the child, has discussed advance directives with the family or guardian and has provided documentation of this discussion to the facility; and(2) the decision made by the family or guardian regarding advance directives is addressed in the comprehensive care plan (see §19.802 of this title (relating to Comprehensive Care Plans)). Source Note: The provisions of this §554.419 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective April 1, 2007, 32 TexReg 1582; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.419 Advance Directives https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203103 03/12/2026 (a) The delegation of resident rights may occur in three cases:(1) when a competent individual chooses to allow another to act for him, such as with a Durable Power of Attorney;(2) when the resident has been adjudicated to be incompetent by a court of law and a guardian has been appointed; or(3) when the physician has determined that, for medical reasons, the resident is incapable of understanding and exercising such rights. The Health and Safety Code, Chapter 313, Consent to Medical Treatment, provides guidance under certain circumstances when a resident is comatose, incapacitated, or otherwise mentally or physically incapable of communication.(b) In order to assure preservation of rights, the physician and the facility must document specific information concerning the incapability of the resident to understand and exercise his rights.(c) Facility documentation must cover:(1) the relationship of the resident to the person assuming his rights and responsibilities;(2) the authority allowing the responsible person to act for the resident;(3) resident assessments, care plans, and progress notes that address the resident's inability to exercise his rights and responsibilities; and(4) assurance that the resident who is mentally capable of understanding and exercising his rights, but physically incapable of doing so, receives interventions which facilitate the exercise of his rights.(d) Physician documentation must cover:(1) resident's comatose state, incapacity, or other mental or physical inability to communicate;(2) proposed medical treatment or decision;(3) periodic assurance that there has been no essential change in the resident's mental function; and(4) reevaluation whenever a significant change in resident status occurs or for orders that impact on resident rights (such as "No CPR"). Source Note: The provisions of this §554.420 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.420 Documentation for the Delegation of Long-Term Care Resident's Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203104 03/12/2026 (a) A resident has the right to refuse a transfer to another room within the facility, if the purpose of the transfer is:(1) to relocate a resident of a skilled nursing facility (SNF) from the distinct part of the facility that is an SNF to a part of the facility that is not an SNF;(2) to relocate a resident of a nursing facility from the distinct part of the facility that is a nursing facility to a distinct part of the facility that is an SNF; or(3) solely for the convenience of the staff.(b) A resident's exercise of the right to refuse transfer under this section does not affect the resident's eligibility or entitlement to Medicaid benefits. Source Note: The provisions of this §554.421 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.421 Refusal of Certain Transfers in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203105 03/12/2026 (a) A facility must permit a resident or the resident's guardian or legal representative to monitor the resident's room through the use of electronic monitoring devices. (b) A facility may not refuse to admit an individual and may not discharge a resident because of a request to conduct authorized video monitoring. (c) The Texas Department of Human Services (DHS) Information Regarding Authorized Electronic Monitoring form must be signed by or on behalf of all new residents upon admission. The form must be completed and signed by or on behalf of all current residents by July 1, 2003. A copy of the form must be maintained in the active portion of the resident's clinical record. Attached Graphic(d) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM must request AEM by giving a completed, signed, and dated DHS Request for Authorized Electronic Monitoring form to the administrator or designee. A copy of the form must be maintained in the active portion of the resident's clinical record. (1) If a resident has capacity to request AEM and has not been judicially declared to lack the required capacity, only the resident may request AEM, notwithstanding the terms of any durable power of attorney or similar instrument. (2) If a resident has been judicially declared to lack the capacity required to request AEM, only the guardian of the resident may request AEM. (3) If a resident does not have capacity to request AEM and has not been judicially declared to lack the required capacity, only the legal representative of the resident may request AEM. (A) A resident's physician makes the determination regarding the capacity to request AEM. Documentation of the determination must be made in the resident's clinical record. (B) When a resident's physician determines the resident lacks capacity to request AEM, a person from the following list, in order of priority, may act as the resident's legal representative for the limited purpose of requesting AEM: (i) a person named in the resident's medical power of attorney or other advance directive; (ii) the resident's spouse; (iii) an adult child of the resident who has the waiver and consent of all other qualified adult children of the resident to act as the sole decision-maker; (iv) a majority of the resident's reasonably available adult children; (v) the resident's parents; or (vi) the individual clearly identified to act for the resident by the resident before the resident became incapacitated or the resident's nearest living relative. (e) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM also must obtain the consent of other residents in the room, using the DHS Consent to Authorized Electronic Monitoring form. When complete, the form must be given to the administrator or designee. A copy of the form must be maintained in the active portion of the resident's clinical record. (1) Consent to AEM may be given only by: (A) the other resident or residents in the room; (B) the guardian of the other resident, if the resident has been judicially declared to lack the required capacity; or (C) the legal representative of the other resident, determined by following the same procedure established under (d)(3) of this section. (2) Another resident in the room may condition consent on: (A) pointing the camera away from the consenting resident, when the proposed electronic monitoring is a video surveillance camera; and (B) limiting or prohibiting the use of an audio electronic monitoring device. (3) AEM must be conducted in accordance with any limitation placed on the monitoring as a condition of the consent given by or on behalf of another resident in the room. The resident's roommate, their guardian, or legal representative assumes responsibility for assuring AEM is conducted according to the designated limitations. (4) If AEM is being conducted in a resident's room, and another resident is moved into the room who has not yet consented to AEM, the monitoring must cease until the new resident, or the resident's guardian or legal representative, consents. (f) When the completed Request for Authorized Electronic Monitoring form and the Consent to Authorized Electronic Monitoring form, if applicable, have been given to the administrator or designee, AEM may begin. (1) Anyone conducting AEM must post and maintain a conspicuous notice at the entrance to the resident's room. The notice must state that the room is being monitored by an electronic monitoring device. (2) The resident, or the resident's guardian or legal representative, must pay for all costs associated with conducting AEM, including installation in compliance with life safety and electrical codes, maintenance, removal of the equipment, posting and removal of the notice, or repair following removal of the equipment and notice, other than the cost of electricity. (3) The facility must meet residents' requests to have a video camera obstructed to protect their dignity. (4) The facility must make reasonable physical accommodation for AEM, which includes providing: (A) a reasonably secure place to mount the video surveillance camera or other electronic monitoring device; and (B) access to power sources for the video surveillance camera or other electronic monitoring device. (g) All facilities, regardless of whether AEM is being conducted, must post an 8-inch by 11-inch notice at the main facility entrance. The notice must be entitled "Electronic Monitoring" and must state, in large, easy-to-read type, "The rooms of some residents may be monitored electronically by or on behalf of the residents. Monitoring may not be open and obvious in all cases." (h) A facility may: (1) require an electronic monitoring device to be installed in a manner that is safe for residents, employees, or visitors who may be moving about the room, and meets all local and state regulations; (2) require AEM to be conducted in plain view; (3) place a resident in a different room to accommodate a request for AEM. (i) A facility may not discharge a resident because covert electronic monitoring is being conducted by or on behalf of a resident. If a facility discovers a covert electronic monitoring device and it is no longer covert as defined in §242.843, Health and Safety Code, the resident must meet all the requirements for AEM before monitoring is allowed to continue. (j) DHS may assess an administrative penalty of $500 against a facility for each instance in which the facility: (1) refuses to permit a resident, or the resident's guardian or legal representative, to conduct AEM; (2) refuses to admit an individual or discharges a resident because of a request to conduct AEM; (3) discharges a resident because covert electronic monitoring is being conducted by or on behalf of the resident; or (4) violates any other provision related to AEM. (k) All instances of abuse or neglect must be reported to DHS, as required by §19.602 of this title (relating to Incidents of Abuse and Neglect Reportable to the Texas Department of Human Services (DHS) by Facilities). For purposes of the duty to report abuse or neglect and the criminal penalty for the failure to report abuse or neglect, established under the Health and Safety Code, §242.122, the following apply: (1) A person who is conducting electronic monitoring on behalf of a resident is considered to have viewed or listened to a tape or recording made by the electronic monitoring device on or before the 14th day after the date the tape or recording is made. (2) If a resident, who has capacity to determine that the resident has been abused or neglected and who is conducting electronic monitoring, gives a tape or recording made by the electronic monitoring device to a person and directs the person to view or listen to the tape or recording to determine whether abuse or neglect has occurred, the person to whom the resident gives the tape or recording is considered to have viewed or listened to the tape or recording on or before the seventh day after the date the person receives the tape or recording. (3) A person is required to report abuse based on the person's viewing of or listening to a tape or recording only if the incident of abuse is acquired on the tape or recording. A person is required to report neglect based on the person's viewing of or listening to a tape or recording only if it is clear from viewing or listening to the tape or recording that neglect has occurred. (4) If abuse or neglect of the resident is reported to the facility and the facility requests a copy of any relevant tape or recording made by an electronic monitoring device, the person who possesses the tape or recording must provide the facility with a copy at the facility's expense. The cost of the copy must not exceed the community standard. If the contents of the tape or recording are transferred from the original technological format, a qualified professional must do the transfer. (5) A person who sends more than one tape or recording to DHS must identify each tape or recording on which the person believes an incident of abuse or evidence of neglect may be found. Tapes or recordings should identify the place on the tape or recording that an incident of abuse or evidence of neglect may be found. Source Note: The provisions of this §554.422 adopted to be effective July 1, 2002, 27 TexReg 4362; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.422 Authorized Electronic Monitoring (AEM) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203106 03/12/2026 The Texas Department of Human Services (DHS) is required to provide a model drug testing policy to nursing facilities under the Health and Safety Code, §242.050. A nursing facility is not required to perform drug testing on its employees or applicants for employment. Although this policy only covers drugs, coverage of alcohol may be added. Before implementing any drug testing policy, including the following model policy, DHS recommends that a facility discuss the policy with its attorney.(1) Policy.(A) (NURSING FACILITY NAME) has a vital interest in maintaining a safe, healthy, and efficient working environment. Being under the influence of a drug on the job poses serious safety and health risks to the user, co-workers, and residents. The use, sale, purchase, transfer, or possession of an illegal drug in the workplace poses unacceptable risks for safe, healthy, and efficient operations.(B) (NURSING FACILITY NAME) has the obligation to maintain a safe, healthy and efficient workplace for all of its employees and residents, and to protect the facility's property, information, equipment, operations, and reputation.(C) (NURSING FACILITY NAME) recognizes its obligation to its residents to provide services that are free of the influence of illegal drugs and endeavors through this policy to provide drug-free services.(D) (NURSING FACILITY NAME) complies with federal and state rules, regulations, or laws that relate to the maintenance of a workplace free from illegal drugs.(E) All employees are required to abide by the terms of this policy and to notify management of any criminal drug statute conviction for a violation that occurred in the workplace no later than five days after such conviction.(2) Purpose. This policy outlines the goals and objectives of (NURSING FACILITY NAME'S) drug testing program and provides guidance to supervisors and employees concerning their responsibilities for carrying out the program.(3) Scope. This policy applies to all departments, all employees, and all job applicants. The term employee includes contracted employees.(4) Definitions. The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(A) Facility premises--All property of (NURSING FACILITY NAME) including, but not limited to, the offices, facilities, and surrounding areas on (NURSING FACILITY NAME)-owned or -leased property, parking lots, and storage areas. The term also includes (NURSING FACILITY NAME)-owned or -leased vehicles and equipment.(B) Drug testing--The scientific analysis of urine, blood, breath, saliva, hair, tissue, and other specimens for detecting a drug.(C) Illegal drug--Any drug that is not legally obtainable. Examples of illegal drugs are marijuana, cocaine, heroin, methamphetamines, and phencyclidine (PCP).(D) Legal drug--Any prescribed drug or over-the-counter drug that has been legally obtained and is being used for the purpose for which it was prescribed or manufactured.(E) Reasonable belief--A belief based on facts sufficient to lead a prudent person to conclude that a particular employee is unable to perform his or her job duties due to drug impairment. Such inability to perform may include, but not be limited to, decreases in the quality or quantity of the employee's productivity, judgment, reasoning, concentration and psychomotor control, and marked changes in behavior. Accidents, deviations from safe working practices, and erratic conduct indicative of impairment are examples of "reasonable belief" situations.(F) Under the influence--A condition in which a person is affected by a drug in any detectable manner. The symptoms of influence are not confined to those consistent with misbehavior or to obvious impairment of physical or mental ability, such as slurred speech or difficulty in maintaining balance. A determination of being under the influence can be established by a professional opinion; a scientifically valid test, such as urinalysis or blood analysis; and in some cases by the opinion of a layperson.(5) Education.(A) Management personnel are to be trained to:(i) detect the signs and behavior of employees who may be using drugs in violation of this policy; and(ii) intervene in situations that may involve violations of this policy.(B) Employees are to be informed of the provisions of this policy.(6) Prohibited activities.(A) Legal drugs. (NURSING FACILITY NAME) reserves the right at all times to judge the effect that a legal drug may have on an employee's job performance and to restrict the employee's work activity or presence at the workplace accordingly.(B) Illegal drugs. The use, sale, purchase, transfer, or possession of an illegal drug by any employee while on (NURSING FACILITY NAME) premises or while performing (NURSING FACILITY NAME) business is prohibited.(7) Discipline.(A) Any employee who possesses, distributes, sells, attempts to sell, or transfers illegal drugs on (NURSING FACILITY NAME) premises or while on (NURSING FACILITY NAME) business will be subject to immediate discharge.(B) Any employee found through drug testing to have in his or her body a detectable amount of an illegal drug will be subject to discipline up to and including discharge. An employee may be offered a one-time opportunity to enter and successfully complete a rehabilitation program, approved by (NURSING FACILITY NAME), at the employee's expense. During rehabilitation, the employee will be subject to unannounced drug testing. Upon return to work from rehabilitation, the employee may be subject to unannounced drug testing at (NURSING FACILITY NAME) expense for a period of 12 months. Any employee whose test is confirmed as positive during or following rehabilitation will be subjected to immediate discharge.(8) Drug testing for job applicants.(A) All applicants for employment, including applicants for part-time and seasonal positions and applicants who are former employees, are subject to drug testing.(B) If an applicant refuses to take a drug test, or if evidence of the use of illegal drugs by an applicant is discovered, either through testing or other means, the pre-employment process will be terminated.(C) An applicant must pass the drug test to be considered for employment.(D) An applicant will be provided written notice of this policy and, by signature, will be required to acknowledge receipt and understanding of the policy before being tested.(9) Drug testing of employees.(A) (NURSING FACILITY NAME) will notify employees of this policy by:(i) providing them with a copy of the policy and obtaining written acknowledgement that the policy has been received and read.(ii) announcing the policy in written communications and making presentations at employee meetings.(B) (NURSING FACILITY NAME) will perform drug testing:(i) of any employee who exhibits "reasonable belief" behavior;(ii) of each employee who has direct contact with residents annually;(iii) of any employee who is subject to drug testing pursuant to federal or state rules, regulations, or laws;(iv) on a random basis of any employee.(C) An employee's consent to submit to drug testing is required as a condition of employment and the employee's refusal to consent may result in disciplinary action, including discharge, for a first refusal or any subsequent refusal.(D) An employee who is tested in a "reasonable belief" situation may be suspended pending receipt of written test results and inquiries that may be required.(10) Appeal of a drug test result.(A) An applicant or employee whose drug test was positive will have an opportunity to explain why the positive finding could have resulted from a cause other than drug use. (NURSING FACILITY NAME) will judge whether the employee's explanation merits further inquiry.(B) An applicant or employee whose drug test is reported positive will be offered the opportunity to:(i) obtain and independently test, at their expense, the remaining portion of the urine specimen that yielded the positive result; and(ii) obtain the written test result and submit it to an independent medical review, at their expense.(C) During an appeal and any resulting inquiries, the pre-employment selection process for an applicant will be placed on hold, and the employment status of an employee may be suspended. An employee who is suspended pending appeal may use any available annual leave to remain in an active pay status. If the employee has no annual leave or chooses not to use it, the suspension will be without pay.(11) Confidentiality. All information related to drug testing or the identification of persons as users of drugs will be protected by (NURSING FACILITY NAME) as confidential unless otherwise required by law or overriding public health and safety concerns, or authorized in writing by the persons in question. Source Note: The provisions of this §554.423 adopted to be effective August 1, 2002, 27 TexReg 6052; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.423 Model Drug Testing Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203107 03/12/2026 (a) For the purposes of this section, a "self-release seat belt" is a seat belt on a resident's wheelchair that the resident demonstrates the ability to fasten and release without assistance. A self-release seat belt is not a restraint.(b) Except as provided in subsection (c) of this section, a facility must allow a resident to use a self-release seat belt if:(1) the resident or the resident's legal guardian requests that the resident use a self-release seat belt;(2) the resident consistently demonstrates the ability to fasten and release the self-release seat belt without assistance;(3) the use of the self-release seat belt is documented in and complies with the resident's comprehensive care plan; and(4) the facility receives written authorization, signed by the resident or the resident's legal guardian, for the resident to use the self-release seat belt.(c) A facility that advertises as a restraint-free facility is not required to allow a resident to use a self-release seat belt if the facility:(1) provides a written statement to all residents that the facility is restraint-free and is not required to allow a resident to use a self-release seat belt; and(2) makes reasonable efforts to accommodate the concerns of a resident who requests a self-release seat belt in accordance with subsection (b) of this section.(d) A facility is not required to continue to allow a resident to use a self-release seat belt in accordance with subsection (b) of this section if:(1) the resident cannot consistently demonstrate the ability to fasten and release the seat belt without assistance;(2) the use of the self-release seat belt does not comply with the resident's comprehensive care plan; or(3) the resident or the resident's legal guardian revokes in writing the authorization for the resident to use the self-release seat belt. Source Note: The provisions of this §554.424 adopted to be effective January 1, 2018, 42 TexReg 7726; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION E RESIDENT RIGHTS §554.424 Wheelchair Self-Release Seat Belts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203097 03/12/2026 (a) The facility must establish and implement an admissions policy.(b) The facility must not request or require:(1) a resident or a potential resident to waive the resident's or potential resident's rights, including the resident's or potential resident's rights to Medicare or Medicaid;(2) oral or written assurance that a resident or a potential resident is not eligible for, or will not apply for, Medicare or Medicaid benefits; and(3) a resident or a potential resident to waive potential facility liability for losses of personal property.(c) The facility must not request or require a third-party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require an individual who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.(d) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State Plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission, or continued stay in the facility. However, a nursing facility may:(1) charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State Plan as included in the term "nursing facility services" so long as the facility gives proper notice of the availability and cost of these services to a resident and does not condition the resident's admission or continued stay on the request for and receipt of these additional services; and(2) solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid-eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid-eligible resident.(e) A nursing facility must disclose and provide a resident or potential resident before time of admission, notice of special characteristics or service limitations of the facility.(f) A nursing facility that is a composite distinct part, as defined by 42 CFR §483.5, must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations. Source Note: The provisions of this §554.501 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION F ADMISSION, TRANSFER, AND DISCHARGE RIGHTS IN MEDICAID-CERTIFIED FACILITIES §554.501 Admissions Policy for Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203098 03/12/2026 (a) Examples. Transfer and discharge includes movement of a resident to a bed outside the certified facility, whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement within the same certified facility.(b) Transfer and discharge requirements. The facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless:(1) the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility;(2) the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;(3) the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;(4) the health of other individuals in the facility would otherwise be endangered;(5) the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for the resident's stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid;(6) the resident or resident representative requests a voluntary transfer or discharge; or(7) the facility ceases to operate as a nursing facility and no longer provides resident care.(c) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in subsection (b)(1) - (7) of this section, the facility must ensure that the transfer or discharge is documented in the resident's clinical record and appropriate information is communicated to the receiving health care institution or provider.(1) Documentation must include:(A) the basis for the transfer per subsection (b)(1) - (7) of this section; and(B) in the case of subsection (b)(1) of this section, the specific resident's needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs.(2) The documentation required by paragraph (1) of this subsection, must be made by:(A) the resident's physician when transfer or discharge is necessary under subsection (b)(1) or (b)(2) of this section; or(B) a physician when transfer or discharge is necessary under subsection (b)(3) or (b)(4) of this section.(3) Information provided to the receiving health care institution or provider must include the following:(A) contact information of the practitioner responsible for the care of the resident;(B) resident representative information, including contact information;(C) advance directive information;(D) all special instructions or precautions for ongoing care, as appropriate;(E) comprehensive care plan goals; and(F) all other necessary information, including a copy of the resident's discharge summary, consistent with §19.803 of this chapter (relating to Discharge Summary (Discharge Plan of Care)), as applicable, to ensure a safe and effective transition of care.(d) Notice before transfer or discharge. Before a facility transfers or discharges a resident, the facility must:(1) notify the resident and the resident representative about the transfer or discharge and the reasons for the move in writing and in a language and manner the resident understands;(2) if the discharge or transfer is initiated by the facility, send a copy of the notice to a representative of the Ombudsman Program at the time a discharge notice is presented to the resident and resident representative, in accordance with the timeframes described in subsection (e) of this section, except that the notice may be provided as soon as practicable, such as in a list of residents sent on a monthly basis, when a resident is temporarily transferred on an emergency basis to an acute care facility;(3) record the reasons for the transfer or discharge in the resident's clinical record;(4) include in the notice the items described in subsection (f) of this section; and(5) comply with §19.2310 of this chapter (relating to Nursing Facility Ceases to Participate) when the facility voluntarily withdraws from Medicaid or Medicare or is terminated from Medicaid or Medicare participation by HHSC or the secretary.(e) Timing of the notice.(1) Except when specified in paragraph (3) of this subsection or in §19.2310 of this chapter, the notice of transfer or discharge required under subsection (d) of this section must be made by the facility at least 30 days before the resident is transferred or discharged.(2) The requirements described in paragraph (1) of this subsection and subsection (h) of this section do not have to be met if the resident or resident representative requests the transfer or discharge.(3) Notice must be made as soon as practicable before transfer or discharge when:(A) the safety of individuals in the facility would be endangered, as specified in subsection (b)(3) of this section;(B) the health of individuals in the facility would be endangered, as specified in subsection (b)(4) of this section;(C) the resident's health improves sufficiently to allow a more immediate transfer or discharge, as specified in subsection (b)(2) of this section;(D) the transfer and discharge is necessary for the resident's welfare because the resident's needs cannot be met in the facility, as specified in subsection (b)(1) of this section, and the resident's urgent medical needs require an immediate transfer or discharge; or(E) a resident has not resided in the facility for 30 days.(4) When an immediate involuntary transfer or discharge as specified in subsection (b)(3) or (4) of this section, is contemplated, unless the discharge is to a hospital, the facility must:(A) immediately call the staff of the Office of the State Long-term Care Ombudsman to report its intention to discharge; and(B) submit to HHSC the required physician documentation regarding the discharge.(f) Contents of the notice. For nursing facilities, the written notice specified in subsection (d) of this section must include the following:(1) the reason for transfer or discharge;(2) the effective date of transfer or discharge;(3) the location to which the resident is transferred or discharged;(4) a statement of the resident's appeal rights, including:(A) the resident has the right to appeal the action as outlined in HHSC's Fair and Fraud Hearings Handbook by requesting a hearing within 90 days after the date of the notice;(B) if the resident requests the hearing before the discharge date, the resident has the right to remain in the facility until the hearing officer makes a final determination unless failure to transfer or discharge would endanger the health or safety of the resident or individuals in the facility. The facility must document the danger failure to discharge would present; and(C) information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(5) the name, address, email address, and telephone number of the managing local ombudsman and the toll-free number of the Ombudsman Program;(6) in the case of a resident with mental illness, the address, email address, and phone number of the state mental health authority; and(7) in the case of a resident with an intellectual or developmental disability, the authority for individuals with intellectual and developmental disabilities, and the phone number, address, and email address of the agency responsible for the protection and advocacy of individuals with intellectual and developmental disabilities.(g) Changes to the notice. If the information in the notice changes before effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.(h) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.(i) Notice of relocation to another room. Except in an emergency, the facility must notify the resident and the resident representative at least five days before relocation of the resident to another room within the facility. The facility must prepare a written notice which contains:(1) the reasons for the relocation;(2) the effective date of the relocation; and(3) the room to which the facility is relocating the resident.(j) Fair hearings.(1) Individuals who receive a discharge notice from a facility have 90 days to appeal. If the recipient appeals before the discharge date, the facility must allow the resident to remain in the facility, except in the circumstances described in subsections (b)(5) and (e)(3) of this section, until the hearing officer makes a final determination. Vendor payments and eligibility will continue until the hearing officer makes a final determination. If the recipient has left the facility, Medicaid eligibility will remain in effect until the hearing officer makes a final determination.(2) When the hearing officer determines that the discharge was inappropriate, the facility, upon written notification by the hearing officer, must readmit the resident immediately, or to the next available bed. If the discharge has not yet taken place, and the hearing officer finds that the discharge will be inappropriate, the facility, upon written notification by the hearing officer, must allow the resident to remain in the facility. The hearing officer will also report the findings to HHSC Regulatory Services Division for investigation of possible noncompliance.(3) When the hearing officer determines that the discharge is appropriate, the resident is notified in writing of this decision. Any payments made on behalf of the recipient past the date of discharge or decision, whichever is later, must be recouped.(k) Discharge of married residents. If two residents in a facility are married and the facility proposes to discharge one spouse to another facility, the facility must give the other spouse notice of the spouse's right to be discharged to the same facility. If the spouse notifies a facility, in writing, that the spouse wishes to be discharged to another facility, the facility must discharge both spouses on the same day, pending availability of accommodations. Source Note: The provisions of this §554.502 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective January 1, 2000, 24 TexReg 11781; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11,2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION F ADMISSION, TRANSFER, AND DISCHARGE RIGHTS IN MEDICAID-CERTIFIED FACILITIES §554.502 Transfer and Discharge in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203099 03/12/2026 (a) Notice before transfer. Before a nursing facility transfers a resident to a hospital or a resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies:(1) the duration of the bed-hold policy under the Medicaid State Plan, if any, during which the resident is permitted to return and resume residence in the facility;(2) the reserved bed payment policy, in the State plan;(3) the facility's policies regarding bed-hold periods, which must be consistent with subsection (c) of this section, permitting a resident to return; and(4) the information specified in §19.502 of this subchapter (relating to Transfer and Discharge in Medicaid-certified Facilities).(b) Bed-hold notice upon transfer. At the time of transfer of a resident to a hospital or for therapeutic leave, a nursing facility must provide to the resident and resident representative, written notice which specifies the duration of the bed-hold policy described in subsection (a) of this section.(c) Permitting resident to return to facility. A nursing facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave.(1) The policy must provide that a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State Plan returns to the facility and to the resident's previous room if available or returns to the facility immediately upon the first availability of a bed in a semi-private room if the resident:(A) requires the services provided by the facility; and(B) is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.(2) If the facility that determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with the requirements of §19.502 of this subchapter.(d) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part, as defined by 42 CFR §483.5, the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which the resident resided previously. If the bed is not available in that location at the time of readmission, the resident must be given the option to return to that location upon the first availability of a bed.(e) Bed-hold charges. The facility may enter into a written agreement with the resident or resident representative to reserve a bed.(1) The facility may charge the recipient an amount not to exceed the HHSC daily vendor rate according to the recipient's classification at the time the resident leaves the facility.(2) The facility must document all bed-hold charges in the recipient's financial record at the time the bed-hold reservation services were provided.(3) The facility may not charge a bed-hold fee if HHSC is paying for the same period of time, as in a three-day therapeutic home visit. Source Note: The provisions of this §554.503 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION F ADMISSION, TRANSFER, AND DISCHARGE RIGHTS IN MEDICAID-CERTIFIED FACILITIES §554.503 Notice of Bed-Hold Policy and Return To Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203100 03/12/2026 (a) A facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source.(b) A facility must establish, maintain, and implement identical policies and practices regarding transfer, discharge, and the provision of services under the Medicaid State Plan for all individuals regardless of source of payment.(c) The facility may charge any amount for services furnished to non-Medicaid residents consistent with the notice requirement in §19.403(i) and (j) of this chapter (relating to Notice of Rights and Services).(d) HHSC is not required to offer additional services on behalf of a recipient other than services provided in the State Plan. Source Note: The provisions of this §554.504 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION F ADMISSION, TRANSFER, AND DISCHARGE RIGHTS IN MEDICAID-CERTIFIED FACILITIES §554.504 Equal Access to Quality Care in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203101 03/12/2026 Discharge planning must be done by appropriate facility staff in accordance with the provisions outlined in §19.803 of this title (relating to Discharge Summary (Discharge Plan of Care)). Source Note: The provisions of this §554.505 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION F ADMISSION, TRANSFER, AND DISCHARGE RIGHTS IN MEDICAID-CERTIFIED FACILITIES §554.505 Discharge Planning in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220623 03/12/2026 (a) General. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in §554.101 of this chapter (relating to Definitions). This includes freedom from any physical or chemical restraint not required to treat the resident's medical symptoms.(b) Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.(c) Policies and procedures. The facility must develop and implement written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation of a resident, and misappropriation of a resident's property.(1) The facility must:(A) not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;(B) not employ or otherwise engage an individual who has:(i) been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment of a resident by a court of law;(ii) had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation or mistreatment of a resident, or misappropriation of a resident's property;(iii) been convicted of any crime contained in §250.006, Texas Health and Safety Code; or(iv) a disciplinary action in effect against the individual's professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of a resident or misappropriation of a resident's property;(C) report any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nurse aide or other staff to the state nurse aide registry or licensing authority; and(D) suspend the employment of an employee who HHSC finds has engaged in reportable conduct, as defined in section §554.101 of this chapter, while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, pending a final decision by an administrative law judge. A facility must not reinstate the employee's employment or contract during any applicable appeals process.(2) The written policies and procedures must:(A) establish protocols to investigate any such allegations; and(B) include training as required by §554.1929 of this chapter (relating to Staff Development).(d) Restraints. The facility must ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. If the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.(1) If physical restraints are used because they are required to treat the resident's medical condition, the restraints must be released and the resident repositioned as needed to prevent deterioration in the resident's condition. Residents must be monitored hourly and, at a minimum, restraints must be released every two hours for a minimum of ten minutes, and the resident repositioned.(2) A facility must not administer to a resident a restraint that:(A) obstructs the resident's airway, including a procedure that places anything in, on, or over the resident's mouth or nose;(B) impairs the resident's breathing by putting pressure on the resident's torso;(C) interferes with the resident's ability to communicate; or(D) places the resident in a prone or supine hold.(3) A behavioral emergency is a situation in which severely aggressive, destructive, violent, or self-injurious behavior exhibited by a resident:(A) poses a substantial risk of imminent probable death of, or substantial bodily harm to, the resident or others;(B) has not abated in response to attempted preventive de-escalatory or redirection techniques;(C) could not reasonably have been anticipated; and(D) is not addressed in the resident's comprehensive care plan.(4) If restraint is used in a behavioral emergency, the facility must use only an acceptable restraint hold. An acceptable restraint hold is a hold in which the resident's limbs are held close to the body to limit or prevent movement and that does not violate the provisions of paragraph (2) of this subsection.(5) A staff person may use a restraint hold only for the shortest period of time necessary to ensure the protection of the resident or others in a behavioral emergency.(6) A facility may adopt policies that allow less use of restraint than allowed by the rules of this chapter.(7) A resident, or the resident's legally authorized representative, must agree to the use of a physical restraint in accordance with §554.402 of this chapter (relating to Exercise of Rights) and §554.406 of this chapter (relating to Free Choice).(8) A physical restraint must be ordered by a physician. The order must include why the restraint is necessary to treat the resident's medical condition and the specified timeframe for re-evaluation of the order.(9) Use of restraints and their release must be documented in the resident's clinical record and in the resident's care plan in accordance with §554.802 of this chapter (relating to Comprehensive Person-Centered Care Planning). Source Note: The provisions of this §554.601 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective June 1, 2006, 31 TexReg 4449; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective September 18, 2024, 49 TexReg 7331. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION G FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION §554.601 Freedom from Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203126 03/12/2026 (a) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:(1) ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported:(A) immediately to the administrator of the facility and to HHSC Complaint and Incident Intake, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury; or(B) no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC Complaint and Incident Intake, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury;(2) conduct an investigation of the reported acts and have evidence that all alleged violations are thoroughly investigated;(3) prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; and(4) report the results of all investigations to the administrator or the administrator's designee and to HHSC Complaint and Incident Intake within five working days of the incident and, if the alleged violation is verified, take appropriate corrective action.(b) A facility owner or employee who has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person must report the abuse, neglect, or exploitation.(c) Reports described in subsections (a)(1) and (b) of this section must be made to HHSC Complaint and Incident Intake.(d) Written investigation reports described in subsection (a)(4) of this section must be sent to HHSC Complaint and Incident Intake no later than the fifth working day after the initial.(e) As a condition of employment, an employee of a facility must sign a statement that states:(1) the employee may be criminally liable for failure to report abuses; and(2) the employee has a cause of action against a facility, its owners or employees if the employee is suspended, terminated, disciplined, discriminated against, or retaliated against, under the Texas Health and Safety Code, Title 4, §260A.014, as a result of:(A) reporting to the employee's supervisor, the administrator, HHSC, or a law enforcement agency a violation of law, including a violation of laws or regulations regarding nursing facilities; or(B) initiating or cooperating in any investigation or proceeding of a governmental entity relating to care, services, or conditions at the nursing facility.(f) The statements described in subsection (e) of this section must be available for inspection by HHSC.(g) A local or state law enforcement agency must be notified of reports described in subsection (b) of this section that allege that:(1) a resident's health or safety is in imminent danger;(2) a resident has recently died because of conduct alleged in the report of abuse or neglect or other complaint;(3) a resident has been hospitalized or treated in an emergency room because of conduct alleged in the report of abuse or neglect or other complaint;(4) a resident has been a victim of any act or attempted act described in the Texas Penal Code, §§21.02, 21.11, 22.011, or 22.021; or(5) a resident has suffered bodily injury, as that term is defined in the Texas Penal Code, §1.07, because of conduct alleged in the report of abuse or neglect or other complaint. Source Note: The provisions of this §554.602 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective September 1, 2003, 28 TexReg 6939; amended to be effective May 1, 2004, 29 TexReg 3235; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effectiveMarch 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION G FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION §554.602 Incidents of Abuse, Neglect, and Exploitation Reportable to the Texas Health and Human Services Commission and Law Enforcement Agencies by Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203127 03/12/2026 (a) A complaint is any allegation received by the Texas Department of Human Services (DHS) other than an incident reported by facility staff. These allegations include, but are not limited to, abuse, neglect, exploitation, or violation of state or federal standards.(b) DHS will furnish the facility with a notification of the complaint received and a summary of the complaint, without identifying the source of the complaint. Source Note: The provisions of this §554.604 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION G FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION §554.604 Complaint Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203128 03/12/2026 (a) All licensed facilities must report to HHSC the death of any resident in the facility and any resident who is transferred from the facility to a hospital and who dies within 24 hours after transfer.(b) The facility must submit to HHSC Complaint and Incident Intake a standard HHSC form within ten working days after the last day of the month in which a resident death occurs. The form must include:(1) name of deceased;(2) social security number of the deceased;(3) date of death; and(4) name and address of the institution.(c) These reports are confidential under the Texas Health and Safety Code, §260A.016; however, a licensed facility must make available historical statistics provided to the facility by HHSC and must provide the statistics, if requested, to an applicant for admission or the applicant's representative.(d) HHSC produces statistical information of official causes of death to determine patterns and trends of incidents of death among the elderly and in specific facilities and makes this information available to the public upon request. Source Note: The provisions of this §554.606 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION G FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION §554.606 Reporting of Resident Death Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203129 03/12/2026 (a) Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and care plan.(1) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that such diminution was unavoidable.(2) This includes the facility ensuring that:(A) a resident is given the appropriate treatment and services to maintain or improve the ability to carry out the activities of daily living, including those specified in subsection (b) of this section;(B) a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and(C) personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.(b) The facility must provide care and services in accordance with subsection (a) of this section for the following activities of daily living:(1) hygiene - bathing, dressing, grooming, and oral care;(2) mobility - transfer and ambulation, including walking;(3) elimination - toileting;(4) dining - eating including meals and snacks; and(5) communication - speech, language, and other functional communication systems.(c) If a child is admitted to a facility, care must be provided to meet the child's unique medical and developmental needs.(d) Pediatric residents should be matched with roommates of similar age and developmental levels. Source Note: The provisions of this §554.701 adopted to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION H QUALITY OF LIFE §554.701 Quality of Life https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203130 03/12/2026 (a) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support a resident in the resident's choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.(b) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who:(1) is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body, such as the National Council for Therapeutic Recreation Certification, on or after October 1, 1990, the Consortium for Therapeutic Recreation/Activities Certification, or the National Certification Council for Activity Professionals;(2) has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program;(3) is a qualified occupational therapist or occupational therapy assistant; or(4) has completed an activity director training course approved by a recognized credentialing body, such as the National Certification Council for Activity Professionals, National Council for Therapeutic Recreation Certification, or the Consortium for Therapeutic Recreation/Activities Certification, Inc.(c) An activity director must complete eight hours of approved continuing education or equivalent continuing education units each year. Approval bodies include organizations or associations recognized as such by certified therapeutic recreation specialists or certified activity professionals or registered occupational therapists.(d) The facility must ensure that activities assessment and care planning are completed and reviewed or updated as provided in §19.801 and §19.802 of this chapter (relating to Resident Assessment and Comprehensive Person-Centered Care Planning). If indicated by the RAI or the resident's need, an in-depth activities assessment is required.(e) Toys and recreational equipment for a pediatric resident must be appropriate for the size, age, and developmental level of the resident. Source Note: The provisions of this §554.702 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective April 1, 2001, 26 TexReg 2407; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION H QUALITY OF LIFE §554.702 Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203131 03/12/2026 (a) The facility must provide medically-related social services to attain the highest practicable physical, mental, or psychosocial well-being of each resident.(1) A facility with more than 120 beds must employ a qualified social worker on a full-time basis.(2) A facility of 120 beds or less must employ or contract with a qualified social worker (or in lieu thereof, a social worker who is licensed by the Texas State Board of Social Worker Examiners, and who meets the requirements of subsection (b)(2) of this section) to provide social services a sufficient amount of time to meet the needs of the residents.(b) A qualified social worker is an individual who is licensed, including a temporary or provisional license, by the Texas State Board of Social Worker Examiners as prescribed by Texas Occupations Code, Chapter 505, and who has at least:(1) a bachelor's degree in social work, or a bachelor's degree in a human services field, including sociology, gerontology, special education, rehabilitation counseling, and psychology; and(2) one year of supervised social work experience in a health care setting working directly with individuals. Source Note: The provisions of this §554.703 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION H QUALITY OF LIFE §554.703 Social Services General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203132 03/12/2026 (a) The facility must ensure that psychosocial assessment and care planning are completed and reviewed or updated as provided in §19.801 and §19.802 of this title (relating to Resident Assessment and Comprehensive Care Plans).(b) If indicated by the Resident Assessment Instrument (RAI) and/or the resident's need, an in-depth psychosocial assessment is required. The social service needs of each resident must be identified and addressed by the direct provision of services or by arranging access to services. Source Note: The provisions of this §554.704 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION H QUALITY OF LIFE §554.704 Social Services Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203133 03/12/2026 (a) A resident has the right to organize and participate in resident groups in a facility.(b) A facility must assist a resident who requires assistance to attend resident group meetings.(c) A resident has the right to have a family member or other resident representative meet in the facility with the family or resident representative of other residents in the facility and organize a family council. A family council may:(1) make recommendations to the facility proposing policy and operational decisions affecting resident care and quality of life; and(2) promote educational programs and projects intended to promote the health and happiness of residents.(d) If a resident group or family council exists, a facility must:(1) listen to and consider the views of a resident group or family council and act promptly upon the grievances and recommendations of residents and families concerning issues of resident care and life in the facility;(2) be able to demonstrate responses to the grievances and recommendations of the resident group or family council and the rationale for such responses;(3) provide a resident group or family council with private space and take reasonable steps with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner;(4) provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from resident group and family council meetings; and(5) allow staff or visitors to attend meetings only at the resident group's or family council's invitation.(e) If a family council exists, a facility must:(1) upon written request, allow the family council to meet in a common meeting room of the facility at least once a month during hours mutually agreed upon by the family council and the facility;(2) provide the family council with adequate space on a prominent bulletin board to post notices and other information;(3) designate a staff person to act as the family council's liaison to the facility;(4) respond in writing to written requests by the family council within five working days;(5) include information about the existence of the family council in a mailing that occurs at least semiannually;(6) permit a representative of the family council to discuss concerns with an individual conducting an inspection or survey of the facility; and(7) allow a resident to participate in a family council.(f) Unless the resident objects, a family council member may authorize, in writing, another member to visit and observe a resident represented by the authorizing member.(g) A facility must not limit the rights of a resident, a resident's family member, or a family council member to meet with an outside person, including:(1) an employee of the facility during the employee's nonworking hours if the employee agrees;(2) a member of a nonprofit or government organization; or(3) another resident representative.(h) A facility must not:(1) terminate an existing family council;(2) prevent or interfere with the family council from receiving outside correspondence addressed to the family council or open family council mail; or(3) willfully interfere with the formation, maintenance, or operation of a family council, including interfering by:(A) denying a family council the opportunity to accept help from an outside person;(B) discriminating or retaliating against a family council participant; or(C) willfully scheduling events in conflict with previously scheduled family council meetings, if the facility has other scheduling options. Source Note: The provisions of this §554.706 adopted to be effective September 1, 2008, 33 TexReg 6151; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION H QUALITY OF LIFE §554.706 Resident Group and Family Council https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203134 03/12/2026 A facility must conduct, initially and periodically, a comprehensive, accurate, standardized, reproducible assessment of a resident's functional capacity. The facility must electronically transmit to CMS resident-entry-and-death-in-facility tracking records required by the RAI; and OBRA assessments, including admission, annual, quarterly, significant change, significant correction, and discharge assessments.(1) Admission orders. At the time a resident is admitted, the facility must have physician orders for the resident's immediate care.(2) Comprehensive assessments.(A) A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the current RAI process, including the MDS, Care Area Assessment process, and the Utilization Guidelines specified by HHSC and approved by CMS. The current RAI process is found in the MDS 3.0 manual posted by CMS on http://www.cms.gov.(B) A facility must conduct an additional assessment and document the summary information if the MDS indicates an additional assessment on a care area is required.(C) A facility must conduct a comprehensive assessment of a resident as follows:(i) within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or for therapeutic leave;(ii) within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. For purposes of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the comprehensive care plan, or both; and(iii) not less often than once every 12 months.(3) Quarterly review assessment. A facility must assess a resident using the quarterly review instrument specified by HHSC and approved by CMS not less frequently than once every three months.(4) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive care plan as specified in §19.802 of this subchapter (relating to Comprehensive Person-Centered Care Planning).(5) PASRR. A Medicaid-certified facility must:(A) coordinate assessments with the PASRR process in 42 CFR, Part 483, Subpart C to the maximum extent practicable to avoid duplicative testing and effort, including:(i) incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care; and(ii) referring a level II resident and a resident suspected of having mental illness, an intellectual disability, or a developmental disability for level II resident review upon a significant change in status assessment; and(B) promptly report a significant change in the mental or physical condition of a resident by submitting an MDS Significant Change in Status Assessment Form in the LTC Online Portal, in accordance with §19.2704(i)(12) of this chapter (Nursing Facility Responsibilities Related to PASRR).(6) Automated data processing requirement.(A) A facility must complete an MDS for a resident. The facility must enter MDS data into the facility's assessment software within 7 days after completing the MDS and electronically transmit the MDS data to CMS within 14 days after completing the MDS.(B) A facility must complete the Long Term Care Medicaid Information form on an OBRA assessment that is submitted to the state Medicaid claims system for a Medicaid recipient or Medicaid applicant according to HHSC instructions located on the Texas Medicaid Healthcare Partnership Long Term Care Portal at http://www.tmhp.com.(C) Data format. The facility must transmit MDS data to CMS in the format specified by CMS and HHSC.(D) Information concerning a resident is confidential and a facility must not release information concerning a resident except as allowed by this chapter, including §19.407 of this chapter (relating to Privacy and Confidentiality) and §19.1910(d) of this chapter (relating to Clinical Records).(7) Accuracy of assessments. The assessment must accurately reflect the resident's status.(8) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.(9) Certification.(A) A registered nurse must sign and certify that the assessment is completed.(B) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.(10) Penalty for falsification under Medicare and Medicaid.(A) An individual who willfully and knowingly:(i) certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or(ii) causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.(B) Clinical disagreement does not constitute a material and false statement.(11) Use of independent assessors in Medicaid-certified facilities and dually certified facilities. If HHSC determines, under a certification survey or otherwise, that there has been a knowing and willful certification of false statements under paragraph (10) of this section, HHSC may require (for a period specified by HHSC) individuals who are independent of the facility and who are approved by HHSC to conduct and certify the resident assessments under this section.(12) Pediatric resident assessment.(A) A facility must ensure that a pediatric assessment:(i) is performed by a licensed health professional experienced in the care and assessment of children;(ii) includes parents or guardians in the assessment process; and(iii) includes a discussion with a parent or guardian about the potential for community transition.(B) The clinical record of a child must include a record of immunizations, blood screening for lead, and developmental assessment. The local school district's developmental assessment may be used if available.(C) A licensed health professional must assess a child's functional status in relation to pediatric developmental levels, rather than adult developmental levels.(D) A facility must ensure pediatric residents receive services in accordance with the guidelines established by the Department of State Health Services' Texas Health Steps (THSteps). For Medicaid-eligible pediatric residents between the ages of six months and six years, blood screening for lead must be done in accordance with THSteps guidelines. Source Note: The provisions of this §554.801 adopted to be effective October 1, 1999, 24 TexReg 7767; amended to be effective January 1, 2000, 24 TexReg 11522; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective June 1, 2006, 31 TexReg 4457; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION I RESIDENT ASSESSMENT §554.801 Resident Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203135 03/12/2026 (a) Baseline care plans.(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must:(A) be developed within 48 hours of a resident's admission;(B) include the minimum healthcare information necessary to properly care for a resident, including:(i) initial goals based on admission orders;(ii) physician orders;(iii) dietary orders;(iv) therapy services;(v) social services; and(vi) PASRR recommendation, if applicable.(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan:(A) is developed within 48 hours of the resident's admission; and(B) meets the requirements set forth in subsections (b) - (g) of this section, except subsection (c)(1) of this section.(3) The facility must provide the resident and the resident representative a summary of the baseline care plan that includes:(A) the initial goals of the resident;(B) a summary of the resident's medications and dietary instructions;(C) any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and(D) any updated information based on the details of the comprehensive care plan, as necessary.(b) A facility must develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. If a child is admitted to the facility, the comprehensive care plan must be based on the child's individual needs. The comprehensive care plan must describe the following:(1) the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §19.701 of this chapter (relating to Quality of Life) and §19.901 of this chapter (relating to Quality of Care);(2) any services that would otherwise be required under §19.701 of this chapter and §19.901 of this chapter but are not provided due to the resident's exercise of rights, including the right to refuse treatment under §19.403(i) of this chapter (relating to Notice of Rights and Services);(3) any nursing facility specialized services or nursing facility PASRR support activities the nursing facility will provide as a result of PASRR recommendations, in accordance with Subchapter BB of this chapter (relating to Nursing Facility Responsibilities Related To Preadmission Screening And Resident Review (PASRR)); and(4) in consultation with the resident and resident representative:(A) the resident's goals for admission and desired outcomes;(B) the resident's preference and potential for future discharge, whether the resident's desire to return to the community was assessed, and any referrals to local contact agencies or other appropriate entities; and(C) discharge plans in the comprehensive care plan as appropriate, in accordance with §19.803 of this subchapter (relating to Discharge Summary (Discharge Plan of Care)).(c) The comprehensive care plan must be:(1) developed within seven days after completion of the comprehensive assessment;(2) prepared by an interdisciplinary team that includes:(A) the attending physician;(B) a registered nurse with responsibility for the resident;(C) a nurse aide with responsibility for the resident;(D) the qualified dietitian or director of food and nutrition services;(E) other appropriate staff in disciplines as determined by the resident's needs or as requested by the resident; and(F) to the extent practicable, the participation of the resident and the resident representative;(3) periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments; and(4) for a resident under 22 years of age, annually reviewed at a comprehensive care plan meeting between the facility and the resident's LAR as defined in §19.805(a)(5) of this subchapter (relating to Permanency Planning for a Resident Under 22 Years of Age), which includes a review of:(A) the LAR's contact information as required by §19.805(b)(4)(F) of this subchapter;(B) the resident's comprehensive assessment;(C) the resident's educational status; and(D) the resident's permanency plan.(d) Regarding subsection (c)(2)(F) of this section, an explanation must be included in a resident's clinical record if the participation of the resident and the resident representative is determined not practicable for the development of the resident's comprehensive care plan.(e) A comprehensive care plan must include:(1) for a resident under 18 years of age, the activities, supports, and services that, when provided or facilitated by the facility, will enable the resident to live with a family; or(2) for a resident 18-22 years of age, the activities, supports, and services that, when provided or facilitated by the facility, will result in the resident having a consistent and nurturing environment in the least restrictive setting, as defined by the resident and LAR as defined in §19.805(a)(5) of this subchapter.(f) A comprehensive care plan may include a palliative plan of care. This plan may be developed only at the request of the resident, surrogate decision maker or legal representative for residents with terminal conditions, end stage diseases or other conditions for which curative medical interventions are not appropriate. The plan of care must have goals that focus on maintaining a safe, comfortable and supportive environment in providing care to a resident at the end of life.(g) For a resident under 22 years of age, the facility must provide written notice to the LAR, as defined in §19.805(a)(5) of this subchapter, of a meeting to conduct an annual review of the resident's comprehensive care plan no later than 21 days before the meeting date and request a response from the LAR.(h) The services provided or arranged by the facility must:(1) meet professional standards of quality;(2) be provided by qualified persons in accordance with each resident's written comprehensive care plan; and(3) effective November 28, 2019, be culturally-competent and trauma-informed.(i) The comprehensive care plan must be made available to all direct care staff. Source Note: The provisions of this §554.802 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 2001, 26 TexReg 3824; amended to be effective September 1, 2006, 31 TexReg 6800; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION I RESIDENT ASSESSMENT §554.802 Comprehensive Person-Centered Care Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203136 03/12/2026 (a) Discharge planning. The facility must develop and implement an effective discharge planning process.(1) The facility's discharge planning process must:(A) ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident;(B) include regular re-evaluation of a resident to identify changes that require modification of the discharge plan and update the discharge plan to reflect these changes;(C) involve the interdisciplinary team in the ongoing process of developing the discharge plan;(D) consider caregiver or support person availability and the resident's or caregiver's or support person's capacity and capability to perform required care, as part of the identification of discharge needs;(E) involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan;(F) address the resident's goals of care and treatment preferences; and(G) document that a resident has been asked about their interest in receiving information regarding returning to the community.(i) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.(ii) Facilities must update a resident's comprehensive care plan and discharge plan as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.(iii) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.(2) The evaluation of the resident's discharge needs and discharge plan must be completed on a timely basis and documented in the resident's clinical record.(3) The results of the evaluation of the resident's discharge needs and discharge plan must be discussed with the resident or the resident representative.(b) When a facility anticipates a resident's discharge, the facility must develop a discharge summary that includes:(1) a recapitulation of the overall course of the resident's stay that includes diagnoses, course of illness, treatment, or therapy and pertinent lab, radiology, and consultation results, a final summary of the resident's status;(2) reconciliation or all pre-discharge medications with the resident's post-discharge medications both prescribed and over-the-counter;(3) a statement notifying a resident granted permanent medical necessity (PMN) under the Medicaid program that:(A) PMN status continues after discharge, unless the resident is discharged to home;(B) PMN status expires 30 consecutive days after the resident is discharged to home; and(C) a new medical necessity determination is required if the resident applies to be admitted to a nursing facility under the Medicaid program more than 30 consecutive days after the resident moves home from a nursing facility; and(4) a post-discharge care plan, developed with the participation of the resident and a resident representative that:(A) will assist the resident to adjust to the new living environment; and(B) indicates where the resident plans to reside and arrangements that have been made for follow-up care and any post discharge medical and non-medical services.(c) The facility discharge summary must be available for release to authorized persons, facilities or agencies with the consent of the resident or resident representative. Source Note: The provisions of this §554.803 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION I RESIDENT ASSESSMENT §554.803 Discharge Summary (Discharge Plan of Care) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203137 03/12/2026 (a) A facility will perform a Capacity Assessment for Self Care and Financial Management for persons who will be referred to a court for guardianship if the person:(1) is elderly, which is defined as a person 60 years of age or older; or(2) has mental retardation or a developmental disability; or(3) is suspected of being a person with mental retardation or a developmental disability.(b) The assessment will be completed when:(1) a facility determines that a guardian of the estate, or the person, or both, may be appropriate and a referral to a court for guardianship is anticipated; or(2) requested to do so by a court.(c) The facility will use the Capacity Assessment for Self Care and Financial Management instrument developed by the Texas Department of Mental Health and Mental Retardation.(d) The Capacity Assessment for Self Care and Financial Management will be performed by the facility social worker, with assistance from other professionals as requested by the social worker. Source Note: The provisions of this §554.804 adopted to be effective March 15, 2000, 25 TexReg 1395; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION I RESIDENT ASSESSMENT §554.804 Capacity Assessment for Self Care and Financial Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203138 03/12/2026 (a) Definitions. The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Permanency planning--A philosophy and planning process that focuses on the outcome of family support by facilitating a permanent living arrangement, with the primary feature of an enduring and nurturing parental relationship. Family-directed planning empowers the family of a child under the age of 18 to direct the development of supports and services that meet the child and family's personal outcomes as related to that child. Person-directed planning empowers the child who is between 18 and 22 years of age to direct the development of a plan of supports and services that meets the needs for self-determination.(2) Child--A person with a developmental disability who is under 22 years of age.(3) CRCG (Community resource coordination group)--A local interagency group composed of public and private agencies that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, available on the Health and Human Services Commission website at www.hhsc.state.tx.us/crcg/crcg.htm.(4) Emergency situation--An unexpected situation involving a child's health, safety, or welfare, of which a person of ordinary prudence would determine that the LAR should be informed, such as:(A) a child needing emergency medical care;(B) a child being removed from his residence by law enforcement;(C) a child leaving his residence without notifying staff and not being located; and(D) a child being moved from his residence to protect the child (for example, because of a hurricane, fire, or flood).(5) LAR (legally authorized representative)--A person authorized by law to act on behalf of a resident with regard to a matter described in this subchapter, which may include a parent, guardian, managing conservator of a minor individual, a guardian of an adult individual, or legal representative of a deceased individual.(6) Permanency planner--A person assigned by DADS to conduct permanency planning activities for a child who resides in a facility.(b) Facility responsibilities regarding permanency planning.(1) A facility must request a Preadmission Screening and Resident Review (PASARR) on every child who is a potential admission to a facility, as well as on all children currently residing in a facility who have not had a previous PASARR completed. Documentation regarding the request for or completion of a PASARR must be kept in the chart.(2) A facility must notify the following entities of the child's admission not later than the third day after a child is initially placed in a facility:(A) DADS via fax, using DADS Form 2437, Notification of Nursing Facility Admission of Individual Under Age 22;(B) the CRCG in the county where the LAR resides (see www.hhsc.state.tx.us/crcg/crcg.htm for a listing of CRCG chairpersons by county);(C) the local office of the Early Childhood Intervention (ECI) Program of the Texas Department of Assistive and Rehabilitative Services, if a child is less than three years of age (see www.dars.state.tx.us/ecis/index.shtml or call 1-800-628-5115 for a listing of ECI programs by county); and(D) the local school district, if a child is 3 to 22 years of age, with which the facility must coordinate educational opportunities (See §19.1934 of this title (relating to Educational Requirements for Persons under Age 22)).(3) A facility must keep in a separate section at the front of each child's records:(A) documentation regarding the notifications required in paragraph (2) of this subsection;(B) a copy of all PASARR documents; and(C) a copy of the current permanency plan.(4) A facility must:(A) cooperate with the permanency planner by:(i) allowing access to a child's records or providing other information in a timely manner as requested by the permanency planner or the Health and Human Services Commission;(ii) participating in meetings to review the child's permanency plan; and(iii) identifying, in coordination with the permanency planner, activities, supports, and services that can be provided by the family, LAR, facility, or the permanency planner to prepare the child for an alternative living arrangement;(B) encourage regular contact between the child and LAR and, if desired by the child and LAR, between the child and advocates and friends in the community to continue supportive and nurturing relationships;(C) encourage participation in the comprehensive care plan meetings by the LAR, and, if desired by the child or LAR, by family members, advocates, and friends in the community;(D) make reasonable accommodations to promote the participation of the LAR in all planning and decision-making regarding the child's care, including participating in:(i) the initial development and annual review of the child's comprehensive care plan;(ii) decision-making regarding the child's medical care;(iii) routine interdisciplinary team meetings; and(iv) decision-making and other activities involving the child's health and safety;(E) ensure that reasonable accommodations include:(i) conducting a meeting in person or by telephone, as mutually agreed upon by the facility and the LAR;(ii) conducting a meeting at a time and, if the meeting is in person, at a location that is mutually agreed upon by the facility and the LAR;(iii) if the LAR has a disability, providing reasonable accommodations in accordance with the Americans with Disabilities Act, including providing an accessible meeting location or a sign language interpreter, if appropriate; and(iv) providing a language interpreter, if appropriate;(F) upon admission and annually thereafter:(i) request from and encourage an LAR to provide the following information for a child during the annual comprehensive care plan meeting and, for an applicant, upon admission:(I) the LAR's:(-a-) name;(-b-) address;(-c-) telephone number;(-d-) driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(-e-) place of employment and the employer's address and telephone number;(II) the name, address, and telephone number of a relative of the child or other person whom DADS or the facility may contact in an emergency situation, a statement indicating the relation between that person and the child, and at the LAR's option:(-a-) that person's driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(-b-) the name, address, and telephone number of that person's employer; and(III) a signed acknowledgement of responsibility stating that the LAR agrees to:(-a-) notify the facility of any changes to the contact information submitted; and(-b-) make reasonable efforts to participate in the child's life and in planning activities for the child; and(ii) inform the LAR that if the information described in clause (i) of this subparagraph is not provided or is not accurate and the facility and DADS are unable to locate the LAR as described in subparagraph (J) of this paragraph, DADS refers the case to the Department of Family and Protective Services, in accordance with subsection (c) of this section;(G) refrain from providing the LAR with inaccurate or misleading information regarding the risks of moving the child to another facility or community setting;(H) if an emergency situation occurs, attempt to notify the LAR as soon as the emergency situation allows and request a response from the LAR;(I) if an LAR does not respond to a notice of the child's annual comprehensive care plan meeting, a request for the LAR's consent, or an emergency situation, attempt to locate the LAR by contacting a person identified by the LAR in the contact information described in subparagraph (F) if this paragraph;(J) no later than 30 days after the date the facility determines that it is unable to locate the LAR, notify DADS at 1-800-458-9858 of that determination and request that DADS initiate a search for the LAR;(K) before a child who is under 18 years of age, or who is 18-22 years of age and for whom an LAR has been appointed, is transferred to another facility operated by the transferring facility, attempt to obtain consent for the transfer from the LAR, unless the transfer is made because of a serious risk to the health and safety of the child or another person; and(L) document compliance with the requirements of this paragraph in the child's records.(5) The facility administrator must ensure that the social worker or other appropriate staff, as needed, will contribute to the development of the permanency plan.(6) Paragraphs (3) - (5) of this subsection do not apply to short-stay care of less than 14 days; however, the facility must notify DADS, the CRCG, ECI, and the local school district as required in paragraph (2)(A) - (D) of this subsection.(c) If, within one year of the date DADS receives the notification described in subsection (b)(4)(J) of this section, DADS is unable to locate the LAR, DADS refers the case to:(1) the Child Protective Services Division of the Department of Family and Protective Services if the child is under 18 years of age; or(2) the Adult Protective Services Division of the Department of Family and Protective Services if the child is 18-22 years of age. Source Note: The provisions of this §554.805 adopted to be effective May 1, 2002, 27 TexReg 2834; amended to be effective September 1, 2006, 31 TexReg 6800; amended to be effective August 3, 2011, 36 TexReg 4809; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION I RESIDENT ASSESSMENT §554.805 Permanency Planning for a Resident Under 22 Years of Age https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203139 03/12/2026 Based on the comprehensive assessment of a resident, the facility must ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including the following:(1) Vision and hearing. To ensure that a resident receives proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident:(A) in making appointments; and(B) by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.(2) Skin Integrity.(A) Pressure ulcers. Based on the comprehensive assessment of the resident, the facility must ensure that:(i) a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the resident's clinical condition demonstrates that they are unavoidable; and(ii) a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing.(B) Foot Care. To ensure that a resident receives proper treatment and care to maintain mobility and good foot health, the facility must:(i) provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition; and(ii) if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.(3) Incontinence.(A) The facility must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless the resident's clinical condition is or becomes such that continence is not possible to maintain.(B) For a resident with urinary incontinence, based on the comprehensive assessment of the resident, the facility must ensure that:(i) a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary;(ii) a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and(iii) a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.(C) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.(4) Colostomy, urostomy, or ileostomy care. The facility must ensure that a resident who requires colostomy, urostomy, or ileostomy services, receives such care consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences.(5) Mobility. The facility must ensure that:(A) a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable;(B) a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion; and(C) a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is unavoidable.(6) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident:(A) maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or the resident preferences indicate otherwise;(B) is offered sufficient fluid intake to maintain proper hydration and health;(C) is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet;(D) who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and(E) who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.(7) Parenteral fluids. Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan, and the resident's goals and preferences.(8) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive care plan, the resident's goals and preferences, and §19.802 of this chapter, (relating to Comprehensive Person-Centered Care Planning).(9) Prostheses. The facility must ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences, to wear and be able to use the prosthetic device.(10) Pain management. The facility must ensure that pain management is provided to a resident who requires such services, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences.(11) Dialysis. The facility must ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive care plan, and the resident's goals and preferences.(12) Trauma-informed care. Effective November 28, 2019, the facility must ensure that a resident who is a trauma survivor receives culturally-competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.(13) Bed rails. The facility must attempt to use appropriate alternatives before installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including the following elements:(A) assess the resident for risk of entrapment from bed rails before installation;(B) review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent before installation;(C) ensure the bed's dimensions are appropriate for the resident's size and weight; and(D) follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.(14) Accidents. The facility must ensure that:(A) the resident environment remains as free of accident hazards as possible; and(B) each resident receives adequate supervision and assistive devices to prevent accidents.(15) Pediatric care.(A) Licensed nursing care of children. A facility caring for children must have 24 hour a day on-site licensed nursing staff in numbers sufficient to provide safe care. For any facility with five or more children under 26 pounds, at least one nurse must be assigned solely to the care of those children.(B) Fewer than five pediatric residents. Facilities with fewer than five pediatric residents must assure that the children's rooms are in close proximity to the nurses' station.(C) Respiratory care of children.(i) To facilitate the care of ventilator-dependent children or children with tracheostomies, a facility must group those children in rooms contiguous or in close proximity to each other. An exception to this rule is children who are able to be schooled off-site.(ii) Facilities must assure that alarms on ventilators, apnea monitors, and any other such equipment uniquely identify the child or the child's room.(iii) A facility caring for children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies) must have 24 hour a day on-site respiratory therapy staff in numbers sufficient to provide a safe ratio of respiratory therapist per these residents. For the purposes of this rule, respiratory therapy staff is defined as a registered respiratory therapist (RRT), a certified respiratory therapy technician (CRT), or a licensed nurse whose primary function is respiratory care.(I) If the facility cares for nine or more children with tracheostomies requiring daily care (including ventilator-dependent children with tracheostomies), the facility must maintain a ratio of no less than one respiratory therapy staff per nine tracheostomy residents 24 hours a day.(II) If the facility cares for six or more ventilator dependent children, the facility must:(-a-) designate a respiratory therapy supervisor, either on staff or contracted who must be credentialed by the National Board for Respiratory Care (either CRT or RRT).(-b-) provide and document that all respiratory therapy staff is trained in the care of children who are ventilator dependent. This training must be reviewed annually.(-c-) assure that appropriate care, maintenance, and disinfection of all ventilator equipment and accessories occurs. Source Note: The provisions of this §554.901 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective May 15, 1998, 23 TexReg 4572; amended to be effective March 24, 2020, 45 TexReg 2020; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION J QUALITY OF CARE §554.901 Quality of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203140 03/12/2026 Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and care plan.(1) The facility must have sufficient staff who provide direct services to a resident with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This is determined by resident assessments and individual comprehensive care plans and considering the number, acuity and diagnoses of the facility's resident population in accordance with §19.1931 of this chapter (relating to Facility Assessment). These competencies and skills sets include knowledge of and appropriate training and supervision for:(A) caring for a resident with mental and psychosocial disorders, as well as a resident with a history of trauma or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §19.1931 of this chapter; and(B) implementing non-pharmacological interventions.(2) Based on the comprehensive assessment of a resident, the facility must ensure that:(A) a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;(B) a resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma or post-traumatic stress disorder does not display a pattern of decreased social interaction or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable; and(C) a resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.(3) If rehabilitative services such as physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability, are required in the resident's comprehensive care plan, the facility must:(A) provide the required services, including specialized rehabilitation services as required in §19.802 of this chapter (relating to Comprehensive Person-Centered Care Planning).(B) obtain the required services from an outside resource in accordance with §19.1906 of this chapter (relating to Use of Outside Resources), from a Medicare or Medicaid provider of specialized rehabilitative services.(4) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Source Note: The provisions of this §554.904 adopted to be effective March 24, 2020, 45 TexReg 2020; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION J QUALITY OF CARE §554.904 Behavioral Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203141 03/12/2026 The Health and Human Services Commission (HHSC) uses an early warning system to detect conditions that could be detrimental to the health, safety, and welfare of residents.(1) Quality-of-care monitors conduct visits that may be announced or unannounced and may occur on any day and at any time, including nights, weekends, and holidays.(2) Quality-of-care monitors may visit a facility:(A) with a history of resident care deficiencies;(B) that is identified as a medium risk through the early warning system; or(C) that requests a visit.(3) Quality-of-care monitors assess:(A) the overall quality of life in the facility; and(B) specific conditions in the facility directly related to resident care, including conditions identified through the facility's quality measure reports based on MDS assessments.(4) A quality-of-care monitor assessment visit includes:(A) observation of the care and services provided to a resident; and(B) formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regular staff, and resident representatives and advocates.(5) HHSC does not disclose the identity of a resident or family member of a resident interviewed by a quality-of-care monitor unless required by law to do so.(6) A quality-of-care monitor provides the findings of a monitoring visit, both positive and negative, orally and in writing to the facility administrator or, in the absence of the facility administrator, to the administrator on duty or the director of nursing.(7) A quality-of-care monitor may recommend to the facility administrator procedural and policy changes and staff training to improve the care or quality of life of residents.(8) A quality-of-care monitor conducts a follow-up visit within 45 days after the date of an initial visit.(9) A quality-of-care monitor who observes conditions that may constitute an immediate threat to the health or safety of a resident immediately reports the conditions to the facility administrator, the monitor's regional office supervisor for appropriate action and, as appropriate, to law enforcement, adult protective services, other divisions of HHSC, and other agencies. Source Note: The provisions of this §554.910 adopted to be effective May 1, 2002, 27 TexReg 3207; amended to be effective June 1, 2006, 31 TexReg 4458; amended to be effective March 27, 2017, 42 TexReg 1575; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION J QUALITY OF CARE §554.910 Quality Assurance Early Warning System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203142 03/12/2026 (a) A rapid response team is comprised of one or more Health and Human Services Commission (HHSC) quality-of-care monitors and visits a facility that:(1) is identified as high risk through the early warning system described in §19.910 of this subchapter (relating to Quality Assurance Early Warning System); or(2) has committed three violations that constitute an immediate threat to health and safety relating to abuse or neglect of a resident as described in §19.2107 of this chapter (relating to Revocation of a License by the HHSC Executive Commissioner).(b) A facility must cooperate with a rapid response team to improve the quality of care provided at the facility by:(1) providing immediate access to all the parts of the building;(2) providing immediate access to residents, staff, contractors and reasonable access to volunteers;(3) providing access to all documents maintained by or on behalf of the facility upon request from the rapid response team;(4) allowing the rapid response team to copy documents, photograph residents, and use any other available recording devices in accordance with §19.2002(h) of this chapter (relating to Procedural Requirements--Licensure Inspections and Surveys); and(5) not interfering with the work of the rapid response team during a visit.(c) In determining whether a facility has demonstrated improvement in the quality of care, the rapid response team may consider factors such as implementation of the team's recommendation or guidance.(d) A rapid response team may visit a facility that requests assistance from HHSC. A visit under this subsection may not occur until at least 60 days after the date of an exit interview following an inspection.(e) A rapid response team may not be deployed for the purpose of helping a facility prepare for an inspection or survey. Source Note: The provisions of this §554.911 adopted to be effective May 1, 2002, 27 TexReg 3207; amended to be effective June 1, 2006, 31 TexReg 4458; amended to be effective March 27, 2017, 42 TexReg 1575; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION J QUALITY OF CARE §554.911 Rapid Response Teams https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207303 03/12/2026 (a) The facility must have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This is determined by resident assessments and individual comprehensive care plans and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §554.1931 of this chapter (relating to Facility Assessment). Staff who have been instructed and who have demonstrated competence in the care of children must provide nursing services to children. Care and services are to be provided as specified in §554.901 of this chapter (relating to Quality of Care).(1) Sufficient staff.(A) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:(i) licensed nurses, except when waived under paragraph (5) of this subsection; and(ii) other nursing personnel, including nurse aides.(B) The facility must designate a licensed nurse to serve as a charge nurse on each shift, except when waived under paragraph (5) of this subsection.(C) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs, as identified through resident assessments, and described in the comprehensive care plan.(D) The facility must provide care that includes assessing, evaluating, planning, and implementing resident comprehensive care plans and responding to a resident's needs.(2) Registered nurse.(A) The facility must use the services of a registered nurse for at least eight consecutive hours a day, seven days a week, except when waived under paragraph (5) or (6) of this subsection.(B) The facility must designate a registered nurse to serve as the director of nursing on a full-time basis, 40 hours per week, except when waived under paragraph (6) of this subsection.(C) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.(3) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for a resident's needs, as identified through resident assessments, and described in the resident's comprehensive care plan.(4) Requirements for facility hiring and use of nurse aides.(A) General rule. A facility must not use any individual working in the facility as a nurse aide for more than four months, on a full-time basis, unless:(i) the individual is competent to provide nursing and nursing related services; and(ii) the individual:(I) has completed a training and competency evaluation program, or a competency evaluation program approved by the state as meeting the requirements of 42 CFR §§483.151-483.154; or(II) has been deemed or determined competent as provided in 42 CFR §483.150(a) and (b).(B) Nonpermanent employees. A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in subparagraphs (4)(A)(i) and (ii) of this paragraph.(C) Competency. A facility must not use any individual who has worked less than four months as a nurse aide in that facility unless the individual:(i) is a full-time employee in a state-approved training and competency evaluation program;(ii) has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program, or competency evaluation program; or(iii) has been deemed or determined competent as provided in 42 CFR §483.150(a) and (b).(D) Registry Verification. Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements and is not designated in the registry as having a finding concerning abuse, neglect or mistreatment of a resident, or misappropriation of a resident's property, unless:(i) the individual is a full-time employee in a training and competency evaluation program approved by the state; or(ii) the individual can prove that the individual has recently successfully completed a training and competency evaluation program, or competency evaluation program approved by the state and has not yet been included in the registry. A facility must follow up to ensure that such an individual actually becomes registered.(E) Multi-state registry verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every state registry, established under §1819(e)(2)(A) or §1919(e)(2)(A) of the Social Security Act (42 U.S.C. §1395i-3(e)(2)(A); 42 U.S.C. §1396r(e)(2)(A)), that the facility believes will include information about the individual.(F) Required retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.(G) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must:(i) be sufficient to ensure the continuing competence of a nurse aide, but must be no less than 12 hours per year;(ii) include at least two hours of training on infection control and personal protective equipment per year;(iii) address areas of weakness as determined in nurse aides' performance reviews and facility assessment at §554.1931 of this chapter, and may address the special needs of a resident as determined by the facility staff;(iv) for a nurse aide providing services to an individual with cognitive impairments, address the care of the cognitively impaired; and(v) include dementia management training and resident abuse prevention training.(H) The facility must comply with the nurse aide training and registry rules found in Chapter 556 of this title (relating to Nurse Aides).(5) Waiver of requirement to provide licensed nurses on a 24-hour basis.(A) To the extent that a facility is unable to meet the requirements of paragraphs (1)(B) and (2)(A) of this subsection, the state may waive these requirements with respect to the facility, if:(i) the facility demonstrates to the satisfaction of HHSC that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel;(ii) HHSC determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility;(iii) the state finds that, for any periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility; and(iv) the waivered facility has a full-time registered or licensed vocational nurse on the day shift seven days a week. For purposes of this requirement, the starting time for the day shift must be between 6 a.m. and 9 a.m. The facility must specify in writing the schedule that it follows.(B) A waiver granted under the conditions listed in this paragraph is subject to annual state review.(C) In granting or renewing a waiver, a facility may be required by the state to use other qualified, licensed personnel.(D) The state agency granting a waiver of these requirements provides notice of the waiver to the State Ombudsman and the protection and advocacy systems in the state for individuals with mental illness established under the Protection and Advocacy for Mentally Ill Individuals Act (42 USC Chapter 114, Subchapter I) and individuals with intellectual or developmental disabilities established under the Developmental Disabilities Assistance and Bill of Rights Act (42 USC Chapter 144, Subchapter I, Part C).(E) The nursing facility that is granted a waiver by the state notifies residents of the facility and the resident representatives of the waiver.(6) Waiver of the requirement to provide services of a registered nurse for more than 40 hours a week in a Medicare skilled nursing facility (SNF).(A) The secretary of the U.S. Department of Health and Human Services (secretary) may waive the requirement that a Medicare SNF provide the services of a registered nurse for more than 40 hours a week, including a director of nursing specified in paragraph (2) of this subsection, if the secretary finds that:(i) the facility is located in a rural area and the supply of Medicare SNF services in the area is not sufficient to meet the needs of individuals residing in the area;(ii) the facility has one full-time registered nurse who is regularly on duty at the facility 40 hours a week; and(iii) the facility either has:(I) only residents whose physicians have indicated (through physician's orders or admission notes) that they do not require the services of a registered nurse or a physician for a 48-hour period; or(II) made arrangements for a registered nurse or a physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty.(B) The secretary provides notice of the waiver to the State Ombudsman and the protection and advocacy systems in the state for individuals with mental illness established under the Protection and Advocacy for Mentally Ill Individuals Act (42 USC Chapter 114, Subchapter I) and individuals with intellectual or developmental disabilities established under the Developmental Disabilities Assistance and Bill of Rights Act (42 USC Chapter 144, Subchapter I, Part C).(C) The SNF that is granted a waiver notifies residents of the facility and the resident representatives of the waiver.(D) A waiver of the registered nurse requirement under subparagraph (A) of this paragraph is subject to annual renewal by the secretary.(7) Request for waiver concerning staffing levels. The facility must request a waiver through the local HHSC Regulatory Services Division, in writing, at any time the administrator determines that staffing will fall, or has fallen, below that required in paragraphs (1) and (2) of this subsection for a period of 30 days or more out of any 45 days.(A) The following information must be included in the request:(i) beginning date when facility was or is unable to meet staffing requirements;(ii) type waiver requested (24-hour licensed nurse or seven-day-per-week R.N.);(iii) projected number of hours per month staffing reduced for 24-hour licensed nurse waiver or seven-day-per-week R.N. waiver; and(iv) staffing adjustments made due to inability to meet staffing requirements.(B) Waivers for licensed-only or certified facilities will be granted by HHSC Regulatory Services Division staff. Waivers for a Medicare SNF receive final approval from the CMS.(C) If a facility, after requesting a waiver, is later able to meet the staffing requirements of paragraphs (1) and (2) of this subsection, HHSC Regulatory Services Division staff must be notified, in writing, of the effective date that staffing meets requirements.(D) Verification that the facility appropriately made a request and notification will be done at the time of survey.(E) Amounts paid to Medicaid-certified facilities in the per diem payment to meet the staffing requirements of paragraphs (1) and (2) of this subsection may be adjusted if staffing requirements are not met.(8) Duration of waiver. Approved waivers are valid throughout the facility licensure or certification period, unless approval is withdrawn. During the relicensure or recertification survey, the determination is made for approval or denial for the next facility licensure or certification period if a waiver continues to be necessary. The facility requests a redetermination for a waiver from HHSC Regulatory Services Division staff at the time the survey is scheduled. At other times if a request is made, HHSC staff may schedule a visit for waiver determination.(9) Requirements for waiver approval. To be approved for a waiver, the nursing facility must meet all of the requirements stated in this subchapter and the requirements specified throughout this chapter. In some instances, the survey agency may require additional conditions or arrangements such as:(A) an additional licensed vocational nurse on day-shift duty when the registered nurse is absent;(B) modification of nursing services operations; and(C) modification of the physical environment relating to nursing services.(10) Denial or withdrawal of a waiver. Denial or withdrawal of a waiver may be made at any time if any of the following conditions exist:(A) requirements for a waiver are not met on a continuing basis;(B) the quality of resident care is not acceptable; or(C) justified complaints are found in areas affecting resident care.(11) Requirement that SNFs be in a rural area. A SNF (Medicare) must be in a rural area for waiver consideration, as specified in paragraph (6) of this subsection. A rural area is any area outside the boundaries of a standard metropolitan statistical area. Rural areas are defined and designated by the federal Office of Management and Budget; are determined by population, economic, and social requirements; and are subject to revisions.(b) Nurse staffing information.(1) Data requirements. The facility must post the following information:(A) on a daily basis:(i) the facility name;(ii) the current date;(iii) the resident census; and(iv) the specific shifts for the day; and(B) at the beginning of each shift, the total number of hours and actual time of day to be worked by the following licensed and unlicensed nursing staff, including relief personnel directly responsible for resident care:(i) RNs;(ii) LVNs; and(iii) CNAs.(2) Posting requirements. The nursing facility must post the data described in paragraph (1) of this subsection:(A) in a clear and readable format; and(B) in a prominent place readily accessible to residents and visitors.(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make copies of nurse staffing data available to the public for review at a cost not to exceed the community standard rate.(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for the period of time specified by written facility policy or for at least two years following the last day in the schedule, whichever is longer. Source Note: The provisions of this §554.1001 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 30, 2011, 36 TexReg 7174; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1001 Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203144 03/12/2026 (a) The ratio of licensed nurses to residents must be sufficient to meet the needs of the residents.(1) At a minimum, the facility must maintain a ratio (for every 24-hour period) of one licensed nursing staff person for each 20 residents or a minimum of .4 licensed-care hours per resident day. To determine licensed-care hours per resident day, multiply the number of licensed nurses by the number of hours they work in a single day and divide the product by the number of residents in the facility. Three nurses working eight-hour shifts is 24 hours, divided by 60 residents, equals .4 licensed-care hours per resident day.(2) Licensed nurses who may be counted in the ratio include, but are not limited to, director of nursing, assistant directors of nursing, staff development coordinators, charge nurses, and medication/treatment nurses. These licensed nurses may be counted subject to the limitations of paragraphs (3) and (4) of this subsection.(3) Staff, who also have administrative duties not related to nursing, may be counted in the ratio only to the degree of hours spent in nursing-related duties.(4) If a multi-level facility (nursing facility or Medicare SNF) has one director of nursing over the entire facility, he may not be counted in the nursing ratio. A director of nursing for a single distinct part may be counted in the ratio for the distinct part.(b) A graduate vocational nurse who has a temporary work permit must work under the direction of a licensed vocational nurse, registered nurse, or licensed physician who is physically present in the facility. The graduate nurse who has a temporary work permit must work under the direction of a registered nurse until registration has been achieved.(c) If the facility uses licensed temporary nursing personnel, the temporary personnel must have the same qualifications that permanent facility employees do. If temporary personnel are used for afternoon or night shifts, a full-time, licensed nurse must be on call and immediately available by telephone. The on-call nurse must be a registered nurse unless the facility has a current waiver from DHS and is not required to provide daily RN coverage.(d) Consultative pediatric nursing services must be available to facility staff if the facility has a pediatric resident. Source Note: The provisions of this §554.1002 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective October 30, 2011, 36 TexReg 7174; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1002 Additional Nursing Services Staffing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203145 03/12/2026 The director of nursing services must serve only one facility in this capacity.(1) If the director of nursing services has other institutional responsibilities, a qualified registered nurse must serve as an assistant so that there is the equivalent of a full-time director of nursing services on duty.(2) If a nursing facility, as a result of waivered status, employs a licensed vocational nurse to supervise and direct nursing services, the facility must have an agreement with a registered nurse who must provide the vocational nurse at least four hours of consultation in the facility per week. The registered nurse must not assume director of nursing duties, but must act as a consultant to solve problems involving resident care, conduct in-service training, and maintain proper clinical records. Source Note: The provisions of this §554.1004 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1004 Director of Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203146 03/12/2026 The facility must have a program of restorative nursing care that is an integral part of nursing service and is directed toward helping each resident to achieve and maintain an optimal level of self-care and independence, as defined by the Comprehensive Assessment and Comprehensive Care Plan. Nursing personnel must be trained in restorative nursing and must provide restorative services daily for residents who require them. Nursing personnel must routinely record these services in the resident's clinical record. Source Note: The provisions of this §554.1006 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1006 Nursing Facility Restorative Nursing Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203147 03/12/2026 (a) A licensed nurse must practice within the constraints of applicable state laws and regulations governing their practice, including the Nurse Practice Act, and must follow the guidelines contained in the facility's written policies and procedures.(b) A nurse must enter, or approve and sign, nurses' notes in the following instances:(1) at least monthly; and(2) at the time of any physical complaints, accidents, incidents, and change in condition or diagnosis, and progress. All of these situations must be promptly recorded as exceptions and included in the clinical record.(c) If permitted by written policies of the nursing facility, an RN or a physician's assistant may determine and pronounce a resident dead unless a resident is being supported by artificial means that preclude a determination that the resident's spontaneous respiratory and circulatory functions have ceased. The facility's nursing staff and the medical staff or consultant must have jointly developed and approved the policies. The policies must include the following requirements:(1) The apparent death of a resident must be reported immediately to the attending physician, relatives, and any guardian or legal representatives.(2) The body of a deceased resident must not be removed from the facility without a physician's or registered nurse's authorization. Telephone authorization is acceptable, if not in conflict with local regulations. Authorization by a justice of the peace, acting as a coroner, is sufficient when the attending or consulting physician or registered nurse is not available.(3) A death that involves trauma, or unusual or suspicious circumstances, must be reported immediately, in accordance with local regulations, and to HHSC Complaint and Incident Intake, in accordance with §19.602(g)(2) of this chapter (relating to Incidents of Abuse, Neglect, and Exploitation Reportable to the Texas Health and Human Services Commission and Law Enforcement Agencies by Facilities). Deaths must also be reported to HHSC monthly, in accordance with §19.606 of this chapter (relating to Reporting of Resident Death Information). Source Note: The provisions of this §554.1010 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1010 Nursing Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203148 03/12/2026 If the facility has a contract or agreement with an accredited school of nursing to use their facility for a portion of the student nurses' clinical experience, those student nurses may provide care under the following conditions.(1) Student nurses may be used in nursing facilities, provided the instructor gives class supervision and assumes responsibility for all student nursing activities occurring within the facility. These students cannot be counted in the nurse-to-resident ratio required in the standards.(2) The student nurse may administer medications only when in the facility on assignment as a student of their school of nursing. Source Note: The provisions of this §554.1011 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1011 Student Nurses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203149 03/12/2026 (a) Facilities may develop their own policies regarding private duty aides and sitters.(b) The nursing facility is responsible for meeting the needs of the residents regardless of the presence of special nurses or sitters.(c) In Medicaid-certified facilities, the following apply.(1) The facility is not responsible for payment for a special nurse (registered nurse or licensed vocational nurse) or sitter requested by the resident's physician or family.(2) The special nurse or sitter must be hired as a separate agreement between the nurse or sitter and resident, or the resident's family or legal representative, and paid directly by them.(3) The facility may assist in the hiring of a special nurse or sitter but may not in any way enter into the billing, collection, or fee-setting for the special duty nurse or sitter. If it is determined by the auditing staff that the facility received monetary benefits from an arrangement for special duty nurses or sitters, a financial exception will be made and the facility will be asked to reimburse the resident or the responsible party who paid the special duty nurses or sitters. If the resident or family hires an individual to do the special duty nursing, who was already on the facility's staff and a replacement for this person was not hired, the facility will be determined to have received a monetary benefit. See §19.2606 of this title (relating to Supplementation of Vendor Payments). Source Note: The provisions of this §554.1012 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION K NURSING SERVICES §554.1012 Special Nurses and Sitters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203150 03/12/2026 The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets each resident's daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Source Note: The provisions of this §554.1101 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1101 Food and Nutrition Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203151 03/12/2026 The facility must employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required at §19.1931 of this chapter (relating to Facility Assessment). This includes:(1) a qualified dietitian, either full-time, part-time, or on a consultant basis. A qualified dietitian:(A) holds a bachelors' or higher degree granted by a regionally accredited college or university in the United States, or an equivalent foreign degree, with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose;(B) has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional; and(C) is licensed as a dietitian by the state of Texas;(2) a dietitian hired or contracted with before November 28, 2016, that does not meet the requirements in paragraph (1)(A) - (C) of this section must:(A) be either:(i) registered by the Commission on Dietetic Registration or;(ii) licensed, or provisionally licensed, by the Texas Department of Licensing and Regulation with at least one year of supervisory experience in dietetic service of a health care facility; and(B) meet the requirements in paragraph (1)(A) - (C) of this section by November 28, 2021;(3) if a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who receives frequent scheduled consultations from a qualified dietitian and who:(A) is a certified dietary manager;(B) is a certified food service manager;(C) has similar national certification for food service management and safety from a national certifying body; or(D) has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning;(4) a director of food and nutrition services who is not a qualified dietitian and does not meet the requirements in paragraph (3)(A) - (D) of this section, and who was designated before November 28, 2016, must:(A) be at least:(i) an associate-in-arts graduate in nutrition and food service management;(ii) a graduate of a dietetic technician or dietetic assistant training program approved by the Academy of Nutrition and Dietetics or the Association of Nutrition & Foodservice Professionals;(iii) a person who has completed a state-agency-approved 90-hour course in food service supervision; or(iv) a person who has training and experience in food service supervision and management in a military service equivalent in content to the programs in paragraph (3) of this section or clauses (i) - (iii) of this subparagraph and has had the person's training credentials evaluated and approved by the nutrition program specialist of the HHSC Regulatory Services Division; and(B) meet one of the requirements in paragraph (3)(A) - (D) of this subsection by November 28, 2021.(5) Support staff. The facility must provide sufficient support personnel to carry out the functions of the food and nutrition service. Source Note: The provisions of this §554.1102 adopted to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1102 Staffing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203152 03/12/2026 (a) The facility must ensure a qualified dietitian is available as frequently and for such time as is necessary to assure each resident a diet that meets the daily nutritional and special dietary needs of each resident, based upon the acuity and clinical needs of the resident. The facility must ensure that monthly dietary consultant hours are provided, at a minimum, as follows:(1) facility population: 60 residents or under - eight hours;(2) facility population: each additional 30 residents or fraction thereof - additional four hours.(b) To meet the consultant-hour requirement, time is accrued and counted exactly as rendered.(c) The facility must outline consultant services in a signed contract. This requirement does not apply to a facility that employs a qualified dietitian on the facility's staff. Source Note: The provisions of this §554.1104 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective December 1, 2000, 25 TexReg 11665; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1104 Dietary Consultant Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203153 03/12/2026 (a) Menus must:(1) meet the nutritional needs of residents in accordance with established national guidelines;(2) be prepared at least one week in advance;(3) be written for each type of diet ordered in the facility, in accordance with the facility's diet manual;(4) be written or completely evaluated for nutritional adequacy by the facility's qualified dietitian;(5) vary from week to week, taking the general age-group of residents into consideration;(6) be followed unless substitutions are documented as required in subsection (d) of this section;(7) reflect, based on a facility's reasonable effort, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups; and(8) be updated periodically.(b) A qualified dietitian may accept diet orders and changes from the physician.(c) The facility must ensure that a current diet manual, approved by the qualified dietitian, is readily available to dietary service personnel and the supervisor of nursing service. To be current, the diet manual must be no more than five years old.(d) The facility must retain records of menus served, including substitutions, and food purchased for 30 days. A list of residents receiving special diets and a record of their diets must be kept in the dietary area for at least 30 days.(e) The facility must post the current week's menu:(1) in the dietary department, including therapeutic diet menus, so employees responsible for purchasing, preparing, and serving foods can use it; and(2) in a convenient location so the residents may see it.(f) The dietary department must keep a seven-day supply of staple foods and a two-day supply of perishable foods at all times. The facility is allowed the flexibility to use food on hand to make substitutions at any interval as long as comparable nutritional value is maintained. Any substitution of menu items must be recorded on the day of use.(g) Accommodation of a resident's needs. The facility must provide:(1) table service for all who can and will eat at the table, including a resident who uses a wheelchair;(2) firm supports, such as over-bed tables, for serving trays to a resident who is bedfast;(3) sturdy tray stands of proper height to a resident able to be out of bed for the resident's meals;(4) special eating equipment and utensils for a resident who needs them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks; and(5) prompt assistance for a resident who needs help eating.(h) An identification system, such as tray cards, must be available to ensure that all diets are served in accordance with physician's orders.(i) Nothing in this section limits a resident's right to make personal dietary choices. Source Note: The provisions of this §554.1107 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1107 Menus, Nutritional Adequacy, and Meal Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203154 03/12/2026 Each resident must receive and the facility must provide:(1) food prepared in accordance with established professional food preparation practices and by methods that conserve nutritive value, flavor, and appearance;(2) adequate amounts of food and drink that is palatable, attractive, and at a safe and appetizing temperature;(3) food prepared in a form designed to meet individual needs;(4) appealing options of similar nutritive value to a resident who chooses not to eat food that is initially served or who requests a different meal choice;(5) food that is prepared and served on schedule;(6) food that accommodates resident allergies, intolerances, and preferences; and(7) drinks, including water and other liquids, consistent with a resident's needs and preferences, and sufficient to maintain resident hydration. Source Note: The provisions of this §554.1108 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1108 Food and Drink https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203155 03/12/2026 Food intake of a resident must be monitored and recorded as follows.(1) Deviations from normal food and fluid intake must be recorded in the clinical records in accordance with §19.1911(b)(16)(E) of this chapter (relating to Contents of the Clinical Record).(2) In-between meals and bedtime snacks, and supplementary feedings, either as a part of the overall comprehensive care plan or as ordered by a physician, including caloric-restricted diets, must be documented using the point, percentage, or other system consistently facility-wide. Source Note: The provisions of this §554.1109 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1109 Food Intake https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203156 03/12/2026 (a) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with a resident's needs, preferences, requests, and comprehensive care plan.(b) There must be not more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.(c) Suitable, nourishing alternative meals and snacks must be provided to a resident who wants to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident's plans of care. Source Note: The provisions of this §554.1110 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1110 Frequency of Meals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203157 03/12/2026 (a) The facility must procure food from sources approved or considered satisfactory by federal, state, and local authorities.(1) The facility may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.(2) This section does not prohibit or prevent a facility from using produce grown in facility gardens, subject to compliance with applicable safe growing and food handling practices.(3) This section does not preclude a resident from consuming foods not procured by the facility.(b) The facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements.(c) The facility must dispose of garbage and refuse properly.(d) The facility must have a written policy regarding use and storage of foods brought to a resident by family and other visitors to ensure safe and sanitary storage, handling, and consumption.(e) Dietary service personnel must be in good health and practice hygienic food-handling techniques. Persons with symptoms of communicable diseases or open, infected wounds may not work.(f) Dietary service personnel must wear clean, washable garments, wear hair coverings or clean caps, and have clean hands and fingernails.(g) The facility and all food service personnel must meet the standards imposed by local, state, and federal codes regarding food and food handling. Source Note: The provisions of this §554.1111 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 2002, 27 TexReg 5245; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1111 Food Safety Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203158 03/12/2026 (a) State-approved training course. The facility may use a paid feeding assistant, if the paid feeding assistant has successfully completed a state-approved training course that meets the requirements of §19.1115 of this subchapter (relating to Requirements for Training of Paid Feeding Assistants) before feeding a resident.(b) Supervision. A paid feeding assistant must work under the supervision of an RN or an LVN. In an emergency, a paid feeding assistant must call a supervisory nurse for help. A paid feeding assistant can only feed a resident in the dining room.(c) Resident selection criteria.(1) The facility must ensure that a paid feeding assistant provides dining assistance only for a resident who has no complicated feeding problems, which include difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.(2) The facility must base resident selection on the interdisciplinary team's assessment and the resident's latest assessment and comprehensive care plan. A resident's comprehensive care plan must reflect the resident's appropriateness for a paid feeding assistant. Source Note: The provisions of this §554.1113 adopted to be effective June 1, 2004, 29 TexReg 5416; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1113 Paid Feeding Assistants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203159 03/12/2026 (a) Minimum training course contents. A state-approved training course for paid feeding assistants must include, at a minimum, 16 hours of training in the following:(1) feeding techniques;(2) assistance with feeding and hydration;(3) communication and interpersonal skills;(4) appropriate response to resident behavior;(5) safety and emergency procedures, including the Heimlich maneuver;(6) infection control;(7) resident rights; and(8) recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse.(b) Maintenance of records. The facility must maintain a record of all individuals used by the facility as paid feeding assistants who have successfully completed the state-approved training course for paid feeding assistants. At a minimum, documentation must include the date and location of the course, the name of the trainer, and a statement that the course was successfully completed.(c) Repeat training. If paid feeding assistants seek employment at a facility other than the facility at which they were trained, they will not be required to repeat the state-approved training course if documentation of successful course completion, as outlined in subsection (b) of this section, is given to the hiring facility. Source Note: The provisions of this §554.1115 adopted to be effective June 1, 2004, 29 TexReg 5416; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1115 Requirements for Training of Paid Feeding Assistants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203160 03/12/2026 If a resident requires a therapeutic diet, the attending physician must prescribe the therapeutic diet, unless the physician delegates this task to a qualified dietitian, to the extent allowed by Texas law. Source Note: The provisions of this §554.1116 adopted to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION L FOOD AND NUTRITION SERVICES §554.1116 Therapeutic Diets https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203180 03/12/2026 A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, or advanced practice registered nurse must provide orders for the resident's immediate care and needs. The facility must ensure that:(1) the medical care and other health care of each resident is supervised by an attending physician. Any consultations must be ordered by the attending physician;(2) another physician supervises the medical care and other health care of a resident when the resident's attending physician is unavailable; and(3) if a child is admitted to the facility:(A) appropriate pediatric consultative services are utilized, in accordance with the comprehensive assessment and comprehensive care plan; and(B) a pediatrician or other physician with training or expertise in the clinical care of children with complex medical needs participates in all aspects of the medical care. Source Note: The provisions of this §554.1201 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1201 Physician Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203181 03/12/2026 The physician must:(1) review, revise, if necessary, and sign orders relating to the resident's total program of care, including medications and treatments, according to the visit schedule required by §19.1203(2) of this subchapter (relating to Frequency of Physician Visits);(2) write, sign, and date progress notes at each visit;(3) sign and date all orders, with the exception of influenza and pneumococcal vaccines, which may be administered per physician's standing order after an assessment for contraindications;(4) write, sign, and date a physician's discharge summary within 20 working days of being notified by the facility of the discharge, except as specified in §19.1912(e) of this chapter (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility; and(5) provide documentation in the clinical record as specified in §19.1911 and §19.1912 of this chapter (relating to Contents of the Clinical Record and Additional Clinical Record Service Requirements). Source Note: The provisions of this §554.1202 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1202 Physician Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203183 03/12/2026 Physician visits must conform to the following schedule:(1) Licensed-only facility. Each resident must have a medical examination at least annually by the resident's physician and as necessary to meet the needs of the resident. Physician orders must be reviewed and revised as necessary at least once every 60 days, unless the resident's physician specifies, in writing in the resident's clinical record, a different schedule for each review and revision.(2) Medicaid-certified facilities and Medicare skilled nursing facilities.(A) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.(B) A physician visit is considered timely if it occurs not later than ten days after the date the visit was required.(C) Except as provided in paragraph (3) of this section and §19.1205(c) of this subchapter (relating to Physician Delegation of Tasks), all required visits must be made by the physician personally.(3) Medicare skilled nursing facilities. At the option of the physician, required visits in Medicare skilled nursing facilities after the initial visit may alternate between personal visits by the physician and visits by a physician assistant or an advanced practice registered nurse in accordance with §19.1205 of this subchapter. Source Note: The provisions of this §554.1203 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1203 Frequency of Physician Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203182 03/12/2026 The facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency. Source Note: The provisions of this §554.1204 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1204 Availability of Physician for Emergency Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203184 03/12/2026 (a) In a Medicare skilled nursing facility (SNF), except as specified in subsection (b) of this section, a physician may delegate tasks to a physician assistant, or an advanced practice registered nurse who:(1) is acting within the scope of practice as defined by state law; and(2) is under the supervision of the physician.(b) In a Medicare SNF, a physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under state law or by the facility's own policies.(c) In a Medicaid nursing facility, any required physician task may also be satisfied when performed by an advanced practice registered nurse or physician assistant who is not an employee of the facility but who is working in collaboration with a physician. Services must be provided in the context of applicable state laws, rules, and regulations governing the practice of an advanced practice registered nurse and physician assistants.(d) A physician may delegate the task of writing dietary orders to a qualified dietitian who:(1) is acting within the scope of practice; and(2) is under the supervision of the physician.(e) A physician may delegate the task of writing therapy orders to a qualified therapist who:(1) is acting within the scope of practice; and(2) is under the supervision of the physician.(f) The physician assistant or advanced practice registered nurse providing care to a pediatric resident must have training and expertise in the care of children with complex medical needs. Source Note: The provisions of this §554.1205 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1205 Physician Delegation of Tasks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203185 03/12/2026 Signature stamps and faxed signed documents are acceptable if used as described in §19.1912(f)(2) of this title (relating to Additional Clinical Record Service Requirements). Source Note: The provisions of this §554.1206 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1206 Physician Signatures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207304 03/12/2026 (a) In this section, the following words and terms have the following meanings, unless the context clearly indicates otherwise:(1) Medication-related emergency--A situation in which it is immediately necessary to administer medication to a resident to prevent:(A) imminent probable death or substantial bodily harm (emotional or physical) to the resident; or(B) imminent physical or emotional harm to another because of threats, attempts, or other acts the resident overtly or continually makes or commits.(2) Psychoactive medication--A medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness. The term includes the following categories when used as described by this subdivision:(A) anti-psychotics or neuroleptics;(B) antidepressants;(C) agents for control of mania or depression;(D) anti-anxiety agents;(E) sedatives, hypnotics, or other sleep-promoting drugs; and(F) psychomotor stimulants.(b) A person may not administer a psychoactive medication to a resident who does not consent to the prescription unless:(1) the resident is having a medication-related emergency; or(2) the person authorized by law to consent on behalf of the resident has consented to the prescription.(c) Consent to the prescription of psychoactive medication given by a resident, or by a person authorized by law to consent on behalf of the resident, is valid only if:(1) the consent is given voluntarily and without coercive or undue influence;(2) the person who prescribes the medication, that person's designee, or the facility's medical director provides the resident and, if applicable, the person authorized by law to consent on behalf of the resident, with a form containing the following information identified as being for the purpose of consent to treatment with psychoactive medication:(A) the specific condition to be treated;(B) the beneficial effects on that condition expected from the medication;(C) the probable clinically significant side effects and risks associated with the medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and(D) the proposed course of the medication;(3) the resident and, if appropriate, the person authorized by law to consent on behalf of the resident, are informed in writing that consent may be revoked;(4) consent is given in writing by a resident or by a person authorized by law to consent on behalf of the resident, on a form prescribed by HHSC, if the prescription is for antipsychotics or neuroleptics; and(5) the consent is evidenced in the resident's clinical record by:(A) a signed form prescribed by the facility, or by a statement of the person who prescribes the medication or that person's designee that documents consent was given by the appropriate person and the circumstances under which the consent was obtained; and(B) the original or a copy of the form described in paragraph (4) of this subsection.(d) Consent is valid until:(1) consent is withdrawn; or(2) the practitioner has discontinued the medication.(e) For purposes of this rule, a medication will be considered to be discontinued if therapy has been suspended for more than 70 days. If the suspended therapy is resumed within the 70-day period, an oral explanation of side effects should be documented in the clinical record.(f) The Health and Safety Code, Chapter 313, Consent to Medical Treatment, provides guidance on treatment decisions when a resident is comatose, incapacitated, or otherwise mentally or physically incapable of communication. An ethics committee also may prove helpful in such situations.(g) A resident's refusal to consent to receive psychoactive medication must be documented in the resident's clinical record.(h) If a person prescribes psychoactive medication to a resident without the resident's consent because the resident is having a medication-related emergency:(1) the person must document the necessity of the order in the resident's clinical record in specific medical or behavioral terms; and(2) treatment of the resident with the psychoactive medication must be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the resident's personal liberty.(i) A physician, or a person designated by the physician, is not liable for civil damages or an administrative penalty and is not subject to disciplinary action for a breach of confidentiality of medical information for a disclosure of the information provided under subsection (c)(2) of this section made by the resident, or the person authorized by law to consent on behalf of the resident, that occurs while the information is in the possession or control of the resident or the person authorized by law to consent on behalf of the resident. Source Note: The provisions of this §554.1207 adopted to be effective July 1, 2002, 27 TexReg 4362; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1207 Prescription of Psychoactive Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203178 03/12/2026 The physician must report all reportable communicable diseases immediately according to the requirements specified in §19.1601(2)(D) of this title (relating to Infection Control). Source Note: The provisions of this §554.1208 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1208 Physicians' Reporting Communicable Diseases https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203179 03/12/2026 (a) A recipient's physician must certify and recertify the recipient's need for nursing facility care in accordance with this section.(b) A recipient's physician must certify the recipient's need for nursing facility care no later than 20 days after the recipient's admission to the facility.(c) A recipient's physician must recertify the recipient's need for nursing facility care every 180 days that the recipient remains in the nursing facility after the first certification.(d) A nursing facility must:(1) ensure that each certification and recertification statement states: "I hereby certify that this resident requires/continues to require nursing facility care for 180 days"; and(2) keep the physician's certification and recertification statements in the recipient's clinical record. Source Note: The provisions of this §554.1210 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION M PHYSICIAN SERVICES §554.1210 Certification and Recertification Requirements in Medicaid-Certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203170 03/12/2026 (a) This subchapter contains the requirements a facility must comply with to provide rehabilitative services to a resident.(b) Subchapter BB (relating to Nursing Facility Responsibilities Related to Preadmission Screening and Resident Review (PASRR) contains the requirements a facility must comply with to provide nursing facility specialized services to a designated resident, as defined in §19.2703 of this chapter (relating to Definitions). Source Note: The provisions of this §554.1300 adopted to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION N REHABILITATIVE SERVICES §554.1300 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203171 03/12/2026 (a) If rehabilitative services are required in a resident's comprehensive care plan, the facility must:(1) provide the required services; or(2) obtain the required services from an outside resource, in accordance with §19.1906 of this chapter (relating to Use of Outside Resources).(b) A facility must ensure that rehabilitative services:(1) are provided to a resident under a comprehensive care plan based on a physician's diagnosis and orders; and(2) are documented in the resident's clinical record. Source Note: The provisions of this §554.1301 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION N REHABILITATIVE SERVICES §554.1301 Provision of Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203172 03/12/2026 A facility must ensure that rehabilitative services are provided by:(1) an individual who:(A) is a speech-language pathologist licensed by the Texas Department of Licensing and Regulation; or(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as a speech-language pathologist;(2) an individual who:(A) is an audiologist licensed by the Texas Department of Licensing and Regulation; or(B) meets the educational requirements and has accumulated, or is in the process of accumulating, the supervised professional experience required to be licensed as an audiologist;(3) an occupational therapist licensed by the Texas Board of Occupational Therapy Examiners;(4) an occupational therapy assistant licensed by the Texas Board of Occupational Therapy Examiners;(5) a physical therapist licensed by the Texas Board of Physical Therapy Examiners;(6) a physical therapist assistant licensed by the Texas Board of Physical Therapy Examiners; or(7) a qualified mental health professional - community services. Source Note: The provisions of this §554.1302 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION N REHABILITATIVE SERVICES §554.1302 Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203173 03/12/2026 (a) Rehabilitative services covered by Medicaid are physical therapy services, occupational therapy services, and speech therapy services.(b) A facility must ensure that rehabilitative services covered by Medicaid are provided to a resident to evaluate or treat a function that has been impaired by illness or injury. Rehabilitative services must be provided with the expectation that the resident's functioning will improve measurably in 30 days. Source Note: The provisions of this §554.1304 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective November 1, 2002, 27 TexReg 9387; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION N REHABILITATIVE SERVICES §554.1304 Rehabilitative Services in Medicaid-certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203174 03/12/2026 (a) HHSC pays a facility for rehabilitative services provided to a Medicaid eligible resident based on fees determined in accordance with 1 TAC §355.313 (relating to Reimbursement Methodology for Rehabilitative and Specialized Services).(b) A facility must ensure that rehabilitative services provided to a resident eligible for Medicaid are:(1) ordered by the resident's attending physician; and(2) except as provided in subsection (c)(1) of this section, pre-certified by DADS.(c) A session is one physical, occupational, or speech therapy service provided to one resident. HHSC pays for an evaluation at the same rate as a session.(1) HHSC pays for one evaluation that is not pre-certified by DADS.(2) To have an additional evaluation pre-certified by DADS, a facility must submit documentation by the attending physician that indicates the resident has a new illness or injury, or a substantive change in a pre-existing condition.(d) A facility must submit a complete and accurate claim for services that is received by DADS within 12 months after the last day services are provided in accordance with a single pre-certification by DADS.(e) A resident whose request for pre-certification of Medicaid rehabilitative services is denied may request a fair hearing in accordance with 1 TAC Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules). Source Note: The provisions of this §554.1306 adopted to be effective November 1, 2002, 27 TexReg 9387; amended to be effective February 1, 2008, 33 TexReg 761; amended to be effective September 10, 2017, 42 TexReg 4468; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION N REHABILITATIVE SERVICES §554.1306 Fee-for-Service Payment for Rehabilitative Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203175 03/12/2026 (a) The facility must assist a resident in obtaining routine and 24-hour emergency dental care.(1) At the time of admission, the facility must obtain the name of the resident's preferred dentist and record the name in the clinical record.(2) At least annually, the facility must ask each resident and resident representative if the resident desires a dental examination at the resident's expense.(3) The facility must make all reasonable efforts to arrange for a dental examination for each resident who desires one.(4) The facility is not liable for the cost of the resident's dental care.(5) Licensed-only facilities must maintain a list of local dentists for a resident who requires a dentist.(b) Medicaid-certified facilities also must provide or obtain from an outside resource, in accordance with §19.1906 of this chapter (relating to Use of Outside Resources), the following dental services to meet the needs of each resident:(1) Emergency dental services, which are limited to procedures necessary to control bleeding, relieve pain, and eliminate acute infection; operative procedures which are required to prevent the imminent loss of teeth; treatment of injuries to the teeth or supporting structures.(A) Covered emergency dental procedures include:(i) alleviation of extreme pain in oral cavity associated with serious infection or swelling;(ii) repair of damage from loss of tooth due to trauma (acute care only, no restoration);(iii) open or closed reduction of fracture of the maxilla or mandible;(iv) repair of laceration in or around oral cavity;(v) excision of neoplasms, including benign, malignant and premalignant lesions, tumors and cysts;(vi) incision and drainage of cellulitis;(vii) root canal therapy, for which payment is subject to dental necessity review and pre- and post-operative x-rays are required; and(viii) extractions: single tooth, permanent; single tooth, primary; supernumerary teeth; soft tissue impaction; partial bony impaction; complete bony impaction; surgical extraction of erupted tooth or residual root tip.(B) Routine restorative procedures are not considered emergency procedures. Dental services not covered include:(i) cleaning;(ii) filling teeth with amalgam composite, glass ionomer, or any other restorative material;(iii) cast or preformed crowns (capping);(iv) restoration of carious or noncarious permanent or primary teeth, including those requiring root canal therapy;(v) replacement or repositioning of teeth;(vi) services to the alveolar ridges or periodontium of the maxilla and the mandible, except for procedures covered under subparagraph (A) of this paragraph; and(vii) complete or partial dentures.(2) Assistance to the resident, if necessary:(A) in making appointments; and(B) by arranging for transportation to and from the dentist's office.(3) Prompt referral, within three days, of a resident with lost or damaged dentures for dental services. If a referral does not occur within three days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.(4) Coordination of dental services for pediatric residents age 12 months to 21 years, in accordance with Texas Health Steps (THSteps) guidelines.(c) The facility must have a written policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility.(d) Medicaid-certified facilities are not required to provide routine dental services.(e) Payment for services provided on the teeth, gums, alveolar ridges, and supporting structures are not a benefit of the Texas Medicaid Program; however, recipients with applied income may use incurred medical expenses to pay for routine dental services and appliances. Source Note: The provisions of this §554.1401 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION O DENTAL SERVICES §554.1401 Dental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203176 03/12/2026 (a) Emergency dental services. The Texas Department of Human Services (DHS) will reimburse nursing facilities the cost of emergency dental services provided to eligible Medicaid residents residing in Medicaid-contracted facilities or distinct parts.(1) Recipients must be 21 years of age or older.(2) Dental care for recipients under the age of 21 is covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.(3) Services reimbursed are subject to the limitations specified in §19.1401(b) of this title (relating to Dental Services).(4) Emergency dental services may be provided only if the attending physician orders a dental consultation. See §19.1201 of this title (relating to Physician Services).(b) Dental providers. Emergency dental services must be provided by a dentist licensed by the Texas State Board of Dental Examiners who, if not employed by the facility, contracts with the facility according to the specifications outlined in §19.1906 of this title (relating to Use of Outside Resources).(c) Reimbursement for Emergency Dental Services. The cost of emergency dental services provided to eligible Medicaid residents residing in nursing facilities will be reimbursed to facilities, provided that the services are not reimbursable by the Medicaid claims processor or the EPSDT program.(d) Payment of Claims.(1) The facility must accept payment by DHS as payment in full for services. Neither the dentist nor the facility may charge an additional fee to the recipient, his family, or his trust fund, except that the dentist may charge the recipient for services that:(A) the recipient requests; and(B) are not reimbursable by the Texas Medical Assistance Program.(2) Payments for emergency dental services are the lower of the:(A) dentist's usual fee; or(B) maximum fee as determined by the Texas Health and Human Services Commission (HHSC).(3) DHS reimburses facilities for services properly rendered in accordance with applicable laws, regulations, and operational instructions. DHS may withhold or suspend payment for services that are not properly rendered.(4) Nursing Facility Emergency Dental Services makes no payment for services that are available under any other Texas Medical Assistance Program.(5) Complete and accurate claims for services must be received within 12 months from the date of service.(6) Claims for services delivered before the effective date of this section must be submitted within 12 months of the effective date of this section.(7) Adjustments to claims must be received by DHS's claims processor during the applicable 12-month period. Claims and adjustments rejected or denied during the 12-month period through no fault of the dentist may be paid upon approval by DHS. Source Note: The provisions of this §554.1402 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective November 1, 2002, 27 TexReg 9387; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION O DENTAL SERVICES §554.1402 Medicaid-certified Nursing Facility Emergency Dental Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203186 03/12/2026 A licensed-only facility must assist the resident in obtaining routine drugs and biologicals and make emergency drugs readily available, or obtain them under an agreement described in §19.1906 of this chapter (relating to Use of Outside Resources). A Medicaid-certified facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §19.1906 of this chapter.(1) Methods and procedures. The facility may permit unlicensed personnel to administer drugs, but only under the general supervision of a licensed nurse. The unlicensed individual must be a nursing student, a medication aide student, or a medication aide with a current permit issued by HHSC.(2) Accuracy in service delivery. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.(3) Service consultation. The facility must employ or obtain the services of a pharmacist, currently licensed by the Texas State Board of Pharmacy and in good standing, who:(A) provides consultation on all aspects of the provision of pharmacy services in the facility;(B) establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation;(C) determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled; and(D) adheres to requirements in §19.1503 of this subchapter (relating to Additional Supervision and Consultation Requirements).(4) Drug regimen review.(A) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The consultant pharmacist's drug regimen review must be maintained in the resident's clinical record. This review must include a review of the resident's medical chart.(B) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include psychoactive medications as defined in §19.1207 of this chapter (relating to Prescription of Psychoactive Medication). These drugs include drugs in the following categories:(i) anti-psychotic;(ii) anti-depressant;(iii) anti-anxiety; and(iv) hypnotic.(C) The pharmacist must report any irregularities to the attending physician and the director of nursing, and these reports must be acted upon.(i) Irregularities include any drug that meets the criteria set forth in paragraph (5) of this subsection.(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists the resident's name, the relevant drug, and the irregularity the pharmacist identified.(iii) The attending physician must document in the resident's clinical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician must document the physician's rationale in the resident's clinical record.(D) The facility must develop and maintain written policies and procedures for the monthly drug regiment review that include time frames for the different steps in the process and steps the pharmacist must take when the pharmacist identifies an irregularity that requires urgent action to protect the resident.(5) Unnecessary Drugs. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:(A) in excessive dose (including duplicate drug therapy);(B) for excessive duration;(C) without adequate monitoring;(D) without adequate indications for its use;(E) in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or(F) in any combination of the reasons stated in subparagraphs (A) - (E) of the paragraph.(6) Psychotropic drugs. Based on a comprehensive assessment of a resident, the facility must ensure that:(A) a resident who has not used psychotropic drugs is not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the resident's clinical record;(B) a resident who uses psychotropic drugs receives gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue use of these drugs;(C) a resident does not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the resident's clinical record; and(D) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in subparagraph (E) of this paragraph, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, the physician must document the rationale in the resident's clinical record and indicate the duration for the PRN order.(E) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of the medication.(7) Medication errors. The facility must ensure that:(A) the medication error rates are not 5 percent or greater; and(B) the residents are free of any significant medication errors.(8) Labeling of drugs and biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principals and in compliance with the state laws and regulations, including the appropriate accessory and cautionary instructions and the expiration date when applicable.(9) Storage of drugs and biologicals.(A) In accordance with state and federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys.(B) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs, listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976, and of other drugs subject to abuse, except when the facility uses single-unit-package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Source Note: The provisions of this §554.1501 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 1, 2002, 27 TexReg 5524; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1501 Pharmacy Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203187 03/12/2026 (a) Unless the facility is paying for the drugs and biologicals, the resident's choice of pharmacy provider and any changes in his choice must be recorded on appropriate forms maintained by the facility.(b) A Medicaid-certified facility must have written agreements with its provider pharmacies that define required services. These agreements will not be considered to abridge the resident's freedom of choice of pharmacy services when they require labeling, packaging, and a drug-distribution system according to facility policy. The drug-distribution system must be accessible to all pharmacies willing to meet the distribution system requirements. The agreements must require the following:(1) that the resident's pharmacy services be provided by a pharmacy on a 24-hour basis for emergency medications; and(2) that the resident's medications be delivered to the facility on a timely and reasonable basis.(c) The resident's choice of pharmacy provider must be in accordance with §19.406(c) of this title (relating to Free Choice). Source Note: The provisions of this §554.1502 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1502 Choice of Pharmacy Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203188 03/12/2026 (a) The facility must provide pharmaceutical services under the responsibility and direction of the consultant pharmacist and the director of nursing.(b) The facility must ensure that notes on the monthly visits by the consulting pharmacist are entered in the resident's clinical record.(c) The number of hours per month the consultant pharmacist devotes to the pharmaceutical services for ordering, storage, administration, disposal, recordkeeping (documentation) of drugs and medications, and drug regimen review must be sufficient to meet the needs of the residents.(d) A record of consultant pharmacist services, consultations, and recommendations for pharmacy procedure must be maintained at the facility. Source Note: The provisions of this §554.1503 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1503 Additional Supervision and Consultation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203189 03/12/2026 (a) The facility must establish procedures for storing and disposing of drugs and biologicals in accordance with federal, state, and local laws.(b) When not in use, a medication cart must be secured in a designated area.(c) Small multiple-dose drug containers which are placed into another container must be labeled in a manner so that, if the two containers become separated, the small drug container still has a strip label attached containing the name of the resident and the prescription number.(d) Self-administered medications may be kept in a locked cabinet in the resident's room. When medications are self-administered, the facility remains responsible for medication security, accurate information, and medication compliance.(e) The facility must store each resident's drugs in their original containers.(f) The facility must store medications under appropriate conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.(g) Medications of deceased residents, medications that have passed the expiration date, and medications that have been discontinued must be securely stored and reconciled. These medications must be disposed of according to federal and state laws or rules on a quarterly basis. Discontinued drugs may be reinstated if reordered prior to destruction. These medications cannot be given to a family member or representative.(h) When the directions for administration of a resident's medication have changed, but the existing supply of medication can still be administered accurately, the medication must not be destroyed. The facility must affix a change-of-direction ancillary sticker or similar system and use the remaining medication. The medication label must be updated at the time of next dispensing. Source Note: The provisions of this §554.1504 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective September 1, 2003, 28 TexReg 6939; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1504 Drug Security https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203190 03/12/2026 (a) All drugs must be prescribed by the resident's physician or consulting physician, dentist, podiatrist, or other individual allowed by law to prescribe. If drug orders are verbal, they must be taken by a licensed nurse, pharmacist, physician assistant or a physician, and immediately recorded and signed by the person receiving the order. All drug orders must be counter-signed by the prescriber and returned to the chart in a timely manner.(b) The facility may permit verbal orders for Schedule II drugs only in an emergency.(c) Medications must be ordered and reordered on a timely basis so that no resident misses a dose.(d) The facility must have written policies and procedures for stopping the administration of drugs. Source Note: The provisions of this §554.1506 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1506 Drug Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203191 03/12/2026 (a) Medications must be released to residents only on the written or verbal authorization of the attending physician. When a resident is transferred directly to another nursing facility or discharged to home, the resident's medications must be released to the new facility or to the resident or his family, respectively.(b) If a resident is leaving the facility on a furlough, enough prescription drugs to last throughout the furlough must be released. The facility must inventory Schedule II, III, and IV drugs in and out. Nonschedule drugs should be listed by name. The pharmacist must handle any division of the prescription, and all information on the original prescription label must appear on the furlough medication supply. Source Note: The provisions of this §554.1507 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1507 Drug Release https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203194 03/12/2026 (a) The facility must establish drug administration procedures to ensure that:(1) drugs to be administered are checked against the physician's orders;(2) the resident is identified before the administration of a drug;(3) each resident has an individual medication record, where the dose of drug administered is properly recorded by the person who administered the drug;(4) drugs and biologicals are prepared and administered by the same person, except under unit-of-use package distribution systems and as outlined in §19.418 of this title (relating to Self-Administration of Drugs); and(5) drugs prescribed for one resident must not be administered to any other person.(b) The facility nursing staff must report drug errors and adverse drug reactions to the resident's physician in a timely manner, as warranted by an assessment of the resident's condition, and record them in the resident's record. An incident report must be completed in accordance with §19.1923 of this title (relating to Incident or Accident Reporting). Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route, omitting a medication, and/or administering to the wrong resident.(c) Nursing facilities must have current medication reference texts or sources, including information on pediatric medications, dosages, sites, routes, techniques of drug administration, desired effects, and possible side effects, if facilities have pediatric residents.(d) A licensed nurse may exercise professional judgment in the crushing of a medication, providing that the medication is not a time-released or enteric coated medication.(1) If there is any question about crushing a medication for a resident, the licensed nurse must check with the treating physician, dispensing pharmacist, or consultant pharmacist.(2) The crushed medication should be administered as soon as feasible once it has been added to another substance. Source Note: The provisions of this §554.1508 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1508 Drug Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203192 03/12/2026 The facility must adhere to the following procedures governing the use of drugs covered by the Controlled Substances Act:(1) a separate record must be maintained for each drug covered by Schedules II, III, and IV of the Controlled Substances Act, Health and Safety Code, Chapter 481;(2) the record for each drug must contain the prescription number, name, and strength of drug, date received by the facility, date and time administered, name of resident, dose, physician's name, signature of person administering dose, and original amount dispensed with the balance verifiable by drug inventory at every shift change; and(3) Schedule V drugs are exempt from the requirements in paragraphs (1) and (2) of this section. Source Note: The provisions of this §554.1509 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1509 Controlled Substances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203193 03/12/2026 Stocks of inventoried emergency medications may be kept in facilities.(1) Emergency medication kits must be maintained in compliance with 22 TAC §291.121(b) (relating to Remote Pharmacy Services), with the exception of emergency medication kits in veterans homes, as defined by Natural Resources Code, §164.002. In veterans homes, a United States Department of Veterans Affairs pharmacy or another federally operated pharmacy may maintain emergency medication kits.(2) Facilities must have contracts with the pharmacy that provides the emergency medication kit. The contract must outline the services to be provided by the pharmacy and the responsibilities and accountabilities of each party in fulfilling the terms of the contract in compliance with federal and state laws and regulations. Source Note: The provisions of this §554.1510 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective May 1, 2002, 27 TexReg 1534; amended to be effective September 1, 2003, 28 TexReg 6939; amended to be effective October 30, 2011, 36 TexReg 7174; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION P PHARMACY SERVICES §554.1510 Emergency Medication Kits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207305 03/12/2026 (a) General. The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.(b) Infection prevention and control program (IPCP). The facility must establish an IPCP and conduct an annual review, effective November 28, 2019, of the IPCP and update the program, as necessary. The Quality Assessment and Assurance Committee, as described in §554.1917 of this chapter (relating to Quality Assessment and Assurance) monitors the IPCP. The IPCP must include:(1) a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §554.1931 of this chapter (relating to Facility Assessment), and following accepted national standards;(2) written standards, policies, and procedures for the program, which must include:(A) a system of surveillance designed to identify possible communicable diseases or infections, including multidrug-resistant organisms, before they can spread to other persons in the facility;(B) when and to whom possible incidents of communicable diseases or infections should be reported;(C) standard and transmission-based precautions to be followed to prevent spread of infections;(D) when and how isolation should be used for a resident; including:(i) the type and duration of the isolation, depending upon the infectious agent or organism involved; and(ii) a requirement that the isolation should be the least restrictive possible for the resident under the circumstances;(E) the circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with a resident or a resident's food, if direct contact will transmit the disease; and(F) the hand hygiene procedures to be followed by staff involved in direct resident contact;(3) an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use;(4) procedures for making rapid influenza diagnostic tests available to facility residents;(5) a system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility; and(6) acceptable accommodations for a resident with a communicable disease according to current practices and policies for infection control.(c) Infection preventionist. Effective November 28, 2019, the facility must designate one or more individuals as the infection preventionist (IP) who is responsible for the facility's IPCP. The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's Quality Assessment and Assurance Committee and report to the committee on the IPCP on a regular basis. The IP must:(1) have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;(2) be qualified by education, training, experience or certification;(3) work at least part-time at the facility; and(4) have completed specialized training in infection prevention and control.(d) Communicable Diseases.(1) Policies. The facility must have and implement written policies for the control of communicable diseases in employees and residents and must maintain evidence of compliance with local and state health codes and ordinances regarding employee and resident health status.(2) Reporting. The name of any resident with a reportable disease as specified in Title 25, Chapter 97, Subchapter A (relating to Control of Communicable Diseases), must be reported immediately to the city health officer, county health officer, or health unit director having jurisdiction, and appropriate infection control procedures must be implemented as directed by the local health authority.(3) Tuberculosis.(A) The facility must conduct and document an annual review that assesses the facility's current risk classification according to the current CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings.(B) The facility must screen all employees before providing services in the facility, according to CDC guidelines. The facility must require all persons providing services under an outside resource contract to provide evidence of a current tuberculosis screening prior to providing services in the facility. The facility must document or keep a copy of the evidence provided.(C) If the facility determines or suspects that an employee or person providing services under an outside resource contract has been exposed to or has a positive screening for a communicable disease, the facility must respond according to the current CDC guidelines and keep documentation of the action taken.(D) If the facility determines that an employee or a person providing services under an outside resource contract has been exposed to a communicable disease, the facility must conduct and document a reassessment of the risk classification. The facility must conduct and document subsequent screening based upon the reassessed risk classification.(E) The facility must screen all residents at admission in accordance with the attending physician's recommendations and current CDC guidelines. If the facility determines or suspects that a resident has been exposed to a communicable disease or has a positive screening, the facility must respond according to the current CDC guidelines and attending physician's recommendations, and keep documentation of the response.(e) Vaccinations.(1) A facility must develop and implement a written policy to protect a resident from vaccine preventable diseases in accordance with Texas Health and Safety Code, Chapter 224.(A) The policy must:(i) require an employee, contractor, or other individual with privileges providing direct care to a resident to receive vaccines for the vaccine preventable diseases specified by the facility based on the level of risk the employee, contractor, or other individual presents to residents by the employee's, contractor's, or other individual's routine and direct exposure to residents;(ii) specify the vaccines an employee, contractor, or other individual with privileges to provide direct resident care is required to receive in accordance with clause (i) of this subparagraph;(iii) include procedures for the facility to verify that an employee, contractor, or other individual with privileges to provide direct resident care has complied with the policy;(iv) include procedures for the facility to exempt an employee, contractor, or other individual with privileges to provide direct resident care from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC;(v) for an employee, contractor, or other individual with privileges to provide direct resident care who is exempt from the required vaccines, include procedures the employee, contractor, or other individual must follow to protect residents from exposure to vaccine preventable diseases, such as the use of protective equipment, such as gloves and masks, based on the level of risk the employee, contractor, or other individual presents to residents by the employee's, contractor's, or other individual's routine and direct exposure to residents;(vi) prohibit discrimination or retaliatory action against an employee, contractor, or other individual with privileges to provide direct resident care who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC, except that required use of protective medical equipment, such as gloves and masks, may not be considered retaliatory action;(vii) require the facility to maintain a written or electronic record of each employee's, contractor's, or other individual's compliance with or exemption from the policy; and(viii) include disciplinary actions the facility may take against an employee, contractor, or other individual with privileges to provide direct resident care who fails to comply with the policy.(B) The policy may:(i) include procedures for an employee, contractor, or other individual with privileges to provide direct resident care to be exempt from the required vaccines based on reasons of conscience, including religious beliefs; and(ii) prohibit an employee, contractor, or other individual with privileges to provide direct resident care who is exempt from the required vaccines from having contact with residents during a public health disaster, as defined in Texas Health and Safety Code, §81.003 (relating to Definitions).(2) A facility must offer vaccinations to a resident in accordance with an immunization schedule adopted by the Advisory Committee on Immunization Practices of the CDC.(A) Pneumococcal vaccinations for residents. The facility must offer pneumococcal vaccination to a resident 65 years of age or older who has not received the vaccination and to a resident younger than 65 years of age, who has not received the vaccination but is a candidate for it because of chronic illness. A pneumococcal vaccination must be offered to a current resident of a facility and to a new resident at the time of admission. A vaccination must be completed unless a physician has indicated that the vaccination is medically contraindicated or the resident refuses the vaccination. The facility must develop and implement policies and procedures to ensure that:(i) before offering the pneumococcal immunization, each resident or resident representative receives education regarding the benefits and potential side effects of the pneumococcal vaccination;(ii) each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;(iii) the resident or the resident representative has the opportunity to refuse immunization; and(iv) the resident's clinical record includes documentation that indicates:(I) that the resident or the resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization;(II) that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal; and(III) the date of the receipt or refusal of the pneumococcal vaccination.(v) Based on an assessment and practitioner recommendation, a second pneumococcal vaccination may be given five years after the first pneumococcal vaccination, unless medically contraindicated or the resident or the resident representative refuses the second vaccination.(B) Influenza vaccinations for residents and employees. The facility must offer an influenza vaccination to a resident and an employee in contact with residents, unless the vaccination is medically contraindicated by a physician or the employee or resident has refused the vaccination.(i) Influenza vaccinations for all residents and employees in contact with a resident must be completed by November 30 of each year. Employees hired or residents admitted after this date and during the influenza season (through March of each year) must receive influenza vaccinations, unless medically contraindicated by a physician or the employee, the resident, or the resident representative refuses the vaccination.(ii) The facility must develop and implement policies and procedures that ensure that:(I) before offering the influenza immunization, each resident or resident representative receives education regarding the benefits and potential side effects of the influenza vaccination; and(II) the resident's clinical record includes documentation that indicates:(-a-) that the resident or the resident representative was provided education regarding the benefits and potential side effects of influenza immunization;(-b-) that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal; and(-c-) the date of the receipt or refusal of the annual influenza vaccination.(C) Hepatitis B vaccinations for employees. The facility must develop a method to identify employees at risk of directly contacting blood or potentially infectious materials. The facility must offer an employee identified as being at risk of directly contacting blood or potentially infectious materials a hepatitis B vaccine within 10 days of employment. If the employee initially declines the hepatitis B vaccination but at a later date, while still at risk of directly contacting blood or potentially infectious materials, decides to accept the vaccination, the facility must make the vaccination available within 10 days after the employee decides to accept that vaccination.(f) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection and in accordance with §554.325 of this chapter (relating to Linen).(g) The Quality Assessment and Assurance Committee as described in §554.1917 of this chapter (relating to Quality Assessment and Assurance) will monitor the Infection Prevention and Control Program. Source Note: The provisions of this §554.1601 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective October 30, 2011, 36 TexReg 7174; amended to be effective June 1, 2012, 37 TexReg 3862; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 2, 2022, 46 TexReg 9037. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Q INFECTION CONTROL §554.1601 Infection Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203196 03/12/2026 Universal precautions must be used in the care of all residents. Facilities are responsible for complying with Occupational Safety Hazards Administration (OSHA) regulations found at 29 Code of Federal Regulations §1910.1030 (relating to Bloodborne Pathogens). Source Note: The provisions of this §554.1602 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Q INFECTION CONTROL §554.1602 Universal Precautions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203197 03/12/2026 The facility must be designed, constructed, equipped, and maintained to protect the health and ensure the safety of residents, personnel, and the public.(1) Life safety from fire.(A) The facility must meet the applicable provisions of NFPA 101 as designated by the federal law and regulations.(B) After consideration of the findings of HHSC, CMS may waive specific provisions of NFPA 101 which, if rigidly applied, would result in unreasonable hardship on the facility, but only if the waiver does not adversely affect the health and safety of residents or personnel.(2) Emergency power.(A) An emergency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and any systems or equipment whose failure is likely to cause major injury or death to a resident if the normal electrical supply is interrupted.(B) When systems or equipment whose failure is likely to cause major injury or death to a resident are used, the facility must provide emergency electrical power with an emergency generator defined in NFPA 99 located on the premises.(3) Space and equipment. The facility must:(A) provide sufficient space and equipment in dining, health services, recreation, living, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident's assessment and plan of care;(B) maintain all essential mechanical, electrical, and patient care equipment in safe operating condition; and(C) conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.(4) Resident rooms. Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.(A) Bedrooms must:(i) accommodate no more than four residents for a facility that receives approval of construction or reconstruction plans by state and local authorities or are newly certified before November 28, 2016;(ii) accommodate no more than two residents for a facility that receives approval of construction or reconstruction plans by state and local authorities or are newly certified on or after November 28, 2016;(iii) measure at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms;(iv) have direct access to an exit corridor;(v) be designed or equipped to ensure full visual privacy for each resident;(vi) in facilities initially certified after March 31, 1992, except in private rooms, have ceiling-suspended curtains for each bed, which extend around the bed to provide total visual privacy, in combination with adjacent walls and curtain;(vii) have at least one window to the outside; and(viii) have a floor at or above grade level.(B) The facility must provide each resident with:(i) a separate bed of proper size and height for the safety and convenience of the resident;(ii) a clean, comfortable mattress;(iii) bedding appropriate to the weather and climate; and(iv) functional furniture appropriate to the resident's needs and individual private closet space in the resident's bedroom with clothes racks and shelves accessible to the resident.(C) HHSC may permit variations in requirements specified in paragraph (1)(A) and (B) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations:(i) are required by the special needs of the residents; and(ii) will not adversely affect residents' health and safety.(5) Bathroom. Each resident room must be equipped with or located near toilet and bathing facilities. For a facility that receives approval of construction from state and local authorities or are newly certified on or after November 28, 2016, each resident room must have its own bathroom equipped with at least a commode and sink.(6) Nurse call system. The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area:(A) before November 28, 2019, from each resident's room;(B) beginning November 28, 2019, from each resident's beside; and(C) from toilet and bathing facilities.(7) Dining and resident activities. The facility must provide one or more rooms designated for resident dining and activities. These rooms must be:(A) well-lighted;(B) well ventilated, with nonsmoking areas identified;(C) adequately furnished; and(D) sufficiently spacious to accommodate all activities.(8) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility must:(A) establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply;(B) have adequate outside ventilation by means of windows, mechanical ventilation, or a combination of the two;(C) equip corridors with firmly secured handrails on each side; and(D) maintain an effective pest control program so that the facility is free of pests and rodents.(E) establish policies, according to applicable federal, state, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. Source Note: The provisions of this §554.1701 adopted to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION R PHYSICAL PLANT AND ENVIRONMENT §554.1701 Physical Environment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203198 03/12/2026 A nursing facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.(1) Licensure. A nursing facility (NF) must be licensed by HHSC as described in §19.201 of this chapter (relating to Criteria for Licensing).(2) Compliance with federal, state, and local laws and professional standards. The facility must operate and provide services in compliance with all applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.(3) Medicaid-certified facilities' relationship to other Health and Human Services regulations.(A) In addition to compliance with the regulations set forth in this chapter, as Medicaid providers, facilities are obliged to meet the applicable provisions of other federal regulations, including those pertaining to:(i) nondiscrimination on the basis of race, color, or national origin (45 CFR, Part 80);(ii) nondiscrimination on the basis of disability (45 CFR, Part 84);(iii) nondiscrimination on the basis of age (45 CFR, Part 91);(iv) nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR, Part 92);(v) protection of human subjects of research (45 CFR, Part 46);(vi) protection from fraud and abuse (42 CFR, Part 455); and(vii) protection of individually identifiable health information (45 CFR, Parts 160 and 164).(B) Although the regulations listed in subparagraph (A) of this paragraph are not in themselves considered requirements under 42 CFR, Part 483, their violation may result in the termination or suspension of payment with federal funds, or the refusal to grant or continue payment with federal funds. Source Note: The provisions of this §554.1901 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1901 Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203199 03/12/2026 (a) The facility must have a governing body, or designated persons functioning as a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The governing body must have periodically updated written policies and procedures that are formally adopted and dated, specifying and governing all services. The policies and procedures must be available to all of the facility's governing body's members, staff, residents, family or resident representatives, and the public. The governing body must:(1) designate a person to exercise the administrator's authority when the facility does not have an administrator. The facility must secure a licensed nursing home administrator within 30 days; and(2) ensure that a person designated as being in authority notifies HHSC immediately when the facility does not have an administrator.(b) The governing board appoints and the facility must operate under the supervision of a nursing facility administrator who is:(1) licensed by the Texas Board of Nursing Facility Administrators;(2) responsible for management of the facility;(3) required to work at least 40 hours per week on administrative duties; and(4) accountable to and who reports to the governing body for the overall management of the facility. Source Note: The provisions of this §554.1902 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1902 Governing Body https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203200 03/12/2026 (a) The facility must employ on a full-time, part-time, or consultant basis those professionals necessary to carry out the provisions of these requirements of participation.(b) Professional staff must be licensed, certified or registered in accordance with applicable state laws. Source Note: The provisions of this §554.1905 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1905 Staff Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203201 03/12/2026 (a) If the facility does not employ a qualified professional to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an agreement described in subsection (b) of this section.(b) Agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for:(1) obtaining services that meet professional standards and principles; and(2) the timeliness of the services.(c) Except for those members of the comprehensive assessment team, the facility allows outside resources access to the clinical records of only those residents who have orders for the service(s) to be provided. Source Note: The provisions of this §554.1906 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1906 Use of Outside Resources https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203203 03/12/2026 (a) The nursing facility must designate a physician to serve as medical director.(b) The medical director is responsible for:(1) implementation of resident care policies (see §19.1922 of this title (relating to Resident Care Policies)); and(2) the coordination of medical care in the facility. Source Note: The provisions of this §554.1907 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1907 Medical Director https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203204 03/12/2026 (a) The facility must provide or obtain clinical laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.(1) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in 42 CFR, Part 493.(2) If the facility provides blood bank and transfusion services, it must meet the applicable requirements for laboratories specified in 42 CFR, Part 493.(3) If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties or subspecialties of services in accordance with 42 CFR, Part 493.(4) If the facility does not provide laboratory services on site, it must have an agreement to obtain these services only from a laboratory that meets the applicable requirements of 42 CFR, Part 493, or from a physician's office.(b) The facility must:(1) provide or obtain laboratory services only when ordered by a physician, physician assistant, or advanced practice registered nurse in accordance with state law, including scope of practice laws;(2) promptly notify the ordering physician, physician assistant, or advanced practice registered nurse of the results that fall outside of clinical reference ranges in accordance with written facility policies and procedures for notification of a practitioner or per the ordering physician's orders;(3) assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance; and(4) file in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory. Source Note: The provisions of this §554.1908 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1908 Laboratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203202 03/12/2026 (a) The nursing facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.(1) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in 42 CFR, §482.26.(2) If the facility does not provide its own diagnostic services, it must have an agreement to obtain these services from a provider or supplier that is approved to provide these services under Medicare.(b) The facility must:(1) provide or obtain radiology and other diagnostic services only when ordered by a physician, physician assistant, or advanced practice registered nurse in accordance with state law, including scope of practice laws;(2) promptly notify the ordering physician, physician assistant, or advanced practice registered nurse of the results that fall outside of clinical reference ranges in accordance with written facility policies and procedures for notification of a practitioner or per the ordering physician's orders;(3) assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance; and(4) file in the resident's clinical record signed and dated reports of x-ray and other diagnostic services. Source Note: The provisions of this §554.1909 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1909 Radiology and Other Diagnostic Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203209 03/12/2026 (a) The facility must maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are:(1) complete;(2) accurately documented;(3) readily accessible;(4) systematically organized; and(5) protected from unauthorized release.(b) Clinical records must be retained:(1) for five years after medical services end; or(2) for a minor, for three years after a resident reaches legal age under Texas law.(c) The facility must safeguard clinical record information against loss, destruction, or unauthorized use.(d) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is:(1) required by law or this chapter;(2) to the resident or resident representative where permitted by applicable law;(3) for treatment, payment, or health care operations, as permitted by and in compliance with applicable law; or(4) for public health activities, reporting of abuse, neglect or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with applicable law. Source Note: The provisions of this §554.1910 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1910 Clinical Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203205 03/12/2026 (a) A resident's clinical record must meet all documentation requirements in the HHSC rule at Texas Administrative Code, Title 1, Part 15, Chapter 371, Subchapter C (relating to Utilization Review).(b) The clinical record of each resident must contain:(1) a face sheet that contains the attending physician's current mailing address and telephone numbers;(2) sufficient information to identify and care for the resident, to include at a minimum:(A) full name of resident;(B) full home or mailing address, or both;(C) social security number;(D) health insurance claim numbers, if applicable;(E) date of birth; and(F) clinical record number, if applicable;(3) a record of the resident's assessments, including 15 months of MDS records;(4) the comprehensive care plan and services provided;(5) a permanency plan, for residents younger than 22 years of age;(6) the results of any Preadmission Screening and Resident Review;(7) signed and dated clinical documentation from all health care practitioners involved in the resident's care, with each page identifying the name of the resident for whom the clinical care is intended;(8) any directives or medical powers of attorney as described in §19.419 of this chapter (relating to Advance Directives);(9) discharge information and a discharge summary in accordance with §19.803 of this chapter (relating to Discharge Summary (Discharge Plan of Care));(10) at admission or within 14 days after admission, documentation of an initial medical evaluation, including history, physical examination, diagnoses and an estimate of discharge potential and rehabilitation potential, and documentation of a previous annual medical examination;(11) authentication of a hospital diagnosis, which may be in the form of a signed hospital discharge summary, a signed report from the resident's hospital or attending physician, or a transfer form signed by the physician;(12) the physician's signed and dated orders, including medication, treatment, diet, restorative and special medical procedures, and routine care to maintain or improve the resident's functional abilities (required for the safety and well-being of the resident), which must not be changed either on a handwritten or computerized physician's order sheet after the orders have been signed by the physician unless space allows for additional orders below the physician's signature, including space for the physician to sign and date again;(13) arrangements for the emergency care of the resident in accordance with §19.1204 of this chapter (relating to Availability of Physician for Emergency Care);(14) observations made by nursing personnel according to the time frames specified in §19.1010 of this chapter (relating to Nursing Practices);(15) items as specified on the MDS assessment;(16) current information, including:(A) PRN medications and results;(B) treatments and any notable results;(C) physical complaints, changes in clinical signs and behavior, mental and behavioral status, and all incidents or accidents;(D) flow sheets, which may include bathing, restraint observation or release documentation, elimination, fluid intake, vital signs, ambulation status, positioning, continence status and care, and weight;(E) a record of dietary intake, including deviations from normal diet, rejection of substitutions, and physician's ordered snacks or supplemental feedings;(F) a record of the date and hour a drug or treatment is administered; and(G) documentation of a special procedure performed for the safety and well-being of the resident; and(17) laboratory, radiology and other diagnostic services reports, as required by §19.1908 of this subchapter (relating to Laboratory Services) and §19.1909 of this subchapter (relating to Radiology and Other Diagnostic Services). Source Note: The provisions of this §554.1911 adopted to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective September 1, 2008, 33 TexReg 7264; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective July 21, 2016, 41 TexReg 5203; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1911 Contents of the Clinical Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203206 03/12/2026 (a) Index of admissions and discharges. The facility must maintain a permanent, master index of all residents admitted to and discharged from the facility. This index must contain at least the following information concerning each resident:(1) name of resident (first, middle, and last);(2) date of birth;(3) date of admission;(4) date of discharge; and(5) social security, Medicare, or Medicaid number.(b) Facility closure. In the event of closure of a facility, change of ownership or change of administrative authority:(1) the facility must have in place written policies and procedures to ensure that the administrator's duties and responsibilities involve providing the appropriate notices, as required by §19.2310 of this chapter (relating to Nursing Facility Ceases to Participate); and(2) the new management must maintain documented proof of the medical information required for the continuity of care of all residents. This documentation may be in the form of copies of the resident's clinical record or the original clinical record. In a change of ownership, the two parties will agree and designate in writing who will be responsible for the retention and protection of the inactive and closed clinical records.(c) Method of recording and correcting information. All resident care information must be recorded in ink or permanent print except for the medication, treatment, or diet section of the resident's comprehensive care plan. Correction of errors will be in accordance with accepted health information management standards.(1) Erasures are not allowed on any part of the clinical record, with the exception of the medication, treatment, or diet section of the resident's comprehensive care plan.(2) Correction of errors will be in accordance with accepted health information management standards.(d) Required record retention. Periodic thinning of active clinical records is permitted; however, the following items must remain in the active clinical record:(1) current history and physical;(2) current physician's orders and progress notes;(3) current RAI and subsequent quarterly reviews; in Medicaid-certified facilities, all RAIs and Quarterly Reviews for the prior 15-month period;(4) current comprehensive care plan;(5) most recent hospital discharge summary or transfer form;(6) current nursing and therapy notes;(7) current medication and treatment records;(8) current lab and x-ray reports;(9) the admission record; and(10) the current permanency plan.(e) Readmissions.(1) If a resident is discharged for 30 days or less and readmitted to the same facility, upon readmission, to update the clinical record, staff must:(A) obtain current, signed physician's orders;(B) record a descriptive nurse note, giving a complete assessment of the resident's condition;(C) include any changes in diagnoses;(D) obtain signed copies of the hospital or transferring facility history and physical and discharge summary and a transfer summary containing this information is acceptable;(E) complete a new RAI and update the comprehensive care plan if evaluation of the resident indicates a significant change, which appears to be permanent and if no such change has occurred, then update only the resident comprehensive care plan; and(F) comply with §19.805 of this chapter (regarding Permanency Planning for a Resident Under 22 Years of Age).(2) A new clinical record must be initiated if the resident is a new admission or has been discharged for over 30 days.(f) Signatures.(1) The use of faxing is acceptable for sending and receiving health care documents, including the transmission of physicians' orders. Long term care facilities may utilize electronic transmission if they adhere to the following requirements:(A) The facility must implement safeguards to assure that faxed documents are directed to the correct location to protect confidential health information.(B) All faxed documents must be signed by the author before transmission.(2) Stamped signatures are acceptable for all health care documents requiring a physician's signature, if the person using the stamp sends a letter of intent which specifies that he will be the only one using the stamp, and then signs the letter with the same signature as the stamp.(3) The facility must maintain all letters of intent on file and make them available to representatives of HHSC upon request.(4) Use of a master signature legend in lieu of the legend on each form for nursing staff signatures of medication, treatment, or flow sheet entries is acceptable under the following circumstances.(A) Each nursing employee documenting on medication, treatment, or flow sheets signs employee's full name, title, and initials on the legend.(B) The original master legend is kept in the clinical records office or director of nurses' office.(C) A current copy of the legend is filed at each nurses' station.(D) When a nursing employee leaves employment with the facility, the employee's name is deleted from the list by lining through it and writing the current date by the name.(E) The facility updates the master legend as needed for newly hired and terminated employees.(F) The master signature legend must be retained permanently as a reference to entries made in clinical records.(g) Destruction of Records. When resident records are destroyed after the retention period is complete, the facility must shred or incinerate the records in a manner which protects confidentiality. At the time of destruction, the facility must document the following for each record destroyed:(1) resident name;(2) clinical or medical record number, if used;(3) social security number, Medicare number, Medicaid number or the date of birth; and(4) date and signature of person carrying out disposal.(h) Confidentiality. The facility must develop and implement written policies and procedures to safeguard the confidentiality of clinical record information from unauthorized access.(1) Except as provided in paragraph (2) of this subsection, the facility must not allow access to a resident's clinical record unless a physician's order exists for supplies, equipment, or services provided by the entity seeking access to the record.(2) The facility must allow access and release confidential medical information under court order or by written authorization of the resident or the resident representative, as in §19.407 of this chapter (relating to Privacy and Confidentiality). Source Note: The provisions of this §554.1912 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective May 1, 2002, 27 TexReg 2834; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1912 Additional Clinical Record Service Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212045 03/12/2026 (a) Definitions. In this section:(1) "emergency situation" means an impending or actual situation that:(A) interferes with normal activities of a facility and its residents;(B) may:(i) cause injury or death to a resident or staff member of the facility; or(ii) cause damage to facility property;(C) requires the facility to respond immediately to mitigate or avoid the injury, death, damage or interference; and(D) does not include a situation that arises from the medical condition of a resident, such as cardiac arrest, obstructed airway, or cerebrovascular accident;(2) "plan" refers to a facility's emergency preparedness and response plan; and(3) "receiving facility" means a facility or location that has agreed to receive the residents of another facility who are evacuated due to an emergency situation.(b) Administration. A facility must:(1) develop and implement a written plan as described in subsection (c) of this section;(2) maintain a current printed copy of the plan in a central location that is accessible to all staff at all times and at a work station of each personnel supervisor who has responsibilities under the plan;(3) evaluate the plan to determine if information in the plan needs to change:(A) within 30 days after an emergency situation;(B) due to remodeling or making an addition to the facility; and(C) at least annually;(4) revise the plan within 30 days after information in the plan changes; and(5) maintain documentation of compliance with this section.(c) Emergency Preparedness and Response Plan. A facility's plan must:(1) include a risk assessment of all potential internal and external emergency situations relevant to the facility's operations and geographical area, such as a fire, failure of heating and cooling systems, a power outage, a bomb threat, an explosion, a hurricane, a tornado, a flood, extreme snow and ice conditions for the area, a wildfire, terrorism, a hazardous materials accident, or a thunderstorm with a risk for harm to persons or property;(2) include a description of the facility's resident population;(3) include a section for each core function of emergency management, as described in subsection (d) of this section, that is based on a facility's decision to either shelter-in-place or evacuate during an emergency situation;(4) include a section for a fire safety plan that complies with §554.326 of this chapter (relating to Safety Operations); and(5) include a section for self reporting incidents that complies with subsection (f) of this section.(d) Plan Requirements Regarding Eight Core Functions of Emergency Management.(1) Direction and control. The facility's plan must contain a section for direction and control that:(A) designates by name or title the emergency preparedness coordinator (EPC), who is the facility staff person with the authority to manage the facility's response to an emergency situation in accordance with the plan, and includes the EPC's current phone number;(B) designates by name or title the alternate EPC, who is the facility staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity, and includes the alternate EPC's current phone number;(C) documents the name and contact information for the local emergency management coordinator (EMC) for the area where the facility is located, as identified by the office of the local mayor or county judge;(D) includes procedures for notifying the local EMC of the execution of the plan;(E) includes a plan for coordinating a staffing response to an emergency situation; and(F) includes a plan for guiding residents to a safe location that is based on the type of emergency situation occurring and a facility's decision to either shelter-in-place or evacuate during an emergency situation.(2) Warning. A facility's plan must contain a section for warning that:(A) describes how the EPC will be notified of an emergency situation;(B) identifies who the EPC will notify of an emergency situation and when the notification will occur, including during off hours, weekends, and holidays; and(C) addresses monitoring local news and weather reports regarding a disaster or potential disaster taking into consideration factors such as geographic specific natural disasters, whether a disaster is likely to be addressed or forecast in the reports, and the conditions, natural or otherwise, that would cause staff to monitor news and weather reports for a disaster.(3) Communication. A facility's plan must contain a section for communication that:(A) identifies the facility's primary mode of communication to be used during an emergency situation and the facility's alternate mode of communication to be used in the event of power failure or the loss of the facility's primary mode of communication in an emergency situation;(B) requires posting of the emergency contact number for the local fire department, ambulance, and police on or near each telephone in the facility in communities where a "911" emergency management system is unavailable;(C) includes procedures for maintaining a current list of telephone numbers for residents' responsible parties;(D) includes procedures for maintaining a current list of telephone numbers for pre-arranged receiving facilities;(E) includes procedures for maintaining a current list of telephone numbers for the facility's staff;(F) identifies the location of the lists described in subparagraphs (C) through (E) of this paragraph and in subsection (d)(1)(A) and (B) of this section;(G) includes procedures to notify:(i) facility staff about an emergency situation;(ii) a receiving facility about an impending or actual evacuation of residents; and(iii) residents and residents' responsible parties about an impending or actual evacuation;(H) provides a method for a person to obtain resident information during an emergency situation; and(I) includes procedures for the facility to maintain communication with:(i) facility staff involved in an emergency situation;(ii) a receiving facility; and(iii) the driver of a vehicle transporting residents, medication, records, food, water, equipment, or supplies during an evacuation.(4) Sheltering Arrangements. A facility's plan must contain a section for sheltering arrangements that:(A) includes procedures for implementing a decision to shelter-in-place that includes:(i) having access to medications, records, food, water, equipment and supplies; and(ii) sheltering facility staff involved in responding to an emergency situation, and their family members, if necessary;(B) includes procedures for notifying HHSC Regulatory Services regional office for the area in which the facility is located by telephone immediately after the EPC makes a decision to shelter-in-place:(i) before, during, or after a hurricane or flood impacts a facility, if the risk assessment identified a hurricane or flood as a potential emergency situation; or(ii) after any other type of emergency situation that has caused property damage to a facility;(C) includes procedures for accommodating evacuated residents, if the facility serves as a receiving facility for a facility that has evacuated.(5) Evacuation. A facility's plan must contain a section for evacuation that:(A) identifies evacuation destinations and routes, and includes a map that shows the destinations and routes;(B) includes procedures for implementing a decision to evacuate residents to a receiving facility;(C) includes a current copy of an agreement with a receiving facility, outlining arrangements for receiving residents in the event of an evacuation, if the evacuation destination identified in accordance with subparagraph (B) of this paragraph is a receiving facility that is not owned by the same entity as the evacuating facility;(D) includes procedures for:(i) ensuring facility staff accompany evacuating residents;(ii) ensuring that residents and facility staff present in the building have been evacuated;(iii) accounting for residents and facility staff after they have been evacuated;(iv) accounting for residents absent from the facility at the time of the evacuation;(v) releasing resident information in an emergency situation to promote continuity of a resident's care;(vi) contacting the local EMC to find out if it is safe to return to the geographical area after an evacuation;(vii) determining if it is safe to re-enter and occupy the building after an evacuation; and(E) includes procedures for notifying the local EMC regarding an evacuation of the facility;(F) includes procedures for notifying HHSC Regulatory Services regional office for the area in which the facility is located by telephone immediately after the EPC makes a decision to evacuate; and(G) includes procedures for notifying HHSC Regulatory Services regional office for the area in which the facility is located by telephone immediately when residents have returned to the facility after an evacuation.(6) Transportation. A facility's plan must contain a section for transportation that:(A) arranges for a sufficient number of vehicles to safely evacuate all residents;(B) identifies facility staff designated to drive a facility owned, leased or rented vehicle during an evacuation;(C) includes procedures for safely transporting residents, facility staff involved in an evacuation; and(D) includes procedures for safely transporting and having timely access to oxygen, medications, records, food, water, equipment, and supplies needed during an evacuation.(7) Health and Medical Needs. A facility's plan must contain a section for health and medical needs that:(A) identifies the types of services used by residents, such as dialysis, oxygen, respirator care, or hospice services; and(B) ensures the resident's needs identified in subparagraph (A) of this paragraph are met during an emergency situation.(8) Resource Management. A facility's plan must contain a section for resource management that:(A) includes a plan for identifying medications, records, food, water, equipment and supplies needed during an emergency situation;(B) identifies facility staff who are assigned to locate the items in subparagraph (A) of this paragraph and who must ensure the transportation of the items during an emergency situation; and(C) includes procedures to ensure medications are secure and maintained at the proper temperature during an emergency situation.(e) Training. The facility must:(1) train a facility staff member on the staff member's responsibilities under the plan within 30 days after assuming job duties;(2) train a facility staff member on the staff member's responsibilities under the plan at least annually and when the staff member's responsibilities under the plan change; and(3) conduct one unannounced annual drill with facility staff for severe weather and other emergency situations identified by the facility as likely to occur, based on the results of the risk assessment required by subsection (c)(1) of this section.(f) Self-Reported Incidents.(1) A facility must report a fire to HHSC as follows:(A) by calling 1-800-458-9858 immediately after the fire; and(B) by submitting a completed HHSC form titled "Fire Report for Long Term Care Facilities" within 15 calendar days after the fire.(2) A facility must report an emergency situation that caused the death or serious injury of a resident to HHSC as follows:(A) by calling 1-800-458-9858 immediately after the death or serious injury; and(B) by submitting a completed HHSC form titled "HHSC Provider Investigation Report" within 5 working days after making the telephone report required by paragraph (2)(A) of this subsection.(g) Emergency Response System.(1) The facility administrator and director of nursing must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The facility must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §554.1914 adopted to be effective August 1, 2011, 36 TexReg 4668; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective January 24, 2023, 48 TexReg 217. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1914 Emergency Preparedness and Response https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203210 03/12/2026 (a) The facility must have in effect a written transfer agreement with one or more hospitals that reasonably assures that:(1) Residents will be transferred from the facility to the hospital and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician or, in an emergency situation, another practitioner in accordance with written facility policy.(2) Providers will exchange medical and other information, including information required under §19.502(b)(4) of this chapter (relating to Transfer and Discharge in Medicaid-certified Facilities), needed for care and treatment of residents, and when the transferring facility deems it appropriate, for determining whether such residents can receive appropriate services, receive services in a less restrictive setting than either the facility or the hospital, or reintegrate into the community.(3) For Medicaid-certified facilities, the hospitals must be approved for participation under the Medicare and Medicaid programs.(b) In addition, to ensure continuity of care, the transfer agreement must:(1) provide for prompt diagnostic and other medical services;(2) ensure accountability for a resident's personal effects at the time of transfer;(3) specify the steps needed to transfer a resident in a prompt, safe and efficient manner; and(4) provide for supplying, at the time of transfer, a summary of administrative, social, medical, and nursing information to the facility to which the resident is transferred.(c) If the board or governing body for a long-term care facility and a hospital are the same, the controlling entity must have written procedures outlining how transfers will occur.(d) The facility is considered to have a transfer agreement in effect if HHSC determines that the facility attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible but could not, and it is in the public interest not to enforce this requirement. The facility must document in writing its good faith effort to enter into an agreement. Source Note: The provisions of this §554.1915 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1915 Transfer Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203211 03/12/2026 Facilities offering respite care must meet the requirements of this chapter, except as provided in paragraph (4) of this section.(1) Definitions. The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(A) Plan of care--A written description of the medical care or the supervision and nonmedical care needed by an individual during respite care.(B) Respite care--The provision by a facility to an individual, for not more than two weeks for each stay in the facility, of room, board, and care at the level ordinarily provided for permanent residents.(2) Plan of care. The facility and the individual arranging respite care must agree on the plan of care, and the plan must be filed at the facility before the facility admits the individual.(A) The plan of care must be signed by:(i) a licensed physician if the individual needing care requires medical care or treatment; or(ii) the individual arranging the care if medical care or treatment is not required.(B) The facility may keep a plan of care for an individual for six months from the date on which it is developed. During that period, the facility may admit the individual as frequently as needed.(3) Notification. A facility must notify the Texas Department of Human Services (DHS) in writing that it offers respite services.(4) Inspections. During licensing or certification inspections, or at other times DHS determines necessary, DHS inspects a facility's records of respite care services, physical accommodations for respite care, and the plan of care records to ensure that the respite care services comply with the certification requirements of this chapter, with the following exceptions.(A) The clinical record of each respite care resident must contain:(i) general identifying information necessary to care for the individual and maintain his clinical record;(ii) resident assessment and care plan according to facility policy;(iii) progress notes and/or flow sheets which document care and services;(iv) reports of diagnostic or lab studies;(v) physician's orders; and(vi) discharge and readmission information as required by facility policy for respite care services.(B) Resident assessment requirements of §19.801 of this title (relating to Resident Assessment) apply to respite care services only on the 14th day of care.(C) The clinical records requirement found at §19.1912(e) of this title (relating to Additional Clinical Record Service Requirements) does not apply.(5) Suspension. DHS may require an institution to cease providing respite care if DHS determines that the respite care does not meet the requirement of this chapter and that the facility cannot comply with those requirements in the respite care it provides. DHS may suspend the license of a facility that continues to provide respite care after receiving a written order from DHS to cease.(6) Licensed capacity. When a facility provides respite care:(A) the total number of individuals receiving services in the facility must not exceed the number of licensed beds; and(B) any required nurse-to-resident ratio must include any individual receiving respite care services regardless of the number of hours that the individual spends in the facility. Source Note: The provisions of this §554.1916 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1916 Respite Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203212 03/12/2026 (a) The facility must maintain a Quality Assessment and Assurance Committee consisting of:(1) the director of nursing services;(2) the medical director or designee;(3) at least three other members of the facility's staff, at least one of whom must be the administrator, a board member or other individual in a leadership role; and(4) effective November 28, 2019, the infection preventionist.(b) The Quality Assessment and Assurance Committee reports to the facility's governing body regarding its activities. The committee must:(1) meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary;(2) develop and implement appropriate plans of action to correct identified quality deficiencies; and(3) regularly review and analyze data, including data resulting from drug regimen reviews, and act on available data to make improvements.(c) The State of Texas or the Secretary of Health and Human Services may not require disclosure of the records of the Quality Assessment and Assurance Committee except insofar as such disclosure is related to the compliance of the committee with the requirements of subsection (b) of this section.(d) Good faith attempts by the committee to identify and correct quality deficiencies may not be used as a basis for sanctions.(e) The Quality Assessment and Assurance Committee must adopt and ensure implementation of a written policy to identify, assess, and develop strategies to control risk of injury to residents and nurses associated with the lifting, transferring, repositioning, or moving of a resident. The policy must establish a process that includes:(1) analysis of the risk of injury to both residents and nurses posed by the resident handling needs of the resident populations served by the nursing facility and the physical environment in which resident handling and moving occurs;(2) annual in-service education of nurses in the identification, assessment, and control of risk of injury to residents and nurses during resident handling;(3) evaluation of alternative ways to reduce risks associated with resident handling, including evaluation of equipment and the environment;(4) restriction, to the extent feasible with existing equipment and aids, of manual resident handling or moving of all or most of a resident's weight to emergency, life-threatening, or otherwise exceptional circumstances;(5) collaboration with and an annual report to the nurse staffing committee;(6) specific procedures for nurses to refuse to perform or be involved in resident handling or moving that the nurse believes in good faith will expose a resident or a nurse to an unacceptable risk of injury;(7) submission of an annual report by the nursing staff to the Quality Assessment and Assurance Committee on activities related to the identification, assessment, and development of strategies to control risk of injury to residents and nurses associated with the lifting, transferring, repositioning, or moving of a resident; and(8) in developing architectural plans for constructing or remodeling a nursing facility or a unit of a nursing facility in which resident handling and moving occurs, consideration of the feasibility of incorporating resident handling equipment or the physical space and construction design needed to incorporate that equipment at a later date. Source Note: The provisions of this §554.1917 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 2006, 31 TexReg 4458; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1917 Quality Assessment and Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203213 03/12/2026 (a) The facility must comply with the disclosure requirements of 42 Code of Federal Regulations, §420.206 and §455.104.(b) The facility must provide written notice to Facility Enrollment, Long-Term Care-Regulatory, Texas Department of Human Services (DHS) at the time of change if a change occurs in:(1) persons with an ownership or control interest, as defined in 42 Code of Federal Regulations, §420.201 and §455.101;(2) the officers, directors, agents or managing employees;(3) the corporation, association, or other company responsible for the management of the facility;(4) the facility's administrator or director of nursing; or(5) the controlling person.(c) The notice specified in subsection (b) of this section must include the identity of each new individual or company.(d) Failure to notify Facility Enrollment within 30 days of a change specified in subsection (b) will result in a $500 administrative penalty. If the notice is postmarked within the 30-day period, 15 days will be added to the time period to receive the notice. Source Note: The provisions of this §554.1918 adopted to be effective October 1, 1990, 15 TexReg 5220; amended to be effective April 1, 1992, 17 TexReg 1915; amended to be effective May 1, 1995, 20 TexReg 2868; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective July 1, 2002, 27 TexReg 5245; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1918 Disclosure of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203214 03/12/2026 (a) As a condition of continued licensure, a license holder must maintain the right to possession of the facility as described in §19.204(b)(1) of this title (relating to Application Requirements).(b) The license holder must notify DADS in writing within 72 hours after the license holder becomes aware of or should have become aware of the loss and imminent loss of the right to possession of the facility, such as notice of eviction, foreclosure, termination of lease, or similar proposed action. The notification must:(1) include a description of the specific situation that resulted in loss of possession of the facility;(2) be faxed to (512) 438-2730 or (512) 438-2728; and(3) be kept on file with a copy of the fax confirmation. Source Note: The provisions of this §554.1919 adopted to be effective September 1, 2007, 32 TexReg 4231; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1919 Right to Possession https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220624 03/12/2026 (a) The facility must have an administrative policy and procedure manual that outlines the general operating policies and procedures of the facility. The manual must include policies and procedures related to admission and admission agreements, resident care services, refunds, transfers and discharges, termination from Medicaid or Medicare participation in accordance with §554.2121 of this chapter (relating to General Provisions), receiving and responding to complaints and recommendations, and protection of a resident's personal property and civil rights. A copy of this manual must be made available for review upon request to each physician, staff member, resident, and resident's next of kin or guardian and to the public.(b) The facility must have written personnel policies and procedures that are explained to employees during initial orientation and are readily available to them after that time.(c) The facility must ensure that personnel records are correct and contain sufficient information to support placement in the assigned position (including a resume of training and experience). When appropriate, a current copy of the person's license or permit must be in the file.(d) Upon request of HHSC, the facility must make available financial records to demonstrate the facility's compliance with applicable state laws and standards relating to licensing.(e) A facility must develop, implement, and enforce a written policy that:(1) requires a facility employee who provides direct care to a resident with Alzheimer's disease or a related disorder to successfully complete training in the provision of care to residents with Alzheimer's disease and related disorders; and(2) ensures the care and services provided by a facility employee to a resident with Alzheimer's disease or a related disorder meet the specific identified needs of the resident relating to the diagnosis of Alzheimer's disease or a related disorder.(f) The training required for facility employees under subsection (e)(1) of this section must include information about:(1) symptoms and treatment of dementia;(2) stages of Alzheimer's disease;(3) person-centered behavioral interventions; and(4) communication with a resident with Alzheimer's disease or a related disorder.(g) A facility must have a workplace violence prevention committee and develop workplace violence prevention policies and procedures in accordance with Texas Health and Safety Code, Chapter 331. Source Note: The provisions of this §554.1920 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effective October 28, 2018, 43 TexReg 7189; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective September 18, 2024, 49 TexReg 7331. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1920 Operating Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210958 03/12/2026 (a) The facility must admit and retain only residents whose needs can be met through service from the facility staff, or in cooperation with community resources or other providers under contract.(b) Individuals who have met the requirements of Chapter 17 of this title (relating to Preadmission Screening and Resident Review (PASRR) and have mental or physical diseases, or both, that endanger other residents may be admitted or retained if adequate rooms and care are provided to protect the other residents.(c) The term "hospital" may not be used as part of the name of a nursing facility unless it has been classified and duly licensed as a hospital by the appropriate state agency.(d) A facility that ceases operation, temporarily or permanently, voluntarily or involuntarily, must provide notice to the residents and residents' relatives or responsible parties of closure. See §554.2310 of this chapter (relating to Nursing Facility Ceases to Participate) for additional notice requirements that apply to a Medicaid or Medicare certified facility.(1) If the closure is voluntary, within one week after the date on which the decision to close is made, the facility must send written notice to residents' relatives or responsible parties stating that the closure will occur no earlier than 60 days after receipt of the notice.(2) If the closure is involuntary, the facility must make the notification, whether orally or in writing, immediately on receiving notice of the closure.(e) Each licensed facility must conspicuously and prominently post the information listed in paragraphs (1) - (13) of this subsection in an area of the facility that is readily available to residents, employees, and visitors. The posting must be in a manner that each item of information is directly visible at a single time. In the case of a licensed section that is part of a larger building or complex, the posting must be in the licensed section or public way leading to it. Any exceptions must be approved by HHSC. The following items must be posted:(1) the facility license;(2) a complaint sign provided by HHSC giving the toll-free telephone number;(3) a notice in a form prescribed by HHSC that inspection and related reports are available at the facility for public inspection;(4) a concise summary prepared by HHSC of the most recent inspection report;(5) a notice of HHSC toll-free telephone number 1-800-458-9858 to request summary reports relating to the quality of care, recent investigations, litigation or other aspects of the operation of the facility that are available to the public;(6) a notice that HHSC can provide information about the nursing facility administrator at (512) 438-2015;(7) if a facility has been ordered to suspend admissions, a notice of the suspension, which must be posted also on all doors providing public ingress to and egress from the facility;(8) the statement of resident rights provided in §554.401 of this chapter (relating to Introduction) and any additional facility requirements involving resident rights and responsibilities;(9) a notice that employees, other staff, residents, volunteers, and family members and guardians of residents are protected from discrimination or retaliation as provided by the Texas Health and Safety Code, §260A.014 and §260A.015; and that the facility has available for public inspection a copy of the Texas Health and Safety Code, Chapter 260A;(10) a prominent and conspicuous sign for display in a public area of the facility that is readily available to the residents, employees, and visitors and that includes the statement: CASES OF SUSPECTED ABUSE, NEGLECT, OR EXPLOITATION SHALL BE REPORTED TO HHSC BY CALLING 1-800-458-9858;(11) for a facility that advertises, markets, or otherwise promotes that it provides services to residents with Alzheimer's disease and related disorders, a disclosure statement describing the nature of its care or treatment of residents with Alzheimer's disease and related disorders in accordance with §554.403(n)(2) of this chapter (relating to Notice of Rights and Services);(12) at each entrance to the facility, a sign that states that a person may not enter the premises with a handgun and that complies with Government Code §411.204; and(13) daily for each shift, the current number of licensed and unlicensed nursing staff directly responsible for resident care in the facility. In addition, the nursing facility must make the information required to be posted available to the public upon request.(f) The reports referenced in subsection (e)(3) of this section must be maintained in a well-lighted, accessible location and must include:(1) a statement of the facility's compliance record that is updated at least bi-monthly and reflects at least one year's compliance record, in a form required by HHSC; and(2) if a facility has been cited for a violation of residents' rights, a copy of the citation, which must remain in the reports until any regulatory action with respect to the violation is complete and HHSC has determined that the facility is in full compliance with the applicable requirement.(g) The facility must inform the resident or responsible party or both upon the resident's admission that the inspection reports referenced in subsection (e)(3) of this section are available for review.(h) A facility must provide the telephone number for reporting cases of suspected abuse, neglect, or exploitation to an immediate family member of a resident of the facility upon the resident's admission to the facility.(i) A copy of the Texas Health and Safety Code, Chapters 242 and 260A, must be available for public inspection at the facility.(j) Within 72 hours after admission, the facility must prepare a written inventory of the personal property a resident brings to the facility, such as furnishings, jewelry, televisions, radios, sewing machines, and medical equipment. The facility does not have to inventory the resident's clothing; however, the operating policies and procedures must provide for the management of resident clothing and other personal property to prevent loss or damage. The facility administrator or his or her designee must sign and retain the written inventory and must give a copy to the resident or the resident's responsible party or both. The facility must revise the written inventory to show if property is lost, destroyed, damaged, replaced, or supplemented. Upon discharge of the resident, the facility must document the disposition of personal effects by a dated receipt bearing the signature of the resident or the resident's responsible party or both. See §554.416 of this chapter (relating to Personal Property).(k) Each facility must comply with the provisions of the Texas Health and Safety Code, Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly or Persons with Disabilities).(l) Before a facility hires an unlicensed employee, the facility must search the employee misconduct registry (EMR) established under §253.007, Texas Health and Safety Code, and the HHSC nurse aide registry (NAR) to determine whether the individual is designated in either registry as unemployable. Both registries can be accessed on the HHSC Internet website.(m) A facility is prohibited from hiring or continuing to employ a person who is listed in the EMR or NAR as unemployable.(n) A facility must provide notification about the EMR to an employee in accordance with 40 TAC §93.3 (relating to Employment and Registry Information).(o) In addition to the initial search of the EMR and NAR, a facility must:(1) conduct a search of the NAR and EMR to determine if an employee of the facility is listed as unemployable in either registry as follows:(A) for an employee most recently hired before September 1, 2009, by August 31, 2011, and at least every 12 months thereafter; and(B) for an employee most recently hired on or after September 1, 2009, at least every twelve months; and(2) keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file. Source Note: The provisions of this §554.1921 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective September 1, 1996, 21 TexReg 7859; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective May 1, 2002, 27 TexReg 2832; amended to be effective June 1, 2003, 28 TexReg 3828; amended to be effective September 1, 2003, 28 TexReg 6939; amended to be effective September 1, 2010, 35 TexReg 6353; amended to be effective August 1,2011,36TexReg 4671; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effective July 21, 2016, 41 TexReg 5203; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1921 General Requirements for a Nursing Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203217 03/12/2026 (a) The facility must have written policies to govern the nursing care and related medical or other services provided. The written policies must include plans for promoting self-care and independence. If children are admitted to the facility, written policies must address the care of children, consistent with currently acceptable pediatric practice and should address the ongoing assessment of the potential for community reintegration.(b) Resident care policies are developed by the medical director and by professional personnel, including one or more physicians, licensed or registered nurses, a registered pharmacist, and the licensed nursing home administrator. The advisory group must review the policies at least annually and update them as necessary. Source Note: The provisions of this §554.1922 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1922 Resident Care Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203218 03/12/2026 (a) The facility must detail in the medical record every accident or incident, including allegations of mistreatment of residents by facility staff, medication errors, and drug reactions.(b) Accidents, whether or not resulting in injury, and any unusual incidents or abnormal events including allegations of mistreatment of residents by staff or personnel or visitors, must be described in a separate administrative record and reported by the facility in accordance with the licensure Act and this section.(1) If the incident appears to be of a serious nature, it must be investigated by or under the direction of the director of nurses, the facility administrator, or a committee charged with this responsibility.(2) If the incident involves a resident and is serious or requires special reporting to HHSC, the resident's responsible party and attending physician must be immediately notified.(c) Accident or incident reports must be retained for at least two years following the occurrence and must contain the following information.(1) For incidents involving residents, the name of the resident; witnesses, if any; date, time, and description of the incident; circumstances under which it occurred; action taken including documentation of notification of the responsible party and attending physician, if appropriate; and the resident's current (post-incident) health condition, including vital signs and date and time of entry.(2) Incident reports describing incidents not involving residents must contain such information as names of individuals involved, date, time, witnesses (if witnesses were present), description of the event or occurrence, including the circumstances under which it occurred, action taken, and final disposition that indicates resolution of the event or occurrence.(d) The facility must investigate incidents/accidents and complaints for trends which may indicate resident abuse. Trends that might be identified include but are not limited to: type of accident, type of injury, time of day, staff involved, staffing level, and relationship to past complaints.(e) The facility must make incident reports available for review, upon request and without prior notice, by representatives of HHSC, the U.S. Department of Health and Human Services, if applicable; and the Texas Department of Family and Protective Services. The facility must make reports related to specific incidents available to the State Ombudsman and a certified ombudsman. Source Note: The provisions of this §554.1923 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1923 Incident or Accident Reporting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203219 03/12/2026 Nursing facility staff must maintain current financial records in accordance with recognized fiscal and accounting procedures. The facility must ensure that records clearly identify each charge and payment made on behalf of each resident residing in the facility. The facility must clearly state in its records to whom charges were made and for whom payment was received. Medicaid-certified facilities must also comply with the following requirements.(1) The facility must make financial records and supporting documents available at any time within working hours and without prior notification for review by the Texas Department of Human Services, the Department of Health and Human Services, and the Texas attorney general's Medicaid Fraud Control Unit.(2) The facility must keep the financial records in the facility for a minimum of three years and 90 days after the termination of the contract period or for three years after the end of the federal fiscal year in which services were provided if there was a provider agreement/contract with no specific termination date in effect. The facility must also keep for the same period of time supporting fiscal documents and other records necessary to ensure claims for federal matching funds. Source Note: The provisions of this §554.1924 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1924 Financial Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203220 03/12/2026 (a) Effective December 1, 2008, minimum standards of financial condition require the applicant or license holder to have sufficient financial resources to:(1) satisfy obligations at the time they come due; and(2) ensure at all times the delivery of essential care and services, such as nursing or dietary services, or utilities.(b) A license holder must notify DADS of significant adverse changes in financial condition, which include changes in financial position, cash flow, results of operation, or other events that could adversely affect the delivery of essential care and services, such as nursing or dietary services, or utilities. The following are examples of significant adverse changes in financial condition that must be reported:(1) The license holder, operator, administrator, manager, or other controlling person receives notice that a judgment or tax lien of at least $50,000 has been filed, recorded, or levied against the facility or any of the assets of the facility or the license holder and the judgment or tax lien is not satisfied, or an appropriate extension has not been obtained, within three working days after receipt of the notice.(2) A financial institution refuses to honor facility-operation-related checks or other financial instruments issued by the license holder, operator, administrator, manager, or other controlling person or agent of the license holder, operator, administrator, manager, or other controlling person and:(A) the cumulative amounts of the checks or financial instruments are $50,000 or more; and(B) the checks or financial instruments are not honored or replaced to the satisfaction of the holders of the instruments within five working days after the holders have notified the license holder, operator, administrator, manager, or the person authorized to issue the instrument of the dishonored items.(3) The facility fails to maintain the facility's utilities or a sufficient quantity of supplies, including nursing, dietary, pharmaceutical, or other care and service supplies, to meet the needs of the residents.(4) The license holder, operator, administrator, manager, or other controlling person fails to make timely payments of any facility-related tax of at least $10,000 and fails to satisfy such tax within five working days after the date the tax becomes due.(5) The license holder, operator, administrator, manager, or other controlling person files a voluntary bankruptcy petition, or a creditor files an involuntary bankruptcy petition against the license holder or controlling person, under the United States Code or any other laws of the United States.(6) A court appoints a bankruptcy trustee for the facility.(7) A person seeking appointment of a receiver for the facility files a petition in any jurisdiction.(8) The license holder, operator, administrator, manager, or other controlling person is unable to meet conditions of a facility-operation-related loan or debt covenant unless the loan or debt covenant has been waived, and that inability leads to:(A) the imposition of a fine or penalty;(B) restructuring;(C) a change in terms or conditions of the loan or debt covenant; or(D) a recall by the issuing entity.(9) The license holder, operator, administrator, manager, or other controlling person is delinquent on more than $50,000 of facility-related contractual obligations or vendor contracts and has not cured the delinquency within five working days after receipt of notice from the creditor or creditors to pay the debt.(c) The license holder must notify DADS in writing of a significant adverse change in its financial condition as required by subsection (b) of this section within 72 hours after the license holder becomes aware of or should have become aware of the change.(d) The license holder's notice required by subsection (b) of this section must include a description of:(1) the specific significant adverse change in financial condition;(2) how the significant adverse change in financial condition affects the license holder's ability to deliver essential care and services; and(3) the actions the license holder has taken to address the significant adverse change in financial condition.(e) The license holder must fax the notice required in subsection (b) of this section to (512) 438-2730 or (512) 438-2728, and the notice must be kept on file with a copy of the fax confirmation.(f) The license holder must provide any other information DADS requests to substantiate continued compliance with the requirements of this section within 30 days after the request. Source Note: The provisions of this §554.1925 adopted to be effective September 1, 2007, 32 TexReg 4231; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1925 Financial Condition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203221 03/12/2026 (a) When a nursing facility (NF) contracts for hospice services for residents, the nursing facility must:(1) have a written contract for the provision of arranged services, which must be signed by authorized representatives of the NF and hospice and must include the following:(A) the services to be provided;(B) a stipulation that hospice-related services performed by NF staff may be provided only with the express authorization of the hospice;(C) how the contracted services are to be coordinated, supervised, and evaluated by the hospice and the NF;(D) delineation of the roles of the hospice and the NF in the admission process, recipient and family assessment, and the interdisciplinary team case conferences;(E) a requirement for documentation of services furnished; and(F) the qualifications of the personnel providing the services;(2) provide room and board services, which include the performance of personal care services, including assistance in the activities of daily living, administration of medication, socializing activities, maintaining the cleanliness of a resident's room, and supervision and assisting in the use of durable medical equipment and prescribed therapies;(3) immediately notify the hospice of any significant changes in the hospice recipient's condition;(4) have joint procedures with the hospice provider for ordering medications that ensure the proper payor is billed and for reconciling billing between NF and hospice, including:(A) contacting the hospice prior to filling a new prescription; and(B) ensuring that drugs unrelated to the terminal illness are ordered through the Vendor Drug program; and(5) ensure that hospice documentation is a part of the current clinical record, which, at a minimum, must include the current and past:(A) Texas Medicaid Hospice Recipient Election/Cancellation form;(B) MDS assessment;(C) Physician Certification of Terminal Illness form;(D) Medicare Election Statement, if dually eligible;(E) verification that the recipient does not have Medicare Part A;(F) hospice interdisciplinary assessments;(G) hospice plan of care; and(H) current interdisciplinary notes, which include the following:(i) nurses notes and summaries;(ii) physician orders and progress notes; and(iii) medication and treatment sheets during the hospice certification period.(b) The NF and hospice must ensure that the coordinated plan of care reflects the participation of the hospice, the NF, the recipient, and the recipient's legal representative to the extent possible. The plan of care must include directives for managing pain and other uncomfortable symptoms, and must be revised and updated as necessary to reflect the recipient's current status.(c) The recipient has the right to refuse any services from the nursing facility and the hospice provider.(d) The hospice retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which includes:(1) designation of a hospice registered nurse to coordinate the implementation of the plan of care;(2) provision of substantially all core services (physician, nursing, medical social work, and counseling services) that must be routinely provided directly by the hospice employees, and cannot be delegated to the NF, as outlined under 42 Code of Federal Regulations §418.80;(3) provision of drugs and medical supplies as needed for palliation and management of the terminal illness and related conditions; and(4) involvement of NF personnel in assisting with the administration of prescribed therapies in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family or caregiver in the home setting.(e) The hospice may arrange to have non-core hospice services provided by the NF if the hospice assumes professional management responsibility for the services and assures these services are performed in accordance with the policies of the hospice and the recipient's plan of care. Source Note: The provisions of this §554.1926 adopted to be effective December 1, 2000, 25 TexReg 10374; amended to be effective January 1, 2002, 26 TexReg 10389; amended to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1926 Medicaid Hospice Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203222 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203222&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203222 03/12/2026 (a) The facility must promote a volunteer program designed to assist in meeting the social and emotional needs of the residents.(b) A volunteer council may be utilized to solicit community involvement in the volunteer program.(c) The facility should promote volunteer programs designed to provide social, emotional, educational, and sensory opportunities for its pediatric residents. Source Note: The provisions of this §554.1928 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1928 Volunteer Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203223 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203223 03/12/2026 Each facility must develop, implement and maintain effective training programs of orientation, training, and continuing in-service education to develop the skills of its staff, including all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Effective November 28, 2019, a facility must determine the amount and types of training necessary based on a facility assessment as specified at §19.1931 of this subchapter (relating to Facility Assessment) and as described in §19.1001 of this chapter (relating to Nursing Services).(1) As part of orientation and annually, each employee must receive instruction regarding:(A) Human Immunodeficiency Virus (HIV), as outlined in the educational information provided by the Texas Department of State Health Services Model Workplace Guidelines. At a minimum the HIV curriculum must include:(i) modes of transmission;(ii) methods of prevention;(iii) behaviors related to substance abuse;(iv) occupational precautions;(v) current laws and regulations concerning the rights of an acquired immune deficiency syndrome/HIV-infected individual; and(vi) behaviors associated with HIV transmission which are in violation of Texas law;(B) restraint reduction and the prevention of falls through competency-based training. Facilities also may choose to train on behavior management, including prevention of aggressive behavior and de-escalation techniques;(C) activities that constitute abuse, neglect, exploitation, or misappropriation of resident property as set forth at §19.601 of this chapter (relating to Freedom from Abuse, Neglect and Exploitation);(D) procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property; and(E) dementia management and resident abuse prevention.(2) Each registered nurse, licensed vocational nurse, and nurse aide (nurse assistant) who provides nursing services must receive at least one hour of training each year in caring for people who have dementia.(3) Nursing staff, licensed nurses, and nurse aides must receive annual in-service training which includes components, appropriate to their job responsibilities, from one or more of the following categories:(A) communication techniques and skills useful when providing geriatric care, such as skills for communicating with the hearing impaired, visually impaired and cognitively impaired; therapeutic touch; and recognizing communication that indicates psychological abuse;(B) assessment and nursing interventions related to the common physical and psychological changes of aging for each body system;(C) geriatric pharmacology, including treatment for pain management and sleep disorders;(D) common emergencies of geriatric residents and how to prevent them, for example, falls, choking on food or medicines, injuries from restraint use; recognizing sudden changes in physical condition, such as stroke, heart attack, acute abdomen, and acute glaucoma; and obtaining emergency treatment;(E) common mental disorders with related nursing implications; and(F) ethical and legal issues regarding advance directives, abuse and neglect, guardianship, and confidentiality.(4) Facilities with pediatric residents must comply with the following:(A) Facility staff must be trained in the use of pediatric equipment and supplies, including emergency equipment and supplies.(B) Facility staff must receive annual continuing education dealing with pediatric issues, including child growth and development and pediatric assessment.(5) Minimum continuing in-service education requirements are listed in subparagraphs (A) - (B) of this paragraph. Attendance at relevant outside training may be used to satisfy the in-service education requirement. The facility must keep in-service records for each employee listed. The minimum requirements are:(A) licensed personnel--two hours per quarter; and(B) nurse aides--12 hours annually. For the purpose of this paragraph, a medication aide is considered a nurse aide and must receive the same continuing in-service education. This in-service education does not qualify as continuing education units required for renewal of a medication aide permit.(6) A rural hospital participating in the Medicaid Swing Bed Program as specified in §19.2326 of this chapter (relating to Medicaid Swing Bed Program for Rural Hospitals) is not required to meet the requirements of this section, if the swing beds are used for no more than one 30-day length of stay per year, per resident.(7) Effective November 28, 2019, the facility must also include as part of its mandatory training the following topics:(A) effective communications for direct care staff;(B) rights of the resident and the responsibilities of a facility to properly care for its residents as set forth in Subchapter E of this chapter (relating to Resident Rights);(C) standards, policies, and procedures for the facility's infection prevention and control program, as set forth in §19.1601 of this chapter (relating to Infection Control); and(D) behavioral health training, as set forth in §19.904 of this chapter (relating to Behavioral Health Services). Source Note: The provisions of this §554.1929 adopted to be effective September 1, 1996, 21 TexReg 7859; amended to be effective June 1, 2003, 28 TexReg 3828; amended to be effective May 1, 2004, 29 TexReg 3235; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1929 Staff Development https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203224 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203224 03/12/2026 If the facility stores and transfers blood or blood products, the facility must meet the conditions established for certification of hospitals that are contained in 42 Code of Federal Regulations §482.27(d)(1)-(6). Source Note: The provisions of this §554.1930 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1930 Blood and Blood Products https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203225 03/12/2026 The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility must address or include:(1) the facility's resident population, including:(A) both the number of residents and the facility's resident capacity;(B) the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;(C) the staff competencies that are necessary to provide the level and types of care needed for the resident population;(D) the physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and(E) any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including activities and food and nutrition services;(2) the facility's resources, including:(A) all buildings and other physical structures and vehicles;(B) equipment (medical and non-medical);(C) services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;(D) all personnel, including managers, employees, contractors, and volunteers, as well as their education, training and any competencies related to resident care;(E) contracts, memorandums of understanding, or other agreements with their parties to provide services or equipment to the facility during both normal operations and emergencies; and(F) health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations; and(3) a facility-based and community-based risk assessment, utilizing an all-hazards approach. Source Note: The provisions of this §554.1931 adopted to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1931 Facility Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203226 03/12/2026 (a) A nursing facility that accepts school-age residents, ages 3 through 21, must provide assurances to the Texas Department of Human Services (DHS) that it has:(1) established a written cooperative agreement with the local independent school district that includes:(A) general responsibilities of the facility and the school district in delivering appropriate and mutually supportive services to eligible school-age residents;(B) a provision allowing the school district staff to access, with appropriate consent of the eligible resident or guardian, the facility's resident record and assessment information to avoid unnecessary duplication of services;(C) a provision allowing the school district staff an opportunity to participate in or provide information for the facility's admission, programmatic, and discharge-planning meetings when the educational needs of an eligible resident are being considered; and(D) a provision allowing the NF staff to participate in or provide information to the school district's admission, review, and dismissal (ARD) committee during its deliberations about each eligible school-age resident; and(2) developed written policies and procedures to ensure that all eligible school-age residents, ages 3 through 21, who have neither successfully graduated from nor completed an approved school program are enrolled in a Texas Education Agency-approved educational program. The facility must:(A) notify the local education agency (LEA), in writing, within three days of the admittance of an individual between the ages of birth and 22; and(B) provide the LEA with any of the following information or records available to the facility within 14 working days of a school-age child's admission to the facility:(i) birth certificate or other document as proof of a child's identity;(ii) medical history and medical records, including current immunization records;(iii) social history;(iv) vision and hearing screening and/or evaluation;(v) assessment reports, including psychological, educational, related service, and vocational assessments;(vi) the facility's care plan;(vii) educational history (at last previous educational placement to facilitate the LEA's efforts to obtain educational records from the previous LEA); and(viii) any court order which authorizes the placement in the facility.(C) maintain, as a separate document in the school-age resident's record, a copy of the original Individual Education Plan (IEP) developed by the school district, and any subsequent changes;(D) document, in the comprehensive care plan, the following:(i) efforts to resolve differences between the IEP and the comprehensive care plan;(ii) educational objectives (such as behavior therapy or speech therapy), services, and approaches;(iii) the resident's adjustment to the educational program;(iv) changes and modifications to the plan; and(v) discipline(s) in the facility responsible for follow-through on each educational objective; and(E) provide to the local ARD committee a description of available space should a child need to be educated at the facility. If the ARD committee decides that the facility is the appropriate educational placement and the space is adequate, the facility must:(i) provide the space as described, free of any costs, including those incurred for the operation and maintenance of the space; and(ii) if the space will no longer be available or must be reduced, notify the LEA 30 days in advance with regard to one student and 90 days in advance regarding more than one student.(b) If a provider desires to provide and administer the provider's own educational program(s), the provider must secure and maintain certification as a nonpublic school from the Texas Education Agency.(c) In accordance with the Education Code, §29.012, DHS adopts by reference 19 TAC §89.1115 (relating to the Memorandum of Understanding Concerning Interagency Coordination of Special Education Services to Students with Disabilities in Residential Facilities). Source Note: The provisions of this §554.1934 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 15, 1997, 22 TexReg 5277; amended to be effective May 1, 2003, 28 TexReg 2619; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1934 Educational Requirements for Persons under Age 22 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210959 03/12/2026 (a) In this section:(1) "automated external defibrillator" means a heart monitor and defibrillator that:(A) has received approval from the United States Food and Drug Administration of its premarket notification filed under United States Code, Title 21, §360(k);(B) is capable of recognizing the presence or absence of ventricular fibrillation or rapid ventricular tachycardia;(C) is capable of determining, without interpretation of cardiac rhythm by an operator, whether defibrillation should be performed; and(D) after determining that defibrillation should be performed, automatically charges and requests delivery of an electrical impulse to an individual's heart; and(2) "onsite" means:(A) in a single story building;(B) on each floor of a multiple story building; or(C) in each small house of a multiple small house model.(b) A facility must have at least one automated external defibrillator available for use onsite at all times. The facility must place the automated external defibrillator in a location that is easily accessible for staff persons who are trained to operate it.(c) A facility must ensure at least one staff person who has completed and maintains training in cardiopulmonary resuscitation (CPR) and automated external defibrillator operation in accordance with the guidelines established by the defibrillator's manufacturer and as approved by the American Heart Association, the American Red Cross, or other nationally recognized associations is onsite at all times.(d) A facility must ensure that a licensed physician provides medical consultation or general oversight of the staff training to ensure the facility complies with subsection (c) of this section.(e) A facility must maintain and test the automated external defibrillator according to the manufacturer's guidelines and keep records of the maintenance and testing.(f) A facility must conduct a monthly inspection to verify the automated external defibrillator:(1) is placed at its designated location;(2) reasonably appears to be ready for use; and(3) does not reasonably appear to be damaged in a manner that could prevent operation.(g) A facility must ensure the use of an automated external defibrillator is consistent with a resident's advance directive executed or issued under Texas Health and Safety Code, Chapter 166, Subchapter C.(h) The facility must notify the local emergency medical services provider by calling 9-1-1, per standard CPR procedures, while using an automated external defibrillator on a resident.(i) Within 24 hours after acquiring an automated external defibrillator, a facility must notify the local emergency medical services provider of:(1) the existence of the automated external defibrillator;(2) the location of the automated external defibrillator in the facility; and(3) the type of automated external defibrillator.(j) If a facility has an automated external defibrillator on the effective date of this rule, the facility must provide the notification described in subsection (i) of this section within seven days after the effective date. Source Note: The provisions of this §554.1935 adopted to be effective April 29, 2015, 40 TexReg 2283; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1935 Automated External Defibrillators https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203228 03/12/2026 (a) A facility must request a copy of any current court order appointing a guardian and letters of guardianship for a resident or a resident's estate from the resident's nearest relative or the person responsible for the resident's support.(b) A facility must request the court order and letters of guardianship:(1) when a facility admits an individual; and(2) when the facility becomes aware a guardian is appointed after the facility admits a resident.(c) A facility must request an updated copy of the court order and letters of guardianship at each annual assessment and retain documentation of any change.(d) A facility must make at least one follow-up request within 30 days after the facility makes a request in accordance with subsection (b) or (c) of this section if the facility has not received:(1) a copy of the court order and letters of guardianship; or(2) a response that there is no court order and letters of guardianship.(e) A facility must keep in the resident's clinical record:(1) documentation of the results of the request for the court order and letters of guardianship; and(2) a copy of the most recent court order appointing a guardian of a resident or a resident's estate and letters of guardianship that the facility received. Source Note: The provisions of this §554.1936 adopted to be effective July 21, 2016, 41 TexReg 5203; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION T ADMINISTRATION §554.1936 Guardianship Orders for a Nursing Facility Resident https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210960 03/12/2026 (a) HHSC inspection and survey personnel perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits from time to time as they deem appropriate or as required for carrying out the responsibilities of licensing.(b) An inspection may be conducted by an individual qualified surveyor or by a team, of which at least one member is a qualified surveyor.(c) To determine standard compliance which cannot be verified during regular working hours, night or weekend inspections may be conducted to cover specific segments of operation and will be completed with the least possible interference to staff and residents.(d) Generally, all inspections, surveys, complaint investigations and other visits, whether routine or non-routine, made for the purpose of determining the appropriateness of resident care and day-to-day operations of a facility will be unannounced; any exceptions must be justified. Releasing advance information of an unannounced inspection is a third degree felony, as provided in §242.045 of the Health and Safety Code.(e) Certain visits may be announced, including, but not limited to, consultation visits to determine how a physical plant may be expanded or upgraded and visits to determine the progress of physical plant construction or repairs, equipment installation or repairs, or systems installation or repairs or conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.(f) Persons authorized to receive advance information on unannounced inspections include:(1) citizen advocates invited to attend inspections, as described in subsection (g) of this section;(2) the State Ombudsman, a certified ombudsman, and an ombudsman intern who are authorized to attend and participate in inspections;(3) representatives of the United States Department of Health and Human Services whose programs relate to the Medicare/Medicaid Long Term Care Program; and(4) representatives of HHSC whose programs relate to the Medicare/Medicaid long term care program.(g) HHSC conducts at least one unannounced inspection annually of each institution licensed under Health and Safety Code, Chapter 242, except as provided for in this subsection. For purposes of this subsection, "annually" means a statewide average of once every 12 months.(1) In order to ensure continuous compliance, a sufficient number of inspections will be conducted between the hours of 5:00 p.m. and 8:00 a.m. in randomly selected institutions. This cursory after-hours inspection is conducted to verify staffing, assurance of emergency egress, resident care, medication security, food service or nourishments, sanitation, and other items as deemed appropriate. To the greatest extent feasible, any disruption of the residents is minimal.(2) For at least one unannounced inspection annually, HHSC invites to the inspections at least one person as a citizen advocate from the Ombudsman Program or any other statewide organization for older adults. HHSC provides to these organizations basic licensing information and requirements for the organizations' dissemination to their members whom they engage to attend the inspections. Advocates participating in the inspections must follow all protocols of HHSC. Advocates provide their own transportation. The schedule of inspections in this category are arranged confidentially in advance with the organizations. Participation by the advocates is not a condition precedent to conducting the inspection.(h) The facility must make all of its books, records, and other documents maintained by or on behalf of a facility accessible to HHSC upon request.(1) During an inspection, survey, or investigation, HHSC is authorized to photocopy documents, photograph residents, and use any other available recordation devices to preserve all relevant evidence of conditions that HHSC reasonably believes threaten the health and safety of a resident.(2) Examples of records and documents which may be requested and photocopied or otherwise reproduced are resident medical records, including nursing notes, pharmacy records medication records, and physician's orders.(3) When the facility is requested to furnish the copies, the facility may charge HHSC at the rate not to exceed the rate charged by HHSC for copies. The procedure of copying is the responsibility of the administrator or his designee. If copying requires the records be removed from the facility, a representative of the facility is expected to accompany the records and assure their order and preservation.(4) HHSC protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.(i) HHSC provides for a special team to conduct validation surveys or verify findings of previous licensure surveys.(1) At HHSC's discretion, based on record review, random sample, or any other determination, HHSC may assign a team to conduct a validation survey. HHSC may use the information to verify previous determinations or identify training needs to assure consistency in deficiencies cited and in punitive actions recommended throughout the state.(2) Facilities are required to correct any additional deficiencies cited by the validation team but are not subject to any new or additional punitive action. Source Note: The provisions of this §554.2002 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2002 Procedural Requirements--Licensure Inspections and Surveys https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203234 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203234 03/12/2026 (a) DADS determines if a facility meets the licensing rules, including both physical plant and facility operation requirements.(b) Violations of regulations will be listed on forms designed for the purpose of the inspection or will be listed in letter form when administrative penalties are being proposed.(c) At the conclusion of an inspection, survey, or investigation, the violations will be discussed in an exit conference with the facility's management. A written list of the violations will be left with the facility at the time of the exit conference; any additional violation that may be determined during review of field notes or preparation of the official final list will be communicated to the facility in writing within 10 working days after the exit conference. DADS gives the facility an additional exit conference regarding the additional violations.(d) Not later than the fifth working day after the date a facility receives the final statement of violations under this section, the facility must provide a copy of the statement to a representative of the facility's family council.(e) Within 10 working days after receipt of the final statement of violations, the facility must submit an acceptable plan of correction to the regional director, except plans of correction under §19.2112(i) of this chapter (relating to Administrative Penalties). An acceptable plan of correction must address the following areas:(1) how corrective action will be accomplished for those residents affected by the violations;(2) how the facility will identify other residents with the potential to be affected by the same violations;(3) what measures will be put into place or systemic changes made to ensure the violations will not recur;(4) how the facility will monitor its corrective actions to ensure that the violations are being corrected and will not recur; and(5) when corrective action will be completed.(f) A clear and concise summary in nontechnical language of each licensure inspection or complaint investigation will be provided by DADS at the time the report of contact or similar document is provided. Source Note: The provisions of this §554.2004 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective January 1, 2000, 24 TexReg 11781; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective September 1, 2008, 33 TexReg 6151; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2004 Determinations and Actions Pursuant to Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203235 03/12/2026 (a) Each incident or complaint report must reflect the reporting person's belief that a resident has been or will be abused or neglected and must contain the following information:(1) the address or phone number of the person making the report so that DADS can contact the person for any additional information, except for an anonymous report;(2) the name and address of the resident;(3) the name and address of the person responsible for the care of the resident, if available;(4) information required by DADS guidelines, when the report is an incident; and(5) any other relevant information. Relevant information includes the reporter's or complainant's basis or cause for reporting and his or her belief that a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person or persons, and any other information DADS considers relevant for the report.(b) Should a report not include the information in subsection (a) of this section, the report may be considered a complaint or an incident report not meeting the reporting criteria and may be investigated using other procedures. In receiving an oral report, DADS will take all reasonable steps to elicit from the reporter all the information in subsection (a) of this section.(c) Anonymous complaints of abuse or neglect will be treated in the same manner as acknowledged reports unless the anonymous report accuses a specific individual of abuse or neglect, which report need not be investigated. Source Note: The provisions of this §554.2006 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective October 31, 2013, 38 TexReg 7465; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2006 Reporting Incidents and Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203229 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203229 03/12/2026 (a) In accordance with a memorandum of understanding between DADS and the Texas Department of Family and Protective Services (DFPS) (relating to Memorandum of Understanding Concerning Protective Services for the Elderly), DADS will receive and investigate reports of abuse, neglect, and exploitation of elderly and disabled persons or other residents living in facilities licensed under this chapter. In investigating allegations of abuse and neglect of children residing in facilities, the definitions of "abuse," "neglect," and "person responsible for a child's care, custody, or welfare" are those found in §261.001 of the Texas Family Code.(b) DADS will investigate complaints of abuse, neglect, or exploitation when the act occurs in the facility, when such licensed facility is responsible for the supervision of the resident at the time the act occurs, or when the alleged perpetrator is affiliated with the facility. Complaints of abuse, neglect, or exploitation not meeting this criteria will be referred to DFPS.(c) The primary purpose of an investigation is the protection of the resident. If, before the completion of an investigation, DADS determines that the immediate removal of the resident is necessary to protect the resident from further abuse or neglect, DADS will petition a court to allow the immediate removal of the resident from the facility.(d) Investigations under this section are conducted in accordance with Texas Health and Safety Code, §260A.007.(e) Investigations of reports do not preclude actions under the provisions of Subchapter V of this chapter (relating to Enforcement).(f) If the initial phase of an incident or complaint investigation concludes that no abuse or neglect adversely affecting the physical or mental health or welfare of a resident has occurred, no further investigation will be undertaken.(g) The individual reporting the alleged abuse or neglect or other complaint, the resident, the resident's family, any person designated by the resident to receive information concerning the resident, and the facility will be notified of the results of DADS investigation of a reported case of abuse or neglect or other complaint. Source Note: The provisions of this §554.2008 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 1997, 22 TexReg 3816; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective July 1, 2001, 26 TexReg 3824; amended to be effective September 1, 2003, 28 TexReg 6939; amended to be effective October 31, 2013, 38 TexReg 7465; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2008 Investigations of Incidents and Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203230 03/12/2026 Hearings required by 42 Code of Federal Regulations §488.335 will be conducted in person or by telephone for the purpose of determining whether sufficient grounds exist for a referral of an individual to the appropriate licensure authority and the facility administrator. The hearings referenced in this section are not applicable to information provided by the Texas Department of Human Services pursuant to 42 CFR §488.325(h) (referrals for substandard quality of care). Source Note: The provisions of this §554.2009 adopted to be effective July 31, 1995, 20 TexReg 5258; amended to be effective August 1, 1998, 23 TexReg 7388; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2009 Hearings on Complaints of Resident Neglect and Abuse, and Misappropriation of Resident Property in Medicaid-Certified Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203231 03/12/2026 (a) Confidentiality. All reports, records, and working papers used or developed by the Texas Department of Human Services (DHS) in an investigation are confidential and may be released to the public only as provided below.(1) Completed written investigation reports are open to the public, provided the report is de-identified. The process of de-identification means removing all names and other personally identifiable data, including any information from witnesses and others furnished to DHS as part of the investigation.(2) If DHS receives written authorization from a facility resident or the resident's legal representative regarding an investigation of abuse or neglect involving that resident, DHS will release the completed investigation report without removing the resident's name. The authorization must:(A) be signed and dated within six months of the request or state a length of time the authorization is valid;(B) detail the information to be released;(C) identify to whom the information can be released; and(D) release DHS from all liability for complying with the authorization.(b) Immunity. A person who reports suspected instances of abuse or neglect will, in the absence of bad faith or malicious conduct, be immune from civil or criminal liability which might have otherwise resulted from making the report. Immunity will extend to participation in any judicial proceeding resulting from the report.(c) Privileged communications. In a proceeding regarding a report or investigation conducted under this subchapter, evidence will not be excluded on a claim of privileged communication except in the case of a communication between an attorney and a client.(d) Central registry. DHS will maintain a central registry of reported cases of abuse and neglect at the central office in Austin. Source Note: The provisions of this §554.2010 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 1997, 22 TexReg 3816; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2010 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203232 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203232 03/12/2026 (a) Procedures for inspection of public records will be in accordance with the Texas Government Code, Chapter 552, and as further described in this section.(b) Long-Term Care-Regulatory, Texas Department of Human Services (DHS), is responsible for the maintenance and release of records on licensed facilities, and other related records.(c) The application for inspection of public records is subject to the following criteria:(1) the application must be made to Long-Term Care-Regulatory, Texas Department of Human Services, 701 West 51st Street, Austin, Texas 78751 or P.O. Box 149030, Austin, Texas 78714-9030;(2) the requestor must identify himself;(3) the requestor must give reasonable prior notice of the time for inspection and/or copying of records;(4) the requestor must specify the records requested;(5) on written applications, if DHS unable to ascertain the records being requested, DHS may return the written application to the requestor for clarification; and(6) DHS will provide the requested records as soon as possible; however, if the records are in active use, or in storage, or time is needed for proper de-identification or preparation of the records for inspection, DHS will so advise the requestor and set an hour and date within a reasonable time when the records will be available.(d) Original records may be inspected or copied, but in no instance will original records be removed from DHS offices.(e) Records maintained by Long-Term Care-Regulatory are open to the public, with the following exceptions:(1) incomplete reports, audits, evaluations, and investigations made of, for, or by DHS are confidential;(2) all reports, records, and working papers used or developed by DHS in an investigation of reports of abuse and neglect are confidential, and may be released to the public as provided in §19.2010(a) of this title (relating to General Provisions);(3) all names and related personal, medical, or other identifying information about a resident are confidential;(4) information about any identifiable person that is defamatory or an invasion of privacy is confidential;(5) information identifying complainants or informants is confidential;(6) itineraries of surveys and inspections are confidential;(7) other information that is excepted from release by the Government Code, Chapter 552, is not available to the public; and(8) to implement this subsection, DHS may not alter or de-identify original records. Instead, DHS will make available for public review or release only a properly de-identified copy of the original record.(f) Long-Term Care-Regulatory will charge for copies of records upon request.(1) If the requestor wants to inspect records, the requestor will specify the records to be inspected. DHS will make no charge for this service, unless the director of Long-Term Care-Regulatory determines a charge is appropriate based on the nature of the request.(2) If the requestor wants copies of a record, the requestor will specify in writing the records to be copied on an appropriate DHS form, and DHS will complete the form by specifying the charge for the records, which the requestor must pay in advance. Checks and other instruments of payment must be made payable to the Texas Department of Human Services.(3) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requestor on a cost basis in accordance with costs established by the State Purchasing and Texas Building and Procurement Commission or DHS for office machine copies.(4) For documents that are mailed, DHS will charge for the postage at the time it charges for the production. All applicable sales taxes will be added to the cost of copying records.(5) When a request involves more than one long-term care facility, each facility will be considered a separate request. Source Note: The provisions of this §554.2011 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 1997, 22 TexReg 3816; amended to be effective May 1, 2002, 27 TexReg 3207; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION U INSPECTIONS, SURVEYS, AND VISITS §554.2011 Procedures for Inspection of Public Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203236 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203236 03/12/2026 The Texas Department of Human Services (DHS), as the state licensing agency and the survey and certification agency for the Medicaid program, may impose concurrently licensing remedies and Medicaid remedies on Medicaid-certified facilities. Source Note: The provisions of this §554.2102 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2102 Enforcement Generally https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203237 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203237 03/12/2026 When Texas Department of Human Services (DHS) personnel determine that a facility is out of compliance with licensure rules to a degree that places the facility at risk of the imposition of licensing actions, DHS may send a warning letter to the facility. The warning letter notifies the facility that the violations of licensing rules must be corrected. Source Note: The provisions of this §554.2103 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2103 Warning Letter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203238 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203238 03/12/2026 (a) The Texas Department of Human Services (DHS) may suspend a facility's license when the license holder, or any other person described in §19.201(e) of this title (relating to Criteria for Licensing), has:(1) violated the requirements in either a repeated or substantial manner; or(2) committed any act described in §19.2112(a)(2)-(6) of this title (relating to Administrative Penalties).(b) Suspension of a license may occur simultaneously with any other enforcement provision available to DHS.(c) The facility will be notified by certified mail of DHS's intent to suspend the license, including the facts or conduct alleged to warrant the suspension. The facility has an opportunity to show compliance with all requirements of law for the retention of the license, as provided in §19.215 of this title (relating to Informal Reconsideration). If the facility requests an informal reconsideration, DHS will give the license holder a written affirmation or reversal of the proposed action.(d) The facility will be notified by certified mail of DHS's suspension of the facility's license. The facility has 15 days from receipt of the certified mail notice to request a hearing in accordance with Chapter 79, Subchapter Q of this title (relating to Formal Appeals). The suspension is effective when the deadline for appeal of the suspension passes, unless the facility appeals the suspension. If the facility appeals the suspension, the status of the license holder is preserved until final disposition of the contested matter.(e) The suspension remains in effect until DHS determines that the reason for suspension no longer exists. DHS will conduct an on-site investigation before making a determination. During the suspension, the license holder must return the license to DHS. Source Note: The provisions of this §554.2104 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2104 Suspension of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203239 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203239 03/12/2026 (a) DADS may revoke a facility's license when the license holder, or any other person described in §19.201(f) of this title (relating to Criteria for Licensing), has:(1) violated the requirements of the Health and Safety Code, Chapter 242, or the rules adopted under that chapter, in either a repeated or substantial manner;(2) committed any act described in §19.2112(a)(2) - (6) of this title (relating to Administrative Penalties); or(3) failed to notify DADS of a significant adverse change in financial condition, as required under §19.1925(b) of this title (relating to Financial Condition).(b) Revocation of a license may occur simultaneously with any other enforcement provision available to DADS.(c) The license holder will be notified by certified mail of DADS' intent to revoke the license, including the facts or conduct alleged to warrant the revocation, with a copy being sent to the facility. The license holder has an opportunity to show compliance with all requirements of law for the retention of the license as provided in §19.215 of this title (relating to Opportunity to Show Compliance). If the license holder requests an opportunity to show compliance, DADS gives the license holder a written affirmation or reversal of the proposed action.(d) The license holder will be notified by certified mail of DADS' revocation of the facility's license, with a copy being sent to the facility. The license holder has 15 days from receipt of the certified mail notice to request a hearing in accordance with the Health and Human Services Commission's formal hearing procedures in 1 TAC, Chapter 357, Subchapter I. The revocation will take effect when the deadline for appeal of the revocation passes, unless the license holder appeals the revocation. If the license holder appeals the revocation, the status of the license holder is preserved until final disposition of the contested matter. Upon revocation, the license must be returned to DADS. Source Note: The provisions of this §554.2106 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 1, 1997, 22 TexReg 5672; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective October 15, 1998, 23 TexReg 10496; amended to be effective October 1, 1999, 24 TexReg 8314; amended to be effective July 1, 2001, 26 TexReg 3824; amended to be effective July l, 2002, 27 TexReg 5245; amended to be effective September 1, 2007, 32 TexReg 4231; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2106 Revocation of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203240 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203240 03/12/2026 (a) In this section, "immediate threat to health and safety," is defined as a condition in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.(b) Except as provided by subsection (d) of this section, the executive commissioner revokes a license if DADS finds that:(1) the license holder has committed three violations in §19.601(b) or (c) of this chapter (relating to Resident Behavior and Facility Practice) that constitute an immediate threat to health and safety related to abuse or neglect of a resident within a 24-month period at the same facility; and(2) each of the violations is reported in connection with a separate survey, inspection, or investigation visit that occurred on separate entrance and exit dates.(c) For purposes of calculating the 24-month period described in subsection (b)(1) of this section, the date a violation occurs is the date of the initial exit conference for the survey, inspection, or investigation visit in which the violation was cited.(d) The executive commissioner does not revoke a license under subsection (b) of this section if:(1) the violation and the determination of an immediate threat to health and safety are not included on the written list of violations for a survey, inspection, or investigation left with the facility at the time of the initial exit conference described in §19.2004 of this chapter (relating to Determinations and Actions Pursuant to Inspections);(2) the violation is not included on the final statement of violations described in §19.2004 of this chapter; or(3) the violation has been reviewed under the informal dispute resolution process described in Title 1, Texas Administrative Code, Chapter 393 (relating to Informal Dispute Resolution and Informal Reconsideration), and the Texas Health and Human Services Commission determines that:(A) the violation should be removed from the license holder's record; or(B) the violation should be reduced in severity so that the violation is no longer cited as an immediate threat to health and safety related to abuse or neglect of a resident.(e) DADS notifies a license holder as provided in §19.2106(d) of this division (relating to Revocation of a License) if the executive commissioner revokes the license holder's license in accordance with this section.(f) A license holder may request, in accordance with §19.2113 of this division (relating to Criteria for the Executive Commissioner to Stay a License Revocation), that the executive commissioner stay a revocation imposed in accordance with this section.(g) A license holder may request a hearing to appeal a revocation imposed in accordance with this section if the license holder does not request a stay of the revocation or if the executive commissioner denies the license holder's request for a stay of the revocation. The request for a hearing must be made in accordance with §19.2106(d) of this division.(h) If a license is revoked in accordance with this section, to ensure the health and safety of residents of the facility, DADS may:(1) request the appointment of a trustee to operate the facility in accordance with §19.2116 of this division (relating to Involuntary Appointment of a Trustee);(2) assist with obtaining a new operator for the facility; or(3) assist with the relocation of residents to another facility. Source Note: The provisions of this §554.2107 adopted to be effective March 27, 2017, 42 TexReg 1575; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2107 Revocation of a License by the HHSC Executive Commissioner https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203241 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203241 03/12/2026 (a) The Texas Department of Human Services (DHS) will suspend a facility's license or order an immediate closing of part of the facility if:(1) DHS finds that the facility is operating in violation of the licensure rules; and(2) the violation creates an immediate threat to the health and safety of a resident.(b) The order suspending a license or closing a part of a facility under this section is immediately effective on the date on which the license holder receives written notice or a later date specified in the order. Written notice includes notice by facsimile transmission.(c) The order suspending a license or ordering an immediate closing of a part of the facility is valid for ten days after the effective date of the order.(d) When an emergency suspension has been ordered and the conditions in the facility indicate that residents should be relocated, the following rules apply unless superseded by DHS's Medicaid discharge rules in §19.502 of this title (relating to Transfer and Discharge in Medicaid-Certified Facilities):(1) A resident's rights or freedom of choice in selecting treatment facilities must be respected.(2) If a facility or part of a facility is closed:(A) DHS will notify the local health department director, city or county health authority, and representatives of the appropriate state agencies of the closure;(B) the facility staff must notify each resident's guardian or responsible party and attending physician, advising them of the action in process;(C) the resident or the resident's guardian or responsible person must be given opportunity to designate a preference for a specific facility or for other arrangements;(D) DHS must arrange for relocation to other facilities in the area in accordance with the resident's preference. A facility chosen for relocation must be in good standing with DHS and, if certified under Titles XVIII and XIX of the Social Security Act, must be in good standing under its contract. The facility chosen must be able to meet the needs of the resident;(E) if absolutely necessary, to prevent transport over substantial distances, DHS will grant a waiver to a receiving facility to temporarily exceed its licensed capacity, provided the health and safety of residents is not compromised and the facility can meet the increased demands for direct care personnel and dietary services. A facility may exceed its licensed capacity under these circumstances, monitored by DHS staff, until residents can be transferred to a permanent location;(F) with each resident transferred, the following reports, records, and supplies must be transmitted to the receiving institution:(i) a copy of the current physician's orders for medication, treatment, diet, and special services required;(ii) personal information such as name and address of next of kin, guardian, or party responsible for the resident; attending physician; Medicare and Medicaid identification number; social security number; and other identification information as deemed necessary and available;(iii) all medication dispensed in the name of the resident for which a physician's orders are current. The medications must be inventoried and transferred with the resident. Medications past an expiration date or discontinued by physician order must be inventoried for disposition in accordance with state law;(iv) the residents' personal belongings, clothing, and toilet articles. An inventory of personal property and valuables must be made by the closing facility; and(v) resident trust fund accounts maintained by the closing facility. All items must be properly inventoried and receipts obtained for audit purposes by the appropriate state agency;(G) if the closed facility is allowed to reopen within 90 days, the relocated residents have the first right to return to the facility. Relocated residents may choose to return, may stay in the receiving facility (if the facility is not exceeding its licensed capacity), or choose any other accommodations;(H) any return to the facility must be treated as a new admission in regard to exchange of medical information, medications, and completion of required forms; and(I) a licensee whose facility is closed under this section is entitled to request an administrative hearing in accordance with Chapter 79, Subchapter Q of this title (relating to Formal Appeals), but requesting a hearing does not suspend the effectiveness of the order. Source Note: The provisions of this §554.2108 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective October 15, 1998, 23 TexReg 10496; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2108 Emergency Suspension and Closing Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203242 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203242 03/12/2026 In this section, "threatened violation" means a situation which, unless immediate steps are taken to correct, may cause injury or harm to a resident's health and safety. The Texas Department of Human Services (DHS) may refer a facility to the attorney general who may petition a district court for:(1) a temporary restraining order to restrain a person from a violation or threatened violation of the requirements or any other law affecting residents if DHS reasonably believes that the violation or threatened violation creates an immediate threat to the health and safety of a resident;(2) an injunction to restrain a person from a violation or threatened violation of the requirements or any other law affecting residents if DHS reasonably believes that the violation or threatened violation creates a threat to the health and safety of a resident; or(3) the assessment of civil penalties under the Texas Health and Safety Code, §242.065, for a violation that threatens the health and safety of a resident. DHS recognizes the limited immunity from civil liability granted to volunteers serving as officers, directors, or trustees of charitable organizations, under the Charitable Immunity and Liability Act of 1987 (Texas Civil Practice and Remedies Code, Chapter 84). Source Note: The provisions of this §554.2110 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective March 1, 1998, 23 TexReg 1314; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2110 Referral to the Attorney General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203249 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203249 03/12/2026 (a) If the commissioner finds that a nursing facility has committed an act for which a civil penalty may be imposed under §242.065, Health and Safety Code, the commissioner may order the nursing facility to immediately suspend admissions. For the purpose of this remedy, the Texas Department of Human Services defines an admission as the entry into a facility of a new resident or of a resident who has been absent from the facility for 24 or more hours.(1) A waiver to allow a resident to be admitted may be considered by the commissioner or his designee.(2) In determining whether to grant a waiver under paragraph (1) of this subsection, factors that the commissioner or his or her designee may consider include, but are not limited to:(A) the reason(s) for which admissions at the facility are suspended;(B) the facility's ability to correct the reasons for which admissions at the facility are suspended;(C) the relation between the reasons for which admissions at the facility are suspended and the health care needs of the resident who seeks to return to the facility;(D) whether the resident who wants to return to the facility has a spouse or relative in the facility; or(E) the effect that barring the resident's return to the facility or other alternative placement will have on the ability of the resident to maintain contact with the resident's attending physician, family, responsible party, and agent (if any) under a medical power of attorney.(3) A facility, with regard to which admissions are suspended, must inform a resident or his responsible party upon leaving that facility, that if he leaves for more than 24 hours, he may not be able to return.(b) A suspension of admissions is effective on the date a nursing facility receives notice of the order and of the manner in which the order may be appealed. The Texas Department of Human Services provides an opportunity for a hearing on the appeal of the order within 14 days of the date the suspension becomes effective.(c) During the time admissions are suspended, a nursing facility must post a notice of the suspension on all entrance and exit doors. The notice must contain the dates of the suspension.(d) A person commits a Class C misdemeanor if the person does not post the required notice or removes a notice while the suspension of admissions is in effect. Source Note: The provisions of this §554.2111 adopted to be effective March 1, 1998, 23 TexReg 1314; amended to be effective March 1, 2001, 26 TexReg 984; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2111 Suspension of Admissions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203243 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203243 03/12/2026 (a) HHSC may assess an administrative penalty against a person who:(1) violates Chapter 242, Health and Safety Code or a rule, standard or order adopted or license issued under Chapter 242;(2) makes a false statement, that the person knows or should know is false, of a material fact:(A) on an application for issuance or renewal of a license or in an attachment to the application; or(B) with respect to a matter under investigation by HHSC;(3) refuses to allow a representative of HHSC to inspect:(A) a book, record, or file required to be maintained by a facility; or(B) any portion of the premises of a facility;(4) willfully interferes with the work of, or retaliates against, a representative of HHSC or the enforcement of this chapter;(5) willfully interferes or retaliates against a representative of HHSC preserving evidence of a violation of a rule, standard, or order adopted or license issued under Chapter 242, Health and Safety Code;(6) fails to pay a penalty assessed by HHSC under Chapter 242, Health and Safety Code by the 10th day after the date the assessment of the penalty becomes final; (7) fails to notify HHSC of a change of ownership before the effective date of the change of ownership; (8) willfully interferes with the State Ombudsman, a certified ombudsman, or an ombudsman intern performing the functions of the Ombudsman Program as described in 26 TAC §88.2 (relating to Definitions); or(9) retaliates against the State Ombudsman, a certified ombudsman, or an ombudsman intern:(A) with respect to a resident, employee of a facility, or other person filing a complaint with, providing information to, or otherwise cooperating with the State Ombudsman, a certified ombudsman, or an ombudsman intern; or(B) for performing the functions of the Ombudsman Program as described in 26 TAC Chapter 88 (relating to State Long-Term Care Ombudsman Program).(b) The persons against whom HHSC may impose an administrative penalty include:(1) an applicant for a license;(2) a license holder;(3) a partner, officer, director, or managing employee of an applicant or a license holder; and(4) a person who controls a nursing facility.(c) HHSC recognizes the limited immunity from civil liability granted to volunteers serving as officers, directors or trustees of charitable organizations, under the Charitable Immunity and Liability Act of 1987 (Texas Civil Practice and Remedies Code, Chapter 84).(d) In determining whether a violation warrants an administrative penalty, HHSC considers the facility's history of compliance and whether:(1) a pattern or trend of violations exists; or(2) the violation is recurrent in nature and type; or(3) the violation presents danger to the health and safety of at least one resident; or(4) the violation is of a magnitude or nature that constitutes a health and safety hazard having a direct or imminent adverse effect on resident health, safety, or security, or which presents even more serious danger or harm; or(5) the violation is of a type established elsewhere in HHSC rules concerning licensing standards for long term care facilities. (e) In determining the amount of the penalty, HHSC considers at a minimum:(1) the gradations of penalties;(2) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation and the hazard or potential hazard to the health and safety of the residents;(3) the history of previous violations;(4) deterrence of future violations; and(5) efforts to correct the violation.(f) Administrative penalties may be levied for each violation found in a single survey. Each day of a continuing violation constitutes a separate violation. The administrative penalties for each day of a continuing violation cease on the date the violation is corrected. A violation that is the subject of a penalty is presumed to continue on each successive day until it is corrected. The date of correction alleged by the facility in its written plan of correction will be presumed to be the actual date of correction unless it is later determined by HHSC that the correction was not made by that date or was not satisfactory.(1) Table of administrative penalties. The following table contains the gradations of penalties in accordance with the relative seriousness of the violation. While the table addresses most administrative penalty situations, administrative penalties for unique circumstances to which the table does not apply are established elsewhere in the requirements. The amount of the administrative penalty listed in subsection (a)(7) of this section is $500.Attached Graphic(2) Definitions. The following terms when used in this section have the following meanings, unless the context clearly indicates otherwise.(A) Severity.(i) No actual harm with a potential for minimal harm is a deficiency that has the potential for causing no more than a minor negative impact on the resident(s).(ii) No actual harm with a potential for more than minimal harm is noncompliance that results in minimal physical, mental and/or psychological discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his/her highest practicable physical, mental, and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services.(iii) Actual harm that is not immediate jeopardy is non-compliance that results in a negative outcome that has compromised the resident's ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services. This does not include a deficient practice that only has limited consequence for the resident and would be included in (i) or (ii) above.(iv) Immediate jeopardy to resident health and safety is a situation in which immediate corrective action is necessary because the facility's non-compliance with one or more requirements has caused, or likely to cause, serious injury, harm, impairment or death to a resident receiving care in the facility.(B) Scope.(i) Isolated means one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, or the situation has occurred only occasionally or in a very limited number of locations.(ii) Pattern means more than a very limited number of residents are affected and/or more than a very limited number of staff are involved, or the situation has occurred in several locations, and/or the same residents have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.(iii) Widespread means the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all of the facility's residents.(g) The penalties for a violation of the requirement to post notice of the suspension of admissions, additional reporting requirements found at §19.601(a) of this chapter (relating to Resident Behavior and Facility Practice), or residents' rights cannot exceed $1,000 a day for each violation, unless the violation of a resident's right also violates a rule in Subchapter H of this chapter (relating to Quality of Life), or Subchapter J of this chapter (relating to Quality of Care).(h) No facility will be penalized because of a physician's or consultant's nonperformance beyond the facility's control or if documentation clearly indicates the violation is beyond the facility's control.(i) HHSC may issue a preliminary report regarding an administrative penalty. Within 10 days of the issuance of the preliminary report, HHSC will give the facility written notice of the recommendation for an administrative penalty. The notice will include:(1) a brief summary of the violations;(2) a statement of the amount of penalty recommended;(3) a statement of whether the violation is subject to correction under §19.2114 of this subchapter (relating to Right to Correct) and if the violation is subject to correction, a statement of:(A) the date on which the facility must file a plan of correction (POC) to be approved by HHSC; and(B) the date on which the POC must be completed to avoid assessment of the penalty; and(4) a statement that the facility has a right to a hearing on the violation, the amount of the penalty, or both.(j) Within 20 days after the date on which written notice of recommended assessment of a penalty is sent to a facility, the facility must give HHSC written consent to the penalty, make a written request for a hearing, or if the violation is subject to correction, submit a plan of correction in accordance with §19.2114 of this subchapter (relating to Right to Correct). If the facility does not make a response within the 20-day period, HHSC will assess the penalty.(k) The procedures for notification of recommended assessment, opportunity for hearing, actual assessment, payment of penalty, judicial review, and remittance will be in accordance with Health and Safety Code, §§242.067 - 242.069. Hearings will be held in accordance with Health and Human Services Commission's rules at 1 TAC, Chapter 357, Subchapter I. Interest on penalties is governed by Health and Safety Code §242.069(g). Source Note: The provisions of this §554.2112 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective September 1, 1996, 21 TexReg 7859; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective January 1, 2000, 24 TexReg 11781; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective April 1, 2001, 26 TexReg 1547; amended to be effective May 4, 2008, 33 TexReg 3446; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2112 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203244 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203244 03/12/2026 (a) A license holder may request that the executive commissioner stay a license revocation imposed in accordance with §19.2107 of this chapter (relating to Revocation of a License by the Executive Commissioner). The request must:(1) be in writing;(2) be submitted to the department within 10 working days after the license holder receives written notification of the revocation;(3) explain how the license holder meets the applicable criteria described in subsection (b) of this section;(4) describe any potential negative impact to residents that may occur if the request for stay is denied;(5) include any documentation supporting the request; and(6) be signed by an authorized representative of the license holder.(b) The executive commissioner grants or denies a request to stay a license revocation imposed in accordance with §19.2107 of this chapter if the license holder requests a stay in accordance with subsection (a) of this section. The executive commissioner may grant the request if, based on a review of the request and any other relevant documentation, the executive commissioner determines that:(1) the stay would not jeopardize the health and safety of the residents or place the residents at risk of abuse or neglect based on the following criteria;(A) no more than one of the violations that resulted in the proposed revocation was widespread in scope;(B) the facility's regulatory record, other than the three violations that resulted in the proposed revocation, encompassing five years preceding the date of the stay request, does not reflect a history of substandard quality of care violations;(C) if the license holder requesting the stay holds licenses for other facilities, the license holder's overall performance does not reflect a history of substandard quality of care violations related to abuse or neglect; and(D) there are no other factors that will jeopardize the health and safety of the residents or place the residents at risk of abuse or neglect;(2) the request submitted by the license holder demonstrates that:(A) the license holder has explained why:(i) the violations that resulted in the proposed revocation are not indicative of the overall quality of care provided at the facility; and(ii) granting the stay will not jeopardize the health and safety of the residents or place the residents at risk of abuse or neglect and is likely to result in future compliance with licensure requirements;(B) the license holder has conducted a system-wide analysis of the facility that identifies all underlying problems that led to or contributed to the violations that resulted in the proposed revocation and has developed a plan to address those problems; and(C) the license holder has initiated action to implement the plan;(3) the license holder meets one of the following criteria:(A) a rapid response team determines that the facility has cooperated with the team and has demonstrated improvement in quality of care as described in §19.911 of this chapter (relating to Rapid Response Team); or(B) for a "veteran's home," as defined in Texas Natural Resources Code §164.002, the Texas Veterans Land Board contracts with a different entity to operate the home than the entity that operated the home during the period in which the violations described by §19.2107 of this chapter occurred; and(4) the license holder has entered into a stay agreement acceptable to the executive commissioner that, at a minimum, includes:(A) a requirement that the license holder complete actions to address the underlying causes that resulted in the violations that led to the proposed revocation in accordance with a schedule;(B) a requirement that the license holder not receive a violation that constitutes an immediate threat to health and safety or that results in actual harm to a resident for a period of time after the effective date of the stay agreement as determined by the executive commissioner, but no less than 12 months; and(C) a waiver of the license holder's right to request a hearing if the stay is lifted and the revocation is imposed in accordance with subsection (d)(2) of this section.(c) For purposes of subsection (b)(4)(B) of this section, a facility has received a violation that constitutes an immediate threat to health and safety or that results in actual harm to a resident if the violation is cited and upheld in informal dispute resolution, if requested.(d) If the executive commissioner grants a license holder's request for a stay in accordance with this section:(1) the stay is lifted and the revocation is rescinded if the executive commissioner determines the license holder has successfully completed all requirements of the stay agreement described in subsection (b)(4) of this section in accordance with the schedule described in subsection (b)(4)(A) of this section; or(2) the stay is lifted and the revocation is imposed if the executive commissioner determines the license holder has not successfully completed all requirements of the stay agreement described in subsection (b)(4) of this section in accordance with the schedule described in subsection (b)(4)(A) of this section. Source Note: The provisions of this §554.2113 adopted to be effective March 27, 2017, 42 TexReg 1574; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2113 Criteria for the Executive Commissioner to Stay a License Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203245 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203245 03/12/2026 (a) HHSC may not collect an administrative penalty if, not later than the 45th day after the date the facility receives notice, the facility corrects the violation.(b) If the facility reports to HHSC that the violation has been corrected, HHSC inspects the facility for the correction or takes any other steps necessary to confirm that the violation has been corrected and notifies the facility that:(1) the correction is satisfactory and a penalty is not assessed; or(2) the correction is not satisfactory and a penalty is recommended.(c) The facility must request a hearing on the violation no later than the 20th day after the date on which the notice is sent.(d) Subsection (a) of this section does not apply to:(1) a violation that HHSC determines:(A) represents a pattern of violation that results in actual harm;(B) is widespread in scope and results in actual harm;(C) is widespread in scope, constitutes a potential for actual harm, and relates to:(i) treatment of residents as described in §19.602 of this chapter (relating to Incidents of Abuse and Neglect Reportable to the Texas Department of Aging and Disability Services (DADS) and Law Enforcement Agencies by Facilities);(ii) resident behavior and institution practices as described in §19.601 of this chapter (relating to Resident Behavior and Facility Practice);(iii) quality of care as described in §19.901 of this chapter (relating to Quality of Care);(iv) medication errors as described in §19.901(13) of this chapter;(v) standard menus and nutritional adequacy as described in §19.1107 of this chapter (relating to Menus and Nutritional Adequacy);(vi) physician visits as described in §19.1201 (relating to Physician Services), §19.1202 (relating to Physician Visits), §19.1203 (relating to Frequency of Physician Visits), §19.1204 (relating to Availability of Physician for Emergency Care), §19.1205 (relating to Physician Delegation of Tasks), §19.1206 (relating to Physician Signatures) and §19.1207 (relating to Prescription of Psychoactive Medication) of this chapter;(vii) infection control as described in §19.1601 of this chapter (relating to Infection Control);(viii) life safety from fire as described in §19.101(69) and (70) (relating to Definitions); or(ix) emergency preparedness and response as described in §19.1914 of this chapter (relating to Emergency Preparedness and Response);(D) constitutes an immediate threat to the health or safety of a resident; or(E) substantially limits the facility's capacity to provide care;(2) the violations listed in §19.214(a)(2)-(6) of this chapter (relating to Criteria for Denying a License or Renewal of a License);(3) the violation of a resident right;(4) a violation listed in §19.2112(a)(8) or (9) of this chapter (relating to Administrative Penalties); or(5) to a second or subsequent violation of §19.1920(e) of this chapter (relating to Operating Policies and Procedures) or §19.1929(2) of this chapter (relating to Staff Development).(e) A facility that corrects a violation under subsection (a) of this section must maintain the correction. If the facility fails to maintain the correction until the first anniversary of the date the correction was made, HHSC may assess an administrative penalty equal to three times the amount of the original penalty assessed, but not collected. HHSC does not provide a facility an opportunity to correct the subsequent violation. Source Note: The provisions of this §554.2114 adopted to be effective March 1, 1998, 23 TexReg 1314; amended to be effective April 5, 2018, 43 TexReg 2017; amended to be effective October 28, 2018, 43 TexReg 7189; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2114 Right To Correct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203246 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203246 03/12/2026 (a) In lieu of demanding payment of an administrative penalty, the commissioner may allow the person to use, under supervision of the Texas Department of Human Services (DHS), a portion of the penalty to ameliorate the violation or to improve services, other than administrative services, in the nursing facility.(b) DHS will offer amelioration to a person for a violation if DHS determines that the violation does not constitute immediate jeopardy to the health and safety of an institution resident. In this section, "immediate jeopardy to health and safety" means a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.(c) DHS will not offer amelioration to a person if:(1) the person has been charged with a violation that is subject to the right-to-correct, or(2) DHS determines that the violation constitutes immediate jeopardy to the health and safety of a resident.(d) DHS will offer amelioration to a person not later than the 10th day after the date the person receives from DHS a final notification of assessment of administrative penalty that is sent to the person after an informal dispute resolution process but before an administrative hearing.(e) A person to whom amelioration has been offered must file a plan for amelioration not later than the 45th day after the date the person receives the offer of amelioration from DHS. In submitting the plan, the person must agree to waive the person's right to an administrative hearing if DHS approves the plan.(f) At a minimum, a plan for amelioration must:(1) propose changes to the management or operation of the facility that will improve services to or quality of care of residents,(2) identify, through measurable outcomes, the ways in which and the extent to which the proposed changes will improve services to or quality of care of residents,(3) establish clear goals to be achieved through the proposed changes,(4) establish a timeline for implementing the proposed changes, and(5) identify specific actions necessary to implement the proposed changes.(g) DHS may require that an amelioration plan propose changes that would result in conditions that exceed the minimum requirements for nursing facility licensure.(h) DHS will approve or deny an amelioration plan not later than the 45th day after the date DHS receives the plan. On approval of a person's plan, DHS will deny a pending request for a hearing submitted by the person.(i) DHS will not offer amelioration to a person:(1) more than three times in a two-year period; or(2) more than one time in a two-year period for the same or similar violation. Source Note: The provisions of this §554.2115 adopted to be effective March 1, 1998, 23 TexReg 1314; amended to be effective June 1, 2002, 27 TexReg 4367; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2115 Amelioration of Violation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203247 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203247 03/12/2026 (a) The Texas Department of Human Services (DHS) may petition a court of competent jurisdiction for the involuntary appointment of a trustee to operate a facility if one or more of the following conditions exist:(1) the facility is operating without a license;(2) the facility's license has been suspended or revoked;(3) license suspension or revocation procedures against a facility are pending and an imminent threat to the health and safety of the residents exists;(4) an emergency exists that presents an immediate threat to the health and safety of the residents; and/or(5) the facility is closing (whether voluntarily or through an emergency closure order) and arrangements for relocation of the residents to other licensed institutions have not been made before closure.(b) A trustee appointed under this section is entitled to a reasonable fee as determined by the court, to be paid from the Nursing and Convalescent Home Trust Fund, unless the trustee is placed in a veterans home. When a trustee is placed in a veterans home (as defined in Natural Resources Code, §164.002), the Veterans Land Board pays the trustee's fee.(c) The trustee may use the emergency assistance funds in the trust fund only to alleviate an immediate threat to the health and safety of the residents, through such disbursements as payments for food; medication; sanitation services; minor repairs; supplies necessary for personal hygiene; or services necessary for the personal care, health, and safety of the residents.(d) Before emergency assistance funds may be dispersed, a court order must be entered authorizing DHS to disburse emergency assistance funds to the facility.(e) A facility that receives emergency assistance funds under this section must reimburse DHS for the amounts received not later that one year after the date on which the funds were received by the trustee. The owner of the facility at the time the trustee was appointed is responsible for the reimbursement and must pay interest from the date the funds were disbursed on the amount outstanding at a rate equal to the rate of interest determined under Texas Civil Statutes, Article 5069-1.05, to be applicable to judgments rendered during the month in which the money was disbursed to the facility. DHS will deposit the reimbursement and the interest received under this subsection to the credit of the Nursing and Convalescent Home Trust Fund. If the funds are not repaid within the year, DHS may determine that the facility is not eligible for a Medicaid contract.(f) Any amount remaining due at the end of one year becomes delinquent and will be referred to the attorney general. Source Note: The provisions of this §554.2116 adopted to be effective May 1, ­1995, 20 TexReg 2054; amended to be effective September 1, 2003, 28 TexReg 6939; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2116 Involuntary Appointment of a Trustee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203248 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203248 03/12/2026 (a) A person holding a controlling interest in a facility may, at any time, request the Texas Department of Human Services (DHS) to assume the operation of the facility through the appointment of a trustee.(b) If DHS believes that the appointment of a trustee is desirable, DHS may enter into an agreement with the person holding the controlling interest for appointment of the trustee to take charge of the facility.(c) Any agreement entered into under this section must:(1) specify all terms and conditions of the trustee's appointment and authority; and(2) preserve all rights of the residents as granted by law.(d) The agreement will terminate either at a time specified in the agreement or upon receipt of notice of intent to terminate sent by either party.(e) If DHS determines that termination of the agreement by the person holding a controlling interest in the facility would not be in the best interest of the residents, DHS will petition a court for an involuntary appointment under the terms of §19.2116 of this title (relating to Involuntary Appointment of a Trustee).(f) The appointment of a trustee by agreement does not suspend the obligation of a facility to pay assessed monetary, civil, or administrative penalties. Source Note: The provisions of this §554.2118 adopted to be effective May 1, 1995, 20 TexReg 2054; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2118 Appointment of a Trustee by Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203250 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203250 03/12/2026 (a) HHSC holds an open hearing in a facility if HHSC:(1) has taken a punitive action against the facility in the preceding 12 months; or(2) receives a complaint that HHSC has reasonable cause to believe is valid from the State Ombudsman, a certified ombudsman, an ombudsman intern, an advocate, a resident, or a relative of a resident relating to a serious or potentially serious problem in the facility.(b) Only one hearing regarding a specific facility is held each year unless HHSC determines that, in the interest of resident health and safety, more should be held.(c) HHSC mails notice of the time, date, and place of the hearing at least ten days before the hearing to:(1) the facility;(2) the designated closest living relative or legal guardian of each resident; and(3) appropriate state and federal agencies that work with the facility.(d) The facility is responsible for furnishing to HHSC a listing of the name and current mailing address of each resident's designated closest living relative, legal guardian, or responsible party.(e) HHSC may exclude a facility's administrator and personnel from the hearing.(f) HHSC confidentially notifies the complainant of the results of the investigation which followed the complaint.(g) HHSC notifies the facility of any complaints received at the hearing and provides a summary of those complaints to the facility. HHSC does not identify the source of the complaints. Source Note: The provisions of this §554.2119 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2119 Open Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203265 03/12/2026 The following term, when used in this undesignated head, Remedies in Medicaid-Certified Facilities, shall have the following meaning, unless the context clearly indicates otherwise. Accountability period--A 24-month period which begins each time the Texas Department of Human Services (DHS) imposes on a facility a required Category II or III remedy. Accountability periods may overlap. Source Note: The provisions of this §554.2120 adopted to be effective May 1, 1995, 20 TexReg 2054; amended to be effective July 31, 1995, 20 TexReg 5259; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2120 Definitions Pertaining to Medicaid Remedies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203266 03/12/2026 Enforcement actions in Medicaid-certified facilities are performed according to regulations found in 42 Code of Federal Regulations §§431.151, 431.153, 488.301, 488.325(g), 488.330, 488.331, 488.335, and 488.400-488.456. Source Note: The provisions of this §554.2121 adopted to be effective July 31, 1995, 20 TexReg 5259; amended to be effective February 1, 1997, 21 TexReg 11822; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2121 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203263 03/12/2026 Interest on civil money penalties accrues at the rate of 10% from the date specified in Code of Federal Regulations §488.442 until paid. Source Note: The provisions of this §554.2129 adopted to be effective January 1, 1997, 21 TexReg 11822; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2129 Interest on Civil Money Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203264 03/12/2026 (a) The Texas Department of Human Services (DHS) may continue payments for no more than 30 days from the date DHS cancels a facility's provider agreement if DHS determines that:(1) reasonable efforts are being made to transfer the residents to another facility, to community care, or to other alternate care; and(2) additional time is needed to effect an orderly transfer of the residents.(b) When a facility's provider agreement is terminated by DHS, the department will not enter into another provider agreement with the facility until 30 days have expired. If the facility reapplies for a provider agreement, DHS conducts an on-site visit to determine if the facility is complying with Medicaid requirements. If the facility is complying with Medicaid requirements and a provider agreement with the facility is not prohibited by DHS debarment rules, DHS enters into a provider agreement with the facility. This remedy will be applied in any category which results in the termination of the provider agreement. Source Note: The provisions of this §554.2144 adopted to be effective July 31, 1995, 20 TexReg 5259; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2144 Procedures Following Termination of the Provider Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203267 03/12/2026 (a) If DADS determines that DADS or CMS has imposed a required Category II or III remedy (as defined in 42 Code of Federal Regulations (CFR)) on a facility three times within an accountability period, a recommendation is made to terminate the facility's provider agreement, unless DADS waives termination after considering the factors described in subsection (e) of this section.(b) DADS notifies a facility in writing of its intention to terminate the facility's provider agreement. Notification occurs within:(1) three calendar days after receipt of the recommendation of remedies for a facility found in immediate jeopardy; or(2) 15 calendar days after receipt of the recommendation of remedies for a facility not found in immediate jeopardy.(c) The provider agreement is terminated on the 20th calendar day after the facility receives notice of DADS' decision to terminate the provider agreement.(d) An appeal for this remedy is the appeal on the issue of noncompliance that led to the imposition of a Category II or III remedy for the third time within the accountability period. The appeal for this remedy follows the federal procedures in 42 CFR Part 498 for a dually-participating facility or in 42 CFR Part 431 for a facility that is Medicaid-certified only.(e) DADS may waive termination of a facility's provider agreement when a facility has received a Category II or III remedy three times within an accountability period of 24 consecutive months. DADS may consider one or more of the following to waive termination of a facility's provider agreement:(1) the history of violations committed by the facility resulting in three Category II or III remedies within an accountability period and the resulting enforcement action compared with the history of violations committed by other facilities that received Category II or III remedies three times within an accountability period and the resulting enforcement action;(2) the history of ownership of the facility when the Category II or III remedies were imposed; or(3) the efforts the facility has made to correct the violations that resulted in the imposition of the Category II or III remedies. Source Note: The provisions of this §554.2146 adopted to be effective July 31, 1995, 20 TexReg 5259; amended to be effective February 1, 1997, 21 TexReg 11822; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective April 21, 2009, 34 TexReg 2541; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2146 Termination of Provider Agreement on the Basis of the Imposition of Enforcement Actions Three Times Within an Accountability Period https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203268 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203268 03/12/2026 The Texas Department of Human Services (DHS) provides an informal dispute resolution process (IDR) in the central office, as follows:(1) A written request, all supporting documentation, and registration information as required under paragraph (3) of this section, must be submitted to the Texas Department of Human Services, Long Term Care-Regulatory, ATTN: IDR Coordinator, P.O. Box 149030 (MC-E-343), Austin, TX 78714-9030, no later than the 10th calendar day after receipt of the official statement of deficiencies.(2) DHS will complete the IDR process no later than the 30th calendar day after receipt of the facility's written request, all documentation, and required registration information.(3) Any individual representing a facility in an IDR must register with DHS and disclose the following:(A) the individual's employment history during the preceding five years, including employment in regulatory agencies of this state and other states;(B) ownership, including the identity of the controlling person or persons, of the facility the person is representing before DHS; and(C) the identity of other entities the person represents or has represented before the agency during the previous 24 months. Source Note: The provisions of this §554.2147 adopted to be effective March 1, 1998, 23 TexReg 1314; amended to be effective January 1, 2000, 24 TexReg 11781; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2147 Informal Dispute Resolution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203269 03/12/2026 A facility may elect arbitration as provided in 1 TAC Chapter 163 (concerning Arbitration Procedures for Certain Enforcement Actions of the Department of Human Resources). Source Note: The provisions of this §554.2148 adopted to be effective March 1, 1998, 23 TexReg 1314; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2148 Arbitration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203270 03/12/2026 This undesignated head governs the cancellation of current Texas Department of Human Services (DHS) Medicaid contracts with nursing facilities; debarment of former or potential contractors is governed by §§69.275-69.279 of this title (relating to Debarment and Suspension of Current and Potential Contractor's Rights, Causes for and Conditions of Debarment, Causes for and Conditions of Suspension, Proof Required for Debarment and Suspension, and Notice Requirements for Debarment and for Suspension). Source Note: The provisions of this §554.2149 adopted to be effective July 31, 1995, 20 TexReg 5259; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2149 Exclusions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203261 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203261 03/12/2026 None of the options described in this undesignated head are intended to restrict the Texas Department of Human Services (DHS) from imposing, as necessary, appropriate remedies for program violations listed in §79.2105 of this title (relating to Grounds for Fraud Referral and Administrative Sanction). Source Note: The provisions of this §554.2150 adopted to be effective July 31, 1995, 20 TexReg 5259; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2150 Fraud Referral https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203262 03/12/2026 The remedies provided under this undesignated head are in addition to those otherwise available under state and federal law and are not to be construed as limiting any other remedies, including any remedy available to an individual at common law. Source Note: The provisions of this §554.2151 adopted to be effective July 31, 1995, 20 TexReg 5259; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION V ENFORCEMENT §554.2151 Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203271 03/12/2026 (a) A facility may apply for certification as a facility that provides specialized care for Alzheimer's disease and related disorders either at the time of the initial application for a license or at any time subsequent to the issuance of a license under this chapter.(b) Application must be made on forms prescribed by the Texas Department of Human Services (DHS). The application fee must accompany the application as provided in §19.216(c) of this title (relating to License Fees).(c) A facility licensed under this chapter is not required to apply for certification under this section in order to provide care and treatment of persons with Alzheimer's disease and related disorders.(d) A facility may not advertise or otherwise communicate that the facility is certified by DHS to provide specialized care for persons with Alzheimer's disease or related disorders unless the facility is certified under this subchapter. Source Note: The provisions of this §554.2204 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION W CERTIFICATION OF FACILITIES FOR CARE OF PERSONS WITH ALZHEIMER'S DISEASE AND RELATED DISORDERS §554.2204 Voluntary Certification of Facilities for Care of Persons with Alzheimer's Disease https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203272 03/12/2026 (a) Resident admission. The facility must admit and retain only residents whose needs can be met through service from the facility staff, or in cooperation with community resources or other providers under contract.(b) Allowable number of residents. Each certificate must specify the maximum allowable number of residents to be cared for at any one time in the certified area. No greater number of residents must be kept in the certified area than is authorized by the certificate.(c) Nullification of certificate. When a certificate becomes null and void, the facility must remove the certificate from display and advertising, and the certificate must be surrendered to DADS on request. A certificate is nontransferable and nonassignable; therefore, a certificate existing at the time of change of ownership becomes null and void.(d) Display of certificate. A certificate must be displayed in a prominent location for public view. The facility may advertise as long as the certificate is in effect; however, the type of advertising must be such that the advertising can be withdrawn if the certificate becomes null and void. Upon removal of the certificate it is the responsibility of the facility to inform interested persons of the revised status. The certificate is the property of DADS.(e) Cancellation of certificate. A certificate must be canceled if DADS finds that the certified unit is not in compliance with applicable laws and rules.(f) Effective period of certificate. An initial certificate that is based on an application submitted to DADS on or after January 1, 2014, or a renewal certificate that has an effective date on or after January 1, 2014, is valid for three years. Source Note: The provisions of this §554.2206 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective January 1, 2014, 38 TexReg 9629; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION W CERTIFICATION OF FACILITIES FOR CARE OF PERSONS WITH ALZHEIMER'S DISEASE AND RELATED DISORDERS §554.2206 General Requirements for a Certified Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203273 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203273 03/12/2026 (a) General requirements.(1) Residents eligible for admission to Alzheimer's units will have a diagnosis of Alzheimer's disease or related disorders. The need for admission to the Alzheimer's unit must be documented by the attending physician.(2) Security and safety measures are provided to prevent the residents from harming themselves or leaving designated indoor or outdoor areas without supervision by staff members or other responsible escort. Policies will also be provided to prevent abuse of the rights and property of other residents.(3) Understanding that security measures to prevent wandering may infringe on resident rights, care must be exercised in the use of physical or chemical restraint. The specific purpose and time-limited orders for any physical or chemical restraint must be written and renewed according to facility policy. The frequency of such renewal must not exceed 60 days.(4) Activity and recreational programs will be provided and utilized to the maximum extent possible for all residents in order to promote physical well being and help with behavior management. The program must be tailored to the individual resident's needs, being appropriate for his specific impairment and stage of disease.(5) Residents are provided privacy in treatment and in care for his or her personal needs.(6) Access to outdoor areas must be provided and such areas must have suitable walls or fencing that do not allow climbing or present a hazard. (A) The minimum distance of the fence from the building must be:(i) 8'-0" from the building if there are no window openings; or(ii) 20'-0" from a bedroom window if the fencing is solid and 15'-0" from a bedroom window if the fencing is open similar to chain-link.(B) The minimum area of enclosure must be 800 square feet. Exception: If the enclosed space has an area of refuge which extends beyond a minimum of 20'-0" from the building and the area of refuge is equal to or greater than 15 square feet per resident for the wings enclosed.(C) An exit gate from the enclosure to a public way must comply with the following criteria.(i) A minimum of two gates must be remotely located from each other if only one wing or exit is enclosed. If the enclosed space between the building and the fence is less than 10'-0", one of the remotely located exit gates must be directly in line with the building exit door.(ii) If doors into two or more smoke compartments are enclosed by the fencing and entry access can be made at each door, a minimum of one gate is required.(iii) The gates must be located to provide a continuous path of travel from the building exit to a public way including walkways of concrete, asphalt, or other approved materials suitable for wheeled beds, chairs, and stretchers. Gates and walkways must be wide enough to accommodate beds and wheelchairs.(D) If gates are locked, the gate nearest the exit from the building must be locked with an electronic lock which operates the same as electronic locks on corridor control doors or exit doors and is in compliance with the NFPA 70 for exterior exposure. Additional gates may also have electronic locks or may have keyed locks provided staff carry the keys. A gate between two enclosed wings may have a keyed lock provided access can be gained into both wings from the exterior.(E) Fencing material must comply with the following:(i) Wood--no limit on height, should be constructed with posts and support members on the exterior to deter residents from climbing over fence.(ii) Wire--if chain-link type fence, provide protection on top of the fence to prevent resident injury from pointed wire.(7) Any security measures taken to provide for the safety of wandering patients should be as unobtrusive as possible.(8) Toxic garden plantings must be prohibited.(b) Staff.(1) All assigned staff members and consultants to the unit must have documented training in the care and handling of Alzheimer's residents, including at least:(A) eight hours of orientation to cover the following:(i) facility Alzheimer's policies;(ii) etiology and treatment of dementias;(iii) stages of Alzheimer's disease;(iv) behavior management; and(v) communication; and(B) four hours of the required annual continuing education must be in Alzheimer's disease or related disorders.(2) A social worker, licensed or temporarily licensed by the State of Texas, must be utilized as Community/Family Support Coordinator whose functions must include:(A) evaluation of resident's initial social history on admission;(B) utilization of community resources;(C) conducting quarterly family support group meetings; and(D) identification and utilization of existing Alzheimer's network.(3) Specially trained staff will be maintained and assigned exclusively to the Alzheimer's unit. Although emergency scheduling may require substitution of staff, every effort should be made to provide residents with familiar staff members in order to minimize resident confusion. Staff training will meet at least the minimum requirements in subsection (a)(2) of this section.(4) Required overall minimum staffing ratios for direct care in certified Alzheimer's units in nursing facilities are as follows. Attached Graphic(c) Physical plant. Alzheimer's units must be segregated from other parts of a facility with appropriate security devices and measures and must meet the following requirements.(1) Living rooms, day rooms, lounges, and sun rooms, must be provided on a sliding scale as follows.Attached Graphic(2) A dining area must provide a minimum of ten square feet per resident with at least one exterior window.(3) Bathtubs or showers must be provided at a minimum rate of one for each 20 beds in nursing facilities.(4) Water closets and lavatories must be provided at a minimum rate of:(A) one for each eight beds in nursing facilities; and(B) one for each 15 clients in adult day health care facilities.(5) In all facilities a lavatory must be provided in or adjacent to each area having a water closet.(6) A monitoring station for staff must be provided with the following:(A) writing surface such as a desk or built-in counter top;(B) chair;(C) task illumination;(D) communication system such as a telephone or intercom to the main staff station of the facility; and(E) storage for resident records such as a lockable metal cabinet or storage closet.(7) Two remote exits must be provided in order to meet NFPA 101 requirements.(8) Corridor control doors, if used for security of the residents, must be similar to smoke doors, that is, be 44 inches in width each leaf, and must swing in opposite directions. A latch or other fastening device on a door must be provided with a knob, handle, panic bar, or other simple type of releasing device, the method of operation of which is obvious, even in darkness.(9) Locking devices may be used on the control doors provided the following criteria are met. (A) The building must have a complete sprinkler system and a complete fire alarm system including a corridor smoke detection system or smoke detectors located in each resident bedroom, which are interconnected into the fire alarm system.(B) The locking device must be electronic and must be released when the following occurs:(i) activation of the fire alarm or sprinkler systems;(ii) power failure to the facility; and(iii) pressing a button located at the main staff station and at the monitoring station.(C) Key pad or buttons may be located at the control doors for routine use by staff for service.(D) Upon loss of primary power, the control doors must not automatically reset on emergency power, but must be reset by manual means only. An exception is when the control doors are not in an exit access, they may automatically reset on emergency power. There must be at least two remote exits on each side of the control doors which meet all of the requirements for exits, such as proper width of egress and proper size of exterior doors, according to the NFPA 101. (E) Staff must be trained in the methods of releasing the locking device.(10) The exit doors may be equipped with a locking device provided one of the following methods is met:(A) the locking arrangement meets the requirements for Delayed Egress Locking Systems in NFPA 101, or(B) the following criteria which have been approved by CMS:(i) The building must have a complete fire alarm system including a corridor smoke detection system or smoke detectors located in each resident bedroom and a complete sprinkler system which are interconnected to the fire alarm system.(ii) The locking device must be electro-magnetic; that is, no type of throw-bolt is to be used.(iii) The device must release when the following occurs:(I) activation of the fire alarm or sprinkler system;(II) power failure to the facility; and(III) activating a switch located at the main staff station and at the monitoring station.(iv) Upon loss of primary power, the exit doors must not automatically reset on emergency power, but must be reset by manual means only.(v) A manual fire alarm pull must be located within 5'0" of the exit door with a sign stating, "Pull to release door in an emergency."(vi) A key pad, card, control button, or other electronic device may be located at the exit door for routine use by staff.(vii) Staff must be trained in the methods of releasing the locking device. Source Note: The provisions of this §554.2208 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective March 22, 2018, 43 TexReg 1646; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION W CERTIFICATION OF FACILITIES FOR CARE OF PERSONS WITH ALZHEIMER'S DISEASE AND RELATED DISORDERS §554.2208 Standards for Certified Alzheimer's Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203274 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203274 03/12/2026 (a) The facility must meet the following conditions to be approved by the Texas Department of Human Services (DHS) for participation in the Title XIX Texas Medical Assistance program and receive state and federal reimbursement for services to Title XIX residents:(1) the facility has been certified by DHS as meeting the conditions of participation, including the requirement to have a license from DHS, in the Title XIX Texas Medical Assistance program;(2) the entity licensed to operate the facility has filed a complete application with the Provider Enrollment Section of DHS for participation as a nursing facility in the Title XIX Texas Medical Assistance program; and(3) the beds for which the facility wishes to contract meet the requirements of §19.2322 of this title (relating to Medicaid Bed Allocation Requirements).(b) Only a facility with a fully executed current contract with DHS may receive state and federal reimbursement for services to Title XIX recipients. Source Note: The provisions of this §554.2301 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 2001, 26 TexReg 3824; amended to be effective November 1, 2002, 27 TexReg 9154; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2301 Conditions for Participation as a Medicaid-Certified Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224576 03/12/2026 (a) This section applies to nursing facilities (NFs) that have been licensed and certified as eligible for participation under Title XIX. (b) Each nursing facility (NF) must comply with the state requirements for participation and the facility's contract on a continuing basis. (c) Each NF must comply with the Texas Health and Human Services Commission's (HHSC's) utilization review requirements as provided in 1 TAC §371.212 (relating to Minimum Data Set Assessments) and §371.214 (relating to Resource Utilization Group Classification System). (d) A facility may not participate in the Texas Medical Assistance Program if it has restrictive policies or practices, including: (1) requiring the resident to make a will, with the facility named as legatee or devisee; (2) requiring the resident to assign his life insurance to the facility; (3) requiring the resident to transfer property to the facility; (4) requiring the resident to pay a lump sum entrance fee or make any other payment or concession to the facility beyond the recognized rate for board, room, and care as a condition for entry, departure, or continued stay; (5) controlling or restricting the resident, the resident's guardian, or responsible party in the use of the resident's personal needs allowance; (6) restricting the resident from leaving the facility at will except as provided by state law; (7) restricting the resident from applying for Medicaid for a specified period of time; (8) denying appropriate care to an individual on the basis of his race, religion, color, national origin, sex, age, disability, marital status, or source of payment; and (9) preventing terminally ill adult residents from exercising their will in making written or unwritten directives to reject life-sustaining procedures. (e) If DADS has documentation showing good cause, it reserves the right to reject the facility's participation or to cancel an existing contract if the facility charges the Title XIX resident, any member of his family, or any other source for supplementation or for any item except as allowed within DADS policies and regulations. (f) If DADS suspends a facility's vendor payments or proposes to terminate a facility's contract, the facility may request an administrative hearing to challenge the action. If a facility requests a hearing, the facility must make the request in accordance with HHSC rules at 1 TAC Chapter 357, Subchapter I. (g) DADS' interpretations of the requirements for participation or the contract may not be appealed to HHSC's hearings department unless the interpretation has caused an adverse action for the facility. (h) Facilities must allow representatives of DADS, the Medicaid Fraud Control Unit, and the Department of Health and Human Services to enter the premises at any time to make inspections or to privately interview the residents receiving assistance from DADS. (i) Facilities must supply DADS complete information according to federal and state requirements about the identity of: (1) each person who directly or indirectly owns interest of 5% or more in the facility; (2) each owner (in whole or in part) of any property, assets, mortgage, deed of trust, note, or other obligation secured by the facility; (3) each officer and director, if the facility is organized as a corporation; (4) each partner, if the facility is organized as a partnership (A copy of the partnership agreement is required, but the dollar amount of capital contributions of the partners may be omitted); and (5) any director, officer, agency, or managing employee of the institution, agency, or organization, who has ever been convicted of a criminal offense related to the person's involvement in programs established by Title XVIII, XIX, and XX (Effective dates for disclosure of any convictions are July 1, 1966, for Medicare, and January 1, 1969, for Medicaid.) (j) If a profit-making corporation operates the facility, a copy of the following material is required: (1) certificate of incorporation (for Texas corporations only); (2) certificate of authority to do business in Texas (for out-of-state corporations only); (3) a resolution from the board of directors authorizing a specific person or officer to sign contracts between DADS and the corporation; and (4) any management contract for the facility. If no stockholder owns, directly or beneficially, 5.0% or more of the corporate stock, the president and secretary of the corporation should state this on the department form. (k) If a nonprofit corporation operates the facility, a copy of the following material is required: (1) certificate of incorporation (for Texas corporations only); (2) certificate of authority to do business in Texas (for out-of-state corporations only); (3) a resolution from the board of directors authorizing a specific person or officer to sign contracts with DADS; and (4) a copy of any management contract for the facility. (l) Facilities other than those described in subsections (j) and (k) of this section must furnish a copy of: (1) charter or other legal basis for the organization which owns the facility; (2) any management contract or agreement for the facility; (3) by-laws of the organization (if applicable); and (4) other information required by DADS to determine the status of the legal entity that owns the facility. (m) Facilities must disclose business transaction information. A facility must send to DADS, within 35 days after the date of a written request, complete information on: (1) the ownership of a subcontractor with whom the facility has had, during the previous 12 months, business transactions totaling more than $25,000; and (2) any business transactions between the facility and any wholly owned supplier, or between the facility and any subcontractor during the five-year period ending on the date of the request. (n) The facility must report changes in the required information promptly to DADS. (o) Failure to provide this information may result in suspension, termination, or other contract action, including holding vendor funds. Payment to the facility is denied beginning on the day after the date information was due, and ending on the day before the date the information is received by DADS. (p) Each facility must comply with Texas Government Code §545.0201. A facility that furnishes services under the Medicaid program is subject to Occupations Code, Chapter 102. The facility's compliance with that chapter is a condition of the facility's eligibility to participate as a facility under those programs. Source Note: The provisions of this §554.2302 adopted to be effective May 1, 1995, 20 TexReg 2393; amneded to be effective January 1, 2002, 26 TexReg 10389; amended to be effective June 1, 2004, 29 TexReg 5416; amended to be effective August 31, 2004, 29 TexReg 8140; amended to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective April 1, 2025, 50 TexReg 2209. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2302 Requirements for a Contracted Medicaid Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203276 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203276 03/12/2026 (a) The Texas Department of Human Services (DHS) may enter into contracts with the facility.(b) Nursing facilities (NFs) must comply with all state and federal requirements for participation.(c) The contracting nursing facility agrees to:(1) comply with Title VI of the Civil Rights Act of 1964 (Public Law 88-352), §504 of the Rehabilitation Act of 1973 (Public Law 93-112), the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990 (Public Law 101-336), the Safe Medical Devices Act of 1990, and all amendments to each, and all requirements imposed by the regulations issued pursuant to these acts. In addition, the contractor agrees to comply with Chapter 73 of this title (relating to Civil Rights). These provide in part that no persons in the United States shall, on the grounds of race, color, national origin, sex, age, disability, political beliefs or religion be excluded from participation in, or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise be subjected to discrimination;(2) comply with Texas Health and Safety Code, Chapter 85, Subchapter E (concerning workplace and confidentiality guidelines regarding AIDS and HIV);(3) comply with 42 Code of Federal Regulations, Part 455, Program Integrity: Medicaid. Source Note: The provisions of this §554.2304 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2304 Contract Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215837 03/12/2026 (a) The effective date of the provider contract for an initial certification is the date the on-site survey is completed if the facility meets:(1) all federal health and safety standards; and(2) any other requirements imposed by the Texas Department of Human Services (DHS).(b) If the facility does not meet any of the requirements specified for an initial certification, the contract is effective on the earlier of the following dates:(1) the day the facility meets all requirements; or(2) the day the facility's correction plan, approvable waiver request, or both are accepted by DHS. The facility must have met all requirements imposed by DHS. Source Note: The provisions of this §554.2306 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2306 Effective Dates of Provider Contracts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203278 03/12/2026 (a) Definition. An ownership change is defined in §19.210(c) of this title (relating to Temporary Change of Ownership). For purposes of this section, prior owner is defined as the legal entity with a Medicaid contract for the facility before the change of ownership. The new owner is the legal entity to which DADS has assigned the contract (in accordance with 42 CFR §442.14 and subsection (d) of this section). The effective date of the ownership change is the effective date of the new owner's license for the facility.(b) Notice of ownership change. The prior owner must give DADS written notice of a change of ownership at least 30 days before the effective date of the change. If written notice of the change is not received 30 days before the agreed change date, DADS is not responsible for payments made to the prior owner or new owner that do not reflect the established change date. DADS will not make a duplicate payment. It is the responsibility of the prior and new owner to make arrangements between themselves for such contingencies.(c) Vendor holds based on a change of ownership.(1) Holds on payments due to a prior owner.(A) When DADS receives information about a proposed or actual change of ownership, DADS may place vendor payments to the prior owner on hold. Vendor payments will not be released until the Texas Health and Human Services Commission notifies DADS that the prior owner meets the final reporting requirements as specified in 1 TAC §355.306 (relating to Cost Finding Methodology) and 1 TAC §355.308(f)(1)(A) (relating to Direct Care Staff Rate Component).(B) Once the final reporting requirements in subparagraph (A) of this paragraph are met, vendor payments may still be held so that money owed to DADS can be recouped from the funds placed on hold. Vendor payments will be released after:(i) completion of a billing and claims reconciliation, or the passing of a time period of 12 months after the effective date of the change of ownership, whichever is sooner; or(ii) the prior owner provides, at DADS' option, either of the following documents in a format acceptable to DADS to cover possible liabilities of the prior owner:(I) a surety bond or an irrevocable letter of credit as described in §19.2312 of this title (relating to Surety Bonds or Letters of Credit); or(II) written authority by the prior owner to withhold and retain funds normally due the prior owner from other Medicaid contracts the prior owner may have with DADS.(2) Waiving holds on payments due to a prior owner.(A) DADS may waive placing vendor payments to the prior owner on hold, if, at least 60 days before the effective date of the change of ownership:(i) the prior owner notifies DADS of the change of ownership;(ii) the new owner provides DADS with a signed and notarized contract application;(iii) DADS receives information sufficient to verify that the ownership change is a reorganization of the prior owner's ownership structure and that the new owner's ownership structure:(I) consists of individuals who owned at least 51% of the ownership in the prior owner and own at least 51% of the ownership in the new owner;(II) does not consist of a change in a general partner, if the prior owner's ownership structure was a limited partnership; and(III) retains control of the prior owner's financial records; and(iv) the prior owner returns to DADS the nontransferable DADS Successor Liability Agreement (provided by DADS) signed by the prior and new owners indicating that the new owner has agreed to pay DADS for any liabilities that exist or may be found to exist during the period of the prior owner's contract with DADS.(B) Meeting the conditions in subparagraph (A) of this paragraph but not meeting the 60-day time frame may result in DADS placing vendor payments to the prior owner on hold; however, once all of the conditions listed in subparagraph (A) of this paragraph are met, the hold will be released.(3) Holds on payment due to the new owner.(A) During the period between the issuance of the temporary change of ownership license and the inspection or survey of the nursing facility, DADS may not place a hold on vendor payments to the temporary license holder.(B) If the nursing facility fails to pass the inspection or survey or fails to meet the requirements in §19.201 of this title (relating to Criteria for Licensing), DADS may place a hold on vendor payments to the new owner.(d) Contract assignment. When a change in ownership occurs, DADS automatically assigns the agreement to the new owner by issuing a new contract. By signing the contract, the new owner is representing to DADS that the new owner meets the requirements of the contract and the requirements for participation in the Medicaid program. The new owner's contract is subject to the prior owner's contract terms and conditions that were in effect at the time of transfer of ownership, including the following:(1) any plan of correction;(2) compliance with health and safety standards;(3) compliance with the ownership and financial interest disclosure requirements of 42 CFR §§455.104, 455.105, and 1002.3;(4) compliance with civil rights requirements in 45 CFR Parts 80, 84, and 90;(5) compliance with additional requirements imposed by DADS; and(6) any sanctions as specified in this chapter relating to remedies for violations of Title XIX nursing facility provider agreements, including deficiencies, vendor holds, compliance periods, accountability periods, monetary penalties, notification for correction of contract violations, probationary contracts, and history of deficiencies.(e) Medical assistance payments nontransferable. Neither medical assistance nor amounts payable to vendors out of public assistance funds are transferable or assignable at law or in equity. DADS will not allow non-split agreements in the case of ownership changes. Non-split agreements are arrangements where DADS does not interrupt payments to prior and new owners but continues reimbursements as though no ownership change has occurred. A split in pay agreement ensures that payments to the prior owner stop on a certain date and payments for services thereafter go to the new owner.(f) Owner agreements. The new owner and the prior owner of a nursing facility may reach any agreement they wish, but DADS will not participate in a non-split procedure which would allow the new owner to receive the prior owner's accrued vendor payments.(g) Financial records. The prior owner of the facility may remove the financial records pertaining to his period of ownership from the facility, but must maintain them for the time period prescribed by law or until such time as all audit exceptions are reconciled, whichever period is the longer. The original copies of the trust fund records, including ledger cards, may be removed by the prior owner if an exact duplicate of the trust fund records, including ledger cards, remains with the new owner. Source Note: The provisions of this §554.2308 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective April 1, 1996, 21 TexReg 1432; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective April 1, 2002, 27 TexReg 2060; amended to be effective February 1, 2003, 27 TexReg 12009; amended to be effective April 2, 2007, 32 TexReg 1916; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2308 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203279 03/12/2026 A nursing facility may voluntarily terminate or be involuntarily terminated from Medicaid participation. A facility must have policies and procedures in place to ensure that the administrator's duties and responsibilities include providing the appropriate notices in the event of a Medicaid termination.(1) If a facility voluntarily closes and ceases providing nursing facility services, the facility must comply with this paragraph.(A) The facility must close on the first day of a month.(B) At least 75 days before closure, the administrator must submit to the HHSC regional director a plan for relocation of all residents. The plan must:(i) provide for the transfer and adequate relocation of the residents;(ii) include assurances that residents are transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each resident; and(iii) be revised as necessary to obtain HHSC approval.(C) At least 60 days before closure, the administrator must submit written notice of the closure that includes the approved closure plan and the closure date to:(i) the secretary or the secretary's designee;(ii) HHSC Regulatory Services;(iii) the State Ombudsman;(iv) each resident; and(v) each resident's legal representative or responsible party.(D) The notice to each resident and the resident's legal representative or responsible party must include the information required by §19.502(f) of this chapter (relating to Transfer and Discharge in Medicaid-certified Facilities).(E) The facility must not admit any new residents on or after the date the written notice is submitted.(F) The facility must have the resources to operate through the closure date.(2) If HHSC or CMS terminates a facility's Medicaid provider agreement, the facility must comply with this paragraph.(A) At least 15 days before the notice date set by HHSC or CMS, the administrator must submit to the HHSC regional director a plan for relocation of all residents. The plan must:(i) provide for the transfer and adequate relocation of the residents;(ii) include assurances that residents are transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each resident; and(iii) be revised as necessary to obtain HHSC approval.(B) By the date set by HHSC or CMS, the administrator must submit written notice of the closure that includes the approved plan and the closure date to:(i) the secretary or secretary's designee;(ii) HHSC Regulatory Services;(iii) the State Ombudsman;(iv) each resident; and(v) each resident's legal representative or responsible party.(C) The notice to each resident and the resident's legal representative or responsible party must include the information required by §19.502(f) of this chapter.(D) The facility must not admit any new residents on or after the date the notice is submitted.(3) If a facility voluntarily withdraws from Medicaid but continues to provide nursing facility services, the facility must comply with this paragraph.(A) The facility may not use the withdrawal as a reason to transfer or discharge a resident who was residing in the facility on the day before the effective withdrawal date.(B) The facility is deemed to have a provider agreement with regard to any resident who was residing in the facility on the day before the effective withdrawal date and who is eligible for Medicaid or who later becomes eligible for Medicaid.(C) The facility must:(i) provide oral and written notice to an individual who is admitted after withdrawal from Medicaid that:(I) the facility is not participating in the Medicaid program with respect to new residents; and(II) the facility may transfer or discharge a resident if the resident does not pay the facility charges even though the resident may have become eligible for Medicaid nursing facility services;(ii) provide the written notice in a prominent manner on a separate page of the admission agreement when the resident is admitted; and(iii) have the resident sign a written receipt, separate from other signed documents, that the resident received the information in the written notice. Source Note: The provisions of this §554.2310 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 1, 2000, 25 TexReg 6779; amended to be effective October 31, 2013, 38 TexReg 7465; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2310 Nursing Facility Ceases to Participate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203281 03/12/2026 DADS may audit or monitor a facility, including the facility's trust fund accounts, periodically or as a result of a complaint investigation. DADS may also refer a facility to the Office of Inspector General for an audit. A facility is notified of monitoring or audit plans and is given a report of the final findings. Source Note: The provisions of this §554.2314 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective April 1, 1996, 21 TexReg 1432; amended to be effective November 20, 2012, 37 TexReg 9112; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2314 Financial Audits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203282 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203282 03/12/2026 (a) Nursing facilities may collect from the recipient only the applied income that is specified on the recipient's payment plan forms, except when that amount exceeds the monthly vendor rate. In this event, the facility may collect only an applied-income amount equal to the maximum monthly Medicaid vendor rate.(b) If a payment plan appears incorrect, the facility administrator should contact the local Texas Department of Human Services (DHS) worker to correct the plan. Even if a recipient's income increases, the administrator must not collect an increased payment until the plan is changed. The administrator should not collect an increased payment in anticipation of a payment plan increase.(c) If an admitted recipient does not have a payment plan, the administrator should contact the local worker for help in determining how much applied income is owed. If the forthcoming forms indicate a lesser payment, the administrator should refund the excess immediately and notify the worker.(d) Facilities that collect payments (part applied income, part Medicaid) in excess of the vendor rate are in violation of DHS regulations and of Public Law 95-142 which makes "solicitation of supplementation" a felony.(e) Regional DHS staff must report any violations. If an investigation shows that the facility has violated this standard, a recommendation for withholding vendor payments, contract termination, referral to the courts, or other contract action may be made.(f) The nursing facility must refund the recipient's prorated applied income money when the recipient has paid in advance for the full month and is discharged from the facility any time during the month. The facility must make the refund within 30 calendar days from and including the date of discharge, even when vendor payment has not been received from DHS. Source Note: The provisions of this §554.2316 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2316 Collection of Applied Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203283 03/12/2026 (a) Reimbursement is computed by multiplying the established daily rate by the number of days in the month. The recipient's applied income is then subtracted and the result is divided by the number of days in the month.(b) A facility may not collect more than the applied income reported on the payment plan form in a 31-day month. Source Note: The provisions of this §554.2318 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2318 Computation of Daily Reimbursement Rate for Recipients with Applied Income https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203284 03/12/2026 (a) The nursing facility is responsible for providing normal transportation for the recipient to medical services outside the facility. The attending physician must have ordered the medical services.(b) Normal transportation is to and from the medical care provider of the recipient's choice, who is generally available and used by recipients of the locality for medical care included under the Texas Medical Assistance program. If a Title XIX provider is not in the locality, transportation is to and from the nearest appropriate Title XIX provider if the recipient so chooses. The term "locality" means the service area surrounding the nursing facility from which individuals ordinarily come or are expected to come for inpatient or outpatient services.(c) Transportation charges, including non-emergency, routine ambulance services, involved in the certification or recertification of a recipient are the responsibility of the nursing facility.(d) The facility may not charge the state's Medicaid health insuring agent, the recipient, the family, or responsible party for normal transportation as defined in this section. Normal transportation charges are covered in the monthly vendor rate. The facility may not use the state's Medicaid community-based Title XIX medical transportation program except to transport recipients for renal dialysis treatments.(e) Charges for the following medically necessary ambulance services, when provided by a Medicaid-enrolled provider, are not the responsibility of the nursing facility, but are payable by the state's Medicaid health insuring agent as a Medicaid benefit:(1) emergency transport, which is ambulance service for a Medicaid recipient with an emergency medical condition. Emergency medical condition is defined as one which manifests itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could result in placing the recipient's health in serious jeopardy; and(2) nonemergency transport, under the following conditions:(A) the recipient is severely disabled, which is defined as a condition which limits mobility and requires confinement to bed at all times, prevents sitting unassisted at all times, or requires the monitoring of life support systems, including oxygen or intravenous infusion;(B) the severely disabled recipient cannot be transported by any means other than an ambulance without endangering the health or safety of the recipient; and(C) the nonemergency ambulance transportation of the severely disabled recipient is to or from a scheduled medical appointment and authorization has been received from the Texas Department of Health or its designee. If payment under the medical assistance program is denied because the facility failed to obtain prior authorization, the facility must pay for the service if presented a copy of the bill for which payment was denied.(f) If ambulance services are reimbursable by the state's Medicaid health insuring agent, they are not the responsibility of the recipient, the family, or the responsible party.(g) Nursing facilities are encouraged to use family, friends, sponsors, civic groups, or charitable organizations as resources for transportation services. If normal transportation is not obtainable from these sources, the facility must provide or purchase the appropriate services. Source Note: The provisions of this §554.2320 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective June 1, 2004, 29 TexReg 5416; amended to be effective August 31, 2004, 29 TexReg 8141; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2320 Medical Transportation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203285 03/12/2026 (a) Definitions. The words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Applicant--An individual or entity requesting a bed allocation waiver or exemption.(2) Assignment of rights--The Health and Human Services Commission (HHSC) conveyance of a specific number of allocated Medicaid beds from a nursing facility or entity to another entity for purposes of constructing a new nursing facility or for any other use as authorized by this chapter.(3) Bed allocation--The process by which HHSC controls the number of nursing facility beds that are eligible to become Medicaid-certified in each nursing facility.(4) Bed certification--The process by which HHSC certifies compliance with state and federal Medicaid requirements for a specified number of Medicaid beds allocated to a nursing facility.(5) County or precinct occupancy rate--The number of residents, regardless of source of payment, occupying certified Medicaid beds in a county divided by the number of Medicaid beds allocated in the county, including Medicaid beds that are certified and Medicaid beds that have been allocated but are not certified. In the four most populous counties in the state, the occupancy rate is calculated for each county commissioner precinct.(6) Licensee--The individual or entity, including a controlling person, that is:(A) an applicant for licensure by HHSC under Chapter 242 of the Texas Health and Safety Code and for Medicaid certification;(B) licensed by HHSC under Chapter 242 of the Texas Health and Safety Code; or(C) licensed under Chapter 242 of the Texas Health and Safety Code and holds the contract to provide Medicaid services.(7) Lien holder--The individual or entity that holds a lien against a physical plant.(8) Multiple-facility owner--An individual or entity that owns, controls, or operates under lease two or more nursing facilities within or across state lines.(9) Occupancy rate--The number of residents occupying certified Medicaid beds divided by the number of certified Medicaid beds in a nursing facility.(10) Open solicitation period--A period during which an individual or entity may apply for an allocation of Medicaid beds in a high-occupancy county or precinct.(11) Physical plant--The land and attached structures to which beds are allocated or for which an application for bed allocation has been submitted.(12) Property owner--The individual or entity that owns a physical plant.(13) Transfer of beds-- HHSC conveyance of a specific number of allocated Medicaid beds from an existing nursing facility or entity to another existing licensed nursing facility. The nursing facility may use the transferred Medicaid beds to increase the number of Medicaid-certified beds currently licensed or to increase the number of Medicaid-certified beds when additional licensed beds are added to the nursing facility in the future.(b) Purpose. The purpose of this section is to control the number of Medicaid beds that HHSC contracts, to improve the quality of resident care by selective and limited allocation of Medicaid beds, and to promote competition.(c) Bed allocation general requirements. The allocation of Medicaid beds is an opportunity for the property owner or the lessee of a nursing facility to obtain a Medicaid nursing facility contract for a specific number of Medicaid-certified beds.(1) Medicaid beds are allocated to a nursing facility and remain at the physical plant where they were originally allocated, unless HHSC transfers or assigns the beds.(2) When HHSC allocates Medicaid beds to a nursing facility as a result of actions by the licensee, HHSC requires that the beds remain allocated to the physical plant, even when the licensee ceases operating the nursing facility, unless HHSC assigns or transfers the beds.(3) Notwithstanding any language in subsections (f) and (g) of this section and the fact that applicants for bed allocation waivers and exemptions may be licensees or property owners, HHSC allocates beds to the physical plant and the owner of that property controls the Medicaid beds subject to HHSC rules and requirements and all valid physical plant liens.(d) Control of beds. Except as specified in this section, HHSC does not accept applications for a Medicaid contract for nursing facility beds from any nursing facility that was not granted:(1) a valid certificate of need (CON) by the Texas Health Facilities Commission before September 1, 1985; (2) a waiver or exemption approved by the Department of Human Services before January 1, 1993; or(3) a valid order that had the effect of authorizing the operation of the nursing facility at the bed capacity for which participation is sought.(e) Level of acceptable care. Unless specifically exempted from this requirement, applicants and controlling persons of an applicant for Medicaid bed allocation waivers or exemptions must comply with level of acceptable care requirements. Level of acceptable care requirements apply only in determining bed allocation waiver and exemption eligibility and have no effect on other sections of this chapter.(1) HHSC determines a waiver or exemption applicant or a controlling person of an applicant complies with level of acceptable care requirements if, within the preceding 24 months, the applicant or controlling person:(A) has not received any of the following sanctions:(i) termination of Medicaid or Medicare certification;(ii) termination of Medicaid contract;(iii) denial, suspension, or revocation of a nursing facility license;(iv) cumulative Medicaid or Medicare civil monetary penalties totaling more than $5,000 per facility; (v) civil penalties pursuant to §242.065 of the Texas Health and Safety Code; or(vi) denial of payment for new admissions;(B) does not have a pattern of substantial or repeated licensing and Medicaid sanctions, including administrative penalties or other sanctions; and(C) does not have a condition listed in §19.214(a) of this chapter (relating to Criteria for Denying a License or Renewal of a License).(2) HHSC considers the criteria in paragraph (1) of this subsection to determine if local facilities provide a level of acceptable care in counties, communities, ZIP codes or other geographic areas that are the subject of a waiver application. HHSC only considers sanctions that are final and are not subject to appeal when determining if a local facility complies with level of acceptable care requirements.(3) Nursing facilities that have received any of the sanctions listed in paragraph (1) of this subsection within the previous 24 months are not eligible for an allocation of Medicaid beds under subsection (h) of this section or an allocation of additional Medicaid beds under subsection (f) of this section. In the case of sanctions against the nursing facility to which the beds would be allocated that are appealed, either administratively or judicially, an application will be suspended until the appeal has been resolved. Sanctions that have been administratively withdrawn or were subsequently reversed upon administrative or judicial appeal are not considered.(4) If an applicant for an allocation of additional Medicaid beds or a controlling person of an applicant is a multiple-facility owner or a multiple-facility owner owns the applicant, the multiple-facility owner must demonstrate an overall record of complying with level of acceptable care requirements. HHSC considers the number of facilities that have received sanctions listed in paragraph (1) of this subsection in relation to the number of facilities that the multiple-facility owner owns to determine if a multiple-facility owner meets level of acceptable care requirements. HHSC only considers sanctions that are final and are not subject to appeal when determining whether the multiple-facility owner's facilities not receiving the new bed allocation comply with level of care requirements.(5) When the applicant is a licensee that has operated a nursing facility less than 24 months, the nursing facility must establish at least a 12-month compliance record immediately preceding the application in which the nursing facility has not received any of the sanctions listed under paragraph (1) of this subsection.(6) When the applicant has no history of operating nursing facilities, HHSC will review the compliance record of health-care facilities operated, managed, or otherwise controlled by controlling parties of the applicant. If a controlling party or the applicant has never operated, managed, or otherwise controlled any health-care facilities, a compliance review is not required.(7) The executive commissioner, or the executive commissioner's designee, may make an exception to any of the requirements in this subsection if the executive commissioner or the executive commissioner's designee determines the needs of Medicaid recipients in a local community will be served best by granting a Medicaid bed allocation waiver or exemption. In determining whether to make an exception to the requirements, the executive commissioner or the executive commissioner's designee may consider the following:(A) the overall compliance record of the waiver or exemption applicant;(B) the current availability of Medicaid beds in facilities that comply with level of acceptable care requirements in the local community;(C) the level of support for the waiver or exemption from the local community;(D) the way a waiver or exemption will improve the overall quality of care for nursing facility residents; and(E) the age and condition of nursing facility physical plants in the local community.(f) Exemptions. HHSC may grant an exemption from the requirements in subsection (d) of this section. All exemption actions must comply with the requirements in this subsection and with requirements of the Centers for Medicare & Medicaid Services (CMS) regarding bed capacity increases and decreases. When a bed allocation exemption is approved, the licensee must comply with the requirements in §19.201 of this chapter (relating to Criteria for Licensing) at the time of licensure and Medicaid certification of the new beds or nursing facility. (1) Replacement Medicaid nursing facilities and beds. An applicant may request that HHSC approve replacement of allocated Medicaid beds by the construction of one or more new nursing facilities.(A) The applicant must own the physical plant where the beds are allocated or possess a valid assignment of rights to the Medicaid beds.(B) The applicant must obtain written approval by all lien holders of the physical plant where the beds are allocated before requesting HHSC approval to relocate the Medicaid beds to the replacement facility if the replacement facility will be constructed at a different address than the current facility. The applicant must submit the lien holder approval with the replacement nursing facility request. If the physical plant where the Medicaid beds are allocated does not have a lien, the applicant must submit a written attestation of that fact with the replacement nursing facility request.(C) Replacement nursing facility applicants, including those who obtained the rights to the beds through a HHSC assignment of beds, must comply with the level of acceptable care requirements in subsection (e) of this section, unless the applicant for a replacement nursing facility is the current property owner.(D) HHSC may grant a replacement facility an increase of up to 25 percent of the currently allocated Medicaid beds, if the applicant complies with the level of acceptable care requirements in subsection (e) of this section. HHSC will not transfer or assign the additional allocation of beds until they are certified at the replacement facility.(E) The physical plant of the replacement nursing facility must be located in the same county in which the Medicaid beds currently are allocated.(2) Transfer of Medicaid beds. An applicant may request HHSC transfer allocated Medicaid beds certified or previously certified to another physical plant.(A) The applicant must own the physical plant where the beds are allocated, or the applicant must present HHSC with:(i) a valid Medicaid bed transfer agreement that specifies the number of additional Medicaid beds the applicant is requesting HHSC allocate to the receiving nursing facility; or(ii) a valid Medicaid bed assignment that specifies the number of additional Medicaid beds the applicant is requesting HHSC allocate to the receiving nursing facility.(B) If the Medicaid beds are allocated to a specific physical plant, the applicant must obtain and submit written approval from the property owner and, if the physical plant has a lien, written approval from all lien holders to obtain a HHSC transfer of the Medicaid beds to another facility. If the physical plant where the Medicaid beds are allocated does not have a lien, the applicant must submit a written attestation of that fact with the transfer request.(C) The receiving licensee must comply with level of acceptable care requirements in subsection (e) of this section.(D) Both facilities must be located in the same county.(3) High-occupancy facilities. Medicaid-certified nursing facilities with high occupancy rates may periodically apply to HHSC to receive bed allocation increases.(A) The occupancy rate of the Medicaid beds of the applicant nursing facility must be at least 90.0 percent for nine of the previous 12 months prior to the application.(B) The application for additional Medicaid beds may be for no more than 10 percent (rounded to the nearest whole number) of the facility's Medicaid-certified nursing facility beds.(C) The applicant nursing facility must comply with level of acceptable care requirements in subsection (e) of this section.(D) The applicant nursing facility may reapply for additional Medicaid beds no sooner than nine months from the date of the previous allocation increase.(E) Medicaid beds allocated to a nursing facility under this requirement may only be certified at the applicant nursing facility. HHSC does not transfer or assign the additional allocation of beds until they are certified at the applicant nursing facility.(4) Non-certified nursing facilities. Licensed nursing facilities that do not have Medicaid-certified beds may apply to HHSC for an initial allocation of Medicaid beds.(A) The application for Medicaid beds may be for no more than 10 percent (rounded to the nearest whole number) of the facility's licensed nursing facility beds.(B) The applicant nursing facility must comply with level of acceptable care requirements in subsection (e) of this section.(C) After the applicant nursing facility receives an allocation of Medicaid beds, the facility may apply for additional Medicaid beds in accordance with paragraph (3) of this subsection.(5) Low-capacity facilities. For purposes of efficiency, nursing facilities with a Medicaid bed capacity of less than 60 may receive additional Medicaid beds to increase their capacity up to a total of 60 Medicaid beds.(A) The nursing facility must be licensed for less than 60 beds and have a current certification of less than 60 Medicaid beds. (B) The nursing facility must have been Medicaid-certified before June 1, 1998.(C) The applicant licensee must comply with level of acceptable care requirements in subsection (e) of this section.(D) Facilities that have a Medicaid capacity of less than 60 beds due to the loss of Medicaid beds under provisions in subsection (j) of this section are not eligible for this exemption.(6) Spend-down Medicaid beds. Licensed nursing facilities may apply to HHSC for temporary spend-down Medicaid beds for residents who have "spent down" their resources to become eligible for Medicaid, but for whom no Medicaid bed is available. A HHSC approval of spend-down Medicaid beds allows a nursing facility to exceed temporarily its allocated Medicaid bed capacity.(A) The applicant nursing facility must have a Medicaid contract with a Medicaid bed capacity of at least 10 percent of licensed capacity authorized in paragraph (4) of this subsection. If the nursing facility is not currently Medicaid-certified, the licensee must be approved for Medicaid certification and obtain a Medicaid contract with a Medicaid bed capacity at least as large as that authorized in paragraph (4) of this subsection.(B) All Medicaid or dually certified beds must be occupied by Medicaid or Medicare recipients at the time of application.(C) The application for a spend-down Medicaid bed must include documentation that the person for whom the spend-down bed is requested:(i) was not eligible for Medicaid at the time of the resident's most recent admission to the nursing facility; and(ii) was a resident of the nursing facility for at least the immediate three months before becoming eligible for Medicaid, excluding hospitalizations.(D) The nursing facility is eligible to receive Medicaid benefits effective the date the resident meets Medicaid eligibility requirements. (E) The nursing facility must assign a permanent Medicaid bed to the resident as soon as one becomes available.(F) Facilities with multiple residents in spend-down beds must assign permanent Medicaid beds to those residents in the same order the residents were admitted to spend-down beds.(G) The assignment of residents in spend-down beds to permanent Medicaid beds must precede the admission of new residents to permanent beds.(H) The nursing facility must notify HHSC immediately upon the death or permanent discharge of the resident or transfer of the resident to a permanent Medicaid bed. Failure of the nursing facility to notify HHSC of these occurrences in a timely manner is basis for denying applications for spend-down Medicaid beds.(I) The nursing facility is not required to comply with level of acceptable care requirements in subsection (e) of this section.(g) Waivers. The executive commissioner or the executive commissioner's designee may grant a waiver of the requirements stated in subsection (d) of this section under certain conditions.(1) Applicants must meet the following conditions to be eligible for the specific waivers in subsection (h) of this section.(A) The applicant must meet the level of acceptable care requirement in subsection (e) of this section.(B) The applicant must submit a complete HHSC waiver application.(C) At the time of licensure and Medicaid certification of the allocated beds, the licensee must comply with the requirements in §19.201 of this chapter.(D) A waiver recipient or a subsequent waiver assignee must, at the time of licensure and Medicaid certification, be the property owner or the licensee of the facility where Medicaid beds allocated through the waiver process are certified.(2) A waiver recipient may request that HHSC approve the assignment of an approved waiver to another entity in accordance with this paragraph. A waiver recipient may request HHSC approval of only one assignment. A waiver assignment is not valid unless and until it is approved by HHSC.(A) The waiver recipient or the owner of the waiver recipient must maintain majority ownership and management control of the assignee.(B) The assignee must not have an owner or controlling person who was not an owner or controlling person of the waiver recipient. (C) The assignee must own the physical plant of the waiver facility at the time of licensure and certification (as landlord) or be the licensee at the time of licensure and certification (as the licensed operator). Under either circumstance, the allocated beds are subject to subsection (c) of this section.(D) The assignee must meet the requirements in subsection (e) of this section regarding level of acceptable care.(3) A waiver recipient entity may remove a controlling person from ownership of the entity, but the waiver recipient entity must not add an owner after the waiver is approved by HHSC. A change to the ownership of the waiver recipient entity or the waiver assignment entity must be reported to HHSC.(4) HHSC may in its sole discretion determine that a waiver applicant that submits false or fraudulent information is not eligible for a waiver. HHSC may, in its sole discretion, revoke a waiver issued and decertify Medicaid beds issued based on false or fraudulent information provided by the applicant.(5) Except as provided in paragraphs (6) - (9) of this subsection, HHSC considers waiver applications in the order in which they are received. A waiver applicant may request that review of its application be deferred until one or more applications submitted after its application has been reviewed. This request must be in writing.(6) HHSC gives priority to a small house waiver application submitted in accordance with subsection (h)(9) of this section over a pending community needs waiver application submitted in accordance with subsection (h)(2) of this section for the same county. If approved, HHSC includes the small house facility beds when determining the need for a community needs waiver.(7) During any period in which HHSC is processing a waiver application in accordance with subsection (h)(2), (4), (5), or (9) of this section, HHSC may suspend processing the waiver application for up to six months if HHSC determines the county or precinct occupancy rate of the county or precinct in which the site of the proposed waiver is located is at least 85 percent during at least six of the previous nine months. HHSC calculates the occupancy rate based on the monthly Medicaid occupancy reports submitted to HHSC by Medicaid-certified nursing facilities and includes the occupancy rate of certified Medicaid beds and allocated Medicaid beds that are encumbered for future certification as a result of approval of a waiver or exemption in the subject county or precinct.(8) HHSC initiates the high occupancy county or precinct waiver process referenced in subsection (h)(1) of this section if HHSC determines requirements for the open solicitation process for a high occupancy county or precinct waiver are met during the temporary suspension period referenced in paragraph (7) of this subsection. HHSC does not process any pending waiver applications in the affected county or precinct until the open solicitation process referenced in subsection (h)(1) of this section is complete.(9) HHSC continues to process a suspended waiver application in the affected county or precinct if HHSC determines requirements for the open solicitation process of the high occupancy county or precinct waiver are not met during the suspension period referenced in paragraph (7) of this subsection.(h) Specific waiver types. HHSC may grant a waiver if it determines that Medicaid beds are necessary for the following circumstances.(1) High occupancy waiver. A high occupancy waiver is designed to meet the needs of counties and certain precincts that have a high county or precinct occupancy rate for multiple months.(A) HHSC monitors monthly county or precinct occupancy rates. If HHSC determines that a county or precinct occupancy rate equals or exceeds 85 percent for at least nine of the previous twelve months, HHSC may initiate a waiver process by placing a public notice in the Texas Register and the Electronic State Business Daily (ESBD) to announce an open solicitation period.(B) The public notice announces that HHSC may allocate 90 additional Medicaid beds in the county or precinct.(C) The notice identifies the county or precinct and the beginning and end dates of the solicitation period. The notice also includes the HHSC address to which the application for additional Medicaid beds must be submitted and specifies that the application must be received by HHSC before the close of business on the end date of the solicitation period.(D) An applicant for additional Medicaid beds must comply with the level of acceptable care requirements in subsection (e) of this section.(E) An applicant must submit a complete HHSC waiver application.(F) At the end of the solicitation period, HHSC determines if an applicant is eligible for additional Medicaid beds. If multiple applicants are eligible, the applicant who will receive the allocation of beds will be chosen by a lottery selection.(G) If no application for the waiver process is received or if no applicant meets the requirements in this section, HHSC conducts no further solicitation. HHSC closes the process without allocating Medicaid beds.(H) An applicant that is granted a high occupancy waiver must provide to HHSC a performance bond, surety bond, or an irrevocable letter of credit in the amount of $500,000 payable to HHSC to ensure that the Medicaid beds granted to the applicant under the waiver are certified within the time periods required by subsection (i)(4)(G) of this section, including any extensions granted under subsection (i)(6) of this section. HHSC will revoke a waiver if the performance bond, surety bond, or irrevocable letter of credit is not provided within 90 days after HHSC approves the waiver application.(I) If an applicant chooses to provide a performance bond or surety bond instead of an irrevocable letter of credit, the performance bond or surety bond provided under this subchapter must:(i) be executed by a corporate entity in accordance with Texas Insurance Code, Chapter 3503, Subchapter A;(ii) be in a form approved by HHSC; and(iii) clearly and prominently display on the face of the bond:(I) the name, mailing address, physical address, and telephone number of the surety company or financial institution to which any notice of claim should be sent; or(II) the toll-free telephone number maintained by the Texas Department of Insurance in accordance with Texas Insurance Code, Chapter 521, Subchapter B, and a statement that the address of the surety company to which any notice of claim should be sent may be obtained from the Texas Department of Insurance by calling the toll-free telephone number.(J) If an applicant chooses to provide an irrevocable letter of credit, the irrevocable letter of credit must be issued by a banking institution or similar financial institution.(K) An applicant must notify HHSC at least 60 days in advance if:(i) the applicant does not intend to renew its performance bond, surety bond, or irrevocable letter of credit on the annual renewal date; or(ii) the applicant changes the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(L) An applicant may choose a performance bond, surety bond, or irrevocable letter of credit and substitute one for the other over the course of development and construction, but regardless of which option is chosen, the performance bond, surety bond, or irrevocable letter of credit must continue in effect until the facility is certified to participate in the Medicaid program or until paid to HHSC after notice provided in accordance with subparagraph (M) of this paragraph.(M) A performance bond, surety bond, or irrevocable letter of credit is immediately due and must be paid to HHSC upon receipt of notice from HHSC to the issuer of the performance bond, surety bond, or irrevocable letter of credit that:(i) the applicant did not comply with subsection (i)(4)(G) of this section, which may include an extension granted under subsection (i)(6) of this section;(ii) HHSC revokes the applicant's waiver;(iii) the applicant did not notify HHSC of its intent not to renew the performance bond, surety bond, or irrevocable letter of credit at least 60 days before its automatic annual renewal date; or(iv) the applicant did not notify HHSC of a change in the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(2) Community needs waiver. A community needs waiver is designed to meet the needs of communities that do not have reasonable access to acceptable nursing facility care.(A) The applicant must submit a demographic or health needs study, prepared by an independent professional experienced at preparing demographic or health needs studies, that documents:(i) an immediate need for additional Medicaid beds in the community; and(ii) Medicaid residents in the community do not have reasonable access to acceptable nursing facility care.(B) The application must include a statement by the preparer of the study that the preparer has no interest, financial or otherwise, in the outcome of the waiver application.(C) The demographic or health needs study must include at least the following information pertaining to the community's population: (i) population growth trends;(ii) population growth trends specific to the elderly, including income or financial condition;(iii) Medicaid bed occupancy data;(iv) level of acceptable care provided by local nursing facilities; and(v) any existing allocated Medicaid beds not currently certified but that could be used for a new Medicaid nursing facility.(D) The applicant must submit documentation of substantial community support for the new nursing facility or beds.(E) When determining the immediate need for additional Medicaid beds, and whether residents have reasonable access to acceptable nursing facility care, HHSC considers:(i) the number and occupancy rate of certified Medicaid beds that comply with level of acceptable care requirements; and(ii) the number of encumbered Medicaid beds that have been approved by HHSC but are not yet certified.(F) Replacement beds or waiver beds approved in accordance with subsection (f)(1) or (h) of this section will not be considered in the calculation in subparagraph (D) of this paragraph if the owner of the replacement beds or waiver beds has not purchased land for a new construction site within 24 months after the date HHSC initially approves the replacement request or the waiver for the beds.(G) HHSC considers an application withdrawn if it is not completed within 90 days after the application is submitted to HHSC.(H) HHSC notifies local nursing facilities when a complete community needs waiver application is received and affords local nursing facilities an opportunity to comment on the waiver application. The notification includes a deadline for submission of comments. HHSC limits subsequent comments during the review process to facilities that submit timely comments in response to the notification of a completed application.(I) An applicant that is granted a community needs waiver must provide to HHSC a performance bond, surety bond, or an irrevocable letter of credit in the amount of $500,000 payable to HHSC to ensure that the Medicaid beds granted to the applicant under the waiver are certified within the time periods required by subsection (i)(4)(G) of this section, including any extensions granted under subsection (i)(6) of this section. HHSC will revoke a waiver if the performance bond, surety bond, or irrevocable letter of credit is not provided within 90 days after HHSC approves the waiver application.(J) If an applicant chooses to provide a performance bond or surety bond, instead of an irrevocable letter of credit, the performance bond provided under this subparagraph must:(i) be executed by a corporate entity in accordance with Texas Insurance Code, Chapter 3503, Subchapter A; (ii) be in a form approved by HHSC; and(iii) clearly and prominently display on the face of the bond:(I) the name, mailing address, physical address, and telephone number of the surety company or financial institution to which any notice of claim should be sent; or(II) the toll-free telephone number maintained by the Texas Department of Insurance in accordance with Texas Insurance Code, Chapter 521, Subchapter B, and a statement that the address of the surety company to which any notice of claim should be sent may be obtained from the Texas Department of Insurance by calling the toll-free telephone number.(K) If an applicant chooses to provide an irrevocable letter of credit, the irrevocable letter of credit must be issued by a banking institution or similar financial/lending institution.(L) An applicant must notify HHSC at least 60 days in advance if:(i) the applicant does not intend to renew its performance bond, surety bond, or irrevocable letter of credit on the annual renewal date; or(ii) the applicant changes the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(M) An applicant may choose a performance bond, surety bond, or irrevocable letter of credit, and may substitute one for the other over the course of development and construction, but regardless of which option is chosen, the performance bond, surety bond, or irrevocable letter of credit must continue in effect until the facility is certified to participate in the Medicaid program; or until paid to HHSC after notice provided in accordance with subparagraph (N) of this paragraph.(N) A performance bond, surety bond, or irrevocable letter of credit is immediately due and must be paid to HHSC upon receipt of notice from HHSC to the issuer of the performance bond, surety bond, or irrevocable letter of credit that:(i) the applicant did not comply with subsection (i)(4)(G) of this section, which may include an extension granted under subsection (i)(6) of this section;(ii) HHSC revokes the applicant's waiver;(iii) the applicant did not notify HHSC of its intent not to renew the performance bond, surety bond, or irrevocable letter of credit at least 60 days before its automatic annual renewal date; or(iv) the applicant did not notify HHSC of a change in the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(3) Criminal justice waiver. The criminal justice waiver is designed to meet the needs of the Texas Department of Criminal Justice (TDCJ). The applicant must document that:(A) the waiver is needed to meet the identified and determined nursing facility needs of TDCJ; and(B) the new nursing facility is approved by TDCJ to serve persons under their supervision who have been released on parole, mandatory supervision, or special needs parole in accordance with Texas Government Code, Chapter 508, Parole and Mandatory Supervision.(4) Economically disadvantaged waiver. The economically disadvantaged waiver is designed to meet the needs of residents of ZIP codes located in communities where a majority of residents have an average income below the countywide average income and do not have reasonable access to acceptable nursing facility care. (A) The applicant must submit a demographic or health needs study, prepared by an independent professional experienced at preparing demographic or health needs studies that documents: (i) the ZIP code in which the new nursing facility will be constructed has a population with an income that is at least 20 percent below the average income of the county according to the most recent U.S. census or more recent census projection; (ii) an immediate need for additional Medicaid beds in the ZIP code in which the new nursing facility will be constructed; and(iii) residents in the ZIP code in which the nursing facility or beds will be located do not have reasonable access to acceptable nursing facility care.(B) The application must include a statement by the preparer of the study that the preparer has no interest, financial or otherwise, in the outcome of the waiver application.(C) The demographic or health needs study must include at least the following information pertaining to the community's population: (i) population growth trends;(ii) population growth trends specific to the elderly, including income or financial condition;(iii) Medicaid bed occupancy data;(iv) level of acceptable care provided by local facilities; and(v) any existing allocated Medicaid beds not currently certified but could be used for a new Medicaid nursing facility.(D) When determining the immediate need for additional Medicaid beds, and whether residents have reasonable access to acceptable nursing facility care, HHSC considers:(i) the number and occupancy rate of certified Medicaid beds that comply with level of acceptable care requirements; and(ii) the number of encumbered Medicaid beds that have been approved by HHSC but are not yet certified.(E) Replacement beds or waiver beds approved in accordance with subsection (f)(1) or (h) of this section will not be considered in the calculation in subparagraph (D) of this paragraph if the owner of the replacement beds or waiver beds has not purchased land for a new construction site within 24 months after the date HHSC initially approves the replacement request or the waiver for the beds.(F) HHSC considers an application withdrawn if it is not completed within 90 days after the application is submitted to HHSC.(G) HHSC notifies local nursing facilities when a complete economically disadvantaged waiver application is received and affords local nursing facilities an opportunity to comment on the waiver application. The notification includes a deadline for submission of comments. HHSC limits subsequent comments during the review process to facilities that submit timely comments in response to the notification of a completed application.(H) An applicant that is granted an economically disadvantaged waiver must provide to HHSC a performance bond, surety bond, or an irrevocable letter of credit in the amount of $500,000 payable to HHSC to ensure that the Medicaid beds granted to the applicant under the waiver are certified within the time periods required by subsection (i)(4)(G) of this section, including any extensions granted under subsection (i)(6) of this section. HHSC will revoke a waiver if the performance bond, surety bond, or irrevocable letter of credit is not provided within 90 days after HHSC approves the waiver application.(I) If an applicant chooses to provide a performance bond or surety bond instead of an irrevocable letter of credit, the performance bond provided under this subparagraph must:(i) be executed by a corporate entity in accordance with Texas Insurance Code, Chapter 3503, Subchapter A;(ii) be in a form approved by HHSC; and(iii) clearly and prominently display on the face of the bond:(I) the name, mailing address, physical address, and telephone number of the surety company or financial institution to which any notice of claim should be sent; or(II) the toll-free telephone number maintained by the Texas Department of Insurance in accordance with Texas Insurance Code, Chapter 521, Subchapter B, and a statement that the address of the surety company to which any notice of claim should be sent may be obtained from the Texas Department of Insurance by calling the toll-free telephone number.(J) If an applicant chooses to provide an irrevocable letter of credit, the irrevocable letter of credit must be issued by a banking institution or similar financial institution.(K) An applicant must notify HHSC at least 60 days in advance if:(i) the applicant does not intend to renew its performance bond, surety bond, or irrevocable letter of credit on the annual renewal date; or(ii) the applicant changes the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(L) An applicant may choose a performance bond, surety bond, or irrevocable letter of credit, and may substitute one for the other over the course of development and construction, but regardless of which option is chosen, the performance bond, surety bond, or irrevocable letter of credit must continue in effect until the facility is certified to participate in the Medicaid program; or until paid to HHSC after notice provided in accordance with subparagraph (M) of this paragraph.(M) A performance bond, surety bond, or irrevocable letter of credit is immediately due and must be paid to HHSC upon receipt of notice from HHSC to the issuer of the performance bond, surety bond, or irrevocable letter of credit that:(i) the applicant did not comply with subsection (i)(4)(G) of this section, which may include an extension granted under subsection (i)(6) of this section;(ii) HHSC revokes the applicant's waiver;(iii) the applicant did not notify HHSC of its intent not to renew the performance bond, surety bond, or irrevocable letter of credit at least 60 days before its automatic annual renewal date; or(iv) the applicant did not notify HHSC of a change in the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(5) Alzheimer's waiver. The Alzheimer's waiver is designed to meet the needs of communities that do not have reasonable access to Alzheimer's nursing facility services.(A) The applicant must document that:(i) the nursing facility is affiliated with a medical school operated by the state;(ii) the nursing facility will participate in ongoing research programs for the care and treatment of persons with Alzheimer's disease;(iii) the nursing facility will be designed to separate and treat residents with Alzheimer's disease by stage and functional level;(iv) the nursing facility will obtain and maintain voluntary certification as an Alzheimer's nursing facility in accordance with §§19.2204, 19.2206, and 19.2208 of this chapter (relating to Voluntary Certification of Facilities for Care of Persons with Alzheimer's Disease; General Requirements for a Certified Facility; and Standards for Certified Alzheimer's Facilities); and(v) only residents with Alzheimer's disease or related dementia will be admitted to the Alzheimer's Medicaid beds.(B) The applicant must submit a demographic or health needs study, prepared by an independent professional experienced at preparing demographic studies that documents the need for the number of Medicaid Alzheimer's beds requested. The study must include a statement by the preparer of the study that the preparer has no interest, financial or otherwise, in the outcome of the waiver application.(C) HHSC notifies local nursing facilities when a complete Alzheimer's waiver application is received and afford local nursing facilities an opportunity to comment on the waiver application. The notification will include a deadline for submission of comments. HHSC limits subsequent comments during the review process to facilities that submit timely comments in response to the notification of a completed application.(D) HHSC considers an application withdrawn if it is not completed within 90 days after the application is submitted to HHSC.(E) A facility that has Medicaid beds allocated under provisions of an Alzheimer's waiver may apply for a waiver in accordance with other subsections of this section, including subsection (f)(3) or (4) of this section. HHSC does not count the beds allocated under an Alzheimer's waiver to determine the allowable bed allocation increase. For example, a 120-bed nursing facility with 60 Alzheimer waiver beds would be eligible for 10 percent of the 60 remaining beds or six additional Medicaid beds.(6) Teaching nursing facility waiver. A teaching nursing facility waiver is designed to meet the statewide needs for providing training and practical experience for health-care professionals. The applicant must submit documentation that the nursing facility:(A) is affiliated with a state-supported medical school;(B) is located on land owned or controlled by the state-supported medical school; and(C) serves as a teaching nursing facility for physicians and related health-care professionals.(7) Rural county waiver. A rural county waiver is designed to meet the needs of rural areas of the state that do not have reasonable access to acceptable nursing facility care. For purposes of this waiver, a rural county is one that has a population of 100,000 or less according to the most recent census, and has no more than two Medicaid-certified nursing facilities. HHSC approves no more than 120 additional Medicaid beds per county per year and no more than 500 additional Medicaid beds statewide in a calendar year under this waiver provision. HHSC considers a waiver application on a first-come, first-served basis. Requests received in a year in which the 500-bed limit has been met will be carried over to the next year. The county commissioner's court must request the waiver.(A) The commissioner's court must notify HHSC of its intent to consider a rural county waiver and obtain verification from HHSC that the county complies with the definition of rural county.(B) The commissioner's court must publish a notice in the Texas Register and in a newspaper of general circulation in the county. The notice must seek:(i) comments on whether a new Medicaid nursing facility should be requested; and(ii) proposals from persons or entities interested in providing additional Medicaid-certified beds in the county, including persons or entities currently operating Medicaid-certified facilities with high occupancy rates. HHSC, in its sole discretion, may eliminate from participating in the process persons or entities that submit false or fraudulent information.(C) The commissioner's court must determine whether to proceed with the waiver request after considering all comments and proposals received in response to the notices provided under subparagraph (B) of this paragraph. In determining whether to proceed with the waiver request, the commissioner's court must consider:(i) the demographic and economic needs of the county;(ii) the quality of existing Medicaid nursing facilities in the county;(iii) the quality of the proposals submitted, including a review of the past history of care provided, if any, by the person or entity submitting the proposal; and(iv) the degree of community support for additional Medicaid nursing facility services.(D) The commissioner's court must document the comments received, proposals offered and factors considered in subparagraph (C) of this paragraph.(E) If the commissioner's court decides to proceed with the waiver request, it must submit a recommendation that HHSC issue a waiver to a person or entity who submitted a proposal for new or additional Medicaid beds. The recommendation must include:(i) the name, address, and telephone number of the person or entity recommended for contracting for the Medicaid beds;(ii) the location, if the commissioner's court desires to identify one, of the recommended nursing facility;(iii) the number of beds recommended; and(iv) the information listed in subparagraph (D) of this paragraph used to make the recommendation.(F) An applicant that is granted a rural county waiver must provide to HHSC a performance bond, surety bond, or an irrevocable letter of credit in the amount of $500,000 payable to HHSC to ensure that the Medicaid beds granted to the applicant under the waiver are certified within the time periods required by subsection (i)(4)(G) of this section, including any extensions granted under subsection (i)(6) of this section. HHSC will revoke a waiver if the performance bond, surety bond, or irrevocable letter of credit is not provided within 90 days after HHSC approves the waiver application.(G) If an applicant chooses to provide a performance bond or surety bond, instead of an irrevocable letter of credit, the performance bond or surety bond provided under this subchapter must:(i) be executed by a corporate entity in accordance with Texas Insurance Code, Chapter 3503, Subchapter A;(ii) be in a form approved by HHSC; and(iii) clearly and prominently display on the face of the bond:(I) the name, mailing address, physical address, and telephone number of the surety company or financial institution to which any notice of claim should be sent; or(II) the toll-free telephone number maintained by the Texas Department of Insurance in accordance with Texas Insurance Code, Chapter 521, Subchapter B, and a statement that the address of the surety company to which any notice of claim should be sent may be obtained from the Texas Department of Insurance by calling the toll-free telephone number.(H) If an applicant chooses to provide an irrevocable letter of credit, the irrevocable letter of credit must be issued by a banking institution or similar financial/lending institution.(I) An applicant must notify HHSC at least 60 days in advance if:(i) the applicant does not intend to renew its performance bond, surety bond, or irrevocable letter of credit on the annual renewal date; or(ii) the applicant changes the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(J) An applicant may choose a performance bond, surety bond, or irrevocable letter of credit, and may substitute one for the other over the course of development and construction, but regardless of which option is chosen, the performance bond, surety bond, or irrevocable letter of credit must continue in effect until the facility if certified to participate in the Medicaid program; or until paid to HHSC after notice provided in accordance with subparagraph (K) of this paragraph.(K) A performance bond, surety bond, or irrevocable letter of credit is immediately due and must be paid to HHSC upon receipt of notice from HHSC to the issuer of the performance bond, surety bond, or irrevocable letter of credit that:(i) the applicant did not comply with subsection (i)(4)(G) of this section, which may include an extension granted under subsection (i)(6) of this section;(ii) HHSC revokes the applicant's waiver;(iii) the applicant did not notify HHSC of its intent not to renew the performance bond, surety bond, or irrevocable letter of credit at least 60 days before its automatic annual renewal date; or(iv) the applicant did not notify HHSC of a change in the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(8) State veterans homes. State veterans homes, authorized and built under the auspices of the Texas Veterans Land Board, must meet all requirements for Medicaid participation.(9) Small house waiver. A small house waiver is designed to promote the construction of smaller nursing facility buildings that provide a homelike environment.(A) A facility must meet the requirements in §19.345 of this chapter (relating to Small House and Household Facilities) for HHSC to grant a small house waiver for the facility.(B) An applicant for a small house waiver must submit an application to HHSC and a schematic building plan of the proposed facility with sufficient detail to demonstrate that the proposed project meets the requirements in §19.345 of this chapter.(C) An applicant that is granted a small house waiver must submit final construction documents in accordance with §19.344 of this chapter (relating to Plans, Approvals, and Construction Procedures) before facility construction begins.(D) HHSC notifies local nursing facilities when a complete small house waiver application is received and allows the local nursing facilities to comment on the waiver application. The notification includes the deadline for submitting comments. HHSC limits subsequent comments during the review process to facilities that submit timely comments in response to the notification of a completed application.(E) HHSC does not approve more than 16 beds for a small house facility or for a household in a facility that is granted a small house waiver.(F) HHSC considers an application withdrawn if it is not completed within 90 days after the application is submitted to HHSC.(G) Subject to subparagraph (E) of this paragraph, HHSC approves the replacement or transfer of beds certified at a small house nursing facility in accordance with subsection (f)(1) or (2) of this section only to another small house or household facility.(H) A facility that has Medicaid beds allocated under provisions of a small house waiver may apply for general Medicaid beds in accordance with other subsections of this section, including subsection (f)(3) or (4) of this section. HHSC does not count the beds allocated under a small house waiver provision in determining the allowable bed allocation increase. For example, a 120-bed nursing facility with 60 Small House waiver beds would be eligible for 10 percent of the 60 remaining beds or six additional Medicaid beds.(I) An applicant that is granted a small house waiver must provide to HHSC a performance bond, surety bond, or an irrevocable letter of credit in the amount of $500,000 payable to HHSC to ensure that the Medicaid beds granted to the applicant under the waiver are certified within the time periods required by subsection (i)(4)(G) of this section, including any extensions granted under subsection (i)(6) of this section. HHSC will revoke a waiver if the performance bond, surety bond, or irrevocable letter of credit is not provided within 90 days after HHSC approves the waiver application.(J) If an applicant chooses to provide a performance bond or surety bond, instead of an irrevocable letter of credit, the performance bond or surety bond provided under this subparagraph must:(i) be executed by a corporate entity in accordance with Texas Insurance Code, Chapter 3503, Subchapter A;(ii) be in a form approved by HHSC; and(iii) clearly and prominently display on the face of the bond:(I) the name, mailing address, physical address, and telephone number of the surety company or financial institution to which any notice of claim should be sent; or(II) the toll-free telephone number maintained by the Texas Department of Insurance in accordance Texas Insurance Code, Chapter 521, Subchapter B, and a statement that the address of the surety company to which any notice of claim should be sent may be obtained from the Texas Department of Insurance by calling the toll-free telephone number.(K) If an applicant chooses to provide an irrevocable letter of credit, the irrevocable letter of credit must be issued by a banking institution or similar financial/lending institution.(L) An applicant must notify HHSC at least 60 days in advance if:(i) the applicant does not intend to renew its performance bond, surety bond, or irrevocable letter of credit on the annual renewal date; or(ii) the applicant changes the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(M) An applicant may choose a performance bond, surety bond, or irrevocable letter of credit, and may substitute one for the other over the course of development and construction, but regardless of which option is chosen, the performance bond, surety bond, or irrevocable letter of credit must continue in effect until the facility is certified to participate in the Medicaid program; or until paid to HHSC after notice provided in accordance with subparagraph (N) of this paragraph.(N) A performance bond, surety bond, or irrevocable letter of credit is immediately due and must be paid to HHSC upon receipt of notice from HHSC to the issuer of the performance bond, surety bond, or irrevocable letter of credit that:(i) the applicant did not comply with subsection (i)(4)(G) of this section, which may include an extension granted under subsection (i)(6) of this section;(ii) HHSC revokes the applicant's waiver;(iii) the applicant did not notify HHSC of its intent not to renew the performance bond, surety bond, or irrevocable letter of credit at least 60 days before its automatic annual renewal date; or(iv) the applicant did not notify HHSC of a change in the lending institution or surety bond company administering the performance bond, surety bond, or irrevocable letter of credit.(i) Time Limits and Extensions.(1) Medicaid beds transferred in accordance with subsection (f)(2) of this section must be certified within six months after HHSC grants the exemption.(2) Time limits applicable to temporary Medicaid beds are specified in subsection (f)(6) of this section.(3) All facilities and beds approved in accordance with waiver provisions of subsection (h) of this section and replacement nursing facilities approved in accordance with subsection (f)(1) of this section, must be constructed, licensed, and Medicaid-certified within 42 months after the waiver or replacement exemption is granted.(4) A recipient of a waiver must provide HHSC with evidence of compliance with subparagraphs (A) - (G) of this paragraph. The recipient must submit evidence of compliance on or before the date stated in the subparagraph, including any extensions granted under paragraph (6) of this subsection.(A) The land must be under contract within 12 months after HHSC approval of the waiver or replacement.(B) An architect or engineer must be under contract to prepare final construction documents within 15 months after HHSC approval of the waiver or replacement.(C) The facility's preliminary plans must be completed within 18 months after HHSC approval of the waiver or replacement.(D) The land must be purchased and a progress report submitted to HHSC within 24 months after HHSC approval of the waiver or replacement.(E) Entitlements (including municipality, planning and zoning, building permit) and the facility's foundation must be completed within six months after land purchase or 30 months after HHSC approval of the waiver or replacement, whichever is later.(F) Facility construction must be active and ongoing, as evidenced by a construction progress report submitted to HHSC within 12 months after land purchase or 36 months after HHSC approval of the waiver or replacement, whichever is later.(G) The facility must be constructed, licensed, and certified within 18 months after land purchase or 42 months after HHSC approval of the waiver or replacement, whichever is later.(5) HHSC, in its sole discretion, may declare the exemption or the waiver void if the applicant fails or refuses to provide evidence of compliance with each benchmark or deadline, or the evidence of compliance submitted to HHSC in accordance with paragraph (4) of this subsection contains false or fraudulent information.(6) Waiver or exemption recipients may request an extension of the deadlines in this section. At the discretion of the executive commissioner or the executive commissioner's designee, deadlines specified in this section may be extended. The applicant must substantiate every element of its extension request with evidence of good-faith efforts to meet the benchmarks and construction deadlines or evidence confirming that delays were beyond the applicant's control.(7) Waiver or exemption recipients who receive an extension of their waiver or exemption must submit a progress report every six months after approval of the extension until the nursing facility beds are certified. HHSC may declare the waiver or exemption void if the applicant fails or refuses to provide the progress report as required or if the progress report contains false or fraudulent information. (8) HHSC may revoke a bed allocation for failure to meet the requirements of this section.(j) Loss of Medicaid Beds.(1) Loss of Medicaid beds that are not available to be occupied.(A) Medicaid nursing facilities must report certified Medicaid beds that do not comply with requirements of §19.1701 of this chapter (relating to Physical Environment) and are not available for occupancy on monthly Medicaid occupancy reports.(B) HHSC decertifies and de-allocates Medicaid beds that are intended for use in bedrooms that have been converted to other uses if the rooms are not being used for bedroom occupancy use on two consecutive standard surveys.(C) HHSC does not decertify and de-allocate Medicaid beds that are intended for use in rooms that are licensed and certified for multi-occupancy use but are being used for single occupancy only.(D) HHSC decertifies and de-allocates Medicaid beds granted through a criminal justice waiver, Alzheimer's waiver, a teaching nursing facility waiver, state veterans home waiver, or a small house waiver that are no longer being used for the intended purpose for which the waiver was granted.(2) Loss of Medicaid beds based on sanctions.(A) A Medicaid nursing facility operated by the person or entity who also owns the property will lose the allocation of all Medicaid beds assigned to the nursing facility property if the nursing facility's license is denied or revoked.(B) A Medicaid nursing facility operated by one person or entity and owned by another person or entity will lose the allocation of Medicaid beds if two or more of the following actions occur within a 42-month period:(i) licensure denial;(ii) licensure revocation; or(iii) Medicaid termination.(C) HHSC may waive this loss of allocation of Medicaid beds in order to facilitate a change of ownership or other actions that would protect the health and safety of residents or assure reasonable access to acceptable nursing facility care.(3) Voluntary decertification of Medicaid beds.(A) Facilities may request to voluntarily decertify Medicaid beds.(B) The licensee must submit written approval of the Medicaid bed reduction signed by the property owner and all physical plant lien holders.(C) HHSC reduces the number of allocated Medicaid beds equal to the number of beds voluntarily decertified. (D) Facilities that voluntarily decertify Medicaid beds are eligible to receive an increased allocation of Medicaid beds if the facility qualifies for a bed allocation waiver or exemption.(4) Nursing facility ceases to operate or participate in Medicaid.(A) The property owner of a nursing facility that closes or ceases to participate in the Medicaid program must inform HHSC in writing of the intended future use of the Medicaid beds within 90 days after closure or ceasing participation in Medicaid.(B) Unless the Medicaid beds will be used for a replacement nursing facility, the allocated beds must be re-certified within 12 months of the date the Medicaid contract was terminated.(C) Time limits in subparagraphs (A) and (B) of this paragraph may be extended in accordance with subsection (i)(6) of this section.(D) HHSC may de-allocate Medicaid beds for failure to meet the requirements of this paragraph.(5) Loss of Medicaid beds based on low occupancy.(A) HHSC may review Medicaid bed occupancy rates annually for the purpose of de-allocating and decertifying unused Medicaid beds. The Medicaid bed occupancy reports for the most recent six-month period that HHSC has validated are used to determine the bed occupancy rate of each nursing facility.(B) HHSC de-allocates and decertifies Medicaid beds in facilities with an average occupancy rate below 70 percent. The number of beds decertified is calculated by subtracting the preceding six-month average occupancy rate of Medicaid-certified beds from 70 percent of the number of allocated certified beds and dividing the difference by 2, rounding the final figure down if necessary. For example, for a facility with 100 Medicaid-certified beds and a 50 percent occupancy rate, the difference between 70 percent (70 beds) and 50 percent (50 beds) is 20 beds, divided by 2, is 10 beds to be decertified.(C) Medicaid beds in a nursing facility that has obtained a replacement nursing facility exemption are not subject to the de-allocation and decertification process.(D) Medicaid beds in a new or replacement physical plant or a newly constructed wing of an existing physical plant are exempt from this de-allocation and decertification process until the new physical plant or new wing has been certified for 24 months.(E) Medicaid beds that have been subject to a change of ownership within the past 24 months are exempt from the de-allocation and decertification process.(F) Medicaid beds in a county or in a precinct in one of the four most populous counties in the state in which a facility approved through the waiver process is constructed are exempt from the de-allocation and decertification process for 24 months after licensure and certification of the facility.(G) Medicaid beds allocated to a closed nursing facility are exempt from this de-allocation and decertification process.(H) Nursing facilities that lose Medicaid beds through this process are eligible to receive an additional allocation of Medicaid beds at a later date if the facility qualifies for a bed allocation waiver or exemption.(I) The de-allocation and decertification of unused beds does not affect the licensed capacity of a nursing facility.(k) Informal review procedures.(1) A waiver or exemption applicant, or a Medicaid nursing facility that has been denied an increase in Medicaid bed allocation or was subject to decertification or de-allocation of Medicaid beds, may request an informal review of HHSC actions regarding bed allocations. The request must be submitted within 30 days after the date referenced on the notification of the proposed action.(2) A waiver or exemption applicant or a Medicaid nursing facility that has been denied an increase in Medicaid bed allocation or was subject to decertification or de-allocation of Medicaid beds, must submit a request for an informal review and all documentation or evidence that forms the basis for the informal review in writing.(3) The executive commissioner or the executive commissioner's designee conducts the informal review.(l) Medicaid occupancy reports.(1) Medicaid nursing facilities must submit occupancy reports to HHSC each month.(A) The occupancy data must be reported on a form prescribed by HHSC. The form must be completed in accordance with instructions and the occupancy data must be accurate and verifiable. The completed report must be received by HHSC no later than the fifth day of the month following the reporting period.(B) HHSC determines the Medicaid occupancy rate by calculating the monthly average of the number of persons who occupy Medicaid beds.(C) HHSC includes all persons residing in Medicaid-certified beds, including Medicaid recipients, Medicare recipients, private-pay residents, or residents with other sources of payment, in the calculation. (D) Failure or refusal to submit accurate occupancy reports in a timely manner may result in the nursing facility's vendor payment being held in abeyance until the report is submitted.(2) HHSC determines nursing facility and county occupancy rates based on the data submitted by the nursing facilities. (A) HHSC uses the occupancy data to determine eligibility for or compliance with waiver and exemption requirements. HHSC also uses the occupancy data to determine if Medicaid beds should be decertified based on low occupancy.(B) HHSC makes the occupancy data available to nursing facilities, licensees, property owners, waiver or exemption applicants, and others in accordance with public disclosure requirements.(C) HHSC may disqualify a facility that provides inaccurate or falsified occupancy data from eligibility for bed allocation exemptions and waivers. HHSC may refuse to accept corrections to bed occupancy data submitted more than six months after the due date of the occupancy report.(m) School-age residents. Any bed allocation waiver or exemption applicant that serves or plans to serve school-age residents must provide written notice to the affected local education agency (LEA) of its intent to establish or expand a nursing facility within the LEA's boundary. Source Note: The provisions of this §554.2322 adopted to be effective November 1, 2002, 27 TexReg 9154; amended to be effective October 23, 2013, 38 TexReg 7316; amended to be effective April 1, 2014, 39 TexReg 2313; amended to be effective August 31, 2015, 40 TexReg 5464; amended to be effective February 20, 2018, 43 TexReg 900; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2322 Medicaid Bed Allocation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210961 03/12/2026 (a) Program description. HHSC operates the Medicaid Swing Bed Program for rural hospitals located in counties with populations of 100,000 or less. The Medicaid Swing Bed Program is modeled on Medicare's Swing Bed Program. The Medicaid Swing Bed Program permits participating rural hospitals to use their beds interchangeably to furnish both acute hospital care and nursing facility care to Medicaid recipients, when no care beds are available in nursing facilities (NFs) in the area. When a participating rural hospital furnishes NF nursing care to Medicaid recipients, HHSC makes payment to the hospital using the same procedures and the same Resource Utilization Group daily rates that the Texas Health and Human Services Commission authorizes for reimbursing NFs participating in the Texas Medicaid Nursing Home Program.(b) Application to participate. Rural hospitals apply to HHSC to participate in the Medicaid Swing Bed Program. Each applicant must be located in a county with a population of 100,000 or less and must meet the qualifying requirements of the Medicare Swing Bed Program. Hospitals approved for participation enter into swing bed provider agreements with HHSC.(c) Parallel participation in Medicare. A rural hospital participating in the Medicaid Swing Bed Program must:(1) have a Medicare hospital provider agreement; and(2) be Medicare-certified as a swing bed hospital in the Medicare Swing Bed Program.(d) Applicability of Medicare requirements. Each participating rural hospital must satisfy all the requirements of the Medicare Swing Bed Program, except that Medicare's five-weekday transfer requirement and 15 percent payment limitation, as stated in 42 CFR §413.114(d)(2), do not apply for Medicaid reimbursement purposes.(e) Applicability of NF requirements. From day one of the resident's stay, a rural hospital participating in the Medicaid Swing Bed Program must meet the requirements set forth in §554.2304(c) of this chapter (relating to Contract Requirements); §§554.2601 - 554.2608 and 554.2610 of this chapter (relating to Vendor Payment (Items and Services Included), Additional Charges (Items and Services Excluded from Vendor Payment), Therapeutic Home Visits Away from the Facility, Vendor Payment Information, Effective Date of Vendor Coverage, Supplementation of Vendor Payments, Penalties for Supplementation, Limitations on Provider Charges, and Medicare part A Skilled Nursing Facility Deductible and Coinsurance Payment); and Subchapter Y of this chapter (relating to Medical Necessity Determinations).(f) Rural hospital (Medicaid swing bed facility) licensure and certification requirements. Pursuant to Texas Health and Safety Code §222.024 concerning the duplication of health care inspections and licensing, a rural hospital participating in the Medicaid Swing Bed Program satisfies licensure and certification requirements referenced in this section when it is currently licensed and certified as a hospital. However, in accordance with Texas Human Resources Code, §32.024, if the rural hospital's swing beds are used for more than one 30-day length of stay per year, per resident the hospital must comply with the full Nursing Facility Requirements.(g) Rural hospital (Medicaid swing bed facility) administrator. The governing body of a rural hospital participating in the Medicaid Swing Bed Program satisfies the requirement to appoint a qualified full-time nursing facility administrator, found at §554.1902(b) of this chapter (relating to Governing Body), when it appoints a hospital administrator as its official representative and designates the administrator's responsibilities and authority, subject to the following exception. If the swing beds are used for more than one 30-day length of stay per year, per resident, the hospital's governing body must appoint a full-time licensed nursing facility administrator.(h) Rural hospital (Medicaid swing bed facility) staff development requirements. A rural hospital participating in the Medicaid Swing Bed Program satisfies the staff development requirements found at §554.1929 of this chapter (relating to Staff Development) if the swing beds are used for no more than one 30-day length of stay per year, per resident.(i) Rural hospital (Medicaid swing bed facility) transfer agreement. A rural hospital participating in the Medicaid Swing Bed Program is not required to have a transfer agreement with another hospital, as required by §554.1915 of this chapter (relating to Transfer Agreement).(j) Rural hospital geographic region. The phrase "a participating rural hospital's geographic region" refers to an area that includes nursing facilities with which the hospital normally arranges transfers and all other nursing facilities in similar proximity to the hospital. If a hospital has no previous transfer practices on which to base a determination, the phrase "geographic region" refers to an area that includes all nursing facilities within 50 miles of the hospital except for facilities that the hospital demonstrates to be inaccessible to its patients. Source Note: The provisions of this §554.2326 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective July 1, 1996, 21 TexReg 4408; amended to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION X REQUIREMENTS FOR MEDICAID-CERTIFIED FACILITIES §554.2326 Medicaid Swing Bed Program for Rural Hospitals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203292 03/12/2026 Medical necessity is the prerequisite for participation in the Medicaid (Title XIX) Long-term Care program. This section contains the general qualifications for a medical necessity determination. To verify that medical necessity exists, an individual must meet the conditions described in paragraphs (1) and (2) of this section.(1) The individual must demonstrate a medical condition that:(A) is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and(B) requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.(2) The individual must require medical or nursing services that:(A) are ordered by a physician;(B) are dependent upon the individual's documented medical conditions;(C) require the skills of a registered or licensed vocational nurse;(D) are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and(E) are required on a regular basis. Source Note: The provisions of this §554.2401 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Y MEDICAL NECESSITY DETERMINATIONS §554.2401 General Qualifications for Medical Necessity Determinations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203293 03/12/2026 (a) Purpose. A recipient must have a determination of medical necessity for nursing facility care to participate in the Texas Medicaid Nursing Facility Program.(1) The state Medicaid claims administrator makes a medical necessity determination by evaluating a recipient's medical and nursing needs based on the MDS assessment required by DADS.(2) A recipient must have a determination of medical necessity for nursing facility care before the nursing facility can be paid for services, except as provided in §19.2413 of this subchapter (relating to Determination of Payment Rate Based on the MDS Assessment Submission) and §19.2611 of this chapter (relating to Retroactive Vendor Payment).(b) Admission MDS assessment review.(1) The admission MDS assessment review process is initiated when the state Medicaid claims administrator receives an MDS assessment and the Long-Term Care Medicaid Information Section, in accordance with §19.2413 of this subchapter, indicating that a Medicaid applicant or recipient is requesting vendor payment for care in a contracted nursing facility. A registered nurse must sign and certify that the MDS assessment is completed in accordance with §19.801 of this chapter (relating to Resident Assessment).(2) The admission MDS assessment review determines medical necessity and establishes the authorization for payment of a calculated RUG rate.(c) Role of the state Medicaid claims administrator. The state Medicaid claims administrator reviews all MDS assessments, including significant change in status assessments, modifications, and significant corrections, and approves or denies medical necessity in accordance with §19.2401 of this subchapter (relating to General Qualifications for Medical Necessity Determinations).(d) Effective period.(1) A determination of medical necessity based on the admission MDS assessment review remains in effect for the time period determined by the federal MDS submission schedule.(2) If a nursing facility submits a recipient's MDS assessment after the due date established by the federal MDS submission schedule, the recipient's medical necessity remains in effect for the period between the due date and the date the state Medicaid claims administrator received the MDS assessment.(3) If a nursing facility submits a recipient's MDS assessment after the due date established by the federal MDS submission schedule and, after reviewing the MDS assessment, the state Medicaid claims administrator determines that the recipient does not meet the criteria for medical necessity, the effective date of the denial of medical necessity is the date the state Medicaid claims administrator received the MDS assessment. A denial of medical necessity is conducted in accordance with §19.2407 of this subchapter (relating to Denied Medical Necessity).(e) Permanent medical necessity.(1) A recipient's permanent medical necessity status is established on the completion date of any MDS assessment approved for medical necessity no less than 184 calendar days after the recipient's admission to the Texas Medicaid Nursing Facility Program.(2) A nursing facility must submit a recipient's MDS assessment in compliance with the federal MDS submission schedule even after the recipient achieves permanent medical necessity status.(3) A recipient's permanent medical necessity status moves with the recipient, unless the recipient is discharged to home for more than 30 days.(4) If a recipient who has permanent medical necessity status transfers to another Medicaid-certified nursing facility, the nursing facility to which the recipient transfers must complete a new MDS assessment in compliance with the federal MDS submission schedule.(f) Insufficient information. If an MDS assessment does not have sufficient information for the state Medicaid claims administrator to make a medical necessity determination, the MDS assessment is put in suspense for 21 days with a message from the state Medicaid claims administrator informing the nursing facility that the MDS assessment has been put in suspense for 21 days. Unless the nursing facility provides sufficient information on the MDS assessment to determine medical necessity within 21 days, medical necessity is denied. Source Note: The provisions of this §554.2403 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Y MEDICAL NECESSITY DETERMINATIONS §554.2403 Medical Necessity Determination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203294 03/12/2026 The recipient's physician is required at intervals specified in §19.1210(b) of this title (relating to Certification and Recertification Requirements in Medicaid-Certified Facilities) to certify or recertify the necessity for continued nursing facility care. Source Note: The provisions of this §554.2405 adopted to be effective May 1, 1995, 20 TexReg 2393; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Y MEDICAL NECESSITY DETERMINATIONS §554.2405 Physicians' Certifications and Recertifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203295 03/12/2026 (a) If the state Medicaid claims administrator determines that a Medicaid applicant or a recipient does not meet the criteria for medical necessity described in §19.2401 of this subchapter (relating to General Qualifications for Medical Necessity Determinations), the state Medicaid claims administrator notifies the attending physician and the nursing facility in writing and provides them an opportunity to present additional information about the applicant's or recipient's medical need for nursing facility care.(1) If the attending physician or a nursing facility physician does not respond or contest the findings of the state Medicaid claims administrator within 10 working days after receipt of the written notice about the decision, the findings are final.(2) If the attending physician or a nursing facility physician contests the findings of the state Medicaid claims administrator, at least one physician with the state Medicaid claims administrator must review the case. If the state Medicaid claims administrator's physician determines that the applicant's or recipient's admission or stay is not medically necessary, the determination becomes final.(3) The state Medicaid claims administrator sends written notification of the final determination of denied medical necessity to the attending physician, the nursing facility, and the applicant or recipient (or responsible party).(b) After an applicant receives written notice of a determination of denied medical necessity, the applicant or responsible party must request a fair hearing within 90 days after the date of denied medical necessity, or the applicant loses the right to a fair hearing.(c) After a recipient receives written notice of a determination of denied medical necessity, the recipient or responsible party must request a fair hearing within 10 days after the date of the written notice in order to have nursing facility services paid for during the appeal.(1) If the recipient requests a fair hearing within 10 days after the date of the written notice and the determination of denied medical necessity is upheld, the effective date of the denial is 10 days after the hearing officer's written decision.(2) If the recipient does not request a fair hearing within 10 days after the date of the written notice, DADS makes vendor payments to the nursing facility at the previously established RUG rate for 15 days or until the recipient is discharged, whichever occurs first.(3) If the recipient does not request a fair hearing within 10 days after the date of the written notice, the recipient must request a fair hearing within 90 days after the date of denied medical necessity, or the recipient loses the right to a fair hearing.(d) Fair hearings are conducted by the Texas Health and Human Services Commission (HHSC) in accordance with HHSC rules at 1 TAC Chapter 357. Source Note: The provisions of this §554.2407 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Y MEDICAL NECESSITY DETERMINATIONS §554.2407 Denied Medical Necessity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203296 03/12/2026 (a) Definitions. In this section, the following words and terms have the following meanings unless the context clearly indicates otherwise.(1) All conditions of eligibility--A recipient meets all conditions of eligibility when the state Medicaid claims administrator approves the recipient for medical necessity and the recipient meets financial eligibility for Medicaid.(2) On-time MDS assessment--An MDS assessment that is submitted in accordance with the federal MDS submission schedule and is received by the state Medicaid claims administrator within 31 days after the completion date.(3) Missed MDS assessment--An MDS assessment that is received by the state Medicaid claims administrator outside the time period that the MDS assessment covers.(b) MDS submission requirement. A nursing facility must:(1) complete all MDS assessments according to CMS' instructions;(2) submit a recipient's MDS assessment, including an admission MDS assessment, a quarterly MDS assessment, and a significant change in status assessment, to the state MDS database in compliance with the federal MDS submission schedule;(3) submit the Long-Term Care Medicaid Information Section to the state Medicaid claims administrator; and(4) submit the recipient's MDS assessment in compliance with the federal MDS submission schedule even after the recipient has permanent medical necessity as described in §19.2403(e) of this subchapter (relating to Medical Necessity Determination).(c) Admission MDS assessments.(1) If a nursing facility discharges a recipient with a status of return not anticipated, and the recipient returns to the facility, the nursing facility must complete an admission MDS assessment for a determination of medical necessity and establishment of a RUG rate, regardless of the amount of time between the recipient's discharge and return.(2) A nursing facility must complete and submit an admission MDS assessment to receive payment for a recipient's period of stay in the nursing facility, even if the recipient leaves the nursing facility before the MDS assessment is completed and never returns long enough for the MDS assessment to be completed. See subsection (i) of this section for completion of an admission MDS assessment in the event of a recipient's death.(3) DADS pays a calculated RUG rate for an admission MDS assessment from the date the recipient was admitted to the nursing facility, except as provided in §19.2611 of this chapter (relating to Retroactive Vendor Payments).(d) Payment of a calculated RUG rate. If a recipient meets all conditions of eligibility, DADS pays a calculated RUG rate for an MDS assessment if it is received by the state Medicaid claims administrator during the time period that the MDS assessment covers.(e) On-time MDS assessment. If a recipient meets all conditions of eligibility, DADS pays a calculated RUG rate from the completion date of the required MDS assessment, except for an admission MDS assessment as described in subsection (c)(3) of this section.(f) MDS assessments that are not on time. The state Medicaid claims administrator stops payment for services if the state Medicaid claims administrator does not receive an on-time MDS assessment. Payment for services resumes when the state Medicaid claims administrator receives all MDS assessments that are due as required by the federal MDS submission schedule.(g) Missed MDS assessments. When the state Medicaid claims administrator receives a missed MDS assessment, DADS pays the nursing facility a default RUG rate for the entire period of the missed MDS assessment if the recipient meets financial eligibility for Medicaid, except as provided in paragraph (2) of this subsection.(1) If an MDS assessment is missed for the purpose of calculating a RUG rate, the nursing facility must still submit the MDS assessment to comply with §19.801 of this chapter (relating to Resident Assessment).(2) For a newly contracted nursing facility and a nursing facility that undergoes a change of ownership, DADS pays the calculated RUG rate for any missed MDS assessments that occur while the nursing facility is unable to submit MDS assessments to the state MDS database.(h) Significant change in status assessment, modification, or significant correction. If a recipient meets all conditions of eligibility, DADS pays the calculated RUG rate from the completion date of a significant change in status assessment, modification, or significant correction.(i) Incomplete or erroneous MDS assessments. If an applicant meets all conditions of eligibility, DADS pays a default rate for an MDS assessment that is incomplete or has errors.(j) Prohibition against recourse. A nursing facility must not charge and must not take any other recourse against a recipient, the recipient's family members, the recipient's estate or the recipient's representative for a claim that is reduced because the facility failed to comply with a DADS rule or procedure pertaining to reimbursement. Source Note: The provisions of this §554.2413 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871. 1 HEALTH AND HUMAN SERVICES COMMISSION 554 NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION Y MEDICAL NECESSITY DETERMINATIONS §554.2413 Determination of Payment Rate Based on the MDS Assessment Submission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206734 03/12/2026 This chapter implements the provisions of the Texas Health and Safety Code, Chapter 242, Subchapter I, Nursing Facility Administration, which concern licensing nursing facility administrators in the state of Texas. Source Note: The provisions of this §555.1 adopted to be effective June 1, 2004, 29 TexReg 4233; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS A GENERAL INFORMATION §555.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220625 03/12/2026 The words and terms in this chapter have the following meanings, unless the context clearly indicates otherwise:(1) Abuse--Negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure) or Texas Penal Code Chapter 22 (relating to Assaultive Offenses), sexual harassment, sexual coercion, or sexual assault.(2) Active duty--Current full-time military service in the armed forces of the United States or as a member of the Texas military forces, as defined in Texas Government Code §437.001, or similar military service of another state.(3) Administrator-in-training (AIT)--A person undergoing an internship under a HHSC-approved certified preceptor.(4) Administrator of Record--The individual who is listed as the facility's licensed nursing facility administrator with the HHSC Licensing and Credentialing Section.(5) Applicant--A person applying for a Texas nursing facility administrator (NFA) license.(6) Armed forces of the United States--The Army, Navy, Air Force, Coast Guard, Space Force, or Marine Corps of the United States, including reserve units of those military branches.(7) Complaint--An allegation that an NFA violated one or more of the licensure rules or statutory requirements.(8) Domains of the NAB --The four categories for education and continuing education of the NAB, which are care, services, and supports; operations; environment and quality; and leadership and strategy.(9) Formal hearing--A hearing held by the State Office of Administrative Hearings to adjudicate a sanction taken by HHSC against an NFA.(10) Good standing--In Texas an NFA is in good standing if the NFA is in compliance with the rules in this chapter and, if applicable, the terms of any sanction imposed by HHSC. An NFA licensed or registered in another state is in good standing if the NFA is in compliance with the NFA licensing or registration rules in the other state and, if applicable, the terms of any sanction imposed by the other state.(11) Health services executive (HSE)--An individual who has entry-level competencies in a nursing facility, assisted living community, or home and community-based service provider in this state or another state. The HSE has met NAB's minimum standards for qualification as an HSE.(12) HHSC--The Texas Health and Human Services Commission. HHSC is responsible for NFA licensure in Texas.(13) Internship--The training period in a nursing facility for an AIT. When HHSC accepts internship hours completed in another state, the hours must be completed in a facility that qualifies as a nursing facility or nursing home under the laws of the other state.(14) License--An NFA license or provisional license.(15) Licensee--A person licensed by HHSC as an NFA.(16) Long-term Care Regulation--The department of HHSC responsible for long-term care regulation, including determining nursing facility compliance with licensure and certification requirements and the regulation of NFAs.(17) Management experience--Full-time employment as a department head, assistant nursing facility administrator, or licensed professional supervising two or more employees in a nursing facility, including a nursing facility outside of Texas, or skilled nursing hospital unit.(18) Military service member--A person who is on active duty.(19) Military spouse--A person who is married to a military service member.(20) Military veteran--A person who has served on active duty and who was discharged or released from active duty.(21) Misappropriation of resident property--Taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real or personal, or anything of value belonging to or under the legal control of a resident without the effective consent of the resident or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct relating to the custody or disposition of property of a resident.(22) NAB--National Association of Long Term Care Administrator Boards. A national organization composed of the state boards or agencies responsible for licensure of NFAs.(23) NAB examination--The national examination developed by NAB that applicants must pass in combination with the state licensure examination to be issued a license to practice nursing facility administration in Texas. The NAB examination consists of two modules: Core of Knowledge and Line of Service.(24) National Continuing Education Review Service (NCERS)--The part of NAB that approves and monitors continuing education activities for NFAs.(25) Neglect--Failure to provide goods or services, including medical services, that are necessary to avoid physical or emotional harm, pain, or mental illness.(26) Nursing facility--A facility licensed in accordance with THSC Chapter 242.(27) Nursing Facility Administrator (NFA)--An individual licensed by HHSC to engage in the practice of nursing facility administration, regardless of whether the individual has an ownership interest in the facility.(28) Nursing Facility Administrators Advisory Committee (NFAAC)--The advisory committee established by THSC §242.303.(29) Online portal--The Texas Unified Licensure Information Portal (TULIP), through which licensing application activities are completed.(30) Preceptor--An NFA certified by HHSC to provide supervision to an AIT.(31) Referral--A recommendation made by Long-term Care Regulation staff to investigate an NFA's compliance with licensure requirements when deficiencies or substandard quality of care deficiencies are found in a nursing facility, as required by 42 Code of Federal Regulations (CFR) §488.325.(32) Sanctions--An adverse licensure action against an NFA. In Texas, a sanction is one of the actions listed in §555.57 of this chapter (relating to Schedule of Sanctions).(33) Self-study course--A NAB-approved education course that an individual pursues independently to meet continuing education requirements for license renewal.(34) State examination--The state licensure examination that applicants must pass, in combination with the NAB examination, to be issued a license to practice nursing facility administration in Texas.(35) Substandard quality of care--For a Medicare- or Medicaid-certified facility, this term has the meaning given in 42 CFR §488.301. For a licensed-only facility, this term has the meaning given in §554.101 of this title (relating to Definitions).(36) THSC--Texas Health and Safety Code.(37) Traditional business hours--Monday through Friday from 8:00 a.m. until 5:00 p.m. Source Note: The provisions of this §555.2 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective March 20, 2016, 41 TexReg 1923; amended to be effective September 28, 2016, 41 TexReg 7514; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS A GENERAL INFORMATION §555.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220626 03/12/2026 (a) HHSC charges the following administrative and licensure fees:(1) application--$100;(2) initial license--$250;(3) provisional license--$250;(4) renewal--$250 every two years when the license is renewed on or before the date the license expires;(5) late renewal fees for license renewals made after the license expires:(A) $375 for an expired license renewed during the first 90 days after the license expires; and(B) $500 for an expired license renewed between 91 and 365 days after the license expires;(6) formal inactive status--$250;(7) reinstatement of licensure--$500.(b) Other administrative fees collected by the National Association of Long Term Care Administrator Boards (NAB) designee or contractor:(1) NAB examination--$425;(2) NAB reexamination, including both NAB Core of Knowledge examination and Line of Service examination, in nursing home administration--$425;(3) NAB Core of Knowledge examination only--$300;(4) Line of Service examination in nursing home administration only--$175; and(5) state examination--$190.(c) All application and licensure fees are nonrefundable, except as provided by Texas Government Code, Chapter 2005. Source Note: The provisions of this §555.3 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS A GENERAL INFORMATION §555.3 Schedule of Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220632 03/12/2026 (a) Except as provided in subsections (b) and (c) of this section, an applicant seeking licensure must submit to the Texas Health and Human Services Commission (HHSC) through the online portal:(1) a complete Nursing Facility Administrator's Application for Licensure form;(2) the application fee;(3) fingerprints for a Federal Bureau of Investigation (FBI)-based criminal background check through the Texas Department of Public Safety;(4) an official transcript reflecting a baccalaureate degree from a college or university accredited by an agency recognized by the Texas Higher Education Coordinating Board;(5) if not a part of the transcript reflecting a baccalaureate degree, another transcript reflecting 12 semester credit hours in long-term care administration, or its equivalent, that include the four domains of the National Association of Long Term Care Administrator Boards; and(6) proof of completing the minimum applicable internship that meets the internship requirements in §555.13 of this subchapter (relating to Internship Requirements).(b) If an applicant has a health services executive (HSE) qualification and is applying for a license under §555.12(a)(5) of this subchapter (relating to Licensure Requirements), the applicant must submit through the online portal:(1) a complete Nursing Facility Administrator's Application for Licensure form;(2) the application fee;(3) proof of the HSE qualification;(4) fingerprints for an FBI-based criminal background check through the Texas Department of Public Safety; and(5) certification that the applicant has not had a license revoked in any state.(c) If an applicant has an NFA license issued by another state and is applying for a license under §555.12(a)(6) of this subchapter, the applicant must submit through the online portal:(1) a complete Reciprocity Licensure Questionnaire;(2) the application fee;(3) fingerprints for an FBI-based criminal background check through the Texas Department of Public Safety; and(4) proof of a license in good standing in another state.(d) An application is valid for one year from the date the application fee is received through the online portal.(e) An applicant who does not meet the requirements for licensure within one year after HHSC receives the application through the online portal must reapply for licensure as provided in this section.(f) HHSC is not responsible for applications, forms, notices, and correspondence unless they are received by HHSC through the online portal.(g) HHSC is not responsible for mail it sends to a licensee or applicant if the licensee's or applicant's current address was not reported to HHSC through the online portal. Source Note: The provisions of this §555.11 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.11 Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220629 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220629 03/12/2026 (a) An applicant must meet one of the following groups of requirements to obtain a license as a nursing facility administrator (NFA).(1) An applicant has a baccalaureate degree in any subject from a college or university accredited by an agency recognized by the Texas Higher Education Coordinating Board and has:(A) a minimum of 12 semester credit hours in long-term care administration, or its equivalent, that includes courses in the four domains of the National Association of Long Term Care Administrator Boards (NAB);(B) completed a 1,000-hour internship that meets the requirements in §555.13 of this subchapter (relating to Internship Requirements); and(C) passed the state and NAB examinations described in §555.18 of this subchapter (relating to Examinations and Requirements to Take the Examinations).(2) An applicant has a baccalaureate degree in health administration, health services administration, health care administration, or nursing that includes coursework encompassing the four domains of the NAB and has:(A) three years of management experience;(B) completed a 500-hour internship that meets the requirements in §555.13 of this subchapter; and(C) passed the state and NAB examinations described in §555.18 of this subchapter.(3) An applicant has a baccalaureate degree with coursework in the four domains of NAB and one year of experience as assistant administrator of record or administrator of record in another state and has:(A) completed a 500-hour internship that meets the requirements in §555.13 of this subchapter; and(B) passed the state and NAB examinations described in §555.18 of this subchapter.(4) An applicant has a master's degree in health administration, health services administration, health care administration, or nursing that includes coursework encompassing the four domains of the NAB and has:(A) one year of management experience;(B) completed a 500-hour internship that meets the requirements in §555.13 of this subchapter; and(C) passed the state and NAB examinations described in §555.18 of this subchapter.(5) An applicant has a health services executive qualification and has:(A) not had a license revoked in any state; and(B) passed the state examination described in §555.18 of this subchapter.(6) An applicant has a license issued by a state other than Texas and meets the requirements for licensure in paragraphs (1), (2), (3), or (4) of this subsection.(b) HHSC accepts foreign university degrees and coursework that is counted as transfer credit by accredited universities recognized by the American Association of Collegiate Registrars and Admissions officers. Source Note: The provisions of this §555.12 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.12 Licensure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220630 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220630 03/12/2026 (a) Except as provided in subsection (b) or (c) of this section, an applicant must complete an internship that meets the following requirements.(1) Before an applicant starts the internship, the applicant and the applicant's preceptor must complete a Texas Health and Human Services (HHSC) internship application through the online portal.(2) The internship must be in a nursing facility.(3) A minimum of half of the internship hours must be during traditional business hours.(4) The administrator-in-training (AIT) can train no more than 40 hours a week.(5) If the internship is completed with a nursing facility administrator (NFA) not associated with a university as the preceptor, the AIT must complete a preceptor performance report. Additionally, the preceptor must complete an AIT final report through the online portal.(6) An AIT must complete an HHSC course in Infection Control and Personal Protective Equipment.(7) If the internship is completed with an NFA associated with a university accredited by an agency recognized by the Texas Higher Education Coordinating Board as the preceptor, the AIT must submit an official transcript to HHSC through the online portal.(8) The internship must be completed at the same facility at which the AIT's preceptor serves as NFA.(b) HHSC may accept an internship completed in another state if:(1) the internship is part of a National Association of Long Term Care Administrator Boards-accredited program; or(2) the internship is approved by the other state and requires a minimum of 1,000 hours or a minimum of 500 hours if the requirements listed in §555.12(a)(2), (3), or (4) of this subchapter (relating to Licensure Requirements) are met. An applicant who has completed fewer than 1,000 hours of internship in another state that does not qualify for a 500-hour internship must complete the remaining hours under a preceptor.(c) As a substitute to meeting the internship requirements described in subsection (a) or (b) of this section, an applicant may submit to HHSC proof of a health services executive (HSE) qualification and certify that the applicant has not had a license or HSE qualification revoked in any state.(d) The AIT must submit proof of completion of the internship or completion of HSE through the online portal. HHSC will review the proof of completion and notify the applicant of the status of the applicant's request. Source Note: The provisions of this §555.13 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.13 Internship Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220631 03/12/2026 (a) A licensee seeking to sponsor an administrator-in-training (AIT) must:(1) have a preceptor certification as provided in §555.15 of this subchapter (relating to Preceptor Certification); and(2) obtain approval through the online portal from the Texas Health and Human Services Commission (HHSC) to sponsor an AIT.(b) A preceptor must submit a complete AIT Performance Report to HHSC through the online portal at the end of the internship, unless the preceptor is a nursing facility administrator associated with a university recognized by the Texas Higher Education Coordinating Board.(c) A preceptor must obtain approval from HHSC before sponsoring more than one AIT at the same time.(d) HHSC may consider any imposed sanction as specified in §555.57 of this chapter (relating to Schedule of Sanctions) against a preceptor as grounds for refusing to allow the preceptor to sponsor an AIT.(e) HHSC may refuse to allow a preceptor to sponsor an AIT if the preceptor did not provide adequate training to previous AITs.(f) HHSC waives 20 of the 40 hours of continuing education required for license renewal for a preceptor who sponsors an AIT.(g) A licensee is qualified to act as a preceptor for two years from the date HHSC certifies the preceptor.(h) A licensee must remain in good standing to act as a preceptor.(i) A preceptor may be allowed to provide direct supervision or guidance of a licensee with a probated sanction as specified in §555.57 of this chapter. Source Note: The provisions of this §555.14 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.14 Preceptor Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220633 03/12/2026 HHSC may issue a preceptor certification to a nursing facility administrator (NFA) who submits through the online portal:(1) proof of license or registration in good standing as an NFA for a minimum of five years, with the two most recent years in Texas;(2) proof of completed Texas Health and Human Services approved preceptor training; and(3) a completed preceptor application. Source Note: The provisions of this §555.15 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.15 Preceptor Certification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220628 03/12/2026 (a) To continue acting as a preceptor, a licensee must renew a preceptor certification every two years through the online portal.(b) A licensee seeking to renew a preceptor certification must submit to HHSC through the online portal:(1) proof of license or registration as a nursing facility administrator for a minimum of five years, with the two most recent years in Texas;(2) proof of completed Texas Health and Human Services approved preceptor training; and(3) a completed preceptor application. Source Note: The provisions of this §555.16 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.16 Preceptor Certification Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206742 03/12/2026 The Texas Health and Human Services may deny an application for a preceptor certification or a preceptor certification renewal for the following reasons:(1) the preceptor committed a violation listed in §555.54 of this chapter (relating to Rule or Statutory Violations); or(2) the preceptor was convicted of a crime listed in §555.41 of this chapter (relating to Licensure of Persons with Criminal Backgrounds). Source Note: The provisions of this §555.17 adopted to be effective November 14, 2021, 46 TexReg 7791. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.17 Preceptor Denial of Certification Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220627 03/12/2026 (a) Except as provided in subsection (b) of this section, an applicant seeking a license as a nursing facility administrator (NFA) from the Texas Health and Human Services Commission (HHSC) must pass the following examinations:(1) the state examination on nursing facility requirements in Texas; and(2) the NAB examinations.(b) An applicant who meets the academic and internship requirements by presenting evidence of a health services executive (HSE) qualification must pass the state examination.(c) An applicant registers for examination at the designated NAB website by:(1) submitting an application for approval to take the examination; and(2) paying the applicable state examination and NAB examination fees online.(d) HHSC sends an e-mail notifying an applicant of the applicant's eligibility to take the examinations.(e) An applicant must not take any examination without HHSC approval.(f) An applicant with a disability, including an applicant with dyslexia as defined in Texas Education Code §51.970 (relating to Instructional Material for Blind and Visually Impaired Students and Students with Dyslexia), may request a reasonable accommodation for the examination under the Americans with Disabilities Act.(g) An applicant completes the online state and NAB examinations.(h) HHSC notifies an applicant of examination scores after receiving examination results.(i) An applicant who fails an examination and wants to retake the examination must pay the appropriate state or NAB examination fee for each exam.(j) An applicant who fails the state or NAB examination three consecutive times must complete an additional 1,000-hour administrator-in-training internship before retaking the examination.(k) An applicant previously licensed as an NFA and whose license expired 365 or more days before the applicant reapplies for a license or who voluntarily surrendered the license must retake the state examination to obtain a new license.(l) An applicant previously licensed as an NFA and whose license expired 365 or more days before the applicant reapplies for a license, or who voluntarily surrendered the license, must retake the NAB examination to obtain a new license if more than five years have passed since the applicant passed the NAB examination. Source Note: The provisions of this §555.18 adopted to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS B REQUIREMENTS FOR LICENSURE §555.18 Examinations and Requirements to Take the Examinations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220634 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) issues a license to an applicant who:(1) receives a passing score on the state and NAB examination;(2) submits the initial license fee to HHSC through the online portal; and(3) does not have a criminal history that HHSC determines is a basis for denying the license under §555.41 of this subchapter (relating to Licensure of Persons with Criminal Backgrounds).(b) HHSC may determine that a criminal conviction or a sanction taken against an applicant in Texas or another state is a basis for pending or denying an initial license.(c) A license expires two years from the date issued.(d) A licensee must keep HHSC informed of the licensee's current home address and employment address. If employed by a nursing facility, a licensee must change his or her employment information through the online portal within 30 days after a change of employment.(e) A licensee who does not notify HHSC through the online portal of a change in address or employment within the required 30 days may be subject to an administrative penalty as provided in §555.57 of this chapter (relating to Schedule of Sanctions).(f) A licensee must notify HHSC of a change of name through the online portal by submitting a name change application. Source Note: The provisions of this §555.31 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.31 Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220638 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) issues a provisional license to an applicant currently licensed or registered as a nursing facility administrator (NFA) in another state who submits the following to HHSC through the online portal:(1) complete Provisional Licensure Questionnaire and Nursing Facility Administrator License Application forms;(2) the application fee;(3) the provisional license fee; and(4) proof of the following:(A) a license and good standing status in another state;(B) employment for at least one year as an administrator of record of a nursing facility in applicant's state;(C) a passing score on the National Association of Long Term Care Administrator Boards examination and the state examination; and(D) sponsorship by an NFA licensed by and in good standing with HHSC, unless HHSC waives sponsorship based on a demonstrated hardship.(b) A provisional license expires 180 days from the date of issue.(c) HHSC issues an initial license to a provisional license holder who satisfies the requirements for a license in §555.12 of this chapter (relating to Licensure Requirements) and §555.31 of this subchapter (relating to Initial License).(d) HHSC may determine that a criminal conviction or sanction taken in another state is a basis for pending or denying a provisional license.(e) If the internship hours completed in another state do not meet the requirements in §555.13 of this chapter (relating to Internship Requirements), then a provisional licensee must complete the required internship hours under the supervision of an HHSC-certified preceptor as described in §555.12 of this chapter. Source Note: The provisions of this §555.32 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.32 Provisional License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220639 03/12/2026 The Texas Health and Human Services Commission (HHSC) replaces lost, damaged, or destroyed license certificates for a licensee. Licensees can print a duplicate license through the online portal. Source Note: The provisions of this §555.33 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.33 Duplicate License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220640 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) notifies a licensee of the license expiration date and renewal requirements through the online portal at least 31 days before the license expires.(b) A licensee who does not receive a renewal notice must renew the license before the license expires.(c) A licensee seeking renewal must submit the following to HHSC through the online portal on or before the date the license expires:(1) a complete License Renewal form;(2) the renewal fee;(3) proof of completion of 40 hours of continuing education, as required by §555.35 of this subchapter (relating to Continuing Education Requirements for License Renewal); and(4) fingerprints for a Federal Bureau of Investigation-based criminal background check through the Texas Department of Public Safety.(d) HHSC uses the date the completed renewal application is submitted online to determine if a renewal application is submitted on time.(e) HHSC issues a two-year license renewal card to eligible licensees who meet the requirements in subsection (c) of this section.(f) HHSC may deny a license renewal according to §555.37 of this subchapter (relating to Denial of License Renewal). Source Note: The provisions of this §555.34 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.34 License Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220641 03/12/2026 (a) The 40 hours of continuing education required for license renewal must:(1) be completed during the previous two-year licensure period;(2) include one or more of the four domains of the NAB;(3) include a Texas Health and Human Services Commission (HHSC) course in infection control and personal protective equipment;(4) include at least six hours of continuing education in ethics; and(5) be:(A) approved by the National Continuing Education Review Service;(B) a HHSC-sponsored event; or(C) an upper-division semester credit course taken or taught at a post-secondary institution of higher education accredited by an agency recognized by the Texas Higher Education Coordinating Board.(b) HHSC accepts NAB-approved self-study courses toward the required 40 hours of continuing education.(c) HHSC waives, at a maximum, 20 of the 40 hours of continuing education required of a licensee who completes one three-semester-hour upper-division course taken at a post-secondary institution of higher education.(d) HHSC approves continuing education credit hours for the same course, seminar, workshop, or program only once per license renewal period.(e) HHSC may perform an audit of continuing education courses, seminars, or workshops that the licensee has reported by requesting certificates of attendance. Source Note: The provisions of this §555.35 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective September 28, 2016, 41 TexReg 7514; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective December 6, 2023, 48 TexReg 7078; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.35 Continuing Education Requirements for License Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220642 03/12/2026 (a) A former licensee has up to one year after the expiration date of a license to renew the license by:(1) completing a license renewal application through the online portal;(2) completing 40 hours of continuing education as provided in §555.35 of this subchapter (relating to Continuing Education Requirements for License Renewal); and(3) submitting the following fee through the online portal to the Texas Health and Human Services Commission (HHSC):(A) a $375 late renewal fee for a license that has been expired for 90 days or less; or(B) a $500 late renewal fee for a license that has been expired for 91 days to 365 days.(b) A former licensee whose license has been expired for more than 365 days must meet the licensure and examination requirements for an initial license.(c) A former licensee must retake the NAB examination if the former licensee last took and passed the NAB examination more than five years before the completed application date.(d) A person who fails to renew a license before the expiration date must not practice in the field of nursing facility administration until the license is renewed.(e) HHSC imposes one or more sanctions listed in §555.57 of this chapter (relating to Schedule of Sanctions) against a person who practices with an expired license. Source Note: The provisions of this §555.36 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.36 Late Renewals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206750 03/12/2026 The Texas Health and Human Services Commission (HHSC) may deny an application for license renewal based on either of the following:(1) the licensee committed a violation listed in §555.54 of this chapter (relating to Rule or Statutory Violations); or(2) the licensee has a criminal history that HHSC determines is a basis for denying the license renewal under §555.41 of this subchapter (relating to Licensure of Persons with Criminal Backgrounds). Source Note: The provisions of this §555.37 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.37 Denial of License Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220643 03/12/2026 (a) A licensee may place a license in a formal inactive status with the Texas Health and Human Services Commission (HHSC) for up to two renewal periods.(b) To place a license in a formal inactive status, the licensee submits the following to HHSC through the online portal on or before the date the license expires:(1) a completed Inactive Status Application form; and(2) the formal inactive status fee.(c) A licensee may renew a license in formal inactive status through the online portal on or before the date that the inactive status expires by submitting to HHSC:(1) the renewal fee; and(2) proof of completing 40 hours of continuing education, as provided in §555.35 of this chapter (relating to Continuing Education Requirements for License Renewal).(d) If a license in formal inactive status expires, the licensee must meet the licensure application and examination requirements as listed in §555.11 of this subchapter (relating to Application Requirements) and §555.18 of this chapter (relating to Examinations and Requirements to Take the Examinations) to obtain a new license.(e) If it has been less than five years since the individual passed the NAB examination, the individual is not required to take the NAB examination but must take the state examination.(f) A former licensee whose license expires while on formal inactive status may not renew the license by paying a late renewal fee. Source Note: The provisions of this §555.38 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.38 Inactive Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220644 03/12/2026 (a) A licensee may voluntarily surrender a license as instructed on the HHS website, NF Administrators Licensing and Enforcement page and by returning the license certificate to the Texas Health and Human Services Commission (HHSC).(b) A licensee who voluntarily surrenders a license while under investigation for a violation of licensure requirements may still receive:(1) a written reprimand; or(2) an administrative penalty.(c) A licensee who voluntarily surrenders a license in lieu of a proposed sanction, other than license revocation, may not reapply for licensure until two years after the surrender date.(d) A licensee who voluntarily surrenders a license in lieu of a proposed license revocation is permanently disqualified from licensure in Texas. Source Note: The provisions of this §555.39 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.39 Voluntary Surrender of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220635 03/12/2026 An applicant who previously was licensed and in good standing in Texas may obtain a new license without taking the examination required by §555.18 of this chapter (relating to Examinations and Requirements to Take the Examinations) if the applicant:(1) is licensed in good standing in another state;(2) practiced in that state for at least the preceding two years before the date of the current licensure application; and(3) pays HHSC a reactivation fee through the online portal. Source Note: The provisions of this §555.40 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.40 Reinstatement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220636 03/12/2026 (a) Subject to subsection (b) of this section, the Texas Health and Human Services Commission (HHSC) may disqualify an applicant or licensee from taking an examination required by §555.18 of this chapter (relating to Examinations and Requirements to Take the Examinations), may deny an initial or renewal application for licensure, or impose a sanction listed in §555.57 of this chapter (relating to Schedule of Sanctions) if the applicant or licensee has been convicted of:(1) committing an offense listed in Texas Health and Safety Code §250.006(a) or (c); or(2) committing an offense listed in Texas Health and Safety Code §250.006(b) within the five years before application for licensure.(b) Convictions under federal law or the laws of another state or nation for offenses containing elements similar to offenses listed in subsection (a) of this section may be a basis for HHSC denying an initial application or imposing sanctions.(c) A notice required under subsection (d) of this section must contain a statement that the applicant or licensee is disqualified from receiving the license or being examined for the license because of the applicant's or licensee's prior conviction of an offense specified in the notice, as provided in subsection (a)(1) and (2) of this section.(d) If HHSC suspends or revokes a license, or denies an applicant or licensee a license or the opportunity to be examined for a license because of the applicant's or licensee's prior conviction of an offense, HHSC notifies the person in writing of:(1) the reason for the suspension, revocation, denial, or disqualification;(2) the procedure for judicial review; and(3) the earliest date the applicant or licensee may appeal HHSC's action. Source Note: The provisions of this §555.41 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective September 1, 2010, 35 TexReg 6832; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.41 Licensure of Persons with Criminal Backgrounds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220637 03/12/2026 (a) Fee waiver based on military experience.(1) The Texas Health and Human Services Commission (HHSC) waives the application fee described in §555.11(a)(2) of this chapter (relating to Application Requirements) and the initial license fee described in §555.31(a)(2) of this chapter (relating to Initial License) for an applicant if HHSC receives and approves a request for a waiver of fees from the applicant in accordance with this subsection.(2) To request a waiver of fees under this subsection, an applicant must submit a written request for a waiver with the applicant's initial license application submitted to HHSC through the online portal in accordance with §555.11 of this chapter. The applicant must include with the request:(A) documentation of the applicant's status as a military service member or military veteran that is acceptable to HHSC; and(B) documentation of the type and dates of the service, training, and education the applicant received and an explanation as to why the applicant's military service, training, or education substantially meets all the requirements for licensure under this chapter.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the applicant by the armed forces of the United States, the State of Texas, or another state; and(B) for status as a military veteran, a copy of a military service discharge order issued to the applicant by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the applicant must submit the requested documentation.(5) HHSC approves a request for a waiver of fees submitted in accordance with this subsection if HHSC determines that the applicant is a military service member or a military veteran and the applicant's military service, training, or education substantially meets all the requirements for licensure under this chapter.(b) Fee waiver for a military spouse.(1) HHSC waives the application fee described in §555.11(a)(2) of this chapter and the initial license fee described in §555.31(a)(2) of this chapter for an applicant who is a military spouse if HHSC receives and approves through the online portal a request for a waiver of fees from the applicant and documentation of the applicant's status as a military spouse.(2) Documentation of military status that is acceptable to HHSC includes:(A) a copy of a marriage certificate issued to the applicant by a state of the United States or a foreign government; and(B) a copy of a current military service order issued to the applicant's spouse by the armed forces of the United States, the State of Texas, or another state.(3) If HHSC requests additional documentation, the applicant must submit the requested documentation.(c) Fee waiver based on license issued by another jurisdiction.(1) HHSC waives the application fee described in §555.11(a)(2) of this chapter and the provisional initial license fee described in §555.32(a)(3) of this chapter (relating to Provisional License) for an applicant if HHSC receives and approves through the online portal a request for a waiver of fees in accordance with this subsection.(2) To request a waiver of fees under this subsection, an applicant must include a written request for a waiver of fees with the applicant's provisional license application that is submitted to HHSC in accordance with §555.32 of this chapter. The applicant must include with the request documentation of the applicant's status as a military service member, military veteran, or military spouse that is acceptable to HHSC.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the applicant by the armed forces of the United States, the State of Texas, or another state;(B) for status as a military veteran, a copy of a military service discharge order issued to the applicant by the armed forces of the United States, the State of Texas, or another state; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the applicant by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the applicant's spouse by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the applicant must submit the requested documentation.(5) HHSC approves a request for a waiver of fees submitted in accordance with this subsection if HHSC determines that:(A) the applicant holds a license in good standing in another jurisdiction with licensing requirements substantially equivalent to the requirements for a license under this chapter; and(B) the applicant is a military service member, a military veteran, or a military spouse.(d) Additional time for license renewal.(1) HHSC gives a nursing facility administrator (NFA) an additional two years to complete the license renewal requirements described in §555.43 of this subchapter (relating to License Renewal) and §555.35 of this subchapter (relating to Continuing Education Requirements for License Renewal), if HHSC receives and approves a request for additional time to complete the licensing renewal requirements from an NFA in accordance with this subsection.(2) To request additional time to complete license renewal requirements, an NFA must:(A) submit a written request for additional time to HHSC through the online portal before the expiration date of the NFA's license; and(B) include with the request, documentation of the NFA's status as a military service member that is acceptable to HHSC, which includes a copy of a current military service order issued to the NFA by the armed forces of the United States, the State of Texas, or another state.(3) If HHSC requests additional documentation, the NFA must submit the requested documentation.(4) HHSC approves a request for two additional years to complete license renewal requirements submitted in accordance with this subsection if HHSC determines that the NFA is a military service member, except HHSC does not approve a request if HHSC granted the NFA a previous extension and the NFA has not completed the license renewal requirements during the two-year extension period.(5) If an NFA does not submit the written request described by paragraph (2) of this subsection before the expiration date of the NFA's license, HHSC considers a request after the expiration date of the license if the NFA establishes to the satisfaction of HHSC that the request was not submitted before the expiration date of the NFA's license because the NFA was serving as a military service member at the time the request was due.(e) Credit toward internship requirements.(1) HHSC gives an applicant credit toward the internship requirements for an administrator-in-training (AIT) described in §555.13 of this chapter (relating to Internship Requirements) based on the applicant's military service, training, or education if HHSC receives and approves a request for credit from an applicant in accordance with this subsection.(2) To request credit for military service, training, or education, the applicant must submit a written request for credit to HHSC through the online portal with the applicant's initial license application. The applicant must include, with the request, documentation of the type and dates of the service, training, and education the applicant received and an explanation as to how the applicant's military service, training, or education is substantially similar to the training or education requirements described in §555.13 of this chapter.(3) If HHSC requests additional documentation, the applicant must submit the requested documentation.(4) HHSC approves a request for credit submitted in accordance with this subsection if HHSC determines that the military service, training, or education that the applicant received is substantially similar to the training or education requirements described in §555.12 of this chapter (relating to Licensure Requirements).(f) Renewal of expired license.(1) HHSC renews an expired license if HHSC receives and approves a request for renewal from a former NFA in accordance with this subsection.(2) To request renewal of an expired license, a former NFA must submit a written request with a license renewal application through the online portal within five years after the former NFA's license expired. The former NFA must include with the request documentation of the former administrator's status as a military service member, military veteran, or military spouse that is acceptable to HHSC.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the former NFA by the armed forces of the United States, the State of Texas, or another state;(B) for status as a military veteran, a copy of a military service discharge order issued to the former NFA by the armed forces of the United States, the State of Texas, or another state; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the former NFA by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the former NFA's spouse by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the former NFA must submit the requested documentation.(5) HHSC approves a request for renewal of an expired license submitted in accordance with this subsection if HHSC determines that:(A) the former NFA is a military service member, military veteran, or military spouse;(B) the former NFA has not committed an offense listed in Texas Health and Safety Code (THSC) §250.006(a) and (c) and has not committed an offense listed in THSC §250.006(b) during the five years before the date the former NFA submitted the initial license application; and(C) the former NFA is not listed on the employee misconduct registry described in THSC Chapter 253.(g) Recognition of Out-of-State License of Military Spouse.(1) A military spouse may engage in the practice of nursing facility administration in Texas without obtaining a license, as required by §555.31 of this subchapter (relating to Initial License) or §555.32 of this subchapter (relating to Provisional License), if the spouse:(A) is currently licensed in good standing by another jurisdiction that has licensing requirements substantially equivalent to the requirements for a license in Texas;(B) notifies HHSC in writing through the online portal of the spouse's intent to practice in Texas;(C) submits to HHSC proof of the spouse's residence in this state and a copy of the spouse's military identification; and(D) receives from HHSC:(i) confirmation that HHSC has verified the spouse's license in the other jurisdiction; and(ii) a license to practice nursing facility administration in Texas.(2) HHSC evaluates the following criteria when determining whether another state's licensing requirements are substantially equivalent to the requirement for a license under the statutes and regulations of this state:(A) whether the other state requires an applicant to pass an examination that demonstrates competence in the field to obtain the license;(B) whether the other state requires an applicant to meet any experience qualifications to obtain the license;(C) whether the other state requires an applicant to meet education qualifications to obtain the license;(D) whether the other state denies an application for licensure from an applicant who has been convicted of an offense containing elements similar to offenses listed in §555.41(a) of this subchapter (relating to Licensure of Persons with Criminal Backgrounds); and(E) the other state's license requirements, including the scope of work authorized to be performed under the license issued by the other state.(3) The military spouse must submit:(A) a written request through the online portal to HHSC for recognition of the spouse's license issued by the other state;(B) any form and additional information regarding the license issued by the other state required by the rules of the specific program or division within HHSC that licenses the business or occupation;(C) proof of residence in this state, which may include a copy of the permanent change of station order for the military service member to whom the military spouse is married;(D) a copy of the military spouse's identification card;(E) proof the military service member is stationed at a military installation in Texas; and(F) fingerprints for a Federal Bureau of Investigation-based criminal background check through the Texas Department of Public Safety criminal background check to enable HHSC to confirm that the military spouse is in compliance with other laws and regulations applicable to nursing facility administration in Texas.(4) Upon verification from the licensing jurisdiction of the military spouse's license and if the license is substantially equivalent to a Texas license, HHSC issues a confirmation that HHSC has verified the spouse's license in the other jurisdiction and a license to practice nursing facility administration in Texas.(5) The license issued under paragraph (4) of this subchapter expires three years from date of issuance or when the military service member is no longer stationed at a military installation in Texas, whichever comes first. The license issued under paragraph (4) of this subsection may not be renewed.(6) HHSC replaces a lost, damaged or destroyed license certificate for a military spouse as provided in §555.33 of this subchapter (relating to Duplicate License) A military spouse with an active nursing facility administrator license can print a duplicate license through the online portal. A military spouse can request a change of name through the online portal by submitting a name change application.(7) The military spouse must comply with all applicable laws, rules and standards of this state, including applicable Texas Health and Safety Code and all relevant Texas Administration Code provision.(8) HHSC may withdraw or modify the verification letter for reasons including the following:(A) the military spouse fails to comply with paragraph (1)(D)(i) of this section; or(B) the military spouse's licensure required under subsection (c)(1) of this section expires or is suspended or revoked in another jurisdiction. Source Note: The provisions of this §555.42 adopted to be effective September 28, 2016, 41 TexReg 7514; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS C LICENSES §555.42 Alternate Licensing Requirements for Military Service Personnel https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220645 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) receives and investigates referrals and complaints.(b) Persons wanting to file a complaint against a licensee may contact HHSC by:(1) calling HHSC at the telephone numbers on the HHSC website;(2) emailing the complaint to HHSC using the email address on the HHSC website;(3) faxing the complaint to HHSC using the fax number on the HHSC website; or(4) mailing the complaint to HHSC at the mailing address on the HHSC website.(c) HHSC sends HHSC Form 5521-NFA, Complaints, to persons wanting to file a complaint. HHSC Form 5521-NFA, Complaints, is also available on the HHSC web page. The complainant must complete, sign, and return the form to HHSC.(d) If a referral or complaint is received, HHSC notifies the licensee and, if applicable, the person filing the complaint of the:(1) alleged rule violation;(2) assigned case number; and(3) investigator contact information.(e) HHSC investigates referrals and complaints by first determining if a complaint is within HHSC's authority to investigate and, if it is, by engaging in one or more of the following investigative activities:(1) reviewing pertinent documentation maintained by the facility, including financial and resident medical records;(2) gathering additional evidence, including licensee and witness statements;(3) determining licensee culpability for survey or investigative findings; and(4) utilizing the services of a private investigator when special circumstances exist.(f) HHSC keeps records confidential in accordance with state and federal law.(g) HHSC prioritizes complaints as follows.(1) Priority one complaints allege physical abuse, sexual abuse, neglect, serious injury, death, or immediate jeopardy to resident health or safety. Investigations are initiated within 24 hours of receipt or by the next working day.(2) Priority two complaints allege all other types of misconduct by the licensee. Investigations are initiated within 30 days after receipt.(h) After the investigation is complete, a final report with supporting documentation is given to the Nursing Facility Administrators Advisory Committee (NFAAC) for review and a recommendation on the appropriate action.(i) After evaluating the NFAAC's recommendation, HHSC decides to:(1) impose a sanction;(2) collect additional information; or(3) dismiss the case.(j) HHSC notifies the licensee and, if applicable, the person filing a complaint of the status and final outcome of a complaint or referral. Source Note: The provisions of this §555.51 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.51 Referral and Complaint Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206756 03/12/2026 (a) Before the Texas Health and Human Services Commission (HHSC) initiates proceedings to revoke a license, suspend a license, or deny a license renewal, HHSC gives a licensee:(1) a description of the alleged rule violation warranting the proposed sanction; and(2) the option to:(A) request an informal review to demonstrate that the licensee did not violate nursing facility administrator (NFA) licensure rules or commit the alleged violation; or(B) request a formal hearing; or(C) accept the sanction.(b) A licensee's request for an informal review must:(1) be received by HHSC within 10 calendar days after the licensee receives the notice letter from HHSC; and(2) contain documentation that refutes the allegations.(c) HHSC conducts the informal review:(1) by telephone;(2) in person; or(3) by reviewing the licensee's written response and supporting evidence.(d) HHSC provides the licensee with official notice of the outcome of the informal review. Source Note: The provisions of this §555.52 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective February 15, 2017, 42 TexReg 569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.52 Informal Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220646 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) gives a licensee a formal hearing notice if:(1) HHSC proposes a sanction; or(2) HHSC upholds or modifies a proposed sanction after an informal review, in accordance with §555.52 of this subchapter (relating to Informal Reviews).(b) The formal hearing notice to the licensee includes:(1) a description of the alleged rule violations warranting the proposed sanction;(2) HHSC decision to uphold or modify the sanction if the notice is issued after an informal review; and(3) the option for the licensee to:(A) accept the sanction; or(B) request a formal hearing no later than 20 days after receiving the formal hearing notice from HHSC.(c) If the licensee does not accept a modified sanction resulting from an informal review, the hearing notice may be for the original sanction HHSC proposed before the informal review.(d) HHSC imposes a sanction against a licensee if:(1) the licensee accepts the decision from HHSC to impose the sanction;(2) the administrative law judge upholds the proposed sanction from HHSC after the formal hearing; or(3) the licensee does not request a hearing within 20 days after receiving the formal hearing notice from HHSC.(e) A hearing is governed by Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §555.53 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective September 1, 2010, 35 TexReg 6832; amended to be effective February 15, 2017, 42 TexReg 569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.53 Formal Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220647 03/12/2026 The Texas Health and Human Services Commission (HHSC) may impose a sanction listed in §555.57 of this subchapter (relating to Schedule of Sanctions) against a licensee on proof of any of the following grounds:(1) the licensee willfully or repeatedly violated a provision of Texas Health and Safety Code, Chapter 242, or a rule in this chapter;(2) the licensee willfully or repeatedly acted in a manner inconsistent with the health and safety of the residents of a nursing facility of which the licensee is a nursing facility administrator (NFA);(3) the licensee obtained or attempted to obtain a license through misrepresentation or deceit or by making a material misstatement of fact on a license application;(4) the licensee's use of alcohol or drugs creates a hazard to the residents of a facility;(5) a judgment of a court of competent jurisdiction finds that the licensee lacks capacity under the laws of Texas;(6) the licensee has been convicted in a court of competent jurisdiction of an offense listed in §555.41(a) of this chapter (relating to Licensure of Persons with Criminal Backgrounds);(7) the licensee has been negligent or incompetent in the licensee's duties as an NFA;(8) the licensee had an NFA license revoked in another jurisdiction; or(9) the licensee did not comply with the terms of a sanction or settlement agreement with HHSC. Source Note: The provisions of this §555.54 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; amended to be effective February 15, 2017, 42 TexReg 569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.54 Rule or Statutory Violations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220648 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may impose a sanction listed in §555.57 of this subchapter (relating to Schedule of Sanctions) against a licensee for violations of the following nursing facility administrator (NFA) Standards of Conduct.(1) A licensee must employ sufficient staff to adequately meet the needs of nursing facility residents as determined by care outcomes.(2) A licensee must ensure that sufficient resources are present to provide adequate nutrition, medications, and treatments to nursing facility residents in accordance with physician orders as determined by care outcomes.(3) A licensee must promote and protect the rights of nursing facility residents and ensure that employees, contractors, and others respect the rights of residents.(4) A licensee must ensure that nursing facility residents remain free of chemical and physical restraints unless required by a physician's order to protect a nursing facility resident's health and safety.(5) A licensee must report and direct nursing facility staff to report to the appropriate government agency any suspected case of abuse, neglect, or misappropriation of resident property as defined in §555.2 of this chapter (relating to Definitions).(6) A licensee must ensure that the nursing facility is physically maintained in a manner that protects the health and safety of the residents and the public.(7) A licensee must notify and direct employees to notify an appropriate government agency of any suspected cases of criminal activity as defined by state and federal laws.(8) A licensee must post in the nursing facility where the licensee is employed the notice provided by HHSC that gives the address and telephone number for reporting complaints against an NFA. The notice must be posted in a conspicuous place and in clearly legible type.(9) A licensee must not knowingly or through negligence commit, direct, or allow actions that result or could result in inadequate care, harm, or injury to a nursing facility resident.(10) A licensee must not knowingly or through negligence allow a nursing facility employee to harm a nursing facility resident by coercion, threat, intimidation, solicitation, harassment, theft of personal property, or cruelty.(11) A licensee must not knowingly or through negligence allow or direct an employee to contradict or alter in any manner the orders of a physician regarding a nursing facility resident's medical or therapeutic care.(12) A licensee must not knowingly commit or through negligence allow another individual to commit an act of abuse, neglect, or misappropriation of resident property as defined in §555.2 of this chapter.(13) A licensee must not permit another individual to use his or her license or allow a nursing facility to falsely post his or her license.(14) A licensee must not advertise or knowingly participate in the advertisement of nursing facility services in a manner that is fraudulent, false, deceptive, or misleading in form or content.(15) A licensee must not knowingly allow, aid, or abet a violation by another NFA of the Texas Health and Safety Code, Chapter 242, Subchapter I (text of Subchapter I effective until federal determination of failure to comply with federal regulations), or the agency's rules adopted under that subchapter and must report such violations to HHSC.(16) A licensee must not make or knowingly allow an employee, contractor, or volunteer to make misrepresentations or fraudulent statements about the operation of a nursing facility.(17) A licensee must not knowingly allow an employee's, a contractor's, or another person's action or inaction to result in harassment or intimidation of any person for purposes of coercing that person to use the services or equipment of a particular health agency or facility.(18) A licensee must not falsely bill for goods or services or allow another person to bill for goods or services other than those that have actually been delivered.(19) A licensee must not make or file a false report or allow an employee, contractor, or volunteer to make or file a report that the licensee knows to be false.(20) A licensee must not intentionally fail to file a report or record required by state or federal law, impede or obstruct such filings, or induce another person to impede or obstruct such filings.(21) A licensee must not use or knowingly allow employees or others to use alcohol, narcotics, or other drugs in a manner that interferes with the performance of the licensee's or other person's duties.(22) A licensee must not knowingly or through negligence violate any confidentiality provisions prescribed by state or federal law concerning a nursing facility resident.(23) A licensee must not interfere with or impede an investigation by withholding or misrepresenting facts to HHSC representatives, or by using threats, harassment, intimidation, or retaliation against any person involved or participating in the investigation.(24) A licensee must not display a license issued by HHSC that is reproduced, altered, expired, suspended, or revoked.(25) A licensee must not, knowingly or through negligence, allow an employee or other individual to mismanage a resident's personal funds deposited with the nursing facility.(26) A licensee must not harass or intimidate an employee or other representative of HHSC, other government agencies, or their representatives.(27) A licensee must not offer or give any gift, loan, or other benefit to a person working for HHSC unless the benefit is offered or given on account of kinship or a personal relationship independent of the official status of the person working for HHSC.(b) Negligence, as referenced in the Standards of Conduct in subsection (a) of this section, means the failure of a licensee to use such care as a reasonably prudent and careful licensee would use in similar circumstances, or failure to act as a reasonably prudent licensee would in similar circumstances. Source Note: The provisions of this §555.55 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.55 Violations of Standards of Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220649 03/12/2026 (a) A person with an expired license must not engage in activities that require a license.(b) A person practicing as a licensed nursing facility administrator after license expiration:(1) commits an offense punishable as a Class B misdemeanor;(2) is subject to local criminal prosecution; and(3) may be referred to the Office of Attorney General for civil penalties not to exceed $1,000 per violation per day for each day the violation continues.(c) A licensee whose license expires before an investigation is complete, may still receive:(1) a written reprimand; or(2) an administrative penalty.(d) A licensee allowing a license to expire instead of accepting a proposed license revocation may be, at HHSC's discretion, disqualified from licensure in Texas permanently or for five years. Source Note: The provisions of this §555.56 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.56 Violations by Unlicensed Persons https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220650 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may impose one or more of the following sanctions against a licensee for a violation listed in §555.54 of this subchapter (relating to Rule or Statutory Violations) or §555.55 of this subchapter (relating to Violations of Standards of Conduct):(1) license revocation;(2) license suspension;(3) denial of application for license renewal;(4) assessment of an administrative penalty;(5) written letter of reprimand;(6) participation in continuing education;(7) probation;(8) denial of preceptor's initial or renewal application; or(9) revocation of preceptor status.(b) If a sanction is probated, HHSC may require the licensee to:(1) report regularly to HHSC on matters that are the basis of the probation;(2) limit practice to the areas prescribed by HHSC;(3) practice under the direct supervision or guidance of a HHSC certified preceptor, as specified in §555.14 of this chapter (relating to Preceptor Requirements); or(4) complete prescribed continuing education until the licensee attains a degree of skill satisfactory to HHSC in those areas that are the basis of the probation.(c) Civil penalties may result from a referral to the Office of Attorney General not to exceed $1,000 per violation per day for each day the violation continues.(d) Administrative penalties may not exceed $1,000 per violation per day for each day the violation continues.(e) The amount of the administrative penalty is assessed is based on:(1) the seriousness of the violation, including:(A) the nature, circumstances, extent, and gravity of prohibited acts; and(B) the hazard or potential hazard created to the health, safety, or economic welfare of the public;(2) economic harm to property or environment;(3) history of previous violations;(4) amount necessary to deter future violations;(5) efforts to correct the violations;(6) the severity level of the violation:(A) Level I--$500 to $1,000 for violations that have or had an adverse impact on nursing facility resident health or safety that includes serious harm, permanent injury, or death to a nursing facility resident;(B) Level II--$250 to $500 for violations that have or had a potential or adverse impact on the health or safety of a nursing facility resident, but less impact than Level I; or(C) Level III--$250 or less for violations having minimal or no significant impact on nursing facility resident health or safety; and(7) any other matter that justice may require.(f) HHSC may deny, suspend, or revoke a license to practice in Texas if the licensee fails to meet and comply with all terms of an HHSC order or settlement agreement, or fails to complete any final sanction imposed against the licensee's license, including satisfactory and timely completion of any continuing education requirements, suspension, probated suspension under a certified preceptor, or timely payment in full of administrative penalties. Source Note: The provisions of this §555.57 adopted to be effective June 1, 2004, 29 TexReg 4233; amended to be effective June 1, 2009, 34 TexReg 2795; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1880; amended to be effective November 14, 2021, 46 TexReg 7791; amended to be effective September 18, 2024, 49 TexReg 7339. 1 HEALTH AND HUMAN SERVICES COMMISSION 555 NURSING FACILITY ADMINISTRATORS D REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS §555.57 Schedule of Sanctions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192258 03/12/2026 The chapter implements the requirements for training and evaluating the competency of nurse aides employed in nursing facilities that participate in Medicaid, Medicare, or both, and for maintaining a registry of nurse aides, required by §1819(b)(5) and §1919(b)(5) of the Social Security Act; the Code of Federal Regulations, Title 42, §§483.150-483.154; and Texas Health and Safety Code, Chapter 250. Source Note: The provisions of this §556.1 adopted to be effective September 24, 2018, 43 TexReg 6326. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.1 Basis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220664 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--Negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure) or Texas Penal Code, Chapter 22 (relating to Assaultive Offenses), sexual harassment, sexual coercion, or sexual assault.(2) Act--The Social Security Act, codified at United States Code, Title 42, Chapter 7.(3) Active duty--Current full-time military service in the armed forces of the United States or as a member of the Texas military forces, as defined in Texas Government Code §437.001, or similar military service of another state.(4) Active status--The designation given to a nurse aide listed on the NAR who is eligible to work in a nursing facility.(5) Armed forces of the United States--The Army, Navy, Air Force, Space Force, Coast Guard, or Marine Corps of the United States, including reserve units of those military branches.(6) Classroom training--The teaching of curriculum components through in-person instruction taught in a physical classroom location, which may include skills practice through online instruction taught in a virtual classroom location, or through an HHSC-approved computer-based training (CBT).(7) Clinical training--The teaching of hands-on care of residents in a nursing facility under the required level of supervision of a licensed nurse, which may include skills practice prior to performing the skills through hands-on care of a resident. The clinical training provides the opportunity for a trainee to learn to apply the classroom training to the care of residents with the assistance and required level of supervision of the instructor.(8) Competency evaluation--A written or oral examination and a skills demonstration administered by a skills examiner to test the competency of a trainee.(9) Competency evaluation application--HHSC Form 5507-NAR, Request for Waiver of Nurse Aide Training and Competency Evaluation, used to request HHSC approval to take a competency evaluation.(10) Direct supervision--Observation of a trainee performing skills in a NATCEP.(11) Employee misconduct registry (EMR)--The registry maintained by HHSC in accordance with Texas Health and Safety Code, Chapter 253, to record findings of reportable conduct by certain unlicensed employees.(12) Facility--Means:(A) a nursing facility licensed or exempt from licensure under Texas Health and Safety Code, Chapter 242;(B) a licensed intermediate care facility for an individual with an intellectual disability or related condition licensed under Texas Health and Safety Code, Chapter 252;(C) a type B assisted living facility licensed under Texas Health and Safety Code, Chapter 247;(D) a general or special hospital licensed under Texas Health and Safety Code, Chapter 241; or(E) a hospice inpatient unit licensed under Texas Health and Safety Code, Chapter 142.(13) Facility-based NATCEP--A NATCEP offered by or in a nursing facility.(14) General supervision--Guidance and ultimate responsibility for another person in the performance of certain acts.(15) HHSC--The Texas Health and Human Services Commission or its designee.(16) Infection control--Principles and practices that prevent or stop the spread of infections in the facility setting.(17) Informal Review (IR)--An opportunity for a nurse aide to dispute a finding of misconduct by providing testimony and supporting documentation to an impartial HHSC staff person.(18) Licensed health professional--A person licensed to practice healthcare in the state of Texas including:(A) a physician;(B) a physician assistant;(C) a physical, speech, or occupational therapist;(D) a physical or occupational therapy assistant;(E) a registered nurse;(F) a licensed vocational nurse; or(G) a licensed social worker.(19) Licensed nurse--A registered nurse or licensed vocational nurse.(20) Licensed vocational nurse (LVN)--An individual licensed by the Texas Board of Nursing to practice as a licensed vocational nurse.(21) Military service member--A person who is on active duty.(22) Military spouse--A person who is married to a military service member.(23) Military veteran--A person who has served on active duty and who was discharged or released from active duty.(24) Misappropriation of resident property--The deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.(25) NATCEP--Nurse Aide Training and Competency Evaluation Program.(26) Neglect--The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.(27) Non-facility-based NATCEP--A NATCEP not offered by or in a nursing facility.(28) Nurse aide--An individual who provides nursing or nursing-related services to residents in a facility under the supervision of a licensed nurse and who has successfully completed a NATCEP or has been determined competent by waiver or reciprocity and who has been issued a certificate of registration. This term does not include an individual who is a licensed health professional or a registered dietitian or who volunteers services without monetary compensation.(29) Nurse aide curriculum--The publication titled Texas Curriculum for Nurse Aides in Long Term Care Facilities, developed by HHSC.(30) Nurse Aide Registry (NAR)--A listing of nurse aides, maintained by HHSC, that indicates if a nurse aide has active status, revoked status, or is unemployable based on a finding of having committed an act of abuse, neglect, or misappropriation of resident property.(31) Nurse aide training and competency evaluation program (NATCEP)--A program approved by HHSC to train and evaluate an individual's ability to work as a nurse aide in a nursing facility.(32) Nurse aide training and competency evaluation program (NATCEP) application--An HHSC form in the online portal used to request HHSC initial approval to offer a NATCEP, to renew approval to offer a NATCEP, or to request HHSC approval of changed information in an approved NATCEP application.(33) Nursing services--Services provided by nursing personnel that include, but are not limited to:(A) promotion and maintenance of health;(B) prevention of illness and disability;(C) management of health care during acute and chronic phases of illness;(D) guidance and counseling of individuals and families; and(E) referral to other health care providers and community resources when appropriate.(34) Online portal--The Texas Unified Licensure Information Portal (TULIP), through which licensing application activities are completed.(35) Performance record--An evaluation of a trainee's performance of major duties and skills taught by a NATCEP and documented on HHSC Form 5497-NATCEP, Texas Nurse Aide Performance Record.(36) Person--A corporation, organization, partnership, association, natural person, or any other entity that can function legally.(37) Personal protective equipment (PPE)--Specialized clothing or equipment, worn by an employee for protection against infectious materials.(38) Program director--An individual who is approved by HHSC and meets the requirements in §556.5(b) and (d) of this chapter (relating to Program Director, Program Instructor, Supplemental Trainers, and Skills Examiner Requirements).(39) Program instructor--An individual who is approved by HHSC to conduct the training in a NATCEP and who meets the requirements in §556.5(c) and (d) of this chapter.(40) Resident--An individual accepted for care or residing in a facility.(41) Registered nurse (RN)--An individual licensed by the Texas Board of Nursing to practice professional nursing.(42) Skills examiner--An individual who is approved by HHSC and meets the requirements in §556.5(h) of this chapter.(43) Trainee--An individual who is enrolled in and attending, but has not completed, a NATCEP. Source Note: The provisions of this §556.2 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective August 8, 2021, 46 TexReg 4693; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective March 17, 2024, 49 TexReg 1476; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220665 03/12/2026 (a) To train nurse aides, a nursing facility must apply for and obtain approval from HHSC to offer a NATCEP or contract with another entity offering a NATCEP. The nursing facility must participate in Medicare, Medicaid, or both, to apply for approval to be a NATCEP.(b) A person who wants to offer a NATCEP must file a complete NATCEP application with HHSC through the online portal.(c) A person applying to offer a NATCEP must submit a separate NATCEP application through the online portal for each location at which training is delivered or administered.(d) A NATCEP application must identify one or more facilities that the NATCEP uses as a clinical site. The clinical site must have all necessary equipment needed to practice and perform skills training.(e) A NATCEP may offer clinical training hours in a laboratory setting under the following circumstances:(1) no appropriate and qualified clinical site is located within 20 miles of the location of the NATCEP; or(2) HHSC has determined that clinical training provided in a facility poses a risk to an individual's health or safety based on the existence of a disaster declared at the federal or state level. A NATCEP must request the ability to complete clinical training hours in a laboratory setting under the circumstances described in subsection (e)(1) of this section. HHSC will alert the public of the availability of laboratory training under the circumstances described in subsection (e)(2) of this section.(f) HHSC does not approve a NATCEP offered by or in a nursing facility if, within the previous two years, the nursing facility:(1) has operated under a waiver concerning the services of a registered nurse under §1819(b)(4)(C)(ii)(II) or §1919(b)(4)(C)(i) - (ii) of the Act;(2) has been subjected to an extended or partially extended survey under §1819(g)(2)(B)(i) or §1919(g)(2)(B)(i) of the Act;(3) has been assessed a civil money penalty of not less than $5,000 as adjusted annually under 45 Code of Federal Regulations (CFR) Part 102 for deficiencies in nursing facility standards, as described in §1819(h)(2)(B)(ii) or §1919(h)(2)(A)(ii) of the Act;(4) has been subjected to denial of payment under Title XVIII or Title XIX of the Act;(5) has operated under state-appointed temporary management to oversee the operation of the facility under §1819(h) or §1919(h) of the Act;(6) had its participation agreement terminated under §1819(h)(4) or §1919(h)(1)(B)(i) of the Act; or(7) pursuant to state action, closed or had its residents transferred under §1919(h)(2) of the Act.(g) Clinical training provided by a NATCEP in a facility other than a nursing facility must be provided under the direct supervision of the NATCEP instructor and cannot be delegated to any staff of the facility.(h) A NATCEP using an assisted living facility as a clinical site may provide clinical training only in those services that are authorized to be provided to residents under Texas Health and Safety Code, Chapter 247.(i) A NATCEP using an intermediate care facility for an individual with an intellectual disability or related conditions as a clinical site may provide clinical training only in those services that are authorized to be provided to individuals under Texas Health and Safety Code, Chapter 252.(j) A NATCEP using a hospice inpatient unit as a clinical site may provide clinical training only in those services that are authorized to be provided to clients under Texas Health and Safety Code, Chapter 142.(k) A NATCEP using a general or special hospital as a clinical site may provide clinical training only in those services that are authorized to be provided to patients under Texas Health and Safety Code, Chapter 241.(l) A nursing facility that is prohibited from offering a NATCEP under subsection (f) of this section may contract with a person to offer a NATCEP in accordance with §1819(f)(2)(C) and §1919(f)(2)(C) of the Act so long as the person has not been employed by the nursing facility or by the nursing facility's owner and:(1) the NATCEP is offered to employees of the nursing facility that is prohibited from training nurse aides under subsection (e) of this section;(2) the NATCEP is offered in, but not by, the prohibited nursing facility;(3) there is no other NATCEP offered within a reasonable distance from the nursing facility; and(4) an adequate environment exists for operating a NATCEP in the nursing facility.(m) A person who wants to contract with a nursing facility in accordance with subsection (l) of this section must submit a completed application to HHSC through the online portal in accordance with §556.4 of this chapter (relating to Filing and Processing an Application for a Nurse Aide Training and Competency Evaluation Program (NATCEP)) and include the name of the prohibited nursing facility in the application. HHSC may withdraw the application within two years of approving it if HHSC determines that the nursing facility is no longer prohibited from offering a NATCEP.(n) A nursing facility that is prohibited from offering a NATCEP under subsection (f)(3) of this section may request a Centers for Medicare and Medicaid Services waiver of the prohibition related to the civil money penalty in accordance with §1819(f)(2)(D) and §1919(f)(2)(D) of the Act and 42 CFR §483.151(c) if:(1) the civil money penalty was not related to the quality of care furnished to residents;(2) the NATCEP submits a request to HHSC for the waiver; and(3) the Centers for Medicare and Medicaid Services approves the waiver.(o) A NATCEP must ensure the trainee has completed 100 hours of training. The 100 hours must include:(1) 60 hours of classroom training:(A) taught by the NATCEP either in-person or virtually; or(B) completed by the trainee through HHSC's computer-based training (CBT) within the preceding 12 months; and(2) 40 hours of clinical training provided by the NATCEP with at least one program instructor for every 10 trainees.(p) A NATCEP that provides online training must:(1) maintain records in accordance with subsection (z) of this section and otherwise comply with this chapter;(2) adopt, implement, and enforce a policy and procedures for establishing that a trainee who registers in an online training is the same trainee who participates in and completes the course and that describe the procedures the NATCEP uses to:(A) verify a trainee's identity;(B) ensure protection of a trainee's privacy and personal information; and(C) document the hours completed by each trainee; and(3) verify on the NATCEP application that the online course has the security features required under paragraph (2) of this subsection.(q) A NATCEP must teach the curriculum established by HHSC and described in 42 CFR §483.152. Except as provided in subsection (r) of this section, the NATCEP must include at least 16 introductory hours of classroom training in the following areas before a trainee has any direct contact with a resident:(1) communication and interpersonal skills;(2) infection control;(3) safety and emergency procedures, including ways to assist someone who is choking, such as the Heimlich maneuver;(4) promoting a resident's independence;(5) respecting a resident's rights;(6) basic nursing skills, including:(A) taking and recording vital signs;(B) measuring and recording height and weight;(C) caring for a resident's environment;(D) recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor; and(E) caring for a resident when death is imminent;(7) personal care skills, including:(A) bathing;(B) grooming, including mouth care;(C) dressing;(D) toileting;(E) assisting with eating and hydration;(F) proper feeding techniques;(G) skin care; and(H) transfers, positioning, and turning;(8) mental health and social service needs, including:(A) modifying the aide's behavior in response to a resident's behavior;(B) awareness of developmental tasks associated with the aging process;(C) how to respond to a resident's behavior;(D) allowing a resident to make personal choices, providing and reinforcing other behavior consistent with the resident's dignity; and(E) using a resident's family as a source of emotional support;(9) care of cognitively impaired residents, including:(A) techniques for addressing the unique needs and behaviors of a resident with a dementia disorder including Alzheimer's disease;(B) communicating with a cognitively impaired resident;(C) understanding the behavior of a cognitively impaired resident;(D) appropriate responses to the behavior of a cognitively impaired resident; and(E) methods of reducing the effects of cognitive impairments;(10) basic restorative services, including:(A) training a resident in self-care according to the resident's abilities;(B) use of assistive devices in transferring, ambulation, eating, and dressing;(C) maintenance of range of motion;(D) proper turning and positioning in bed and chair;(E) bowel and bladder training; and(F) care and use of prosthetic and orthotic devices; and(11) a resident's rights, including:(A) providing privacy and maintenance of confidentiality;(B) promoting the resident's right to make personal choices to accommodate their needs;(C) giving assistance in resolving grievances and disputes;(D) providing needed assistance in getting to and participating in resident, family, group, and other activities;(E) maintaining care and security of the resident's personal possessions;(F) promoting the resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff; and(G) avoiding the need for restraints in accordance with current professional standards.(r) If a trainee completes HHSC's 60-hour classroom training CBT, a NATCEP must accept proof of completion of the CBT in lieu of the 16 introductory hours of classroom training in subsection (q) of this section and the eight hours of infection control training in subsection (u) of this section. The NATCEP must ensure that the trainee:(1) only performs services for which the trainee has been trained and has been found to be proficient by a program instructor;(2) is under the direct supervision of a licensed nurse when performing skills as part of a NATCEP until the trainee has been found competent by the program instructor to perform that skill;(3) is under the general supervision of a licensed nurse when providing services to a resident after a trainee has been found competent by the program instructor; and(4) is clearly identified as a trainee during the clinical training portion of the NATCEP.(s) A NATCEP that fails to accept proof of completion of the classroom training in accordance with subsection (o)(1)(B) of this chapter may be subject to §556.8 of this chapter (relating to Withdrawal of Approval of a NATCEP).(t) A NATCEP must have a program director and a program instructor when the NATCEP applies for initial approval by HHSC in accordance with §556.7 of this chapter (relating to Review and Reapproval of a Nurse Aide Training and Competency Evaluation Program (NATCEP)) and to maintain HHSC approval. The program director and program instructor must meet the requirements of §556.5(b) - (d) of this chapter (relating to Program Director, Program Instructor, Supplemental Trainers, and Skills Examiner Requirements).(u) Except as provided in subsection (r) of this section, a NATCEP must teach eight hours of infection control that includes the proper use of personal protective equipment (PPE) before a trainee has any direct contact with a resident.(v) A NATCEP must verify that a trainee:(1) is not listed on the NAR in revoked status;(2) is not listed as unemployable on the EMR; and(3) has not been convicted of a criminal offense listed in Texas Health and Safety Code (THSC) §250.006(a) or convicted of a criminal offense listed in THSC §250.006(b) within the five years immediately before participating in the NATCEP.(w) A NATCEP must ensure that a trainee:(1) completes the first 16 introductory hours of training (Section I of the curriculum) before having any direct contact with a resident;(2) only performs services for which the trainee has been trained and has been found to be proficient by a program instructor;(3) is under the direct supervision of a licensed nurse when performing skills as part of the NATCEP until the trainee has been found competent by the program instructor to perform that skill;(4) is under the general supervision of a licensed nurse when providing services to a resident after a trainee has been found competent by the program instructor; and(5) is clearly identified as a trainee during the clinical training portion of the NATCEP.(x) A NATCEP must submit a NATCEP application through the online portal to HHSC if the information in an approved NATCEP application changes. The NATCEP may not continue training or start new training until HHSC approves the change. HHSC conducts a review of the NATCEP information if HHSC determines the changes are substantive.(y) A NATCEP must use HHSC Form 5497-NATCEP, Texas Nurse Aide Performance Record, to document major duties or skills taught, trainee performance of a duty or skill, satisfactory or unsatisfactory performance, and the name of the instructor supervising the performance. At the completion of the NATCEP, the trainee and the employer, if applicable, will receive a copy of the performance record. The NATCEP must maintain a copy of the performance record.(z) A NATCEP must maintain records for each session of classroom training, whether offered in person or online, and of clinical training, and must make these records available to HHSC or its designees at any reasonable time.(1) The classroom and clinical training records must include:(A) dates and times of all classroom and clinical training;(B) the full name and social security number of each trainee;(C) a record of the date and time of each classroom and clinical training session a trainee attends;(D) a final course grade that indicates pass or fail for each trainee; and(E) a physical or electronic sign-in record for each classroom and clinical training session. An electronic sign-in must include a form of identity verification for the trainee conducted in compliance with the requirements of subsection (p)(2) of this section.(2) If a trainee completes the classroom training by successfully completing HHSC's CBT, a NATCEP must retain records that include a copy of the trainee's certification of completion for the CBT. The certificate of completion must be issued by HHSC and include the date the trainee completed the CBT.(3) A NATCEP must provide to HHSC, on the NATCEP application through the online portal, the physical address where all records are maintained and must notify HHSC of any change in the address provided.(aa) A nursing facility must not charge a nurse aide for any portion of a NATCEP, including any fees for textbooks or other required course materials, if the nurse aide is employed by or has received an offer of employment from a facility on the date the nurse aide begins the NATCEP.(bb) HHSC reimburses a nurse aide for a portion of the costs incurred by the nurse aide to complete a NATCEP if the nurse aide is employed by or has received an offer of employment from a nursing facility within 12 months of completing the NATCEP.(cc) HHSC must approve a NATCEP before the NATCEP solicits or enrolls trainees.(dd) HHSC approval of a NATCEP only applies to the required curriculum and hours. HHSC does not approve additional content or hours.(ee) A new employee or trainee orientation given by a nursing facility to a nurse aide employed by the facility does not constitute a part of a NATCEP.(ff) A NATCEP that provides training to renew a nurse aide's listing on the NAR must include training in geriatrics and the care of residents with a dementia disorder, including Alzheimer's disease. Source Note: The provisions of this §556.3 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective August 8, 2021, 46 TexReg 4693; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective March 17, 2024, 49 TexReg 1476; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.3 NATCEP Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220666 03/12/2026 (a) A person that wants to offer a NATCEP must complete a NATCEP application on forms prescribed by HHSC and submit the application to HHSC through the online portal.(b) HHSC determines whether to approve or deny the NATCEP application.(c) Within 90 days after HHSC receives a complete NATCEP application, HHSC notifies a NATCEP applicant of approval or proposed denial of a NATCEP application through the online portal, or notifies the applicant through the online portal of a deficiency or error in accordance with subsection (d) of this section. If HHSC proposes to deny the application due to the applicant's noncompliance with the requirements of the Act or this chapter, HHSC provides the reason for the denial in the notice.(d) If HHSC finds a deficiency or error in a NATCEP application, HHSC notifies the applicant in writing through the online portal of the deficiency or error and gives the applicant an opportunity to correct the deficiency or error. The applicant must submit the additional or corrected information to HHSC, through the online portal, within 10 days after the applicant receives notice of the deficiency or error.(e) If HHSC proposes to deny a NATCEP application based on the NATCEP's failure to comply with §556.3 of this chapter (relating to Nurse Aide Training and Competency Evaluation Program (NATCEP) Requirements), or §556.7 of this chapter (relating to Review and Reapproval of a Nurse Aide Training and Competency Evaluation Program (NATCEP)), the applicant may request a hearing to challenge the denial. A hearing is governed by 1 Texas Administrative Code (TAC) Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act). 1 TAC §357.484 (relating to Request for a Hearing) requires a hearing to be requested in writing within 15 days after the date the notice is received by the applicant. If an applicant does not make a timely request for a hearing, the applicant waives a hearing and HHSC may deny the NATCEP application. Source Note: The provisions of this §556.4 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.4 Filing and Processing an Application for a Nurse Aide Training and Competency Evaluation Program (NATCEP) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220667 03/12/2026 (a) A NATCEP must have an approved program director and program instructor to provide training.(1) Training of trainees must be performed by or under the general supervision of a registered nurse (RN) who has a minimum of two years of nursing experience, at least one year of which must be in a nursing facility.(2) An applicant for a NATCEP must certify on the NATCEP application that the NATCEP meets the requirements in paragraph (1) of this subsection.(b) A program director must:(1) be an RN in the State of Texas;(2) have a minimum of two years of nursing experience; and(3) have completed a course focused on teaching adult students or have experience in teaching adult students or supervising nurse aides.(c) An instructor must:(1) be a licensed vocational nurse (LVN) or an RN in the state of Texas;(2) have a minimum of two years of nursing experience; and(3) have completed a course focused on teaching adult students or have experience in teaching adult students or supervising nurse aides.(d) Either the program director or a program instructor must have at least one year of experience providing long term care services in a nursing facility. If an instructor is an LVN, a NATCEP must have:(1) a director with at least one year of providing long term care services in a nursing facility; or(2) an instructor who is an RN with at least one year of providing long term care services in a nursing facility.(e) Program director. A program director must directly perform training or have general supervision of the program instructor and supplemental trainers. A NATCEP must have a program director when the NATCEP applies for initial approval by HHSC in accordance with §556.7 of this chapter (relating to Review and Reapproval of a Nurse Aide Training and Competency Evaluation Program (NATCEP)) and to maintain HHSC approval.(1) In a facility-based NATCEP, the director of nursing (DON) for the nursing facility may be approved as the program director but must not conduct the training.(2) A program director may supervise more than one NATCEP.(3) A program director's responsibilities include, but are not limited to:(A) directing the NATCEP in compliance with the Act and this chapter;(B) directly performing training or having general supervision of the program instructor and supplemental trainers;(C) ensuring that NATCEP records are maintained;(D) determining if trainees have passed both the classroom and clinical training portions of the NATCEP;(E) signing a competency evaluation application completed by a trainee who has passed both the classroom and clinical training portions of the NATCEP; and(F) signing a certificate of completion or a letter on letterhead stationery of the NATCEP or the nursing facility, stating that the trainee passed both the classroom and clinical training portions of the NATCEP if the trainee does not take the competency evaluation with the same NATCEP. The certificate or letter must include the date training was completed, the total training hours completed, and the official NATCEP name and number on file with HHSC.(G) Completion of the classroom training for trainees who complete the HHSC CBT is determined by the certificate of completion, which includes the date the trainee completed the CBT.(4) A NATCEP must submit a NATCEP application for HHSC approval if the program director of the NATCEP changes.(f) Program instructor. A NATCEP must have at least one qualified program instructor when the NATCEP applies for initial approval by HHSC in accordance with §556.7 of this chapter and when training occurs.(1) The program instructor is responsible for conducting the classroom and clinical training of the NATCEP under the general supervision of the program director.(2) An applicant for a NATCEP must certify on the NATCEP application that all program instructors meet the requirements in subsection (c) of this section.(3) A NATCEP must submit a NATCEP application for HHSC approval if a program instructor of the NATCEP changes.(g) Supplemental trainers. Supplemental trainers may supplement the training provided by the program instructor in a NATCEP.(1) A supplemental trainer must be a licensed health professional acting within the scope of the professional's practice and have at least one year of experience in the field of instruction.(2) The program director must select and supervise each supplemental trainer.(3) A supplemental trainer must not act in the capacity of the program instructor without HHSC approval. To request approval, a NATCEP must submit a NATCEP application to HHSC.(h) Skills examiner. A skills examiner must administer the competency evaluation.(1) HHSC or its designee approves an individual as a skills examiner if the individual:(A) is an RN;(B) has a minimum of one year of professional experience in providing care for the elderly or chronically ill of any age; and(C) has completed a skills training seminar conducted by HHSC or its designee.(2) A skills examiner must:(A) adhere to HHSC standards for each skill examined;(B) conduct a competency evaluation in an objective manner according to the criteria established by HHSC;(C) validate competency evaluation results on forms prescribed by HHSC;(D) submit prescribed forms and reports to HHSC or its designee; and(E) not administer a competency evaluation to an individual who participates in a NATCEP for which the skills examiner was the program director, the program instructor, or a supplemental trainer. Source Note: The provisions of this §556.5 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective March 17, 2024, 49 TexReg 1476; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.5 Program Director, Program Instructor, Supplemental Trainers, and Skills Examiner Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220668 03/12/2026 (a) Only HHSC, or an entity HHSC approves, may provide a competency evaluation, which must be administered by a skills examiner at an approved evaluation site.(b) A trainee is eligible to take a competency evaluation if the trainee has successfully completed the training portion of a NATCEP, as determined by the program director, or is eligible under §556.12 of this chapter (relating to Waiver, Reciprocity, and Exemption Requirements).(c) If a trainee cannot take a competency evaluation at the NATCEP location where the trainee received training, the trainee may take a competency evaluation at another location approved to offer the evaluation.(d) An eligible trainee must obtain from the program director a signed competency evaluation application and a certificate or letter of completion of training. The trainee must arrange to take the competency evaluation at an approved location and must follow the instructions on the competency evaluation application.(e) A NATCEP must:(1) promptly, after one of its trainees successfully completes the NATCEP training, approve the trainee to take a competency evaluation;(2) provide the trainee with information regarding scheduling a competency evaluation; and(3) ensure that the trainee accurately completes the competency evaluation applications.(f) A trainee must:(1) take a competency evaluation within 24 months after completing the training portion of a NATCEP;(2) apply to take the competency evaluation through the online portal;(3) verify the arrangements for a competency evaluation;(4) complete a competency evaluation application and submit the application in accordance with application instructions;(5) request another competency evaluation if the trainee fails a competency evaluation; and(6) meet any other procedural requirements specified by HHSC or its designated skills examiner.(g) A competency evaluation must consist of:(1) a skills demonstration that requires the trainee to demonstrate five randomly selected skills drawn from a pool of skills that are generally performed by nurse aides, including all personal care skills listed in the curriculum; and(2) a written or oral examination, which includes 60 scored multiple-choice questions selected from a pool of test items that address each course requirement in the curriculum. Written examination questions may be printed in a test booklet with a separate answer sheet or provided in an online testing format as approved by HHSC. An oral examination must be a recorded presentation read from a prepared text in a neutral manner that includes questions to test reading comprehension.(h) A trainee with a disability, including a trainee with dyslexia as defined in Texas Education Code §51.970 (relating to Instructional Material for Blind and Visually Impaired Students and Students with Dyslexia), may request a reasonable accommodation for the competency evaluation under the Americans with Disabilities Act.(i) To successfully complete the competency evaluation, a trainee must achieve a score HHSC designates as a passing score on:(1) the skills demonstration; and(2) the written or oral examination.(j) A trainee who fails the skills demonstration or the written or oral examination may retake the competency evaluation twice.(1) A trainee must be advised of the areas of the competency evaluation that the trainee did not pass.(2) If a trainee fails a competency evaluation three times, the trainee must complete the training portion of a NATCEP before taking a competency evaluation again.(k) HHSC informs a trainee before the trainee takes a competency evaluation that HHSC issues a certificate of registration and records successful completion of the competency evaluation on the Nurse Aide Registry (NAR).(l) HHSC issues the certificate of registration through the online portal and records successful completion of the competency evaluation on the NAR within 30 days after the date the trainee passes the competency evaluation.(m) A nursing facility must not offer or serve as a competency evaluation site if the nursing facility is prohibited from offering a NATCEP under the provisions of §556.3(f) of this chapter (relating to Nurse Aide Training and Competency Evaluation Program (NATCEP) Requirements).(n) A trainee may not be charged for any portion of a competency evaluation if the trainee is employed by or has received an offer of employment from a nursing facility on the date the trainee takes the competency evaluation.(o) HHSC reimburses a nurse aide for a portion of the costs incurred by the individual to take a competency evaluation if the individual is employed as a nurse aide by, or has received an offer of employment from, a nursing facility within 12 months after taking the competency evaluation. Source Note: The provisions of this §556.6 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective August 8, 2021, 46 TexReg 4693; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.6 Competency Evaluation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220669 03/12/2026 (a) A NATCEP must apply to have its approval renewed every two years. HHSC sends a notice of renewal through the online portal to a NATCEP at least 60 days before the expiration date of an approval.(b) A NATCEP must submit a NATCEP application through the online portal at least 30 days before the expiration date of an approval. If a NATCEP does not file an application to renew an approval at least 30 days before the expiration of the approval, the approval expires.(c) HHSC uses the results of an on-site or off-site visit to determine NATCEP compliance with the Act and this chapter and to decide whether to renew the approval of a NATCEP.(d) HHSC may conduct an on-site or off-site review of a NATCEP at any reasonable time.(e) HHSC provides written notification through the online portal to a NATCEP of deficiencies found during an on-site or off-site review.(1) If a NATCEP receives a notification of deficiencies from HHSC, the NATCEP must submit a written response to HHSC through the online portal, which must include a plan of correction (POC) to correct all deficiencies.(2) HHSC may direct a NATCEP to comply with the requirements of the Act and this chapter.(3) HHSC may not renew the approval of a NATCEP that does not meet the requirements of the Act and this chapter by failing to provide an adequate POC.(f) A NATCEP approved by HHSC may provide in-service education to a nurse aide that is necessary to have the certificate of registration and associated listing on the NAR renewed.(g) A NATCEP must receive approval or an exemption under Texas Education Code Chapter 132 (relating to Career Schools and Colleges). Source Note: The provisions of this §556.7 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.7 Review and Reapproval of a Nurse Aide Training and Competency Evaluation Program (NATCEP) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220670 03/12/2026 (a) HHSC immediately withdraws approval of a facility-based NATCEP if the nursing facility where the NATCEP is offered has:(1) been granted a waiver concerning the services of an RN under §1819(b)(4)(C)(ii)(II) or §1919(b)(4)(C)(i)-(ii) of the Act;(2) been subject to an extended (or partially extended) survey under §1819(g)(2)(B)(i) or §1919(g)(2)(B)(i) of the Act;(3) been assessed a civil money penalty of not less than $5,000, as adjusted annually under 45 Code of Federal Regulations (CFR), Part 102, for deficiencies in nursing facility standards, as described in §1819(h)(2)(B)(ii) or §1919(h)(2)(A)(ii) of the Act;(4) been subject to denial of payment under Title XVIII or Title XIX of the Act;(5) operated under state-appointed or federally appointed temporary management to oversee the operation of the facility under §1819(h) or §1919(h) of the Act;(6) had its participation agreement terminated under §1819(h)(4) or §1919(h)(1)(B)(i) of the Act;(7) pursuant to state action, closed or had its residents transferred under §1919(h)(2); or(8) refused to permit unannounced visits by HHSC.(b) HHSC withdraws approval of a NATCEP if the NATCEP does not comply with §556.3 of this chapter (relating to NATCEP Requirements).(1) HHSC reviews allegations of noncompliance with this chapter by a NATCEP. If HHSC receives an allegation of noncompliance, HHSC notifies the NATCEP in writing and gives the NATCEP an opportunity to correct the noncompliance or provide documentation showing compliance. The NATCEP must correct the noncompliance or provide evidence of compliance and submit notification of the correction or documentation to show compliance to HHSC, in writing, within 10 days after receipt of the notice of noncompliance.(2) If the NATCEP fails to correct the noncompliance, provide documentation showing compliance, or respond to the first notification from HHSC, HHSC sends a second notice. The NATCEP must correct the noncompliance or provide documentation showing compliance and submit notification of the correction or documentation to show compliance to HHSC, in writing, within 20 days after receipt of the second notice. Failure to comply will result in withdrawal of approval of the NATCEP.(c) If HHSC withdraws approval of a NATCEP for failure to comply with §556.3 of this chapter, HHSC does not approve the NATCEP for at least two years after the date the approval was withdrawn.(d) If HHSC proposes to withdraw approval of a NATCEP based on subsection (a) of this section, HHSC notifies the NATCEP via email and through the online portal of the facts or conduct alleged to warrant the withdrawal.(e) A dually certified nursing facility that offers a NATCEP may request a hearing to challenge the findings of noncompliance that led to the withdrawal of approval of the NATCEP, but not the withdrawal of approval of the NATCEP itself, in accordance with 42 CFR, Part 498.(f) A nursing facility that offers a NATCEP and that participates only in Medicaid may request a hearing to challenge the findings of noncompliance that led to the withdrawal of approval of the NATCEP, but not the withdrawal of approval of the NATCEP itself. A hearing is governed by 1 Texas Administrative Code (TAC) Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act), except the nursing facility must request the hearing within 60 days after receipt of the notice described in subsection (d) of this section, as allowed by 42 CFR §431.153.(g) A nursing facility may request a hearing under subsection (e) or (f) of this section, but not both.(h) If the finding of noncompliance that led to the denial of approval of the NATCEP by HHSC is overturned, HHSC rescinds the denial of approval of the NATCEP.(i) If HHSC proposes to withdraw approval of a NATCEP based on §556.3 of this chapter or §556.7 of this chapter (relating to Review and Reapproval of a Nurse Aide Training and Competency Evaluation Program (NATCEP)), the NATCEP may request a hearing to challenge the withdrawal. A hearing is governed by 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedures Act), and Chapter 110 of this title (relating to Hearings Under the Administrative Procedures Act). 1 TAC §357.484 (relating to Request for a Hearing) requires a hearing to be requested in writing within 15 days after the date the notice is received by the applicant. If a NATCEP does not make a timely request for a hearing, the applicant has waived the opportunity for a hearing and HHSC may withdraw the approval.(j) A trainee who started a NATCEP before HHSC sent notice that it was withdrawing approval of the NATCEP may complete the NATCEP. Source Note: The provisions of this §556.8 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective March 17, 2024, 49 TexReg 1476; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.8 Withdrawal of Approval of a NATCEP https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220671 03/12/2026 (a) HHSC is the agency responsible for issuing individuals a certificate of registration and listing them on the Nurse Aide Registry (NAR).(b) To be issued a certificate of registration and be listed on the NAR as having active status, a nurse aide must successfully complete a NATCEP, as described in §556.6(i) of this chapter (relating to Competency Evaluation Requirements) and apply for certificate of registration through the online portal.(c) HHSC does not charge a fee to issue the certificate of registration or list a nurse aide on the NAR or to renew the certificate of registration and the nurse aide's listing of active status on the NAR.(d) A nurse aide listed on the NAR must inform HHSC of the nurse aide's current address and telephone number through the online portal.(e) The certificate of registration and the listing of active status on the NAR expires 24 months after the certificate of registration was issued and the nurse aide was listed on the NAR or 24 months after the last date of verified employment as a nurse aide, whichever is earlier. To renew the certificate of registration and active status on the NAR, the following requirements must be met:(1) A nursing facility must submit a HHSC Form 5506-NAR, Employment Verification, renewal to HHSC through the online portal that documents that the nurse aide has performed paid nursing or nursing-related services at the nursing facility during the preceding year.(2) A nurse aide must submit a HHSC Form 5506-NAR, Employment Verification, renewal to HHSC through the online portal to document that the nurse aide has performed paid nursing or nursing-related services, if documentation is not submitted in accordance with paragraph (1) of this subsection by the nursing facility or facilities where the nurse aide was employed.(3) A nurse aide must complete an HHSC course in infection control and proper use of PPE every year.(4) A nurse aide must complete at least 24 hours of in-service education every two years. The in-service education must include training in geriatrics and the care of residents with a dementia disorder, including Alzheimer's disease. The in-service education must be provided by:(A) a nursing facility;(B) an approved NATCEP;(C) HHSC; or(D) a healthcare entity, other than a nursing facility, licensed or certified by HHSC, the Texas Department of State Health Services, or the Texas Board of Nursing.(5) No more than 12 hours of the in-service education required by paragraph (4) of this subsection may be provided by an entity described in paragraph (4)(D) of this subsection. Source Note: The provisions of this §556.9 adopted to be effective September 24, 2018, 43 TexReg 6326; amended to be effective August 8, 2021, 46 TexReg 4693; amended to be effective September 27, 2022, 47 TexReg 6201; amended to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.9 Certificate of Registration, Nurse Aide Registry, and Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220672 03/12/2026 HHSC may suspend or revoke an existing certification, deny a certification, or deny a person the opportunity to take the examination for certification if the person has any conviction barring employment listed in Texas Health and Safety Code §250.006. Source Note: The provisions of this §556.10 adopted to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.10 Certification of Individuals with Criminal Convictions in Their Backgrounds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220673 03/12/2026 (a) A nurse aide's certificate of registration and status on the Nurse Aide Registry (NAR) is changed to expired if the nurse aide has not performed nursing-related services or acted as a nurse aide for monetary compensation for 24 consecutive months and does not apply for renewal in the online portal.(b) A nurse aide whose certificate of registration has expired and is listed as expired on the NAR must complete a Nurse Aide Training and Competency Evaluation Program or a competency evaluation and apply through the online portal to reactivate the certificate of registration and be listed on the NAR with active status. Source Note: The provisions of this §556.11 adopted to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.11 Expiration of the Certificate of Registration and Active Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220674 03/12/2026 (a) HHSC may waive the requirement for a nurse aide to take the NATCEP specified in §556.3 of this chapter (relating to Nurse Aide Training and Competency Evaluation Program (NATCEP) Requirements) and issue a certificate of registration and place a nurse aide on the Nurse Aide Registry (NAR) on active status if the nurse aide:(1) submits proof of completing a nurse aide training course of at least 100 hours duration before July 1, 1989, through the online portal;(2) submits HHSC Form 5506-NAR, Employment Verification, to HHSC through the online portal to document that the nurse aide performed nursing or nursing-related services for monetary compensation at least once every two years since July 1, 1989;(3) is not listed as unemployable on the EMR;(4) has not been convicted of a criminal offense listed in Texas Health and Safety Code (THSC) §250.006(a) and (c), or convicted of a criminal offense listed in THSC §250.006(b) within the preceding five years; and(5) completes HHSC Form 5507-NAR, Waiver of Nurse Aide Training and Competency Evaluation Program, and submits it to HHSC through the online portal.(b) HHSC issues the certificate of registration through the online portal and places a nurse aide on the NAR by reciprocity if:(1) the nurse aide is listed as having active status on another state's registry of nurse aides;(2) the other state's registry of nurse aides is in compliance with the Act;(3) the nurse aide is not listed as unemployable on the EMR;(4) the nurse aide has not been convicted of a criminal offense listed in THSC §250.006(a) and (c), or convicted of a criminal offense listed in THSC §250.006(b) within the preceding five years; and(5) the nurse aide completes a Request for Entry on the Texas Nurse Aide Registry Through Reciprocity, via the online portal.(c) A person is eligible to take a competency evaluation with an exemption from the nurse aide training specified in §556.3 of this chapter if the individual:(1) meets one of the following requirements for eligibility:(A) is seeking renewal under §556.9 of this chapter (relating to Certificate of Registration, Nurse Aide Registry, and Renewal);(B) has successfully completed at least 100 hours of training at a NATCEP in another state within the preceding 24 months but has not taken the competency evaluation or been placed on an NAR in another state;(C) has successfully completed at least 100 hours of military training, equivalent to civilian nurse aide training, on or after July 1, 1989;(D) has successfully completed an RN or LVN program at an accredited school of nursing in the United States within the preceding 24 months;(i) is not licensed as an RN or LVN in the state of Texas; and(ii) has not held a license as an RN or LVN in another state that has been revoked; or(E) is enrolled or has been enrolled within the preceding 24 months in an accredited school of nursing in the United States and demonstrates competency in providing basic nursing skills in accordance with the school's curriculum;(2) is not listed as unemployable on the EMR;(3) has not been convicted of a criminal offense listed in THSC §250.006(a) and (c), or convicted of a criminal offense listed in THSC §250.006(b) within the preceding five years;(4) submits documentation to verify at least one of the requirements in paragraph (1) of this subsection;(5) arranges for a nursing facility or NATCEP to serve as a competency evaluation site; and(6) before taking the competency evaluation, presents to the skills examiner an original letter from HHSC authorizing the person to take the competency evaluation. Source Note: The provisions of this §556.12 adopted to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.12 Waiver, Reciprocity, and Exemption Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220675 03/12/2026 (a) HHSC reviews and investigates allegations of abuse, neglect, or misappropriation of resident property by a nurse aide employed in a nursing facility. If HHSC finds that a nurse aide committed an act of abuse, neglect, or misappropriation of resident property, before entry of the finding on the Nurse Aide Registry (NAR), HHSC provides the nurse aide an opportunity to dispute the finding through an informal review (IR) and a hearing as described in this section.(b) If HHSC finds that a nurse aide committed an act of abuse, neglect, or misappropriation of resident property, HHSC sends the nurse aide a written notice regarding the finding. The notice includes:(1) a summary of the findings and facts on which the findings are based;(2) a statement informing the nurse aide of the right to an IR to dispute HHSC findings;(3) a statement informing the nurse aide that a request for an IR must be made within 10 days after the date the nurse aide receives the written notice; and(4) the address and contact information where the nurse aide must submit a request for an IR.(c) If a nurse aide requests an IR, HHSC sets a date to allow the nurse aide to dispute the findings of the investigation of abuse, neglect, or misappropriation of resident property. The nurse aide may dispute the findings by providing testimony, in person or by telephone, to impartial HHSC staff.(1) If HHSC does not uphold the findings, HHSC notifies the nurse aide of the results of the IR and closes the investigation. HHSC does not record information related to the investigation in the NAR.(2) If HHSC upholds the findings, HHSC notifies the nurse aide of the results of the IR. The nurse aide may request a hearing in accordance with subsection (d) of this section.(3) If the nurse aide does not request an IR, or fails to appear for a requested IR, HHSC upholds the findings. The nurse aide may request a hearing in accordance with subsection (d) of this section.(d) A nurse aide may request a hearing after receipt of HHSC notice of the results of an IR described in subsection (c)(2) of this section. Texas Administrative Code (TAC), Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act) govern the hearing, except that a nurse aide must request a formal hearing within 30 days after receipt of HHSC notice in compliance with 42 Code of Federal Regulations §488.335. If the nurse aide fails to request a hearing, the nurse aide waives the opportunity for a hearing and HHSC enters the finding of abuse, neglect, or misappropriation of resident property, as appropriate, on the NAR.(e) If HHSC receives an allegation that a nurse aide, who has a medication aide permit under Chapter 557 of this title (relating to Medication Aides--Program Requirements), committed an act of abuse, neglect, or misappropriation of resident property, HHSC investigates the allegation under this section regarding the nurse aide practice and under Chapter 557 of this title to determine if the allegation violates the medication aide practice. The investigations run concurrently. If after the investigations, the nurse aide requests hearings on the findings under the nurse aide practice and the medication aide practice, only one hearing, conducted in accordance with subsection (d) of this section, is available to the nurse aide.(f) If HHSC finds that a nurse aide committed an act of abuse, neglect, or misappropriation of resident property, HHSC reports the finding to:(1) the NAR;(2) the nurse aide;(3) the administrator of the nursing facility in which the act occurred; and(4) the administrator of the nursing facility that employs the nurse aide, if different from the nursing facility in which the act occurred.(g) The NAR must include the findings involving a nurse aide listed on the NAR as well as any brief statement of the nurse aide disputing the findings.(h) The information on the NAR is available to the public.(i) If an inquiry is made about a nurse aide's status on the NAR, HHSC must:(1) verify if the nurse aide is listed on the NAR;(2) disclose information concerning a finding of abuse, neglect, or misappropriation of resident property involving the nurse aide; and(3) disclose any statement by the nurse aide related to the finding.(j) If a nurse aide works in a capacity other than a nurse aide in a nursing facility and is listed as unemployable in the EMR, HHSC revokes or suspends the certificate of registration and changes the status of the nurse aide's listing on the NAR to revoked or suspended. The due process available to the nurse aide before placement on the EMR satisfies the due process required before HHSC revokes or suspends the certificate of registration and changes the nurse aide's status on the NAR.(k) If HHSC revokes or suspends the certificate of registration and lists a nurse aide's status on the NAR as suspended or revoked because of a single finding of neglect, the nurse aide may request that HHSC reissue the certificate of registration and remove the finding after the finding has been listed on the NAR for one year. To request removal of the finding, the nurse aide must submit a HHSC Petition for Removal of Neglect Finding to HHSC in accordance with the petition's instructions. Source Note: The provisions of this §556.13 adopted to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.13 Findings and Inquiries https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220676 03/12/2026 (a) Additional time for in-service education.(1) HHSC gives a nurse aide an additional two years to complete in-service education required for a nurse aide to maintain his or her certificate of registration and an active listing on the Nurse Aide Registry (NAR), as described in §556.9(f) of this chapter (relating to Certificate of Registration, Nurse Aide Registry, and Renewal), if HHSC receives and approves a request through the online portal for additional time to complete in-service training from a nurse aide in accordance with this subsection.(2) To request additional time to complete in-service education, a nurse aide must submit a written request for additional time to HHSC through the online portal before the expiration date of the nurse aide's certification. The nurse aide must include with the request documentation of the nurse aide's status as a military service member that is acceptable to HHSC. Documentation as a military service member that is acceptable to HHSC includes a copy of a military service order issued by the United States Armed Forces, the State of Texas, or another state.(3) If HHSC requests additional documentation, the nurse aide must submit the requested documentation.(4) HHSC approves a request for two additional years to complete in-service education submitted in accordance with this subsection if HHSC determines that the nurse aide is a military service member, except HHSC does not approve a request if HHSC granted the nurse aide a previous extension and the nurse aide did not complete the in-service education requirements during the previous extension period.(b) Renewal of expired certificate of registration and NAR listing.(1) HHSC renews the certificate of registration and changes the status of a listing from expired to active if HHSC receives and approves a request through the online portal for renewal and an active status listing from a former nurse aide in accordance with this subsection.(2) To request renewal and an active status listing, a former nurse aide must submit a written request with the documents required for renewal through the online portal in accordance with §556.9(f) of this chapter within five years after the former nurse aide's certificate of registration and listing expired. The former nurse aide must include with the request documentation of the former nurse aide's status as a military service member, military veteran, or military spouse that is acceptable to HHSC.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the former nurse aide by the armed forces of the United States, the State of Texas, or another state;(B) for status as a military veteran, a copy of a military service discharge order issued to the former nurse aide by the armed forces of the United States, the State of Texas, or another state; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the former nurse aide by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the former nurse aide's spouse by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the former nurse aide must submit the requested documentation.(5) HHSC approves a request for an active status listing submitted in accordance with this subsection if HHSC determines that:(A) the former nurse aide meets the requirements for renewal described in §556.9(f) of this chapter;(B) the former nurse aide is a military service member, military veteran, or military spouse;(C) the former nurse aide has not committed an offense listed in Texas Health and Safety Code (THSC) §250.006(a) and (c) and has not committed an offense listed in THSC §250.006(b) during the five years before the date the former nurse aide submitted the initial license application; and(D) the former nurse aide is not listed on the EMR.(c) HHSC replaces a lost, damaged, or destroyed certificate for a military spouse. A military spouse with an active nurse aide certificate can print a duplicate license through the online portal. A military spouse can request a change of name through the online portal by submitting a name change application. Source Note: The provisions of this §556.14 adopted to be effective September 18, 2024, 49 TexReg 7342. 1 HEALTH AND HUMAN SERVICES COMMISSION 556 NURSE AIDES §556.14 Alternate Licensing Requirements for Military Service Personnel https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220677 03/12/2026 (a) Purpose. The purpose of this chapter is to implement the provisions of the:(1) Texas Health and Safety Code, Chapter 242, Subchapter N, concerning the administration of medications to facility residents;(2) Texas Health and Safety Code, Chapter 142, Subchapter B, concerning the administration of medication by a home and community support services agency; and(3) Texas Human Resource Code §161.083, concerning the administration of medication to an inmate in a correctional facility.(b) Corrections medication aide permit requirements. Section 557.125 of this chapter (relating to Requirements for Corrections Medication Aides) applies to a corrections medication aide or an applicant for a corrections medication aide permit.(c) Definitions. The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--Negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident; or sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure) or Texas Penal Code, Chapter 22 (relating to Assaultive Offenses), sexual harassment, sexual coercion, or sexual assault.(2) Active duty--Current full-time military service in the armed forces of the United States or as a member of the Texas military forces, as defined in Texas Government Code §437.001, or similar military service of another state.(3) Armed forces of the United States--The Army, Navy, Air Force, Coast Guard, Space Force, or Marine Corps of the United States, including reserve units of those military branches.(4) BON--Texas Board of Nursing.(5) Classroom instruction and training--Teaching curriculum components through in-person instruction taught in a physical classroom location, which may include skills practice, or through online instruction taught in a virtual classroom location.(6) Client--An individual receiving home health, hospice, or personal assistance services from a HCSSA.(7) Clinical experience--Teaching hands-on care of residents in a nursing facility under the required level of supervision of a licensed nurse, which may include skills practice prior to performing the skills through hands-on care of a resident. The clinical experience provides the opportunity for a trainee to learn to apply the classroom instruction and training to the care of residents with the assistance and required level of supervision of the instructor.(8) Correctional facility--a facility operated by or under contract with the Texas Department of Criminal Justice.(9) Day--Any day, including a Saturday, a Sunday, and a holiday.(10) EMR--Employee misconduct registry. The registry maintained by HHSC in accordance with Texas Health and Safety Code, Chapter 253, to record findings of reportable conduct by certain unlicensed employees.(11) Examination--A written competency evaluation for medication aides administered by HHSC.(12) Facility--An institution licensed under Texas Health and Safety Code, Chapter 242; a state supported living center as defined in Texas Health and Safety Code §531.002(19); a licensed intermediate care facility for an individual with an intellectual disability or related condition as defined in the Texas Health and Safety Code Chapter 252; an intermediate care facility for an individual with an intellectual disability or related condition operated by a community center as described in Texas Health and Safety Code, Chapter 534; or an assisted living facility licensed under Texas Health and Safety Code, Chapter 247.(13) HCSSA--A home and community support services agency licensed under Texas Health and Safety Code, Chapter 142 and Chapter 558 of this title (relating to Licensing Standards for Home and Community Support Services Agencies).(14) HHSC--The Texas Health and Human Services Commission.(15) Licensed nurse--A licensed vocational nurse or an RN.(16) LVN--Licensed vocational nurse. A person licensed by the BON, or who holds a license from another state recognized by the BON, to practice vocational nursing in Texas.(17) Medication aide--A person who is issued a permit by HHSC under Texas Health and Safety Code Chapter 242, Subchapter N, Texas Human Resources Code, Chapter 161, Subchapter D, and Texas Health and Safety Code, Chapter 142, Subchapter B to administer medications to facility residents, correctional facility inmates, or to persons served by home and community support services agencies.(18) Military service member--A person who is on active duty.(19) Military spouse--A person who is married to a military service member.(20) Military veteran--A person who has served on active duty and who was discharged or released from active duty.(21) Misappropriation of resident property--The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.(22) NAR--Nurse aide registry. A state listing of nurse aides maintained by HHSC in accordance with Texas Health and Safety Code, Chapter 250 that indicates if a nurse aide has active status, revoked status, or is unemployable based on a finding of having committed an act of abuse, neglect or misappropriation of resident property.(23) Neglect--The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.(24) Non-licensed direct care staff--Employees of facilities other than Medicare-skilled nursing facilities or Medicaid nursing facilities who are primarily involved in the delivery of services to assist with residents' activities of daily living or active treatment programs.(25) Nurse aide--An individual who has completed a nurse aide training and competency evaluation program (NATCEP) approved by HHSC as meeting the requirements of 42 Code of Federal Regulations (CFR) §§483.150 - 483.154, or has been determined competent as provided in 42 CFR §483.150(a) and (b), and is listed as certified on the HHSC nurse aide registry.(26) Online portal--The Texas Unified Licensure Information Portal (TULIP), through which licensing application activities are completed.(27) PRN medication--Pro re nata medication. Medication administered as the occasion arises or as needed.(28) Registered pharmacist--An individual currently licensed by the Texas Board of Pharmacy to practice pharmacy.(29) RN--Registered nurse. A person who is licensed by the BON, or who holds a license from another state recognized by the BON, to practice professional nursing in Texas.(30) TDCJ--Texas Department of Criminal Justice.(31) Training program--A program approved by HHSC to instruct individuals to act as medication aides. Source Note: The provisions of this §557.101 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.101 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220678 03/12/2026 (a) General. A person may not administer medication to a resident in a facility, an inmate in a correctional facility, or a client receiving home health services unless the person:(1) holds a current license under state law which authorizes the licensee to administer medication; or(2) holds a current permit issued under this chapter and acts under the authority of a person who holds a current license under state law which authorizes the licensee to administer medication.(b) Supervision and applicable law and rules. A medication aide must function under the direct supervision of a licensed nurse on duty or on call by the facility, correctional facility, or home health agency using the medication aide. A medication aide must:(1) function in accordance with applicable law and rules relating to administration of medication and operation of a facility, correctional facility, or home health agency; and(2) comply with HHSC rules applicable to personnel used in a facility or for a home health agency, or TDCJ rules applicable to personnel in a correctional facility.(c) Governmental employees. Governmental employees may receive a permit to administer medications under this chapter as authorized by Texas Health and Safety Code §242.610(f) or Texas Human Resources Code §161.083:(1) state supported living center employees and employees of an intermediate care facility for persons with an intellectual disability operated by a community center established under Texas Health and Safety Code, Chapter 534 must comply with subsection (b) of this section and §557.105 of this chapter (relating to Allowable and Prohibited Practices of a Medication Aide); §557.107 of this chapter (relating to Training Requirements; Nursing Graduates; Reciprocity); §557.109 of this chapter (relating to Application Procedures); §557.111 of this chapter (relating to Examination); §557.113 of this chapter (relating to Determination of Eligibility); §557.115 of this chapter (relating to Permit Renewal); §557.117 of this chapter (relating to Changes); §557.119 of this chapter (relating to Training Program Requirements); §557.121 of this chapter (relating to Permitting of Persons with Criminal Backgrounds; and §557.123 of this chapter (relating to Violations, Complaints, and Disciplinary Actions).(2) correctional facility employees and employees of medical services contractors for a correctional facility who administer medication as medication aides must comply with §557.125 of this chapter (relating to Requirements for Corrections Medication Aides).(3) home health employees who administer medication as medication aides must comply with §557.128 of this chapter (relating to Home Health Medication Aides).(d) medication aides in nursing facilities. Persons employed as medication aides in a Medicare skilled nursing facility or a Medicaid nursing facility must comply with the requirements relating to nurse aides as set forth in United States Code, Part 42 §1396r(b)(5) and Chapter 556 of this title (relating to Nurse Aides).(e) Exemptions.(1) A person may administer medication to a resident in a facility without the license or permit as required in subsection (a) of this section, if the person is:(A) a graduate nurse holding a temporary permit issued by the BON;(B) a student enrolled in an accredited school of nursing or program for the education of registered nurses who is administering medications as part of the student's clinical experience;(C) a graduate vocational nurse holding a temporary permit issued by the BON;(D) a student enrolled in an accredited school of vocational nursing or program for the education of vocational nurses who is administering medications as part of the student's clinical experience; or(E) a trainee in a medication aide training program approved by HHSC under this chapter who is administering medications as part of the trainee's clinical experience.(2) A student described in paragraph (1)(B), (D), or (E) of this subsection may administer medication only as part of the student's clinical experience.(3) A person described in paragraph (1) of this subsection must act under the supervision of an individual as set forth in applicable law and rules. Source Note: The provisions of this §557.103 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.103 Requirements for Administering Medications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220679 03/12/2026 (a) A medication aide permitted under this chapter:(1) must observe and report to the facility's or home health agency's licensed nurse on duty or on call any reactions or side effects to medication shown by a resident or client, and document such side effects to the medication in the resident's or client's clinical or equivalent record;(2) must take and record vital signs before the administration of medication that could affect or change vital signs;(3) may administer regularly prescribed medication to a resident or client if the medication aide:(A) is trained to administer the medication;(B) personally prepares the medication or sets up the medication to be administered; and(C) documents the administration of the medication in the resident's or client's clinical or equivalent record;(4) may administer oxygen per nasal cannula or a non-sealing mask only in an emergency, after which the medication aide must verbally notify the licensed nurse on duty or on call and appropriately document the action and notification;(5) may apply specifically ordered ophthalmic, otic, nasal, vaginal, and rectal medication unless prohibited by subsection (b)(10) of this section;(6) may administer medications only from the manufacturer's original container or the original container in which the medication had been dispensed and labeled by the pharmacy with all information mandated by the Texas State Board of Pharmacy;(7) may administer previously ordered PRN medication, if:(A) the facility's or home health agency's licensed nurse on duty or on call authorizes the medication;(B) the medication aide documents in the resident's or client's records the symptoms indicating the need for the medication and the time the symptoms occurred;(C) the medication aide documents in the resident's or client's records that the facility's or home health agency's licensed nurse on duty or on call was contacted, symptoms were described, and the licensed nurse granted permission to administer the medication, including the time of contact;(D) the medication aide obtains authorization to administer the medication from the facility's or home health agency's licensed nurse on duty or on call each time the symptoms occur;(E) except as required by subparagraph (F) of this paragraph, the medication aide ensures that the resident's or client's record is co-signed by the licensed nurse who provided authorization by the end of the nurse's shift or, if the nurse was on call, by the end of the nurse's next on duty shift; and(F) must, if a home health medication aide, ensure that the client's clinical record is co-signed by the RN who provided authorization within seven days after the notes are incorporated into the clinical record;(8) may measure a prescribed amount of a liquid medication to be administered to a resident or client;(9) may break a tablet to be administered to a resident or client, if:(A) the resident's or client's medication card or its equivalent accurately documents how the tablet must be broken before administration; and(B) the licensed nurse on duty or on call has calculated the dosage;(10) may crush medication, if:(A) authorization has been given in the original physician's order or the medication aide obtains authorization to crush the medication from the licensed nurse on duty or on call; and(B) the medication aide documents the authorization on the resident or client's medication card or its equivalent; and(11) may, except as prohibited by subsection (d) of this section, electronically order a refill of medication from a pharmacy, if the refill request is signed by the licensed nurse on duty or on call.(b) A medication aide permitted under this chapter may not:(1) administer medication by the injection route including the:(A) intramuscular route;(B) intravenous route;(C) subcutaneous route;(D) intradermal route; and(E) hypodermoclysis route;(2) administer medication used for intermittent positive pressure breathing treatments or any form of medication inhalation treatments;(3) administer previously ordered PRN medication, except in accordance with subsection (a)(7) of this section;(4) administer medication that, according to the resident's or client's clinical records, has not been previously administered to the resident or client;(5) calculate resident's or client's medication doses for administration;(6) crush medication, except in accordance with subsection (a)(10) of this section;(7) administer medications or feedings by way of a tube inserted in a cavity of the body, except as specified for home health medication aides in §558.404(h) of this title (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services);(8) receive or assume responsibility for reducing to writing a verbal or telephone order from a healthcare professional including a physician, dentist, podiatrist or advanced practice nurse;(9) order a resident's or client's medications from a pharmacy, except in accordance with subsection (a)(11) of this section;(10) apply topical medications that involve the treatment of skin that is broken or blistered or when a specified aseptic technique is ordered by the attending physician;(11) steal, divert, or otherwise misuse medication;(12) violate any provision of the Texas Health and Safety Code, Texas Human Resources Code, or this chapter;(13) fraudulently procure or attempt to procure a permit;(14) neglect to administer appropriate medications, as prescribed, in a responsible manner; or(15) administer medications if the person is unable to do so with reasonable skill and safety to residents or clients by reason of drunkenness or excessive use of drugs, narcotics, chemicals, or any other type of material.(c) If a practice is not described in subsection (a) of this section the practice is prohibited for a medication aide permitted under this chapter.(d) A home health medication aide may not order a client's medication from a pharmacy. Source Note: The provisions of this §557.105 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.105 Allowable and Prohibited Practices of a Medication Aide https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220680 03/12/2026 (a) Each applicant for a permit issued under this chapter must complete a training program unless the applicant meets the requirements of subsection (c) or (e) of this section.(b) Before submitting an application for a permit under this chapter, an applicant must:(1) be able to read, write, speak, and understand English;(2) be at least 18 years of age;(3) be free of communicable diseases and in suitable physical and emotional health to safely administer medications;(4) be a high school graduate or have proof of successfully passing a general educational development test;(5) if a home health medication aide, have satisfactorily completed a home health aide training and competency evaluation program or a competency evaluation program under §558.701 of this title (relating to Home Health Aides);(6) be employed in a facility or home health agency, as a nurse aide or nonlicensed direct care staff person on the first official day of the applicant's medication aide training program;(7) have been employed:(A) as a nurse aide in a Medicare-skilled nursing facility or a Medicaid nursing facility; or(B) in a facility or by a home health agency, for 90 days as a nonlicensed direct care staff person during the 12-month period before the first official day of the applicant's medication aide training program;(8) not have a criminal history that HHSC determines is a basis for denying the permit under §557.121 of this chapter (relating to Permitting of Persons with Criminal Backgrounds);(9) not be listed as unemployable on the EMR; and(10) not be listed with a revoked or suspended status on the NAR.(c) A person who is attending or has attended an accredited school of nursing and who does not hold a license to practice professional or vocational nursing meets the training requirement for issuance of a permit under this chapter if the person:(1) attended the nursing school no earlier than January 1 of the year immediately preceding the year of application for a permit under this chapter;(2) successfully completed courses at the nursing school that covered the HHSC curriculum for a medication aide training program;(3) submits a statement, with the application for a permit and combined permit application and examination fee as provided in §557.109 of this chapter (relating to Application Procedures), on the form provided by HHSC, signed by the nursing school's administrator or other authorized individual, certifying that the person completed the courses specified in paragraph (2) of this subsection; and(4) complies with subsection (e)(5) and (6) of this section.(d) The administrator or other authorized individual referred to in subsection (c)(3) of this section is responsible for determining that the nursing school courses cover HHSC curriculum.(e) A person who is a graduate of an accredited school of nursing and who does not hold a license to practice professional or vocational nursing meets the training requirement for issuance of a permit under this chapter if the date of graduation from the nursing school was no earlier than January 1 of the year immediately preceding the year of application for a permit under this chapter.(1) The applicant must submit an official application form to HHSC through the online portal. The applicant must meet the requirements of subsection (b)(1) - (4), (8), and (9) of this section.(2) The application must be accompanied by the combined permit application and examination fee as set out in §557.109(c) of this chapter.(3) The applicant must include an official transcript documenting graduation from an accredited school of nursing.(4) HHSC acknowledges receipt of the application by sending the applicant a copy of this chapter and the HHSC open book examination.(5) The applicant must complete the open book examination and return it to HHSC via email by the date given in the examination notice.(6) The applicant must complete the HHSC written examination. HHSC denies the application of an applicant who fails to schedule and take the written examination by the date given in the examination notice.(7) The open-book or written examination may not be retaken if the applicant fails the examination.(8) Upon successful completion of the open-book and written examinations, HHSC evaluates all application documents submitted by the applicant.(9) HHSC notifies the applicant of the examination results through the online portal.(f) A person who holds a valid license, registration, certificate, or permit as a medication aide issued by another state whose minimum standards or requirements are substantially equivalent to or exceed the requirements of this chapter that is in effect at the time of application, may request a waiver of the training program requirement as follows:(1) The applicant must submit an official application form to HHSC through the online portal. The applicant must meet the requirements of subsection (b)(1) - (4), (8), and (9) of this section.(2) The application must be accompanied by the combined permit application and examination fee required in §557.109(c) of this chapter.(3) The application must include a current copy of the rules of the other state governing its licensing and regulation of medication aides, a copy of the legal authority (law, act, code, or other) for the state's licensing program, and a certified copy of the license or certificate for which the reciprocal permit is requested.(4) HHSC acknowledges receipt of the application by sending the applicant a copy of this chapter and the HHSC open book examination.(5) HHSC may contact the issuing agency to verify the applicant's status with the agency.(6) The applicant must complete the HHSC open-book examination and return it to HHSC via email by the date given in the examination notice.(7) The applicant must complete the HHSC written examination. The site of the examination is determined by HHSC. HHSC denies the application of an applicant failing to schedule and take the examination by the date given in the examination notice.(8) An open-book or written examination may not be retaken if the applicant fails the examination.(9) Upon successful completion of the two examinations, HHSC evaluates all application documents submitted by the applicant.(10) HHSC notifies the applicant of the examination results through the online portal. Source Note: The provisions of this §557.107 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.107 Training Requirements; Nursing Graduates; Reciprocity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220681 03/12/2026 (a) An applicant for a permit under this chapter, who complies with §557.107(a) of this chapter (relating to Training Requirements; Nursing Graduates; Reciprocity) must, no later than 20 days after enrollment in a training program:(1) complete an application through the online portal, including submitting the following materials:(A) the general statement enrollment form, which must contain:(i) specific information regarding the applicant's personal data, certain misdemeanor and felony convictions, work experience, education, and training;(ii) a statement that the applicant has met all the requirements in §557.107(b) of this chapter before the start of the program;(iii) a statement that the applicant understands that application fees submitted in the permit process are nonrefundable;(iv) a statement that the applicant understands materials submitted in the application process are nonreturnable;(v) a statement that the applicant understands that it is a misdemeanor to falsify any information submitted to HHSC; and(vi) the applicant's signature through the online portal; and(B) upload through the online portal a certified copy or a notarized photocopy of the applicant's unaltered, original, high school diploma or transcript or the written results of a general educational development (GED) test demonstrating that the applicant passed the GED test, unless the applicant is applying under §557.107(e) of this chapter;(2) submit the application to HHSC through the online portal; and(3) submit the applicant's fingerprints to the Texas Department of Public Safety for a Federal Bureau of Investigation criminal background check.(b) HHSC considers an application under subsection (a) of this section as officially submitted when HHSC receives the permit application and examination fee through the online portal.(c) An applicant must pay the combined permit and examination fees through the online portal. All fees are nonrefundable, except as provided by Texas Government Code, Chapter 2005.(1) The fee schedule is as follows:(A) combined permit application and examination fee--$25;(B) renewal fee--$15;(C) late renewal fees for permit renewals made after the permit expires:(i) $22.50 for an expired permit renewed from one to 90 days after expiration;(ii) $30 for an expired permit renewed from 91 days to one year after expiration; and(iii) $30 for a former medication aide who meets the criteria in §557.115(c)(5) of this chapter (relating to Permit Renewal).(2) An initial or a renewal application is considered incomplete until the fee has been received and cleared through the appropriate financial institution.(3) The fee schedule that applies to a correctional medication aide is in §557.125 of this chapter (relating to Requirements for Corrections Medication Aides), and the fee schedule that applies to a home health medication aide is in subsection (c) of this section.(d) HHSC reviews high school diploma or GED documentation submitted by the applicant. If HHSC determines additional information is required, and HHSC requests additional documentation from the applicant, the applicant must provide the documentation to HHSC through the online portal.(e) HHSC sends a notice through the online portal listing the additional materials required to an applicant who does not submit a complete application. An applicant must submit a complete application by the date of HHSC final exam.(f) HHSC sends notice of HHSC application approval or deficiency to an applicant through the online portal in accordance with §557.121 of this chapter (relating to Permitting of Persons with Criminal Backgrounds) or §557.127 of this chapter (relating to Application Processing). Source Note: The provisions of this §557.109 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.109 Application Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220682 03/12/2026 (a) HHSC gives a written examination to each applicant at a site determined by HHSC.(1) The applicant must meet the requirements of §557.107 of this chapter (relating to Training Requirements; Nursing Graduates; Reciprocity) and §557.109 of this chapter (relating to Application Procedures) before taking the written examination.(2) The applicant is tested on the subjects taught in the training program curricula and clinical experience. The examination covers an applicant's knowledge of accurate and safe drug therapy that will be administered to a facility's residents or home health agency's clients.(3) The examination must be given after the applicant has successfully completed the training program or met the requirements of §557.107(c) - (e) of this chapter.(4) An applicant with a disability, including an applicant with dyslexia as defined in Texas Education Code §51.970 (relating to Instructional Material for Blind and Visually Impaired Students and Students with Dyslexia), may request a reasonable accommodation for the examination under the Americans with Disabilities Act.(5) HHSC determines the passing grade on the examination.(6) If HHSC grades or reviews the examination, HHSC notifies the applicant of the results of the examination not later than the 30th day after the date the applicant took the examination through the online portal.(7) If a testing service grades or reviews the examination:(A) HHSC notifies the applicant of the results of the examination through the online portal not later than the 14th day after the date HHSC receives the results from the testing service; and(B) if notice of the examination results will be delayed for longer than 90 days after the examination date, HHSC notifies the applicant via email of the reasons for the delay before the 90th day.(8) HHSC may require a testing service to notify an applicant of the results of the applicant's examination.(9) HHSC notifies in writing an applicant who fails the examination through the online portal.(A) HHSC may give an applicant under §557.107(a) of this chapter one subsequent examination, without additional payment of a fee, upon the applicant's request to HHSC through the online portal.(B) The subsequent examination must be completed by the date given in the failure notification. The site of the examination is determined by HHSC.(C) HHSC gives no further examinations if the student fails the subsequent examination, unless the student enrolls in and successfully completes another training program.(D) If requested in writing by an applicant who fails the examination, HHSC furnishes the applicant with an analysis of the applicant's performance on the examination.(b) An applicant who is unable to attend the applicant's scheduled examination due to unforeseen circumstances may be given an examination at another time without payment of an additional fee upon the applicant's written request to HHSC via email. The examination must be completed within 45 days from the date of the originally scheduled examination. The rescheduled examination is at a site determined by HHSC.(c) An applicant whose application for a permit is denied under §557.113 of this chapter (relating to Determination of Eligibility) is ineligible to take the examination. Source Note: The provisions of this §557.111 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.111 Examination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220683 03/12/2026 (a) HHSC approves or denies each application for a permit.(b) HHSC provides notices of application approval, denial, or deficiency in accordance with §557.127 of this chapter (relating to Application Processing).(c) HHSC denies an application for a permit if the applicant:(1) does not meet the requirements in §557.107 of this chapter (relating to Training Requirements; Nursing Graduates; Reciprocity) or §557.125 of this chapter (relating to Requirements for Corrections Medication Aides);(2) fails to pass the examination prescribed by HHSC, as referenced in §557.111 of this chapter (relating to Examination), or developed by TDCJ, as referenced in §557.125(h) of this chapter;(3) fails or refuses to properly complete or submit an application form or fee through the online portal, or deliberately submits false information on any form or document required by HHSC;(4) violates or conspires to violate Texas Health and Safety Code, Chapter 242, Subchapter N, Texas Human Resources Code §161.083, or any provision of this chapter;(5) has a criminal history that HHSC determines is a basis for denying the permit under §557.121 of this chapter (relating to Permitting of Persons with Criminal Backgrounds);(6) is listed with a revoked or suspended status on the HHSC NAR; or(7) is listed as unemployable on the EMR.(d) If, after review, HHSC determines that the application should be denied, HHSC gives the applicant written notice of the reason for the proposed decision and of the opportunity for a formal hearing in accordance with §557.123(c)(3) of this chapter (relating to Violations, Complaints, and Disciplinary Actions). Source Note: The provisions of this §557.113 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.113 Determination of Eligibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220684 03/12/2026 (a) General.(1) An initial permit is valid for 12 months from the date of issue.(2) A medication aide must renew his or her permit annually.(3) Each medication aide is responsible for renewing the permit before the expiration date. Failure to receive notification from HHSC before the expiration date of the permit does not excuse a medication aide's failure to file for timely renewal.(4) Continuing education hours are not required for the first renewal. However, after a permit is renewed for the first time, a medication aide must complete a seven-hour continuing education program approved by HHSC annually before expiration of his or her permit to renew the permit for each additional year.(5) HHSC denies renewal of the permit of a medication aide who:(A) is in violation of Texas Health and Safety Code, Chapter 242, Subchapter N, Texas Human Resources Code §161.083, or this chapter at the time of application for renewal;(B) has a conviction of a criminal offense listed in Texas Health and Safety Code §250.006(a) or (c), or a conviction of a criminal offense listed in Texas Health and Safety Code §250.006(b) within five years before the date HHSC receives the renewal application;(C) is listed as unemployable on the EMR; or(D) is listed with a revoked or suspended status on the NAR.(6) A person whose permit has expired may not engage in activities that require a permit until the permit has been renewed.(b) Permit renewal procedures.(1) After receiving proof of the successful completion of the seven hour continuing education requirement, HHSC sends notice of the amount of the renewal fee due, and a renewal form to the medication aide through the online portal.(2) The renewal form located in the online portal, which includes the contact information and preferred mailing address of the medication aide.(3) Medication aides are required to submit fingerprints to the Texas Department of Public Safety for a Federal Bureau of Investigation criminal background check, if not submitted previously.(4) HHSC issues a renewal permit to a medication aide who meets all requirements for renewal, including payment of the renewal fee.(c) Late renewal procedures.(1) If a medication aide submits a renewal application to HHSC through the online portal that is late or incomplete, HHSC assesses the appropriate late fee described in §557.109(c)(1)(C) of this chapter (relating to Application Procedures). HHSC uses the submission date in the online portal to determine if a renewal application is late.(2) A person whose permit has been expired for less than one year may renew the permit through the online portal by submitting to HHSC:(A) the permit renewal form;(B) all accrued renewal fees;(C) proof of having earned, during the expired period, seven hours in an approved continuing education program for each year, or part of a year, since the permit expired; and(D) proof of having earned, before expiration of the permit, seven hours in an approved continuing education program as required by subsection (a)(4) of this section.(3) A person whose permit has been expired for 90 days or less must pay HHSC the late renewal fee provided in §557.109(c)(1)(C)(i) of this chapter (relating to Application Procedures) or §557.125(g)(3)(A) of this chapter (relating to Requirements for Corrections Medication Aides).(4) A person whose permit has been expired for more than 90 days but less than one year must pay HHSC the late renewal fee stated in §557.109(c)(1)(C)(ii) or §557.125(g)(3)(B) of this chapter.(5) A person who previously held a permit in Texas issued under this chapter may obtain a new permit without reexamination if the person holds a medication aide permit from another state, practiced in that state for at least the two years preceding the application date, and pays to HHSC the late renewal fee stated in §557.109(c)(1)(C)(iii) of this chapter.(6) HHSC denies late renewal of the permit if a permit holder:(A) is in violation of Texas Health and Safety Code, Chapter 242, Subchapter N, Texas Human Resources Code §161.083, or this chapter on the date HHSC receives the application for late renewal;(B) has a conviction of a criminal offense listed in Texas Health and Safety Code §250.006(a) or (c), or a conviction of a criminal offense listed in Texas Health and Safety Code §250.006(b) within five years before the date HHSC receives the application for late renewal;(C) is listed as unemployable on the EMR; or(D) is listed with a revoked or suspended status on the NAR.(d) A person whose permit has been expired for one year or more may not renew the permit. To obtain a new permit, the person must apply for a permit in accordance with §557.109 of this chapter (relating to Application Procedures) and in §557.111 of this chapter (relating to Examination). Source Note: The provisions of this §557.115 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.115 Permit Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220685 03/12/2026 (a) A medication aide must notify HHSC through the online portal within 30 days after changing the medication aide's required contact information, including name, preferred mailing address, or email address. The medication aide can request a change of name through the online portal by submitting a name change application.(b) HHSC replaces a lost, damaged, or destroyed permit upon receipt of a completed duplicate permit request form. A medication aide can print a duplicate permit through the online portal. Source Note: The provisions of this §557.117 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.117 Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220686 03/12/2026 (a) Application. An educational institution accredited by the Texas Workforce Commission or Texas Higher Education Coordinating Board that desires to offer a training program must file an application for approval on an HHSC form through the online portal. Programs sponsored by state agencies for the training and preparation of their own employees are exempt from the accreditation requirement. An approved institution may offer the training program and a continuing education program.(1) The application through the online portal must include:(A) the anticipated dates of the program;(B) the location of the classroom instruction and training course;(C) the name of the coordinator of the program;(D) a list that includes the address and telephone number of each instructor and any other persons responsible for the conduct of the program; and(E) an outline of the program content and curriculum if the curriculum covers more than HHSC established curricula.(2) HHSC may conduct an inspection of the classroom instruction and training site.(3) HHSC sends notice of approval or proposed denial of the application to the program within 30 days after receiving a complete application through the online portal. If HHSC proposes to deny the application due to noncompliance with the requirements of this chapter, it provides the reasons for denial in the notice.(4) An applicant may request in writing a hearing on a proposed denial. The applicant must submit a request within 15 days after the applicant receives notice of the proposed denial. The hearing is governed by 1 Texas Administrative Code Chapter 357, Subchapter I (relating the Hearings under the Administrative Procedure Act); Chapter 110 of this title (relating to Hearings under the Administrative Procedure Act); and Texas Government Code, Chapter 2001. If no request is made, the applicant has waived the opportunity for a hearing, and HHSC takes the proposed action.(b) Basic training program.(1) A training program must include the following instruction and training:(A) procedures for preparation and administration of medications;(B) responsibility, control, accountability, storage, and safeguarding of medications;(C) use of reference material;(D) documentation of medications in resident's or client's clinical records, including PRN medications;(E) minimum licensing standards for facilities covering pharmaceutical service, nursing service, and clinical records;(F) federal and state certification standards for participation under Title XVIII (Medicare) and Title XIX (Medicaid) of the Social Security Act pertaining to pharmaceutical service, nursing service, and clinical records;(G) lines of authority in the facility, including facility personnel who are immediate supervisors;(H) responsibilities and liabilities associated with the administration and safeguarding of medications;(I) allowable and prohibited practices of medication aides in the administration of medication;(J) drug reactions and side effects of medications commonly administered to residents or clients; and(K) rules covering the medication aide program.(2) The program must consist of 140 hours in the following sequence: 100 hours of classroom instruction and training; 20 hours of return skills demonstration laboratory; 10 hours of clinical experience, including clinical observation and skills demonstration under the direct supervision of a licensed nurse in a facility; and 10 hours of return skills demonstration laboratory. A classroom instruction and training or laboratory hour must include 50 minutes of actual classroom instruction and training or laboratory time.(A) Class time must not exceed:(i) four hours in a 24-hour period for a facility training program; or(ii) eight hours in a 24-hour period for a correctional facility training program.(B) The completion date of the program must be:(i) a minimum of 60 days and a maximum of 180 days after the starting date of the facility training program; or(ii) a minimum of 30 days and a maximum of 180 days after the starting date of a correctional facility training program.(3) Each program must follow the curricula established by HHSC.(4) Before a student begins a training program, the program must:(A) ensure the student meets training requirements in §557.107(b)(1) - (9) of this chapter (relating to Training Requirements; Nursing Graduates; Reciprocity);(B) check the EMR to verify that the student is not listed as unemployable; and(C) check the NAR to verify if the student is listed in revoked or suspended status.(5) At least seven days before the beginning of a training program, the coordinator must notify HHSC in writing through the online portal of the dates and daily hours of the program, and the projected number of students.(6) A change in any information presented by the program in an approved application, including location, instructors, and content must be approved by HHSC through the online portal before the change is implemented.(7) The program instructors of the classroom instruction and training hours must be a registered nurse and registered pharmacist.(A) The nurse instructor must have:(i) a minimum of two years of experience in caring for individuals in a long-term care setting or be an instructor in a school of nursing, for a facility training program; or(ii) a minimum of two years of experience employed in a correctional setting or be an instructor in a school of nursing, for a correctional facility program.(B) The pharmacist instructor must have:(i) a minimum of one year of experience and be currently employed or contracted as a consultant pharmacist in a facility; or(ii) a minimum of one year of experience employed or contracted as a pharmacist in a correctional setting.(8) The program coordinator must provide clearly defined and written policies regarding each student's clinical experience to the student, the administrator, and the director of nursing in the facility used for the clinical experience.(A) The clinical experience must be counted only when the student is performing functions involving medication administration and under the direct supervision of a licensed nurse.(B) The program coordinator must be responsible for final evaluation of the student's clinical experience.(9) Each program must issue to each student, upon successful completion of the program, a certificate of completion, which must include the program's name, the student's name, the date of completion, and the signature of the program coordinator or administrative official.(10) Each program must inform HHSC through the online portal on the HHSC class roster form of the final grade results for each student within 15 days after the student's completion of the course and prior to scheduling the exam.(11) A student without an HHSC-approved criminal background check will not be allowed to take the exam.(c) Continuing education training program.(1) The program must consist of at least seven hours of classroom instruction and training or online instruction.(2) The instructors must meet the requirements in subsection (b)(7) of this section.(3) Each program must follow the curricula established by HHSC or the curriculum established by TDCJ for corrections medication aides, as applicable.(4) Within 10 days after a medication aide's completion of the course, each program must inform HHSC through the online portal using the HHSC class roster form of the name of each medication aide who has completed the course.(d) In developing a training program for corrections medication aides that complies with Texas Government Code §501.1485, TDCJ may modify, as appropriate, the content of the training program curriculum originally developed under Texas Health and Safety Code, Chapter 242, to produce content suitable for administering medication in a correctional facility. The training program curriculum must be approved by HHSC.(e) Subsection (c) of this section applies to a training program for medication aides and corrections medication aides. Source Note: The provisions of this §557.119 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.119 Training Program Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220687 03/12/2026 (a) HHSC may suspend or revoke an existing permit, deny a permit, or deny a person the opportunity to take the examination for a permit if the person has a conviction for an offense listed in Texas Health and Safety Code §250.006.(b) HHSC reviews an applicant's or existing medication aide's criminal background based on the Federal Bureau of Investigation fingerprinting submitted through the Texas Department of Public Safety.(c) A person who is denied a permit, or who has a permit suspended or revoked, due to his or her criminal background is given notice in accordance with §557.123(d) and (e) of this chapter (relating to Violations, Complaints, and Disciplinary Actions). Source Note: The provisions of this §557.121 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.121 Permitting of Persons with Criminal Backgrounds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220688 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220688 03/12/2026 (a) Filing of complaints. Any person may file a complaint with HHSC alleging that a person or program has violated the Texas Health and Safety Code, Chapter 242, Subchapter N; Texas Human Resources Code §161.083; or this chapter.(1) Persons wishing to file a complaint against a medication aide, training program, or other person related to medication aide training or permitting, must notify HHSC by calling 1-800-458-9858 or by writing the Medication Aide Permit Program, Health and Human Services Commission, P.O. Box 149030, Mail Code E-416, Austin, Texas 78714-9030.(2) Anonymous complaints may be investigated by HHSC if the complainant provides sufficient information.(b) Investigation of complaints. If HHSC's initial investigation determines:(1) the complaint is not within HHSC jurisdiction, HHSC advises the complainant and, if applicable, refers the complainant to the appropriate governmental agency for handling the complaint;(2) there are insufficient grounds to support the complaint, HHSC dismisses the complaint and gives written notice of the dismissal to the medication aide or person against whom the complaint has been filed and the complainant; or(3) there are sufficient grounds to support the complaint, HHSC may propose to deny, suspend, emergency suspend, revoke, or not renew a permit or to rescind program approval.(c) Disciplinary actions. HHSC may revoke, suspend, or refuse to renew a permit, or reprimand a medication aide for a violation of Texas Health and Safety Code, Chapter 242, Subchapter N; Texas Human Resources Code §161.083; or this chapter. HHSC may suspend a permit in an emergency or rescind HHSC approval for an educational institution to offer a training program if the medication aide or educational institution fails to comply with the requirements in this chapter.(1) HHSC may place on probation a person whose permit is suspended. HHSC may require the person on probation:(A) to report regularly to HHSC on matters that are the basis of the probation;(B) to limit practice to the areas prescribed by HHSC; or(C) to continue or pursue professional education until the person attains a degree of skill satisfactory to HHSC in those areas that are the basis of the probation.(2) Before institution of formal proceedings to revoke or suspend a permit or rescind program approval, HHSC gives written notice to the medication aide or program of the facts or conduct alleged to warrant revocation, suspension, or rescission, and the medication aide or program must be given an opportunity, as described in the notice, to show compliance with all requirements of the Texas Health and Safety Code, Chapter 242, Subchapter N; Texas Human Resources Code §161.083; or this chapter. When there is a finding of an alleged act of abuse, neglect, or misappropriation of resident property by a medication aide employed at a Medicaid-certified nursing facility or a Medicare-certified skilled nursing facility, HHSC complies with the hearings process as provided in 42 Code of Federal Regulations §488.335.(3) If denial, revocation, or suspension of a permit or rescission of program approval is proposed, HHSC gives written notice that the medication aide or program must request, in writing, a hearing within 30 days after receipt of the notice, or the right to a hearing is waived and the permit is denied, revoked, or suspended or the program approval is rescinded.(4) A hearing is governed by 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act); and Chapter 110 of this title (relating to Hearings under the Administrative Procedure Act).(5) If HHSC receives an allegation that a medication aide, who has a nurse aide certificate under Chapter 556 of this title (relating to Nurse Aides), committed an act of abuse, neglect, or misappropriation of resident property, HHSC investigates the allegation under this section regarding the medication aide practice and under Chapter 556 of this title to determine if the allegation violates the nurse aide practice. The investigations run concurrently. If after the investigations, the medication aide requests hearings on the findings under the nurse aide practice and the medication aide practice, only one hearing, conducted in accordance with paragraph (4) of this subsection, is available to the medication aide.(d) Denial based on criminal history.(1) HHSC provides written notice to any person HHSC proposes to deny an application based on the person's criminal history. The written notice must contain a statement that the person is disqualified from receiving a permit or being examined for a permit because of the person's prior conviction for the offense or offenses specified in the notice, as provided in §557.121(a) of this chapter (relating to Permitting of Persons with a Criminal Background).(2) If, upon reviewing the evidence provided by the person, HHSC upholds its decision to deny the person, HHSC notifies the person in writing of:(A) the reason for the denial or disqualification; and(B) the process for requesting a formal hearing before a State Office of Administrative Hearings administrative law judge.(3) If HHSC's decision to deny the person is upheld during a formal hearing, HHSC shall notify the person in writing of:(A) the process for requesting a motion for rehearing to appeal the decision; and(B) if the decision is upheld upon a motion for rehearing, the process for requesting judicial review.(e) Suspension or revocation based on criminal history.(1) HHSC provides written notice to a permit holder that HHSC proposes to suspend or revoke the permit holder's permit. The written notice must contain a statement that the permit holder is no longer eligible to have the permit because of the permit holder's prior conviction for the offense or offenses specified in the notice, as provided in §557.121(a) of this chapter.(2) If HHSC's decision to suspend or revoke the permit holder's permit is upheld during a formal hearing, HHSC notifies the permit holder in writing of:(A) the process for requesting a motion for rehearing to appeal the decision; and(B) if the decision is upheld upon a motion for rehearing, the process for requesting judicial review.(f) Suspension, revocation, or nonrenewal. If HHSC suspends a permit, the suspension remains in effect until HHSC determines that the reason for suspension no longer exists or HHSC revokes or determines not to renew the permit.(1) During the time of suspension, the suspended medication aide must return his or her permit to HHSC.(2) If a suspension overlaps a permit renewal date, the suspended medication aide may comply with the renewal procedures in §557.115 of this chapter (relating to Permit Renewal); however, HHSC does not renew the permit until HHSC determines that the reason for suspension no longer exists.(3) If HHSC revokes or does not renew a permit, a person may reapply for a permit by complying with the requirements and procedures in this chapter at the time of reapplication. HHSC may refuse to issue a permit if the reason for revocation or nonrenewal continues to exist.(g) Complaints of abuse and neglect by medication aides who are issued a permit under this chapter and employed in a correctional facility, are investigated in accordance with §557.125(l) of this chapter (relating to Requirements for Corrections Medication Aides). Source Note: The provisions of this §557.123 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.123 Violations, Complaints, and Disciplinary Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220689 03/12/2026 (a) Purpose. The purpose of this section is to provide the qualifications, conduct, and practice activities of a medication aide employed in a correctional facility or employed by a medical services contractor for a correctional facility.(b) Supervision and applicable law and rules. A medication aide must function under the direct supervision of a licensed nurse on duty or on call by the correctional facility using the medication aide. The medication aide must:(1) function in accordance with applicable law and rules relating to administration of medication and operation of a correctional facility; and(2) comply with TDCJ rules applicable to personnel used in a correctional institution.(c) Allowable practices of a corrections medication aide. A medication aide:(1) must observe and report to the correctional facility's charge nurse reactions and side effects to medication shown by an inmate;(2) may take and record vital signs before the administration of medication which could affect or change the vital signs;(3) may administer regularly prescribed medication to an inmate if the medication aide:(A) is trained to administer the medication;(B) personally prepares the medication or sets up the medication to be administered; and(C) documents the administration of the medication in the inmate's clinical record;(4) may administer oxygen per nasal cannula or a non-sealing mask only in an emergency, after which the medication aide must verbally notify the licensed nurse on duty or on call and appropriately document the action and notification;(5) may apply specifically ordered ophthalmic, otic, nasal, vaginal, and rectal medication;(6) may administer previously ordered PRN medication but must document in the inmate's records any symptoms indicating the need for the medication, and the time the symptoms occurred;(7) may administer the initial dose of a medication;(8) may order an inmate's medications from the correctional institution's pharmacy;(9) may measure a prescribed amount of a liquid medication to be administered;(10) may break a tablet for administration to an inmate if:(A) the licensed nurse on duty or on call has calculated the dosage; and(B) the inmate's medication card or its equivalent accurately documents how the tablet must be altered before administration; and(11) may crush medication if:(A) authorization is obtained from the licensed nurse on duty or on call; and(B) the authorization is documented on the inmate's medication card or its equivalent.(d) Prohibited practices of a corrections medication aide. A medication aide may not:(1) administer medication by the injection route including the:(A) intramuscular route;(B) intravenous route;(C) subcutaneous route;(D) intradermal route; and(E) hypodermoclysis route;(2) administer medication used for intermittent positive pressure breathing treatments or any form of medication inhalation treatments;(3) calculate an inmate's medication dose for administration;(4) crush medication, except in accordance with subsection (c)(11) of this section;(5) administer medications or feedings by way of a tube inserted in a cavity of the body;(6) receive or assume responsibility for reducing to writing a verbal or telephone order from a physician, dentist, or podiatrist;(7) apply topical medications that involve the treatment of skin that is broken or blistered or when a specified aseptic technique is ordered by the attending licensed practitioner;(8) steal, divert, or otherwise misuse medications;(9) violate any provision of Texas Human Resources Code §161.083, or this chapter;(10) fraudulently procure or attempt to procure a permit;(11) neglect to administer appropriate medications, as prescribed, in a responsible manner; or(12) administer medications if the person is unable to do so with reasonable skill and safety to inmates by reason of drunkenness or excessive use of drugs, narcotics, chemicals, or any other type of material.(e) Background and education requirements. Before applying for a corrections medication aide permit under Texas Human Resources Code §161.083, an applicant must be:(1) able to read, write, speak, and understand English;(2) at least 18 years of age;(3) free of communicable diseases and in suitable physical and emotional health to safely administer medications;(4) a graduate of a high school or successfully passed a general educational development test (GED); and(5) employed in a correctional facility or by a medical service contractor for a correctional facility on the first day of an applicant's medication aide training program.(f) Application. An applicant for a corrections medication aide permit under this chapter must submit an official Corrections Medication Aide application form to HHSC through the online portal.(1) The applicant must submit the general statement enrollment form through the online portal that contains:(A) specific information regarding personal data, certain misdemeanor and felony convictions, work experience, education, and training;(B) a statement that all the requirements in subsection (e) of this section were met before the start of the program;(C) a statement that the applicant understands that application fees submitted in the permit process are nonrefundable;(D) a statement that the applicant understands material submitted in the application process are nonreturnable;(E) a statement that the applicant understands that it is a misdemeanor to falsify any information submitted to HHSC; and(F) the applicant's dated signature through the online portal.(2) An applicant must upload through the online portal a certified copy or a photocopy that has been notarized as a true and exact copy of an unaltered original of the applicant's high school graduation diploma or transcript, or the written results of a GED test.(3) HHSC reviews high school or GED documentation submitted by the applicant. If HHSC determines additional information is required, and HHSC requests additional documentation from the applicant, the applicant must provide the documentation to HHSC.(4) HHSC considers a corrections medication aide permit application as officially submitted based on the submission date in the online portal.(5) HHSC sends a notice through the online portal listing the additional materials required to an applicant who does not complete the application. An application not completed by the day of the TDCJ final exam is void.(6) HHSC sends notice through the online portal of application approval or deficiency in accordance with §557.127 of this chapter (relating to Application Processing).(g) Fees. An applicant must pay application and permit renewal fees for a corrections medication aide permit through the online portal. All fees are nonrefundable, except as provided by Texas Government Code, Chapter 2005. The fee schedule is as follows:(1) permit application fee--$15;(2) renewal fee--$15; and(3) late renewal fees for permit renewals made after the permit expires:(A) $22.50 for an expired permit renewed from one to 90 days after expiration; and(B) $30 for an expired permit renewed from 91 days to one year after expiration.(h) Examination procedures. TDCJ gives a written examination to each applicant at a site determined by TDCJ. An applicant with a disability, including an applicant with dyslexia as defined in Texas Education Code §51.970 (relating to Instructional Material for Blind and Visually Impaired Students and Students with Dyslexia), may request a reasonable accommodation for the examination under the Americans with Disabilities Act.(1) The applicant must meet the requirements of the TDCJ training program described in §557.119(d) of this chapter (relating to Training Program Requirements) before taking the written examination.(2) The applicant must be tested on the subjects taught in the TDCJ training program curriculum and correctional facility clinical experience. The examination must test an applicant's knowledge of accurate and safe drug therapy administered to a correctional facility inmate.(3) TDCJ administers the examination and determines the passing grade.(4) TDCJ must inform HHSC through the online portal, on the HHSC class roster form, of the final exam results for each applicant within 15 days after completion of the exam.(5) An applicant who is unable to attend the applicant's scheduled examination due to unforeseen circumstances must contact TDCJ to reschedule.(6) If an applicant fails the examination, TDCJ notifies HHSC and the applicant in writing of the failure to pass the examination. The applicant may take one subsequent examination without having to re-enroll in the training program described in §557.119 of this chapter.(7) An applicant whose application for a permit is denied under §557.113 of this chapter (relating to Determination of Eligibility) is ineligible to take the examination.(i) Determination of eligibility. HHSC determines eligibility for a corrections medication aide permit applicant according to §557.113 of this chapter and subsections (e) - (h) of this section.(j) Renewal. A permit must be renewed in accordance with §557.115 of this chapter (relating to Permit Renewal).(k) Changes. Medication aides must report changes in accordance with §557.117 of this chapter (relating to Changes).(l) Violations, complaints, and disciplinary actions.(1) Complaints. Any person may file a complaint with HHSC alleging that a person or program has violated Texas Human Resources Code §161.083, or this chapter. HHSC handles complaints in the manner set forth in §557.123 of this chapter (relating to Violations, Complaints, and Disciplinary Actions).(2) Investigations of abuse and neglect complaints. Allegations of abuse and neglect of inmates by corrections medication aides are investigated by the TDCJ Office of Inspector General. After an investigation, the TDCJ Office of Inspector General issues a report to HHSC with findings of abuse or neglect against the corrections medication aide. After reviewing the report and findings, HHSC determines whether to initiate a formal proceeding to revoke, suspend, or refuse to renew a corrections medication aide permit. If HHSC determines a formal proceeding to revoke, suspend, or refuse to renew a corrections medication aide permit should be initiated, §557.123(c) and (d) of this chapter apply. If HHSC determines that no formal proceeding to revoke, suspend, or refuse to renew a corrections medication aide permit should be initiated, HHSC dismisses the complaint against the corrections medication aide and gives written notice of the dismissal to the corrections medication aide.(m) Section 557.121 of this chapter (relating to Permitting of Persons with Criminal Backgrounds) applies to corrections medication aides under this chapter. Source Note: The provisions of this §557.125 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.125 Requirements for Corrections Medication Aides https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220690 03/12/2026 (a) Time periods. HHSC complies with the following procedures in processing applications for a facility and corrections medication aide permit and renewal.(1) The following periods of time apply from the date HHSC receives an application through the online portal until the date HHSC issues a written notice through the online portal that the application is complete and accepted for filing or that the application is deficient and additional specific information is required. HHSC may issue a written notice through the online portal stating that the application has been approved instead of a notice that the application is complete. The time periods are as follows:(A) letter of acceptance of application for a permit--21 days;(B) letter of application deficiency or ineligibility--21 days;(C) acceptance of renewal permit--21 days; and(D) letter of renewal of permit deficiency--21 days.(2) The following periods of time apply from the date HHSC receives the last item necessary to complete the application through the online portal until the date HHSC issues written notice through the online portal approving or denying the application. For the purpose of this section, an application is not considered complete until any required examination has been successfully completed by the applicant. The time periods for denial include notification of a proposed decision and an opportunity, if required, for the applicant to show compliance with law, and an opportunity to request a hearing. The time periods are as follows:(A) issuance of initial permit--60 days;(B) letter of denial for a permit or renewal permit--60 days; and(C) issuance of renewal permit after receipt of documentation of the completion of all renewal requirements--20 days.(b) Reimbursement of fees.(1) If an application is not processed in the time periods stated in subsection (a) of this section, the applicant has the right to request reimbursement of all fees paid in that particular application process. Application for reimbursement must be made to the program administrator for HHSC Medication Aide Permit Program. If the program administrator does not agree that the time period has been violated or finds that good cause existed for exceeding the time period, the request must be denied.(2) Good cause for exceeding the time period exists if the number of applications for a permit and permit renewal exceeds by 15 percent or more the number of applications processed in the same calendar quarter the preceding year; another public or private entity relied upon by HHSC in the application process caused the delay; or any other condition exists giving HHSC good cause for exceeding the time period.(c) Appeal. If a request for reimbursement under subsection (b) of this section is denied by the program administrator, the applicant may appeal in writing to the Texas Health and Human Services Commission's hearings section to request a hearing on the reimbursement denial. A hearing is governed by 1 Texas Administrative Code Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act); and Chapter 110 of this title (relating to Hearings under the Administrative Procedure Act). Source Note: The provisions of this §557.127 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.127 Application Processing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220691 03/12/2026 (a) A home heath medication aide must be permitted as a medication aide in accordance with this chapter.(b) A HCSSA that provides licensed and certified home health services, licensed home health services, hospice services, or personal assistance services may use a home health medication aide. If there is a direct conflict between the requirements of this chapter and federal regulations, the requirements that are more stringent apply to the licensed and certified HCSSA.(c) If a HCSSA provides home health medication aide services, the HCSSA must employ a home health medication aide to provide the home health medication aide services. The HCSSA must employ or contract with an RN to perform the initial health assessment, prepare the client care plan, establish the medication list, medication administration record, and medication aide assignment sheet, and supervise the home health medication aide. The RN must be available to supervise the home health medication aide when home health medication aide services are provided.(d) The clinical records of a client using a home health medication aide must include a statement signed by the client or family acknowledging receipt of the list of permitted and prohibited acts of a home health medication aide.(e) The RN must be knowledgeable of HHSC rules governing home health medication aides and must ensure that the home health medication aide complies with the Texas Health and Safety Code, Chapter 142, Subchapter B and this chapter.(f) A home health medication aide must:(1) function under the supervision of an RN;(2) comply with applicable law and this chapter relating to administration of medication and operation of the HCSSA;(3) comply with HHSC rules applicable to personnel used in a HCSSA; and(4) comply with this section and §558.701 of this title (relating to Home Health Aides) if the person will be used as a home health aide and a home health medication aide.(g) The RN must make a supervisory visit while the medication aide is in the client's residence in accordance with §558.298 of this title (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel and Tasks Not Requiring Delegation). Source Note: The provisions of this §557.128 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.128 Home Health Medication Aides https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220692 03/12/2026 (a) Fee waiver based on military experience.(1) HHSC waives the combined permit application and examination fee described in §557.109(c)(1)(A) of this chapter (relating to Application Procedures) and the permit application fee described in §557.125(g)(1) of this chapter (relating to Requirements for Corrections Medication Aides) for an applicant if HHSC receives and approves a request for a waiver of fees through the online portal from the applicant in accordance with this subsection.(2) To request a waiver of fees under this subsection, an applicant must submit a written request for a waiver with the applicant's application for a permit submitted to HHSC through the online portal in accordance with this section. The applicant must include with the request:(A) documentation of the applicant's status as a military service member, military veteran, or military spouse that is acceptable to HHSC;(B) documentation of the type and dates of the service, training, and education the applicant received and an explanation as to why the applicant's military service, training, and education substantially meets all of the requirements for a permit under this chapter; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the applicant by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the applicant's spouse by the armed forces of the United States, the State of Texas, or another state.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the applicant by the armed forces of the United States, the State of Texas, or another state; and(B) for status as a military veteran, a copy of a military service discharge order issued to the applicant by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the applicant must submit the requested documentation.(5) HHSC approves a request for a waiver of fees submitted in accordance with this subsection if HHSC determines that the applicant is a military service member or a military veteran and the applicant's military service, training, and education substantially meet all of the requirements for licensure under this chapter.(b) Fee waiver based on reciprocity.(1) HHSC waives the combined permit application and examination fee described in §557.109(c)(1)(A) of this chapter and the permit application fee described in §557.125(g)(1) of this chapter for an applicant if HHSC receives and approves a request through the online portal for a waiver of fees from the applicant in accordance with this subsection.(2) To request a waiver of the fee under this subsection, an applicant must include a written request for a waiver of the fee with the applicant's application that is submitted to HHSC through the online portal in accordance with §557.107(f) (relating to Training Requirements; Nursing Graduates; Reciprocity) of this chapter. The applicant must include with the request documentation of the applicant's status as a military service member, military veteran, or military spouse that is acceptable to HHSC.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the applicant by the armed forces of the United States, the State of Texas, or another state;(B) for status as a military veteran, a copy of a military service discharge order issued to the applicant by the armed forces of the United States, the State of Texas, or another state; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the applicant by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the applicant's spouse by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the applicant must submit the requested documentation.(5) HHSC approves a request for a waiver of the fee submitted in accordance with this subsection if HHSC determines that:(A) the applicant holds a license, registration, certificate, or permit as a medication aide in good standing in another jurisdiction with licensing requirements substantially equivalent to or that exceed the requirements for a permit under this chapter; and(B) the applicant is a military service member, a military veteran, or a military spouse.(c) Additional time for permit renewal.(1) HHSC gives a medication aide an additional two years to complete the permit renewal requirements described in §557.115 of this chapter (relating to Permit Renewal) if HHSC receives and approves through the online portal a request for additional time to complete the permit renewal requirements from a medication aide in accordance with this subsection.(2) To request additional time to complete permit renewal requirements, a medication aide must:(A) submit a written request for additional time to HHSC through the online portal before the expiration date of the medication aide's permit; and(B) include, along with the request, documentation of the medication aide's status as a military service member that is acceptable to HHSC, which includes a copy of a current military service order issued to the medication aide by the armed forces of the United States, the State of Texas, or another state.(3) If HHSC requests additional documentation, the medication aide must submit the requested documentation.(4) HHSC approves a request for two additional years to complete permit renewal requirements submitted in accordance with this subsection if HHSC determines that the medication aide is a military service member, except HHSC does not approve a request if HHSC granted the medication aide a previous extension and the medication aide has not completed the permit renewal requirements during the two-year extension period.(5) If a medication aide does not submit the written request described by paragraph (2) of this subsection before the expiration date of the medication aide's permit, HHSC will consider a request after the expiration date of the permit if the medication aide establishes to the satisfaction of HHSC that the request was not submitted before the expiration date of the medication aide's permit because the medication aide was serving as a military service member at the time the request was due.(d) Renewal of expired permit.(1) HHSC renews an expired permit if HHSC receives and approves a request for renewal from a former medication aide through the online portal in accordance with this subsection.(2) To request renewal of an expired permit, a former medication aide must submit a written request with a permit renewal application through the online portal within five years after the former medication aide's permit expired. The former medication aide must include with the request documentation of the former medication aide's status as a military service member, military veteran, or military spouse that is acceptable to HHSC.(3) Documentation of military status that is acceptable to HHSC includes:(A) for status as a military service member, a copy of a current military service order issued to the former medication aide by the armed forces of the United States, the State of Texas, or another state;(B) for status as a military veteran, a copy of a military service discharge order issued to the former medication aide by the armed forces of the United States, the State of Texas, or another state; and(C) for status as a military spouse:(i) a copy of a marriage certificate issued to the former medication aide by a state of the United States or a foreign government; and(ii) a copy of a current military service order issued to the former medication aide's spouse by the armed forces of the United States, the State of Texas, or another state.(4) If HHSC requests additional documentation, the former medication aide must submit the requested documentation.(5) HHSC approves a request for renewal of an expired permit submitted in accordance with this subsection if HHSC determines that:(A) the former medication aide is a military service member, military veteran, or military spouse;(B) the former medication aide has not committed an offense listed in Texas Health and Safety Code §250.006(a) or (c) and has not committed an offense listed in Texas Health and Safety Code §250.006(b) during the five years before the date the former medication aide submitted the initial permit application;(C) the former medication aide is not listed on the EMR; and(D) the former medication aide is not listed with revoked or suspended status on the NAR.(e) Recognition of Out-of-State Permit of Military Spouse.(1) A military spouse may engage in the practice of a medication aide in Texas without obtaining a permit, according to the application requirements of §557.103 of this chapter (relating to Requirements for Administering Medications), §557.125 of this chapter (relating to Requirements for Corrections Medication Aides) or §557.128 of this chapter (relating to Home Health Medication Aides), if the spouse:(A) is currently licensed in good standing by another jurisdiction that has permitting requirements substantially equivalent to the requirements for a permit in Texas;(B) notifies HHSC in writing of the spouse's intent to practice in Texas;(C) submits to HHSC proof of the spouse's residence in this state and a copy of the spouse's military identification; and(D) receives from HHSC:(i) confirmation that HHSC has verified the spouse's permit in the other jurisdiction; and(ii) a permit to practice as a medication aide in Texas.(2) HHSC will review and evaluate the following criteria when determining whether another state's permitting requirements are substantially equivalent to the requirement for a permit under the statutes and regulations of this state:(A) whether the other state requires an applicant to pass an examination that demonstrates competence in the field to obtain the permit;(B) whether the other state requires an applicant to meet any experience qualifications to obtain the permit;(C) whether the other state requires an applicant to meet education qualifications to obtain the permit;(D) the other state's permit requirements, including the scope of work authorized to be performed under the permit issued by the other state.(3) The military spouse must submit:(A) a written request to HHSC for recognition of the spouse's permit issued by the other state;(B) any form and additional information regarding the permit issued by the other state required by the rules of the specific program or division within HHSC that licenses the business or occupation;(C) proof of residence in this state, which may include a copy of the permanent change of station order for the military service member to whom the military spouse is married;(D) a copy of the military spouse's identification card;(E) proof the military service member is stationed at a military installation in Texas; and(F) proof that fingerprints submitted to the Texas Department of Public Safety for a Federal Bureau of Investigation criminal background check enable HHSC to confirm that the military spouse is in compliance with other laws and regulations applicable to medication aides in Texas.(4) Upon verification from the permitting jurisdiction of the military spouse's permit, and if the permit is substantially equivalent to a Texas permit, HHSC shall issue a confirmation that HHSC has verified the spouse's permit in the other jurisdiction and a permit to practice as a medication aide in Texas.(5) The permit issued under paragraph (4) of this subsection will expire three years from date of issuance or when the military service member is no longer stationed at a military installation in Texas, whichever comes first. The permit issued under paragraph (4) of this subsection may not be renewed.(6) HHSC replaces a lost, damaged, or destroyed permit for a military spouse as provided in §557.117 of this chapter (relating to Changes). A military spouse with an active medication aide permit can print a duplicate permit through the online portal. A military spouse can request a change of name through the online portal by submitting a name change application.(7) The military spouse shall comply with all applicable laws, rules, and standards of this state, including applicable Texas Health and Safety Code and Texas Administration Code provisions.(8) HHSC may withdraw or modify the verification letter for reasons including:(A) the military spouse fails to comply with subsection (i) of this section; or(B) the military spouse's licensure required under paragraph (1)(A) of this subsection expires or is suspended or revoked in another jurisdiction. Source Note: The provisions of this §557.129 adopted to be effective September 24, 2018, 43 TexReg 6328; amended to be effective December 26, 2021, 46 TexReg 9054; amended to be effective September 18, 2024, 49 TexReg 7350. 1 HEALTH AND HUMAN SERVICES COMMISSION 557 MEDICATION AIDES--PROGRAM REQUIREMENTS §557.129 Alternate Licensing Requirements for Military Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204531 03/12/2026 (a) Purpose.(1) The purpose of this chapter is to implement Texas Health and Safety Code, Chapter 142, which requires the Texas Health and Human Services Commission (HHSC) to adopt minimum standards that a person must meet in order to be licensed as a home and community support services agency (HCSSA) and also to qualify to provide certified home health services. The requirements serve as a basis for licensure and survey activities.(2) Except as provided by Texas Health and Safety Code §142.003 (relating to Exemptions from Licensing Requirement), a person, including a health care facility licensed under the Texas Health and Safety Code, may not engage in the business of providing home health, hospice, or personal assistance services (PAS), or represent to the public that the person is a provider of home health, hospice, or PAS for pay without a HCSSA license authorizing the person to perform those services issued by HHSC for each place of business from which home health, hospice, or PAS is directed. A certified HCSSA must have a license to provide certified home health services.(b) Scope. This chapter establishes the minimum standards for acceptable quality of care. A violation of a minimum standard established by Texas Health and Safety Code Chapter 142, or by a rule adopted under that chapter, is a violation of law. The rules in this chapter are adopted to protect clients of HCSSAs by establishing minimum standards relating to quality of care and quality of life.(c) Limitations. Requirements established by private or public funding sources such as health maintenance organizations or other private third-party insurance, Medicaid (42 United States Code (USC) Chapter 7, Subchapter XIX), Medicare (42 USC Chapter 7, Subchapter XVIII), or state-sponsored funding programs are separate and apart from the requirements in this chapter for agencies. No matter what funding sources or requirements apply to an agency, the agency must still comply with the applicable provisions in the Statute and this chapter. The agency is responsible for researching availability of any funding source to cover a service provided by the agency. Source Note: The provisions of this §558.1 adopted to be effective June 1, 1994, 19 TexReg 2915; amended to be effective July 21, 1997, 22 TexReg 6573; amended to be effective March 2, 1998, 23 TexReg 1958; transferred effective September 1, 1999, as published in the August 6, 1999 issue of the Texas Register, 24 TexReg 6099; amended to be effective June 15, 2000, 25 TexReg 5929; amended to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES A GENERAL PROVISIONS §558.1 Purpose and Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204532 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Accessible and flexible services--Services that are delivered in the least intrusive manner possible and are provided in all settings where individuals live, work, and recreate.(2) Accreditation organization--The Joint Commission, Community Health Accreditation Partner, Accreditation Commission for Health Care, Inc., or another accrediting entity approved by HHSC that demonstrates it meets or exceeds applicable rule requirements of this chapter. The entity reviews HCSSAs for compliance with standards for accreditation by the organization that apply to a HCSSA's licensed category of service.(3) Administration of medication--The direct application of any medication by injection, inhalation, ingestion, or any other means to the body of a client. The preparation of medication is part of the administration of medication and is the act or process of making ready a medication for administration, including the calculation of a client's medication dosage; altering the form of the medication by crushing, dissolving, or any other method; reconstitution of an injectable medication; drawing an injectable medication into a syringe; preparing an intravenous admixture; or any other act required to render the medication ready for administration.(4) Administrative support site--A facility or site where an agency performs administrative and other support functions but does not provide direct home health, hospice, or personal assistance services. This site does not require an agency license.(5) Administrator--The person who is responsible for implementing and supervising the administrative polices and operations of a home and community support services agency and for administratively supervising the provision of all services to agency clients on a day-to-day basis.(6) ADS--Alternate delivery site. A facility or site, including a residential unit or an inpatient unit:(A) that is owned or operated by an agency providing hospice services;(B) that is not the hospice's parent agency;(C) that is located in the geographical area served by the hospice; and(D) from which the hospice provides hospice services.(7) Advanced practice nurse--An advanced practice registered nurse.(8) Advanced practice registered nurse--A person licensed by the Texas Board of Nursing as an advanced practice registered nurse. The term is synonymous with "advanced practice nurse."(9) Advisory committee--A committee, board, commission, council, conference, panel, task force, or other similar group, or any subcommittee or other subgroup, established for the purpose of obtaining advice or recommendations on issues or policies that are within the scope of a person's responsibility.(10) Affiliate--With respect to an applicant or license holder that is:(A) a corporation--means each officer, director, and stockholder with direct ownership of at least 5.0 percent, subsidiary, and parent company;(B) a limited liability company--means each officer, member, and parent company;(C) an individual--means:(i) the individual's spouse;(ii) each partnership and each partner thereof of which the individual or any affiliate of the individual is a partner; and(iii) each corporation in which the individual is an officer, director, or stockholder with a direct ownership or disclosable interest of at least 5.0 percent.(D) a partnership--means each partner and any parent company; and(E) a group of co-owners under any other business arrangement--means each officer, director, or the equivalent under the specific business arrangement and each parent company.(11) Agency-- A HCSSA.(12) Applicant--The owner of an agency that is applying for a license under the Statute. This is the person in whose name the license will be issued.(13) Assistance with self-administration of medication--Any needed ancillary aid provided to a client in the client's self-administered medication or treatment regimen, such as reminding a client to take a medication at the prescribed time, opening and closing a medication container, pouring a predetermined quantity of liquid to be ingested, returning a medication to the proper storage area, and assisting in reordering medications from a pharmacy. Such ancillary aid includes administration of any medication when the client has the cognitive ability to direct the administration of their medication and would self-administer if not for a functional limitation.(14) Association--A partnership, limited liability company, or other business entity that is not a corporation.(15) Audiologist--A person who is currently licensed under the Texas Occupations Code, Chapter 401, as an audiologist.(16) Bereavement--The process by which a survivor of a deceased person mourns and experiences grief.(17) Bereavement services--Support services offered to a family during bereavement. Services may be provided to persons other than family members, including residents of a skilled nursing facility, nursing facility, or intermediate care facility for individuals with an intellectual disability or related conditions, when appropriate and identified in a bereavement plan of care.(18) Biologicals--A medicinal preparation made from living organisms and their products, including serums, vaccines, antigens, and antitoxins.(19) Boarding home facility--An establishment defined in Texas Health and Safety Code §260.001(2).(20) Branch office--A facility or site in the service area of a parent agency from which home health or personal assistance services are delivered or where active client records are maintained. This does not include inactive records that are stored at an unlicensed site.(21) Care plan--(A) a written plan prepared by the appropriate health care professional for a client of the home and community support services agency; or(B) for home dialysis designation, a written plan developed by the physician, registered nurse, dietitian, and qualified social worker to personalize the care for the client and enable long- and short-term goals to be met.(22) Case conference--A conference among personnel furnishing services to the client to ensure that their efforts are coordinated effectively and support the objectives outlined in the plan of care or care plan.(23) Certified agency--A home and community support services agency, or portion of the agency, that:(A) provides a home health service; and(B) is certified by an official of the U.S. Department of Health and Human Services as in compliance with Medicare conditions of participation in 42 USC Chapter 7, Subchapter XVIII.(24) Certified home health services--Home health services that are provided by a certified agency.(25) CFR--Code of Federal Regulations. The regulations and rules promulgated by agencies of the Federal government that address a broad range of subjects, including hospice care and home health services.(26) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of an agency. The substitution of a personal representative for a deceased license holder is not a change of ownership.(27) Chief financial officer--An individual who is responsible for supervising and managing all financial activities for a home and community support services agency.(28) Client--An individual receiving home health, hospice, or personal assistance services from a licensed home and community support services agency. This term includes each member of the primary client's family if the member is receiving ongoing services. This term does not include the spouse, significant other, or other family member living with the client who receives a one-time service (for example, vaccination) if the spouse, significant other, or other family member receives the service in connection with the care of a client.(29) Clinical note--A dated and signed written notation by agency personnel of a contact with a client containing a description of signs and symptoms; treatment and medication given; the client's reaction; other health services provided; and any changes in physical and emotional condition.(30) CMS--Centers for Medicare & Medicaid Services. The federal agency that administers the Medicare program and works in partnership with the states to administer Medicaid.(31) Complaint--An allegation against an agency regulated by HHSC or against an employee of an agency regulated by HHSC that involves a violation of this chapter or the Statute.(32) Community disaster resources--A local, statewide, or nationwide emergency system that provides information and resources during a disaster, including weather information, transportation, evacuation, and shelter information, disaster assistance and recovery efforts, evacuee and disaster victim resources, and resources for locating evacuated friends and relatives.(33) Controlled substance--Has the meaning assigned in Texas Health and Safety Code Chapter 481, Subchapter A.(34) Controlling person--A person with the ability, acting alone or with others, to directly or indirectly influence, direct, or cause the direction of the management, expenditure of money, or policies of an agency or other person.(A) A controlling person includes:(i) a management company or other business entity that operates or contracts with others for the operation of an agency;(ii) a person who is a controlling person of a management company or other business entity that operates an agency or that contracts with another person for the operation of an agency; and(iii) any other individual who, because of a personal, familial, or other relationship with the owner, manager, or provider of an agency, is in a position of actual control or authority with respect to the agency, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the agency.(B) A controlling person, as described by subparagraph (A)(iii) of this paragraph, does not include an employee, lender, secured creditor, or other person who does not exercise formal or actual influence or control over the operation of an agency.(35) Conviction--An adjudication of guilt based on a finding of guilt, a plea of guilty, or a plea of nolo contendere.(36) Counselor--An individual qualified under Medicare standards to provide counseling services, including bereavement, dietary, spiritual, and other counseling services to both the client and the family.(37) Day--Any reference to a day means a calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.(38) Deficiency--A finding of noncompliance with federal requirements resulting from a survey.(39) Designated survey office--An HHSC HCSSA Program office located in an agency's geographic region.(40) Dialysis treatment record--For home dialysis designation, a dated and signed written notation by the person providing dialysis treatment, which contains a description of signs and symptoms, machine parameters and pressure settings, type of dialyzer and dialysate, actual pre- and post-treatment weight, medications administered as part of the treatment, and the client's response to treatment.(41) Dietitian--A person who is currently licensed under the laws of the State of Texas to use the title of licensed dietitian or provisional licensed dietitian, or who is a registered dietitian.(42) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.(43) Disaster--The occurrence or imminent threat of widespread or severe damage, injury, or loss of life or property resulting from a natural or man-made cause, such as fire, flood, earthquake, wind, storm, wave action, oil spill or other water contamination, epidemic, air contamination, infestation, explosion, riot, hostile military or paramilitary action, or energy emergency. In a hospice inpatient unit, a disaster also includes failure of the heating or cooling system, power outage, explosion, and bomb threat.(44) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.(45) ESRD--End stage renal disease. For home dialysis designation, the stage of renal impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.(46) Functional need--Needs of the individual that require services without regard to diagnosis or label.(47) Habilitation--Habilitation services, as defined by Texas Government Code §534.001, provided by an agency licensed under this chapter.(48) HCSSA--Home and community support services agency. A person who provides home health, hospice, or personal assistance services for pay or other consideration in a client's residence, an independent living environment, or another appropriate location.(49) Health assessment--A determination of a client's physical and mental status through inventory of systems.(50) HHSC--Texas Health and Human Services Commission.(51) Home health aide--An individual working for an agency who meets at least one of the requirements for home health aides as described in §558.701 of this chapter (relating to Home Health Aides).(52) Home health medication aide--An unlicensed person issued a permit by HHSC to administer medication to a client under Texas Health and Safety Code Chapter 142, Subchapter B.(53) Home health service--The provision of one or more of the following health services required by an individual in a residence or independent living environment:(A) nursing, including blood pressure monitoring and diabetes treatment;(B) physical, occupational, speech, or respiratory therapy;(C) medical social service;(D) intravenous therapy;(E) dialysis;(F) service provided by unlicensed personnel under the delegation or supervision of a licensed health professional;(G) the furnishing of medical equipment and supplies, excluding drugs and medicines; or(H) nutritional counseling.(54) Hospice--A person licensed under this chapter to provide hospice services, including a person who owns or operates a residential unit or an inpatient unit.(55) Hospice aide--A person working for an agency licensed to provide hospice services who meets the qualifications for a hospice aide as described in §558.843 of this chapter (relating to Hospice Aide Qualifications).(56) Hospice homemaker--A person working for an agency licensed to provide hospice services who meets the qualifications described in §558.845 of this chapter (relating to Hospice Homemaker Qualifications).(57) Hospice services--Services, including services provided by unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to a client or a client's family as part of a coordinated program consistent with the standards and rules adopted under this chapter. These services include physical care and support services to optimize quality of life for terminally ill clients and their families that:(A) are available 24 hours a day, seven days a week, during the last stages of illness, death, and bereavement;(B) are provided by a medically directed interdisciplinary team; and(C) may be provided in a home, nursing facility, residential unit, inpatient unit, or other residence according to need. These services do not include inpatient care normally provided in a licensed hospital to a terminally ill person who has not elected to be a hospice client.(58) IDR--Informal dispute resolution. An informal process that allows an agency to refute a violation or condition-level deficiency cited during a survey.(59) Independent living environment--A client's residence, which may include a group home, foster home, or boarding home facility, or other settings where a client participates in activities, including school, work, or church.(60) Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder.(61) Individual and family choice and control--Individuals and families who express preferences and make choices about how their support service needs are met.(62) Individualized service plan--A written plan prepared by the appropriate health care personnel for a client of a home and community support services agency licensed to provide personal assistance services.(63) Inpatient unit--A facility, also referred to as a hospice freestanding inpatient facility, that provides a continuum of medical or nursing care and other hospice services to clients admitted into the unit and that is in compliance with:(A) the Medicare conditions of participation for inpatient units adopted under 42 USC Chapter 7, Subchapter XVIII; and(B) standards adopted under this chapter.(64) Joint training--Training provided by HHSC at least semi-annually for home and community support services agencies and HHSC surveyors on subjects that address the 10 most commonly cited violations of federal or state law by home and community support services agencies as published in HHSC annual reports.(65) LAR--Legally authorized representative. A person authorized by law to act on behalf of a client regarding a matter described in this chapter, and may include a parent of a minor, guardian of an adult or minor, managing conservator of a minor, agent under a medical power of attorney, or surrogate decision-maker under Texas Health and Safety Code §313.004.(66) License holder--A person that holds a license to operate an agency.(67) Life Safety Code (also referred to as NFPA 101)--The Code for Safety to Life from Fire in Buildings and Structures, Standard 101, of the National Fire Protection Association (NFPA).(68) Local emergency management agencies--The local emergency management coordinator, fire, police, and emergency medical services.(69) Local emergency management coordinator--The person identified as the emergency management coordinator by the mayor or county judge in an agency's service area.(70) LVN--Licensed vocational nurse. A person who is currently licensed under Texas Occupations Code Chapter 301, as a licensed vocational nurse.(71) Manager--An employee or independent contractor responsible for providing management services to a home and community support services agency for the overall operation of a home and community support services agency including administration, staffing, or delivery of services. Examples of contracts for services that will not be considered contracts for management services include contracts solely for maintenance, laundry, or food services.(72) Medication administration record--A record used to document the administration of a client's medications.(73) Medication list--A list that includes all prescription and over-the-counter medication that a client is currently taking, including the dosage, the frequency, and the method of administration.(74) Mitigation--An action taken to eliminate or reduce the probability of a disaster or reduce a disaster's severity or consequences.(75) Multiple location--A Medicare-approved ADS that meets the definition in 42 CFR §418.3.(76) Notarized copy--A sworn affidavit stating that attached copies are true and correct copies of the original documents.(77) Nursing facility--An institution licensed as a nursing home under Texas Health and Safety Code, Chapter 242.(78) Nutritional counseling--Advising and assisting individuals or families on appropriate nutritional intake by integrating information from the nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention, and nutrition education. Nutritional counseling may include the following:(A) dialogue with the client to discuss current eating habits, exercise habits, food budget, and problems with food preparation;(B) discussion of dietary needs to help the client understand why certain foods should be included or excluded from the client's diet and to help with adjustment to the new or revised or existing diet plan;(C) a personalized written diet plan as ordered by the client's physician or practitioner, to include instructions for implementation;(D) providing the client with motivation to help the client understand and appreciate the importance of the diet plan in getting and staying healthy; or(E) working with the client or the client's family members by recommending ideas for meal planning, food budget planning, and appropriate food gifts.(79) Occupational therapist--A person who is currently licensed under the Texas Occupations Code Chapter 454, as an occupational therapist.(80) Online portal--A secure portal provided on the HHSC website for licensure activities, including for a HCSSA applicant to submit licensure applications and information.(81) Operating hours--The days of the week and the hours of day an agency's place of business is open as identified in an agency's written policy as required by §558.210 of this chapter (relating to Agency Operating Hours).(82) Original active client record--A record composed first-hand for a client currently receiving services.(83) Palliative--Ameliorating the symptoms associated with serious illness without the primary goal of curing an underlying condition.(84) Parent agency--An agency's principal place of business; the location where an agency develops and maintains administrative controls and provides supervision of branch offices and ADSs.(85) Parent company--A person, other than an individual, who has a direct 100 percent ownership interest in the owner of an agency.(86) Person--An individual, corporation, or association.(87) Personal assistance services--Routine ongoing care or services required by an individual in a residence or independent living environment that enable the individual to engage in the activities of daily living or to perform the physical functions required for independent living, including respite services. The term includes:(A) personal care;(B) health-related services performed under circumstances that are defined as not constituting the practice of professional nursing by the Texas Board of Nursing; and(C) health-related tasks provided by unlicensed personnel under the delegation of a registered nurse or that a registered nurse determines do not require delegation.(88) Personal care--The provision of one or more of the following services required by an individual in a residence or independent living environment:(A) bathing;(B) dressing;(C) grooming;(D) feeding;(E) exercising;(F) toileting;(G) positioning;(H) assisting with self-administered medications;(I) routine hair and skin care; and(J) transfer or ambulation.(89) Pharmacist--A person who is licensed to practice pharmacy under Texas Occupations Code Chapter 558.(90) Pharmacy--A facility defined in Texas Occupations Code §551.003(31), at which a prescription drug or medication order is received, processed, or dispensed, and which holds a pharmacy license issued under Texas Occupations Code Title 3, Subtitle J.(91) Physical therapist--A person who is currently licensed under Texas Occupations Code Chapter 453, as a physical therapist.(92) Physician--This term includes a person who is:(A) licensed in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code Chapter 155;(B) licensed in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of a client and orders home health or hospice services for the client, in accordance with Texas Occupations Code §151.056(b)(4); or(C) a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service, if the person is not engaged in private practice, in accordance with the Texas Occupations Code §151.052(a)(8).(93) Physician assistant--A person who is licensed under Texas Occupations Code Chapter 204, as a physician assistant.(94) Physician-delegated task--A task performed in accordance with Texas Occupations Code Chapter 157, including orders signed by a physician that specify the delegated task, individual to whom the task is delegated, and client's name.(95) Place of business--An office of a home and community support services agency that maintains client records or directs home health, hospice, or personal assistance services. This term includes a parent agency, a branch office, and an ADS. The term does not include an administrative support site.(96) Plan of care--The written orders of a practitioner for a client who requires skilled services.(97) Practitioner--A person who is currently licensed in a state in which the person practices as a physician, dentist, podiatrist, or a physician assistant, or a person who is an RN registered with the Texas Board of Nursing as an advanced practice nurse.(98) Preparedness--Actions taken in anticipation of a disaster.(99) Presurvey training--A computer-based training provided by HHSC for the applicant or the applicant's representatives to review licensure standards and survey documents, and to provide information regarding the survey process.(100) Progress note--A dated and signed written notation by agency personnel summarizing facts about care and the client's response during a given period of time.(101) Psychoactive treatment--The provision of a skilled nursing visit to a client with a psychiatric diagnosis under the direction of a physician that includes one or more of the following:(A) assessment of alterations in mental status or evidence of suicide ideation or tendencies;(B) teaching coping mechanisms or skills;(C) counseling activities; or(D) evaluation of the plan of care.(102) Recovery--Activities implemented during and after a disaster response designed to return an agency to its normal operations as quickly as possible.(103) Registered nurse delegation--Delegation by a registered nurse in accordance with:(A) 22 TAC Chapter 224 (concerning Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and(B) 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).(104) Residence--A place where a person resides, including a home, a nursing facility, a convalescent home, or a residential unit.(105) Residential unit--A facility that provides living quarters and hospice services to clients admitted into the unit and that is in compliance with standards adopted under Texas Health and Safety Code Chapter 142.(106) Respiratory therapist--A person who is currently licensed under Texas Occupations Code Chapter 604, as a respiratory care practitioner.(107) Respite services--Support options that are provided temporarily for the purpose of relief for a primary caregiver in providing care to individuals of all ages with disabilities or at risk of abuse or neglect.(108) Response--Actions taken immediately before an impending disaster or during and after a disaster to address the immediate and short-term effects of the disaster.(109) Restraint--A restraint is:(A) a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a client in a hospice inpatient unit to move his or her arms, legs, body, or head freely, but does not include a device, such as an orthopedically prescribed device, a surgical dressing or bandage, a protective helmet, or other method that involves the physical holding of the client for the purpose of:(i) conducting a routine physical examination or test;(ii) protecting the client from falling out of bed; or(iii) permitting the client to participate in activities without the risk of physical harm, not including a physical escort; or(B) a drug or medication when used as a restriction to manage a client's behavior or restrict the client's freedom of movement in a hospice inpatient unit, but not as a standard treatment or medication dosage for the client's condition.(110) RN--Registered nurse. A person who is currently licensed under the Nursing Practice Act, Texas Occupations Code Chapter 301, as a registered nurse.(111) Seclusion--The involuntary confinement of a client alone in a room or an area in a hospice inpatient unit from which the client is physically prevented from leaving.(112) Section--A reference to a specific rule in this chapter.(113) Service area--A geographic area established by an agency in which all or some of the agency's services are available.(114) Skilled services--Services in accordance with a plan of care that require the skills of:(A) an RN;(B) an LVN;(C) a physical therapist;(D) an occupational therapist;(E) a respiratory therapist;(F) a speech-language pathologist;(G) an audiologist;(H) a social worker; or(I) a dietitian.(115) Social worker--A person who is currently licensed as a social worker under Texas Occupations Code Chapter 505.(116) Speech-language pathologist--A person who is currently licensed as a speech-language pathologist under Texas Occupations Code Chapter 401.(117) Statute--Texas Health and Safety Code Chapter 142.(118) Substantial compliance--A finding in which an agency receives no recommendation for enforcement action after a survey.(119) Supervised practical training--Hospice aide training that is conducted in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual. The training is supervised by an RN or by an LVN who works under the direction of a registered nurse.(120) Supervising nurse--The person responsible for supervising skilled services provided by an agency and who has the qualifications described in §558.244(c) of this chapter (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications). This person may also be known as the director of nursing or similar title.(121) Supervision--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity.(122) Supportive palliative care--Physician-directed interdisciplinary patient and family-centered care provided to a patient with a serious illness without regard to the patient's age or terminal prognosis that:(A) may be provided concurrently with methods of treatment or therapies that seek to cure or minimize the effects of the patient's illness; and(B) seek to optimize the quality of life for a patient with a life-threatening or life-limiting illness and the patient's family through various methods, including methods that seek to:(i) anticipate, prevent, and treat the patient's total suffering related to the patient's physical, emotional, social, and spiritual condition;(ii) address the physical, intellectual, emotional, cultural, social, and spiritual needs of the patient; and(iii) facilitate for the patient, regarding treatment options, education, informed consent, and expression of desires.(123) Support services--Social, spiritual, and emotional care provided to a client and a client's family by a hospice.(124) Survey--An on-site inspection or complaint investigation conducted by an HHSC representative to determine if an agency is in compliance with the Statute and this chapter or in compliance with applicable federal requirements or both.(125) TAC--Texas Administrative Code.(126) Terminal illness--An illness for which there is a limited prognosis if the illness runs its usual course.(127) Unlicensed person--A person not licensed as a health care provider. The term includes home health aides, hospice aides, hospice homemakers, medication aides permitted by HHSC, and other unlicensed individuals providing personal care or assistance in health services.(128) Unsatisfied judgments--A failure to fully carry out the terms or meet the obligation of a court's final disposition on the matters before it in a suit regarding the operation of an agency.(129) Violation--A finding of noncompliance with this chapter or the Statute resulting from a survey.(130) Volunteer--An individual who provides assistance to a home and community support services agency without compensation other than reimbursement for actual expenses.(131) Working day--Any day except Saturday, Sunday, a state holiday, or a federal holiday. Source Note: The provisions of this §558.2 adopted to be effective June 1, 1994, 19 TexReg 2915; amended to be effective July 21, 1997, 22 TexReg 6573; amended to be effective June 7, 1998, 23 TexReg 5694; transferred effective September 1, 1999, as published in the August 6, 1999 issue of the Texas Register, 24 TexReg 6099; amended to be effective June 15, 2000, 25 TexReg 5929; amended to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 29, 2003, 28 TexReg 4931; amended to be effective October 15, 2003, 28 TexReg 8955; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effectiveDecember 1, 2006, 31 TexReg 9620; amended to be effective May 1, 2008, 33 TexReg 1136; amended to be effective September 1, 2009, 34 TexReg 5139; amended to be effective July 1, 2012, 37 TexReg 4613; amended to be effective October 1, 2013, 38 TexReg 6628; amended to be effective September 1, 2016, 41 TexReg 6501; amended to be effective October 5, 2016, 41 TexReg 7717; amended to be effective October 11, 2017, 42 TexReg 5514; amended to be effective January 17, 2018, 43 TexReg 238; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES A GENERAL PROVISIONS §558.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204533 03/12/2026 (a) The schedule of fees for licensure of an agency authorized to provide one or more services is as follows:(1) initial (includes change of ownership) license fee--$2,625;(2) renewal license fee for a three-year license--$2,625;(3) renewal license fee for a two-year license--$1,750;(4) initial (includes change of ownership) branch office license fee--$2,625;(5) renewal branch office license fee for a three-year license--$2,625;(6) renewal branch office license fee for a two-year license--$1,750;(7) initial (includes change of ownership) ADS license fee--$1,000;(8) renewal ADS license fee for a three-year license--$900; and(9) renewal ADS license fee for a two-year license--$600.(b) Separate fees for branch office and ADS licenses and renewals are required for each physical address. To renew a branch office or ADS license, the licensee must submit the renewal application and payment in full, of all applicable licensing fees, for each branch office and ADS sought to be renewed, at the same time as the parent agency submission for renewal.(c) A late fee assessed under Subchapter B of this chapter (relating to Criteria and Eligibility, Application Procedures, and Issuance of a License) is one-half the amount of the required renewal license fee established in subsection (a) of this section. If HHSC assesses a late fee described in this subsection, the applicant must pay the applicable renewal application fee in full plus the late fee described in this section. HHSC may assess a separate late fee for each parent agency, branch office, and ADS renewal application.(d) If an applicant for an initial license based on a change of ownership submits a late application for a license to HHSC, as described in §558.25 of this chapter (relating to Requirements for Change of Ownership), the applicant must pay the required initial license fee, as set out in subsection (a) of this section, plus a late fee of $250.(e) HHSC does not review an application until the applicant submits the application and the online portal reflects a status of payment received.(f) A fee paid to HHSC is not refundable but may be reimbursed under the circumstances and conditions described in §558.31 of this chapter (relating to Time Frames for Processing and Issuing a License).(g) HHSC accepts payment of required fees made in accordance with options made available through the online portal. Source Note: The provisions of this §558.3 adopted to be effective June 1, 1994, 19 TexReg 2915; amended to be effective June 7, 1998, 23 TexReg 5694; transferred effective September 1, 1999, as published in the August 6, 1999 issue of the Texas Register, 24 TexReg 6099; amended to be effective June 15, 2000, 25 TexReg 5929; amended to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective January 15, 2009, 34 TexReg 252; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effectiveMay 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES A GENERAL PROVISIONS §558.3 License Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204534 03/12/2026 (a) An applicant for a license must not admit a client or initiate services until the applicant completes the application process and receives an initial license.(b) A first-time application for a license is an application for an initial license.(c) An application for a license when there is a change of ownership is an application for an initial license.(d) A separate license is required for each place of business as defined in §558.2 of this chapter (relating to Definitions).(e) An agency's place of business must be located in and have an address in Texas. An agency located in another state must receive a license as a parent agency in Texas to operate as an agency in Texas.(f) An applicant must be at least 18 years of age.(g) Before issuing a license, HHSC considers the background of:(1) the applicant;(2) a controlling person of the applicant;(3) a person with a disclosable interest;(4) an affiliate of the applicant; and(5) the chief financial officer.(h) Before issuing a license, HHSC considers the background and qualifications of the administrator and alternate administrator in accordance with §558.244 of this chapter (relating Administrator Qualifications and Conditions and Supervising Nurse Qualifications).(i) HHSC may deny an application for an initial license or for renewal of a license if a person described in subsection (g) or (h) of this section:(1) on the date of the application:(A) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;(B) has an unsatisfied final judgment in any state or other jurisdiction; or(C) is delinquent on child support obligations (Texas Family Code Chapter 232);(2) for two years preceding the date of the application, has a history in any state or other jurisdiction of any of the following:(A) an unresolved federal or state tax lien;(B) an eviction involving any property or space used as an inpatient hospice agency; or(C) an unresolved final Medicare or Medicaid audit exception; or(3) for 12 months preceding the date of the application, has a history in any state or other jurisdiction of any of the following:(A) denial, suspension, or revocation of an agency license or a license for a health care facility;(B) surrendering a license before expiration or allowing a license to expire instead of the licensing authority proceeding with enforcement action;(C) a Medicaid or Medicare sanction or penalty relating to the operation of an agency or a health care facility;(D) operating an agency that has been decertified in any state under Medicare or Medicaid; or(E) debarment, exclusion, or involuntary contract cancellation in any state from Medicare or Medicaid. Source Note: The provisions of this §558.11 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective December 1, 2006, 31 TexReg 9620; amended to be effective September 1, 2009, 34 TexReg 5139; amended to be effective January 18, 2012, 37 TexReg 127; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.11 Criteria and Eligibility for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204535 03/12/2026 (a) An applicant must submit an application on the forms prescribed by HHSC through the online portal.(b) An applicant must complete and furnish all documents and information that HHSC requests in accordance with instructions provided with the application. All uploaded documents an applicant submits must be complete and accurate. If an applicant provides incorrect or false information, or withholds information, on an application, HHSC may:(1) deny the application; or(2) assess an administrative penalty, as described in §558.602(e)(5) of this chapter (relating to Administrative Penalties).(c) When an applicant submits an application through the online portal with full payment of applicable license fees, HHSC reviews the application and supporting documents to determine if it is complete and accurate. A complete and accurate application includes all documents and information that HHSC requests as part of the application process.(1) HHSC processes the application in accordance with time frames established in §558.31 of this subchapter (relating to Time Frames for Processing and Issuing a License).(2) If an applicant decides not to continue the application process for a license after submitting the application and license fee, the applicant must submit a written request to HHSC to withdraw the application. HHSC does not refund the license fee.(d) If an application is not complete and accurate, HHSC provides the applicant with electronic notice through the online portal, that the application is incomplete and specifies the information required to complete the application.(1) The applicant must submit to HHSC, through the online portal, the additional information requested to complete the application by no later than 30 days after the date of the notice. HHSC sends only one electronic notice through the online portal of the information needed to complete the application.(2) If an applicant fails to submit the required information to complete the application within 30 days after HHSC provides electronic notice through the online portal, HHSC considers the application incomplete and may deny the application. If HHSC denies the application, HHSC does not refund the license fee.(3) HHSC, at its discretion, may accept information later than 30 days based on extenuating circumstances. HHSC may assess the late fee authorized in §558.3(c) and set out in §558.3(d) of this chapter (relating to License Fees) for the parent agency and any applicable branch offices or ADSs for failure to comply with paragraph (1) of this subsection.(e) HHSC may deny issuance of a license for any of the reasons specified in §558.21 of this subchapter (relating to Denial of an Application or a License). Source Note: The provisions of this §558.12 adopted to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.12 General Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204536 03/12/2026 (a) The following staff must complete the Presurvey Training before submitting an application for a license:(1) the administrator and alternate administrator; and(2) the supervising nurse and alternate supervising nurse of an agency that provides licensed home health services with or without home dialysis designation, licensed and certified home health services with or without home dialysis designation, or hospice services.(b) An applicant may request to be licensed in one or more of the following categories:(1) licensed and certified home health services;(2) licensed and certified home health services with home dialysis designation;(3) licensed home health services;(4) licensed home health services with home dialysis designation;(5) hospice services; or(6) personal assistance services.(c) HHSC does not require an agency to be licensed in more than one category if the category for which the agency is licensed includes the services the agency provides.(d) An applicant who has requested the category of licensed and certified home health services on the initial license application must also apply to CMS for certification as a Medicare-certified agency under the 42 United States Code Chapter 7, Subchapter XVIII.(1) While the applicant is waiting for CMS to certify it as a Medicare-certified agency:(A) HHSC issues an initial license reflecting the category of licensed home health services if the applicant meets the criteria for the license; and(B) the applicant must comply with the Medicare conditions of participation for home health agencies in 42 CFR Part 484, as if the applicant were dually certified.(2) If CMS certifies an agency to participate in the Medicare program during the initial license period, HHSC sends a notice to the agency that the category of licensed and certified home health services has been added to the license. If the agency wants to remove the licensed home health services category from the agency's license after the category of licensed and certified home health services has been added, the agency must submit to HHSC an application through the online portal to remove that category from the agency's license.(3) If CMS denies certification to an agency or an agency withdraws the application for participation in the Medicare program, the agency may retain the category of licensed home health services on its license.(e) An applicant for an initial license must comply with §558.30 of this subchapter (relating to Operation of an Inpatient Unit at a Parent Agency) to operate an inpatient unit at the applicant's parent agency. Source Note: The provisions of this §558.13 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 17, 2018, 43 TexReg 238; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.13 Obtaining an Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204537 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204537 03/12/2026 (a) HHSC issues an initial license when HHSC determines:(1) the application, including supporting documents, submitted are complete and accurate;(2) HHSC has received funds constituting full payment of all applicable license fees, including late fees; and(3) an applicant meets the criteria for a license as described in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing) and §558.13 of this subchapter (relating to Obtaining an Initial License).(b) An initial license is valid for three years from the date of issuance.(c) HHSC may deny an application to renew an initial license, or revoke or suspend an initial license, if an agency fails to:(1) meet the requirements for an initial survey as specified in Subchapter E of this chapter (relating to Licensure Surveys); or(2) maintain compliance with the Statute and this chapter for the services authorized under the license.(d) HHSC may deny an application for an initial license for any of the reasons specified in §558.21 of this chapter (relating to Denial of an Application or a License).(e) A license designates an agency's place of business from which services are to be provided and designates an agency's authorized category or categories of service. Source Note: The provisions of this §558.15 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.15 Issuance of an Initial License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204538 03/12/2026 (a) To renew its license, an agency must submit a renewal application through the online portal.(b) An agency must submit its renewal application in accordance with §558.12 of this subchapter (relating to General Application) when submitting a renewal application through the online portal.(c) For each license period, an agency must provide services to at least one client to be eligible to renew its license.(d) HHSC does not require an agency to admit a client under each category of service authorized under the license to be eligible to renew its license.(e) With each renewal application, an agency accredited by an accreditation organization referenced in §558.503 of this chapter (relating to Exemption from Survey) must submit to HHSC through the online portal a copy of the accreditation documentation that the agency receives from the accreditation organization.(f) At least 120 days before the expiration date of a license, HHSC makes the renewal application and instructions available through the online portal. HHSC notifies the agency with electronic notice that the application and instructions to renew the license are made available through the online portal.(1) If the renewal application is not made available by HHSC in accordance with this subsection, the agency must, at least 90 days before the expiration date of a license, notify HHSC in writing that it has not received notice of expiration and request that HHSC make a renewal application available.(2) To avoid a late fee, an agency must submit to HHSC a complete and accurate renewal application, as described in §558.12(c) of this subchapter, with full payment of all required license fees as specified in §558.3 of this chapter (relating to License Fees), no later than the 45th day before the expiration date of the license.(3) If an agency submits a renewal application after the 45th day before the expiration date of a license, but before the expiration date of the license, HHSC assesses the late fee set out in §558.3(c) of this chapter for failure to comply with paragraph (2) of this subsection.(g) If an agency submits a renewal application to HHSC after the expiration date of the license, HHSC denies the renewal application and does not refund the renewal license fee. The agency is not eligible to renew the license and must cease operation on the date the license expires. An agency whose license expires must apply for an initial license in accordance with §558.13 of this subchapter (relating to Obtaining an Initial License).(h) If an agency submits a renewal application before the expiration date of the license in accordance with this subsection, the license does not expire until HHSC has made a final determination on the application.(1) If an enforcement action is pending at the time the renewal applicant submits a renewal application, the agency's license does not expire and the agency may continue to operate until HHSC had made a final determination on the application, concurrent with the agency's opportunity for a formal hearing as described in §558.601 of this chapter (relating to Enforcement Actions).(2) A license expires if the license holder fails to submit a renewal application in accordance with the subsection before the expiration date.(i) If a license holder fails to submit a renewal application in accordance with subsection (h) of this section because the license holder is or was on active duty with the armed forces of the United States of America outside the State of Texas, the license holder may renew the license pursuant to this subsection.(1) An individual having power of attorney from the license holder or other authority to act on behalf of the license holder may request renewal of the license. The renewal application must include a current address and telephone number for the individual requesting the renewal.(2) An agency may submit a request for a renewal application through the online portal before or after the expiration of the license.(3) A copy of the official orders or other official military documentation showing that the license holder is or was on active military duty serving outside the State of Texas must be submitted to HHSC with the renewal application.(4) A copy of the power of attorney from the license holder or other authority to act on behalf of the license holder must be submitted to HHSC with the renewal application.(5) A license holder applying to renew a license under this subsection must pay the required renewal fee in full.(6) A license holder may not operate the agency for which the license was obtained after the expiration of the license unless and until HHSC renews the license.(7) This subsection applies to a license holder who is an individual or a partnership comprised of individuals, all of whom are or were on active duty with the armed forces of the United States of America serving outside the State of Texas.(j) An applicant for a renewal license must comply with §558.30 of this subchapter (relating to Operation of an Inpatient Unit at a Parent Agency) to operate an inpatient unit at the applicant's parent agency. Source Note: The provisions of this §558.17 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective January 15, 2009, 34 TexReg 252; amended to be effective July 1, 2012, 37 TexReg 4613; amended to be effective January 17, 2018, 43 TexReg 238; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.17 Application Procedures for a Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204539 03/12/2026 (a) A license issued under this chapter expires three years after the date HHSC issues it, except as provided in subsections (e)(1) and (f)(1) of this section.(b) Except as specified in §558.503 of this chapter (relating to Exemption From a Survey), HHSC may not renew an initial license unless HHSC conducts an initial survey of the agency. For renewal of an initial license, an agency must:(1) meet the requirements for an initial survey as specified in Subchapter E of this chapter (relating to Licensure Surveys);(2) demonstrate substantial compliance with the Statute and this chapter for the services authorized under the license as confirmed by an initial survey; and(3) apply for renewal of the license in accordance with §558.17 of this subchapter (relating to Application Procedures for a Renewal License).(c) For renewal of a license other than an initial license, an agency must:(1) maintain substantial compliance with the Statute and this chapter for the services authorized under the license; and(2) apply for renewal of the license in accordance with §558.17 of this subchapter.(d) If HHSC grants the renewal application, it issues a renewal license effective on the day after the previous license expires.(e) If HHSC renews a license that expires after December 31, 2020, and before January 1, 2022, HHSC:(1) issues a license that is valid for two years, if the license is for an agency with a license number that ends in 0-3 or 7-9; and(2) issues a license that is valid for three years, if the license is for an agency with a license number that ends in 4-6.(f) If HHSC renews a license that expires after December 31, 2020, and before January 1, 2023, HHSC:(1) issues a license that is valid for two years, if the license is for an agency with a license number that ends in 4-6; and(2) issues a license that is valid for three years, if the license is for an agency with a license number that ends in 0-3 or 7-9.(g) HHSC may deny a renewal application:(1) if an agency fails to meet the eligibility criteria in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing);(2) if the agency fails to meet the requirements for renewal of a license as specified in this subchapter; or(3) for any of the reasons specified in §558.21 of this subchapter (relating to Denial of an Application or a License).(h) A renewal license designates an agency's place of business from which services are to be provided or directed and designates an agency's authorized category or categories of service. Source Note: The provisions of this §558.19 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective December 1, 2006, 31 TexReg 9620; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.19 Issuance of a Renewal License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204540 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204540 03/12/2026 (a) HHSC may deny an application for a license on any ground described in this chapter, or if any person described in §558.11(g) or (h) of this subchapter (relating to Criteria and Eligibility for Licensing):(1) fails to comply with the Statute;(2) fails to comply with this chapter;(3) knowingly aids, abets, or permits another person to violate the Statute or this chapter;(4) fails to meet the criteria for a license established in §558.11 of this subchapter; or(5) violates Texas Occupations Code §102.001.(b) If HHSC denies an application for a license, the applicant or agency may request an administrative hearing in accordance with §558.601 of this chapter (relating to Enforcement Actions). Source Note: The provisions of this §558.21 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2009, 34 TexReg 5139; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.21 Denial of an Application or a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204541 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204541 03/12/2026 (a) A license holder may not transfer its license. If there is a change of ownership, the license holder's license becomes invalid on the date of the licensure change of ownership. The prospective license holder must apply for a license in accordance with §558.12 of this subchapter (relating to General Application) and §558.13 of this subchapter (relating to Obtaining an Initial License).(b) If HHSC grants the application for an initial change of ownership license and allows an initial change of ownership application to occur without a gap in the agency's licensed status, the license holder at the time of the application must maintain an active and valid license until HHSC grants and issues an initial license to the change of ownership applicant.(c) A change of ownership for a parent agency is a change of ownership for the parent agency's branch office or ADS and requires the submittal of an application and license fee for each branch office and ADS at the same time as the parent agency application and fee.(d) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a license as a result of a change of ownership. HHSC may conduct a desk review instead of an on-site health inspection after issuing a license as a result of a change of ownership if:(1) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or(2) every owner with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(e) For an agency licensed to provide licensed and certified home health services or certified, as well as licensed, to provide hospice services, applicable federal laws and regulations relating to change of ownership or control apply in addition to the requirements of this section. Source Note: The provisions of this §558.23 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 11, 2017, 42 TexReg 5514; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.23 Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204542 03/12/2026 To apply for an initial change of ownership license, a prospective new owner must submit an initial license application to HHSC through the online portal in accordance with paragraph (2) of this subsection. The application must be complete and accurate, as described in §558.12(c) of this subchapter (relating to General Application), and the applicant must submit the appropriate license fee with the application.(1) The change of ownership applicant must submit the complete and accurate initial application with full payment of required license fees at least 30 days before the anticipated date of sale or other transfer of ownership and before the expiration date of the license.(A) HHSC may accept a change of ownership application less than 30 days before the effective date.(B) HHSC may assess a late fee set out in §558.3(d) of this chapter (relating to License Fees).(2) The change of ownership applicant must apply for the initial license in accordance with §558.23(a) of this subchapter (relating to Change of Ownership) and meet the criteria for a license as described in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing) and §558.13 of this subchapter (relating to Obtaining an Initial License).(3) If an applicant submits a complete and accurate application through the online portal, has met all the criteria for a license, and HHSC has received funds constituting full payment of all required license fee HHSC issues the change of ownership applicant an initial license. The effective date of the license constitutes the licensure change of ownership date.(4) The initial license issued to the new owner is valid for three years from the date of issuance. Source Note: The provisions of this §558.25 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective January 15, 2009, 34 TexReg 252; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.25 Requirements for Change of Ownership https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204543 03/12/2026 (a) An agency with a current license to provide licensed home health services, licensed and certified home health services, or personal assistance services may qualify for a branch office license, if the parent agency:(1) is found to be in substantial compliance with the Statute and this chapter;(2) has no enforcement action pending against the license; and(3) meets its initial survey requirements before HHSC approves a branch office license.(b) To apply for a branch office license, an agency must submit an application for the license to HHSC through the online portal, in accordance with §558.12 of this subchapter (relating to General Application).(c) A designated survey office conducts a review of an agency's request to establish a branch office. The survey office makes a recommendation to approve or disapprove the branch office request.(d) HHSC approves or denies the application for a branch office license after considering the designated survey office's recommendation. If HHSC denies the application, HHSC sends the agency a written notice:(1) of its decision; and(2) the agency's opportunity to appeal its decision through a formal hearing process as described in §558.601 of this chapter (relating to Enforcement Actions).(e) CMS approves or denies the branch location if an agency is licensed to provide licensed and certified home health services.(f) A branch office license expires on the same expiration date as the parent agency's license. To renew a branch office license, the license holder must submit, to HHSC through the online portal, a complete and accurate renewal application and all required fees for the branch office license application, and the agency may renew it with the parent agency's license.(g) If HHSC grants a branch office license, it provides the branch office license to the license holder for the parent agency and branch office. The branch office must post the license in a conspicuous place on the licensed branch office premises.(h) A branch office must comply with §558.321 of this title (relating to Standards for Branch Offices) and the additional standards that relate to the agency's authorized categories under the license.(i) Unless an agency is exempt from the survey, as specified in §558.503 of this chapter (relating to Exemption From a Survey), HHSC does not renew a branch office license if it has not conducted a health survey of a branch office after issuance of the license to verify compliance with the Statute and this chapter. Source Note: The provisions of this §558.27 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.27 Application and Issuance of an Initial Branch Office License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204544 03/12/2026 (a) An agency with a license to provide hospice services may qualify for an ADS license if the parent agency:(1) is in substantial compliance with the Statute and this chapter; and(2) has no enforcement action pending against its license.(b) To apply for an ADS license, an agency must submit an ADS application to HHSC through the online portal, in accordance with §558.12 of this subchapter (relating to General Application).(1) In the application, an agency may request to operate an inpatient unit at the ADS location.(2) To add an inpatient unit to a licensed ADS, an agency must submit a change of service category application through the online portal according to the instructions for requesting HHSC approval, and otherwise comply with requirements of this section.(c) After an agency submits an application for an ADS with an inpatient unit, the agency must contact the HHSC Architectural Unit to request a Life Safety Code survey. Before HHSC considers whether the application is complete, HHSC determines an agency's compliance with the Life Safety Code requirements §558.871 of this chapter (relating to Physical Environment in a Hospice Inpatient Unit).(d) A designated survey office reviews an agency's application for an ADS license and makes a recommendation to the HHSC HCSSA licensing unit whether to approve or deny the application. The HCSSA licensing unit approves or denies the agency's application.(e) If HHSC denies an agency's application, HHSC sends the agency a written notice:(1) informing the agency of its decision; and(2) providing the agency with an opportunity to appeal its decision through a formal hearing process as described in §558.601 of this chapter (relating to Enforcement Actions).(f) Except as provided in subsection (g) of this section, after HHSC issues a license for an ADS with an inpatient unit, the agency must, after providing inpatient services to a client, submit the Notification of Readiness for a Health Survey of a Hospice Inpatient Unit (HHSC Form 2020-A), to the designated survey office. HHSC conducts an initial licensure health survey to review the requirements in §558.871 of this chapter specified in Subchapter H, Division 7 of this chapter (relating to Hospice Inpatient Units) that an HHSC Life Safety Code surveyor did not review during the initial Life Safety Code survey.(g) An agency is not required to request an initial licensure health survey of an ADS with an inpatient unit if the agency is exempt from the health survey as specified in §558.503 of this chapter (relating to Exemption From a Survey). To demonstrate that it is exempt, the agency must send the accreditation documentation from the accreditation organization to the HHSC designated survey office within seven days after the agency receives the accreditation documentation.(h) If an agency receives accreditation documentation from the accreditation organization after the agency submits a written request to HHSC for an initial licensure health survey, the agency may demonstrate that it is exempt from the survey by sending the accreditation documentation to the HHSC designated survey office before HHSC arrives at the agency to conduct an initial health survey.(i) A Medicare-certified hospice agency must also submit a request to CMS for approval of an ADS, including an ADS with an inpatient unit. CMS approves or denies the request.(j) An ADS license expires on the same date the parent agency's license expires. To renew an ADS license, the license holder must submit to HHSC through the online portal a renewal application and all required fees for the ADS license when submitting a renewal application for the parent agency's license.(k) If HHSC grants an ADS license, it will provide the license to the parent agency. The agency must post the ADS license in a conspicuous place on the licensed ADS premises.(l) An ADS must comply with the Statute and this chapter, including the applicable additional standards for hospice agencies in Subchapter H of this chapter (relating to Standards Specific to Agencies Licensed to Provide Hospice Services) and §558.322 of this chapter (relating to Standards for Alternate Delivery Sites). A Medicare-certified hospice agency's ADS must also comply with the applicable federal rules and regulations for hospice agencies in 42 CFR Part 418. Source Note: The provisions of this §558.29 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893 amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.29 Application and Issuance of an Alternate Delivery Site License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204545 03/12/2026 (a) To operate an inpatient unit at a parent agency, the license holder for the parent agency or an applicant for an initial license to provide hospice services must:(1) submit an initial parent application through the online portal according to applicable instructions for requesting HHSC approval to operate an inpatient unit at the parent agency;(2) send written notice to HHSC that it is ready for a Life Safety Code inspection through the online portal;(3) allow HHSC to conduct an on-site Life Safety Code inspection to determine if the inpatient unit is in compliance with §558.871 of this chapter (relating to Physical Environment in a Hospice Inpatient Unit);(4) obtain verification from HHSC that the inpatient unit is in compliance with Subchapter H, Division 7 of this chapter (relating to Hospice Inpatient Units) before admitting a client to the inpatient unit;(5) after HHSC issues a license authorizing the inpatient unit, admit and provide hospice services to a client in the inpatient unit; and(6) except as provided in subsection (c) of this section:(A) submit the Notification of Readiness for a Health Survey of a Hospice Inpatient Unit (HHSC Form 2020-A) to HHSC after admitting and providing services to at least one client in the inpatient unit; and(B) be determined by HHSC to be in substantial compliance with the Statute and this chapter, including Subchapter H of this chapter (relating to Standards Specific to Agencies Licensed to Provide Hospice Services).(b) If the applicant is currently licensed at the time an agency notifies HHSC in accordance with subsection (a)(1) of this section, the agency must not have enforcement action pending against the license under which the agency would operate the inpatient unit.(c) An agency that provides hospice services is not required to submit the Notification of Readiness for a Health Survey of a Hospice Inpatient Unit (HHSC Form 2020-A) in accordance with subsection (a)(6)(A) of this section if the agency demonstrates that it is exempt from a health survey, as described in §558.503 of this chapter (relating to Exemption From a Survey). The agency may demonstrate that it is exempt from the initial health survey described in §558.521 of this chapter (relating to Requirements for an Initial Survey) by submitting the accreditation documentation from an approved accreditation organization referenced in §558.503 of this chapter to the designated HHSC survey office within seven days after the agency receives the accreditation documentation.(d) If HHSC grants an application for an initial parent agency license with an inpatient unit or to add an inpatient unit to a licensed parent agency, the licensed agency and the license holder must comply with the Statute and this chapter, including Subchapter H of this chapter. Source Note: The provisions of this §558.30 adopted to be effective January 17, 2018, 43 TexReg 238; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.30 Operation of an Inpatient Unit at a Parent Agency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204546 03/12/2026 (a) General.(1) In this section, the date of an application is the date an applicant successfully submits an application to HHSC through the online portal as described in subsection (b)(1) of this section.(2) HHSC considers an application complete for purposes of this section when it is complete and accurate as described in §558.12 of this subchapter (relating to General Applications), and the applicant has met all requirements for licensure, including applicable background and survey standards before HHSC issues a license.(b) Time frames. HHSC processes an application in accordance with the following time frames.(1) The first time frame begins on the date the applicant successfully submits an application through the online portal and the online portal reflects a status of "payment received" for applicable license fees, including late fees, and ends on the date HHSC determines the submission is complete and accurate, as described in §558.12 of this subchapter (relating to General Applications). If HHSC receives an incomplete application, the first time frame ends on the date HHSC sends an electronic notice, through the online portal, to the agency that the application is incomplete. The electronic notice specifies the information that the applicant must submit to complete the application. The first time frame is no longer than 45 days.(2) The second time frame begins on the date that the application is complete, as described for the purpose of this section, in subsection (a)(2) of this section, and ends on the date the license is issued. The second time frame is no longer than 45 days.(3) If an agency is subject to a proposed or pending enforcement action on its license, on or within 45 days before the expiration date of the license, HHSC may postpone decision on a renewal application while the action is pending.(c) Reimbursement of fees.(1) If HHSC does not process the application in the time frames stated in subsection (b) of this section, the applicant has the right to request that HHSC reimburse the license fee. If HHSC does not agree that the established time frames have been violated or finds that good cause existed for exceeding the established time frames, HHSC denies the request.(2) HHSC considers that good cause for exceeding the established time frames exists if:(A) the number of applications to be processed exceeds by 15 percent or more the number of applications processed in the same quarter for the preceding year;(B) another public or private entity used in the application process caused the delay; or(C) other conditions existed giving good cause for exceeding the established time frames.(d) Appeal. If HHSC denies the request for reimbursement of the license fee, as authorized by subsection (c) of this section, the applicant may appeal the denial. In order to appeal, the applicant must send a written request for reimbursement of the license fee to the HHSC executive commissioner. The request must include that the application was not processed within the established time frame. The HHSC HCSSA licensing unit provides the HHSC executive commissioner with a written report of the facts related to the processing of the application and good cause for exceeding the established time frame. The HHSC executive commissioner makes the final decision and provides written notification of the decision to the applicant and the HHSC HCSSA licensing unit. Source Note: The provisions of this §558.31 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 252; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE §558.31 Time Frames for Processing and Issuing a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195064 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195064&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195064 03/12/2026 (a) This subchapter applies to a home and community support services agency providing licensed home health services or licensed and certified home health services with and without home dialysis designation, hospice services, or personal assistance services.(b) In addition to the minimum standards in this subchapter, an agency must also comply with applicable standards in Subchapter D of this chapter (relating to Additional Standards Specific to License Category and Specific to Special Services) and Subchapter H of this chapter (relating to Standards Specific to Agencies Licensed to Provide Hospice Services). Source Note: The provisions of this §558.201 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.201 Applicability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204547 03/12/2026 (a) An agency may provide habilitation.(b) An agency that provides habilitation must provide habilitation in accordance with this chapter, including any licensure standards in Subchapter D of this chapter (relating to Additional Standards Specific to License Category and Specific to Special Services) that apply to the categories of service designated on the agency's license. Source Note: The provisions of this §558.202 adopted to be effective September 1, 2016, 41 TexReg 6501; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.202 Habilitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204554 03/12/2026 (a) If certain information provided on an initial or renewal application changes after HHSC issues the license, an agency must report the change to HHSC via the online portal. The agency must use the Home and Community Support Services Agency License Application, (HHSC Form 2021) to report the change. To avoid a late fee, an agency must report a change as required in this subsection and pay in full applicable fees required under subsection (b) of this section, within the time frame specified for the type of change.(1) For requirements on reporting a change in the agency's location, see §558.213 of this division (relating to Agency Relocation);(2) For requirements on reporting a change in the agency's contact information and operating hours, see §558.214 of this division (relating to Notification Procedures for a Change in Agency Contact Information and Operating Hours);(3) For requirements on reporting a change to the agency's name, see §558.215 of this division (relating to Notification Procedures for an Agency Name Change);(4) For requirements on reporting a change in the agency's organizational management personnel, see §558.218 of this division (relating to Agency Organizational Changes);(5) For requirements on adding or deleting a category of service to the license, see §558.219 of this division (relating to Procedures for Adding or Deleting a Category to the License); and(6) For requirements on expanding or reducing the agency's service area, see §558.220 of this division (relating to Service Areas).(b) The schedule of fees an agency must pay when the agency timely submits HHSC Form 2021, to report changes in application information, is as follows.(1) An agency is not required to pay a fee if the agency reports changes to contact information and operating hours, within the required time frame, as specified in §558.214 of this division.(2) An agency is not required to pay a fee if the agency reports a change in the alternate administrator, within the required time frame, as specified in §558.218 of this division.(3) An agency must pay a fee of $30 if the agency, within the required time frame, reports one or more of the following changes:(A) a change in physical location, as specified in §558.213 of this division;(B) a change in name (legal entity or doing business as), as specified in §558.215 of this division;(C) a change in administrator, chief financial officer, or controlling person, as specified in §558.218 of this division;(D) a change in category of service designated on a license, as specified in §558.219 of this division; or(E) a change in service area, as specified in §558.220 of this division.(4) HHSC does not consider a change of information as officially submitted until the online portal reflects a status of payment received, if a fee is applicable.(c) If an agency untimely submits HHSC Form 2021 to report one or more changes referenced in subsection (a) of this section, the agency must pay a late fee of $100. If an agency must pay a fee of $30 for reporting a change referenced in subsection (b)(3) of this section, the $100 late fee is in addition to the $30 fee.(d) If HHSC determines, based on review of an agency's renewal application, that an agency did not report a change in application information as required by this section, HHSC notifies the agency in writing of the fee amount due for payment.(e) If HHSC determines, based on a survey, that an agency did not report a change in application information as required by this section, HHSC notifies the agency in writing of the fee amount due for payment. Reporting the change and paying the required fee does not preclude HHSC from taking other enforcement action against the agency as specified in §558.601 of this chapter (relating to Enforcement Actions).(f) If an agency pays a fee to HHSC to report a change in application information, the fee is not refundable. HHSC accepts payment for a required fee as described in §558.3(f) of this chapter (relating to License Fees).(g) HHSC may suspend or revoke a license or deny an application for a renewal license if an agency does not pay a fee, as required by this section, within 30 days after HHSC provides written notice of a fee amount due for payment. Within 10 days after receipt of HHSC's written notice of a fee amount due for payment, an agency may submit proof to HHSC that the agency:(1) submitted HHSC Form 2021 to timely report a change in application information, as specified in each rule referenced in subsection (a) of this section; and(2) paid the fee amount required by this section when the agency submitted HHSC Form 2021. Source Note: The provisions of this §558.208 adopted to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.208 Reporting Changes in Application Information and Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195070 03/12/2026 (a) An agency must adopt and enforce a written policy identifying the agency's operating hours.(b) For the purposes of this section, the person in charge means the administrator, the designated alternate administrator, the supervising nurse, or the alternate supervising nurse.(c) If an agency is closed during the agency's operating hours or between the hours of 8:00 a.m. and 5:00 p.m. Monday through Friday, the person in charge must:(1) post a notice in a visible location outside the agency that will provide information regarding how to contact the person in charge; and(2) leave a message on an answering machine or similar electronic mechanism that will provide information regarding how to contact the person in charge. Source Note: The provisions of this §558.210 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.210 Agency Operating Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195071 03/12/2026 The license must be displayed in a conspicuous place in the designated place of business. If the information on the license is officially amended during the licensure period, a notice must be posted beside the license to provide public notice of the change. Source Note: The provisions of this §558.211 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.211 Display of License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195072 03/12/2026 A license may not be altered. Source Note: The provisions of this §558.212 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.212 License Alteration Prohibited https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204555 03/12/2026 (a) An agency must not transfer a license from one location to another without prior notice to HHSC. If an agency is considering relocation, the agency must submit written notice to HHSC to report a change in physical location at least 30 days before the intended relocation, unless HHSC grants the agency an exemption from the 30-day time frame as specified in subsection (b) of this section. A change in physical location for a hospice inpatient unit requires HHSC to conduct a survey to approve the new location.(b) An agency must notify HHSC immediately if an unexpected situation beyond the agency's control makes it impossible for the agency to submit written notice to HHSC no later than 30 days before the agency relocates. HHSC grants or denies the exemption.(1) If HHSC grants the exemption, the agency must submit written notice to HHSC as described in subsection (c) of this section within 30 days after the date HHSC grants the exemption.(2) If HHSC denies the exemption, the agency may not relocate until at least 30 days after the agency submits the written notice to HHSC, as described in subsection (c) of this section.(c) An agency must report a change in physical location to HHSC in accordance with §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(d) If an agency reports a change in physical location, the agency must pay a fee and may be subject to a late fee, as described in §558.208 of this division.(e) HHSC sends the agency a Notification of Change reflecting the new location. The agency must post the Notification of Change beside its license in accordance with §558.211 of this division (relating to Display of License).(f) A Medicare certified home health and hospice agency must comply with applicable federal laws and regulations and the requirements of this section for reporting an agency relocation. A change in physical location for a Medicare-certified agency requires HHSC review.(g) An agency is exempt from the requirements in subsections (a) - (d) of this section when reporting a temporary relocation that results from the effects of an emergency or disaster, as specified in §558.256(o) of this subchapter (relating to Emergency Preparedness Planning and Implementation). Source Note: The provisions of this §558.213 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.213 Agency Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204556 03/12/2026 (a) An agency must report to HHSC no later than seven days after a change in the agency's:(1) telephone number;(2) mailing address, if different than the physical location; or(3) operating hours.(b) An agency must report the changes described in subsection (a) of this section to HHSC in accordance with §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(c) If an agency reports the information after the timeframes required by this section, the agency must pay a late fee as described in §558.208 of this division. Source Note: The provisions of this §558.214 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.214 Notification Procedures for a Change in Agency Contact Information and Operating Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204557 03/12/2026 (a) If an agency intends to change its name (legal entity or assumed (doing business as) name), but does not undergo a change of ownership as defined in §558.23(c) of this chapter (relating to Change of Ownership), the agency must report the name change to HHSC no later than seven days after the effective date of the name change.(b) An agency must report a name change to HHSC in accordance with §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(c) If an agency reports a name change, the agency must pay a fee and may be subject to a late fee, as described in §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(d) After HHSC receives and verifies the required documents and information, HHSC sends the agency a Notification of Change reflecting the agency's new name. The agency must post the Notification of Change beside its license in accordance with §558.211 of this division (relating to Display of License). Source Note: The provisions of this §558.215 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.215 Notification Procedures for an Agency Name Change https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204548 03/12/2026 (a) An agency must notify HHSC in writing no later than five days after the agency decides to voluntarily withdraw from the Medicare program. If an agency's voluntary withdrawal from the Medicare program is based on the permanent closure of the agency, the agency must also comply with §558.217 of this division (relating to Agency Closure Procedures and Voluntary Suspension of Operations).(b) If an agency chooses to voluntarily withdraw from the Medicare program, or if CMS involuntarily terminates or denies its certification, the license will be affected as follows:(1) If an agency licensed to provide licensed and certified home health services has no other license categories remaining on the license after losing its Medicare certification, its license is void and the agency must cease operation. If the agency wants to resume providing services, it must apply for an initial license.(2) If a Medicare-certified agency has another license category remaining on the current license and the agency wants to continue providing services under the remaining license category, HHSC surveys the agency under the remaining license category.(c) As specified in §558.601(c)(2) of this chapter (relating to Enforcement Actions), HHSC may take enforcement action against an agency licensed to provide licensed and certified home health services if the agency fails to maintain its Medicare certification. The agency may request an administrative hearing in accordance with §558.601 of this chapter to contest the enforcement action taken by HHSC against the agency. Source Note: The provisions of this §558.216 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.216 Change in Agency Certification Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204549 03/12/2026 (a) Permanent closure. An agency must notify HHSC in writing within five days before the permanent closure of the agency, branch office, or ADS.(1) The agency must include in the written notice the reason for closing, the location of the client records (active and inactive), and the name and address of the client record custodian.(2) If the agency closes with an active client roster, the agency must transfer a copy of the active client record with the client to the receiving agency in order to ensure continuity of care and services to the client.(3) The agency must mail or return the initial license or renewal license to HHSC at the end of the day that services cease.(4) If an agency continues to operate after the closure date specified in the notice, HHSC may take enforcement action against the agency.(b) Applicability. This subsection applies to an agency licensed to provide licensed home health services, personal assistance services, and licensed-only hospice services.(1) Voluntary suspension of operations occurs when an agency voluntarily suspends its normal business operations for 10 or more consecutive days. A voluntary suspension of operations may not last longer than the licensure renewal period. If an agency voluntarily suspends operations, the agency must:(A) discharge or arrange for backup services for active clients;(B) provide written notification to the designated survey office at least five days before the voluntary suspension of operations, or within two working days before the voluntary suspension of operations, if an emergency occurs that is beyond the agency's control; and(C) post a notice of voluntary suspension of operations on the entry door of the agency and leave a voice message that informs callers of the voluntary suspension of operations.(2) An agency must notify the HHSC HCSSA licensing unit in writing no later than seven days after resuming operations. Source Note: The provisions of this §558.217 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.217 Agency Closure Procedures and Voluntary Suspension of Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204550 03/12/2026 (a) If a change occurs in the following management personnel, an agency must submit written notice to HHSC no later than seven days after the date of a change in:(1) administrator;(2) alternate administrator;(3) chief financial officer; or(4) controlling person, as defined in §558.2 of this chapter (relating to Definitions).(b) An agency must report a change in the management personnel listed in subsection (a) of this section to HHSC in accordance with §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(c) If an agency reports a change in the administrator, chief financial officer, or controlling person, the agency must pay a fee and may be subject to a late fee, as described in §558.208 of this division.(d) An agency is not required to pay a fee to report a change in alternate administrator, but the agency must pay a late fee, as described in §558.208 of this division, if the agency does not report the change within the time frame required in this section.(e) A change in the management personnel listed in subsection (a) of this section requires HHSC evaluation and approval. HHSC reviews the required documents and information submitted. HHSC notifies an agency if the information the agency provides does not reflect that a person listed in subsection (a)(1) - (4) of this section meets the required qualifications. Source Note: The provisions of this §558.218 adopted to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.218 Agency Organizational Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204551 03/12/2026 (a) To add or delete a category of service to a license, an agency must submit the appropriate application to HHSC through the online portal at least 30 days before adding or deleting the category.(b) HHSC either approves or denies the application to add a category of service no later than 30 days after HHSC receives the application through the online portal. An agency must not provide the services under the category the agency is adding until the agency receives written notice of approval from HHSC.(1) To add a category of service to a license, an agency must:(A) be in substantial compliance with the Statute and this chapter; and(B) have no enforcement action pending against the license.(2) If HHSC denies the application to add a category of service, HHSC informs the agency of the reason for denial.(3) HHSC may conduct a survey after the approval of a category.(c) An agency's submission of an application to delete a category from a license does not preclude HHSC from taking enforcement action as appropriate in accordance with Subchapter F of this chapter (relating to Enforcement).(d) An agency must submit to HHSC the application to add or delete a category of service in accordance with §558.208 of this division (relating to Reporting Changes in Application Information and Fees).(e) If an agency submits an application to add or delete a category of service, the agency must pay a fee and may be subject to a late fee, as described in §558.208 of this division.(f) If HHSC grants an agency's application to add or delete a category of service, HHSC sends the agency a Notification of Change reflecting the change in the category of service. The agency must post the Notification of Change beside its license in accordance with §558.211 of this division (relating to Display of License). Source Note: The provisions of this §558.219 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.219 Procedures for Adding or Deleting a Category to the License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204552 03/12/2026 (a) An agency must identify its licensed service area. A branch office or ADS must be located within the parent agency's licensed service area. An agency must not provide services outside its licensed service area, except as provided in subsections (i) and (j) of this section.(b) An agency must maintain adequate staff to provide services and to supervise the provision of services.(c) An agency may expand its service area at any time during the licensure period. An agency must submit an application to HHSC through the online portal to expand the agency's service area at least 30 days before the expansion, unless HHSC grants the agency an exemption from the 30-day time frame as specified in subsection (d) of this section.(d) An agency is exempt from the requirement to submit an application to HHSC through the online portal no later than 30 days before the agency expands its service area if HHSC determines an emergency situation exists that would affect client health and safety.(1) An agency must notify HHSC immediately of a possible emergency situation that would affect client health and safety.(2) HHSC grants or denies an exemption from the 30-day application submission requirement.(A) If HHSC grants an exemption, the agency must submit an application to HHSC through the online portal, as described in subsection (e) of this section, no later than 30 days after the date HHSC grants the exemption.(B) If HHSC denies an exemption, the agency may not expand the agency's service area until at least 30 days after the agency submits the written notice to HHSC, as described in subsection (e) of this section.(e) If an agency intends to expand or reduce the agency's service area, the agency must submit an application to HHSC through the online portal, in accordance with §558.208 of this subchapter (relating to Reporting Changes in Application Information and Fees).(f) If an agency reports a change in service area, the agency must pay a fee and may be subject to a late fee, as described in §558.208 of this subchapter.(g) An agency may reduce its service area at any time during the licensure period. An agency must submit an application to HHSC through the online portal informing HHSC that the agency reduced its service area, no later than 10 days after the reduction.(h) HHSC sends the agency a Notification of Change reflecting the change in service area. An agency is not required to post the Notification of Change in service area beside its license.(i) An agency is exempt from the requirements described in subsections (c) - (f) of this section if a temporary expansion results from an emergency or disaster, as specified in §558.256(o) of this subchapter (relating to Emergency Preparedness Planning and Implementation).(j) An agency may provide services to a client outside the agency's licensed service area, but within the State of Texas, in accordance with this subsection and, for an agency licensed to provide hospice services, with the additional standards in §558.830 of this chapter (relating to Provision of Hospice Core Services).(1) The agency may provide the services for no more than 60 consecutive days, unless the agency expands its service area as described in subsections (e) and (f) of this section.(2) The client must reside in the agency's service area and be receiving services from the agency at the time the client leaves the agency's service area.(3) The agency must maintain compliance with the Statute and this chapter and, if applicable, federal home health and hospice regulations.(4) The agency must document in the client record the start and end dates for the services.(5) An agency's authority to provide services to a client outside its service area may depend on regulations or requirements established by the client's private or public funding source, including a health maintenance organization or other private third-party insurance; Medicaid, under 42 United States Code Chapter 7, Subchapter XVIII; or a state-funded program. The agency is responsible for knowing these requirements.(k) If a client notifies an agency that the client is leaving the agency's service area and the agency does not provide services in accordance with subsection (j) of this section, the agency must inform the client that leaving the agency's service area requires the agency to:(1) place the client's services on hold in accordance with the agency's written policy, required by §558.281 of this subchapter (relating to Client Care Policies), until the client returns to the agency's service area;(2) transfer and discharge the client in accordance with §558.295 of this subchapter (relating to Client Transfer or Discharge Notification Requirements) and the agency's written policy required by §558.281 of this subchapter; or(3) discharge the client in accordance with §558.295 of this subchapter and the agency's written policy required by §558.281 of this subchapter. Source Note: The provisions of this §558.220 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; amended to be effective October 1, 2013, 38 TexReg 6645; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.220 Service Areas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204553 03/12/2026 An agency must maintain satisfactory compliance with all the provisions of the Statute and this chapter to maintain licensure. Source Note: The provisions of this §558.222 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.222 Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204558 03/12/2026 (a) Agency policies. The license holder is responsible for the conduct of the agency and for the adoption, implementation, enforcement, and monitoring of adherence to the written policies required throughout this chapter. The license holder is also responsible for ensuring that the policies comply with the Statute and the applicable provisions of this chapter and are administered to provide safe, professional, quality health care.(b) Criminal conviction. The persons described in §558.11(g) of this chapter (relating to Criteria and Eligibility for Licensing) must not have been convicted of an offense described in §560.2 of this title (relating to Convictions Barring Licensure), during the time frames described in that section.(c) Documentation. The license holder must ensure that all documents submitted to HHSC, or maintained by the agency pursuant to this chapter, are accurate and do not misrepresent or conceal a material fact.(d) Compliance with enforcement orders. The license holder must comply with an order of the HHSC executive commissioner or other enforcement orders that may be imposed on the agency in accordance with the Statute and this chapter. Source Note: The provisions of this §558.241 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective December 1, 2006, 31 TexReg 9620; amended to be effective September 1, 2009, 34 TexReg 5139; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.241 Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204559 03/12/2026 (a) An agency must prepare and maintain a current written description of the agency's organizational structure. The document may be either in the form of a chart or a narrative.(b) The description must include:(1) all services provided by the agency;(2) the governing body, administrator, supervising nurse, advisory committee, interdisciplinary team, and staff, as appropriate, based on services provided by the agency; and(3) the lines of authority and the delegation of responsibility down to and including the client care level. Source Note: The provisions of this §558.242 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.242 Organizational Structure and Lines of Authority https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204560 03/12/2026 (a) Administrative responsibilities.(1) A license holder, or the license holder's designee, must designate an individual who meets the qualifications and conditions set out in §558.244 of this division (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications) to serve as the administrator of the agency.(2) A license holder, or the license holder's designee, must designate in writing an alternate administrator who meets the qualifications and conditions of an administrator to act in the absence of the administrator.(b) Administrator responsibilities.(1) An administrator must be responsible for implementing and supervising the administrative policies and operations of the agency and for administratively supervising the provision of all services to agency clients on a day-to-day basis. An administrator must:(A) manage the daily operations of the agency;(B) organize and direct the agency's ongoing functions;(C) administratively supervise the provision of quality care to agency clients;(D) supervise to ensure implementation of agency policy and procedures;(E) ensure that the documentation of services provided is accurate and timely;(F) employ or contract with qualified personnel;(G) ensure adequate staff education and evaluations, according to requirements in §558.245(b) of this division (relating to Staffing Policies);(H) ensure the accuracy of public information materials and activities;(I) implement an effective budgeting and accounting system that promotes the health and safety of the agency's clients; and(J) supervise and evaluate client satisfaction survey reports on all clients served.(2) An administrator or alternate administrator must be available to agency personnel, in person or by telephone, during the agency's operating hours and in accordance with the rules in this chapter, including §558.210 of this subchapter (relating to Agency Operating Hours), §558.404(h)(2) of this chapter (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services), §558.523 of this chapter (relating to Personnel Requirements for a Survey), and §558.527 of this chapter (relating to Post-Survey Procedures).(3) An administrator must designate, in writing, an agency employee who must provide HHSC surveyors entry to the agency in accordance with §558.523(e) of this chapter (relating to Personnel Requirements for a Survey), if the administrator and alternate administrator are not available.(c) Supervision of services.(1) Except as provided in paragraph (3) of this subsection, an agency licensed to provide licensed home health services, licensed and certified home health services, or hospice services must directly employ or contract with an individual who meets the qualifications in §558.244 of this division to serve as the supervising nurse.(2) An agency must designate, in writing, a similarly qualified alternate to serve as supervising nurse in the absence of the supervising nurse.(A) The supervising nurse or alternate supervising nurse must:(i) always be available to agency personnel, in person or by telephone;(ii) participate in activities relevant to services furnished, including the development of qualifications and assignment of agency personnel;(iii) ensure that a client's plan of care or care plan is executed as written; and(iv) ensure that an appropriate health care professional performs a reassessment of a client's needs:(I) when there is a significant health status change in the client's condition;(II) at the physician's request; or(III) after hospital discharge.(B) A supervising nurse may also be the administrator of the agency, if the supervising nurse meets the qualifications and conditions of an administrator described in §558.244(a) and (b) of this division.(3) An agency that provides only physical, occupational, speech or respiratory therapy, medical social services, or nutritional counseling is not required to employ or contract with a supervising nurse. A qualified licensed professional must supervise these services, as applicable.(d) Supervision of branch offices and ADSs. An agency must adopt and enforce a written policy relating to the supervision of branch offices or ADSs, if established. This policy must be consistent with the following:(1) for a branch office, §558.27 of this chapter (relating to Application and Issuance of an Initial Branch Office License) and §558.321 of this chapter (relating to Standards for Branch Offices); or(2) for an ADS, §558.29 of this chapter (relating to Application and Issuance of an Alternate Delivery Site License) and §558.322 of this chapter (relating to Standards for Alternate Delivery Sites). Source Note: The provisions of this §558.243 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective December 1, 2006, 31 TexReg 7368; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.243 Administrative and Supervisory Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204561 03/12/2026 (a) Administrator qualifications.(1) For an agency licensed to provide licensed home health services, licensed and certified home health services, or hospice services, the administrator and the alternate administrator must:(A) be a licensed physician, RN, licensed social worker, licensed therapist, or licensed nursing home administrator with at least one year of management or supervisory experience in a health-related setting, such as:(i) a home and community support services agency;(ii) a hospital;(iii) a nursing facility;(iv) a hospice;(v) an outpatient rehabilitation center;(vi) a psychiatric facility;(vii) an intermediate care facility for individuals with an intellectual disability or related conditions; or(viii) a licensed health care delivery setting providing services for individuals with functional disabilities; or(B) have a high school diploma or a general equivalency degree (GED) with at least two years of management or supervisory experience in a health-related setting, such as:(i) a home and community support services agency;(ii) a hospital;(iii) a nursing facility;(iv) a hospice;(v) an outpatient rehabilitation center;(vi) a psychiatric facility;(vii) an intermediate care facility for individuals with an intellectual disability or related conditions; or(viii) a licensed health care delivery setting providing services for individuals with functional disabilities.(2) For an agency licensed to provide hospice services, in addition to the qualifications listed in paragraph (1)(A) or (B) of this subsection, the administrator and the alternate administrator must:(A) be a hospice employee; and(B) have any additional education and experience required by the hospice's governing body, as specified in the agency's job description.(3) For an agency licensed to provide only personal assistance services, the administrator and the alternate administrator must meet at least one of the following qualifications:(A) have a high school diploma or a GED with at least one year of experience or training in caring for individuals with functional disabilities;(B) have completed two years of full-time study at an accredited college or university in a health-related field; or(C) meet the qualifications listed in paragraph (1)(A) or (B) of this subsection.(b) Administrator conditions.(1) An administrator and alternate administrator must be able to read, write, and comprehend English.(2) An administrator and alternate administrator designated as an administrator or alternate administrator for the first time on or after December 1, 2006, must meet the initial educational training requirements specified in §558.259 of this division (relating to Initial Educational Training in Administration of Agencies).(3) An administrator and alternate administrator designated as an administrator or alternate administrator before December 1, 2006, must meet the continuing education requirements specified in §558.260 of this division (relating to Continuing Education in Administration of Agencies).(4) A person is not eligible to be the administrator or alternate administrator of any agency if the person was the administrator of an agency cited with a violation that resulted in HHSC taking enforcement action against the agency while the person was the administrator of the cited agency.(A) This paragraph applies for 12 months after the date of the enforcement action.(B) For purposes of this paragraph, enforcement action means license revocation, suspension, emergency suspension of a license, denial of an application for a license, or the imposition of an injunction, but it does not include administrative or civil penalties.(C) If HHSC prevails in one enforcement action against the agency and proceeds with, but does not prevail in, another enforcement action based on some or all of the same violations, this paragraph does not apply.(5) An administrator and alternate administrator must not be convicted of an offense described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter.(c) Supervising nurse qualifications.(1) For an agency without a home dialysis designation, a supervising nurse and alternate supervising nurse must each:(A) be an RN licensed in Texas or in accordance with the Texas Board of Nursing rules for Nurse Licensure Compact (NLC); and(B) have at least one year of experience as an RN within the last 36 months.(2) For an agency with home dialysis designation, a supervising nurse and alternate supervising nurse must each:(A) be an RN licensed in Texas or in accordance with the Texas Board of Nursing rules, 22 TAC Chapter 220 for NLC, and:(i) have at least three years of current experience in hemodialysis; or(ii) have at least two years of experience as an RN and hold a current certification from a nationally recognized board in nephrology nursing or hemodialysis; or(B) be a nephrologist or physician with training or demonstrated experience in the care of ESRD clients. Source Note: The provisions of this §558.244 adopted to be effective December 1, 2006, 31 TexReg 7368; amended to be effective May 1, 2008, 33 TexReg 1136; amended to be effective September 1, 2009, 34 TexReg 5139; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.244 Administrator Qualifications and Conditions and Supervising Nurse Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204562 03/12/2026 (a) An agency must adopt and enforce written staffing policies that govern all personnel used by the agency, including employees, volunteers, and contractors.(b) An agency's written staffing policies must:(1) include requirements for orientation to the policies, procedures, and objectives of the agency;(2) include requirements for participation by all personnel in job-specific training. Agency training program policies must:(A) ensure personnel are properly oriented to tasks performed;(B) ensure demonstration of competency for tasks when competency cannot be determined through education, license, certification, or experience;(C) ensure a continuing systematic program for the training of all personnel; and(D) ensure personnel are informed of changes in techniques, philosophies, goals, client's rights, and products relating to client's care;(3) address participation by all personnel in appropriate employee development programs;(4) include a written job description (statement of those functions and responsibilities that constitute job requirements) and job qualifications (specific education and training necessary to perform the job) for each position within the agency;(5) include procedures for processing criminal history checks and searches of the nurse aide registry and the employee misconduct registry for unlicensed personnel in accordance with §558.247 of this division (relating to Verification of Employability and Use of Unlicensed Persons);(6) ensure annual evaluation of employee and volunteer performance;(7) address employee and volunteer disciplinary action and procedures;(8) address the use of volunteers, if volunteers are used by the agency. The policy must be in compliance with §558.248 of this division (relating to Volunteers);(9) address requirements for providing and supervising services to pediatric clients. Services provided to pediatric clients must be provided by staff who have been instructed and have demonstrated competency in the care of pediatric clients; and(10) include a requirement that all personnel who are direct care staff and who have direct contact with clients (employed by or under contract with the agency) sign a statement that they have read, understand, and will comply with all applicable agency policies. Source Note: The provisions of this §558.245 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.245 Staffing Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204563 03/12/2026 (a) An agency must maintain a personnel record for an employee and volunteer. A personnel record may be maintained electronically if it meets the same requirements as a paper record. All information must be kept current. A personnel record must include the following:(1) a signed job description and qualifications for each position accepted, or a signed statement that the person read the job description and qualifications for each position accepted;(2) an application for employment or volunteer agreement;(3) verification of license, permits, references, job experience, and educational requirements, as conducted by the agency to verify qualifications for each position accepted;(4) performance evaluations and disciplinary actions;(5) the signed statement about compliance with agency policies required by §558.245(b)(10) of this division (relating to Staffing Policies), if applicable; and(6) for an unlicensed employee and unlicensed volunteer whose duties would or do include face-to-face contact with a client:(A) a printed copy of the results of the initial and annual searches of the nurse aide registry (NAR) and employee misconduct registry (EMR) obtained from the HHSC website; and(B) documentation that the employee, in accordance with §558.247(a)(4) of this division (relating to Verification of Employability and Use of Unlicensed Persons), or volunteer, in accordance with §558.247(b)(4) of this division, received written information about the EMR.(b) An agency may keep a complete and accurate personnel record for an employee and volunteer in any location, as determined by the agency. An agency must provide personnel records not stored at the site of a survey upon request by a HHSC surveyor, as specified in §558.507(c) of this chapter (relating to Agency Cooperation with a Survey). Source Note: The provisions of this §558.246 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; amended to be effective September 1, 2010, 35 TexReg 7879; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.246 Personnel Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204564 03/12/2026 (a) The provisions in this subsection apply to an unlicensed applicant for employment and an unlicensed employee, if the person's duties would or do include face-to-face contact with a client.(1) An agency must conduct a criminal history check authorized by, and in compliance with, Texas Health and Safety Code Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illnesses) for an unlicensed applicant for employment and an unlicensed employee.(2) The agency must not employ an unlicensed applicant whose criminal history check includes a conviction listed in Texas Health and Safety Code §250.006 that bars employment, or a conviction the agency has determined is a contraindication to employment. If an applicant's or employee's criminal history check includes a conviction of an offense that is not listed in Texas Health and Safety Code §250.006, the agency must document its review of the conviction and its determination of whether the conviction is a contraindication to employment.(3) Before the agency hires an unlicensed applicant, or before an unlicensed employee's first face-to-face contact with a client, the agency must search the nurse aide registry (NAR) and the employee misconduct registry (EMR) using the HHSC website to determine if the applicant or employee is listed in either registry as unemployable. The agency must not employ an unlicensed applicant who is listed as unemployable in either registry.(4) The agency must provide written information about the EMR to an unlicensed employee in compliance with the requirements of 40 TAC §93.3(c) (relating to Employment and Registry Information).(5) In addition to the initial verification of employability, the agency must search the NAR and the EMR to determine if the employee is listed as unemployable in either registry as follows:(A) for an employee most recently hired before September 1, 2009, by August 31, 2011, and at least every twelve months thereafter; and(B) for an employee most recently hired on or after September 1, 2009, at least every 12 months.(6) The agency must immediately discharge an unlicensed employee whose duties would or do include face-to-face contact with a client when the agency becomes aware:(A) that the employee is designated in the NAR or the EMR as unemployable; or(B) that the employee's criminal history check reveals conviction of a crime that bars employment or that the agency has determined is a contraindication to employment.(b) The provisions in this subsection apply to an unlicensed volunteer if the person's duties would or do include face-to-face contact with a client.(1) An agency must conduct a criminal history check before an unlicensed volunteer's first face-to-face contact with a client of the agency.(2) The agency must not use the services of an unlicensed volunteer for duties that would or do include face-to-face contact with a client whose criminal history information includes a conviction that bars employment under Texas Health and Safety Code §250.006 or a conviction the agency has determined is a contraindication to employment. If an unlicensed volunteer's criminal history check includes a conviction of an offense that is not listed in Texas Health and Safety Code §250.006, the agency must document its review of the conviction and its determination of whether the conviction is a contraindication to employment.(3) Before an unlicensed volunteer's first face-to-face contact with a client, the agency must conduct a search of the NAR and the EMR using the HHSC website to determine if an unlicensed volunteer is listed in either registry as unemployable. The agency must not use the services of an unlicensed volunteer who is listed as unemployable in either registry.(4) The agency must provide written information about the EMR that complies with the requirements of 40 TAC §93.3(c) to an unlicensed volunteer within five working days from the date of the person's first face-to-face contact with a client.(5) In addition to the initial verification of employability, the agency must search the NAR and the EMR to determine if a volunteer is designated in either registry as unemployable, as follows:(A) for a volunteer with face-to-face contact with a client for the first time before September 1, 2009, by August 31, 2011, and at least every twelve months thereafter; and(B) for a volunteer with face-to-face contact with a client for the first time on or after September 1, 2009, at least every twelve months.(6) The agency must immediately stop using the services of an unlicensed volunteer for duties that would or do include face-to-face contact with a client when the agency becomes aware that:(A) the unlicensed volunteer is designated in the NAR or the EMR as unemployable; or(B) the unlicensed volunteer's criminal history check reveals conviction of a crime that bars employment or that the agency has determined is a contraindication to employment.(c) Upon request by HHSC, an agency must provide documentation to demonstrate compliance with subsections (a) and (b) of this section.(d) An agency that contracts with another agency or organization for an unlicensed person to provide home health services, hospice services, or personal assistance services under arrangement must also comply with the requirements in §558.289(c)-(d) of this subchapter (relating to Independent Contractors and Arranged Services). Source Note: The provisions of this §558.247 adopted to be effective September 1, 2010, 35 TexReg 7879; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.247 Verification of Employability and Use of Unlicensed Persons https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204565 03/12/2026 (a) This section applies to all licensed agencies. However, agencies certified by CMS to provide hospice services also must comply with 42 CFR §418.78, Conditions of Participation--Volunteers.(b) If an agency uses volunteers, the agency must use volunteers in defined roles under the supervision of a designated agency employee.(1) A volunteer must meet the same requirements and standards in this chapter that apply to agency employees performing the same activities.(2) An agency may use volunteers in administrative and direct client care roles.(3) Volunteers must document services provided to a client and, if applicable, services provided to the client's family. Source Note: The provisions of this §558.248 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.248 Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204566 03/12/2026 (a) The following words and terms, when used in this section or §558.250 of this division (relating to Agency Investigations), have the following meanings, unless the context clearly indicates otherwise.(1) Abuse, neglect, and exploitation--Have the meanings assigned by:(A) Chapter 711, Subchapter A of this title (relating to Introduction), if the term is used in connection with alleged conduct against a child or an adult receiving services from certain providers, as defined in Texas Human Resources Code §48.251, or against a child receiving services from an agency, as that term is defined in this chapter, whose employee is the alleged perpetrator; or(B) 40 TAC Chapter 705, Subchapter A (relating to Definitions), if the term is used in connection with alleged conduct against an adult, other than as described in subparagraph (A) of this paragraph.(2) Adult--A client who is:(A) 18 years of age or older; or(B) under 18 years of age who:(i) is or has been married; or(ii) has had the disabilities of minority removed pursuant to the Texas Family Code Chapter 31.(3) Agent--An individual (e.g., student, volunteer), not employed by but working under the auspices of an agency.(4) Cause to believe--An agency knows, suspects, or receives an allegation regarding abuse, neglect, or exploitation.(5) Child--A client under 18 years of age who:(A) is not and has not been married; or(B) has not had the disabilities of minority removed pursuant to the Texas Family Code Chapter 31.(6) Employee--An officer, an individual directly employed by an agency or a contractor, volunteer, or agent working under the auspices of an agency.(b) An agency must adopt and enforce a written policy relating to the agency's procedures for reporting alleged acts of abuse, neglect, and exploitation of a client by an employee of the agency.(c) If an agency has cause to believe that a client served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, meaning within 24 hours, to:(1) the Department of Family and Protective Services (DFPS) at 1-800-252-5400, or through the DFPS secure website at www.txabusehotline.org; and(2) HHSC at 1-800-458-9858. Source Note: The provisions of this §558.249 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective November 1, 2002, 27 TexReg 9774; amended to be effective April 1, 2004, 29 TexReg 3237; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.249 Self-Reported Incidents of Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204567 03/12/2026 (a) Written policy.(1) An agency must adopt and enforce a written policy relating to the agency's procedures for investigating complaints and reports of abuse, neglect, and exploitation.(2) The policy must meet the requirements of this section.(b) Reports of abuse, neglect, and exploitation (ANE).(1) Immediately upon witnessing the act or upon receipt of the allegation, an agency must initiate an investigation of known and alleged acts of ANE by agency employees, including volunteers and contractors.(2) An agency must complete an HHSC Provider Investigation Report form and include the following information:(A) incident date;(B) the name of the alleged victim;(C) the age of the alleged victim at the time of the incident;(D) the name of the alleged perpetrator;(E) any witnesses;(F) the allegation;(G) any injury or adverse effect;(H) any assessments made;(I) any treatment required;(J) the investigation summary; and(K) any action taken.(3) An agency must send the completed HHSC Provider Investigation Report form to HHSC Complaint Intake Unit no later than the 10th day after reporting the act to the Department of Family and Protective Services and HHSC.(c) Agency complaint investigations.(1) An agency must investigate complaints made by a client, a client's family or guardian, or a client's health care provider, in accordance with this subsection, regarding:(A) treatment or care that was furnished by the agency;(B) treatment or care that the agency failed to furnish; or(C) a lack of respect for the client's property by anyone furnishing services on behalf of the agency.(2) An agency must:(A) document receipt of the complaint and initiate a complaint investigation within 10 days after the agency's receipt of the complaint; and(B) document all components of the investigation.(d) Completing agency investigations. An agency must complete the investigation and documentation within 30 days after the agency receives a complaint or report of abuse, neglect, and exploitation, unless the agency has and documents reasonable cause for a delay.(e) Retaliation.(1) An agency may not retaliate against a person for filing a complaint, presenting a grievance, or providing, in good faith, information relating to home health, hospice, or personal assistance services provided by the agency.(2) An agency is not prohibited from terminating an employee for a reason other than retaliation. Source Note: The provisions of this §558.250 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.250 Agency Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195038 03/12/2026 An agency must adopt and enforce a written policy to ensure that all professional disciplines comply with their respective professional practice acts or title acts relating to reporting and peer review. Source Note: The provisions of this §558.251 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.251 Peer Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204568 03/12/2026 An agency must have the financial ability to carry out its functions.(1) An agency must not intentionally or knowingly pay employees or contracted staff with checks from accounts with insufficient funds.(2) An agency must have sufficient funds to meet its payroll.(3) An agency must make available to HHSC, upon request, business records relating to its ability to carry out its functions. If there is a question relating to the accuracy of the records or the agency's financial ability to carry out its functions, HHSC or its designee may conduct a more extensive review of the records.(4) An agency must maintain business records in their original state. Each entry must be accurate and dated with the date of entry. Correction fluid or tape may not be used in the record. Corrections must be made in accordance with standard accounting practices. Source Note: The provisions of this §558.252 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.252 Financial Solvency and Business Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195040 03/12/2026 (a) An agency must have a written policy describing whether it will conduct drug testing of its employees who have direct contact with clients.(b) If an agency conducts drug testing, the written policy must describe the method by which drug testing is conducted.(c) If an agency does not practice drug testing of its employees, the written policy must state that the agency does not conduct drug testing of its employees.(d) An agency must provide a copy of the policy to anyone applying for services from the agency and any person who requests it. Source Note: The provisions of this §558.253 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.253 Disclosure of Drug Testing Policy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195041 03/12/2026 The agency must adopt and enforce a written policy to ensure that the agency submits accurate billings and insurance claims. Source Note: The provisions of this §558.254 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.254 Billing and Insurance Claims https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204569 03/12/2026 (a) An agency must adopt and enforce a written policy to ensure compliance of the agency and its employees and contractors with Texas Occupations Code Chapter 102. For the purpose of this section, a patient is considered to be a client.(b) HHSC may take enforcement action against an agency in accordance with §558.601 of this chapter (relating to Enforcement Actions) and §558.602 of this chapter (relating to Administrative Penalties), if the agency violates Texas Occupations Code §102.001, Soliciting Patients; Offense or §102.006, Failure to Disclose; Offense. Source Note: The provisions of this §558.255 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.255 Prohibition of Solicitation of Patients https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212046 03/12/2026 (a) An agency must have a written emergency preparedness and response plan that comprehensively describes its approach to a disaster that could affect the need for its services or its ability to provide those services. The written plan must be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the agency's service area. Except for a freestanding hospice inpatient unit, HHSC does not require an agency to physically evacuate or transport a client.(b) Agency personnel that must be involved with developing, maintaining, and implementing an agency's emergency preparedness and response plan include:(1) the administrator;(2) the supervising nurse, if the agency is required to employ or contract with a supervising nurse, as required by §558.243 of this subchapter (relating to Administrative and Supervisory Responsibilities);(3) the agency disaster coordinator; and(4) the alternate disaster coordinator.(c) An agency's written emergency preparedness and response plan must:(1) designate, by title, an employee, and at least one alternate employee, to act as the agency's disaster coordinator;(2) include a continuity of operations business plan that addresses emergency financial needs, essential functions for client services, critical personnel, and how to return to normal operations as quickly as possible;(3) include how the agency will monitor disaster-related news and information, including after hours, weekends, and holidays, to receive warnings of imminent and occurring disasters;(4) include procedures to release client information in the event of a disaster, in accordance with the agency's written policy required by §558.301(a)(2) of this subchapter (relating to Client Records); and(5) describe the actions and responsibilities of agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery.(d) The response and recovery phases of the plan must describe:(1) the actions and responsibilities of agency staff when warning of an emergency is not provided;(2) who at the agency will initiate each phase;(3) a primary mode of communication and alternate communication or alert systems in the event of telephone or power failure; and(4) procedures for communicating with:(A) staff;(B) clients or persons responsible for a client's emergency response plan;(C) local, state, and federal emergency management agencies; and(D) other entities including HHSC and other health care providers and suppliers.(e) An agency's emergency preparedness and response plan must include procedures to triage clients that allow the agency to:(1) readily access recorded information about an active client's triage category in the event of an emergency to implement the agency's response and recovery phases, as described in subsection (d) of this section; and(2) categorize clients into groups based on:(A) the services the agency provides to a client;(B) the client's need for continuity of the services the agency provides; and(C) the availability of someone to assume responsibility for a client's emergency response plan, if needed by the client.(f) The agency's emergency preparedness and response plan must include procedures to identify a client who may need evacuation assistance from local or state jurisdictions because the client:(1) cannot provide or arrange for his or her transportation; or(2) has special health care needs requiring special transportation assistance.(g) If the agency identifies a client who may need evacuation assistance, as described in subsection (f) of this section, agency personnel must provide the client with the amount of assistance the client requests to complete the registration process for evacuation assistance, if the client:(1) wants to register with the State of Texas Emergency Assistance Registry (STEAR), accessed by dialing 2-1-1; and(2) is not already registered, as reported by the client or legally authorized representative.(h) An agency must provide and discuss the following information about emergency preparedness with each client:(1) the actions and responsibilities of agency staff during and immediately following an emergency;(2) the client's responsibilities in the agency's emergency preparedness and response plan;(3) materials that describe survival tips and plans for evacuation and sheltering in place; and(4) a list of community disaster resources that may assist a client during a disaster, including the STEAR, for which registration is available through 2-1-1 Texas, and other community disaster resources provided by local, state, and federal emergency management agencies. An agency's list of community disaster resources must include information on how to contact the resources directly or instructions to call 2-1-1 for more information about community disaster resources.(i) An agency must orient and train employees, volunteers, and contractors about their responsibilities in the agency's emergency preparedness and response plan.(j) An agency must complete an internal review of the plan at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed.(k) As part of the annual internal review, an agency must test the response phase of its emergency preparedness and response plan in a planned drill, if not tested during an actual emergency response. Except for a freestanding hospice inpatient unit, a planned drill can be limited to the agency's procedures for communicating with staff.(l) An agency must make a good faith effort to comply with the requirements of this section during a disaster. If the agency is unable to comply with any of the requirements of this section, it must document in the agency's records attempts of staff to follow procedures outlined in the agency's emergency preparedness and response plan.(m) An agency is not required to continue to provide care to clients in emergency situations that are beyond the agency's control and that make it impossible to provide services, such as when roads are impassable or when a client relocates to a place unknown to the agency. An agency may establish links to local emergency operations centers to determine a mechanism by which to approach specific areas within a disaster area for the agency to reach its clients.(n) If written records are damaged during a disaster, the agency must not reproduce or recreate client records, except from existing electronic records. Records reproduced from existing electronic records must include:(1) the date the record was reproduced;(2) the agency staff member who reproduced the record; and(3) how the original record was damaged.(o) Notwithstanding the provisions specified in Division 2 of this subchapter (relating to Conditions of a License), no later than five working days after an agency temporarily relocates a place of business, or temporarily expands its service area resulting from the effects of an emergency or disaster, an agency must notify and provide the following information to the HHSC Home and Community Support Services Agencies licensing unit:(1) if temporarily relocating a place of business:(A) the license number for the place of business and the date of relocation;(B) the physical address and phone number of the location; and(C) the date the agency returns to a place of business after the relocation; or(2) if temporarily expanding the service area to provide services during a disaster:(A) the license number and revised boundaries of the service area;(B) the date the expansion begins; and(C) the date the expansion ends.(p) An agency must provide the notice and information described in subsection (o) of this section by fax or email. If fax and email are unavailable, the agency may notify the HHSC licensing unit by telephone but must provide the notice and information in writing as soon as possible. If communication with the HHSC licensing unit is not possible, the agency must provide the notice and information by fax, email, or telephone to the designated survey office.(q) Emergency Response System.(1) The agency administrator and alternate administrator must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The agency must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §558.256 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective May 1, 2008, 33 TexReg 1136; amended to be effective August 1, 2011, 36 TexReg 4673; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427; amended to be effective January 24, 2023, 48 TexReg 217. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.256 Emergency Preparedness Planning and Implementation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204571 03/12/2026 (a) An agency that applies for the category of licensed and certified home health services must comply with the regulations in, the Medicare Conditions of Participation for Home Health Agencies, 42 CFR Part 484, pending approval of certification granted by CMS. After HHSC receives written approval from CMS, HHSC amends the licensing status of the agency to include the licensed and certified home health services category.(b) An agency providing hospice services and applying for participation in the Medicare program must comply with the Medicare Conditions of Participation for Hospice Care, 42 CFR Part 418, pending approval of certification granted by CMS. After HHSC receives written approval from CMS, HHSC enters the hospice provider number issued by CMS into its Home and Community Support Services Agencies database but does not amend the hospice services category on the license. Source Note: The provisions of this §558.257 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.257 Medicare Certification Optional https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204572 03/12/2026 (a) This section applies only to an administrator and alternate administrator designated as an administrator or alternate administrator for the first time on or after December 1, 2006.(b) In addition to the qualifications and conditions described in §558.244 of this division (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications), a first-time administrator and alternate administrator of an agency must each complete a total of 24 clock hours of educational training in the administration of an agency before the end of the first 12 months after designation to the position.(c) Prior to designation, a first-time administrator or alternate administrator must complete eight clock hours of educational training in the administration of an agency. The initial eight clock hours must be completed during the 12 months immediately preceding the date of designation to the position. The initial eight clock hours must include:(1) information on the licensing standards for an agency; and(2) information on the state and federal laws applicable to an agency, including:(A) Texas Health and Safety Code Chapters 142 and 250.(B) Texas Human Resources Code Chapter 102, Rights of the Elderly;(C) the Americans with Disabilities Act;(D) the Civil Rights Act of 1991;(E) the Rehabilitation Act of 1993;(F) the Family and Medical Leave Act of 1993; and(G) the Occupational Safety and Health Administration requirements.(d) A first-time administrator and alternate administrator must complete an additional 16 clock hours of educational training before the end of the first 12 months after designation to the position. Any of the additional 16 clock hours may be completed prior to designation, if completed during the 12 months immediately preceding the date of designation to the position. The additional 16 clock hours must include the following subjects and may include other topics related to the duties of an administrator:(1) information regarding fraud and abuse detection and prevention;(2) legal issues regarding advance directives;(3) client rights, including the right to confidentiality;(4) agency responsibilities;(5) complaint investigation and resolution;(6) emergency preparedness planning and implementation;(7) abuse, neglect, and exploitation;(8) infection control;(9) nutrition (for agencies licensed to provide inpatient hospice services); and(10) the Outcome and Assessment Information Set (OASIS) (for agencies licensed to provide licensed and certified home health services).(e) The 24-hour educational training requirement described in subsection (b) of this section must be met through structured, formalized classes, correspondence courses, competency-based computer courses, training videos, distance learning programs, or off-site training courses. Subject matter that deals with the internal affairs of an organization does not qualify for credit.(1) The training must be provided or produced by:(A) an academic institution;(B) a recognized state or national organization or association;(C) an independent contractor who consults with agencies; or(D) an agency.(2) If an agency or independent contractor provides or produces the training, the training must be approved by HHSC or recognized by a state or national organization or association. The agency must maintain documentation of this approval or recognition for review by HHSC surveyors.(3) A first-time administrator and alternate administrator may apply joint training provided by HHSC toward the 24 hours of educational training required by this section if the joint training meets the educational training requirements described in subsections (c) and (d) of this section.(f) Documentation of administrator and alternate administrator training must:(1) be on file at the agency; and(2) contain the name of the class or workshop, the course content (such as the curriculum), the hours and dates of the training, and the name and contact information of the entity and trainer who provided the training.(g) A first-time administrator and alternate administrator must not apply the HHSC Presurvey Training toward the 24 hours of educational training required in this section.(h) After completing the 24 hours of initial educational training prior to or during the first 12 months after designation as a first-time administrator and alternate administrator, an administrator and alternate administrator must complete the continuing education requirements as specified in §558.260 of this division (relating to Continuing Education in Administration of Agencies) in each subsequent 12-month period after designation. Source Note: The provisions of this §558.259 adopted to be effective May 1, 2008, 33 TexReg 1136; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.259 Initial Educational Training in Administration of Agencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204573 03/12/2026 (a) In addition to the qualifications and conditions described in §558.244 of this division (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications), an administrator and alternate administrator must complete 12 clock hours of continuing education within each 12-month period beginning with the date of designation. The 12 clock hours of continuing education must include at least two of the following topics and may include other topics related to the duties of an administrator:(1) any one of the educational training subjects listed in §558.259(d) of this division (relating to Initial Educational Training in Administration of Agencies);(2) development and interpretation of agency policies;(3) basic principles of management in a licensed health-related setting;(4) ethics;(5) quality improvement;(6) risk assessment and management;(7) financial management;(8) skills for working with clients, families, and other professional service providers;(9) community resources; or(10) marketing.(b) This subsection applies only to an agency administrator or alternate administrator designated as an agency administrator or alternate administrator before December 1, 2006, who has not served as an administrator or alternate administrator for 180 days or more immediately preceding the date of designation. Within the first 12 months after the date of designation, at least eight of the 12 clock hours of continuing education must include the topics listed in §558.259(c) of this division. The remaining four hours of continuing education must include topics related to the duties of an administrator and may include the topics listed in subsection (a) of this section.(c) Documentation of administrator and alternate administrator continuing education must:(1) be on file at the agency; and(2) contain the name of the class or workshop, the topics covered, and the hours and dates of the training.(d) An administrator or alternate administrator must not apply the HHSC Presurvey Training toward the continuing education requirements in this section. Source Note: The provisions of this §558.260 adopted to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.260 Continuing Education in Administration of Agencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204574 03/12/2026 An agency must adopt and enforce a written policy that specifies the agency's client care practices. The written policy must include the following elements if covered under the scope of services provided by the agency:(1) initial assessment, reassessment;(2) start of care, placing services on hold, transfer, and discharge;(3) intravenous services;(4) care of the pediatric client;(5) triaging clients in the event of disaster;(6) how to handle emergencies in the home;(7) safety of staff;(8) procedures the staff will perform for clients, such as dressing changes, Foley catheter changes, wound irrigation, administration of medication;(9) psychiatric nursing procedures;(10) patient and caregiver teaching relating to disease process/procedures;(11) care planning;(12) care of a client who has a terminal illness or a terminal prognosis;(13) receiving physician orders;(14) performing waived testing;(15) medication monitoring; and(16) anything else pertaining to client care. Source Note: The provisions of this §558.281 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6645; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.281 Client Care Policies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204575 03/12/2026 (a) An agency must adopt and enforce a written policy governing client conduct and responsibility and client rights, in accordance with this section. The written policy must include a grievance mechanism under which a client can participate without fear of reprisal.(b) An agency must protect and promote the rights of all clients.(c) An agency must comply with the provisions of the Texas Human Resources Code Chapter 102, which applies to a client 60 years of age or older.(d) At the time of admission, an agency must provide a client who receives licensed home health services, licensed and certified home health services, hospice services, or personal assistance services, with a written statement that informs the client that a complaint against the agency may be directed to HHSC Complaint and Incident Intake, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858. The statement also may inform the client that a complaint against the agency may be directed to the administrator of the agency. The statement about complaints directed to the administrator also must include the time frame in which the agency reviews and resolves a complaint.(e) In advance of furnishing care to a client, or during the initial evaluation visit before the initiation of treatment, an agency must provide the client, or their legal representative, with a written notice of all policies governing client conduct and responsibility and client rights.(f) A client has the following rights:(1) A client has the right to be informed in advance about the care to be furnished, the plan of care, expected outcomes, barriers to treatment, and any changes in the care to be furnished. The agency must ensure that written informed consent, specifying the type of care and services that may be provided by the agency, has been obtained for every client, either from the client or their legal representative. The client or the legal representative must sign or mark the consent form.(2) A client has the right to participate in planning the care or treatment and in planning a change in the care or treatment.(A) An agency must advise or consult with the client or legal representative in advance of any change in the care or treatment.(B) A client has the right to refuse care and services.(C) A client has the right to be informed, before care is initiated, of the extent to which payment may be expected from the client, a third-party payer, and any other source of funding known to the agency.(3) A client has the right to have assistance in understanding and exercising the client's rights. The agency must maintain documentation showing that it has complied with the requirements of this paragraph and that the client demonstrates understanding of the client's rights.(4) A client has the right to exercise rights as a client of the agency.(5) A client has the right to have the client's person and property treated with consideration, respect, and full recognition of the client's individuality and personal needs.(6) A client has the right to be free from abuse, neglect, and exploitation by an agency employee, volunteer, or contractor.(7) A client has the right to confidential treatment of the client's personal and medical records.(8) A client has the right to voice grievances regarding treatment or care that is, or fails to be, furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the agency, and they must not be subjected to discrimination or reprisal for doing so.(g) In the case of a client adjudged incompetent, the rights of the client are exercised by the person appointed by law to act on the client's behalf.(h) In the case of a client who has not been adjudged incompetent, any legal representative may exercise the client's rights to the extent permitted by law. Source Note: The provisions of this §558.282 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective April 1, 2004, 29 TexReg 3237; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.282 Client Conduct and Responsibility and Client Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204576 03/12/2026 (a) An agency must maintain a written policy regarding implementation of advance directives. The policy must comply with the Advance Directives Act, Texas Health and Safety Code Chapter 166. The policy must include a clear and precise statement of any procedure the agency is unwilling or unable to provide or withhold in accordance with an advance directive.(b) The agency must provide written notice to a client of the written policy required by subsection (a) of this section. The notice must be provided at the earlier of:(1) the time the client is admitted to receive services from the agency; or(2) the time the agency begins providing care to the client.(c) If, at the time notice must be provided under subsection (b) of this section, the client is incompetent or otherwise incapacitated and unable to receive the notice, the agency must provide the required written notice, in the following order of preference, to:(1) the client's legal guardian;(2) a person responsible for the health care decisions of the client;(3) the client's spouse;(4) the client's adult child;(5) the client's parent; or(6) the person admitting the client.(d) If subsection (c) of this section applies, except as provided by subsection (e) of this section, and an agency is unable, after a diligent search, to locate an individual listed by subsection (c) of this section, the agency is not required to provide the notice.(e) If a client who was incompetent or otherwise incapacitated and unable to receive the notice required by this section, at the time notice was to be provided under subsection (b) of this section, later becomes able to receive the notice, the agency must provide the written notice at the time the client becomes able to receive the notice.(f) HHSC assesses an administrative penalty of $500 without an opportunity to correct against an agency that violates this section. Source Note: The provisions of this §558.283 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective December 1, 2006, 31 TexReg 9620; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.283 Advance Directives https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204577 03/12/2026 An agency that provides laboratory services must adopt and enforce a written policy to ensure that the agency meets applicable requirements of 42 United States Code (USC) §263a, concerning certification and certificates of waiver of a clinical laboratory (CLIA 1988). The section 42 USC §263a applies to all agencies with laboratories that examine human specimens to provide information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. Source Note: The provisions of this §558.284 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.284 Laboratory Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204578 03/12/2026 An agency must adopt and enforce written policies addressing infection control, including the prevention of the spread of infectious and communicable disease. The policies must:(1) ensure compliance by the agency, its employees, and its contractors with:(A) Texas Health and Safety Code Chapter 81, relating to prevention and control of communicable diseases;(B) Occupational Safety and Health Administration regulations relating to Bloodborne Pathogens at, 29 CFR Part 1910.1030, and Appendix A to that section; and(C) Texas Health and Safety Code Chapter 85, Subchapter I, concerning the prevention of the transmission of human immunodeficiency virus and hepatitis B virus; and(2) require documentation of infections that the client acquires while receiving services from the agency.(A) If an agency is licensed to provide services other than personal assistance services, documentation must include the date that the infection was detected, the client's name, primary diagnosis, signs and symptoms, type of infection, pathogens identified, and treatment.(B) If an agency is licensed to provide only personal assistance services, documentation must include the date that the infection was disclosed to the agency employee, the client's name, and treatment as disclosed by the client. Source Note: The provisions of this §558.285 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.285 Infection Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204579 03/12/2026 (a) An agency must adopt and enforce a written policy for the safe handling and disposal of biohazardous waste and materials, if applicable.(b) An agency that generates special or medical waste while providing home health services must dispose of the waste according to the requirements in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities). An agency must provide both verbal and written instructions to the agency's clients regarding the proper procedure for disposing of sharps. For purposes of this subsection, sharps include hypodermic needles, hypodermic syringes with attached needles, scalpel blades, razor blades, disposable razors, disposable scissors used in medical procedures, and intravenous stylets and rigid introducers. Source Note: The provisions of this §558.286 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.286 Disposal of Special or Medical Waste https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204580 03/12/2026 (a) Quality Assessment and Performance Improvement (QAPI) Program.(1) An agency must maintain a QAPI Program that is implemented by a QAPI Committee. The QAPI Program must be ongoing, focused on client outcomes that are measurable, and have a written plan of implementation. The QAPI Committee must review and update or revise the plan of implementation at least once within a calendar year, or more often if needed. The QAPI Program must include:(A) a system that measures significant outcomes for optimal care. The QAPI Committee must use the measures in the care planning and coordination of services and events. The measures must include the following as appropriate for the scope of services provided by the agency:(i) an analysis of a representative sample of services furnished to clients contained in both active and closed records;(ii) a review of:(I) negative client care outcomes;(II) complaints and incidents of unprofessional conduct by licensed staff and misconduct by unlicensed staff;(III) infection control activities;(IV) medication administration and errors; and(V) effectiveness and safety of all services provided, including:(-a-) the competency of the agency's clinical staff;(-b-) the promptness of service delivery; and(-c-) the appropriateness of the agency's responses to client complaints and incidents;(iii) a determination that services have been performed as outlined in the individualized service plan, care plan, or plan of care; and(iv) an analysis of client complaint and satisfaction survey data; and(B) an annual evaluation of the total operation, including services provided under contract or arrangement.(i) An agency must use the evaluation to correct identified problems and, if necessary, to revise policies.(ii) An agency must document corrective action to ensure that improvements are sustained over time.(2) An agency must immediately correct identified problems that directly or potentially threaten the client care and safety.(3) QAPI documents must be kept confidential and be made available to HHSC staff upon request.(b) QAPI Committee membership. At a minimum, the QAPI Committee must consist of:(1) the administrator;(2) the supervising nurse or therapist, or the supervisor of an agency licensed to provide personal assistance services; and(3) an individual representing the scope of services provided by the agency.(c) Frequency of QAPI Committee meeting. The QAPI Committee must meet twice a year or more often if needed. Source Note: The provisions of this §558.287 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.287 Quality Assessment and Performance Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195054 03/12/2026 (a) An agency must adopt and enforce a written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of client services among:(1) all agency personnel providing care and services, whether the care and services are provided directly or under arrangement;(2) the agency and other providers of health care services involved in the care of a client, if known by the agency; and(3) the agency and a licensed facility, group home, foster home, or boarding home facility in which a client resides.(b) The agency must include documentation in the client record of coordination of services as specified in subsection (a) of this section.(c) In this section, other providers of health care services involved in the care of a client may include:(1) a physician;(2) another agency;(3) an adult day care center;(4) an outpatient facility; and(5) a managed care organization. Source Note: The provisions of this §558.288 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.288 Coordination of Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204581 03/12/2026 (a) Independent contractors. If an agency uses independent contractors, there must be a contract between each independent contractor that performs services and the agency. The contract must be enforced by the agency and clearly designate:(1) that clients are accepted for care only by the agency;(2) the services to be provided by the contractor and how they will be provided (i.e. per visit, per hours, etc.);(3) the necessity of the contractor to conform to all applicable agency policies, including personnel qualifications;(4) the contractor's responsibility for participating in developing the plan of care, care plan, or individualized service plan;(5) the way services will be coordinated and evaluated by the agency in accordance with §558.288 of this division (relating to Coordination of Services);(6) the procedures for:(A) submitting information and documentation by the contractor, in accordance with the agency's client record policies;(B) scheduling of visits by the contractor or the agency;(C) periodic client evaluation by the contractor; and(D) determining charges and reimbursement payable by the agency for the contractor's services under the contract.(b) Arranged services. Home health services, hospice services, or personal assistance services provided by an agency under arrangement with another agency or organization must be provided under a written contract conforming to the requirements specified in subsection (a) of this section.(c) If an agency contracts with another agency or organization for an unlicensed person to provide home health services, hospice services, or personal assistance services under arrangement, the agency must ensure that either it or the contracting agency or organization:(1) searches the nurse aide registry (NAR) and the employee misconduct registry (EMR) before the unlicensed person's first face-to-face contact with a client of the agency, using the HHSC Internet website to confirm that the unlicensed person is not listed in either registry as unemployable;(2) provides written information to the unlicensed person about the EMR that complies with the requirements of 40 TAC §93.3(c) (relating to Employment and Registry Information); and(3) searches the NAR and the EMR at least every 12 months using the HHSC Internet website to confirm that the person is not listed in either registry as unemployable.(d) If an agency contracts with another agency or organization for an unlicensed person to provide home health services, hospice services, or personal assistance services under arrangement, the agency must ensure that the contracting agency or organization:(1) conducts a criminal history check before the unlicensed person's first face-to-face contact with a client of the agency; and(2) verifies that the unlicensed person's criminal history information does not include a conviction that bars employment under Texas Health and Safety Code §250.006.(e) Documentation for contract staff. An agency is not required to maintain a personnel record for independent contractors or staff who provide services under arrangement with another agency or organization. Upon request by HHSC, an agency must provide documentation at the site of a survey within eight working hours of the request to demonstrate that:(1) independent contractors or staff under arrangement meet the agency's written job qualifications for the position and duties performed;(2) the agency ensures compliance with subsection (c) of this section for unlicensed staff providing services to the agency's clients under arrangement; and(3) the agency complies with subsection (d) of this section for unlicensed staff providing services to the agency's clients under arrangement by providing a written statement, signed by a person authorized to make decisions on personnel matters for the contracting agency or organization, attesting that a criminal history check was conducted before an unlicensed person's first face-to-face contact with a client, and did not include a conviction barring employment under Texas Health and Safety Code §250.006. Source Note: The provisions of this §558.289 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective September 1, 2010, 35 TexReg 7879; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.289 Independent Contractors and Arranged Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204582 03/12/2026 (a) Backup services. An agency must adopt and enforce a written policy to ensure that backup services are available when an agency employee or contractor is not available to deliver the services.(1) Backup services may be provided by an agency employee, a contractor, or the client's designee who is willing and able to provide the necessary services.(2) If the client's designee has agreed to provide backup services required by this section, the agency must have the designee sign a written agreement to be the backup service provider. The agency must keep the agreement in the client's file.(3) An agency must not coerce a client to accept backup services.(b) After-hours care. An agency must adopt and enforce a written policy to ensure that clients are educated in how to access care from the agency or another health care provider after regular business hours. Source Note: The provisions of this §558.290 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.290 Backup Services and After-Hours Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204583 03/12/2026 An agency must adopt and enforce a written policy that describes the agency's written contingency plan.(1) The plan must be implemented in the event of dissolution to assure continuity of client care.(2) The plan must:(A) be consistent with §558.295 of this division (relating to Client Transfer or Discharge Notification Requirements);(B) include procedures for:(i) notifying the client of the agency's dissolution;(ii) documenting the notification;(iii) carrying out the notification; and(C) comply with §558.217(a)(2) of this subchapter (relating to Agency Closure Procedures and Voluntary Suspension of Operations). Source Note: The provisions of this §558.291 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.291 Agency Dissolution https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204584 03/12/2026 (a) The agency must provide the client or the client's family with a written agreement for services. The agency must comply with the terms of the agreement. The agreement must include at a minimum the following:(1) notification of client rights;(2) documentation concerning notification to the client of the availability of medical power of attorney for health care, advance directive or "Do Not Resuscitate" orders in accordance with the applicable law;(3) services to be provided;(4) supervision by the agency of services provided;(5) agency charges for services rendered if the charges will be paid in full or in part by the client or the client's family, or on request;(6) a written statement containing procedures for filing a complaint in accordance with §558.282(d) of this division (relating to Client Conduct and Responsibility and Client Rights); and(7) a client agreement to and acknowledgement of services by home health medication aides, if home health medication aides are used.(b) The agency must obtain an acknowledgment of receipt from the client or his family of the items listed under subsection (a) of this section. This acknowledgment of receipt must be kept in the client's record. Source Note: The provisions of this §558.292 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.292 Agency and Client Agreement and Disclosure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195059 03/12/2026 An agency must maintain a current list of clients for each category of service licensed.(1) The list must include all services being delivered by the agency and services being delivered under contract.(2) The client list must include the client's name, identification or clinical record number, start of care date or admission date, certification period (if applicable), diagnosis(es) or functional assessment (as appropriate), and the disciplines that are providing services. Source Note: The provisions of this §558.293 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.293 Client List and Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195060 03/12/2026 An agency must adopt and enforce a written policy establishing time frame(s) for the initiation of care or services. Source Note: The provisions of this §558.294 adopted to be effective February 1, 2002, 26 TexReg 9159 ; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.294 Time Frame(s) for the Initiation of Care or Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204585 03/12/2026 (a) Except as provided in subsection (e) of this section, an agency intending to transfer or discharge a client must:(1) provide written notification to the client or the client's parent, family, spouse, significant other, or legal representative; and(2) notify the client's attending physician or practitioner if he is involved in the agency's care of the client.(b) An agency must ensure delivery of the written notification no later than five days before the date on which the client will be transferred or discharged.(c) The agency must deliver the required notice by hand or by mail.(d) If the agency delivers the written notice by mail:(1) the notice must be mailed at least eight working days before the date of transfer or discharge; and(2) the agency must speak with the client by telephone or in person to ensure the client's knowledge of the transfer or discharge, at least five days before the date of transfer or discharge.(e) An agency may transfer or discharge a client without prior notice required by subsection (b) of this section:(1) upon the client's request;(2) if the client's medical needs require transfer, such as a medical emergency;(3) in the event of a disaster when the client's health and safety is at risk, in accordance with provisions of §558.256 of this subchapter (relating to Emergency Preparedness Planning and Implementation);(4) for the protection of staff or a client after the agency has made a documented reasonable effort to notify the client, the client's family and physician, and appropriate state or local authorities, of the agency's concerns for staff or client safety, and in accordance with agency policy;(5) according to physician orders; or(6) if the client fails to pay for services, except as prohibited by federal law.(f) An agency must keep the following in the client's file:(1) a copy of the written notification provided to the client or the client's parent, family, spouse, significant other, or legal representative;(2) documentation of the personal contact with the client, if the required notice was delivered by mail; and(3) documentation that the client's attending physician or practitioner was notified of the date of discharge. Source Note: The provisions of this §558.295 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective December 1, 2006, 31 TexReg 7368; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.295 Client Transfer or Discharge Notification Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204586 03/12/2026 (a) An agency must adopt and enforce a written policy that states whether physician delegation will be honored by the agency. If an agency accepts physician delegation, the agency must comply with Texas Occupations Code Chapter 157, concerning physician delegation.(b) An agency may accept delegation from a physician only if the agency receives the following from the physician:(1) the name of the client;(2) the name of the delegating physician;(3) the task(s) to be performed;(4) the name of the individual(s) to perform the task(s);(5) the time frame for the delegation order; and(6) if the task is medication administration, the medication to be given, route, dose, and frequency. Source Note: The provisions of this §558.296 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.296 Physician Delegation and Performance of Physician-Delegated Tasks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204587 03/12/2026 An agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when receiving physician orders.(1) The policy must address the time frame for countersignature of physician verbal orders.(2) Signed physician orders may be submitted via fax machine. The agency is not required to have the original signatures on file. However, the agency must be able to obtain original signatures if an issue surfaces that would require verification of an original signature. The policy must include protocols to follow when accepting physician orders via fax. If physician orders are accepted via fax, the policy must:(A) outline safeguards to assure that transmitted information is sent to the appropriate individual; and(B) outline the procedures to be followed in the case of misdirected transmission. Source Note: The provisions of this §558.297 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.297 Receipt of Physician Orders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204588 03/12/2026 (a) An agency must adopt and enforce a written policy to ensure compliance with the following rules adopted by the Texas Board of Nursing:(1) 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and(2) 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).(b) Requirements for RN delegation for personal assistance service clients are located in §558.404 of this chapter (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). Source Note: The provisions of this §558.298 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 29, 2003, 28 TexReg 4931; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25,2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.298 Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel and Tasks Not Requiring Delegation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204589 03/12/2026 If providing nursing services, an agency must adopt and enforce a written policy to ensure compliance with the rules of the Texas Board of Nursing adopted in 22 TAC Chapters 211 - 226 (relating to Nursing Continuing Education, Licensure, and Practice in the State of Texas). Source Note: The provisions of this §558.299 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.299 Nursing Education, Licensure and Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195068 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195068&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195068 03/12/2026 (a) This section applies only to clients to whom agency staff administer medications.(b) An agency must adopt and enforce a written policy for maintaining a current medication list and a current medication administration record.(1) A client's practitioner must order administration of medication.(2) An agency may incorporate a current medication list and medication administration record into one document.(A) An agency must use the medication list to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindications.(B) An agency must document in the medication administration record or clinical notes any medication that is not administered and the reason it was not administered.(3) An individual delivering care must report any adverse reaction to a supervisor and document this in the client's record on the day of occurrence. If the adverse reaction occurs after regular business hours, the individual delivering care must report the adverse reaction as soon as it is disclosed. Source Note: The provisions of this §558.300 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.300 Medication Administration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204590 03/12/2026 (a) In accordance with accepted principles of practice, an agency must establish and maintain a client record system to ensure that the care and services provided to each client are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.(1) An agency must establish a record for each client and must maintain the record in accordance with and contain the information described in paragraph (9) of this subsection. An agency must keep a single file or separate files for each category of service provided to the client and the client's family. Hospice services provided to a client's family must be documented in the clinical record.(2) The agency must adopt and enforce written procedures regarding the use and removal of records, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the client record. An agency may not release any portion of a client record to anyone other than the client except as allowed by law.(3) All information regarding the client's care and services must be centralized in the client's record and be protected against loss or damage.(4) The agency must establish an area for original active client record storage at the agency's place of business. The original active client record must be stored at the place of business (parent agency, branch office, or ADS) from which services are provided. Original active client records must not be stored at an administrative support site or records storage facility.(5) The agency must ensure that each client's record is treated with confidentiality, safeguarded against loss and unofficial use, and is maintained according to professional standards of practice.(6) A clinical record must be an original, a microfilmed copy, an optical disc imaging system, or a certified copy.(A) An original record is a signed paper record or an electronically signed computer record. A signed paper record may include a physician's stamped signature if the agency meets the following requirements:(i) An agency must have on file at the agency a current written authorization letter from the physician whose signature the stamp represents, stating that he is the only person authorized to have the stamp and use it.(ii) The authorization letter must be dated before a stamped record from the physician was accepted by the agency.(iii) An agency must obtain a new authorization letter from the physician annually. A physician authorization letter is void one year from the date of the letter.(iv) The authorization letter must be manually signed by the physician and include a copy of the stamped signature that the physician will use.(B) Computerized records must meet all requirements of paper records, including protection from unofficial use and retention for the period specified in subsection (b) of this section.(C) An agency must ensure that entries regarding the delivery of care or services are not altered without evidence and explanation of such alteration.(7) Each entry to the client record must be current, accurate, signed, and dated with the date of entry by the individual making the entry. The record must include all services whether furnished directly or under arrangement. Correction fluid or tape must not be used in the record. Corrections must be made by striking through the error with a single line and must include the date the correction was made and the initials of the person making the correction.(8) Inactive client records may be preserved on microfilm, optical disc or other electronic means and may be stored at the parent agency location, branch office, ADS, administrative support site, or records storage facility. Security must be maintained, and the record must be readily retrievable by the agency.(9) Each client record must include the following elements as applicable to the scope of services provided by the agency:(A) client application for services including, but not limited to, the following information:(i) the client's full name;(ii) sex;(iii) date of birth;(iv) the name, address, and telephone number of each parent or legal guardian of a minor child;(v) the name, address, and telephone number of any other person; as identified by the individual;(vi) the physician's name and telephone numbers, including emergency numbers; and(vii) services requested;(B) initial health assessment, pertinent medical history, and subsequent health assessments;(C) care plan, plan of care, or individualized service plan, as applicable. The care plan or the plan of care must include, as applicable, medication, dietary, treatment, and activities orders. An individualized service plan for a personal assistance service client must comply with §558.404 of this chapter (relating to Standards Specific to Agencies Licensed to Provide Personal Assistance Services). A plan of care for a hospice client must comply with §558.821 of this chapter (relating to Hospice Plan of Care);(D) clinical and progress notes. Such notes must be written the day service is rendered and incorporated into the client record within 14 working days;(E) current medication list;(F) medication administration record (if medication is administered by agency staff). Notation must also be made in the medication administration record or in the clinical notes of medications not given and the reason. Any adverse reaction must be reported to a supervisor and documented in the client record;(G) acknowledgement of hospice agency's policy regarding disposal of controlled substance prescription drugs;(H) records of supervisory visits;(I) complete documentation of all known services and significant events. Documentation must show that effective interchange, reporting, and coordination of care occurs as required in §558.288 of this division (relating to Coordination of Services);(J) for clients 60 years and older, acknowledgment of the client's receipt of a copy of the right and responsibilities listed in Texas Human Resources Code Chapter 102;(K) acknowledgment of the client's receipt of the agency's policy relating to the reporting of abuse, neglect, or exploitation of a client;(L) documentation that the client has been informed of how to register a complaint in accordance with §558.282(d) of this division (relating to Client Conduct and Responsibility and client Rights);(M) client agreement to and acknowledgment of services by home health medication aides, if home health medication aides are used;(N) discharge summary, including the reason for discharge or transfer and the agency's documented notice to the client, the client's physician (if applicable), and other individuals as required in §558.295 of this division (relating to Client Transfer or Discharge Notification Requirements);(O) acknowledgement of receipt of the notice of advance directives;(P) services provided to the client's family (as applicable); and(Q) consent and authorization and election forms, as applicable.(b) An agency must adopt and enforce a written policy relating to the retention of records in accordance with this subsection.(1) An agency must retain original client records for a minimum of five years after the discharge of the client.(2) The agency may not destroy client records that relate to any matter that is involved in litigation if the agency knows the litigation has not been finally resolved.(3) There must be an arrangement for the preservation of inactive records to insure compliance with this subsection. Source Note: The provisions of this §558.301 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.301 Client Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204591 03/12/2026 An agency must adopt and enforce a written policy on pronouncement of death, if that function is carried out by an agency RN. The policy must comply with Texas Health and Safety Code §671.001 (relating to Standard Used in Determining Death). Source Note: The provisions of this §558.302 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.302 Pronouncement of Death https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209113 03/12/2026 An agency that possesses sterile water or saline, certain vaccines or tuberculin, or certain dangerous drugs, as specified by this section, must comply with the provisions of this section.(1) Possession of sterile water or saline. An agency or its employees, who are RNs or LVNs, may purchase, store, or transport for the purpose of administering to their home health or hospice clients under physician's orders:(A) sterile water for injection and irrigation; and(B) sterile saline for injection and irrigation.(2) Possession of certain vaccines or tuberculin.(A) An agency or its employees, who are RNs or LVNs, may purchase, store, or transport for administering to the agency's employees, home health or hospice clients, or client family and household members under physician's standing orders the following dangerous drugs:(i) hepatitis B vaccine;(ii) influenza vaccine;(iii) tuberculin purified protein derivative for tuberculosis testing;(iv) pneumococcal polysaccharide vaccine; and(v) any other vaccine approved, authorized for emergency use, or otherwise permitted for use by the United States Food and Drug Administration to treat or mitigate the spread of a communicable disease, as defined by Texas Health and Safety Code §81.003.(B) An agency that purchases, stores, or transports a vaccine or tuberculin under this section must ensure that any standing order for the vaccine or tuberculin:(i) is signed and dated by the physician;(ii) identifies the vaccine or tuberculin covered by the order;(iii) indicates that the recipient of the vaccine or tuberculin has been assessed as an appropriate candidate to receive the vaccine or tuberculin and has been assessed for the absence of any contraindication;(iv) indicates that appropriate procedures are established for responding to any negative reaction to the vaccine or tuberculin; and(v) orders that a specific medication or category of medication be administered if the recipient has a negative reaction to the vaccine or tuberculin.(C) An agency or the agency's authorized employees may purchase, store, or transport vaccines or tuberculin in a sealed portable container only if the agency has established policies and procedures to ensure that:(i) the container is handled properly with respect to storage, transportation, and temperature stability according to manufacturer's instructions; and(ii) the agency adheres to guidance from the Centers for Disease Control and Prevention and the Texas Health and Human Services Commission.(3) Possession of certain dangerous drugs.(A) In compliance with Texas Health and Safety Code §142.0063, an agency or its employees, who are RNs or LVNs, may purchase, store, or transport for the purpose of administering to their home health or hospice patients, in accordance with subparagraph (C) of this paragraph, the following dangerous drugs:(i) any of the following items in a sealed portable container of a size determined by the dispensing pharmacist:(I) 1,000 milliliters of 0.9 percent sodium chloride intravenous infusion;(II) 1,000 milliliters of 5.0 percent dextrose in water injection; or(III) sterile saline; or(ii) not more than five dosage units of any of the following items in an individually sealed, unused portable container:(I) heparin sodium lock flush in a concentration of 10 units per milliliter or 100 units per milliliter;(II) epinephrine HCI solution in a concentration of one to 1,000;(III) diphenhydramine HCI solution in a concentration of 50 milligrams per milliliter;(IV) methylprednisolone in a concentration of 125 milligrams per two milliliters;(V) naloxone in a concentration of one milligram per milliliter in a two-milliliter vial;(VI) promethazine in a concentration of 25 milligrams per milliliter;(VII) glucagon in a concentration of one milligram per milliliter;(VIII) furosemide in a concentration of 10 milligrams per milliliter;(IX) lidocaine 2.5 percent and prilocaine 2.5 percent cream in a five-gram tube; or(X) lidocaine HCL solution in a concentration of 1 percent in a two-milliliter vial.(B) An agency or the agency's authorized employees may purchase, store, or transport dangerous drugs in a sealed portable container only if the agency has established policies and procedures to ensure that:(i) the container is handled properly with respect to storage, transportation, and temperature stability;(ii) a drug is removed from the container only on a physician's written or oral order;(iii) the administration of any drug in the container is performed in accordance with a specific treatment protocol; and(iv) the agency maintains a written record of the dates and times the container is in the possession of an RN or LVN.(C) An agency or the agency's authorized employee who administers a drug listed in subparagraph (A) of this paragraph may administer the drug only in the client's residence, under physician's orders, in connection with the provision of emergency treatment or the adjustment of:(i) parenteral drug therapy; or(ii) vaccine or tuberculin administration.(D) If an agency or the agency's authorized employee administers a drug listed in subparagraph (A) of this paragraph, pursuant to a physician's oral order, the agency must receive a signed copy of the order:(i) not later than 24 hours after receipt of the order, reduce the order to written form and send a copy of the form to the dispensing pharmacy by mail or fax transmission; and(ii) not later than 20 days after receipt of the order, send a copy of the order, as signed by and received from the physician, to the dispensing pharmacy.(E) A pharmacist that dispenses a sealed portable container under this subsection will ensure that the container:(i) is designed to allow access to the contents of the container only if a tamper-proof seal is broken;(ii) bears a label that lists the drugs in the container and provides notice of the container's expiration date, which is the earlier of:(I) the date that is six months after the date on which the container is dispensed; or(II) the earliest expiration date of any drug in the container; and(iii) remains in the pharmacy or under the control of a pharmacist, RN, or LVN.(F) If an agency or the agency's authorized employee purchases, stores, or transports a sealed portable container under this subsection, the agency must deliver the container to the dispensing pharmacy for verification of drug quality, quantity, integrity, and expiration dates not later than the earlier of:(i) the seventh day after the date on which the seal on the container is broken; or(ii) the date for which notice is provided on the container label.(G) A pharmacy that dispenses a sealed portable container under this section is required to take reasonable precautionary measures to ensure that the agency receiving the container complies with subparagraph (F) of this paragraph. On receipt of a container under subparagraph (F) of this paragraph, the pharmacy will perform an inventory of the drugs used from the container and will restock and reseal the container before delivering the container to the agency for reuse. Source Note: The provisions of this §558.303 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective October 15, 2003, 28 TexReg 8955; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427; amended to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.303 Standards for Possession of Sterile Water or Saline, Certain Vaccines or Tuberculin, and Certain Dangerous Drugs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204593 03/12/2026 (a) A branch office operates as a part of the parent agency and must comply with the same regulations as the parent agency. The parent agency is responsible for ensuring that its branches comply with licensing standards.(b) A branch office providing licensed and certified home health services must comply with the standards for certified agencies in §558.402 of this chapter (relating to Standards Specific to Licensed and Certified Home Health Services).(c) The service area of a branch office must be located within the parent agency's service area.(1) A branch office must not provide services outside its licensed service area.(2) A branch office must maintain adequate staff to provide services and to supervise the provision of services within the service area.(3) A branch office may expand its service area at any time during the licensure period.(A) Unless exempted under subparagraph (B) of the paragraph, a branch office must submit to HHSC a written notice to expand its service area at least 30 days before the expansion. The notice must include:(i) revised boundaries of the branch office's original service area;(ii) the effective date of the expansion; and(iii) an updated list of management and supervisory personnel (including names), if changes are made.(B) An agency is exempt from the 30-day written notice requirement under subparagraph (A) of this paragraph if HHSC determines an emergency exists that would impact client health and safety. An agency must notify HHSC immediately of a possible emergency. HHSC determines if an exemption can be granted.(4) A branch office may reduce its service area at any time during the licensure period by sending HHSC written notification of the reduction, revised boundaries of the branch office's original service area, and the effective date of the reduction.(d) A parent agency and a branch office providing home health or personal assistance services must meet the following requirements:(1) The parent agency administrator or alternate administrator, or supervising nurse or alternate supervising nurse, must conduct an on-site supervisory visit to the branch office at least monthly. The parent agency may visit the branch office more frequently considering the size of the service area and the scope of services provided by the parent agency. The supervisory visits must be documented and include the date of the visit, the content of the consultation, the individuals in attendance, and the recommendations of the staff.(2) The original active clinical record must be kept at the branch office.(3) The parent agency must approve all branch office policies and procedures. This approval must be documented and filed in the parent and branch offices.(e) HHSC issues or renews a branch office license for applicants who meet the requirements of this section.(1) Issuance or renewal of a branch office license is contingent upon compliance with the Statute and this chapter by the parent agency and branch office.(2) HHSC may take enforcement action against a parent agency license for a branch office's failure to comply with the Statute or this chapter in accordance with Subchapter F of this chapter (relating to Enforcement).(3) Revocation, suspension, denial, or surrender of a parent agency license will result in the same revocation, suspension, denial, or surrender of a branch office license for all branch office licenses of the parent agency.(f) A branch office may offer fewer health services or categories than the parent office but may not offer health services or categories that are not also offered by the parent agency. Source Note: The provisions of this §558.321 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.321 Standards for Branch Offices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204594 03/12/2026 (a) An ADS must comply with the Statute and this chapter, including the additional standards in Subchapter H of this chapter (relating to Standards Specific to Agencies Licensed to Provide Hospice Services).(b) If certified by CMS, an ADS must comply with the applicable federal rules and regulations for hospice agencies in 42 CFR Part 418.(c) A parent agency and an ADS must meet the following requirements:(1) The parent agency administrator or alternate administrator, or supervising nurse or alternate supervising nurse, must conduct an on-site supervisory visit to the ADS at least monthly. The parent agency may visit the ADS more frequently considering the size of the service area provided by the parent agency. The supervisory visits must be documented and include the date of the visit, the content of the consultation, the individuals in attendance, and the recommendations of the staff.(2) The parent agency must approve all ADS policies and procedures. This approval must be documented and filed in the parent agency and ADS.(d) Issuance or renewal of an ADS license is contingent upon compliance by the parent agency and ADS with the Statute and this chapter.(1) HHSC may take enforcement action against a parent agency license for an ADS' failure to comply with the Statute or this chapter in accordance with Subchapter F of this chapter (relating to Enforcement).(2) Revocation, suspension, denial or surrender of a parent agency license results in the same revocation, suspension, denial or surrender of all ADS licenses of the parent agency. Source Note: The provisions of this §558.322 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019, issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §558.322 Standards for Alternate Delivery Sites https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204595 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204595 03/12/2026 (a) In addition to the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency providing licensed home health services must also meet the standards of this section.(b) The agency must accept a client for home health services based on a reasonable expectation that the client's medical, nursing, and social needs can be met adequately in the client's residence. An agency has made a reasonable expectation that it can meet a client's needs if, at the time of the agency's acceptance of the client, the client and the agency have agreed as to what needs the agency would meet; for instance, the agency and the client could agree that some needs would be met but not necessarily all needs.(1) The agency must start providing licensed home health services to a client within a reasonable time after acceptance of the client and according to the agency's policy. The initiation of licensed home health services must be based on the client's health service needs.(2) An initial health assessment must be performed in the client's residence by the appropriate health care professional prior to or at the time that licensed home health services are initially provided to the client. The assessment must determine whether the agency can provide the necessary services.(A) If a practitioner has not ordered skilled care for a client, then the appropriate health care professional must prepare a care plan. The care plan must be developed after consultation with the client and the client's family and must include services to be rendered, the frequency of visits or hours of service, identified problems, method of intervention, and projected date of resolution. The care plan must be reviewed and updated by all appropriate staff members involved in client care at least annually, or more often as necessary to meet the needs of the client.(B) If a practitioner orders skilled treatment, then the appropriate health care professional must prepare a plan of care. The plan of care must be signed and approved by a practitioner in a timely manner. The plan of care must be developed in conjunction with agency staff and must cover all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits at the time of admission, prognoses, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, and any other appropriate items. The appropriate health care personnel must perform services as specified in the plan of care. The plan of care must be revised as necessary, but it must be reviewed and updated at least every six months.(c) Agency staff must provide at least one home health service.(d) All services must be provided and supervised by qualified personnel. The appropriate licensed health care professional must be available to supervise as needed, when services are provided. If medical social service is provided, the social worker must be licensed in the State of Texas to provide social work services.(e) All staff providing services, delegation, and supervision must be employed by or be under contract with the agency.(f) An agency is not required to employ home health aides. If an agency employs home health aides, the agency must comply with §558.701 of this chapter (relating to Home Health Aides).(g) Unlicensed personnel employed by an agency to provide licensed home health services must:(1) have demonstrated competency in the task assigned when competency cannot be determined through education and experience; and(2) be at least 18 years of age or, if under 18 years of age, be a high school graduate or enrolled in a vocational education program. Source Note: The provisions of this §558.401 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective April 1, 2004, 29 TexReg 2383; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.401 Standards Specific to Licensed Home Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204596 03/12/2026 (a) In addition to the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency providing licensed and certified home health services must comply with applicable requirements of 42 United States Code Chapter 7, Subchapter XVII and the regulations in 42 CFR Part 484.(b) An agency providing licensed and certified home health services that plans to implement a home health aide training and competency evaluation program must meet the requirements in §558.701(d)-(f) of this chapter (relating to Home Health Aides).(c) An agency providing licensed and certified home health services that plans to implement a competency evaluation program must comply with §558.701(f) of this chapter.(d) An agency providing licensed and certified home health services may not use an individual as a home health aide unless:(1) the individual has met the federal requirements under subsection (a) of this section;(2) the individual qualifies as a home health aide based on a:(A) training and competency evaluation program, and the program meets the requirements of subsection (b) of this section; or(B) competency evaluation program, and the program meets the requirements of subsection (c) of this section; or(3) the individual is a licensed health care provider.(e) Since the individual's most recent completion of a training and competency evaluation program, or a competency evaluation program, if there has been a period of 24 consecutive months during which the individual has not furnished home health services, the individual will not be considered as having completed a training and competency evaluation program or a competency evaluation program. Source Note: The provisions of this §558.402 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.402 Standards Specific to Licensed and Certified Home Health Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204597 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204597 03/12/2026 (a) In addition to meeting the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency holding a license with the category of personal assistance services must meet the standards of this section.(b) A person who is not licensed to provide personal assistance services under this chapter may not indicate or imply that the person is licensed to provide personal assistance services by using the words "personal assistance services" or in any other manner.(c) Personal assistance services, as defined in §558.2 of this chapter (relating to Definitions), may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency, when competency cannot be determined through education and experience, to perform the tasks assigned by the supervisor. An unlicensed person who is under 18 years of age, is a high school graduate or is enrolled in a vocational educational program, and has demonstrated competency to perform the tasks assigned by the supervisor, may perform personal assistance services.(d) The following tasks may be performed under a personal assistance services category:(1) personal care as defined in §558.2 of this chapter;(2) health-related tasks provided by unlicensed personnel that may be delegated by an RN, or that an RN determines do not require delegation, in accordance with the agency's written policy adopted, implemented, and enforced to ensure compliance with the rules adopted by the Texas Board of Nursing in 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions);(3) health-related tasks that are not the practice of professional nursing under the memorandum of understanding between HHSC and the Texas Board of Nursing; and(4) health-related tasks that are delegated by a physician under the Texas Occupations Code Chapter 157.(e) The agency must ensure that when developing its operational policies, the policies are considerate of principles of individual and family choice and control, functional need, and accessible and flexible services.(f) In addition to the client record requirements in §558.301(a)(9) of this chapter (relating to Client Records), the client file must include the following:(1) documentation of determination of services based on an on-site visit by the supervisor where services will be primarily delivered and records of supervisory visits, if applicable;(2) individualized service plan developed, agreed upon, and signed by the client or family and the agency. The individualized service plan must include:(A) types of services, supplies, and equipment to be provided;(B) locations of services;(C) frequency and duration of services;(D) planned date of service initiation;(E) charges for services rendered if the charges will be paid in full or in part by the client or significant other(s), or on request; and(F) plan of supervision; and(3) documentation that the services have been provided according to the individualized service plan.(g) In addition to the written policies required by §558.245 of this chapter (relating to Staffing Policies) the agency must adopt and enforce a written policy addressing the supervision of personnel with input from the client or family on the frequency of supervision.(1) Supervision of personnel must be in accordance with the agency's policies and applicable State laws and rules, including rules adopted by the Texas Board of Nursing in 22 TAC Chapter 225.(2) A supervisor must be a licensed nurse or have completed two years of full-time study at an accredited college or university. An individual with a high school diploma or general equivalence diploma (GED) may substitute one year of full-time employment in a supervisory capacity in a health care facility, agency, or community-based agency for each required year of college.(3) The client in a client managed attendant care program funded by HHSC or the Department of Assistive and Rehabilitative Services is not required to meet the standard in paragraph (2) of this subsection.(h) Tube feedings and medication administration through a permanently placed gastrostomy tube (g-tube) in accordance with subsection (d)(3) of this section may be performed by an unlicensed person only after successful completion of the training and competency program and procedures described in paragraphs (1) - (5) of this subsection.(1) The training and competency program for the performance of g-tube feedings by an unlicensed person must be taught by an RN, physician, physician assistant (PA), or qualified trainer. A qualified trainer must:(A) have successfully completed the training and competency program described in paragraphs (2) and (3) of this subsection taught by an RN, physician, or PA;(B) have demonstrated upon return demonstration to an RN, physician, or PA the performance of the task and the ability to teach the task; and(C) have been deemed competent by an RN, physician, or PA, to train unlicensed personnel in these procedures. Documentation of competency to perform, train, and teach must be maintained in the employee's or contractor's file. Competency must be evaluated and documented annually by an RN, physician, or PA.(2) The minimum training program must include:(A) a description of the g-tube placement, including its purpose;(B) infection control procedures and universal precautions to be used when performing g-tube feedings or medication administration through a g-tube;(C) a description of conditions that must be reported to the client or the primary caregiver, or in the absence of the primary caregiver, to the agency administrator, supervisor, or the client's physician. The description of conditions must include a plan to be effected if the g-tube comes out or is not positioned correctly to ensure medical attention is provided within one hour;(D) review of a written procedure for g-tube feeding or medication administration through a g-tube. The written procedure must be equivalent to current acceptable nursing standards of practice, including addressing the crushing of medications;(E) conditions under which g-tube feeding or medication administration must not be performed; and(F) demonstration of a g-tube feeding and medication administration to a client. If the trainee will become a qualified trainer, the demonstration must be done by the RN, PA, or physician. If the trainee will not become a qualified trainer, the demonstration may be done by an RN, PA, physician, or qualified trainer.(3) The minimum competency evaluation must be documented and maintained in the employee's file and must include:(A) a score of 100 percent on a written multiple-choice test that consists of situational questions to include the criteria in paragraph (2)(A) - (E) of this subsection and an evaluation of the trainee's judgment and understanding of the essential skills, risks, and possible complications of a g-tube feeding or medication administration through a g-tube;(B) a skills checklist demonstrating that the trainee has successfully completed the necessary skills for a g-tube feeding and medication administration via g-tube, and if the trainee will become a qualified trainer, the skills checklist must also demonstrate the ability to teach another person to perform the task. The skills checklist must be completed by an RN, physician, or PA, if the trainee will become a qualified trainer. The skills checklist for a trainee who will not become a qualified trainer may be completed by an RN, physician, PA, or qualified trainer; and(C) documentation of an accurate demonstration of the g-tube feeding and medication administration performed by the trainee as required by paragraph (2)(F) of this subsection. If the trainee will become a qualified trainer, documentation of competency to teach this task must be maintained in the file of the qualified trainer. The person responsible for the training of the trainee must document the successful demonstration of the g-tube feeding and medication administration via g-tube by the trainee and the trainee's competency to perform this task in the trainee's file.(4) The client or primary caregiver must provide information on the client's g-tube feeding or medication administration to the agency supervisor. If the client is not capable of directing his or her own care, the client's primary caregiver must be present to instruct and orient the supervisor regarding the client's g-tube feeding and medication regime. A copy of the current regime including unique conditions specific to the client must be placed in the client's file by the agency supervisor and provided to the respite caregiver. The respite caregiver must be oriented by the client, the client's primary caregiver, or the agency supervisor. The supervisor of the delivery of these services must have successfully completed a training and competency program outlined in paragraphs (2) and (3) of this subsection or be a qualified trainer.(5) Legend medications that are to be administered must be in a legally labeled container from a pharmacy that contains the name of the client. Instructions for dosages according to weight or age for over-the-counter drugs commonly given the client must be furnished by the primary caregiver to the respite caregiver performing the tube feeding or medication administration. Source Note: The provisions of this §558.404 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 29, 2003, 28 TexReg 4931; amended to be effective October 15, 2003, 28 TexReg 8955; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.404 Standards Specific to Agencies Licensed to Provide Personal Assistance Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204598 03/12/2026 (a) License designation. An agency may not provide peritoneal dialysis or hemodialysis services in a client's residence, independent living environment, or other appropriate location unless the agency holds a license to provide licensed home health or licensed and certified home health services and designated to provide home dialysis services. In order to receive a home dialysis designation, the agency must meet the licensing standards specified in this section and the standards for home health services in accordance with Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies) and §558.401 of this subchapter (relating to Standards Specific to Licensed Home Health Services), except for §558.401(b)(2)(A) and (B) of this subchapter. If there is a conflict between the standards specified in this section and those specified in Subchapter C of this chapter and §558.401 of this subchapter, the standards specified in this section will apply to the home dialysis services.(b) Governing body. An agency must have a governing body. The governing body must appoint a medical director and the physicians who are on the agency's medical staff. The governing body must annually approve the medical staff policies and procedures. The governing body on a biannual basis must review and consider for approval continuing privileges of the agency's medical staff. The minutes from the governing body of the agency must be on file in the agency office.(c) Qualifications and responsibilities of the medical director.(1) Qualifications. The medical director must be a physician licensed in the State of Texas who:(A) is eligible for certification or is certified in nephrology or pediatric nephrology by a professional board; or(B) during the five-year period prior to September 1, 1996, served at least 12 months as director of a dialysis facility or program.(2) Responsibilities. The medical director must:(A) participate in the selection of a suitable treatment modality for all clients;(B) assure adequate training of nurses in dialysis techniques;(C) assure adequate monitoring of the client and the dialysis process; and(D) assure the development and availability of a client care policy and procedures manual and its implementation.(d) Personnel files. An agency must have individual personnel files on all physicians, including the medical director. The file must include the following:(1) a curriculum vitae which documents undergraduate, medical school, and all pertinent post graduate training; and(2) evidence of current licensure, and evidence of current United States Drug Enforcement Administration certification, Texas Department of Public Safety registration, and the board eligibility or certification, or the experience or training described in subsection (c)(1) of this section.(e) Provision of services. An agency that provides home staff-assisted dialysis must, at a minimum, provide nursing services, nutritional counseling, and medical social service. These services must be provided as necessary and as appropriate at the client's home, by telephone, or by a client's visit to a licensed ESRD facility in accordance with this subsection. The use of dialysis technicians in home dialysis is prohibited.(1) Nursing services.(A) An RN, licensed by the State of Texas, who has at least 18 months experience in hemodialysis obtained within the last 24 months and has successfully completed the orientation and skills education described in subsection (f) of this section, must be available whenever dialysis treatments are in progress in a client's home. The agency administrator must designate a qualified alternate to this RN.(B) Dialysis services must be supervised by an RN who meets the qualifications for a supervising nurse as set out in §558.244(c)(2) of this chapter (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications).(C) Dialysis services must be provided by a qualified licensed nurse who:(i) is licensed as an RN or LVN by the State of Texas;(ii) has at least 18 months experience in hemodialysis obtained within the last 24 months; and(iii) has successfully completed the orientation and skills education described in subsection (f) of this section.(2) Nutritional counseling. A dietitian who meets the qualifications of this paragraph must be employed by or under contract with the agency to provide services. A qualified dietitian must meet the definition of dietitian in §558.2 of this chapter (relating to Definitions) and have at least one year of experience in clinical nutrition after obtaining eligibility for registration by the American Dietetic Association, Commission on Dietetic Registration.(3) Medical social services. A social worker who meets the qualifications established in this paragraph must be employed by or be under contract with the agency to provide services. A qualified social worker is a person who:(A) is currently licensed under the laws of the State of Texas as a social worker and has a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education; or(B) has served for at least two years as a social worker, one year of which was in a dialysis facility or program prior to September 1, 1976, and has established a consultative relationship with a licensed master social worker.(f) Orientation, skills education, and evaluation.(1) All personnel providing dialysis in the home must receive orientation and skills education and demonstrate knowledge of the following:(A) anatomy and physiology of the normal kidney;(B) fluid, electrolyte, and acid-base balance;(C) pathophysiology of renal disease;(D) acceptable laboratory values for the client with renal disease;(E) theoretical aspects of dialysis;(F) vascular access and maintenance of blood flow;(G) technical aspects of dialysis;(H) peritoneal dialysis catheter, testing for peritoneal membrane equilibration, and peritoneal dialysis adequacy clearance, if applicable;(I) the monitoring of clients during treatment, beginning with treatment initiation through termination;(J) the recognition of dialysis complications, emergency conditions, and institution of the appropriate corrective action. This includes training agency personnel in emergency procedures and how to use emergency equipment;(K) psychological, social, financial, and physical complications of chronic dialysis;(L) care of the client with chronic renal failure;(M) dietary modifications and medications for the uremic client;(N) alternative forms of treatment for ESRD;(O) the role of renal health team members (physician, nurse, social worker, and dietitian);(P) performance of laboratory tests (hematocrit and blood glucose);(Q) the theory of blood products and blood administration; and(R) water treatment to include:(i) standards for treatment of water used for dialysis as described in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standard, Hemodialysis Systems, March 1992 Edition, published by the Association for the Advancement of Medical Instrumentation (AAMI), 3330 Washington Boulevard, Suite 500, Arlington, Virginia 22201. Copies of the standards are indexed and filed in the Texas Health and Human Services Commission, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours;(ii) systems and devices;(iii) monitoring; and(iv) risks to clients of unsafe water.(2) The requirements for the orientation and skills education period for licensed nurses are as follows.(A) The agency must develop an 80-hour written orientation program that includes classroom theory and direct observation of the licensed nurse performing procedures on a client in the home.(i) The orientation program must be provided by an RN qualified under subsection (e)(1) of this section to supervise the provision of dialysis services by a licensed nurse.(ii) The licensed nurse must pass a written skills examination or competency evaluation at the conclusion of the orientation program and prior to the time the licensed nurse delivers independent client care.(B) The licensed nurse must complete the required classroom component as described in paragraph (1)(A) - (E), (K) - (O), (Q) and (R) of this subsection and satisfactorily demonstrate the skills described in paragraph (1)(F) - (J) and (P) of this subsection. The orientation program may be waived by successful completion of the written examination as described in subparagraph (A)(ii) of this paragraph.(C) The supervising nurse or qualified designee must complete an orientation competency skills checklist for each licensed nurse to reflect the progression of learned skills, as described in subsection (f)(1) of this section.(D) Prior to the delivery of independent client care, the supervising nurse or qualified designee must directly supervise the licensed nurse for a minimum of three dialysis treatments and ensure satisfactory performance. Dependent upon the trainee's experience and accomplishments on the skills checklist, additional supervised dialysis treatments may be required.(E) Continuing education for employees must be provided quarterly.(F) Performance evaluations must be done annually.(G) The supervising nurse or qualified designee must provide direct supervision to the licensed nurse providing dialysis services monthly, or more often if necessary. Direct supervision means that the supervising nurse is on the premises but not necessarily immediately present where dialysis services are being provided.(g) Hospital transfer procedure. An agency must establish an effective procedure for the immediate transfer to a local Medicare-certified hospital for clients requiring emergency medical care. The agency must have a written transfer agreement with such a hospital, or all physician members of the agency's medical staff must have admitting privileges at such a hospital.(h) Backup dialysis services. An agency that supplies home staff-assisted dialysis must have an agreement with a licensed ESRD facility to provide backup outpatient dialysis services.(i) Coordination of medical and other information. An agency must provide for the exchange of medical and other information necessary or useful in the care and treatment of clients transferred between treating facilities. This provision must also include the transfer of the client care plan, hepatitis B status, and long-term program.(j) Transplant recipient registry program. An agency must ensure that the names of clients awaiting cadaveric donor transplantation are entered in a recipient registry program.(k) Testing for hepatitis B. An agency must conduct routine testing of home dialysis clients and agency employees to ensure detection of hepatitis B in employees and clients.(1) An agency must offer hepatitis B vaccination to previously unvaccinated, susceptible new staff members in accordance with 29 CFR §1910.1030(f)(1) - (2) (Bloodborne Pathogens).(A) Staff vaccination records must be maintained in each staff member's personnel file.(B) New staff members providing home dialysis care must be screened for hepatitis B surface antigen (HBsAg) and the results reviewed prior to the staff providing client care, unless the new staff member provides the agency documentation of positive serologic response to hepatitis B vaccine.(C) An agency must establish, implement, and enforce a policy for repeated serologic screening of staff. The repeated serologic screening must be based on each staff member's HBsAg/antibody to HBsAg (anti-HBs) and must be congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Disease in the United States, 1993, published by the United States Department of Health and Human Services (USDHHS).(2) With the advice and consent of a client's nephrologist or attending physician, an agency must make the hepatitis B vaccine available to a client who is susceptible to hepatitis B, provided that the client has coverage or is willing to pay for vaccination.(A) An agency must make available to clients literature describing the risks and benefits of the hepatitis B vaccination.(B) Candidates for home dialysis must be screened for HBsAg within one month before or at the time of admission to the agency.(C) Repeated serologic screening must be based on the antigen or antibody status of the client.(D) Monthly screening for HBsAg is required for clients whose previous test results are negative for HBsAg.(E) Screening of HbsAg-positive or anti-HbsAg-positive clients may be performed on a less frequent basis, provided that the agency's policy on this subject remains congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Diseases in the United States, 1993, published by the USDHHS.(l) CPR certification. All direct client care employees must have current CPR certification.(m) Initial admission assessment. Assessment of the client's residence must be made to ensure a safe physical environment for the performance of dialysis. The initial admission assessment must be performed by a qualified RN who meets the qualifications under subsection (e)(1)(A) of this section.(n) Client long-term program. The agency must develop a long-term program for each client admitted to home dialysis. Criteria must be defined in writing and must provide guidance to the agency in the selection of clients suitable for home staff-assisted dialysis and in noting changes in a client's condition that would require discharge from the program. For the purposes of this subsection, Long-term program means the written documentation of the selection of a suitable treatment modality and dialysis setting, which has been selected by the client and the interdisciplinary team.(o) Client history and physical. The agency must ensure that the history and physical is conducted upon the client's admission, or no more than six months prior to the date of admission, then annually after the date of admission.(p) Physician orders. If home staff-assisted dialysis is selected, the physician must prepare orders outlining specifics of prescribed treatment.(1) If these physician's orders are received verbally, they must be confirmed in writing within a reasonable time frame. An agency must adopt and enforce a policy on the time frame for the countersignature of a physician's verbal orders. Medical orders for home staff-assisted dialysis must be revised as necessary but reviewed and updated at least every six months.(2) The initial orders for home staff-assisted dialysis must be received prior to the first treatment and must cover all pertinent diagnoses, including mental status, prognosis, functional limitations, activities permitted, nutritional requirements, medications and treatments, and any safety measures to protect against injury. Orders for home staff-assisted dialysis must include frequency and length of treatment, target weight, type of dialyzer, dialysate, dialysate flow rate, heparin dosage, and blood flow rate, and must specify the level of preparation required for the caregiver, such as an LVN or RN.(q) Client care plan. The client care plan must be developed after consultation with the client and the client's family by the interdisciplinary team. The interdisciplinary team must include the physician, the RN, the dietitian, and the qualified social worker responsible for planning the care delivered to the home staff-assisted dialysis patient.(1) The initial client care plan must be completed by the interdisciplinary team within 10 calendar days after the first home dialysis treatment.(2) The client care plan must implement the medical orders and must include services to be rendered, such as the identification of problems, methods of intervention, and the assignment of health care personnel.(3) The client care plan must be in writing, be personalized for the individual, and reflect the ongoing medical, psychological, social, nutritional, and functional needs of the client, including treatment goals.(4) The client care plan must include written evidence of coordination with other service providers, such as dialysis facilities or transportation providers, as needed to assure the provision of safe care.(5) The client care plan must include written evidence of the client's or client's legal representative's input and participation, unless they refuse to participate. At a minimum, the client care plan must demonstrate that the content was shared with the client or the client's legal representative.(6) For non-stabilized clients, where there is a change in modality, unacceptable laboratory work, uncontrolled weight changes, infections, or a change in family status, the client care plan must be reviewed at least monthly by the interdisciplinary team. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when progress toward stabilization or the goals are not achieved, must be documented and included in the client record.(7) For a stable client, the client care plan must be reviewed and updated as indicated by any change in the client's medical, nutritional, or psychosocial condition or at least every six months. The long-term program must be revised as needed and reviewed annually. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when the goals are not achieved, must be documented and included in the client record.(r) Medication administration. Medications must be administered only by licensed personnel.(s) Client records. In addition to the applicable information described in §558.301(a)(9) of this chapter (relating to Client Records), records of home staff assisted dialysis clients must include the following:(1) a medical history and physical;(2) clinical progress notes by the physician, qualified licensed nurse, qualified dietitian, and qualified social worker;(3) dialysis treatment records;(4) laboratory reports;(5) a client care plan;(6) a long-term program; and(7) documentation of supervisory visits.(t) Water treatment.(1) Water used for dialysis purposes must be analyzed for chemical contaminants every six months. Additional chemical analysis must be conducted if test results exceed the maximum levels of chemical contaminants listed in §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standards for Hemodialysis Systems, March 1992 Edition, published by the AAMI. Copies of the standards are indexed and filed in the Texas Health and Human Services Commission, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.(2) Water used for dialysis must be treated as necessary to maintain a continuous water supply that is biologically and chemically compatible with acceptable dialysis techniques.(3) Water used to prepare dialysate must meet the requirements set forth in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants), March 1992 Edition, published by the AAMI. Copies of the standards are indexed and filed in the Texas Health and Human Services Commission 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.(4) Records of test results and equipment maintenance must be maintained at the agency.(u) Equipment testing. An agency must adopt and enforce a policy to describe how the nurse will check the machine for conductivity, temperature, and pH prior to treatment, and describe the equipment required for these tests. The equipment must be available for use prior to each treatment. This policy must reflect current standards.(v) Preventive maintenance for equipment. An agency must develop and enforce a written preventive maintenance program to ensure client care related equipment receives electrical safety inspections, if appropriate, and maintenance at least annually or more frequently if recommended by the manufacturer. The preventive maintenance may be provided by agency or contract staff qualified by training or experience in the maintenance of dialysis equipment.(1) All equipment used by a client in home dialysis must be maintained free of defects, which could be a potential hazard to clients, the client's family, or agency personnel.(A) Agency staff must be able to identify malfunctioning equipment and report such equipment to the appropriate agency staff. Malfunctioning equipment must be immediately removed from use.(B) Written evidence of all preventive maintenance and equipment repairs must be maintained.(C) After repairs or alterations are made to any equipment, the equipment must be thoroughly tested for proper operation before returning to service.(D) An agency must comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code (USC) §360i(b), concerning reporting when a medical device, as defined in 21 USC §321(h), has or may have caused or contributed to the injury or death of an agency client.(2) In the event that the water used for dialysis purposes or home dialysis equipment is found not to meet safe operating parameters, and corrections cannot be effected to ensure safe care promptly, the client must be transferred to a licensed hospital (if inpatient care is required) or licensed ESRD facility until such time as the water or equipment is found to be operating within safe parameters.(w) Reuse or reprocessing of medical devices. Reuse or reprocessing of disposable medical devices, including but not limited to, dialyzers, end-caps, and blood lines must be in accordance with this subsection.(1) An agency's reuse practice must comply with the American National Standard, Reuse of Hemodialyzers, 1993 Edition, published by the AAMI. An agency must adopt and enforce a policy for dialyzer reuse criteria (including any agency-set number of reuses allowed) which is included in client education materials.(2) A transducer protector must be replaced when wetted during a dialysis treatment and must be used for one treatment only.(3) Arterial lines may be reused only when the arterial lines are labeled to allow for reuse by the manufacturer and the manufacturer-established protocols for the specific line have been approved by the United States Food and Drug Administration.(4) An agency must consider and address the health and safety of clients sensitive to disinfectant solution residuals.(5) An agency must provide each client and the client's family or legal representative with information regarding the reuse practices of the agency, the opportunity to tour the reuse facility used by the agency, and the opportunity to have questions answered.(6) An agency practicing reuse of dialyzers must:(A) ensure that dialyzers are reprocessed via automated reprocessing equipment in a licensed ESRD facility or a centralized reprocessing facility;(B) maintain responsibility and accountability for the entire reuse process;(C) adopt and enforce policies to ensure that the transfer and transport of used and reprocessed dialyzers to and from the client's home does not increase contamination of the dialyzers, staff, or the environment; and(D) ensure that HHSC staff has access to the reprocessing facility as part of an agency inspection.(x) Laboratory services. Provision of laboratory services must be as follows.(1) All laboratory services ordered for the client by a physician must be performed by a laboratory which meets the applicable requirements of 42 United States Code (USC) §263a, concerning certification and certificates of waiver of a clinical laboratory (CLIA 1988) and in accordance with a written arrangement or agreement with the agency. CLIA 1988 applies to all agencies with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.(2) Copies of all laboratory reports must be maintained in the client's medical record.(3) Hematocrit and blood glucose tests may be performed at the client's home in accordance with §558.284 of this chapter (relating to Laboratory Services). Results of these tests must be recorded in the client's medical record and signed by the qualified licensed nurse providing the treatment. Maintenance, calibration, and quality control studies must be performed according to the equipment manufacturer's suggestions, and the results must be maintained at the agency.(4) Blood and blood products must only be administered to dialysis clients in their homes by a licensed nurse or physician.(y) Home dialysis supplies. Supplies for home dialysis must meet the following requirements.(1) All drugs, biologicals, and legend medical devices must be obtained for each client pursuant to a physician's prescription in accordance with applicable rules of the Texas State Board of Pharmacy.(2) In conjunction with the client's attending physician, the agency must ensure that there are sufficient supplies maintained in the client's home to perform the scheduled dialysis treatments and to provide a reasonable number of backup items for replacements, if needed, due to breakage, contamination, or defective products. All dialysis supplies, including medications, must be delivered directly to the client's home by a vendor of such products. However, agency personnel may transport prescription items from a vendor's place of business to the client's home for the client's convenience, so long as the item is properly labeled with the client's name and direction for use. Agency personnel may transport medical devices for reuse.(z) Emergency procedures. The agency must adopt and enforce policies and procedures for medical emergencies and emergencies resulting from a disaster.(1) Procedures must be individualized for each client to include the appropriate evacuation from the home and emergency telephone numbers. Emergency telephone numbers must be posted at each client's home and must include 911, if available, the number of the physician, the ambulance, the qualified RN on call for home dialysis, and any other phone number deemed as an emergency number.(2) The agency must ensure that the client and the client's family know the agency's procedures for medical emergencies and emergencies resulting from a disaster.(3) The agency must ensure that the client and the client's family know the procedure for disconnecting the dialysis equipment.(4) The agency must ensure that the client and the client's family know emergency call procedures.(5) A working telephone must be available during the dialysis procedure.(6) Depending on the kinds of medications administered, an agency must have available emergency drugs as specified by the medical director.(7) In the event of a medical emergency or an emergency resulting from a disaster requiring transport to a hospital for care, the agency must assure the following:(A) the receiving hospital is given advance notice of the client's arrival;(B) the receiving hospital is given a description of the client's health status; and(C) the selection of personnel, vehicle, and equipment are appropriate to effect a safe transfer. Source Note: The provisions of this §558.405 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective May 1, 2008, 33 TexReg 1136; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.405 Standards Specific to Agencies Licensed to Provide Home Dialysis Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204599 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204599 03/12/2026 An agency that provides skilled nursing psychoactive treatments must comply with the requirements of this section.(1) An agency must adopt and enforce a written policy relating to the provision of psychoactive treatments consistent with this section.(2) Skilled nursing psychoactive treatments must be under the direction of a physician. Psychoactive treatments may only be provided by a physician or an RN.(3) An RN providing skilled nursing psychoactive treatments must have one of the following qualifications:(A) a master's degree in psychiatric or mental health nursing;(B) a bachelor's degree in nursing with one year of full-time experience in an active treatment unit in a mental health facility or outpatient clinic;(C) a diploma or associate degree with two years of full-time experience in an active treatment unit in a mental health facility or outpatient clinic; or(D) for an RN for Medicare certified agencies, as allowed by the fiscal intermediary for Texas contracting with the United States Department of Health and Human Services (USDHHS) CMS.(4) An agency must have written documentation that an RN providing skilled nursing psychoactive treatments is qualified under paragraph (3) of this section.(5) The initial health assessment of a client receiving skilled nursing psychoactive treatments must include:(A) mental status including psychological and behavioral status;(B) sensory and motor function;(C) cranial nerve function;(D) language function; and(E) any other criteria established by an agency's policy. Source Note: The provisions of this §558.406 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.406 Standards for Agencies Providing Psychoactive Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204600 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204600 03/12/2026 An agency furnishing intravenous therapy directly or under arrangement must comply with the following standards of care.(1) A physician's order must be written specifically for intravenous therapy.(2) Intravenous therapy must be provided by a licensed nurse.(3) To ensure that prescribed care is administered safely, a licensed nurse must have the knowledge and documented competency to interpret and implement the written order.(4) Written policies and procedures regarding the agency's provision of intravenous therapy must include, but are not limited to, addressing initiation, medication administration, monitoring, and discontinuation. Responsibilities of the licensed nurse must be clearly delineated in written policies and procedures.(5) An RN must be available 24 hours a day.(6) The client and caregiver must be assessed for the ability to safely administer the prescribed intravenous therapy, as per agency written criteria.(7) If the client or caregiver is willing and able to safely administer the prescribed intravenous therapy, the agency must offer to teach the client or caregiver such administration. The teaching process is based on the client and caregiver needs and may include written instructions, verbal explanations, demonstrations, evaluation and documentation of competency, proficiency in performing intravenous therapy, scope of physical activities, and safe disposal of equipment.(8) Actions must be implemented prior to and during all intravenous therapy to minimize the risk of anaphylaxis or other adverse reactions, as stated in the agency's written policy.(9) An ongoing assessment of client and caregiver compliance in performing intravenous therapy related procedures must be done at periodic intervals.(10) Care coordination must be provided to ensure continuity of care.(11) The client and caregiver must be provided with 24-hour access to appropriate health care professionals employed by or having a contract with the agency. Source Note: The provisions of this §558.407 adopted to be effective February 1, 2002, 26 TexReg 9159; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES §558.407 Standards for Agencies Providing Home Intravenous Therapy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204601 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204601 03/12/2026 (a) At a minimum, HHSC conducts a survey:(1) after an agency submits a written request for an initial survey in accordance with §558.521 of this subchapter (relating to Requirements for an Initial Survey); and(2) within 18 months after conducting an initial survey and at least every 36 months thereafter.(b) HHSC may conduct a survey or investigation to determine an agency's compliance with:(1) this chapter or the Statute in the provision of licensed home health services, licensed and certified home health services, hospice services, or personal assistance services; and(2) federal requirements in the provision of licensed and certified home health services or licensed and certified hospice services.(c) HHSC may conduct a survey for the renewal of a license or the issuance of a branch office or ADS license. Source Note: The provisions of this §558.501 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; amended to be effective September 1, 2015, 40 TexReg 5467; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.501 Survey and Investigation Frequency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204603 03/12/2026 Except for the investigation of complaints, an agency is exempt from additional surveys by HHSC if the agency maintains accreditation status for the services for which the agency seeks exemption and applicable to the agency's category of license from an accreditation organization with current HHSC approval. As of the effective date of this rule, accreditation organizations with current HHSC approval on its HCSSA licensure website are the Joint Commission, Community Health Accreditation Partner, and Accreditation Commission for Health Care, Inc. Source Note: The provisions of this §558.503 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.503 Exemption From a Survey https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204604 03/12/2026 HHSC does not announce or give prior notice of a survey to an agency. Source Note: The provisions of this §558.505 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.505 Notice of a Survey https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204602 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204602 03/12/2026 (a) By applying for or holding a license, an agency consents to entry and survey by a HHSC representative to verify compliance with the Statute or this chapter.(b) An agency must provide the surveyor access to all agency records required by HHSC to be maintained by or on behalf of the agency.(c) If a surveyor requests an agency record that is stored at a location other than the survey site, the agency must provide the record to the surveyor within eight working hours after the request.(d) An agency must provide the surveyor with copies of agency records upon request.(e) During a survey, agency staff must not:(1) make a false statement of a material fact about a matter under investigation by HHSC that a person knows, or should know, is false;(2) willfully interfere with the work of a HHSC representative;(3) willfully interfere with a HHSC representative in preserving evidence of a violation; or(4) refuse to allow a HHSC representative to inspect a book, record, or file required to be maintained by or on behalf of an agency.(f) An agency must provide a HHSC representative with a reasonable and safe workspace, free from hazards, at which to conduct a survey at a parent office, branch office, or ADS.(g) If there is a disagreement between the agency and a HHSC representative, the program manager or designee in the designated survey office determines what is reasonable and safe. After consulting with the program manager or designee and obtaining the program manager's agreement, the HHSC representative will notify the agency administrator or designee if the requirement in subsection (f) of this section is not met. Within two working hours of this notice the agency must:(1) provide a HHSC representative with a different workspace at the agency that meets the requirement in subsection (f) of this section; or(2) correct the unmet requirement in such a way as to allow the representative to reasonably and safely conduct the survey.(h) If an agency willfully refuses to comply with subsection (g) of this section, thereby interfering with the work of the HHSC representative, the representative will terminate the survey and recommend enforcement action as described in subsection (i) of this section.(i) HHSC may assess an administrative penalty without an opportunity to correct for a violation of provisions in this section, or may take other enforcement action to deny, revoke, or suspend a license, if an agency does not cooperate with a survey. Source Note: The provisions of this §558.507 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.507 Agency Cooperation with a Survey https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195113 03/12/2026 (a) If an agency is applying for or renewing a branch office or alternate delivery site license, a survey covers all locations.(b) If an agency is applying for a license to provide more than one category of service, a survey covers all provided services of the agency. Source Note: The provisions of this §558.509 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.509 Survey of a Branch Office, Alternate Delivery Site, and Services Provided https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204607 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204607 03/12/2026 (a) No later than six months after the effective date of an agency's initial license, an agency must:(1) admit and provide services to clients as described in subsection (b) of this section; and(2) except as provided in subsection (f) of this section, submit a written request for an initial licensure survey to the designated survey office, as described in subsection (c) of this section.(b) Before submitting a written request to HHSC for an initial licensure survey, an agency must admit clients and provide services as described in this subsection. The categories of service on an initial license may include licensed home health services (LHHS), LHHS with home dialysis designation, hospice services, and personal assistance services (PAS).(1) When an initial license includes only one category of service, an agency must admit and provide services to at least one client.(2) When an initial license includes the LHHS and the PAS categories, an agency must admit and provide LHHS to at least one client.(3) When an initial license includes the LHHS and the LHHS with home dialysis designation categories, with or without the PAS category, an agency must admit and provide LHHS with home dialysis designation to at least one client.(4) When an initial license includes the hospice services and the PAS categories, an agency must admit and provide hospice services to at least one client.(5) When an initial license includes the LHHS and the hospice services categories, with or without the PAS category, an agency must admit and provide LHHS services to at least one client and admit and provide hospice services to at least one client.(6) When an initial license includes the LHHS, the LHHS with home dialysis designation, and the hospice services categories, with or without the PAS category, an agency must admit and provide LHHS with home dialysis designation to at least one client. The agency must also admit and provide hospice services to at least one client.(c) The agency's written request for an initial survey must be submitted to the designated survey office using HHSC Form 2020 Notification of Readiness for Initial Survey. The written request must include the name, date of admission, and the category of service provided to each client admitted for services to demonstrate that the agency has admitted clients and provided services as described in subsection (b) of this section.(d) An agency must have the following information available and ready for review by a surveyor upon the surveyor's arrival at the agency:(1) a list of clients who are receiving services or who have received services from the agency for each category of service licensed. The list must comply with the requirements of §558.293 of this chapter (relating to Client List and Services);(2) the client records for each client admitted during the licensing period before the initial survey;(3) all agency policies as required by this chapter; and(4) all personnel records of agency employees.(e) HHSC may propose to deny an application to renew, or revoke or suspend, an initial license for the reasons specified in §558.15(c) of this chapter (relating to Issuance of an Initial License).(f) An agency is not required to request an initial survey in accordance with subsection (a)(2) of this section if the agency is exempt from the survey as specified in §558.503 of this subchapter (relating to Exemption From a Survey). To demonstrate that it is exempt, the agency must send the accreditation documentation from the accreditation organization to the HHSC designated survey office no later than six months after the effective date of its license.(g) If an agency receives written notice of accreditation from the accreditation organization after the agency submits a written request to HHSC for an initial licensure survey, the agency may demonstrate that it is exempt from the survey by sending the accreditation documentation to the HHSC designated survey office before HHSC arrives at the agency to conduct an initial survey. Source Note: The provisions of this §558.521 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective September 1, 2008, 33 TexReg 1149; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.521 Requirements for an Initial Survey https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204605 03/12/2026 (a) For an initial survey, the administrator or alternate administrator must be present at the entrance conference, available in person or by telephone during the survey, and present in person at the exit conference.(b) For a survey other than an initial survey, the administrator or alternate administrator must be available in person or by telephone during the entrance conference and the survey and must be present in person at the exit conference.(c) The supervising nurse or alternate supervising nurse must be available in person or by telephone, if necessary, to provide information unique to the duties and functions of the position during the survey.(d) If a required individual is unavailable during the survey process and is not at the agency when the surveyor arrives, the surveyor makes reasonable attempts to contact the individual.(e) If a surveyor arrives during regular business hours and the agency is closed, an administrator, alternate administrator, or a designated agency representative must provide the surveyor entry to the agency within two hours after the surveyor's arrival at the agency. The administrator must designate in writing the agency representatives who may grant entry to a surveyor. The agency must comply with notice requirements described in §558.210 of this chapter (relating to Agency Operating Hours).(f) If the surveyor is unable to contact a required individual or the agency fails to comply with subsection (e) of this section, the surveyor may recommend enforcement action against the agency.(g) If compliance with this section would cause an interruption in client care being provided by the administrator, the alternate administrator, the supervising nurse, or the alternate supervising nurse, the administrator must contact its backup service provider to ensure continued client care. Source Note: The provisions of this §558.523 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.523 Personnel Requirements for a Survey https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204606 03/12/2026 (a) Before beginning a survey, a surveyor holds an entrance conference, as specified in §558.523 of this division (relating to Personnel Requirements for a Survey), to explain the purpose of the survey and the survey process and provides an opportunity to ask questions.(b) During a survey, a surveyor:(1) conducts at least three home visits to determine an agency's compliance with licensing requirements;(2) reviews any agency records that the surveyor believes are necessary to determine an agency's compliance with licensing requirements; and(3) evaluates an agency's compliance with each standard.(c) An agency accredited by an accreditation organization must have the documentation of accreditation available at the time of a survey.(d) HHSC keeps agency records confidential, except as allowed by Texas Health and Safety Code §142.009(d).(e) A surveyor may remove original agency records from an agency only with the consent of the agency, as provided in Texas Health and Safety Code §142.009(e). Source Note: The provisions of this §558.525 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective January 15, 2009, 34 TexReg 254; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.525 Survey Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204608 03/12/2026 (a) After a survey is completed, the surveyor holds an exit conference with the administrator or alternate administrator to inform the agency of the preliminary findings.(b) An agency may make an audio recording of the exit conference only if the agency:(1) records two tapes simultaneously;(2) allows the surveyor to review the tapes; and(3) gives the surveyor the tape of the surveyor's choice before leaving the agency.(c) An agency may make a video recording of the exit conference only if the surveyor agrees to allow it and if the agency:(1) records two tapes simultaneously;(2) allows the surveyor to review the tapes; and(3) gives the surveyor the tape of the surveyor's choice before leaving the agency.(d) An agency may submit additional written documentation and facts after the exit conference only if the agency describes the additional documentation and facts to the surveyor during the exit conference.(1) The agency must submit the additional written documentation and facts to the designated survey office within two working days after the end of the exit conference.(2) If an agency properly submits additional written documentation, the surveyor may add the documentation to the record of the survey.(e) If HHSC identifies additional violations or deficiencies after the exit conference, HHSC holds an additional face-to-face exit conference with the agency regarding the additional violations or deficiencies.(f) HHSC provides official written notification of the survey findings to the agency within 10 working days after the exit conference.(g) The official written notification of the survey findings includes a statement of violations, condition-level deficiencies, or both, cited by HHSC against the agency as a result of the survey, and instructions for submitting an acceptable plan of correction, and for requesting IDR.(1) If the official written notification of the survey findings declares that an agency is in violation of the Statute or this chapter, an agency must follow HHSC instructions included with the statement of violations for submitting an acceptable plan of correction.(2) An acceptable plan of correction includes the corrective measures and time frame with which the agency must comply to ensure correction of a violation. If an agency fails to correct each violation by the date on the plan of correction, HHSC may take enforcement action against the agency. An agency must correct a violation in accordance with the following time frames:(A) A Severity Level B violation that results in serious harm to or death of a client or constitutes a serious threat to the health or safety of a client, must be addressed upon receipt of the official written notice of the violations and corrected within two days.(B) A Severity Level B violation that substantially limits the agency's capacity to provide care must be corrected within seven days after receipt of the official written notice of the violations.(C) A Severity Level A violation that has or had minor or no health or safety significance must be corrected within 20 days after receipt of the official written notice of the violations.(D) A violation that is not designated as Severity Level A or Severity Level B must be corrected within 60 days after the date the violation was cited.(3) An agency must submit an acceptable plan of correction for each violation or deficiency no later than 10 days after its receipt of the official written notification of the survey findings.(4) If HHSC finds the plan of correction unacceptable, HHSC gives the agency written notice and provides the agency one additional opportunity to submit an acceptable plan of correction. An agency must submit a revised plan of correction no later than 30 days after the agency's receipt of HHSC written notice of an unacceptable plan of correction.(h) An acceptable plan of correction does not preclude HHSC from taking enforcement action against an agency.(i) An agency must submit a plan of correction in response to an official written notification of survey findings that declares a violation or deficiency even if the agency disagrees with the survey findings.(j) If an agency disagrees with the survey findings citing a violation or condition-level deficiency, the agency may request IDR to refute the violation or deficiency.(1) HHSC does not grant an agency's request for IDR if:(A) HHSC cited the violation or deficiency at the agency's immediately preceding survey; and(B) HHSC cited the violation or deficiency again, with no new findings.(2) To request IDR, an agency must:(A) mail or fax a complete and accurate IDR request form to the address or fax number listed on the form, which must be postmarked or faxed within 10 days after the date of receipt of the official written notification of the survey findings;(B) mail or fax a rebuttal letter and supporting documentation to the address or fax number listed on the IDR request form and ensure receipt by the HHSC Survey and Certification Enforcement Unit within seven days after the postmark or fax date of the IDR request form; and(C) mail or fax a copy of the IDR request form, rebuttal letter, and supporting documentation to the designated survey office within the same time frames each is submitted to the HHSC Survey and Certification Enforcement Unit.(3) An agency may not submit information after the deadlines established in paragraph (2)(A) and (B) of this subsection unless HHSC requests additional information. The agency's response to HHSC request for information must be received within three working days after the request is made.(4) An agency waives its right to IDR if the agency fails to submit the required information to the HHSC Survey and Certification Enforcement Unit within the required time frames.(5) An agency must present sufficient information to the HHSC Survey and Certification Enforcement Unit to support the agency's desired IDR outcome.(6) The rebuttal letter and supporting documentation must include:(A) identification of the disputed deficiencies or violations;(B) the reason the deficiencies or violations are disputed;(C) the desired outcome for each disputed deficiency or violation; and(D) copies of client records, policies and procedures, and other documentation and information that directly demonstrate that the condition-level deficiency or violation should not have been cited.(7) The written decision issued by HHSC after the completion of its review is the final decision from IDR. Source Note: The provisions of this §558.527 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective November 1, 2007, 32 TexReg 7495; amended to be effective January 15, 2009, 34 TexReg 254; amended to be effective October 5, 2016, 41 TexReg 7717; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES E LICENSURE SURVEYS §558.527 Post-Survey Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204609 03/12/2026 (a) Enforcement actions. HHSC may take the following enforcement actions against an agency:(1) license suspension;(2) immediate license suspension;(3) license revocation;(4) immediate license revocation;(5) administrative penalties; and(6) denial of license application.(b) Denial of license application. HHSC may deny a license application for the reasons set out in §558.21 of this chapter (relating to Denial of an Application or a License).(c) Suspension or revocation.(1) HHSC may suspend or revoke an agency's license if the license holder, the controlling person, the affiliate, the administrator, or the alternate administrator:(A) fails to comply with this chapter;(B) fails to comply with the Statute; or(C) violates Texas Occupations Code §102.001 (relating to Soliciting Patients; Offense) and §102.006 (relating to Failure to Disclose; Offense).(2) HHSC may suspend or revoke an agency's license to provide licensed and certified home health services if the agency fails to maintain its certification qualifying the agency as a certified agency, as referenced in Texas Health and Safety Code §142.011(c).(d) Administrative penalties.(1) HHSC may assess an administrative penalty against an agency in accordance with §558.602 of this subchapter (relating to Administrative Penalties).(2) HHSC may consider the assessment of past administrative penalties when considering another enforcement action against an agency.(e) Immediate licensure suspension or revocation. HHSC may immediately suspend or revoke an agency's license when the health and safety of persons are threatened.(1) If HHSC issues an order for immediate suspension or revocation of the agency's license, HHSC provides immediate notice to the controlling person, administrator, or alternate administrator of the agency by fax and either by certified mail with return receipt requested or hand-delivery. The notice includes:(A) the action taken;(B) legal grounds for the action;(C) the procedure governing appeal of the action; and(D) the effective date of the order.(2) An order for immediate suspension or revocation goes into effect immediately.(3) An agency is entitled to a formal administrative hearing not later than seven days after the effective date of the order for immediate suspension or revocation.(4) If an agency requests a formal administrative hearing, the hearing is held in accordance with the Texas Government Code Chapter 2001, and with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and 40 TAC Chapter 91 (relating to Hearings Under the Administrative Procedure Act).(f) Opportunity to show compliance.(1) Before revocation or suspension of an agency's license or denial of an application for the renewal of an agency's license, HHSC gives the license holder:(A) a notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action, with a copy sent to the agency; and(B) an opportunity to show compliance with all requirements of law for the retention of the license by sending HHSC Regulatory Services office a written request. The request must:(i) be postmarked within 10 days after the date of HHSC notice and be received in HHSC Regulatory Services office within 10 days after the date of the postmark; and(ii) contain specific documentation refuting HHSC allegations.(2) HHSC limits its review to the documentation submitted by the license holder and information HHSC used as the basis for its proposed action. An agency may not attend HHSC meeting to review the opportunity to show compliance. HHSC gives a license holder a written affirmation or reversal of the proposed action.(3) After an opportunity to show compliance, HHSC sends a license holder a written notice that:(A) informs the license holder of HHSC decision; and(B) provides the agency with an opportunity to appeal HHSC decision through a formal hearing process.(g) Notice of denial of application for license or renewal of a license, suspension or revocation of license. HHSC sends an applicant or license holder notice by fax and either by certified mail with return receipt requested or hand-delivery of HHSC denial of an application for an initial license or renewal of a license, suspension of a license or revocation of a license.(h) Formal appeal. An applicant or license holder has the right to make a formal appeal after receipt of HHSC notification of denial of an application for an initial license or renewal of a license and suspension or revocation of a license.(1) An agency must request a formal administrative hearing within 20 days of receipt of HHSC notice of denial of an application for an initial license or renewal of a license, suspension of a license, or revocation of a license. To make a formal appeal, the applicant or agency must comply with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I and 40 TAC Chapter 91.(2) HHSC presumes receipt of HHSC notice to occur on the 10th day after the notice is mailed to the last known address, unless another date is reflected on the return receipt.(3) If an agency does not meet the deadline for requesting a formal hearing, the agency has lost its opportunity for a formal hearing, and HHSC takes the proposed action.(4) A formal administrative hearing is held in accordance with Government Code, Chapter 2001, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I and 40 TAC Chapter 91.(5) Except for the denial of an application for an initial license, if an agency appeals, the license remains valid until all appeals are final, unless the license expires without a timely application for renewal submitted to HHSC. The agency must continue to submit a renewal application in accordance with §558.17 of this chapter (relating to Application Procedures for a Renewal License) until the action to revoke, suspend, or deny renewal of the license is completed. However, HHSC does not renew the license until it determines the reason for the proposed action no longer exists.(6) If an agency appeals, the enforcement action will take effect when all appeals are final, and the proposed enforcement action is upheld. If the agency wins the appeal, the proposed action does not happen.(7) If HHSC suspends a license, the suspension remains in effect until HHSC determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC conducts a survey of the agency before making a determination to recommend cancellation of a suspension.(8) If HHSC revokes or does not renew a license and one year has passed following the effective date of revocation or denial of licensure renewal, a person may reapply for a license by complying with the requirements and procedures in §558.13 of this chapter (relating to Obtaining an Initial License). HHSC does not issue a license if the reason for revocation or nonrenewal continues to exist.(i) Agency dissolution. Upon suspension, revocation, or nonrenewal of a license, the license holder must:(1) return the original license to HHSC; and(2) implement its written plan required in §558.291 of this chapter (relating to Agency Dissolution). Source Note: The provisions of this §558.601 adopted to be effective June 1, 2006, 31 TexReg 1455; amended to be effective July 1, 2012, 37 TexReg 4613; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES F ENFORCEMENT §558.601 Enforcement Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204610 03/12/2026 (a) Assessing penalties. HHSC may assess an administrative penalty against a person who violates: (1) the Statute; (2) a provision in this chapter for which a penalty may be assessed; or (3) Texas Occupations Code §102.001 (relating to Soliciting Patients; Offense) or §102.006 (relating to Failure to Disclose; Offense), if related to the provision of home health, hospice, or personal assistance services. (b) Criteria for assessing penalties. HHSC assesses administrative penalties in accordance with the schedule of appropriate and graduated penalties established in this section. (1) The schedule of appropriate and graduated penalties for each violation is based on the following criteria: (A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation and the hazard of the violation to the health or safety of clients; (B) the history of previous violations by a person or a controlling person with respect to that person; (C) whether the affected agency identified the violation as part of its internal quality assurance process and made a good faith, substantial effort to correct the violation in a timely manner; (D) the amount necessary to deter future violations; (E) efforts made to correct the violation; and (F) any other matters that justice may require. (2) In determining which violation warrants a penalty, HHSC considers: (A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation and the hazard of the violation to the health or safety of clients; and (B) whether the affected agency identified the violation as part of its internal quality assurance program and made a good faith, substantial effort to correct the violation in a timely manner. (c) Opportunity to correct. Except as provided in subsections (e) and (f) of this section, HHSC provides an agency with an opportunity to correct a violation in accordance with the time frames established in §558.527(g)(2) of this chapter (relating to Post-Survey Procedures) before assessing an administrative penalty if a plan of correction has been implemented. (d) Minor violations. (1) HHSC may not assess an administrative penalty for a minor violation unless the violation is of a continuing nature or is not corrected in accordance with an accepted plan of correction. (2) HHSC may assess an administrative penalty for a subsequent occurrence of a minor violation when cited within three years from the date the agency first received written notice of the violation. (3) HHSC does not assess an administrative penalty for a subsequent occurrence of a minor violation when cited more than three years from the date the agency first received written notice of the violation. (e) No opportunity to correct. HHSC may assess an administrative penalty without providing an agency with an opportunity to correct a violation if HHSC determines that the violation: (1) results in serious harm to or death of a client; (2) constitutes a serious threat to the health or safety of a client; (3) substantially limits the agency's capacity to provide care; (4) involves the provisions of Texas Human Resources Code Chapter 102, Rights of the Elderly; (5) is a violation in which a person: (A) makes a false statement, that the person knows or should know is false of a material fact: (i) on an application for issuance or renewal of a license or in an attachment to the application; or (ii) with respect to a matter under investigation by HHSC; (B) refuses to allow a representative of HHSC to inspect a book, record, or file required to be maintained by an agency; (C) willfully interferes with the work of a representative of HHSC or the enforcement of this chapter; (D) willfully interferes with a representative of HHSC preserving evidence of a violation of this chapter or a rule, standard, or order adopted, or license issued under this chapter; (E) fails to pay a penalty assessed by HHSC under this chapter within 10 days after the date the assessment of the penalty becomes final; or (F) fails to submit: (i) a plan of correction within 10 days after the date the person receives a statement of licensing violations; or (ii) an acceptable plan of correction within 30 days after the date the person receives notification from HHSC that the previously submitted plan of correction is not acceptable. (f) Violations relating to Advance Directives. As provided in Texas Health and Safety Code §142.0145, HHSC assesses an administrative penalty of $500 for a violation of §558.283 of this chapter (relating to Advance Directives) without providing an agency with an opportunity to correct the violation. (g) Penalty calculation and assessment. (1) Each day that a violation occurs before the date on which the person receives written notice of the violation is considered one violation. (2) Each day that a violation occurs after the date on which an agency receives written notice of the violation constitutes a separate violation. (h) Schedule of appropriate and graduated penalties. (1) If two or more rules listed in paragraphs (2) and (3) of this subsection relate to the same or similar matter, one administrative penalty may be assessed at the higher severity level violation. (2) Severity Level A violations. (A) The penalty range for a Severity Level A violation is $100 - $250 per violation. (B) A Severity Level A violation is a violation that has or has had minor or no client health or safety significance. (C) HHSC assesses a penalty for a Severity Level A violation only if the violation is of a continuing nature or was not corrected in accordance with an accepted plan of correction. (D) HHSC may assess a separate Severity Level A administrative penalty for each of the rules listed in the following table.Attached Graphic(3) Severity Level B violations. (A) The penalty range for a Severity Level B violation is $500-$1,000 per violation. (B) A Severity Level B violation is a violation that: (i) results in serious harm to or death of a client; (ii) constitutes an actual serious threat to the health or safety of a client; or (iii) substantially limits the agency's capacity to provide care. (C) The penalty for a Severity Level B violation that: (i) results in serious harm to or death of a client is $1,000; (ii) constitutes an actual serious threat to the health or safety of a client is $500 - $1,000; and (iii) substantially limits the agency's capacity to provide care is $500 - $750. (D) As provided in subsection (e) of this section, a Severity Level B violation is a violation for which HHSC may assess an administrative penalty without providing an agency with an opportunity to correct the violation. (E) HHSC may assess a separate Severity Level B administrative penalty for each of the rules listed in the following table. Attached Graphic(i) Violations for which HHSC may assess an administrative penalty of $500. (1) HHSC may assess an administrative penalty of $500 for each of the violations listed in subsection (e)(4) and (5) of this section, without providing an agency with an opportunity to correct the violation. (2) A separate penalty may be assessed for each of these violations. (j) Proposal of administrative penalties. (1) If HHSC assesses an administrative penalty, HHSC provides a written notice of violation letter to an agency. The notice includes: (A) a summary of the violation; (B) the amount of the proposed penalty; and (C) a statement of the agency's right to a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both the occurrence of the violation and the amount of the penalty. (2) An agency may accept HHSC determination within 20 days after the date on which the agency receives the notice of violation letter, including the proposed penalty, or may make a written request for a formal administrative hearing on the determination. (A) If an agency notified of a violation accepts HHSC determination, the HHSC executive commissioner or the HHSC executive commissioner's designee issues an order approving the determination and ordering that the agency pay the proposed penalty. (B) If an agency notified of a violation does not accept HHSC determination, the agency must submit to the Health and Human Services Commission a written request for a formal administrative hearing on the determination and must not pay the proposed penalty. Remittance of the penalty to HHSC is deemed acceptance by the agency of HHSC determination, is final, and waives the agency's right to a formal administrative hearing. (C) If an agency notified of a violation fails to respond to the notice of violation letter within the required time frame, the HHSC executive commissioner or the HHSC executive commissioner's designee issues an order approving the determination and ordering that the agency pay the proposed penalty. (D) If an agency requests a formal administrative hearing, the hearing is held in accordance with the Statute §142.0172, §142.0173, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and 40 TAC Chapter 91 (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §558.602 adopted to be effective January 15, 2009, 34 TexReg 254; amended to be effective September 1, 2010, 35 TexReg 7879; amended to be effective August 1, 2011, 36 TexReg 4673; amended to be effective July 1, 2012, 37 TexReg 4613; amended to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES F ENFORCEMENT §558.602 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204611 03/12/2026 (a) If a person operates an agency without a license issued under this chapter, the person is liable for a civil penalty of not less than $1,000 or more than $2,500 for each day of violation.(b) If a person violates the licensing requirements of the Statute, HHSC may petition the district court to restrain the person from continuing the violation. Source Note: The provisions of this §558.603 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES F ENFORCEMENT §558.603 Court Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204612 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204612 03/12/2026 (a) After a survey in which a surveyor cited deficiencies, an agency may surrender its license or allow its license to expire to avoid enforcement action by HHSC.(b) If an agency surrenders its license before the expiration date, the agency must return its original license and provide the following information to HHSC:(1) the effective date of closure;(2) the location of client records;(3) the name and address of the client record custodian;(4) a statement signed and dated by the license holder agreeing to the surrender of the license; and(5) the disposition of active clients at the time of closure.(c) If an agency surrenders its license or allows its license to expire, HHSC denies an application for license by the agency, its license holder, and its affiliate for one year after the date of the surrender or expiration. Source Note: The provisions of this §558.604 adopted to be effective June 1, 2006, 31 TexReg 1455; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES F ENFORCEMENT §558.604 Surrender or Expiration of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204613 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204613 03/12/2026 (a) A home health aide may be used by an agency providing licensed home health services if the aide meets one of the following requirements:(1) a minimum of one year of full-time experience in direct client care in an institutional setting (hospital or nursing facility);(2) one year of full-time experience within the last five years in direct client care in an agency setting;(3) satisfactorily completed a training and competency evaluation program that complies with the requirements of this section;(4) satisfactorily completed a competency evaluation program that complies with the requirements of this section;(5) submitted to the agency documentation from the director of programs or the dean of a school of nursing that states that the individual is a nursing student who has demonstrated competency in providing basic nursing skills in accordance with the school's curriculum; or(6) listed on the HHSC nurse aide registry (NAR) with no finding against the aide relating to client abuse or neglect or misappropriation of client property.(b) A home health aide must have provided home health services within the previous 24 months to qualify under subsection (a)(3) or (4) of this section.(c) Assignment, delegation, and supervision of services provided by home health aides must be performed in accordance with rules in this chapter governing the agency's license category.(d) The training portion of a training and competency evaluation program for home health aides must be conducted by or under the general supervision of an RN who possesses a minimum of two years of nursing experience, at least one year of which must be in the provision of home health care. The training program may contain other aspects of learning, but must contain the following:(1) a minimum of 75 hours as follows:(A) an appropriate number of hours of classroom instruction; and(B) a minimum of 16 hours of clinical experience, which will include in-home training and must be conducted in a home, hospital, nursing home, or laboratory;(2) completion of at least 16 hours of classroom training before a home health aide begins clinical experience working directly with clients under the supervision of qualified instructors;(3) if LVN instructors are used for the training portion of the program, the following qualifications and supervisory requirements apply:(A) an LVN may provide the home health aide classroom training under the supervision of an RN who has two years of nursing experience, at least one year of which must be in the provision of home health care;(B) LVNs, as well as RNs, may supervise home health aide candidates in the course of the clinical experience; and(C) an RN must maintain overall responsibility for the training and supervision of all home health aide training students; and(4) an assessment that the student knows how to read and write English and carry out directions.(e) The classroom instruction and clinical experience content of the training portion of a training and competency evaluation program must include, but is not limited to:(1) communication skills;(2) observation, reporting, and documentation of a client's status and the care or service furnished;(3) reading and recording temperature, pulse, and respiration;(4) basic infection control procedures and instruction on universal precautions;(5) basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;(6) maintenance of a clean, safe, and healthy environment;(7) recognizing emergencies and knowledge of emergency procedures;(8) the physical, emotional, and developmental needs of and ways to work with the populations served by the agency including the need for respect for the client and his or her privacy and property;(9) appropriate and safe techniques in personal hygiene and grooming that include:(A) bed bath;(B) sponge, tub, or shower bath;(C) shampoo, sink, tub, or bed;(D) nail and skin care;(E) oral hygiene; and(F) toileting and elimination;(10) safe transfer techniques and ambulation;(11) normal range of motion and positioning;(12) adequate nutrition and fluid intake;(13) any other task the agency may choose to have the home health aide perform in accordance with §558.298 of this chapter (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel and Tasks Not Requiring Delegation); and(14) the rights of the elderly.(f) This section addresses the requirements for the competency evaluation program or the competency evaluation portion of a training and competency evaluation program.(1) The competency evaluation must be performed by an RN.(2) The competency evaluation must address each of the subjects listed in subsection (e)(2) - (13) of this section.(3) Each of the areas described in subsection (e)(3) and (9) - (11) of this section must be evaluated by observation of the home health aide's performance of the task with a client or person.(4) Each of the areas described in subsection (e)(2), (4) - (8), (12), and (13) of this section may be evaluated through written examination, oral examination, or by observation of a home health aide with a client.(5) A home health aide is not considered to have successfully completed a competency evaluation if the aide has an unsatisfactory rating in more than one of the areas described in subsection (e)(2) - (13) of this section.(6) If an aide receives an unsatisfactory rating, the aide must not perform that task without direct supervision by an RN or LVN, until the aide receives training in the task for which he or she was evaluated as unsatisfactory and successfully completes a subsequent competency evaluation with a satisfactory rating on the task.(7) If an individual fails to complete the competency evaluation satisfactorily, the individual must be advised of the areas in which he or she is inadequate.(g) If a person, who is not an agency licensed under this section, desires to implement a home health aide training and competency evaluation program or a competency evaluation program, the person must meet the requirements of this section in the same manner as set forth for an agency. Source Note: The provisions of this §558.701 adopted to be effective February 1, 2002, 26 TexReg 9159; amended to be effective June 29, 2003, 28 TexReg 4931; amended to be effective April 1, 2004, 29 TexReg 2383; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES G HOME HEALTH AIDES §558.701 Home Health Aides https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204614 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204614 03/12/2026 (a) This subchapter applies to an agency licensed with the hospice services category. An agency licensed to provide hospice services must adopt and enforce written policies in accordance with this subchapter.(b) A hospice that provides inpatient care directly in its own inpatient unit must comply with the additional standards in Division 7 of this subchapter (relating to Hospice Inpatient Units).(c) A hospice that provides hospice care to a resident of a skilled nursing facility, nursing facility, or an intermediate care facility for individuals with an intellectual disability or related conditions, must comply with the additional standards in Division 8 of this subchapter (relating to Hospices that Provide Hospice Care to Residents of a Skilled Nursing Facility, Nursing Facility, or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions).(d) A Medicare-certified hospice agency must comply with the Medicare Conditions of Participation in 42 CFR Part 418, Hospice Care.(e) A person who is not licensed to provide hospice services may not use the word "hospice" in a title or description of a facility, organization, program, service provider, or services or use any other words, letters, abbreviations, or insignia indicating or implying that the person holds a license to provide hospice services.(f) For the purposes of this subchapter, the term "attending practitioner:"(1) includes a physician or an advanced practice nurse identified by a hospice client at the time he or she elects to receive hospice services as having the most significant role in the determination and delivery of the client's medical care; and(2) is synonymous with "attending physician," as defined in 42 CFR §418.3.(g) For the purposes of this subchapter, election of hospice care occurs on the effective date included in a client's hospice election statement. A hospice election statement must include:(1) identification of the hospice that will provide care to the client;(2) the client's or the client's legal representative's acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of hospice care, as it relates to the client's terminal illness, as well as the potential availability of supportive palliative care options outside a hospice setting;(3) acknowledgement by Medicare beneficiaries that certain Medicare services, as described in 42 CFR §418.24(d), are waived by the hospice election;(4) the effective date of the election of hospice care, which may be later but not earlier than the date of the client's or the client's legal representative's signature and may be the first day of hospice care or a later date; and(5) the signature of the client or legal representative.(h) For the purposes of this subchapter, the term "comprehensive assessment" means a thorough evaluation of a client's physical, psychosocial, emotional, and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver's and family's willingness and capability to care for the client. Source Note: The provisions of this §558.801 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.801 Subchapter H Applicability https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204615 03/12/2026 (a) A hospice RN must complete an initial assessment of a client where hospice services will be delivered within 48 hours after the election of hospice care, unless the client's physician, the client, or the client's legal representative requests that the initial assessment be completed in less than 48 hours.(b) The initial assessment must assess a client's immediate physical, psychosocial, and emotional status related to the terminal illness and related conditions. The information gathered must be used by the hospice to begin the plan of care and to provide care and services to treat a client's and a client's family's immediate care and support needs. Source Note: The provisions of this §558.810 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.810 Hospice Initial Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204616 03/12/2026 (a) The hospice must conduct and document a client-specific comprehensive assessment that identifies a client's need for hospice care and services. The comprehensive assessment must:(1) identify the client's physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the client's well-being, comfort, and dignity throughout the dying process;(2) include all areas of hospice care related to the palliation and management of the client's terminal illness and related conditions;(3) accurately reflect the client's health status at the time of the comprehensive assessment and include information to establish and monitor a plan of care; and(4) identify the caregiver's and family's willingness and capability to care for the client.(b) The hospice interdisciplinary team, in consultation with the client's attending practitioner, if any, must complete the comprehensive assessment within five days after the election of hospice care.(c) The comprehensive assessment must take into consideration the following factors:(1) the nature of the condition causing admission, including the presence or lack of objective data and the client's subjective complaints;(2) complications and risk factors that could affect care planning;(3) the client's functional status, including the client's ability to understand and participate in the client's own care;(4) the imminence of the client's death;(5) the severity of the client's symptoms;(6) a review of all the client's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy, to identify the following:(A) the effectiveness of drug therapy;(B) drug side effects;(C) actual or potential drug interactions;(D) duplicate drug therapy; and(E) drug therapy currently associated with laboratory monitoring;(7) an initial bereavement assessment of the needs of the client's family and other persons that:(A) focuses on the social, spiritual, and cultural factors that may impact their ability to cope with the client's death; and(B) gathers information that must be incorporated into the plan of care and considered in the bereavement plan of care; and(8) the need for the hospice to refer the client or the client family member to appropriate health professionals for further evaluation. Source Note: The provisions of this §558.811 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.811 Hospice Comprehensive Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195123 03/12/2026 (a) The hospice interdisciplinary team, in collaboration with a client's attending practitioner, if any, must update the client's comprehensive assessment as frequently as the condition of the client requires, but no less than every 15 days.(b) The update of the comprehensive assessment must include:(1) changes that have taken place since the initial assessment;(2) information on the client's progress toward desired outcomes; and(3) a reassessment of the client's response to care. Source Note: The provisions of this §558.812 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.812 Update of the Hospice Comprehensive Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195124 03/12/2026 (a) The comprehensive assessment must include data elements that allow the hospice to measure client outcomes. The hospice must measure and document data in the same way for all clients.(b) The data elements must:(1) consider aspects of care related to hospice and palliation;(2) be an integral part of the comprehensive assessment;(3) be documented by the hospice in a systematic and retrievable way for each client;(4) be used by the hospice in individual client care planning and in the coordination of a client's services; and(5) be used in the aggregate for the hospice's quality assessment and performance improvement program. Source Note: The provisions of this §558.813 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.813 Hospice Client Outcome Measures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204618 03/12/2026 (a) A hospice must designate an interdisciplinary team (IDT) composed of persons who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of a hospice client and family facing terminal illness and bereavement. The IDT members must provide the care and services offered by the hospice and all the members of the IDT must supervise the care and services the hospice provides.(b) An IDT must include persons who are qualified and competent to practice in the following professional roles:(1) a physician who is an employee or under contract with the hospice, who may also be the hospice medical director or physician designee;(2) an RN;(3) a social worker; and(4) a pastoral or other counselor.(c) The hospice must designate an RN who is a member of the client's IDT to provide coordination of care and to ensure continuous assessment of the client's and family's needs and implementation of the interdisciplinary plan of care.(d) A hospice may have more than one IDT. If the hospice has more than one IDT, the hospice must identify the IDT specifically designated to establish policies governing the day-to-day provision of hospice care and services. Source Note: The provisions of this §558.820 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.820 Hospice Interdisciplinary Team https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204619 03/12/2026 (a) A hospice must designate an interdisciplinary team (IDT) to prepare a written plan of care for a client in consultation with the client's attending practitioner, if any, the client or the client's legal representative, and the primary caregiver, if any of them so desire.(b) The IDT must develop an individualized written plan of care for each client. The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.(c) The hospice must provide care and services to a client and the client's family in accordance with an individualized written plan of care established by the hospice IDT.(d) The client's plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care must include:(1) interventions to manage pain and symptoms;(2) a detailed statement of the scope and frequency of services necessary to meet the specific client and family needs;(3) measurable outcomes anticipated from implementing and coordinating the plan of care;(4) drugs and treatments necessary to meet the needs of the client;(5) medical supplies and equipment necessary to meet the needs of the client; and(6) the IDT's documentation, in the client record, of the client's or the client's legal representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's policies.(e) The hospice must ensure that the client and the client's primary caregiver receives education and training provided by hospice staff as appropriate to the client's and the client's primary caregiver's responsibilities for providing the care and services specified in the client's plan of care. Source Note: The provisions of this §558.821 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.821 Hospice Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195126 03/12/2026 (a) A hospice interdisciplinary team, in collaboration with a client's attending practitioner, if any, must review, revise and document the individualized plan of care as frequently as the client's condition requires, but no less than every 15 days.(b) A revised plan of care must include information from the client's updated comprehensive assessment and must note the client's progress toward outcomes and goals specified in the plan of care. Source Note: The provisions of this §558.822 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.822 Review of the Hospice Plan of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204617 03/12/2026 In addition to the requirements in §558.288 of this chapter (relating to Coordination of Services), a hospice must develop and maintain a system of communication and integration in accordance with its written policy on coordination of services. The policy must:(1) ensure that the interdisciplinary team maintains responsibility for directing, coordinating, and supervising the care and services provided to a client;(2) provide for and ensure the ongoing sharing of information between all hospice personnel providing care and services in all settings, whether the care and services are provided directly or under contract; and(3) provide for an ongoing sharing of information with other non-hospice health care providers furnishing services unrelated to the terminal illness and related conditions. Source Note: The provisions of this §558.823 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.823 Coordination of Services by the Hospice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204620 03/12/2026 (a) A hospice must routinely provide substantially all core services directly by hospice employees in a manner consistent with accepted standards of practice. A hospice must provide the following core services:(1) physician services;(2) nursing services;(3) medical social services; and(4) counseling services.(b) A hospice may contract for physician services as specified in §558.831 of this division (relating to Hospice Physician Services).(c) A hospice may use contracted staff if necessary to supplement hospice employees to meet the needs of clients under extraordinary or other non-routine circumstances. A Medicare-certified hospice may also enter into a written contract with another Medicare-certified hospice to provide core services if necessary to supplement hospice employees to meet the needs of a client. The contracting hospice must maintain professional management responsibility for the services provided in accordance with §558.854 of this subchapter (relating to Hospice Professional Management Responsibility). Circumstances under which the hospice may enter into a written contract for the provision of core services include:(1) unanticipated periods of high client loads;(2) staffing shortages due to illness or other short-term temporary staffing situations that could interrupt client care; and(3) temporary travel of a client outside of the hospice's service area. Source Note: The provisions of this §558.830 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.830 Provision of Hospice Core Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195130 03/12/2026 (a) The hospice medical director, physician employees, and contracted physicians of the hospice, in conjunction with a client's attending practitioner, if any, are responsible for the palliation and management of a client's terminal illness and related conditions.(b) A physician employee or a contracted physician must function under the supervision of the hospice medical director.(c) A physician employee or a contracted physician must meet the requirement in subsection (a) of this section by either providing physician services directly or by coordinating a client's care with the attending practitioner.(d) If an attending practitioner is unavailable, the medical director, a hospice physician employee, or a contracted physician is responsible for meeting the medical needs of the client. Source Note: The provisions of this §558.831 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.831 Hospice Physician Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204621 03/12/2026 (a) A hospice must provide nursing services by or under the supervision of an RN. An RN must ensure that the nursing needs of a client are met as identified in the client's initial assessment, comprehensive assessment, and updated assessments.(b) An advanced practice nurse providing nursing services to a client and acting within the nurse's scope of practice may write orders for the client in accordance with a hospice's written policies and applicable State law, including the Texas Occupations Code Chapter 157, Authority of Physician to Delegate Certain Medical Acts; Texas Occupations Code Chapter 301, Nurses; and Texas Health and Safety Code Chapter 481, Texas Controlled Substances Act, and Chapter 483, Dangerous Drugs.(c) A hospice may provide highly specialized nursing services under contract if the hospice provides such nursing services to a client so infrequently that providing them by a hospice employee would be impracticable and prohibitively expensive. A hospice may determine that a nursing service, such as complex wound care, infusion specialties, and pediatric nursing, is highly specialized by the nature of the service and the level of nursing skill required to be proficient in the service. Source Note: The provisions of this §558.832 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.832 Hospice Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195132 03/12/2026 (a) Medical social services must be provided to a client by a qualified social worker. A qualified hospice social worker must meet one of the following requirements:(1) active licensure in the state of Texas as a master social worker (MSW) and one year of social work experience in a health care setting; or(2) active licensure in the state of Texas as a baccalaureate social worker, one year of social work experience in a health care setting, and if employed by a hospice after December 2, 2008, must be supervised by a qualified MSW.(b) A qualified licensed baccalaureate social worker employed by a hospice before December 2, 2008, is exempt from the MSW supervision requirement.(c) Medical social services must be provided under the direction of a physician.(d) The social work services provided must be based on:(1) the client's and family's needs as identified in the client's psychosocial assessment; and(2) the client's and family's acceptance of these services. Source Note: The provisions of this §558.833 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.833 Hospice Medical Social Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204622 03/12/2026 (a) Counseling services must be available to a client and family to assist the client and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process.(b) Counseling services must include bereavement, dietary, and spiritual counseling.(1) Bereavement counseling. Bereavement counseling means emotional, psychosocial, and spiritual support and services provided before and after the death of the client to assist with issues related to grief, loss, and adjustment. A hospice must have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling. A hospice must:(A) develop a bereavement plan of care that notes the kind of bereavement services to be offered to the client's family and other persons and the frequency of service delivery;(B) make bereavement services available to a client's family and other persons in the bereavement plan of care for up to one year following the death of the client;(C) extend bereavement counseling to residents of a skilled nursing facility, a nursing facility, or an intermediate care facility for individuals with an intellectual disability or related conditions when appropriate and as identified in the bereavement plan of care; and(D) ensure that bereavement services reflect the needs of the bereaved.(2) Dietary counseling. Dietary counseling means education and interventions provided to a client and family regarding appropriate nutritional intake as a hospice client's condition progresses. Dietary counseling, when identified in the plan of care, must be performed by a qualified person. A qualified person includes a dietitian, nutritionist, or RN. A person that provides dietary counseling must be appropriately trained and qualified to address and assure that the specific dietary needs of a client are met.(3) Spiritual counseling. A hospice must provide spiritual counseling that meets the client's and the client's family's spiritual needs in accordance with their acceptance of this service and in a manner consistent with their beliefs and desires. A hospice must:(A) provide an assessment of the client's and family's spiritual needs;(B) make all reasonable efforts to the best of the hospice's ability to facilitate visits by local clergy, a pastoral counselor, or other persons who can support a client's spiritual needs; and(C) advise the client and family of the availability of spiritual counseling services. Source Note: The provisions of this §558.834 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.834 Hospice Counseling Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195134 03/12/2026 (a) A hospice must provide the following non-core services in a manner consistent with accepted standards of practice:(1) physical therapy services;(2) occupational therapy services;(3) speech-language pathology services;(4) hospice aide and hospice homemaker services; and(5) volunteers.(b) A hospice must provide non-core services directly or through a written contract. Source Note: The provisions of this §558.840 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.840 Provision of Hospice Non-Core Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195135 03/12/2026 Physical therapy services, occupational therapy services, and speech-language pathology services must be available and, when provided, offered by the hospice in a manner consistent with accepted standards of practice. Source Note: The provisions of this §558.841 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.841 Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204623 03/12/2026 (a) Hospice aide services must be provided by a hospice aide who meets the training and competency evaluation requirements, or the competency evaluation requirements specified in §558.843 of this division (relating to Hospice Aide Qualifications).(b) A client's hospice aide services must be:(1) ordered by the designated interdisciplinary team (IDT);(2) included in the client's plan of care;(3) performed by a hospice aide in accordance with State law and applicable rules, including 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments), and 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments For Clients with Stable and Predictable Conditions); and(4) consistent with a hospice aide's documented training and competency skills.(c) An RN who is a member of a client's designated IDT must assign a hospice aide to a specific client. An RN who is responsible for the supervision of a hospice aide, as specified in subsection (d) of this section, must prepare written client-care instructions for the hospice aide. The duties of a hospice aide include:(1) providing hands-on personal care;(2) performing simple procedures as an extension of therapy or nursing services;(3) assisting with ambulation or exercises;(4) assisting with self-administered medication;(5) reporting changes in a client's medical, nursing, rehabilitative, and social needs to an RN as the changes relate to the client's plan of care and the hospice's quality assessment and improvement activities; and(6) completing client record documentation in compliance with the hospice's policies and procedures.(d) An RN must make an on-site visit to a client's home to supervise the hospice aide services at least every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice IDT meet the client's needs. The hospice aide does not have to be present during this visit.(1) If the RN notes an area of concern in the care provided by the aide, the RN must make an on-site visit to the location where the client is receiving care to observe and assess the hospice aide while the aide performs care.(2) If, during the on-site visit to observe the hospice aide, the RN confirms an area of concern in the aide's skills, the hospice must ensure that the aide completes a competency evaluation in accordance with §558.843 of this division.(e) An RN must make an annual on-site visit to the location where a hospice client is receiving care to observe and assess each hospice aide while the aide performs care. During this on-site visit, the RN must assess the aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria including:(1) following the client's plan of care for completion of tasks assigned to the hospice aide by an RN;(2) creating successful interpersonal relationships with the client and the client's family;(3) demonstrating competency with assigned tasks;(4) complying with infection control policies and procedures; and(5) reporting changes in the client's condition. Source Note: The provisions of this §558.842 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.842 Hospice Aide Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204624 03/12/2026 (a) A hospice must use a qualified hospice aide to provide hospice aide services. A qualified hospice aide is a person who has successfully completed:(1) a training program and competency evaluation program that complies with the requirements in subsections (c) and (d) of this section; or(2) a competency evaluation program that complies with the requirements in subsection (d) of this section.(b) A person who has not provided home health or hospice aide services for compensation in an agency during the most recent continuous period of 24 consecutive months must successfully complete the programs described in subsection (a)(1) of this section or the program described in subsection (a)(2) of this section before providing hospice aide services.(c) A hospice aide training program must address each of the subject areas listed in paragraph (1) of this subsection through classroom and supervised practical training totaling at least 75 hours. At least 16 hours must be devoted to supervised practical training. At least 16 hours of classroom training must be completed before the supervised practical training begins.(1) Subject areas that must be addressed in a hospice aide training program include:(A) communication skills, including the ability to read, write, and verbally report clinical information to clients, caregivers, and other hospice staff;(B) observation, reporting, and documentation of a client's status and the care or service provided;(C) reading and recording temperature, pulse, and respiration;(D) basic infection control procedures;(E) basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;(F) maintenance of a clean, safe, and healthy environment;(G) recognizing emergencies and the knowledge of emergency procedures and their application;(H) the physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for a client and his or her privacy and property;(I) appropriate and safe techniques for performing personal hygiene and grooming tasks, including:(i) bed bath;(ii) sponge, tub, and shower bath;(iii) hair shampoo in sink, tub, and bed;(iv) nail and skin care;(v) oral hygiene; and(vi) toileting and elimination;(J) safe transfer techniques and ambulation;(K) normal range of motion and positioning;(L) adequate nutrition and fluid intake; and(M) other tasks that the hospice may choose to have an aide perform. The hospice must train hospice aides, as needed, for skills not listed in subparagraph (I) of this paragraph.(2) The classroom training of hospice aides and the supervision of hospice aides during supervised practical training must be conducted by or under the general supervision of an RN who possesses a minimum of two years of nursing experience, at least one of which must be in the provision of home health or hospice care. Other persons, such as a physical therapist, occupational therapist, medical social worker, and speech-language pathologist may be used to provide instruction under the supervision of a qualified RN who maintains overall responsibility for the training.(3) An agency must maintain documentation that demonstrates that its hospice aide training program meets the requirements in this subsection. Documentation must include a description of how additional skills, beyond the basic skills listed in paragraph (1) of this subsection, are taught and tested if the agency requires a hospice aide to perform more complex tasks.(d) A hospice aide competency evaluation program must address each of the subject areas listed in paragraphs (2) and (3) of this subsection.(1) An RN, in consultation with the other persons described in subsection (c)(2) of this section, must perform the competency evaluation.(2) The RN must observe and evaluate the hospice aide's performance of tasks with a client in the following areas:(A) communication skills, including the ability to read, write, and verbally report clinical information to clients, caregivers, and other hospice staff;(B) reading and recording temperature, pulse, and respiration;(C) appropriate and safe techniques for performing personal hygiene and grooming tasks, including:(i) bed bath;(ii) sponge, tub, and shower bath;(iii) hair shampoo in sink, tub, and bed;(iv) nail and skin care;(v) oral hygiene; and(vi) toileting and elimination;(D) safe transfer techniques and ambulation; and(E) normal range of motion and positioning.(3) The RN must evaluate a hospice aide's performance of each of the tasks listed in this paragraph by requiring the aide to submit to a written examination, an oral examination, or by observing the hospice aide's performance with a client. The tasks must include:(A) observing, reporting, and documenting client status and the care or service provided;(B) basic infection control procedures;(C) basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;(D) maintaining a clean, safe, and healthy environment;(E) recognizing emergencies and knowing emergency procedures and their application;(F) the physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for a client and his or her privacy and property;(G) adequate nutrition and fluid intake; and(H) other tasks the hospice may choose to have the hospice aide perform. The hospice must evaluate the competency of a hospice aide, as needed, for skills not listed in paragraph (2)(C) of this subsection.(4) A hospice aide has not successfully completed a competency evaluation program if the aide has an unsatisfactory rating in more than one subject area listed in paragraphs (2) and (3) of this subsection.(5) If a hospice aide receives an unsatisfactory rating in any of the subject areas listed in paragraphs (2) and (3) of this subsection, the aide must not perform that task without direct supervision by an RN until after:(A) the aide receives training in the task for which the aide was evaluated as unsatisfactory; and(B) successfully completes a subsequent competency evaluation with a satisfactory rating on the task.(6) An agency must maintain documentation that its hospice aide competency evaluation program meets the requirements in this subsection. The agency's documentation of a hospice aide's competency evaluation must demonstrate the aide's competency to provide services to a client that exceed the basic skills taught and tested before the aide is assigned to care for a client who requires more complex services.(e) A hospice aide must receive at least 12 hours of in-service training during each 12-month period. The agency may provide the 12 hours of in-service training during the 12-month calendar year, or within 12 months after a hospice aide's employment or contract anniversary date.(1) The in-service training must be supervised by an RN.(2) An agency may provide hospice aide in-service training supervised by an RN while the aide is providing care to a client. The RN must document the exact new skill or theory taught in the client's residence and the duration of the training. The in-service training provided in a client's residence must not be a repetition of a hospice aide's competency in a basic skill.(3) An agency must maintain documentation that demonstrates the agency meets the hospice aide in-service training requirements in this subsection.(f) An agency that hires or contracts to use a hospice aide who completes a training program and competency evaluation program, or a competency evaluation program provided by another agency or a person who is not licensed as an agency must ensure that the programs or program completed comply with the requirements in subsection (c) and (d) of this section.(g) A Medicare-certified hospice agency must also comply with 42 CFR §418.76(b) and 42 CFR §418.76(f). Source Note: The provisions of this §558.843 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.843 Hospice Aide Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204625 03/12/2026 (a) Homemaker services must be provided by a qualified hospice homemaker as described in §558.845 of this division (relating to Hospice Homemaker Qualifications).(b) A member of a client's designated interdisciplinary team (IDT) must coordinate and supervise the homemaker services provided and prepare written instructions for the duties a hospice homemaker performs.(c) Hospice homemaker services may include assistance in maintaining a safe and healthy environment and services to enable the client and the client's family to carry out the hospice treatment plan. Hospice homemaker services do not include providing personal care or any hands-on services.(d) A hospice homemaker must report all concerns about a client or the client's family to the member of the IDT responsible for coordinating the hospice homemaker services. Source Note: The provisions of this §558.844 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.844 Hospice Homemaker Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204626 03/12/2026 (a) A hospice must use a qualified hospice homemaker to provide hospice homemaker services. A qualified hospice homemaker is a person who:(1) successfully completes an agency's hospice orientation and training as specified in subsection (b) of this section; or(2) is a qualified hospice aide as described in §558.843 of this division (relating to Hospice Aide Qualifications).(b) The orientation for a hospice homemaker must address the needs and concerns of a client and a client's family who are coping with a terminal illness. The training for a hospice homemaker must include:(1) assisting in maintaining a safe and healthy environment for a client and the client's family; and(2) providing homemaker services to help the client and the client's family to carry out the treatment plan.(c) If there is a direct conflict between the requirements of this chapter and federal regulations, the requirements that are more stringent apply to a Medicare-certified hospice agency. Source Note: The provisions of this §558.845 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.845 Hospice Homemaker Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195140 03/12/2026 (a) If a client receives services under a state Medicaid personal care benefit, a hospice may use the services provided under the Medicaid personal care benefit to the extent the hospice would routinely use the services of a hospice client's family in implementing the client's plan of care.(b) The hospice must coordinate its hospice aide and homemaker services with the Medicaid personal care benefit to ensure that the client receives the hospice aide and homemaker services the client needs. Source Note: The provisions of this §558.846 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.846 Services Provided Under a State Medicaid Personal Care Benefit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195141 03/12/2026 (a) A hospice must organize, manage, and administer its hospice program to provide hospice care and support services to a client, the client's caregivers, and the client's family that are necessary for the palliation and management of a client's terminal illness and related conditions. A hospice must provide hospice care and support services that:(1) optimize the client's comfort and dignity; and(2) are consistent with the client's and the client's family's needs and goals with priority given to the client's needs and goals.(b) Hospice services may be provided in the client's residence or independent living environment and, when needed, in a hospice inpatient unit or in a Medicare/Medicaid-certified facility where the hospice makes inpatient care available under arrangement.(c) A hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice:(1) physician services;(2) nursing services;(3) medical social services;(4) counseling services, including bereavement, dietary, and spiritual counseling;(5) physical therapy, occupational therapy, and speech-language pathology services;(6) hospice aide and hospice homemaker services;(7) volunteer services;(8) short-term inpatient care; and(9) medical supplies and appliances, durable medical equipment, and drugs and biologicals.(d) A hospice must make the following services routinely available 24 hours a day, seven days a week:(1) nursing services;(2) physician services; and(3) drugs and biologicals.(e) A hospice must make the following services available 24 hours a day when reasonable and necessary to meet the client's and the client's family's needs:(1) medical social services;(2) counseling services, including bereavement, dietary, and spiritual counseling;(3) physical therapy, occupational therapy, and speech-language pathology services;(4) hospice aide and hospice homemaker services;(5) volunteer services;(6) short-term inpatient care; and(7) medical supplies and appliances and durable medical equipment.(f) A Medicare-certified hospice may not discontinue or reduce care provided to a Medicare or Medicaid beneficiary because of the beneficiary's inability to pay for the care. Source Note: The provisions of this §558.850 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.850 Organization and Administration of Hospice Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195142 03/12/2026 (a) Services provided by a licensed person directly or under contract by a hospice must be authorized, delivered, and supervised only by a qualified licensed person who practices under the hospice's policies and procedures. For the purpose of this section, services provided by a licensed person include skilled nursing care, physical therapy, occupational therapy, speech language pathology, and medical social services.(b) A licensed person providing hospice services directly or under contract must:(1) actively participate in the coordination of all aspects of a client's hospice care, in accordance with accepted standards of practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to client and family counseling and education; and(2) participate in the hospice's quality assessment and performance improvement program and hospice-sponsored in-service training. Source Note: The provisions of this §558.851 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.851 Hospice Services Provided by a Licensed Person https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204641 03/12/2026 (a) The hospice must have a governing body that assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement.(b) The governing body must appoint an administrator who:(1) meets the qualifications and conditions specified in §558.244(a)(1) and (2) of this chapter (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications); and(2) reports to the governing body or persons serving as the governing body. Source Note: The provisions of this §558.852 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.852 Hospice Governing Body and Administrator https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204642 03/12/2026 (a) In addition to the requirements in §558.285 of this chapter (relating to Infection Control), a hospice must maintain an effective infection control program that protects clients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.(b) A hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.(c) A hospice must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's quality assessment and performance improvement program. The infection control program must include:(1) a method of identifying infectious and communicable disease problems; and(2) a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention.(d) A hospice must provide infection control education to employees, volunteers, contract staff, clients, and family members and other caregivers. Source Note: The provisions of this §558.853 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.853 Hospice Infection Control Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204643 03/12/2026 (a) A hospice that has a written contract with another agency, person, or organization to furnish services must retain administrative and financial management and oversight of staff and services for all contracted services to ensure the provision of quality care.(b) In addition to the requirements in §558.289 of this chapter (relating to Independent Contractors and Arranged Services), a hospice's written contracts must require that all services are:(1) authorized by the hospice;(2) furnished in a safe and effective manner by qualified personnel; and(3) delivered in accordance with a client's plan of care. Source Note: The provisions of this §558.854 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.854 Hospice Professional Management Responsibility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204644 03/12/2026 (a) In addition to the requirements in §558.247 of this chapter (relating to Verification of Employability and Use of Unlicensed Persons), a hospice must conduct a criminal history check on all hospice employees and volunteers with direct client contact or access to client records to verify each employee's or volunteer's criminal history report does not include a conviction that bars employment under Texas Health and Safety Code §250.006, or a conviction that the hospice determines is a contraindication to employment.(b) In addition to the requirements in §558.289 of this chapter (relating to Independent Contractors and Arranged Services), hospice contracts to provide inpatient care must require that all contracted entities conduct a criminal history check on contracted staff who have direct client contact or access to client records to verify each contract staff's criminal history report does not include a conviction that bars employment under Texas Health and Safety Code §250.006. Source Note: The provisions of this §558.855 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.855 Criminal Background Checks https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204645 03/12/2026 (a) If a hospice operates an ADS, the hospice must comply with this section.(b) A Medicare-certified hospice agency must have an ADS approved by CMS before providing Medicare-reimbursed hospice services to Medicare clients from the ADS.(c) An ADS must be part of the hospice and must share administration, supervision, and services with the parent agency.(d) In addition to the requirements in §558.242 of this chapter (relating to Organizational Structure and Lines of Authority), the lines of authority and professional and administrative control must be clearly delineated in the hospice's organizational structure and in practice and must be traced to the parent agency.(e) The hospice must continually monitor and manage all services provided by its ADS to ensure that services are delivered in a safe and effective manner and to ensure that a client and the client's family receives the necessary care and services outlined in the plan of care. Source Note: The provisions of this §558.856 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.856 Hospice Alternate Delivery Sites https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204646 03/12/2026 In addition to the requirements in §558.245 of this chapter (relating to Staffing Policies), a hospice must:(1) provide orientation about the hospice philosophy, and about supportive palliative care, to all employees and contracted staff who have client and family contact;(2) provide an initial orientation for an employee that addresses the employee's specific job duties;(3) assess the skills and competence of all persons furnishing care, including volunteers furnishing services, and, as necessary, provide in-service training and education programs where required;(4) have written policies and procedures describing its methods for assessing competency; and(5) maintain a written description of the in-service training provided during the previous 12 months. Source Note: The provisions of this §558.857 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.857 Hospice Staff Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195149 03/12/2026 (a) A hospice must designate in writing one physician to serve as its medical director. The medical director must be a doctor of medicine or osteopathy who is an employee or under contract with the hospice. The medical director may also be a volunteer physician under the control of the hospice.(b) A hospice must designate in writing a physician designee to assume the same responsibilities and obligations as the medical director when the medical director is not available.(c) A hospice may contract for a physician to serve as its medical director with either a self-employed physician or a physician employed by a professional entity or physicians group. The contract for medical director services must specify the name of the physician who assumes the medical director responsibilities and obligations.(d) The medical director or physician designee assumes responsibility for the medical component of a hospice's client care program.(e) The medical director or physician designee must review a client's clinical information and provide written initial certification that the client's life expectancy is anticipated to be six months or less if the client's terminal illness runs its normal course.(f) Before each recertification period for the client, the medical director or physician designee must review the client's clinical information and provide written recertification of the client's terminal illness.(g) When determining the client's life expectancy is six months or less, the medical director or physician designee must consider:(1) the primary terminal condition;(2) related diagnoses, if any;(3) current subjective and objective medical findings;(4) current medication and treatment orders; and(5) information about the medical management of any of the client's conditions unrelated to the terminal illness. Source Note: The provisions of this §558.858 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.858 Hospice Medical Director https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204647 03/12/2026 (a) If a hospice transfers the care of a client to another facility or agency, the hospice must provide a copy of the hospice discharge summary and, if requested, a copy of the client's record to the receiving facility or agency.(b) If a client revokes the election of hospice care or is discharged by the hospice for any reason listed in subsection (d) of this section, the hospice must provide a copy of the hospice discharge summary and, if requested, a copy of the client's record to the client's attending practitioner.(c) A hospice discharge summary must include:(1) a summary of the client's stay, including treatments, symptoms, and pain management;(2) the client's current plan of care;(3) the client's latest physician orders; and(4) any other documentation needed to assist in post-discharge continuity of care or that is requested by the attending practitioner or receiving facility or agency.(d) In addition to the requirements in §558.295 of this chapter (relating to Client Transfer or Discharge Notification Requirements), a hospice may discharge a client if:(1) the client moves out of the hospice's service area or transfers to another hospice;(2) the hospice determines that the client is no longer terminally ill; or(3) the hospice determines, under a policy set by the hospice for addressing discharge for cause, that the behavior of the client or other person in the client's home is disruptive, abusive, or uncooperative to the extent that delivery of care to the client or the ability of the hospice to operate effectively is seriously impaired.(e) Before a hospice seeks to discharge a client for cause, the hospice must:(1) advise the client that a discharge for cause is being considered;(2) make a reasonable effort to resolve the problems presented by the client's behavior or situation;(3) document in the client's record the problems and efforts made by the hospice to resolve the problems; and(4) ascertain that the client's proposed discharge is not due to the client's use of necessary hospice services.(f) Before discharging a client for any reason listed in subsection (d) of this section, the hospice must obtain a written physician's discharge order from the hospice medical director. If the client has an attending practitioner involved in the client's care, the attending practitioner should be consulted before discharge and the practitioner's review and decision should be included in the discharge note.(g) A hospice must have a discharge planning process that addresses the possibility that a client's condition might stabilize or otherwise change such that the client cannot continue to be certified as terminally ill. A client's discharge planning must include any necessary family counseling, client education or other services before the hospice discharges the client based on a decision by the hospice medical director or physician designee that the client is no longer terminally ill. Source Note: The provisions of this §558.859 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.859 Hospice Discharge or Transfer of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204648 03/12/2026 (a) While a client is under hospice care, a hospice must provide medical supplies and appliances as well as durable medical equipment related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care.(b) A hospice must ensure that manufacturer recommendations for performing routine and preventive maintenance on durable medical equipment are followed. The equipment must be safe, and work as intended for use in the client's environment. Where a manufacturer recommendation for a piece of equipment does not exist, the hospice must ensure that repair and routine maintenance policies are developed. The hospice may use persons under contract to ensure the maintenance and repair of durable medical equipment.(c) A hospice must ensure that a client, where appropriate, as well as the family or other caregivers, receive instruction in the safe use of durable medical equipment and supplies. The hospice may use persons under contract to ensure client and family instruction. The client, family, or caregiver must be able to demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff.(d) A hospice may only contract for durable medical equipment services with a durable medical equipment supplier that meets the Medicare standards for durable medical equipment, prosthetics, orthotics, and supplies suppliers at 42 CFR §424.57. Source Note: The provisions of this §558.860 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.860 Provision of Medical Supplies, and Durable Medical Equipment by a Hospice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204649 03/12/2026 (a) While a client is under hospice care, a hospice must provide drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care.(b) A hospice must ensure that the interdisciplinary team (IDT) confers with a person with education and training in drug management, as defined in hospice policies and procedures and State law, who is an employee of or under contract with the hospice to ensure that drugs and biologicals meet a client's needs. The hospice must be able to demonstrate that the person has specific education and training in drug management. Persons with education and training in drug management include:(1) a licensed pharmacist, a physician who is board certified in hospice and palliative medicine, or an RN who is certified in palliative nursing; or(2) a physician, an RN, or an advanced practice nurse who completes a specific drug management course for hospice or palliation.(c) Only a physician or an advanced practice nurse, in accordance with the plan of care, may order drugs for a client.(d) If the drug order is verbal or given by or through electronic transmission:(1) it must be given only to a licensed nurse, pharmacist, or physician; and(2) the person receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with the agency's policies and applicable State and federal regulations.(e) A hospice must obtain drugs and biologicals from community or institutional pharmacists or stock drugs and biologicals itself. A hospice that dispenses, stores, and transports drugs must do so in accordance with federal, State, and local laws and regulations, as well as the hospice's own policies and procedures. A hospice that operates its own pharmacy must comply with the Texas Occupations Code, Subtitle J, and applicable pharmacy and pharmacists' regulations adopted by the Texas Board of Pharmacy under that subtitle.(f) The IDT, as part of the review of the plan of care, must determine the ability of the client or the client's family to safely administer drugs and biologicals to the client in the client's home.(g) Drugs and biologicals must be labeled in accordance with currently accepted professional practice and must include appropriate usage and cautionary instructions, as well as an expiration date, if applicable.(h) A hospice must have written policies and procedures for the safe use and storage of drugs and biologicals in a client's home.(i) A hospice must have written policies and procedures that address management of controlled substance prescription drugs in a client's home, including:(1) at the time when controlled substance prescription drugs are first ordered;(2) when controlled substance prescription drugs are discontinued;(3) when a new controlled substance prescription drug is ordered; and(4) when the client dies.(j) At the time when controlled substance prescription drugs are first ordered for use in a client's home, the hospice must:(1) provide a copy of the hospice's written policies and procedures on the management of controlled substance prescription drugs in a client's home to the client or client representative and family;(2) discuss the hospice policies and procedures for managing the safe use of controlled substance prescription drugs with the client or LAR and the family in a language and manner that they understand, to ensure that these parties are educated regarding the safe use, storage, and disposal of controlled substance prescription drugs in the client's home; and(3) document in the client record that the hospice provided and discussed its written policies and procedures for managing the safe use and storage of controlled substance prescription drugs in the client's home, as described in subsection (m) of this section.(k) A hospice must have a written policy describing whether the agency will dispose of a client's unused controlled substance prescription drugs on the client's death or in other circumstances in which disposal is appropriate, as described in subsection (m) of this section.(l) If a hospice agency's policy under subsection (k) of this section provides that the agency will dispose of a client's unused controlled substance prescription drugs as described in that subsection, the written policies and procedures which the hospice must implement and enforce, must:(1) identify disposal methods that are consistent with recommendations by the United States Food and Drug Administration and the laws of the State of Texas;(2) permit disposal described in subsection (k) of this section only by a hospice employee or contractor who is a health care practitioner licensed to perform medical or nursing services who meets the conditions of this section;(3) require each health care practitioner responsible for disposal of an unused controlled substance of a client under this section to receive training regarding the secure and responsible disposal of controlled substance prescription drugs in accordance with paragraph (1) of this subsection and in a manner that discourages abuse, misuse, or diversion;(4) require that hospice agency staff:(A) provide a copy of the disposal policies and procedures to a licensed facility in which the client is residing or receiving short-term in-patient hospice services;(B) provide a copy of the disposal policies and procedures to the client and the client's family;(C) discuss the policies and procedures with the patient and the client's family in a language and manner the client and client's family understand;(D) document in the client's clinical record that the policies and procedures were provided and discussed as required by subsections (b) and (c) of this section; and(E) document the client's agreement to the disposal of the client's unused controlled substance prescription drugs under circumstances described in subsection (m) of this section by a qualified health practitioner employed or contracted by the agency; and(5) otherwise comply with state, federal, and local laws applicable to the disposal of drugs and biologicals in a facility.(m) A health care practitioner qualified under subsection (l) of this section may confiscate and dispose of a client's unused controlled substance prescription drug if:(1) the client has died;(2) the drug has expired; or(3) the client's physician has given written instructions that the patient should no longer use the drug.(n) A hospice agency may not dispose of controlled prescription drugs not prescribed to the client.(o) A health care practitioner qualified under subsection (l) of this section, confiscating the controlled substance prescription drug, must dispose of the drug in a manner consistent with recommendations of the United States Food and Drug Administration and the laws of the State of Texas.(p) A health care practitioner qualified under subsection (l) of this section must dispose of a client's unused controlled substance prescription drugs as described in this section only at the location at which practitioner confiscated the drug.(q) A health care practitioner disposal of a client's unused controlled substance prescription drugs as described in this section must be witnessed by another person 18 years of age or older. The witness does not have to be a hospice employee.(r) After disposing of the client's unused controlled substance prescription drug, the health care practitioner shall document in the client's record:(1) the name of the drug;(2) the dosage of the drug the client was receiving;(3) the route of controlled substance prescription drug administration;(4) the quantity of the controlled substance prescription drug originally dispensed and the quantity of the drug remaining;(5) the time, date, and manner of disposal; and(6) name and relationship of the witness to the client.(s) A health care practitioner shall document in the client's file if a family member of the client prevented the confiscation and disposal of a controlled substance prescription drug authorized under this section.(t) A health care practitioner shall document in the client's file if an employee of a licensed facility where the client is receiving in-patient hospice services prevented the confiscation and disposal of a controlled substance prescription drug otherwise authorized under this section. Source Note: The provisions of this §558.861 adopted to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.861 Management of Drugs and Biologicals and Disposal of Controlled Substance Prescription Drugs in a Client's Home or Community Setting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204650 03/12/2026 (a) The requirements stated in §558.861(a)-(g) of this division (relating to Management of Drugs and Biologicals and Disposal of Controlled Substance Prescription Drugs in a Client's Home or Community Setting) also apply to a hospice that provides inpatient care directly in its own inpatient unit.(b) A hospice that provides inpatient care directly in its own inpatient unit must provide pharmaceutical services under the direction of a qualified licensed pharmacist who is an employee of or under contract with the hospice. The services provided by the pharmacist must include evaluation of a client's response to medication therapy, identification of potential adverse drug reactions, and recommended appropriate corrective action.(c) A hospice that provides inpatient care directly in its own inpatient unit must:(1) have a written policy in place that promotes dispensing accuracy; and(2) maintain current and accurate records of the receipt and disposition of all controlled drugs.(d) Clients receiving care in a hospice inpatient unit may only be administered medications by the following persons:(1) a licensed nurse, physician, or other health care professional in accordance with their scope of practice and State law;(2) a home health medication aide; or(3) a client, upon approval by the interdisciplinary team.(e) A hospice that provides inpatient care directly in its own inpatient unit must comply with the following additional requirements.(1) All drugs and biologicals must be stored in secure areas. All controlled drugs listed in Schedules II, III, IV, and V, established under 21 United States Code §812, must be stored in locked compartments within such secure storage areas. Only personnel authorized to administer controlled drugs as noted in subsection (i) of this section may have access to the locked compartments.(2) Discrepancies in the acquisition, storage, dispensing, administration, disposal, or return of controlled drugs must be investigated immediately by the pharmacist and hospice administrator and reported, without limitation, to the United States Department of Justice, Drug Enforcement Administration, Diversion Control Division. A hospice must maintain a written account of its investigation and make it available to State and federal officials if requested.(f) A hospice that provides inpatient care directly in its own inpatient unit must dispose of controlled drugs in compliance with the hospice's policy and in accordance with State and federal requirements, including Texas Health and Safety Code Chapter 481. The hospice must maintain current and accurate records of the receipt and disposition of all controlled drugs. Source Note: The provisions of this §558.862 adopted to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.862 Management of Drugs and Biologicals and Disposal of Controlled Substance Prescription Drugs in an Inpatient Hospice Unit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204651 03/12/2026 (a) A hospice must make inpatient care available when needed for pain control, symptom management, and respite purposes.(b) A hospice must ensure that inpatient care for pain control and symptom management is provided in either:(1) a hospice inpatient unit that meets the additional standards in Division 7 of this subchapter (relating to Hospice Inpatient Units) and the Medicare Conditions of Participation for providing inpatient care directly as specified in 42 CFR §418.110; or(2) a Medicare-certified hospital or skilled nursing facility that also meets:(A) the licensing standards specified in §558.870(b)(1) and (2) of this subchapter (relating to Staffing in a Hospice Inpatient Unit) regarding 24-hour nursing services, and in §558.871(d)(1)-(4) of this subchapter (relating to Physical Environment in a Hospice Inpatient Unit); and(B) the federal Medicare standards specified in 42 CFR §418.110(b) and (e) regarding 24-hour nursing services and patient areas.(c) A hospice must ensure that inpatient care for respite purposes is provided either by:(1) a facility specified in subsection (b)(1) or (2) of this section; or(2) a Medicare-certified or Medicaid-certified nursing facility that also meets the licensing standards specified in §558.871(d)(1)-(4) of this subchapter regarding client areas and the federal Medicare standards specified in 42 CFR §418.110(e) regarding patient areas.(d) A facility providing respite care must provide 24-hour nursing services that meet the nursing needs of all clients and are furnished in accordance with each client's plan of care. Each client must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.(e) In addition to the requirements in §558.289(b) of this chapter (relating to Independent Contractors and Arranged Services), if a hospice has an agreement with a facility to provide for inpatient care, there must be a written contract coordinated by the hospice that specifies that:(1) the hospice supplies the facility with a copy of the client's plan of care and specifies the inpatient services to be furnished;(2) the facility has established client care policies consistent with those of the hospice and agrees to abide by the plan of care established by the hospice for each client and to follow the hospice agency's protocols for supporting optimal quality of life for its clients;(3) the facility's clinical record for a hospice client includes documentation of all inpatient services furnished and events regarding care that occurred at the facility;(4) a copy of the discharge summary be provided to the hospice at the time of discharge;(5) a copy of the inpatient clinical record is available to the hospice at the time of discharge;(6) the facility has identified a person within the facility who is responsible for the implementation of the provisions of the agreement;(7) the hospice retains responsibility for ensuring that the training of personnel who will be providing the client's care in the facility has been provided and that a description of the training and the names of those giving the training are documented; and(8) a method for verifying that the requirements in paragraphs (1) - (7) of this subsection are met. Source Note: The provisions of this §558.863 adopted to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.863 Hospice Short-term Inpatient Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204638 03/12/2026 (a) A hospice is responsible for staffing its inpatient unit with the numbers and types of qualified, trained, and experienced staff to meet the care needs of every client in the inpatient unit to ensure that plan of care outcomes are achieved and negative outcomes are avoided.(b) A hospice inpatient unit must provide 24-hour nursing services that meet the nursing needs of all clients and are furnished in accordance with each client's plan of care.(1) A client must receive all nursing services as prescribed in the plan of care and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.(2) If at least one client in the hospice inpatient unit is receiving general inpatient care for pain control or symptom management, then each shift must include an RN who provides direct client care.(3) A hospice inpatient unit must have a nurse call system. The hospice must install in a client's room a system that:(A) is equipped with an easily activated, functioning device accessible to the client; and(B) allows the client to call for assistance from a staff person on the unit. Source Note: The provisions of this §558.870 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 201, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.870 Staffing in a Hospice Inpatient Unit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204639 03/12/2026 (a) Safety Management. A hospice inpatient unit must maintain a safe physical environment free of hazards for clients, staff, and visitors.(1) A hospice inpatient unit must address real or potential threats to the health and safety of the clients, others, and property.(2) In addition to §558.256 of this chapter (relating to Emergency Preparedness Planning and Implementation), a hospice inpatient unit must have a written disaster preparedness plan that addresses the core functions of emergency management as described in subparagraphs (A) - (G) of this paragraph. The facility must maintain documentation of compliance with this paragraph.(A) The portion of the plan on direction and control must:(i) designate a person by position, and at least one alternate, to be in charge during implementation of an emergency response plan, with authority to execute a plan to evacuate or shelter in place;(ii) include procedures the facility will use to maintain continuous leadership and authority in key positions;(iii) include procedures the facility will use to activate a timely response plan based on the types of disasters identified in the risk assessment;(iv) include procedures the facility will use to meet staffing requirements;(v) include procedures the facility will use to warn or notify facility staff about internal and external disasters, including during off hours, weekends, and holidays;(vi) include procedures the facility will use to maintain a current list of who the hospice will notify once warning of a disaster is received;(vii) include procedures the facility will use to alert critical facility personnel once a disaster is identified; and(viii) include procedures the facility will use to maintain a current 24-hour contact list for all personnel.(B) The portion of the plan on communication must include procedures:(i) for continued communication, including procedures during an evacuation to maintain contact with critical personnel and with all vehicles traveling in an evacuation caravan;(ii) to maintain an accessible, current list of the phone numbers of:(I) client family members;(II) local shelters;(III) prearranged receiving facilities;(IV) the local emergency management agencies;(V) other health care providers; and(VI) State and federal emergency management agencies;(iii) to notify staff, clients, families of clients, families of critical staff, prearranged receiving facilities, and others of an evacuation or the plan to shelter in place;(iv) to provide a contact number for out-of-town family members to call for information; and(v) to relocate and track clients during disasters that require mass evacuations.(C) The portion of the plan on resource management must include procedures:(i) to maintain contracts and agreements with vendors as needed to ensure the availability of the supplies and transportation needed to execute the plan to shelter in place or evacuate;(ii) to develop accurate, detailed, and current checklists of essential supplies, staff, equipment, and medications;(iii) to designate responsibility for completing the checklists during disaster operations;(iv) for the safe and secure transportation of adequate amounts of food, water, medications, and critical supplies and equipment during an evacuation; and(v) to maintain a supply of sufficient resources for at least seven days to shelter in place, which must include:(I) emergency power, including backup generators and accounts for maintaining a supply of fuel;(II) potable water in an amount based on population and location;(III) the types and amounts of food for the number and types of clients served;(IV) extra pharmacy stocks of common medications; and(V) extra medical supplies and equipment, such as oxygen, linens, and any other vital equipment.(D) The portion of the plan on sheltering in place must:(i) be developed using information about the building's construction and Life Safety Code (LSC) systems;(ii) describe the criteria to be used to decide whether to shelter in place versus evacuate;(iii) include procedures to assess whether the building is strong enough to withstand the various types of possible disasters and to identify the safest areas of the building;(iv) include procedures to secure the building against damage;(v) include procedures for collaborating with the local emergency management agencies regarding the decision to shelter in place;(vi) include procedures to assign each task in the sheltering plan to facility staff;(vii) describe procedures to shelter in place that allow the facility to maintain 24-hour operations for a minimum of seven days to maintain continuity of care for the number and types of clients served; and(viii) include procedures to provide for building security.(E) The portion of the plan on evacuation must:(i) include contracts with prearranged receiving facilities, including a hospice inpatient facility, skilled nursing facility, nursing facility, assisted living facility, or hospital, with at least one facility located at least 50 miles away;(ii) include procedures to identify and follow evacuation and alternative routes for transporting clients to a receiving facility and to notify the proper authorities of the decision to evacuate;(iii) include procedures to protect and transport client records and to match them to each client;(iv) include procedures to maintain a checklist of items to be transported with clients, including medications and assistive devices, and how the items will be matched to each client;(v) include staffing procedures the facility will use to ensure that staff accompanies evacuating clients when the hospice transports clients to a receiving facility;(vi) include procedures to identify and assign staff responsibilities, including how clients will be cared for during evacuations and a backup plan for lack of sufficient staff;(vii) include procedures facility staff will use to account for all persons in the building during the evacuation and to track all persons evacuated;(viii) include procedures for the use, protection, and security of the identifying information the facility will use to identify evacuated clients;(ix) include procedures facility staff will follow if a client becomes ill or dies in route when the hospice transports clients to a receiving facility;(x) include procedures to make a hospice counselor available when staff accompanies clients during transport by the hospice to a receiving facility;(xi) include the facility's policy on whether family of staff and clients can shelter at the hospice and evacuate with staff and clients;(xii) include procedures to coordinate building security with the local emergency management agencies;(xiii) include procedures facility staff will use to determine when it is safe to return to the geographical area;(xiv) include procedures facility staff will use to determine if the building is safe for reoccupation; and(xv) be approved by the local emergency management coordinator (EMC) at least annually and when updated.(F) The portion of the plan on transportation must:(i) describe how the hospice prearranges for a sufficient number of vehicles to provide suitable, safe transportation for the type and number of clients being served; and(ii) include procedures to contact the local EMC to coordinate the facility's transportation needs in the event its prearrangements for transportation fail for reasons beyond the facility's control.(G) The portion of the plan on training must include:(i) procedures that specify when and how the disaster response plan is reviewed with clients and family members;(ii) procedures to review the role and responsibility of a client able to participate with the plan;(iii) procedures for initial and periodic training for all facility staff to carry out the plan;(iv) the frequency for conducting disaster drills and demonstrations to ensure staff are fully trained with respect to their duties under the plan; and(v) procedures to conduct emergency response drills at least annually either in response to an actual disaster or in a planned drill, which may be in addition to or combined with the drills required by the LSC as specified in subsection (c)(1) of this section.(b) Physical plant and equipment. A hospice must develop procedures for controlling the reliability and quality of:(1) the routine storage and prompt disposal of trash and medical waste;(2) light, temperature, and ventilation and air exchanges throughout the hospice inpatient unit;(3) emergency gas and water supply; and(4) the scheduled and emergency maintenance and repair of all equipment.(c) Fire protection. Except as otherwise provided in this subsection:(1) A hospice must meet the provisions applicable to the health care occupancy chapters of the 2000 edition of the LSC of the National Fire Protection Association (NFPA). Chapter 19.3.6.3.2, exception number 2 of the 2000 edition of the LSC does not apply to hospices.(2) In consideration of a recommendation by HHSC, CMS may waive, for periods deemed appropriate, specific provisions of the LSC which if rigidly applied would result in unreasonable hardship for the hospice, but only if the waiver would not adversely affect the health and safety of clients.(3) The provisions of the adopted edition of the LSC do not apply in the State of Texas if CMS finds that a fire and safety code imposed by State law adequately protects clients in hospices.(4) Notwithstanding any provisions of the 2000 edition of the LSC to the contrary, a hospice inpatient unit may place alcohol-based hand rub dispensers in its facility if:(A) use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;(B) the dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;(C) the dispensers are installed in a manner that adequately protects against access by vulnerable populations; and(D) the dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the LSC, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the NFPA on April 15, 2004.(d) Client areas. A hospice inpatient unit must provide a home-like atmosphere and ensure that client areas are designed to preserve the dignity, comfort, and privacy of clients. A hospice inpatient unit must provide:(1) physical space for private client and family visiting;(2) accommodations for family members to remain with the client throughout the night;(3) physical space for family privacy after a client's death; and(4) the opportunity for the client to receive visitors at any hour, including infants and small children.(e) Client rooms. A hospice must ensure that client rooms are designed and equipped for nursing care, as well as the dignity, comfort, and privacy of clients. A hospice must accommodate a client and family request for a single room whenever possible. A client's room must:(1) be at or above grade level;(2) contain a suitable bed and other appropriate furniture for the client;(3) have closet space that provides security and privacy for clothing and personal belongings;(4) accommodate no more than two clients and their family members; and(5) provide at least 80 square feet for a client residing in a double room and at least 100 square feet for a client residing in a single room.(f) Toilet and bathing facilities. A client room in an inpatient unit must be equipped with, or conveniently located near, toilet and bathing facilities.(g) Plumbing facilities. A hospice inpatient unit must:(1) always have an adequate supply of hot water; and(2) have plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by a client.(h) Infection control. A hospice inpatient unit must maintain an infection control program that protects clients, staff, and others by preventing and controlling infections and communicable disease in accordance with §558.853 of this subchapter (relating to Hospice Infection Control Program).(i) Sanitary environment. A hospice inpatient unit must provide a sanitary environment by following accepted standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases.(j) Linen. A hospice inpatient unit must always have available a quantity of clean linen in sufficient amounts for a client's use. Linens must be handled, stored, processed, and transported in such a manner as to prevent the spread of contaminants.(k) Meal service and menu planning. A hospice inpatient unit must furnish meals to a client that are:(1) consistent with the client's plan of care, nutritional needs, and therapeutic diet;(2) palatable, attractive, and served at the proper temperature; and(3) obtained, stored, prepared, distributed, and served under sanitary conditions.(l) Use of restraint or seclusion. A client in a hospice inpatient unit has the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the client, a staff member, or others and must be discontinued at the earliest possible time.(1) Restraint or seclusion may only be used when less restrictive interventions are determined to be ineffective to protect the client, a staff member, or others from harm.(2) The type or technique of restraint or seclusion used must be the least restrictive intervention that is effective to protect the client, a staff member, or others from harm.(3) The use of restraint or seclusion must be:(A) in accordance with a written modification to the client's plan of care; and(B) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospice policy.(4) The use of restraint or seclusion must be in accordance with the order of a physician authorized to order restraint or seclusion by hospice policy.(5) An order for the use of restraint or seclusion must never be written as a standing order or on an as needed basis.(6) The medical director or physician designee must be consulted as soon as possible if the attending practitioner did not order the restraint or seclusion.(7) An order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:(A) four hours for adults 18 years of age or older;(B) two hours for children and adolescents nine to 17 years of age; or(C) one hour for children under nine years of age.(8) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician authorized to order restraint or seclusion by hospice policy must see and assess the client.(9) Each order for restraint used to ensure the physical safety of a non-violent or non-self-destructive client may be renewed as authorized by hospice policy.(10) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.(11) The condition of the client who is restrained or secluded must be monitored by a physician or trained staff who have completed the training criteria specified in subsection (o) of this section at an interval determined by hospice policy.(12) Training requirements for a physician and for an attending practitioner must be specified in hospice policy. At a minimum, a physician and an attending practitioner authorized to order restraint or seclusion by hospice policy must have a working knowledge of hospice policy regarding the use of restraint or seclusion.(13) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the client, a staff member, or others:(A) the client must be seen face-to-face within one hour after the initiation of the intervention by a physician or RN who has been trained in accordance with the requirements specified in subsection (m) of this section; and(B) the physician or RN must evaluate:(i) the client's immediate situation;(ii) the client's reaction to the intervention;(iii) the client's medical and behavioral condition; and(iv) the need to continue or terminate the restraint or seclusion.(14) If the face-to-face evaluation specified in paragraph (13) of this subsection is conducted by a trained RN, the trained RN must consult the medical director or physician designee as soon as possible after the completion of the one-hour face-to-face evaluation.(15) All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion. Simultaneous restraint and seclusion is only permitted if the client is continually monitored:(A) face-to-face by an assigned, trained staff member; or(B) by trained staff using both video and audio equipment. This monitoring must be close to the client.(16) When restraint or seclusion is used, there must be documentation in the client's record of:(A) the one-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior;(B) a description of the client's behavior and the intervention used;(C) alternatives or other less restrictive interventions attempted, if applicable;(D) the client's condition or symptoms that warranted the use of the restraint or seclusion; and(E) the client's response to the interventions used, including the rationale for continued use of the intervention.(m) Restraint or seclusion staff training requirements. A client has the right to safe implementation of restraint or seclusion by trained staff.(1) Client care staff working in the hospice inpatient unit must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a client in restraint or seclusion:(A) before performing any of the actions specified in paragraph (1) of this subsection;(B) as part of orientation; and(C) subsequently on a periodic basis consistent with hospice policy.(2) A hospice must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the client population in:(A) techniques to identify staff and client behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion;(B) the use of nonphysical intervention skills;(C) choosing the least restrictive intervention based on an individualized assessment of the client's medical or behavioral status or condition;(D) the safe application and use of all types of restraint or seclusion used in the hospice, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia);(E) clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary;(F) monitoring the physical and psychological well-being of a client who is restrained or secluded, including but not limited to respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospice policy associated with the one-hour face-to-face evaluation; and(G) the use of first-aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.(3) Persons providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address a client's behaviors.(4) A hospice must document in the staff personnel records that the training and demonstration of competency were successfully completed.(n) Death reporting requirements. A hospice must report deaths associated with the use of seclusion or restraint in its inpatient unit.(1) The hospice must report:(A) an unexpected death that occurs while a client is in restraint or seclusion;(B) an unexpected death that occurs within 24 hours after the client has been removed from restraint or seclusion; and(C) a death known to the hospice that occurs within one week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to the client's death. The term "reasonable to assume" in this context includes but is not limited to death related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing, or asphyxiation.(2) The hospice must report a death described in paragraph (1) of this subsection to HHSC by telephone at 1-800-458-9858 within 24 hours after knowledge of a client's death.(3) The hospice must complete Provider Investigation Report For Home and Community Support Services Agency (HHSC Form 3613) and send it to HHSC Complaint Intake Unit within 10 days after reporting the death to HHSC by telephone.(4) Hospice personnel must document in the client's record the date and time the death was reported to HHSC. Source Note: The provisions of this §558.871 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register, 44 TexReg 1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.871 Physical Environment in a Hospice Inpatient Unit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204640 03/12/2026 (a) Professional management. A hospice must assume responsibility for professional management of the hospice services it provides to a resident of a skilled nursing facility (SNF), nursing facility (NF), or an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), in accordance with the hospice plan of care. The hospice must make arrangements, as necessary for hospice-related inpatient care in a participating Medicare or Medicaid facility, in accordance with §558.850 of this subchapter (relating to Organization and Administration of Hospice Services) and §558.863 of this subchapter (relating to Hospice Short-term Inpatient Care).(b) Written contract. A hospice and SNF, NF, or ICF/IID must have a written contract that allows the hospice to provide services in the facility. The contract must be signed by an authorized representative of the hospice and the SNF, NF, or ICF/IID before hospice services are provided. In addition to the requirements in §558.289 of this chapter (relating to Independent Contractors and Arranged Services), the written contract must include:(1) the way the SNF, NF, or ICF/IID and the hospice are to communicate with each other and document such communications to ensure that the needs of a client are addressed and met 24 hours a day;(2) a provision that the SNF, NF, or ICF/IID immediately notifies the hospice of:(A) a significant change in the client's physical, mental, social, or emotional status;(B) clinical complications that suggest a need to alter the plan of care;(C) the need to transfer the client from the SNF, NF, or ICF/IID; or(D) the death of a client;(3) a provision stating that if the SNF, NF, or ICF/IID transfers the client from the facility that the hospice arranges for, and remains responsible for, any necessary continuous care or inpatient care related to the terminal illness and related conditions;(4) a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided;(5) an agreement that the SNF, NF, or ICF/IID is responsible for furnishing 24-hour room and board care, meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before the client elected hospice care;(6) an agreement that the hospice is responsible for providing services at the same level and to the same extent as those services would be provided if the SNF, NF, or ICF/IID resident were in his or her own home;(7) a delineation of the hospice's responsibilities, which include providing medical direction and management of the client; nursing; counseling, including spiritual, dietary and bereavement counseling; social work; medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions;(8) a provision that the hospice may use the SNF, NF, or ICF/IID nursing personnel where permitted by State law and as specified by the SNF, NF, or ICF/IID to assist in the administration of prescribed therapies included in the plan of care, only to the extent that the hospice would routinely use the services of a hospice client's family in implementing the plan of care;(9) a provision stating that the hospice must report an alleged violation involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client property by non-hospice personnel to the SNF, NF, or ICF/IID administrator within 24 hours after the hospice becomes aware of the alleged violation;(10) a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff; and(11) a provision regarding management and disposal, in compliance with applicable law, of drugs, including controlled substance prescription drugs and biologicals.(c) Hospice plan of care. In accordance with §558.821 of this subchapter (relating to Hospice Plan of Care), a written hospice plan of care must be established and maintained in consultation with SNF, NF, or ICF/IID representatives. Hospice care must be provided in accordance with the hospice plan of care.(1) A hospice plan of care must identify the care and services needed to care for the client and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care.(2) A hospice plan of care must reflect the participation of the hospice, representatives of the SNF, NF, or ICF/IID, and the client and family to the extent possible.(3) Any changes in the hospice plan of care must be discussed with the client or the client's LAR, and SNF, NF, or ICF/IID representatives, and must be approved by the hospice before implementation.(d) Coordination of services. In addition to the requirements in §558.288 of this chapter (relating to Coordination of Services) and §558.823 of this subchapter (relating to Coordination of Services by the Hospice), a hospice must:(1) designate a member of each interdisciplinary team (IDT) that is responsible for a client who is a resident of a SNF, NF, or ICF/IID who is responsible for:(A) providing overall coordination of the hospice care of the SNF, NF, or ICF/IID resident with SNF, NF, or ICF/IID representatives; and(B) communicating with SNF, NF, or ICF/IID representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the client and family; and(2) ensure that the hospice IDT communicates with the SNF, NF, or ICF/IID medical director, the client's attending practitioner, and other physicians participating in the provision of care to the client as needed to coordinate hospice care with medical care provided by other physicians; and(3) provide the SNF, NF, or ICF/IID with:(A) the most recent hospice plan of care specific to the client;(B) the hospice election form and any advance directives specific to the client;(C) physician certification and recertification of the terminal illness specific to the client;(D) names and contact information for hospice personnel involved in hospice care of the client;(E) instructions on how to access the hospice's 24-hour on-call system;(F) hospice medication information specific to the client; and(G) hospice physician and, if any, attending practitioner orders specific to the client.(e) Orientation and training of staff. Hospice personnel must ensure that SNF, NF or ICF/IID staff who provide care to the hospice's clients have been oriented and trained in the hospice philosophy, including the hospice's policies and procedures regarding methods of comfort, pain control, and symptom management, as well as principles about death and dying, how a person may respond to death, the hospice's client rights, the hospice's forms, and the hospice's record keeping requirements.(f) Management and disposal of drugs and biologicals. The policies and procedures of the hospice may not impede the SNF, NF, or ICF/IID from adhering to state, federal, and local law applicable to the disposal of drugs and biologicals in a facility. Source Note: The provisions of this §558.880 adopted to be effective October 1, 2013, 38 TexReg 6628; transferred effective May 1, 2019, as published in the April 12, 2019 issue of the Texas Register,44 TexReg1893; amended to be effective April 25, 2021, 46 TexReg 2427. 1 HEALTH AND HUMAN SERVICES COMMISSION 558 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES §558.880 Providing Hospice Care to a Resident of a Skilled Nursing Facility, Nursing Facility, or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219478 03/12/2026 The purpose of this chapter is to implement Texas Human Resources Code, Chapter 103, by establishing licensing procedures and standards for a DAHS facility. Source Note: The provisions of this §559.1 adopted to be effective August 31, 1993, 18 TexReg 2726; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective January 1, 1995, 19 TexReg 9531; amended to be effective May 1, 1999, 24 TexReg 3100; amended to be effective December 1, 2016, 41 TexReg 9327; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249; amended to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS A INTRODUCTION §559.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219479 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse-- Negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person's caretaker, family member, or other individual who has an ongoing relationship with the person, or sexual abuse of an elderly or disabled person, including any involuntary or nonconsensual sexual conduct that would constitute an offense under Texas Penal Code §21.08 (relating to Indecent Exposure) or Texas Penal Code, Chapter 22 (relating to Assaultive Offenses) committed by the person's caretaker, family member, or other individual who has an ongoing relationship with the person.(2) Actual harm--A negative outcome that compromises the physical, mental, or emotional well-being of an elderly person or a person with a disability receiving services at a facility.(3) Adult--A person 18 years of age or older or an emancipated minor.(4) Affiliate--With respect to a:(A) partnership, each partner of the partnership;(B) corporation, each officer, director, principal stockholder, and subsidiary; and each person with a disclosable interest;(C) natural person, includes each:(i) person's spouse;(ii) partnership and each partner thereof, of which said person or any affiliate of said person is a partner; and(iii) corporation in which the person is an officer, director, principal stockholder, or person with a disclosable interest.(5) Alzheimer's disease and related disorders--Alzheimer's disease and any other irreversible dementia described by the Centers for Disease Control and Prevention (CDC) or the most current edition of the Diagnostic and Statistical Manual of Mental Disorders.(6) Ambulatory--Mobility not relying on walker, crutch, cane, or other physical object or use of wheelchair.(7) Applicant--A person applying for a license under Texas Human Resources Code, Chapter 103.(8) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership.(9) Client--An individual receiving day activity and health services.(10) Construction, existing--See definition of existing building.(11) Construction, new--Construction begun after April 1, 2007.(12) Construction, permanent--A building or structure that meets a nationally recognized building code's details for foundations, floors, walls, columns, and roofs.(13) Controlling person--A person with the ability, acting alone or with others, to directly or indirectly influence, direct, or cause the direction of management, expenditure of money, or policies of a facility or other person. A controlling person includes:(A) a management company, landlord, or other business entity that operates or contracts with others for the operation of a facility;(B) any person who is a controlling person of a management company or other business entity that operates a facility or that contracts with another person for the operation of a facility;(C) an officer or director of a publicly traded corporation that is, or that controls, a facility, management company, or other business entity described in subparagraph (A) of this paragraph but does not include a shareholder or lender of the publicly traded corporation; and(D) any other individual who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of a facility, is in a position of actual control or authority with respect to the facility, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the facility, except an employee, lender, secured creditor, landlord, or other person who does not exercise formal or actual influence or control over the operation of a facility.(14) DADS--The term referred to the Texas Department of Aging and Disability Services; it now refers to HHSC.(15) DAHS--Day activity and health services. Health, social, and related support services as defined in this section.(16) DAHS facility--A facility that provides services through a day activity and health services program on a daily or regular basis, but not overnight, to four or more elderly persons or persons with disabilities who are not related to the owner of the facility by blood, marriage, or adoption.(17) DAHS program--A structured, comprehensive program offered by a DAHS facility that is designed to meet the needs of adults with functional impairments by providing DAHS in accordance with individual plans of care in a protective setting.(18) Days--Calendar days, unless otherwise specified.(19) Department--HHSC.(20) Dietitian consultant--A person licensed as a dietitian by the Texas Department of Licensing and Regulation or a person with a bachelor's degree with major studies in food and nutrition, dietetics, or food service management.(21) Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.(22) Direct service staff--An employee or contractor of a facility who directly provides services to individuals, including the director, a licensed nurse, the activities director, and an attendant. An attendant includes a driver, food service worker, aide, janitor, housekeeper, and laundry worker. A dietitian consultant is not a member of the direct service staff.(23) Director--The person responsible for the overall operation of a facility.(24) Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.(25) Elderly person--A person 65 years of age or older(26) Executive Commissioner--The executive commissioner of HHSC.(27) Existing building--A building or portion thereof that, at the time of initial inspection by HHSC, is used as an adult day care occupancy, as defined by Life Safety Code, NFPA 101, 2000 edition, Chapter 17, for existing adult day care occupancies; or has been converted from another occupancy or use to an adult day care occupancy, as defined by Chapter 16 for new adult day care occupancies.(28) Exploitation--An illegal or improper act or process of a caretaker, family member, or other individual who has an ongoing relationship with the elderly person or person with a disability, using the resources of an elderly person or person with a disability for monetary or personal benefit, profit, or gain without the informed consent of the elderly person or person with a disability.(29) Facility--A licensed DAHS facility.(30) Fence--A barrier to prevent elopement of an individual or intrusion by an unauthorized person, consisting of posts, columns, or other support members, and vertical or horizontal members of wood, masonry, or metal.(31) FM--FM Global (formerly known as Factory Mutual). A corporation whose approval of a product indicates a level of testing and certification that is acceptable to HHSC.(32) Fraud--A deliberate misrepresentation or intentional concealment of information to receive or to be reimbursed for service delivery to which an individual is not entitled.(33) Functional impairment--A condition that requires assistance with one or more personal care services.(34) Health assessment--An assessment of an individual by a facility used to develop the individual's plan of care.(35) Health services--Services that include personal care, nursing, and therapy services.(A) Personal care services include:(i) bathing;(ii) dressing;(iii) preparing meals;(iv) feeding;(v) grooming;(vi) taking self-administered medication;(vii) toileting;(viii) ambulation; and(ix) assistance with other personal needs or maintenance.(B) Nursing services may include:(i) administering medications;(ii) physician-ordered treatments, such as dressing changes; and(iii) monitoring the health condition of the individual.(C) Therapy services may include:(i) physical therapy;(ii) occupational therapy; and(iii) speech therapy.(36) HHSC--The Texas Health and Human Services Commission.(37) Human service program--An intentional, organized, ongoing effort designed to provide good to others. The characteristics of a human service program are:(A) dependent on public resources and are planned and provided by the community;(B) directed toward meeting human needs arising from day-to-day socialization, health care, and developmental experiences; and(C) used to aid, rehabilitate, or treat people in difficulty or need.(38) Human services--Include:(A) personal social services, including:(i) DAHS;(ii) counseling;(iii) in-home care; and(iv) protective services;(B) health services, including:(i) home health;(ii) family planning;(iii) preventive health programs;(iv) nursing facility; and(v) hospice;(C) education services, meaning:(i) all levels of school;(ii) Head Start; and(iii) vocational programs;(D) housing and urban environment services, including public housing;(E) income transfer services, including:(i) Temporary Assistance for Needy Families; and(ii) Supplemental Nutrition Assistance Program; and(F) justice and public safety services, including:(i) parole and probation; and(ii) rehabilitation.(39) Immediate threat to the health or safety of an elderly person or a person with a disability--A situation that causes, or is likely to cause, serious injury, harm, or impairment to, or the death of, an elderly person or a person with a disability receiving services at a facility.(40) Indirect ownership interest--Any ownership or membership interest in a person who has a direct ownership interest in an applicant or license holder.(41) Individual--A person who applies for or is receiving services at a facility.(42) Isolated--When a very limited number of elderly persons, or persons with disabilities, receiving services at a facility are affected and a very limited number of staff are involved, or the situation has occurred only occasionally.(43) License holder--A person who holds a license to operate a facility.(44) Life Safety Code, NFPA 101--The Code for Safety to Life from Fire in Buildings and Structures, NFPA 101, a publication of the National Fire Protection Association, Inc. that:(A) addresses the construction, protection, and occupancy features necessary to minimize danger to life from fire, including smoke, fumes, or panic; and(B) establishes minimum criteria for the design of egress features to permit prompt escape of occupants from buildings or, where desirable, into safe areas within the building.(45) Long-term care facility--A facility that provides care and treatment or personal care services to four or more unrelated persons, including:(A) a nursing facility licensed under Texas Health and Safety Code, Chapter 242;(B) an assisted living facility licensed under Texas Health and Safety Code, Chapter 247; and(C) an intermediate care facility serving individuals with an intellectual disability or related conditions licensed under Texas Health and Safety Code, Chapter 252.(46) LVN--Licensed vocational nurse. A person licensed by the Texas Board of Nursing who works under the supervision of an RN or a physician.(47) Management services--Services provided under contract between the owner of a facility and a person to provide for operation of a facility, including administration, staffing, maintenance, and delivery of services. Management services do not include contracts solely for maintenance, laundry, or food services.(48) Manager--A person who has a contractual relationship to provide management services to a facility.(49) Medically related program--A program providing the services listed in paragraph (37)(B) of this section.(50) Neglect--Failure to provide for oneself goods or services, including medical services, that are necessary to avoid physical harm, mental anguish, or mental illness; or failure of a caregiver to provide these goods or services.(51) NFPA--The National Fire Protection Association. The NFPA is an organization that develops codes, standards, recommended practices, and guides through a consensus standards development process approved by the American National Standards Institute.(52) NFPA 10--Standard for Portable Fire Extinguishers. A standard developed by the NFPA for selection, installation, inspection, maintenance, and testing of portable fire extinguishing equipment.(53) NFPA 13--Standard for the Installation of Sprinkler Systems. A standard developed by the NFPA for the minimum requirements for design and installation of automatic fire sprinkler systems, including the character and adequacy of water supplies and selection of sprinklers, fittings, pipes, valves, and all maintenance and accessories.(54) NFPA 70--National Electrical Code. A code developed by the NFPA for installation of electric conductors and equipment.(55) NFPA 72--National Fire Alarm Code. A code developed by the NFPA for application, installation, performance, and maintenance of fire alarm systems and their components.(56) NFPA 90A--Standard for the Installation of Air Conditioning and Ventilating Systems. A standard developed by the NFPA for systems for the movement of environmental air in structures that serve spaces over 25,000 cubic feet or buildings of certain heights and construction types, or both.(57) NFPA 90B--Standard for the Installation of Warm Air Heating and Air-Conditioning Systems. A standard developed by the NFPA for systems for movement of environmental air in one- or two-family dwellings and structures that serve spaces not exceeding 25,000 cubic feet.(58) NFPA 96--Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. A standard developed by the NFPA that provides the minimum fire safety requirements related to design, installation, operation, inspection, and maintenance of all public and private cooking operations, except for single-family residential usage.(59) Nurse--An RN or LVN licensed in the state of Texas.(60) Nursing services--Services provided by a nurse, including:(A) observation;(B) promoting and maintaining health;(C) preventing illness and disability;(D) managing health care during acute and chronic phases of illness;(E) guiding and counseling individuals and families; and(F) referral to physicians, other health care providers, and community resources when appropriate.(61) Online portal--A secure portal provided on the HHSC website for licensure activities, including for a DAHS facility applicant to submit licensure applications and information.(62) Pattern of violation--Repeated, but not widespread in scope, failures of a facility to comply with Texas Human Resources Code, Chapter 103, or a rule, standard, or order adopted under Texas Human Resources Code, Chapter 103 that:(A) result in a violation; and(B) are found throughout the services provided by the facility or that affect or involve the same elderly persons or persons with disabilities receiving services at the facility or the same facility employees.(63) Person--An individual, corporation, or association.(64) Person with a disability--A person whose functioning is sufficiently impaired to require frequent medical attention, counseling, physical therapy, therapeutic or corrective equipment, or another person's attendance and supervision.(65) Plan of care--A written plan, based on a health assessment and developed jointly by a facility and an individual or the individual's responsible party, that documents the functional impairment of the individual and the DAHS needed by the individual.(66) Potential for minimal harm--A violation that has the potential for causing no more than a minor negative impact to an individual.(67) Protective setting--A setting in which an individual's safety is ensured by the physical environment by staff.(68) Related support services--Services to an individual, family member, or caregiver that may improve the person's ability to assist with an individual's independence and functioning. Services include:(A) information and referral;(B) transportation;(C) teaching caregiver skills;(D) respite;(E) counseling;(F) instruction and training; and(G) support groups.(69) Responsible party--A person designated by an individual as the individual's representative.(70) RN--Registered nurse. A person licensed by the Texas Board of Nursing to practice professional nursing.(71) Safety--Protection from injury or loss of life due to conditions such as fire, electrical hazard, unsafe building or site conditions, and presence of hazardous materials.(72) Sanitation--Protection from illness, transmission of disease, or loss of life due to unclean surroundings, the presence of disease transmitting insects or rodents, unhealthful conditions or practices in preparation of food and beverage, or care of personal belongings.(73) Semi-ambulatory--Mobility relying on a walker, crutch, cane, or other physical object, or independent use of wheelchair.(74) Serious injury--An injury requiring emergency medical intervention or treatment by medical personnel, either at a facility or at an emergency room or medical office.(75) Social activities--Therapeutic, educational, cultural enrichment, recreational, and other activities in a facility or in the community provided as part of a planned program to meet the social needs and interests of an individual.(76) TAC--Texas Administrative Code.(77) UL--Underwriters Laboratories, Inc. A corporation whose approval of a product indicates a level of testing and certification that is acceptable to HHSC.(78) Widespread in scope--A violation of Texas Human Resources Code, Chapter 103, or a rule, standard, or order adopted under Texas Human Resources Code, Chapter 103, that:(A) is pervasive throughout the services provided by the facility; or(B) represents a systematic failure by the facility that affects or has the potential to affect a large portion or all the elderly persons or persons with disabilities receiving services at the facility.(79) Willfully interfere--To act or not act to intentionally prevent, interfere with, or impede.(80) Working with people--Acts involving delivery of services to individuals either directly or indirectly. Experience as a manager would meet this definition; however, experience in an administrative support position such as a bookkeeper does not. Experience does not have to be in a paid capacity. Source Note: The provisions of this §559.3 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS A INTRODUCTION §559.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219512 03/12/2026 (a) A person must not establish or operate a DAHS facility in Texas without a license issued by HHSC in accordance with Texas Human Resources Code, Chapter 103, and this chapter.(b) An applicant for a license must submit a complete application form and license fee to HHSC through the online portal in accordance with instructions provided with the application.(c) An applicant for a license must affirmatively demonstrate that the applicant meets:(1) the standards of the Life Safety Code, NFPA 101, 2000 edition;(2) the construction standards in Subchapter C of this chapter (relating to Facility Construction Procedures); and(3) the requirements for operation based on an on-site survey.(d) HHSC may deny an application that remains incomplete after 120 days.(e) Before issuing a license, HHSC considers the background and qualifications of:(1) the applicant or license holder:(2) a person with a disclosable interest;(3) an affiliate of the applicant or license holder;(4) controlling parties, such as a director or manager; and(5) anyone disclosed in the application in accordance with the instructions provided with the application.(f) HHSC issues a license if it finds that the applicant, and all persons described in subsection (e) of this section, meet all requirements of this chapter. The license is valid for three years.(g) A facility must not provide services to more clients than the number specified on its license.(h) A facility must prominently and conspicuously post its license for display in a public area of the facility that is readily accessible to individuals, employees, and visitors. Source Note: The provisions of this §559.11 adopted to be effective August 31, 1993, 18 TexReg 2726; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective January 1, 1995, 19 TexReg 9531; amended to be effective May 1, 1999, 24 TexReg 3100; amended to be effective May 1, 2002, 27 TexReg 3370; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective September 1, 2008, 33 TexReg 1151; amended to be effective September 1, 2009, 34 TexReg 5141; amended to be effective December 1, 2016, 41 TexReg 9327; amended to be effective October29, 2018, 43 TexReg 7219; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249; amended to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.11 Criteria for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219513 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219513 03/12/2026 (a) An applicant must use the online portal and the forms prescribed by HHSC to submit a license application and fulfill all licensure requirements and activities that can be met or conducted using the online portal.(b) An applicant must complete the application and furnish all documents and information that HHSC requests in accordance with the instructions provided with the application. An application must be complete, accurate, and submitted with full payment of applicable license fees described in §559.37 of this subchapter (relating to Fees). If an applicant provides incorrect or false information, or withholds information, HHSC may deny the application as described in §559.31 of this subchapter (relating to Criteria for Denying a License or Renewal of a License).(c) An application must include documentation from the local fire authority that the facility and its operations meet local fire ordinances.(d) If an applicant decides not to continue the application process for a license after submitting an application and license fee, the applicant must submit to HHSC a request to withdraw the application. HHSC does not refund the license fee for an application that is withdrawn, except as provided in §559.15(e) - (g) of this subchapter (relating to Time Periods for Processing Licensing Applications). Source Note: The provisions of this §559.13 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.13 General Application Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219514 03/12/2026 (a) HHSC only processes applications received at least 60 days before the requested date of the license issuance.(b) An application is complete when all requirements for licensing have been met, including compliance with standards. If an inspection for compliance is required, the application is not complete until the inspection has occurred, reports have been reviewed, and the applicant complies with the standards.(c) The HHSC Regulatory Services Licensing and Credentialing Section notifies facilities through the online portal within 30 days after receipt of the application if any of the following applications are incomplete:(1) initial;(2) change of ownership;(3) renewal; and(4) increase in capacity.(d) Except as provided in subsection (e) of this section, HHSC issues or denies a license within 30 days after the receipt of a complete application or within 30 days before the expiration date of the license. HHSC may delay an action on an application for renewal of a license for up to six months if the facility is subject to a proposed or pending licensure termination action on or within 30 days before the expiration date of the license. Issuing the license constitutes HHSC's official written notice to the facility of application acceptance and filing.(e) In the event an application is not processed in the time periods established in this section, the applicant has a right to request from the program director full reimbursement of all filing fees paid as part of that application process. If the program director does not agree that the established periods have been exceeded or finds that good cause existed for exceeding the established periods, the request is denied.(f) Good cause for exceeding an established period is considered to exist if:(1) the number of applications to be processed by HHSC exceeds by 15 percent or more the number processed in the same calendar quarter of the preceding year;(2) another public or private entity involved in the application process caused the delay; or(3) other conditions existed giving good cause for exceeding the established periods.(g) If the request for full reimbursement is denied, the applicant may appeal directly to HHSC's executive commissioner for resolution of the dispute. The applicant must send a written statement to the executive commissioner describing the request for reimbursement and the reasons for it. The program director may also send a written statement to the executive commissioner describing the program's reasons for denying reimbursement. The executive commissioner makes a timely decision concerning the appeal and notifies the applicant and the program in writing of the decision. Source Note: The provisions of this §559.15 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.15 Time Periods for Processing Licensing Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219515 03/12/2026 (a) Local fire authority. All initial, change of ownership, and renewal applications for licensure must include the written approval of the local fire authority that the facility and its operation meet local fire ordinances. The written approval must be uploaded into the application in the online portal.(b) Local health authority. The following procedures allow the local health authority to provide recommendations to HHSC concerning facility licensure.(1) New facility. The sponsor of a new facility under construction or a previously unlicensed facility must provide to HHSC a copy of a dated written notice to the local health authority that construction or modification has been or will be completed by a specific date. This notice must be uploaded into the application submitted through the online portal. The sponsor must also provide a copy of a dated written notice of the approval for occupancy by the local fire marshal or local building code authority, if applicable, by uploading the notice into the application submitted through the online portal. The local health authority may provide recommendations to the HHSC Regulatory Services Licensing and Credentialing Section regarding the status of compliance with local codes, ordinances, or regulations.(2) Increase in capacity. The license holder must submit an application through the online portal for approval of an increase in capacity from the HHSC Regulatory Services Licensing and Credentialing Section. The license holder must notify the local fire marshal and health authority of the request. The license holder must arrange for the inspection of the facility by the local fire marshal. The facility must upload a copy of the written notice sent to the local health authority notifying them of the increase in capacity into the capacity increase application submitted through the online portal. HHSC approves the application only if the facility is found to be in compliance with the standards. Upon approval, the HHSC Regulatory Licensing and Credentialing Section issues a license with the increased capacity.(3) Change of ownership. The applicant for a change of ownership license must provide to HHSC a copy of a letter notifying the local health authority of the request for a change of ownership by uploading the letter into the change of ownership application submitted through the online portal. The local health authority may provide recommendations to HHSC regarding the status of compliance with local codes, ordinances, or regulations.(4) Renewal. The applicant for renewal must provide to HHSC a copy of a letter notifying the local health authority of the request for a renewal by uploading the letter into the renewal application submitted through the online portal. The local health authority may provide recommendations to HHSC regarding the status of compliance with local codes, ordinances, or regulations. The local authority may also recommend that a state license be issued or denied; however, the final decision on licensure status remains with HHSC. Source Note: The provisions of this §559.17 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.17 Building Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219516 03/12/2026 (a) Scope of section. No person may apply for a license, change of ownership, increase in capacity, or license renewal to operate or maintain a facility without disclosing information as required in this section.(b) Disclosures. Disclosures are made on each application as defined in this section and as required by the instructions for the application submitted.(c) General information required.(1) For initial, change of ownership, renewal, and change applications related to capacity and real estate, evidence of the right to possession of the facility at the time of the application must be submitted. This requirement may be satisfied by uploading applicable portions of a lease agreement, deed or trust, or other appropriate legal document into the application submitted through the online portal. The names and addresses of any persons or organizations listed as owner of record in the real estate, including the buildings and grounds appurtenant to the buildings, must be disclosed to HHSC in the application submitted through the online portal.(2) At the request of HHSC, an applicant or license holder must provide to HHSC any additional background information within 30 days after HHSC's request. Source Note: The provisions of this §559.19 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.19 Applicant Disclosure Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219517 03/12/2026 (a) An applicant for an initial license must submit an application in accordance with §559.13 of this subchapter (relating to General Application Requirements) and include full payment of the fees required in §559.37 of this subchapter (relating to Fees).(b) HHSC reviews an application for an initial license within 30 days after the date the HHSC Licensing and Credentialing Section, Long-term Care Regulation, receives the application and the associated fees and notifies the applicant if additional information is needed to complete the application.(c) The applicant must notify HHSC via the online portal indicating that the facility is ready for a Life Safety Code (LSC) inspection. The notice must be submitted with the application or within 120 days after the HHSC Licensing and Credentialing Section, Long-term Care Regulation, receives the application. After the applicant has satisfied the application submission requirements in §559.11 of this subchapter (relating to Criteria for Licensing) and §559.13 of this subchapter, HHSC staff conduct an on-site LSC inspection of the facility to determine if the facility meets the applicable physical plant requirements in Subchapter C of this chapter (relating to Facility Construction Procedures).(d) If the applicant fails to meet the licensure requirements within 120 days after the initial LSC inspection, HHSC denies the application for a license.(e) After an applicant has met the licensure requirements in Subchapter C of this chapter and admitted at least one but no more than three clients, the applicant must notify HHSC via the online portal that the facility is ready for a health inspection.(1) HHSC staff conduct an on-site health inspection to determine if the facility meets the licensure requirements for standards of operation and client care in Subchapter D of this chapter (relating to Standards for Licensure).(2) If the facility fails to meet the licensure requirements for standards of operation and client care within 120 days after the initial health inspection, HHSC denies the application for a license.(f) HHSC issues a license within 30 days after HHSC determines that the applicant and the facility have met the licensure requirements of this section. Issuing a license constitutes HHSC's official written notice to the facility of the approval of the application.(g) HHSC may deny an application for an initial license if the applicant, controlling person, or any person required to submit background and qualification information fails to meet the criteria for a license established in §559.11 of this subchapter.(h) If HHSC denies an application for an initial license, HHSC sends the applicant a written notice of the denial and informs the applicant of the applicant's right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with HHSC rules in 1 TAC, Part 15, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). Source Note: The provisions of this §559.21 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.21 Initial License Application Procedures and Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219518 03/12/2026 (a) A license issued under this chapter:(1) expires three years after the date issued;(2) must be renewed before the license expiration date; and(3) is not automatically renewed.(b) The submission of a license fee alone does not constitute an application for renewal.(c) The completion of a renewal survey alone does not renew the license. A renewal application submitted through the online portal is required.(d) If a renewal application is not generated in the online portal within 120 days of expiration, it is the responsibility of the facility to request from HHSC that one be generated.(e) To renew a license, a license holder must submit an application for renewal through the online portal no later than the 45th day before the expiration date of the current license. HHSC considers that an application for renewal has met the submission deadline if the license holder:(1) submits a complete application to HHSC, and HHSC receives that complete application through the online portal no later than the 45th day before the expiration date of the current license;(2) submits an incomplete application to HHSC through the online portal and uploads a letter explaining the circumstances that prevented the inclusion of the missing information, and HHSC receives the incomplete application and letter no later than the 45th day before the expiration date of the current license; or(3) submits a complete application or an incomplete application through the online portal with a letter uploaded into the application explaining the circumstances that prevented the inclusion of the missing information to HHSC, HHSC receives the application during the 45-day period ending on the date the current license expires, and the license holder pays a late fee in accordance with §559.37(a)(2) of this subchapter (relating to Fees) in addition to the license renewal fee.(f) If the application is submitted through the online portal along with the appropriate licensing fee by the submission deadline, HHSC considers the application to be timely filed. It is the license holder's responsibility to ensure that the application is timely received by HHSC by submission through the online portal.(g) For purposes of Texas Government Code §2001.054, HHSC considers that an individual has submitted a timely and sufficient application for renewal of a license if the license holder's application has met the submission deadlines in subsections (e) and (f) of this section. Failure to submit a timely and sufficient application results in the expiration of the license on the expiration date listed on the license.(h) HHSC does not accept an application for renewal submitted after the expiration date of the license. An application for an initial license must be submitted and must comply with the requirements for an initial license in §559.11 of this subchapter (relating to Criteria for Licensing) and §559.19 of this subchapter (relating to Applicant Disclosure Requirements).(i) The application for renewal must contain the same information required for an initial application and the license fee as described in §559.37 of this subchapter.(j) The renewal of a license may be denied for the same reasons an original application for a license may be denied under the criteria in §559.31 of this subchapter (relating to Criteria for Denying a License or Renewal of a License).(k) The facility must have an annual inspection by the local fire marshal and must submit a copy of the most current inspection as part of the renewal procedures by uploading the report into the renewal application through the online portal. Source Note: The provisions of this §559.23 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.23 Renewal Procedures and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219519 03/12/2026 (a) For purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the new operator of a facility that exists on the date the application is submitted.(b) A license holder may not transfer its license. The applicant (new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When HHSC approves the change of ownership by issuing a temporary change of ownership license to the new license holder, the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the change of ownership application. Between the effective date of the change of ownership and issuance of the temporary change of ownership license, the existing license holder remains responsible under its license; however, the applicant may operate a facility on behalf of the current license holder during such time period.(c) The applicant must submit to HHSC through the online portal:(1) a complete application for a license in accordance with HHSC instructions and §559.11 of this subchapter (relating to Criteria for Licensing) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) the application fee, in accordance with §559.37 of this subchapter (relating to Fees); and(3) a signed and notarized Change of Ownership Transfer Affidavit, HHSC Form 1092, from the applicant and the facility's current license holder of intent to transfer operation of the facility from the current license holder to the applicant, beginning on the change of ownership effective date specified on the change of ownership application.(d) To avoid a facility operating without a license, an applicant must submit all items required by subsection (c) of this section at least 30 days before the anticipated date of a change of ownership, unless the 30-day notice requirement is waived in accordance with subsection (e) of this section.(e) HHSC may waive the 30-day notice required in subsection (d) of this section if HHSC determines that the applicant presents evidence showing that circumstances prevented the submission of the items in subsection (c) of this section at least 30 days before the anticipated change of ownership and that not waiving the 30-day requirement would create a threat to client health and safety.(f) Upon HHSC approval of the items specified in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all persons disclosed in the application satisfy all applicable requirements in §559.11 of this subchapter, §559.19 of this subchapter (relating to Applicant Disclosure Requirements), and §559.31 of this subchapter (relating to Criteria for Denying a License or Renewal of a License).(1) Issuing a temporary change of ownership license constitutes HHSC's official written notice to the facility of the approval of the application for a change of ownership.(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online portal.(g) A temporary change of ownership license expires on the earlier of:(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (h) of this section; or(2) the date HHSC issues a three-year license in accordance with subsection (k) of this section.(h) HHSC, in its sole discretion, may extend a temporary change of ownership license for a term of 90 days at a time based upon extenuating circumstances.(i) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site health inspection after issuing a temporary change of ownership license if:(1) less than 50 percent of the direct or indirect ownership interest of the former license holder changed, when compared to the new license holder; or(2) every person with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(j) HHSC, in its sole discretion, may conduct an on-site Life Safety Code inspection after issuing a temporary change of ownership license.(k) If the applicant, all controlling persons, and all persons disclosed in the application satisfy all applicable requirements for a license in §§559.11, 559.19, and 559.31 of this subchapter, and the facility passes the change of ownership health inspection as described in subsection (i) of this section, HHSC issues a three-year license. The effective date of the three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application was received by HHSC through the online portal.(l) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC of the addition no later than 30 days after the addition of the owner.(m) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name. Source Note: The provisions of this §559.25 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.25 Change of Ownership and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219520 03/12/2026 (a) A license holder must not relocate a facility without approval from HHSC. The license holder must submit a complete application and the fee required under §559.37 of this subchapter (relating to Fees) to HHSC through the online portal before the relocation.(b) Clients must not be relocated until the new building has been inspected and approved as meeting the standards of Life Safety Code, NFPA 101, 2000 edition, as applicable to day activity health services facilities.(c) Following Life Safety Code, NFPA 101, 2000 edition, approval by HHSC, the license holder must notify HHSC of the date clients will be relocated. If the new facility meets the standards for operation based on an on-site survey, HHSC issues a license for the new location.(d) The effective date of this license is the date all clients are relocated.(e) The license holder must continue to maintain the license at the current location and meet all requirements for facility operation until the date of the relocation. Source Note: The provisions of this §559.27 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.27 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219521 03/12/2026 (a) A facility must submit an application for a change of director through the online portal within 30 days before or after the change. The new director must submit qualifying documentation for approval to the HHSC Regulatory Services Regional Office within 30 days before or after the change, as specified in §559.59 of this chapter (relating to Staff Qualifications).(b) A new facility activities director must submit qualifying documentation for approval within 30 days before or after the change, as specified in §559.59 of this chapter.(c) If the facility does not have a director or activities director within 30 days after a vacancy, the facility must submit a letter to the HHSC Regulatory Services Regional Office requesting an extension. The HHSC Regulatory Services Regional Office notifies the facility in writing of the length of any extension. Source Note: The provisions of this §559.29 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.29 Change of Staff https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219522 03/12/2026 (a) HHSC may deny an initial license or refuse to renew a license if any person described in §559.11(e) of this subchapter (relating to Criteria for Licensing):(1) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;(2) substantially fails to comply with the requirements described in §559.42 of this chapter (relating to Safety), §559.43 of this chapter (relating to Sanitation), and Subchapter D of this chapter (relating to Standards for Licensure), including:(A) noncompliance that poses a serious threat to health and safety; or(B) failure to maintain compliance on a continuous basis;(3) aids, abets, or permits a substantial violation described in paragraph (2) of this subsection about which the person had or should have had knowledge;(4) fails to provide the required information, facts, or references;(5) knowingly provides false or fraudulent information by:(A) submitting false or intentionally misleading statements to HHSC;(B) using subterfuge or other evasive means of filing;(C) engaging in subterfuge or other evasive means of filing on behalf of another who is unqualified for licensure;(D) knowingly concealing a material fact; or(E) being responsible for fraud;(6) fails to pay when due:(A) licensing fees as described in §559.37 of this subchapter (relating to Fees); and(B) franchise taxes, if applicable; or(7) has a history of any of the following actions during the five-year period preceding the date of the application:(A) received a sanction for operating a facility that has been decertified or had its contract canceled under the Medicare or Medicaid program in any state;(B) being assessed federal or state Medicare or Medicaid sanctions or penalties;(C) received unsatisfied final judgments;(D) was evicted from any property or space used as a facility in any state; or(E) received a suspension of a license to operate a health facility, long-term care facility, assisted living facility, or a similar facility in any state.(b) Concerning subsection (a)(7) of this section, HHSC may consider exculpatory information provided by any person described in §559.11(e) of this subchapter and grant a license if HHSC finds that person able to comply with the rules in this chapter.(c) HHSC does not issue a license to an applicant to operate a new facility if the applicant has a history of any of the following actions during the five-year period preceding the date of the application:(1) revocation of a license to operate a health care facility, nursing facility, assisted living facility, or similar facility in any state;(2) debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or(3) a court injunction prohibiting any person described in §559.11(e) of this subchapter from operating a facility.(d) Only final actions are considered for purposes of subsection (a)(7) of this section and subsection (c) of this section. An action is final when routine administrative and judicial remedies are exhausted. All actions, whether pending or final, must be disclosed.(e) If an applicant owns multiple facilities, the overall record of compliance in all the facilities is examined. An overall record poor enough to deny issuing a new license does not preclude renewing licenses of individual facilities with satisfactory records.(f) If HHSC denies a license or refuses to issue a license renewal, the applicant or license holder may request a hearing by following HHSC rules in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). An administrative hearing is conducted in accordance with Texas Government Code, Chapter 2001, and 1 TAC Chapter 357, Subchapter I. Source Note: The provisions of this §559.31 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.31 Criteria for Denying a License or Renewal of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219523 03/12/2026 (a) Before starting proceedings to revoke or suspend a license or deny an application for the renewal of a license, HHSC gives the applicant or license holder:(1) notice by personal service or registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all requirements of law for the retention of the license by sending the director of the HHSC Regulatory Enforcement Section a written request for an opportunity to show compliance. The request must:(A) be postmarked within 10 days after the date of HHSC's notice and received in the state office of the director of the HHSC Regulatory Enforcement Section within 10 days after the date of the postmark; and(B) contain specific documentation refuting HHSC's allegations.(b) HHSC's review is limited to a review of documentation submitted by the license holder and information used by HHSC as the basis for its proposed action and is not conducted as an adversary hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action. Source Note: The provisions of this §559.33 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.33 Opportunity to Show Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219524 03/12/2026 (a) Increase in Capacity.(1) During the license term, a license holder may not increase capacity without approval from HHSC. The license holder must submit to HHSC a complete application for increase in capacity through the online portal.(2) Upon approval of an increase in capacity following a Life Safety Code Survey, HHSC issues a new license.(b) Decrease in Capacity.(1) A license holder that wishes to decrease the licensed capacity of the facility must provide notification via the online portal to HHSC Licensing and Credentialing Section, Long-term Care Regulation. The notification must include the desired capacity for the new license.(2) Upon receipt of the notification, HHSC issues a new license with the desired capacity indicated in the notification. Source Note: The provisions of this §559.35 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.35 Change in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219525 03/12/2026 (a) License Fees.(1) The license fee is $75 for a three-year license. The fee must be paid with each initial application, change of ownership application, and application for license renewal. A facility or applicant must pay fees in accordance with the options available in the online portal.(2) An applicant for license renewal who submits an application during the 45-day period ending on the date the current license expires must pay a late fee of $25 in addition to the license fee described in paragraph (1) of this subsection.(b) Plan Review Fees.(1) HHSC charges a fee to review plans for new buildings and conversion of buildings not licensed by HHSC and for additions and remodeling existing licensed facilities.(2) HHSC fee schedule by building type:(A) new buildings or conversion of buildings not licensed by HHSC--$12 per client (minimum $500 and maximum $1,000); or(B) additions or remodeling existing licensed facilities--2 percent of construction cost (minimum $250 and maximum $750). Source Note: The provisions of this §559.37 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.37 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219526 03/12/2026 (a) A provider must notify HHSC in writing at least five days before permanent closure of the operation.(b) The provider must include in the written notice:(1) the date of permanent closure;(2) the reason for closing;(3) the location of individual records, both active and inactive; and(4) the name and address of the individual records custodian. Source Note: The provisions of this §559.39 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS B APPLICATION PROCEDURES §559.39 Voluntary Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202979 03/12/2026 (a) Construction phase.(1) DADS' Regulatory Services Licensing and Credentialing Section must be notified in writing before construction starts.(2) All construction must be done in accordance with minimum licensing requirements. It is the sponsor's responsibility to employ qualified personnel to prepare the contract documents for construction of a new facility or remodeling of an existing facility. Contract documents for additions and remodeling and for the construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect. Certain parts of final plans, designs, and specifications must bear the seal of a registered professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. These certain parts include sheets and sections covering structural, electrical, mechanical, and sanitary engineering.(A) Remodeling is the construction, removal, or relocation of walls and partitions; the construction of foundations, floors, or ceiling-roof assemblies; the expanding or altering of safety systems (including sprinkler, fire alarm, and emergency systems); or the conversion of space in a facility to a different use.(B) General maintenance and repairs of existing material and equipment, repainting, applications of new floor, wall, or ceiling finishes, or similar projects are not included as remodeling, unless as a part of new construction. DADS must be provided flame spread documentation for new materials applied as finishes.(b) Contract documents.(1) Site plan documents must include grade contours; streets with names; north arrow; fire hydrants; fire lanes; utilities, public or private; fences; unusual site conditions, such as ditches, low water levels, other buildings on-site; and indications of buildings five feet or less beyond site property lines.(2) Foundation plan documents must include general foundation design and details.(3) Floor plan documents must include room names, numbers, and usages; numbered doors including swing; windows; legend or clarification of wall types; dimensions; fixed equipment; plumbing fixtures; and kitchen basic layout; and identification of all smoke barrier walls (outside wall to outside wall) or fire walls.(4) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2 inch by 11 inch sheet; two reduced plans must be submitted for file record. See subsection (d)(3) of this section.(5) Schedules must include door materials, widths, types; window materials, sizes, types; room finishes; and special hardware.(6) Elevations and roof plan must include exterior elevations, including material note indications and any roof top equipment; roof slopes, drains, and gas piping; and interior elevations where needed for special conditions.(7) Details must include wall sections as needed (especially for special conditions); cabinet and built-in work, basic design only; cross sections through buildings as needed; and miscellaneous details and enlargements as needed.(8) Building structure documents must include structural framing layout and details (primarily for column, beam, joist, and structural frame building); roof framing layout (when this cannot be adequately shown on cross section); cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design, also calculated design loads.(9) Electrical documents must include electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices; service, circuiting, distribution, and panel diagrams; exit light system (exit signs and emergency egress lighting); emergency electrical provisions (such as generators and panels); fire alarm and similar systems (such as control panel, devices, and alarms); sizes and details sufficient to assure safe and properly operating systems; and a staff communication system.(10) Plumbing documents must include plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems, water systems, sanitary systems, gas systems, other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(11) Heating, ventilation, and air-conditioning (HVAC) documents must include sufficient details of HVAC systems and components to assure a safe and properly operating installation, including heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke, fire dampers, or combination fire and smoke dampers; and equipment types, sizes, and locations.(12) If a sprinkler system is provided or required by any authority, documents must include plans and details of NFPA designed systems; plans and details of partial systems provided only for hazardous areas; and electrical devices interconnected to the alarm system.(13) Other layouts, plans, or details as may be necessary for a clear understanding of the design and scope of the project, including plans covering private water or sewer systems must be reviewed by the local health or waste water authority having jurisdiction.(14) Specifications must include installation techniques, quality standards and/or manufacturers, references to specific codes and standards, design criteria, special equipment, hardware, painting, and any others as needed to amplify drawings and notes.(c) Initial survey of completed construction.(1) Upon completion of construction, including grounds and basic equipment and furnishings, a final construction inspection (initial survey) of the facility, including additions or remodeled areas, is required to be performed by the DADS Regulatory Services Regional Office before occupancy. The completed construction must have the written approval of the local authorities having jurisdiction, including the fire marshal and building inspector.(2) After the completed construction has been surveyed by DADS and found acceptable, this information will be conveyed to DADS' Regulatory Services Licensing and Credentialing Section as part of the information needed to issue a license to the facility. In the case of additions or remodeling of existing facilities, a revision or modification to an existing license may be necessary. The building, grades, drives, and parking must essentially be 100% complete at the time of this initial visit for occupancy approval and licensing, including basic furnishings and operational needs. A facility may accept up to three clients between the time it receives initial approval from DADS and the time the license is issued.(3) The following documents must be available to DADS' surveyor at the time of the survey of the completed building:(A) written approval of local authorities as called for in paragraph (1) of this subsection;(B) written certification of the fire alarm system by the installing agency (Fire Alarm Installation Certificate of the Texas State Fire Marshal);(C) documentation for all materials used in the building that are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant curtains (including cubicle curtains), and rated ceilings. This documentation must include a signed letter from the installer verifying that the material installed is named in the laboratory test document;(D) approval of the completed sprinkler system installation by the designing engineer, including a copy of the material list and test certification;(E) service contracts for maintenance and testing of alarm systems, sprinkler systems, etc.;(F) a copy of gas test results of the facility's gas lines from the meter;(G) a written statement from an architect or engineer stating that he certifies that the building was constructed to meet Life Safety Code, NFPA 101, 2000 edition, and all locally applicable codes, and that the facility is in substantial conformance with minimum licensing requirements; and(H) the contract documents specified in subsection (b) of this section.(d) Nonapproval of new construction.(1) If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, he may recommend to DADS that the facility not yet be licensed and approved for occupancy. Such basic items may include the following:(A) construction that does not meet minimum code or licensure standards for basic requirements such as corridors being less than required width, ceilings installed at less than the minimum seven-foot six-inch height, client bedroom dimensions less than required, and other such features that would disrupt or otherwise adversely affect the clients and staff if corrected after occupancy;(B) no written approval by local authorities;(C) fire protection systems not completely installed or not functioning properly, including fire alarm systems, emergency power and lighting, and sprinkler systems;(D) required exits not all usable according to Life Safety Code, NFPA 101, 2000 edition;(E) telephone not installed or not properly working;(F) sufficient basic furnishings, essential appliances, and equipment are not installed or not functioning; and(G) any other basic operational or safety feature that the surveyor, as the authority having jurisdiction, encounters, which in his judgment would preclude safe and normal occupancy by clients on that day.(2) If the surveyor encounters only less basic and less important deficiencies, licensure may be recommended based on an approved written plan of correction from the facility's administrator.(3) Copies of reduced size floor plans on an 8 1/2 inch by 11 inch sheet must be submitted in duplicate to DADS for record or file use and for the facility's use and for facility's use for evacuation plan, fire alarm zone identification, etc. The plan must contain basic legible information such as scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information. Source Note: The provisions of this §559.41 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective November 1, 2000, 25 TexReg 10753; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS C FACILITY CONSTRUCTION PROCEDURES §559.41 Construction and Initial Survey of Completed Construction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202980 03/12/2026 (a) Environmental safety. (1) The physical plant safety requirements are designed to provide safety to the clients, participants, or adult individuals receiving day care. (2) The facility must conform to all applicable state laws and local ordinances pertaining to occupancy. When these laws, codes, and ordinances are more stringent than the standards in this section, the more stringent requirements govern. If state laws or local codes or ordinances conflict with the requirements of these standards, DADS' Regulatory Services Licensing and Credentialing Section will be so informed so that these conflicts may be legally resolved. (3) The facility must meet the provisions and requirements concerning accessibility for individuals with disabilities in the following laws and regulations: the Americans with Disabilities Act (ADA) of 1990 (Title 42, United States Code, Chapter 126); Title 28, Code of Federal Regulations, Part 35; Texas Government Code, Chapter 469, Elimination of Architectural Barriers; and 16 TAC, Chapter 68, Elimination of Architectural Barriers. Plans for new construction, substantial renovations, modifications, and alterations must be submitted to the Texas Department of Licensing and Regulation (Attn: Elimination of Architectural Barriers Program) for accessibility approval under Texas Government Code, Chapter 469. At least 50% of the client restrooms must be in accordance with ADA. Exception: Facilities licensed for 45 or fewer persons may provide one unisex restroom in accordance with accessibility requirements. (4) DADS' jurisdiction extends beyond the licensed facility when the licensed area is only a part of a building or floor that is not fire-separated in accordance with the Life Safety Code, NFPA 101, 2000 edition, §16.1.2, New Day-Care Centers, or Life Safety Code, NFPA 101, 2000 edition, §17.1.2, Existing Day-Care Centers with Mixed Occupancies. (b) Life Safety Code, NFPA 101, 2000 edition. (1) The principles of the Life Safety Code, NFPA 101, 2000 edition, under Chapter 16 for new day-care centers or Chapter 17 for existing day-care centers, and operating features under §16.7 or §17.7, must be used in establishing life safety requirements for adult day care facilities, with the interpretation and exceptions as listed in paragraphs (2) and (3) of this subsection. Chapter 16 of the Life Safety Code, NFPA 101, 2000 edition, is applicable to new construction, conversions of existing unlicensed buildings, remodeling, and additions conducted after April 1, 2007. Chapter 17 of the Life Safety Code, NFPA 101, 2000 edition, is applicable to existing adult day-care facilities licensed before April 1, 2007. Life safety features and equipment installed in existing buildings that are now in excess of what is required by the Life Safety Code, NFPA 101, 2000 edition, must continue to be maintained or may be completely removed if prior written approval is obtained from DADS. (2) Interpretations of the Life Safety Code, NFPA 101, 2000 edition, chapters 16 and 17, are as follows: (A) The principles of chapters 16 and 17 apply to any size facility requiring licensing with four or more clients or participants. (B) The principles of §16.1.4.2 and §17.1.4.2 relating to a building or portion thereof used less than 24 hours per day to house more than three adults requiring care, maintenance, and supervision by other than a relative apply to all facilities requiring licensing. A client must be ambulatory or semi-ambulatory and must not be bedridden. A client must not exhibit behavior that is harmful to the client or others. (C) The manual fire alarm system and automatic smoke detection system must be installed in accordance with NFPA 72 National Fire Alarm Code series and state fire marshal licensing requirements. (D) The facility must have a program to inspect, test, and maintain the fire alarm system and must execute the program at least once every six months. (i) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program. (ii) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign, and date an inspection form similar to the inspection and testing form in NFPA 72 for a service provided under the contract. (iii) The facility must ensure fire alarm system components that require visual inspection are visually inspected in accordance with NFPA 72. (iv) The facility must ensure fire alarm system components that require testing are tested in accordance with the NFPA 72. (v) The facility must ensure fire alarm system components that require maintenance are maintained in accordance with NFPA 72. (vi) The facility must ensure smoke dampers are inspected and tested in accordance with NFPA 101, 2000 edition. (vii) The facility must maintain onsite documentation of compliance with this subsection and have available for examination by DADS, operation and maintenance manuals, and a written sequence of operation. (E) If the facility has a complete NFPA 13 system, the facility must have a program to inspect, test, and maintain the sprinkler system and must execute the program at least once every six months. (i) The facility must contract with a company that is registered by the State Fire Marshal's Office to execute the program. (ii) The person who performs a service under the contract must be licensed by the State Fire Marshal's Office to perform the service and must complete, sign, and date an inspection form similar to the inspection and testing form in NFPA 25 for a service provided under the contract. (iii) The facility must ensure sprinkler system components that require visual inspection are visually inspected in accordance with NFPA 13 and 25. (iv) The facility must ensure sprinkler system components that required testing are tested in accordance with the NFPA 13 and 25. (v) The facility must ensure sprinkler system components that require maintenance are maintained in accordance with NFPA 13 and 25. (vi) The facility must ensure that individual sprinkler heads are inspected and maintained in accordance with NFPA 13 and 25. (vii) The facility must maintain onsite documentation of compliance with this subsection and have available for examination by DADS as built drawings, operation and maintenance manuals, and a written sequence of operation. (F) All facilities must follow the Life Safety Code, NFPA 101, 2000 edition, chapters 16 or 17, including the following: (i) If a center is located in a building containing mixed occupancies, the occupancies must be separated by one-hour fire barriers. (ii) Each floor occupied by clients must have access to two remote exits in accordance with Chapter 7, Means of Egress. (I) Doors in the means of egress must be equipped with hardware that opens with a single motion. (II) Doors must swing in the direction of egress for occupant loads greater than 50 occupants. (iii) Every room or space normally subject to client occupancy, other than bathrooms or any room with attended individual clients, must have at least one outside window for emergency rescue or ventilation. Such window must be able to be opened from the inside without the use of tools and provide a clear opening of not less than 20 inches in width, 24 inches in height, and 5.7 sq. ft. (821 sq. in.) in area (minimum width of 20 inches by 41.2 inches high and minimum height of 24 inches by 34.2 inches wide). The bottom of the opening must be not more than 44 inches (112 cm.) above the floor. In rooms located greater than three stories above grade, the openable clear height, width, and area of the window may be modified to the dimensions necessary for ventilation. Exceptions are: (I) buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with §9.7; (II) rooms or spaces with a door leading directly to the outside of the building; or (III) in existing facilities, rooms smaller than 250 square feet. (iv) Interior finish in stairways, corridors, and lobbies must be Class A. All other walls and ceilings must be Class A or Class B interior finish in accordance with Life Safety Code, NFPA 101, 2000 edition, §10.2.3. Flame spread is the rate of fire travel along the surface of a material. (This is different from other requirements for time-rated "burn through" resistance ratings such as one-hour rated.) Flame spread ratings are Class A (0-25), Class B (26-75), and Class C (76-200). (v) Floor finish materials within corridors and exits must be Class I or Class II in accordance with §10.2.7 in new construction or new installations of flooring. Replacement or newly installed floor finish materials must be Class I or II. Existing floor finish materials in good condition may remain in use in accordance with §10.2. (vi) A smoke detection system must be installed in accordance with §9.6 with placement of detectors in each story in front of the doors to the stairways and in the corridors of all floors occupied by the day-care occupancy. Detectors also must be installed in lounges, recreation areas, dining areas, and sleeping rooms in the center (vii) Fire department notification must be accomplished in accordance with §9.6.4, except in day-care centers with not more than 100 clients. (3) Exceptions to the Life Safety Code, NFPA 101, 2000 edition, chapters 16 or 17, are as follows. (A) All required smoke detectors must be powered by the facility electrical system and be interconnected with the fire alarm system. (B) Reference to apartment buildings in §16.1.2 or §17.1.2 must be deleted. Any floor above or below the floor of exit discharge that is used by semi-ambulatory clients, or those whose disability prevents them from taking appropriate action for self-preservation in emergencies, must be provided with smoke compartmentation. (C) Emergency lighting is not required for means of egress if the facility operation is during daylight hours and if natural light, direct or borrowed, is provided so that the means of egress is usable in emergencies. (D) Special protective electrical receptacle covers are not required. (E) NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, is not applicable if the facility has residential-type cooking equipment. (F) Public corridors must not be used for return or supply air systems. (G) Residential-type heating units or heating units designed for attic installations must not be considered to be units requiring furnace room construction as specified under §16.3.2.1 or §17.3.2.1. (H) New additions or remodeling must be as required for new construction in accordance with paragraph (4) of this subsection. (I) Sprinkler system for a janitor's closet as specified under §16.3.2.1 or §17.3.2.1 is not required unless the building has a complete NFPA 13 system. (4) For new construction, DADS requires conformance to the following codes, except that DADS may accept other nationally recognized codes that are locally enforced. (A) If the municipality has a building code and a plumbing code, then those codes govern in those areas of construction. Where local codes or ordinances are applicable, the most restrictive parts concerning the same subject item apply unless otherwise determined by the authority having jurisdiction for local codes and the licensing agency. (B) In the absence of local municipal codes or ordinances, nationally recognized codes must be used, such as the International Building Code and the compatible International Codes published by the International Code Council. These nationally recognized codes, when used, must all be publications of the same group or organization to assure the intended continuity. (C) Heating, ventilating, and air-conditioning (HVAC) systems must be designed and installed in accordance with NFPA 90A and NFPA 90B, as applicable, and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), except as may be modified in this subchapter. Buildings required to meet NFPA 90A must have automatic shutdown upon initiation of the fire alarm system, in accordance with NFPA 90A, §4.4. (D) Electrical and illumination systems must be designed and installed in accordance with NFPA 70 and the Lighting Handbook of the Illuminating Engineering Society (IES) of North America, except as may be modified in this subchapter. (i) Minimum illumination must be 20 foot candles in the toilets, bathing, and general use areas, such as living areas, dining areas, corridors, and lobbies. (ii) Minimum illumination must be 50 foot candles in the kitchen, medication or food preparation areas, and activity areas for handicrafts or reading. (5) An existing building either occupied as an adult day care facility at the time of initial inspection by DADS, or converted to occupancy as an adult day care facility, must meet all local requirements pertaining to the building for that occupancy. DADS may require the facility sponsor or licensee to submit evidence that local requirements are satisfied. (6) Adult day care facilities must be of recognized permanent type construction as distinguished from movable buildings or construction. Buildings must be structurally sound with regard to actual or expected dead, live, and wind loads. DADS may require submission of evidence to this effect. Foundations must be permanent, structurally sound for local soil conditions, and in good repair. A letter from a registered professional engineer may be required as validation of a permanent and structurally sound foundation. (7) The walking surface in a facility and at the exit discharge must be consistent, nominally level, and without abrupt changes in elevation, trip hazards, or gaps. Floor surfaces may be on different elevations if connected with ramps or steps in accordance with the Life Safety Code, NFPA 101, 2000 edition, means of egress chapter. (8) DADS will consider a written request from the facility for a waiver of requirements which, if strictly applied, would clearly be impractical in DADS' judgment for existing buildings and structures that have been converted to adult day care occupancy. Any of these modifications will be allowed only to the extent that reasonable life safety against the hazards of fire, explosion, structural, or other building failure and panic are provided and maintained. (c) Personal safety. (1) Fire safety. (A) The facility must maintain an onsite copy of the annual fire marshal inspection report by the local fire marshal. (B) Storage items must be neatly arranged and placed in the facility to minimize fire hazard. Gasoline, volatile materials, paint, and similar products must not be stored in the building housing clients unless approved by the local fire marshal. Accumulations of extraneous material and refuse are not permitted in the facility. (C) The building must be kept in good repair. (D) The facility's electrical, mechanical, heating, and cooling systems must be maintained in a safe manner and in working order. DADS may require the facility sponsor or licensee to submit evidence to this effect, consisting of a report from the fire marshal or city or county building official having jurisdiction or a report from a registered professional engineer. (E) Electrical appliances, devices, and lamps used in the facility must be used in a manner that prevents overloaded circuits. (F) If the facility uses extension cords in excess of six feet, they must be shielded or protected. (G) Smoking regulations must be established and enforced by the facility and conspicuously posted in the facility. (i) All smoking must be supervised. (ii) The facility must prohibit smoking in any room, ward, or compartment where flammable liquids, combustible gas, or oxygen are used or stored and in any other hazardous location. The facility must post a "No Smoking" sign in these areas. (iii) Ashtrays of noncombustible material and safe design must be provided in all areas where smoking is permitted. (iv) Metal containers of substantial gauge or any UL- or FM-approved containers with self- closing cover devices into which ashtrays can be emptied must be provided in all areas where smoking is permitted. (H) The facility must have an emergency fire lane for access of fire apparatus if required by local authorities. (I) An initial pressure test of facility gas lines from the meter must be provided. Additional pressure tests are required when the facility has major renovations or additions during which the gas service is interrupted. Testing must be performed by a person licensed with the State Board of Plumbing Examiners. (J) The facility must have all gas heating systems checked for proper operation and safety before the heating season by a person licensed by the Texas Department of Licensing and Regulation to perform maintenance work on gas-fired equipment. Any unsatisfactory conditions must be corrected promptly. (K) Curtains or draperies in public spaces and individual rooms in which smoking is allowed must be flame retardant. (L) Portable fire extinguishers of appropriate type and placed in the appropriate location must be provided by the facility in accordance with NFPA 10. (M) The facility must inspect and maintain portable fire extinguishers. (i) Portable fire extinguishers must be visually inspected monthly by facility staff. Facility staff conducting the monthly visual inspection must assure portable fire extinguishers are protected from damage, kept on their mounting brackets or in cabinets at all times, and kept in proper condition and working order. (ii) Portable fire extinguishers must be inspected and maintained at least once every 12 months in accordance with NFPA 10 by a person licensed by the State Fire Marshal's office, to include hydrostatic testing as recommended by the manufacturer. (iii) A record of all fire extinguisher inspections and maintenance performed must be kept onsite by the facility. (N) Garbage, waste, or trash containers provided for kitchens, janitor closets, laundries, mechanical or boiler rooms, general storage, and similar places must be made of metal or any UL- or FM-approved material, having a close fitting cover. Disposable plastic liners may be used in these containers for sanitation. (2) General requirements. (A) All exterior site conditions must be designed, constructed, and maintained in the interest of clients' safety. Newly constructed ramps must not exceed 1:12 slope. Ramps, walks, and steps must be of slip-resistive texture and be smooth and uniform, without irregularities. Guard rails, fences, and hand rails must be provided as required. (B) All stairways must have substantial hand rails properly secured. (C) Tubs or showers for client use must have non-slip bottoms or floor surfaces, either built in or applied to the surface. (D) Elevators for client use must be in safe operating condition. (E) An adequate supply of hot water must be provided. The hot water system connected to all client-use fixtures must deliver warm water no hotter than 120 degrees Fahrenheit at the fixture. Hot water for other sanitary usages must be provided at the temperatures required for the appliance or fixture served, or for the operation involved. (F) There must be no occupancies or activities adversely affecting the safety of the clients in the buildings or on the premises of the facility. (G) Licensure capacity will be calculated at 40 square feet per client. This space may not include the kitchen/food service area, rest rooms, bath areas, office, corridors, stairways, storage areas, and outdoor space. Facilities licensed before October 1, 2000, will be allowed to meet the requirements in effect before October 1, 2000, of 35/50 square feet for ambulatory and semi- ambulatory clients. If a facility licensed before October 1, 2000, chooses to increase its capacity, changes ownership, or relocates, the facility will be required to meet the current standards for usable space, outdoor area, and rooms for privacy. (H) An office area must be provided in a central location to record and maintain files for each client. (I) An area for rest, other than the treatment and/or exam room, must be provided with a sufficient number of reclining lounge chairs or beds to accommodate the needs of clients. (J) The facility must provide a separate room or rooms with beds and with walls from floor to ceiling for those clients who prefer privacy. Facilities licensed on or after May 1, 1999, must ensure that the room(s) with beds provide space for a minimum 5% of the licensed capacity. The usable space in the room(s) must provide not less than 80 square feet per bed for a one-bed room and not less than 60 square feet per bed for multiple-bed rooms. A bedroom shall be not less than eight feet in its smallest dimension, unless otherwise approved by DADS. (K) The facility must have at least one room available as a treatment or examination room for use by the nursing staff or the client's physician. The client may not be treated or examined in an area other than the treatment room. (L) The facility must have a safe, secure, and suitable outdoor recreation or relaxation area for clients. This area must be connected to, be a part of, be controlled by, and be directly accessible from the facility. This area must be enclosed by a wall or a fence or located in a courtyard and supervised by staff to prevent wandering and large enough to conduct outdoor activities. A chain- link fence must provide protection on top to prevent injury from wire points. This area must be suitably furnished. A minimum of 20% of the required outdoor space must be shaded. The required outdoor space for facilities licensed on or after May 1, 1999 is: (i) 400 square feet for facilities up to 59 clients; (ii) 600 square feet for facilities up to 99 clients; and (iii) 800 square feet for facilities with 100 or more clients. Source Note: The provisions of this §559.42 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective November 1, 2000, 25 TexReg 10753; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective August 1, 2011, 36 TexReg 4677; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS C FACILITY CONSTRUCTION PROCEDURES §559.42 Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202981 03/12/2026 (a) General.(1) Wastewater and sewage must be discharged into a state-approved municipal sewage system; any exception such as an on-site sewage facility must be as approved by the Texas Commission on Environmental Quality or authorized agent.(2) The water supply must be from a system approved by the Public Drinking Water Section of the Texas Commission on Environmental Quality, or from a system regulated by an entity responsible for water quality in that jurisdiction as approved by the Public Drinking Water Section of the Texas Commission on Environmental Quality.(3) Waste, trash, and garbage must be disposed from the premises at regular intervals in accordance with state and local practices. Excessive accumulations are not permitted. Outside containers must have tight-fitting lids left in closed position. Containers must be maintained in a clean and serviceable condition.(4) The building and grounds must be kept neat and free of refuse, litter, extraneous materials, and unsightly or injurious accumulations.(5) The facility must make every effort possible to guard against insects, rodents, rainwater, and other conditions adversely affecting a sanitary environment or the well-being of the client.(6) A pest control program must be provided by qualified facility staff or by contract with a licensed pest control company. The least toxic and least flammable effective chemicals must be used. Documented evidence of routine efforts to remove rodents and insects must be maintained.(7) The facility must be kept free of offensive odors, accumulations of dirt, rubbish, dust, and hazards. Floors must be maintained in good condition and cleaned regularly; walls and ceilings must be structurally maintained, repaired, and repainted or cleaned as needed. Storage areas, attics, and cellars must be free of refuse and extraneous materials.(8) There must be complete, separate, and adequate rest room facilities for men and women. Toilets must be provided as necessary to meet the needs of the clients; however, there must be not less than one toilet and one lavatory for every 15 clients or fraction thereof. A urinal may be substituted as the third required toilet in the men's bathroom. Multiple toilets must be compartmented. All toilets must be equipped with grab bars. Lavatories must be provided with hot and cold water, soap, and individual towels. A minimum of one bathing unit must be provided. Facilities licensed on or after May 1, 1999, must provide a minimum of one bathing unit that does not interfere with the use of the restroom by other clients. Each tub or shower must be in an individual room or enclosure that provides space for the private use of the bathing fixture, for drying and dressing, and for the client and attendant.(9) All bathrooms, toilet rooms, and other odor-producing rooms or areas for soiled and unsanitary operations must be ventilated to the exterior for odor control; the use of windows is not permissible.(10) In kitchens and laundries, there must be procedures that prevent cross contamination between clean and soiled utensils and clean and soiled linens.(b) Kitchen.(1) The Department of State Health Services (DSHS) rules in 25 TAC §§229.161 - 229.171 and §§229.173 - 229.175 (relating to Texas Food Establishments) and local health ordinances or requirements must be observed in the storage, preparation, and distribution of food; in the cleaning of dishes, equipment, and work area; and in the storage and disposal of waste.(2) Facilities licensed after May 1, 1999, must provide three compartment sinks. A three- compartment sink must be used if washing, rinsing, and sanitizing utensils and equipment is done manually. Sinks must be large enough to permit the complete immersion of utensils and equipment and each compartment sink must be supplied with hot and cold potable water. A two- compartment sink will be acceptable where only single-service tableware is provided.(3) Food preparation kitchens must have separate hand-washing fixtures including hot and cold water, soap, and individual towels, preferably paper towels, in accordance with DSHS rules in 25 TAC §§229.161 - 229.171 and §§229.173 - 229.175.(4) Where kitchen provisions consist of serving kitchens only, and cooking equipment is used only to warm food, prepare hot drinks, or provide similar food service, the kitchen is not required to have separate hand-washing fixtures. Source Note: The provisions of this §559.43 adopted to be effective May 1, 1999, 24 TexReg 3100; amended to be effective November 1, 2000, 25 TexReg 10753; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS C FACILITY CONSTRUCTION PROCEDURES §559.43 Sanitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202982 03/12/2026 At the option of the applicant, DADS will review plans for new buildings, additions, conversion of buildings not licensed by DADS, or remodeling of existing licensed facilities. DADS will, within 30 days, inform the applicant in writing of the results of the review. If the plans comply with DADS' architectural requirements, DADS may not subsequently change the architectural requirement applicable to the project unless the change is required by federal law or the applicant fails to complete the project within two years. DADS may grant a waiver of this two-year period for delays due to unusual circumstances. There is no time limit to complete a project, only a time limit for completing a project using requirements that have been revised after the project was reviewed.(1) Submittal of plans.(A) For review of plans, submit one copy of working drawings and specifications (contract documents) before construction begins. Documents must be in sufficient detail to interpret compliance with these standards and assure proper construction. Documents must be prepared according to accepted architectural practice and must include general construction, special conditions, and schedules.(B) Final copies of plans must have (in the reproduction process by which plans are reproduced) a title block that shows name of facility, person, or organization preparing the sheet, sheet numbers, facility address, and drawing date. Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a registered professional engineer approved by the Texas Board of Professional Engineers to operate in Texas. Contract documents for additions, remodeling, and construction of an entirely new facility must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect.(C) A final plan for a major addition to a facility must include a basic layout to scale of the entire building onto which the addition will connect. North direction must be shown. The entire basic layout usually can be to scale such as 1/16 inch per foot or 1/32 inch per foot for very large buildings.(D) Plans and specifications for conversions or remodeling must be complete for all parts and features involved.(E) The sponsor is responsible for employing qualified personnel to prepare the contract documents for construction. If the contract documents have errors or omissions to the extent that conformance with standards cannot be reasonably assured or determined, a revised set of documents for review may be requested.(F) The review of plans and specifications by DADS is based on general utility, the minimum licensing standards, and conformance of the Life Safety Code, NFPA 101, 2000 edition, and is not to be construed as all-inclusive approval of the structural, electrical, or mechanical components, nor does it include a review of building plans for compliance with the Texas Accessibility Standards as administered and enforced by the Texas Department of Licensing and Regulation.(G) Fees for plan review will be required in accordance with §98.22 of this title (relating to Plan Review Fees).(2) Contract documents.(A) Site plan documents must include:(i) grade contours;(ii) streets (with names);(iii) north arrow;(iv) fire hydrants;(v) fire lanes;(vi) utilities, public or private;(vii) fences; and(viii) unusual site conditions, such as:(I) ditches;(II) low water levels;(III) other buildings on-site; and(IV) indications of buildings five feet or less beyond site property lines.(B) Foundation plan documents must include general foundation design and details.(C) Floor plan documents must include:(i) room names, numbers, and usages;(ii) doors (numbered), including swing;(iii) windows;(iv) legend or clarification of wall types;(v) dimensions;(vi) fixed equipment;(vii) plumbing fixtures;(viii) kitchen basic layout; and(ix) identification of all smoke barrier walls (outside wall to outside wall) or fire walls.(D) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building must be drawn or reduced to fit on an 8 1/2-inch by 11-inch sheet.(E) Schedules must include:(i) door materials, widths, and types;(ii) window materials, sizes, and types;(iii) room finishes; and(iv) special hardware.(F) Elevations and roof plan must include:(i) exterior elevations, including:(I) material note indications; and(II) any rooftop equipment;(ii) roof slopes;(iii) drains;(iv) gas piping, etc.; and(v) interior elevations where needed for special conditions.(G) Details must include:(i) wall sections as needed, especially for special conditions;(ii) cabinet and built-in work, basic design only;(iii) cross sections through buildings as needed; and(iv) miscellaneous details and enlargements as needed.(H) Building structure documents must include:(i) structural framing layout and details (primarily for column, beam, joist, and structural building);(ii) roof framing layout (when it cannot be adequately shown on cross section); and(iii) cross sections in quantity and detail to show sufficient structural design and structural details as necessary to assure adequate structural design and calculated design loads.(I) Electrical documents must include:(i) electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices;(ii) service, circuiting, distribution, and panel diagrams;(iii) exit light system (exit signs and emergency egress lighting);(iv) emergency electrical provisions (such as generators and panels, if applicable);(v) staff communication system;(vi) fire alarm and similar systems (such as control panel, devices, and alarms); and(vii) sizes and details sufficient to assure safe and properly operating systems.(J) Plumbing documents must include:(i) plumbing layout with pipe sizes and details sufficient to assure safe and properly operating systems;(ii) water systems;(iii) sanitary systems;(iv) gas systems; and(v) other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.(K) Heating, ventilating, and air-conditioning systems (HVAC) documents must include:(i) sufficient details of HVAC systems and components to assure a safe and properly operating installation, including heating, ventilating, and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke and/or fire dampers; and(ii) equipment types, sizes, and locations.(L) If applicable, sprinkler system documents must include:(i) plans and details of NFPA designed systems;(ii) plans and details of partial systems provided only for hazardous areas; and(iii) electrical devices interconnected to the alarm system.(M) Specifications must include:(i) installation techniques;(ii) quality standards and/or manufacturers;(iii) references to specific codes and standards;(iv) design criteria;(v) special equipment;(vi) hardware;(vii) finishes; and(viii) any others as needed to amplify drawings and notes.(N) Other layout, plans, or details as may be necessary for a clear understanding of the design and scope of the project, including plans covering private water or sewer systems, must be reviewed by local health or wastewater authority having jurisdiction.(3) Construction phase.(A) DADS must be notified in writing before construction starts.(B) All construction not done in accordance with the completed plans and specifications as submitted for review and as modified in accordance with review requirements will require additional drawings if the change is significant.(4) Initial survey of completed construction.(A) Upon completion of construction, including grounds and basic equipment and furnishings, a final construction inspection (initial survey) of the facility must be performed by DADS before admitting clients. An initial architectural inspection will be scheduled after DADS receives a notarized licensure application, required fee, fire marshal approval, and a letter from an architect or engineer stating that to the best of their knowledge the facility meets the architectural requirements for licensure.(B) After the completed construction has been surveyed by DADS and found acceptable, this information will be forwarded to DADS' Regulatory Services Licensing and Credentialing Section as part of the information needed to issue a license to the facility. In the case of additions or remodeling of existing facilities, a revision or modification to an existing license may be necessary. The building, including basic furnishings and operational needs, grades, drives, and parking, must essentially be 100% complete at the time of this initial visit for occupancy approval and licensing. A facility may accept up to three clients between the time it receives initial approval from DADS and the time the license is issued.(C) The following documents must be available to DADS' architectural inspecting surveyor at the time of the survey of the completed building:(i) written approval of local authorities as required in subparagraph (A) of this paragraph;(ii) written certification of the fire alarm system by the installing agency (the Texas State Fire Marshal's Fire Alarm Installation Certificate);(iii) documentation of materials used in the building that are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant curtains (including cubicle curtains), rated ceilings, etc., and, in the case of carpeting, a signed letter from the installer verifying that the carpeting installed is named in the laboratory test document;(iv) approval of the completed sprinkler system installation by the Texas Department of Insurance or designing engineer, including a copy of the material list and test certification;(v) service contracts for maintenance and testing of alarm systems, sprinkler systems, etc.;(vi) a copy of gas test results of the facility's gas lines from the meter;(vii) a written statement from an architect/engineer stating, to the best of his knowledge, the building was constructed in substantial compliance with the construction documents, the Life Safety Code, NFPA 101, 2000 edition, DADS licensure standards, and local codes; and(viii) any other such documentation as needed.(5) Nonapproval of new construction.(A) If, during the initial on-site survey of completed construction, the surveyor finds certain basic requirements not met, DADS may recommend the facility not be licensed and approved for occupancy. Such items may include the following:(i) substantial changes made during construction that were not submitted to DADS for review and that may require revised "as-built" drawings to cover the changes, including architectural, structural, mechanical, and electrical items as specified in paragraph (3)(B) of this section;(ii) construction that does not meet minimum code or licensure standards, such as corridors that are less than required width, ceilings installed at less than the minimum seven-foot, six-inch height, client bedroom dimensions less than required, and other such features that would disrupt or otherwise adversely affect the clients and staff if corrected after occupancy;(iii) no written approval by local authorities;(iv) fire protection systems, including fire alarm systems, emergency power and lighting, and sprinkler systems, not completely installed or not functioning properly;(v) required exits not all usable according to Life Safety Code, NFPA 101, 2000 edition requirements;(vi) telephone not installed or not properly working;(vii) sufficient basic furnishings, essential appliances, and equipment not installed or not functioning; and(viii) any other basic operational or safety feature that would preclude safe and normal occupancy by clients on that day.(B) If the surveyor encounters only minor deficiencies, licensure may be recommended based on an approved written plan of correction from the facility's administrator.(C) Copies of reduced-size floor plans on an 8 1/2-inch by 11-inch sheet must be submitted in duplicate to DADS for record or file use and for the facility's use for evacuation plan, fire alarm zone identification, etc. The plan must contain basic legible information such as scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information. Source Note: The provisions of this §559.44 adopted to be effective April 1, 2002, 27 TexReg 2250; amended to be effective April 1, 2007, 32 TexReg 1749; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS C FACILITY CONSTRUCTION PROCEDURES §559.44 Plans, Approvals, and Construction Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219495 03/12/2026 For purposes of this subchapter, the term, "communicable diseases" has the meaning assigned to it in 25 TAC Chapter 97 (relating to Communicable Diseases). Source Note: The provisions of this §559.50 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.50 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219496 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219496 03/12/2026 (a) For purposes of this section, "reportable conduct" includes:(1) abuse or neglect that causes or may cause death or harm to a client;(2) sexual abuse of a client;(3) financial exploitation of a client in the amount of $25 or more; or(4) emotional, verbal, or psychological abuse that causes harm to a client.(b) A facility must:(1) comply with the requirements for advance directives as outlined under §559.53 of this subchapter (relating to Maintenance of Policies and Procedures);(2) comply with the provisions of Texas Health and Safety Code, Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illness);(3) before offering employment to any individual, search on the HHSC internet website, employee misconduct registry (EMR) established under Texas Health and Safety Code §253.007, and HHSC nurse aide registry (NAR) to determine if an individual is designated in either registry as unemployable;(A) not employ a person who is listed as unemployable in either registry;(B) provide information about the EMR to an employee in accordance with §561.3 of this title (relating to Employment and Registry Information);(C) conduct a search of the EMR and NAR at least once every 12 months to determine if the employee is designated in either registry as unemployable;(D) keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file; and(E) suspend the employment of an employee who HHSC finds has engaged in reportable conduct, as defined in subsection (a) of this section, while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, pending a final decision by an administrative law judge, and not reinstate the employee's employment or contract during any applicable appeals process;(4) develop policies to comply with standards for universal precautions for HIV/AIDS and related conditions in the workplace;(5) develop written policies for control of communicable diseases in employees and clients, which include tuberculosis screening and provision of a safe and sanitary environment for clients and their families;(6) comply with all relevant federal and state standards; and(7) comply with all applicable provisions of Texas Human Resource Code, Chapter 102. Source Note: The provisions of this §559.51 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.51 Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219497 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219497 03/12/2026 A facility must ensure that all adult clients receiving services provided by the facility are guaranteed the following rights.(1) The facility must ensure that the facility's policies and procedures:(A) enable a client to exercise his or her rights;(B) promote the highest practicable quality of life for all clients and not deliberately or inadvertently prohibit a client from exercising the rights stated in this section or the rights of citizenship; and(C) ensure that a client, in exercising his or her rights, does not impede the rights of others in the facility.(2) The facility must ensure a listing of client rights is:(A) provided in writing to each client or client's responsible party; and(B) posted in English and Spanish in a prominent place in the facility accessible by clients and visitors.(3) A client has all the rights, benefits, responsibilities, and privileges stated in the Constitution and laws of this state and the United States, except where lawfully restricted.(4) A client has the right to be free of interference, coercion, discrimination, and reprisal in exercising his or her civil rights. Examples of interference, coercion, discrimination, and reprisal include:(A) prohibiting a client from selecting the client's responsible party of the client's choice;(B) intimidating a client to provide information about a private conversation with another person;(C) not allowing a client to use the client's private property, such as durable medical equipment, recreational items, and assistive devices;(D) not allowing a client to visit with an individual of the client's choice, unless the individual poses a threat to the health and safety of the client, other clients, or staff;(E) discharging a client for filing a complaint or grievance; and(F) using derogatory language to describe or address a client.(5) A client has the right to be free from physical and mental abuse, including corporal punishment, physical restraints and seclusion, and chemical restraints that are administered for the purpose of discipline or convenience and not required to treat the client's medical symptoms.(6) A client has the right to participate in activities of social, religious, and community groups unless the participation interferes with the rights of others.(7) A client has the right to practice the religion of the client's choice or to abstain from religious activities.(8) A client with an intellectual disability and who is represented by a court-appointed guardian may participate in a behavior modification program that involves the use of restraints or adverse stimuli only with the informed consent of the guardian.(9) A client has the right to be treated with respect, courtesy, consideration, and recognition of his or her dignity and individuality, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the client:(A) has the right to make individualized choices regarding personal affairs, care, benefits, schedules and activities, and services;(B) has the right to be free from abuse, neglect, and exploitation;(C) has the right, if protective measures are required and the client has not been adjudicated cognitively impaired, to designate a guardian or representative to ensure the right to quality stewardship of the client's affairs; and(D) has the right to protection of the client's personal image. A facility employee must not share or post to the internet or social media any photographs or video of a client without the client's written consent.(10) A client has the right to a safe and clean environment that:(A) is free of pests;(B) is free of electrical and structural hazards; and(C) has clean bathrooms and client areas.(11) A client has the right to communicate with staff and others in the client's native language for the purpose of acquiring or providing any type of treatment, care, or services.(12) A client has the right to make a complaint about the client's care or treatment.(A) A client's complaint may be made anonymously or communicated by a person designated by the client.(B) The facility must promptly respond to resolve each client complaint.(C) The facility must not discriminate or take other punitive action against a client who makes a complaint.(D) The facility must not impede a client's right to make a formal complaint to HHSC or require that complaints be made to the facility prior to lodging a formal complaint with HHSC.(13) The facility must ensure a client is given personal privacy while attending to personal needs.(14) A client has the right to review and obtain copies of the client's records in accordance with §559.75 of this subchapter (relating to Client Records).(15) A client has the right to be fully informed in advance about treatment, care, and services provided by the facility.(16) A client has the right to participate in developing his or her individual plan of care that describes the client's DAHS needs and how the needs will be met.(17) A client has the right to refuse medical treatment or services. The facility must ensure the client is advised by the person providing treatment or services of the possible consequences of refusing treatment or services.(18) A client has the right to refuse to perform services for the facility, except as contracted for by the client and director.(19) A client has the right to be informed by the provider, no later than the 30th day after admission:(A) whether the client is entitled to benefits under Medicare or Medicaid related to DAHS services; and(B) which items and services are covered by these benefits, including items or services for which the client may not be charged.(20) A client has the right to execute an advance directive, under Texas Health and Safety Code, Chapter 166, or designate a guardian in advance of need to make decisions regarding the client's health care should the client become incapacitated. Source Note: The provisions of this §559.52 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.52 Client Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219498 03/12/2026 A facility must maintain policies and procedures regarding the following with respect to all clients receiving services provided by the facility.(1) The facility must provide a client with written information about:(A) the client's rights under Texas law (whether statutory or as recognized by the courts of the state) to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;(B) the facility's policies respecting the implementation of these rights; and(C) a written list of the client's rights as applicable, as outlined under Texas Human Resource Code §102.004 (relating to List of Rights), and as required in §559.52 of this subchapter (relating to Client Rights).(2) The facility must document in the client's record whether the client has executed an advance directive.(3) The facility must not condition the provision of care or otherwise discriminate against a client based on whether the client has executed an advance directive.(4) The facility must ensure compliance with the requirements of Texas law, whether statutory or as recognized by the courts of Texas, respecting advance directives.(5) The facility must educate the client, family members, and staff, in a language each understands, on issues concerning advance directives.(6) The facility must provide the attending physician with any information relating to a known existing Directive to Physicians, Living Will, or Durable Power of Attorney for Health Care and assist with coordinating prescribing practitioners' orders with any directive.(7) When a client is in an incapacitated state, and therefore is unable to receive information or articulate whether he or she has executed an advance directive, the family, surrogate, or other concerned person must receive the information concerning advance directives. The facility must provide this information to the client in a language he or she understands if he or she is no longer incapacitated.(8) When the client or a relative, surrogate, or other concerned or related individual presents the facility with a copy of the client's advance directive, the facility must comply with the advance directive including recognition of a durable power of attorney for health care to the extent allowed under state law. If no one comes forward with a previously executed advance directive and the client is incapacitated or otherwise unable to receive information or articulate whether he has executed an advance directive, the facility must note that the client was not able to receive information and was unable to communicate whether an advance directive existed. Source Note: The provisions of this §559.53 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.53 Maintenance of Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219499 03/12/2026 A facility must:(1) report to HHSC via the online portal, or by speaking with an HHSC agent at 1-800-458-9858, upon learning of alleged abuse or neglect of a client and submit an investigation report to HHSC no later than the fifth working day after the initial report;(2) maintain incident reports as required by §559.75 of this subchapter (relating to Client Records);(3) ensure the confidentiality of individual client records and other information related to clients; and(4) inform the client, or client's responsible party, orally and in writing of the client's rights, responsibilities, and grievance procedures in a language the client, or client's responsible party, understands. Source Note: The provisions of this §559.55 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.55 Reporting Incidents of Abuse or Neglect https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219500 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219500 03/12/2026 A facility must prominently and conspicuously post for display in a public area of the facility that is readily available to clients, employees, and visitors:(1) the license issued under this chapter;(2) a sign prescribed by HHSC that can be found on the HHSC website that describes complaint procedures and specifies how complaints may be filed with HHSC;(3) a notice in the form prescribed by HHSC stating that inspection and related reports are available at the facility for public inspection and providing the HHSC toll-free telephone number that may be used to obtain information concerning the facility;(4) a copy of the most recent inspection report relating to the facility;(5) a brochure or letter that outlines the facility's hours of operation, holidays, and a description of activities offered; and(6) emergency telephone numbers, including the abuse hotline telephone number, near all telephones. Source Note: The provisions of this §559.57 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.57 Postings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219501 03/12/2026 (a) Director. A facility must employ a director.(1) The director must:(A) have graduated from an accredited four-year college or university and have no less than one year of experience in working with people in a human service or medically related program, or have an associate degree or 60 semester hours from an accredited college or university with three years of experience working with people in a human service or medically related program;(B) be an RN with one year of experience in a human service or medically related program;(C) meet the training and experience requirements for a license as a nursing facility administrator under Chapter 555 of this title (relating to Nursing Facility Administrators); or(D) have met the qualifications for a director required on July 16, 1989, and served continuously in the capacity of director since that date.(2) The director must show evidence of 12 hours of annual continuing education in at least two of the following areas:(A) client and provider rights and responsibilities, abuse, neglect, exploitation, and confidentiality;(B) basic principles of supervision;(C) skills for working with individuals, families, and other professional service providers;(D) individual characteristics and needs;(E) community resources;(F) basic infection prevention and control measures;(G) emergency preparedness and response;(H) basic emergency first aid, such as cardiopulmonary resuscitation or choking; or(I) federal laws, such as Americans with Disabilities Act, Civil Rights Act of 1991, Rehabilitation Act of 1993, and Family and Medical Leave Act of 1993.(3) The activities director may fulfill the function of director if the activities director meets the qualifications for facility director.(4) One person may not serve as facility nurse, activities director, and director.(5) The facility must have a policy regarding the delegation of responsibility in the director's absence from the facility.(6) The facility must notify HHSC Regulatory Services Regional Office for the region in which the facility is located if the director is absent from the facility for more than 10 working days.(b) Nurse. A facility must employ a nurse.(1) An RN must have a license from the Texas Board of Nursing and practice in compliance with the Nurse Practice Act and rules and regulations of the Texas Board of Nursing.(2) An LVN must have a license from the Texas Board of Nursing and practice in compliance with the Nurse Practice Act and rules and regulations of the Texas Board of Nursing.(3) If a nurse serving as director leaves the facility to perform other duties related to the DAHS program, an LVN or another RN must fulfill the duties of the facility nurse.(4) A facility that does not have a DAHS contract, but that has a Special Services to Persons with Disabilities contract, is not required to have an RN on duty if the clients receiving services have no medical needs and are able to self-administer medication.(c) Activities director. A facility must employ an activities director.(1) Except as provided in paragraph (2) of this subsection, an activities director must have graduated from high school or have a certificate recognized by a state of the United States as the equivalent of a high-school diploma and have:(A) a bachelor's degree from an accredited college or university and one year of full-time experience working with elderly people or people with disabilities in a human service or medically related program;(B) 60 semester hours from an accredited college or university and two years of full-time experience working with elderly people or people with disabilities in a human service or medically related program; or(C) completed an activities director's course and two years of full-time experience working with elderly people or people with disabilities in a human service or medically related program.(2) An activities director hired before May 1, 1999, with four years of full-time experience working with elderly people or people with disabilities in a human service or medically related program is not subject to the requirements of paragraph (1) of this subsection.(d) Attendants. An attendant must be at least 18 years of age and may be employed as a driver, aide, food service worker, janitor, housekeeper, or laundry services worker.(1) If a facility employs a driver, the driver must have a current operator's license, issued by the Texas Department of Public Safety, that is appropriate for the class of vehicle used to transport clients.(2) If an attendant handles food in the facility, the attendant must meet the requirements of the Texas Department of State Health Services (DSHS) rules on food service sanitation as described in 25 TAC Chapter 228 (relating to Retail Food Establishments).(e) Food service personnel. If a facility prepares meals on site, the facility must have sufficient food service personnel to prepare meals and snacks. Food service personnel must meet the requirements of the DSHS rules on food service sanitation as described in 25 TAC Chapter 228. Source Note: The provisions of this §559.59 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.59 Staff Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219502 03/12/2026 A facility must ensure that:(1) the ratio of direct service staff to clients is at least one to eight, which must be maintained during provision of all services except during facility-provided transportation;(2) at least one RN or LVN is working at the facility for at least eight hours per day and sufficient nurses are at the facility to meet the nursing needs of the clients at all times;(3) the facility director routinely works at least 40 hours per week performing duties relating to provision of the DAHS program;(4) the activities director routinely works at least 40 hours a week;(5) clients whose needs cannot be met by the facility are not admitted or retained; and(6) sufficient attendants are on duty at all times clients are present to meet the needs of the clients who are served by the facility. Source Note: The provisions of this §559.61 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.61 Staffing Ratio and Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219503 03/12/2026 (a) A facility must develop, implement, enforce, and maintain an infection prevention and control program that provides a safe, sanitary, and comfortable environment and helps prevent development and transmission of disease and infection.(1) The infection prevention and control program must include policies and procedures that reduce the risk of spreading communicable diseases in the facility, including:(A) wearing personal protective equipment, such as gloves, a gown, or a mask when called on for anticipated exposure;(B) properly cleaning hands after using the lavatory, before and after touching another client, and in between glove changes;(C) cleaning and disinfecting environmental surfaces, including doorknobs, handrails, light switches, control panels, and remote controls;(D) using universal precautions for blood and bodily fluids; and(E) disposing of soiled items (such as used tissues, wound dressings, incontinence briefs, and soiled linens) from the environment.(2) Staff must handle, store, process, and transport linens to prevent the spread of infection.(3) If the facility knows or suspects an employee has contracted a communicable disease that is transmissible to clients through food handling or direct client care, the facility must exclude the employee from providing these services for the applicable period of communicability.(4) The facility must maintain evidence of compliance with local and state health codes and ordinances regarding employee and client health status.(5) The facility must immediately report the name of any client with a reportable disease as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases), to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority.(b) The facility must comply with rules regarding special waste in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(c) The facility's infection prevention and control program must include a policy to minimize the risk for transmission of tuberculosis (TB). The facility must screen a new employee for TB within two weeks of employment, according to Centers for Disease Control and Prevention screening guidelines and any additional guidance from HHSC.(1) The facility must provide annual TB education to employees that must include the following topics:(A) TB risk factors;(B) the signs and symptoms of TB disease; and(C) TB infection control policies and procedures.(2) The facility may request evidence of compliance with this requirement from a person who provides services under an outside resource contract. Source Note: The provisions of this §559.63 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.63 Infection Prevention and Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219504 03/12/2026 (a) The facility director:(1) manages the DAHS program and the facility;(2) trains and supervises facility staff, contractors, and volunteers;(3) monitors the facility building and grounds to ensure compliance;(4) maintains all financial and client records;(5) develops relationships with community groups and agencies for identification and referral of clients;(6) maintains communication with clients' family members or responsible parties;(7) ensures development and maintenance of the clients' plans of care; and(8) ensures that, if the facility director also serves as the RN consultant, the facility director fulfills the responsibility as director.(b) The facility nurse:(1) assesses clients' nursing and medical needs;(2) develops clients' plans of care;(3) obtains prescribing practitioner's orders for medication and treatments to be administered;(4) determines whether self-administered medications have been appropriately taken, applied, or used;(5) enters, dates, and signs monthly progress notes on medical care provided;(6) administers medication and treatments;(7) provides health education;(8) maintains medical records; and(9) oversees implementation of the facility's infection prevention and control policies.(c) The activities director:(1) plans and directs the daily program of activities, including physical fitness exercises or other recreational activities;(2) records client's social histories;(3) assists clients' related support needs;(4) ensures that the identified related support services are included in clients' plans of care;(5) signs and dates monthly progress notes about social and related support services activities provided; and(6) ensures clients have a choice in whether to participate in activities.(d) An attendant:(1) provides personal care services to assist with activities of daily living;(2) assists the activities director with recreational activities; and(3) provides protective supervision through observation and monitoring.(e) Food service personnel:(1) prepare meals and snacks; and(2) maintain the kitchen area and utensils in a safe and sanitary condition.(f) A facility must obtain consultation at least four hours per month from a dietitian consultant.(1) The dietitian consultant plans and reviews menus and must:(A) approve and sign snack and lunch menus;(B) review menus monthly to ensure that substitutions were appropriate; and(C) develop a special diet for clients if ordered by a prescribing practitioner.(2) A facility must obtain consultation from a dietitian consultant even if the facility has meals delivered from another facility with a dietitian consultant or the facility contracts for the preparation and delivery of meals with a contractor that employs a registered dietician. A consultant who provides consultation to several facilities must provide at least four hours of consultation per month to each facility.(g) If a facility employs an LVN as the facility nurse, the facility must ensure that an RN consultant provides consultation at the facility at least four hours per week. The RN consultant must document the consultation provided. The RN consultant must provide the consultation when clients are present in the facility. The RN consultant may provide the following types of assistance:(1) review plans of care and suggest changes, if appropriate;(2) assess clients' health conditions;(3) consult with the LVN in solving problems involving care and service planning;(4) counsel clients on health needs;(5) train, consult, and assist the LVN to maintain proper medical records; and(6) provide in-service training for direct service staff. Source Note: The provisions of this §559.65 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.65 Staff Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219505 03/12/2026 (a) Initial training.(1) A facility must provide direct service staff with training in its fire, disaster, and evacuation procedures within three workdays after the start of employment and document the training in the facility records.(2) A facility must provide direct service staff a minimum of 18 hours of training during the first three months after the start of employment and document the training in the facility records.(3) The training provided in accordance with paragraph (2) of this subsection must include:(A) a nationally or locally recognized adult cardiopulmonary resuscitation (CPR) course or certification;(B) first aid;(C) orientation to health care delivery, including:(i) safe body function and mechanics;(ii) personal care techniques and procedures; and(iii) overview of the population served at the facility;(D) identification and reporting of abuse, neglect, or exploitation; and(E) basic infection prevention and control measures.(b) Continuing training.(1) A facility must provide at least three hours of continuing training to direct service staff quarterly and document the training in the facility records. Training may include:(A) assisting clients with personal care services;(B) health conditions and diagnoses of clients in the facility and how they may affect provision of care;(C) safety measures to prevent accidents and injuries;(D) emergency first aid procedures, such as the Heimlich maneuver and actions to take when a client falls, suffers a laceration, or is experiencing a sudden change in physical or cognitive status;(E) managing dysfunctional, disruptive, or maladaptive behavior and de-escalation techniques;(F) client rights;(G) communication techniques for working with clients with hearing, visual, or cognitive impairment;(H) basic infection prevention and control measures; and(I) fall prevention.(2) A facility must practice evacuation procedures with staff and individuals at least once a month and document evacuation results in the facility records.(3) The facility must ensure that direct service staff maintain current certification in CPR.(c) Policy for clients with Alzheimer's disease or a related disorder. A facility must adopt, implement, and enforce a written policy that:(1) requires direct service staff who provide care at the facility to a client with Alzheimer's disease or a related disorder to successfully complete training in the provision of care to clients with Alzheimer's disease or related disorders;(2) ensures the care and services provided by direct service staff to a client with Alzheimer's disease or a related disorder meet the specific identified needs of the client relating to the diagnosis of Alzheimer's disease or a related disorder; and(3) ensures the training required for direct service staff under paragraph (1) of this subsection includes information about:(A) symptoms and treatment of dementia;(B) stages of Alzheimer's disease;(C) person-centered behavioral interventions; and(D) communication with a client with Alzheimer's disease or a related disorder. Source Note: The provisions of this §559.67 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.67 Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219506 03/12/2026 (a) Administration.(1) A facility must ensure that a person who administers medications to clients who choose not to or who cannot self-administer his or her medications holds a current license under applicable state law that authorizes the licensee to administer medications.(2) A facility must ensure that all medication prescribed to a client that is administered at the facility is dispensed through a pharmacy or by the client's prescribing practitioner.(3) A facility may administer sample medications at the facility if the medication has been prescribed to the client and includes specific dosage instructions for the client.(4) A facility must record a client's medications on the client's medication profile record. The recorded information must be obtained from the prescription label and must include the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and date each medication was issued by the pharmacy.(b) Assistance with self-administration. A nurse may assist with self-administration of a client's medication if the client is unable to administer the medication without assistance. Assistance with self-administration of medication is limited to:(1) reminding the client to take medications at the prescribed time;(2) opening and closing containers or packages;(3) pouring prescribed dosage according to the client's medication profile record;(4) returning medications to the proper locked areas;(5) obtaining medications from a pharmacy; and(6) listing on the client's medication profile record the medication name, strength, dosage, amount received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.(c) Self-administration.(1) A nurse must counsel a client who self-administers medication or treatment at least once per month to ascertain if the client continues to be able to self-administer the medication or treatment. The facility must keep a written record of the counseling.(2) A facility may permit a client who chooses to keep the client's medication locked in the facility's central medication storage area to enter or have access to the area for the purpose of self-administering medication or treatment. A facility staff member must remain in or at the storage area the entire time the client is present in the area.(d) General.(1) A facility director, an activities director, or a facility nurse must immediately report to a client's prescribing practitioner and responsible party any unusual reactions to a medication or treatment.(2) When a facility supervises or administers medications, the facility must document in writing if a client does not receive or take the medication and treatment as prescribed. The documentation must include the date and time the dose should have been taken and the name and strength of medication missed.(e) Storage.(1) A facility must provide a locked area for all medications, which may include:(A) a central storage area; or(B) a medication cart.(2) A facility must store a client's medication separately from other clients' medications within the storage area.(3) A facility must store medication requiring refrigeration in a locked refrigerator that is used only for medication storage or in a separate, permanently attached, locked medication storage box in a refrigerator.(4) A facility must store poisonous substances and medications labeled for "external use only" separately from other substances within the locked area.(5) A facility must store drugs covered by Schedule II of the Controlled Substances Act of 1970 in a locked, permanently attached cabinet, box, or drawer that is separate from the locked storage area for other medications.(f) Disposal.(1) In accordance with applicable federal and state laws, a facility must dispose of medication that:(A) has been discontinued by order of the client's prescribing practitioner;(B) remains after the client no longer attends the DAHS; or(C) has passed the medication expiration date.(2) A facility must ensure the medication identified in paragraph (1) of this subsection is disposed by:(A) a registered pharmacist licensed in the State of Texas;(B) a local pharmacy on-site medication drop-off box; or(C) a local law enforcement or community drug take-back program.(3) A facility must inventory and store medications awaiting disposal separate from current client medications.(4) A facility must dispose of needles and hypodermic syringes with needles attached as required by 25 TAC Chapter 1, Subchapter K (relating to the Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).(5) A facility must obtain a signed receipt from the client or the client's responsible party if the facility releases medication to the client or responsible party. Source Note: The provisions of this §559.69 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.69 Medications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219507 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219507 03/12/2026 (a) A facility must stock and maintain in a single location first aid supplies to treat burns, cuts, and poisoning.(b) In the event of accident or injury to a client requiring emergency medical, dental, or nursing care, or in the event of death of a client, a facility must:(1) arrange for emergency care or transfer of the client to an appropriate place for treatment, including:(A) a physician's or practitioner's office;(B) a clinic; or(C) a hospital;(2) immediately notify the client's physician and responsible party or agency who admitted the client to the facility; and(3) describe and document the accident, injury, or illness on a separate report. The report must contain a statement of final disposition and be maintained on file as required by §559.75 of this subchapter (relating to Client Records). Source Note: The provisions of this §559.71 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.71 Accident, Injury, or Acute Illness https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219508 03/12/2026 A facility that prepares meals on-site must:(1) serve meals according to the menu;(2) plan, date, post a menu at least two weeks in advance, maintain a copy of the menu; and(3) ensure that a special diet meal ordered by a client's prescribing practitioner and developed by the dietician consultant is labeled with the client's name and type of diet. Source Note: The provisions of this §559.73 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.73 Menus https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219509 03/12/2026 (a) Retention of Records. The retention of client records must comply with the following.(1) Client records must be retained for five years after the client's services end.(2) A facility must safeguard a client's records against loss, destruction, or unauthorized use.(3) A facility must keep confidential all information contained in a client's records, except when release is:(A) required by law or this chapter;(B) to the client or client representative, where permitted by applicable law;(C) for treatment, payment, or health care operations, as permitted by and in compliance with applicable law; or(D) for public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, or to avert a serious threat to health or safety as permitted by and in compliance with applicable law.(b) Destruction of Records. When client records are destroyed after the retention period, the facility must shred or incinerate the records in a manner that protects confidentiality. At the time of destruction, the facility must document for each record destroyed:(1) client name;(2) client record number, if used;(3) the client's social security number and date of birth, if available; and(4) date and signature of the person carrying out disposal.(c) Client Access to Records. The client or the client's representative has the right to:(1) upon an oral or written request to the facility, view all records pertaining to the client, within 24 hours (excluding weekends and holidays); and(2) obtain hard copies of all or any portion of the records upon request within 48 hours (excluding weekends and holidays).(d) Right of Refusal. A client does not have the right to refuse release of the client's records:(1) when the client is transferred to another health care institution;(2) when the record release is required by law or permitted by this chapter; or(3) during surveys. Source Note: The provisions of this §559.75 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.75 Client Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219510 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219510 03/12/2026 A facility must adopt and enforce a written policy to ensure that all professional disciplines comply with their professional practice acts or title acts relating to reporting and peer review. Source Note: The provisions of this §559.77 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.77 Peer Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219511 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219511 03/12/2026 (a) Definitions. The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Designated emergency contact--A person whom a client, or a client's representative, identifies in writing for the facility to contact in the event of a disaster or emergency.(2) Disaster or emergency--An impending, emerging, or actual situation that:(A) interferes with normal activities of a facility or its clients;(B) may:(i) cause injury or death to a client or staff member of the facility; or(ii) cause damage to facility property;(C) requires the facility to respond immediately to mitigate or avoid the injury, death, damage, or interference; and(D) does not include a situation that arises from the medical condition of a client such as cardiac arrest, obstructed airway, cerebrovascular accident.(3) Emergency management coordinator (EMC)--The person appointed by the local mayor or county judge to plan, coordinate, and implement public health emergency preparedness planning and response within the local jurisdiction.(4) Emergency preparedness coordinator (EPC)--The facility staff person with the responsibility and authority to direct, control, and manage the facility's response to a disaster or emergency.(5) Plan--A facility's emergency preparedness and response plan.(6) Risk assessment--The process of evaluating, documenting, and examining potential disasters or emergencies that pose the highest risk to the facility and assessing their foreseeable impacts based on the facility's geographical location, structural conditions, client needs and characteristics, and other influencing factors, to develop an effective emergency preparedness and response plan.(b) Administration. A facility must:(1) develop and implement a written plan as described in subsection (c) of this section;(2) maintain a current printed copy of the plan that is accessible to all staff, clients, and client representatives at all times;(3) evaluate and revise the plan as necessary:(A) within 30 days after an emergency situation;(B) as soon as possible after the remodeling or construction of an addition to the facility; and(C) at least annually; and(4) revise the plan within 30 days after information included in the plan changes.(c) Emergency preparedness and response plan. A facility's plan must:(1) include a risk assessment of all potential internal and external emergency situations relevant to the facility operations and geographical area, such as a fire, failure of heating and cooling systems, a power outage, an explosion, a hurricane, a tornado, a flood, extreme snow and ice for the area, a wildfire, terrorism, or a hazardous materials accident;(2) include a description of the facility's client population;(3) include a description of the services and assistance needed by the clients in an emergency situation;(4) include a section for each core function of emergency management, as described in subsection (d) of this section, that is based on a facility's decision to either shelter-in-place or evacuate during an emergency; and(5) include a fire safety plan that complies with subsection (f) of this section.(d) Plan requirements regarding eight core functions of emergency management.(1) Direction and control. A facility's plan must contain a section for direction and control that:(A) designates by name or title the emergency preparedness coordinator (EPC) who is the facility staff person with the authority to manage the facility's response to an emergency situation in accordance with the plan;(B) designates by name or title the alternate EPC who is the facility staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity;(C) documents the name and contact information for the local EMC for the area where the facility is located, as identified by the office of the local mayor or county judge; and(D) documents coordination with the local EMC as required by the local EMC's guidelines relating to emergency situations.(2) Warning. A facility's plan must contain a section for warning that:(A) describes how the EPC will be notified of an emergency situation;(B) identifies who the EPC will notify of an emergency situation and when the notification will occur; and(C) ensures monitoring of local news and weather reports.(3) Communication. A facility's plan must contain a section for communication that:(A) identifies the facility's primary mode of communication and alternate mode of communication to be used in the event of power failure or the loss of the facility's primary mode of communication in an emergency situation;(B) includes procedures for maintaining a current list of telephone numbers for clients and responsible parties;(C) includes procedures for maintaining a current list of telephone numbers for the facility's staff that also identifies the facility's EPC;(D) identifies the location of the lists described in subparagraphs (B) and (C) of this paragraph where facility staff can obtain the lists quickly;(E) includes procedures to notify:(i) facility staff about an emergency situation;(ii) the alternate location about an impending or actual evacuation of clients; and(iii) clients, legally authorized representatives and other persons about an emergency situation;(F) describes how the facility will provide, during an emergency situation, general information to the public, such as the change in the facility's location and hours, or that the facility is closed due to the emergency situation;(G) includes procedures for the facility to maintain communication with:(i) facility staff during an emergency situation;(ii) an alternate location if applicable; and(iii) facility staff who will transport clients to a secure location during an evacuation in a facility vehicle;(H) includes procedures for reporting to HHSC an emergency situation that caused the death or serious injury of a client:(i) by telephone, at 1-800-458-9858, within 24 hours after the death or serious injury; and(ii) electronically via the online portal on the HHSC form titled HHSC Provider Investigation Report, within five working days after the facility makes the telephone report required by clause (i) of this subparagraph.(4) Sheltering-in-place. A facility's plan must contain a section that includes procedures to shelter clients in place during an emergency situation.(5) Evacuation. A facility's plan must contain a section for evacuation that:(A) requires posting building evacuation routes prominently throughout the facility, except in small, one-story buildings where all exits are obvious;(B) includes procedures for evacuating clients to a pre-arranged location in an emergency situation, if applicable;(C) includes an agreement with an alternate location which must specify the arrangements for receiving clients in the event of an evacuation;(D) identifies primary and alternate evacuation destinations and routes, and includes a map that shows the destination and routes;(E) includes procedures for:(i) ensuring facility staff accompany evacuating clients;(ii) ensuring that all persons present in the building have been evacuated;(iii) accounting for clients and staff after they have been evacuated;(iv) accounting for clients who are absent from the facility at the time of the evacuation;(v) contacting the local EMC, if required by the local EMC guidelines, to find out if it is safe to return to the geographical area; and(vi) determining if it is safe to re-enter and occupy the building after an evacuation;(F) includes procedures for notifying the local EMC regarding an evacuation of the facility, if required by the local EMC guidelines;(G) includes procedures for notifying HHSC by telephone, at 1-800-458-9858, within 24 hours after an evacuation that clients have been evacuated;(H) includes procedures for notifying the HHSC Regulatory Services Regional Office for the area in which the facility is located, by telephone, as soon as safely possible after a decision to evacuate is made; and(I) includes procedures for notifying the HHSC Regulatory Services Regional Office for the area in which the facility is located, by telephone, that clients have returned to the facility after an evacuation, within 48 hours after their return.(6) Transportation. A facility's plan must contain a section for transportation that:(A) provides for a sufficient number of vehicles that are safe and suitable for any special needs of the clients or requires that the facility maintain a contract for transporting clients during an evacuation;(B) identifies facility staff authorized to drive a vehicle during an evacuation;(C) establishes alternate transportation arrangements if the vehicles or contracted transportation described in subparagraph (A) of this paragraph are not available;(D) includes procedures for safely transporting oxygen tanks currently being used by clients and any extra oxygen tanks that may be needed during an evacuation; and(E) includes procedures that will ensure:(i) safe transport of records, food, water, equipment, and supplies needed during an evacuation; and(ii) that the records, food, water, equipment, and supplies, described in clause (i) of this subparagraph, arrive at the alternate location at the same time as the clients.(7) Health and medical needs. A facility's plan must contain a section for client health and special needs that:(A) identifies all the facility's special needs clients including clients with conditions requiring assistance during an evacuation; and(B) ensures the needs of those clients are met during an emergency.(8) Resource management. A facility's plan must contain a section for resource management that:(A) includes procedures for accessing medications, records, food, water, equipment and supplies needed during an emergency;(B) identifies facility staff who are assigned to locate and ensure the transportation of items described in subparagraph (A) of this paragraph during an emergency situation; and(C) includes procedures to ensure medications are secure and stored at the proper temperatures during an emergency situation.(e) Training. A facility must:(1) train all staff on their responsibilities under the plan when hired in accordance with §559.67 of this subchapter (relating to Training);(2) retrain staff at least annually on the staff member's responsibilities under the plan and when the staff member's responsibilities under the plan change; and(3) conduct unannounced drills with facility staff for severe weather and other emergency situations identified by the facility as likely to occur, based on the results of the risk assessment required by subsection (c)(1) of this section.(f) Fire safety plan. A facility's fire safety plan must:(1) include the provisions described in the Operating Features section of the NFPA 101 Life Safety Code, 2000 Edition, Chapter 16 (relating to New Day-Care Occupancies) and Chapter 17 (relating to Existing Day-Care Occupancies), concerning:(A) use of alarms;(B) transmission of alarms to the fire department;(C) response to alarms;(D) isolation of fire;(E) evacuation of immediate area;(F) evacuation of smoke compartment;(G) preparation of floors and building for evacuation; and(H) fire extinguishment;(2) include procedures to contact HHSC by telephone, at 1-800-458-9858, within 24-hours after a fire in accordance with §559.42 of this chapter (relating to Safety); and(3) include procedures to submit to HHSC, within 15 days after the fire, the form Fire Report for Long Term Care Facilities;(4) include in the fire safety plan the provisions described in the Operating Features section of the NFPA 101 Life Safety Code, 2000 Edition, Chapter 16 and Chapter 17 concerning drills and inspections, except as superseded by this section; and(5) establish procedures to:(A) perform a monthly fire drill with all occupants of the building at expected and unexpected times and under varying conditions;(B) relocate, during the monthly fire drill, all occupants of the building to a predetermined location where participants must remain until a recall or dismissal signal is given;(C) complete the HHSC Fire Drill Report Form for each required fire drill;(D) conduct a monthly fire prevention inspection performed by a trained and senior member of the facility and prepare a report of the inspection results;(E) maintain copies of the fire prevention inspection report, described in subparagraph (D) of this paragraph, that were prepared by the facility within the last 12 months; and(F) post a copy of the most recent fire prevention inspection report, described in subparagraph (D) of this paragraph, in a conspicuous place in the facility.(g) Emergency Response System.(1) The facility director and designee must enroll in an emergency communication system in accordance with instructions from HHSC.(2) The facility must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §559.79 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS D STANDARDS FOR LICENSURE §559.79 Emergency Preparedness and Response https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219531 03/12/2026 (a) HHSC may enter the premises of a facility at reasonable times and make an inspection necessary to issue a license or renew a license. HHSC inspection and survey personnel perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits as required for carrying out the responsibilities of licensing.(b) Generally, all inspections, surveys, complaint investigations, and other visits, whether routine or nonroutine, made for the purpose of determining the appropriateness of client care and day-to-day operations of a facility are unannounced. Any exceptions must be justified.(c) Certain visits may be announced, including initial architectural inspections, visits to determine the progress of physical plant construction or repairs, equipment installation or repairs, systems installation or repairs, or conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.(d) Any person may request an inspection of a facility by notifying HHSC of an alleged violation of a licensing requirement. The complaint should be as detailed as possible and signed by the complainant; however, HHSC does investigate anonymous complaints. Unless a complaint is anonymous, HHSC responds to the complainant in writing but without the outcome of the investigation.(e) If the complaint alleges abuse, neglect, or exploitation, HHSC performs an inspection as soon as feasible but not later than the 14th day after the date HHSC receives the complaint, unless after an investigation the complaint is found to be frivolous. If the complaint does not allege abuse, neglect, or exploitation, HHSC investigates the complaint not later than the 45th day after the date HHSC receives the complaint.(f) The facility must make all its books, records, electronic records, and other documents maintained by or on behalf of a facility accessible to HHSC upon request.(1) HHSC is authorized to photocopy documents, photograph clients, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection, survey, or investigation.(2) Examples of records and documents that may be requested and photocopied or otherwise reproduced are client medical records, including nursing notes, pharmacy records, medication records, and prescribing practitioner's orders.(3) The facility may charge HHSC at a rate not to exceed the rate HHSC charges for copies. The procedure of copying is the responsibility of the director or his or her designee. If copying requires that the records be removed from the facility, a representative of the facility is expected to accompany the records and ensure their order and preservation.(4) HHSC protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.(5) If a facility maintains electronic records, it must have a mechanism for printing all documentation if a surveyor or investigator requests a printed copy.(g) HHSC does not reveal the source of a complaint.(h) HHSC inspects a facility at least once every two years after the initial inspection. Source Note: The provisions of this §559.81 adopted to be effective August 31, 1993, 18 TexReg 2726; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective January 1, 1995, 19 TexReg 9531; amended to be effective May 1, 1999, 24 TexReg 3100; amended to be effective November 1, 2000, 25 TexReg 10753; amended to be effective April 1, 2007, 32 TexReg 1749; amended to be effective October 29, 2018, 43 TexReg 7219; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249; amended to be effectiveJuly 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS E INSPECTIONS, SURVEYS, AND VISITS §559.81 Procedural Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219532 03/12/2026 (a) HHSC determines if a facility meets the licensing rules, including both physical plant and facility operation requirements.(b) Violations of regulations are listed on forms designed for the purpose of the inspection.(c) At the conclusion of an inspection or survey, any violations are discussed in an exit conference with the facility's management. HHSC leaves s written list of violations with the facility at the time of the exit conference.(d) If additional violations are cited after the initial exit conference, the violations are communicated to the facility within 10 working days after the initial exit conference.(e) HHSC provides a clear and concise written summary in nontechnical language of each licensure inspection, inspection of care, and complaint investigation. The summary outlines significant violations noted at the time of the inspection or survey but does not include names of clients, staff, or any other information that would identify individual clients or other prohibited information under general rules of public disclosure. The summary is provided to the facility at the time the report of contact or similar document is provided.(f) Upon receipt of the final statement of violations, the facility has 10 working days to submit an acceptable plan of correction to the HHSC Regulatory Services Regional Office director. An acceptable plan of correction must address:(1) how the facility will accomplish the corrective action for those clients affected by each violation;(2) how the facility will identify other clients with the potential to be affected by the same violation;(3) how the facility will put the corrective measure into practice or make systemic changes to ensure that the violation does not recur;(4) how the facility will monitor the corrective action to ensure that the violation is corrected and will not recur; and(5) the date the corrective action will be completed.(g) If the facility disagrees with a survey finding regarding a violation of regulations, the facility is entitled to an informal dispute resolution (IDR) for the violation.(1) The facility must request an IDR by submitting all supporting documentation to HHSC Regulatory Enforcement no later than the tenth day after receipt of the official statement of violations.(2) HHSC completes the IDR process no later than the 30th day after receipt of a request from a facility.(3) HHSC notifies the facility of the results of the IDR process in writing, and violations deemed invalid in the IDR are so noted in HHSC's records. Source Note: The provisions of this §559.83 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS E INSPECTIONS, SURVEYS, AND VISITS §559.83 Determinations and Actions Pursuant to Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219533 03/12/2026 HHSC may refer a facility to the attorney general who may petition a district court for:(1) a temporary restraining order to restrain a person from a violation or threatened violation of the requirements or any other law affecting clients if HHSC reasonably believes that the violation or threatened violation creates an immediate threat to the health and safety of a client; and(2) an injunction to restrain a person from a violation or threatened violation of the requirements or any other law affecting clients if HHSC reasonably believes that the violation or threatened violation creates a threat to the health and safety of a client. Source Note: The provisions of this §559.85 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS E INSPECTIONS, SURVEYS, AND VISITS §559.85 Referrals to the Attorney General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219534 03/12/2026 (a) Procedures for inspection of public records are in accordance with Texas Government Code, Chapter 552, and as further described in this section.(b) The HHSC Regulatory Services Division is responsible for the maintenance and release of records on licensed facilities and other related records.(c) The application for inspection of public records is subject to the following criteria.(1) The application must be made to Regulatory Services, Texas Health and Human Services Commission, Mail Code E-349, P.O. Box 149030, Austin, Texas 78714-9030.(2) The requester must identify himself or herself.(3) The requester must specify the records requested.(4) On written applications, if HHSC is unable to ascertain what records are being requested, HHSC may return the written application to the requester for clarification.(5) HHSC provides the requested records as soon as possible; however, if the records are in active use, or in storage, or time is needed for proper de-identification or preparation of the records for inspection, HHSC so advises the requester and sets an hour and date within a reasonable time when the records will be available.(d) Original records may be inspected or copied, but in no instance will original records be removed from HHSC offices.(e) HHSC Regulatory Services charges for copies of records requested.(1) If the requester wants to inspect records without requesting copies, the requester specifies the records to be inspected. HHSC does not charge this service, unless the director of HHSC Regulatory Services determines a charge is appropriate based on the nature of the request.(2) If the requester wants copies of a record, the requester specifies in writing the records to be copied on an appropriate HHSC form, and HHSC completes the form by specifying the cost of the records, which the requester must pay in advance. Checks and other instruments of payment must be made payable to the Texas Health and Human Services Commission.(3) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requester on a cost basis in accordance with costs established by the Office of the Attorney General or HHSC for office machine copies. All applicable sales taxes are added to the cost of copying records.(4) For documents that are mailed, HHSC charges for postage at the time it charges for the production.(5) When a request involves information pertaining to multiple facilities, HHSC may consider each facility's information a separate request. Source Note: The provisions of this §559.87 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS E INSPECTIONS, SURVEYS, AND VISITS §559.87 Procedures for Inspection of Public Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219535 03/12/2026 For purposes of this subchapter, the definitions of abuse, neglect, and exploitation are those found in Chapter 48, Human Resources Code, and §559.3 of this chapter (relating to Definitions). Source Note: The provisions of this §559.91 adopted to be effective May 1, 1999, 24 TexReg 3100; transferred effective January 15, 2021, as published in the Texas Register December 18, 2020, 45 TexReg 9249; amended to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS F ABUSE, NEGLECT, AND EXPLOITATION: COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §559.91 Definitions of Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219536 03/12/2026 (a) Any facility staff who has reasonable cause to believe that a client is experiencing abuse, neglect, or exploitation must report the abuse, neglect, or exploitation to HHSC's state office at 1-800-458-9858 immediately and must follow the facility's internal policies regarding abuse, neglect, or exploitation.(b) The following information must be reported to HHSC:(1) name, age, and address of the client;(2) name and address of the person responsible for the care of the client, if available;(3) nature and extent of the elderly or disabled person's condition;(4) basis of the reporter's knowledge; and(5) any other relevant information.(c) The facility must investigate the alleged abuse, neglect, or exploitation and submit a written report of the investigation electronically via the online portal to HHSC no later than the fifth day after the oral report and be available for inspection by HHSC. Source Note: The provisions of this §559.93 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS F ABUSE, NEGLECT, AND EXPLOITATION: COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §559.93 Abuse, Neglect, or Exploitation Reportable to HHSC by Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219537 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219537 03/12/2026 (a) A complaint is any allegation received by HHSC regarding abuse, neglect, or exploitation of a client or a violation of state standards.(b) HHSC must give the facility notification of the complaint received and a summary of the complaint, without identifying the source of the complaint. Source Note: The provisions of this §559.95 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS F ABUSE, NEGLECT, AND EXPLOITATION: COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §559.95 Complaint Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219538 03/12/2026 (a) HHSC only investigates complaints of abuse, neglect, or exploitation when the act occurs in the facility, the licensed facility is responsible for the supervision of the client at the time the act occurs, or the alleged perpetrator is affiliated with the facility. HHSC refers complaints of abuse, neglect, or exploitation not meeting these criteria to the Texas Department of Family and Protective Services.(b) Complaint investigations must include a visit to the facility and consultation with persons thought to have knowledge of the relevant circumstances. If the facility fails to admit HHSC staff for a complaint investigation, HHSC seeks a probate or county court order for admission. Investigators may request of the court that a peace officer accompany them during investigations.(c) In cases concluded to be physical abuse, HHSC submits the written report of the investigation to the appropriate law enforcement agency.(d) In cases concluded to be abuse, neglect, or exploitation of a client with a guardian, HHSC submits the written report of the investigation to the probate or county court that oversees the guardianship. Source Note: The provisions of this §559.97 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS F ABUSE, NEGLECT, AND EXPLOITATION: COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §559.97 Investigations of Complaints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219539 03/12/2026 All reports, records, communications, and working papers used or developed by HHSC in an investigation are confidential and may be released only as provided in this section.(1) HHSC may furnish the final written investigation report on cases to the district attorney and law enforcement agencies exercising jurisdiction if the investigation reveals abuse that is a criminal offense. HHSC may provide to another state agency or governmental entity information that is necessary for HHSC, the state agency, or entity to properly execute its duties and responsibilities to provide services to the elderly or disabled.(2) HHSC may release the final written investigation report to the public upon request provided the report is de-identified to remove all names and other personally identifiable data, including any information from witnesses and other person furnished to HHSC as part of the investigation.(3) HHSC notifies the reporter and the facility of the results of HHSC's investigation of a reported case of abuse, neglect, or exploitation, regardless of whether HHSC concluded that abuse, neglect, or exploitation occurred or did not occur.(4) Upon the written request of the person who is the subject of a report of abuse, neglect, or exploitation, his or her legal representative, or the personal representative of the person's estate if he or she is deceased, HHSC releases to the person or the representative otherwise confidential information relating to the final report. The request must specify the information desired and be signed and dated by the person making the request. A legal representative or personal representative must also specify the reason the information is requested and include with the request sufficient documentation to establish his or her authority as the representative. HHSC edits the information requested before release to protect the confidentiality of information related to the reporter's identify and to protect any other individual whose safety or welfare may be endangered by disclosure. Source Note: The provisions of this §559.99 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS F ABUSE, NEGLECT, AND EXPLOITATION: COMPLAINT AND INCIDENT REPORTS AND INVESTIGATIONS §559.99 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219527 03/12/2026 (a) HHSC may suspend a facility's license when the facility's violation of the licensure rules threatens to jeopardize the health and safety of clients.(b) Suspension of a license may occur simultaneously with any other enforcement provision available to HHSC.(c) HHSC notifies the facility of its intent to suspend the license, including the facts or conduct alleged to warrant the suspension. The facility has an opportunity to show compliance with all requirements of law for retention of the license as provided in §559.33 of this chapter (relating to Opportunity to Show Compliance). If the facility requests an opportunity to show compliance, HHSC gives the license holder a written affirmation or reversal of the proposed action.(d) HHSC notifies the facility of a suspension of the facility's license. If HHSC suspends a facility's license, the licensee may request a formal appeal by following HHSC's formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). A formal administrative hearing is conducted in accordance with Texas Government Code, Chapter 2001, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I. The suspension takes effect when the deadline for appeal of the suspension passes unless the facility appeals the suspension. If the facility appeals the suspension, the status of the license holder is preserved until final disposition of the contested matter. The license holder must return the license to HHSC within 72 hours of passing the appeal deadline or, if an appeal is filed, the final disposition of the appeal.(e) The suspension remains in effect until HHSC determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC conducts an on-site investigation before making a determination to lift a suspension. Source Note: The provisions of this §559.101 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS G ENFORCEMENT §559.101 Nonemergency Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219528 03/12/2026 (a) HHSC may revoke a facility's license when the license holder has violated the requirements of Texas Human Resources Code, Chapter 103.(b) In addition, HHSC may revoke a license if the licensee:(1) submitted false or misleading statements in the application for a license or any accompanying attachments;(2) used other evasive means to obtain the license;(3) concealed a material fact in the application for a license or failed to disclose information required in §559.19 of this chapter (relating to Applicant Disclosure Requirements) that would have been the basis to deny the license under §559.31 of this chapter (relating to Criteria for Denying a License or Renewal of a License); or(4) violated the rules adopted under this chapter.(c) Revocation of a license may occur simultaneously with any other enforcement provision available to HHSC.(d) HHSC notifies the facility of its intent to revoke the license, including the facts or conduct alleged to warrant the revocation. The facility has an opportunity to show compliance with all requirements of law for retention of the license as provided in §559.33 of this title (relating to Opportunity to Show Compliance). If the facility requests an opportunity to show compliance, HHSC gives the license holder a written affirmation or reversal of the proposed action.(e) If HHSC revokes a facility's license, the licensee may request a formal appeal by following the HHSC's formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). A formal administrative hearing is conducted in accordance with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I. If the facility appeals the revocation, the status of the license holder is preserved until final disposition of the contested matter. The license holder must return the license to HHSC within 72 hours of passing the appeal deadline or, if an appeal is filed, final disposition of the appeal. Source Note: The provisions of this §559.103 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS G ENFORCEMENT §559.103 Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219529 03/12/2026 (a) HHSC suspends a facility's license or orders an immediate closing of part of the facility if:(1) HHSC finds that the facility is operating in violation of the licensure rules; and(2) the violation creates an immediate threat to the health and safety of a client.(b) The order suspending a license or closing a part of a facility under this section is immediately effective on the date the license holder receives a written notice or on a later date specified in the order.(c) The order suspending a license or ordering an immediate closing of a part of the facility is valid for ten days after the effective date of the order.(d) A licensee whose facility is closed under this section is entitled to request a formal administrative hearing under HHSC's formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), but a request for an administrative hearing does not suspend the effectiveness of the order.(e) When an emergency suspension has been ordered and the conditions in the facility indicate that clients should be relocated, the following requirements apply.(1) In all circumstances, a client's rights and freedom of choice in selecting another DAHS must be respected.(2) If a facility or part thereof is closed, the following procedures must be followed.(A) HHSC notifies the local health department director, city or county health authority, and representatives of the appropriate state agencies of the closure.(B) The facility staff must notify each client's guardian or responsible party and attending physician, advising them of the action in process.(C) The client or client's guardian or responsible party must be given opportunity to designate a preference for another specific facility or for other arrangements.(D) HHSC arranges for relocation to another facility in the area in accordance with the client's preference. A facility chosen for relocation must be in good standing with HHSC and, if certified under Titles XVIII and XIX of the United States Social Security Act, must be in good standing under its contract. The facility chosen must be able to meet the needs of the client.(E) If necessary to prevent the transport of a client over a substantial distance, HHSC may grant a waiver to a receiving facility to temporarily exceed its licensed capacity, provided the health and safety of clients is not compromised and the facility can meet the increased demands for direct service staff and dietary services. A facility may exceed its licensed capacity under these circumstances, monitored by HHSC staff, until clients can be transferred to a permanent location.(F) With each client transferred, the following reports, records, and supplies must be transmitted to the receiving institution:(i) a copy of the current prescribing practitioner's orders for medication, treatment, diet, and special services required;(ii) personal information such as the name and address of the next of kin, guardian, or responsible party for the client; attending physician; Medicare and Medicaid identification number; social security number; and other identifying information as deemed necessary and available; and(iii) all medication dispensed in the name of the client for which prescribing practitioner's orders are current. These must be inventoried and transferred with the client.(G) If the closed facility is allowed to reopen within 90 days, the relocated clients have the first right to return to the facility. Relocated clients may choose to return, to stay in the receiving facility (if the facility is not exceeding its licensed capacity), or any other available accommodations.(H) Any return to the facility must be treated as a new admission, including exchange of medical information, medications, and completion of required forms. Source Note: The provisions of this §559.105 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS G ENFORCEMENT §559.105 Emergency Suspension and Closing Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219530 03/12/2026 (a) HHSC may assess an administrative penalty if a facility:(1) violates Texas Human Resources Code, Chapter 103, a rule, standard, or order adopted under this chapter, or a term of a license issued under this chapter;(2) makes a false statement of a material fact that the facility knows or should know is false:(A) on an application for a license or a renewal of a license or in an attachment to the application; or(B) with respect to a matter under investigation by HHSC;(3) refuses to allow an HHSC representative to inspect:(A) a book, record, or file required to be maintained by a facility; or(B) any portion of the premises of a facility;(4) willfully interferes with the work of a representative of HHSC or the enforcement of this chapter;(5) willfully interferes with an HHSC representative who is preserving evidence of a violation of Texas Human Resources Code, Chapter 103, a rule adopted under this chapter, or a term of a license issued under this chapter;(6) fails to pay a penalty assessed under Texas Human Resources Code, Chapter 103, or a rule adopted under this chapter not later than the 30th day after the date the assessment of the penalty becomes final; or(7) fails to notify HHSC of a change of ownership before the effective date of the change of ownership.(b) HHSC assesses administrative penalties against a facility in accordance with the schedule of appropriate and graduated penalties established in this section. To determine the amount of an administrative penalty, HHSC considers:(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the situation, and the hazard or potential hazard created by the situation to the health or safety of the public;(2) the history of previous violations by a facility;(3) the amount necessary to deter future violations;(4) the facility's efforts to correct the violation; and(5) any other matter that justice may require.(c) Each day of a continuing violation constitutes a separate violation. The administrative penalties for each day of a continuing violation cease on the date the violation is corrected. A violation that is the subject of a penalty is presumed to continue each successive day until it is corrected. The date of correction alleged by the facility in its written plan of correction is be presumed to be the actual date of correction unless it is later determined by HHSC that the correction was not made by that date or was not satisfactory. (d) The administrative penalty schedule includes violations that warrant an administrative penalty.Attached Graphic(e) HHSC may not collect an administrative penalty from a facility if, not later than the 45th day after the date, the facility receives notice under subsection (j) of this section, the facility corrects the violation to the satisfaction of HHSC.(f) Subsection (e) of this section does not apply to:(1) a violation that HHSC determines is:(A) a pattern of violation that results in actual harm;(B) widespread in scope and results in actual harm;(C) widespread in scope, constitutes a potential for more than minimal harm, and relates to:(i) staffing, including staff ratio, health, and training under §559.61 of this chapter (relating to Staffing Ratio and Hours), §559.63 of this chapter (relating to Infection Prevention and Control), and §559.67 of this chapter (relating to Training);(ii) administration of medication under §559.69 of this chapter (relating to Medications); or(iii) emergency preparedness and response under §559.79 of this chapter (relating to Emergency Preparedness and Response);(D) an immediate threat to the health or safety of an elderly person or a person with a disability receiving services at a facility; or(E) substantially limits the facility's capacity to provide care;(2) a violation described by subsection (a)(2) - (7) of this section;(3) a violation of Texas Human Resources Code, Chapter 102; or(4) a second or subsequent violation of §559.67(c) of this chapter that occurs before the second anniversary of the date of a previous violation of §559.67(c) of this chapter.(g) A facility that corrects a violation must maintain the correction. If the facility fails to maintain the correction until at least the first anniversary after the date the correction was made, HHSC may assess and collect an administrative penalty for the subsequent violation. An administrative penalty assessed under this subsection is equal to three times the amount of the original penalty assessed but not collected. HHSC is not required to provide the facility with an opportunity to correct the subsequent violation.(h) HHSC issues a preliminary report stating the facts on which HHSC concludes that a violation has occurred after HHSC has:(1) examined the possible violation and facts surrounding the possible violation; and(2) concluded that a violation has occurred.(i) In the report, HHSC may recommend the assessment of an administrative penalty for each violation and the amount of the administrative penalty.(j) HHSC provides a written notice of a preliminary report to the facility not later than 10 days after the date HHSC issues the preliminary report. The written notice includes:(1) a brief summary of each violation;(2) the amount of each recommended administrative penalty; (3) a statement of whether a violation is subject to correction in accordance with subsection (e) of this section and, if the violation is subject to correction, a statement of:(A) the date on which the facility must file with HHSC a plan of correction for approval by HHSC;(B) the date on which the facility must complete the plan of correction to avoid assessment of the administrative penalty; and(4) a statement that the facility has a right to an administrative hearing on the occurrence of the violation, the amount of the penalty, or both.(k) Not later than 20 days after the date on which a facility receives a written notice of a preliminary report, the facility may:(1) give HHSC written notice that the facility agrees with HHSC report and consents to the recommended penalty; or(2) make a written request for an administrative hearing.(l) If a violation is subject to correction under subsection (e) of this section, the facility must submit a plan of correction to HHSC for approval not later than 10 days after the date on which the facility receives the written notice.(m) If a violation is subject to correction, and the facility reports to HHSC that the violation has been corrected, HHSC inspects the correction or takes any other step necessary to confirm the correction and notify the facility that:(1) the correction is satisfactory and HHSC will not assess an administrative penalty; or(2) the correction is not satisfactory and HHSC recommends an administrative penalty.(n) Not later than 20 days after the date on which a facility receives a notice that the correction is not satisfactory and HHSC recommends an administrative penalty, the facility may:(1) give HHSC written notice that the facility agrees with HHSC's determination and consents to the recommended administrative penalty; or(2) make a written request to HHSC for an administrative hearing.(o) If a facility consents to the recommended administrative penalty or does not timely respond to a notice sent under subsection (j) of this section, the executive commissioner or designee assesses the recommended administrative penalty. If the executive commissioner or designee assesses the penalty, HHSC gives written notice of the penalty to the facility and the facility must pay the penalty within 30 days after receiving the notice.(p) An administrative hearing is held in accordance with Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act) and HHSC rules at 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(q) An administrative law judge sets a hearing and gives notice of the hearing if a facility that is assessed a penalty requests a hearing.(r) The hearing is held before an administrative law judge who makes findings of fact and conclusions of law regarding the occurrence of a violation under Texas Human Resources Code, Chapter 103, a rule adopted under this chapter, or a term of a license issued under this chapter.(s) Based on the findings of fact and conclusions of law and the recommendation of the administrative law judge, the executive commissioner or designee, by order, finds:(1) a violation has occurred and assesses an administrative penalty; or(2) a violation has not occurred.(t) The executive commissioner or designee provides notice of the findings made under subsection (s) of this section to the facility charged with a violation. If the executive commissioner finds that a violation has occurred, the executive commissioner or designee provides written notice to the facility of:(1) the findings;(2) the amount of the administrative penalty;(3) the rate of interest payable on the penalty and the date on which interest begins to accrue; and(4) the facility's right to judicial review of the order of the executive commissioner.(u) Not later than the 30th day after the date on which the order of the executive commissioner or designee is final, the facility assessed an administrative penalty must:(1) pay the full amount of the penalty; or(2) file a petition for judicial review contesting the occurrence of the violation, the amount of the penalty, or both.(v) Notwithstanding subsection (o) of this section, HHSC may permit a facility to pay an administrative penalty in installments. (w) If a facility does not pay an administrative penalty within the period provided by subsection (o) or (u) of this section or in accordance with the installment plan permitted by HHSC:(1) the penalty is subject to interest; and(2) HHSC may refer the matter to the attorney general for collection of the penalty and interest.(x) Interest accrues:(1) at a rate equal to the rate charged on loans to depository institutions by the New York Federal Reserve Bank; and(2) for the period beginning on the day after the date on which the penalty becomes due and ending on the date the penalty is paid.(y) If the amount of a penalty is reduced or the assessment of a penalty is not upheld on judicial review, the executive commissioner or designee must:(1) remit to the facility the appropriate amount of any penalty payment plus accrued interest; or(2) execute a release of the supersedeas bond if one has been posted.(z) Accrued interest on the amount remitted by the executive commissioner or designee must be paid:(1) at a rate equal to the rate charged on loans to depository institutions by the New York Federal Reserve Bank; and(2) for the period beginning on the date the penalty is paid and ending on the date the penalty is remitted to the facility. Source Note: The provisions of this §559.107 adopted to be effective July 10, 2024, 49 TexReg 4909. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS G ENFORCEMENT §559.107 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227524 03/12/2026 (a) The purpose of this subchapter is to:(1) establish licensing procedures, standards, and requirements for an individualized skills and socialization provider licensed as a Day Activity and Health Services (DAHS) facility in accordance with Texas Human Resources Code Chapter 103; and(2) establish health and safety requirements for a provider licensed by the Texas Health and Human Services Commission to deliver individualized skills and socialization services, including:(A) environmental safety;(B) prevention and investigation of abuse, neglect, or exploitation; and(C) general and program provider requirements.(b) This subchapter applies to an individualized skills and socialization provider and the provision of on-site and off-site individualized skills and socialization services.(c) This subchapter does not apply to:(1) a DAHS facility providing services in the DAHS program; or(2) the provision of in-home individualized skills and socialization in the Home and Community-based Services and Texas Home Living waiver programs. Source Note: The provisions of this §559.201 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.201 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227525 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--Intentional or negligent act that results in physical or emotional harm or pain to an individual by an individualized skills and socialization provider or an employee, a contractor, or a volunteer of an individualized skills and socialization provider, including;(A) injury;(B) confinement;(C) intimidation;(D) cruel punishment; or(E) sexual abuse, including:(i) any sexual conduct conducted by a direct provider of individualized skills and socialization services that would constitute an offense under Penal Code §21.08 (relating to Indecent Exposure); or(ii) any sexual conduct conducted by a direct provider of individualized skills and socialization services that would constitute an offense under Penal Code, Chapter 22 (relating to Assaultive Offenses), committed by a direct provider of individualized skills and socialization services.(2) Actual harm--A negative outcome that compromises the physical, emotional, or mental well-being of any individual receiving services from the individualized skills and socialization provider.(3) Applicant--A person or entity seeking licensing through the Texas Health and Human Services Commission (HHSC) to provide individualized skills and socialization services.(4) Cause to believe--An individualized skills and socialization provider knows, suspects, or receives an allegation regarding abuse, neglect, or exploitation.(5) Centers for Medicare and Medicaid Services (CMS)--The federal agency within the United States Department of Health and Human Services (HHS) that administers Medicare and Medicaid programs.(6) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder. The substitution of a personal representative for a deceased license holder is not a change of ownership.(7) Community setting--A setting accessible to the general public within an individual's community.(8) Complaint--Any allegation received by HHSC regarding abuse, neglect, or exploitation of an individual or a violation of Texas Human Resources Code Chapter 103 or a rule, standard, or order adopted under Texas Human Resources Code Chapter 103.(9) Day Activity and Health Services (DAHS) directory--A public list generated and maintained by HHSC, listing all DAHS providers, including individualized skills and socialization providers.(10) Deaf Blind with Multiple Disabilities (DBMD) program--A waiver program operated by HHSC, as authorized by CMS in accordance with §1915(c) of the Social Security Act.(11) Exploitation--An illegal or improper act or process of using resources belonging to an individual receiving services by an individualized skills and socialization provider or an employee, a contractor, or a volunteer of an individualized skills and socialization provider without informed consent from the individual or the individual's legally authorized representative (LAR) for personal or monetary benefit. (12) Home and Community-based Services (HCS) program--A waiver program operated by HHSC as authorized by CMS in accordance with §1915(c) of the Social Security Act.(13) Immediate threat--A situation that causes, or is likely to cause, injury, harm, impairment, or death of an individual.(14) Implementation plan--In the HCS and TxHmL programs, a written document developed by a program provider outlining the outcomes, objectives, frequency, and duration for each program service on the individual's IPC to be provided by the program provider.(15) Incident--Any non-routine occurrence that has an impact on the care, supervision, or treatment of an individual receiving services, as described in accordance with HHSC guidance.(16) Individual--A person who applies for or is receiving services from an individualized skills and socialization provider.(17) Individual plan of care (IPC)--A written plan authorized by HHSC that states the type and amount of each DBMD, TxHmL, or HCS program service to be provided to the individual during an IPC year.(18) Individual program plan (IPP)--In the DBMD program, a written plan documented on an HHSC form and completed by an individual's case manager that describes the goals and outcomes for each DBMD program service and Community First Choice (CFC) service, other than CFC support management, included on the individual's IPC.(19) Individualized skills and socialization--A DBMD, TxHmL, or HCS program service described in §260.503 of this title (relating to Description of Individualized Skills and Socialization), §262.905 of this title (relating to Description of On-Site and Off-Site Individualized Skills and Socialization), or §263.2005 of this title (relating to Description of On-Site and Off-Site Individualized Skills and Socialization). The two types of individualized skills and socialization are on-site individualized skills and socialization and off-site individualized skills and socialization.(20) Individualized skills and socialization provider--A provider licensed as a DAHS provider by HHSC to provide individualized skills and socialization services. A provider of individualized skills and socialization services is considered an individualized skills and socialization provider once licensed.(21) In person or in-person--Within the physical presence of another person who is awake. In person or in-person does not include using videoconferencing or a telephone.(22) Isolated--Describing a violation of Texas Human Resources Code Chapter 103 or a rule, standard, or order adopted under Texas Human Resources Code Chapter 103 by an individualized skills and socialization provider that affects a very limited number of individuals receiving services and that:(A) involves a very limited number of service providers; or(B) has only occurred occasionally.(23) Legally authorized representative (LAR)--A person authorized by law to act on behalf of another person regarding a matter described in this subchapter, including a parent, guardian, or managing conservator of a minor; a guardian of an adult; an agent appointed under a power of attorney; or a representative payee appointed by the Social Security Administration. An LAR, such as an agent appointed under a power of attorney or representative payee appointed by the Social Security Administration, may have limited authority to act on behalf of a person.(24) License holder--A person who holds a license as an individualized skills and socialization provider.(25) Neglect--Failure to provide an individual receiving services with identified health and safety services necessary to avoid infliction of injury, physical or emotional harm, or pain to an individual receiving services by an individualized skills and socialization provider or an employee, contractor, or volunteer of an individualized skills and socialization provider. This includes failure to:(A) provide services in accordance with an individual's IPC, IPP, PDP, and implementation plan, resulting in infliction of injury, physical or emotional harm, or pain; and(B) establish effective health and safety precautions to ensure an individual is protected from infliction of injury, physical or emotional harm, or pain.(26) Off-site individualized skills and socialization only--An individualized skills and socialization service provider who only delivers off-site individualized skills and socialization services and does not deliver on-site individualized skills and socialization services.(27) On-site individualized skills and socialization location--The building or a portion of a building that is owned or leased by an individualized skills and socialization provider where on-site individualized skills and socialization service is provided.(28) Online licensure portal--The Texas Unified Licensure Information Portal (TULIP) system. TULIP is the online system for submitting long-term care licensure applications.(29) Pattern--Describing repeated, but not widespread in scope, violations of Texas Human Resources Code Chapter 103 or a rule, standard, or order adopted under Texas Human Resources Code Chapter 103 by an individualized skills and socialization provider that:(A) is found throughout the services provided by the individualized skills and socialization provider; or(B) affects or involves one or more of the same individuals receiving services, or one or more of the same service providers.(30) Person-directed plan (PDP)--In the HCS and the TxHmL programs, a written plan, based on person-directed planning and developed with an applicant or individual using the HHSC person-directed plan form and discovery tool found on the HHSC website, that:(A) describes the supports and services necessary to achieve the desired outcomes identified by the applicant, individual, or LAR and ensures the applicant's or individual's health and safety; and(B) includes the setting for each service, which is selected by the individual or LAR from setting options.(31) Program provider--A person, as defined in §52.3 of this title (relating to Definitions), who has a contract with HHSC to provide DBMD, TxHmL, or HCS program services, excluding a financial management services agency.(32) Service provider--A person, who may be an employee, contractor, or volunteer of an individualized skills and socialization provider, who directly provides individualized skills and socialization services to an individual.(33) Substantial violation--A violation for which HHSC may assess an administrative penalty before giving an individualized skills and socialization provider an opportunity to correct the violation. A substantial violation is a violation that HHSC determines:(A) represents a pattern of violation that results in actual harm;(B) is widespread in scope and results in actual harm;(C) is widespread in scope, constitutes a potential for actual harm, and relates to:(i) staffing, including staff training, ratio, and health under §559.227 of this subchapter (relating to Program Requirements);(ii) administration of medication under §559.227(m) of this subchapter; or(iii) emergency preparedness and response under §559.229 of this subchapter (relating to Environment and Emergency Response Plan);(D) constitutes an immediate threat to the health or safety of an individual receiving services;(E) substantially limits the provider's ability to meet identified health and safety needs of an individual;(F) a violation described by §559.253(a)(2) - (7) of this subchapter (relating to Administrative Penalties);(G) a violation of Texas Human Resources Code §103.011; or(H) a second or subsequent violation of Texas Health and Safety Code §326.002, that occurs before the second anniversary of the date of the first violation.(34) Texas Home Living (TxHmL) program--A waiver program operated by HHSC and approved by CMS in accordance with §1915(c) of the Social Security Act.(35) Widespread--Describing a violation of Texas Human Resources Code Chapter 103 or a rule, standard, or order adopted under Texas Human Resources Code Chapter 103 by an individualized skills and socialization provider that:(A) is pervasive throughout the services delivered by the individualized skills and socialization provider; or(B) represents a systematic failure by the individualized skills and socialization provider that affects or has the potential to affect a large portion of or all individuals receiving services from the individualized skills and socialization provider. Source Note: The provisions of this §559.203 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.203 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227526 03/12/2026 (a) An entity may not establish or provide individualized skills and socialization services in Texas without a license issued by the Texas Health and Human Services Commission (HHSC) in accordance with Texas Human Resources Code, Chapter 103, and this subchapter.(b) An individualized skills and socialization provider must be listed on the HHSC Day Activity and Health Services (DAHS) directory as an individualized skills and socialization provider to provide individualized skills and socialization services.(c) An applicant for a license must follow the application instructions and submit a completed application form, required documentation, and required license fee to HHSC through the online licensure portal.(d) An applicant for a license must complete HHSC required training to become an individualized skills and socialization provider and provide documentation that required training is complete through the application in the online licensure portal.(e) An applicant for a license must submit to HHSC as part of the application the:(1) name of the business entity to be licensed;(2) tax identification number;(3) name of the chief executive officer (CEO) or equivalent person;(4) ownership information;(5) address of the on-site individualized skills and socialization location or, for providers of off-site individualized skills and socialization services only, the designated place of business where records are kept;(6) name of program providers using this entity for individualized skills and socialization services, if any;(7) maximum number of individuals, regardless of funding source, who can receive services at or from this location, as determined by the provider and informed by building occupancy requirements, staff availability, and Medicaid program requirements, which will become the licensed capacity when approved;(8) effective date the entity will be available to provide individualized skills and socialization services;(9) attestation that the applicant has created and implemented a community engagement plan, including:(A) a description of how the organization will meet the requirement to make off-site individualized skills and socialization available to individuals;(B) a description of how the organization will work with contracted program providers to obtain information from the individuals' person-directed plans (PDP) and implementation plan, and use that information to inform on-site and off-site activities that are aligned with an individual's PDP; and(C) a description of how staff will respond to an emergency or other unexpected circumstance that may occur during the provision of on-site and off-site individualized skills and socialization services to ensure the health and safety of all individuals; and(10) any other information required by the online application instructions.(f) HHSC may deny an application that remains incomplete after 120 days.(g) Before issuing a license, HHSC considers the background and qualifications of:(1) the applicant or license holder;(2) a person with a disclosable interest;(3) an affiliate of the applicant or license holder;(4) an administrator;(5) a manager; and(6) any other person disclosed on the submitted application as defined by the application instructions.(h) If the location where an applicant intends to provide on-site or off-site individualized skills and socialization services is located within, on the grounds of, or physically adjacent to a prohibited setting as set forth in the rules governing the Home and Community-based Services (HCBS) waiver programs, as described in §263.2005(d) of this title (relating to Description of On-Site and Off-Site Individualized Skills and Socialization), and the applicant has not been approved through heightened scrutiny process as described in §263.2005(e) of this title, HHSC will refer the application for enforcement.(i) HHSC issues a license if it finds that the applicant or license holder, and all persons described in subsection (g) of this section, affirmatively demonstrate compliance with all applicable requirements of this subchapter, based on an on-site survey. (j) For DAHS Individualized Skills and Socialization Only licensure applications, HHSC may:(1) at its sole discretion, issue a temporary initial license effective for 180 days, which may be extended until such time as an applicant demonstrates that it meets the requirements for operation based on an on-site survey; and(2) issue a three-year license to applicants described under this subsection.(k) For DAHS with Individualized Skills and Socialization licensure applications, HHSC will follow the criteria for licensure as described in §559.11 of this chapter (related to Criteria for Licensing).(l) An individualized skills and socialization provider must not provide services to more individuals than the number of individuals specified on its license.(m) An individualized skills and socialization provider must prominently and conspicuously post its license for display in a public area of the on-site individualized skills and socialization location that is readily accessible to individuals, employees, and visitors. For an off-site only individualized skills and socialization provider, the license must be displayed in a conspicuous place in the designated place of business.(n) If any information submitted through the application process changes following licensure, the license holder must submit an application through the online licensure portal to make the changes. Source Note: The provisions of this §559.205 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.205 Criteria for Licensing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211684 03/12/2026 (a) During the license term, a license holder may not increase capacity without approval from the Texas Health and Human Services Commission (HHSC). The license holder must submit to HHSC a complete application for increase in capacity through the online licensure portal.(b) Upon approval of an increase in capacity, HHSC will issue a new license. Source Note: The provisions of this §559.207 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.207 Increase in Capacity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211685 03/12/2026 (a) A license issued under this chapter:(1) must be renewed before the license expiration date; and(2) is not automatically renewed.(b) All renewal licenses issued under this subchapter are valid for three years.(c) The submission of a license fee alone does not constitute an application for renewal.(d) To renew a license, a license holder must submit an application for renewal to HHSC through the online licensure portal no later than the 45th day before the expiration date of the current license. HHSC considers that an application for renewal has met the submission deadline if the license holder:(1) submits a complete application to HHSC, and HHSC receives that complete application no later than the 45th day before the expiration date of the current license;(2) submits an incomplete application to HHSC with a letter explaining the circumstances that prevented the inclusion of the missing information, and HHSC receives the incomplete application and letter no later than the 45th day before the expiration date of the current license; or(3) submits a complete application or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information to HHSC, HHSC receives the application during the 45-day period ending on the date the current license expires, and the license holder pays a late fee in accordance with §559.219(c) of this subchapter (relating to License Fees) in addition to the license renewal fee.(e) For purposes of Texas Government Code §2001.054, HHSC considers that a person has submitted a timely and sufficient application for the renewal of a license if the license holder's application has met the submission deadlines in subsection (e) of this section, including submission of the required fee. Failure to submit a timely and sufficient application will result in the expiration of the license on the expiration date listed on the license.(f) An application for renewal submitted after the expiration date of the license will not be accepted and an application for an initial license complying with the requirements in §559.205 of this subchapter must be submitted (relating to Criteria for Licensing).(g) The application for renewal must contain the same information required for an original application and the license fee as described in §559.219 of this subchapter.(h) The renewal of a license may be denied for the same reasons an original application for a license may be denied as described in §559.215 of this subchapter (relating to Criteria for Denying a License or Renewal of a License). Source Note: The provisions of this §559.209 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.209 Renewal Procedures and Qualifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211686 03/12/2026 (a) For the purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the license holder of a current individualized skills and socialization provider that exists on the date the application is submitted.(b) A license holder may not transfer its license. The applicant (new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When the Texas Health and Human Services Commission (HHSC) approves the change of ownership by issuing a temporary change of ownership license to the new license holder, the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the change of ownership application. Between the effective date of the change of ownership and the issuance of the temporary change of ownership license, the existing license holder remains responsible under its license; however, the applicant may operate as the individualized skills and socialization provider on behalf of the current license holder during such time period.(c) The applicant must submit to HHSC through the online licensure portal:(1) a complete change of ownership application for a license in accordance with HHSC instructions and §559.205 of this subchapter (relating to Criteria for Licensing) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;(2) the application fee, in accordance with §559.219 of this subchapter (relating to License Fees); and(3) a signed and notarized Change of Ownership Transfer Affidavit HHSC Form 1092 from the applicant and the individualized skills and socialization provider's current license holder of intent to transfer the individualized skills and socialization provider operation from the current license holder to the applicant, beginning on the change of ownership effective date specified on the change of ownership application.(d) To avoid an individualized skills and socialization provider operating without a license, an applicant must submit all items required by subsection (c) of this section at least 30 days before the anticipated date of a change of ownership, unless the 30-day notice requirement is waived in accordance with subsection (e) of this section.(e) HHSC may waive the 30-day notice required in subsection (d) of this section if HHSC determines that the applicant presents evidence showing that circumstances prevented the submission of the items in subsection (c) of this section at least 30 days before the anticipated change of ownership and that not waiving the 30-day requirement would create a threat to the health and safety of an individual.(f) Upon HHSC approval of the items specified in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all persons disclosed in the application satisfy all applicable requirements in §559.205 of this subchapter and §559.215 of this subchapter (relating to Criteria for Denying a License or Renewal of a License).(1) The issuance of a temporary change of ownership license constitutes HHSC's official written notice to the individualized skills and socialization provider of the approval of the application for a change of ownership.(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online licensure portal.(g) A temporary change of ownership license expires on the earlier of:(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (h) of this section; or(2) the date HHSC issues a three-year license in accordance with subsection (k) of this section.(h) HHSC, in its sole discretion, may extend a temporary change of ownership license for a term of 90 days at a time based upon extenuating circumstances.(i) HHSC conducts an on-site survey to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site survey after issuing a temporary change of ownership if:(1) less than 50 percent of the direct or indirect ownership interest of the former license holder changed, when compared to the new license holder; or(2) every person with a disclosable interest in the new license holder had a disclosable interest in the former license holder.(j) If the applicant, all controlling persons, and all persons disclosed in the application satisfy all applicable requirements of §559.205 and §559.215 of this subchapter for a license, and the individualized skills and socialization provider passes the change of ownership survey as described in subsection (i) of this section, HHSC issues a three-year license. The effective date of the three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application was received by HHSC through the online licensure portal.(k) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC of the addition no later than 30 days after the addition of the owner through the submission of an application in the online licensure portal.(l) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online licensure portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name. Source Note: The provisions of this §559.211 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.211 Change of Ownership and Notice of Changes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211687 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) will process only applications received within 60 days before the requested date of the issuance of the license.(b) An application is complete when all requirements for licensing have been met, including compliance with standards and payment of the licensing fee. If a survey for compliance is required, the application is not complete until the survey has occurred, reports have been reviewed, and the applicant complies with the standards.(c) HHSC will notify applicants within 30 days after receipt of the application if any of the following applications are incomplete:(1) initial application;(2) change of ownership;(3) renewal; and(4) increase in capacity.(d) Except as provided in the following sentence, a license will be issued or denied within 30 days after the receipt of a complete application or within 30 days before the expiration date of the license. However, HHSC may delay an action on an application for renewal of a license for up to six months if the individualized skills and socialization provider is subject to a proposed or pending licensure termination action on or within 30 days before the expiration date of the license. The issuance of the license constitutes HHSC's official written notice to the individualized skills and socialization provider of the acceptance and filing of the application.(e) In the event the application is not processed in the time periods stated in this section, the applicant has a right to request of HHSC full reimbursement of all filing fees paid in that particular application process. If HHSC does not agree that the established periods have been violated or finds that good cause existed for exceeding the established periods, the request will be denied.(f) Good cause for HHSC exceeding the period established is considered to exist if:(1) the number of applications to be processed exceeds by 15 percent or more the number processed in the same calendar quarter of the preceding year;(2) another public or private entity used in the application process caused the delay; or(3) other conditions existed giving good cause for exceeding the established periods.(g) If the request for full reimbursement is denied, the applicant may appeal to HHSC for resolution of the dispute. The applicant must send a statement to HHSC describing the request for reimbursement and the reasons for it. HHSC makes a decision concerning the appeal and notifies the applicant of the decision. Source Note: The provisions of this §559.213 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.213 Time Periods for Processing Licensing Applications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227527 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may deny an initial license or renewal of a license if any person described in §559.205(g) of this division(relating to Criteria for Licensing):(1) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;(2) substantially fails to comply with the requirements described in §559.225 of this subchapter (relating to General Requirements) and §559.227 of this subchapter (relating to Program Requirements), including:(A) noncompliance that poses a serious threat to health and safety; or(B) a failure to maintain compliance on a continuous basis;(3) aids, abets, or permits a substantial violation described in paragraph (2) of this subsection about which the person had or should have had knowledge;(4) fails to provide the required information, facts, or references;(5) knowingly provides the following false or fraudulent information:(A) submits false or intentionally misleading statements to HHSC;(B) uses subterfuge or other evasive means of filing;(C) engages in subterfuge or other evasive means of filing on behalf of another who is unqualified for licensure;(D) knowingly conceals a material fact; or(E) is responsible for fraud;(6) fails to pay the following fees, taxes, and assessments when due:(A) licensing fees as described in §559.219 of this division (relating to License Fees); and(B) franchise taxes, if applicable; or(7) has a history of any of the following actions during the five-year period preceding the date of the application:(A) operation of a facility that has been decertified or had its contract canceled under the Medicare or Medicaid program in any state;(B) federal or state Medicare or Medicaid sanctions or penalties;(C) unsatisfied final judgments;(D) eviction involving any property or space used as a facility in any state; or(E) suspension of a license to operate a health facility, long-term care facility, or a similar facility in any state.(b) Concerning subsection (a)(7) of this section, HHSC may consider exculpatory information provided by any person described in §559.205(g) of this division and grant a license if HHSC finds that person able to comply with the rules in this chapter.(c) HHSC does not issue a license to an applicant if the applicant has a history of any of the following actions during the five-year period preceding the date of the application:(1) revocation of a license to operate a health care facility, long-term care facility, or similar facility in any state;(2) debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or(3) a court order prohibiting any person described in §559.205(g) of this division from operating a facility.(d) HHSC considers only final actions for purposes of subsections (a)(7) and (c) of this section. An action is final when routine administrative and judicial remedies are exhausted. However, a provider must disclose all actions to HHSC, whether pending or final.(e) If an applicant owns multiple facilities, HHSC examines the overall record of compliance for all facilities. An overall record poor enough to deny issuance of a new license will not preclude the renewal of licenses of individual facilities with satisfactory records.(f) If HHSC denies a license or refuses to issue a renewal of a license, the applicant or license holder may request a hearing by following HHSC rules in Texas Administrative Code (TAC), Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). An administrative hearing is conducted in accordance with Texas Government Code, Chapter 2001, and 1 TAC Chapter 357, Subchapter I. Source Note: The provisions of this §559.215 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.215 Criteria for Denying a License or Renewal of a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211689 03/12/2026 (a) Before the institution of proceedings to revoke or suspend a license or deny an application for the renewal of a license, the Texas Health and Human Services Commission (HHSC) gives the license holder:(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and(2) an opportunity to show compliance with all requirements of law for the retention of the license by sending HHSC a written request for an opportunity to show compliance. The request must:(A) be postmarked within 10 days after the date of HHSC's notice and be received by HHSC within 10 days after the date of the postmark; and(B) contain specific documentation refuting HHSC's allegations.(b) HHSC's review will be limited to a review of documentation submitted by the license holder and information used by HHSC as the basis for its proposed action and will not be conducted as an adversary hearing. HHSC will give the license holder a written affirmation or reversal of the proposed action. Source Note: The provisions of this §559.217 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.217 Opportunity to Show Compliance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211690 03/12/2026 (a) The license fee is $75 for a three-year license. The license fee for a license issued in accordance with §559.205(k) of this subchapter (relating to Criteria for Licensing) is:(1) $25 for a one-year license;(2) $50 for a two-year license; and(3) $75 for a three-year license.(b) The fee must be paid with each initial application, change of ownership application, and application for renewal of the license. A license holder or applicant must pay fees as defined in the online licensure portal.(c) An applicant for license renewal that submits an application during the 45-day period ending on the date the current license expires must pay a late fee of $25 in addition to the license fee described in subsection (a) of this section. Source Note: The provisions of this §559.219 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.219 License Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211691 03/12/2026 (a) A license holder must not relocate to another on-site individualized skills and socialization location without approval from the Texas Health and Human Services Commission (HHSC). The license holder must submit a complete application and the fee required under §559.219 of this subchapter (relating to License Fees) to HHSC before the relocation.(b) The effective date of this license will be the date HHSC approves the relocation.(c) The license holder must continue to maintain the license at the current on-site individualized skills and socialization location and must continue to meet all requirements for operation until the date of the relocation. Source Note: The provisions of this §559.221 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.221 Relocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211692 03/12/2026 An individualized skills and socialization provider must notify the Texas Health and Human Services Commission in writing at least five days before the permanent closure of operation. The individualized skills and socialization provider must include in the written notice the date of permanent closure, reason for closing, location of individual records (active and inactive), and name and address of the individual record custodian. Source Note: The provisions of this §559.223 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.223 Voluntary Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227528 03/12/2026 (a) An individualized skills and socialization provider must:(1) comply with the provisions of Texas Health and Safety Code (HSC), Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illnesses);(2) before offering employment to any person, search the following registries to determine if the person is eligible for employment:(A) the employee misconduct registry (EMR) established under HSC §253.007;(B) the Texas Health and Human Services Commission (HHSC) nurse aide registry (NAR) and medication aide registry (MAR);(C) the List of Excluded Individuals and Entities (USLEIE) maintained by the United States Department of Health and Human Services; and(D) the List of Excluded Individuals and Entities (LEIE) maintained by HHSC Office of Inspector General;(3) not employ a person who is listed on the:(A) HHSC employee misconduct registry as unemployable; or(B) HHSC nurse or medication aide registries as revoked or suspended; and(4) provide information about the EMR to an employee in accordance with §561.3 of this title (relating to Employment and Registry Information).(b) In addition to the initial search of the EMR, LEIE, NAR, MAR, and USLEIE, an individualized skills and socialization provider must:(1) conduct a search of the NAR, MAR, and EMR to determine if the employee is designated in those registries as unemployable at least every 12 months;(2) keep a copy of the results of the initial and annual searches of the NAR, MAR, and EMR in the employee's personnel file and make it available to HHSC upon request; and(3) comply with all relevant federal and state standards.(c) An individualized skills and socialization provider must:(1) report abuse, neglect, and exploitation in accordance with §559.241 of this subchapter (relating to Reporting Abuse, Neglect, or Exploitation to HHSC);(2) suspend a service provider who HHSC finds has engaged in reportable conduct while the service provider exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, pending a final decision by an administrative law judge, and may not reinstate the service provider during any applicable appeals process;(3) develop and enforce policies and procedures for creating and maintaining incident reports; and(4) ensure the confidentiality of individual records and other information related to individuals.(d) An individualized skills and socialization provider must prominently and conspicuously post for display in a public area of the on-site individualized skills and socialization location, or designated place of business for off-site only individualized skills and socialization, that is readily available to individuals, employees, and visitors:(1) the license issued under this chapter;(2) a sign prescribed by HHSC that describes complaint procedures and specifies how complaints may be filed with HHSC;(3) a notice in the form prescribed by HHSC stating that survey and related reports are available at the on-site individualized skills and socialization location for public survey and providing the HHSC toll-free telephone number that may be used to obtain information concerning the individualized skills and socialization provider;(4) a copy of the most recent survey report relating to the individualized skills and socialization provider;(5) a brochure, letter, or website that outlines the individualized skills and socialization provider's hours of operation, holidays, and a description of activities offered; and(6) emergency telephone numbers, including the abuse hotline telephone number.(e) In addition to the list of individuals served as described in §559.231(f)(3) of this subchapter (relating to Surveys and Visits), an individualized skills and socialization provider must also maintain an individual information document that includes:(1) information on the individualized skills and socialization provider's service delivery method for each individual, such as on-site and off-site, or off-site only;(2) the individual's name, identification, or clinical record number; and(3) the date the individual began receiving on-site and off-site, or off-site only individualized skills and socialization services from the provider.(f) An individualized skills and socialization provider may combine the list of individuals served and the information required for the individual information document into a single document. However, the provider must ensure the combined document meets all requirements of §559.231(f)(3) of this subchapter and subsection (e) of this section.(g) An individualized skills and socialization provider may maintain records or forms either on the HHSC-prescribed form or on a provider-developed form or template maintained through the provider's own documentation system, whether digital or paper, including electronic health records or other documents maintained for the purpose of compliance with the licensure requirements of this subchapter, unless otherwise specified. Records maintained through the provider's own documentation system must:(1) contain the same information as the HHSC-prescribed document or form as outlined in this subchapter;(2) meet the confidentiality and recordkeeping requirements outlined in this subchapter; and(3) be readily accessible and available for review by HHSC upon request, as required under §559.231(f) of this subchapter. Source Note: The provisions of this §559.225 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.225 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227529 03/12/2026 (a) An individualized skills and socialization provider must ensure the facility interior of the on-site location:(1) has furnishings that are appropriately maintained and safe for use;(2) is clean, sanitary, and free of odors that are considered disruptive, unpleasant, or potentially offensive;(3) is free of infestation by bugs, rodents, and other pests;(4) has walls, ceilings, floors, and windows that are structurally sound;(5) is free of environmental contaminants, physical hazards, and accumulated waste or trash;(6) has bathrooms that are accessible, functional, and safe for use;(7) has hot water available for use by individuals receiving services that:(A) is located at sinks in the facility that may be used by individuals receiving services; and(B) does not exceed 120 degrees Fahrenheit;(8) has any major appliances maintained in a safe and operational condition necessary to meet the health and safety needs of individuals served by the provider, such as refrigerators for medication storage;(9) has a secure storage area for cleaning chemicals and supplies that is located separately from any storage area for food items;(10) has cleaning chemicals that are used in accordance with directions and warnings on the product label and that are stored:(A) in their original containers; or(B) in clearly labeled secondary containers with a label that includes, at a minimum, warnings, chemical names, and handling precautions;(11) has a location where perishable food is either refrigerated or otherwise stored safely; and(12) has working smoke alarms in all main areas that:(A) are maintained in accordance with the manufacturer's instructions;(B) emit a distinguishable audible response that can be heard throughout the facility including classrooms, common areas, and hallways; and(C) are used solely for the purpose of alerting individuals and service providers of a fire.(b) When determining whether a violation of the standards outlined in subsection (a)(2) or (3) of this section has occurred, HHSC considers actions taken by the provider to meet the requirements of these standards. (c) An individualized skills and socialization provider must ensure the interior of the on-site location is serviced by a functioning heating and cooling system.(1) If the heating and cooling system fails, the provider must ensure temporary alternate methods of heating and cooling are available to individuals, including methods such as using back-up generators or fans that meet state, local, and federal guidelines in the event the system does not work or is in repair. (2) If alternate methods are not available, the provider must ensure alternate arrangements of service provision or methods of heating and cooling are provided in accordance with the provider's emergency plan, as outlined in §559.229 of this division (relating to Environment and Emergency Response Plan).(3) The provider must ensure that heating and cooling temperature settings for its system, or any alternate method, are appropriate for maintaining a safe environment for individuals and consider the specific health and safety needs of individuals when determining the appropriate heating and cooling temperature settings.(d) An individualized skills and socialization provider must ensure the facility exterior of the on-site location:(1) is free of hazards and the accumulation of waste and trash;(2) is accessible to individuals receiving services;(3) does not compromise the health or safety of individuals; and(4) if applicable, has exterior furnishings that are maintained appropriately and safe for use. Source Note: The provisions of this §559.226 adopted to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.226 Environmental Safety Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227530 03/12/2026 (a) Staff qualifications.(1) An individualized skills and socialization provider must:(A) employ an administrator;(B) ensure the administrator meets the requirements outlined in paragraph (2) of this subsection; and(C) have a policy regarding the delegation of responsibility in the administrator's absence.(2) A service provider of individualized skills and socialization must be at least 18 years of age and:(A) have a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(B) have documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(i) a written competency-based assessment of the ability to document service delivery and observations of the individuals receiving services; and(ii) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals receiving services.(3) A service provider of individualized skills and socialization who provides transportation must:(A) have a valid driver's license; and(B) transport individuals in a vehicle that:(i) is insured in accordance with state law; and(ii) meets all state registration and safety requirements. (b) Admission and retention of individuals; staffing. An individualized skills and socialization provider must ensure the following.(1) An individualized skills and socialization provider must not admit an individual whose needs the provider cannot meet. The determination that the provider cannot meet the individual's needs must be based on:(A) information provided by the program provider regarding the individual's health and safety needs, as documented in the individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), and implementation plan, as applicable; and(B) the provider's availability of trained staff to meet the individual's needs.(2) An individualized skills and socialization provider must not retain an individual whose needs the provider can no longer meet. The determination that the provider can no longer meet the individual's needs must be based on:(A) documented reasonable efforts by the individualized skills and socialization provider to meet the individual's needs and discussion with the individual, the individual's LAR, and the program provider, as applicable, regarding the provider's efforts and any identified areas of concern; and (B) notification to the individual, the individual's LAR, and the program provider, as applicable, prior to discharge, that the individualized skills and socialization provider can no longer meet the individual's needs.(3) An individualized skills and socialization provider must maintain a ratio of service providers to individuals in accordance with §260.507 of this title (relating to Staffing Ratios), §262.917 of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), and §263.2017 of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), during the provision of off-site individualized skills and socialization, including during transportation.(4) An individualized skills and socialization provider must ensure adequate numbers of appropriately trained staff are on duty at all times during the provision of on-site individualized skills and socialization to ensure:(A) the health and safety of the individuals;(B) the needs and behaviors of the individuals are managed;(C) supervision is provided in accordance with the needs of an individual; and(D) individualized skills and socialization services or similar services are provided in accordance with an individual's individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), and implementation plan, as applicable.(c) Staff responsibilities.(1) The administrator:(A) manages the individualized skills and socialization services and the on-site individualized skills and socialization location; (B) ensures staff are trained;(C) supervises staff; and(D) maintains all records.(2) A service provider:(A) delivers individualized skills and socialization services;(B) assists with recreational activities; (C) provides protective supervision through observation and monitoring; and(D) is trained on the needs of the individual.(d) An individualized skills and socialization provider must make both on-site and off-site individualized skills and socialization services available to an individual who receives Home and Community-based Services (HCS), Texas Home Living (TxHmL), or Deaf Blind with Multiple Disabilities (DBMD) services, unless the individualized skills and socialization provider provides off-site individualized skills and socialization services only.(e) An individualized skills and socialization provider must ensure that on-site individualized skills and socialization services: (1) are provided in a building or a portion of a building that is owned or leased by an individualized skills and socialization provider; (2) promote an individual's development of skills and behavior that support the individual's independence and personal choice; and(3) are not provided in:(A) a prohibited setting for an individual, as set forth in the rules governing Home and Community-based Services (HCBS) waiver programs; or(B) the residence of an individual or another person.(f) An individualized skills and socialization provider must ensure that off-site individualized skills and socialization services:(1) include activities that:(A) integrate the individual into the community; and(B) promote the individual's development of skills and behavior that support the individual's independence and personal choice;(2) are provided in a community setting chosen by the individual from among available community setting options;(3) include transportation necessary for the individual's participation in off-site individualized skills and socialization; and(4) are not provided in:(A) a building in which on-site individualized skills and socialization are provided;(B) a prohibited setting for an individual, as set forth in the rules governing Home and Community-based Services (HCBS) waiver programs, unless:(i) provided in an event open to the public; or(ii) the activity is a volunteer activity performed by an individual in such a setting; or(C) the residence of an individual or another person, unless the activity is a volunteer activity performed by an individual in the residence.(g) An individualized skills and socialization provider must:(1) provide services:(A) that promote autonomy and positive social interaction; (B) in accordance with:(i) the individuals IPC, IPP, PDP, or implementation plan as applicable; and(ii) the individuals identified health and safety needs, physicians' orders, and goals, as documented and agreed upon by the individual or the individual's legally authorized representative (LAR); and(2) develop and implement written policies and procedures for consistent and effective monitoring and documentation of an individual's progress towards person-centered objectives related to skill development and socialization, in accordance with the individuals IPC, IPP, PDP, or implementation plan as applicable.(h) An individualized skills and socialization provider must not require an individual to take a skills test or meet other requirements to receive off-site individualized skills and socialization services.(i) If an individual does not want to participate in a scheduled on-site or off-site individualized skills and socialization activity, or the individual's LAR does not want the individual to participate in a scheduled on-site or off-site individualized skills and socialization activity, the individualized skills and socialization provider must document the decision not to participate in the individual's record. Documentation is not required if an individual chooses one activity over another during the scheduled on-site or off-site individualized skills and socialization activity.(j) If an individualized skills and socialization provider becomes aware that a modification or restriction to the services provided is needed based on a specific assessed need of an individual, the individualized skills and socialization provider must:(1) inform the individual's program provider of the needed modification or restriction;(2) obtain updated documentation from the program provider outlining the modification or restriction on the individual's person-centered service plan, which includes:(A) for HCS and TxHmL, the individual's PDP; or(B) for DBMD, the individual's IPP;(3) ensure the updated person-centered service plan is received from the program provider and maintained in the individual's record, and that any updates are included on the individual information document as described in §559.225(e) of this division (relating to General Requirements) prior to the implementation of the modification or restriction;(4) inform service providers of updates to an individual's person-centered service plan; and(5) ensure the implementation of modifications or restrictions is in accordance with the individual's updated person-centered service plan.(k) An individualized skills and socialization provider must provide on-site and off-site individualized skills and socialization services in-person.(l) Training.(1) Initial training.(A) An individualized skills and socialization provider must:(i) provide service providers with training on fire, disaster, and their responsibilities under the emergency response plan developed in accordance with §559.229 of this division (relating to Environment and Emergency Response Plan) within three workdays after the start of employment and document the training in the individualized skills and socialization provider's records; and(ii) provide service providers with a minimum of eight hours of training during the first three months after the start of employment and document the training in the records of the individualized skills and socialization provider.(B) The training provided in accordance with subparagraph (A)(ii) of this paragraph must include:(i) any nationally or locally recognized adult CPR course or certification;(ii) first aid;(iii) infection control;(iv) an overview of the population served by the individualized skills and socialization provider; and(v) identification and reporting of abuse, neglect, or exploitation.(2) Ongoing training. In addition to initial training requirements described in paragraph (1)(A) of this subsection, an individualized skills and socialization provider must:(A) maintain current documentation of each service provider's CPR course completion or certification in CPR;(B) retrain service providers on their responsibilities under the emergency response plan developed in accordance with §559.229 of this division at least biannually and when the service provider's responsibilities under the plan change;(C) conduct training for service providers on infection control policies and procedures developed in accordance with subsection (o) of this section at least biannually;(D) retrain service providers on the population served whenever there is an update to an individual's plan; and (E) conduct training for service providers on the identification and reporting of abuse, neglect, or exploitation at least biannually.(m) Medications.(1) Administration.(A) If individuals cannot or choose not to self-administer medications, an individualized skills and socialization provider must provide assistance with such medications and the performance of related tasks if:(i) a registered nurse has assessed the need for assistance and related tasks and delegated such to the individualized skills and socialization provider in accordance with state law and rules; or(ii) a physician has delegated the assistance and related tasks as a medical act to the individualized skills and socialization provider under Texas Occupations Code Chapter 157, as documented by the physician.(B) An individualized skills and socialization provider must record an individual's medications, including over-the-counter medications, on the individual's medication profile record and ensure that medication labels are:(i) original and current;(ii) easily readable;(iii) affixed to the corresponding prescription bottle, container, or packaging; and(iv) include the appropriate accessory and cautionary instructions and prescription expiration date when applicable.(C) An individualized skills and socialization provider must ensure that information on the medication profile record:(i) reflects current prescription orders as verified by the pharmacy label or updated healthcare provider order; and(ii) includes the medication name, strength, dosage, doses received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.(2) General.(A) An individualized skills and socialization provider must immediately report to an individual's program provider any unusual reactions to a medication or treatment.(B) When an individualized skills and socialization provider supervises or administers medications, the individualized skills and socialization provider must:(i) maintain accurate, current, and accessible documentation of medication administration for each individual; and(ii) document the date and time each medication was taken in accordance with recorded information on the individual's medication profile record.(C) In the event of a medication error, or if an individual does not receive or take the medication or treatment as prescribed, the individualized skills and socialization provider must:(i) document the date and time the medication dose should have been administered or provided to the individual; and(ii) the name and strength of any medication missed.(3) Storage.(A) An individualized skills and socialization provider must provide a locked area for all medications, which may include:(i) a central storage area;(ii) a medication cart that, when not in use, is secured in the area designated for its storage; or(iii) for off-site individualized skills and socialization services, a secure, portable, locked container under the direct control of authorized staff at all times.(B) An individualized skills and socialization provider must store an individual's medication separately from other individuals' medications within the storage area.(C) An on-site individualized skills and socialization provider must store medication requiring refrigeration in a locked refrigerator used only for medication storage, or in a separate, permanently attached, locked medication storage box in a refrigerator.(D) An individualized skills and socialization provider must store poisonous substances and medications labeled for "external use only" separately within the locked area.(E) An on-site individualized skills and socialization provider must store drugs covered by Schedule II of the Controlled Substances Act of 1970 in a locked, permanently attached cabinet, box, or drawer that is separate from the locked storage area for other medications.(F) An individualized skills and socialization provider must store medications in accordance with manufacturer's instructions, under sanitary conditions, and with consideration of requirements pertaining to temperature, light, moisture, ventilation, segregation, and security.(G) An individualized skills and socialization provider must ensure that during the provision of off-site individualized skills and socialization services, all medications for which the provider is responsible:(i) remain in a secure, portable, locked container; and(ii) remain under the direct control of authorized staff at all times.(H) An individualized skills and socialization provider must ensure that, during the provision of off-site individualized skills and socialization services, all medications requiring refrigeration: (i) are maintained at the manufacturer's recommended temperature using a portable, insulated, temperature-controlled container; (ii) remain under the direct control and supervision of authorized staff at all times; and(iii) have documented temperature maintenance and chain of custody in accordance with the requirements of this section.(I) An individualized skills and socialization provider must ensure that, during the provision of off-site individualized skills and socialization services, medications classified as Schedule II under the Controlled Substances Act of 1970:(i) are stored in a secure, locked container or drawer, separately from medications that are not Schedule II;(ii) remain under direct control of authorized staff at all times; and(iii) are handled in accordance with all state and federal requirements for long-term care providers relating to security and safeguarding of Schedule II controlled substances.(J) An individualized skills and socialization provider must develop written policies and procedures addressing the storage, transportation, administration, and safeguarding of all medications for which the provider is responsible and ensure staff compliance with these policies and procedures. The provider's written policies and procedures must:(i) designate authorized staff;(ii) describe security and handling procedures, including off-site transportation and refrigeration;(iii) specify documentation, accountability, and reporting requirements for discrepancies, loss, or theft; and(iv) ensure compliance with the requirements of this subsection and any applicable federal requirements relating to the security and safeguarding of Schedule II controlled substances.(n) Accident, injury, or acute illness.(1) An individualized skills and socialization provider must stock and maintain in a single location in the on-site individualized skills and socialization location first aid supplies to treat burns, cuts, and poisoning.(2) An individualized skills and socialization provider delivering off-site individualized skills and socialization must ensure first aid supplies to treat burns, cuts, and poisoning are immediately available at all times during service provision.(3) In the event of accident or injury to an individual requiring emergency care, or in the event of death of an individual, an individualized skills and socialization provider must:(A) arrange for emergency care or transfer to an appropriate place for treatment, including:(i) a physician's office;(ii) a clinic; or(iii) a hospital;(B) immediately notify an individual's program provider with which the individualized skills and socialization provider contracts to provide services to the individual; and(C) describe and document the accident, injury, or illness on a separate report containing a statement of final disposition and maintain the report on file.(o) An individualized skills and socialization provider must develop and enforce written policies and procedures for infection control, including spread of disease to ensure staff compliance with state law, the Occupational Safety and Health Administration, and the Centers for Disease Control and Prevention. Source Note: The provisions of this §559.227 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.227 Program Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227531 03/12/2026 (a) An individualized skills and socialization provider must:(1) provide each individual referenced in Texas Human Resources Code (HRC) §103.011 and the individual's legally authorized representative (LAR), as appropriate, with a written list of the individual's rights, as outlined under HRC §102.004 (relating to List of Rights); and(2) comply with all applicable provisions of HRC Chapter 102 (relating to Rights of the Elderly).(b) An individualized skills and socialization provider must ensure that individuals are informed of their rights and responsibilities and of grievance procedures in a language they comprehend:(1) through the individual's preferred mode of communication; and(2) in a manner accessible to the individual.(c) An individualized skills and socialization provider must develop and implement written policies and procedures that protect and promote the rights of all individuals receiving services and ensure individuals can exercise their rights without interference, coercion, discrimination, or retaliation from the provider.(d) An individualized skills and socialization provider must ensure that any deviation from the requirements of this section is based on an assessed need and documented in accordance with the requirements outlined in §559.227(j) of this division (relating to Program Requirements) prior to implementation. This includes an individual's right to:(1) control and support personal schedules and activities; (2) access personal food items at any time;(3) receive visitors of the individual's choosing at any time; and(4) physically access the building.(e) An individualized skills and socialization provider must develop and implement policies and procedures for ensuring individuals: (1) receive support and assistance from the individualized skills and socialization provider in addressing concerns with the program provider regarding the individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), or implementation plan when the individual dislikes or disagrees with the services being rendered by the individualized skills and socialization provider;(2) live free from abuse, neglect, or exploitation;(3) receive services in a safe and clean environment;(4) receive services in accordance with the individuals IPC, IPP, PDP, and implementation plan, as applicable, through service providers who are responsive to the needs of the individual;(5) have privacy during treatment and care of personal needs; and(6) participate in social, recreational, and group activities. Source Note: The provisions of this §559.228 adopted to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.228 Rights of Individuals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211695 03/12/2026 (a) Definitions. In this section:(1) "emergency situation" means an impending or actual situation that:(A) interferes with normal activities of an individualized skills and socialization provider or the individuals receiving services from the individualized skills and socialization provider;(B) may:(i) cause injury or death to an individual or staff member of the individualized skills and socialization provider; or(ii) cause damage to property of the individualized skills and socialization provider;(C) requires the individualized skills and socialization provider to respond immediately to mitigate or avoid the injury, death, damage, or interference; and(D) does not include a situation that arises from the medical condition of an individual such as cardiac arrest, obstructed airway, cerebrovascular accident; and(2) "plan" refers to an individualized skills and socialization provider's emergency response plan.(b) Administration. An individualized skills and socialization provider must:(1) develop and implement a written plan as described in subsection (c) of this section;(2) maintain a written copy of the plan that is accessible to all staff at all times;(3) evaluate and revise the plan as necessary:(A) within 30 days after an emergency situation;(B) at least annually; and(4) revise the plan within 30 days after information included in the plan changes.(c) Emergency response plan. An individualized skills and socialization provider's plan must:(1) include a risk assessment of all potential internal and external emergency situations relevant to the individualized skills and socialization provider's operations and geographical area, such as a fire, failure of heating and cooling systems, a power outage, an explosion, a hurricane, a tornado, a flood, extreme snow and ice for the area, a wildfire, terrorism, or a hazardous materials accident;(2) include a description of the services and assistance needed by the individuals in an emergency situation;(3) include a section for each core function of emergency management, as described in subsection (d) of this section, that is based on an individualized skills and socialization provider's decision to either shelter-in-place or evacuate during an emergency; and(4) for the on-site individualized skills and socialization location, include a fire safety plan that complies with subsection (e) of this section.(d) Plan requirements regarding eight core functions of emergency management.(1) Direction and control. An individualized skills and socialization provider's plan must contain a section for direction and control that:(A) designates by name or title the emergency preparedness coordinator (EPC) who is the staff person with the authority to manage the individualized skills and socialization provider's response to an emergency situation in accordance with the plan;(B) designates by name or title the alternate EPC who is the staff person with the authority to act as the EPC if the EPC is unable to serve in that capacity;(C) documents the name and contact information for the local emergency management coordinator (EMC) for the area where the individualized skills and socialization provider is located, as identified by the office of the local mayor or county judge; and(D) documents coordination with the local EMC as required by the local EMC's guidelines relating to emergency situations.(2) Warnings, emergency alerts, or notifications. An individualized skills and socialization provider's plan must contain a section for warnings, emergency alerts, or notifications that:(A) describes how the EPC will be notified of an emergency situation;(B) identifies how the EPC will receive notification of relevant local news and weather reports; and(C) ensures monitoring of local news and weather reports.(3) Communication. An individualized skills and socialization provider's plan must contain a section for communication that:(A) identifies the individualized skills and socialization provider's primary mode of communication and alternate mode of communication to be used in the event of power failure or the loss of the individualized skills and socialization provider's primary mode of communication in an emergency situation;(B) includes procedures for maintaining a current list of telephone numbers for individuals, their program providers, and other relevant emergency contacts as appropriate;(C) includes procedures for maintaining a current list of telephone numbers for the individualized skills and socialization provider's staff that also identifies the EPC;(D) identifies the location of the lists described in subparagraphs (B) and (C) of this paragraph where individualized skills and socialization provider staff can obtain the list quickly;(E) includes procedures to notify:(i) staff about an emergency situation;(ii) a receiving facility, if applicable, about an impending or actual evacuation of individuals; and(iii) individuals, LARs, and other persons about an emergency situation;(F) describes how the individualized skills and socialization provider will provide, during an emergency situation, general information to the public, such as the change in location and hours, or that the individualized skills and socialization provider is closed due to the emergency situation;(G) includes procedures for the individualized skills and socialization provider to maintain communication with:(i) staff during an emergency situation;(ii) a receiving facility, if applicable; and(iii) staff or other responsible parties who will transport individuals to a secure location during an evacuation in a vehicle;(H) includes procedures for reporting to the Texas Health and Human Services Commission (HHSC) an emergency situation that caused the death or serious injury of an individual while receiving individualized skills and socialization services as follows:(i) by telephone, at 1-800-458-9858, within 24 hours after the death or serious injury; and(ii) within five working days after making a report described by clause (i) of this subparagraph, the individualized skills and socialization provider must ensure an investigation of the incident is conducted and send a written investigation report on Form 3613-A, Provider Investigation Report, or a form containing, at a minimum, the information required by Form 3613-A, to HHSC's Complaint and Incident Intake.(4) Sheltering-in-place. An individualized skills and socialization provider that provides on-site services must include in the plan a section that includes procedures to shelter individuals in place during an emergency situation.(5) Evacuation. An individualized skills and socialization provider that provides on-site services must include in the plan a section for evacuation that:(A) requires posting building evacuation routes prominently throughout the on-site individualized skills and socialization location;(B) includes procedures for evacuating individuals to a pre-arranged location in an emergency situation, if applicable;(C) includes procedures for:(i) ensuring staff accompany evacuating individuals, as appropriate;(ii) ensuring that all persons present in the building have been evacuated;(iii) accounting for individuals and staff after they have been evacuated;(iv) accounting for individuals who are absent from the individualized skills and socialization provider at the time of the evacuation;(v) contacting the local EMC, if required by the local EMC guidelines, to find out if it is safe to return to the geographical area; and(vi) determining if it is safe to re-enter and occupy the building after an evacuation;(D) includes procedures for notifying the local EMC regarding an evacuation of the building, if required by the local EMC guidelines;(E) includes procedures for notifying HHSC by telephone, at 1-800-458-9858, within 24 hours after an evacuation that individuals have been evacuated;(F) includes procedures for notifying the HHSC Regulatory Services regional office for the area in which the individualized skills and socialization provider is located, by telephone, as soon as safely possible after a decision to evacuate is made; and(G) includes procedures for notifying the HHSC regional office for the area in which the individualized skills and socialization provider is located, by telephone, that individuals have returned to the building after an evacuation, within 48 hours after their return.(6) Transportation. An individualized skills and socialization provider must include in the plan a section with procedures for transportation.(7) Health and Medical Needs. An individualized skills and socialization provider's plan must contain a section ensuring that the health and medical needs of individuals are met during an emergency.(8) Resource Management. An individualized skills and socialization provider's plan must contain a section for resource management that ensures individuals have appropriate access to resources during an emergency.(e) Training. An individualized skills and socialization provider must:(1) train all staff when hired on fire, disaster, and their responsibilities under the plan in accordance with §559.227(k) of this subchapter (relating to Program Requirements); and(2) retrain staff at least annually on fire, disaster, and the staff member's responsibilities under the plan and when the staff member's responsibilities under the plan change.(f) An individualized skills and socialization provider offering on-site services must:(1) conduct unannounced drills with staff for fire, severe weather, and other emergency situations identified by the individualized skills and socialization provider as likely to occur, based on the results of the risk assessment required by subsection (c)(1) of this section; and(2) establish procedures to:(A) perform a fire drill at least once every 90 days with all occupants of the building at the time of the fire drill at expected and unexpected times and under varying conditions;(B) relocate, during the fire drill, all occupants of the building to a predetermined location where participants must remain until a recall or dismissal signal is given; and(C) complete the HHSC Fire Drill Report Form for each required fire drill.(g) An individualized skills and socialization services provider or designee must enroll in an emergency communication system in accordance with instructions from HHSC.(h) An individualized skills and socialization services provider or designee must respond to requests for information received through the emergency communication system in the format established by HHSC.(i) An individualized skills and socialization services provider must ensure that each facility has:(1) exterior doors that are unobstructed and accessible to all individuals;(2) two means of escape from the facility;(3) fire extinguishers that are:(A) accessible and unobstructed to the service provider;(B) on each level of the facility;(C) serviced or replaced after each use; and(D) if unused, serviced according to the manufacturer's instructions, or as required by the state or local fire marshal.(j) The facility must conform to all applicable state laws and local ordinances pertaining to occupancy. When these laws, codes, and ordinances are more stringent than the standards in this section, the more stringent requirements govern. If state laws or local codes or ordinances conflict with the requirements of these standards, the provider must submit an application to alter the licensed capacity so that these conflicts may be legally resolved.(k) The facility must meet the provisions and requirements concerning accessibility for individuals with disabilities in the following laws and regulations: the Americans with Disabilities Act (ADA) of 1990 (Title 42, United States Code, Chapter 126); Title 28, Code of Federal Regulations, Part 35; Texas Government Code, Chapter 469, Elimination of Architectural Barriers; and 16 TAC Chapter 68, Elimination of Architectural Barriers. Plans for new construction, substantial renovations, modifications, and alterations must be submitted to the Texas Department of Licensing and Regulation (Attn: Elimination of Architectural Barriers Program) for accessibility approval under Texas Government Code, Chapter 469. At least 50 percent of the client restrooms must be in accordance with ADA. Exception: facilities licensed for 45 or fewer persons may provide one unisex restroom in accordance with accessibility requirements. Source Note: The provisions of this §559.229 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.229 Environment and Emergency Response Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211696 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may enter the premises of an individualized skills and socialization provider at reasonable times and perform a survey necessary to issue a license or renew a license. HHSC survey personnel will perform surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits as required for carrying out the responsibilities of licensing.(b) Generally, all surveys, complaint investigations, and other visits, whether routine or non-routine, made for the purpose of determining the appropriateness of care of individuals and day-to-day operations of an individualized skills and socialization provider will be unannounced. Any exceptions must be justified.(c) HHSC may conduct any survey or investigation as a desk review, if appropriate, and at the discretion of HHSC, except for the on-site components of:(1) an initial survey; and(2) a complaint investigation.(d) Any person may request a survey of an individualized skills and socialization provider by notifying HHSC Complaint and Incident Intake at 1-800-458-9858 of an alleged violation of a licensing requirement. HHSC performs an on-site survey as soon as feasible but no later than 30 days after receiving the complaint, unless after a preliminary investigation the complaint is found to be frivolous. HHSC will respond to the complainant in writing if the complainant provides a mailing address.(e) HHSC receives and investigates anonymous complaints.(f) The individualized skills and socialization provider must provide all its books, records, and other documents maintained by or on behalf of an individualized skills and socialization provider to HHSC upon request.(1) HHSC is authorized to photocopy documents, photograph individuals, and use any other available recording devices to preserve all relevant evidence of conditions found during a survey, or investigation that HHSC reasonably believes threatens the health and safety of an individual.(2) Examples of records and documents that may be requested and photocopied or otherwise reproduced are individual program plans, person-directed plans, and medication records.(3) Upon request, an individualized skills and socialization provider must provide HHSC with a list of all individuals served by the individualized skills and socialization provider. The list must include the waiver program or funding source used by the individual to receive services from the individualized skills and socialization provider.(4) The individualized skills and socialization provider may charge HHSC at a rate not to exceed the rate HHSC charges for copies. The procedure of copying is the responsibility of the administrator or designee. If copying requires that the records be removed from the individualized skills and socialization provider, a representative of the individualized skills and socialization provider is expected to accompany the records and assure their order and preservation.(5) HHSC protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.(g) The source of the complaint is not revealed.(h) HHSC inspects an individualized skills and socialization provider at least once every two years after the initial survey. Source Note: The provisions of this §559.231 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.231 Surveys and Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211697 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) determines if an individualized skills and socialization provider is in compliance with the licensing rules.(b) Violations of regulations are listed on forms designed for the purpose of the survey.(c) At the conclusion of a survey, the violations are discussed in an exit conference with the individualized skills and socialization provider's management. A written list of the violations is left with the individualized skills and socialization provider at the time of the exit conference.(d) If, after the initial exit conference, additional violations are cited, the violations are communicated to the individualized skills and socialization provider within 10 working days after the initial exit conference.(e) HHSC provides a clear and concise summary in nontechnical language of each licensure survey and complaint investigation, if applicable. The summary outlines significant violations noted at the time of the survey, but does not include names of individuals, staff, or any other information that would identify individuals or other prohibited information under general rules of public disclosure. The summary is provided to the individualized skills and socialization provider at the time the report of contact or similar document is provided.(f) Upon receipt of the final statement of violations, the individualized skills and socialization provider has 10 working days to submit an acceptable plan of correction to the HHSC Regulatory Services regional director. An acceptable plan of correction must address:(1) how the individualized skills and socialization provider will accomplish the corrective action for those individuals affected by each violation;(2) how the individualized skills and socialization provider will identify other individuals with the potential to be affected by the same violation;(3) how the individualized skills and socialization provider will put the corrective measure into practice or make systemic changes to ensure that the violation does not recur;(4) how the individualized skills and socialization provider will monitor the corrective action to ensure that the violation is corrected and will not recur; and(5) the date the corrective action will be completed.(g) If the individualized skills and socialization provider and the inspector cannot resolve a dispute regarding a violation of regulations, the individualized skills and socialization provider is entitled to an informal dispute resolution (IDR) at the regional level for all violations. For a violation that resulted in an adverse action, the individualized skills and socialization provider is entitled to an IDR at either the regional or state office level.(1) A written request and all supporting documentation must be submitted to the Regional Director, HHSC Long-term Care Regulation, for a regional IDR; or to Regulatory Services, Texas Health and Human Services Commission, P.O. Box 149030, E-351, Austin, Texas 78714-9030, for a state office IDR, no later than the 10th day after receipt of the official statement of violations.(2) HHSC completes the IDR process no later than the 30th day after receipt of a request from an individualized skills and socialization provider.(3) Violations deemed invalid in an IDR will be so noted in HHSC's records. Source Note: The provisions of this §559.233 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.233 Determinations and Actions Pursuant to Surveys https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211698 03/12/2026 The Texas Health and Human Services Commission (HHSC) may refer an individualized skills and socialization provider to the attorney general who may petition a district court for:(1) a temporary restraining order to restrain a person from a violation or threatened violation of the requirements or any other law affecting individuals if HHSC reasonably believes that the violation or threatened violation creates an immediate threat to the health and safety of an individual; and(2) an injunction to restrain a person from a violation or threatened violation of the requirements or any other law affecting individuals if HHSC reasonably believes that the violation or threatened violation creates a threat to the health and safety of an individual. Source Note: The provisions of this §559.235 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.235 Referrals to the Attorney General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211699 03/12/2026 (a) Procedures for inspection of public records will be in accordance with the Texas Government Code, Chapter 552, and as further described in this section.(b) The Texas Health and Human Services Commission (HHSC) Regulatory Services Division is responsible for the maintenance and release of records on licensed facilities, and other related records.(c) The application for inspection of public records is subject to the following criteria.(1) The application must be made to HHSC Long-term Care Regulation, Regulatory Services Division, Mail Code E-349, P.O. Box 149030, Austin, Texas 78714-9030;(2) The requester must identify themselves.(3) The requester must give reasonable prior notice of the time for inspection or copying of records.(4) The requester must specify the records requested.(5) On written applications, if HHSC is unable to ascertain the records being requested, HHSC may return the written application to the requester for clarification.(6) HHSC will provide the requested records as soon as possible; however, if the records are in active use, or in storage, or time is needed for proper de-identification or preparation of the records for inspection, HHSC will so advise the requester and set an hour and date within a reasonable time when the records will be available.(d) Original records may be inspected or copied, but in no instance will original records be removed from HHSC offices.(e) Records maintained by HHSC Regulatory Services Division are open to the public, with the following exceptions.(1) Incomplete reports, audits, evaluations, and investigations made of, for, or by HHSC are confidential.(2) All reports, records, and working papers used or developed by HHSC in and investigation of reports of abuse and neglect are confidential and may be released to the public as provided in §559.95 of this chapter (relating to confidentiality).(3) All names and related personal, medical, or other identifying information about an individual are confidential.(4) Information about any identifiable person that is defamatory or an invasion of privacy is confidential.(5) Information identifying complainants or informants is confidential.(6) Itineraries of surveys are confidential.(7) Other information that is excepted from release by Texas Government Code, Chapter 552, is not available to the public.(8) To implement this subsection, HHSC may not alter or de-identify original records. Instead, HHSC will make available for public review or release only a properly de-identified copy of the original record.(f) HHSC will charge for copies of records upon request.(1) If the requester simply wants to inspect records, the requester will specify the records to be inspected. HHSC will make no charge for this service, unless HHSC determines a charge is appropriate based on the nature of the request.(2) If the requester wants copies of a record, the requester will specify in writing the records to be copied on an appropriate HHSC form, and HHSC will complete the form by specifying the cost of the records, which the requester must pay in advance. Checks and other instruments of payment must be made payable to the Texas Health and Human Services Commission.(3) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requester on a cost basis in accordance with costs established by the Office of the Attorney General or HHSC for office machine copies.(4) For documents that are mailed, HHSC will charge for the postage at the time it charges for the production. All applicable sales taxes will be added to the cost of copying records.(5) When a request involves more than one long-term care facility, each facility will be considered a separate request. Source Note: The provisions of this §559.237 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.237 Procedures for Inspection of Public Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227532 03/12/2026 (a) Any individualized skills and socialization provider who has cause to believe that an individual is being or has been subjected to abuse, neglect, or exploitation must report the abuse, neglect, or exploitation to the Texas Health and Human Services (HHSC) Complaint and Incident Intake Section through the online licensure portal or by telephone to 1-800-458-9858 within one hour after suspecting or learning of the alleged abuse, neglect, or exploitation.(b) In addition to the reporting requirements described in subsection (a) of this section, an individualized skills and socialization provider must report the death of an individual when the death occurs while the individual is receiving services from an individualized skills and socialization provider to the HHSC Complaint and Incident Intake Section within one hour after learning of the death.(c) The following information must be reported to HHSC when making a report described in subsections (a) or (b) of this section: (1) name, age, and address of the individual;(2) name and address of the person responsible for the care of the individual, if available;(3) nature and extent of the individual's condition;(4) basis of the reporter's knowledge; and(5) any other relevant information.(d) Within five working days after making a report described in subsections (a) or (b) of this section, the individualized skills and socialization provider must conduct an investigation of the incident and send a written investigation report on Form 3613-A, Provider Investigation Report, to HHSC Complaint and Incident Intake.(e) An individualized skills and socialization provider may not retaliate against an individual, legally authorized representative, or service provider for filing a complaint or presenting a grievance or for providing, in good faith, information to HHSC relating to abuse, neglect, or exploitation. Source Note: The provisions of this §559.241 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.241 Reporting Abuse, Neglect, or Exploitation to HHSC https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227533 03/12/2026 (a) HHSC must give the individualized skills and socialization provider notification of the complaint received and a summary of the complaint, without identifying the source of the complaint.(b) HHSC investigates complaints of abuse, neglect, or exploitation when the alleged victim is an individual receiving services from an individualized skills and socialization provider and:(1) the act occurs at the on-site individualized skills and socialization location;(2) the act occurs during the provision of off-site individualized skills and socialization services;(3) the individualized skills and socialization provider is responsible for the supervision of the individual at the time the act occurs; or(4) the alleged perpetrator is affiliated with the individualized skills and socialization provider.(c) Complaint investigations must include a visit to the individualized skills and socialization provider and consultation with persons thought to have knowledge of the circumstances. If the individualized skills and socialization provider fails to admit HHSC staff for a complaint investigation, HHSC will seek a district court order for admission. Investigators may request from the court that a peace officer accompany them. Source Note: The provisions of this §559.243 adopted to be effective January 1, 2023, 47 TexReg 8709; amended to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.243 HHSC Complaint Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211703 03/12/2026 All reports, records, communications, and working papers used or developed by the Texas Health and Human Services Commission (HHSC) in an investigation are confidential and may be released only as provided in this section.(1) The final written investigation report on cases may be furnished to the district attorney and appropriate law enforcement agencies if the investigation reveals abuse that is a criminal offense. HHSC may provide to another state agency or governmental entity information that is necessary for HHSC, state agency, or entity to properly execute its duties and responsibilities to provide services to a person with a disability or the elderly.(2) The final written investigation report may be released to the public upon request provided the report is de-identified to remove all names and other personally identifiable data, including any information from witnesses and other person furnished to HHSC as part of the investigation.(3) The reporter and the individualized skills and socialization provider will be notified of the results of HHSC's investigation of a reported case of abuse, neglect, or exploitation, whether HHSC concluded that abuse, neglect, or exploitation occurred or did not occur.(4) Upon written request of the person who is the subject of the report of abuse, neglect, or exploitation or his or her legal representative, HHSC releases to the person or his or her legal representative otherwise confidential information relating to the final report. The request must specify the information desired and be signed and dated by the person or his or her legal representative. The legal representative of a deceased person may make a written request for this information. The legal representative of a deceased person must also specify the reason the information is requested. Any legal representative must include with the request sufficient documentation to establish his or her authority. HHSC edits the information before release to protect the confidentiality of information related to the reporter's identity and to protect any other person whose safety or welfare may be endangered by disclosure. Source Note: The provisions of this §559.245 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.245 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211704 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may suspend an individualized skills and socialization provide's license when the individualized skills and socialization provider's violation of the licensure rules threatens to jeopardize the health and safety of individuals.(b) Suspension of a license may occur simultaneously with any other enforcement provision available to HHSC.(c) The individualized skills and socialization provider will be notified by certified mail of HHSC's intent to suspend the license, including the facts or conduct alleged to warrant the suspension. The individualized skills and socialization provider has an opportunity to show compliance with all requirements of law for the retention of the license as provided in §559.217 of this subchapter (relating to Opportunity to Show Compliance). If the individualized skills and socialization provider requests an opportunity to show compliance, HHSC will give the license holder a written affirmation or reversal of the proposed action.(d) The individualized skills and socialization provider will be notified by certified mail of HHSC's suspension of the individualized skills and socialization provider's license. If HHSC suspends an individualized skills and socialization provider's license, the licensee may request a formal appeal by following the HHSC's formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act). A formal administrative hearing is conducted in accordance with Texas Government Code, Chapter 2001, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I. The suspension will take effect when the deadline for appeal of the suspension passes unless the individualized skills and socialization provider appeals the suspension. If the individualized skills and socialization provider appeals the suspension, the status of the license holder is preserved until final disposition of the contested matter.(e) The suspension will remain in effect until HHSC determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC will conduct an on-site investigation before making a determination.(f) An individualized skills and socialization provider with a suspended license will be removed from HHSC's Day Activity and Health Services (DAHS) directory while the suspension is in effect. Source Note: The provisions of this §559.247 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.247 Nonemergency Suspension https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211705 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may revoke an individualized skills and socialization provider's license when the license holder has violated the requirements of the Texas Human Resources Code, Chapter 103.(b) In addition, HHSC may revoke a license if the licensee:(1) submitted false or misleading statements in the application for a license or any accompanying attachments;(2) used subterfuge or other evasive means to obtain the license;(3) concealed a material fact in the application for a license or failed to disclose information required in §559.205 of this subchapter (relating to Criteria for Licensing) that would have been the basis to deny the license under §559.215 of this subchapter (relating to Criteria for Denying a License or Renewal of a License); or(4) violated the requirements of the Texas Human Resources Code, Chapter 103, or the rules adopted under this subchapter.(c) Revocation of a license may occur simultaneously with any other enforcement provision available to HHSC.(d) The individualized skills and socialization provider will be notified by certified mail of HHSC's intent to revoke the license, including the facts or conduct alleged to warrant the revocation. The individualized skills and socialization provider has an opportunity to show compliance with all requirements of law for the retention of the license as provided in §559.217 of this subchapter (relating to Opportunity to Show Compliance). If the individualized skills and socialization provider requests an opportunity to show compliance, HHSC will give the license holder a written affirmation or reversal of the proposed action.(e) If HHSC revokes an individualized skills and socialization provider's license, the licensee may request a formal appeal by following the Health and Human Services Commission's formal hearing procedures in 1 TAC Chapter 357, Subchapter I. A formal administrative hearing is conducted in accordance with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I. If the individualized skills and socialization provider appeals the revocation, the status of the license holder is preserved until final disposition of the contested matter.(f) An individualized skills and socialization provider will be removed from HHSC's Day Activity and Health Services (DAHS) directory if the license is revoked. Source Note: The provisions of this §559.249 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.249 Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211706 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) will suspend an individualized skills and socialization provider's license or order an immediate closing of part of the facility if:(1) HHSC finds that the individualized skills and socialization provider is operating in violation of the licensure rules; and(2) the violation creates an immediate threat to the health and safety of an individual.(b) The order suspending a license or closing a part of a facility under this section is immediately effective on the date the license holder receives a hand-delivered written notice or on a later date specified in the order.(c) The order suspending a license or ordering an immediate closing of a part of the facility is valid for ten days after the effective date of the order.(d) A licensee whose facility is closed under this section is entitled to request a formal administrative hearing under the Health and Human Services Commission's formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), but a request for an administrative hearing does not suspend the effectiveness of the order.(e) An individualized skills and socialization provider will be removed from HHSC's Day Activity and Health Services (DAHS) directory during an effective emergency suspension. Source Note: The provisions of this §559.251 adopted to be effective January 1, 2023, 47 TexReg 8709. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.251 Emergency Suspension and Closing Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227534 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may impose an administrative penalty if an individualized skills and socialization provider:(1) fails to comply with Texas Human Resources Code (HRC) Chapter 103 or a rule, standard, or order adopted under HRC Chapter 103;(2) makes a false statement of a material fact that the provider knows or should know is false:(A) on an application for a license or a renewal of a license or in an attachment to the application; or(B) with respect to a matter under investigation by HHSC;(3) refuses to allow an HHSC representative to inspect:(A) a book, record, or file required to be maintained by the provider; or(B) any portion of the premises of the on-site location, or for off-site only providers, the designated place of business where records are kept;(4) willfully interferes with the work of an HHSC representative who is preserving evidence of a violation of:(A) HRC Chapter 103;(B) a rule, standard, or order adopted under HRC Chapter 103; or(C) a term of a license issued under this chapter;(5) willfully interferes with the work of an HHSC representative or the enforcement of this chapter;(6) fails to pay a penalty assessed under HRC Chapter 103, or a rule adopted under this chapter within 30 calendar days after the date the assessment of the penalty becomes final;(7) fails to notify HHSC of a change of ownership in accordance with §559.211 of this subchapter (relating to Change of Ownership and Notice of Changes); or(8) fails to submit an approved plan of correction to HHSC within 10 calendar days after receiving the final notification of assessed penalties.(b) The range of the administrative penalty that may be imposed against the individualized skills and socialization provider each day for a violation described in subsection (a)(1) of this section is based on the scope and severity of the violation and whether it is an initial or repeated violation, as set forth in the following figure.Attached Graphic(c) HHSC imposes administrative penalties in accordance with the schedule of appropriate and graduated penalties established in this section. When determining the amount of an administrative penalty, HHSC considers:(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the situation, and the hazard or potential hazard created by the situation to the health or safety of the public;(2) the history of previous violations by a facility;(3) the amount necessary to deter future violations;(4) the facility's efforts to correct the violation; and(5) any other matter that justice may require.(d) If HHSC determines a violation is non-substantial, HHSC allows the individualized skills and socialization provider one opportunity to correct the violation to avoid an administrative penalty.(e) If HHSC determines a violation is substantial as defined in §559.203 of this subchapter (relating to Definitions), HHSC does not allow the individualized skills and socialization provider an opportunity to correct the violation before HHSC imposes an administrative penalty.(f) If HHSC imposes an administrative penalty for a violation as described in subsection (a) of this section, the administrative penalty begins accruing:(1) for a substantial violation, on the date HHSC identifies the violation; or(2) for a violation that is non-substantial, on the date of the exit conference of the post 45-day follow-up survey.(g) An administrative penalty accrues each day until the individualized skills and socialization provider completes corrective action for that violation, as determined by HHSC.(h) If an individualized skills and socialization provider demonstrates the corrective action is complete on the same day an administrative penalty begins accruing, HHSC imposes an administrative penalty for one day.(i) For an administrative penalty imposed in accordance with subsection (a)(2) of this section:(1) HHSC imposes the penalty no more than once per survey;(2) HHSC does not allow the individualized skills and socialization provider an opportunity to correct the action before imposing the penalty; and(3) the amount of the penalty is $500.(j) If HHSC imposes an administrative penalty against the individualized skills and socialization provider in accordance with subsection (a)(2) - (8) of this section, HHSC does not, at the same time, impose a closing order or licensure suspension from the program provider for the same violation, action, or failure to act. Source Note: The provisions of this §559.253 adopted to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.253 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227535 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may conduct an unannounced survey or investigation in accordance with §559.231 of this division (relating to Surveys and Visits) to assess the health and safety of individuals receiving services from an individualized skills and socialization provider and make a determination regarding the provider's compliance with licensing and program requirements under this subchapter.(b) During a survey or investigation, if HHSC determines there is an immediate threat to the health and safety of individuals due to an individualized skills and socialization provider's non-compliance with one or more regulatory requirements identified under this subchapter, HHSC notifies the individualized skills and socialization provider orally and in writing of the determination. In accordance with HHSC instructions and the requirements of this subchapter, the individualized skills and socialization provider must develop and document a plan of removal and submit the written plan to HHSC. The plan must include:(1) a separate plan of removal for each identified area of non-compliance;(2) a description of:(A) immediate actions the individualized skills and socialization provider will take to ensure there is no longer a threat of harm to individuals receiving services;(B) how the provider will identify all affected individuals; (C) how the provider will monitor and document progress on:(i) each action identified on the plan of removal; and(ii) the effectiveness of the plan;(D) actions the provider will take to ensure each identified non-compliance will not reoccur; and(E) specific dates and times by which the individualized skills and socialization provider will complete each corrective action identified in this paragraph.(c) HHSC notifies an individualized skills and socialization provider if a plan of removal is approved or not approved, and HHSC conducts daily visits and monitoring of the provider until HHSC determines threat of immediate harm no longer exists.(d) If HHSC does not approve an individualized skills and socialization provider's plan of removal, the provider must resubmit a revised plan of removal to HHSC.(e) If an individualized skills and socialization provider fails to submit a plan of removal as required, or does not implement an approved plan of removal, HHSC may deny or revoke the individualized skills and socialization provider's license.(f) If HHSC determines the individualized skills and socialization provider complies with the regulatory requirements as indicated under this subchapter, HHSC:(1) sends the individualized skills and socialization provider a final survey report stating that the individualized skills and socialization provider complies with the regulatory requirements;(2) does not require any action by the individualized skills and socialization provider; and(3) issues a license to the individualized skills and socialization provider as described in §559.205 of this subchapter (relating to Criteria for Licensing) if the survey is an initial or a re-licensing survey.(g) If HHSC determines from an initial licensure survey, re-licensure survey, intermittent survey, or investigation that the individualized skills and socialization provider is not in compliance with a regulatory requirement:(1) HHSC provides a final statement of violations in accordance with §559.233 of this division (relating to Determinations and Actions Pursuant to Surveys).(2) HHSC may recommend with the final statement of violations the assessment of an administrative penalty for each violation and the amount of the administrative penalty, in which case HHSC provides: (A) written notice to the individualized skills and socialization provider, indicating the amount of the recommended administrative penalty; and(B) a statement of whether the violation is subject to correction in accordance with subsection (b) of this section and, if the violation is subject to correction:(i) a statement of the date on which the individualized skills and socialization provider must file with HHSC a plan of correction for approval by HHSC;(ii) the date on which the individualized skills and socialization provider must complete the plan of correction to avoid assessment of the administrative penalty; and(iii) a statement that the license holder has a right to an administrative hearing on the occurrence of the violation, the amount of the penalty, or both.(3) Within 20 calendar days after the date on which the individualized skills and socialization provider receives a written notice of the final statement of violations, the provider may:(A) agree to the final statement of violations in writing, including the recommended administrative penalty; or(B) submit a written request for an administrative hearing to HHSC.(h) After HHSC receives the plan of correction as required by §559.233(f) of this division, HHSC notifies the individualized skills and socialization provider whether the plan is approved or not approved.(1) If HHSC does not approve a plan of correction, the individualized skills and socialization provider must submit a revised plan of correction within five business days after the date of the HHSC notice that the plan of correction was not approved. After HHSC receives the revised plan of correction, HHSC notifies the individualized skills and socialization provider whether the revised plan is approved or not approved.(2) If HHSC approves a plan of correction, HHSC notifies the individualized skills and socialization provider in writing that the plan of correction has been approved, and HHSC takes the following actions to determine if the individualized skills and socialization provider has completed the corrective action as outlined on the approved plan of correction:(A) HHSC may request that the individualized skills and socialization provider submit evidence of corrective action; and(B) HHSC may conduct:(i) for a substantial violation, a follow-up survey after the date specified in the plan of correction for correcting the violation but within 45 calendar days after the survey exit conference; or(ii) for a violation that is non-substantial, an off-site desk review or a post 45-day follow-up survey based on HHSC discretion.(i) If an individualized skills and socialization provider does not submit a plan of correction as required by §559.233(f) of this division or a revised plan of correction required by subsection (h) of this section, or if HHSC notifies the individualized skills and socialization provider that a revised plan of correction is not approved, HHSC may impose administrative penalties in accordance with §559.253 of this division (relating to Administrative Penalties).(j) If an individualized skills and socialization provider corrects a violation, the individualized skills and socialization provider must maintain the correction until the first anniversary of the date the correction was made.(k) If an individualized skills and socialization provider fails to maintain a correction in accordance with subsection (j) of this section, HHSC may assess an administrative penalty equal to three times the amount of the original penalty assessed, but not collected. HHSC does not provide the individualized skills and socialization provider an opportunity to correct the subsequent violation.(l) If HHSC determines from a follow-up survey described in subsection (h)(2)(B)(i) of this section that the individual skills and socialization provider has completed a corrective action for a substantial violation, the administrative penalty associated with the substantial violation stops accruing on the date the corrective action was completed, as determined by HHSC.(m) If HHSC determines from a follow-up survey described in subsection (h)(2)(B)(i) of this section that the individualized skills and socialization provider has not completed the corrective action for a substantial violation, HHSC may:(1) continue to impose an administrative penalty and conduct a second follow-up survey to determine if the individualized skills and socialization provider completed the corrective action;(2) impose a license suspension or closing order against the individualized skills and socialization provider; or(3) deny or revoke the license of the individualized skills and socialization provider.(n) If HHSC determines from a follow-up survey or off-site desk review described in subsection (h)(2)(B)(ii) of this section that the individualized skills and socialization provider has completed the corrective action for a violation that is non-substantial, HHSC does not impose an administrative penalty for the non-substantial violation.(o) If HHSC determines from a follow-up survey or off-site desk review described in subsection (h)(2)(B)(ii) of this section that the individualized skills and socialization provider has not completed the corrective action for a violation that is non-substantial, HHSC:(1) imposes an administrative penalty for the non-substantial violation in accordance with §559.253 of this division;(2) notifies the individualized skills and socialization provider of the administrative penalty; and(3) conducts a survey:(A) after the date of the post 45-day exit conference of the follow-up survey; or(B) after the date of the exit conference of the post 45-day follow-up survey if the program provider has submitted evidence of corrective action to HHSC during the 30-day period.(p) If an individualized skills and socialization provider cannot resolve a dispute regarding a violation of regulations, the individualized skills and socialization provider is entitled to an informal dispute resolution (IDR) as outlined in §559.233(g) of this division.(q) If HHSC determines that the individualized skills and socialization provider committed any of the actions described in §559.253(a) of this division, HHSC may:(1) impose an administrative penalty against the individualized skills and socialization provider as described in §559.253 of this division;(2) impose a non-emergency license suspension against the individualized skills and socialization provider as described in §559.247 of this division (relating to Nonemergency Suspension); or(3) deny or revoke the license of the individualized skills and socialization provider as described in §559.215 of this subchapter (relating to Criteria for Denying a License or Renewal of a License) and §559.249 of this division (relating to Revocation). (r) HHSC does not cite an individualized skills and socialization provider for violation of a regulatory requirement based solely on the action or inaction of a person who is not an employee, contractor, or volunteer of the individualized skills and socialization provider. HHSC may cite the individualized skills and socialization provider for violation of a regulatory requirement based on the individualized skills and socialization provider's response to the action or inaction of such a person. Source Note: The provisions of this §559.255 adopted to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.255 Individualized Skills and Socialization Provider Compliance and Corrective Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=227536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 227536 03/12/2026 (a) An administrative hearing is held in accordance with Chapter 110 of this title (relating to Hearings Under the Administrative Procedure Act), Texas Government Code Chapter 2001, Subchapter I (relating to Administrative Procedure), and Texas Administrative Code, Title 1, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(b) An administrative law judge sets a hearing date and gives notice of the hearing if an individualized skills and socialization provider is assessed an administrative penalty and requests a hearing.(c) The requested hearing is held before an administrative law judge who makes findings of fact and conclusions of law regarding the occurrence of a violation under Texas Human Resources Code Chapter 103, a rule adopted under this chapter, or a term of a license issued under this chapter.(d) Based on the findings of fact and conclusions of law and the recommendation of the administrative law judge, the executive commissioner or designee, by order, finds:(1) a violation has occurred and assesses an administrative penalty; or(2) a violation has not occurred.(e) The executive commissioner or designee provides notice of the findings made under subsection (d) of this section to the individualized skills and socialization provider charged with a violation. If the executive commissioner finds that a violation has occurred, the executive commissioner or designee provides written notice to the provider of:(1) the findings;(2) the amount of the administrative penalty;(3) the rate of interest payable on the penalty and the date on which interest begins to accrue; and(4) the provider's right to judicial review of the order of the executive commissioner.(f) Not later than the 30th day after the date on which the order of the executive commissioner or designee is final, the individualized skills and socialization provider assessed an administrative penalty must:(1) pay the full amount of the penalty; or(2) file a petition for judicial review contesting the occurrence of the violation, the amount of the penalty, or both.(g) Notwithstanding subsection (e) of this section, HHSC may permit the individualized skills and socialization provider to pay an administrative penalty in installments.(h) If an individualized skills and socialization provider does not pay an administrative penalty within the period provided by subsection (f) or (g) of this section or in accordance with the installment plan permitted by HHSC:(1) the penalty is subject to interest; and(2) HHSC may refer the matter to the attorney general for collection of the penalty and interest.(i) Interest accrues:(1) at a rate equal to the rate charged on loans to depository institutions by the New York Federal Reserve Bank; and(2) for the period beginning on the day after the date on which the penalty becomes due and ending on the date the penalty is paid.(j) Accrued interest on the amount remitted by the executive commissioner or designee must be paid:(1) at a rate equal to the rate charged on loans to depository institutions by the New York Federal Reserve Bank; and(2) for the period beginning on the date the penalty is paid and ending on the date the penalty is remitted to the individualized skills and socialization provider. Source Note: The provisions of this §559.257 adopted to be effective February 9, 2026, 51 TexReg 740. 1 HEALTH AND HUMAN SERVICES COMMISSION 559 DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS H INDIVIDUALIZED SKILLS AND SOCIALIZATION PROVIDER REQUIREMENTS §559.257 Administrative Hearings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192286 03/12/2026 In this chapter:(1) HHSC means the Texas Health and Human Services Commission; and(2) facility means:(A) a nursing facility licensed under Chapter 242 of the Texas Health and Safety Code;(B) an assisted living facility licensed under Chapter 247 of the Texas Health and Safety Code;(C) a home and community support services agency licensed under Chapter 142 of the Texas Health and Safety Code;(D) a day activity and health services facility licensed under Chapter 103 of the Texas Human Resources Code;(E) an intermediate care facility for individuals with an intellectual disability or related conditions licensed under Chapter 252 of the Texas Health and Safety Code; or(F) a prescribed pediatric extended care center licensed under Chapter 248A of the Texas Health and Safety Code. Source Note: The provisions of this §560.1 adopted to be effective September 24, 2018, 43 TexReg 6329. 1 HEALTH AND HUMAN SERVICES COMMISSION 560 DENIAL OR REFUSAL OF LICENSE §560.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192287 03/12/2026 (a) HHSC may deny an initial facility license, or refuse to renew a facility license, if an applicant for a facility license, a facility license holder, or any other person whose criminal history must be verified before a facility license is issued:(1) has been convicted, regardless of the date of conviction, of any of the following misdemeanor or felony offenses:(A) an offense listed in Texas Health and Safety Code §250.006(a) or (c) (relating to Convictions Barring Employment);(B) an offense relating to the practice of a health-related profession without a license;(C) an offense relating to drugs, dangerous drugs, or controlled substances; or(D) an offense under any of the following sections of the Texas Penal Code:(i) Section 22.09, Tampering with consumer product;(ii) Section 22.10, Leaving a child in a vehicle;(iii) Section 32.42, Deceptive business practices;(iv) Section 32.51, Fraudulent use or possession of identifying information;(v) Section 35.02, Insurance fraud;(vi) Section 42.072, Stalking;(vii) Section 42.10, Dog fighting;(viii) Section 43.05, Compelling prostitution;(ix) Section 43.24, Sale, distribution, or display of harmful material to minor;(x) Section 43.25, Sexual performance by a child;(xi) Section 43.251, Employment harmful to children;(xii) Section 43.26, Possession or promotion of child pornography;(xiii) Section 46.06, Unlawful transfer of certain weapons;(xiv) Section 46.13, Making a firearm accessible to a child;(xv) Section 48.02, Prohibition of the purchase and sale of human organs;(xvi) Section 49.07, Intoxication assault;(xvii) Section 49.08, Intoxication manslaughter; or(xviii) Section 71.022, Coercing, inducing, or soliciting membership in a criminal street gang; or(2) has been convicted, during the five years preceding the date of the facility license application, of any of the following misdemeanor or felony offenses:(A) an offense listed in Texas Health and Safety Code §250.006(b); or(B) an offense under any of the following sections of the Texas Penal Code:(i) Section 30.03, Burglary of coin-operated or coin collection machines;(ii) Section 30.04, Burglary of vehicles;(iii) Section 31.03, Theft;(iv) Section 31.04, Theft of service;(v) Section 32.21, Forgery;(vi) Section 32.31, Credit card or debit card abuse;(vii) Section 32.33, Hindering secured creditors;(viii) Section 32.48, Simulating legal process;(ix) Section 33.02, Breach of computer security;(x) Section 42.061, Silent or abusive calls to 9-1-1 service;(xi) Section 42.07, Harassment; or(xii) Section 42.091, Attack on assistance animal.(b) HHSC may revoke a facility license if HHSC becomes aware of:(1) a conviction described in subsection (a)(1) of this section regardless of the date of the conviction; or(2) a conviction described in subsection (a)(2) of this section if the conviction occurred during the five years preceding the date HHSC became aware of the conviction.(c) HHSC considers a conviction of an offense under the laws of another state, federal law, or the Uniform Code of Military Justice containing elements that are substantially similar to the elements of an offense listed in subsection (a) of this section as if it is a conviction of one of the listed offenses.(d) HHSC considers the following information when deciding if it will deny a facility license, refuse to renew a facility license, or revoke a facility license in accordance with this section:(1) the nature and seriousness of the offense;(2) the relationship of the offense to the operation of a facility;(3) the extent to which a facility license might offer an opportunity for the person to engage in activity similar to the offense;(4) the age of the person at the time of the offense;(5) the amount of time since the offense; and(6) any other information provided by the person to explain the circumstances of the offense or to evidence the person's conduct since the offense.(e) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Article 42A.111, Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision. Source Note: The provisions of this §560.2 adopted to be effective September 24, 2018, 43 TexReg 6329. 1 HEALTH AND HUMAN SERVICES COMMISSION 560 DENIAL OR REFUSAL OF LICENSE §560.2 Convictions Barring Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224577 03/12/2026 HHSC may deny an application for a license or refuse to renew a license for a facility described in §560.1(2)(A) - (E) of this chapter (relating to Definitions) if: (1) any of the following persons are listed in a record maintained by a health and human services agency under Texas Government Code §526.0454: (A) the applicant or facility license holder; (B) a person listed on an initial or renewal application; or (C) a controlling person of the applicant or facility license holder; and (2) the health and human services agency's action that resulted in the person being listed in a record maintained under Texas Government Code §526.0454 is based on: (A) an act or omission that resulted in physical or mental harm to an individual in the care of the person; (B) a threat to the health, safety, or well-being of an individual in the care of the person; (C) the physical, mental, or financial exploitation of an individual in the care of the person; or (D) a determination by the health and human services agency that the person has committed an act or omission that renders the person unqualified or unfit to fulfill the obligations of the license, listing, or registration. Source Note: The provisions of this §560.3 adopted to be effective September 24, 2018, 43 TexReg 6329; amended to be effective April 1, 2025, 50 TexReg 2209. 1 HEALTH AND HUMAN SERVICES COMMISSION 560 DENIAL OR REFUSAL OF LICENSE §560.3 Adverse Licensing Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192289 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192289 03/12/2026 HHSC may deny an application for an initial facility license, or refuse to renew a facility license, if the applicant for the facility license, the facility license holder, or a controlling person of the applicant or facility license holder is listed:(1) as unemployable on the Employee Misconduct Registry maintained by HHSC in accordance with Texas Health and Safety Code, Chapter 253; or(2) with a revoked or suspended status on the Nurse Aide Registry maintained by HHSC in accordance with Texas Health and Safety Code, Chapter 250. Source Note: The provisions of this §560.4 adopted to be effective September 24, 2018, 43 TexReg 6329. 1 HEALTH AND HUMAN SERVICES COMMISSION 560 DENIAL OR REFUSAL OF LICENSE §560.4 Registry Listings Barring Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208470 03/12/2026 (a) This chapter implements Texas Health and Safety Code (THSC), Chapter 253, Employee Misconduct Registry (EMR), regarding investigating an allegation of abuse, neglect, or exploitation, and entering information in the EMR about a finding of reportable conduct by an unlicensed employee of a facility, an agency, or an individual employer.(b) The Texas Health and Human Services Commission maintains the EMR and enters information in the EMR in accordance with §561.8 of this chapter (relating to Entering Information in the EMR).(c) The EMR lists persons who are not employable by a facility, agency, or individual employer. Source Note: The provisions of this §561.1 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208471 03/12/2026 The following words and terms in this chapter have the following meanings, unless the context clearly indicates otherwise:(1) Abuse--Is defined by the statute or rule that governs the investigation of alleged abuse of an individual using the CDS option or receiving facility or agency services.(2) Administrative law judge--An administrative law judge from the Texas State Office of Administrative Hearings (SOAH) who is authorized to preside over certain administrative hearings under this chapter and in accordance with Texas Government Code, Chapter 2001.(3) Administrative hearing--A contested case hearing conducted under this chapter by SOAH based on a written request for hearing by an employee contesting the Texas Health and Human Services Commission's (HHSC's) determination that the employee committed reportable conduct.(4) Agency--In this chapter means:(A) a home and community support services agency licensed under Texas Health and Safety Code (THSC) Chapter 142, that provides services to an elderly or disabled adult;(B) a person exempt from licensing under THSC §142.003(a)(19);(C) a facility for persons with an intellectual disability or related conditions licensed under THSC Chapter 252;(D) a state supported living center as defined in THSC §531.002;(E) a local authority designated under THSC §533.035;(F) a community center as defined in THSC §531.002;(G) a mental health facility operated by the Texas Department of State Health Services;(H) the intermediate care facility for individuals with an intellectual disability component of the Rio Grande State Center; or(I) a contractor of an entity described in subparagraphs (D) - (H) of this paragraph.(5) Child--A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.(6) Consumer directed services option (CDS option)--A service delivery option, described in Texas Administrative Code, Title 40, Chapter 41 (relating to Consumer Directed Services Option), in which an individual or legally authorized representative (LAR) employs and retains service providers and directs the delivery of program services.(7) Executive Commissioner--The executive commissioner of HHSC.(8) Employee--A person who:(A) works for an agency, a facility, or an individual employer;(B) provides personal care services, active treatment, or any other personal services to an individual using the CDS option or receiving facility or agency services; and(C) is not licensed to perform those services or is a nurse aide.(9) Employee Misconduct Registry--The registry established in THSC Chapter 253, and available on the HHSC website.(10) Exploitation--Is defined by the statute or rule that governs the investigation of alleged exploitation of an individual using the CDS option or receiving facility or agency services.(11) Facility--In this chapter means:(A) a nursing facility licensed under THSC Chapter 242;(B) an assisted living facility licensed under THSC Chapter 247;(C) a home and community support services agency licensed under THSC Chapter 142, that provides services to a child;(D) a home and community support services agency licensed under THSC Chapter 142, as a hospice inpatient unit or hospice residential unit;(E) a day activity and health services facility licensed under Texas Human Resources Code, Chapter 103;(F) an adult foster care provider that contracts with HHSC; or(G) a prescribed pediatric extended care center licensed under THSC, Chapter 248A.(12) Financial management services agency (FMSA)--As defined in Texas Administrative Code, Title 40, Chapter 41 §41.103 (relating to Definitions), an entity that contracts with HHSC to provide financial management services to individuals who use the CDS option.(13) Individual employer--An employer, as defined in Texas Administrative Code, Title 40, Chapter 41 §41.103, which is an individual or LAR who participates in the CDS option and is responsible for hiring and retaining service providers to deliver program services.(14) Informal review (IR)--An opportunity for an employee to dispute the preliminary results of an investigation by providing HHSC with additional information, initiated by a written request by the employee.(15) Neglect--Is defined by the statute or rule that governs the investigation of alleged neglect of an individual using the CDS option or receiving facility or agency services.(16) Nurse Aide Registry (NAR)--The registry established in THSC §250.001(1), and available on the HHSC website.(17) Reportable conduct--Reportable conduct, as defined in THSC §253.001, which includes:(A) abuse or neglect that causes or may cause death or harm to an individual using the CDS option or receiving facility or agency services;(B) sexual abuse of an individual using the CDS option or receiving facility or agency services;(C) financial exploitation of an individual using the CDS option or receiving facility or agency services in the amount of $25 or more; and(D) emotional, verbal, or psychological abuse that causes harm to an individual using the CDS option or receiving facility or agency services.(18) Texas State Office of Administrative Hearings (SOAH)--The state agency responsible for conducting certain administrative hearings for other state agencies, including HHSC.(19) THSC--Texas Health and Safety Code. Source Note: The provisions of this §561.2 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208472 03/12/2026 (a) Before a facility, agency, or individual employer hires an employee, the facility, agency, individual employer, or a financial management services agency (FMSA), on behalf of the individual employer, must search the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) to determine if the person applying for employment is listed as unemployable on either registry.(b) A facility, agency, or individual employer must not hire or continue to employ a person listed in the EMR or NAR as unemployable.(c) A facility, agency, or individual employer must, within five working days after hiring an employee, provide written information to the employee explaining:(1) that a person listed in the EMR is not employable by a facility, agency, or individual employer; and(2) that the EMR is governed by this chapter and Texas Health and Safety Code Chapter 253.(d) A facility, agency, individual employer, or FMSA, on behalf of an individual employer, must search the EMR and NAR annually to determine if an employee is listed on either registry as unemployable.(e) A facility, or agency, individual employer, or FMSA, on behalf of an individual employer, must maintain a copy of the results of the searches required by subsections (a) and (d) of this section in the books and records maintained by the entity that conducted the search. Source Note: The provisions of this §561.3 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.3 Employment and Registry Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208473 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) investigates certain allegations of abuse, neglect, and exploitation made against an employee.(b) After commencing an investigation, if the preliminary results indicate an allegation of abuse, neglect, or exploitation by an employee might meet the definition of reportable conduct, HHSC complies with §561.5 of this chapter (relating to Preliminary Results of Investigation and Notice to Employee) and §561.6 of this chapter (relating to Informal Review).(c) If HHSC determines that the reportable conduct occurred, after completing its investigation into an allegation of abuse, neglect, or exploitation by an employee, HHSC provides the employee with written notice of the findings in accordance with §561.7 of this chapter (relating to Reportable Conduct Finding and Notice and Opportunity for Administrative Hearing).(d) Sections 561.5, 561.6, and 561.7 of this chapter apply only to an investigation conducted by HHSC, as described in subsection (a) of this section. Source Note: The provisions of this §561.4 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.4 Investigations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208474 03/12/2026 (a) When the preliminary results of the Texas Health and Human Services Commission's (HHSC) investigation indicate that an employee might have committed reportable conduct, HHSC sends the employee a written notice that includes:(1) a brief summary of the preliminary results of the investigation and facts on which they are based;(2) a statement that the employee may request an informal review (IR) by HHSC to dispute the preliminary results of the investigation;(3) a statement that a request for an IR must be made in writing no later than 10 calendar days after the date the employee receives written notice of the preliminary results of the investigation; and(4) contact information for the HHSC office where an employee must submit the request for an IR.(b) An employee may dispute the preliminary results of the investigation by requesting an IR in writing no later than 10 calendar days after the date the employee received the written notice described in subsection (a) of this section.(c) An employee's request for or participation in a requested IR does not relieve the employee of the requirement to comply with §561.7 of this chapter (relating to Reportable Conduct Finding and Notice and Opportunity for Administrative Hearing). If HHSC upholds the preliminary results of the investigation, HHSC will provide the employee with notice of reportable conduct in accordance with §561.7. Source Note: The provisions of this §561.5 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.5 Preliminary Results of Investigation and Notice to Employee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208475 03/12/2026 (a) If an employee requests an informal review (IR) in accordance with §561.5(b) of this chapter (relating to Preliminary Results of Investigation and Notice to Employee), the Texas Health and Human Services Commission (HHSC) sets an informal review (IR) date no later than 30 calendar days after the date the request is received by HHSC.(1) The employee may dispute the preliminary results of the investigation by providing additional information to designated HHSC staff.(2) If the designated HHSC staff does not uphold the preliminary investigation results, HHSC notifies the employee of the results of the IR and does not enter the employee's name or related information in the Employee Misconduct Registry.(3) If designated HHSC staff upholds the preliminary investigation results and finds reportable conduct, HHSC sends written notice to the employee, as described in §561.7(a) of this chapter (relating to Reportable Conduct Finding and Notice and Opportunity for Administrative Hearing).(b) If an employee does not timely request an IR or fails to participate in a requested IR, HHSC upholds the preliminary investigation results, finds reportable conduct occurred, and sends the employee the written notice described in §561.7(a) of this chapter, except that the notice does not include a summary of the results of an IR. Source Note: The provisions of this §561.6 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.6 Informal Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208476 03/12/2026 (a) After an investigation in which HHSC finds that reportable conduct occurred, HHSC provides the employee with written notice of its findings, which includes:(1) a summary of HHSC's Reportable Conduct finding;(2) a statement that the employee has the right to an administrative hearing on the occurrence of reportable conduct;(3) a statement that:(A) a request for hearing must be made in writing no later than 30 calendar days after the date the employee receives the written notice; or(B) the employee may accept the reportable conduct finding, which would result in HHSC placing the employee on the EMR; and(4) the contact information for the Texas Health and Human Services Commission (HHSC) where the employee must submit the request for an administrative hearing.(b) If the employee accepts HHCS's determination or does not timely request an administrative hearing, the employee's name and related information are entered in the Employee Misconduct Registry (EMR).(c) An employee may request an administrative hearing conducted in accordance with the Health and Human Services Commission's administrative hearing procedures in Title 1, Texas Administrative Code, Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act).(d) If an employee timely requests a hearing, the employee is granted an administrative hearing on the occurrence of reportable conduct before an administrative law judge at Texas State Office of Administrative Hearings (SOAH).(e) The administrative hearing described in §561.7(d) requires the hearing and hearing record to be completed no later than 120 days after the date HHSC received the hearing request.(f) The administrative law judge makes findings of facts and conclusions of law and issues a proposal for decision as to the occurrence of reportable conduct.(g) Based on the findings of fact and conclusions of law and the recommendation of the administrative law judge, HHSC by order may find that the reportable conduct occurred.(h) If after an administrative hearing, HHSC finds that the employee committed reportable conduct under §561.7(g), HHSC must issue a final order on that determination and enter into the EMR the information described in §561.8(c) of this chapter (relating to Entering Information into the EMR.)(i) Notice of a final order issued by HHSC under §561.7(h) must be sent to the employee and must include:(1) separate statements of the findings of fact and conclusions of law;(2) a statement of the right of the employee to judicial review of the order; and(3) a statement that the reportable conduct will be recorded in the EMR under Texas Health and Safety Code §253.007, if:(A) the employee does not request judicial review of the determination; or(B) the determination is sustained by the court.(j) Not later than the 30th day after the date on which the decision becomes final as provided by Texas Government Code Ch. 2001, the employee may file a petition for judicial review contesting the finding of the reportable conduct. If the employee does not request judicial review of the determination, the department will record the reportable conduct in the EMR as set forth in §561.8 of this chapter. Source Note: The provisions of this §561.7 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.7 Reportable Conduct Finding and Notice and Opportunity for Administrative Hearing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208477 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) enters the information described in subsection (c) of this section in the Employee Misconduct Registry (EMR):(1) when HHSC investigates and all applicable due process procedures are completed for a substantiated finding of reportable conduct;(2) as required by Texas Health and Safety Code (THSC) §253.0075, when HHSC receives notice of a finding of reportable conduct from the Texas Department of Family and Protective Services (DFPS);(3) as a finding of reportable conduct when HHSC finds that a nurse aide working in a nursing facility has committed abuse, neglect, or misappropriation (as those terms are defined in §561.2 of this chapter (relating to Definitions)) and HHSC lists the nurse aide's certification as revoked on the Nurse Aide Registry (NAR); or(4) at HHSC's discretion in accordance with THSC §253.007(b), if an agency of another state or the federal government finds that an employee has committed an act that constitutes reportable conduct.(b) HHSC does not offer an informal review (IR), as described in §561.6 of this chapter (relating to Informal Review), or an administrative hearing, as described in §561.7 of this chapter (relating to Reportable Conduct Finding and Notice and Opportunity for Administrative Hearing), to an employee regarding a finding of reportable conduct described in §561.8(a)(2), (3), or (4) before entering employee information related to the finding in the EMR.(1) For a finding under subsection (a)(2) or (4) of this section, the Texas Department of Family and Protective Services, the federal government, or an agency of another state provides any due process required by its laws, rules, or regulations before sending a finding to HHSC.(2) For a finding under subsection (a)(3) of this section, HHSC provides due process before listing a nurse aide's certification as revoked in the NAR in accordance with Title 26, Texas Administrative Code §556.12 (relating to Findings and Inquiries).(c) The following information is entered in the EMR in accordance with THSC §253.007 (relating to Employee Misconduct Registry):(1) the employee's name;(2) the employee's address;(3) the employee's social security number;(4) the name of the facility or agency, or a notation that the employee was an employee of an individual employer;(5) the address of the facility or agency, or the city and state of the individual employer;(6) the date the reportable conduct occurred; and(7) a description of the reportable conduct. Source Note: The provisions of this §561.8 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.8 Entering Information in the EMR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208478 03/12/2026 An employee's name remains in the Employee Misconduct Registry (EMR) unless:(1) After receiving a written request from the employee, the Texas Health and Human Services Commission (HHSC) determines that the employee does not meet the requirements for listing in the EMR based on additional information gathered by HHSC or notification received from the Texas Department of Family and Protective Services or another referring entity; or(2) an entry of reportable conduct in the EMR was based on an entry in the Nurse Aide Registry (NAR) and the entry in the NAR is subsequently removed. Source Note: The provisions of this §561.9 adopted to be effective April 21, 2022, 47 TexReg 2012. 1 HEALTH AND HUMAN SERVICES COMMISSION 561 EMPLOYEE MISCONDUCT REGISTRY §561.9 Removing Information from the EMR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223788 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223788 03/12/2026 Notwithstanding the provisions of §441.101 of this title (relating to Definitions), the following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--An intentional, knowing, or reckless act or omission by a counselor, applicant for counselor licensure, counselor intern, certified clinical supervisor, clinical training institution, or personnel of any such person that causes or may cause death, emotional harm or physical injury to a client. Abuse includes, without limitation, the following:(A) any sexual contact, sexual exploitation, or indecent exposure between a counselor, applicant for counselor licensure, counselor intern, certified clinical supervisor, clinical training institution, or personnel of any such person, and a client, or as otherwise defined in this section;(B) corporal punishment or physical assault;(C) nutritional deprivation or sleep deprivation;(D) efforts to cause fear;(E) the use of any form of communication to threaten, curse, shame, or degrade a client;(F) restraint that does not conform with Chapter 448 of this title (relating to Standard of Care);(G) coercive or restrictive actions taken in response to a client's request for discharge or refusal of medication or treatment that are illegal or not justified by the client's condition; and(H) any other act or omission classified as abuse by Texas law, including, but not limited to, Texas Family Code, §261.001 and Texas Human Resources Code, §48.002.(2) Accredited institution of higher education--An institution that holds accreditation or candidacy status from an accreditation organization recognized by the Council for Higher Education Accreditation.(3) Act--Texas Occupations Code, Chapter 504, Chemical Dependency Counselors.(4) Administrative Hearing--A contested case hearing conducted by the State Office of Administrative Hearings (SOAH) under Texas Government Code, Chapter 2001, Administrative Procedure Act.(5) Administrative Law Judge--An individual appointed by the chief administrative law judge of SOAH under Texas Government Code, §2003.041, to preside over a contested case proceeding.(6) Administrative Procedure Act (APA)--Texas Government Code, Chapter 2001, as amended.(7) Adolescent--An individual 13 through 17 years of age whose disabilities of minority have not been removed by marriage or judicial decree.(8) Adult--An individual 18 years of age or older, or an individual under the age of 18 whose disabilities of minority have been removed by marriage or judicial decree.(9) Advanced Practice Nurse--A registered nurse currently licensed in Texas who is approved by the Texas Board of Nursing to engage in advanced practice.(10) Applicant--A person who has submitted an application for an initial, or for the renewal of, a license, certification, or registration.(11) Assessment--An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for developing and revising a treatment plan and evaluating client progress toward achievement of goals identified in the treatment plan, resulting in comprehensive identification of the client's strengths, weaknesses, and problems/needs.(12) Career School or College--An organization approved and regulated by the Texas Workforce Commission, pursuant to Title 40, Texas Administrative Code, Chapter 807 (relating to Career Schools and Colleges), that offers a course of study in chemical dependency counseling.(13) Certified Clinical Supervisor (CCS)--A person certified by the department pursuant to Texas Occupations Code §504.1521 (relating to Supervised Work Experience).(14) Chemical Dependency Treatment (treatment)--A planned, structured, and organized chemical dependency program designed to initiate and promote a person's chemical-free status or to maintain the person free of illegal drugs. It includes, but is not limited to, the application of planned procedures to identify and change patterns of behavior related to or resulting from substance-related disorders that are maladaptive, destructive, or injurious to health, or to restore appropriate levels of physical, psychological, or social functioning.(15) Child--For purposes of reporting abuse and neglect, a child is an individual under the age of 18 whose disabilities of minority have not been removed by marriage or judicial decree. For all other purposes in these rules, child shall mean an individual under the age of 13.(16) Client--An individual who receives or has received services, including admission authorization or assessment or referral, from a chemical dependency counselor, counselor intern, applicant for licensure as a counselor, certified clinical supervisor, clinical training institution, or from a person for whom the counselor, intern, certified clinical supervisor or applicant is working on a paid or voluntary basis, or was working at the time the individual was a client.(17) Clinical Training Institution (CTI)--An individual or legal entity registered with the department to supervise a counselor intern.(18) Counseling-related field--A mental health discipline utilizing human development, psychotherapeutic, and mental health principles including, but not limited to, psychology, psychiatry, social work, marriage and family therapy, and counseling and guidance. Non-counseling related fields include, but are not limited to, sociology, education, administration, dance therapy and theology.(19) Counselor--A licensed chemical dependency counselor.(20) Counselor Intern (CI or intern)--A person seeking a license as a chemical dependency counselor who is registered with the department and pursuing a course of training in chemical dependency counseling at a registered clinical training institution or under the supervision of a certified clinical supervisor.(21) CSAT--Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services.(22) Diagnostic and Statistical Manual of Mental Disorders (DSM)--The Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Any reference to DSM shall constitute a reference to the most recent edition published.(23) Department--The Department of State Health Services.(24) Exploitation--The illegal or improper use of a client, or the client's resources, for monetary or personal benefit, profit, or gain by a counselor, counselor intern, or applicant for counselor licensure, or any other act or omission classified as exploitation by Texas law including, but not limited to, Texas Family Code, §261.001 and Texas Human Resources Code, §48.002. Exploitation includes, but is not limited to, sexual exploitation, as defined herein.(25) Graduate--An individual who has successfully completed, or been exempted from, as applicable, the 270 hours of education, 300 hour practicum, and 4,000 hours of supervised work experience and who is still registered with the department as a counselor intern.(26) Hearing--Administrative Hearing.(27) Indecent Exposure--Exposure by a chemical dependency counselor, counselor intern, certified clinical supervisor, applicant for any such license, or personnel of a clinical training institution or other licensee, of the individual's anus or any part of the individual's genitals, knowing a client is present; or compulsion or encouragement by a chemical dependency counselor, counselor intern, certified clinical supervisor, applicant for any such license, or personnel of a clinical training institution or other licensee, for a client to expose the client's anus or any part of the client's genitals.(28) Knowledge, Skills, and Attitudes (KSAs)--The knowledge, skills, and attitudes of addictions counseling as defined by CSAT Technical Assistance Publication (TAP 21) "Addictions Counseling Competencies: the Knowledge, Skills, and Attitudes of Professional Practice."(29) License--Unless otherwise specified explicitly or by the context, any form of licensure issued under this subchapter, including a CI registration, CCS certification, CTI registration, or licensed chemical dependency counselor license.(30) Licensed Chemical Dependency Counselor (LCDC)--A counselor licensed by the department, pursuant to Texas Occupations Code, Chapter 504, to engage in the practice of chemical dependency counseling.(31) Licensee--Unless otherwise specified explicitly or by the context, any holder of a license issued under this subchapter, including the holder of a CI registration, CCS certification, CTI registration, or LCDC license.(32) Neglect--A negligent act or omission by a counselor, applicant for counselor licensure, counselor intern, certified clinical supervisor, clinical training institution, or personnel of any such person that causes or may cause death, physical injury, or substantial emotional harm to a participant or client. Examples of neglect include, but are not limited to:(A) failure to provide adequate nutrition, clothing, or health care;(B) failure to provide a safe environment free from abuse;(C) failure to maintain adequate numbers of appropriately trained staff;(D) failure to establish or carry out an appropriate individualized treatment plan; and(E) any other act or omission classified as neglect by the Texas law including, but not limited to, Texas Family Code, §261.001 and Texas Human Resources Code, §48.002.(33) Peer Assistance Program--A program approved by the department pursuant to Texas Occupations Code, §504.057 (relating to Approval of Peer Assistance Programs).(34) Person--An individual, corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, and any other legal entity.(35) Practice of Chemical Dependency Counseling--Providing or offering to provide chemical dependency counseling services involving the application of the principles, methods, and procedures of the chemical dependency counseling profession, as defined by the practice dimensions and competencies identified and described in the CSAT Technical Assistance Publication (TAP 21) "Addictions Counseling Competencies: the Knowledge, Skills, and Attitudes of Professional Practice."(36) Prevention--A proactive process that uses multiple strategies to preclude the illegal use of alcohol, tobacco and other drugs and to foster safe, healthy, drug-free environments.(37) Private Practice--The individual practice of a private, licensed chemical dependency counselor who personally renders individual or group services within the scope of the LCDC's license and in the LCDC's offices. To qualify to be engaged in private practice, the individual LCDC must not hold him/herself out as an organized program, or a part thereof, that provides counseling or treatment. This definition does not prohibit the sharing of office space or administrative support staff.(38) Qualified Credentialed Counselor (QCC)--A licensed chemical dependency counselor or one of the practitioners listed below, if the practitioner is licensed and in good standing in the State of Texas, and, in performing any activity as a QCC, is acting within the authorized scope of the individual's license:(A) licensed professional counselor (LPC);(B) licensed social worker;(C) licensed marriage and family therapist (LMFT);(D) licensed psychologist;(E) licensed physician;(F) licensed physician's assistant;(G) certified addictions registered nurse (CARN); or(H) advanced practice nurse recognized by the Texas Board of Nursing as a clinical nurse specialist or practitioner with a specialty in psychiatric-mental health nursing.(39) Referral--The process of identifying appropriate services and providing the information and assistance needed to access them.(40) Rules--An agency statement of general applicability, including a state rule or federal regulation, that implements or prescribes law or policy by defining general standards of conduct, rights, or obligations of persons, or describes the procedure or practice requirements that prescribe the manner in which public business before an agency may be initiated, scheduled, or conducted, or interprets or clarifies law or agency policy. The term includes the amendment or repeal of a prior rule but does not include statements concerning only the internal management or organization of the agency that does not affect private rights or procedures. Any reference to a rule shall mean the rule then in effect and as amended, unless otherwise specified.(41) Screening--The process through which qualified staff, client, and available significant others, as appropriate, determine the most appropriate initial course of action, given the individual's needs and characteristics and the available resources within the community. In a treatment program, screening includes determining whether an individual is appropriate and eligible for admission to a particular program.(42) Services--Substance abuse services.(43) Sexual contact--Any intentional touching, or request to be allowed to touch, by a chemical dependency counselor, counselor intern, certified clinical supervisor, applicant for any such license, or personnel of a clinical training institution or other licensee, including touching through clothing, of the anus, breast, or any part of the genitals of a client; any intentional touching of any part of the body of a client, or request to be allowed to touch, including touching through clothing, with the anus, breast, or any part of the genitals of a chemical dependency counselor, counselor intern, certified clinical supervisor, applicant for any such license, or personnel of a clinical training institution or other licensee; or any compulsion or encouragement by a chemical dependency counselor, counselor intern, certified clinical supervisor, clinical training institution, applicant for any such license, or personnel of such licensee, for a client to engage in touching through clothing, of the anus, breast, or any part of the genitals of another individual, or for a client to touch any part of the body of another individual with the anus, breast, or any part of the client's genitals.(44) Sexual Exploitation--A pattern, practice, or scheme of conduct by a chemical dependency counselor, counselor intern, certified clinical supervisor, clinical training institution, applicant for any such license, or personnel of any such person, that involves a client and can reasonably be construed as being for the purpose of sexual arousal or gratification or sexual abuse. It may include, without limitation, sexual contact, a request for sexual contact, or a representation that sexual contact or exploitation is consistent with, a part of, or a condition of receiving services. It is not a defense to sexual exploitation of a client if it occurs:(A) with the actual or perceived consent of the client;(B) outside of the delivery of services;(C) off of the premises used for the delivery of substance abuse services; or(D) after the client has stopped receiving services, where the conduct occurs within two years of when the client stopped receiving services.(45) State Office of Administrative Hearings (SOAH)--The agency to which contested cases are referred by the department.(46) Substance Abuse--A maladaptive pattern of substance use leading to clinically significant impairment or distress, as defined by the most recently published version of the DSM.(47) Substance Abuse Education--A planned, structured presentation of information provided by qualified staff, related to substance abuse or substance dependence, allowing for discussion of the material presented, and relevant to the client's goals.(48) Substance Abuse Services (Services)--A comprehensive term intended to describe activities undertaken to address any substance-related disorder as well as education and prevention activities. The term includes, without limitation, the provision of screening, assessment, referral, chemical dependency treatment, and chemical dependency counseling.(49) Treatment Plan--An individualized, written plan developed and implemented through a collaborative process between qualified personnel and the client and reflecting and identifying desired treatment outcomes and the strategies for achieving them. At a minimum, the treatment plan addresses the identified substance use disorder(s), as well as issues related to treatment progress, including relationships with family and significant others, employment, education, spirituality, health concerns, and legal needs.(50) Unethical Conduct--Conduct prohibited by the ethical standards adopted by state or national professional organizations or by rules established by a profession's state licensing agency. Source Note: The provisions of this §562.1 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223789 03/12/2026 (a) An individual identified to the public as a chemical dependency counselor must be licensed or exempt under this subchapter. Except as provided by this section, individuals who are not LCDCs shall not:(1) offer or provide chemical dependency counseling services other than education;(2) represent themselves as chemical dependency counselors; or(3) use any name, title, or designation that implies licensure as a chemical dependency counselor.(b) The following individuals are exempt from LCDC licensure requirements when they offer or provide chemical dependency counseling services within the scope of their authorized duties and scope of practice:(1) counselors employed by federal institutions;(2) school counselors certified by the Texas Education Agency;(3) to the extent such licensees are acting within the authorized scope of their respective licenses, licensed physicians, licensed psychologists, licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), and licensed social workers;(4) religious leaders of congregations providing pastoral counseling within the scope of their congregational duties and people who are working for or providing counseling with a program exempted under Texas Health and Safety Code, §§464.051 - 464.061 (relating to Faith-Based Chemical Dependency Treatment Programs);(5) students who are participating in a practicum that meets the requirements as set forth in §140.407 of this title (relating to Practicum Standards) as part of a supervised course of clinical training at a regionally accredited institution of higher education or a career school or college, as long as they do not hold themselves out as, or use any name, title, or designation that implies licensure as a chemical dependency counselor or registration under this subchapter as a counselor intern; or(6) provides chemical dependency counseling through a program or in a facility that receives funding from the Texas Department of Criminal Justice and who is credentialed as:(A) a certified criminal justice addictions professional by the International Certification and Reciprocity Consortium; or(B) having certified criminal justice professional applicant status issued by the Texas Certification Board of Addiction Professionals.(c) Residents of other states are exempt from the LCDC licensure requirements of this subchapter if they:(1) are legally authorized to provide chemical dependency counseling in those states; and(2) do not offer or provide chemical dependency counseling in Texas for more than 30 days in any 12-month period.(d) An individual who qualifies for an exemption but chooses to obtain an LCDC license from the department under this subchapter is subject to the same rules and disciplinary actions as other licensees. Source Note: The provisions of this §562.2 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.2 License Required https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223790 03/12/2026 (a) An LCDC is authorized to provide chemical dependency counseling services involving the application of the principles, methods, and procedures of the chemical dependency profession as defined by the profession's ethical standards and the KSAs as defined in §140.400 of this title (relating to Definitions). The license does not qualify an individual to provide services outside this scope of practice.(b) The scope of practice for an LCDC includes services that address substance abuse/dependence and/or its impact on the service recipient subject to the following:(1) the LCDC is prohibited from using techniques that exceed his or her professional competence;(2) the service recipient may only be the user, family member or any other individual involved in a significant relationship with a user;(3) the focus of an LCDC's services shall be on assisting individuals or groups to develop an understanding of chemical dependency problems, define goals, and plan action reflecting the individual's or group's interest, abilities, and needs, as affected by claimed or indicated chemical dependency problems; and(4) LCDCs are not qualified to treat individuals with a mental health disorder or provide family counseling to individuals whose presenting problems do not include chemical dependency. Source Note: The provisions of this §562.3 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.3 Scope of Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223791 03/12/2026 (a) The schedule of fees is:(1) initial LCDC application fee--$25, in addition to any fees assessed under subsection (e) of this section;(2) initial LCDC licensure fee--$75, plus a surcharge of $10 to fund one or more approved peer assistance programs and administrative costs of the department related to peer assistance programs;(3) LCDC renewal and renewal application fee--$115, plus a surcharge of $10 to fund one or more approved peer assistance programs and administrative costs of the department related to peer assistance programs, in addition to any fees assessed under subsection (e) of this section:(A) late renewal penalty fee (up to 90 days after the license expiration date)--$37.50;(B) late renewal penalty fee (between 91 days and one year after the license expiration date)--$75;(4) background investigation fee--$40;(5) inactive status fee--$50;(6) licensure certificate replacement or duplication fee--$10;(7) returned check fee--$25;(8) clinical supervisor initial and renewal application and certification fee--$20; and(9) criminal history evaluation letter fee--$50.(b) The department may contract or enter into a memorandum of understanding with a person to administer the LCDC licensure examination, and the fee charged by that person is subject to change. The current fee shall be printed in the examination registration form. Examination fees shall be paid directly to the contract organization administering the examination.(c) Licensure fees paid to the department are not refundable.(d) Fees shall be paid in full with a personal check, cashier's check, commercial check, or money order.(e) For all new and renewal applications, the department is authorized to collect subscription and convenience fees in amounts determined by the Texas Online Authority to recover costs associated with new and renewal application processing through texas.gov. The fees may be paid with a credit card when applying for or renewing a license online. Source Note: The provisions of this §562.4 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective November 4, 2010, 35 TexReg 9739; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.4 Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223792 03/12/2026 (a) Every individual seeking LCDC licensure shall apply for registration as a counselor intern and initiate the licensure application process with the department by submitting the following items in a form acceptable to the department:(1) the initial LCDC application fee and the background investigation fee;(2) the department's current application form that has been completed, signed, dated, and notarized;(3) a recent full-face wallet-sized photograph of the applicant;(4) two sets of fingerprints completed according to department instructions; and(5) documentation that the applicant has successfully completed intern registration requirements in §140.405 of this title (relating to Requirements for Counselor Intern Registration).(b) A licensure or counselor intern registration applicant shall:(1) read the department rules in this subchapter;(2) follow all laws and rules, including the ethical standards;(3) provide to the department, or give the department permission to request from third parties, any additional information or references needed or requested by the department; and(4) notify the department in writing within 30 days of a change in name, address, or telephone number.(c) Application materials become the property of the department.(d) No determination will be made on an application unless it is complete.(1) Incomplete documents will be returned to the sender. The department will hold the remaining documents, but will not take action on the application until all outstanding documents have been completed as required by the department.(2) The application and background fee is not refundable and will not be returned. When resubmitting documents that were returned to the sender as incomplete, a second application fee is not required.(e) A document may be considered incomplete if it does not conform to the following standards.(1) All documents must be complete, signed, and dated. Signatures shall include credentials. If the documentation relates to past activity, the date of the activity shall also be recorded.(2) Documentation shall be permanent and legible.(3) When it is necessary to correct a document, the error shall be marked through with a single line, dated, and initialed by the writer. Correction fluid shall not be used.(f) An applicant for CI registration must receive written notice of registration from the department before accumulating any supervised work, holding oneself out as a registered counselor intern, taking the licensure examination, or providing chemical dependency services supervised in accordance with the requirements of this subchapter.(g) Within 45 days of receipt of the application, the department will notify the applicant that the application is complete or specify the additional information required.(h) An application shall be voided after one year if the applicant has not provided the additional information necessary to process the application.(i) By signing the application, the applicant accepts responsibility for remaining knowledgeable of and abiding by the applicable rules of this subchapter, including revisions. Source Note: The provisions of this §562.5 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.5 LCDC Licensure Application Standards and Counselor Intern Registration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223793 03/12/2026 (a) To be eligible for counselor intern registration under this subchapter, an individual must:(1) be at least 18 years of age;(2) have a high school diploma or its equivalent;(3) successfully complete 270 classroom hours, or 18 semester hours (or 27 quarter hours), of chemical dependency curricula as described in §140.406 of this title (relating to Standards for 270 Educational Hours);(4) complete 300 hours of approved supervised field work practicum as described in §140.407 of this title (relating to Practicum Standards);(5) pass the criminal history standards described in §140.431 of this title (relating to Criminal History Standards);(6) sign a written agreement to abide by the ethical standards contained in §140.423 of this title (relating to Professional and Ethical Standards for all License Holders); and(7) be worthy of the public trust and confidence as determined by the department.(b) Applicants holding at least a baccalaureate degree in chemical dependency counseling, sociology, psychology, or a major approved by the department as one related to human behavior and development are exempt from the 270 hours of education and the 300 hour practicum. The applicant must submit an official college transcript. Source Note: The provisions of this §562.6 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.6 Requirements for Counselor Intern Registration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223794 03/12/2026 (a) At least 135 clock hours (nine semester hours) of the education must be specific to substance use disorders and their treatment. The remaining 135 clock hours may be specific or related to chemical dependency counseling. Related education hours may include courses in psychology, sociology, counseling, mental health, behavioral science, psychiatric nursing, ethics, and rehabilitation counseling.(b) The education shall be provided by a career school or college, or an accredited institution of higher education.(c) Educational hours obtained at a career school or college must follow the curriculum for Transdisciplinary Foundations outlined in the KSAs:(1) Understanding Addiction;(2) Treatment Knowledge;(3) Application to Practice; and(4) Professional Readiness.(d) The department will not accept hours unless documented with a passing grade on an official transcript from the school. The applicant shall submit additional information requested by the department if needed to verify the content of a course. Source Note: The provisions of this §562.7 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.7 Standards for 270 Educational Hours https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223823 03/12/2026 (a) The practicum shall be completed under the administration of a career school or an accredited institution of higher education.(b) The applicant must complete the practicum under the administration of a single school.(c) The department will not accept a practicum without an official transcript from the school and a letter from the school's educational coordinator or chair verifying that the practicum was completed in the field of substance abuse.(d) Practicum hours may be paid or voluntary.(e) The practicum shall be delivered according to a written training curriculum that provides the student with an orientation to treatment services and exposure to treatment activities in each of the KSA dimensions. The practicum must include the intern observing treatment delivery and the intern providing services under direct observation. The practicum shall include at least 20 hours of experience in each of the KSA dimensions.(f) All practicum training shall be provided by qualified credentialed counselors (QCCs). Source Note: The provisions of this §562.8 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.8 Practicum Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223796 03/12/2026 (a) To be eligible for, and to complete an initial application for, a chemical dependency counselor license under this subchapter, an individual must:(1) complete the application required under §140.404 of this title (relating to LCDC Licensure Application Standards and Counselor Intern Registration);(2) meet the requirements to be a counselor intern in §140.405 of this title (relating to Requirements for Counselor Intern Registration);(3) hold an associate degree or more advanced degree, with the exception of those LCDCs who are renewing an existing license;(4) complete 4,000 hours of approved supervised experience working with chemically dependent individuals as described in §140.409 of this title (relating to Standards for Supervised Work Experience);(5) pass the written chemical dependency counselor examination approved by the department;(6) submit an acceptable written case presentation to the test administrator;(7) submit two letters of recommendation from LCDCs;(8) submit written assurance that the individual has access to an approved peer assistance program. The department may waive this requirement if the department determines, based upon information submitted by the applicant sufficient to support the determination, that a peer assistance program is not reasonably available to the individual; and(9) pay the initial LCDC licensure fee.(b) The department may waive the 4,000 hours of supervised work experience for individuals who hold a masters or doctoral degree in social work or a counseling-related field, and have 48 semester hours of graduate-level courses. An applicant for waiver shall submit an official college transcript with the official seal of the college and the signature of the registrar, and any other related documentation requested by the department. Source Note: The provisions of this §562.9 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.9 Requirements for LCDC Licensure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223797 03/12/2026 (a) An LCDC applicant must be registered with the department as described in §140.404 and §140.405 of this title (relating to LCDC Licensure Application Standards and Counselor Intern Registration, and Requirements for Counselor Intern Registration) before accumulating supervised work experience.(b) All supervised work experience obtained in Texas and all chemical dependency counseling services offered or provided by a CI must be completed at a registered CTI or under the supervision of a CCS. The department will not accept hours from an unregistered CTI or from a CCS that has not been certified by the department.(c) Work experience must be documented on the department's supervised work experience documentation form and signed by a CTI coordinator or a CCS.(1) All hours included in the documented supervised work experience must be performed within the KSA dimensions and in compliance with the Professional and Ethical Standards set forth in §140.423 of this title (relating to Professional and Ethical Standards for all License Holders).(2) The supervised work experience form must be accompanied by the counselor intern's job description reflecting duties in the KSA dimensions.(d) Out-of-state supervised work experience will be accepted only if the following conditions are met.(1) The applicant is either certified or licensed or in the process of seeking licensure or certification in the other state.(2) The standards for clinical supervision of work experience must meet or exceed Texas standards and be outlined in the governing agency's rules or standards. A copy of the governing rules or standards must be submitted with the other required documentation of supervised work experience.(3) The supervised work experience must be documented on the department's supervised work experience form or a comparable form used by the governing agency of the other state.(e) Supervised work experience may be paid or voluntary.(f) An individual who has completed the 4,000 hours of supervised work experience and is currently eligible to take or retake the examination is a graduate intern and may continue to provide chemical dependency services under the auspices of a registered clinical training institution or a certified clinical supervisor during the five-year registration period.(g) It is the applicant's responsibility to verify the CTI or CCS holds a valid registration or certification issued by the department.(h) The department may refuse to accept supervised work experience hours submitted to the department that relate to a violation of the Act or this subchapter for which final disciplinary action has been taken against the CI or the CI's registration under this subchapter. Source Note: The provisions of this §562.10 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.10 Standards for Supervised Work Experience https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223798 03/12/2026 (a) To become a registered clinical training institution (CTI), a person shall:(1) provide activities in an array of the KSA dimensions, including assessment and counseling;(2) serve a predominantly substance-abusing population;(3) employ a full time QCC as the CTI coordinator;(4) be in good standing, with no pending disciplinary actions, with applicable licensing and regulatory agencies;(5) agree to comply with applicable rules in this subchapter; and(6) submit a complete application.(b) The program shall receive the registration and training program number before training begins. Approval allows the CTI to provide clinical training at any of its programs or sites with relevant services.(c) The registration shall expire on the second anniversary of the date of issue. The CTI shall apply to renew the registration every two years by submitting a completed application form. The department may mail a courtesy notice, but it is the program's responsibility to apply in a timely manner.(d) The CTI shall notify the department in writing within 30 days of the following changes:(1) a change in the CTI coordinator;(2) a change in the CTI's name, mailing address, or telephone number; and(3) closure of the CTI. The CTI shall return its registration with its notice of closure. Closure of the CTI and/or surrender of a CTI's registration in response to a complaint shall be deemed to be the result of formal disciplinary action, as described in §140.429 of this title (relating to Voluntary Surrender of License, Certification, or Registration In Response to a Complaint). Source Note: The provisions of this §562.11 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.11 Clinical Training Institution (CTI) Registration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223799 03/12/2026 (a) To become a certified clinical supervisor, an individual shall:(1) be a QCC, as set forth in §140.400 of this title (relating to Definitions), in good standing, with no active suspension or probated suspension in effect against the individual's license, and no unpaid administrative penalties;(2) submit verification of current certification as a clinical supervisor issued by the International Certification and Reciprocity Consortium or one of its member boards;(3) submit a plan of activities, to be implemented for any CI the CCS supervises, in an array of the KSA dimensions, including assessment and counseling;(4) serve a predominantly substance-abusing population;(5) submit a completed application;(6) submit two sets of fingerprints completed according to department instructions, if the individual has not previously submitted fingerprints for the purposes of licensure under this subchapter, and pass the criminal history standards described in §140.431 of this title (relating to Criminal History Standards);(7) pay the background investigation fee, if the individual has not previously paid this fee for the purposes of licensure under this subchapter; and(8) pay the application and certification fee.(b) If the individual is licensed as a chemical dependency counselor, then the certification as a clinical supervisor will expire on the same day as the license. If the individual is not licensed as a chemical dependency counselor, then the certification as a clinical supervisor will expire on the second anniversary of the last day of the month of issuance.(c) An individual may renew this certification by submitting the items as described in subsection (a) of this section. Source Note: The provisions of this §562.12 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.12 Certified Clinical Supervisor (CCS) Certification Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223800 03/12/2026 (a) To be eligible for the LCDC licensure examination, an applicant shall:(1) be registered with the department as a counselor intern;(2) submit an acceptable case study to the test administrator; and(3) pay the examination fee to the test administrator.(b) All required documentation and fees must be submitted to the test administrator by the specified deadlines. It is the applicant's responsibility to obtain testing information.(c) An applicant may only take the examination four times, and all testing must be completed within five years from the date of registration. Source Note: The provisions of this §562.13 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.13 LCDC Licensure Examination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223801 03/12/2026 A counselor intern's registration will expire if an applicant fails the LCDC licensure examination a fourth time or if an applicant does not complete one or more of the requirements for licensure as set forth in §140.408 of this title (relating to Requirements for LCDC Licensure) within five years from the date of registration, whichever date is earlier. In either case, the department will not issue a license. To re-register as a counselor intern after expiration of a counselor intern's registration, the individual must meet the requirements for subsequent registration set forth in this section.(1) An applicant whose registration has expired cannot offer or provide chemical dependency counseling services or represent himself or herself as a CI or graduate CI.(2) An individual whose CI registration has expired under this section may reapply for CI registration and licensure only after completing 12 semester hours or 18 quarter hours of course work at a career school or college or an accredited institution of higher education. The coursework must be related to chemical dependency counseling, psychology, sociology, counseling, mental health, behavioral science, psychiatric nursing, ethics, or rehabilitation counseling. The new application shall not be considered complete without an official college transcript documenting the required course work, a subsequent registration application form with the other items required under §140.404 of this title (relating to LCDC Licensure Application Standards and Counselor Intern Registration), and the initial LCDC application and background investigation fee. In addition, the applicant must pass the criminal history standards described in §140.431 of this title (relating to Criminal History Standards) at the time of re-registration and is subject to the applicable requirements of the following subparagraphs:(A) if an individual whose CI registration has expired applies to re-register within five years of the date of expiration of the individual's CI registration and the department grants the new application for CI registration, the individual must complete only the requirements for licensure that were not fulfilled during the individual's previous period of registration, and may take the examination an additional three times, if needed. The outstanding requirements for licensure must be completed within three years of the new date of registration. During this period, the applicant may provide chemical dependency counseling services as a counselor intern in accordance with the supervision requirements of this subchapter.(B) if an individual applies for re-registration as a CI more than five years after the individual's CI registration expired and the department grants the new application for CI registration, the applicant must complete all requirements of §140.408 of this title (relating to Requirements for LCDC licensure) during the new period of registration to become licensed, except that the applicant may rely on a qualifying degree obtained prior to the period of registration. Source Note: The provisions of this §562.14 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.14 Counselor Intern Registration Expiration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223802 03/12/2026 (a) An individual licensed or certified in another state as a chemical dependency counselor may apply for licensure as an LCDC through reciprocity by submitting:(1) a copy of the reciprocal license or certification, with verified information from the issuing authority as to any disciplinary history;(2) the department's current reciprocity application, which has been completed, signed, dated, and notarized;(3) two sets of fingerprints completed according to department instructions;(4) a recent full-face wallet-sized photograph of the applicant;(5) two letters of recommendation; and(6) the application fee and the background investigation fee;(7) proof of successful completion of a licensing examination approved by the department; and(8) an official transcript showing that the individual holds an associate degree or more advanced degree.(b) The applicant shall meet the criminal history standards described in §140.431 of this title (relating to Criminal History Standards).(c) The department will not issue a license based on reciprocity unless it finds that the licensing or certification standards of the state of origin are at least substantially equivalent to the requirements for licensure of the Act and this subchapter. A state that does not require successful completion of a licensing examination approved by the department or a degree, as set forth in subsection (a) of this section, does not have standards that are substantially equivalent to the requirements for licensure under the Act and this subchapter. Any applicant for reciprocity that has not successfully completed a licensure examination approved by the department or a degree that satisfies subsection (a) of this section shall be required to do so as a prerequisite to eligibility for a license based upon reciprocity.(d) An applicant who does not qualify for reciprocity may apply for licensure based upon the standards set forth in §140.408 of this title. Source Note: The provisions of this §562.15 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.15 LCDC Licensure Through Reciprocity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223803 03/12/2026 (a) Absent action by the department against the applicant under §140.426 of this title (relating to Disciplinary Actions), the department will issue the applicable form of license under this subchapter when the applicant has met all requirements and paid all required fees for the license.(b) All licensees under this subchapter shall keep current versions of the certificate of licensure and the department's public complaint notice containing the current name, mailing address, and telephone number for the department, and a statement that a complaint against a licensee under this subchapter may be directed to the department, prominently displayed in their place of business. LCDCs may apply an adhesive label issued by the Texas Certification Board of Addiction Professionals with the designation and expiration date of any other related certification held by the license holder that is approved by the International Certification and Reciprocity Consortium or another person approved by the department.(c) A licensee shall not duplicate a licensure certificate to obtain a second copy of the license. A licensee may obtain an official duplicate certificate from the department by submitting a written request and the fee specified in §140.403 of this title (relating to Fees).(d) The department will replace a lost or damaged certificate if the licensee provides:(1) the remnants of the original licensure certificate (if damaged);(2) the original licensure certificate and copy of legal documents (for a name change);(3) the original licensure certificate (for printing error); or(4) a notarized statement if the licensure certificate has been lost, stolen, or destroyed.(e) A license replaced because of a printing error or mail damage will be replaced without cost, but all other replacements of licensure certificates require a fee, as specified in §140.403 of this title.(f) LCDCs and CCSs shall notify the department in writing within 30 days of a change in name, address, or telephone number.(g) The licensee shall return the original licensure certificate if it is relinquished, suspended, revoked, or voluntarily surrendered.(h) All licensees shall remain knowledgeable of and abide by applicable statutes and rules and their amendments.(i) A licensee may at any time voluntarily offer to relinquish his or her license for any reason, without compulsion.(1) The original licensure certificate may be delivered to the department by hand or postal delivery.(2) If there is no complaint pending against the licensee, the department may accept the relinquishment and void the applicable license.(3) If a complaint is pending, the procedures for acceptance of a license surrender are set out in §140.429 of this title (relating to Voluntary Surrender of License, Certification, or Registration In Response to a Complaint).(4) A license that has been surrendered and accepted may not be reinstated. However, a person may apply for a new license in accordance with the Act and this subchapter. Source Note: The provisions of this §562.16 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.16 Issuing Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223804 03/12/2026 (a) An LCDC license issued under this subchapter is valid until the expiration date printed on the license, which is calculated on a two-year renewal cycle from the date of original licensure. The licensee is responsible for renewing the license in a timely manner. The department will send the licensee a renewal notice, but failure to receive notice from the department does not waive or extend renewal deadlines.(b) To renew a license, the LCDC shall:(1) send a complete renewal application to the department;(2) pay the renewal and renewal application fees as set forth in §140.403 of this title (relating to Fees);(3) meet the criminal history standards described in §140.431 of this title (relating to Criminal History Standards); and(4) complete all required continuing education as described in §140.418 of this title (relating to Continuing Education Standards).(c) An LCDC who is otherwise eligible to renew a license may renew an unexpired license by submitting a complete renewal application and paying the required renewal fee to the department before the expiration date of the license. The renewal application and fee must be postmarked on or before the expiration date.(d) If the LCDC's license has been expired for 90 days or less, the person may renew the license by paying to the department a fee in an amount specified in §140.403 of this title (relating to Fees).(e) If the LCDC's license has been expired for more than 90 days but less than one year, the person may renew the license by paying to the department a fee in an amount specified in §140.403 of this title.(f) If the LCDC's license has been expired for one year or more, the person may not renew the license. The LCDC may obtain a new license by submitting to reexamination and complying, under current standards, with the requirements and procedures for obtaining an initial license.(g) Notwithstanding in subsection (f) of this section, the department may renew an LCDC license that has been expired for one or more years without reexamination if the applicant was licensed in this state, moved to another state, and is currently licensed as an LCDC and in good standing in that state, with no pending disciplinary actions or active sanctions against the license or LCDC, and has been in practice in the other state for the two years preceding the date the person applies for renewal. The person must pay to the department a fee in an amount equal to two times the required renewal fee for the license.(h) An LCDC whose license has expired cannot offer or provide chemical dependency counseling services as defined by the KSAs or represent himself or herself as an LCDC.(i) An LCDC who holds a master's degree or more advanced degree shall complete at least 24 hours of continuing education during each two-year licensure period. The 24 hours of education must include the specific courses required in subsection (k) of this section and, if applicable, in subsection (l) of this section.(j) An LCDC who does not meet the criteria in subsection (i) of this section must complete at least 40 hours of continuing education. The 40 hours of education must include the specific courses required in subsection (k) of this section and, if applicable, in subsection (l) of this section.(k) Continuing education hours must include at least three hours of ethics training and a total of at least six hours of training in HIV, Hepatitis C, and sexually transmitted diseases.(l) If an individual's job duties include clinical supervision, required hours of continuing education must include three hours of clinical supervision training.(m) An LCDC who teaches a qualifying continuing education course shall receive the same number of hours as students attending the course. Only one set of hours can be accrued for a single curriculum, and no more than one half of the required amount of hours of continuing education as set forth in subsections (i) and (j) of this section shall be granted for courses taught by the LCDC. Source Note: The provisions of this §562.17 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.17 LCDC License Expiration, Renewal, and Continuing Education Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223805 03/12/2026 (a) The department will accept continuing education (CE) hours that meet the criteria in this section. Hours that do not meet these criteria may be evaluated on a case-by-case basis.(b) Subject to department review, the department will accept continuing education credits approved by:(1) recognized state boards, including, but not limited to the Texas State Board of Social Work Examiners, the Texas State Board of Examiners of Marriage and Family Therapists, and the Texas State Board of Examiners of Professional Counselors;(2) the National Association of Alcohol and Drug Abuse Counselors; and(3) the Texas Certification Board for Addiction Professionals.(c) All continuing education hours must be specific to substance use disorders and their treatment, or related to chemical dependency counseling, as defined by the KSA dimensions. Related education hours may include psychology, sociology, counseling, mental health, behavioral science, psychiatric nursing, ethics, and rehabilitation counseling.(d) The department may accept continuing education hours approved by other state or federal agencies or organizations, subject to the department's review and approval.(e) The department will monitor an LCDC's compliance with continuing education requirements by the use of random audit. Licensees will be notified in writing if they have been selected for a continuing education audit. Individual supporting documents of participation in continuing education courses are not to be submitted to the department unless written notification of an audit is received informing the licensee that he or she has been randomly selected for a document audit. Upon receipt of written notification of an audit, the licensee shall submit all appropriate documentation to substantiate compliance with the continuing education and documentation requirements as set forth in this section and §140.416 of this title (relating to LCDC License Expiration, Renewal and Continuing Education Requirements).(f) Continuing education certificates must contain:(1) applicant's name and license number;(2) date the continuing education hours were completed;(3) number of hours assigned to each course;(4) course title;(5) educational provider name and, if applicable, number;(6) approving agency or entity's name; and(7) name and signature of instructor or coordinator.(g) The department will accept education hours from an accredited college or university.(1) College transcripts must contain the official seal of the college and the signature of the registrar.(2) One semester hour of college credit is equivalent to 15 continuing education hours. One quarter hour of college credit is equivalent to 10 continuing education hours.(h) Independent study or distance learning courses must be guided and monitored by the instructor and include an evaluation of performance and/or participation verification. In addition, the course must be structured so that students have access to faculty or instructors for questions and assistance in the completion of such course work. Source Note: The provisions of this §562.18 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.18 Continuing Education Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223806 03/12/2026 (a) An LCDC may request to have his or her license placed on inactive status by submitting a written request and paying the inactive status fee before the license expires. Inactive status shall not be granted unless the license is current and in good standing.(b) A person on inactive status cannot perform activities outlined in the KSA dimensions, represent himself or herself as an LCDC, or act in the capacity of a QCC. A person is subject to investigation and enforcement action during the period of inactive status.(c) Inactive status shall not exceed two years and is not renewable.(d) To return to active status, the person shall submit a written request to reactivate the license, a completed renewal application form, the renewal application fee and the license renewal fee, and documentation of 20 hours of continuing education obtained within the inactive status period. The continuing education shall include the courses described in §140.416(k) of this title (relating to LCDC License Expiration, Renewal, and Continuing Education Requirements).(e) An inactive license will automatically expire at the end of the two-year inactive period. Renewal of an expired inactive license shall be subject to the provisions set forth in §504.203 of the Act (relating to License Renewal). Source Note: The provisions of this §562.19 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.19 Inactive Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223807 03/12/2026 (a) The department may issue or renew, as applicable, a license, registration or certification to an individual convicted or placed on community supervision in any jurisdiction for a drug or alcohol offense described in §140.431 of this title (relating to Criminal History Standards) if the department determines that the applicant has successfully completed participation in an approved peer assistance program.(b) A peer assistance program shall identify, assist, and monitor participating LCDCs whose ability to perform a professional service is impaired or likely to be impaired by abuse of or dependency on drugs or alcohol, so that the individuals may return to safe practice. An LCDC who meet the standard for participation shall be referred to in this section as an "impaired professional." A peer assistance program shall offer support and assistance with a rehabilitative emphasis rather than a disciplinary emphasis.(c) To become an approved peer assistance program, a professional association shall:(1) submit an application form prescribed by the department;(2) submit a written description of the peer assistance program that includes:(A) goals and objectives, including criteria for successful completion of the peer assistance program;(B) target population;(C) the plan for ensuring services are available throughout the state;(D) how the following areas are to be addressed:(i) identification of and intervention with impaired professionals;(ii) assistance with accessing quality treatment;(iii) monitoring, support, and evaluation of participants;(iv) intervention in crises, including relapses; and(v) support during the reentry by participants to professional practice or instructional roles.(E) staffing plans, minimum staff qualifications by position, and planned staffing levels relative to numbers of participants.(F) the plan for program quality assurance and self-evaluation; and(G) the methods that will be utilized to promote and encourage use of the program.(3) meet the minimum criteria established for peer assistance programs under Texas Health and Safety Code, Chapter 467 and Chapter 451 of this title, as well as any additional criteria set forth in this section and in Texas Occupations Code, §504.057 for peer assistance programs for LCDCs. An approved peer assistance program will remain subject to and comply with these provisions once approved. In the event of direct conflict between any of the provisions, the provisions of Texas Occupations Code, §504.057 and this section shall govern.(d) A peer assistance program may seek department funding for its program by responding to a department solicitation relating to peer assistance programs established under Texas Occupations Code, §504.057. A peer assistance program must be approved by the department to be eligible to contract with the department for funding of its program. Approval of the peer assistance program shall expire on the second anniversary of the date of approval. To renew the approval status, a professional association shall submit the materials as outlined in subsection (c) of this section.(e) The peer assistance program shall comply with applicable Federal and State confidentiality laws and regulations, including, without limitation, Code of Federal Regulations, Title 42, Part 2 (relating to Confidentiality of Alcohol and Drug Abuse Patient Records) and Texas Health and Safety Code, Chapter 611 (relating to Mental Health Records).(f) The peer assistance program shall notify the department, and, if required by Texas Health and Safety Code, §467.005 (relating to Reports), the person who made the report of the impaired professional to the peer assistance program, if the impaired individual fails to participate in the applicable program as required by the department.(g) An impaired professional who is reported to a peer assistance program by the department or another third party shall, as a condition of participation in the program, give consent to the program that, at a minimum, authorizes the program to disclose the impaired person's failure to successfully complete the program to the department, and, as necessary for the peer assistance program to comply with its notification requirements, to the person who reported the impaired professional to the program.(h) The department may revoke its approval of a program established by a professional association under this chapter, after a right to a fair hearing in accordance with §§1.41, 1.51 - 1.55 of this title (relating to Fair Hearing Procedures), if the authority determines that:(1) the program does not comply with the criteria established by the department; and(2) the professional association does not bring the program into compliance within a reasonable time, as determined by the department. Source Note: The provisions of this §562.20 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.20 Peer Assistance Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223808 03/12/2026 (a) A CTI shall appoint a single training coordinator who is a qualified credentialed counselor (QCC). The CTI coordinator or a CCS shall oversee all training activities and ensure compliance with department requirements and rules relating to the training and supervision of CIs.(b) The CTI or CCS shall establish acceptance criteria for CIs. No applicant shall be accepted to a CTI or accepted for CCS supervision without:(1) documentation that the applicant is registered as a counselor intern with the department; and(2) a signed ethics agreement that is consistent with the Professional and Ethical Standards in §140.423 of this title (relating to Professional and Ethical Standards).(c) The CTI or CCS shall establish the following level system to classify counselor interns according to hours of supervised work experience:(1) Level I: 0-1,000 hours of work experience;(2) Level II: 1,001-2000 hours of work experience;(3) Level III: 2,001-4,000 hours of work experience; and(4) Graduate Status: over 4,000 hours of work experience.(d) The CTI or CCS shall have a supervision structure that includes all intern levels. The CTI or CCS shall designate each intern's level in writing and provide the intern with a copy of the documentation.(e) All counselor interns at a CTI must be under the direct supervision of a QCC as described in §140.422 of this title (relating to Direct Supervision of Interns). A CCS must directly supervise a counselor intern under the CCS's supervision, as described in §140.422 of this title.(f) The CTI or CCS shall provide each Level I, II, and III intern with reading assignments and training activities for the supervised work experience that includes material in each KSA dimension.(g) The CTI or CCS shall use the department's counselor intern evaluation forms to structure the intern's 4,000 hours of supervised work experience. The CI's supervising QCC, under the oversight and monitoring of the CTI coordinator, shall perform the CTI's responsibilities in the following paragraphs of this subsection.(1) The CCS or CTI shall set weekly objectives with the CI based on areas targeted for improvement.(2) The CCS or CTI shall provide the CI reading, computer, and/or video assignments that address areas needing improvement. The CTI or CCS shall allow the intern two hours per month to complete these assignments.(3) The CCS or CTI shall monitor the intern's progress and provide verbal and written feedback during weekly supervision meetings.(4) The intern shall complete a written KSA self-evaluation during the first 50 hours of work experience.(5) The CCS or the CTI and the intern shall complete and discuss a written KSA evaluation at the completion of each level of experience (after 1,000 hours, 2,000 hours, and 4,000 hours).(h) The CTI or CCS shall not allow a Level I, II, or III intern to accrue more than 40 hours of work experience per week.(i) A graduate intern may continue to provide chemical dependency counseling services at a registered clinical training institution or with a CCS during that individual's maximum CI registration period.(j) The CTI coordinator or CCS shall send the following documents directly to the department and provide the intern with copies within ten working days from the date the intern completes the required 4,000 hours or leaves the agency:(1) the department's supervised work experience documentation form, fully completed and signed by the CCS or the CI's supervising QCC and the CTI Coordinator; and(2) a copy of the intern's job description showing job responsibilities within the KSAs.(k) All activities counted towards the intern's supervised work experience shall be within the scope of chemical dependency counseling services as defined by the KSAs.(l) The CTI or CCS shall not approve hours for which the intern fails to substantially complete related activities and supervision assignments. Any failure to complete assignments shall be documented on the weekly supervision form.(m) The CTI or CCS shall give each CI the department's CTI and CCS Assessment Form with instructions to complete the assessment and mail it directly to the department.(n) The CTI or CCS shall use current department forms for all training and supervision documentation mandated by the department.(o) The CTI shall ensure that each CTI coordinator and supervising QCC obtains three hours of continuing education in clinical supervision every two years.(p) The CTI or CCS shall inform interns of licensure examination requirements and procedures, as well as examination schedules and information provided by the department.(q) The CTI or CCS shall ensure that interns designate their status by using "counselor intern," "intern" or "CI" when signing client record entries, and that only registered CIs use this designation.(r) The CTI or CCS shall maintain a complete file for each counselor intern for five years from the end of the CI's employment with a CTI or supervision by a CCS, as applicable, to include:(1) letter of registration;(2) ethics agreement signed by the intern;(3) copies of KSA evaluations;(4) documentation of all supervision activities;(5) documentation of intern levels and accumulated hours at each level; and(6) copy of the supervised work experience documentation form.(s) The CTI or CCS shall give the intern a copy of all information contained in the intern file when the intern completes the required supervised work experience and/or leaves the agency. Source Note: The provisions of this §562.21 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.21 Standards for the Training and Supervision of Counselor Interns https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223809 03/12/2026 (a) Direct supervision is oversight and direction of a counselor intern by a CCS, or either the CTI coordinator or the intern's supervising QCC at a CTI, which complies with the provisions in this section. Nothing in this section or subchapter shall be construed to authorize the provision of chemical dependency treatment without a license, where a license is required under Texas Health and Safety Code, Chapter 464 and Chapter 448 of this title.(b) The CCS, or the CTI coordinator and the intern's supervising QCC at a CTI, shall assume responsibility for the actions of the intern within the scope of the intern's clinical training.(c) If the intern has less than 2,000 hours of supervised work experience, the supervisor must be on site when the intern is providing services. If the intern has at least 2,000 hours of documented supervised work experience, the supervisor may be on site or immediately accessible by telephone.(d) During an intern's first 1,000 hours of supervised work experience (Level I), the CCS, or the CTI coordinator or intern's supervising QCC at a CTI, shall:(1) be on duty at the program site where the intern is working;(2) observe and document the intern performing assigned activities at least once every two weeks (or at least once every 80 hours of the CI's work schedule);(3) provide and document one hour of face-to-face individual or group supervision each week; and(4) sign off on all clinical assessments, treatment plans, and discharge summaries completed by the intern.(e) During an intern's second 1,000 hours of supervised work experience (Level II), the CCS, or the CTI coordinator or intern's supervising QCC at a CTI, shall:(1) be on duty at the program site where the intern is working;(2) observe and document the intern performing assigned activities at least once every month (or at least once every 160 hours of the CI's work schedule);(3) provide and document one hour of face-to-face individual or group supervision each week; and(4) sign off on all clinical assessments, treatment plans, and discharge summaries completed by the intern.(f) An individual who has successfully completed the licensing examination may be supervised in accordance with Level III standards set forth in subsection (g) of this section, but is still required to complete 4,000 hours of supervised work experience before achieving graduate status in the absence of a waiver under §140.408 of this title (relating to Requirements for LCDC Licensure).(g) During an intern's last 2,000 hours of required supervised work experience (Level III), the CCS, or the CTI coordinator or intern's supervising QCC at a CTI, shall:(1) be available by phone while the intern is working;(2) observe and document the intern performing assigned activities as determined necessary by the CTI coordinator or CCS;(3) provide and document one hour of face-to-face individual or group supervision each week; and(4) sign off on all clinical assessments, treatment plans, and discharge summaries completed by the intern.(h) After an intern achieves graduate status, the CCS, or the CTI coordinator or intern's supervising QCC at a CTI, shall:(1) be available by phone while the graduate intern is working;(2) provide and document one hour of face-to-face individual or group supervision each week; and(3) sign off on all clinical assessments, treatment plans, and discharge summaries completed by the graduate intern.(i) A supervisor must provide, at a minimum, an average of two hours of supervision-related activity per week per intern. Source Note: The provisions of this §562.22 adopted to be effective September 9, 2008, 33 TexReg 7520; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.22 Direct Supervision of Interns https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223810 03/12/2026 (a) A licensee shall not discriminate against any client or other person on the basis of gender, race, religion, age, national origin, disability, sexual orientation, or economic condition.(b) A licensee shall maintain objectivity, integrity, and the highest standards in providing services to the client.(c) A licensee shall:(1) in addition to complying with any other applicable reporting requirements, promptly report to the department any suspected, alleged, or substantiated incidents of abuse, neglect, or exploitation committed by oneself or another licensee under this subchapter;(2) unless otherwise prohibited by law, promptly report to the department violations of Texas Occupations Code, Chapter 504 (relating to Chemical Dependency Counselors), or rules adopted under the Act, including violations of this subchapter by oneself or another licensee;(3) recognize the limitations of the licensee's ability and shall not offer services outside the licensee's scope of practice or licensure or use techniques that exceed the person's license authorization or professional competence; and(4) make every effort to prevent the practice of chemical dependency counseling by unqualified or unauthorized persons.(d) A licensee shall not engage in the practice of chemical dependency counseling if impaired by, intoxicated by, or under the influence of chemicals, including alcohol.(e) A licensee shall uphold the law and refrain from unprofessional and unethical conduct. In so doing, the licensee shall:(1) comply with all applicable laws, regulations, and orders;(2) not make any claim, directly or by implication, that the person possesses professional qualifications, licensure, or affiliations that the person does not possess;(3) include, as applicable, their current credentials when signing all professional documents;(4) not mislead or deceive the public or any person; and(5) refrain from any act that might tend to discredit the license or profession.(f) A licensee shall:(1) report information fairly, professionally, and accurately to clients, other professionals, the department, and the general public;(2) maintain complete, accurate, and appropriate documentation of services provided;(3) not submit or cause or allow to be submitted to a client or third party payer a bill for services that were not provided or were improper, unreasonable, or medically or clinically unnecessary, with the exception of a missed appointment for which notice has been given that a charge will be assessed, and as permitted by law concerning third party billing; and(4) provide responsible and objective training and supervision to interns and subordinates under the LCDC, CCS, or CTI's supervision. This includes properly documenting supervision and work experience and providing supervisory documentation needed for licensure.(g) In any publication, a licensee shall give written credit to all persons or works that have contributed to or directly influenced the publication.(h) Licensees shall respect a client's dignity, and shall not engage in, or permit their employees or supervisees to engage in, any action that may injure the welfare of any client or person to whom the licensee is providing services. The licensee shall:(1) make every effort to provide access to treatment, including advising clients about resources and services, taking into account the financial constraints of the client;(2) remain loyal and professionally responsible to the client at all times, disclose the counselor's ethical code of standards, and inform the client of the counselor's loyalties and responsibilities;(3) not engage in any activity that could be considered a professional conflict, and shall immediately remove oneself from such a conflict if one occurs;(4) terminate any professional relationship or counseling services that are not beneficial, or are in any way detrimental to the client;(5) always act in the best interest of the client;(6) not abuse, neglect, or exploit a client;(7) not engage in a sexual, personal, or business relationship with a client or a member of the client's immediate family (including any client receiving services from the licensee's employer) for at least two years after the client's services end;(8) not request a client to divulge confidential information that is not necessary and appropriate for the services being provided;(9) not offer or provide chemical dependency counseling, supervision, or related services, nor meet with a client, in settings or locations which are inappropriate, harmful to the client or others, or which would tend to discredit the profession of chemical dependency counseling; and(10) refrain from using any method or engaging in any conduct that could be considered coercive or degrading to the client or another, including, without limitation, threats, negative labeling, or attempts to provoke shame or humiliation.(i) A licensee shall protect the privacy of all clients and shall not disclose confidential information without express written consent, except as permitted by law. The licensee shall remain knowledgeable of and obey all state and federal laws and regulations relating to confidentiality of chemical dependency treatment records, and shall:(1) inform the client, and obtain the client's consent, before tape-recording the client or allowing another person to observe or monitor the client;(2) ensure the security of client records;(3) not discuss or divulge information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes which clearly relate to the case, to the extent authorized by law;(4) avoid invasion of the privacy of the client;(5) provide the client his/her rights regarding confidentiality, in writing, as part of informing the client in any areas likely to affect the client's confidentiality; and(6) ensure the data requested from other parties is limited to information that is necessary and appropriate to the services being provided and is accessible only to appropriate parties.(j) A licensee shall inform the client about all relevant and important aspects of the professional relationship between the client and the licensee, and shall:(1) in the case of clients who are not their own consenters, inform the client's parent(s) or legal guardian(s) of circumstances that might influence the professional relationship;(2) not enter into a professional relationship with members of the counselor's family, close friends or associates, or others whose welfare might be jeopardized in any way by such relationship;(3) not establish a personal relationship with any client (including any individual receiving services from the licensee's employer) for at least two years after the client's services end;(4) neither engage in any type or form of romantic or sexual behavior with a client (including any individual receiving services from the licensee's employer) for at least two years after the client's services end nor accept as a client anyone with whom they have engaged in romantic or sexual behavior; and(5) not exploit relationships with clients for personal gain.(k) A licensee shall treat other professionals with respect, courtesy, and fairness, and shall:(1) refrain from providing or offering professional services to a client who is receiving chemical dependency treatment and/or counseling services from another professional, except with the knowledge of the other professional and the consent of the client, until treatment and/or counseling services with the other professional ends;(2) cooperate with the department, professional peer review groups or programs, and professional ethics committees or associations, and promptly supply all requested or relevant information, unless prohibited by law; and(3) ensure that the person's actions in no way exploit relationships with supervisees, employees, students, research participants or volunteers.(l) Prior to providing treatment and/or counseling or substance abuse services, a licensee shall inform the client of the licensee's fee schedule and establish financial arrangements with a client. The counselor shall not:(1) charge exorbitant or unreasonable fees for any service;(2) pay or receive any commission, consideration, or benefit of any kind related to the referral of a client for services;(3) use the client relationship for the purpose of personal gain, or profit, except for the normal, usual charge for services provided; or(4) accept a private professional fee or any gift or gratuity from a client if the client's services are paid for by another funding source, or if the client is receiving treatment from a facility where the licensee provides services (unless all parties agree to the arrangement in writing). Source Note: The provisions of this §562.23 adopted to be effective September 9, 2008, 33 TexReg 7520; ; amended to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.23 Professional and Ethical Standards for all License Holders https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223811 03/12/2026 (a) This subsection applies to counseling records of an LCDC's private practice. Documentation of professional services rendered in another setting shall be created and maintained in accordance with any legal requirements for documentation applicable to the particular setting in which they were provided.(1) The counselor shall establish and maintain a record for every client at the time of initial service delivery. The client record shall include:(A) client identifying information;(B) assessment results, including a statement of the client's problems and/or diagnosis;(C) plan of care;(D) documentation of all services provided, including date, duration, and method of delivery; and(E) a description of the client's status at the time services are discontinued.(2) The counselor shall maintain a record of all charges billed and all payments received.(3) All entries shall be permanent, legible, accurate, and completed in a timely manner.(4) All documents and entries shall be dated and authenticated. Authentication of electronic records shall be by a digital authentication key.(5) When it is necessary to correct a record, the error shall be marked through with a single line, dated, and initialed by the counselor.(6) The counselor shall protect all client records and other client-identifying information from destruction, loss, tampering, and unauthorized access, use or disclosure. Electronic client information shall be protected to the same degree as paper records and in accordance with applicable law and accepted security standards for electronic health records prevailing at the time, and shall have a reliable backup system.(7) The counselor shall comply with all applicable state and federal laws relating to confidentiality, including the requirements of Texas Health and Safety Code, Chapter 611 (relating to Mental Health Records) and Code of Federal Regulations, Title 42, Part 2 (relating to Confidentiality of Alcohol and Drug Abuse Patient Records).(8) The counselor shall not deny clients access to the content of their records except as provided by law, including Texas Health and Safety Code, §611.0045 (relating to Right to Mental Health Record).(9) Client records shall be kept for at least five years. Records of adolescent clients shall be kept for at least five years after the client becomes eighteen years of age.(b) This subsection applies to an LCDC in private practice using the internet or telephone to provide chemical dependency counseling services.(1) The counselor must reside in and perform the services from Texas.(2) The department maintains its authority to regulate the counselor regardless of the location of the client.(3) The counselor is subject to the applicable laws of other states and countries where the client may reside or receive services by electronic means, including any laws limiting the counselor's practice.(4) The counselor's provision of services by electronic medium must comply with applicable law and accepted security standards at the time, including, as applicable, Code of Federal Regulations, Title 42, Part 2 (relating to Confidentiality of Alcohol and Drug Abuse Patient Records), Texas Health and Safety Code, Chapter 611 (relating to Mental Health Records), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P.L. 104-191), and Health Information Technology for Economic and Clinical Health Act (HITECH Act), Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-5 (Feb. 17, 2009), and their implementing regulations, including 45 Code of Federal Regulations Parts 160 (relating to General Administrative Requirements), 164 (relating to Security and Privacy), and 170 (Health Information Technology Standards, Implementation Specifications, And Certification Criteria And Certification Programs For Health Information Technology).(5) The counselor must be able to verify the identification of the client and ensure the client's appropriate age.(6) If a counselor uses the Internet as the electronic means by which counseling is provided or transfers client or other protected health information through the Internet, the counselor must comply with the following:(A) counseling, client, and other protected health information may only be transferred using encryption that meets or exceeds the Security Standards for the Protection of Electronic Protected Health Information under 45 Code of Federal Regulations Part 164, Subpart C, that are in effect at the time;(B) e-mail communication containing counseling, client, and/or other protected health information is subject to the restrictions set forth in subparagraph (A) of this paragraph; and(C) the counselor must provide technical backup for system problems by providing a phone number to the client to call for technical support and a contingency plan for the client when a technical problem occurs.(7) The counselor must provide services that utilize audio or video in real time.(8) The counselor must provide a description of all services offered to the client in writing and describe who is appropriate for the services. The description must include:(A) a grievance procedure and provide a link to department information for filing a complaint when using the Internet and the toll-free number for the department when counseling by telephone;(B) the counselor's credentials, education level, and training;(C) a link to the licensure verification page when using the Internet and the toll-free number for the department when counseling by telephone;(D) the difference between electronic counseling and traditional counseling; and(E) the potential risk regarding clinical issues, security and confidentiality.(9) Services may only be offered by licensed chemical dependency counselors.(10) The counselor must provide an emergency contact person and phone number and emergency procedures to the client in writing. Source Note: The provisions of this §562.24 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.24 Standards for Private Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223812 03/12/2026 (a) The provisions of this section shall apply to complaints against a licensee under this subchapter, notwithstanding the provisions of §442.102 of this title (relating to Complaints and Investigations).(b) A person wishing to report an alleged violation of the Act or this subchapter may file a complaint with the department. All complaints shall be in writing and under oath.(c) Upon receipt of a complaint, the department will send an acknowledgment letter to the complainant, together with the department's policies and procedures pertaining to complaint investigation and resolution. The department may accept an anonymous complaint if there is sufficient information for the investigation.(d) The department will document, evaluate, prioritize, and investigate complaints based on the seriousness of the alleged violation and the level of client or participant risk, and will make any report to another agency required by law.(e) Prior to or during an investigation, the department will request a response from the licensee or person against whom a complaint has been filed, and provide the department's policies and procedures pertaining to complaint investigation and resolution. The licensee or person against whom an alleged violation has been filed shall respond within 15 working days of receipt of the department's request.(f) Pursuant to a department investigation regarding an alleged violation of the Act or this subchapter, a licensee shall produce records, documents and other evidence related to the license, registration, or approval to the department, upon request, unless otherwise prohibited by law. A licensee shall not interfere with the department's access to clients, witnesses or other parties.(g) If it is determined that the matters alleged in the complaint are non-jurisdictional, or if the matters alleged in the complaint would not constitute a violation of the Act or this subchapter, the department may close the complaint and give written notice of the closure to the person against whom the complaint was filed and the complainant.(h) The department may refer complaints outside its jurisdiction, or also within the jurisdiction of another licensing program within the department or of another agency, to the appropriate program or agency for action, as permitted by law.(i) The department, at least quarterly and until final disposition of the complaint, shall notify the person filing the complaint and each person against whom the complaint was made of the status of the complaint, unless the notice would jeopardize an undercover investigation. Source Note: The provisions of this §562.25 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.25 Complaint and Investigation Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223813 03/12/2026 (a) The provisions of this section shall apply to all types of licensees under this subchapter, notwithstanding the provisions of §442.103 of this title (relating to Procedure for Contested Cases for Counselor and Facility Licenses), and shall not limit the authority of the department to take any other action against a license, registration, or certification, or the holder of, or applicant for, a license, registration, or certification, under §140.431 of this title (relating to Criminal History Standards), or as otherwise authorized by applicable statute or rule.(b) The department may take action as authorized under subsection (c) of this section if an applicant for, or holder of, a license, registration, or certification issued under this subchapter: (1) violates or assists another to violate the Act, a rule under this subchapter, or an Order issued under the Act or this subchapter's rules;(2) circumvents or attempts to circumvent the Act or a rule under this subchapter;(3) directly or indirectly participates in a plan to evade the Act or a rule under this subchapter;(4) has a license to practice chemical dependency counseling in another jurisdiction refused, suspended, or revoked for a reason that the department determines would constitute a violation of the Act or a rule under this subchapter;(5) engages in false, misleading, or deceptive conduct as defined by Business and Commerce Code, §17.46;(6) engages in conduct that discredits or tends to discredit the profession of chemical dependency counseling;(7) directly or indirectly reveals a confidential communication made to the person by a client or recipient of services, except as required or permitted by law;(8) refuses to perform an act or service the person is licensed to perform under this subchapter on the basis of the client's or recipient's age, sex, race, religion, national origin, color, or political affiliation; or(9) commits an act for which liability exists under Civil Practice and Remedies Code, Chapter 81 (Relating to Sexual Exploitation By Mental Health Services Provider).(c) Where grounds exist to take action against a person, against a license, certification, or registration issued under this subchapter, or against an applicant or holder of a license, certification, or registration issued under this subchapter, the department may:(1) deny, refuse to issue, or refuse to renew a license, certification, or registration;(2) revoke or suspend a license, certification, or registration;(3) probate a suspension of a license, certification, or registration;(4) impose an administrative penalty against a person who violates the Act or a rule under this subchapter; or(5) issue a reprimand against the applicable license holder.(d) The department will determine the length of the probation or suspension. If the department probates the suspension of a license, certification, or registration, the department may require the holder of the applicable license to:(1) report regularly to the department on matters that are the basis of the probation;(2) limit practice to the areas prescribed by the department; or(3) complete additional educational requirements, as required by the department to address the areas of concern that are the basis of the probation.(e) An individual whose license, registration, or certification is revoked under this subchapter is not eligible to apply for a license, registration, or certification under this subchapter for a minimum of two years after the date of revocation. The department may consider the findings that resulted in revocation and any other relevant facts in determining whether to deny the application under this section, or as otherwise permitted by law, if an otherwise complete and sufficient application for a license, registration, or certification is submitted after two years have elapsed since revocation.(f) A voluntary surrender accepted by the department in response to a complaint under §140.429 of this title (relating to Voluntary Surrender of License, Certification, or Registration In Response to a Complaint) shall be deemed to be the result of a formal disciplinary action as provided for in that section.(g) The department, upon determination that grounds may exist to take disciplinary action, shall issue a notice of violation notifying the respondent of the proposed action.(1) The notice letter shall be sent via regular first-class and certified mail to the respondent's address of record.(2) The notice shall specify:(A) the statutes, rules, or orders allegedly violated;(B) the factual basis of the alleged violations;(C) the disciplinary action the department intends to take; and(D) notice of an opportunity for a hearing to be held under the Administrative Procedure Act, Texas Government Code, Chapter 2001.(3) If the department is proposing to assess an administrative penalty, the letter shall also inform the respondent of the amount of the proposed penalty and of the opportunity for a hearing on the occurrence of the violation, the amount of the penalty, or both.(4) The letter shall also include the following notices:(A) If the respondent does not request a hearing on or before the 20th day after notice is effective, the allegations will be deemed true and the department will issue a default final order implementing the proposed action.(B) Notice is effective three days after the date of mailing.(h) A respondent must submit a timely written request for a hearing to avoid having the allegations in the notice letter deemed true and a default order implementing the proposed action issued by the department. The request for hearing is timely if filed with the department or postmarked on or before the 20th day after the notice is effective. If the respondent fails to timely file a request for a hearing, the factual allegations of the notice letter may be deemed true and shall form the basis of a default final order by the department making findings of fact and conclusions of law consistent with the notice of violation, and implementing the proposed action.(i) The department shall implement a final order to suspend a license issued under this subchapter for failure to pay child support as provided by the Texas Family Code, Chapter 232. Source Note: The provisions of this §562.26 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.26 Disciplinary Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223814 03/12/2026 (a) The provisions of this section shall apply to administrative penalties proposed or assessed against any person for violation of the Act or a rule under this subchapter, notwithstanding the provisions of §442.104 of this title (relating to Administrative Penalties for Licensed Facilities and Counselors and Offender Education Programs).(b) The amount of an administrative penalty shall be based on the following criteria:(1) the seriousness of the violation;(2) the history of previous violations;(3) the amount necessary to deter a future violation;(4) efforts made to correct the violation; and(5) any other matter that justice requires.(c) The seriousness of a violation shall be categorized by one of the following severity levels:(1) Level I--violations in which harm or other adverse impact to public health, safety, or welfare has actually occurred or is likely to occur and/or recur;(2) Level II--violations that demonstrate a potential for harm or other adverse impact to public health, safety, or welfare; or(3) Level III--violations that are not likely to substantially affect public health, safety, or welfare.(d) The range of administrative penalties by severity levels is as follows for each violation:(1) Level I--up to $1000 per day;(2) Level II--up to $500 per day; or(3) Level III--up to $100 per day.(e) Subsequent violations of the same or similar nature in the same severity level for which an administrative penalty has previously been imposed may be categorized at the next higher severity level, based upon the repeated violation. Subsequent Level I violations of the same or similar nature for which an administrative penalty has previously been imposed at the Level I severity level may be assessed a higher penalty within that severity level, up to $1,000 per day per violation, based upon the repeated violation. Source Note: The provisions of this §562.27 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.27 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223815 03/12/2026 (a) At any stage of a disciplinary case, informal disposition of a complaint or contested case involving an applicant or licensee may be made through an informal conference held to determine whether the matters in controversy can be resolved without further proceedings, including by agreed order.(b) In any case where a notice of violation has been issued proposing disciplinary action against an applicant or licensee, that person will be given the opportunity to attend an informal conference to show compliance with the law, pursuant to Texas Government Code §2001.054 (relating to Licenses), prior to a requested hearing. If the applicant or licensee fails to appear at a scheduled informal conference, the department may deem that person to have waived the right to an informal conference and may proceed to hearing.(c) An informal conference shall be voluntary for the applicant or licensee and shall not be a prerequisite to a formal hearing.(d) The conference shall be informal and shall not follow the procedures established in this subchapter for contested cases and formal hearings.(e) The department will establish the time, date and place of the informal conference, and provide written notice to the licensee or applicant. Written notice will be provided no less than 10 business days prior to the date of the informal conference at the last known address of the licensee or applicant.(f) The applicant or licensee may be represented by legal counsel at the informal conference. The department's legal counsel and appropriate staff will be present at the conference.(g) At the conclusion of the informal conference, the department may propose an informal disposition of the complaint or contested case. The proposal may include proposed entry of an agreed order imposing any disciplinary action authorized by the Act or this subchapter. The department may also conclude that the department lacks jurisdiction; that the matter should be referred for further investigation; that the complaint should be closed without action; or that the department will proceed to a contested case hearing on the proposed action, if one has been requested by the applicant or licensee, in accordance with §140.430 of this title (relating to Procedures for Contested Cases).(h) The licensee or applicant may either accept or reject the department's proposal at the informal conference. If the recommendations are accepted, a proposed agreed order will be forwarded to the licensee or applicant, or that person's attorney. The order will include any agreed findings of fact and conclusions of law. If the licensee or applicant fails to return the signed order within 20 days of receipt of the proposed order, or within another time frame specified or agreed to by the department, the department's proposed order will be deemed withdrawn and the department may proceed to a contested case hearing on the action originally proposed, if the applicant or licensee has requested one, or otherwise proceed with appropriate action against the applicant or licensee. The licensee or applicant will be deemed to have received the proposed agreed order three days after mailing. Source Note: The provisions of this §562.28 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.28 Informal Disposition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223816 03/12/2026 (a) When a licensee has offered the surrender of that person's license in response to a complaint, the department will consider whether to accept the surrender of the license. A licensee will be deemed to have offered the surrender of that person's license in response to a complaint when the surrender is offered after the licensee has received notice that a complaint has been received by the department. A licensee will be deemed to have received notice that a complaint has been received by the department three days after a letter notifying the licensee is mailed by the department.(b) Surrender of a license without the department's acceptance thereof shall not deprive the department of jurisdiction under the Act, this subchapter, or other applicable law.(c) When the department accepts the surrender of a license offered in response to a complaint, the license surrender is deemed to be the result of a formal disciplinary action and an order shall be prepared accepting the license surrender on that basis.(d) If the department accepts the surrender of a license offered in response to a complaint, the person is not eligible to apply for a license, registration, or certification under this subchapter for a minimum of two years after the date of acceptance of the surrender. Source Note: The provisions of this §562.29 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.29 Voluntary Surrender of License, Certification, or Registration In Response to a Complaint https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223817 03/12/2026 (a) The provisions of this section shall apply to licensees under this subchapter, notwithstanding the provisions of §442.103 of this title (relating to Procedure for Contested Cases for Counselor and Facility Licenses).(b) Where the department has issued a notice of violation that has not been resolved by informal disposition and the respondent has timely requested a hearing, the department will proceed to a hearing under the APA, Texas Government Code, Chapter 2001; SOAH Rules of Procedure, 1 Texas Administrative Code, Chapter 155; and formal hearing procedures set forth at §§1.21, 1.23, 1.25, and 1.27 of this title.(c) The department will provide written notice of the hearing to the respondent by first class mail and certified mail, return receipt requested, at respondent's last known address as reflected in the department's address of record for the respondent. A Notice of Hearing that complies with the requirements of Texas Government Code, §2001.051 and §2001.052 (relating to Opportunity for Hearing and Participation; Notice of Hearing and Contents of Notice), and 1 Texas Administrative Code §155.401 (relating to Notice of Hearing), will be provided at least ten days before the date of the hearing. Respondent's receipt of the Notice of Hearing at least ten days before the date of the hearing will be presumed if the department mailed the Notice of Hearing at least ten days before the date of the hearing, and allowed an additional three days for mailing.(d) If the respondent fails to appear at a scheduled SOAH hearing after being given proper notice of the hearing at respondent's last known address as reflected in the department's address of record for the respondent, the department may move for dismissal of the case from the SOAH docket, without prejudice, to allow for informal disposition of the case by default order, as provided for in §1.25 of this title (relating to Default). Based upon the respondent's failure to appear after proper notice of the hearing, the factual allegations of the notice letter may be deemed true and shall form the basis of a final default order by the department making findings of fact and conclusions of law consistent with the notice of violation, and implementing the proposed action.(e) If a respondent makes a written request to the department for a transcript of a SOAH proceeding, the department will assess the cost of the transcript to that respondent. If there were multiple respondents to the proceeding, the department will assess the cost proportionally among those respondents requesting a transcript. Where a respondent appeals a final department decision in a contested case, the respondent shall pay the cost of preparation of the original or a certified copy of the record that is required to be sent to the reviewing court, and such charge may be assessed against respondent by the court in accordance with the Texas Rules of Civil Procedure as a court cost. Source Note: The provisions of this §562.30 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.30 Procedures for Contested Cases https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223818 03/12/2026 (a) The department reviews the criminal history of each applicant for initial licensure, certification, and registration. Reviews are also conducted when the department receives information that a licensee has been charged, indicted, placed on deferred adjudication, community supervision, or probation, or convicted of an offense described in subsection (d) of this section.(b) An applicant shall disclose and provide complete information about all misdemeanor and felony charges, indictments, deferred adjudications, episodes of community supervision or probation, and convictions. Failure to make full and accurate disclosure may be grounds for application denial or disciplinary action, including revocation, against the applicant for, or holder of, a license, registration, or certification.(c) The department obtains criminal history information from the Texas Department of Public Safety, including information from the Federal Bureau of Investigations (FBI).(d) For purposes of this section, the department has identified the following offenses as offenses directly related to the duties and responsibilities of the licenses, certifications, and registrations issued under this subchapter, and has categorized them according to the seriousness of the offense. The provisions of this section shall not limit the authority of the department to take any other action against a license, registration, or certification, or the holder of, or applicant for, a license, registration, or certification, as otherwise authorized by applicable statute or rule.(1) Category X includes:(A) capital offenses;(B) sexual offenses involving a child victim;(C) felony sexual offenses involving an adult victim who is a client (one or more counts);(D) multiple counts of felony sexual offenses involving any adult victim; and(E) homicide 1st degree.(2) Category I includes:(A) kidnapping;(B) arson;(C) homicide lesser degrees;(D) felony sexual offenses involving an adult victim who is not a client (single count); and(E) attempting to commit crimes in Category I or X.(3) Category II includes felony offenses that are not listed separately in this section and that result in actual or potential physical harm to others and/or animals.(4) Category III includes:(A) class A misdemeanor alcohol and drug offenses;(B) class A misdemeanor offenses resulting in actual or potential physical harm to others or animals;(C) felony alcohol and drug offenses; and(D) all other felony offenses not listed separately in this section.(5) Category IV includes:(A) class B misdemeanor alcohol and drug offenses; and(B) class B misdemeanor offenses resulting in actual or potential physical harm to others or animals.(e) Except as provided in subsection (j) of this section, the department shall deny the initial or renewal licensure, certification, or registration application of a person who has been convicted or placed on community supervision in any jurisdiction for a:(1) category X offense during the person's lifetime;(2) category I offense during the 15 years preceding the date of application;(3) category II offense during the ten years preceding the date of application;(4) category III offense during the five years preceding the date of application, unless, at the time of application, proceedings have been dismissed and the person has been discharged after having been placed on and completing community supervision following a deferred adjudication; or(5) category IV offense during the three years preceding the date of application.(f) The department shall deny the initial or renewal license, certification, or registration application of a person who has been found to be incapacitated by a court on the basis of a mental defect or disease.(g) When a person's application is denied under subsection (e) or (f) of this section, the person may reapply when:(1) the person receives a full pardon based on the person's wrongful conviction;(2) the timeframes established in subsection (e) of this section have been met; or(3) the person who had been found to be incapacitated is found to be no longer incapacitated, in which case the provisions of this section applicable to the status of the charge and prosecution at that time will apply.(h) The department shall suspend a license, certification, or registration if the department receives written notice from the Texas Department of Public Safety or another law enforcement agency that the individual has been charged, indicted, placed on deferred adjudication, community supervision, or probation, or convicted of an offense described in subsections (d) and (e) of this section. The licensee will remain subject to applicable renewal requirements during the period of suspension. An application to renew any form of license suspended under this subsection will be subject to the denial and exception provisions as stated in subsection (e) of this section, to the extent applicable at the time of renewal application. If subsection (e) of this section does not apply, the applicant is otherwise eligible for renewal, and the applicant is still subject to summary suspension under this subsection, the applicable license will remain suspended under this subsection upon renewal, and until paragraph (2) of this subsection or subsection (e) of this section becomes applicable.(1) The department shall send notice stating the grounds for summary suspension by certified mail to the license, certification, or registration holder at the address listed in the department's records. The suspension is effective three days after the date of mailing.(2) If no other bar to licensure, certification, or registration exists at the time, the department will restore the person's license, certification, or registration upon receipt of official documentation that the charges have been dismissed or the person has been acquitted, except that, where the dismissal follows a deferred adjudication, the time frames set forth in subsection (e) of this section will apply.(i) The department will defer action on the application of a person who has been charged or indicted for an offense described in subsection (d) of this section. If the person is convicted or placed on community supervision for the offense, subsection (e) of this section will apply. If the charges are dismissed or the person is acquitted, the application will be processed without adverse action under this section on the basis of those charges. However, the department may consider the facts and evidence underlying the charge in determining whether adverse action against the applicant might be warranted under §140.426 of this title (relating to Disciplinary Actions).(j) Notwithstanding subsection (e) of this section, if no other bar to the applicable licensure or renewal exists at the time, the department may issue or renew, as applicable, an LCDC license, registration, or certification of a person convicted or placed on community supervision in any jurisdiction, within the timeframes set forth in subsection (e) of this section, for a drug or alcohol offense described in subsection (d) of this section, if the department determines that the individual has successfully completed participation in a peer assistance program approved by the department.(1) When an individual described in subsection (j) of this section successfully reaches the re-entry phase of a peer assistance program, the department may grant a temporary "re-entry approval," with a limited term and any appropriate conditions, set in conjunction with the peer assistance program, based upon the applicant's needs and the anticipated length of the re-entry phase of the peer assistance program for the applicant.(2) At the end of the term of the re-entry approval, the department may extend the term if the applicant is still successfully participating in the re-entry phase of the peer assistance program, may grant the applicable initial or renewal license, registration, or certification, or renew the LCDC license if the department determines that the applicable individual has successfully completed the peer assistance program, or shall deny the license under subsection (e) of this section, if the LCDC has failed to successfully complete the peer assistance program.(k) A person whose license, certification, or registration has been denied or suspended under this section may only appeal the action if:(1) the person was convicted or placed on community supervision; and(2) the appeal is based on the grounds that the timeframes defined in subsection (e) of this section have been met. Source Note: The provisions of this §562.31 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.31 Criminal History Standards https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223819 03/12/2026 (a) In accordance with Occupations Code, §53.102, a person may request the department to issue a criminal history evaluation letter regarding the person's eligibility for a license if the person:(1) is enrolled or planning to enroll in an educational program that prepares a person for an initial license or is planning to take an examination for an initial license; and(2) has reason to believe that the person is ineligible for the license due to a conviction or deferred adjudication for a felony or misdemeanor offense.(b) A person making a request for issuance of a criminal history evaluation letter shall submit the request on a form prescribed by the department, accompanied by the criminal history evaluation letter fee and the required supporting documentation, as described on the form. The request shall state the basis for the person's potential ineligibility.(c) The department has the same authority to investigate a request submitted under this section and the requestor's eligibility that the department has to investigate a person applying for a license.(d) If the department determines that a ground for ineligibility does not exist, the department shall notify the requestor in writing of the determination. The notice shall be issued not later than the 90th day after the date the department received the request form, the criminal history evaluation letter fee, and any supporting documentation as described in the request form.(e) If the department determines that the requestor is ineligible for a license, the department shall issue a letter setting out each basis for potential ineligibility and the department's determination as to eligibility. The letter shall be issued not later than the 90th day after the date the department received the request form, the criminal history evaluation letter fee, and any supporting documentation as described in the request form. In the absence of new evidence known to but not disclosed by the requestor or not reasonably available to the department at the time the letter is issued, the department's ruling on the request determines the requestor's eligibility with respect to the grounds for potential ineligibility set out in the letter. Source Note: The provisions of this §562.32 adopted to be effective August 9, 2012, 37 TexReg 5788; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.32 Request for Criminal History Evaluation Letter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223820 03/12/2026 (a) This section sets out licensing procedures applicable to military service members, military spouses, and military veterans, pursuant to Texas Occupations Code Chapter 55 and does not modify or alter rights that may be provided under federal law. For purposes of this section:(1) "Active duty" means current full-time military service in the armed forces of the United States or active duty military service as a member of the Texas military forces, as defined by Texas Government Code §437.001, or similar military service of another state.(2) "Alternative licensing" means the process under the Texas Health and Human Services Commission (HHSC) rule at 1 Texas Administrative Code (TAC) §351.6 (relating to Alternative Licensing for Military Service Members, Military Spouses, and Military Veterans) by which HHSC may issue a license to a military service member, military spouse, or military veteran who is currently licensed in good standing with another jurisdiction or has held the same license in Texas within the preceding five years.(3) "Armed forces of the United States" means the Army, Navy, Air Force, Space Force, Coast Guard, or Marine Corps of the United States or a reserve unit of one of those branches of the armed forces.(4) "License" means a license, certificate, registration, permit, or other form of authorization required by law or an HHSC rule to practice as a licensed chemical dependency counselor (LCDC), certified clinical supervisor, or counselor intern (CI).(5) "Military service member" means a person who is on active duty.(6) "Military spouse" means a person who is married to a military service member.(7) "Military veteran" means a person who has served on active duty and who was discharged or released from active duty.(8) "Verification letter" means a verification letter issued in accordance with 1 TAC §351.3 (relating to Recognition of Out-of-State License of Military Service Members and Military Spouses). (b) A military service member, military spouse, or military veteran may apply for alternative licensing in accordance with 1 TAC §351.6 if the applicant:(1) has an active license issued by another jurisdiction with licensing requirements substantially equivalent to the requirements for a license under this subchapter and seeks a license as an LCDC or to register as a CI in Texas; or(2) held the same license in Texas within the five years preceding the application date.(c) A military service member, military spouse, or military veteran who does not comply with or qualify for alternative licensing or practicing under another jurisdiction's license must seek a license under the standard processes of this subchapter.(d) A military service member or military spouse currently licensed by another jurisdiction with licensing requirements substantially equivalent to the requirements for a license under this subchapter, may work in Texas under that jurisdiction's license if the applicant complies with the requirements of 1 TAC §351.3 (relating to Recognition of Out-of-State License of Military Service Members and Military Spouses), including obtaining a verification letter.(e) For license renewal under this subchapter, HHSC will exempt an individual currently licensed under this subchapter from any increased fee or other penalty for failing to renew the license in a timely manner because the individual was serving as a military service member. The individual must establish the reason for timely renewal failure to HHSC's satisfaction.(f) A military service member who holds a license under this subchapter is entitled to two years of additional time beyond the expiration date of the license to complete:(1) any continuing education requirements; and(2) any other requirement related to the renewal of the military service member's license.(g) When a verified military service member or military veteran submits an application for a license under this subchapter, the applicant will receive credit towards any licensing or internship requirements, except an examination requirement, for verified military service, training, or education that HHSC determines relevant, as applicable, to the occupation or licensing requirements, unless the applicant holds a restricted license issued by another jurisdiction or has a criminal history for which adverse licensure action is authorized by law.(h) HHSC's authority to require an applicant to undergo a criminal history background check, and the timeframes associated with that process, are not affected by the provisions of this section. Source Note: The provisions of this §562.33 adopted to be effective November 29, 2024, 49 TexReg 9240; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.33 Licensing, Certification, or Registration of Military Service Members, Military Spouses, and Military Veterans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223821 03/12/2026 (a) An individual who holds a license as an LCDC does not have a license required under Family Code, §107.104(b)(1) (relating to Child Custody Evaluator: Minimum Qualifications) or under Family Code, §107.154(b)(1) (relating to Adoption Evaluator: Minimum Qualifications), to qualify the LCDC under those subsections, as a licensee, to conduct a child custody or adoption evaluation. An LCDC is prohibited from conducting a child custody evaluation under Family Code, Chapter 107, Subchapter D (relating to Child Custody Evaluation), and as defined therein, except as described in subsection (b) of this section, and from conducting an adoption evaluation under Family Code, Chapter 107, Subchapter E (relating to Adoption Evaluation), and as defined therein, except as described in subsection (b) of this section.(b) An individual who holds a license as an LCDC may conduct a child custody evaluation under Family Code, Chapter 107, Subchapter D, or an adoption evaluation under Family Code, Chapter 107, Subchapter E, §§107.151-107.163, only if the individual is acting consistent with the applicable Subchapter and subsection (a) of this section, and is:(1) otherwise qualified by law to conduct such an evaluation; or(2) appointed by a court to conduct the evaluation under Family Code, §107.106 (relating to Exception to Qualifications Required to Conduct Child Custody Evaluation) or under Family Code, §107.155 (relating to Exception to Qualifications Required to Conduct Adoption Evaluation). Source Note: The provisions of this §562.34 adopted to be effective February 2, 2017, 42 TexReg 314; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.34 Prohibition related to Child Custody and Adoption Evaluations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223822 03/12/2026 A licensed chemical dependency counselor shall not discriminate based on a client's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §562.35 adopted to be effective January 6, 2022, 46 TexReg 9307; transferred effective January 31, 2025, as published in the January 10, 2025, issue of the Texas Register, 50 TexReg 431. 1 HEALTH AND HUMAN SERVICES COMMISSION 562 LICENSED CHEMICAL DEPENDENCY COUNSELORS §562.35 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221939 03/12/2026 The purpose of the sections in this chapter is to provide assurance that facilities holding an approved narcotic drug permit are regulated under a set of minimum standards for the establishment and operation of a narcotic treatment program pursuant to Texas Health and Safety Code, Chapter 466. Each facility shall be approved and monitored by the department at 1100 West 49th Street, Austin, Texas 78756. Source Note: The provisions of this §563.141 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.141 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221940 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221940 03/12/2026 The following words and terms, when used in the sections of this chapter, shall have the following meanings, unless the context clearly indicates otherwise.(1) Administer--The direct application of a prescription drug by ingestion or any other means to the body of a patient by: a licensed practitioner, an agent of the practitioner, supervised by and under the order of the practitioner; or, the patient, at the direction of or in the presence of a practitioner.(2) Agent--A pharmacist, registered nurse, licensed practical/vocational nurse, physician's assistant, or any other health care professional authorized by federal and state law to administer or dispense narcotic drugs.(3) Approved narcotic drug--A drug approved by the United States Food and Drug Administration for maintenance and/or detoxification of a person physiologically addicted to opiate class of drugs.(4) Approved narcotic drug permit--A permit issued by the department to an applicant to operate a Narcotic Treatment Program (NTP) which provides an approved narcotic drug for maintenance and/or detoxification and rehabilitative services to opioid addicted individuals.(5) Approved to treat (ATT)--The maximum number of patients the NTP is allowed to treat at any point in time under the approved permit. This number is based on a maximum of 50 patients for each counselor employed by the program.(6) Formal hearing procedures--The formal hearing procedures of the department in §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearing Procedures) for conducting hearings on denial of application, suspension, or revocation of permit.(7) Central Registry--A process in which an NTP shall share patient identifying information about individuals who are applying for or undergoing detoxification or maintenance treatment on an approved narcotic drug to a central record system at the department.(8) Chemical dependency counseling--Face-to-face interactions between patients and counselors to help patients identify, understand, and resolve issues and problems related to chemical dependency.(9) Chemical dependency counselor--A qualified credentialed counselor, as defined in Title 40, Texas Administrative Code (TAC), Chapter 150, or, counselor intern working under direct supervision of a licensed counselor or physician.(10) Counselor intern (CI)--A person pursuing a course of training in chemical dependency counseling as defined in 40 TAC, Chapter 150.(11) Department--The Department of State Health Services.(12) DEA--Drug Enforcement Administration.(13) Dispense--Preparing, packaging, compounding, or labeling for delivery a prescription drug in the course of professional practice to an ultimate user by or pursuant to the lawful order of a practitioner.(14) FDA--Food and Drug Administration.(15) Fee certificate--A document issued annually by the department after payment by the narcotic treatment program of the required fee based on the number of patients approved to treat.(16) Hospital--A health care facility licensed by the department as a general hospital or a special hospital under the Health and Safety Code, Chapter 241; or a health care facility licensed as a private mental hospital under Health and Safety Code, Chapter 577; or a hospital directly operated under the authority of other statutes of the state.(17) Medical director--A physician, licensed to practice medicine in the jurisdiction in which the program is located, who assumes responsibility for the administration of all medical services performed by the NTP, including ensuring that the program is in compliance with all federal, state, and local laws and regulations regarding the medical treatment of narcotic addiction with a narcotic drug.(18) Medication unit--A facility established as part of, but geographically dispersed (i.e., separate) from a narcotic treatment program from which licensed private practitioners and community pharmacists are permitted to administer and dispense a narcotic drug, and are authorized to collect samples for drug testing or analysis for narcotic drugs.(19) Narcotic drug--A drug as defined in Texas Controlled Substances Act, Health and Safety Code, §481.002(29)(A)-(D) and Title 42, Code of Federal Regulations (CFR), Part 8.(20) Narcotic treatment program (NTP)--An organization which has been issued an approved narcotic drug permit by the department and the permit has not been suspended, revoked, or surrendered to the department.(21) Person--An individual, corporation, organization, government or governmental subdivision, agency, business trust, partnership, association, or any other legal entity.(22) Practitioner--As defined in Health and Safety Code, Chapter 481.(23) Program director--An individual who provides overall administrative management to the NTP under guidelines established by the permit holder and the medical director.(24) Program physician--A licensed physician who will provide medical treatment and counsel to the patients of an NTP under the supervision of the medical director.(25) Program sponsor--A person named in the application for an NTP permit who is responsible for the operation of the narcotic treatment program and who assumes responsibility for all its employees, including any practitioners, agents, or other persons providing medical, rehabilitative, or counseling services at the program or any of its medication units. The program sponsor need not be a licensed physician but shall employ a licensed physician for the position of medical director.(26) Standing orders--Written instructions prepared by a licensed physician pursuant to the rules of the Texas State Board of Medical Examiners relating to standing delegation orders, as described in 22 TAC §§193.1-193.6, and shall be approved by the State Methadone Authority (SMA).(27) State Methadone Authority (SMA)--The department, Drugs and Medical Devices Division.(28) Status Report--A bi-annual report submitted by the permit holder on a form provided by the department. The content of the report is determined by the department.(29) SAMHSA--Substance Abuse and Mental Health Services Administration. Source Note: The provisions of this §563.142 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.142 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221941 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221941 03/12/2026 (a) Organization types. A narcotic treatment program (NTP) may be organized as an independent single program or may be a part of a centralized organization. Each location site must receive independent approval and, upon approval, be issued an approved narcotic drug permit. If an applicant is a partnership or a corporation, all individuals having a majority or management interest in such corporation or partnership must be identified.(b) Persons responsible. Where two or more NTPs share a central administration (e.g., a city or statewide organization), the person responsible for the organization is required to be listed as the permit holder for each separate participating program. An individual shall indicate participation in the central organization at the time of the application. The permit holder shall fulfill all recordkeeping and reporting requirements for these programs, but each program must continue to receive separate approval. If a physician assumes medical responsibility for more than one NTP, a statement describing how medical services will be provided to each NTP shall be submitted to the department.(c) Medication unit. A program may establish a medication unit to facilitate the needs of patients who are stabilized on an optimal dosage level. A medication unit is limited to administering or dispensing a narcotic drug and collecting samples for drug testing or analysis for narcotic drugs in accordance with §229.148(h)(1). The only patients who shall be referred to a medication unit are those not in need of frequent counseling, rehabilitative, or other services. The physician shall be responsible for making this determination and documenting the patient's record. If a private practitioner wishes to provide other services besides administering or dispensing a narcotic drug and collecting samples for drug testing or analysis for narcotic drugs, he or she must submit an application for separate approval as an NTP. Source Note: The provisions of this §563.143 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.143 Organization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221942 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221942 03/12/2026 (a) A permit holder shall assure that the narcotic treatment program (NTP) is in compliance with all State of Texas laws and rules regulating chemical dependency treatment facilities including the following laws: Texas Health and Safety Code Chapters 464 and 466; the Medical Practice Act, Texas Occupations Code Chapters 151-160 and 162-165; the Nurse Practice Act, Texas Occupations Code Chapter 301; the Texas Pharmacy Act, Texas Occupations Code Chapters 551-566; and the Licensed Professional Counselor Act, Texas Occupations Code Chapter 503.(b) The permit holder shall assure the NTP is in compliance with Title 42, Code of Federal Regulations, Part 8. To the extent that the Code of Federal Regulation conflicts with these sections, these sections shall prevail.(c) An NTP shall comply with the following balance billing requirements.(1) An NTP may not violate a law that prohibits the NTP from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) An NTP shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 -21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the NTP.(d) An NTP shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002.(e) All citations in these sections to statutes or regulations include those statutes or regulations as amended.(f) An NTP shall not discriminate based on a patient's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S. Source Note: The provisions of this §563.144 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; amended to be effective April 15, 2021, 46 TexReg 2423; amended to be effective January 6, 2022, 46 TexReg 9308; amended to be effective August 18, 2024, 49 TexReg 6218; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.144 State and Federal Statutes and Regulations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221943 03/12/2026 (a) Application.(1) A complete narcotic drug treatment application provided by the department must be submitted to the State Methadone Authority (SMA) to apply for an approved narcotic drug permit to operate a narcotic treatment program (NTP).(2) A complete application filed in accordance with this subsection for an NTP will be reviewed and evaluated by the department, in accordance with §229.281 of this title (relating to Processing Permit Application Relating to Food and Drug Operation). An application shall not be considered complete until an application for an NTP has been submitted to the Drug Enforcement Administration (DEA), and to the Substance Abuse and Mental Health Services Administration (SAMHSA). If the program application is denied by the department, the applicant shall have an opportunity for a hearing pursuant to §229.147 of this title (relating to Denial of Application; Suspension or Revocation of Narcotic Drug Permit).(3) A person acquiring an NTP currently operating under department approval must submit a new application in accordance with this subsection and an initial fee as required in subsection (b)(1) of this section. A narcotic drug permit will be issued to a new owner or new location and the permit issued to the previous owner or location shall be void and surrendered to the department by certified or registered mail within 24 hours following receipt of the new approved narcotic drug permit.(4) Individuals who are currently chemical dependent and/or have a history of chemical dependency on any substances that are subjected to abuse within two years of application for a permit, are not eligible for ownership of an NTP.(5) The number of patients that a clinic is approved to treat is in direct proportion to the number of counselors employed by that clinic. This proportion is a maximum of 50 patients for each counselor. The NTP may exceed the counselor to patient ratio on a temporary basis to permit hiring of new staff when new admissions cause a ratio imbalance or when current staff leave and must be replaced.(6) Applicants must provide to the department complete information for evaluation of criteria concerning location, funding, compliance history, and competency to operate an NTP.(A) Scope. The department intends that new NTP locations be established to serve diverse patient populations without singular regard to proximity of location to an existing program(s). The department has established criteria to prevent competition for patients among NTPs in the same area that may result in increased noncompliance with state and federal regulations and compromised patient care.(B) Criteria. An applicant must affirmatively demonstrate the following:(i) serviceability of the program at the proposed location by providing the department the following:(I) a map showing proximity of the proposed NTP to existing programs within a three-mile radius;(II) a description of how the new program will ensure it will provide treatment services for an underserved population and not duplicate treatment services for existing patients in treatment at an established program in the area;(III) copies of planned promotional materials, advertisements, and other techniques to publicize the proposed program; and(IV) procedures that will be used to identify whether a patient is enrolled in another clinic;(ii) the source and adequacy of financial assets necessary to operate the program;(iii) if applicable, the compliance history of the applicant, which includes any issues reported to the department by SAMHSA, DEA or any other regulatory agency;(iv) adequate planning and organizational structure demonstrated by full and complete answers submitted to all questions in the application materials; and(v) a statement that the applicant has read, understood and agreed to follow all federal and state regulations concerning operation of an NTP.(b) Fees and fee assessments.(1) Initial fees. All applicants for an NTP permit must submit an initial application fee of $1,000 with each application. All initial fees are nonrefundable. An application will not be processed unless it is submitted with the initial fees.(2) Patient fees. A permit holder must submit a patient fee for each patient the NTP is approved to treat. The patient fee must be paid no later than 30 days from the date the permit is issued. A nonrefundable initial fee of $150 must be submitted for each medication unit requested in the initial application. The NTP or medication unit will be issued a patient fee certificate for a two-year term. The patient fee is $60 per patient.(3) A current or renewal patient fee certificate is transferable until the expiration date on the certificate if the following conditions are met:(A) the permit holder relocates with no change of name of the permit holder; or(B) a new permit holder takes over operation of an existing NTP at the existing location with no interruption of patient treatment operations.(4) Renewal permit fees. A permit holder must submit a renewal application form, a current status report, and renewal fees prior to the expiration date of the current patient fee certificate. A renewal permit shall only be issued when all past due fees and delinquency fees are paid.(A) A permit holder who submits a renewal application and fees after the expiration date must pay delinquency fees of $5 for each patient the NTP is approved to treat.(B) A permit holder who submits a current status report after the expiration date must pay a delinquency fee of $350.(C) Renewal patient fee certificates are issued for two-year terms. The renewal fee is nonrefundable and is $60 per patient.(D) Increase in patient certificates. A permit holder who requests an increase in the number of patients the NTP is approved to treat prior to the expiration of a current patient certificate must provide documentation demonstrating adequate facility and staff capacity to accommodate an increase. Temporary transfer patients should not be included. The patient fee is $60 for each additional patient.(c) Permit.(1) All NTPs, persons, or organizations are required by the Health and Safety Code, Chapter 466, to obtain an approved narcotic drug permit in order to provide treatment to patients with a primary diagnosis of an opiate addiction.(2) An approved narcotic drug permit shall be issued by the department subsequent to federal and state approval of an application as required in subsection (a) of this section, and payment of a fee as required in subsection (b)(1) of this section which will provide authorization to operate an NTP.(3) Failure to pay the appropriate fee as required in subsection (b) of this section is grounds for suspension, revocation, or denial of a permit as provided in §229.147 of this title (relating to Denial of Application; Suspension or Revocation of a Narcotic Drug Permit).(4) A permit issued by the department for the operation of an NTP is valid only for the location of the NTP stated on the permit. A permit issued by the department is not transferable from one facility to another facility and must be surrendered to the department if the person holding the permit sells or otherwise conveys the facility to another person. If the permit holder sells or otherwise conveys the facility to another person or changes the location of the facility, a new application must be submitted as required in subsection (a) of this section and the fees must be paid as required in subsection (b) of this section. The previous permit must be surrendered to the department as specified in subsection (a)(3) of this section.(5) A permit holder requesting to move an NTP to another location must submit a new application for a new permit as required in subsection (a) of this section, and pay the initial fee in accordance with subsection (b)(1) of this section. The previous permit must be surrendered to the department as specified in subsection (a)(3) of this section.(6) An approved narcotic drug permit issued by the department shall remain in effect until suspended or revoked by the department or surrendered by the permit holder.(7) The approved narcotic drug permit and the current certificate must be posted in a conspicuous location within the premises of the NTP.(8) Methadone, or any other drug approved by the FDA for the treatment of opiate addiction, are the only drugs which shall be used in NTPs for patients with opiate addiction.(d) Texas Online. Applicants may submit initial and renewal permit applications under these sections electronically by the Internet through Texas Online at www.texasonline.state.tx.us. The department is authorized to collect fees, in amounts determined by the Texas Online Authority to recover costs associated with application and renewal application processing through Texas Online. Source Note: The provisions of this §563.145 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; amended to be effective February 1, 2006, 31 TexReg 501; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.145 Applications, Fees, Permits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221944 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221944 03/12/2026 (a) The department may take any action provided in the Texas Health and Safety Code (code), Chapter 466, including emergency orders when it appears that a person violated, is violating, or is threatening to violate the code, these sections, or an order or permit issued pursuant to the code.(b) If an emergency order is issued to suspend or revoke the permit of a narcotic treatment program (NTP), the department may notify other NTPs to expect patients so that treatment services for the patients are maintained.(c) The department will assess administrative penalties in accordance with the provisions in §229.261 of this title (relating to Assessment of Administrative Penalties). Source Note: The provisions of this §563.146 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.146 Failure to Comply https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221932 03/12/2026 (a) Failure to comply with Chapter 466 or any of these sections shall be grounds for denial, suspension, or revocation of a narcotic drug permit.(b) The department may deny an application for a license or may suspend or revoke a license if the applicant or licensee:(1) has been convicted of a felony or misdemeanor that involves moral turpitude;(2) is an association, partnership, or corporation and the managing officer has been convicted of a felony or misdemeanor that involves moral turpitude;(3) has been convicted of a felony or misdemeanor in a state or federal court for the illegal use, sale or transportation of narcotic drugs, barbiturates, amphetamines, or any other dangerous or habit-forming drugs;(4) is an association, partnership, or corporation and the managing officer has been convicted of a felony or misdemeanor in a state or federal court for the illegal use, sale, or transportation of narcotic drugs, barbiturates, amphetamines, or any other dangerous or habit-forming drugs;(5) has had a permit to operate a narcotic treatment program denied, revoked, surrendered, and/or suspended by the department, Drug Enforcement Administration (DEA), Food and Drug Administration (FDA), and/or Substance Abuse and Mental Health Services Administration (SAMHSA); or(6) has obtained or attempted to obtain a license by fraud or deception.(c) If it appears that an applicant or permit holder has failed to achieve or demonstrate compliance with these sections, the applicant or permit holder shall be given written notice of the denial, suspension, or revocation of the permit and an opportunity for a hearing. Any hearings under this section are governed by §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearings Procedures), except for Emergency Orders under Health and Safety Code, §466.041.(d) An applicant or permit holder may request one informal reconsideration conference with the department prior to the requesting or setting of an administrative hearing under this chapter. The request for such an informal reconsideration may be in addition to the request for a formal hearing and will not waive the person's right to a formal hearing if the outcome of the informal reconsideration is adverse to the person. Requests for the informal reconsideration conference shall be addressed as provided in subsection (e) of this section.(e) If the applicant or permit holder requests a hearing or informal reconsideration, he/she shall notify the department in writing at 1100 West 49th Street, Austin, Texas 78756, within 15 days of receipt of the notice provided in subsection (c) of this section. If the applicant or permit holder does not request a hearing or reconsideration within the specified time in the notice, then the applicant or permit holder shall be presumed to have agreed with denial of the application, or suspension or revocation of the permit as stated in the notice.(1) The request for a hearing and/or informal reconsideration shall:(A) indicate the name(s) of the person(s) who will represent the applicant or permit holder; and(B) include an explanation of the specific point(s) that are being disputed.(2) Regarding the informal reconsideration conference, the department will contact the applicant or permit holder in writing or orally to discuss a mutually agreeable time and place for the meeting.(3) The department may orally advise the applicant or permit holder of their decision relative to the informal hearing, with written confirmation to follow.(f) The department may take emergency action in accordance with the Health and Safety Code, §466.041, and may immediately suspend an approved narcotic drug permit when approval is withdrawn from the permit holder by the SAMHSA or a registration is revoked by the DEA. The suspension shall be effective until the permit is surrendered, revoked, or reinstated. Any hearings under this section are governed by §§1.21, 1.23, 1.25, and 1.27 of this title (relating to Formal Hearings Procedures). Source Note: The provisions of this §563.147 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845.; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.147 Denial of Application; Suspension or Revocation of a Narcotic Drug Permit https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221933 03/12/2026 (a) Management and administration.(1) Human resources management.(A) The narcotic treatment program (NTP) shall employ a sufficient number of qualified personnel to fulfill the service objectives of the program and to satisfy the intent of this section.(B) Each NTP shall notify the State Methadone Authority (SMA) within seven days, in writing, of any change in the employment status of any of its program personnel. For new hires, the employee's home address and telephone number, copies of a current Texas driver's license and verification of professional licensure shall be provided with this notification. In addition, copies of a curriculum vitae, physician permit, Drug Enforcement Administration (DEA) certificate, and Texas Department of Public Safety registrations shall be provided for physicians. Notice of change of medical director or program sponsor must be given prior to the change or on the date the change occurs.(C) Employees who are currently or formerly addicted within the past two years to drugs of abuse and/or opiates (including methadone) or alcohol are considered risks to the security of drug stocks and shall not have access to the drug stocks or to the drug dispensing area.(D) The NTP shall develop job descriptions for all staff members which include job duties and responsibilities, dates of regular review for continuing appropriateness, and documentation that the descriptions are provided to the individual staff member.(2) Program operations.(A) Each NTP shall provide medical and rehabilitative services and programs. These services should normally be made available at the primary facility, but the program sponsor may enter into a formal documented agreement with private or public agencies, organizations, or institutions for these services if they are available elsewhere. The program sponsor, in any event, must be able to document that medical and rehabilitative services are fully available to patients. Any service not furnished at the primary facility is required to be listed in any application for program approval submitted to the SMA. The addition, modification, or deletion of any program service is required to be reported immediately to the SMA.(B) Each program must notify the SMA in writing of clinic closure due to holidays, training, and emergencies.(C) Each program must provide a written response to a warning letter issued by the SMA within 15 days of the receipt of the letter.(D) Each program must be able to provide observed daily dosing six days a week.(3) Patients' rights and grievance procedures.(A) Each program shall develop and implement written policies regarding the patients' rights that include the following:(i) the right to receive a written copy of these rights, which include the address and telephone number of the department, prior to admission;(ii) the right to a humane environment that provides reasonable protection from harm and appropriate privacy for personal needs;(iii) the right to be free from physical and verbal abuse, neglect and exploitation;(iv) the right to be treated with dignity and respect;(v) the right to be informed about the individualized plan of treatment and to participate in the planning, as able;(vi) the right to be promptly and fully informed of any changes in the plan of treatment;(vii) the right to accept or refuse proposed treatment;(viii) the right to have personal information and medical records kept private;(ix) the right to make a complaint and receive a fair response from the facility within a reasonable amount of time; and(x) the right to complain directly to the department.(B) Each program shall have a written grievance procedure for patients and others to present complaints, either orally or in writing, and to have their complaints addressed and resolved as appropriate in a timely manner.(C) Each program shall maintain documentation of grievances and complaints and the resolution in the patient's file.(b) Facilities and clinical environmental.(1) Each facility shall have adequate and appropriate space and equipment to meet the objectives of the program and the needs of each person receiving services.(2) Each facility shall be in compliance with all applicable local health, safety, sanitation, building and zoning requirements.(3) All buildings and grounds must be constructed, maintained, repaired and cleaned so that they are not hazardous to the health and safety of the patients and staff.(4) The patient medication area must be physically separate from the waiting area.(5) Counseling areas, bathrooms, and medical examination areas must be designed to ensure patient privacy.(c) Risk management.(1) Each program shall develop and maintain a written plan to ensure the continuity of patient treatment in the event that an emergency or disaster disrupts the program's functions. This plan shall include a requirement for a program representative to notify the department of the disruption in function.(2) The NTP sponsor must report to the department any patient death. The program shall report orally and in writing within two weeks of the program's knowledge of the death. A detailed account of any adverse reaction to an approved narcotic drug will be maintained in the patient treatment record.(3) Security of drug stocks.(A) Any theft, break-in, or diversion of drug stocks from the clinic must be reported to the SMA within 48 hours of discovery of the event.(B) Adequate security is required to be maintained over drug stocks, and over the manner in which it is administered or dispensed. The program is required to meet the security standards for the distribution and storage of controlled substances as required by the DEA, Department of Justice (21 CFR 1301).(4) Staff shall complete an incident report for all significant patient incidents including, but not limited to: violation of patients' rights, accidents and injuries, medical emergencies, behavioral and psychiatric emergencies, medication errors, medication adverse events, diversion, illegal or violent behavior, loss of a patient record, and release of confidential information without patient consent. The treatment facility shall ensure full documentation of the event is placed in the patient file; prompt investigation and review of the situation surrounding the event; implementation of timely and appropriate corrective action; and ongoing monitoring of any corrective actions until all corrections have been made.(d) Professional staff credentials and development.(1) Each program shall have and follow written policies and procedures for training program staff. A minimum of 12 clock hours of training or instruction must be provided annually for each staff member who provides treatment or services to patients. Such training must be in subjects that relate to the employee's assigned duties and responsibilities. Programs shall maintain records that each staff member has received the required annual training and be able to present copies of these records to the department upon request.(2) The program sponsor shall:(A) be a licensed health care professional or qualified credentialed counselor or have worked in the field of substance abuse a minimum of three years;(B) have at least one year in the management or administration of direct services to persons with substance abuse problems; and(C) submit a list of educational levels and work experience to the SMA upon employment.(3) A legal entity organized and operating under the laws of this state shall:(A) have at least one year experience in the management or administration of direct services to persons with substance abuse problems;(B) employ a program director that is a licensed health care professional or qualified credentialed counselor or have worked in the field of substance abuse a minimum of three years; and(C) submit a list of educational levels and work experience for the program director to the SMA upon employment.(4) Medical director.(A) The medical director shall be licensed to practice medicine in Texas and in accordance with 22 Texas Administrative Code (TAC), Chapter 163, and shall have worked in the field of addiction medicine a minimum of two years.(B) Programs that are unable to secure the services of a medical director who meets the requirements of subparagraph (A) of this paragraph may apply to the SMA for a variance. The SMA has the discretion to grant such a variance for the two years experience in the field of addiction medicine when there is a showing that:(i) the program has made good faith efforts to secure a qualified medical director, but has failed;(ii) the program can secure the services of a licensed physician who is willing to serve as medical director and participate in an in-service training plan;(iii) the program has developed an in-service training plan which is acceptable to the SMA;(iv) the program has obtained the services of a medical consultant who meets the requirements of subparagraph (A) of this paragraph above and will be available to oversee the in-service training of the medical director and the delivery of medical services at the program requesting the variance.(5) Physicians.(A) The program physician(s) other than the medical director shall be licensed to practice medicine in Texas and in accordance with 22 TAC, Chapter 163, and shall have worked in the field of addiction medicine a minimum of one year.(B) Programs that are unable to secure the services of a physician who meets the requirements of subparagraph (A) of this paragraph regarding the 1 year experience in the field of addiction medicine may apply to the SMA for a variance. The SMA has the discretion to grant such a variance when there is a showing that:(i) the program has made good faith efforts to secure a qualified physician, but has failed;(ii) the program can secure the services of a licensed physician who is willing to serve as program physician and participate in an in-service training plan;(iii) the program has developed an in-service training plan which is acceptable to the SMA; and(iv) the program employs a qualified medical director who has the experience and credentials specified in paragraph (3)(A) of this subsection or has completed the in-service training program specified in paragraph (3)(B) of this subsection.(6) Counseling staff shall meet the requirements of a qualified credentialed counselor or counselor intern in Texas as defined in 40 TAC, Chapter 150, unless exempted.(7) Nursing staff shall be licensed to practice in Texas and in accordance with 22 TAC, Chapter 217 or 22 TAC, Chapter 235.(8) Pharmacists shall be licensed to practice in Texas and in accordance with 22 TAC, Chapter 283.(9) Other health care professionals must be licensed in Texas and in accordance with applicable Texas state regulations.(e) Patient admission and assessment.(1) Voluntary participation. The person responsible for the program shall ensure that:(A) a patient voluntarily chooses to participate in a program;(B) all relevant facts concerning the use of the narcotic drug used by the program are clearly and adequately explained to the patient;(C) all patients, with full knowledge and understanding of its contents, sign an informed written consent to treatment; and(D) a parent, legal guardian, or responsible adult designated by the state authority (e.g., "Emancipated minor laws") consents in writing for the treatment of patients under the age of 18.(2) Screening. All applicants for admission must be initially screened by a health care professional certified or licensed in accordance with applicable Texas state regulations to determine eligibility for admission. No applicant may be processed for admission until it has been verified that he or she meets all applicable criteria, and that the sources and methods of verification have been recorded in the applicant's file. The screening process must include:(A) verification, to the extent possible, of an applicant's identity including name, address, date of birth, and other identifying data;(B) history of narcotic dependence, evidence of current physiologic dependence, and a physical examination;(C) medical history, including HIV status, pregnancy, current medications (prescription and non-prescription), and active medical conditions;(D) patient history including, but not limited to, psychological and sociological background, educational and vocational achievements, and current mental status exam; and(E) determination if the applicant needs special services and determination that the program is capable of addressing these needs either directly or through referral.(3) Exceptions.(A) Pregnant patients, regardless of age, who have had a documented opiate dependency in the past and who may return to opiate dependency may be admitted to treatment and placed on a maintenance regimen. For such patients, evidence of current dependence on opiates is not needed if a program physician certifies in writing the pregnancy and finds treatment to be medically justified. Pregnant patients are required to be given the opportunity for, and should be encouraged to access prenatal care either by the program or by referral to appropriate health-care providers.(B) A person who has resided in a penal or chronic care institution for one month or longer may be admitted to maintenance treatment within six months after release from such an institution without documented evidence of opiate dependency, provided the person would have been eligible for admission prior to incarceration or institutionalization, and the admission is medically justified. The medical justification must be documented in the patient's record.(C) Applicants under 18 years of age are required to have had two documented attempts at short-term detoxification or drug-free treatment to be eligible for maintenance treatment. No person under 18 years of age may be admitted to a maintenance treatment program unless a parent, legal guardian, or responsible adult designated by the state authority completes and signs an informed written consent form. A person under 18 years of age shall not be given an initial dose of narcotic drug until the results of the admission drug test for drugs of abuse are reviewed by the physician. All documents must be kept in the patient's record.(D) Under certain circumstances, a patient who has been treated and later voluntarily detoxified from comprehensive maintenance treatment may be readmitted to maintenance treatment without evidence to support findings of current physiologic dependence, up to two years after discharge, if the program attended is able to document prior narcotic drug comprehensive maintenance treatment of six months or more, and the admitting program physician, in his or her reasonable clinical judgment, finds readmission to comprehensive treatment to be medically justified. For patients meeting these criteria, the quantity of take-home medication, if take-home medication is permitted for the narcotic drug, will be determined in the reasonable clinical judgment of the program physician, but in no case may the quantity of take-home medication be greater than would have been allowed at the time the patient voluntarily terminated previous treatment. The admitting program physician or a program employee under supervision of the admitting program physician must enter in the patient's record documented evidence of the patient's prior treatment and evidence of all decisions and criteria used relating to the admission of the patient and the quantity of take-home medication permitted. The admitting program physician shall date and sign these entries in the patient's record or review the health-care professional's entries therein before the program administers any medication to the patient. In the latter case, the admitting program physician shall date and sign the entries in the patient's record made by the health-care professional within 72 hours of administration of the initial dose to the patient.(4) Assessment. Each patient admitted to the program must be evaluated by the medical director or program physician and clinical staff who have been determined to be qualified by education, training, and experience to perform such assessments. The purpose of such assessments shall be to determine whether maintenance treatment, detoxification, or drug free treatment will be the most appropriate treatment modality for the patient. The evaluation must include an assessment of the patient's needs for other services including, but not limited to, medical, psychosocial, educational, and vocational. A signed and dated statement by the program physician, that he or she has reviewed all documented evidence to support a one year history of opiate dependence and current opiate dependence, and that in his or her reasonable clinical judgment, the applicant fulfills the requirements for admission to the program is required to be recorded in the patient's file prior to the administration of an any narcotic drug to the patient.(5) Transfer of patients.(A) The admitting program shall obtain from the patient an authorization for disclosure of confidential information, pursuant to 42 CFR, §§2.31-2.34, for the purpose of obtaining accurate and current information concerning the patient's treatment at the former program.(B) The program physician or an appropriately trained health care professional supervised by the admitting program physician shall consider data obtained from the transferring program that verifies the amount of time the patient has spent satisfactorily adhering to the eight criteria found in subsections (i)(1)(A)-(H) of this section in determining if the patient may continue the same frequency of clinic attendance permitted at the former program immediately before transferring to the new program.(C) The program physician shall not allow the patient to attend the clinic less frequently than the most recent schedule allowed at the former program unless:(i) copies of the patient's records are obtained to sufficiently document the patient's satisfactory adherence to federal and state regulations for the required time in treatment; and(ii) the physician has completed an evaluation of the patient that includes consideration of the eight criteria in subsections (i)(1)(A)-(H) of this section and the additional criteria for attendance as found in 42 CFR, §8.12(i).(D) At a minimum, an agent of the practitioner from the admitting program shall document in the patient file and an agent of the practitioner from the transferring program must provide the following information before the initial dose of narcotic drug is administered to a transfer patient:(i) the last date and amount of narcotic drug administered or dispensed at the former program;(ii) the length of time in continuous treatment;(iii) the most recent record of clinic attendance;(iv) the name, address, and telephone number of the program contacted;(v) the date and time of the contact; and(vi) the name of the program employee furnishing the information.(E) Medical records.(i) Patients who have had a physical examination and laboratory tests within the past three months may be admitted without a new physical examination and laboratory tests, unless the program physician requests it. The admitting program shall obtain copies of these results within 15 days of admission. If records are not obtained within 15 days, the program shall consider the patient a new patient and fulfill the minimum standards for admission.(ii) The transferring program must supply patient medical records necessary to fulfill the requirements of paragraph (5)(B)-(D) of this section in response to a written request from the patient. The program shall furnish copies of medical records requested, or a summary or narrative of the records, including records received from a physician or other health care provider involved in the care or treatment of the patient, pursuant to a written consent for release of the information as provided by subparagraph (A) of this paragraph, except if the physician determines that access to the information would be harmful to the physical, mental, or emotional health of the patient, and the program may delete confidential information about another patient or family member of the patient who has not consented to the release. The information shall be furnished by the program within 15 days after the date of receipt of the request. If the program denies the request, in whole or in part, the program shall furnish the patient a written statement, signed and dated, stating the reason for the denial. A copy of the statement denying the request shall be placed in the patient's record.(F) Fees. The transferring program responding to a request for medical records shall be entitled to receive a reasonable fee for providing the requested information. A reasonable fee shall be a charge of no more than $25 for the first 20 pages and $.15 per page for every page thereafter. In addition, a reasonable fee may include actual costs for mailing, shipping, or delivery. The program providing copies of requested medical records or a summary or a narrative of such records shall be entitled to payment of a reasonable fee prior to release of the information, unless the information is requested by a licensed Texas health care provider for purposes of emergency or acute medical care. In the event the program receives a proper request for copies of medical records or a summary or narrative of the medical records for purposes other than for emergency or acute medical care, the program may retain the requested information until payment is received. In the event payment is not routed with such a request, the program shall notify the requesting party in writing of the need for payment and may withhold the information until payment of a reasonable fee is received. A copy of the letter regarding the need for payment shall be made part of the patient's medical record. Medical records requested pursuant to a proper request for release may not be withheld from the patient, the patient's authorized agent, or the patient's designated recipient for such records based on a past due account for medical care or treatment previously rendered to the patient.(6) For record keeping purposes, if a patient misses appointments for two weeks or more without notifying the clinic, the episode of care is considered terminated and is to be so noted in the patient's record. An exception determination would be in circumstances where the patient can provide documentation of continuation of care. The documentation must be maintained in the patient's record. This does not mean that the patient cannot return for care. If the patient does return for care and is accepted into the program, the patient is considered a new patient and is to be so noted in the patient's record. Cumulative time spent by the patient in treatment is counted toward the number of years of treatment, provided there has not been a continuous absence of 90 days or more.(7) Dual enrollment. There is a danger of drug dependent persons attempting to enroll in more than one NTP to obtain quantities of drugs for the purpose of self-administration or illicit marketing. Therefore, drugs shall not be provided to a patient who is known to be currently receiving drugs from another treatment program without prior approval from the SMA. Patients who are known to be enrolled in more than one NTP at a time will be forced to choose one clinic for treatment. That patient must then begin treatment as a completely new patient, including attending the clinic on a daily basis or a minimum of six days per week, for a period of six months.(8) Medical Evaluation. Each patient is required to have a medical evaluation by a program physician or an authorized health-care professional under the supervision of a program physician on admission to a program. A patient is required to have a face-to-face meeting with the program physician no later than one week after admission. A patient readmitted within three months after discharge does not require a repeat physical examination unless requested by the program physician. The admission medical evaluation must be documented in the patient's record and shall include at a minimum:(A) a medical history including the required history of opiate dependence;(B) evidence of current physiologic and/or psychologic dependence unless excepted under sections (e)(3)(A)-(D);(C) investigation of the organ systems for possibilities of infectious disease, pulmonary, hepatic, and cardiac abnormalities, and dermatologic sequelae of addiction;(D) examination of the patient's general appearance, head, ears, eyes, nose, throat (thyroid), chest (including heart, lungs, and breasts), abdomen, extremities, skin, and neurological assessment;(E) determination of the patient's vital signs (temperature, pulse, blood pressure, and respiratory rate); and(F) the program physician's overall impression of the patient.(9) Intradermal tuberculosis test.(A) Programs shall follow the Mantoux technique, using 0.1 ml of purified protein derivative (PPD) tuberculin containing five tuberculin units (TU) injected into the volar surface of the forearm.(B) Reaction to the Mantoux test shall be read by a trained health care worker 48 to 72 hours after the injection.(C) Results should be recorded in millimeters (mm) in the patient's record.(D) Patients who had negative tuberculin skin tests on admission must be retested each year and results recorded in the patient's record.(E) Patients with a positive skin test must have further diagnostic evaluation as designated by the Centers for Disease Control and Prevention (CDC).(F) Documented verification of follow-up on all patients referred for tuberculosis evaluation must be placed in the patient's record.(G) Patients with previously positive PPD shall not be retested. The program shall obtain verification of diagnostic evaluation and therapeutic follow-up, including preventive treatment or treatment of tuberculosis. The patient shall be referred for further evaluation if disposition cannot be verified. Documentation of the above shall be placed in the patient's record.(H) Immuno-suppressed populations shall be evaluated periodically as indicated to rule out active tuberculosis, particularly after contact with persons known to be infectious. HIV-infected persons with a positive tuberculin skin test (equal to or greater than 5 mm of indurations) should have a chest x-ray and be evaluated by a clinician to rule out active tuberculosis. HIV-infected individuals who have symptoms suggestive of tuberculosis shall be referred for chest x-ray and clinical evaluation regardless of their tuberculin skin test status.(10) Minimum required laboratory tests. All biological samples must be analyzed by a laboratory approved under the Clinical Laboratory Improvement Amendments (CLIA) and all applicable Texas state standards. For those tests requiring a blood sample, if in the reasonable clinical judgment of the program physician, a patient's subcutaneous veins are severely damaged to the extent that a blood specimen cannot be obtained, the lab tests may be omitted; however, an attempt to perform the required laboratory tests must be made annually or the patient must be referred to a medical facility that is able to draw blood. The following tests must be performed and documented:(A) CBC and differential;(B) routine and microscopic urinalysis;(C) liver functions profile (SGOT, SGPT); and(D) serological test for syphilis.(11) Short-term detoxification. A patient may be admitted to short-term detoxification regardless of age. The program physician shall document in the patient record the reason for admitting the patient to short-term detoxification. Take-home medication is not allowed during short-term detoxification. A history of one year opiate dependence is not required for admission to short-term detoxification. No test or analysis is required except for the initial drug screening test, and a tuberculin skin test. The initial treatment plan and periodic treatment plan evaluation required for comprehensive maintenance patients are not necessary for short-term detoxification patients. A primary counselor must be assigned by the program to monitor a patient's progress toward the goal of short-term detoxification and possible drug-free treatment referral. The narcotic drug is required to be administered daily by an agent authorized by the physician in reducing doses to reach a drug-free state over a period not to exceed 30 days. All other requirements of comprehensive maintenance treatment shall apply.(12) Long-term detoxification. A patient may be admitted to long-term detoxification regardless of age. The narcotic drug is required to be administered daily in reducing doses to reach a drug-free state over a period not to exceed 180 days. The patient is required to be under observation while ingesting the drug at least six days a week. Initial and random monthly drug screening tests must be performed on each patient. Initial and monthly treatment plans are required. All other requirements of comprehensive maintenance treatment shall apply.(13) Denial of admission. If in the reasonable clinical judgment of the medical director a particular patient would not benefit from treatment with a narcotic drug, the patient may be refused such treatment even if the patient meets the admission standards.(f) Treatment planning.(1) Initial treatment plan. The primary counselor shall enter in the patient's record the counselor's name, the contents of the patient's initial assessment, and the initial treatment plan. The primary counselor shall make these entries immediately after the patient is stabilized on a dose or within four weeks after admission, whichever is sooner. The initial treatment plan is required to contain a statement that outlines:(A) realistic short-term treatment goals which are mutually acceptable to the patient and the program;(B) behavioral tasks a patient must perform to complete each short-term goal;(C) the patient's requirements for education, vocational rehabilitation, and employment;(D) the medical psychosocial, economic, legal, or other supportive services that a patient needs;(E) the frequency with which these services are to be provided and/or the source to which the patient will be referred to receive the necessary services; and(F) the treatment plan must be signed and dated by the primary counselor and the patient.(2) Periodic treatment planning. The program physician or primary counselor shall review, reevaluate, and alter where necessary each patient's treatment plan at least once each 90 days during the first year of treatment, and at least twice a year thereafter. The treatment plan must be signed and dated by the primary counselor and the patient. At least once a year, the program physician shall review the treatment plan documented in each patient's record, and ensure that each patient's progress or lack of progress in achieving the treatment goals is entered in the patient's record by the primary counselor.(3) The program supervisory counselor or physician shall review and countersign all treatment plans formulated by counselor interns.(4) Counseling sessions. Frequency and content of counseling sessions with patients shall be in keeping with patient needs and modality of treatment.(g) Approved narcotic drugs.(1) Methadone. The program medical director or program physician shall prescribe methadone in accordance with 42 CFR, §8.12(h)(3-4). If opiate abstinence symptoms are not suppressed, the physician may administer additional methadone, within a scope that ensures patient safety, and taking into consideration the pharmacokinetic properties of the methadone. The medical director shall take into consideration the drug manufacturer's dosing instructions and current best practices when prescribing and administering. Methadone shall be administered or dispensed in oral form only when used in an outpatient treatment program. Hospitalized patients under care for a medical or surgical condition are permitted to receive methadone in parenteral form when the attending physician judges it advisable. All forms of methadone shall be dispensed in such a way as to reduce its potential for parenteral abuse and to differentiate it from other narcotic drugs (i.e., contrasting color and taste), unless prior SMA approval is obtained.(2) Levo-alpha acetyl methadol (LAAM). The program medical director shall prescribe LAAM in accordance with drug manufacturer's dosing instructions and current best practices.(3) A narcotic drug may be administered or dispensed only by an agent of the practitioner. The licensed practitioner assumes responsibility for the amounts of narcotic drugs administered or dispensed and shall record and countersign all changes in dosage schedules. If the program keeps the record of administration and dispensing of narcotic drugs separate from the patient's file, the program shall transfer data from the dosing record to the patient's file at least monthly.(h) Testing for licit and illicit drug use. The physician shall ensure that test results are not used as the sole criterion to force a patient out of treatment, but are used as a guide to change treatment approaches. The program shall ensure that when test results are used, presumptive laboratory results are distinguished from results that are definitive.(1) Drug abuse tests. Analysis of such tests shall be performed in a laboratory approved under the Clinical Laboratory Improvement Amendments (CLIA) and all applicable Texas state standards.(A) The program shall ensure that an initial drug test or analysis is performed for each new patient, including permanent transfer patients, before the initial or maintenance dose is administered, and at least monthly random tests or analyses are performed on each patient in comprehensive maintenance treatment for the initial year of treatment and eight random drug abuse tests yearly thereafter. When a sample is collected from each patient for such test or analysis, it must be done in a manner that minimizes opportunity for falsification.(B) The program must have and follow written procedures for the screening of test samples for licit and illicit drugs. The procedures shall describe in sufficient detail a plan for collection, storage, handling and analysis of test samples. The procedures shall further describe the program's response to test results that include at least the following:(i) training for staff members of the importance and relevance of reliable and timely drug abuse test procedures and reports, the purpose of conducting drug abuse tests, and the significance of the results;(ii) a protocol for collection of test samples that minimizes the opportunity for falsification and incorporates the elements of randomness and surprise;(iii) storage of test samples in a secure place to avoid substitution;(iv) a requirement for disclosure of test sample results to the patient and documentation in the patient record of program and patient response to the test results; and(v) if a patient refuses to provide a test sample, that shall be considered the same as a positive result for illicit drugs. Such refusals shall be documented in the patient record.(C) Each sample must be analyzed for opiates, methadone, methadone metabolite, amphetamines, cocaine, barbiturates, and benzodiazepines. In addition, if any other drug or drugs have been determined by a program to be abused in that program's locality, or as otherwise indicated, each sample must be analyzed for any of those drugs as well. If a program proposes to change a laboratory used for such testing or analysis, the program shall notify the SMA in writing and provide copies of any contracts or agreements.(2) Prescription Medications. The patient record shall contain adequate documentation of any prescription drug, other than methadone, that a patient may be taking, including the name of the drug, the prescription number, the dose, the reason for prescribing, the name of the prescribing doctor, the pharmacy's name and telephone number, the date it was prescribed, and the length of time the patient is to be taking the drug.(i) Unsupervised use.(1) The program physician shall comply with 42 CFR, §8.12(i) regarding the dispensing of take-home doses of medication. The program physician shall adhere to the following criteria in determining whether a patient is responsible in handling narcotic drugs:(A) absence of recent abuse of drugs (opioid or non-narcotic), including alcohol;(B) regularity of clinic attendance;(C) absence of serious behavioral problems at the clinic;(D) absence of known recent criminal activity;(E) stability of the patient's home environment and social relationships;(F) length of time in comprehensive maintenance treatment;(G) assurance that take-home medication can be safely stored within the patient's home; and(H) whether the rehabilitative benefit to the patient derived from decreasing the frequency of clinic attendance outweighs the potential risks of diversion of narcotic drugs.(2) Take-home protocol. Regardless of time in treatment, a program physician may deny or rescind the take-home medication privileges of a patient if any of the eight criteria found in subsections (i)(1)(A)-(H) of this section are not met.(3) Treatment program decisions on dispensing opioid treatment medications to patients for unsupervised use beyond that set forth in 42 CFR, §8.12(i)(1) shall be determined by the medical director or program physician only. In any event, a patient may not be given an additional supply of narcotic drugs beyond their current unsupervised use without prior written approval from the SMA.(4) Packaging. Take-home medication must be packaged in special packaging as required by 16 CFR, §1700.14 in accordance with the Poison Prevention Packaging Act (Pub. L. 91-601, 15 U.S.C., 1471 et seq.) to reduce the chances of accidental ingestion.(5) Labeling. The take-home medication must be labeled with the following:(A) Clinic name, address, and telephone number;(B) The word "METHADONE" in larger capital letters;(C) The phrase "Date Dispensed" or "Dispensed On";(D) The phrase "To Be Taken On";(E) Client's name;(F) Physician's name;(G) Label should contain some warning similar to the following:(i) "WARNING: This drug may be FATAL to any person other than to whom prescribed";(ii) "Law Prohibits Transfer To Any Person Other Than For Whom Prescribed"; and(H) Mixing and diluting directions in accordance with its approved product labeling.(6) Patients must provide a secure storage container for all take-home medications.(j) Discharge from treatment.(1) Voluntary discharge. If a patient decides to discontinue treatment, the program shall ensure that the patient receives medical withdrawal or appropriate transfer or referral. The program shall not try to keep a client in treatment by coercion, intimidation or misrepresentation.(2) Involuntary discharge and termination from treatment. Involuntary discharge from treatment is an action of last resort. Involuntary discharge occurs in response to behavioral problems where a threat to the well-being of the program, staff, or other patients outweighs the potential risk of harm to the individual patient.(3) Discharge against medical advice. The patient has the right to discontinue treatment when he or she chooses to do so. The program shall explain the risks of leaving treatment. The physician, or agent of the practitioner, shall have a face-to-face consultation with the patient. The physician shall determine the schedule for withdrawal from opiate maintenance therapy to ensure humane withdrawal. The program shall document the issue that caused the patient to seek discharge, and shall provide full documentation in the patient's record of steps taken to avoid discharge.(4) Other types of discharge. Discharge for non-payment of fees, serious non-compliance, or other reasons shall be determined by the program physician only. The physician, or agent of the practitioner, shall have a face-to-face consultation with the patient. The physician shall determine the schedule for withdrawal from opiate maintenance therapy to ensure humane withdrawal and shall document the reason for the discharge in the patient's record.(k) Record keeping and documentation.(1) Patient records.(A) The medical director or authorized physician shall sign or countersign and date all records within 72 hours of the occurrence of the action or order. The documents that require signature include, but are not limited to: all medical orders, changes in medical orders, changes in dosage schedule, changes in dose, exceptions to mandatory take-home schedule, the rationale for allowing exceptions to the mandatory take-home schedule, review of the eight point criteria prior to altering a schedule of take-home medication, exceptions due to special circumstances, findings from the admission medical evaluation, exceptions to the minimum requirements for admission into treatment, all admission evaluations performed by health care professionals, all medical evaluations performed by health care professionals, yearly treatment plans, initial medical orders, and any other record required by the SMA.(B) All patient records must be maintained in a secure room, locked file cabinet, safe or other similar container when not in use; and, accessibility shall be limited to staff directly involved in patient care.(C) The program shall ensure that accurate records traceable to specific patients are maintained showing dates, quantity, and batch or code marks of the drug dispensed. These records must be retained for a period of three years from the date of dispensing. An adequate record must be maintained for each patient. The record is required to contain a copy of the signed consent, the date of each visit, the amount of drug administered or dispensed, the results of each test or analysis for drugs, any significant physical or psychological disability, the type of rehabilitative and counseling efforts employed, an account of the patient's progress, and other relevant aspects of the treatment program. For recordkeeping purposes, if a patient misses appointments for two weeks or more without notifying the program, the episode of care is considered terminated and is to be so noted in the patient's record. This does not mean that the patient cannot return for care. If the patient does return for care and is accepted into the program, this is considered a readmission and is to be so noted in the patient's record. In calculating the number of years of comprehensive maintenance treatment, the period is considered to begin on the first day the medication is administered, or on readmission if a patient has had a continuous absence of 90 days or more. Cumulative time spent by the patient in more than one program is counted toward the number of years of treatment, provided there has not been a continuous absence of 90 days or more.(D) Confidentiality.(i) The program must comply with the provisions of 42 CFR, Part 2, and all applicable Texas statutes and regulations, governing confidentiality of patient records.(ii) The program shall implement a written policy to protect client records and other client identifying information from loss, tampering, and unauthorized access or disclosure.(iii) The program shall limit access to the records to staff with job duties requiring their use.(iv) The staff shall keep records locked at all times unless an authorized person is continuously present in the immediate area.(v) The staff shall have an effective tracking system and shall ensure that each record is returned to the file at the end of each day or shift.(vi) A treatment program or medication unit or any part thereof, including any facility or any employee, shall permit a duly authorized employee of SAMHSA or the department to have access to and to copy all records on the use of narcotic drugs in accordance with the provisions of 42 CFR, Part 2.(E) All notations by NTP personnel on patient files and other files kept by the NTP for purposes of this chapter shall be typed, printed, or legibly handwritten so that any regulatory authority can read the writing.(F) An NTP may not refuse to allow an inspection or otherwise interfere with personnel of the SMA in the performance of their duties, including the photocopying of patient records during an inspection. It is a violation for an NTP not to fully cooperate in any inspection by the SMA.(2) Records on the receipt, storage, and distribution of narcotic medication are subject to inspection under federal and Texas controlled substances laws.(3) Personnel records shall contain results of annual tuberculosis testing. Each employee working in an NTP must receive an intradermal skin test using the Mantoux technique at the start of employment and annually thereafter. Programs shall follow the Mantoux technique, using 0.1 ml of purified protein derivative (PPD) tuberculin containing five tuberculin units (TU) injected into the volar surface of the forearm. Reaction to the Mantoux test shall be read by a trained health care worker 48 to 72 hours after the injection. Results should be recorded in millimeters (mm) and documented in the employee's file. Employees who had negative tuberculin skin tests at the start of employment must be retested each year and results recorded in the employee's file. Employees with a positive skin test must have further diagnostic evaluation as designated by the Centers for Disease Control and Prevention (CDC). Documented verification of follow-up on all employees referred for tuberculosis evaluation must be placed in the employee's file. Employees with previously positive PPD shall not be retested. The program shall obtain verification of diagnostic evaluation and therapeutic follow-up, including preventive treatment or treatment of tuberculosis. The employee shall be referred for further evaluation if disposition cannot be verified. Documentation of the above shall be placed in the employee's file.(4) Personnel records shall also contain a job description, employment application, verification of credentials, evidence of a current driver's license, job performance evaluation completed annually and reviewed with the individual, and any other information required by law. Source Note: The provisions of this §563.148 adopted to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.148 State Operational Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221934 03/12/2026 In order to determine compliance with the sections in this chapter and related statutes, the department may enter and inspect the location of an applicant or a permit holder at any reasonable time without prior notification. This unannounced monitoring may include inspection of relevant records and/or interviews with patients, narcotic treatment program (NTP) personnel and prospective NTP personnel, to determine knowledge of and compliance with the rules and statutes governing the operation of an NTP. Inspection and monitoring can occur at unspecified frequencies and are subject to the provisions of the Code of Federal Regulations, Title 42, Part 2. Source Note: The provisions of this §563.149 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.149 Inspections and Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221935 03/12/2026 (a) The permit holder shall participate in the central registry for the purpose of sharing patient identifying information as requested by the department to prevent multiple enrollment of patients in narcotic treatment programs (NTPs).(b) A narcotic drug shall not be provided to a patient who is known to be currently enrolled in another NTP except when the patient is a temporary transfer patient.(c) The patient shall always report to the same NTP unless prior approval is requested by the parent NTP's program physician or program director for the patient to receive treatment as a temporary transfer patient at another NTP. In any event, a patient may not be authorized more than two weeks away from their home clinic without prior approval from the State Methadone Authority (SMA).(d) A central registry shall be established by the department which shall maintain a record of the patient's identification and the NTP to which each patient is enrolled. Information shall be maintained in accordance with confidentiality requirements in the Code of Federal Regulations, Title 42, Part 2, and Title 42, §8.12(g).(e) Each NTP shall report to the central registry specific information.(1) The following changes in patient status: new patient, readmitted to the same clinic, admitted from another NTP as a permanent transfer patient, transferred to another narcotic maintenance or detoxification program, deceased patient, or discharged (terminated) from maintenance or detoxification treatment shall be identified and reported to the central registry located at the department by telephone, electronic mail, or facsimile on the day the action occurs and written documentation must be submitted within a 24-hour period (or the next state working day immediately following weekends or holidays).(2) Each NTP's verbal and written report to the central registry shall identify and provide the following information for each patient:(A) name, address, and telephone number of the NTP, and approved narcotic drug permit number;(B) date action was taken (MO-DA-YR);(C) action taken identified as:(i) new patient, readmitted patient (NP);(ii) terminated patient (TP);(iii) permanent transfer-in patient (TIP);(iv) permanent transfer-out patient (TOP); or(v) deceased patient (DP); and(D) patient identification as follows:(i) Upon admission, the patient must be identified with a current Texas state driver's license, United States passport, military identification card, or Texas state-issued identification card containing a photograph of the patient or other identification approved by the SMA. If a patient is not able or willing to furnish the required documents, the program shall contact the SMA within 72 hours to access the Central Registry to check for possible duplicate enrollment and to discuss acceptable, alternate forms of identification. Photocopies of each of these documents must be maintained in the patient's record. The program shall document in the patient's file attempts to induce the patient to obtain state identification.(ii) An identification number shall be constructed using the following code numbers for the patient:(I) color of eyes: Brown (1), Blue (2), Green (3), Hazel (4), Gray (5), and Other (6);(II) date of birth stated in number digits with two digits for the month, day, and year (example: January 9, 1953--010953);(III) gender: male (1) and female (2); and(IV) race: White (1), Black (2), Hispanic (3), Asian (4), American Indian (5), and Other (6).(iii) An example of a patient identification number in accordance with clause (ii) of this subparagraph for a patient with blue eyes, date of birth--January 9, 1953, male, and white is 201095311. Patients with the same identification code will be assigned an alphabetical extension by the SMA (for example 201095311A, 201095311B, etc.). Source Note: The provisions of this §563.150 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.150 Central Registry https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221936 03/12/2026 (a) Application.(1) The hospital administrator must submit a complete hospital narcotic drug detoxification treatment application provided by the department, a copy of federal form SMA -162 filed with the Substance Abuse and Mental Health Services Administration (SAMHSA), and a copy of federal form DEA 363 filed with the Drug Enforcement Agency (DEA), to apply for an approved narcotic drug permit for inpatient narcotic drug detoxification.(2) The hospital administrator shall submit to the department the name of the individual (e.g., pharmacist) responsible for receiving and securing supplies of narcotic drugs for the treatment of narcotic addicts. The individuals responsible for supplies of narcotic drugs must be authorized to do so by federal or state law.(3) The hospital administrator shall submit to the department a general description of the hospital including the number of beds, specialized treatment facilities for drug dependence, and nature of patient care undertaken.(4) The hospital pharmacist shall submit to the department the quantity of narcotic drugs anticipated to be used per year for narcotic addiction detoxification treatment.(5) A member of the hospital medical staff shall be named by the administrator or chief of medical staff as the responsible physician for the narcotic drug detoxification treatment.(6) A hospital pharmacy registered by the Texas State Board of Pharmacy must be registered as a narcotic treatment program (NTP) for detoxification by the DEA.(7) A complete application filed in accordance with this subsection for an NTP will be reviewed and evaluated by the department in accordance with §229.281 of this title (relating to Processing Permit Applications Related to Food and Drug Operations). Denial of application shall be in accordance with §229.147 of this title (relating to Denial of Application; Suspension or Revocation of a Narcotic Drug Permit).(b) Fees.(1) A nonrefundable initial fee of $200 must be submitted for each location or each owner with the application for an inspection, evaluation, and processing of the application. An application will not be considered unless the application is accompanied by the initial fee.(2) The nonrefundable renewal fee of $400 shall be submitted by the permit holder to the department by filing a renewal form provided by the department prior to the expiration of the current fee certificate. A program that files a renewal fee after the expiration date must pay an additional $100 as a delinquency fee. The department is authorized to collect fees in amounts determined by the Texas Online Authority to recover costs associated with renewal application processing through Texas Online. A renewal permit shall only be issued when all past due fees and delinquency fees are paid. A fee certificate will be issued for a 24-month period from the expiration date. The department may not issue a permit if the current permit has been suspended, revoked, or surrendered by the permit holder.(3) A status report must be submitted to the department along with the renewal fee. A program that files a current status report after the expiration date must pay a delinquency fee of $250.(c) Permit.(1) A hospital providing treatment to patients with a primary diagnosis of opiate addiction must apply for and be issued an approved narcotic drug permit by the department which shall remain in effect until suspended or revoked by the department or surrendered by the permit holder.(2) An approved narcotic drug permit authorizing the hospital to operate a narcotic drug detoxification treatment program shall be issued subsequent to federal and state approval of the application as required in subsection (a) of this section, and payment of the fee as required in subsection (b) of this section.(3) Failure to pay the fee as required in subsection (b) of this section is grounds for denial of the application, suspension, or revocation of the permit as provided in §229.147 of this title (relating to Denial of Application; Suspension or Revocation of a Narcotic Drug Permit).(4) A hospital must be licensed as a chemical treatment facility under Health and Safety Code, Chapter 464, or have received an exemption from licensure standards from the Texas Commission on Alcohol and Drug Abuse.(5) A permit issued by the department for the operation of an approved narcotic drug detoxification treatment program in a hospital applies both to the hospital owner and to the place where the hospital is to be located. A permit issued by the department is not transferable from one facility to another facility and must be surrendered to the department if the person holding the permit sells or otherwise conveys the facility to another person.(6) If the permit holder sells or otherwise conveys the facility to another person or changes the location of the facility, a new application must be submitted as required in subsection (a) of this section and fees must be paid as required in subsection (b) of this section. When an approved narcotic drug permit is issued to a new permit holder or new location, the permit issued to the previous permit holder and/or location shall be revoked without hearing and must be surrendered to the department by certified or registered mail within 24 hours following receipt of the new approved narcotic drug permit.(7) The approved narcotic drug permit and the current fee certificate must be posted in a conspicuous location within the premises of the NTP.(8) Methadone, or any other drug approved by the United States Food and Drug Administration for the treatment of opiate addiction, are the only drugs which shall be used in hospital inpatient detoxification treatment of patients with opiate addiction. Source Note: The provisions of this §563.151 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.151 Approved Hospital Narcotic Drug Detoxification Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221937 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221937 03/12/2026 The department adopts by reference the federal regulations on "Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Addiction" found in Title 42, Code of Federal Regulations, Part 8. A copy of these regulations is indexed and filed at the department, located at 1100 West 49th Street, Austin, Texas 78756. Source Note: The provisions of this §563.152 adopted to be effective September 3, 1990, 15 TexReg 4823; amended to be effective September 1, 1992, 17 TexReg 5545; amended to be effective August 28, 1996, 21 TexReg 7845; amended to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.152 Federal Regulations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221938 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221938 03/12/2026 (a) Denial, Suspension or Revocation of Permit. Except for Emergency Orders under the Health and Safety Code, §466.041, after notice to an applicant or a permit holder and after the opportunity for a hearing, the department may:(1) deny an application of the person if the person fails to comply with this chapter or the rules establishing minimum standards for the issuance of a permit adopted under this chapter; or(2) suspend or revoke the permit of a person who has committed a Level I, II, or III violation as defined in subsection (d) of this section.(b) Administrative Penalty. When a person violates this chapter, a rule adopted under this chapter, or an order or permit issued under this chapter, the commissioner may assess an administrative penalty against the person.(c) Criteria for the assessment of administrative penalties. Administrative penalties will be assessed in accordance with the following criteria:(1) history of previous violations;(2) seriousness of the violation;(3) hazard to the health and safety of the public; and(4) demonstrated good faith.(d) Severity levels.(1) Severity Level I, penalty of $7,500-10,000, covers violations that are most significant and have a direct negative impact on the public health and safety including, but not limited to, adulteration, misbranding, or false advertising that results in fraud.(2) Severity Level II, penalty of $5,000-7,500, covers violations that are very significant and have an impact on the public health and safety including, but not limited to, adulteration, misbranding, or false advertising that results in fraud.(3) Severity Level III, penalty of $2,500-5,000, covers violations that are significant and which, if not corrected, could threaten the public and have an adverse impact on the public health and safety including, but not limited to, adulteration, misbranding, or false advertising that results in fraud.(4) Severity Level IV, penalty of $1,250-2,500, covers violations that are of more than minor significance, and if left uncorrected, would lead to more serious circumstances.(5) Severity Level V, penalty of $500-1,250, covers violations that are of minor safety or fraudulent significance.(e) Severity of a violation. The severity of a violation may be increased if the violation involves deception, fraud, or other indication of willfulness. In determining the severity of a violation, there shall be taken into account the economic benefit gained through noncompliance.(f) Adjustments to penalties. The department may make adjustments to the penalties listed in subsections (e), (f), or (g) of this section for any one of the following factors.(1) Previous violations. The department may consider previous violations. The penalty may be reduced or increased within the specified range of each severity level for past performance. Past performance involves the consideration of the following factors: whether the previous violation was identical or similar to the current violation; how recent the previous violation was; the number of previous violations; and the violator's response to previous violation(s) in regard to correction of the problem.(2) Demonstrated good faith. The department may consider good faith effort(s) of the violator to correct the violations and demonstrate compliance with the department's rules and regulations as a basis to reduce the proposed penalty. The penalty may be reduced within the specified range of each severity level if good faith efforts to correct a violation have been, or are being made. The department on a case-by-case basis will determine good faith effort. All good faith effort(s) to comply with the department's rules and regulations must be fully documented by the violator to merit consideration from the department as to whether to reduce the proposed penalty.(3) Hazard to the health and safety of the public. The department may consider the hazard to the health and safety of the public. The penalty may be increased within the specified range of each severity level when a direct hazard to the health and safety of the public is involved. It shall take into account, but need not be limited to, the following factors:(A) whether any death(s), disease or injuries have occurred from the violation;(B) whether any existing conditions contribute to a situation that could expose humans to a health hazard;(C) the impact that the hazard has on various segments of the population such as children, surgical patients, and the elderly; and(D) whether the consequences would be of an immediate or long-range hazard.(g) Hearings, appeals from, and judicial review of final administrative decisions under this section shall be conducted according to the contested case provisions of the Government Code, Chapter 2001. Any hearings under this section are governed by §§1.21, 1.23, 1.25 and 1.27 of this title (relating to Formal Hearings Procedures). Source Note: The provisions of this §563.153 adopted to be effective December 31, 2001, 26 TexReg 10871; amended to be effective January 1, 2005, 29 TexReg 11980; transferred effective November 29, 2024, as published in the November 8, 2024, issue of the Texas Register, 49 TexReg 9026. 1 HEALTH AND HUMAN SERVICES COMMISSION 563 MINIMUM STANDARDS FOR NARCOTIC TREATMENT PROGRAMS §563.153 Enforcement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217734 03/12/2026 The following words and terms, when used in 40 TAC chs. 141, 142, 144, 147, 148, 150, and 153 of this title shall have the following meanings, unless the context clearly indicates otherwise:(1) Abuse--An intentional, knowing, or reckless act or omission by provider personnel, a counselor, applicant for counselor licensure, or counselor intern that causes or may cause death, emotional harm or physical injury to a participant or client. Abuse includes without limitation the following:(A) any sexual activity between provider personnel, a counselor, applicant for counselor licensure, or counselor intern and a participant or client;(B) corporal punishment;(C) nutritional deprivation or sleep deprivation;(D) efforts to cause fear;(E) the use of any form of communication to threaten, curse, shame, or degrade a participant or client;(F) restraint that does not conform with chapter 148 of this title (relating to Standard of Care);(G) coercive or restrictive actions taken in response to a participant or client's request for discharge or refusal of medication or treatment that are illegal or not justified by the participant or client's condition; and(H) any other act or omission classified as abuse by Texas law, including but not limited to, TEX. FAMILY CODE ANN. §261.001 (Vernon 1996) and TEX. HUM. RES. CODE ANN. §48.002 (Vernon Supp. 2004).(2) Administrative Discharge--A discharge report processed by the Commission for a client whose last admission date and/or last billing end date exceeds 50 days.(3) Administrative Follow-up--A report processed by the Commission if 90 days for non-detoxification clients or 40 days for detoxification clients have elapsed from the client's last discharge date and the client has not been readmitted to the same provider within 60 days (non-detoxification clients) or ten days (detoxification clients).(4) Administrative Hearing--An appeals hearing conducted by the State Office of Administrative Hearings (SOAH).(5) Administrative Law Judge (ALJ)--An individual appointed by the chief administrative law judge of SOAH under TEX. GOV'T CODE ANN. §2003.041 (Vernon 2004) to preside over a contested case proceeding.(6) Administrative Procedure Act (APA)--TEX. GOV'T CODE ANN. ch. 2001 (Vernon 2000 & Supp. 2004), as amended.(7) Adolescent--An individual 13 through 17 years of age whose disabilities of minority have not been removed by marriage or judicial decree.(8) Adult--An individual 18 years of age or older, or an individual under the age of 18 whose disabilities of minority have been removed by marriage or judicial decree.(9) Agency--TCADA.(10) Alternative Activities--A strategy that gives participants and their families the opportunity to take part in educational, cultural, recreational, skill-building, and work-oriented substance-free activities. Activities under this strategy are designed to encourage and foster bonding with peers, family and community.(11) Applicant--A person who has submitted an application for an initial license to provide chemical dependency counseling or treatment, renewal of a license, or certification or approval for provision of an offender education program. For funding purposes, an applicant is a person who has submitted a proposal or application to provide substance abuse services in response to a solicitation issued by the Commission.(12) Assessment--An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for developing and revising a treatment plan and evaluating client progress toward achievement of goals identified in the treatment plan, resulting in comprehensive identification of the client's strengths, weaknesses, and problems/needs.(13) ATOD--Alcohol, tobacco and other drugs collectively.(14) Authorized Representative--An attorney authorized to practice law in the State of Texas or, if authorized by applicable law, a person designated in writing by a party to represent the party.(15) Behavioral Health Integrated Provider System (BHIPS)--The Commission's Internet-based computer system for contracted service providers that offers contractors the tools to meet State and Federal requirements for reporting, including capturing required client and billing data.(16) Block Grant--Substance Abuse Prevention and Treatment Block Grant, 42 U.S.C. 300x-21, et seq.(17) Brief Interventions--Practices designed to initiate a resolution of a problem and motivate an individual to begin to do something about his or her substance abuse. Brief interventions are described in "Brief Interventions and Brief Therapies for Substance Abuse" (Treatment Improvement Protocol 34), published by the United States Department of Health and Human Services Center for Substance Abuse Treatment (CSAT). Brief interventions are short counseling sessions that can be as short as five minutes or long as an hour for "at risk" or "harmful" users that are not chemically dependent. These interventions are for the purpose of goal setting within safe limits, giving self care instruction and referral to other sources that are appropriate. For those clients that are dependent or for whom the position along the stage of change spectrum of alcohol or drug problems is uncertain, the brief intervention is a negotiation process to seek further assessment and referral to an appropriate level of care. The brief intervention is summarized by the acronym FRAMES: feedback, responsibility, advice, menu of strategies, empathy and self-efficacy.(18) Brief Therapy--A systematic, focused process that relies on client engagement, and rapid implementation of change strategies. Brief therapies are described in "Brief Interventions and Brief Therapies for Substance Abuse" (Treatment Improvement Protocol 34), published by CSAT.(19) Business Day--A weekday on which State offices are open.(20) Center for Substance Abuse Prevention (CSAP) Prevention Strategies--(A) Community-Based Process--A strategy designed to enhance the ability of the community to provide effective prevention, intervention, and treatment services for ATOD problems and HIV infection through community mobilization and empowerment. Activities include multi-agency coordination and collaboration, networking, and development of written agreements among community organizations.(B) Environmental and Social Policy--A strategy designed to establish or change written and unwritten community standards, codes, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population. It includes activities that center on legal and regulatory initiatives and those that relate to the service and action-oriented initiatives.(C) Information Dissemination--A strategy that provides awareness and knowledge of ATOD problems and/or HIV infection and their harmful effects on individuals, families, and communities. It also gives the general population information about available programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Information is disseminated through written communications and/or in-person community presentations.(D) Prevention Education and Skills Training--A curriculum-based strategy designed to develop decision-making, problem solving, and other life skills. It also provides accurate information about the harmful effects of ATOD use, abuse and addiction pertinent to the needs of the target population. The basis of activities under this strategy is interaction between the educator/facilitator and the participants. These activities are aimed to increase protective factors, foster resiliency, decrease risk factors and affect critical life and social skills relative to substance abuse and/or HIV risk of the participant and/or family members.(E) Problem Identification and Referral--A strategy that provides services designed to ensure access to appropriate levels and types of services needed by youth or adult participants.(F) Alternative Activities--A strategy that gives participants and their families the opportunity to take part in educational, cultural, recreational, skill-building, and work-oriented substance-free activities. Activities under this strategy are designed to encourage and foster bonding with peers, family and community.(21) Chemical Dependency--In addition to the statutory provisions defining chemical dependency as abuse of, dependence on, or addiction to alcohol or a controlled substance (as defined by TEX. HEALTH & SAFETY CODE ANN. ch. 481 (Vernon 2001) and related statutory provisions in TEX. HEALTH & SAFETY CODE ANN. chs. 461 and 464 (Vernon 2001 & Supp. 2004), the Commission also defines chemical dependency as substance-related disorders as that term is used in the most recent published edition of the Diagnostic and Statistical Manual of Mental Disorders (See DSM).(22) Chemical Dependency Counseling--See Practice of Chemical Dependency Counseling.(23) Chemical Dependency Counselor--See Licensed Chemical Dependency Counselor (LCDC).(24) Chemical Dependency Counselor Intern--A person registered with the Commission who is pursuing a course of training in chemical dependency counseling at a registered clinical training institution.(25) Chemical Dependency Treatment--A planned, structured, and organized chemical dependency program designed to initiate and promote a person's chemical-free status or to maintain the person free of illegal drugs. It includes, but is not limited to, the application of planned procedures to identify and change patterns of behavior related to or resulting from substance-related disorders that are maladaptive, destructive, or injurious to health, or to restore appropriate levels of physical, psychological, or social functioning.(26) Child--For purposes of reporting abuse and neglect, a child is an individual under the age of 18 whose disabilities of minority have not been removed by marriage or judicial decree. For all other purposes in these rules, child shall mean an individual under the age of 13.(27) Child Abuse and Neglect--Any act or omission that constitutes abuse or neglect of a child under the age of 18 by a person responsible for a child's care, custody, or welfare as defined in the TEX. FAM. CODE ANN. §261.001 (Vernon 1996).(28) Client--An individual who receives or has received services, including admission authorization or assessment or referral, from a chemical dependency treatment provider, counselor, counselor intern, or applicant for licensure as a counselor, or from an organization where the counselor, intern or applicant is working on a paid or voluntary basis.(29) Client Data Systems (CDS) Forms--CDS forms consist of the admission/transfer admission report, discharge report, and follow-up report.(30) Clinical Evaluation--A systematic approach to screening and assessment.(31) Clinical Training Institution (CTI)--An individual or legal entity registered with the Commission to supervise a counselor intern.(32) Cognizant Agency--The Federal or State agency responsible for reviewing, negotiating, and approving an organization's indirect cost rate. TCADA has not been designated as a cognizant agency.(33) Commission--Texas Commission on Alcohol and Drug Abuse and its branches, divisions, departments, and employees.(34) Consenter--The individual legally responsible for giving informed consent for a client. Unless otherwise provided by law, a legally competent adult is his or her own consenter and the consenter for an adolescent or child is the parent, guardian, or conservator. Texas law allows a person 16 or 17 years of age to consent to his or her own treatment.(35) Contested Case--A proceeding, including but not restricted to licensing, in which the legal rights, duties, or privileges of a party are to be determined by the Commission after an opportunity for adjudicative hearing.(36) Contractor--Person funded by the Commission to provide substance abuse services unless otherwise specified.(37) Cost Reimbursement--A payment mechanism used for prevention and intervention services in which funds are provided to carry out approved activities based on an approved budget.(38) Counseling--A collaborative process that facilitates the client's progress toward mutually determined treatment goals and objectives. Counseling includes methods that are sensitive to individual client characteristics and to the influence of significant others, as well as the client's cultural and social context. Competence in counseling is built upon the understanding of, appreciation of, and ability to appropriately use the modalities of care for individuals, groups, families, couples, and significant others.(39) Counselor--A qualified credentialed counselor, graduate or counselor intern working towards licensure that would qualify them to be a qualified credentialed counselor (QCC).(40) Crisis Intervention--Actions designed to intervene in situations which require immediate attention to avert potential harm to self or others. Services include face-to-face individual, family, or group interviews/interactions and/or telephone contacts to identify needs.(41) Days--Calendar days, unless otherwise specified.(42) Digital Authentication Key--Identification data (that includes user identification and a time stamp) that is digitally stamped on electronic documents identifying the specific user that created the document. The identification data shall be controlled by a unique user ID and an encrypted password.(43) Direct Care Staff--Staff responsible for providing treatment, care, supervision, or other direct client services that involve face-to-face contact with a client.(44) Discharge--Formal, documented termination of services.(45) Document (noun)--A written or electronic record.(46) Diagnostic and Statistical Manual of Mental Disorders (DSM)--The Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The current version is the Fourth Edition, Text Revision (DSM-IV-TR). Any reference to DSM shall constitute a reference to the most recent edition then published.(47) Driving While Intoxicated (DWI)--The offense of driving while intoxicated as defined in the TEX. PEN. CODE ANN. ch. 49 (Vernon 2003).(48) Elderly--A person 65 years of age or older.(49) Emergency Behavioral Health Condition--Any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent lay person possessing an average knowledge of medicine and health, requires immediate intervention and/or medical attention without which an individual would present a danger to themselves or others or which renders individuals incapable of controlling, knowing or understanding the consequences of their actions.(50) Encryption--A method that allows secure transmittal of information along the Internet by encoding the transmitted data using a mathematical formula that scrambles the data. Without a corresponding "decoder," the transmission would be unusable.(51) Executive Director--The chief administrative officer or designee of the Texas Commission on Alcohol and Drug Abuse.(52) Exploitation--The illegal or improper use of a client or participant, or their resources, for monetary or personal benefit, profit, or gain by provider personnel, a staff member, volunteer, or other individual working under the auspices of a provider or by a counselor, counselor intern or applicant for counselor licensure or any other act or omission classified as exploitation by Texas law including, but not limited to, TEX. FAM. CODE §261.001 (Vernon 1996) and TEX. HUM. RES. CODE §48.002 (Vernon Supp. 2004).(53) Facility--See Treatment Facility.(54) Family--The children, parents, brothers, sisters, other relatives, foster parents, guardians, and/or significant others who perform the roles and functions of family members in the lives of clients or participants.(55) Fiscal Year--The Commission's fiscal year, September 1-August 31, unless otherwise specified.(56) Gender Specific--Therapy, education and/or program components that are designed to address emotional, developmental, rehabilitative, health and/or other issues that are specific to the gender of the client.(57) Graduate--An individual who has successfully completed the 270 hours of education, 300 hour practicum, and 4,000 hours of supervised work experience and who is still registered with the Commission as a counselor intern.(58) Health Insurance Portability and Accountability Act of 1996 (HIPAA)--Pub. L. No. 104-191, 45 C.F.R. pts. 160 and 164.(59) Human Immunodeficiency Virus (HIV)--The virus that causes Acquired Immune Deficiency Syndrome (AIDS). Infection is determined through a testing and counseling process overseen by the Texas Department of Health (TDH). Being infected with HIV is not necessarily equated with having a diagnosis of AIDS, which can only be diagnosed by a physician using criteria established by the National Centers for Disease Control and Prevention.(60) HIV Antibody Counseling and Testing--A structured counseling session performed by Prevention Counseling and Partner Elicitation (PCPE) counselors registered with TDH. It promotes risk reduction behavior for those at risk of infection with HIV and other sexually transmitted diseases and offers testing for HIV infection.(61) HIV Early Intervention Services--(A) appropriate pretest counseling for HIV and AIDS;(B) testing individuals with respect to such disease, including tests to confirm the presence of the disease, tests to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating conditions arising from the disease;(C) appropriate post-test counseling; and(D) providing the therapeutic measures described in subparagraph (B) of this paragraph.(62) Indicated Population--The population who may already be experimenting with drugs or who exhibit other problem-related behaviors.(63) Individual Service Day--A day on which a specific client receives services.(64) Intake--The process for gathering information about a prospective client and giving a prospective client information about treatment and services.(65) Intervention--The interruption of the onset or progression of chemical dependency in the early stages. Intervention strategies target indicated populations.(66) Intervention Counseling--Interactions to assist individuals, families, and groups to identify, understand, and resolve issues and problems related to ATOD use within a specific number of sessions or within a certain time frame. It is intended to intervene in problem situations and high-risk behaviors, which, if not addressed, may escalate to substance abuse or cause communicable disease. Such interactions should not include determining whether a person is in need of treatment. The use of the term "counseling" does not carry the same meaning as defined in paragraph (38) of this section.(67) Key Performance Measures--Measures that reflect the services that are critical to the program design and intended outcomes of the program. Key performance measures are specified for all Commission-funded programs.(68) Knowledge, Skills, and Attitudes (KSAs)--The knowledge, skills, and attitudes of addictions counseling as defined by CSAT Technical Assistance Publication (TAP 21) "Addictions Counseling Competencies: the Knowledge, Skills, and Attitudes of Professional Practice."(69) License--The whole or part of any agency permit, certificate, approval, registration, or similar form of permission authorized by law.(70) Licensed Chemical Dependency Counselor (LCDC)--A counselor licensed by the Texas Commission on Alcohol and Drug Abuse pursuant to TEX. OCC. CODE ch. 504 (Vernon 2002 & Supp. 2003).(71) Licensed Health Professional--A physician, physician assistant, advanced practice nurse practitioner, registered nurse, or licensed vocational nurse authorized to practice in the State of Texas.(72) Licensee--Any individual or person to whom the agency has issued any permit, certificate, approved registration, or similar form of permission authorized by law.(73) Licensing--The agency process relating to the granting, denial, renewal, revocation, suspension, annulment, withdrawal, or amendment of a license.(74) Life Skills Training (Treatment)--A structured program of training, based upon a written curriculum and provided by qualified staff designed to help clients with social competencies such as communication and social interaction, stress management, problem solving, decision making, and management of daily responsibilities.(75) Mechanical Restraint--(A) The application of a device restricting the movement of the whole or a portion of an individual's body to control physical activity. Only commercially available devices specifically designed for the safe and comfortable restraint of humans may be used as mechanical restraints.(B) Despite their commercial availability, the following types of devices may not be used to implement restraint:(i) those with metal wrist or ankle cuffs;(ii) those with rubber bands, rope, cord, or padlocks or key locks as fastening devices;(iii) long ties (e.g., leashes); or(iv) bed sheets.(C) The following devices may be utilized to implement restraint.(i) Anklets--A cloth or leather band fastened around the ankle or leg and secured to a stationary object (e.g., bed or chair frame). Acceptable fasteners include Velcro and buckles. The device must not be secured so tightly as to interfere with vital functions, including circulation, or so loose as to permit chafing of the skin. Padding on the inside of the device, which aids in preventing chafing, is required.(ii) Belts--A cloth or leather band fastened around the waist. The belt may either be attached to a stationary object (e.g., chair frame) or used for securing the arms to the sides of the body. The device must not be secured so tightly as to interfere with vital functions, including breathing and circulation.(iii) Chair restraint--A well-padded stabilized chair that supports all body parts and prevents the individual's voluntary egress from the chair without assistance (e.g., table top chair, Geri-chair). Mechanical restraint devices (e.g., wristlets, anklets) are attached or may be easily attached to restrict movement. The devices must not be secured so tightly as to interfere with vital functions, including breathing and circulation.(iv) Ties--A length of cloth or leather used to secure approved mechanical restraints (i.e., mittens, wristlets, arm splints, belts, anklets, vests, etc.) to a stationary object (i.e., bed or wheelchair frame) or to other approved mechanical restraints. Ties must not be secured so tightly as to interfere with vital functions, including breathing and circulation.(v) Wristlets--A cloth or leather band fastened around the wrist or arm and secured to a stationary object (e.g., bed or chair frame, waist belt). Acceptable fasteners include Velcro and buckles. The device must not be secured so tightly as to interfere with vital functions, including circulation or so loose as to permit chafing of the skin. Padding on the inside of the device, which aids in preventing chafing, is required.(76) Medication Error--Medication not given according to the written order by the prescribing professional or as recommended on the medication label. Medication errors include without limitation, duplicate doses, missed doses, and doses of the wrong amount or drug.(77) Minor--A person under the age of 18.(78) Neglect--A negligent act or omission by provider personnel, a staff member, volunteer, or other individual working under the auspices of a provider, or by a counselor, applicant for counselor licensure, or counselor intern that causes or may cause death, physical injury, or substantial emotional harm to a participant or client. Examples of neglect include, but are not limited to:(A) failure to provide adequate nutrition, clothing, or health care;(B) failure to provide a safe environment free from abuse;(C) failure to maintain adequate numbers of appropriately trained staff;(D) failure to establish or carry out an appropriate individualized treatment plan; and(E) any other act or omission classified as neglect by the Texas law including, but not limited to, TEX. FAM. CODE §261.001 (Vernon 1996) and TEX. HUM. RES. CODE §48.002 (Vernon Supp. 2004).(79) Advanced Practice Nurse Practitioner--A registered nurse currently licensed in Texas who is approved by the Texas State Board of Nurse Examiners to engage in advanced practice.(80) Offender Education Program--An Alcohol Education Program for Minors, Drug Offender Education Program, DWI Education Program, or DWI Intervention Program approved by the Commission under 40 TAC ch. 153 of this title (relating to Offender Education Programs).(81) OMB--United States Office of Management and Budget.(82) On Duty--Present, ready, awake and able to perform job duties at the physical locations where services are provided.(83) Outcome--The results of a service on clients or participants or the service delivery system itself.(84) Outreach--Activities directed toward finding individuals who might not use services due to lack of awareness or active avoidance.(85) Participant--An individual who is receiving prevention or intervention services.(86) Party--A person or agency formally named or admitted as a party.(87) Person--An individual, corporation, organization, government or governmental subdivision or agency, business trust, estate, trust, partnership, association, or any other legal entity.(88) Personal Restraint--Physical contact to control or restrict an individual's physical movement or actions. See also Mechanical Restraint.(89) Personnel--The members of the governing body of a provider and, without limitation, its staff, employees, contractors, consultants, agents, representatives, volunteers, or other individuals working for or on behalf of the provider through a formal or informal agreement.(90) Pleading--A written document submitted by a party, or a person seeking to participate in a case as a party, which requests procedural or substantive relief, makes claims, alleges facts, makes legal argument, or otherwise addresses matters involved in the case.(91) Practice of Chemical Dependency Counseling Services--Providing or offering to provide chemical dependency counseling services involving the application of the principles, methods, and procedures of the chemical dependency counseling profession as defined by the activities listed in the domains of TAP 21 "Addictions Counseling Competencies: the Knowledge, Skills, and Attitudes of Professional Practice" published by CSAT.(92) Prevention--A proactive process that uses multiple strategies to preclude the illegal use of alcohol, tobacco and other drugs and to foster safe, healthy, drug-free environments.(93) Private Practice--The individual practice of a private, licensed health care practitioner who personally renders individual or group services within the scope of the practitioner's license and in the practitioner's offices. To qualify to be engaged in private practice, the individual licensed health care practitioner must not hold him/herself out as an organized program, or a part thereof, that provides counseling or treatment. This definition does not prohibit the sharing of office space or administrative support staff.(94) Program--A specific type of service delivered to a specific population, at a specific location.(95) Proprietary School--An organization approved and regulated by the Texas Workforce Commission under 40 TAC ch. 807 (2003) (relating to Proprietary Schools) that offers a course of study in chemical dependency counseling.(96) Protective Factors--Characteristics within individuals and social systems which may inoculate or protect persons against risk factors and strengthen their determination to reject or avoid substance abuse.(97) Provider--A person that performs or offers to perform substance abuse services. The term includes but is not limited to, a qualified credentialed counselor, applicant for counselor licensure, and counselor intern.(98) Qualified Credentialed Counselor (QCC)--A licensed chemical dependency counselor or one of the practitioners listed below who is licensed and in good standing in the State of Texas and has at least 1,000 hours of documented experience treating substance-related disorders:(A) licensed professional counselor (LPC);(B) licensed master social worker (LMSW);(C) licensed marriage and family therapist (LMFT);(D) licensed psychologist;(E) licensed physician;(F) licensed physician's assistant;(G) certified addictions registered nurse (CARN); or(H) advanced practice nurse practitioner recognized by the Board of Nurse Examiners as a clinical nurse specialist or nurse practitioner with a specialty in psych-mental health (APN-P/MH).(99) Qualified Mental Health Professional--A qualified mental health professional as defined in the 25 TAC §401.583 (15) (2003).(100) Recovery Maintenance--A level of treatment designed to maintain and support a client's continued recovery.(101) Referral--The process of identifying appropriate services and providing the information and assistance needed to access them.(102) Residential Site--A physical location owned, leased, or operated by a provider where clients reside in a supervised treatment environment.(103) Respondent--A person against whom the Commission seeks an administrative, civil or criminal remedy for non-compliance with law and rules governing substance abuse services.(104) Restraint--See Personal and Mechanical Restraint.(105) Retaliate--Actions taken to punish or discourage a person, including a participant or client, who reports a violation of these rules or cooperates with an investigation, inspection, or intimidation proceeding by the Commission. Such actions include, but are not limited to, suspension or termination of employment, demotion, discharge, transfer, discipline, abuse, neglect, restriction of privileges, harassment, or discrimination.(106) Risk Factor--A characteristic or attribute of an individual, group, or environment associated with an increased probability of certain disorders, addictive diseases, or behaviors.(107) Risk Management--The process of identifying, evaluating and taking steps to minimize the risk associated with any activity, function, or process.(108) Rules--An agency statement of general applicability that implements, or prescribes law or policy by defining general standards of conduct, rights, or obligations of persons, or describes the procedure or practice requirements that prescribe the manner in which public business before an agency may be initiated, scheduled, or conducted, or interprets or clarifies law or agency policy. The term includes the amendment or repeal of a prior rule but does not include statements concerning only the internal management or organization of the agency and does not affect private rights or procedures. This definition includes regulations. Any reference to the rules herein shall mean Commission rules currently in effect unless otherwise specified.(109) Screening--The process through which a qualified staff, client or participant, and available significant others determine the most appropriate initial course of action, given the individual's needs and characteristics and the available resources within the community. In a treatment program, screening includes determining whether an individual is appropriate and eligible for admission to a particular program.(110) Seclusion--Confinement of an individual for a period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented.(111) Selective Program--A prevention program designed to target subsets of the total population that are deemed to be at higher risk for substance abuse by virtue of membership in a particular population segment. Risk groups may be identified on the basis of biological, psychological, social or environmental risk factors, and targeted groups may be defined by age, gender, family history, place of residence, or victimization by physical and/or sexual abuse. Selective prevention programs target the entire subgroup regardless of the degree of individual risk.(112) Services--Substance abuse services.(113) Service Coordination--Administrative, clinical, and evaluative activities that bring the client, treatment services, community agencies, and other resources together to focus on issues and needs identified in the treatment plan. Service coordination, which includes care management and client advocacy, establishes a framework of action for the client to achieve specified goals. It involves collaboration with the client and significant others, coordination of treatment and referral services, liaison activities with community resources and managed care systems, client advocacy, and ongoing evaluation of treatment progress and client needs.(114) Sexual Exploitation--A pattern, practice, or scheme of conduct by provider personnel or other individual working under the auspices of a provider, or by a counselor, intern, or applicant that involves a client or participant and can reasonably be construed as being for the purpose of sexual arousal or gratification or sexual abuse. It may include sexual contact, a request for sexual contact, or a representation that sexual contact or exploitation is consistent with, a part of or, a condition of receiving services. It is not a defense to sexual exploitation of a client, or participant if it occurs:(A) with consent of the client or participant;(B) outside of the delivery of services; or(C) off of the premises used for the delivery of substance abuse services; or(D) after the client or participant is no longer receiving services, unless it occurred two years after the client or participant stopped receiving services.(115) Signature--Authentication of a record that meets the criteria established in §148.507 of this title (relating to General Documentation Requirements).(116) Staff--Individuals working for a person in exchange for money or other compensation.(117) State Office of Administrative Hearings (SOAH)--The agency to which contested cases are referred by the Commission.(118) Substance Abuse--A maladaptive pattern of substance use leading to clinically significant impairment or distress, as defined by the most recently published version of the DSM.(119) Substance Abuse Education--A planned, structured presentation of information provided by qualified staff, which is related to substance abuse or substance dependence, allows for discussion of the material presented and is relevant to the client or participant's goals.(120) Substance Abuse Services (Services)--A comprehensive term intended to describe activities undertaken to address any substance-related disorder as well as prevention activities. The term includes the provision of screening, assessment, referral, treatment for chemical dependency and chemical dependency counseling.(121) Substance-Related Disorders--Defined by the most recently published version of the DSM.(122) TCADA--Texas Commission on Alcohol and Drug Abuse(123) Texas Public Information Act--TEX. GOV'T CODE ANN. ch. 552 (Vernon 2000 & Supp. 2004).(124) Therapeutic Services for Women--Education, services and/or therapy to address: parenting, reproductive and general health, self-esteem, physical and sexual abuse, mental health, child development and self-sufficiency.(125) Toxic Inhalant--A gaseous substance that is inhaled by a person to produce a desired physical or psychological effect and that may cause personal injury or illness to the inhaler.(126) Treatment--See Chemical Dependency Treatment.(127) Treatment Facility--(A) a public or private hospital;(B) a detoxification facility;(C) a primary care facility;(D) an intensive care facility;(E) a long-term care facility;(F) an outpatient care facility;(G) a community mental health center;(H) a health maintenance organization;(I) a recovery center;(J) a halfway house;(K) an ambulatory care facility; or(L) any other facility that offers or purports to offer treatment.(128) Treatment Planning--A collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them. At a minimum, the treatment plan addresses the identified substance use disorder(s), as well as issues related to treatment progress, including relationships with family and significant others, employment, education, spirituality, health concerns, and legal needs.(129) Unethical Conduct--Conduct prohibited by the ethical standards adopted by state or national professional organizations or by rules established by a profession's state licensing agency.(130) Unit Rate--A payment mechanism in which a specified rate of payment is made in exchange for a specified unit of service.(131) Universal Population--Universal prevention programs are delivered to large groups without any prior screening for substance abuse risk. A prevention program designed to address an entire population with messages and programs aimed at preventing or delaying the use and abuse of alcohol, tobacco, and other drugs.(132) Utilization Review--The process of evaluating the necessity, appropriateness and efficiency of the use of chemical dependency treatment services, procedures and facilities.(133) Youth--Individuals between the ages of 13 through 17. See also Young Adult in chapters 147 and 148 of this title (relating to Contract Program Requirements and Standard of Care). Source Note: The provisions of this §564.1 adopted to be effective February 1, 2004, 29 TexReg 460; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES A GENERAL PROVISIONS §564.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217766 03/12/2026 The purpose of these rules is to ensure that individuals seeking substance abuse services are offered an efficient, effective, and appropriate continuum of services that will enable them to lead a normal life as a productive member of society. These rules further serve to protect the health, safety, and welfare of those receiving substance abuse services. Source Note: The provisions of this §564.2 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES A GENERAL PROVISIONS §564.2 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217767 03/12/2026 (a) All providers shall comply with the provisions of Subchapter B in all matters related to the provision of services.(b) Providers who offer or purport to offer chemical dependency treatment and are not exempt from licensure under TEX. HEALTH & SAFETY CODE ANN. ch. 464 (Vernon 2001) are also required to comply with the provisions of Subchapter D through Subchapter N.(c) Providers who engage in prevention or intervention activities shall also comply with the requirements of Subchapter C, and §148.703 of this title (relating to Abuse, Neglect and Exploitation). Source Note: The provisions of this §564.3 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES A GENERAL PROVISIONS §564.3 Scope of Rule https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217768 03/12/2026 The provider shall provide adequate and appropriate services consistent with best practices and industry standards. The provider shall maintain objectivity. The provider shall respect each individual's dignity, and shall not engage in any action that may cause injury and shall always act with integrity in providing services. Source Note: The provisions of this §564.4 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.4 General Standard https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217769 03/12/2026 The provider shall recognize the limitations of their ability and shall not offer services outside the provider's scope of practice or use techniques that exceed their professional competence. The provider shall not make any claim, directly or by implication, that they possess professional qualifications or affiliations that they do not possess. Source Note: The provisions of this §564.5 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.5 Scope of Practice https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217773 03/12/2026 Providers shall plan, supervise adequately, and evaluate any activity for which they are responsible. Providers shall render services carefully and promptly. Providers shall follow the technical and ethical standards related to the provision of services, strive continually to improve personal competence and quality of service delivery, and discharge their professional responsibility to the best of their abilities. Providers are responsible for assessing the adequacy of their own competence for the responsibility to be assumed. Services shall be designed and administered as to do no harm to recipients. The provider shall always act in the best interest of the individual being served. The provider shall terminate any professional relationship that is not beneficial, or is in any way detrimental, to the individual being served. Source Note: The provisions of this §564.6 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.6 Competence and Due Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217774 03/12/2026 Services should be appropriate for the individual's needs and circumstances, including age and developmental level, and should be culturally sensitive. Providers shall possess an understanding of the cultural norms of the individuals receiving services. Services shall be respectful and non exploitative. Source Note: The provisions of this §564.7 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.7 Appropriate Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217775 03/12/2026 The provider shall report information fairly, professionally, and accurately when providing services and when communicating with other professionals, the Commission, and the general public. Each provider shall document and assign credit to all contributing sources used in published material or public statements. Providers shall not misrepresent either directly or by implication professional qualifications or affiliations. Source Note: The provisions of this §564.8 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.8 Accuracy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217776 03/12/2026 The provider shall maintain required documentation of services provided and related transactions including financial records. Source Note: The provisions of this §564.9 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.9 Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217777 03/12/2026 The provider shall not discriminate against any individual on the basis of gender, race, religion, age, national origin, disability (physical or mental), sexual orientation, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected. The provider may consider economic condition and financial resources in admission criteria, but economic condition shall not affect the services once an individual is admitted. Source Note: The provisions of this §564.10 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.10 Discrimination https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217784 03/12/2026 The provider shall provide access to services, including providing information about other services and alternative providers, taking into account an individual's financial constraints and special needs. Source Note: The provisions of this §564.11 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.11 Access to Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217785 03/12/2026 The provider shall not offer or provide services in settings or locations that are inappropriate or harmful to individuals served or others. Source Note: The provisions of this §564.12 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.12 Location https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217786 03/12/2026 The provider shall protect the privacy of individuals served and shall not disclose confidential information without express written consent, except as permitted by law. The provider shall remain knowledgeable of, and obey, all State and Federal laws and regulations relating to confidentiality of records relating to the provision of services. The provider shall not discuss or divulge information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes that demonstrably relate to the case. Confidential information acquired during delivery of services shall be safeguarded from illegal or inappropriate use, access and disclosure or from loss, destruction or tampering. These safeguards shall protect against verbal disclosure, prevent unsecured maintenance of records, or recording of an activity or presentation without appropriate releases. Source Note: The provisions of this §564.13 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.13 Confidentiality https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217787 03/12/2026 The provider shall provide an appropriate, safe, clean, and well-maintained environment. Source Note: The provisions of this §564.14 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.14 Environment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217788 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217788 03/12/2026 The provider shall inform the individual receiving services about all relevant and important aspects of the service relationship. Source Note: The provisions of this §564.15 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.15 Communications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217789 03/12/2026 The provider shall not exploit relationships with individuals receiving services for personal or financial gain of the provider or its personnel. The provider shall not charge exorbitant or unreasonable fees for any service. The provider shall not pay or receive any commission, consideration, or benefit of any kind related to the referral of an individual for services. Source Note: The provisions of this §564.16 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.16 Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217792 03/12/2026 When a provider or its personnel have knowledge of unethical conduct or practice on the part of a person or provider, they have a responsibility to report the conduct or practices to appropriate funding or regulatory bodies or to the public. Any provider or provider personnel who receive an allegation or have reason to suspect that an individual has been, is, or will be subject to abuse, neglect or exploitation by any provider shall immediately inform TCADA's investigations division. The provider shall also take immediate action to prevent or stop the abuse, neglect, or exploitation and provide appropriate care and treatment. The provider shall report allegations of child abuse or neglect to the Texas Department of Protective and Regulatory Services as required by the TEX. FAM. CODE ANN. §261.101 (Vernon 2002 & Supp. 2004). The provider shall report allegations of abuse, neglect or exploitation of elderly or disabled individuals to the Texas Department of Protective and Regulatory Services as required by the TEX. HUM. RES. CODE ANN. §48.051 (Vernon 2001 & Supp. 2004). If the allegation involves sexual exploitation, the service provider shall comply with reporting requirements listed in the TEX. CIV. PRAC. & REM. CODE ANN. §81.006 (Vernon 1997 & Supp. 2004). Source Note: The provisions of this §564.17 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.17 Duty to Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217793 03/12/2026 Providers should recognize the effect of impairment on professional performance and should be willing to seek needed treatment. Where there is evidence of impairment in a colleague, a provider should be supportive of assistance or treatment. An employer shall provide access to information regarding available services to impaired employees. Source Note: The provisions of this §564.18 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.18 Impaired Providers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217794 03/12/2026 Providers shall adhere to established professional codes of ethics. These codes of ethics define the professional context within which the provider works, in order to maintain professional standards and safeguard the client or participant. Provider and all of its personnel shall protect consumers and act in an ethical manner at all times. Source Note: The provisions of this §564.19 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.19 Ethics https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217797 03/12/2026 In addition to the provider's general duty to provide services in a professional manner, the following acts are specifically prohibited and shall constitute a violation of these rules:(1) Providers shall not provide services, interact with individuals receiving services, or perform any job duties while under the influence or impaired by the use of alcohol, or mood altering substances, including prescription medications not used in accordance with a physician's order.(2) Providers shall not commit an illegal, unprofessional or unethical act (including acts constituting abuse, neglect, or exploitation).(3) Providers shall not assist or knowingly allow another person to commit an illegal, unprofessional, or unethical act.(4) Providers shall not falsify, alter, destroy or omit significant information from required reports and records or interfere with their preservation.(5) Providers shall not retaliate against anyone who reports a violation of these rules or cooperates during a review, inspection, investigation, hearing, or other related activity.(6) Providers shall not interfere with Commission reviews, inspections, investigations, hearings, or related activities. This includes taking action to discourage or prevent someone else from cooperating with the activity.(7) Providers shall not enter into a personal or business relationship of any type with an individual receiving services until at least two years after the last date an individual receives services from the provider.(8) Providers shall not discourage, intimidate, harass, or retaliate against individuals who try to exercise their rights or file a grievance.(9) Providers shall not restrict, discourage, or interfere with any communication with law enforcement, an attorney, or with the Commission for the purposes of filing a grievance.(10) Providers shall not allow unqualified persons or entities to provide services.(11) Provider shall not hire or utilize known sex offenders in adolescent programs or programs that house children.(12) Providers shall prohibit adolescent clients and participants from using tobacco products on the program site. Staff and other adults (volunteers, clients, participants and visitors) shall not use tobacco products in the presence of adolescent clients or participants. Source Note: The provisions of this §564.20 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.20 Specific Acts Prohibited https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217798 03/12/2026 (a) The facility and all of its personnel shall protect clients' rights and provide competent services.(b) Any person associated with the facility that receives an allegation or has reason to suspect that a person associated with the facility has been, is, or will be engaged in illegal, unethical, or unprofessional conduct shall immediately inform the Commission's investigations division and the facility's chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported to the Commission and the facility's governing body.(c) The facility and its personnel shall comply with TEX. HEALTH & SAFETY CODE ANN. ch. 164 (Vernon 2001 & Supp. 2003)(relating to Treatment Facilities Marketing and Admission Practices).(d) The facility shall have written policies on staff conduct that complies with this section. Source Note: The provisions of this §564.21 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES B STANDARD OF CARE APPLICABLE TO ALL PROVIDERS §564.21 Standards of Conduct https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220250 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220250 03/12/2026 (a) A facility shall comply with the following balance billing requirements.(1) A facility may not violate a law that prohibits the facility from billing a patient who is an insured, participant, or enrollee in a managed care plan an amount greater than an applicable copayment, coinsurance, and deductible under the insured's, participant's, or enrollee's managed care plan or that imposes a requirement related to that prohibition.(2) A facility shall comply with Senate Bill 1264, 86th Legislature, Regular Session, 2019, and with related Texas Department of Insurance rules at 28 TAC Chapter 21, Subchapter OO, §§21.4901 - 21.4904 (relating to Disclosures by Out-of-Network Providers) to the extent this subchapter applies to the facility.(b) A facility shall comply with the itemized bill requirements under Texas Health and Safety Code §185.002. Source Note: The provisions of this §564.28 adopted to be effective April 15, 2021, 46 TexReg 2435; amended to be effective August 18, 2024, 49 TexReg 6221. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES C OPERATIONAL REQUIREMENTS §564.28 Billing Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222388 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222388 03/12/2026 (a) The purpose of this section is to establish the requirements for an educational program on the dangers of substance misuse pursuant to Texas Transportation Code Chapter 521, Subchapter P.(b) Pursuant to Texas Transportation Code §521.374(a)(2), a residential chemical dependency treatment facility (CDTF) may provide an educational program to a resident of that facility whose driver's license is suspended under Texas Transportation Code §521.372. The facility must meet all requirements in this section for the CDTF's educational program to be considered equivalent under Texas Transportation Code §521.374(a)(2) to an educational program approved by the Texas Department of Licensing and Regulation under Texas Government Code Chapter 171.(c) A CDTF that provides an educational program under this section may provide the educational program in person or online.(d) The curriculum for an educational program provided under this section shall include at least the following key elements:(1) Texas drug laws, including laws and penalties relating to controlled substances and the difference between state and federal statutes;(2) history of substance misuse, including trends in the history of substance misuse and how substances impact individuals and society;(3) stages of change, including how individuals integrate new behaviors and goals through five stages of change;(4) substance misuse and the impact on physical health;(5) physical health, human immunodeficiency virus (HIV), and sexually transmitted infections;(6) community resources, including referrals to counseling, services that support the person's recovery, and testing;(7) brain and the central nervous system;(8) disease model of substance use disorder (mild, moderate, and severe);(9) society and substance misuse, including how advertising, movies, and television influence substance misuse trends;(10) Maslow's hierarchy of needs, including understanding basic human needs and how substance misuse impacts a person's ability to meet personal needs;(11) substance misuse and its impact on personal and work relationships;(12) personal values, attitude, and behavior;(13) recovery, including treatment and community-based support programs or services;(14) return to use prevention; and(15) recovery plan.(e) A CDTF that provides an online version of an educational program under this section shall comply with §564.911 of this chapter (relating to Treatment Services Provided by Electronic Means).(f) A CDTF that provides an in-person version of an educational program under this section shall conduct the educational program's course at the CDTF's physical location.(g) The CDTF shall make provisions for residents unable to read or speak English. The facility shall provide separate courses in English and in a second language(s) appropriate to the population(s) served at the CDTF.(h) To serve as an instructor of an educational program under this section, an individual must be an employee of the CDTF and must have a minimum of two years of relevant and documented experience providing direct client services to persons with substance misuse problems and serve as one of the following:(1) licensed chemical dependency counselor;(2) registered counselor intern;(3) licensed social worker;(4) licensed professional counselor;(5) licensed professional counselor intern;(6) certified teacher;(7) licensed psychologist;(8) licensed physician or psychiatrist;(9) probation or parole officer;(10) adult or child protective services worker;(11) licensed vocational nurse; or(12) licensed registered nurse.(i) A single instructor shall teach the entire course. The instructor shall document all information related to the resident participating and completing the course. The CDTF shall ensure all course documentation is placed in the resident's client record.(j) The instructor shall:(1) require participants to complete all the class modules within the course in the proper sequence;(2) administer and evaluate pre-course and post-course program test instruments for each participant;(3) administer a participant course evaluation at the end of each course; and(4) conduct an exit interview with each participant.(k) Each educational program shall include at least:(1) 15 hours of class instruction per course; and(2) five class modules of instruction per course.(l) In order for the Texas Department of Public Safety (DPS) and Texas Health and Human Services Commission (HHSC) to accept a certificate as valid, the CDTF shall use the standardized certificate format described in this subsection.(1) The CDTF shall create and issue a certificate of completion to a resident on the resident's participation in and successful completion of the educational program. The CDTF shall maintain an ascending numerical accounting record of all issued certificates.(2) The certificate issued by the CDTF for completion of the education program under this section shall use the following format and, at minimum, consist of the following:(A) The CDTF shall create a certificate that:(i) is 8.5 inches wide and 3.5 inches long;(ii) consists of a blue background color; and(iii) aside from the required handwritten signature, consists only of a typed 12-point font that is legible and easy to read.(B) The CDTF shall include on the left side of the certificate:(i) the resident's:(I) full name;(II) date of birth;(III) driver's license or identification card number;(IV) address; and(V) offense cause number;(ii) the name of the county that convicted the resident; and(iii) the date the resident successfully completed the educational program under this section.(C) The CDTF shall include on the right side of the certificate:(i) the CDTF's:(I) full name as it appears on the facility's license, including any headquarters or Assumed Name or Doing Business As names;(II) address;(III) phone number; and(IV) residential facility license number;(ii) the instructor's printed full name and signature; and(iii) the date of the instructor's signature.(D) The CDTF shall include a serial number unique to each certificate issued in the top right corner of the certificate. When creating certificate serial numbers, the CDTF shall use consecutive serial numbers and issue certificates to residents in consecutive order.(3) The CDTF shall maintain a copy of each issued certificate of program completion for at least three years from the date of course completion.(m) An HHSC representative may determine compliance with this section during an inspection or investigation of a CDTF that offers an educational program under this section.(n) In accordance with Transportation Code §521.375(a-1), HHSC and DPS are responsible for jointly adopting rules for qualification and approval of an educational program a CDTF provides under this section. For any proposed changes to the rules outlined in this section, HHSC solicits input from DPS during the rulemaking process. Source Note: The provisions of this §564.39 adopted to be effective November 28, 2024, 49 TexReg 9756. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES C OPERATIONAL REQUIREMENTS §564.39 Dangers of Substance Misuse Educational Program Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217799 03/12/2026 (a) A facility providing or offering chemical dependency treatment in Texas shall have a license issued by the Texas Health and Human Services Commission (HHSC) unless it is:(1) a facility maintained or operated by the Federal government or its agencies;(2) a facility directly operated by the State of Texas;(3) a facility licensed by HHSC under Texas Health and Safety Code Chapter 241, 243, 248, 466, or 577;(4) an educational program for intoxicated drivers;(5) an individual who personally provides counseling or support services to a person with a chemical dependency but does not offer or purport to offer a chemical dependency treatment program;(6) the private practice of a licensed health care practitioner or licensed chemical dependency counselor who personally renders individual or group services within the scope of the practitioner's license and in the practitioner's office;(7) a religious organization registered under Texas Health and Safety Code Chapter 464, Subchapter C;(8) a 12-step or similar self-help chemical dependency recovery program:(A) that does not offer or purport to offer a chemical dependency treatment program;(B) that does not charge program participants; and(C) in which program participants may maintain anonymity;(9) a juvenile justice facility or juvenile justice program, as defined by Texas Family Code §261.405; or(10) a satellite office or location in which the person providing services is operating under the supervision of a licensed outpatient care facility and the services delivered at the satellite site fall within the scope of the licensure of the outpatient care facility.(b) The facility shall have a license for each physical location at which it provides residential services or outpatient services.(c) A license is not transferable to a separate legal entity or to a different physical address. Source Note: The provisions of this §564.401 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.401 License Required https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217800 03/12/2026 (a) The Commission's executive director or designee may grant a temporary variance to a facility or group of facilities.(b) To be eligible for a variance, a facility shall show:(1) an alternative method is used to meet the intent of the rule; and(2) the variance will not jeopardize the health, safety, or welfare of clients or compromise substance abuse services.(c) The Commission's executive director or designee will determine if an alternative is equivalent to the written rule and when it will be accepted during licensure reviews.(d) A variance cannot be granted for a statutory requirement.(e) The grounds for, and term of, the variance shall be set forth in writing. Source Note: The provisions of this §564.402 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.402 Variances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217804 03/12/2026 (a) An applicant for initial licensure shall submit a complete licensure application, operational plan as described in §148.502 of this title (relating to Operational Plan, Policies and Procedures), items outlined on the new applicant checklist, proof of liability insurance, and an application fee.(b) Within 45 days of receipt of the application, the Commission will notify the applicant that the application is materially complete or specify the additional information required.(c) The applicant shall submit all requested materials and correct any deficiencies identified by the Commission within specified time frames.(d) If an on-site inspection is necessary, the Commission will conduct the inspection within 45 days of receiving a materially complete application packet. The Commission will notify the provider of any deficiencies identified during an on-site inspection within 30 days, and the provider shall provide evidence of sufficient corrective action within the timeframe specified in the inspection report.(e) The Commission will issue the license within 45 days of receiving all required evidence of compliance and all required fees.(f) If an applicant fails to provide evidence of compliance within six months from the date the application is received, the application will be denied. Six months after the date of denial, the applicant may reapply by submitting a new application and application fee.(g) The applicant shall not provide chemical dependency treatment before receiving written notice of licensure approval.(h) The facility shall display its licensure certificate prominently at each outpatient location and each approved residential site. Source Note: The provisions of this §564.403 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.403 New Licensure Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217805 03/12/2026 (a) A license issued by the Commission expires two years from the date of issuance.(b) The licensee shall file a request for renewal and pay the renewal fee at least 60 days before the license expires. Failure to file the required renewal and pay the renewal fee as specified may delay approval.(c) The facility shall not provide services after the license expiration date unless it has submitted the application update and fee by the date of expiration. Source Note: The provisions of this §564.404 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.404 Licensure Renewal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217809 03/12/2026 (a) A facility shall submit the appropriate application and fees and receive written approval before:(1) adding a new detoxification service;(2) adding a new residential site;(3) moving to a new residential site; or(4) increasing the number of beds in a residential program.(b) If the facility fails to provide the information the Commission requires to process the change in status application within six months from the date of application, the application may be denied. The facility shall not reapply for six months from the date of denial.(c) A facility shall also notify the Commission's licensure department in writing before adding a new residential service, day treatment service or outpatient service; adding a new outpatient site or moving an outpatient site to a new location; or providing services to a new age group or gender.(d) A facility shall notify the Commission's facility licensure department prior to, or immediately after, a change in the organization's name, closure of a residential or outpatient location, decrease in the number of residential beds or discontinuance of a service. Source Note: The provisions of this §564.405 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.405 Changes in Status https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217810 03/12/2026 (a) Inactive Status. The Commission will automatically retire the license of a facility site in which services are suspended or not provided for more than 60 days, unless the facility sends a written request to place the license on inactive status. To be eligible for inactive status, the facility must be in good standing with no pending legal actions or investigations.(1) If granted, inactive status is limited to 60 days. The licensee is responsible for all licensure fees and for proper maintenance of client records while on inactive status.(2) To reactivate the license, the facility shall submit a written request to reactivate the license no later than the date the inactivation period expires.(3) If the license is not reactivated, it will be automatically retired at the end of the 60 day deactivation period.(b) Closure. The facility shall notify the Commission's facility licensure department in writing prior to or immediately upon closure of a chemical dependency treatment program.(1) A license becomes invalid when a program closes. The licensure certificate shall be returned to the Commission's licensure department within 30 days.(2) When a facility closes, the provider shall ensure that all clients are appropriately discharged or transferred before the program closes and make appropriate arrangements for properly maintaining client records in compliance with Federal and State law and Commission rules. Source Note: The provisions of this §564.406 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.406 Inactive Status and Closure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217813 03/12/2026 The Commission may conduct a scheduled or unannounced inspection or request materials for review at reasonable times, including any time treatment services are provided. The facility shall allow Commission staff to access the facility's grounds, buildings, and records. The facility shall allow Commission staff to interview members of the governing body, staff, and clients. The facility shall make all property, records, and documents available upon request for examination, copy, or reproduction, on or off premises. Source Note: The provisions of this §564.407 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.407 Licensure Inspection https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217814 03/12/2026 (a) A facility shall pay the full licensure fee for any licensure period during which it provides chemical dependency treatment. Failure to notify the licensure department of closure does not excuse a licensee from paying fees.(b) Fees shall be paid in full by cashier's check, or money order.(c) The schedule for licensure fees is:(1) base fee for initial and renewal licenses, which includes application and review fees--$1,200;(2) fee for each outpatient or residential site located at a separate physical address--$125; and(3) fee per bed--$35.(d) A $25 fee is charged for a printed list of licensed facilities, a set of mailing labels for licensed facilities, or a replacement certificate.(e) Licensure fees are not refundable. Source Note: The provisions of this §564.408 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective February 1, 2006, 31 TexReg 401; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.408 Licensure Fees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217817 03/12/2026 (a) The Commission may take action as described herein against an applicant for licensure or a facility if the applicant, licensee, owner, member of the governing body, administrator, or clinical staff member, or any other personnel associated with the applicant or licensee:(1) has a documented history of client abuse, exploitation, or neglect;(2) violates any provision of TEX. HEALTH & SAFETY CODE ANN. ch. 464 (Vernon 2001 & Supp. 2004), or any other applicable statute, or a Commission rule; or(3) owes the Commission money.(b) Action taken may include:(1) suspending or revoking a license;(2) refusing to issue or renew a license;(3) placing a facility on probation when the facility's license has been suspended;(4) imposing an administrative penalty; and(5) any other action allowed under the law or these rules.(c) The Commission will determine the length of probation or suspension. The Commission may hold a hearing at any time and revoke probation or suspension.(d) Surrender or expiration of a license does not interrupt an investigation or action taken against a license. The facility is not eligible to regain the license until all outstanding investigations, disciplinary proceedings, or hearings are resolved and the licensee is found to have acted in compliance with these rules.(e) If a facility has its license revoked, its governing body, administrators, and management are not eligible to apply for, or be associated with an application for facility licensure until they have petitioned the Commission and demonstrated the following:(1) they were not directly involved in, aware of, or responsible for the acts or omissions that were the basis of the revocation; or(2) sufficient time has passed to allow the events that led to the revocation to no longer serve as the basis of denial of application for licensure.(f) After an investigation has been initiated by the Commission, or a facility's license has been revoked or surrendered, a facility is not eligible to receive a faith-based exemption under Subchapter O of this title (relating to Faith-Based Chemical Dependency Programs) until two years have elapsed. Source Note: The provisions of this §564.409 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES D FACILITY LICENSURE INFORMATION §564.409 Action Against a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217818 03/12/2026 (a) Governing Body. If incorporated, the facility shall have a governing body and shall have legal authority to operate in the State of Texas. If the organization is governed by a board of directors, the board shall meet with sufficient frequency to monitor the quality of care provided and maintain minutes for each meeting. The governing body shall ensure that members are provided training regarding their responsibilities and liabilities.(b) Organizational Structure. The facility shall maintain current documentation of the organization's staffing structure, including lines of supervision and the number of staff members for each position.(c) Facility Contact Information. The facility shall provide the Commission's facility licensure department with a current mailing address, electronic mail address (if any), contact name, and contact phone number in writing or through electronic mail and shall update that information in writing or through electronic mail when there are changes. The facility is deemed to have received any correspondence or notice mailed to the address provided. Source Note: The provisions of this §564.501 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.501 Facility Organization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217819 03/12/2026 (a) The facility shall operate according to an operational plan. The operational plan shall reflect:(1) program purpose or mission statement;(2) services and how they are provided;(3) description of the population to be served; and(4) goals and objectives of the program.(b) The facility shall adopt and implement written policies and procedures as deemed necessary by the facility and as required herein. The policies and procedures shall contain sufficient detail to ensure compliance with all applicable Commission rules.(c) The policy and procedure manual shall be current, consistent with program practices, individualized to the program, and easily accessible to all staff at all times. Source Note: The provisions of this §564.502 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.502 Operational Plan, Policies and Procedures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217820 03/12/2026 Facilities shall submit the following information annually, electronically or in paper form, in a format provided by the Commission, unless a current contract with TCADA is in effect:(1) total number of clients served by diagnosis;(2) gender of clients served;(3) ethnicity of clients served;(3) ages of clients served;(4) primary and secondary drug at admission;(5) discharge reason per treatment episode, including length of stay at time of discharge; and(6) average percent of occupancy for each residential program. Source Note: The provisions of this §564.503 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.503 Reporting Measures https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217735 03/12/2026 The facility shall develop procedures and implement a quality management process. The procedures shall address at a minimum:(1) goals and objectives that relate to the program purpose or mission statement;(2) methods to review the progress toward the goals and a documented process to implement corrections or changes;(3) a mechanism to review and analyze incident reports, monitor compliance with rules and other requirements, identify areas where quality is not optimal and procedures to analyze identified issues, implement corrections, and evaluate and monitor their ongoing effectiveness;(4) methods of utilization review to ensure appropriate client placement, adequacy of services provided and length of stay; and(5) documentation of the activities of the quality management process. Source Note: The provisions of this §564.504 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.504 Quality Management https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217736 03/12/2026 (a) The facility shall comply with applicable requirements of the Americans with Disabilities Act (ADA). The facility shall maintain documentation that it has conducted a self-inspection to evaluate compliance and implemented a corrective action plan, as necessary, with reasonable time frames to address identified deficiencies.(b) The facility shall have a certificate of occupancy from the local authority that reflects the current use by the occupant or documentation that the locality does not issue occupancy certificates.(c) The site, including grounds, buildings, electrical and mechanical systems, appliances, equipment, and furniture shall be structurally sound, in good repair, clean, and free from health and safety hazards.(d) The facility shall provide a safe, clean, well-lighted and well-maintained environment.(e) The facility shall have adequate space, furniture, and supplies.(f) The facility shall have private space for confidential interactions, including all group counseling sessions.(g) The facility shall prohibit smoking inside facility buildings and vehicles and during structured program activities. If smoking areas are permitted, they shall be clearly marked as designated smoking areas and shall not be less than 15 feet from any entrance to any building(s) and comply with local codes and ordinances. Staff shall not provide or facilitate client access to tobacco products.(h) The facility shall prohibit firearms and other weapons, alcohol, illegal drugs, illegal activities, and violence on the program site or at or during the course of any program activity, except as provided for in paragraphs (1) and (2) of this subsection. The facility shall be responsible for any noncompliance with this subsection.(1) The facility may allow a clergy member to bring four ounces or less of alcohol on site or to a program activity for purposes of presiding over a religious or spiritual rite, as long as the alcohol remains in the possession, custody, or control of the presiding clergy member at all times while on the program site or at the program activity, is not distributed, and is consumed only by the presiding clergy member, if at all.(2) The facility shall inform any clergy member bringing alcohol on site or to a program activity under paragraph (1) of this subsection of the requirements of this subsection. The facility shall create and maintain documentation, which shall be available to staff of the Department of State Health Services upon request, reflecting each date and time when alcohol is permitted to be brought onto the program site or to a program activity pursuant to this subsection. The documentation shall include the name, address, and title of the clergy member, and shall document staff verification that the clergy member was self-identified as such, that alcohol was brought on site or to a program activity and that it was thereafter either removed from the site or program activity, or represented by the presiding clergy member to have been personally consumed.(i) Animals shall be properly vaccinated and supervised. Source Note: The provisions of this §564.505 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective October 1, 2006, 31 TexReg 8105; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.505 General Environment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217737 03/12/2026 (a) The facility shall post a legible copy of the following documents in a prominent public location that is readily available to clients, visitors, and staff:(1) the Client Bill of Rights;(2) the Commission's current poster on reporting complaints and violations; and(3) the client grievance procedure.(b) These documents shall be displayed in English and in a second language(s) appropriate to the population(s) served at every location where services are provided. Source Note: The provisions of this §564.506 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.506 Required Postings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217738 03/12/2026 (a) The facility shall keep complete, current documentation.(b) All documents shall be factual and accurate.(c) All documents and entries shall be dated and authenticated by the person responsible for the content.(1) Authentication of paper records shall be an original signature that includes at least the first initial, last name, and credentials. Initials may be used if the client record includes a document that identifies all individuals initialing entries, including the full printed name, signature, credentials, and initials.(2) Authentication of electronic records shall be by a digital authentication key.(d) Documentation shall be permanent and legible.(e) When it is necessary to correct a client record, incident report, or other document, the error shall be marked through with a single line, dated, and initialed by the writer.(f) Records shall contain only those abbreviations included on the facility's list of approved abbreviations. Source Note: The provisions of this §564.507 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.507 General Documentation Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217742 03/12/2026 (a) The facility shall establish and maintain a single record for every client beginning at the time of admission. The content of client records shall be complete, current, and well organized.(b) The facility shall protect all client records and other client-identifying information from destruction, loss, tampering, and unauthorized access, use or disclosure.(1) All active client records shall be stored at the facility. Inactive records, if stored off-site, shall be fully protected. All original client records shall be maintained in the State of Texas.(2) Information that identifies those seeking services shall be protected to the same degree as information that identifies clients.(3) Electronic client information shall be protected to the same degree as paper records and shall have a reliable backup system.(c) Only personnel whose job duties require access to client records shall have such access.(d) Personnel shall keep records locked at all times unless authorized staff is continuously present in the immediate area.(e) The facility shall ensure that all client records can be located and retrieved upon request at all times.(f) The facility shall comply with Federal and State confidentiality laws and regulations, including 42 C.F.R pt. 2 (Federal regulations on the Confidentiality of Alcohol and Drug Abuse Patient Records), TEX. HEALTH & SAFETY CODE ANN. ch. 611 (Vernon Supp. 2004)(relating to Mental Health Records) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The facility shall also protect the confidentiality of HIV information as required in TEX. HEALTH & SAFETY CODE ANN. §81.103 (Vernon 2001) (relating to Confidentiality; Criminal Penalty).(g) The facility shall not deny clients access to the content of their records except as provided by TEX. HEALTH & SAFETY CODE ANN. §611.0045 (Vernon Supp. 2004) and HIPAA.(h) Client records shall be maintained for at least six years. Records of adolescent clients shall be maintained for at least five years after the client turns 18.(i) If client records are microfilmed, scanned, or destroyed, the facility shall take steps to protect confidentiality. The facility shall maintain a record of all client records destroyed on or after September 1, 1999, including the client's name, record number, birth date, and dates of admission and discharge. Source Note: The provisions of this §564.508 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.508 Client Records https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217743 03/12/2026 (a) The facility shall report to the Commission's investigations division, all allegations of client abuse, neglect, and exploitation. Acts constituting client abuse, neglect and exploitation are specifically described in §148.703 of this title (relating to Abuse, Neglect, and Exploitation).(b) The facility shall complete an internal incident report for all client incidents, including:(1) a violation of a client rights, including but not limited to, allegations of abuse, neglect and exploitation;(2) accidents and injuries;(3) medical emergencies;(4) psychiatric emergencies;(5) medication errors;(6) illegal or violent behavior;(7) loss of a client record;(8) personal or mechanical restraint or seclusion;(9) release of confidential information without client consent;(10) fire;(11) death of an active outpatient or residential client (on or off the program site);(12) clients absent without permission from a residential program;(13) suicide attempt by an active client (on or off the program site);(14) medical and psychiatric emergencies that result in admission to an inpatient unit of a medical or psychiatric facility; and(15) any other significant disruptions.(c) The incident report shall be completed within 24 hours of the occurrence of an incident on-site, or within 24 hours of when the facility became aware of, or reasonably should have known of an incident that occurred off-site. The incident report shall provide a detailed description of the event, including the date, time, location, individuals involved, and action taken.(d) The individual writing the report shall sign it and record the date and time it was completed.(e) All incident reports shall be stored in a single, separate file.(f) The facility shall have a designated individual responsible for reviewing incident reports and all incidents should be evaluated through the quality management process to determine opportunities to improve or address program and staff performance. Source Note: The provisions of this §564.509 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.509 Incident Reporting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217744 03/12/2026 (a) The facility shall have a written policy on the use of facility vehicles and/or staff to transport clients.(b) If the facility allows the use of facility vehicles and/or staff to transport clients, it shall adopt transportation procedures which include the following.(1) Any vehicle used to transport a client must have appropriate insurance coverage for business use with a current safety inspection sticker and license.(2) All vehicles used to transport clients must be maintained in safe driving condition.(3) Drivers must have a valid driver's license.(4) Drivers and passengers must wear seatbelts at all times the vehicle is in operation as required by law.(5) A vehicle shall not be used to transport more passengers than designated by the manufacturer.(6) Drivers shall not use cell phones while driving.(7) Use of tobacco products shall not be allowed in the vehicle.(8) Every vehicle used for client transportation shall have a fully stocked first aid kit and an A:B:C fire extinguisher that are easily accessible. Source Note: The provisions of this §564.510 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES E FACILITY REQUIREMENTS §564.510 Client Transportation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217746 03/12/2026 (a) A facility whose personnel includes counselor interns shall be registered with the Commission as a clinical training institution and comply with all applicable requirements.(b) The facility shall verify by Internet, telephone or letter and document the current status of all required credentials with the credentialing authority.(c) The facility shall be aware of its obligations under TEX. CIV. PRAC. & REM. CODE ANN. §81.003 (Vernon 1997 & Supp. 2004).(d) The facility shall obtain and assess the results of a criminal background check from the Department of Public Safety on all staff within four weeks of the hiring date. Individuals hired may not have any client contact until the results of the criminal background check are assessed. The facility shall use the criteria listed in TEX. OCC. CODE ANN. §53.022, §53.023 (Vernon 2004) to evaluate criminal history reports and make related employment decisions.(e) The facility shall not hire an individual who has not passed a pre-employment drug test that meets criteria established by the Commission. This requirement does not restrict facilities from implementing random drug testing of its staff as permitted by law.(f) The facility shall develop a job description which outlines job duties and minimum qualifications for all personnel.(g) The facility shall maintain a personnel file for each employee, and all contractors, students and volunteers with any direct client contact which contains documentation demonstrating compliance with this section. Source Note: The provisions of this §564.601 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES F PERSONNEL PRACTICES AND DEVELOPMENT §564.601 Hiring Practices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217747 03/12/2026 (a) The facility shall ensure that students and volunteers comply with all applicable rules.(b) Students and volunteers shall be qualified to perform assigned duties.(c) Students and volunteers shall receive orientation and training appropriate to their qualifications and responsibilities.(d) Students and volunteers shall be appropriately supervised. Source Note: The provisions of this §564.602 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES F PERSONNEL PRACTICES AND DEVELOPMENT §564.602 Students and Volunteers https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217748 03/12/2026 (a) Unless otherwise specified, video, manual, or computer-based training is acceptable if the supervisor discusses and documents the material with the staff person in a face-to-face session to highlight key issues and answer questions. (b) The facility shall maintain documentation of all required training. (1) Documentation of external training shall include: (A) date; (B) number of hours; (C) topic; (D) instructor's name; and (E) signature of the instructor (or equivalent verification). (2) The facility shall maintain documentation of all internal training. For each topic, the file shall include: (A) an outline of the contents; (B) the name, credentials, relevant qualifications of the person providing the training, and (C) the method of delivery. (3) For each group training session, the facility shall maintain on file a dated attendee sign-in sheet. (c) Prior to performing their duties and responsibilities, the facility shall provide orientation to staff, volunteers, and students. This orientation shall include information addressing: (1) TCADA rules; (2) facility policies and procedures; (3) client rights; (4) client grievance procedures; (5) confidentiality of client-identifying information (42 C.F.R. pt. 2; HIPAA); (6) standards of conduct; and (7) emergency and evacuation procedures. (d) The following initial training(s) must be received within the first 90 days of employment and must be completed before the employee can perform a function to which the specific training is applicable. Subsequent training must be completed as specified. (1) Abuse, Neglect, and Exploitation. All residential program personnel with any direct client contact shall receive eight hours of face-to-face training as described in Figure: 40 TAC §148.603(d)(1) which is attached hereto and incorporated herein as if set forth at length. All outpatient program personnel with any direct client contact shall received two hours of abuse, neglect and exploitation training. Attached Graphic(2) HIV, Hepatitis B and C, Tuberculosis and Sexually Transmitted Diseases. All personnel with any direct client contact shall receive this training. The training shall be based on the Texas Commission on Alcohol and Drug Abuse Workplace and Education Guidelines for HIV and Other Communicable Diseases. (A) The initial training shall be three hours in length. (B) Staff shall receive annual updated information about these diseases. (3) Cardio Pulmonary Resuscitation (CPR). (A) All direct care staff in a residential program shall maintain current CPR and First Aid certification. (B) Licensed health professionals and personnel in licensed medical facilities are exempt if emergency resuscitation equipment and trained response teams are available 24 hours a day. (4) Nonviolent Crisis Intervention. All direct care staff in residential programs and outpatient programs shall receive this training. The face-to-face training shall teach staff how to use verbal and other non-physical methods for prevention, early intervention, and crisis management. The instructor shall have documented successful completion of a course for crisis intervention instructors or have equivalent documented training and experience. (A) The initial training shall be four hours in length. (B) Staff shall complete two hours of annual training thereafter. (5) Restraint and/or Seclusion. All direct care staff in residential programs and programs accepting court commitments that use or authorize the use of restraint or seclusion shall have face-to-face training and demonstrate competency in the safe methods of the specific procedures before assuming job duties involving direct care responsibilities. This includes programs that accept adolescent residential and emergency detentions. (A) The initial training must be four hours in length. (B) Staff shall complete four hours of annual training thereafter. (C) The training shall include hands-on practice under the supervision of a qualified instructor. (D) The training program shall include: (i) identifying the underlying causes of threatening behaviors exhibited by the clients receiving services; (ii) identifying aggressive or threatening behavior; (iii) explaining how the behavior of personnel can affect the behaviors of clients; (iv) using de-escalation, mediation, self-protection, and other techniques; (v) recognizing and responding to signs of physical distress in clients who are being restrained, if the facility uses or authorizes the use of restraint; (vi) identifying the risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds, if the facility uses or authorizes the use of restraint; (vii) the initiation of seclusion, if the facility uses or authorizes the use of seclusion; (viii) the application of personal restraint, if the facility uses or authorizes the use of personal restraint; (ix) the application of approved restraint devices, if the facility has on premises, authorizes the use of, or uses any mechanical restraint devices; (x) monitoring cardiac and respiratory status and interpreting their relevance to the physical safety of the client in restraint, if the facility uses or authorizes the use of restraint, or seclusion, if the facility uses or authorizes the use of seclusion; (xi) addressing physical and psychological status and comfort, including signs of distress; (xii) assisting clients in meeting behavioral criteria for the discontinuation of restraint, if the facility uses or authorizes the use of restraint, or seclusion, if the facility uses or authorizes the use of seclusion; (xiii) recognizing readiness for the discontinuation of restraint, if the facility uses or authorizes the use of restraint, or seclusion, if the facility uses or authorizes the use of seclusion; and (xiv) recognizing when to contact emergency medical services to evaluate and/or treat a client for an emergency medical condition. (6) Intake, Screening and Admission Authorization. All staff who conduct intake, screening and authorize admission for applicants to receive program services shall complete training in the program's screening and admission procedures. The training shall include two hours of DSM diagnostic criteria for substance-related disorders, and other mental health diagnoses. (A) The initial training shall be eight hours in length. (B) Staff shall complete eight hours of annual training thereafter. (C) The training shall be completed before staff screen or authorize applicants for admission. (7) Self-administration of Medication. All personnel responsible for supervising clients in self-administration of medication, who are not credentialed to administer medication, shall complete this training before performing this task. (A) Staff shall complete two hours initial one time training. (B) The training shall be provided by a physician, pharmacist, physician assistant, or registered nurse before administering medication and shall include: (i) prescription labels; (ii) medical abbreviations; (iii) routes of administration; (iv) use of drug reference materials; (v) storage, maintenance, handling, and destruction of medication; (vi) documentation requirements; and (vii) procedures for medication errors, adverse reactions, and side effects. Source Note: The provisions of this §564.603 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective June 1, 2006, 31 TexReg 4433; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES F PERSONNEL PRACTICES AND DEVELOPMENT §564.603 Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217749 03/12/2026 (a) The facility shall respect, protect, implement and enforce each client right required to be contained in the facility's Client Bill of Rights. The Client Bill of Rights for all facilities shall include:(1) You have the right to accept or refuse treatment after receiving this explanation.(2) If you agree to treatment or medication, you have the right to change your mind at any time (unless specifically restricted by law).(3) You have the right to a humane environment that provides reasonable protection from harm and appropriate privacy for your personal needs.(4) You have the right to be free from abuse, neglect, and exploitation.(5) You have the right to be treated with dignity and respect.(6) You have the right to appropriate treatment in the least restrictive setting available that meets your needs.(7) You have the right to be told about the program's rules and regulations before you are admitted, including, without limitation, the rules and policies related to restraints and seclusion. Your legally authorized representative, if any, also has the right to be and shall be notified of the rules and policies related to restraints and seclusion.(8) You have the right to be told before admission:(A) the condition to be treated;(B) the proposed treatment;(C) the risks, benefits, and side effects of all proposed treatment and medication;(D) the probable health and mental health consequences of refusing treatment;(E) other treatments that are available and which ones, if any, might be appropriate for you; and(F) the expected length of stay.(9) You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan.(10) You have the right to meet with staff to review and update the plan on a regular basis.(11) You have the right to refuse to take part in research without affecting your regular care.(12) You have the right not to receive unnecessary or excessive medication.(13) You have the right to have information about you kept private and to be told about the times when the information can be released without your permission.(14) You have the right to be told in advance of all estimated charges and any limitations on the length of services of which the facility is aware.(15) You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment.(16) You have the right to make a complaint and receive a fair response from the facility within a reasonable amount of time.(17) You have the right to complain directly to the Texas Commission on Alcohol and Drug Abuse at any reasonable time.(18) You have the right to get a copy of these rights before you are admitted, including the address and phone number of the Texas Commission on Alcohol and Drug Abuse.(19) You have the right to have your rights explained to you in simple terms, in a way you can understand, within 24 hours of being admitted.(b) For residential sites, the Client Bill of Rights shall also include:(1) You have the right not to be restrained or placed in a locked room by yourself unless you are a danger to yourself or others.(2) You have the right to communicate with people outside the facility. This includes the right to have visitors, to make telephone calls, and to send and receive sealed mail. This right may be restricted on an individual basis by your physician or the person in charge of the program if it is necessary for your treatment or for security, but even then you may contact an attorney or the Texas Commission on Alcohol and Drug Abuse at any reasonable time.(3) If you consented to treatment, you have the right to leave the facility within four hours of requesting release unless a physician determines that you pose a threat of harm to yourself and others.(c) If a client's right to free communication is restricted under the provisions of subsection (b)(2) of this section, the physician or program director shall document the clinical reasons for the restriction and the duration of the restriction in the client record. The physician or program director shall also inform the client, and, if appropriate, the client's consenter of the clinical reasons for the restriction and the duration of the restriction. Source Note: The provisions of this §564.701 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective June 1, 2006, 31 TexReg 4433; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.701 Client Bill of Rights https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217750 03/12/2026 (a) The facility shall have a written client grievance procedure.(b) Staff shall give each client and consenter a copy of the grievance procedure within 24 hours of admission and explain it in clear, simple terms that the client understands.(c) The grievance procedure shall tell clients that they can:(1) file a grievance about any violation of client rights or Commission rules;(2) submit a grievance in writing and get help writing it if they are unable to read or write; and(3) request writing materials, postage, and access to a telephone for the purpose of filing a grievance.(d) The procedure shall also inform clients that they can submit a complaint directly to the Commission at any time and include the current mailing address and toll-free telephone number of the Commission's investigations division.(e) The facility shall have a written procedure for staff to follow when responding to client grievances. The facility shall:(1) evaluate the grievance thoroughly and objectively, obtaining additional information as needed;(2) provide a written response to the client within seven days of receiving the grievance;(3) take action to resolve all grievances promptly and fairly; and(4) document all grievances, including the final disposition, and keep the documentation in a central file.(f) The facility shall not:(1) retaliate against clients who try to exercise their rights or file a grievance; or(2) restrict, discourage, or interfere with client communication with an attorney or with the Commission for the purposes of filing a grievance. Source Note: The provisions of this §564.702 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.702 Client Grievances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217751 03/12/2026 (a) Any person who receives an allegation or has reason to suspect that a client or participant has been, is, or will be abused, neglected, or exploited by any person shall immediately inform the Commission's investigations division and the provider's chief executive officer or designee. If the allegation involves the chief executive officer, it shall be reported directly to the provider's governing body.(1) The person shall also report allegations of child abuse or neglect to the Texas Department of Protective and Regulatory Services as required by TEX. FAM. CODE ANN. §261.101 (Vernon 2002 & Supp. 2004).(2) The person shall also report allegations of abuse or neglect of an elderly or disabled individual to the Texas Department of Protective and Regulatory Services as required by TEX. HUM. RES. CODE ANN. §48.051 (Vernon 2001 & Supp. 2004).(b) If the allegation involves sexual exploitation, the chief executive officer or designee shall comply with reporting requirements listed in TEX. CIV. PRAC. & REM. CODE ANN. §81.006 (Vernon 1997 & Supp. 2004).(c) The chief executive officer or designee shall take immediate action to prevent or stop the abuse, neglect, or exploitation and provide appropriate care.(d) The chief executive officer or designee shall ensure that a verbal report has been or is made to the Commission's investigations division as required in subsection (a) of this section.(e) The person who reported the incident shall submit a written incident report to the chief executive officer within 24 hours.(f) The chief executive officer or designee shall send a written report to the Commission's investigations division within two business days after receiving notification of the incident. This report shall include:(1) the name of the client or participant and the person the allegations are against;(2) the information required in the incident report or a copy of the incident report; and(3) other individuals, organizations, and law enforcement notified.(g) The chief executive officer or designee shall also notify the consenter. If the client is the consenter, family members may be notified only if the client gives written consent. If the consenter is not the client, the chief executive officer may withhold notification to the consenter if this action may place the client at additional risk. In this situation, the chief executive officer will notify the Commission's investigations division in writing of this decision.(h) The provider shall investigate the complaint and take appropriate action unless otherwise directed by the Commission's investigations division. The investigation and the results shall be documented.(i) The governing body or its designee shall take action needed to prevent any confirmed incident from recurring.(j) The provider shall:(1) document all investigations and resulting actions and keep the documentation in a single, segregated file;(2) have a written policy that clearly prohibits the abuse, neglect, and exploitation of clients and/or participants;(3) enforce appropriate sanctions for confirmed violations; including, but not limited to, termination of personnel with confirmed violations of client or participant physical or sexual abuse or instances of neglect that result in client or participant harm. Source Note: The provisions of this §564.703 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.703 Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217752 03/12/2026 (a) The facility shall establish therapeutically sound written program rules addressing client behavior designed to protect their health, safety, and welfare.(b) The consequences for violating program rules shall be defined in writing and shall include clear identification of violations that may result in discharge. The consequences shall be reasonable, take into account the client's diagnosis and progress in treatment, and shall not include:(1) physical discipline or measures involving the denial of food, water, sleep, or bathroom privileges; or(2) discipline that is authorized, supervised, or carried out by clients.(c) At the time of admission, every client shall be informed verbally, and in writing, of the program rules and consequences for violating the rules.(d) The facility shall enforce the rules fairly and objectively and shall not implement consequences for the convenience of staff. Source Note: The provisions of this §564.704 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.704 Program Rules https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217753 03/12/2026 (a) The facility shall not hire or utilize clients to fill staff positions. Former clients are not eligible for employment at the facility until at least two years after documented discharge from active treatment from the facility.(b) The facility shall not require clients to participate in any fund raising or publicity activities for the facility.(c) The facility and its personnel shall not enter into a business or personal relationship with a client, give a personal gift to a client, or accept a personal gift of value from a client until at least two years after services to the client cease. Source Note: The provisions of this §564.705 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.705 Client Labor and Interactions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217754 03/12/2026 (a) A small residential facility is defined as a treatment facility with less than eight licensed beds.(b) The governing body shall adopt a policy to either authorize or prohibit the use of personal restraint, mechanical restraint, and seclusion. Any facility authorizing use of restraint or seclusion shall comply with and have a written procedure that ensures compliance with Health and Safety Code, Chapter 322, including its definition of seclusion; the rules adopted under that chapter; and this section. Outpatient programs shall prohibit the use of restraint or seclusion, except as it relates to court commitment clients.(c) In programs authorizing use of restraint or seclusion, direct care staff shall be trained as described in the applicable provisions of §448.603 of this title (relating to Training). Staff sufficient in number and who have the training required by §448.603 of this title to safely implement any permitted restraint or seclusion shall be on duty at all times.(d) Staff shall not use restraint or seclusion unless it is necessary to intervene to prevent imminent probable death or substantial bodily harm to the client or imminent physical harm to another and less restrictive methods have been tried and failed.(e) Staff shall not use more force than is necessary to prevent imminent harm and shall ensure the safety, well-being, and dignity of clients who are restrained or secluded, including attention for personal needs. Staff shall not deny bathroom privileges, water, sleep, or regularly scheduled meals and snacks.(f) Staff shall obtain authorization from the supervising Qualified Credentialed Counselor (QCC) before starting restraint or seclusion or as soon as possible after initiation or implementation.(1) The facility shall not use standing authorizations for restraint or seclusion.(2) Authorization for mechanical restraint or seclusion shall be based on a face-to-face evaluation by the authorizing QCC, if on site or reasonably available, or by the direct care staff initiating or implementing the procedure.(3) Each authorization shall include a specific time limit, not to exceed 12 hours.(4) The QCC must take into consideration information that could contraindicate or otherwise affect the use of restraint or seclusion, including information obtained during the initial assessment of each client at the time of admission or intake. This information includes, but is not limited to:(A) techniques, methods, or tools that would help the client effectively cope with his or her environment;(B) pre-existing medical conditions or any physical disabilities and limitations, including substance use disorders, that would place the client at greater risk during restraint or seclusion;(C) any history of sexual or physical abuse that would place the client at greater psychological risk during restraint or seclusion; and(D) any history that would contraindicate seclusion, the type of restraint (personal or mechanical), or a particular type of restraint devise.(g) When the client has been safely restrained or secluded, staff shall tell the client what behavior and timeframes are required for release and shall release the client as soon as the criteria are met.(h) Clinical staff shall review and document alternative strategies for dealing with behaviors necessitating the use of restraint or seclusion for an individual client two or more times in any 30-day period.(i) The chief executive officer of the facility or designee shall review all incident reports involving restraint or seclusion and take action to address unwarranted use of these measures.(j) A client held in restraint shall be under continuous direct observation. The facility shall ensure adequate breathing and circulation during restraint and shall only use devices designed for therapeutic restraint. An acceptable hold is one that engages one or more limbs close to the body to limit or prevent movement and is performed in a manner consistent with the requirements set forth in this section.(k) Seclusion rooms shall be constructed to prevent clients from harming themselves and shall allow staff to observe clients easily in all parts of the room. When a client is in seclusion, staff shall conduct a visual check at least every 15 minutes.(l) Staff shall record the following information in the client record within 24 hours:(1) the circumstances leading to the use of restraint or seclusion;(2) the specific behavior necessitating the restraint or seclusion and the behavior required for release;(3) less restrictive interventions that were tried before restraint or seclusion began;(4) the signed authorization of the supervising QCC;(5) the names of the staff members who implemented the restraint or seclusion;(6) the date and time the procedure began and ended;(7) the behavior and timeframes required for release;(8) the client's response;(9) observations made, including the 15 minute checks; and(10) attention given for personal needs.(m) A prone or supine hold shall not be used except as a last resort when other less restrictive interventions have proven to be ineffective. The hold shall be used only to transition a client into another position, and shall not exceed one minute in duration. Except in small residential facilities, when the prone or supine hold is used, an observer, who is trained to identify the risks associated with positional, compression, or restraint asphyxiation and with prone and supine holds, and who is not involved in the restraint, shall ensure the client's breathing is not impaired.(n) No intervention, voluntary or involuntary, shall be used:(1) as a means of discipline, retaliation, punishment, or coercion;(2) for the purpose of convenience of staff members or other individuals; or(3) as a substitute for effective treatment.(o) A restraint shall not be used that:(1) secures a client to a stationary object while the client is in a standing position;(2) causes pain to restrict a client's movement (pressure points or joint locks);(3) restricts circulation;(4) obstructs a client's airway, including a procedure that places anything in, on, or over a client's mouth or nose or puts pressure on the torso;(5) impairs a client's breathing;(6) interferes with a client's ability to communicate; or(7) is inconsistent with training received in compliance with §448.603 of this title (relating to Training).(p) Use of chemical restraint is prohibited.(q) Use of restraint or seclusion solely as a behavior therapy program or as part of a behavior therapy program is prohibited.(r) Immediately following the release of a client from restraint or seclusion, a direct care staff must:(1) take appropriate action to facilitate the client's reentry into the facility environment by providing the client with transition activities and an opportunity to return to ongoing activities;(2) observe the client for at least 15 minutes; and(3) document observations of the client's behavior during this transition period in the client's record.(s) As soon as possible after an episode of restraint or seclusion, staff members involved in the episode, supervisory staff, the client, the legally authorized representative, if any, and, with the consent of the client, family members must meet to discuss the episode. The purpose of the debriefing is to:(1) identify what led to the episode and what could have been handled differently;(2) identify strategies to prevent future restraint or seclusion, taking into consideration suggestions from the client;(3) ascertain whether the client's physical well-being, psychological comfort, and right to privacy were addressed;(4) counsel the client in relation to any trauma that may have resulted from the episode;(5) when indicated, identify appropriate modifications to the client's treatment plan; and(6) when clinically indicated or upon request of individuals who witnessed the restraint debrief persons who witnessed the restraint. Source Note: The provisions of this §564.706 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective June 1, 2006, 31 TexReg 4433; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.706 Restraint and Seclusion https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217755 03/12/2026 (a) The facility shall ensure that staff have the training and resources necessary to protect the health and safety of clients and other individuals during medical and psychiatric emergencies.(b) The facility shall have written procedures for responding to medical and psychiatric emergencies.(c) Emergency numbers shall be posted by all telephones.(d) The facility shall have fully stocked first aid supplies that are visible, labeled and easy to access. Source Note: The provisions of this §564.707 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.707 Responding to Emergencies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217756 03/12/2026 (a) All facilities shall adopt a written policy on client searches. Client searches include personal searches and searches of a client's property or sleeping quarters. If client searches are allowed, the facility shall adopt a written search procedure that ensures the protection of client rights.(b) Client searches may only be conducted to protect the health, safety, and welfare of clients, staff, or the facility.(c) Searches shall be conducted in a professional manner that maintains respect and dignity for the client. The facility shall not conduct a directly observed strip search of any client.(d) A witness shall be present during all client searches.(e) Staff and witnesses involved in a personal search must be the same gender as the client.(f) Routine searches of possessions performed when a client returns to a facility may be documented in a central log. All other client searches shall be documented in the client record, including the reason for the search, the result of the search, and the signatures of the individual conducting the search and the witness. Source Note: The provisions of this §564.708 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES G CLIENT RIGHTS §564.708 Searches https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217757 03/12/2026 (a) To be eligible for admission to a treatment program, an individual must meet the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for substance use disorders (or substance withdrawal or intoxication in the case of a detoxification program). The facility shall use a screening process appropriate for the target population, individual's age, developmental level, culture, and gender, which includes the Texas Department of Insurance (TDI) criteria to determine eligibility for admission or referral including an assessment of the client's financial resources and insurance benefits.(b) The screening process shall collect other information as necessary to determine the type of services that are required to meet the individual's needs. This may necessitate the administration of all or part of validated assessment instruments.(c) TDI criteria shall guide referral and treatment recommendations as well as placement decisions.(d) Sufficient documentation shall be maintained in the client record to support the diagnosis and justify the referral or placement decision. Documentation shall include the date of the screening and the signature and credentials of the Qualified Credentialed Counselor (QCC) supervising the screening process.(e) For admission to a detoxification program, the screening will be conducted by a physician, the physician's designee, physician assistant, nurse practitioner, registered nurse, or licensed vocational nurse (LVN). An LVN may conduct a screening under the following conditions:(1) the LVN has completed detoxification training and demonstrated competency in the detoxification process;(2) the training and competency verification is documented in the LVN's personnel file;(3) the LVN shall convey in person or via telephone the medical data obtained during the screening process to a physician or the physician's designee, who shall determine the appropriateness of the admission and authorize the admission or give instructions for an alternative course of action; and(4) the physician or the physician's designee shall examine the client in person and sign the admission order within 24 hours of authorizing admission.(f) For admission to all other treatment programs, the screening will be conducted by a counselor or counselor intern.(g) A detoxification program shall not offer screenings through electronic means.(h) A treatment program, other than a detoxification program, may offer screenings in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1) of this chapter (relating to Treatment Services Provided by Electronic Means). A facility offering screenings through electronic means shall comply with the applicable requirements under §448.911 of this chapter and the following requirements.(1) Prior to screening an individual through electronic means:(A) a counselor intern, licensed professional counselor assistant (LPC-A), or licensed master social worker (LMSW) must have more than 2,000 hours of supervised work experience or have a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure); and(B) if the provider is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam.(2) A counselor or counselor intern screening an individual through electronic means shall use synchronous audiovisual technology, as that term is defined by §448.911(a)(4) of this chapter, except as provided under paragraph (3) of this subsection.(3) To the extent allowed by federal law and only when all the following criteria are met, the counselor or counselor intern may screen an individual using synchronous audio-only technology, as that term is defined by §448.911(a)(3) of this chapter, when:(A) the screening occurs during a declared state of disaster under Texas Government Code §418.014 (relating to Declaration of State of Disaster) in the county in which the facility where the client signed the client's consent for treatment form is located;(B) the counselor or counselor intern determines and documents a justification for their determination in the individual's record that screening the individual using synchronous audio-only technology is safe and clinically appropriate for the individual being screened and the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen the individual; and(C) the individual being screened agrees and provides verbal consent, as that term is defined by §448.911(a)(5) of this chapter, to participate in a screening using synchronous audio-only technology.(4) The counselor or counselor intern shall conduct an in-person and face-to-face screening with an individual at the individual's request or if the individual does not provide their verbal consent to participate in a screening through electronic means as required by §448.911(u) of this chapter. Source Note: The provisions of this §564.801 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; amended to be effective February 22, 2024, 49 TexReg 871; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES H SCREENING AND ASSESSMENT §564.801 Screening https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217758 03/12/2026 (a) A QCC shall authorize each admission in writing and specify the level of care to be provided. If the screening counselor or intern is not qualified to authorize admission, the QCC shall review the results of the screening with the applicant, directly or indirectly, before authorizing admission. The authorization shall be documented in the client record and shall contain sufficient documentation to support the diagnosis and the placement decision.(b) The facility shall obtain written authorization from the consenter before providing any treatment or medication. The consent form shall be dated and signed by the client, the consenter, and the staff person providing the information, and shall document that the client and consenter have received and understood the following information:(1) the specific condition to be treated;(2) the recommended course of treatment;(3) the expected benefits of treatment;(4) the probable health and mental health consequences of not consenting;(5) the side effects and risks associated with the treatment;(6) any generally accepted alternatives and whether an alternative might be appropriate;(7) the qualifications of the staff that will provide the treatment;(8) the name of the primary counselor;(9) the client grievance procedure;(10) the Client Bill of Rights as specified in §148.701 of this title;(11) the program rules, including rules about visits, telephone calls, mail, and gifts, as applicable;(12) violations that can lead to disciplinary action or discharge;(13) any consequences or searches used to enforce program rules;(14) the estimated daily charges, including an explanation of any services that may be billed separately to a third party or to the client, based on an evaluation of the client's financial resources and insurance benefits;(15) the facility's services and treatment process; and(16) opportunities for family to be involved in treatment.(c) This information shall be explained to the client and consenter in simple, non-technical terms. If an emergency or the client's physical or mental condition prevents the explanation from being given or understood by the client within 24 hours, staff shall document the circumstances in the client record and present the explanation as soon as possible. Documentation of the explanation shall be dated and signed by the client, the consenter, and the staff person providing the explanation.(d) The client record shall include a copy of the Client Bill of Rights dated and signed by the client and consenter.(e) If possible, all information shall be provided in the consenter's primary language.(f) If an individual is not admitted, the program shall refer and assist the applicant to obtain appropriate services.(g) When an applicant is screened and determined to be eligible for services but denied admission, the facility shall maintain documentation signed by the examining QCC which includes the reason for the denial and all referrals made. Source Note: The provisions of this §564.802 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES H SCREENING AND ASSESSMENT §564.802 Admission Authorization and Consent to Treatment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217759 03/12/2026 (a) A counselor or counselor intern shall conduct and document a comprehensive psychosocial assessment with the client admitted to the facility. The assessment shall document and elicit enough information about the client's past and present status to provide a thorough understanding of the following areas:(1) presenting problems resulting in admission;(2) alcohol and other drug use;(3) psychiatric and chemical dependency treatment;(4) medical history and current health status, to include an assessment of Tuberculosis (TB), HIV and other sexually transmitted disease (STD) risk behaviors as permitted by law;(5) relationships with family;(6) social and leisure activities;(7) education and vocational training;(8) employment history;(9) legal problems;(10) mental/emotional functioning; and(11) strengths and weaknesses.(b) The counselor or counselor intern may conduct the assessment with a client in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1) of this chapter (relating to Treatment Services Provided by Electronic Means). A facility offering assessments through electronic means shall comply with the applicable requirements under §448.911 of this chapter and the following requirements.(1) Prior to conducting an assessment through electronic means:(A) a counselor intern, licensed professional counselor assistant (LPC-A), or licensed master social worker (LMSW) must have more than 2,000 hours of supervised work experience or have a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure); and(B) if the provider is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam.(2) A counselor or counselor intern assessing a client through electronic means shall use synchronous audiovisual technology, as that term is defined by §448.911(a)(4) of this chapter, except as provided under paragraph (3) of this subsection.(3) To the extent allowed by federal law and only when all the following criteria are met, the counselor or counselor intern may assess a client using synchronous audio-only technology, as that term is defined by §448.911(a)(3) of this chapter, when:(A) the assessment occurs during a declared state of disaster under Texas Government Code §418.014 (relating to Declaration of State of Disaster) in the county in which the facility where the client signed their consent for treatment form is located;(B) the counselor or counselor intern determines and documents a justification for their determination in the client's record that assessing the client using synchronous audio-only technology is safe and clinically appropriate for the client being assessed and the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen the individual; and(C) the client being assessed agrees and provides verbal consent, as that term is defined by §448.911(a)(5) of this chapter, to participate in an assessment using synchronous audio-only technology.(4) The counselor or counselor intern shall conduct an in-person and face-to-face assessment with a client at the client's request or if the client does not provide their verbal consent to participate in an assessment through electronic means, as required by §448.911(u) of this chapter.(c) The assessment shall result in a comprehensive listing of the client's problems, needs, and strengths.(d) The assessment shall result in a comprehensive diagnostic impression. The diagnostic impression shall correspond to current Diagnostic and Statistical Manual of Mental Disorders (DSM) standards. A licensed intern or other provider shall operate within the scope of their license when conducting assessments.(e) If the assessment identifies a potential mental health problem, the facility shall obtain a mental health assessment and seek appropriate mental health services when resources for mental health assessments or services, or both, are available internally or through referral at no additional cost to the program. These services shall be provided by a facility or person authorized to provide such services or a qualified professional as described in §448.901 of this chapter (relating to Requirements Applicable to all Treatment Services).(f) The assessment shall be signed by a QCC and filed in the client record within three individual service days of admission.(g) The program may accept an evaluation from an outside source if:(1) it meets the criteria set forth herein;(2) it was completed during the 30 days preceding admission or is received directly from a facility that is transferring the client; and(3) a counselor reviews the information with the client and documents an update.(h) For residential clients, a licensed health professional shall conduct a health assessment of the client's physical health status within 96 hours of admission. The facility may accept a health assessment from an outside source completed no more than 30 days before admission or received directly from a transferring facility. If the client has any physical complaints or indications of medical problems, the client shall be referred to a physician, physician assistant, or nurse practitioner for a history and physical examination. The examination, if needed, shall be completed within a reasonable time frame and the results filed in the client record. Source Note: The provisions of this §564.803 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; amended to be effective February 22, 2024, 49 TexReg 871; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES H SCREENING AND ASSESSMENT §564.803 Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217760 03/12/2026 (a) The counselor and client shall work together to develop and implement an individualized, written treatment plan that identifies services and support needed to address problems and needs identified in the assessment. When appropriate, family shall also be involved.(1) When the client needs services not offered by the facility, appropriate referrals shall be made and documented in the client record. When feasible, other QCCs or mental health professionals serving the client from a referral agency should participate in the treatment planning process.(2) The client record shall contain justification when identified needs are temporarily deferred or not addressed during treatment.(b) The treatment plan shall include goals, objectives, and strategies.(1) Goals shall be based on the client's problems/needs, strengths, and preferences.(2) Objectives shall be individualized, realistic, measurable, time specific, appropriate to the level of treatment, and clearly stated in behavioral terms.(3) Strategies shall describe the type and frequency of the specific services and interventions needed to help the client achieve the identified goals and shall be appropriate to the level of intensity of the program in which the client is receiving treatment.(c) The treatment plan shall identify discharge criteria and include initial plans for discharge. The Texas Department of Insurance criteria shall be used as a general guideline for determining when clients are appropriate for transfer or discharge, but individualized criteria shall be specifically developed for each client.(d) A treatment plan shall include a projected length of stay.(e) The treatment plan shall identify the client's primary counselor, and shall be dated and signed by the client, and the counselor. When the treatment plan is conducted by an intern or graduate, a QCC shall review and sign the treatment plan.(f) The treatment plan shall be completed and filed in the client record within five individual service days of admission.(g) The treatment plan shall be evaluated on a regular basis and revised as needed to reflect the ongoing reassessment of the client's problems, needs, and response to treatment.(h) The primary counselor shall meet with the client to review and update the treatment plan at appropriate intervals defined in writing by the program. At a minimum, treatment plans shall be reviewed midway through the projected duration of treatment, and no less frequently than monthly in residential programs.(i) The treatment plan review shall include:(1) an evaluation of the client's progress toward each goal and objective;(2) revision of the goals, objectives; and(3) justifications of continued length of stay.(j) Treatment plan reviews shall be dated and signed by the client, the counselor and the supervising QCC, if applicable.(k) When a client's intensity of service is changed, the client record shall contain:(1) clear documentation of the decision signed by a QCC, including the rationale and the effective date;(2) a revised treatment plan; and(3) documentation of coordination activities with receiving treatment provider.(l) Program staff shall document all treatment services (counseling, chemical dependency education, and life skills training) in the client record within 72 hours, including the date, nature, and duration of the contact, and the signature and credentials of the person providing the service.(1) Education, life skills training, and group counseling notes shall also include the topic/issue addressed.(2) Individual counseling notes shall include the goals addressed, clinical observation and new issues or needs identified during the session. Source Note: The provisions of this §564.804 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES H SCREENING AND ASSESSMENT §564.804 Treatment Planning, Implementation and Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217761 03/12/2026 (a) The counselor and client/consenter shall develop and implement an individualized discharge plan.(b) Discharge plans shall be updated as the client progresses through treatment and shall address the continued appropriateness of the current treatment level.(c) The discharge plan shall address continuity of services to the client.(1) When a client is referred or transferred to another chemical dependency or mental health service provider for continuing care, the facility shall contact the receiving program before the client is discharged to make arrangements for the transfer.(2) Coordination activities shall be documented in the client record, including timeframe for client being able to access needed services and any constraints associated with the referral.(3) With proper client consent, the facility shall provide the receiving program with copies of relevant parts of the client's record.(d) The program shall involve the client's family or an alternate support system in the discharge planning process when appropriate.(e) Discharge planning shall be completed before the client's scheduled discharge.(f) A written discharge plan shall be developed to address ongoing client needs, including:(1) individual goals or activities to sustain recovery;(2) referrals; and(3) recovery maintenance services, if applicable.(g) The completed discharge plan shall be dated and signed by the counselor, the client, and the consenter (if applicable).(h) The program shall give the client and consenter a copy of the plan, and file the original signed plan in the client record.(i) The program shall complete a discharge summary for each client within 30 days of discharge. The discharge summary shall be signed by a QCC and shall include:(1) dates of admission and discharge;(2) needs and problems identified at the time of admission, during treatment, and at discharge;(3) services provided;(4) assessment of the client's progress towards goals;(5) reason for discharge; and(6) referrals and recommendations, including arrangements for recovery maintenance.(j) The facility shall contact each client no sooner than 60 days and no later than 90 days after discharge from the facility and document the individual's current status or the reason the contact was unsuccessful. Source Note: The provisions of this §564.805 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES H SCREENING AND ASSESSMENT §564.805 Discharge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217762 03/12/2026 (a) Each client's treatment shall be based on a treatment plan developed from the client's comprehensive assessment.(b) Group counseling sessions are limited to a maximum of 16 clients. Group education and life skills training sessions are limited to a maximum of 35 clients. This limit does not apply to multi-family educational groups, seminars, outside speakers, or other events designed for a large audience.(c) Chemical dependency education and life skills training shall follow a written curriculum. All educational sessions shall include client participation and discussion of the material presented.(d) The program shall provide education about Tuberculosis (TB), HIV, Hepatitis B and C, and sexually transmitted diseases (STDs) based on the Texas Commission on Alcohol and Drug Abuse Workplace and Education Guidelines for HIV and Other Communicable Diseases.(e) The program shall provide education about the health risks of tobacco products and nicotine addiction.(f) The program shall provide access to screening for TB and testing for HIV antibody, Hepatitis C, and STDs.(1) HIV antibody testing shall be carried out by an entity approved by the Texas Department of Health.(2) If a client tests positive, the program shall refer the client to an appropriate health care provider.(g) The program shall facilitate access to physical health, mental health, and ancillary services if those services are not available through the program and are necessary to meet treatment goals and shall document these efforts.(h) Individuals shall not be denied admission or discharged from treatment because they are taking prescribed medication.(i) The facility shall maintain an adequate number of qualified staff to comply with licensure rules, provide appropriate and individualized treatment, and protect the health, safety, and welfare of clients.(j) All personnel shall receive the training and supervision necessary to ensure compliance with Commission rules, provision of appropriate and individualized treatment, and protection of client health, safety and welfare.(k) Direct care staff shall be awake and on site during all hours of program operation.(l) Residential direct care staff included in staff-to-client ratios shall not have job duties that prevent ongoing and consistent client supervision.(m) Residential programs shall have at least one counselor on duty at least eight hours a day, six days a week.(n) Clients in residential programs shall have an opportunity for eight continuous hours of sleep each night. Staff shall conduct and document at least three checks while clients are sleeping.(o) Individuals responsible for planning, directing, or supervising treatment programs shall be QCCs. The clinical program director must have at least two years of post-licensure experience providing chemical dependency treatment.(p) Chemical dependency counseling must be provided by a qualified credentialed counselor (QCC), graduate, or counselor intern. Chemical dependency education and life skills training shall be provided by counselors or individuals who have the specialized education and expertise.(q) All counselor interns shall work under the direct supervision of a QCC as required in 40 TEX. ADMIN. CODE ch. 150 of this title (relating to Counselor Licensure). Source Note: The provisions of this §564.901 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.901 Requirements Applicable to All Treatment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217763 03/12/2026 (a) A facility providing detoxification services shall ensure every individual admitted to a detoxification program meets the DSM criteria for substance intoxication or withdrawal.(b) All detoxification programs shall ensure continuous access to emergency medical care.(c) The program shall have a medical director who is a licensed physician. The medical director shall be responsible for admission, diagnosis, medication management, and client care.(d) The medical director or his/her designee (physician assistant, or nurse practitioner) shall approve all medical policies, procedures, guidelines, tools, and the medical content of all forms, which shall include:(1) screening instruments and procedures;(2) protocol or standing orders for each major drug category of abusable drugs (opiates, alcohol and other sedative-hypnotic/anxiolytics, inhalants, stimulants, hallucinogens) that are consistent with guidelines published by nationally recognized organizations (e.g., Substance Abuse and Mental Health Services Administration, American Society of Addiction Medicine, American Academy of Addiction Psychology);(3) procedures to deal with medical emergencies;(4) medication and monitoring procedures for pregnant women that address effects of detoxification and medications used on the fetus; and(5) special consent forms for pregnant women identifying risks inherent to mother and fetus.(e) The medical director or his/her designee (physician assistant, nurse practitioner) shall authorize all admissions, conduct a face-to-face examination, to include both a history and physical examination of each applicant for services to establish the Axis I diagnosis, assess level of intoxication or withdrawal potential, and determine the need for treatment and the type of treatment to be provided to reach a placement decision.(1) The examination shall identify potential physical and mental health problems and/or diagnoses that warrant further assessment.(2) The authorization and examination shall be documented in the client record and shall contain sufficient documentation to support the diagnoses and the placement decision. If the physician determines an admission was not appropriate, the client shall be transferred to an appropriate service provider.(3) The face-to-face examination (history and physical examination) and signed orders of admission shall occur within 24 hours of admission.(4) The program may accept an examination completed during the 24 hours preceding admission if it is approved by the program's medical director or designee and includes the elements of paragraphs (1) and (2) of this subsection. The program may not require a client to obtain a history and physical as a condition of admission.(5) Detoxification programs shall have a licensed vocational nurse or registered nurse on duty for at least eight hours every day and a physician or designee on call 24 hours a day.(6) Detoxification programs shall ensure that detoxification services are accessible at least 16 hours per day, seven days per week.(f) Providers shall develop and implement a mechanism to ensure that all direct care staff in detoxification programs have the knowledge, skills, abilities to provide detoxification services, as they relate to the individual's job duties. Providers must be able to demonstrate through documented training, credentials and/or experience that all direct care staff are proficient in areas pertaining to detoxification, including but not limited to areas regarding:(1) signs of withdrawal;(2) observation and monitoring procedures;(3) pregnancy-related complications (if the program admits women);(4) complications requiring transfer;(5) appropriate interventions; and(6) frequently used medications including purpose, precautions, and side effects.(g) Residential and ambulatory (outpatient) detoxification programs shall provide monitoring to manage the client's physical withdrawal symptoms. Monitoring shall be conducted at a frequency consistent with the degree of severity of the client's withdrawal symptoms, the drug(s) from which the client is withdrawing, and/or the level of intoxication of the client. This information will be documented in the client's record and reflected in the client's orders.(1) Monitoring shall include:(A) changes in mental status;(B) vital signs; and(C) response of the client's symptoms to the prescribed detoxification medications(2) Use of instruments such as the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) for alcohol and sedative hypnotic withdrawal and the "clinician's assessment" in the Behavioral Health Integrated Provider System (BHIPS) is recommended.(3) More intensive monitoring is required for clients with a history of severe withdrawal symptoms (e.g. a history of hallucinosis, delirium tremors, seizures, uncontrolled vomiting/dehydration, psychosis, inability to tolerate withdrawal symptoms, self harming attempts), or the presence of current severe withdrawal symptoms and/or co-occurring medical and psychiatric disorders.(4) At a minimum, monitoring should be done every four hours in residential detoxification programs for the first 72 hours and as ordered by the medical director or designee thereafter, dependent on the client's signs and symptoms.(5) Medication should be available to manage withdrawal/intoxication from all classes of abusable drugs.(6) Medication "regimens", "protocols" or standing orders can be used, but detoxification should be tailored to each client's need based on vital signs and symptom severity (objective and subjective) and noted in the client's record.(7) Ambulatory detoxification should have clear documentation by the physician or designee that the client's symptoms are or are expected to be of a severity that necessitates a minimum of once a day monitoring.(h) In addition to the management of withdrawal and intoxicated states, detoxification programs shall provide services, including counseling, which are designed to:(1) assess the client's readiness for change;(2) offer general and individualized information on substance abuse and dependency;(3) enhance client motivation;(4) engage the client in treatment; and(5) include a detoxification plan that contains the goals of successful and safe detoxification as well as transfer to another intensity of treatment. At least one daily individual session by a registered nurse, QCC or counselor intern with the client will be conducted.(i) Ambulatory detoxification shall not be a stand alone service and services shall be provided in conjunction with outpatient treatment services. When treatment services are not available in conjunction with ambulatory detoxification services, the ambulatory detoxification program shall arrange for them.(j) Bunk beds shall not be used in residential detoxification programs.(k) In residential programs, direct care staff shall be on duty where the clients are located 24 hours a day.(1) During day and evening hours, at least two staff shall be on duty for the first 12 clients, with one more staff on duty for each additional one to 16 clients.(2) At night, at least one staff member with detoxification training shall be on duty for the first 12 clients with one more staff on duty for each additional one to 16 clients.(l) Clients who are not in withdrawal but meet the DSM criteria for substance dependence may be admitted to detoxification services for 72 hours for crisis stabilization.(m) Crisis stabilization is appropriate for clients who have diagnosed conditions that result in current emotional or cognitive impairment in clients such that they would not be able to participate in a structured and rigorous schedule of formal chemical dependency treatment.(1) The specific client signs and symptoms that meet the DSM or other medical criteria for the disorder must be documented in the client record.(2) Documentation must also include what symptoms are precluding the client from participating in treatment and the manner in which they are to be resolved. Source Note: The provisions of this §564.902 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.902 Requirements Applicable to Detoxification Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217764 03/12/2026 (a) Residential treatment provides 24-hour per day, 7 days per week multidisciplinary professional clinical support to facilitate recovery from addiction. Clients are housed in a residential site. Comprehensive chemical dependency treatment services offer a structured therapeutic environment.(b) The facility shall ensure access to the full continuum of treatment services and will ensure sufficient treatment intensity to achieve treatment plan goals. Intensity and content of treatment shall be appropriate to the client's needs and consistent with generally accepted placement guidelines and standards of care.(c) Each individual admitted to intensive residential services shall be appropriate for this treatment setting, with written justification to support the admission.(d) Intensive residential shall provide an average of at least 30 hours of services per week for each client, comprised of at least:(1) ten hours of chemical dependency counseling, (one hour of which shall be individual counseling);(2) ten hours of additional counseling, chemical dependency education, life skills training, relapse prevention education; and(3) ten hours of planned, structured activities monitored by staff. Five hours of these services shall occur on weekends and evenings.(e) In adult intensive residential programs, the direct care staff-to-client ratio shall be at least 1:16 when clients are awake and 1:32 during sleeping hours.(f) In intensive residential programs counselor caseloads shall not exceed ten clients for each counselor.(g) Supportive residential shall provide at least six hours of treatment services per week for each client, comprised of at least :(1) three hours of chemical dependency counseling (one hour per month of which shall be individual counseling); and(2) three hours of additional counseling, chemical dependency education, life skills training, and relapse prevention education.(h) In adult supportive residential programs, the direct care staff-to-client ratio shall be at least 1:20 when clients are awake and 1:50 during sleeping hours.(i) Each supportive residential program shall set limits on caseload size that ensure effective, individualized treatment. The program shall justify the caseload size in writing based on the program design, characteristics and needs of the population served, and any other relevant factors. Source Note: The provisions of this §564.903 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.903 Requirements Applicable to Residential Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217765 03/12/2026 (a) Outpatient programs are designed for clients who do not require the more structured environment of residential treatment to maintain sobriety.(b) Outpatient programs shall ensure access to full continuum of care and ensure sufficiency of treatment intensity to achieve treatment plan goals. Intensity and content of treatment shall be appropriate to the client's needs and consistent with generally accepted placement guidelines and standards of care.(c) Each individual admitted to an outpatient program shall be appropriate for this treatment setting, with written justification to support the admission.(d) Treatment includes individualized treatment planning based on a comprehensive assessment, educational and process groups, and individual counseling.(e) Each client's progress is assessed regularly by clinical staff to help determine the length and intensity of the program for that client. Source Note: The provisions of this §564.904 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.904 Requirements for Outpatient Treatment Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217770 03/12/2026 (a) Facilities providing adolescent residential services shall:(1) maintain separation between adults and adolescents;(2) have separate sleeping areas, bedrooms, and bathrooms for adults and adolescents, and for males and females;(3) provide access to education approved by the Texas Education Agency within three school days of admission when treatment is expected to last more than 14 days;(4) in addition to the service requirements set forth in §148.903(d)(3), provide five hours of planned, structured activities during evenings and weekends. Recreational and leisure activities shall be included in the structured time. The total number of hours of planned, structured activities must be at least 15. Attendance in school may be counted toward this requirement;(5) ensure the direct care staff-to-client ratio is at least 1:8 during waking hours (including program-sponsored activities away from the facility) and 1:16 during sleeping hours;(6) ensure clients are under direct supervision at all times. During sleeping hours, staff shall conduct and document hourly bed checks;(7) facilitate regular communication between an adolescent client and the client's family and shall not arbitrarily restrict any communications without clear individualized clinical justification documented in the client record; and(8) have written procedures addressing notification of parents or guardians in the event an adolescent leaves a residential program without authorization.(b) Facilities providing outpatient services shall:(1) maintain separation between adults and adolescents; and(2) provide access to education approved by the Texas Education Agency within three school days of admission when treatment is expected to last more than 14 days, if required by law.(c) Facilities providing day treatment shall provide at least 15 hours of services per week, comprised of at least:(1) one hour of individual counseling; and(2) 14 hours of additional counseling, chemical dependency education, life skills training, and relapse prevention education. Attendance in school may not be counted toward this requirement.(d) All facilities shall:(1) ensure the program's treatment services, lectures, and written materials are age-appropriate and easily understood by clients;(2) involve the client's family or an alternate support system in the treatment process or document why this is not possible; and(3) develop and implement a mechanism to ensure that all direct care staff in adolescent programs have the knowledge, skills, and abilities to provide services to adolescents, as they relate to the individual's job duties. Providers must be able to demonstrate through documented training, credentials and/or experience that all direct care staff are proficient in areas pertaining to adolescent services, including but not limited to areas regarding:(A) chemical dependency problems specific to adolescent treatment;(B) appropriate treatment strategies, including family engagement strategies; and(C) emotional, developmental, and mental health issues for adolescents.(e) Adolescent programs may serve children 13 to 17 years of age. However, young adults aged 18 to 21 may be admitted to an adolescent program when the screening process indicates the individual's needs, experiences, and behavior are similar to those of adolescent clients.(f) Adult programs serve individuals 18 years of age or older. However, adolescents aged 17 may be admitted to an adult program when they are referred by the adult criminal justice system or when the screening process indicates the individual's needs, experiences, and behavior are similar to those of adult clients.(g) Every exception to the general age requirements shall be clinically justified and documented and approved in writing by a QCC. Source Note: The provisions of this §564.905 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.905 Additional Requirements for Adolescent Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217771 03/12/2026 (a) In determining an individual's initial and ongoing eligibility for any service, an entity may not exclude an individual based on the following factors:(1) the individual's past or present mental illness;(2) medications prescribed to the individual in the past or present;(3) the presumption of the individual's inability to benefit from treatment; or(4) the individual's level of success in prior treatment episodes.(b) Providers must ensure that a client's refusal of a particular service does not preclude the client from accessing other needed mental health or substance abuse services.(c) Providers must establish and implement procedures to ensure the continuity between screening, assessment, treatment and referral services provided to clients. Source Note: The provisions of this §564.906 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.906 Access to Services for Co-Occurring Psychiatric and Substance Use Disorders (COPSD) Clients https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217772 03/12/2026 (a) The services provided to a client with co-occurring psychiatric and substance use disorders (COPSD) must:(1) address both psychiatric and substance use disorders;(2) be provided within established practice guidelines for this population; and(3) facilitate individuals in accessing available services they need and choose, including self-help groups.(b) The services provided to a client with COPSD must be provided by staff who are competent in the areas identified in §148.908 of this title (relating to Specialty Competencies of Staff Providing Services to Clients with COPSD). Source Note: The provisions of this §564.907 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.907 Additional Requirements for COPSD Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217778 03/12/2026 (a) Providers must ensure that services to clients are age-appropriate and are provided by staff within their scope of practice who have the following minimum knowledge, technical, and interpersonal competencies prior to providing services.(1) Knowledge competencies:(A) knowledge of the fact that psychiatric and substance use disorders are potentially recurrent relapsing disorders, and that although abstinence is the goal, relapses can be opportunities for learning and growth;(B) knowledge of the impact of substance use disorders on developmental, social, and physical growth and development of children and adolescents;(C) knowledge of interpersonal and family dynamics and their impact on individuals;(D) knowledge of the current Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for psychiatric disorders and substance use disorders and the relationship between psychiatric disorders and substance use disorders;(E) knowledge regarding the increased risks of self-harm, suicide, and violence in individuals;(F) knowledge of the elements of an integrated treatment plan and community support plan for individuals;(G) basic knowledge of pharmacology as it relates to individuals with a mental disorder;(H) basic understanding of the neurophysiology of addiction;(I) knowledge of the phases of recovery for individuals;(J) knowledge of the relationship between COPSD and DSM Axis III disorders; and(K) knowledge of self-help in recovery.(2) Technical competencies:(A) ability to perform age-appropriate assessments of clients; and(B) ability to formulate an individualized treatment plan and community support plan for clients.(3) Interpersonal competencies:(A) ability to tailor interventions to the process of recovery for clients;(B) ability to tailor interventions with readiness to change; and(C) ability to engage and support clients who choose to participate in 12-step recovery programs.(b) Within 90 days of the effective date of this rule, providers must ensure that staff who provide services to clients with COPSD have demonstrated the competencies described in subsection (a) of this section. These competencies may be evidenced by compliance with current licensure requirements of the governing or supervisory boards for the respective disciplines involved in serving clients with COPSD or by documentation regarding the attainment of the competencies described in subsection (a) of this section. Source Note: The provisions of this §564.908 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.908 Specialty Competencies of Staff Providing Services to Clients with COPSD https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217779 03/12/2026 (a) The treatment plan must identify services to be provided and must include measurable outcomes that address COPSD.(b) The treatment plan must identify the family members' need for education and support services related to the client's mental illness and substance abuse and a method to facilitate the family members' receipt of the needed education and support services.(c) The client and, if requested, family member, must be given a copy of the treatment plan as permitted by law. Source Note: The provisions of this §564.909 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.909 Treatment Planning of Services to Clients with COPSD https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217780 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217780 03/12/2026 (a) Clients shall receive gender-specific services in female-only specialized programs.(b) When appropriate, pre-admission service coordination shall be provided to reduce barriers to treatment, enhance motivation, stabilize life situations, and facilitate engagement in treatment.(c) Services shall address relationship issues, including past or current experience with sexual, physical, and emotional abuse.(d) Providers shall develop and implement a mechanism to ensure that all direct care staff in programs that treat women and children have the knowledge, skills, and abilities to provide services to women and children, as they relate to the individual's job duties. Providers must be able to demonstrate through documented training, credentials and/or experience that all direct care staff are proficient in areas pertaining to the needs of and provision of services to women and children.(e) Individuals responsible for the planning and supervision of the program shall participate in at least 15 clock hours of training annually in understanding children, child development, and/or early childhood education.(f) Clients shall receive access to appropriate primary medical care, including prenatal care and reproductive health education and services.(g) Pregnant clients, women with children in custody, and women with dependent children shall receive parenting education and support services.(h) Women and their dependent children shall be treated as a unit, and both the woman and her children will be admitted into treatment when appropriate.(i) Children shall receive services to address their needs and support healthy development, including primary pediatric care, early childhood intervention services, substance abuse prevention services, and/or other therapeutic interventions.(j) Facilities housing children shall comply with the provisions of 40 TEX. ADMIN. CODE ch. 746 (2003)(relating to Minimum Standards for Child-Care Centers) set forth below:(1) Subchapter B, Administration and Communication §§746.307(a)(b), 746.405(a)(1)(2)(3) and 746.501(6-16)(2) Subchapter C, Record Keeping, §§746.603(a)(3)-(6), 746.605-627, 746.801(22) and 746.901(3)(3) Subchapter D, Personnel §§746.1105(2) and 746.1303(2)(3)(4) Subchapter E, Child/Caregiver Ratios and Group Sizes §§746.1501-2117(5) Subchapter G, Basic Care Requirements for Children with Special Care Needs §746.2301(6) Subchapter H, Basic Care Requirements for Infants §§746.2401-2429(7) Subchapter I, Basic Care Requirements for Toddlers §§746.2501-2509(8) Subchapter J, Basic Care Requirements for Pre-Kindergarten Age Children §§746.2601-2607(9) Subchapter K, Basic Care Requirements for School-age Children §§746.2701-2707(10) Subchapter L, Discipline and Guidance §§746.2801-2813(11) Subchapter N, Field Trips §746.3001(1)(8)(12) Subchapter Q, Nutrition and Food Service §§746.3301, 746.3307 and 746.3311(13) Subchapter R, Health Practices §§746.3407, 746.3423, 746.3501 and 746.3503(14) Subchapter S, Safety Practices §§746.3701, 746.3709 and 746.3901-4101(15) Subchapter T, Physical Facilities §§746.4201, 746.4217, 746.4301, 746.4305-4309, 746.4419-4501, 746.4505 and 746.4509(16) Subchapter U, Outdoor Safety and Play Equipment §§746.4601-4913(17) Subchapter V, Swimming Pools and Wading/Splashing Pools §§746.5001-5015(k) The facility shall adopt program specific rules regarding child care.(1) These program rules will include provisions addressing:(A) clients supervising the children of other clients, and(B) opportunities for indoor and outdoor activities for the children.(2) The facility shall not allow a client to supervise more than two additional children at any time.(3) The facility shall provide each client with a copy of these program rules within 24 hours of admission.(4) Off-site contracted daycare providers shall be licensed by the Texas Department of Protective and Regulatory Services.(5) If a program has an attendance of more than 30 children at lunch or dinner time, staff shall be provided for meal preparation, serving and cleanup. The staff providing meal services shall not be included in staff to child ratios during this time.(l) The program shall assist the parent/guardian as necessary to ensure educational opportunities for school age children in accordance with the requirements of the Texas Education Agency.(m) School age children shall have access and transport to school.(n) The program shall document any services provided to children, including daycare and community support. The record shall document the child's developmental, physical, emotional, social, and educational needs, and family background and current status. Source Note: The provisions of this §564.910 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.910 Treatment Services for Women and Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217781 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217781 03/12/2026 (a) In this section, the following words and terms have the following meanings:(1) Electronic means--Live, synchronous, interactive treatment program services delivered using telecommunications or information technology by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional. This term includes services delivered using synchronous audiovisual technology or synchronous audio-only technology but does not include pre-recorded videos.(2) Existing clinical relationship--A relationship that occurs when a person has received at least one in-person or synchronous audiovisual treatment service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology.(3) Synchronous audio-only technology--An interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).(4) Synchronous audiovisual technology--An interactive, two-way audio and video telecommunications platform that meets HIPPA privacy requirements.(5) Verbal consent--The spoken agreement of a client or a client's legally authorized representative to participate in treatment services through electronic means.(b) Except as provided under §448.801 of this chapter (relating to Screening) and §448.803 of this chapter (relating to Assessment), only a licensed outpatient chemical dependency treatment program may provide treatment program services through electronic means.(c) The program providing treatment services through electronic means may provide treatment services to adult and adolescent clients to the extent allowed by the facility's license and shall comply with all requirements of this section.(d) The program shall ensure only the following individuals provide services through electronic means under this section:(1) a qualified credentialed counselor (QCC); or(2) a counselor intern who has more than 2,000 hours of supervised work experience or a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure) and who has passed the chemical dependency counselor licensing exam.(e) The program's physical location shall be equipped to provide in-person, face-to-face treatment services with an individual at the individual's request.(f) The program shall ensure all treatment sessions shall have the following two forms of access control:(1) all contact between a QCC and clients via electronic means shall begin with a verification of the client through a name, password or pin number; and(2) security as detailed in HIPAA.(g) A facility shall implement adequate security and encryption measures to ensure all patient communications, recordings and records are protected and adhere to federal and state privacy laws, including HIPAA and Texas Health and Safety Code Chapters 181, 464, and 466 (relating to Medical Records Privacy; Facilities Treating Persons with a Chemical Dependency, and Regulation of Narcotic Drug Treatment Programs).(h) A program shall maintain compliance with HIPAA and Code of Federal Regulations (CFR) Title 42, Part 2 (relating to Confidentiality of Substance Use Disorder Patient Records).(i) A program shall not use e-mail communications containing client identifying information.(j) A program shall use synchronous audiovisual technology, except as provided in subsection (k) of this section.(k) A program may provide outpatient individual and group counseling to clients using synchronous audio-only technology only when all the following criteria are met:(1) the client and provider have an existing clinical relationship;(2) the provider receives the client's verbal consent before each session; and(3) the provider documents in the client's record the specific reason why the provider provided outpatient counseling services using synchronous audio-only technology.(l) A program shall ensure timely access to individuals qualified in the technology as backup for systems problems.(m) A program shall develop a contingency plan and maintain alternate means of communication for clients when technical problems occur during the provision of services.(n) A program shall provide individuals and clients with a description of all services offered.(o) A program shall provide developed criteria, in addition to the Diagnostic and Statistical Manual of Mental Disorders, to assess clients for appropriateness of utilizing services through electronic means.(p) A program shall provide appropriate referrals for clients who do not meet the criteria for services.(q) A program shall develop a grievance procedure and provide the website and phone number to the Texas Health and Human Services Commission (HHSC) for filing a complaint.(r) Prior to clients engaging in services through electronic means, a program shall describe and provide in writing the potential risks to clients. The risks shall address at a minimum the following areas:(1) clinical aspects;(2) security; and(3) confidentiality.(s) In a HIPAA-compliant manner, a program shall document and maintain in a client's record the client's verbal consent to participate in services provided through electronic means. The program shall provide the verbal consent documentation to HHSC upon request.(t) A program shall explain to the client or the client's legally authorized representative what verbal consent means and to what the client or client's legally authorized representative is consenting. The verbal consent a client provides when electing to participate in a treatment service delivered through electronic means only applies to one treatment service at a time. A program shall obtain the client's verbal consent before the client receives each service through electronic means.(u) If the program does not obtain verbal consent for a treatment service through electronic means, the program shall provide the service to the client in-person and face-to-face.(v) A program shall inform a client who chooses to receive services through electronic means that the program will:(1) monitor services for evidence of fraud, waste, and abuse;(2) determine whether the client needs additional social services or supports;(3) ensure the provider documents, in writing and in the client's record, the client's verbal consent to participate in services provided through electronic means; and(4) adhere to HIPPA, including using HIPAA-compliant technology for services provided through electronic means.(w) A program shall create safeguards to ensure adolescents receive treatment services separately from adults and verify a client's identity and the identity of any authorized participant.(x) A program shall provide clients with information to access online or a copy of the current version of the following chemical dependency treatment facility (CDTF) rules, statutes, and federal regulations to notify clients of applicable rules and laws regarding CDTFs:(1) This chapter;(2) Texas Health and Safety Code Chapter 464; and(3) 42 CFR Part 2.(y) A program shall provide the program's emergency contact information to the client.(z) A program shall maintain resource information for the local area of the client.(aa) A program shall provide reasonable Americans with Disabilities Act of 1990 (ADA) accommodations for clients upon request.(bb) A program shall be located and perform services in Texas.(cc) HHSC maintains the authority to regulate the program regardless of the location of the client.(dd) The facility shall provide the facility's emergency contact information to the client.(ee) The facility shall maintain resource information for the local area of the client. Source Note: The provisions of this §564.911 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective March 3, 2022, 47 TexReg 655; amended to be effective February 22, 2024, 49 TexReg 871; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.911 Treatment Services Provided by Electronic Means https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217782 03/12/2026 A licensed chemical dependency treatment facility shall not discriminate based on a client's disability and shall comply with Texas Health and Safety Code Chapter 161, Subchapter S (relating to Allocation of Kidneys and Other Organs Available for Transplant). Source Note: The provisions of this §564.912 adopted to be effective January 6, 2022, 46 TexReg 9396; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES I TREATMENT PROGRAM SERVICES §564.912 Miscellaneous Policies and Protocols https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217783 03/12/2026 (a) All facilities that provide medication shall implement written procedures for medication storage, administration, documentation, inventory, and disposal.(b) Prescription medication shall be used only for therapeutic and medical purposes and shall be administered as prescribed by an appropriately licensed professional.(c) Single doses of prescription medication shall be prepared and packaged by a licensed pharmacist or physician.(d) The facility shall ensure that staff that provide medication are properly credentialed and trained.(e) The program shall have the phone number of a pharmacy and a comprehensive drug reference manual easily accessible to staff. Source Note: The provisions of this §564.1001 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES J MEDICATION §564.1001 General Provisions for Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217790 03/12/2026 (a) Prescription and over-the-counter medications, syringes, and needles shall be kept in locked storage and accessible only to staff who are authorized to provide medication.(b) Clients may keep prescription or over-the-counter medication in their personal possession on site with written authorization from the program director. Staff shall ensure that authorized clients keep medication on their persons or safely stored and inaccessible to other clients.(c) The program shall store all medications, syringes, and needles in their original containers under appropriate conditions. Medications requiring refrigeration shall not be stored with food and other items.(d) The facility shall ensure that stock prescription medications are stored in a licensed pharmacy or physician's office and dispensed by a pharmacist or physician as required by TEX. OCC. CODE ANN. ch. 551 (Vernon 2004).(e) The facility shall ensure that prescription medication is in a container labeled by the pharmacy.(f) Sample medications provided by physicians must be stored with client specific labeling information, including dosing instructions. Source Note: The provisions of this §564.1002 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES J MEDICATION §564.1002 Medication Storage https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217791 03/12/2026 (a) The program shall use an effective system to track and account for all prescription medication.(b) Staff shall inventory and inspect all stored DEA Schedule II, III, and IV prescription medication at least daily using a centralized medication inventory form.(c) The staff member conducting the inventory shall sign and date the inventory sheet. When a discrepancy exists between the administration record and the inventory count form, a note explaining the reason for the discrepancy or action taken to reconcile/correct the discrepancy shall be signed by the staff member conducting the inventory and kept with the medication inventory forms.(d) Staff shall separate unused and outdated medication immediately and dispose of it within 30 days.(e) Methods used for disposal shall prevent medication from being retrieved, salvaged, or used. Two staff members shall witness and document disposal, including amount of medication disposed and method used. Source Note: The provisions of this §564.1003 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES J MEDICATION §564.1003 Medication Inventory and Disposal https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217795 03/12/2026 (a) Staff shall provide and discontinue medication exactly as prescribed.(b) Prescription medication shall be administered only by nurses and other staff who are legally authorized to administer medication.(c) Clients may self-administer medication under the supervision of staff who are trained as described in §148.603 of this title (relating to Training).(d) Each dose of prescription and over-the-counter medication taken by the client shall be documented in the client's medication record.(e) The medication record shall include:(1) the client's name;(2) drug allergies (or the absence of known allergies);(3) the name and dose of each medication;(4) the frequency and route of each medication;(5) the date and time of each dose; and(6) the signature of the staff person who administered or supervised each dose.(f) The facility shall document the circumstances and reason for any missed doses.(g) When a client appears to have an adverse reaction to medication, a staff member shall:(1) notify the prescribing professional or another physician, dentist, podiatrist, physician assistant or nurse practitioner (preferably the prescribing professional);(2) complete an incident report; and(3) document the facts in the client record, including the date and time of notification and any other action taken. Source Note: The provisions of this §564.1004 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES J MEDICATION §564.1004 Administration of Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217796 03/12/2026 (a) Programs shall provide a meal break after five consecutive hours of scheduled activities.(b) If the facility prepares meals in a centralized kitchen on site, it shall pass an annual kitchen health inspection as required by law. Source Note: The provisions of this §564.1101 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES K FOOD AND NUTRITION §564.1101 Meals in Outpatient Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217801 03/12/2026 (a) The residential program shall provide wholesome, well-balanced meals, according to posted weekly approved menus.(b) The program shall provide modified diets to residents who medically require them as determined by a licensed health professional. Special diets shall be prepared in consultation with a licensed dietitian.(c) All food shall be selected, stored, prepared, and served in a safe and healthy manner.(d) The program shall provide at least three meals daily. The program shall provide packaged meals or make other arrangements for clients who are scheduled to be away from the facility during meal time.(e) A licensed dietitian shall approve menus and written guidelines for substitutions in advance; or(1) approve a meal planning manual with sample menus and guidelines for substitutions;(2) approve menus prepared by new staff before they plan meals independently;(3) review a sample of menus served at least annually; and(4) provide staff training as needed. Source Note: The provisions of this §564.1102 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES K FOOD AND NUTRITION §564.1102 Meals in Residential Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217802 03/12/2026 (a) Staff shall provide training and supervision needed to ensure compliance with the rules in §148.1102 of this title (relating to Meals in Residential Programs).(b) The program shall define duties in writing and have written instructions posted or easily accessible to clients.(c) If menu planning and independent meal preparation are part of the clients' treatment program, a licensed dietitian shall:(1) approve the client training curriculum; and(2) provide training or approve a training program for staff that instruct and supervise clients in meal preparation. Source Note: The provisions of this §564.1103 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES K FOOD AND NUTRITION §564.1103 Meals Prepared by Clients https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217803 03/12/2026 (a) When meals are provided by a food service, a written contract shall require the food service to:(1) comply with the rules in §148.1102 of this title (relating to Meals in Residential Programs); and(2) pass an annual kitchen health inspection as required by law.(b) The facility shall ensure the meals are transported to the facility in temperature controlled containers to ensure the food remains at the temperature at which it was prepared.(c) The facility shall ensure that at least one staff, at a minimum, maintains a current food handler's permit. Source Note: The provisions of this §564.1104 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES K FOOD AND NUTRITION §564.1104 Meals Provided by a Food Service https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217806 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217806&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217806 03/12/2026 (a) Physical plant requirements apply only to residential programs.(b) The water supply shall be of safe, sanitary quality, suitable for use, and adequate in quantity and pressure. The water shall be obtained from a water supply system approved by the Texas Natural Resource Conservation Commission (TNRCC).(c) Sewage shall be discharged into a State-approved sewage system or septic system; otherwise, the sewage must be collected, treated, and disposed of in a manner which is approved by TNRCC.(d) Mobile homes, recreational vehicles, and campers shall not be used for client sleeping areas. Source Note: The provisions of this §564.1201 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1201 General Physical Plant Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217807 03/12/2026 The residential site shall pass all required inspections and keep a current file of reports and other documentation needed to demonstrate compliance with applicable laws and regulations. The inspections must be signed, dated, and free of any outstanding corrective actions. The following inspections are required:(1) annual inspection by the local certified fire inspector or the State fire marshal;(2) annual inspection of the alarm system by the fire marshal or an inspector authorized to install and inspect such systems;(3) annual kitchen inspection by the local health authority or the Texas Department of Health;(4) gas pipe pressure test once every three years by the local gas company or a licensed plumber;(5) annual inspection and maintenance of fire extinguishers by personnel licensed or certified to perform those duties; and(6) annual inspection of liquefied petroleum gas systems by an inspector certified by the Texas Railroad Commission. Source Note: The provisions of this §564.1202 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1202 Required Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217808 03/12/2026 Every residential program shall:(1) have emergency evacuation procedures that include provisions for individuals with disabilities;(2) hold fire drills on each shift at least quarterly and correct identified problems promptly;(3) post exit diagrams conspicuously throughout the program site (except in small one-story buildings where all exits are obvious); and(4) be able to clear the building safely and in a timely manner at all times. Source Note: The provisions of this §564.1203 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1203 Emergency Evacuation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217811 03/12/2026 (a) Every building shall have at least two well-separated exits on each story.(b) Every route of exit shall be free of hazards and obstructions, well lit, and marked clearly with illuminated exit signs at all times.(c) Rooms for 50 or more people shall have exit doors that swing out.(d) No door may require a key for emergency exit. Locked facilities shall have emergency exit door releases as described in the Life Safety Code and approved by the fire marshal. Source Note: The provisions of this §564.1204 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1204 Exits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217812 03/12/2026 (a) The facility shall have areas for leisure and dining with adequate space for the number of residents.(b) Sleeping areas shall have at least:(1) 80 usable square feet per individual in single-occupancy rooms;(2) 60 usable square feet per individual in multiple-occupancy rooms (or 50 square feet per individual if bunk beds are used); and(3) 40 usable square feet for each child 18 months and older and 30 usable square feet per infant under 18 months.(c) The facility shall provide adequate personal storage space for each client, including space for hanging clothes.(d) The program shall make at least one phone available to clients.(e) Each client shall have a separate bed of solid construction with a mattress. Clean bed linen, towels, and soap shall be available at all times and in quantity sufficient to meet the needs of the residents.(f) All clients shall have access to laundry services or properly maintained laundry facilities equivalent to one washer and dryer per 25 clients. Source Note: The provisions of this §564.1205 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1205 Space, Furniture and Supplies https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217815 03/12/2026 (a) A fire detection, alarm, and communication system required for life safety shall be installed, tested, and maintained in accordance with the facility's occupancy and capacity classifications.(b) Electrical fire alarm systems shall be installed by agents registered with the State fire marshal's office. The facility shall maintain a copy of the fire alarm installation certificate.(c) Quarterly fire alarm system tests shall be conducted and documented by facility staff.(d) Alarms shall be loud enough to be heard above normal noise levels throughout the building.(e) Fire extinguishers shall be mounted throughout the facility as required by code and approved by the fire marshal.(1) Each laundry and walk-in mechanical room shall have at least one portable A:B:C extinguisher, and each kitchen shall have at least one B:C fire extinguisher.(2) Each extinguisher shall have the required maintenance service tag attached.(f) Staff shall conduct quarterly inspections of fire extinguishers for proper location, obvious physical damage, and a full charge on the gauge. Source Note: The provisions of this §564.1206 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1206 Fire Systems https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217816 03/12/2026 (a) Occupied parts of the building shall be kept between 65 degrees and 85 degrees Fahrenheit, including kitchens and laundry areas. Cooling and heating shall be provided, as necessary, for resident comfort.(b) Portable electric heaters and open-flame heating devices are prohibited. All fuel-burning devices shall be vented.(c) The facility shall be well ventilated through the use of windows, mechanical ventilation, or a combination. Windows used regularly for ventilation shall be screened.(d) Bedrooms and bathrooms with windows shall have appropriate window coverings for privacy.(e) The facility shall have adequate internal and external lighting to provide a safe environment and meet user needs.(f) There shall be at least one sink, one tub or shower, and one toilet for every eight residents. All of the fixtures must be in good working order and have the appropriate drain and drain trap to prevent sewage gas escape back into the facility.(g) The facility shall provide an adequate supply of hot water for the number of residents and the program schedule.(h) Showers and tubs shall have no-slip surfaces and curtains or other safe enclosures for privacy.(i) Clean drinking water shall be readily available to all residents.(j) Food and waste shall be stored, handled, and removed in a way that will not spread disease, cause odors, or provide a breeding place for pests.(k) The facility shall be kept free of insects, rodents, and vermin.(l) Poisonous, toxic, and flammable materials shall be labeled, stored, and used safely. Source Note: The provisions of this §564.1207 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES L RESIDENTIAL PHYSICAL PLANT REQUIREMENTS §564.1207 Other Physical Plant Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217821 03/12/2026 (a) Facilities accepting court commitments shall be licensed to provide the appropriate level of service:(1) emergency detention: residential detoxification or intensive residential services;(2) adult inpatient involuntary commitments: intensive residential or residential services for adults;(3) adult outpatient involuntary commitments: day treatment or outpatient services;(4) juvenile inpatient commitments: intensive residential services for adolescents; and(5) juvenile outpatient commitments: day treatment or outpatient services for adolescents.(b) The facility's court commitment program shall comply with the TEX. HEALTH & SAFETY CODE ANN. ch. 462 (Vernon Supp. 2004).(c) The facility shall report unauthorized departures to the referring courts. Verbal reports shall be made immediately, with written confirmation within 24 hours.(d) The program shall provide the judiciary with sufficient written information about its program design, treatment methods, admission processes, lengths of stay and continuum of care to assist the judiciary in committing appropriate clients to the facility.(e) The program shall accept all chemical dependency clients brought to the facility under an emergency detention warrant, order of protective custody, or civil court order for treatment. A formal screening and assessment is not required before admission.(f) A program that accepts emergency detentions shall adopt a written policy authorizing use of restraint and/or seclusion and implement procedures that conform with §148.706 of this title (relating to Restraint and Seclusion).(g) The client record shall contain documentation of the conditions and/or behaviors that caused the client's entry into the civil court commitment process.(h) The client record shall also contain copies of the legal documents required for civil court commitment as specified by TEX. HEALTH & SAFETY CODE ANN. ch. 462 (Vernon 2001 & Supp. 2004).(i) The facility shall provide training for at least two designated staff to ensure they understand and comply with court commitment statutes, regulations, and procedures. Source Note: The provisions of this §564.1301 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES M COURT COMMITMENT SERVICES §564.1301 Court Commitment Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217822 03/12/2026 (a) Programs that conduct adult residential treatment services using the therapeutic community (TC) methodology are required to comply with this section in addition to all other rules regarding health, safety and physical plant requirements in this chapter. This section of the rules does not apply to those programs serving adolescents. Adolescent programs shall follow the minimum service and staffing requirements in the other sections of this chapter.(b) A TC methodology to treatment is distinguished from other models of care by the following:(1) TCs are highly structured residential programs intended to treat criminal and antisocial behaviors occurring with substance abuse or dependence.(2) This model views recovery from these disorders as a developmental learning process in which the social and psychological characteristics of the client must be changed to one of "right living" and the client must adopt appropriate morals and values promoted by the program as opposed to solely recovering from an illness.(3) The model utilizes the community itself and TC specific group-type meetings as the primary modality of change. Confrontation amongst clients regarding their behaviors, a carefully orchestrated consequence-reward system and hierarchical privilege system are the primary approaches utilized instead of the counseling and therapy utilized in other models of treatment.(4) Counselors act primarily as role models and rational authorities rather than as counselors or therapists.(5) The model expects the client length of stay to be a minimum of 90 days in order to achieve positive outcomes.(6) The program is divided into 3 phases: The Orientation Phase (Information Dissemination), Primary Treatment Phase (Personal Application), and Re-Entry/Relapse Prevention Phase (Social Application).(c) Treatment programs using the TC methodology are required to comply with Subchapter H. of this title (relating to Screening and Assessment).(d) If the comprehensive psychosocial assessment identifies a potential mental health problem, the program shall arrange for the client to obtain a mental health evaluation by a Qualified Mental Health Professional.(1) If the mental health evaluation reflects the client currently has a diagnosis, or has been diagnosed during the last year with an Axis I diagnosis or post traumatic stress disorder, and/or moderate to severe mental retardation, the program shall obtain written authorization from a licensed psychiatrist or licensed physician experienced in treating chemical dependency, for the client to receive TC treatment services prior to providing TC program services.(2) A QCC, with at least one year documented experience in treating individuals with mental illness, shall act as the primary counselor and confer at least monthly with the authorizing psychiatrist or physician.(e) The admission authorization process shall follow the rules as outlined in §148.802 of this title (relating to Admission Authority and Consent to Treatment). In addition to the elements outlined in §148.802(b)(1)-(16), the consent to treatment form shall contain the information in (b)(1)-(6), above. The client shall voluntarily agree to participate in the TC program.(1) If the client is pregnant at the time of admission, the program shall obtain written authorization from a licensed physician for the client to receive TC treatment services prior to providing TC program services. If the pregnancy is determined after admission, the program shall obtain written authorization from a licensed physician for the client to receive TC treatment services.(2) A physician or physician assistant shall monitor the client's response to treatment at least monthly or more often as needed.(f) The TC Program shall ensure that all staff receive training in the TC methodology. All staff members shall receive 16 hours of training in TC theory, TC methods, and TC intervention techniques. This training is in addition to the applicable training requirements outlined in §148.603 of this title (relating to Training), and must take place within the first ninety days of employment.(g) Intensive residential TC programs shall provide a minimum of 20 hours of services per week, which shall include:(1) Six hours of counseling (which shall include two hours of individual counseling per month);(2) Six hours of additional counseling, CD education, and life skills training; and(3) Eight hours of TC groups, such as cognitive restructuring, AM/PM development, and encounter-confrontation groups. A counselor shall be present to supervise or monitor the activity and maintain structure in the TC groups.(h) In addition to the 20 hours outlined above, the program shall provide ten additional hours of peer driven activities, such as community meetings, house meetings, peer support, recreation, seminars, and self help groups.(i) Attendance shall be documented for peer driven activities. Documentation shall contain date, duration and type of activity. There is no size limitation or staffing requirement for peer driven activities.(j) Ten hours of the above services shall be in provided in the evenings and on weekends.(k) Adult Supportive TC Residential Programs shall provide at least six hours of treatment services per week for each client, comprised of at least:(1) two hours of chemical dependency counseling (one hour per month of which shall be individual counseling);(2) two hours of additional counseling, chemical dependency education, and life skills training; and(3) two hours of TC groups such as cognitive restructuring, AM/PM development, and encounter-confrontation groups. A counselor shall be present to supervise or monitor the activity and maintain structure in the TC groups.(l) Group counseling size is limited to 16 clients. Chemical dependency education and life skills classes are limited to 35 clients.(m) The TC program shall set limits on counselor caseload size that ensures effective, individualized treatment. The TC program shall justify the caseload size in writing based on the program design, characteristics and needs of the population served, and the minimum client service hours as indicated in this section.(n) In intensive residential TC programs the direct care staff to client ratio shall be 1:16 while awake and 1:32 during sleeping hours.(o) In supportive residential TC programs the direct care staff to client ratio shall be 1:20 while awake and 1:50 during sleeping hours.(p) In addition to the other requirements of this subchapter, the TC program's policy and procedure manual shall contain the following:(1) written program description explaining how the therapeutic community functions;(2) program structure, including rules, methods, and service schedule;(3) overview of the TC treatment process;(4) a description of consequences and rewards system; and(5) policy stating that interventions are not used as punishment and that access to medical and psychiatric care will not be denied. Source Note: The provisions of this §564.1401 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES N THERAPEUTIC COMMUNITIES §564.1401 Therapeutic Communities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217823 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217823&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217823 03/12/2026 The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:(1) Medical Care--Diagnosis or treatment of a physical or mental disorder.(2) Medical Detoxification Services--Chemical dependency treatment designed to systematically reduce the amount of alcohol and other toxic chemicals in a client's body, manage withdrawal symptoms, and encourage the client to seek ongoing treatment for chemical dependency.(3) Medical Withdrawal Service--See Medical Detoxification Services.(4) Program--For the purposes of this subchapter, program means a system of care delivered to chemically dependent individuals.(5) Religious Organization--A church, synagogue, mosque, or other religious institution:(A) the purpose of which is the propagation of religious beliefs; and(B) that is exempt from Federal income tax under Section 501(a) of the Internal Revenue Code of 1986, 26 U.S.C. §501(a), by being listed as an exempt organization under §501(c) of that code, 26 U.S.C. §501(c). Source Note: The provisions of this §564.1501 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1501 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217824 03/12/2026 (a) A chemical dependency treatment program is exempt from licensure under TEX. HEALTH & SAFETY CODE ANN. §§464.051-.061 (Vernon 2001 & Supp. 2004) if it:(1) is conducted by a religious organization;(2) is exclusively religious, spiritual, or ecclesiastical in nature;(3) does not treat minors; and(4) is registered under this chapter.(b) An exempt program registered under this section may not provide medical care, medical detoxification, or medical withdrawal services. Source Note: The provisions of this §564.1502 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1502 Exemption for Faith-Based Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217739 03/12/2026 (a) To register its exemption, the religious organization shall complete and submit these documents to the Commission:(1) a registration application;(2) a copy of the determination letter from the Internal Revenue Service documenting the organization's tax exempt status under the Internal Revenue Code (26 U.S.C. §501(c)(3); and(3) a copy of the organization's articles of incorporation documenting that the primary purpose of the organization is the propagation of religious beliefs or a letter from the State of Texas Comptroller's Office documenting the organization's religious tax exemption status.(b) The Commission shall issue a letter documenting the organization's registered exemption if the application packet satisfies the requirements in this section.(c) An exempt organization registered under this section shall notify the Commission in writing within ten working days of any change affecting the program's exemption.(d) Incomplete applications shall be returned to the applicant. Source Note: The provisions of this §564.1503 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1503 Registration for Exempt Faith-Based Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217740 03/12/2026 (a) An exempt program registered under this section may not admit an individual unless the individual signs the admission statement at the time of admission.(b) The program shall keep the original signed admission statement and give a copy of it to the individual admitted. Source Note: The provisions of this §564.1504 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1504 Admission to Faith-Based Programs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217741 03/12/2026 (a) An exempt program registered under this section must include a notice in any advertisements or literature that promotes or describes the program or its chemical dependency treatment services.(b) This statement shall reflect the following: The treatment and recovery services at (name of program) are exclusively religious in nature and are not subject to licensure or regulation by the Texas Commission on Alcohol and Drug Abuse. This program offers only non-medical treatment and recovery methods, such as prayer, moral guidance, spiritual counseling, and scriptural study. Source Note: The provisions of this §564.1505 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1505 Advertisement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=217745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 217745 03/12/2026 (a) The Commission may revoke the exemption after notice and hearing if:(1) the organization conducting the program fails to inform the Commission of any material changes in the program's registration information in a timely manner;(2) any program advertisement or literature fails to include the statements required under this section; or(3) the organization violates TEX. HEALTH & SAFETY CODE ANN. §§464.051-.061 (Vernon 2001 & Supp. 2004) or any Commission rule adopted under the subchapter.(b) The Commission shall notify the organization in writing of its intent to revoke the exemption and offer the organization the opportunity for an informal hearing.(c) The organization shall have 15 calendar days from the postmark date of the notice to submit a written request for an informal hearing.(d) If the organization does not request an informal hearing, the revocation shall go into effect 30 calendar days from the postmark date of the notice of intent.(e) If the organization requests an informal hearing, the Commission shall schedule the informal hearing within 15 calendar days of the postmark date of the request.(f) At the hearing, the organization shall have opportunity to show compliance.(g) If the organization does not show compliance, the Commission's governing board shall consider the information received at the hearing and determine whether or not to revoke the organization's exemption.(h) The Commission shall send the organization written notification of its decision within 30 calendar days of the date of the hearing.(i) The revocation shall take effect 30 calendar days from the postmark date of the written notice of decision.(j) An organization whose exemption has been revoked may apply to reinstate the exemption one year after the effective date of the revocation. Source Note: The provisions of this §564.1506 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective April 30, 2024, as published in the Texas Register April 5, 2024, 49 TexReg 2197. 1 HEALTH AND HUMAN SERVICES COMMISSION 564 CHEMICAL DEPENDENCY TREATMENT FACILITIES O FAITH BASED CHEMICAL DEPENDENCY PROGRAMS §564.1506 Revocation of Exemption https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212048 03/12/2026 (a) The program provider designee must enroll in an emergency communication system in accordance with instructions from HHSC.(b) The program provider designee must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §565.1 adopted to be effective January 24, 2023, 48 TexReg 218. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS A EMERGENCY RESPONSE SYSTEM §565.1 Emergency Response System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213901 03/12/2026 (a) The purpose of this chapter is to promote the health, safety, and welfare of the individuals in the Home and Community-based Services (HCS) program by establishing the minimum health and safety expectations and responsibilities of a HCS program provider.(b) This chapter applies to program providers.(c) The Texas Health and Human Services Commission will use the rules in this chapter to establish regulatory compliance by a program provider. Source Note: The provisions of this §565.2 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS B OVERVIEW §565.2 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213902 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) Abuse--Considered to be: (A) physical abuse; (B) sexual abuse; or (C) verbal or emotional abuse. (2) Actively involved--Significant, ongoing, and supportive involvement with an applicant or individual by a person, as determined by the applicant's or individual's service planning team or program provider, based on the person's: (A) interactions with the applicant or individual; (B) availability to the applicant or individual for assistance or support when needed; and (C) knowledge of, sensitivity to, and advocacy for the applicant's or individual's needs, preferences, values, and beliefs. (3) Activities of daily living (ADL)--Basic personal everyday activities, including tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (4) Actual harm--A negative outcome that compromises an individual's physical, mental, or emotional well-being but does not constitute an immediate threat. (5) Alarm call--A signal transmitted from an individual's Community First Choice (CFC) emergency response services (ERS) equipment to the CFC ERS response center indicating that the individual needs immediate assistance. (6) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual. (7) Applicant--A Texas resident seeking services in the Home and Community-based Services (HCS) Program. (8) Behavioral emergency--A situation in which an individual's severely aggressive, destructive, violent, or self-injurious behavior: (A) poses a substantial risk of imminent probable death of, or substantial bodily harm to, the individual or others; (B) has not abated in response to preventive de-escalatory or redirection techniques; (C) is not addressed in a written behavior support plan; and (D) does not occur during a medical or dental procedure. (9) Business day--Any day except a Saturday, Sunday, or national or state holiday listed in Texas Government Code §662.003(a) or (b). (10) Calendar day--Any day, including weekends and holidays. (11) Centers for Medicare and Medicaid Services (CMS)--The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs. (12) Certification standard--A minimum standard for a program provider used by the Texas Health and Human Services Commission (HHSC) during a survey to ensure health and safety of an individual. Violations of a certification principle or standard are subject to administrative penalties. (13) CFC--Community First Choice. (14) CFC emergency response services (CFC ERS)--Backup systems and supports used to ensure continuity of services and supports. CFC ERS includes electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices. (15) CFC ERS provider--The entity directly providing CFC ERS to an individual, which may be the program provider or a contractor of the program provider. (16) CFC Financial management services (CFC FMS)--The term used for FMS on the individual plan of care (IPC) of an applicant or individual if the applicant or individual receives only CFC personal assistance services/habilitation (PAS/HAB) through the CDS option. (17) CFC personal assistance services/habilitation (CFC PAS/HAB). A service that: (A) consists of: (i) personal assistance services that aid an individual in performing ADLs and instrumental activities of daily living (IADLs) based on the individual's person-centered service plan, including: (I) non-skilled assistance with the performance of the ADLs and IADLs; (II) household chores necessary to maintain the home as a clean, sanitary, and safe environment; (III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and (IV) assistance with health-related tasks; and (ii) habilitation that aids an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, such as: (I) self-care; (II) personal hygiene; (III) household tasks; (IV) mobility; (V) money management; (VI) community integration, including how to get around in the community; (VII) use of adaptive equipment; (VIII) personal decision making; (IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and (X) self-administration of medication; and (B) does not include transporting the individual, which means driving the individual from one location to another. (18) CFC support consultation--The term used for support consultation on the IPC of an applicant or individual if the applicant or individual receives only CFC PAS/HAB through the CDS option. (19) CFC support management--Training regarding how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB, as described in the HCS Handbook. (20) Chemical restraint--A medication used to control an individual's behavior or to restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition. (21) Cognitive rehabilitation therapy--A service that: (A) assists an individual in learning or relearning cognitive skills that have been lost or altered because of damage to brain cells or brain chemistry in order to enable the individual to compensate for lost cognitive functions; and (B) includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems. (22) Community resource coordination group (CRCG)--A local interagency group composed of public and private agencies that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, which is available on the HHSC website. (23) Competitive employment--Employment that pays an individual at least minimum wage if the individual is not self-employed. (24) Consumer directed services option (CDS option)--A service delivery option in which an individual or legally authorized representative employs and retains service providers and directs the delivery of program services. (25) Contract--A provisional contract or a standard contract. (26) Controlling person--A person who: (A) has an ownership interest in a program provider; (B) is an officer or director of a corporation that is a program provider; (C) is a partner in a partnership that is a program provider; (D) is a member or manager in a limited liability company that is a program provider; (E) is a trustee or trust manager of a trust that is a program provider; or (F) because of a personal, familial, or other relationship with a program provider, is in a position of actual control or authority with respect to the program provider, regardless of the person's title. (27) Critical incident--An event listed in the HCS Provider User Guide found on the HHSC website. (28) Critical violation--A violation for which HHSC may assess an administrative penalty before giving a program provider an opportunity to correct the violation. A critical violation: (A) is an immediate threat; (B) has resulted in actual harm and is widespread; (C) has resulted in actual harm and is a pattern; or (D) has the potential to result in actual harm and is widespread. (29) DADS--Formerly the Texas Department of Aging and Disability Services. Its functions have been transferred to the Texas Health and Human Services Commission.(30) DFPS--The Department of Family and Protective Services. (31) Emergency--An unexpected situation in which the absence of an immediate response could reasonably be expected to result in risk to the health and safety of an individual or another person. (32) Emergency Plan--A written plan that describes the actions that will be taken to protect individuals, including evacuation or sheltering-in-place, in the event of an emergency such as a fire or natural disaster.(33) Emergency situation--An unexpected situation involving an individual's health, safety, or welfare, of which a person of ordinary prudence would determine that the legally authorized representative (LAR) should be informed, such as: (A) an individual needing emergency medical care; (B) an individual being removed from his or her residence by law enforcement; (C) an individual leaving his or her residence without notifying a staff member or service provider and not being located; and (D) an individual being moved from his or her residence to protect the individual (for example, because of a hurricane, fire, or flood). (34) Enclosed bed--A protective device that:(A) is commercially produced; (B) includes a 360-degree side enclosure, inclusive of a top cover or canopy; and(C) must be appropriate for the size and weight of the individual.(35) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain. (36) Family-based alternative--A family setting in which the family provider or providers are specially trained to provide support and in-home care for children with disabilities or children who are medically fragile. (37) Financial management services (FMS)--A service that is provided to an individual participating in the CDS option, as defined in 40 TAC §41.103 (relating to Definitions). (38) Financial management services agency (FMSA)--An entity that provides financial management services to an individual participating in the CDS option, as defined in 40 TAC §41.103. (39) Follow-up survey--A review by HHSC of a program provider to determine if the program provider has completed corrective action. (40) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force: (A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and (B) who was killed in action or died while in service, or whose active duty otherwise ended. (41) Four-person residence--A residence: (A) that a program provider leases or owns; (B) in which at least one person but no more than four persons receive: (i) residential support; (ii) supervised living; (iii) a non-HCS Program service like residential support or supervised living (for example, services funded by DFPS or by a person's own resources); or (iv) respite; (C) that, if it is the residence of four persons, at least one of those persons receives residential support; (D) that is not the residence of any persons other than a service provider, the service provider's spouse, or person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and (E) that is not a dwelling described in §263.101(a)(5) of this title (relating to Eligibility Criteria for HCS Program Services and CFC Services). (42) General residential operation (GRO)--The term has the meaning set forth in Texas Human Resources Code §42.002. (43) Good cause--As used in §565.19(10) of this chapter (relating to Community First Choice (CFC) Emergency Response Systems (ERS) Services), a reason outside the control of the CFC ERS provider, as determined by HHSC. (44) Health-related tasks--Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health care professionals under state law to be performed by a service provider of CFC PAS/HAB. These include tasks delegated by a registered nurse (RN); health maintenance activities as defined in 22 TAC §225.4 (relating to Definitions), that may not require delegation; and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist. (45) Home and Community-based Services Program (HCS Program)--The program operated by HHSC as authorized by CMS in accordance with §1915(c) of the Social Security Act. (46) HHSC--The Texas Health and Human Services Commission. (47) Instrumental activities of daily living (IADLs)--Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community. (48) ICAP--Inventory for Client and Agency Planning. (49) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which the ICF/IID program is: (A) licensed in accordance with Texas Health and Safety Code Chapter 252; or (B) certified by HHSC, including a state supported living center. (50) ICF/IID program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions. (51) Immediate threat--A situation that causes, or is likely to cause, serious injury, harm, impairment to, or the death of an individual. (52) Implementation plan--A written document developed by the program provider that, for each HCS Program service, except for transportation provided as a supported home living activity, and CFC service, except for CFC support management, on the individual's IPC to be provided by the program provider, includes: (A) a list of outcomes identified in the person-directed plan (PDP) that will be addressed using HCS Program and CFC services; (B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are: (i) observable, measurable, and outcome-oriented; and (ii) derived from assessments of the individual's strengths, personal goals, and needs; (C) a target date for completion of each objective; (D) the number of units of HCS Program and CFC services needed to complete each objective; (E) the frequency and duration of HCS Program and CFC services needed to complete each objective; and (F) the signature and date of the individual, LAR, and program provider. (53) Individual--A person enrolled in the HCS Program. (54) Individual plan of care (IPC)--A written plan that: (A) states: (i) the type and amount of each HCS Program service and each CFC service, except for CFC support management, to be provided to the individual during an IPC year; (ii) the services and supports to be provided to the individual through resources other than HCS Program services or CFC services, including natural supports, medical services, and educational services; and (iii) if an individual will receive CFC support management; and (B) is authorized by HHSC. (55) Initial certification survey--A review by HHSC of a program provider with a provisional contract to determine if the program provider complies with the certification standards. (56) Initial IPC--The first IPC for an individual developed before the individual's enrollment into the HCS Program. (57) Intellectual disability--Significant sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period. (58) Intellectual Disability/Related Conditions Assessment (ID/RC Assessment)--A form used by HHSC for level of care (LOC) determination and level of need (LON) assignment. (59) Intermittent survey--A review by HHSC of a program provider, which may originate from a complaint, that is not an initial certification survey, a recertification survey, or a follow-up survey, to determine if the program provider complies with the certification standards. (60) IPC cost--Estimated annual cost of HCS Program services included on an IPC. (61) IPC year--A 12-month time period starting on the date an initial or renewal IPC begins. A revised IPC does not change the begin or end date of an IPC year. (62) Isolated--The scope of a violation that has affected a very limited number of individuals or that has occurred only occasionally. (63) Legally authorized representative (LAR)--A person authorized by law to act on behalf of a person in a matter described in this subchapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (64) Level of care (LOC)--A determination given to an individual as part of the eligibility determination process based on data submitted on the ID/RC Assessment. (65) Level of need (LON)--An assignment given by HHSC to an individual upon which reimbursement for host home/companion care, supervised living, residential support, and individualized skills and socialization is based. (66) Licensed vocational nurse (LVN)--A person licensed to practice vocational nursing in accordance with Texas Occupations Code Chapter 301. (67) Local intellectual and developmental disability authority (LIDDA)--An entity designated by the HHSC Executive Commissioner, in accordance with Texas Health and Safety Code §533A.035. (68) Managed care organization--This term has the meaning set forth in Texas Government Code §536.001. (69) Means of escape--A continuous and unobstructed path of travel from an occupied portion of a building to an outside area.(70) Mechanical restraint--A mechanical device, material, or equipment used to control an individual's behavior by restricting the ability of the individual to freely move part or all of the individual's body. (71) Medical Assistance Only Medicaid (MAO Medicaid)--A type of Medicaid for which an applicant or individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income benefits. (72) Microboard--A program provider: (A) that is a non-profit corporation: (i) that is created and operated by no more than 10 persons, including an individual; (ii) the purpose of which is to address the needs of the individual and directly manage the provision of HCS Program services or CFC services; and (iii) in which each person operating the corporation participates in addressing the needs of the individual and directly managing the provision of HCS Program services or CFC services; and (B) that has a service capacity designated in the HHSC data system of no more than three individuals. (73) Military family member--A person who is the spouse or child (regardless of age) of: (A) a military member; or (B) a former military member. (74) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, Coast Guard, or Space Force on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch. (75) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who assist an individual. (76) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death. (77) Nursing facility--A facility licensed in accordance with Texas Health and Safety Code Chapter 242. (78) Pattern--The scope of a violation that is not widespread but represents repeated failures by the program provider to comply with certification standards and the failures: (A) are found throughout the services provided by the program provider; or (B) involve or affect the same individuals, service providers, or volunteers. (79) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an applicant or individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship. (80) Permanency Planning Review Screen--A screen in the HHSC data system, completed by a LIDDA, that identifies community supports needed to achieve an applicant's or individual's permanency planning outcomes and provides information necessary for approval to provide supervised living or residential support to the applicant or individual. (81) Person-directed plan (PDP)--A written plan, based on person-directed planning and developed with an applicant or individual in accordance with the HHSC Person-Directed Plan form and discovery tool found on the HHSC website, that describes the supports and services necessary to achieve the desired outcomes identified by the applicant or individual (and LAR on the applicant's or individual's behalf) and ensure the applicant's or individual's health and safety. (82) Person-directed planning--An ongoing process that empowers the applicant or individual (and the LAR on the applicant's or individual's behalf) to direct the development of a PDP. The process: (A) identifies supports and services necessary to achieve the applicant's or individual's outcomes; (B) identifies existing supports, including natural supports and other supports available to the applicant or individual and negotiates needed services system supports; (C) occurs with the support of a group of people chosen by the applicant or individual (and the LAR on the applicant's or individual's behalf); and (D) accommodates the applicant's or individual's style of interaction and preferences. (83) Physical abuse--Any of the following: (A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death; (B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual; (C) the use of a restraint on an individual in a manner that is not in compliance with federal and state laws, rules, and regulations; or (D) seclusion. (84) Physical restraint--Any manual method used to control an individual's behavior, except for physical guidance or prompting of brief duration that an individual does not resist, that restricts: (A) the free movement or normal functioning of all or a part of the individual's body; or (B) normal access by an individual to a portion of the individual's body. (85) Plan of correction--A plan documented on the HHSC Plan of Correction form that includes the corrective action that a program provider will take for each violation identified on a final survey report. (86) Plan of removal--A written plan that describes the action a program provider will take to remove an immediate threat that HHSC identifies. (87) Post 45-day follow-up survey--A follow-up survey conducted at least 46 calendar days after the exit conference of the survey in which the violation requiring corrective action was identified. (88) Post-move monitoring visit--A visit conducted by the service coordinator in accordance with the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook. (89) Pre-enrollment minor home modifications--Minor home modifications, as described in the HCS Program Billing Requirements, completed before an applicant is discharged from a nursing facility, an ICF/IID, or a GRO and before the effective date of the applicant's enrollment in the HCS Program. (90) Pre-enrollment minor home modifications assessment--An assessment performed by a licensed professional as required by the HCS Program Billing Requirements to determine the need for pre-enrollment minor home modifications. (91) Pre-move site review--A review conducted by the service coordinator in accordance with HHSC's IDD-PASRR Handbook. (92) Program provider--A "person" as defined in 40 TAC §49.102 (relating to Definitions) that has a contract with HHSC to provide HCS Program services, excluding an FMSA. (93) Protective Device--An item or device, such as a safety vest, lap belt, bed rail, safety padding, adaptation to furniture, or helmet, used only to protect an individual from injury, or for body positioning of the individual to ensure health and safety, and not used to modify or control behavior. The device or item is considered a protective device only when used in accordance with §565.37 of this chapter (relating to Protective Devices).(94) Provisional contract--A contract that HHSC enters into with a program provider in accordance with 40 TAC §49.208 (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §49.208(e). (95) Public emergency personnel--Personnel of a sheriff's department, police department, emergency medical service, or fire department. (96) Recertification survey--A review by HHSC of a program provider with a standard contract to determine if the program provider complies with the certification standards and will be certified for a new certification period. (97) Registered nurse (RN)--A person licensed to practice professional nursing in accordance with Texas Occupations Code Chapter 301. (98) Related condition--A severe and chronic disability that: (A) is attributed to: (i) cerebral palsy or epilepsy; or (ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior, similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability; (B) is manifested before the individual reaches age 22; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in at least three of the following areas of major life activity: (i) self-care; (ii) understanding and use of language; (iii) learning; (iv) mobility; (v) self-direction; and (vi) capacity for independent living. (99) Relative--A person related to another person within the fourth degree of consanguinity or within the second degree of affinity. A more detailed explanation of this term is included in the HCS Program Billing Requirements. (100) Renewal IPC--An IPC developed for an individual in accordance with §263.302(a) of this title (relating to Renewal and Revision of an IPC). (101) Repeated violation--A violation that is based on the same certification standard and involves the same HCS Program service or CFC service as a previous violation. (102) Residence--A host home/companion care, three-person, or four-person residence, as defined by the HCS Program Billing Requirements. (103) Residential survey--A review of a residence HHSC to determine if the program provider complies with §565.23 of this chapter (relating to Residential Requirements).(104) Responder--A person designated to respond to an alarm call activated by an individual. (105) Restraint--Any of the following: (A) a physical restraint; (B) a mechanical restraint; or (C) a chemical restraint. (106) Revised IPC--An initial IPC or a renewal IPC that is revised during an IPC year, in accordance with §263.302(b) or (d) of this title, to add a new HCS Program service or CFC service or change the amount of an existing service. (107) Seclusion--The involuntary placement of an individual in an area from which the individual is prevented from leaving. (108) Service backup plan--A plan that ensures continuity of critical program services if service delivery is interrupted. (109) Service coordination--A service as defined in Chapter 331 of this title (relating to LIDDA Service Coordination). (110) Service coordinator--An employee of a LIDDA who provides service coordination to an individual. (111) Service planning team--One of the following: (A) for an applicant or individual other than one described in subparagraphs (B) or (C) of this paragraph, a planning team consisting of: (i) an applicant, individual, and LAR; (ii) service coordinator; and (iii) other persons chosen by the applicant, individual, or LAR, for example, a staff member of the program provider, a family member, a friend, or a teacher; (B) for an applicant 21 years of age or older who is residing in a nursing facility and enrolling in the HCS Program, a planning team consisting of: (i) the applicant and LAR; (ii) a service coordinator; (iii) a staff member of the program provider; (iv) providers of specialized services; (v) a nursing facility staff person who is familiar with the applicant's needs; (vi) other persons chosen by the applicant or LAR, for example, a family member, friend, or teacher; and (vii) at the discretion of the LIDDA, and with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability; or (C) for an individual 21 years of age or older who has enrolled in the HCS Program from a nursing facility or has enrolled in the HCS Program as a diversion from admission to a nursing facility, for 365 calendar days after enrollment, a planning team consisting of: (i) the individual and LAR; (ii) a service coordinator; (iii) a staff member of the program provider; (iv) other persons chosen by the individual or LAR, for example, a family member, a friend, or a teacher; and (v) with the approval of the individual or LAR, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability. (112) Service provider--A person, who may be a staff member, who directly provides an HCS Program service or CFC service to an individual. (113) Sexual abuse--Any of the following: (A) sexual exploitation of an individual; (B) non-consensual or unwelcomed sexual activity with an individual; or (C) consensual sexual activity between an individual and a service provider, staff member, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff member, volunteer, or controlling person became a service provider, staff member, volunteer, or controlling person. (114) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent. (115) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person: (A) which may include sexual contact; and (B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice. (116) Specialized services--The services defined in §303.102 of this title (relating to Definitions). (117) SSI--Supplemental Security Income. (118) Staff member--An employee or contractor of an HCS Program provider. (119) Standard contract--A contract that HHSC enters into with a program provider in accordance with 40 TAC §49.209 (relating to Standard Contract) that has a term of no more than five years, not including any extension agreed to in accordance with 40 TAC §49.209(d). (120) State Medicaid claims administrator--The entity contracting with the state as the Medicaid claims administrator and fiscal agent. (121) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in acquiring personal, social, and vocational skills, but does not include a community-based facility owned by HHSC. (122) Support consultation--A service, as defined in 40 TAC §41.103, that is provided to an individual participating in the CDS option at the request of the individual or LAR. (123) Survey--An initial certification survey, a recertification survey, a follow-up survey, and an intermittent survey. (124) System check--A test of the CFC ERS equipment to determine if: (A) the individual can successfully activate an alarm call; and (B) the equipment is working properly. (125) Three-person residence--A residence: (A) that a program provider leases or owns; (B) in which at least one person but no more than three persons receive: (i) residential support; (ii) supervised living; (iii) a non-HCS Program service like residential support or supervised living (for example, services funded by DFPS or by a person's own resources); or (iv) respite; (C) that is not the residence of any person other than a service provider, the service provider's spouse, a person with whom the service provider has a spousal relationship, or a person described in subparagraph (B) of this paragraph; and (D) that is not a dwelling described in §263.101(a)(5) of this title. (126) Transition plan--As described in §303.102 of this title, a written plan developed by the service planning team for an applicant who is residing in a nursing facility and enrolling in the HCS Program. A transition plan includes essential and nonessential services and supports the applicant needs to transition from a nursing facility to a community setting. (127) Transition assistance services (TAS)--Services provided to assist an applicant in setting up a household in the community before being discharged from a nursing facility, an ICF/IID, or a GRO and before enrolling in the HCS Program. TAS consists of: (A) for an applicant whose proposed initial IPC does not include residential support, supervised living, or host home/companion care: (i) paying security deposits required to lease a home, including an apartment, or to establish utility services for a home; (ii) purchasing essential furnishings for a home, including a table, a bed, chairs, window blinds, eating utensils, and food preparation items; (iii) paying for expenses required to move personal items, including furniture and clothing, into a home; (iv) paying for services to ensure the health and safety of the applicant in a home, including pest eradication, allergen control, or a one-time cleaning before occupancy; and (v) purchasing essential supplies for a home, including toilet paper, towels, and bed linens; and (B) for an applicant whose initial proposed IPC includes residential support, supervised living, or host home/companion care: (i) purchasing bedroom furniture; (ii) purchasing personal linens for the bedroom and bathroom; and (iii) paying for allergen control. (128) Transportation plan--A written plan based on person-directed planning and developed with an applicant or individual using the HHSC Individual Transportation Plan form found on the HHSC website. A transportation plan is used to document how transportation as a supported home living activity will be delivered to support an individual's desired outcomes and purposes for transportation as identified in the PDP. (129) Vendor hold--A temporary suspension of payments that are due to a program provider under a contract. (130) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures: (A) to: (i) harass, intimidate, humiliate, or degrade an individual; or (ii) threaten an individual with physical or emotional harm; and (B) that: (i) results in observable distress or harm to the individual; or (ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress. (131) Violation--A finding by HHSC that a program provider is not or was not in compliance with a certification standard. (132) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. (133) Widespread--The scope of a violation that: (A) is pervasive throughout the services provided by the program provider; or(B) represents a systemic failure by the program provider that affects or has the potential to affect a large portion of, or all, individuals. (134) Willfully interfering--Acting or not acting to intentionally prevent, interfere with, or impede, or to attempt to intentionally prevent, interfere with, or impede. Source Note: The provisions of this §565.3 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS B OVERVIEW §565.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213903 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213903 03/12/2026 (a) The program provider cannot prohibit:(1) an individual, or the legally authorized representative (LAR) on behalf of the individual, from exercising the same rights and responsibilities exercised by people without disabilities; and(2) a LAR or family members from encouraging the individual to exercise the same rights and responsibilities exercised by people without disabilities.(b) The program provider must develop and implement policies that ensure the individual is informed of his or her rights and can exercise his or her rights without interference, coercion, discrimination, or retaliation from the program provider. This includes the right to:(1) manage, be trained to manage, or have assistance in managing financial affairs upon documentation of the individual's written request for assistance;(2) access public accommodations;(3) be informed of the requirements for participation;(4) be informed, both orally and in writing, of all the HCS Program and CFC services available and rules pertaining to the individual's enrollment and participation in the program provider's program, including those related to the use of restraint, as well as any changes in these that occur;(5) be informed of the individual plan of care (IPC), implementation plan, and transportation plan, including any restrictions affecting the individual's rights;(6) participate in decisions and be informed of the reasons for decisions regarding plans for enrollment, service termination, transfer, relocation, or denial of Home and Community-based Services Program (HCS) Program or Community First Choice (CFC) services;(7) be informed about the individual's own health, mental condition, and related progress;(8) be informed of the name and qualifications of any person serving or treating the individual and to choose among various available service providers;(9) receive visitors without prior notice to the program provider;(10) have privacy in visitation with family and other visitors;(11) make and receive telephone calls in private;(12) send and receive sealed and uncensored mail;(13) attend or refuse to attend religious activities;(14) participate in developing a pre-discharge plan that addresses assistance for the individual after he or she leaves the program;(15) be free from the use of unauthorized restraints;(16) live in a normative residential living environment;(17) access free public schooling according to Texas Education Code;(18) live where the individual is within proximity of and can access treatment and services that are best suited to meet the individual's needs and abilities and enhance that individual's strengths;(19) have a personalized IPC, implementation plan, and transportation plan based on individualized assessments that meet the individual's needs and abilities and enhance that individual's strengths;(20) help decide what the implementation plan and transportation plan will be;(21) be informed as to the progress or lack of progress being made in the execution of the implementation plan and transportation plan;(22) choose from the same services that are available to all community members, including those without disabilities;(23) be evaluated as needed, but at least annually, to determine the individual's strengths, needs, preferences, and appropriateness of the implementation plan and transportation plan;(24) complain at any time to a staff member or service provider;(25) receive appropriate support and assistance from a staff member or service provider to address concerns if the individual dislikes or disagrees with the services being rendered or thinks that his or her rights are being violated;(26) live free from abuse, neglect, or exploitation in a healthful and safe environment;(27) participate in decisions regarding the individual's living environment, including location, furnishings, personal property, other individuals residing in the residence, and moves to other residential locations;(28) have service providers who are responsive to the individual and, at the same time, are responsible for the overall functioning of the HCS Program;(29) have active personal assistance in exercising civil and self-advocacy rights attainment by provisions for:(A) complaints;(B) voter registration;(C) citizenship information and education;(D) advocacy services; and(E) guardianship;(30) receive counseling concerning the use of money;(31) possess and to use money in personal and individualized ways or learn to do so;(32) access all financial records regarding the individual's funds;(33) have privacy during treatment and care of personal needs;(34) have privacy during visits by his or her spouse if living apart;(35) share a room when both spouses are living in the same residence;(36) be free from serving as a source of labor when residing with persons other than family members;(37) communicate, associate, and meet privately with any person of his or her choice, including other individuals, unless this violates the rights of another individual;(38) participate in social, recreational, and community group activities;(39) have his or her LAR involved in activities, including:(A) being informed of all rights and responsibilities when the individual is enrolled in the program provider's program, as well as any changes in rights or responsibilities before they become effective;(B) participating in the planning for HCS Program and CFC services; and(C) advocating for all rights of the individual;(40) be informed of the individual's option to transfer to other program providers as chosen by the individual or LAR as often as desired;(41) complain to HHSC when the program provider's resolution of a complaint is unsatisfactory to the individual or LAR, and to be informed of the Intellectual and Developmental Disability Ombudsman telephone number to initiate complaints (1-800-252-8154); and(42) have opportunities for leisure time activities, vacation periods, religious observances, holidays, and days off, consistent with the individual's choice and routines of other members of the community. Source Note: The provisions of this §565.5 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS C CERTIFICATION STANDARDS: INDIVIDUAL'S RIGHTS §565.5 Rights of Individuals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213904 03/12/2026 (a) The program provider must employ or contract with a person who oversees the provision of Home and Community-based Services Program (HCS) Program services and CFC services to an individual. The person must: (1) have at least three years paid work experience in planning and providing HCS Program services or CFC services to an individual with an intellectual disability or related condition as verified by written statements from the person's employer;(2) have at least three years of experience planning and providing services like HCS Program services or CFC services to a person with an intellectual disability or related condition as verified by written statements from organizations or agencies that provided services to the person; or (3) have at least three years of experience on a microboard with duties that include overseeing, planning, or providing services to an individual with an intellectual disability or related condition as verified, in a statement by the board of directors of the non-profit corporation that the person is a member of the microboard. (b) The program provider must ensure that a staff member or service provider of individualized skills and socialization, supported home living, host home/companion care, supervised living, residential support, respite, supportive employment, and employment assistance: (1) meets the criteria for employment in the HCS Billing Requirements and Appendix C of the HCS Program waiver application from CMS located on the Texas Health and Human Services Commission (HHSC) website; and (2) is qualified to deliver required services from the person-directed plan, individual plan of care, and implementation plan to meet the needs of each individual it provides services to as evidence by: (A) documented training specific to the individual's needs and characteristics conducted before service provision and at least every twelve months thereafter; (B) observed competency; and(C) if the service provider participates in developing an implementation plan for CFC personal assistance services/habilitation (CFC PAS/HAB), the service provider or staff member must complete the Online Introductory Course to Person Centered Planning training approved by HHSC within 90 days of hire. (c) A program provider must develop and implement policy and procedures that ensure only qualified service providers administer nursing, dental, or professional therapies which includes: (1) ensuring that the service providers:(A) meet eligibility criteria in the HCS Billing Requirements and Waiver Application from the Centers for Medicare and Medicaid Services located on the HHSC website; and (B) if providing behavioral support services, complete the web-based HCS and Texas Home Living Behavioral Support Services Provider Policy Training available on the HHSC website: (i) before providing behavioral support services; (ii) within 90 calendar days after the date HHSC issues notice to program providers that HHSC revised the web-based training; and (iii) within three years after the most recent date of completion. (2) putting safeguards in place to ensure:(A) the service provider continues to be licensed and in good standing with its licensing board during the provision of services to an individual;(B) the service provider only provides services that fall within the scope of its license as defined in the Texas Occupation Code;(C) the program provider complies with each applicable regulation required by the State of Texas in ensuring that its operations, staff members and service providers meet state certification, licensure, and regulatory requirements for any tasks performed or services delivered in part or in entirety for the HCS Program; and(D) the policy or practice is revised if a shortcoming is identified.(d) A program provider must ensure that a service provider of transition assistance services (TAS):(1) is at least 18 years of age;(2) has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma;(3) is not a relative of the applicant;(4) is not the legally authorized representative (LAR) of the applicant;(5) does not live with the applicant; and(6) can provide TAS and complying with the documentation requirements described in §565.21(a)(2)(A) of this chapter (relating to Transitional Assistance Service (TAS)).(e) A program provider must:(1) ensure that a service provider of CFC PAS/HAB:(A) is at least 18 years of age;(B) has:(i) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(ii) documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(I) a written competency-based assessment of the ability to document service delivery and observations of the individuals to be served; and(II) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals being served;(C) is not:(i) the spouse of the individual; or(ii) a parent of the individual if the individual is a minor; and(D) meets any other qualifications requested by the individual or LAR based on the individual's needs and preferences; and(2) if requested by an individual or LAR:(A) allow the individual or LAR to:(i) train a CFC PAS/HAB service provider in the specific assistance needed by the individual; and(ii) have the service provider perform CFC PAS/HAB in a manner that comports with the individual's personal, cultural, or religious preferences; and(B) ensure that a CFC PAS/HAB service provider attends training by HHSC to meets any additional qualifications requested by the individual or LAR. Source Note: The provisions of this §565.7 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS D CERTIFICATION STANDARDS: STAFF MEMBER AND SERVICE PROVIDER REQUIREMENTS §565.7 Staff Member and Service Provider Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213905 03/12/2026 (a) The program provider must ensure the continuous availability of trained and qualified service providers to deliver the required services, as determined by the individual's needs and characteristics.(b) The program provider must:(1) comply with 40 Texas Administrative Code (TAC) §49.304 (relating to Background Checks);(2) comply with 40 TAC §49.312 (relating to Personal Attendants), including when the service provider of supported home living or CFC personal assistance services/habilitation (CFC PAS/HAB) is employed by or contracts with a contractor of a program provider;(3) obtain the criminal history record of the potential staff member or potential contractor from the Texas Department of Public Safety directly or through a private agency before hiring or contracting with the potential staff member;(4) not employ or contract with a potential staff member, service provider, or volunteer who:(A) has been convicted of an offense listed, and for the time periods set forth, in Texas Health and Safety Code §250.006;(B) is a registered sex offender; or(C) has been convicted of an offense that the program provider determines is a contraindication;(5) search the following registries before hire or execution of a contract and every 12 months thereafter to determine if a staff member or service provider is eligible for employment:(A) the Employee Misconduct Registry; and(B) the Nurse Aide Registry;(6) search the following registries before hire or execution of a contract and every month thereafter to determine if an employee or contractor is eligible for employment:(A) the List of Excluded Individuals and Entities maintained by the United States Department of Health and Human Services; and(B) the List of Excluded Individuals and Entities maintained by the Texas Health and Human Services Commission (HHSC) Office of Inspector General; and(7) not hire or continue employment for a staff member or service provider who is listed on:(A) the Employee Misconduct Registry as unemployable;(B) the Nurse Aide Registry as revoked or suspended;(C) the List of Excluded Individuals and Entities maintained by the United States Department of Health; or(D) the List of Excluded Individuals and Entities maintained by Health and Human Services office of Inspector General or by HHSC Office of Inspector General.(c) The program provider must develop and implement policy and procedures:(1) that ensure only staff members and service providers with a valid driver's license and insurance transport individuals; and(2) are revised if a shortcoming is identified.(d) If the service provider of supported home living or CFC PAS/HAB is employed by or contracts with a contractor of a program provider, the program provider must ensure that the contractor complies with subsection (b)(2) of this section as if the contractor were the program provider.(e) The program provider must:(1) employ or contract with a person or entity of the individual's or legally authorized representative's (LAR's) choice to provide a Home and Community-based Services Program or CFC service to the individual if that person or entity:(A) is qualified to provide the service; and(B) is willing to contract with or be employed by the program provider to provide the service in accordance with this subchapter; or(2) have and document good cause not to employ or contract with the person or entity of the individual's or LAR's choice.(f) If a program provider contracts with a person or entity to provide transition assistance services (TAS), the person or entity must have a contract to provide TAS in accordance with 40 TAC Chapter 49 (relating to Contracting for Community Services).(g) The program provider must create and implement a policy that prevents:(1) conflicts of interest between the program provider, a staff member, or a service provider and an individual, such as the acceptance of payment for goods or services (except payment for room and board) from which the program provider, staff member, or service provider could financially benefit;(2) financial impropriety toward an individual including:(A) unauthorized disclosure of information related to an individual's finances; and(B) any purchase of goods that are not requested for the individual, cannot be used by the individual, or are not intended for the individual's use;(3) abuse, neglect, or exploitation of an individual;(4) damage to, or prevention of an individual's access to, the individual's possessions; and(5) threats of the actions described in paragraphs (2) - (4) of this subsection.(h) A program provider must comply with 42 United States Code §1396a(w), regarding requirements about advance directives. Source Note: The provisions of this §565.9 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS D CERTIFICATION STANDARDS: STAFF MEMBER AND SERVICE PROVIDER REQUIREMENTS §565.9 Program Provider Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213906 03/12/2026 (a) The program provider must:(1) serve an eligible applicant who has selected the program provider unless the program provider's enrollment has reached its service capacity as identified in the Texas Health and Human Services Commission (HHSC) data system;(2) serve an eligible applicant without regard to age, sex, race, or level of disability;(3) provide or obtain as needed and without delay all Home and Community-based Services Program (HCS) Program and Community First Choice (CFC) services for an individual;(4) maintain a system of delivering HCS Program and CFC services that is continuously responsive to changes in the individual's personal goals, condition, abilities, and needs as identified by the service planning team;(5) ensure that each applicant or individual, or legally authorized representative (LAR), chooses where the individual or applicant will reside from available options consistent with the applicant's or individual's needs;(6) ensure that an individual's rights as identified in §565.5 of this chapter (relating to Rights of Individuals) are not violated, unless contraindications are documented with justification in a Behavior Support Plan;(7) notify the service coordinator if a change in an individual's condition necessitates a change in residential, educational, or work settings;(8) inform appropriate staff members, service providers, and the service coordinator when a circumstance or event occurs in an individual's life or a change to an individual's condition affects the provision of services to the individual;(9) notify the service coordinator if the program provider has reason to believe that an individual is no longer eligible for HCS Program services or CFC services or an individual or LAR has requested termination of all HCS Program services or all CFC services;(10) ensure that the individual plan of care (IPC) for each individual:(A) is renewed or revised in accordance with §263.302 of this title (relating to Renewal and Revision of an IPC); and(B) is authorized by the Health and Human Services Commission in accordance with §263.303 of this title (relating to HHSC Review of an IPC);(11) ensure that HCS Program and CFC services identified in the individual's implementation plan and transportation plan are provided in an individualized manner and are based on the results of assessments of the individual's and the family's strengths, the individual's personal goals, the family's goals for the individual, and the individual's needs rather than which services are available;(12) ensure that each individual's progress or lack of progress toward desired outcomes is documented in observable, measurable, or outcome-oriented terms;(13) ensure that individuals who perform work for the program provider are paid on the basis of their production or performance and at a wage level commensurate with that paid to persons who are without disabilities and who would otherwise perform that work, and that compensation is based on local, state, and federal regulations, including Department of Labor regulations, as applicable;(14) ensure that individuals who produce marketable goods and services in habilitation training programs are paid at a wage level commensurate with that paid to persons who are without disabilities and who would otherwise perform that work. Compensation is based on requirements contained in the Fair Labor Standards Act, which include:(A) accurate recordings of individual production or performance;(B) valid and current time studies or monitoring as appropriate; and(C) prevailing wage rates;(15) ensure that individuals provide no training, supervision, or care to other individuals unless they are qualified and compensated in accordance with local, state, and federal regulations, including Department of Labor regulations;(16) ensure that adaptive aids are provided in accordance with the individual's person-directed plan (PDP), IPC, implementation plan, and Appendix C of the HCS Program waiver application, approved by the Centers for Medicare and Medicaid Services (CMS) and found on the HHSC website, and include the full range of lifts, mobility aids, control switches/pneumatic switches and devices, environmental control units, medically necessary supplies, and communication aids and repair and maintenance of the aids, as determined by the individual's needs;(17) ensure the coordination and compatibility of HCS Program and CFC services with non-HCS Program services and non-CFC services together with an individual's service coordinator;(18) ensure that an individual has a current implementation plan;(19) ensure professional therapies:(A) are provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website:(i) audiology services;(ii) speech/language pathology services;(iii) occupational therapy services;(iv) physical therapy services;(v) dietary services;(vi) social work services;(vii) behavioral support; and(viii) cognitive rehabilitation therapy; and(B) if the service planning team determines that an individual may need cognitive rehabilitation therapy, the program provider:(i) in coordination with the service coordinator, assists the individual in obtaining, in accordance with the Medicaid State Plan, a neurobehavioral or neuropsychological assessment and plan of care from a qualified professional as a non-HCS Program service; and(ii) use a qualified professional as described in §565.7 of this chapter (relating to Staff Member and Service Provider Requirements) to provide and monitor the provision of cognitive rehabilitation therapy to the individual in accordance with the plan of care described in clause (i) of this subparagraph;(20) ensure that individualized skills and socialization is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website;(21) ensure that dental treatment is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website including:(A) emergency dental treatment;(B) preventive dental treatment;(C) therapeutic dental treatment; and(D) orthodontic dental treatment, excluding cosmetic orthodontia;(22) ensure that minor home modifications are provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website but are limited to the following categories:(A) purchase and repair of wheelchair ramps;(B) modifications to bathroom facilities;(C) modifications to kitchen facilities;(D) specialized accessibility and safety adaptations or additions; and(E) repair and maintenance of minor home modifications not covered by a warranty;(23) ensure that supported home living:(A) is available only to an individual who is not receiving:(i) host home/companion care;(ii) supervised living; or(ii) residential support; and(B) is available to an individual who is receiving foster care services from DFPS;(24) ensure that supported home living is provided in accordance with the individual's PDP, IPC, implementation plan, transportation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website and includes the following elements:(A) direct personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene);(B) assisting with meal planning and preparation;(C) providing transportation;(D) securing transportation;(E) assisting with housekeeping;(F) assisting with ambulation and mobility;(G) reinforcing professional therapy activities;(H) assisting with medications and the performing tasks delegated by a registered nurse (RN);(I) supervising of individuals' safety and security;(J) facilitating inclusion in community activities, use of natural supports, social interaction, participation in leisure activities, and development of socially valued behaviors; and(K) habilitation, exclusive of individualized skills and socialization;(25) ensure that HCS host home/companion care is provided:(A) by a host home/companion care provider who lives in the residence in which no more than three individuals or other persons receiving similar services are living at any one time; and(B) in a residence in which the program provider does not hold a property interest;(26) ensure that host home/companion care is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website and includes the following elements:(A) direct personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene);(B) assisting with meal planning and preparation;(C) securing and providing transportation;(D) assisting with housekeeping;(E) assisting with ambulation and mobility;(F) reinforcing professional therapy activities;(G) assisting with medications and the performance of tasks delegated by an RN;(H) supervising of safety and security;(I) facilitating inclusion in community activities, use of natural supports, social interaction, participation in leisure activities, and development of socially valued behaviors; and(J) habilitation, exclusive of individualized skills and socialization;(27) ensure that supervised living is provided:(A) in a four-person residence that is approved in accordance with §565.23(i) of this chapter (relating to Residential Requirements) or a three-person residence;(B) by a service provider who provides services and supports as needed by the individuals residing in the residence and is present in the residence and able to respond to the needs of the individuals during normal sleeping hours; and(C) only with approval by the HHSC commissioner or designee for the initial six months and one six-month extension and only with approval by the HHSC Executive Commissioner after such 12-month period, if provided to an individual under 22 years of age;(28) ensure that supervised living is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website and includes the following elements:(A) direct personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene);(B) assisting with meal planning and preparation;(C) securing and providing transportation;(D) assisting with housekeeping;(E) assisting with ambulation and mobility;(F) reinforcing professional therapy activities;(G) assisting with medications and the performance of tasks delegated by an RN;(H) supervising of individuals' safety and security;(I) facilitating inclusion in community activities, use of natural supports, social interaction, participation in leisure activities, and development of socially valued behaviors; and(J) habilitation, exclusive of individualized skills and socialization;(29) ensure that residential support is provided:(A) in a four-person residence that is approved in accordance with §565.23(i) of this chapter or in a three-person residence;(B) by a service provider who is present in the residence and awake whenever an individual is present in the residence;(C) by service providers assigned on a daily shift schedule that includes at least one complete change of service providers each day; and(D) only with approval by the HHSC commissioner or designee for the initial six months and one six-month extension and only with approval by the HHSC Executive Commissioner after such 12-month period, if provided to an individual under 22 years of age;(30) ensure that residential support is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website, and includes the following elements:(A) direct personal assistance with activities of daily living (grooming, eating, bathing, dressing, and personal hygiene);(B) assisting with meal planning and preparation;(C) securing and providing transportation;(D) assisting with housekeeping;(E) assisting with ambulation and mobility;(F) reinforcing professional therapy activities;(G) assisting with medications and the performance of tasks delegated by an RN;(H) supervising of individuals' safety and security;(I) facilitating inclusion in community activities, use of natural supports, social interaction, participation in leisure activities, and development of socially valued behaviors; and(J) habilitation, exclusive of individualized skills and socialization;(31) if making a recommendation to the service planning team that the individual receive residential support, document the reasons for the recommendation, which may include:(A) the individual's medical condition;(B) a behavior displayed by the individual that poses a danger to the individual or to others; or(C) the individual's need for assistance with activities of daily living during normal sleeping hours;(32) ensure that respite is available on a 24-hour increment or any part of that increment to individuals living in their family homes;(33) ensure that respite is provided in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website; and:(A) includes:(i) training in self-help and independent living skills;(ii) providing room and board when respite is provided in a setting other than the individual's normal residence;(iii) assisting with:(I) ongoing provision of needed waiver services; and(II) securing and providing transportation; and(B) is only provided:(i) to individuals who are not receiving residential support, supervised living, or host home/companion care; and(ii) when the unpaid caregiver is temporarily unavailable to provide supports;(34) provide respite in the residence of an individual or in other locations, including residences in which host home/companion care, supervised living, or residential support is provided or in a respite facility or camp, that:(A) meets HCS Program requirements and is an environment that ensures the health and safety of the individual; and(B) if respite is provided:(i) in the residence of another individual, the program provider must obtain permission from that individual or LAR and ensure that the respite visit will cause no threat to the health, safety, or welfare of either individual;(ii) in a respite facility, the program provider must obtain written approval from the local fire authority having jurisdiction stating that the facility and its operation meet the local fire ordinances before initiating services in the facility if more than three individuals receive services in the facility at any one time; or(iii) in a camp setting, the program provider must ensure the camp is accredited by the American Camp Association;(iv) in a home and community-based setting, the setting must comply with §263.501(b) of this title (relating to Requirements for Home and Community-Based Settings);(35) ensure that employment assistance:(A) is provided to an individual to help the individual locate competitive employment in the community;(B) consists of a service provider:(i) identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;(ii) locating prospective employers offering employment compatible with an individual's identified preferences, skills, and requirements;(iii) contacting a prospective employer on behalf of an individual and negotiating the individual's employment;(iv) transporting an individual to help the individual locate competitive employment in the community; and(v) participating in service planning team meetings;(C) is provided in accordance with an individual's PDP, IPC, implementation plan, and with Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website;(D) is not provided to an individual with the individual present at the same time that respite, supported home living, individualized skills and socialization, supported employment, or CFC personal assistance services/habilitation (CFC PAS/HAB) is provided; and(E) does not include using Medicaid funds paid by HHSC to the program provider for incentive payments, subsidies, or unrelated vocational training expenses, such as:(i) paying an employer:(I) to encourage the employer to hire an individual; or(II) for supervision, training, support, or adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(ii) paying an individual:(I) as an incentive to participate in employment assistance activities; or(II) for expenses associated with the start-up costs or operating expenses of the individual's business;(36) ensure that supported employment:(A) is assistance provided to an individual:(i) who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which persons without disabilities are employed;(ii) in order for the individual to sustain competitive employment; and(iii) in accordance with the individual's PDP, IPC, implementation plan, and Appendix C of the HCS Program waiver application approved by CMS and found on the HHSC website;(B) consists of a service provider:(i) making employment adaptations, supervising, and providing training related to an individual's assessed needs;(ii) transporting an individual to support the individual to be self-employed, work from home, or perform in a work setting; and(iii) participating in service planning team meetings;(C) is not provided to an individual with the individual present at the same time that respite, supported home living, individualized skills and socialization, employment assistance, or CFC PAS/HAB is provided; and(D) does not include:(i) sheltered work or other similar types of vocational services furnished in specialized facilities; or(ii) using Medicaid funds paid by HHSC to the program provider for incentive payments, subsidies, or unrelated vocational training expenses such as:(I) paying an employer:(-a-) to encourage the employer to hire an individual; or(-b-) to supervise, train, support, or make adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(II) paying an individual:(-a-) as an incentive to participate in supported employment activities; or(-b-) for expenses associated with the start-up costs or operating expenses of the individual's business;(37) ensure that CFC PAS/HAB is provided in accordance with the individual's PDP, IPC, and implementation plan;(38) ensure that CFC support management is provided to an individual or LAR if:(A) the individual is receiving CFC PAS/HAB; and(B) the individual or LAR requests to receive CFC support management;(39) inform the service coordinator of changes related to an individual's residential setting that do not require a change to the individual's IPC;(40) maintain current information in the HHSC data system about the individual and the individual's LAR, including:(A) the individual's full name, address, location code, and phone number; and(B) the LAR's full name, address, and phone number;(41) maintain a single record related to HCS Program and CFC services provided to an individual for an IPC year that includes:(A) the IPC;(B) the PDP and, if CFC PAS/HAB is included on the PDP, the completed HHSC HCS/TxHmL CFC PAS/HAB Assessment form;(C) the implementation plan;(D) a behavior support plan, if one has been developed;(E) a transportation plan, if one is required;(F) documentation that describes the individual's progress or lack of progress on the implementation plan;(G) documentation that describes any changes to an individual's personal goals, condition, abilities, or needs;(H) the Intellectual Disability/Related Conditions Assessment (ID/RC Assessment);(I) documentation supporting the recommended level of need, including the Inventory for Client and Agency Planning booklet, assessments and interventions by qualified professionals, and time sheets of service providers;(J) results and recommendations from individualized assessments that support the individual's current need for each service included in the IPC;(K) documentation concerning any use of restraint as described in §565.33(a)(2) and (3) of this chapter (relating to Restraints);(L) documentation related to the suspension of an individual's HCS Program services or CFC services;(M) for an individual under 22 years of age, a copy of the permanency plan; and(N) documentation required by subsection §565.17(a)(2) of this subchapter (relating to Pre-enrollment Minor Home Modification) and subsection §565.21(a)(2) of this subchapter (relating to Transitional Assistance Service (TAS));(42) upon request by the service coordinator:(A) permit the service coordinator access to the record that is required by paragraph (41) of this subsection; and(B) provide the service coordinator a legible copy, including an electronic copy, of a document in the record at no charge to the service coordinator;(43) provide a copy of the following documents to the service coordinator:(A) an individual's IPC; and(B) an individual's ID/RC Assessment;(44) if a physician delegates a medical act to an unlicensed service provider in accordance with Texas Occupations Code Chapter 157, and the program provider has concerns about the health or safety of the individual in performance of the medical act, communicate the concern to the delegating physician and take additional steps as necessary to ensure the health and safety of the individual;(45) for an individual receiving host home/companion care, residential support, or supervised living, ensure that the individual or LAR is involved in planning the individual's residential relocation, except in the case of an emergency;(46) for an HCS Program or CFC service identified on the PDP as critical to meeting the individual's health and safety:(A) develop a service backup plan that:(i) contains the name of the critical service;(ii) specifies the time period in which an interruption to the critical service would result in an adverse effect to the individual's health or safety; and(iii) in the event of a service interruption resulting in an adverse effect, as described in clause (ii) of this subparagraph, describe the actions the program provider will take to ensure the individual's health and safety;(B) ensure that:(i) if the action in the service backup plan required by subparagraph (A) of this paragraph identifies a natural support, that the natural support receives pertinent information about the individual's needs and can protect the individual's health and safety; and(ii) a person identified in the service backup plan, if paid to provide the service, meets the qualifications described in this subchapter; and(C) if the service backup plan required by subparagraph (A) of this paragraph is implemented:(i) discuss the implementation of the service backup plan with the individual and the service providers or natural supports identified in the service backup plan to determine whether the plan was effective;(ii) document whether the plan was effective; and(iii) revise the plan if the program provider determines the plan was ineffective;(47) for an applicant 21 years of age or older who is residing in a nursing facility and enrolling in the HCS Program:(A) participate as a member of the service planning team, which includes attending service planning team meetings scheduled by the service coordinator;(B) assist in the implementation of the applicant's transition plan as described in the plan; and(C) be physically present for the pre-move site review and assist the service coordinator during the review as requested; and(48) for 365 calendar days after an individual 21 years of age or older has enrolled in the HCS Program from a nursing facility or has enrolled in the HCS Program as a diversion from admission to a nursing facility:(A) be physically present for each post-move monitoring visit and assist the service coordinator during the visit as requested;(B) assist in the implementation of the individual's transition plan as described in the plan;(C) participate as a member of the service planning team, which includes attending service planning team meetings scheduled by the service coordinator; and(D) within one calendar day after becoming aware of an event or condition that may put the individual at risk of admission or readmission to a nursing facility, notify the service planning team of the event or condition.(b) A program provider may suspend HCS Program services or CFC services because an individual is temporarily admitted to a setting described in §263.705(a) of this title (relating to Suspension of HCS Program Services and CFC Services).(1) If a program provider suspends HCS Program services or CFC services, the program provider must:(A) notify HHSC of the suspension by entering data in the HHSC data system in accordance with HHSC instructions; and(B) notify the service coordinator of the suspension within one business day after services are suspended.(2) A program provider may not suspend HCS Program services or CFC services for more than 270 calendar days without approval from HHSC as described in §263.705(h) of this title. Source Note: The provisions of this §565.11 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.11 Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213907 03/12/2026 (a) A program provider must:(1) ensure that nursing is provided in accordance with the individual's person-directed plan (PDP); individual plan of care (IPC); implementation plan; Texas Occupations Code Chapter 301 (Nursing Practice Act); 22 Texas Administrative Code (TAC) Chapter 217 (relating to Licensure, Peer Assistance and Practice); 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions); and Appendix C of the HCS Program waiver application approved by the Centers for Medicare and Medicaid Services (CMS) and found on the Texas Health and Human Services Commission (HHSC) website, and consists of performing health care activities and monitoring the individual's health conditions;(2) this includes:(A) administering medication;(B) monitoring the individual's use of medications;(C) monitoring health risks, data, and information, including ensuring that an unlicensed service provider is performing only those nursing tasks identified from a nursing assessment;(D) assisting the individual to secure emergency medical services;(E) making referrals for appropriate medical services;(F) performing health care procedures ordered or prescribed by a physician or medical practitioner and required by standards of professional practice or law to be performed by a registered nurse (RN) or licensed vocational nurse (LVN);(G) delegating nursing tasks to an unlicensed service provider and supervising the performance of those tasks in accordance with state law and rules;(H) teaching an unlicensed service provider about the specific health needs of an individual;(I) performing an assessment of an individual's health condition;(J) ensuring a registered nurse (RN):(i) performs a nursing assessment for each individual:(I) before an unlicensed service provider performs a nursing task for the individual, unless a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician; and(II) as determined necessary by an RN, including if the individual's health needs change;(ii) documents information from performance of a nursing assessment;(iii) if an individual is receiving a service through the consumer directed services (CDS) option, provides a copy of the documentation described in clause (ii) of this subparagraph to the individual's service coordinator;(iv) develops the nursing service portion of an individual's implementation plan, which includes developing a plan and schedule for monitoring and supervising delegated nursing tasks; and(v) makes and documents decisions related to the delegation of a nursing task to an unlicensed service provider; and(K) in accordance with Texas Human Resources Code Chapter 161:(i) allowing an unlicensed service provider to provide administration of medication to an individual without the delegation or oversight of an RN if:(I) an RN has performed a nursing assessment and based on the results of the assessment, determined that the individual's health permits the administration of medication by an unlicensed service provider;(II) the medication is:(-a-) an oral medication;(-b-) a topical medication; or(-c-) a metered dose inhaler;(III) the medication is administered to the individual for a predictable or stable condition; and(IV) the unlicensed service provider has been:(-a-) trained by an RN or a licensed vocational nurse (LVN) under the direction of an RN regarding the proper administration of medication; or(-b-) determined to be competent by an RN or LVN under the direction of an RN regarding proper administration of medication, including through a demonstration of proper technique by the unlicensed service provider; and(ii) ensuring that an RN or LVN under the supervision of an RN reviews the administration of medication to an individual by an unlicensed service provider at least annually and after any significant change in the individual's condition.(b) A program provider may determine that an individual does not require a nursing assessment if:(1) nursing services are not on the individual's IPC and the program provider has determined that no nursing task will be performed by an unlicensed service provider as documented on HHSC form "Nursing Task Screening Tool"; or(2) a nursing task will be performed by an unlicensed service provider and a physician has delegated the task as a medical act under Texas Occupations Code Chapter 157, as documented by the physician.(c) If an individual or LAR refuses a nursing assessment described in subsection (a)(1)(J)(i) of this section, the program provider must not:(1) provide nursing services to the individual; or(2) provide host home/companion care, residential support, supervised living, supported home living, respite, employment assistance, supported employment, individualized skills and socialization, or CFC PAS/HAB to the individual unless:(A) an unlicensed service provider does not perform nursing tasks in the provision of the service; and(B) the program provider determines that it can ensure the individual's health, safety, and welfare in the provision of the service.(d) If an individual or LAR refuses a nursing assessment and the program provider determines that the program provider cannot ensure the individual's health, safety, and welfare in the provision of a service as described in subsection (c) of this section, the program provider must:(1) immediately notify the individual or LAR and the individual's service coordinator, in writing, of the determination; and(2) include in the notification required by paragraph (1) of this subsection the reasons for the determination and the services affected by the determination.(e) If notified by the service coordinator that the individual or LAR refuses the nursing assessment after the discussion with the service coordinator as described in §263.901(e)(22) of this title (relating to LIDDA Requirements for Providing Service Coordination in the HCS Program), the program provider must immediately send the written notification described in subsection (d) of this section to HHSC. Source Note: The provisions of this §565.13 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.13 Nursing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213908 03/12/2026 The program provider must:(1) request from and encourage the parent or legally authorized representative (LAR) of an individual under 22 years of age receiving supervised living or residential support to provide the program provider with the following information:(A) the parent's or LAR's:(i) name;(ii) address;(iii) telephone number;(iv) driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(v) place of employment and the employer's address and telephone number;(B) name, address, and telephone number of a relative of the individual or other person whom the Texas Health and Human Services Commission (HHSC) or the program provider may contact in an emergency situation, a statement indicating the relationship between that person and the individual, and at the parent's or LAR's option:(i) that person's driver license number and state of issuance or personal identification card number issued by the Department of Public Safety; and(ii) the name, address, and telephone number of that person's employer; and(C) a signed acknowledgement of responsibility stating that the parent or LAR agrees to:(i) notify the program provider of any changes to the contact information submitted; and(ii) make reasonable efforts to participate in the individual's life and in planning activities for the individual;(2) inform the parent or LAR that if the information described in paragraph (1) of this subsection is not provided or is not accurate and the service coordinator and HHSC are unable to locate the parent or LAR as described in §263.902(e)(33) of this title (relating to Permanency Planning) and §263.903 of this title (relating to Referral from HHSC to DFPS), HHSC refers the case to DFPS;(3) for an individual under 22 years of age receiving supervised living or residential support:(A) make reasonable accommodations to promote the participation of the LAR in all planning and decision-making regarding the individual's care, including participating in meetings conducted by the program provider;(B) take the following actions to assist a local intellectual and developmental disability authority (LIDDA) in conducting permanency planning:(i) cooperate with the LIDDA responsible for conducting permanency planning by:(I) allowing access to an individual's records or providing other information in a timely manner, as requested by the local authority or HHSC;(II) participating in meetings to review the individual's permanency plan; and(III) identifying, in coordination with the individual's LIDDA, activities, supports, and services that can be provided by the family, LAR, program provider, or the LIDDA to prepare the individual for an alternative living arrangement;(ii) encourage regular contact between the individual and the LAR and, if desired by the individual and LAR, between the individual and advocates and friends in the community to continue supportive and nurturing relationships;(iii) keep a copy of the individual's current permanency plan in the individual's record; and(iv) refrain from providing the LAR with inaccurate or misleading information regarding the risks of moving the individual to another institutional setting or to a community setting;(C) if an emergency situation occurs, attempt to notify the parent or LAR and service coordinator as soon as the emergency situation allows and request a response from the parent or LAR; and(D) if the program provider determines it is unable to locate the parent or LAR, notify the service coordinator of such determination. Source Note: The provisions of this §565.15 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.15 Individuals under the Age of 22 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213909 03/12/2026 The program provider must provide pre-enrollment minor home modifications and a pre-enrollment minor home modifications assessment in accordance with this subsection. (1) The program provider must: (A) complete a pre-enrollment minor home modifications assessment in accordance with the Home and Community-based Services (HCS) Program Billing Requirements; (B) provide pre-enrollment minor home modifications to an applicant for whom the program provider receives from the service coordinator a completed Pre-enrollment Minor Home Modifications/Assessments Authorization form authorized by the Texas Health and Human Services Commission (HHSC), as described in §263.104(k)(8)(C) of this title (relating to Process for Enrollment of Applicants); (C) provide to the applicant the specific pre-enrollment minor home modifications identified on the form; (D) provide the pre-enrollment minor home modifications for the applicant within the monetary amount identified on the form; (E) ensure pre-enrollment minor home modifications and pre-enrollment minor home modifications assessments are provided in accordance with Appendix C of the HCS Program waiver application approved by the Centers for Medicare and Medicaid Services (CMS) and found on the HHSC website; and (F) complete the pre-enrollment minor home modifications at least two days before the date of the applicant's discharge from the nursing facility, intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), or general residential operation (GRO) unless the delay in completion is beyond the control of the program provider. (2) If the program provider does not complete pre-enrollment minor home modifications in accordance with paragraph (1) of this subsection, the program provider must: (A) document: (i) a description of the pending modifications; (ii) the reason for the delay; (iii) the date the program provider anticipates it will complete the pending modifications or specific reasons why the program provider cannot anticipate a completion date; and (iv) a description of the program provider's ongoing efforts to complete the modifications; and (B) at least two days before the date of the applicant's discharge from the nursing facility, ICF/IID, or GRO, provide the information described in subparagraph (A) of this paragraph to: (i) the applicant or legally authorized representative (LAR); and (ii) the service coordinator. (3) Within one business day after completion of the pre-enrollment minor home modifications, the program provider must notify the service coordinator and the applicant or LAR that the modifications have been completed. Source Note: The provisions of this §565.17 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.17 Pre-enrollment Minor Home Modification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213910 03/12/2026 CFC ERS must be provided in accordance with this section.(1) A program provider must ensure that CFC ERS is provided only to an individual who:(A) is not receiving host home/companion care, supervised living, or residential support;(B) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(C) would otherwise require extensive routine supervision.(2) A program provider must ensure that CFC ERS is provided in accordance with the individual's person-directed plan, individual plan of care (IPC), and implementation plan.(3) A program provider must ensure that CFC ERS equipment is installed within 14 business days after one of the following dates, whichever is later:(A) the date the Texas Health and Human Services Commission authorizes the proposed IPC that includes CFC ERS; or(B) the effective date of the individual's IPC as determined by the service planning team.(4) At the time CFC ERS equipment is installed, a program provider must ensure that:(A) the equipment is installed in accordance with the manufacturer's installation instructions;(B) an initial test of the equipment is made;(C) the equipment has an alternate power source in the event of a power failure;(D) the individual is trained on the use of the equipment, including:(i) demonstrating how the equipment works; and(ii) having the individual activate an alarm call;(E) an explanation is given to the individual that the individual must:(i) participate in a system check each month; and(ii) contact the CFC ERS provider if:(I) the individual's telephone number or address changes; or(II) one or more of the individual's responders change; and(F) the individual is informed that a responder, in response to an alarm call, may forcibly enter the individual's home if necessary.(5) A program provider must ensure that the date and time of the CFC ERS equipment installation and compliance with the requirements in paragraphs (3) and (4) of this section are documented in the individual's record.(6) A program provider must ensure that, on or before the date CFC ERS equipment is installed:(A) an attempt is made to obtain from an individual, the names and telephone numbers of at least two responders, such as a relative or neighbor;(B) public emergency personnel:(i) are designated as a second responder if the individual provides the name of only one responder; or(ii) are designated as the sole responder if the individual does not provide the names of any responders; and(C) the name and telephone number of each responder is documented in the individual's record.(7) At least once during each calendar month a program provider must ensure that a system check is conducted on a date and time agreed to by the individual.(8) A program provider must ensure that the date, time, and result of the system check is documented in the individual's record.(9) If, because of the system check:(A) the equipment is working properly but the individual is unable to successfully activate an alarm call, the program provider must ensure that a request is made of the service coordinator to hold a service planning team meeting to determine if CFC ERS meets the individual's needs; or(B) the equipment is not working properly, the program provider must ensure that, within three calendar days of the system check, the equipment is repaired or replaced.(10) If a system check is not conducted in accordance with paragraph (7) of this section, the program provider must ensure that:(A) the failure to comply is because of good cause; and(B) the good cause is documented in the individual's record.(11) A program provider must ensure that an alarm call is responded to 24 hours a day, seven days a week.(12) A program provider must ensure that, if an alarm call is made, the CFC ERS provider:(A) within 60 seconds of the alarm call, attempts to contact the individual to determine if an emergency exists;(B) immediately contacts a responder after attempting to contact the individual, if:(i) the CFC ERS provider confirms there is an emergency; or(ii) the CFC ERS provider is unable to communicate with the individual; and(C) documents in the individual's record when the information becomes available:(i) the name of the individual;(ii) the date and time of the alarm call, recorded in hours, minutes, and seconds;(iii) the response time, recorded in seconds;(iv) the time the individual was called in response to the alarm call, recorded in hours, minutes, and seconds;(v) the name of the contacted responder, if applicable;(vi) a brief description of the reason for the alarm call; and(vii) if the reason for the alarm call is an emergency, a statement of how the emergency was resolved.(13) If an alarm call results in a responder being dispatched to the individual's home for an emergency, the program provider must ensure that:(A) the service coordinator receives written notice of the alarm call within one business day after the alarm call;(B) if the CFC ERS provider is a contracted provider, the program provider receives written notice from the contracted provider within one business day after the alarm call; and(C) the written notices required by subparagraphs (A) and (B) of this paragraph are maintained in the individual's record.(14) A program provider must ensure that, if an equipment failure occurs, other than during a system check required by paragraph (7) of this section:(A) the individual is informed of the equipment failure; and(B) the equipment is replaced within one business day after the failure becomes known by the CFC ERS provider.(15) If an individual is not informed of the equipment failure and the equipment is not replaced in compliance with paragraph (14) of this section, the program provider must ensure that:(A) the failure to comply is because of good cause; and(B) as soon as possible, the individual is informed of the equipment failure and the equipment is replaced.(16) A program provider must ensure that, if the CFC ERS equipment registers five or more "low battery" signals in a 72-hour period:(A) a visit to an individual's home is made to conduct a system check within five business days after the low battery signals occur; and(B) if the battery is defective, the battery is replaced during the visit.(17) A program provider must ensure that, if a system check or battery replacement is not made in accordance with paragraph (16) of this section:(A) the failure to comply is because of good cause; and(B) as soon as possible, the program provide makes a system check or battery replacement.(18) A program provider must document in an individual's record:(A) the date the equipment failure or low battery signal became known by the CFC ERS provider;(B) the equipment or subscriber number;(C) a description of the problem;(D) the date the equipment or battery was repaired or replaced; and(E) the good cause for failure to comply as described in paragraphs (15)(A) and (17)(A) of this section. Source Note: The provisions of this §565.19 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.19 Community First Choice (CFC) Emergency Response Systems (ERS) Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213911 03/12/2026 The program provider must provide TAS in accordance with this section. (1) The program provider must: (A) provide TAS to an applicant for whom the program provider receives from the service coordinator a completed Form 8604, Transition Assistance Services (TAS) Assessment and Authorization authorized by HHSC, as described in §263.104(k)(6)(C) of this title (relating to Process for Enrollment of Applicants); (B) purchase TAS for the applicant within the monetary amount identified on the form; (C) deliver to the applicant the specific TAS identified on the form; (D) ensure TAS is provided in accordance with the individual's person-directed plan and Appendix C of the HCS Program waiver application approved by the Centers for Medicare and Medicaid and found on the HHSC website; and (E) complete the delivery of TAS at least two days before the date of the applicant's discharge from the nursing facility, ICF/IID, or GRO unless the delay in completion is beyond the control of the program provider. (2) If the program provider does not deliver TAS in accordance with paragraph (1) of this section, the program provider must: (A) document the following: (i) a description of the pending TAS; (ii) the reason for the delay; (iii) the date the program provider anticipates it will deliver the pending TAS or specific reasons why the program provider cannot anticipate a delivery date; and (iv) a description of the program provider's ongoing efforts to deliver the TAS; and (B) at least two days before the date of the applicant's discharge from the nursing facility, ICF/IID, or GRO, provide the information described in subparagraph (A) of this paragraph to: (i) the applicant or LAR; and (ii) the service coordinator. (3) Within one business day after the TAS has been delivered, the program provider must notify the service coordinator and the applicant or LAR that the TAS has been delivered. Source Note: The provisions of this §565.21 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS E CERTIFICATION STANDARDS: SERVICE DELIVERY §565.21 Transitional Assistance Service (TAS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213912 03/12/2026 (a) This applies to all three-person and four-person residences and host home/companion care settings, unless otherwise specified.(b) A program provider must ensure that:(1) the residence, neighborhood, and community meet the needs of the individual and provide an environment that ensures the health, safety, and welfare of the individual;(2) the home is modified to meet the specific adaptive needs of the individual;(3) adaptive equipment is functional for the individual or, if the equipment is not functional, the provider has documented:(A) the broken equipment;(B) the order date of new or replacement equipment;(C) the date of the new or replacement equipment installment; and(D) alternative strategies used during the interim;(4) mattresses are off the floor and a mattress cover is utilized unless contraindicated and documented by the service planning team;(5) home furnishings are safe and fit for use;(6) the home is clean and sanitary;(7) the home is free of infestations including bugs, rodents, and other pests;(8) the walls, ceilings, floors, and windows are in good condition and not hazardous to the individual;(9) the bathrooms are functional and safe to use;(10) there is hot water available at sinks and in bathing facilities;(11) the temperature of the hot water at sinks and bathing facilities does not exceed 120 degrees Fahrenheit unless the program provider, in accordance with subsection (c) of this section, conducts a competency-based skills assessment showing that all individuals in the residence can independently regulate the temperature of the hot water from the sinks and bathing facilities;(12) the major home appliances are in working order, including kitchen appliances and heating and cooling systems;(13) the individual's bedroom door has a lock that:(A) is operable by the individual;(B) only the individual, a roommate of the individual if applicable, and staff designated by the program provider have keys to the individual's bedroom door; and(C) is not purchased and installed at the individual's or LAR's expense;(14) the individual does not require a lock if:(A) the individual lives in a host home/companion care setting and the service provider is the LAR; or(B) there is a documented modification in the individual's person-directed plan;(15) household cleaners and chemicals are stored securely; (16) perishable foods are refrigerated or stored safely;(17) animals and pets are kept free of disease and vaccinated as required by Texas Health and Safety Code, Chapter 826; and(18) the interior and exterior of the home:(A) is free of accumulation of waste and trash;(B) is accessible and free of hazards to an individual; and(C) does not compromise the health or safety of an individual.(c) If the program provider conducts the competency-based skills assessment described in subsection (b)(11) of this section:(1) the assessment must:(A) be conducted by a staff member who is not a service provider of residential support, supervised living, or host home/companion care who works or lives in the residence;(B) be conducted for each individual;(C) evaluate the individual's cognitive and physical ability to independently mix or regulate the hot water temperature without assistance or guidance from each sink and bathing facility in the residence; and(D) be based on a face-to-face demonstration by the individual; and (2) the program provider must:(A) complete the assessment at least annually;(B) document the results of the assessment; and(C) keep a copy of the results in the residence.(d) The program provider must ensure that each residence has:(1) exterior doors that are unobstructed and accessible to all individuals living in the residence;(2) two means of escape from the residence;(3) two means of escape from an individual's bedroom, unless the program provider has a fire sprinkler system that is checked and maintained according to Texas Insurance Code, Chapter 6003, at which point there can be one means of escape from an individual's bedroom;(4) working smoke alarms in each bedroom and immediately outside the bedrooms; and(5) fire extinguishers that are:(A) accessible and unobstructed to the service provider;(B) on each level of the home;(C) serviced or replaced after each use; and(D) if unused, serviced according to the manufacturer's instructions, or as required by the state or local fire marshal.(e) The program provider, as it relates to fire drills, must:(1) conduct at each residence at least:(A) one fire drill every 90 days;(B) four fire drills every 365 days; and(C) two of the fire drills listed in subparagraph (B) of this paragraph must be conducted during sleeping hours;(2) ensure that each staff member participates in a fire drill within 90 days of hire and at least annually thereafter;(3) ensure that the staff member can explain the emergency plans for the residence;(4) provide training for a staff member who does not follow the emergency plan during the fire drill; and(5) revise the emergency plan to ensure the individual can exit the residence safely if the individual is unable to exit the home according to the emergency plan.(f) The program provider, as it relates to emergency plans, must:(1) ensure that a staff member reviews the emergency plans for each individual at a residence before providing services;(2) instruct staff members on where to locate the emergency plans at the residence; and(3) maintain documentation related to emergency preparedness accessible to staff members at the residence, including:(A) emergency plans that address:(i) the relevant emergencies given the geographic location; (ii) the needs of the individuals living in the residence; and(iii) fire drill responses; and(B) emergency numbers publicly posted in an area of the residence that is easily accessible to staff members.(g) A program provider must implement and maintain personnel practices that safeguard individuals against infectious and communicable diseases, which includes:(1) using standard precautions in the care of all individuals, including hand hygiene and maintaining a sanitary environment to avoid sources and transmission of infections;(2) creating written policies for the prevention and control of communicable diseases among employees and individuals, including the appropriate use of transmission-based precautions and protective measures the program provider must take if an employee contracts a communicable disease; and(3) revising a policy or practice if a shortcoming is identified.(h) A program provider must implement and maintain medication administration and storage practices that safeguard an individual's medication, which includes:(1) creating written policies for preventing unauthorized access to medications;(2) using a procedure that ensures safe medication administration to the individual;(3) ensuring staff are trained and knowledgeable about the individuals' medications;(4) ensuring staff who are administering medications have been trained and delegated by a registered nurse (RN);(5) maintaining accurate, current, and accessible documentation of medication administration; and(6) revising a policy or practice if a shortcoming is identified.(i) A program provider must comply with the requirements in this subsection regarding a four-person residence.(1) Before providing residential support in a four-person residence, the program provider must:(A) obtain an inspection by the local fire marshal, or the Texas State Fire Marshal's office in locations where there is no local fire marshal, and correct any items cited by the local fire marshal or Texas State Fire Marshal's Office to the satisfaction of those authorities; and(B) obtain Texas Health and Human Services Commission (HHSC)approval of the residence in accordance with §565.43 of this chapter(relating to HHSC Approval of Four Person Residences).(2) HHSC inspects for certification, as described in paragraph(1)(A) of this subsection, only if the program provider submits to the HHSC Architectural Unit:(A) one of the following:(i) if the four-person residence is located in a jurisdiction with a local fire safety authority:(I) a completed HHSC Form 5606, Life Safety Code Certification, available on the HHSC website, documenting that the local fire safety authority having jurisdiction refused to inspect for certification using the code (i.e., the Life Safety Code or International Fire Code) for that jurisdiction; and(II) written documentation from the Texas State Fire Marshal's Office that it refused to inspect for certification using the Life Safety Code; or(ii) if the four-person residence is located in a jurisdiction without a local fire safety authority, written documentation from the Texas State Fire Marshal's Office that it refused to inspect for certification using the Life Safety Code; and(B) a completed HHSC Form 5604, HCS Program Provider Request for Life Safety Inspection, available on the HHSC website.(3) The program provider must:(A) obtain the certification required by this subsection annually; and(B) ensure that a four-person residence:(i) contains a copy of the most recent inspection of the residence by the local fire safety authority, Texas State Fire Marshal's Office, or HHSC; and(ii) is in continuous compliance with all applicable local building codes and ordinances and state and federal laws, rules, and regulations. Source Note: The provisions of this §565.23 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.23 Residential Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213913 03/12/2026 (a) Before providing services to an individual in a residence in which supervised living or residential support is provided, and annually thereafter, the program provider must:(1) conduct an on-site inspection to ensure that, based on the individual's needs, the environment is safe, accessible and suited for the individual's abilities, and complies with applicable federal, state, and local regulations for the community in which the individual lives;(2) complete any action identified in the on-site inspection for a residence in which supervised living or residential support will be provided:(A) before an individual moves in; or(B) within 30 days if an individual is already in the residence; and(C) document justification for any actions that cannot be completed before the individual moving in or within 30 days with a plan for completion.(b) Before providing services to an individual in a residence in which host home/companion care is provided and quarterly thereafter, the program provider must:(1) conduct an on-site inspection to ensure that, based on the individual's needs, the environment is safe, accessible, and suited for the individual's abilities and needs, and complies with applicable federal, state, and local regulations for the community in which the individual lives; and(2) require proof of completion of any action identified in the on-site inspection for a residence in which host home/companion care will be provided to ensure that the residence meets the needs of the individual:(A) before an individual moves in; or(B) within 30 days if an individual is already in the residence; and(C) document justification for any actions that cannot be completed before the individual moving in or within 30 days and include a plan for completion.(c) The program provider must establish an ongoing consumer/advocate advisory committee composed of individuals, legally authorized representatives (LARs), community representatives, and family members that meets at least quarterly. The committee:(1) at least annually, reviews the information provided to the committee by the program provider in accordance with subsection(l)(6) of this section; and(2) based on the information reviewed, makes recommendations to the program provider for improvements to the processes and operations of the program provider.(d) The program provider must make available all records, reports, and other information related to the delivery of HCS Program and CFC services as requested by the Texas Health and Human Services Commission (HHSC), other authorized agencies, or the Centers for Medicare and Medicaid and deliver such items, as requested, to a specified location or delivered electronically if available.(e) The program provider must establish a procedure to assess at least annually the satisfaction of all individuals and LARs in the program provider's services and act within 60 days regarding any areas of dissatisfaction.(f) The program provider must comply with 40 Texas Administrative Code (TAC) §49.309 (relating to Complaint Process).(g) In all respite facilities and all residences in which a service provider of residential assistance or the program provider hold a property interest, the program provider must post in a conspicuous location:(1) the name, address, and telephone number of the program provider;(2) the effective date of the contract; and(3) the name of the legal entity named on the contract.(h) A program provider must report the death of an individual:(1) to HHSC and the local intellectual and developmental disability authority by the end of the next business day after the program provider becomes aware of the death; and(2) if the program provider reasonably believes that the LAR does not know of the individual's death, to the LAR as soon as possible, but not later than 24 hours after the program provider becomes aware of the death.(i) A program provider must not retaliate against:(1) a staff member, service provider, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) use of seclusion; and(B) use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) use of seclusion; and(B) use of a restraint not in compliance with federal and state laws, rules, and regulations.(j) A program provider must enter critical incident data in the HHSC data system no later than the last calendar day of the month that follows the month being reported in accordance with HHSC guidance found on the HHSC website.(k) A program provider must ensure that:(1) the name and phone number of an alternate to the Chief Executive Officer (CEO) of the program provider is entered in the HHSC data system; and(2) the alternate to the CEO:(A) performs the duties of the CEO during the CEO's absence; and(B) acts as the contact person in an HHSC investigation if the CEO is named as an alleged perpetrator of abuse, neglect, or exploitation of an individual, and complies with§565.31(d) - (f) of this subchapter (relating to Requirements Related to the Abuse, Neglect, and Exploitation).(l) At least annually, the program provider must:(1) evaluate information about the satisfaction of individuals and LARs with the program provider's services and identify program process improvements to increase the satisfaction;(2) review complaints, as described in 40 TAC §49.309, and identify program process improvements to reduce the need for filing complaints;(3) review all final investigative reports from HHSC and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services;(4) review the reasons for terminating HCS Program or CFC services and identify any related need for program process improvements;(5) evaluate critical incident data described in subsection (j) of this section, compare the program provider's use of restraint to aggregate data provided by HHSC on the HHSC website, and identify program process improvements that help prevent the reoccurrence of restraints and improve service delivery;(6) provide all information the program provider reviewed, evaluated, and created as described in paragraphs (1) - (5) of this subsection to the consumer/advocate advisory committee required by subsection (c) of this section;(7) implement any program process improvements identified by the program provider in accordance with this subsection; and(8) review recommendations made by the consumer/advocate advisory committee as described in subsection (c)(2) of this section and implement the recommendations approved by the program provider.(m) The program provider must ensure that all personal information concerning an individual is kept confidential, such as lists of names, addresses, and records obtained by the program provider, and that the use or disclosure of such information and records is limited to purposes directly connected with the administration of the program provider's HCS Program or provision of CFC services and is otherwise neither directly nor indirectly used or disclosed unless the consent of the individual to whom the information applies or the individual's LAR is obtained beforehand.(n) The program provider must include the individual or LAR in planning the individual's residential relocation, except in cases of emergency. Source Note: The provisions of this §565.25 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.25 Programmatic Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213914 03/12/2026 (a) The program provider must comply with this subsection regarding charges against an individual's personal funds.(1) The program provider must, in accordance with this paragraph, collect a monthly amount for room from an individual who lives in a three-person or four-person residence. The cost for room must consist only of:(A) an amount equal to:(i) rent of a comparable dwelling in the same geographical area that is unfurnished; or(ii) the program provider's ownership expenses, limited to the interest portion of a mortgage payment, depreciation expense, property taxes, neighborhood association fees, and property insurance; and(B) the cost of:(i) shared appliances, electronics, and housewares;(ii) shared furniture;(iii) monitoring for a security system;(iv) monitoring for a fire alarm system;(v) property maintenance, including personnel costs, supplies, lawn maintenance, pest control services, carpet cleaning, septic tank services, and painting;(vi) utilities, limited to electricity, gas, water, garbage collection, and a landline telephone; and(vii) shared television and Internet service used by the individuals who live in the residence.(2) Except as provided in subparagraphs (B) and (C) of this paragraph, a program provider must collect a monthly amount for board from an individual who lives in a three-person or four-person residence.(A) The cost for board must consist only of the cost of food, including food purchased for an individual to consume while away from the residence as a replacement for food and snacks normally prepared in the residence, and of supplies used for cooking and serving, such as utensils and paper products.(B) A program provider is not required to collect a monthly amount for board from an individual if collecting such an amount may make the individual ineligible for the Supplemental Nutrition Assistance Program operated by the Texas health and Human Services Commission(HHSC).(C) A program provider must not collect a monthly amount for board from an individual if the individual chooses to purchase the individual's own food, as documented in the individual's implementation plan.(3) To determine the maximum room and board charge for each individual, a program provider must:(A) develop a process or formula that divides the rent equitably and considers:(i) the number of residents receiving HCS Program services or similar services that the residence has been developed to support plus the number of service providers and other persons who live in the residence; and(ii) the features or space to which an individual has exclusive or shared access, unless the additional space is requested and needed for accessibility purposes;(B) divide the board cost described in paragraph (2) of this subsection by the number of persons consuming the food; and(C) add the amounts calculated in accordance with subparagraphs (A)and (B) of this paragraph.(4) A program provider must not increase the charge for room and board because a resident moves from the residence.(5) A program provider:(A) must not charge an individual a room and board amount that exceeds an amount determined in accordance with paragraphs (1) - (3)of this subsection; and(B) must maintain documentation demonstrating that the room and board charge was determined in accordance with paragraphs (1) - (3)of this subsection.(6) Before an individual or legally authorized representative (LAR)selects a residence, the program provider must ensure the individual or LAR has a written residential agreement with:(A) the program provider if the individual lives in a three-person residence or four-person residence; or(B) the service provider of host home/companion care if the individual does not own the residence or lease the residence from another person.(7) Except as provided in paragraph (8) of this subsection, a program provider may not charge or collect payment from any person for room and board provided to an individual receiving host home/companion care.(8) If a program provider makes a payment to an individual's host home/companion care provider while waiting for the individual's federal or state benefits to be approved, the program provider may seek reimbursement from the individual for such payments.(9) For a program provider who manages personal funds of an individual who receives host home/companion care, the program provider:(A) must pay the agreed upon amount for the host home/companion care services;(B) must pay the host home/companion care provider directly from the individual's account;(C) may pay a room and board charge for the individual that is less than the host home/companion care provider's cost of room and board, as determined using the calculations described in paragraphs (1) and(2) of this subsection, for a three-person or four-person residence, divided by the number of persons living in the host home/companion care provider's home; and(D) must not pay a host home/companion care provider a room and board charge that exceeds the host home/companion care provider's cost of room and board, as determined using the calculations described in paragraphs (1) and (2) of this subsection for a three-person or four-person residence, divided by the number of persons living in the host home/companion care provider's home.(10) For an item or service other than room and board, the program provider must apply a consistent method in assessing a charge against the individual's personal funds that ensures that the charge for the item or service is reasonable and comparable to the cost of a similar item or service generally available in the community.(b) The program provider must inform the individual and LAR orally or in writing of any charges assessed by the program provider against the individual's personal funds, the purpose of those charges, and effects of the charges in relation to the individual's financial status.(c) The program provider must ensure that the individual or LAR has agreed in writing to all charges assessed by the program provider against the individual's personal funds before the charges are assessed.(d) The program provider must not assess charges against the individual's personal funds for costs for items or services reimbursed through the HCS Program or through CFC.(e) At the written request of an individual or LAR, the program provider must manage the individual's personal funds entrusted to the program provider, without charge to the individual or LAR in accordance with this subsection.(1) The program provider must not commingle the individual's personal funds with the program provider's funds.(2) The program provider must maintain a separate, detailed record of:(A) all deposits into the individual's account; and(B) all expenditures from the individual's account.(3) If an expenditure is for the individual to use as personal spending money, the program provider must have a process to show the individual acknowledged receiving the funds.(4) The program provider may accrue an expense for necessary items and services for which the individual's personal funds are not available for payment, such as room and board, medical and dental services, legal fees or fines, and essential clothing.(5) If an expense is accrued as described in paragraph (4) of this subsection, the program provider must enter a written payment plan with the individual or LAR for reimbursement of the funds. Source Note: The provisions of this §565.27 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.27 Finances and Rent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213915 03/12/2026 If the program provider determines that an individual's behavior may require the implementation of behavior management techniques involving intrusive interventions or restriction of the individual's rights, the program provider must comply with this section.(1) The program provider must:(A) obtain an assessment of the individual's needs and current level and severity of the behavior; and(B) ensure that a service provider of behavioral support services:(i) develops, with input from the individual, legally authorized representative (LAR), program provider, and actively involved persons, a behavior support plan that includes the use of techniques appropriate to the level and severity of the behavior; and(ii) considers the effects of the techniques on the individual's physical and psychological well-being in developing the plan.(2) The behavior support plan must:(A) describe how the behavioral data concerning the behavior is collected and monitored;(B) allow for the decrease in the use of the techniques based on the behavioral data; and(C) allow for revision of the plan when desired behavior is not shown, or the techniques are not effective.(3) Before implementation of the behavior support plan, the program provider must:(A) obtain written consent from the individual or LAR to implement the plan;(B) provide written notification to the individual or LAR of the right to discontinue implementation of the plan at any time; and(C) notify the individual's service coordinator of the plan.(4) The program provider must, at least annually:(A) review the effectiveness of the techniques and determine whether the behavior support plan needs to be continued; and(B) notify the service coordinator if the plan needs to be continued. Source Note: The provisions of this §565.29 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.29 Behavior Support Plan https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213916 03/12/2026 (a) A program provider must:(1) ensure that an individual and legally authorized representative(LAR), at the time the individual begins receiving a Home and Community-based Services (HCS) Program or Community First Choice(CFC) service and at least annually thereafter, are:(A) informed of how to report allegations of abuse, neglect, or exploitation to:(i) the Texas Department of Family and Protective Services (DFPS)and given the toll-free telephone number, 1-800-647-7418, in writing; and(ii) HHSC Complaint and Incident Intake (CII) by calling the toll-free telephone number, 1-800-458-9858; and(B) educated about protecting the individual from abuse, neglect, and exploitation;(2) ensure that each staff member, service provider, and volunteer are:(A) trained and knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation; (ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation; (B) instructed to report to DFPS immediately, but not later than one hour after having knowledge or suspicion, that an individual has been or is being abused, neglected, or exploited, by:(i) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-647-7418; or(ii) using the DFPS Abuse Hotline website; and(C) given the instructions described in subparagraph (B) of this paragraph in writing;(3) ensure that each staff member, service provider, and volunteer sign an acknowledgement that they understand all individuals must live free of abuse, neglect, and exploitation; and(4) conduct the activities described in paragraph (2) and (3) of this subsection before a staff member, service provider, or volunteer assumes job duties and at least annually thereafter.(b) Except as provided by §559.241(a) of this title (relating to Reporting Abuse, Neglect, Exploitation, or Incidents to HHSC), if a program provider, staff member, service provider, volunteer, or controlling person knows or suspects an individual is being or has been abused, neglected, or exploited, the program provider must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to DFPS immediately, but not later than one hour after having knowledge or suspicion, by:(1) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-647-7418; or(2) using the DFPS Abuse Hotline website.(c) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by a person who is not a service provider, staff member, volunteer, or controlling person, a program provider must:(1) assess the individual and allegation and as necessary: (A) obtain appropriate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) discuss with the individual or LAR safety measures, including alternative residential settings or individualized skills and socialization providers that may help ensure the individual's safety; (3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(4) preserve and protect evidence related to the allegation. (d) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by a service provider, staff member, volunteer, or controlling person; or if a program provider is notified by HHSC of an allegation of abuse, neglect, or exploitation by a service provider, staff member, volunteer, or controlling person, the program provider must:(1) assess the individual and allegation as necessary:(A) obtain appropriate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) notify, as soon as possible, but no later than 24 hours after the program provider reports or is notified of the allegation, the individual, the LAR, and the service coordinator of:(A) the allegation report; and(B) the actions the program provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(e) During an HHSC investigation of an alleged perpetrator who is a service provider, staff member, volunteer, or controlling person, a program provider must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview; (2) provide HHSC access to:(A) sites owned, operated, or controlled by the program provider;(B) individuals, service providers, staff members, volunteers, and controlling persons; and(C) evidence pertinent to the investigation of the allegation; and(3) ensure that staff members, service providers, volunteers, and controlling persons comply with paragraphs (1) and (2) of this subsection.(f) After a program provider receives a final investigative report from HHSC for an investigation described in subsection (e) of this section, the program provider must:(1) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the program provider's authority to prevent the reoccurrence of abuse, neglect or exploitation, including disciplinary action against the service provider, staff member, or volunteer confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the program provider's authority, to ensure the individual's safety, as necessary;(3) immediately, but not later than five calendar days after the date the program provider receives the HHSC final investigative report:(A) notify the individual, the LAR, and the service coordinator of: (i) the investigation finding; and(ii) the action taken by the program provider in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection; and(B) notify the individual or LAR of:(i) the process to appeal the investigation finding as described in Chapter 711, Subchapter J of this title (relating to Appealing the Investigation Finding); and(ii) the process for requesting a copy of the investigative report from the program provider;(4) within 14 calendar days after the date the program provider receives the final investigative report, complete and send to HHSC the Form 8494, Notification Regarding an Investigation of Abuse, Neglect or Exploitation, located on the HHSC website; and(5) upon request of the individual or LAR, provide to the individual or LAR a copy of the HHSC final investigative report after removing any information that would reveal the identity of the reporter or of any individual who is not the alleged victim.(g) The program provider must ensure the coordination of services with the licensed individualized skills and socialization provider, including information regarding abuse, neglect, and exploitation. Source Note: The provisions of this §565.31 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.31 Requirements Related to Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213917 03/12/2026 (a) Within 30 calendar days of receiving services from a program provider and annually thereafter, a program provider must:(1) with the involvement of a physician, identify:(A) the individual's known physical or medical conditions that might constitute a risk to the individual during the use of restraint;(B) the individual's ability to communicate; and(C) other factors that must be taken into account if the use of restraint is considered, including the individual's:(i) cognitive functioning level;(ii) height;(iii) weight;(iv) emotional condition that could contraindicate the use of restraint, including whether the individual has a history of having been physically or sexually abused; and(v) age;(2) document the conditions and factors identified in accordance with paragraph (1) of this subsection, and, as applicable, limitations on specific restraint techniques or mechanical restraint devices in the individual's record; and(3) review and update with a physician, registered nurse (RN), or licensed vocational nurse (LVN), at least annually or when a condition or factor documented in accordance with paragraph (2) of this subsection changes significantly, information in the individual's record related to the identified condition, factor, or limitation.(b) A program provider may use a restraint:(1) in a behavioral emergency;(2) as part of a behavior support plan that addresses inappropriate behavior exhibited voluntarily by an individual;(3) during or as a follow-up to a medical or dental procedure or treatment of an injury if the restraint is ordered by the physician or dentist as necessary to protect the individual or others or promote the healing of wounds;(4) to protect the individual from involuntary self-injury; and(5) if used as a protective device in accordance with §565.37 of this subchapter (relating to Protective Devices).(c) A program provider must not use restraint:(1) in a manner that:(A) restricts circulation;(B) obstructs the individual's airway, including the placement of anything in, on, or over the individual's mouth or nose;(C) impairs the individual's breathing by putting pressure on the individual's torso;(D) interferes with the individual's ability to communicate;(E) places the individual in a prone or supine position;(F) extends muscle groups away from each other;(G) uses hyperextension of joints;(H) uses pressure points or pain; or(I) secures the individual to a stationary object while the individual is in a standing position;(2) for disciplinary purposes, that is, as retaliation or retribution;(3) for the convenience of a staff member or service provider or other individuals; or(4) as a substitute for effective treatment or habilitation.(d) If a program provider restrains an individual as provided in subsection (b) of this section, the program provider must:(1) take into account the conditions, factors, and limitations on specific restraint techniques or mechanical restraint devices documented in accordance with subsection (a)(2) and (3) of this section;(2) use the minimal amount of force or pressure that is reasonable and necessary to ensure the safety of the individual and others; and(3) safeguard the individual's dignity, privacy, and well-being.(e) In a circumstance described in subsection (b)(1) or (2) of this section, a program provider may use only a restraint hold in which the individual's limbs are held close to the body to limit or prevent movement and that does not violate the provisions of subsection(c)(1) of this section.(f) A program provider must release an individual from restraint:(1) as soon as the individual no longer poses a risk of imminent physical harm to the individual or others;(2) if the individual in restraint experiences a medical emergency, as soon as possible as indicated by the medical emergency; or(3) as soon as an individual in a restraint hold described in subsection (e) of this section who moves toward the floor reaches the floor.(g) After restraining an individual in a behavioral emergency, a program provider must:(1) as soon as possible but no later than one hour after the use of restraint, notify an RN or LVN of the restraint;(2) ensure that medical services are obtained for the individual as necessary;(3) as soon as possible but no later than 24 hours after the use of restraint, notify one of the following persons, if there is such a person, that the individual has been restrained:(A) the individual's legally authorized representative; or(B) a person actively involved with the individual, unless the release of this information would violate other law; and(4) notify the individual's service coordinator by the end of the first business day after the use of restraint.(h) If, under the Health Insurance Portability and Accountability Act, the program provider is a "covered entity," as defined in 45 Code of Federal Regulations (CFR) §160.103, any notification provided under subsection (g)(3)(B) of this section must be to a person to whom the program provider is allowed to release information under 45 CFR §164.510. Source Note: The provisions of this §565.33 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.33 Restraints https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213918 03/12/2026 (a) The program provider may allow the use of an enclosed bed in a residence if the enclosed bed is purchased, obtained, and complies with the requirements in subsection (c) of this section prior to June 19, 2023.(b) An enclosed bed is prohibited in a residence if it is purchased or obtained on or after June 19, 2023, even if it complies with subsection (c) of this section.(c) If the program provider allows the use of an enclosed bed in a residence, the program provider must:(1) visually inspect the enclosed bed to ensure it meets the criteria of an enclosed bed as defined in §565.3 of this chapter(related to Definitions);(2) ensure that a physician, occupational therapist, or physical therapist:(A) conducts an annual assessment to determine:(i) if the individual has a medical need for the enclosed bed;(ii) the circumstances under which the enclosed bed may be used;(iii) that less restrictive methods would be ineffective in protecting the individual and the reasons for that determination;(iv) how to use the enclosed bed and any contraindications specific to the individual;(v) how and when to document the use of the enclosed bed; and(vi) how to monitor the use of the enclosed bed to ensure it is being used in accordance with the assessment; and(B) follows up after any significant change to determine if the individual still has a medical need for the enclosed bed;(3) obtain and retain the following documentation:(A) a letter of medical necessity from the prescribing physician or professional therapist; and(B) a receipt from a durable medical equipment company for the enclosed bed;(4) develop and implement policies and procedures that require:(A) routine checks of the enclosure bed to ensure it is in good repair and safe for the individual;(B) a documented quarterly review by a registered nurse (RN) or professional therapist to ensure the enclosed bed is still safe and necessary given the individual's current needs and other less restrictive options available; and(C) an order for the enclosed bed updated annually, or sooner if the RN has determined there is a significant change to the individual's condition.(d) To prevent misuse or overuse of the enclosed bed, the program provider must:(1) develop and implement a usage plan that details when the enclosed bed will be used that is consistent with the assessment and order;(2) require any staff member who provides services to an individual with an enclosed bed to read and document understanding of the usage plan before providing services; and(3) make the usage plan readily available to staff members providing services.(e) All enclosed beds are prohibited after June 19, 2028. Source Note: The provisions of this §565.35 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.35 Enclosed Beds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213919 03/12/2026 (a) Except as provided in §565.35 of this subchapter (relating to Enclosed Beds), if a protective device is used, the program provider must ensure that it is used in accordance with this section.(b) A program provider must not use a protective device:(1) to modify or control an individual's behavior;(2) for disciplinary purposes;(3) for staff convenience; or(4) as a substitute for an effective, less restrictive method.(c) If a need for a protective device is identified, the program provider must ensure that a physician, occupational therapist, physical therapist, or registered nurse (RN):(1) conducts an initial assessment to determine:(A) if the individual has a medical need for a protective device;(B) that less restrictive methods would be ineffective in protecting the individual, and the reasons for that determination;(C) the type of protective device to be used, which must be the least restrictive protective device that will protect the individual;(D) the circumstances under which the protective device may be used;(E) how to use the protective device and any contraindications specific to the individual;(F) how and when to document the use of the protective device; and(G) how to monitor the use of the protective device to ensure it is being used in accordance with the assessment; and(2) then annually and after any significant change to determine:(A) if the individual has a medical need for a protective device;(B) that less restrictive methods would be ineffective in protecting the individual, and the reasons for that determination; and(C) the type of protective device to be used, which must be the least restrictive protective device that will protect the individual.(d) Before a program provider uses a protective device, the program provider must:(1) obtain and retain in the individual's record:(A) an order for the use of the protective device identified in the initial assessment;(B) complete initial and subsequent assessments from subsection (c)of this section; and(C) consent of the individual or legally authorized representative(LAR) to use the protective device;(2) provide oral and written notification to the individual or LAR of the right at any time to withdraw consent for the use of the protective device; and(3) develop a policy and procedure to ensure that each service provider who will use the protective device has been trained in the proper use of the protective device, in accordance with the initial assessment. Source Note: The provisions of this §565.37 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.37 Protective Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213920 03/12/2026 (a) A program provider must not use seclusion.(b) An enclosed bed must not be used for behavioral management. Source Note: The provisions of this §565.39 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS F CERTIFICATION STANDARDS: QUALITY ASSURANCE §565.39 Prohibitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213923 03/12/2026 (a) A program provider must be in continuous compliance with the certification standards contained in this subchapter that apply to program providers.(b) The Texas Health and Human Services Commission (HHSC) conducts the following unannounced surveys:(1) an initial certification survey;(2) a recertification survey;(3) a follow-up survey;(4) a residential survey; and(5) an intermittent survey.(c) HHSC conducts an initial certification survey within 120 calendar days after the date HHSC approves the enrollment or transfer of the first individual to receive HCS Program services from the program provider.(d) HHSC may conduct an intermittent survey at any time during a certification period.(e) HHSC may conduct a combination of two or more different types of surveys at the same time.(f) If HHSC certifies a program provider after completion of an initial or a recertification survey, the certification period is for no more than 365 calendar days.(g) HHSC may choose not to conduct a recertification survey of a program provider that has a standard contract if the program provider is not the program provider for one or more individuals for at least 60 consecutive calendar days during the period beginning the first day of the certification period to be surveyed through the 121st calendar day before the end of the certification period.(h) During a survey, HHSC may:(1) review the HCS Program or CFC services provided to any individual to determine if a program provider complies with the certification standards; and(2) determine if a program provider has implemented an approved plan for amelioration as described in §565.47 of this subchapter (relating to Amelioration).(i) HHSC conducts an exit conference at the end of a survey, at a time and location determined by HHSC. At the exit conference, HHSC informs a program provider of preliminary findings, in writing, including findings that may result in a critical violation.(j) If HHSC identifies a finding that may be a critical violation not discussed during an exit conference, HHSC holds a new exit conference with a program provider to discuss the finding.(k) In addition to the surveys described in this section, HHSC conducts, at least annually, an unannounced visit of each residence in which residential support or supervised living is provided to determine if the residence provides a safe and healthy environment that complies with the certification standards.(l) Based on the information obtained from a visit described in subsection (k) of this section, HHSC may:(1) require the program provider to complete corrective action before the residential visit ends;(2) require the program provider to submit, before the residential visit ends, a written plan describing how the safety of the individuals will be protected until corrective action is completed;(3) require the program provider to submit evidence of corrective action within a time period determined by HHSC; or(4) conduct an intermittent survey of the program provider.(m) Based on a survey, HHSC acts as described in §565.49 of this subchapter (relating to Program Provider Compliance and Corrective Action).(n) HHSC may evaluate the health and safety of an individual at any time.(o) HHSC may conduct an unannounced residential survey of a residence in which host home/companion care, residential support, or supervised living is provided to determine if the residence provides a safe environment. Source Note: The provisions of this §565.41 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS G HHSC ACTIONS §565.41 HHSC Surveys of a Program Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213921 03/12/2026 (a) A program provider must obtain written approval from the Texas Health and Human Services Commission (HHSC) in accordance with subsection (b) of this section before providing residential support in a four-person residence.(b) To obtain approval of a four-person residence, the program provider must submit the following written documentation to HHSC:(1) the address and county of the residence;(2) certification from the program provider that the program provider intends to provide residential support to one or more individuals who will live in the residence;(3) one of the certifications required by §565.23(i)(1)(A) of this chapter (relating to Residential Requirements); and(4) written certification from the program provider that the residence to be approved is not the residence of any person other than a person permitted to live in a "four-person residence," as defined in §565.3 of this chapter (relating to Definitions).(c) HHSC notifies the program provider in writing of its approval or disapproval of the four-person residence within 14 calendar days after HHSC receives the documentation specified in subsection (b) of this section. Source Note: The provisions of this §565.43 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS G HHSC ACTIONS §565.43 HHSC Approval of Four Person Residences https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213693 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213693 03/12/2026 (a) HHSC may impose and collect an administrative penalty against a program provider for:(1) a violation of a certification principle that applies to a program provider; and(2) any of the following:(A) willfully interfering with the work of a representative of HHSC or the enforcement of this subchapter, which may include:(i) making a false statement of material fact that the program provider knows or should know is false with respect to a matter under investigation by HHSC; and(ii) falsifying documentation, including documenting the provision of a service before the service has been provided; or(B) failing to pay an administrative penalty within 10 calendar days after the date the assessment of the penalty becomes final.(b) The range of the administrative penalty that may be imposed against a program provider each day for a violation described in subsection (a)(1) of this section is based on the scope and severity of the violation and whether it is an initial or repeated violation, as set forth in the following figure:Attached Graphic(c) In determining the amount of an administrative penalty within a range, HHSC considers:(1) the seriousness of the violation, including:(A) the nature, circumstances, extent, and gravity of the violation; and(B) the hazard to the health or safety of individuals resulting from the violation;(2) the program provider's history of previous violations; (3) whether the program provider:(A) had prior knowledge of the violation, including whether the program provider identified the violation through the program provider's internal quality assurance process; and(B) made any efforts to mitigate or correct the identified violation;(4) the penalty amount necessary to deter future violations; and(5) any other matter that justice may require.(d) If HHSC determines that a violation is not a critical violation, HHSC allows a program provider one opportunity to correct the violation to avoid the imposition of an administrative penalty. If HHSC determines that a violation is a critical violation, HHSC does not allow a program provider an opportunity to correct the violation before HHSC imposes an administrative penalty. (e) If HHSC imposes an administrative penalty for a violation described in subsection (a)(1) of this section, the administrative penalty begins accruing:(1) for a critical violation, on the date HHSC identifies the violation; or (2) for a violation that is not critical, on the date of the exit conference of the post 45-day follow-up survey.(f) An administrative penalty accrues each day until the earliest of the following: (1) the program provider completes corrective action for that violation, as determined by HHSC;(2) HHSC imposes a vendor hold for that violation; or (3) HHSC withholds payments as the result of a proposed contract termination.(g) If the program provider demonstrates that corrective action is complete on the same day an administrative penalty begins accruing, HHSC imposes an administrative penalty for one day.(h) For an administrative penalty imposed in accordance with subsection (a)(2) of this section:(1) HHSC imposes the penalty no more than once per survey; (2) HHSC does not allow a program provider an opportunity to correct the action before imposing the penalty; and (3) the amount of the penalty is $1000.(i) If HHSC imposes an administrative penalty against a program provider in accordance with subsection (a) of this section, HHSC does not, at the same time, impose a vendor hold or otherwise withhold contract payments from the program provider for the same violation, action, or failure to act. Source Note: The provisions of this §565.45 adopted to be effective April 28, 2020, 45 TexReg 2704; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2731. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS G HHSC ACTIONS §565.45 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213922 03/12/2026 (a) In lieu of requiring payment for an administrative penalty imposed against a program provider in accordance with §565.45 of this chapter (relating to Administrative Penalties), the Texas Health and Human Services Commission (HHSC) may give the program provider the opportunity for amelioration in accordance with this section.(b) HHSC does not give a program provider the opportunity for amelioration:(1) more than three times in a two-year period;(2) more than one time in a two-year period for the same or similar violation;(3) for a critical violation that is an immediate threat; or(4) for the actions or failures to act described in §565.45 of this chapter.(c) HHSC gives a program provider the opportunity for amelioration in the notice required by 40 TAC §49.535(c) (relating to Administrative Penalties in the HCS and TxHmL Programs). If the program provider does not notify HHSC that the program provider chooses amelioration within the required period described in the notice, the program provider forfeits the opportunity to choose amelioration and HHSC requires the program provider to pay the administrative penalty in accordance with §565.45 of this chapter.(d) If a program provider chooses amelioration in accordance with the notice required by 40 TAC §49.535(c), the program provider must submit a written plan for amelioration to HHSC within 45 calendar days after the date of the notice required by 40 TAC §49.535(c). If a program provider does not submit a plan for amelioration within 45 calendar days, HHSC requires the program provider to pay the administrative penalty in accordance with 40 TAC §49.535(d)(1).(e) A plan for amelioration must include:(1) proposed changes to the management or operation of the program provider that will improve services or the quality of care for the individuals;(2) the ways in which and the extent to which the proposed changes will improve services or quality of care for the individuals through measurable outcomes;(3) clear goals to be achieved through the proposed changes;(4) a timeline for implementing the proposed changes;(5) specific actions necessary to implement the proposed changes;(6) the cost of the proposed changes; and(7) an agreement to waive the program provider's right to appeal the imposition of the administrative penalty if HHSC approves the plan for amelioration.(f) The cost of the proposed changes must be incurred by the program provider after HHSC approves the plan for amelioration. If HHSC approves the plan and the cost of the proposed changes is less than the amount of the administrative penalty, HHSC requires the program provider to pay the difference between the cost of the proposed changes and the administrative penalty.(g) HHSC may require a plan for amelioration to propose changes that result in conditions exceeding the requirements of this subchapter.(h) HHSC notifies a program provider of its decision to approve or deny a plan for amelioration within 45 calendar days after the date HHSC receives the plan. During the 45-day period, HHSC may allow the program provider an opportunity to revise the plan.(1) If HHSC approves the plan:(A) the program provider must implement the plan; and(B) HHSC:(i) requires the program provider to pay the amount of the difference between the cost of the proposed changes and the administrative penalty, if any; and(ii) determines in one or more surveys conducted in accordance with §565.41 of this subchapter (relating to HHSC Surveys of a Program Provider) if the program provider has implemented the plan.(2) If HHSC denies the plan, HHSC requires the program provider to pay the amount of the administrative penalty in accordance with 40 TAC §49.535(d)(2). The program provider may appeal the administrative penalty in accordance with 40 TAC §49.541 (relating to Contractor's Right to Appeal).(i) If HHSC determines that a program provider did not implement an approved plan for amelioration, HHSC requires the program provider to pay the amount of the administrative penalty in accordance with 40 TAC §49.535(d)(3). The program provider may appeal the sole issue of whether the plan for amelioration was implemented. Source Note: The provisions of this §565.47 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS G HHSC ACTIONS §565.47 Amelioration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213924 03/12/2026 (a) If the Texas Health and Human Services Commission (HHSC) determines from a survey that a program provider complies with the certification standards, HHSC:(1) sends the program provider a final survey report stating that the program provider complies with the certification standards;(2) does not require any action by the program provider; and(3) if the survey is an initial or a recertification survey, certifies the program provider as described in §565.41(f) of this subchapter (relating to HHSC Surveys of a Program Provider).(b) If HHSC determines from a survey that a program provider is not in compliance with a certification standard and the violation is an immediate threat, HHSC notifies the program provider of the determination. The program provider must immediately provide HHSC with a plan of removal.(c) In a plan of removal provided in accordance with subsection (b) of this section, a program provider must specify the time by which the program provider will remove the immediate threat. HHSC approves or disapproves the plan of removal and monitors to ensure the immediate threat is removed.(d) If a program provider that is required to provide a plan of removal does not provide a plan of removal, HHSC does not approve the program provider's plan of removal, or the program provider does not implement the plan of removal approved by HHSC, HHSC:(1) denies or terminates certification of the program provider; and(2) coordinates with the local intellectual and developmental disability authorities (LIDDAs) the immediate provision of alternative services for the individuals.(e) If HHSC determines from a survey that a program provider is not in compliance with a certification standard, HHSC sends to the program provider, within 10 business days after the date of the exit conference:(1) a final survey report with a list of violations;(2) a letter notifying the program provider that the program provider may request an informal dispute resolution to dispute a violation in the final survey report; and(3) if HHSC imposes an administrative penalty in accordance with §565.45 of this subchapter (relating to Administrative Penalties), a written notice of the administrative penalty as described in 40 TAC §49.535(b) (relating to Administrative Penalties in the HCS and TxHmL Programs).(f) If HHSC determines from an initial certification survey, recertification survey, or intermittent survey that a program provider is not in compliance with a certification standard, the program provider must submit to HHSC, within 14 calendar days after the date the program provider receives the final survey report, a plan of correction for each violation identified by HHSC in the final survey report. The program provider must submit a plan of correction in accordance with this subsection even if the program provider disagrees with the violation or requests an informal dispute resolution.(g) In a plan of correction submitted in accordance with subsection (f) of this section, a program provider must specify a date by which the program provider will complete corrective action for each violation and such date must:(1) for a critical violation, be no later than 30 calendar days after the date of the survey exit conference; and(2) for a violation that is not a critical violation, be no later than 45 calendar days after the date of the survey exit conference.(h) After HHSC receives the plan of correction required by subsection (f) of this section, HHSC notifies the program provider whether the plan is approved or not approved.(i) If HHSC does not approve a plan of correction required by subsection (f) of this section, the program provider must submit a revised plan of correction within five business days after the date of HHSC's notice that the plan of correction was not approved. After HHSC receives the revised plan of correction, HHSC notifies the program provider whether the revised plan is approved or not approved.(j) If the program provider does not submit a plan of correction required by subsection (f) of this section or a revised plan of correction required by subsection (i) of this section, or if HHSC notifies the program provider that a revised plan of correction is not approved, HHSC:(1) imposes a vendor hold against the program provider until HHSC approves a plan of correction submitted by the program provider; or(2) denies or terminates certification of the program provider.(k) If HHSC approves a plan of correction, HHSC takes the following actions to determine if a program provider has completed its corrective action:(1) requests that the program provider submit evidence of correction to HHSC; and(2) conducts:(A) for a critical violation, a follow-up survey after the date specified in the plan of correction for correcting the violation but within 45 calendar days after the survey exit conference, unless HHSC conducts an earlier follow-up survey as described in subsection (l) of this section; or(B) for a violation that is not critical, a post 45-day follow-up survey, unless HHSC conducts an earlier follow-up survey as described in subsection (l) of this section.(l) At the request of a program provider, HHSC may conduct a follow-up survey earlier than the timeframes described in subsection (k)(2) of this section.(1) If HHSC determines from the earlier follow-up survey that corrective action has been completed and the program provider has not yet submitted a plan of correction to HHSC in accordance with subsection (f) of this section, the program provider must include the corrective action taken on the plan of correction that is submitted.(2) If HHSC determines from the earlier follow-up survey that corrective action has not been completed for a violation that is not critical, HHSC conducts the post 45-day follow-up survey.(m) If HHSC determines from a follow-up survey described in subsections (k)(2)(A) or (l) of this section that the program provider has completed corrective action for a critical violation, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in 40 TAC §49.535(c).(n) If HHSC determines from a follow-up survey described in subsections (k)(2)(A) or (l) of this section that the program provider has not completed the corrective action for a critical violation, HHSC:(1) continues the administrative penalty and conducts another follow-up survey to determine if the program provider completed the corrective action;(2) imposes a vendor hold against the program provider; or(3) denies or terminates certification of the program provider.(o) HHSC takes the actions described in this subsection regarding a follow-up survey described in subsection (n)(1) of this section.(1) If HHSC determines from the survey that the program provider has completed the corrective action, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in 40 TAC §49.535(c).(2) If HHSC determines from the survey that the program provider has not completed the corrective action, the administrative penalty stops accruing and HHSC:(A) imposes a vendor hold against the program provider; or(B) denies or terminates certification of the program provider.(p) If HHSC determines from a post 45-day follow-up survey or an earlier survey described in subsection (l) of this section that a program provider has completed corrective action for a violation that is not critical, HHSC does not impose an administrative penalty for the non-critical violation.(q) If HHSC determines from a post 45-day follow-up survey that a program provider has not completed corrective action for a violation that is not critical, HHSC:(1) imposes an administrative penalty for the non-critical violation in accordance with §565.45 of this subchapter;(2) notifies the program provider of the administrative penalty, as described in 40 TAC §49.535(b); and(3) conducts a survey:(A) at least 31 calendar days after the date of the post 45-day exit conference of the follow-up survey; or(B) earlier than 31 calendar days after the date of the exit conference of the post 45-day follow-up survey if the program provider has submitted evidence of corrective action to HHSC during the 30-day period.(r) HHSC takes the actions described in this subsection regarding a survey described in subsection (q)(3) of this section.(1) If HHSC determines from the survey that the program provider has completed corrective action, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in 40 TAC §49.535(c).(2) If HHSC determines from the survey that the program provider has not completed the corrective action, the administrative penalty stops accruing and HHSC:(A) imposes a vendor hold against the program provider; or(B) denies or terminates certification of the program provider.(s) If HHSC determines that a program provider committed any of the actions described in §565.45(a)(2) of this subchapter, HHSC takes one of the following actions:(1) imposes an administrative penalty against the program provider as described in §565.45 of this subchapter;(2) imposes a vendor hold against the program provider; or(3) denies or terminates certification of the program provider.(t) If HHSC imposes a vendor hold in accordance with this section:(1) for a program provider with a provisional contract, HHSC initiates termination of the program provider's contract in accordance with 40 TAC §49.534 (relating to Termination of Contract by HHSC); or(2) for a program provider with a standard contract, HHSC conducts a survey at least 31 calendar days after the effective date of the vendor hold to determine if the program provider completed the corrective action required to release the vendor hold and:(A) if the program provider completed the corrective action, HHSC releases the vendor hold; or(B) if the program provider has not completed the corrective action, HHSC denies or terminates certification.(u) If HHSC determines that a program provider is out of compliance with §565.9(b)(2) of this chapter (relating to Program Provider Requirements), corrective action required by HHSC may include the program provider paying or ensuring payment to a service provider of supported home living or CFC PAS/HAB who was not paid the wages required by §565.9(b)(2) of this chapter, the difference between the amount required and the amount paid to the service provider.(v) HHSC does not cite a program provider for violation of a certification standard based solely on the action or inaction of a person who is not a service provider or a staff member. HHSC may cite a program provider for violation of a certification standard based on the program provider's response to the action or inaction of such a person. Source Note: The provisions of this §565.49 adopted to be effective June 21, 2023, 48 TexReg 3246. 1 HEALTH AND HUMAN SERVICES COMMISSION 565 HOME AND COMMUNITY-BASED (HCS) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS G HHSC ACTIONS §565.49 Program Provider Compliance and Corrective Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212049 03/12/2026 (a) The program provider designee must enroll in an emergency communication system in accordance with instructions from HHSC.(b) The program provider designee must respond to requests for information received through the emergency communication system in the format established by HHSC. Source Note: The provisions of this §566.1 adopted to be effective January 24, 2023, 48 TexReg 219. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.1 Emergency Response System https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224578 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise: (1) Abuse-- (A) physical abuse; (B) sexual abuse; or (C) verbal or emotional abuse. (2) Actual harm--A negative outcome that compromises an individual's physical, mental, or emotional well-being but does not constitute immediate threat. (3) ADLs--Activities of daily living. Basic personal everyday activities including tasks such as eating, toileting, grooming, dressing, bathing, and transferring. (4) Alarm call--A signal transmitted from an individual's CFC ERS equipment to the CFC ERS response center indicating that the individual needs immediate assistance. (5) Alleged perpetrator--A person alleged to have committed an act of abuse, neglect, or exploitation of an individual. (6) Applicant--A Texas resident seeking services in the TxHmL Program. (7) Business day--Any day except a Saturday, a Sunday, or a national or state holiday listed in Texas Government Code §662.003(a) or (b). (8) Calendar day--Any day, including weekends and holidays. (9) CDS option--Consumer directed services option. A service delivery option as defined in §41.103 of this title (relating to Definitions). (10) CFC--Community First Choice. (11) CFC ERS--CFC emergency response services. Backup systems and supports used to ensure continuity of services and supports. CFC ERS includes electronic devices and an array of available technology, personal emergency response systems, and other mobile communication devices. (12) CFC ERS provider--The entity directly providing CFC ERS to an individual, which may be the program provider or a contractor of the program provider. (13) CFC FMS--The term used for FMS on the IPC of an applicant or individual if the applicant or individual receives only CFC PAS/HAB through the CDS option. (14) CFC PAS/HAB--CFC personal assistance services/habilitation. A service that: (A) consists of: (i) personal assistance services that provide assistance to an individual in performing ADLs and IADLs based on the individual's person-centered service plan, including: (I) non-skilled assistance with the performance of the ADLs and IADLs; (II) household chores necessary to maintain the home in a clean, sanitary, and safe environment; (III) escort services, which consist of accompanying and assisting an individual to access services or activities in the community, but do not include transporting an individual; and (IV) assistance with health-related tasks; and (ii) habilitation that provides assistance to an individual in acquiring, retaining, and improving self-help, socialization, and daily living skills and training the individual on ADLs, IADLs, and health-related tasks, such as: (I) self-care; (II) personal hygiene; (III) household tasks; (IV) mobility; (V) money management; (VI) community integration, including how to get around in the community; (VII) use of adaptive equipment; (VIII) personal decision making; (IX) reduction of challenging behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks; and (X) self-administration of medication; and (B) does not include transporting the individual, which means driving the individual from one location to another. (15) CFC support consultation--The term used for support consultation on the IPC of an applicant or individual if the applicant or individual receives only CFC PAS/HAB through the CDS option. (16) CFC support management--Training regarding how to select, manage, and dismiss an unlicensed service provider of CFC PAS/HAB as described in the HCS Handbook. (17) Chemical restraint--A medication used to control an individual's behavior or to restrict the individual's freedom of movement that is not a standard treatment for the individual's medical or psychological condition. (18) CMS--Centers for Medicare & Medicaid Services. The federal agency within the United States Department of Health and Human Services that administers the Medicare and Medicaid programs. (19) Competitive employment--Employment that pays an individual at least minimum wage if the individual is not self-employed. (20) Contract--A provisional contract or a standard contract. (21) Controlling person--A person who: (A) has an ownership interest in a program provider; (B) is an officer or director of a corporation that is a program provider; (C) is a partner in a partnership that is a program provider; (D) is a member or manager in a limited liability company that is a program provider; (E) is a trustee or trust manager of a trust that is a program provider; or (F) because of a personal, familial, or other relationship with a program provider, is in a position of actual control or authority with respect to the program provider, regardless of the person's title. (22) Critical incident--An event listed in the TxHmL Provider User Guide found at www.hhsc.state.tx.us. (23) Critical violation--A violation for which HHSC may assess an administrative penalty before giving a program provider an opportunity to correct the violation and that: (A) is an immediate threat; (B) has resulted in actual harm and is widespread; (C) has resulted in actual harm and is a pattern; or (D) has the potential to result in actual harm and is widespread. (24) DADS--HHSC. (25) Department of Assistive and Rehabilitative Services--The Texas Workforce Commission. (26) DFPS--The Department of Family and Protective Services. (27) Exploitation--The illegal or improper act or process of using, or attempting to use, an individual or the resources of an individual for monetary or personal benefit, profit, or gain. (28) FMS--Financial management services. A service, as defined in §41.103 of this title, that is provided to an individual participating in the CDS option. (29) FMSA--Financial management services agency. As defined in §41.103 of this title, an entity that provides financial management services to an individual participating in the CDS option. (30) Follow-up survey--A review by HHSC of a program provider to determine if the program provider has completed corrective action. (31) Former military member--A person who served in the United States Army, Navy, Air Force, Marine Corps, or Coast Guard: (A) who declared and maintained Texas as the person's state of legal residence in the manner provided by the applicable military branch while on active duty; and (B) who was killed in action or died while in service, or whose active duty otherwise ended. (32) Good cause--As used in §9.578 of this subchapter, (relating to Program Provider Certification Principles: Service Delivery), a reason outside the control of the CFC ERS provider, as determined by HHSC. (33) HCS Program--The Home and Community-based Services Program operated by HHSC as authorized by CMS in accordance with §1915(c) of the Social Security Act. (34) Health-related tasks--Specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health care professionals under state law to be performed by a service provider of CFC PAS/HAB. These include tasks delegated by an RN; health maintenance activities as defined in 22 TAC §225.4 (relating to Definitions), that may not require delegation; and activities assigned to a service provider of CFC PAS/HAB by a licensed physical therapist, occupational therapist, or speech-language pathologist. (35) HHSC--The Texas Health and Human Services Commission. (36) IADLs--Instrumental activities of daily living. Activities related to living independently in the community, including meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone or other media; and traveling around and participating in the community. (37) ICAP--Inventory for Client and Agency Planning. (38) ICF/IID--Intermediate care facility for individuals with an intellectual disability or related conditions. An ICF/IID is a facility in which ICF/IID Program services are provided and that is: (A) licensed in accordance with THSC, Chapter 252; or (B) certified by HHSC, including a state supported living center. (39) ICF/IID Program--The Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, which provides Medicaid-funded residential services to individuals with an intellectual disability or related conditions. (40) ID/RC Assessment--A form used by HHSC for LOC determination and LON assignment. (41) Immediate threat--A situation that caused, or is likely to cause, serious physical harm or serious emotional harm to an individual, or the death of an individual. (42) Implementation plan--A written document developed by a program provider for an individual that, for each TxHmL Program service, except for transportation provided as a community support activity, and CFC service, except for CFC support management, on the individual's IPC to be provided by the program provider, includes: (A) a list of outcomes identified in the PDP that will be addressed using TxHmL Program services and CFC services; (B) specific objectives to address the outcomes required by subparagraph (A) of this paragraph that are: (i) observable, measurable, and outcome-oriented; and (ii) derived from assessments of the individual's strengths, personal goals, and needs; (C) a target date for completion of each objective; (D) the number of units of TxHmL Program services and CFC services needed to complete each objective; (E) the frequency and duration of TxHmL Program services and CFC services needed to complete each objective; and (F) the signature and date of the individual, LAR, and the program provider. (43) Individual--A person enrolled in the TxHmL Program. (44) Initial certification survey--A review by HHSC of a program provider with a provisional contract to determine if the program provider is in compliance with the certification principles. (45) Intellectual disability--Significant sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period. (46) Intermittent survey--A review by HHSC of a program provider that is not an initial certification survey, a recertification survey, or a follow-up survey, to determine if the program provider is in compliance with the certification principles. (47) IPC--Individual plan of care. A written plan that: (A) states: (i) the type and amount of each TxHmL Program service and each CFC service, except for CFC support management, to be provided to an individual during an IPC year; (ii) the services and supports to be provided to the individual through resources other than TxHmL Program services or CFC services, including natural supports, medical services, and educational services; and (iii) if an individual will receive CFC support management; and (B) is authorized by HHSC. (48) IPC cost--Estimated annual cost of program services included on an IPC. (49) IPC year--A 12-month period of time starting on the date an authorized initial or renewal IPC begins. (50) Isolated--The scope of a violation that has affected a very limited number of individuals or that has occurred only occasionally. (51) LAR--Legally authorized representative. A person authorized by law to act on behalf of a person with regard to a matter described in this subchapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult. (52) LIDDA--Local intellectual and developmental disability authority. An entity designated by the executive commissioner of HHSC, in accordance with THSC §533A.035. (53) LOC--Level of care. A determination made by HHSC about an applicant or individual as part of the TxHmL Program eligibility determination process based on data electronically transmitted on the ID/RC Assessment. (54) LON--Level of need. An assignment given by HHSC for an applicant or individual that is derived from the service level score obtained from the administration of the ICAP to the individual and from selected items on the ID/RC Assessment. (55) LVN--Licensed vocational nurse. A person licensed to practice vocational nursing in accordance with Texas Occupations Code, Chapter 301. (56) Managed care organization--This term has the meaning set forth in Texas Government Code §543A.0001. (57) MAO Medicaid--Medical Assistance Only Medicaid. A type of Medicaid by which an applicant or individual qualifies financially for Medicaid assistance but does not receive Supplemental Security Income (SSI) benefits. (58) Mechanical restraint--A mechanical device, material, or equipment used to control an individual's behavior by restricting the ability of the individual to freely move part or all of the individual's body. (59) Microboard--A program provider: (A) that is a non-profit corporation; (i) that is created and operated by no more than 10 persons, including an individual; (ii) the purpose of which is to address the needs of the individual and directly manage the provision of the TxHmL Program services or CFC services; and (iii) in which each person operating the corporation participates in addressing the needs of the individual and directly managing the provision of TxHmL Program services or CFC services; and (B) that has a service capacity designated in the HHSC data system of no more than three individuals. (60) Military family member--A person who is the spouse or child (regardless of age) of: (A) a military member; or (B) a former military member. (61) Military member--A member of the United States military serving in the Army, Navy, Air Force, Marine Corps, or Coast Guard on active duty who has declared and maintains Texas as the member's state of legal residence in the manner provided by the applicable military branch. (62) Natural supports--Unpaid persons, including family members, volunteers, neighbors, and friends, who assist and sustain an individual. (63) Neglect--A negligent act or omission that caused physical or emotional injury or death to an individual or placed an individual at risk of physical or emotional injury or death. (64) Nursing facility--A facility licensed in accordance with THSC, Chapter 242. (65) Own home or family home--A residence that is not: (A) an ICF/IID; (B) a nursing facility; (C) an assisted living facility licensed or subject to being licensed in accordance with THSC, Chapter 247; (D) a residential child-care operation licensed or subject to being licensed by DFPS unless it is a foster family home or a foster group home; (E) a facility licensed or subject to being licensed by the Department of State Health Services; (F) a residential facility operated by the Texas Workforce Commission; (G) a residential facility operated by the Texas Juvenile Justice Department, a jail, or a prison; or (H) a setting in which two or more dwellings, including units in a duplex or apartment complex, single family homes, or facilities listed in subparagraphs (A) - (G) of this paragraph, but excluding supportive housing under Section 811 of the National Affordable Housing Act of 1990, meet all of the following criteria: (i) the dwellings create a residential area distinguishable from other areas primarily occupied by persons who do not require routine support services because of a disability; (ii) most of the residents of the dwellings are persons with an intellectual disability; and (iii) the residents of the dwellings are provided routine support services through personnel, equipment, or service facilities shared with the residents of the other dwellings. (66) Pattern--The scope of a violation that is not widespread but represents repeated failures by the program provider to comply with certification principles, and the failures: (A) are found throughout the services provided by the program provider; or (B) involve or affect the same individuals, service providers, or volunteers. (67) PDP--Person-directed plan. A written plan, based on person-directed planning and developed with an applicant or individual in accordance with the HHSC Person-Directed Plan form and discovery tool found on the HHSC website, that describes the supports and services necessary to achieve the desired outcomes identified by the applicant, individual, or LAR and ensure the applicant's or individual's health and safety. (68) Performance contract--A written agreement between HHSC and a LIDDA for the performance of delegated functions, including those described in THSC, §533A.035. (69) Physical abuse--Any of the following: (A) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, that caused physical injury or death to an individual or placed an individual at risk of physical injury or death; (B) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual; (C) the use of a restraint on an individual not in compliance with federal and state laws, rules, and regulations; or (D) seclusion. (70) Physical restraint--Any manual method used to control an individual's behavior, except for physical guidance or prompting of brief duration that an individual does not resist, that restricts: (A) the free movement or normal functioning of all or a part of the individual's body; or (B) normal access by an individual to a portion of the individual's body. (71) Plan of correction--A plan documented on the HHSC Plan of Correction form that includes the corrective action that a program provider will take for each violation identified on a final survey report. (72) Plan of removal--A written plan that describes the action a program provider will take to remove an immediate threat that HHSC identifies. (73) Post 45-day follow-up survey--A follow-up survey conducted at least 46 calendar days after the exit conference of the survey in which the violation requiring corrective action was identified. (74) Post-move monitoring visit--As described in 26 TAC §303.702 (relating to Post-transition Responsibilities), a visit conducted by the service coordinator in the individual's residence and other locations, as determined by the service planning team, for an individual who enrolled in the TxHmL Program from a nursing facility or enrolled in the TxHmL Program as a diversion from admission to a nursing facility. The purpose of the visit is to review the individual's residence and other locations to: (A) assess whether essential supports identified in the transition plan are in place; (B) identify gaps in care; and (C) address such gaps, if any, to reduce the risk of crisis, re-admission to a nursing facility, or other negative outcome. (75) Pre-move site review--As described in 26 TAC §303.701 (relating to Transition Planning for a Designated Resident), a review conducted by the service coordinator in the planned residence and other locations, as determined by the service planning team, for an applicant transitioning from a nursing facility to the TxHmL Program. The purpose of the review is to ensure that essential services and supports described in the applicant's transition plan are in place before the applicant moves to the residence or receives services in the other locations. (76) Program provider--A person, as defined in §49.102 of this title (relating to Definitions), that has a contract with HHSC to provide TxHmL Program services, excluding an FMSA. (77) Provisional contract--A contract that HHSC enters into with a program provider in accordance with §49.208 of this title (relating to Provisional Contract Application Approval) that has a term of no more than three years, not including any extension agreed to in accordance with §49.208(e) of this title (relating to Standard Contract). (78) Public emergency personnel--Personnel of a sheriff's department, police department, emergency medical service, or fire department. (79) Recertification survey--A review by HHSC of a program provider with a standard contract to determine if the program provider is in compliance with the certification principles and will be certified for a new certification period. (80) Related condition--A severe and chronic disability that: (A) is attributed to: (i) cerebral palsy or epilepsy; or (ii) any other condition, other than mental illness, found to be closely related to an intellectual disability because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an intellectual disability, and requires treatment or services similar to those required for individuals with an intellectual disability; (B) is manifested before the individual reaches age 22; (C) is likely to continue indefinitely; and (D) results in substantial functional limitation in at least three of the following areas of major life activity: (i) self-care; (ii) understanding and use of language; (iii) learning; (iv) mobility; (v) self-direction; and (vi) capacity for independent living. (81) Repeated violation--A violation that is: (A) based on the same certification principle; and (B) involves the same TxHmL Program service. (82) Respite facility--A site that is not a residence and that is owned or leased by a program provider for the purpose of providing out-of-home respite to not more than six individuals receiving TxHmL Program services or other persons receiving similar services at any one time. (83) Responder--A person designated to respond to an alarm call activated by an individual. (84) Restraint--Any of the following: (A) a physical restraint; (B) a mechanical restraint; or (C) a chemical restraint. (85) RN--Registered nurse. A person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301. (86) Seclusion--The involuntary placement of an individual alone in an area from which the individual is prevented from leaving. (87) Service backup plan--A plan that ensures continuity of a service that is critical to an individual's health and safety if service delivery is interrupted. (88) Service coordination--A service as defined in Chapter 2, Subchapter L of this title (relating to Service Coordination for Individuals with an Intellectual Disability). (89) Service coordinator--An employee of a LIDDA who provides service coordination to an individual. (90) Service planning team--One of the following: (A) for an applicant or individual other than one described in subparagraphs (B) or (C) of this paragraph, a planning team consisting of: (i) an applicant or individual and LAR; (ii) service coordinator; and (iii) other persons chosen by the applicant, individual, or LAR, for example, a staff member of the program provider, a family member, a friend, or a teacher; (B) for an applicant 21 years of age or older who is residing in a nursing facility and enrolling in the TxHmL Program, a planning team consisting of: (i) the applicant and LAR; (ii) service coordinator; (iii) a staff member of the program provider; (iv) providers of specialized services; (v) a nursing facility staff person who is familiar with the applicant's needs; (vi) other persons chosen by the applicant or LAR, for example, a family member, a friend, or a teacher; and (vii) at the discretion of the LIDDA, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability; or (C) for an individual 21 years of age or older who has enrolled in the TxHmL program from a nursing facility or has enrolled in the TxHmL Program as a diversion from admission to a nursing facility, for 180 days after enrollment, a planning team consisting of: (i) the individual and LAR; (ii) service coordinator; (iii) a staff member of the program provider; (iv) other persons chosen by the individual or LAR, for example, a family member, a friend, or a teacher; and (v) at the discretion of the LIDDA, other persons who are directly involved in the delivery of services to persons with an intellectual or developmental disability. (91) Service provider--A person, who may be a staff member, who directly provides a TxHmL Program service or CFC service to an individual. (92) Sexual abuse--Any of the following: (A) sexual exploitation of an individual; (B) non-consensual or unwelcomed sexual activity with an individual; or (C) consensual sexual activity between an individual and a service provider, staff member, volunteer, or controlling person, unless a consensual sexual relationship with an adult individual existed before the service provider, staff member, volunteer, or controlling person became a service provider, staff member, volunteer, or controlling person. (93) Sexual activity--An activity that is sexual in nature, including kissing, hugging, stroking, or fondling with sexual intent. (94) Sexual exploitation--A pattern, practice, or scheme of conduct against an individual that can reasonably be construed as being for the purposes of sexual arousal or gratification of any person: (A) which may include sexual contact; and (B) does not include obtaining information about an individual's sexual history within standard accepted clinical practice. (95) Specialized services--The services defined in 26 TAC §303.102 (relating to Definitions). (96) Staff member--An employee or contractor of a TxHmL Program provider. (97) Standard contract--A contract that HHSC enters into with a program provider in accordance with §49.209 of this title that has a term of no more than five years, not including any extension agreed to in accordance §49.209(d) of this title. (98) State supported living center--A state-supported and structured residential facility operated by HHSC to provide to persons with an intellectual disability a variety of services, including medical treatment, specialized therapy, and training in the acquisition of personal, social, and vocational skills, but does not include a community-based facility owned by HHSC. (99) System check--A test of the CFC ERS equipment to determine if: (A) the individual can successfully activate an alarm call; and (B) the equipment is working properly. (100) Support consultation--A service, as defined in §41.103 of this title, that is provided to an individual participating in the CDS option at the request of the individual or LAR. (101) Survey--An initial certification survey, a recertification survey, a follow-up survey, and an intermittent survey. (102) TAC--Texas Administrative Code. A compilation of state agency rules published by the Texas Secretary of State in accordance with Texas Government Code, Chapter 2002, Subchapter C. (103) THSC--Texas Health and Safety Code. Texas statutes relating to health and safety. (104) Transition plan--As described in 26 TAC §303.102, a written plan developed by the service planning team for an applicant residing in a nursing facility who is enrolling in the TxHmL Program. A transition plan includes the essential and nonessential services and supports the applicant needs to transition from a nursing facility to a community setting. (105) Transportation plan--A written plan, based on person-directed planning and developed with an applicant or individual using HHSC Individual Transportation Plan form found on the HHSC website. A transportation plan is used to document how transportation as a community support activity will be delivered to support an individual's desired outcomes and purposes for transportation as identified in the PDP. (106) TxHmL Program--The Texas Home Living Program, operated by HHSC and approved by CMS in accordance with §1915(c) of the Social Security Act, that provides community-based services and supports to eligible individuals who live in their own homes or in their family homes. (107) Vendor hold--A temporary suspension of payments that are due to a program provider under a contract. (108) Verbal or emotional abuse--Any act or use of verbal or other communication, including gestures: (A) to: (i) harass, intimidate, humiliate, or degrade an individual; or (ii) threaten an individual with physical or emotional harm; and (B) that: (i) results in observable distress or harm to the individual; or (ii) is of such a serious nature that a reasonable person would consider it harmful or a cause of distress. (109) Violation--A finding by HHSC that a program provider is not or has not been in compliance with a certification principle. (110) Volunteer--A person who works for a program provider without compensation, other than reimbursement for actual expenses. (111) Widespread--The scope of a violation that: (A) is pervasive throughout the services provided by the program provider; or (B) represents a systemic failure by the program provider that affects or has the potential to affect a large portion of or all individuals. (112) Willfully interfering--Acting or not acting to intentionally prevent, interfere with, or impede, or to attempt to intentionally prevent, interfere with, or impede.ot including any extension agreed to in accordance §49.209(d) of this title. Source Note: The provisions of this §566.3 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective June 1, 2008, 33 TexReg 4340; amended to be effective December 1, 2013, 38 TexReg 8673; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective July 1, 2015, 40 TexReg 2760; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016,41 TexReg 1867; amended to be effective October 1, 2019, 44 TexReg 5062; amended to be effective April 28, 2020, 45 TexReg 2704; amended to be effective December 22, 2020, 45 TexReg 9232; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732; amended to be effective April 1, 2025, 50 TexReg 2210. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213695 03/12/2026 (a) Community support provides services and supports in an individual's home and at other community locations that are necessary to achieve outcomes identified in an individual's PDP.(1) Community support provides:(A) habilitative or support activities that:(i) provide or foster improvement of or facilitate an individual's ability to perform functional living skills and other activities of daily living;(ii) assist an individual to develop competencies in maintaining the individual's home life;(iii) foster improvement of or facilitate an individual's ability and opportunity to:(I) participate in typical community activities including activities that lead to successful employment;(II) access and use of services and resources available to all citizens in the individual's community;(III) interact with members of the community;(IV) access and use available non-TxHmL Program services or supports for which the individual may be eligible; and(V) establish or maintain relationships with people who are not paid service providers that expand or sustain the individual's natural support network;(B) transportation; and or(C) assistance in obtaining transportation.(2) Community support, as determined by an assessment conducted by an RN, provides assistance with medications and the performance of tasks delegated by an RN in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician.(3) Community support does not include payment for room or board.(4) Community support may not be provided to the individual at the same time that any of the following services are provided:(A) respite;(B) day habilitation;(C) employment assistance with the individual present; or(D) supported employment with the individual present.(b) Day habilitation assists an individual to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life.(1) Day habilitation provides:(A) individualized activities consistent with achieving the outcomes identified in the individual's PDP;(B) activities necessary to reinforce therapeutic outcomes targeted by other waiver services, school, or other support providers;(C) services in a group setting other than the individual's home for normally up to five days a week, six hours per day;(D) personal assistance for an individual who cannot manage personal care needs during the day habilitation activity;(E) as determined by an assessment conducted by an RN, assistance with medications and the performance of tasks delegated by an RN in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician; and(F) transportation during the day habilitation activity necessary for the individual's participation in day habilitation activities.(2) Day habilitation may not be provided at the same time that any of the following services are provided:(A) respite;(B) community support;(C) employment assistance with the individual present;(D) supported employment with the individual present; or(E) CFC PAS/HAB.(c) Nursing provides treatment and monitoring of health care procedures ordered or prescribed by a practitioner and as required by standards of professional practice or state law to be performed by an RN or LVN. Nursing includes:(1) administering medication;(2) monitoring an individual's use of medications;(3) monitoring an individual's health risks, data, and information, including ensuring that an unlicensed service provider is performing only those nursing tasks identified in a nursing assessment;(4) assisting an individual or LAR to secure emergency medical services for the individual;(5) making referrals for appropriate medical services;(6) performing health care procedures as ordered or prescribed by a practitioner and required by standards of professional practice or law to be performed by an RN or LVN;(7) delegating nursing tasks assigned to an unlicensed service provider and supervising the performance of those tasks in accordance with state law and rules;(8) teaching an unlicensed service provider about the specific health needs of an individual;(9) performing an assessment of an individual's health condition;(10) an RN doing the following:(A) performing a nursing assessment for each individual:(i) before an unlicensed service provider performs a nursing task for the individual unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician; and(ii) as determined necessary by an RN, including if the individual's health needs change;(B) documenting information from performance of a nursing assessment;(C) if an individual is receiving a service through CDS, providing a copy of the documentation described in described in subparagraph (B) of this paragraph to the individual's service coordinator;(D) developing the nursing service portion of an individual's implementation plan required by §9.578(c)(2) of this subchapter (relating to Program Provider Certification Principles: Service Delivery), which includes developing a plan and schedule for monitoring and supervising delegated nursing tasks; and(E) making and documenting decisions related to the delegation of a nursing task to an unlicensed service provider;(11) in accordance with Texas Human Resources Code, Chapter 161:(A) allowing an unlicensed service provider to provide administration of medication to an individual without the delegation or oversight of an RN if:(i) an RN has performed a nursing assessment and, based on the results of the assessment, determined that the individual's health permits the administration of medication by an unlicensed service provider;(ii) the medication is:(I) an oral medication;(II) a topical medication; or(III) a metered dose inhaler;(iii) the medication is administered to the individual for a predictable or stable condition; and(iv) the unlicensed service provider has been:(I) trained by an RN or an LVN under the direction of an RN regarding the proper administration of medication; or(II) determined to be competent by an RN or an LVN under the direction of an RN regarding proper administration of medication, including through a demonstration of proper technique by the unlicensed service provider; and(B) ensuring that an RN or an LVN under the supervision of an RN reviews the administration of medication to an individual by an unlicensed service provider at least annually and after any significant change in the individual's condition.(d) Employment assistance:(1) is assistance provided to an individual to help the individual locate competitive employment in the community;(2) consists of a service provider performing the following activities:(A) identifying an individual's employment preferences, job skills, and requirements for a work setting and work conditions;(B) locating prospective employers offering employment compatible with an individual's identified preferences, skills, and requirements;(C) contacting a prospective employer on behalf of an individual and negotiating the individual's employment;(D) transporting the individual to help the individual locate competitive employment in the community; and(E) participating in service planning team meetings;(3) is not provided to an individual with the individual present at the same time that respite, community support, day habilitation, or supported employment, or CFC PAS/HAB is provided;(4) does not include using Medicaid funds paid by HHSC to the program provider for incentive payments, subsidies, or unrelated vocational training expenses, such as:(A) paying an employer:(i) to encourage the employer to hire an individual; or(ii) for supervision, training, support, or adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(B) paying the individual:(i) as an incentive to participate in employment assistance activities; or(ii) for expenses associated with the start-up costs or operating expenses of an individual's business; and(5) as determined by an assessment conducted by an RN, provides assistance with medications and the performance of tasks delegated by an RN in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician.(e) Supported employment:(1) is assistance provided to an individual:(A) who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which individuals without disabilities are employed; and(B) in order for the individual to sustain competitive employment;(2) consists of a service provider performing the following activities:(A) making employment adaptations, supervising, and providing training related to an individual's assessed needs;(B) transporting the individual to support the individual to be self-employed, work from home, or perform in a work setting; and(C) participating in service planning team meetings;(3) is not provided to an individual with the individual present at the same time that respite, community support, day habilitation, employment assistance, or CFC PAS/HAB is provided;(4) does not include sheltered work or other similar types of vocational services furnished in specialized facilities, or using Medicaid funds paid by HHSC to the program provider for incentive payments, subsidies, or unrelated vocational training expenses, such as:(A) paying an employer:(i) to encourage the employer to hire an individual; or(ii) to supervise, train, support, or make adaptations for an individual that the employer typically makes available to other workers without disabilities filling similar positions in the business; or(B) paying the individual:(i) as an incentive to participate in supported employment activities; or(ii) for expenses associated with the start-up costs or operating expenses of an individual's business; and(5) as determined by an assessment conducted by an RN, provides assistance with medications and the performance of tasks delegated by an RN in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician.(f) Behavioral support provides specialized interventions that assist an individual to increase adaptive behaviors to replace or modify challenging or socially unacceptable behaviors that prevent or interfere with the individual's inclusion in home and family life or community life. Behavioral support includes:(1) assessment and analysis of assessment findings of the behavior(s) to be targeted necessary to design an appropriate behavioral support plan;(2) development of an individualized behavioral support plan consistent with the outcomes identified in the individual's PDP;(3) training of and consultation with the LAR, family members, or other support providers and, as appropriate, with the individual in the purpose/objectives, methods and documentation of the implementation of the behavioral support plan or revisions of the plan;(4) monitoring and evaluation of the success of the behavioral support plan implementation; and(5) modification, as necessary, of the behavioral support plan based on documented outcomes of the plan's implementation.(g) Adaptive aids enable an individual to increase mobility, the ability to perform activities of daily living, or the ability to perceive, control, or communicate with the environment in which the individual lives. Adaptive aids include devices, controls, appliances, or supplies and the repair or maintenance of such aids, if not covered by warranty, as specified in the TxHmL Program Billing Guidelines.(1) Adaptive aids are provided to address specific needs identified in an individual's PDP and are limited to:(A) lifts;(B) mobility aids;(C) positioning devices;(D) control switches/pneumatic switches and devices;(E) environmental control units;(F) medically necessary supplies;(G) communication aids;(H) adapted/modified equipment for activities of daily living; and(I) safety restraints and safety devices.(2) Adaptive aids may be provided up to a maximum of $10,000 per individual per IPC year.(3) Adaptive aids do not include items or supplies that are not of direct medical or remedial benefit to the individual or that are available to the individual through the Medicaid State Plan, through other governmental programs, or through private insurance.(h) Minor home modifications are physical adaptations to the individual's home that are necessary to ensure the health, welfare, and safety of the individual or to enable the individual to function with greater independence in the home and the repair or maintenance of such adaptations, if not covered by warranty.(1) Minor home modifications may be provided up to a lifetime limit of $7,500 per individual. After the $7,500 lifetime limit has been reached, an individual is eligible for an additional $300 per IPC year for additional modifications or maintenance of home modifications.(2) Minor home modifications do not include adaptations or improvements to the home that are of general utility, are not of direct medical or remedial benefit to the individual, or add to the total square footage of the home.(3) Minor home modifications are limited to:(A) purchase and repair of mobility/wheelchair ramps;(B) modifications to bathroom facilities;(C) modifications to kitchen facilities; and(D) specialized accessibility and safety adaptations.(i) Dental treatment may be provided up to a maximum of $1,000 per individual per IPC year for the following treatments:(1) emergency dental treatment;(2) preventive dental treatment;(3) therapeutic dental treatment; and(4) orthodontic dental treatment, excluding cosmetic orthodontia.(j) Respite is provided for the relief of an unpaid caregiver of an individual when the caregiver is temporarily unavailable to provide supports.(1) Respite includes:(A) assistance with activities of daily living and functional living tasks;(B) assistance with planning and preparing meals;(C) transportation or assistance in securing transportation;(D) assistance with ambulation and mobility;(E) as determined by an assessment conducted by an RN, assistance with medications and the performance of tasks delegated by an RN in accordance with state law and rules, unless a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician;(F) habilitation and support that facilitate:(i) an individual's inclusion in community activities, use of natural supports and typical community services available to all people;(ii) an individual's social interaction and participation in leisure activities; and(iii) development of socially valued behaviors and daily living and independent living skills.(2) Reimbursement for respite provided in a setting other than the individual's residence includes payment for room and board.(3) Respite may be provided in the individual's residence or, if certification principles stated in §9.578(o) of this subchapter are met, in other locations.(k) Professional therapies provide assessment and treatment by a licensed professional who meets the qualifications specified in §9.579 of this subchapter (relating to Certification Principles: Staff Member and Service Provider Requirements) and include training and consultation with an individual's LAR, family members or other support providers. Professional therapies available under the TxHmL Program are:(1) audiology services;(2) speech/language pathology services;(3) occupational therapy services;(4) physical therapy services;(5) dietary services; and(6) behavioral support.(l) FMS are provided if the individual's IPC includes at least one TxHmL Program service to be delivered through the CDS option.(m) Support consultation is provided at the request of the individual or LAR if the individual's IPC includes at least one TxHmL Program service to be delivered through the CDS option. Source Note: The provisions of this §566.5 adopted to be effective January 5, 2003, 27 TexReg 12254; amended to be effective March 11, 2004, 29 TexReg 2317; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective December 1, 2013, 38 TexReg 8673; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20,2016, 41 TexReg 1867; amended to be effective October 1, 2019, 44TexReg 5062; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.5 Description of TxHmL Program Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213696 03/12/2026 (a) A program provider must serve an eligible applicant or individual who selects the program provider unless the program provider's enrollment has reached its service capacity as identified in the DADS data system.(b) The program provider must maintain a separate record for each individual enrolled with the provider. The individual's record must include:(1) a copy of the individual's current PDP and, if CFC PAS/HAB is included on the PDP, a copy of the completed DADS HCS/TxHmL CFC PAS/HAB Assessment form as provided by the LIDDA;(2) a copy of the individual's current IPC as provided by the LIDDA; and(3) a copy of the individual's current ID/RC Assessment as provided by the LIDDA.(c) The program provider must:(1) participate as a member of the service planning team, if requested by the individual or LAR;(2) develop:(A) in conjunction with the individual, the individual's family or LAR, an implementation plan for:(i) TxHmL Program services, except for transportation as a community support activity; and(ii) CFC services, except for CFC support management; and(B) a transportation plan, if transportation as a community support activity is included on the PDP.(d) The program provider must provide:(1) TxHmL Program services in accordance with an individual's PDP, IPC, implementation plan, transportation plan, §9.555 of this subchapter (relating to Description of TxHmL Program Services), and Appendix C of the TxHmL Program waiver application approved by CMS and found at www.dads.state.tx.us; and(2) CFC services in accordance with an individual's PDP, IPC, and implementation plan.(e) The program provider must ensure that services and supports provided to an individual assist the individual to achieve the outcomes identified in the PDP.(f) The program provider must ensure that an individual's progress or lack of progress toward achieving the individual's identified outcomes is documented in observable, measurable terms that directly relate to the specific outcome addressed, and that such documentation is available for review by the service coordinator.(g) The program provider must communicate to the individual's service coordinator changes needed to the individual's PDP or IPC as such changes are identified by the program provider or communicated to the program provider by the individual or LAR.(h) The program provider must ensure that an individual who performs work for the program provider is paid at a wage level commensurate with that paid to a person without disabilities who would otherwise perform that work. The program provider must comply with local, state, and federal employment laws and regulations.(i) The program provider must ensure that an individual provides no training, supervision, or care to another individual unless the individual is qualified and compensated in accordance with local, state, and federal regulations.(j) The program provider must ensure that an individual who produces marketable goods and services during habilitation activities is paid at a wage level commensurate with that paid to a person without disabilities who would otherwise perform that work. Compensation must be paid in accordance with local, state, and federal regulations.(k) The program provider must offer an individual opportunity for leisure time activities, vacation periods, religious observances, holidays, and days off, consistent with the individual's choice and the routines of other members of the community.(l) The program provider must offer an individual of retirement age opportunities to participate in activities appropriate to individuals of the same age and provide supports necessary for the individual to participate in such activities consistent with the individual's or LAR's choice and the individual's PDP.(m) The program provider must offer an individual choices and opportunities for accessing and participating in community activities including employment opportunities and experiences available to peers without disabilities and provide supports necessary for the individual to participate in such activities consistent with an individual's or LAR's choice and the individual's PDP.(n) A program provider must develop a written service backup plan for a TxHmL Program service or a CFC service identified on the PDP as critical to meeting an individual's health and safety.(1) A service backup plan must:(A) contain the name of the service;(B) specify the period of time in which an interruption to the service would result in an adverse effect to the individual's health or safety; and(C) in the event of a service interruption resulting in an adverse effect as described in subparagraph (B) of this paragraph, describe the actions the program provider will take to ensure the individual's health and safety.(2) A program provider must ensure that:(A) if the action in the service backup plan required by paragraph (1) of this subsection identifies a natural support, that the natural support receives pertinent information about the individual's needs and is able to protect the individual's health and safety; and(B) a person identified in the service backup plan, if paid to provide the service, meets the qualifications described in this subchapter.(3) If a service backup plan is implemented, a program provider must:(A) discuss the implementation of the service backup plan with the individual and the service providers or natural supports identified in the service backup plan to determine whether or not the plan was effective;(B) document whether or not the plan was effective; and(C) revise the plan if the program provider determines the plan was ineffective.(o) If respite is provided in a location other than an individual's family home, the location must be acceptable to the individual or LAR and provide an accessible, safe, and comfortable environment for the individual that promotes the health and welfare of the individual.(1) Respite may be provided in the residence of another individual receiving TxHmL Program services or similar services if the program provider has obtained written approval from the individuals living in the residence or their LARs and:(A) no more than three individuals receiving TxHmL Program services or CFC services and other persons receiving similar services are provided services at any one time; or(B) no more than four individuals receiving TxHmL Program services or CFC services and other persons receiving similar services are provided services in the residence at any one time and the residence is approved in accordance with §9.188 of this chapter (relating to DADS Approval of Residences).(2) Respite may be provided in a respite facility if the program provider provides or intends to provide respite to more than three individuals receiving TxHmL Program services or CFC services or persons receiving similar services at the same time; and(A) the program provider has obtained written approval from the local fire authority having jurisdiction stating that the facility and its operation meet the local fire ordinances; and(B) the program provider obtains such written approval from the local fire authority having jurisdiction on an annual basis.(3) If respite is provided in a camp setting, the program provider must ensure the camp is accredited by the American Camp Association.(4) Respite must not be provided in an institution such as an ICF/IID, nursing facility, or hospital.(p) The program provider must ensure that nursing is provided in accordance with:(1) Texas Occupations Code, Chapter 301 (Nursing Practice Act);(2) 22 TAC Chapter 217 (relating to Licensure, Peer Assistance, and Practice);(3) 22 TAC Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and(4) 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions).(q) A program provider may determine that an individual does not require a nursing assessment if:(1) nursing services are not on the individual's IPC and the program provider has determined that no nursing task will be performed by the program provider's unlicensed service provider as documented on DADS form "Nursing Task Screening Tool"; or(2) a nursing task will be performed by the program provider's unlicensed service provider and a physician has delegated the task as a medical act under Texas Occupations Code, Chapter 157, as documented by the physician.(r) If an individual or LAR refuses a nursing assessment described in §9.555(c)(10)(A) of this subchapter, the program provider must not:(1) provide nursing services to the individual; or(2) provide community support, day habilitation, employment assistance, supported employment, respite, or CFC PAS/HAB to the individual unless:(A) an unlicensed service provider does not perform nursing tasks in the provision of the service; and(B) the program provider determines that it can ensure the individual's health, safety, and welfare in the provision of the service.(s) If an individual or LAR refuses a nursing assessment and the program provider determines that the program provider cannot ensure the individual's health, safety, and welfare in the provision of a service as described in subsection (r) of this section, the program provider must:(1) immediately notify the individual or LAR and the individual's service coordinator, in writing, of the determination; and(2) include in the notification required by paragraph (1) of this subsection the reasons for the determination and the services affected by the determination.(t) If notified by the service coordinator that the individual or LAR refuses the nursing assessment after the discussion with the service coordinator as described in §9.583(j)(6) of this subchapter (relating to TxHmL Program Principles for LIDDAs), the program provider must immediately send the written notification described in subsection (s) of this section to DADS.(u) The program provider must, if a physician delegates a medical act to an unlicensed service provider in accordance with Texas Occupations Code, Chapter 157, and the program provider has concerns about the health or safety of the individual in performance of the medical act, communicate the concern to the delegating physician and take additional steps as necessary to ensure the health and safety of the individual.(v) The program provider must:(1) for an applicant 21 years of age or older residing in a nursing facility who is enrolling in the TxHmL Program:(A) participate as a member of the service planning team, which includes attending service planning team meetings scheduled by the service coordinator;(B) assist in the implementation of the applicant's transition plan as described in the plan; and(C) be physically present for the pre-move site review and assist the service coordinator during the review as requested; and(2) for 365 calendar days after an individual 21 years of age or older has enrolled in the TxHmL Program from a nursing facility or has enrolled in the TxHmL Program as a diversion from admission to a nursing facility:(A) be physically present for each post-move monitoring visit and assist the service coordinator during the visit as requested;(B) assist in the implementation of the individual's transition plan as described in the plan;(C) participate as a member of the service planning team, which includes attending service planning team meetings scheduled by the service coordinator; and(D) within one calendar day after becoming aware of an event or condition that may put the individual at risk of admission or readmission to a nursing facility, notify the service planning team of the event or condition.(w) A program provider must ensure that CFC PAS/HAB is provided in accordance with the individual's PDP, IPC, and implementation plan.(x) CFC ERS must be provided in accordance with this subsection.(1) A program provider must ensure that CFC ERS is provided only to an individual who:(A) lives alone, who is alone for significant parts of the day, or has no regular caregiver for extended periods of time; and(B) would otherwise require extensive routine supervision.(2) A program provider must ensure that CFC ERS is provided in accordance with the individual's PDP, IPC, and implementation plan.(3) A program provider must ensure that CFC ERS equipment is installed within 14 business days after one of the following dates, whichever is later:(A) the date DADS authorizes the proposed IPC that includes CFC ERS; or(B) the effective date of the individual's IPC as determined by the service planning team.(4) At the time CFC ERS equipment is installed, a program provider must ensure that:(A) the equipment is installed in accordance with the manufacturer's installation instructions;(B) an initial test of the equipment is made;(C) the equipment has an alternate power source in the event of a power failure;(D) the individual is trained on the use of the equipment, including:(i) demonstrating how the equipment works; and(ii) having the individual activate an alarm call;(E) an explanation is given to the individual that the individual must:(i) participate in a system check each month; and(ii) contact the CFC ERS provider if:(I) the individual's telephone number or address changes; or(II) one or more of the individual's responders change; and(F) the individual is informed that a responder, in response to an alarm call, may forcibly enter the individual's home if necessary.(5) A program provider must ensure that the date and time of the CFC ERS equipment installation and compliance with the requirements in paragraphs (4) and (5) of this subsection are documented in the individual's record.(6) A program provider must ensure that, on or before the date CFC ERS equipment is installed:(A) an attempt is made to obtain from an individual, the names and telephone numbers of at least two responders, such as a relative or neighbor;(B) public emergency personnel:(i) is designated as a second responder if the individual provides the name of only one responder; or(ii) is designated as the sole responder if the individual does not provide the names of any responders; and(C) the name and telephone number of each responder is documented in the individual's record.(7) At least once during each calendar month a program provider must ensure that a system check is conducted on a date and time agreed to by the individual.(8) A program provider must ensure that the date, time, and result of the system check is documented in the individual's record.(9) If, as a result of the system check:(A) the equipment is working properly but the individual is unable to successfully activate an alarm call, the program provider must ensure that a request is made of the service coordinator to convene a service planning team meeting to determine if CFC ERS meets the individual's needs; or(B) the equipment is not working properly, the program provider must ensure that, within three calendar days of the system check, the equipment is repaired or replaced.(10) If a system check is not conducted in accordance with paragraph (7) of this subsection, the program provider must ensure that:(A) the failure to comply is because of good cause; and(B) the good cause is documented in the individual's record.(11) A program provider must ensure that an alarm call is responded to 24 hours a day, seven days a week.(12) A program provider must ensure that, if an alarm call is made, the CFC ERS provider:(A) within 60 seconds of the alarm call, attempts to contact the individual to determine if an emergency exists;(B) immediately contacts a responder, if as a result of attempting to contact the individual:(i) the CFC ERS provider confirms there is an emergency; or(ii) the CFC ERS provider is unable to communicate with the individual; and(C) documents the following information in the individual's record when the information becomes available:(i) the name of the individual;(ii) the date and time of the alarm call, recorded in hours, minutes, and seconds;(iii) the response time, recorded in seconds;(iv) the time the individual is called in response to the alarm call, recorded in hours, minutes, and seconds;(v) the name of the contacted responder, if applicable;(vi) a brief description of the reason for the alarm call; and(vii) if the reason for the alarm call is an emergency, a statement of how the emergency was resolved.(13) If an alarm call results in a responder being dispatched to the individual's home for an emergency, the program provider must ensure that:(A) the service coordinator receives written notice of the alarm call within one business day after the alarm call;(B) if the CFC ERS provider is a contracted provider, the program provider receives written notice from the contracted provider within one business day after the alarm call; and(C) written notices required by subparagraphs (A) and (B) of this paragraph is maintained in the individual's record.(14) A program provider must ensure that, if an equipment failure occurs, other than during a system check required by paragraph (7) of this subsection:(A) the individual is informed of the equipment failure; and(B) the equipment is replaced within one business day after the failure becomes known by the CFC ERS provider.(15) If an individual is not informed of the equipment failure and the equipment is not replaced in compliance with paragraph (14) of this subsection, the program provider must ensure that:(A) the failure to comply is because of good cause; and(B) as soon as possible, the individual is informed of the equipment failure and the equipment is replaced.(16) A program provider must ensure that, if the CFC ERS equipment registers five or more "low battery" signals in a 72-hour period:(A) a visit to an individual's home is made to conduct a system check within five business days after the low battery signals occur; and(B) if the battery is defective, the battery is replaced during the visit.(17) A program provider must ensure that, if a system check or battery replacement is not made in accordance with paragraph (16) of this subsection:(A) the failure to comply is because of good cause; and(B) as soon as possible, a system check and battery replacement is made.(18) A program provider must ensure that the following information is documented in an individual's record:(A) the date the equipment failure or low battery signal became known by the CFC ERS provider;(B) the equipment or subscriber number;(C) a description of the problem;(D) the date the equipment or battery was repaired or replaced; and(E) the good cause for failure to comply as described in paragraphs (15)(A) and (17)(A) of this subsection.(y) A program provider must ensure that CFC support management is provided to an individual or LAR if:(1) the individual is receiving CFC PAS/HAB; and(2) the individual or LAR requests to receive CFC support management. Source Note: The provisions of this §566.7 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective December 1, 2013, 38 TexReg 8673; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016, 41 TexReg 1867; transferred effective June 19, 2023, as published in the May 26, 2023 issue ofthe Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.7 Program Provider Certification Principles: Service Delivery https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223266 03/12/2026 (a) The program provider must ensure the continuous availability of trained and qualified employees and contractors to provide the services in an individual's IPC.(b) The program provider must comply with applicable laws and regulations to ensure that:(1) its operations meet necessary requirements; and(2) its employees or contractors possess legally necessary licenses, certifications, registrations, or other credentials and are in good standing with the appropriate professional agency before performing any function or delivering services.(c) The program provider must employ or contract with a service provider of the individual's or LAR's choice to provide a TxHmL Program service or a CFC service if that service provider:(1) is qualified to provide the service;(2) unless the program provider agrees to pay a higher amount, provides the service at or below:(A) for any service except CFC ERS, the direct services portion of the applicable TxHmL Program rate; and(B) for CFC ERS, the reimbursement rate; and(3) contracts with or is employed by the program provider.(d) The program provider must:(1) conduct initial and periodic training that ensures staff members and service providers are trained and qualified to deliver services as required by the current needs and characteristics of the individual to whom they deliver services; and(2) ensure that a staff member who participates in developing an implementation plan for CFC PAS/HAB completes person-centered service planning training approved by HHSC:(A) by June 1, 2017, if the staff member was hired on or before June 1, 2015; or(B) within two years after hire, if the staff member was hired after June 1, 2015.(e) The program provider must implement and maintain personnel practices that safeguard an individual against infectious and communicable diseases.(f) The program provider must prevent:(1) conflicts of interest between program provider personnel and an individual;(2) financial impropriety toward an individual;(3) abuse, neglect, or exploitation of an individual; and(4) threats of harm or danger toward an individual's possessions.(g) The program provider must employ or contract with a person who oversees the provision of TxHmL Program services and CFC services to an individual. The person must:(1) have at least three years paid work experience in planning and providing TxHmL Program services or CFC services to an individual with an intellectual disability or related condition as verified by written statements from the person's employer; or(2) have both of the following:(A) at least three years of experience planning and providing services similar to TxHmL Program services or CFC services to a person with an intellectual disability or related condition as verified by written statements from organizations or agencies that provided services to the person; and(B) participation as a member of a microboard, as verified in writing by:(i) the certificate of formation of the non-profit corporation under which the microboard operates filed with the Texas Secretary of State;(ii) the bylaws of the non-profit corporation; and(iii) a statement by the board of directors of the non-profit corporation that the person is a member of the microboard.(h) The program provider must ensure that a service provider of community support, day habilitation, or respite is at least 18 years of age and:(1) has a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(2) has documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(A) written competency-based assessment of the ability to document service delivery and observations of an individual to be served; and(B) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for an individual being served.(i) The program provider must ensure that a service provider of employment assistance or a service provider of supported employment:(1) is at least 18 years of age;(2) is not:(A) the spouse of the individual; or(B) a parent of the individual if the individual is a minor; and(3) has:(A) a bachelor's degree in rehabilitation, business, marketing, or a related human services field, and at least six months of paid or unpaid experience providing services to people with disabilities;(B) an associate's degree in rehabilitation, business, marketing, or a related human services field, and at least one year of paid or unpaid experience providing services to people with disabilities; or(C) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma, and at least two years of paid or unpaid experience providing services to people with disabilities.(j) A program provider must ensure that the experience required by subsection (i) of this section is evidenced by:(1) for paid experience, a written statement from a person who paid for the service or supervised the provision of the service; and(2) for unpaid experience, a written statement from a person who has personal knowledge of the experience.(k) The program provider must ensure that a service provider who provides transportation:(1) has a valid driver's license; and(2) transports individuals in a vehicle insured in accordance with state law.(l) The program provider must ensure that dental treatment is provided by a dentist licensed in accordance with Texas Occupations Code, Chapter 256.(m) The program provider must ensure that nursing is provided by an RN or an LVN.(n) The program provider must ensure that adaptive aids meet applicable standards of manufacture, design, and installation.(o) The program provider must ensure that a service provider of behavioral support:(1) meets one of the following:(A) is licensed as a psychologist in accordance with Texas Occupations Code, Chapter 501;(B) is licensed as a psychological associate in accordance with Texas Occupations Code, Chapter 501;(C) is certified by HHSC as described in §5.161 of this title (relating to Certified Authorized Provider);(D) is licensed as a licensed behavior analyst in accordance with Texas Occupations Code, Chapter 506;(E) has been issued a provisional license to practice psychology in accordance with Texas Occupations Code, Chapter 501;(F) is licensed as a licensed clinical social worker in accordance with Texas Occupations Code, Chapter 505; or(G) is licensed as a licensed professional counselor in accordance with Texas Occupations Code, Chapter 503; and(2) completes the web-based HHSC HCS and TxHmL Behavioral Support Services Provider Policy Training available on the HHSC website:(A) before providing behavioral support services;(B) within 90 calendar days after the date HHSC issues notice to program providers that HHSC revised the web-based training; and(C) within three years after the most recent date of completion.(p) The program provider must ensure that minor home modifications are delivered by contractors who provide the service in accordance with state and local building codes and other applicable regulations.(q) The program provider must ensure that a service provider of professional therapies is licensed for the specific therapeutic service provided as follows:(1) for audiology services, an audiologist licensed in accordance with Texas Occupations Code, Chapter 401;(2) for speech and language pathology services, a speech-language pathologist or licensed assistant in speech-language pathology licensed in accordance with Texas Occupations Code, Chapter 401;(3) for occupational therapy services, an occupational therapist or occupational therapy assistant licensed in accordance with Texas Occupations Code, Chapter 454;(4) for physical therapy services, a physical therapist or physical therapist assistant licensed in accordance with Texas Occupations Code, Chapter 453; and(5) for dietary services, a licensed dietitian licensed in accordance with Texas Occupations Code, Chapter 701.(r) The program provider must comply with §49.304 of this title (relating to Background Checks).(s) A program provider must comply with §49.312 of this title (relating to Personal Attendants).(t) If the service provider of community support or CFC PAS/HAB is employed by or contracts with a contractor of a program provider, the program provider must ensure that the contractor complies with subsection (s) of this section as if the contractor were the program provider.(u) A program provider must:(1) ensure that a service provider of CFC PAS/HAB:(A) is at least 18 years of age;(B) has:(i) a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or(ii) documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:(I) a written competency-based assessment of the ability to document service delivery and observations of the individuals to be served; and(II) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals being served;(C) is not:(i) the spouse of the individual; or(ii) a parent of the individual if the individual is a minor; and(D) meets any other qualifications requested by the individual or LAR based on the individual's needs and preferences; and(2) if requested by an individual or LAR:(A) allow the individual or LAR to train a CFC PAS/HAB service provider in the specific assistance needed by the individual and to have the service provider perform CFC PAS/HAB in a manner that comports with the individual's personal, cultural, or religious preferences; and(B) ensure that a CFC PAS/HAB service provider attends training by HHSC so the service provider meets any additional qualifications desired by the individual or LAR. Source Note: The provisions of this §566.9 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective January 1, 2014, 38 TexReg 9628; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016, 41 TexReg 1867; amended to be effective October 1, 2019, 44 TexReg 5062; amended to be effective May 10, 2020, 45 TexReg 2886; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.9 Certification Principles: Staff Member and Service Provider Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213698 03/12/2026 (a) The program provider must:(1) assist the individual or LAR in understanding the requirements for participation in the TxHmL Program and include the individual or LAR in planning service provision and any changes to the plan for service provision if changes become necessary;(2) assist and cooperate with the individual's or LAR's request to transfer to another program provider;(3) assist the individual to access public accommodations or services available to all citizens;(4) assist the individual to manage the individual's financial affairs upon documentation of the individual's or LAR's written request for such assistance;(5) ensure that any restriction affecting the individual is approved by the individual's service planning team before the imposition of the restriction;(6) inform the individual or LAR about the individual's health, mental condition, and related progress;(7) inform the individual or LAR of the name and qualifications of any person serving the individual and the option to choose among various available service providers;(8) provide the individual or LAR access to TxHmL Program and CFC records, including, if applicable, financial records maintained on the individual's behalf, about the individual and the delivery of services by the program provider to the individual;(9) assist the individual to communicate by phone or by mail during the provision of TxHmL Program services or CFC services unless the service planning team has agreed to limit the individual's access to communicating by phone or by mail;(10) assist the individual, as specified in the individual's PDP, to attend religious activities as chosen by the individual or LAR;(11) ensure the individual is free from unnecessary restraints during the provision of TxHmL Program services or CFC services;(12) regularly inform the individual or LAR about the individual's or program provider's progress or lack of progress made in the implementation of the PDP;(13) receive and act on complaints about the TxHmL Program services or CFC services provided by the program provider;(14) ensure that the individual is free from abuse, neglect, or exploitation by program provider staff members, service providers, and volunteers;(15) provide active, individualized assistance to the individual or LAR in exercising the individual's rights and exercising self-advocacy, including:(A) making complaints;(B) registering to vote;(C) obtaining citizenship information and education;(D) obtaining advocacy services; and(E) obtaining information regarding legal guardianship;(16) provide the individual privacy during treatment and care of personal needs;(17) include the individual's LAR in decisions involving the planning and provision of TxHmL Program services and CFC services;(18) inform the individual or LAR of the process for reporting a complaint to HHSC or the LIDDA when the program provider's resolution of a complaint is unsatisfactory to the individual or LAR, including the HHSC Complaint and Incident Intake toll-free telephone number, 1-800-458-9858, to initiate complaints and the LIDDA telephone number to initiate complaints;(19) ensure the individual is free from seclusion;(20) inform the individual or LAR, orally and in writing, of the requirements described in paragraphs (1) - (19) of this subsection:(A) when the individual is enrolled in the program provider's program;(B) if the requirements described in paragraphs (1) - (19) of this subsection are revised;(C) at the request of the individual or LAR; and(D) if the legal status of the individual changes;(21) obtain an acknowledgement stating that the information described in paragraph (20) of this subsection was provided to the individual or LAR and that is signed by:(A) the individual or LAR;(B) the program provider staff person providing such information; and(C) a third-party witness; and(22) notify the individual's service coordinator of an individual's or LAR's expressed interest in the CDS option and document such notification.(b) The program provider must make available all records, reports, and other information related to the delivery of TxHmL Program services and CFC services as requested by HHSC, other authorized agencies, or CMS and deliver such items, as requested, to a specified location.(c) At least annually, the program provider must conduct a satisfaction survey of individuals, their families, and LARs, and take action regarding any areas of dissatisfaction.(d) The program provider must comply with §49.309 of this title (relating to Complaint Process).(e) In all respite facilities, the program provider must post in a conspicuous location:(1) the name, address, and telephone number of the program provider;(2) the effective date of the contract; and(3) the name of the legal entity named on the contract.(f) At least annually, the program provider must review:(1) all final investigative reports from HHSC and, based on the review, identify program process improvements that help prevent the occurrence of abuse, neglect, and exploitation and improve the delivery of services;(2) complaints, as described in §49.309 of this title, and identify program process improvements to reduce the filing of complaints;(3) the reasons for suspensions, terminations, and transfers and identify any related need for program process improvements; and(4) critical incident data reported in accordance with subsection (n) of this section and identify program process improvements that help prevent the reoccurrence of critical incidents and improve the delivery of services.(g) A program provider must ensure that all personal information maintained by the program provider or its contractors concerning an individual, such as lists of names, addresses, and records created or obtained by the program provider or its contractor, is kept confidential, that the use or disclosure of such information and records is limited to purposes directly connected with the administration of the TxHmL Program or provision of CFC services, and is otherwise neither directly nor indirectly used or disclosed unless the written permission of the individual to whom the information applies or the individual's LAR is obtained before the use or disclosure.(h) The program provider must ensure that:(1) the individual or LAR has agreed in writing to all charges assessed by the program provider against the individual's personal funds before the charges are assessed; and(2) charges for items or services are reasonable and comparable to the costs of similar items and services generally available in the community.(i) The program provider must not charge an individual or LAR for costs for items or services reimbursed through the TxHmL Program or through CFC.(j) At the written request of an individual or LAR, the program provider:(1) must manage the individual's personal funds entrusted to the program provider;(2) must not commingle the individual's personal funds with the program provider's funds; and(3) must maintain a separate, detailed record of all deposits and expenditures for the individual.(k) When a behavioral support plan includes techniques that involve restriction of individual rights or intrusive techniques, the program provider must ensure that the implementation of such techniques includes:(1) approval by the individual's service planning team;(2) written consent of the individual or LAR;(3) verbal and written notification to the individual or LAR of the right to discontinue participation in the behavioral support plan at any time;(4) assessment of the individual's needs and current level/severity of the behavior targeted by the plan;(5) use of techniques appropriate to the level/severity of the behavior targeted by the plan;(6) a written behavioral support plan developed by a service provider of behavioral support with input from the individual, LAR, the individual's service planning team, and other professional personnel;(7) collection and monitoring of behavioral data concerning the targeted behavior;(8) allowance for the decrease in the use of intervention techniques based on behavioral data;(9) allowance for revision of the behavioral support plan when the desired behavior is not displayed or techniques are not effective;(10) consideration of the effects of the techniques in relation to the individual's physical and psychological well-being; and(11) at least annual review by the individual's service planning team to determine the effectiveness of the program and the need to continue the techniques.(l) A program provider must report the death of an individual:(1) to HHSC and the LIDDA by the end of the next business day after the program provider becomes aware of the death; and(2) if the program provider reasonably believes that the LAR does not know of the individual's death, to the LAR as soon as possible, but not later than 24 hours after the program provider becomes aware of the death.(m) A program provider must not retaliate against:(1) a staff member, service provider, individual, or other person who files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations; and(2) an individual because a person on behalf of the individual files a complaint, presents a grievance, or otherwise provides good faith information relating to the possible abuse, neglect, or exploitation of an individual, including:(A) the use of seclusion; and(B) the use of a restraint not in compliance with federal and state laws, rules, and regulations.(n) A program provider must enter critical incident data in the HHSC data system no later than the last calendar day of the month that follows the month being reported in accordance with the TxHmL Provider User Guide.(o) A program provider must ensure that:(1) the name and phone number of an alternate to the Chief Executive Officer (CEO) of the program provider is entered in the HHSC data system; and(2) the alternate to the CEO:(A) performs the duties of the CEO during the CEO's absence; and(B) if the CEO is named as an alleged perpetrator of abuse, neglect, or exploitation of an individual, acts as the contact person in an HHSC investigation and complies with §9.585(d) - (f) of this subchapter (relating to Certification Principles: Requirements Related to the Abuse, Neglect, and Exploitation of an Individual). Source Note: The provisions of this §566.11 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective June 1, 2008, 33 TexReg 4340; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective November 15, 2015, 40 TexReg 7827; amended to be effective March 20, 2016, 41 TexReg 1867; amended to be effective October 1, 2019, 44 TexReg 5062; transferred effective June 19, 2023, aspublished in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.11 Certification Principles: Quality Assurance https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213699 03/12/2026 A program provider must not use seclusion. Source Note: The provisions of this §566.13 adopted to be effective September 1, 2014, 39 TexReg 6549; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.13 Certification Principles: Prohibitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213700 03/12/2026 (a) A program provider must:(1) ensure that an individual and LAR are, before or at the time the individual begins receiving a TxHmL Program service or a CFC service and at least annually thereafter:(A) informed of how to report allegations of abuse, neglect, or exploitation to DFPS and are provided with the toll-free telephone number, 1-800-647-7418, in writing; and(B) educated about protecting the individual from abuse, neglect, and exploitation;(2) ensure that each staff member, service provider, and volunteer are:(A) trained and knowledgeable of:(i) acts that constitute abuse, neglect, and exploitation;(ii) signs and symptoms of abuse, neglect, and exploitation; and(iii) methods to prevent abuse, neglect, and exploitation;(B) instructed to report to DFPS immediately, but not later than one hour after having knowledge or suspicion, that an individual has been or is being abused, neglected, or exploited, by:(i) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-647-7418; or(ii) using the DFPS Abuse Hotline website; and(C) provided with the instructions described in subparagraph (B) of this paragraph in writing; and(3) conduct the activities described in paragraph (2)(A) - (C) of this subsection before a staff member, service provider, or volunteer assumes job duties and at least annually thereafter.(b) If a program provider, staff member, service provider, volunteer, or controlling person knows or suspects an individual is being or has been abused, neglected, or exploited, the program provider must report or ensure that the person with knowledge or suspicion reports the allegation of abuse, neglect, or exploitation to DFPS immediately, but not later than one hour after having knowledge or suspicion, by:(1) calling the DFPS Abuse Hotline toll-free telephone number, 1-800-647-7418; or(2) using the DFPS Abuse Hotline website.(c) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by a person who is not a service provider, staff member, volunteer, or controlling person, a program provider must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual; and(2) discuss with the individual or LAR alternative residential settings and additional services that may help ensure the individual's safety;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual; and(4) preserve and protect evidence related to the allegation.(d) If a report required by subsection (b) of this section alleges abuse, neglect, or exploitation by a service provider, staff member, volunteer, or controlling person; or if a program provider is notified by HHSC of an allegation of abuse, neglect, or exploitation by a service provider, staff member, volunteer, or controlling person, the program provider must:(1) as necessary:(A) obtain immediate medical or psychological services for the individual; and(B) assist in obtaining ongoing medical or psychological services for the individual;(2) take actions to secure the safety of the individual, including if necessary, ensuring that the alleged perpetrator does not have contact with the individual or any other individual until HHSC completes the investigation;(3) when taking the actions described in paragraphs (1) and (2) of this subsection, avoid compromising the investigation or further traumatizing the individual;(4) preserve and protect evidence related to the allegation; and(5) notify, as soon as possible, but no later than 24 hours after the program provider reports or is notified of an allegation, the individual, the LAR, and the service coordinator of:(A) the allegation report; and(B) the actions the program provider has taken or will take based on the allegation, the condition of the individual, and the nature and severity of any harm to the individual, including the actions required by paragraph (2) of this subsection.(e) During an HHSC investigation of an alleged perpetrator who is a service provider, staff member, volunteer, or controlling person, a program provider must:(1) cooperate with the investigation as requested by HHSC, including providing documentation and participating in an interview;(2) provide HHSC access to:(A) sites owned, operated, or controlled by the program provider;(B) individuals, service providers, staff members, volunteers, and controlling persons; and(C) records pertinent to the investigation of the allegation; and(3) ensure that staff members, service providers, volunteers, and controlling persons comply with paragraphs (1) and (2) of this subsection.(f) After a program provider receives a final investigative report from HHSC for an investigation described in subsection (e) of this section, the program provider must:(1) if the allegation of abuse, neglect, or exploitation is confirmed by HHSC:(A) review the report, including any concerns and recommendations by HHSC; and(B) take action within the program provider's authority to prevent the reoccurrence of abuse, neglect or exploitation, including disciplinary action against the service provider, staff member, or volunteer confirmed to have committed abuse, neglect, or exploitation;(2) if the allegation of abuse, neglect, or exploitation is unconfirmed, inconclusive, or unfounded:(A) review the report, including any concerns and recommendations by HHSC; and(B) take appropriate action within the program provider's authority, as necessary;(3) immediately, but not later than five calendar days after the date the program provider receives the HHSC final investigative report:(A) notify the individual, the LAR, and the service coordinator of:(i) the investigation finding; and(ii) the action taken by the program provider in response to the HHSC investigation as required by paragraphs (1) and (2) of this subsection; and(B) notify the individual or LAR of:(i) the process to appeal the investigation finding as described in 26 TAC Chapter 711, Subchapter J (relating to Appealing the Investigation Finding); and(ii) the process for requesting a copy of the investigative report from the program provider;(4) within 14 calendar days after the date the program provider receives the final investigative report, complete and send to HHSC the HHSC Notification to Waiver Survey and Certification (WSC) Regarding an Investigation of Abuse, Neglect or Exploitation form; and(5) upon request of the individual or LAR, provide to the individual or LAR a copy of the HHSC final investigative report after removing any information that would reveal the identity of the reporter or of any individual who is not the alleged victim. Source Note: The provisions of this §566.15 adopted to be effective October 1, 2019, 44 TexReg 5062; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.15 Certification Principles: Requirements Related to the Abuse, Neglect, and Exploitation of an Individual https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213701 03/12/2026 Program providers must comply with United States Code, Title 42, §1396a(w), regarding requirements about advance directives. Source Note: The provisions of this §566.17 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2014, 39 TexReg 6549; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.17 Other Program Provider Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213702 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213702 03/12/2026 (a) A program provider must be in continuous compliance with the certification principles contained in this subchapter that apply to program providers.(b) HHSC conducts the following surveys:(1) an initial certification survey;(2) a recertification survey;(3) a follow-up survey; and(4) an intermittent survey.(c) HHSC conducts an initial certification survey within 120 calendar days after the date HHSC approves the enrollment or transfer of the first individual to receive TxHmL Program services from the program provider.(d) HHSC may conduct an intermittent survey at any time during a certification period.(e) HHSC may conduct a combination of two or more different types of surveys at the same time.(f) If HHSC certifies a program provider after completion of an initial or a recertification survey, the certification period is for no more than 365 calendar days.(g) HHSC may choose not to conduct a recertification survey of a program provider that has a standard contract if the program provider is not the program provider for one or more individuals for at least 60 consecutive calendar days during the period beginning the first day of the certification period to be surveyed through the 121st calendar day before the end of the certification period.(h) During a survey, HHSC may:(1) review the TxHmL Program services or CFC services provided to any individual to determine if a program provider is in compliance with the certification principles; and(2) determine if a program provider has implemented an approved plan for amelioration as described in §9.586 of this subchapter (relating to Amelioration).(i) HHSC conducts an exit conference at the end of a survey, at a time and location determined by HHSC. At the exit conference, HHSC informs a program provider of preliminary findings, in writing, including findings that may result in a critical violation.(j) If HHSC identifies a finding that may be a critical violation not discussed during an exit conference, HHSC holds a new exit conference with a program provider to discuss the finding.(k) Based on a survey, HHSC takes action as described in §9.587 of this subchapter (relating to Program Provider Compliance and Corrective Action).(l) HHSC may evaluate the health and safety of an individual at any time. If HHSC identifies a concern from the evaluation, HHSC may conduct an intermittent survey. Source Note: The provisions of this §566.19 adopted to be effective January 5, 2003, 27 TexReg 12254; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective March 1, 2007, 32 TexReg 544; amended to be effective September 1, 2014, 39 TexReg 6549; amended to be effective July 1, 2015, 40 TexReg 2760; amended to be effective March 20, 2016, 41 TexReg 1867; amended to be effective April 28, 2020, 45 TexReg 2704; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.19 HHSC Surveys of a Program Provider https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213703 03/12/2026 (a) If HHSC determines from a survey that a program provider is in compliance with the certification principles, HHSC:(1) sends the program provider a final survey report stating that the program provider is in compliance with the certification principles;(2) does not require any action by the program provider; and(3) if the survey is an initial or a recertification survey, certifies the program provider as described in §9.576(f) of this subchapter (relating to HHSC Surveys of a Program Provider).(b) If HHSC determines from a survey that a program provider is not in compliance with a certification principle and the violation is an immediate threat, HHSC notifies the program provider of the determination. The program provider must immediately provide HHSC with a plan of removal.(c) In a plan of removal provided in accordance with subsection (b) of this section, a program provider must specify the time by which the program provider will remove the immediate threat. HHSC approves or disapproves the plan of removal and monitors to ensure the immediate threat is removed.(d) If a program provider that is required to provide a plan of removal does not provide a plan of removal, HHSC does not approve the program provider's plan of removal, or the program provider does not implement the plan of removal approved by HHSC, HHSC:(1) denies or terminates certification of the program provider; and(2) coordinates with the LIDDAs the immediate provision of alternative services for the individuals.(e) If HHSC determines from a survey that a program provider is not in compliance with a certification principle, HHSC sends to the program provider, within 14 calendar days after the date of the exit conference:(1) a final survey report with a list of violations;(2) a letter notifying the program provider that the program provider may request an informal dispute resolution to dispute a violation in the final survey report; and(3) if HHSC imposes an administrative penalty in accordance with §9.581 of this subchapter (relating to Administrative Penalties), a written notice of the administrative penalty as described in §49.535(b) of this title (relating to Administrative Penalties in the HCS and TxHmL Programs).(f) If HHSC determines from an initial certification survey, recertification survey, or intermittent survey that a program provider is not in compliance with the certification principles, the program provider must submit to HHSC, within 14 calendar days after the date the program provider receives the final survey report, a plan of correction for each violation identified by HHSC in the final survey report. The program provider must submit a plan of correction in accordance with this subsection even if the program provider disagrees with the violation or requests an informal dispute resolution.(g) In a plan of correction submitted in accordance with subsection (f) of this section, a program provider must specify a date by which the program provider will complete corrective action for each violation and such date must:(1) for a critical violation, be no later than 30 calendar days after the date of the survey exit conference; and(2) for a violation that is not a critical violation, be no later than 45 calendar days after the date of the survey exit conference.(h) After HHSC receives the plan of correction required by subsection (f) of this section, HHSC notifies the program provider of whether the plan is approved or not approved.(i) If HHSC does not approve a plan of correction required by subsection (f) of this section, the program provider must submit a revised plan of correction within five business days after the date of HHSC's notice that the plan of correction was not approved. After HHSC receives the revised plan of correction, HHSC notifies the program provider whether the revised plan is approved or not approved.(j) If the program provider does not submit a plan of correction required by subsection (f) of this section or a revised plan of correction required by subsection (i) of this section, or if HHSC notifies the program provider that a revised plan of correction is not approved, HHSC:(1) imposes a vendor hold against the program provider until HHSC approves a plan of correction submitted by the program provider; or(2) denies or terminates certification of the program provider.(k) If HHSC approves a plan of correction, HHSC takes the following actions to determine if a program provider has completed its corrective action:(1) requests that the program provider submit evidence of correction to HHSC; and(2) conducts:(A) for a critical violation, a follow-up survey after the date specified in the plan of correction for correcting the violation but within 45 calendar days after the survey exit conference, unless HHSC conducts an earlier follow-up survey as described in subsection (i) of this section; or(B) for a violation that is not critical, a post 45-day follow-up survey, unless HHSC conducts an earlier follow-up survey as described in subsection (l) of this section.(l) At the request of a program provider, HHSC may conduct a follow-up survey earlier than the timeframes described in subsection (k)(2) of this section.(1) If HHSC determines from the earlier follow-up survey that corrective action has been completed and the program provider has not yet submitted a plan of correction to HHSC in accordance with subsection (l) of this section, the program provider must include the corrective action taken on the plan of correction that is submitted.(2) If HHSC determines from the earlier follow-up survey that corrective action has not been completed for a violation that is not critical, HHSC conducts the post 45-day follow-up survey.(m) If HHSC determines from a follow-up survey described in subsection (k)(2)(A) or (l) of this section that the program provider has completed corrective action for a critical violation, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in §49.535(c) of this title.(n) If HHSC determines from a follow-up survey described in subsection (k)(2)(A) or (l) of this section that the program provider has not completed the corrective action for a critical violation, HHSC:(1) continues the administrative penalty and conducts another follow-up survey to determine if the program provider completed the corrective action;(2) imposes a vendor hold against the program provider; or(3) denies or terminates certification of the program provider.(o) HHSC takes the actions described in this subsection regarding a follow-up survey described in subsection (n)(1) of this section.(1) If HHSC determines from the survey that the program provider has completed the corrective action, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in §49.535(c) of this title.(2) If HHSC determines from the survey that the program provider has not completed the corrective action, the administrative penalty stops accruing and HHSC:(A) imposes a vendor hold against the program provider; or(B) denies or terminates certification of the program provider.(p) If HHSC determines from a post 45-day follow-up survey or an earlier survey described in subsection (l) of this section that a program provider has completed corrective action for a violation that is not critical, HHSC does not impose an administrative penalty for the non-critical violation.(q) If HHSC determines from a post 45-day follow-up survey that a program provider has not completed corrective action for a violation that is not critical, HHSC:(1) imposes an administrative penalty for the non-critical violation in accordance with §9.581 of this subchapter;(2) notifies the program provider of the administrative penalty, as described in §49.535(b) of this title; and(3) conducts a survey:(A) at least 31 calendar days after the date of the exit conference of the post 45-day follow-up survey; or(B) earlier than 31 calendar days after the date of the exit conference of the post 45-day follow-up survey if the program provider has submitted evidence of corrective action to HHSC during the 30-day period.(r) HHSC takes the actions described in this subsection regarding a survey described in subsection (q)(3) of this section.(1) If HHSC determines from the survey that the program provider has completed corrective action, the administrative penalty stops accruing on the date corrective action was completed, as determined by HHSC. HHSC sends the program provider a written notice as described in §49.535(c) of this title.(2) If HHSC determines from the survey that the program provider has not completed the corrective action, the administrative penalty stops accruing and HHSC:(A) imposes a vendor hold against the program provider; or(B) denies or terminates certification of the program provider.(s) If HHSC determines that a program provider committed any of the actions described in §9.581(a)(2) of this subchapter, HHSC takes one of the following actions:(1) imposes an administrative penalty against the program provider as described in §9.581 of this subchapter;(2) imposes a vendor hold against the program provider; or(3) denies or terminates certification of the program provider.(t) If HHSC imposes a vendor hold in accordance with this section:(1) for a program provider with a provisional contract, HHSC initiates termination of the program provider's contract in accordance with §49.534 of this title (relating to Termination of Contract by HHSC); or(2) for a program provider with a standard contract, HHSC conducts a survey at least 31 calendar days after the effective date of the vendor hold to determine if the program provider completed the corrective action required to release the vendor hold and:(A) if the program provider completed the corrective action, HHSC releases the vendor hold; or(B) if the program provider has not completed the corrective action, HHSC denies or terminates certification.(u) If HHSC determines that a program provider is out of compliance with §9.579(s) or (t) of this subchapter (relating to Certification Principles: Qualified Personnel), corrective action required by HHSC may include the program provider paying or ensuring payment to a service provider of supported home living or CFC PAS/HAB who was not paid the wages required by §9.579(s) of this subchapter, the difference between the amount required and the amount paid to the service provider.(v) HHSC does not cite a program provider for violation of a certification principle based solely on the action or inaction of a person who is not a service provider or a staff member. HHSC may cite a program provider for violation of a certification principle based on the program provider's response to the action or inaction of such a person. Source Note: The provisions of this §566.21 adopted to be effective April 28, 2020, 45 TexReg 2704; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.21 Program Provider Compliance and Corrective Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213704 03/12/2026 (a) HHSC may impose and collect an administrative penalty against a program provider for:(1) a violation of a certification principle that applies to a program provider; and(2) any of the following:(A) willfully interfering with the work of a representative of HHSC or the enforcement of this subchapter which may include:(i) making a false statement of material fact that the program provider knows or should know is false with respect to a matter under investigation by HHSC; and(ii) falsifying documentation including documenting the provision of a service before the service has been provided; or(B) failing to pay an administrative penalty within 10 calendar days after the date the assessment of the penalty becomes final.(b) The range of the administrative penalty that may be imposed against a program provider each day for a violation described in subsection (a)(1) of this section is based on the scope and severity of the violation and whether it is an initial or repeated violation, as set forth in the following figure:Attached Graphic(c) In determining the amount of an administrative penalty within a range, HHSC considers:(1) the seriousness of the violation, including:(A) the nature, circumstances, extent, and gravity of the violation; and(B) the hazard to the health or safety of individuals resulting from the violation;(2) the program provider's history of previous violations; (3) whether the program provider:(A) had prior knowledge of the violation, including whether the program provider identified the violation through the program provider's internal quality assurance process; and(B) made any efforts to mitigate or correct the identified violation;(4) the penalty amount necessary to deter future violations; and(5) any other matter that justice may require.(d) If HHSC determines that a violation is not a critical violation, HHSC allows a program provider one opportunity to correct the violation to avoid the imposition of an administrative penalty. If HHSC determines that a violation is a critical violation, HHSC does not allow a program provider an opportunity to correct the violation before HHSC imposes an administrative penalty. (e) If HHSC imposes an administrative penalty for a violation described in subsection (a)(1) of this section, the administrative penalty begins accruing:(1) for a critical violation, on the date HHSC identifies the violation; or (2) for a violation that is not critical, on the date of the exit conference of the post 45-day follow-up survey.(f) An administrative penalty accrues each day until the earliest of the following: (1) the program provider completes corrective action for that violation, as determined by HHSC;(2) HHSC imposes a vendor hold for that violation; or (3) HHSC withholds payments as the result of a proposed contract termination.(g) If the program provider demonstrates that corrective action is complete on the same day an administrative penalty begins accruing, HHSC imposes an administrative penalty for one day.(h) For an administrative penalty imposed in accordance with subsection (a)(2) of this section:(1) HHSC imposes the penalty no more than once per survey; (2) HHSC does not allow a program provider an opportunity to correct the action before imposing the penalty; and(3) the amount of the penalty is $1000.(i) If HHSC imposes an administrative penalty against a program provider in accordance with subsection (a) of this section, HHSC does not, at the same time, impose a vendor hold or otherwise withhold contract payments from the program provider for the same violation, action, or failure to act. Source Note: The provisions of this §566.23 adopted to be effective April 28, 2020, 45 TexReg 2704; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.23 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213705 03/12/2026 (a) In lieu of requiring payment for an administrative penalty imposed against a program provider in accordance with §9.581 of this subchapter (relating to Administrative Penalties), HHSC may give the program provider the opportunity for amelioration in accordance with this subsection.(b) HHSC does not give a program provider the opportunity for amelioration:(1) more than three times in a two-year period;(2) more than one time in a two-year period for the same or similar violation;(3) for a critical violation that is an immediate threat; or(4) for the actions or failures to act described in §9.581(a)(2) of this subchapter.(c) HHSC gives a program provider the opportunity for amelioration in the notice required by §49.535(c) of this title (relating to Administrative Penalties in the HCS and TxHmL Programs). If the program provider does not notify HHSC that the program provider chooses amelioration within the required period described in the notice, the program provider forfeits the opportunity to choose amelioration and HHSC requires the program provider to pay the administrative penalty.(d) If a program provider chooses amelioration in accordance with the notice required by §49.535(c) of this title, the program provider must submit a written plan for amelioration to HHSC within 45 calendar days after the date of the notice required by §49.535(c) of this title. If a program provider does not submit a plan for amelioration within 45 calendar days, HHSC requires the program provider to pay the administrative penalty in accordance with §49.535(d)(1).(e) A plan for amelioration must include:(1) proposed changes to the management or operation of the program provider that will improve services or the quality of care for the individuals;(2) the ways in which and the extent to which the proposed changes will improve services or quality of care for the individuals through measurable outcomes;(3) clear goals to be achieved through the proposed changes;(4) a timeline for implementing the proposed changes:(5) specific actions necessary to implement the proposed changes;(6) the cost of the proposed changes; and(7) an agreement to waive the program provider's right to appeal the imposition of the administrative penalty if HHSC approves the plan for amelioration.(f) The cost of the proposed changes must be incurred by the program provider after HHSC approves the plan for amelioration. If HHSC approves the plan and the cost of the proposed changes is less than the amount of the administrative penalty, HHSC requires the program provider to pay the difference between the cost of the proposed changes and the administrative penalty.(g) HHSC may require a plan for amelioration to propose changes that result in conditions exceeding the requirements of this subchapter.(h) HHSC notifies a program provider of its decision to approve or deny a plan for amelioration within 45 calendar days after the date HHSC receives the plan. During the 45-day period, HHSC may allow the program provider an opportunity to revise the plan.(1) If HHSC approves the plan:(A) the program provider must implement the plan; and(B) HHSC:(i) requires the program provider to pay the amount of the difference between the cost of the proposed changes and the administrative penalty, if any; and(ii) determines in one or more surveys conducted in accordance with §9.576 of this subchapter (relating to HHSC Surveys of a Program Provider) if the program provider has implemented the plan.(2) If HHSC denies the plan HHSC requires the program provider to pay the amount of the administrative penalty in accordance with §49.535(d)(2). The program provider may appeal the administrative penalty in accordance with §49.541 of this title (relating to Contractor's Right to Appeal).(i) If HHSC determines that a program provider did not implement an approved plan for amelioration, HHSC requires the program provider to pay the amount of the administrative penalty in accordance with §49.535(d)(3) of this title. The program provider may appeal the sole issue of whether the plan for amelioration was implemented. Source Note: The provisions of this §566.25 adopted to be effective April 28, 2020, 45 TexReg 2704; transferred effective June 19, 2023, as published in the May 26, 2023 issue of the Texas Register, 48 TexReg 2732. 1 HEALTH AND HUMAN SERVICES COMMISSION 566 TEXAS HOME LIVING (TXHML) PROGRAM AND COMMUNITY FIRST CHOICE (CFC) CERTIFICATION STANDARDS §566.25 Amelioration https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205079 03/12/2026 The purpose of this chapter is to describe standards to ensure the proper care and treatment of prospective patients and patients in private psychiatric hospitals licensed under Texas Health and Safety Code Chapter 577, and Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units), and in identifiable mental health services units in hospitals licensed under Texas Health and Safety Code Chapter 241, and 25 TAC Chapter 133 (relating to Hospital Licensing). Source Note: The provisions of this §568.1 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS A GENERAL REQUIREMENTS §568.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205080 03/12/2026 This chapter applies to:(1) private psychiatric hospitals licensed under Texas Health and Safety Code Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities) and Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units); and(2) identifiable mental health services units in hospitals licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals) and 25 TAC Chapter 133 (relating to Hospital Licensing). Source Note: The provisions of this §568.2 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS A GENERAL REQUIREMENTS §568.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205081 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205081 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Administrator--The individual, appointed by a governing body, who has authority to represent the hospital and, as delegated by the governing body, has responsibility for operating the hospital in accordance with the hospital's written policies and procedures.(2) Administrator's designee--An individual designated in a hospital's written policies and procedures to act for a specified purpose on behalf of the administrator.(3) Admission--The acceptance of an individual to a hospital's custody and care for inpatient mental health treatment based on:(A) a physician's order issued in accordance with §568.22(f)(2)(B) of this chapter (relating to Voluntary Admission);(B) a physician's order issued in accordance with §568.23(c)(3) of this chapter (relating to Emergency Detention);(C) an order of protective custody issued in accordance with Texas Health and Safety Code §574.022;(D) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code §574.034; (E) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code §574.035;(F) an order for commitment issued in accordance with Texas Code of Criminal Procedure Chapters 46B or 46C; or(G) an order for placement in accordance with Texas Family Code Chapter 55.(4) Adult--An individual 18 years of age.(5) Business day--Any day except a Saturday, Sunday, or legal holiday listed in Texas Government Code §662.021.(6) CFR--The Code of Federal Regulations.(7) Day--Calendar day.(8) Discharge--The release by a hospital of a patient from the custody and care of the hospital.(9) DSM--The current edition of the Diagnostic Statistical Manual of Mental Disorders published by the American Psychiatric Association.(10) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance use disorder) such that the absence of immediate medical attention could reasonably be expected to result in:(A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) or others in serious jeopardy;(B) serious impairment to bodily functions;(C) serious dysfunction of any bodily organ or part; (D) serious disfigurement; or(E) in the case of a pregnant woman who is having contractions: (i) that there is inadequate time to effect a safe transfer to another hospital before delivery; or(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.(11) Governing body--The governing authority of a hospital that is responsible for the hospital's organization, management, control and operation, including appointment of the administrator.(12) HHSC--The Texas Health and Human Services Commission. (13) Hospital--(A) A private psychiatric hospital licensed under Texas Health and Safety Code Chapter 577 (relating to Private Mental Hospitals and Other Mental Health Facilities) and Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units); or(B) an identifiable inpatient mental health services unit in a hospital licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals) and 25 TAC Chapter 133 (relating to Hospital Licensing).(14) Interdisciplinary treatment team (IDT)--A group of individuals who possess the knowledge, skills and expertise to develop and implement a patient's treatment plan and includes:(A) the patient's treating physician;(B) the patient and the patient's legally authorized representative (LAR), if any;(C) the staff members identified in the treatment plan as responsible for providing or ensuring the provision of each treatment in accordance with §568.61(c)(1)(E)(iii) of this chapter (relating to Inpatient Mental Health Treatment and Treatment Planning);(D) any individual identified by the patient or the patient's LAR, unless clinically contraindicated; and(E) other staff members as clinically appropriate.(15) Inpatient mental health treatment--Residential care provided in a hospital for a patient with a mental illness diagnosis, which may include a co-occuring diagnosis of a substance use, neurodevelopmental disorder, or both, which includes:(A) medical services;(B) nursing services;(C) social services;(D) therapeutic activities, if ordered by the treating physician; and(E) psychological services, if ordered by the treating physician.(16) Involuntary patient--A patient who is receiving inpatient mental health treatment based on an admission made in accordance with:(A) §568.23 of this chapter (relating to Emergency Detention); or(B) §568.24 of this chapter (relating to Admission of an Individual under an Order of Protective Custody, for Court-ordered Inpatient Mental Health Services, or Under Order for Commitment or Order for Placement).(17) Legally authorized representative (LAR)-- A parent, guardian, or managing conservator of a minor, or the guardian of an adult authorized by law to act on behalf of an individual regarding a matter described in this subchapter regarding:(A) admission, treatment, transfer, or discharge, including: (i) a parent, non-Department of Family and Protective Services managing conservator or guardian of minor; (ii) a Department of Family and Protective Service managing conservator of a minor acting pursuant to Texas Health and Safety Code §572.001(c-2)-(c-4); and (iii) a person eligible to consent to treatment for a minor under Texas Family Code §32.001(a)(1), (2), or (3), who may request from a district court authorization under Texas Family Code Chapter 35A for the temporary admission of a minor who has been within their care for the past 6 months. (B) consent on behalf of an individual with regard to a matter described in this subchapter other than admission, treatment, transfer, or discharge, including:(i) persons described by subparagraph (A) of this paragraph; and (ii) an agent acting under a Medical Power of Attorney under Texas Health and Safety Code Chapter 250 or a Declaration for Mental Health Treatment under Texas Civil Practice and Remedies Code Chapter 137.(18) Legal holiday--A holiday listed in Texas Government Code §662.021 and an officially designated county holiday applicable to a court in which proceedings are held under the Texas Mental Health Code.(19) Licensed marriage and family therapist--An individual who is licensed as a marriage and family therapist by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 502.(20) Licensed master social worker--An individual who is licensed as a master social worker by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 505.(21) Licensed professional counselor--An individual who is licensed as a professional counselor by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 503.(22) Licensed psychologist--An individual who is licensed as a psychologist by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 501.(23) Licensed social worker--An individual who is licensed as a social worker by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 505.(24) Licensed vocational nurse (LVN)--An individual who is licensed as a vocational nurse by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301.(25) Mandatory overtime--The time, other than on-call time, a nursing staff member is required to work at a hospital beyond the hours or days that were scheduled for the staff member. Neither the length of the shift (whether 4, 8, 12, or 16 hours) nor the number of shifts scheduled to work per week (whether 4, 5, or 6 per week) is the determinative factor in deciding whether time is mandatory overtime.(26) Medical services--Services provided or delegated by a physician acting within the scope of the physician's practice, as described in Texas Occupations Code Title 3, Subtitle B (the Medical Practice Act).(27) Mental illness--An illness, disease, or condition (other than epilepsy, dementia, substance-related and addictive disorders, or intellectual disability) that:(A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.(28) Minor--An individual under 18 years of age.(29) Monitoring--One or more staff members observing a patient on a continual basis or at pre-determined intervals and intervening when necessary to protect the patient from harming self or others.(30) Neurological screening--A screening to assess an individual's neurological functioning.(31) Nosocomial infection--A hospital-acquired infection of a patient.(32) Nursing services--Services provided by, assigned to an LVN by, or delegated to unlicensed assistive personnel (UAP) by an RN acting within the scope of the RN's practice, as described in Texas Occupations Code Chapter 301.(33) Nursing staff--Staff members of a hospital who are registered nurses, licensed vocational nurses, or UAP.(34) Occupational therapist--An individual who is licensed as an occupational therapist by the Texas Board of Occupational Therapy Examiners in accordance with Texas Occupations Code Chapter 454.(35) Pre-admission screening professional (PASP)--A staff member whose responsibilities include conducting a pre-admission screening and who is:(A) a physician;(B) a physician assistant;(C) a registered nurse;(D) a licensed psychologist;(E) a psychological associate;(F) a licensed social worker;(G) a licensed professional counselor; or(H) a licensed marriage and family therapist.(36) Patient--An individual who has been admitted to a hospital and has not been discharged.(37) Physician--An individual who is licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code Chapter 155 or otherwise authorized to perform medical acts under that chapter.(38) Physician assistant--An individual who is licensed as a physician assistant by the Texas Physician Assistant Board in accordance with Texas Occupations Code Chapter 204.(39) Pre-admission screening--The clinical process used to gather information from a prospective patient, including a medical history, any history of substance use, and the problem for which the prospective patient is seeking treatment, to determine if a physician should conduct an admission examination.(40) Prospective patient--An individual:(A) for whom a request for voluntary admission has been made, in accordance with §568.22(a) of this chapter (relating to Voluntary Admission); or(B) who has been accepted by a hospital for a preliminary examination, in accordance with §568.23(a) of this chapter (relating to Emergency Detention).(41) Psychological associate--An individual who is licensed as a psychological associate by the Texas Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 501.(42) Psychological services--Services provided by a psychologist or psychological associate acting within the scope of the psychologist's practice, as described in Texas Occupations Code Chapter 501.(43) Psychologist--An individual who is licensed as a psychologist by the Texas State Behavioral Health Executive Council in accordance with Texas Occupations Code Chapter 501.(44) Registered nurse (RN)--An individual who is licensed as an RN by the Texas Board of Nursing in accordance with Texas Occupations Code Chapter 301.(45) Sentinel event--Any of the following occurrences:(A) the death of a patient;(B) the serious physical injury of a patient;(C) the serious psychological injury of a patient; or(D) circumstances that present the imminent risk of death, serious physical injury, or serious psychological injury of a patient.(46) Social services--Services provided by:(A) a licensed master social worker or licensed social worker acting within the scope of the social worker's practice, as described in Texas Occupations Code Chapter 505; or(B) a licensed professional counselor acting within the scope of the professional counselor's practice, as described in Texas Occupations Code Chapter 503.(47) Stabilize--To provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital or, if the emergency medical condition for a woman is that she is in labor, that the woman has delivered the child and the placenta.(48) Staff members--All personnel of a hospital including full-time and part-time employees, contractors, students, volunteers, and professionals granted privileges by the hospital.(49) Substance-related disorder--The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which currently meets the criteria for substance-related and addictive disorders as described in the DSM. May also be known as a substance use disorder, substance abuse disorder, or addictive disorder.(50) TAC--The Texas Administrative Code.(51) Therapeutic activity--One of the following structured activities designed to develop, restore or maintain a patient's optimal level of physical and psychosocial functioning:(A) recreational therapy provided by a therapeutic recreation specialist;(B) physical therapy, speech therapy, or occupational therapy, provided by a licensed staff member acting within the scope of the staff member's practice;(C) art therapy provided by a staff member who is a Board-Certified Art Therapist;(D) music therapy provided by a staff member who is a Board-Certified Music Therapist; or(E) psychosocial or leisure activities provided by qualified staff members.(52) Therapeutic recreation specialist--An individual who is certified as a therapeutic recreation specialist by the Texas Consortium for Therapeutic Recreation/Activities Certification or a certified therapeutic recreation specialist by the National Council for Therapeutic Recreation Certification.(53) Treating physician--A physician who coordinates and oversees the implementation of a patient's treatment plan.(54) Unit--A discrete and identifiable area of a hospital that includes patients' rooms or other patient living areas and is separated from another similar area:(A) by a locked door;(B) by a floor; or(C) because the other similar area is in a different building.(55) Unlicensed assistive personnel (UAP)--An individual, not licensed as a health care provider, who provides certain health related tasks or functions in a complementary or assistive role to a registered nurse in providing direct patient care or carrying out common nursing functions.(56) Voluntary patient--A patient who is receiving inpatient mental health treatment based on an admission made in accordance with:(A) §568.22 of this chapter (relating to Voluntary Admission); or(B) §568.26 of this chapter (relating to Voluntary Treatment Following Involuntary Admission). Source Note: The provisions of this §568.3 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS A GENERAL REQUIREMENTS §568.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205082 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205082 03/12/2026 (a) Written policies and procedures. A hospital shall develop written policies and procedures that ensure compliance with this subchapter.(b) Compliance by staff. All staff members shall comply with this subchapter and the policies and procedures of the hospital required by subsection (a) of this section.(c) Responsibility of hospital. A hospital shall be responsible for a staff member's compliance with this subchapter and the policies and procedures required by subsection (a) of this section.(d) Enforcement of policies and procedures. A hospital shall take appropriate measures to ensure a staff member's compliance with this subchapter and the policies and procedures required by subsection (a) of this section.(e) Implementation of physician orders. A hospital shall implement all orders issued by a physician for a patient or provide adequate written justification for failing to implement the orders.(f) Physician delegation. Except as provided by §568.22(h)(3) of this chapter (relating to Voluntary Admission), or other state law as applicable, a physician may delegate any medical service described in this subchapter in accordance with Texas Occupations Code §157.001.(g) Compliance with rules. A hospital shall comply with the following HHSC rules:(1) 25 TAC Chapter 405, Subchapter E (relating to Electroconvulsive Therapy (ECT));(2) 25 TAC Chapter 415, Subchapter A (relating to Prescribing of Psychoactive Medication);(3) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services) however, this does not prohibit the use of law enforcement in a situation that sufficiently warrants the need for law enforcement assistance, including to regain safety in the hospital;(4) 25 TAC Chapter 414, Subchapter I (relating to Consent to Treatment with Psychoactive Medication-Mental Health Services); and(5) 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services).(h) Compliance with Treatment Facilities Marketing Practices Act. Unless it is exempt, a hospital shall comply with Texas Health and Safety Code Chapter 164 (relating to Treatment Facilities Marketing and Admission Practices). Source Note: The provisions of this §568.4 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS A GENERAL REQUIREMENTS §568.4 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205083 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205083 03/12/2026 A hospital shall comply with 25 TAC Chapter 448 (relating to Standard of Care) in admitting, treating, and discharging an individual with a sole diagnosis of a substance-related or addictive disorder. Source Note: The provisions of this §568.5 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS A GENERAL REQUIREMENTS §568.5 Individuals with a Sole Diagnosis of a Substance-related or Addictive Disorder https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205084 03/12/2026 A hospital shall develop and implement written admission criteria that:(1) uniformly apply to all prospective patients;(2) permit the admission of a prospective patient only if the patient has a mental illness of sufficient severity to require inpatient mental health treatment; and(3) prevent the admission of a prospective patient who:(A) requires specialized care not available at the hospital; or(B) has a physical medical condition that is unstable and could reasonably be expected to require inpatient medical treatment for the condition. Source Note: The provisions of this §568.21 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.21 Admission Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205085 03/12/2026 (a) A request for voluntary admission:(1) may be made only by a person authorized to do so under Texas Health and Safety Code §572.001;(2) must be in writing and signed by the individual making the request; and(3) must include a statement that the individual making the request:(A) certifies that the individual is legally authorized to act on the prospective patient's behalf;(B) has provided the facility with documentation demonstrating that the individual is legally authorized to act on the prospective patient's behalf;(C) agrees that the prospective patient will remain in the hospital until discharged; and(D) consents to diagnosis, observation, care and treatment of the prospective patient until the earlier of:(i) the discharge of the prospective patient; or(ii) the prospective patient is entitled to leave the hospital, in accordance with Texas Health and Safety Code §572.004, after a request for discharge is made.(b) The consent given under subsection (a)(3)(D) of this section does not waive any rights a patient has under any statute or rule.(c) Capacity to consent. If a prospective patient does not have the capacity to consent to diagnosis, observation, care and treatment, as determined by a physician, then the hospital may not admit the prospective patient on a voluntary basis. When appropriate, the hospital may initiate an emergency detention proceeding in accordance with Texas Health and Safety Code Chapter 573 or file an application for court-ordered inpatient mental health services in accordance with Texas Health and Safety Code Chapter 574.(d) An individual who voluntarily presents to the hospital may leave the hospital at any time during the pre-admission screening and assessment process prior to their admission.(e) Pre-admission screening.(1) Before voluntary admission of a prospective patient, pre-admission screening personnel (PASP) shall conduct a pre-admission screening of the prospective patient.(2) If the PASP determines that the prospective patient does not need an admission examination, the hospital may not admit the prospective patient and shall refer the prospective patient to alternative services. If the PASP determines the prospective patient needs an admission examination, a physician shall conduct an admission examination of the prospective patient.(3) If the pre-admission screening is conducted by a physician, the physician may conduct the pre-admission screening as part of the admission examination referenced in subsection (f)(2)(A) of this section.(f) Requirements for voluntary admission. A hospital may voluntarily admit a prospective patient only if:(1) a request for admission is made in accordance with subsection (a) of this section;(2) a physician has, in accordance with Texas Health and Safety Code §572.0025:(A) conducted, or consulted with a physician who has conducted, either in person or through telemedicine medical services, an admission examination in accordance with subsection (h) of this section within 72 hours before or 24 hours after admission; and(B) issued an order admitting the prospective patient;(3) the prospective patient meets the hospital's admission criteria;(4) the prospective patient is a person:(A) with mental illness or who demonstrates symptoms of a serious emotional disorder; and(B) who presents a risk of serious harm to self or others if not immediately restrained or hospitalized; and(5) in accordance with Texas Health and Safety Code §572.0025(f)(2), the administrator or administrator's designee has signed a written statement agreeing to admit the prospective patient.(g) Intake. In accordance with Texas Health and Safety Code §572.0025(b), a hospital shall, before voluntary admission of a prospective patient, conduct an intake process, that includes:(1) obtaining relevant information about the prospective patient, including information about finances, insurance benefits and advance directives; and(2) explaining, orally and in writing, the prospective patient's rights described in 25 TAC Chapter 404, Subchapter E (concerning Rights of Persons Receiving Mental Health Services), including:(A) the hospital's services and treatment as they relate to the prospective patient; and(B) explaining, orally and in writing, the existence, purpose, telephone number, and address of the protection and advocacy system of the state of Texas, pursuant to Texas Health and Safety Code §576.008.(h) Admission examination.(1) The admission examination referenced in subsection (d)(2)(A) of this section shall be conducted by a physician in accordance with Texas Health and Safety Code Chapter 572 and include a physical and psychiatric examination conducted in the physical presence of the patient or by using audiovisual telecommunications.(2) The physical examination may consist of an assessment for medical stability.(3) The physician may not delegate conducting the admission examination to a non-physician.(i) Documentation of admission order. In accordance with Texas Health and Safety Code §572.0025(f)(1), the order described in subsection (f)(2)(B) of this section shall:(1) be issued in writing and signed by the issuing physician; or(2) be issued orally or electronically if, within 24 hours after its issuance, the hospital has a written order signed by the issuing physician. Source Note: The provisions of this §568.22 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.22 Voluntary Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205086 03/12/2026 (a) Acceptance for preliminary examination. In accordance with Texas Health and Safety Code §573.021 and §573.022, a hospital shall accept for a preliminary examination:(1) an individual who has been transported to a hospital by peace officer or emergency medical services personnel in accordance with Texas Health and Safety Code §573.001 or §573.012; or(2) an individual who is at least 18 years of age or older and who has been transported to the hospital by the individual's guardian of the person in accordance with Texas Health and Safety Code §573.003.(b) Preliminary examination.(1) A physician shall examine the person as soon as possible within 12 hours after the time the person is apprehended by the peace officer or transported for emergency detention by the person's guardian, in accordance with Texas Health and Safety Code §573.021.(2) The preliminary examination shall include:(A) an assessment for medical stability; and(B) a psychiatric examination to determine if the individual meets the criteria described in subsection (c)(1) of this section.(c) Requirements for emergency detention. A hospital may admit a prospective patient for emergency detention only if:(1) in accordance with Texas Health and Safety Code §573.022(a)(2), a physician determines from the preliminary examination that:(A) the prospective patient has a mental illness;(B) the prospective patient evidences a substantial risk of serious harm to self or others;(C) the described risk of harm is imminent unless the prospective patient is immediately detained; and(D) emergency detention is the least restrictive means by which the necessary detention may be accomplished;(2) in accordance with Texas Health and Safety Code §573.022(a)(3), a physician makes a written statement:(A) documenting the determination described in paragraph (1) of this subsection; and(B) describing:(i) the nature of the prospective patient's mental illness;(ii) the risk of harm the individual evidences, demonstrated either by the prospective patient's behavior or by evidence of severe emotional distress and deterioration in the prospective patient's mental condition to the extent that the prospective patient may harm themselves or another; and(iii) the detailed information on which the physician based the determination described in paragraph (1) of this subsection;(3) based on the determination described in paragraph (1) of this subsection, the physician issues an order admitting the prospective patient for emergency detention; and(4) the prospective patient meets the hospital's admission criteria, as required by §568.21 of this subchapter (relating to Admission Criteria).(d) Release.(1) A hospital shall release a prospective patient accepted for a preliminary examination if:(A) a preliminary examination of the prospective patient has not been conducted within the time frame described in subsection (b)(1) of this section; or(B) in accordance with Texas Health and Safety Code §573.023(a), the prospective patient is not admitted for emergency detention in accordance with subsection (c) of this section on completion of the preliminary examination.(2) In accordance with Texas Health and Safety Code §576.007, before releasing a prospective patient who is at least 18 years of age or older, a hospital shall make a reasonable effort to notify the prospective patient's family of the release if the prospective patient grants permission for the notification.(3) Before releasing a patient who is younger than 18 years of age, a hospital shall notify the patient's legally authorized representative (LAR) or the LAR's designee of the release.(4) Upon release, the hospital may release a minor younger than 18 years of age only to the minor's LAR or the LAR's designee.(5) In accordance with Texas Health and Safety Code §573.021(b), a person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the person was presented to the facility, unless a written order for protective custody is obtained. If the 48-hour period ends on a Saturday, Sunday, legal holiday, or before 4:00 PM on the first succeeding business day, the person may be detained until 4:00 PM on the first succeeding business day. If the 48-hour period ends at a different time, the person may be detained only until 4:00 PM on the day the 48-hour period ends.(e) Intake. A hospital shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted for emergency detention.(1) The intake process shall include:(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and(B) explaining to the patient and their LAR, when applicable, orally and in writing, the patient's rights described in 25 TAC Chapter 404, Subchapter E (concerning Rights of Persons Receiving Mental Health Services), including:(i) the hospital's services and treatment as they relate to the patient; and(ii) the existence, purpose, telephone number, and address of the protection and advocacy system of the state of Texas, as required by Texas Health and Safety Code §576.008.(2) The hospital shall determine whether the patient comprehends the information provided in accordance with paragraph (1)(B) of this subsection. If the hospital determines that the patient comprehends the information, the hospital shall document in the patient's medical record the reasons for such determination. If the hospital determines that the patient does not comprehend the information, the hospital shall:(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information. Source Note: The provisions of this §568.23 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.23 Emergency Detention https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205087 03/12/2026 (a) Requirements for admission under court order. A hospital may admit an individual:(1) under an order of protective custody only if a court has issued an order in accordance with Texas Health and Safety Code §574.022;(2) for court-ordered inpatient mental health services only if a court has issued:(A) an order for temporary inpatient mental health services in accordance with Texas Health and Safety Code §574.034; or(B) an order for extended inpatient mental health services in accordance with Texas Health and Safety Code §574.035;(3) under an order for commitment issued in accordance with the Texas Code of Criminal Procedure Chapters 46B or 46C; or(4) under an order for placement issued in accordance with Texas Family Code Chapter 55.(b) Intake. A hospital shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted under one of the orders described in subsection (a) of this section.(1) The intake process shall include:(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and(B) explaining to the patient and their LAR, when applicable, orally and in writing, the patient's rights described in 25 TAC Chapter 404, Subchapter E (concerning Rights of Persons Receiving Mental Health Services), including:(i) the hospital's services and treatment as they relate to the patient; and(ii) the existence, purpose, telephone number, and address of the protection and advocacy system of the state of Texas, as required by Texas Health and Safety Code §576.008.(2) The hospital shall determine whether the patient comprehends the information provided in accordance with paragraph (1)(B) of this subsection. If the hospital determines that the patient comprehends the information, the hospital shall document in the patient's medical record the reasons for such determination. If the hospital determines that the patient does not comprehend the information, the hospital shall:(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information. Source Note: The provisions of this §568.24 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.24 Admission of an Individual under an Order of Protective Custody, for Court-ordered Inpatient Mental Health Services, or Under Order for Commitment or Order for Placement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205088 03/12/2026 At the time a patient is admitted, a hospital shall assign and implement one of the levels of monitoring identified by the hospital in accordance with §568.67(b) of this chapter (relating to Protection of a Patient), based on the patient's needs. Source Note: The provisions of this §568.25 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.25 Monitoring Upon Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205089 03/12/2026 A hospital may provide inpatient mental health treatment to an involuntary patient after the patient is eligible for discharge, as described in §568.84 of this chapter (relating to Discharge of an Involuntary Patient), if before the provision of such treatment:(1) the hospital obtains written consent for voluntary inpatient mental health treatment that meets the requirements of a request for voluntary admission, as described in §568.22(a) of this subchapter (relating to Voluntary Admission); and(2) the patient's treating physician:(A) examines the patient; and(B) based on that examination, issues an order for voluntary inpatient mental health treatment that meets the requirements of §568.22(i) of this subchapter. Source Note: The provisions of this §568.26 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS B ADMISSION §568.26 Voluntary Treatment Following Involuntary Admission https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205090 03/12/2026 (a) Planning responses to emergency medical conditions. A hospital shall:(1) identify potential emergency medical conditions of:(A) a patient;(B) a prospective patient; and(C) an individual who arrives on hospital property, as defined in 42 CFR §489.24(b), requesting examination or treatment for a medical condition; and(2) develop a written plan describing the specific and appropriate action to be taken by the hospital to evaluate for and stabilize each identified potential emergency medical condition, which shall include:(A) the administration of first aid and basic life support when clinically indicated; and(B) the use of the supplies and equipment described in subsection (f)(2) of this section.(b) Written record of evaluations. The hospital shall keep a written record of all evaluations of individuals who arrive on hospital property, as defined in 42 CFR §489.24(b), requesting examination or treatment for a medical condition. The written record shall include the following information:(1) demographic data regarding the individual evaluated, including the name, age, and sex of the individual;(2) a description of the individual's complaint or symptoms;(3) whether the hospital determined that the individual had an emergency medical condition and, if so, a description of the condition;(4) whether the hospital treated or refused to treat the individual;(5) whether the individual refused or consented to treatment or transfer;(6) whether the hospital stabilized the emergency medical condition;(7) whether the hospital admitted or released the individual; and(8) whether the hospital transferred the individual and, if so, the individual's destination, time of transfer and mode of transportation.(c) Availability of physicians. At least one physician shall always:(1) be physically present at the hospital to respond to an emergency medical condition of a patient; or(2) be available to staff members by telephone, radio, or audiovisual telecommunication to provide medical consultation.(d) Response to emergency medical conditions. If a hospital determines that a patient, prospective patient, or an individual who arrives on hospital property requesting examination or treatment for a medical condition has an emergency medical condition, the hospital shall:(1) act to stabilize the emergency medical condition in accordance with the plan required by subsection (a)(2) of this section; and(2) if appropriate, transfer the individual in accordance with the following, as applicable:(A) §510.43 of this title (relating to Patient Transfer Policy), or a transfer agreement made in accordance with §510.61 of this title (relating to Patient Transfer Agreements); or(B) 25 TAC §133.44 (relating to Hospital Patient Transfer Policy), or a transfer agreement made in accordance with 25 TAC §133.61 (relating to Hospital Patient Transfer Agreements).(e) Qualified staff members. The hospital shall have an adequate number of staff members who are qualified and available to evaluate for and respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.(f) Supplies and equipment.(1) The hospital shall have an adequate amount of appropriate supplies and equipment immediately available and fully operational at the hospital to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.(2) The emergency supplies and equipment required by paragraph (1) of this subsection shall include, at a minimum:(A) oxygen;(B) airways, manual breathing bags, and masks; and(C) an automated external defibrillator.(3) If an identifiable inpatient mental health services unit in a hospital licensed under Texas Health and Safety Code Chapter 241 and 25 TAC Chapter 133 (relating to Hospital Licensing) has immediate access to an automated external defibrillator located in another area, the identifiable inpatient mental health services unit is not required to comply with paragraph (2)(C) of this subsection. Source Note: The provisions of this §568.41 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS C EMERGENCY TREATMENTS §568.41 Responding to an Emergency Medical Condition https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223278 03/12/2026 (a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.(1) Emergency psychoactive medication--A psychoactive medication administered to a patient in a psychiatric emergency that is used to exercise an immediate effect on the central nervous system.(2) Psychiatric emergency--A situation in which it is immediately necessary to administer medication to a patient to prevent:(A) imminent probable death or substantial bodily harm to the patient because the patient:(i) overtly or continually is threatening or attempting to commit suicide or serious bodily harm; or(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or(B) imminent physical or emotional harm to another because of threats, attempts, or other acts the patient overtly or continually makes or commits.(3) Psychoactive medication--A medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness. "Psychoactive medication" includes the following categories when used as described in this section:(A) antipsychotics or neuroleptics;(B) antidepressants;(C) agents for control of mania or depression;(D) antianxiety agents;(E) sedatives, hypnotics, or other sleep-promoting drugs; and(F) psychomotor stimulants.(b) In accordance with 25 TAC §414.410 (relating to Psychiatric Emergencies), only a treating physician may issue an order to administer emergency psychoactive medication without a patient's consent.(c) A treating physician may only issue an order to administer emergency psychoactive medication without a patient's consent when less restrictive interventions are determined ineffective to protect the patient or others from harm.(d) A hospital shall adopt, implement, and enforce written policies and procedures to ensure safe and appropriate administration and monitoring of an emergency psychoactive medication. These policies and procedures shall:(1) identify the staff members authorized to administer an emergency psychoactive medication;(2) identify the psychoactive medications permitted and approved by the hospital for administration in a psychiatric emergency;(3) prescribe how and with what frequency and duration a staff member shall monitor a patient who has received an emergency psychoactive medication to ensure the health and safety of the patient, in addition to the in-person evaluation conducted as required by subsection (f) of this section;(4) identify the licensed practitioners authorized to examine the patient as required by subsection (f) of this section; and(5) ensure staff members follow all monitoring and evaluation requirements under this section and all hospital policies and procedures regarding administration of an emergency psychoactive medication each time a patient receives a separate dose of an emergency psychoactive medication.(e) Staff members authorized by the hospital's policies and procedures to administer an emergency psychoactive medication shall receive training on and demonstrate competency in the following:(1) knowledge of the psychoactive medications permitted and approved by the hospital for administration in a psychiatric emergency;(2) safe and appropriate administration and monitoring of an emergency psychoactive medication per hospital policies and procedures as required by subsection (d) of this section; and(3) management of emergency medical conditions in accordance with the hospital's policies and procedures and other applicable requirements for:(A) obtaining emergency medical assistance; and(B) obtaining training in and using techniques for cardiopulmonary respiration and airway obstruction removal.(f) When a staff member administers a psychoactive medication to a patient experiencing a psychiatric emergency, a physician, other licensed practitioner, or registered nurse trained in accordance with the requirements specified in subsection (g) of this section shall examine the patient in person within one hour after the administration of the psychoactive medication to evaluate and document in the patient's clinical record:(1) the patient's immediate situation;(2) the patient's reaction to the medication;(3) the patient's medical and behavioral condition; and(4) whether to return to or modify the patient's plan of care.(g) A physician, other licensed practitioner, or registered nurse who conducts the in-person evaluation specified in subsection (f) of this section shall receive training and demonstrate competency in the following:(1) techniques identifying staff member and patient behaviors, events, and environmental factors that may trigger a psychiatric emergency;(2) use of nonphysical intervention skills;(3) choosing the least restrictive intervention based on an individualized assessment of the patient's medical or behavioral status or condition;(4) safe administration of emergency psychoactive medications and how to recognize and respond to signs of physical and psychological distress;(5) clinical identification of specific behavioral changes indicating the psychiatric emergency's conclusion;(6) monitoring the physical and psychological well-being of the patient who has received an emergency psychoactive medication, including the patient's respiratory and circulatory status, vital signs, and any special requirements specified by hospital policy associated with conducting the in-person evaluation; and(7) the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.(h) If a trained registered nurse conducts the in-person evaluation specified in subsection (f) of this section, the trained registered nurse shall consult the attending physician or other licensed practitioner responsible for the patient's care as soon as possible after completing the evaluation.(i) The physician or other licensed practitioner responsible for the patient's care shall document in the patient's clinical record in specific medical and behavioral terms:(1) the information required by 25 TAC §414.410(b) (relating to Psychiatric Emergencies);(2) the evaluation findings specified in subsection (f)(1) - (4) of this section;(3) a description of the patient's behavior and the emergency psychoactive medication used;(4) alternatives or other less restrictive interventions attempted, as applicable;(5) the patient's condition or symptoms warranting the emergency psychoactive medication; and(6) the patient's response to the emergency psychoactive medication, including the rationale for continued use of the medication. Source Note: The provisions of this §568.42 adopted to be effective January 6, 2025, 50 TexReg 155. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS C EMERGENCY TREATMENTS §568.42 Responding to a Psychiatric Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205093 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205093 03/12/2026 (a) Inpatient mental health treatment. A hospital shall provide inpatient mental health treatment and medical care to a patient under the direction of a physician, in accordance with the highest standards accepted in medical practice, and in accordance with the patient's treatment plan and this subchapter. The treatment plan shall be appropriate to the needs and interests of the patient and be directed toward restoring and maintaining optimal levels of physical and psychological functioning.(b) Treatment plan content within 24 hours. A hospital, in collaboration with the patient and LAR, when applicable, shall develop and implement a written treatment plan within 24 hours after the patient's admission. If the patient is unable or unwilling to collaborate with the hospital, the circumstances of such inability or unwillingness shall be documented in the patient's medical record.(1) The treatment plan shall be based on the findings of:(A) the physical examination described in §568.62(e)(1)(A) or (B) of this subchapter (relating to Medical Services);(B) the psychiatric evaluation described in §568.62(f) of this subchapter; and(C) the initial nursing assessment described in §568.63(e) of this subchapter (relating to Nursing Services).(2) The treatment plan shall contain:(A) a list of all diagnoses for the patient with notation as to which diagnoses will be treated at the hospital, including:(i) at least one mental illness diagnosis;(ii) any substance-related or addictive disorder diagnoses;(iii) neurodevelopmental disorders; and(iv) any other non-psychiatric conditions;(B) a list of problems and needs that are to be addressed during the patient's hospitalization;(C) a description of all treatment interventions intended to address the patient's problems and needs, including the medications prescribed and the symptoms each medication is intended to address;(D) identification of any additional assessments and evaluations to be conducted, which shall include the social assessment described in §568.64(d) of this subchapter (relating to Social Services);(E) identification of the level of monitoring assigned to the patient; and(F) the rationale for the treatment interventions and any enhanced levels of monitoring described in subparagraphs (C) and (E) of this paragraph.(c) Treatment plan content within 72 hours.(1) Within 72 hours of the patient's admission the hospital shall:(A) establish an interdisciplinary treatment team (IDT) for a patient;(B) conduct the social assessment described in subsection (b)(2)(D) of this section;(C) initiate referrals for any additional assessments and evaluations identified in accordance with subsection (b)(2)(D) of this section;(D) review the content of the treatment plan required by subsection (b)(2) of this section, and revise the plan, if necessary, based on the findings of the social assessment or as otherwise clinically indicated; and(E) add to the treatment plan:(i) a description of the goals of the patient relating to the problems and needs listed in accordance with subsection (b)(2)(B) of this section;(ii) the specific treatment modalities for each treatment intervention by type and frequency;(iii) the IDT member responsible for providing or ensuring the provision of each treatment intervention;(iv) the time frames and measures to evaluate progress of the treatment plan toward meeting the goals of the patient;(v) a description of the clinical criteria for the patient to be discharged; and(vi) a description of the recommended services and supports needed by the patient after discharge as required by §568.81(a)(3)(A) of this chapter (relating to Discharge Planning).(2) The treatment plan shall be signed by all members of the IDT. If the patient is unable or unwilling to sign the treatment plan, the reason for or circumstances of such inability or unwillingness shall be documented in the patient's medical record.(d) Treatment plan review. In addition to the review required by subsection (c)(1)(D) of this section, the treatment plan shall be reviewed, and its effectiveness evaluated:(1) when there is a significant change in the patient's condition or diagnosis or as otherwise clinically indicated:(2) in accordance with the time frames and measures described in the treatment plan; and(3) upon request by the patient or the patient's legally authorized representative.(e) Treatment plan revision. In addition to a revision required by subsection (c)(1)(D) of this section, the treatment plan shall be revised, if necessary, based on the findings of any assessment, reassessment, evaluation, or re-evaluation, or as otherwise clinically indicated.(f) Documentation of treatment plan review and revisions. A treatment plan review and revision shall be signed by all members of the IDT. If the patient is unable or unwilling to sign the review or revision, the reason for or circumstances of such inability or unwillingness shall be documented in the patient's medical record. Source Note: The provisions of this §568.61 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.61 Inpatient Mental Health Treatment and Treatment Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205091 03/12/2026 (a) Medical services in treatment plan. A hospital shall provide medical services to a patient in accordance with a treatment plan developed in accordance with §568.61 of this subchapter (relating to Inpatient Mental Health Treatment and Treatment Planning).(b) Director of psychiatric services. A hospital shall have a director of psychiatric services who directs, monitors, and evaluates the psychiatric services provided.(c) Qualifications of director of psychiatric services. In accordance with Texas Health and Safety Code §577.008, the director of psychiatric services shall be a physician who:(1) is certified in psychiatry by the American Board of Psychiatry and Neurology or by the American Osteopathic Board of Psychiatry and Neurology; or(2) has three years of experience as a physician in psychiatry in a "mental hospital" as defined in Texas Health and Safety Code §571.003.(d) Treating physician. A hospital shall assign a treating physician to a patient and document such assignment in the patient's medical record at the time the patient is admitted.(e) Physical examination.(1) A physician shall:(A) review written findings of a physical examination of the patient conducted by another physician no more than seven days before the patient's admission; or(B) conduct a physical examination of the patient.(2) The physical examinations described in paragraph (1) of this subsection shall include a neurological screening and, if indicated, a comprehensive neurological examination.(f) Psychiatric evaluation. A physician shall conduct an initial psychiatric evaluation of a patient. The results of the initial evaluation shall include:(1) a description of the patient's medical history;(2) a determination of the patient's mental status;(3) a description of the onset of the patient's mental illness, any substance-related or addictive disorder, and the circumstances leading to admission;(4) an estimation of the patient's intellectual functioning, memory functioning, and orientation;(5) a description of the patient's strengths and limitations; and(6) the diagnoses of the patient's mental illness and, if applicable, any substance-related and addictive disorders.(g) Re-evaluation. A physician shall re-evaluate a patient:(1) once a day for five of the first seven days after the initial psychiatric evaluation described in subsection (f) of this section is conducted and once a week thereafter; and(2) as clinically indicated.(h) Provision of medical services. A hospital shall provide:(1) medical services to a patient in response to an emergency medical condition in accordance with the plan required by §568.41 of this chapter (relating to Responding to an Emergency Medical Condition); and(2) other medical services, as needed by the patient, or transfer the patient to a health care entity that can provide the medical services in accordance with the following, as applicable:(A) §510.43 of this title (relating to Patient Transfer Policy), or a transfer agreement made in accordance with §510.61 of this title (relating to Patient Transfer Agreements); or(B) 25 TAC §133.44 (relating to Hospital Patient Transfer Policy), or a transfer agreement made in accordance with 25 TAC §133.61 (relating to Hospital Patient Transfer Agreements).(i) Availability of physicians. At least one physician shall always:(1) be physically present at the hospital to provide medical services to a patient; or(2) be available to staff members by telephone, radio, or audiovisual telecommunication to provide medical consultation. Source Note: The provisions of this §568.62 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.62 Medical Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205092 03/12/2026 (a) Nursing services in treatment plan. A hospital shall provide nursing services to a patient in accordance with a treatment plan developed in accordance with §568.61 of this subchapter (relating to Inpatient Mental Health Treatment and Treatment Planning).(b) Organization of nursing staff. The hospital shall have a written description of the organizational hierarchy and responsibilities of the nursing staff.(c) Director of psychiatric nursing (DPN). A hospital shall have a DPN who:(1) has administrative authority over the nursing staff;(2) directs, monitors, and evaluates the nursing services provided;(3) for a hospital licensed under Texas Health and Safety Code Chapter 577 and Chapter 510 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units), reports directly to the administrator; and(4) for an identifiable mental health services unit in a hospital licensed under Texas Health and Safety Code Chapter 241, and 25 TAC Chapter 133 (relating to Hospital Licensing), reports directly to the chief nursing officer as described in 25 TAC §133.41 (relating to Hospital Functions and Services) or reports directly to a registered nurse (RN) who reports directly to the chief nursing officer.(d) Qualifications of DPN. The DPN shall be:(1) an RN with a master's degree in psychiatric-mental health from a nursing education program accredited by an organization recognized by the U.S. Commission of Education and Council for Higher Education Accreditation as an accreditation agency, such as the National League for Nursing or the Commission on Collegiate Nursing Education;(2) an RN with a bachelor's degree in nursing and a master's degree in a health-related field from an accredited college or university and have three years of experience as a full-time employee or contractor (or its equivalent as a part-time employee or contractor) as an RN in a hospital; or(3) an RN with a bachelor's degree in nursing and:(A) have three years of experience as a full-time employee or contractor (or its equivalent as a part-time employee or contractor) as an RN in a hospital; and(B) receive four hours per month of clinical consultation from an RN with:(i) a master's degree in psychiatric-mental health from a nursing education program accredited by an organization recognized by the U.S. Commission of Education and Council for Higher Education Accreditation as an accreditation agency, such as the National League for Nursing or the Commission on Collegiate Nursing Education; or(ii) a bachelor's degree in nursing and a master's degree in a health-related field from an accredited college or university.(e) Assessment. An RN shall conduct and complete an initial comprehensive nursing assessment of a patient within eight hours of the patient's admission.(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this section, is conducted.(g) Staffing plan.(1) The DPN shall develop and implement a written staffing plan that:(A) describes the number of RNs, licensed vocational nurses (LVNs), and unlicensed assistive personnel (UAPs) on each unit for each shift;(B) provides for at least one RN to be physically present and on-duty at all times on each unit when a patient is present on the unit;(C) if the hospital has only one unit, in addition to the RN required by subparagraph (B) of this paragraph, provides for at least two staff members who provide direct patient care to be physically present and on-duty at all times on the unit when a patient is present on the unit; and(D) provides for an adequate number of registered nurses on each unit to supervise all UAPs.(2) The staffing plan described in paragraph (1) of this subsection shall be based on the following factors:(A) the number of patients;(B) the characteristics of the patients, including the intensity of the patient's emotional, mental, and medical needs;(C) the anticipated admissions, discharges and transfers;(D) the architecture of the unit, including geographic dispersion of patients, arrangement of the unit and surveillance and communication technology;(E) the expertise of the nursing staff;(F) the nursing staff's familiarity with the patients;(G) nursing staff continuity and cohesion;(H) the amount of time required by the nursing staff to perform administrative activities; and(I) recommendations of the advisory committee regarding the adequacy of the staffing plan made in accordance with §568.144(b)(3) of this chapter (relating to Advisory Committee for Nurse Staffing).(3) The DPN shall document the DPN's determinations made about each factor described in paragraph (2) of this subsection, at the time the staffing plan is developed and when the staffing plan is revised based on a change in such factors.(4) A hospital shall retain the staffing plan and the documentation required by paragraph (3) of this subsection, for two years after such documentation is created.(5) The DPN shall revise the staffing plan, as necessary.(6) The DPN shall report to the advisory committee established in accordance with §568.144 of this chapter (relating to Advisory Committee for Nurse Staffing) any variance between the number of staff members specified in the staffing plan and the actual number of staff members on duty.(h) Process for reporting concerns regarding staffing plan.(1) A hospital shall develop and implement a process for RNs and LVNs to report concerns regarding the adequacy of the staffing plan to the advisory committee established in accordance with §568.144 of this chapter.(2) A hospital shall not retaliate against a nurse for reporting a concern to the advisory committee.(i) Orientation of nursing staff.(1) A hospital shall provide orientation to a nursing staff member when the staff member is initially assigned to a unit on either a temporary or long-term basis. The orientation shall include a review of:(A) the location of equipment and supplies on the unit;(B) the staff member's responsibilities on the unit;(C) relevant information about patients on the unit;(D) relevant schedules of staff members and patients; and(E) procedures for contacting the staff member's supervisor.(2) A hospital shall document the provision of orientation to nursing staff.(j) Verification of licensure. A hospital shall verify that a member of the nursing staff for whom a license is required has a valid license at the time the staff member assumes responsibilities at the hospital and maintains the license throughout the staff member's employment or association with the hospital.(k) Mandatory overtime. A hospital shall develop and implement a policy regarding the use of mandatory overtime by the nursing staff. The policy shall require:(1) documentation of the justification for the use of mandatory overtime;(2) monitoring and evaluation of the use of mandatory overtime; and(3) development of a plan to reduce or eliminate the use of mandatory overtime.(l) The hospital shall establish a nursing peer review committee to conduct nursing peer review, as required by Texas Occupations Code Chapter 303. Source Note: The provisions of this §568.63 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.63 Nursing Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205094 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205094 03/12/2026 (a) Social services in treatment plan. A hospital shall provide social services to a patient in accordance with a treatment plan developed in accordance with §568.61 of this subchapter (relating to Inpatient Mental Health Treatment and Treatment Planning).(b) Director of social services. A hospital shall have a director of social services who directs, monitors, and evaluates the social services provided.(c) Qualifications of director of social services. The director of social services shall:(1) be a licensed master social worker; or(2) be a licensed social worker who is enrolled in a graduate program accredited by the Council on Social Work Education, receiving eight hours per month of clinical consultation from a licensed master social worker with three years of experience in the provision of psychiatric social work, and summarizing, in writing, the content of each consultation with the licensed master social worker including clinical issues discussed and recommendations made by the licensed master social worker regarding such issues.(d) Assessment.(1) A licensed master social worker, licensed social worker, licensed professional counselor, licensed psychologist, psychological associate, or licensed marriage and family therapist shall conduct a social services assessment of a patient.(2) If a licensed social worker, licensed professional counselor, licensed psychologist, psychological associate, or licensed marriage and family therapist conducts the social services assessment, the results of the assessment shall be signed by the licensed master social worker evidencing approval of such results. Source Note: The provisions of this §568.64 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.64 Social Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205095 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205095 03/12/2026 (a) Therapeutic activities in treatment plan. If ordered by the patient's treating physician, a hospital shall provide therapeutic activities to the patient in accordance with a treatment plan developed in accordance with §568.61 of this subchapter (relating to Inpatient Mental Health Treatment and Treatment Planning).(b) Assessment.(1) If ordered by the patient's treating physician, an occupational therapist, a therapeutic recreation specialist, or a staff member under the supervision of an occupational therapist or a therapeutic recreation specialist shall conduct a therapeutic activities assessment of the patient.(2) The assessment shall include an evaluation of the patient in the following domains:(A) sensory;(B) cognitive;(C) social;(D) physical;(E) emotional; and(F) leisure.(3) If a staff member under the supervision of an occupational therapist or a therapeutic recreation specialist conducts the therapeutic activities assessment, the results of the assessment shall be signed by the occupational therapist or a therapeutic recreation evidencing approval of such results.(c) Qualified staff members. A hospital shall have qualified staff members who are available to provide the therapeutic activities necessary to address the problems identified by a patient's therapeutic activities assessment. Source Note: The provisions of this §568.65 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.65 Therapeutic Activities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205096 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205096 03/12/2026 (a) Psychological services in treatment plan. If ordered by a patient's treating physician, a hospital shall provide psychological services to the patient in accordance with a treatment plan developed in accordance with §568.61 of this subchapter (relating to Inpatient Mental Health Treatment and Treatment Planning).(b) Assessment. If ordered by a patient's treating physician, a licensed psychologist shall conduct a psychological assessment of the patient. Source Note: The provisions of this §568.66 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.66 Psychological Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205097 03/12/2026 (a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by taking the following measures:(1) modifying the hospital environment based on the patient's needs, including:(A) providing furnishings that do not present safety hazards to the patient;(B) securing or removing objects that are hazardous to the patient; and(C) installing any necessary safety devices;(2) monitoring the patient at the level of monitoring most recently specified in the patient's medical record; and(3) making roommate assignments and other decisions affecting the interaction of the patient with other patients, based on patient needs and vulnerabilities.(b) Levels of monitoring. A hospital shall:(1) define each level of monitoring in the hospital's policies and procedures, including a description of the responsibilities of staff members for each level of monitoring;(2) implement the level of monitoring ordered by the physician, or physician-delegated physician's assistant or advanced practice registered nurse, based on the individual's needs; and(3) document the clinical justification for any level of monitoring.(c) Separation of patients by age. A provider that delivers mental health community services to children and adolescents in group settings (e.g., residential, day programs, group therapy, partial hospitalization, and inpatient) shall separate children and adolescents from adults. The provider shall further separate children from adolescents according to age and developmental needs, unless there is a clinical or developmental justification in the medical record. Source Note: The provisions of this §568.67 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS D SERVICE REQUIREMENTS §568.67 Protection of a Patient https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205100 03/12/2026 (a) Involvement of staff, patient, and legally authorized representative (LAR), when applicable, in planning activities.(1) Following the admission of a patient to a hospital, the hospital shall conduct discharge planning with the patient and LAR, as well as the LMHA or LBHA if the patient is in a psychiatric inpatient bed funded under a contract with HHSC or operated by or funded under a contract with a LMHA or LBHA.(2) Discharge planning shall involve the interdisciplinary treatment team (IDT), which includes the patient and LAR, as well as the LMHA or LBHA if the patient is in a psychiatric inpatient bed funded under a contract with HHSC or operated by or funded under a contract with a LMHA or LBHA.(3) Discharge planning shall include, at a minimum, the following activities:(A) the patient's IDT recommending services and supports needed by the patient after discharge, including the placement after discharge;(B) qualified staff members arranging for the services and supports recommended by the patient's IDT;(C) qualified staff members counseling the patient, the patient's LAR, when applicable, and as appropriate, the patient's caregivers, to prepare them for post-discharge care; and(D) Preadmission Screening and Resident Review (PASRR) as required by paragraph (5) of this subsection.(4) The discharge plan shall consist of:(A) a description of the individual's living arrangement after discharge that reflects the individual's preferences, choices, and available community resources;(B) arrangements and referrals for the available and accessible services and supports agreed upon by the individual or LAR recommended in the individual's discharge plan;(C) a written description of recommended clinical and non-clinical services and supports the individual may receive after discharge. The hospital documents arrangements and referrals for the services and supports recommended upon discharge in the discharge plan;(D) a description of problems identified at discharge, including any issues that may disrupt the individual's stability in the community;(E) the individual's goals, strengths, interventions, and objectives as stated in the individual's discharge plan in the hospital;(F) comments or additional information;(G) a final diagnosis based on the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association;(H) the names, contact information, and addresses of providers to whom the individual will be referred for any services or supports after discharge; and(I) in accordance with Texas Health and Safety Code §574.081, a description of:(i) the types and amount of medication the individual needs after discharge until the individual is evaluated by a physician; and(ii) the person or entity responsible for providing and paying for the medication.(5) Screening and evaluation before patient discharge from hospital. In accordance with 42 CFR Part 483, Subpart C (relating to Requirements for Long Term Care Facilities) and the rules set forth in Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)), all patients who are being considered for discharge from the hospital to a nursing facility shall be screened, and if appropriate, evaluated, before discharge by the hospital and admission to the nursing facility to determine whether the patient may have a mental illness, intellectual disability, or developmental disability. If the screening indicates that the patient has a mental illness, intellectual disability, or developmental disability, the hospital shall contact and arrange for the local mental health authority designated pursuant to Texas Health and Safety Code §533.035, to conduct before hospital discharge an evaluation of the patient in accordance with the applicable provisions of the PASRR rules. The purpose of PASRR is:(A) to ensure that placement of the patient in a nursing facility, is necessary;(B) to identify alternate placement options, when applicable; and(C) to identify specialized services that may benefit the person with a diagnosis of mental illness, intellectual disability, or developmental disability.(b) Discharge summary. The patient's treating physician shall prepare a written discharge summary that includes:(1) a description of the patient's treatment at the hospital and the response to that treatment;(2) a description of the patient's condition at discharge;(3) a description of the patient's placement after discharge;(4) a description of the services and supports the patient will receive after discharge;(5) a final diagnosis based on the DSM;(6) a description of the amount of medication the patient will need until the patient is evaluated by a physician; and(7) in accordance with Texas Health and Safety Code §574.081(c) and (h), for involuntary patients admitted under an order described in §568.24(a)(2) of this chapter (related to Admission of an Individual under an Order of Protective Custody, for Court-ordered Inpatient Mental Health Services, or Under Order for Commitment or Order for Placement), the name of the individual or entity responsible for providing and paying for the medication referenced in paragraph (6) of this subsection, which is not required to be the hospital.(c) Documentation of refusal. If it is not feasible for any of the activities listed in subsection (a)(3) of this section to be performed because the patient, the patient's LAR, when applicable, or the patient's caregivers refuse to participate in the discharge planning, the circumstances of the refusal shall be documented in the patient's medical record. Source Note: The provisions of this §568.81 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS E DISCHARGE §568.81 Discharge Planning https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205101 03/12/2026 (a) Discharge notice to family or legally authorized representative (LAR).(1) In accordance with Texas Health and Safety Code §576.007, before discharging a patient who is an adult, a hospital shall make a reasonable effort to notify the patient's family of the discharge, if the patient grants permission for the notification.(2) Except as provided by 42 CFR Part 2 and subsection (b) of this section, before discharging a patient who is at least 16 years of age, a hospital shall make a reasonable effort to notify the patient's LAR of the discharge.(3) Except as provided by subsection (b) of this section, before discharging a patient who is younger than 16 years of age, a hospital shall notify the patient's LAR of the discharge.(b) Disclosure harmful to patient. As permitted by 45 C.F.R. §164.524 and Texas Health and Safety Code §611.0045(b), a hospital may deny a patient's LAR access to any portion of the patient's record if the hospital determines that the disclosure of such portion would be reasonably likely to endanger the life or physical safety of the patient or another person.(c) Release of minors. Except as required by §568.84(e) of this subchapter (relating to Discharge of an Involuntary Patient), upon discharge, the hospital may release a minor younger than 16 years of age only to the minor's LAR or the LAR's designee.(d) Notice of protection and advocacy system. Upon discharge, the hospital shall provide the patient with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system of the state of Texas, as required by Texas Health and Safety Code §576.008. Source Note: The provisions of this §568.82 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS E DISCHARGE §568.82 Discharge Notices and Release of Minors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205098 03/12/2026 (a) Request for discharge. If a hospital is informed that a voluntary patient desires to leave the hospital or a voluntary patient or the patient's legally authorized representative (LAR), when applicable, requests that the patient be discharged, the hospital shall, in accordance with Texas Health and Safety Code §572.004:(1) inform the patient or the patient's LAR that the request must be in writing and signed, timed, and dated by the requestor; and(2) if necessary, and as soon as possible, assist the patient in creating a written request for discharge and present it to the patient for the patient's signature.(b) Responding to a written request for discharge. If a written request for discharge from a voluntary patient or the patient's LAR, when applicable, is made known to a hospital, the hospital shall:(1) within four hours after the request is made known to the hospital, notify the treating physician or, if the treating physician is not available during that time, notify another physician who is a hospital staff member of the request;(2) file the request in the patient's medical record; and(3) if the request is from a patient admitted under §568.22(a)(3)(D) of this chapter (relating to Voluntary Admission), notify the patient's LAR of the request, except as provided by 42 CFR Part 2.(c) Discharge or examination. In accordance with Texas Health and Safety Code §572.004(c) and (d), if the physician who is notified in accordance with subsection (b)(1) of this section:(1) does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, a hospital shall discharge the patient within the four-hour time period described in subsection (b)(1) of this section; or(2) has reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician shall examine the patient as soon as possible within 24 hours after the request for discharge is made known to the hospital.(d) Discharge if not examined within 24 hours or if criteria not met.(1) If a patient whom a physician believes may meet the criteria for court-ordered inpatient mental health services or emergency services is not examined within 24 hours after the request for discharge is made known to the hospital, the hospital shall discharge the patient.(2) In accordance with Texas Health and Safety Code §572.004(d), if the physician conducting the examination described in subsection (c)(2) of this section determines that the patient does not meet the criteria for court-ordered inpatient mental health services or emergency detention, the hospital shall discharge the patient upon completion of the examination.(e) Discharge or filing application if criteria met. In accordance with Texas Health and Safety Code §572.004(d), if the physician conducting the examination described in subsection (c)(2) of this section determines that the patient meets the criteria for court-ordered inpatient mental health services or emergency detention, the hospital shall, by 4:00 p.m. on the next business day:(1) file an application for court-ordered inpatient mental health services or emergency detention and obtain a court order for further detention of the patient; or(2) discharge the patient.(f) Notification by physician. In accordance with Texas Health and Safety Code §572.004(d), if the hospital intends to detain a patient to file an application and obtain a court order for further detention of the patient, a physician shall:(1) notify the patient of such intention; and(2) document the reasons for the decision to detain the patient in the patient's medical record.(g) Withdrawal of request for discharge. In accordance with Texas Health and Safety Code §572.004(f), a hospital is not required to complete the discharge process described in this section if the patient makes a written statement to withdraw the request for discharge.(h) Discharge of patients receiving court-ordered mental health services. In accordance with Texas Health and Safety Code §574.81 (relating to Continuing Care Plan Before Furlough or Discharge), for any patient residing in an psychiatric inpatient bed funded under a contract with HHSC or operated by or funded under a contract with a local mental health authority (LMHA) or a behavioral mental health authority (LBHA), the physician responsible for the patient's treatment is required to inform the LMHA/LBHA prior to the discharge must include them in planning the discharge of a patient. The plan must address:(1) the patient's mental health and physical needs;(2) the need for outpatient mental health services following furlough or discharge, if applicable; and(3) the need for sufficient psychoactive medications for the patient until the patient sees a physician, not to exceed seven days after discharge. Source Note: The provisions of this §568.83 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS E DISCHARGE §568.83 Discharge of a Voluntary Patient Requesting Discharge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205099 03/12/2026 (a) Discharge from emergency detention.(1) Except as provided by §568.26 of this chapter (relating to Voluntary Treatment Following Involuntary Admission), and in accordance with Texas Health and Safety Code §573.023(b) and §573.021(b), a hospital shall immediately discharge a patient under emergency detention if either of the following occurs:(A) the administrator or the administrator's designee determines, based on a physician's determination, that the patient no longer meets the criteria described in §568.23(c)(1) of this chapter (relating to Emergency Detention); or(B) except as provided in paragraphs (2) and (3) of this subsection, 48 hours elapse from the time the patient was presented to the hospital and the hospital has not obtained a court order for further detention of the patient.(2) In accordance with Texas Health and Safety Code §573.021(b), if the 48-hour period described in paragraph (1)(B) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the patient was presented to the hospital, the patient may be detained until 4:00 p.m. on such business day.(b) Discharge under Order of Protective Custody. Except as provided by §568.26 of this chapter and in accordance with Texas Health and Safety Code §574.028, a hospital shall immediately discharge a patient under an Order of Protective Custody if any of the following occurs:(1) the administrator or the administrator's designee determines that, based on a physician's determination, the patient no longer meets the criteria described in Texas Health and Safety Code §574.022(a);(2) the administrator or the administrator's designee does not receive notice that the patient's continued detention is authorized after a probable cause hearing held within the time prescribed by Texas Health and Safety Code §574.025(b);(3) a final order for court-ordered inpatient mental health services has not been entered within the time prescribed by Texas Health and Safety Code §574.005; or(4) an order to release the patient is issued in accordance with Texas Health and Safety Code §574.028(a).(c) Discharge under court-ordered inpatient mental health services.(1) Except as provided by §568.26 of this chapter, and in accordance with Texas Health and Safety Code §574.085 and §574.086(a), a hospital shall immediately discharge a patient under a temporary or extended order for inpatient mental health services if either of the following occurs:(A) the order for inpatient mental health services expires; or(B) the administrator or the administrator's designee determines that, based on a physician's determination, the patient no longer meets the criteria for court-ordered inpatient mental health services.(2) In accordance with Texas Health and Safety Code §574.086(b), before discharging a patient in accordance with paragraph (1) of this subsection, the administrator or administrator's designee shall consider whether the patient should receive court-ordered outpatient mental health services in accordance with a modified order described in Texas Health and Safety Code §574.061.(d) Discharge under Texas Code of Criminal Procedure order for commitment. A patient admitted under an order for commitment issued in accordance with the Texas Code of Criminal Procedure Chapter 46B or 46C may only be discharged in accordance with the applicable provisions in Chapter 46B or 46C.(e) Discharge under Texas Family Code order for placement. A patient admitted under an order for placement issued in accordance with Texas Family Code Chapter 55 shall be discharged in accordance with the Texas Family Code Chapter 55.(f) Discharge planning shall involve the interdisciplinary treatment team, which includes the patient and LAR, as well as the LMHA or LBHA if the patient is in a psychiatric inpatient bed funded under a contract with HHSC or operated by or funded under a contract with a LMHA or LBHA. Source Note: The provisions of this §568.84 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS E DISCHARGE §568.84 Discharge of an Involuntary Patient https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205102 03/12/2026 (a) Medical record. A hospital shall maintain a medical record for a patient. The medical record shall include, at a minimum:(1) documentation of whether the patient is a voluntary patient, on emergency detention, or under a court order, including the physician or court order, as appropriate;(2) any applications for admission, court orders for admission, or notices of detention;(3) documentation of the reasons the patient, legally authorized representative (LAR), family members, or other caregivers state that the patient was admitted to the hospital;(4) justification for each mental illness diagnosis and any substance-related or addictive disorder diagnosis;(5) the level of monitoring assigned and implemented in accordance with §568.25 of this chapter (relating to Monitoring Upon Admission) and any changes to such level before the implementation of the patient's treatment plan;(6) the patient's treatment plan;(7) the name of the patient's treating physician;(8) the names of the members of the patient's interdisciplinary treatment team (IDT), if required by the patient's length of stay;(9) written findings of the physical examination described in §568.62(e)(1)(A) or (B) of this chapter (relating to Medical Services);(10) written findings of:(A) the psychiatric evaluation described in §568.62(f) of this chapter; and(B) the assessments described in §568.63(e) of this chapter (relating to Nursing Services), §568.64(d) of this chapter (relating to Social Services), §568.65(b) of this chapter (relating to Therapeutic Activities), and §568.66(b) of this chapter (relating to Psychological Services); and(C) any other assessment of the patient conducted by a staff member;(11) the progress notes for the patient as described in subsection (b) of this section;(12) documentation of the monitoring of the patient by the staff members responsible for such monitoring, including observations of the patient at pre-determined intervals;(13) documentation of the discharge planning activities required by §568.81(a)(3) of this chapter (relating to Discharge Planning);(14) the discharge summary as required by §568.81(b) of this chapter;(15) the estimate of charges required to be made part of the record by Texas Health and Safety Code §164.009;(16) medication consent required by Texas Health and Safety Code §576.025;(17) medication administration records; and(18) evidence that the patient or LAR received and signed a copy of the patients' rights booklet explaining rights listed in the patient bill of rights, plus that it was explained orally or by other means calculated to communicate these rights to a patient. This is specifically required by Texas Health and Safety Code §321.002(g)(2) to be included in the patient's record.(b) Progress notes. The progress notes referenced in subsection (a)(11) of this section must be documented in accordance with this subsection.(1) The appropriate members of the patient's IDT shall make written notes of the patient's progress to include, at a minimum:(A) documentation of the patient's response to treatment provided under the treatment plan;(B) documentation of the patient's progress toward meeting the goals listed in the patient's treatment plan; and(C) documentation of the findings of any re-evaluation or reassessment conducted by a staff member.(2) Requirements regarding the frequency of making progress notes are as follows:(A) a physician shall document the findings of a re-evaluation described in §568.62(g) of this chapter at the time each re-evaluation is conducted; and(B) a registered nurse shall document the findings of a reassessment described in §568.63(f) of this chapter at the time each reassessment is conducted. Source Note: The provisions of this §568.101 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS F DOCUMENTATION §568.101 Content of Medical Record https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205103 03/12/2026 (a) Staff member training shall be in accordance with §301.331 of this title (relating to Competency and Credentialing).(1) A hospital administrator, or administrator's designee, shall:(A) ensure that services are provided by staff members who are operating within their scope of their license, credentialing, job description, or contract specification, and in accordance with applicable state law and rule, including 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services);(B) define competency-based expectations for each hospital staff position and ensure each staff member receives initial training before the staff member assumes responsibilities required by the hospital and annually throughout the staff member's employment with the hospital;(C) provide hospital staff live, interactive, instructor-led electronic or face-to-face training competency-based training; and(D) require all staff members to demonstrate required competencies delineated in §301.331(a)(3)(A) of this title, including:(i) identifying, preventing, and reporting abuse and neglect of patients and unprofessional or unethical conduct in the hospital, as defined by Texas Health and Safety Code §161.131 (relating to Definitions);(ii) identifying, preventing, and reporting abuse, neglect, and exploitation as follows, in accordance with Texas Health and Safety Code §161.133 (relating to In-service Training):(I) residential staff must receive eight hours of training;(II) training must be conducted in person, and not through teleconferencing, web-based video conferencing, or other technology;(III) a hospital must ensure all new employees receive training on abuse, neglect, and exploitation; and(IV) a hospital may provide abuse, neglect, and exploitation training to staff or may choose to contract with an outside entity to provide the training;(iii) preserving and protecting dignity and rights of a patient in accordance with 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services); and(iv) preserving and protecting confidentiality of a patient's information in accordance with Texas Health and Safety Code Chapter 611 or Chapter 241, Subchapter G, as applicable, 42 CFR Part 2, and 45 CFR Parts 160 and 164.(2) All registered nurses (RNs), licensed vocational nurses (LVNs), and unlicensed assistive personnel (UAP) shall receive training in:(A) monitoring for patient safety in accordance with §568.67 of this chapter (relating to Protection of a Patient);(B) infection control in accordance with §510.41(d) of this title (relating to Facility Functions and Services); and(C) the hospital's mandatory overtime policy required by §568.63(k) of this chapter (relating to Nursing Services).(3) An RN and LVN shall receive training in the process for reporting concerns regarding the adequacy of the staffing plan, as described in §568.63(h) of this chapter.(4) A staff member routinely providing treatment to, working with, or providing consultation about a patient who is younger than 18 years of age shall receive training in the aspects of growth and development (including physical, emotional, cognitive, educational and social) and the treatment needs of patients in the following age groups:(A) early childhood (1-5 years of age);(B) late childhood (6-13 years of age); and(C) adolescent (14-17 years of age).(5) A staff member routinely providing treatment to, working with, or providing consultation about a patient diagnosed with co-occurring psychiatric and substance-related disorders (COPSD) shall receive training in substance-related and addictive disorders.(6) A staff member routinely providing treatment to, working with, or providing consultation about a geriatric patient shall receive training in the social, psychological, and physiological changes associated with aging.(7) In accordance with Texas Health and Safety Code §572.0025(e), a pre-admission screening professional (PASP) shall receive at least eight hours of pre-admission screening and intake training, as described in subsection (c) of this section.(8) In accordance with Texas Health and Safety Code §572.0025(e), a staff member whose responsibilities include conducting the hospital's intake process for a patient shall receive at least eight hours of pre-admission screening and intake training, as described in subsection (c) of this section.(9) A staff member who may initiate an involuntary intervention shall receive training in and demonstrate competency in performing such interventions in accordance with 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Services) prior to performing such interventions.(b) A staff member providing direct patient care shall maintain certification in a course developed by the American Heart Association, the American Red Cross, or the Health and Safety Institute in recognizing and caring for breathing and cardiac emergencies. The course shall teach the following skills appropriate to the age of the hospital's patients:(1) rescue breathing, with and without devices;(2) airway obstruction;(3) cardiopulmonary resuscitation; and(4) use of an automated external defibrillator.(c) Pre-admission screening and intake training. The pre-admission screening and intake training required by subsections (a)(7) and (8) of this section shall provide instruction to staff members regarding:(1) assessing, interviewing, and diagnosing an individual with a mental illness and an individual diagnosed with COPSD;(2) obtaining relevant information about the patient, including information about finances, insurance benefits and advance directives;(3) explaining, orally and in writing, the patient's rights described in 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(4) explaining, orally and in writing, the hospital's services and treatment as they relate to the patient;(5) informing the patient in writing of the existence, telephone number, and address of the protection and advocacy system of the state of Texas; and(6) determining whether the patient comprehends the information provided in accordance with paragraphs (3) - (5) of this subsection.(d) Frequency of training. A hospital shall provide the training described in subsection (a) of this section, periodically, as follows.(1) A staff member shall receive the patient rights training required by subsection (a)(1)(D)(iii) of this section:(A) before assuming responsibilities at the hospital; and(B) annually throughout the staff member's employment or association with the hospital.(2) A staff member shall receive the training in identifying, preventing, and reporting abuse and neglect of patients and unprofessional or unethical conduct required by subsection (a)(1)(D)(i) of this section annually throughout the staff member's employment or association with the hospital, as set forth in Texas Health and Safety Code §161.133.(3) A staff member shall receive the training required by subsections (a)(1)(D) and (a)(2) - (5) of this section:(A) before assuming responsibilities at the hospital; and(B) annually throughout the staff member's employment or association with the hospital.(4) A staff member shall have the certification required by subsection (b) of this section:(A) before assuming responsibilities at the hospital; or(B) not later than 30 days after the staff member is hired by the hospital if another staff member who has such certification is physically present and on-duty on the same unit on which the uncertified staff member is on-duty.(5) A pre-admission screening professional (PASP) shall receive the training required by subsection (a)(7) of this section:(A) before the PASP conducting a pre-admission screening; and(B) annually throughout the PASP's employment or association with the hospital.(6) A staff member shall receive the training required by subsection (a)(8) of this section:(A) before conducting the intake process; and(B) annually throughout the staff member's employment or association with the hospital.(7) A staff member shall receive the training required by subsection (a)(9) of this section at the intervals described in 25 TAC Chapter 415, Subchapter F .(e) Documentation of training.(1) A hospital shall document that a staff member has successfully completed the training described in subsection (a) of this section including:(A) the date of the training;(B) the length of the training session; and(C) the name of the instructor.(2) A hospital shall maintain certification or other evidence issued by the American Heart Association, the American Red Cross or the Health and Safety Institute that a staff member has successfully completed the training described in subsection (b) of this section.(f) Performance in accordance with training. A staff member shall perform the staff member's responsibilities in accordance with the training and certification required by this section. Source Note: The provisions of this §568.121 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS G STAFF DEVELOPMENT §568.121 Staff Member Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205104 03/12/2026 (a) Scope and content of program. A hospital shall develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The program shall:(1) reflect the complexity of the hospital's organization and services;(2) involve all the hospital's services;(3) specify the frequency and detail of data collected; and(4) focus on high-risk, high-volume, and problem-prone areas in the hospital.(b) Approval by governing body. The hospital's governing body shall approve the hospital's quality assessment and performance improvement program.(c) Staff member participation. The director of psychiatric nursing (DPN), the director of psychiatric services, and other appropriate staff members shall participate in the development and implementation of the quality assessment and performance improvement program.(d) Quality assessment and performance improvement program activities.(1) As part of its quality assessment and performance improvement activities, a hospital shall collect and aggregate data to:(A) monitor the effectiveness and safety of services and the quality of care; and(B) identify opportunities for improvement and changes that will lead to improvement.(2) The hospital shall collect and aggregate all data, on an ongoing basis, for each of the following performance indicators at a minimum:(A) sentinel events;(B) allegations of abuse and neglect, as defined in §510.46 of this title (relating to Abuse and Neglect Issues);(C) findings of abuse and neglect made by HHSC, in accordance with §510.46 of this title (relating to Abuse and Neglect Issues);(D) violations of patient rights described in 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(E) nosocomial infections;(F) injuries of patients;(G) medication errors;(H) unauthorized departures of patients;(I) deaths of patients;(J) surveys of patients, patient's families, and legally authorized representatives (LAR) regarding satisfaction with hospital services; and(K) complaints and grievances made by patients, patient's families, and LARs.(3) The hospital shall analyze the aggregated data, at least quarterly, to assess the need for performance improvement.(4) When a need for performance improvement is identified, the hospital shall develop and implement an action plan to address the identified need.(5) The hospital shall evaluate the success of the action plan to determine if the positive outcomes are achieved and sustained.(6) If the hospital determines that the positive outcomes have not been achieved or sustained, the hospital shall modify the action plan and re-evaluate its implementation until the outcomes are achieved and sustained.(e) Evidence of program. The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including HHSC, the Centers for Medicare and Medicaid Services, or the accrediting organization. Source Note: The provisions of this §568.141 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS H PERFORMANCE IMPROVEMENT §568.141 Quality Assessment and Performance Improvement Program https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205105 03/12/2026 A hospital shall develop and implement written procedures to identify, report, and investigate sentinel events. The procedures shall include:(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least one hour after a staff member becomes aware of the incident;(2) a requirement that, within 24 hours of a sentinel event being reported, the administrator designate a committee to investigate the sentinel event that includes a physician, a Registered Nurse (RN), and any other staff members determined appropriate by the administrator; and(3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document:(A) the cause or causes of the sentinel event;(B) whether the cause or causes are random or a pattern of error in the hospital's processes or systems;(C) any improvements to the hospital's processes or systems that may reduce the occurrence of similar incidents in the future;(D) how such improvements will be implemented including a timeline for implementation;(E) the staff members responsible for such implementation; and(F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents. Source Note: The provisions of this §568.142 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS H PERFORMANCE IMPROVEMENT §568.142 Reporting and Investigating Sentinel Events https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205106 03/12/2026 A hospital shall develop and implement a written plan to evaluate the effectiveness of any plan of correction the hospital submits to an external review entity, including HHSC, the Centers for Medicare and Medicaid Services, or the accrediting organization. Source Note: The provisions of this §568.143 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS H PERFORMANCE IMPROVEMENT §568.143 Response to External Reviews https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205107 03/12/2026 (a) Advisory committee members.(1) A hospital shall establish an advisory committee that meets the requirements of Texas Health and Safety Code Chapter 161, Subchapter D (relating to Medical Committees, Medical Peer Review Committees, and Compliance Officers).(2) At least one-third of the advisory committee shall be registered nurses (RNs) who provide direct patient care at least 50 percent of their work time and at least one of the RNs shall be from either infection control, quality assurance, or risk management.(3) For an identifiable mental health services unit in a hospital licensed under Texas Health and Safety Code Chapter 241 (relating to Hospitals) and 25 TAC Chapter 133 (relating to Hospital Licensing), the advisory committee may be the advisory committee required by 25 TAC §133.41 (relating to Hospital Functions and Services).(b) Advisory committee responsibilities. The advisory committee shall:(1) consider input from RNs and licensed vocational nurses (LVNs) regarding the adequacy of the staffing plan required by §568.63(g) of this chapter (relating to Nursing Services), including any concerns reported in accordance with the process required by §568.63(h) of this chapter;(2) consider variances between planned and actual numbers of staff members, as indicated by a report to the advisory committee by the director of psychiatric nursing (DPN) made in accordance with §568.63(g)(6) of this chapter;(3) make recommendations regarding the adequacy of the staffing plan required by §568.63(g) of this chapter;(4) evaluate, at least annually, the staffing plan required by §568.63(g) of this chapter including, in part, evaluating the aggregated data required by §568.141(d)(2) of this subchapter (relating to Quality Assessment and Performance Improvement Program) to determine if such data has a relationship to the adequacy of the staffing plan; and(5) document in the minutes of its meetings the actions required in paragraphs (1) - (4) of this subsection.(c) Confidentiality of advisory committee records. As provided by Texas Health and Safety Code §161.032, the records and proceedings of the advisory committee are confidential and not subject to disclosure under Texas Government Code Chapter 552 (the Texas Public Information Act), and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release. Source Note: The provisions of this §568.144 adopted to be effective May 27, 2021, 46 TexReg 3276. 1 HEALTH AND HUMAN SERVICES COMMISSION 568 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS H PERFORMANCE IMPROVEMENT §568.144 Advisory Committee for Nurse Staffing https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209114 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Assisted Living Facility (ALF)--A facility licensed under Texas Health and Safety Code, Chapter 247.(2) Client--For a Home and Community Support Services Agency (HCSSA), this term means a person receiving home health, hospice, or personal assistance services from a HCSSA.(3) Communicable disease--An infection transmissible by direct contact with an affected individual or the individual's body fluids, or by indirect means, or by direct or indirect contact with disease carriers.(4) Community health risk--A risk to the community of individuals or residents residing at a facility.(5) DSHS--Texas Department of State Health Services.(6) End-of-life visit--A personal visit between a visitor and an individual, resident, or client who is receiving hospice services; who is at or near the end of life, with or without receiving hospice services; or whose prognosis does not indicate recovery.(7) Essential caregiver--A family member, friend, guardian, volunteer, or other person designated for in-person visits by an individual, resident, or client or the individual's, resident's, or client's guardian or legally authorized representative (LAR). In case of conflict between an individual's, resident's, or client's selection and a guardian's selection on behalf of the individual, resident, or client, the guardian's selection prevails, in accordance with the terms of the guardianship. If an individual, resident, or client has no guardian and is unable to select an essential caregiver, the individual's, resident's, or client's LAR may select the essential caregiver.(8) Essential caregiver visit--An in-person visit between an individual, resident, or client and a designated essential caregiver.(9) Home and Community-based Services (HCS)--A program operated by HHSC as authorized by Centers for Medicare and Medicaid Services (CMS) in accordance with §1915(c) of the Social Security Act.(10) Home and Community Support Services Agency (HCSSA)--An agency licensed under Texas Health and Safety Code, Chapter 142, to provide home health, hospice, or personal assistance services.(11) Individual--A person enrolled in the Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID) program or HCS program. This definition applies to the ICF/IID and HCS programs only.(12) Intermediate Care Facility for Individuals with an Intellectual Disability or Related Condition (ICF/IID)--A facility licensed under Texas Health and Safety Code, Chapter 252, or exempt from licensure under Texas Health and Safety Code §252.003.(13) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual, resident, or client with regard to a matter described by this chapter, and who may be the parent of a minor child or the legal guardian of or surrogate decision maker for the individual, resident, or client.(14) Nursing facility (NF)--A facility licensed under Texas Health and Safety Code, Chapter 242.(15) Program provider--A contractor, as defined in 40 TAC §49.102 (relating to Definitions), that has a contract with the Texas Health and Human Services Commission (HHSC) to provide HCS program services, excluding a Financial Management Services Agency.(16) Public health emergency or disaster--A federal declaration of a public health emergency or a statewide or regional declaration of a public health disaster by the commissioner of DSHS under Chapter 81 of the Texas Health and Safety Code. A state or regional public health disaster can be declared only if the governor has declared a state of disaster for the same threat under Chapter 418 of the Texas Government Code.(17) Religious counselor--A person acting substantially in a pastoral or religious capacity to provide spiritual counsel to other persons.(18) Religious counselor visit--An in-person visit between a religious counselor and an individual or resident, that may occur at any time. A religious counselor visit must not be limited to an individual or resident at the end of life.(19) Residence--(A) for purposes of Subchapter H of this chapter (relating to Home and Community-Based Services), a host home or companion care, three-person, or four-person residence, as defined by the HCS billing guidelines, unless otherwise specified; or(B) a private home, a nursing facility, an assisted living facility, an ICF/IID facility, or an unlicensed independent living environment; or(C) for purposes of Subchapter D of this chapter (relating to Home and Community Support Services Agencies), a place where a client resides.(20) Resident--A person residing in a facility. This definition applies to NFs and ALFs only.(21) Resident representative--(A) A person chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage the resident's financial matters; or receive notifications regarding the resident; or(B) A person authorized by state or federal law (including agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social, or other personal information of the resident; manage the resident's financial matters; or receive notifications regarding the resident; or(C) A legally authorized representative; or(D) The court-appointed guardian of a resident. Source Note: The provisions of this §570.2 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER A INTRODUCTION §570.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209119 03/12/2026 (a) An assisted living facility's visitation policies and procedures may change during a public health emergency or disaster. Assisted living facility (ALF) visitation policies and procedures may not be more restrictive than guidance or directives issued by HHSC, DSHS, executive or local orders.(b) An ALF may not prohibit a resident from receiving in-person visitation with a religious counselor during a public health emergency or disaster on request from the resident, resident's legally authorized representative (LAR), or resident's family member unless a federal law or a federal agency requires the facility to prohibit in-person visitation during a public health emergency.(c) An ALF must adopt policies and procedures for in-person visitation with a religious counselor during a public health emergency or disaster. These policies and procedures:(1) must comply with the minimum health and safety requirements for in-person visitation with religious counselors developed by HHSC;(2) may include reasonable time, place, and manner restrictions on in-person visitation with religious counselors to:(A) mitigate the spread of a communicable disease; and(B) address the resident's medical condition;(3) must include special consideration for residents receiving end-of-life care; and(4) may condition in-person visitation with a religious counselor on the religious counselor's compliance with an ALF's guidelines, policies, and procedures for in-person visitation with a religious counselor.(d) An ALF must permit end-of-life visits and immediately communicate any changes in a resident's condition that would qualify the resident for end-of-life visits to the resident representative. Source Note: The provisions of this §570.111 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER B ASSISTED LIVING FACILITIES §570.111 Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209120 03/12/2026 (a) A resident or the resident's legally authorized representative (LAR), if the resident is unable, has the right to designate at least one essential caregiver.(b) An assisted living facility (ALF) must permit essential caregiver visits except as provided by subsection (j) of this section.(c) An ALF must allow essential caregiver visits to occur outdoors, in the resident's bedroom, or in another area designated for visitation by the ALF upon request by a resident or resident's LAR.(d) An ALF must develop a visitation policy that permits an essential caregiver to visit the resident for at least two hours each day.(e) An ALF must have procedures in place to enable physical contact between the resident and the essential caregiver.(f) The ALF must develop safety protocols for essential caregiver visits. The safety protocols may not be more stringent for essential caregivers than safety protocols for staff.(g) An ALF must obtain the signature of the essential caregiver certifying that the essential caregiver will follow the facility's safety protocols for essential caregiver visits.(h) An ALF may revoke an essential caregiver designation if the caregiver violates the facility's safety protocols or rules adopted under this chapter.(i) If an ALF revokes a person's designation as an essential caregiver under subsection (h) of this section:(1) the resident or the resident's LAR has the right to immediately designate another person as the essential caregiver;(2) within 24 hours after the revocation, the facility must inform the resident or the resident's legally authorized representative, in writing, of the right to appeal the revocation and the procedures for filing an appeal with the Texas Health and Human Services Commission (HHSC) Appeals Division by:(A) email at OCC_Appeals_ContestedCases@hhs.texas.gov; or(B) mail at HHSC Appeals Division, P.O. Box 149030, MC W-613, Austin, TX 78714-9030; and(3) the ALF must comply with a hearing officer's decision regarding an appeal of an essential caregiver revocation.(j) An ALF may petition HHSC to suspend in-person essential caregiver visits for no more than seven consecutive calendar days if in-person visitation poses a serious community health risk. An ALF may request an extension from HHSC to suspend in-person essential caregiver visitation beyond the ALF's original request, but HHSC may not approve an extension for a period that exceeds seven days and an ALF must separately request each extension. HHSC may deny the ALF's original request to suspend in-person essential caregiver visitation or the ALF's extension request if HHSC determines that in-person visitation does not pose a serious community health risk.(k) An ALF may not suspend in-person essential caregiver visits in a calendar year for a time period that:(1) is more than 14 consecutive days; or(2) is more than a total of 45 days. Source Note: The provisions of this §570.113 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER B ASSISTED LIVING FACILITIES §570.113 Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209117 03/12/2026 (a) A hospice agency operating a hospice inpatient unit's visitation policies and procedures may change during a public health emergency or disaster. A hospice agency operating a hospice inpatient unit's policies and procedures may not be more restrictive than directives issued by HHSC, DSHS, executive orders, or local orders.(b) A hospice agency operating a hospice inpatient unit must permit a religious counselor to visit a resident at the request of the resident.(c) A hospice agency operating a hospice inpatient unit may not prohibit a client from receiving in-person visitation with a religious counselor during a public health emergency on request from the client, client's legally authorized representative (LAR), or client's family member unless a federal law or a federal agency requires the facility to prohibit in-person visitation during a public health emergency.(d) A hospice agency operating a hospice inpatient unit must adopt policies and procedures for in-person visitation with a religious counselor during a public health emergency or disaster. These policies and procedures:(1) must comply with the minimum health and safety requirements for in-person visitation with religious counselors developed by HHSC;(2) may include reasonable time, place, and manner restrictions on in-person visitation with religious counselors to:(A) mitigate the spread of a communicable disease; and(B) address the resident's medical condition;(3) must include special consideration for residents receiving end-of-life care; and(4) may require religious counselors to comply with a hospice agency operating a hospice inpatient unit's guidelines, policies, and procedures for in-person visitation with a religious counselor.(e) A hospice agency operating a hospice inpatient unit must permit end-of-life visits and immediately communicate any changes in a resident's condition that would qualify the resident for end-of-life visits to the resident's representative or resident's legally authorized representative. Source Note: The provisions of this §570.325 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER D HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §570.325 Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209118 03/12/2026 (a) A resident or the resident's legally authorized representative (LAR), if the resident is unable, has the right to designate at least one essential caregiver.(b) A hospice agency operating a hospice inpatient unit must permit essential caregiver visits except as provided by subsection (i) of this section.(c) A hospice agency operating a hospice inpatient unit must develop a visitation policy that permits an essential caregiver to visit the resident for at least two hours each day.(d) A hospice agency operating a hospice inpatient unit must have procedures in place to enable physical contact between the resident and the essential caregiver.(e) A hospice agency operating a hospice inpatient unit must develop safety protocols for essential caregiver visits. The safety protocols may not be more stringent for essential caregivers than safety protocols for staff.(f) A hospice agency operating a hospice inpatient unit must obtain the signature of the essential caregiver certifying that the essential caregiver will follow the facility's safety protocols for essential caregiver visits.(g) A hospice agency operating a hospice inpatient unit may revoke an essential caregiver designation if the caregiver violates the facility's safety protocols or rules adopted under this chapter.(h) If a hospice agency operating a hospice inpatient unit revokes a person's designation as an essential caregiver under subsection (g) of this section:(1) the resident or the resident's LAR has the right to immediately designate another person as the essential caregiver;(2) within 24 hours after the revocation, the hospice agency operating a hospice inpatient unit must inform the resident or the resident's LAR, in writing, of the right to appeal the revocation and the with the Texas Health and Human Services Commission (HHSC) Appeals Division by:(A) email at OCC_Appeals_ContestedCases@hhs.texas.gov; or(B) mail at HHSC Appeals Division, P.O. Box 149030, MC W-613, Austin, TX 78714-9030; and(3) the hospice agency operating a hospice inpatient unit must comply with a hearing officer's decision regarding an appeal of an essential caregiver revocation.(i) A hospice agency operating a hospice inpatient unit may petition HHSC to suspend in-person essential caregiver visits for no more than seven consecutive calendar days if in-person visitation poses a serious community health risk. A hospice agency operating a hospice inpatient unit may request an extension from HHSC to suspend in-person essential caregiver visitation beyond the hospice agency operating a hospice inpatient unit's original request, but HHSC may not approve an extension for a period that exceeds seven days and a hospice agency operating a hospice inpatient unit must separately request each extension. HHSC may deny the hospice agency operating a hospice inpatient unit's original request to suspend in-person essential caregiver visitation or the hospice agency operating a hospice inpatient unit's extension request if HHSC determines that in-person visitation does not pose a serious community health risk.(j) A hospice agency operating a hospice inpatient unit may not suspend in-person essential caregiver visits in a calendar year for a time period that:(1) is more than 14 consecutive days; or(2) is more than a total of 45 days. Source Note: The provisions of this §570.327 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER D HOME AND COMMUNITY SUPPORT SERVICES AGENCIES §570.327 Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209121 03/12/2026 (a) A nursing facility's visitation policies and procedures may change during a public health emergency or disaster in response to directives issued by the Centers for Medicare and Medicaid Services (CMS), HHSC, or DSHS. Nursing facility (NF) visitation policies and procedures may not be more restrictive than directives issued by CMS, HHSC, DSHS, executive orders, or local orders.(b) A NF must permit a religious counselor to visit a resident at the request of the resident.(c) A NF may not prohibit a resident from receiving in-person visitation with a religious counselor during a public health emergency on request from the resident, resident's legally authorized representative (LAR), or resident's family member unless a federal law or a federal agency requires the facility to prohibit in-person visitation during a public health emergency.(d) A NF must adopt policies and procedures for in-person visitation with a religious counselor during a public health emergency or disaster. These policies and procedures:(1) must comply with the minimum health and safety requirements for in-person visitation with religious counselors developed by HHSC;(2) may include reasonable time, place, and manner restrictions on in-person visitation with religious counselors to:(A) mitigate the spread of a communicable disease; and(B) address the resident's medical condition;(3) must include special consideration for residents receiving end-of-life care; and(4) may require religious counselors to comply with a NF's guidelines, policies, and procedures for in-person visitation with a religious counselor.(e) A NF must permit end-of-life visits and immediately communicate any changes in a resident's condition that would qualify the resident for end-of-life visits to the resident representative. Source Note: The provisions of this §570.513 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER F NURSING FACILITIES §570.513 Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209122 03/12/2026 (a) A resident or the resident's legally authorized representative (LAR), if the resident is unable, has the right to designate at least one essential caregiver.(b) A nursing facility (NF) must permit essential caregiver visits except as provided by subsection (j) of this section.(c) A NF must allow essential caregiver visits to occur outdoors, in the resident's bedroom when possible, or in another area upon request by a resident or resident's LAR.(d) A NF must develop a visitation policy that permits an essential caregiver to visit the resident for at least two hours each day.(e) A NF must have procedures in place to enable physical contact between the resident and the essential caregiver, if the resident chooses to have physical contact.(f) A NF must develop safety protocols for essential caregiver visits. The safety protocols may not be more stringent for essential caregivers than safety protocols for staff.(g) A NF must obtain the signature of the essential caregiver certifying that the essential caregiver will follow the NF's safety protocols for essential caregiver visits.(h) A NF may revoke an essential caregiver designation if the caregiver violates the NF's safety protocols or rules adopted under this chapter.(i) If A NF revokes a person's designation as an essential caregiver under subsection (h) of this section:(1) the resident or the resident's LAR has the right to immediately designate another person as the essential caregiver;(2) within 24 hours after the revocation, the facility must inform the resident or the resident's LAR, in writing, of the right to appeal the revocation and the procedures for filing an appeal with the Texas Health and Human Services Commission (HHSC) Appeals Division by:(A) email at OCC_Appeals_ContestedCases@hhs.texas.gov; or(B) mail at HHSC Appeals Division, P.O. Box 149030, MC W-613, Austin, TX 78714-9030; and(3) the NF must comply with a hearing officer's decision regarding an appeal of an essential caregiver revocation.(j) A NF may petition HHSC to suspend in-person essential caregiver visits for no more than seven consecutive calendar days if in-person visitation poses a serious community health risk. A NF may request an extension from HHSC to suspend in-person essential caregiver visitation beyond the NF's original request, but HHSC may not approve an extension for a period that exceeds seven days and a NF must separately request each extension. HHSC may deny the NF's original request to suspend in-person essential caregiver visitation or the NF's extension request if HHSC determines that in-person visitation does not pose a serious community health risk.(k) A NF may not suspend in-person essential caregiver visits in a calendar year for a time period that:(1) is more than 14 consecutive days; or(2) is more than a total of 45 days. Source Note: The provisions of this §570.514 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER F NURSING FACILITIES §570.514 Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209123 03/12/2026 (a) An intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) visitation policies and procedures may change during a public health emergency or disaster. ICF/IID visitation policies and procedures may not be more restrictive than directives issued by HHSC, DSHS, executive orders, or local orders.(b) An ICF/IID must permit a religious counselor to visit an individual at the request of the individual.(c) An ICF/IID may prohibit in-person visitation with a religious counselor during a public health emergency if a federal law or federal agency requires the facility to prohibit in-person visitation during that period.(d) An ICF/IID must permit end-of-life visits and immediately communicate any changes in an individual's condition that would qualify the individual for end-of-life visits to the individual's representative. Source Note: The provisions of this §570.611 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER G INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS §570.611 Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209124 03/12/2026 (a) An individual, or the individual's legally authorized representative (LAR), if the individual is unable, has the right to designate at least one essential caregiver.(b) An intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) must permit essential caregiver visits except as provided by subsection (i) of this section.(c) An ICF/IID must develop a visitation policy that permits an essential caregiver to visit the individual for at least two hours each day.(d) An ICF/IID must have procedures in place to enable physical contact between the individual and the essential caregiver.(e) An ICF/IID must develop safety protocols for essential caregiver visits. The safety protocols may not be more stringent for essential caregivers than safety protocols for staff.(f) An ICF/IID must obtain the signature of the essential caregiver certifying that the essential caregiver will follow the ICF/IID's safety protocols for essential caregiver visits.(g) An ICF/IID may revoke an essential caregiver designation if the caregiver violates the facility's safety protocols or rules adopted under this chapter.(h) If an ICF/IID revokes a person's designation as an essential caregiver under subsection (g) of this section:(1) the individual or the individual's legally authorized representative has the right to immediately designate another person as the essential caregiver;(2) within 24 hours after the revocation, the ICF/IID must inform the individual or the individual's LAR, in writing, of the right to an appeal the revocation and the procedures for filing an appeal with the Texas Health and Human Services Commission (HHSC) Appeals Division by:(A) email at OCC_Appeals_ContestedCases@hhs.texas.gov; or(B) mail at HHSC Appeals Division, P.O. Box 149030, MC W-613, Austin, TX 78714-9030; and(3) the ICF/IID must comply with a hearing officer's decision regarding an appeal of an essential caregiver revocation.(i) An ICF/IID may petition HHSC to suspend in-person essential caregiver visits for no more than seven consecutive calendar days if in-person visitation poses a serious community health risk. An ICF/IID may request an extension from HHSC to suspend in-person essential caregiver visitation beyond the ICF/IID's original request, but HHSC may not approve an extension for a period that exceeds seven days and an ICF/IID must separately request each extension. HHSC may deny the ICF/IID's original request to suspend in-person essential caregiver visitation or the ICF/IID's extension request if HHSC determines that in-person visitation does not pose a serious community health risk.(j) An ICF/IID may not suspend in-person essential caregiver visits in a calendar year for a time period that:(1) is more than 14 consecutive days; or(2) is more than a total of 45 days. Source Note: The provisions of this §570.613 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER G INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH AN INTELLECTUAL DISABILITY OR RELATED CONDITIONS §570.613 Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209125 03/12/2026 (a) This section does not apply to host home/companion care, unless otherwise specified.(b) A program provider's visitation policies and procedures may change during a public health emergency or disaster. A program provider's visitation policies and procedures may not be more restrictive than directives issued by HHSC, DSHS, executive orders, or local orders.(c) A program provider must permit a religious counselor to visit an individual at the request of the individual.(d) A program provider may prohibit in-person visitation with a religious counselor during a public health emergency if a federal law or federal agency requires the residence to prohibit in-person visitation during that period.(e) A program provider must permit end-of-life visits and immediately communicate any changes in an individual's condition that would qualify the individual for end-of-life visits to the individual's representative. Source Note: The provisions of this §570.711 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER H HOME AND COMMUNITY-BASED SERVICES §570.711 Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209126 03/12/2026 (a) An individual, or individual's legally authorized representative (LAR), if the individual is unable, has the right to designate at least one essential caregiver.(b) A program provider must permit essential caregiver visits except as provided by subsection (i) of this section.(c) A program provider must develop a visitation policy that permits an essential caregiver to visit the individual for at least two hours each day.(d) A program provider must have procedures in place to enable physical contact between the individual and the essential caregiver.(e) A program provider must develop safety protocols for essential caregiver visits. The safety protocols may not be more stringent for essential caregivers than safety protocols for staff.(f) A program provider must obtain the signature of the essential caregiver certifying that the essential caregiver will follow the program provider's safety protocols for essential caregiver visits.(g) A program provider may revoke an essential caregiver designation if the caregiver violates the program provider's safety protocols or rules adopted under this chapter.(h) If a program provider revokes a person's designation as an essential caregiver under subsection (g) of this section:(1) the individual, or individual's LAR, has the right to immediately designate another person as the essential caregiver;(2) within 24 hours after the revocation, the program provider must inform the individual or the individual's legally authorized representative, in writing, of the right to an appeal the revocation and the procedures for filing an appeal with the Texas Health and Human Services Commission (HHSC) Appeals Division by:(A) email at OCC_Appeals_ContestedCases@hhs.texas.gov; or(B) mail at HHSC Appeals Division, P.O. Box 149030, MC W-613, Austin, TX 78714-9030; and(3) a program provider must comply with a hearing officer's decision regarding an appeal of an essential caregiver revocation.(i) A program provider may petition HHSC to suspend in-person essential caregiver visits for no more than seven consecutive calendar days if in-person visitation poses a serious community health risk. A program provider may request an extension from HHSC to suspend in-person essential caregiver visitation beyond the program provider's original request, but HHSC may not approve an extension for a period that exceeds seven days and a program provider must separately request each extension. HHSC may deny the program provider's original request to suspend in-person essential caregiver visitation or the program provider's extension request if HHSC determines that in-person visitation does not pose a serious community health risk.(j) A program provider may not suspend in-person essential caregiver visits in a calendar year for a time period that:(1) is more than 14 consecutive days; or(2) is more than a total of 45 days. Source Note: The provisions of this §570.713 adopted to be effective June 1, 2022, 47 TexReg 3143. 1 HEALTH AND HUMAN SERVICES COMMISSION 570 LONG-TERM CARE PROVIDER RULES DURING A PUBLIC HEALTH EMERGENCY OR DISASTER H HOME AND COMMUNITY-BASED SERVICES §570.713 Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220251 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220251 03/12/2026 The purpose of this chapter is to:(1) implement Texas Health and Safety Code (THSC) Chapter 469;(2) establish the minimum standards for voluntary accreditation as a recovery house as required by THSC §469.002; and(3) inform the public that accreditation under this chapter does not authorize a recovery house to provide chemical dependency treatment services. Source Note: The provisions of this §571.1 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION A GENERAL PROVISIONS §571.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220254 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220254 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.(1) Accrediting organization:(A) the National Alliance for Recovery Residences; or(B) the Oxford House Incorporated.(2) Applicant--A recovery house applying for accreditation.(3) HHSC--The Texas Health and Human Services Commission.(4) Personal care services--In accordance with Texas Health and Safety Code (THSC) §247.002:(A) assistance with feeding, dressing, moving, bathing, or other personal needs or maintenance; or(B) general supervision or oversight of the physical and mental well-being of a person who needs assistance to maintain a private and independent residence in an assisted living facility or who needs assistance to manage the person's personal life, regardless of whether a guardian has been appointed for the person.(5) Recovery house--In accordance with THSC §469.001, a shared living environment that:(A) promotes sustained recovery from substance use disorders by integrating residents into the surrounding community and providing a setting that connects residents to supports and services promoting sustained recovery from substance use disorders;(B) is centered on peer support; and(C) is free from alcohol and drug use.(6) State health care regulatory agency--In accordance with THSC §161.131, a state agency that licenses a health care professional.(7) THSC--Texas Health and Safety Code. Source Note: The provisions of this §571.2 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION A GENERAL PROVISIONS §571.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220252 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220252 03/12/2026 In accordance with THSC §469.002(b), HHSC may approve only the National Alliance for Recovery Residences or the Oxford House Incorporated as an accrediting organization for a recovery house. Source Note: The provisions of this §571.3 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION A GENERAL PROVISIONS §571.3 Approved Accrediting Organizations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220253 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220253 03/12/2026 (a) The accreditation process outlined in this chapter is voluntary. A recovery house is encouraged to seek and maintain accreditation but is not required to be accredited to operate in the state of Texas.(b) Effective September 1, 2025, in accordance with THSC §469.009, a recovery house that is not accredited by an accrediting organization under THSC Chapter 469 and this chapter is ineligible for and may not receive funding from the state of Texas. Source Note: The provisions of this §571.4 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION A GENERAL PROVISIONS §571.4 Accreditation Not Required https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220255 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220255 03/12/2026 Pursuant to THSC §469.003, the following places are ineligible for accreditation as a recovery house:(1) a home and community support services agency licensed under THSC Chapter 142;(2) a nursing facility licensed under THSC Chapter 242;(3) a continuing care facility regulated under THSC Chapter 246;(4) an assisted living facility licensed under THSC Chapter 247;(5) an intermediate care facility for individuals with an intellectual disability licensed under THSC Chapter 252;(6) a boarding home facility, as defined by THSC §260.001;(7) a chemical dependency treatment facility licensed under THSC Chapter 464, Subchapter A;(8) a child-care facility licensed under Texas Human Resources Code Chapter 42;(9) a family violence shelter center, as defined by Texas Human Resources Code §51.002;(10) an entity qualified as a community home under Texas Human Resources Code Chapter 123; and(11) a hotel, as defined by Texas Tax Code §156.001. Source Note: The provisions of this §571.5 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION A GENERAL PROVISIONS §571.5 Places Ineligible for Accreditation as a Recovery House https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220256 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220256 03/12/2026 (a) In accordance with THSC §469.002(a), HHSC adopts by reference the following standards established by the National Alliance for Recovery Residences and the Oxford House Incorporated as minimum standards for accreditation as a recovery house:(1) Recovery Residence Quality Standards published by the National Alliance for Recovery Residences on November 19, 2018; and(2) the Oxford House manual published September 2017.(b) In addition to the minimum standards in subsection (a) of this section, a recovery house:(1) may not provide personal care services; and(2) if accredited by the National Alliance for Recovery Residences, must designate at least one individual to serve as the responsible party for the recovery house in accordance with THSC §469.004. Source Note: The provisions of this §571.11 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION B MINIMUM STANDARDS FOR ACCREDITATION §571.11 Standards for Accreditation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220257 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220257 03/12/2026 (a) An accrediting organization shall:(1) develop procedures to:(A) provide an easily accessible method for a recovery house seeking accreditation to find, complete, and submit an accreditation application;(B) before accrediting an applicant or reaccrediting a recovery house, ensure the applicant or accredited recovery house at a minimum meets:(i) the accrediting organization's standards in §571.11(a) of this chapter (relating to Standards for Accreditation) adopted by HHSC by reference; and(ii) the additional standards in §571.11(b) of this chapter;(C) determine the accreditation and reaccreditation period;(D) require an accredited recovery house to submit all required reaccreditation information before the recovery house's accreditation period expires;(E) require an applicant or accredited recovery house to adjust its practices to meet the standards for accreditation or reaccreditation;(F) take an adverse action under §571.41 of this chapter (relating to Accrediting Organization Enforcement Actions) when a recovery house fails to meet the standards described in paragraph (2) of this subsection; and(G) assess application accreditation and reaccreditation fees;(2) provide training to recovery house staff concerning the accreditation standards in §571.11 of this chapter;(3) develop a code of ethics;(4) annually provide the following information to HHSC:(A) the total number of accredited recovery houses;(B) the number of recovery houses accredited during the preceding year;(C) any issues concerning the accreditation or reaccreditation process;(D) the number of accredited recovery houses that had an accreditation revoked during the preceding year; and(E) the reasons for the revocation; and(5) ensure a recovery house does not offer or claim to offer chemical dependency treatment services as outlined in THSC §464.001(4) and Title 26 Texas Administrative Code (26 TAC) Chapter 564 (relating to Chemical Dependency Treatment Facilities) at the site of the recovery house without a chemical dependency treatment facility license issued under 26 TAC Chapter 564.(b) In addition to the requirements in subsection (a) of this section, the National Alliance for Recovery Residences shall:(1) require an applicant or accredited recovery house to designate at least one individual to serve as the recovery house's responsible party, in accordance with THSC §469.004;(2) require the responsible party to:(A) satisfactorily complete training the accrediting organization provides concerning the accreditation standards in §571.11 of this chapter and the accrediting organization's accreditation and reaccreditation requirements; and(B) be responsible for administering the recovery house in accordance with the accreditation standards in this chapter and the accrediting organization's accreditation and reaccreditation requirements; and(3) require an accredited recovery house to notify the accrediting organization before the 30th business day after the date of any change to the recovery house's designated responsible party. Source Note: The provisions of this §571.21 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION C ACCREDITING ORGANIZATION REQUIREMENTS §571.21 Accrediting Organization Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220258 03/12/2026 Pursuant to THSC §469.006, an accrediting organization shall prohibit an accredited recovery house's responsible party designated under §571.21(b)(1) of this chapter (relating to Accrediting Organization Requirements), employee, or agent from offering to pay or agreeing to accept, directly or indirectly, overtly or covertly, remuneration in cash or in kind to or from another for securing or soliciting a patient or patronage for or from a person licensed, certified, or registered by a state health care regulatory agency. Source Note: The provisions of this §571.31 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION D PROHIBITED ACTIONS §571.31 Soliciting https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220259 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220259 03/12/2026 Pursuant to THSC §469.007, an accrediting organization shall ensure a recovery house accredited by that organization:(1) does not advertise or otherwise communicate that the recovery house is accredited by an accrediting organization unless the recovery house is accredited by an accrediting organization in accordance with THSC Chapter 469 and this chapter; and(2) does not advertise or cause to be advertised in any manner any false, misleading, or deceptive information about the recovery house. Source Note: The provisions of this §571.32 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION D PROHIBITED ACTIONS §571.32 Advertising Restrictions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220260 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220260 03/12/2026 (a) Pursuant to THSC §469.008, if an accredited recovery house violates a provision in THSC Chapter 469 or in this chapter, the accrediting organization that issued the accreditation to the recovery house may suspend the accreditation for a period not to exceed six months while the accrediting organization conducts an audit of the recovery house.(b) The accrediting organization may implement a corrective action plan or revoke the recovery house's accreditation after completing the audit under subsection (a) of this section. Source Note: The provisions of this §571.41 adopted to be effective August 18, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 571 VOLUNTARY RECOVERY HOUSING ACCREDITATION E ENFORCEMENT §571.41 Accrediting Organization Enforcement Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224579 03/12/2026 The purpose of this chapter is to: (1) implement Human Resources Code (HRC), Chapter 48, Subchapter F, and Texas Family Code §261.404. (2) describe: (A) Adult Protective Services (APS) investigations of allegations of abuse, neglect, and exploitation involving: (i) adults or children receiving services from a provider, as that term is defined in HRC §48.251(9), if the person alleged or suspected to have committed the abuse, neglect, or exploitation is a provider; (ii) adults or children who live in a residence that is owned, operated, or controlled by a provider in the home and community-based services (HCS) waiver program described by Texas Government Code §542.0001, regardless of whether the individual is receiving services under the home and community-based services (HCS) waiver program; and (iii) children receiving services from a home and community support services agency licensed under Chapter 142, Health and Safety Code, if the person alleged or suspected to have committed the abuse, neglect, or exploitation is an officer, employee, agent, contractor, or subcontractor of the home and community support services agency; and (B) that APS does not investigate allegations if the provider alleged or suspected to have committed the abuse, neglect, or exploitation is operated, licensed, or certified, or registered by a state agency that has the authority to investigate a report of abuse, neglect, or exploitation of an individual by the provider; (3) define abuse, neglect, and exploitation for investigations conducted under Human Resources Code, Chapter 48, Subchapter F and Texas Family Code §261.404; (4) describe procedures for reporting and investigating allegations; and (5) implement Human Resources Code, Chapter 48, Subchapter I, relating to the Employee Misconduct Registry maintained by DADS, as described in Subchapter O of this chapter (relating to Employee Misconduct Registry). Source Note: The provisions of this §711.1 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2002, 27 TexReg 955; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective September 1, 2012, 37 TexReg 6322; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617; amended to be effective April 1, 2025, 50 TexReg 2210. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.1 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224580 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: (1) Adult--An adult is a person: (A) 18 years of age or older; or (B) under 18 years of age who: (i) is or has been married; or (ii) has had the disabilities of minority removed pursuant to the Texas Family Code, Chapter 31. (2) APS--Adult Protective Services. (3) Agent--An individual (e.g., student, volunteer), not employed by but working under the auspices of a service provider. (4) Allegation--A report by an individual that an individual receiving services has been or is in a state of abuse, neglect, or exploitation as defined by this subchapter. (5) Allegation type--The type of allegation investigated under this chapter. APS investigates the following allegation types: (A) physical abuse; (B) sexual abuse; (C) verbal/emotional abuse; (D) neglect; and (E) exploitation. (6) Alleged perpetrator-- A direct provider alleged to have committed an act of abuse, neglect, or exploitation. (7) Child--A person under 18 years of age who: (A) is not and has not been married; or (B) has not had the disabilities of minority removed pursuant to the Texas Family Code, Chapter 31. (8) Clinical practice--Relates to the demonstration of professional competence of a licensed professional as described by the appropriate licensing professional board. (9) Community center--A community mental health center; community center for individuals with intellectual or developmental disabilities; or community mental health center and community center for individuals with intellectual or developmental disabilities, established under the Health and Safety Code, Title 7, Chapter 534, Subchapter A. (10) Consumer Directed Services (CDS) employer--A consumer directed services client or their legally authorized representative. (11) DADS--Department of Aging and Disability Services. (12) DFPS--Department of Family and Protective Services. (13) DSHS--Department of State Health Services. (14) Designated Perpetrator--A direct provider who has committed an act of abuse, neglect, or exploitation. (15) Direct Provider--A person, employee, agent, contractor, or subcontractor of a service provider responsible for providing services to an individual receiving services. (16) Emergency order for protective services--A court order for protective services obtained under Human Resources Code, §48.208. (17) Facility--(A) DADS and DSHS central offices, state supported living centers, state hospitals, the Rio Grande State Center, the Waco Center for Youth, the El Paso Psychiatric Center, and community services operated by DADS or DSHS; (B) A person contracting with a health and human services agency to provide inpatient mental health services; and (C) Intermediate care facilities for individuals with an intellectual disability or related conditions (ICF-IID) licensed under Chapter 252, Health and Safety Code. (18) HHSC--Health and Human Services Commission. (19) Home and community-based services--Have the meaning given to them in Human Resources Code §48.251(a)(5) as services provided in the home or community in accordance with 42 U.S.C. §1315, 42 U.S.C. §1315a, 42 U.S.C. §1396a, or 42 U.S.C. §1396n. (20) Home and community-based services (HCS) waiver program--The Medicaid program authorized under §1915(c) of the federal Social Security Act (42 U.S.C. §1396n(c)) for the provision of services to persons with an intellectual or developmental disability described by Texas Government Code §542.0001.(21) Home and community support services agency (HCSSA)--An agency licensed under Chapter 142, Health and Safety Code. (22) ICF-IID--A licensed intermediate care facility for individuals with an intellectual disability or related conditions as described in Chapter 252, Health and Safety Code. (23) Incitement--To spur to action or instigate into activity; the term implies responsibility for initiating another's actions. (24) Individual receiving services-- (A) An adult or child who receives services from a provider as that term is defined in §48.251(a)(9), Human Resources Code. (B) An adult or child who lives in a residence that is owned, operated, or controlled by an HCS waiver program provider regardless of whether the individual is receiving HCS waiver program services; or (C) A child receiving services from a HCSSA. (25) Investigator--An employee of Adult Protective Services who has: (A) demonstrated competence and expertise in conducting investigations; and (B) received training on techniques for communicating effectively with individuals with a disability. (26) Limited Service Provider--An entity that contracts with a service provider to provide services. (27) Local authority-- Either: (A) a local mental health authority designated by the HHSC executive commissioner in accordance with §533.035, Health and Safety Code, and as defined by §531.002, Health and Safety Code; or (B) a local intellectual and developmental disability authority designated by the HHSC executive commissioner in accordance with §533A.035, Health and Safety Code, and as defined by §531.002, Health and Safety Code. (28) Non-serious physical injury-- (A) In state supported living centers and state hospitals only, any injury requiring minor first aid and determined not to be serious by a registered nurse, advanced practice registered nurse (APRN), or physician. (B) For all other service providers any injury determined not to be serious by the appropriate medical personnel. Examples of non-serious physical injury include: (i) superficial laceration; (ii) contusion two and one-half inches in diameter or smaller; or (iii) abrasion. (29) Perpetrator--A direct provider who has committed or alleged to have committed an act of abuse, neglect, or exploitation. (30) Preponderance of evidence--Evidence which is of greater weight or more convincing than the evidence which is offered in opposition to it; that is, evidence which as a whole shows that the fact sought to be proved is more probable than not. (31) Prevention and management of aggressive behavior (PMAB)--DADS and DSHS' proprietary risk management program that uses the least intrusive, most effective options to reduce the risk of injury for persons served and staff from acts or potential acts of aggression. (32) Provider--A provider is: (A) a facility; (B) a community center, local mental health authority, and local intellectual and developmental disability authority; (C) a person who contracts with a health and human services agency or managed care organization to provide home and community-based services; (D) a person who contracts with a Medicaid managed care organization to provide behavioral health services; (E) a managed care organization; (F) an officer, employee, agent, contractor, or subcontractor of a person or entity listed in subparagraphs (A)-(E) of this paragraph; and (G) an employee, fiscal agent, case manager, or service coordinator of an individual employer participating in the consumer-directed service option, as defined by Texas Government Code §546.0101. (33) Reporter--The person, who may be anonymous, making an allegation. (34) Serious physical injury-- (A) In state supported living centers and state hospitals only, any injury requiring medical intervention or hospitalization or any injury determined to be serious by a physician or APRN. Medical intervention is treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician assistant, or APRN. For the purposes of this subchapter, medical intervention does not include first aid, an examination, diagnostics (e.g., x-ray, blood test), or the prescribing of oral or topical medication; (B) For all other service providers, any injury determined to be serious by the appropriate medical personnel. Examples of serious physical injury include: (i) fracture; (ii) dislocation of any joint; (iii) internal injury; (iv) contusion larger than two and one-half inches in diameter; (v) concussion; (vi) second or third degree burn; or (vii) any laceration requiring sutures or wound closure. (35) Service Provider--A provider, HCSSA, or HCS waiver program provider responsible for employing, contracting with, or supervising the direct provider. (36) Sexually transmitted disease--Any infection with or without symptoms or clinical manifestations that can be transmitted from one person to another by sexual contact. (37) Texas Home Living (TxHmL) waiver program--The Medicaid program authorized under §1915(c) of the federal Social Security Act (42 U.S.C. §1396n(c)) for the provision of services to persons with an intellectual or developmental disability described by Texas Government Code §542.0001. (38) Victim--An individual receiving services who is alleged to have been abused, neglected, or exploited. Source Note: The provisions of this §711.3 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617; amended to be effective April 1, 2025, 50 TexReg 2210. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.3 How are the terms in this chapter defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195441 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195441 03/12/2026 (a) When the alleged perpetrator is a direct provider, or is unknown, and the alleged victim is an individual receiving services, APS investigates the following allegation types:(1) physical abuse;(2) sexual abuse;(3) verbal/emotional abuse;(4) neglect; and(5) exploitation.(b) APS also investigates:(1) pregnancy of an individual receiving services from a facility or facility contractor if there is:(A) medical verification that conception could have occurred while the individual receiving services was a resident of the facility or facility contractor; and(B) a reasonable expectation that conception occurred while the individual was a resident of the facility or facility contractor;(2) sexually transmitted disease (STD) of an individual receiving services from a facility or facility contractor, if the individual could have acquired the STD while a resident of the facility or facility contractor; and(3) injury of unknown origin if appropriate medical personnel, after examining the individual receiving services, suspect the injury is the result of abuse or neglect. Source Note: The provisions of this §711.5 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.5 What does APS investigate under this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195442 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195442 03/12/2026 APS does not investigate:(1) if another branch of HHSC or another state agency is responsible under state law for the investigation;(2) general complaints such as:(A) rights violations;(B) daily administrative operations;(3) operational issues related to the business of managed care or consumer directed services;(4) if the allegation involves only the clinical practice of a licensed professional;(5) theft, as defined in Chapter 31 of the Texas Penal Code;(6) allegations of exploitation less than $25.00; or(7) loans made by an individual receiving services to a provider. Source Note: The provisions of this §711.7 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective January 1, 2004, 28 TexReg 11345; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.7 What does APS not investigate under this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195443&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195443 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195443&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195443 03/12/2026 In this chapter, when the alleged perpetrator is a direct provider, physical abuse is defined as:(1) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused physical injury or death to an individual receiving services;(2) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to an individual receiving services; or(3) the use of chemical or bodily restraints or seclusion on an individual receiving services not in compliance with federal and state laws and regulations, including:(A) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Programs);(B) 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(C) 40 TAC Chapter 3, Subchapter F (relating to Restraints);(D) 40 TAC Chapter 90, Subchapter C (relating to Standards for Licensure);(E) 40 TAC Chapter 2, Subchapter G (relating to Role and Responsibilities of a Local Authority);(F) 40 TAC Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC));(G) 40 TAC Chapter 9, Subchapter N (relating to Texas Home Living (TxHmL) Program and Community First Choice (CFC));(H) 40 TAC Chapter 97, Subchapter H (relating to Standards Specific to Agencies Licensed to Provide Hospice Services);(I) 40 TAC Chapter 42, Subchapter D (relating to Additional Program Provider Provisions);(J) 1 TAC Chapter 353, Subchapter C (Member Bill of Rights); and(K) 40 TAC Chapter 45, Subchapter H (relating to Additional DSA Requirements). Source Note: The provisions of this §711.11 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.11 How is physical abuse defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195444 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195444 03/12/2026 (a) In this chapter, when the alleged perpetrator is a direct provider, sexual abuse is defined as any sexual activity, including but not limited to:(1) kissing an individual receiving services with sexual intent;(2) hugging an individual receiving services with sexual intent;(3) stroking an individual receiving services with sexual intent;(4) fondling an individual receiving services with sexual intent;(5) engaging in with an individual receiving services:(A) sexual conduct as defined in the Texas Penal Code, §43.01; or(B) any activity that is obscene as defined in the Texas Penal Code, §43.21;(6) requesting, soliciting, or compelling an individual receiving services to engage in:(A) sexual conduct as defined in the Texas Penal Code, §43.01; or(B) any activity that is obscene as defined in the Texas Penal Code, §43.21;(7) in the presence of an individual receiving services:(A) engaging in or displaying any activity that is obscene, as defined in the Texas Penal Code §43.21; or(B) requesting, soliciting, or compelling another person to engage in any activity that is obscene, as defined in the Texas Penal Code §43.21;(8) committing sexual exploitation. Sexual exploitation is defined as:(A) a pattern, practice, or scheme of conduct against an individual receiving services, which may include sexual contact, that can reasonably be construed as being for the purposes of sexual arousal or gratification or sexual abuse of any person.(B) The term does not include obtaining information about a patient's sexual history within standard accepted clinical practice.(9) committing sexual assault as defined in the Texas Penal Code §22.011, against an individual receiving services;(10) committing aggravated sexual assault as defined in the Texas Penal Code, §22.021, against an individual receiving services; and(11) causing, permitting, encouraging, engaging in, or allowing the photographing, filming, videotaping, or depicting of an individual receiving services if the direct provider knew or should have known that the resulting photograph, film, videotape, or depiction of the individual receiving services is obscene as defined in the Texas Penal Code, §43.21, or is pornographic.(b) Notwithstanding any other provision in this section, consensual sexual activity between a direct provider and an adult receiving services is not considered sexual abuse if the consensual sexual relationship began prior to the direct provider becoming a direct provider. Source Note: The provisions of this §711.13 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective September 1, 2012, 37 TexReg 6322; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.13 How is sexual abuse defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195445 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195445 03/12/2026 (a) In this chapter, when the alleged perpetrator is a direct provider, verbal/emotional abuse is defined as:(1) the willful infliction of an act or repeated acts of verbal or other communication, including gestures, to harass, intimidate, humiliate, or degrade an individual receiving services; or(2) threats of physical or emotional harm against an individual receiving services.(b) In order for the definition of verbal/emotional abuse to be met, the act or communication must:(1) result in an individual receiving services experiencing:(A) significant impairment to his or her physical, mental, or emotional health;(B) substantial physical, mental, or emotional distress as identified by an appropriate medical professional; or(2) be of such a serious nature that a reasonable person would consider it causing significant impairment to the physical, mental, or emotional health of the victim. Source Note: The provisions of this §711.17 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective January 1, 2004, 28 TexReg 11345; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.17 How is verbal/emotional abuse defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195446 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195446 03/12/2026 (a) In this chapter, when the alleged perpetrator is a direct provider to an individual receiving services in or from a facility, local authority, community center, or HCS waiver program or TxHmL waiver program provider, neglect is defined as a negligent act or omission which caused or may have caused physical or emotional injury or death to an individual receiving services or which placed an individual receiving services at risk of physical or emotional injury or death.(b) Examples of neglect may include, but are not limited to, the failure to:(1) establish or carry out an appropriate individual program plan or treatment plan for a specific individual receiving services, if such failure results in physical or emotional injury or death to an individual receiving services or which placed an individual receiving services at risk of physical or emotional injury or death;(2) provide adequate nutrition, clothing, or health care to a specific individual receiving services in a residential or inpatient program if such failure results in physical or emotional injury or death to an individual receiving services or which placed an individual receiving services at risk of physical or emotional injury or death; or(3) provide a safe environment for a specific individual receiving services, including the failure to maintain adequate numbers of appropriately trained staff, if such failure results in physical or emotional injury or death to an individual receiving services or which placed an individual receiving services at risk of physical or emotional injury or death.(c) In this chapter, when the alleged perpetrator is a direct provider to an individual receiving services from any other service provider, neglect is defined as a negligent act or omission which caused physical or emotional injury or death to an individual receiving services. Source Note: The provisions of this §711.19 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective January 1, 2004, 28 TexReg 11345; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.19 How is neglect defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195447 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195447 03/12/2026 In this chapter, when the alleged perpetrator is a direct provider to an individual receiving services, exploitation is defined as the illegal or improper act or process of using an individual receiving services or the resources of an individual receiving services for monetary or personal benefit, profit, or gain, and excludes:(1) theft as defined in Chapter 31 of the Texas Penal Code;(2) allegations of exploitation less than $25.00; and(3) a loan, which includes money or property given to someone to use for a period of time with an understanding that it will be paid back or returned, made by an individual receiving services to a direct provider in a community provider setting. Source Note: The provisions of this §711.21 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.21 How is exploitation defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195448 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195448 03/12/2026 Abuse, neglect, and exploitation do not include the following:(1) the proper use of restraints and seclusion, including Prevention and Management of Aggressive Behavior (PMAB), and the approved application of behavior modification techniques as described in:(A) 25 TAC Chapter 415, Subchapter F (relating to Interventions in Mental Health Programs);(B) 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);(C) 40 TAC Chapter 3, Subchapter F (relating to Restraints);(D) 40 TAC Chapter 90, Subchapter C (relating to Standards for Licensure);(E) 40 TAC Chapter 2, Subchapter G (relating to Role and Responsibilities of a Local Authority);(F) 40 TAC Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) Program and Community First Choice (CFC));(G) 40 TAC Chapter 9, Subchapter N (relating to Texas Home Living (TxHmL) Program and Community First Choice (CFC));(H) 40 TAC Chapter 97, Subchapter H (Standards Specific to Agencies Licensed to Provide Hospice Services);(I) 40 TAC Chapter 42, Subchapter D (relating to Additional Program Provider Provisions);(J) 1 TAC Chapter 353, Subchapter C (Member Bill of Rights); and(K) 40 TAC Chapter 45, Subchapter H (relating to Additional DSA Requirements).(2) actions taken in accordance with the rules of DADS, DSHS, or HHSC; or(3) actions that a direct provider may reasonably believe to be immediately necessary to avoid imminent harm to self, individuals receiving services, or other individuals provided the actions are limited only to those actions reasonably believed to be necessary under the existing circumstances. Source Note: The provisions of this §711.23 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS A INTRODUCTION §711.23 What is not considered abuse, neglect, or exploitation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195438 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195438 03/12/2026 (a) If you know or suspect that any individual receiving services is being or has been abused, neglected, or exploited or meets other criteria specified in §711.5 of this title (relating to What does APS investigate under this chapter?), you must:(1) report such knowledge or suspicion to DFPS immediately, if possible, by calling the DFPS toll-free number at 1-800-647-7418 or using the Internet at http://www.txabusehotline.org;(2) preserve and protect any evidence related to the allegation in accordance with instructions from DFPS; and(3) cooperate with the investigator during the investigation.(b) For facilities, community centers, local authorities, and HCS waiver program and TxHmL waiver program providers, the report made under subsection (a)(1) of this section must be made no more than one hour after knowledge or suspicion of abuse, neglect, or exploitation of an individual receiving services. Source Note: The provisions of this §711.201 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective December 1, 2011, 36 TexReg 6150; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS C DUTY TO REPORT §711.201 What is your duty to report if you are a direct provider or service provider? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195451 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195451 03/12/2026 (a) When the provider is a state supported living center, state hospital, or the ICF-IID component of the Rio Grande State Center, the investigator makes the following notifications:(1) the investigator notifies law enforcement within one (1) hour of any allegation of abuse, neglect, or exploitation involving a child.(2) the investigator notifies law enforcement within one (1) hour of any allegation of abuse, neglect, or exploitation involving an adult believed to constitute a criminal offense under any law.(3) the investigator notifies OIG within one (1) hour of any allegation of abuse, neglect, or exploitation involving an individual receiving services believed to constitute a criminal offense under any law.(b) For all other providers, the investigator notifies law enforcement within 24 hours of any allegation of abuse, neglect, or exploitation involving:(1) a child.(2) an adult believed to constitute a criminal offense under any law.(c) As provided in subsection (b) of this section the investigator notifies law enforcement:(1) unless the law enforcement agency reported the alleged abuse, neglect, or exploitation to the department; and(2) using a method that is mutually agreed upon between DFPS and the law enforcement agency.(d) For all notifications described in this section, the identity of the reporter is revealed. Source Note: The provisions of this §711.401 adopted to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.401 When does the Investigator notify law enforcement and OIG for allegations of abuse, neglect, or exploitation and when is the identity of the reporter revealed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195452 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195452 03/12/2026 (a) For all allegations of abuse, neglect, or exploitation of an individual receiving services, the investigator makes the following notifications, as appropriate: Attached Graphic(b) For these notifications, described in subsection (a) of this section, the identity of the reporter is revealed only if the alleged perpetrator is a mental health service provider and the allegation is sexual exploitation in accordance with Chapter 81, Texas Civil Practice and Remedies Code. Source Note: The provisions of this §711.402 adopted to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.402 What provider and Health and Human Services agency does the Investigator notify for allegations of abuse, neglect, or exploitation and when is the identity of the reporter revealed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195453 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195453 03/12/2026 Within 24 hours or the next working day following receipt of an allegation that relates to a general complaint, as described in §711.7(2) of this title (relating to What does APS not investigate under this chapter?), the investigator makes notifications per §711.401(a) of this title (relating to Who and when does the investigator notify for allegations of abuse, neglect, or exploitation and when is the identity of the reporter revealed?) if the service provider is identified at intake. Source Note: The provisions of this §711.403 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective December 1, 2011, 36 TexReg 6150; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.403 Who and when does the investigator notify upon receiving an allegation that relates to a general complaint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195454 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195454 03/12/2026 (a) The investigator determines whether the allegation involves clinical practice by consultation with an appropriate professional, and in state hospitals, in accordance with 25 TAC §417.509 (relating to Peer Review).(b) If the allegation is determined to involve clinical practice, the investigator refers the allegation to the service provider for peer or professional review. If the service provider does not have a peer or professional review process, the investigator refers the allegation to the service provider as well as the appropriate professional licensing board.(c) If the allegation is determined to not involve clinical practice, the investigator investigates the allegation.(d) If there are multiple allegations, the investigator refers any allegation involving clinical practice to the service provider for peer/professional review and investigates any allegation not involving clinical practice. Source Note: The provisions of this §711.405 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.405 What action does the investigator take if the alleged perpetrator is a licensed professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195455 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195455 03/12/2026 Each investigation is assigned a priority in accordance with the following:(1) Priority I reports have a serious risk that a delay in investigation will impede the collection of evidence, or allege that the victim has been subjected to abuse, neglect, or exploitation by act or omission that caused or may have caused serious physical or emotional harm. Priority 1 reports include, but are not limited to, the following:(A) Death;(B) Sexual abuse;(C) Serious physical injury; or(D) Verbal/emotional abuse, such as a death threat, or a threat of serious physical or emotional harm; or(E) Incitement to harm self or others.(2) Priority II reports have some risk that a delay in investigation will impede the collection of evidence, or allege that the victim has been subjected to abuse, neglect, or exploitation by act or omission that caused or may have caused non-serious physical injury, or emotional harm not included in Priority I. Priority II reports include, but are not limited to, the following:(A) Non-serious physical injury; or(B) Verbal/emotional abuse, such as name-calling, cursing, degrading, or vilifying remarks.(3) Priority III reports allege:(A) Abuse, neglect, or exploitation that would otherwise be classified as Priority I or II but the alleged incident occurred more than 30 days prior to the date of the report; or(B) Exploitation, when it is the only allegation type in the report.(4) The following allegations cannot be classified as a Priority III:(A) Allegations of abuse, neglect, or exploitation in state supported living centers and the ICF-IID component of the Rio Grande State Center; and(B) Allegations involving children.(5) If another allegation type occurs in conjunction with exploitation, the report is classified as the more urgent priority. Source Note: The provisions of this §711.413 adopted to be effective January 1, 2004, 28 TexReg 11345; amended to be effective December 1, 2011, 36 TexReg 6150; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.413 How are investigations prioritized? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195456 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195456 03/12/2026 (a) The investigator makes a face-to-face contact with the alleged victim except when the intake alleges any allegation type when there is no physical or emotional injury to the alleged victim and no risk of physical or emotional injury or death to the alleged victim.(b) If during the course of an investigation the investigator determines a face-to-face contact with the alleged victim is necessary, the investigator conducts such contact. Source Note: The provisions of this §711.415 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective January 1, 2004, 28 TexReg 11345; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective November 5, 2017, 42 TexReg 6187 ; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.415 What are the requirements for face-to-face contact with the alleged victim? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195457&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195457 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195457&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195457 03/12/2026 (a) Unless an extension is granted in accordance with §711.419 of this title (relating to What if the investigator cannot complete the investigation on time?), the investigator must complete the investigation within the following time frames:(1) within 10 calendar days of the allegation by DFPS if the investigation is in a state supported living center or the ICF-IID component of the Rio Grande State Center.(2) within 14 calendar days of receipt of the allegation by DFPS if the investigation is in a state hospital and is a Priority I or II.(3) within 21 calendar days of receipt of the allegation by DFPS if the investigation is in a state hospital and is a Priority III.(4) within 30 calendar days of receipt of the allegation by DFPS for all other investigations.(b) For investigations conducted under subsection (a)(2) - (4) of this section, if the deadline for completion of the investigation falls on a weekend or state holiday, then the investigator must complete the investigation by the end of the next business day. Source Note: The provisions of this §711.417 adopted to be effective January 1, 2004, 28 TexReg 11345; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective December 1, 2011, 36 TexReg 6150; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective November 5, 2017, 42 TexReg 6187; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.417 When must the investigator complete the investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195458&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195458 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195458&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195458 03/12/2026 (a) If additional time is required to complete the investigation, the investigator must request an extension by submitting an extension request to the appropriate program administrator or designee.(b) The program administrator or designee may grant an extension for good cause.(c) The investigator notifies the service provider of the extension. Source Note: The provisions of this §711.419 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective November 5, 2017, 42 TexReg 6187; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.419 What if the investigator cannot complete the investigation on time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195450 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195450 03/12/2026 At the conclusion of an investigation, the investigator must make one of the following findings: Attached Graphic Source Note: The provisions of this §711.421 adopted to be effective May 1, 2001, 26 TexReg 2755; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.421 What are the possible findings of an investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195449 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195449 03/12/2026 (a) The investigator must designate a perpetrator or alleged perpetrator if the investigation results in a confirmed finding.(b) The perpetrator is "perpetrator unknown" when a positive identification of the responsible person(s) cannot be made.(c) The perpetrator is "systems issue" when the investigator determines that the lack of established policy or procedure contributed to the abuse, neglect, or exploitation. Source Note: The provisions of this §711.423 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective December 1, 2011, 36 TexReg 6150; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS E CONDUCTING THE INVESTIGATION §711.423 Is the investigator required to designate a perpetrator or alleged perpetrator? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195459 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195459 03/12/2026 (a) If the investigator determines that an individual receiving HCS waiver program services from an HCS waiver program provider is in immediate threat of serious physical harm or death as a result of abuse, neglect, or exploitation, then the investigator requests that the HCS waiver program provider, if appropriate, take action to remove the threat of physical harm or death. In deciding whether it is appropriate to request that the HCS waiver program provider take action, the investigator considers the following factors at a minimum:(1) the ability of the HCS waiver program provider to take action in a timely manner;(2) identity of the alleged perpetrator;(3) setting/location of the HCS waiver program provider; and(4) type of action needed to remove the threat.(b) If the investigator determines that it is not appropriate to request that the HCS waiver program provider take action, or if the HCS waiver program provider does not respond appropriately to a request, then the investigator utilizes the resources of the APS In-home staff to provide emergency services necessary to prevent serious physical harm or death.(c) The investigator informs DADS Office of Consumer Rights and Services of the investigator's determination that an individual enrolled in the HCS waiver program receiving services from an HCS waiver program provider was in immediate threat of serious physical harm or death as a result of abuse, neglect, or exploitation, within 24 hours or the next working day of such determination. Source Note: The provisions of this §711.551 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS F PROVISION OF SERVICES §711.551 What action does the investigator take if an individual enrolled in the HCS waiver program receiving services from an HCS waiver program provider needs emergency services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195460 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195460 03/12/2026 (a) If the investigator determines that an individual receiving services from a licensed ICF-IID is in immediate threat of serious physical harm or death as a result of abuse, neglect, or exploitation, then the investigator requests that the licensed ICF-IID, if appropriate, take action to remove the threat of physical harm or death. In deciding whether it is appropriate to request that the licensed ICF-IID take action, the investigator considers the following factors at a minimum:(1) the ability of the licensed ICF-IID to take action in a timely manner;(2) identity of the alleged perpetrator;(3) location of the licensed ICF-IID site; and(4) type of action needed to remove the threat.(b) If the investigator determines that it is not appropriate to request the licensed ICF-IID to take action or if the licensed ICF-IID does not respond appropriately to a request, then the investigator contacts DADS Regulatory division and provides DADS with all information that DFPS believes makes it necessary for DADS to file a petition for temporary care and protection of a resident. If DADS determines, based on information from the DFPS investigator, that immediate removal is necessary to protect the resident from further abuse, neglect, or exploitation, DADS will file the petition. Source Note: The provisions of this §711.553 adopted to be effective June 1, 2010, 35 TexReg 4180; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS F PROVISION OF SERVICES §711.553 What action does the investigator take if an individual receiving services from a licensed ICF-IID needs emergency services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195461 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195461 03/12/2026 (a) If the investigator determines that an adult who lives in a residence that is owned, operated, or controlled by an HCS waiver program provider but does not receive HCS waiver services is in immediate threat of serious physical harm or death as a result of abuse, neglect, or exploitation, then the investigator requests that the HCS waiver program provider, if appropriate, take action to remove the threat of physical harm or death. In deciding whether it is appropriate to request that the provider take action, the investigator considers the following factors at a minimum:(1) ability of the provider to take action in a timely manner;(2) identity of the alleged perpetrator;(3) setting of the service provision; and(4) type of action needed to remove the threat.(b) If the investigator determines that it is not appropriate to request that the HCS waiver program provider take action or if the HCS waiver program provider does not respond appropriately to a request, then the investigator utilizes the resources of the APS In-home staff to provide emergency services necessary to prevent serious physical harm or death. Source Note: The provisions of this §711.555 adopted to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS F PROVISION OF SERVICES §711.555 What action does the investigator take if an adult lives in a residence that is owned, operated, or controlled by an HCS waiver program provider but does not receive HCS waiver services and needs emergency services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195462 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195462 03/12/2026 (a) If the investigator determines that a child who lives in a residence that is owned, operated, or controlled by an HCS waiver program provider but does not receive HCS waiver services is in immediate threat of serious physical harm or death as a result of abuse, neglect, or exploitation, then the investigator requests that the HCS waiver program provider, if appropriate, take action to remove the threat of physical harm or death. In deciding whether it is appropriate to request that the HCS waiver program provider take action, the investigator considers the following factors at a minimum the:(1) ability of the provider to take action in a timely manner;(2) identity of the alleged perpetrator;(3) setting/location of the HCS waiver program provider; and(4) type of action needed to remove the threat.(b) If the investigator determines that it is not appropriate to request that the HCS waiver program provider take action or if the HCS waiver program provider does not respond appropriately to a request, then the investigator contacts the parent, legally authorized representative, or Child Protective Services (CPS) conservator.(c) If the parent or legally authorized representative does not respond appropriately to a request, the investigator makes a case-related special request for services to CPS. Source Note: The provisions of this §711.557 adopted to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS F PROVISION OF SERVICES §711.557 What action does the investigator take if a child lives in a residence that is owned, operated, or controlled by an HCS waiver program provider but does not receive HCS waiver services and needs emergency services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195463 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195463 03/12/2026 Yes. The reports, records, and working papers used by or developed in the investigative process, and the resulting investigative report, are confidential and may be disclosed only as allowed by law or this chapter. Source Note: The provisions of this §711.601 adopted to be effective May 1, 2001, 26 TexReg 2755; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.601 Are investigation documents confidential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195464 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195464 03/12/2026 The investigative report includes the following:(1) a statement of the allegation or allegations;(2) a summary of the investigation;(3) an analysis of the evidence;(4) a finding that the allegation is confirmed, unconfirmed, inconclusive, or unfounded;(5) concerns and recommendations, if any, resulting from the investigation;(6) the name of the perpetrator or alleged perpetrator;(7) photographs relevant to the investigation, including photographs showing the existence of injuries or the non-existence of injuries, when appropriate; and(8) all witness statements and supporting documents. Source Note: The provisions of this §711.603 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.603 What is included in the investigative report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195465 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195465 03/12/2026 (a) The investigator sends a copy of the investigative report to:(1) The notification contact identified in §711.401(a) of this title (relating to Who and When does the investigator notify for allegations of abuse, neglect, or exploitation and when is the identity of the reporter revealed?) with the identity of the reporter revealed in accordance with §711.401(b);(2) The appropriate health and human service agency including:(A) HHSC for investigations involving managed care organization members;(B) DADS State Office, if the investigation involves:(i) A state supported living center;(ii) An HCS waiver program or TxHmL waiver program providers; or(iii) Licensed ICF-IID; and(C) DSHS State Office, if the investigation involves:(i) Youth Empowerment Services (YES) waiver program, the waiver authorized under 1915c of the Social Security Act; or(ii) Home and Community-based Services-Adult Mental Health Program (HCBS-AMH), the program authorized under 1915i of the Social Security Act;(3) The DADS Assistant Commissioner of state supported living centers (SSLC) or the DSHS Assistant Commissioner for Mental Health and Substance Abuse Services or their designee for an investigation in a facility, as applicable;(4) Local law enforcement when an individual receiving services has been abused, neglected, or exploited in a manner that constitutes a criminal offense under any law, including Texas Penal Code §22.04;(5) The Office of the Inspector General when an individual receiving services at a state hospital, SSLC, or ICF-IID component of the Rio Grande State Center has been abused, neglected, or exploited in a manner that constitutes a criminal offense under any law; and(6) The state office of Adult Protective Services for any confirmed finding against a licensed professional except for investigations involving licensed professionals employed at a state hospital or state supported living center.(b) The state office of APS forwards a copy of the report received under subsection (a)(6) of this section to the appropriate professional licensing board.(c) A provider who contracts with a managed care organization must forward any completed investigation report received under subsection (a) of this section to the managed care organization with which the provider contracts for services for the alleged victim.(d) Law enforcement or a prosecutor may request that DFPS delay the release of the investigative report, or may request that DFPS delay forwarding a copy of the report to the appropriate licensing authority. Source Note: The provisions of this §711.605 adopted to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.605 Who receives the investigative report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195466 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195466 03/12/2026 Yes; the reporter is notified of the finding of the investigation and the method to appeal the finding. The investigator makes the notification within 5 business days of completion of the investigation. Source Note: The provisions of this §711.609 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.609 Is the reporter notified of the finding and the method to appeal, and if so, how? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195467 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195467 03/12/2026 Yes; the victim or alleged victim, guardian, or parent (if the victim or alleged victim is a child) is notified of the finding of the investigation and the method to appeal the finding.(1) For facilities, community centers, local authorities, and HCS waiver program or TxHmL waiver program providers providing services to an individual enrolled in the HCS or TxHmL waiver programs, the notification is made in accordance with the following rules of DADS and DSHS:(A) for state hospitals and the mental health services of the Rio Grande State Center--25 TAC §417.510 (relating to Completion of the Investigation);(B) for state supported living centers and the ICF-IID component of the Rio Grande State Center--40 TAC §3.305(c) (relating to Completion of an Investigation);(C) for local authorities and community centers--25 TAC §414.555 and 40 TAC §4.555 (relating to Information To Be Provided to Victim or Alleged Victim and Others);(D) for HCS waiver programs--40 TAC Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) program;(E) for TxHmL waiver programs--40 TAC Chapter 9, Subchapter N (relating to Texas Home Living (TxHmL) program); or(F) for licensed ICFs-IID--40 TAC Chapter 90, Subchapter G (relating to Abuse, Neglect, and Exploitation; Complaint and Incident Reports and Investigations); and(2) For all other service providers, the investigator makes the notification within 5 business days following the date the investigation report was signed and dated by the investigator. Source Note: The provisions of this §711.611 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective September 1, 2012, 37 TexReg 6322; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 6218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.611 Is the victim or alleged victim, guardian, or parent notified of the finding and the method to appeal, and if so, how? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195468 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195468 03/12/2026 Upon request, the investigative report (with any information concealed that would reveal the identities of the reporter and any individual receiving services who is not the victim or alleged victim) may be released:(1) by a facility to:(A) the victim or alleged victim, guardian, or parent (if the victim or alleged victim is a child), in accordance with 25 TAC §417.511(b) (relating to Confidentiality of Investigative Process and Report), and 40 TAC §3.305(k) (relating to Completion of an Investigation); and(B) the perpetrator in accordance with 25 TAC §417.512(d) (relating to Classifications and Disciplinary Actions) and 40 TAC §3.305(e);(2) by a local authority or community center to:(A) the victim or alleged victim, guardian, or parent (if the victim or alleged victim is a child), in accordance with 25 TAC §414.559(b) and 40 TAC §4.559(b) (relating to Confidentiality of Investigative Process and Report); and(B) the perpetrator or alleged perpetrator;(3) for HCS waiver program or TxHmL waiver program providers providing services to an individual enrolled in the HCS waiver program or TxHmL waiver programs to the victim or alleged victim, guardian, or parent (if the victim or alleged victim is a child), in accordance with 40 TAC Chapter 9, Subchapter D (relating to Home and Community-based Services (HCS) Program) and 40 TAC Chapter 9, Subchapter N (relating to Texas Home Living (TxHmL) Program); and(4) for all other service providers, the investigative report shall not be released except in accordance with §711.605(c) of this chapter (relating to Who receives the investigative report?). Source Note: The provisions of this §711.613 adopted to be effective May 1, 2001, 26 TexReg 2755; amended to be effective March 1, 2008, 33 TexReg 1360; amended to be effective June 1, 2010, 35 TexReg 4180; amended to be effective September 1, 2012, 37 TexReg 6322; amended to be effective June 1, 2014, 39 TexReg 3878; amended to be effective September 1, 2016, 41 TexReg 4218; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS G RELEASE OF REPORT AND FINDINGS §711.613 Can the investigative report be released by a service provider? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195469 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195469 03/12/2026 (a) An appeal is a challenge of the findings of the investigation, as described in §711.421 of this chapter (relating to What are the possible findings of an investigation?) by a qualified party, as described by §711.905 of this chapter (relating to Who may request an appeal of the investigation?) that results in a review of the investigation.(b) An appeal may not challenge the determination of whether a confirmation rises to the level of reportable conduct for purposes of the Employee Misconduct Registry.(c) There are two levels of appeal:(1) The first level appeal is conducted by the Director of Provider Investigations or his or her designee, or a reviewer designated by the Director of Provider Investigations.(2) If a qualified party disagrees with the decision of the first appeal, the qualified party may further appeal. This second level appeal is conducted by a reviewer designated by the Director of Provider Investigations.(d) The determination resulting from the second appeal is final and cannot be appealed by any qualified party except Disability Rights Texas or as described in §711.913 (relating to What if the administrator of a state-operated facility disagrees with the second level appeal decision?). Source Note: The provisions of this §711.901 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.901 What is an appeal of the investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195470 03/12/2026 (a) An appeal that is described in this subchapter is not affected by a determination that the confirmed act or acts of abuse, neglect, or exploitation may rise to the level of reportable conduct.(b) The designated perpetrator will not receive notice about his or her right to request an EMR hearing until:(1) the timeframe for all appeals described in this subchapter have expired; or(2) until the second appeal is completed and a confirmed finding that rises to the level of reportable conduct is upheld. Source Note: The provisions of this §711.903 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.903 How is an appeal affected by a determination that the perpetrator's confirmed act of abuse, neglect, or exploitation may rise to the level of reportable conduct? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195471 03/12/2026 (a) In order to be a qualified party to request an appeal, you must be:(1) the administrator of the service provider or their attorney;(2) the CDS employer or their legal representative;(3) the reporter;(4) the victim or alleged victim, or the legal guardian or parent (if the victim or alleged victim is a child); or(5) Disability Rights Texas, only if Disability Rights Texas represents the victim or alleged victim or is authorized by law to represent the victim or alleged victim.(b) An alleged or designated perpetrator may not request an appeal even if they are otherwise a qualified party. An alleged or designated perpetrator may not coerce a provider into requesting an appeal on the alleged perpetrator's behalf. Source Note: The provisions of this §711.905 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.905 Who may request an appeal of the investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195472 03/12/2026 (a) To request an appeal, the qualified party must:(1) complete the required form; and(2) send the completed form either via email to the email address or via mail to the mailing address designated on the form.(b) The victim, alleged victim, legal guardian, parent (if the victim or alleged victim is a child), and reporter may request an appeal by calling the designated phone number. Source Note: The provisions of this §711.907 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.907 How does a qualified party request an appeal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195473 03/12/2026 (a) To request a first level appeal:(1) service providers may request an appeal no later than the 30th calendar day following the date the investigative report was signed and dated by the investigator; and(2) reporters, alleged victims, legal guardians, and Disability Rights Texas may request an appeal no later than the 60th calendar day following the date the investigative report was signed and dated by the investigator.(b) A qualified party has 30 calendar days following the date the first level appeal decision letter is signed to request a second level appeal.(c) APS Provider Investigations may accept a request for appeal after the deadline for good cause as determined by APS Provider Investigations. Source Note: The provisions of this §711.909 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.909 What is the timeline for requesting an appeal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195474 03/12/2026 (a) A first level appeal is conducted by the Director of Provider Investigations or his or her designee, or a reviewer designated by the Director or Provider Investigations, who:(1) analyzes the investigative report and the methodology used to conduct the investigation and makes a decision to sustain, alter, or reverse the original finding;(2) completes the review within 14 calendar days after receipt of the complete appeal request;(3) notifies the appeal requestor of the appeal decision; and(4) notifies the service provider, victim, or reporter, as appropriate, if the finding changed.(b) A second level appeal is conducted by a reviewer designated by the Director of Provider Investigations, who:(1) analyzes the investigative report and makes a decision to sustain, alter, or reverse the original finding;(2) completes the review within 14 calendar days after receipt of the request; and(3) notifies the appeal requestor of the appeal decision; and(4) notifies the service provider, victim, or reporter, as appropriate, if the finding changed. Source Note: The provisions of this §711.911 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.911 How and when is the appeal conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195475 03/12/2026 If the administrator of a state-operated facility disagrees with the second level appeal decision, as referenced in §711.911(b) of this chapter (relating to How and when is the appeal conducted?), then the administrator may contest the decision in accordance with 25 TAC §417.510(g)(2) (relating to Completion of the Investigation) and 40 TAC §3.305(b) (relating to Completion of an Investigation). Source Note: The provisions of this §711.913 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.913 What if the administrator of a state-operated facility disagrees with the second level appeal decision? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195476 03/12/2026 Provider Investigations, in its sole discretion, may designate a person to conduct a review of the investigation records or reopen an investigation to collect additional evidence. If a review of the records and any additional investigation results in a change of the finding, the reviewer or his or her designee will notify the appropriate parties in writing. Source Note: The provisions of this §711.915 adopted to be effective September 1, 2016, 41 TexReg 6218; amended to be effective March 1, 2018, 43 TexReg 903; transferred effective June 15, 2019, as published in the Texas Register May 24, 2019, 44 TexReg 2617. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS J APPEALING THE INVESTIGATION FINDING §711.915 Is a finding ever changed without an appeal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200036 03/12/2026 The purpose of this subchapter is to implement Subchapter I, Chapter 48, Human Resources Code, relating to the Employee Misconduct Registry (EMR), established under Chapter 253, Health and Safety Code, and maintained by the Health and Human Services Commission (HHSC). Source Note: The provisions of this §711.1401 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1401 What is the purpose of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224581 03/12/2026 The following words and terms when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise: (1) Administrative law judge--An attorney who serves as a hearings examiner and conducts an EMR hearing. (2) Agency--An entity, person, facility, or provider, as defined in §711.1406 of this subchapter (relating to How is the term agency defined for the purpose of this subchapter?). (3) APS--The Adult Protective Services division within the Department of Family and Protective Services, which is authorized to conduct investigations of alleged abuse, neglect, or exploitation of certain adults under Chapter 48, Human Resources Code, and certain children under §261.404, Family Code. (4) Designated perpetrator--A person determined by Provider Investigations (PI) to have committed abuse, neglect, or exploitation who may be eligible for inclusion on the Employee Misconduct Registry, when the abuse, neglect or exploitation meets the definition of reportable conduct. (5) DFPS--The Department of Family and Protective Services. (6) Employee--A person who: (A) works for: (i) an agency, whether as an employee contractor, volunteer or agent; or (ii) an individual employer participating in the consumer-directed service option, as defined by Texas Government Code §546.0101; (B) provides personal care services, active treatment, or any other services to an individual receiving agency services, an individual who is a child for whom an investigation is authorized under Family Code §261.404, or an individual receiving services through the consumer-directed service option, as defined by Texas Government Code §546.0101; and (C) is not licensed by the state to perform the services the person performs for the agency or the individual employer participating in the consumer-directed service option, as defined by Texas Government Code §546.0101. (7) EMR--The Employee Misconduct Registry. (8) EMR hearing--An administrative hearing offered to a person who has been found to have committed reportable conduct for the purpose of appealing the finding of reportable conduct as well as the underlying finding of abuse, neglect, or exploitation. (9) Executive Commissioner--The executive commissioner of HHSC or the executive commissioner's designee. (10) HHSC--The Texas Health and Human Services Commission. (11) Individual receiving services: an individual receiving services as provided in §711.3 of this chapter (relating to How are the terms in this chapter defined?). (12) In-home investigation--An investigation conducted by DFPS Adult Protective Services (APS) under Title 40, Texas Administrative Code, Chapter 705 (relating to Adult Protective Services). (13) Provider investigation--An investigation conducted by HHSC Provider Investigations under Chapter 48, Subchapter F, Human Resources Code, or §261.404, Texas Family Code, as applicable. (14) PI--The Provider Investigations program within the Regulatory Services Division of HHSC, which is authorized to conduct investigations of alleged abuse, neglect, or exploitation of certain adults under Chapter 48, Human Resources Code, and certain children under §261.404, Family Code. (15) Reportable conduct--A confirmed or validated finding of abuse, neglect or exploitation that meets the definition in §48.401(5), Human Resources Code, and as further defined in §711.1408 of this subchapter (relating to What is reportable conduct?). Source Note: The provisions of this §711.1402 adopted to be effective July 5, 2020, 45 TexReg 4525; amended to be effective April 1, 2025, 50 TexReg 2210. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1402 How are the terms in this subchapter defined? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200038 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200038&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200038 03/12/2026 (a) This subchapter applies to PI investigations involving an employee as defined in §711.1402 of this subchapter (relating to How are the terms in this subchapter defined?).(b) Notwithstanding subsection (a) of this section, a certified nurse aide who commits reportable conduct while working for an agency is eligible to be reported to the EMR, as provided by §253.001(3), Health and Safety Code. Source Note: The provisions of this §711.1403 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1403 To which investigations does this subchapter apply? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200039 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200039&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200039 03/12/2026 (a) For In-home investigations, the definitions of physical abuse, sexual abuse, verbal or emotional abuse, neglect, and financial exploitation are adopted pursuant to §48.002(c), Human Resources Code, and are found in Title 40, Texas Administrative Code, Chapter 705, Subchapter A (relating to Definitions) in the rules adopted pursuant to §48.002(c) of the Human Resources Code.(b) For provider investigations--the definitions of physical abuse, sexual abuse, verbal or emotional abuse, neglect, and exploitation are adopted pursuant to §48.002(b), Human Resources Code, and are found in Subchapter A of this chapter (relating to Introduction). Source Note: The provisions of this §711.1404 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1404 How are the terms physical abuse, sexual abuse, verbal or emotional abuse, neglect, exploitation, and financial exploitation defined for the purpose of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224582 03/12/2026 (a) For the purpose of this chapter, the term "agency" has the meaning given by §48.401, Human Resources Code, as further clarified in this rule. Any terms used within the definition of "agency" have the meaning given by statute or elaborated upon by this chapter or Title 40, Texas Administrative Code, Chapter 705 (relating to Adult Protective Services). The purpose of this rule is to provide a non-exhaustive list of agencies, the employees of which are subject to being listed on the EMR if they are found to have committed reportable conduct. The list is illustrative and not exclusionary. Employees of agencies not specifically enumerated that are within the meaning of §48.401 continue to be eligible for the EMR without regard to whether the agency is specifically enumerated below. (b) The term "agency" means: (1) a home and community support services agency licensed under Chapter 142, Health and Safety Code; (2) a person exempt from licensure who provides home health, hospice, habilitation, or personal assistance services only to persons receiving benefits under: (A) the home and community-based services (HCS) waiver program; (B) the Texas home living (TxHmL) waiver program; (C) the STAR + PLUS or other Medicaid managed care program under the program's HCS or TxHmL certification; or (D) Texas Government Code §542.0152; (3) an intermediate care facility for individuals with an intellectual disability or related conditions (ICF-IID) licensed under Chapter 252, Health and Safety Code; or (4) a provider investigated by HHSC under Subchapter F, Human Resources Code or §261.404, Family Code. Such providers include: (A) a facility as defined in §711.3 of this chapter (relating to How are the terms in this chapter defined?); (B) a community center, local mental health authority, and local intellectual and developmental disability authority, as defined in §711.3 of this chapter; (C) a person who contracts with a health and human services agency or managed care organization to provide home and community-based services (HCBS) as that term is defined in §48.251, Human Resources Code and which is the umbrella term for various long-term services and supports within the Medicaid program, whether delivered in a fee-for-service, managed care, or other service delivery model, and which includes but is not limited to: (i) Waiver programs including: (I) community living assistance and support services (CLASS); (II) Deaf Blind Multiple Disabilities; (III) HCS; (IV) TxHmL; (V) Medically Dependent Child Program (MDCP); and (VI) Youth Empowerment Services (YES); (ii) Community First Choice; (iii) Texas Dual Eligible Integrated Care Project; (iv) State plan services including: (I) Community attendant services; and (II) Personal attendant services; (v) Managed Care Programs including: (I) HCBS - Adult Mental Health; (II) STAR + PLUS Managed Care program; and (III) STAR Kid Managed Care program; and (vi) any other program, project, waiver demonstration, or service providing long-term services and supports through the Medicaid program; (D) a person who contracts with a Medicaid managed care organization to provide behavioral health services as that term is defined in §48.251 and which include but are not limited to: (i) Targeted Case Management; and (ii) Psychiatric Rehabilitation services; (E) a managed care organization; (F) an officer, employee, agent, contractor, or subcontractor of a person or entity listed in subparagraphs (A) - (E) of this paragraph; and (G) an employee, fiscal agent, case manager, or service coordinator of an individual employer participating in the consumer directed service option, as defined by Texas Government Code §546.0101. Source Note: The provisions of this §711.1406 adopted to be effective July 5, 2020, 45 TexReg 4525; amended to be effective April 1, 2025, 50 TexReg 2210. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1406 How is the term agency defined for the purpose of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200041 03/12/2026 The EMR is a database maintained by HHSC that contains the names of persons who have committed reportable conduct. A person whose name is recorded in the registry is prohibited by law from working for certain facilities or agencies, as provided under Chapter 253, Health and Safety Code. Source Note: The provisions of this §711.1407 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1407 What is the Employee Misconduct Registry? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200042 03/12/2026 (a) Reportable conduct is defined in §48.401, Human Resources Code, as:(1) abuse or neglect that causes or may cause death or harm to an individual receiving agency services;(2) sexual abuse of an individual receiving agency services;(3) financial exploitation of an individual receiving agency services in an amount of $25 or more; and(4) emotional, verbal, or psychological abuse that causes harm to an individual receiving agency services.(b) For purposes of subsection (a) of this section, the terms abuse, neglect, sexual abuse, and financial exploitation have the meanings provided in Title 40, Texas Administrative Code, Chapter 705, Subchapter A (relating to Definitions) or subchapter A of this chapter (relating to Introduction) and incorporated by reference in §711.1404 of this subchapter (relating to How are the terms physical abuse, sexual abuse, verbal or emotional abuse, neglect, exploitation, and financial exploitation defined for the purpose of this subchapter?).(c) For purposes of subsection (a)(1) of this section the term harm means:(1) a significant injury or risk of significant injury, including a fracture, dislocation of any joint, internal injury, a contusion larger than 2 and 1/2 inches, concussion, second or third-degree burn, or any laceration requiring sutures;(2) an adverse health effect that results or is at risk of resulting from failure to receive medications in the amounts or at the times prescribed; or(3) any other harm or risk of harm that warranted, or would reasonably be expected to have warranted, medical treatment or hospitalization.(d) For purposes of subsection (a)(4) of this section, the term harm means substantial harm as evidenced by observable signs of substantial physical or emotional distress or as diagnosed by an appropriate medical professional. Source Note: The provisions of this §711.1408 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1408 What is reportable conduct? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200043 03/12/2026 When HHSC determines that an employee committed reportable conduct, HHSC must provide a written "Notice of Finding" to the employee. The notice must include:(1) a brief summary of the incident that resulted in a confirmed or validated finding of abuse, neglect, or exploitation and a brief explanation of why the finding meets the definition of reportable conduct;(2) a statement of the employee's right to dispute the finding by filing a "Request for EMR Hearing" and the instructions for doing so;(3) a statement that HHSC will submit the employee's name for inclusion in the EMR if the employee accepts the finding of reportable conduct;(4) an explanation of how the employee may obtain a copy of the investigation records;(5) a statement that a person whose name is recorded in the registry is prohibited by law from working for certain facilities or agencies, as provided under Chapters 250 and 253, Health and Safety Code;(6) a statement that HHSC may determine that this situation is an emergency and that the case information or finding may be released immediately to the agency where the employee is or was employed so that the agency may take any precautions it determines necessary to protect clients or persons served;(7) a statement that HHSC reserves the right to make an emergency release of the findings to any subsequent employer of the employee if the employee has access to similar clients or persons served;(8) a statement that the employee is responsible for keeping HHSC timely informed of the employee's current employment and residential contact information, including addresses and phone numbers, pending the outcome of any appeal filed by the employee; and(9) a statement that if the employee fails, without good cause, to file a timely request for an EMR hearing, the employee will be deemed to have waived the employee's rights to dispute the finding and the employee's name will be submitted to the EMR. Source Note: The provisions of this §711.1413 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1413 What notice must HHSC give to an employee before the employee's name is submitted to the EMR? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200044 03/12/2026 (a) The "Notice of Finding" will be mailed to the employee's last known address by first class mail and by certified mail, return receipt requested.(b) If HHSC knows the employee's last known address is incorrect, or if the employee fails to provide an address, HHSC may hand-deliver the Notice of Finding to the employee. The affidavit of the person delivering the notice is proof of such notice.(c) It is the responsibility of the employee to provide HHSC with a valid address where notice can be mailed or, if no address is available, with valid contact information, including telephone numbers. It is also the responsibility of the employee to immediately notify HHSC of any change of address or contact information throughout the investigation and any period of time during which a dispute of the finding is pending. Source Note: The provisions of this §711.1414 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1414 How will the Notice of Finding be provided to an employee and who is responsible for ensuring that HHSC has a valid mailing address for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200045 03/12/2026 (a) An employee may dispute a finding of reportable conduct by submitting a Request for EMR Hearing. The Notice of Finding will contain instructions for filing the Request for EMR Hearing.(b) The employee will be deemed to have accepted the finding of reportable conduct and HHSC will submit the employee's name for inclusion in the EMR if the employee:(1) does not file a Request for EMR Hearing;(2) fails to file the Request for EMR Hearing before the deadline has passed, as provided under §711.1417 of this subchapter (relating to What is the deadline for filing the Request for EMR Hearing?); or(3) files a Request for EMR Hearing, but fails to follow the filing instructions and, as a result, HHSC does not receive the Request for EMR Hearing in a timely manner or cannot determine the matter being disputed. Source Note: The provisions of this §711.1415 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1415 How does an employee dispute a finding of reportable conduct and what happens if the "Request for EMR Hearing" is not filed or not filed properly? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200046 03/12/2026 (a) The employee must file the Request for EMR Hearing no later than 30 calendar days from the date the employee receives the Notice of Finding.(b) A Notice of Finding is presumed received by the employee on the date of delivery as indicated on the certified mail return receipt. If the certified mailing is returned unclaimed, but the regular mailing is not returned, the Notice of Finding will be presumed received on the third business day following the date the notice was mailed to the employee's last known address. A personally delivered Notice of Finding is presumed received on the date of delivery as indicated on the affidavit of the person delivering the notice.(c) If the Request for EMR Hearing is submitted by mail, the envelope must be postmarked no later than 30 days after the date the employee received the Notice of Finding. If the Request for EMR Hearing is hand-delivered or submitted by fax, the request must be received in the appropriate HHSC office by 5:00 p.m., no later than 30 days from the date the employee received the Notice of Finding.(d) If an employee files the Request for EMR Hearing after the deadline, HHSC will notify the employee that the request was not filed by the deadline, no EMR hearing will be granted, and the employee's name will be submitted for inclusion in the EMR.(e) If an employee disputes the fact that the Request for EMR Hearing was filed late, the employee may file a request for a telephonic hearing, to be conducted by an administrative law judge, and limited solely to the issue of whether the Request for EMR Hearing was filed on time. If, as a result of that hearing, the employee proves that the original Request for EMR Hearing was filed on or before the deadline, a separate hearing will be scheduled as soon as possible on the issue of whether the employee committed reportable conduct. Source Note: The provisions of this §711.1417 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1417 What is the deadline for filing the Request for EMR Hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200047 03/12/2026 Prior to a hearing, HHSC, in its sole discretion, may designate a person to conduct a review of the investigation records. If a review of the records results in a reversal of the finding of reportable conduct, HHSC will send the employee a new Notice of Finding, which will indicate that the employee's name will not be submitted to the EMR. If the review does not result in a reversal of the finding of reportable conduct a hearing will be scheduled, as described in this subchapter. Source Note: The provisions of this §711.1419 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1419 Is a finding of reportable conduct ever reversed without conducting a hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200048 03/12/2026 (a) An EMR hearing will be conducted by an administrative law judge with HHSC. The administrative law judge is responsible for scheduling the date, time, and location for the hearing. At the discretion of the administrative law judge, a pre-hearing conference may be conducted in person or by phone prior to the scheduling or conduct of the EMR hearing.(b) The administrative law judge will send the parties a Notice of EMR Hearing providing the date, time, and location for the hearing, as well as the name of the administrative law judge, and how to contact the administrative law judge.(c) The hearing will usually be held in the same HHSC region where the alleged reportable conduct took place. The administrative law judge reserves the right to take all or some of the testimony at the hearing by telephone or video-conference and may consider a request by any party to have the hearing conducted in a different location for good cause.(d) If a criminal case against the employee arises because of the same reportable conduct, HHSC may postpone the EMR hearing until the criminal case resolves. Source Note: The provisions of this §711.1421 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1421 When and where will the EMR hearing take place and who conducts the hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200049 03/12/2026 Yes. Both the employee and HHSC may request that the administrative law judge reschedule the hearing for good cause. Except in cases of emergency, the request to reschedule the hearing must be made no later than three working days prior to the hearing date. The administrative law judge must grant the request if good cause is shown. Source Note: The provisions of this §711.1423 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1423 May an employee or HHSC request that the EMR hearing be rescheduled? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200050 03/12/2026 Yes. An employee may withdraw a Request for EMR Hearing any time before the hearing is conducted. An employee who withdraws a Request for EMR Hearing will be deemed to have accepted the finding of reportable conduct and HHSC will submit the employee's name for inclusion in the EMR. Source Note: The provisions of this §711.1425 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1425 May an employee withdraw a Request for EMR Hearing after it is filed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200033 03/12/2026 (a) If either party fails, without good cause, to appear at a scheduled pre-hearing conference or a hearing on the merits, the administrative law judge may issue a default judgment against the party that failed to appear.(b) A party against whom a default judgment is rendered may, within 10 calendar days of receipt of the default judgment, request a hearing on the issue of whether good cause existed for failing to appear.(c) The administrative law judge may make a determination on the issues of good cause based on a review of the assertions and evidence submitted with the party's request for a good cause hearing or may schedule the matter for a hearing if additional testimony and evidence are deemed necessary for making the good cause finding. If a hearing is scheduled on the issue of good cause for failure to appear, the administrative law judge may limit the hearing solely to the issue of good cause or may combine the hearing with other pre-hearing conference matters or with the hearing on the merits, at the discretion of the administrative law judge.(d) Unless a default judgment for failure to appear is challenged and reversed, as described in subsections (b) and (c) of this section, the default judgment shall be considered the final Hearing Order of HHSC and may not be further appealed except as provided under §711.1431 of this subchapter (relating to How is judicial review requested and what is the deadline?).(e) If a default judgment rendered against an employee becomes the final Hearing Order, HHSC will submit the employee's name for inclusion in the EMR in the same manner as it would after any other final Hearing Order that affirms the finding of reportable conduct, as provided in this subchapter.(f) If a default judgment rendered against HHSC becomes the final Hearing Order, HHSC shall amend its records to reverse the findings at issue in the EMR hearing and shall issue an amended Notice of Finding to the employee reflecting that change. Source Note: The provisions of this §711.1426 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1426 What happens if a party fails to appear at a pre-hearing conference or a hearing on the merits? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200031 03/12/2026 (a) The hearing is similar to a civil court trial, but less formal. The parties to the hearing are the employee and HHSC.(b) The hearing is conducted by an administrative law judge who has the duty to provide a fair and impartial hearing and to ensure that the available and relevant testimony and evidence is presented in an orderly manner. The administrative law judge has authority to administer oaths, issue subpoenas, and order discovery.(c) Prior to the hearing the employee may request a copy of the investigation record, edited to remove the identity of the reporter and any other confidential information to which the employee is not entitled. The administrative law judge will only issue subpoenas or order additional discovery upon request of a party and a finding of good cause for the issuance or order.(d) Both parties will be given the opportunity to present their own testimony and evidence, as well as the testimony and evidence of witnesses. Any person who provides testimony at the hearing will be sworn under oath.(e) Both parties will be given the opportunity to examine the evidence presented by the other party, to cross-examine any witnesses presented by the other party, and to rebut or respond to the evidence presented by the other party.(f) Testimony of a witness may be presented by written affidavit but may be given less weight than the credible testimony of a witness who testifies in person, under oath, subject to cross-examination.(g) Presentation of evidence at the hearing is not restricted under the rules of evidence used in civil cases. The administrative law judge will admit evidence if it is of a type on which a reasonably prudent person commonly relies in the conduct of the person's affairs. Evidence will not be admitted if it is irrelevant, immaterial, unduly repetitious, or precluded by statutory law.(h) Both parties have the right to be represented at the hearing by a person of their choosing who may be, but is not required to be, an attorney.(i) The administrative law judge will assist either party in presenting their evidence and testimony, as needed, to ensure that a complete and proper record is developed at the hearing.(j) The administrative law judge will arrange to have an interpreter available for the hearing if a party or witness requires an interpreter in order to effectively participate in the hearing.(k) The hearing will be recorded by audio or video tape in order to preserve a record of the hearing. A transcription of the hearing tape will not be made or provided unless an employee seeks judicial review, as provided in this subchapter. The costs of transcribing the testimony and preparing the record for judicial review shall be paid by the party who files for judicial review, unless the party establishes indigence as provided in Rule 20 of the Texas Rules of Appellate Procedure.(l) The hearing is closed to the general public consistent with the required statutory confidentiality of records, as outlined in the Texas Human Resources Code, Chapter 48. Only the employee, the employee's representative, and any testifying witnesses may attend the hearing. Source Note: The provisions of this §711.1427 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1427 How is the EMR hearing conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200032 03/12/2026 (a) The administrative law judge will prepare a "Hearing Order" which will be mailed to the employee at the employee's last known mailing address. The Hearing Order must contain the following:(1) separate statements of the findings of fact and conclusions of law that uphold, reverse, or modify the findings as to whether:(A) the employee committed abuse, neglect, or financial exploitation; and(B) the abuse, neglect, or financial exploitation committed by the employee meets the definition of reportable conduct; and(2) if reportable conduct is found to have occurred:(A) a statement of the right of the employee to seek judicial review of the order; and(B) a statement that the finding of reportable conduct will be forwarded to HHSC to be recorded in the EMR unless the employee timely files a petition for judicial review as provided in §711.1431 of this subchapter (relating to How is judicial review requested and what is the deadline?).(b) The executive commissioner may designate a Hearing Order to be published in an Index of Hearing Orders that are deemed to have precedential authority for guiding future decisions and HHSC policy. A Hearing Order must be edited to remove all personal identifying information before publication in the Index of Hearing Orders. Source Note: The provisions of this §711.1429 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1429 How and when is the decision made after the EMR hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200030 03/12/2026 (a) A timely motion for rehearing is a prerequisite to judicial review and must be filed in accordance with Subchapters F and G, Chapter 2001, Government Code. The motion for rehearing must be served on the administrative law judge and on HHSC's attorney of record.(b) To seek judicial review of a Hearing Order, a party must file a petition for judicial review in a Travis County district court, in accordance with Subchapters F and G, Chapter 2001, Government Code.(c) Judicial review by the court is under the substantial evidence rule, as provided by §48.406, Human Resources Code.(d) Unless citation for a petition for judicial review is served on HHSC within 90 days after the date on which the order under review becomes final, HHSC will submit the employee's name for inclusion in the EMR. If valid service of citation is received after the employee's name has been recorded in the registry, HHSC will request that the employee's name be removed from the registry pending the outcome of the judicial review in district court. Source Note: The provisions of this §711.1431 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1431 How is judicial review requested and what is the deadline? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200034 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200034&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200034 03/12/2026 (a) An employee has exhausted the employee's administrative remedies if the employee has been found to have committed reportable conduct and the employee has received or is no longer eligible for:(1) an EMR hearing;(2) a rehearing of the employee's case following an EMR hearing; or(3) judicial review.(b) HHSC takes the following actions once an employee has exhausted the employee's administrative remedies:(1) modifies HHSC's internal records to reflect the final outcome in the case;(2) provides notice of the final outcome in the case to any person or entity that was previously notified of HHSC's findings, if the finding is modified; and(3) sends the employee's name and required information to the EMR if the finding of reportable conduct was sustained. Source Note: The provisions of this §711.1432 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1432 What action does HHSC take when an employee has exhausted the employee's administrative remedies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=200035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 200035 03/12/2026 (a) The sole way to dispute a finding of reportable conduct and submission of the employee's name to the EMR is provided by the procedures in this subchapter. A Request for EMR hearing filed under this subchapter is not a request for a grievance on disciplinary action from an employer.(b) If an employee of a state-operated facility is notified by the employer that the employee is entitled to a grievance on disciplinary action based on a finding of reportable conduct by HHSC, the employee makes a separate request for a grievance hearing in accordance with the employment policies of the employer. A request for a grievance on disciplinary action will not be considered a request for an EMR hearing under this subchapter.(c) When an employee files both a Request for EMR hearing under this subchapter and a grievance on disciplinary action based on HHSC's finding of reportable conduct, the EMR hearing will take place prior to the grievance hearing.(d) The outcome of a grievance on disciplinary action will not change HHSC's finding of reportable conduct. Source Note: The provisions of this §711.1434 adopted to be effective July 5, 2020, 45 TexReg 4525. 1 HEALTH AND HUMAN SERVICES COMMISSION 711 INVESTIGATIONS OF INDIVIDUALS RECEIVING SERVICES FROM CERTAIN PROVIDERS L EMPLOYEE MISCONDUCT REGISTRY §711.1434 What special considerations apply to employees of state-operated facilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203999 03/12/2026 The purpose of this chapter is to establish minimum standards that apply to listed family homes. Source Note: The provisions of this §742.101 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.101 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204000 03/12/2026 For purposes of this chapter, a listed family home:(1) Provides care and supervision in the primary caregiver's own home:(A) For compensation;(B) For three or fewer children who are 13 years of age or younger and not related to the primary caregiver; and(C) For at least four hours a day:(i) Three or more days a week, for three or more consecutive weeks; or(ii) For 40 or more days in a 12-month period; and(2) May not provide care for more than 12 children, including children related to the primary caregiver. Source Note: The provisions of this §742.103 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.103 What is a listed family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204001 03/12/2026 (a) For a listed family home, as described in §742.103 of this subchapter (relating to What is a listed family home?), the permit holder must ensure compliance with all minimum standards in this chapter at all times.(b) Any home that provides care and supervision, as described in §742.103 of this subchapter, is responsible for meeting the requirements in this chapter. If a home operates a listed family home without a permit, the home is still accountable for failing to meet any requirement in this chapter in addition to the legal consequences for operating without a permit. Source Note: The provisions of this §742.105 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.105 Who is responsible for complying with these minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204002 03/12/2026 A listed family home is not required to comply with the minimum standards in this chapter if:(1) The permit holder is receiving federal subsidies from the Texas Workforce Commission; and(2) The home only provides care and supervision to children related to the primary caregiver. Source Note: The provisions of this §742.107 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.107 Is a listed family home that only provides care and supervision for children related to the primary caregiver required to comply with the minimum standards in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204003 03/12/2026 The following pronouns and title have the following meanings when used in this chapter:(1) I, my, you, and your--The primary caregiver in a listed family home, unless otherwise stated.(2) Licensing--The Child Care Regulation department of the Texas Health and Human Services Commission. Source Note: The provisions of this §742.109 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.109 What do certain pronouns or titles mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204004 03/12/2026 The following words and terms used in this chapter have the following meanings unless the context clearly indicates otherwise:(1) Caregiver--A person whose duties include the care, supervision, guidance, and protection of a child or children in care.(2) Children related to the primary caregiver--Children who are children, grandchildren, siblings, great-grandchildren, first cousins, nieces, or nephews of the primary caregiver. This includes any of those relationships that exist due to common ancestry, adoption, or marriage.(3) Health-care professional--A licensed physician, a licensed advanced practice registered nurse (APRN), a licensed vocational nurse (LVN), a licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the license. This does not include physicians, nurses, or other medical personnel who are not licensed in the United States or in the country in which the person practices.(4) Infant--A child from birth through 17 months.(5) Pre-kindergarten age child--A child who is three or four years of age before the beginning of the current school year.(6) Restrictive device--Equipment that places the body of a child in a position that may restrict airflow or cause strangulation; usually, the child is placed in a semi-seated position. Examples of restrictive devices are car seats, swings, bouncy seats, and high chairs.(7) School-age child--A child who is five years of age or older and is enrolled in or has completed kindergarten.(8) Toddler--A child from 18 months through 35 months. Source Note: The provisions of this §742.111 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES A PURPOSE, SCOPE, AND DEFINITIONS §742.111 What do certain words and terms mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204005 03/12/2026 The primary caregiver is the person responsible for ensuring that the listed family home operates in compliance with these minimum standards and the licensing laws. The primary caregiver must:(1) Live in the home where care is provided; and(2) Be the permit holder, unless the primary caregiver forms a business entity that is the permit holder for the home. Source Note: The provisions of this §742.201 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES B CAREGIVERS §742.201 Who is a primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204006 03/12/2026 (a) As the primary caregiver, you must routinely be present in your listed family home during the hours of operation.(b) You may be temporarily absent for limited periods of time only if you designate a substitute caregiver to be in charge of the home during your absence. Substitutes must:(1) Know they are in charge of the home and for how long;(2) Know their responsibilities while in charge;(3) Have access to all information that would be necessary to communicate with parents and state and local authorities; and(4) Have the responsibility from you to run the home in compliance with the minimum standards. Source Note: The provisions of this §742.203 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES B CAREGIVERS §742.203 Must I be present at my home during all hours of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204007 03/12/2026 Primary caregivers and substitute caregivers must:(1) Be at least 18 years of age; and(2) Meet the requirements in Chapter 745, Subchapter F of this title (relating to Background Checks). Source Note: The provisions of this §742.301 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES C CAREGIVER QUALIFICATIONS AND RESPONSIBILITIES §742.301 What types of minimum qualifications must caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204008 03/12/2026 Primary and substitute caregivers:(1) Are responsible for seeing that children are:(A) Treated with courtesy, respect, acceptance, and patience;(B) Not abused, neglected, or exploited; and(C) Released only to a parent or a person designated by a parent;(2) Must demonstrate competency, good judgment, and self-control in the presence of children;(3) Must know and comply with the minimum standards specified in this chapter;(4) Must know each child's name and age;(5) Must supervise children at all times, as specified in §742.305 of this subchapter (relating to What does "supervise children at all times" mean?); and(6) Must interact with children in a positive manner. Source Note: The provisions of this §742.303 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES C CAREGIVER QUALIFICATIONS AND RESPONSIBILITIES §742.303 What general responsibilities do caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204009 03/12/2026 Supervising children at all times means the primary caregiver and substitute caregiver are accountable for each child's care. This includes responsibility for the ongoing activity of each child, appropriate visual and auditory awareness, physical proximity, and knowledge of each child's needs. The caregiver must intervene when necessary to ensure each child's safety. In deciding how closely to supervise children, the caregiver must take into account the:(1) Ages of the children;(2) Individual differences and abilities;(3) Layout of the home and play area; and(4) Neighborhood circumstances, hazards, and risks. Source Note: The provisions of this §742.305 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES C CAREGIVER QUALIFICATIONS AND RESPONSIBILITIES §742.305 What does "supervise children at all times" mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204010 03/12/2026 Primary caregivers are also responsible for:(1) Initiating background checks on caregivers, household members, and anyone else who requires a background check, as specified in Chapter 745, Subchapter F of this title (relating to Background Checks);(2) Obtaining from parents, when admitting a child into care:(A) The child's name and date of birth;(B) The parent's home address and telephone number;(C) The names of other persons the child may be released to;(D) A list of each food a child is allergic too, possible symptoms if the child is exposed to the food, and the steps to take if the child has an allergic reaction; and(E) Authorization to give the child medication, if applicable;(3) Ensuring the following regarding the number of children in care at the home or away from the home:(A) The number of children not related to the primary caregiver never exceeds three; and(B) The total number of children, both related and not related to the primary caregiver, never exceeds 12; and(4) Ensuring parents can visit your home any time during the hours of operation to observe their child, without having to secure prior approval. Source Note: The provisions of this §742.307 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES C CAREGIVER QUALIFICATIONS AND RESPONSIBILITIES §742.307 What additional responsibilities do primary caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206492 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206492 03/12/2026 (a) A caregiver must notify the Department of Family and Protective Services immediately at 1-800-252-5400 if:(1) There is any suspected abuse, neglect, or exploitation;(2) A child dies while in your care; or(3) A child was forgotten in a vehicle or wandered away from your home or care unsupervised.(b) You must notify Licensing immediately if you become aware that a household member, caregiver, or child in care contracts an illness deemed notifiable by the Texas Department of State Health Services.(c) After you ensure the safety of the child, you must notify the parent immediately if the child:(1) Is injured and the injury requires medical treatment by a health-care professional or hospitalization;(2) Shows signs or symptoms of an illness that requires hospitalization;(3) Has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector; or(4) Was forgotten in a vehicle or wandered away from your home or care unsupervised.(d) You must notify the parent of a child of less serious injuries when the parent picks the child up from the home. Less serious injuries include, minor cuts, scratches, and bites from other children requiring first aid treatment by caregivers.(e) You must notify the parent of each child attending the home in writing within 48 hours after you become aware that a household member, caregiver, or child in care contracts an illness deemed notifiable by the Texas Department of State Health Services; or(f) You must notify Licensing in writing within 15 days of:(1) Relocating your listed family home; or(2) Closing the home. Source Note: The provisions of this §742.401 adopted to be effective March 10, 2021, 46 TexReg 1247; amended to be effective October 25, 2021, 46 TexReg 7215. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES D NOTIFICATIONS AND LIABILITY INSURANCE REQUIREMENTS §742.401 What are the notification requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204012 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Have liability insurance coverage:(A) Of at least $300,000 for each occurrence of negligence; and(B) That covers injury to a child that occurs while the child is in your care, regardless of whether the injury occurs on or off the premises of your home; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit to operate a listed family home. Source Note: The provisions of this §742.403 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES D NOTIFICATIONS AND LIABILITY INSURANCE REQUIREMENTS §742.403 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204013 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §742.403 of this subchapter (relating to What are the liability insurance requirements?) if you are unable to carry the insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the home; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you are unable to carry the liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit to operate a listed family home. Your notification must include the reason that you are unable to carry the insurance. Source Note: The provisions of this §742.405 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES D NOTIFICATIONS AND LIABILITY INSURANCE REQUIREMENTS §742.405 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204014 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §742.403 of this subchapter (relating to What are the liability insurance requirements?), then you must notify a child's parent in writing that you do not carry liability insurance before you admit a child into your care.(b) If you received your permit to operate a listed family home before April 25, 2021, and cannot obtain the liability insurance by that date, then you must notify the parents of children in your care that you do not carry the insurance by May 25, 2021.(c) If you previously carried the liability insurance and you subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care that you do not carry the insurance, in writing, within 30 days after you stop carrying it.(d) You may use Form 2962, Attachment A, Parental Notification of Lack of Required Liability Insurance, located on Licensing's provider website to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parent of each child in your care. Source Note: The provisions of this §742.407 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES D NOTIFICATIONS AND LIABILITY INSURANCE REQUIREMENTS §742.407 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204015 03/12/2026 Basic care for an infant must include:(1) Giving individual attention to the infant including, playing, talking, cuddling, and holding;(2) Holding and comforting the infant when the infant is upset;(3) Giving prompt attention to the physical needs of the infant, such as feeding and diapering;(4) Talking to the infant while you are feeding, changing, and holding the infant, such as naming objects, singing, or saying rhymes;(5) Storing objects that could cause choking (objects that are less than 1 and 1/4 inches in diameter) out of the infant's reach;(6) Providing or having the parent provide an individual crib or play yard (also known as a play pen) for each non-walking infant younger than 12 months of age to sleep in; and(7) Providing or having the parent provide an individual cot, bed, or mat that is waterproof or washable for each walking infant to sleep or rest on. Source Note: The provisions of this §742.501 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.501 What are the basic care requirements for an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204016 03/12/2026 (a) Each crib or play yard (also known as a play pen), whether provided by the home or the child's parent, must have a firm, flat mattress that the manufacturer designed specifically for the crib or play yard model number that snugly fits the sides of the crib or play yard. You may not supplement the mattress with additional foam material or pads.(b) Each crib or play yard must be bare for an infant younger than 12 months of age, except for a tight-fitting sheet and a mattress cover to protect against wetness. The mattress cover, whether provided by the home or the parent, must:(1) Be designed specifically for the size and type of crib and crib mattress that the cover is being used with;(2) Be tight fitting and thin; and(3) Not be designed to make the sleep surface softer. Source Note: The provisions of this §742.503 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.503 What safety requirements must my cribs meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204017 03/12/2026 (a) You may not use a bean bag, waterbed, or a foam pad as sleeping equipment for an infant.(b) An infant may not sleep in a restrictive device, unless you have a signed statement from a health-care professional stating that it is medically necessary for the infant to sleep in a restrictive device. If an infant falls asleep in a restrictive device, you must remove the infant from the device and place the infant in a crib as soon as possible. Source Note: The provisions of this §742.505 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.505 What types of sleeping equipment am I prohibited from using with infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204018 03/12/2026 (a) You must place an infant who is not yet able to turn over without assistance in a face-up sleeping position, unless you have a signed statement from a health-care professional stating that it is medically necessary for the infant to sleep in a different sleeping position.(b) You may not lay a swaddled infant down to sleep or rest on any surface at any time, unless you have a signed statement from a health-care professional stating it is medically necessary for the infant to be swaddled while the infant is sleeping.(c) An infant's head, face, or crib must not be covered by items such as blankets, linens, or clothing at any time. Source Note: The provisions of this §742.507 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.507 What additional requirements apply when an infant is sleeping or resting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209257 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209257 03/12/2026 When an infant is positioned for tummy time activities, you must:(1) Ensure that you can see and hear the infant;(2) Move the infant into another position as necessary to maintain the infant's comfort and safety; and(3) If the infant has fallen asleep, move the infant immediately into a face-up position as required by §742.507(a) of this subchapter (relating to What additional requirements apply when an infant is sleeping or resting?). Source Note: The provisions of this §742.508 adopted to be effective June 13, 2022, 47 TexReg 3465. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.508 What are the requirements when an infant is engaged in tummy time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204019 03/12/2026 Basic care for a toddler must include:(1) Giving individual attention to the toddler, including playing, talking, cuddling, and holding;(2) Holding and comforting a toddler when the toddler is upset;(3) Maintaining routines, such as feeding, diapering, sleeping, and indoor and outdoor play during the same time each day, as closely as possible;(4) Storing objects that could cause choking (objects that are less than 1 and 1/4 inches in diameter) out of the toddler's reach; and(5) Providing, or having the parent provide, an individual cot, bed, or mat that is waterproof or washable for each toddler to sleep or rest on. Source Note: The provisions of this §742.509 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.509 What are the basic care requirements for a toddler? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204020 03/12/2026 Basic care for a pre-kindergarten age child must include:(1) Giving individual attention to the child;(2) Encouraging the child to communicate and express feelings in appropriate ways; and(3) Providing, or having the parent provide, an individual cot, bed, or mat that is waterproof or washable for each toddler to sleep or rest on. Source Note: The provisions of this §742.511 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.511 What are the basic care requirements for a pre-kindergarten age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204021 03/12/2026 Basic care for a school-age child must include:(1) Giving individual attention to the child;(2) Encouraging the child to converse with adults; and(3) Providing physical care routines that are appropriate to the child's developmental needs. Source Note: The provisions of this §742.513 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES E BASIC CARE REQUIREMENTS §742.513 What are the basic care requirements for a school-age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204022 03/12/2026 Discipline and guidance must be:(1) Individualized and consistent for each child;(2) Appropriate to the child's level of understanding;(3) Directed toward teaching the child acceptable behavior and self-control; and(4) A positive method of discipline and guidance that encourages self-esteem, self-control, and self-direction, including:(A) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;(B) Reminding a child of behavior expectations daily by using clear, positive statements;(C) Redirecting behavior using positive statements; and(D) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per the year of the child's age. Source Note: The provisions of this §742.601 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES F DISCIPLINE AND GUIDANCE §742.601 What methods of discipline and guidance may I use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204023 03/12/2026 (a) You may not use or threaten to use corporal punishment with any child in care. Corporal punishment is the infliction of physical pain on a child as a means of controlling or managing behavior, including hitting or spanking a child with a hand or an instrument or slapping or thumping a child.(b) In addition to corporal punishment, prohibited discipline or guidance techniques include:(1) Any harsh, cruel, or unusual treatment of any child;(2) Punishment associated with food, naps, or toilet training;(3) Pinching, shaking, or biting a child;(4) Putting anything in or on a child's mouth;(5) Humiliating, ridiculing, rejecting, or yelling at a child;(6) Subjecting a child to harsh, abusive, or profane language;(7) Placing a child in a locked or dark room, bathroom, or closet; and(8) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age, including requiring a child to remain in a restrictive device. Source Note: The provisions of this §742.603 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES F DISCIPLINE AND GUIDANCE §742.603 What types of punishment, discipline, or guidance are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204024 03/12/2026 (a) You must offer a child a meal or snack every three hours, unless the child is sleeping.(b) Parents may provide meals and snacks for their children instead of you providing them.(c) You must ensure a supply of drinking water is always available to each child. You must serve water at every snack, mealtime, and after active play.(d) All food and drinks must be of safe quality. You must store, prepare, distribute, and serve food and drinks under sanitary and safe conditions.(e) You must not use food as a reward. Source Note: The provisions of this §742.701 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES G NUTRITION AND FOOD §742.701 What are the basic food requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204025 03/12/2026 (a) If the child has a food allergy, you must ensure the child does not have access to foods that will cause an allergic reaction.(b) If a child shows symptoms of an allergic reaction, you must follow the steps to be taken for an allergic reaction that the parent provided at admission. Source Note: The provisions of this §742.703 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES G NUTRITION AND FOOD §742.703 How should I care for a child with a food allergy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204026 03/12/2026 (a) You must clean, repair, and maintain your listed family home, grounds, pool, hot tub, and equipment to protect the health safety of the children in your care, including:(1) Keeping all parts of your listed family home used by children well heated, lighted, and ventilated;(2) Having at least one working sink and flushing toilet in the home; and(3) Sanitizing toys and equipment that are placed in a child's mouth or are otherwise contaminated by food, body secretions, or excrement.(b) You must clearly mark cleaning supplies and hazardous materials and ensure that they are inaccessible to children.(c) Caregivers should wash their hands and children's hands often.(d) All areas accessible to a child must be free from hazards.(e) During operating hours, people must not consume or be under the influence of alcohol or controlled substances in the home, during transportation, or on field trips.(f) During operating hours, people must not smoke any e-cigarette, vaporizer, or tobacco product or otherwise use any tobacco product in your home, in the garage, on the playground, in transportation vehicles, or during field trips. Source Note: The provisions of this §742.801 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.801 How do I ensure a healthy environment for children at my home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204027 03/12/2026 (a) Medication in this chapter means:(1) A prescription medication; or(2) A non-prescription medication, excluding topical ointments such as diaper ointment, insect repellant, or sunscreen.(b) Before you may give medication to a child in care, the child's parent must authorize you to give the medication to the child. The authorization must be:(1) In writing, signed, and dated;(2) In an electronic format that is capable of being viewed and saved; or(3) By telephone to administer a single dose of a medication.(c) You must administer medication as required on the medication's label instructions, unless amended in writing by the prescribing health-care professional.(d) Parental authorization to give medication is only good for one year. The child's parent must give you a new authorization in order for you to continue giving the child medication after the year expires.(e) You may administer medication to a child without parental authorization in a medical emergency to prevent the death or serious bodily injury of the child. Source Note: The provisions of this §742.803 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.803 What are the medication requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204028 03/12/2026 If a child in your care requires the immediate medical attention of a health-care professional, you must contact emergency medical services or take the child to the nearest emergency room after you have ensured the supervision of the other children in the home. Source Note: The provisions of this §742.805 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.805 How should I respond to an illness or injury that requires the immediate attention of a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206493 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206493 03/12/2026 If your home maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, you must adopt and implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in 25 TAC Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and Texas Health and Safety Code §773.0145. Source Note: The provisions of this §742.806 adopted to be effective October 25, 2021, 46 TexReg 7215. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.806 What are the requirements if my home chooses to maintain and administer unassigned epinephrine auto-injectors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204029 03/12/2026 (a) You must maintain constant and active supervision when a child is in or around water.(b) When an infant or toddler is taking part in a water activity, there must always be one caregiver for each infant or toddler who is wading, bathing, or swimming.(c) You must take precautionary measures to protect the safety of a non-swimmer of any age.(d) You must not allow children to swim in a lake, pond, river, or similar body of water.(e) You may allow children to wade in a wading pool of less than two feet of water if you are present and have completed an online water safety course. Otherwise, you may allow children to swim or wade in a swimming pool or wading pool only if a lifeguard is on duty. Source Note: The provisions of this §742.807 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.807 What are the water activity and swimming requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204030 03/12/2026 (a) You must account for all children exiting a vehicle before leaving the vehicle unattended.(b) You must abide by all state laws, including:(1) Never leaving a child unattended in a vehicle;(2) Always using a child safety seat system (an infant safety seat, rear-facing convertible safety seat, forward facing safety seat, booster seat), safety vest, harness, or safety belt, as appropriate to the child's age, height, and weight and according to the manufacturer's instructions, for children as required by law;(3) Always using a safety belt for adults; and(4) Requiring the driver while transporting children to:(A) Have proof of automobile liability insurance; and(B) Carry a current driver's license. Source Note: The provisions of this §742.809 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.809 What are the transportation requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204031 03/12/2026 (a) You must have an emergency preparedness plan that addresses the types of emergencies most likely to occur in your area, including:(1) An evacuation of your home to a designated safe area in an emergency such as a fire or gas leak;(2) A relocation of the children and caregivers to a designated, alternate shelter in an emergency such as a flood, a hurricane, medical emergency, or communicable disease outbreak; and(3) The sheltering and lock-down of children and caregivers within your home to temporarily protect them from situations such as a tornado, volatile person on the premises, or an endangering person in the area.(b) You must practice the emergency preparedness plan on a routine basis. Source Note: The provisions of this §742.811 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.811 What type of emergency preparedness plan must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204032 03/12/2026 (a) Your home must have a fire extinguisher that is serviced according to the manufacturer's instructions, or as required by the state or local fire marshal.(b) Your home must have a smoke detector and you must replace the batteries annually.(c) If your home uses gas or propane or your garage is directly connected to your home, then your home must have a carbon monoxide detector and you must replace the batteries annually. Source Note: The provisions of this §742.813 adopted to be effective March 10, 2021, 46 TexReg 1247. 1 HEALTH AND HUMAN SERVICES COMMISSION 742 MINIMUM STANDARDS FOR LISTED FAMILY HOMES H HEALTH AND SAFETY PRACTICES §742.813 What are the Fire Safety Requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190868 03/12/2026 The following words have the following meanings when used in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated.(2) We, us, our, and Licensing--The Licensing Division of the Department of Family and Protective Services (DFPS). Source Note: The provisions of this §743.1 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE A DEFINITIONS AND SERVICES §743.1 What do certain pronouns mean as used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190869 03/12/2026 The following words have the following meanings in this chapter:(1) Caregiver--A person counted in the child/caregiver ratio whose duties include direct care, supervision, guidance, and protection of a child in your care. Caregivers may be employees, contractors, or volunteers.(2) Child--A child 13 years old or younger who is in your care.(3) Infant--A child in your care from birth through 17 months.(4) Primary Caregiver--A caregiver that is also responsible for being available to other caregivers during any child-care hours of operation and for ensuring that all children in care are adequately supervised per §743.109 of this title (relating to How many caregivers are required?).(5) Resident--An adult resident of your operation.(6) Supplemental caregiver--A person who is not counted in the child/caregiver ratio but provides direct care, supervision, guidance, or protection of a child in your care. Source Note: The provisions of this §743.3 adopted to be effective September 1, 2010, 35 TexReg 7465; amended to be effective March 1, 2012, 37 TexReg 913; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE A DEFINITIONS AND SERVICES §743.3 What do certain words and terms mean in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190870 03/12/2026 (a) Child care is regulated under this chapter if it is provided:(1) At a temporary shelter, such as a family violence or homeless shelter;(2) Only for children temporarily residing with a parent at the shelter;(3) While the child's resident parent is away from the shelter;(4) On a recurring and scheduled basis; and(5) For at least four hours per day and three or more days per week.(b) If you also offer care for the children of employees, the children of non-resident clients, or any other non-resident children, your entire child-care program is regulated as a child-care center and must follow the requirements in Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers).(c) If you only offer care for children while the resident parent is on the shelter premises, then the program is exempt from regulation. If you provide care for both children whose parents are on the premises and children whose parents are away from the shelter, all of the child care is regulated under this chapter unless the two groups of children are separated. Source Note: The provisions of this §743.5 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE A DEFINITIONS AND SERVICES §743.5 What child care is regulated under this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190871 03/12/2026 You must: (1) Provide the location of your operation, so that we may conduct inspections and investigations, by giving us: (A) Your location address; or (B) A method to immediately contact your operation that allows our staff to obtain your location address within 30 minutes; (2) Provide in writing to Licensing any change in location of the shelter care operation, or change in the method to contact your operation for location purposes, at least 30 days before the change occurs; (3) Provide in writing to Licensing any changes to your correspondence address or telephone number before the change occurs; (4) Allow us to inspect your operation during its hours of operation, as outlined in §745.8407(6) of this title (relating to When will Licensing inspect and/or investigate an operation?); (5) Post at your operation the: (A) Permit we issue you; and (B) Licensing notice Keeping Children Safe; (6) Observe the conditions and restrictions of your permit; (7) Maintain true, current, accurate, and complete records at your operation for us to review, as required by this chapter and any other applicable law or rule; and (8) Comply with the applicable Child Care Licensing laws found in Chapter 42 of the Human Resources Code, the applicable minimum standards, and other applicable law and rule. Source Note: The provisions of this §743.7 adopted to be effective September 1, 2010, 35 TexReg 7465; amended to be effective March 1, 2012, 37 TexReg 913; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE A DEFINITIONS AND SERVICES §743.7 What are my operational responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190872 03/12/2026 Residents providing care for the children of other residents are not regulated by Licensing. Source Note: The provisions of this §743.9 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE A DEFINITIONS AND SERVICES §743.9 If residents provide care for other residents' children, is this subject to regulation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190873 03/12/2026 (a) Primary caregivers must:(1) Be at least 18 years of age;(2) Have a high school diploma or its equivalent; and(3) Meet the background check requirements in this subchapter.(b) Caregivers must:(1) Be at least 14 years of age and at least two years older than the oldest child in their care; and(2) Meet the background check requirements in this subchapter.(c) Supplemental caregivers must meet the background check requirements in this subchapter. Source Note: The provisions of this §743.101 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE B PERSONNEL AND TRAINING §743.101 What are the minimum qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190879 03/12/2026 (a) Within 30 days after beginning duties, primary caregivers, caregivers, and supplemental caregivers must complete the following training:(1) A presentation on your applicable operational policies, including discipline;(2) An overview of signs of child abuse, neglect, and sexual abuse and the responsibility for reporting these;(3) Emergency procedures, including fire, severe weather, volatile person on the premises, and severe injury or illness of a child;(4) Prevention and spread of communicable disease; and(5) The use and location of fire extinguishers and first-aid equipment.(b) Primary caregivers must, within 30 days after hire and annually thereafter, have at least one hour of training regarding the following topics:(1) Recognizing and preventing shaken baby syndrome;(2) Preventing sudden infant death syndrome; and(3) Understanding early childhood brain development.(c) Each year, primary caregivers must obtain at least 15 clock hours of training relevant to child care, such as child development.(d) At all times, at least one caregiver counted in the child-to-caregiver ratio must have CPR certification.(e) At all times, at least one caregiver counted in the child-to-caregiver ratio must have first-aid certification. Source Note: The provisions of this §743.103 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE B PERSONNEL AND TRAINING §743.103 What training is required? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=193465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 193465 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=193465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 193465 03/12/2026 (a) Shelter care operations must comply with the background check requirements found in Subchapter F of Chapter 745 of Title 40 (relating to Background Checks).(b) You do not have to submit a request for a background check on a person 14 years of age or older who resides at the shelter, as required by §745.605(a)(6)(A) of Title 40 (relating to For whom must I submit requests for background checks?), unless the person is otherwise required to have a background check under §745.605(a). For example, you must request a background check for a person who resides at the shelter if the person is a caregiver at the operation. Source Note: The provisions of this §743.105 adopted to be effective January 13, 2019, 43 TexReg 8124. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE B PERSONNEL AND TRAINING §743.105 What are the background check requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190874 03/12/2026 For primary caregivers, caregivers, and supplemental caregivers, you must have a record at the operation that includes at least:(1) Proof that the person meets the age and education requirements in §743.101 of this title (relating to What are the minimum qualifications?);(2) Proof of required background check(s); and(3) Documentation that training requirements have been met. Source Note: The provisions of this §743.107 adopted to be effective September 1, 2010, 35 TexReg 7465; amended to be effective March 1, 2012, 37 TexReg 913; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE B PERSONNEL AND TRAINING §743.107 What personnel records are required? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190875 03/12/2026 (a) At least one primary caregiver must be on duty and available to other caregivers during all child-care hours of operation.(b) Each primary caregiver or caregiver may not be responsible for more than 12 children five years old or younger. Children under one year old count as two children.(c) Each primary caregiver or caregiver may not be responsible for more than 28 children six years old and older.(d) When age groups are mixed, there must be at least one primary caregiver or caregiver per 20 children, with no more than 12 children in the group five years old or younger.(e) The primary caregiver is responsible for ensuring that all children in care are adequately supervised.(f) If a child is attending a therapeutic activity, which the child would attend whether or not he was in your child-care program, the child is not considered to be in the child-care program for the duration of the therapeutic activity.(g) If a child is attending an activity sponsored by a volunteer organization, which the child would attend whether or not he was in your child-care program, the child is not considered to be in the child-care program for the duration of the activity sponsored by the volunteer organization. Source Note: The provisions of this §743.109 adopted to be effective March 1, 2012, 37 TexReg 913; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE B PERSONNEL AND TRAINING §743.109 How many caregivers are required? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190876 03/12/2026 (a) You must report the following types of serious incidents if they occur when the child is in your child-care program. The reports must be made to the following entities, and the reporting must be within the specified time frames: Attached Graphic(b) You must report the following types of serious incidents involving your operation or an employee to the following entities within the specified time frame: Attached Graphic Source Note: The provisions of this §743.201 adopted to be effective September 1, 2010, 35 TexReg 7465; amended to be effective March 1, 2012, 37 TexReg 913; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE C SERIOUS INCIDENT REPORTING §743.201 When must I report a serious incident to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190877 03/12/2026 In addition to reporting serious incidents, you must inform your employees of the duty to report suspected abuse, neglect, or exploitation as required by the Texas Family Code, §261.101. Source Note: The provisions of this §743.203 adopted to be effective September 1, 2010, 35 TexReg 7465; transferred effective May 15, 2018, as published in the Texas Register May 4, 2018, 43 TexReg 2799. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE C SERIOUS INCIDENT REPORTING §743.203 What are my responsibilities regarding the report of abuse, neglect, or exploitation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206494 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206494 03/12/2026 If your operation maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, you must:(1) Adopt and implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in 25 TAC Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and Texas Health and Safety Code §773.0145; and(2) Notify the child's parent, immediately after ensuring the safety of the child, if the child has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector. Source Note: The provisions of this §743.301 adopted to be effective October 25, 2021, 46 TexReg 7215. 1 HEALTH AND HUMAN SERVICES COMMISSION 743 MINIMUM STANDARDS FOR SHELTER CARE D SAFETY PRACTICES §743.301 What are the requirements if my operation chooses to maintain and administer unassigned epinephrine auto-injectors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187733 03/12/2026 The purpose of this chapter is to set forth the minimum standards that apply to operations exclusively providing before and after-school care services as defined by the Human Resources Code (HRC) §42.002(20) and school-age program services as defined by the HRC §42.002(21). Source Note: The provisions of this §744.101 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS A PURPOSE, SCOPE, AND DEFINITIONS §744.101 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187734 03/12/2026 The minimum standards in this chapter apply to:(1) Day-care operations licensed to provide before and/or after-school care program services;(2) Day-care operations licensed to provide school-age program services;(3) Any unlicensed day-care operation that requires a license per Human Resources Code (HRC), Chapter 42, because the operation provides before and/or after-school program services; and(4) Any unlicensed day-care operation that requires a license per HRC, Chapter 42, because the operation provides school-age program services. Source Note: The provisions of this §744.111 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS A PURPOSE, SCOPE, AND DEFINITIONS §744.111 What types of operations do these minimum standards apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187735 03/12/2026 (a) For a licensed before or after-school program or school-age program, the permit holder must ensure compliance with all minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of child-care programs or activities that the operation does not offer. For example, if we license the operation to offer a before and after-school program, the operation does not have to comply with minimum standards that apply to nighttime-care programs; however, the operation must comply with all other minimum standards.(b) For an unlicensed before or after-school program or school-age program that is subject to Licensing's regulation, the operation's director, owner, or person overseeing the operation or other controlling person who has the ability to influence or direct the operation's management, expenditures, or policies must ensure compliance with all minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of child-care programs or activities that the unlicensed operation does not offer. Source Note: The provisions of this §744.113 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS A PURPOSE, SCOPE, AND DEFINITIONS §744.113 Who is responsible for complying with these minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212659 03/12/2026 The following pronouns and words have the following meanings when used in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated.(2) We, us, our, and Licensing--The Child Care Regulation department of the Texas Health and Human Services Commission (HHSC). Source Note: The provisions of this §744.121 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexRg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS A PURPOSE, SCOPE, AND DEFINITIONS §744.121 What do certain pronouns mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220702 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220702 03/12/2026 The words and terms used in this chapter have the meanings assigned to them under §745.21 of this title (relating to What do the following words and terms mean when used in this chapter?), unless another meaning is assigned in this section or another subchapter or unless the context clearly indicates otherwise. In addition, the following words and terms used in this chapter have the following meanings unless the context clearly indicates otherwise:(1) Activity plan--A written plan that outlines the daily routine and activities in which a group of children will engage while in your care. The plan is designed to meet the children's cognitive, language, social, emotional, and physical developmental strengths and needs.(2) Activity space--An area or room used for children's activities, including areas separate from a group's classroom.(3) Administrative and clerical duties--Duties that involve the administration of an operation, such as bookkeeping, enrolling children, answering the telephone, and collecting fees.(4) Admission--The process of enrolling a child in an operation. The date of admission is the first day the child is physically present at the operation.(5) Adult--A person 18 years old and older.(6) Age-appropriate--Activities, equipment, materials, curriculum, and environment, including the child's assigned classroom, that are developmentally consistent with the developmental or chronological age of the child being served.(7) Attendance--When referring to a child's attendance, the physical presence of a child at the operation on any given day or at any given time, as distinct from the child's enrollment in the operation.(8) Before or after-school program--An operation that provides care before and after or before or after the customary school day and during school holidays, for at least two hours a day, three days a week, to children who attend pre-kindergarten through grade six.(9) Body of water--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D (relating to Sanitation and Safety of Facilities Used by Public).(10) Caregiver--A person who is counted in the child to caregiver ratio, whose duties include the supervision, guidance, and protection of a child. As used in this chapter, a caregiver must meet the minimum education, work experience, and training qualifications required under Subchapter D of this chapter (relating to Personnel). A caregiver is usually an employee, but may also be a substitute, volunteer, or contractor, as outlined in paragraph (16) of this section and Subchapter D, Division 5 of this chapter (relating to Substitutes, Volunteers, and Contractors).(11) Certified Child-Care Professional Credential--A credential given by the National Early Childhood Program Accreditation to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(12) Certified lifeguard--A person who has been trained in life saving and water safety by a qualified instructor, from a recognized organization that awards a certificate upon successful completion of the training. The certificate is not required to use the term "lifeguard," but you must be able to document that the certificate is current, relevant to the type of water activity in which children will engage, and represents the type of training described.(13) CEUs--Continuing education units. A standard unit of measure for adult education and training activities. One CEU equals 10 clock hours of participation in an organized, continuing-education experience, under responsible, qualified direction and instruction. Although a person may obtain a CEU in many of the same settings as clock hours, the CEU provider must meet the criteria established by the International Association for Continuing Education and Training to be able to offer the CEU.(14) Child Development Associate Credential--A credential given by the Council for Professional Recognition to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(15) Clock hour--An actual hour of documented:(A) Attendance at instructor-led training, such as seminars, workshops, conferences, early childhood classes, and other planned learning opportunities, provided by an individual or individuals, as specified in §744.1319(a) of this chapter (relating to Must the training for my caregivers and the director meet certain criteria?); or(B) Self-instructional training that was created by an individual or individuals, as specified in §744.1319(a) and (b) of this chapter, or self-study training.(16) Contract service provider--A person or entity contracting with the operation to provide a service, whether paid or unpaid. Also referred to as "contract staff" and "contractor" in this chapter.(17) Corporal punishment--The infliction of physical pain on a child as a means of controlling behavior. This includes spanking, hitting with a hand or instrument, slapping, pinching, shaking, biting, or thumping a child.(18) Days--Calendar days, unless otherwise stated.(19) Director--An adult you designate to have daily, on-site responsibility for your operation, including maintaining compliance with the minimum standards, rules, and laws. As this term is used in this chapter, a director may be an operation director, program director, or site director, unless the context clearly indicates otherwise.(20) Employee--A person an operation employs full-time or part-time to work for wages, salary, or other compensation. Employees are all of the operation staff, including caregivers, kitchen staff, office staff, maintenance staff, the assistant director, all directors, and the owner, if the owner is ever on site at the operation or transports a child.(21) Enrollment--The list of names or number of children who have been admitted to attend an operation for any given period of time; the number of children enrolled in an operation may vary from the number of children in attendance on any given day.(22) Entrap--A component or group of components on equipment that forms angles or openings that may trap a child's head by being too small to allow the child's body to pass through, or large enough for the child's body to pass through but too small to allow the child's head to pass through.(23) Field trips--Activities conducted away from the operation.(24) Food service--The preparation or serving of meals or snacks.(25) Frequent--More than two times in a 30-day period. Note: For the definition of "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title (relating to What words must I know to understand this subchapter?).(26) Garbage--Waste food or items that when deteriorating cause offensive odors and attract rodents, insects, and other pests.(27) Governing body--A group of persons or officers of a corporation or other type of business entity having ultimate authority and responsibility for the operation.(28) Grounds--Includes any parcel of land where the operation is located and any building, other structure, body of water, play equipment, street, sidewalk, walkway, driveway, parking garage, or parking lot on the parcel. Also referred to as "premises" in this chapter.(29) Group activities--Activities that allow children to interact with other children in large or small groups. Group activities include storytelling, finger plays, show and tell, organized games, and singing.(30) Hazardous materials--Any substance or chemical that is a health hazard or physical hazard as determined by the Environmental Protection Agency. Also referred to as "toxic materials" and "toxic chemicals" in this chapter.(31) Health-care professional--A licensed physician, a licensed advanced practice registered nurse (APRN), a licensed vocational nurse (LVN), a licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the license. This does not include physicians, nurses, or other medical personnel who are not licensed in the United States or in the country in which the person practices.(32) Health check--A visual or physical assessment of a child to identify potential concerns about a child's health, including signs or symptoms of illness and injury, in response to changes in the child's behavior since the last date of attendance.(33) High school equivalent--(A) Documentation of a program recognized by the Texas Education Agency (TEA) or other public educational entity in another state, which offers similar training on reading, writing, and math skills taught at the high school level, such as a General Educational Development (GED) certificate; or(B) Confirmation that the person received home-schooling that adequately addressed basic competencies such as basic reading, writing, and math skills, which would otherwise have been documented by a high school diploma.(34) Individual activities--Opportunities for the child to work independently or to be away from the group but supervised.(35) Inflatable--An amusement ride or device, consisting of air-filled structures designed for use by children, as specified by the manufacturer, which may include bouncing, climbing, sliding, or interactive play. They are made of flexible fabric, kept inflated by continuous air flow by one or more blowers, and rely upon air pressure to maintain their shape.(36) Instructor-led training--Training characterized by the communication and interaction that takes place between the student and the instructor. The training must include an opportunity for the student to interact with the instructor to obtain clarifications and information beyond the scope of the training materials. For such an opportunity to exist, the instructor must communicate with the student in a timely fashion, including answering questions, providing feedback on skills practice, providing guidance or information on additional resources, and proactively interacting with students. Examples of this type of training include, classroom training, web-based on-line facilitated learning, video-conferencing, or other group learning experiences.(37) Janitorial duties--Those duties that involve the cleaning and maintenance of the operation's building, rooms, furniture, etc. Cleaning and maintenance include such duties as cleansing carpets, washing cots, and sweeping, vacuuming, or mopping a restroom or a classroom. Sweeping up after an activity or mopping up a spill in a classroom that is immediately necessary for the children's safety is not considered a janitorial duty.(38) Local sanitation official--A sanitation official designated by the city or county government.(39) Multi-site operations--Two or more operations owned by the same person or entity, but the operations have separate permits. These operations may have centralized business functions, record keeping, and leadership.(40) Natural environment--Settings that are natural or typical for all children of the same age without regard to ability or disability. For example, a natural environment for learning social skills is a play group of peers.(41) Nighttime care--Care given on a regular or frequent basis to children who are starting or continuing their night sleep, or to children who spend the night or part of the night at the operation between the hours of 9:00 p.m. and 6:00 a.m.(42) Operation--A person or entity offering a before or after-school program or school-age program that is subject to Licensing's regulation. An operation includes the grounds where the program is offered, any person involved in providing the program, and any equipment used in providing the program.(43) Operation director--A director at your operation who is not supervised by a program director. An operation that has an operation director cannot have a program director or a site director.(44) Owner--The sole proprietor, partnership, corporation, or other type of business entity who owns the operation.(45) Permit holder--The owner of the operation that is granted the permit.(46) Permit is no longer valid--For purposes of this chapter, a permit remains valid through the renewal process. A permit only becomes invalid when your:(A) Operation voluntarily closes;(B) Operation must close because of an enforcement action in Chapter 745, Subchapter L of this title (relating to Enforcement Actions);(C) Permit expires according to §745.481 of this title (relating to When does my permit expire?); or(D) Operation must close because its permit is automatically revoked according to Texas Human Resources Code §§42.048(e), 42.052(j), or 42.054(f).(47) Personal flotation device (PFD)--A United States Coast Guard approved life jacket.(48) Physical activity (moderate)--Levels of activity for a child that are at intensities faster than a slow walk, but still allow the child to talk easily. Moderate physical activity increases heart rate and breathing rate.(49) Physical activity (vigorous)--Rhythmic, repetitive physical movement for a child that uses large muscle groups, causing the child to breathe rapidly and only enabling the child to speak in short phrases. Typically, the child's heart rate is substantially increased, and the child is likely to be sweating while engaging in the vigorous physical activity.(50) Pre-kindergarten age child--A child who is three or four years of age before the beginning of the current school year.(51) Premises--See the term "grounds" and its definition in this section.(52) Program--The services and activities provided by an operation.(53) Program director--A director who oversees your program at multi-site operations and supervises a site director at each operation.(54) Regular--On a recurring, scheduled basis. Note: For the definition of "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title.(55) Safety belt--A lap belt and any shoulder straps included as original equipment on or added to a vehicle.(56) Sanitize--The use of a disinfecting product that provides instructions specific for sanitizing and is registered by the Environmental Protection Agency (EPA) to substantially reduce germs on inanimate objects to levels considered safe by public health requirements. Many bleach and hydrogen peroxide products are EPA-registered. You must follow the product's labelling instructions for sanitizing or disinfecting, depending on the surface (paying attention to any instructions regarding contact time and toxicity on surfaces likely to be mouthed by children). If you use bleach instead of an approved disinfecting product, you must follow these steps in order:(A) Washing with water and soap;(B) Rinsing with clear water;(C) Soaking in or spraying on a bleach solution for at least two minutes;(D) Rinsing with cool water only those items that children are likely to place in their mouths; and(E) Allowing the surface or item to air-dry.(57) School-age child--A child who is five years of age and older and is enrolled in or has completed kindergarten.(58) School-age program--An operation that provides supervision and recreation, skills instruction, or skills training for at least two hours a day and three days a week to children who attend pre-kindergarten through grade six. A school-age program operates before or after the customary school day and may also operate during school holidays, the summer period, or any other time when school is not in session.(59) Screen time activity--An activity during which a child views media content on a cell or mobile phone, tablet, computer, television, video, film, or DVD. Screen time activities do not include video chatting with a child's family or assistive and adaptive computer technology used by a child with special care needs on a consistent basis.(60) Self-instructional training--Training designed to be used by one individual working alone and at the individual's own pace to complete lessons or modules. Lessons or modules commonly include questions with clear right and wrong answers. An example of this type of training is web-based training. Self-study training is also a type of self-instructional training.(61) Self-study training--Non-standardized training where an individual reads written materials, watches a training video, or listens to a recording to obtain certain knowledge that is required for annual training. Self-study training is limited to three hours of annual training per year.(62) Site director--A director who has on-site responsibility at a specific operation, but who is supervised by a program director.(63) Special care needs--A child with special care needs is a child who has:(A) A chronic physical, developmental, behavioral, or emotional condition or a disability and who also requires assistance beyond that required by a child generally to perform tasks that are within the typical chronological range of development, including the movement of large or small muscles, learning, talking, communicating, comprehension, emotional regulation, self-help, social skills, emotional well-being, seeing, hearing, and breathing; or(B) A limitation due to an injury, illness, or allergy.(64) State or local fire authority--A fire official who is authorized to conduct fire safety inspections on behalf of the city, county, or state government, including certified fire inspectors. Also referred to as "fire marshal" in this chapter.(65) Swimming Pool--An artificial body of water with a water depth of more than 18 inches that is maintained or used expressly for public or private recreational purposes, swimming, diving, aquatic sports or activities, or therapeutic purposes.(66) Universal precautions--An approach to infection control where all human blood and certain human bodily fluids are treated as if known to be infectious for HIV, HBV, and other blood-borne pathogens.(67) Wading pool--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D.(68) Water activities--Related to the use of swimming pools, wading pools, or sprinkler play.(69) Weather permitting--Weather conditions that do not pose any concerns for health and safety, such as significant risk of frostbite or heat-related illness. This includes adverse weather conditions in which children may still play safely outdoors for shorter periods with appropriate adjustments to clothing and any necessary access to water, shade, or shelter. Source Note: The provisions of this §744.123 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473; amended to be effective December 21, 2022, 47 TexReg 8113; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS A PURPOSE, SCOPE, AND DEFINITIONS §744.123 What do certain words and terms mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212661 03/12/2026 You are responsible for:(1) Developing and implementing your operational policies, which must comply with or exceed the minimum standards specified in this subchapter;(2) Developing written personnel policies, including job descriptions, job responsibilities, and requirements;(3) Making provisions for training that comply with Division 4, Subchapter D of this chapter (relating to Professional Development);(4) Designating an operation director, program director, or site director, as applicable, who meets minimum standard qualifications as specified in Subchapter D of this chapter;(5) Reporting and ensuring your employees and volunteers report suspected abuse, neglect, or exploitation directly to the Texas Abuse and Neglect Hotline, as required by Texas Family Code §261.101; an employee may not delegate the responsibility to make a report, and you may not require an employee to seek approval to file a report or notify you that a report was made;(6) Ensuring all information related to background checks is kept confidential and not disclosed to unauthorized persons, as required by the Human Resources Code §40.005(d) and (e);(7) Ensuring parents can visit the operation any time during your hours of operation to observe their child, program activities, the building, the premises, and the equipment without having to secure prior approval;(8) Complying with the liability insurance requirements in this division;(9) Complying with the child-care licensing law found in Chapter 42 of the Human Resources Code, the applicable minimum standards, and other applicable rules in the Texas Administrative Code;(10) Reporting to Licensing any Department of Justice substantiated complaints related to Title III of the Americans with Disabilities Act, which applies to commercial public accommodations; and(11) Ensuring the total number of children in care at the operation or away from the operation, such as during a field trip, never exceeds the licensed capacity of the operation. Source Note: The provisions of this §744.201 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.201 What are my responsibilities as the permit holder? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204654 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit. Source Note: The provisions of this §744.203 adopted to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.203 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204655 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §744.203 of this division (relating to What are the liability insurance requirements?) if you cannot carry insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the operation; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit. Your notification must include the reason that you cannot carry the insurance. Source Note: The provisions of this §744.205 adopted to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.205 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204656 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204656 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §744.203 of this division (relating to What are the liability insurance requirements?), then you must notify the parent of each child in your care in writing that you do not carry liability insurance before you admit the child into your care.(b) If you previously carried the liability insurance and subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care in writing that you do not carry the insurance, within 14 days after you stop carrying it.(c) You may use Form 2962, Verification of Liability Insurance, located on the Licensing provider website, to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parents of each child in your care, as required in §744.801(5) of this chapter (relating to What records must I keep at my operation?). Source Note: The provisions of this §744.207 adopted to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.207 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192449 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192449 03/12/2026 You must notify us in writing before:(1) Changing the address or location of the operation;(2) Adding to or reducing indoor or outdoor space;(3) Reducing the number of toilets or sinks;(4) Adding a swimming pool or other permanent body of water;(5) Changing the age range of children to be cared for;(6) Changing the hours, days, or months of operation;(7) Offering new services relating to minimum standards found in this chapter, such as nighttime care, transportation, or field trips;(8) Planned closure of five consecutive days or more, during designated hours of operation, when the operation is not caring for children, with the exception of nationally recognized holidays;(9) Going out of business; or(10) There is a change in the ownership of an operation as specified in §745.437 of this title (relating to What is a change in ownership of an operation?). Source Note: The provisions of this §744.301 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.301 What changes regarding my operation must I notify Licensing about before making the change? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192453 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192453 03/12/2026 You must notify us in writing no later than five days after a change is made regarding:(1) The designee of an operation that is not a sole proprietorship. The designee for a sole proprietorship is the sole proprietor;(2) The board chair for a corporate facility or other executive officer of the governing body;(3) The address of the operation's designee or governing body; and(4) A director. Source Note: The provisions of this §744.303 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.303 What changes must I notify Licensing of regarding the operation's designee, governing body, and directors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212662 03/12/2026 (a) You must notify us as soon as possible, but no later than two days after:(1) Any occurrence that renders all or part of your operation unsafe or unsanitary for a child;(2) Injury to a child in your care that requires medical treatment by a health-care professional or hospitalization;(3) A child in your care shows signs or symptoms of an illness that requires hospitalization;(4) You become aware that an employee or child in your care contracts an illness deemed notifiable by the Texas Department of State Health Services, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases);(5) A person for whom you are required to request a background check, under Chapter 745, Subchapter F of this title (relating to Background Checks), is arrested or charged with a crime;(6) The occurrence of any other non-routine situation that places, or may place, a child at risk for injury or harm, such as forgetting a child in an operation vehicle or on the playground or not preventing a child from wandering away from the operation unsupervised; and(7) A new individual becomes a controlling person at your operation, or an individual that was previously a controlling person ceases to be a controlling person at your operation.(b) You must notify us immediately if a child dies while in your care. Source Note: The provisions of this §744.305 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective December 1, 2012, 37 TexReg 9127; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.305 What other situations require notification to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212663 03/12/2026 (a) You must notify the parent of a child immediately if there is an allegation that the child has been abused, neglected, or exploited, as defined in Texas Family Code §261.001, while in your care.(b) After you ensure the safety of the child, you must notify the parent of the child immediately after the child:(1) Is injured and the injury requires medical treatment by a health-care professional or hospitalization;(2) Shows signs or symptoms of an illness that requires hospitalization;(3) Has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) Has been involved in any non-routine situation that placed, or may have placed, the child at risk for injury or harm. For example, a caregiver forgetting the child in an operation vehicle or on the playground or failing to prevent the child from wandering away from the operation unsupervised; or(5) Has been involved in any situation that renders the operation unsafe, such as a fire, flood, or damage to the operation as a result of severe weather.(c) You must notify the parent of less serious injuries when the parent picks the child up from the operation. Less serious injuries include minor cuts, scratches, and contusions requiring first-aid treatment by employees.(d) You must provide written notice to the parent of each child attending the operation within 48 hours of becoming aware that a child in your care or an employee has contracted a communicable disease deemed notifiable by the Department of State Health Services, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases).(e) You must provide written notice to the parent of each child in a group within 48 hours when there is an outbreak of lice or other infestation in the group. You must either post this notice in a prominent and publicly accessible place where parents can easily view it or send an individual note to each parent. Source Note: The provisions of this §744.307 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435; amended to be effective October 25, 2021, 46 TexReg 7216; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.307 What emergency or medical situations must I notify parents about? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204659 03/12/2026 You must notify the parent of each child attending your child-care operation of a deficiency in the abuse, neglect, or exploitation standard in §744.1201(4) of this chapter (relating to What general responsibilities do my employees have?). Source Note: The provisions of this §744.309 adopted to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.309 What are the notification requirements when Licensing finds my operation deficient in the standard related to the abuse, neglect, or exploitation of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204660 03/12/2026 Within five days after you receive notification of a deficiency described in §744.309 of this division (relating to What are the notification requirements when Licensing finds my operation deficient in the standard related to the abuse, neglect, or exploitation of a child?), you must use Form 7266, Notification of Abuse/Neglect/Exploitation Deficiency, located on the Licensing provider website, to notify the parents of each child attending your child-care operation at the time of the notification, including a child who may not have been in care on the day of the actual incident. Source Note: The provisions of this §744.311 adopted to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.311 How must I notify parents of an abuse, neglect, or exploitation deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212664 03/12/2026 You must post the following items: (1) Your license; (2) The letter or form from the most recent Licensing inspection or investigation; (3) The Licensing notice Keeping Children Safe; (4) Your emergency evacuation and relocation diagram as specified in §744.3561 of this title (relating to Must I have an emergency evacuation and relocation diagram?); (5) The activity plan for each group of children, if required by §744.2005 of this title (relating to What written activity plans must caregivers follow?); (6) The daily menu, if applicable, including all snacks and meals prepared or served by the operation; (7) The Licensing Parent Notification Poster; (8) Telephone numbers specified in §744.405 of this title (relating to What telephone numbers must I post and where must I post them?); (9) A list of each child's food allergies that require an emergency plan, as specified in §744.2669 of this title (relating to When must I have a food allergy emergency plan for a child?); and(10) Any other Licensing notices with specific instructions to post the notice. Source Note: The provisions of this §744.401 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.401 What items must I post at my operation at all times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187744 03/12/2026 (a) Unless otherwise specified, the items specified in §744.401 of this title (relating to What items must I post at my operation at all times?) must be available by posting or placing in a binder, in a prominent and publicly accessible place where employees, parents, and others may easily view them at all times.(b) For a list of each child's food allergies that require an emergency plan:(1) You must post the list during all hours of operation where you prepare food and in each room where the child may spend time;(2) The posting must be in a place where employees may easily view the list, and if a parent requests it, you must maintain privacy for the child (for example, a clipboard hung on the wall with a cover sheet over the list); and(3) You must ensure that all caregivers and employees who prepare and serve food are aware of each child's food allergies. Source Note: The provisions of this §744.403 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.403 When and where must these items be posted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220261 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220261 03/12/2026 (a) You must post in a prominent place the following telephone numbers:(1) 911 or, if 911 is not available in your area, you must post the telephone numbers for:(A) Emergency medical services;(B) Law enforcement; and(C) Fire department;(2) Poison control (1-800-222-1222); and(3) The Texas Abuse and Neglect Hotline (1-800-252-5400).(b) You must post in a prominent place the name, address, and telephone number for:(1) The local Child Care Regulation office; and(2) The operation.(c) If you use cellular phone service at your operation, you must ensure all employees and caregivers know the address of the operation to direct emergency personnel to the operation when dialing 911 from the operation. Source Note: The provisions of this §744.405 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective August 19, 2024, 49 TexReg 6225. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.405 What telephone numbers and other contact information must I post and where must I post this information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220262 03/12/2026 You must develop written operational policies and procedures that at a minimum address each of the following:(1) Hours, days, and months of operation;(2) Procedures for the release of children;(3) Illness and exclusion criteria;(4) Procedures for dispensing medication or a statement that medication is not dispensed;(5) Procedures for handling medical emergencies;(6) Procedures for parental notifications;(7) Discipline and guidance that is consistent with Subchapter G of this chapter (relating to Discipline and Guidance). A copy of Subchapter G may be used for your discipline and guidance policy, unless you use disciplinary and training measures specific to a skills-based program, as specified in §744.2109 of this chapter (relating to May I use disciplinary measures that are fundamental to teaching a skill, talent, ability, expertise, or proficiency?);(8) Suspension and expulsion of children;(9) Meals and food service practices;(10) Immunization requirements for children, including tuberculosis screening and testing if required by your regional Texas Department of State Health Services or local health authority;(11) Enrollment procedures, including how and when parents will be notified of policy changes;(12) Transportation, if applicable;(13) Water activities, if applicable;(14) Field trips, if applicable;(15) Animals, if applicable;(16) Procedures for providing and applying, as needed, insect repellent and sunscreen, including what types will be used, if applicable;(17) Parent rights that are consistent with the rules in Division 5 of this subchapter (relating to Parent Rights);(18) Procedures for parents to review and discuss with the director any questions or concerns about the policies and procedures of the operation;(19) Procedures for parents to participate in the operation's activities;(20) Instructions on how a parent may access the:(A) Minimum standards online;(B) Texas Abuse and Neglect Hotline; and(C) HHSC website.(21) Emergency preparedness plan;(22) Procedures for conducting health checks, if applicable;(23) Information on vaccine-preventable diseases for employees, unless your operation is in the home of the permit holder, the director, or a caregiver. The policy must address the requirements outlined in §744.2581 of this chapter (relating to What must a policy for protecting children from vaccine-preventable diseases include?);(24) If your operation maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, policies for maintenance, administration, and disposal of unassigned epinephrine auto-injectors that comply with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in Texas Administrative Code, Title 25, Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and Texas Health and Safety Code §773.0145; and(25) Procedures for supporting inclusive services to children with special care needs. The policy must address the requirements outlined in §744.2009 of this chapter (relating to What are my responsibilities when planning activities for a child in care with special care needs?). Source Note: The provisions of this §744.501 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective December 1, 2012, 37 TexReg 9126; amended to be effective June 1, 2014, 39 TexReg 3716; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473; amended to be effective October 25, 2021, 46 TexReg 7216; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective August 19, 2024, 49 TexReg 6225. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.501 What written operational policies must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187747 03/12/2026 Yes. On or before the date of admission, the parents must sign a child-care enrollment agreement or other similar documents, which must include at least the operational policies listed in this division. You must keep this signed document in the child's record or at least one for each family, if siblings are enrolled at the same time. Source Note: The provisions of this §744.503 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.503 Must I provide parents with a copy of my operational policies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187748 03/12/2026 When you change an operational policy or your child-care enrollment agreement, you must notify:(1) Your employees of any changes; and(2) The parents in writing of any changes. At least one copy of the updated operational policies or child-care enrollment agreement must be signed and dated for each family and kept in the child's record. Source Note: The provisions of this §744.505 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.505 What must I do when I change an operational policy or an item in the child-care enrollment agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220263 03/12/2026 A parent of a child in care has the right to:(1) Enter and examine your operation during its hours of operation without advance notice;(2) File a complaint against your operation;(3) Review your operation's publicly accessible records;(4) Review your operation's written records concerning the parent's child, as outlined in §744.601 of this chapter (relating to Who has the right to access children's records?);(5) Receive from your operation:(A) HHSC's inspection reports for your operation; and(B) Information regarding how to access your operation's compliance history online;(6) Have your operation comply with a valid court order signed by a judge that prevents another parent from visiting or removing the parent's child from your operation, as outlined in §744.2801 of this chapter (relating to To whom may I release a child?);(7) Be provided with contact information for Child Care Regulation, including the department's name, address, and telephone number;(8) View any video recordings of an alleged incident of abuse or neglect involving the parent's child maintained by your operation as long as:(A) Video recordings of the alleged incident are available;(B) The parent is not allowed to retain any portion of the video depicting a child who is not the parent's child; and(C) Your operation notifies in writing the parent of any other child captured in the video recording, before allowing the parent to inspect the video recording;(9) Obtain a copy of your operation's policies and procedures, as outlined in §744.503 of this subchapter (relating to Must I provide parents with a copy of my operational policies?);(10) Review, upon request of the parent, your:(A) Staff training records; and(B) In-house training curriculum, if any; and(11) Be free from any retaliatory action by your operation for exercising any of the parent's rights. Source Note: The provisions of this §744.521 adopted to be effective August 19, 2024, 49 TexReg 6225. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS B ADMINISTRATION AND COMMUNICATION §744.521 What rights does a parent of a child in care of my child-care operation have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187752 03/12/2026 (a) All children's records must be immediately accessible to caregivers during your hours of operation for use in an emergency.(b) Parents have the right to access their own child's record during a parent conference with the caregiver or director.(c) All children's records are subject to review and/or reproduction by Licensing upon request during your hours of operation. Source Note: The provisions of this §744.601 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.601 Who has the right to access children's records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187753 03/12/2026 (a) You must maintain the following records for each child enrolled in your operation:(1) A child-care enrollment agreement specified in §744.503 of this title (relating to Must I provide parents with a copy of my operational policies?);(2) Admission information as specified in §744.605 of this title (relating to What admission information must I obtain for each child?);(3) Immunization records;(4) Tuberculosis screening and testing information, if required by your regional Texas Department of State Health Services or local health authority;(5) Licensing Incident/Illness Report form, if applicable;(6) A daily tracking system for when a child's care begins and ends as specified in §744.627 of this title (relating to Must I have a system for signing children in and out of my care?);(7) Medication administration records, if applicable; and(8) A copy of any health-care professional recommendations or orders for providing specialized medical assistance to the child. In some instances, minimum standards allow for a deviation from a minimum standard with written documentation from a health-care professional. You must also maintain this written documentation in the child's record.(b) These records must at a minimum be kept at the operation and be available during your hours of operation for the following periods of time: (1) Medication administration records for three months after administering the medication;(2) Health-care professional recommendations or orders for three months after the health-care professional has indicated that the specialized medical assistance is no longer needed; and(3) All other records noted in subsection (a) of this section for three months after the child's last day in care. Source Note: The provisions of this §744.603 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.603 What records must I have for children in my care and how long must I keep them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220694 03/12/2026 You must obtain at least the following information before admitting a child to the operation:(1) The child's name and birth date;(2) The child's home address and telephone number;(3) Date of the child's admission to the operation;(4) Name and address of parents;(5) Telephone numbers at which parents can be reached while the child is in care;(6) Name, address, and telephone number of another responsible individual (friend or relative) who should be contacted in an emergency when the parent cannot be reached;(7) Names and telephone numbers of persons other than a parent to whom the child may be released;(8) Permission for transportation, if provided, including any authorized pick-up and drop-off locations;(9) Permission for field trips, if provided;(10) Name, address, and telephone number of the child's physician or an emergency-care facility;(11) Authorization to obtain emergency medical care and to transport the child for emergency medical treatment;(12) A statement of the child's special problems or special care needs, which must include:(A) Any limitations or restrictions on the child's activities;(B) Special care the child requires, including:(i) Any reasonable accommodations or modifications;(ii) Any adaptive equipment provided for the child, including instructions for how to use the equipment; and(iii) Symptoms or indications of potential complications related to a physical, cognitive, or mental condition that may warrant prevention or intervention while the child is in care; and(C) Any medications prescribed for continuous, long-term use.(13) The name and telephone number of the school that a school-age child attends, unless the operation is located at the child's school;(14) Permission for a school-age child to ride a bus, walk to or from school or home, or to be released to the care of a sibling under 18 years old, if applicable;(15) The child's allergies and a completed food allergy emergency plan for the child, if applicable; and(16) Permission for participation in water activities, if provided. If you allow a child to access a swimming pool, the parent must also indicate whether the child:(A) Is able to swim competently, as defined by the American Red Cross; or(B) Requires a personal flotation device because the child is:(i) Unable to swim competently, as defined by the American Red Cross; or(ii) At risk of injury or death when swimming or otherwise accessing a body of water. Source Note: The provisions of this §744.605 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.605 What admission information must I obtain for each child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187754 03/12/2026 Yes. The parent must sign the admission information before you admit the child to your care. Source Note: The provisions of this §744.607 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.607 Must the child's parent sign the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187755 03/12/2026 (a) Yes. You must develop a procedure for regularly updating the admission information, including information on special care needs.(b) The parent must sign and date the updated information. You may use a new form or have the parent initial and date amendments to a previously signed form. You must keep the updated information in the child's record. Source Note: The provisions of this §744.609 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.609 Must I update the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187756 03/12/2026 No. Since your operation exclusively serves children that attend pre-kindergarten or school, you are not required to have a health statement for children in your care. Source Note: The provisions of this §744.611 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.611 Must I have a health statement for children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187758 03/12/2026 (a) Each child enrolled or admitted to your operation must meet and continue to meet applicable immunization requirements specified by the Texas Department of State Health Services (DSHS). This requirement applies to all children in care through 14 years of age.(b) You must maintain current immunization records for each child in your care, including any immunization exemptions or exceptions.(c) All immunizations required for the child's age must be completed by the date of admission, unless:(1) The child is exempt or excepted from an immunization, and you verify the exemption or exception by the date of admission; or(2) The child is homeless or in foster care and is provisionally admitted for up to 30 days because evidence of immunization is not available. You should immediately refer the child to an appropriate health-care professional to obtain the required immunizations. The DSHS rule at 25 TAC §97.66 (relating to Provisional Enrollment for Students) establishes the guidelines for a provisional enrollment. Source Note: The provisions of this §744.613 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.613 What immunizations must a child in my care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187761 03/12/2026 (a) A child may be exempt from immunization requirements for a medical reason or reason of conscience, including a religious belief. To claim an exemption, the person applying for the child's admission must meet criteria specified by the Department of State Health Services (DSHS) rule at 25 TAC §97.62 (relating to Exclusions from Compliance).(b) For some diseases, a child who previously had a disease and is accordingly naturally immune from it may qualify for an exception to the immunization requirements for the disease. To claim this exception, the person applying for the child's admission must meet the criteria specified by the DSHS rule at 25 TAC §97.65 (relating to Exceptions to Immunization Requirements). Source Note: The provisions of this §744.615 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.615 What exemptions or exceptions are there concerning immunization requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187762 03/12/2026 Acceptable documentation includes:(1) A signed statement from the child's parent that the child's immunization record is current and on file at the pre-kindergarten or school that the child attends. The statement must be dated and include the name, address, and telephone number of the pre-kindergarten or school listed in the statement;(2) An official immunization record generated from a state or local health authority, including a record from another state. Examples include a record from the Texas Immunization Registry, a copy of the current immunization record that is on file at the pre-kindergarten or school that the child attends, or the health passport for a child in the conservatorship of DFPS. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses; and(C) The month, day, and year the child received each vaccination; or(3) An official immunization record or photocopy. An example includes a record from a doctor's office or a pharmacy. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses;(C) The month, day, and year the child received each vaccination; and(D) The signature (including a rubber stamp or electronic signature) of the health-care professional who administered the vaccine, or another health-care professional's documentation of the immunization as long as the name and address of the health-care professional that administered the vaccine is documented. Source Note: The provisions of this §744.623 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.623 What documentation is acceptable for an immunization record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187759 03/12/2026 Requirements for tuberculosis screening and testing vary across the state. If the Texas Department of State Health Services (DSHS) or local health authority requires tuberculosis testing for children in your operation, then you must have documentation to indicate that each child in your care is free of active tuberculosis. Documentation of a TB screening is not required to be on file. If you are unsure of the requirements for your area, contact the TB manager at the DSHS regional office nearest you. Source Note: The provisions of this §744.625 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.625 Must children in my care have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187760 03/12/2026 (a) Yes. You must have a tracking system for each child coming and going from your operation throughout the day. This tracking system must include the name of each child; the date, time of arrival, and time of departure; and the employee or parent's initials or other unique identifier.(b) All caregivers must have access to the tracking system to determine which children are in care during their work shift, changes in caregivers, and emergency evacuations. Source Note: The provisions of this §744.627 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.627 Must I have a system for signing children in and out of my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212668 03/12/2026 You must record the following information on the Licensing Incident/Illness Report Form 7239 or another form that contains at least the same information:(1) An injury to a child in care that required medical treatment by a health-care professional or hospitalization; (2) An illness that required the hospitalization of a child in care; (3) An incident where a child in care had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) An incident of a child in care or employee contracting a communicable disease deemed notifiable by the Texas Department of State Health Services as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases); and (5) Any other non-routine situation that placed, or may have placed, a child at risk for injury or harm, such as forgetting a child in an operation's vehicle or not preventing a child from wandering away from the operation unsupervised. Source Note: The provisions of this §744.701 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435; amended to be effective October 25, 2021, 46 TexReg 7216; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.701 What written records must I keep of accidents and incidents that occur at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187764 03/12/2026 Yes. After the caregiver completes the form, the director of the operation or, if the director is not available, the person designated to be in charge of the operation must sign and date the completed report. Source Note: The provisions of this §744.705 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.705 Must someone from my operation sign the Incident/Illness Report form? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187765 03/12/2026 Yes. You must share a copy of the report with the child's parent and obtain the parent's signature on the report indicating the parent has reviewed it or received a copy of the report within 48 hours of when the incident occurred. Source Note: The provisions of this §744.707 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.707 Must I share a copy of the Incident/Illness Report form with the child's parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187766 03/12/2026 You must keep the Incident/Illness Report form with the child's record at the operation while the child is in care, and for at least three months after the child's last day in care. Source Note: The provisions of this §744.709 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.709 Where must I file the Incident/Illness Report form and how long must I keep it? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204662 03/12/2026 You must maintain and make the following records available for our review, upon request, during your hours of operation. Paragraphs (13), (14), and (15) of this section are optional, but if provided will allow Licensing to avoid duplicating the evaluation of standards that have been evaluated by another state agency within the past year:(1) Children's records, as specified in Division 1 of this subchapter (relating to Records of Children);(2) Personnel and training records according to Division 4 of this subchapter (relating to Personnel Records);(3) Licensing Director's Certificate;(4) Attendance records or time sheets listing all days and hours worked for each employee;(5) Proof of current liability insurance coverage or, if applicable, that you have provided written notice to the parent of each child that you do not carry the insurance;(6) Medication records, if applicable;(7) Playground maintenance checklists;(8) Pet vaccination records, if applicable;(9) Safety documentation for emergency drills, fire extinguishers, and smoke detectors;(10) Most recent fire inspection report, including any written approval from the fire marshal to provide care above or below ground level, if applicable;(11) Most recent sanitation inspection report, if applicable;(12) Most recent gas inspection report, if applicable;(13) Most recent Texas Department of State Health Services immunization compliance review form, if applicable;(14) Most recent Texas Department of Agriculture Child and Adult Care Food Program report, if applicable;(15) Most recent local workforce board Child-Care Services contractor inspection report, if applicable;(16) Record of pest extermination, if applicable;(17) A daily tracking system for when a child's care begins and ends, as specified in §744.627 of this subchapter (relating to Must I have a system for signing children in and out of my care?); and(18) Proof that you have notified parents in writing of deficiencies in abuse, neglect, or exploitation, as specified in §744.309 of this chapter (relating to What are the notification requirements when Licensing finds my operation deficient in the standard related to the abuse, neglect, or exploitation of a child?) and in §744.311 of this chapter (relating to How must I notify parents of an abuse, neglect, or exploitation deficiency?). Source Note: The provisions of this §744.801 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.801 What records must I keep at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187767 03/12/2026 (a) If you are required to post or keep a record in this chapter, you must keep the record at your operation for at least three months from the date the record was created unless otherwise stated.(b) You must keep training records for each current director and caregivers for at least the current and last full training year. Source Note: The provisions of this §744.803 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.803 How long must I keep records at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187768 03/12/2026 Yes, you may keep electronic records or a combination of paper and electronic records.(1) If you keep a combination of paper and electronic records, you must develop procedures that address what must be in the external paper file and what can be in the electronic file;(2) Children's records must be accessible to all caregivers during their work shift, changes in caregivers, and emergency evacuations; and(3) All records must be available during your hours of operation for review by Licensing upon request. Source Note: The provisions of this §744.805 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.805 May I keep electronic records or a combination of paper and electronic records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220819 03/12/2026 You must have the following records at the operation and available for review during your hours of operation for each employee, caregiver, substitute, and volunteer as specified in this chapter: (1) Documentation showing the dates of the first and last day on the job; (2) Documentation showing how the employee meets the minimum age and education qualifications, if applicable; (3) A copy of a health card or health care professional's statement verifying the employee is free of active tuberculosis, if required by the regional Texas Department of State Health Services tuberculosis program or local health authority; (4) A notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) as specified in Texas Human Resources Code §42.059; (5) A Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) as specified in Texas Human Resources Code §42.0563;(6) A record of training hours, including documentation required by §744.1331 of this chapter (relating to What documentation must I provide to Licensing to verify that employees have met training requirements?); (7) A statement signed and dated by the employee showing he has received a copy of the operation's: (A) Operational policies; and (B) Personnel policies; (8) Proof of request for background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks); (9) A copy of a photo identification; (10) A copy of the person's current driver's license if the person transports a child in care; and (11) A statement signed and dated by the employee verifying the date the employee attended training during orientation that includes an overview regarding the prevention, recognition, and reporting of child maltreatment, as outlined in §744.1303 of this chapter (relating to What must orientation for employees at my operation include?). Source Note: The provisions of this §744.901 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2014, 39 TexReg 1181; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective August 14, 2024, 49 TexReg 4916. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.901 What information must I maintain in my personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192440 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192440 03/12/2026 (a) You must keep all records for at least three months after an employee's last day on the job, with the exception of annual training records.(b) You must maintain annual training records for current personnel for the last full training year and current training year.(c) You must keep personnel records and attendance records for employees at the operation or in a central administrative location, provided they are immediately available for review during your hours of operation. Source Note: The provisions of this §744.907 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.907 How long and where must I keep the required personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192441 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192441 03/12/2026 Yes. Licensing staff must be given immediate access to all personnel records that document compliance with minimum standards. You must allow Licensing to photograph, copy, or scan these records if requested. Source Note: The provisions of this §744.909 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS C RECORD KEEPING §744.909 May Licensing access my personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187908 03/12/2026 (a) You are required to designate an adult that has the daily, on-site responsibility for your operation, including maintaining compliance with the minimum standards and Licensing laws.(b) There are three types of recognized directors in a before and after-school or school-age program:(1) An operation director, who is responsible for your operation without the supervision of a program director;(2) A program director, who oversees your program at multi-site operations and supervises a site director at each operation;(3) A site director, who has the daily responsibility for a specific operation but is supervised by a program director.(c) In this subchapter, the term director applies to all types of directors listed in subsection (b) of this section, unless otherwise specified. Source Note: The provisions of this §744.1001 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1001 Am I required to have a director for my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187909 03/12/2026 (a) If you have multi-site operations, you must designate a director at each operation. However, a site director may share his responsibilities at an operation with a program director, provided the operation maintains substantial compliance with minimum standards and other relevant law.(b) A program director may supervise no more than:(1) Nine site directors at multi-site before and after-school care programs; or(2) Five site directors at multi-site school-age programs or at a combination of school-age programs and before and after-school programs. Source Note: The provisions of this §744.1003 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1003 If I have multiple operations, must I designate a director for each operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187910 03/12/2026 (a) Your director must ensure:(1) Your operation complies with the minimum standards specified in this chapter;(2) All employees comply with the minimum standards;(3) All employees have assignments that match their skills, abilities, and training;(4) All employees are supervised. Supervision includes, but is not limited to, knowing what the employees are doing and ensuring that they fulfill their assignments and responsibilities;(5) Caregivers are not regularly scheduled for more than ten hours of direct child care during a 24-hour period; and(6) Qualified substitutes are called as necessary to meet minimum standards.(b) If a program director and a site director share the director's responsibilities at an operation, you must provide Licensing with a written plan designating which responsibilities specified in subsection (a) of this section the site director and program director are responsible for on a daily basis. You must follow your plan and submit revisions to Licensing upon request. Source Note: The provisions of this §744.1005 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1005 What are the director's responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187911 03/12/2026 You may be both the director and permit holder of an operation if you meet all of the required qualifications and are able to fulfill the responsibilities of a director. Source Note: The provisions of this §744.1007 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1007 May I be a director of my own operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187912 03/12/2026 You may designate more than one operation director if each director:(1) Meets the qualifications specified in this division; and(2) Receives a written job description that includes his job responsibilities. Source Note: The provisions of this §744.1009 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1009 May I have more than one operation director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187913 03/12/2026 A director must be present a minimum of 75% of the program's operating hours each week or a minimum of 30 hours per week, whichever is less, to ensure the operation complies with all minimum standards. Source Note: The provisions of this §744.1011 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1011 For how many hours must a director be at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187914 03/12/2026 (a) Yes. You or your director must designate a qualified caregiver to be in charge of the operation anytime the director is away from the operation during your hours of operation. If your operation has a program director and a site director, the written plan designating their responsibilities must address whether either or both directors may designate a qualified caregiver to be in charge of your operation in the site director's absence.(b) Designated individuals must:(1) Know they are in charge and for how long;(2) Know their responsibilities while in charge;(3) Have access to all essential information to communicate with parents and state and local authorities as needed; and(4) Have the authority to direct the operation in compliance with minimum standards.(c) You or your director must ensure that all other employees know who is in charge in the director's absence. Source Note: The provisions of this §744.1013 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1013 Must someone else be designated to be in charge of my operation in the director's absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212670 03/12/2026 Except as otherwise provided in this division, an operation director or program director must be at least 21 years of age, have a high school diploma or its equivalent, and meet one of the following combinations of education and experience:Attached Graphic Source Note: The provisions of this §744.1015 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1015 What qualifications must an operation director or a program director meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187916 03/12/2026 (a) The qualifications for education and experience that a site director must meet depend in part on how many site directors are supervised by a program director. Except as otherwise provided in this division, the site director of an operation must have a high school diploma or its equivalent, and meet one of the following combinations of education and experience:Attached Graphic(b) Except as otherwise provided in this division, a site director of an operation that provides care exclusively for children five years old and older must be at least 18 years of age, while the site director of an operation that also provides care for children younger than five years must be at least 21 years of age.(c) A site director may complete the required education during the first 90 days of employment, if:(1) The site director completed at least half of the required education prior to beginning work as the site director; and (2) You provide Licensing a written plan describing the oversight the program director will be providing the site director until the required education is completed. If applicable, the plan must include the sharing of director responsibilities as required in §744.1005(b) of this title (relating to What are the director's responsibilities?). Source Note: The provisions of this §744.1017 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1017 What qualifications must a site director meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187917 03/12/2026 (a) The following types of experience may be counted as experience:(1) Experience as a director, assistant director, or caregiver working directly with children, obtained in any operation regulated by DFPS, whether paid or unpaid;(2) Experience as a director, assistant director, or caregiver working directly with children in a licensed or certified operation in another state or country;(3) One year experience providing skill-based instruction or as a caregiver in a recreational or youth development program, where children in pre-kindergarten through grade six are in care for at least two hours a day, three days a week;(4) One year of full-time classroom teaching in a public or private accredited school in grades pre-kindergarten through grade six, during a customary school year;(5) Substitute or part-time classroom teaching in a public or private accredited school in grades pre-kindergarten through grade six, if the total length of time adds up to one year of full-time teaching during a customary school year; or(6) One year of post-graduate study in child development, early childhood education, or a closely related field.(b) You must have obtained all work experience in a full-time capacity or its equivalent in a part-time capacity. Full-time is defined as 30 hours per week. Source Note: The provisions of this §744.1021 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1021 What types of experience may count towards meeting director qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187918 03/12/2026 Yes. To determine whether a person has sufficient experience to qualify as a director, we may, at our own discretion, verify the person's child-care experience and substitute child-care experience via the Internet, telephone or mail contact with previous employer(s), or through our records. Source Note: The provisions of this §744.1023 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1023 Can Licensing verify whether someone has sufficient experience? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187919 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the child development requirement. Courses in early childhood education, child growth and development, psychology, sociology, classroom management, child psychology, health and safety of children, elementary education related to pre-kindergarten through grade six, youth development, kinesiology, biomechanics, motor development and performance, physiology of exercise, physical education, and other similar courses may be counted, provided the course content relates to child development or the topics specified in §744.1309 of this title (relating to How many clock hours of annual training must be obtained by caregivers and site directors?). Abnormal psychology and secondary education courses are not recognized as child development. Source Note: The provisions of this §744.1025 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1025 What credit courses does Licensing recognize as child development? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187920 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the management requirement. Management courses may include administration of a child-care facility, recreational leadership, accounting, goal and objective setting, performance planning and evaluation, management techniques, risk management and other administrative, management, or supervisory-related courses. Courses in office machines or computer training are not recognized as management. Source Note: The provisions of this §744.1027 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1027 What credit courses does Licensing recognize as management? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187921 03/12/2026 If requested by Licensing, you must provide original transcripts and supporting documentation, such as a credit course catalog description or a course syllabus or outline, so that Licensing may determine whether the course is recognized as child development or management. Source Note: The provisions of this §744.1029 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1029 What documentation must I provide to show that my director meets the child development and management education qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212671 03/12/2026 (a) Clock hours or CEUs may only be substituted for the required credit hours in child development and management.(b) 50 clock hours or five CEUs may only be substituted for every three college credit hours required in child development and/or management.(c) The documentation to verify the clock hours or CEUs must be as specified in §744.1331 of this title (relating to What documentation must I provide to Licensing to verify that employees have met training requirements?). Source Note: The provisions of this §744.1035 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1035 May clock hours or CEUs (continuing education units) be substituted for any of the educational requirements in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187923 03/12/2026 (a) In addition to showing that your director meets the minimum qualifications for an employee (and minimum qualifications for a caregiver, if applicable), you must submit the following for each director at your operation:(1) A completed Licensing Personal History Statement form specifying the education and experience of each designated director;(2) A completed Licensing Governing Body/Director Designation form; and(3) An original and current Licensing Director's Certificate form, or an original college transcript or original training certificates which verify the educational requirements. Original letters may be substituted for training certificates, provided they include the same information as specified in §744.1331 of this title (relating to What documentation must I provide to Licensing to verify that training requirements have been met?); and (4) Complete dates, names, addresses, and telephone numbers which support the required experience. (b) You must submit the information to us:(1) As part of a new application for a permit; or (2) Within five days of designating a new operation director, program director, or site director. Source Note: The provisions of this §744.1037 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1037 What additional documentation must I submit to Licensing to show my director is qualified and when must I submit it? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187924 03/12/2026 Yes. However, you must provide supporting information such as a copy of the diploma or transcript or letter from the school to indicate that the education is equivalent to a program in the United States. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §744.1043 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1043 Does education received outside of the United States substitute for the education requirements for a child-care director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187925 03/12/2026 No. After we evaluate this information and issue a director's certificate, we will return the original documents to you along with the certificate or if a certificate is not issued, along with the letter notifying you of the decision. Source Note: The provisions of this §744.1045 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1045 Will Licensing keep the original training certificates and college transcripts I submit to obtain a Licensing director's certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187926 03/12/2026 We will notify you that your director is in violation of minimum standards for failure to meet director qualifications as soon as possible, but no later than ten days after a determination is made. We will give you a deadline to submit additional paperwork or to designate another director and submit new paperwork. Source Note: The provisions of this §744.1047 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1047 What happens if Licensing determines that a director for my operation does not meet minimum standard qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187927 03/12/2026 Yes. After we determine that your director meets minimum standard qualifications, we will issue a Licensing Director's Certificate. The certificate verifies only that the named person meets minimum standard qualifications specified in §744.1015 of this title (relating to What qualifications must an operation director or a program director meet?) or §744.1017 of this title (What qualifications must a site director meet?). Source Note: The provisions of this §744.1049 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1049 Will my director receive a certificate verifying that director qualifications have been met? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187928 03/12/2026 (a) An operation director's certificate or program director's certificate will expire if the operation director or program director was qualified under options (4) or (6) of Figure: 40 TAC §744.1015 of this title (relating to What qualifications must an operation director or a program director meet?). Otherwise, an operation director's certificate and a program director's certificate will not expire.(b) A site director's certificate will not expire. Source Note: The provisions of this §744.1051 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1051 Will a director's certificate expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187929 03/12/2026 If an operation director or program director qualifies under options (4) or (6) of Figure: 40 TAC §744.1015 of this title (relating to What qualifications must an operation director or program director meet?), the operation director or program director must maintain the credential according to the issuing organization's or educational institution's requirements. The director with the certificate must submit to us a copy of a letter or other documentation confirming the credential is current before we can renew the Director's Certificate. Source Note: The provisions of this §744.1053 adopted to be effective September 1, 2010, 35 TexReg 7469 ; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1053 How often must an expiring certificate be renewed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187930 03/12/2026 We will give you a deadline for your operation director or program director to submit the required documentation or for you to designate another qualified director. If your operation director or program director allows the certificate to expire without submitting the required documentation confirming that the credential is current, then your operation will no longer meet the minimum standards for that director position. Source Note: The provisions of this §744.1055 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1055 What happens if my operation director's or program director's credential expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187931 03/12/2026 (a) If you can provide an original and current Licensing Director's Certificate, you will not be required to resubmit the information establishing qualifications. (b) If an original and current Licensing Director's Certificate is not available, or Licensing cannot verify the director is qualified, you must resubmit the information to us to determine if your designated director meets minimum director qualifications. Source Note: The provisions of this §744.1057 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1057 If I hire someone who was qualified as a director at another licensed operation in Texas, must I resubmit all of the information to Licensing staff for review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187932 03/12/2026 No. We do not charge a fee for processing a director's certificate. Source Note: The provisions of this §744.1059 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1059 Does Licensing charge a fee for issuing the director's certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187933 03/12/2026 Yes. We will issue a replacement Director's Certificate, if you submit your request to us in writing, specifying: (1) The name and address of your operation; (2) The name of the director for whom the replacement certificate is needed; (3) The date we issued the original certificate; and (4) The reason a replacement certificate is needed. Source Note: The provisions of this §744.1061 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1061 Can my director get a replacement Director's Certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219541 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219541 03/12/2026 Each employee must: (1) Meet the requirements in Chapter 745, Subchapter F of this title (relating to Background Checks); (2) Have a current record of a tuberculosis (TB) examination, showing the employee is free of contagious TB, if required by the Texas Department of State Health Services or local health authority; (3) Complete a notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) before you hire the employee, as specified in Texas Human Resources Code §42.059; and(4) Complete a Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) before you hire the employee, as specified in Texas Human Resources Code §42.0563. Source Note: The provisions of this §744.1103 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645; amended to be effective August 14, 2024, 49 TexReg 4916. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1103 What minimum qualifications must each of my employees meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192448 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192448 03/12/2026 Except as otherwise provided in this division, each caregiver must comply with minimum standards for employees and must:(1) Be at least 18 years of age; and(2) Have a:(A) High school diploma;(B) High school equivalent; or(C) High school certificate of coursework completion as defined in Texas Education Code, §28.025(d). Source Note: The provisions of this §744.1105 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1105 What additional minimum qualifications must each of my caregivers meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192445 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192445 03/12/2026 (a) You may employ a 16 or 17-year-old who has a high school diploma or its equivalent and count the person in the child/caregiver ratio, provided that:(1) You don't leave the person alone with sole responsibility for or in charge of an individual child, a group of children, or the operation;(2) The person works in the same room with and is supervised by a caregiver qualified under §744.1105 of this title (relating to What additional minimum qualifications must each of my caregivers meet?); and(3) The person has completed a child-care-related career program, which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes the eight hours of pre-service training before being placed in a room with children.(b) You may employ a 16-,17-, or 18-year-old who attends high school but has not graduated and count the person in the child/caregiver ratio, provided that:(1) You do not leave the person alone with sole responsibility for or in charge of an individual child, a group of children, or the operation;(2) The person works in the same room with and is supervised by a caregiver qualified under §744.1105;(3) The person is currently enrolled in or has completed a child-care-related career program, which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes the eight hours of pre-service training before being placed in a room with children;(4) The person is expected to obtain a high school diploma or equivalent. Source Note: The provisions of this §744.1107 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1107 When may I employ a person under the age of 18 or a person who does not have a high school diploma or equivalent as a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192446 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192446 03/12/2026 Yes. However, you must provide supporting information such as a copy of the diploma or letter from the school district to indicate that the education is equivalent to a high school diploma program in the United States. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §744.1109 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1109 Does education received outside of the United States count toward caregiver qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187938 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=187938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 187938 03/12/2026 All employees, including persons not counted in the child/caregiver ratio, must:(1) Demonstrate competency, good judgment, and self-control in the presence of children and when performing assigned responsibilities;(2) Relate to children with courtesy, respect, acceptance, and patience;(3) Recognize and respect the uniqueness and potential of all children, their families, and their cultures;(4) Ensure that no child is abused, neglected, or exploited while in the care of the operation; and(5) Report suspected abuse, neglect, and exploitation to DFPS or to law enforcement, as specified in the Texas Family Code §261.101. Source Note: The provisions of this §744.1201 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1201 What general responsibilities do my employees have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212672 03/12/2026 In addition to the responsibilities for employees specified in this division, caregivers must:(1) Know and comply with the minimum standards in this chapter;(2) Supervise children at all times, as specified in §744.1205 of this division (relating to What responsibilities does a caregiver have when supervising a child or children?);(3) Be free from activities not directly involving the teaching, care, and supervision of children, such as:(A) Administrative and clerical duties that take the caregiver's attention away from the children;(B) Meal preparation, except when 12 or fewer children are in care;(C) Janitorial duties; and(D) Personal use of electronic devices, such as cell phones, MP3 players, tablets, and video games;(4) Provide care that is consistent with the child's habits, interests, strengths, and any special needs, including any special supervision needs or care, as outlined in §744.2009 of this chapter (relating to What are my responsibilities when planning activities for a child in care with special care needs?);(5) Interact with children in a positive manner;(6) Set appropriate behavior expectations based on the child's current stage of development;(7) Foster developmentally appropriate independence in children through planned but flexible program activities;(8) Foster a cooperative rather than a competitive atmosphere;(9) Show appreciation of children's efforts and accomplishments; and(10) Ensure continuity of care for children by sharing with incoming caregivers information about each child's activities during the previous shift and any verbal or written instructions given by the parent. Source Note: The provisions of this §744.1203 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1203 What additional responsibilities do my caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212673 03/12/2026 (a) The caregiver is responsible for:(1) Knowing which children the caregiver is responsible for;(2) Knowing how many children the caregiver is responsible for;(3) Knowing each child's name and having information showing each child's age;(4) Providing the level of supervision necessary to ensure each child's safety and well-being, including physical proximity and auditory or visual awareness of each child's ongoing activity as appropriate; and(5) Being able to intervene when necessary to ensure each child's safety.(b) In deciding how closely to supervise a child, the caregiver must take into account:(1) The child's chronological age;(2) The child's current stage of development;(3) The child's individual differences and abilities;(4) The indoor and outdoor layout of the operation;(5) The circumstances, hazards, and risks surrounding the child; and(6) The child's physical, mental, emotional, and social needs. Source Note: The provisions of this §744.1205 adopted to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1205 What responsibilities does a caregiver have when supervising a child or children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220696 03/12/2026 (a) Employees, caregivers, and directors must complete the following training requirements. Attached Graphic(b) If a caregiver or employee does not yet have a current certificate in pediatric CPR, as required in (a)(4)(A) in Figure: 26 TAC §744.1301(a), at least one caregiver or employee with a current certificate must also be on the premises with the caregiver. Source Note: The provisions of this §744.1323 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1301 What are the training requirements for employees, caregivers, and directors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192863 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192863 03/12/2026 Your orientation for employees must include at least the following:(1) An overview of the minimum standards found in this chapter;(2) An overview of operational policies, including discipline and guidance practices and procedures for the release of children;(3) An overview regarding the prevention, recognition, and reporting of child maltreatment including:(A) Factors indicating a child is at risk of abuse or neglect;(B) Warning signs indicating a child may be a victim of abuse or neglect;(C) Procedures for reporting child abuse or neglect; and(D) Community organizations that have training programs available to employees, children, and parents;(4) An overview of the procedures to follow in handling emergencies, which includes sharing the emergency preparedness plan with all employees. Emergencies may include fire, explosion, tornado, toxic fumes, volatile persons, and severe injury or illness of a child or adult;(5) The location and use of fire extinguishers and first-aid equipment.(6) Administering medication, if applicable, including compliance with §744.2653 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(7) Preventing and responding to emergencies due to food or an allergic reaction;(8) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic;(9) Handling, storing, and disposing of hazardous materials, including compliance with §744.2523 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?); and(10) Precautions in transporting children, if your operation transports a child whose chronological or developmental age is younger than nine years old. Source Note: The provisions of this §744.1303 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1303 What must orientation for employees at my operation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192864 03/12/2026 The eight clock hours of pre-service training must cover the following areas:(1) Developmental stages of children;(2) Age-appropriate activities for children;(3) Positive guidance and discipline of children;(4) Fostering children's self-esteem;(5) Supervision and safety practices in the care of children;(6) Positive interaction with children; and(7) Preventing and controlling the spread of communicable diseases, including immunizations. Source Note: The provisions of this §744.1305 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1305 What areas of training must the pre-service training for caregivers cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192865 03/12/2026 Yes. A caregiver is exempt from the pre-service training requirements if the caregiver has:(1) At least six months prior experience in a regulated operation; or(2) Documentation of at least eight clock hours of training in the areas specified in §744.1305 of this division (relating to What areas of training must the pre-service training for caregivers cover?) at another regulated operation. Source Note: The provisions of this §744.1307 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1307 Are any caregivers exempt from the pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220697 03/12/2026 (a) The 15 clock hours of annual training must:(1) For a caregiver, be relevant to the age of the children for whom the caregiver provides care; or(2) For a site director, be relevant to the age of the children for whom the operation provides care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum; and(4) Teacher-child interaction.(c) At least one clock hour of the annual training hours must focus on prevention, recognition, and reporting of child maltreatment, including:(1) Factors indicating a child is at risk for abuse or neglect;(2) Warning signs indicating a child may be a victim of abuse or neglect;(3) Procedures for reporting child abuse or neglect; and(4) Community organizations that have training programs available to employees, children, and parents.(d) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §744.2653 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §744.2523 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(e) The remaining annual training hours must be in one or more of the following topics:(1) Care of children with special needs;(2) Child health (for example, nutrition, and physical activity);(3) Safety;(4) Risk management;(5) Identification and care of ill children;(6) Cultural diversity for children and families;(7) Professional development (for example, effective communication with families and time and stress management);(8) Topics relevant to the particular age group the caregiver is assigned;(9) Planning developmentally appropriate learning activities; and(10) Minimum standards and how they apply to the caregiver.(f) At least three of the 15 required annual training hours must be instructor-led training. The remaining 12 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(g) The 15 clock hours of annual training are exclusive of any requirements for orientation, pre-service training, pediatric first aid and pediatric CPR training, transportation safety training, water safety training, and high school child-care work-study classes. Source Note: The provisions of this §744.1309 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1309 What areas of training must the annual training for caregivers and site directors cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220698 03/12/2026 (a) The 20 clock hours of annual training must be relevant to the age of the children for whom the operation provides care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum;(4) Teacher-child interaction; and(5) Serving children with special care needs.(c) At least one clock hour of the annual training hours must focus on prevention, recognition, and reporting of child maltreatment, including:(1) Factors indicating a child is at risk for abuse or neglect;(2) Warning signs indicating a child may be a victim of abuse or neglect;(3) Procedures for reporting child abuse or neglect; and(4) Community organizations that have training programs available to employees, children, and parents.(d) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §744.2653 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §744.2523 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(e) An operation director or program director with:(1) Five or fewer years of experience as a designated operation director or program director must complete at least six clock hours of the annual training hours in management techniques, leadership, or staff supervision; or(2) More than five years of experience as a designated operation director or program director must complete at least three clock hours of the annual training hours in management techniques, leadership, or staff supervision.(f) The remainder of the 20 clock hours of annual training must be selected from the training topics specified in §744.1309(e) of this division (relating to What areas of training must the annual training for caregivers and site directors cover?).(g) An operation director or program director may obtain clock hours or CEUs from the same sources as caregivers.(h) A director may not earn training hours by presenting training to others.(i) At least four of the required 20 annual training hours must come from instructor-led training. The remaining 16 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(j) The 20 clock hours of annual training are exclusive of any requirements for orientation, pre-service training, pediatric first aid and pediatric CPR training, transportation safety training, and water safety training. Source Note: The provisions of this §744.1311 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645; amended to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1311 What areas of training must the annual training for an operation director or a program director cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192474 03/12/2026 Each caregiver and director must obtain their annual training within 12 months from the date of their employment and during each subsequent 12-month period, unless otherwise specified in this division. If they obtain more than the minimum number of annual training clock hours required, they may not carry the additional clock hours over to the next year. Source Note: The provisions of this §744.1313 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1313 When must annual training for my caregivers and director be obtained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192868 03/12/2026 (a) Each caregiver, operation director, program director, and site director must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking.(b) Each caregiver, operation director, program director, and site director must have a current certificate of training with an expiration or renewal date in pediatric cardiopulmonary resuscitation (CPR). A new caregiver does not have to have a current certificate in pediatric CPR before having unsupervised access to a child in care. However, the operation must have at least one employee or caregiver on the premises while children are in care that has a current certificate in pediatric CPR. The pediatric CPR:(1) Must adhere to the guidelines for CPR for a layperson established by the American Heart Association, and consist of a curriculum that incudes use of a CPR manikin and both written and hands-on skill-based instruction, practice, and testing; and(2) May be provided through blended learning that utilizes online technology, including self-instructional training, as long as the criteria in paragraph (1) of this subsection is met. Source Note: The provisions of this §744.1315 adopted to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1315 Who must have pediatric first aid and pediatric CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192869 03/12/2026 (a) If the operation transports children whose chronological or developmental age is younger than nine years old, two clock hours of annual transportation safety training is required for:(1) Each employee prior to transporting a child; and(2) Each site director, and program director or operation director.(b) The two clock hours of transportation safety training are exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §744.1317 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1317 What additional training must an employee and director have if the operation transports children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220699 03/12/2026 (a) If the operation allows a child to access a swimming pool at or away from the operation, annual water safety training is required for:(1) Each employee prior to accompanying a child to a swimming pool; and(2) Each site director and program director or operation director.(b) The training must be specific to water safety in and around swimming pools.(c) Water safety training is exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §744.1318 adopted to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1318 What additional training must an employee and director have if the operation allows a child to access a swimming pool at or away from the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192464 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192464 03/12/2026 (a) Training may include clock hours or CEUs provided by:(1) A training provider registered with the Texas Early Childhood Professional Development System Training Registry, maintained by the Texas Head Start State Collaboration Office;(2) An instructor who teaches early childhood development or another relevant course at a secondary school or institution of higher education accredited by a recognized accrediting agency;(3) An employee of a state agency with relevant expertise;(4) A physician, psychologist, licensed professional counselor, social worker, or registered nurse;(5) A person who holds a generally recognized credential or possesses documented knowledge relevant to the training the person will provide; or(6) A person who has at least two years of experience working in child development, a child development program, early childhood education, a childhood education program, or a Head Start or Early Head Start program and:(A) Has a current Child Development Associate (CDA) credential; or(B) Holds at least an associate's degree in child development, early childhood education, or a related field.(b) Training may include clock hours or CEUs obtained through self-instructional materials, if the materials were developed by a person who meets one of the qualifications in subsection (a) of this section.(c) Instructor-led training and self-instructional training, excluding self-study training, must include:(1) Specifically stated learning objectives;(2) A curriculum, which includes experiential or applied activities;(3) An evaluation/assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(4) A certificate of successful completion from the training source. Source Note: The provisions of this §744.1319 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1319 Must the training for my caregivers and the director meet certain criteria? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212677 03/12/2026 (a) We do not approve or endorse training resources or trainers for training hours. But you must ensure you and your employees receive training that:(1) Meets the criteria specified in §744.1319 of this title (relating to Must the training for my caregivers and the director meet certain criteria?);(2) Is relevant to the topics specified in this division; and(3) Provides the participants with original documentation of completion, as specified in this division.(b) If the training is provided through a block certification training, the training must allocate clock hours to each specific topic included in the training. Source Note: The provisions of this §744.1321 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1321 Does Licensing approve training resources or trainers for training hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192466 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192466 03/12/2026 Yes. If the training is in a topic specified in this division and the caregiver can provide documentation of completion as specified in this division, then you may count this training toward the annual training requirement. Source Note: The provisions of this §744.1323 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1323 If I have a caregiver who attends college or a Child Development Associate/Certified Child-Care Professional credential program, may I count these clock hours toward the annual training requirement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192467 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192467 03/12/2026 Training received at another operation can be applied towards the annual training requirement, if:(1) The caregiver or director provides documentation of training, as specified in §744.1331 of this title (relating to What documentation must I provide to Licensing to verify that training requirements have been met?);(2) The person obtained the training from a child-care center, a school-age or before or after-school program, or a child-care home that we license or register; and(3) The training was obtained within two months before coming to work for your operation. Source Note: The provisions of this §744.1325 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1325 If I hire a caregiver or a director that received training at another operation, may these hours count towards the annual training requirement at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192870 03/12/2026 (a) You must maintain the original certificate or letter documenting the completion of annual training in each employee's personnel record at the operation.(b) For annual training to be counted toward compliance with the minimum standards, the trainer or training source must provide the participant with an original certificate or letter showing:(1) The participant's name;(2) Date of the training;(3) Title/subject of the training;(4) The trainer's name, or the source of the training for self-instructional training;(5) The trainer's qualifications, in compliance with §744.1319 of this division (relating to Must the training for my caregivers and the director meet certain criteria?); and(6) Length of the training specified in clock hours, CEUs, or college credit hours, as appropriate.(c) For pediatric first aid with rescue breathing and choking and pediatric CPR to count toward compliance with the minimum standards:(1) The certificate or letter must include:(A) The same information required in subsection (b) of this section; and(B) The expiration or renewal date of the training, as determined by the organization providing the training; and(2) You must maintain:(A) The original certificate or letter documenting the completion of pediatric first aid and pediatric CPR in each employee's personnel record at the operation; or(B) A photocopy of the original certificate or letter documenting the completion of pediatric first aid and pediatric CPR in each employee's personnel record at the operation, so long as the employee is able to provide an original certificate or letter upon Licensing's request.(d) For orientation and pre-service training, you must obtain a signed and dated statement from the employee and the person providing the orientation or pre-service training stating the employee has received the orientation or pre-service training, or you may obtain an original certificate or letter as specified in subsection (b) of this section. Source Note: The provisions of this §744.1331 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective March 1, 2012, 37 TexReg 916; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1331 What documentation must I provide to Licensing to verify that employees have met training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212678 03/12/2026 (a) Substitutes not counted in the child/caregiver ratio must comply with minimum standards that apply to employees, except as otherwise provided in this division.(b) Volunteers and contractors who are regularly or frequently present at the operation but not counted in the child/caregiver ratio must comply with minimum standards that apply to employees.(c) Substitutes, volunteers, and contractors who are counted in the child/caregiver ratio must comply with minimum standards that apply to employees and caregivers, except as otherwise noted in subsection (d) of this section.(d) Volunteers, including parents, who only supplement the ratios for field trips and water activities do not have to comply with the minimum standards that apply to employees and caregivers, but they do have to comply with the relevant minimum standards in Subchapter E of this chapter relating to (Child/Caregiver Ratios and Group Sizes).(e) Substitutes, volunteers, and contractors who do not meet caregiver qualifications must never be left alone with children.(f) Substitutes, volunteers, and contractors must comply with the training requirements in §744.1403 of this division (relating to What are the training requirements for substitutes, volunteers, and contractors?). Source Note: The provisions of this §744.1401 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1401 What minimum standards must substitutes, volunteers, or contractors comply with? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220701 03/12/2026 (a) Substitutes, volunteers, and contractors must complete the following training requirements.Attached Graphic(b) If a substitute, volunteer, or contractor who is counted in the child to caregiver ratio does not yet have a current certificate in pediatric CPR, as required in (a)(4)(A) in Figure: 26 TAC §744.1403(a), at least one caregiver or employee with a current certificate must also be on the premises with the substitute, volunteer, or contractor. Source Note: The provisions of this §744.1403 adopted to be effective March 1, 2023, 48 TexReg 921; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1403 What are the training requirements for substitutes, volunteers, and contractors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212680 03/12/2026 A substitute, volunteer, or contractor is exempt from the pre-service training requirements if the substitute, volunteer, or contractor:(1) Has at least six months of documented prior experience in a regulated operation; or(2) Provides documentation of at least eight clock hours of training in the areas specified in §744.1305 of this chapter (relating to What areas of training must the pre-service training for caregivers cover?) at another regulated operation. Source Note: The provisions of this §744.1405 adopted to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS D PERSONNEL §744.1405 When is a substitute, volunteer, or contractor exempt from the pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188020 03/12/2026 (a) The child/caregiver ratio is the maximum number of children one caregiver can be responsible for.(b) Each child must have a caregiver who is responsible for the child and who is aware of details of the child's habits, interests, and any special needs. Source Note: The provisions of this §744.1501 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1501 What is child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188021 03/12/2026 A group of children is defined by the number of children assigned to a specific caregiver or group of caregivers, occupying an individual classroom or well-defined physical space within a larger room. Each child in any group has two things in common with every other child in his group: the same caregiver(s) responsible for the child's basic needs and the same classroom or activity space. Generally, the group stays with the assigned caregiver(s) throughout the day and may move to different areas throughout the operation, indoors and out. The group may not mix freely with other children, unless specific criteria are met as specified in this subchapter. The number of children who may be in a group varies according to the age of the children and the number of caregivers as specified in this subchapter. Source Note: The provisions of this §744.1503 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1503 What is considered a group? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188022 03/12/2026 Yes. More than one group of children may occupy a room, provided the following conditions are met:(1) The room is divided so that groups are separated. For example, a group of 25 children and another group of 10 children may be cared for in the same room if the placement of shelves, accordion doors, low movable walls, or symbolic boundaries divide the area so that children in one group do not freely mix with children in another group;(2) Groups may move from one activity area to another within the room during the day, but individual children may not freely mingle between groups; and(3) The total number of children must not routinely exceed the room capacity based on activity space. Source Note: The provisions of this §744.1505 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1505 May I place more than one group of children in a large room? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188023 03/12/2026 In determining child/caregiver ratio, the following apply:(1) Child/caregiver ratio is based on the specified age of the children in the caregiver's group or the age of the youngest child in the group, depending on the activity and the number of children at the operation.(2) You may use the developmental or emotional age, rather than the chronological age, of a child with special care needs, if this is recommended by a health-care professional or other qualified professional and is documented in the child's record.(3) You must consider the skills of the caregiver and the needs of the individual children and the group when assigning a caregiver to a group of children.(4) You must include all children in care, including children related to the director and employees.(5) In emergency situations, you may use employees of the operation who do not meet caregiver qualifications for a limited time while a substitute caregiver is being secured. The time must be no longer than is reasonably necessary to secure a qualified substitute caregiver. Emergency situations include, but are not limited to, illness, accident, or death.(6) The total number of children in care at the operation and in care away from the operation, such as during a field trip, must never exceed the licensed capacity of the operation. Source Note: The provisions of this §744.1507 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1507 How do I determine the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188024 03/12/2026 You must comply with the classroom ratios and group sizes in §746.1601 of this title (relating to How many children may one caregiver supervise?) and §746.1615 of this title (relating to May I adjust the child/caregiver ratio when I am opening and closing my child-care center?). Source Note: The provisions of this §744.1601 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1601 How many children may one caregiver supervise? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188025 03/12/2026 Identify the specified age of the children in each group using this formula:(1) List all of the children in the group in order of their ages from youngest to oldest;(2) Determine the total number of children in the group and divide this number by two. If the result is not a whole number but is .5, such as 6.5, round up to the next number, which is 7. This will be the core number of the group; and(3) Begin counting at the first or youngest child on your list and count down the list from youngest to oldest, until you reach the core number. The age of this child is the specified age of the children in this group. Source Note: The provisions of this §744.1603 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1603 How do I determine the specified age of the children in each group? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188026 03/12/2026 The maximum number of children two or more caregivers may supervise is limited by the maximum group size. Source Note: The provisions of this §744.1605 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1605 If I have two or more caregivers with each group, what is the maximum number of children each caregiver may supervise? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188027 03/12/2026 You must comply with §746.1609 of this title (relating to What is the maximum group size?). Source Note: The provisions of this §744.1607 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1607 What is the maximum group size? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188028 03/12/2026 (a) Yes. When 13 or more children are in care, you may mix groups for joint activities and exceed the maximum group size for limited times under the following conditions:(1) For children three years through four years old, for a maximum of 30 minutes;(2) For children five years old and older, for a maximum of 1 1/2 hours;(3) For mealtimes, field trips, outdoor play, and naptimes, for the length of that activity; and(4) For activities that are fundamental to the core development of a skill, talent, ability, expertise, or proficiency that is the goal of skill instruction or training that is a core component of your operation's program, for the length of the activity.(b) The child/caregiver ratio must be met for each group and activity. Source Note: The provisions of this §744.1609 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1609 Are there times when I may mix groups of children and exceed the maximum group size? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188029 03/12/2026 (a) Yes. If 13 or more children are in care, you may reduce the child/caregiver ratio for children by 50% during naptime under the following conditions: (1) Groups of children using reduced ratio must be combined in a central sleeping location that safely accommodates naptime equipment; (2) Groups of children that cannot be combined in a central location due to space limitations must not use reduced ratios; (3) Caregivers with groups that cannot be combined must not be counted as additional caregivers in the building or in the naptime ratio; (4) If only one caregiver is required to supervise the naptime group, at least one other employee or caregiver must be present in the building; (5) If more than one caregiver(s) must supervise the naptime group, one additional employee or caregiver must be present in the building for every two caregivers supervising the naptime group; (6) Caregivers supervising during naptime must be physically present in the room or area in which children are napping and must be able to summon the additional employee(s) without leaving the room or area; and (7) Other employees, such as the director or cook, who are not supervising a group of children may be counted as additional adults required in the building during naptime. (b) The following chart shows the 50% naptime ratio and the number of additional caregivers required in the building:Attached Graphic Source Note: The provisions of this §744.1611 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1611 May I reduce the number of caregivers supervising children during naptime? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188031 03/12/2026 You must comply with §746.1801 of this title (relating to Do I need additional caregivers when I take children away from the child-care center for field trips or walks?). Source Note: The provisions of this §744.1701 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1701 Do I need additional caregivers when I take children away from the operation for field trips or walks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188032 03/12/2026 You must comply with classroom child/caregiver ratios when transporting children. The driver may be counted in this ratio if the driver meets caregiver qualifications. Source Note: The provisions of this §744.1705 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1705 If I provide transportation, how many caregivers must I have in the vehicle to supervise the children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188033 03/12/2026 No. Additional caregivers are not needed for the child/caregiver ratio for nighttime care, although naptime ratios must not be used during nighttime care. Source Note: The provisions of this §744.1801 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1801 Must I have additional caregivers during nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220703 03/12/2026 You must comply with §746.2101 of this title (relating to Must I have additional caregivers for wading activities?). Source Note: The provisions of this §744.1901 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1901 Must I have additional caregivers for wading activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188035 03/12/2026 You must comply with §746.2105 of this title (relating to What are the child/caregiver ratios for swimming activities?). Source Note: The provisions of this §744.1905 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1905 What are the child/caregiver ratios for swimming activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220704 03/12/2026 A certified lifeguard must be on duty at all times when children are swimming in more than 18 inches of water. Source Note: The provisions of this §744.1907 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1907 Must a certified lifeguard be on duty when children are swimming in more than 18 inches of water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188037 03/12/2026 (a) You must not count the certified lifeguard in the child/caregiver ratio when people other than the children from your operation are swimming.(b) If only children from your operation are swimming, you may count the certified lifeguard in the child/caregiver ratio, although the lifeguard must never be left alone with any of the children unless the lifeguard is also a qualified caregiver you employ at your operation. Source Note: The provisions of this §744.1909 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1909 May I count the certified lifeguard in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220705 03/12/2026 Each caregiver included in the child/caregiver ratio for swimming in 18 inches or more of water must be able to swim and must be prepared to do so in an emergency. Source Note: The provisions of this §744.1911 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1911 Must persons who are counted in the child/caregiver ratio during swimming activities know how to swim? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220706 03/12/2026 You may include adult volunteers and employees of your operation who do not meet the minimum qualifications for caregivers specified in Subchapter D of this chapter (relating to Personnel) to meet the child/caregiver ratio for swimming and wading activities, provided that:(1) You maintain at least the classroom child/caregiver ratios required in this subchapter with caregivers who do meet the minimum qualifications for caregivers;(2) All persons included in the ratios for water activities must be able to swim and must be prepared to do so in an emergency; and(3) You ensure compliance with all other minimum standards, including, but not limited to, standards relating to supervision, discipline, and guidance. Source Note: The provisions of this §744.1913 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1913 May I include volunteers or child-care employees who do not meet minimum qualifications for caregivers in the child/caregiver ratio for water activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188040 03/12/2026 We do not require additional caregivers for sprinkler play; however, you must not leave a child alone with the sprinkler equipment. Source Note: The provisions of this §744.1915 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §744.1915 Must I have additional caregivers for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212681 03/12/2026 Caregivers must ensure children receive individual attention and care including:(1) Flexible programming according to each child's age, interest, and abilities;(2) Encouraging communication and expression of feelings in appropriate ways;(3) Study time for those children who choose to work on homework assignments;(4) Physical care routines appropriate to each child's developmental needs; and(5) A caregiver who is aware of the arrival and departure of each child, including dismissing children who ride the bus or walk home. Source Note: The provisions of this §744.2001 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2001 What planned activities must caregivers provide for children in their care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204089 03/12/2026 You must include the following activities for programs where you anticipate a child will be in care five or more consecutive hours in a day.(1) Outdoor play in which the child makes use of both small and large muscles, as weather permits;(2) A balance of active and quiet play, including group and individual activities;(3) Opportunities for active play both indoors and outdoors. Examples include active games such as tag and Simon Says, dancing and creative movement to music and singing, simple games and dramatic or imaginary play that encourages running, stretching, climbing, and walking;(4) Child-initiated activities where:(A) The equipment, materials, and supplies are within reach of the child; and(B) The child chooses the activity on the child's own initiative;(5) Caregiver-initiated activities that the caregiver directs or chooses, at least two of which must promote movement;(6) Regular meal and snack times as specified in Subchapter J of this Chapter (relating to Nutrition and Food Service);(7) Supervised naptimes or rest times;(8) Sufficient time for activities and routines so that the child can progress at the child's own developmental rate; and(9) No long waiting periods between activities or prolonged periods during which a child stands or sits. Source Note: The provisions of this §744.2002 adopted to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2002 What additional activities must caregivers provide when a child is in care for more than five consecutive hours in a day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204092 03/12/2026 If your operation cares for a child under the age of five, you must:(1) Have written procedures that include the following:(A) How caregivers will supervise the child while transitioning the child to and from restrooms, indoor and outdoor activity spaces, and spaces shared by other persons outside of the operation;(B) How caregivers will meet the unique care needs of the child;(C) How caregivers will meet the outdoor play and physical activity needs in §744.2002(1) and (3) of this division (relating to What additional activities must caregivers provide when a child is in care for more than five consecutive hours in a day?), including:(i) A minimum of two opportunities for outdoor play, weather permitting, for at least 60 total minutes when a child is in care for eight hours, although you may prorate this requirement if a child is in care for less than eight hours; and(ii) A minimum of 90 minutes of moderate to vigorous active play when a child is in care for eight hours, although you may prorate this requirement if a child is in care for less than eight hours;(D) Under what circumstances the child will be mixing with older children in the operation; and(E) Any modifications to space or equipment that will be made to accommodate the child.(2) Have written policies that address the promotion of indoor and outdoor physical activity that are consistent with this division. Your policies must include:(A) The benefits of physical activity and outdoor play;(B) The duration of physical activity at your operation, both indoor and outdoor;(C) The type of physical activity (structured and unstructured) that children may engage in at your operation;(D) Each setting in which your physical activity program will take place;(E) The recommended clothing and footwear that will allow a child to participate freely and safely in physical activities; and(F) A plan to ensure physical activity occurs on days when extreme weather conditions prohibit or limit outdoor play.(3) Follow the policies and procedures and make the policies and procedures available for review by:(A) Licensing upon request during your hours of operation; and(B) Parents at enrollment and as needed thereafter. Source Note: The provisions of this §744.2003 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2003 What are the additional requirements if my operation cares for a child under the age of five? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204090 03/12/2026 (a) For programs with a child whom you anticipate to be in care for five or more consecutive hours in a day, you must have a written activity plan that complies with §744.2002 of this division (relating to What additional activities must caregivers provide when a child is in care for more than five consecutive hours in a day?) and §744.2003(1)(C) of this division (relating to What are the additional requirements if my operation cares for a child under the age of five?).(b) A written activity plan must:(1) Identify the age group the activity plan is designed for and list the dates (daily, weekly, or monthly) the plan covers;(2) Outline the daily routines and specific activities for each group and the approximate times those activities will occur;(3) Be followed by the caregiver or caregivers responsible for the relevant group of children; and(4) Be inclusive for all children in the group regardless of special care needs.(c) A written activity plan may include one or more screen time activities specified in §744.2007 of this division (relating to May I use a screen time activity with a child?), if you also include alternative activities for children who do not want to participate. Source Note: The provisions of this §744.2005 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2005 What written activity plans must caregivers follow? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204091 03/12/2026 (a) You may use a screen time activity to supplement, but not to replace, an activity for children described in §744.2001 of this division (relating to What planned activities must caregivers provide for children in their care?) and §744.2002 of this division (relating to What additional activities must caregivers provide when a child is in care for more than five consecutive hours in a day?).(b) If you use a screen time activity for a child at the operation, you must ensure that the activity:(1) Is related to the planned activities that meet educational goals;(2) Is age-appropriate;(3) Does not exceed one hour per day;(4) Is not used during mealtime, snack times, naptimes, or rest times;(5) Does not include advertising or violence; and(6) Is turned off when not in use.(c) A school-age child may use screen time without restriction for homework. Source Note: The provisions of this §744.2007 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2007 May I use a screen time activity with a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212682 03/12/2026 You must:(1) Provide a child with special care needs with the accommodations recommended by:(A) A health-care professional; or(B) A qualified professional affiliated with the local school district;(2) Utilize as recommended any adaptive equipment that has been provided to the operation for a child's use;(3) Ensure that a child who receives specialized services, such as speech therapy, occupational therapy, or physical therapy, for the child's disability can receive those services from a qualified service provider at your operation, with parental request and approval;(4) Ensure that activities integrate all children with special care needs; and(5) Ensure that caregivers adapt equipment and procedures and vary methods as necessary to ensure that you care for a child with special needs in a natural environment. Source Note: The provisions of this §744.2009 adopted to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2009 What are my responsibilities when planning activities for a child in care with special care needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188045 03/12/2026 Physical space and equipment for children must include:(1) Space for furnishings and activities without limiting children's movement;(2) Space where children can be supervised while they participate in individual activities;(3) Space for quiet time to do homework, if applicable;(4) Workspace to do homework and table-top activities, if applicable;(5) Tables and chairs that are safe, easy to clean, and of a height and size appropriate for each age group in care;(6) Age-appropriate nap or rest equipment for children who are in care more than five consecutive hours per day or whose physical needs otherwise require nap or rest;(7) Containers or low shelving available so items children can safely use without direct supervision are accessible to children; and(8) A system for storing each child's belongings, which allows a child to easily recognize and retrieve his belongings. Source Note: The provisions of this §744.2051 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS F DEVELOPMENTAL ACTIVITIES AND EQUIPMENT §744.2051 What physical space and equipment must I provide for children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188046 03/12/2026 (a) Each disciplinary measure must:(1) Be consistent with your policies and procedures;(2) Not be physically or emotionally damaging to the child;(3) Be appropriate to the child's age and level of understanding; and(4) Be appropriate to the incident and severity of the behavior demonstrated.(b) A caregiver may only use positive methods of discipline and guidance that encourages self-esteem, self-control, and self-direction, including the following:(1) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;(2) Reminding a child of behavior expectations daily by using clear, positive statements;(3) Redirecting behavior using positive statements; and(4) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per year of the child's age. Source Note: The provisions of this §744.2103 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS G DISCIPLINE AND GUIDANCE §744.2103 What methods of discipline and guidance may a caregiver use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212683 03/12/2026 There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:(1) Corporal punishment or threats of corporal punishment;(2) Punishment associated with food, naps, or toilet training;(3) Grabbing or pulling on a child;(4) Putting anything in or on a child's mouth;(5) Humiliating, ridiculing, rejecting, or yelling at a child;(6) Subjecting a child to harsh, abusive, or profane language;(7) Placing a child in a locked or dark room, bathroom, or closet;(8) Withholding active play or keeping a child inside as a consequence for behavior, unless the child is exhibiting behavior during active play that requires a brief supervised separation or time out that is consistent with §744.2103(b)(4) of this subchapter (relating to What methods of discipline and guidance may a caregiver use?); and(9) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age. Source Note: The provisions of this §744.2105 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS G DISCIPLINE AND GUIDANCE §744.2105 What types of discipline and guidance or punishment are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188048 03/12/2026 Yes, during operating hours an employee may discipline the employee's own child as long as the employee does not violate the requirements specified in this subchapter. Source Note: The provisions of this §744.2107 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS G DISCIPLINE AND GUIDANCE §744.2107 May my employees discipline their own children who are in care at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188049 03/12/2026 You may use disciplinary measures for teaching a skill, talent, ability, expertise, or proficiency that is the goal of skill instruction or training that is a core component of your operation's program so long as:(1) The measures are considered commonly accepted teaching or training techniques;(2) You provide a description of the training and disciplinary measures in writing to parents and employees and include the following information:(A) The disciplinary measures that may be used, such as physical exercise or sparring used in martial arts programs;(B) What behaviors would warrant the use of these measures; and(C) The maximum amount of time the measures would be imposed;(3) Inform parents that they have the right to ask for additional information; and(4) Ensure that the disciplinary measures used are not considered abuse, neglect, or exploitation as specified in the Texas Family Code §261.401 and Chapter 745, Subchapter K, Division 5, of this title (relating to Abuse and Neglect). Source Note: The provisions of this §744.2109 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS G DISCIPLINE AND GUIDANCE §744.2109 May I use disciplinary measures that are fundamental to teaching a skill, talent, ability, expertise, or proficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188050 03/12/2026 You must provide a supervised nap, or a period of rest for those children too old to nap, for all children who are in care five or more consecutive hours, or according to the child's individual physical needs. You may provide a sleep or rest period for each child who attends the program for fewer than five hours and whose individual physical needs call for a rest period while the child is in care. Source Note: The provisions of this §744.2201 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2201 Must children have a naptime every day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188051 03/12/2026 The nap or rest period must not exceed three hours. Source Note: The provisions of this §744.2203 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2203 How long may the nap and rest time last each day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188052 03/12/2026 No. You must not force a child to sleep or put anything in or on a child's head or body to force the child to rest or sleep. Source Note: The provisions of this §744.2205 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2205 Are children required to sleep during this time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188053 03/12/2026 Yes. You must allow each child who is awake after resting or sleeping for 30 minutes to participate in an alternative, quiet activity until the nap/rest time is over for the other children. Source Note: The provisions of this §744.2207 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2207 Must I provide an alternative activity for those children who cannot sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212684 03/12/2026 Napping equipment must:(1) Not block entrances or exits to the area;(2) Not be set up during other activities or left in place to interfere with children's activity space;(3) Be arranged so that each child and caregiver has access to a walkway without having to walk on or over the sleep or rest equipment of other children; and(4) Be arranged so the caregiver can adequately supervise all of the children in the group as specified in §744.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §744.2209 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2209 Must I arrange the napping equipment in a specific manner? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188055 03/12/2026 Yes. You may lower the lighting, provided there is adequate lighting to allow visual supervision of all children in the group at all times. Lighting in a room is adequate if a person's eyes do not need to adjust for the person to be able to see upon entering the room. Source Note: The provisions of this §744.2211 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2211 May I lower the lighting in the room while children are sleeping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188056 03/12/2026 If your operation offers nighttime care, you must follow the rules specified in Chapter 746, Subchapter P of this title (relating to Nighttime Care). Source Note: The provisions of this §744.2251 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS H NAPTIME §744.2251 May I provide nighttime care to children at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192469 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192469 03/12/2026 Yes. You must ensure the safety of all children on field trips or excursions and during any transportation provided by the operation. Anytime you take a child on a field trip, you must comply with each of the following requirements:(1) You must have signed permission from the parent to take a child on a field trip, including permission to transport the child, if applicable;(2) One or more caregivers must carry emergency medical consent forms and emergency contact information for each child on the field trip;(3) Caregivers must have a written list of all children on the field trip and must check the list frequently to account for the presence of all children;(4) Caregivers must have a first-aid kit immediately available on field trips;(5) Caregivers must have a copy of a child's food allergy emergency plan and allergy medications, if applicable;(6) Each child must wear a shirt, nametag, or other identification listing the name of the operation and the operation's telephone number;(7) Each caregiver must be easily identifiable by all children on the field trip by wearing a hat, operation tee-shirt, brightly-colored clothes, or other easily spotted identification;(8) Each caregiver supervising a field trip must have transportation available, a communication device such as a cellular phone or two-way radio available, or an alternate plan for transportation at the field-trip location in case of emergency; and(9) One or more caregivers per group of children must have current training in pediatric first aid and pediatric CPR. Source Note: The provisions of this §744.2301 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6645. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS I FIELD TRIPS §744.2301 May I take children away from my operation for field trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188058 03/12/2026 Yes. You must notify the parent of each child who will be on the field trip, indicating when and where the child will be going, and when the child is expected to return to the operation. The notice must be posted at least 48 hours in advance of a field trip. You must post the field trip notice in a prominent place where parents and others may view it. The notice must remain posted until all children on the field trip have returned to the operation. Source Note: The provisions of this §744.2303 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS I FIELD TRIPS §744.2303 Must I notify parents before I take children away from the operation on a field trip? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212685 03/12/2026 (a) You must serve all children regular meals and morning and afternoon snacks as specified in this subchapter.(b) The meals and snacks must follow the meal patterns established by the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) that is administered by the Texas Department of Agriculture. You must follow these patterns regardless of whether you are participating in the program for reimbursement.(c) If you serve breakfast, you do not have to serve a morning snack.(d) A child must not go more than three hours without a meal or snack being offered unless the child is sleeping.(e) You must serve enough food to allow a child to have a second serving from the vegetable, fruit, grain, and milk groups if the child requests it.(f) You must ensure a supply of clean, sanitary drinking water:(1) Is readily available to each child at every snack, mealtime, and during and after active play; and(2) Is served in a safe and sanitary manner.(g) You must not serve beverages with added sugars, such as carbonated beverages, fruit punch, or sweetened milk, unless otherwise allowed by the CACFP.(h) You must not use food as a reward.(i) You must not serve a child a food identified on the child's food allergy emergency plan as specified in §744.2667 of this chapter (relating to What is a food allergy emergency plan?). Source Note: The provisions of this §744.2401 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2401 What are the basic requirements for meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204099 03/12/2026 You must follow the guidelines in Figure 26 TAC §744.2403 when determining how often to feed a child in your care.Attached Graphic Source Note: The provisions of this §744.2403 adopted to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2403 How often must I feed a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204095 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204095 03/12/2026 (a) Yes. However, your enrollment agreement, or an addendum to the agreement, signed by the parent must include a statement that the parent:(1) Is choosing to provide the child's meals and snacks from home; and(2) Understands the operation is not responsible for its nutritional value or for meeting the child's daily food needs.(b) If the parent provides a meal but not a snack, you are responsible for providing a snack as specified in this subchapter.(c) You must provide safe and proper storage and service of the individual meals and snacks provided by parents.(d) Snacks provided by a parent must not be shared with other children, unless:(1) A parent is providing baked goods for a celebration or party being held at the operation; and(2) You ensure that the shared snacks meet the needs of children who require special diets. Source Note: The provisions of this §744.2409 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2409 May parents provide meals and snacks for their child instead of my operation providing them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204096 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204096 03/12/2026 (a) To serve a child a therapeutic or special diet, you must:(1) Have written approval from:(A) A physician or health-care professional with prescriptive authority if the diet relates to a disability that restricts the child's diet; or(B) A health-care professional or a registered or licensed dietician if the diet does not relate to a disability that restricts the child's diet;(2) Maintain the written approval in the child's record; and(3) Give the information to all employees preparing and serving food.(b) You must discuss recurring eating problems with the child's parent.(c) You may encourage but must not force children to eat.(d) You must not serve nutrient concentrates and supplements such as protein powders, liquid protein, vitamins, minerals, and other nonfood substances without written instructions as required in subsection (a)(1) of this section. Source Note: The provisions of this §744.2411 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2411 What are the requirements for a child who requires a special diet or does not want to eat foods the operation serves? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188063 03/12/2026 Yes:(1) Substitutions of comparable food value may be made to the daily menu, but you must keep a record of any substitutions; and(2) You may rotate menus, but you must keep a record of which menu was used for each date. Source Note: The provisions of this §744.2413 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2413 Can I make substitutions and/or rotate the daily menus? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188067 03/12/2026 All food and drinks must be of safe quality and must be stored, prepared, distributed, and served under sanitary and safe conditions, including but not limited to the following:(1) You must sanitize food service equipment, dishes, and utensils after each use;(2) If your operation lacks adequate facilities for sanitizing dishes and utensils, you must use only disposable, single-use items;(3) You must wash re-useable napkins and tablecloths after each use;(4) You must discard single-service napkins, dishes, and utensils after use;(5) Caregivers with open wounds and/or any injury that inhibits hand washing, such as casts, bandages, or braces, must not prepare food;(6) You must serve children's food on plates or napkins, and you must not place food on a bare table or eating surface, which includes the floor;(7) You must cover all food stored in the refrigerator;(8) When meals are prepared at the operation, the food preparation area must be separated from the eating, play, and bathroom areas. You must not use the food preparation area as a passageway while food is being prepared; and(9) You must not store poisonous or toxic materials and cleaning supplies with food. Source Note: The provisions of this §744.2419 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2419 What general requirements apply to food service and preparation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204097 03/12/2026 (a) No, you do not have to use family-style meal service, although all meals and snack times must:(1) Be unhurried;(2) Allow children to feed themselves according to their developmental level; and(3) Include adult supervision of children.(b) If meals and snacks are served family style, caregivers must supervise children to prevent cross-contamination of the food. Source Note: The provisions of this §744.2421 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1473. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2421 Must I serve meals family style? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188070 03/12/2026 (a) Yes, although toothbrushes and tooth powders or pastes provided for each child's individual use must be:(1) Labeled with the child's full name;(2) Stored out of children's reach when not in use; and(3) Stored in a manner that prevents the toothbrushes from touching each other during storage.(b) Children must have adult supervision while brushing their teeth. Source Note: The provisions of this §744.2423 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS J NUTRITION AND FOOD SERVICE §744.2423 Are children allowed to use toothbrushes after meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188071 03/12/2026 (a) Your operation must have a sanitation inspection before we issue your initial permit and at least once every 12 months, unless your operation is located in a public school facility operated by the local independent school district.(b) If an inspection is required, a local sanitation official must conduct the inspection.(c) If an inspection is not available from a local sanitation official, you must:(1) Obtain documentation from a local sanitation official or county judge stating that an inspection is not available; and(2) Maintain this documentation at the operation and make it available to us upon request. Source Note: The provisions of this §744.2501 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective June 1, 2014, 39 TexReg 3716; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2501 Must my operation have an annual sanitation inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188072 03/12/2026 If required, you must keep a copy of the most recent sanitation report, letter, or checklist at the operation during hours of operation to verify the inspection date and findings. The report must include the name and telephone number of the inspector. Source Note: The provisions of this §744.2503 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2503 How do I document that a sanitation inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188077 03/12/2026 Yes, you must comply with corrections, restrictions, or conditions specified by the inspector in the sanitation report, letter, or checklist. Source Note: The provisions of this §744.2505 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2505 Do I have to make corrections called for in the report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188078 03/12/2026 You must clean, repair, and maintain the building, grounds, and equipment to protect the health of the children. This includes, but is not limited to:(1) Machine washing used cloth toys at least weekly and when contaminated;(2) Machine washing used linens at least weekly, and when soiled or before a different child uses them;(3) Sanitizing sleeping and rest equipment before a different child uses it and when soiled;(4) Maintaining sand boxes and sand tables in a sanitary manner;(5) Making all garbage inaccessible to children and managing it to keep the operation inside and outside, free of insects, rodents, and offensive odors, and disposing of it according to local and state requirements;(6) Keeping all floors, ceilings, and walls in good repair and clean;(7) Ensuring that all paints used at the operation are lead-free;(8) Keeping all parts of the operation used by children well heated, lighted, and ventilated;(9) Sanitizing table tops, furniture, and other similar equipment used by children when soiled or contaminated with matter such as food or bodily secretions;(10) Clearly marking cleaning supplies and other toxic materials and keeping them separate from food and inaccessible to children; and(11) Using, storing, and disposing of hazardous materials as recommended by the manufacturer. Source Note: The provisions of this §744.2507 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2507 What steps must I take to ensure a healthy environment for children at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188073 03/12/2026 Items that may be washed in a dishwasher or hot cycle of a washing machine which runs at a temperature of 160 degrees Fahrenheit or higher for five or more minutes do not need additional disinfecting, because these machines use water that is hot enough, for long enough, to kill most germs. Source Note: The provisions of this §744.2513 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2513 May I use a dishwasher or washing machine to sanitize items at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188074 03/12/2026 Employees must wash their hands:(1) Before eating or handling food or medication;(2) Before feeding a child;(3) After arriving at the operation;(4) After assisting a child with toileting;(5) After personal toileting;(6) After handling or cleaning bodily fluids, such as after tending sores and wiping noses, mouths, or bottoms;(7) After handling or feeding animals;(8) After outdoor activities;(9) After handling raw food products;(10) After eating, drinking, or smoking;(11) After using any cleaners or toxic chemicals; and(12) After removing gloves. Source Note: The provisions of this §744.2515 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2515 When must employees wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188075 03/12/2026 Children must wash their hands:(1) Before eating;(2) Before playing in a water play table;(3) After toileting;(4) After outdoor activities;(5) After playing in sand;(6) After feeding or touching animals; and(7) Any other time that the caregiver has reason to believe the child has come in contact with substances that could be harmful to the child. Source Note: The provisions of this §744.2517 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2517 When must children wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188076 03/12/2026 Children and employees must wash their hands with soap and running water. Source Note: The provisions of this §744.2519 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2519 How must children and employees wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188079 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188079&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188079 03/12/2026 You may use hand sanitizers as a substitute for washing hands if all of the following conditions are met:(1) You do not use hand sanitizers to wash hands that are visibly dirty or greasy or have chemicals on them, unless you are away from the classroom and soap and water are not available for hand washing;(2) You follow the labelling instructions for the appropriate amount to be used and for how long the hand sanitizer needs to remain on the skin surface to be effective;(3) Children have adult supervision when using hand sanitizers; and(4) You store hand sanitizers out of the reach of children when not in use. Source Note: The provisions of this §744.2520 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2520 May I use hand sanitizer as a substitute for washing hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188080 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188080&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188080 03/12/2026 No. We do not require you to have hot water for hand washing. However, if hot water is accessible to the children, a thermostat must control it so that the water temperature is no higher than 120 degrees Fahrenheit. Source Note: The provisions of this §744.2521 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2521 Must my operation have hot water for hand washing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188081 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188081&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188081 03/12/2026 Yes. Caregivers must follow universal precautions outlined by the Centers for Disease Control (CDC) when handling blood, vomit, or other bodily fluids that may contain blood including:(1) Using disposable, nonporous gloves;(2) Placing gloves contaminated with blood in a tied, sealed, or otherwise closed plastic bag and discarding them immediately;(3) Discarding all other gloves immediately after one use; and(4) Washing hands after using and disposing of the gloves. Source Note: The provisions of this §744.2523 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2523 Must caregivers wear gloves when handling blood or bodily fluids containing blood? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188082 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188082&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188082 03/12/2026 You may treat your operation for pests only if you are certified as a noncommercial applicator by the Texas Department of Agriculture. Otherwise, you must use a pest control operator licensed by the Texas Department of Agriculture to prevent, control, or eliminate pest infestations at your operation, including the use of over-the-counter products designed for controlling insects, rodents, and other pests. Source Note: The provisions of this §744.2525 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2525 Must I use a licensed exterminator to treat my operation for insects, rodents, and other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188083 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188083&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188083 03/12/2026 (a) Children must not be allowed in areas where there is pesticide residue that may be harmful to them. Follow written instructions from the licensed pest control operator or label directions in order to determine whether the residue may be harmful to children.(b) Areas where children are present may be treated with chemicals only when permissible under the label directions. Source Note: The provisions of this §744.2527 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2527 Are there general precautions I must take when my operation is being treated for insects, rodents, and other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188084 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188084&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188084 03/12/2026 Yes, you may use water from a private water supply, although you must:(1) Maintain the water supply in a safe and sanitary manner; and(2) Maintain written records indicating the private water supply meets the requirements of the Texas Commission on Environmental Quality, if applicable. Source Note: The provisions of this §744.2529 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2529 May I use water from a private water supply instead of a public water supply for my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188085 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188085&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188085 03/12/2026 Yes, if the septic system is sanitary and meets the standards of the Texas Commission on Environmental Quality, including any routine inspections required by law. Source Note: The provisions of this §744.2531 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2531 May I use a septic system for sewage disposal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188086 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188086&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188086 03/12/2026 Caregivers must:(1) Promptly change soiled or wet clothing;(2) Thoroughly cleanse and dry children with individual cloths or disposable towels. You must discard the disposable towels after use and launder any cloths before using them again;(3) Not change children in or on areas that children come in close contact with during play or eating, such as dining tables, sofas, or floor play areas;(4) Wash their hands after assisting with toileting. Refer to §744.2519 of this title (relating to How must children and employees wash their hands?); and(5) Place soiled clothing in a tied, sealed, or otherwise closed plastic bag. Source Note: The provisions of this §744.2551 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2551 What steps must caregivers follow for assisting children with toileting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212686 03/12/2026 You must not allow an ill child to attend your operation if one or more of the following exists:(1) The illness prevents the child from participating comfortably in the operation activities, including outdoor play;(2) The illness results in a greater need for care than caregivers can provide without compromising the health, safety, and supervision of the other children in care;(3) The child has one of the following (unless a medical evaluation by a health-care professional indicates that you can include the child in your operation's activities):(A) An oral temperature above 101 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(B) A tympanic (ear) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(C) An axillary (armpit) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(D) An infrared temporal (forehead) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness; or(E) Symptoms and signs of possible severe illness such as lethargy, abnormal breathing, uncontrolled diarrhea, two or more vomiting episodes in 24 hours, rash with fever, mouth sores with drooling, behavior changes, or other signs that the child may be severely ill; or(4) A health-care professional has diagnosed the child with a communicable disease, and the child does not have medical documentation to indicate that the child is no longer contagious. Source Note: The provisions of this §744.2571 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2571 What type of illness would prohibit a child from attending the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188090 03/12/2026 You must follow the communicable disease exclusions required for schools as defined by the Texas Department of State Health Services (DSHS) in 25 TAC §97.7 (relating to Diseases Requiring Exclusion from Schools). Source Note: The provisions of this §744.2573 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2573 What communicable diseases would exclude a child from attending my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204664 03/12/2026 (a) If a child becomes ill while in your care but does not require immediate treatment by a health-care professional or hospitalization, you must:(1) Contact the parent to pick up the child;(2) Care for the child apart from other children;(3) Give appropriate attention and supervision until the parent picks the child up; and(4) Give extra attention to hand washing and sanitation if the child has diarrhea or vomiting.(b) If a child becomes ill while in your care and requires immediate treatment by a health-care professional or hospitalization, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the group);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure the supervision of other children in the group. Source Note: The provisions of this §744.2575 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2575 How must caregivers respond when a child becomes ill? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188088 03/12/2026 A child who was ill may return to your operation when:(1) The child is free of symptoms of illness for 24 hours; or(2) You have obtained a health-care professional's statement that the child no longer has an excludable disease or condition. Source Note: The provisions of this §744.2576 adopted to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2576 When may a child who was ill return to my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204663 03/12/2026 For an injury that requires immediate treatment by a health-care professional, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the group);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure supervision of other children in the group. Source Note: The provisions of this §744.2577 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2435. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2577 How must caregivers respond when a child is injured and requires immediate treatment by a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188092 03/12/2026 A vaccine-preventable disease is a disease that is included in the most current recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Source Note: The provisions of this §744.2579 adopted to be effective June 1, 2014, 39 TexReg 3716; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2579 What is a vaccine-preventable disease for the purpose of this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188093 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188093 03/12/2026 A policy for protecting the children in your care from vaccine-preventable diseases must:(1) Specify any vaccines that you have determined an employee must have for vaccine-preventable diseases based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(2) Require each employee to receive each specified vaccine that the employee is not exempt from having;(3) Include procedures for verifying whether an employee has complied with your policy;(4) Include procedures for an employee to be exempt from having a required vaccine because of:(A) Medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention (CDC); or(B) Reasons of conscience, including a religious belief;(5) Include procedures that an exempt employee must follow to protect children in your care from exposure to disease, such as the use of protective medical equipment, including gloves and masks, based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(6) Prohibit discrimination or retaliatory action against an exempt employee, except that required use of protective medical equipment, including gloves and masks, may not be considered retaliatory action for purposes of this section;(7) Outline how you will maintain a written or electronic record of each employee's compliance with or exemption from your policy; and(8) State the disciplinary actions you may take against an employee who fails to comply with your policy. Source Note: The provisions of this §744.2581 adopted to be effective June 1, 2014, 39 TexReg 3716; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS K HEALTH PRACTICES §744.2581 What must a policy for protecting children from vaccine-preventable diseases include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220707 03/12/2026 All areas accessible to a child must be free from hazards including the following:(1) Electrical outlets accessible to a child younger than five years old must have childproof covers or safety outlets;(2) 220-volt electrical connections within a child's reach must be covered with a screen or guard;(3) Air conditioners, electric fans, and heaters must be mounted out of all children's reach or have safeguards that keep any child from being injured;(4) Glass in sliding doors must be clearly marked with decals or other materials placed at children's eye level;(5) Play materials and equipment must be safe and free from sharp or rough edges and toxic paints;(6) Poisonous or potentially harmful plants must be inaccessible to all children;(7) All storage chests, boxes, trunks, or similar items with hinged lids must be equipped with a lid support designed to hold the lid open in any position, be equipped with ventilation holes, and must not have a latch that might close and trap a child inside;(8) All bodies of water, wading pools, hot tubs, birdbaths, fountains, buckets, and rain barrels must be inaccessible to all children; and(9) All televisions must be anchored, so they cannot tip over. A television may be anchored to a rolling cart, if it is anchored in a way that the cart will not tip over. Source Note: The provisions of this §744.2601 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2601 What safety precautions must I take to protect children in my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188097 03/12/2026 (a) People whose behavior and/or health status poses an immediate threat or danger to the health or safety of the children must not be present when children are in care.(b) People must not consume alcohol or controlled substances without a prescription in the operation, during transportation, or on field trips.(c) People must not be under the influence of or impaired by alcohol or controlled substances in the operation, during transportation, or on field trips.(d) People must not smoke any e-cigarette, vaporizer, or tobacco product or otherwise use any tobacco product at your operation, on the premises, on the playground, in transportation vehicles, or during field trips. Source Note: The provisions of this §744.2603 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2603 How can I ensure the safety of the children from other persons? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188098 03/12/2026 Although permissible, you are not required to have a video or audio monitoring system. Source Note: The provisions of this §744.2605 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2605 Am I required to have a video or audio monitoring system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188095 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188095 03/12/2026 (a) Peace officers as listed in §2.12 of the Code of Criminal Procedure and security officers commissioned by the Texas Private Security Board who are trained and certified to carry a firearm on duty may have firearms and ammunition on the premises of the operation.(b) For all other persons, firearms, hunting knives, bows and arrows, and other weapons are prohibited on the premises of the operation, unless the operation is also your home and except as allowed under subsection (e) of this section. This prohibition does not apply to personal vehicles.(c) Firearms, hunting knives, bows and arrows, and other weapons kept on the premises of an operation located in your home must remain in a locked cabinet inaccessible to children during your hours of operation.(d) Ammunition must be kept in a separate locked cabinet and inaccessible to children during your hours of operation.(e) If your operation uses specialized equipment or weapons that are fundamental to teaching a skill, talent, ability, expertise, or proficiency that is the goal of skill instruction or training that is a core component of your operation's program, such as batons and sticks used in martial arts programs:(1) The equipment must be used according to manufacturer's instructions and supervised by trained personnel;(2) The safety practices employed by the operation and the risks associated with the use of the equipment must be outlined in your policies and procedures; and(3) Parents must provide written consent before children may use the equipment. Written consent must be kept on file at the operation in the child's record and available for review by Licensing during your hours of operation. Source Note: The provisions of this §744.2607 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2607 Are firearms or other weapons allowed at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188094 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188094 03/12/2026 A child may not use any type of toy or equipment that explodes or that shoots things, such as caps, BB guns, darts, or fireworks at the operation or on field trips. These types of toys and equipment are not allowed at your operation unless your operation is located in your home. If your operation is located in your home, you must keep any such toy or equipment in a locked cabinet inaccessible to any child during your hours of operation. Source Note: The provisions of this §744.2609 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2609 May I have toys or other types of equipment that explode or shoot things? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188099 03/12/2026 In this division, medication means:(1) A prescription medication; or(2) A non-prescription medication, excluding topical ointments such as insect repellent and sunscreen. Source Note: The provisions of this §744.2651 adopted to be effective March 1, 2012, 37 TexReg 916; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2651 What does "medication" refer to in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188100 03/12/2026 (a) Authorization to administer medication to a child in your care must be obtained from the child's parent:(1) In writing, signed and dated;(2) In an electronic format that is capable of being viewed and saved; or(3) By telephone to administer a single dose of a medication.(b) Authorization to administer medication expires on the first anniversary of the date the authorization is provided.(c) The child's parent may not authorize you to administer medication in excess of the medication's label instructions or the directions of the child's health-care professional.(d) Parent authorization is not required if you administer a medication to a child in a medical emergency to prevent the death or serious bodily injury of the child, provided that you administer the medication as prescribed, directed, or intended. Source Note: The provisions of this §744.2653 adopted to be effective March 1, 2012, 37 TexReg 916; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2653 What authorization must I obtain before administering a medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188101 03/12/2026 (a) Medication must be given:(1) As stated on the label directions; or(2) As amended in writing by the child's health-care professional.(b) Medication must:(1) Be in the original container labeled with the child's full name and the date brought to the operation;(2) Be administered only to the child for whom it is intended; and(3) Not be administered after its expiration date.(c) When you administer medication to a child in your care, you must record the following:(1) Full name of the child to whom the medication was given;(2) Name of the medication;(3) Date, time, and amount of medication given; and(4) Full name of the employee administering the medication.(d) You must keep all medication records for at least three months after administering the medication. Source Note: The provisions of this §744.2655 adopted to be effective March 1, 2012, 37 TexReg 916; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2655 How must I administer medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188107 03/12/2026 You must store medications as follows:(1) Keep it out of the reach of children or in locked storage;(2) Store it in a manner that does not contaminate food; and(3) Refrigerate it, if refrigeration is required, and keep it separate from food. Source Note: The provisions of this §744.2657 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2657 How must I store medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188102 03/12/2026 You must dispose of the medication or return it to the parent when the child withdraws from the operation, or when the medication is out-of-date or is no longer required for the child. Source Note: The provisions of this §744.2659 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2659 How long may I keep the medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188103 03/12/2026 Yes. If you choose not to administer medication to children, you must inform the parents of this policy in writing before the child's enrollment. Source Note: The provisions of this §744.2661 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2661 Do I have to notify parents if I do not want to administer medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188104 03/12/2026 Specialized medical assistance is any medical assistance other than medication. Examples include, but are not limited to, assisting with an apnea monitor, protective helmet, or leg brace. Source Note: The provisions of this §744.2663 adopted to be effective March 1, 2012, 37 TexReg 916; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2663 What is specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188105 03/12/2026 (a) If a child in your care requires specialized medical assistance, then you are required to provide the specialized medical assistance as recommended or ordered by a health-care professional.(b) If you are provided with a written copy of the health-care professional's recommendations or orders, you must maintain this written information in the child's record for at least three months after the health-care professional has indicated that the specialized medical assistance is no longer needed. Source Note: The provisions of this §744.2665 adopted to be effective March 1, 2012, 37 TexReg 916; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2665 What are my requirements regarding specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188106 03/12/2026 A food allergy emergency plan is an individualized plan prepared by the child's health care professional that includes:(1) a list of each food the child is allergic to;(2) possible symptoms if exposed to a food on the list; and(3) the steps to take if the child has an allergic reaction. Source Note: The provisions of this §744.2667 adopted to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2667 What is a food allergy emergency plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188108 03/12/2026 You must have a food allergy emergency plan for each child with a known food allergy that has been diagnosed by a health-care professional. The child's heath care professional and parent must sign and date the plan. You must keep a copy of the plan in the child's file. Source Note: The provisions of this §744.2669 adopted to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2669 When must I have a food allergy emergency plan for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188109 03/12/2026 If you choose to have animals on the premises of your operation and/or on a field trip, you must:(1) Notify parents in writing when animals are or will be present;(2) Ensure the animals do not create unsafe or unsanitary conditions;(3) Ensure that children do not handle any animal that shows signs of illness, such as lethargy or diarrhea; and(4) Ensure that caregivers and children practice good hygiene and hand washing after handling or coming into contact with an animal and items used by an animal, such as water bowls, food bowls, and cages. Source Note: The provisions of this §744.2701 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2701 What steps must I take to have animals at my operation and/or on a field trip? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188110 03/12/2026 (a) Yes. You must have documentation at your operation showing dogs and cats have been vaccinated as required by Texas Health and Safety Code, Chapter 826.(b) You must have a statement of health from a local veterinarian at your operation for dogs, cats, ferrets, and other animals other than small rodents, such as guinea pigs, mice, and hamsters. Source Note: The provisions of this §744.2703 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2703 Must I keep documentation of vaccinations on file for the animals? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188111 03/12/2026 (a) Yes. Children must not have contact with chickens, ducks, and reptiles, such as snakes, turtles, lizards, iguanas, and amphibians, such as frogs and toads.(b) You must keep the operation and playground free of animals unfamiliar to you.(c) You must not allow children to play with animals unfamiliar to you or other animals that could be dangerous, including exotic animals such as monkeys. Source Note: The provisions of this §744.2705 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2705 Must I prevent children from having contact with certain animals while at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188112 03/12/2026 Yes. You must have a complete first-aid kit available in each building at the operation, during all field trips, and while transporting children. Each first-aid kit must be:(1) Clearly labeled;(2) Kept in a clean and sanitary condition;(3) Easily accessible to all employees;(4) Stored in a designated location known to all employees; and(5) Kept out of the reach of children. Source Note: The provisions of this §744.2751 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2751 Must I have a first-aid kit at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212687 03/12/2026 (a) Each first-aid kit must contain the following supplies:(1) A guide to first aid and emergency care;(2) Adhesive tape;(3) Antiseptic solution or wipes;(4) Adhesive bandages;(5) Scissors;(6) Sterile gauze pads;(7) Thermometer, preferably non-glass;(8) Tweezers; and(9) Waterproof, disposable gloves.(b) The first-aid supplies must not have expired. Source Note: The provisions of this §744.2753 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2753 What items must each first-aid kit contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220264 03/12/2026 (a) You must release a child only to a parent or a person designated by the parent.(b) Upon receipt of a valid court order signed by a judge that prohibits a parent from removing the named child or children from the child-care operation, the child-care operation must:(1) Comply with the court order immediately and until:(A) Receipt of a subsequent court order that revokes the primary order; or(B) The court order expires as defined in the document; and(2) Maintain a copy of the court order in the child's file. Source Note: The provisions of this §744.2801 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective August 19, 2024, 49 TexReg 6222. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2801 To whom may I release a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188115 03/12/2026 (a) You must develop operation policies for the release of children, including a plan to verify the identity of a person authorized to pick up a child but whom the caregiver does not know. If your operation transports children, the plan must include verifying the identity of a person to whom you release a child from an operation transportation vehicle.(b) Your policies must include a reasonable means to record the identity of the individual, such as a copy of valid photo identification, an instant photograph of the individual, or recording the driver's license number and car license plate numbers. You must retain this information in the child's records for at least three months.(c) You must instruct all employees in the operation's policies for the release of children, including the verification plan. Source Note: The provisions of this §744.2803 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS L SAFETY PRACTICES §744.2803 How do my employees verify the identity of a parent or a person a parent has designated to pick up the child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188116 03/12/2026 You must have at least 30 square feet of indoor activity space for each child that you are licensed to serve, unless the operation is exempt based on criteria specified in this division. Source Note: The provisions of this §744.2901 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2901 How many square feet of indoor activity space must I have for children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188117 03/12/2026 The number of children in each room must not routinely exceed what the room measurement will accommodate. However the number of children may exceed what the room measurement will accommodate if it is appropriate given the age of the children using the space, and whether the equipment and furnishings allow the children to safely participate in the activities. Source Note: The provisions of this §744.2903 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2903 Must I limit the number of children in each room based on the indoor activity space measurements for that room? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188118 03/12/2026 (a) Yes, the only exemption is for operations licensed as kindergarten and nursery schools, or schools: grades kindergarten and above, before September 1, 2003. These operations must have at least 20 square feet of indoor activity space for each child the operation is licensed to serve.(b) The exemption specified in subsection (a) of this section remains in effect until a permit issued prior to September 1, 2010, is no longer valid. Source Note: The provisions of this §744.2905 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2905 Do these indoor activity space requirements apply to my operation if it was licensed before September 1, 2010? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188119 03/12/2026 (a) We determine indoor activity space by:(1) Measuring all indoor activity space wall to wall on the inside at floor level;(2) Rounding all measurements up to the nearest inch;(3) Excluding single-use areas, which are areas not routinely used for children's activities, such as a bathroom, hallway, storage room, cooking area of a kitchen, swimming pool, and storage building; and(4) Excluding floor space occupied by permanent and stationary fixtures, such as bookcases, shelving, and storage/counter space, that is not intended for use by the children.(b) We use the sum of the measurements to calculate the indoor activity space and to determine the maximum number of children you may care for. Source Note: The provisions of this §744.2907 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2907 How does Licensing determine the indoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188120 03/12/2026 (a) You may share the indoor activity space that is not classroom space with other programs at the same time you have children in care, if you have a written plan specifying how caregivers will supervise and account for children in your care. The plan must address the following:(1) The ages of the children;(2) The proximity of restroom facilities and the operation entrances and exits to the children's area; and(3) The nature of other activities and persons who may be sharing the space.(b) You must follow your written plan and submit a copy to Licensing upon request. Source Note: The provisions of this §744.2909 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2909 May other programs use my indoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212688 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212688 03/12/2026 To care for children on any level above or below ground level, you must:(1) Obtain written approval from the state or local fire authority; and(2) Follow any restrictions issued by the state or local fire authority, including any age limits placed on the approval. Source Note: The provisions of this §744.2911 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2911 May I care for children above or below ground level? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188122 03/12/2026 (a) If children are in care for five or more consecutive hours, you must have 80 square feet of outdoor activity space for each child using the outdoor activity area at one time, or the indoor activity space must allow for room and equipment that permits children the opportunity to engage in age appropriate active play.(b) If you were licensed before September 1, 2003, you do not have to comply with the outdoor activity space requirements specified in subsection (a) of this section unless the permit issued prior to September 1, 2003, is no longer valid.(c) As long as children are in care for less than five consecutive hours, you are not required to have outdoor activity space if your program provides only indoor instruction that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency that requires physical activity. Source Note: The provisions of this §744.2951 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2951 How many square feet of outdoor activity space must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188123 03/12/2026 Yes. A fence or wall at least four feet high must enclose the outdoor activity space unless you meet one of the following:(1) Your operation is located at a public school facility operated by the local independent school district; or(2) The only children using the outdoor activity space are five years old or older. Source Note: The provisions of this §744.2953 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2953 Must I fence the outdoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188124 03/12/2026 Each fenced yard must have at least two exits. An entrance to the building may count as one exit, but one exit must be away from the building. Source Note: The provisions of this §744.2955 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2955 How many exits must I have from my fenced outdoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188125 03/12/2026 Yes, however the locking mechanism must be accessible to all employees at all times. Employees must be able to open the gates immediately in an emergency and satisfactorily demonstrate this ability to Licensing staff upon request. Source Note: The provisions of this §744.2957 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2957 May I keep the gates leading into my outdoor activity space locked while children are in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188126 03/12/2026 No; however, all outdoor activity areas used by children must be accessible from the operation by a safe route. We must approve a plan to use an outdoor activity space that is not connected to the operation, such as a near-by park, schoolyard, or other alternative. We will consider the following criteria before approving the plan:(1) Traffic patterns of vehicles and people in the area;(2) Ages of children in the groups;(3) Availability of appropriate equipment;(4) Usage of the location by other persons when the children would be most likely to use it;(5) Neighborhood circumstances, hazards, and risks;(6) Accessibility to children and caregivers on foot;(7) Reasonable accessibility of restroom facilities; and(8) Ability to obtain assistance if needed when injury or illness occurs. Source Note: The provisions of this §744.2959 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2959 Must the outdoor activity space be connected to the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188127 03/12/2026 Yes. If we approve the outdoor activity space, you must:(1) Give parents written notification of the location of the outdoor activity area, upon their child's enrollment;(2) Develop a written plan to supervise children, both during play and while traveling to and from the outdoor activity space; and(3) Meet other conditions specified by Licensing staff, if applicable. Source Note: The provisions of this §744.2961 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2961 Must I comply with additional requirements if my plan to use an outdoor activity space not connected to my operation is approved by Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188128 03/12/2026 (a) You may share the outdoor activity space with other programs at the same time you have children in care if you have a written plan specifying how caregivers will supervise and account for children in your care. The plan must address the following:(1) The ages of the children;(2) The proximity of restroom facilities and the operation entrances and exits to the children's area; and(3) The nature of other activities and persons who may be sharing the space.(b) You must follow your written plan and submit a copy to Licensing upon request. Source Note: The provisions of this §744.2963 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.2963 May other programs use my outdoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188129 03/12/2026 (a) If you are licensed to serve 13 or more children ages five years old and older, unless otherwise specified in this division, you must have one sink for every 20 children.(b) If you are licensed to serve 13 or more children, and have children younger than five years of age in care, unless otherwise specified in this division, you must have one sink for every 17 children.(c) If you are licensed to serve 12 or fewer children, unless otherwise specified in this division, you must have at least one sink available for the children's use.(d) If you were licensed as a kindergarten and nursery school, or school: grades kindergarten and above, before September 1, 2003, you must have one sink for every 20 children.(e) If you were licensed as a drop-in center before September 1, 2003, you must have at least one sink for every 25 children.(f) A kindergarten and nursery school, school: grades kindergarten and above, and drop-in center must comply with the requirements specified in subsection (a) or (b) of this section if the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §744.3001 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3001 How many hand-washing sinks must I have in my operation for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188130 03/12/2026 Hand-washing sinks must be inside the operation. Children must be able to safely and independently access the sink. Hand-washing sinks must be equipped with soap, running water, and single-use disposable towels or hot-air hand dryers. Source Note: The provisions of this §744.3003 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3003 Where must I locate the hand-washing sinks for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188131 03/12/2026 (a) If you are licensed to serve 13 or more children ages five years and older, you must have one flush toilet for every 20 children.(b) If you are licensed to serve 13 or more children, and have children younger than five years of age in care, unless otherwise specified in this division, you must have one flush toilet for every 17 children.(c) If you are licensed to serve 12 or fewer children, you must have at least one flush toilet available for the children's use.(d) If you were licensed as a kindergarten and nursery school, or school: grades kindergarten and above, before September 1, 2003, you must have one flush toilet for every 20 children.(e) If you were licensed as a drop-in center before September 1, 2003, you must have at least one flush toilet for every 25 children.(f) An operation licensed before September 1, 2003, must comply with the requirements specified in subsection (a) or (b) of this section if the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §744.3005 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3005 How many toilets am I required to have in my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188132 03/12/2026 Toilets must be inside the operation and include toilet paper. Children must be able to safely and independently access the toilet. Toilets must be equipped for independent use by children and allow supervision by caregivers, as needed. Source Note: The provisions of this §744.3007 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3007 Where must the toilets be located? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188133 03/12/2026 (a) Urinals may be counted in the ratio of children to toilets, but may not exceed 50% of the total number of toilets.(b) Restrooms containing urinals must also have flush toilets. Source Note: The provisions of this §744.3009 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3009 May I count urinals in the ratio of children to toilets? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188134 03/12/2026 No. However if you use a sink, urinal, toilet, or drinking fountain that is too high for children to use safely and independently, you must equip it with anchored steps and/or a broad-based platform with a non-slip surface. Source Note: The provisions of this §744.3011 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3011 Do I have to use toilets, sinks and fountains that are child sized? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188135 03/12/2026 Yes. Doors on restrooms and toilets used by children may have locks, although:(1) Locks must be out of children's reach; or(2) If locks are within children's reach there must be a way to immediately open the door from the outside in an emergency, and:(A) The unlocking mechanism must be accessible to all employees at all times and must be demonstrated satisfactorily to Licensing staff upon request; and(B) An adult must be present in the restroom area when children younger than five years old are using restrooms with door locks within children's reach. Source Note: The provisions of this §744.3013 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3013 May the doors to the restroom or toilets have locks on them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188136 03/12/2026 (a) Yes. You may share the toilets and hand washing sinks counted in your indoor activity space with other programs at the same time you have children in care, provided you:(1) Ensure adequate facilities are available to children when needed; and(2) Have a written plan specifying how caregivers will supervise and account for children in your care that addresses:(A) The ages of the children;(B) The proximity of restroom facilities, and operation entrances and exits to the children's area; and(C) The nature of other activities and persons who may be sharing the toilet and hand washing sinks.(b) You must follow your written plan, and submit a copy to Licensing upon request. Source Note: The provisions of this §744.3015 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3015 May other programs use the toilets and hand washing sinks counted in my indoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188137 03/12/2026 Yes. You must have:(1) A telephone at your operation with a listed telephone number; or(2) Access to a telephone located in the same building for use in an emergency and where a person is available to:(A) Receive incoming calls to the operation;(B) Immediately transmit messages regarding children in care to operation caregivers; and(C) Make outgoing calls for the operation as necessary. Source Note: The provisions of this §744.3051 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3051 Must I have a telephone at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188138 03/12/2026 (a) You may have an indoor loft that is designed and used as an extension of the classroom if you comply with the following safety standards:(1) Caregivers must be able to adequately supervise children at all times;(2) Stairs and steps, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails; and(3) Platforms over 20 inches in height must be equipped with protective barriers that prevent children from crawling over or falling through the barrier, or becoming entrapped.(b) If a loft is used as indoor active play space, it must comply with minimum standards as specified in Subchapter N of this chapter (relating to Indoor and Outdoor Active Play Space and Equipment). Source Note: The provisions of this §744.3071 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS M PHYSICAL FACILITIES §744.3071 May I have indoor lofts? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188139 03/12/2026 (a) Indoor and outdoor active play equipment used both at and away from the operation must be safe for the children as follows:(1) The indoor and outdoor active play equipment must be arranged so that caregivers can adequately supervise children at all times;(2) The design, scale, and location of the equipment must be used according to the manufacturer's instructions;(3) Equipment must not have openings or angles that can entrap a child's body or body part that has penetrated the opening;(4) Equipment must not have protrusions or openings that can entangle something around a child's neck or a child's clothing;(5) Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, moving, or overturning;(6) All anchoring devices must be placed below the level of the playing surface to prevent tripping or injury resulting from a fall;(7) Equipment must not have exposed pinch, crush, or shear points, on or underneath it;(8) Climbing equipment, swings, or inflatables must not be installed over asphalt or concrete unless the asphalt or concrete is covered with properly installed unitary surfacing materials as specified in §744.3259 of this title (relating to What are unitary surfacing materials?) and §744.3261 of this title (relating to How should unitary surfacing materials be installed?);(9) Porches or platforms more than 20 inches in height for pre-kindergarten and younger children, and more than 30 inches in height for school-age children, must be equipped with protective barriers that surround the elevated surface except for entrances and exits and that prevent children from crawling over or through the barrier;(10) Stairs and steps on climbing equipment, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails; and(11) If you are licensed to provide only care in a public school facility operated by the local independent school district, you must inform parents in writing at the time they enroll their child if the active play equipment you plan to use at the public school facility does not meet Licensing standards specified in this subchapter. Otherwise, children must not be allowed to use equipment that does not meet Licensing standards.(b) Equipment that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency, such as gym floors and mats, platforms and steps used in gymnastics programs, are not subject to the safety requirements specified in subsection (a)(8) - (10) of this section provided:(1) The equipment or surfacing is installed and used according to manufacturer's instructions or industry standards;(2) A child's use of the equipment is supervised by trained personnel;(3) The safety practices employed by the operation and the risks associated with the use of each type of equipment are outlined in your policies and procedures; and(4) Parents provide written consent before children use the equipment. Written consent must be kept on file at the operation in the child's record. Source Note: The provisions of this §744.3101 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3101 What minimum safety requirements must my active play equipment meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188140 03/12/2026 Indoor equipment used both at and away from the operation must be safe for the children as follows:(1) Floor surfaces under indoor equipment designed for climbing must have a unitary shock-absorbing surface that will effectively cushion the fall of a child. The surface must be installed in the use zone and maintained according to the manufacturer's directions. See §744.3201 of this title (relating to What does Licensing mean by the term "use zone?"). Carpeting alone, even if it is installed over thick padding, is not an acceptable resilient surface under indoor climbing equipment;(2) Platforms over 20 inches in height for pre-kindergarten and younger children, and more than 30 inches in height for school-age children, must be equipped with protective barriers that prevent children from crawling over or falling through the barrier, or becoming entrapped; and(3) If your program uses specialized equipment that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency, such as parallel bars and trampolines used in gymnastics programs:(A) The equipment must be installed and used according to manufacturer's instructions and supervised by trained personnel;(B) The safety practices employed by the operation and the risks associated with the use of each type of equipment must be thoroughly outlined in your policies and procedures; and(C) Parents must provide written consent before children may use the equipment. Written consent must be kept on file at the operation in the child's record. Source Note: The provisions of this §744.3103 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3103 What additional safety requirements must my indoor equipment meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188141 03/12/2026 (a) Yes. Children must not use the following types of equipment at or away from the operation:(1) Heavy swings made of metal or that have metal components, such as animal figure swings;(2) Equipment that allows children to fall inside the structure and onto other parts of the structure, such as certain styles of monkey bars or jungle gyms;(3) Trampolines, except those less than four feet in diameter that are no higher than 12 inches above a properly installed and maintained resilient surface;(4) Swinging exercise rings and trapeze bars on long chains or swinging rope;(5) Multiple occupancy swings, such as teeter-totters, gliders, or chair swings (other than tire swings); or(6) Swinging gates and giant strides.(b) Equipment that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency, such as trampolines and exercise rings and ropes used in gymnastics programs, may be used if:(1) The equipment is installed and used according to manufacturer's instructions;(2) A child's use of the equipment is supervised by trained personnel;(3) The safety practices employed by the operation and the risks associated with the use of each type of equipment are outlined in your policies and procedures; and(4) Parents provide written consent before children use the equipment. Written consent must be kept on file at the operation in the child's record. Source Note: The provisions of this §744.3105 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3105 Are there some types of equipment that children must not use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188142 03/12/2026 (a) Yes. Children younger than five years of age must not be allowed to use the following pieces of equipment at or away from the operation:(1) Free standing arch climbers;(2) Free standing climbing pieces with flexible parts;(3) Fulcrum seesaws;(4) Log rolls;(5) Spiral slides with more than one 360 degree turn; or(6) Track rides.(b) In addition, children younger than four years of age must not be allowed to use the following pieces of equipment at or away from the operation:(1) Chain or cable walks;(2) Horizontal ladders;(3) Vertical slide poles;(4) Over-head swinging rings; or(5) Parallelbars.(c) Equipment that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency, such as swinging rings and parallel bars used in gymnastics programs, may be used if:(1) The equipment is installed and used according to manufacturer's instructions;(2) A child's use of the equipment is supervised by trained personnel;(3) The safety practices employed by the operation and the risks associated with the use of each type of equipment are outlined in your policies and procedures; and(4) Parents provide written consent before children use the equipment. Written consent must be kept on file at the operation in the child's record. Source Note: The provisions of this §744.3107 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3107 Are there additional equipment restrictions for children younger than five years of age? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188143 03/12/2026 (a) The maximum height of the highest designated play surface on active play equipment is based on the age of children who will be using the equipment.(b) The maximum height allowed is:(1) Five feet for equipment designed to be used by children younger than five years old; or(2) Seven feet for equipment designed to be used by children who are at least five years old.(c) Equipment that is fundamental to the core development of a skill, talent, ability, expertise, or proficiency, such as parallel bars and trampolines used in gymnastics programs, may exceed the maximum height allowed if:(1) The equipment is installed and used according to manufacturer's instructions;(2) A child's use of the equipment is supervised by trained personnel;(3) The safety practices employed by the operation and the risks associated with the use of each type of equipment are outlined in your policies and procedures; and(4) Parents provide written consent before children use the equipment. Written consent must be kept on file at the operation in the child's record. Source Note: The provisions of this §744.3109 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3109 What is the maximum height of the highest designated play surface allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188145 03/12/2026 (a) If you were licensed before September 1, 2010, the maximum height allowed for the highest designated play surface on active play equipment is:(1) Six feet for equipment designed to be used by children younger than five years old; or(2) Eight feet for equipment designed to be used by children five years old and older.(b) If your operation re-designs the existing playground or adds new playground equipment, then as the changes are made you must meet equipment height requirements specified in §744.3109 of this title (relating to What is the maximum height of the highest designated play surface allowed?). You must submit a written plan for compliance to us upon request. Source Note: The provisions of this §744.3111 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3111 What is the maximum height allowed for the highest designated play surface if my operation was licensed before September 1, 2010? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188144 03/12/2026 (a) The director or designee must inspect the active play space and equipment daily before children begin to play to ensure there are no hazards present.(b) The director or designee must conduct at least monthly inspections of the active play space and equipment, utilizing a general maintenance checklist or safety checklist that includes checking the equipment and surfacing material for normal wear and tear, broken or missing parts, debris or foreign objects, drainage problems, or other hazards.(c) The director or designee must ensure hazards or defects identified during inspections are removed or repaired promptly, and must arrange for protection of the children or prohibit use of hazardous equipment until the hazards can be removed or repairs can be made.(d) You must keep maintenance inspections and repair records at the operation for review during your hours of operation for at least the previous three months. Source Note: The provisions of this §744.3113 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3113 What special maintenance procedures must I follow for my active play space and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188154 03/12/2026 (a) All swing seats must be constructed of durable, lightweight, rubber, or plastic material.(b) Edges of all swing seats must be smooth or rounded and have no protrusions.(c) Swings must not be attached to a composite play structure.(d) A full bucket seat swing, intended for children under four years of age to use with adult assistance, may be used provided the distance between the bottom of the unoccupied swing seat is at least 24 inches above the protective surfacing. Source Note: The provisions of this §744.3151 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3151 What are the safety requirements for swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188155 03/12/2026 Yes. Tire swings must:(1) Not be made from heavy truck tires, or tires with exposed steel-belted radials;(2) Not be suspended from a composite structure or with other swings in the same swing bay;(3) Have drainage holes drilled in the underside of the tire and maintained to facilitate water drainage; and(4) Have a minimum clearance between the seating surface of a tire swing and the uprights of the supporting structure of 30 inches or more when the tire is in a position closest to the support structure. Source Note: The provisions of this §744.3153 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3153 Are there additional safety requirements for tire swings or other multi-axis swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188146 03/12/2026 The use zone is the surface area under and around a piece of equipment onto which a child falling from or exiting from the equipment would be expected to land. Other than the equipment itself, the use zone must be free of obstacles that a child could run into or fall on top of and be injured. Source Note: The provisions of this §744.3201 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3201 What does Licensing mean by the term "use zone"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188147 03/12/2026 The use zone for stationary equipment, excluding slides and soft contained play equipment, must extend a minimum of six feet in all directions from the perimeter of the equipment. Use zones for stationary equipment must not overlap other use zones. Source Note: The provisions of this §744.3203 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3203 How do I measure the use zone for stationary equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188148 03/12/2026 (a) The use zone in front of the access and to the sides of a slide must extend a minimum of six feet from the perimeter of the equipment.(b) For slides six feet high or less, the use zone in front of the exit of a slide must extend at least six feet.(c) For slides greater than six feet high, the use zone in front of the exit of a slide must be equal to the distance from the slide platform to the protective surfacing up to a maximum of eight feet.(d) The use zone in front of the slide exit must not overlap the use zone of any other equipment. Source Note: The provisions of this §744.3205 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3205 How do I measure the use zone for slides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188149 03/12/2026 (a) The use zone to the front and rear of to-fro swings (single-axis swings) must extend twice the height of the vertical distance from the swing beam to the protective surfacing below.(b) The use zone to the front and rear of the to-fro swing must not overlap any other use zone.(c) The use zone around the sides of the to-fro swing structure (frame which supports the swings) must be at least six feet and may overlap the use zone of an adjacent swing structure. Source Note: The provisions of this §744.3207 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3207 How do I measure the use zone for to-fro swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188153 03/12/2026 (a) The use zone for tire swings or other multi-axis swings must extend in all directions for a distance equal to the distance from the swing beam to the top of the sitting surface of the tire, plus six feet.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the tire swing support structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §744.3209 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3209 How do I measure the use zone for tire swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188150 03/12/2026 (a) The use zone to the front and rear of the bucket swing must be at least two times the vertical distance from the swing beam to the top of the swing-sitting surface.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the bucket swing structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §744.3211 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3211 How do I measure the use zone for bucket swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188151 03/12/2026 (a) The use zone for rotating or rocking equipment on which the child sits must be at least six feet from the perimeter when not in use.(b) The use zone for rotating or rocking equipment or track rides on which the child stands or rides must be at least seven feet from the perimeter of the equipment when not in use.(c) The use zone for rocking and rotating equipment must not overlap any other use zone. Source Note: The provisions of this §744.3213 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3213 How do I measure the use zone for rotating or rocking equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188152 03/12/2026 (a) If you were licensed before September 1, 2003, you must at least maintain the following use zones, unless you meet one of the conditions specified in subsection (b) of this section:(1) Four feet from climbing structures;(2) Five feet from the bottom of a slide. The other parts of the slide are considered a climbing structure;(3) Seven feet plus the length of a swing's chain from the point of suspension; and(4) Seven feet from a merry-go-round or other revolving devices.(b) An operation licensed before September 1, 2003, must comply with the use zone requirements specified in this division, under the following circumstances:(1) An operation re-designs the existing playground or adds new playground equipment. The permit holder must meet use zone requirements specified in this division as the changes are made. You must submit a written plan for compliance to us upon request; or(2) Your existing permit is no longer valid. Source Note: The provisions of this §744.3215 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3215 Do the use zone requirements apply to my operation if it was licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188156 03/12/2026 (a) There must be loose-fill surfacing material or unitary surfacing material in the use zones for all climbing, rocking, rotating, bouncing, or moving equipment, slides, and swings.(b) The height of the highest designated play surface on the equipment will determine the depth of loose materials or the attenuation rating (thickness) of the unitary materials. Source Note: The provisions of this §744.3251 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3251 What type of surfacing must I have under my active play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188157 03/12/2026 Loose-fill surfacing materials include, but are not limited to, loose particles such as sand, pea gravel, shredded wood products, and shredded rubber. Source Note: The provisions of this §744.3253 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3253 What are acceptable loose-fill surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188158 03/12/2026 (a) If you use loose-fill surfacing materials in your outdoor active play space, you must install and maintain nine inches or more of uncompressed loose-fill material in the use zones.(b) You must not install loose-fill surfacing materials over concrete or asphalt.(c) You must mark all equipment support posts to indicate the depth at which the loose-fill surfacing material must be maintained under and around the equipment.(d) You must ensure the loose-fill materials are maintained at the proper depth at all times.(e) Loose-fill surfacing materials must not be used indoors. Source Note: The provisions of this §744.3255 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective June 1, 2014, 39 TexReg 3716; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3255 How should outdoor loose-fill surfacing materials be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188159 03/12/2026 Unitary surfacing materials are manufactured materials including rubber tiles, mats, or poured-in-place materials cured to form a unitary shock-absorbing surface. Source Note: The provisions of this §744.3259 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3259 What are unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188160 03/12/2026 (a) If you use unitary materials, they must be installed and maintained according to manufacturer's specifications.(b) Unitary materials may be installed over concrete or asphalt only if recommended by the manufacturer. Source Note: The provisions of this §744.3261 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3261 How should unitary surfacing materials be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188161 03/12/2026 If you use unitary surfacing materials, you must have test data from the manufacturer showing the impact rating of the material (the maximum height of equipment that may be installed over the surfacing material), and installation and maintenance requirements. This documentation must be at the operation and made available for review by parents and Licensing staff upon request during your hours of operation. Source Note: The provisions of this §744.3263 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3263 What documentation must I keep at the operation if I use unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212689 03/12/2026 Soft contained play equipment is a play structure that:(1) Is fully enclosed with pliable material such as net, plastic, or fabric;(2) The user enters to access one or more play components; and(3) Allows caregivers to supervise children as specified in §744.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §744.3301 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3301 What is soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188163 03/12/2026 Yes. Soft contained play equipment must:(1) Not have to-fro, bucket, or tire swings attached inside or outside of the structure;(2) Have no more than a 24-inch difference in height between two connecting platforms;(3) Have use zones as outlined in §744.3305 of this title (relating to How do I measure the use zone for soft contained play equipment?) that are free of obstacles and covered with unitary surfacing material;(4) Be installed, maintained and cleaned according to manufacturer's instructions; and(5) Include closer supervision when in use by requiring at least one caregiver to be positioned at each level of the play area. Source Note: The provisions of this §744.3303 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3303 Are there additional safety requirements for soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188164 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188164 03/12/2026 (a) The use zone for entrances and exits to the soft contained play equipment, excluding slide exits, is a minimum of five feet from all portions of the entrance and exit which are outside of the contained area of the equipment.(b) The use zone in front of slide exits must extend a minimum of five feet if the slide run-out is 36 inches or greater. If the slide run-out is less than 36 inches, the use zone at the end of the slide must be six feet. In addition, this use zone may not overlap with any other use zones.(c) Entrances and exits that terminate inside of the soft contained play equipment are exempt from use zone requirements.(d) External portions of the soft contained play equipment that contain no designated play surfaces and serve only to enclose the equipment are exempt from use zone requirements.(e) The critical height of resilient surfacing material must be equal to the highest designated play surface outside of the contained area of the equipment or for one foot, which ever is greater. Source Note: The provisions of this §744.3305 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3305 How do I measure the use zone for soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220708 03/12/2026 You may use inflatable equipment both at and away from your operation if you follow these guidelines:(1) You use enclosed inflatables (such as bounce houses or moon walks) according to the manufacturer's instructions;(2) You use open inflatables (such as obstacle courses, slides, or games) according to the manufacturer's instructions; and(3) Inflatables that include water activity also comply with all applicable requirements in Subchapter O of this chapter (relating to Swimming Pools, Wading Pools, and Sprinkler Play). Source Note: The provisions of this §744.3351 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS N INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §744.3351 May I use inflatable active play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220709 03/12/2026 In addition to complying with the child/caregiver ratios specified in §744.1905 of this chapter (relating to What are the child/caregiver ratios for swimming activities?) and other safety requirements specified in §744.1907 of this chapter (relating to Must a certified lifeguard be on duty when children are swimming in more than 18 inches of water?) and §744.1911 of this chapter (relating to Must persons who are counted in the child/caregiver ratio during swimming know how to swim?), you must comply with the following safety precautions when any child uses a swimming pool both at and away from your operation: (1) A minimum of two life-saving devices must be available; (2) One additional life-saving device must be available for each 2,000 square feet of water surface;(3) Drain grates must be in place, in good repair, and must not be able to be removed without using tools;(4) Pool chemicals and pumps must be inaccessible to any child;(5) Machinery rooms must be locked when any child is present;(6) Employees must be able to clearly see all parts of the swimming area;(7) The bottom of the pool must be visible at all times;(8) An adult must be present who is able to immediately turn off the pump and filtering system when any child is in a pool; and(9) All indoor/outdoor areas must be free of furniture and equipment that any child could use to scale a fence or barrier or release a lock. Source Note: The provisions of this §744.3401 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3401 What safety precautions must I follow when a child in my care uses a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188167 03/12/2026 Swimming pools used both at and away from the operation must be built and maintained according to the standards of the Department of State Health Services for public pools and any other applicable state or local regulations. Source Note: The provisions of this §744.3403 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3403 How should the swimming pool be built and maintained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188168 03/12/2026 Yes. Above-ground pools must meet all pool safety requirements specified in this subchapter and must have a barrier that prevents a child's access to the pool. Source Note: The provisions of this §744.3405 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3405 Do the same safety precautions apply for above-ground pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188169 03/12/2026 (a) You must enclose a swimming pool at your operation with a six-foot fence or wall that prevents children's access to the pool.(b) Fence gates leading to the pool area must have self-closing and self-latching hardware out of children's reach. Gates must be locked when the pool is not in use.(c) Doors from the operation leading to the pool area must have a lock out of children's reach that can only be opened by an adult.(d) These doors and gates must not be designated as fire and emergency evacuation exits. Source Note: The provisions of this §744.3407 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3407 Must I have a fence around a swimming pool at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226991 03/12/2026 (a) Before a child who is unable to swim competently or who is at risk of injury or death when swimming enters a swimming pool, the operation must:(1) Provide the child with a United States Coast Guard approved PFD that has a rating of Type I, II, or III, or a buoyancy level of 70 or above;(2) Ensure the child is wearing the PFD; and(3) Ensure the PFD is properly fitted and fastened for the child.(b) A PFD must be in good repair to meet the requirements in subsection (a) of this section. Source Note: The provisions of this §744.3409 adopted to be effective September 26, 2024, 49 TexReg 7351; amended to be effective December 21, 2025, 50 TexReg 8045. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3409 Personal Flotation Device (PFD) Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220711 03/12/2026 You are not required to provide the child with a PFD or ensure the child is wearing the device if:(1) The child is actively participating in swim instruction or a competition; and(2) You ensure that the child is supervised in accordance with §744.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?) during the instruction or competition. Source Note: The provisions of this §744.3410 adopted to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3410 Must I provide a personal flotation device (PFD) to a child in care who is unable to swim competently or who is at risk of injury or death when swimming when the child is participating in swim instruction or a competition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220712 03/12/2026 (a) Wading pools at your operation must be:(1) Stored out of children's reach when not in use;(2) Drained at least daily and sanitized; and(3) Stored so they do not hold water.(b) You must comply with the safety precautions specified in §744.3401 of this subchapter (relating to What safety precautions must I follow when a child in my care uses a swimming pool?) when using wading pools away from your operation. Source Note: The provisions of this §744.3411 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3411 What are the safety requirements for wading pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188172 03/12/2026 (a) You must ensure that no child uses sprinkler equipment on or near a hard, slippery surface, such as a concrete driveway, sidewalk, or patio.(b) You must not leave a child alone with the sprinkler equipment.(c) You must store sprinkler equipment and water hoses out of the reach of children when not in use.(d) You must maintain your splash pad/sprinkler play area according to manufacturer's instructions. Source Note: The provisions of this §744.3413 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3413 Are there specific safety requirements for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220713 03/12/2026 You must not allow a child to swim in a body of water other than a swimming pool that complies with the rules specified in this subchapter. Source Note: The provisions of this §744.3415 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7351. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS O SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §744.3415 Can a child in my care swim in a body of water other than a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188173 03/12/2026 (a) Your operation must have a fire inspection before we issue your initial permit and at least once every 12 months, unless your operation is in a public school facility operated by the local independent school district.(b) If an inspection is required, a state or local fire marshal must conduct the inspection. If an inspection is not available, you must provide documentation of this from a state or local fire marshal or county judge. Source Note: The provisions of this §744.3501 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3501 Must my operation have an annual fire inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188174 03/12/2026 If required, you must keep a copy of the most recent fire-inspection report, letter, or checklist at the operation during your hours of operation to verify the inspection date and findings. The report must include the name and telephone number of the inspector. Source Note: The provisions of this §744.3503 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3503 How do I document that a fire inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188175 03/12/2026 Yes, you must comply with all corrections, restrictions, or conditions specified by the inspector in the fire inspection report, letter, or checklist. Source Note: The provisions of this §744.3505 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3505 Must I make all corrections specified in the fire-inspection report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188176 03/12/2026 An emergency preparedness plan is designed to ensure the safety of children during an emergency by addressing staff responsibility and facility readiness with respect to emergency evacuation, relocation, and sheltering/lock-down. The plan addresses the types of responses to emergencies most likely to occur in your area including:(1) An evacuation of the children and caregivers to a designated safe area in an emergency such as a fire or gas leak;(2) A relocation of the children and caregivers to a designated, alternate shelter in an emergency such as a flood, a hurricane, medical emergency, or communicable disease outbreak; and(3) The sheltering and lock-down of children and caregivers within the operation to temporarily protect them from situations such as a tornado, volatile person on the premises, or an endangering person in the area. Source Note: The provisions of this §744.3551 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3551 What is an emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188180 03/12/2026 Your emergency preparedness plan must include written procedures for:(1) Evacuation, relocation, and sheltering/lock-down of children including:(A) The first responsibility of staff in an emergency evacuation or relocation is to move the children to a designated safe area or alternate shelter known to all employees, caregivers, parents, and volunteers;(B) How children will be evacuated or relocated to the designated safe area or alternate shelter, including but not limited to specific procedures for evacuating and relocating children with limited mobility or who otherwise may need assistance in an emergency, such as children who have mental, visual, or hearing impairments;(C) An emergency evacuation and relocation diagram as outlined in §744.3561 of this title (relating to Must I have an emergency evacuation and relocation diagram?);(D) The staff responsibility in a sheltering/lock-down emergency for the orderly movement of children to a designated location within the operation where children should gather;(E) Name and address of the alternate shelter away from the operation you will use as needed; and(F) How children in attendance at the time of the emergency will be accounted for at the designated safe area or alternate shelter;(2) Communication, including:(A) The emergency telephone number that is on file with us; and(B) How you will communicate with local authorities (such as fire, law enforcement, emergency medical services, health department), parents, and us; and(3) How your staff will evacuate and relocate with the essential documentation including:(A) Parent and emergency contact telephone numbers for each child in care;(B) Authorization for emergency care for each child in care; and(C) The child tracking system information for children in care;(4) How your staff will continue to care for children until each child has been released; and(5) How you will reunify the children with their parents as the evacuation, relocation, or sheltering/lock-down is lifted. Source Note: The provisions of this §744.3553 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective June 1, 2014, 39 TexReg 3716; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3553 What must my emergency preparedness plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188177 03/12/2026 (a) The director is responsible for implementing the emergency preparedness plan.(b) The director may also designate additional employees to be in charge during an emergency evacuation and relocation that occurs when the director is not at the operation. Source Note: The provisions of this §744.3557 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3557 Who must coordinate the implementation of an emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188178 03/12/2026 The following components of your operation's emergency preparedness plan must be practiced as specified below:(1) You must practice a fire drill every month. The children must be able to safely exit the building within three minutes;(2) You must practice a sheltering drill for severe weather at least four times in a calendar year;(3) You must practice a lock-down drill for a volatile or endangering person on the premises or in the area at least four times in a calendar year; and(4) You must document these drills, including the date of the drill, time of the drill, and length of time for the evacuation, sheltering, or lock-down to take place. Source Note: The provisions of this §744.3559 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3559 Must I practice my emergency preparedness plans? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188179 03/12/2026 (a) Yes. Your emergency evacuation and relocation diagram must be on file at the operation and must show the following:(1) A floor plan of your operation;(2) Two exit paths from each room, unless a room opens directly to the outdoors at ground level;(3) The designated location outside of the operation where all caregivers and children meet to ensure everyone has exited the operation safely; and(4) The designated location inside the operation where all caregivers and children take shelter from threatening weather.(b) You must post an emergency evacuation and relocation diagram in each room the children use. You must post the diagram near the entrance and/or exit of the room and where children and employees may easily view the diagram. Source Note: The provisions of this §744.3561 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective September 1, 2016, 41 TexReg 6225; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3561 Must I have an emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188181 03/12/2026 (a) The operation must have at least two exits to the outside that are located in distant parts of each building.(b) If any doors open into a fenced yard, the children must be able to open the doors easily from the inside.(c) You may not count doors that are blocked or locked as exits.(d) An exit through a kitchen or other hazardous area may not be one of the required exits unless the state or local fire marshal specifically approves in writing.(e) Doors and gates leading into a pool area may not be counted as an exit.(f) A window may be used as a designated fire exit only if all children and caregivers are physically able to exit through the window to the ground outside safely and quickly. Source Note: The provisions of this §744.3563 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3563 How many exits must my operation have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188182 03/12/2026 Yes. You must have a source of emergency lighting that is approved by the state or local fire marshal, or battery-powered lighting, available in each classroom in case of electrical failure. Source Note: The provisions of this §744.3565 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3565 Must I have emergency lighting in case of an emergency evacuation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188191 03/12/2026 Your operation must have a fire-extinguishing system. This may be a sprinkler system and/or fire extinguishers. If your program is located in a public school facility operated by the local school district, the fire-extinguishing system utilized by the school complies with this standard. Source Note: The provisions of this §744.3601 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3601 Must my operation have a fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188192 03/12/2026 The state or local fire marshal must approve a sprinkler system and/or fire extinguishers in your operation. If an inspection is not available, you must have at least one fire extinguisher rated 3A-40BC in the operation. Source Note: The provisions of this §744.3603 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3603 Who must approve my fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188193 03/12/2026 You must mount all fire extinguishers on the wall by a hanger or bracket. The top of all extinguishers must be no higher than five feet above the floor and the bottom at least four inches above the floor or any other surface. If the state or local fire marshal or the manufacturer's instructions has different mounting instructions, you must follow those instructions. All fire extinguishers must be readily available for immediate use by employees and caregivers. Source Note: The provisions of this §744.3605 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3605 Where must I mount fire extinguishers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188185 03/12/2026 (a) The director or designee must inspect all fire extinguishers monthly. The date of the inspection and the name of the director or designee who inspects the extinguisher(s) must be recorded and kept at the operation for review during your hours of operation.(b) Fire extinguishers must be serviced as required by manufacturer's instructions, or as required by the state or local fire marshal. Source Note: The provisions of this §744.3607 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3607 How often must I inspect and service the fire extinguisher(s)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188189 03/12/2026 The system monitoring company or the state or local fire marshal must test sprinkler systems at least annually. You must keep the most recent inspection report at the operation for review during your hours of operation. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §744.3609 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3609 How often must I inspect a sprinkler system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188190 03/12/2026 (a) Your operation must have a working smoke-detection system. This may be an electronic alarm and smoke-detection system, or individual electric or battery-operated smoke detectors located in each room used by children, or both.(b) If your operation is located in a public school facility operated by the local independent school district, the smoke-detection system utilized by the school complies with this standard. Source Note: The provisions of this §744.3611 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3611 Must my operation have a smoke-detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188184 03/12/2026 The state or local fire marshal must approve electronic alarm and smoke-detection systems. If an inspection is not available, you must have at least one working smoke detector in each room used by children. Source Note: The provisions of this §744.3613 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3613 Who must approve my operation's smoke-detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188186 03/12/2026 The monitoring company or the state or local fire marshal must test an electronic smoke alarm system at least annually. You must keep documentation of the inspection at the operation for review during your hours of operation. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §744.3615 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3615 How often must I have an electronic smoke alarm system tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188187 03/12/2026 If you use smoke detectors, they must be installed and maintained according to the manufacturer's instructions or in compliance with the state or local fire marshal's instructions. Source Note: The provisions of this §744.3617 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3617 How must smoke detectors be installed at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188188 03/12/2026 The director or designee must test all smoke detectors monthly. The date of the test and the name of the director or designee who does the testing must be documented and kept at the operation for review during your hours of operation. Source Note: The provisions of this §744.3619 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3619 How often must the smoke detectors at my operation be tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188194 03/12/2026 If your operation uses natural or liquid propane (LP) gas, your operation must be inspected for gas leaks before we issue your initial permit, and once every two years after your permit is issued, unless your operation is located in a public school building operated by the local independent school district. Source Note: The provisions of this §744.3651 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3651 Must my operation be inspected for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188196 03/12/2026 (a) If your operation uses natural gas, you must have your operation inspected for gas leaks by a licensed plumber or a gas company official.(b) If your operation uses liquid propane (LP)-gas, you must have your LP-gas system inspected for proper installation and leaks by a licensed LP-gas servicing company or licensed plumber who is also licensed with the LP-gas section of the Texas Railroad Commission. Source Note: The provisions of this §744.3653 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3653 Who must conduct the inspection for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188197 03/12/2026 A written gas inspection report must show your gas system is free of leaks and must indicate the date of the inspection, as well as the name and telephone number of the inspector. You must keep the most recent inspection report on file at your operation. Source Note: The provisions of this §744.3655 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3655 How do I document that a gas leak inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188195 03/12/2026 You must comply with all corrections, conditions, or restrictions specified in the gas inspection report within the timeframes specified by the inspector. Source Note: The provisions of this §744.3657 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3657 Must I make all corrections specified in the gas inspection report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188183 03/12/2026 (a) Gas appliances must have metal tubing and connections, be in good repair, and be free from leaks.(b) Open flame heaters (heaters where the flame can be easily touched or accessed) are prohibited.(c) Space heaters must be enclosed and have the seal of approval of a United States test laboratory or be approved by the state or local fire marshal.(d) You must safeguard floor and wall furnace grates, steam and hot water pipes, and electric space heaters so that children do not have access to them.(e) Liquid fuel heaters are prohibited.(f) Gas fuel heaters, fireplaces, and wood-burning stoves must be properly vented to the outside.(g) If you use a fireplace, wood-burning stove, or space heater, you must install a screen or guard with sufficient strength to prevent children from falling into the fire or against the stove or heater. Source Note: The provisions of this §744.3701 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3701 What steps must I take to ensure that heating devices do not present hazards to children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188198 03/12/2026 Your operation must be equipped with a working carbon monoxide detection system, unless it is located in a school facility that complies:(1) With the school facility standards adopted by the commissioner of education under the Education Code, §46.008; or(2) With standards adopted by the board of a local school district that are similar to those described in paragraph (1) of this section. Source Note: The provisions of this §744.3751 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3751 Must my operation have a carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188199 03/12/2026 You must install:(1) Individual electric (plug-in or hardwire) or battery-operated carbon monoxide detectors that meet Underwriters Laboratories Inc. requirements (UL-Listed); or(2) An electronic carbon monoxide detection system connected to an electronic alarm/smoke detection system that is UL-Listed. Source Note: The provisions of this §744.3753 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3753 What type of carbon monoxide detection system must I install? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188200 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors:(1) At least one detector must be installed on every level of each building in the child-care operation; and(2) The detector(s) must be installed in compliance with the state or local fire marshal's instructions.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, the system must be installed according to the state or local fire marshal's instructions. Source Note: The provisions of this §744.3755 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3755 How many carbon monoxide detectors must be installed in my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188201 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors:(1) The director or designee must install a new battery in each battery-operated detector at least annually;(2) The director or designee must test all detectors monthly;(3) The date of each monthly test, date of each installation of new batteries, and the name of the director or designee who does the installment of new batteries and each testing must be recorded and kept at the operation for review during your hours of operation.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, you must:(1) Ensure the system monitoring company or the state or local fire marshal tests the system at least annually;(2) Keep the most recent inspection report at the operation for review during your hours of operation;(3) Ensure the report includes the date of the inspection and the inspector's name and telephone number; and(4) Make any corrections required in the report. Source Note: The provisions of this §744.3757 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS P FIRE SAFETY AND EMERGENCY PRACTICES §744.3757 How often must I inspect and service the carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188202 03/12/2026 We regulate all transportation provided by or for the operation to children in care, including, transportation between the home and the school, the school and the operation, the operation and home, the operation or the school and field trip locations, or the operation or the school and other drop off locations. Source Note: The provisions of this §744.3801 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3801 What types of transportation does Licensing regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188203 03/12/2026 (a) We do not regulate the type of vehicle you use to transport children, although we recommend that you check with the Texas Department of Motor Vehicles or refer to the federal motor vehicle safety standards regulating transportation to and from school and your operation.(b) For the purpose of this chapter, we categorize vehicle types as:(1) General purpose vehicle--passenger vehicles as defined in the Texas Transportation Code §545.412, and buses that do not meet the federal motor vehicle safety standards for school buses or multi-function school activity buses (MFSAB);(2) Small school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a gross vehicle weight rating (GVWR) of 10,000 pounds or less; and(3) Large school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a GVWR of greater than 10,000 pounds.(c) All vehicles must be maintained in safe operating condition at all times. Source Note: The provisions of this §744.3803 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3803 What type of vehicle may I use to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188204 03/12/2026 You must take the following precautions when loading and unloading children from any vehicle, including any type of bus:(1) You must load and unload children at the curbside of the vehicle or in a protected parking area or driveway;(2) You must not allow a child to cross a street any time before a child enters or exits a vehicle, unless the child is accompanied by an adult;(3) You must account for all children exiting the vehicle before leaving the vehicle unattended; and(4) You must never leave a child unattended in a vehicle. Source Note: The provisions of this §744.3805 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3805 What safety precautions must I take when loading and unloading children from the vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212690 03/12/2026 (a) You must use a child passenger safety seat system to restrain a child when transporting the child. The restraint system: (1) Must meet the federal standards for crash-tested systems as set by the National Highway Traffic Safety Administration; and (2) Must be properly secured in the vehicle according to manufacturer's instructions. (b) You must use child safety seats and child booster seats that have not expired or been damaged or involved in an accident.(c) You must secure each child in a rear-facing convertible child safety seat, forward-facing child safety seat, child booster seat, safety vest, harness, or a safety belt, as appropriate to the child's age, height, and weight according to manufacturer's instructions for all vehicles specified in subsection (e) of this section, unless otherwise noted in this subchapter. (d) A child 12 years old or younger must not ride in the front seat of a vehicle. (e) The following safety restraint devices for a child must be used when the vehicle is on and during all times when the vehicle is in motion:Attached Graphic Source Note: The provisions of this §744.3807 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 921. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3807 What child passenger safety seat system must I use when I transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188206 03/12/2026 (a) The driver must be properly restrained by a safety belt before starting the vehicle and at all times the vehicle is in motion.(b) All adult passengers in a vehicle transporting children, other than a large school bus, must be properly restrained by safety belts. Source Note: The provisions of this §744.3809 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3809 Must caregivers and/or the driver wear a safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188207 03/12/2026 Parents may provide the safety seat system for use in transporting their child, provided the equipment is appropriate and can be properly secured in the vehicle. You must use the equipment according to manufacturer's instructions. Source Note: The provisions of this §744.3811 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3811 May parents provide the safety seat equipment required for their child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188208 03/12/2026 No; only one person may use each safety belt. Source Note: The provisions of this §744.3813 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3813 May I place more than one person in each safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188209 03/12/2026 A child may ride in a safety belt with a shoulder harness if the shoulder harness goes across the child's chest and not across the child's face or neck. The lap belt should fit low across the child's thighs or top of the legs and not across the child's stomach area. Never put a shoulder belt under the child's arm or behind the child's back. If the lap belt and shoulder harness do not fit properly, a booster seat must be used. Source Note: The provisions of this §744.3815 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3815 May a child ride in a safety belt with a shoulder harness? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188210 03/12/2026 (a) You must have the following in each vehicle you use to transport children:(1) A list of the children being transported;(2) Emergency medical transport and treatment authorization forms for each child being transported;(3) The operation's name and telephone number and the director or permit holder's name. The information must be in the glove compartment or clearly visible inside the passenger compartment, or the operation's name and telephone number must be clearly visible on the outside of the vehicle;(4) Parent's names and telephone numbers and emergency telephone numbers for each child being transported;(5) A fire extinguisher approved by the local or state fire marshal, secured in the passenger compartment and accessible to the adult occupants; and(6) A first-aid kit as specified in Division 4 of Subchapter L (relating to First-Aid Kits).(b) The driver must have a current driver's license and carry it while transporting children. Source Note: The provisions of this §744.3817 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3817 Must I carry specific information and equipment in the vehicles used to transport children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188211 03/12/2026 You must ensure the driver/caregivers have clear instructions in handling emergency breakdowns and accidents, including vehicle evacuation procedures, supervision of the children, and contacting emergency help. The director or designee in charge of the operation must know what action to take in responding to a transportation emergency call. Source Note: The provisions of this §744.3819 adopted to be effective September 1, 2010, 35 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3819 What plan must I have for transportation emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188212 03/12/2026 When transporting children in a vehicle:(1) The vehicle must have a communications device such as a cellular phone or two-way radio; or(2) A caregiver at the operation must know the routine arrival and departure times of the vehicle and take action if the vehicle does not return to the operation at a scheduled time. The driver must travel a known fixed route within an approximate timeframe. Source Note: The provisions of this §744.3821 adopted to be effective September 1, 2010, 35 TexReg 7469; amended to be effective April 15, 2017, 42 TexReg 1779; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 744 MINIMUM STANDARDS FOR SCHOOL-AGE AND BEFORE OR AFTER-SCHOOL PROGRAMS Q TRANSPORTATION §744.3821 What communication requirements are there for a vehicle used to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223835 03/12/2026 The following words have the following meanings when used in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated or the context clearly indicates otherwise.(2) We, us, our, Licensing, and Child Care Regulation--The Child Care Regulation department of the Texas Health and Human Services Commission. Source Note: The provisions of this §745.11 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING A PRECEDENCE AND DEFINITIONS §745.11 General Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204666 03/12/2026 The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise:(1) Abuse--As defined in the Texas Family Code, §261.001(1) (relating to Definitions) and Texas Administrative Code, Title 40, Chapter 707, Subchapter C, Division 5 (relating to Abuse, Neglect, and Exploitation).(2) Affinity--Related by marriage as set forth in Texas Government Code, §573.024 (relating to Determination of Affinity).(3) Business entity--May be an association, corporation, nonprofit association, nonprofit corporation, nonprofit association with religious affiliation, nonprofit corporation with religious affiliation, or limited liability company.(4) Capacity--The maximum number of children that a permit holder may care for at one time.(5) Caregiver--A person who is counted in the child to caregiver ratio, whose duties include the supervision, guidance, and protection of a child.(6) Child--A person under 18 years old.(7) Child-care facility--An establishment subject to regulation by Licensing that provides assessment, care, training, education, custody, treatment, or supervision for a child who is not related by blood, marriage, or adoption to the owner or operator of the facility, for all or part of the 24-hour day, whether or not the establishment operates for profit or charges for its services. A child-care facility includes the people, administration, governing body, activities on or off the premises, operations, buildings, grounds, equipment, furnishings, and materials. A child-care facility does not include child-placing agencies, listed family homes, employer-based child care operations, or shelter care operations.(8) Child day care--As defined in §745.33 of this chapter (relating to What is child day care?).(9) Child-placing agency (CPA)--A person, including a sole proprietor, partnership, or business or governmental entity, other than the parents of a child, who plans for the placement of or places a child in a child care operation or adoptive home.(10) Children related to the caregiver--Children who are the children, grandchildren, siblings, great-grandchildren, first cousins, nieces, or nephews of the caregiver, whether by affinity or consanguinity or as the result of a relationship created by court decree.(11) Consanguinity--Two individuals are related to each other by consanguinity if one is a descendant of the other; or they share a common ancestor. An adopted child is related by consanguinity for this purpose. Consanguinity is defined in Texas Government Code, §573.022 (relating to Determination of Consanguinity).(12) Contiguous operations--Two or more operations that touch at a point on a common border are located in the same building.(13) Controlling person--As defined in §745.901 of this chapter (relating to Who is a controlling person at a child-care operation?).(14) Deficiency--Any failure to comply with a minimum standard, rule, statute, specific term of your permit, or condition of your probation.(15) Designated perpetrator--As defined in §745.731 of this chapter (relating to What are designated perpetrators and sustained perpetrators of child abuse or neglect?).(16) Designee--The person named on the application as the designated representative of the operation who is officially authorized by the owner to speak for and act on the operations' behalf.(17) Employee--Any person employed by or that contracts with the permit holder, including caregivers, drivers, kitchen personnel, maintenance and administrative personnel, and the center or program director.(18) Endanger--To expose a child to a situation where physical or mental injury to a child is likely to occur.(19) Exploitation--As defined in Texas Family Code, §261.001(3) and Texas Administrative Code, Title 40, Chapter 707, Subchapter C, Division 5.(20) Finding--The conclusion of a Licensing investigation or inspection indicating compliance or deficiency with one or more minimum standards, rules, or statutes.(21) Full license--The type of full permit that is issued to an operation that requires a license. See also §745.341 of this chapter (relating to What type of permit does Licensing issue?) and §745.343 of this chapter (relating to What is the difference between an initial license and a full license?).(22) Full permit--A full permit includes a listing, registration, compliance certificate, or a full license. See also §745.341 and §745.343 of this chapter.(23) Governing body--A group of persons or officers of a business or governmental entity that has ultimate control over the entity.(24) Governmental entity--A political subdivision or state agency of Texas.(25) Household member--An individual, other than the caregivers, who resides in an operation.(26) Initial license--A time-limited license that we issue to certain applicants for a full license in situations described in §745.345 of this chapter (relating to When does Licensing issue an initial license?).(27) Licensed administrator--As defined in §745.8905 of this chapter (relating to What is a licensed administrator?).(28) Minimum standards-- Minimum requirements for permit holders that are enforced by Licensing to protect the health, safety, and well-being of children. The minimum standards consist of the rules contained in:(A) Chapter 742 of this title (relating to Minimum Standards for Listed Family Homes;(B) Chapter 743 of this title (relating to Minimum Standards for Shelter Care);(C) Chapter 744 of this title (relating to Minimum Standards for School-Age and Before or After-School Programs);(D) Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers);(E) Chapter 747 of this title (relating to Minimum Standards for Child-Care Homes);(F) Chapter 748 of this title (relating to Minimum Standards for General Residential Operations);(G) Chapter 749 of this title (relating to Minimum Standards for Child-Placing Agencies);(H) Chapter 750 of this title (relating to Minimum Standards for Independent Foster Homes); and(I) Subchapter D, Division 11 of this chapter (relating to Employer-Based Child Care).(29) Neglect--As defined in the Texas Family Code, §261.001(4) and Texas Administrative Code, Title 40, Chapter 707, Subchapter C, Division 5.(30) Operation (also known as a child care operation)--A sole proprietor, partnership, or business or governmental entity offering a program that is subject to Licensing's regulation, including day-care operations and residential child care operations. An operation includes the building and grounds where the program is offered, any person involved in providing the program, and any equipment used in providing the program. An operation includes a child-care facility, child-placing agency, listed family home, employer-based child care operation, shelter care operation, or any operation that requires a permit under Chapter 42, Texas Human Resources Code.(31) Owner--The sole proprietor, partnership, or business or governmental entity that owns an operation that is subject to regulation by Licensing.(32) Parent--A person who has legal responsibility for or legal custody of a child, including the managing conservator or legal guardian.(33) Permit--A license, certification, registration, listing, compliance certificate, or any other written authorization granted by Licensing to operate a child care operation. This also includes an administrator's license.(34) Permit holder--The owner of the operation that is granted the permit.(35) Pre-kindergarten age child--A child who is three or four years of age before the beginning of the current school year.(36) Program--Activities and services provided by an operation.(37) Regulation--Includes the following:(A) The development of rules, including minimum standards, as provided by statutory authority; and(B) The enforcement of requirements that are minimum standards, rules, statutes, or any condition or restriction we have placed on a permit. Anyone providing or seeking to provide care or a service that is subject to regulation must comply with the applicable requirements. This includes a permit holder, an applicant for a permit, and anyone providing care or a service without the appropriate permit.(38) Report--A communication to Licensing or the Department of Family and Protective Services (DFPS), including the Statewide Intake division of DFPS, of:(A) An allegation of a deficiency in a minimum standard, rule, or statute; or(B) Any other possible risk to a child in the care of an operation that is subject to regulation by Licensing.(39) Residential child care--As defined in §745.35 of this chapter (relating to What is residential child care?).(40) School-age child--A child who is five years of age or older and is enrolled in or has completed kindergarten.(41) State Office of Administrative Hearings (SOAH)--See §745.8831 of this chapter (relating to What is a due process hearing?).(42) Sustained perpetrator--See §745.731 of this chapter (relating to Who are designated perpetrators and sustained perpetrators of child abuse or neglect?). Source Note: The provisions of this §745.21 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective December 1, 2012, 37 TexReg 9127; amended to be effective March 1, 2014, 38 TexReg 8249; amended to be effective March 1, 2016, 41 TexReg 1123; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, aspublished in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING A PRECEDENCE AND DEFINITIONS §745.21 What do the following words and terms mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221108 03/12/2026 (a) Child day care and residential child care are subject to regulation under this chapter and corresponding minimum standards, unless Child Care Regulation (CCR) determines the operation is exempt from regulation.(b) Residential child-care operations include:(1) Child-placing agencies that verify foster homes and approve adoptive homes; and(2) General residential operations, which CCR may also certify as a psychiatric residential youth treatment facility (PRYTF) as defined at §745.9051 of this chapter (relating to What do the following words and terms mean when used in this subchapter?).(c) For a PRYTF, CCR regulates the operation's care of young adults 18 to 21 years of age in addition to child care. Source Note: The provisions of this §745.31 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective December 1, 2012, 37 TexReg 9127; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.31 What operations are subject to regulation under this chapter and corresponding minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195759 03/12/2026 Child day care means the care, supervision, training, or education of:(1) An unrelated child or children under 14 years old for less than 24 hours per day that occurs in a place other than the child's own home, including child day care provided to school-age children before and/or after the customary school day; or(2) A related child or children under 14 years old for less than 24 hours per day that occurs in the caregiver's or child's home if the care is provided:(A) Under the auspices of a listed family home; and(B) In full compliance with Chapter 313 of the Labor Code, including providing care in the child's home only if:(i) Care is provided for a disabled child, which may include the child's siblings;(ii) Care is provided for a child under 18 months of age, which may include the child's siblings;(iii) Care is provided for a child of a parent 18 years or younger;(iv) Care is provided for a child of a parent 19 years of age and the parent is fully enrolled in a secondary school in a program leading toward a high school diploma;(v) Care is provided when the parent's work schedule necessitates child-care services during the evening, overnight, or on the weekend and taking the child outside of the child's home would be disruptive to the child; or(vi) The Texas Workforce Commission determines that other child-care provider arrangements are not available in the community. Source Note: The provisions of this §745.33 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.33 What is child day care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195757 03/12/2026 Residential child care means the care, custody, supervision, assessment, training, education, or treatment of a child who is not related by blood, marriage, or adoption to the owner or operator of the operation, for all of the 24-hour day, regardless of whether the operation is operated for profit or charges for the services it offers. Source Note: The provisions of this §745.35 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.35 What is residential child care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221109 03/12/2026 The charts in paragraphs (1) and (2) of this section list the types of operations for child day care and residential child care that are subject to regulation under this chapter and corresponding minimum standards. (1) Types of Child Day-Care Operations: Attached Graphic(2) Types of Residential Child-Care Operations: Attached Graphic Source Note: The provisions of this §745.37 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective November 1, 2002, 27 TexReg 9393; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective March 1, 2006, 31 TexReg 858; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective September 1, 2010, 35 TexReg 7494; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective December 1, 2012, 37TexReg 9127; amended to be effective June 1, 2014, 39TexReg 3718;transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.37 What specific types of operations are subject to regulation under this chapter and corresponding minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195761 03/12/2026 Yes. While state agencies that run non-exempt operations do not have to obtain a license from us, they must obtain a certificate. We will monitor the operation on a regular basis for compliance with minimum standards. Source Note: The provisions of this §745.39 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.39 Does Licensing regulate state agencies that run child-care operations? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195762 03/12/2026 You must apply for a permit, unless we determine you are exempt from regulation. See more about applying for a permit in Subchapter D of this chapter (relating to Application Process). See more about being exempt from regulation in Subchapter C of this chapter (relating to Operations that are Exempt from Regulation). Source Note: The provisions of this §745.41 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective December 1, 2012, 37 TexReg 9127; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.41 How do I start a child day care or residential child-care operation, including a child-placing agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214278 03/12/2026 The permit holder for a relative-only listed family home must:(1) Operate within the limits of its permit;(2) Ensure there is no immediate risk to the health or safety of a child while in care;(3) Ensure any medication given to a child in care is administered according to Texas Human Resources Code §42.065;(4) Request background checks as required in Subchapter F of this chapter (relating to Background Checks);(5) Ensure that each child is free from abuse, neglect, and exploitation while in care;(6) Pay all required fees as outlined in Subchapter E of this chapter (relating to Fees); and(7) Comply with all other applicable laws and rules. Source Note: The provisions of this §745.43 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING B CHILD CARE AND OTHER OPERATIONS THAT ARE SUBJECT TO REGULATION §745.43 What are the requirements for a relative-only listed family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204667 03/12/2026 These words have the following meanings:(1) Nearby--A person is in the same building, across the street from, or in the same city block as the operation.(2) Three consecutive weeks--A 21-day time period that includes the first and last days that a program operates and all of the days in between, regardless of whether the program operates on a particular day. Source Note: The provisions of this §745.101 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.101 What words must I know to understand this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195764 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195764&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195764 03/12/2026 You can operate your program legally without receiving a license from us. We do not require you to comply with our statutes, rules, and standards. Source Note: The provisions of this §745.111 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.111 What does "exempt from regulation" mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195765 03/12/2026 The programs exempt from regulation by Licensing fall into four categories:(1) Certain programs and facilities regulated by other government entities;(2) Programs of limited duration;(3) Educational facilities and programs; and(4) Miscellaneous programs. Source Note: The provisions of this §745.113 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.113 What programs are exempt from regulation by Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209511 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209511 03/12/2026 The following programs and facilities are exempt from our regulation: Attached Graphic Source Note: The provisions of this §745.115 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2004, 28 TexReg 11353; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective March 1, 2014, 39 TexReg 1182; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective July 8, 2022, 47 TexReg 4336. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.115 What programs regulated by other governmental entities are exempt from Licensing regulation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225725 03/12/2026 The following programs of limited-duration are exempt from CCR regulation: Attached Graphic Source Note: The provisions of this §745.117 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective June 1, 2010, 35 TexReg 4184; mended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective March 10, 2025, 50 TexReg 1824; amended to be effective August 3, 2025, 50 TexReg 4937. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.117 Programs of Limited Duration Exempt from Regulation by Child Care Regulation (CCR) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204670 03/12/2026 The following educational facilities and programs are exempt from our regulation: Attached Graphic Source Note: The provisions of this §745.119 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective June 1, 2008, 33 TexReg 4190; amended to be effective June 1, 2010, 35 TexReg 4184; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.119 What educational facilities are exempt from Licensing regulation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195769 03/12/2026 You must obtain a permit for the portion of your program caring for children younger than the exemption allows. Source Note: The provisions of this §745.121 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.121 What if my educational facility meets every criterion for an education exemption, except some of the children in care are younger than the exemption allows? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195770 03/12/2026 You must obtain a permit for the portion of your program caring for children longer than the number of hours the exemption allows. Source Note: The provisions of this §745.123 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.123 What if my educational facility meets every criterion for an education exemption, except some of the children in care stay in care longer than the number of hours the exemption allows? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204671 03/12/2026 Yes, if your educational facility offers residential child care, then you must meet the criteria in §745.119 of this division (relating to What educational facilities are exempt from Licensing regulation?) and the following additional criteria to be exempt from our regulation:(1) Parents must retain primary responsibility for financial support, health problems, or serious personal problems of the students; and(2) The provision of residential child care must be solely for facilitating the student's participation in the educational program and must not exist apart from the educational aspect of the facility. Source Note: The provisions of this §745.125 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.125 Are additional exemption criteria required for an educational facility that provides residential child care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204672 03/12/2026 The organization to which an educational facility belongs must send the following to us:(1) Documentation that the organization has its own health, safety, fire, and sanitation standards that are equal to those required for licensed operations, or documentation that the organization requires members to comply with state, county, or municipal health, safety, fire, and sanitation codes;(2) A monitoring plan to ensure that members comply with either the health, safety, fire, and sanitation standards of the organization or the health, safety, and fire codes of the state, county, or municipality. We must review the monitoring plan of the organization; and(3) A current list of names and addresses of members every six months Source Note: The provisions of this §745.127 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.127 What does an organization need to submit to Licensing to determine exemption from regulation for member educational facilities under §745.119(4) of this division (relating to What educational facilities are exempt from Licensing regulation?)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204673 03/12/2026 The following miscellaneous programs are exempt from our regulation: Attached Graphic Source Note: The provisions of this §745.129 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective November 1, 2002, 27 TexReg 9393; amended to be effective March 1, 2006, 31 TexReg 858; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective June 1, 2010, 35 TexReg 4184; amended to be effective March 1, 2014, 39 TexReg 1182; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25,2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.129 What miscellaneous programs are exempt from Licensing regulation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204674 03/12/2026 (a) Except for subsection (b) of this section, a person or entity must submit:(1) A description of the program on a form we provide; and(2) Additional documentation to verify that the program meets the criteria required for an exemption.(b) An educational facility that may be exempt under §745.119(1) or (2) of this division (relating to What educational facilities are exempt from Licensing regulation?), may contact us to determine whether the facility needs to complete an exemption form. Source Note: The provisions of this §745.131 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.131 How does a person or entity request that Licensing determine whether a program is exempt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195775 03/12/2026 We must notify you within 21 days after we receive all of the information necessary for us to review whether your program meets all exemption criteria. If the information you submit does not satisfy the exemption criteria, we may request additional documentation or visit your program to gain additional information so that we may determine whether your program meets the criteria for exemption. Source Note: The provisions of this §745.133 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective June 1, 2010, 35 TexReg 4184; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.133 When will I know if my program is exempt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204675 03/12/2026 (a) If we determine that your program does not meet all the criteria for exemption outlined in this division, we will send you a letter stating that you must apply for a permit within certain timeframes. You will then need to take immediate steps to follow Licensing instructions to submit an application for a permit within the time frames outlined in the letter.(b) We may file suit in district court for both a civil penalty and injunctive relief if you:(1) Fail to meet the criteria for an exemption or knowingly engage in activities that require a permit; and(2) Fail to submit an application for a permit.(c) There are criminal penalties for operating without a permit. Source Note: The provisions of this §745.135 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective June 1, 2010, 35 TexReg 4184; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.135 What if Licensing determines that my program does not meet the exemption criteria outlined in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195777 03/12/2026 You may request an administrative review if you disagree with the determination. See Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.137 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.137 What if I disagree with Licensing's determination that my program is not exempt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209512 03/12/2026 (a) If the programs are separate, each program that meets the criteria for an exemption is exempt. If they are not separate, then they are all subject to our regulation, unless the exempt program meets the exemption described in §745.115(1)(B) of this division.(b) To demonstrate that the programs are separate, you must show that the programs:(1) Have separate caregivers or have caregivers that do not provide care to more than one program at the same time; and(2) Do not use the same building or areas at the same time, except that the programs may share restrooms and indoor/outdoor activity areas if you have a written plan regarding how caregivers from each program will supervise children using shared spaces. Source Note: The provisions of this §745.139 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective June 1, 2010, 35 TexReg 4184; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective July 8, 2022, 47 TexReg 4336. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.139 What will Licensing do if I operate a combination of exempt and regulated programs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204676 03/12/2026 You may apply for a permit if you must have one for your program to receive public funding. If we issue you a permit, then you must comply with all minimum standards, rules, and statutes that apply to that permit. Source Note: The provisions of this §745.141 adopted to be effective November 1, 2002, 27 TexReg 9393; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to b effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.141 In what circumstances may I apply for a permit even though my program is exempt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204677 03/12/2026 No, if your program is exempt and we do not regulate it under §745.141 of this division (relating to In what circumstances may I apply for a permit even though my program is exempt?), we will not issue you a permit. Source Note: The provisions of this §745.143 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective November 1, 2002, 27 TexReg 9393; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING C OPERATIONS THAT ARE EXEMPT FROM REGULATION §745.143 If my program is exempt and does not need regulation for funding purposes, can I still obtain a permit from Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195819 03/12/2026 These words have the following meanings:(1) Nearby--For child day-care operations, "nearby" means next to, across the street from, or in the same city block. For residential child-care operations, "nearby" means across the street from, in the same city block, or on the same property.(2) Newspaper of general circulation--A community's own newspaper, or if this is not available, a newspaper purporting to serve the community, or the daily newspaper of the nearest metropolitan area. Source Note: The provisions of this §745.201 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.201 What words must I know to understand this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204678 03/12/2026 The application process includes:(1) The applicant completing the pre-application interview, except for an application for a:(A) Listed family home; or(B) Compliance Certificate;(2) The applicant submitting the application materials;(3) The applicant and Licensing completing the public notice and hearing requirements for residential child-care operations;(4) Licensing reviewing the application for compliance with minimum standards, rules, and statutes;(5) Licensing accepting the application as complete, or returning it if incomplete;(6) Licensing inspecting the applicant's operation and determining whether the operation is in compliance with minimum standards, rules, and statutes, except for listed family homes; and(7) Licensing issuing or denying a permit. Source Note: The provisions of this §745.211 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.211 What are the different parts of the application process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195821 03/12/2026 The pre-application interview teaches applicants about the application process, the licensing requirements, and the administrative procedures. Source Note: The provisions of this §745.213 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.213 What is the purpose of the pre-application interview? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204679 03/12/2026 We conduct the pre-application interview in the following ways to meet the needs of both our staff and the applicant:(1) A group meeting or class, which we may conduct online or through a virtual meeting;(2) A Licensing office interview;(3) An interview at the applicant's office;(4) An interview at the potential operation; or(5) A telephone interview, if we cannot handle the interview any other way. Source Note: The provisions of this §745.215 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.215 How does Licensing conduct the pre-application interview? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204680 03/12/2026 (a) The individual or governing body planning to operate the program must return a completed application to us, unless we have determined the program is exempt from regulation.(b) The governing body of a general residential operation must submit a new application with updated application materials required in §745.243(6) of this division (relating to What does a completed application for a permit include?), including a completed General Residential Operations - Additional Operation Plan (Form 2960, Attachment C), if the operation:(1) Currently provides treatment services to children with emotional disorders and is requesting to amend its permit to increase its capacity; or(2) Does not currently provide treatment services to children with emotional disorders but is requesting to amend its permit in order to provide those services. Source Note: The provisions of this §745.241 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.241 Who must submit the application for a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219542 03/12/2026 Application forms vary according to the type of permit. We will provide you with the required forms. Contact your local Licensing office for additional information. The following table outlines the requirements for a completed application: Attached Graphic Source Note: The provisions of this §745.243 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective September 1, 2010, 35 TexReg 7494; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective December 1, 2012, 37 TexReg 9127; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective August 14, 2024, 49 TexReg 4917. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.243 What does a completed application for a permit include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195825 03/12/2026 If the governing body is a for-profit corporation or a limited liability company, then you must submit:(1) The governing body's most recent Franchise Tax Certificate of Good Standing; or(2) The Articles of Incorporation if the corporation or company has not existed long enough to owe the tax at the time of the application; or(3) Documented proof that Texas Tax Code, Chapter 171, exempts the corporation or company from paying the tax. Source Note: The provisions of this §745.245 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.245 How do I demonstrate that the governing body is not delinquent in paying the franchise tax? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195826 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195826&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195826 03/12/2026 A permit holder must immediately forward us a copy of any written notice from any governmental entity indicating that the holder's corporate privileges are forfeited and/or in danger of forfeiture. We may suspend a permit held by a governing body that forfeits its corporate privileges. The suspension will end if the forfeiture is set aside and the corporate privileges are revived as set forth in the Texas Tax Code. We may revoke the permit held by a governing body that does not forward to us a copy of forfeiture notice and loses its corporate privileges. Source Note: The provisions of this §745.247 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.247 What happens if the governing body is delinquent in paying the tax after receiving a permit from Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204682 03/12/2026 (a) Unless you have an acceptable reason not to have the insurance as specified in §745.251 of this division (relating to What are acceptable reasons not to have liability insurance?), a licensed operation, registered child-care home, or listed family home must:(1) Have liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit.(b) A listed family home that only provides care to related children under Chapter 313 of the Texas Labor Code (relating to Requirements for Providers of Relative Child Care) does not have to meet these liability insurance requirements. Source Note: The provisions of this §745.249 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.249 What are the liability insurance requirements for a licensed operation, registered child-care home, or listed family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204683 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §745.249 of this division (relating to What are the liability insurance requirements for a licensed operation, registered child-care home, or listed family home?) if you cannot carry the insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the operation or home; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry the liability insurance because of a reason listed in subsection (a) of this section, you must submit with your application a statement that you cannot carry the insurance and the reason that you cannot carry the insurance. Source Note: The provisions of this §745.251 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.251 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204684 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §745.249 of this division (relating to What are the liability insurance requirements for a licensed operation, registered child-care home, or listed family home?), then you must notify a child's parent in writing that you do not carry the insurance before you admit a child into your care.(b) You may use Form 2962, Attachment A, Parental Notification of Lack of Required Liability Insurance, located on Licensing's provider website to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parent of each child in your care. Source Note: The provisions of this §745.253 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.253 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204685 03/12/2026 An applicant for a listed family home, including a home that will only provide care and supervision for children related to the primary caregiver, must successfully complete one hour of safe sleeping training that covers the following topics:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding and using safe sleeping practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development. Source Note: The provisions of this §745.255 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.255 What safe sleeping training must a person complete when applying to operate a listed family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210915 03/12/2026 (a) Except as specified in subsection (c) of this section, a general residential operation located in a county with a population of less than 300,000 must meet the public notice and hearing requirements when applying for a license.(b) Except as specified in subsection (c) of this section, a general residential operation requesting to amend its permit must meet the public notice and hearing requirements if it is:(1) An operation located in a county with a population of less than 300,000 requesting to increase capacity;(2) An operation requesting to relocate permanently to a location in:(A) a county with a population of less than 300,000 where the operation did not meet the public notice and hearing requirements with respect to its current location; or(B) the same county with a population of less than 300,000 if the location is in a different community or is served by a different school district; or(3) An operation located in a county with a population of less than 300,000 that does not currently provide treatment services to children with emotional disorders but is requesting to amend its permit to begin providing treatment services to children with emotional disorders.(c) A general residential operation that applies to provide services under Chapter 748 of this title, Subchapter V (relating to Additional Requirements for Operations that Provide Trafficking Victim Services) is exempt from any public notice and hearing requirements in subsection (a) of this section, unless the general residential operation intends to provide or provides treatment services to children with emotional disorders.(d) Notwithstanding the exemption provided in subsection (c) of this section, if the operation never provides or ceases to provide trafficking victim services, then the operation must meet the public notice and hearing requirements. To meet public notice and hearing requirements, the operation may need to surrender its permit or withdraw its application, as applicable, and reapply. Source Note: The provisions of this §745.273 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective December 1, 2012, 37 TexReg 9127; amended to be effective March 1, 2016, 41 TexReg 1123; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective November23, 2022, 47 TexReg 7725. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.273 Which residential child-care operations must meet the public notice and hearing requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210916 03/12/2026 (a) The following chart lists the public notice, hearing requirements, and subsequent report you must complete: Attached Graphic(b) During an active declaration of a state of disaster under Texas Government Code, Chapter 418, public hearings concerning an operation located in an area subject to the declaration of disaster may be held in a manner that allows remote participation. Source Note: The provisions of this §745.275 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective November 23, 2022, 47 TexReg 7725. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.275 What are the specific requirements for a public notice and hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210917 03/12/2026 If you fail to comply with any one of the public notice and hearing requirements that are set forth under §745.273 of this division (relating to Which residential child-care operations must meet the public notice and hearing requirements?) and §745.275 of this division (relating to What are the specific requirements for a public notice and hearing?), we may do the following:(1) Deny you a permit;(2) Deny you an amendment to your permit that would allow you to increase capacity;(3) Deny you an amendment to your permit that would allow you to operate at the new location; or(4) Deny you an amendment to your permit that would allow you to provide treatment services to children with emotional disorders. Source Note: The provisions of this §745.277 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective November 23, 2022, 47 TexReg 7725. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.277 What will happen if I fail to comply with the public notice and hearing requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204688 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204688 03/12/2026 (a) If you are applying for:(1) A permit other than a compliance certificate, we have 21 days after receiving your application to review the paperwork; or(2) A compliance certificate, we have 10 days after receiving your application to review the paperwork.(b) After the review of your application, we will notify you in writing that:(1) There is good cause to delay the timeframe for making a determination on the application, consistent with §745.327 of this subchapter (relating to When does Licensing have good cause for exceeding its timeframes for processing my application?);(2) You are ineligible to apply for a permit;(3) Your application is complete and accepted for processing; or(4) Your application is incomplete. The notification letter will:(A) Identify any application materials that you submitted that do not show compliance with relevant minimum standards, rules, and statutes; and(B) Explain what you must do to complete the application. Source Note: The provisions of this §745.301 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.301 How long does Licensing have to review my application and notify me of my application status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195835 03/12/2026 (a) Unless you are applying for a compliance certificate, you have three times to submit all required material. If we return your application as incomplete three times, you may not apply again until one year from the date that we returned your last application as incomplete.(b) If you are applying for a compliance certificate to operate an employer-based child care operation or shelter care operation, you have an unlimited amount of times to submit the required material. Source Note: The provisions of this §745.303 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.303 How many chances do I have to submit all of the required information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204689 03/12/2026 (a) If you are applying for a permit other than a compliance certificate, we will issue or deny you a permit no later than two months after we accept your application, unless there is good cause to exceed this timeframe.(b) If you are applying for a compliance certificate, we will issue or deny you a certificate no later than 30 days after we accept your application, unless there is good cause to exceed this timeframe. Source Note: The provisions of this §745.321 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.321 How long does Licensing have to issue or deny a permit after accepting my application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204690 03/12/2026 You may file a complaint with the Associate Commissioner for Child Care Regulation. The Associate Commissioner will resolve the dispute in a timely manner. We must reimburse you for your application fee if we do not establish good cause for exceeding the time limit. Source Note: The provisions of this §745.323 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.323 What if Licensing exceeds its timeframes for processing my application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204691 03/12/2026 (a) You must send a written complaint regarding the timeframes for processing your application before we issue or deny you a permit.(b) You must send your complaint stating the nature of the dispute to the Associate Commissioner for Child Care Regulation, Texas Health and Human Services Commission, Mail Code E-550, P.O. Box 149030, Austin, Texas 78714. Source Note: The provisions of this §745.325 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.325 How do I file a complaint regarding timeframes for processing my application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195781 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195781 03/12/2026 We have good cause to exceed our timeframes for processing your application in the following circumstances:(1) We are processing at least 15% more applications than we did in the same quarter of the previous year;(2) The delay is caused by another public or private entity that we must rely on to process all or part of the applications we receive;(3) You are the subject of a pending investigation; or(4) Other conditions exist that give us good cause for exceeding the timeframes. Source Note: The provisions of this §745.327 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.327 When does Licensing have good cause for exceeding its timeframes for processing my application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204692 03/12/2026 When we determine whether to issue or amend a permit, we will consider the following:(1) The application or request to amend the permit and any information submitted with the application or request;(2) The on-site inspection to determine compliance with minimum standards, rule, and statutes;(3) Any information that Licensing gathers through the application or amendment process, including any written comments and written information submitted to Licensing during the process that Licensing considers to be relevant to the decision to issue or deny the permit or amendment;(4) If a public hearing is required in §745.273 of this subchapter (relating to Which residential child-care operations must meet the public notice and hearing requirements?):(A) Any written comments and written information provided by interested parties at a public hearing; and(B) The Verbatim Record and summary Report of Public Comment from the Community, as required in §745.275 of this subchapter (relating to What are the specific requirements for a public notice and hearing?); and(5) If the application or the request to amend the permit is for a general residential operation that will provide treatment services to children with emotional disorders:(A) All parts of the Additional Operation Plan required in §745.243(6)(M) of this subchapter (relating to What does a completed application for a permit include?);(B) Evidence of community support for, or opposition to, the proposed general residential operation, including any public comment relating to the licensing of the proposed operation; and(C) The impact statement from the school district likely to be affected by the proposed general residential operation, including information relating to any financial impact on the district that may result from an increase in enrollment. Source Note: The provisions of this §745.339 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.339 What factors will we consider when evaluating an application for a permit or a request to amend a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204693 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204693 03/12/2026 If a public hearing is required in §745.273 of this subchapter, we may deny you a license or an amendment to your permit if we determine that:(1) The community has insufficient resources to support the children that you propose to serve;(2) Issuing the license or amending the permit would adversely affect the children you propose to serve:(A) By increasing the ratio in the local school district of students enrolled in a special education program to students enrolled in a regular education program; or(B) If you are providing or seeking to provide treatment services to children with emotional disorders by significantly impacting the local school district; or(3) Issuing the license or amending the permit would have a significant adverse impact on the community and would limit opportunities for social interaction for the children that you propose to serve. Source Note: The provisions of this §745.340 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.340 For what reason may Licensing deny me a permit based on the results of a required public hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204694 03/12/2026 (a) We issue a full permit to an applicant seeking to operate a listed family home, registered child-care home, shelter care operation, or employer-based child care operation if we accept the application and the operation meets all of the requirements in this chapter.(b) We issue either an initial license or a full license, as described in §745.345 of this division (relating to When does Licensing issue an initial license?) and §745.351 of this division (relating to If I have an initial license, when will I be eligible for a full license?).(c) If you are applying for a certification, you must go through the same requirements as an applicant for a full license, including being issued an initial certification and, if appropriate, a subsequent full certification. The rules in this division that pertain to an initial license also apply to an initial certification. Source Note: The provisions of this §745.341 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2008, 33 TexReg 1367; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.341 What type of permit does Licensing issue? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204695 03/12/2026 (a) An initial license is a permit allowing you to operate pending the possible issuance of a full license.(b) A full license is a type of full permit. Source Note: The provisions of this §745.343 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.343 What is the difference between an initial license and full license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204696 03/12/2026 Your full permit will remain valid if:(1) You comply with renewal requirements, as explained in Division 12 of this subchapter (relating to Permit Renewal);(2) Your permit is not automatically suspended or revoked:(A) For failure to pay a fee under Human Resources Code (HRC) §42.054(f);(B) For failure to submit information for a background check for a listed family home under HRC §42.052(j); or(C) Because the license changes location or ownership, as further explained in Division 10 of this subchapter (relating to Relocation of Operation and Change in Ownership);(3) We do not suspend, revoke, or refuse to renew your permit; and(4) You do not relinquish your permit and close your operation. Source Note: The provisions of this §745.344 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.344 How long is a full permit valid? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204697 03/12/2026 We issue you an initial license instead of a full license when we accept your application, determine that your operation is in compliance with applicable minimum standards, rules, and statutes, you pay the initial license fee, and one of the following situations exists:(1) We have not been able to evaluate your operation's ability to comply with all minimum standards, rules, and statutes relating to children in care because:(A) Your operation is not currently providing care to children; or(B) Your operation has been operating without a license;(2) Your operation has changed location and has made changes in the type of child-care services it offers;(3) We licensed you for one type of child care, and you apply to add another type of child care to your program (an initial license is issued for the new type of child care); or(4) Change in ownership results in changes in policy and procedure or in the staff who have direct contact with the children. (See §745.437 of this subchapter (relating to What is a change in the ownership of an operation?)). Source Note: The provisions of this §745.345 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective December 1, 2012, 37 TexReg 9127; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.345 When does Licensing issue an initial license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204698 03/12/2026 (a) An initial license is valid for six months from the date we issue it.(b) We may renew an initial license for up to an additional six months. You may only have an initial license for a maximum of one year.(c) The initial license expires when we issue or deny you a full license, even if the period for the initial license has not yet expired at the time the full license is issued or denied. Source Note: The provisions of this §745.347 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective June 1, 2014, 39 TexReg 3718; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.347 How long is an initial license valid? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204699 03/12/2026 We cannot determine compliance with all minimum standards unless you have children in care. If you do not have children in care during the initial license period:(1) We may renew your initial license, if you have not exceeded the maximum one year period;(2) We may deny you a full license if we determine that denial is appropriate under §745.8650 of this chapter (relating to When may Licensing deny a permit?); or(3) You may submit a new application form and fees. Source Note: The provisions of this §745.349 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective December 1, 2012, 37 TexReg 9127; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.349 What if I am not able to care for children during the initial period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204700 03/12/2026 You will be eligible for a full license when:(1) Your initial license has been in effect for at least three months;(2) You have met all minimum standards on a continuing basis;(3) A general residential operation that is exempt from the hearing and notice requirements at §745.273(b) of this subchapter (relating to Which residential child-care operations must meet the public notice and hearing requirements?) begins providing trafficking victim services;(4) The Licensing staff has made three inspections, unless supervisory approval is obtained to make fewer visits; and(5) You have paid your full license fee in accordance with Subchapter E of this chapter (relating to Fees). Source Note: The provisions of this §745.351 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2016, 41 TexReg 1123; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.351 If I have an initial license, when will I be eligible for a full license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204701 03/12/2026 You may request an administrative review or an appeal regarding the denial of a permit. The letter notifying you of the denial will include instructions and timeframes for requesting an administrative review or an appeal. Also see Subchapters L and M of this chapter (relating to Enforcement Actions, and Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.353 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.353 What can I do if Licensing denies me a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204702 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204702 03/12/2026 We may issue a full license instead of an initial license when we determine that it is unnecessary for us to evaluate the operation's ability to comply with minimum standards, rules, and statutes, including when:(1) The ownership of an operation changes as follows without changing the type of child care services that the operation offers, any policy or procedures, or the staff who have direct contact with children in care:(A) An owner changes from one type of business entity to another, and the new business entity has the same governing body as the previous owner;(B) An owner that is a sole proprietor or partnership forms a business entity to be the new owner, and the business entity's governing body consists only of persons who were a part of the previous ownership; or(C) A third party acquires the publicly traded stock of a business entity that will continue to own and operate the operation following acquisition;(2) The operation changes location, and we determine that the new location complies with the minimum standards; or(3) We were able to evaluate the operation's ability to comply with minimum standards, rules, and statutes during a recent initial license period, but circumstances required the owner to withdraw the previous application and submit a new application at the same location. Source Note: The provisions of this §745.355 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.355 When may Licensing issue a full license in lieu of an initial license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204703 03/12/2026 No. We can issue only one registration or listing per single living unit. For a registered child-care home or listed family home, if more than one person cares for children in a single living unit or home, the name on the registration or listing must be the name of the primary caregiver. Source Note: The provisions of this §745.371 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective December 1, 2008, 33 TexReg 9272; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.371 Can Licensing issue more than one registration or listing for a single child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204704 03/12/2026 (a) Except as described in subsection (b) of this section, you may not have more than one licensed child-care home, because a primary caregiver must provide care in the caregiver's own residence.(b) If you were licensed to operate more than one group day-care home prior to September 1, 2003, you may continue to operate two or more licensed child-care homes as long as the license remains valid and you meet the following conditions:(1) Your facilities are at separate locations;(2) You maintain your operations separately; and(3) You do not move children back and forth between the two licensed child-care homes. Source Note: The provisions of this §745.373 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 22021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.373 May I have more than one licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204706 03/12/2026 You may only obtain a child day care permit for a registration or a listing at your agency foster home under the following conditions:(1) Both the Director of Residential Regional Operations or designee and the Director of Day Care Regional Operations or designee approve the child day care permit for the foster home;(2) The total number of children in care does not exceed six, including your own children, your foster children, children receiving respite care at your foster home, and the children to whom you provide child day care; and(3) You meet the requirements for your registration or listing, including the payment of fees. Source Note: The provisions of this §745.375 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2010, 35 TexReg 7495; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.375 May I offer child day care at my agency foster home or independent foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204705 03/12/2026 A single operation may not have more than one child day care license at the same location. Source Note: The provisions of this §745.379 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.379 Can a single operation have more than one child day care license at the same location? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195793 03/12/2026 Your child day-care operation may provide overnight care once a month without our permission. For example, you may have an overnight slumber party for the children in care. Source Note: The provisions of this §745.381 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.381 Do I need Licensing's permission for my child day-care operation to provide occasional overnight care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204707 03/12/2026 (a) A person or governing body may not operate multiple operations under the same permit unless the operations are:(1) The same type of child care operations;(2) Contiguous or nearby one another; and(3) Operate as a single operation as evidenced by staffing, finance, and administrative supervision.(b) A permit that we issued prior to September 1, 2005, that allows multiple residential child-care operations to operate under that permit remains valid regarding the addresses listed on the permit until it expires or is revoked or voluntarily relinquished. Source Note: The provisions of this §745.385 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.385 Can a person or governing body operate multiple operations under the same permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195796 03/12/2026 Unless you are reapplying within 30 days after you withdrew your original application, you must pay all fees. The reapplication is considered an original application. Source Note: The provisions of this §745.401 adopted to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.401 What fees must I pay when I reapply for a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204708 03/12/2026 (a) You are eligible to apply for another permit after the fifth anniversary of the date on which any of the following adverse actions takes effect or you voluntarily close or relinquish your permit after receiving notice of our intent to take such an action:(1) A denial of your application under §745.8650 of this chapter (relating to When may Licensing deny a permit?);(2) A revocation of your permit under §745.8654 of this chapter (relating to When may Licensing revoke my permit?); or(3) A refusal to renew your permit under §745.8655 of this chapter (relating to When may Licensing refuse to renew my permit?).(b) A denial, revocation, or refusal to renew takes effect when:(1) You have waived or exhausted your due process rights regarding the denial, revocation, or refusal to renew; and(2) The denial, revocation, or refusal to renew is upheld.(c) This rule does not apply if:(1) Your permit is automatically revoked:(A) For failure to pay a fee under Human Resources Code (HRC) §42.054(f);(B) For failure to submit information for a background check for a listed family home under HRC §42.052(j); or(C) Because the license changes location or ownership, as further explained in Division 10 of this subchapter (relating to Relocation of Operation and Change in Ownership); or(2) Your permit expires. Source Note: The provisions of this §745.403 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective June 1, 2010, 35 TexReg 4184; amended to be effective September 1, 2016, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.403 When am I eligible to apply for another permit after Licensing denies, revokes, or refuses to renew my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195798 03/12/2026 You cannot operate merely because you apply for a permit. We may deny you a permit if you operate before a permit is issued. Source Note: The provisions of this §745.405 adopted to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.405 Can I operate after I apply for a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204710 03/12/2026 (a) A change in location automatically revokes your compliance certificate.(b) If you are going to relocate your operation for any reason, you must notify us as early as possible before the move to voluntarily relinquish your permit. You may reapply for a permit to operate at your new location. See Division 3 of this subchapter (relating to Submitting the Application Materials).(c) If you fail to notify us before you relocate, we may deny you a permit for the new location. Source Note: The provisions of this §745.429 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.429 What must I do if I relocate my operation after I receive my compliance certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204711 03/12/2026 If you relocate your listed family home, you must notify us of the new address within 15 days after the move. We will amend the listing to reflect the new address. The issuance date on the original listing will remain in effect. There is no additional fee for your change in location. We may revoke your listing if you do not notify us within 15 days of the relocation. Source Note: The provisions of this §745.431 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.431 What must I do if I relocate my listed family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204712 03/12/2026 If you relocate your registered child-care home, you must notify us of the new address within 15 days after the move. We will inspect your new location. If the new location complies with the minimum standards, we will amend the registration to reflect the new address. The issuance date on the registration will remain in effect. There is no additional fee for your change in location. We may revoke your registration if you do not notify us within 15 days of the relocation. Source Note: The provisions of this §745.433 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.433 What must I do if I relocate my registered child-care home after I receive my registration? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210918 03/12/2026 (a) If you are going to relocate your operation permanently to a new location, you must notify us as early as possible before the move and meet the notification requirements in the following table. Attached Graphic(b) If you fail to notify us before you relocate, we may deny you an amendment to your permit that would allow you to operate at the new location. (c) You must notify us of the address of your new location by completing a form that we provide you. After we inspect your new location, we will amend your permit to reflect the new address if:(1) The new location complies with the minimum standards; and(2) You meet the requirements in Division 4 of this subchapter (relating to Public Notice and Hearing Requirements for Residential Child-Care Operations), if applicable. (d) If we amend your permit to reflect a new address as described in subsection (c) of this section:(1) The issuance date and permit number that is on your original permit will remain in effect; and(2) There is no additional fee for your change in location. (e) For temporary re-location of a residential child-care facility during a declared disaster, see §748.303(e)(3) of this title (relating to When must I report and document a serious incident?) and §749.503(e)(3) of this title (relating to When must I report and document a serious incident?). Source Note: The provisions of this §745.435 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective November 23, 2022, 47 TexReg 7725. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.435 What must I do if I relocate my operation after I receive my license or certification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204714 03/12/2026 A change in the ownership of an operation with a license results in the automatic revocation of the license. Source Note: The provisions of this §745.436 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.436 What is the result of a change in the ownership of an operation with a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204715 03/12/2026 (a) A change in ownership of an operation occurs when:(1) The owner stated on the license no longer owns the operation;(2) The governing body stated on the license no longer has the ultimate authority and responsibility for the operation;(3) There is a change in the legal organizational structure of the operation; or(4) A business entity that is a permit holder is sold or otherwise acquired by one or more persons or business entities, except as set forth in subsection (b) of this section.(b) A change in ownership of an operation does not include the acquisition of the publicly traded stock of a business entity if the following conditions exist:(1) The business entity listed on the application and on the permit will continue to own and operate the operation following acquisition;(2) There will be no change in the operation's policy or procedure because of the transaction;(3) There will be no change in the staff who have contact with children in care because of the transaction; and(4) Any change in the day-to-day operations that might occur after the sale is in the ordinary course of business and not as a result of the stock transaction. Source Note: The provisions of this §745.437 adopted to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.437 What is a change in the ownership of an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195805 03/12/2026 (a) A change in your ownership automatically revokes your permit.(b) If you are going to change ownership, you must notify us as early as possible before the change. See Division 3 of this subchapter (relating to Submitting the Application Materials). Source Note: The provisions of this §745.439 adopted to be effective March 1, 2008, 33 TexReg 1367; amended to be effective September 1, 2016, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.439 What must I do if the ownership of my employer-based child care operation or shelter care operation changes? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204716 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204716 03/12/2026 A parent must:(1) Work within the same building in which the child care is located;(2) Routinely be present at the work site for most of the time the child is in care;(3) Be physically accessible to the child, although the parent may be away from the building for a limited period of time, such as for lunch or to attend a business meeting, a medical appointment, or training related to work; and(4) Not be away from the building for more than four hours in a day or for more than ten hours in a week. Source Note: The provisions of this §745.461 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.461 Where must a child's parent be while the child is in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195807 03/12/2026 A caregiver must:(1) Be at least 18 years of age;(2) Have a high school diploma or its equivalent, and upon request verify completion of any high school equivalency program with original documentation to us. A high school equivalent is a program recognized by the Texas Education Agency (TEA) or other public educational entity outside of Texas, which offers training similar to reading, writing, and problem-solving skills taught at the high school level, such as a General Educational Development (GED) certificate;(3) Meet the requirements in Subchapter F of Chapter 745 of this title (relating to Background Checks);(4) Before being counted in the caregiver-to-child ratio, complete an orientation for caregivers to include at least the following:(A) A presentation of your operational policies including discipline, guidance, and the release of children;(B) An overview of symptoms of child abuse, neglect, and sexual abuse and the responsibility for reporting these;(C) The procedures to follow in handling emergencies, which may include, but are not limited to, fire, explosion, tornado, toxic fumes, volatile persons, and severe injury or illness of a child or adult; and(D) The use and location of fire extinguishers and first-aid equipment;(5) Before being counted in the caregiver-to-child ratio, complete eight hours of pre-service training, as specified in §746.1305 of this title (relating to What must be covered in the eight clock hours of pre-service training for caregivers?), unless exempted as specified in §746.1307 of this title (relating to Are any caregivers exempt from the pre-service training?);(6) Obtain at least 15 clock hours of training each year as specified in §746.1309 of this title (relating to How many clock hours of annual training must be obtained by caregivers?), §746.1313 of this title (relating to When must annual training for my caregivers and director be obtained?), §746.1317 of this title (relating to Must the training for my caregivers and the director meet certain criteria?), §746.1323 of this title (relating to If I hire a caregiver or a director that received training at another child-care center, may these hours count towards the annual training requirement at my center?), §746.1325 of this title (relating to What is self-instructional and instructor-led training?), and §746.1327 of this title (relating to How many annual training clock hours may caregivers obtain from self-instructional materials?);(7) Obtain first-aid and CPR training as specified in §746.1315 of this title (relating to Who must have first-aid and CPR training?); and(8) Have a Child Development Associate, a Certified Child-Care Professional credential, or a day-care administrator's credential issued by a professional organization or educational institution and approved by Licensing based on criteria specified in Subchapter P of Chapter 745 of this title (relating to Day Care Administrator's Credential Program). These credentials require documentation and periodic renewal to remain qualified. Source Note: The provisions of this §745.463 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.463 What are the qualifications to be a caregiver at an employer-based child care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204717 03/12/2026 In addition to meeting the requirements in Subchapter F of this chapter (relating to Background Checks), you must ensure all information related to background checks is kept confidential as required by Texas Human Resources Code §40.005(d) and (e) and Texas Government Code §411.084 and §411.085. Source Note: The provisions of this §745.464 adopted to be effective March 1, 2015, 40 TexReg 834; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.464 What are my responsibilities regarding criminal background check requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195809 03/12/2026 (a) You must report the following types of serious incidents involving a child in your care. The reports must be made to the following entities, and the reporting must be within the specified time frames: Attached Graphic(b) You must report the following types of serious incidents involving your operation or an employee to the following entities within the specified time frame: Attached Graphic Source Note: The provisions of this §745.465 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.465 When must my employer-based child care report a serious incident to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204718 03/12/2026 In addition to reporting serious incidents, you must inform your employees of the duty to report suspected abuse, neglect, or exploitation to the Texas Department of Family and Protective Services as required by the Texas Family Code, §261.101, and Texas Human Resources Code, §42.063(c). Source Note: The provisions of this §745.467 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.467 What are my responsibilities regarding the report of abuse, neglect, or exploitation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206498 03/12/2026 If your operation maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, you must:(1) Adopt and implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in 25 TAC Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and Texas Health and Safety Code §773.0145; and(2) Notify the child's parent, immediately after ensuring the safety of the child, if the child has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector. Source Note: The provisions of this §745.469 adopted to be effective October 25, 2021, 46 TexReg 7217. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.469 What are the requirements if my operation chooses to maintain and administer unassigned epinephrine auto-injectors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204732 03/12/2026 (a) A full license, certification, or registration will expire if it is not renewed.(b) There are no renewal requirements for a compliance certificate or listing. Source Note: The provisions of this §745.471 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.471 What types of permits need to be renewed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204731 03/12/2026 (a) If your permit is subject to renewal as outlined in §745.471 of this division (relating to What types of permits need to be renewed?), you must apply to renew your permit every two years after the date we issue your full permit.(b) If your operation is under an enforcement action described in §745.8603 of this chapter (relating to What enforcement actions may Licensing recommend or impose?), you must still timely apply to renew your permit.(c) During the year that you must renew your permit, your renewal period:(1) Begins 60 calendar days before the anniversary of when we issued your full permit to you; and(2) Ends on the date of the anniversary.(d) If you are late in applying for the renewal of your permit, you have 30 additional calendar days after your renewal period to apply for the renewal. Source Note: The provisions of this §745.473 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.473 When do I need to apply to renew my full license, certification, or registration? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213743 03/12/2026 (a) A completed renewal application includes:(1) Verification that the following information is current and accurate:(A) Your operation's basic information on Licensing's consumer website;(B) The list of controlling persons at your operation;(C) The list of your governing body's members, such as officers and owners, if applicable;(2) A statement as to whether your operation continues to need any existing waivers and variances;(3) Validating on your provider website the list of persons who require a background check because of their association with your operation; and(4) If you operate a general residential operation that provides treatment services for children with emotional disorders, a written response that addresses any public comments made regarding the renewal of the operation's license during a public hearing, if required by §745.487 of this division (relating to When is a public hearing required for the renewal of a license?).(b) You must submit a completed renewal application for us to evaluate your permit for renewal. Source Note: The provisions of this §745.475 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective March 27, 2023, 48 TexReg 1565. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.475 What does a completed renewal application for a permit include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213744 03/12/2026 (a) After receiving your renewal application, we evaluate whether:(1) You completed the renewal application as required by §745.475 of this division (relating to What does a completed renewal application for a permit include?);(2) We have cited you for repeated deficiencies or a pattern of deficiencies during the previous five years;(3) You have corrected each deficiency with an expired compliance date that is not pending due process, including an administrative review, a due process hearing, or any subsequent rights of appeal;(4) You currently meet all background check requirements in Subchapter F of this chapter (relating to Background Checks);(5) You have paid:(A) All fees required by Subchapter E of this chapter (relating to Fees); and(B) Each administrative penalty that you owe after waiving or exhausting any due process provided under Texas Human Resources Code §42.078;(6) We must visit your operation to determine your eligibility for renewal, such as to review records to determine whether you have corrected all relevant deficiencies; and(7) We must hold a public hearing as required by §745.487 of this division (relating to Is a public hearing required for the renewal of a license?).(b) Within 30 days of receiving your renewal application, we will send you written notice that:(1) We have renewed your permit;(2) Your renewal application is incomplete as further described in subsection (c) of this section; or(3) We refuse to renew your permit as provided in §745.8655 of this chapter (relating to When may Licensing refuse to renew my permit?).(c) If your renewal application is incomplete, the written notice will include:(1) Our evaluation that you did not complete one or more of the renewal application requirements at §745.475 of this division (relating to What does a completed renewal application for a permit include?);(2) A list of the requirements that must be completed before we can renew your permit, which may include:(A) Correcting a deficiency with an expired compliance date that is not pending due process;(B) Meeting a certain background check requirement; or(C) Paying any of the following:(i) A fee required by Subchapter E of this chapter (relating to Fees); or(ii) An administrative penalty that you owe after waiving or exhausting any due process provided under Texas Human Resources Code §42.078; and(3) A statement that we must hold a public hearing required by §745.487 of this division (relating to When is a public hearing required for the renewal of a license?), if applicable.(d) If your renewal application is incomplete and you submitted it during the renewal period, you have unlimited attempts to submit the missing information and to correct the deficiencies until your permit expires.(e) If your renewal application is incomplete and you submitted it during the late renewal period, you have 15 days to submit a completed renewal application from the date it was rejected. Source Note: The provisions of this §745.477 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective March 27, 2023, 48 TexReg 1565. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.477 What happens after Licensing receives my renewal application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204734 03/12/2026 We have good cause to exceed the 30-day timeframe for processing your renewal application:(1) For a reason that would allow us to exceed our timeframes for processing an application for a permit at §745.327 of this subchapter (relating to When does Licensing have good cause for exceeding its timeframes for processing my application?);(2) Because of an enforcement action, including when:(A) We are in the process of revoking or suspending your permit;(B) Your permit is presently suspended; or(C) We recommend or impose a voluntary plan of action or a corrective action plan;(3) We impose any other appropriate action to address an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?); or(4) We are in the process of holding a public hearing as required by §745.487 of this division (relating to When is a public hearing required for the renewal of a license?). Source Note: The provisions of this §745.478 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.478 When does Licensing have good cause to exceed the timeframe for processing my renewal application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195815 03/12/2026 Yes. Upon receiving the written notice of your permit's renewal, you must post the notice at your operation. Source Note: The provisions of this §745.479 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.479 Will I need to post the written notice of my permit's renewal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204736 03/12/2026 (a) Your permit expires if:(1) You do not submit your renewal application during your renewal period or the late renewal period;(2) You submit your renewal application during the renewal period, you were notified that your application was incomplete, and you do not submit a completed renewal application before the end of the late renewal period; or(3) You submit your renewal application during the late renewal period, you were notified that your application was incomplete, and you do not submit a completed renewal application within 15 calendar days after notification.(b) If your permit does not expire under subsection (a) of this section, you may continue to operate while Licensing processes your renewal application, unless we determine the operation poses an immediate threat or danger to the health or safety of children, according to §745.751 of this chapter (relating to What factors does Licensing consider when determining if a person or operation is an immediate threat to the health or safety of children?). For how an enforcement action may affect your ability to renew your permit, see §745.485 of this division (relating to How does an enforcement action affect the renewal of my permit?). Source Note: The provisions of this §745.481 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.481 When does my permit expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204737 03/12/2026 If your permit expires, your operation must cease operating immediately. Before you can operate again, you will have to submit a new application as required by §745.243 of this chapter (relating to What does a completed application for a permit include?) and pay any necessary fees. Source Note: The provisions of this §745.483 adopted to be effective December 1, 2017, 41 TexReg 6082; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.483 What must I do if my permit expired? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204738 03/12/2026 (a) During the renewal period, or before your permit is renewed, your permit will be affected as stated in subsections (b) and (c) of this section if:(1) Your operation is presently under an enforcement action; or(2) We recommend or impose an enforcement action against your permit.(b) If we renew your permit while your operation is already on a voluntary plan of action or corrective action plan:(1) You must continue to meet any requirement related to the action taken. For example, if you are on a corrective action plan, you must continue to meet all conditions in the plan; and(2) Our renewal of your permit does not affect our ability to impose a more serious enforcement action if you do not follow the conditions of the voluntary plan of action or corrective action plan or your operation's compliance with minimum standards, rules, or statutes does not improve as a result of the plan.(c) The following table describes how certain enforcement actions affect our ability to renew your permit:Attached Graphic Source Note: The provisions of this §745.485 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.485 How does an enforcement action affect the renewal of my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204729 03/12/2026 (a) We must hold a public hearing to obtain public comments regarding the renewal of the license of a general residential operation that provides treatment services to children with emotional disorders, if the commissioner's court in the county in which the operation is located requests one.(b) The commissioner's court must submit its request to hold a hearing prior to Licensing renewing the operation's license. Source Note: The provisions of this §745.487 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.487 When is a public hearing required for the renewal of a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204730 03/12/2026 (a) For a public hearing related to the renewal of a license to operate a general residential operation that provides treatment services to children with emotional disorders:(1) A Licensing representative will facilitate the hearing;(2) A representative of the general residential operation that submitted the renewal application must attend the hearing;(3) 10 days prior to the scheduled public hearing, Licensing will send a notice of the public hearing to the commissioner's court and the general residential operation that submitted the renewal application and post it on the Licensing consumer website with the following information:(A) The name, address, and phone number of the Licensing representative who will facilitate the hearing;(B) The name and address of the general residential operation that submitted the renewal application;(C) The date, time, and location of the hearing;(D) A description of the population that the general residential operation currently serves, the services being provided (except for the provision of trafficking victim services), the number of children that the operation is currently licensed to serve, and the number of children the operation is currently serving; and(E) A statement that the public hearing is for Licensing to receive public comments regarding the renewal of the general residential operation's license; and(4) Licensing will provide written procedures that Licensing has adopted to provide the public with a reasonable opportunity to offer public comments on any issues related to the renewal of the general residential operation's license, including how the hearing will be conducted, order of witnesses, and the conduct of participants at the hearing.(b) During an active declaration of a state of disaster under Texas Government Code, Chapter 418, public hearings concerning an operation located in an area subject to the declaration of disaster may be held in a manner that allows remote participation. Source Note: The provisions of this §745.489 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.489 What is required for a public hearing for the renewal of a license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205230 03/12/2026 The following terms have the following meanings when used in this division:(1) Change in ownership--As stated in §745.437 of this chapter (relating to What is a change in ownership of an operation?). (2) Heightened monitoring--An increase in oversight of a residential child-care operation that has a pattern of deficiencies relating to minimum standard deficiencies weighted medium or higher, confirmed abuse or neglect findings, or Texas Department of Family and Protective Services (DFPS) contract violations. Heightened monitoring is mandated by a court order in the MD vs. Abbott litigation dated March 18, 2020. Source Note: The provisions of this §745.491 adopted to be effective June 13, 2021, 46 TexReg 3523. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.491 What do the following terms mean when used in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205231 03/12/2026 This division applies to an applicant for a general residential operation or child-placing agency license that demonstrates an intent to obtain a contract with:(1) the Texas Department of Family and Protective Services (DFPS) to provide care to children in the conservatorship of DFPS; or(2) a single source continuum contractor that contracts with DFPS to provide community-based care as described in Subchapter B-1, Chapter 264, Texas Family Code. Source Note: The provisions of this §745.493 adopted to be effective June 13, 2021, 46 TexReg 3523. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.493 Who does this division apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205228 03/12/2026 (a) When evaluating an application for a residential child-care license, Licensing must consider the previous five-year compliance history of a residential child-care operation that:(1) Is applying for a new license in a different location;(2) Is re-applying for a new license after voluntarily closing; or(3) Had a change in ownership; and(A) Any controlling person from the previous operation serves or intends to serve as a controlling person in the new operation; or(B) A new owner, including a sole proprietor, either partner of a partnership, or any member of the governing body of a corporation, is related to a controlling person of the previous operation by a third degree of consanguinity or second degree of affinity as defined in §745.21 of this chapter (relating to What do the following words and terms mean when used in this chapter?).(b) The five-year compliance history consideration required by this section must include and document information concerning a related residential child-care operation, including:(1) The number of abuse, neglect, or exploitation intakes in the previous five years;(2) The number of confirmed abuse, neglect, or exploitation findings in the previous five years;(3) The number of citations issued for corporal punishment in the previous five years; and(4) A narrative description of how this data and information was or will be considered.(c) The five-year compliance history consideration required by this section is a component of the application evaluation and must be completed prior to the on-site inspection related to the application for a new license.(d) The five-year compliance history collected under subsection (b) of this section may be considered in future extended compliance history reviews of a license granted pursuant to an application subject to subsection (a) of this section. Source Note: The provisions of this §745.495 adopted to be effective June 13, 2021, 46 TexReg 3523. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.495 What previous compliance history of a residential child-care operation must Licensing consider when evaluating an application for a license to operate a residential child-care operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205229 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205229&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205229 03/12/2026 (a) When issuing an initial license to a residential child-care operation that is on or otherwise meets the criteria for heightened monitoring and is applying for a new license in a different location, Licensing must include a condition on the license that the operation is on heightened monitoring.(b) When issuing an initial license to a residential child-care operation that was on heightened monitoring at the time of voluntary closure or otherwise met the criteria for heightened monitoring in the five years before voluntarily closing and reapplying for a new license at the same or a different location, Licensing must include a condition on the license that the operation is on heightened monitoring.(c) When issuing an initial license to a residential child-care operation that had a change in ownership while on heightened monitoring or otherwise met the criteria for heightened monitoring in the five years before the change in ownership, Licensing must include a condition on the license that the operation is on heightened monitoring if:(1) Any controlling person from the previous operation serves or intends to serve as a controlling person in the new operation; or(2) A new owner, including a sole proprietor, either partner of a partnership, or any member of the governing body of a corporation, is related to a controlling person of the previous operation by a third degree of consanguinity or second degree of affinity as defined in §745.21 of this chapter (relating to What do the following words and terms mean when used in this chapter?).(d) If an operation successfully completed heightened monitoring in the five years prior to the relocation, voluntary closure, or change of ownership, Licensing will not include a condition on the license that the operation is on heightened monitoring, unless the operation again met the criteria for heightened monitoring after successfully completing it.(e) When issuing an initial license to a residential child-care operation, if Licensing determines that the applicant has employed or intends to employ a substantial number of employees from a previous operation, Licensing as a condition of the license may include employee screening requirements or training requirements that must be met before employees may have contact with children.(f) The timeframes for an initial license in §745.347 of this chapter (relating to How long is an initial license valid?) may be extended for an initial license issued with conditions as described by this section. Source Note: The provisions of this §745.497 adopted to be effective June 13, 2021, 46 TexReg 3523. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING D APPLICATION PROCESS §745.497 May Licensing issue a new license to a residential child-care operation that was previously on heightened monitoring? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195839 03/12/2026 We may charge the following fees:(1) Fees for processing your application;(2) Fees for conducting your background checks;(3) Fees for issuing your initial license;(4) Fees for renewing your initial license;(5) Fees for issuing your non-expiring permit;(6) Annual fees for maintaining your permit; and(7) Fees for amending your permit. Source Note: The provisions of this §745.501 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.501 What type of fees may Licensing charge me? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195840 03/12/2026 (a) Certified or state-run operations are exempt from paying fees listed in §745.501 of this title (relating to What type of fees may Licensing charge me?).(b) A listed family home in which a relative child-care provider cares for the child(ren) in the child(ren)'s own home is exempt from paying fees listed in §745.501 of this title.(c) The following residential child-care operations must pay application fees but are exempt from all other fees listed in §745.501 of this title:(1) Independent foster family homes and foster group homes;(2) Nonprofit operations that provide residential child care for children in the managing conservatorship of DFPS during the 12-month period immediately preceding the anniversary date of the permit; and(3) Nonprofit operations that provide residential child care and do not charge for that care. Source Note: The provisions of this §745.503 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.503 Is anyone exempt from paying fees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195841 03/12/2026 (a) The following chart contains the fees required for listed family homes, when the fees are due, and the consequences for failure to pay the fees on time: Attached Graphic(b) The fees listed in subsection (a) of this section are waived for a person with a listing who only provides child care to a related child in the child's own home as approved by the Texas Workforce Commission's Listed Family Home Fee Waiver Authorization form. Source Note: The provisions of this §745.505 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.505 What fees must I pay to list my family home and maintain the listing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195842 03/12/2026 The following chart contains the fees required for registered child-care homes, when the fees are due, and the consequences for failure to pay the fees on time: Attached Graphic Source Note: The provisions of this §745.507 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 16, 2003, 28 TexReg 7999; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.507 What fees must I pay to register my child-care home and maintain the registration? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195843 03/12/2026 The following chart contains fees required for licenses (including child day-care and residential child-care operations, and child-placing agencies), when the fees are due, and the consequences for failure to pay the fees on time: Attached Graphic Source Note: The provisions of this §745.509 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective June 1, 2008, 33 TexReg 4190; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective December 1, 2012, 37 TexReg 9127; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.509 What fees must I pay to apply for and maintain a license for an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195844 03/12/2026 Yes, you must pay a fee for each license, even if the separate licenses are at the same location. Source Note: The provisions of this §745.511 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.511 Must I pay fees for more than one license if I have separate licenses for different types of operations? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195845 03/12/2026 We base your fees on the highest capacity. Source Note: The provisions of this §745.513 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.513 If my license allows for different capacities at different times of the day, how does Licensing determine my fees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195846 03/12/2026 Yes, before the due date we will send you a notice that your fees are due along with a Child Care Fee Schedule Form and a return envelope. Source Note: The provisions of this §745.515 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.515 Will I receive notice telling me when my non-expiring and annual fees are due? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195847 03/12/2026 You must send a cashier's check, corporate check, money order, or certified check made payable to the Texas Department of Protective and Regulatory Services along with a Child Care Fee Schedule Form. Mail the fee information to the Texas Department of Protective and Regulatory Services, Accounting Division E-672, P.O. Box 149030, Austin, Texas 78714-9030. This also applies to background checks. Source Note: The provisions of this §745.517 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.517 How do I submit a fee to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195848 03/12/2026 The following fees are refundable under the conditions noted:(1) We refund the application fee if the issuance of the permit was late without good cause and the applicant requests the refund;(2) We refund the initial license fee if the application is withdrawn, or the license is not issued;(3) We refund the non-expiring license fee if the initial license expires without the non-expiring license being issued; and(4) We refund the amendment fee if the amendment is not issued. Source Note: The provisions of this §745.519 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.519 Are any fees refundable? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195849 03/12/2026 The following chart contains fees required for your employer-based child care, when the fees are due, and the consequences for failure to pay on time: Attached Graphic Source Note: The provisions of this §745.521 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.521 What fees must I pay to apply for and to maintain a certificate of compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195850 03/12/2026 You must submit background checks on the persons, as applicable, and within the timeframes as required for a licensed child-care center in Subchapter F of this chapter (relating to Background Checks). Source Note: The provisions of this §745.523 adopted to be effective March 1, 2008, 33 TexReg 1367; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING E FEES §745.523 Who must I submit background checks on, and when must they be submitted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205739 03/12/2026 These words have the following meanings:(1) CBCU--The Centralized Background Check Unit is a subdivision of Licensing that conducts background checks and risk evaluations.(2) Central Registry--A Texas Department of Family and Protective Services (DFPS) database of persons who have been found by Licensing or an investigations division within DFPS to have abused or neglected a child.(3) Client in care--A child, young adult, or adult in the care of your operation, including foster children or young adults for whom your operation is receiving foster care payments, adults in care through the Health and Human Services System, court-ordered placements, and kinship care. A biological or adopted child is not a client in care.(4) Criminal history--Includes arrests, dispositions, and deferred adjudication community supervision. Criminal history does not include expunged criminal history or non-disclosure history. It does not include juvenile history, although the CBCU may determine that the subject of a background check poses an immediate threat or danger to the health or safety of children based on a juvenile adjudication that the CBCU receives with the subject's criminal history.(5) Days--Calendar days.(6) Designated finding--A finding in the Central Registry against a person (also known as a designated perpetrator) who has not exhausted the person's due process rights, including an administrative review, a due process hearing, and any subsequent rights of appeal. See Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings).(7) DFPS--Texas Department of Family and Protective Services.(8) DPS--Texas Department of Public Safety.(9) Direct access--Being counted in the child to caregiver ratio or having any responsibility that requires contact with children in care.(10) FBI--Federal Bureau of Investigation.(11) HHSC--Texas Health and Human Services Commission.(12) Initial background check--The first background check that your operation submits for a person required to have a background check, as specified in §745.605 of this subchapter (relating to For whom must I submit requests for background checks?).(13) Licensing--The Child Care Regulation department of HHSC.(14) National Sex Offender Registry--A National Crime Information Center file that contains records on persons who are required to register in a jurisdiction's sex offender registry.(15) Present at an operation--A person is present at an operation if the person has or may have contact with children in care as follows:(A) The person is physically present at an operation while any child is in care, unless the person is present for the sole purpose of attending orientation or pre-service training and does not have contact with children in care;(B) The person has responsibilities that may require the person to be present at an operation while any child is in care;(C) The person resides at an operation or is present at an operation on a regular or frequent basis; or(D) The person has direct access to any child in care, including supervised or unsupervised direct access to any child.(16) Regularly or frequently present at an operation--The definition means:(A) A person is regularly or frequently present at an operation if the person:(i) Is present at an operation on a scheduled basis;(ii) Visits the operation three or more times in a 30-day period, with each visit being a period of time of less than 24 hours, and with multiple or periodic visits to an operation within the same day counting as one visit;(iii) Stays or resides at the operation for more than seven consecutive days; or(iv) Stays or resides at the operation three or more times per year, and the duration of each stay exceeds 48 hours.(B) For foster homes, the following persons are not considered to be regularly or frequently present at a foster home:(i) A child unrelated to a foster parent who visits the foster home unless:(I) The child is responsible for the care of a foster child; or(II) There is a reason to believe that the child has a criminal history or previously abused or neglected a child; and(ii) An adult unrelated to a foster parent who visits the foster home unless:(I) The adult has unsupervised access to children in care; or(II) There is a reason to believe that the adult has a criminal history or previously abused or neglected a child.(C) For a child day-care operation, parents are not regularly or frequently present at an operation solely because they are visiting their child, which may include dropping off or picking up their child, eating lunch with their child, visiting or observing their child, or consoling their child. However, a parent may be regularly or frequently present at an operation if he or she volunteers at an operation or is otherwise present at an operation for a reason other than visiting his or her child.(17) Renewal background check--A subsequent background check that your operation submits for a person who has already had an initial background check at your operation as specified in §745.605 of this subchapter.(18) Risk evaluation--A process conducted by the CBCU that is initiated by the subject of a background check with a criminal history or child abuse and neglect history. During this process the CBCU reviews information and determines whether the subject with a criminal conviction or child abuse or neglect finding or the subject who has been arrested or charged with a crime poses a risk to the health or safety of children in a particular operation.(19) Subject or subject of a background check--A person on whom the operation submits a request for a background check.(20) Substitute employee--A person present at an operation usually for the purpose of fulfilling an absent employee or caregiver role.(21) Sustained finding--A finding in the Central Registry against a person who has already been offered due process rights to an administrative review and a due process hearing, and:(A) The person has waived all of the person's due process rights by not timely requesting an administrative review and a due process hearing or by waiving those rights in writing as specified in §745.8817 of this chapter (relating to Can I waive my right to an administrative review?) and §745.8855 of this chapter (relating to Can I waive my right to a due process hearing?); or(B) The child abuse or neglect finding was upheld in the due process hearing and any subsequent appeals.(22) Unsupervised access--The person is allowed to be with children without the presence of a caregiver that is counted in the child to caregiver ratio and meets the minimum education requirements, work experience, training qualifications, and background check requirements. Source Note: The provisions of this §745.601 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective June 1, 2008, 33 TexReg 4190; amended to be effective June 1, 2010, 35 TexReg 4184; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective March 1, 2014, 39 TexReg 1182; amended to be effective March 1, 2015, 40 TexReg 834; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective August 30, 2021, 46 TexReg 4854. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.601 What words must I know to understand this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195852 03/12/2026 (a) You must submit a request for a background check for:(1) The owner of the operation, including:(A) A sole proprietor;(B) Each partner in a partnership; and(C) A board member or an officer of a governing body who is involved in the everyday management of the operation, including participating in the development of policies that address the Licensing requirements or the everyday running of the operation, or submitting requests for background checks for the operation;(2) Each person employed or prospectively employed at the operation, including:(A) All directors and administrators of the operation; and(B) Substitutes, unless you confirm that the organization providing the substitute has:(i) Submitted a request for a background check for the substitute through the CBCU within the last five years; and(ii) You have a copy of the background check determination that allows the substitute to be present at an operation;(3) Each current or prospective foster parent providing foster care through a child-placing agency;(4) Each prospective adoptive parent seeking to adopt through a child-placing agency;(5) Each person 14 years of age or older, including a contract employee, self-employed person, or volunteer who:(A) Is counted in the child/caregiver ratio in accordance with the relevant minimum standards, unless the person is a parent or volunteer as described in subsection (b)(2) of this section;(B) Has unsupervised access to children in care; or(C) Provides direct care or supervision to children in care;(6) Each person 14 years of age or older who:(A) Resides in the operation; or(B) Will reside in a prospective adoptive home if the adoption is through a child-placing agency; and(7) Each person 14 years of age or older, including a volunteer, who is regularly or frequently present at an operation or prospective adoptive home.(b) You do not have to submit a request for a background check on:(1) A client in care;(2) A parent or volunteer who only supplements the child-caregiver ratio for a field trip or water activity;(3) A professional who is licensed or is required to have a background check to meet compliance with another governmental entity's requirements, so long as:(A) You do not employ or contract with the professional;(B) The professional will only be present at an operation in an official capacity; and(C) For day care operations, you obtain written parental consent before allowing the professional to have unsupervised access to a child in care; and(4) Controlling persons who do not fulfill a role specified in subsection (a) of this section, such as a board member of a corporation or association that owns or governs the operation. Source Note: The provisions of this §745.605 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.605 For whom must I submit requests for background checks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205740 03/12/2026 The different types of background checks are described in the following table:Attached Graphic Source Note: The provisions of this §745.607 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective August 30, 2021, 46 TexReg 4854. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.607 What are the different types of background checks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209681 03/12/2026 (a) Except as described in subsection (b) of this section, persons required to have a background check under §745.605 of this division (relating to For whom must I submit requests for background checks?) must have the following types of background checks:(1) As further described in §745.611 of this division (relating to Which persons at my operation require either a fingerprint-based criminal history check or a name-based Texas criminal history check?), either a:(A) Fingerprint-based criminal history check; or(B) Name-based Texas criminal history check;(2) A Central Registry check;(3) If your operation is a child day-care operation that is not an employer-based child care operation or a shelter care operation, a National Sex Offender Registry check for persons who require a fingerprint-based criminal history check under §745.611(a)(1) of this division; and(4) As further described in §745.613 of this division (relating to Which persons at my operation must have an out-of-state criminal history check, an out-of-state child abuse and neglect registry check, and an out-of-state sex offender registry check?), for certain persons, an:(A) Out-of-state criminal history check;(B) Out-of-state child abuse and neglect registry check; and(C) Out-of-state sex offender registry check.(b) This rule does not apply to listed family homes that only provide care to related children. See §745.615 of this division (relating to What types of background checks are required for persons at listed family homes that only provide care to related children?). Source Note: The provisions of this §745.609 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective August 30, 2021, 46 TexReg 4854; amended to be effective July 26, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.609 What types of background checks are required for persons at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209682 03/12/2026 (a) Except as described in subsections (b) and (c) of this section, a person required to have a background check under:(1) §745.605(a)(1) - (6) of this division (relating to For whom must I submit requests for background checks?) must have a fingerprint-based criminal history check; or(2) §745.605(a)(7) of this division is only required to have a name-based Texas criminal history check, except the person must have a fingerprint-based criminal history check if:(A) The person has resided outside of Texas any time during the five-year period prior to the date you submit a request for a background check; or(B) There is reason to believe the person has criminal history in another state.(b) A person who is present at the operation to complete a skills practicum or receive observation requires a check described in subsection (a)(2) of this section if:(1) The skills practicum or observation is a requirement for a high school or college child-care related course that the person is enrolled in at an accredited high school, college, or university;(2) The person is paired with one or more qualified caregivers, one of whom must always be present when the person interacts with children or observes children; and(3) The person is only present at the operation in order to fulfill the course requirement and not in any role that would require a fingerprint-based check. For example, the operation may not use the person to meet child-caregiver ratios.(c) This rule does not apply to listed family homes that only provide care to related children. See §745.615 of this division (relating to What types of background checks are required for persons at listed family homes that only provide care to related children?). Source Note: The provisions of this §745.611 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective July 26, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.611 Which persons at my operation require either a fingerprint-based criminal history check or a name-based Texas criminal history check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209683 03/12/2026 (a) Except as described in subsections (d) and (e) of this section, a person required to have a background check under §745.605 of this division (relating to For whom must I submit requests for background checks?) must have an out-of-state criminal history check, an out-of-state abuse and neglect registry check, and an out-of-state sex offender registry check:(1) In each state where the person resided during the preceding five-year period, if the person has lived outside of Texas any time during the five-year period prior to the date you submit a request for a background check; or(2) In each state where there is reason to believe the person has criminal history, has a child abuse or neglect history, or is registered as a sex offender.(b) The out-of-state criminal history check must be a fingerprint-based criminal history check if the person currently resides in a state outside of Texas but is employed at an operation regulated by Licensing.(c) The CBCU will inform a person when the person requires any out-of-state checks. The person must ensure that the person's own out-of-state criminal history check and out-of-state child abuse and neglect registry check are provided to the CBCU. The CBCU will conduct the person's out-of-state sex offender registry check.(d) A person does not have to have an out-of-state criminal history check if:(1) The operation submitting the request for a background check is a residential child-care operation, including a child-placing agency, agency foster home, or general residential operation; or(2) The state where the person resided during the preceding five-year period is participating in the FBI's National Fingerprint File (NFF) program.(e) This rule does not apply to listed family homes that only provide care to related children, employer-based child care operations, and shelter care operations. Source Note: The provisions of this §745.613 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective July 26, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.613 Which persons at my operation must have an out-of-state criminal history check, an out-of-state child abuse and neglect registry check, and an out-of-state sex offender registry check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209684 03/12/2026 For listed family homes that only provide care to related children, persons required to have a background check under §745.605 of this division (relating to For whom must I submit requests for background checks?) must have the following types of background checks:(1) A name-based Texas criminal history check with a Texas sex offender registry check, except the person must have a fingerprint-based criminal history check if:(A) The person has resided outside of Texas any time during the five-year period prior to the date you submit a request for a background check; or(B) There is reason to believe the person has criminal history in another state; and(2) A Central Registry check. Source Note: The provisions of this §745.615 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective July 26, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.615 What types of background checks are required for persons at listed family homes that only provide care to related children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209685 03/12/2026 (a) The process for submitting a request for a background check depends on the type of operation submitting the request:Attached Graphic(b) You do not have to submit a request for a background check for a person who requires a background check under this subchapter because of the person's responsibilities as a Texas Department of Family and Protective Services (DFPS) or Licensing employee or volunteer. The person will have a background check conducted by DFPS or the Texas Health and Human Services Commission as part of the person's application to become an employee or volunteer. Source Note: The provisions of this §745.617 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective July 26, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.617 How do I submit a request for a background check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195859 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195859 03/12/2026 You must verify and send the following information to the CBCU for every person required to have a background check under §745.605 of this division (relating to For whom must I submit requests for background checks?):(1) Name (first, middle, and last), including any maiden or married names or aliases;(2) Social security number, if one exists;(3) Driver's license or a state issued identification card number;(4) Date of birth;(5) Sex;(6) Ethnicity and race (this information does not have to be verified);(7) Current and previous addresses in Texas;(8) The city and state of each residence where the person has lived outside of the state of Texas any time during the five-year period prior to the date you submit a request for a background check;(9) An e-mail address for the person, if available; and(10) The role of the person at the operation, including:(A) The person's title and job duties;(B) Whether the person will be supervised by a caregiver counted in the child/caregiver ratio; and(C) The ages of children the person will be caring for. Source Note: The provisions of this §745.619 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.619 What information must I include with a request for a background check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195860 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195860 03/12/2026 (a) You must submit a request for an initial background check for each person required to have a background check under §745.605 of this division (relating to For whom must I submit requests for background checks?):(1) When you submit your application for a permit to us;(2) When you hire someone;(3) When you contract with someone who requires a background check;(4) When a person applies to be a foster or adoptive parent;(5) When a resident 14 years or older moves into your home or operation;(6) Between 90 days before and 90 days after a resident living in your home or operation becomes 14 years old; and(7) When you become aware of anyone requiring a background check under §745.605 of this division, on whom you have not previously submitted a request for a background check.(b) You must submit a request for a renewal background check for each person required to have a background check under §745.605 of this division:(1) No later than:(A) Five years from the date you last submitted a request for an initial or renewal background check on the subject of a background check who had a fingerprint-based criminal history check; or(B) Two years from the date you last submitted a request for an initial or renewal background check on the subject of a background check who only had a name-based Texas criminal history check;(2) When you become aware that the subject of a background check has had a change in the subject's state of residence; and(3) When there is a change in the subject's role at the operation that requires the person to have a fingerprint-based criminal history check instead of a previously conducted name-based Texas criminal history check. Source Note: The provisions of this §745.621 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.621 When must I submit a request for an initial or renewal background check for a person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195861 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195861 03/12/2026 After you submit a request for an initial or renewal background check to the CBCU for a person required to have a fingerprint-based criminal history check, the CBCU will send the subject of the background check a notification with information on how to schedule an appointment to submit fingerprints with the DPS approved fingerprinting vendor. Source Note: The provisions of this §745.623 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.623 How does the subject of a background check submit fingerprints for a fingerprint-based criminal history check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195862 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195862 03/12/2026 (a) When you submit a request for a background check for a subject who has previously undergone a fingerprint-based criminal history check, the CBCU will determine whether the previous fingerprint-based criminal history check remains valid or whether the subject must resubmit fingerprints for a new fingerprint-based criminal history check.(b) A previously completed fingerprint-based criminal history check remains valid, and Licensing will waive the requirement to submit new fingerprints, if Licensing has an active subscription or can reactivate a subscription to the FBI's national rap back service for the subject. Source Note: The provisions of this §745.625 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.625 Does the subject of a background check who has already undergone a fingerprint-based criminal history check have to submit new fingerprints? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195863 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195863 03/12/2026 The CBCU will notify the subject of a background check and the operation with a written determination of the background check as soon as possible, but no later than 45 days from the date the background check was submitted. Source Note: The provisions of this §745.627 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.627 How soon will the CBCU notify the subject of a background check and me of the determination of the background check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195864 03/12/2026 There are four possible determinations regarding a background check: Attached Graphic Source Note: The provisions of this §745.629 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.629 What are the possible determinations for the subject of a background check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195865 03/12/2026 The CBCU may place conditions or restrictions on a subject's presence at an operation that the CBCU determines to be necessary to protect the health or safety of children, including in the following situations:(1) While the subject's out-of-state criminal history check or out-of-state child abuse or neglect registry check is pending, if applicable, and the CBCU has not received information that renders the subject ineligible to be present at an operation;(2) Pending the outcome of a risk evaluation for an eligible criminal conviction, child abuse and neglect finding, or crime for which the subject has been arrested or charged;(3) For an approved risk evaluation; or(4) For a minimum standard violation that is relevant to a condition or restriction already placed on a subject's presence at an operation. Source Note: The provisions of this §745.631 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.631 In what situations may the CBCU place conditions or restrictions on a subject's presence at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195866 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195866 03/12/2026 (a) After the operation submits a request for a background check, the notice letter that the CBCU sends to an operation regarding the subject of a background check will include the following information:(1) A determination of whether the subject may be present at an operation, as defined in §745.629 of this division (relating to What are the possible determinations for the subject of a background check?);(2) Any conditions or restrictions placed on the subject's presence at an operation, if applicable; and(3) A list of each additional operation that has submitted a request for a background check on the subject and when the operation submitted the request.(b) If a child-placing agency submitted a request for a background check because of the subject's association with a current or prospective foster or adoptive home, the notice letter to the child-placing agency will also include:(1) The sources of information that were used for the background check, as specified in §745.607 of this subchapter (relating to What are the different types of background checks?);(2) Any criminal history obtained on the subject, if applicable;(3) Any sustained Central Registry finding listed in §745.671 of this subchapter (relating to What types of findings from the Central Registry or out-of-state child abuse and neglect registries may affect a subject's ability to be present at an operation?), if applicable;(4) Whether the subject is eligible to request a risk evaluation, if applicable, and whether the subject may be present at your operation pending the outcome of the risk evaluation; and(5) Any Central Registry finding of child abuse or neglect that is not sustained, if the CBCU has determined the subject is ineligible to be present at the operation. The notification letter will inform you that this subject has not exhausted the subject's due process regarding this matter and that you must immediately remove the subject from being present at the operation. The CBCU will subsequently notify you of any future determination regarding this matter that affects the subject's ability to be present at the operation. Source Note: The provisions of this §745.633 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.633 What information will a notice letter that the CBCU sends to an operation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195867 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195867 03/12/2026 If the subject's determination is:(1) Eligible, you do not need to take any further action;(2) Ineligible, you must immediately remove the subject from being present at your operation and confirm to the CBCU the receipt of the CBCU notice letter; or(3) Provisionally eligible with conditions or eligible with conditions, you must restrict the subject's duties in a manner that follows the conditions, restrictions, or both that the CBCU has placed on the subject's presence at your operation. Source Note: The provisions of this §745.635 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.635 What must I do after the CBCU notifies my operation of a subject's background check determination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195868 03/12/2026 If you do not follow each of the conditions or restrictions that the CBCU has placed on a subject's presence at an operation or there is a minimum standard violation that is relevant to a condition or restriction already placed on the subject's presence at your operation, then Licensing may take any of the following actions:(1) The CBCU may amend the conditions or restrictions that the CBCU has placed on the subject's presence at your operation;(2) The CBCU may rescind the approved risk evaluation decision; and(3) Licensing may take an enforcement action against you. Source Note: The provisions of this §745.637 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.637 What actions may Licensing take if I do not follow the conditions or restrictions on a subject's presence at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195869 03/12/2026 After the operation submits a request for a background check, the notice letter that the CBCU sends to the subject of a background check will include the following information, as applicable:(1) The sources of information that were used for the background check, as specified in §745.607 of this subchapter (relating to What are the different types of background checks);(2) Whether the CBCU needs any additional information to complete the background check and when the information is due;(3) Any criminal history obtained on the subject;(4) Any sustained Central Registry finding listed in §745.671 of this subchapter (relating to What types of findings from the Central Registry or out-of-state child abuse and neglect registries may affect a subject's ability to be present at an operation?);(5) Whether the subject is eligible to request a risk evaluation and may be present at an operation pending the outcome of the risk evaluation;(6) A determination of whether the subject may be present at an operation, as defined in §745.629 of this division (relating to What are the possible determinations for the subject of a background check?);(7) Any conditions or restrictions placed on the subject's presence at an operation;(8) Any Central Registry finding of child abuse or neglect that is not sustained, and when the CBCU has determined the presence of the subject at an operation:(A) Does not pose an immediate threat or danger to the health or safety of children, the notification letter will also state:(i) That the subject is provisionally eligible with conditions to be present at the operation;(ii) That the subject may request a hearing before the State Office of Administrative Hearings (SOAH); and(iii) Whether the subject is entitled to a risk evaluation regarding the finding pending a hearing before SOAH; or(B) Poses an immediate threat or danger to the health or safety of children, the notification letter will also state that the subject:(i) Is ineligible to be present at the operation; and(ii) May request a hearing before SOAH; and(9) Information on where to obtain instructions on how to challenge the accuracy or completeness of the results of the background check, including results from other agencies, and how to request a review of the background check determination. Source Note: The provisions of this §745.639 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.639 What information will a notice letter that the CBCU sends to the subject of a background check include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195870 03/12/2026 You must receive notification from the CBCU that the subject of a background check is eligible, eligible with conditions, or provisionally eligible with conditions before allowing the subject to be present at your operation. However, pending the eligibility determination, the subject may be present at an operation for the sole purpose of attending orientation or pre-service training, as long as the subject does not have contact with children in care. Source Note: The provisions of this §745.641 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.641 How soon after I submit a request for a background check on a subject can that subject be present at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195871 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195871&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195871 03/12/2026 To challenge the accuracy or completeness of the information contained in the results of the background check:(1) The subject should first work with the CBCU representative that made the background check determination to provide updated disposition information or additional documentation; and(2) If the subject is unable to resolve the issue in this manner, then the subject may seek resolution of the issue from the agency that provided the results upon which the CBCU background check determination was made. Source Note: The provisions of this §745.643 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.643 How can the subject of a background check challenge the accuracy or completeness of the information contained in the results of the background check? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195872 03/12/2026 (a) The subject may request that the CBCU review the background check determination, if the subject:(1) Disagrees with the determination; or(2) Has new information that was not available at the time of the determination.(b) The subject of a background check may request that the CBCU review the background check determination:(1) Within 30 days from the date on the notice letter from the CBCU that informs the subject of the determination; or(2) Anytime the subject can provide new information that was not available at the time of the determination.(c) The request for the CBCU to review the background check determination must:(1) Be in writing;(2) Be addressed to the CBCU staff member that issued the determination;(3) Include:(A) The subject's name;(B) The date the CBCU issued the background check determination;(C) The reason the subject disagrees with the background check determination, if applicable; and(D) Any new information that was not available at the time of the determination, if applicable; and(4) Be sent by e-mail, regular mail, or fax to the specified address or fax number.(d) The CBCU has 30 days to provide the subject with a written response regarding the review of the background check determination. The CBCU may extend the 30-day time period for good cause.(e) While conducting the review, the CBCU will consider any reason the subject disagrees with the background check determination, any new information provided, and whether the rules in this subchapter were followed. During a review, the CBCU will have a limited ability to look at issues of accuracy and completeness, because the CBCU does not have control over the background check results from other agencies. As much as possible, subjects should resolve those issues with the agency that provided the results upon which the background check determination was made, see §745.643 of this division (relating to How can the subject of a background check challenge the accuracy or completeness of the information contained in the results of the background check?).(f) If the subject disagrees with the CBCU's review determination, the subject may request that the Director of the CBCU review the accuracy of the CBCU's determination. The CBCU Director may conduct this review or assign the review to a designee that was not previously involved in the background check determination. The determination by the CBCU Director or designee is final. Source Note: The provisions of this §745.645 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.645 How can the subject request that the CBCU review the background check determination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195873 03/12/2026 (a) If you are applying to operate a licensed child-care home, a registered child-care home, or a listed family home, the CBCU must determine that all household members who must have a background check under §745.605 of this subchapter (relating to For whom must I submit requests for background checks?) are eligible or eligible with conditions before Licensing may issue you a permit.(b) Except as described in subsection (a) of this section, Licensing may issue a permit to an applicant after the CBCU has determined that any owner who must have a background check under §745.605(a)(1) of this subchapter is eligible or eligible with conditions. Source Note: The provisions of this §745.647 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.647 Must the CBCU complete the background checks before Licensing issues my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195874 03/12/2026 No, a CPA must receive background check determinations from the CBCU indicating that all household members of a foster family home or adoptive home who must have a background check under §745.605 of this subchapter (relating to For whom must I submit requests for background checks?) are eligible or eligible with conditions before the CPA may verify the foster family home or approve the adoptive home. Source Note: The provisions of this §745.649 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.649 Can a child-placing agency (CPA) verify a foster family home or approve an adoptive home prior to receiving the background check determinations? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195875 03/12/2026 Yes, you must indicate that the subject of a background check is no longer associated with your operation by:(1) Inactivating the subject within seven days of when the subject is no longer associated with your operation; and(2) Validating your current list of subjects associated with your operation:(A) Every three months through your:(i) Licensing account for all operations except licensed child-care homes, registered child-care homes, listed family homes, employer-based child care, and shelter care operations; and(ii) Licensing account or local Licensing office for employer-based child care and shelter care operations; and(B) Once a year through your:(i) Licensing account for licensed child-care homes and registered child-care homes; and(ii) Licensing account or local Licensing office for listed family homes. Source Note: The provisions of this §745.651 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.651 Am I required to indicate when the subject of a background check is no longer associated with my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195876 03/12/2026 Yes, but any background checks you conduct on your own will not replace the requirement to complete background checks through the CBCU. You must still complete the background check requirements in this subchapter. Source Note: The provisions of this §745.653 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.653 Can I do my own criminal history background checks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195877 03/12/2026 (a) A felony or misdemeanor conviction under Texas law, the laws of another state, or federal law may affect a subject's ability to be present at an operation. There are three charts with information regarding specific crimes that may affect a subject's ability to be present at an operation. Each chart specifies whether a conviction permanently or temporarily bars a subject from being present at an operation, whether a subject is eligible for a risk evaluation, and whether a subject who is eligible for a risk evaluation may be present at an operation pending the outcome of the risk evaluation. The three charts are: (1) Licensed or Certified Child Care Operations: Criminal History Requirements; (2) Foster or Adoptive Placements: Criminal History Requirements; and (3) Registered Child Care Homes and Listed Family Homes: Criminal History Requirements. (b) HHSC will review the three charts listed in subsection (a) of this section annually to determine whether any changes are needed. HHSC will publish any changes in January as an "In Addition" document in the Texas Register and make them available on the Licensing public website. A written public comment period will be available for 30 days following publication. HHSC will consider any written comments HHSC receives during the 30-day time period, and provide a response to the commenter that will also be included on the Licensing public website. In response to any comment, HHSC may implement changes to a chart, withdraw changes to a chart, or alter a chart based on a reasoned justification. If HHSC changes a chart, HHSC will subsequently re-publish the chart in the "In Addition" section of the Texas Register. (c) A subject currently on parole for a felony offense must have an approved risk evaluation prior to being present at an operation. (d) For any felony offense that is not specifically enumerated in the relevant chart listed in subsection (a) of this section, a subject convicted within the past 10 years for the offense must have an approved risk evaluation prior to being present at an operation. (e) Substantially similar federal offenses and offenses in other states will be treated the same as the similar Texas offense. On a case-by-case basis, HHSC will determine whether a federal offense or an offense in another state is substantially similar to a Texas offense by comparing the legal elements of each offense, including the mens rea (meaning the state of mind of the person, i.e., an intentional, knowing, or reckless act), and assessing the similarity of the legal elements. (f) This rule does not apply to a person who requires a background check under this subchapter because of the person's responsibilities as a DFPS or Licensing employee or volunteer. The person will have a background check conducted by DFPS or HHSC as part of the person's application to become an employee or volunteer. Source Note: The provisions of this §745.661 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.661 What types of criminal convictions may affect a subject's ability to be present at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195878 03/12/2026 For an offense that may affect a subject's ability to be present at an operation, deferred adjudication community supervision is a criminal conviction as follows: Attached Graphic Source Note: The provisions of this §745.663 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.663 For the purpose of this subchapter, when do criminal convictions include deferred adjudication community supervision? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195879 03/12/2026 If you have knowledge that the subject of a background check at your operation has been arrested or charged with a crime, you must report this information to Licensing immediately. The subject may be present at the operation unless the CBCU notifies you that the subject is ineligible to be present at the operation. Source Note: The provisions of this §745.665 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.665 What must I do if the subject of a background check at my operation has been arrested or charged with a crime? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195880 03/12/2026 (a) A subject who has been arrested or charged with a crime may not be present at an operation if:(1) A conviction for the arrest or charged offense would:(A) Bar the subject from being present at an operation permanently or on a time-limited basis; or(B) Prohibit the subject from being present at an operation pending the outcome of a risk evaluation; or(2) The CBCU determines that the subject poses an immediate threat to the health or safety of children.(b) If a subject has been arrested or charged with a crime, the CBCU may place conditions or restrictions on the subject's presence at an operation as the CBCU finds necessary to protect the health or safety of children:(1) If a conviction for the arrest or charged offense would not:(A) Bar the subject from being present at an operation permanently or on a time-limited basis; or(B) Prohibit the subject from being present at an operation pending the outcome of a risk evaluation; and(2) The CBCU does not determine that the subject poses an immediate threat to the health or safety of children.(c) The determination of whether the subject arrested or charged with a crime may be present at an operation and any condition or restriction placed on a subject's presence at an operation are temporary pending the final outcome of the alleged crime (i.e., charges never filed, dismissal, conviction, or acquittal). Once there is a final outcome to the alleged crime, the CBCU will determine whether the subject may be present at an operation based on criteria in §745.661 of this division (relating to What types of criminal convictions may affect a subject's ability to be present at an operation?) and other relevant rules in this subchapter. Source Note: The provisions of this §745.667 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.667 How will the CBCU determine whether a subject who has been arrested or charged with a crime may be present at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205742 03/12/2026 No, a subject who is registered or required to register as a sex offender with the Texas Sex Offender Registry, an out-of-state sex offender registry, or the National Sex Offender Registry may not be present at an operation. Source Note: The provisions of this §745.669 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective August 30, 2021, 46 TexReg 4854. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.669 Will a subject who is registered or required to register with the Texas Sex Offender Registry, an out-of-state sex offender registry, or the National Sex Offender Registry be allowed to be present at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195882 03/12/2026 (a) The following chart lists the types of findings from the Central Registry and out-of-state child abuse and neglect registries that may affect a subject's ability to be present at an operation. The chart specifies whether a subject with a finding is barred from being present at an operation or is eligible for a risk evaluation, and whether a subject eligible for a risk evaluation may be present at an operation pending the outcome of the risk evaluation: Attached Graphic(b) A subject who requires a background check under this subchapter in relation to a current or prospective foster or adoptive home is eligible for a risk evaluation for a sustained finding of physical abuse, if: (1) It has been more than five years since the date of the physical abuse finding; and (2) The prospective foster or adoptive parent is related to or has a significant longstanding relationship with the foster or adoptive child. (c) This rule does not apply to a person who requires a background check under this subchapter because of the person's responsibilities as a DFPS or Licensing employee or volunteer. The person will have a background check conducted by DFPS or HHSC as part of the person's application to become an employee or volunteer. Source Note: The provisions of this §745.671 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.671 What types of findings from the Central Registry or out-of-state child abuse and neglect registries may affect a subject's ability to be present at an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195883 03/12/2026 If you have knowledge that DFPS or a similar agency in another state is conducting an investigation of child abuse or neglect on the subject of a background check at your operation, you must report this information to Licensing immediately. The subject under investigation may be present at your operation unless the CBCU notifies you that the subject is ineligible to be present at the operation. Source Note: The provisions of this §745.673 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.673 What must I do if the subject of a background check at my operation is under investigation for child abuse or neglect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195884 03/12/2026 The subject of a background check must request the risk evaluation. Source Note: The provisions of this §745.681 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.681 Who is responsible for requesting a risk evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195885 03/12/2026 After an operation has submitted a request for a background check, the subject of a background check may request a risk evaluation when the CBCU has provided the subject with written notice that the subject is eligible for a risk evaluation for a criminal conviction, child abuse or neglect finding, or crime for which the subject has been arrested or charged. Source Note: The provisions of this §745.683 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.683 When may the subject of a background check request a risk evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195886 03/12/2026 The subject of a background check must submit a request for a risk evaluation within 30 calendar days from when the operation requested the background check. The CBCU will provide in a notice letter the due date by which the subject may request a risk evaluation. Source Note: The provisions of this §745.685 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.685 How long does the subject of a background check have to request a risk evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195887 03/12/2026 The subject of a background check must submit a completed risk evaluation packet to the CBCU by e-mail, regular mail, or fax to the specified address or fax number. The risk evaluation packet must include the completed risk evaluation request form and all required supporting documentation, as specified in §745.689 of this division (relating to What must a request for a risk evaluation based on criminal history include?) or §745.691 of this division (relating to What must a request for a risk evaluation based on a child abuse or neglect finding include?). Source Note: The provisions of this §745.687 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.687 How does the subject of a background check request a risk evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195888 03/12/2026 The subject of a background check must include the following in a request for a risk evaluation based on criminal history:(1) A completed Form 2974, Request for Risk Evaluation Based on Past Criminal History or Child Abuse or Neglect Findings;(2) A copy of the police report regarding the circumstances of the arrest;(3) An official copy of the final record of judicial finding or conviction (signed by a judge and file stamped);(4) If the subject was incarcerated:(A) A copy of local, state, or federal release order;(B) The date the subject was released from incarceration; and(C) If applicable, the terms and conditions of parole;(5) If the subject was given a probated sentence (including deferred adjudication community supervision), the dates of the probation and information related to the terms and conditions of the probation, including documentation regarding whether or not the subject successfully completed the terms of probation and paid all court costs, supervision fees, and court-ordered restitution and fines. If the subject is presently on probation, a statement from the subject's probation officer regarding the status of the subject's probation;(6) Age of the subject at the time the crime was committed;(7) A detailed, signed statement from the subject regarding the nature and seriousness of the crime for which the subject was arrested, charged, or convicted, including:(A) Why the subject was arrested;(B) Where the subject was when arrested;(C) Who else was involved in the criminal incident;(D) Whether anyone was injured;(E) The extent and nature of other arrests within the subject's past criminal history;(F) What has changed for this subject since the time of the arrest; and(G) Why the subject does not feel that he or she poses a risk to children in care;(8) Any evidence of rehabilitative effort, such as a copy of a certificate indicating completion of classes, treatment, or support groups (either mandatory or voluntary) that relate to the criminal history;(9) The subject's work history for the past 10 years, which must include the names of employers, dates of employment, and positions held;(10) At least three reference letters from persons who are not related to the subject (professionals, employers, law enforcement, etc.) and who have knowledge about the subject's character and, if applicable, the subject's ability to work with children;(11) If the risk evaluation is for a foster or adoptive placement, then:(A) The names and dates of birth of any foster or adoptive children who have been or are expected to be placed in the home (if known);(B) A description of the foster or adoptive parent's relationship to each child;(C) A copy of a home assessment or home screening, if one has been completed; and(D) A valid rationale from the child-placing agency's owner, executive director, administrator, or some other similar position of authority explaining why the subject does not pose a risk to the health or safety of children; and(12) Any additional items requested by the CBCU Manager to assist with the risk evaluation decision. Source Note: The provisions of this §745.689 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.689 What must a request for a risk evaluation based on criminal history include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195889 03/12/2026 The subject of a background check must include the following in a request for a risk evaluation based on a child abuse or neglect finding:(1) A completed Form 2974, Request for Risk Evaluation Based on Past Criminal History or Child Abuse or Neglect Findings;(2) Age of the subject at the time of the abuse or neglect;(3) The amount of time that has elapsed since the subject's last abuse or neglect finding;(4) A detailed, signed statement from the subject regarding the nature and seriousness of the abuse or neglect finding, including:(A) The circumstances involved in the abuse or neglect incident and investigation;(B) The extent and nature of the subject's past abuse or neglect history;(C) What has changed for this subject since the time of the abuse or neglect finding; and(D) Why the subject does not feel that he or she poses a risk to children in care;(5) Any evidence of rehabilitative effort, such as a copy of a certificate indicating completion of classes, treatment, or support groups (either mandatory or voluntary) that relate to the incident of abuse or neglect;(6) At least three reference letters from persons who are not related to the subject (professionals, employers, caseworkers, etc.) and who have knowledge about the subject's character and, if applicable, the subject's ability to work with children;(7) The subject's work history for the past 10 years, which must include the names of employers, dates of employment, and positions held;(8) If the risk evaluation is for a foster or adoptive placement, then:(A) The names and dates of birth of any foster or adoptive children who have been or are expected to be placed in the home (if known);(B) A description of the foster or adoptive parent's relationship to each child;(C) A copy of a home assessment or home screening, if one has been completed; and(D) A valid rationale from the child-placing agency's owner, executive director, administrator, or some other similar position of authority explaining why the subject does not pose a risk to the health or safety of children; and(9) Any additional items requested by the CBCU Manager to assist with the risk evaluation decision. Source Note: The provisions of this §745.691 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.691 What must a request for a risk evaluation based on a child abuse or neglect finding include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195890 03/12/2026 A CBCU manager or designee reviews the request for a risk evaluation and decides whether the subject of a background check poses a risk to the health or safety of children in a particular operation. The CBCU manager or designee must provide the subject and the operation with a written determination, including the final decision on a risk evaluation, within 45 days from the date the background check was submitted. Source Note: The provisions of this §745.693 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.693 Who makes the final decision on a risk evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195891 03/12/2026 When making a risk evaluation decision, the CBCU will review all of the information submitted under §745.689 or §745.691 of this division (relating to What must a request for a risk evaluation based on criminal history include? and What must a request for a risk evaluation based on a child abuse or neglect finding include?, respectively), consider whether the requestor failed to submit any information, and review any other relevant information. The CBCU will consider the following factors when assessing whether the subject poses a risk to the health or safety of children:(1) The compliance history and regulatory status of the operation;(2) The subject of a background check's intended or current role and responsibility at the operation;(3) The length of time that has elapsed since the criminal conviction, child abuse or neglect finding, or crime for which the subject has been arrested or charged;(4) The nature and severity of the criminal conviction, child abuse or neglect finding, or crime for which the subject has been arrested or charged;(5) The subject's role in the criminal conviction, child abuse or neglect finding, or crime for which the subject has been arrested or charged, including the age of the subject at the time of the crime or abuse or neglect;(6) Whether there is a pattern of any type of crime or abuse or neglect;(7) Work history, references, and any evidence of rehabilitative effort over the past 10 years, such as a copy of a certificate indicating completion of classes, treatment, or support groups (either mandatory or voluntary) that the subject has taken;(8) Any federal requirements regarding criminal history and child abuse and neglect findings; and(9) Any other relevant factor that enhances or mitigates the risk to the health or safety of children in a particular operation. Source Note: The provisions of this §745.695 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.695 What factors does the CBCU use when deciding whether the subject of a background check poses a risk to the health or safety of children in a particular operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195892 03/12/2026 (a) An approved risk evaluation by the CBCU for a criminal conviction or child abuse or neglect finding does not expire, unless:(1) The subject of a background check has been arrested or charged with another crime or has an additional criminal conviction or child abuse or neglect finding;(2) The subject's role at the operation, including the circumstances of the subject's contact with children at the operation, becomes different than when the CBCU approved the risk evaluation;(3) The subject becomes employed at a different operation than when the CBCU approved the risk evaluation; or(4) The CBCU amends or rescinds the risk evaluation in response to:(A) A request for a review of the risk evaluation as specified in §745.699 of this division (relating to Can the subject of a background check request that the CBCU review a risk evaluation?); or(B) An action taken in response to an operation not following the conditions or restrictions on a subject's presence at an operation as specified in §745.637 of this subchapter (relating to What actions may Licensing take if I do not follow the conditions or restrictions on a subject's presence at an operation?).(b) If a risk evaluation expires because of subsection (a)(1), (a)(2), or (a)(3) of this section, then the CBCU will either conduct a new risk evaluation or reprocess the current risk evaluation based on the new information.(c) An approved risk evaluation by the CBCU for a crime for which the subject has been arrested or charged is temporary pending the final outcome of the alleged crime (i.e. charges never filed, dismissal, conviction, or acquittal). Once there is a final outcome to the alleged crime, the CBCU will make a final decision on the risk evaluation if one continues to be required. Source Note: The provisions of this §745.697 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.697 Does an approved risk evaluation expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195893 03/12/2026 (a) The subject of a background check may request the CBCU to review the risk evaluation decision, including conditions or restrictions, if there is new information that was not available at the time of the risk evaluation decision.(b) The request for the CBCU to review the risk evaluation decision must:(1) Be in writing;(2) Be addressed to the CBCU staff member that issued the decision;(3) Include:(A) The subject's name;(B) The date the CBCU issued the risk evaluation decision; and(C) Any new information that was not available at the time of the decision; and(4) Be sent by e-mail, regular mail, or fax to the specified address or fax number.(c) The Director of the CBCU or a designee has 30 days to provide the subject with a written response regarding the review of the risk evaluation decision. The CBCU may extend the 30-day time period for good cause. While conducting the review, the CBCU will consider any new information provided. The decision by the CBCU Director or designee is final. Source Note: The provisions of this §745.699 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.699 Can the subject of a background check request that the CBCU review a risk evaluation decision? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195894 03/12/2026 (a) A designated perpetrator is a person in the Central Registry who has not exhausted the person's due process rights, including an administrative review, a due process hearing, and any subsequent rights of appeal. See Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings).(b) A sustained perpetrator is a person in the Central Registry who has already been offered due process rights to an administrative review and due process hearing, and:(1) The person waived all of the person's due process rights by not timely requesting an administrative review and due process hearing or by waiving those rights in writing as specified in §745.8817 of this chapter (relating to Can I waive my right to an administrative review?) and §745.8855 of this chapter (relating to Can I waive my right to a due process hearing?); or(2) The child abuse or neglect finding was upheld in the due process hearing and any subsequent appeals. Source Note: The provisions of this §745.731 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.731 Who are designated perpetrators and sustained perpetrators of child abuse or neglect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195895 03/12/2026 Licensing considers the following factors when determining if a person, including the subject of a background check, or an operation is an immediate threat to the health or safety of children:(1) The severity of the deficiency, including abuse or neglect;(2) The circumstances surrounding the deficiency, including abuse or neglect;(3) The seriousness of any injuries to children;(4) The length of time since the deficiency, including abuse or neglect, occurred;(5) Whether the deficiency has been repeated;(6) The compliance history of the operation;(7) The current regulatory status of the operation;(8) How quickly corrections to the deficiency can be made;(9) If any corrections have already been made;(10) The role of the person in the abuse or neglect;(11) The current position, role, and responsibilities of the person; and(12) The degree and immediacy of the threat or danger. Source Note: The provisions of this §745.751 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.751 What factors does Licensing consider when determining if a person or an operation is an immediate threat to the health or safety of children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195896 03/12/2026 (a) You must meet the background check requirements that are part of the administrator's licensing process in Subchapter N of this chapter (relating to Administrator's Licensing).(b) In addition to complying with the criminal conviction requirements specified in §745.661(a)(1) of this subchapter (relating to What types of criminal convictions may affect a subject's ability to be present at an operation?), you are also monitored for offenses related to financial crimes, including all Title 7 Offenses Against Property, Title 8 Offenses Against Administration, and Title 11 Organized Crime offenses in the Penal Code.(c) You may not receive or maintain an administrator's license if you:(1) Have a criminal conviction as specified in §745.661(a)(1) of this subchapter or a child abuse or neglect finding as specified in §745.671 of this subchapter (relating to What types of findings from the Central Registry or out-of-state child abuse and neglect registries may affect a subject's ability to be present at an operation?) that would bar you from being present at an operation;(2) Are on a sex offender registry; or(3) Have a felony conviction of a financial crime, as specified in subsection (b) of this section, within the past 10 years.(d) You may receive and maintain an administrator's license if you have a felony conviction of a financial crime older than 10 years or a misdemeanor conviction of a financial crime. However, these crimes do require a risk evaluation and Licensing may place restrictions on your license. You must have an approved risk evaluation before you may be present at an operation.(e) You may receive and maintain an administrator's license if you have a criminal conviction or a child abuse or neglect finding that only requires a risk evaluation. However, Licensing may place restrictions on your license. You must have an approved risk evaluation before you may be present at an operation.(f) In addition to the Administrator's Licensing background check process, the operation where you serve as an administrator must also request a background check on you, as specified in §745.605(a)(2)(A). This process is separate and apart from the Administrator's Licensing background check process. Source Note: The provisions of this §745.775 adopted to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING F BACKGROUND CHECKS §745.775 How may a criminal conviction or a child abuse or neglect finding affect my ability to receive or maintain an administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195897 03/12/2026 (a) A controlling person of a child-care operation is any:(1) Owner of the operation or member of the governing body of the operation, including, as applicable, an executive, an officer, a board member, a partner, a sole proprietor and the sole proprietor's spouse, or the primary caregiver at a child-care home and the primary caregiver's spouse;(2) Person who manages, administrates, or directs the operation or its governing body, including a day care director or a licensed administrator; or(3) Person who either alone or in connection with others has the ability to influence or direct the management, expenditures, or policies of the operation. For example, a person may have influence over the operation because of a personal, familial, or other relationship with the governing body, manager, or other controlling person of the operation.(b) A person does not have to be present at the operation or hold an official title at the operation or governing body in order to be a controlling person.(c) An employee, lender, secured creditor, or landlord of the operation is not a controlling person unless the person meets a definition in subsection (a) of this section. Source Note: The provisions of this §745.901 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.901 Who is a controlling person at a child-care operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195898 03/12/2026 (a) You must provide information about each person that is a controlling person at your operation as defined in §745.901(a) of this title (relating to Who is a controlling person at a child-care operation?) when you apply for your permit.(b) After you receive a permit from us, you must provide us information about someone who is a controlling person at your operation within two days after a person becomes a controlling person.(c) To provide the information to us, you must either:(1) Enter the information on-line through the DFPS website; or(2) Submit a completed Controlling Person Form to your local Licensing office. Source Note: The provisions of this §745.903 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective March 1, 2013, 38 TexReg 990; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.903 When and how must an operation submit controlling-person information to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195899 03/12/2026 (a) We will designate each person who meets the definition of a controlling person in §745.901(a) of this title (relating to Who is a controlling person at a child-care operation?) as a controlling person at your operation when:(1) We revoke your permit; or(2) You voluntarily close your operation or relinquish your permit after you receive notice of our intent to revoke your permit or that we are revoking your permit.(b) We may designate a person at your operation as controlling, regardless of whether you submitted their name on a Controlling Person Form. Source Note: The provisions of this §745.905 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.905 When will Licensing designate someone at my child-care operation as a controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224583 03/12/2026 (a) If we designate you as a controlling person: (1) We may not issue you a permit to operate a child-care operation for five years after our designation is sustained; and (2) You may not be the controlling person at a child-care operation for five years after the designation is sustained. (b) Our designation of you as a controlling person is sustained when the revocation or voluntary closure described in §745.905 of this title (relating to When will Licensing designate someone at my child-care operation as a controlling person?) is final and: (1) You have waived your due process rights regarding the designation; or (2) The designation is upheld after you have exhausted your due process rights. (c) Another state agency may deny your application for a permit based on information obtained from us, as outlined in Texas Government Code Chapter 526, Subchapter J. Source Note: The provisions of this §745.907 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 1, 2025, 50 TexReg 2211. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.907 What are the consequences of Licensing designating me as a controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195901 03/12/2026 (a) If we designate you as a controlling person, we will offer you an administrative review and due process hearing. See Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings).(b) At our discretion, we may combine the administrative review with a review regarding the revocation. The administrative law judge may combine hearings that involve issues related to the same decision or action. Source Note: The provisions of this §745.909 adopted to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.909 What due process rights do I have if Licensing designates me as a controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224584 03/12/2026 A person may not serve as a controlling person in a child-care operation if: (1) We sustained the person as a controlling person within the previous five years; (2) The person is ineligible to apply for a permit because of an adverse action that was sustained during the previous five years; or (3) The person was a permit holder, controlling person, or otherwise listed on the application for a permit for a facility that had its permit denied, revoked, suspended, or terminated by a state health and human services agency in the last 10 years, as outlined in Texas Government Code Chapter 526, Subchapter J (relating to Licensing, Listing, or Registration of Certain Entities). Depending upon the circumstances that led to the previous permit denial, suspension, revocation, or termination and the person's relationship to that facility, we may determine that this person may not serve as a controlling person for your child-care operation. Source Note: The provisions of this §745.911 adopted to be effective March 1, 2013, 38 TexReg 990; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 1, 2025, 50 TexReg 2211. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.911 In what other circumstances may a person not serve as a controlling person at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195903 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195903&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195903 03/12/2026 Licensing will check to determine whether someone is ineligible to serve as a controlling person, when:(1) You submit an application for a permit; and(2) Any time we receive information that identifies someone as a controlling person. Source Note: The provisions of this §745.913 adopted to be effective March 1, 2013, 38 TexReg 990; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.913 When does Licensing check whether someone is ineligible to serve as a controlling person at my child-care operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195904 03/12/2026 (a) We will notify you in writing if someone is ineligible to serve as a controlling person at your operation.(b) If the person that we have prohibited from serving as a controlling person believes that the results of the check are inaccurate, you may contact the Licensing office that sent the notice to you to discuss the accuracy of the information.(c) Unless we determine that the notification was inaccurate, this person may not serve as a controlling person at your operation. Source Note: The provisions of this §745.915 adopted to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2013, 38 TexReg 990; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING G CONTROLLING PERSONS §745.915 What happens after Licensing determines that someone is ineligible to serve as a controlling person at my child-care operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195905 03/12/2026 (a) The Department of Family and Protective Services is required to adopt a model drug testing policy for residential child-care operations under the Human Resources Code, 42.057. Your residential child-care operation must either adopt the model drug testing policy or have a written drug testing policy that meets or exceeds the criteria in the model policy. Although this policy only covers drugs, coverage of alcohol may be included. The department recommends that an operation obtain legal advice before adopting and implementing any drug testing policy.(b) Residential child-care operations must pay for any required drug tests, except as provided in subsection (c)(7) of this section.(c) The mandatory criteria for the Model Drug Testing Policy For Residential Child-Care Operations include:(1) Purpose. (Name of residential child-care operation) has a vital interest in ensuring the safety of resident children through the appropriate drug testing of employees, while also protecting the rights of the employees.(2) Scope. This policy applies to all employees of residential child-care operations, including child-placing agencies, that directly care for or has access to a child in care, and applicants for such employment. With respect to allegations of drug abuse (See paragraph (4)(D) of this subsection), this policy applies to any person who works under the auspices of a residential child-care operation and directly cares for or has access to a child in care.(3) Definitions. The following definitions apply to this section.(A) Abusing drugs--The use of any:(i) Drug or substance defined by the Texas Controlled Substances Act, Texas Health and Safety Code, Chapter 481; or(ii) Prescription or non-prescription drug that is not being used for the purpose for which it was prescribed or manufactured.(B) Drug testing--The scientific analysis of urine, blood, breath, saliva, hair, tissue, and other specimens for detecting a drug.(C) Employee--A person is an employee of your operation if you pay the person a wage or salary and direct or have the right to direct his work. For the purposes of this definition:(i) Directing a person's work includes having control over when, where, and how the person conducts his work and providing the person with training that is necessary for the person to conduct his work;(ii) Controlling when a person works includes setting the person's work hours;(iii) Controlling how a person works includes assigning the person the task(s) that he must accomplish and exercising responsibility for the means and details by which the person accomplishes the task(s); and(iv) A person is not an "employee" of a child-placing agency merely because the agency verifies him as a foster parent.(D) Random drug testing--A testing cycle that varies the frequency and intervals that specimens are collected for testing and selects employees in a random manner that does not eliminate already tested employees from future testing. The testing should ensure all employees are subject to random testing on a continuing basis.(E) Good cause to believe the person may be abusing drugs--A reasonable belief based on facts sufficient to lead a prudent person to conclude that the person who works under the auspices of the residential child-care operation may be abusing drugs. Sufficient facts may include direct observations of the person using or possessing drugs, or exhibiting physical symptoms, including but not limited to slurred speech or difficulty in maintaining balance; erratic or marked changes in behavior, including a decrease in the quality or quantity of the person's productivity, judgment, reasoning, and concentration and psychomotor control, accidents, and deviations from safe working practices; or any other reliable information.(F) Person who works under the auspices of the residential child-care operation--A person who meets the definition in §745.8553 of this title (relating to Who works "under the auspices of an operation"?).(4) Mandatory drug testing.(A) All applicants that are intended to be hired for employment are subject to pre-employment testing, and may not provide direct care or have access to a child in care until the drug test results are available;(B) All employees are subject to random, unannounced drug testing;(C) Any employee that is the subject of a child abuse or neglect investigation, when DFPS determines there is "good cause to believe the employee may be abusing drugs", must be drug tested within 24 hours of notification by DFPS to the residential child-care operation; and(D) Any person alleged to be abusing drugs may be tested within 24 hours, if the person:(i) Works under the auspices of the residential child-care operation;(ii) Directly cares for or has access to a child in care; and(iii) There is "good cause to believe the person may be abusing drugs."(5) Drug testing procedures. All drug testing will:(A) At a minimum screen for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP);(B) Use one of the following drug-testing methods:(i) A drug test performed by a certified laboratory;(ii) A testing kit with proven rates of false positives below 2% and false negatives below 8% on all drugs screened; or(iii) Another testing method for which there is scientific proof of accuracy comparable to either of the first two choices, such as saliva, hair, or spray drug testing;(C) Ensure the integrity and identity of the specimen collected from the time of collection to the time of disposal to minimize the opportunity for an employee to adulterate or substitute a specimen; and(D) Preserve the privacy and rights of the person tested. This includes safeguarding the results of any test and maintaining them, so they remain confidential and free from unauthorized access.(6) Discipline.(A) An applicant or employee's consent to submit to drug testing is required as a condition of employment, and the refusal to consent may result in refusal to hire the applicant and disciplinary action, including discharge, against the employee for a refusal;(B) An employee who is tested because there is "good cause to believe the employee may be abusing drugs," may be suspended pending receipt of written test results and further inquiries that may be required;(C) An employee determined through drug testing to have abused drugs is subject to discipline, up to and including discharge;(D) An applicant for employment or an employee determined through drug testing to have abused drugs may not be employed in a position with direct contact with children in care if the employee presents a risk of harm to children; and(E) An employee determined through drug testing to have abused drugs may be offered the opportunity to complete a rehabilitation program at the employee's expense.(7) Appeal. An applicant or employee whose drug test is positive may, at the applicant or employee's expense:(A) Have an opportunity to explain and offer written documentation why there is another cause for the positive drug test;(B) Request that the remaining portion of the sample that yielded the positive results, if available, be submitted for an additional independent test, including second tests to rule out false positive results; and/or(C) Submit the written test result for an independent medical review.(8) Documentation.(A) All applicants that you intend to hire for employment and employees must be provided a copy of your drug testing policy and must sign a document consenting to these terms and conditions of employment.(B) All drug test results of employees will be kept for one year after an employee's last work day with the residential child-care operation, or until any investigation involving the person is resolved, whichever is later. All other drug test results required by this rule will be kept for one year from the date the drug test was administered. The results must be available for review by Licensing Division within 24 hours of the request. Source Note: The provisions of this §745.4151 adopted to be effective December 1, 2005, 30 TexReg 7493; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING H RESIDENTIAL CHILD-CARE: DRUG TESTING AND LAW ENFORCEMENT ADMISSIONS §745.4151 What drug testing policy must my residential child-care operation have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195906 03/12/2026 You may take possession of a child directly from a law enforcement officer if you are:(1) A general residential operation licensed to provide emergency care services; or(2) A licensed child-placing agency that we have authorized to take possession of children from a law enforcement officer. Source Note: The provisions of this §745.4201 adopted to be effective March 1, 2006, 31 TexReg 858; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING H RESIDENTIAL CHILD-CARE: DRUG TESTING AND LAW ENFORCEMENT ADMISSIONS §745.4201 May I take possession of a child from a law enforcement officer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195907 03/12/2026 If you are a child-placing agency, the following must occur before you can take possession of a child from a law enforcement officer:(1) You submit to us a Request to Accept Children from a Law Enforcement Officer form;(2) We review the request to determine whether you are equipped to accept these types of emergency admissions; and(3) If we authorize you to accept such admissions, we add your ability to accept these admissions to the conditions on your license. Source Note: The provisions of this §745.4203 adopted to be effective March 1, 2006, 31 TexReg 858; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING H RESIDENTIAL CHILD-CARE: DRUG TESTING AND LAW ENFORCEMENT ADMISSIONS §745.4203 How does a child-placing agency become authorized to take possession of a child from a law enforcement officer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195908 03/12/2026 When you take possession of a child from a law enforcement officer, you must:(1) With the assistance of the officer who has the child, obtain and document any available information regarding:(A) The identity of the child, including name, age, date of birth, gender, race, hair color, eye color, height, and address;(B) The identity of the child's parents, including names, dates of birth, addresses, and phone numbers;(C) Individuals or relatives that the child may be released to;(D) The officer that you are taking possession of the child from, including the officer's full name, badge number, department the officer works for, and case number; and(E) Any other information that must be included in the child's record for an emergency admission, as listed in 26 TAC §748.1271 (relating to At the time of an emergency admission, what information must I document in the child's record?) or 26 TAC §749.1189 (relating to At the time of an emergency admission, what information must I document in the child's record?);(2) Immediately notify the Department of Family and Protective Services (DFPS) that you have taken possession of the child by calling the Texas Abuse Hotline; and(3) Provide the information obtained and documented from paragraph (1) of this section to the DFPS investigator who responds to the call. Source Note: The provisions of this §745.4205 adopted to be effective March 1, 2006, 31 TexReg 858; amended to be effective July 29, 2018, 43 TexReg 4472; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING H RESIDENTIAL CHILD-CARE: DRUG TESTING AND LAW ENFORCEMENT ADMISSIONS §745.4205 What must I do when I take possession of a child from a law enforcement officer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214279 03/12/2026 (a) A voluntary action under this subchapter is not an enforcement action.(b) The following chart lists the voluntary actions that are available for all operation types:Attached Graphic Source Note: The provisions of this §745.5001 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5001 What are the different types of voluntary actions that an operation may take? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214280 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214280 03/12/2026 (a) We may impose an enforcement action against your operation:(1) Even if you have taken a voluntary action; and(2) Any time while the voluntary action is in effect.(b) If your action is voluntary suspension or voluntary closure, we may also impose the enforcement action:(1) When you reopen your operation after your voluntary suspension ends; or(2) If you apply for another permit after your voluntary closure; for example, if your operation met the requirements for probation when you voluntarily closed your operation, we may include a condition on your new permit that your operation is on probation.(c) We may also determine that an enforcement action is unnecessary because of your voluntary action. Source Note: The provisions of this §745.5003 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5003 How does my taking a voluntary action affect Licensing's ability to impose an enforcement action against my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214968 03/12/2026 The following chart notes whether notice to and approval by Licensing are required before an operation may take the voluntary action:Attached Graphic Source Note: The provisions of this §745.5051 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5051 What notice and approval are required for a voluntary action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214282 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214282 03/12/2026 You must:(1) Complete the notice requirements in §745.5051 of this subchapter (relating to What notice and approval is required for a voluntary action?);(2) Prior to a planned temporary relocation:(A) Obtain any inspections at the temporary location that are identified in the applicable minimum standards, which may include fire, sanitation, and gas leak inspections;(B) Ensure the temporary location complies with applicable licensing statutes, rules, and minimum standards;(C) Allow us to conduct an inspection under §745.5103 of this division (relating to What actions will Licensing take after receiving a notice that you are temporarily relocating?); and(D) Obtain our approval for any aspect of the temporary location that does not comply with the applicable licensing statutes, rules, and minimum standards; and(3) For an emergency relocation:(A) Complete each step in paragraph (1) of this section as soon as possible after the relocation; and(B) If you are a residential child care operation, meet any additional reporting and documentation requirements under:(i) §748.303(e)(1) and (3) of this title (relating to When must I report and document a serious incident?); or(ii) §749.503(e)(1) and (3) of this title (relating to When must I report and document a serious incident?). Source Note: The provisions of this §745.5101 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5101 What must I do when I temporarily relocate my operation because of a renovation or damage that makes the operation temporarily unsuitable for child care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214283 03/12/2026 (a) We will conduct an inspection before or as soon as possible after the relocation to determine whether the temporary location complies with the applicable licensing statutes, rules, and minimum standards.(b) We will consider the following when deciding whether to approve a temporary location that does not comply with minimum standards:(1) The anticipated length of stay at the temporary location;(2) The degree of deviation from minimum standards; and(3) Whether there is a risk to children considering the activities and services that the operation offers. Source Note: The provisions of this §745.5103 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5103 What actions will Licensing take after receiving a notice that you are temporarily relocating? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214284 03/12/2026 You may request a voluntary suspension of your permit because you are unable to operate for a specific time period for the following reasons:(1) You are repairing or making changes to your operation;(2) You do not have children in care or enrollment is too low for you to operate; or(3) You are unable to operate due to:(A) Illness;(B) An extended absence;(C) A staffing shortage;(D) Personal reasons; or(E) A declared disaster. Source Note: The provisions of this §745.5151 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5151 For what reasons may I request a voluntary suspension of my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214285 03/12/2026 You must submit a written request for a voluntary suspension to your Licensing representative. In your request, you must include:(1) The reason that you are requesting a voluntary suspension from §745.5151 of this division (relating to For what reasons may I request a voluntary suspension of my permit?);(2) The proposed dates for the suspension to begin and end;(3) Plans to resume operating; and(4) A statement about how you will meet the applicable licensing statutes, rules, and minimum standards at the end of the suspension period. Source Note: The provisions of this §745.5153 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5153 How do I request a voluntary suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214286 03/12/2026 After we receive your written request for a voluntary suspension, we may approve, deny, or add conditions to your request to voluntarily suspend your permit based on the following factors:(1) Whether an enforcement action is currently pending or we are considering imposing an enforcement action against your operation;(2) Whether we can confirm that you do not plan to care for children during the voluntary suspension period;(3) The length of the time you plan to suspend your permit; and(4) Whether your request meets one of the reasons of §745.5151 of this division (relating to For what reasons may I request a voluntary suspension?). Source Note: The provisions of this §745.5155 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5155 What actions may Licensing take after receiving written notice that you are requesting a voluntary suspension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214287 03/12/2026 (a) As soon as possible, but no later than 24 hours after we notify you of our approval, you must notify the parents of any children attending or enrolled in your operation of the voluntary suspension, including the dates of the voluntary suspension period.(b) During the voluntary suspension period, you must:(1) Not have children in care;(2) Notify us at least 15 days before resuming operation, as required by §745.5159 of this division (relating to What must occur before I may reopen and begin operating at the end of the voluntary suspension period?);(3) Return the permit to us during the suspension period;(4) Meet the permit renewal requirements in Subchapter D, Division 12 of this chapter (relating to Permit Renewal), if applicable, so your permit does not expire while under voluntary suspension; and(5) Remit all fees due during the suspension period. Source Note: The provisions of this §745.5157 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5157 What are my responsibilities during the voluntary suspension period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214288 03/12/2026 (a) You must notify us in writing at least 15 days before you plan to begin operating.(b) We will conduct an inspection within 15 days to determine whether you are meeting all applicable licensing statutes, rules, and minimum standards.(c) After the inspection, we will determine whether to give you permission to reopen and operate.(d) You may reopen only if we give you permission to operate after conducting the inspection. Source Note: The provisions of this §745.5159 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5159 What must occur before I may reopen and begin operating at the end of the voluntary suspension period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214289 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214289 03/12/2026 If you have not met the requirements of §745.5159 of this division (relating to What must occur before I may reopen and begin operating at the end of the voluntary suspension period?) and do not begin operating at the end of the voluntary suspension period:(1) You may request an extension if your voluntary suspension was for less than two years;(2) You may voluntarily close your operation; or(3) We may take an enforcement action, including revoking your permit. Source Note: The provisions of this §745.5161 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5161 What if I do not begin operating at the end of the voluntary suspension period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214290 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214290 03/12/2026 (a) You must notify the parents of any children that you are voluntarily closing your operation as provided in this chart:Attached Graphic(b) When you voluntarily close your operation, you must:(1) Notify us as soon as possible, but no later than 10 days after you close your operation; and(2) Surrender your permit. If you want to operate again after you voluntarily close your operation, you will have to apply for a new permit. (c) Residential child care operations that are closing in response to a disaster or an emergency must meet the reporting and documentation requirements of §748.303(e)(2) of this title (relating to When must I report and document a serious incident?), and §749.503(e)(2) of this title (relating to When must I report and document a serious incident?), including making a report to us and the parents as soon as possible, but no later than 24 hours after the incident. Source Note: The provisions of this §745.5201 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING I NON-ENFORCEMENT VOLUNTARY ACTIONS §745.5201 How do I voluntarily close my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226468 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226468 03/12/2026 These words have the following meanings in this subchapter:(1) Foster family home--A home that is the primary residence of the foster parent or parents and provides care to six or fewer children or young adults, under the regulation of a child-placing agency. Also referred to as "foster home."(2) Foster parent--A person verified to provide child care services in the foster home.(3) Kinship foster home--A foster family home with a foster parent or parents who:(A) Is related to a foster child by consanguinity or affinity; or(B) Has a longstanding and significant relationship with the foster child or the foster child's family.(4) Variance--A decision by Child Care Regulation (CCR) that there is good and just cause for an operation to meet the purpose of a minimum standard in a different way.(5) Waiver--A decision by CCR that waives an operation's compliance with a minimum standard if the economic impact of compliance with that standard is great enough to make compliance impractical. Source Note: The provisions of this §745.8301 adopted to be effective October 16, 2023, 48 TexReg 5739; amended to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8301 Definitions for Subchapter J https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215265 03/12/2026 A minimum standard is ineligible for a waiver or variance if the minimum standard is required by state or federal law. Source Note: The provisions of this §745.8303 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8303 What minimum standards are ineligible for a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215266 03/12/2026 (a) You must request a waiver or variance in writing by submitting a completed:(1) Waiver/Variance Request through your online account and separately providing any supporting documentation to your Licensing representative; or(2) Form 2937 Child Care Regulation Waiver/Variance Request , or the information required by the form and any supporting documentation, to your Licensing representative.(b) A waiver or variance request may only be for:(1) One operation; and(2) One minimum standard number or subsection.(c) If a child-placing agency is requesting a waiver or variance for a minimum standard related to foster care, the waiver or variance request can be for only one foster home. Source Note: The provisions of this §745.8305 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8305 How do I request a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215269 03/12/2026 (a) Within 15 days after Licensing receives a request, the Licensing representative:(1) Reviews the request and any supporting documentation; and(2) Makes a recommendation to the supervisor or the supervisor's designee whether to grant the request for a waiver or variance.(b) Within 15 days after receiving the Licensing representative's recommendation, the supervisor or designee makes the final decision whether to grant the waiver or variance.(c) Within five days after the supervisor makes the final decision, Licensing staff notifies the requester of the final decision. Source Note: The provisions of this §745.8307 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8307 How long does Licensing have to process a request for a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215267 03/12/2026 (a) We grant a waiver or variance for a specific amount of time. The waiver or variance will include its expiration date.(b) We may issue a waiver or variance for up to three years. If you need a waiver or variance for a time period that exceeds three years, you will have to submit a new request as explained in subsection (c) of this section.(c) If you will still need a waiver or variance after the waiver or variance expires, you must submit a new request to us according to §745.8305 of this subchapter (relating to How do I request a waiver or variance?):(1) At least 35 days prior to the expiration; or(2) As soon as possible, if the expiration date of the waiver or variance is less than 35 days from the date we granted it.(d) When your waiver or variance expires, you must comply with the minimum standard, even if a new request related to that standard is pending our review. Source Note: The provisions of this §745.8309 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8309 When does a waiver or variance expire, and what must I do before it expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215268 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215268 03/12/2026 (a) We may place any condition on a waiver or variance we determine is necessary to protect the health and safety of children in your care.(b) You must comply with each condition while the waiver or variance is in effect. Source Note: The provisions of this §745.8311 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8311 What conditions may Licensing place on an approved waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215259 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215259 03/12/2026 When deciding whether to grant a waiver or variance, we consider:(1) Whether the minimum standard is ineligible for a waiver or variance as outlined in §745.8303 of this subchapter (relating to What minimum standards are ineligible for a waiver or variance?);(2) The risk to children if your operation or foster home does not meet the standard;(3) The compliance history of your operation, including past and current enforcement actions;(4) Any waivers or variances currently in effect;(5) Your permit status, including if you are an applicant or have an initial license;(6) Whether your operation is on heightened monitoring;(7) Any economic factors or other constraints affecting your ability to comply;(8) If the request is for a foster home, the additional factors for a foster home as required by §745.8315 of this subchapter (relating to What additional factors does Licensing consider when deciding whether to grant a waiver or variance for a foster home?); and(9) Any other factor relevant to your request or operation that we identify. Source Note: The provisions of this §745.8313 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8313 What factors do we consider when deciding whether to grant a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215260 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215260 03/12/2026 When the request is associated with a foster home, we will consider:(1) The compliance history of the foster home.(2) If the request is to increase the maximum number of foster children a foster home may care for, whether you may use the exception criteria under §749.2551(b) of this title (relating to What is the maximum number of children a foster family home may care for?); and(3) Any limitations in state or federal law, including that:(A) We only may issue a waiver if the home is a kinship foster home;(B) We may not approve a request that would result in a foster home's total capacity exceeding eight foster children; and(C) We may not approve a request that would result in a foster home's foster care capacity exceeding six foster children unless:(i) You are requesting a variance for a reason in §749.2551(b)(1) of this title; and(ii) You are not able to use the exception criteria under §749.2551(b) of this title to increase the foster home's foster care capacity. Source Note: The provisions of this §745.8315 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8315 What additional factors does Licensing consider when deciding whether to grant a waiver or variance for a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215261 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215261 03/12/2026 If we grant you a waiver or variance, we will also use the factors listed in §745.8313 of this subchapter (relating to What factors do we consider when deciding whether to grant a waiver or variance?) when determining the expiration date and what conditions to put on the waiver or variance. Source Note: The provisions of this §745.8317 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8317 What factors do we consider when determining the expiration date and conditions for a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215262 03/12/2026 (a) A waiver or variance is not an entitlement. Accordingly, we may amend or revoke your waiver or variance if we determine that:(1) Your waiver or variance does not address a risk to children that currently exists;(2) The circumstances that supported the decision to grant the waiver or variance have changed;(3) You fail to meet a condition; or(4) Your waiver or variance requires an additional or alternative condition.(b) If you disagree with an amendment to your waiver or variance, see §745.8321 of this subchapter (relating to What can I do if I disagree with Licensing's decision related to a waiver or variance?). Source Note: The provisions of this §745.8319 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8319 Can Licensing amend or revoke a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215263 03/12/2026 (a) When you disagree with the original expiration date or original conditions associated with a waiver or variance that Licensing granted:Attached Graphic(b) When we deny, revoke, or amend a waiver or variance:Attached Graphic Source Note: The provisions of this §745.8321 adopted to be effective October 16, 2023, 48 TexReg 5739. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING J WAIVERS AND VARIANCES FOR MINIMUM STANDARDS §745.8321 What can I do if I disagree with Licensing's decision related to a waiver or variance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222341 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222341 03/12/2026 (a) Child Care Regulation (CCR) is responsible for inspecting or investigating:(1) An operation that is subject to regulation under Texas Human Resources Code (HRC) Chapter 42 to:(A) Monitor the operation's compliance with statutes, rules, and minimum standards; and(B) Investigate an allegation of non-compliance with statutes, rules, and minimum standards; and(2) An unlicensed program providing care to children to determine whether the program is subject to regulation by CCR.(b) The following entities are responsible for investigating an allegation of abuse, neglect, or exploitation:(1) The Texas Department of Family and Protective Services is responsible for investigating an allegation of child abuse, neglect, or exploitation at an operation that is subject to regulation under HRC Chapter 42, as described in Title 40, Part 19, Chapter 707, Subchapter C, Child Care Investigations; and(2) The Texas Health and Human Services Commission (HHSC) is responsible for investigating an allegation of abuse, neglect, or exploitation of an elderly adult or an adult with a disability in a residential child-care operation, as described in Texas Human Resources Code, Chapter 48, Subchapter F.(c) An authorized representative of CCR may inspect under subsection (a) of this section during or after an investigation under subsection (b) of this section. Source Note: The provisions of this §745.8401 adopted to be effective August 23, 2023, 48 TexReg 3990; amended to be effective December 22, 2024, 49 TexReg 9553. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8401 Who is responsible for inspecting or investigating an operation under this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214292 03/12/2026 During an inspection or investigation, we may take actions that reduce the risk to children and protect the health, safety, and well-being of children in care, including:(1) Evaluating whether the operation is subject to regulation;(2) Conducting a walkthrough of the operation;(3) Verifying compliance with licensing statutes, rules, and minimum standards;(4) Assessing the risk to children in the operation;(5) Assisting the operation with identifying problems contributing to deficiencies in licensing statutes, rules, and minimum standards;(6) Offering technical assistance;(7) Gathering information; and(8) Making a fair, accurate, and impartial decision regarding your compliance with licensing statutes, rules, and minimum standards. Source Note: The provisions of this §745.8403 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8403 What actions may Licensing take during an inspection or investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214293 03/12/2026 (a) The following chart describes when we inspect or investigate an operation:Attached Graphic(b) We may inspect or investigate your operation or program during its hours of operation.(c) If you operate a child-placing agency main office or branch office that is not open between 8:00 a.m. and 5:00 p.m., Monday through Friday, you must ensure that the office and employees are available upon our request for the purpose of inspecting or investigating your agency. Source Note: The provisions of this §745.8405 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8405 When does Licensing inspect or investigate an operation or program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214294 03/12/2026 We may inspect or investigate your operation as often as is necessary to verify compliance with licensing statutes, rules, and minimum standards or to complete an investigation. Source Note: The provisions of this §745.8407 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8407 How often may Licensing inspect or investigate my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214295 03/12/2026 (a) One inspection every year must be unannounced for a:(1) Licensed operation;(2) Certified operation; and(3) Registered child-care home that is receiving a subsidy for a child in care through the Texas Workforce Commission (TWC).(b) One inspection every two years must be unannounced for a registered child-care home that is not receiving a subsidy for a child in care through TWC.(c) All other inspections and investigations may be announced or unannounced. Source Note: The provisions of this §745.8409 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8409 Are inspections and investigations announced or unannounced? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222342 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222342 03/12/2026 (a) An operation must ensure that no one at the operation interferes with an inspection or investigation by Child Care Regulation (CCR), another department of the Texas Health and Human Services Commission (HHSC), or the Department of Family and Protective Services (DFPS).(b) For an inspection or investigation described in subsection (a), the operation must ensure that the operation:(1) Admits authorized representatives involved in conducting the inspection or investigation;(2) Provides access to all areas of the operation;(3) Provides access to all records; and(4) Does not delay or prevent authorized representatives from conducting an inspection or investigation.(c) If anyone at the operation refuses to admit, refuses access, or prevents or delays an authorized representative of CCR, another department of HHSC, or DFPS from visiting, inspecting, or investigating the operation, any or all of the following may occur:(1) CCR may issue the operation a deficiency;(2) CCR may recommend an enforcement action as specified in Subchapter L of this chapter (relating to Enforcement Actions); or(3) CCR, DFPS, or HHSC may seek a court order granting access to the operation and records maintained by the operation. Source Note: The provisions of this §745.8411 adopted to be effective August 23, 2023, 48 TexReg 3990; amended to be effective December 22, 2024, 49 TexReg 9553. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8411 What are an operation's responsibilities when an authorized representative inspects or investigates the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214297 03/12/2026 (a) We may inspect and investigate any part of your operation that could affect the health, safety, or well-being of children. This includes access to:(1) All records of the operation, including child records, personnel records, and any audio or visual records;(2) Any area of the building, home, or grounds where your operation is located; and(3) Any equipment the operation uses when providing care.(b) We may interview anyone who may have information relevant to an inspection or investigation when we are at an operation during the inspection or investigation, including:(1) A child;(2) An employee; or(3) Any other person.(c) Regarding our access to records of the operation during an inspection or investigation, we:(1) Determine what records that we need to review; and(2) May make or take copies of any records from the operation. Source Note: The provisions of this §745.8413 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8413 What can Licensing inspect or investigate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214298 03/12/2026 (a) If an anonymous report contains an allegation that the health or safety of children is at risk, we will investigate the report and any alleged deficiencies.(b) If an anonymous report does not contain an allegation that the health or safety of children is at risk, we will evaluate the anonymous report to determine whether any alleged deficiency has a factual basis.(c) To evaluate the anonymous report, we:(1) Check the operation's compliance history for similar allegations or deficiencies; and(2) Contact the operation and collaterals.(d) If we find a factual basis for at least one alleged deficiency, we will investigate the anonymous report.(e) If we do not find a factual basis for any of the alleged deficiencies, we will administratively close the anonymous report. Source Note: The provisions of this §745.8415 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8415 How does Licensing investigate an anonymous report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214299 03/12/2026 After investigating an anonymous report:(1) We will not post a record of the report on the Search Texas Child Care website if we do not find a factual basis for any of the alleged deficiencies in the report;(2) We will post a record of the report and the findings on the Search Texas Child Care website if:(A) We determine the operation had any deficiencies; and(B) The operation waives its right to an administrative review for any deficiency, or any deficiency is upheld in the administrative review process.(3) We will post any additional deficiency on the Search Texas Child Care website that:(A) We observed during an inspection related to the investigation; and(B) The operation waives its right to an administrative review for the deficiency, or the deficiency is upheld after the administrative review process. Source Note: The provisions of this §745.8417 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8417 What will Licensing post on its Search Texas Child Care website about findings from the investigation of an anonymous report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214300 03/12/2026 (a) For an announced or unannounced inspection, we will notify the person in charge of the operation of the purpose of the inspection at the time of the inspection.(b) For an investigation regarding a statute, rule, or minimum standard deficiency, we will notify the person in charge of the operation of the nature of the allegation made in the report when we first contact the operation, except as provided in subsection (c) of this section.(c) When we first contact an operation, we do not have to notify the person in charge of the operation of the nature of the allegation made in the report if:(1) The allegation is against the person in charge, designee, administrator, director, or primary caregiver; or(2) We have a reason to believe that disclosing the nature of the allegation may compromise the investigation.(d) If we did not notify the person in charge of the nature of the allegation as explained in subsection (c) of this section, then we will notify the person in charge, designee, administrator, director, or primary caregiver for the operation as soon as possible after we determine that doing so will not compromise the investigation. Source Note: The provisions of this §745.8441 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8441 When will we notify the operation of the purpose of an unannounced inspection or investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214301 03/12/2026 (a) Once an inspection or investigation is complete, we will notify the operation of the outcome of the inspection or investigation by providing a completed inspection form or notification letter to the:(1) Designee, director, administrator, or primary caregiver; and(2) Person in charge, if the designee, director, administrator, or primary caregiver is not available during the exit interview.(b) We will also notify the reporter of the outcome of an investigation, unless:(1) There is a reasonable likelihood that notifying the reporter will jeopardize the reporter's safety; or(2) The reporter is anonymous. Source Note: The provisions of this §745.8443 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8443 Whom will Licensing notify of the outcome of an inspection or investigation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214302 03/12/2026 (a) The notification of the outcome of the inspection or investigation sent to the operation will include:(1) Any licensing statutes, rules, or minimum standards that we investigated and whether the operation was in compliance;(2) The specifics of any deficiency that we found during an investigation or inspection;(3) The date by which you must comply with a particular licensing statute, rule, or minimum standard; and(4) Your right to an administrative review to dispute any deficiency that we found.(b) The notification of the outcome of the investigation we send to the reporter will include:(1) Whether we found any deficiencies during the investigation; and(2) A reference to the Search Texas Child Care website. Source Note: The provisions of this §745.8445 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8445 What will the notification of the outcome of the inspection or investigation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214303 03/12/2026 (a) You must:(1) Correct the deficiency within the timeframe that we specified, unless we approve an extension as provided in subsections (c) and (d) of this section; and(2) Meet all licensing statutes, rules, and minimum standards.(b) You may dispute the deficiency by requesting an administrative review; see Title 26, Chapter 745, Subchapter M, Division 1 (relating to Administrative Reviews).(c) We may extend the timeframe we specified to correct a cited deficiency if you send us a written request that:(1) Includes a reason for an extension, and we determine that:(A) There is cause for the extension; and(B) Extending the time frame would not pose an immediate danger to children in care; or(2) States you have requested an administrative review of the deficiency, and we determine that extending the timeframe would not pose an immediate danger to children in care.(d) If you request an extension, we will notify you:(1) Whether we approve or deny your request for an extension to the compliance date; and(2) If we approve your request, what the new compliance date is.(e) If we approve your request for an extension, you must correct the deficiency within the new timeframe we specified or request a new extension. Source Note: The provisions of this §745.8447 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8447 What must I do if Licensing notifies me of a deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214304 03/12/2026 (a) The Texas Department of Family and Protective Services (DFPS) provides notifications regarding child abuse, neglect, and exploitation investigations, as provided in Title 40, Part 19, Chapter 707, Subchapter C, Division 3 (relating to Notification), including:(1) Notification to Licensing of the investigation findings, any evidence gathered regarding possible minimum standard deficiencies, and any safety plan implemented; and(2) For an investigation in a residential child care operation, notification to the residential child care operation of the investigation findings and the name of the person alleged or designated as a perpetrator of child abuse, neglect, or exploitation.(b) Licensing will notify you of any statute, rule, or minimum standard deficiencies within 10 days after receiving the results from a DFPS child abuse, neglect, or exploitation investigation. Source Note: The provisions of this §745.8449 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8449 Who provides notices related to investigations of child abuse, neglect, and exploitation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214305 03/12/2026 (a) We maintain a record for each:(1) Operation that applies for a permit;(2) Regulated operation (a regulated operation's record was previously known as the operation's monitoring file);(3) Program or operation that we investigate as a possible unregulated operation;(4) Exemption determination that we make under §745.131 of this chapter (relating to How does a person or entity request that Licensing determine whether a program is exempt?) and any information that we gather to make such a determination; and(5) Individual who applies for an administrator's license.(b) Each record consists of one of the following or a combination of both:(1) Electronic records maintained in the Child Care Licensing Automated Support System (CLASS), including information related to inspections and investigations that we conduct; and(2) A hard copy or any digital files of information that is not included in CLASS, such as:(A) Pictures;(B) Applications;(C) Forms with signatures;(D) Correspondence from an applicant, permit holder, or others involved in the regulatory process; and(E) Other supporting documentation.(c) Records that we maintain are subject to retention periods that may affect the availability of a record that a person may request. Source Note: The provisions of this §745.8481 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8481 What types of child care records does Licensing maintain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219988 03/12/2026 We can provide most portions of a child care record to the public. However, the following lists the portions of a child care record that are confidential and will not be released to the public in any manner, unless noted as an exception in §745.8487 of this division (relating to Are there any exceptions that allow the portions of a child care record that are confidential to be released to the public or certain persons?):(1) Information concerning an open investigation, including:(A) Interviews with operation staff, foster parents or other caregivers, children, or any other person; and(B) Internal discussions by or among Licensing staff;(2) The name of the reporter and any information that identifies the reporter;(3) Information received or obtained from another agency, entity, or person, if that information is confidential under law, including information related to background checks as explained further in Subchapter F of this title (relating to Background Checks);(4) Any private information that is confidential under state or federal law, including:(A) A person's social security number;(B) A foster home screening, adoptive home screening, and post-placement adoptive report; and(C) Any information pertaining to pending court cases where the state is a party;(5) Any information that would interfere with:(A) An ongoing law enforcement investigation or prosecution;(B) A Texas Department of Family and Protective Services child abuse, neglect, or exploitation investigation; or(C) A Texas Health and Human Services Commission Long-Term Care Regulation adult abuse, neglect, or exploitation investigation;(6) The location of a family violence shelter or a victims of trafficking shelter center as defined by Texas Government Code §552.138;(7) Information pertaining to an individual who received services at a family violence shelter or a victims of trafficking shelter center;(8) Any photograph, audio or visual recording, or documentation of a child;(9) Information that is confidential as described in §745.8497 of this division (relating to What confidentiality requirements apply to a person who is an applicant for a permit, a permit holder, or a former permit holder?); and(10) Any other information that is confidential under state or federal law. Source Note: The provisions of this §745.8483 adopted to be effective August 23, 2023, 48 TexReg 3990; amended to be effective October 9, 2024, 49 TexReg 5779. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8483 What portions of a child care record are confidential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214307 03/12/2026 (a) In order to preserve the integrity and confidentiality of the Licensing inspection and investigation process, an operation or any person acting on the operation's behalf may not make a visual or audio recording, listen to, or eavesdrop on any:(1) Licensing interview with operation staff, foster parents or other caregivers, children, or any other person; or(2) Internal discussion by or among Licensing staff.(b) This section does not prohibit an individual from recording a Licensing interview with the individual. Source Note: The provisions of this §745.8485 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8485 Can an operation record the inspection or investigation process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214308 03/12/2026 Notwithstanding §745.8483 of this division (relating to What portions of a child care record are confidential?), the below exceptions allow certain portions of a child care record that are confidential to be released in the following manner:(1) Information obtained during an open investigation that was confidential under §745.8483(1) of this division is no longer confidential under that provision after the investigation is completed.(2) Information obtained during an open investigation that is otherwise confidential under §745.8483(1) of this division may be released to an operation if Licensing determines it is necessary to protect the health, safety, or well-being of a child and the release is compliant with applicable state and federal law including the federal Child Abuse Prevention and Treatment Act.(3) A foster home screening, adoptive home screening, and post-placement adoptive report is confidential under §745.8483(4)(B) of this division, but the screening or report may be released to:(A) The individual who is the subject of the screening or report; or(B) Any other person, if the Associate Commissioner for Child Care Regulation or designee determines the release of the screening or report is necessary to protect the health or safety of a child.(4) The location of a family violence shelter or a victims of trafficking shelter center is confidential under §745.8483(6) of this division, except for when the location of the shelter or center must be provided in a public hearing under Texas Human Resources Code §42.0461 because the shelter or center is a general residential operation that will provide services to children with emotional disorders. The operation does not have to identify that the operation intends to provide services to victims of human trafficking.(5) Any photograph, audio or visual recording, or documentation of a child is confidential under §745.8483(8) of this division, unless it is releasable under §745.8491 of this division (relating to Who can review or have a copy of a photograph, audio or visual recording, or documentation of a child that is in our records?). Source Note: The provisions of this §745.8487 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8487 Are there any exceptions that allow the portions of a child care record that are confidential to be released to the public or certain persons? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214309 03/12/2026 (a) Notwithstanding §745.8483 of this division (relating to What portions of a child care record are confidential?), we may provide a copy of the portions of a child care record that are confidential to the following persons and entities in the relevant situations:(1) Texas Health and Human Services Commission (HHSC) staff, including volunteers, as necessary to perform their assigned duties;(2) Texas Department of Family and Protective Services (DFPS) staff, including volunteers, as necessary to perform their assigned duties;(3) A single source continuum contractor (SSCC) that contracts with DFPS to provide community-based care in Texas Family Code, Subchapter B-1, Chapter 264, as necessary for the SSCC's staff, including volunteers, to perform the SSCC's duties under that subchapter;(4) Law enforcement personnel for the purpose of investigating a crime that is related to the record;(5) An administrative law judge or judge of a competent jurisdiction in a civil or criminal case arising out of a related inspection, investigation, or enforcement action; and(6) Any other person authorized by state or federal law to have a copy.(b) Notwithstanding subsection (a) of this section, Licensing, in consultation with the HHSC Legal Services Division, may withhold any information in its records if the release of that information would endanger the life or safety of any individual.(c) Notwithstanding §745.8483 of this division, a judge of a competent jurisdiction may order us to disclose otherwise confidential information if:(1) A party in a matter before the judge files a motion requesting the judge to compel us to disclose the information and provides notice to HHSC and any other interested parties;(2) After conducting a hearing and reviewing the information, including an audio or visual recording, the judge determines that disclosure is essential to the administration of justice and will not endanger the life or safety of any individual; and(3) The judge includes in the disclosure order any safeguards that the court finds appropriate.(d) Any person or entity that receives a copy of the portions of a child care record that are confidential under this section:(1) May only use the confidential information for the purpose or duty that authorized the release of the confidential information; and(2) May not release the confidential information to any person or entity that is not authorized to have the confidential information under this section. Source Note: The provisions of this §745.8489 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8489 Who may get a copy of the portions of a child care record that are confidential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214310 03/12/2026 (a) In addition to the persons and entities identified in §745.8489 of this division (relating to Who may get a copy of the portions of a child care record that are confidential?):(1) The parent of the child may get a copy of a photograph, audio or visual recording, or documentation of the child that is in our records; and(2) The following persons may review a photograph, audio or visual recording, or documentation of a child in our records, but may not have a copy:(A) Attorney ad litem, guardian ad litem, or court appointed special advocate of a child; and(B) The operation cited for a deficiency from the inspection or investigation during which the photograph was taken or the audio or visual recording, or documentation was made.(b) Any person or operation that receives a copy of a photograph, recording, or documentation of a child under subsection (a)(2) of this section:(1) May only use it for the purpose or duty that authorized the release of the photograph, recording, or documentation of a child; and(2) May not release it to any person or entity that is not authorized to have the photograph, recording, or documentation of a child under this section. Source Note: The provisions of this §745.8491 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8491 Who can review or have a copy of a photograph, audio or visual recording, or documentation of a child that is in our records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214311 03/12/2026 (a) DFPS investigations of child abuse, neglect, or exploitation remain confidential after DFPS provides the information to Licensing as described in Texas Human Resources Code §40.042(f).(b) A person must request information related to an investigation conducted by DFPS from DFPS.(c) We may release information related to a DFPS investigation in our records to:(1) An operation to support a licensing statute, rule, or minimum standard deficiency that we assessed against the operation, so long as we redact any confidential information;(2) An operation if Licensing determines that the operation needs the information to protect the health, safety, or well-being of a child, and the release is compliant with state and federal law including the federal Child Abuse Prevention and Treatment Act; or(3) Any other person or entity authorized by state or federal law to have a copy.(d) Any operation, person, or entity that receives information related to a DFPS child abuse, neglect, or exploitation investigation under this section:(1) May only use the DFPS investigation information for the purpose or duty that authorized the release of the information; and(2) May not release the DFPS investigation information to any other person or entity that is not authorized to have the information under this section. Source Note: The provisions of this §745.8493 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8493 Will Licensing release any information related to a child abuse, neglect, or exploitation investigation conducted by the Texas Department of Family and Protective Services (DFPS)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219989 03/12/2026 (a) Except as provided by subsection (b) of this section, the following information regarding a person who is an applicant for a permit, a permit holder, or a former permit holder is confidential and may not be released to the public:(1) Home address;(2) Home telephone number;(3) Email address;(4) Social security number;(5) Date of birth;(6) Driver's license number;(7) State identification number;(8) Passport number;(9) Emergency contact information; and(10) Payment information.(b) The following information is not confidential or exempt from public disclosure under this section:(1) A home address that is also the operation's physical address;(2) A home telephone number that is also the operation's telephone number; and(3) An email address that is also the operation's email address. Source Note: The provisions of this §745.8497 adopted to be effective October 9, 2024, 49 TexReg 5779. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8497 What confidentiality requirements apply to a person who is an applicant for a permit, a permit holder, or a former permit holder? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214312 03/12/2026 (a) Technical assistance is additional information or clarification we provide to help you understand and comply with licensing statutes, rules, and minimum standards.(b) Technical assistance is not a deficiency or an enforcement action. Our provision of technical assistance does not affect our ability to issue a deficiency or take an enforcement action. Source Note: The provisions of this §745.8581 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8581 What is technical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214313 03/12/2026 We may provide technical assistance orally or in writing:(1) At any time during or at the conclusion of an inspection or investigation, including on the inspection form or investigation letter, regardless of whether the operation is deficient or in compliance with a particular licensing statute, rule, or minimum standard;(2) As part of the ongoing regulatory process; or(3) At your request. Source Note: The provisions of this §745.8583 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8583 When does Licensing provide technical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214314 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=214314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 214314 03/12/2026 No. We provide technical assistance to help you understand and comply with licensing statutes, rules, and minimum standards. Technical assistance does not include a decision or action you may challenge through an administrative review. If we provide you with technical assistance in addition to citing you for a deficiency, you will have the right to request an administrative review related to the deficiency but not the technical assistance. Source Note: The provisions of this §745.8585 adopted to be effective August 23, 2023, 48 TexReg 3990. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING K INSPECTIONS, INVESTIGATIONS, AND CONFIDENTIALITY §745.8585 May I request an administrative review for technical assistance that Licensing provided? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204739 03/12/2026 (a) The rules in this subchapter contain:(1) The different types of actions that we use to enforce the requirements in minimum standards, rules, and statutes; and(2) The criteria that we use to determine what type of enforcement action we will take in specific circumstances.(b) Our goal with respect to enforcement is to ensure the safety of children in care that is subject to our regulation. Our use of enforcement actions is tailored toward the objective of safety and not to be punitive in nature. Source Note: The provisions of this §745.8600 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8600 What is the general purpose of the rules in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204740 03/12/2026 If you are deficient in a minimum standard, rule, statute, specific term of your permit, or a condition of probation, we may take one or both of the following actions:(1) Offer technical assistance; or(2) Recommend or impose an enforcement action against your permit. Source Note: The provisions of this §745.8601 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8601 What happens if I am deficient in a minimum standard, rule, statute, specific term of my permit, or condition of probation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204741 03/12/2026 (a) We may recommend a voluntary plan of action or impose a more serious enforcement action as outlined in the following chart: Attached Graphic(b) We may impose an action listed in subsection (a) of this rule any time we determine there is a reason for imposing the action. We will choose the action based on its appropriateness in relation to the situation we are seeking to address. We do not have to recommend or impose a less restrictive action if we determine that a more restrictive action is more appropriate. (c) In some situations, we may take multiple types of actions against your operation at the same time. For example, if you continue to operate pending the appeal of a denial, we may pursue a judicial action to prevent you from operating without a permit. Source Note: The provisions of this §745.8603 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8603 What enforcement actions may Licensing recommend or impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224585 03/12/2026 We can recommend or impose an enforcement action any time we find one of the following: (1) You supplied false information or made false statements during the application process; (2) You falsified or permitted to be falsified any record or other materials that are required to be maintained by minimum standards; (3) You do not have an acceptable reason for not having the required liability insurance in §745.251 of this chapter (relating to What are the acceptable reasons not to have liability insurance?); (4) You do not pay the required fees; (5) A single serious deficiency of a minimum standard, rule, or statute, including a finding of abuse or neglect or background check matches; (6) Several deficiencies that create an endangering situation; (7) A repetition or pattern of deficiencies; (8) An immediate threat or danger to the health or safety of children; (9) You or someone working at your operation refuses, prevents, or delays our ability to conduct an inspection or investigation, or the ability of the Department of Family and Protective Services to conduct an investigation of an allegation of abuse, neglect, or exploitation; (10) A failure to timely report necessary changes to Licensing; (11) A failure to comply with any restrictions or limits placed on your permit; (12) A failure to meet the terms and conditions of your probation; (13) A failure to comply with minimum standards, rules, or statutes at the end of the suspension period; (14) A failure to submit information to us within two days of a change in your controlling persons, as required in §745.903 of this chapter (relating to When and how must an operation submit controlling-person information to Licensing?); (15) You fail to correct by the compliance date any deficiency that is not pending due process; (16) You apply for a permit after we designate you as a controlling person, but before the designation is sustained; (17) It is within five years since your designation as a controlling person has been sustained; (18) You apply for a permit to operate a child care operation, and you are barred from operating a child care operation in another state; (19) You apply for a permit to operate a child care operation, and your permit to operate a child care operation in another state was revoked; (20) You apply for a permit to operate a child care operation, and your permit to operate was revoked, suspended, or terminated by another Texas state agency as outlined in Texas Government Code Chapter 526, Subchapter J; (21) You apply for a permit to operate a child care operation and: (A) You fail to comply with public notice and hearing requirements as set forth in §745.277 of this chapter (relating to What will happen if I fail to comply with public notice and hearing requirements?); or (B) The results of the public hearing meet one of the criteria set forth in §745.340(b) of this chapter (relating to What factors will we consider when evaluating an application for a permit?). (22) You operate a child care operation, and that operation discharges or retaliates against an employee, client, resident, or other person because the person or someone on behalf of the person files a complaint, presents a grievance, or otherwise provides in good faith, information relating to the misuse of restraint or seclusion at the operation; (23) A reason set forth in Texas Human Resources Code, §42.078; (24) A failure to pay an administrative penalty under Texas Human Resources Code, §42.078; (25) A failure to follow conditions or restrictions placed on a person's presence at an operation; (26) During the application process you were exempt from the public notice and hearing requirements under §745.273(b) of this chapter (relating to Which residential child-care operations must meet the public notice and hearing requirements?), but you never provide or cease to provide trafficking victim services and fail to meet the public notice and hearing requirements; or (27) You provide care to an unlawfully present individual in violation of Chapter 748, Subchapter B, Division 3 of this title (relating to Care of Unlawfully Present Individuals). Source Note: The provisions of this §745.8605 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective October 1, 2004, 29 TexReg 9206; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective March 1, 2015, 40 TexReg 834; amended to be effective March 1, 2016, 41 TexReg 1123; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437; amended to be effective July 8, 2022, 47 TexReg 4336; amended to be effective April 1, 2025, 50 TexReg 2211. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8605 When can Licensing recommend or impose an enforcement action against my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204743 03/12/2026 We decide to recommend or impose enforcement actions based upon our assessment of the following:(1) The severity of any deficiency that is a reason for the enforcement action, including whether the deficiency involved the abuse or neglect or resulted in the death or near fatal injury of a child;(2) The severity and frequency of a repetition or pattern of deficiencies;(3) The extent to which a deficiency or repetition or pattern of deficiencies can be corrected;(4) How quickly you can make the necessary correction (for a suspension, whether the deficiency can be corrected within the suspension period);(5) Whether you demonstrate the responsibility and ability to maintain compliance with minimum standards, rules, and statutes;(6) Whether we must impose conditions to avoid further deficiencies;(7) Your compliance history;(8) The degree or immediacy of danger or threat of danger posed to the health or safety of children; and(9) Any aggravating or mitigating factors. Source Note: The provisions of this §745.8607 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8607 How will Licensing decide which type of enforcement action to recommend or impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195924 03/12/2026 We will not impose an enforcement action against a child-placing agency or general residential operation based on the conduct of a foster parent or designated person who appropriately followed the reasonable and prudent parent standard when determining whether a child will be allowed to participate in a childhood activity. Source Note: The provisions of this §745.8608 adopted to be effective January 1, 2017, 41 TexReg 9943; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8608 How will Licensing implement the "reasonable and prudent parent standard" when determining whether to impose an enforcement action against a child-placing agency or general residential operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204744 03/12/2026 We will notify you in the following manner: Attached Graphic Source Note: The provisions of this §745.8609 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8609 How will I know when Licensing is recommending or imposing an enforcement action against my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204745 03/12/2026 (a) The following chart describes the length of time that we may recommend or impose an enforcement action:Attached Graphic(b) The court will specify the timeframe for a Judicial Action/Temporary Restraining Order and any extensions. (c) We may end a voluntary or corrective action early if we determine: (1) That you meet minimum standards and any imposed conditions, and we are able to evaluate for ongoing compliance; or (2) Your compliance does not improve and a more restrictive enforcement action is necessary. Source Note: The provisions of this §745.8611 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8611 How long do enforcement actions that cover a specific period of time last? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204746 03/12/2026 (a) The rights you have vary depending upon the type of enforcement action that we recommend or take against you. The chart in this subsection describes your rights to challenge each type of enforcement action: Attached Graphic(b) For additional information regarding administrative reviews and due process hearings, see Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.8613 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9333; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8613 What rights do I have to challenge an enforcement action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204747 03/12/2026 We may recommend or impose the following types of voluntary or corrective actions: Attached Graphic Source Note: The provisions of this §745.8631 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8631 What types of voluntary or corrective actions may Licensing recommend or impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204748 03/12/2026 (a) Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may recommend a voluntary plan of action for your operation for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) You:(A) Demonstrate the ability to identify risk;(B) Accept responsibility for correcting deficiencies; and(C) Have the ability to make corrections;(2) If applicable, your operation has a history of making corrections to maintain compliance;(3) Your operation can reduce risk by following the plan in addition to complying with minimum standards; and(4) Your operation has not participated in a voluntary plan of action during the previous 12 months for similar issues.(b) If you are responsible for multiple operations, we may consider your compliance history at any of those multiple operations when we use the factors listed in subsection (a) of this section to determine your eligibility to participate in a voluntary plan of action.(c) We will impose a more restrictive enforcement action instead of recommending a voluntary plan of action when appropriate under the criteria for that enforcement action. Source Note: The provisions of this §745.8633 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8633 When may Licensing recommend a voluntary plan of action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204749 03/12/2026 You must:(1) Correct the deficiencies and reduce risk through your compliance with the plan of action; and(2) Maintain compliance with all other minimum standards, rules, and statutes. Source Note: The provisions of this §745.8635 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8635 What requirements must I meet during a voluntary plan of action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204750 03/12/2026 (a) Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may place your operation on probation for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) Your operation:(A) Is eligible to participate in a voluntary plan of action, but you refuse to do so; or(B) Does not qualify for a voluntary plan of action, including not meeting all of the requirements in §745.8633 of this division (relating to When may Licensing recommend a voluntary plan of action?);(2) Your operation has not demonstrated the ability to make the necessary changes to reduce risk, but expresses a willingness to comply and make corrections;(3) Your operation can reduce risk by complying with the conditions identified in the corrective action plan in addition to minimum standards; and(4) A more restrictive enforcement action is not necessary to reduce risk.(b) If you are responsible for multiple operations, we may consider your compliance history at any of those operations when we use the factors listed in subsection (a) of this section to determine your eligibility for probation.(c) If we determine that are you not eligible for probation, we will consider imposing an adverse action. Source Note: The provisions of this §745.8637 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8637 When may Licensing place my operation on probation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204751 03/12/2026 You must:(1) Comply with all of the conditions imposed by the corrective action plan;(2) Correct the deficiencies and reduce risk;(3) Unless you are an independent or agency foster family home, post the probation notice or copy in prominent places near all public entrances; and(4) Maintain compliance with all other minimum standards, rules, and statutes. Source Note: The provisions of this §745.8641 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8641 What requirements must I meet during the probation period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204752 03/12/2026 If your operation's compliance with minimum standards, rules, or statutes does not improve sufficiently to reduce risk at your operation as a result of the voluntary plan of action or corrective action plan, we will reevaluate your plan to determine the appropriateness of its terms and conditions. As a result, we may take one or more of the following actions:(1) Recommend or impose additional conditions;(2) Increase inspections; or(3) Impose a more serious enforcement action. Source Note: The provisions of this §745.8643 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8643 What may Licensing do if my operation's compliance with minimum standards, rules, or statutes does not improve as a result of the voluntary plan of action or corrective action plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204753 03/12/2026 We may impose the following adverse actions:Attached Graphic Source Note: The provisions of this §745.8649 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8649 What adverse actions may Licensing impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204754 03/12/2026 Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may deny you a permit for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) A background check result makes you ineligible for a permit, because either the result is ineligible for a risk evaluation or the Centralized Background Check Unit does not approve a risk evaluation as provided in Subchapter F of this chapter (relating to Background Checks);(2) Your operation does not demonstrate the ability to comply with minimum standards, rules, and during your initial permit period;(3) The results of a public hearing make you ineligible for a permit;(4) Your operation presents an immediate threat to the health or safety of children; or(5) You are otherwise ineligible for a permit because of a criterion identified in §745.8605 of this subchapter. Source Note: The provisions of this §745.8650 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8650 When may Licensing deny a permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204755 03/12/2026 Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may impose an adverse amendment on your permit for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) An amendment on your permit will reduce risk;(2) The amendment would be the most effective enforcement action to reduce risk at your operation; and(3) You will be able to follow the restrictions or conditions of the amendment. Source Note: The provisions of this §745.8651 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8651 When may Licensing impose an adverse amendment on my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204756 03/12/2026 Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may suspend your permit for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) Your operation will pose a danger or threat of danger to the health or safety of children in your operation's care until the issue is resolved;(2) You cannot correct the issue while children are in care, but you can do so during a specific period of time;(3) You can make the necessary corrections while your permit is suspended; and(4) There are no additional concerns about your compliance history that would make revocation a more appropriate enforcement action for the health or safety of children. Source Note: The provisions of this §745.8652 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8652 When will Licensing suspend my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204757 03/12/2026 (a) When your suspension period ends, we will assess whether:(1) You have resolved all the issues that were the basis for the suspension;(2) There are any new issues identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?); or(3) There is any unresolved issue or new issue that would pose a danger or threat of danger to the health or safety of children in your care.(b) Following our assessment, we may either end the suspension or take any further enforcement action as described in this subchapter. Source Note: The provisions of this §745.8653 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8653 What happens when my suspension period ends? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204760 03/12/2026 Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may revoke your permit for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we determine that:(1) Your operation is ineligible for corrective action;(2) We cannot reduce the risk at your operation by placing your operation on probation or suspending your permit;(3) A background check result or a finding of abuse or neglect makes you ineligible for a permit, either because the result is ineligible for a risk evaluation or the Centralized Background Check Unit will not approve a risk evaluation as provided in Subchapter F of this chapter (relating to Background Checks); or(4) Revocation is otherwise necessary to address the issue identified in §745.8605 of this subchapter. Source Note: The provisions of this §745.8654 adopted to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8654 When may Licensing revoke my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204761 03/12/2026 (a) Based on our assessment of the criteria provided in §745.8607 of this subchapter (relating to How will Licensing decide which type of enforcement action to recommend or impose?), we may refuse to renew your permit for an issue identified in §745.8605 of this subchapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) if we:(1) Cannot take another type of enforcement action because:(A) Your operation is ineligible for corrective action; or(B) The action would not resolve the issue or reduce risk at your operation;(2) Determine that a background check result or a finding of abuse or neglect makes you ineligible for a permit, either because the result is ineligible for a risk evaluation or the Centralized Background Check Unit does not approve a risk evaluation as provided in Subchapter F of this chapter (relating to Background Checks); or(3) Otherwise refuse to renew your permit to address the issue identified in §745.8605 of this subchapter.(b) We may refuse to renew your permit at any point before or after the renewal period expires. For example, if there is a finding of abuse or neglect that makes you ineligible for a permit, then we may refuse to renew your permit before the expiration of your permit.(c) The basis for refusing to renew your permit may be based on grounds that occurred before or after the renewal period expires.(d) If we are:(1) Refusing to renew your permit, we do not also have to revoke your permit; or(2) Revoking your permit before or after the renewal period expires, we do not also have to refuse to renew your permit.(e) You are entitled to an administrative review and a due process hearing if we refuse to renew your permit. You may continue to operate pending the outcome of the administrative review and due process hearing unless we determine the operation poses an immediate threat or danger to the health or safety of children.(f) For other rules relating to renewals, see Division 12 of Subchapter D (relating to Permit Renewal). Source Note: The provisions of this §745.8655 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8655 When may Licensing refuse to renew my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204758 03/12/2026 (a) You must post the notice of the adverse action or a copy in prominent places near each public entrance. You must post this notice as soon as you receive it.(b) You must notify the parents of each child in your care that we are attempting to take adverse action. You must send a copy of the notice of the adverse action from us to the parents within five days of your receipt of the notice. You must send the notice by certified mail and give us a copy of each return receipt (the green card) within five days after the receipt is returned to you.(c) Neither of these notice requirements apply to:(1) A denial; or(2) An adverse amendment. Source Note: The provisions of this §745.8656 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8656 Are there any notice requirements when Licensing attempts to take adverse action against my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204759 03/12/2026 (a) The fact that we are attempting to deny, suspend, revoke, or refuse to renew your permit is available to the public.(b) We will inform the following that we are attempting to suspend, revoke, or refuse to renew your permit:(1) The Texas Workforce Commission Local Workforce Board or the Child and Adult Care Food Program, if you are a child day-care operation participating in that program;(2) The Department of Family and Protective Services (DFPS), if you are a residential child care operation who cares for a child in DFPS conservatorship; or(3) Any other state or federal program or agency, as appropriate.(c) When we inform a program or agency under subsection (b), we will include whether you may care for children pending any due process. Source Note: The provisions of this §745.8657 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8657 Whom may Licensing inform when attempting to deny, suspend, revoke, or refuse to renew my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204762 03/12/2026 (a) If you waive the administrative review and due process hearing or if the denial, suspension, revocation, or refusal to renew your permit is upheld in the process, we will publish a notice of the adverse action taken against you on the Licensing consumer website along with other information regarding your child-care services.(b) In addition, we will send notification of the outcomes of the administrative review and the due process hearing to those state and federal programs or agencies that we previously informed of the adverse action. Source Note: The provisions of this §745.8659 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective March 1, 2010, 35 TexReg 881; amended to be effective September 1, 2016, 41 TexReg 6234; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8659 Will there be any publication of the denial, suspension, revocation, or refusal to renew my permit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204763 03/12/2026 If you are operating at the time you receive the final notice, you must notify the parents of each child that is enrolled of the denial, suspension, revocation, or refusal to renew your permit. You must send notice of this action to the parents by certified mail within five days of the receipt of the notice of the denial, suspension, revocation, or refusal to renew. Source Note: The provisions of this §745.8661 adopted to be effective January 1, 2007, 31 TexReg 9333; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8661 What notice must I provide parents when the denial, suspension, or revocation of my permit is final? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204772 03/12/2026 Only courts may impose judicial actions. The judicial actions we may ask the court to order include the following: Attached Graphic Source Note: The provisions of this §745.8681 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8681 What judicial actions may Licensing impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204773 03/12/2026 (a) The fact that we are taking a judicial action against your operation is available to the public.(b) We will inform the following that we are taking a judicial action against your operation:(1) The Texas Workforce Commission Local Workforce Board or the Child and Adult Care Food Program, if you are a child day-care operation participating in that program;(2) The Department of Family and Protective Services (DFPS), if you are a residential child care operation who cares for a child in DFPS conservatorship; or(3) Any other state or federal program or agency, as appropriate.(c) When we inform a program or agency under subsection (b) of this section, we will include whether:(1) We have obtained a temporary restraining order preventing your operation from caring for children;(2) We are attempting to extend the order or make it permanent; and(3) Your operation may care for children pending a final hearing in the matter. Source Note: The provisions of this §745.8683 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8683 Whom may Licensing inform when taking a judicial action against my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204774 03/12/2026 (a) When a court orders you to close your operation immediately:Attached Graphic(b) In addition to notifying the parents as required in subsection (a) of this section, within five days of delivery of the temporary restraining order (TRO) you must inform the parents of each child in care or enrolled in the operation of the reason for the closure and the length of the closure by: (1) Sending to each parent a copy of the TRO by certified mail and giving us a copy of each return receipt (the green card) within five days after the receipt is returned to you; or (2) Delivering a copy of the TRO in person to the parents when the child is picked up from your care and giving us a copy of an acknowledgment of receipt of the TRO that the parents signed. Source Note: The provisions of this §745.8685 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8685 What steps must I take regarding children in my care when a court orders me to close my operation immediately? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204775 03/12/2026 Yes, once there is a final court order, we will publish a notice of the judicial action taken against you on Licensing's consumer website. In addition, we will send notifications of the outcome of the final judicial action to those state and federal programs or agencies that we had previously informed of the judicial action. Source Note: The provisions of this §745.8687 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8687 Will there be any type of publication of the judicial action taken against me? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204771 03/12/2026 We may impose administrative penalties or ask the court to order civil penalties, which are described below:Attached Graphic Source Note: The provisions of this §745.8711 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective March 1, 2014, 39 TexReg 1182; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8711 What monetary actions may Licensing impose? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204768 03/12/2026 (a) We may impose an administrative penalty before imposing a corrective action any time we find a deficiency of a high risk minimum standard, including a deficiency for:(1) The abuse, neglect, or exploitation of a child;(2) A safety hazard standard;(3) A safe sleeping standard;(4) Any standard establishing times for reporting information to a parent or Licensing;(5) A supervision standard; or (6) One of the following background check standards: (A) A failure to timely submit the information required to conduct a background check under Subchapter F of this chapter (relating to Background Checks) on two or more occasions; (B) You knowingly allow a person to be present at your operation before you receive notification from the Centralized Background Check Unit (CBCU) that a person is eligible, eligible with conditions, or provisionally eligible with conditions to be present at your operation; (C) You knowingly allow a subject of a background check to be present at your operation after you have received notification from the CBCU that the subject is ineligible to be present at your operation; or (D) You violate a condition or restriction that the CBCU has placed on the subject of a background check at your operation as part of the CBCU background check determination. (b) For more information regarding deficiencies that may result in an administrative penalty, go to the Child Care Regulation Enforcement Actions page on hhs.texas.gov. Source Note: The provisions of this §745.8713 adopted to be effective March 1, 2014, 39 TexReg 1182; amended to be effective September 1, 2016, 41 TexReg 6234; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8713 When may Licensing impose an administrative penalty before a corrective action? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204769 03/12/2026 (a) Except for subsection (b) of this section, an administrative penalty for a deficiency is based on the maximum number of children the operation is authorized to provide care for or the number of children under the care of a child-placing agency, and may not exceed the following amounts:(1) For deficiencies that occur in a child day-care operation:Attached Graphic(2) For deficiencies that occur in a residential child-care operation:Attached Graphic(b) For the following deficiencies, Licensing must recommend the following penalty amounts:Attached Graphic(c) For a penalty that Licensing assesses under subsection (a) of this section, Licensing may assess the penalty for each day the deficiency occurs.(d) For penalty that Licensing assesses under subsections (b)(3) - (b)(5), Licensing must recommend $50 for the initial deficiency and an additional $50 for each day the deficiency continues to occur. Source Note: The provisions of this §745.8714 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8714 What penalty amounts must Licensing recommend for certain deficiencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204770 03/12/2026 We may impose an administrative penalty against a controlling person when the controlling person:(1) Violates a term of a license or registration;(2) Makes a statement about a material fact that the person knows or should know is false:(A) On an application for the issuance of a license or registration or an attachment to the application; or(B) In response to a matter under investigation;(3) Refuses to allow a representative of Licensing to inspect:(A) A book, record, or file required to be maintained by the child care operation; or(B) Any part of the premises of the child care operation;(4) Purposefully interferes with the work of a Licensing representative or the enforcement of Texas Human Resources Code (HRC), Chapter 42; or(5) Fails to pay a penalty assessed under HRC, Chapter 42, on or before the date the penalty is due as determined under HRC §42.078. Source Note: The provisions of this §745.8715 adopted to be effective April 25, 2021, 46 TexReg 2437. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING L ENFORCEMENT ACTIONS §745.8715 When may Licensing impose an administrative penalty against a controlling person? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225840 03/12/2026 (a) An administrative review is an informal review that determines whether a decision or action was appropriate under applicable laws and rules. An administrative review is not a formal hearing and does not involve formal examination and cross-examination of witnesses. (b) The scope of an administrative review is based on the specific decision or action that is the subject of the review, as described in the following chart.Attached Graphic(c) If you request an administrative review to dispute a deficiency, we may consider the deficiency when determining whether to impose an enforcement action and we may issue notice of intent to impose an enforcement action before the person who conducts the administrative review issues a decision on the deficiency. If the person who conducts the review overturns the deficiency, we will consider that outcome when determining whether to continue with the enforcement action and during an administrative review related to the enforcement action.(d) If you do not waive your right to request an administrative review, we may not finalize any decision or action that is the subject of the review until you exhaust your due process rights concerning the decision or action. However, you may not be able to operate pending due process for some enforcement actions as provided by Division 3 of this subchapter (relating to Operating Pending an Administrative Review and Due Process Hearing). Source Note: The provisions of this §745.8801 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8801 Introduction https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225841 03/12/2026 (a) The following chart describes who may request an administrative review to dispute a decision or action: Attached Graphic(b) An owner, partner, governing body, director, licensed administrator, or designee of an operation may not request an administrative review to dispute: (1) An automatic suspension or revocation of a permit under Texas Human Resources Code (HRC) §§42.048(e), 42.052(j), or 42.054(f); (2) The implementation of a court order against the operation; (3) An emergency suspension or closure of the operation under HRC §42.073; (4) A determination that the operation poses an immediate threat or danger to the health or safety of children;(5) An imposition of an administrative penalty against the operation; or(6) An allegation against an administrator's license or administrator's license application as listed in §745.9037 of this chapter. Source Note: The provisions of this §745.8803 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8803 Administrative Review Requestors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225842 03/12/2026 (a) To request an administrative review, a person must submit a written request by regular mail, email, or fax to the name and address indicated in the notification letter or inspection report. (b) The written request must: (1) Describe the specific decision or action that the requestor is disputing; (2) Describe the reasons why the decision or action should not be upheld; (3) Include any documentation, if applicable, that supports the requestor's position, such as photographs, diagrams, or written and signed statements; and (4) Be timely. (c) For a request to be timely: (1) A mailed request must be postmarked within 15 days after the person receives notification of the right to request an administrative review; or (2) An emailed or faxed request must be received within the 15 days after the person receives notification of the right to request an administrative review. (d) When determining whether a request was made timely: (1) If the notification or inspection report was delivered in person or by email: (A) Add 15 calendar days to the date the notification or inspection report was delivered; and (B) Identify the first date after adding the 15 calendar days that is not a Saturday, Sunday, or legal holiday; or (2) If the notification or inspection report was delivered by regular mail: (A) Add 18 calendar days to the date the notification or inspection report was mailed (a requestor is presumed to have received the notification or inspection report three days after it was mailed); and (B) Identify the first date after the 18 calendar days that is not on a Saturday, Sunday, or legal holiday. (e) Requesting records for an administrative review.(1) Upon notice of a Texas Health and Human Services Commission (HHSC) decision or action for which you may request an administrative review, you may request a copy of an investigation report or administrator licensure records related to the subject of the administrative review from the following databases. This request must be made before we schedule an administrative review if we determine that the investigation report or administrator licensure records are directly related to the decision or action. Request the report or records from the:(A) Texas Department of Family and Protective Services Information Management Protecting Adults and Children in Texas; and(B) HHSC Child-Care Licensing Automation Support System.(2) HHSC must receive the request under paragraph (1) of this subsection via email or by online submission within the timeframe for requesting the administrative review as described in §745.8805 of this division (relating to How to Request an Administrative Review). You must provide verification to HHSC that you made the records request within the 15-day timeframe.(3) Except as described in paragraph (4) of this subsection, HHSC will proceed with the administrative review process according to timeframes identified in this subchapter after HHSC has produced documents described in paragraph (1) of this subsection.(4) HHSC will not delay the administrative review process for you to obtain a record if:(A) The record is not an investigation report or administrator licensure record from a database listed in paragraph (1) of this subsection; (B) You did not request the record as described in paragraph (2) of this subsection;(C) We determine that the record is not directly related to the decision or action that is the subject of the administrative review;(D) You were provided the record prior to your administrative review request; or(E) The record is related to a deficiency for which you waived the right to an administrative review under §745.8805 of this division or that was upheld prior to the request. Source Note: The provisions of this §745.8805 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8805 How to Request an Administrative Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225843 03/12/2026 (a) A person waives the right to an administrative review by: (1) Failing to meet the requirements of §745.8805 of this division (relating to How to Request an Administrative Review); or (2) Submitting a written statement stating that the person waives the right to the administrative review. (b) If a person waives the right to an administrative review, the decision or action will be upheld. When applicable, the Texas Health and Human Services Commission will send a notice of the right to a due process hearing as set forth in Division 2 of this subchapter (relating to Due Process Hearings). If the person does not have a right to a due process hearing, the decision or action will be final. Source Note: The provisions of this §745.8807 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8807 Waiving the Right to an Administrative Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225844 03/12/2026 (a) Administrative Reviews are conducted by Texas Health and Human Services Commission Regulatory Enforcement staff. (b) The person conducting an administrative review must not have: (1) Directly supervised the person making the decision or action or conducting the inspection or investigation that is being reviewed; or (2) Otherwise, been involved in the original decision, action, inspection, or investigation. Source Note: The provisions of this §745.8809 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8809 Administrative Review Conductors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225845 03/12/2026 (a) The person conducting an administrative review may conduct the review by telephone conference, including virtual conferencing, or in a face-to-face meeting at the person's office. (b) Within 10 calendar days after receiving a request that meets the requirements of §745.8805 of this division (relating to How to Request an Administrative Review), the person conducting the administrative review will contact the requestor to schedule a date and time to conduct the review. (c) Subject to the limitations in subsection (h) of this section, the telephone conference or meeting must occur within 30 days of the date of the initial contact described in subsection (b) of this section, unless additional time is necessary to complete a records request related to the subject of the administrative review. If additional time is necessary, the 30-day timeframe for completing the conference or meeting will begin when the requestor obtains the records. (d) The person conducting the administrative review will proceed with the review without conducting the telephone conference or meeting if: (1) The requestor does not respond to the person's attempts to schedule the conference or meeting within the 30-day timeframe and does not show good cause for the requestor's failure to respond within the timeframe; (2) The requestor does not schedule the conference or meeting within the 30-day timeframe and does not show good cause for the requestor's failure to schedule the conference or meeting within the timeframe; or (3) The requestor misses the scheduled conference or meeting without requesting a delay under subsection (e) of this section. (e) To delay the telephone conference or meeting, the requestor must present a good cause reason for a delay, in writing, to the person conducting the administrative review before the time of the scheduled telephone conference or meeting. The person conducting the review will decide whether good cause exists to delay the conference or meeting. (f) "Good cause" in this section is a reason for taking an action or failing to take an action that is reasonable and justified when viewed in the context of the surrounding circumstances. (g) Following the telephone conference or meeting, the person conducting the administrative review will review any documentation the requestor provided, may review any other relevant files, may ask additional questions, and may gather other relevant information, as needed. (h) When an operation has been cited for the abuse, neglect, or exploitation of a child in care, an administrative review for a deficiency in the following will be postponed while the finding is pending an administrative review before the Texas Department of Family and Protective Services: (1) A standard related to ensuring that no child is abused, neglected, or exploited while in the care of the operation; or (2) A standard stating that the child has the right to be free from abuse, neglect, or exploitation. Source Note: The provisions of this §745.8811 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8811 Conducting an Administrative Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225846 03/12/2026 (a) The person conducting an administrative review may uphold or overturn the decision or action. (b) If the telephone conference or meeting did not occur for a reason outlined in §745.8811(d) of this division (relating to Conducting an Administrative Review), the person conducting the administrative review will base the decision to uphold or overturn the decision or action on the written request for a review, any supporting documentation submitted with the request, and any other information that the person gathered. (c) If the person conducting the administrative review overturns the decision or action, the Texas Health and Human Services Commission (HHSC) will update HHSC records to reflect the change. (d) If the requestor has the right to request a due process hearing related to the upheld decision or action, the upheld decision or action will be the subject of the hearing. (e) If the requestor does not have the right to request a due process hearing, the upheld decision or action will be final. Source Note: The provisions of this §745.8813 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8813 Administrative Review Decisions and Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225847 03/12/2026 (a) The person conducting the administrative review will prepare and send a written decision to the requestor within the following timeframes, unless the person determines good cause exists to extend the relevant timeframe: (1) Within 21 calendar days of conducting the telephone conference or meeting; or (2) Within 60 days of the request for an administrative review, if the telephone conference or meeting was not held for a reason outlined in §745.8811(d) of this division (relating to Conducting an Administrative Review). (b) "Good cause" in this section has the same meaning as stated in §745.8811(f) of this division. Source Note: The provisions of this §745.8815 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8815 Timeframe for Administrative Review Decisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212066 03/12/2026 A due process hearing is a formal legal proceeding before an administrative law judge of the State Office of Administrative Hearings to determine whether a decision or action was appropriate under applicable laws and rules. Source Note: The provisions of this §745.8831 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8831 What is a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212067 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212067&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212067 03/12/2026 The Legal Enforcement Department is the department of the Legal Services Division of the Texas Health and Human Services Commission (HHSC) that represents HHSC during due process hearings and handles other matters related to these hearings. Source Note: The provisions of this §745.8833 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8833 What does "Legal Enforcement Department" mean in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225848 03/12/2026 (a) The following chart describes who may request a due process hearing to dispute a decision or action.Attached Graphic(b) An owner, partner, governing body, director, licensed administrator, or designee of an operation may not request a due process hearing to dispute:(1) An automatic suspension or revocation of a permit under Texas Human Resources Code (HRC) §§42.048(e), 42.052(j), or 42.054(f);(2) The implementation of a court order against the operation;(3) An emergency suspension or closure of the operation under HRC §42.073; or(4) A determination that the operation poses an immediate threat or danger to the health or safety of children. Source Note: The provisions of this §745.8835 adopted to be effective January 26, 2023, 48 TexReg 220; amended to be effective August 14, 2025, 50 TexReg 5227. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8835 Who may request a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212069 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212069&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212069 03/12/2026 (a) To request a due process hearing, a person must send a written request to the Docket Clerk for Licensing in the Legal Enforcement Department at the mailing address, email address, or fax number listed in the notice informing the person of the right to request a due process hearing.(b) The written request must:(1) Describe the specific decision or action that the requestor is disputing;(2) Describe the reasons why this decision or action should not be upheld;(3) Include a copy of the notification letter informing the requestor of the right to request a due process hearing;(4) Include the requestor's mailing address, even if the request is by email or fax; and(5) Be timely.(c) For a request to be timely:(1) A mailed request must be postmarked within 30 days after the person receives notification of the right to request a due process hearing;(2) An emailed or faxed request must be received within the 30 days after the person receives notification of the right to request a due process hearing; and(d) When determining whether a request was made timely:(1) If the notification of the right to request a due process hearing was delivered in person:(A) Add 30 calendar days to the date the notification was delivered; and(B) Identify the first date after adding the 30 calendar days that is not a Saturday, Sunday, or legal holiday; or(2) If the notification of the right to request a due process hearing was delivered by regular mail:(A) Add 33 calendar days to the date the notification was mailed (a requestor is presumed to have received the notification three days after it was mailed); and(B) Identify the first date after the 33 calendar days that is not on a Saturday, Sunday, or legal holiday. Source Note: The provisions of this §745.8837 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8837 How does a person request a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212070 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212070&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212070 03/12/2026 (a) After a person requests a due process hearing, the Legal Enforcement Department will ask the State Office of Administrative Hearings (SOAH) to appoint an administrative law judge to conduct a hearing to make a final decision regarding whether the decision or action was appropriate under applicable laws and rules.(b) After SOAH assigns a docket number to the case:(1) The Legal Enforcement Department will send the requestor a notice of the hearing by regular and certified mail to the last known address noted in the records; or(2) If the Docket Clerk has received written notice of representation from an attorney who will be representing the requestor at the hearing, the Legal Enforcement Department will send the notice to the attorney in a manner allowed under the rules referenced in §745.8845 of this division (relating to How is a due process hearing conducted?). Source Note: The provisions of this §745.8839 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8839 What is the process for scheduling a due process hearing and notifying the requestor? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212071 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212071&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212071 03/12/2026 (a) The requestor is responsible for notifying the Docket Clerk in writing of any change in the requestor's address that occurs after the initial request for a hearing.(b) If the requestor fails to notify the Docket Clerk of an address change, the last address that the requestor provided to the Docket Clerk will remain the address of record for any notice that the Legal Enforcement Department sends the requestor. Source Note: The provisions of this §745.8841 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8841 What happens if a requestor's address changes after the initial request for a hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212072 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212072&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212072 03/12/2026 (a) If the request for a due process hearing relates to a Central Registry finding of child abuse, neglect, or exploitation that was not conducted in a child care operation under Texas Administrative Code, Title 40, Chapter 707, Subchapter C (relating to Child Care Investigations), the Legal Enforcement Department may nullify the request upon determining that the requestor is no longer present at the operation that requested the original background check on the requestor.(b) A nullification will not affect the requestor's ability to dispute the finding in relation to a future background check.(c) The Legal Enforcement Department may not nullify a request for a hearing if:(1) The requestor is not present at the operation because Licensing determined that the requestor is ineligible to be present at the operation because of the finding, unless the requestor agrees to the nullification; or(2) The Texas Health and Human Services Commission is taking adverse action against an operation because of the finding. Source Note: The provisions of this §745.8843 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8843 When may the Legal Enforcement Department nullify a request for a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212073 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212073&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212073 03/12/2026 A due process hearing is conducted according to the following procedural rules, which are incorporated into this rule by reference:(1) Rules of the State Office of Administrative Hearings (SOAH) found at Texas Administrative Code, Title 1, Part 7, Chapter 155 (relating to Rules of Procedure);(2) Applicable provisions of the Texas Government Code, Chapter 2001, Administrative Procedures Act (APA); and(3) The Texas Rules of Civil Procedure, to the extent that they do not conflict with the SOAH rules or the applicable APA provisions. Source Note: The provisions of this §745.8845 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8845 How is a due process hearing conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212074 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212074&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212074 03/12/2026 (a) During a due process hearing the parties may discuss:(1) Facts directly relevant to the decision or action, including relevant facts that staff did not previously evaluate; and(2) Interpretations of directly relevant facts.(b) Alleged changes that have been made to the operation after the decision to take adverse action are not directly relevant to the due process hearing, and the administrative law judge may exclude them. Source Note: The provisions of this §745.8847 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8847 What information can the parties discuss in a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212075 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212075&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212075 03/12/2026 An administrative law judge (ALJ) appointed by the State Office of Administrative Hearings may address multiple decisions and actions that are related to each other during a single due process hearing. For example, if the Texas Health and Human Services Commission (HHSC) has decided to revoke an operation's license based on an abuse finding made by the Texas Department of Family and Protective Services (DFPS), the ALJ may address these matters during the same hearing. However, the ALJ's final decision must include determinations for both DFPS's finding of abuse and HHSC's revocation of the operation's license. Source Note: The provisions of this §745.8849 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8849 Can an administrative law judge address multiple decisions and actions during a single due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212076 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212076&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212076 03/12/2026 After the administrative law judge appointed by the State Office of Administrative Hearings (SOAH) issues the final decision after a due process hearing, either party may file an appeal in district court by following the provisions of Texas Government Code, Chapter 2001, Administrative Procedures Act, including filing a timely motion for rehearing with SOAH. Source Note: The provisions of this §745.8851 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8851 Who may appeal the final decision after a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212077 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212077&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212077 03/12/2026 After there is a final decision in a due process hearing, including the results of a subsequent appeal, the Texas Health and Human Services Commission (HHSC) must take the action described in the following chart:Attached Graphic Source Note: The provisions of this §745.8853 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8853 What action must the Texas Health and Human Services Commission take after the final decision in a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212078 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212078&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212078 03/12/2026 (a) A person may waive the right to a due process hearing: (1) By not requesting a hearing according to §745.8837 of this division (relating to How does a person request a due process hearing?); or(2) By submitting a written statement that waives the right to a due process hearing to the Legal Enforcement Department.(b) If a person waives the right to a due process hearing: (1) By not requesting a hearing according to §745.8837 of this division, the decision or action will be effective as noted in the chart:Attached Graphic(2) By submitting a written statement waiving the right to a hearing, the decision or action will be effective on the date the Texas Health and Human Services Commission receives the waiver. Source Note: The provisions of this §745.8855 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8855 Can a person waive the right to a due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212087 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212087&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212087 03/12/2026 (a) If you request an administrative review regarding probation, the probation, including the implementation of the corrective action plan and the posting requirements at §745.8641(3) of this chapter (relating to What requirements must I meet during the probation period?), are suspended pending the outcome of the administrative review. Once the administrative review is complete, the Texas Health and Human Services Commission (HHSC) will notify you of the decision of the administrative review and the new start date for the probation, if appropriate.(b) If HHSC adds a condition of probation while you are currently on probation and you request an administrative review on the new condition of probation, your current probation will continue. Once the administrative review is complete, HHSC will notify you of the decision and any change in conditions that need to be made to the probation. Source Note: The provisions of this §745.8871 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8871 Does a request for an administrative review suspend the start date of probation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212088 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212088&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212088 03/12/2026 No, you must meet the notice requirements for a suspension, revocation, or refusal to renew at §745.8656 of this chapter (relating to Are there any notice requirements when Licensing attempts to take adverse action against my operation?) pending the outcome of the administrative review and due process hearing. Source Note: The provisions of this §745.8873 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8873 If the Texas Health and Human Services Commission is imposing a suspension of, revocation of, or refusal to renew my permit, are the notice requirements postponed until the outcome of the administrative review and due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212089 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212089&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212089 03/12/2026 Whether you may operate during the appeal of an adverse action depends upon the type of adverse action the Texas Health and Human Services (HHSC) is imposing against you:(1) If HHSC is suspending your permit or denying you a permit, you may not operate pending the outcome of an administrative review and due process hearing;(2) If HHSC is revoking or refusing to renew your permit, you may continue to operate pending the outcome of the administrative review and due process hearing unless Licensing determines the operation poses an immediate threat or danger to the health or safety of children according to §745.751 of this chapter (relating to What factors does Licensing consider when determining if a person or operation is an immediate threat to the health or safety of children?); and(3) If HHSC is adversely amending your permit, you may continue to operate without the adverse amendment pending the outcome of the administrative review and due process hearing. Source Note: The provisions of this §745.8875 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8875 May I operate during the appeal of an adverse action, including pending the outcome of an administrative review and due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212090 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212090&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212090 03/12/2026 If you disagree with the determination that your operation poses an immediate threat or danger to the health or safety of children as described in §745.8875(2) of this division (relating to May I operate during the appeal of an adverse action, including pending the outcome of an administrative review and due process hearing?), you may seek injunctive relief from a district court in Travis County or in the county where the operation is located, as required by Texas Human Resources Code §42.072(e). Source Note: The provisions of this §745.8877 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8877 What if I disagree with Licensing's decision that my operation poses an immediate threat or danger to the health or safety of children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212091 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212091&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212091 03/12/2026 (a) You may enroll new children pending the outcome of an administrative review and due process hearing for a revocation of or a refusal to renew your permit:(1) If you are able to continue to operate as explained in §745.8875(2) of this division (relating to May I operate during the appeal of an adverse action, including pending the outcome of an administrative review and due process hearing?); or(2) A district court grants you injunctive relief to continue to operate as explained in §745.8877 of this division (relating to What if I disagree with Licensing's decision that my operation poses an immediate threat or danger to the health or safety of children?).(b) If you are allowed to enroll children pending the outcome of an administrative review and due process hearing according to subsection (a) of this section, you must inform anyone seeking to enroll a child that HHSC is seeking to revoke or refuse to renew your permit and that you are continuing to care for children pending the outcome of the administrative review and due process hearing. Source Note: The provisions of this §745.8879 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8879 If the Texas Health and Human Services Commission is imposing a revocation of or refusal to renew my permit, may I enroll new children pending the outcome of an administrative review and due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212092 03/12/2026 A pending enforcement action does not affect Licensing's responsibility to inspect or investigate your operation. Licensing must continue to conduct inspections and investigations while you are operating. The Texas Department of Family and Protective Services must also investigate any allegations of child abuse, neglect, and exploitation while you are operating. Source Note: The provisions of this §745.8881 adopted to be effective January 26, 2023, 48 TexReg 220. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING M ADMINISTRATIVE REVIEWS AND DUE PROCESS HEARINGS §745.8881 What kinds of inspections and investigations will be conducted if I continue to operate pending the outcome of an administrative review and due process hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223836 03/12/2026 These terms have the following meanings:(1) Another state--Includes:(A) Any state in the United States other than the State of Texas;(B) Any territory of the United States; or(C) The District of Columbia.(2) Child-care administrator--A person who:(A) Supervises and exercises direct control over a general residential operation, including a residential treatment center, as described in Figure: 26 TAC §745.37(2) of this chapter (relating to What specific types of operations are subject to regulation under this chapter and corresponding minimum standards?); and(B) Is responsible for the operation's program and personnel, regardless of whether the person has an ownership interest in the operation or shares duties with anyone.(3) Child-placing agency administrator--A person who:(A) Supervises and exercises direct control over a child-placing agency, as described in Figure: 26 TAC §745.37(2) of this chapter; and(B) Is responsible for the agency's program and personnel, regardless of whether the person has an ownership interest in the agency or shares duties with anyone.(4) Licensed administrator--A licensed child-care administrator or a licensed child-placing agency administrator.(5) Licensed in good standing by another state--Requires the license issued by another state to be:(A) Valid, active, and current (has not expired); and(B) Not subject to a disciplinary action or corrective action. Source Note: The provisions of this §745.8905 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8905 Definitions for Subchapter N https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223837 03/12/2026 Child Care Regulation may issue an administrator's license to an applicant as described in the following chart.Attached Graphic Source Note: The provisions of this §745.8906 adopted to be effective October 19, 2023, 48 TexReg 5977; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8906 Types of Administrator's Licenses https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223838 03/12/2026 (a) A person must have a full Child-Care Administrator's License (CCAL) to serve as a child-care administrator for a general residential operation, including a residential treatment center, except:(1) When serving as a child-care administrator for a general residential operation that only provides emergency care services according to §745.8911 of this division (relating to Exception for a General Residential Operation that Only Provides Emergency Care Services); or(2) When serving as a child-care administrator under a provisional CCAL according to:(A) §745.8913(c) of this division (relating to Qualifying for an Administrator's License Through a License from Another State); or(B) §745.8925 of this division (relating to Qualifying for a Provisional Child-Care Administrator's License Without Meeting Management and Supervisory Experience) at a general residential operation that meets the requirements of §748.532 of this title (relating to When can a child-care administrator with a provisional license serve as the administrator for a general residential operation?).(b) A person must have a full Child-Placing Agency Administrator's License to serve as a child-placing agency administrator. Source Note: The provisions of this §745.8907 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8907 Exceptions to Full Administrator's License Requirement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223839 03/12/2026 (a) A person may serve as a child care administrator without having a Child-Care Administrator's License (CCAL) if:(1) The person would be serving as a child care administrator for a general residential operation that only provides emergency care services; and(2) Child Care Regulation exempts the general residential operation from needing a licensed child-care administrator after receiving the information required under subsection (b) of this section.(b) To qualify for the exemption described in subsection (a) of this section, the governing body or designee of the emergency shelter must send to the Associate Commissioner for Child Care Regulation a letter that includes the following:(1) The name of the county with a population of less than 40,000 where the operation is located;(2) The date that the operation's governing body adopted a resolution certifying that the operation made a reasonable attempt to hire a licensed child-care administrator but was unable to do so;(3) A statement that the governing body adopted the resolution by a majority vote;(4) The name of the unlicensed administrator hired; and(5) A statement of the administrator's qualifications, including any areas where the person's qualifications do not meet the requirements for a CCAL. Source Note: The provisions of this §745.8911 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8911 Exception for a General Residential Operation that Only Provides Emergency Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223840 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223840&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223840 03/12/2026 (a) Child Care Regulation (CCR) will waive the examination, experience, and education prerequisites for a full administrator's license under §745.8915 of this division (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?), §745.8917 of this division (relating to How do I qualify for a full Child-Placing Agency Administrator's License (CPAAL)?), or both, if the applicant:(1) Is licensed in good standing by another state; and(2) Either:(A) CCR determines the other state's license requirements are substantially equivalent to the requirements for a license according to §745.8914 of this division (relating to Determining Whether Another State's Licensing Requirements Are Substantially Equivalent to the Requirements in This Subchapter); or(B) There is a reciprocity agreement between Texas and the other state.(b) To be eligible to obtain a license under subsection (a) of this section, the applicant must be eligible to:(1) Receive and continue to maintain an administrator's license, as specified in §745.775(c) of this chapter (relating to How may a criminal conviction or a child abuse or neglect finding affect my ability to receive or maintain an administrator's license?); and(2) Apply for an administrator's license under §745.9037(c) of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?).(c) CCR may issue a provisional license to an applicant licensed by another state if the applicant meets the requirements in Human Resources Code §43.0081(a)(1). Source Note: The provisions of this §745.8913 adopted to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2014, 38 TexReg 8249; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8913 Qualifying for an Administrator's License Through a License from Another State https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223841 03/12/2026 Child Care Regulation will review and evaluate the following criteria when determining whether another state's licensing requirements are substantially equivalent to the requirements for an administrator's license under this subchapter and Chapter 43 of the Texas Human Resources Code:(1) Whether the other state requires an applicant to pass an examination that demonstrates competence in the field of child care administration or placing children in residential settings, as appropriate, to obtain the license;(2) Whether the other state requires an applicant to meet the full-time experience qualifications, as described in this division, to obtain the license;(3) Whether the other state requires an applicant to meet the education qualifications, as described in this division, to obtain the license; and(4) The other state's license requirements, including the scope of work authorized to be performed under the license issued by the other state. For example, the license in the other state must require an administrator to meet responsibilities equivalent to those that an administrator of an applicable residential child-care operation in Texas must meet. Source Note: The provisions of this §745.8914 adopted to be effective December 1, 2019, 44 TexReg 6898; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8914 Determining Whether Another State's Licensing Requirements Are Substantially Equivalent to the Requirements in This Subchapter https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215448 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215448 03/12/2026 (a) To qualify for a full CCAL, you must:(1) Pass an examination, which is offered by Licensing, that demonstrates competence in the field of child-care administration;(2) Be in compliance with Subchapter F of this chapter (relating to Background Checks), including not having a criminal history or child abuse or neglect finding that would prohibit you from working in a residential child-care operation;(3) Have one year of full-time experience in management or supervision of personnel and programs as specified in §745.8919 of this division (relating to What qualifies as one year of experience in management or supervision of personnel and programs required to qualify for a full Child-Care Administrator's (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL)?); and(4) Have one of the following qualifications:(A) A master's or doctor of philosophy degree in social work or other area of study; or(B) A bachelor's degree and two years' full-time experience in residential child care or a closely related field.(b) In order to determine whether you meet the educational requirements in subsection (a) of this section, your application must include a transcript or letter of verification from the appropriate educational institution. Our determination will include whether you completed the required course of study. In order to determine the authenticity of the transcript or the educational institution listed on the transcript or letter of verification, we may:(1) Contact the educational institution; and(2) Conduct other research to assist our determination. Source Note: The provisions of this §745.8915 adopted to be effective January 1, 2007, 31 TexReg 9342; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8915 How do I qualify for a full Child-Care Administrator's License (CCAL)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215449 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215449 03/12/2026 (a) To qualify for a full CPAAL, you must:(1) Pass an examination, which is offered by Licensing, that demonstrates competence in the field of child-placing administration;(2) Be in compliance with Subchapter F of this chapter (relating to Background Checks), including not having a criminal history or child abuse or neglect finding that would prohibit you from working in a residential child-care operation;(3) Have one year of full-time experience in management or supervision of personnel and programs as specified in §745.8919 of this division (relating to What qualifies as one year of experience in management or supervision of personnel and programs required to qualify for a full Child-Care Administrator's (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL)?); and(4) Have one of the following qualifications:(A) A master's or doctor of philosophy degree in social work or other area of study; or(B) A bachelor's degree and two years' full-time experience in residential child care or a closely related field.(b) In order to determine whether you meet the educational requirements in subsection (a) of this section, your application must include a transcript or letter of verification from the appropriate educational institution. Our determination will include whether you completed the required course of study. In order to determine the authenticity of the transcript or the educational institution listed on the transcript or letter of verification, we may:(1) Contact the educational institution; and(2) Conduct other research to assist our determination. Source Note: The provisions of this §745.8917 adopted to be effective January 1, 2007, 31 TexReg 9342; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8917 How do I qualify for a full Child-Placing Agency Administrator's License (CPAAL)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215450 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215450 03/12/2026 (a) To qualify for a full CCAL, you must substantiate through an employer reference that:(1) You have completed the one year of full-time experience in management or supervision of residential child-care personnel and programs within the past 10 years;(2) Your experience was at a general residential operation, residential treatment center, or in a comparable residential operation in which you worked primarily with children;(3) If you were not solely responsible for implementing the operation's child-care program, that you shared in that responsibility; and(4) You supervised at least one member of the child-care personnel and your supervision responsibilities included assigning duties, hiring, disciplining, rewarding, approving leave requests, and conducting formal employee evaluations.(b) To qualify for a full CPAAL, you must substantiate through an employer reference that:(1) You have completed the one year of full-time experience in management or supervision of child-placing personnel and programs within the past 10 years;(2) Your experience was at a child-placing agency;(3) If you were not solely responsible for implementing the agency's child-placing program, that you shared in that responsibility; and(4) You supervised at least one member of the child-placing agency personnel and your supervision responsibilities included assigning duties, hiring, disciplining, rewarding, approving leave requests, and conducting formal employee evaluations.(c) Experience as a foster parent, adoptive parent, or any other type of caregiver or staff person in an agency home does not meet the requirements of subsection (a) or (b) of this section. Source Note: The provisions of this §745.8919 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8919 What qualifies as one year of experience in management or supervision of personnel and programs required to qualify for a full Child-Care Administrator's License (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195962 03/12/2026 (a) "Child-placing personnel" are persons, who, under the auspices of a child-placing agency, plan for the placement of or place a child in a residential child-care operation, agency foster home, or adoptive home.(b) For the purposes of this section, planning for placement or placing a child includes any of the following activities:(1) Developing a child's admission assessment or service plan for a child in the care of a child-placing agency;(2) Performing case management activities for a child in the care of a child-placing agency;(3) Conducting a home study;(4) Conducting foster home verification activities; and/or(5) Developing corrective or adverse actions for agency foster homes.(c) Planning for placement or placing a child does not include serving as a foster parent or a caregiver for the child. Source Note: The provisions of this §745.8921 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8921 Who are "child-placing personnel"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223842 03/12/2026 If an applicant does not meet the minimum management or supervisory experience in §745.8919(a) of this division (relating to What qualifies as one year of experience in management or supervision of personnel and programs required for a full Child-Care Administrator's License (CCAL) or full Child-Placing Agency Administrator's License (CPAAL)?), the applicant will qualify for, and Child Care Regulation (CCR) may issue, a provisional CCAL if:(1) The applicant meets the requirements in §745.8915(a)(1), (2), and (4) of this division (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?);(2) The applicant has six months of full-time experience in management or supervision of personnel as specified in §745.8927 of this division (relating to What qualifies as six months of experience in management or supervision of personnel required for a provisional Child-Care Administrator's License (CCAL)?); and(3) CCR has not denied the applicant a full CCAL for an issue identified in §745.9037(a) of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?) while the applicant had a provisional CCAL. Source Note: The provisions of this §745.8925 adopted to be effective October 19, 2023, 48 TexReg 5977; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8925 Qualifying for a Provisional Child-Care Administrator's License Without Meeting Management and Supervisory Experience https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215453 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215453 03/12/2026 To qualify for a provisional CCAL under §745.8925 of this division (relating to How do I qualify for a provisional Child-Care Administrator's License (CCAL) if I do not meet the minimum management or supervisory experience required for a full CCAL?), you must substantiate through an employer reference that:(1) You have completed six months of full-time experience in management or supervision of personnel within the last 10 years;(2) Your experience was in a setting where you worked primarily with children; and(3) You supervised at least one employee and your supervision responsibilities included assigning duties, hiring, disciplining, rewarding, approving leave requests, and conducting formal employee evaluations. Source Note: The provisions of this §745.8927 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8927 What qualifies as six months of experience in management or supervision of personnel required for a provisional Child-Care Administrator's License (CCAL)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215454 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215454 03/12/2026 (a) A licensed administrator or applicant for an administrator's license may not attempt to interfere with HHSC's ability to conduct agency business.(b) Conduct that constitutes an attempt to interfere with HHSC's ability to conduct agency business includes:(1) Interfering with, coercing, threatening, intimidating, retaliating against, or harassing an HHSC staff member in connection with the person's exercise of HHSC's regulatory duties; or(2) Engaging in conduct or directing language at HHSC staff that a reasonable person would find to be harassing, intimidating, or threatening to HHSC staff. Source Note: The provisions of this §745.8929 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8929 What conduct requirements must a licensed administrator or a person applying to become a licensed administrator follow in relation to the Texas Health and Human Services Commission (HHSC)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215455 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215455 03/12/2026 (a) While serving as the child-care administrator for a general residential operation, a licensed administrator must carry out the responsibilities outlined in §748.535 of this title (relating to What responsibilities must the child-care administrator have?); or(b) While serving as the child-placing agency administrator for a child-placing agency, a licensed administrator must carry out the responsibilities outlined in §749.635 of this title (relating to What responsibilities must the child-placing agency administrator have?). Source Note: The provisions of this §745.8930 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8930 What responsibilities does a licensed administrator have when employed as the administrator for an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195963 03/12/2026 To apply to become a licensed administrator, you must submit all required application materials and a $100 application fee to the address on the application form. The application fee is nonrefundable. Source Note: The provisions of this §745.8931 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8931 How do I apply to become a licensed administrator? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223843 03/12/2026 (a) A complete application to become a licensed administrator must include:(1) A completed Application for a Child Care Administrator License or a Child-Placing Agency Administrator License (Form 3015);(2) An official, stamped transcript or certification on letterhead from the appropriate educational institutions to substantiate educational qualifications;(3) Three completed references, using Administrator Licensing - Reference for an Applicant (Form 3016), including:(A) Two professional references who can attest to work experience and competence as a child-care administrator or child-placing agency administrator, as applicable; and(B) An employer or supervisor reference that documents one year of management or supervisory experience as described in §745.8919 of this subchapter (relating to What qualifies as one year of experience in management or supervision of personnel and programs required to qualify for a full Child-Care Administrator's License (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL)?);(4) A notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) documenting criminal history background information;(5) A completed Request for Background Checks for an Administrator's License (Form 3017) and background check fee; and(6) An application fee of $100.(b) An applicant for a full CCAL that does not meet the one year of management or supervisory experience required in §745.8915(a)(3) of this subchapter (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?) may qualify for a provisional CCAL. To apply for a provisional CCAL, the applicant's employer or supervisor reference required in subsection (a)(3)(B) of this section must document six months of management or supervisory experience as required in §745.8927 of this subchapter (relating to What qualifies as six months of experience in management or supervision of personnel required for a provisional Child Care Administrator's License (CCAL)?).(c) An applicant for an administrator's license under §745.8913(a) of this subchapter (relating to Qualifying for an Administrator's License Through a License from Another State) is only required to submit:(1) An Application for a Child-Care Administrator's License or a Child-Placing Agency Administrator's License (Form 3015) and complete Sections I, VIII, and X;(2) A notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) documenting criminal history background information;(3) A completed Request for Background Checks for an Administrator's License (Form 3017) and background check fee;(4) Proof of the applicant's administrator's license or any other professional or occupational license that the applicant holds by another state; and(5) A copy of the regulations pertaining to the license issued by another state or a web address where the regulations can be found.(d) A military member, military spouse, or military veteran applying for an administrator's license through alternative licensing or by demonstrating other methods of competency must comply with the application requirements at §745.9027 of this subchapter (relating to Application Requirements for an Administrator's License from a Military Member, Spouse, or Veteran).(e) A military member or military spouse applying to act as an administrator without a license must comply with the application requirements at §745.9030 of this subchapter (relating to Military Member or Spouse Acting as an Administrator Without a License),(f) An application is incomplete if it fails to include any requirement of this section, as applicable, including inadequate documentation of qualifications. Source Note: The provisions of this §745.8933 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2014, 38 TexReg 8249; amended to be effective March 1, 2016, 41 TexReg 1123; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective October 19, 2023, 48 TexReg 5977; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8933 Application Requirements for an Administrator's License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195965 03/12/2026 In addition to submitting the background check request form required by §745.8933 of this division (relating to What does a complete application to become a licensed administrator include?), you must submit fingerprints for a fingerprint-based criminal history check, as specified in §745.623 of this chapter (relating to How does the subject of a background check submit fingerprints for a fingerprint-based criminal history check?), unless the CBCU determines that you have previously undergone a fingerprint-based criminal history check that remains valid, as specified in §745.625 of this chapter (relating to Does the subject of a background check who has already undergone a fingerprint-based criminal history check have to submit new fingerprints?). Source Note: The provisions of this §745.8934 adopted to be effective March 1, 2014, 39 TexReg 1182; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8934 What other actions must I take to become a licensed administrator? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215304 03/12/2026 (a) To apply for both licenses simultaneously, you must submit:(1) An application fee for each license; and(2) All application materials required by §745.8933 of this division (relating to What does a complete application to become a licensed administrator include?), except that you must have two employee references, one verifying your supervisory experience in a general residential operation or a residential treatment center, and the other verifying your supervisory experience in a child-placing agency.(b) To apply for one of the license types after you already have the other type of license, you must submit an:(1) Application fee;(2) Updated complete application form; and(3) Employee reference verifying your required supervisory experience related to the license for which you are applying, as required by §745.8919 of this subchapter (relating to What qualifies as one year of experience in management or supervision of personnel and programs required for a full Child-Care Administrator's License (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL)?). Source Note: The provisions of this §745.8935 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8935 How do I apply for both a full Child-Care Administrator's License (CCAL) and a full Child-Placing Agency Administrator's License (CPAAL)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195967 03/12/2026 Within 21 days of our receipt of your application materials and fees, we will notify you in writing of one of the following:(1) We have received a complete set of application materials and fees and determined that you meet the initial qualifications and are eligible to take the licensing examination;(2) We have received a complete set of application materials and fees and determined that you do not meet the initial qualifications and are not eligible to take the licensing examination; or(3) Your application is pending because it is incomplete and/or the materials submitted do not show compliance with relevant statutes and rules. The notification letter will explain what is needed to complete the application and/or why your materials do not show compliance. If your application remains pending, you will receive reminder letters regarding the status of your application at three months and six months after the first notification letter is sent. If your application remains pending for 12 months from the date we first receive any part of your application, then your application will expire. If your application expires, then you may not apply again for one year from the date your application expired. Source Note: The provisions of this §745.8951 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2014, 38 TexReg 8249; amended to be effective March 1, 2016, 41 TexReg 1123; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8951 What happens after Licensing receives my application materials and fees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195968 03/12/2026 If you disagree with the determination, you may request an administrative review and/or a due process hearing as set forth in Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.8955 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8955 What if I disagree with Licensing's determination that I do not meet the initial qualifications required to take the licensing examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195969 03/12/2026 (a) You may take a licensing examination up to three times within 24 months of the date that we receive your application. We cannot issue you a license until you pass the examination with a score of 70% or higher during that time period.(b) If you fail the examination three times within 24 months after we receive your application, you may submit a new application one year after the date you fail your third examination.(c) If you take the examination less than three times within 24 months after we receive your application and do not pass the examination, your application will be void. You will have to reapply in order to pursue an administrator's license. Source Note: The provisions of this §745.8957 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8957 What if I fail the licensing examination or do not take the examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195970 03/12/2026 Yes. You must pay the nonrefundable examination fee of $50 each time before taking a licensing examination. Source Note: The provisions of this §745.8959 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8959 Must I pay an examination fee each time I take a licensing examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195971 03/12/2026 (a) We will send you the results of your examination within 14 days after we receive them from the testing organization.(b) We will issue or deny you a license within 14 days after we have your examination results and the results of your criminal history and central registry checks, including the results of any risk evaluation required based on your criminal history or central registry history. Source Note: The provisions of this §745.8961 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8961 What happens after I take a licensing examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195972 03/12/2026 If your background check results in a positive match, we will take action in accordance with Subchapter F of this chapter (relating to Background Checks). Source Note: The provisions of this §745.8963 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8963 What if my criminal history background check or central registry check results in a positive match? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223844 03/12/2026 If an applicant believes that Child Care Regulation (CCR) did not process the Administrator's License application within the appropriate timeframes, the applicant may request that the Associate Commissioner for Child Care Regulation review the situation. The applicant must submit the written request for review within 30 days after the CCR timeframe expires. The applicant must send the request to: Associate Commissioner for Child Care Regulation, Texas Health and Human Services Commission, E-550, P.O. Box 149030, Austin, Texas 78714-9030. The request must include a specific complaint and any supporting documentation. Source Note: The provisions of this §745.8965 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8965 Requesting Review of Timeframes for an Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223845 03/12/2026 (a) After receiving a request for a review of the Administrator's License application timeframes, the associate commissioner or designee will:(1) Determine if Child Care Regulation (CCR) processed the application within the appropriate timeframes, and if not, whether there was good cause to exceed the timeframes; and(2) Notify the applicant of the decision within 30 days of receiving the request.(b) CCR will reimburse the application fee if the associate commissioner or designee determines that CCR exceeded the timeframes without good cause. Source Note: The provisions of this §745.8967 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8967 Review of Timeframes for an Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195975 03/12/2026 We have good cause for exceeding the timeframes if:(1) While we are processing your application, we are processing at least 15% more applications than we did during the same quarter of the previous calendar year;(2) Another public or private entity that we rely on to process all or part of the applications causes the delay;(3) You are the subject of a pending investigation; or(4) Any other conditions exist that give us good cause for exceeding the time period. Source Note: The provisions of this §745.8969 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8969 When does Licensing have good cause for not processing my application within the established time period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215315 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215315 03/12/2026 (a) You must notify us in writing within 30 days after:(1) A change of your mailing address, place of employment, or business or home phone number;(2) A change in your legal name;(3) The filing of a criminal case against you;(4) A criminal conviction against you, other than a Class C misdemeanor traffic offense;(5) The filing of a civil lawsuit against you that relates to your role as a licensed administrator;(6) The settlement of or judgment rendered in a civil lawsuit filed against you that relates to your role as a licensed administrator; or(7) A complaint against, an investigation involving, or an enforcement or legal action against you that you are aware of related to abuse or neglect or another licensing or certification body regarding health, mental health, or child-care services.(b) We may use information received under this section when determining whether you performed your duties as an administrator in a negligent manner. Source Note: The provisions of this §745.8973 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8973 What information must I report to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215314 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215314 03/12/2026 A full CCAL or full CPAAL is valid for two years. For your full license to continue to be valid, you must renew it every two years before the expiration date. Source Note: The provisions of this §745.8975 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8975 How long is a full Child-Care Administrator's License (CCAL) or a full Child-Placing Agency Administrator's License (CPAAL) valid? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223846 03/12/2026 A provisional Child-Care Administrator's License (CCAL) is valid for the timeframe listed in the following chart.Attached Graphic Source Note: The provisions of this §745.8976 adopted to be effective October 19, 2023, 48 TexReg 5977; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8976 Length of Time a Provisional Child-Care Administrator's License is Valid https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215305 03/12/2026 (a) If you have a provisional CCAL issued under §745.8925 of this subchapter (relating to How do I qualify for a provisional Child-Care Administrator's License (CCAL) if I do not meet the minimum management or supervisory experience required for a full CCAL?), you may request to change the status of your administrator's license from a provisional CCAL to a full CCAL when you meet the one year of management or supervisory experience required in §745.8915(3) of this subchapter (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?) before your provisional CCAL expires.(b) To change the status of your child-care administrator's license from provisional CCAL to full CCAL, you must submit to us before the date your provisional CCAL expires:(1) A completed Form 3014, Administrator License - Renewal or Status Change request;(2) Evidence that you have completed any required continuing education hours as required in §745.8983(b) of this division (relating to How many hours of continuing education must I complete to maintain my administrator's license?); and(3) An employer reference that substantiates you meet the one year of management or supervisory experience required for a full CCAL in §745.8919(a) of this subchapter (relating to What qualifies as one year of experience in management or supervision or personnel required for a full Child-Care Administrator's License (CCAL) or Child-Placing Agency Administrator's License (CPAAL)?).(c) We will not change your status to a full CCAL if we have a reason to deny you a full CCAL for an issue identified in §745.9037(a) of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?).(d) If you do not submit a request to change the status of your provisional CCAL to a full CCAL before the expiration date listed on your permit:(1) Your provisional CCAL will expire; and(2) You must reapply for another administrator's license. Source Note: The provisions of this §745.8977 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8977 If I have a provisional Child-Care Administrator's License (CCAL), when and how do I request to change the status of my administrator's license from a provisional CCAL to a full CCAL? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215306 03/12/2026 Your provisional CCAL will expire if you are not able to meet the one year of management or supervisory experience required in §745.8915(3) of this subchapter (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?) to qualify for a full CCAL before the expiration date on your provisional CCAL. Source Note: The provisions of this §745.8979 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8979 What if I am unable to meet the minimum management or supervisory requirements before my provisional Child-Care Administrator's License (CCAL) expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215307 03/12/2026 (a) If your provisional CCAL expires, you must:(1) Cease acting as and representing yourself as a licensed child-care administrator; and(2) Return your provisional CCAL certificate to us.(b) To be eligible to receive another provisional CCAL, you must submit a new application for a full CCAL and meet the requirements for a complete application in §745.8933 of this subchapter (relating to What must a complete application to become a licensed administrator include?).(c) We will not accept a new application for a full CCAL from you if you have not returned the expired provisional CCAL certificate to us. Source Note: The provisions of this §745.8981 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8981 What happens if my provisional Child-Care Administrator's License (CCAL) expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215308 03/12/2026 You may continue to serve as a child-care administrator if your provisional CCAL expires while we process your request to change the status to a full CCAL if you:(1) Request the change of status under §745.8977 of this division (relating to If I have a provisional Child-Care Administrator's License (CCAL), when and how do I request to change the status of my administrator's license from a provisional CCAL to a full CCAL?);(2) Submit your request at least 15 days before the expiration date listed on your permit; and(3) Are serving as a child-care administrator for an operation when you submit your request. Source Note: The provisions of this §745.8982 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8982 May I continue to serve as a child-care administrator if my provisional Child-Care Administrator's License (CCAL) expires while Licensing processes my request to change the status to a full CCAL? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215309 03/12/2026 (a) To maintain your full administrator's license, you must complete 15 clock hours of continuing education each year.(b) If you have a provisional Child-Care Administrator's License (CCAL) issued under §745.8925 of this subchapter (relating to how do I qualify for a provisional Child-Care Administrator's License (CCAL) if I do not meet the management or supervisory experience required for a full CCAL?), you must complete mandatory continuing education hours by the time you request to change the status of your provisional CCAL to a full CCAL. The number of clock hours of mandatory continuing education varies depending on how long the provisional CCAL has been in effect at the time you request to change the status of your provisional CCAL. The number of clock hours of continuing education required is described in the following chart:Attached Graphic Source Note: The provisions of this §745.8983 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8983 How many hours of continuing education must I complete to maintain my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215310 03/12/2026 (a) To meet the continuing education requirements for your provisional Child-Care Administrator's License or to renew your full administrator's license, you may only count training that:(1) Is directly relevant to the type of administrator's license that you have; and(2) You completed as an attendee. You may not count training where you were the presenter.(b) If you have taken a training more than once during the two-year period since your license was issued or last renewed, you may only count the training one time. Source Note: The provisions of this §745.8985 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8985 What training qualifies as continuing education I need to maintain my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215311 03/12/2026 (a) You may request us to put your full administrator's license on inactive status if you are not working as an administrator.(b) While your full administrator's license is on inactive status:(1) You may not serve as a licensed administrator;(2) You are not required to obtain continuing education;(3) You must renew your administrator's license when the renewal is due; and(4) We may still take remedial action against your administrator's license as described in §745.9037 of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?).(c) We may not make a provisional Child-Care Administrator's License inactive. Source Note: The provisions of this §745.8986 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8986 When may I request Licensing to place my full administrator's license on inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215312 03/12/2026 (a) To change the status of your inactive full administrator's license to active when renewing your license, you must submit to us:(1) A completed Form 3014, Administrator License - Renewal or Status Change request;(2) A $50 renewal fee;(3) If your administrator's license was active at any point during the renewal period, documentation of continuing education training completed; and(4) A completed background check form and fee.(b) To change the status of your inactive full administrator's license to active in the middle of a renewal period, you must submit to us a:(1) Completed Form 3014, Administrator License - Renewal or Status Change request;(2) $25 change of status fee; and(3) Completed background check form and fee. Source Note: The provisions of this §745.8987 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8987 How do I change my full administrator's license status from inactive to active? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215313 03/12/2026 (a) You must send us your request in writing along with a $5 fee for the replacement copy of your current administrator's license. Your request must include:(1) A statement detailing the loss or destruction of your original license; or(2) Be accompanied by your damaged license.(b) Fraud or deceit related to a request for an additional copy of your license may result in remedial action as described in §745.9037 of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?). Source Note: The provisions of this §745.8989 adopted to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8989 How do I get a replacement copy of my current administrator's license if the original is lost or destroyed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215321 03/12/2026 To be eligible to renew your administrator's license, you must:(1) Be in current compliance with all applicable laws, including these rules;(2) Have completed 15 clock hours of continuing education each year during the two-year period before renewal;(3) Be in compliance with Subchapter F of this chapter (relating to Background Checks), including not having a criminal history or child abuse or neglect finding that would prohibit you from working in a residential child-care operation; and(4) Submit the appropriate renewal fee. Source Note: The provisions of this §745.8993 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2014, 39 TexReg 1182; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8993 Am I eligible to renew my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215322 03/12/2026 To continue operating as a licensed administrator, you must request your administrator's license renewal before your license expires. We may not renew your administrator's license after it has been expired for more than one year. Source Note: The provisions of this §745.8995 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8995 When do I request renewal of my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215323 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215323&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215323 03/12/2026 To request an administrator's license renewal, you must send us:(1) Evidence that you have completed 15 clock hours of continuing education each year during the two-year period before renewal;(2) A completed renewal form;(3) The renewal fee; and(4) A completed background check form and fee. Source Note: The provisions of this §745.8997 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.8997 How do I request renewal of my administrator's license ? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215324 03/12/2026 No, you are not required to undergo a background check in order to renew your administrator's license as inactive. Source Note: The provisions of this §745.9001 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9001 Must I undergo a background check in order to renew my administrator's license as inactive? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215325 03/12/2026 (a) The amount of the renewal fee varies depending on when we receive it: Attached Graphic(b) Failure to receive notice from us of your license's expiration or impending expiration does not waive the increase of the fee for late renewals. Source Note: The provisions of this §745.9003 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9003 How much is the renewal fee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215326 03/12/2026 (a) The renewal fee for inactive status is half the amount of the regular renewal fee: Attached Graphic(b) Failure to receive notice from us of your license's expiration or impending expiration does not waive the increase of the fee for late renewals. Source Note: The provisions of this §745.9005 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9005 How much is the renewal fee if I am requesting inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215327 03/12/2026 You must:(1) Pay the appropriate renewal fee for each license;(2) Complete the renewal form for each license; and(3) Submit evidence that you have completed 15 clock hours of continuing education each year during the two-year renewal period for each license. The same training hours may be counted toward both licenses only if the training appropriately applies to both license types. (For example, training on adoption law would count toward renewal of a Child-Placing Agency Administrator's License but not a Child Care Administrator's License, whereas training on federal equal employment opportunity hiring requirements and guidelines would count toward renewal of both licenses.) Source Note: The provisions of this §745.9009 adopted to be effective January 1, 2007, 31 TexReg 9342; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9009 What are the renewal requirements if I have both a CCAL and a CPAAL? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215328 03/12/2026 (a) If you fail to renew your administrator's license before the expiration date of the license, you must cease acting as or representing yourself as a licensed administrator.(b) If you do not renew your administrator's license within one year after its expiration date, the license is considered lapsed and is no longer eligible for renewal.(c) If you would like to be a licensed administrator after your license has lapsed, you must reapply as if you had never been licensed. You must return the expired license certificate to us before we can accept a new application from you. Source Note: The provisions of this §745.9011 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9011 What happens if I do not renew my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215329 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215329 03/12/2026 (a) A remedial action that is pending against your administrator's license has no effect on renewal requirements for that license. You must still submit timely and complete renewal documentation and fees.(b) If the pending remedial action results in the revocation or refusal to renew your license, any renewal fees paid during the time the remedial action was pending will be refunded upon our receipt of a written request from you. Source Note: The provisions of this §745.9013 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9013 How does a remedial action that is pending against my administrator's license affect renewal requirements for that license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215330 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215330 03/12/2026 Yes, upon your written request, we will refund your renewal fee if we determine that you are not eligible for renewal. Source Note: The provisions of this §745.9017 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9017 Will Licensing return my renewal fee if I am not eligible for renewal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223847 03/12/2026 These terms have the following meanings when used in this division: (1) Military member--A person who is currently serving full-time in: (A) Any branch of the United States Armed Forces, which include the United States Army, Navy, Air Force, Space Force, Coast Guard, and Marine Corps; (B) A reserve unit of one of the branches of the United States Armed Forces, including the National Guard; or (C) The state military service of any state, such as the Texas National Guard or the Texas State Guard.(2) Military spouse--A person married to a military member.(3) Military veteran--A person who has served as a military member and was discharged or released from service. Source Note: The provisions of this §745.9023 adopted to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9023 Definitions for Division 6 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223848 03/12/2026 (a) Alternative licensing is available to a military member, military spouse, or military veteran who applies for an administrator's license and:(1) Is licensed in good standing by another state that has licensing requirements substantially equivalent to the requirements for a license under this chapter as determined by Child Care Regulation (CCR) under §745.8914 of this subchapter (relating to Determining Whether Another State's Licensing Requirements Are Substantially Equivalent to the Requirements in This Subchapter); or(2) Held an administrator's license in Texas within the last five years.(b) If the military member, military spouse, or military veteran meets an alternative licensing requirement in subsection (a) of this section, CCR will waive the examination, experience, and education prerequisites for an administrator's license in §745.8915 of this subchapter (relating to How do I qualify for a full Child-Care Administrator's License (CCAL)?), §745.8917 of this subchapter (relating to How do I qualify for a full Child-Placing Agency Administrator's License (CPAAL)?), or both.(c) To be eligible to obtain a license under this section, the military member, military spouse, or military veteran must not be: (1) Prohibited from receiving or continuing to maintain an administrator's license, as specified in §745.775(c) of this chapter (relating to How may a criminal conviction or a child abuse or neglect finding affect my ability to receive or maintain an administrator's license?); or(2) Ineligible to apply for an administrator's license under §745.9037(c) of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?).(d) If CCR issues an administrator's license under this section, the license will be a full license. Source Note: The provisions of this §745.9024 adopted to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9024 Alternative Licensing for a Military Member, Spouse, or Veteran https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223849 03/12/2026 For a military member, military spouse, or military veteran who is applying for an administrator's license, but does not have an administrator's license issued by another state and has not held an administrator's license in Texas within the last five years, the Associate Commissioner for Child Care Regulation, or a designee may accept a substitute method to demonstrate compliance with examination, experience, and education qualifications, including:(1) Accepting proof of a passing score on a national exam or other examination that demonstrates, as appropriate, competence in the field of:(A) Child-care administration; or(B) Child-placing administration. (2) Crediting the military member, military spouse, or military veteran for verified military service, training, education, or clinical or professional experience that meets the experience or education requirements; and (3) Substituting any demonstrated competency that a military member, military spouse, or military veteran has to meet the experience and education qualifications. Source Note: The provisions of this §745.9025 adopted to be effective March 1, 2016, 41 TexReg 1123; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9025 Substitute Methods for a Military Member, Spouse, or Veteran to Demonstrate Competency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223850 03/12/2026 Child Care Regulation will waive the following fees for a military member, military spouse, or military veteran who meets the requirements to obtain an administrator's license under this subchapter: (1) The application and examination fees; and(2) A replacement fee as required by §745.8989 of this subchapter (relating to How do I get a replacement copy of my current administrator's license if the original is lost or destroyed?). Source Note: The provisions of this §745.9026 adopted to be effective March 1, 2016, 41 TexReg 1123; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9026 Waiving Fees for a Military Member, Spouse, or Veteran https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223851 03/12/2026 (a) If a military member, military spouse, or military veteran applies to become a licensed administrator or to act as an administrator without a license, the application must meet the requirements in this chart.Attached Graphic(b) An application is incomplete if it fails to include any requirement of this section, as applicable. Source Note: The provisions of this §745.9027 adopted to be effective March 1, 2016, 41 TexReg 1123; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9027 Application Requirements for an Administrator's License from a Military Member, Spouse, or Veteran https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223852 03/12/2026 (a) Subsections (b) - (d) of this section apply to an application from:(1) A military member, military spouse, or military veteran for an administrator's license under §745.9024 of this division (relating to Alternative Licensing for a Military Member, Spouse, or Veteran); or (2) A military member or military spouse to act as an administrator without a license under §745.9030 of this division (relating to Military Member or Spouse Acting as an Administrator Without a License).(b) Within 21 days after receiving an application, Child Care Regulation (CCR) will determine whether the application is complete as described in §745.9027 of this division (relating to Application Requirements for an Administrator's License from a Military Member, Spouse, or Veteran). If CCR determines that the application is incomplete, CCR will notify the applicant of the following, as applicable:(1) Why any application materials the applicant submitted do not show compliance with relevant statutes and rules; and(2) Any additional materials that the applicant must submit to show compliance.(c) Within 30 days after receiving a complete application, CCR will: (1) Issue the applicant an administrator's license or approve the ability to act as an administrator without having an administrator's license; or(2) Forward to Child Care Regulation Administrator (CCRA) Enforcement a recommendation to deny the applicant an administrator's license or the ability to act as an administrator without a license. (d) CCRA Enforcement may deny:(1) An administrator's license under §745.9024 of this division because: (A) The license by another state:(i) Is not in good standing; or(ii) Does not meet the requirements of §745.8914 of this subchapter (relating to Determining Whether Another State's Licensing Requirements Are Substantially Equivalent to the Requirements in This Subchapter); (B) The applicant is prohibited from receiving or continuing to maintain an administrator's license, as specified in §745.775(c) of this chapter (relating to How may a criminal conviction or a child abuse or neglect finding affect my ability to receive or maintain an administrator's license?); or (C) The applicant is ineligible to apply for an administrator's license under §745.9037(c) of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?); or(2) The applicant the ability to act as an administrator without a license because the applicant does not meet one of the requirements of §745.9030 of this division, including the applicant's license by another state:(A) Is not in good standing; or(B) Does not meet the requirements of §745.8914 of this subchapter.(e) For a military member, military spouse, or military veteran who is applying for an administrator's license under this subchapter and does not have a license from another state, CCR will expedite the applicable application processes described in the following rules unless there is good cause to delay the process as described in §745.8969 of this chapter (relating to When does Licensing have good cause for not processing my application within the established time period?):(1) §745.8951 of this subchapter (relating to What happens after Licensing receives my application materials and fees?); and(2) §745.8961 of this subchapter (relating to What happens after I take a licensing examination?). Source Note: The provisions of this §745.9028 adopted to be effective March 1, 2016, 41 TexReg 1123; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9028 Expedited Application Process for a Military Member, Spouse, or Veteran https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223853 03/12/2026 (a) The following special considerations are applicable to the renewal of a military member's administrator's license:(1) An administrator's license will no longer be valid after two years, but the license will be considered dormant until the military member requests Child Care Regulation (CCR) to renew it or for two additional years, whichever comes first;(2) No continuing education will be required prior to renewal; and(3) CCR will waive late renewal fees required in (a)(2) and (3) in Figure: 40 TAC §745.9003(a) of this subchapter (relating to How much is the renewal fee?) if the military member establishes that the failure to renew the license in a timely manner was due to the military member's service.(b) To be eligible for any special consideration under this section, the military member must not be prohibited from receiving or continuing to maintain an administrator's license, as specified in §745.775(c) of this chapter (relating to How may a criminal conviction or a child abuse or neglect finding affect my ability to receive or maintain an administrator's license?). Source Note: The provisions of this §745.9029 adopted to be effective March 1, 2016, 41 TexReg 1123; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9029 Special Considerations for Renewal of a Military Member's Administrator's License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=223854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 223854 03/12/2026 (a) A military member or military spouse may act as an administrator for a general residential operation, child-placing agency, or both, without obtaining an administrator's license under this subchapter and Chapter 43 of the Texas Human Resources Code, for up to three years if Child Care Regulation (CCR) determines that the military member or military spouse:(1) Is licensed in good standing by another state that has licensing requirements that are substantially equivalent to the requirements for an administrator's license under this subchapter; and(2) Meets the other requirements in this section.(b) To evaluate whether the military member or military spouse is licensed in good standing by another state with requirements that are substantially equivalent to the requirements for an administrator's license under this subchapter, the military member or military spouse must submit:(1) An Application for a Child-Care Administrator's License or a Child-Placing Agency Administrator's License (Form 3015) and complete Sections I, VIII, and X;(2) A copy of a valid military identification card to establish the status of the military member or military spouse;(3) A letter indicating intent to act as an administrator for a general residential operation, child-placing agency, or both in Texas;(4) A copy of the permanent change of station order to Texas for the military member;(5) Proof of the administrator's license or any other professional or occupational license held by another state; and(6) A copy of the regulations pertaining to the license issued by another state or a web address where the regulations can be found.(c) Once CCR receives the application and the additional documentation, CCR will:(1) Verify that the application is complete, and the documentation is accurate;(2) Determine whether the requirements for the license issued by another state are substantially equivalent to the requirements for an administrator's license according to §745.8914 of this subchapter (relating to Determining Whether Another State's Licensing Requirements Are Substantially Equivalent to the Requirements in This Subchapter); and(3) Verify that the license by another state is in good standing.(d) CCR will complete the actions in subsection (c) of this section and notify the military member or military spouse according to §745.9028(b) - (d) of this division (relating to Expedited Application Process for a Military Member, Spouse, or Veteran). (e) If CCR approves the applicant's ability to act as an administrator for a general residential operation, child-placing agency, or both, the person acting as the administrator without a license must comply with all other applicable statutes, rules, and minimum standards, including those relating to:(1) Administrator's Licensing in this subchapter and Chapter 43 of the Texas Human Resources Code;(2) Subchapter F of this chapter (relating to Background Checks) when employed by a general residential operation or a child-placing agency; and(3) Minimum standards for general residential operations and child-placing agencies. (f) The approval to act as an administrator expires as provided in the following chart. Attached Graphic(g) A military member or military spouse may request in writing a replacement copy of the letter approving the military member or military spouse to act as an administrator without a license. No fee is required, but the written request must include:(1) A statement detailing the loss or destruction of the original approval letter; or(2) The damaged letter. (h) Child Care Regulation Administrator Enforcement may revoke the approval to act as an administrator without a license: (1) For failure to comply with subsection (e) of this section;(2) For any reason noted in §745.9037 of this subchapter (relating to Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application?); or(3) If the military member or military spouse is no longer licensed in good standing by another state.(i) CCR may not renew the approval to act as an administrator without a license. Source Note: The provisions of this §745.9030 adopted to be effective December 1, 2019, 44 TexReg 6898; amended to be effective January 23, 2022, 47 TexReg 152; amended to be effective February 12, 2025, 50 TexReg 656. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9030 Military Member or Spouse Acting as an Administrator Without a License https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215319 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215319 03/12/2026 (a) We may take the following actions against your full administrator's license:Attached Graphic(b) If you have a provisional Child-Care Administrator's License (CCAL) we may deny you a full CCAL. We do not have to separately revoke your provisional CCAL. Source Note: The provisions of this §745.9031 adopted to be effective March 1, 2002, 27 TexReg 965; amended to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9031 What remedial actions can Licensing take against my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215337 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215337 03/12/2026 A letter of reprimand will contain the following information:(1) The reason(s) for the reprimand;(2) That further disciplinary actions may result from future violations; and(3) Your right to request an administrative review within 15 calendar days after receiving the letter. Source Note: The provisions of this §745.9033 adopted to be effective March 1, 2002, 27 TexReg 965; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9033 What information does a letter of reprimand contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215338 03/12/2026 A court or Title IV-D agency may suspend your administrator's license if you fail to pay child support. As set forth in Texas Family Code, §232.011, we must follow an order suspending your administrator's license. Source Note: The provisions of this §745.9035 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9035 Can any authority besides Licensing suspend my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221987 03/12/2026 (a) We may take remedial action against your administrator's license or administrator's license application if you:(1) Violate Chapter 43 of the Human Resources Code (HRC) or a rule adopted under that chapter;(2) Circumvent or attempt to circumvent the requirements of Chapter 43 of the HRC or a rule adopted under that chapter;(3) Engage in fraud or deceit related to the requirements of Chapter 43 of the HRC or a rule adopted under that chapter;(4) Provide false or misleading information to us during the application or renewal process for your own or someone else's application or license;(5) Make a statement about a material fact during the license application or renewal process that you know or should know is false;(6) Do not comply with Subchapter F of this chapter (relating to Background Checks);(7) Use or abuse drugs or alcohol in a manner that jeopardizes your ability to function as an administrator;(8) Perform your duties as an administrator in a negligent manner; or(9) Engage in conduct that makes you ineligible to:(A) Receive a permit under HRC §42.072; or(B) Be employed as a controlling person or serve in that capacity in a facility or family home under HRC §42.062.(b) If we deny you a full Child-Care Administrator's License (CCAL) for an issue identified in subsection (a) of this section while you have a provisional CCAL, your provisional CCAL is no longer valid. You may not continue serving or representing yourself as a licensed child-care administrator pending the outcome of due process.(c) If we revoke or refuse to renew your administrator's license, you are not eligible to apply for another administrator's license for five years after the date the revocation or refusal to renew was imposed.(d) If you have both a Child Care Administrator's License and a Child-Placing Agency Administrator's License, remedial action may be taken against both licenses. If we take remedial action against both of your licenses, you will be notified that the action applies to both licenses. In such a case, any administrative review or due process hearing for both licenses may be combined at our discretion.(e) If we revoke your full administrator's license, deny you a full CCAL after issuing you a provisional CCAL, refuse to renew your full administrator's license, or you do not meet the renewal requirements, you must return your license certificate to us. Source Note: The provisions of this §745.9037 adopted to be effective January 1, 2007, 31 TexReg 9342; amended to be effective March 1, 2012, 37 TexReg 921; amended to be effective March 1, 2014, 39 TexReg 1182; amended to be effective January 13, 2019, 43 TexReg 8142; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963; amended to be effective October 19, 2023, 48 TexReg 5977; amended to be effective November 19, 2024, 49 TexReg 9319. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9037 Under what circumstances may Licensing take remedial action against my administrator's license or administrator's license application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215339 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215339 03/12/2026 If you disagree with a remedial action that we take against your administrator's license, you may request an administrative review. You may also request a due process hearing of our decision to deny, revoke, suspend, or refuse to renew your administrator's license. See Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.9039 adopted to be effective January 1, 2007, 31 TexReg 9342; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING N ADMINISTRATOR'S LICENSING §745.9039 What can I do if I disagree with a remedial action that Licensing takes against my administrator's license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221110 03/12/2026 The following terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:(1) Individual--A person who is 21 years of age or younger.(2) Psychiatric health treatments and services--In addition to basic child-care services, a specialized type of child-care services provided by a certified psychiatric residential youth treatment facility to treat and support individuals who have a severe emotional disturbance.(3) Psychiatric Residential Youth Treatment Facility (PYRTF)--As defined at Texas Health and Safety Code §577A.001(3), a private facility that provides psychiatric health treatments and services in a residential, non-hospital setting exclusively to individuals and is licensed as a general residential operation.(4) Severe emotional disturbance--As defined at Texas Health and Safety Code §577A.001(4), a mental, behavioral, or emotional disturbance of sufficient duration to result in functional impairment that substantially interferes with or limits an individual's role or ability to function in family, school, or community activities. Source Note: The provisions of this §745.9051 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9051 What do the following terms mean when used in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221111 03/12/2026 (a) Before applying for a PRYTF certificate a general residential operation must:(1) Have a current initial or full license as a general residential operation;(2) Have Child Care Regulation's approval to provide treatment services to children with an emotional disorder, as provided in §748.63 of this title (relating to Can I provide each type of service that Licensing regulates?); and(3) Be accredited by:(A) The Joint Commission;(B) The Commission on Accreditation of Rehabilitation Facilities;(C) The Council on Accreditation; or(D) Another accreditation organization whose standards relate to the care of children and young adults receiving mental health services in a residential setting and is approved by Child Care Regulation.(b) To meet the accreditation requirement under subsection (a)(3) of this section, a general residential operation:(1) May obtain accreditation for:(A) The entire general residential operation, including the PRYTF; or(B) Only the part of the general residential operation where the PRYTF will operate; and(2) May have an initial, provisional, full, or other type of accreditation that is appropriate to the accreditation organization. Source Note: The provisions of this §745.9053 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9053 What requirements must a general residential operation meet before applying for a psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221112 03/12/2026 (a) A general residential operation (GRO) must submit:(1) A PRYTF certificate application (Form 2973, Psychiatric Residential Youth Treatment Facility Application);(2) A General Residential Operations - Additional Operation Plan (Form 2960, Application for a License to Operate a Residential Child Care Facility, Attachment C) that describes and includes the capacity of the children to be served by the GRO, including any children and young adults that the PRYTF will serve and as required by Texas Human Resources Code §42.252;(3) An updated floor plan of the building and surrounding space the entire operation will use, including dimensions of the indoor space and the specific areas to be used by the PRYTF;(4) Additional written policies required in §748.4821 of this title (relating to What additional policies must a general residential operation (GRO) submit as part of the application process for a psychiatric residential youth treatment facility (PRYTF) certificate?); and(5) The PRYTF certificate application fee.(b) The GRO may submit an updated General Residential Operations - Additional Operation Plan (Form 2960, Attachment C) if the GRO is already licensed to provide treatment services to children with emotional disorders. Source Note: The provisions of this §745.9055 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9055 What does a completed application for a psychiatric residential youth treatment facility (PRYTF) certificate include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221113 03/12/2026 (a) A general residential operation (GRO) that is applying for a PRYTF certificate must comply with the rules in Subchapter D, Division 4 of this chapter (relating to Public Notice and Hearing Requirements for Residential Child-Care Operations) if the addition of the PRYTF causes the GRO to meet one of the exceptions in §745.273(b) of this chapter (relating to Which residential child care operations must meet the public notice and hearing requirements?).(b) The initial public notice and hearing, or a subsequent public notice and hearing, of the GRO must describe and include the capacity of the children and young adults the PRYTF will serve.(c) If the GRO does not comply with the public notice and hearing requirements, Child Care Regulation may deny the operation a PRYTF certificate. Source Note: The provisions of this §745.9057 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9057 How do the public notice and hearing requirements apply to an application for a psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221114 03/12/2026 (a) CCR has 21 calendar days after receiving a general residential operation's (GRO's) application for a PRYTF certificate to review the paperwork, unless there is good cause to exceed this timeframe.(b) After CCR reviews the GRO's application, CCR will notify the GRO in writing that:(1) There is good cause to delay the timeframe for making a determination on the application, consistent with §745.327 of this chapter (relating to When does Licensing have good cause for exceeding its timeframes for processing my application?);(2) The GRO is ineligible to receive a PRYTF certificate because it does not meet one or more of the requirements under §745.9053(a) of this division (relating to What requirements must a general residential operation meet before applying for a psychiatric residential youth treatment facility (PRYTF) certificate?);(3) The GRO's application is complete and accepted for processing; or(4) The GRO's application is incomplete. The notification letter will:(A) Identify any application materials submitted that do not show compliance with relevant statutes, rules, or minimum standards; and(B) Explain what the GRO must do to complete the application.(c) If the GRO's application is not complete by the first anniversary of the date the GRO submitted its application for a PRYTF certificate, CCR will close the application and the GRO must submit a new application, materials, and a PRYTF certificate application fee. Source Note: The provisions of this §745.9059 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9059 How long does Child Care Regulation (CCR) have to review an application for a psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221115 03/12/2026 (a) CCR determines whether to issue a PRYTF certificate no later than two months after CCR accepts the application, unless there is good cause to exceed this timeframe consistent with §745.327 of this chapter (relating to When does Licensing have good cause for exceeding its timeframes for processing my application?).(b) The general residential operation may file a complaint regarding timeframes according to §745.325 of this chapter (relating to How do I file a complaint regarding timeframes for processing my application?). Source Note: The provisions of this §745.9061 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9061 How long does Child Care Regulation (CCR) have to determine whether to issue a psychiatric residential youth treatment facility (PRYTF) certificate after accepting the application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221116 03/12/2026 CCR determines whether to issue a PRYTF certificate by considering:(1) The application and any information submitted with the application, including any information noted in Texas Human Resources Code §42.252(f);(2) The on-site inspection to determine compliance with relevant statutes, rules, and minimum standards;(3) Any information that CCR gathers through the application process, including any written comments and written information submitted to CCR during the process that CCR considers to be relevant to the decision to issue the PRYTF certificate; and(4) If a public hearing is required by the GRO under §745.273(b) of this chapter (relating to Which residential child-care operations must meet the public notice and hearing requirements?) any requirements under Texas Human Resources Code §42.0461, including the Verbatim Record and summary Report of Public Comment from the Community, as required in §745.275 of this chapter (relating to What are the specific requirements for a public notice and hearing?). Source Note: The provisions of this §745.9063 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9063 What factors will Child Care Regulation (CCR) consider when evaluating an application for a psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221117 03/12/2026 If a public hearing is required in §745.273 of this chapter (relating to Which residential child-care operations must meet the public notice and hearing requirements?), CCR may deny the general residential operation's request for a PRYTF certificate for a reason described in Texas Human Resources Code §42.0461(e). Source Note: The provisions of this §745.9065 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9065 For what reason may Child Care Regulation (CCR) deny a psychiatric residential youth treatment facility (PRYTF) certificate based on the results of a required public hearing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221118 03/12/2026 (a) A PRYTF must apply to renew the PRYTF certificate every two years after the date Child Care Regulation (CCR) issues the certificate.(b) A PRYTF must timely apply to renew the PRYTF certificate, even if:(1) There is a pending civil or administrative penalty against the PRYTF; or(2) The general residential operation or PRYTF is under an enforcement action.(c) During the year that the PRYTF renews the PRYTF certificate, the renewal period:(1) Begins 60 calendar days before the anniversary of when CCR issued the PRYTF certificate; and(2) Ends on the date of the anniversary.(d) If the PRYTF is late in applying for renewal of the PRYTF certificate, the PRYTF has 30 additional calendar days after the renewal period to apply for renewal. Source Note: The provisions of this §745.9067 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9067 When does a psychiatric residential youth treatment facility (PRYTF) need to apply to renew the PRYTF certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221119 03/12/2026 A PRYTF must submit a completed PRYTF renewal application, which includes:(1) Timely submitting the renewal application as required by §745.9067 of this division (relating to When does a psychiatric residential youth treatment facility (PRYTF) need to apply to renew the PRYTF certificate?);(2) Verification that the following information is current and accurate:(A) The list of controlling persons at the operation; and(B) The list of governing body's members, such as officers and owners, if applicable;(3) A statement as to whether the operation continues to need any existing waivers and variances that the PRYTF will also want to apply to the care of children and young adults receiving psychiatric health treatments and services;(4) Validation on the provider website the list of persons who require a background check because of their association with the operation;(5) Verification of the ongoing accreditation of the PRYTF; and(6) A PRYTF certificate renewal fee. Source Note: The provisions of this §745.9069 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9069 What does a completed renewal application for a psychiatric residential youth treatment facility (PRYTF) certificate include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221120 03/12/2026 (a) After receiving a PRYTF renewal application, CCR evaluates whether:(1) The PRYTF completed the renewal application as required by §745.9069 of this division (relating to What does a completed renewal application for a psychiatric residential youth treatment facility (PRYTF) certificate include?);(2) The general residential operation license is current and approved to provide treatment services to children with emotional disorders;(3) The PRYTF has paid each administrative penalty that the PRYTF owes after waiving or exhausting any due process provided under Texas Health and Safety Code §571.025; and(4) The PRYTF meets the statutory, rule, and minimum standard requirements after CCR inspects the PRYTF.(b) Within 30 calendar days of receiving the renewal application, CCR will send written notice that:(1) CCR has renewed the PRYTF certificate;(2) The PRYTF renewal application is incomplete because it did not meet one or more of the renewal application requirements in subsection (a) of this section; or(3) CCR refuses to renew the PRYTF certificate because:(A) The PRYTF did not submit a completed PRYTF renewal application;(B) The PRYTF is no longer accredited as required by §748.4823(a) of this title (relating to When must a psychiatric residential youth treatment facility (PRYTF) notify Child Care Regulation (CCR) about accreditation changes regarding the PRYTF?);(C) The general residential operation does not have a license;(D) The general residential operation is not approved to provide treatment services to children with emotional disorders;(E) The PRYTF did not pay the PRYTF certificate renewal fee;(F) The PRYTF did not pay an administrative penalty that the PRYTF owes after waiving or exhausting any due process provided under Texas Health and Safety Code §571.025; or(G) After inspecting the PRYTF, CCR determined that it does not meet the statute, rule, and minimum standard requirements.(c) If the PRYTF renewal application is incomplete, the written notice will include:(1) CCR's determination that the PRYTF did not meet one or more of the renewal application requirements in subsection (a) of this section; and(2) A list of the requirements that the PRYTF must complete before CCR can renew the PRYTF certificate.(d) If the PRYTF submitted an incomplete renewal application during the renewal period, the PRYTF may attempt to submit the missing information until the PRYTF certificate expires.(e) If the PRYTF submitted an incomplete renewal application during the late renewal period, the PRYTF has 15 calendar days to submit a completed application from the date CCR determined that the renewal application was incomplete. Source Note: The provisions of this §745.9071 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9071 What happens after Child Care Regulation (CCR) receives a psychiatric residential youth treatment facility (PRYTF)renewal application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221121 03/12/2026 (a) A PRYTF certificate expires if:(1) The PRYTF does not submit a renewal application during the renewal period or late renewal period;(2) The PRYTF submits a renewal application during the renewal period, the PRYTF was notified that the application was incomplete, and the PRYTF did not submit a completed renewal application before the end of the late renewal period; or(3) The PRYTF submits a renewal application during the late renewal period, the PRYTF was notified that the application was incomplete, and the PRYTF did not submit a completed renewal application within 15 calendar days after notification.(b) If the PRYTF certificate expires:(1) Within 24 hours, the general residential operation (GRO) must inform the following persons that the PRYTF certificate has expired;(A) All parents of children receiving psychiatric health treatments and services; and(B) Young adults and any guardians of the young adults receiving psychiatric health treatments and services;(2) The GRO must immediately:(A) Discharge and stop providing care to the young adults 18 to 21 years of age receiving psychiatric health treatments and services unless the young adult meets the requirements of §748.1931 of this title (relating to After a child in my care turns 18 years old, may the person remain in my care?);(B) For children receiving psychiatric health treatments and services:(i) Enroll the child into the general residential operation, if appropriate; or(ii) Discharge the child to the child's parents.(3) Before the GRO that had the PRYTF certificate can operate again as a PRYTF, the PRYTF must submit a new PRYTF application, materials, and PRYTF certificate application fee. Source Note: The provisions of this §745.9073 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9073 When does a psychiatric residential youth treatment facility (PRYTF) certificate expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221351 03/12/2026 In addition to the fees required by §745.509 of this chapter (relating to What fees must I pay to apply for and maintain a license for an operation?), the following chart contains non-refundable fees applicable to a PRYTF, when the fees are due, and the consequences for failure to pay on time: Attached Graphic Source Note: The provisions of this §745.9075 to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9075 What fees must a general residential operation (GRO) pay to apply for and maintain its psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221131 03/12/2026 The rules in Subchapter K of this chapter (relating to Inspections, Investigations, and Confidentiality) apply to a PRYTF certificate in the same manner as the rules would apply for a general residential operation permit, including:(1) For an inspection or investigation in a PRYTF;(2) Relating to confidentiality, which apply to an applicant for a PRYTF certificate, holder of a PRYTF certificate, or former holder of a PRYTF certificate as if a PRYTF certificate is a permit; and(3) Technical assistance provided to a PRYTF. Source Note: The provisions of this §745.9077 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9077 How do the provisions in Subchapter K of this chapter apply to a psychiatric residential youth treatment facility (PRYTF)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221124 03/12/2026 (a) The Texas Health and Human Services Commission may impose the following enforcement actions against a psychiatric residential youth treatment facility (PRYTF):(1) A denial of a PRYTF certificate;(2) A refusal to renew a PRYTF certificate;(3) An administrative penalty under Texas Health and Safety Code §571.025; and(4) A civil penalty under Texas Health and Safety Code §571.023.(b) An enforcement action taken against a PRYTF certificate is separate from an action taken against a general residential operation license. Source Note: The provisions of this §745.9085 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9085 Overview of Enforcement Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221125 03/12/2026 The Texas Health and Human Services Commission (HHSC) may deny a psychiatric residential youth treatment facility (PRYTF) certificate if HHSC determines ineligibility based on:(1) A provision in Texas Health and Safety Code Chapter 577A; or(2) HHSC's evaluation of the application under the criteria described in §745.9063 of this subchapter (relating to What factors will Child Care Regulation (CCR) consider when evaluating an application for a psychiatric residential youth treatment facility (PRYTF) certificate?). Source Note: The provisions of this §745.9087 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9087 Denial of certificate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221126 03/12/2026 The Texas Health and Human Services Commission (HHSC) may refuse to renew a psychiatric residential youth treatment facility (PRYTF) certificate for a reason listed in §745.8605 of this chapter (relating to When can Licensing recommend or impose an enforcement action against my operation?) or if:(1) The PRYTF did not submit a complete renewal application, timely or otherwise, according to §745.9069 of this subchapter (relating to What does a completed renewal application for a psychiatric residential youth treatment facility (PRYTF) certificate include?);(2) The PRYTF was not accredited at the time of the renewal;(3) The general residential operation (GRO) does not have a current license to operate at the time of the renewal, including if:(A) HHSC revokes the GRO's license;(B) HHSC refuses to renew the GRO's license;(C) The GRO voluntarily closes;(D) HHSC suspends the GRO's license; or(E) The GRO voluntarily suspends their license;(4) The GRO is not approved to provide treatment services to children with an emotional disorder at the time of renewal;(5) The PRYTF has not paid an administrative penalty after waiving or exhausting any due process provided under Texas Health and Safety Code §571.025;(6) The PRYTF has not timely submitted the renewal fee to HHSC; or(7) The PRYTF does not meet:(A) A provision in Texas Health and Safety Code Chapter 577A;(B) A rule in this subchapter; or(C) A minimum standard in Chapter 748, Subchapter W of this title (relating to Additional Requirements for Operations that Provide Psychiatric Health Treatments and Services). Source Note: The provisions of this §745.9089 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9089 Refusal To Renew https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221127 03/12/2026 (a) An administrative review is an informal review to determine whether a decision or action was appropriate under applicable laws and rules. An administrative review is not a formal hearing.(b) An administrative review may be requested to dispute the following in relation to a psychiatric residential youth treatment facility (PRYTF) certificate:(1) The denial of a PRYTF certificate;(2) The refusal to renew a PRYTF certificate; or(3) The citation of a deficiency of a statute, rule, or minimum standard.(c) An administrative review must be requested in accordance with Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings).(d) The administrative review process and all administrative review requirements will be conducted in accordance with Subchapter M of this chapter. Source Note: The provisions of this §745.9091 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9091 Administrative Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221128 03/12/2026 (a) The Texas Health and Human Services Commission (HHSC) may impose and collect an administrative penalty against a psychiatric residential youth treatment facility (PRYTF) for a violation of: (1) A provision in Texas Health and Safety Code Chapter 577A;(2) A rule in this subchapter; or(3) A minimum standard in Chapter 748, Subchapter W of this title (relating to Additional Requirements for Operations that Provide Psychiatric Health Treatments and Services). (b) Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty.(c) HHSC imposes an administrative penalty based on the number of individuals under the care of the PRYTF when the violation occurred:Attached Graphic Source Note: The provisions of this §745.9093 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9093 Administrative Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221129 03/12/2026 The Texas Health and Human Services Commission (HHSC) may impose a civil penalty against a psychiatric residential youth treatment facility (PRYTF) according to Texas Health and Safety Code §571.023 for a violation of:(1) A provision in Texas Health and Safety Code Chapter 577A; or(2) A rule adopted under Texas Health and Safety Code Chapter 577A, including:(A) A rule in this subchapter; or(B) A minimum standard in Chapter 748, Subchapter W of this title (relating to Additional Requirements for Operations that Provide Psychiatric Health Treatments and Services). Source Note: The provisions of this §745.9095 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9095 Civil Penalties https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221130 03/12/2026 A psychiatric residential youth treatment facility (PRYTF) has the right to a due process hearing before the SOAH in accordance with Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings) for:(1) The denial of a PRYTF certificate;(2) The refusal to renew a PRYTF certificate; or(3) The imposition of an administrative penalty. Source Note: The provisions of this §745.9097 adopted to be effective October 15, 2024, 49 TexReg 8158. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING O PSYCHIATRIC RESIDENTIAL YOUTH TREATMENT FACILITY §745.9097 State Office of Administrative Hearings (SOAH) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195998 03/12/2026 This subchapter is cross-referenced in Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers) and Chapter 747 of this title (relating to Minimum Standards for Child-Care Homes). Source Note: The provisions of this §745.9101 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9101 How does this subchapter relate to other Licensing chapters? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=195999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 195999 03/12/2026 The following words have the following meanings when used in this subchapter:(1) Day care administrator's credential - A credential that we recognize as meeting qualifications for a child-care center director or primary caregiver of a licensed home. Qualifications for a center director can be found in Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers). Qualifications for a primary caregiver of a licensed home are specified in Chapter 747 of this title (relating to Minimum Standards for Child-Care Homes).(2) I, my, you, and your - The professional organization or educational institution sponsoring a day care administrator's credential.(3) Credential program - The program a person must complete to receive a day care administrator's credential. Source Note: The provisions of this §745.9103 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9103 What words must I know to understand this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196000 03/12/2026 We will recognize your day care administrator's credential when you demonstrate that your credential program meets specific criteria. Source Note: The provisions of this §745.9105 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9105 When will Licensing recognize my day care administrator's credential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196001 03/12/2026 We may recognize your day care administrator's credential if you can demonstrate the following:(1) How you will ensure the continuity of your credential program;(2) How you will assess and select candidates for the credential program;(3) That a person must acquire competencies in administering a day care program to complete the credential program;(4) How you assess satisfactory completion of the credential program;(5) How the participant maintains the credential after acquiring it; and(6) When you will deny or revoke a credential or otherwise reprimand a credential holder. Source Note: The provisions of this §745.9107 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9107 What criteria must my credential program meet before Licensing will recognize my day care administrator's credential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196002 03/12/2026 To demonstrate how you will ensure the continuity of your credential program, you must provide the following:(1) A statement of your mission or purpose, your number of years in existence, and a description of your target audience;(2) A description of the organizational structure of your credential program and your experience or track record in related fields;(3) A statement of training outcomes and competencies participants will attain from the training; and(4) A statement of your plan for communicating with us, credential candidates, and credential holders, including your system for maintaining a database or keeping records of the following for at least three years:(A) Candidate applications for the credential program;(B) Names and social security numbers of persons granted a credential;(C) Effective dates and renewal dates for persons granted a credential; and(D) Adverse actions against persons granted a credential. Source Note: The provisions of this §745.9109 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9109 What must I submit to Licensing to demonstrate how I will ensure the continuity of my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196003 03/12/2026 To demonstrate your method for assessing and selecting candidates for your credential program, you must show us the following:(1) Specific training and/or education requirements required to enter the program;(2) Specific work experience, skills, and knowledge required to enter the program;(3) Policy regarding fees and fee refunds, if fees are collected;(4) Copy of the application;(5) A copy of the agreement specifying obligations of both the organization and the participant; and(6) A statement of any minimum and maximum timeframes for obtaining the credential. Source Note: The provisions of this §745.9111 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9111 How do I demonstrate my method for assessing and selecting candidates for my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196004 03/12/2026 To demonstrate that someone must acquire competencies in administering a day care program to complete your credential program, you must provide the following:(1) A description of the knowledge and skills that you have identified as necessary for obtaining a credential. For example, the ability to articulate expectations of staff, and the knowledge and ability to supervise and evaluate the performance of staff and develop a staff development plan;(2) An outline of the program content and learning objectives, which must include at least the following:(A) Child development concepts as specified in this subchapter;(B) Business management concepts as specified this subchapter; and(C) Work or practical experience in the child-care field;(3) Examples showing how the program content utilizes effective instruction methods and materials that take into account individual experiences, educational levels, and learning styles that challenge and involve participants;(4) A plan for updating the program content to reflect the latest knowledge and best practices in the child-care industry; and(5) A list of qualifications for instructors, including relevant education and experience in child care, training adults, assessing performance, and oral and written communication. Source Note: The provisions of this §745.9113 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9113 How do I demonstrate that someone must acquire competencies in administering a day care program to complete my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196005 03/12/2026 To demonstrate your criteria for assessing satisfactory completion of the program, you must demonstrate the following:(1) A statement of the passing level of performance and copy of the assessment tool used for this process; and(2) A copy of the credential including name, address, and telephone number of the organization, effective date of the credential, and a statement of how long the credential is valid. Source Note: The provisions of this §745.9115 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9115 How do I demonstrate my criteria for assessing satisfactory completion of the program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196006 03/12/2026 To demonstrate how a participant must maintain his credential, you must provide the following:(1) Requirements for renewal of the credential, including training topics and hours, work experience if required, renewal process, and renewal fees, if any;(2) Plan for communicating updates to persons holding a credential; and(3) Plan for assessment and update of performance standards. Source Note: The provisions of this §745.9117 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9117 How do I demonstrate the way in which a participant must maintain his credential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196007 03/12/2026 To demonstrate your criteria for revoking or denying a credential or otherwise reprimanding a credential holder, you must provide us with the following:(1) A clear statement of the basis for revocation or denial of the credential;(2) A clear statement of the basis for a reprimand and the resulting consequences;(3) A list of any other negative sanctions, basis for the sanctions, the resulting consequences, and procedures for removal of the sanction;(4) A plan for notifying us when a negative sanction is imposed; and(5) A clear statement of the credential holder's right to review and procedures for requesting this from you. Source Note: The provisions of this §745.9119 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9119 How do I demonstrate my criteria for revoking or denying a credential or otherwise reprimanding a credential holder? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196008 03/12/2026 To obtain our approval of your credential program, you must send a written request for recognition along with the necessary information about you and your credentialing procedures. You must send this to the Director of Licensing, Mail Code E-550, Texas Department of Protective and Regulatory Services, P.O. Box 149030, Austin, Texas 78714. Source Note: The provisions of this §745.9121 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9121 How do I obtain Licensing's approval of my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196009 03/12/2026 The Director of Licensing or designee reads and evaluates the information submitted to meet the criteria specified in this subchapter. If she gives your request for recognition a score of at least 95 points out of a possible 100 points, we will approve your program. Source Note: The provisions of this §745.9123 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9123 What will Licensing do with my request for approval of my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196010 03/12/2026 If your request for recognition does not score 95 points, we will send you a written response explaining what additional information we would need to recognize your program. Source Note: The provisions of this §745.9125 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9125 What if my request does not score 95 points for the required criteria? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196011 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196011 03/12/2026 We will send you a two-year Certificate of Recognition. We also place your name and contact information on the list of organizations that can grant credentials. The list is available on the PRS Internet website www.tdprs.state.tx.us or through us. We update the list regularly. Source Note: The provisions of this §745.9127 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9127 How will I prove that Licensing recognizes my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196012 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196012&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196012 03/12/2026 You may begin to provide training at any time, although we will not recognize a credential that you issue until we have issued you a certificate of recognition for your program. Source Note: The provisions of this §745.9129 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9129 Can I begin my credential program before Licensing issues my certificate of recognition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196013 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196013&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196013 03/12/2026 Your program's curriculum must cover child-development and business-management concepts. Source Note: The provisions of this §745.9131 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9131 What learning objectives must my program's curriculum include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196014 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196014&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196014 03/12/2026 The child-development portion of your curriculum must address the learning objectives in this chart:Attached Graphic Source Note: The provisions of this §745.9133 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9133 What learning objectives must the child-development portion of my curriculum include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196015 03/12/2026 The business-management portion of your curriculum must address the learning objectives in this chart: Attached Graphic Source Note: The provisions of this §745.9135 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9135 What learning objectives must the business-management portion of my curriculum include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196016 03/12/2026 To maintain your certificate of recognition, you must:(1) Maintain records specified in this subchapter;(2) Follow the plan under which you received recognition;(3) Survey all credential holders once every two years for a report of their compliance with our minimum standards;(4) Follow up with credential holders who do not indicate substantial compliance with our minimum standards by offering remedial training or review of relevant topics that may assist the credential holder in achieving compliance with minimum standards;(5) Document survey and follow up with credential holders;(6) Ensure each program instructor and administrator obtains from training sources outside of your credential program:(A) Ten clock hours of annual training in child growth and development, early childhood education, or related areas; and(B) Ten clock hours in management or related areas; and(7) Document training with original certificates, including the name of the participant, training topic, name of the instructor and telephone number, date of the training, and number of training hours stated in contact hours or CEUs. Source Note: The provisions of this §745.9137 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9137 What must I do to maintain the Licensing Certificate of Recognition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196017 03/12/2026 You must submit a written request to the Director of Licensing for renewal of your certificate of recognition 30 days before the certificate will expire. The written request must include:(1) Original certificates of documentation of training as specified in Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers) and Chapter 747 of this title (relating to Minimum Standards for Child-Care Homes) for each program instructor and administrator;(2) Updates to original program materials as required by any change in our rules or through advances in the child-care industry, child growth and development, and children's safety and health;(3) The number of credentials you have awarded and renewed in the previous two years; and(4) The numbers and types of sanctions you have issued in the previous two years. Source Note: The provisions of this §745.9139 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9139 What steps must I take to renew my Certificate of Recognition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196018 03/12/2026 Your Certificate of Recognition is valid for two years if you can demonstrate that you have complied with the criteria specified in this subchapter. Source Note: The provisions of this §745.9141 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9141 How long will my Certificate of Recognition be valid? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196019 03/12/2026 We may periodically assess whether your credential program complies with the criteria in this subchapter and your credential plan by:(1) Observing training, assessment activities, or remedial activities;(2) Requesting a current list of credential holders and evaluating compliance with minimum standards at operations administered by a credential holder;(3) Auditing credential holders for proof of compliance with your renewal requirements; and(4) Auditing candidate applications to determine compliance with the approved credential plan. Source Note: The provisions of this §745.9143 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9143 Will Licensing assess my credential program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196020 03/12/2026 No, but we will notify you of the results of our assessment, including any deficiencies that we identify. Source Note: The provisions of this §745.9145 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9145 Will Licensing notify me before assessing my program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196021 03/12/2026 Yes. You will have an opportunity to correct any deficiencies we identify. The time given to correct a deficiency will vary depending on the seriousness of the deficiency and the amount of time and expense needed to correct it. Source Note: The provisions of this §745.9147 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9147 Will I have an opportunity to correct any deficiencies that Licensing identifies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196022 03/12/2026 If we determine deficiencies continue after your opportunity to comply expires, we will place your organization on probation for a stated period of time not to exceed one year. We will notify you of the corrections needed. You must develop and submit a corrective action plan for our approval. We will continue to recognize your credentials during the probation period. Source Note: The provisions of this §745.9149 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9149 What happens when my opportunity to correct deficiencies passes before I correct them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196023 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196023&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196023 03/12/2026 You have the right to request an administrative review as specified in Subchapter M of this chapter (relating to Administrative Reviews and Due Process Hearings). Source Note: The provisions of this §745.9151 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9151 What are my rights if I disagree with Licensing imposing probation on my organization? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196024 03/12/2026 At the end of the probation period, we will evaluate the conditions of probation and reinstate, renew, or revoke the Certificate of Recognition. Source Note: The provisions of this §745.9153 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9153 What happens at the end of the probation period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196025 03/12/2026 No. We do not charge fees for this process. Source Note: The provisions of this §745.9155 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9155 Does Licensing charge fees for the application, recognition approval, and renewal process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196026 03/12/2026 If you hold a Certificate of Recognition on September 1, 2003, you must re-apply for approval by submitting all required information specified in this subchapter no later than six months from September 1, 2003. You must include a plan for transition with your request. You must achieve a score of 95 points or more before we can grant you a Certificate of Recognition. You may continue to offer credentials during the six months period. Source Note: The provisions of this §745.9157 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9157 If I currently hold a Certificate of Recognition, when will I have to meet the criteria specified in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196027 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196027&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196027 03/12/2026 If you have not complied with the criteria specified in this subchapter within the six-month period, we will not recognize credentials issued by your program until you comply with all criteria and we issue a Certificate of Recognition. Source Note: The provisions of this §745.9159 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9159 What if my application materials do not comply within this period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196028 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=196028&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 196028 03/12/2026 You have three times to submit all required material. If we return your application as incomplete three times, you may not apply again until one year from the date that we returned your last application as incomplete. Source Note: The provisions of this §745.9161 adopted to be effective September 1, 2003, 28 TexReg 1400; transferred effective July 15, 2019, as published in the June 14, 2019 issue of the Texas Register, 44 TexReg 2963. 1 HEALTH AND HUMAN SERVICES COMMISSION 745 LICENSING P DAY CARE ADMINISTRATOR'S CREDENTIAL PROGRAM §745.9161 How many chances do I have to submit all of the required information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188279 03/12/2026 The purpose of this chapter is to set forth the minimum standards that apply to child-care centers. Source Note: The provisions of this §746.101 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS A PURPOSE, SCOPE, AND DEFINITIONS §746.101 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188280 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188280 03/12/2026 The minimum standards in this chapter apply to:(1) Licensed child-care centers; and(2) Any unlicensed child-care center that is subject to Licensing's regulation and requires a license per Chapter 42 of the Human Resources Code. Source Note: The provisions of this §746.111 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS A PURPOSE, SCOPE, AND DEFINITIONS §746.111 What types of operations do these minimum standards apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188281 03/12/2026 (a) For a licensed child-care center, the permit holder must ensure compliance with all minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of child-care programs or activities that the center does not offer. For example, if we license the center to offer only toddler and pre-kindergarten care programs, the center does not have to comply with minimum standards that apply only to infant care, school-age care, get-well care, or nighttime-care programs; however, the center must comply with all other minimum standards.(b) For an unlicensed child-care center that is subject to Licensing's regulation, the center's director, owner, or operator or any other controlling person who has the ability to influence or direct the center's management, expenditures, or policies must ensure compliance with all minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of child-care programs or activities that the unlicensed center does not offer. Source Note: The provisions of this §746.113 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS A PURPOSE, SCOPE, AND DEFINITIONS §746.113 Who is responsible for complying with these minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212691 03/12/2026 The following words have the following meanings when used in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated.(2) We, us, our, and Licensing--The Child Care Regulation department of the Texas Health and Human Services Commission (HHSC). Source Note: The provisions of this §746.121 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS A PURPOSE, SCOPE, AND DEFINITIONS §746.121 What do certain pronouns mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220714 03/12/2026 The words and terms used in this chapter have the meanings assigned to them under §745.21 of this title (relating to What do the following words and terms mean when used in this chapter?), unless another meaning is assigned in this section or another subchapter or unless the context clearly indicates otherwise. In addition, the following words and terms used in this chapter have the following meanings unless the context clearly indicates otherwise:(1) Activity plan--A written plan that outlines the daily routine and activities in which a group of children will engage while in your care. The plan is designed to meet the children's cognitive, language, social, emotional, and physical developmental strengths and needs.(2) Activity space--An area or room used for children's activities, including areas separate from a group's classroom.(3) Administrative and clerical duties--Duties that involve the operation of a child-care center, such as bookkeeping, enrolling children, answering the telephone, and collecting fees.(4) Admission--The process of enrolling a child in a child-care center. The date of admission is the first day the child is physically present in the center.(5) Adult--A person 18 years old and older.(6) Age-appropriate--Activities, equipment, materials, curriculum, and environment, including the child's assigned classroom, that are developmentally consistent with the developmental or chronological age of the child being served.(7) Alternate care program--A program in which no child is in care for more than five consecutive days, and no child is in care for more than 15 days in one calendar month, regardless of the duration of each stay.(8) Attendance--When referring to a child's attendance, the physical presence of a child at the child-care center's program on any given day or at any given time, as distinct from the child's enrollment in the child-care center.(9) Body of water--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D (relating to Sanitation and Safety of Facilities Used by Public).(10) Bouncer seat--A stationary seat designed to provide gentle rocking or bouncing motion by an infant's movement, or by battery-operated movement. This type of equipment is designed for an infant's use from birth until the child can sit up unassisted.(11) Caregiver--A person who is counted in the child to caregiver ratio, whose duties include the supervision, guidance, and protection of a child. As used in this chapter, a caregiver must meet the minimum education, work experience, and training qualifications required under Subchapter D of this chapter (relating to Personnel). A caregiver is usually an employee, but may also be a substitute, volunteer, or contractor, as outlined in paragraph (20) of this section and Subchapter D, Division 5 of this chapter (relating to Substitutes, Volunteers, and Contractors).(12) Certified Child-Care Professional Credential--A credential given by the National Early Childhood Program Accreditation to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(13) Certified lifeguard--A person who has been trained in life saving and water safety by a qualified instructor, from a recognized organization that awards a certificate upon successful completion of the training. The certificate is not required to use the term "lifeguard," but the permit holder must be able to document that the certificate is current, relevant to the type of water activity in which children will engage, and represents the type of training described.(14) CEUs--Continuing education units. A standard unit of measure for adult education and training activities. One CEU equals 10 clock hours of participation in an organized, continuing-education experience, under responsible, qualified direction and instruction. Although a person may obtain a CEU in many of the same settings as clock hours, the CEU provider must meet the criteria established by the International Association for Continuing Education and Training to be able to offer the CEU.(15) Child--An infant, a toddler, a pre-kindergarten age child, or a school-age child.(16) Child-care center--A child-care facility that is licensed to care for seven or more children for less than 24 hours per day, at a location other than the permit holder's home. If you were licensed before September 1, 2003, the location of the center could be in the permit holder's home.(17) Child-care program--The services and activities provided by a child-care center.(18) Child Development Associate Credential--A credential given by the Council for Professional Recognition to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(19) Clock hour--An actual hour of documented:(A) Attendance at instructor-led training, such as seminars, workshops, conferences, early childhood classes, and other planned learning opportunities, provided by an individual or individuals as specified in §746.1317(a) of this chapter (relating to Must the training for my caregivers and the director meet certain criteria?); or(B) Self-instructional training that was created by an individual or individuals, as specified in §746.1317(a) and (b) of this chapter, or self-study training.(20) Contract service provider--A person or entity contracting with the operation to provide a service, whether paid or unpaid. Also referred to as "contract staff" and "contractor" in this chapter.(21) Corporal punishment--The infliction of physical pain on a child as a means of controlling behavior. This includes spanking, hitting with a hand or instrument, slapping, pinching, shaking, biting, or thumping a child.(22) Days--Calendar days, unless otherwise stated.(23) Employee--A person a child-care center employs full-time or part-time to work for wages, salary, or other compensation. Employees are all of the child-care center staff, including caregivers, kitchen staff, office staff, maintenance staff, the assistant director, the director, and the owner, if the owner is ever on site at the center or transports a child.(24) Enrollment--The list of names or number of children who have been admitted to attend a child-care center for any given period of time; the number of children enrolled in a child-care center may vary from the number of children in attendance on any given day.(25) Entrap--A component or group of components on equipment that forms angles or openings that may trap a child's head by being too small to allow the child's body to pass through, or large enough for the child's body to pass through but too small to allow the child's head to pass through.(26) Field trips--Activities conducted away from the child-care center.(27) Food service--The preparation or serving of meals or snacks.(28) Frequent--More than two times in a 30-day period. Note: For the definition of "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title (relating to What words must I know to understand this subchapter?).(29) Garbage--Waste food or items that when deteriorating cause offensive odors and attract rodents, insects, and other pests.(30) Grounds--Includes any parcel of land where the child-care center is located and any building, other structure, body of water, play equipment, street, sidewalk, walkway, driveway, parking garage, or parking lot on the parcel. Also referred to as "premises" in this chapter.(31) Group activities--Activities that allow children to interact with other children in large or small groups. Group activities include storytelling, finger plays, show and tell, organized games, and singing.(32) Hazardous materials--Any substance or chemical that is a health hazard or physical hazard, as determined by the Environmental Protection Agency. Also referred to as "toxic materials" and "toxic chemicals" in this chapter.(33) Health-care professional--A licensed physician, a licensed advanced practice registered nurse (APRN), a licensed vocational nurse (LVN), a licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the license. This does not include physicians, nurses, or other medical personnel who are not licensed in the United States or in the country in which the person practices.(34) Health check--A visual or physical assessment of a child to identify potential concerns about a child's health, including signs or symptoms of illness and injury, in response to changes in the child's behavior since the last date of attendance.(35) High school equivalent--(A) Documentation of a program recognized by the Texas Education Agency (TEA) or other public educational entity in another state, which offers similar training on reading, writing, and math skills taught at the high school level, such as a General Educational Development (GED) certificate; or(B) Confirmation that the person received home-schooling that adequately addressed basic competencies such as basic reading, writing, and math skills, which would otherwise have been documented by a high school diploma.(36) Individual activities--Opportunities for the child to work independently or to be away from the group but supervised.(37) Infant--A child from birth through 17 months.(38) Inflatable--An amusement ride or device, consisting of air-filled structures designed for use by children, as specified by the manufacturer, which may include bouncing, climbing, sliding, or interactive play. They are made of flexible fabric, kept inflated by continuous air flow by one or more blowers, and rely upon air pressure to maintain their shape.(39) Instructor-led training--Training characterized by the communication and interaction that takes place between the student and the instructor. The training must include an opportunity for the student to interact with the instructor to obtain clarifications and information beyond the scope of the training materials. For such an opportunity to exist, the instructor must communicate with the student in a timely fashion, including answering questions, providing feedback on skills practice, providing guidance or information on additional resources, and proactively interacting with students. Examples of this type of training include classroom training, web-based on-line facilitated learning, video-conferencing, or other group learning experiences.(40) Janitorial duties--Those duties that involve the cleaning and maintenance of the child-care center building, rooms, furniture, etc. Cleaning and maintenance include such duties as cleansing carpets, washing cots, and sweeping, vacuuming, or mopping a restroom or a classroom. Sweeping up after an activity or mopping up a spill in a classroom that is immediately necessary for the children's safety is not considered a janitorial duty.(41) Local sanitation official--A sanitation official designated by the city or county government.(42) Natural environment--Settings that are natural or typical for all children of the same age without regard to ability or disability. For example, a natural environment for learning social skills is a play group of peers.(43) Permit is no longer valid--For purposes of this chapter, a permit remains valid through the renewal process. A permit only becomes invalid when your center voluntarily closes or must close because of an enforcement action in Chapter 745, Subchapter L of this title (relating to Enforcement Actions).(44) Personal flotation device (PFD)--A United States Coast Guard approved life jacket.(45) Physical activity (moderate)--Levels of activity for a child that are at intensities faster than a slow walk, but still allow the child to talk easily. Moderate physical activity increases the child's heart rate and breathing rate.(46) Physical activity (vigorous)--Rhythmic, repetitive physical movement for a child that uses large muscle groups, causing the child to breathe rapidly and only enabling the child to speak in short phrases. Typically, the child's heart rate is substantially increased, and the child is likely to be sweating while engaging in vigorous physical activity.(47) Pre-kindergarten age child--A child who is three or four years of age before the beginning of the current school year.(48) Premises--See the term "grounds" and its definition in this section.(49) Regular--On a recurring, scheduled basis. Note: For the definition of "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title.(50) Restrictive device--Equipment that places the body of a child in a position that may restrict airflow or cause strangulation; usually, the child is placed in a semi-seated position. Examples of restrictive devices are car seats, swings, bouncy seats, and high chairs.(51) Safety belt--A lap belt and any shoulder straps included as original equipment on or added to a vehicle.(52) Sanitize--The use of a disinfecting product that provides instructions specific for sanitizing and is registered by the Environmental Protection Agency (EPA) to substantially reduce germs on inanimate objects to levels considered safe by public health requirements. Many bleach and hydrogen peroxide products are EPA-registered. You must follow the product's labeling instructions for sanitizing or disinfecting, depending on the surface (paying particular attention to any instructions regarding contact time and toxicity on surfaces likely to be mouthed by children, such as toys and crib rails). If you use bleach instead of an approved disinfecting product, you must follow these steps in order:(A) Washing with water and soap;(B) Rinsing with clear water;(C) Soaking in or spraying on a bleach solution for at least two minutes;(D) Rinsing with cool water only those items that children are likely to place in their mouths; and(E) Allowing the surface or item to air-dry.(53) School-age child--A child who is five years of age and older and is enrolled in or has completed kindergarten.(54) Screen time activity--An activity during which a child views media content on a cell or mobile phone, tablet, computer, television, video, film, or DVD. Screen time activities do not include video chatting with a child's family or assistive and adaptive computer technology used by a child with special care needs on a consistent basis.(55) Self-instructional training--Training designed to be used by one individual working alone and at the individual's own pace to complete lessons or modules. Lessons or modules commonly include questions with clear right and wrong answers. An example of this type of training is web-based training. Self-study training is also a type of self-instructional training.(56) Self-study training--Non-standardized training where an individual reads written materials, watches a training video, or listens to a recording to obtain certain knowledge that is required for annual training. Self-study training is limited to three hours of annual training per year.(57) Special care needs--A child with special care needs is a child who has:(A) A chronic physical, developmental, behavioral, or emotional condition or a disability and who also requires assistance beyond that required by a child generally to perform tasks that are within the typical chronological range of development, including the movement of large or small muscles, learning, talking, communicating, comprehension, emotional regulation, self-help, social skills, emotional well-being, seeing, hearing, and breathing; or(B) A limitation due to an injury, illness, or allergy.(58) State or local fire authority--A fire official who is authorized to conduct fire safety inspections on behalf of the city, county, or state government, including certified fire inspectors. Also referred to as "fire marshal" in this chapter.(59) Swimming Pool--An artificial body of water with a water depth of more than 18 inches that is maintained or used expressly for public or private recreational purposes, swimming, diving, aquatic sports or activities, or therapeutic purposes.(60) Toddler--A child from 18 months through 35 months.(61) Universal precautions--An approach to infection control where all human blood and certain human bodily fluids are treated as if known to be infectious for HIV, HBV, and other blood-borne pathogens.(62) Wading pool--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D.(63) Water activities--Related to the use of swimming pools, wading pools, or sprinkler play.(64) Weather permitting--Weather conditions that do not pose any concerns for health and safety, such as a significant risk of frostbite or heat-related illness. This includes adverse weather conditions in which children may still play safely outdoors for shorter periods with appropriate adjustments to clothing and any necessary access to water, shade, or shelter. Source Note: The provisions of this §746.123 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479; amended to be effective December 21, 2022, 47 TexReg 8114; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS A PURPOSE, SCOPE, AND DEFINITIONS §746.123 What do certain words and terms mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215009 03/12/2026 You are responsible for:(1) Developing and implementing your child-care center's operational policies, which must comply with or exceed the minimum standards specified in this subchapter;(2) Developing written personnel policies, including job descriptions, job responsibilities, and requirements;(3) Making provisions for training that comply with Division 4, Subchapter D of this chapter (relating to Professional Development);(4) Designating a child-care center director who meets minimum standard qualifications and has daily, on-site responsibility for the operation of the child-care center;(5) Reporting and ensuring your employees and volunteers report suspected abuse, neglect, or exploitation directly to the Texas Abuse and Neglect Hotline, as required by Texas Family Code §261.101; an employee may not delegate the responsibility to make a report, and you may not require an employee to seek approval to file a report or notify you that a report was made;(6) Ensuring all information related to background checks is kept confidential and not disclosed to unauthorized persons, as required by the Human Resources Code, §40.005(d) and (e);(7) Ensuring parents can visit the child-care center any time during the child-care center's hours of operation to observe their child, program activities, the building, the grounds, and the equipment without having to secure prior approval;(8) Complying with the liability insurance requirements in this division;(9) Complying with the child-care licensing law found in Chapter 42 of the Human Resources Code, the applicable minimum standards, and other applicable rules in the Texas Administrative Code;(10) Reporting to Licensing any Department of Justice substantiated complaints related to Title III of the Americans with Disabilities Act, which applies to commercial public accommodations; and(11) Ensuring the total number of children in care at the center or away from the center, such as during a field trip, never exceeds the licensed capacity of the center. Source Note: The provisions of this §746.201 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2008, 33 TexReg 1373; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effectiveSeptember 11, 2023, 48 TexReg 5070. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.201 What are my responsibilities as the permit holder? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204777 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit. Source Note: The provisions of this §746.203 adopted to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.203 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204778 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §746.203 of this division (relating to What are the liability insurance requirements?) if you cannot carry insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the operation; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit. Your notification must include the reason that you cannot carry the insurance. Source Note: The provisions of this §746.205 adopted to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.205 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204779 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §746.203 of this division (relating to What are the liability insurance requirements?), then you must notify the parent of each child in your care in writing that you do not carry liability insurance before you admit the child into your care.(b) If you previously carried the liability insurance and subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care in writing that you do not carry the insurance within 14 days after you stop carrying it.(c) You may use Form 2962, Verification of Liability Insurance , located on the Licensing provider website, to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parent of each child in your care, as required in §746.801(6) of this chapter (relating to What records must I keep at my child-care center?). Source Note: The provisions of this §746.207 adopted to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.207 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188284 03/12/2026 You must notify us in writing before:(1) Changing the address or location of the child care center;(2) Adding to or reducing indoor or outdoor space;(3) Reducing the number of toilets or sinks;(4) Adding a swimming pool or other permanent body of water;(5) Changing the age range of children to be cared for;(6) Changing the hours, days, or months of operation;(7) Offering new services, relating to minimum standards found in this chapter, such as a get-well care program, nighttime care, transportation, or field trips;(8) Planned closure of five consecutive days or more, during designated hours of operation, when the operation is not caring for children, with the exception of nationally recognized holidays;(9) Going out of business; or(10) There is a change in ownership of a center as specified in §745.437 of this title (relating to What is a change in ownership of an operation?). Source Note: The provisions of this §746.301 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.301 What changes regarding my child-care center must I notify Licensing about before making the change? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=202338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 202338 03/12/2026 (a) You must notify us in writing, no later than five days after a change is made, regarding:(1) The designee of your center that is not a sole proprietorship. The designee for a sole proprietorship is the owner/sole proprietor;(2) The board chair for a corporate facility or other executive officer of the governing body;(3) The address of the center's designee or governing body; and(4) The center director.(b) By January 15 of each year, you must report to us through your online Child Care Licensing Account the total number of employees who ceased working at your center during the previous calendar year. Source Note: The provisions of this §746.303 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 15, 2020, 45 TexReg 8524. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.303 What changes must I notify Licensing of regarding the child-care center's designee, governing body, director, and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212694 03/12/2026 (a) You must notify us as soon as possible, but no later than two days after:(1) Any occurrence that renders all or part of your center unsafe or unsanitary for a child;(2) Injury to a child in your care that requires medical treatment by a health-care professional or hospitalization;(3) A child in your care shows signs or symptoms of an illness that requires hospitalization;(4) You become aware that an employee or child in your care contracts an illness deemed notifiable by the Texas Department of State Health Services as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases);(5) A person for whom you are required to request a background check under Chapter 745, Subchapter F of this title (relating to Background Checks) is arrested or charged with a crime;(6) The occurrence of any other non-routine situation that places, or may place, a child at risk for injury or harm, such as forgetting a child in a center vehicle or on the playground or not preventing a child from wandering away from the child-care center unsupervised; and(7) A new individual becomes a controlling person at your operation, or an individual that was previously a controlling person ceases to be a controlling person at your operation.(b) You must notify us immediately if a child dies while in your care. Source Note: The provisions of this §746.305 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective December 1, 2012, 37 TexReg 9136; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.305 What other situations require notification to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212695 03/12/2026 (a) You must notify the parent of a child immediately if there is an allegation that the child has been abused, neglected, or exploited, as defined in Texas Family Code §261.001, while in your care.(b) After you ensure the safety of the child, you must notify the parent of the child immediately after the child:(1) Is injured and the injury requires medical treatment by a health-care professional or hospitalization;(2) Shows signs or symptoms of an illness that requires hospitalization;(3) Has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) Has been involved in any non-routine situation that placed, or may have placed, the child at risk for injury or harm. For example, a caregiver forgetting the child in a center vehicle or failing to prevent the child from wandering away from the child-care center unsupervised; or(5) Has been involved in any situation that renders the child-care center unsafe, such as a fire, flood, or damage to the child-care center as a result of severe weather.(c) You must notify the parent of less serious injuries when the parent picks the child up from the child-care center. Less serious injuries include minor cuts, scratches, and bites from other children requiring first-aid treatment by employees.(d) You must provide written notice to the parent of each child attending the child-care center within 48 hours of becoming aware that a child in your care or an employee has contracted a communicable disease deemed notifiable by the Texas Department of State Health Services, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases).(e) You must provide written notice to the parent of each child in a group within 48 hours when there is an outbreak of lice or other infestation in the group. You must either post this notice in a prominent and publicly accessible place where parents can easily view it or send an individual note to each parent. Source Note: The provisions of this §746.307 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447; amended to be effective October 25, 2021, 46 TexReg 7218; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.307 What emergency or medical situations must I notify parents about? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212696 03/12/2026 (a) You must notify the parent of each child attending your child-care center of a deficiency in:(1) A safe sleeping standard noted in subsection (b) of this section; or(2) The abuse, neglect, or exploitation standard in §746.1201(4) of this chapter (relating to What general responsibilities do my child-care center employees have?).(b) The following are safe sleeping standards requiring notification:(1) §746.2409(a)(1) of this chapter (relating to What specific safety requirements must my cribs meet?);(2) §746.2411(2)(A) of this chapter (relating to Are play yards allowed?);(3) §746.2415(a)(5) and (b) of this chapter (relating to What specific types of equipment am I prohibited from using with infants?);(4) §746.2426 of this chapter (relating to May I allow infants to sleep in a restrictive device?);(5) §746.2427 of this chapter (relating to How must I position an infant for sleep?);(6) §746.2428 of this chapter (relating to May I swaddle an infant to help the infant sleep?); and(7) §746.2429 of this chapter (relating to If an infant has difficulty falling asleep, may I cover the infant's head or crib?). Source Note: The provisions of this §746.309 adopted to be effective April 25, 2021, 46 TexReg 2447; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.309 What are the notification requirements when Licensing finds my center deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204783 03/12/2026 (a) Within five days after you receive notification of a deficiency described in §746.309 of this division (relating to What are the notification requirements when Licensing finds my center deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child in care?), you must notify the parents of each child attending your child-care center at the time of notification, including a child who may not have been in care on the day of the actual incident. (b) If the deficiency is for a safe sleeping standard, you must notify the parents using Form 2970, Notification of Safe Sleeping Deficiency , located on the Licensing provider website.(c) If the deficiency is for the standard related to the abuse, neglect, or exploitation of a child in care, you must notify the parents using Form 7266, Notification of Abuse/Neglect/Exploitation Deficiency , located on the Licensing provider website. Source Note: The provisions of this §746.311 adopted to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.311 How must I notify parents of a safe sleeping deficiency or an abuse, neglect, or exploitation deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188287 03/12/2026 You must post the following items:(1) The child-care center's license;(2) The letter or form from the most recent Licensing inspection or investigation;(3) The Licensing notice Keeping Children Safe;(4) Your emergency evacuation and relocation diagram as specified in §746.5207 of this title (relating to Must I have an emergency evacuation and relocation diagram?);(5) The activity plan for each group of children in the child-care center;(6) The daily menu, including all snacks and meals served by the child-care center;(7) The Licensing Parent Notification Poster;(8) Telephone numbers specified in §746.405 of this title (relating to What telephone numbers must I post and where must I post them?);(9) A list entitled "Current Employees." The list must be at least 8 1/2 inches by 11 inches in size, printed legibly, and must include each employee's first and last name;(10) A list of each child's food allergies that require an emergency plan, as specified in §746.3819 of this title (relating to When must I have a food allergy emergency plan for a child?); and(11) Any other Licensing notices with specific instructions to post the notice. Source Note: The provisions of this §746.401 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2006, 31 TexReg 860; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.401 What items must I post at my child-care center at all times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188293 03/12/2026 (a) Unless otherwise specified, the items specified in §746.401 of this title (relating to What items must I post at my child-care center at all times?) must be posted at all times, in a prominent and publicly accessible place where employees, parents, and others may easily view them.(b) For a list of each child's food allergies that require an emergency plan:(1) You must post the list during all hours of operation where you prepare food and in each room where the child may spend time;(2) The posting must be in a place where employees may easily view the list, and if a parent requests it, you must maintain privacy for the child (for example, a clipboard hung on the wall with a cover sheet over the list); and(3) You must ensure that all caregivers and employees who prepare and serve food are aware of each child's food allergies. Source Note: The provisions of this §746.403 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.403 When and where must these items be posted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220265 03/12/2026 (a) You must post in a prominent place the following telephone numbers:(1) 911 or, if 911 is not available in your area, you must post the telephone numbers for:(A) Emergency medical services;(B) Law enforcement; and(C) Fire department;(2) Poison control (1-800-222-1222); and(3) The Texas Abuse and Neglect Hotline (1-800-252-5400).(b) You must post in a prominent place the name, address, and telephone number for:(1) The local Child Care Regulation office; and(2) The child-care center. Source Note: The provisions of this §746.405 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective August 19, 2024, 49 TexReg 6227. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.405 What telephone numbers and other contact information must I post and where must I post this information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220266 03/12/2026 (a) You must develop written operational policies and procedures that at a minimum address each of the following:(1) Hours, days, and months of operation;(2) Procedures for the release of children;(3) Illness and exclusion criteria;(4) Procedures for dispensing medication or a statement that medication is not dispensed;(5) Procedures for handling medical emergencies;(6) Procedures for parental notifications;(7) Discipline and guidance that is consistent with Subchapter L of this chapter (relating to Discipline and Guidance). A copy of Subchapter L may be used for your discipline and guidance policy;(8) Suspension and expulsion of children;(9) Safe sleep policy for infants from birth through 12 months old that is consistent with the rules in Subchapter H of this chapter (relating to Basic Requirements for Infants) that relate to sleep requirements and restrictions, including sleep positioning, and crib requirements and restrictions, including mattresses, bedding, blankets, toys, and restrictive devices;(10) Meals and food service practices;(11) Immunization requirements for children, including tuberculosis screening and testing if required by your regional Texas Department of State Health Services or local health authority;(12) Hearing and vision screening requirements;(13) Enrollment procedures, including how and when parents will be notified of policy changes;(14) Transportation, if applicable;(15) Water activities, if applicable;(16) Field trips, if applicable;(17) Animals, if applicable;(18) Promotion of indoor and outdoor physical activity that is consistent with Subchapter F of this chapter (relating to Developmental Activities and Activity Plan); your policies must include:(A) The benefits of physical activity and outdoor play;(B) The duration of physical activity at your operation, both indoor and outdoor;(C) The type of physical activity (structured and unstructured) that children may engage in at your operation;(D) Each setting in which your physical activity program will take place;(E) The recommended clothing and footwear that will allow a child to participate freely and safely in physical activities;(F) The criteria you will use to determine when extreme weather conditions pose a significant health risk that prohibits or limits outdoor play; and(G) A plan to ensure physical activity occurs on days when extreme weather conditions prohibit or limit outdoor play.(19) Procedures for providing and applying, as needed, insect repellent and sunscreen, including what types will be used, if applicable;(20) Parent rights that are consistent with the rules in Division 5 of this subchapter (relating to Parent Rights);(21) Procedures for parents to review and discuss with the child-care center director any questions or concerns about the policies and procedures of the child-care center;(22) Procedures for parents to participate in the child-care center's operation and activities;(23) Instructions on how a parent may access the:(A) Minimum standards online;(B) Texas Abuse and Neglect Hotline; and(C) HHSC website.(24) Your emergency preparedness plan;(25) Your provisions to provide a comfortable place with an adult sized seat in your center or within a classroom that enables a mother to breastfeed her child. In addition, your policies must inform parents that they have the right to breastfeed or provide breast milk for their child while in care;(26) Preventing and responding to abuse and neglect of children, including:(A) Required annual training for employees;(B) Methods for increasing employee and parent awareness of issues regarding child abuse and neglect, including warning signs that a child may be a victim of abuse or neglect and factors indicating a child is at risk for abuse or neglect;(C) Methods for increasing employee and parent awareness of prevention techniques for child abuse and neglect;(D) Strategies for coordination between the center and appropriate community organizations; and(E) Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention, including procedures for reporting child abuse or neglect;(27) Procedures for conducting health checks, if applicable;(28) Information on vaccine-preventable diseases for employees, unless your center is in the home of the permit holder. The policy must address the requirements outlined in §746.3611 of this chapter (relating to What must a policy for protecting children from vaccine-preventable diseases include?);(29) If your operation maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, policies for maintenance, administration, and disposal of unassigned epinephrine auto-injectors that comply with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in Texas Administrative Code, Title 25, Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and in Texas Health and Safety Code §773.0145; and(30) Procedures for supporting inclusive services to children with special care needs. The policy must address the requirements outlined in §746.2202 of this chapter (relating to What are my responsibilities when planning activities for a child in care with special care needs?).(b) You must also inform the parents that any area within 1,000 feet of a child-care center is a gang-free zone, where criminal offenses related to organized criminal activity are subject to a harsher penalty under the Texas Penal Code. You may inform the parents by:(1) Providing this information in the operational policies;(2) Distributing the information in writing to the parents; or(3) Informing the parents verbally as part of an individual or group parent orientation. Source Note: The provisions of this §746.501 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2010, 35 TexReg 1293; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective December 1, 2012, 37 TexReg 9133; amended to be effective June 1, 2014, 39 TexReg 3720; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021,46TexReg 1479; amended to be effective October 25, 2021, 46 TexReg 7218; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective August 19, 2024, 49 TexReg 6227. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.501 What written operational policies must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188291 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188291 03/12/2026 Yes. On or before the date of admission, the parents must sign a child-care enrollment agreement or other similar documents, which must include at least the operational policies listed in this division. You must keep this signed document in the child's record or at least one for each family, if siblings are enrolled at the same time. Source Note: The provisions of this §746.503 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.503 Must I provide parents with a copy of my operational policies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188292 03/12/2026 When you change an operational policy or your child-care enrollment agreement, you must notify:(1) Your employees of any changes; and(2) The parents in writing of any changes. At least one copy of the updated operational policies or child-care enrollment agreement must be signed and dated for each family and kept in the child's record. Source Note: The provisions of this §746.505 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.505 What must I do when I change an operational policy or an item in the child-care enrollment agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220267 03/12/2026 A parent of a child in care has the right to:(1) Enter and examine your center during its hours of operation without advance notice;(2) File a complaint against your center;(3) Review your center's publicly accessible records;(4) Review your center's written records concerning the parent's child, as outlined in §746.601 of this chapter (relating to Who has the right to access children's records?);(5) Receive from your center:(A) HHSC's inspection reports for your center; and(B) Information regarding how to access your center's compliance history online;(6) Have your center comply with a valid court order signed by a judge that prevents another parent from visiting or removing the parent's child from your center, as outlined in §746.4101 of this chapter (relating to To whom may I release a child?);(7) Be provided with contact information for Child Care Regulation, including the department's name, address, and telephone number;(8) View any video recordings of an alleged incident of abuse or neglect involving the parent's child maintained by your center as long as:(A) Video recordings of the alleged incident are available;(B) The parent is not allowed to retain any portion of the video depicting a child who is not the parent's child; and(C) Your center notifies in writing the parent of any other child captured in the video recording, before allowing the parent to inspect the video recording;(9) Obtain a copy of your center's policies and procedures, as outlined in §746.503 of this subchapter (relating to Must I provide parents with a copy of my operational policies?);(10) Review, upon request of the parent, your:(A) Staff training records; and(B) In-house training curriculum, if any; and(11) Be free from any retaliatory action by your center for exercising any of the parent's rights. Source Note: The provisions of this §746.521 adopted to be effective August 19, 2024, 49 TexReg 6227. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS B ADMINISTRATION AND COMMUNICATION §746.521 What rights does a parent of a child in care of my child-care center have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188317 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188317 03/12/2026 (a) All children's records must be immediately accessible to caregivers during hours of operation for use in an emergency.(b) Parents have the right to access their own child's record during a parent conference with the caregiver or child-care center director.(c) All children's records are subject to review and/or reproduction by Licensing upon request during hours of operation. Source Note: The provisions of this §746.601 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.601 Who has the right to access children's records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188298 03/12/2026 (a) You must maintain the following records for each child enrolled in your child-care center:(1) Child-care enrollment agreement specified in §746.503 of this title (relating to Must I provide parents with a copy of my operational policies?);(2) Admission information specified in §746.605 of this title (relating to What admission information must I obtain for each child?); (3) Statement of the child's health from a health-care professional;(4) Immunization records;(5) Tuberculosis screening and testing information, if required by your regional Texas Department of State Health Services or local health authority;(6) Vision and hearing screening results, if applicable;(7) Licensing Incident/Illness Report form, if applicable; (8) A daily tracking system for when a child's care begins and ends as specified in §746.631 of this title (relating to Must I have a system for signing children in and out of my care?);(9) Medication administration records, if applicable; and(10) A copy of any health-care professional recommendations or orders for providing specialized medical assistance to the child. In some instances minimum standards allow for a deviation from a minimum standard with written documentation from a health-care professional. You must also maintain this written documentation in the child's record.(b) These records must at a minimum be kept at the child-care center and must be available during hours of operation and for the following periods of time:(1) Medication administration records for three months after administering the medication;(2) Health-care professional recommendations or orders for three months after the health-care professional has indicated that the specialized medical assistance is no longer needed; and(3) All other records noted in subsection (a) of this section for three months after the child's last day in care. Source Note: The provisions of this §746.603 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.603 What records must I have for children in my care and how long must I keep them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220715 03/12/2026 You must obtain at least the following information before admitting a child to care:(1) The child's name and birth date;(2) The child's home address and telephone number;(3) Date of the child's admission to the child-care center;(4) Name and address of parents;(5) Telephone numbers at which parents can be reached while the child is in care;(6) Name, address, and telephone number of another responsible individual (friend or relative) who should be contacted in an emergency when the parent cannot be reached;(7) Names and telephone numbers of persons other than a parent to whom the child may be released;(8) Permission for transportation, if provided;(9) Permission for field trips, if provided;(10) Name, address, and telephone number of the child's physician or an emergency-care facility;(11) Authorization to obtain emergency medical care and to transport the child for emergency medical treatment;(12) A statement of the child's special care needs, which must include:(A) Any limitations or restrictions on the child's activities;(B) Special care the child requires, including:(i) Any reasonable accommodations or modifications;(ii) Any adaptive equipment provided for the child, including instructions for how to use the equipment; and(iii) Symptoms or indications of potential complications related to a physical, cognitive, or mental condition that may warrant prevention or intervention while the child is in care; and(C) Any medications prescribed for continuous, long-term use;(13) The name and telephone number of the school that a school-age child attends, unless the operation is located at the child's school;(14) Permission for a school-age child to ride a bus, walk to or from school or home, or to be released to the care of a sibling under 18 years old, if applicable;(15) The child's allergies and a completed food allergy emergency plan for the child, if applicable; and(16) Permission for participation in water activities, if provided. If you allow a child to access a swimming pool, the parent must also indicate whether the child:(A) Is able to swim competently, as defined by the American Red Cross; or(B) Requires a personal flotation device because the child is:(i) Unable to swim competently, as defined by the American Red Cross; or(ii) At risk of injury or death when swimming or otherwise accessing a body of water. Source Note: The provisions of this §746.605 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.605 What admission information must I obtain for each child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188296 03/12/2026 Yes. The parent must sign the admission information before you admit the child to your care. Source Note: The provisions of this §746.607 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.607 Must the child's parent sign the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188297 03/12/2026 (a) Yes. You must develop a procedure for regularly updating the admission information, including information on special care needs.(b) The parent must sign and date the updated information. You may use a new form or have the parent initial and date amendments to a previously signed form. You must keep the updated information in the child's record. Source Note: The provisions of this §746.609 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.609 Must I update the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188299 03/12/2026 (a) A health statement is:(1) A written statement, from a health-care professional who has examined the child within the past year, indicating the child is able to take part in the child-care program;(2) A signed affidavit from the parent stating that medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization of which the parent is an adherent or a member; or(3) A signed statement from the parent giving the name and address of a health-care professional who has examined the child within the past year stating that the child is able to participate in the program. This must be followed by a signed statement from a health-care professional as specified in paragraph (1) of this subsection within 12 months of the date of admission.(b) You must have a health statement on file at the center, within one week after the date of admission, for each child who does not attend pre-kindergarten or school away from the child-care center. Source Note: The provisions of this §746.611 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2008, 33 TexReg 1373; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.611 Must I have a health statement for children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188300 03/12/2026 (a) Each child enrolled or admitted to child-care centers must meet and continue to meet applicable immunization requirements specified by the Texas Department of State Health Services (DSHS). This requirement applies to all children in care from birth through 14 years of age.(b) You must maintain current immunization records for each child in your care, including any immunization exemptions or exceptions.(c) All immunizations required for the child's age must be completed by the date of admission, unless:(1) The child is exempt or excepted from an immunization, and the exemption or exception is verified by the date of admission; or(2) The child is homeless or a child in foster care and is provisionally admitted for up to 30 days if evidence of immunization is not available. You should immediately refer the child to an appropriate health-care professional to obtain the required immunizations. The DSHS rule at 25 TAC §97.66 (relating to Provisional Enrollment for Students) establishes the guidelines for a provisional enrollment. Source Note: The provisions of this §746.613 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.613 What immunizations must a child in my care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188301 03/12/2026 (a) A child may be exempt from immunization requirements for a medical reason or reason of conscience, including a religious belief. To claim an exemption, the person applying for the child's admission must meet criteria specified by the Department of State Health Services (DSHS) rule at 25 TAC §97.62 (relating to Exclusions from Compliance).(b) For some diseases, a child who previously had a disease and is accordingly naturally immune from it may qualify for an exception to the immunization requirements for the disease. To claim this exception, the person applying for the child's admission must meet the criteria specified by the DSHS rule at 25 TAC §97.65 (relating to Exceptions to Immunization Requirements). Source Note: The provisions of this §746.615 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.615 What exemptions or exceptions are there concerning immunization requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188302 03/12/2026 Acceptable documentation includes:(1) An official immunization record generated from a state or local health authority, including a record from another state. Examples include a record from the Texas Immunization Registry, a copy of the current immunization record that is on file at the pre-kindergarten or school that the child attends, or the health passport for a child in the conservatorship of DFPS. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses; and(C) The month, day, and year the child received each vaccination; or(2) An official immunization record or photocopy. An example includes a record from a doctor's office or a pharmacy. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses;(C) The month, day, and year the child received each vaccination;(D) The signature (including a rubber stamp or electronic signature) of the health-care professional who administered the vaccine, or another health-care professional's documentation of the immunization as long as the name of the health-care professional that administered the vaccine is documented; and(E) Clinic contact information, if the immunization record is generated from an electronic health record system. Source Note: The provisions of this §746.623 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.623 What documentation is acceptable for an immunization record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188307 03/12/2026 For each child attending a pre-kindergarten program or school away from the child-care center, you must have either:(1) A copy of the current immunization record that is on file at the pre-kindergarten program or school the child attends; or(2) A signed statement from the child's parent that the child's immunization record is current and on file at the pre-kindergarten program or school that the child attends. The statement must be dated and include the name, address, and telephone number of the pre-kindergarten program or school listed in the statement. Source Note: The provisions of this §746.625 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.625 If a child's immunization record is already on file at a pre-kindergarten program or school away from the child-care center, must I also have a copy of the child's immunization record in my files? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188308 03/12/2026 Requirements for tuberculosis screening and testing vary across the state. If your regional Texas Department of State Health Services (DSHS) or local health authority requires tuberculosis testing for children in your child-care center, then you must have documentation to indicate that each child in your care is free of active tuberculosis. Documentation of a TB screening is not required to be on file. If you are unsure of the requirements for your area, contact the TB manager at the DSHS regional office nearest you. Source Note: The provisions of this §746.627 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.627 Must children in my care have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188303 03/12/2026 (a) The Special Senses and Communication Disorders Act, Texas Health and Safety Code, Chapter 36, requires a screening or a professional examination for possible vision and hearing problems for children of certain ages and grades. Refer to 25 TAC Chapter 37, Subchapter C, (relating to Vision and Hearing Screening), for specifics on vision and hearing screening. This information may be accessed on the Internet at: www.dshs.state.tx.us/vhs/.(b) You must keep one of the following at the child-care center for each child required to be screened:(1) The individual visual acuity and sweep check results;(2) A signed statement from the child's parent that the child's screening records are current and on file at the pre-kindergarten program or school the child attends away from the center. The statement must be dated and include the name, address, and telephone number of the pre-kindergarten program or school; or(3) An affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination of which the affiant is an adherent or member. Source Note: The provisions of this §746.629 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.629 Must children in my care have vision and hearing screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188304 03/12/2026 (a) Yes. You must have a tracking system for each child coming and going from your child-care center throughout the day. This tracking system must include the name of each child; the date, time of arrival, and time of departure; and the employee or parent's initials or other unique identifier code.(b) All caregivers must have access to the tracking system to determine which children are in care during their work shift, changes in caregivers, and emergency evacuations. Source Note: The provisions of this §746.631 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.631 Must I have a system for signing children in and out of my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213016 03/12/2026 You must record the following information on the Licensing Incident/Illness Report Form 7239 or another form that contains at least the same information: (1) An injury to a child in care that required medical treatment by a health-care professional or hospitalization; (2) An illness that required the hospitalization of a child in care; (3) An incident where a child in care had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) An incident of a child in care or employee contracting a communicable disease deemed notifiable by the Texas Department of State Health Services, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases); and (5) Any other non-routine situation that placed, or may have placed, a child at risk for injury or harm, such as forgetting a child in a center vehicle or not preventing a child from wandering away from the child-care center unsupervised. Source Note: The provisions of this §746.701 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447; amended to be effective October 25, 2021, 46 TexReg 7218; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.701 What written records must I keep of accidents and incidents that occur at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188306 03/12/2026 Yes. After the caregiver completes the form, the director of the child-care center, or if the director is not available, the person in charge of the center must sign and date the completed report. Source Note: The provisions of this §746.705 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.705 Must someone from my child-care center sign the Incident/Illness Report form? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188312 03/12/2026 Yes. You must share a copy of the report with the child's parent and obtain the parent's signature on the report indicating the parent has reviewed it or received a copy of the report within 48 hours of when the incident occurred. Source Note: The provisions of this §746.707 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.707 Must I share a copy of the Incident/Illness Report form with the child's parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188309 03/12/2026 You must keep the Incident/Illness Report form with the child's record at the child-care center while the child is in care, and for at least three months after the child's last day in care. Source Note: The provisions of this §746.709 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.709 Where must I file the Incident/Illness Report form and how long must I keep it? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206502 03/12/2026 You must maintain and make the following records available for our review upon request, during hours of operation. Paragraphs (14), (15), and (16) of this section are optional, but if provided will allow Licensing to avoid duplicating the evaluation of standards that have been evaluated by another state agency within the past year:(1) Children's records, as specified in Division 1 of this subchapter (relating to Records of Children);(2) Infant feeding instructions, as required in §746.2421 of this chapter (relating to What written feeding instructions must I obtain for an infant not ready for table food?), if applicable;(3) Personnel and training records according to Division 4 of this subchapter (relating to Personnel Records);(4) Licensing Child-Care Center Director's Certificate; (5) Attendance records or time sheets listing all days and hours worked for each employee;(6) Proof of current liability insurance coverage or, if applicable, that you have provided written notice to the parent of each child that you do not carry the insurance;(7) Medication records, if applicable;(8) Playground maintenance checklists;(9) Pet vaccination records, if applicable;(10) Safety documentation for emergency drills, fire extinguishers, and smoke detectors;(11) Most recent fire inspection report, including any written approval from the fire marshal to provide care above or below ground level, if applicable;(12) Most recent sanitation inspection report;(13) Most recent gas inspection report, if applicable;(14) Most recent Texas Department of State Health Services immunization compliance review form, if applicable;(15) Most recent Texas Department of Agriculture Child and Adult Care Food Program report, if applicable;(16) Most recent local workforce board Child-Care Services Contractor inspection report, if applicable;(17) Record of pest extermination, if applicable;(18) Most recent Licensing form certifying that you have reviewed each of the bulletins and notices issued by the United States Consumer Product Safety Commission regarding unsafe children's products and that there are no unsafe children's products in use or accessible to children in the child-care center;(19) A daily tracking system for when a child's care begins and ends, as specified in §746.631 of this subchapter (relating to Must I have a system for signing children in and out of my care?);(20) Documentation for all full-size and non-full-size cribs, as specified in §746.2409(a)(9) of this chapter (relating to What specific safety requirements must my cribs meet?);(21) Documentation for vehicles, as specified in §746.5627 of this chapter (relating to What documentation must I keep at the child-care center for each vehicle used to transport children in care?), if applicable;(22) Proof that you have notified parents in writing of deficiencies in safe sleeping and abuse, neglect, or exploitation, as specified in §746.309 of this chapter (relating to What are the notification requirements when Licensing finds my center deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child?) and §746.311 of this chapter (relating to How must I notify parents of a safe sleeping deficiency or an abuse, neglect, or exploitation deficiency?); and(23) A copy of each completed Texas Department of State Health Services Epinephrine Auto-Injectors Reporting Form used to report the administration of an unassigned epinephrine auto-injector, if your operation administers and maintains unassigned epinephrine auto-injectors. Source Note: The provisions of this §746.801 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2010, 35 TexReg 1293; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective December 1, 2012, 37 TexReg 9133; amended to be effective March 1, 2014, 39 TexReg 1189; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447; amended to be effective October 25, 2021, 46 TexReg 7218. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.801 What records must I keep at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188311 03/12/2026 (a) Unless otherwise stated in this chapter, you must keep at the child-care center for at least three months from the date the record was created each record that your center is required to post or keep.(b) You must keep training records for the current director and caregivers for at least the current and last full training year. Source Note: The provisions of this §746.803 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.803 How long must I keep records at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188313 03/12/2026 Yes, you may keep electronic records or a combination of paper and electronic records.(1) If you keep a combination of electronic and paper records, you must develop procedures that address what must be in the external paper file and what can be in the electronic file;(2) Children's records must be accessible to all caregivers during their work shift, changes in caregivers, and emergency evacuations; and(3) Records must be available during operating hours for review by Licensing upon request. Source Note: The provisions of this §746.805 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.805 May I keep electronic records or a combination of paper and electronic records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219543 03/12/2026 You must have the following records at the child-care center and available for review during hours of operation for each employee, caregiver, substitute, and volunteer as specified in this chapter: (1) Documentation showing the dates of the first and last day on the job; (2) Documentation showing how the employee meets the minimum age and education qualifications, if applicable; (3) A copy of a health card or health care professional's statement verifying the employee is free of active tuberculosis, if required by the regional Texas Department of State Health Services TB program or local health authority; (4) A notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) as specified in Texas Human Resources Code §42.059; (5) A Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) as specified in Texas Human Resources Code §42.0563;(6) A record of training hours, including documentation required by §746.1329 of this chapter (relating to What documentation must I provide to Licensing to verify that employees have met training requirements?); (7) A statement signed and dated by the employee showing he has received a copy of the child-care center's: (A) Operational policies; and (B) Personnel policies; (8) Proof of request for background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks); (9) A copy of a photo identification; (10) A copy of the person's current driver's license if the person transports a child in care; and (11) A statement signed and dated by the employee verifying the date the employee attended training during orientation that includes an overview of your policy on the prevention, recognition, and reporting of child maltreatment outlined in §746.1303 of this chapter (relating to What must orientation for employees at my child-care center include?). Source Note: The provisions of this §746.901 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2014, 39 TexReg 1189; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective August 14, 2024, 49 TexReg 4918. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.901 What information must I maintain in my personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188315 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188315 03/12/2026 (a) You must keep all records for at least three months after an employee's last day on the job, with the exception of annual training records.(b) You must maintain annual training records for current personnel for the last full training year and current training year.(c) You must keep personnel records at the child-care center or in a central administrative location provided they are immediately available for review during hours of operation. Source Note: The provisions of this §746.907 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.907 How long and where must I keep the required personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188316 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188316 03/12/2026 Yes. Licensing staff must be given immediate access to all personnel records that document compliance with minimum standards. You must allow Licensing to photograph, copy, or scan these records if requested. Source Note: The provisions of this §746.909 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS C RECORD KEEPING §746.909 May Licensing access my personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192506 03/12/2026 The child-care center director is the adult you designate to have the daily, on-site responsibility for the operation of the child-care center, including maintaining compliance with the minimum standards and Licensing laws. Source Note: The provisions of this §746.1001 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1001 Who is the child-care center director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192507 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192507 03/12/2026 Your child-care center director must ensure:(1) The child-care center's daily operation is administered in compliance with the minimum standards specified in this chapter;(2) All employees comply with the minimum standards;(3) All employees have assignments that match their skills, abilities, and training;(4) All employees are supervised. Supervision includes, but is not limited to, knowing what the employees are doing and ensuring that they fulfill their assignments and responsibilities;(5) Caregivers are not regularly scheduled for more than ten hours of direct child care during a 24-hour period; and(6) Qualified substitutes are called as necessary to meet minimum standards. Source Note: The provisions of this §746.1003 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1003 What are the director's responsibilities while at the child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212710 03/12/2026 (a) If you have multiple operations under the same governing body, you must designate a separate director for each operation.(b) If you have designated a single director for more than one operation, you must comply with the requirement specified in subsection (a) of this section no later than March 1, 2025. Source Note: The provisions of this §746.1005 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1005 If I have multiple operations, must I designate a separate director for each operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192508 03/12/2026 Yes. You may be both the director and permit holder of a child-care center if you meet all of the required qualifications and are able to fulfill the responsibilities of a child-care center director. Source Note: The provisions of this §746.1007 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1007 May I be the director of my own child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192509 03/12/2026 Yes. You may designate more than one director for your child-care center; however, each director must meet the qualifications specified in this division and receive a written job description that includes job responsibilities. Source Note: The provisions of this §746.1009 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1009 May I have more than one director for my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212711 03/12/2026 (a) A director must be present a minimum of 75 percent of the program's operating hours each week or a minimum of 30 hours per week, whichever is less, to ensure the operation complies with all minimum standards, unless:(1) The director is absent from the operation temporarily for vacation or other personal time off; or(2) The director is engaging in professional development activities related to the role of director.(b) If you have designated a single director for more than one operation, you must comply with the requirements specified in subsection (a) of this section no later than March 1, 2025. Source Note: The provisions of this §746.1011 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1011 Must my director be at my child-care center during all hours of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192511 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192511 03/12/2026 (a) Yes. Anytime your director is away from the child-care center during hours of operation, you or your director must designate a qualified caregiver or director to be in charge of the child-care center. Designated individuals must:(1) Know they are in charge and for how long;(2) Know their responsibilities while in charge;(3) Have access to all essential information to communicate with parents and state and local authorities as needed; and(4) Have the authority to direct the child-care center in compliance with minimum standards.(b) If the director must be absent for an extended period of time for any reason, you must name someone who meets director qualifications to serve during the director's absence and you must report the name of the temporary director to Licensing.(c) You or your director must ensure that all other employees know who is in charge in the director's absence. Source Note: The provisions of this §746.1013 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1013 Must someone else be designated to be in charge of my child-care center in my director's absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212712 03/12/2026 Except as otherwise provided in this division, the director of a child-care center licensed for 13 or more children must be at least 21 years of age, have a high school diploma or its equivalent, and meet one of the following combinations of education and experience, as defined in §746.1021 of this division (relating to What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home?): Attached Graphic Source Note: The provisions of this §746.1015 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1015 What qualifications must the director of my child-care center licensed for 13 or more children meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212713 03/12/2026 Except as otherwise provided in this division, the director of a child-care center licensed for 12 or fewer children must be at least 21 years old, have a high school diploma or its equivalent, and meet one of the following combinations of education and experience, as defined in §746.1021 of this division (relating to What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home?): Attached Graphic Source Note: The provisions of this §746.1017 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective June 1, 2009, 34 TexReg 2982; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1017 What qualifications must the director of my child-care center licensed for 12 or fewer children meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192514 03/12/2026 (a) Only the following types of experience may be counted as experience in a licensed child-care center:(1) Experience as a director, assistant director, or as a caregiver working directly with children in a DFPS licensed or certified child-care center (or similar type of day care center that was formerly licensed, certified, or accredited by DFPS); and(2) Experience as a director, assistant director, or caregiver working directly with children in a licensed or certified child-care center in another state or country.(b) Only experience working directly with children in a DFPS licensed or registered child-care home (or in a group day-care home that was formerly licensed by DFPS) as an assistant caregiver, substitute caregiver, or primary caregiver may be counted as experience in a licensed or registered child-care home.(c) You must have obtained all work experience in a full-time capacity or its equivalent in a part-time capacity. Full-time is defined as at least 30 hours per week. The work experience may be paid or unpaid. Source Note: The provisions of this §746.1021 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1021 What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192515 03/12/2026 The following types of experience may be substituted for one year of the required experience:(1) One year of full-time classroom teaching in a public or private accredited school in grades pre-kindergarten through third, during a customary school year;(2) Substitute or part-time classroom teaching in a public or private accredited school in grades pre-kindergarten through third, if the total length of time adds up to one year of full-time teaching during a customary school year; and(3) One year of post-graduate study in child development, early childhood education, or a closely related field. Source Note: The provisions of this §746.1023 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1023 May other types of experience be substituted for the required experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192516 03/12/2026 Yes. To determine whether a person has sufficient experience to qualify as a director, we may, at our own discretion, verify child-care experience and substitute child-care experience via the Internet, telephone or mail contact with previous employer(s), or through our records. Source Note: The provisions of this §746.1025 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1025 Can Licensing verify whether someone has sufficient experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192517 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the child development requirement. Courses in early childhood education, child growth and development, psychology, sociology, classroom management, child psychology, health and safety of children, elementary education related to pre-kindergarten through third grade, and other similar courses may be counted, provided the course content relates to child development or the topics specified in §746.1309 of this title (relating to How many clock hours of annual training must be obtained by caregivers?). Abnormal psychology and secondary education courses are not recognized as child development. Source Note: The provisions of this §746.1027 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1027 What credit courses does Licensing recognize as child development? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192518 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the management requirement. Management courses may include administration of a child-care facility, recreational leadership, accounting, goal and objective setting, performance planning and evaluation, management techniques, risk management and other administrative, management, or supervisory-related courses. Courses in office machines or computer training are not recognized as management. Source Note: The provisions of this §746.1029 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1029 What credit courses does Licensing recognize as management? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192519 03/12/2026 If requested by Licensing, you must provide original transcripts and supporting documentation, such as a credit course catalog description or a course syllabus or outline to determine whether the course is recognized as child development or management. Source Note: The provisions of this §746.1031 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1031 What documentation must I provide to show that my director meets the child development and management education qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212714 03/12/2026 (a) Clock hours or CEUs may only be substituted for the required credit hours in child development and management.(b) 50 clock hours or five CEUs may only be substituted for every three college credit hours required in child development and management.(c) The documentation to verify the clock hours or CEUs must be as specified in §746.1329 of this title (relating to What documentation must I provide to Licensing to verify that employees have met training requirements?). Source Note: The provisions of this §746.1037 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1037 May clock hours or CEUs (continuing education units) be substituted for any of the educational requirements in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192521 03/12/2026 (a) In addition to showing that your director meets the minimum qualifications for an employee (and minimum qualifications for a caregiver, if applicable), you must submit the following for each director at your child-care center:(1) A completed Licensing Personal History Statement form specifying the education and experience of your designated director;(2) A completed Licensing Governing Body/Director Designation form; (3) An original and current Licensing Child-Care Center Director's Certificate form; or an original college transcript or original training certificates which verify the educational requirements; and (4) Complete dates, names, addresses, and telephone numbers which support the required experience.(b) You must submit the information to us:(1) As part of a new application for a permit; or(2) Within five days of designating a new director. Source Note: The provisions of this §746.1039 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1039 What additional documentation must I submit to Licensing to show my child-care center director is qualified and when must I submit it? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192522 03/12/2026 Yes, however you must provide supporting information such as a copy of the diploma or transcript or letter from the school to indicate that the education is equivalent to a program in the United States. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §746.1045 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1045 Does education received outside of the United States substitute for the education requirements for a child-care director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192523 03/12/2026 No. After we evaluate this information and issue a director's certificate, we will return the original documents to you along with the certificate or if a certificate is not issued along with the letter notifying you of the decision. Source Note: The provisions of this §746.1047 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1047 Will Licensing keep the original training certificates and college transcripts I submit to obtain a Licensing director's certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192524 03/12/2026 We will notify you that your director is in violation of minimum standards for failure to meet child-care center director qualifications as soon as possible but no later than ten days after a determination is made. We will give you a deadline to submit additional paperwork or to designate another director and submit new paperwork. Source Note: The provisions of this §746.1049 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1049 What happens if Licensing determines that my child-care center director does not meet minimum standard qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192525 03/12/2026 Yes. After we determine that your director meets minimum standard qualifications, we will issue a Licensing Child-Care Center Director's Certificate. The certificate verifies only that the named person meets minimum standard qualifications specified in §746.1015 of this title (relating to What qualifications must the director of my child- care center licensed for 13 or more children meet?) or §746.1017 of this title (relating to What qualifications must the director of my child-care center licensed for 12 or fewer children meet?). Source Note: The provisions of this §746.1051 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1051 Will my director receive a certificate verifying that director qualifications have been met? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221988 03/12/2026 The director's certificate will not expire unless the director was qualified:(1) Under (5) or (6) in Figure: 26 TAC §746.1015 of this division (relating to What qualifications must the director of my child-care center licensed for 13 or more children meet?);(2) Under (4) or (6) in Figure: 26 TAC §746.1017 of this division (relating to What qualifications must the director of my child-care center licensed for 12 or fewer children meet?); or(3) As an interim director as outlined in §746.1067 of this division (relating to When may a child-care center designate someone as its interim director?). Source Note: The provisions of this §746.1053 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 15, 2024, 49 TexReg 9320. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1053 Will the director's certificate expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192527 03/12/2026 If you qualify under subsection (a), options (5) or (6) in §746.1015 of this title (relating to What qualifications must the director of my child-care center licensed for 13 or more children meet?) or subsection (a), options (4) or (6) in §746.1017 of this title (relating to What qualifications must the director of my child-care center licensed for 12 or fewer children meet?), you must maintain your credential according to the issuing organization's or educational institution's requirements. You must submit to us a copy of a letter or other documentation confirming the credential is current before we can renew your Child-Care Center Director's Certificate. Source Note: The provisions of this §746.1055 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1055 How often must an expiring certificate be renewed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192528 03/12/2026 We will give you a deadline for your director to submit the required documentation or for you to designate another qualified director. If your director allows the Child-Care Center Director's Certificate to expire without submitting the required documentation confirming that the credential is current, then your center will no longer meet the minimum standards for a child-care center director. Source Note: The provisions of this §746.1057 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1057 What happens if my Child-Care Center Director's Certificate expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192529 03/12/2026 (a) If you can provide an original and current Licensing director's certificate, you will not be required to resubmit the information establishing qualifications. (b) If an original and current Licensing Child-Care Center Director's Certificate is not available, or Licensing cannot verify the director is qualified, you must resubmit the information to us to determine if your designated director meets minimum child-care center director qualifications. Source Note: The provisions of this §746.1059 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1059 If I hire someone who was qualified as a director at another licensed child-care center in Texas, must I resubmit all of the information to Licensing staff for review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192530 03/12/2026 No. We do not charge a fee for processing a director's certificate. Source Note: The provisions of this §746.1061 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1061 Does Licensing charge a fee for issuing the director's certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192531 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192531&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192531 03/12/2026 Yes. We will issue a replacement Child-Care Center Director's Certificate, if you submit your request to us in writing, specifying: (1) The name and address of your child-care center; (2) The name of the director for whom the replacement certificate is needed; (3) The date we issued the original certificate; and (4) The reason a replacement certificate is needed. Source Note: The provisions of this §746.1063 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1063 Can my director get a replacement Child-Care Center Director's Certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221989 03/12/2026 (a) An interim director is an individual designated to serve as the director of a child-care center under §746.1067 of this division (relating to When may a child-care center designate someone as its interim director?).(b) The interim director has the same responsibilities as a child-care center director as outlined in this chapter. Source Note: The provisions of this §746.1065 adopted to be effective Dcember 15, 2024, 49 TexReg 9320. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1065 What is an interim director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221990 03/12/2026 A child-care center may designate an individual to serve as its interim director if:(1) The center is operating with an initial license; and(2) The individual meets all the requirements to serve as director except the educational requirement in:(A) §746.1015 of this division (relating to relating to What qualifications must the director of my child-care center licensed for 13 or more children meet?); or(B) §746.1017 of this division (relating to What qualifications must the director of my child-care center licensed for 12 or fewer children meet?). Source Note: The provisions of this §746.1067 adopted to be effective Dcember 15, 2024, 49 TexReg 9320. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1067 When may a child-care center designate someone as its interim director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221991 03/12/2026 (a) Someone serving as interim director of a child-care center may serve as the center's director after the center receives a full license if:(1) The individual has completed the educational requirement and fully qualifies to serve as a child-care center director; or(2) The child-care center obtains a waiver or variance from Child Care Regulation that allows the center to have a director who does not meet the educational requirement.(b) A child-care center must employ a new director if the individual who served as interim director does not qualify under subsection (a) of this section. Source Note: The provisions of this §746.1069 adopted to be effective Dcember 15, 2024, 49 TexReg 9320. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1069 May someone serving as interim director of a child-care center continue to serve as director after the center receives a full license? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219544 03/12/2026 Each child-care center employee must: (1) Meet the requirements in Chapter 745, Subchapter F of this title (relating to Background Checks); (2) Have a current record of a tuberculosis examination, showing the employee is free of contagious TB, if required by the Texas Department of State Health Services or local health authority; (3) Complete a notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) before you hire the employee, as specified in Human Resources Code §42.059; and(4) Complete a Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) before you hire the employee, as specified in Texas Human Resources Code §42.0563. Source Note: The provisions of this §746.1105 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective August 14, 2024, 49 TexReg 4918. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1105 What minimum qualifications must each of my child-care center employees meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192483 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192483 03/12/2026 Except as otherwise provided in this division, each caregiver must comply with minimum standards for employees and must:(1) Be at least 18 years of age; and(2) Have a:(A) High school diploma;(B) High school equivalent; or(C) High school certificate of coursework completion as defined in Texas Education Code, §28.025(d). Source Note: The provisions of this §746.1107 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1107 What additional minimum qualifications must each of my caregivers meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192480 03/12/2026 (a) You may employ a 16 or 17 year old who has a high school diploma or its equivalent and count the person in the child/caregiver ratio, provided that:(1) You don't leave the person alone with sole responsibility for or in charge of an individual child, a group of children, or the child-care center;(2) The person works in the same room with and is supervised by a caregiver qualified under §746.1107 of this title (relating to What additional minimum qualifications must each of my caregivers meet?); and(3) The person has completed a child-care-related career program, which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes all 24 hours of pre-service training before being placed in a room with children.(b) You may employ a 16, 17, or 18 year old who attends high school but has not graduated and count the person in the child/caregiver ratio, provided that:(1) You don't leave the person alone with sole responsibility for or in charge of an individual child, a group of children, or the child-care center;(2) The person works in the same room with and is supervised by a caregiver qualified under §746.1107 of this title;(3) The person is currently enrolled in or has completed a child-care-related career program, which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes all 24 hours of pre-service training before being placed in a room with children; and(4) The person is expected to obtain a high school diploma or equivalent. Source Note: The provisions of this §746.1109 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1109 When may I employ a person under the age of 18 or a person who does not have a high school diploma or equivalent as a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192481 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192481 03/12/2026 Yes, however you must provide supporting information such as a copy of the diploma or letter from the school district to indicate that the education is equivalent to a high school diploma program in the United States. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §746.1111 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1111 Does education received outside of the United States count toward caregiver qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188416 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188416 03/12/2026 All child-care center employees, including persons not counted in the child/caregiver ratio, must:(1) Demonstrate competency, good judgment, and self-control in the presence of children and when performing assigned responsibilities;(2) Relate to children with courtesy, respect, acceptance, and patience;(3) Recognize and respect the uniqueness and potential of all children, their families, and their cultures;(4) Ensure that no child is abused, neglected, or exploited while in the care of the center; and(5) Report suspected abuse, neglect, and exploitation to DFPS as specified in the Texas Family Code, §261.101. Source Note: The provisions of this §746.1201 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1201 What general responsibilities do my child-care center employees have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212708 03/12/2026 In addition to the responsibilities for employees specified in this division, caregivers must:(1) Know and comply with the minimum standards for child-care centers;(2) Supervise children at all times, as specified in §746.1205 of this division (relating to What responsibilities does a caregiver have when supervising a child or children?);(3) Be free from activities not directly involving the teaching, care, and supervision of children, such as:(A) Administrative and clerical duties that take the caregiver's attention away from the children;(B) Meal preparation, except when 12 or fewer children are in care;(C) Janitorial duties; and(D) Personal use of electronic devices, such as cell phones, MP3 players, tablets, and video games;(4) Provide care that is consistent with the child's habits, interests, strengths, and any special needs, including any special supervision needs or care as outlined in §746.2202 of this chapter (relating to What are my responsibilities when planning activities for a child in care with special care needs?);(5) Interact with children in a positive manner;(6) Set appropriate behavior expectations based on the child's current stage of development;(7) Foster developmentally appropriate independence in children through planned but flexible program activities;(8) Foster a cooperative rather than a competitive atmosphere;(9) Show appreciation of children's efforts and accomplishments; and(10) Ensure continuity of care for children by sharing with incoming caregivers information about each child's activities during the previous shift and any verbal or written instructions given by the parent. Source Note: The provisions of this §746.1203 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1203 What additional responsibilities do my caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212709 03/12/2026 (a) The caregiver is responsible for:(1) Knowing which children the caregiver is responsible for;(2) Knowing how many children the caregiver is responsible for;(3) Knowing each child's name and having information showing each child's age;(4) Providing the level of supervision necessary to ensure each child's safety and well-being, including physical proximity and auditory or visual awareness of each child's on going activity as appropriate; and(5) Being able to intervene when necessary to ensure each child's safety.(b) In deciding how closely to supervise a child, the caregiver must consider:(1) The child's chronological age;(2) The child's current stage of development;(3) The child's individual differences and abilities;(4) The indoor and outdoor layout of the operation;(5) The circumstances, hazards, and risks surrounding the child; and(6) The child's physical, mental, emotional, and social needs. Source Note: The provisions of this §746.1205 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1205 What responsibilities does a caregiver have when supervising a child or children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220716 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220716 03/12/2026 (a) Employees, caregivers, and directors must complete the following training requirements.Attached Graphic(b) If a caregiver or employee does not yet have a current certificate in pediatric CPR as required in (a)(4)(A) in Figure: 26 TAC §746.1301(a), at least one caregiver or employee with a current certificate must also be on the premises with the caregiver. Source Note: The provisions of this §746.1301 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1301 What are the training requirements for employees, caregivers, and directors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192499 03/12/2026 Your orientation for employees must include at least the following:(1) An overview of the minimum standards found in this chapter;(2) An overview of your operational policies, including discipline and guidance practices and procedures for the release of children;(3) An overview of your policy on the prevention, recognition, and reporting of child maltreatment, including:(A) Factors indicating a child is at risk of abuse or neglect;(B) Warning signs indicating a child may be a victim of abuse or neglect;(C) Procedures for reporting child abuse or neglect; and(D) Community organizations that have training programs available to employees, children, and parents;(4) An overview of the procedures to follow in handling emergencies, which includes sharing the emergency preparedness plan with all employees. Emergencies may include, but are not limited to, fire, explosion, tornado, toxic fumes, volatile persons, and severe injury or illness of a child or adult;(5) The location and use of fire extinguishers and first-aid equipment;(6) Administering medication, if applicable, including compliance with §746.3803 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(7) Preventing and responding to emergencies due to food or an allergic reaction;(8) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic;(9) Handling, storing, and disposing of hazardous materials including compliance with §746.3425 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?); and(10) Precautions in transporting children if your center transports a child whose chronological or developmental age is younger than nine years old. Source Note: The provisions of this §746.1303 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1303 What must orientation for employees at my child-care center include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192484 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192484 03/12/2026 (a) Pre-service training for caregivers must cover the following areas:(1) Developmental stages of children;(2) Age-appropriate activities for children;(3) Positive guidance and discipline of children;(4) Fostering children's self-esteem;(5) Supervision and safety practices in the care of children;(6) Positive interaction with children; and(7) Preventing and controlling the spread of communicable diseases, including immunizations.(b) If a caregiver provides care for children younger than 24 months of age, one hour of that caregiver's pre-service training must cover the following topics:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development. Source Note: The provisions of this §746.1305 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1305 What must be covered in pre-service training for caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192485 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192485 03/12/2026 Yes. A caregiver is exempt from the pre-service training requirements if the caregiver has:(1) At least two years prior experience in a regulated child-care center; or(2) Documentation of at least 24 clock hours of training in the areas specified in §746.1305 of this title (relating to What must be covered in pre-service training for caregivers?) at another regulated child-care center. Source Note: The provisions of this §746.1307 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1307 Are any caregivers exempt from the pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220717 03/12/2026 (a) The 24 clock hours of annual training must be relevant to the age of the children for whom the caregiver provides care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum; and(4) Teacher-child interaction.(c) At least one clock hour of the annual training hours must focus on prevention, recognition, and reporting of child maltreatment, including:(1) Factors indicating a child is at risk for abuse or neglect;(2) Warning signs indicating a child may be a victim of abuse or neglect;(3) Procedures for reporting child abuse or neglect; and(4) Community organizations that have training programs available to employees, children, and parents.(d) If a caregiver provides care for children younger than 24 months of age, one clock hour of the annual training hours must cover the following topics:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development.(e) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §746.3803 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §746.3425 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(f) The remaining annual training hours must be in one or more of the following topics:(1) Care of children with special needs;(2) Child health (for example, nutrition and physical activity);(3) Safety;(4) Risk management;(5) Identification and care of ill children;(6) Cultural diversity for children and families;(7) Professional development (for example, effective communication with families and time and stress management);(8) Topics relevant to the particular age group the caregiver is assigned (for example, caregivers assigned to an infant or toddler group should receive training on biting and toilet training);(9) Planning developmentally appropriate learning activities;(10) Observation and assessment;(11) Attachment and responsive care giving; and(12) Minimum standards and how they apply to the caregiver.(g) At least five of the 24 required annual training hours must come from instructor-led training. The remaining 19 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(h) The 24 clock hours of annual training are exclusive of any requirements for orientation, pre-service training, pediatric first-aid and pediatric CPR training, transportation safety training, water safety training, and high school child-care work-study classes. Source Note: The provisions of this §746.1309 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2010, 35 TexReg 1293; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective September26, 2024, 49 TexReg 7654. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1309 What areas of training must the annual training for caregivers cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212718 03/12/2026 (a) The 30 clock hours of annual training must be relevant to the age of the children for whom the child-care center provides care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum;(4) Teacher-child interaction; and(5) Serving children with special care needs.(c) At least one clock hour of the annual training hours must focus on prevention, recognition, and reporting of child maltreatment, including:(1) Factors indicating a child is at risk for abuse or neglect;(2) Warning signs indicating a child may be a victim of abuse or neglect;(3) Procedures for reporting child abuse or neglect; and(4) Community organizations that have training programs available to employees, children, and parents.(d) If the center provides care for children younger than 24 months of age, one hour of the annual training hours must cover the following topics:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development.(e) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §746.3803 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §746.3425 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(f) A director with:(1) Five or fewer years of experience as a designated director of a child-care center must complete at least six clock hours of the annual training hours in management techniques, leadership, or staff supervision; or(2) More than five years of experience as a designated director of a child-care center must complete at least three clock hours of the annual training hours in management techniques, leadership, or staff supervision.(g) The remainder of the 30 clock hours of annual training must be selected from the training topics specified in §746.1309(f) of this division (relating to What areas of training must the annual training for caregivers cover?).(h) The director may obtain clock hours or CEUs from the same sources as caregivers.(i) A director may not earn training hours by presenting training to others.(j) At least six of the required 30 annual training hours must come from instructor-led training. The remaining 24 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training. Source Note: The provisions of this §746.1311 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2008, 33 TexReg 1373; amended to be effective March 1, 2010, 35 TexReg 1293; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1311 What areas of training must the annual training for my child-care center director cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192491 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192491 03/12/2026 Each caregiver and director must obtain their annual training within 12 months from the date of their employment and during each subsequent 12-month period unless otherwise specified in this division. If they obtain more than the minimum number of annual training clock hours required, they may not carry the additional clock hours over to the next year. Source Note: The provisions of this §746.1313 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1313 When must annual training for my caregivers and director be obtained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192502 03/12/2026 (a) Each caregiver and the child-care center director must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking.(b) Each caregiver and the child-care center director must have a current certificate of training with an expiration or renewal date in pediatric cardiopulmonary resuscitation (CPR). A new caregiver does not have to have a current certificate in pediatric CPR before having unsupervised access to a child in care. However, the operation must have at least one employee or caregiver on the premises while children are in care that has a current certificate in pediatric CPR. The pediatric CPR:(1) Must adhere to the guidelines for CPR for a layperson established by the American Heart Association, and consist of a curriculum that incudes use of a CPR manikin and both written and hands-on skill-based instruction, practice, and testing; and(2) May be provided through blended learning that utilizes online technology, including self-instructional training, as long as the criteria in paragraph (1) of this subsection is met. Source Note: The provisions of this §746.1315 adopted to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1315 Who must have pediatric first-aid and pediatric CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192503 03/12/2026 (a) If the operation transports children whose chronological or developmental age is younger than nine years old, two clock hours of annual transportation safety training is required for:(1) Each employee prior to transporting a child; and(2) Each child-care center director.(b) The two clock hours of transportation safety training are exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §746.1316 adopted to be effective March 1, 2010, 35 TexReg 1293; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1316 What additional training must an employee and director have if the operation transports children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220268 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220268 03/12/2026 (a) Training may include clock hours or CEUs provided by:(1) A training provider registered with the Texas Early Childhood Professional Development System Training Registry, maintained by the Texas Head Start State Collaboration Office;(2) An instructor who teaches early childhood development or another relevant course at a secondary school or institution of higher education accredited by a recognized accrediting agency;(3) An employee of a state agency with relevant expertise;(4) A physician, psychologist, licensed professional counselor, social worker, or registered nurse;(5) A person who holds a generally recognized credential or possesses documented knowledge relevant to the training the person will provide;(6) A director at your child-care center if:(A) The director has demonstrated core knowledge in child development and caregiving;(B) HHSC has not placed your center on probation or suspended, revoked, or refused to renew your permit in the two years preceding the training;(C) HHSC has not assessed an administrative penalty against your center during the previous two years while your director was serving in that role; and(D) The only caregivers receiving the training are employees of your center.(7) A person who has at least two years of experience working in child development, a child development program, early childhood education, a childhood education program, or a Head Start or Early Head Start program and:(A) Has a current Child Development Associate (CDA) credential; or(B) Holds at least an associate degree in child development, early childhood education, or a related field.(b) Training may include clock hours or CEUs obtained through self-instructional materials, if the materials were developed by a person who meets one of the qualifications in subsection (a) of this section.(c) Instructor-led and self-instructional training, but not self-study training, must include:(1) Specifically stated learning objectives;(2) A curriculum, which includes experiential or applied activities;(3) An evaluation/assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(4) A certificate of successful completion from the training source. Source Note: The provisions of this §746.1317 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective March 1, 2012, 37 TexReg 928; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective August 19, 2024, 49 TexReg 6227. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1317 Must the training for my caregivers and the director meet certain criteria? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212719 03/12/2026 (a) We do not approve or endorse training resources or trainers for training hours; however, you must ensure you and your employees receive training that:(1) Meets the criteria specified in §746.1317 of this title (relating to Must the training for my caregivers and the director meet certain criteria?);(2) Is relevant to the topics specified in this division; and(3) Provides the participants with original documentation of completion, as specified in this division.(b) If the training is provided through a block certification training, the training must allocate clock hours to each specific topic included in the training. Source Note: The provisions of this §746.1319 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to b eeffective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1319 Does Licensing approve training resources or trainers for training hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192495 03/12/2026 Yes. If the training is in a topic specified in this division and the caregiver can provide documentation of completion as specified in this division, then you may count this training toward the annual training requirement. Source Note: The provisions of this §746.1321 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1321 If I have a caregiver who attends college or a Child Development Associate/Certified Child-Care Professional credential program, may I count these clock hours toward the annual training requirement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212720 03/12/2026 Training received at another operation can be applied towards the annual training requirement, if:(1) The caregiver or director provides documentation of training as specified in §746.1329 of this title (relating to What documentation must I provide to Licensing to verify that employees have met training requirements?);(2) The person obtained the training from a child-care center, a school-age or before or after-school program, or a child-care home that we license or register; and(3) The training was obtained within two months before coming to work for your child-care center. Source Note: The provisions of this §746.1323 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1323 If I hire a caregiver or a director that received training at another operation, may these hours count towards the annual training requirement at my center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220718 03/12/2026 (a) If the child-care center allows a child to access a swimming pool at or away from the center, annual water safety training is required for:(1) Each employee prior to accompanying a child to a swimming pool; and(2) Each child-care center director.(b) The training must be specific to water safety in and around swimming pools.(c) Water safety training is exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §746.1325 adopted to be effective September 26, 2024, 49 TexReg 7654. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1325 What additional training must an employee and director have if the child-care center allows a child to access a swimming pool at or away from the center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192505 03/12/2026 (a) You must maintain the original certificate or letter documenting the completion of annual training in each employee's personnel record at the child-care center.(b) For annual training to be counted toward compliance with the minimum standards, the trainer or training source must provide the participant with an original certificate or letter showing:(1) The participant's name;(2) Date of the training;(3) Title/subject of the training;(4) The trainer's name, or the source of the training for self-instructional training;(5) The trainer's qualifications, in compliance with §746.1317 of this division (relating to Must the training for my caregivers and the director meet certain criteria?); and(6) Length of the training specified in clock hours, CEUs, or college credit hours, as appropriate.(c) For pediatric first aid with rescue breathing and choking and pediatric CPR to count toward compliance with the minimum standards:(1) The certificate or letter must include:(A) The same information required in subsection (b) of this section; and(B) The expiration or renewal date of the training, as determined by the organization providing the training; and(2) You must maintain:(A) The original certificate or letter documenting the completion of pediatric first aid and pediatric CPR in each employee's personnel record at the center; or(B) A photocopy of the original certificate or letter documenting the completion of pediatric first aid and pediatric CPR in each employee's personnel record at the center, so long as the employee is able to provide an original certificate or letter upon Licensing's request.(d) For orientation and pre-service training, you must obtain a signed and dated statement from the employee and the person providing the orientation or pre-service training stating the employee has received the orientation or pre-service training, or you may obtain an original certificate or letter as specified in subsection (b) of this section. Source Note: The provisions of this §746.1329 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2004, 29 TexReg 1423; amended to be effective March 1, 2012, 37 TexReg 928; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1329 What documentation must I provide to Licensing to verify that employees have met training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212721 03/12/2026 (a) Substitutes not counted in the child/caregiver ratio must comply with minimum standards that apply to employees, except as otherwise provided in this division.(b) Volunteers and contractors who are regularly or frequently present at the child-care center but not counted in the child/caregiver ratio must comply with minimum standards that apply to employees.(c) Substitutes, volunteers, and contractors who are counted in the child/caregiver ratio must comply with minimum standards that apply to employees and caregivers, except as otherwise noted in subsection (d) of this section.(d) Volunteers, including parents, who only supplement the ratios for field trips and water activities do not have to comply with the minimum standards that apply to employees and caregivers, but they do have to comply with the relevant minimum standards in Subchapter E of this chapter (relating to Child/Caregiver Ratios and Group Sizes).(e) Substitutes, volunteers, and contractors who do not meet caregiver qualifications must never be left alone with children.(f) Substitutes, volunteers, and contractors must comply with the training requirements in §746.1403 of this division (relating to What are the training requirements for substitutes, volunteers, and contractors?). Source Note: The provisions of this §746.1401 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1401 What minimum standards must substitutes, volunteers, or contractors comply with? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220719 03/12/2026 (a) Substitutes, volunteers, and contractors must complete the following training requirements.Attached Graphic(b) If the person does not complete the pre-service training within the 90-day period as specified in (a)(2)(C)(ii) in Figure: 26 TAC §746.1403(a), the person must cease performing any caregiver duties at the center until the person completes the pre-service training.(c) If a substitute, volunteer, or contractor who is counted in the child to caregiver ratio does not yet have a current certificate in pediatric CPR, as required in (a)(4)(A) in Figure: 26 TAC §746.1403(a), at least one caregiver or employee with a current certificate must also be on the premises with the substitute, volunteer, or contractor. Source Note: The provisions of this §746.1403 adopted to be effective March 1, 2023, 48 TexReg 933; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1403 What are the training requirements for substitutes, volunteers, and contractors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212723 03/12/2026 A substitute, volunteer, or contractor is exempt from the pre-service training requirements if the substitute, volunteer, or contractor:(1) Has at least two years of documented prior experience in a regulated child-care center; or(2) Provides documentation of at least 24 clock hours of training in the areas specified in §746.1305 of this chapter (relating to What must be covered in pre-service training for caregivers?) at another regulated child-care center. Source Note: The provisions of this §746.1405 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS D PERSONNEL §746.1405 When is a substitute, volunteer, or contractor exempt from the pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188318 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188318 03/12/2026 (a) The child/caregiver ratio is the maximum number of children one caregiver can be responsible for.(b) Each child must have a caregiver who is responsible for the child and who is aware of details of the child's habits, interests, and any special problems. Source Note: The provisions of this §746.1501 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1501 What is child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188319 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188319 03/12/2026 A group of children is defined by the number of children assigned to a specific caregiver or group of caregivers, occupying an individual classroom or well-defined physical space within a larger room. Each child in any group has two things in common with every other child in his group: the same caregiver(s) responsible for the child's basic needs and the same classroom or activity space. Generally, the group stays with the assigned caregiver(s) throughout the day and may move to different areas throughout the child-care center, indoors and out. The group may not mix freely with other children, unless specific criteria are met as specified in this subchapter. The number of children who may be in a group varies according to the age of the children and the number of caregivers as specified in this subchapter. Source Note: The provisions of this §746.1503 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1503 What is considered a group? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188320 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188320 03/12/2026 Yes. More than one group of children may occupy a room, provided the following conditions are met:(1) The room is divided so that groups are separated. For example, a group of 25 children and another group of ten children may be cared for in the same room if the placement of shelves, accordion doors, or low movable walls divide the area so that children in one group do not freely mix with children in another group;(2) Groups may move from one activity area to another within the room during the day, but individual children may not freely mingle between groups; and(3) The total number of children must not routinely exceed the room capacity based on activity space. Source Note: The provisions of this §746.1505 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1505 May I place more than one group of children in a large room? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188324 03/12/2026 In determining child/caregiver ratio, the following apply:(1) Child/caregiver ratio is based on the specified age of the children in the caregiver's group or the age of the youngest child in the group, depending on the activity and the number of children at the child-care center.(2) You may use the developmental or emotional age, rather than the chronological age, of a child with special care needs, if this is recommended by a health-care professional or other qualified professional and is documented in the child's record.(3) You must consider the skills of the caregiver and the needs of the individual children and the group when assigning a caregiver to a group of children. For example, if a group of toddlers is experiencing biting, consider assigning a caregiver who is trained to handle these behaviors and perhaps additional caregivers or volunteers to assist in the supervision and redirection of the children.(4) You must include all children in care, including children related to the child-care center director and employees.(5) In emergency situations, you may use child-care center employees who do not meet caregiver qualifications for a limited time while a substitute caregiver is being secured. The time must be no longer than is reasonably necessary to secure a qualified substitute caregiver. Emergency situations include, but are not limited to, illness, accident, or death.(6) The total number of children in care at the center and in care away from the center, such as during a field trip, must never exceed the licensed capacity of the center. Source Note: The provisions of this §746.1507 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1507 How do I determine the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188321 03/12/2026 The classroom ratio is the number of children one caregiver may supervise and is shown in the following chart. The classroom ratio is based on the specified age of the children in the group, unless otherwise stated in this subchapter: Attached Graphic Source Note: The provisions of this §746.1601 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective June 1, 2009, 34 TexReg 2982; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1601 How many children may one caregiver supervise? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188322 03/12/2026 Identify the specified age of the children in each group using this formula:(1) List all of the children in the group in order of their ages from youngest to oldest. Children younger than 24 months should be listed by their age in months. Children two years and older are listed by their age in years.(2) Determine the total number of children in the group and divide this number by two. If the result is not a whole number but is .5, such as 6.5, round up to the next number, which is 7. This will be the core number of the group.(3) Begin counting at the first or youngest child on your list and count down the list from youngest to oldest, until you reach the core number. The age of this child is the specified age of the children in this group. Source Note: The provisions of this §746.1603 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1603 How do I determine the specified age of the children in each group? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212724 03/12/2026 You may combine infants with children 18 months and older in the following situations.(1) If you have 13 or more children in care, you may combine infants with older children as long as the oldest child in the group is not more than 18 months older than the youngest child. For example, if the youngest child in a group is eight months old, the oldest child in the group must not be more than 26 months old; or(2) If you have 12 or fewer children in care you may combine infants with older children without regard to age, as described in §746.1703 of this subchapter (relating to If I have 12 or fewer children in care, may I combine infants with children 18 months and older?). Source Note: The provisions of this §746.1605 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1605 When may I combine infants with children 18 months and older? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188325 03/12/2026 The maximum number of children two or more caregivers may supervise is limited by the maximum group size. Source Note: The provisions of this §746.1607 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1607 If I have two caregivers with each group, may I double the number of children one caregiver may supervise? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188326 03/12/2026 The maximum group size and the number of children two or more caregivers may supervise when 13 or more children are in care is specified in the following chart and is based on the specified age of the children in the group:Attached Graphic Source Note: The provisions of this §746.1609 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective June 1, 2009, 34 TexReg 2982; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1609 What is the maximum group size? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188328 03/12/2026 (a) Yes. When 13 or more children are in care, you may mix groups for joint activities and exceed the maximum group size for limited times under the following conditions:(1) For children 18 months through four years, for a maximum of 30 minutes;(2) For children five years and older, for a maximum of 1 1/2 hours;(3) For mealtimes, field trips, outdoor play, and naptimes, for the length of that activity.(b) The child/caregiver ratio must be met for each group and activity. Source Note: The provisions of this §746.1611 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1611 Are there times when I may mix groups of children and exceed the maximum group size? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188327 03/12/2026 (a) Yes. If 13 or more children are in care, you may reduce the child/caregiver ratio for children 18 months and older by 50% during naptime under the following conditions: (1) Groups of children using reduced ratio must be combined in a central sleeping location that safely accommodates naptime equipment; (2) Groups of children that cannot be combined in a central location due to space limitations must not use reduced ratios; (3) Caregivers with groups that cannot be combined must not be counted as additional caregivers in the building or in the naptime ratio; (4) If only one caregiver is required to supervise the naptime group, at least one other employee or caregiver must be present in the building; (5) If more than one caregiver(s) must supervise the naptime group, one additional employee or caregiver must be present in the building for every two caregivers supervising the naptime group; (6) Caregivers supervising during naptime must be physically present in the room or area in which children are napping and must be able to summon the additional employee(s) without leaving the room or area; and (7) Other child-care center employees, such as the director or cook, who are not supervising a group of children may be counted as additional adults required in the building during naptime. (b) The following chart shows the 50% naptime ratio and the number of additional caregivers required in the building: Attached Graphic Source Note: The provisions of this §746.1613 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1613 If 13 or more children are in care, may I reduce the number of caregivers supervising children during naptime? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188329 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188329&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188329 03/12/2026 Yes. When 13 or more children are in care, children who are 18 months and older may be grouped at a ratio of one caregiver per group of 16 children during the 45 minutes after opening and 45 minutes before closing. Child/caregiver ratios cannot be adjusted during opening and closing for children who are younger than 18 months. Source Note: The provisions of this §746.1615 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1615 May I adjust the child/caregiver ratio when I am opening and closing my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188330 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188330&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188330 03/12/2026 The number of children one caregiver may supervise when 12 or fewer children are present at the child-care center is specified in the following ratio chart and is based on the number of children in each age category:Attached Graphic Source Note: The provisions of this §746.1701 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1701 How many children may one caregiver supervise if 12 or fewer children are in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188331 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188331 03/12/2026 Yes. If you have 12 or fewer children in care, infants may be cared for with older children without regard to age, although you must ensure the safety of all children in the group. Source Note: The provisions of this §746.1703 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1703 If I have 12 or fewer children in care, may I combine infants with children 18 months and older? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188332 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188332 03/12/2026 No. The maximum number of children two caregivers may supervise is limited by the maximum group size. When 12 or fewer children are in care, the number of children two caregivers may supervise and the maximum group size is specified in the following chart and is based on the number of children in each age group:Attached Graphic Source Note: The provisions of this §746.1705 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1705 If I have two caregivers with each group, may I double the number of children one caregiver may supervise? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188333 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188333 03/12/2026 If 12 or fewer children are in care and you have more than two caregivers supervising the children, the 12 children in care may be any age from birth through 13 years. Source Note: The provisions of this §746.1707 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1707 What is the maximum group size if I have more than two caregivers supervising the children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188334 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188334 03/12/2026 No. Ratios may not be adjusted for opening and closing when 12 or fewer children are in care. Source Note: The provisions of this §746.1709 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1709 May I adjust the child/caregiver ratio when I am opening and closing my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220720 03/12/2026 (a) When children are on a field trip and are mixing with children and adults who are not from your child-care center, such as during trips to the skating rink, shopping center, public or amusement park, you must meet the following child/caregiver ratio: Attached Graphic(b) The child/caregiver ratio for a field trip to a location where children mix with non-center children and adults may include adult volunteers or child-care center employees who do not meet the minimum qualifications for caregivers specified in Subchapter D of this chapter (relating to Personnel) if you maintain at least the classroom child/caregiver ratio required in the following, as applicable:(1) Division 2 of this subchapter (relating to Classroom Ratios and Group Sizes for Centers Licensed to Care for 13 or More Children); or(2) Division 3 of this subchapter (relating to Classroom Ratios and Group Sizes for Centers When 12 or Fewer Children are in Care).(c) When children are on a walk or field trip in an enclosed, controlled area, such as specially arranged trips for children in your child-care center only to a fire station, library, or museum, you must maintain at least the classroom child/caregiver ratio. Refer to §746.2101 of this subchapter (relating to Must I have additional caregivers for wading activities?) and §746.2105 of this subchapter (relating to What are the child/caregiver ratios for swimming activities?) for child/caregiver ratios for wading and swimming activities when children are not mixing with other children and adults. Source Note: The provisions of this §746.1801 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1801 Do I need additional caregivers when I take children away from the child-care center for field trips or walks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188336 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188336 03/12/2026 (a) When you transport children younger than two years, you must have one caregiver in addition to the driver for each group of four children younger than two years.(b) When you transport children two years and older, you must comply with classroom child/caregiver ratio. The driver may be counted in this ratio if the driver meets caregiver qualifications. Source Note: The provisions of this §746.1805 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1805 If I provide transportation, how many caregivers must I have in the vehicle to supervise the children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188337 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188337 03/12/2026 The number of children one caregiver may supervise in a get-well care program is specified in the following chart and is based on the age of the youngest child in the program:Attached Graphic Source Note: The provisions of this §746.1901 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1901 If I operate a get-well care program, must I use a different child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188338 03/12/2026 The maximum number of children two caregivers may supervise is limited by the maximum group size. The number of children two caregivers may supervise in a get-well care program is specified in the following chart and is based on the age of the youngest child in the group: Attached Graphic Source Note: The provisions of this §746.1903 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1903 What is the child/caregiver ratio if I have more than two caregivers supervising the children in the get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188339 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188339 03/12/2026 You may care for infants with older children only if there are 12 or fewer children present in the get-well care program. Source Note: The provisions of this §746.1905 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.1905 May I combine infants with children 18 months and older in my get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188340 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188340 03/12/2026 No. Additional caregivers are not needed for the child/caregiver ratio for nighttime care, although naptime ratios must not be used during nighttime care. Source Note: The provisions of this §746.2001 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2001 Must I have additional caregivers during nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220722 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220722 03/12/2026 (a) The maximum number of children one caregiver can supervise while children use a wading pool is based on the age of the youngest child in the group and is specified in the following chart: Attached Graphic(b) When children are using a wading pool while mixing with children and adults who are not from your child-care center, you must follow the child/caregiver ratios for field trips as specified in §746.1801 of this subchapter (relating to Do I need additional caregivers when I take children away from the child-care center for field trips or walks?). Source Note: The provisions of this §746.2101 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2101 Must I have additional caregivers for wading activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220723 03/12/2026 (a) When your child-care center uses a swimming pool, there must be at least two caregivers supervising the children if four or more children are swimming. (b) The maximum number of children one caregiver can supervise while children are swimming is based on the age of the youngest child in the group and is specified in the following chart: Attached Graphic Source Note: The provisions of this §746.2105 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2105 What are the child/caregiver ratios for swimming activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220721 03/12/2026 A certified lifeguard must be on duty at all times when children are swimming in more than 18 inches of water. Source Note: The provisions of this §746.2109 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2109 Must a certified lifeguard be on duty when children are swimming in more than 18 inches of water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188345 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188345 03/12/2026 (a) You must not count the certified lifeguard in the child/caregiver ratio when people other than the children from your child-care center are swimming.(b) If only children from your child-care center are swimming, you may count the certified lifeguard in the child/caregiver ratio, although the lifeguard must never be left alone with any of the children unless the lifeguard is also a qualified caregiver for your center. Source Note: The provisions of this §746.2111 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2111 May I count the certified lifeguard in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220724 03/12/2026 Each caregiver included in the child/caregiver ratio for swimming in 18 inches or more of water must be able to swim and must be prepared to do so in an emergency. Source Note: The provisions of this §746.2113 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2113 Must persons who are counted in the child/caregiver ratio during swimming know how to swim? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220725 03/12/2026 You may include adult volunteers and adult child-care center employees who do not meet the minimum qualifications for caregivers specified in Subchapter D of this chapter (relating to Personnel) to meet the child/caregiver ratio for swimming and wading activities, provided that:(1) You maintain at least the classroom child/caregiver ratios required in this subchapter with caregivers who do meet the minimum qualifications for caregivers;(2) All persons included in the ratios for water activities must be able to swim and must be prepared to do so in an emergency; and(3) You ensure compliance with all other minimum standards, including, but not limited to, standards relating to supervision, discipline and guidance. Source Note: The provisions of this §746.2115 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2115 May I include volunteers or child-care employees who do not meet minimum qualifications for caregivers in the child/caregiver ratio for water activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188348 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188348 03/12/2026 We do not require additional caregivers for sprinkler play; however, you must not leave a child alone with the sprinkler equipment. Source Note: The provisions of this §746.2117 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS E CHILD/CAREGIVER RATIOS AND GROUP SIZES §746.2117 Must I have additional caregivers for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212725 03/12/2026 Caregivers must provide planned activities designed to meet the individual needs and developmental level of each child. Source Note: The provisions of this §746.2201 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2201 What must caregivers consider when providing planned activities for the children in their care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212726 03/12/2026 You must:(1) Provide a child with special care needs with the accommodations recommended by:(A) A health-care professional; or(B) A qualified professional affiliated with the local school district or early childhood intervention program;(2) Utilize as recommended any adaptive equipment that has been provided to the center for a child's use;(3) Ensure that a child who receives early intervention services or special education services can receive those services from a qualified service provider at your operation, with parental request and approval;(4) Ensure that activities integrate children with and without special care needs; and(5) Ensure that caregivers adapt equipment and procedures and vary methods as necessary to ensure that you care for a child with special needs in a natural environment. Source Note: The provisions of this §746.2202 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2202 What are my responsibilities when planning activities for a child in care with special care needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204102 03/12/2026 (a) Your operation, director, or each caregiver must develop a written activity plan that complies with §746.2205 of this subchapter (relating to What must a written activity plan include?).(b) The caregivers responsible for the relevant group of children must follow the plan.(c) The activity plan must include all children in the group regardless of special care needs. Source Note: The provisions of this §746.2203 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2203 What written activity plans must caregivers follow? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204103 03/12/2026 (a) A written activity plan must:(1) Identify the group the activity plan is designed for and list the dates (daily, weekly, or monthly) the plan covers;(2) Outline the specific daily activities, as required by §746.2206 of this subchapter (relating to What specific activities must I include in a written activity plan?);(3) Include sufficient time for activities and routines so that children can progress at their own developmental rate; and(4) Not include long waiting periods between activities or prolonged periods during which children stand or sit.(b) A written activity plan may include one or more screen time activities, as specified in §746.2207 of this subchapter (relating to May I use a screen time activity with a child?), if you also include alternative activities for children who do not want to participate. Source Note: The provisions of this §746.2205 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2205 What must a written activity plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204104 03/12/2026 You must include these daily activities and the approximate times they will occur in your written activity plan:(1) A minimum of two daily opportunities for outdoor play, weather permitting, in which a child makes use of both small and large muscles:(A) An infant birth through 12 months of age may engage in outdoor play for an amount of time as tolerated by the infant; and(B) An infant 13 months through 17 months of age, a toddler, or a pre-kindergarten age child must engage in outdoor play for a minimum of 60 total minutes daily;(2) A balance of active and quiet play that incorporates group and individual activities, both indoors and outdoors, and must include:(A) A minimum of 60 minutes of moderate to vigorous active play for toddlers; and(B) A minimum of 90 minutes of moderate to vigorous active play for pre-kindergarten age children;(3) Child-initiated activities where:(A) The equipment, materials, and supplies are within reach of the child; and(B) The child chooses the activity on the child's own initiative;(4) Caregiver-initiated activities that the caregiver directs or chooses, at least two of which must promote movement;(5) Regular meal and snack times, as specified in Subchapter Q of this chapter (relating to Nutrition and Food Service); and(6) Supervised naptimes or rest times. Source Note: The provisions of this §746.2206 adopted to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2206 What specific activities must I include in a written activity plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204105 03/12/2026 (a) You may not use a screen time activity for a child under the age of two years.(b) You may use a screen time activity to supplement, but not to replace, an activity for a child who is two years old or older that is described in §746.2507 of this chapter (relating to What activities must I provide for a toddler?); §746.2607 of this chapter (relating to What activities must I provide for a pre-kindergarten-age child?); and §746.2707 of this chapter (relating to What activities must I provide for a school-age child?).(c) If you use a screen time activity for a child at the center, you must ensure that the activity:(1) Is related to the planned activities that meet educational goals;(2) Is age-appropriate;(3) Does not exceed one hour per day;(4) Is not used during mealtime, snack times, naptimes, or rest times;(5) Does not include advertising or violence; and(6) Is turned off when not in use.(d) A school-age child may use screen time without restriction for homework. Source Note: The provisions of this §746.2207 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2207 May I use a screen time activity with a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188353 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188353 03/12/2026 Yes. You must post the activity plan for each group of children in the child-care center in a prominent place where parents and others can see it. Source Note: The provisions of this §746.2209 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2209 Must I post the activity plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188354 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188354 03/12/2026 You must keep activity plans at your child-care center for at least three months and you must make them available for review by Licensing and parents upon request during hours of operation. Source Note: The provisions of this §746.2211 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §746.2211 How long must I keep the activity plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188360&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188360 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188360&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188360 03/12/2026 Basic care for infants must include:(1) Care by the same caregiver on a regular basis, when possible;(2) Individual attention given to each infant including playing, talking, cuddling, and holding;(3) Holding and comforting an infant who is upset;(4) Prompt attention given to physical needs, such as feeding and diapering;(5) Talking to infants as they are fed, changed, and held, such as naming objects, singing, or saying rhymes;(6) Ensuring the environment is free of objects that may cause choking in infants or toddlers; and(7) Never leaving an infant unsupervised. Source Note: The provisions of this §746.2401 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2401 What are the basic care requirements for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212727 03/12/2026 The room arrangement of the infant care area must:(1) Make it possible for caregivers to hear all infants and see all infants at a glance, and be able to intervene when necessary;(2) Include safe, open floor space for floor time play;(3) Separate infants from children more than 18 months older than the youngest child in the group, except when 12 or fewer children are in care, as required by §746.1605 of this chapter (relating to May I combine infants with children 18 months and older?);(4) Have cribs far enough apart so that one infant may not reach into another crib;(5) Provide caregivers with enough space to walk and work between cribs, cots, and mats; and(6) Ensure older children do not use the infant area as a passageway to other areas of the building. Source Note: The provisions of this §746.2403 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2403 How must I arrange the infant care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212728 03/12/2026 Furnishings and equipment for infants must include at least the following:(1) An adult-sized rocker or chair;(2) An individual crib to sleep in for each non-walking infant younger than 12 months of age;(3) An individual crib, cot, bed, or mat that is waterproof or washable for each:(A) Walking infant; and(B) Non-walking infant 12 months of age or older;(4) A hand-washing sink in the diaper-changing area, as specified in §746.4403 of this title (relating to Must I have a hand-washing sink in the diaper-changing area?); and(5) A sufficient number of toys to keep the infants engaged in activities. Source Note: The provisions of this §746.2405 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2405 What furnishings and equipment must I have in the infant care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188363 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188363 03/12/2026 If you use high chairs, swings, strollers, infant carriers, bouncer seats, or similar types of equipment, they must be equipped with safety straps that must be fastened whenever an infant is using the equipment. Source Note: The provisions of this §746.2407 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2407 Must the equipment I use for infants be equipped with safety straps? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188364 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188364 03/12/2026 (a) All full-size and non-full-size cribs must have:(1) A firm, flat mattress that snugly fits the sides of the crib and that is designed specifically for use with the crib model number. The mattress must not be supplemented with additional foam material or pads.(2) Sheets that fit snugly and do not present an entanglement hazard;(3) A mattress that is waterproof or washable;(4) Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts;(5) A maximum of 2 3/8 inches between crib slats or poles;(6) No corner posts over 1/16 inch above the end panels;(7) No cutout areas in the headboard or footboard that would entrap an infant's head or body;(8) Drop gates, if present, which fasten securely and cannot be opened by a child;(9) Documentation that each crib meets the applicable federal rules at Title 16, Code of Federal Regulations, Parts 1219 or 1220, concerning "Safety Standards for Full-Size Baby Cribs" and "Safety Standards for Non-Full-Size Baby Cribs," respectively, or documentation that each crib is a medical device listed and registered with the U.S. Food and Drug Administration; and(10) A label with the infant's name. As an alternative, you may label cribs with a number and have a number/infant assignment map available.(b) You must sanitize each crib before a different infant uses it and when soiled.(c) You must never leave an infant in the crib with the drop gate down. Source Note: The provisions of this §746.2409 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2012, 37 TexReg 9133; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2409 What specific safety requirements must my cribs meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188365 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188365 03/12/2026 You may use a play yard, which is a mesh or fabric sided crib, if it meets the following safety requirements:(1) The play yards must be used according to the manufacturer's instructions, including the cleaning of the play yards;(2) Play yards must have:(A) A firm, flat mattress that snugly fits the sides of the play yard and that is designed by the manufacturer specifically for this play yard model number. The mattress must not be supplemented with additional foam material or pads;(B) Sheets that fit snugly and do not present an entanglement hazard;(C) A mattress that is waterproof or washable;(D) Secure mattress support hangers, and no loose hardware or improperly installed ordamaged parts;(E) A minimum height of 22 inches from the top of the railing to the mattress support atits lowest level;(F) Folded sides that securely latch in place when raised;(G) For play yards that have mesh sides, mesh openings that are 1/4 inch or less;(H) Mesh or fabric that is securely attached to the top rail, side rail, and floor plate; and(I) A label with the infant's name. As an alternative, you may label play yards with a number and have a number/infant assignment map available; and(3) You must never leave an infant in a play yard with a side folded down. Source Note: The provisions of this §746.2411 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2411 Are play yards allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188366 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188366&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188366 03/12/2026 You may use a stacking wall crib that meets the requirements in §746.2409 of this title (relating to What specific safety requirements must my cribs meet?), and you:(1) Do not stack more than two cribs;(2) Only use a stacked crib for an infant who cannot stand or is able to stand without hitting the infant's head on either the top crib or the ceiling above the top crib;(3) Use the crib according to manufacturer's directions; and(4) Securely latch the crib's doors/gates anytime an infant is in the crib. Source Note: The provisions of this §746.2413 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2413 Are stacking wall cribs allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212729 03/12/2026 (a) You may not use the following equipment for infants, which has been identified as unsafe for infants by the Consumer Product Safety Commission and the American Academy of Pediatrics:(1) Baby walkers, which are devices that allow an infant to sit inside a walker equipped with rollers or wheels and move across the floor;(2) Baby doorway jumpers, which are devices that allow an infant to bounce while supported in a seat by an elastic "bungee cord" suspended from a doorway;(3) Accordion safety gates;(4) Toys that are not large enough to prevent swallowing or choking; or(5) Bean bags, waterbeds, and foam pads for use as sleeping equipment.(b) Except for a tight-fitting sheet and as provided in subsection (c), the crib or play yard must be bare for an infant younger than 12 months of age.(c) A crib mattress cover may also be used to protect against wetness, but the cover must:(1) Be designed specifically for the size and type of crib and crib mattress that it is being used with;(2) Be tight fitting and thin; and(3) Not be designed to make the sleep surface softer. Source Note: The provisions of this §746.2415 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2012, 37 TexReg 9133; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2415 What specific types of equipment am I prohibited from using with infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204106 03/12/2026 Daily activities for an infant must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §746.2206 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Multiple opportunities to explore that ensure the infant is:(A) Outside of the crib; and(B) Not seated in any restrictive device for more than 15 minutes, unless the infant is eating or being transported;(3) Opportunities for physical activity, including supervised tummy time, reaching, grasping, pulling up, creeping, crawling, and walking in a safe, clean, uncluttered area;(4) Opportunities for visual stimulation through nonverbal communication. Examples of age-appropriate equipment include large pictures of faces and familiar objects; simple, soft, washable books and toys; unbreakable mirrors or mobiles attached to cribs visible from the baby's position; and brightly patterned crib sheets;(5) Opportunities for auditory stimulation. Examples of age-appropriate equipment or activities include verbal communication, soothing music, and musical or sounding toys;(6) Opportunities for sensory stimulation. Examples of age-appropriate equipment include surfaces, fabrics, textured toys, washable dolls, and toy animals;(7) Opportunities for small-muscle development. Examples of age-appropriate equipment include busy boxes, rattles, teethers, grasping toys, shaking or squeezing toys, or cloth toys; and(8) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include blankets or quilts for floor or supervised tummy time, crib and play gyms, variety of light-weight balls, and pillows or supportive equipment for those learning to sit up. Source Note: The provisions of this §746.2417 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2417 What activities must I provide for an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188369 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188369 03/12/2026 Yes. You must:(1) Hold infants birth through six months while feeding them;(2) Hold infants over six months who are unable to sit unassisted in a high chair or other seating equipment while feeding them;(3) Never prop or support bottles with some object. The infant or an adult must hold the bottle;(4) Provide regular snack and meal times for infants who eat table food;(5) Ensure infants no longer being held for feeding are fed in a safe manner;(6) Label bottles and training cups with the infant's first name and initial of last name;(7) Never allow infants to walk around with or sleep with a bottle or training cup;(8) Never use the hand-washing sink or diaper-changing surface for food preparation, or for washing food service/preparation equipment, bottles, pacifiers or toys; and(9) Sanitize high chair trays before each use. Source Note: The provisions of this §746.2419 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2419 Are there specific requirements for feeding infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188370 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188370 03/12/2026 (a) For an infant who is not yet ready for table food, you must obtain and follow written feeding instructions that are signed and dated by the infant's parent or health-care professional.(b) You must review and update the feeding instructions with the parent every 30 days until the infant is able to eat table food. Source Note: The provisions of this §746.2421 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2421 What written feeding instructions must I obtain for an infant not ready for table food? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188371 03/12/2026 Yes. Each infant must have a supervised nap period that allows the infant to maintain his or her own pattern of sleeping and waking periods. Source Note: The provisions of this §746.2423 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2423 Must I provide a regularly scheduled naptime for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212730 03/12/2026 An infant must sleep in a designated crib, cot, bed, or mat as required by §746.2405 of this subchapter (relating to What furnishings and equipment must I have in the infant care area?). Source Note: The provisions of this §746.2424 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2424 Where must an infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188372 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188372 03/12/2026 An infant may remain in the crib for up to 30 minutes after awakening, as long as the infant is content and responsive. Source Note: The provisions of this §746.2425 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2425 How long are infants allowed to remain in their cribs after awakening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212731 03/12/2026 (a) If you do not have a Sleep Exception Form that includes a signed statement from a health-care professional stating that the child sleeping in a restrictive device is medically necessary:(1) You may not allow an infant to sleep in a restrictive device; and(2) If an infant falls asleep in a restrictive device, you must remove the infant from the device and place the infant in a crib as soon as possible.(b) You may allow an infant to sleep in a restrictive device if you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that the child sleeping in a restrictive device is medically necessary. Source Note: The provisions of this §746.2426 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2426 May I allow infants to sleep in a restrictive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212732 03/12/2026 (a) You must place an infant in a face-up sleeping position in the infant's own crib, unless you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that a different sleeping position for the child is medically necessary.(b) An infant who is developmentally able to roll from back to stomach and stomach to back may do so independently after you have placed the infant in a face-up position for sleep. Source Note: The provisions of this §746.2427 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2427 How must I position an infant for sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188375 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188375 03/12/2026 You may not lay a swaddled infant down to sleep or rest on any surface at any time unless you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that swaddling the child for sleeping purposes is medically necessary. Source Note: The provisions of this §746.2428 adopted to be effective June 1, 2014, 39 TexReg 3720; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2428 May I swaddle an infant to help the infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188376 03/12/2026 No. Infants must not have their heads, faces, or cribs covered by items such as blankets, linens, or clothing at any time. Source Note: The provisions of this §746.2429 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2429 If an infant has difficulty falling asleep, may I cover the infant's head or crib? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188377 03/12/2026 You must provide a daily written or electronic report to the infant's parent when or by the time the infant is picked up from the child-care center. The report must contain:(1) Times the infant slept;(2) Times and amount of food consumed;(3) Times of diaper changes;(4) Infant's general mood for the day; and(5) A brief summary of the activities in which the infant participated. Source Note: The provisions of this §746.2431 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS H BASIC CARE REQUIREMENTS FOR INFANTS §746.2431 Must I share a daily report with parents for each infant in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188355 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188355 03/12/2026 Basic care for toddlers must include:(1) Routines such as diapering, feeding, sleeping, and indoor and outdoor activity times, maintained as closely as possible;(2) Care given by the same caregiver on a regular basis, when possible;(3) Individual attention given to each toddler including playing, talking, and cuddling;(4) Holding and comforting a toddler who is upset; and(5) Ensuring the environment is free of objects that may cause choking in infants or toddlers. Source Note: The provisions of this §746.2501 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS I BASIC CARE REQUIREMENTS FOR TODDLERS §746.2501 What are the basic care requirements for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212733 03/12/2026 The toddler care area must include:(1) Spaces in the room that allow both individual and group time; and(2) A play environment that allows the caregiver to supervise all children as defined in §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §746.2503 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS I BASIC CARE REQUIREMENTS FOR TODDLERS §746.2503 How must I arrange the toddler care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188357 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188357 03/12/2026 Furnishings and equipment for toddlers must include at least the following:(1) Age-appropriate seating, tables, and nap or rest equipment;(2) Enough popular items available so that toddlers are not forced to compete for them;(3) Containers or low shelving that are accessible to toddlers, so toddlers can safely obtain the items without adult intervention; and(4) Bottles and training cups, if used, must be:(A) Labeled with the toddler's first name and initial of last name or otherwise individually assigned to each toddler;(B) Cleaned and sanitized between each use; and(C) Used for drinking and feeding, and never allow toddlers to sleep with or walk around with a bottle or training cup. Source Note: The provisions of this §746.2505 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS I BASIC CARE REQUIREMENTS FOR TODDLERS §746.2505 What furnishings and equipment must I provide for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204107 03/12/2026 Daily activities for a toddler must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §746.2206 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include shape or item sorting toys, stacking or nesting toys, puzzles with less than six pieces, washable board books, washable blocks, and snapping and take-apart toys;(3) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include large-size washable crayons and markers, variety of paper and art materials, table or easel for art, large paintbrushes, non-toxic play-dough, large-sized washable toy transportation vehicles, toy animals, and toy people;(4) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include low-climbing structures, small riding toys, toys for pushing or pulling, a variety of light-weight balls for indoor and outdoor play, and rhythm instruments;(5) Opportunities for moderate to vigorous active play, both indoors and outdoors, as specified in §746.2206 of this chapter. Examples of age-appropriate equipment or activities include music, songs, simple games and dramatic or imaginary play that encourage movement such as dancing, running, climbing, stretching, walking, and marching;(6) Opportunities for language development. Examples of age-appropriate equipment or activities include washable soft animals or puppets, simple picture books, and pictures of familiar items and places;(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dress-up clothes and accessories, housekeeping equipment, unbreakable mirrors, washable dolls with accessories, items for practicing buttoning, zipping, lacing, and snapping, and baskets, tubs, and tote bags (not plastic bags) for carrying and toting; and(8) Opportunities to develop self-help skills such as toileting, hand washing, and self-feeding. Source Note: The provisions of this §746.2507 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS I BASIC CARE REQUIREMENTS FOR TODDLERS §746.2507 What activities must I provide for a toddler? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188359&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188359 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188359&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188359 03/12/2026 No, however you must have a plan for personal contact with parents that provides for an exchange of information regarding observations, comments, and concerns regarding their toddler. Source Note: The provisions of this §746.2509 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS I BASIC CARE REQUIREMENTS FOR TODDLERS §746.2509 Must I share a daily report with parents for each toddler in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212734 03/12/2026 Basic care for pre-kindergarten age children must include:(1) Routines such as diapering or toileting, eating, napping or resting, indoor activity times, and outdoor activity times;(2) Individual attention given to each pre-kindergarten age child; and(3) Interactions that encourage children to communicate and express feelings in appropriate ways. Source Note: The provisions of this §746.2601 adopted to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §746.2601 What are the basic requirements for pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188379 03/12/2026 Physical space requirements for pre-kindergarten age children must include:(1) Space for furnishings and activities without limiting children's movement; and(2) Space in which children are allowed to find or create individual activities, but which still permits the caregiver to easily supervise. Source Note: The provisions of this §746.2603 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §746.2603 What physical space requirements must I provide for pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188380 03/12/2026 Furnishings and equipment for pre-kindergarten age children must include at least the following:(1) Interest centers, such as dramatic play, block building, stories and books, science and nature activities, art and music activities, sensory, and problem-solving activities that are:(A) Clearly defined;(B) Organized for independent use by children; and(C) Arranged so the children's activities are visible to the caregiver;(2) Age-appropriate seating, tables, and nap or rest equipment;(3) Enough popular items available so that children are not forced to compete for them; and(4) Containers or low shelving available so items children can safely use without direct supervision are accessible to children. Source Note: The provisions of this §746.2605 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §746.2605 What furnishings and equipment must I provide for pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204108 03/12/2026 Daily activities for a pre-kindergarten age child must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §746.2206 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include sand and water play, blocks, framed puzzles with up to 30 pieces, variety of large stringing beads, and simple board games;(3) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include large non-toxic crayons, markers, paint, water colors and various size brushes, adjustable easels, collage materials, chalkboard and chalk, clay or dough and tools, workbench and accessories, round end scissors, glue and paste, different types of music and videos, rhythm instruments, and fingerplays;(4) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include small wagons, light-weight balls of all sizes, small wheelbarrows, tricycles, push toys, swings, slides, climbing equipment, balance beam, hanging bars, and outdoor building materials;(5) Opportunities for moderate to vigorous active play, both indoors and outdoors, as specified in §746.2206 of this chapter. Examples of age-appropriate equipment or activities include active games such as tag and hot potato, dancing and creative movement to music and singing, simple games and dramatic or imaginary play that encourages running, stretching, climbing, walking and marching;(6) Opportunities for language development. Examples of age-appropriate equipment or activities include flannel board stories, puppets, and variety of storybooks, writing materials, and stories on tape;(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dress-up clothes and accessories, mirrors, dolls, simple props for different themes, puppets, transportation toys, play animals, and table games; and(8) Opportunities to develop self-help skills such as toileting, hand washing, returning equipment to storage areas or containers, and serving and self-feeding. Source Note: The provisions of this §746.2607 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §746.2607 What activities must I provide for a pre-kindergarten age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188382 03/12/2026 Basic care requirements for school-age children must include:(1) Individual attention from and conversation with adults;(2) Physical care routines appropriate to each child's developmental needs;(3) Flexible programming according to ages, interests, and abilities of the children; and(4) A caregiver who is aware of the arrival and departure of each child, including dismissing children who ride the bus or walk home. Source Note: The provisions of this §746.2701 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §746.2701 What are the basic care requirements for school-age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212735 03/12/2026 The school-age care area must include:(1) Space to set up interest centers or focused play areas during the activity, such as arts and crafts; music and movement; blocks and construction; drama and theater; math and reasoning activities; science and nature; language and reading activities, such as books, story tapes and language games, stories read or told on a weekly basis, and cultural awareness, which are:(A) Organized for independent use by children; and(B) Arranged so the caregiver can supervise the children according to §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?);(2) Space where children can have individual activities yet be supervised; and(3) Space for quiet time to do homework. Source Note: The provisions of this §746.2703 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §746.2703 What physical space requirements must I provide for the school-age care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188384 03/12/2026 Furnishings and equipment for school-age children must include at least the following:(1) Age-appropriate seating, tables, or desks to meet children's needs, such as workspace to do homework and table-top activities;(2) Age-appropriate nap or rest equipment; and(3) Containers or shelving available so that items children can safely use without direct supervision are accessible to children. Source Note: The provisions of this §746.2705 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §746.2705 What furnishings and equipment must I provide for school-age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204109 03/12/2026 Daily activities for a school-age child must include at least the following:(1) Study time for those children who choose to work on homework;(2) Opportunities for outdoor play, weather permitting;(3) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include sand and water play; construction materials and blocks; puzzles with 50 or more pieces; pattern-making materials, such as wood, paper, plastic, beads, ceramic tiles, cloth, or cardboard; games that contain rules and require some skill or strategy; specific skill development materials, such as rulers, tape measures, telescopes, weather observation equipment, models of the solar system, and microscopes; books; and magazines;(4) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include art and craft materials, such as paints, markers, colored pencils, crayons, clay, weaving, or braiding materials; music and musical instruments of all types; and puzzles or interlocking building blocks;(5) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include balls and sports equipment, such as kick balls, baseballs, soccer balls, basketballs, skates, and horseshoes; riding equipment, such as kick scooters or skateboards, with kneepads, elbow pads, and helmets; and outdoor and gym equipment, such as slides, swings, climbing apparatus, and upper-body equipment;(6) Opportunities for active play both indoors and outdoors. Examples of age-appropriate equipment or activities include active games such as tag and Simon Says, dancing and creative movement to music and singing, simple games and dramatic or imaginary play that encourages running, stretching, climbing, and walking; and(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dolls with detailed, realistic accessories; role-play materials, including real equipment for library, hospital, post office, costumes, makeup and disguise materials; puppets and puppet show equipment; transportation toys, such as small vehicles or models; play and art materials; nature materials; and human and animal figurines. Source Note: The provisions of this §746.2707 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §746.2707 What activities must I provide for a school-age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188434&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188434 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188434&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188434 03/12/2026 Discipline must be:(1) Individualized and consistent for each child;(2) Appropriate to the child's level of understanding;(3) Directed toward teaching the child acceptable behavior and self-control; and(4) A positive method of discipline and guidance that encourages self-esteem, self-control, and self-direction, including the following:(A) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;(B) Reminding a child of behavior expectations daily by using clear, positive statements;(C) Redirecting behavior using positive statements; and(D) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per year of the child's age. Source Note: The provisions of this §746.2803 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS L DISCIPLINE AND GUIDANCE §746.2803 What methods of discipline and guidance may a caregiver use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212736 03/12/2026 There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:(1) Corporal punishment or threats of corporal punishment;(2) Punishment associated with food, naps, or toilet training;(3) Grabbing or pulling a child;(4) Putting anything in or on a child's mouth;(5) Humiliating, ridiculing, rejecting, or yelling at a child;(6) Subjecting a child to harsh, abusive, or profane language;(7) Placing a child in a locked or dark room, bathroom, or closet;(8) Placing a child in a restrictive device for time out;(9) Withholding active play or keeping a child inside as a consequence for behavior, unless the child is exhibiting behavior during active play that requires a brief supervised separation or time out that is consistent with §746.2803(4)(D) of this subchapter (relating to What methods of discipline and guidance may a caregiver use?); and(10) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age. Source Note: The provisions of this §746.2805 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS L DISCIPLINE AND GUIDANCE §746.2805 What types of discipline and guidance or punishment are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188436&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188436 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188436&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188436 03/12/2026 Yes, during operating hours an employee may discipline the employee's own child as long as the employee does not violate the requirements specified in this subchapter. Source Note: The provisions of this §746.2807 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS L DISCIPLINE AND GUIDANCE §746.2807 May my employees discipline their own children who are in care at my center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188437 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188437 03/12/2026 You must provide a supervised sleep or rest period after the noon meal for all children 18 months of age or older who are in care five or more consecutive hours, or according to the child's individual physical needs. You may provide sleep or rest for each child who attends the child-care center for fewer than five hours and whose individual physical needs call for a rest period while the child is in care. Source Note: The provisions of this §746.2901 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2901 Must children have a naptime every day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188438 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188438 03/12/2026 The sleep or rest period must not exceed three hours. Source Note: The provisions of this §746.2903 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2903 How long may the nap and rest time last each day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188439 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188439 03/12/2026 No. You must not:(1) Force a child to sleep or put anything in or on a child's head or body to force the child to rest or sleep; or(2) Confine a child in a restrictive device to make the child rest or sleep. Source Note: The provisions of this §746.2905 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2905 Are children required to sleep during this time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188440 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188440 03/12/2026 (a) Yes. You must allow each child who is awake after resting or sleeping for one hour to participate in an alternative, quiet activity until the nap/rest time is over for the other children.(b) You must take a toddler who sleeps or rests in a crib out of the crib for other activities when he awakens. Source Note: The provisions of this §746.2907 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2907 Must I provide an alternative activity for those children who cannot sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212737 03/12/2026 Napping equipment must:(1) Not block entrances or exits to the area;(2) Not be set up during other activities or left in place to interfere with children's activity space;(3) Be arranged to provide a sufficient walk and work space for caregivers between each cot and mat;(4) Be arranged so that each child and caregiver has access to a walkway without having to walk on or over the cots or mats of other children; and(5) Be arranged so the caregiver can adequately supervise all children in the group, as specified in §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §746.2909 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2909 Must I arrange the napping equipment in a specific manner? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188442 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188442 03/12/2026 Yes. You may lower the lighting, provided there is adequate lighting to allow visual supervision of all children in the group at all times. Lighting in a room is adequate if a person's eyes do not need to adjust for the person to be able to see upon entering the room. Source Note: The provisions of this §746.2911 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS M NAPTIME §746.2911 May I lower the lighting in the room while children are sleeping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192532 03/12/2026 Yes. You must ensure the safety of all children on field trips or excursions and during any transportation provided by the child-care center. Anytime you take a child on a field trip, you must comply with each of the following requirements:(1) You must have signed permission from the parent to take a child on a field trip, including permission to transport the child, if applicable;(2) One or more caregivers must carry emergency medical consent forms and emergency contact information for each child on the field trip;(3) Caregivers must have a written list of all children on the field trip and must check the list frequently to account for the presence of all children;(4) Caregivers must have a first-aid kit immediately available on field trips;(5) Caregivers must have a copy of a child's food allergy emergency plan and allergy medications, if applicable;(6) Each child must wear a shirt, nametag, or other identification listing the name of the child-care center and the child-care center's telephone number;(7) Each caregiver must be easily identifiable by all children on the field trip by wearing a hat, child-care center tee-shirt, brightly-colored clothes, or other easily spotted identification;(8) Each caregiver supervising a field trip must have transportation available, a communication device such as a cellular phone or two-way radio available, or an alternate plan for transportation at the field-trip location in case of emergency; and(9) One or more caregivers per group of children must have current training in pediatric first aid and pediatric CPR. Source Note: The provisions of this §746.3001 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS N FIELD TRIPS §746.3001 May I take children away from my child-care center for field trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188444 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188444 03/12/2026 Yes. You must notify the parent of each child who will be on the field trip, indicating when and where the child will be going, and when the child is expected to return to the child-care center. The notice must be posted at least 48 hours in advance of a field trip. You must post the field trip notice in a prominent place where parents and others may view it. The notice must remain posted until all children on the field trip have returned to the child-care center. Source Note: The provisions of this §746.3003 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS N FIELD TRIPS §746.3003 Must I notify parents before I take children away from the child-care center on a field trip? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188445 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188445 03/12/2026 Yes, if you are licensed as a get-well care program to provide care for children who are ill. The primary objective of this program is to ensure that children in care receive the required attention necessary for certain ill children, as specified in this subchapter. Source Note: The provisions of this §746.3101 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3101 May I care for children who are ill? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188446 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188446 03/12/2026 Get-well care includes care for children who are too sick to attend well-child day care according to the exclusions in Subchapter R, Division 3 of this chapter (relating to Illness and Injury), but who do not exhibit any of the excludable diseases defined by the Texas Department of State Health Services (DSHS) in 25 TAC §97.7 (relating to Diseases Requiring Exclusion from Schools). Source Note: The provisions of this §746.3103 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3103 Which children may be included in the get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188447 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188447 03/12/2026 Before a child may enter your get-well care program, you must determine the child's needs and that your program can meet those needs without compromising the care of other children in the program. Source Note: The provisions of this §746.3105 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3105 What must I do before I admit a child to my get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188448 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188448 03/12/2026 You must remove a child from your get-well care program immediately when the child's condition meets one of the excludable diseases or symptoms specified by DSHS. The child may return to your regular child-care program when you have obtained a doctor's statement that he no longer has the excludable condition, or when the child is free of symptoms for 24 hours. Source Note: The provisions of this §746.3107 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3107 When must I remove a child from my get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188449 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188449 03/12/2026 No. Each parent must provide you with information on the child's specific diagnosis from a health-care professional, including current status of the illness, any dietary needs, activity level, and medication plan. You must record this information and the name and telephone number of the health-care professional on the get-well care program admission form or other similar form that captures the same information. You must update this information as the child's needs or diagnosis changes. Source Note: The provisions of this §746.3109 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3109 Are the parents of children in the get-well care program required to provide a doctor's statement before I may admit the child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188450 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188450 03/12/2026 If your get-well care program is located in the same building as your other child-care programs:(1) The get-well care program must have a separate entrance and a separate ventilation system;(2) Indoor hallways, bathrooms, and activity areas utilized by the get-well care program must be separate from the other child-care programs;(3) A single kitchen may be used if the cook has no child-care responsibility;(4) Separate toileting facilities must be available for the children in the get-well care program from the children in the well child-care program at a ratio of one toilet for every ten children; and(5) Linens, furniture, fixtures, equipment, and supplies designated for use by the get-well care program must be sanitized before being used by the well children. Source Note: The provisions of this §746.3111 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3111 Must I care for children in the get-well care program in an area separate from the well children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188451 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188451 03/12/2026 (a) You must care for children with respiratory illnesses separately from children with gastrointestinal illnesses. Curtains, partitions, or walls can define separate rooms.(b) A hand-washing sink must be available in every room in your get-well care program.(c) If children in diapers are in care, the diaper-changing surface must be adjacent to the hand-washing sink. Source Note: The provisions of this §746.3113 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3113 What extra safety features must I have in my get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188452 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188452 03/12/2026 No. Caregivers supervising and caring for children in your get-well care program must not also care for well children in the child-care center on the same day. Source Note: The provisions of this §746.3115 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3115 May caregivers working with the get-well care program also work with other children in the child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192533 03/12/2026 Yes, in addition to the orientation, pre-service training, pediatric first aid, pediatric CPR, and annual training required of caregivers in this chapter, all get-well care program caregivers must have five additional hours of annual training in prevention and control of communicable diseases and care of ill children for a total of 29 hours per year. Source Note: The provisions of this §746.3117 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6649. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3117 Do caregivers in my get-well care program require special training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188454 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188454 03/12/2026 Yes, although the director of your get-well care program must:(1) Meet all qualifications specified in Subchapter D of this chapter (relating to Personnel);(2) Not be counted in child/caregiver ratio or be responsible for supervising or caring for any children in either program;(3) Have current certification in CPR and first aid, including rescue breathing and choking; and(4) Have ten additional hours of annual training in prevention and control of communicable diseases and care of ill children for a total of 40 hours per year. Source Note: The provisions of this §746.3119 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3119 May the director of my well child-care program also direct my get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188455 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188455 03/12/2026 You must:(1) Provide quiet activities appropriate to each child's developmental age and needs; outdoor play is not required;(2) Give children access to nap or rest areas without distraction or disturbance from other activities when the child demonstrates a need for rest or desires to rest; and(3) Follow physician's directions. Source Note: The provisions of this §746.3121 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3121 Must I provide activities for children in the get-well care program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188456 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188456 03/12/2026 Yes. In addition to following the minimum standards noted in this Chapter, including Subchapter R (relating to Health Practices), you must follow these procedures when providing get-well care:(1) Sanitize all laundry each day and when soiled;(2) Keep all garbage containers covered and take them out of the building daily;(3) Sanitize all toys and equipment after every use and before a different child uses them;(4) Use disposable, single-use cups, plates, and utensils for food service and drinks; and(5) Provide nutritious meals and snacks according to the children's needs or the directions of a health-care professional. Source Note: The provisions of this §746.3123 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS O GET-WELL CARE PROGRAMS §746.3123 Must my get-well care program follow any special handling procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188457&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188457 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188457&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188457 03/12/2026 (a) Nighttime care is care given on a regular or frequent basis to children who are starting or continuing their night sleep, or to children who spend the night or part of the night at the child-care center between the hours of 9:00 p.m. and 6:00 a.m.(b) Nighttime care does not include the occasional sleep-over program offered at infrequent intervals. Source Note: The provisions of this §746.3201 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS P NIGHTTIME CARE §746.3201 What is nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188459 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188459 03/12/2026 (a) You may care for children both during the day and night if we approve it. Even then, a child may only be in care for:(1) No more than 16 hours within a 24-hour period on a daily basis; or(2) No more than three consecutive 24-hour periods with a maximum of six 24-hour periods per month, as specified in §745.383 of this title (relating to Can a licensed child day-care operation offer 24-hour care?).(b) You cannot exceed these limits. Source Note: The provisions of this §746.3203 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS P NIGHTTIME CARE §746.3203 May I provide nighttime care to children at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212738 03/12/2026 Yes. Caregivers supervising children during nighttime care must be awake and supervising the children at all times, as specified in §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §746.3205 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS P NIGHTTIME CARE §746.3205 Must caregivers stay awake while supervising children during nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188461 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188461 03/12/2026 In addition to all other building, furnishing, physical space, and equipment requirements specified in this chapter:(1) All exits must be visible. This may be provided by lighted exit signs or by lighted exits (such as a hall light or lamp, which lights the exit path and door);(2) You cannot count a window as one of the child-care center's required fire exits;(3) Each child 18 months and older must be provided a cot, bed, or mattress that is waterproof or washable and developmentally appropriate;(4) Children under the age of 18 months must be provided with a crib for nighttime sleeping; and(5) Boys and girls six years old or older must have separate sleeping and dressing areas. Source Note: The provisions of this §746.3207 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS P NIGHTTIME CARE §746.3207 What are the building, furnishings, physical space, and equipment requirements for nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204111 03/12/2026 (a) Activities and routines must meet the unique needs of children in nighttime care. These may include quiet activities, such as homework, reading, puzzles, or board games; time for personal care routines and preparation for sleep, such as brushing teeth, washing hands and face, toileting, and changing clothes; and an evening meal, breakfast, and snack as specified in Subchapter Q of this chapter (relating to Nutrition and Food Service).(b) Screen time activities:(1) Must meet the requirements of §746.2207 of this chapter (relating to May I use a screen time activity with a child?); and(2) May not be used in a cot, bed, or mattress, or one hour before bedtime. Source Note: The provisions of this §746.3209 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS P NIGHTTIME CARE §746.3209 Must I provide activities for children in nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212739 03/12/2026 (a) You must serve all children regular meals and morning and afternoon snacks as specified in this subchapter.(b) The meals and snacks must follow the meal patterns established by the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) that is administered by the Texas Department of Agriculture. You must follow these patterns regardless of whether you are participating in the program for reimbursement.(c) If you serve breakfast, you do not have to serve a morning snack.(d) A child must not go more than three hours without a meal or snack being offered unless the child is sleeping.(e) You must serve enough food to allow a child to have second servings from the vegetable, fruit, grain, and milk groups if the child requests it.(f) You must ensure a supply of clean, sanitary drinking water:(1) Is always available to each child at every snack, mealtime, and during and after active play; and(2) Is served in a safe and sanitary manner.(g) You must not serve beverages with added sugars, such as carbonated beverages, fruit punch, or sweetened milk except for a special occasion such as a holiday or birthday celebration, unless otherwise allowed by the CACFP.(h) You must not use food as a reward.(i) You must not serve a child a food identified on the child's food allergy emergency plan, as specified in §746.3817 of this chapter (relating to What is a food allergy emergency plan?). Source Note: The provisions of this §746.3301 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3301 What are the basic requirements for meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204113 03/12/2026 You must follow the guidelines in Figure 26 TAC §746.3303 when determining how often to feed a child in your care.Attached Graphic Source Note: The provisions of this §746.3303 adopted to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3303 How often must I feed a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204114 03/12/2026 (a) Yes. However, your enrollment agreement, or an addendum to the agreement, signed by the parent must include a statement that the parent:(1) Is choosing to provide the child's meals and snacks from home; and(2) Understands the child-care center is not responsible for its nutritional value or for meeting the child's daily food needs.(b) If the parent provides a meal but not a snack, you are responsible for providing a snack as specified in this subchapter.(c) You must provide safe and proper storage and service of the individual meals and snacks provided by parents.(d) Snacks provided by a parent must not be shared with other children, unless:(1) A parent is providing baked goods for a celebration or party being held at the center; and(2) You ensure that the shared snacks meet the needs of children who require special diets. Source Note: The provisions of this §746.3309 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3309 May parents provide meals and snacks for their child instead of my child-care center providing them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204115 03/12/2026 (a) To serve a child a therapeutic or special diet, you must:(1) Have written approval from:(A) A physician or health-care professional with prescriptive authority if the diet relates to a disability that restricts the child's diet; or(B) A health-care professional or a registered or licensed dietician if the diet does not relate to a disability that restricts the child's diet;(2) Maintain the written approval in the child's record; and(3) Give the information to all employees preparing and serving food.(b) You must discuss recurring eating problems with the child's parent.(c) You may encourage but must not force children to eat.(d) You must not serve nutrient concentrates and supplements such as protein powders, liquid protein, vitamins, minerals, and other nonfood substances without written instructions as required in paragraph (a)(1) of this section. Source Note: The provisions of this §746.3311 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3311 What are the requirements for a child who requires a special diet or does not want to eat foods that the center serves? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188471 03/12/2026 Yes:(1) Substitutions of comparable food value may be made to the daily menu, but you must keep a record of any substitutions made; and(2) You may rotate menus, but you must keep a record of which menu was used for each date. Source Note: The provisions of this §746.3313 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3313 Can I make substitutions and/or rotate the daily menus? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188468 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188468 03/12/2026 All food and drinks must be of safe quality and must be stored, prepared, distributed, and served under sanitary and safe conditions, including but not limited to the following:(1) You must sanitize food service equipment, dishes, and utensils after each use;(2) If your child-care center lacks adequate facilities for sanitizing dishes and utensils, you must use only disposable, single-use items;(3) You must wash re-useable napkins, bibs, and tablecloths after each use;(4) You must discard single-service napkins, bibs, dishes, and utensils after use;(5) Caregivers with open wounds and/or any injury that inhibits hand washing, such as casts, bandages, or braces, must not prepare food;(6) You must serve children's food on plates, napkins, or other sanitary holders such as a high chair tray, and you must not place food on a bare table or eating surface, which includes the floor;(7) You must not serve foods that present a risk of choking for infants and toddlers;(8) You must cover all food stored in the refrigerator;(9) When meals are prepared at the child-care center, the food preparation area must be separated from the eating, play, and bathroom areas. You must not use the food preparation area as a passageway while food is being prepared; and(10) You must not store poisonous or toxic materials and cleaning supplies with food. Source Note: The provisions of this §746.3317 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3317 What general requirements apply to food service and preparation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204116 03/12/2026 (a) You do not have to use family-style meal service, although all meals and snack times must:(1) Be unhurried;(2) Allow children to feed themselves according to their developmental level; and(3) Include adult supervision of children.(b) If meals and snacks are served family style, caregivers must supervise children to prevent cross-contamination of the food. Source Note: The provisions of this §746.3319 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1479. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3319 Must I serve meals family style? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188470 03/12/2026 (a) Yes, although toothbrushes and tooth powders or pastes provided for each child's individual use must be:(1) Labeled with the child's full name;(2) Stored out of children's reach when not in use; and(3) Stored in a manner that prevents the toothbrushes from touching each other during storage.(b) Children must have adult supervision while brushing their teeth. Source Note: The provisions of this §746.3321 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS Q NUTRITION AND FOOD SERVICE §746.3321 Are children allowed to use toothbrushes after meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188499 03/12/2026 (a) Your child-care center must have a sanitation inspection before we issue your initial permit and at least once every 12 months, unless your child-care center is located in a public school facility operated by the local independent school district.(b) If an inspection is required, a local sanitation official must conduct the inspection.(c) If an inspection is not available from a local sanitation official, you must:(1) Obtain documentation from a local sanitation official or county judge stating that an inspection is not available; and(2) Maintain this documentation at the center and make it available to us upon request. Source Note: The provisions of this §746.3401 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective January 1, 2007, 31 TexReg 9351; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective June 1, 2014, 39 TexReg 3720; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3401 Must my child-care center have an annual sanitation inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188500 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188500 03/12/2026 If required, you must keep a copy of the most recent sanitation report, letter, or checklist at the child-care center during hours of operation to verify the inspection date and findings. The report must include the name and telephone number of the inspector. Source Note: The provisions of this §746.3403 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3403 How do I document that a sanitation inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188501 03/12/2026 Yes, you must comply with corrections, restrictions, or conditions specified by the inspector in the sanitation report, letter, or checklist. Source Note: The provisions of this §746.3405 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3405 Do I have to make corrections called for in the report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188502 03/12/2026 You must clean, repair, and maintain the building, grounds, and equipment to protect the health of the children. This includes, but is not limited to:(1) Setting aside toys and equipment that are placed in children's mouths, or are otherwise contaminated by body secretion or excrement, to be sanitized before handling by another child;(2) Machine washing cloth toys, if used, at least weekly and when contaminated;(3) Machine washing all linens at least weekly, and when soiled or before another child uses them;(4) Sanitizing sleeping equipment before a different child uses it and when soiled;(5) Sanitizing potty-chairs after each child's use;(6) Emptying water play tables and toys used in water tables daily, sanitizing, and ensuring children and caregivers wash their hands before using the water table;(7) Maintaining sand boxes and sand tables in a sanitary manner;(8) Making all garbage inaccessible to children and managing it to keep the child-care center inside and outside, free of insects, rodents, and offensive odors, and disposing of it according to local and state requirements;(9) Keeping all floors, ceilings, and walls in good repair and clean. Paints used at the child-care center must be lead-free;(10) Keeping all parts of the child-care center used by children well heated, lighted, and ventilated;(11) Sanitizing table tops, furniture, and other similar equipment used by children when soiled or contaminated with matter such as food, body secretions, or excrement;(12) Clearly marking cleaning supplies and other toxic materials and keeping them separate from food and inaccessible to children; and(13) Using, storing, and disposing of hazardous materials as recommended by the manufacturer. Source Note: The provisions of this §746.3407 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3407 What steps must I take to ensure a healthy environment for children at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188503 03/12/2026 Items that may be washed in a dishwasher or hot cycle of a washing machine which runs at a temperature of 160 degrees Fahrenheit or higher for five or more minutes do not need additional disinfecting because these machines use water that is hot enough, for long enough, to kill most germs. Source Note: The provisions of this §746.3413 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3413 May I use a dishwasher or washing machine to sanitize items at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188504 03/12/2026 Employees must wash their hands:(1) Before eating or handling food or medication;(2) Before feeding a child;(3) After arriving at the child-care center;(4) After diapering a child;(5) After assisting a child with toileting;(6) After personal toileting;(7) After handling or cleaning bodily fluids, such as after wiping noses, mouths, or bottoms, and tending sores;(8) After handling or feeding animals;(9) After outdoor activities;(10) After handling raw food products;(11) After eating, drinking, or smoking;(12) After using any cleaners or toxic chemicals; and(13) After removing gloves. Source Note: The provisions of this §746.3415 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3415 When must employees wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188505 03/12/2026 Children must wash their hands:(1) Before eating;(2) Before playing in a water play table;(3) After toileting or having a diaper changed;(4) After outdoor activities;(5) After playing in sand;(6) After feeding or touching animals; and(7) Any other time that the caregiver has reason to believe the child has come in contact with substances that could be harmful to the child. Source Note: The provisions of this §746.3417 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3417 When must children wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188506 03/12/2026 Children 18 months of age and older and employees must wash their hands with soap and running water. Source Note: The provisions of this §746.3419 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3419 How must children and employees wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188507 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188507 03/12/2026 You may use hand sanitizers as a substitute for washing hands if all of the following conditions are met:(1) You only use hand sanitizers on children 24 months and older;(2) You do not use hand sanitizers to wash hands that are visibly dirty or greasy or have chemicals on them, unless you are away from the classroom and soap and water are not available for hand washing;(3) You follow the labeling instructions for the appropriate amount to be used and for how long the hand sanitizer needs to remain on the skin surface to be effective;(4) Children have adult supervision when using hand sanitizers; and(5) You store hand sanitizers out of the reach of children when not in use. Source Note: The provisions of this §746.3420 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3420 May I use hand sanitizer as a substitute for washing hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188508 03/12/2026 (a) Until the infant is old enough to be raised to the faucet and reach for the water, you must wash the infant's hands using an individual cloth or disposable towel with soap, followed by a cloth or disposable towel used to rinse with clear water and dry.(b) Use soap and running water as specified in this division when infants are old enough to be raised to the faucet and reach for the water and any other time that the caregiver has reason to believe the infant has come in contact with substances that could be harmful to the infant. Source Note: The provisions of this §746.3421 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3421 How must I wash an infant's hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188509 03/12/2026 No. We do not require you to have hot water for hand washing. However, if hot water is accessible to the children, a thermostat must control it so that the water temperature is no higher than 120 degrees Fahrenheit. Source Note: The provisions of this §746.3423 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3423 Must my child-care center have hot water for hand washing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188510 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188510 03/12/2026 Yes. Caregivers must follow universal precautions outlined by the Centers for Disease Control (CDC) when handling blood, vomit, or other bodily fluids that may contain blood including:(1) Using disposable, nonporous gloves;(2) Placing gloves contaminated with blood in a tied, sealed, or otherwise closed plastic bag and discarding them immediately;(3) Discarding all other gloves immediately after one use; and(4) Washing hands after using and disposing of the gloves. Source Note: The provisions of this §746.3425 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3425 Must caregivers wear gloves when handling blood or bodily fluids containing blood? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188511 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188511 03/12/2026 You may treat your center for pests only if you are certified as a noncommercial applicator by the Texas Department of Agriculture. Otherwise, you must use a pest control operator licensed by the Texas Department of Agriculture to prevent, control, or eliminate pest infestations at your child-care center, including the use of over-the-counter products designed for controlling insects, rodents, and other pests. Source Note: The provisions of this §746.3427 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective March 1, 2008, 33 TexReg 1376; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3427 Must I use a licensed exterminator to treat my child-care center for insects, rodents, and other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188512 03/12/2026 (a) Children must not be allowed in areas where there is pesticide residue that may be harmful to them. Follow written instructions from the licensed pest control operator or label directions in order to determine whether the residue may be harmful to children.(b) Areas where children are present may be treated with chemicals only when permissible under the label directions. Source Note: The provisions of this §746.3429 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3429 Are there general precautions I must take when my child-care center is being treated for insects, rodents, and other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188513 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188513 03/12/2026 Yes, you may use water from a private water supply, although you must:(1) Maintain the water supply in a safe and sanitary manner.(2) Maintain written records indicating the private water supply meets the requirements of the Texas Commission on Environmental Quality, if applicable. Source Note: The provisions of this §746.3431 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3431 May I use water from a private water supply instead of a public water supply for my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188514 03/12/2026 Yes, if the septic system is sanitary and meets the standards of the Texas Commission on Environmental Quality, including any routine inspections required by law. Source Note: The provisions of this §746.3433 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3433 May I use a septic system for sewage disposal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188517 03/12/2026 Caregivers must:(1) Promptly change soiled or wet diapers or clothing;(2) Thoroughly cleanse a child with individual cloths or disposable towels. You must discard any disposable towels after use and launder any cloths before using them again;(3) Ensure that a child is dry before placing a new diaper on the child. If the child must be dried, you must use a clean, individual cloth or disposable towel to dry the child. You must discard the disposable towel after use and launder any cloth before using it again;(4) Not apply powders, creams, ointments, or lotions unless you obtain the parent's written permission. If the parent supplies these items, permission is implicit and you do not need to obtain permission for each use;(5) Label powders, creams, ointments, or lotions with the individual child's name; and(6) Keep all diaper-changing supplies out of the reach of children. Source Note: The provisions of this §746.3501 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3501 What steps must caregivers follow for diaper changing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188515 03/12/2026 (a) You must have a diaper-changing table or surface that is smooth, non-absorbent, and easy to clean.(b) You must not use areas that children come in close contact with during play or eating, such as dining tables, sofas, or floor play areas, for diaper changing.(c) If the diaper-changing table or surface is above the floor level, then at all times when the child is on the table/surface:(1) There must be a safety mechanism (such as raised sides) that is used;(2) The caregiver's hand must remain on the child; or(3) The caregiver must be facing the child and within an arm's length of the child.(d) You must have a hand-washing sink in the diaper-changing area. Refer to §746.4403 of this title (relating to Must I have a hand-washing sink in the diaper-changing area?). Source Note: The provisions of this §746.3503 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3503 What equipment must I have for diaper changing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188516 03/12/2026 (a) You must wash your hands as specified in §746.3419 of this title (relating to How must children and employees wash their hands?).(b) You must wash the infant's hands or see that the child's hands are washed after each diaper change as specified in §746.3421 of this title (relating to How must I wash an infant's hands?).(c) If you use disposable gloves, you must discard them after each diaper change and wash your hands with soap and running water.(d) Caregivers with open wounds and/or any injury that inhibits hand washing, such as casts, bandages, or braces, must not change diapers.(e) You must sanitize the diaper-changing surface after each use. However, if you are changing diapers on a number of children consecutively, you may cover the surface with a non-absorbent paper liner that is disposed of between each diaper change.(f) You must cover containers used for soiled diapers or keep them in a sanitary manner, such as placing soiled diapers in individual sealed bags.(g) You must place soiled clothing in a sealed plastic bag to be sent home with the child. Source Note: The provisions of this §746.3505 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3505 What must I do to prevent the spread of germs when diapering children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212740 03/12/2026 Unless you are licensed to provide get-well care, you must not allow an ill child to attend your child-care center if one or more of the following exists:(1) The illness prevents the child from participating comfortably in child-care center activities including outdoor play;(2) The illness results in a greater need for care than caregivers can provide without compromising the health, safety, and supervision of the other children in care;(3) The child has one of the following (unless a medical evaluation by a health-care professional indicates that you can include the child in the child-care center's activities):(A) An oral temperature above 101 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(B) A tympanic (ear) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness. Tympanic thermometers are not recommended for children under six months old;(C) An axillary (armpit) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(D) An infrared temporal (forehead) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness; or(E) Symptoms and signs of possible severe illness such as lethargy, abnormal breathing, uncontrolled diarrhea, two or more vomiting episodes in 24 hours, rash with fever, mouth sores with drooling, behavior changes, or other signs that the child may be severely ill; or(4) A health-care professional has diagnosed the child with a communicable disease, and the child does not have medical documentation to indicate that the child is no longer contagious. Source Note: The provisions of this §746.3601 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3601 What type of illness would prohibit a child from attending the child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188576 03/12/2026 You must follow the communicable disease exclusions required for schools as defined by the Texas Department of State Health Services (DSHS) in 25 TAC §97.7 (relating to Diseases Requiring Exclusion from Schools). You can access this information from DSHS or Licensing staff. Source Note: The provisions of this §746.3603 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3603 What communicable diseases would exclude a child from attending my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204786 03/12/2026 (a) If a child becomes ill while in your care but does not require immediate treatment by a health-care professional or hospitalization, you must:(1) Contact the parent to pick up the child;(2) Care for the child apart from other children;(3) Give appropriate attention and supervision until the parent picks the child up; and(4) Give extra attention to hand washing and sanitation if the child has diarrhea or vomiting.(b) If a child becomes ill while in your care and requires immediate treatment by a health-care professional or hospitalization, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the group);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure the supervision of other children in the group. Source Note: The provisions of this §746.3605 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3605 How must caregivers respond when a child becomes ill? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188578 03/12/2026 A child who was ill may return to your child-care center when:(1) The child is free of symptoms of illness for 24 hours; or(2) You have obtained a health-care professional's statement that the child no longer has an excludable disease or condition. Source Note: The provisions of this §746.3606 adopted to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3606 When may a child who was ill return to my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204787 03/12/2026 For an injury that requires immediate treatment by a health-care professional, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the group);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure supervision of other children in the group. Source Note: The provisions of this §746.3607 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2447. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3607 How must caregivers respond when a child is injured and requires immediate treatment by a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188580 03/12/2026 A vaccine-preventable disease is a disease that is included in the most current recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Source Note: The provisions of this §746.3609 adopted to be effective June 1, 2014, 39 TexReg 3720; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3609 What is a vaccine-preventable disease for the purpose of this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188581 03/12/2026 A policy for protecting the children in your care from vaccine-preventable diseases must:(1) Specify any vaccines that you have determined an employee must have for vaccine-preventable diseases based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(2) Require each employee to receive each specified vaccine that the employee is not exempt from having;(3) Include procedures for verifying whether an employee has complied with your policy;(4) Include procedures for an employee to be exempt from having a required vaccine because of:(A) Medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention (CDC); or(B) Reasons of conscience, including a religious belief;(5) Include procedures that an exempt employee must follow to protect children in your care from exposure to disease, such as the use of protective medical equipment, including gloves and masks, based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(6) Prohibit discrimination or retaliatory action against an exempt employee, except that required use of protective medical equipment, including gloves and masks, may not be considered retaliatory action for purposes of this section;(7) Outline how you will maintain a written or electronic record of each employee's compliance with or exemption from your policy; and(8) State the disciplinary actions you may take against an employee who fails to comply with your policy. Source Note: The provisions of this §746.3611 adopted to be effective June 1, 2014, 39 TexReg 3720; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS R HEALTH PRACTICES §746.3611 What must a policy for protecting children from vaccine-preventable diseases include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220726 03/12/2026 All areas accessible to a child must be free from hazards including the following:(1) Electrical outlets accessible to a child younger than five years must have childproof covers or safety outlets;(2) 220-volt electrical connections within a child's reach must be covered with a screen or guard;(3) Air conditioners, electric fans, and heaters must be mounted out of all children's reach or have safeguards that keep any child from being injured;(4) Glass in sliding doors must be clearly marked with decals or other materials placed at children's eye level;(5) Play materials and equipment must be safe and free from sharp or rough edges and toxic paints;(6) Poisonous or potentially harmful plants must be inaccessible to all children;(7) Bottle warmers must be inaccessible to all children and used only according to manufacturer instructions;(8) All storage chests, boxes, trunks, or similar items with hinged lids must be equipped with a lid support designed to hold the lid open in any position, be equipped with ventilation holes, and must not have a latch that might close and trap a child inside;(9) All bodies of water, wading pools, hot tubs, birdbaths, fountains, buckets, and rain barrels must be inaccessible to all children; and(10) All televisions must be anchored, so they cannot tip over. A television may be anchored to a rolling cart, if it is anchored in a way that the cart will not tip over. Source Note: The provisions of this §746.3701 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3701 What safety precautions must I take to protect children in my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188475 03/12/2026 (a) People whose behavior and/or health status poses an immediate threat or danger to the health or safety of the children must not be present when children are in care.(b) People must not consume alcohol or controlled substances without a prescription in the child-care center, during transportation, or on field trips.(c) People must not be under the influence of or impaired by alcohol or controlled substances in the child-care center, during transportation, or on field trips.(d) People must not smoke any e-cigarette, vaporizer, or tobacco product or otherwise use any tobacco product at your child-care center, on the premises, on the playground, in transportation vehicles, or during field trips. Source Note: The provisions of this §746.3703 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3703 How can I ensure the safety of the children from other persons? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188479 03/12/2026 Although permissible, you are not required to have a video or audio monitoring system. Source Note: The provisions of this §746.3705 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3705 Am I required to have a video or audio monitoring system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188481 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188481 03/12/2026 (a) Peace officers as listed in §2.12 of the Code of Criminal Procedure and security officers commissioned by the Texas Private Security Board who are trained and certified to carry a firearm on duty may have firearms and ammunition on the premises of your child-care center.(b) For all other persons, firearms, hunting knives, bows and arrows, and other weapons are prohibited on the premises of the child-care center, unless the child-care center is also your residence. This prohibition does not apply to personal vehicles.(c) Firearms, hunting knives, bows and arrows, and other weapons kept on the premises of a child-care center located in your home must remain in a locked cabinet inaccessible to children during all hours of operation.(d) Ammunition must be kept in a separate locked cabinet and inaccessible to children during all hours of operation. Source Note: The provisions of this §746.3707 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3707 Are firearms or other weapons allowed at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188476 03/12/2026 A child may not use any type of toy or equipment that explodes or that shoots things, such as caps, BB guns, darts, or fireworks at the child-care center or on field trips. These types of toys and equipment are not allowed at your operation unless your operation is located in your home. If your child-care center is located in your home, you must keep any such toy or equipment in a locked cabinet inaccessible to any child during your hours of operation. Source Note: The provisions of this §746.3709 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3709 May I have toys or other types of equipment that explode or shoot things? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188477 03/12/2026 In this division, medication means:(1) A prescription medication; or(2) A non-prescription medication, excluding topical ointments such as diaper ointment, insect repellent, or sunscreen. Source Note: The provisions of this §746.3801 adopted to be effective March 1, 2012, 37 TexReg 928; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3801 What does "medication" refer to in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188478 03/12/2026 (a) Authorization to administer medication to a child in your care must be obtained from the child's parent:(1) In writing, signed and dated;(2) In an electronic format that is capable of being viewed and saved; or(3) By telephone to administer a single dose of a medication.(b) Authorization to administer medication expires on the first anniversary of the date the authorization is provided.(c) The child's parent may not authorize you to administer medication in excess of the medication's label instructions or the directions of the child's health-care professional.(d) Parent authorization is not required if you administer a medication to a child in a medical emergency to prevent the death or serious bodily injury of the child, provided that you administer the medication as prescribed, directed, or intended. Source Note: The provisions of this §746.3803 adopted to be effective March 1, 2012, 37 TexReg 928; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3803 What authorization must I obtain before administering a medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188480 03/12/2026 (a) Medication must be given:(1) As stated on the label directions; or(2) As amended in writing by the child's health-care professional.(b) Medication must:(1) Be in the original container labeled with the child's full name and the date brought to the operation;(2) Be administered only to the child for whom it is intended; and(3) Not be administered after its expiration date.(c) When you administer medication to a child in your care, you must record the following:(1) Full name of the child to whom the medication was given;(2) Name of the medication;(3) Date, time, and amount of medication given; and(4) Full name of the employee administering the medication.(d) You must keep all medication records for at least three months after administering the medication. Source Note: The provisions of this §746.3805 adopted to be effective March 1, 2012, 37 TexReg 928; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3805 How must I administer medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188482 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188482 03/12/2026 You must store medications as follows:(1) Keep it out of the reach of children or in locked storage;(2) Store it in a manner that does not contaminate food; and(3) Refrigerate it, if refrigeration is required, and keep it separate from food. Source Note: The provisions of this §746.3807 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3807 How must I store medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188483 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188483 03/12/2026 You must dispose of the medication or return it to the parent when the child withdraws from the child-care center, or when the medication is out-of-date or is no longer required for the child. Source Note: The provisions of this §746.3809 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3809 How long may I keep the medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188484 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188484 03/12/2026 Yes. If you choose not to administer medication to children, you must inform the parents of this policy in writing before the child's enrollment. Source Note: The provisions of this §746.3811 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3811 Do I have to notify parents if I do not want to administer medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188485 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188485 03/12/2026 Specialized medical assistance is any medical assistance other than medication. Examples include, but are not limited to, assisting with an apnea monitor, protective helmet, or leg brace. Source Note: The provisions of this §746.3813 adopted to be effective March 1, 2012, 37 TexReg 928; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3813 What is specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188486 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188486 03/12/2026 (a) If a child in your care requires specialized medical assistance, then you are required to provide specialized medical assistance as recommended or ordered by a health-care professional.(b) If you are provided with a written copy of the health-care professional's recommendations or orders, you must maintain this written information in the child's record for at least three months after the health-care professional has indicated that the specialized medical assistance is no longer needed. Source Note: The provisions of this §746.3815 adopted to be effective March 1, 2012, 37 TexReg 928; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3815 What are my requirements regarding specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188487 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188487 03/12/2026 A food allergy emergency plan is an individualized plan prepared by the child's health care professional that includes:(1) a list of each food the child is allergic to;(2) possible symptoms if exposed to a food on the list; and(3) the steps to take if the child has an allergic reaction. Source Note: The provisions of this §746.3817 adopted to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3817 What is a food allergy emergency plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188488 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188488 03/12/2026 You must have a food allergy emergency plan for each child with a known food allergy that has been diagnosed by a health-care professional. The child's heath care professional and parent must sign and date the plan. You must keep a copy of the plan in the child's file. Source Note: The provisions of this §746.3819 adopted to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3819 When must I have a food allergy emergency plan for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188489 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188489 03/12/2026 If you choose to have animals on the premises of your child-care center and/or on field trips, you must:(1) Notify parents in writing when animals are or will be present;(2) Ensure the animals do not create unsafe or unsanitary conditions;(3) Ensure that children do not handle any animal that shows signs of illness, such as lethargy or diarrhea; and(4) Ensure that caregivers and children practice good hygiene and hand washing after handling or coming in to contact with an animal and items used by an animal, such as water bowls, food bowls, and cages. Source Note: The provisions of this §746.3901 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3901 What steps must I take to have animals at my child-care center and/or on field trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188495 03/12/2026 (a) Yes. You must have documentation at your child-care center showing dogs and cats have been vaccinated as required by Texas Health and Safety Code, Chapter 826.(b) You must have a statement of health from a local veterinarian at your child-care center for dogs, cats, ferrets, and other animals other than small rodents, such as guinea pigs, mice, and hamsters. Source Note: The provisions of this §746.3903 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3903 Must I keep documentation of vaccinations on file for the animals? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188490 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188490 03/12/2026 (a) Yes. Children must not have contact with chickens, ducks, and reptiles, such as snakes, turtles, lizards, iguanas, and amphibians, such as frogs and toads.(b) You must keep the child-care center and playground free of animals unfamiliar to you.(c) You must not allow children to play with animals unfamiliar to you or other animals that could be dangerous, including exotic animals such as monkeys. Source Note: The provisions of this §746.3905 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.3905 Must I prevent children from having contact with certain animals while at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188491 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188491 03/12/2026 Yes. You must have a complete first-aid kit available in each building at the child-care center, during all field trips, and while transporting children. Each first-aid kit must be:(1) Clearly labeled;(2) Kept in a clean and sanitary condition;(3) Easily accessible to all employees;(4) Stored in a designated location known to all employees; and(5) Kept out of the reach of children. Source Note: The provisions of this §746.4001 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4001 Must I have a first-aid kit at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212742 03/12/2026 (a) Each first-aid kit must contain the following supplies:(1) A guide to first aid and emergency care;(2) Adhesive tape;(3) Antiseptic solution or wipes;(4) Adhesive bandages;(5) Scissors;(6) Sterile gauze pads;(7) Thermometer, preferably non-glass;(8) Tweezers; and(9) Waterproof, disposable gloves.(b) The first-aid supplies must not have expired. Source Note: The provisions of this §746.4003 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4003 What items must each first-aid kit contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220269 03/12/2026 (a) You must release a child only to a parent or a person designated by the parent.(b) Upon receipt of a valid court order signed by a judge that prohibits a parent from removing the named child or children from the child-care center, the child-care center must:(1) Comply with the court order immediately and until:(A) Receipt of a subsequent court order that revokes the primary order; or(B) The court order expires as defined in the document; and(2) Maintain a copy of the court order in the child's file. Source Note: The provisions of this §746.4101 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective August 19, 2024, 49 TexReg 6227. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4101 To whom may I release a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188494 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188494 03/12/2026 (a) You must develop child-care center policies for the release of children, including a plan to verify the identity of a person authorized to pick up a child but whom the caregiver does not know. If your child-care center transports children, the plan must include verifying the identity of a person to whom you release a child from a child-care-center transportation vehicle.(b) Your policies must include a reasonable means to record the identity of the individual, such as a copy of a valid photo identification, an instant photograph of the individual, or recording the driver's license number and car tag numbers. You must retain this information in the child's records for at least three months.(c) You must instruct all employees in the child-care center's policies for the release of children, including the verification plan. Source Note: The provisions of this §746.4103 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4103 How do my employees verify the identity of a parent or a person a parent has designated to pick up the child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188496 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188496 03/12/2026 Children's products are products that are designed or intended to be used by a child under 13 years of age or used by a caregiver during the care of a child under 13 years of age. The term does not include:(1) An item that is not designed or intended to be used solely or primarily by a child under 13 years of age or for the care of a child under 13 years of age;(2) A medication, drug, food, or other item that is intended to be ingested; or(3) Clothing. Source Note: The provisions of this §746.4131 adopted to be effective March 1, 2010, 35 TexReg 1293; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4131 What are "children's products?" https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188497 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188497 03/12/2026 A children's product is considered to be unsafe if after it has been recalled for any reason by the United States Consumer Product Safety Commission:(1) The recall has not been rescinded; and(2) The product has not been made safe through being remanufactured or retrofitted. Source Note: The provisions of this §746.4133 adopted to be effective March 1, 2010, 35 TexReg 1293; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4133 When is a children's product considered to be unsafe? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188498 03/12/2026 (a) You are responsible for reviewing the United States Consumer Product Safety Commission (CPSC) recall list. You may view all current and past recalls through the CPSC's Internet website at: www.cpsc.gov. You must ensure that there are no unsafe children's products in your child-care center unless one or more of the following apply:(1) The product is an antique or collectible children's product and is not used by, or accessible to any child; or(2) The unsafe children's product is being retrofitted to make it safe and the product is not used by, or accessible to any child.(b) You must certify annually in writing using a form provided by DFPS that you have reviewed each of the recall notices issued by the CPSC and that there are no unsafe products in the center except products specified in subsection (a) of this section. The form must be kept on file and available for review upon request by Licensing staff, parents, and employees during hours of operation.(c) You must post a notice for parents and employees in a prominent and publicly accessible place that includes information on how to access a listing of unsafe children's products through the CPSC Internet website or through the DFPS Internet website. Source Note: The provisions of this §746.4135 adopted to be effective March 1, 2010, 35 TexReg 1293; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS S SAFETY PRACTICES §746.4135 What are my responsibilities regarding unsafe children's products in my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188518 03/12/2026 You must have at least 30 square feet of indoor activity space for each child that you are licensed to serve, unless the child-care center is exempt based on criteria specified in this division. Source Note: The provisions of this §746.4201 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4201 How many square feet of indoor activity space must I have for children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188519 03/12/2026 Yes. You must care for children younger than 18 months in rooms and outdoor activity space areas separate from older children unless there are 12 or fewer children in the child-care center, or the child-care center is exempt based on criteria specified in this division. Source Note: The provisions of this §746.4203 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4203 Am I required to care for children younger than 18 months separately from older children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188520 03/12/2026 (a) Yes. For children less than 18 months old, the number of infants must not exceed the activity space.(b) For children 18 months and older, more children than the room measurement will accommodate must not routinely occupy rooms, unless the age of the children, the equipment and furnishings, and the activity being conducted in the room make it possible. Source Note: The provisions of this §746.4205 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4205 Must I limit the number of children in each room based on the indoor activity space measurements for that room? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188521 03/12/2026 (a) Yes, the only exemption is for child-care centers licensed as kindergarten and nursery schools, or schools: grades kindergarten and above, before September 1, 2003. These centers must have at least 20 square feet of indoor activity space for each child the center is licensed to serve.(b) The exemption specified in subsection (a) of this section remains in effect until a permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §746.4207 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4207 Do these indoor activity space requirements apply to my child-care center if it was licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188522 03/12/2026 (a) We determine indoor activity space by:(1) Measuring all indoor activity space wall to wall on the inside at floor level;(2) Rounding all measurements up to the nearest inch; and(3) Excluding single-use areas, which are areas not routinely used for children's activities, such as a bathroom, hallway, storage room, cooking area of a kitchen, swimming pool, and storage building; and(4) Excluding floor space occupied by permanent and stationary fixtures, such as bookcases, shelving, and storage/counter space, that is not intended for use by the children.(b) We use the sum of the measurements to calculate the indoor activity space and to determine the maximum number of children you may care for. Source Note: The provisions of this §746.4213 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4213 How does Licensing determine the indoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188524 03/12/2026 (a) You may share the indoor activity space that is not classroom space with other programs at the same time you have children in care, if you have a written plan specifying how caregivers will supervise and account for children in your care. The plan must address the following:(1) The ages of the children;(2) The proximity of restroom facilities and the operation entrances and exits to the children's area; and(3) The nature of other activities and persons who may be sharing the space.(b) You must follow your written plan and submit a copy to Licensing upon request. Source Note: The provisions of this §746.4215 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4215 May other programs use my indoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212743 03/12/2026 To care for children on any level above or below ground level, you must:(1) Obtain written approval from the state or local fire authority; and(2) Follow any restrictions issued by the state or local fire authority, including any age limits placed on the approval. Source Note: The provisions of this §746.4217 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4217 May I care for children above or below ground level? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188525 03/12/2026 (a) You must have 80 square feet of outdoor activity space for each child using the outdoor activity area at one time, unless you are licensed to provide only:(1) An alternate care program; or(2) A get-well care program.(b) You must have enough square footage in the outdoor activity space to equal at least 25% of your licensed indoor capacity.(c) If you were licensed before September 1, 2003, you do not have to comply with the outdoor activity space requirements specified in subsection (b) of this section unless the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §746.4301 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4301 How many square feet of outdoor activity space must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188526 03/12/2026 Yes. A fence or wall at least four feet high must enclose the outdoor activity space unless you meet one of the following:(1) You are licensed to provide only an after-school care program in a classroom facility owned, operated, and administered by and located in a public school as defined by the Texas Education Agency;(2) You are licensed to provide only an alternate care program;(3) You are licensed to provide only a get-well care program; or(4) The only children using the outdoor activity space are five years old or older. Source Note: The provisions of this §746.4305 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4305 Must I fence the outdoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188527 03/12/2026 Each fenced yard must have at least two exits. An entrance to the building may count as one exit, but one exit must be away from the building. Source Note: The provisions of this §746.4307 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4307 How many exits must I have from my fenced outdoor activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188528 03/12/2026 Yes, however the locking mechanism must be accessible to all employees at all times. Employees must be able to open the gates immediately in an emergency and satisfactorily demonstrate this ability to Licensing staff upon request. Source Note: The provisions of this §746.4309 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4309 May I keep the gates leading into my outdoor activity space locked while children are in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188529 03/12/2026 No; however, all outdoor activity areas used by children must be accessible by a safe route. We must approve a plan to use an outdoor activity space that is not connected to the child-care center, such as a near-by park, schoolyard, rooftop, or other alternative. We will consider the following criteria before approving the plan:(1) Traffic patterns of vehicles and people in the area;(2) Ages of children in the groups;(3) Availability of appropriate equipment;(4) Usage of the location by other persons when the children would be most likely to use it;(5) Neighborhood circumstances, hazards, and risks;(6) Accessibility to children and caregivers on foot or the availability of push-carts or other means of transporting infants and toddlers;(7) Reasonable accessibility of restroom facilities; and(8) Ability to obtain assistance if needed when injury or illness occurs. Source Note: The provisions of this §746.4311 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4311 Must the outdoor activity space be connected to the child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188533 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188533&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188533 03/12/2026 Yes. If we approve the outdoor activity space, you must:(1) Give parents written notification of the location of the outdoor activity area, upon their child's enrollment;(2) Develop a written plan to supervise children, both during play and while traveling to and from the outdoor activity space; and(3) Meet other conditions specified by Licensing staff, if applicable. Source Note: The provisions of this §746.4313 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4313 Must I comply with additional requirements if my plan to use an outdoor activity space not connected to my child-care center is approved by Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188534 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188534&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188534 03/12/2026 (a) You may share the outdoor activity space with other programs at the same time you have children in care, if you have a written plan specifying how caregivers will supervise and account for children in your care. The plan must address the following:(1) The ages of the children;(2) The proximity of restroom facilities and the operation entrances and exits to the children's area; and(3) The nature of other activities and persons who may be sharing the space.(b) You must follow your written plan and submit a copy to Licensing upon request. Source Note: The provisions of this §746.4315 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4315 May other programs use my outdoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188530 03/12/2026 (a) If you are licensed to serve 13 or more children, unless otherwise specified in this division, you must have one sink for every 17 children who are 18 months of age and older.(b) If you are licensed to serve 12 or fewer children, unless otherwise specified in this division, you must have at least one sink available for the children's use.(c) If you were licensed as a kindergarten and nursery school, or school: grades kindergarten and above, before September 1, 2003, you must have one sink for every 20 children.(d) If you were licensed as a drop-in child-care center before September 1, 2003, you must have at least one sink for every 25 children.(e) A kindergarten and nursery school; school: grades kindergarten and above; and drop-in child-care center must comply with the requirements specified in subsection (a) or (b) of this section if the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §746.4401 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4401 How many hand-washing sinks must I have in my child-care center for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212744 03/12/2026 (a) You must have one hand-washing sink in each diaper-changing area, placed so that the caregiver using it can maintain supervision of the children in the group as specified in §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?).(b) If your child-care center was licensed as a day care center, group day care home or drop-in child-care center before September 1, 2003, and you are unable to comply with subsection (a) of this section, you must submit to us and follow a plan for each diaper-changing area that ensures children are supervised at all times and caregivers and children are washing hands as specified in this chapter.(c) A child-care center licensed before September 1, 2003, must comply with the requirements specified in subsection (a) of this section if the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §746.4403 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4403 Must I have a hand-washing sink in the diaper-changing area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188532 03/12/2026 Hand-washing sinks must be inside the child-care center. Children 18 months of age and older must be able to safely and independently access the sink. Hand-washing sinks must be equipped with soap, running water, and single-use disposable towels or hot-air hand dryers. Refer to Subchapter R of this chapter (relating to Health Practices) for further information on hand washing. Source Note: The provisions of this §746.4405 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4405 Where must I locate the hand-washing sinks for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188535 03/12/2026 (a) If you are licensed to serve 13 or more children, you must have one flush toilet for every 17 children who are 18 months of age and older.(b) If you are licensed to serve 12 or fewer children, you must have at least one flush toilet available for the children's use.(c) If you were licensed as a kindergarten and nursery school, or school: grades kindergarten and above, before September 1, 2003, you must have one toilet for every 20 children.(d) If you were licensed as a drop-in child-care center before September 1, 2003, you must have at least one toilet for every 25 children.(e) A child-care center licensed before September 1, 2003, must comply with the requirements specified in subsection (a) or (b) of this section if the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §746.4407 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4407 How many toilets am I required to have in my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188536 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188536&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188536 03/12/2026 Toilets must be inside the child-care center. Children 18 months of age and older must be able to safely and independently access the toilet. Toilets must be equipped for independent use by children and allow supervision by caregivers, as needed. Source Note: The provisions of this §746.4409 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4409 Where must the toilets be located? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188537 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188537&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188537 03/12/2026 (a) Urinals may be counted in the ratio of children to toilets, but may not exceed 50% of the total number of toilets.(b) Restrooms containing urinals must also have flush toilets. Source Note: The provisions of this §746.4411 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4411 May I count urinals in the ratio of children to toilets? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188538 03/12/2026 Yes. Potty-chairs may be used, but you may not count them in the ratio of children to toilets. Source Note: The provisions of this §746.4417 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4417 May potty-chairs be used? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188539 03/12/2026 No, however if you use a sink, urinal, toilet, or drinking fountain that is too high for children to use safely and independently, you must equip them with anchored steps and/or a broad-based platform with a non-slip surface. Source Note: The provisions of this §746.4419 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4419 Do I have to use toilets, sinks and fountains that are child sized? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188540 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188540 03/12/2026 Yes. Doors on restrooms and toilets used by children may have locks, although:(1) Locks must be out of children's reach; or(2) If locks are within children's reach there must be a way to immediately open the door from the outside in an emergency, and:(A) The unlocking mechanism must be accessible to all employees at all times and must be demonstrated satisfactorily to Licensing staff upon request; and(B) An adult must be present in the restroom area when children younger than five years are using restrooms with door locks within children's reach. Source Note: The provisions of this §746.4421 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4421 May the doors to the restroom or toilets have locks on them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188541 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188541&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188541 03/12/2026 (a) Yes. You may share the toilets and hand washing sinks counted in your indoor activity space with other programs at the same time you have children in care, provided you:(1) Ensure adequate facilities are available to children when needed; and(2) Have a written plan specifying how caregivers will supervise and account for children in your care, that address:(A) The ages of the children;(B) The proximity of restroom facilities, and the center's entrances and exits to the children's area; and(C) The nature of other activities and persons who may be sharing the toilets and hand washing sinks.(b) You must follow the plan and submit a copy of Licensing upon request. Source Note: The provisions of this §746.4423 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4423 May other programs use the toilets and hand washing sinks counted in my indoor activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188542 03/12/2026 (a) Tables and chairs that you use for children must be safe, easy to clean, and of a height and size appropriate for each age group in care.(b) If the manufacturer requires safety straps on a chair, then the safety straps must be fastened whenever a child is using the chair. Source Note: The provisions of this §746.4501 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4501 What type of tables and chairs must I use for the children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188543 03/12/2026 (a) Yes. You must provide or have the parent provide an individual cot, bed, or mat that is waterproof or washable for each walking child through four years to sleep or rest on.(b) Cots, beds, or mats must be labeled with the child's name. As an alternative, you may label cots, beds, or mats with a number and have a number/child assignment map available as an alternative.(c) Floor mats used for napping must be marked or colored so that the sleeping side can be distinguished from the floor side. Source Note: The provisions of this §746.4503 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4503 Must I provide a cot or mat for each child to sleep or rest on? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188544 03/12/2026 Yes. You must have individual lockers, cubicles, separate hooks and shelves, or other adequate storage space for each child's personal belongings. You must clearly label the storage space with the child's name, a photograph of the child, or other symbol the child recognizes as his own. Source Note: The provisions of this §746.4505 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4505 Must I have storage for each child's individual belongings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188545 03/12/2026 Yes. You must have:(1) A telephone at your child-care center with a listed telephone number; or(2) Access to a telephone located in the same building for use in an emergency and where a person is available to:(A) Receive incoming calls to the child-care center;(B) Immediately transmit messages regarding children in care to child-care center caregivers; and(C) Make outgoing calls for the child-care center as necessary. Source Note: The provisions of this §746.4507 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4507 Must I have a telephone at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188546 03/12/2026 (a) Yes, as long as the lofts are designed and used as an extension of the classroom and you comply with the following safety standards:(1) Caregivers must be able to adequately supervise children at all times;(2) Stairs and steps, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails; and(3) Platforms over 20 inches in height must be equipped with protective barriers that prevent children from crawling over or falling through the barrier, or becoming entrapped.(b) If lofts are used as indoor active play space or equipment, they must comply with minimum standards specified in Subchapter U of this chapter (relating to Indoor and Outdoor Active Play Space and Equipment). Source Note: The provisions of this §746.4509 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS T PHYSICAL FACILITIES §746.4509 May I have indoor lofts? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188547 03/12/2026 Indoor and outdoor active play equipment used both at and away from the child-care center must be safe for the children as follows:(1) The indoor and outdoor active play equipment must be arranged so that caregivers can adequately supervise children at all times;(2) The design, scale, and location of the equipment must be used according to the manufacturer's instructions;(3) Equipment must not have openings or angles that can entrap a child's body or body part that has penetrated the opening;(4) Equipment must not have protrusions or openings that can entangle something around a child's neck or a child's clothing;(5) Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, moving, or overturning;(6) All anchoring devices must be placed below the level of the playing surface to prevent tripping or injury resulting from a fall;(7) Equipment must not have exposed pinch, crush, or shear points, on or underneath it;(8) Climbing equipment, swings, or inflatables must not be installed over asphalt or concrete unless the asphalt or concrete is covered with properly installed unitary surfacing materials as specified in §746.4909 of this title (relating to What are unitary surfacing materials?) and §746.4911 of this title (relating to How should unitary surfacing materials be installed?);(9) Porches or platforms more than 20 inches in height for pre-kindergarten and younger children, and more than 30 inches in height for school-age children, must be equipped with protective barriers that surround the elevated surface except for entrances and exits and that prevent children from crawling over or through the barrier;(10) Stairs and steps on climbing equipment, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails; and(11) If you are licensed to provide care for children in a public school facility operated by the local independent school district, you must inform parents in writing at the time they enroll their child if the active play space or equipment you plan to use at the public school facility does not meet Licensing standards specified in this subchapter. Otherwise, children must not be allowed to use space or equipment that does not meet Licensing standards. Source Note: The provisions of this §746.4601 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4601 What minimum safety requirements must my active play equipment meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188548 03/12/2026 Yes. Children must not use the following types of equipment at or away from the child-care center:(1) Heavy swings made of metal or that have metal components, such as animal figure swings;(2) Equipment that allows children to fall inside the structure and onto other parts of the structure, such as certain styles of monkey bars or jungle gyms;(3) Trampolines, except those less than four feet in diameter that are no higher than 12 inches above a properly installed and maintained resilient surface;(4) Swinging exercise rings and trapeze bars on long chains or free swinging ropes;(5) Multiple occupancy swings, such as teeter-totters, gliders, or chair swings (other than tire swings); or(6) Swinging gates and giant strides. Source Note: The provisions of this §746.4603 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4603 Are there some types of equipment that children must not use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188549 03/12/2026 (a) Yes. Children younger than five years of age must not be allowed to use the following pieces of equipment at or away from the child-care center:(1) Free standing arch climbers;(2) Free standing climbing pieces with flexible parts;(3) Fulcrum seesaws;(4) Log rolls;(5) Spiral slides with more than one 360 degree turn; or(6) Track rides.(b) In addition, children younger than four years of age must not be allowed to use the following pieces of equipment at or away from the child-care center:(1) Chain or cable walks;(2) Horizontal ladders;(3) Vertical slide poles;(4) Over-head rings; or(5) Parallel bars. Source Note: The provisions of this §746.4605 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4605 Are there additional equipment restrictions for children younger than five years of age? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188550 03/12/2026 (a) The maximum height of the highest designated play surface on active play equipment is based on the age of children who will be using the equipment.(b) The maximum height allowed is as follows:(1) 32 inches for equipment designed to be used by children under the age of two years;(2) Five feet for equipment designed to be used by children younger than five; or(3) Seven feet for equipment designed to be used by children who are at least five years of age. Source Note: The provisions of this §746.4607 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4607 What is the maximum height of the highest designated play surface allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188551 03/12/2026 (a) If you were licensed before September 1, 2010, the maximum height allowed for the highest designated play surface on active play equipment is:(1) Six feet for equipment designed to be used by children younger than five years old; or(2) Eight feet for equipment designed to be used by children five years old and older.(b) If your center re-designs the existing playground or adds new playground equipment, then as the changes are made you must meet equipment height requirements specified in §746.4607 of this title (relating to What is the maximum height of the highest designated play surface allowed?). You must submit a written plan for compliance to us upon request. Source Note: The provisions of this §746.4609 adopted to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4609 What is the maximum height allowed for the highest designated play surface, if my child-care center was licensed before September 1, 2010? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188552 03/12/2026 (a) All swing seats must be constructed of durable, lightweight, rubber or plastic material.(b) Edges of all swing seats must be smooth or rounded and have no protrusions.(c) Swings must not be attached to a composite play structure. Source Note: The provisions of this §746.4701 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4701 What are the safety requirements for swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188553 03/12/2026 Yes. Bucket swings are intended for use by children under four years of age with an adult present to lift and secure the child into the swing. Therefore, the distance between the protective surfacing and the bottom of a bucket swing must be at least 24 inches. This will minimize the likelihood of unsupervised young children climbing into the swing. Source Note: The provisions of this §746.4703 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4703 Are there additional safety requirements for bucket swings designed for tots? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188558 03/12/2026 Yes. Tire swings must:(1) Not be made from heavy truck tires, or tires with exposed steel-belted radials;(2) Not be suspended from a composite structure or with other swings in the same swing bay;(3) Have drainage holes drilled in the underside of the tire and maintained to facilitate water drainage; and(4) Have a minimum clearance between the seating surface of a tire swing and the uprights of the supporting structure of 30 inches or more when the tire is in a position closest to the support structure. Source Note: The provisions of this §746.4705 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4705 Are there additional safety requirements for tire swings or other multi-axis swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188559 03/12/2026 (a) The child-care center director or designee must inspect the active play space and equipment daily before children begin play to ensure there are no hazards present.(b) The child-care center director or designee must conduct at least monthly inspections of the active play space and equipment, utilizing a general maintenance checklist or safety checklist that includes checking the equipment and surfacing material for normal wear and tear, broken or missing parts, debris or foreign objects, drainage problems, or other hazards.(c) The child-care center director or designee must ensure hazards or defects identified during inspections are removed or repaired promptly, and must arrange for protection of the children or prohibit use of hazardous equipment until the hazards can be removed or repairs can be made.(d) You must keep maintenance inspections and repair records at the child-care center for review during the center's hours of operation for at least the previous three months. Source Note: The provisions of this §746.4751 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4751 What special maintenance procedures must I follow for my active play space and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188554 03/12/2026 The use zone is the surface area under and around a piece of equipment onto which a child falling from or exiting from the equipment would be expected to land. Other than the equipment itself, the use zone must be free of obstacles that a child could run into or fall on top of and be injured. Source Note: The provisions of this §746.4801 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4801 What does Licensing mean by the term "use zone"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188555 03/12/2026 The use zone for stationary equipment, excluding slides and soft contained play equipment, must extend a minimum of six feet in all directions from the perimeter of the equipment. Use zones for stationary equipment must not overlap other use zones. Source Note: The provisions of this §746.4803 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4803 How do I measure the use zone for stationary equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188556 03/12/2026 (a) The use zone in front of the access and to the sides of a slide must extend a minimum of six feet from the perimeter of the equipment.(b) For slides six feet high or less, the use zone in front of the exit of a slide must extend at least six feet.(c) For slides greater than six feet high, the use zone in front of the exit of a slide must be equal to the distance from the slide platform to the protective surfacing up to a maximum of eight feet.(d) The use zone in front of the slide exit must not overlap the use zone of any other equipment. Source Note: The provisions of this §746.4805 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4805 How do I measure the use zone for slides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188557 03/12/2026 (a) The use zone to the front and rear of to-fro swings (single-axis swings) must extend twice the height of the vertical distance from the swing beam to the protective surfacing below.(b) The use zone to the front and rear of the to-fro swing must not overlap any other use zone.(c) The use zone around the sides of the to-fro swing structure (frame which supports the swings) must be at least six feet and may overlap the use zone of an adjacent swing structure. Source Note: The provisions of this §746.4807 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4807 How do I measure the use zone for to-fro swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188560 03/12/2026 (a) The use zone for tire swings or other multi-axis swings must extend in all directions for a distance equal to the distance from the swing beam to the top of the sitting surface of the tire, plus six feet.(b) The use zone specified is subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the tire swing support structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §746.4809 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4809 How do I measure the use zone for tire swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188561 03/12/2026 (a) The use zone to the front and rear of the bucket swing for tots must be at least two times the vertical distance from the swing beam to the top of the swing-sitting surface.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the bucket swing structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §746.4811 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4811 How do I measure the use zone for bucket swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188562 03/12/2026 (a) The use zone for rotating or rocking equipment on which the child sits must be at least six feet from the perimeter when not in use.(b) The use zone for rotating or rocking equipment or track rides on which the child stands or rides must be at least seven feet from the perimeter of the equipment when not in use.(c) The use zone for rocking and rotating equipment must not overlap any other use zone. Source Note: The provisions of this §746.4813 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4813 How do I measure the use zone for rotating or rocking equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188563 03/12/2026 (a) If you were licensed before September 1, 2003, you must at least maintain the following use zones, unless you meet one of the conditions specified in subsection (b) of this section:(1) Four feet from climbing structures;(2) Five feet from the bottom of a slide. The other parts of the slide are considered a climbing structure;(3) Seven feet plus the length of a swing's chain from the point of suspension; and(4) Seven feet from a merry-go-round or other revolving devices.(b) A child-care center licensed before September 1, 2003, must comply with the use zone requirements specified in this division, under the following circumstances:(1) A child-care center re-designs the existing playground or adds new playground equipment. The permit holder must meet use zone requirements specified in this division as the changes are made. You must submit a written plan for compliance to us upon request.(2) Your existing permit is no longer valid. Source Note: The provisions of this §746.4815 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4815 Do the use zone requirements apply to my child-care center if it was licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188564 03/12/2026 (a) There must be loose-fill surfacing material or unitary surfacing material in the use zones (area around and under equipment where resilient surfacing is needed to prevent serious injury from occurring as result of a fall) for all climbing, rocking, rotating, bouncing, or moving equipment, slides, and swings.(b) The height of the highest designated play surface on the equipment will determine the depth of loose materials or the attenuation rating (thickness) of the unitary materials. Source Note: The provisions of this §746.4901 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4901 What type of surfacing must I have under my active play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188565 03/12/2026 Loose-fill surfacing materials include, but are not limited to, loose particles such as sand, pea gravel, shredded wood products, and shredded rubber. Source Note: The provisions of this §746.4905 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4905 What are acceptable loose-fill surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188570 03/12/2026 (a) You must install and maintain loose-fill surfacing materials to a depth of:(1) At least six inches when the height of the highest designated play surface is five feet or less; and(2) At least nine inches when the height of the highest designated play surface is greater than five feet.(b) You must not install loose-fill surfacing materials over concrete or asphalt.(c) You must mark all equipment support posts to indicate the depth at which the loose-fill surfacing material must be maintained under and around the equipment.(d) You must ensure the loose-fill materials are maintained at the proper depth at all times.(e) Loose-fill surfacing materials must not be used indoors. Source Note: The provisions of this §746.4907 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective June 1, 2014, 39 TexReg 3720; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4907 How should outdoor loose-fill surfacing materials be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188566 03/12/2026 Unitary surfacing materials are manufactured materials including rubber tiles, mats, or poured-in-place materials cured to form a unitary shock-absorbing surface. Source Note: The provisions of this §746.4909 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4909 What are unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188567 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188567&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188567 03/12/2026 (a) If you use unitary materials, they must be installed and maintained according to manufacturer's specifications.(b) Unitary materials may be installed over concrete or asphalt only if recommended by the manufacturer. Source Note: The provisions of this §746.4911 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4911 How should unitary surfacing materials be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188568 03/12/2026 If you use unitary surfacing materials, you must have test data from the manufacturer showing the impact rating of the material (the maximum height of equipment that may be installed over the surfacing material), and installation and maintenance requirements. This documentation must be at the child-care center and made available for review by parents and Licensing staff upon request during hours of operation. Source Note: The provisions of this §746.4913 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4913 What documentation must I keep at the child-care center if I use unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188569 03/12/2026 Floor surfaces under indoor-climbing equipment and platforms over 20 inches in height must have a unitary shock-absorbing surface that will effectively cushion the fall of a child. The surface must be installed in the use zone and maintained according to the manufacturer's directions. See §746.4801 of this title (relating to What does Licensing mean by the term "use zone"?). Carpeting alone, even if it is installed over thick padding, is not an acceptable resilient surface. Source Note: The provisions of this §746.4915 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4915 What additional surfacing requirements must my indoor equipment meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212745 03/12/2026 Soft contained play equipment is a play structure that:(1) Is fully enclosed with pliable material such as net, plastic, or fabric;(2) The user enters to access one or more play components; and(3) Allows caregivers to supervise children as specified in §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §746.4951 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4951 What is soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188572 03/12/2026 Yes, Soft contained play equipment must also:(1) Not have to-fro, bucket, or tire swings attached inside or outside of the structure;(2) Have no more than 24 inch difference in height between two connecting platforms;(3) Have use zones as outlined in §746.4955 of this title (relating to How do I measure the use zone for soft contained play equipment?) that are free of obstacles and covered with unitary surfacing material;(4) Be installed, maintained and cleaned according to manufacturer's instructions; and(5) Include closer supervision when in use by requiring at least one caregiver to be positioned at each level of the play area. Source Note: The provisions of this §746.4953 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4953 Are there additional safety requirements for soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188573 03/12/2026 (a) The use zone for entrances and exits to the soft contained play equipment, excluding slide exits, is a minimum of five feet from all portions of the entrance and exit which are outside of the contained area of the equipment.(b) The use zone in front of slide exits must extend a minimum of five feet if the slide run-out is 36 inches or greater. If the slide run-out is less than 36 inches, the use zone at the end of the slide must be six feet. In addition, this use zone may not overlap with any other use zones.(c) Entrances and exits that terminate inside of the soft contained play equipment are exempt from use zone requirements.(d) External portions of the soft contained play equipment that contain no designated play surfaces and serve only to enclose the equipment are exempt from use zone requirements.(e) The critical height of resilient surfacing material must be equal to the highest designated play surface outside of the contained area of the equipment or one foot, which ever is greater. Source Note: The provisions of this §746.4955 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4955 How do I measure the use zone for soft contained play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220727 03/12/2026 You may use inflatable equipment both at and away from your child-care center if you follow these guidelines:(1) You use enclosed inflatables (such as bounce houses or moon bounces) according to the manufacturer's instructions;(2) You use open inflatables (such as obstacle courses, slides, or games) according to the manufacturer's label and instructions for the user; and(3) Inflatables that include water activity also comply with all applicable requirements in Subchapter V of this chapter (relating to Swimming Pools, Wading Pools, and Sprinkler Play). Source Note: The provisions of this §746.4971 adopted to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §746.4971 May I use inflatable active play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220728 03/12/2026 In addition to complying with the child/caregiver ratios specified in §746.2105 of this chapter (relating to What are the child/caregiver ratios for swimming activities?) and other safety requirements specified in §746.2109 of this chapter (relating to Must a certified lifeguard be on duty when children are swimming in more than 18 inches of water) and §746.2113 of this chapter (relating to Must persons who are counted in the child/caregiver ratio during swimming know how to swim?), you must comply with the following safety precautions when any child uses a swimming pool both at and away from your child-care center:(1) A minimum of two life-saving devices must be available;(2) One additional life-saving device must be available for each 2,000 square feet of water surface;(3) Drain grates must be in place, in good repair, and must not be able to be removed without using tools;(4) Pool chemicals and pumps must be inaccessible to any child;(5) Machinery rooms must be locked when any child is present;(6) Employees must be able to clearly see all parts of the swimming area;(7) The bottom of the pool must be visible at all times;(8) An adult must be present who is able to immediately turn off the pump and filtering system when any child is in a pool; and(9) All indoor/outdoor areas must be free of furniture and equipment that any child could use to scale a fence or barrier or release a lock. Source Note: The provisions of this §746.5001 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5001 What safety precautions must I follow when a child in my care uses a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188583 03/12/2026 Swimming pools used both at and away from the child-care center must be built and maintained according to the standards of the Texas Department of State Health Services for public pools and any other applicable state or local regulations. Source Note: The provisions of this §746.5003 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5003 How should the swimming pool be built and maintained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188584 03/12/2026 Yes. Above-ground pools must meet all pool safety requirements specified in this subchapter and must have a barrier that prevents a child's access to the pool. Source Note: The provisions of this §746.5005 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5005 Do the same safety precautions apply for above-ground pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188585 03/12/2026 (a) Yes. You must enclose a swimming pool at your child-care center with a six-foot fence or wall that prevents children's access to the pool.(b) Fence gates leading to the pool area must have self-closing and self-latching hardware out of children's reach. Gates must be locked when the pool is not in use.(c) Doors from the child-care center leading to the pool area must have a lock out of children's reach that can only be opened by an adult.(d) These doors and gates must not be designated as fire and emergency evacuation exits. Source Note: The provisions of this §746.5007 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5007 Must I have a fence around a swimming pool at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220729 03/12/2026 (a) Before a child who is unable to swim competently or who is at risk of injury or death when swimming enters a swimming pool, you must:(1) Provide the child with a Type I, II, or III United States Coast Guard approved personal flotation device (PFD);(2) Ensure the child is wearing the PFD; and(3) Ensure the PFD is properly fitted and fastened for the child.(b) A PFD must be in good repair to meet the requirements in subsection (a) of this section. Source Note: The provisions of this §746.5009 adopted to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5009 What additional safety precautions must I take for a child in care who is unable to swim competently or who is at risk of injury or death when swimming? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220730 03/12/2026 You are not required to provide the child with a PFD or ensure the child is wearing the device if:(1) The child is actively participating in swim instruction or a competition; and(2) You ensure that the child is supervised in accordance with §746.1205 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?) during the instruction or competition. Source Note: The provisions of this §746.5011 adopted to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5011 Must I provide a personal flotation device (PFD) to a child in care who is unable to swim competently or who is at risk of injury or death when swimming when the child is participating in swim instruction or a competition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220731 03/12/2026 (a) Wading pools at your child-care center must be:(1) Stored out of children's reach when not in use;(2) Drained at least daily and sanitized; and(3) Stored so they do not hold water.(b) You must comply with the safety precautions specified in §746.5001 of this subchapter (relating to What safety precautions must I follow when a child in my care uses a swimming pool?) when using wading pools away from your child-care center. Source Note: The provisions of this §746.5013 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5013 What are the safety requirements for wading pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188587 03/12/2026 (a) You must ensure that no child uses sprinkler equipment on or near a hard, slippery surface, such as a concrete driveway, sidewalk, or patio.(b) You must not leave a child alone with the sprinkler equipment.(c) You must store sprinkler equipment and water hoses out of the reach of children when not in use.(d) You must maintain your splash pad/sprinkler play area according to manufacturer's instructions. Source Note: The provisions of this §746.5015 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5015 Are there specific safety requirements for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220732 03/12/2026 You must not allow a child to swim in a body of water other than a swimming pool that complies with the rules specified in this subchapter. Source Note: The provisions of this §746.5017 adopted to be effective July 1, 2005, 30 TexReg 3598; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7354. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS V SWIMMING POOLS, WADING/SPLASHING POOLS, AND SPRINKLER PLAY §746.5017 Can a child in my care swim in a body of water other than a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188611 03/12/2026 (a) Your child-care center must have a fire inspection before we issue your initial permit and at least once every 12 months, unless your child-care center is located in a public school facility operated by the local independent school district.(b) If an inspection is required, a state or local fire marshal must conduct the inspection. If an inspection is not available, you must provide documentation of this from a state or local fire marshal or county judge. Source Note: The provisions of this §746.5101 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective January 1, 2007, 31 TexReg 9351; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5101 Must my child-care center have an annual fire inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188612 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188612 03/12/2026 If required, you must keep a copy of the most recent fire-inspection report, letter, or checklist at the child-care center during hours of operation to verify the inspection date and findings. The report must include the name and telephone number of the inspector. Source Note: The provisions of this §746.5103 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5103 How do I document that a fire inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188615 03/12/2026 Yes, you must comply with all corrections, restrictions, or conditions specified by the inspector in the fire inspection report, letter, or checklist. Source Note: The provisions of this §746.5105 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5105 Must I make all corrections specified in the fire-inspection report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188616 03/12/2026 An emergency preparedness plan is designed to ensure the safety of children during an emergency by addressing staff responsibility and facility readiness with respect to emergency evacuation, relocation, and sheltering/lock-down. The plan addresses the types of responses to emergencies most likely to occur in your area, including:(1) An evacuation of the children and caregivers to a designated safe area in an emergency such as a fire or gas leak;(2) A relocation of the children and caregivers to a designated, alternate shelter in an emergency such as a flood, a hurricane, medical emergency, or communicable disease outbreak; and(3) The sheltering and lock-down of children and caregivers within the center to temporarily protect them from situations such as a tornado, volatile person on the premises, or an endangering person in the area. Source Note: The provisions of this §746.5201 adopted to be effective December 1, 2010, 35 TexReg 10238; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5201 What is an emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188617 03/12/2026 Your emergency preparedness plan must include written procedures for:(1) Evacuation, relocation, and sheltering/lock-down of children including:(A) The first responsibility of staff in an emergency evacuation or relocation is to move the children to a designated safe area or alternate shelter known to all employees, caregivers, parents, and volunteers;(B) How children will be evacuated or relocated to the designated safe area or alternate shelter, including specific procedures for evacuating and relocating children who are under 24 months of age, who have limited mobility, or who otherwise may need assistance in an emergency, such as children who have mental, visual, or hearing impairments;(C) The staff responsibility in a sheltering/lock-down emergency for the orderly movement of children to a designated location within the center where children should gather;(D) An emergency evacuation and relocation diagram as outlined in §746.5207 of this title (relating to Must I have an emergency evacuation and relocation diagram?);(E) Name and address of the alternate shelter away from the center you will use as needed; and(F) How children in attendance at the time of the emergency will be accounted for at the designated safe area or alternate shelter.(2) Communication, including:(A) The emergency telephone number that is on file with us; and(B) How you will communicate with local authorities (such as fire, law enforcement, emergency medical services, health department), parents and us; and(3) How your staff will evacuate and relocate with the essential documentation including:(A) Parent and emergency contact telephone numbers for each child in care;(B) Authorization for emergency care for each child in care; and(C) The child tracking system information for children in care;(4) How your staff will continue to care for the children until each child has been released; and(5) How you will reunify the children with their parents as the evacuation, relocation, or sheltering/lock-down is lifted. Source Note: The provisions of this §746.5202 adopted to be effective December 1, 2010, 35 TexReg 10238; amended to be effective June 1, 2014, 39 TexReg 3720; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5202 What must my emergency preparedness plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188613 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188613 03/12/2026 (a) The director is responsible for implementing the emergency preparedness plan.(b) The director may also designate additional employees to be in charge during an emergency evacuation and relocation that occurs when the director is not at the operation. Source Note: The provisions of this §746.5204 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5204 Who must coordinate the implementation of an emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188614 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188614 03/12/2026 Yes, the following components of your center's emergency preparedness plan must be practiced as specified below:(1) You must practice a fire drill every month. The children must be able to safely exit the building within three minutes;(2) You must practice a sheltering drill for severe weather at least four times in a calendar year;(3) You must practice a lock-down drill for a volatile or endangering person on the premises or in the area at least four times in a calendar year; and(4) You must document these drills, including the date of the drill, time of the drill, and length of the time for the evacuation, sheltering, or lock-down to take place. Source Note: The provisions of this §746.5205 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5205 Must I practice my emergency preparedness plans? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188593 03/12/2026 (a) Yes. Your emergency evacuation and relocation diagram must be on file at the child-care center and must show the following:(1) A floor plan of your child-care center;(2) Two exit paths from each room, unless a room opens directly to the outdoors at ground level;(3) The designated location outside of the child-care center where all caregivers and children meet to ensure everyone has exited the child-care center safely; and(4) The designated location inside the child-care center where all caregivers and children take shelter from threatening weather.(b) You must post an emergency evacuation and relocation diagram in each room the children use. You must post the diagram near the entrance and/or exit of the room and where children and employees may easily view the diagram. Source Note: The provisions of this §746.5207 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective September 1, 2016, 41 TexReg 6240; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5207 Must I have an emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188589 03/12/2026 (a) The child-care center must have at least two exits to the outside that are located in distant parts of each building.(b) If any doors open into a fenced yard, the children must be able to open the doors easily from the inside.(c) You may not count doors that are blocked or locked as exits.(d) An exit through a kitchen or other hazardous area may not be one of the required exits unless the state or local fire marshal specifically approves in writing.(e) Doors and gates leading into a pool area may not be counted as an exit.(f) A window may be used as a designated fire exit only if all children and caregivers are physically able to exit through the window to the ground outside safely and quickly. Source Note: The provisions of this §746.5209 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5209 How many exits must my child-care center have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188590 03/12/2026 Yes. You must have a source of emergency lighting that is approved by the state or local fire marshal, or battery-powered lighting, available in each classroom in case of electrical failure. Source Note: The provisions of this §746.5211 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5211 Must I have emergency lighting in case of an emergency evacuation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188591 03/12/2026 Your child-care center must have a fire-extinguishing system. This may be a sprinkler system and/or fire extinguishers. If your center is located in a public school facility operated by the local independent school district, the fire-extinguishing system utilized by the school complies with this standard. Source Note: The provisions of this §746.5301 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5301 Must my child-care center have a fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188592 03/12/2026 The state or local fire marshal must approve a sprinkler system and/or fire extinguishers in your child-care center. If an inspection is not available, you must have at least one fire extinguisher rated 3A-40BC in the child-care center. Source Note: The provisions of this §746.5303 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5303 Who must approve my fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188594 03/12/2026 You must mount all fire extinguishers on the wall by a hanger or bracket. The top of all extinguishers must be no higher than five feet above the floor and the bottom at least four inches above the floor or any other surface. If the state or local fire marshal or the manufacturer's instructions has different mounting instructions, you must follow those instructions. All fire extinguishers must be readily available for immediate use by employees and caregivers. Source Note: The provisions of this §746.5305 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5305 Where must I mount fire extinguishers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188595 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188595 03/12/2026 (a) The director or designee must inspect them monthly. The date of the inspection and the name of the employee must be recorded.(b) Fire extinguishers must be serviced as required by manufacturer's instructions, or as required by the state or local fire marshal. Source Note: The provisions of this §746.5307 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5307 How often must I inspect and service the fire extinguisher(s)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188602 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188602 03/12/2026 The system monitoring company or the state or local fire marshal must test sprinkler systems at least annually. You must keep the most recent inspection report at the child-care center for review during hours of operation. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §746.5309 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5309 How often must I inspect a sprinkler system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188596 03/12/2026 (a) Your child-care center must have a working smoke-detection system. This may be an electronic alarm and smoke-detection system, or individual electric or battery-operated smoke detectors located in each room used by children, or both.(b) If your center is located in a public school operated by the local independent school district, the smoke detection system utilized by the school complies with this standard. Source Note: The provisions of this §746.5311 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5311 Must my child-care center have a smoke-detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188597 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188597 03/12/2026 The state or local fire marshal must approve electronic alarm and smoke-detection systems. If an inspection is not available, you must have at least one working smoke detector in each room used by children. Source Note: The provisions of this §746.5313 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5313 Who must approve my child-care center's smoke-detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188598 03/12/2026 The monitoring company or the state or local fire marshal must test an electronic smoke alarm system at least annually. You must keep documentation of the inspection at the child-care center for review during hours of operation. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §746.5315 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5315 How often must I have an electronic smoke alarm system tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188599 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188599 03/12/2026 If you use smoke detectors, they must be installed and maintained according to the manufacturer's instructions or in compliance with the state or local fire marshal's instructions. Source Note: The provisions of this §746.5317 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5317 How must smoke detectors be installed at my child-care center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188600 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188600 03/12/2026 The director or designee must test all smoke detectors monthly. The date of the test and the name of the employee who does the testing must be documented and kept at the center for review during hours of operation. Source Note: The provisions of this §746.5319 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5319 How often must the smoke detectors at my child-care center be tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188601 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188601 03/12/2026 If your child-care center uses natural or liquid propane (LP) gas, your child-care center must be inspected for gas leaks before we issue your initial permit, and once every two years after your permit is issued, unless your child-care center is located in a public school building operated by the local independent school district. Source Note: The provisions of this §746.5401 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective January 1, 2007, 31 TexReg 9351; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5401 Must my child-care center be inspected for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188603 03/12/2026 (a) If your child-care center uses natural gas, you must have your child-care center inspected for gas leaks by a licensed plumber or a gas company official.(b) If your child-care center uses liquid propane (LP)-gas, you must have your LP-gas system inspected for proper installation and leaks by a licensed LP-gas servicing company or licensed plumber who is also licensed with the LP-gas section of the Texas Railroad Commission. Source Note: The provisions of this §746.5403 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective July 1, 2005, 30 TexReg 3598; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5403 Who must conduct the inspection for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188604 03/12/2026 A written gas inspection report must show your gas system is free of leaks and must indicate the date of the inspection, as well as the name and telephone number of the inspector. You must keep the most recent inspection report on file at your child-care center. Source Note: The provisions of this §746.5405 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5405 How do I document that a gas leak inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188605 03/12/2026 Yes. You must comply with all corrections, conditions, or restrictions specified in the gas inspection report within the timeframes specified by the inspector. Source Note: The provisions of this §746.5407 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5407 Must I make all corrections specified in the gas inspection report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188606 03/12/2026 (a) Gas appliances must have metal tubing and connections, be in good repair, and free from leaks.(b) Open flame heaters (heaters where the flame can be easily touched or accessed) are prohibited.(c) Space heaters must be enclosed and have the seal of approval of a United States test laboratory or be approved by the state or local fire marshal.(d) You must safeguard floor and wall furnace grates, steam and hot water pipes, and electric space heaters so that children do not have access to them.(e) Liquid fuel heaters are prohibited.(f) Gas fuel heaters, fireplaces, and wood-burning stoves must be properly vented to the outside.(g) If you use a fireplace, wood-burning stove, or space heater, you must install a screen or guard with sufficient strength to prevent children from falling into the fire or against the stove or heater. Source Note: The provisions of this §746.5501 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5501 What steps must I take to ensure that heating devices do not present hazards to children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188607 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188607&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188607 03/12/2026 Your child-care center must be equipped with a working carbon monoxide detection system, unless it is located in a school facility that complies:(1) With the school facility standards adopted by the commissioner of education under the Education Code, §46.008; or(2) With standards adopted by the board of a local school district that are similar to those described in paragraph (1) of this section. Source Note: The provisions of this §746.5531 adopted to be effective January 1, 2004, 28 TexReg 11354; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5531 Must my child-care center have a carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188608 03/12/2026 You must install:(1) Individual electric (plug-in or hardwire) or battery-operated carbon monoxide detectors that meet Underwriters Laboratories Inc. requirements (UL-Listed); or(2) An electronic carbon monoxide detection system connected to an electronic alarm/smoke detection system that is UL-Listed. Source Note: The provisions of this §746.5533 adopted to be effective January 1, 2004, 28 TexReg 11354; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5533 What type of carbon monoxide detection system must I install? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188609 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors:(1) At least one detector must be installed on every level of each building in the child-care operation; and(2) The detector(s) must be installed in compliance with the state or local fire marshal's instructions.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, the system must be installed according to the state or local fire marshal's instructions. Source Note: The provisions of this §746.5535 adopted to be effective January 1, 2004, 28 TexReg 11354; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5535 How many carbon monoxide detectors must be installed in my child-care center and how must they be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188610 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors, you must:(1) Install a new battery in each battery-operated detector at least annually;(2) Test all detectors monthly;(3) Document the date of the test, date of installation of new batteries, and the name of the employee who does the testing and installment of new batteries; and(4) Keep this documentation at the center for review during hours of operation.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, you must:(1) Ensure the system monitoring company or the state or local fire marshal tests the system at least annually;(2) Keep the most recent inspection report at the child-care center for review during hours of operation;(3) Ensure the report includes the date of the inspection and the inspector's name and telephone number; and(4) Make any corrections required in the report. Source Note: The provisions of this §746.5537 adopted to be effective January 1, 2004, 28 TexReg 11354; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS W FIRE SAFETY AND EMERGENCY PRACTICES §746.5537 How often must I inspect and service the carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188621 03/12/2026 We regulate any transportation provided by or for the child-care center, including but not limited to, transportation between home and school, between school and the child-care center, the child-care center and home, the child-care center or school and field trip locations or other drop off locations, authorized by the parent. Source Note: The provisions of this §746.5601 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5601 What types of transportation does Licensing regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188618 03/12/2026 (a) We do not regulate the type of vehicle you use to transport children, although we recommend that you check with the Texas Department of Motor Vehicles or refer to the federal motor vehicle safety standards regulating transportation to and from school and your operation.(b) For the purpose of this chapter, we categorize vehicle types as:(1) General purpose vehicle--a passenger vehicles as defined in the Texas Transportation Code §545.412, and buses that do not meet the federal motor vehicle safety standards for school buses or multi-function school activity buses (MFSAB);(2) Small school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a gross vehicle weight rating (GVWR) of 10,000 pounds or less; and(3) Large school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a GVWR of greater than 10,000 pounds.(c) All vehicles must be maintained in safe operating condition at all times. Source Note: The provisions of this §746.5603 adopted to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5603 What type of vehicle may I use to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188619 03/12/2026 You must take the following precautions when loading and unloading children from any vehicle, including any type of bus:(1) You must load and unload children at the curbside of the vehicle or in a protected parking area or driveway.(2) You must not allow a child to cross a street unless the child is accompanied by an adult anytime before entering or after leaving a vehicle.(3) You must account for all children exiting the vehicle before leaving the vehicle unattended.(4) You must never leave a child unattended in a vehicle. Source Note: The provisions of this §746.5605 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5605 What safety precautions must I take when loading and unloading children from the vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212746 03/12/2026 (a) You must use a child passenger safety seat system to restrain a child when transporting the child. The restraint system:(1) Must meet the federal standards for crash-tested systems as set by the National Highway Traffic Safety Administration; and(2) Must be properly secured in the vehicle according to manufacturer's instructions.(b) You must use child safety seats and child booster seats that have not expired or been damaged or involved in an accident.(c) You must secure each child in an infant only rear-facing child safety seat, rear-facing convertible child safety seat, forward-facing child safety seat, child booster seat, safety vest, harness, or a safety belt, as appropriate to the child's age, height, and weight according to manufacturer's instructions for all vehicles specified in subsection (e) of this section, unless otherwise noted in this subchapter. (d) A child 12 years old or younger must not ride in the front seat of a vehicle. (e) The following safety restraint devices for a child must be used when the vehicle is on and during all times when the vehicle is in motion. Attached Graphic Source Note: The provisions of this §746.5607 adopted to be effective December 1, 2010, 35 TexReg 10238; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5607 What child passenger safety seat system must I use when I transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188622 03/12/2026 (a) The driver must be properly restrained by a safety belt before starting the vehicle and at all times the vehicle is in motion.(b) All adult passengers in a vehicle transporting children, other than a large school bus, must be properly restrained by safety belts. Source Note: The provisions of this §746.5609 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective December 1, 2010, 35 TexReg 10238; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5609 Must caregivers and/or the driver wear a safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188627 03/12/2026 Yes. Parents may provide the safety seat system for use in transporting their child, provided the equipment is appropriate and can be properly secured in the vehicle. You must use the equipment according to manufacturer's instructions. Source Note: The provisions of this §746.5611 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5611 May parents provide the safety seat equipment required for their child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188628 03/12/2026 No. Only one person may use each safety belt. Source Note: The provisions of this §746.5613 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5613 May I place more than one person in each safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188629 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188629 03/12/2026 A child may ride in a safety belt with a shoulder harness if the shoulder harness goes across the child's chest and not across the child's face or neck. The lap belt should fit low across the child's thighs or top of the legs and not across the child's stomach area. Never put a shoulder belt under the child's arm or behind the child's back. If the lap belt and shoulder harness do not fit properly, a booster seat must be used. Source Note: The provisions of this §746.5615 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5615 May a child ride in a safety belt with a shoulder harness? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188630 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188630 03/12/2026 (a) You must have the following in each vehicle you use to transport children:(1) A list of the children being transported;(2) Emergency medical transport and treatment authorization forms for each child being transported;(3) The child-care center's name, child-care center director or permit holder's name, and child-care center telephone number in the glove compartment or clearly visible inside the passenger compartment, or the child-care center's name and telephone number must be clearly visible on the outside of the vehicle;(4) Parent's names and telephone numbers and emergency telephone numbers for each child being transported;(5) A fire extinguisher approved by the local or state fire marshal, secured in the passenger compartment and accessible to the adult occupants; and(6) A first-aid kit as specified in §746.4003 of this title (relating to What items must each first-aid kit contain?).(b) The driver must have a current driver's license. Source Note: The provisions of this §746.5617 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5617 Must I carry specific equipment in vehicles used to transport children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188623 03/12/2026 Yes. You must ensure the driver/caregivers have clear instructions in handling emergency breakdowns and accidents, including vehicle evacuation procedures, supervision of the children, and contacting emergency help. The director or designee in charge of the child-care center must know what action to take in responding to a transportation emergency call. Source Note: The provisions of this §746.5619 adopted to be effective September 1, 2003, 28 TexReg 1402; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5619 Must I have a plan to handle transportation emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188624 03/12/2026 When transporting children in a vehicle:(1) The vehicle must have a communications device such as a cellular phone or two-way radio; or(2) A caregiver at the child-care center must know the routine arrival and departure times of the vehicle and take action if the vehicle does not return to the child-care center at a scheduled time. The driver must travel a known fixed route within an approximate timeframe. Source Note: The provisions of this §746.5621 adopted to be effective September 1, 2003, 28 TexReg 1402; amended to be effective April 15, 2017, 42 TexReg 1575; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5621 What communication requirements are there for a vehicle used to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188625 03/12/2026 An electronic child safety alarm is an alarm system installed in a vehicle. The alarm prompts the driver of a vehicle to inspect the vehicle to determine whether children are in the vehicle before the driver exits the vehicle. Source Note: The provisions of this §746.5623 adopted to be effective March 1, 2014, 39 TexReg 1189; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5623 What is an electronic child safety alarm? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212747 03/12/2026 (a) You must ensure that a vehicle purchased or leased on or after December 31, 2013, is equipped with an electronic child safety alarm if:(1) The vehicle is designed to seat eight or more persons; and(2) Your operation uses the vehicle to transport children in care.(b) You are responsible for ensuring that the alarm is installed and maintained according to the manufacturer's instructions.(c) The alarm must be used at all times whenever a vehicle describe in subsection (a) of this section is used to transport a child in care.(d) The driver of the vehicle or a designated employee must complete the following tasks before disabling the alarm from the rear of the vehicle:(1) Verify that all children have been accounted for; and(2) Conduct a physical walk-through and visual check of the vehicle, including the seats, seat rows, and interior, to ensure no children remain in the vehicle. Source Note: The provisions of this §746.5625 adopted to be effective March 1, 2014, 39 TexReg 1189; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 933. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5625 When and how must I install and use an electronic child safety alarm in a vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188631 03/12/2026 You must keep documentation at your child-care center that shows when your center first purchased or leased a vehicle unless it:(1) Is equipped with an electronic child safety alarm; or(2) Is not designed to seat eight or more persons. Source Note: The provisions of this §746.5627 adopted to be effective March 1, 2014, 39 TexReg 1189; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 746 MINIMUM STANDARDS FOR CHILD-CARE CENTERS X TRANSPORTATION §746.5627 What documentation must I keep at the child-care center for each vehicle used to transport children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188632 03/12/2026 The purpose of this chapter is to set forth the minimum standards that apply to child-care homes. Source Note: The provisions of this §747.101 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.101 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188633 03/12/2026 The minimum standards in this chapter apply to:(1) Child-care homes registered or licensed by us to care for 12 or fewer children in the caregiver's own home for less than 24 hours per day; and(2) Any unlicensed child-care home that requires a registration or license per the Human Resources Code, Chapter 42, because the home is providing child-care services. Source Note: The provisions of this §747.111 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.111 What types of operations do these minimum standards apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188636 03/12/2026 (a) In a registered child-care home, the registered primary caregiver provides care in the caregiver's own residence for not more than six children from birth through 13 years, and may provide care after-school hours for not more than six additional elementary school children. The total number of children in care at any given time, including the children related to the caregiver, must not exceed 12.(b) A registered child-care home includes the program, building, grounds, furnishings, and equipment. Source Note: The provisions of this §747.113 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.113 What is a registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188634 03/12/2026 (a) In a licensed child-care home, the licensed primary caregiver provides care in the caregiver's own residence for children from birth through 13 years, unless the operation was licensed as a group day care home prior to September 1, 2003.(b) A child-care home licensed as a group day care home prior to September 1, 2003, may provide care at a location other than the primary caregiver's own residence, until the permit is no longer valid. A location, other than the primary caregiver's own residence, is subject to the minimum standards in this chapter and, if applicable, the conditions specified in §745.373 of this title (relating to May I have more than one licensed child-care home?).(c) The total number of children in care varies with the ages of the children, but the total number of children in care in a licensed child-care home at any given time, including the children related to the caregiver, must not exceed 12.(d) A licensed child-care home includes the program, building, grounds, furnishings, and equipment. Source Note: The provisions of this §747.115 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.115 What is a licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188635 03/12/2026 (a) For a registered child-care home, the permit holder must ensure compliance with all minimum standards in this chapter at all times, with the exception of any minimum standard identified:(1) Only for licensed child-care homes; or(2) For specific types of child-care programs or activities the child-care home does not offer, such as transportation or swimming activities.(b) For a licensed child-care home, the permit holder must ensure compliance with all minimum standards in this chapter at all times, with the exception of any minimum standard identified:(1) Only for registered child-care homes; or(2) For specific types of child-care programs or activities the child-care home does not offer, such as transportation or swimming activities.(c) For a child-care home that is subject to Licensing's regulation under this chapter but does not have the appropriate registration or license, the owner, other person overseeing the child-care services, or controlling person who has the ability to influence or direct the home's management, expenditures, or policies must ensure compliance with all minimum standards in this chapter as described in (a) and (b) of this section. Source Note: The provisions of this §747.117 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.117 Who is responsible for complying with these minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212748 03/12/2026 The following words have the following meanings when used in this chapter:(1) I, my, you, and your--A permit holder who is the primary caregiver in a licensed or registered child-care home, unless otherwise stated.(2) We, us, our, and Licensing--The Child Care Regulation department of the Texas Health and Human Services Commission (HHSC). Source Note: The provisions of this §747.121 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.121 What do certain pronouns mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220733 03/12/2026 The words and terms used in this chapter have the meanings assigned to them under §745.21 of this title (relating to What do the following words and terms mean when used in this chapter?), unless another meaning is assigned in this section or another subchapter or unless the context clearly indicates otherwise. In addition, the following words and terms used in this chapter have the following meanings unless the context clearly indicates otherwise:(1) Activity plan--A written plan that outlines the daily routine and activities in which a group of children will engage while in your care. The plan is designed to meet the children's cognitive, social, language, emotional, and physical developmental strengths and needs.(2) Activity space--An area or room used for children's activities.(3) Administrative and clerical duties--Duties that involve the operation of a child-care home, such as bookkeeping, enrolling children, answering the telephone, and collecting fees.(4) Admission--The process of enrolling a child in a child-care home. The date of admission is the first day the child is physically present in the home.(5) Adult--A person 18 years old and older.(6) After-school hours--Hours before and after school, and days when school is not in session, such as school holidays, summer vacations, and teacher in-service days.(7) Age-appropriate--Activities, equipment, materials, curriculum, and environment that are developmentally consistent with the developmental or chronological age of the child being served.(8) Attendance--When referring to a child's attendance, the physical presence of a child at the child-care home on any given day or at any given time, as distinct from the child's enrollment in the child-care home.(9) Body of water--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D (relating to Sanitation and Safety of Facilities Used by Public).(10) Bouncer seat--A stationary seat designed to provide gentle rocking or bouncing motion by an infant's movement or by battery-operated movement. This type of equipment is designed for an infant's use from birth until the child can sit up unassisted.(11) Caregiver--A person who is counted in the child to caregiver ratio, whose duties include the supervision, guidance, and protection of a child. As used in this chapter, a caregiver must meet the minimum education, work experience, and training qualifications required under Subchapter D of this chapter (relating to Personnel).(12) Certified Child-Care Professional Credential--A credential given by the National Early Childhood Program Accreditation to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(13) Certified lifeguard--A person who has been trained in life saving and water safety by a qualified instructor, from a recognized organization that awards a certificate upon successful completion of the training. The certificate is not required to use the term "lifeguard," but you must be able to document that the certificate is current, relevant to the type of water activity in which children will engage, and representative of the type of training described.(14) CEUs--Continuing education units. A standard unit of measure for adult education and training activities. One CEU equals 10 clock hours of participation in an organized, continuing-education experience, under responsible, qualified direction and instruction. Although a person may obtain a CEU in many of the same settings as clock hours, the CEU provider must meet the criteria established by the International Association for Continuing Education and Training to be able to offer the CEU.(15) Child--An infant, a toddler, a pre-kindergarten age child, or a school-age child.(16) Child-care home--A registered or licensed child-care home, as specified in §747.113 of this chapter (relating to What is a registered child-care home?) or §747.115 of this chapter (relating to What is a licensed child-care home?). This term includes the program, home, grounds, furnishings, and equipment.(17) Child-care program--The services and activities provided by a child-care home.(18) Child Development Associate Credential--A credential given by the Council for Professional Recognition to a person working directly with children. The credential is based on assessed competency in several areas of child care and child development.(19) Clock hour--An actual hour of documented:(A) Attendance at instructor-led training, such as seminars, workshops, conferences, early childhood classes, and other planned learning opportunities, provided by an individual or individuals as specified in §747.1315(a) of this chapter (relating to Must child-care training meet certain criteria?); or(B) Self-instructional training that was created by an individual or individuals, as specified in §747.1315(a) and (b) of this chapter, or self-study training.(20) Corporal punishment--The infliction of physical pain on a child as a means of controlling behavior. This includes spanking, hitting with a hand or instrument, slapping, pinching, shaking, biting, or thumping a child.(21) Days--Calendar days, unless otherwise stated.(22) Employee--An assistant caregiver, substitute caregiver, or any other person a child-care home employs full-time or part-time to work for wages, salary, or other compensation, including kitchen staff, office staff, maintenance staff, or anyone hired to transport a child.(23) Enrollment--The list of names or number of children who have been admitted to attend a child-care home for any given period of time; the number of children enrolled in a child-care home may vary from the number of children in attendance on any given day.(24) Entrap--A component or group of components on equipment that forms angles or openings that may trap a child's head by being too small to allow the child's body to pass through, or large enough for the child's body to pass through but too small to allow the child's head to pass through.(25) Field trips--Activities conducted away from the child-care home.(26) Food service--The preparation or serving of meals or snacks.(27) Frequent--More than two times in a 30-day period. Note: For the definition of "regularly or frequently present at an operation" (child-care home) as it applies to background checks, see §745.601 of this title (relating to What words must I know to understand this subchapter?).(28) Garbage--Waste food or items that when deteriorating cause offensive odors and attract rodents, insects, and other pests.(29) Grounds-- Includes any parcel of land where the home of the primary caregiver is located and any building, other structure, body of water, play equipment, street, sidewalk, walkway, driveway, parking garage, or parking lot on the parcel. Also referred to as "premises" in this chapter.(30) Group activities--Activities that allow children to interact with other children in large or small groups. Group activities include storytelling, finger plays, show and tell, organized games, and singing.(31) Hazardous materials--Any substance or chemical that is a health hazard or physical hazard, as determined by the Environmental Protection Agency. Also referred to as "toxic materials" and "toxic chemicals" in this chapter.(32) Health check--A visual or physical assessment of a child to identify potential concerns about a child's health, including signs or symptoms of illness and injury, in response to changes in the child's behavior since the last date of attendance.(33) Health-care professional--A licensed physician, a licensed advanced practice registered nurse (APRN), a licensed vocational nurse (LVN), a licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the license. This does not include physicians, nurses, or other medical personnel who are not licensed in the United States or in the country in which the person practices.(34) High school equivalent--(A) Documentation of a program recognized by the Texas Education Agency (TEA) or other public educational entity in another state, which offers similar training on reading, writing, and math skills taught at the high school level, such as a General Educational Development (GED) certificate; or(B) Confirmation that the person received home-schooling that adequately addressed basic competencies such as basic reading, writing, and math skills, which would otherwise have been documented by a high school diploma.(35) Individual activities--Opportunities for the child to work independently or to be away from the group but supervised.(36) Infant--A child from birth through 17 months.(37) Inflatable--An amusement ride or device, consisting of air-filled structures designed for use by children, as specified by the manufacturer, which may include bouncing, climbing, sliding, or interactive play. They are made of flexible fabric, kept inflated by continuous air flow by one or more blowers, and rely upon air pressure to maintain their shape.(38) Instructor-led training--Training characterized by the communication and interaction that takes place between the student and the instructor. The training must include an opportunity for the student to interact with the instructor to obtain clarifications and information beyond the scope of the training materials. For such an opportunity to exist, the instructor must communicate with the student in a timely fashion, including answering questions, providing feedback on skills practice, providing guidance or information on additional resources, and proactively interacting with students. Examples of this type of training include classroom training, web-based online facilitated learning, video-conferencing, or other group learning experiences.(39) Janitorial duties--Those duties that involve the cleaning and maintenance of the child-care home, building, rooms, furniture, etc. Cleaning and maintenance include such duties as cleansing carpets, washing cots, and sweeping, vacuuming, or mopping a restroom or a classroom. Sweeping up after an activity or mopping up a spill in a classroom that is immediately necessary for the children's safety is not considered a janitorial duty.(40) Natural environment--Settings that are natural or typical for all children of the same age without regard to ability or disability. For example, a natural environment for learning social skills is a play group of peers.(41) Permit is no longer valid--For purposes of this chapter, a permit remains valid through the renewal process. A permit only becomes invalid when your:(A) Home voluntarily closes;(B) Home must close because of an enforcement action in Chapter 745, Subchapter L of this title (relating to Enforcement Actions);(C) Permit expires according to §745.481 of this title (relating to When does my permit expire?); or(D) Home must close because its permit is automatically revoked according to the Human Resources Code §§42.048(e), 42.052(i), or 42.054(f).(42) Personal flotation device (PFD)--A United States Coast Guard approved life jacket.(43) Physical activity (moderate)--Levels of activity for a child that are at intensities faster than a slow walk, but still allow the child to talk easily. Moderate physical activity increases the child's heart rate and breathing rate.(44) Physical activity (vigorous)--Rhythmic, repetitive physical movement for a child that uses large muscle groups, causing the child to breathe rapidly and only enabling the child to speak in short phrases. Typically, the child's heart rate is substantially increased, and the child is likely to be sweating while engaging in vigorous physical activity.(45) Pre-kindergarten age child--A child who is three or four years of age before the beginning of the current school year.(46) Premises--See the term "grounds" and its definition in this section.(47) Regular--On a recurring, scheduled basis. Note: For the definition of "regularly or frequently present at an operation" (child-care home) as it applies to background checks, see §745.601 of this title.(48) Restrictive device--Equipment that places the body of a child in a position that may restrict airflow or cause strangulation; usually, the child is placed in a semi-seated position. Examples of restrictive devices are car seats, swings, bouncy seats, and high chairs.(49) Safety belt--A lap belt and any shoulder straps included as original equipment on or added to a vehicle.(50) Sanitize--The use of a disinfecting product that provides instructions specific for sanitizing and is registered by the Environmental Protection Agency (EPA) to substantially reduce germs on inanimate objects to levels considered safe by public health requirements. Many bleach and hydrogen peroxide products are EPA-registered. You must follow the product's labelling instructions for sanitizing or disinfecting, depending on the surface (paying particular attention to any instructions regarding contact time and toxicity on surfaces likely to be mouthed by children, such as toys and crib rails). If you use bleach instead of an approved disinfecting product, you must follow these steps in order:(A) Washing with water and soap;(B) Rinsing with clear water;(C) Soaking in or spraying on a bleach solution for at least two minutes;(D) Rinsing with cool water only those items that children are likely to place in their mouths; and(E) Allowing the surface or item to air-dry.(51) School-age child--A child who is five years of age and older and is enrolled in or has completed kindergarten.(52) Screen time activity--An activity during which a child views media content on a cell or mobile phone, tablet, computer, television, video, film, or DVD. Screen time activities do not include video chatting with a child's family or assistive and adaptive computer technology used by a child with special care needs on a consistent basis.(53) Self-instructional training--Training designed to be used by one individual working alone and at the individual's own pace to complete lessons or modules. Lessons or modules commonly include questions with clear right and wrong answers. An example of this type of training is web-based training. Self-study training is also a type of self-instructional training.(54) Self-study training--Non-standardized training where an individual reads written materials, watches a training video, or listens to a recording to obtain certain knowledge that is required for annual training. Self-study training is limited to three hours of annual training per year.(55) Special care needs--A child with special care needs is a child who has:(A) A chronic physical, developmental, behavioral, or emotional condition or a disability and who also requires assistance beyond that required by a child generally to perform tasks that are within the typical chronological range of development, including the movement of large or small muscles, learning, talking, communicating, comprehension, emotional regulation, self-help, social skills, emotional well-being, seeing, hearing, and breathing; or(B) A limitation due to an injury, illness, or allergy.(56) State or local fire authority--A fire official who is authorized to conduct fire safety inspections on behalf of the city, county, or state government, including certified fire inspectors. Also referred to as "fire marshal" in this chapter.(57) Swimming Pool--An artificial body of water with a water depth of more than 18 inches that is maintained or used expressly for public or private recreational purposes, swimming, diving, aquatic sports or activities, or therapeutic purposes.(58) Toddler--A child from 18 months through 35 months.(59) Universal precautions--An approach to infection control where all human blood and certain human bodily fluids are treated as if known to be infectious for HIV, HBV, and other blood-borne pathogens.(60) Wading pool--As defined by Texas Health and Safety Code, Chapter 341, Subchapter D.(61) Water activities--Related to the use of swimming pools, wading pools, or sprinkler play.(62) Weather permitting--Weather conditions that do not pose any concerns for health and safety such as significant risk of frostbite or heat-related illness. This includes adverse weather conditions in which children may still play safely outdoors for shorter periods with appropriate adjustments to clothing and any necessary access to water, shade, or shelter. Source Note: The provisions of this §747.123 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488; amended to be effective December 21, 2022, 47 TexReg 8114; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective September 26, 2024, 49 TexReg7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES A PURPOSE, SCOPE, AND DEFINITIONS §747.123 What do certain words and terms mean when used in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188669 03/12/2026 (a) The primary caregiver is the person responsible for ensuring that the home operates in compliance with these minimum standards and the licensing laws. The primary caregiver of a licensed or registered child-care home must:(1) Live in the home where care is provided, unless the home was licensed as a group day care home prior to September 1, 2003. Refer to §747.111 of this title (relating to What is a licensed child-care home?); and(2) Be the permit holder unless the primary caregiver forms a business entity that is the permit holder for the home.(b) A permit holder licensed to operate one or more group day care homes prior to September 1, 2003, must designate, on a DFPS form, a person who meets the qualifications in §747.1101 of this title (relating to Who is required to meet the qualifications specified in this division?) to act as the primary caregiver for each licensed child-care home. This exception will not apply to an operation when the permit issued prior to September 1, 2003, is no longer valid. Source Note: The provisions of this §747.201 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; amended to be effective June 1, 2014, 39 TexReg 3724; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.201 Who is a primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188670 03/12/2026 Yes. When you are absent from the child-care home, you must designate a substitute caregiver to be in charge of the child-care home. Substitutes must:(1) Know they are in charge and for how long;(2) Know their responsibilities while in charge;(3) Have access to all essential information to communicate with parents and state and local authorities as needed; and(4) Have the authority to run the child-care home in compliance with minimum standards. Source Note: The provisions of this §747.203 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.203 As the primary caregiver, may I leave someone else in charge if I cannot be home during all hours of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188667 03/12/2026 As the primary caregiver, you must routinely be present in your child-care home during its hours of operation; however, you may be temporarily absent for limited periods of time for vacations, short-term family emergencies or family business, illness, hospitalization or doctor appointments, jury duty, to attend training, or to attend to child- care business. Source Note: The provisions of this §747.205 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.205 Must I be present at my child-care home during all hours of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212750 03/12/2026 You are responsible for:(1) Developing and implementing your child-care home's operational policies, which comply with or exceed Division 4 of this subchapter (relating to Operational Policies);(2) Ensuring all assistant caregivers and substitute caregivers comply with the relevant minimum standards for those caregivers, as specified in this chapter, and are provided assignments that match their skills, abilities, and training;(3) Ensuring all household members comply with the minimum standards that apply to household members, as specified in this chapter;(4) Reporting suspected abuse, neglect, or exploitation directly to the Texas Abuse and Neglect Hotline, as required by Texas Family Code §261.1401. You may not delegate your responsibility to make a report, and you may not require a household member or employee to seek approval to file a report or notify you that a report was made;(5) Ensuring parents can visit your child-care home any time during all hours of operation to observe their child, program activities, the home, the grounds, and the equipment, without having to secure prior approval;(6) Initiating background checks as specified in Chapter 745, Subchapter F of this title (relating to Background Checks);(7) Ensuring all information related to background checks is kept confidential and not disclosed to unauthorized persons, as required by the Human Resources Code, §40.005(d) and (e);(8) Complying with the liability insurance requirements in this division;(9) Complying with:(A) The child-care licensing law, found in Chapter 42 of the Human Resources Code;(B) All the minimum standards that apply to your licensed or registered child-care home, as specified in this chapter;(C) All other applicable laws and rules in the Texas Administrative Code; and(10) Ensuring the total number of children in care at the home or away from the home, such as during a field trip, never exceeds the capacity of the home as specified on the license or registration. Source Note: The provisions of this §747.207 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.207 What are my responsibilities as the primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204789 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit. Source Note: The provisions of this §747.209 adopted to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.209 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204790 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §747.209 of this division (relating to What are the liability insurance requirements?) if you are unable to carry the insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the home; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit. Your notification must include the reason that you cannot carry the insurance. Source Note: The provisions of this §747.211 adopted to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.211 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204791 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §747.209 of this division (relating to What are the liability insurance requirements?), then you must notify the parent of each child in your care in writing that you do not carry liability insurance before you admit the child into your care.(b) If you received your permit before April 25, 2021 and cannot obtain the liability insurance by that date, then you must notify the parent of each child in your care in writing that you do not carry the insurance by May 25, 2021.(c) If you previously carried the liability insurance and subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care in writing that you do not carry the insurance within 14 days after you stop carrying it.(d) You may use Form 2962, Verification of Liability Insurance, located on the Licensing provider website, to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parent of each child in your care, as required in §747.801(14) of this chapter (relating to What records must I keep at my child-care home?). Source Note: The provisions of this §747.213 adopted to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.213 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188671 03/12/2026 You must notify us in writing before:(1) Changing the address or location of the child-care home;(2) Adding to or reducing indoor or outdoor space;(3) Adding a swimming pool or other permanent body of water;(4) Changing the age range of children to be cared for;(5) Changing the hours, days, or months of operation;(6) Offering new services relating to minimum standards found in this chapter, such as nighttime care, transportation, or field trips;(7) Planned closure of five consecutive days or more, during designated hours of operation when the home is not caring for children, with the exception of nationally recognized holidays; or(8) Going out of business. Source Note: The provisions of this §747.301 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.301 What changes regarding my child-care home must I notify Licensing about before making the change? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212751 03/12/2026 (a) You must notify us as soon as possible, but no later than two days after:(1) Any occurrence that renders all or part of your child-care home unsafe or unsanitary for a child;(2) Injury to a child in your care that requires medical treatment by a health-care professional or hospitalization;(3) A child in your care shows signs or symptoms of an illness that requires hospitalization;(4) You become aware that a household member, caregiver, or child in care contracts an illness deemed notifiable by the Texas Department of State Health Services as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Disease);(5) A person for whom you are required to request a background check under Chapter 745, Subchapter F of this title (relating to Background Checks) is arrested or charged with a crime;(6) The occurrence of any other non-routine situation that places, or may place, a child at risk for injury or harm, such as forgetting a child in a vehicle or not preventing a child from wandering away from your child-care home unsupervised; and(7) A new individual becomes a controlling person at your operation, or an individual that was previously a controlling person ceases to be a controlling person at your operation.(b) You must notify us immediately if a child dies while in your care. Source Note: The provisions of this §747.303 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective March 1, 2012, 37 TexReg 935; amended to be effective December 1, 2012, 37 TexReg 9140; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.303 What other situations require notification to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212752 03/12/2026 (a) You must notify the parent of a child immediately if there is an allegation that the child has been abused, neglected, or exploited, as defined in Texas Family Code §261.001, while in your care.(b) After you ensure the safety of the child, you must notify the parent of the child immediately after the child:(1) Is injured and the injury requires medical treatment by a health-care professional;(2) Shows signs or symptoms of an illness that requires hospitalization;(3) Has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) Has been involved in any non-routine situation that placed, or may have placed, the child at risk for injury or harm. For example, forgetting the child in a vehicle or failing to prevent the child from wandering away from your child-care home unsupervised; or(5) Has been involved in any situation that renders the child-care home unsafe, such as a fire, flood, or damage to the child-care home as a result of severe weather.(c) You must notify the parent of less serious injuries when the parent picks the child up from your child-care home. Less serious injuries include minor cuts, scratches, and bites from other children requiring first-aid treatment by caregivers.(d) You must provide written notice to the parent of each child attending the child-care home within 48 hours when any child in your care, a caregiver, or a household member has contracted a communicable disease deemed notifiable by the Texas Department of State Health Services as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Disease).(e) You must provide written notice to the parent of each child attending the child-care home within 48 hours when there is an outbreak of lice or other infestation in the child-care home. Source Note: The provisions of this §747.305 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449; amended to be effective October 25, 2021, 46 TexReg 7219; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.305 What emergency and medical situations must I notify parents about? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212753 03/12/2026 (a) You must notify the parent of each child attending your child-care home of a deficiency in:(1) A safe sleeping standard noted in subsection (b) of this section; or(2) The abuse, neglect, or exploitation standard in §747.1501(a)(3) of this chapter (relating to What general responsibilities do caregivers have in my child-care home?).(b) The following are safe sleeping standards requiring notification:(1) §747.2309(a)(1) of this chapter (relating to What specific safety requirements must my cribs meet?);(2) §747.2311(2)(A) of this chapter (relating to Are play yards allowed?);(3) §747.2315(a)(4) and (b) of this chapter (relating to What specific types of equipment am I prohibited from using with infants?);(4) §747.2326 of this chapter (relating to May I allow infants to sleep in a restrictive device?);(5) §747.2327 of this chapter (relating to How must I position an infant for sleep?);(6) §747.2328 of this chapter (relating to May I swaddle an infant to help the infant sleep?); and(7) §747.2329 of this chapter (relating to If an infant has difficulty falling asleep, may I cover the infant's head or crib?). Source Note: The provisions of this §747.307 adopted to be effective April 25, 2021, 46 TexReg 2449; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.307 What are the notification requirements when Licensing finds my child-care home deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204795 03/12/2026 (a) Within five days after you receive notification of a deficiency described in §747.307 of this division (relating to What are the notification requirements when Licensing finds my child-care home deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child?), you must notify the parents of each child attending your child-care home at the time of the notification, including a child who may not have been in care on the day of the actual incident.(b) If the deficiency is for a safe sleeping standard, you must notify the parents using Form 2970, Notification of Safe Sleeping Deficiency, located on the Licensing provider website.(c) If the deficiency is for the standard related to the abuse, neglect, or exploitation of a child in care, you must notify the parents using Form 7266, Notification of Abuse/Neglect/Exploitation Deficiency, located on the Licensing provider website. Source Note: The provisions of this §747.309 adopted to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.309 How must I notify parents of a safe sleeping deficiency or an abuse, neglect, or exploitation deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188674 03/12/2026 (a) You must post the following in a prominent and publicly accessible place where parents and others may easily view them during all hours of operation:(1) The child-care home's license or registration certificate; (2) The letter or form from the most recent Licensing inspection or investigation;(3) The Licensing notice Keeping Children Safe; (4) Telephone numbers specified in this division; (5) A list of your employees, which must be printed on paper at least 8 1/2 inches by 11 inches in size and must include each employee's first and last name; and(6) Any other Licensing notices requiring posting.(b) For food allergies that require an emergency plan, you must either: (1) Post the list of each child's food allergies in a prominent place during all hours of operation, and if a parent requests it, you must maintain privacy for the child (for example, a clipboard hung on the wall with a cover sheet over the list); or(2) Ensure that all caregivers, employees, and household members who prepare and serve food are aware of each child's food allergies. Source Note: The provisions of this §747.401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective March 1, 2006, 31 TexReg 861; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.401 What records must I post at my child-care home during hours of operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220270 03/12/2026 (a) You must post in a prominent place the following telephone numbers:(1) 911 or, if 911 is not available in your area, you must post the telephone numbers for:(A) Emergency medical services;(B) Law enforcement; and(C) Fire department;(2) Poison control (1-800-222-1222); and(3) The Texas Abuse and Neglect Hotline (1-800-252-5400).(b) You must post in a prominent place the name, address, and telephone number for:(1) The local Child Care Regulation office; and(2) Your child-care home. Source Note: The provisions of this §747.403 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective August 19, 2024, 49 TexReg 6233. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.403 What telephone numbers and other contact information must I post and where must I post this information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220271 03/12/2026 You must develop written operational policies and procedures that at a minimum address each of the following:(1) Procedure for the release of children;(2) Illness and exclusion criteria;(3) Procedures for dispensing medication, or a statement that medication is not dispensed;(4) Procedures for handling medical emergencies;(5) Discipline and guidance policy that is consistent with Subchapter L of this title (relating to Discipline and Guidance). A copy of Subchapter L may be used for your discipline and guidance policy;(6) Safe sleep policy for infants from birth through 12 months old that is consistent with the rules in Subchapter H of this chapter (relating to Basic Requirements for Infants) that relate to sleep requirements and restrictions, including sleep positioning, and crib requirements and restrictions, including mattresses, bedding, blankets, toys, and restrictive devices;(7) Animals, if applicable;(8) Promotion of indoor and outdoor physical activity that is consistent with Subchapter F of this chapter (relating to Developmental Activities and Activity Plan). Your policies must include:(A) The duration of physical activity at your home, both indoor and outdoor;(B) The recommended clothing and footwear that will allow a child to participate freely and safely in physical activities; and(C) A plan to ensure physical activity occurs on days when extreme weather conditions prohibit or limit outdoor time.(9) Parent rights that are consistent with the rules in Division 5 of this subchapter (relating to Parent Rights);(10) Instructions on how a parent may access the:(A) Minimum standards online;(B) Texas Abuse and Neglect Hotline; and(C) HHSC website.(11) Your emergency preparedness plan;(12) Procedures for conducting health checks, if applicable;(13) Information on vaccine-preventable diseases for employees, if your licensed child-care home is not located in your own residence. The policy must address the requirements outlined in §747.3411 of this chapter (relating to What must a policy for protecting children from vaccine-preventable diseases include?); and(14) If your home maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, policies for maintenance, administration, and disposal of unassigned epinephrine auto-injectors that comply with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in Texas Administrative Code, Title 25, Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and in Texas Health and Safety Code §773.0145. Source Note: The provisions of this §747.501 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective December 1, 2012, 37 TexReg 9137; amended to be effective June 1, 2014, 39 TexReg 3724; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488; amended to be effective October 25, 2021, 46 TexReg 7219; amended to be effective August 19,2024, 49 TexReg 6233. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.501 What written operational policies must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188676 03/12/2026 Yes. On or before the date of the child's admission, the parents must sign an enrollment agreement or other similar documents, which must include at least the operational policies listed in this division. You must keep the signed document in the child's record or at least one for each family, if siblings are enrolled at the same time. Source Note: The provisions of this §747.503 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.503 Must I provide parents with a copy of my operational polices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188677 03/12/2026 When you change an operational policy or your enrollment agreement, you must notify:(1) Your caregivers of any changes:(2) The parents in writing of any changes. Parents must sign and date the updated information. You must keep the updated information in the child's record or at least one for each family; and(3) Your household members of any changes to the discipline and guidance policy, which must be documented. Source Note: The provisions of this §747.505 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.505 What must I do when I change an operational policy or an item in the enrollment agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220272 03/12/2026 A parent of a child in care has the right to:(1) Enter and examine your child-care home during its hours of operation without advance notice;(2) File a complaint against your child-care home;(3) Review your child-care home's publicly accessible records;(4) Review your child-care home's written records concerning the parent's child, as outlined in §747.601 of this chapter (relating to Who has the right to access children's records?);(5) Receive from your child-care home:(A) HHSC's inspection reports for your child-care home; and(B) Information regarding how to access your child-care home's compliance history online;(6) Have your child-care home comply with a valid court order signed by a judge that prevents another parent from visiting or removing the parent's child from your child-care home, as outlined in §747.3901 of this chapter (relating to To whom may I release a child?);(7) Be provided with contact information for Child Care Regulation, including the department's name, address, and telephone number;(8) View any video recordings of an alleged incident of abuse or neglect involving the parent's child maintained by your child-care home as long as:(A) Video recordings of the alleged incident are available;(B) The parent is not allowed to retain any portion of the video depicting a child who is not the parent's child; and(C) Your child-care home notifies in writing the parent of any other child captured in the video recording, before allowing the parent to inspect the video recording;(9) Obtain a copy of your child-care home's policies and procedures, as outlined in §747.503 of this subchapter (relating to Must I provide parents with a copy of my operational policies?);(10) Review, upon request of the parent, your:(A) Staff training records; and(B) In-house training curriculum, if any; and(11) Be free from any retaliatory action by your child-care home for exercising any of the parent's rights. Source Note: The provisions of this §747.521 adopted to be effective August 19, 2024, 49 TexReg 6233. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES B ADMINISTRATION AND COMMUNICATION §747.521 What rights does a parent of a child in care of my child-care home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188639 03/12/2026 (a) All children's records must be immediately accessible to caregivers during hours of operation for use in an emergency.(b) Parents have the right to access their own child's record during a scheduled parent conference with the primary caregiver.(c) All children's records are subject to review and/or reproduction by Licensing upon request during hours of operation. Source Note: The provisions of this §747.601 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.601 Who has the right to access children's records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188640 03/12/2026 (a) You must maintain the following records for each child enrolled in your child-care home:(1) Child-care enrollment agreement specified in §747.503 of this title (relating to Must I provide parents with a copy of my operational policies?);(2) Admission information specified in §747.605 of this title (relating to What admission information must I obtain for each child?);(3) Statement of the child's health from a health-care professional;(4) Immunization records;(5) Tuberculosis screening and testing information, if required by your regional Texas Department of State Health Services or local health authority;(6) Vision and hearing screening results, if applicable; (7) Licensing Incident/Illness Report form, if applicable;(8) Medication administration records, if applicable; and(9) A copy of any health-care professional recommendations or orders for providing specialized medical assistance to the child. In some instances, minimum standards allow for a deviation from a minimum standard with written documentation from a health-care professional. You must also maintain this written documentation in the child's record.(b) These records must at a minimum be kept at the child-care home and must be available for review during operating hours, and for the following periods of time:(1) Medication administration records for three months after administering the medication;(2) Health-care professional recommendations or orders for three months after the health-care professional has indicated that the specialized medical assistance is no longer needed; and(3) All other records noted above for three months after the child's last day in care. Source Note: The provisions of this §747.603 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective March 1, 2012, 37 TexReg 935; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.603 What records must I have for the children in my care and how long must I keep them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220734 03/12/2026 You must obtain at least the following information before admitting a child to the child-care home:(1) The child's name and birth date;(2) The child's home address and telephone number;(3) Date of the child's admission to the child-care home;(4) Name and address of parents;(5) Telephone numbers at which parents can be reached while the child is in care;(6) Name, address, and telephone number of another responsible individual (friend or relative) who should be contacted in an emergency when the parent cannot be reached;(7) Names and telephone numbers of persons other than a parent to whom the child may be released;(8) Permission for transportation, if provided, including any authorized pick-up and drop-off locations;(9) Permission for field trips, if provided;(10) Name, address, and telephone number of the child's physician or an emergency-care facility;(11) Authorization to obtain emergency medical care and to transport the child for emergency medical treatment;(12) A statement of the child's special care needs, which must include:(A) Any limitations or restrictions on the child's activities;(B) Special care the child requires, including:(i) Any reasonable accommodations or modifications;(ii) Any adaptive equipment provided for the child, including instructions for how to use the equipment; and(iii) Symptoms or indications of potential complications related to a physical, cognitive, or mental condition that may warrant prevention or intervention while the child is in care; and(C) Any medications prescribed for continuous, long-term use;(13) The name and telephone number of the school a school-age child attends;(14) Permission for a school-age child to ride a bus, walk to or from school or home, or to be released to the care of a sibling under 18 years old, if applicable;(15) The child's allergies and a completed food allergy emergency plan for the child, if applicable; and(16) Permission for participation in water activities, if provided. If you allow a child to access a swimming pool, the parent must also indicate whether the child:(A) Is able to swim competently, as defined by the American Red Cross; or(B) Requires a personal flotation device because the child is:(i) Unable to swim competently, as defined by the American Red Cross; or(ii) At risk of injury or death when swimming or otherwise accessing a body of water. Source Note: The provisions of this §747.605 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.605 What admission information must I obtain for each child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188644 03/12/2026 Yes. The parent must sign the admission information before you admit the child to your care. Source Note: The provisions of this §747.607 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.607 Must the child's parent sign the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188645 03/12/2026 (a) Yes. You must develop a procedure for regularly updating the admission information, including information on special care needs.(b) The parent must sign and date the updated information. You may use a new form or have the parent initial and date amendments to a previously signed form. You must keep the updated information in the child's record. Source Note: The provisions of this §747.609 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.609 Must I update the admission information? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188646 03/12/2026 (a) A health statement is:(1) A written statement, from a licensed health-care professional who has examined the child within the past year, indicating the child is able to take part in the child-care home's program;(2) A signed affidavit from the parent stating that medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization of which the parent is an adherent or a member; or(3) A signed statement from the parent giving the name and address of a health-care professional who has examined the child within the past year stating that the child is able to participate in the program. This must be followed by a signed statement from a health-care professional as specified in paragraph (1) of this subsection within 12 months of the date of admission.(b) You must have a health statement at your child-care home, within one week after the date of admission, for each child who does not attend pre-kindergarten or school away from the child-care home. Source Note: The provisions of this §747.611 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.611 Must I have a health statement for children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188642 03/12/2026 (a) Each child enrolled or admitted to a child-care home must meet and continue to meet applicable immunization requirements specified by the Texas Department of State Health Services (DSHS). This requirement applies to all children in the child-care home from birth through 14 years.(b) You must maintain current immunization records for each child in your care, including any immunization exemptions or exceptions.(c) All immunizations required for the child's age must be completed by the date of admission, unless:(1) The child is exempt or excepted from an immunization, and you verify the exemption or exception by the date of admission; or(2) The child is homeless or a child in foster care and is provisionally admitted for up to 30 days if evidence of immunization is not available. You should immediately refer the child to an appropriate health-care professional to obtain the required immunizations. The DSHS rule at 25 TAC §97.66 (relating to Provisional Enrollment for Students) establishes the guidelines for a provisional enrollment. Source Note: The provisions of this §747.613 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.613 What immunizations must a child in my care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188643 03/12/2026 (a) A child may be exempt from immunization requirements for a medical reason or reason of conscience, including a religious belief. To claim an exemption, the person applying for the child's admission must meet criteria specified by the Department of State Health Services (DSHS) rule at 25 TAC §97.62 (relating to Exclusions from Compliance).(b) For some diseases, a child who previously had a disease and is accordingly naturally immune from it may qualify for an exception to the immunization requirements for the disease. To claim this exception, the person applying for the child's admission must meet the criteria specified by the DSHS rule at 25 TAC §97.65 (relating to Exceptions to Immunization Requirements). Source Note: The provisions of this §747.615 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.615 What exemptions or exceptions are there concerning immunization requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188647 03/12/2026 Acceptable documentation includes:(1) A signed statement from the child's parent that the child's immunization record is current and on file at the pre-kindergarten or school that the child attends. The statement must be dated and include the name, address, and telephone number of the pre-kindergarten or school listed in the statement.(2) An official immunization record generated from a state or local health authority, including a record from another state. Examples include a record from the Texas Immunization Registry, a copy of the current immunization record that is on file at the pre-kindergarten or school that the child attends, or the health passport for a child in the conservatorship of DFPS. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses; and(C) The month, day, and year the child received each vaccination; or(3) An official immunization record or photocopy. An example includes a record from a doctor's office or a pharmacy. The record must include:(A) The child's name and date of birth;(B) The type of vaccine and number of doses;(C) The month, day, and year the child received each vaccination;(D) The signature (including a rubber stamp or electronic signature) of the health-care professional who administered the vaccine, or another health-care professional's documentation of the immunization as long as the name of the health-care professional that administered the vaccine is documented; and(E) Clinic contact information, if the immunization record is generated from an electronic health record system. Source Note: The provisions of this §747.623 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.623 What documentation is acceptable for an immunization record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188648 03/12/2026 Yes. Any child in care during hours of operation, whether the child is related to you or not, must have these records at your child-care home. Source Note: The provisions of this §747.627 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.627 Must I maintain immunization and health records on children in my care that are related to me? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188649 03/12/2026 Requirements for tuberculosis screening and testing vary across the state. If your regional Texas Department of State Health Services (DSHS) or local health authority requires tuberculosis testing for children in your area, then you must have documentation to indicate that each child in your care is free of active tuberculosis. Documentation of a TB screening is not required to be on file. If you are unsure of the requirements for your area, contact the TB program manager at the DSHS regional office nearest you. Source Note: The provisions of this §747.629 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.629 Must children in my care have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188650 03/12/2026 No. The Special Senses and Communication Disorders Act, Texas Health and Safety Code, Chapter 36, does not require a screening or a professional examination for possible vision and hearing problems for a child enrolled in a child-care home that we register. Source Note: The provisions of this §747.631 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.631 Must children in my registered child-care home have vision and hearing screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188651 03/12/2026 (a) The Special Senses and Communication Disorders Act, Texas Health and Safety Code, Chapter 36, requires a screening or a professional examination for possible vision and hearing problems for children of certain ages and grades. Refer to 25 TAC, Chapter 37, Subchapter C, (relating to Vision and Hearing Screening), for specifics on vision and hearing screening. This information may be accessed on the Internet at: www.dshs.state.tx.us/vhs/.(b) You must keep one of the following at the child-care home for each child required to be screened:(1) The individual visual acuity and sweep check results; or(2) A signed statement from the child's parent that the child's screening records are current and on file at the pre-kindergarten program or school the child attends away from the child-care home. The statement must be dated and include the name, address, and telephone number of the pre-kindergarten program or school; or(3) An affidavit stating that the vision or hearing screening conflicts with the tenets or practices of a church or religious denomination of which the affiant is an adherent or member. Source Note: The provisions of this §747.633 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.633 Must children in my licensed child-care home have vision and hearing screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188652 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188652 03/12/2026 (a) Yes. You must maintain a record of attendance for each child in your care. You may use a sign-in and sign-out log or other attendance chart.(b) You must keep attendance records for the previous three months and make them available to Licensing for review upon request. Source Note: The provisions of this §747.635 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.635 Must I keep attendance records or a sign-in and sign-out log for children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212756 03/12/2026 You must record the following information on the Licensing Incident/Illness Report Form 7239 or another form that contains at least the same information:(1) An injury to a child in care that required medical treatment by a health-care professional or hospitalization;(2) An illness that required the hospitalization of a child in care;(3) An incident where a child in care had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector;(4) An incident of a child in care or caregiver contracting a communicable disease deemed notifiable by the Texas Department of State Health Services as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases); and(5) Any other non-routine situation that placed, or may have placed, a child at risk for injury or harm, such as forgetting a child in a vehicle or not preventing a child from wandering away from the child-care home. Source Note: The provisions of this §747.701 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449; amended to be effective October 25, 2021, 46 TexReg 7219; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.701 What written records must I keep of accidents and injuries that occur at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188654 03/12/2026 Yes. You or your substitute caregiver must complete, sign, and date the form. Source Note: The provisions of this §747.705 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.705 Must someone from my child-care home sign the Incident/Illness Report form? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188655 03/12/2026 Yes. You must share a copy of the report with the child's parent and obtain the parent's signature on the report indicating the parent has reviewed it or received a copy of the report within 48 hours of when the incident occurred. Source Note: The provisions of this §747.707 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.707 Must I share a copy of the Incident/Illness Report form with the child's parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188656 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188656 03/12/2026 You must keep the form with the child's record at the child-care home while the child is in care and for at least three months after the child's last day in care. Source Note: The provisions of this §747.709 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.709 Where must I file the Incident/Illness Report form and how long must I keep it? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212757 03/12/2026 You must maintain and make the following records available for our review upon request during hours of operation. Paragraphs (8), (9), and (10) are optional, but if provided, will allow Licensing to avoid duplicating the evaluation of standards that have been evaluated by another state agency within the past year:(1) Children's records, as specified in Division 1 of this subchapter (relating to Records of Children);(2) Infant feeding instructions, as required in §747.2321 of this chapter (relating to Must I obtain written feeding instructions for children not ready for table food?), if applicable;(3) Personnel and training records, as required in §747.901 of this subchapter (relating to What information must I maintain in my personnel records?), and in §747.1327 of this chapter (relating to What documentation must I provide to Licensing to verify that caregivers have met training requirements?);(4) Menus, as required in §747.3113 of this chapter (relating to Must I post and maintain daily menus?);(5) Medication records, as required in §747.3605 of this chapter (relating to How must I administer medication to a child in my care?) if applicable;(6) Pet vaccination records, as required in §747.3703 of this chapter (relating to Must I keep documentation of vaccinations for the animals?), if applicable;(7) Safety documentation for emergency drills, fire extinguishers, smoke detectors, and emergency evacuation and relocation diagram, as required in §747.5005 of this chapter (relating to Must I practice my emergency preparedness plan?), §747.5007 of this chapter (relating to Must I have an emergency evacuation and relocation diagram?), §747.5107 of this chapter (relating to How often must I inspect and service the fire extinguisher?), §747.5115 of this chapter (relating to How often must the smoke detectors at my child-care home be tested?), and §747.5117 of this chapter (relating to How often must I have an electronic smoke alarm system tested?);(8) Most recent Texas Department of State Health Services immunization compliance review form, if applicable;(9) Most recent Texas Department of Agriculture Child and Adult Care Food Program report, if applicable;(10) Most recent local workforce board Child-Care Services Contractor inspection report, if applicable;(11) Written approval from the fire marshal to provide care above or below ground level, if applicable;(12) Most recent Licensing form certifying that you have reviewed each of the bulletins and notices issued by the United States Consumer Product Safety Commission regarding unsafe children's products and that there are no unsafe children's products in use or accessible to children in the home;(13) Documentation for all full-sized and non-full-sized cribs, as specified in §747.2309(a)(9) of this chapter (relating to What specific safety requirements must my cribs meet?);(14) Proof of current liability insurance coverage or, if applicable, that you have provided written notice to the parent of each child that you do not carry the insurance; and(15) Proof that you have notified parents in writing of deficiencies in safe sleeping and abuse, neglect, or exploitation, as specified in §747.307 of this chapter (relating to What are the notification requirements when Licensing finds my child-care home deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child?) and §747.309 of this chapter (relating to How must I notify parents of a safe sleep deficiency or an abuse, neglect, or exploitation deficiency?). Source Note: The provisions of this §747.801 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective March 1, 2010, 35 TexReg 1296; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective December 1, 2012, 37 TexReg 9137; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.801 What records must I keep at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188658 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188658 03/12/2026 (a) Unless otherwise stated in this chapter:(1) You must keep at the child-care home each record that your home is required to post or keep; and(2) These records must be kept for at least three months from the date the record was created.(b) You must keep training records for at least the current and last full training year. Source Note: The provisions of this §747.803 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.803 How long must I keep records at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219547 03/12/2026 You must keep at least the following at the child-care home for each assistant caregiver and substitute caregiver, as specified in this chapter: (1) Documentation showing the dates of the first and last day on the job; (2) Documentation showing how the caregiver meets the minimum age and education qualifications, if applicable; (3) A copy of a health card or health care professional's statement verifying the caregiver is free of active tuberculosis, if required by the regional Texas Department of State Health Services tuberculosis program or local health authority; (4) A notarized Licensing Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) as specified in Texas Human Resources Code §42.059; (5) A Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) as specified in Texas Human Resources Code §42.0563;(6) A record of training hours, including documentation required by §747.1327 of this chapter (relating to What documentation must I provide to Licensing to verify that caregivers have met training requirements?); (7) Proof of request for all background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks); (8) A copy of a photo identification; (9) A copy of the person's current driver's license if the person or caregiver transports a child in care; and (10) A statement signed and dated by the caregiver in a licensed child-care home verifying the date the caregiver attended training during orientation that includes an overview regarding the prevention, recognition, and reporting of child maltreatment, as specified in §747.1301 of this chapter (relating to What must orientation for caregivers at my child-care home include?) Source Note: The provisions of this §747.901 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective March 1, 2014, 39 TexReg 1191; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective August 14, 2024, 49 TexReg 4918. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.901 What information must I maintain in my personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188664 03/12/2026 Yes. You must keep the same personnel records specified in §747.901 of this title (relating to What information must I maintain in my personnel records?) for all household members who are used as assistant or substitute caregivers as defined in Subchapter D, Division 3 of this chapter (relating to Assistant and Substitute Caregivers), whether they are paid or unpaid. Source Note: The provisions of this §747.903 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.903 Must I keep records for my household members who are counted in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188665 03/12/2026 You must keep at least the following for each person that you are required to request a background check on, as specified in Chapter 745, Subchapter F of this title (relating to Background Checks):(1) A copy of a health card or physician's statement verifying the household member is free of active tuberculosis, if required by the regional Texas Department of State Health Services TB program or local health authority;(2) Documentation verifying orientation to the child-care home was completed; and(3) Proof of request for a DFPS Background Check. Source Note: The provisions of this §747.905 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.905 What records must I keep for my household members who are not counted in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188666 03/12/2026 You must have the following records available for review during hours of operation:(1) A copy of a health card or health-care professional's statement verifying you are free of contagious tuberculosis, if required by the regional Texas Department of State Health Services TB program or local health authority;(2) A record of your training hours; and(3) A copy of a current driver's license or other photo identification. Source Note: The provisions of this §747.909 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.909 What records must I maintain on myself? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188660 03/12/2026 We do not require you to maintain attendance records or time sheets for yourself or any other person you count in the child/caregiver ratio. Source Note: The provisions of this §747.911 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.911 Must I maintain attendance records or time sheets on caregivers that assist me? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188661 03/12/2026 You must keep records for at least three months after a caregiver's last day on the job or after the household member is no longer living in your home. Source Note: The provisions of this §747.913 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.913 How long must I keep the required records on caregivers and household members? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188662 03/12/2026 All records required to be maintained under this division are subject to our immediate review and reproduction, upon our request, during all hours of operation. Source Note: The provisions of this §747.915 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.915 May Licensing access my records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188663 03/12/2026 Yes, you may keep electronic records or a combination of paper and electronic records.(1) If you keep a combination of electronic and paper records, you must develop procedures that address what must be in the external paper file and what can be in the electronic file;(2) Children's records must be accessible to all caregivers during their work shift, changes in caregivers, and emergency evacuations; and(3) Records must be available during business hours for review by Licensing upon request. Source Note: The provisions of this §747.917 adopted to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES C RECORD KEEPING §747.917 May I keep electronic records or a combination of paper and electronic records, and what procedures must I have for these records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188679 03/12/2026 The primary caregiver of a registered child-care home, as defined in §747.201 of this title (relating to Who is a primary caregiver?) must meet the qualifications specified in this division. Source Note: The provisions of this §747.1001 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1001 Who is required to meet the qualifications specified in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188680 03/12/2026 You must meet the qualifications before we register your child-care home. Source Note: The provisions of this §747.1003 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1003 When must I meet qualifications to be a primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188681 03/12/2026 No. A registered child-care home may have only one primary caregiver. Source Note: The provisions of this §747.1005 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1005 May I have more than one primary caregiver for my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192535 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192535&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192535 03/12/2026 Except as otherwise provided in this division, you must:(1) Be at least 21 years old;(2) Have a:(A) High school diploma; or(B) High school equivalent;(3) Have a certificate of completion of the Licensing pre-application course within one year prior to your application date;(4) Meet the requirements in Subchapter F of Chapter 745 of this title (relating to Background Checks);(5) Have a current certificate of training in pediatric first aid and pediatric CPR as specified in §747.1313 of this subchapter (relating to Who must have pediatric first-aid and pediatric CPR training?);(6) Have a current record of a tuberculosis (TB) examination showing you are free of contagious TB, if required by the Texas Department of State Health Services or local health authority; and(7) Have proof of training in the following:(A) Prevention, recognition, and reporting of child maltreatment, including:(i) Factors indicating a child is at risk for abuse or neglect;(ii) Warning signs indicating a child may be a victim of abuse or neglect;(iii) Procedures for reporting child abuse or neglect; and(iv) Community organizations that have training programs available to employees, children, and parents.(B) Recognizing and preventing shaken baby syndrome and abusive head trauma;(C) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS);(D) Understanding early childhood brain development;(E) Understanding the developmental stages of children;(F) Emergency preparedness;(G) Preventing and controlling the spread of communicable diseases, including immunizations;(H) Administering medication, if applicable, including compliance with §747.3603 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(I) Preventing and responding to emergencies due to food or an allergic reaction;(J) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic;(K) Handling, storing, and disposing of hazardous materials including compliance with §747.3221 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?); and(L) Precautions in transporting children if your child-care home plans to transport a child whose chronological or developmental age is younger than nine years old. Source Note: The provisions of this §747.1007 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1007 What qualifications must I meet to be the primary caregiver of a registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188683 03/12/2026 You may be a registered caregiver if you are 18 through 20 years old, have a high school diploma or its equivalent, and one of the following:(1) A Child Development Associate or Certified Child-Care Professional credential;(2) An associate's of applied science degree in child care;(3) A community college certificate in child care;(4) A day-care administrator's credential approved by Licensing; or(5) Six college credit hours in child development and nine months' experience in a licensed child-care center or in a licensed or registered child-care home, as specified in §747.1113 of this title (relating to What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home?). Source Note: The provisions of this §747.1013 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1013 What if I am younger than 21 years old but I want to be registered? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188686 03/12/2026 Yes, however you must provide supporting information such as a copy of the diploma or letter from the school district to indicate that the education is equivalent to a high school diploma program in the United States. Documentation written in a foreign language must be translated into English. Source Note: The provisions of this §747.1015 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1015 Does education received outside of the United States count toward primary caregiver qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188687 03/12/2026 The primary caregiver of a licensed child-care home, as defined in §747.201 of this title (relating to Who is a primary caregiver?) must meet the qualifications specified in this division. Source Note: The provisions of this §747.1101 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1101 Who is required to meet the qualifications specified in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188684 03/12/2026 You must meet the qualifications before we license your child-care home. Source Note: The provisions of this §747.1103 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1103 When must I meet qualifications to be a primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188685 03/12/2026 No. A licensed child-care home may have only one primary caregiver. Source Note: The provisions of this §747.1105 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1105 May I have more than one primary caregiver for my licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212759 03/12/2026 Except as otherwise provided in this division, you must: (1) Be at least 21 years of age; (2) Have a: (A) High school diploma; or (B) High school equivalent; (3) Have a certificate of completion of the Licensing pre-application course within one year prior to your application date; (4) Meet the requirements in Subchapter F of Chapter 745 of this title (relating to Background Checks); (5) Have a current certificate of training in pediatric first aid and pediatric CPR as specified in §747.1313 of this subchapter (relating to Who must have pediatric first-aid and pediatric CPR training?); (6) Have a current record of a tuberculosis (TB) examination showing you are free of contagious TB, if required by the Texas Department of State Health Services or local health authority; (7) Have proof of training in the following: (A) Prevention, recognition, and reporting of child maltreatment, including: (i) Factors indicating a child is at risk for abuse or neglect; (ii) Warning signs indicating a child may be a victim of abuse or neglect; (iii) Procedures for reporting child abuse or neglect; and (iv) Community organizations that have training programs available to employees, children, and parents; (B) Recognizing and preventing shaken baby syndrome and abusive head trauma; (C) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); (D) Understanding early childhood brain development; (E) Understanding the developmental stages of children; (F) Emergency preparedness; (G) Preventing and controlling the spread of communicable diseases, including immunizations; (H) Administering medication, if applicable, including compliance with §747.3603 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?); (I) Preventing and responding to emergencies due to food or an allergic reaction; (J) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; (K) Handling, storing, and disposing of hazardous materials including compliance with §747.3221 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?); and (L) Precautions in transporting children if your child-care home plans to transport a child whose chronological or developmental age is younger than nine years old; and (8) Have one of the following combinations of education and experience in a licensed child-care center, or in a licensed or registered child-care home, as defined in §747.1113 of this division (relating to What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home?): Attached Graphic Source Note: The provisions of this §747.1107 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1107 What qualifications must I meet to be the primary caregiver of a licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188689 03/12/2026 (a) Only the following types of experience may be counted as experience in a licensed child-care center:(1) Experience as a director, assistant director, or as a caregiver working directly with children in a DFPS licensed or certified child-care center (or similar type of day care center that was formerly licensed, certified, or accredited by DFPS); and(2) Experience as a director, assistant director, or caregiver working directly with children in a licensed or certified child-care center in another state or country.(b) Only experience working directly with children in a DFPS licensed or registered child-care home (or in a group day-care home that was formerly licensed by DFPS) as an assistant caregiver, substitute caregiver, or primary caregiver may be counted as experience in a licensed or registered child-care home.(c) You must have obtained all work experience in a full-time capacity or its equivalent in a part-time capacity. Full-time is defined as 30 hours per week. The work experience may be paid or unpaid. Source Note: The provisions of this §747.1113 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1113 What constitutes experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188690 03/12/2026 The following types of experience may be substituted for one year of the required experience:(1) One year of full-time classroom teaching in a public or private accredited school setting in grades pre-kindergarten through third, during a customary school year;(2) Substitute or part-time classroom teaching in a public or private accredited school setting in grades pre-kindergarten through third, if the total length of time adds up to one year of full-time teaching during a customary school year; and(3) One-year of postgraduate study in child development, early childhood education, or a related field. Source Note: The provisions of this §747.1115 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1115 May other types of experience be substituted for the required experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188691 03/12/2026 Yes. To determine whether a person has sufficient experience to qualify as a primary caregiver, we may, at our own discretion, verify child-care experience and substitute child-care experience via the Internet, telephone, or mail contact with previous employer(s), or through our records. Source Note: The provisions of this §747.1117 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1117 Can Licensing verify whether someone has sufficient experience in a licensed child-care center, or in a licensed or registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188692 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the child development requirement. Courses in early childhood education, child growth and development, psychology, sociology, classroom management, child psychology, health and safety of children, elementary education related to pre-kindergarten through third grade, youth development and other similar courses may be counted if they are related to child development or the topics specified in §747.1305 of this title (relating to What topics must the annual training for caregivers include?). Abnormal psychology and secondary education courses are not recognized as child development. Source Note: The provisions of this §747.1119 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1119 What credit courses does Licensing recognize as child development? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188693 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188693 03/12/2026 Due to a large variation in credit course titles and content, it is impossible to list all courses that may be counted toward the management requirement. Management courses may include administration of a child-care facility, recreational leadership, accounting, goal and objective setting, performance planning and evaluation, management techniques, risk management and other administrative, management, or supervisory-related courses. Courses in office machines or computer training are not recognized as management. Source Note: The provisions of this §747.1121 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1121 What credit courses does Licensing recognize as management? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188694 03/12/2026 If requested by Licensing, you must provide original transcripts and supporting documentation, such as a credit course catalog description or a course syllabus or outline, to determine whether the course is recognized as child development or management. Source Note: The provisions of this §747.1123 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1123 What documentation must I provide to show that I meet the child development and management education qualifications for a primary caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212760 03/12/2026 (a) Clock hours or CEUs may only be substituted for the required college credit hours in child development and management.(b) 50 clock hours or five CEUs may be substituted for every three college credit hours required in child development and management.(c) The documentation to verify the clock hours or CEUs must be as specified in §747.1327 of this subchapter (relating to What documentation must I provide to Licensing to verify that caregivers have met training requirements?). Source Note: The provisions of this §747.1129 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1129 May I substitute clock hours or CEUs for any of the educational requirements in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212761 03/12/2026 (a) In addition to showing that you meet the minimum qualifications for a primary caregiver, you must submit the following to Licensing staff: (1) A completed Licensing Personal History Statement form specifying your education and experience; (2) An original and current Licensing Child-Care Director's Certificate form, an original college transcript, or original training certificates which verify the educational requirements. Original letters may be substituted for training certificates, provided they include the same information as specified in §747.1327 of this subchapter (relating to What documentation must I provide to Licensing to verify that caregivers have met training requirements?); and (3) Complete dates, names, addresses, and telephone numbers which support the required experience. (b) You must submit the information to us as a part of a new application for a permit. Source Note: The provisions of this §747.1131 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1131 What additional documentation must I submit to show I am qualified to be a primary caregiver of a licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188697 03/12/2026 Yes, but you must provide supporting information, such as a copy of the diploma, transcript, or letter from the school to indicate that the education is equivalent to a program in the United States. Documentation written in a foreign language must be translated into English. Source Note: The provisions of this §747.1137 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1137 Does education received outside of the United States substitute for primary caregiver qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188698 03/12/2026 No. After we evaluate this information and issue a Child-Care Director's Certificate , we will return the original documents to you along with the certificate or if a certificate is not issued, along with a letter notifying you of the decision. Source Note: The provisions of this §747.1139 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1139 Will Licensing keep the original training certificates and college transcripts I submit to obtain a Licensing Child-Care Director's Certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188699 03/12/2026 We will notify you that you do not meet minimum standard qualifications. We will give you a deadline to submit additional paperwork, or ask you to withdraw your application and re-apply after you have obtained the necessary training and experience. Source Note: The provisions of this §747.1141 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1141 What if Licensing determines I do not meet minimum standard qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188700 03/12/2026 Yes. After we determine that you meet minimum standard qualifications for a licensed primary caregiver we will issue a Licensing Child-Care Director's Certificate . The certificate verifies only that you meet minimum standard qualifications specified in §747.1107 of this title (relating to What qualifications must I meet to be the primary caregiver of a licensed child-care home?). Source Note: The provisions of this §747.1143 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1143 Will I receive a certificate verifying that I meet qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188703 03/12/2026 The Licensing Child-Care Director's Certificate will have an expiration date if you qualified under paragraph (8), options (D) or (F) in §747.1107 of this title (relating to What qualifications must I meet to be the primary caregiver of a licensed child-care home?). Otherwise, the certificate will not expire. Source Note: The provisions of this §747.1145 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1145 Will the Child-Care Director's Certificate expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188701 03/12/2026 If you qualified under paragraph (8), options (D) or (F) in §747.1107 of this title (relating to What qualifications must I meet to be the primary caregiver of a licensed child-care home?), you must maintain your credential according to the organization's requirements. You must submit to us a copy of a letter or other documentation confirming the credential is current before we can renew your Child-Care Director's Certificate. Source Note: The provisions of this §747.1147 adopted to be effective September 1, 2003, 28 TexReg 1462 ; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1147 How often must an expiring Child-Care Director's Certificate be renewed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188702 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188702 03/12/2026 We will give you a deadline to submit the required documentation. If you allow the Child-Care Director's Certificate to expire without submitting the required documentation confirming that your credential is current, then your home will no longer meet the minimum standards related to primary caregiver qualifications. Source Note: The provisions of this §747.1149 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1149 What happens if my Child-Care Director's Certificate expires? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188704 03/12/2026 No. We do not charge a fee for processing a Licensing Child-Care Director's Certificate . Source Note: The provisions of this §747.1151 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1151 Does Licensing charge a fee for issuing the director's certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188705 03/12/2026 Yes. We will issue a replacement Child-Care Director's Certificate, if you submit your request to us in writing, specifying:(1) Your name and address; (2) The date we issued the original certificate; and (3) The reason a replacement certificate is needed. Source Note: The provisions of this §747.1153 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1153 Can I get a replacement Child-Care Director's Certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188706 03/12/2026 There are two kinds of caregivers: assistant caregivers and substitute caregivers. Source Note: The provisions of this §747.1201 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1201 What types of caregivers may I use in my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188707 03/12/2026 (a) An assistant caregiver is counted in the child/caregiver ratio and assists in the care and supervision of children. An assistant caregiver may not be left to supervise and care for children without the primary caregiver or a substitute caregiver being present in the child-care home at the same time.(b) A substitute caregiver is the caregiver you leave in charge of your child-care home in your absence. You must give the substitute caregiver the authority to administer your child-care home in compliance with the minimum standards and the Licensing law in your absence. Your substitute caregiver may also be counted in the child/caregiver ratio. Source Note: The provisions of this §747.1203 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1203 What is the difference between an assistant caregiver and a substitute caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219546 03/12/2026 A person must meet the following qualifications to be an assistant caregiver who is counted in the child/caregiver ratio: (1) Be 18 years old, except as provided by §747.1211 of this division (relating to When may I employ a person under the age of 18 or a person who does not have a high school diploma or equivalent as a caregiver?); (2) Except as provided by §747.1211 of this division, have a: (A) High school diploma; (B) High school equivalent; or (C) High school certificate of coursework completion, as defined in Texas Education Code §28.025(d); (3) Have completed orientation to your child-care home; (4) Meet the requirements in Chapter 745, Subchapter F of this title (relating to Background Checks); (5) Have a current record of a tuberculosis (TB) examination showing the caregiver is free of contagious TB, if required by the Texas Department of State Health Services or local health authority; (6) Complete a notarized Licensing Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) before you allow the person to be an assistant caregiver, as specified in Human Resources Code §42.059; and(7) Complete a Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) before you allow the person to be an assistant caregiver, as specified in Texas Human Resources Code §42.0563. Source Note: The provisions of this §747.1207 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective August 14, 2024, 49 TexReg 4918. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1207 What minimum qualifications must an assistant caregiver meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192538 03/12/2026 A person must meet the following qualifications in order to be a substitute caregiver who is counted in the child/caregiver ratio:(1) Comply with all of the minimum qualifications for an assistant caregiver, as specified in §747.1207 of this division (relating to What minimum qualifications must an assistant caregiver meet?); and(2) Have training in pediatric first aid and pediatric CPR as required by §747.1313 of this subchapter (relating to Who must have pediatric first-aid and pediatric CPR?). Source Note: The provisions of this §747.1209 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1209 What minimum qualifications must a substitute caregiver meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188710 03/12/2026 (a) You may employ a 16 or 17 year old who has a high school diploma or its equivalent as an assistant caregiver, provided that:(1) The person is never in charge of an individual child, never has sole responsibility for a group of children, and does not act as the substitute caregiver in your absence;(2) The person works close by and is supervised by you or a qualified caregiver; and(3) The person has completed a child-care-related career program, which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes eight hours of annual training before being placed in a room with children.(b) You may employ a 16, 17, or 18 year old who attends high school but has not graduated as an assistant caregiver, provided that:(1) The person is never in charge of an individual child, never has sole responsibility for a group of children, and does not act as the substitute caregiver in your absence;(2) The person works close by and is supervised by you or a qualified caregiver;(3) The person is currently enrolled in or has completed a child-care-related career program which:(A) The Texas Education Agency (including a charter school), the Texas Private School Accreditation Commission, other similar educational entity in another state, or federal agency approves; or(B) A home-school approves, and the person completes eight hours of annual training before being placed in a room with children; and(4) The person is expected to obtain a high school diploma or equivalent. Source Note: The provisions of this §747.1211 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1211 When may I employ a person under the age of 18 or a person who does not have a high school diploma or equivalent as a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188711 03/12/2026 Yes, however, you must provide supporting information such as a copy of the diploma or letter from the school district to indicate that the education is equivalent to a high school diploma program in the United States. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §747.1213 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1213 Does education received outside of the United States count toward caregiver qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192540 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192540&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192540 03/12/2026 Orientation for caregivers at your child-care home must include at least the following:(1) An overview of the minimum standards found in this chapter;(2) An overview of your operational policies, including discipline and guidance practices and procedures for the release of children, and the provision of copies of these practices and procedures;(3) An overview regarding the prevention, recognition, and reporting of child maltreatment, including:(A) Factors indicating a child is at risk of abuse or neglect;(B) Warning signs indicating a child may be a victim of abuse or neglect;(C) Procedures for reporting child abuse or neglect; and(D) Community organizations that have training programs available to child-care staff, children, and parents;(4) An overview of your home's Emergency Preparedness Plan;(5) Locating and using fire extinguishers and first-aid equipment;(6) Recognizing and preventing shaken baby syndrome and abusive head trauma;(7) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS);(8) Understanding early childhood brain development;(9) Understanding the developmental stages of children;(10) Preventing and controlling the spread of communicable diseases, including immunizations;(11) Administering medication, if applicable, including compliance with §747.3603 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(12) Preventing and responding to emergencies due to food or an allergic reaction;(13) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic;(14) Handling, storing, and disposing of hazardous materials including compliance with §747.3221 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?); and(15) Precautions in transporting children if your child-care home transports a child whose chronological or developmental age is younger than nine years old. Source Note: The provisions of this §747.1301 adopted to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1301 What must orientation for caregivers at my child-care home include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220735 03/12/2026 You must make sure that each caregiver has the training within the timeframe required in the following chart:Attached Graphic Source Note: The provisions of this §747.1303 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1303 What training must I ensure that my caregivers have within certain timeframes? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220736 03/12/2026 (a) Each caregiver counted in the child/caregiver ratio on more than ten separate occasions in one training year, as specified in §747.1311 of this division (relating to When must the annual training be obtained?) must obtain annual training relevant to the age of the children for whom the caregiver provides care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum; and(4) Teacher-child interaction.(c) If your home provides care for a child younger than 24 months, one hour of the annual training hours must cover all the following topics:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development.(d) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §747.3603 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §747.3221 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(e) The remaining annual training hours must be in one or more of the following topics:(1) Care of children with special needs;(2) Child health (for example, nutrition and physical activity);(3) Safety;(4) Risk management;(5) Identification and care of ill children;(6) Cultural diversity for children and families;(7) Professional development (for example, effective communication with families and time and stress management);(8) Topics relevant to the particular ages of children in care (for example, caregivers working with infants or toddlers should receive training on biting and toilet training);(9) Planning developmentally appropriate learning activities;(10) Observation and assessment;(11) Attachment and responsive care giving; and(12) Minimum standards and how they apply to the caregiver.(f) For an assistant caregiver or substitute caregiver described in §747.1303(3)(B) of this division (relating to What training must I ensure that my caregivers have within certain timeframes?), at least three of the required 15 annual training hours must come from instructor-led training. The remaining 12 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(g) For an assistant caregiver or substitute caregiver described in §747.1303(4)(B) of this division, at least five of the required 24 annual training hours must come from instructor-led training. The remaining 19 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(h) Annual training is exclusive of any requirements for orientation, pediatric first aid and pediatric CPR training, transportation safety training, water safety training, and any training received through a high school child-care work-study program. Source Note: The provisions of this §747.1305 adopted to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1305 What areas of training must the annual training for substitute and assistant caregivers cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220737 03/12/2026 (a) You must obtain at least 30 clock hours of training each year relevant to the age of the children for whom you provide care.(b) At least six clock hours of the annual training hours must be in one or more of the following topics:(1) Child growth and development;(2) Guidance and discipline;(3) Age-appropriate curriculum; and(4) Teacher-child interaction.(c) If your home provides care for children younger than 24 months, one hour of the annual training hours must cover all the following topics:(1) Recognizing and preventing shaken baby syndrome;(2) Understanding and using safe sleep practices and preventing sudden infant death syndrome (SIDS); and(3) Understanding early childhood brain development.(d) While there are no clock hour requirements for the topics in this subsection, the annual training hours must also include training on the following topics:(1) Emergency preparedness;(2) Preventing and controlling the spread of communicable diseases, including immunizations;(3) Administering medication, if applicable, including compliance with §747.3603 of this chapter (relating to What authorization must I obtain before administering a medication to a child in my care?);(4) Preventing and responding to emergencies due to food or an allergic reaction;(5) Understanding building and physical premises safety, including identification and protection from hazards that can cause bodily injury such as electrical hazards, bodies of water, and vehicular traffic; and(6) Handling, storing, and disposing of hazardous materials including compliance with §747.3221 of this chapter (relating to Must caregivers wear gloves when handling blood or bodily fluids containing blood?).(e) If you have:(1) Five or fewer years of experience as a primary caregiver in a licensed or registered child-care home, you must complete at least six of the annual training hours in management techniques, leadership, or staff supervision; or(2) More than five years of experience as a primary caregiver in a licensed or registered child-care home, you must complete at least three of the annual training hours in management techniques, leadership, or staff supervision.(f) The remainder of annual training hours must be selected from the training topics specified in §747.1305(e) of this chapter (relating to What areas of training must the annual training for substitute and assistant caregivers cover?).(g) You may obtain clock hours or CEUs from the same sources as other caregivers.(h) You may not earn training hours by presenting training to other caregivers.(i) At least six of the required 30 annual training hours must come from instructor-led training. The remaining 24 required annual training hours may come from self-instructional training, of which no more than three hours may come from self-study training.(j) The 30 clock hours of annual training are exclusive of any requirements for the Licensing pre-application course, pediatric first aid and pediatric CPR training, transportation safety training, and water safety training. Source Note: The provisions of this §747.1309 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective March 1, 2010, 35 TexReg 1296; amended to be effective March 1, 2012, 37 TexReg 935; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effectiveSeptember 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1309 What areas of training must the annual training for the primary caregiver cover? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188717 03/12/2026 (a) The annual training for a primary caregiver must be obtained within 12 months from the date you are registered or licensed with us and during each subsequent 12-month period.(b) The annual training for each assistant caregiver and substitute caregiver must be obtained within 12 months from the date of the caregiver's employment and during each subsequent 12-month period.(c) If a caregiver obtains more than the minimum number of annual training clock hours required, the caregiver may not carry the additional hours over to the next year. Source Note: The provisions of this §747.1311 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1311 When must the annual training be obtained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192543 03/12/2026 (a) The primary caregiver, each substitute caregiver, and each assistant caregiver must have a current certificate of training with an expiration or renewal date in:(1) Pediatric first aid with rescue breathing and choking; and(2) Pediatric cardiopulmonary resuscitation (CPR).(b) The pediatric CPR:(1) Must adhere to the guidelines for CPR for a layperson established by the American Heart Association, and consist of a curriculum that incudes use of a CPR manikin and both written and hands-on skill-based instruction, practice, and testing; and(2) May be provided through blended learning that utilizes online technology, including self-instructional training, as long as the criteria in paragraph (1) of this subsection is met. Source Note: The provisions of this §747.1313 adopted to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1313 Who must have pediatric first-aid and pediatric CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192544 03/12/2026 (a) If the home transports children whose chronological or developmental age is younger than nine years old, two clock hours of annual transportation safety training is required for:(1) Each employee prior to transporting a child; and(2) The primary caregiver.(b) The two clock hours of transportation safety training are exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §747.1314 adopted to be effective March 1, 2010, 35 TexReg 1296; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1314 What additional training must an employee and caregiver have if the home transports children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188719 03/12/2026 (a) Training may include clock hours or CEUs provided by:(1) A training provider registered with the Texas Early Childhood Professional Development System Training Registry, maintained by the Texas Head Start State Collaboration Office;(2) An instructor who teaches early childhood development or another relevant course at a secondary school or institution of higher education accredited by a recognized accrediting agency;(3) An employee of a state agency with relevant expertise;(4) A physician, psychologist, licensed professional counselor, social worker, or registered nurse;(5) A person who holds a generally recognized credential or possesses documented knowledge relevant to the training the person will provide;(6) The primary caregiver who has demonstrated core knowledge in child development and caregiving; and:(A) The primary caregiver only provides training to the caregivers at your home; and(B) Your home has not been on probation, suspension, emergency suspension, or revocation in the two years preceding the training or been assessed an administrative penalty in the two years preceding the training; or(7) A person who has at least two years of experience working in child development, a child development program, early childhood education, a childhood education program, or a Head Start or Early Head Start program and:(A) Has a current Child Development Associate (CDA) credential; or(B) Holds at least an associate's degree in child development, early childhood education, or a related field.(b) Training may include clock hours or CEUs obtained through self-instructional materials, if the materials were developed by a person who meets one of the qualifications in subsection (a) of this section.(c) Instructor-led and self-instructional training, but not self-study training, must include:(1) Specifically stated learning objectives;(2) A curriculum, which includes experiential or applied activities;(3) An evaluation/assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(4) A certificate of successful completion from the training source. Source Note: The provisions of this §747.1315 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective March 1, 2012, 37 TexReg 935; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1315 Must child-care training meet certain criteria? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188720 03/12/2026 No. We do not approve or endorse training resources or trainers for training hours. But you must ensure you and your caregivers receive training that:(1) Meets the criteria specified in §747.1315 of this title (relating to Must child-care training meet certain criteria?);(2) Is relevant to the topics specified in this division; and(3) The participants receive original documentation of completion, as specified in this division. Source Note: The provisions of this §747.1317 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1317 Does Licensing approve training resources or trainers for training hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188725 03/12/2026 Yes. If the training is in a topic specified in this division and you can provide documentation of completion as specified in this division, then you may count this training toward the annual training requirement. Source Note: The provisions of this §747.1319 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1319 If I am attending, or I have a caregiver who is attending, a college or Child Development Associate/Certified Child-Care Professional credential program, may I count these clock hours toward the annual training requirement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188722 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188722 03/12/2026 Training received at another operation can be applied towards the annual training requirement, if:(1) The caregiver provides documentation of training, as specified in §747.1327 of this title (relating to What documentation must I provide to Licensing to verify that training requirements have been met?);(2) The caregiver obtained the training from a child-care center, school-age or before or after-school program, or child-care home that we license or register; and(3) The training was obtained within two months before coming to work for your child-care home. Source Note: The provisions of this §747.1321 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1321 If I hire a caregiver that received training at another operation, may these hours count towards the annual training requirement at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220738 03/12/2026 (a) If the child-care home allows a child to access a swimming pool at or away from the home, annual water safety training is required for:(1) Each substitute or assistant caregiver prior to accompanying a child to a swimming pool; and(2) The primary caregiver.(b) The training must be specific to water safety in and around swimming pools.(c) Water safety training is exclusive of any requirements for orientation, pre-service training, and annual training. Source Note: The provisions of this §747.1323 adopted to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1323 What additional training must an employee and caregiver have if the child-care home allows a child to access a swimming pool at or away from the home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192545 03/12/2026 (a) You must maintain the original certificate or letter documenting the completion of annual training in each caregiver's personnel record at the child-care home.(b) For annual training to be counted toward compliance with the minimum standards, the trainer or training source must provide the participant with an original certificate or letter showing:(1) The participant's name;(2) Date of the training;(3) Title/subject of the training;(4) The trainer's name, or the source of the training for self-instructional training;(5) The trainer's qualifications, in compliance with §747.1315 of this division (relating to Must child-care training meet certain criteria?); and(6) Length of the training specified in clock hours, CEUs, or college credit hours, as appropriate.(c) For pediatric first aid with rescue breathing and choking and pediatric CPR to count toward compliance with the minimum standards:(1) The certificate or letter must include:(A) The same information required in subsection (b) of this section; and(B) The expiration or renewal date of the training, as determined by the organization providing the training; and(2) You must maintain:(A) The original certificate or letter documenting the completion of the pediatric first aid and pediatric CPR in each caregiver’s personnel record at the home; or(B) A photocopy of the original certificate or letter documenting the completion of the pediatric first aid and pediatric CPR in each caregiver's personnel record at the home, so long as the caregiver is able to provide an original certificate or letter upon Licensing' s request.(d) For orientation, you must obtain a signed and dated statement from the caregiver and the person providing the orientation stating the caregiver has received the orientation, or you may obtain an original statement or letter as specified in subsection (b) of this section. Source Note: The provisions of this §747.1327 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective March 1, 2004, 29 TexReg 1424; amended to be effective March 1, 2012, 37 TexReg 935; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1327 What documentation must I provide to Licensing to verify that caregivers have met training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188724 03/12/2026 (a) For each household member that is 14 years of age or older the member must:(1) Have a current record of a tuberculosis (TB) examination showing the caregiver is free of contagious TB, if required by the Texas Department of State Health Services or local health authority; and(2) Complete orientation to your child-care home as specified in §747.1403 of this title (relating to What must orientation for household members at my child-care home include?).(b) Any household member who is counted in the child/caregiver ratio on more than ten separate occasions in one training year, whether paid or unpaid, must meet the minimum qualifications for assistant caregivers and training requirements for caregivers as specified in this subchapter.(c) Any household member who is left in charge of the child-care home in the absence of the primary caregiver, whether paid or unpaid, must meet the minimum qualifications for a substitute caregiver and training requirements for caregivers specified in this subchapter.(d) A household member who is 14 years of age or older, but is not regularly or frequently present at the child-care home while children are in care, must never be left alone with a child in care, unless the household member meets the qualifications requirements for caregivers specified in this chapter. Source Note: The provisions of this §747.1401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1401 Must members of my household meet specific qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192546 03/12/2026 The orientation for household members at your child-care home must include at least the following:(1) An overview of your home's child-care policies, including discipline and guidance practices and the procedures for the release of children, and the provision of copies of these practices and procedures;(2) An overview of symptoms of child maltreatment and the responsibility for reporting these;(3) The procedures to follow in handling emergencies. Emergencies include fire, explosion, tornado, toxic fumes, volatile individuals, and severe injury or illness of a child or adult; and(4) The location and use of fire extinguishers and first-aid equipment. Source Note: The provisions of this §747.1403 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1403 What must orientation for household members at my child-care home include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188726 03/12/2026 The minimum qualifications and training requirements for volunteers or any other person under contract with the home are the same as those specified in §747.1401 of this title (relating to Must members of my household meet specific qualifications?). Source Note: The provisions of this §747.1405 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1405 What are the minimum qualifications and training requirements for volunteers or any other person under contract with the home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212768 03/12/2026 (a) You and all other caregivers are responsible for seeing that children are:(1) Treated with courtesy, respect, acceptance, and patience;(2) Recognized and respected for their uniqueness as an individual;(3) Not abused, neglected, or exploited; and(4) Released only to a parent or a person designated by a parent.(b) You and all other caregivers must report suspected abuse, neglect, or exploitation to DFPS as specified in Texas Family Code §261.101.(c) You and all other caregivers must also:(1) Demonstrate competency, good judgment, and self-control in the presence of children;(2) Know and comply with the minimum standards specified in this chapter;(3) Supervise children at all times, as specified in §747.1503 of this division (relating to What responsibilities does a caregiver have when supervising a child or children?);(4) Be free from other activities not directly involving the teaching, care, and supervision of children, such as:(A) Administrative and clerical duties that take the caregiver's attention away from the children;(B) Janitorial duties; and(C) Personal use of electronic devices, such as cell phones, MP3 players, and video games. Cell phones may be briefly used for necessary phone calls, as long as appropriate supervision is maintained;(5) Provide care that is consistent with the child's habits, interests, strengths, and any special needs, including any special supervision needs or care as outlined in §747.2107 of this chapter (relating to What are my responsibilities when planning activities for a child in care with special care needs?);(6) Interact with children in a positive manner; and(7) Set appropriate behavior expectations based on the child's current stage of development. Source Note: The provisions of this §747.1501 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1501 What general responsibilities do caregivers have in my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212769 03/12/2026 (a) The caregiver is responsible for:(1) Knowing which children the caregiver is responsible for;(2) Knowing how many children the caregiver is responsible for;(3) Knowing each child's name and having information showing each child's age;(4) Providing the level of supervision necessary to ensure each child's safety and well-being, including physical proximity and auditory or visual awareness of each child's on going activity as appropriate; and(5) Being able to intervene when necessary to ensure each child's safety.(b) In deciding how closely to supervise a child, the caregiver must take into account:(1) The child's chronological age;(2) The child's current stage of development;(3) The child's individual differences and abilities;(4) The indoor and outdoor layout of the operation;(5) The circumstances, hazards, and risks surrounding the child; and(6) The child's physical, mental, emotional, and social needs. Source Note: The provisions of this §747.1503 adopted to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES D PERSONNEL §747.1503 What responsibilities does a caregiver have when supervising a child or children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188748 03/12/2026 The child/caregiver ratio is the maximum number of children one caregiver may be responsible for. Source Note: The provisions of this §747.1601 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1601 What is child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188730 03/12/2026 In determining child/caregiver ratio, the following apply:(1) The total number of children you may supervise is determined by the ages of the children in the child-care home.(2) You may use the developmental or emotional age, rather than the chronological age, of a child with special care needs, if this is recommended by a health-care professional or a qualified professional and is documented in the child's record.(3) All children present, including children related to you, assistant and substitute caregiver's children, and drop-in and part-time children must be counted in the child/caregiver ratio, by age of the child, regardless of the length of time they are present.(4) You must also count neighborhood children visiting your child-care home, if you are responsible for their care and supervision in the absence of the parent.(5) In a registered child-care home, you may count a child who is at least four years of age and attending a pre-kindergarten program during the customary school day in the same way children five years old and older who are in care after school hours are counted. The pre-kindergarten program must be operated by or in collaboration with the local school district. Source Note: The provisions of this §747.1603 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1603 How do I determine child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188731 03/12/2026 No. The total number of children in care must never exceed 12, and may be fewer than 12 depending on the ages of the children in the child-care home. This number includes all children present in the child-care home and any children in your care away from the child-care home, such as those on a field trip or being transported. Source Note: The provisions of this §747.1605 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1605 May I ever care for more than 12 children in my registered or licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188732 03/12/2026 No. You may not reduce the number of caregivers while children are napping. Source Note: The provisions of this §747.1607 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1607 May I reduce the number of caregivers supervising children during naptime? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188733 03/12/2026 No. You may not reduce the number of caregivers supervising the children during opening and closing times. Source Note: The provisions of this §747.1609 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1609 May I adjust the child/caregiver ratio when I am opening and closing my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188734 03/12/2026 There must not be more children in your registered child-care home at the same time than is shown in the following chart: Attached Graphic Source Note: The provisions of this §747.1701 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1701 How many children may I care for in my registered child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188735 03/12/2026 If your child-care home is registered, you may not increase the number of children in care if two or more caregivers are caring for the children. Source Note: The provisions of this §747.1703 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1703 If I have an additional caregiver present to supervise children in my registered child-care home, may I care for more children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188736 03/12/2026 There must not be more children in your licensed child-care home at the same time than is shown in the following chart:Attached Graphic Source Note: The provisions of this §747.1801 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1801 How many children may I care for in my licensed child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188740 03/12/2026 If your child-care home is licensed, then the following child/caregiver ratio and maximum group size applies when two caregivers are caring for the children: Attached Graphic Source Note: The provisions of this §747.1803 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1803 If I have an additional caregiver present to supervise children in my licensed child-care home, may I care for more children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188741 03/12/2026 If your child-care home is licensed and more than two caregivers are present caring for the children, then you may care for 12 children of any age from birth through 13 years. Source Note: The provisions of this §747.1805 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1805 Must I limit the ages of children in care if there are three or more caregivers present? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188742 03/12/2026 (a) When children are on a field trip and are mixing with children and adults who are not from your child-care home, including but not limited to, trips to the skating rink, shopping, public park, or amusement park, you must meet the following child/caregiver ratio: Attached Graphic(b) The child/caregiver ratio for field trips may include adult volunteers or household members who are not qualified as caregivers only for trips when children are mixing with children and adults who are not from your child-care home, as long as you maintain at least the regular ratio for your registered or licensed child-care home, as applicable, with qualified caregivers. (c) You must maintain the regular child/caregiver ratio specified in this subchapter for registered and licensed child-care homes, as applicable, when children are on a field trip in an enclosed controlled area, including but not limited to, events planned only for your group such as library story time, tours of the fire department, or on a walk in the neighborhood. Source Note: The provisions of this §747.1901 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1901 Do I need additional caregivers when I take children away from my licensed or registered child-care home for field trips or walks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188737 03/12/2026 (a) You must have one caregiver in addition to the driver if you transport more than four children who are younger than 24 months.(b) When you transport children two years and older, you must comply with the regular child/caregiver ratio. The driver may be counted in this ratio if the driver meets the caregiver qualifications. Source Note: The provisions of this §747.1903 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.1903 If I provide transportation, how many caregivers must I have in the vehicle to supervise the children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220739 03/12/2026 (a) Whenever children use a wading pool, you must use the child/caregiver ratio for wading activities for all children in care. (b) If there is more than one child under 24 months in care, a second adult must be present. (c) The maximum number of children one caregiver can supervise while children use a wading pool is based on the age of the youngest child in the group and is specified in the following chart: Attached Graphic Source Note: The provisions of this §747.2001 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2001 Must I have additional caregivers for wading activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220740 03/12/2026 (a) When your child-care home uses a swimming pool and four or more children are swimming, there must be at least two caregivers present supervising the children who are swimming. (b) The maximum number of children one caregiver can supervise while children are swimming is based on the age of the youngest child in the group. You must use the following child/caregiver ratio for swimming activities: Attached Graphic Source Note: The provisions of this §747.2005 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2005 What are the child/caregiver ratios for swimming activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220741 03/12/2026 A certified lifeguard must be on duty at all times when children are swimming in more than 18 inches of water. Source Note: The provisions of this §747.2009 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2009 Must I have a certified lifeguard on duty when children are swimming in more than 18 inches of water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188745 03/12/2026 (a) You must not count the certified lifeguard in the child/caregiver ratio when people other than the children from your child-care home are swimming.(b) If only children from your child-care home are swimming, you may count the certified lifeguard in the child/caregiver ratio, although the lifeguard must never be left alone with any of the children unless the lifeguard is also a qualified caregiver for your child care home. Source Note: The provisions of this §747.2011 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2011 May I count the certified lifeguard in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220742 03/12/2026 Each caregiver included in the child/caregiver ratio for swimming in 18 inches or more of water must be able to swim and must be prepared to do so in an emergency. Source Note: The provisions of this §747.2013 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2013 Must persons who are counted in the child/caregiver ratio during swimming know how to swim? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220743 03/12/2026 You may include adult volunteers and adult household members who do not meet the minimum qualifications for caregivers specified in Subchapter D of this chapter (relating to Personnel) to meet the child/caregiver ratio for swimming and wading activities, provided that:(1) You maintain at least the child/caregiver ratios required in Division 2 of this subchapter (relating to Regular Ratios and Group Sizes in the Registered Child-Care Home), or Division 3 of this subchapter (relating to Regular Ratios and Group Sizes in the Licensed Child-Care Home), as applicable, with caregivers who do meet the minimum qualifications for caregivers;(2) All persons included in the ratios for water activities must be able to swim and must be prepared to do so in an emergency; and(3) You ensure compliance with all other minimum standards, including, but not limited to, standards relating to supervision, discipline, and guidance. Source Note: The provisions of this §747.2015 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2015 May I include volunteers or household members who do not meet minimum qualifications for caregivers in the child/caregiver ratio for water activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188743 03/12/2026 We do not require additional caregivers for sprinkler play; however, you must not leave a child alone with the sprinkler equipment. Source Note: The provisions of this §747.2017 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES E CHILD/CAREGIVER RATIOS AND GROUP SIZES §747.2017 Must I have additional caregivers for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212766 03/12/2026 You must provide a planned program of activities designed to meet the individual needs and developmental levels of the children in the group. Source Note: The provisions of this §747.2101 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2101 What must I consider when providing planned activities for the children in my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204140 03/12/2026 (a) You must develop and follow a written activity plan that complies with §747.2103 of this subchapter (relating to What must a written activity plan include?).(b) The activity plan must include all children in the group regardless of special care needs. Source Note: The provisions of this §747.2102 adopted to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2102 What written activity plans must I follow? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204141 03/12/2026 (a) A written activity plan must:(1) List the dates (daily, weekly, or monthly) the plan covers;(2) Outline the specific daily activities, as required by §747.2104 of this subchapter (relating to What specific activities must I include in a written activity plan?);(3) Include sufficient time for activities and routines so that children can progress at their own developmental rate; and(4) Not include long waiting periods between activities or prolonged periods during which children stand or sit.(b) A written activity plan may include one or more screen time activities, as specified in §747.2105 of this subchapter (relating to May I use a screen time activity with a child?), if you also include alternative activities for children who do not want to participate. Source Note: The provisions of this §747.2103 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2103 What must a written activity plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204142 03/12/2026 (a) You must include these daily activities in your written activity plan:(1) A minimum of two daily opportunities for outdoor play, weather permitting, in which a child makes use of both small and large muscles;(2) A balance of active and quiet play that incorporates group and individual activities both indoors and outdoors;(3) Child-initiated activities where:(A) The equipment, materials, and supplies are within reach of the child; and (B) The child chooses the activity on the child's own initiative;(4) Caregiver-initiated activities that the caregiver directs or chooses, at least two of which must promote movement;(5) Regular meal and snack times as specified in Subchapter Q of this Chapter (relating to Nutrition and Food Service); and(6) Supervised naptimes or rest times. (b) Your written activity plan must also include the approximate times that each child may engage in outdoor play and moderate to vigorous active play, as provided in Figure 26 TAC §747.2104(b).Attached Graphic(c) Children in your care must be able to engage in outdoor and active play for the times provided in subsection (b) of this section if your home:(1) Has more than one caregiver; or(2) Only cares for one age range of children described in subsection (b)(1) and (b)(2) of this section. For example, if your home does not care for an infant birth through 12 months of age, you must allow the children in your care to engage in outdoor play for 60 total minutes.(d) If your home only has one caregiver and cares for more than one age range of children described in subsection (b)(1) and(b)(2) of this section, children in care must engage in outdoor and active play for the time required for the younger age group. Source Note: The provisions of this §747.2104 adopted to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2104 What specific activities must I include in a written activity plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204143 03/12/2026 (a) You may not use a screen time activity for a child under the age of two years.(b) You may use a screen time activity to supplement, but not to replace, an activity with a child who is two years old or older that is described in §747.2407 of this chapter (relating to What activities must I provide for a toddler?), §747.2507 of this chapter (relating to What activities must I provide for a pre-kindergarten age child?), and §747.2607 of this chapter (relating to What activities must I provide for a school-age child?).(c) If you use a screen time activity for a child at your home, you must ensure that the activity:(1) Is related to the planned activities that meet educational goals;(2) Is age-appropriate;(3) Does not exceed one hour per day;(4) Is not used during mealtime, snack times, naptimes, or rest times;(5) Does not include advertising or violence; and(6) Is turned off when not in use.(d) A school-age child may use screen time without restriction for homework. Source Note: The provisions of this §747.2105 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2105 May I use a screen time activity with a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212767 03/12/2026 You must:(1) Provide a child with special care needs with the accommodations recommended by:(A) A health-care professional; or(B) A qualified professional affiliated with the local school district or early childhood intervention program;(2) Utilize as recommended any adaptive equipment that has been provided to the home for a child's use;(3) Ensure that a child who receives early intervention services or special education services can receive those services from a qualified service provider at your home, with parental request and approval;(4) Ensure that activities integrate children with and without special care needs; and(5) Ensure that caregivers adapt equipment and procedures and vary methods as necessary to ensure that you care for a child with special needs in a natural environment. Source Note: The provisions of this §747.2107 adopted to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES F DEVELOPMENTAL ACTIVITIES AND ACTIVITY PLAN §747.2107 What are my responsibilities when planning activities for a child in care with special care needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188753 03/12/2026 Basic care for infants must include:(1) Individual attention given to each infant including playing, talking, cuddling, and holding;(2) Holding and comforting an infant who is upset;(3) Prompt attention given to physical needs, such as feeding and diapering;(4) Talking to infants as they are fed, changed, and held, such as naming objects, singing, or saying rhymes; and(5) Ensuring objects less than 1 and 1/4 inches in diameter are kept out of the reach of infants or toddlers. Source Note: The provisions of this §747.2301 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2301 What are the basic care requirements for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188754 03/12/2026 The room arrangement of the infant care area must:(1) Make it possible for caregivers to see and/or hear infants and be able to intervene when necessary;(2) Include safe, open, floor space for floor time play;(3) Have cribs far enough apart so that one infant may not reach into another crib; and(4) Provide caregivers enough space to walk and work between cribs, cots, and mats. Source Note: The provisions of this §747.2303 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2303 How must I arrange the space where I care for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212774 03/12/2026 Furnishings and equipment for infants must include at least the following:(1) An individual crib to sleep in for each non-walking infant younger than 12 months of age;(2) An individual crib, cot, bed, or mat that is waterproof or washable for each:(A) Walking infant; and(B) Non-walking infant 12 months of age or older;(3) A sufficient number of toys to keep the infants engaged in activities. Source Note: The provisions of this §747.2305 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2305 What furnishings and equipment must I have available for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188758 03/12/2026 If the manufacturer requires safety straps on a chair, swing, stroller, infant carrier, bouncer seat, or similar type of equipment, then the safety straps must be fastened whenever a child is using the equipment. Source Note: The provisions of this §747.2307 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2307 Must the equipment I use for infants be equipped with safety straps? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188759 03/12/2026 (a) All full-size and non-full-size cribs must have:(1) A firm, flat mattress that snugly fits the sides of the crib and that is specifically designed for use with the crib model number. The mattress must not be supplemented with additional foam material or pads;(2) Sheets that fit snugly and do not present an entanglement hazard;(3) A mattress that is waterproof or washable;(4) Secure mattress support hangers, and no loose hardware, or improperly installed or damaged parts;(5) A maximum of 2 3/8 inches between crib slats or poles;(6) No corner posts over 1/16 inch above the end panels;(7) No cutout areas in the headboard or footboard that would entrap an infant's head or body;(8) Drop gates, if present, which fasten securely and cannot be opened by a child; and(9) Documentation that each crib meets the applicable federal rules at Title 16, Code of Federal Regulations, Parts 1219 or 1220, concerning "Safety Standards for Full-Size Baby Cribs" and "Safety Standards for Non-Full-Size Baby Cribs," respectively, or documentation that each crib is a medical device listed and registered with the U.S. Food and Drug Administration.(b) You must sanitize each crib when soiled and before another infant uses the crib.(c) You must never leave an infant in a crib with the drop gate down. Source Note: The provisions of this §747.2309 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2012, 37 TexReg 9137; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2309 What specific safety requirements must my cribs meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188755 03/12/2026 You may use a play yard, which is a mesh or fabric sided crib, if it meets the following safety requirements:(1) The play yards must be used according to the manufacturer's instructions, including the cleaning of the play yard;(2) Play yards must have:(A) A firm, flat mattress that snugly fits the sides of the play yard and that is designed by the manufacturer specifically for the play yard model number. The mattress must not be supplemented with additional foam material or pads;(B) Sheets that fit snugly and do not present an entanglement hazard;(C) A mattress that is waterproof or washable;(D) Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts;(E) A minimum height of 22 inches from the top of the railing to the mattress support at its lowest level;(F) Folded sides that securely latch in place when raised;(G) For play yards that have mesh sides, mesh openings that are 1/4 inch or less; and(H) Mesh or fabric that is securely attached to the top rail, side rail, and floor plate; and(3) You must never leave an infant in a play yard with a side folded down. Source Note: The provisions of this §747.2311 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2311 Are play yards allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188756 03/12/2026 You may use a stacking wall crib that meets the requirements specified in §747.2309 of this title (relating to What specific safety requirements must my cribs meet?), and you:(1) Do not stack more than two cribs;(2) Only use a stacked crib for an infant who cannot stand or is able to stand without hitting the infant's head on either the top crib or the ceiling above the top crib;(3) Use the crib according to manufacturer's directions; and(4) Securely latch the crib's doors/gates anytime an infant is in the crib. Source Note: The provisions of this §747.2313 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2313 Are stacking wall cribs allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212775 03/12/2026 (a) You may not use the following equipment for infants, which has been identified as unsafe for infants by the Consumer Product Safety Commission and the American Academy of Pediatrics:(1) Baby walkers, which are devices that allow an infant to sit inside a walker equipped with rollers or wheels and move across the floor;(2) Baby doorway jumpers, which are devices that allow an infant to bounce while supported in a seat by an elastic "bungee cord" suspended from a doorway;(3) Accordion Safety gates; and(4) Bean bags, waterbeds, and foam pads used as sleeping equipment.(b) Except for a tight-fitting sheet and as provided in subsection (c) of this section, the crib or play yard must be bare for an infant younger than twelve months of age.(c) A crib mattress cover may also be used to protect against wetness, but the cover must:(1) Be designed specifically for the size and type of crib and crib mattress that it is being used with;(2) Be tight fitting and thin; and(3) Not be designed to make the sleep surface softer. Source Note: The provisions of this §747.2315 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2012, 37 TexReg 9137; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2315 What specific types of equipment am I prohibited from using with infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204144 03/12/2026 Daily activities for an infant must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §747.2104 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Multiple opportunities to explore that ensure the infant is:(A) Outside of the crib; and(B) Not seated in any restrictive device for more than 15 minutes, unless the infant is eating or being transported;(3) Opportunities for physical activity, including supervised tummy time, reaching, grasping, pulling up, creeping, crawling, and walking in a safe, clean, uncluttered area;(4) Opportunities for visual stimulation through nonverbal communication. Examples of age-appropriate equipment include large pictures of faces and familiar objects; simple, soft, washable books and toys; unbreakable mirrors or mobiles attached to cribs visible from the baby's position; and brightly patterned crib sheets;(5) Opportunities for auditory stimulation. Examples of age-appropriate equipment or activities include verbal communication, soothing music, and musical or sounding toys;(6) Opportunities for sensory stimulation. Examples of age-appropriate equipment include surfaces, fabrics, textured toys, washable dolls, and toy animals;(7) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include busy boxes, rattles, teethers, grasping toys, shaking or squeezing toys, or cloth toys; and(8) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include blankets or quilts for floor or supervised tummy time, crib and play gyms, variety of light-weight balls, or pillows or supportive equipment for those learning to sit up. Source Note: The provisions of this §747.2317 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2317 What activities must I provide for an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209258 03/12/2026 When an infant is positioned for tummy time activities, you must:(1) Ensure that you can see and hear the infant;(2) Move the infant into another position as necessary to maintain the infant's comfort and safety; and(3) If the infant has fallen asleep, move the infant immediately to the infant's crib and position the infant on the infant's back as required by §747.2327 of this subchapter (relating to Are infants required to sleep on their backs?). Source Note: The provisions of this §747.2318 adopted to be effective June 13, 2022, 47 TexReg 3466. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2318 What are the requirements when an infant is engaged in tummy time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188762 03/12/2026 Yes. You must:(1) Hold infants who are unable to sit unassisted in a high chair or other seating equipment while feeding them;(2) Not prop or support bottles with some object. The infant or an adult must hold the bottle;(3) Provide regular snack and meal times for infants who eat table food;(4) Ensure infants no longer being held for feeding are fed in a safe manner;(5) Label, color-code or otherwise distinguish among bottles and training cups used by different infants;(6) Never allow infants to walk around with or sleep with a bottle or training cup;(7) Never use the bathroom sink or diaper-changing surface for food preparation, or for washing food service/preparation equipment, bottles, pacifiers, or toys; and(8) Sanitize high chair trays before each use. Source Note: The provisions of this §747.2319 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2319 Are there specific requirements for feeding infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188763 03/12/2026 (a) For an infant who is not ready for table food, you must obtain and follow written feeding instructions that are signed and dated by the infant's parent or health-care professional.(b) You must review and update the feeding instructions with the parent every 30 days until the infant is able to eat table food. Source Note: The provisions of this §747.2321 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2321 What written, feeding instructions must I obtain for an infant not ready for table food? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212770 03/12/2026 Each infant must have a nap period that:(1) Allows the infant to maintain his or her own pattern of sleeping and waking periods; and(2) Is supervised by the caregiver to ensure auditory or visual awareness of the infant in accordance with §747.1503 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §747.2323 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2323 What are the requirements regarding a regularly scheduled naptime for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212771 03/12/2026 An infant must sleep:(1) In a designated crib, cot, bed, or mat as required by §747.2305 of this subchapter (relating to What furnishings and equipment must I have available for infants?); and(2) In an area where the caregiver has auditory or visual awareness of the infant. Source Note: The provisions of this §747.2324 adopted to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2324 Where must an infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188769 03/12/2026 An infant may remain in the crib for up to 30 minutes after awakening, as long as the infant is content and responsive. Source Note: The provisions of this §747.2325 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2325 How long are infants allowed to remain in their cribs after awakening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212772 03/12/2026 (a) If you do not have a Sleep Exception Form that includes a signed statement from a health-care professional stating that the child sleeping in a restrictive device is medically necessary:(1) You may not allow an infant to sleep in a restrictive device; and(2) If an infant falls asleep in a restrictive device, you must remove the infant from the device and place the infant in a crib as soon as possible.(b) You may allow an infant to sleep in a restrictive device if you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that the infant sleeping in a restrictive device is medically necessary. Source Note: The provisions of this §747.2326 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2326 May I allow infants to sleep in a restrictive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212773 03/12/2026 (a) You must place an infant in a face-up sleeping position in the infant's own crib, unless you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that a different sleeping position for the infant is medically necessary.(b) An infant who is developmentally able to roll from back to stomach and stomach to back may do so independently after you have placed the infant in a face-up position for sleep. Source Note: The provisions of this §747.2327 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2327 How must I position an infant for sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188766 03/12/2026 You may not lay a swaddled infant down to sleep or rest on any surface at any time, unless you have a completed Sleep Exception Form that includes a signed statement from a health-care professional stating that swaddling the infant for sleeping purposes is medically necessary. Source Note: The provisions of this §747.2328 adopted to be effective June 1, 2014, 39 TexReg 3724; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2328 May I swaddle an infant to help the infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188767 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188767&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188767 03/12/2026 No. Infants must not have their heads, faces, or cribs covered by items such as blankets, linens, or clothing at any time. Source Note: The provisions of this §747.2329 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2329 If an infant has difficulty falling asleep, may I cover the infant's head or crib? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188770 03/12/2026 No, you are not required to provide a daily written report to the infant's parent. Source Note: The provisions of this §747.2331 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES H BASIC CARE REQUIREMENTS FOR INFANTS §747.2331 Must I share a daily report with parents for each infant in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188775 03/12/2026 Basic care for toddlers must include:(1) Routines such as diapering, feeding, sleeping, and indoor and outdoor activity times maintained as closely as possible;(2) Individual attention given to each toddler including playing, talking, and cuddling;(3) Holding and comforting a toddler who is upset; and(4) Ensuring objects less than 1 and 1/4 inches in diameter are kept out of the reach of infants or toddlers. Source Note: The provisions of this §747.2401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES I BASIC CARE REQUIREMENTS FOR TODDLERS §747.2401 What are the basic care requirements for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212776 03/12/2026 The toddler care area must include:(1) Spaces in the child-care home that allow both individual and group time; and(2) A play environment that allows the caregiver to supervise all children as defined in §747.1503 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §747.2403 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES I BASIC CARE REQUIREMENTS FOR TODDLERS §747.2403 How must I arrange the space where I care for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188777 03/12/2026 Furnishings and equipment for toddlers must include at least the following:(1) Age-appropriate nap or rest equipment;(2) Enough popular items are available so that toddlers are routinely engaged in either solitary or parallel play;(3) Containers or low shelving that are accessible to toddlers, so toddlers can safely obtain the items without adult intervention; and(4) Bottles and training cups if used, must be:(A) Labeled with the toddler's first name and initial of last name or otherwise individually assigned to each toddler;(B) Cleaned and sanitized between each use; and(C) Used for drinking and feeding, and you must never allow toddlers to sleep with or walk around with a bottle or training cup. Source Note: The provisions of this §747.2405 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES I BASIC CARE REQUIREMENTS FOR TODDLERS §747.2405 What furnishings and equipment must I provide for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204145 03/12/2026 Daily activities for a toddler must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §747.2104 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include shape or item sorting toys, stacking or nesting toys, puzzles with less than six pieces, washable board books, washable blocks, snapping and take apart toys;(3) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include large-size washable crayons and markers, variety of paper and art materials, table or easel for art, large paintbrushes, non-toxic play-dough, toddler-sized washable cars and trucks, toy animals, and toy people;(4) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include low climbing structures, small riding toys, toys for pushing or pulling, variety of light-weight balls for indoor and outdoor play, and rhythm instruments;(5) Opportunities for moderate to vigorous active play, both indoors and outdoors, as specified in §747.2104 of this chapter. Examples of age-appropriate activities include music, songs, simple games and dramatic or imaginary play that encourage movement such as dancing, running, climbing, stretching, walking, and marching;(6) Opportunities for language development. Examples of age-appropriate equipment or activities include washable, soft animals or puppets, simple picture books, and pictures of familiar items and places;(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dress-up clothes and accessories, housekeeping equipment, unbreakable mirrors, washable dolls with accessories, items for practicing buttoning, zipping, lacing, and snapping, and baskets, tubs, and tote bags (not plastic bags) for carrying and toting; and(8) Opportunities to develop self-help skills such as toileting, hand washing, and self-feeding. Source Note: The provisions of this §747.2407 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES I BASIC CARE REQUIREMENTS FOR TODDLERS §747.2407 What activities must I provide for a toddler? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212777 03/12/2026 Basic care for pre-kindergarten age children must include:(1) Routines such as diapering or toileting, eating, napping or resting, indoor activity times, and outdoor activity times;(2) Individual attention given to each pre-kindergarten age child; and(3) Interactions that encourage a child to communicate and express feelings in appropriate ways. Source Note: The provisions of this §747.2501 adopted to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §747.2501 What are the basic care requirements for pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188782 03/12/2026 The pre-kindergarten age care area(s) must include:(1) Space to set up interest centers or focused play areas during the activity, such as arts and crafts, music and movement, blocks and construction, drama and theater, math and reasoning activities, science and nature, language and reading activities, such as books, story tapes and language games, stories read or told on a weekly basis, and cultural awareness, which are:(A) Organized for independent use by children; and(B) Arranged so the children's activities are visible to the supervising caregiver;(2) Space for furnishings and activities without limiting children's movement; and(3) Space that children are allowed to find or create individual activities, but which still permits the caregiver to easily supervise. Source Note: The provisions of this §747.2503 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §747.2503 How must I arrange the space used by pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188783 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188783&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188783 03/12/2026 Furnishings and equipment for pre-kindergarten age children must include at least the following:(1) Age-appropriate nap or rest equipment;(2) Enough popular items are available so that pre-kindergarten age children are routinely engaged in either solitary, parallel, or group play;(3) Containers or low shelving so items children can safely use without direct supervision are accessible to children. Source Note: The provisions of this §747.2505 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §747.2505 What furnishings and equipment must I provide for pre-kindergarten age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204146 03/12/2026 Daily activities for a pre-kindergarten age child must include at least the following:(1) Opportunities for outdoor play, weather permitting, as specified in §747.2104 of this chapter (relating to What specific activities must I include in a written activity plan?);(2) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include sand and water play, blocks, framed puzzles with up to 30 pieces, variety of large stringing beads, and simple board games;(3) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include large non-toxic crayons, markers, paint, water colors and various size brushes, adjustable easels, collage materials, chalkboard and chalk, clay or dough and tools, workbench and accessories, round-end scissors, glue and paste, different types of music and videos, rhythm instruments, and fingerplays;(4) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include small wagons, light-weight balls of all sizes, small wheelbarrows, tricycles, push toys, swings, slides, climbing equipment, balance beam, hanging bars, and outdoor building materials;(5) Opportunities for moderate to vigorous active play, both indoors and outdoors, as specified in §747.2104 of this chapter. Examples of age-appropriate active play include active games such as tag and hot potato, dancing and creative movement to music and singing, simple games and dramatic or imaginary play that encourages running, stretching, climbing, walking, and marching;(6) Opportunities for language development. Examples of age-appropriate equipment or activities include flannel board stories, puppets, and variety of storybooks, writing materials, and stories on tape;(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dress up clothes and accessories, mirrors, dolls, simple props for different themes, puppets, transportation toys, toy animals, and table games; and(8) Opportunities to develop self-help skills such as toileting, hand washing, returning equipment to storage areas or containers, and serving and self-feeding. Source Note: The provisions of this §747.2507 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES J BASIC CARE REQUIREMENTS FOR PRE-KINDERGARTEN AGE CHILDREN §747.2507 What activities must I provide for a pre-kindergarten age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188785 03/12/2026 Basic care requirements for school-age children must include:(1) Individual attention and conversation with adults; and(2) Physical care routines appropriate to each child's developmental needs. Source Note: The provisions of this §747.2601 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §747.2601 What basic care requirements must I provide for school-age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212778 03/12/2026 The school-age care area must include:(1) Space to set up interest centers or focused play areas during the activity, such as arts and crafts; music and movement; blocks and construction; drama and theater; math and reasoning activities; science and nature; language and reading activities, such as books, story tapes and language games, stories read or told on a weekly basis, and cultural awareness, which are:(A) Organized for independent use by children; and(B) Arranged so that the caregiver can supervise the children according to §747.1503 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?);(2) Space where children can have individual activities yet be supervised; and(3) Space for quiet time to do homework. Source Note: The provisions of this §747.2603 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §747.2603 How must I arrange the space used by school-age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188787 03/12/2026 Furnishings and equipment for school-age children must include:(1) Workspace to do homework and table-top activities;(2) Age-appropriate nap or rest equipment; and(3) Containers or shelving to make items accessible to the children and the items can be used safely without direct supervision. Source Note: The provisions of this §747.2605 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §747.2605 What furnishings and equipment must I provide for school-age children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204147 03/12/2026 Daily activities for a school-age child must include at least the following:(1) Study time for those who choose to do homework;(2) Opportunities for outdoor play, weather permitting;(3) Opportunities for thinking skills and sensory development. Examples of age-appropriate equipment or activities include sand and water play; construction materials and blocks; puzzles with 50 or more pieces; pattern-making materials, such as wood, paper, plastic, beads, ceramic tiles, cloth, or cardboard; games that contain rules and require some skill or strategy; specific skill development materials such as rulers, tape measures, telescopes, weather observation equipment, models of the solar system, and microscopes; books; and magazines;(4) Opportunities for small-muscle development. Examples of age-appropriate equipment or activities include art and craft materials, such as paints, markers, colored pencils, crayons, clay, weaving, or braiding materials; music and musical instruments of all types; and puzzles or interlocking building blocks;(5) Opportunities for large-muscle development. Examples of age-appropriate equipment or activities include balls and sports equipment, such as kick balls, baseballs, soccer balls, basketballs, skates, and horseshoes; riding equipment, such as kick scooters or skateboards, with knee pads, elbow pads, and helmets; and outdoor and gym equipment, such as slides, swings, climbing apparatus, and upper-body equipment;(6) Opportunities for active play both indoors and outdoors. Examples of age-appropriate active play include active games such as tag and Simon Says, dancing and creative movement to music and singing, simple games, and dramatic or imaginary play that encourages running, stretching, climbing, and walking; and(7) Opportunities for social and emotional development. Examples of age-appropriate equipment or activities include dolls with detailed, realistic accessories; role-play materials, including real equipment for library, hospital, post office, costumes, makeup, and disguise materials; puppets and puppet show equipment; transportation toys, such as small vehicles or models; play and art materials; nature materials; and human and animal figurines. Source Note: The provisions of this §747.2607 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES K BASIC CARE REQUIREMENTS FOR SCHOOL-AGE CHILDREN §747.2607 What activities must I provide for a school-age child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188779 03/12/2026 Discipline must be:(1) Individualized and consistent for each child;(2) Appropriate to the child's level of understanding;(3) Directed toward teaching the child acceptable behavior and self-control; and(4) A positive method of discipline and guidance that encourages self-esteem, self-control, and self-direction, including the following:(A) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;(B) Reminding a child of behavior expectations daily by using clear, positive statements;(C) Redirecting behavior using positive statements; and(D) Using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more than one minute per year of the child's age. Source Note: The provisions of this §747.2703 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES L DISCIPLINE §747.2703 What methods of discipline and guidance may I use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212779 03/12/2026 There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:(1) Corporal punishment or threats of corporal punishment;(2) Punishment associated with food, naps, or toilet training;(3) Grabbing or pulling on a child;(4) Putting anything in or on a child's mouth;(5) Humiliating, ridiculing, rejecting, or yelling at a child;(6) Subjecting a child to harsh, abusive, or profane language;(7) Placing a child in a locked or dark room, bathroom, or closet;(8) Placing a child in a restrictive device for time out;(9) Withholding active play or keeping a child inside as a consequence for behavior, unless the child is exhibiting behavior during active play that requires a brief supervised separation or time out that is consistent with §747.2703(4)(D) of this subchapter (relating to What methods of discipline and guidance may I use?); and(10) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age. Source Note: The provisions of this §747.2705 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES L DISCIPLINE §747.2705 What types of discipline and guidance or punishment are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188789 03/12/2026 You must provide a supervised nap or rest period for all children 18 months of age or older who are in care for five or more consecutive hours or according to the child's individual physical needs. You may provide a supervised nap or rest period for each child who attends the child-care home for fewer than five hours and whose individual physical needs call for a nap or rest period while the child is in care. Source Note: The provisions of this §747.2801 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2801 Must children have a naptime every day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188790 03/12/2026 The nap or rest period must not exceed three hours. Source Note: The provisions of this §747.2803 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2803 How long may the nap or rest period last each day? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188791 03/12/2026 No. You must not:(1) Force a child to sleep, or put anything in or on a child's head or body to force the child to rest or sleep; or(2) Confine a child in a restrictive device in an attempt to make the child rest or sleep. Source Note: The provisions of this §747.2805 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2805 Are children required to sleep during this time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188792 03/12/2026 (a) Yes. You must allow each child who is awake after napping or resting for one hour to participate in an alternative, quiet activity until the nap/rest period is over for the other children.(b) You must take a toddler who naps or rests in a crib out of the crib for other activities when he awakens. Source Note: The provisions of this §747.2807 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2807 Must I provide an alternative activity for those children who cannot sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188793 03/12/2026 Napping equipment must:(1) Not block entrances or exits to the area;(2) Not be set up during other activities or left in place to interfere with children's useable activity space;(3) Be arranged to provide a sufficient walk and work space for caregivers between each cot or mat; and(4) Be arranged so that each child and caregiver has access to a walkway without having to walk on or over the cots or mats of other children. Source Note: The provisions of this §747.2809 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2809 Must I arrange the napping equipment in a specific manner? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188794 03/12/2026 Yes, you may lower the lighting, provided there is adequate lighting to allow visual supervision of all children in the group at all times. Lighting in a room is adequate if a person's eyes do not need to adjust for the person to be able to see upon entering the room. Source Note: The provisions of this §747.2811 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES M NAPTIME §747.2811 May I lower the lighting in the room while children are sleeping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192549 03/12/2026 (a) Yes. You must ensure the children's safety on field trips and excursions and during any transportation provided by the child-care home. Anytime you take a child on a field trip, you must comply with each of the following requirements:(1) You must have signed permission from the parent to take a child away from your child-care home, including permission to transport the child, if applicable;(2) You must carry emergency medical consent forms and emergency contact information for each child on the field trip;(3) You must have a written list of all children on the field trip and must check the list frequently to account for the presence of all children on the field trip;(4) You must have a first-aid kit immediately available on all field trips;(5) You must have a copy of a child's food allergy emergency plan and allergy medications, if applicable;(6) Each child must wear a shirt, name tag, or other identification listing the name and telephone number of the child-care home;(7) Each caregiver must be easily identifiable by all children on the field trip, by wearing a hat, specialized tee-shirt, brightly colored clothes, or other easily spotted identification;(8) Each caregiver supervising a field trip must have transportation available, a communication device such as a cellular phone or two-way radio available, or an alternate plan for transportation at the field trip location in case of emergency; and(9) You must ensure that a caregiver with current training in pediatric first aid and pediatric CPR is present on the field trip.(b) A walk around the caregiver's neighborhood must comply only with paragraphs (2), (5) and (9) of subsection (a) of this section. Source Note: The provisions of this §747.2901 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 8, 2018, 43 TexReg 6654. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES N FIELD TRIPS §747.2901 May I take children away from my child-care home for field trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192548 03/12/2026 Yes. You must notify the parent of each child who will be on the field trip, indicating when and where the child will be going, and when the child is expected to return to your child-care home. Source Note: The provisions of this §747.2903 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES N FIELD TRIPS §747.2903 Must I notify parents before I take a child away from my child-care home on a field trip? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188799 03/12/2026 (a) Nighttime care is care given on a regular or frequent basis to children who are starting or continuing their night sleep, or to children who spend the night or part of the night at the child-care home between the hours of 9:00 p.m. and 6:00 a.m.(b) Nighttime care does not include the occasional sleep-over program offered at infrequent intervals. Source Note: The provisions of this §747.3001 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES P NIGHTTIME CARE §747.3001 What is nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188800 03/12/2026 (a) You may care for children both during the day and night if we approve it. Even then, a child may only be in care for:(1) No more than 16 hours within a 24-hour period on a daily basis; or(2) No more than three consecutive 24-hour periods with a maximum of six 24-hour periods per month, as specified in §745.383 of this title (relating to Can a licensed child day care operation offer 24-hour care?).(b) You cannot exceed these limits. Source Note: The provisions of this §747.3003 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES P NIGHTTIME CARE §747.3003 May I provide nighttime care to children at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188801 03/12/2026 No. Caregivers supervising children during nighttime care in your child-care home do not have to be awake to supervise the children if:(1) The children are asleep before the caregivers;(2) The caregivers are on the same floor as the sleeping children; and(3) The caregivers are close enough to the children to respond or intervene if a child awakens for feeding, becomes ill, is afraid of the dark, or in the event of an emergency. Source Note: The provisions of this §747.3005 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES P NIGHTTIME CARE §747.3005 Must I stay awake while supervising children during nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188802 03/12/2026 In addition to all other building, furnishing, physical space, and equipment requirements specified in this chapter:(1) All exits must be visible. This may be provided by lighted exit signs or by lighted exits (such as a hall light or lamp that lights the exit path and door);(2) You cannot count a window as one of the child-care home's required fire exits;(3) Each child 18 months old or older must be provided a cot, bed, or mattress that is waterproof or washable, and developmentally appropriate;(4) Children younger than the age of 18 months must be provided with a crib for nighttime sleeping; and(5) Boys and girls six years old or older must have separate sleeping and dressing areas. Source Note: The provisions of this §747.3007 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES P NIGHTTIME CARE §747.3007 What are the building, furnishing, physical space, and equipment requirements for nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204149 03/12/2026 (a) Activities and routines must meet the unique needs of children in nighttime care. These may include quiet activities, such as homework, reading, puzzles, or board games; time for personal care routines and preparation for sleep, such as brushing teeth, washing hands and face, toileting, and changing clothes; and an evening meal, breakfast, and snack as specified in Subchapter Q of this chapter (relating to Nutrition and Food Service).(b) Screen time activities:(1) Must meet the requirements in §747.2105 of this chapter (relating to May I use a screen time activity with a child?); and(2) May not be used in a cot, bed, or mattress, or one hour before bedtime. Source Note: The provisions of this §747.3009 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES P NIGHTTIME CARE §747.3009 Must I provide activities for children in nighttime care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212780 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212780 03/12/2026 (a) You must serve all children regular meals and morning and afternoon snacks as specified in this subchapter.(b) The meals and snacks must follow the meal patterns established by the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) that is administered by the Texas Department of Agriculture. You must follow these patterns regardless of whether you are participating in the program for reimbursement.(c) If you serve breakfast, you do not have to serve a morning snack.(d) A child must not go more than three hours without a meal or snack being offered unless the child is sleeping.(e) You must serve enough food to allow a child to have second servings from the vegetable, fruit, grain, and milk groups, if the child requests it.(f) You must ensure a supply of clean, sanitary drinking water:(1) Is always available to each child at every snack, mealtime, and during and after active play; and(2) Is served in a safe and sanitary manner.(g) You must not serve beverages with added sugars, such as carbonated beverages, fruit punch, or sweetened milk except for a special occasion such as a holiday or birthday celebration, unless otherwise allowed by the CACFP.(h) You must not use food as a reward.(i) You must not serve a child a food identified on the child's food allergy emergency plan as specified in §747.3617 of this chapter (relating to What is a food allergy emergency plan?). Source Note: The provisions of this §747.3101 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3101 What are the basic requirements for meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204151 03/12/2026 You must follow the guidelines in Figure 26 TAC §747.3103 when determining how often to feed a child in your care.Attached Graphic Source Note: The provisions of this §747.3103 adopted to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3103 How often must I feed a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204152 03/12/2026 (a) Yes. However, your enrollment agreement, or an addendum to the agreement, signed by the parent must include a statement that the parent:(1) Is, choosing to provide the child's meals and snacks from home; and(2) Understands the child-care home is not responsible for its nutritional value or for meeting the child's daily food needs.(b) If the parent provides a meal but not a snack, you are responsible for providing a snack as specified in this subchapter.(c) You must provide safe and proper storage and service of the individual meals and snacks provided by parents.(d) Snacks provided by a parent must not be shared with other children, unless:(1) A parent is providing baked goods for a celebration or party being held at the home; and(2) You ensure that the shared snacks meet the needs of children who require special diets. Source Note: The provisions of this §747.3109 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3109 May parents provide meals and/or snacks for their children instead of my child-care home providing them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204154 03/12/2026 (a) To serve a child a therapeutic or special diet, you must:(1) Have written approval from:(A) A physician or health-care professional with prescriptive authority if the diet relates to a disability that restricts the child's diet; or(B) A health-care professional or a registered or licensed dietician if the diet does not relate to a disability that restricts the child's diet;(2) Maintain the written approval in the child's record; and(3) Give the information to all caregivers preparing and serving food.(b) You must discuss recurring eating problems with the child's parent.(c) You may encourage, but not force children to eat.(d) You must not serve nutrient concentrates and supplements such as protein powders, liquid protein, vitamins, minerals, and other nonfood substances without written instructions as required in subsection (a)(1) of this section. Source Note: The provisions of this §747.3111 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3111 What are the requirements for a child who requires a special diet or does not want to eat foods I serve? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188822 03/12/2026 No, however you must:(1) Maintain menus showing all meals and snacks prepared and served at your child- care home for the previous three months.(2) Keep a record of any substitutions made. Substitutions must be of comparable food value.(3) Date the menus. If you rotate menus, there must be a record of which menu was used for each date.(4) Make menus available to Licensing and parents for review upon request. Source Note: The provisions of this §747.3113 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3113 Must I post and maintain daily menus? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188825 03/12/2026 All food and drinks must be of safe quality and stored, prepared, distributed, and served under sanitary and safe conditions, including:(1) You must sanitize food service equipment, dishes, and utensils after each use;(2) If your child-care home lacks adequate facilities for sanitizing dishes and utensils, you must use only disposable, single-use items;(3) You must wash re-useable napkins, bibs, and tablecloths after each use;(4) You must discard single-service napkins, bibs, dishes, and utensils after use;(5) You must serve children's food on plates, napkins, or other sanitary holders, such as a high chair tray, and you must not place food on a bare table or eating surface, which includes the floor;(6) You must not serve foods that present a risk of choking for infants and toddlers;(7) You must cover all food stored in the refrigerator; and(8) You must not store poisonous or toxic materials and cleaning supplies with food. Source Note: The provisions of this §747.3117 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3117 What general requirements apply to food service and preparation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204153 03/12/2026 (a) You do not have to use family style meal service, although all meals and snack times must:(1) Be unhurried;(2) Allow children to feed themselves according to their developmental level; and(3) Include adult supervision of children.(b) If meals and snacks are served family style, you must supervise children to prevent cross-contamination of the food. Source Note: The provisions of this §747.3119 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 10, 2021, 46 TexReg 1488. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3119 Must I serve meals family style? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188827 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188827&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188827 03/12/2026 (a) Yes, although toothbrushes and tooth powders or pastes provided for each child's individual use must be:(1) Labeled with the child's full name;(2) Stored out of children's reach when not in use; and(3) Stored in a manner that prevents the toothbrushes from touching each other during storage.(b) Children must have adult supervision during tooth brushing activities. Source Note: The provisions of this §747.3121 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES Q NUTRITION AND FOOD SERVICE §747.3121 Are children allowed to use toothbrushes after meal and snack times? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188828 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188828&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188828 03/12/2026 No. We do not require you to have an annual sanitation inspection, although your local ordinances may require this. Source Note: The provisions of this §747.3201 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3201 Must my child-care home have an annual sanitation inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188829 03/12/2026 You must clean, repair, and maintain your child-care home, grounds, and equipment to protect the health of the children, including:(1) Setting aside toys and equipment that are placed in children's mouths or are otherwise contaminated by body secretion or excrement, to be sanitized daily or before handling by another child;(2) Machine washing used cloth toys at least weekly and when contaminated;(3) Machine washing used linens at least weekly, and when soiled and before another child uses them;(4) Sanitizing sleeping equipment before a different child uses it and when soiled;(5) Sanitizing potty chairs after each child's use;(6) Emptying water play tables and toys used in water play tables daily, sanitizing, and ensuring children and caregivers wash their hands before using the water table;(7) Maintaining sand boxes and sand tables in a sanitary manner;(8) Making all garbage inaccessible to children, and managing it to keep the child-care home, inside and outside, free of insects, rodents, and offensive odors;(9) Keeping all floors, ceilings, and walls in good repair and clean;(10) Ensuring paints used at the child-care home are lead-free;(11) Keeping all parts of the child-care home used by children well heated, lighted, and ventilated;(12) Sanitizing table tops, furniture, and other similar equipment used by children when soiled or contaminated with matter such as food, body secretions, or excrement;(13) Clearly marking cleaning supplies and other toxic materials and keeping them separate from food and inaccessible to children; and(14) Using, storing, and disposing of hazardous materials as recommended by the manufacturer. Source Note: The provisions of this §747.3203 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3203 What steps must I take to ensure a healthy environment for children at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188830 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188830&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188830 03/12/2026 Items that can be washed in a dishwasher or hot cycle of a washing machine which runs at a temperature of 160 degrees Fahrenheit or higher for five or more minutes do not need additional disinfecting because these machines use water that is hot enough, for long enough, to kill most germs. Source Note: The provisions of this §747.3209 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3209 May I use a dishwasher or washing machine to sanitize items at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188831 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188831&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188831 03/12/2026 Caregivers must wash their hands:(1) Before eating or handling food or medication;(2) Before feeding a child;(3) After arriving at the child-care home;(4) After diapering a child;(5) After assisting a child with toileting;(6) After personal toileting;(7) After handling or cleaning bodily fluids, such as after tending sores and wiping noses, mouths, or bottoms;(8) After handling or feeding animals;(9) After outdoor activities;(10) After handling raw food products;(11) After eating, drinking, or smoking;(12) After using any cleaners or toxic chemicals; and(13) After removing gloves. Source Note: The provisions of this §747.3211 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3211 When must caregivers wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188832 03/12/2026 Children must wash their hands:(1) Before eating;(2) Before playing in a water play table or other water activities;(3) After toileting or having a diaper changed;(4) After outdoor activities;(5) After playing in sand;(6) After feeding or touching animals; and(7) Any other time that the caregiver has reason to believe the child has come in contact with substances that could be harmful to the child. Source Note: The provisions of this §747.3213 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3213 When must children wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188833 03/12/2026 Children 18 months and older and caregivers must wash their hands with soap and running water. Source Note: The provisions of this §747.3215 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3215 How must children and caregivers wash their hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188834 03/12/2026 You may use hand sanitizers as a substitute for washing hands if all of the following conditions are met:(1) You only use hand sanitizers on children 24 months and older;(2) You do not use hand sanitizers to wash hands that are visibly dirty or greasy or have chemicals on them, unless you are away from the activity space and soap and water are not available for hand washing;(3) You follow the labelling instructions for the appropriate amount to be used and for how long the hand sanitizer needs to remain on the skin surface to be effective;(4) Children have adult supervision when using hand sanitizers; and(5) You store hand sanitizers out of the reach of children when not in use. Source Note: The provisions of this §747.3216 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3216 May I use hand sanitizer as a substitute for washing hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188835 03/12/2026 (a) Until the infant is old enough to be raised to the faucet and reach for the water, you must wash the infant's hands using an individual cloth or disposable towel with soap, followed by a cloth or disposable towel used to rinse with clear water and dry.(b) Use soap and running water as specified in this division when infants are old enough to be raised to the faucet and reach for the water and any other time that the caregiver has reason to believe the infant has come in contact with substances that could be harmful to the infant. Source Note: The provisions of this §747.3217 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3217 How must I wash an infant's hands? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188836 03/12/2026 No. We do not require you to have hot water for hand washing. However, if hot water is accessible to the children, a thermostat must control it so that the water temperature is no higher than 120 degrees Fahrenheit. Source Note: The provisions of this §747.3219 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3219 Must I have hot water for hand washing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188837 03/12/2026 Yes, caregivers must follow universal precautions outlined by the Centers for Disease Control (CDC) when handling blood, vomit, or other bodily fluids that may contain blood including:(1) Using disposable, nonporous gloves;(2) Placing gloves contaminated with blood in a tied, sealed, or otherwise closed plastic bag and discarding them immediately;(3) Discarding all other gloves immediately after one use; and(4) Washing your hands with soap and running water after using and disposing of the gloves. Source Note: The provisions of this §747.3221 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3221 Must caregivers wear gloves when handling blood or bodily fluids containing blood? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188841 03/12/2026 No, although you must keep your child-care home and yard free of insects, rodents, or pests. Source Note: The provisions of this §747.3223 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3223 Must I use a licensed exterminator to treat my child-care home for insects, rodents, or other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188842 03/12/2026 Yes. You must do the following when your child-care home is being treated for insects, rodents, or other pests:(1) Ensure children are not present in an area being treated with chemicals as required by label directions;(2) Apply over-the counter products used for insects, rodent, and pest control only by following label directions;(3) Minimize children's exposure to chemical residue that may be harmful to them, including odors;(4) Store all pest control products according to label directions;(5) Immediately dispose of dead insects and rodents in a safe and sanitary manner. Source Note: The provisions of this §747.3225 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3225 Are there general precautions I must take when my child-care home is being treated for insects, rodents, or other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188843 03/12/2026 Yes, you may use water from a private water supply, although you must:(1) Maintain the water supply in a safe and sanitary manner.(2) Maintain written records indicating that the private water supply meets the requirements of the Texas Commission on Environmental Quality, if applicable. Source Note: The provisions of this §747.3227 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3227 May I use water from a private water supply instead of a public water supply for my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188838 03/12/2026 Yes, if the septic system is sanitary and meets the standards of the Texas Commission on Environmental Quality, including any routine inspections required by law. Source Note: The provisions of this §747.3229 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3229 May I use a septic system for sewage disposal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188839 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188839&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188839 03/12/2026 Caregivers must:(1) Promptly change soiled or wet diapers or clothing;(2) Thoroughly cleanse the child with individual cloths or disposable towels. You must discard the disposable towels after use and launder any cloths before using them again;(3) Ensure that the children are dry before placing a new diaper on the child. If the child must be dried, you must use a clean, individual cloth or disposable towel to dry the child. You must discard the disposable towel after use and launder any cloth before using it again;(4) Not apply powders, creams, ointments, or lotions unless you obtain the parent's written permission. If the parent supplies these items, permission is implicit and you do not need to obtain permission for each use;(5) Label powders, creams, ointments, or lotions with the individual child's name; and(6) Keep all diaper changing supplies out of the reach of children. Source Note: The provisions of this §747.3301 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3301 What steps must I follow for diaper changing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212781 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212781&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212781 03/12/2026 (a) You must have a diaper changing table or surface that is:(1) Smooth, non-absorbent, and easy to clean; and(2) Located so that the caregiver using the diapering surface can supervise children at all times, as specified in §747.1503 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?).(b) You must not use areas for diaper changing that children come in close contact with during play or eating, such as dining tables, sofas, or floor play areas.(c) If the diaper changing table or surface is above the floor level, then at all times when the child is on the table/surface:(1) There must be a safety mechanism (such as raised sides) that is used;(2) The caregivers hand must remain on the child; or(3) The caregiver must be facing the child and within an arm's length of the child. Source Note: The provisions of this §747.3303 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3303 What equipment must I have for diaper changing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188848 03/12/2026 (a) You must wash your hands after each diaper change. Refer to §747.3215 of this title (relating to How must children and caregivers wash their hands?).(b) You must wash the infant's hands or see that the child's hands are washed after each diaper change. Refer to §747.3217 of this title (relating to How must I wash an infant's hands?).(c) If you use disposable gloves, you must discard them after each diaper change and wash your hands with soap and running water.(d) You must sanitize the diapering-changing surface after each use, or use a clean, disposable covering on the diapering surface that must be changed after each use.(e) You must cover containers used for soiled diapers or keep them in a sanitary manner, such as placing soiled diapers in a tied, sealed, or otherwise closed plastic bag.(f) You must place soiled clothing in a tied, sealed, or otherwise closed plastic bag to be sent home with the child. Source Note: The provisions of this §747.3307 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3307 What must I do to prevent the spread of germs when diapering children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212782 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212782&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212782 03/12/2026 You must not allow an ill child to attend your child-care home if one or more of the following exists:(1) The illness prevents the child from participating comfortably in child-care activities, including outdoor play;(2) The illness results in a greater need for care than caregivers can provide without compromising the health, safety, and supervision of the other children in care;(3) The child has one of the following (unless a medical evaluation by a health-care professional indicates that you can include the child in the child-care activities):(A) An oral temperature above 101 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(B) A tympanic (ear) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness. Tympanic thermometers are not recommended for children under six months old;(C) An axillary (armpit) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness;(D) An infrared temporal (forehead) temperature above 100 degrees that is accompanied by behavior changes or other signs or symptoms of illness; or(E) Symptoms and signs of possible severe illness, such as lethargy, abnormal breathing, uncontrolled diarrhea, two or more vomiting episodes in 24 hours, rash with fever, mouth sores with drooling, behavior changes, or other signs that the child may be severely ill; or(4) A health-care professional has diagnosed the child with a communicable disease, and the child does not have medical documentation to indicate that the child is no longer contagious. Source Note: The provisions of this §747.3401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3401 What type of illness would prohibit a child from attending the child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188845 03/12/2026 You must follow the communicable disease exclusions required for schools as defined by the Texas Department of State Health Services (DSHS) in 25 TAC §97.7 (relating to Diseases Requiring Exclusion from Schools). Source Note: The provisions of this §747.3403 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3403 What communicable diseases would exclude a child from attending my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204798 03/12/2026 (a) If a child becomes ill while in your care but does not require immediate treatment by a health-care professional or hospitalization, you must:(1) Contact the parent to pick up the child;(2) Care for the child apart from other children;(3) Give appropriate attention and supervision until the parent picks the child up; and(4) Give extra attention to hand washing and sanitation if the child has diarrhea or vomiting.(b) If a child becomes ill while in your care and requires immediate treatment by a health-care professional or hospitalization, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the group);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure the supervision of other children in the group. Source Note: The provisions of this §747.3405 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3405 How must caregivers respond when a child becomes ill? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188847 03/12/2026 A child who was ill may return to your child-care home when:(1) The child is free of symptoms of illness for 24 hours; or(2) You have obtained a health-care professional's written statement that the child no longer has an excludable disease or condition. Source Note: The provisions of this §747.3406 adopted to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3406 When may a child who was ill return to my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204799 03/12/2026 For an injury that requires immediate treatment by a health-care professional, you must:(1) Contact emergency medical services (or take the child to the nearest emergency room after you have ensured the supervision of other children in the home);(2) Give the child first-aid treatment or CPR when needed;(3) Contact the child's parent;(4) Contact the physician or other health-care professional identified in the child's record; and(5) Ensure supervision of other children in the group. Source Note: The provisions of this §747.3407 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2449. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3407 How must caregivers respond when a child is injured and requires immediate treatment by a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188850 03/12/2026 A vaccine-preventable disease is a disease that is included in the most current recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Source Note: The provisions of this §747.3409 adopted to be effective June 1, 2014, 39 TexReg 3724; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3409 What is a vaccine-preventable disease for the purpose of this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188851 03/12/2026 A licensed child-care home that is not located in the primary caregiver's own residence must have a policy for protecting the children in your care from vaccine-preventable diseases. The policy must:(1) Specify any vaccines that you have determined an employee must have for vaccine-preventable diseases based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(2) Require each employee to receive each specified vaccine that the employee is not exempt from having;(3) Include procedures for verifying whether an employee has complied with your policy;(4) Include procedures for an employee to be exempt from having a required vaccine because of:(A) Medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention (CDC); or(B) Reasons of conscience, including a religious belief;(5) Include procedures that an exempt employee must follow to protect children in your care from exposure to disease, such as the use of protective medical equipment, including gloves and masks, based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(6) Prohibit discrimination or retaliatory action against an exempt employee, except that required use of protective medical equipment, including gloves and masks, may not be considered retaliatory action for purposes of this section;(7) Outline how you will maintain a written or electronic record of each employee's compliance with or exemption from your policy; and(8) State the disciplinary actions you may take against an employee who fails to comply with your policy. Source Note: The provisions of this §747.3411 adopted to be effective June 1, 2014, 39 TexReg 3724; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES R HEALTH PRACTICES §747.3411 What must a policy for protecting children from vaccine-preventable diseases include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220744 03/12/2026 All areas accessible to a child must be free from hazards including, the following:(1) Electrical outlets accessible to a child younger than five years must have child-proof covers or safety outlets;(2) 220-volt electrical connections within any child's reach must be covered with a screen or guard;(3) Air conditioners, electric fans, and heaters must be mounted out of all children's reach or have safeguards that keep any child from being injured;(4) Glass in sliding doors must be clearly marked with decals or other materials placed at children's eye level;(5) Play materials and equipment must be safe and free from sharp or rough edges and toxic paints;(6) Poisonous or potentially harmful plants must be inaccessible to children;(7) Bottle warmers must be inaccessible to all children and used only according to manufacturer instructions;(8) All storage chests, boxes, trunks, or similar items with hinged lids must be equipped with a lid support designed to hold the lid open in any position, be equipped with ventilation holes, and must not have a latch that might close and trap a child inside; and(9) All bodies of water, wading pools, hot tubs, birdbaths, fountains, buckets, and rain barrels must be inaccessible to children. Source Note: The provisions of this §747.3501 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3501 What safety precautions must I take to protect children in my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188853 03/12/2026 (a) People whose behavior and/or health status poses an immediate threat or danger to the health or safety of the children must not be present when children are in care.(b) People must not consume alcohol or controlled substances without a prescription in the child-care home, during transportation, or on field trips.(c) People must not be under the influence of or impaired by alcohol or controlled substances in the child-care home, during transportation, or on field trips.(d) People must not smoke any e-cigarette, vaporizer, or tobacco product or otherwise use any tobacco product during operating hours in your child-care home, garage, on the playground, in transportation vehicles, or during field trips. Source Note: The provisions of this §747.3503 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3503 How can I ensure the safety of the children from other persons? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188854 03/12/2026 (a) Firearms, hunting knives, bows and arrows, or other weapons kept on the premises of a child-care home must remain in a locked cabinet that is inaccessible to children during all hours of operation, with the exception of peace officers as listed in §2.12 of the Code of Criminal Procedure and security officers commissioned by the Texas Private Security Board who are trained and certified to carry a firearm and ammunition.(b) Ammunition must be kept in a separate locked cabinet that is inaccessible to children during all hours of operation. Source Note: The provisions of this §747.3505 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3505 Are firearms or other weapons allowed at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188855 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188855 03/12/2026 A child may not use any type of toy or equipment that explodes or that shoots things, such as caps, BB guns, darts, or fireworks at the child-care home or on field trips. These types of toys and equipment must remain in a locked cabinet inaccessible to children during your hours of operation. Source Note: The provisions of this §747.3507 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3507 May I have toys or other types of equipment that explode or shoot things? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188856 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188856 03/12/2026 In this division, medication means:(1) A prescription medication; or(2) A non-prescription medication, excluding topical ointments such as diaper ointment, insect repellant, or sunscreen. Source Note: The provisions of this §747.3601 adopted to be effective March 1, 2012, 37 TexReg 935; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3601 What does "medication" refer to in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188857 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188857 03/12/2026 (a) Authorization to administer medication to a child in your care must be obtained from the child's parent:(1) In writing, signed and dated;(2) In an electronic format that is capable of being viewed and saved; or(3) By telephone to administer a single dose of a medication.(b) Authorization to administer medication expires on the first anniversary of the date the authorization is provided.(c) The child's parent may not authorize you to administer medication in excess of the medication's label instructions or the directions of the child's health-care professional.(d) Parent authorization is not required if you administer a medication to a child in a medical emergency to prevent the death or serious bodily injury of the child, provided that you administer the medication as prescribed, directed, or intended. Source Note: The provisions of this §747.3603 adopted to be effective March 1, 2012, 37 TexReg 935; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3603 What authorization must I obtain before administering a medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188858 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188858&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188858 03/12/2026 (a) Medication must be given:(1) As stated on the label directions; or(2) As amended in writing by the child's health-care professional.(b) Medication must:(1) Be in the original container labeled with the child's full name and the date brought to the operation;(2) Be administered only to the child for whom it is intended; and(3) Not be administered after its expiration date.(c) When you administer medication to a child in your care, you must make a record of the following:(1) Full name of the child to whom the medication was given;(2) Name of the medication;(3) Date, time, and amount of medication given; and(4) Full name of the caregiver administering the medication, if it is not the primary caregiver.(d) You must keep all medication records for at least three months after administering the medication. Source Note: The provisions of this §747.3605 adopted to be effective March 1, 2012, 37 TexReg 935; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3605 How must I administer medication to a child in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188859 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188859&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188859 03/12/2026 You must store medication as follows:(1) Keep it out of the reach of children or in locked storage;(2) Store it in a manner that does not contaminate food; and(3) Refrigerate it, if refrigeration is required, and keep it separate from food. Source Note: The provisions of this §747.3607 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3607 How must I store medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188860 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188860 03/12/2026 You must dispose of the medication, or return it to the parent, when the child withdraws from the child-care home, or when the medication is out-of-date, or is no longer required for the child. Source Note: The provisions of this §747.3609 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3609 How long may I keep the medication that I administer to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188861 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188861 03/12/2026 Yes. If you choose not to administer medication to children, you must inform the parents of this policy in writing, prior to the child's enrollment. Source Note: The provisions of this §747.3611 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3611 Do I have to notify parents if I do not want to administer medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188862 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188862&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188862 03/12/2026 Specialized medical assistance is any medical assistance other than medication. Examples include, but are not limited to, assisting with an apnea monitor, protective helmet, or leg brace. Source Note: The provisions of this §747.3613 adopted to be effective March 1, 2012, 37 TexReg 935; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3613 What is specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188863 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188863 03/12/2026 (a) If a child in your care requires specialized medical assistance, then you are required to provide specialized medical assistance as recommended or ordered by a health-care professional.(b) If you are provided with a written copy of the health-care professional's recommendations or orders, you must maintain this written information in the child's record for at least three months after the health-care professional has indicated that the specialized medical assistance is no longer needed. Source Note: The provisions of this §747.3615 adopted to be effective March 1, 2012, 37 TexReg 935; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3615 What are my requirements regarding specialized medical assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188864 03/12/2026 A food allergy emergency plan is an individualized plan prepared by the child's health care professional that includes:(1) a list of each food the child is allergic to;(2) possible symptoms if exposed to a food on the list; and(3) the steps to take if the child has an allergic reaction. Source Note: The provisions of this §747.3617 adopted to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3617 What is a food allergy emergency plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188865 03/12/2026 You must have a food allergy emergency plan for each child with a known food allergy that has been diagnosed by a health-care professional. The child's health-care professional and parent must sign and date the plan. You must keep a copy of the plan in the child's file. Source Note: The provisions of this §747.3619 adopted to be effective September 1, 2016, 41 TexReg 6250; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3619 When must I have a food allergy plan for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188866 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188866 03/12/2026 If you choose to have animals on the premises of your child-care home while children are in care or on field trips, you must:(1) Notify parents in writing when animals are or will be present;(2) Ensure the animals do not create unsafe or unsanitary conditions;(3) Ensure that children do not handle any animal that shows signs of illness, such as lethargy or diarrhea; and(4) Ensure that caregivers and children practice good hygiene and hand washing after handling or coming into contact with an animal and items used by an animal, such as water bowls, food bowls, and cages. Source Note: The provisions of this §747.3701 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3701 What steps must I take to have animals at my child-care home or on field trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188867 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188867 03/12/2026 (a) Yes. You must have documentation at your child-care home showing dogs and cats have been vaccinated as required by Texas Health and Safety Code, Chapter 826.(b) You must have a statement of health from a local veterinarian at your child-care home for all animals, such as dogs, cats, and ferrets, with the exception of small rodents, such as guinea pigs, mice, and hamsters. Source Note: The provisions of this §747.3703 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3703 Must I keep documentation of vaccinations for the animals? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188868 03/12/2026 (a) Yes. Children must not have contact with chickens, ducks, and reptiles, such as snakes, turtles, lizards, iguanas, and amphibians, such as frogs and toads.(b) You must keep the child-care home and playground free of animals unfamiliar to you.(c) In addition to the animals specified in subsection (a) of this section, you must not allow children to play with:(1) animals unfamiliar to you;(2) animals familiar to you but showing behavioral changes that could be perceived as dangerous; and(3) animals that could be dangerous, such as monkeys. Source Note: The provisions of this §747.3705 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3705 Must I prevent children from having contact with certain animals while at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188869 03/12/2026 Yes. You must have a first-aid kit available in the child-care home and on all field trips that is:(1) Clearly labeled;(2) Kept in a clean and sanitary manner;(3) Easily accessible to all caregivers and household members;(4) In a designated location; and(5) Kept out of the reach of children. Source Note: The provisions of this §747.3801 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3801 Must I have a first-aid kit at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212784 03/12/2026 (a) Each first-aid kit must contain the following supplies:(1) A guide to first aid and emergency care;(2) Adhesive tape;(3) Antiseptic solutions or wipes;(4) Adhesive bandages;(5) Scissors;(6) Sterile gauze pads;(7) Thermometer, preferably non-glass;(8) Tweezers; and(9) Waterproof, disposable gloves.(b) The first-aid supplies must not have expired. Source Note: The provisions of this §747.3803 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective July 1, 2005, 30 TexReg 3602; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3803 What items must each first-aid kit contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220273 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220273 03/12/2026 (a) You may release a child only to a parent or a person designated by the parent.(b) Upon receipt of a valid court order signed by a judge that prohibits a parent from removing the named child or children from the child-care home, the child-care home must:(1) Comply with the court order immediately and until:(A) Receipt of a subsequent court order that revokes the primary order; or(B) The court order expires as defined in the document; and(2) Maintain a copy of the court order in the child's file. Source Note: The provisions of this §747.3901 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective August 19, 2024, 49 TexReg 6233. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3901 To whom may I release a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188872 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188872&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188872 03/12/2026 (a) You must develop policies for the release of children, including a plan to verify the identity of a person authorized to pick up a child, but whom the caregiver does not know. If your child-care home transports children, the plan must include verifying the identity of a person to whom you release a child from a child-care home transportation vehicle.(b) Caregivers must be the individuals responsible for overseeing the release of children in care.(c) Your policies must include a reasonable means to record the identity of the individual, such as making a copy of a valid photo identification or instant photograph of the individual or recording the driver's license number or license plate number. You must retain this information in the child's record for at least three months.(d) You must instruct all caregivers and household members, who are 14 years of age and older who are regularly or frequently present at the child-care home while children are in care, of your policies for the release of children, including the verification plan. Source Note: The provisions of this §747.3903 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3903 How does a caregiver verify the identity of a parent or a person a parent has designated to pick up the child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188875 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188875&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188875 03/12/2026 Children's products are products that are designed or intended to be used by a child under 13 years of age or used by a caregiver during the care of a child under 13 years of age. The term does not include:(1) An item that is not designed or intended to be used solely or primarily by a child under 13 years of age or for the care of a child under 13 years of age;(2) A medication, drug, food, or other item that is intended to be ingested; or(3) Clothing. Source Note: The provisions of this §747.3931 adopted to be effective March 1, 2010, 35 TexReg 1296; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3931 What are "children's products?" https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188873 03/12/2026 A children's product is considered to be unsafe if after it has been recalled for any reason by the United States Consumer Product Safety Commission:(1) The recall has not been rescinded; and(2) The product has not been made safe through being remanufactured or retrofitted. Source Note: The provisions of this §747.3933 adopted to be effective March 1, 2010, 35 TexReg 1296; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3933 When is a children's product considered to be unsafe? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188874 03/12/2026 (a) You are responsible for reviewing the United States Consumer Product Safety Commission (CPSC) recall list. You may view all current and past recalls through the CPSC's Internet website at: www.cpsc.gov. You must ensure that there are no unsafe children's products in your child-care home unless one or more of the following apply:(1) The product is an antique or collectible children's product and is not used by, or accessible to any child; or(2) The unsafe children's product is being retrofitted to make it safe and the product is not used by, or accessible to any child.(b) You must certify annually in writing using a form provided by DFPS that you have reviewed each of the recall notices issued by the CPSC and that there are no unsafe products in the home except products specified in subsection (a) of this section. The form must be kept on file and available for review upon request by Licensing staff, parents, and employees during hours of operation.(c) You must post a notice for parents and employees in a prominent and publicly accessible place that includes information on how to access a listing of unsafe children's products through the CPSC Internet website or through the DFPS Internet website. Source Note: The provisions of this §747.3935 adopted to be effective March 1, 2010, 35 TexReg 1296; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES S SAFETY PRACTICES §747.3935 What are my responsibilities regarding unsafe children's products in my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188876 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188876&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188876 03/12/2026 Your registered or licensed child-care home must have at least 30 square feet of indoor useable activity space for each child in care. Source Note: The provisions of this §747.4001 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4001 How many square feet of indoor useable activity space must I have for each child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188877 03/12/2026 No. We will limit the number of children you may care for based on the indoor useable activity space in the child-care home. Source Note: The provisions of this §747.4003 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4003 May I care for 12 children if I do not have 30 square feet of indoor useable activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188878 03/12/2026 Indoor useable activity space is space that may be used by a child in the child-care home for a variety of activities specified in this chapter. You must demonstrate to us how the space will be used for at least the following activities:(1) Use of cribs and space to explore outside of the crib;(2) Use of interest centers or activity stations;(3) Space for meals and snack time;(4) Space for individual and group activities; and(5) Space for nap or rest time. Source Note: The provisions of this §747.4005 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4005 What does Licensing mean by "indoor useable activity space"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188879 03/12/2026 No, but you must be close enough to the younger children to interact with them and to intervene, if needed to protect them. Source Note: The provisions of this §747.4007 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4007 Am I required to care for children younger than 18 months separately from older children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188880 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188880&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188880 03/12/2026 If you were registered or licensed before September 1, 2003, you are exempt from this requirement until your permit to operate is no longer valid. Source Note: The provisions of this §747.4009 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4009 Do the indoor useable activity space requirements in §747.4001 of this title (relating to How many square feet of indoor useable activity space must I have for each child?) apply to my home if it was registered or licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188881 03/12/2026 (a) We determine the indoor useable activity space by:(1) Measuring all indoor useable activity space from wall to wall on the inside at floor level;(2) Rounding all measurements up to the nearest inch;(3) Excluding single-use areas, which are areas not routinely used for children's activities, such as a bathroom, hallway, storage room, cooking area of a kitchen, swimming pool, and storage building; and(4) Excluding floor space occupied by permanent and stationary fixtures, such as built-in bookcases, shelving, and storage/counter space that is not intended for use by children.(b) We use the sum of the measurements to calculate the indoor useable activity space and to determine the maximum number of children you may care for. Source Note: The provisions of this §747.4011 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4011 How does Licensing determine the indoor useable activity space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188882 03/12/2026 No. You must not share the indoor useable activity space with other programs at the same time you have children in care. Source Note: The provisions of this §747.4013 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4013 May other programs use my indoor useable activity space at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212786 03/12/2026 To care for children on any level above or below ground level, you must:(1) Obtain written approval from the state or local fire authority; and(2) Follow any restrictions issued by the state or local fire authority, including any age limits placed on the approval. Source Note: The provisions of this §747.4015 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4015 May I care for children above or below ground level? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188884 03/12/2026 Your registered or licensed child-care home must have 80 square feet of outdoor activity space for each child using the outdoor area at one time. Source Note: The provisions of this §747.4101 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4101 How many square feet of outdoor activity space must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188885 03/12/2026 If your child-care home was licensed or registered before September 1, 2003, you are exempt from the requirements in §747.4101 of this title (relating to How many square feet of outdoor activity space must I have?) until your permit to operate is no longer valid. Source Note: The provisions of this §747.4103 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4103 Do the outdoor activity space requirements apply to my home if it was registered or licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188886 03/12/2026 You must enclose your outdoor activity space area with a fence at least four feet high, unless the only children using the outdoor area are five years old and older. The wall of a building may serve as part of the enclosure, provided it is at least four feet tall. Source Note: The provisions of this §747.4105 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4105 Must I fence the outdoor activity space area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188887 03/12/2026 Each fenced yard must have at least two exits. An entrance to your child-care home may count as one exit, but one exit must be away from the child-care home. Source Note: The provisions of this §747.4109 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4109 How many exits must I have from my fenced outdoor activity space area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188892 03/12/2026 Yes, but caregivers must be able to open the gates immediately in an emergency. For example, all caregivers would carry a key with them to open the locked exits. Caregivers must be able to demonstrate to Licensing staff that they can open the gate immediately. Source Note: The provisions of this §747.4111 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4111 May I keep the gates leading into my outdoor activity area locked while children are in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188893 03/12/2026 We must approve a plan to use an outdoor activity space area that is not connected to your child-care home, such as a near-by park, schoolyard, or other alternative. All outdoor activity areas used by children must be accessible from the home by a safe route. We will consider the following criteria before approving the plan:(1) Traffic patterns of vehicles and people in the area;(2) Ages of children in your care;(3) Availability of appropriate equipment;(4) Usage of the location by other groups when the children would be most likely to use it;(5) Neighborhood circumstances, hazards, and risks, including the crime rate for the area;(6) Accessibility to children and caregivers by foot or the availability of push carts or other means of transporting infants and toddlers;(7) Reasonable accessibility of restroom facilities; and(8) Ability to obtain assistance, if needed, when injury or illness occurs. Source Note: The provisions of this §747.4113 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4113 Must the outdoor activity space area be connected to the child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188894 03/12/2026 Yes. If we approve an outdoor activity area not connected to your child-care home, you must:(1) Give parents written notification of the location of the outdoor activity area, upon children's enrollment;(2) Supervise children both during play and while traveling to and from the activity area; and(3) Meet other conditions we specify, if applicable. Source Note: The provisions of this §747.4115 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4115 Must I comply with additional requirements if my plan to use an outdoor activity area not connected to my child-care home is approved by Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188888 03/12/2026 No. You must not share the outdoor activity space at your child-care home with other programs at the same time children are in care. Source Note: The provisions of this §747.4117 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4117 May other programs use the outdoor activity space at my child-care home at the same time I have children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188889 03/12/2026 You must have at least one sink and one flush toilet available for children's use. A urinal may not substitute for a toilet. Source Note: The provisions of this §747.4201 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4201 How many sinks and toilets must I have for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188890 03/12/2026 (a) Sinks and toilets must be located inside the child-care home and allow supervision by caregivers as needed.(b) Children must be able to safely and independently access the toilet.(c) Children must be able to safely and independently access the sink for hand washing. Source Note: The provisions of this §747.4203 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4203 Where must the sink and toilet be located for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188891 03/12/2026 You must equip sinks children use for hand washing with soap and running water. Single-use disposable towels or an individual towel labeled with the child's name may be provided for children to dry their hands. Source Note: The provisions of this §747.4205 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4205 Must I supply soap and disposable towels for children's use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188895 03/12/2026 Yes. You may use potty-chairs, but a potty chair is not a substitute for a flush toilet required under §747.4201 of this title (relating to How many sinks and toilets must I have for children's use?). Source Note: The provisions of this §747.4207 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4207 May potty-chairs be used? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188901 03/12/2026 No, but you must equip a sink, urinal, or toilet that is too high for children to use safely and independently with anchored steps or a broad-based platform with a non-slip surface. Source Note: The provisions of this §747.4209 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4209 Do I have to use toilets and sinks that are sized for children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188902 03/12/2026 Yes. Doors on restrooms and toilets used by children may have locks, although:(1) Locks must be out of children's reach; or(2) If locks are within children's reach, there must be a way to immediately open the door from the outside in an emergency, and:(A) The unlocking mechanism must be accessible to all caregivers at all times and must be demonstrated satisfactorily to Licensing staff upon request; and(B) A caregiver must be present in or near the restroom when children younger than five years are using restrooms with door locks within children's reach. Source Note: The provisions of this §747.4211 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4211 May the doors to the restrooms have locks on them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188896 03/12/2026 (a) No, but you must ensure that any table or chair used by a child is safe, easy to clean, and of a height and size that the child can use it safely and easily.(b) If the manufacturer requires safety straps on a chair, then the safety straps must be fastened whenever a child is using the chair. Source Note: The provisions of this §747.4301 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4301 Must I use child-sized tables and chairs for children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188897 03/12/2026 (a) Yes. You must provide or have the parent provide an individual cot, bed, or mat that is waterproof or washable for each walking child through four years old to sleep or rest on.(b) Cots, beds, or mats must be labeled with the child's name. As an alternative, you may label cots, beds, or mats with a number and have a number/child assignment map available.(c) Floor mats used for napping must be marked or colored so that the sleeping side can be distinguished from the floor side. Source Note: The provisions of this §747.4303 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4303 Must I provide a cot or mat for each child to sleep or rest on? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188898 03/12/2026 Yes. You must have individual lockers, cubicles, baskets, separate hooks and shelves, or other adequate storage space for each child's personal belongings. You must clearly label the storage space with the child's name, a photograph of the child, or other symbol the child recognizes. Source Note: The provisions of this §747.4305 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4305 Must I have storage for each child's individual belongings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212785 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212785&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212785 03/12/2026 (a) You must have a working telephone or cellular phone at your child-care home.(b) If your telephone is a landline, the telephone number must be listed.(c) If you use cellular phone service at your home, you must ensure all caregivers and adult household members know the address of the home to direct emergency personnel to the home when dialing 911 from the home.(d) You must post your phone number as required by §747.403 of this chapter (relating to What telephone numbers must I post and where must I post them?) and update the posting any time your phone number changes. Source Note: The provisions of this §747.4307 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4307 Must I have a telephone at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188900 03/12/2026 (a) You may have an indoor loft that is designed and used as an extension of the learning area, if you comply with the following safety standards:(1) Caregivers must be able to adequately supervise children at all times;(2) Stairs and steps, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails;(3) Platforms over 20 inches in height must be equipped with protective barriers that prevent children from crawling over or falling through the barrier, or becoming entrapped; and(4) Section 747.4015 of this title (relating to May I care for children above or below ground level?).(b) If lofts are used as indoor active play space or equipment they must comply with the requirements specified in Subchapter U of this chapter (relating to Indoor and Outdoor Active Play Space and Equipment). Source Note: The provisions of this §747.4309 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES T PHYSICAL FACILITIES §747.4309 May I have indoor lofts? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188904 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188904&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188904 03/12/2026 Indoor and outdoor active play equipment used both at and away from the child-care home must be safe for the children as follows:(1) The indoor and outdoor active play equipment must be arranged so that caregivers can adequately supervise children at all times;(2) The design, scale, and location of the equipment must be used according to the manufacturer's instructions;(3) Equipment must not have openings or angles that can entrap a child's body or body part that has penetrated the opening;(4) Equipment must not have protrusions or openings that can entangle something around a child's neck or a child's clothing;(5) Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, moving, or overturning;(6) All anchoring devices must be placed below the level of the playing surface to prevent tripping or injury resulting from a fall;(7) Equipment must not have exposed pinch, crush, or shear points on or underneath it;(8) Climbing equipment, swings, or inflatables must not be installed over asphalt or concrete, unless the asphalt or concrete is covered with properly installed unitary surfacing material as specified in §747.4707 of this title (relating to What are unitary surfacing materials?) and §747.4709 of this title (relating to How should unitary surfacing materials be installed?);(9) Porches or platforms more than 20 inches in height for pre-kindergarten and younger children, and more than 30 inches in height for school-age children, must be equipped with protective barriers that surround the elevated surface, except for entrances and exits and that prevent children from crawling over or falling through the barrier, or becoming entrapped; and(10) Stairs and steps on climbing equipment, regardless of height, must have handrails the children can reach. Rung ladders do not require handrails. Source Note: The provisions of this §747.4401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4401 What minimum safety requirements must my active play equipment meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188905 03/12/2026 Yes. Children must not use the following types of equipment at or away from the child-care home:(1) Heavy swings made of metal or that have metal components, such as animal figure swings;(2) Equipment that allows children to fall inside the structure and onto other parts of the structure, such as certain styles of monkey bars or jungle gyms;(3) Trampolines, except those less than four feet in diameter that are no higher than 12 inches above a properly installed and maintained resilient surface;(4) Swinging exercise rings and trapeze bars on long chains or free swinging ropes;(5) Multiple occupancy swings, such as teeter-totters, gliders, or chair swings; or(6) Swinging gates and giant strides. Source Note: The provisions of this §747.4403 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4403 Are there some types of equipment that children must not use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188906 03/12/2026 (a) Yes. Children younger than five years of age must not be allowed to use the following pieces of equipment at or away from the child-care home:(1) Free standing arch climbers;(2) Free standing climbing pieces with flexible parts;(3) Fulcrum seesaws;(4) Log rolls;(5) Spiral slides with more than one 360 degree turn;(6) Track rides.(b) In addition, children younger than four years of age must not be allowed to use the following pieces of equipment at or away from the child-care home:(1) Chain or cable walks;(2) Horizontal ladders;(3) Vertical slide poles;(4) Over-head rings; or(5) Parallel bars. Source Note: The provisions of this §747.4405 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4405 Are there additional equipment restrictions for children younger than five years of age? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188907 03/12/2026 (a) You or someone you designate must inspect the indoor and outdoor active play space and equipment daily before children go out to play to ensure there are no hazards present.(b) You must ensure hazards or defects identified during the daily inspections are repaired promptly, and must arrange for protection of the children, or you must prohibit use of the hazardous equipment, until repairs can be made. Source Note: The provisions of this §747.4407 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4407 What special maintenance procedures must I follow for my active play space and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188908 03/12/2026 (a) All swing seats must be constructed of durable, lightweight, rubber or plastic material.(b) Edges of all swing seats must be smooth or rounded and have no protrusions.(c) Swings must not be attached to a composite play structure, unless they are on a swing set designed for residential use. Source Note: The provisions of this §747.4501 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4501 What are the safety requirements for swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188909 03/12/2026 Yes. Bucket swings are intended for use by children under four years of age with an adult present to lift and secure the child into the swing. Therefore, the distance between the surface under the swing and the bottom of a bucket swing must be at least 24 inches. This will minimize the likelihood of unsupervised young children climbing into the swing. Source Note: The provisions of this §747.4503 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4503 Are there additional safety requirements for bucket swings designed for tots? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188910 03/12/2026 Yes. Tire swings must also:(1) Not be made from heavy truck tires, or tires with exposed steel-belted radials;(2) Not be suspended from a composite structure or with other swings in the same bay;(3) Have drainage holes drilled in the underside of the tire and maintained to facilitate water drainage; and(4) Have a minimum clearance between the seating surface of a tire swing, and the uprights of the supporting structure must be 30 inches or more when the tire is in a position closest to the support structure. Source Note: The provisions of this §747.4505 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4505 Are there additional safety requirements for tire swings (multi-axis swings)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188911 03/12/2026 The use zone is the surface area under and around a piece of equipment onto which a child falling from or exiting from the equipment would be expected to land. Other than the equipment itself, the use zone must be free of obstacles that a child could run into or fall on top of and be injured. Source Note: The provisions of this §747.4601 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4601 What does Licensing mean by the term "use zone"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188912 03/12/2026 The use zone for stationary equipment, excluding slides, must extend a minimum of six feet in all directions from the perimeter of the equipment. Use zones for stationary equipment must not overlap other use zones. Source Note: The provisions of this §747.4603 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4603 How do I measure the use zone for stationary equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188913 03/12/2026 (a) The use zone in front of the access and to the sides of a slide must extend a minimum of six feet from the perimeter of the equipment.(b) For slides six feet high or less, the use zone in front of the exit of a slide must extend at least six feet.(c) For slides greater than six feet high, the use zone in front of the exit of a slide must be equal to the distance from the slide platform to the protective surfacing up to a maximum of eight feet.(d) The use zone in front of the slide exit must not overlap the use zone of any other equipment. Source Note: The provisions of this §747.4605 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4605 How do I measure the use zone for slides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188914 03/12/2026 (a) The use zone to the front and rear of a to-fro swing (single-axis swing) must extend twice the height of the vertical distance from the swing beam to the surface below.(b) The use zone to the front and rear of the to-fro swing must not overlap any other use zone.(c) The use zone around the sides of the to-fro swing structure (frame which supports the swings) must be at least six feet and may overlap the use zone of an adjacent swing structure. Source Note: The provisions of this §747.4607 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4607 How do I measure the use zone for to-fro swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188915 03/12/2026 (a) The use zone for tire swings or other multi-axis swings must extend in all directions for a distance equal to a distance from the swing beam to the top of the sitting surface of the tire, plus six feet.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the tire swing structure must be at least six feet, and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §747.4609 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4609 How do I measure the use zone for tire swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188916 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188916&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188916 03/12/2026 (a) The use zone to the front and rear of the bucket swing for tots must be at least two times the vertical distance from the swing beam to the top of the swing-sitting surface.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the bucket swing structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure Source Note: The provisions of this §747.4611 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4611 How do I measure the use zone for bucket swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188917 03/12/2026 (a) The use zone for rotating or rocking equipment on which the child sits must be at least six feet from the perimeter when not in use.(b) The use zone for rotating or rocking equipment or track rides on which the child stands or rides must be at least seven feet from the perimeter of the equipment when not in use.(c) The use zone for rocking or rotating equipment must not overlap any other use zone. Source Note: The provisions of this §747.4613 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4613 How do I measure the use zone for rotating or rocking equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188918 03/12/2026 (a) If your child-care home was registered or licensed before September 1, 2003, you must at least maintain the following use zones until you meet one of the conditions specified in subsection (b) of this section:(1) Four feet from climbing structures;(2) Five feet from the bottom of a slide. The other parts of the slide are considered a climbing structure;(3) Seven feet plus the length of a swing's chain from the point of suspension; and(4) Seven feet from a merry-go-round or other revolving devices.(b) A child-care home registered or licensed before September 1, 2003, must comply with the use zone requirements specified in this division, under the following circumstances:(1) A child-care home re-designs the existing playground or adds new playground equipment. The permit holder must meet use zone requirements specified in this division as the changes are made. You must submit a written plan for compliance to us upon request.(2) Your permit to operate is no longer valid. Source Note: The provisions of this §747.4615 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4615 Do these use zone requirements apply to my child-care home if it was registered or licensed before September 1, 2003? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188919 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188919&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188919 03/12/2026 Unitary surfacing materials are manufactured materials including rubber tiles, mats, or poured in place materials cured to form a unitary shock-absorbing surface. Source Note: The provisions of this §747.4707 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4707 What are unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188920 03/12/2026 (a) If you use unitary materials, they must be installed and maintained according to manufacturer's specifications.(b) Unitary materials may be installed over concrete or asphalt, only if recommended by the manufacturer. Source Note: The provisions of this §747.4709 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4709 How should unitary surfacing materials be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188921 03/12/2026 If you use unitary surfacing materials, you must have test data from the manufacturer showing the impact rating of the material (the maximum height of equipment that may be installed over the surfacing material), and installation and maintenance requirements. This documentation must be at your child-care home and made available for review by parents and Licensing staff upon request during hours of operation. Source Note: The provisions of this §747.4711 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4711 What documentation must I keep at my child-care home if I use unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220745 03/12/2026 You may use inflatable equipment both at and away from your child-care home if you follow these guidelines:(1) You use enclosed inflatables (such as bounce houses or moon bounces/walks) according to the manufacturer's instructions;(2) You use open inflatables (such as obstacle courses, slides, or games) according to the manufacturer's label and instructions for the user; and(3) Inflatables that include water activity also comply with all applicable requirements in Subchapter V of this chapter (relating to Swimming Pools, Wading Pools, and Sprinkler Play). Source Note: The provisions of this §747.4751 adopted to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES U INDOOR AND OUTDOOR ACTIVE PLAY SPACE AND EQUIPMENT §747.4751 May I use inflatable active play equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220746 03/12/2026 In addition to complying with the child/caregiver ratios specified in §747.2005 of this chapter (relating to What are the child/caregiver ratios for swimming activities?) and other safety requirements specified in §747.2009 of this chapter (relating to Must I have a certified lifeguard on duty when children are swimming in more than 18 inches of water?) and §747.2013 of this chapter (relating to Must persons who are counted in the child/caregiver ratio during swimming know how to swim?), you must comply with the following safety precautions when any child uses a swimming pool both at and away from your child-care home:(1) A minimum of two life-saving devices must be available;(2) One additional life-saving device must be available for each 2,000 square feet of water surface;(3) Drain grates must be in place, in good repair, and must not be able to be removed without using tools;(4) Pool chemicals and pumps must be inaccessible to any child;(5) Machinery rooms must be locked when a child is present;(6) Caregivers must be able to clearly see all parts of the swimming area;(7) The bottom of the pool must be visible at all times; and(8) An adult must be present who is able to immediately turn off the pump and filtering system when a child is in a pool. Source Note: The provisions of this §747.4801 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4801 What safety precautions must I follow when a child in my care uses a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188922 03/12/2026 Swimming pools at the child-care home must be maintained according to the standards of the Texas Department of State Health Services for public pools, and any other state or local regulations. Source Note: The provisions of this §747.4803 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4803 How should the swimming pool be maintained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188923 03/12/2026 Yes. Above-ground pools must meet all pool safety requirements specified in this subchapter and must have a barrier that prevents a child's access to the pool. Source Note: The provisions of this §747.4805 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4805 Do the same safety precautions apply for above-ground pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188924 03/12/2026 (a) You must prevent children from entering the pool area by a wall, fence, or other durable impenetrable barrier at least four feet high.(b) Fence gates leading to the pool area must have self-closing and self-latching hardware out of children's reach. Gates must be locked when the pool is not in use.(c) Doors from the child-care home leading to the pool area must have a lock out of children's reach that can only be opened by an adult.(d) These doors and gates must not be designated as fire and emergency evacuation exits. Source Note: The provisions of this §747.4807 adopted to be effective September 1, 2003, 28 TexReg 146; amended to be effective April 15, 2017, 42 TexReg 19062; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4807 Must I have a fence around a swimming pool at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188925 03/12/2026 No. Although a fence and locked access provides a layer of protection for a child who strays from supervision and may deter some children from entering the pool area, these do not replace the need to supervise children at all times and monitoring of safety features to protect children from unsupervised access to the pool. Source Note: The provisions of this §747.4809 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4809 Does having a fence affect my duty to supervise children's access to the pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220747 03/12/2026 (a) Before a child who is unable to swim competently or who is at risk of injury or death when swimming enters a swimming pool, you must:(1) Provide the child with a Type I, II, or III United States Coast Guard approved personal flotation device (PFD);(2) Ensure the child is wearing the PFD; and(3) Ensure the PFD is properly fitted and fastened for the child.(b) A PFD must be in good repair to meet the requirements in subsection (a) of this section. Source Note: The provisions of this §747.4811 adopted to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4811 What additional safety precautions must I take for a child in care who is unable to swim competently or who is at risk of injury or death when swimming? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220748 03/12/2026 You are not required to provide the child with a PFD or ensure the child is wearing the device if:(1) The child is actively participating in swim instruction or a competition; and(2) You ensure that the child is supervised in accordance with §747.1503 of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?) during the instruction or competition. Source Note: The provisions of this §747.4812 adopted to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4812 Must I provide a personal flotation device (PFD) to a child in care who is unable to swim competently or who is at risk of injury or death when swimming when the child is participating in swim instruction or a competition? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220749 03/12/2026 (a) Wading pools used at your child-care home must be:(1) Stored out of children's reach when not in use;(2) Drained and sanitized at least daily; and(3) Stored so they cannot hold water.(b) You must comply with the safety precautions specified in §747.4801 of this subchapter (relating to What safety precautions must I follow when a child in my care uses a swimming pool?) when using wading pools away from your child-care home. Source Note: The provisions of this §747.4813 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4813 What are the safety requirements for wading pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188928 03/12/2026 (a) You must ensure that no child uses sprinkler equipment on or near a hard, slippery surface, such as a concrete driveway, sidewalk, or patio.(b) You must not leave a child alone with the sprinkler equipment.(c) You must store sprinkler equipment and water hoses out of the reach of children when not in use.(d) You must maintain your splash pad/sprinkler play area according to manufacturer's instructions. Source Note: The provisions of this §747.4815 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4815 Are there specific safety requirements for sprinkler play? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220750 03/12/2026 You must not allow a child to swim in a body of water other than a swimming pool that complies with the rules specified in this subchapter. Source Note: The provisions of this §747.4817 adopted to be effective July 1, 2005, 30 TexReg 3602; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 26, 2024, 49 TexReg 7358. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES V SWIMMING POOLS, WADING POOLS, AND SPRINKLER PLAY §747.4817 Can a child in my care swim in a body of water other than a swimming pool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188930 03/12/2026 We do not regulate fire inspections and do not require that you have a fire inspection as part of these minimum standards; however your local ordinances may require one. If you want to care for children above or below the ground floor of your child-care home, you must obtain written approval from the state or local fire marshal as specified in §747.4015 of this title (relating to May I care for children above or below ground level?). Source Note: The provisions of this §747.4901 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.4901 Must I have a fire inspection of my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188931 03/12/2026 An emergency preparedness plan is designed to ensure the safety of children during an emergency by addressing staff responsibility and your home's readiness with respect to emergency evacuation, relocation, and sheltering/lock-down. The plan addresses the types of responses to emergencies most likely to occur in your area including:(1) An evacuation of your home to a designated safe area in an emergency such as a fire or gas leak;(2) A relocation of the children and caregivers to a designated, alternate shelter in an emergency such as a flood, a hurricane, medical emergency, or communicable disease outbreak; and(3) The sheltering and lock-down of children and caregivers within your home to temporarily protect them from situations such as a tornado, volatile person on the premises, or an endangering person in the area. Source Note: The provisions of this §747.5001 adopted to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5001 What is an emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188932 03/12/2026 Your emergency preparedness plan must include written procedures for:(1) Evacuation, relocation, and sheltering/lock-down of children, including:(A) Your first responsibility in an emergency evacuation or relocation is to move the children to a designated safe area or alternate shelter known to all household members, caregivers, parents, and volunteers;(B) How children will be evacuated or relocated to the designated safe area or alternate shelter, including specific procedures for evacuating or relocating children who are under 24 months of age, who have limited mobility, or who otherwise may need assistance in an emergency, such as children who have mental, visual, or hearing impairments;(C) An emergency evacuation and relocation diagram as outlined in §747.5007 of this title (relating to Must I have an emergency evacuation and relocation diagram?);(D) The caregivers' responsibility in a sheltering/lock-down emergency for the orderly movement of children to a designated location in your home where children should gather;(E) Name and address of the alternate shelter away from your home you will use as needed; and(F) How children in attendance at the time of the emergency will be accounted for at the designated safe area or alternate shelter;(2) Communication, including:(A) The emergency telephone number that is on file with us; and(B) How you will communicate with local authorities (such as fire, law enforcement, emergency medical services, and health department), parents, and us;(3) How you will evacuate and relocate with the essential documentation including:(A) Parent and emergency contact telephone numbers for each child in care;(B) Authorization for emergency care for each child in care; and(C) The attendance record information for children in care at the time of the emergency;(4) How you will continue to care for the children until each child has been released; and(5) How you will reunify the children with their parents as the evacuation, relocation, or sheltering/lock-down is lifted. Source Note: The provisions of this §747.5003 adopted to be effective December 1, 2010, 35 TexReg 10266; amended to be effective June 1, 2014, 39 TexReg 3724; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5003 What must my emergency preparedness plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188933 03/12/2026 Yes, the following components of your home's emergency preparedness plan must be practiced as follows:(1) You must practice a fire drill every month. The children must be able to safely exit the child-care home within three minutes; and(2) You must practice a sheltering drill for severe weather at least four times in a calendar year; and(3) You must practice a lock-down drill for a volatile or endangering person on the premises or in the area at least four times in a calendar year. Source Note: The provisions of this §747.5005 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective September 1, 2016, 41 TexReg 6250; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5005 Must I practice my emergency preparedness plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188934 03/12/2026 Your emergency evacuation and relocation diagram must be on file at your child-care home and must show the following:(1) A floor plan of your child-care home;(2) Two exit paths from each room, unless a room opens directly to the outdoors at ground level;(3) The designated location outside the child-care home where all adults and children meet to ensure everyone has exited the home safely; and(4) The designated location inside the home where all adults and children take shelter from threatening weather. Source Note: The provisions of this §747.5007 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5007 Must I have an emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188935 03/12/2026 No. You are not required to post an emergency evacuation and relocation diagram, however, if you leave a substitute in charge of your child-care home, a copy of the diagram must be readily accessible to the substitute caregiver. Source Note: The provisions of this §747.5009 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5009 Must I post an emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188936 03/12/2026 (a) Your child-care home must have at least two exits to the outside, located in distant parts of the home.(b) You must be able to immediately open any locked doors used as exits.(c) You must not count doors that are blocked as exits.(d) An exit through a kitchen or other hazardous area may not be one of the required exits. Source Note: The provisions of this §747.5011 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5011 How many exits must my child-care home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188940 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188940 03/12/2026 You may count a window as an exit for your child-care home if all children in care and caregivers are physically able to get through the window to the ground outside safely and quickly. Source Note: The provisions of this §747.5013 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5013 May a window count as one of the designated exits for my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188941 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188941 03/12/2026 Yes. You must have a battery-powered source of emergency lighting readily accessible in case of electrical failure. Source Note: The provisions of this §747.5015 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5015 Must I have emergency lighting in case of an emergency evacuation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188943 03/12/2026 Yes. Your child-care home must have a fire-extinguishing system. This may be a sprinkler system and/or fire extinguishers. The state or local fire marshal must approve a sprinkler system. Source Note: The provisions of this §747.5101 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5101 Must my child-care home have a fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188944 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188944&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188944 03/12/2026 Yes, you must have at least one 3A-40BC dry chemical fire extinguisher, or a fire extinguisher approved by a state or local fire marshal. Source Note: The provisions of this §747.5103 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5103 Am I required to have a fire extinguisher? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188937 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188937 03/12/2026 You must mount all fire extinguishers on the wall by a hanger or bracket. The top of all extinguishers must be no higher than five feet above the floor and the bottom at least four inches above the floor or any other surface. If a state or local fire marshal or the manufacturer's instructions has different mounting instructions, you must follow those instructions. All fire extinguishers must be readily available for immediate use by household members and caregivers. Source Note: The provisions of this §747.5105 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5105 Where must I mount fire extinguishers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188938 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188938&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188938 03/12/2026 (a) You must:(1) Inspect all fire extinguishers monthly;(2) Record the date of the inspection; and(3) Keep this record at your child-care home.(b) You must service fire extinguishers as needed and required by the manufacturer's instructions, or as required by the state or local fire marshal. Source Note: The provisions of this §747.5107 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5107 How often must I inspect and service fire extinguishers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188939 03/12/2026 If you use a sprinkler system:(1) The monitoring company or a state or local fire marshal must test the system at least annually;(2) You must document the date of the inspection, and the name and telephone number of the inspector; and(3) You must keep the most recent inspection report at your child-care home. Source Note: The provisions of this §747.5109 adopted to be effective September 1, 2003, 28 TexReg 146; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5109 How often must I inspect my sprinkler system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188942 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188942 03/12/2026 Yes. Your child-care home must have a working smoke-detection system. This may be an electronic alarm and smoke detection system or individual electric or battery- operated smoke detectors located in each room used by children. Source Note: The provisions of this §747.5111 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5111 Must my child-care home have a smoke-detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188945 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188945 03/12/2026 Smoke detectors must be installed and maintained according to the manufacturer's instructions, or in compliance with the state or local fire marshal's instructions. Source Note: The provisions of this §747.5113 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5113 How must smoke detectors be installed at my child-care home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188946 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188946 03/12/2026 You must:(1) Test all smoke detectors monthly;(2) Record the date of the test and date of the installation of new batteries; and(3) Keep this record at your child-care home. Source Note: The provisions of this §747.5115 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5115 How often must the smoke detectors at my child-care home be tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188947 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188947 03/12/2026 If you use an electronic smoke alarm system;(1) The monitoring company or state or local fire marshal must test the system at least annually;(2) You must document the date of the inspection and the name and telephone number of the inspector; and(3) You must keep the most recent inspection report at your child-care home. Source Note: The provisions of this §747.5117 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5117 How often must I have an electronic smoke alarm system tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188948 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188948 03/12/2026 We do not require that your home have a gas leak inspection as a part of these minimum standards; however, your local ordinances may require one. Source Note: The provisions of this §747.5201 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5201 Must I have my child-care home inspected for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188949 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188949 03/12/2026 (a) Gas appliances must have metal tubing and connections, be in good repair and free from leaks.(b) Open flame heaters (heaters where the flame can be easily touched or accessed) are prohibited.(c) Space heaters must be enclosed and have the seal of approval of a United States test laboratory, or be approved by the state or local fire marshal.(d) You must safeguard floor and wall furnace grates, steam and hot water pipes, and electric space heaters so that children do not have access to them.(e) Liquid fuel heaters are prohibited.(f) Gas fuel heaters, fireplaces, and wood-burning stoves must be properly vented to the outside.(g) If you use a fireplace, wood-burning stove, or space heater, you must install a screen or guard with sufficient strength to prevent children from falling into the fire or against the stove or heater. Source Note: The provisions of this §747.5301 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5301 What steps must I take to ensure that heating devices used at my child-care home do not present hazards to children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188950 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188950 03/12/2026 A registered or licensed child-care home must be equipped with a working carbon monoxide detection system unless it is located in a school facility that complies:(1) With the school facility standards adopted by the commissioner of education under the Education Code, §46.008; or(2) With standards adopted by the board of a local school district that are similar to those described in paragraph (1) of this section. Source Note: The provisions of this §747.5331 adopted to be effective January 1, 2004, 28 TexReg 11355; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5331 Must my child-care home have a carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188951 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188951 03/12/2026 You must install:(1) Individual electric (plug-in or hardwire) or battery-operated carbon monoxide detectors that meet Underwriters Laboratories Inc. requirements (UL-Listed); or(2) An electronic carbon monoxide detection system connected to an electronic alarm/smoke detection system that is UL-Listed. Source Note: The provisions of this §747.5333 adopted to be effective January 1, 2004, 28 TexReg 11355; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5333 What type of carbon monoxide detection system must I install? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188953 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188953 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors:(1) At least one detector must be installed on every level of each building in the child-care operation; and(2) The detector(s) must be installed in compliance with the state or local fire marshal's instructions.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, the system must be installed according to the state or local fire marshal's instructions. Source Note: The provisions of this §747.5335 adopted to be effective January 1, 2004, 28 TexReg 11355; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5335 How many carbon monoxide detectors must be installed in my child-care home and how must they be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188952 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188952 03/12/2026 (a) If you use electric or battery-operated carbon monoxide detectors, you must:(1) Install a new battery in each battery-operated detector at least annually;(2) Test all detectors monthly;(3) Document the date of the test and the date of installation of new batteries; and(4) Keep this documentation at the home for review during hours of operation.(b) If you use an electronic carbon monoxide detection system connected to an alarm/smoke detection system, you must:(1) Ensure the system monitoring company or the state or local fire marshal inspects and tests the system at least annually;(2) Keep the most recent inspection report at the child-care home for review during hours of operation;(3) Ensure the report includes the date of the inspection and the inspector's name and telephone number; and(4) Make any corrections required in the report. Source Note: The provisions of this §747.5337 adopted to be effective January 1, 2004, 28 TexReg 11355; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES W FIRE SAFETY AND EMERGENCY PRACTICES §747.5337 How often must I inspect and service the carbon monoxide detection system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188954 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188954 03/12/2026 We regulate all transportation provided by or for the child-care home to children in care, including transportation between the child's home and the school, the child's home and your home, your home and the school, your home or the school and field trip locations, and your home or the school and other drop-off locations. Source Note: The provisions of this §747.5401 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5401 What types of transportation does Licensing regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188955 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188955 03/12/2026 (a) We do not regulate the type of vehicle you use to transport children, although we recommend that you check with the Texas Department of Motor Vehicles or refer to the federal motor vehicle safety standards regulating transportation to and from school and your operation.(b) For the purpose of this chapter, we categorize vehicle types as:(1) General purpose vehicle--passenger vehicles as defined in the Texas Transportation Code §545.412, and buses that do not meet the federal motor vehicle safety standards for school buses or multi-function school activity buses (MFSAB);(2) Small school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a gross vehicle weight rating (GVWR) of 10,000 pounds or less; and(3) Large school bus--school buses and MFSABs that meet federal motor vehicle safety standards for school buses and MFSABs respectively and have a GVWR of greater than 10,000 pounds.(c) All vehicles must be maintained in safe operating condition at all times. Source Note: The provisions of this §747.5403 adopted to be effective December 1, 2010, 35 TexReg 10266; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5403 What type of vehicle may I use to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188956 03/12/2026 You must take the following precautions when loading and unloading children from any vehicle, including any type of bus:(1) You must load and unload children at the curbside of the vehicle or in a protected parking area or driveway;(2) You must not allow a child to cross a street anytime before a child enters or exits a vehicle, unless the child is accompanied by an adult;(3) You must account for all children exiting the vehicle before leaving the vehicle unattended; and(4) You must never leave a child unattended in a vehicle. Source Note: The provisions of this §747.5405 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5405 What safety precautions must I take when loading and unloading children from the vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=212787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 212787 03/12/2026 (a) You must use a child passenger safety seat system to restrain a child when transporting the child. The restraint system:(1) Must meet the federal standards for crash-tested systems as set by the National Highway Traffic Safety Administration; and (2) Must be properly secured in the vehicle according to manufacturer's instructions.(b) You must use child safety seats and child booster seats that have not expired or been damaged or involved in an accident.(c) You must secure each child in an infant safety seat, rear-facing convertible child safety seat, forward-facing child safety seat, child booster seat, safety vest, harness, or a safety belt, as appropriate to the child's age, height, and weight according to manufacturer's instructions for all vehicles specified in subsection (e) of this section, unless otherwise noted in this subchapter. (d) A child 12 years old or younger must not ride in the front seat of a vehicle. (e) The following safety restraint devices for a child must be used when the vehicle is on and during all times when the vehicle is in motion: Attached Graphic Source Note: The provisions of this §747.5407 adopted to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective March 1, 2023, 48 TexReg 950. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5407 What child passenger safety seat system must I use when I transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188958 03/12/2026 (a) The driver must be properly restrained by a safety belt before starting the vehicle and at all times the vehicle is in motion.(b) All adult passengers in a vehicle transporting children, other than a large school bus, must be properly restrained by safety belts. Source Note: The provisions of this §747.5409 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective December 1, 2010, 35 TexReg 10266; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5409 Must caregivers and/or the driver wear a safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188959 03/12/2026 Parents may provide the child passenger safety seat system for use in transporting their child, if the equipment is appropriate and can be properly secured in the vehicle. You must use the equipment according to manufacturer's instructions. Source Note: The provisions of this §747.5411 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5411 May parents provide the child passenger safety seat equipment required for their child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188960 03/12/2026 No. Only one person may use each safety belt. Source Note: The provisions of this §747.5413 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5413 May I place more than one person in each safety belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188961 03/12/2026 A child may ride in a safety belt with a shoulder harness if the shoulder harness goes across the child's chest and not across the child's face or neck. The lap belt should fit low across the child's thighs or top of the legs and not across the child's stomach area. Never put a shoulder belt under the child's arm or behind the child's back. If the lap belt and shoulder harness do not fit properly, a booster seat must be used. Source Note: The provisions of this §747.5415 adopted to be effective September 1, 2003, 28 TexReg 1462; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5415 May a child ride in a safety belt with a shoulder harness? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188962 03/12/2026 (a) You must have the following in each vehicle used to transport children:(1) A list of the children being transported;(2) Emergency medical transport and treatment authorization forms for each child being transported; and(3) Parent's names and telephone numbers and emergency telephone numbers for each child being transported; and(b) The driver must have a current driver's license and carry it while transporting children. Source Note: The provisions of this §747.5417 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5417 Must I carry specific information in the vehicles used to transport children in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188963 03/12/2026 You must ensure the caregiver who is transporting a child has clear instructions for handling emergency breakdowns and accidents, including vehicle evacuation procedures, supervision of the children, and contacting emergency help. Source Note: The provisions of this §747.5419 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5419 What plan must I have to handle transportation emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188964 03/12/2026 Yes, in case of an emergency you must have a communications device such as a cellular phone or two-way radio when transporting a child. Source Note: The provisions of this §747.5421 adopted to be effective September 1, 2003, 28 TexReg 1462; amended to be effective April 15, 2017, 42 TexReg 1906; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 747 MINIMUM STANDARDS FOR CHILD-CARE HOMES X TRANSPORTATION §747.5421 Must I have a communications device in a transportation vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188969 03/12/2026 The purpose of this chapter is to set forth rules that apply to General Residential Operations and Residential Treatment Centers. Source Note: The provisions of this §748.1 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS A PURPOSE AND SCOPE §748.1 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188966 03/12/2026 (a) For a licensed general residential operation, the permit holder must ensure compliance with the minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of services that your operation does not offer. For example, if we license your operation to offer emergency care services only, you do not have to comply with the minimum standards that apply to treatment services for a child with an emotional disorder, treatment services for a child with an intellectual disability, or a transitional living program; however, you must comply with all other applicable minimum standards of this chapter.(b) For an unlicensed general residential operation that is subject to Licensing's regulation, the operation's administrator, owner, or operator or any other controlling person who has the ability to influence or direct the operation's management, expenditures, or policies must ensure compliance with all minimum standards in this chapter at all times, with the exception of those minimum standards identified for specific types of services that the unlicensed operation does not offer. Source Note: The provisions of this §748.3 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS A PURPOSE AND SCOPE §748.3 Who is responsible for complying with these minimum standards? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188967 03/12/2026 Residential Treatment Centers (RTCs) are general residential operations that provide treatment services to children with emotional disorders. RTCs, by definition, must always comply with the rules of this chapter as if 100% of the children in their care require treatment services for emotional disorders. This includes, but is not limited to, services to individual children, personnel requirements, and child/caregiver ratio requirements. Source Note: The provisions of this §748.5 adopted to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS A PURPOSE AND SCOPE §748.5 How do Residential Treatment Centers comply with the rules of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209514 03/12/2026 (a) Definition. A family residential center is one that meets all of the following requirements:(1) The center is operated by or under a contract with United States Immigration and Customs Enforcement;(2) The center is operated to enforce federal immigration laws;(3) Each child at the center is detained with a parent or other adult family member, who remains with the child at the center; and(4) A parent or family member with a child provides the direct care for the child except for specific circumstances when the child is cared for directly by the center or another adult in the custody of the center.(b) Classification. A family residential center is a general residential operation (GRO) and must comply with all associated requirements for GROs, unless the family residential center is approved for an individual waiver or variance or an exception is provided in this section. The department is responsible for regulating the provision of childcare as authorized by Chapters 40 and 42, Texas Human Resources Code and Chapter 261, Texas Human Resources Code. The department does not oversee requirements that pertain to other law, including whether the facilities are classified as secure or in compliance with any operable settlement agreements or other state or federal restrictions.(c) Exceptions. A family residential center is not required to comply with all terms of the following Minimum Standards:(1) the limitation of room occupants to four in §748.3357 of this title (relating to What are the requirements for floor space in a bedroom used by a child?), except that nothing in this exception shall be construed to require fewer than 60 square feet per child;(2) the limitation on a child sharing a bedroom with an adult in §748.3361 of this title (relating to May a child in care share a bedroom with an adult?), if the bedroom is being shared in order to allow a child to remain with the child's parent or other family member; and(3) the limitations on children of the opposite gender sharing a room in §748.3363 of this title (relating to May children of opposite genders share a bedroom?), except that nothing in this exception shall be construed to permit children from different families who are over the age of six and members of the opposite gender to share a bedroom.(d) Limitation of exception. Notwithstanding subsection (c) of this section, and as further described in §745.8313 of this title (relating to Is a waiver or variance unconditional?), the department retains the authority for placing conditions on the scope of the exceptions authorized for a family residential center, including conditions related to limiting occupancy in accordance with fire safety standards, limitations related to allowing children and adults of the opposite gender to occupy the same room only if they are part of the same family, and any other limitation determined by the department to be necessary to the health, safety, or welfare of children in care.(e) Division of responsibility. In addition to the application materials described in §745.243(6) of this title (relating to What does a completed application for a permit include?), an applicant for a license under this section must submit the policies, procedures, and any other documentation that the department deems necessary to clarify the division of supervisory and caretaking responsibility between employees of the facility and the parents and other adult family members who are housed with the children. The department must approve the documentation during the application process and any subsequent amendments to the policies and procedures.(f) Applicability. This rule is applicable only to the extent that a GRO may provide care to children who are unlawfully present in the United States and in the custody of the federal government. Source Note: The provisions of this §748.7 adopted to be effective March 1, 2016, 41 TexReg 1493; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 8, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS A PURPOSE AND SCOPE §748.7 How are these regulations applied to family residential centers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188989 03/12/2026 The following words have the following meanings in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated.(2) We, us, our, and Licensing--The Licensing Division of the Department of Family and Protective Services (DFPS). Source Note: The provisions of this §748.41 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.41 What do certain pronouns mean in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211289 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211289&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211289 03/12/2026 The words and terms used in this chapter have the meanings assigned to them under §745.21 of this title (relating to What do the following words and terms mean when used in this chapter?), unless another meaning is assigned in this section or unless the context clearly indicates otherwise. The following words and terms have the following meanings, unless the context clearly indicates otherwise:(1) Accredited college or university--An institution of higher education accredited by one of the following regional accrediting entities:(A) The Southern Association of Colleges and Schools Commission on Colleges, a subdivision of the Southern Association of Colleges and Schools;(B) The Middle States Commission on Higher Education, a component of the Middle States Association of Colleges and Schools;(C) The Commission on Institutions of Higher Education, a subdivision of the New England Association of Schools and Colleges;(D) The Higher Learning Commission (formerly part of the North Central Association of Colleges and Schools);(E) The Northwest Commission on Colleges and Universities;(F) The Accrediting Commission for Senior Colleges and Universities, a subdivision of the Western Association of Schools and Colleges; or(G) The Accrediting Commission for Community and Junior Colleges, a subdivision of the Western Association of Schools and Colleges.(2) Activity space--An area or room used for child activities.(3) Adaptive functioning--Refers to how effectively a person copes with common life demands and how well the person meets standards of personal independence expected of someone in his particular age group, sociocultural background, and community setting.(4) Adult--A person 18 years old or older.(5) Caregiver--A person counted in the child/caregiver ratio, whose duties include the direct care, supervision, guidance, and protection of a child. This does not include a contract service provider who:(A) Provides a specific type of service to your operation for a limited number of hours per week or month; or(B) Works with one particular child.(6) Certified lifeguard--A person who has been trained in rescue techniques, lifesaving, and water safety by a qualified instructor from a recognized organization that awards a certificate upon successful completion of the training. A certified lifeguard ensures the safety of persons by preventing and responding to water related emergencies.(7) Chemical restraint--A prohibited type of emergency behavior intervention that uses chemicals or pharmaceuticals through topical application, oral administration, injection, or other means to immobilize or sedate a child as a mechanism of control. The use of a medication is not a chemical restraint under this chapter if the medication:(A) Is prescribed by a treating health-care professional;(B) Is administered solely for medical or dental reasons; and(C) Has a secondary effect of immobilizing or sedating a child.(8) Child in care--A child who is currently admitted as a resident of a general residential operation, regardless of whether the child is temporarily away from the operation, as in the case of a child at school or at work. Unless a child has been discharged from the operation, the child is considered a child in care.(9) Child passenger safety seat system--An infant or child passenger restraint system that meets the federal standards for crash-tested restraint systems as set by the National Highway Traffic Safety Administration.(10) Child/caregiver ratio--The maximum number of children for whom one caregiver can be responsible.(11) Childhood activities--Activities that are generally accepted as suitable for children of the same chronological age, level of maturity, and developmental level as determined by a reasonable and prudent parent standard as specified in §748.705 of this chapter (relating to What is the "reasonable and prudent parent standard"?). Examples of childhood activities include extracurricular activities, in-school and out-of-school activities, enrichment activities, cultural activities, and employment opportunities. Childhood activities include unsupervised childhood activities.(12) Contract service provider--A person or entity that is contracting with the operation to provide a service, whether paid or unpaid. Also referred to as "contract staff" and "contractor" in this chapter.(13) Corporation or other type of business entity--May include an association, corporation, nonprofit association, nonprofit corporation, nonprofit association with religious affiliation, nonprofit corporation with religious affiliation, limited liability company, political subdivision, or state agency. For purposes of this chapter, this definition does not include any type of "partnership," which is defined separately.(14) Cottage or cottage home--A living arrangement for children who are not receiving treatment services in which:(A) Each group of children has separate living quarters;(B) 12 or fewer children are in each group;(C) Primary caregivers live in the children's living quarters, 24 hours per day for at least four days a week or 15 days a month; and(D) Other caregivers are used only to meet the child-to-caregiver ratio in an emergency or to supplement care provided by the primary caregivers.(15) Counseling--A procedure used by professionals from various disciplines in guiding individuals, families, groups, and communities by such activities as delineating alternatives, helping to articulate goals, processing feelings and options, and providing needed information. This definition does not include career counseling.(16) Days--Calendar days, unless otherwise stated.(17) De-escalation--Strategies used to defuse a volatile situation, to assist a child to regain behavioral control, and to avoid a physical restraint or other behavioral intervention.(18) Department--The Texas Department of Family and Protective Services (DFPS).(19) Discipline--A form of guidance that is constructive or educational in nature and appropriate to the child's age, development, situation, and severity of the behavior.(20) Emergency behavior intervention (EBI)--Interventions used in an emergency situation, including personal restraints, mechanical restraints, emergency medication, and seclusion.(21) Emergency medication--A type of emergency behavior intervention that uses chemicals or pharmaceuticals through topical application, oral administration, injection, or other means to modify a child's behavior. The use of a medication is not an emergency medication under this chapter if the medication:(A) Is prescribed by a treating health-care professional;(B) Is administered solely for a medical or dental reason (e.g. Benadryl for an allergic reaction or medication to control seizures); and(C) Has a secondary effect of modifying a child's behavior.(22) Emergency situation--A situation in which attempted preventative de-escalatory or redirection techniques have not effectively reduced the potential for injury, so that intervention is immediately necessary to prevent:(A) Imminent probable death or substantial bodily harm to the child because the child attempts or continually threatens to commit suicide or substantial bodily harm; or(B) Imminent physical harm to another because of the child's overt acts, including attempting to harm others. These situations may include aggressive acts by the child, including serious incidents of shoving or grabbing others over their objections. These situations do not include verbal threats or verbal attacks.(23) Employee--A person an operation employs full-time or part-time to work for wages, salary, or other compensation. For the purposes of this chapter, employees include all operation staff and any owner who is present at the operation or transports any child in care.(24) Family members--An individual related to another individual within the third degree of consanguinity or affinity. For the definitions of consanguinity and affinity, see Chapter 745 of this title (relating to Licensing). The degree of the relationship is computed as described in Government Code, §573.023 (relating to Computation of Degree of Consanguinity) and §573.025 (relating to Computation of Degree of Affinity).(25) Field trip--A group activity conducted away from the operation.(26) Food service--The preparation or serving of meals or snacks.(27) Full-time--At least 30 hours per week.(28) Garbage--Food or items that when deteriorating cause offensive odors and/or attract rodents, insects, and other pests.(29) General Residential Operation--A residential child-care operation that provides child care for seven or more children or young adults. The care may include treatment services or programmatic services. These operations include formerly titled emergency shelters, operations providing basic child care, residential treatment centers, and halfway houses.(30) Governing body--A group of persons or officers of the corporation or other type of business entity having ultimate authority and responsibility for the operation.(31) Grounds--Includes any parcel of land where the operation is located and any building, other structure, body of water, play equipment, street, sidewalk, walkway, driveway, parking garage, or parking lot on the parcel. Also referred to as "premises" in this chapter.(32) Group of children--Children assigned to a specific caregiver or specific caregivers. Generally, the group stays with the assigned caregivers throughout the day and may move to different areas throughout the operation, indoors and out. For example, children who are assigned to specific caregivers occupying a unit or cottage are considered a group.(33) Health-care professional--A licensed physician, licensed advanced practice registered nurse (APRN), physician's assistant, licensed vocational nurse (LVN), licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the person's license. This does not include physicians, nurses, or other medical personnel not licensed to practice in the United States or in the country in which the person practices.(34) High-risk behavior--Behavior of a child that creates an immediate safety risk to self or others. Examples of high-risk behavior include suicide attempt, self-abuse, physical aggression causing bodily injury, chronic running away, substance abuse, fire-setting, and sexual aggression or perpetration.(35) Human services field--A field of study that contains coursework in the social sciences of psychology and social work including some counseling classes focusing on normal and abnormal human development and interpersonal relationship skills from an accredited college or university. Coursework in guidance counseling does not apply.(36) Immediate danger--A situation where a prudent person would conclude that bodily harm would occur if there were no immediate interventions. Immediate danger includes a serious risk of suicide, serious physical injury to self or others, or the probability of bodily harm resulting from a child running away. Immediate danger does not include:(A) Harm that might occur over time or at a later time; or(B) Verbal threats or verbal attacks.(37) Infant--A child from birth through 17 months.(38) Livestock--An animal raised for human consumption or an equine animal.(39) Living quarters--A structure or part of a structure where a group of children reside, such as a building, house, cottage, or unit.(40) Mechanical restraint--A type of emergency behavior intervention that uses the application of a device to restrict the free movement of all or part of a child's body in order to control physical activity.(41) Mental health professional--Refers to:(A) A psychiatrist licensed by the Texas Medical Board;(B) A psychologist licensed by the Texas State Board of Examiners of Psychologists;(C) A master's level social worker or higher licensed by the Texas State Board of Social Work Examiners;(D) A professional counselor licensed by the Texas State Board of Examiners of Professional Counselors;(E) A marriage and family therapist licensed by the Texas State Board of Examiners of Marriage and Family Therapists; and(F) A master's level or higher nurse licensed as an Advanced Practice Registered Nurse by the Texas Board of Nursing and board certified in Psychiatric/Mental Health.(42) Non-ambulatory--A child that is only able to move from place to place with assistance, such as a walker, crutches, a wheelchair, or prosthetic leg.(43) Non-mobile--A child that is not able to move from place to place, even with assistance.(44) Normalcy--See §748.701 of this chapter (relating to What is "normalcy"?).(45) Operation--General residential operations, including residential treatment centers.(46) Owner--The sole proprietor, partnership, or corporation or other type of business entity who owns the operation.(47) Parent--A person or entity that has legal responsibility for or legal custody of a child, including the managing conservator, or legal guardian of the child or a legally authorized representative of an entity with that status.(48) Partnership--A partnership may be a general partnership, (general) limited liability partnership, limited partnership, or limited partnership as limited liability partnership.(49) Permit holder--The owner of the operation that is granted the permit.(50) Permit is no longer valid--For purposes of this chapter, a permit remains valid through the renewal process. A permit only becomes invalid when your operation voluntarily closes or is required to close through an enforcement action in Subchapter L of Chapter 745 (relating to Enforcement Actions).(51) Person legally authorized to give consent--The person legally authorized to give consent by the Texas Family Code or a person authorized by the court.(52) Personal restraint--A type of emergency behavior intervention that uses the application of physical force without the use of any device to restrict the free movement of all or part of a child's body in order to control physical activity.(53) Physical force--Pressure applied to a child's body that reduces or eliminates the child's ability to move freely.(54) Premises--See the term "grounds" and its definition in this section.(55) PRN--A standing order or prescription that applies "pro re nata" or "as needed according to circumstances."(56) Prone restraint--A restraint in which the child is placed in a chest-down hold.(57) Psychosocial assessment--An evaluation by a mental health professional of a child's mental health that includes a:(A) Clinical interview of the child;(B) Diagnosis from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), or statement that rules out a DSM-5 diagnosis;(C) Treatment plan for the child, including whether further evaluation of the child is needed (for example: is a psychiatric evaluation needed to determine if the child would benefit from psychotropic medication or hospitalization; or is a psychological evaluation with psychometric testing needed to determine if the child has a learning disability or an intellectual disability); and(D) Written summary of the assessment.(58) Re-evaluate--Re-assessing all factors required for the initial evaluation for the purpose of determining if any substantive changes have occurred. If substantive changes have occurred, these areas must be fully evaluated.(59) Regularly--On a recurring, scheduled basis. Note: For the definition for "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title (relating to What words must I know to understand this subchapter?).(60) Residential child-care operation--A licensed or certified operation that provides residential child care. Also referred to as a "residential child-care facility."(61) Residential Treatment Center (RTC)--A general residential operation for seven or more children or young adults that exclusively provides treatment services for children with emotional disorders.(62) Sanitize--The use of a product (usually a disinfecting solution) registered by the Environmental Protection Agency (EPA) that substantially reduces germs on inanimate objects to levels considered safe by public health requirements. Many bleach and hydrogen peroxide products are EPA-registered. You must follow the product's labeling instructions for sanitizing (paying particular attention to any instructions regarding contact time and toxicity on surfaces likely to be mouthed by children, such as toys and crib rails). For an EPA-registered sanitizing product or disinfecting solution that does not include labeling instructions for sanitizing (a bleach product, for example), you must conduct these steps in the following order:(A) Washing with water and soap;(B) Rinsing with clear water;(C) Soaking in or spraying on a disinfecting solution for at least two minutes. Rinsing with cool water only those items that a child is likely to place in his mouth; and(D) Allowing the surface or item to air-dry.(63) School-age child--A child who is five years old or older and is enrolled in or has completed kindergarten.(64) Seat belt--A lap belt and any shoulder strap included as original equipment on or added to a motor vehicle.(65) Seclusion--A type of emergency behavior intervention that involves the involuntary separation of a child from other children and the placement of the child alone in an area from which the child is prevented from leaving. Examples of such an area include where the child is prevented from leaving by a physical barrier, force, or threat of force.(66) Service plan--A plan that identifies a child's basic and specific needs and how those needs will be met.(67) Short personal restraint--A personal restraint that does not last longer than one minute before the child is released.(68) State or local fire authority--A fire official who is authorized to conduct fire safety inspections on behalf of the city, county, or state government, including certified fire inspectors.(69) State or local sanitation official--A sanitation official who is authorized to conduct environmental sanitation inspections on behalf of the city, county, or state government.(70) Substantial physical injury--Physical injury serious enough that a reasonable person would conclude that the injury needs treatment by a medical professional, including dislocated, fractured, or broken bones; concussions; lacerations requiring stitches; second and third degree burns; and damages to internal organs. Evidence that physical injury is serious includes the location, severity of the bodily harm, and age of the child. Substantial physical injury does not include minor bruising, the risk of minor bruising, or similar forms of minor bodily harm that will resolve healthily without professional medical attention.(71) Supine restraint--Placing a child in a chest up restraint hold.(72) Supplements--Includes vitamins, herbs, and any supplement labeled dietary supplement.(73) Swimming activities--Activities related to the use of swimming pools, wading/splashing pools, hot tubs, or other bodies of water.(74) Toddler--A child from 18 months through 35 months.(75) Trafficking victim--A child who has been recruited, harbored, transported, provided or obtained for the purpose of forced labor or commercial sexual activity, including any child subjected to an act or practice as specified in Texas Penal Code §20A.02 or §20A.03.(76) Trauma informed care (TIC)--Care for children that is child-centered and considers the unique culture, experiences, and beliefs of the child. TIC takes into consideration:(A) The impact that traumatic experiences have on the lives of children;(B) The symptoms of childhood trauma;(C) An understanding of a child's personal trauma history;(D) The recognition of a child's trauma triggers; and(E) Methods of responding that improve a child's ability to trust, to feel safe, and to adapt to changes in the child's environment.(77) Treatment director--The person responsible for the overall treatment program providing treatment services. A treatment director may have other responsibilities and may designate treatment director responsibilities to other qualified persons.(78) Universal precautions--An approach to infection control where all human blood and certain human bodily fluids are treated as if known to be infectious for the human immunodeficiency virus (HIV), the hepatitis B virus (HBV), and other blood-borne pathogens.(79) Unsupervised childhood activities--Childhood activities that a child in care participates in away from the operation and the caregivers. Childhood activities that an operation sponsors, conducts, or supervises are not unsupervised childhood activities. Unsupervised childhood activities may include playing sports, going on field trips, spending the night with a friend, going to the mall, or dating. Unsupervised childhood activities may last one or more days.(80) Vaccine-preventable disease--A disease that is included in the most current recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.(81) Volunteer--A person who provides:(A) Child-care services, treatment services, or programmatic services under the auspices of the operation without monetary compensation; or(B) Any type of services under the auspices of the operation without monetary compensation when the person has unsupervised access to a child in care.(82) Young adult--An adult whose chronological age is between 18 and 22 years, who is currently in a residential child-care operation, and who continues to need child-care services. Source Note: The provisions of this §748.43 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective March 1, 2010, 35 TexReg 881; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective June 1, 2014, 39 TexReg 3727; amended to be effective June 1, 2015, 40 TexReg 2789; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248; amended to be effective December 21, 2022,47 TexReg 8115. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.43 What do certain words and terms mean in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221133 03/12/2026 The following types of services are subject to regulation under this chapter:(1) Child-Care Services--Services that meet a child's basic need for shelter, nutrition, clothing, nurture, socialization and interpersonal skills, care for personal health and hygiene, supervision, education, and service planning;(2) Treatment Services--In addition to child-care services, a specialized type of child-care services designed to treat and support children:(A) With an Emotional Disorder who have a:(i) Current Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnosis, such as mood disorders, psychotic disorders, or dissociative disorders, and demonstrate two or more of the following:(I) Major self-injurious actions, including a suicide attempt within the last 12 months;(II) Difficulties that present a significant risk of harm to others, including frequent or unpredictable physical aggression; or(III) An additional DSM-5 diagnosis of substance-related or addictive disorder with severe impairment; or(ii) Severe emotional disturbance as defined by §748.4801 of this chapter (relating to What do the following terms mean when used in this subchapter?) who are admitted to a certified psychiatric residential youth treatment facility also defined at §748.4801 of this chapter, in addition to young adults 18 to 21 years of age who also qualify for these services;(B) With a DSM-5 diagnosis of Intellectual Disability that is characterized by prominent, severe deficits and pervasive impairment in one or more of the following areas:(i) Conceptual, social, and practical adaptive skills to include daily living and self-care;(ii) Communication, cognition, or expressions of affect;(iii) Self-care activities or participation in social activities;(iv) Responding appropriately to an emergency; or(v) Multiple physical disabilities, including sensory impairments;(C) With a DSM-5 diagnosis of Autism Spectrum Disorder that is characterized by prominent, severe deficits and pervasive impairment in one or more of the following areas of development:(i) Conceptual, social, and practical adaptive skills to include daily living and self-care;(ii) Communication, cognition, or expressions of affect;(iii) Self-care activities or participation in social activities;(iv) Responding appropriately to an emergency; or(v) Multiple physical disabilities, including sensory impairments;(D) With Primary Medical Needs, who cannot live without mechanical supports or the services of others because of life-threatening conditions, including:(i) The inability to maintain an open airway without assistance, which does not include the use of inhalers for asthma;(ii) The inability to be fed except through a feeding tube, gastric tube, or a parenteral route;(iii) The use of sterile techniques or specialized procedures to promote healing, prevent infection, prevent cross-infection or contamination, or prevent tissue breakdown; or(iv) Multiple physical disabilities including sensory impairments; and(E) Determined to be a trafficking victim, including a child:(i) Determined to be a trafficking victim as the result of a criminal prosecution or who is currently alleged to be a trafficking victim in a pending criminal investigation or prosecution;(ii) Identified by the parent or agency that placed the child in the operation as a trafficking victim; or(iii) Determined by the operation to be a trafficking victim based on reasonably reliable criteria, including one or more of the following:(I) The child's own disclosure as a trafficking victim;(II) The assessment of a counselor or other professional; or(III) Evidence that the child was recruited, harbored, transported, provided to another person, or obtained for the purpose of forced labor or commercial sexual activity; and(3) Additional Programmatic Services, which include:(A) Emergency Care Services--A specialized type of child-care services designed and offered to provide short-term child care to children who, upon admission, are in an emergency constituting an immediate danger to the physical health or safety of the child or the child's offspring;(B) Transitional Living Program--A residential services program designed to serve children 14 years old or older for whom the service or treatment goal is basic life skills development toward independent living, which includes basic life skills training and the opportunity for children to practice those skills and is not an independent living program;(C) Assessment Services Program--Services to provide an initial evaluation of the appropriate placement for a child to ensure that appropriate information is obtained to facilitate service planning;(D) Therapeutic Camp Services--A camping program to augment an operation's treatment services with an experiential curriculum exclusively for a child with an emotional disorder who has difficulty functioning in his home, school, or community and is only available to children 13 years old and older; and(E) Respite Child-Care Services--See §748.73 of this chapter (relating to What are respite child-care services?). Source Note: The provisions of this §748.61 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective December 1, 2014, 39 TexReg 9052; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.61 What types of services are subject to regulation under this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188982 03/12/2026 You may provide each type of service that we regulate under the following conditions:(1) On your permit, we list the type of service that you have been approved to provide; and(2) Your operational policies and procedures ensure:(A) Children are admitted appropriately;(B) The needs of all children in care are met;(C) Children are appropriately supervised;(D) Children are protected from one another, if appropriate; and(E) You meet the applicable rules of this chapter. Source Note: The provisions of this §748.63 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.63 Can I provide each type of service that Licensing regulates? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188983 03/12/2026 For a child to be eligible to participate in a transitional living program, the child must:(1) Be 14 years old or older; and(2) Not be receiving therapeutic camp services. Source Note: The provisions of this §748.65 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.65 What children are eligible to participate in a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188984 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188984 03/12/2026 A transitional living program must have a training program for children that develops competency in the following areas:(1) Health, general safety, and fire safety practices;(2) Money management;(3) Transportation skills;(4) Accessing community and other resources; and(5) Child health and safety, child development, and parenting skills, if the child is a parent of a child living with him. Source Note: The provisions of this §748.67 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.67 What are the requirements for a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188985 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188985 03/12/2026 An "independent living program" is a program that provides case management services to a child who lives independently, without supervision and child/caregiver ratio, and the constant presence of an on-site caregiver. Source Note: The provisions of this §748.69 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.69 What is an "independent living program"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188986 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188986 03/12/2026 Your operation may not provide an independent living program for a child in care under 18 years old. Source Note: The provisions of this §748.71 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.71 May I have an independent living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188987 03/12/2026 Respite child-care services are planned alternative 24-hour care that an operation provides for a child as part of the regulated child care. Source Note: The provisions of this §748.73 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.73 What are respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188988 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188988&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188988 03/12/2026 Only general residential operations that offer emergency care services may provide respite child-care services. Other operations may not provide respite child-care services, and no operation may use respite child-care services. The purpose of respite child-care services is to provide relief to a child's biological or foster parent, not an employee. Respite for an employee is provided through time off, vacations, holidays, and sick leave. Source Note: The provisions of this §748.75 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.75 May I use or provide respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209515 03/12/2026 The terms used in this division have the following meanings:(1) Exempt program--A child-care program that is exempt from or otherwise not subject to regulation as a child-care operation by the Texas Health and Human Services Commission (HHSC) under Chapter 42, Texas Human Resources Code (HRC), and Chapter 745, Subchapter C of this title (relating to Operations that are Exempt from Regulation).(2) Unlawfully present individual--An individual who is neither a citizen nor has a right to be present in the United States under the Immigration and Nationality Act or accompanying regulations or decisions, who is in the custody of the federal government. This term includes a child who has no lawful immigration status in the United States and:(A) With respect to whom, there is no parent or legal guardian in the United States, or no parent or legal guardian in the United States available to provide care and physical custody, as described in 6 U.S. Code §279(g)(2); or(B) Who is detained with a parent or other adult family member who is not lawfully present in the United States. Source Note: The provisions of this §748.81 adopted to be effective July 8, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.81 What do certain terms mean in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209516 03/12/2026 You may not provide care or shelter to an unlawfully present individual at your general residential operation. However, you may operate an exempt program that provides care for an unlawfully present individual separately from your general residential operation. Source Note: The provisions of this §748.83 adopted to be effective July 8, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.83 May I provide care to or shelter an unlawfully present individual? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209517 03/12/2026 (a) If you provide care for an unlawfully present individual at an exempt program while you operate your general residential operation:(1) You must notify Licensing in writing;(2) You must ensure that the exempt program:(A) Has separate caregivers from your operation or caregivers that do not provide care at your operation while they care for children at the exempt program; and(B) Does not use an area of your building or grounds at the same time that your operation is using the area, except that the exempt program and your operation may share restrooms and indoor and outdoor activity areas under a written plan regarding how caregivers from your operation and the exempt program will supervise the children in the shared space.(b) You must submit to Licensing a written plan for how the exempt program will operate separately from your general residential operation, as required by subsection (a)(2) of this section. Source Note: The provisions of this §748.85 adopted to be effective July 8, 2022, 47 TexReg 4337. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS B DEFINITIONS AND SERVICES §748.85 What are the requirements if I operate my general residential operation while an exempt program separately provides care for an unlawfully present individual? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204800 03/12/2026 In addition to the relevant application forms required by §745.243 of this title (relating to What does a completed application for a permit include?), as part of the application process, you must submit the following plans to us for approval:(1) A business plan that includes:(A) The location and telephone numbers of all your general residential operations; and(B) A list of persons or officers and their titles that comprise the governing body, if applicable;(2) A fiscal plan that includes:(A) A detailed estimate of the operating costs of the operation for the first three months;(B) Documentation of reserve funds or available credit at least equal to operating costs for the first three months;(C) An estimated 12-month budget of income and expenses; and(D) Predictable funds sufficient for the first year of operation;(3) A sketch of the operation's floor plan showing the dimensions and the purpose of all rooms and specifying where children and caregivers, if applicable, will sleep; and(4) An emergency evacuation and relocation plan that complies with Division 6 of Subchapter O (relating to Emergency Evacuation and Relocation). Source Note: The provisions of this §748.101 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2451. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.101 What plans must I submit for Licensing's approval as part of the application process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210094 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210094&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210094 03/12/2026 (a) You must develop the policies and procedures identified in subsection (b) of this section. Your policies and procedures must comply with or exceed the minimum standards specified in this chapter, Chapter 42 of the Human Resources Code, and Chapter 745 of this title (relating to Licensing), and any other applicable law.(b) As part of the application process, you must submit the following policies and procedures to us for our approval:(1) Policies and procedures related to record keeping, including where the records will be located. The policies must be consistent with Subchapter D of this chapter (relating to Reports and Records Keeping);(2) Personnel policies and procedures consistent with §748.105 of this title (relating to What are the requirements for my personnel policies and procedures?);(3) Conflict of interest policies consistent with §748.107 of this title (relating to What must my conflict of interest policies include?);(4) Admission policies consistent with §748.109 of this title (relating to What must my admission policies include?);(5) Child-care policies consistent with §748.111 of this title (relating to What child-care policies must I develop?);(6) Emergency behavior intervention policies consistent with §748.113 of this title (relating to What emergency behavior intervention policies must I develop if my operation is permitted to use emergency behavior intervention?);(7) Discipline policies consistent with §748.115 of this title (relating to What are the requirements for my discipline policies for children in care?);(8) Policies for a transitional living program, if applicable, consistent with §748.117 of this title (relating to What policies for a transitional living program must I develop?);(9) Volunteer policies consistent with §748.119 of this title (relating to What policies must I develop if I use volunteers?);(10) Abuse and neglect policies consistent with §748.121 of this title (relating to What abuse and neglect policies must I develop?);(11) Employee policies and procedures that protect children from vaccine-preventable diseases. The policies must be consistent with §748.123 of this title (relating to What must an employee policy for protecting children from vaccine-preventable diseases include?);(12) A weapons, firearms, explosive materials, and projectiles policy consistent with Division 6 of Subchapter Q (relating to Weapons, Firearms, Explosive Materials, and Projectiles);(13) A tobacco and e-cigarette policy consistent with §748.1661 of this title (relating to What policies must I enforce regarding tobacco products and e-cigarettes?); and(14) A suicide prevention, intervention, and postvention policy consistent with §748.124 of this division (relating to What suicide prevention, intervention, and postvention policy must I have?). Source Note: The provisions of this §748.103 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.103 What policies and procedures must I submit for Licensing's approval as part of the application process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213925 03/12/2026 Your personnel policies and procedure must:(1) Include an organizational chart showing the administrative, professional, and staffing structures and lines of authority;(2) Include written job descriptions, including minimum qualifications and job responsibilities for each position;(3) Include written procedures for screening applicants to determine suitability for any position for which you are considering an applicant. These procedures must include:(A) Verifying an applicant's employment history as required by §748.751 of this chapter (relating to What are the requirements for obtaining and verifying an applicant's employment history?); and(B) Conducting reference checks as required by §748.753 of this chapter (relating to What are the requirements for completing an applicant's reference checks?);(4) Include a written professional staffing plan that:(A) Demonstrates that the number, qualifications, and responsibilities of professional positions, including the child-care administrator, are appropriate for the size and scope of your services and that workloads are reasonable enough to meet the needs of the children in care;(B) Describes in detail the qualifications, duties, responsibilities, and authority of professional positions; for each position, the plan must show whether employment is on a full-time, part-time, or continuing consultative basis; and for part-time and consulting positions, the plan must specify the number of hours and frequency of services;(C) Documents your staffing patterns, including your child/caregiver ratios, hours of coverage, and plans for providing backup caregivers in emergencies; and(D) Identifies, if you provide treatment services, your ability to have enough caregivers, including caregivers who are awake throughout the night to supervise children 24 hours a day, including frequent one-to-one monitoring whenever necessary to meet the needs of a particular child;(5) Include written training requirements for employees and caregivers;(6) Include policies on whether your operation allows individual caregivers to take children away from the operation for day or overnight visits. The policy must require obtaining the parent's written approval prior to allowing overnight visits with staff. The policy must also address the issue outlined in §748.685(e) of this chapter (relating to What responsibilities does a caregiver have when supervising a child or children?);(7) Comply with background check requirements outlined in Subchapter F of Chapter 745 of this title (relating to Background Checks);(8) Require your employees to report serious incidents and suspected abuse, neglect, or exploitation. An employee who suspects abuse, neglect, or exploitation must report the employee's suspicion directly to the Texas Abuse and Neglect Hotline, as directed by Texas Family Code §261.101(b). An employee may not delegate the responsibility to make a report, and you may not require an employee to seek approval to file a report or to notify you that a report was made;(9) Require that all employees and consulting, contracting, and volunteer professionals who work with a child and others with access to information about a child be informed in writing of their responsibility to maintain child confidentiality; and(10) Include either the model drug testing policy or a written drug testing policy that meets or exceeds the criteria in the model policy provided in §745.4151 of this title (relating to What drug testing policy must my residential child-care operation have?). Source Note: The provisions of this §748.105 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248; amended to be effective August 9, 2023, 48 TexReg 3280. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.105 What are the requirements for my personnel policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189017 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189017&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189017 03/12/2026 Your conflict of interest policies must include:(1) A code of conduct on the relationship between your operation's owners (including members of the governing body, if applicable), employees, contract service providers, children in placement, and children's families, including required parameters for entering into independent financial relationships or transactions; and(2) For corporations or other types of business entities, a statement that the majority of the voting members of the governing body must consist of persons who do not have a conflict of interest that would potentially interfere with objective decision making. Persons who have such a conflict of interest include the following:(A) Family members of:(i) An officer of the governing body;(ii) The administrator or executive director of the operation; or(iii) Any person with a controlling interest in the entity's stock; or(B) If the governing body is a non-profit entity, persons who benefit financially from the operation, including persons employed by or working at the operation, paid consultants, subcontractors, and vendors. Source Note: The provisions of this §748.107 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.107 What must my conflict of interest policies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189015 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189015&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189015 03/12/2026 Your admission policies must include a description of each program you offer, including:(1) The program's goals and services provided, including whether the program accepts emergency admissions; and(2) The characteristics of the population the program serves, such as gender, age range, behaviors, and diagnoses. If the program includes treatment services, your policy must describe the type of treatment services the program is designed to treat, including emotional disorders, intellectual disability, autism spectrum disorder, primary medical needs, or trafficking victim services. Source Note: The provisions of this §748.109 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.109 What must my admission policies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189016 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189016&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189016 03/12/2026 You must develop policies that describe:(1) Visitation rights between the child and family members and the child and friends;(2) The child's right to correspond by mail with family members and friends, including any policies regarding mail restrictions and receipt of electronic messages and mail;(3) The child's right to correspond by telephone with family members and friends;(4) The child's right to receive and give gifts to family, friends, employees, or other children in care, including any restrictions on gifts;(5) How a child obtains clothing;(6) Personal possessions a child is or is not allowed to have, where the possessions may be stored, and search policies;(7) Emergency behavior intervention techniques if the use of emergency behavior intervention is permitted in your operation. The policy must be consistent with §748.113(5) of this title (relating to What emergency behavior intervention policies must I develop if my operation is permitted to use emergency behavior intervention?);(8) Any religious program or activity that you offer, including whether children must participate in the program or activity;(9) The plans for meeting the educational needs of each child;(10) When trips with caregivers away from the operation are allowed and what protocols will be used;(11) Program expectations and rules that apply to all children, including an overview of your discipline policy;(12) Child grievance procedures;(13) The types and frequency of reports to parents;(14) Procedures for routine and emergency diagnosis and treatment of medical and dental problems;(15) Routine health care relating to pregnancy and childbirth, if you admit and/or care for a pregnant child;(16) Your plan for providing health-care services to a child with primary medical needs;(17) Transitional living policies, if applicable; and(18) If applicable, how you will determine whether it is appropriate for a child to use weapons, firearms, explosive materials, and projectiles. This information must be consistent with §748.103(b)(12) of this title (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?). Source Note: The provisions of this §748.111 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.111 What child-care policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189018 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189018&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189018 03/12/2026 At a minimum, you must develop emergency behavior intervention policies to implement the requirements in Subchapter N of this chapter (relating to Emergency Behavior Intervention). The policies must include the following:(1) A complete description of emergency behavior interventions that you permit caregivers to use;(2) The specific techniques that caregivers can use;(3) The qualifications for caregivers who assume the responsibility for emergency behavior intervention implementation, including required experience and training, and an evaluation component for determining when a specific caregiver meets the requirements of a caregiver qualified in emergency behavior intervention. You must have an on-going program to evaluate caregivers qualified in emergency behavior intervention and the use of emergency behavior interventions;(4) Your requirements for and restrictions on the use of permitted emergency behavior interventions;(5) For the orientation required in §748.1209(b)(6) of this title (relating to What orientation must I provide a child?), how you will:(A) Explain and document to a child in a manner that the child can understand:(i) Who can use an emergency behavior intervention;(ii) The actions a caregiver must first attempt to defuse the situation and avoid the use of emergency behavior intervention;(iii) The situations in which emergency behavior intervention may be used;(iv) The types of emergency behavior intervention you permit;(v) When the use of an emergency behavior intervention must cease;(vi) What action the child must exhibit to be released from the emergency behavior intervention;(vii) The way to report an inappropriate emergency behavior intervention;(viii) The way to provide voluntary comments during or after an emergency behavior intervention; and(ix) The process for making written comments after an emergency behavior intervention, such as comments regarding the incident that led to the emergency behavior intervention, the manner in which a caregiver intervened, and the manner in which the child was the subject or to which they were a witness. You may create a standardized form that is easily accessible or give children the permission to submit comments on regular paper; and(B) Obtain each child's input on preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process;(6) That you will either:(A) Post in a place where children and adult clients can view them, the emergency behavior interventions that you permit at your operation; or(B) Provide the children and adult clients at admission a personal copy of the operation's emergency behavior intervention policies;(7) Requirements that caregivers must attempt less restrictive and less intrusive emergency behavior interventions as preventive measures and de-escalating interventions to avoid the use of emergency behavior intervention;(8) Training for emergency behavior intervention. The policy must include a description of the emergency behavior intervention training curriculum that meets the requirements in the rules of this chapter, the amount and type of training required for different levels of caregivers (if applicable), training content, and how the training will be delivered; and(9) Prohibitions for discharging or otherwise retaliating against:(A) An employee, child in care, adult client, resident, or other person for filing a complaint, presenting a grievance, or otherwise providing in good faith information relating to the misuse of emergency behavior intervention at the operation; or(B) A child in care, adult client, or resident because someone on behalf of the client or resident files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of emergency behavior intervention at the operation. Source Note: The provisions of this §748.113 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.113 What emergency behavior intervention policies must I develop if my operation is permitted to use emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189019 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189019&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189019 03/12/2026 The discipline policies you develop for children in care must be consistent with Subchapter M of this chapter (relating to Discipline and Punishment). The discipline policies you develop must also:(1) Guide caregivers and employees in the methods used for the discipline of children;(2) Integrate trauma informed care into the care, treatment, and management of each child;(3) Include measures for positive responses to appropriate behavior;(4) Include the importance of nurturing behavior, stimulation, and promptly meeting the child's needs; and(5) Include a statement that discipline of any type is not allowable for infants. Source Note: The provisions of this §748.115 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.115 What are the requirements for my discipline policies for children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189020 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189020&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189020 03/12/2026 For operations who offer a transitional living program, you must develop policies that address the following:(1) Criteria used to select participants for the program;(2) Supervision of participants consistent with §748.1019 of this title (relating to What are the supervision requirements for a transitional living program?) and §748.1021 of this title (relating to When does a child who is in a transitional living program not need supervision?);(3) Expected behaviors of participants and consequences for failure to comply;(4) Training, education, and experiences to be achieved in the program; and(5) Roles of participants, employees, contract staff, and caregivers. Source Note: The provisions of this §748.117 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.117 What policies for a transitional living program must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189021 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189021&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189021 03/12/2026 If you use volunteers, you must develop policies that:(1) Include job descriptions and/or responsibilities for the volunteers;(2) Address qualifications, screening, and selection procedures for the volunteers;(3) Address orientation and training programs for the volunteers;(4) Address supervision of volunteers; and(5) Address volunteer contact with children in care. Source Note: The provisions of this §748.119 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.119 What policies must I develop if I use volunteers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189022 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189022&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189022 03/12/2026 You must develop policies on preventing, recognizing, and responding to abuse and neglect of children, including:(1) Required annual training for employees;(2) Methods for increasing employee awareness of issues regarding child abuse and neglect, including warning signs that a child may be a victim of abuse or neglect;(3) Methods for increasing employee awareness of prevention techniques for child abuse and neglect;(4) Strategies for coordination between the operation and appropriate community organizations; and(5) Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention. Source Note: The provisions of this §748.121 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.121 What abuse and neglect policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189026 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189026&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189026 03/12/2026 A policy for protecting the children in your care from vaccine-preventable diseases must:(1) Specify any vaccines that you have determined an employee must have for vaccine-preventable diseases based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(2) Require each employee to receive each specified vaccine that the employee is not exempt from having;(3) Include procedures for verifying whether an employee has complied with your policy;(4) Include procedures for an employee to be exempt from having a required vaccine because of:(A) Medical conditions identified as contraindications or precautions by the Centers for Disease Control and Prevention (CDC); or(B) Reasons of conscience, including a religious belief;(5) Include procedures that an exempt employee must follow to protect children in your care from exposure to disease, such as the use of protective medical equipment, including gloves and masks, based on the level of risk the employee presents to children by the employee's routine and direct exposure to children;(6) Prohibit discrimination or retaliatory action against an exempt employee, except that required use of protective medical equipment, including gloves and masks, may not be considered retaliatory action for purposes of this section;(7) Outline how you will maintain a written or electronic record of each employee's compliance with or exemption from your policy; and(8) State the disciplinary actions you may take against an employee who fails to comply with your policy. Source Note: The provisions of this §748.123 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.123 What must an employee policy for protecting children from vaccine-preventable diseases include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210095 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210095&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210095 03/12/2026 (a) You must adopt either:(1) The model suicide prevention, intervention, and postvention policy in §748.125 of this division (relating to What is the model suicide prevention, intervention, and postvention policy?); or(2) Another suicide prevention, intervention, and postvention policy that is approved by the Executive Commissioner of the Texas Health and Human Services Commission or designee and:(A) Addresses suicide prevention, intervention, and postvention;(B) Is based on current and best evidence-based practices;(C) Requires all caregivers and employees to receive annual suicide prevention training that includes understanding of safety planning and screening for risk;(D) Promotes suicide prevention training for non-employees, as appropriate; and(E) Includes plans and procedures to support children who return to the operation following hospitalization for a mental health condition.(b) The suicide prevention, intervention, and postvention policy adopted under subsection (a) of this section may be part of a broader mental health crisis plan if the components of the plan include suicide prevention, intervention, and postvention. Source Note: The provisions of this §748.124 adopted to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.124 What suicide prevention, intervention, and postvention policy must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210096 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210096&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210096 03/12/2026 (a) Purpose. The purpose of the model suicide prevention, intervention, and postvention policy is to:(1) Protect the health and well-being of children in the care of general residential operations by implementing procedures to prevent suicide, including screening and assessment procedures for risk of suicide;(2) Require intervention when a child attempts or dies by suicide; and(3) Address the needs of children in care and staff after a child attempts or dies by suicide.(b) Definitions.(1) Postvention--Activities that promote healing and reduce the risk of suicide by a person affected by the suicide of another.(2) Protective factors of suicide--Characteristics that make it less likely that a child will consider, attempt, or die by suicide, including:(A) Effective behavioral health care;(B) Connectedness to individuals, family, community, and social institutions;(C) Supportive relationships with caregivers;(D) Problem-solving skills, coping skills, and ability to adapt to change;(E) Self-esteem or sense of purpose; and(F) Cultural or personal beliefs that discourage suicide.(3) Risk factors of suicide--Characteristics or conditions that increase the chance that a child may consider, attempt, or die by suicide, including:(A) A prior suicide attempt;(B) Knowing someone who died by suicide, particularly a family member, friend, peer, or hero;(C) Access to lethal means;(D) History of childhood trauma, including neglect, physical abuse, or sexual abuse or assault;(E) A history of being bullied;(F) A mental health diagnosis, particularly depressive disorders and other mood disorders;(G) Abuse of alcohol or drugs;(H) Social isolation;(I) Severe or prolonged stress;(J) Chronic physical pain or illness;(K) Loss of a family member; or(L) The ending of a relationship.(4) Suicide contagion--Exposure to suicide or suicidal behaviors within a family, or from friends or media reports, that can result in an increase in suicide or suicidal behaviors.(5) Suicide risk assessment--A comprehensive evaluation of a child by a medical health professional to confirm suspected suicide risk, estimate the immediate danger to the child, and decide on a course of treatment and a plan for intervention to ensure the child's safety.(6) Suicide risk screening--A procedure in which a standardized instrument is used to identify children who may be at risk of suicide. The screening may be done orally (with the screener asking questions), with pencil and paper, or using a computer.(7) Warning signs of suicide--Indicators that a child may be in danger of suicide and need help, including:(A) Talking about wanting to die or to hurt or kill oneself;(B) Looking for a way to kill oneself;(C) Being preoccupied with death in conversation, writing, or drawing;(D) Talking about feeling hopeless or having no reason to live;(E) A change in personality;(F) Giving away belongings;(G) Withdrawing from friends and family;(H) Having aggressive or hostile behavior;(I) Neglecting personal appearance;(J) Running away from home or a residential placement; or(K) Risk-taking behavior, such as reckless driving or being sexually promiscuous.(c) Prevention--Training.(1) All caregivers and employees must complete at least one hour of annual suicide prevention training that meets the instructor and documentation requirements of Subchapter F, Division 6 of this chapter (relating to Annual Training) with a curriculum that includes:(A) The risk factors, protective factors, and warning signs of suicide;(B) Understanding safety planning, including:(i) How safety plans are created;(ii) How safety plans are shared with employees and caregivers;(iii) How safety plans are expected to be implemented by employees and caregivers; and(iv) Each employee's or caregiver's role in the prevention of suicide, including never leaving a child alone if the suicide risk screening finds that the child is a high risk for suicide, until a mental health professional conducts a suicide risk assessment; and(C) Understanding suicide screening, including clarifying:(i) Each person's role in the screening process;(ii) When an employee or caregiver should initiate a suicide risk screening for a child; and(iii) What actions an employee or caregiver must take to initiate a suicide risk screening for a child.(2) The operation must promote suicide prevention training for non-employees, as appropriate.(d) Prevention--Suicide Risk Screening.(1) The policy must describe the suicide risk screening tool that you will use and the process for implementing the screenings.(2) The suicide risk screening tool must be supported by evidence-based research demonstrating the tool performs reliably regardless of who administers the tool or performs the scoring or rating.(3) Any person who meets the conditions and training requirements of the screening tool manual or instructions may administer the suicide risk screening to a child. You must document that any person conducting a screening meets the conditions and training requirements.(4) At a minimum, the screening tool must be administered:(A) At admission for each child 10 years of age or older;(B) At admission for each child younger than 10 years of age if:(i) The information provided to the operation at the time of admission indicates that the child has a history of suicide attempts or suicidal thoughts; or(ii) The parent who admits the child or operation requests a screening to be administered because of the child's risk factors or warning signs of suicide;(C) Every 30 days after admission for each child 10 years of age or older in a residential treatment center;(D) Every 90 days after admission for each child 10 years of age or older in a general residential operation that is not a residential treatment center; and(E) Immediately for a child of any age whenever the child exhibits warning signs of suicide that necessitate a suicide screening be conducted.(5) Any screening must be performed in a manner that protects the child's privacy.(6) Each screening must be documented.(e) Intervention--Based on the Results of a Suicide Risk Screening.(1) If the suicide risk screening finds the child to be a high risk for suicide, the operation must:(A) Immediately refer the child to a mental health professional for a suicide risk assessment;(B) Not leave the child alone until a mental health professional assesses the child;(C) Remove any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt;(D) Alert each person responsible for the child's care or supervision of the high risk for suicide and any new or updated safety plan; and(E) Upon conclusion of the risk assessment, follow through on recommendations by the mental health professional and update the child's safety plan and service plan accordingly.(2) If the suicide risk screening finds the child to have a potential for risk of suicide, the operation must:(A) Refer the child to a mental health professional for a suicide risk assessment within 24 hours;(B) Closely monitor the child to ensure the child's safety until a mental health professional assesses the child;(C) Remove any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt;(D) Alert each person responsible for the child's care or supervision of the potential risk of suicide and any new or updated safety plan; and(E) Upon conclusion of the risk assessment, follow through on recommendations by the mental health professional and update the child's safety plan and service plan accordingly.(f) Intervention--Returning Post Hospitalization. To ensure a child's readiness to return to the care of your operation following a mental health crisis (for example, from a suicide attempt or psychiatric hospitalization):(1) A professional level service provider must meet with the child within 24 hours of the child's return to an operation to discuss protocols that would help to ease the child's transition back into the operation, ensure the child's safety, and reduce any risk of suicide.(2) The protocols must include:(A) Weekly suicide risk screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer;(B) Creating or reviewing and updating the child's safety plan; and(C) Removal of any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt or self-harm for a period to be determined by the treatment team, but not less than 30 days.(3) The operation must alert any persons responsible for the child's care or supervision of the new protocols and new or updated safety plan.(g) Postvention.(1) Addressing Suicide Deaths.(A) Create a Postvention Team and Written Action Plan and Protocols. To prevent suicide contagion and support the children and staff at the operation, you must create a postvention team. This team is responsible for developing a written action plan with protocols in the event of a death by suicide. The postvention team should consider how a death would affect other children and staff at the operation and consider how to provide psychological first aid, crisis intervention, and other support to children and staff at your operation.(B) While the action plan needs to be flexible for varying situations, the written action plan must include:(i) A communication strategy that:(I) Does not inadvertently glamorize or romanticize the child or the death;(II) Occurs in small group settings, allowing the postvention team to monitor responses of individuals in the group;(III) Strives to treat all deaths at the operation in the same way (for example, having one approach for honoring a child who dies from cancer, a car accident, or suicide);(IV) Emphasizes the importance of seeking help for anyone with an underlying mental health diagnosis, such as a mood disorder;(V) Emphasizes the importance of staff and other children recognizing the signs of suicide; and(VI) Decreases the stigma associated with seeking help for mental health concerns;(ii) Mental health resources for children and staff who have a difficult time coping, including:(I) Opportunities to debrief to process thoughts and feelings related to the suicide death; and(II) Referrals to grief counseling and suicide survivor support groups to the extent possible; and(iii) A review of lessons learned from the child's death by suicide. All communications regarding lessons learned should be approached in a way that ensures a blame-free environment.(2) Addressing Suicide Attempts. In the event of a suicide attempt according to §748.305 of this chapter (relating to What constitutes a suicide attempt by a child?), you must:(A) As needed, immediately call emergency services and render first aid until professional medical treatment can be provided;(B) Not leave the child alone until a mental health professional assesses the child;(C) Move all other children out of the immediate area as soon as possible;(D) Report and document the suicide attempt as a serious incident as required by:(i) §748.303(a)(12) of this chapter (relating to When must I report and document a serious incident?);(ii) §748.311 of this chapter (relating to How must I document a serious incident?); and(iii) §748.313(1) of this chapter (relating to What additional documentation must I include with a written serious incident report?); and(E) Offer mental health resources for children and staff who have a difficult time coping, including:(i) Opportunities to debrief to process thoughts and feelings related to the suicide attempt; and(ii) Referrals to grief counseling and suicide survivor support groups to the extent possible; and(F) Conduct a review of lessons learned from the child's suicide attempt. All communications regarding lessons learned should be approached in a way that ensures a blame-free environment. Source Note: The provisions of this §748.125 adopted to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.125 What is the model suicide prevention, intervention, and postvention policy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210097 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210097&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210097 03/12/2026 (a) The requirements for policies only apply to your policies that are required or governed by this chapter.(b) All employees and caregivers must be aware of and follow your policies and procedures. Source Note: The provisions of this §748.126 adopted to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.126 What are the general requirements for an operation's policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189024 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189024&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189024 03/12/2026 (a) Your operation's plans, policies, and procedures must indicate the date on which you adopted them and their effective date.(b) You must formalize the adoption of your operation's plans, policies, and procedures as appropriate for your type of ownership:(1) If you are a sole proprietor, you must sign them;(2) If you are a partnership, each partner must sign them; or(3) If you are a corporation or other type of business entity, the governing body must take a written action to adopt (sometimes this may be an order or the adoption may be included in the minutes of the governing body). Source Note: The provisions of this §748.127 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.127 What requirements must I follow when adopting my operation's plans, policies, and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189025 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189025&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189025 03/12/2026 Yes, if you violate plans, policies, or procedures, then we may cite the relevant standard in Division 1 of this Subchapter (relating to Plans and Policies Required for the Application Process) as a deficiency. Source Note: The provisions of this §748.129 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.129 Can Licensing cite my operation for a deficiency if I fail to operate according to my approved plans, policies, and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204803 03/12/2026 While you are operating, you must:(1) Have a designated full-time child-care administrator who meets the minimum qualifications of §748.531 of this chapter (relating to What qualifications must a child-care administrator meet?);(2) Operate according to your approved plans, policies, and procedures;(3) Maintain current, true, accurate, and complete records;(4) Allow us to inspect your operation during its hours of operation;(5) Not offer unrelated types of services that conflict or interfere with the best interests of a child in care, a caregiver's responsibilities, or operation space. If you offer more than one type of service, you must determine and document that no conflict exists;(6) Complying with the liability insurance requirements in this division; and(7) Prepare the annual budget and control expenditures and ensure compliance with Division 3 of this subchapter (relating to General Fiscal Requirements). Source Note: The provisions of this §748.151 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.151 What are my operational responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215282 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215282 03/12/2026 You must provide written notification to your Licensing Representative:(1) As soon as possible, but at least 30 days before you:(A) Change the legal structure of your operation or your governing body, if applicable;(B) Move your operation to another location as required in §745.435 of this title (relating to What must I do if I relocate my operation after I receive my license or certification?); or(C) Change your operating hours;(2) As soon as possible, but at least 15 days before:(A) You make changes to the policies and procedures required in §748.103(b) of this subchapter (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?);(B) Changes are made to the operation's floor plan showing the dimensions and the purpose of all rooms and specifying where children and caregivers, if applicable, will sleep; and(C) Construction begins on adding a swimming pool or other permanent body of water;(3) As soon as possible, but no later than two days after:(A) You change your child-care administrator, or your child-care administrator position becomes vacant;(B) A new individual becomes a controlling person at your operation;(C) An individual ceases to be a controlling person at your operation; or(D) There is a significant change in the information we maintain about a controlling person, such as a name change or mailing address change; and(4) Within 24 hours of the child's placement, if you provide emergency care services and exceed capacity according to §748.155(b) of this division (relating to May I exceed my operation's capacity?). Source Note: The provisions of this §748.153 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective November 23, 2022, 47 TexReg 7727; amended to be effective October 19, 2023, 48 TexReg 5979. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.153 What changes must I notify Licensing about regarding my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215283 03/12/2026 If you do not have a back-up child-care administrator when your administrator position becomes vacant, as required in §748.535 of this chapter (relating to What responsibilities must the child-care administrator have?), you have 60 days from the date the position becomes vacant to obtain a licensed child-care administrator before we can cite you for not having an administrator. Source Note: The provisions of this §748.154 adopted to be effective October 19, 2023, 48 TexReg 5979. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.154 What is my timeframe for filling my child-care administrator position if it becomes vacant while I do not have a back-up administrator to carry out the administrator duties? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189029 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189029&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189029 03/12/2026 (a) The number of children and young adults in your care must not exceed the capacity stated on your permit, except as described in subsection (b) of this section.(b) If you are licensed to provide emergency care services, you may temporarily exceed your licensed capacity for not more than 48 hours to provide temporary care for a child needing emergency care services.(c) For the purpose of determining whether you exceed your capacity, the number of children in your care includes a caregiver's own children who are at the operation, if they share general living space, bedroom, and/or bathroom space with children in care, and any children receiving respite child-care services at an operation providing emergency care services. Source Note: The provisions of this §748.155 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.155 May I exceed my operation's capacity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189030 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189030&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189030 03/12/2026 You may provide child day care services under the following conditions:(1) You don't provide treatment services to children with emotional disorders;(2) You care for and supervise children who receive day care services separately from the children receiving residential services; and(3) You have separate administrative employees and caregivers for each program. Source Note: The provisions of this §748.157 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.157 May I provide child day care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204801 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit. Source Note: The provisions of this §748.158 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.158 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204802 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §748.158 of this division (relating to What are the liability insurance requirements?) if you cannot carry insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the operation; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit. Your notification must include the reason that you cannot carry the insurance. Source Note: The provisions of this §748.159 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.159 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204804 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §748.158 of this division (relating to What are the liability insurance requirements?), then you must notify the parent of each child in your care in writing that you do not carry liability insurance before you admit the child into your care.(b) If you previously carried the liability insurance and subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care in writing that you do not carry the insurance within 14 days after you stop carrying it.(c) You may use the Form 2962, Verification of Liability Insurance, located on the Licensing provider website, to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parents of each child in your care. Source Note: The provisions of this §748.160 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.160 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189031 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189031&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189031 03/12/2026 (a) You must establish and maintain your operation on a sound fiscal basis, including:(1) Paying your employees timely; and(2) Making sure the needs of children in care are being met.(b) You must maintain complete financial records that comply with Generally Accepted Accounting Principles, including accounting for a child's money separately from the funds of your operation. You may not use a child's personal earnings, allowances, or gifts to pay for the child's room and board, unless such use is a part of the child's service plan and the child's parent approves it in writing. You must give or send the child's money to the child, parent, or next placement within 30 days of the child's discharge. Source Note: The provisions of this §748.161 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.161 What are my fiscal requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189032 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189032&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189032 03/12/2026 The items listed below must be posted in a prominent and publicly accessible place where employees, children, parents, and others may easily view them at all times:(1) Your permit. An operation does not have to post its permit in its cottage homes, as long as it posts the permit at the main office location;(2) The Licensing notice Keeping Children Safe; and(3) Emergency and evacuation relocation plans posted in each building and living quarters used by children. Source Note: The provisions of this §748.191 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS C ORGANIZATION AND ADMINISTRATION §748.191 What items must I post at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199367 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199367&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199367 03/12/2026 These terms have the following meanings in this subchapter:(1) Serious incident--A non-routine occurrence that has or may have dangerous or significant consequences for the care, supervision, or treatment of a child. The different types of serious incidents are noted in §748.303 of this division (relating to When must I report and document a serious incident?).(2) Triggered review of a child's unauthorized absences--A review of a specific child's pattern of unauthorized absences when the child has had three unauthorized absences within a 60-day timeframe.(3) Unauthorized absence--A child is absent from the grounds of an operation without permission from a caregiver and cannot be located. This includes when an unauthorized person has removed the child from the operation. Source Note: The provisions of this §748.301 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.301 What do certain terms mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222373 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222373 03/12/2026 (a) A GRO must report and document the following types of serious incidents involving a child in its care. The reports must be made to the following entities, and the reporting and documenting must be within the specified time frames: Attached Graphic(b) If there is a medically pertinent incident that does not rise to the level of a serious incident, a GRO does not have to report the incident but the GRO must document the incident in the same manner as for a serious incident, as described in §748.311 of this division (relating to How must I document a serious incident?). (c) If a child returns before the required reporting timeframe outlined in (a)(8) - (10) in Figure: 26 TAC §748.303(a), the GRO is not required to report the absence as a serious incident. Instead, the GRO must document within 24 hours after becoming aware of the unauthorized absence in the same manner as for a serious incident, as described in §748.311 of this division. (d) If there is a serious incident involving an allegation of abuse, neglect, or exploitation of an elderly adult or an adult with a disability in a residential child-care operation, the GRO must document the incident in the same manner as a serious incident. The GRO must also report the incident to: (1) The Department of Family and Protective and Services intake through:(A) The Texas Abuse and Neglect Hotline (1-800-252-5400); or(B) Online at https://www.txabusehotline.org;(2) Law enforcement, if there is a fatality; and(3) The parent, if the adult resident is not capable of making decisions about the resident's own care.(e) A GRO must report and document the following types of serious incidents involving the GRO, an employee, a professional level service provider, contract staff, or a volunteer to the following entities within the specified time frames: Attached Graphic Source Note: The provisions of this §748.303 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective June 1, 2014, 39 TexReg 3727; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 1, 2020, 45 TexReg 3324; amended to be effective April 25, 2021, 46 TexReg 2452; amended to be effective April 25, 2022, 47 TexReg 2248;amended to be effective November 23, 2022, 47 TexReg 7727; amended to be effective December 22, 2024, 49 TexReg 9554. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.303 When must a general residential operation (GRO) report and document a serious incident? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188992 03/12/2026 A suicide attempt is a child's attempt to take his own life using means or methods for causing his death, including any act a child commits intending to cause his death, but excluding suicidal gestures where it is clear that the act was unlikely to cause death. Suicidal thoughts are not reportable as a suicide attempt. Source Note: The provisions of this §748.305 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.305 What constitutes a suicide attempt by a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188993 03/12/2026 All serious incident reports must be made directly to the Texas Abuse and Neglect Hotline. Source Note: The provisions of this §748.309 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.309 How do I make a report of a serious incident or occurrence to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208570 03/12/2026 A serious incident must be documented in a written report that includes the following information:(1) The name of the operation, physical address, and telephone number;(2) The time and date of the incident;(3) The name, age, gender, and date of admission of the child or children involved;(4) The names of all adults involved and their role in relation to the child(ren);(5) The names or other means of identifying witnesses to the incident, if any;(6) The nature of the incident;(7) The circumstances surrounding the incident;(8) Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions;(9) The treating licensed health-care professional's name, findings, and treatment, if any;(10) The resolution of the incident; and(11) If the child returns to the operation after you complete the report for an unauthorized absence, an update regarding the unauthorized absence and the child's return. Source Note: The provisions of this §748.311 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.311 How must I document a serious incident? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199369 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199369 03/12/2026 You must include the following additional documentation with a written serious incident report, as applicable:Attached Graphic Source Note: The provisions of this §748.313 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 1, 2020 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.313 What additional documentation must I include with a written serious incident report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188996 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188996&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188996 03/12/2026 You must keep the incident reports on file at the operation for two years. The reports must be easily accessible to Licensing upon request. Source Note: The provisions of this §748.315 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.315 How long must I keep incident reports? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204850 03/12/2026 (a) You must notify the parent of each child residing at your child-care operation of a deficiency in:(1) A safe sleeping standard noted in subsection (b) of this section; or(2) The abuse, neglect, or exploitation standard in §748.1101(b)(1)(B) of this chapter (relating to What rights does a child in care have?).(b) The following are safe sleeping standards requiring notification:(1) §748.1751(a)(1) of this chapter (relating to What specific safety requirements must my cribs meet?);(2) §748.1753(a)(2)(A) of this chapter (relating to Are play yards allowed?);(3) §748.1757(a)(5) and (b) of this chapter (relating to What types of equipment are not allowed for use with infants?);(4) §748.1763 of this chapter (relating to What are the specific sleeping requirements for infants?);(5) §748.1765 of this chapter (relating to May I allow infants to sleep in a restrictive device?); and(6) §748.1767 of this chapter (relating to May I swaddle an infant to help the infant sleep?). Source Note: The provisions of this §748.317 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.317 What are the notification requirements when Licensing finds my operation deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204849 03/12/2026 (a) Within five days after you receive notification of a deficiency described in §748.317 of this division (relating to What are the notification requirements when Licensing finds my operation deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child in care?), you must notify the parents of each child residing at your child-care operation at the time of notification, including a child who may not have been in care on the day of the actual incident. (b) If the deficiency is for a safe sleeping standard, you must notify the parents using Form 2970, Notification of Safe Sleeping Deficiency, located on the Licensing provider website.(c) If the deficiency is for the standard related to the abuse, neglect, or exploitation of a child in care, you must notify the parents using Form 7266, Notification of Abuse/Neglect/Exploitation Deficiency, located on the Licensing provider website. (d) You must maintain and make available for our review, upon request, proof that you have notified parents in writing of deficiencies in safe sleeping and abuse, neglect, or exploitation, as required by subsection (a) of this section. Source Note: The provisions of this §748.319 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.319 How must I notify parents of a safe sleeping deficiency or an abuse, neglect, or exploitation deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188997 03/12/2026 (a) You must maintain a copy of your policies and procedures at the operation. They must be available for review by employees, contract staff, caregivers, Licensing, or your clients, upon request.(b) You must maintain copies of all current and previous policies for at least two years. Source Note: The provisions of this §748.341 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.341 What are the retention requirements for my operation's policies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188998 03/12/2026 You must have policies and procedures for:(1) Protecting paper and electronic records from destruction and loss; and(2) Clarifying the persons:(A) Within your operation who are authorized to access records; and(B) Outside of your operation who are authorized by law to have access to records. Source Note: The provisions of this §748.343 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.343 What policies and procedures must I have for protecting records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=188999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 188999 03/12/2026 If you keep electronic records, you must develop policies and procedures in addition to the requirements in §748.343 of this title (relating to What policies and procedures must I have for protecting records?). These policies and procedures must address:(1) What records must be in the external paper file and what records can be stored in the electronic file;(2) Computer security systems, including confidentiality, passwords, and employee procedures to ensure the security of the system;(3) Requirements for routine back-up of data;(4) Anti-virus protection systems; and(5) Limit access to your electronic files to persons within your operation authorized to see specific information in an electronic file. Source Note: The provisions of this §748.345 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.345 What additional policies and procedures must I have for electronic records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189000 03/12/2026 Yes, you may use electronic and digital signatures, including approvals by e-mail and electronic approvals. Source Note: The provisions of this §748.347 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.347 Are electronic signatures allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189001 03/12/2026 (a) You must maintain all active personnel records at the operation.(b) You must maintain archived personnel records at the operation and/or in a designated location, as long as they are available for our review within 48 hours.(c) You may archive entire closed personnel records electronically.(d) Your system for maintaining all personnel records must be uniform throughout the operation.(e) You must maintain in the main office of the operation a master list of active and archived personnel records with a notation of the location of those records. Source Note: The provisions of this §748.361 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.361 Where must I maintain personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219548 03/12/2026 For each employee, the personnel record must include: (1) Documentation showing the date of employment; (2) Documentation showing how the person meets the minimum age and qualifications for the position; (3) Documentation that your operation has: (A) Verified employment history as required by §748.751 of this chapter (relating to What are the requirements for obtaining and verifying an applicant's employment history?); and (B) Conducted reference checks as required by §748.753 of this chapter (relating to What are the requirements for completing an applicant's reference checks?); (4) A current job description; (5) Evidence of any valid professional licensures, certifications, or registrations the person must have to meet qualifications for the position, such as a current renewal card or a letter from the credentialing entity verifying that the person has met the required renewal criteria; (6) A copy of the record of tuberculosis screening conducted prior to the person having contact with children in care showing that the employee is free of contagious tuberculosis as provided in §748.1583 of this title (relating to Who must have a tuberculosis (TB) examination?); (7) A notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) as specified in Texas Human Resources Code §42.059; (8) A Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) as specified in Texas Human Resources Code §42.0563;(9) A statement signed and dated by the employee documenting that the employee has read a copy of the operational policies required by §748.103 of this title (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?); (10) A statement signed and dated by the employee indicating the employee must immediately report any suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and to the operation's administrator or administrator's designee; (11) Proof of request for background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks); (12) For each person who transports a child, a copy of: (A) The person's valid driver's license; or (B) A driver's license check conducted through the Texas Department of Public Safety within the last 12 months; (13) A record of training, including the date of the training, the number of training hours, and the curriculum covered; (14) Any documentation of the person's performance with the operation; and (15) The date and reason for the person's separation, if applicable. Source Note: The provisions of this §748.363 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective March 1, 2014, 39 TexReg 1192; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective August 9, 2023, 48 TexReg 3280; amended to be effective August 14, 2024, 49 TexReg 4919. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.363 What information must the personnel record of an employee include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189003 03/12/2026 All background check results must be kept confidential, in accordance with HRC §40.005, subsections (d) and (e). Background check results must be protected from unauthorized access or release. Source Note: The provisions of this §748.365 adopted to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.365 What information regarding personnel must be kept confidential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189004 03/12/2026 An active child record consists of the child's record for the most recent 12 months of service. Source Note: The provisions of this §748.391 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.391 What is an active child record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189005 03/12/2026 (a) You must keep active child records at the operation where the child is receiving services. This may include electronic records.(b) On an on-going basis, you must ensure that each child's record:(1) Includes the child's full name and another method of identifying the child, such as a client number;(2) Includes documentation of known allergies and chronic health conditions on the exterior of the child's record or in another place where the information is clearly visible to persons with access to the record, including a notation of "no known allergies" when applicable;(3) Is kept accurate and current;(4) Is locked and kept in a safe location; and(5) Is kept confidential as required by law. Source Note: The provisions of this §748.393 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.393 How must I maintain an active child record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189006 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189006&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189006 03/12/2026 All documentation must be in the record:(1) No later than 30 days after the occurrence or event; or(2) As otherwise specified in this chapter. Source Note: The provisions of this §748.395 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.395 How current must a child's record be? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189007 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189007&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189007 03/12/2026 Unless you are releasing the record to the parents, to us, or as required by law, you may not release any portion of a child's record to any agency, organization, or individual without the written consent of the person legally authorized to consent to the release. Source Note: The provisions of this §748.397 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.397 Who must consent to the release of a child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189008 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189008&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189008 03/12/2026 (a) You must make all active records available for our immediate review and reproduction.(b) We must have reasonable access to your storage and file areas in order to monitor your record keeping. Source Note: The provisions of this §748.399 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.399 Must I make records available for Licensing to review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189009 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189009&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189009 03/12/2026 These records must be available for our review within 48 hours. Otherwise, the records may be archived electronically or kept anywhere and in any manner, as long as they are safe from damage or destruction. Source Note: The provisions of this §748.401 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.401 How must I maintain a child's record that is not active? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189010 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189010&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189010 03/12/2026 (a) You must maintain annual training records for current personnel for the last full training year and current training year.(b) With the exception of subsection (a) of this section, you must maintain personnel records for a year after an employee's last day of employment or until any investigation involving the employee is resolved, whichever is longer. Source Note: The provisions of this §748.431 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.431 How long must I maintain personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189011 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189011&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189011 03/12/2026 You must maintain a child's complete record from admittance to discharge for two years from the date of discharge, or until the resolution of any investigation involving the child, whichever is longer. Source Note: The provisions of this §748.433 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.433 How long must I maintain child records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199389 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199389 03/12/2026 (a) For each unauthorized absence of a child, you must:(1) Document the unauthorized absence in an annual summary log, as required by §748.453 of this division (relating to What documentation must be included in an annual summary log for a child who has an unauthorized absence?); and(2) Debrief the child, as required by §748.455 of this division (relating to What are the requirements for debriefing a child after an unauthorized absence?).(b) If a child has three unauthorized absences within a 60-day timeframe, you must conduct a triggered review of the child's unauthorized absences that is consistent with the rules in this division; and(c) You must conduct an overall operation evaluation for unauthorized absences every six months, as required by §748.463 of this division (relating to What is an overall operation evaluation for unauthorized absences?). Source Note: The provisions of this §748.451 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.451 What additional requirements are there for unauthorized absences of children from my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199390 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199390 03/12/2026 (a) For each unauthorized absence during the relevant year, you must document the following information in an annual summary log:(1) The name, age, gender, and date of admission of the child who was absent;(2) The time and date the unauthorized absence was discovered;(3) How long the child was gone or if the child did not return;(4) The name of the caregiver responsible for the child at the time the child's absence was discovered;(5) The intake report number, if a report was made to Licensing or the Department of Family and Protective Services; and(6) Whether law enforcement was contacted, including the name of any law enforcement agency that was contacted and the number of the police report, if applicable.(b) You must maintain each annual summary log for five years.(c) You must make the annual summary logs available to Licensing for review and reproduction, upon request. Source Note: The provisions of this §748.453 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.453 What documentation must be included in an annual summary log for a child who has an unauthorized absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199391 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199391 03/12/2026 (a) After a child returns to an operation from an unauthorized absence, the caregiver, or other appropriate person, must conduct a debriefing with the child as soon as possible, but no later than 24 hours after the child's return. The purpose of the debriefing is for the child and the caregiver, or other appropriate person, to discuss the following:(1) The circumstances that led to the child's unauthorized absence;(2) The trauma informed strategies the child can use to avoid future unauthorized absences and how the operation can support those strategies;(3) The child's condition; and(4) What occurred while the child was away from the operation, including where the child went, who was with the child, the child's activities, and any other information that may be relevant to the child's health and safety.(b) The caregiver must allow the child to return to routine activities, excluding any activity that the caregiver determines would be inappropriate because of the child's condition following the unauthorized absence or something that occurred during the unauthorized absence.(c) The debriefing must be documented in the child's record, including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate. Source Note: The provisions of this §748.455 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.455 What are the requirements for debriefing a child after an unauthorized absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199392 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199392 03/12/2026 (a) A triggered review of a child's unauthorized absences must occur as soon as possible, but no later than 30 days after the child's third unauthorized absence within a 60-day timeframe.(b) A regularly scheduled review of the child's service plan can serve as the triggered review of a child's unauthorized absences, if the regularly scheduled review:(1) Meets the requirements in §748.461 of this division (relating to What must the triggered review of a child's unauthorized absences include?); and(2) Takes place no later than 30 days after the child's third unauthorized absence within a 60-day timeframe. Source Note: The provisions of this §748.457 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.457 When must a triggered review of a child's unauthorized absences occur? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199393 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199393 03/12/2026 (a) The triggered review of a child's unauthorized absences must include the following participants:(1) The child;(2) An individual designated to make decisions regarding the child's participation in childhood activities, as described in §748.707 of this chapter (relating to Who makes the decision regarding a foster child's participation in childhood activities?); and(3) The child's case manager.(b) You must notify the child's parent at least two weeks before the triggered review of a child's unauthorized absences, so the parent will have an opportunity to participate in the review. Source Note: The provisions of this §748.459 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.459 Who must participate in a triggered review of a child's unauthorized absences? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199394 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199394 03/12/2026 A triggered review of a child's unauthorized absences must include the following:(1) A review of the child's records documenting previous unauthorized absences, including previous debriefings;(2) A review of service plan elements identified in §748.1337(b)(1)(D) and (H) and, as applicable, §748.1337(b)(2) and (3) of this chapter (relating to What must a child's initial service plan include?);(3) An examination of trauma informed alternatives to minimize the unauthorized absences of the child; and(4) A written plan to reduce the unauthorized absences of the child, which you must document in the child's record. Source Note: The provisions of this §748.461 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.461 What must a triggered review of a child's unauthorized absences include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199395 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199395 03/12/2026 (a) Every six months, you must conduct an overall operation evaluation for unauthorized absences that have occurred at your operation during that time period.(b) The objectives of the evaluation are to:(1) Develop and maintain a trauma informed environment that supports positive and constructive behaviors by children in care; and(2) Ensure the overall safety and well-being of children in care.(c) The evaluation must include:(1) The frequency and patterns of unauthorized absences of children in your operation; and(2) Specific trauma informed strategies to reduce the number of unauthorized absences in your operation.(d) You must maintain the results of each six-month overall operation evaluation for unauthorized absences for five years.(e) You must make the results of each overall operation evaluation for unauthorized absences available to Licensing for review and reproduction, upon request. Source Note: The provisions of this §748.463 adopted to be effective June 1, 2020, 45 TexReg 3324. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS D REPORTS AND RECORD KEEPING §748.463 What is an overall operation evaluation for unauthorized absences? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189033 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189033&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189033 03/12/2026 Yes, however you must provide supporting information indicating that the education is equivalent to the minimum educational qualifications for the position for which the person is applying. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §748.503 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.503 Does education received outside of the United States count toward educational qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219549 03/12/2026 (a) An employee's behavior or health status must not present a danger to children in care. (b) Each employee must: (1) Meet the requirements in Chapter 745, Subchapter F of this title (relating to Background Checks); (2) Have a record of a tuberculosis screening showing the employee is free of contagious TB as provided in §748.1583 of this chapter (relating to Who must have a tuberculosis (TB) examination); (3) Be physically, mentally, and emotionally capable of performing assigned tasks and have the skills necessary to perform assigned tasks; (4) Complete a notarized Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (Form 2985) before you hire the employee, as specified in Texas Human Resources Code §42.059; (5) Complete a Pre-Employment Affidavit for Applicants for Employment at Certain Child Care Operations (Form 2912) before you hire the employee, as specified in Texas Human Resources Code §42.0563; and (6) Have cleared a pre-employment screening assessment in which you determined the employee's suitability for the employee's position. The screening must have included: (A) Verification of employment history as required by §748.751 of this subchapter (relating to What are the requirements for obtaining and verifying an applicant's employment history?); and (B) Reference checks, as required by §748.753 of this subchapter (relating to What are the requirements for completing an applicant's reference checks?). Source Note: The provisions of this §748.505 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective August 9, 2023, 48 TexReg 3280; amended to be effective August 14, 2024, 49 TexReg 4919. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.505 What minimum qualifications must all employees meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189035 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189035&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189035 03/12/2026 Regardless of whether the employee is counted in the child/caregiver ratio, each employee must:(1) In the absence of a more specific rule requirement, demonstrate competency, prudent judgment, and self-control in the presence of children and when performing assigned responsibilities;(2) Report suspected abuse, neglect, and exploitation to the Child Abuse Hotline and to the designated employee or administrator; and(3) Know and comply with rules of this chapter, Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating to Licensing), and any other laws which are relevant to the person's duties. Source Note: The provisions of this §748.507 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.507 What general responsibilities do all employees have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189036 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189036&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189036 03/12/2026 Before having contact with children in care, all caregivers, employees, volunteers, and contract service providers must be screened for tuberculosis as provided in §748.1583 of this title (relating to Who must have a tuberculosis (TB) examination?). Source Note: The provisions of this §748.509 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.509 What are the requirements for tuberculosis screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208571 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208571&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208571 03/12/2026 An employee, contract service provider, or volunteer may not be in possession of a handgun while at your operation or while caring for children. Source Note: The provisions of this §748.511 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.511 Is an employee, contract service provider, or volunteer allowed to be in possession of a handgun? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189037 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189037&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189037 03/12/2026 (a) A child-care administrator must:(1) Meet the qualifications established by the operation's governing body;(2) Be a Licensed Child-Care Administrator according to Chapter 43 of the Human Resources Code and Chapter 745, Subchapter N of this title (relating to Administrators Licensing); and(3) Be a full-time employee of the operation.(b) If acting as the administrator for two residential child-care operations under §748.533 of this title (relating to Can a child-care administrator be an administrator for two residential child-care operations?), the administrator must split a full-time schedule between the two operations as described in the professional staffing plans for each operation. Source Note: The provisions of this §748.531 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.531 What qualifications must a child-care administrator meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215284 03/12/2026 A child-care administrator with a provisional license may serve as the child-care administrator at a general residential operation if, at the time the administrator is hired, the operation is not:(1) On a voluntary plan of action;(2) On corrective action;(3) Subject to an adverse action; or(4) Pending due process for a corrective or an adverse action. Source Note: The provisions of this §748.532 adopted to be effective October 19, 2023, 48 TexReg 5979. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.532 When can a child-care administrator with a provisional license serve as the administrator for a general residential operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215285 03/12/2026 (a) Except as provided in subsections (b) and (c) of this section, a child-care administrator can be an administrator for two residential child-care operations, including a child-placing agency, if:(1) Both operations are in good standing with Licensing;(2) The size and scope of the operations are manageable by one person, which is clarified in the written professional staffing plans;(3) The child-placing agency, if applicable, is not managing more than 25 foster homes;(4) The person also holds a valid full Child-Placing Agency Administrator License, if the second operation is a child-placing agency; and(5) The general residential operations are contiguous. A child-placing agency does not have to be contiguous.(b) An operation that provides emergency care services must designate an employee in the staffing plan that is solely responsible for administering those services. This employee must have the experience and background to be able to perform the child-care administrator responsibilities. See §748.535 of this title (relating to What responsibilities must the child-care administrator have?). A designated employee, other than the child-care administrator for the operation, is not required if the emergency care services program has a capacity of not more than 30 children.(c) A child-care administrator with a provisional child-care administrator's license may only serve as a licensed administrator at one residential child-care operation. Source Note: The provisions of this §748.533 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 19, 2023, 48 TexReg 5979. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.533 Can a child-care administrator be an administrator for two residential child-care operations? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208572 03/12/2026 The child-care administrator must:(1) Have daily supervision and on-site administrative responsibility for the overall operation;(2) Ensure that the operation complies with current heightened monitoring plans, if applicable; and(3) Be responsible for or assign responsibility for:(A) Overseeing staffing patterns to ensure the supervision and the provision of child-care services that meet the needs of children in care;(B) Ensuring the provision of planned but flexible program activities designed to meet the developmental needs of children;(C) Having a system in place to ensure an employee is available to handle emergencies;(D) Assigning tasks to caregivers that do not conflict or interfere with caregiver responsibilities;(E) Administering and managing the operation according to your policies;(F) Ensuring that the operation complies with applicable rules of this chapter, Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating to Licensing), and other applicable laws;(G) Ensuring a child in care is not assigned, utilized, or allowed to act as a caregiver; and(H) Ensuring persons whose behavior or health status is known to present a danger to children are not allowed at the operation. Source Note: The provisions of this §748.535 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.535 What responsibilities must the child-care administrator have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189040 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189040&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189040 03/12/2026 (a) A person designated to handle emergencies must be on call and accessible to your caregivers.(b) You must inform all caregivers and us of the system and how to contact the person on call in case of an emergency.(c) The employee is not required to be a Licensed Child-Care Administrator. Source Note: The provisions of this §748.537 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.537 What must the system for ensuring that an employee is available to handle emergencies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189045 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189045&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189045 03/12/2026 When the child-care administrator is absent on a frequent and/or extended basis, the administrator must designate an employee that has a Child-Care Administrator's License to be responsible for the overall administration of the operation while the administrator is absent. Source Note: The provisions of this §748.539 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.539 Who must have overall administrative responsibility when the child-care administrator is absent on a frequent and/or extended basis? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189041 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189041&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189041 03/12/2026 A professional level service provider must perform the following functions:(1) Completing an admission assessment or any other evaluation of a child for placement;(2) Developing, reviewing, and updating of service plans for a child in care;(3) Completing a discharge or transfer summary for a child;(4) Approving any restrictions that will be imposed on a child for more than seven days that have not been reviewed and approved by the treatment director or service planning team, and any monthly re-evaluations of restrictions that continue for more than 30 days;(5) Approving any restrictions to communication and visitation with the child's family that are imposed on a child, but have not been reviewed and approved by the treatment director or service planning team, including monthly re-evaluations of restrictions that continue for more than 30 days; and(6) Approving any restrictions to a particular room or building for more than 24 hours that are imposed on a child, but have not been reviewed and approved by the treatment director or service planning team. Source Note: The provisions of this §748.561 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.561 What professional level service activities must a professional level service provider perform at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189042 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189042&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189042 03/12/2026 (a) If you provide treatment services to 25 or more children with emotional disorders, or if more than 30% of the children in your care receive treatment services for emotional disorders, a professional level service provider must have the following qualifications: Attached Graphic(b) If you provide treatment services to 25 or more children with primary medical needs, or if more than 30% of the children in your care receive treatment services for primary medical needs, a professional level service provider must have the following qualifications: Attached Graphic(c) To provide services for any other children, a professional level service provider must have the following qualifications:Attached Graphic Source Note: The provisions of this §748.563 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.563 What professional qualifications must a professional level service provider have in order to perform professional level service activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189043 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189043&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189043 03/12/2026 A professional level service provider must sign and date the following documents to indicate review and approval or disapproval:(1) Admission assessments or any other evaluation of a child for placement;(2) Initial service plans, updates, and reviews;(3) Discharge or transfer summaries;(4) Any restrictions that will be imposed on a child for more than seven days that have not been reviewed and approved by the treatment director or service planning team;(5) Any restrictions to communication and visitation with the child's family that are imposed on a child, but have not been reviewed and approved by the treatment director or service planning team; and(6) Any restrictions to a particular room or building for more than 24 hours that are imposed on a child, but have not been reviewed and approved by the treatment director or service planning team. Source Note: The provisions of this §748.565 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.565 How must a professional level service provider document approval of professional level service functions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189044 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189044&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189044 03/12/2026 There is not a maximum caseload for a professional level service provider; however, you must ensure manageable caseloads that allow professional level service providers to meet the needs of children on their caseload. Source Note: The provisions of this §748.567 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.567 What are the requirements for the caseloads of a professional level service provider? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189049 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189049&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189049 03/12/2026 If you provide treatment services to 25 or more children with primary medical needs or if more than 30% of the children in your care receive treatment services for primary medical needs:(1) You must have a licensed registered nurse on staff or on contract to respond to emergencies, questions, or other medical issues. A registered nurse must work full-time at the operation. A registered nurse in this position may be relieved on days off by a licensed registered nurse or by a licensed vocational nurse with appropriate supervision as defined in Tex. Occ. Code §301.353.(2) You must arrange for:(A) 24-hour availability of nursing, medical, and psychiatric services;(B) Licensed nursing services, including 24-hour nursing direction or supervision;(C) Assistance with mobility;(D) Routine adjustments or replacement of medical equipment; and(E) As needed, caregiver supervision of children during the provision of medical and dental services.(3) You must ensure that a physician on staff or on contract recommends and approves services at each initial diagnosis and at each review. Source Note: The provisions of this §748.569 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.569 Must I have health-care professionals on staff or on contract if I provide services to children with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189046 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189046&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189046 03/12/2026 The responsibilities of a registered nurse include:(1) Performing a nursing assessment of the child to include documentation of the child's diagnosed medical needs and selection of placement;(2) Leading or participating in the service planning process for the child's care;(3) Directing the health care training of unlicensed caregivers, such as care of a permanently placed feeding tube;(4) Ensuring non-mobile children are turned every two hours to increase circulation and to prevent bedsores or contractures, unless medical orders are to the contrary. This procedure must be documented in the child's record;(5) Reviewing medical records;(6) Contacting other professionals, as needed, for the child's care;(7) On-site visits for nursing assessments and child record reviews, including compliance with written physician orders;(8) Monitoring the implementation of the child's service plan; and(9) Documenting outcomes for interventions used in the child's care. Source Note: The provisions of this §748.571 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.571 What are the responsibilities of a registered nurse at an operation that provides services to a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189047 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189047&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189047 03/12/2026 Your nursing personnel must:(1) Be awake and available at the operation on a 24-hour basis;(2) Be under the direction of a registered nurse who is licensed to practice in Texas; and(3) Include a licensed vocational nurse or registered nurse. Source Note: The provisions of this §748.573 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.573 What are the requirements for other nursing personnel for an operation that provides treatment services to 25 or more children with primary medical needs, or for an operation in which more than 30% of the children in care receive treatment services for primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189048 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189048&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189048 03/12/2026 The physician or registered nurse may delegate nursing tasks to unlicensed caregivers only if all delegation criteria are met for the task to be delegated, including, but not limited to:(1) The nursing task is one that a reasonable and prudent physician or registered nurse would find is within the scope of sound nursing judgment to delegate;(2) The physician or registered nurse determines that the nursing task can be properly and safely performed by the unlicensed caregiver without jeopardizing the child's welfare;(3) The operation employing or contracting with the unlicensed caregivers develops and follows a protocol, with input from a physician or registered nurse, for the instruction and training of unlicensed caregivers performing nursing tasks. The protocol must address:(A) An established mechanism for identifying those individuals to whom nursing tasks may be designated;(B) The manner in which the instruction addresses the complexity of the delegated task;(C) The manner in which the unlicensed caregivers demonstrate the competency of the delegated task; and(D) The mechanism for re-evaluation of the competency;(4) The training protocol recognizes that the final decision as to what nursing tasks can be safely delegated in any specific situation is within the specific scope of the physician's or registered nurse's judgment; and(5) A physician or registered nurse must instruct unlicensed caregivers in performing nursing tasks. Source Note: The provisions of this §748.575 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.575 In what circumstances may a physician or registered nurse (including an advanced practice registered nurse) delegate nursing tasks to unlicensed caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189050 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189050&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189050 03/12/2026 You must have a treatment director if you provide treatment services to 25 or more children, or to more than 30% of the children in your care. Your treatment director must be a full-time employee of your operation. Source Note: The provisions of this §748.601 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.601 Must I have a treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189051 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189051&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189051 03/12/2026 (a) The treatment director:(1) Is responsible for the overall treatment program, including clinical responsibility for the management of your operation's therapeutic interventions; and(2) Provides direction and overall management of your treatment program.(b) When assigning responsibilities to your treatment director, you must ensure that the treatment director can oversee the treatment of all children receiving treatment services. Source Note: The provisions of this §748.603 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.603 What are the responsibilities of a treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189052 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189052&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189052 03/12/2026 (a) A treatment director that provides or oversees treatment services for children with intellectual disabilities or children with autism spectrum disorder must be:(1) Licensed as a psychiatrist, psychologist, professional counselor, clinical social worker, marriage and family therapist, or registered nurse; or(2) Certified by the Texas Education Agency as an education diagnostician, have a master's degree in special education or a human services field, and have three years of experience working with children with intellectual disabilities or autism spectrum disorder.(b) A treatment director that provides or oversees treatment services for children with primary medical needs must be a physician or a licensed registered nurse.(c) A treatment director that provides or oversees treatment services for children with emotional disorders must:(1) Be a psychiatrist or psychologist;(2) Have a master's degree in a human services field from an accredited college or university and three years of experience providing treatment services for children with an emotional disorder, including one year in a residential setting; or(3) Be a licensed master social worker, a licensed clinical social worker, a licensed professional counselor, or a licensed marriage and family therapist, and have three years of experience providing treatment services for children with an emotional disorder, including one year in a residential setting. Source Note: The provisions of this §748.605 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.605 What qualifications must a treatment director have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189053 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189053&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189053 03/12/2026 Yes, you can have one treatment director if he meets the required qualifications for the most prevalent treatment services your operation offers. Source Note: The provisions of this §748.607 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.607 If I provide more than one type of treatment service, can I have one treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189054 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189054&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189054 03/12/2026 Each employee must meet the following qualifications before you can count the employee in the child/caregiver ratio:(1) Be at least:(A) 18 years old if all the children in the group the caregiver serves are under 13 years old; or(B) 21 years old if at least one child in the group the caregiver serves is 13 years old or older;(2) Have either:(A) A high school diploma or high school equivalency, such as a General Educational Development (GED) from a program recognized by the Texas Education Agency (TEA), the Texas Private School Accreditation Commission (TPSAC), or other similar educational entity from another state; or(B) Documentation to verify high school equivalency from home schooling. The documentation must adequately address basic competencies that would be otherwise met by a high-school diploma or a GED, including basic reading, writing, and math skills; and(3) Be able to read, write, and communicate with co-workers, medical personnel, and other persons necessary to care for the child's needs. Source Note: The provisions of this §748.681 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.681 What minimum qualifications must a caregiver meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189055 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189055&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189055 03/12/2026 You must provide oversight of caregivers, including volunteers to:(1) Protect children's health, safety, and well-being; and(2) Ensure that assigned duties are performed adequately. Source Note: The provisions of this §748.683 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.683 What are the general requirements for supervising caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189056 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189056&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189056 03/12/2026 (a) The caregiver is responsible for:(1) Knowing which children they are responsible for;(2) Child care services for each assigned child;(3) Being aware of and accountable for each child's on-going activity;(4) Providing the level of supervision necessary to ensure each child's safety and well being, including auditory and/or visual awareness of each child's on-going activity as appropriate; and(5) Being able to intervene when necessary to ensure each child's safety.(b) In deciding how closely to supervise a child, the caregiver must take into account:(1) The child's age;(2) The child's individual differences and abilities;(3) The indoor and outdoor layout of the operation;(4) Surrounding circumstances, hazards, and risks; and(5) The child's physical, mental, emotional, and social needs.(c) Caregivers must:(1) Be aware of the children's habits, interests, and any special needs, including any special supervision needs;(2) Provide a safe environment;(3) Cultivate developmentally appropriate independence in children through planned but flexible program activities;(4) Positively reinforce children's efforts and accomplishments;(5) Ensure continuity of care for children by sharing with incoming caregivers information about each child's activities during the previous shift and any verbal or written information or instructions given by the parent or other professionals; and(6) Implement and follow the children's service plans.(d) If a child is participating in an unsupervised childhood activity, the caregiver must:(1) Know where the child will be;(2) Give the child a specific time to return to the operation or the caregiver's location;(3) Provide, arrange, or confirm an appropriate method of transportation to and from the activity;(4) Give the child a way to contact the caregiver in an emergency; and(5) Be available to respond if the child contacts the caregiver and needs immediate assistance.(e) Caregivers that supervise a child receiving treatment services for an emotional disorder must maintain daily progress notes for the child. Caregivers must sign and date each progress note at the time the progress note is completed.(f) If a child or children are allowed overnight visits with staff, the child(ren) must be properly fed, lodged, and supervised, and their health, safety, and well-being protected. The person(s) responsible for the child(ren) must be given information about obtaining emergency medical care. Source Note: The provisions of this §748.685 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.685 What responsibilities does a caregiver have when supervising a child or children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189057 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189057&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189057 03/12/2026 Normalcy is the ability of a child in care to live as normal a life as possible, including engaging in childhood activities that are suitable for children of the same age, level of maturity, and developmental level as determined by a reasonable and prudent parent standard. Source Note: The provisions of this §748.701 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.701 What is "normalcy"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189058 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189058&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189058 03/12/2026 (a) Children in care must participate in childhood activities, including unsupervised childhood activities, as much as possible.(b) Service planning meetings, and any decision making regarding the child's need for supervision, must include discussions on how normalcy for the child can be achieved, and discussions, if applicable, regarding a child's refusal to participate in childhood activities. The child's service plan must specify whether there are any restrictions on the child's participation in these activities and whether the activities may extend into sleeping hours. Source Note: The provisions of this §748.703 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.703 Are children in care required to participate in childhood activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189059 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189059&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189059 03/12/2026 (a) The reasonable and prudent parent standard is the standard of care that a parent of reasonable judgment, skill, and caution would use to maintain the health, safety, and best interest of the child and encourage the emotional and social growth and development of the child.(b) When using the reasonable and prudent parent standard, a person must take into consideration the following when deciding whether a child may participate in childhood activities:(1) The child's age and level of maturity;(2) The child's cognitive, social, emotional, and physical development level;(3) The child's behavioral history and ability to safely participate in a proposed activity;(4) The child's overall abilities;(5) Whether the activity is a normal childhood activity for a child of that age and level of maturity;(6) The child's desires;(7) The surrounding circumstances, hazards, and risks of the activity;(8) Outside supervision of the activity, if available and appropriate;(9) The supervision instructions in the child's service plan; and(10) The importance of providing the child with the most normal family-like living experience possible. Source Note: The provisions of this §748.705 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.705 What is the "reasonable and prudent parent standard"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189065 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189065&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189065 03/12/2026 (a) A General Residential Operation (GRO) must designate one or more persons to make decisions regarding a child's participation in childhood activities, except as otherwise provided in subsection (c) of this section.(b) When making decisions regarding a child's participation in childhood activities, a designated person must follow the reasonable and prudent parent standard.(c) The service plan may not require the prior approval of the parent before a designated person may consent to a child's participation in childhood activities. However, if the parent provides notice in advance that the child is prohibited from participating in a specific activity, a designated person must follow the parent's decision. Source Note: The provisions of this §748.707 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.707 Who makes the decision regarding a foster child's participation in childhood activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189060 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189060&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189060 03/12/2026 (a) Caregivers hired after August 31, 2016, may not be a designated person that makes decisions regarding a child's participation in childhood activities until the caregiver completes either a two hour pre-service training regarding normalcy or the annual training specific to normalcy.(b) A designated person that makes decisions regarding a child's participation in childhood activities must:(1) Work at the location where the child resides; and(2) Be knowledgeable about the child's current needs and history.(c) The name of each designated person must be documented on the face sheet of the child's record. Source Note: The provisions of this §748.709 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.709 Are there any restrictions on who can be a designated person that makes decisions regarding a child's participation in childhood activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208573 03/12/2026 (a) You must maintain a personnel record for each volunteer.(b) The personnel record must include a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation's administrator or administrator's designee. An internal reporting policy may not require or allow a person to delegate the person's responsibility or require a person to obtain approval to report suspected abuse, neglect, or exploitation. Source Note: The provisions of this §748.721 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.721 What are the requirements for a volunteer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189062 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189062&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189062 03/12/2026 (a) A volunteer or contractor that performs any employee function must meet the same requirements as an employee who performs that function.(b) You must maintain records documenting how these requirements are met. Source Note: The provisions of this §748.723 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.723 Are there additional requirements for a volunteer or contractor that performs employee functions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189063 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189063&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189063 03/12/2026 (a) A volunteer or contractor who is part of another organization is subject to your policies and procedures unless that organization provides screening, training, and supervision to the volunteer/contractor that are adequate to protect the health and safety of children. Before the volunteer/contractor can have contact with children:(1) The volunteer/contractor must meet the relevant requirements of your policies and procedures; or(2) You must confirm that the organization provides adequate screening, training, and supervision.(b) An organization may be another licensed operation. Source Note: The provisions of this §748.724 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.724 When is a volunteer or contractor who is a part of another organization subject to my policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208574 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208574&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208574 03/12/2026 (a) Yes, but when a volunteer or a volunteer's family takes a child who is in care for an overnight or weekend visit, this is a volunteer activity.(b) Neither the volunteer nor the family would have to comply with employee or caregiver requirements, but:(1) The volunteer or the family would have to meet the relevant background checks; and(2) You must get written approval from the parent. Source Note: The provisions of this §748.725 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.725 Can a volunteer or a volunteer's family take a child in care for an overnight or weekend visit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208575 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208575&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208575 03/12/2026 If a child has a day or overnight visit with a volunteer or a volunteer's family, you must ensure that:(1) The child is properly supervised, properly fed and hydrated, and provided with safe housing accommodations, if applicable;(2) The child's health, safety, and well-being are protected; and(3) Prior to the visit, the person responsible for the child during the visit has to receive the same information that you as a respite child-care services provider would receive, as specified in §748.4265 of this chapter (relating to What information regarding a child must I receive prior to providing respite child-care services to that child?). Source Note: The provisions of this §748.729 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.729 What must I do when a child in care visits a volunteer or a volunteer's family for a day or overnight? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189066 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189066&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189066 03/12/2026 A person may not perform community service hours at your operation. For the purposes of this rule, community service includes service a person must perform because the person is on probation, parole, or otherwise required to perform the service through the courts because of criminal activity. Source Note: The provisions of this §748.731 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.731 May a person perform community service hours at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213928 03/12/2026 (a) Before hiring an applicant for a position, you must:(1) Obtain in writing the applicant's employment history for the last five years, which may include:(A) Any history for an applicant who has not continuously been employed during the last five years; or(B) A statement that the applicant has no employment history during the last five years; and(2) When the applicant's employment history indicates the applicant has been employed within the last five years, verify whether the applicant was employed as described in the applicant's employment history by contacting:(A) Each employer included in the five-year employment history; or(B) The applicant's three most recent employers, at a minimum, if the five-year employment history includes more than three employers; and(b) If you hire the applicant, you must maintain documentation of the following in the applicant's personnel file:(1) The applicant's employment history required by subsection (a)(1) of this section; and(2) If the applicant has been employed in the last five years, the results of any contact with an applicant's previous employers related to employment verification. If you are unable to contact an employer or obtain the information described in subsection (a)(2) of this section from an employer:(A) Any refusal by the employer to provide the information; or(B) Your diligent efforts to contact the employer, which must include more than one attempt to contact an employer who is not permanently unreachable. If the employer is permanently unreachable, your documentation must include the reason why you made that determination. Examples of an employer being unreachable include:(i) The employer is out of business and there is no alternative contact information to obtain information from the employer; or(ii) The employer is deceased.(c) This rule applies only to applicants who seek employment with your operation on or after August 9, 2023. Source Note: The provisions of this §748.751 adopted to be effective August 9, 2023, 48 TexReg 3280. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.751 What are the requirements for obtaining and verifying an applicant's employment history? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=213929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 213929 03/12/2026 (a) Before hiring an applicant for a position, you must complete the applicant's reference checks by:(1) Obtaining from the applicant the name and contact information of at least two individuals unrelated to the applicant who can serve as references by answering questions related to the applicant's suitability to work with or around children; and(2) Contacting each of the two required references to verify that the applicant is suitable to work with or around children. You may contact the reference through an interview or in writing.(b) For an applicant who is currently or was previously employed in a position responsible for providing care or services to children within the past five years, at least one of the reference checks required in subsection (a) of this section must be a current or prior employer who has supervised or is otherwise familiar with the history and performance of the applicant in that capacity.(c) For any reference check you are unsuccessful in completing as required by subsection (a) or (b) of this section, you must document:(1) Any refusal by the reference to provide the information; or(2) Your diligent efforts to contact the reference, which must include more than one attempt to contact a reference who is not permanently unreachable. If the reference is permanently unreachable, your documentation must include the reason why you made that determination. Examples of a reference being unreachable include:(A) The reference is out of business and there is no alternative contact information to obtain information from the employer; or(B) The reference is deceased; and(3) Your assessment of the applicant's suitability to work with or around children.(d) For each person you hire, you must maintain in the employee's personnel file:(1) Documentation of each reference check that includes:(A) The reference's name;(B) The relation of the reference to the applicant;(C) The reference's contact information;(D) The date you completed the check;(E) Information you obtained from the check, documented as:(i) A summary of the interview; or(ii) A copy of the written information provided by the reference; and(F) If you conducted the check through an interview, the name of the person who interviewed the reference; and(2) If you were unsuccessful in completing a reference check, documentation required by subsection (c) of this section.(e) This rule applies only to applicants who seek employment with your operation on or after August 9, 2023. Source Note: The provisions of this §748.753 adopted to be effective August 9, 2023, 48 TexReg 3280. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS E PERSONNEL §748.753 What are the requirements for completing an applicant's reference checks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208576 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208576&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208576 03/12/2026 The words and terms used in this subchapter have the following meaning:(1) CPR--Cardiopulmonary resuscitation.(2) Hours--Clock hours.(3) Instructor-led training--Training that is characterized by the communication and interaction that takes place between the student and the instructor. Instructor-led training does not have to be in person, but it must include an opportunity for the student to interact with the instructor to obtain clarifications and information beyond the scope of the training material. For such an opportunity to exist, the instructor must be able to answer questions, provide feedback on skills practice, provide guidance or information on additional resources, and proactively interact with students. Examples of this type of training include classroom training, online distance learning, blended learning, video-conferencing, or other group learning experiences.(4) Self-instructional training--Training designed to be used by one individual working alone and at the individual's own pace to complete lessons or modules. Lessons or modules commonly include questions with clear right and wrong answers. An example of this type of training is web-based training. Self-study training is also a type of self-instructional training.(5) Self-study training--Non-standardized training where an individual reads written materials, watches a training video, or listens to a recording to obtain certain knowledge that is required for annual training. Self-study training is limited to three hours of annual training per year. See 748.937(d) of this subchapter (relating to What types of hours or instruction can be used to complete the annual training requirements?). Source Note: The provisions of this §748.801 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.801 What do certain words mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208577 03/12/2026 (a) A caregiver must complete the following training requirements, unless the caregiver meets the requirements of an exemption or a waiver for the training that is provided in this subchapter:Attached Graphic(b) You must ensure that a caregiver who provides care to a child receiving treatment services meets the pre-service experience requirements specified in §748.861 of this subchapter (relating to What are the pre-service experience requirements for a caregiver?). Source Note: The provisions of this §748.811 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.811 What are the training and experience requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208578 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208578&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208578 03/12/2026 An employee must complete the following training requirements, unless the employee meets the requirements of an exemption for the training that is provided in this subchapter:Attached Graphic Source Note: The provisions of this §748.813 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.813 What are the training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208585 03/12/2026 (a) Prior to beginning job duties or having contact with children in care, each caregiver or employee must have orientation that includes:(1) An overview of the relevant and applicable rules of this chapter;(2) Your philosophy, organizational structure, policies, and a description of the services and programs you offer; and(3) The needs and characteristics of children that you serve.(b) You must document the completion of the orientation in the appropriate personnel record. Source Note: The provisions of this §748.831 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.831 What is the orientation requirement for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208586 03/12/2026 (a) A person who was a caregiver or employee at your operation during the past 12 months may be exempt from orientation if you meet the following requirements:(1) You discuss with the person any changes in your services or programs that have occurred since the person was previously a caregiver or employee;(2) If the person is an employee, you ensure the employee received training during the past 12 months from your operation on prevention, recognition, and reporting on child abuse, neglect, and exploitation; and(3) If the person is acting as a caregiver, you do not allow the person to be the only caregiver for a group of children before you meet the requirement in paragraph (1) of this section.(b) You must document the discussion and the previous training in the person's personnel record. Source Note: The provisions of this §748.833 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.833 When may a caregiver or employee be exempt from orientation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208701 03/12/2026 (a) If less than 25 children and less than 30% of your total population of children in care are receiving treatment services, then there are no pre-service experience requirements.(b) If 25 or more children or 30% or more of your total population of children in care are receiving treatment services, then a caregiver must have 40 hours of supervised child-care experience in your operation and/or another operation that provides the same treatment services. Until the caregiver has met this 40-hour experience requirement, the caregiver:(1) May not be assigned as the only caregiver responsible for a group of children;(2) Must be supervised at all times by another caregiver who has already satisfied the 40-hour experience requirement; and(3) The supervised child-care experience must be documented in the appropriate personnel record. Source Note: The provisions of this §748.861 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.861 What are the pre-service experience requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208588 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208588&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208588 03/12/2026 (a) A caregiver must complete the following applicable types of pre-service training within the noted time frame:Attached Graphic(b) A caregiver who has not completed all the pre-service training requirements in subsection (a) of this section may not be counted in the child to caregiver ratio unless there is a fully qualified caregiver counted in ratio at the same time.(c) A caregiver who cares exclusively for children receiving treatment services for primary medical needs is exempt from the pre-service EBI training requirement.(d) To meet the pre-service training requirements, the training must comply with the applicable curriculum requirements in Division 5 of this subchapter (relating to Curriculum Components for Pre-Service Training).(e) You must document the completion of each training requirement in the appropriate personnel record. Source Note: The provisions of this §748.863 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.863 What are the pre-service training requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208587 03/12/2026 (a) An employee must complete the following applicable training types and hours within the noted time frames:Attached Graphic(b) To meet the pre-service training requirements, the training must comply with the applicable curriculum requirements in Division 5 of this subchapter (relating to Curriculum Components for Pre-Service Training).(c) You must document the completion of each training requirement in the appropriate personnel record. Source Note: The provisions of this §748.864 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.864 What are the pre-service training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208597 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208597&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208597 03/12/2026 No, the orientation training must be separate from the pre-service training requirement. Source Note: The provisions of this §748.865 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.865 Can time spent in orientation training count towards pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208589 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208589&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208589 03/12/2026 (a) A caregiver is exempt from completing the eight hours of general pre-service training if the caregiver has been employed as a caregiver in a general residential operation during the past 12 months.(b) An employee is exempt from completing the two hours of normalcy training if the employee has:(1) Been employed by a general residential operation during the past 12 months;(2) Received training on normalcy during the past 12 months; and(3) Can document that the training was received.(c) A caregiver or an employee is exempt from completing the pre-service training for emergency behavior intervention if the caregiver or employee:(1) Has been employed by a general residential operation during the last 12 months;(2) Has received emergency behavior intervention training during the past 12 months that meets the required curriculum components of:(A) §748.887 of this subchapter (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavioral intervention?); or(B) §748.889 of this subchapter (relating to If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?); and(3) Can demonstrate knowledge and competency of the training material in writing and, if the general residential operation allows the use of emergency behavior intervention, in physical techniques.(d) You must document the exemption factors in the appropriate personnel record. Source Note: The provisions of this §748.867 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.867 What caregivers or employees are exempt from certain pre-service training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208590 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208590&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208590 03/12/2026 (a) Instructor-led training and self-instructional training must include:(1) Specifically stated learning objectives;(2) An evaluation or assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(3) A certificate, letter, or a signed and dated statement of successful completion from the training source.(b) Pre-service training must be provided by an instructor who:(1) Holds a generally recognized credential; or(2) Possesses documented knowledge or experience relevant to the training the instructor will provide.(c) Training on administering psychotropic medication must be instructor-led, as defined §748.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?). The instructor must be a health-care professional or pharmacist.(d) Training on emergency behavior intervention must:(1) Be instructor-led with each instructor certified in a recognized method of emergency behavior intervention or otherwise able to document knowledge of:(A) Emergency behavior intervention;(B) The course material;(C) Methods for delivering the training, including physical techniques for restraints, if applicable; and(D) Methods for evaluating and assessing a participant's knowledge and competency of the training material and physical techniques, if applicable;(2) Be competency-based; and(3) At the end of the training, require each participant to demonstrate knowledge and competency of the training material:(A) In writing; and(B) If the general residential operation allows the use of emergency behavior intervention, by demonstrating each physical technique the participant is allowed to use. Source Note: The provisions of this §748.869 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.869 How must pre-service training be conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208592 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208592&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208592 03/12/2026 The general pre-service training must include the following curriculum components:(1) Topics appropriate to the needs of children for whom the caregiver will be providing care, such as developmental stages of children, fostering children's self-esteem, constructive guidance and discipline of children, water safety, strategies and techniques for monitoring and working with these children, and age-appropriate activities for the children;(2) Measures to prevent, recognize, and report suspected occurrences of child abuse (including sexual abuse), neglect, and exploitation;(3) Procedures to follow in emergencies, such as weather-related emergencies, volatile persons, and severe injury or illness of a child or adult;(4) Preventing the spread of communicable diseases;(5) The location and use of fire extinguishers and first-aid equipment;(6) Trauma informed care; and(7) Normalcy. Source Note: The provisions of this §748.881 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.881 What curriculum components must be included in the general pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208593 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208593&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208593 03/12/2026 The pre-service training for normalcy must include the following curriculum components:(1) A discussion of the definitions of normalcy and the reasonable and prudent parent standard;(2) The developmental stages of children, including a discussion of the cognitive, social, emotional, and physical development of children;(3) Age appropriate activities for children, including unsupervised childhood activities;(4) The benefits of childhood activities to a child's well-being, mental health, and social, emotional, and developmental growth;(5) How to apply the reasonable and prudent parent standard to make decisions; and(6) The child's and the caregiver's responsibilities when participating in childhood activities. Source Note: The provisions of this §748.882 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.882 What curriculum components must be included in the pre-service training for normalcy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208591 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208591&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208591 03/12/2026 The pre-service training for safe sleeping must include the following curriculum components:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding safe sleeping practices and preventing sudden infant death syndrome; and(3) Understanding early childhood brain development. Source Note: The provisions of this §748.883 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.883 What curriculum components must be included in the pre-service training for safe sleeping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208594 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208594&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208594 03/12/2026 The pre-service training for administering psychotropic medication must include the following curriculum components:(1) Identification of psychotropic medications;(2) Basic pharmacology (the actions and side effects of, and possible adverse reactions to, various psychotropic medications);(3) Techniques and methods of administering medications;(4) Who is legally authorized to provide consent for the psychotropic medication; and(5) Any related policies and procedures, including how to document when a medication is administered. Source Note: The provisions of this §748.885 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.885 What curriculum components must be included in the pre-service training for administering psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208595 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208595&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208595 03/12/2026 If you do not allow the use of emergency behavior intervention, the pre-service training curriculum for emergency behavior intervention must focus on early identification of potential problem behaviors and strategies and techniques for less restrictive interventions, including the following curriculum components:(1) Developing and maintaining an environment that supports positive and constructive behaviors;(2) The causes of behaviors potentially harmful to a child, including aspects of the environment;(3) Early signs of behaviors that may become dangerous to a child or others;(4) Strategies and techniques a child can use to avoid harmful behaviors;(5) Teaching a child to use the strategies and techniques of your operation's de-escalation protocols to avoid harmful behavior, and supporting the child's efforts to progress into a state of self-control;(6) Less restrictive strategies caregivers can use to intervene in potentially harmful behaviors;(7) Less restrictive strategies caregivers can use to engage a child and de-escalate a situation;(8) Addressing circumstances when all de-escalation strategies fail; and(9) The risks associated with the use of prone or supine restraints, including positional, compression, or restraint asphyxia. Source Note: The provisions of this §748.887 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.887 If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208596 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208596&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208596 03/12/2026 (a) If you allow the use of emergency behavior intervention, at least 75 percent of the pre-service training for emergency behavior intervention must focus on early identification of potential problem behaviors and strategies and techniques for less restrictive interventions, including the curriculum components listed in §748.887 of this division (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?).(b) The training does not have to address the use of any emergency behavior intervention that your policies do not allow.(c) The other 25 percent of the pre-service training for emergency behavior intervention must include the following components:(1) Different roles and responsibilities of caregivers qualified in emergency behavior intervention, versus employees or volunteers who are not qualified in emergency behavior intervention;(2) Escape and evasion techniques to prevent harm to the child and caregiver without requiring the use of an emergency behavior intervention;(3) Safe implementation of the restraints and seclusion techniques and procedures that are appropriate for the age and weight of children served and permitted by the rules in this chapter and your policies and procedures;(4) The physiological impact of emergency behavior intervention;(5) The psychological impact of emergency behavior intervention, such as flashbacks from prior abuse;(6) How to adequately monitor the child during the administration of an emergency behavior intervention to prevent injury or death;(7) Monitoring physical signs of distress and obtaining medical assistance;(8) Health risks for children associated with the use of specific techniques and procedures;(9) Drawings, photographs, or videos of each personal or mechanical restraint permitted by your policy; for mechanical restraints, this must include the manufacturer's complete specifications for each device permitted, an explanation of modifications to the manufacturer's specifications, and a copy of the approval of the modification from a licensed psychiatrist; and(10) Strategies for re-integration of children into the environment after the use of emergency behavior intervention, including the debriefing of caregivers and the child. Source Note: The provisions of this §748.889 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.889 If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208598 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208598&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208598 03/12/2026 (a) Each caregiver must have a current certificate of training with an expiration or renewal date in first aid with rescue breathing and choking. This training may be through instructor-led training or self-instructional training.(b) At least one caregiver counted in the child to caregiver ratio must have a current certificate of training with an expiration or renewal date in:(1) Pediatric CPR, if your operation only serves children under 12 years of age;(2) Adult CPR, if your operation only serves children 12 years of age and older; or(3) Pediatric and Adult CPR, if your operation serves children between the ages of birth through 17. You may meet this requirement if:(A) One caregiver counted in the child to caregiver ratio has a current certificate of training in both types of CPR; or(B) One caregiver counted in the child to caregiver ratio has a current certificate of training in Pediatric CPR, and another caregiver counted in the child to caregiver ratio has a current certificate of training in Adult CPR.(c) Each caregiver must:(1) Be certified in first aid within 90 days of employment; and(2) Be certified in CPR and able to respond to emergencies prior to being the only caregiver counted in the child to caregiver ratio. Source Note: The provisions of this §748.911 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.911 Who must have first aid and CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208599 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208599&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208599 03/12/2026 CPR training:(1) Must adhere to the guidelines for CPR for a layperson established by the American Heart Association, and consist of a curriculum that includes use of a CPR manikin and both written and hands-on skill-based instruction, practice, and testing; and(2) May be provided through blended learning that utilizes online technology, including self-instructional training, as long as the learning meets the criteria in paragraph (1) of this section. Source Note: The provisions of this §748.913 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.913 What are the requirements for CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208600 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208600&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208600 03/12/2026 (a) You must document the caregiver's completion of each training requirement in the appropriate personnel record. The documentation may be a certificate, letter, or a signed and dated statement of successful completion from the training source. You may maintain a photocopy of the original first-aid or CPR certificate or letter in the personnel record, as long as the caregiver can provide an original document upon request by Licensing.(b) The documentation must include:(1) The participant's name;(2) Date of the training;(3) Title or subject of the training;(4) The trainer's name and qualifications;(5) The expiration date of the certification as determined by the organization providing the certification; and(6) Length of the training in hours. Source Note: The provisions of this §748.915 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.915 What documentation must I maintain for first aid and CPR certifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208601 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208601&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208601 03/12/2026 (a) A caregiver must complete the number of annual training hours described in the following chart:Attached Graphic(b) For the annual training hours described in subsection (a) of this section, each caregiver must complete the following specific types of training and hours:Attached Graphic(c) To meet the mandated annual training requirements in subsection (b) of this section, the training must comply with the applicable curriculum requirements in Division 8 of this subchapter (relating to Topics and Curriculum Components for Annual Training).(d) After completing the type of annual training required in subsection (b) of this section, any remaining number of annual training hours must be in areas appropriate to the needs of children for whom the caregiver provides care, as required by §748.943 of this subchapter (relating to What areas or topics are appropriate for annual training?). Source Note: The provisions of this §748.930 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.930 What are the annual training requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208602 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208602&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208602 03/12/2026 (a) Each type of employee in the chart must complete the following number of annual training hours:Attached Graphic(b) For the annual training hours described in subsection (a)(1) of this section, each employee must complete the following specific types of training and hours:Attached Graphic(c) For the annual training hours described in subsection (a)(2) of this section, each employee must complete the following specific types of training and hours:Attached Graphic(d) An employee described in subsection (a)(2) of this section may use annual training hours that the employee completes to maintain a relevant professional license, if the hours include the necessary components of subsection (c) of this section or completes the components separately.(e) There are no annual training requirements for emergency behavior intervention. However, the employee must be retrained whenever there is a substantial change in techniques, types of intervention, or agency policies for emergency behavior intervention. Source Note: The provisions of this §748.931 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.931 What are the annual training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208603 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208603&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208603 03/12/2026 (a) With the exception of emergency behavior intervention training, each person must complete the annual training:(1) Within 12 months from when you hire the person; and(2) During each subsequent 12-month period after the anniversary date of hire.(b) Alternately, you have the option of prorating the person's annual training requirements from the date of hire to the end of the calendar year or the end of the operation's fiscal year and then beginning a new 12-month period that coincides with the calendar or fiscal year.(c) Whether you use subsection (a) or (b) of this section as your method for completing annual training requirements, you must use the method consistently throughout your operation. Source Note: The provisions of this §748.935 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.935 When must an employee or caregiver complete the annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208604 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208604&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208604 03/12/2026 Each caregiver must complete emergency behavior intervention training within:(1) Six months from the date that the caregiver last received the training, if the caregiver cares for children at an operation where children receive treatment services; or(2) 12 months from the date the caregiver last received the training, if the caregiver cares for children in a cottage home. Source Note: The provisions of this §748.936 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.936 When must a caregiver complete emergency behavior intervention training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208605 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208605&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208605 03/12/2026 (a) If the training complies with the other rules in this division (relating to Annual Training), annual training may include hours or Continuing Education Units earned through:(1) Workshops or courses offered by local school districts, colleges or universities, or Licensing;(2) Conferences or seminars;(3) Instructor-led training, as defined at §748.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?);(4) Self-instructional training, as defined at §748.801(4) of this subchapter;(5) Planned learning opportunities provided by child-care associations or Licensing;(6) Planned learning opportunities provided by a professional contract service provider, child-care administrator, professional level service provider, treatment director, or caregiver who meets minimum qualifications in the rules of this chapter; or(7) Completed college courses for which a passing grade is earned, with three college credit hours being equivalent to 50 clock hours of required training. College courses do not substitute for required CPR or first-aid certification or required annual training on emergency behavior intervention or psychotropic medication.(b) For annual training hours, you may count:(1) The hours of annual training that a person received at another residential child-care operation, if the person:(A) Received the training within the time period you are using to calculate the person's annual training; and(B) Provides documentation of the training;(2) First aid and CPR;(3) Any hours of pre-service training that the person earned in addition to the required pre-service hours, although you may not carry over more than 15 hours of a person's pre-service training hours for use as annual training hours during the upcoming year;(4) Half of the hours spent developing initial training curriculum that is relevant to the population of children served. No additional credit hours for training curriculum development are permitted for repeated training sessions; and(5) One-fourth of the hours spent updating and making revisions to training curriculum that is relevant to the population of children served.(c) For annual training hours, you may not count:(1) Orientation training;(2) Required pre-service training;(3) The hours involved in case staffings and conferences with the supervisor; or(4) The hours presenting training to others.(d) No more than 80 percent of the required annual training hours may come from self-instructional training, as defined at §748.801(4) of this subchapter. No more than three of those self-instructional hours may come from self-study training, as defined at §748.801(5) of this subchapter.(e) If a person earns more than the minimum number of annual training hours required during a particular year, the person can carry over to the next year a maximum of 15 annual training hours. Source Note: The provisions of this §748.937 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.937 What types of hours or instruction can be used to complete the annual training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208606 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208606&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208606 03/12/2026 We do not approve or endorse training resources or trainers for training hours. Source Note: The provisions of this §748.939 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.939 Does Licensing approve training resources or trainers for annual training hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208702 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208702&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208702 03/12/2026 (a) Instructor-led training and self-instructional training, excluding self-study training, must include:(1) Specifically stated learning objectives;(2) A curriculum that includes experiential or applied activities;(3) An evaluation or assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(4) A certificate, letter, or a signed and dated statement of successful completion from the training source.(b) Training on emergency behavior intervention and administering psychotropic medication must be instructor-led, as defined at §748.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?).(c) Training on emergency behavior intervention must:(1) Be led by an instructor who is certified in a recognized method of emergency behavior intervention or otherwise able to document knowledge of:(A) Emergency behavior intervention;(B) The course material;(C) Methods for delivering the training, including physical techniques for restraints, if applicable; and(D) The methods for evaluating and assessing a participant's knowledge and competency of the training material and physical techniques, if applicable;(2) Be competency-based; and(3) At the end of the training, require each participant to demonstrate knowledge and competency of the training material:(A) In writing; and(B) If the general residential operation allows the use of emergency behavior intervention, by demonstrating the physical techniques that the participant may use.(d) A health-care professional or a pharmacist must lead the training in administering psychotropic medication. The trainer must assess each participant after the training to ensure that the participant has learned the course content.(e) Training on transportation safety must be instructor led and provided by:(1) A training provider registered with the Texas Early Care and Education Career Development System's Texas Trainer Registry, maintained by the Texas Head Start Collaboration Office;(2) An instructor who teaches early childhood development or another relevant course at a secondary school or institution of higher education accredited by a recognized accrediting agency;(3) An employee of a state agency with relevant expertise;(4) A physician, psychologist, licensed professional counselor, social worker, or registered nurse;(5) A person who holds a generally recognized credential or possesses documented knowledge relevant to the training the person will provide; or(6) A person who has at least two years of experience working in child development, a child development program, early childhood education, a childhood education program, or a Head Start or Early Head Start program and:(A) Has been awarded a Child Development Associate Credential; or(B) Holds at least an Associate's Degree in child development, early childhood education, or a related field. Source Note: The provisions of this §748.941 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.941 How must annual training be conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208610 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208610&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208610 03/12/2026 (a) Other than the mandated topics, annual training for caregivers must be in areas appropriate to the needs of children for whom the operation or employee will be providing care, which may include:(1) Developmental stages of children;(2) Constructive guidance and discipline of children;(3) Fostering children's self-esteem;(4) Positive interaction with children;(5) Strategies and techniques for working with the population of children served;(6) Supervision and safety practices for children in care;(7) Preventing the spread of communicable diseases;(8) Water safety;(9) Administration of medication;(10) Medical-related training to help children receiving treatment services for primary medical needs;(11) Helping children experience grief or loss;(12) Prevention, recognition, and reporting of child abuse, neglect, and exploitation; or(13) Safe sleeping, as specified in §748.883 of this subchapter (relating to What curriculum components must be included in the additional general pre-service training for safe sleeping?).(b) Other than mandated topics, annual training for employees must be in areas appropriate to the needs of children for whom the general residential operation provides care, which may include:(1) The areas listed in subsection (a) of this section; and(2) Emergency behavior intervention. Source Note: The provisions of this §748.943 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.943 What areas or topics are appropriate for annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208611 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208611&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208611 03/12/2026 (a) The annual training for normalcy must include the curriculum components covered in the pre-service training for normalcy, see §748.882 of this subchapter (relating to What curriculum components must be included in the pre-service training for normalcy?).(b) Subsequent annual training for normalcy should include curriculum that further develops and refines an employee's knowledge and understanding of normalcy, including how to implement normalcy. Source Note: The provisions of this §748.944 adopted to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.944 What curriculum components must be included in the annual training for normalcy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208608 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208608&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208608 03/12/2026 The annual training for administering psychotropic medication must include the curriculum components identified in §748.885 of this subchapter (relating to What curriculum components must be included in the pre-service training for administering psychotropic medication?). Source Note: The provisions of this §748.945 adopted to be effective April 25, 2022, 4 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.945 What curriculum components must be included in the annual training for administering psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208609 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208609&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208609 03/12/2026 (a) The annual training for emergency behavior intervention must include curriculum components that:(1) Reinforce basic principles covered in the pre-service training identified in §748.887 of this subchapter (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?) and §748.889 of this subchapter (relating to If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?); and(2) Develop and refine the caregiver's skills.(b) You may determine the content of the training based on your evaluation of your emergency behavior interventions.(c) The training may repeat pre-service training components, including training in the proper use and implementation of emergency behavior intervention. Source Note: The provisions of this §748.947 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 4 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.947 What curriculum components must be included in the annual training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208700 03/12/2026 (a) You must keep documentation verifying completion of annual training in the appropriate personnel record. The documentation may be a certificate, letter, or a signed and dated statement of successful completion from the training source. The documentation may also be a transcript from an accredited college or university.(b) The documentation for training other than college courses must include the following information:(1) The participant's name;(2) Date of the training;(3) Title or subject of the training;(4) The trainer's name and qualifications, or the source of the training for self-instructional training; and(5) Length of the training in hours. Source Note: The provisions of this §748.949 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS F TRAINING AND PROFESSIONAL DEVELOPMENT §748.949 What documentation must I maintain for annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189101 03/12/2026 The child/caregiver ratio is the maximum number of children for whom one caregiver can be responsible. Source Note: The provisions of this §748.1001 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1001 What is the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189102 03/12/2026 (a) The number of children that a single caregiver may care for during waking hours depends on the ages and treatment service needs of the children in the group. A single caregiver may care for five children if at least one child in the group requires treatment services, or eight children if none of the children in the group require treatment services. Children younger than five years old count as two children.(b) You may separate children into groups based on age and/or treatment services in order to vary the child/caregiver ratio required for each group, as long as:(1) The groups remain easily distinguishable and separated, such as by cottage or unit; and(2) The child/caregiver ratio is re-calculated any time groups intermingle, such as on a field trip or in the dining room.(c) A cottage home may be out of ratio during waking hours for short periods to enable a normal home-like routine as long as the care and supervision needs of the children continue to be met. Staff or other caregivers must be on the premises and available to respond in an emergency. These additional staff or caregivers must be specifically addressed in the written professional staffing plan.(d) A child does not count in the child/caregiver ratio while participating in an approved unsupervised childhood activity. Source Note: The provisions of this §748.1003 adopted to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1003 For purposes of the child/caregiver ratio, how many children can a single caregiver care for during the children's waking hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189103 03/12/2026 Each group of children must have sufficient caregivers to meet the required child/caregiver ratio for that group of children. A person may not be counted in the ratio for a group of children if he is caring for children outside the group or working in an administrative capacity. Source Note: The provisions of this §748.1005 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1005 Can child/caregiver ratios be averaged on an operation-wide basis? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189104 03/12/2026 (a) The number of children that a single caregiver may care for during night-time sleeping hours depends on whether the caregiver stays awake or sleeps during these hours and on the ages and treatment service needs of the children in the group. Children younger than five years old count as two children.(b) If the caregiver stays awake, the caregiver may care for:(1) 15 children if at least one child in the group requires treatment services; or(2) 24 children if none of the children in the group require treatment services.(c) If the caregiver sleeps, the caregiver may care for:(1) 10 children if at least one child in the group requires treatment services; or(2) 16 children if none of the children in the group require treatment services.(d) You may separate children into groups based on age and/or treatment services in order to vary the child/caregiver ratio required for each group, as long as:(1) The groups remain easily distinguishable and separated, such as by cottage or unit; and(2) The child/caregiver ratio is re-calculated any time groups intermingle, such as on a field trip.(e) A cottage home may be out of ratio during night-time sleeping hours for short periods to enable a normal home-like routine as long as the care and supervision needs of the children continue to be met. Staff or other caregivers must be on the premises and available to respond in an emergency. These additional staff or caregivers must be specifically addressed in the written professional staffing plan. Source Note: The provisions of this §748.1007 adopted to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1007 For purposes of the child/caregiver ratio, how many children can a single caregiver care for when children are asleep at night? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189105 03/12/2026 You must employ an adequate number of qualified caregivers to meet the needs of children, taking into account each child's age, medical, physical, and mental condition and other factors that affect the amount of supervision the child requires, including enough caregivers to meet:(1) Child/caregiver ratios; and(2) All of their responsibilities required in §748.685 of this title (relating to What responsibilities does a caregiver have when supervising a child or children?). Source Note: The provisions of this §748.1009 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1009 How many caregivers must I employ? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189106 03/12/2026 The child/caregiver ratio only includes qualified caregivers who are working directly with a child or group of children. Source Note: The provisions of this §748.1011 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1011 What employees can be counted as a caregiver in the child/caregiver ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189107 03/12/2026 (a) A caregiver must always be awake when caring for a child needing constant supervision, such as a medically fragile child or a child that is an immediate danger to self or others.(b) To facilitate continuous care for a child, the caregiver may move a child to a location where the caregiver can directly and continuously supervise a child until there is no longer an immediate danger to self or others. The caregiver must provide comfortable sleeping arrangements for the child. Source Note: The provisions of this §748.1013 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1013 How does a caregiver care for a child needing constant supervision during sleeping hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189108 03/12/2026 (a) The child/caregiver ratio applies to the children of caregivers who are present with children in care.(b) For both children and adult residents, you must maintain the ratio as outlined in §748.1935 of this title (relating to How does the child/caregiver ratio apply if I provide care to both children and adults?). Source Note: The provisions of this §748.1015 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1015 How does the child/caregiver ratio apply if I provide care for both children in care and children of caregivers, or for both children and adult residents? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189109 03/12/2026 (a) The child/caregiver ratio applies to activities sponsored or conducted by the operation, including field trips, higher risk recreational activities, and appointments that occur away from the operation.(b) You must have additional caregivers to meet the special needs of children when there are activities away from your operation, for example a non-ambulatory child. Source Note: The provisions of this §748.1017 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1017 How does the child/caregiver ratio apply to activities that occur away from my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189100 03/12/2026 A caregiver counted in the child/caregiver ratio who is responsible for supervising children of the same gender in a transitional living program must:(1) Reside in or within close physical proximity of the children's living quarters;(2) Be onsite at the operation during times when children are awake, but the caregiver is not physically present with the children;(3) Be physically available to the children at all times;(4) Be capable of responding quickly in an emergency; and(5) Be capable of monitoring the comings and goings of the children in the program. Source Note: The provisions of this §748.1019 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1019 What are the supervision requirements for a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189098 03/12/2026 (a) The child must be 16 years old or older.(b) You must evaluate each child in a transitional living program to determine whether the child needs supervision. The evaluation must:(1) Include a written plan defining the periods of time the child may be left unsupervised;(2) Include a written plan for addressing behavioral problems that a child may have while in the transitional living program; and(3) Identify how the child may contact the caregivers when caregivers are not physically present with the child, such as being available to the child by telephone or other means of contact.(c) The child's service planning team must approve the evaluation.(d) You must document the evaluation of the child and the approval in the child's record. You must review and update the evaluation during the child's service planning meetings. Source Note: The provisions of this §748.1021 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1021 When does a child who is in a transitional living program not need supervision? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189099 03/12/2026 You must not have living quarters, a cottage, or a house with both male and female residents, unless caregivers are always present when children are at the living quarters, cottage, or house of the transitional living program. Source Note: The provisions of this §748.1023 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS G CHILD/CAREGIVER RATIOS §748.1023 Is my operation permitted to have a transitional living program with living quarters, a cottage, or a house with both male and female residents? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189110 03/12/2026 (a) A child's rights are cumulative of any other rights granted by law or other Licensing rules.(b) The following categories include the child's rights that you must adhere to:(1) Safety and care, including:(A) The right to good care and treatment that meets the child's needs in the most family-like setting possible;(B) The right to be free from abuse, neglect, and exploitation; and(C) The right to fair treatment;(2) Family contacts, including the right to maintain regular contact with the child's parents and siblings, unless restrictions are necessary because of the child's best interest, the decision of an appropriate professional, or a court order;(3) Living a normal life, including:(A) The right to be able to communicate in a language or any other means that is understandable to the child at admission or within a reasonable time after an emergency admission, if applicable, such as having a plan for an interpreter, having at least one person at the operation at all times who can communicate with the child in the child's own language, or other means to communicate with the child in the child's own language;(B) The right to receive educational services appropriate to the child's age and developmental level;(C) The right to have the child's religious needs met;(D) The right to participate in childhood activities, including unsupervised childhood activities away from the operation and the caregivers, that are appropriate for the child's age, maturity, and developmental level;(E) The right to privacy, including sending and receiving unopened mail, making and receiving phone calls, keeping a personal journal, and having visitors, unless the child's best interest, appropriate professionals, or court order necessitates restrictions;(F) The right to personal care, hygiene, and grooming equipment and supplies and training in how to use them;(G) The right to have comfortable clothing, which is suitable to the child's age and size and similar to the clothing of other children in the community. Teenagers should have reasonable opportunities to select the clothing;(H) The right to clothing that protects the child against the weather;(I) The right to have personal items in the child's room and to get additional items within reasonable limits;(J) The right to personal space in the child's bedroom to store the child's clothes and belongings;(K) The right to be informed of search policies and be free of unreasonable searches and unreasonable removal of personal items;(L) Depending on the child's age and maturity, the right to seek employment, keep the child's own money, have a bank account in the child's name, and get paid for any work done for the operation as part of the child's service plan or vocational training, with the exception of assigned routine duties that relate to the child's living environment, such as cleaning the child's room, or other chores, or work assigned as a disciplinary measure;(M) The right to consent in writing before taking part in any publicity or fund raising activity for the operation, including the use of the child's photograph;(N) The right to refuse to make public statements showing gratitude to the operation; and(O) The right to not be pressured to get an abortion, give up her child for adoption, or parent her child, if applicable;(4) Discipline, including:(A) The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment. This means the child must not be:(i) Shaken;(ii) Subjected to or threatened with corporal punishment, including spanking or hitting the child;(iii) Forced to do unproductive work that serves no purpose except to demean the child, such as moving rocks from one pile to another or digging a hole and then filling it in;(iv) Denied food, sleep, a bathroom, mail, or family visits as punishment;(v) Subjected to remarks that belittles or ridicules the child or the child's family;(vi) Threatened with the loss of placement or shelter as punishment; and(vii) Subjected to demeaning behavior to embarrass, control, harm, intimidate, or isolate the child. "Demeaning behavior" may include using physical force, rumors, threats, or inappropriate comments;(B) The right to discipline that is appropriate to the child's age, maturity, and developmental level; and(C) The right to have restrictions or disciplinary policies explained to the child at admittance and when the measures are imposed;(5) Plans for the child while in care, including:(A) The right to have a comprehensive service plan that addresses the child's needs, including transitional and discharge planning; and(B) The right to actively participate in the development of the child's service plan within the limits of the child's comprehension and ability to manage the information. The child has the right to a copy or summary of the plan. A child 14 years of age or older has the right to review and sign the service plan, unless there is a reason not to provide the plan;(6) Medical care and records, including:(A) The right to medical, dental, vision, and mental health care and developmental services that adequately meet the child's needs. The right to request that the care or services be separate from adults (other than young adults) who are receiving services;(B) The right to be free of unnecessary or excessive medication; and(C) The right to confidential care and treatment, including keeping medical records and operation records private and only discussing them when it is about the child's care; and(7) Complaints, including the right to make calls, reports, or complaints without interference, coercion, punishment, retaliation, or threats of punishment or retaliation. The child may make these calls, reports, or complaints anonymously. Depending upon the nature of the complaint, the child has the right to call, report, or complain to:(A) The DFPS Texas Abuse/Neglect Hotline at 1-800-252-5400;(B) The HHSC Ombudsman for Children and Youth Currently in Foster Care at 1-844-286-0769;(C) The DFPS Office of Consumer Affairs at 1-800-720-7777; or(D) Disability Rights of Texas at 1-800-252-9108. Source Note: The provisions of this §748.1101 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1101 What rights does a child in care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189111 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189111&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189111 03/12/2026 (a) Within seven days after you admit a child into your operation, you must review the child's rights with the child and a child's parent, unless the parent's consent is not required. You must also provide the child and a child's parent with a written copy of the child's rights.(b) Child rights must be written in:(1) Simple, non-technical terms; and(2) English, unless the person does not understand English. The child's rights must be written in the person's primary language, if possible.(c) If the person you are informing has a visual or auditory impairment, you must explain the child's rights in a manner that is understandable to the person.(d) The person you are informing of the child's rights must sign a statement indicating that the person has read and understands these rights. A copy of a timely signed "CPS Rights of Children and Youth in Foster Care" will meet this standard. You must put the signed copy in the child's record. Source Note: The provisions of this §748.1103 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1103 How must I inform a child and the child's parents of their rights? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189112 03/12/2026 (a) You must allow contact between a child and his parent(s) whose parental rights have not been terminated according to:(1) Your policies; and(2) The provisions of a court order or any visitation agreements.(b) You must document in the child's record:(1) Any plans for contact between the child and a parent; and(2) Any decision to limit contact with a parent.(c) Before the service planning team, treatment director, or professional level service provider can temporarily restrict ongoing contacts or communication between the child and a parent, you must:(1) Explain the reasons for the restrictions to the child and the child's parent; and(2) Document the reasons in the child's record.(d) Restrictions imposed by you that continue for more than 30 days must be re-evaluated monthly by a professional level service provider, who also must:(1) Explain the reasons for the continued restrictions to the child and the child's parents; and(2) Document the reasons in the child's record.(e) If you limit communications or visits with a parent for practical reasons, such as geographical distance or expense, you must discuss the limits with the child and the child's parents. You must document the limits in the child's record. Source Note: The provisions of this §748.1107 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1107 What right does a child have regarding contact with his parent(s)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189113 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189113&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189113 03/12/2026 (a) A child must have a reasonable opportunity for sibling visits and contacts in an effort to preserve sibling relationships.(b) You must address plans for sibling visits and contacts in the child's record.(c) When you restrict sibling contact, you must include justification in the child's record. Restrictions imposed by you that continue for more than 60 days must be re-evaluated every 60 days by a professional level service provider, who also must:(1) Explain the reasons for the continued restrictions to the child; and(2) Document the reasons in the child's record.(d) If barriers to visits exist, such as unavoidable geographic distance and expense issues, the operation must make provisions for sibling contact through letters, telephone calls, or some other means. Source Note: The provisions of this §748.1109 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1109 What right does a child have regarding contact with siblings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189114 03/12/2026 (a) Except as determined by the child's service planning team, treatment director, professional level service provider, or parent, you may not:(1) Open or read the child's incoming or outgoing mail, including electronic mail, unless necessary to assist the child with reading or writing; or(2) Listen to or screen the child's telephone calls unless the child needs assistance with using the telephone.(b) You must document in the child's record:(1) Any reason for restrictions on the child's mail or telephone calls that you impose; and(2) A list of the mail or telephone calls that you restrict.(c) You must inform the child and his parent about restrictions you place on the child.(d) Restrictions imposed by you that continue for more than 30 days must be re-evaluated monthly by a professional level service provider, who also must:(1) Explain the reasons for the continued restrictions to the child; and(2) Document the reasons in the child's record. Source Note: The provisions of this §748.1111 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1111 What right to privacy does a child have in his contact with others? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189115 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189115&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189115 03/12/2026 (a) A child's possessions must be free of unreasonable searches and unreasonable removal of personal items.(b) You may search a child, his possessions, or his room when you have reasonable suspicion:(1) Of the presence of a prohibited item or an item that endangers the child's safety;(2) That the child made suicidal threats or threatened to hurt himself or others; or(3) That the child was involved in theft.(c) Residential treatment centers and emergency care services programs may conduct routine searches (such as upon return from a home visit or return from school) as long as the routine searches are:(1) Justified in your policies;(2) Conducted uniformly; and(3) Do not involve the removal of clothing, other than outer clothing, such as coats, jackets, hats, gloves, shoes, or socks.(d) Only a caregiver of the same gender as the child may conduct a search that involves the removal of clothing, other than outer clothing, such as coats, jackets, hats, gloves, shoes, or socks.(e) If a search involves the removal of clothing (other than outer clothing), a second caregiver must witness the search.(f) The caregiver must ensure that other children do not witness a search that involves the removal of clothing, other than outer clothing. Source Note: The provisions of this §748.1113 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1113 Under what circumstances may I conduct a search for prohibited items or items that endanger a child's safety? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189116 03/12/2026 With the exception of a child's mouth, a caregiver may not conduct a body cavity search of a child in care. Source Note: The provisions of this §748.1115 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1115 May a caregiver conduct a body cavity search of a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189117 03/12/2026 You must document the following in the child's record when you conduct a search under §748.1113(b) of this title (relating to Under what circumstances may I conduct a search for prohibited items or items that endanger a child's safety?):(1) The date of the search;(2) The name of the child;(3) Reason for the search;(4) A description of what you searched;(5) The clothing removed, if applicable;(6) The name of the caregivers conducting the search;(7) The name of the witness, if applicable;(8) The results of the search; and(9) The resolution of the issue with the child, including increased supervision, additional counseling, or disciplinary consequences. Source Note: The provisions of this §748.1117 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1117 What must I document regarding a search? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189118 03/12/2026 Certain techniques must not be used on a child, including:(1) Chemical restraints. For more information on emergency behavior intervention, see Subchapter N of this chapter (relating to Emergency Behavior Intervention);(2) Aversive conditioning, which includes, but is not limited to, any technique designed to or likely to cause a child physical pain, the application of startling stimuli, and the release of noxious stimuli or toxic sprays, mists, or substances in proximity to the child's face;(3) Pressure points;(4) Rebirthing therapy;(5) Hug and/or holding therapy; and(6) Taser or stun guns. Source Note: The provisions of this §748.1119 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS H CHILD RIGHTS §748.1119 What techniques am I prohibited from using on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189122 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189122&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189122 03/12/2026 (a) Except as provided by subsection (c) of this section, children receiving different types of service may reside in the same living quarters as long as:(1) A professional level service provider completes an evaluation of the living quarters for each child that you place in the living quarters; and(2) In each evaluation, the professional level service provider ensures that:(A) There is no conflict of care with the best interests of any of the children placed in the living quarters;(B) Placing the child with different service or treatment needs in the living quarters will not adversely impact the other children in the living quarters;(C) The number of children in the living quarters is appropriate at all times based on the needs of all children in the living quarters;(D) Caregivers can appropriately supervise all children in the living quarters at all times; and(E) You can meet the needs of all children in the living quarters.(b) If the treatment or service needs of any children in the living quarters changes, the professional level service provider must evaluate the needs of each child in the living quarters to ensure there is no conflict of care.(c) Children admitted for emergency care services must receive any therapeutic services (such as group therapy or art therapy) separate from children admitted for non-emergency care and must have separate living quarters, such as a separate wing of an operation, or a separate cottage. Children admitted for emergency care services may be combined with children in non-emergency care for meals, recreation, and transportation. Source Note: The provisions of this §748.1201 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1201 May children receiving different types of service live in the same living quarters? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189123 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189123&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189123 03/12/2026 (a) You may only admit children or young adults who meet your admission policy guidelines and whose needs you can meet. If you adopt a change in your admission policies that requires a change in the conditions of your permit, you must request an amendment to your permit with us.(b) Each placement must meet the child's physical, medical, recreational, educational, and emotional needs as identified in the child's admission assessment. Source Note: The provisions of this §748.1203 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective March 1, 2008, 33 TexReg 1376; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1203 Who may I admit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210092 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210092&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210092 03/12/2026 (a) You must include the following in the child's record at the time of admission:(1) The child's name, gender, race, religion, and date of birth;(2) The name, address, and telephone number of the managing conservator, the primary caregivers for the child, any person with whom the child is allowed to leave the operation, and any other individual who has the legal authority to consent to the child's medical care;(3) The names, addresses, and telephone numbers of biological or adoptive parents, unless parental rights have been terminated;(4) The names, addresses, and telephone numbers of siblings;(5) The date of admission;(6) Medication the child is taking;(7) The child's immunization record;(8) Allergies, such as food, medication, sting, and skin allergies;(9) Chronic health conditions, such as asthma or diabetes;(10) Known contraindications to the use of restraint;(11) Identification of the child's treatment needs, if applicable, and any additional treatment services or programmatic services the child is receiving;(12) Identification of the child's high-risk behaviors, if applicable, and the safety plan staff and caregivers will implement related to the behaviors;(13) If a suicide risk screening is required at admission and the child is screened as having a high or potential risk of suicide:(A) The identification of any risk factors or warning signs of suicide, if applicable and not already identified in paragraph (12) of this subsection; and(B) The safety plan staff and caregivers will implement related to the risk factors and warning signs;(14) The results of the suicide screening at admission, if required;(15) A copy of the placement agreement, if applicable; and(16) Documentation of the attempt to notify the parent of the child's location as required by §748.1211(c)(3) of this title (relating to What information must I share with the parent at the time of placement?), if applicable.(b) If you admit a child for emergency care services, you must document the information:(1) Regarding the reason for admission in the child's record upon admission; and(2) In subsection (a) of this section within 72 hours after you admit the child. If any information is not available within that time frame, you must document in the child's record reasonable efforts made to obtain the information.(c) For emergency admissions, as opposed to a child receiving emergency care services, you must meet the requirements in Division 2 of this subchapter (relating to Emergency Admission). Source Note: The provisions of this §748.1205 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective March 1, 2014, 39 TexReg 1192; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1205 What information must I document in the child's record at the time of admission? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189125 03/12/2026 (a) A placement agreement is your agreement with a child's parent or the child that defines your roles and responsibilities and authorizes you to obtain or provide services for the child. The placement agreement must include:(1) Authorization permitting you to care for the child;(2) A medical consent form signed by a person legally authorized by the Texas Family Code to provide consent; and(3) The reason for placement and anticipated length of time in care.(b) A placement agreement must be signed by the child's parent, except as provided in subsection (c).(c) For a transitional living program, a child 16 years of age or older may sign the placement agreement on the child's own behalf, as provided in the Texas Family Code §32.203, without the consent of the child's parent if the child:(1) Resides separate and apart from the child's parent and manages the child's own financial affairs;(2) Is unmarried and pregnant; or(3) Is unmarried and a parent. Source Note: The provisions of this §748.1207 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1207 What is a placement agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189127 03/12/2026 (a) Within seven days of admission, you must provide orientation to each newly admitted child who is five years old or older. You must gear orientation to the intellectual level of the child.(b) Orientation must include information about your policies on the following:(1) Visitation, including family visitation and overnight visitation;(2) Mail;(3) Telephone calls;(4) Gifts;(5) Personal possessions, including any limits placed on the possessions the child may or may not have;(6) Emergency behavior intervention, including your policies and practices on the use of personal restraint and the child's input on preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process;(7) Discipline;(8) The religious program and practices;(9) The educational program;(10) Trips away from the operation;(11) Program expectations and rules;(12) A general daily schedule for routine activities for children in care; and(13) Internal grievance procedures.(c) Orientation must include information on how to:(1) Make complaints to outside agencies; and(2) Contact parties to a child's case (i.e. caseworker, attorney ad litem, guardian ad litem, CASA worker, etc.).(d) You must document in the child's record when the orientation occurred, any item that the orientation did not include, and the reason that the orientation did not include that item. Source Note: The provisions of this §748.1209 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1209 What orientation must I provide a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208612 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208612&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208612 03/12/2026 (a) At admission, you must provide the following policies to the parent placing the child:(1) Fee policies;(2) Emergency behavior intervention policies;(3) Discipline policies; and(4) Any other policies required by us, upon request of the parent.(b) At admission, you must provide and explain the following written information and policies to the parent placing the child:(1) Information about the policies that you would present a child during orientation;(2) Your policies regarding the:(A) Use of volunteers, if applicable;(B) Type and frequency of notifications made to parents; and(C) Involvement of the child in any publicity or fundraising activity for the operation; and(3) Information about the parent's right to refuse to or withdraw consent for a child to participate in:(A) Research programs; or(B) Publicity or fundraising activities for the operation.(c) If you sign a placement agreement for a transitional living program with a child as specified in §748.1207 of this title (relating to What is a placement agreement?), then you:(1) Must share the policies noted in subsection (a) of this section with the child, instead of the parent;(2) Do not have to comply with subsection (b) of this section, but you must provide and explain to the child your policies regarding the:(A) Use of volunteers, if applicable;(B) Involvement of the child in any publicity or fundraising activity for the operation; and(C) Child's right to refuse to or withdraw consent to participate in:(i) Research programs; or(ii) Publicity or fundraising activities for the operation; and(3) Must attempt to notify the child's parent of the child's location, if the child was admitted without the consent of the parent. Source Note: The provisions of this §748.1211 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective March 1, 2014, 39 TexReg 1192; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1211 What information must I share with the parent at the time of placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189126 03/12/2026 (a) By the day you admit the child for care, you must provide caregivers responsible for the child's care with information about the child's immediate needs such as enrolling the child in school or obtaining needed medical care or clothing.(b) You must inform appropriate caregivers of any special needs, such as medical or dietary needs or conditions or supervision needs, and document that you shared the information with the caregiver. Source Note: The provisions of this §748.1213 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1213 What information must I provide caregivers when I admit a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189133 03/12/2026 (a) You must complete a non-emergency admission assessment prior to admission.(b) A professional level service provider must sign and date each assessment, which must be in the child's record. Source Note: The provisions of this §748.1215 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1215 When must I complete the admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208613 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208613&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208613 03/12/2026 (a) An admission assessment must provide an initial evaluation of the appropriate placement for a child and ensure that you obtain the information necessary for you to facilitate service planning.(b) Prior to a child's non-emergency admission, an admission assessment must be completed which includes:(1) The child's legal status;(2) A description of the circumstances that led to the child's referral for substitute care;(3) A description of the child's behavior, including appropriate and maladaptive behavior, and any high-risk behavior;(4) Any history of physical, sexual, or emotional abuse or neglect;(5) Any history of trauma;(6) Current medical and dental status, including the available results of any medical and dental examinations;(7) Current mental health and substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment;(8) The child's current developmental, educational, and behavioral level of functioning;(9) The child's current educational level and any school problems;(10) Any applicable requirements of §748.1219 of this title (relating to What are the additional admission assessment requirements when I admit a child for treatment services?);(11) Documentation indicating efforts made to obtain any of the information in paragraphs (1) - (10) of this subsection, if any information is not obtainable;(12) The services you plan to provide to the child;(13) Immediate goals of placement;(14) The parent's expectations for placement, duration of the placement, and family involvement;(15) The child's understanding of the placement; and(16) A determination of whether and how you can meet the needs of the child.(c) Prior to completing a child's initial service plan, the following information must be added to the admission assessment:(1) The child's social history. The history must include information about past and existing relationships with the child's birth parents, siblings, extended family members, and other significant adults and children, and the quality of those relationships with the child;(2) A description of the child's home environment and family functioning;(3) The child's birth and neonatal history;(4) The child's developmental history;(5) The child's mental health and substance abuse history;(6) The child's school history, including the names of previous schools attended and the dates the schools were attended, grades earned and special achievements;(7) The child's history of any other placements outside the child's home, including the admission and discharge dates and reasons for placement;(8) The child's criminal history, if applicable;(9) The child's skills and special interests;(10) Documentation indicating efforts made to obtain any of the information in paragraphs (1) - (9) of this subsection, if any information is not obtainable;(11) The services you plan to provide to the child, including long-range goals of placement;(12) Recommendations for any further assessments and testing;(13) A recommended behavior management plan; and(14) A determination of whether and how you can meet the needs of the child, based on an evaluation of the child's special strengths and needs.(d) You must attempt to obtain a signed authorization, so you can subsequently request in writing materials from the child's current or most recent placement, such as the admission assessment, professional assessments, and the discharge summary. You must consider information from these materials when you complete your admission assessment if they are made available to you.(e) This rule does not apply to children receiving emergency care services. See §748.4231 of this chapter (relating to What information must an admission assessment include for a child needing emergency care services, including respite child-care services?). Source Note: The provisions of this §748.1217 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1217 What information must an admission assessment include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210093 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210093&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210093 03/12/2026 When you admit a child for treatment services, you must do the following, as applicable:Attached Graphic Source Note: The provisions of this §748.1219 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective June 1, 2015, 40 TexReg 2789; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1219 What are the additional admission assessment requirements when I admit a child for treatment services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189130 03/12/2026 (a) You must make reasonable efforts to obtain all required information.(b) If you and the child's parent determine that attempting to get information at the time of placement would not be in the child's best interests, you may postpone attempting to acquire the information.(c) In the child's admission assessment, you must document why a:(1) Particular piece of information is unavailable; or(2) Delay in obtaining a piece of information is necessary, including efforts made to obtain the information. Source Note: The provisions of this §748.1221 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1221 What must I do if I cannot obtain the required information for an admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189131 03/12/2026 (a) You must ensure that the child has a medical examination by a health-care professional within 30 days after the date of admission. This exam is not required if you have documentation that the child has had a medical examination within the past year, including documentation in the child's health passport if the child is in the department's conservatorship.(b) If you admit a child with primary medical needs, you must provide the child with a medical examination by a health-care professional within seven days before or three days after the date of admission.(c) If a child admitted shows symptoms of abuse or illness, a health-care professional must examine the child immediately.(d) The report and findings of any medical examination must be documented in the child's record, according to §748.1531(b) and (c) of this title (relating to What general medical requirements must my operation meet?). Source Note: The provisions of this §748.1223 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1223 What are the medical requirements when I admit a child into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189132 03/12/2026 (a) If the child is younger than three years old and a health-care professional recommends a dental examination, then you must ensure that a dentist examines the child.(b) A child three years old or older must have a dental appointment scheduled with a dentist within 30 days after the date of admission, and the examination must occur within 90 days after the date of admission. A dental examination is not required if you have documentation that the child has had a dental examination within the past year, including documentation in the child's health passport if the child is in the department's conservatorship.(c) The report and findings of the dental examination must be documented in the child's record, according to §748.1501(b) and (c) of this title (relating to What general dental requirements must my operation meet?). Source Note: The provisions of this §748.1225 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1225 What are the dental requirements when I admit a child into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189135 03/12/2026 For re-admission, you must complete the admission documentation as if the child was never in your care; or for children that were discharged from your operation within the last 12 months, you may update the previous admission documentation. Source Note: The provisions of this §748.1227 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1227 What must I document when I re-admit a child for care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189136 03/12/2026 Neither a transitional living program nor a therapeutic camp program may accept emergency admissions. All other programs may accept emergency admissions. Source Note: The provisions of this §748.1261 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1261 For which of my programs may I accept emergency admissions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191420 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191420 03/12/2026 It is an emergency admission if:(1) You must place the child within 72 hours;(2) The child was removed from a situation involving alleged abuse or neglect;(3) The child is an alleged perpetrator of abuse and cannot be served in the child's current placement due to the child's perpetrating behaviors;(4) The child displays behavior that is an immediate danger to self or others and cannot function or be served in the child's current setting;(5) The child was abandoned and after exercising reasonable efforts, the child's identity cannot be immediately determined. You must document the efforts made to obtain information on the child's identity in the child's record;(6) The child was removed from the child's home or placement, and there is an immediate need to find a residence for the child;(7) A law enforcement officer released the child to your operation that is licensed to provide emergency care services; or(8) The child is otherwise without adult care. Source Note: The provisions of this §748.1263 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4462. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1263 What constitutes an emergency admission to my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191421 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191421 03/12/2026 You may take possession of a child from a law enforcement officer only if you meet the requirements of 40 TAC Chapter 745, Subchapter H, Division 2 (relating to Taking Possession of a Child Directly from a Law Enforcement Officer). Source Note: The provisions of this §748.1265 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4462. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1265 May I take possession of a child from a law enforcement officer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189139 03/12/2026 (a) For an emergency admission, you must complete all of the requirements (see Division 1 of this subchapter (relating to Admission)) for an admission assessment within 40 days from the date of the child's admission.(b) In an emergency admission of a child receiving treatment services, the child must not continue in care for more than 30 days after the date of admission or 10 days after the date of admission for a residential treatment center, unless the child has received the psychiatric evaluation, psychological evaluation, psychosocial assessment, or medical evaluation that is required by §748.1219 of this title (relating to What are the additional admission assessment requirements when I admit a child for treatment services?), and the evaluation or assessment indicates manifestations of the disorder requiring treatment services. All evaluations and assessments must be signed, dated, and documented in the child's record. Source Note: The provisions of this §748.1269 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1269 For an emergency admission, when must I complete all of the requirements for an admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210098 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210098&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210098 03/12/2026 At the time of the emergency admission you must document in the child's record:(1) A brief description of the circumstances necessitating the emergency admission;(2) The date of admission;(3) Allergies, such as food, medication, sting, and skin allergies;(4) Chronic health conditions, such as asthma or diabetes;(5) Known contraindications to the use of restraint;(6) Identification of the child's high-risk behaviors, if applicable, and the safety plan staff and caregivers will implement related to the behaviors;(7) If a suicide risk screening is required at admission and the child is screened as having a high or potential risk of suicide:(A) The identification of any risk factors or warning signs of suicide, if applicable and not already identified in paragraph (6) of this section; and(B) The safety plan staff and caregivers will implement related to the risk factors and warning signs;(8) The results of the suicide screening at admission, if required; and(9) For the purpose of providing treatment services:(A) A brief description of the child's history;(B) The child's current behavior; and(C) Your evaluation of how the placement will meet the child's needs and best interests. Source Note: The provisions of this §748.1271 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1271 At the time of an emergency admission, what information must I document in the child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189144 03/12/2026 (a) You must arrange an appropriate education for each child, including:(1) Ensuring the child in care attends an educational facility or program that is approved or accredited by the Texas Education Agency, the Southern Association of Colleges and Schools, the Texas Private School Accreditation Commission or by the out-of-state school district funding the child;(2) Ensuring a school-age child has the training and education in the least restrictive setting necessary to meet the child's needs and abilities;(3) Ensuring a child in care attends an educational facility or program that implements a special education student's individual education plan (IEP); and(4) Advocating that a school-age child receives the educational and related services to which he is entitled under provisions of federal and state law and regulations.(b) For children receiving treatment services you must designate a liaison between the agency and the child's school. Source Note: The provisions of this §748.1301 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1301 What responsibilities do I have for the education of a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208614 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208614&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208614 03/12/2026 You must:(1) Review report cards and other information received from teachers or school authorities with the child and provide necessary information to caregivers;(2) Counsel and assist the child regarding adequate classroom performance;(3) Permit, encourage, and make reasonable efforts to involve the child in extracurricular activities to the extent of the child's interests and abilities and in accordance with the child's service plan;(4) Provide a quiet, well-lighted space for the child to study and allow regular times for homework and study;(5) Know what emergency behavior interventions are permitted and being used with the child;(6) Let the parent know that an ARD (Admission, Review, and Dismissal), IEP (Individual Education Plan), or ITP (Individual Transitional Planning) meeting should be requested if you are concerned with the child's educational program or if the child does not appear to be making progress;(7) Attend ARD, IEP, and ITP meetings and other school staffings and conferences, if requested by the parent, to represent the child's educational best interests, including the child being evaluated for and provided with related services needed to benefit from educational services, and positive behavior supports designed to decrease the need for negative disciplinary techniques or interventions; and(8) Know what is in the child's IEP and support the school's efforts to implement the IEP, if applicable. Source Note: The provisions of this §748.1303 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1303 What responsibilities do I have for a child's individual educational needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189142 03/12/2026 If you have an educational program, you must include the following information in the discussion and in the written material you give to parents when you admit the child:(1) The name of any educational program operated on the premises of your operation;(2) Whether the program is accredited;(3) Whether the Texas Education Agency has approved the program;(4) Whether the educational course work is transferable to public schools; and(5) The credentials of the teachers, if the teachers are not approved and regulated by the State Board of Educator Certification (SBEC). Source Note: The provisions of this §748.1305 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1305 If I have an educational program, what information must I provide to a child's parent about that program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189143 03/12/2026 (a) You must complete a preliminary service plan that addresses the immediate needs of a child within 72 hours, such as supervision requirements, enrolling the child in school, or obtaining needed medical care or clothing.(b) In addition, for a child receiving treatment services the preliminary service plan must include:(1) A description of the child's immediate treatment and care needs;(2) A description of the child's immediate educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child;(3) A description of how you will meet the child's needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child;(4) The identification of any issues or concerns the child may have that could escalate a child's behavior. Identification of a child's issues or concerns must serve to avoid the use of unnecessary emergency behavior interventions with the child. Child concerns may include issues with food, eye contact, physical touch, personal property, or certain topics; and(5) A designation of who will be responsible for meeting each of the child's needs.(c) The plan must be compatible with the information included in the child's admission assessment.(d) You must document the plan in the child's record.(e) You must inform each professional level service provider and caregiver working with a child about the child's preliminary service plan.(f) You must implement and follow the preliminary service plan. Source Note: The provisions of this §748.1331 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1331 What are the requirements for a preliminary service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189149 03/12/2026 The treatment director or a professional level service provider must develop, sign, and date the preliminary service plan for children receiving treatment services. Source Note: The provisions of this §748.1333 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1333 Who must be involved in developing the preliminary service plan for children receiving treatment services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189145 03/12/2026 You must complete the initial service plan within 45 days after you admit the child. Source Note: The provisions of this §748.1335 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1335 When must I complete an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210099 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210099&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210099 03/12/2026 (a) You must base the child's initial service plan on the child's needs identified in the child's admission assessment and integrate trauma informed care in the care, treatment, and management of each child. The service planning team may prioritize the child's service planning goals and objectives based on the child's admission assessment. However, any required service plan components not initially addressed must have a justification for the delay in addressing the needs. (b) The child's initial service plan must be documented in the child's record and include those items that a preliminary plan must include (see §748.1331 of this title (relating to What are the requirements for a preliminary service plan?)), and the items noted below for each specific type of service that you provide the child:Attached Graphic Source Note: The provisions of this §748.1337 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5484. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1337 What must a child's initial service plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189147 03/12/2026 (a) A service planning team must develop the service plan. The team must consist of:(1) At least one of the child's current caregivers;(2) A person designated to make decisions regarding a child's participation in childhood activities; and(3) At least one professional level service provider who provides direct services to the child.(b) If you are providing treatment services to the child, the team must also consist of two of the following professions, which may or may not include additional members:(1) A licensed professional counselor;(2) A psychologist;(3) A psychiatrist or physician;(4) A licensed registered nurse;(5) A licensed masters level social worker;(6) A licensed or registered occupational therapist; or(7) Any other person in a related discipline or profession that is licensed or regulated in accordance with state law.(c) The child, if verbal and developmentally able to participate, and the parents must be invited to a service planning meeting, so that they may participate and provide input into the development of the service plan, including discussions regarding the child's participation in childhood activities. Source Note: The provisions of this §748.1339 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1339 Who must be involved in developing an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189148 03/12/2026 Yes, the service planning team may meet in one meeting, two or more meetings, or in separate meetings, provided that each service planning team member is informed of the discussions and comments regarding the child's service plan that were made in each meeting. Source Note: The provisions of this §748.1340 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1340 Can the service planning team discuss to develop a child's service plan in separate meetings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189150 03/12/2026 (a) The child's parent(s) must have at least two weeks advance notice of the initial service plan meeting.(b) The child's record must include documentation of the notice and any responses from the parents. Source Note: The provisions of this §748.1341 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1341 When must I inform the child's parent(s) of an initial service plan meeting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189156 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189156&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189156 03/12/2026 No. You may employ or contract with a professional level service provider or any other professional who participates in a child's service plan. Source Note: The provisions of this §748.1343 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1343 Must a professional level service provider or a professional who must participate in a child's service plan be an employee of my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189151 03/12/2026 The roles of professional level service providers in service planning include:Attached Graphic Source Note: The provisions of this §748.1345 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1345 What roles do professional level service providers have in service planning? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189152 03/12/2026 (a) You must document the professional level service provider's:(1) Name; and(2) Date of participation.(b) The professional level service provider must sign and date the document. If the provider disagrees with any portion of the plan, the provider must document the issue(s) of contention before signing it. Source Note: The provisions of this §748.1347 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1347 What must I document regarding a professional level service provider's participation in the development of an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189153 03/12/2026 (a) You must give a copy or summary of the initial service plan to the:(1) Child, when appropriate. At a minimum, you must give a copy or summary of the plan to a child 14 years of age or older, unless there is justification for not providing the plan;(2) Child's parents; and(3) Child's caregivers.(b) If you provide a copy or summary of the initial service plan to a child:(1) The child must review the plan;(2) The child must sign the plan, or you must document the child's refusal to sign it; and(3) You must document if the child disagrees with the plan.(c) If you do not provide a copy or summary of the initial service plan to a child, you must document your justification for not sharing the plan in the child's record.(d) You must document in the child's record that you provided a copy or summary of the initial service plan to the child's parents. Source Note: The provisions of this §748.1349 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1349 To whom do I provide a copy of the child's initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189154 03/12/2026 You must implement and follow an initial service plan as soon as all of the service planning team members have reviewed and signed the plan, but no later than 15 days after the date of the scheduled service-planning meeting involving the parents and the child. Source Note: The provisions of this §748.1351 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1351 When must I implement a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189155 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189155&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189155 03/12/2026 Except for when the child's placement within your operation changes because of a change in the child's needs, you must review and update the service plan as follows:Attached Graphic Source Note: The provisions of this §748.1381 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1381 How often must I review and update a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189157 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189157&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189157 03/12/2026 (a) You must review a child's service plan whenever the child's placement changes because of a change in the child's needs.(b) If the child's placement changes for another reason:(1) The child's service planning team must approve the decision not to review the plan; and(2) You must document the decision not to review the plan. Source Note: The provisions of this §748.1383 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1383 How does a child's transfer affect the timing of the review of a child's service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189161 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189161&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189161 03/12/2026 To review and update a service plan, you must:(1) Evaluate the child's progress and the effectiveness of strategies and techniques used toward meeting identified needs, including educational progress reports and medical interventions;(2) Identify any new needs and strategies or techniques to meet these needs, including instructions to appropriate employees;(3) Document any achieved or changed objectives;(4) If the review shows no progress towards meeting the identified needs of the child, document reasons for continued placement;(5) Evaluate the possible effectiveness and side effects in the use of psychotropic medications prescribed for the child, any change in psychotropic medications during the period since the last review, and the behaviors and reactions of the child observed by caregivers, professional level service providers, and parents, if applicable;(6) Document visitation and contacts between the child and the child's parents, the child and the child's siblings, and the child and the child's extended family;(7) Update the estimated length-of-stay and discharge plans, if changed;(8) Evaluate the use and effectiveness of emergency behavior intervention techniques, if used, since the last service plan. If applicable, this evaluation must focus on:(A) The frequency, patterns, and effectiveness of types of emergency behavior interventions;(B) Strategies to reduce the need for emergency behavior interventions overall; and(C) Specific strategies to reduce the need for use of personal and mechanical restraints, emergency medication, and/or seclusion, where applicable;(9) Document in the child's record the review and update of the plan; and(10) Document the names of the persons participating in the review and update. Source Note: The provisions of this §748.1385 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1385 How do I review and update a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189158 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189158&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189158 03/12/2026 Yes, a single service plan that continues throughout the time a child is in residential child care is acceptable, as long as you:(1) Complete a preliminary service plan as required by §748.1331 of this title (relating to What are the requirements for a preliminary service plan?) each time a child is admitted into your care; and(2) Continue to comply with the service plan review and update requirements in this division of this subchapter (relating to Service Plan Reviews and Updates). Source Note: The provisions of this §748.1386 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1386 Can an operation continue to review and update a child's previous service plan without creating a new service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189159 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189159&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189159 03/12/2026 Yes, the same requirements found in Division 4 of this subchapter (relating to Service Plans) apply to a service plan review and update. Source Note: The provisions of this §748.1387 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1387 Are the notification, participation, implementation, and documentation requirements for a service plan review and update the same as for an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189160 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189160&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189160 03/12/2026 (a) Each child's intellectual functioning must be re-evaluated at least every three years by a psychologist qualified to provide psychological testing; or(b) A psychologist must determine the need and frequency for a specific child's intellectual functioning to be re-evaluated, such as a young child who may require more frequent testing. This determination, including justification for the time frame, must be documented in the child's record annually by the service planning team. Source Note: The provisions of this §748.1389 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1389 How often must I re-evaluate the intellectual functioning of a child receiving treatment services for intellectual disabilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189162 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189162&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189162 03/12/2026 A transfer refers to a child in care who is moved from one of your programs to another one of your programs that you operate under the same permit or at the same location. For example, you may transfer a child from your emergency care services program to your transitional living services program, if the programs are under the same permit or at the same location. You may also transfer a child from your general residential operation to your child-placing agency, if your child-placing agency office is located on the same property as your general residential operation. Source Note: The provisions of this §748.1431 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1431 What does a "transfer" of a child in care mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189163 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189163&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189163 03/12/2026 (a) You must involve the following persons in planning the child's non-emergency discharge or transfer:(1) At least one of the child's current caregivers; and(2) At least one professional level service provider involved in the child's service planning.(b) You must invite the following persons to participate in planning the child's non-emergency discharge or transfer, if appropriate:(1) The child;(2) The child's parent(s); and(3) Any other person pertinent to the child's care.(c) If you are unable to plan the transfer or discharge with the persons as required in subsections (a) and (b) of this section, you must document in the child's record the reason why. For example, an emergency transfer or discharge was necessary or the child met the requirements to consent for emergency care services and decided not to include his parents in planning for the child's transfer or discharge.(d) If a child in your care is not receiving treatment services, you must inform the child of the non-emergency discharge or transfer at least four days prior to the date of the discharge or transfer, unless your licensed child-care administrator or a professional level service provider has clear justification for not giving the child such notice. The licensed child-care administrator or professional level service provider who determines the justification for the child not having the advance notice of the discharge or transfer, must put the justification in writing and sign and date it. The justification must be in the child's record.(e) If a child in your care is receiving treatment services, you must inform the child of the non-emergency discharge or transfer at least four days prior to the date of the discharge or transfer, unless your treatment director, three members of the child's service planning team, or the child's psychiatrist or psychologist has justification for not giving the child such notice. Whoever determines the justification for the child not having the advance notice of the discharge or transfer must put the justification in writing and sign and date it. The justification must be in the child's record. Source Note: The provisions of this §748.1433 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1433 Who must plan a child's non-emergency discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189164 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189164&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189164 03/12/2026 An employee of your operation must accompany the child to the receiving operation, agency, or person unless the child's parent or law enforcement transports the child. Source Note: The provisions of this §748.1435 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1435 How do I discharge or transfer a child who is an immediate danger to self or others? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189165 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189165&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189165 03/12/2026 At the time of a discharge or transfer, you must document the following:(1) The date and circumstances of the discharge or transfer;(2) Date and time the child was informed of his discharge or transfer, if applicable;(3) For discharge, the name, address, telephone number, and relationship of the person to whom you discharge the child, unless the child legally consents to a discharge. If the child legally consents to a discharge and does not want to involve the child's parent(s), you must document this in the child's record;(4) The child's service plans while in your care for the past 12 months;(5) A list of medications the child is taking, the dosage, frequency, and reason the medication was prescribed;(6) Any treatment for a physical condition that is in progress and requires continuing or follow-up medical care; and(7) For emergency discharge or transfer, the explanation given to the child regarding the reason for the discharge or transfer and the child's reaction to the discharge or transfer. Source Note: The provisions of this §748.1437 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1437 What must I document in the child's record at the time of a discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189119 03/12/2026 (a) On or before the child's discharge, you must attempt to obtain legal consent to release the information in subsection (b) of this section. If consent is not obtained, your attempt to obtain consent must be documented in the child's record. If consent is obtained, the information must be provided to the receiving placement or caregiver within 15 days of the date the child is discharged.(b) If not already provided at the time of discharge, copies of the following documentation must be provided to the next placement or caregiver:(1) A written discharge summary, which must include:(A) Services provided to the child while in your care;(B) Accomplishments of the child while in your care;(C) An assessment of the child's remaining needs;(D) Recommendations about the services to meet the child's remaining needs;(E) Support resources for the child, including telephone numbers and addresses; and(F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments;(2) The child's background information, including progress notes for the past 60 days, if applicable;(3) Any unresolved incidents or investigations involving the child, if applicable; and(4) Assessments and/or evaluations that you have performed for the child, including the child's admission assessment, diagnostic assessment, educational assessment, neurological assessment, and psychiatric or psychological evaluation. Source Note: The provisions of this §748.1439 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1439 When I discharge a child, what information must I provide to the next placement or caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189120 03/12/2026 An emergency discharge or transfer occurs when:(1) The parent withdraws a child unexpectedly from care;(2) There is a medical emergency requiring inpatient care;(3) The child is absent from your operation and cannot be located; or(4) There is an immediate danger to the child or others and you determine that you cannot serve the child. Source Note: The provisions of this §748.1443 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1443 What constitutes an emergency discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189121 03/12/2026 (a) Except in an emergency, you must only release a child to the child's parent, a person designated by the parent, law enforcement authorities, or a person authorized by law to take possession of the child.(b) You must instruct all employees and service providers to follow your policies for:(1) Releasing a child;(2) Verifying the identity of a person authorized to pick up a child but whom the caregiver does not know;(3) Recording the identity of the person in a log or other designated location; and(4) Retaining the identifying information at the operation until the child returns. Source Note: The provisions of this §748.1481 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS I ADMISSION, SERVICE PLANNING, AND DISCHARGE §748.1481 To whom may I release a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189166 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189166&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189166 03/12/2026 (a) A child in your care must receive dental care:(1) Initially, according to the requirements in §748.1225 of this title (relating to What are the dental requirements when I admit a child into care?);(2) At as early an age as necessary;(3) As needed for relief of pain and infections; and(4) As needed for ongoing maintenance of dental health.(b) The child's record must include a written record of each dental examination that consists of:(1) A copy of the results of the dental examination;(2) Follow-up treatment recommended and any appointments scheduled; and(3) A notation of the child's refusal to accept dental treatment, if applicable.(c) For a child in the conservatorship of the department, you must supplement any information already documented in the child's health passport in order to comply with subsection (b) of this section. In your written record for the child, you are not required to repeat information that is already in the child's health passport.(d) You must obtain follow-up dental work recommended by the dentist, such as treatment of cavities and cleaning. Source Note: The provisions of this §748.1501 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1501 What general dental requirements must my operation meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189167 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189167&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189167 03/12/2026 A licensed dentist must determine the need and frequency of ongoing maintenance of dental health. You must comply with dentist recommendations for examinations and treatment for each child. Source Note: The provisions of this §748.1503 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1503 Who must determine the need and frequency of ongoing maintenance of dental health for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189168 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189168&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189168 03/12/2026 A health-care professional licensed in the United States to practice dentistry must provide dental care. Source Note: The provisions of this §748.1505 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1505 Who must perform dental examinations and provide dental treatment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189169 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189169&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189169 03/12/2026 (a) A child in your care must receive medical care:(1) Initially, according to the requirements in §748.1223 of this title (relating to What are the medical requirements when I admit a child into care?);(2) As needed for injury, illness, and pain; and(3) As needed for ongoing maintenance of medical health.(b) The child's record must include a written record of each medical examination that consists of:(1) A copy of the results of the medical examination;(2) The follow-up treatment recommended and any appointments scheduled;(3) A notation of the child's refusal to accept medical treatment, if applicable;(4) If the medical examination is a result of an injury or illness, the documentation of the date, time, and circumstances surrounding the injury or illness; and(5) Any other documentation provided by the health-care professional who performed the examination.(c) For a child in the conservatorship of the department, you must supplement any information already documented in the child's health passport in order to comply with subsection (b) of this section. In your written record for the child, you are not required to repeat information that is already in the child's health passport.(d) You must obtain follow-up medical treatment as recommended by the health-care professional. Source Note: The provisions of this §748.1531 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1531 What general medical requirements must my operation meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189170 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189170&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189170 03/12/2026 A health-care professional determines the need and frequency for ongoing maintenance of medical care and treatment for a child. Source Note: The provisions of this §748.1533 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1533 Who determines the need and frequency for ongoing maintenance of medical care and treatment for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189171 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189171&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189171 03/12/2026 A health-care professional licensed in the United States to practice in an appropriate medical or health-care discipline must perform medical examinations and provide medical treatment for a child. Source Note: The provisions of this §748.1535 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1535 Who must perform medical examinations and provide medical treatment for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189172 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189172&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189172 03/12/2026 (a) Each child that you admit must meet and continue to meet the applicable immunization requirements as specified by the Department of State Health Services.(b) You must maintain current immunizations records for each child in your care, including any immunization exemptions or exceptions.(c) Unless the child is exempt from immunization requirements, all immunizations required for the child's age must:(1) Be completed by the date of admission; or(2) A child that is homeless or a child in foster care shall be admitted temporarily for 30 days if acceptable evidence of immunization is not available. You should immediately refer the child to an appropriate health care professional to obtain the required immunizations. Source Note: The provisions of this §748.1539 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1539 What immunizations must a child in my care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189176 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189176&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189176 03/12/2026 (a) A child may be exempt from immunization requirements for a medical reason or reason of conscience, including a religious belief. To claim an exemption, the person applying for the child's admission must meet criteria specified by:(1) §42.043(d) and (d-1) of the Human Resources Code; or(2) The Department of State Health Services rule in 25 TAC §97.62 (relating to Exclusions from Compliance).(b) For some diseases, a child who previously had a disease and is accordingly naturally immune from it may qualify for an exception to immunization requirements for the disease. To claim this exception, the person applying for the child's admission must meet the criteria specified by the Department of State Health Services rule in 25 TAC §97.65 (relating to Exceptions to Immunization Requirements). Source Note: The provisions of this §748.1541 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1541 What exemptions or exceptions are there concerning immunization requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189173 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189173&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189173 03/12/2026 Acceptable documentation includes:(1) An official immunization record generated from a state or local health authority, including a record from another state. Examples include a registry, a copy of the current immunization record that is on file at the pre-kindergarten program or school, or the health passport for a child in the conservatorship of DFPS, so long as the record includes:(A) The child's name and date of birth;(B) The type of vaccine and number of doses; and(C) The month, day, and year the child received each vaccination; or(2) An official immunization record or photocopy, such as from a doctor's office, that includes:(A) The child's name and date of birth;(B) The type of vaccine and number of doses;(C) The month, day, and year the child received each vaccination;(D) The signature (including a rubber stamp or electronic signature) of the health-care professional who administered the vaccine, or another health-care professional's documentation of the immunization as long as the name of the health-care professional that administered the vaccine is documented; and(E) Clinic contact information, if the immunization record is generated from an electronic health record system. Source Note: The provisions of this §748.1543 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1543 What documentation is acceptable for an immunization record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189174 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189174&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189174 03/12/2026 (a) You must ensure that each child you admit is screened for possible vision and hearing problems that meet the requirements of the Special Senses and Communication Disorders Act, Health and Safety Code, Chapter 36. If problems are detected, the child must have a professional vision and hearing examination.(b) For each child required to be screened, you must keep one of the following in each child's record:(1) The individual vision and hearing screening results; however, results found in the child's health passport if the child is in DFPS conservatorship are sufficient to meet this requirement;(2) A signed statement from the child's parent that the child's screening records are current and on file at the program or school the child attends away from the operation. The statement must be dated and include the name, address, and telephone number of the program or school; or(3) An affidavit from the child's parent stating that the vision or hearing screening and/or examination conflicts with the tenets or practices of a church or religious denomination of the parents. Source Note: The provisions of this §748.1545 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1545 Must children in my care have a vision and hearing screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189175 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189175&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189175 03/12/2026 You must:(1) Schedule the child for a professional examination and needed health services;(2) Ensure the professional and medical recommendations are carried out; and(3) Convey the information concerning the child's visual and/or hearing difficulty to the educational and operation caregivers, so the recommended adjustments can be made in programs. Source Note: The provisions of this §748.1547 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1547 What must I do if a child in my care is identified as needing a diagnostic vision or hearing examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189177 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189177&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189177 03/12/2026 When recommended by a health-care professional, you must ensure that a child with a physical disability has any special equipment that can be reasonably obtained. Source Note: The provisions of this §748.1549 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1549 What special equipment must I provide for a child with a physical disability? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189178 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189178&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189178 03/12/2026 (a) A licensed physician must review a child's primary medical needs:(1) At least every 90 days or on a schedule recommended by the child's physician; and(2) Whenever a medical or related problem occurs.(b) The review must address:(1) Whether the child can continue to be cared for appropriately in the operation; and(2) Any new or changed orders regarding the items outlined in §748.1219(3)(B) of this title (relating to What are the additional admission assessment requirements when I admit a child for treatment services?).(c) Documentation of each physician review must be filed in the child's record. Source Note: The provisions of this §748.1551 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1551 How often must the physician review a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208615 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208615&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208615 03/12/2026 For an injury or illness that requires immediate treatment by a health-care professional, the caregiver must immediately have the child treated by a healthcare professional, contact emergency services, or take the child to the nearest emergency room after ensuring the supervision of any other children present. The caregiver must not be required to seek approval to contact emergency services or to take the child to the nearest emergency room. Source Note: The provisions of this §748.1553 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1553 How must a caregiver respond when a child is injured or ill and requires immediate treatment by a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189179 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189179&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189179 03/12/2026 (a) You must notify the Department of State Health Services (DSHS) after you become aware that a person in your care, a person who resides at your operation, an employee, a contract service provider, or a volunteer has contracted a communicable disease that the law requires you to report to the DSHS as specified in 25 TAC 97, Subchapter A (relating to Control of Communicable Diseases).(b) If a person in your care or a person who resides at your operation has symptoms of a communicable disease that is reportable to the Department of State Health Services, you must:(1) Consult a health-care professional about the person's treatment;(2) Follow the treating physician's orders, which may include separating the person from others;(3) Notify the person's parent, if applicable; and(4) Sanitize all items used by the sick person before another person uses one of them.(c) If a health-care professional diagnoses a person in your care or a person who resides at your operation with a communicable disease that is reportable to DSHS, a health-care professional must authorize the person's participation in any routine activities at your operation. The authorization must:(1) Be in the person's record, if the person is in care at your operation;(2) Include a written statement that the person will not pose a serious threat to the health of the others; and(3) Include any specific instructions and precautions to be taken for the protection of others, if necessary.(d) If an employee, contract service provider, or volunteer has a communicable disease that is reportable to DSHS, you must obtain written authorization from a health-care professional for the person to be present at the operation. The written authorization must include a statement that the person will not pose a serious threat to the health of the others.(e) You must follow any written instructions and precautions specified by a health-care professional. Source Note: The provisions of this §748.1581 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1581 What health precautions must I take if someone in my operation has a communicable disease? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189180 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189180&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189180 03/12/2026 (a) All persons over the age of one year old must have a documented tuberculosis screening that was conducted as recommended by the Center for Disease Control, within 30 days before or after beginning to live, work, or volunteer at your operation unless the person:(1) Has lived, worked, or volunteered at a regulated residential child-care operation within the previous 12 months. For example, an employee beginning employment in a regulated residential child-care operation for the first time would need a baseline tuberculosis screening. Employment in a different residential child-care operation would not require a new screening, as long as documentation in paragraph (2) of this subsection is also provided. If the employee left employment in regulated residential child-care for more than 12 months and then returned, a new screening would be required; and(2) Provides documentation of a tuberculosis screening.(b) Documentation must consist of a copy of the results of the baseline tuberculosis screening or chest radiograph, which must be in the person's record at your operation within 40 days of the person beginning to live, work, or volunteer at your operation. Documentation of a copy of the results of treatment (if treatment is required) must also be maintained in the person's record. For a child in DFPS conservatorship, documentation in the child's health passport is sufficient.(c) Except on the advice of a physician, no additional screening is required for a person who continues to live, work, and/or volunteer in a regulated residential child-care setting. Source Note: The provisions of this §748.1583 adopted to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1583 Who must have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189181 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189181&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189181 03/12/2026 (a) A protective device:(1) Protects a person from involuntary self-injurious behavior or permits wounds to heal; and(2) Does not prohibit a person's mobility.(b) Examples of a protective device are helmets, elbow guards, mittens, and wheelchair seat belts.(c) If used appropriately, devices intended to encourage mobility or minimally restrain a young child for safety purposes, such as wheelchairs, car seats, high chairs, strollers, bed rails, and child leashes manufactured and sold specifically to harness a young child for safety purposes, are not protective devices. Source Note: The provisions of this §748.1611 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1611 What is a protective device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189182 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189182&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189182 03/12/2026 Involuntary self-injurious behavior means a person's physical movements that are automatic and not subject to control of the person's will that may inflict injury to the person. Source Note: The provisions of this §748.1613 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1613 What does "involuntary self-injurious behavior" mean when used in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189183 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189183&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189183 03/12/2026 (a) You may use protective devices if a licensed physician orders their use for a specific child. The orders must indicate the circumstances under which the protective device is permitted.(b) You may not use protective devices as:(1) Punishment;(2) Retribution or retaliation;(3) A means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation.(c) You must document the use of protective devices in the child's record, service plan, and service plan reviews. The service planning team must discuss and document in the child's service plan reviews:(1) Clinical justification for continued use of protective devices; and(2) Ways to reduce the need for protective devices. Source Note: The provisions of this §748.1615 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1615 May I use protective devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189184 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189184&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189184 03/12/2026 A licensed physician ordering protective devices may use PRN orders. The physician must review PRN orders for protective devices at least every 90 days. Source Note: The provisions of this §748.1617 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1617 Who may use PRN orders with respect to protective devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189185 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189185&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189185 03/12/2026 (a) A supportive device is used:(1) To support a person's posture;(2) To assist a person who cannot obtain and/or maintain normal physical functioning to improve his mobility and independent functioning; or(3) As an adjunct to proper care and treatment, for example physical therapy.(b) The purpose of a supportive device is not to restrict movement. Source Note: The provisions of this §748.1631 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1631 What is a supportive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189186 03/12/2026 (a) You may use supportive devices if a licensed physician orders their use for a specific child. The orders must indicate the circumstances under which the supportive device is permitted.(b) You may not use a supportive device as a substitute for appropriate nursing care.(c) You may not use supportive devices that include tying or depriving or limiting the use of a child's hands or feet.(d) You may not use supportive devices as:(1) Punishment;(2) Retribution or retaliation;(3) Means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation.(e) If a device is not specifically for assisting with sleep or safety during sleep, you must remove the device during rest periods.(f) You must document the use of supportive devices in the child's record, service plan, and service plan reviews. The service planning team must discuss and document in the child's service plan review:(1) Clinical justification for continued use of supportive devices; and(2) Ways to reduce the need for supportive devices. Source Note: The provisions of this §748.1633 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1633 May I use supportive devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189187 03/12/2026 A licensed physician ordering supportive devices may use PRN orders. The physician must review PRN orders for supportive devices at least every 90 days. Source Note: The provisions of this §748.1635 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1635 Who may use PRN orders with respect to supportive devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189188 03/12/2026 (a) A child may not use or possess tobacco products, e-cigarettes, or any type of vaporizers.(b) An adult may not smoke tobacco products, e-cigarettes, or vaporizers in the children's living quarters or inside any building on your premises where children are present.(c) An adult may only smoke tobacco products, e-cigarettes, or vaporizers on your premises at a safe distance from the children's living quarters.(d) No one may smoke tobacco products, e-cigarettes, or vaporizers in motor vehicles when transporting children in care. Source Note: The provisions of this §748.1661 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1661 What policies must I enforce regarding tobacco products and e-cigarettes? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189189 03/12/2026 (a) You must feed an infant whenever the infant is hungry.(b) For a toddler or school-age child:(1) You must provide the child with three meals and at least one snack a day; and(2) No more than 14 hours may pass between the last meal or snack of the day and the serving of the first meal of the following day. Source Note: The provisions of this §748.1691 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1691 How often must I feed children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189190 03/12/2026 (a) You must provide a child with food that is:(1) Of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development according to the United States Department of Agriculture guidelines; and(2) Appropriate for the child's age and activity level.(b) You must not serve a child nutrient concentrates and supplements, such as protein powders, liquid protein, vitamins, minerals, and other nonfood substances, in lieu of food to meet the child's daily nutritional needs, except with written instructions from a licensed health-care professional.(c) You must ensure drinking water is always available to each child and is served in a safe and sanitary manner. Children must be well hydrated and must be encouraged to drink water during physical activity and in warm weather. Source Note: The provisions of this §748.1693 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1693 What type of food and water must I provide children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189191 03/12/2026 (a) You must feed the infant:(1) On demand following the infant's lead on when to feed, how long to feed, and how much to feed; and(2) Based on the recommendation of the infant's health-care professional, who must approve you giving the infant any milk other than fortified formula.(b) You must hold the infant while feeding an infant that is:(1) Birth through six months old; or(2) Unable to sit unassisted in a high chair or other seating equipment during feeding.(c) You must never prop a bottle by supporting it with something other than the infant's or adult's hand.(d) If you care for more than one infant, you must:(1) Label each bottle and training cup with the child's first name and initial of last name;(2) Not permit the infant to share bottles or training cups; and(3) Sanitize high chair trays before each use. Source Note: The provisions of this §748.1695 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1695 What are the specific requirements for feeding an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189192 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189192&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189192 03/12/2026 (a) A toddler or older child must eat meals in the dining areas unless the service planning team's recommendations are to the contrary.(b) Food service practices for children receiving treatment services for primary medical needs or an intellectual disability, including non-mobile children, must encourage self-help and development. Source Note: The provisions of this §748.1697 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1697 What are the specific requirements for feeding toddlers and older children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189193 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189193&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189193 03/12/2026 (a) You must offer a child a meal or snack according to this division, but you may not force the child to eat. You are not required to offer other food to a child who:(1) Refuses a meal or snack; or(2) Chooses not to be present when a meal or snack is scheduled.(b) You must discuss recurring eating problems with the child's parent.(c) If a meal or snack is not appropriate to meet a child's individual needs, for example food allergies or religious reasons, then you must offer the child an appropriate nutritional substitute. Source Note: The provisions of this §748.1699 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1699 What must I do if a child refuses to or cannot eat a meal or snack that I offer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189194 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189194&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189194 03/12/2026 (a) To serve a therapeutic or special diet to a child, you must have written approval in the child's record from a licensed physician or a registered or licensed dietitian.(b) If a child requires a therapeutic or special diet, you must give the following people information regarding the diet:(1) All employees who prepare and serve food; and(2) The child's caregivers.(c) You must make dietary alternatives available to a child who has special health needs. Source Note: The provisions of this §748.1701 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1701 What must I do if a child requires a therapeutic or special diet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189195 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189195&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189195 03/12/2026 (a) You must maintain daily menus showing all meals and snacks that you prepare and serve.(b) You must document food substitutions on the menu. Food substitutions must be of comparable food value.(c) You must date menus and keep copies for 90 days.(d) This rule does not apply to meals prepared and served in cottage homes. Source Note: The provisions of this §748.1703 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1703 What are the requirements for daily menus? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189196 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189196&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189196 03/12/2026 (a) You must feed a child with primary medical needs according to his medical and developmental needs.(b) A licensed physician must prescribe tube feeding. A dietitian or physician must plan the diet that the physician prescribes.(c) Children must eat in an upright position unless the service planning team recommendations are to the contrary. Source Note: The provisions of this §748.1705 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2008, 33 TexReg 6606; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1705 What are the nutrition requirements for a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189197 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189197&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189197 03/12/2026 (a) A registered or licensed dietitian, physician, or a registered nurse must ensure the caregiver that prepares the formula is adequately trained and has demonstrated competency in preparing the formula.(b) Tube feeding formulas must supply the recommended dietary allowance for each child.(c) You must prepare and store the formula:(1) According to directions; or(2) As prescribed by a health-care professional. Source Note: The provisions of this §748.1707 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1707 What are the requirements for tube-feeding formula? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189198 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189198&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189198 03/12/2026 (a) Only the following may insert a nasogastric tube:(1) A physician; or(2) A registered nurse according to a physician's written orders.(b) You must document each insertion in the child's record. The documentation for each insertion must include the:(1) Signature of the nurse who inserted the tube; and(2) Date of the insertion.(c) You must follow the physician's written orders concerning the tube. Source Note: The provisions of this §748.1709 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1709 What are the requirements for using a nasogastric tube to feed a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189199 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189199&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189199 03/12/2026 These terms have the following meaning in this division:(1) Baby doorway jumper--A bucket seat that is suspended from a doorway by an elastic bungee cord that allows an infant to bounce while sitting in the seat.(2) Baby walker--A baby walker allows an infant to sit inside the walker equipped with rollers or wheels and move across the floor.(3) Bouncer seat--A stationary seat designed to provide gentle rocking or bouncing motion by an infant's movement, or by battery-operated movement. This type of equipment is designed for an infant's use from birth until the child can sit up unassisted.(4) Restrictive device--Equipment that places the body of an infant in a position that may restrict airflow or cause strangulation; usually, the infant is placed in a semi-seated position. Examples of restrictive devices are car seats, swings, bouncy seats, and high chairs. Source Note: The provisions of this §748.1741 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1741 What do certain words mean in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189200 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189200&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189200 03/12/2026 (a) Each infant must receive individual attention, including playing, talking, cuddling, and holding.(b) When an infant is upset, a caregiver must hold and comfort the infant.(c) A caregiver must provide prompt attention to an infant's physical needs, such as feeding and diapering.(d) An infant's caregiver must ensure that the environment is safe. For example, the caregiver must free the area of objects that may choke or harm the infant, take measures to prevent electric shock, free the area of furniture that is in disrepair or unstable, and allow no unsupervised access to water to prevent the risk of drowning.(e) Items necessary for diaper changing must be kept out of the reach of children, but do not need to be in locked storage.(f) An infant's caregiver must never leave the infant unsupervised. A sleeping infant is considered supervised if the caregiver is within eyesight or hearing range of the infant and can intervene as needed, or if the caregiver uses a video camera or audio monitoring device to monitor the infant and is close enough to the infant to intervene as needed. Source Note: The provisions of this §748.1743 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1743 What are the basic care requirements for an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189201 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189201&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189201 03/12/2026 A caregiver must:(1) Promptly change soiled or wet diapers or clothing;(2) Thoroughly cleanse children with individual cloths or disposable towels;(3) Use a clean, individual cloth or disposable towel to dry the child;(4) Ensure that the child is dry before placing a new diaper on the child; and(5) Keep all diaper-changing supplies out of children's reach. Source Note: The provisions of this §748.1745 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1745 What steps must a caregiver follow when changing a child's diaper? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189202 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189202&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189202 03/12/2026 To prevent the spread of germs when diapering a child, you must:(1) Wash your hands with soap and running water before and after diapering a child;(2) Cover a container used for soiled diapers or keep it in a sanitary manner, such as placing soiled diapers in individual sealed bags;(3) Discard a disposable towel after use; and(4) Launder any cloth before reusing it. Source Note: The provisions of this §748.1747 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1747 What must I do to prevent the spread of germs when diapering children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189203 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189203&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189203 03/12/2026 Your infant care area must at a minimum include the following furnishings and equipment:(1) An individual crib for each infant; and(2) A sufficient number of toys to keep each child engaged in activities. Source Note: The provisions of this §748.1749 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1749 What furnishings and equipment must I have in my infant care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189204 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189204&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189204 03/12/2026 (a) All cribs must have:(1) A firm, flat mattress that snugly fits the sides of the crib. The mattress must not be supplemented with additional foam material or pads;(2) Sheets that fit snugly and do not present an entanglement hazard;(3) A mattress that is waterproof or washable;(4) Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts;(5) A maximum of 2 3/8 inches between crib slats or poles;(6) No corner posts over 1/16 inch above the end panels;(7) No cutout areas in the headboard or footboard that would entrap a child's head or body;(8) Drop gates, if present, which fasten securely and cannot be opened by a child; and(9) Documentation that each crib meets the applicable federal rules at Title 16, Code of Federal Regulations, Parts 1219 or 1220, concerning "Safety Standards for Full-Size Baby Cribs" and "Safety Standards for Non-Full-Size Baby Cribs," respectively, or documentation that each crib is a medical device listed and registered with the U.S. Food and Drug Administration.(b) You must sanitize each crib when soiled and before reassigning the crib to a different child.(c) You must never leave a child in the crib with the drop gate down.(d) You may not have stackable cribs. Source Note: The provisions of this §748.1751 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective December 1, 2012, 37 TexReg 9140; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1751 What specific safety requirements must my cribs meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189205 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189205&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189205 03/12/2026 (a) Play yards, which are mesh or fabric sided cribs, are allowed if they meet the following safety requirements:(1) The play yards must be used according to the manufacturer's instructions, including the cleaning of the cribs;(2) Play yards must have:(A) A firm, flat mattress that snugly fits the sides of the crib and that is designed for the crib. The mattress must not be supplemented with additional foam material or pads;(B) Sheets that fit snugly and do not present an entanglement hazard;(C) A mattress that is waterproof or washable;(D) Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts;(E) A minimum height of 22 inches from the top of the railing to the mattress support at its lowest level;(F) Folded sides that securely latch in place when raised;(G) For mesh cribs, mesh openings that are 1/4 inch or less; and(H) Mesh or fabric that is securely attached to the top rail, side rail, and floor plate; and(3) You must never leave an infant in a play yard with a side folded down.(b) If you become aware of a recall for a non-full-size crib or a mesh crib that you are using, you must discontinue its use immediately. Source Note: The provisions of this §748.1753 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1753 Are play yards allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189206 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189206&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189206 03/12/2026 If you use a high chair, swing, stroller, infant carrier, rocker, bouncer seat, or a similar type of equipment for an infant:(1) It must be equipped with safety straps; and(2) The safety straps must be fastened whenever the infant is using the equipment. Source Note: The provisions of this §748.1755 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1755 What equipment must have safety straps before I can use it with an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189207 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189207&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189207 03/12/2026 (a) You may not use any of the following types of equipment with infants:(1) Baby walkers;(2) Baby doorway jumpers;(3) Accordion safety gates;(4) Toys that are not large enough to prevent swallowing or choking; and(5) Bean bags, waterbeds, and foam pads for use as sleeping equipment.(b) Except for a tight fitting sheet and as provided in subsection (c), the crib must be bare for an infant younger than twelve months of age.(c) A crib mattress cover may be used to protect against wetness, but the cover must:(1) Be designed specifically for the size and type of crib and crib mattress that it is being used with;(2) Be tight fitting and thin; and(3) Not be designed to make the sleep surface softer.(d) An infant receiving treatment services for primary medical needs may have special items that assist with safe sleep at the written recommendation of a health-care professional. You must keep the recommendation in the child's record. Source Note: The provisions of this §748.1757 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective December 1, 2012, 37 TexReg 9140; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1757 What types of equipment are not allowed for use with infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189208 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189208&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189208 03/12/2026 You must provide the following activities for an infant:(1) Multiple opportunities each day to explore in a safe and clean area that is outside of the crib or restrictive device;(2) Opportunities for visual, auditory, and sensory stimulation;(3) Opportunities for small- and large-muscle development; and(4) A supervised nap period that allows the infant to maintain the child's own pattern of sleeping and waking. Source Note: The provisions of this §748.1759 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1759 What activities must I provide for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189209 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189209&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189209 03/12/2026 An infant may remain in the crib for up to 30 minutes after awakening, as long as the infant is content and responsive. Source Note: The provisions of this §748.1761 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1761 How long may an infant remain in a crib after awakening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189210 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189210&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189210 03/12/2026 (a) You must place an infant not yet able to turn over on his own in a face-up sleeping position unless a health-care professional orders otherwise. You must keep any orders from a health-care professional in the child's record.(b) An infant's head, face, or crib must not be covered at any time by an item such as a blanket, linen, or clothing.(c) An infant may not sleep in a prone position with a sleeping adult at any time, including in the adult's bed, on a couch, etc. Source Note: The provisions of this §748.1763 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1763 What are the specific sleeping requirements for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189211 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189211&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189211 03/12/2026 No. You may not allow an infant to sleep in a restrictive device. If an infant falls asleep in a restrictive device, the infant should be removed from the device and placed in a crib as soon as possible. Source Note: The provisions of this §748.1765 adopted to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1765 May I allow infants to sleep in a restrictive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204805 03/12/2026 You may not lay a swaddled infant down to sleep or to rest on any surface at any time, unless you have an order signed by a health-care professional. You must keep the order in the child's record. Source Note: The provisions of this §748.1767 adopted to be effective April 25, 2021, 46 TexReg 2452. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1767 May I swaddle an infant to help the infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189212 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189212&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189212 03/12/2026 (a) Each toddler must receive individual attention, including playing, talking, and cuddling.(b) A toddler's caregiver must ensure that the environment is safe. For example, the caregiver must free the area of objects that may choke or harm the toddler, take measures to prevent electric shock, free the area of furniture that is in disrepair or unstable, and allow no unsupervised access to water to prevent the risk of drowning.(c) A toddler's caregiver must never leave the toddler unsupervised. A sleeping toddler is considered supervised if the caregiver is within eyesight or hearing range of the toddler and can intervene as needed, or if the caregiver uses a video camera or audio monitoring device to monitor the toddler and is close enough to the toddler to intervene as needed. Source Note: The provisions of this §748.1791 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1791 What are the basic care requirements for a toddler? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189213 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189213&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189213 03/12/2026 Furnishings and equipment for toddlers must at a minimum include the following:(1) Age-appropriate seating, tables, and nap and sleep equipment. Toddlers may use cribs or beds, as appropriate;(2) Enough popular items available, so a toddler is not forced to compete for them; and(3) Containers or low shelving that are accessible to toddlers, so toddlers can safely obtain the items without adult intervention. Source Note: The provisions of this §748.1793 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1793 What furnishings and equipment must I provide for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189214 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189214&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189214 03/12/2026 You must provide the following activities for a toddler:(1) Daily opportunities for outdoor play, when weather permits;(2) Opportunities for thinking skills and sensory development;(3) Opportunities for small and large-muscle development;(4) Opportunities for language development;(5) Opportunities for social/emotional development;(6) Opportunities to develop self-help skills such as toileting, hand washing, and feeding; and(7) Supervised naptimes. You must provide a supervised sleep or rest period after the noon meal for all toddlers. Source Note: The provisions of this §748.1795 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1795 What activities must I provide for toddlers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189215 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189215&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189215 03/12/2026 You must:(1) Ensure information, training, and counseling is available regarding health aspects of pregnancy, preparation for child birth, and recovery from child birth;(2) Ensure the pregnant child receives nutritional counseling and guidance that meets generally accepted standards, including nutrition during pregnancy, lactation, and foods to avoid; and(3) Inform the child, within seven days of admission or upon learning of the pregnancy, of her right to be free from pressure to get an abortion, relinquish her child for adoption, or to parent her child. Source Note: The provisions of this §748.1821 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1821 What information must I provide a pregnant child regarding her pregnancy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189216 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189216&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189216 03/12/2026 If your policies allow for the use of personal restraints on a pregnant child:(1) The health-care professional attending to the child's pregnancy must document whether any type of emergency behavior intervention that your policies allow is inadvisable; and(2) You may not use any emergency behavior intervention that the child's health-care professional attending to her pregnancy finds inadvisable. Source Note: The provisions of this §748.1823 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1823 Is the use of emergency behavior intervention of a pregnant child permitted in my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189217 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189217&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189217 03/12/2026 If your policies permit the admission of adolescent parents with their child(ren):(1) An adolescent parent must provide most of the care for her child;(2) Caregivers must be available to the adolescent parent as a resource and support; and(3) When you care for an adolescent's child in the adolescent parent's absence, you are responsible for that child as if the child is in your care. Source Note: The provisions of this §748.1825 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS J CHILD CARE §748.1825 If my policies permit the admission of adolescent parents with their child(ren), who is responsible for the care of the adolescent's child(ren)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189218 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189218&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189218 03/12/2026 The rules in this subchapter apply to operations that provide care for both children and adults. Source Note: The provisions of this §748.1901 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1901 What operations do the rules in this subchapter apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189219 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189219&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189219 03/12/2026 (a) A young adult may remain in your care until his 23rd birthday in order to:(1) Transition to independence, including attending college or vocational or technical training;(2) Attend high school, a program leading to a high school diploma, or GED classes;(3) Complete your program; or(4) Stay with a minor sibling.(b) A young adult who turns 18 in your care may remain in your care indefinitely if the person:(1) Continues to need the same level of care; and(2) Is unlikely to physically and/or intellectually progress over time. Source Note: The provisions of this §748.1931 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1931 After a child in my care turns 18 years old, may the person remain in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189220 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189220&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189220 03/12/2026 (a) You may admit a young adult into your transitional living program.(b) For other programs or services, the young adult must:(1) Come immediately from another residential child-care operation if the reason for admittance is consistent with a condition listed in §748.1931 of this title (relating to After a child in my care turns 18 years old, may the person remain in my care?); or(2) Be in the care of the Texas Department of Family and Protective Services.(c) A young adult may remain in your care until his 23rd birthday. Source Note: The provisions of this §748.1933 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1933 May I admit a young adult into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189221 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189221&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189221 03/12/2026 (a) If you provide care to both children and adults, you may maintain the required child/caregiver ratio by:(1) Counting all residents in your care as children and maintaining the appropriate ratio; or(2) Assigning caregivers to work exclusively with the children in care.(b) The child/caregiver ratio for minor and adult residents applies to operation-sponsored activities or appointments, regardless of where they occur.(c) You may not count adult residents as caregivers in the child/caregiver ratio. Source Note: The provisions of this §748.1935 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1935 How does the child/caregiver ratio apply if I provide care to both children and adults? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208616 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208616&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208616 03/12/2026 (a) An adult in care may share a bedroom with a child in care if:(1) The adult and child are siblings;(2) The adult is the child's parent;(3) Both of them are non-ambulatory and receive treatment services for primary medical needs; or(4) The child is at least 16 years old, the age difference between them does not exceed 24 months, and the adult meets the requirements of:(A) §748.1931 of this division (relating to After a child in my care turns 18 years old, may the person remain in my care?); or(B) §748.1933 of this division (relating to May I admit a young adult into care?).(b) The following must occur before you may allow an adult in care and a child in care to share a bedroom, unless the adult is the child's parent:(1) The service planning team must determine that there is no known risk of harm to the child after assessing:(A) Their behaviors;(B) Their compatibility with each other;(C) Their respective relationships;(D) Any history of possible sexual trauma or sexually inappropriate behavior; and(E) Any other identifiable factor that may affect the appropriateness of the adult and child sharing a bedroom; and(2) The service planning team must date and document the assessment and approval in the child's service plan.(c) The adult and the child must not sleep in the same bed unless the adult is the child's parent, and the child is between the ages of one year and 10 years old.(d) Subsections (a) and (b) of this section do not apply to travel and camping situations. Source Note: The provisions of this §748.1937 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1937 May an adult in care share a bedroom with a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189223 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189223&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189223 03/12/2026 For adult residents, you must meet the space requirements listed in §748.3351 of this title (relating to What are the requirements for general living space?) and §748.3357 of this title (relating to What are the requirements for floor space in a bedroom used by a child?). Source Note: The provisions of this §748.1939 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1939 How much general living space and floor space in a bedroom must I provide for children and young adults who are in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189224 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189224&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189224 03/12/2026 If an adult resident is responsible for his own medication, you must:(1) Establish written safeguards to prevent children in care from having access to the medications; and(2) Implement the safeguards. Source Note: The provisions of this §748.1941 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1941 What must I do if an adult resident is responsible for his own medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189225 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189225&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189225 03/12/2026 Yes. You must meet applicable requirements listed in §748.1583 of this title (relating to Who must have a tuberculosis (TB) examination?). Source Note: The provisions of this §748.1943 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1943 Must adult residents have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189226 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189226&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189226 03/12/2026 You must meet applicable requirements listed in §748.1581 of this title (relating to What health precautions must I take if someone in my operation has a communicable disease?). Source Note: The provisions of this §748.1945 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS K OPERATIONS THAT PROVIDE CARE FOR CHILDREN AND ADULTS §748.1945 What must I do if an adult resident has a positive tuberculosis test result? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189227 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189227&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189227 03/12/2026 (a) You must obtain a general written consent to administer routine, preventive, and emergency medications.(b) You must obtain a written, signed, and dated consent, specific to the psychotropic medication to be administered, from the person legally authorized to give medical consent before administering a new psychotropic medication to a child, per §748.2253 of this title (relating to If my operation employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give consent before requesting his consent for the child to be placed on psychotropic medication?) or §748.2255 of this title (relating to If my operation does not employ or contract with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give medical consent prior to the health-care professional prescribing psychotropic medications to a child in care?). Source Note: The provisions of this §748.2001 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2001 What consent must I obtain to administer medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189232 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189232&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189232 03/12/2026 (a) To the best of your knowledge, you must inform the person legally authorized to give medical consent of the benefits, risks, and side effects of all prescription medication and treatment procedures used and the medical consequences of refusing them, and/or provide the name and telephone number of the prescribing health-care professional for more information.(b) For prescription medications, you must:(1) Be informed about possible side effects of medications administered to the child;(2) Store all medication in the original container unless you have an additional container with the same label and instructions;(3) Administer all medications according to the instructions on the label or according to a prescribing health-care professional's subsequent signed orders (See §748.2005 of this title (relating to May I accept verbal orders on the administration of medication?));(4) Administer each child's medication within one hour of preparation;(5) Ensure the child has taken the medication as prescribed;(6) Ensure a person trained in and authorized to administer medication administers the medication to a child in care unless the child is on a self-medication program;(7) Maintain any documentation provided by the health-care professional on the administration of current medication;(8) Not physically force a child to take medication except as allowed by §748.2455(a)(2)(B) of this title (relating to What actions must a caregiver take before using a permitted type of emergency behavior intervention?);(9) Ensure that your employees do not provide any medication or treatment to a child except on written orders of a health-care professional;(10) Not borrow or administer medication to a child that is prescribed to another person; and(11) Not administer medication to more than one child from the same container. Only the child for whom the medication was prescribed may use the medication. Source Note: The provisions of this §748.2003 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2003 What are the requirements for administering prescription medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189228 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189228&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189228 03/12/2026 (a) Assuming you have obtained written consent according to §748.2001 of this title (relating to What consent must I obtain to administer medications?), a licensed health-care professional may provide verbal orders. However, the health-care professional must write and sign orders within 72 hours of the verbal order.(b) The verbal order must be documented in the child's record, including the health care professional's name and the date and time of the call. Source Note: The provisions of this §748.2005 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2005 May I accept verbal orders on the administration of medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208617 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208617&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208617 03/12/2026 (a) For non-prescription medications and supplements, you must:(1) Follow the label instructions for dosage; and(2) Ensure that the non-prescription medication or supplement is not contraindicated with any medication prescribed for the child or medical condition that the child has.(b) You may give nonprescription medication or supplements to more than one child from one container. Source Note: The provisions of this §748.2009 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2009 What are the requirements for administering non-prescription medication and supplements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189230 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189230&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189230 03/12/2026 For a child to be on a self-medication program:(1) The child's parent must give written authorization for the child to be on the program;(2) The child's service plan must include the self-medication program and any requirements for caregiver supervision; and(3) The health-care professional who prescribed the medication must be consulted, and any concerns of the health-care professional documented in the child's record. Source Note: The provisions of this §748.2051 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2051 What are the requirements for a self-medication program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189231 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189231&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189231 03/12/2026 When a child who is on a self-medication program takes a dosage of the medication, you must ensure there is a system for reviewing the child's medication each day and that the child either:(1) Records the daily dosage; or(2) Reports the medication to an appropriate employee or service provider, who must then do the actual daily recording. Source Note: The provisions of this §748.2053 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2053 Who must record the medication dosage if a child is on a self-medication program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189235 03/12/2026 You must:(1) Store medication in a locked container;(2) Keep medication inaccessible other than to employees responsible for stored medication;(3) Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container. For example, a double lock can include a lock on the cabinet or filing cabinet and the door to the closet where medications are stored;(4) Make provisions for storing medication that requires refrigeration;(5) Keep medication storage area(s) clean and orderly;(6) Remove discontinued medication immediately and destroy it in a way that ensures that children do not have access to it;(7) Remove medication on or before the expiration date and destroy it in a way that ensures that children do not have access to it;(8) Remove medication of a discharged or deceased child immediately and destroy it in a way that ensures that children do not have access to it; and(9) Provide prescription medication to the person to whom a child is discharged or transferred if the child is taking the medication at that time. Source Note: The provisions of this §748.2101 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2101 What medication storage requirements must my operation meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189236 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189236&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189236 03/12/2026 (a) Discontinued medication, expired medication, and medication left at your operation must be inventoried and stored separately from current medications as directed by the administrator.(b) When you have an accumulation of this medication, you must destroy the medication in accordance with state and federal law and in a way that ensures children do not have access to it. The medication must be destroyed by:(1) A health-care professional or pharmacist; or(2) The licensed child-care administrator and another adult who is not a resident. Source Note: The provisions of this §748.2103 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2103 What are the requirements for discontinued or expired medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189233 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189233 03/12/2026 (a) You must maintain a cumulative medication record of all:(1) Prescription medication dispensed to each child; and(2) Nonprescription medications and supplements that are dispensed to a child under five years old.(b) The cumulative medication record must be updated:(1) Within 2 hours of administering medication, unless you operate a cottage home model; or(2) Within 24 hours of administering medication if you operate a cottage home model.(c) You must maintain the medication record, which must include:(1) Child's full name;(2) Prescribing health-care professional's name, if applicable;(3) Reason medication was prescribed, for prescription medication;(4) Medication name, strength, and dosage;(5) Date (day, month, and year) and time the medication was administered;(6) Name and signature of the person who administered the medication;(7) Child's refusal to accept medication, if applicable; and(8) Reasons for administering the medication, including the specific symptoms, condition, and/or injuries of the child that you are treating, only for:(A) PRN psychotropic medications; and(B) Nonprescription medications and supplements for children under five years old.(d) Unless you operate on a cottage home model, you must count each medication prescribed to a child at least daily and document the count. The medication count must match the medication documentation.(e) You must document in the medication record any non-prescription medication or supplement that is given to the child and how often the child receives the medication or supplement.(f) You must document any prohibited prescription medications (for example, medication allergies or contraindications) or prohibited non-prescription medications and supplements in the medication record.(g) You must incorporate the medication record into the child's record. Source Note: The provisions of this §748.2151 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2151 What records must you maintain for each child receiving medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189234 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189234 03/12/2026 A medication error includes, but is not limited to, the following:(1) A child receives the wrong medication;(2) A child receives medication prescribed for someone else;(3) A child receives the wrong dosage of medication;(4) A child receives medication at the wrong time;(5) A medication dose is skipped or missed;(6) A child receives expired medication;(7) Not following the medication administration instructions, such as giving a child medication on an empty stomach when the medication should be given with food; and(8) A child receives medication that was not stored as required to maintain the effectiveness of the medication, such as refrigerating or not refrigerating the medication or exposing the medication to heat or sunlight. Source Note: The provisions of this §748.2201 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2201 What is a medication error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189240 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189240&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189240 03/12/2026 (a) If you find a medication error regarding a prescribed medication, you must contact a health-care professional immediately, unless the error is the type described in paragraph (4) or (5) of §748.2201 of this title (relating to What is a medication error?), and follow the health-care professional's recommendations.(b) If you find a medication error regarding an nonprescription medication, you must take the appropriate and necessary actions as required by the circumstances.(c) For all medication errors, you must document the following within 24 hours:(1) The time and date of the error;(2) The medication error;(3) The time and date of the call(s) to the licensed health-care professional, if applicable;(4) The name and title of the health-care professional contacted, if applicable; and(5) The health-care professional's medical recommendations for ensuring the child's safety, if applicable. Source Note: The provisions of this §748.2203 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2203 What must I do if I find a medication error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189237 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189237&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189237 03/12/2026 If you find a medication label error, you must:(1) Report the error to the pharmacist; and(2) Have the label on the medication container corrected as soon as possible, but no later than the next business day. Source Note: The provisions of this §748.2205 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2205 What must I do if I find a medication label error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189238 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189238&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189238 03/12/2026 If a child has an adverse reaction (unexpected or dangerous reaction) to a medication, you must:(1) Immediately report the reaction to a health-care professional and the child's parent;(2) Follow the health-care professional's recommendations;(3) Seek further medical care for the child if the child's condition appears to worsen; and(4) Document in the child's medical record the:(A) Adverse reactions that the child had to the medication;(B) Time and date of call(s) to the health-care professional;(C) Name and title of the health-care professional contacted; and(D) Health-care professional's medical recommendations for ensuring the child's safety. Source Note: The provisions of this §748.2231 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2231 What must I do if a child has an adverse reaction to a medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189239 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189239&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189239 03/12/2026 (a) A side effect from any medication is an effect of medication in addition to the medication's intended effect, often an undesirable effect.(b) If a child experiences side effects from any medication, you must:(1) Document the observed and reported side effects;(2) Immediately report any serious side effects to the child's prescribing health-care professional and the child's parent; and(3) Report any other side effect to the prescribing health-care professional within 72 hours. Source Note: The provisions of this §748.2233 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2233 What must I do if a child experiences side effects from any medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189241 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189241&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189241 03/12/2026 (a) Before requesting the person's written consent to give the child psychotropic medication, the prescribing health-care professional must give the following in writing or document a discussion with the person or a combination of both:(1) The child's diagnosis;(2) The nature of the child's mental illness or condition;(3) An explanation of the purpose of the medication;(4) A description of the benefits expected;(5) A description of any accompanying discomforts and risks, including those which could result from long-term use of the medication, and possible side effects, including side effects that are known to frequently occur in persons, side effects to which the child may be predisposed, and the nature and possible occurrence of irreversible symptoms;(6) A statement of whether the medication is habituating in nature;(7) Alternative interventions to the use of psychotropic medication that have been attempted and that have been unsuccessful;(8) Other alternative treatments or procedures to the use of the psychotropic medication;(9) Risks and benefits of the alternative treatments or procedures;(10) Risks and benefits of not receiving or undergoing a treatment or procedure;(11) An explanation that the person legally authorized to give medical consent may ask questions about the child's response to the medication, and may review your daily records on request; and(12) An explanation that the person legally authorized to give medical consent may withdraw consent and request the medication be discontinued at any time.(b) The health-care professional must offer to answer any questions the person legally authorized to give consent has about the medication.(c) The person must sign a consent form that acknowledges that you have provided all of the information set forth in subsection (a) of this section. A copy of this signed consent form must be filed in the child's record. Source Note: The provisions of this §748.2253 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2253 If my operation employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give consent before requesting his consent for the child to be placed on psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189242 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189242&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189242 03/12/2026 If you are requesting consent and the person legally authorized to give consent is not privy to this information, you must:(1) Before requesting the person's written consent to give the child psychotropic medication, provide information in writing or document a discussion with the person regarding:(A) The nature of the child's mental illness or condition;(B) A general explanation of the purpose of the medication;(C) A general description of the benefits expected;(D) An explanation that the person may ask questions about the child's response to the medication; and(E) An explanation that the person may withdraw medical consent and request the medication be discontinued at any time.(2) Offer to answer any questions the person legally authorized to give medical consent has about the medication and/or provide the name and telephone number of the prescribing health-care professional for further information.(3) Obtain a signed consent form from the person legally authorized to give medical consent that acknowledges that you have provided all of the information set forth in paragraph (1) of this section. A copy of this signed consent form must be filed in the child's record. Source Note: The provisions of this §748.2255 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2255 If my operation does not employ or contract with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give medical consent prior to the health-care professional prescribing psychotropic medications to a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189243 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189243&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189243 03/12/2026 (a) If a physician has made a determination that there is an emergency according to §266.009 of the Family Code and the emergency requires the administration of a psychotropic medication, then you must follow the physician's orders and do not have to obtain consent prior to the administration of the medication.(b) Within 72 hours after you have administered the medication, you must notify the parent and the person legally authorized to give medical consent.(c) The physician's statement regarding the emergency and the prescription must be documented in the child's record. Source Note: The provisions of this §748.2257 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2257 What are the requirements if a physician orders administration of a psychotropic medication to a child in an emergency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189244 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189244&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189244 03/12/2026 (a) You must maintain a daily record of the child's use of such medication according to the requirements in §748.2151 of this title (relating to What records must I maintain for each child receiving medication?).(b) You must document in the child's record a description of any noticeable change in the child's behavior in response to the medication.(c) You must provide the information in subsection (b) of this section to the prescribing health-care professional or the child's current health-care professional to use in evaluating the appropriateness of continuing the medication. You must document the health-care professional's evaluation and review in the child's record. Source Note: The provisions of this §748.2259 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2259 What information must I document about a child's use of psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189245 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189245&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189245 03/12/2026 (a) If a child takes psychotropic medications, the prescribing health-care professional must evaluate and document in the child's medication record a description of the child's response to the medication and an assessment of its effectiveness and the appropriateness of continuing the medication at least quarterly. The written evaluation must include any reasons for discontinuing the medication.(b) If the health-care professional decides that he can evaluate the appropriateness of continuing the medication without seeing the child, you do not have to schedule an appointment for the evaluation.(c) The health-care professional must consider the target symptoms and treatment goals in evaluating the child's use of psychotropic medications.(d) The health-care professional must document whether the child needs to continue taking the medication. You must document the health-care professional's decision in the child's record.(e) If the health-care professional does not substantiate the effectiveness of a specific psychotropic medication within 90 days, the health-care professional must provide a written rationale for continuing the medication for an additional period. The continuation of the medication may not exceed an additional 90 days (for a total of 180 days) if effectiveness is not substantiated by the health-care professional. A copy of the written rationale must be documented in the child's record. Source Note: The provisions of this §748.2261 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2261 If my operation employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what are the requirements for evaluating whether a child should continue taking a psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206506 03/12/2026 If your operation maintains and administers unassigned epinephrine auto-injectors to use when a child in care has an emergency anaphylaxis reaction, you must:(1) Adopt and implement a written policy that complies with the unassigned epinephrine auto-injector requirements set by the Texas Department of State Health Services, as specified in 25 TAC Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in Youth Facilities) and Texas Health and Safety Code §773.0145;(2) Notify the child's parent, immediately after ensuring the safety of the child, if the child has had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector; and(3) Maintain and make available for review, upon our request, proof that you have notified the child's parent of an incident where the child in care had an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector. Source Note: The provisions of this §748.2271 adopted to be effective October 25, 2021, 46 TexReg 7221. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS L MEDICATION §748.2271 What are the requirements if my operation chooses to maintain and administer unassigned epinephrine auto-injectors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189247 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189247 03/12/2026 (a) Only a caregiver known to and knowledgeable of a child may discipline the child.(b) Each disciplinary measure must:(1) Be consistent with your policies and procedures;(2) Not be physically or emotionally damaging to the child;(3) Be individualized to meet each child's needs;(4) Be appropriate to the child's level of understanding, age, and developmental level; and(5) Be appropriate to the incident and severity of the behavior demonstrated.(c) The goal of each disciplinary measure must be to teach the child acceptable behavior and self-control. The caregiver must explain the reason for the disciplinary measure when the caregiver imposes the measure. Source Note: The provisions of this §748.2301 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2301 What are the requirements for disciplinary measures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189248 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189248 03/12/2026 (a) You may not use or threaten to use corporal punishment with any child in care.(b) Corporal punishment is the infliction of physical pain on any part of a child's body as a means of controlling or managing the child's behavior. It includes:(1) Hitting or spanking a child with a hand or instrument; or(2) Forcing or requiring the child to do any of the following as a method of managing or controlling behavior:(A) Perform any form of physical exercise, such as running laps or doing sit ups or push ups;(B) Hold a physical position, such as kneeling or squatting; or(C) Do any form of "unproductive work." Source Note: The provisions of this §748.2303 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2303 May I use corporal punishment for children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189246 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189246&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189246 03/12/2026 (a) "Unproductive work" is work that serves no purpose except to demean the child. Examples include moving rocks or logs from one pile to another or digging a hole and then filling it in. Unproductive work is never an appropriate behavior management tool.(b) "Unproductive work" does not include work that corrects damage that the child's behavior caused. For example, you may require a child who defaces a fence or wall to repaint it. This example includes a logical consequence and is an acceptable behavior management tool. Source Note: The provisions of this §748.2305 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2305 What is "unproductive work"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208618 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208618&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208618 03/12/2026 In addition to corporal punishment, prohibited discipline techniques include:(1) Any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline or punishment;(2) Denial of mail or visits with their families as discipline or punishment;(3) Threatening with the loss of placement as discipline or punishment;(4) Using sarcastic or cruel humor;(5) Maintaining an uncomfortable physical position, such as kneeling, or holding his arms out;(6) Pinching, pulling hair, biting, or shaking a child;(7) Putting anything in or on a child's mouth;(8) Humiliating, shaming, ridiculing, rejecting, or yelling at a child;(9) Subjecting a child to abusive or profane language;(10) Placing a child in a dark room, bathroom, or closet;(11) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age;(12) Confining a child to a highchair, box, or other similar furniture or equipment as discipline or punishment;(13) Denying basic child rights as discipline or punishment;(14) Withholding food that meets the child's nutritional requirements; and(15) Using or threatening to use emergency behavior intervention as discipline or punishment. Source Note: The provisions of this §748.2307 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2307 What other methods of punishment are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189250 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189250&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189250 03/12/2026 (a) Within limits, a caregiver may restrict a child's activities as a behavior management tool.(b) Restrictions of activities that will be imposed on a child for more than fourteen days, must have prior approval by the treatment director, service planning team, or professional level service provider.(c) Restrictions to a particular room or building that will be imposed on a child for more than 24 hours must have prior approval by the treatment director, service planning team, or professional level service provider.(d) You must inform the child and parent about any restrictions that you place on the child.(e) Documentation of all approvals, justification for the restriction, and informing the child and parents must be in the child's record. Source Note: The provisions of this §748.2309 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2309 To what extent may I restrict a child's activities as a behavior management tool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189251 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189251 03/12/2026 No. A person in care must not discipline or punish another person in care. Source Note: The provisions of this §748.2311 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS M DISCIPLINE AND PUNISHMENT §748.2311 May a child or adult in care discipline or punish another person in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189252 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189252 03/12/2026 These terms have the following meaning in this subchapter:(1) Transitional hold--The use of a temporary restraint technique that lasts no longer than one minute as part of the continuation of a longer personal or mechanical restraint.(2) Triggered review--A review of a specific child's placement, treatment plan, and orders or recommendations for intervention, because a certain number of interventions have been made within a specified period of time (e.g. three seclusions within a seven-day period). Source Note: The provisions of this §748.2401 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2401 What do certain words mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189253 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189253 03/12/2026 (a) If permitted in your policies and you meet the requirements of this subchapter, you may administer the following types of emergency behavior intervention to a child in your care:(1) Short personal restraint;(2) Personal restraint;(3) Emergency medication;(4) Seclusion:(A) Only for a child with an emotional disorder or an Autism Spectrum Disorder; and only if you provide treatment services to 25 or more children with emotional disorders or Autism Spectrum Disorder, or if more than 30% of the children in your care receive treatment services for emotional disorders or Autism Spectrum Disorder. Seclusion is not permitted for children receiving therapeutic camp services; or(B) Only if you provide emergency care services to the child and only while waiting for the arrival of law enforcement or emergency medical services; and(5) Mechanical restraint, only if you are a Residential Treatment Center.(b) You may never administer chemical restraints.(c) Protective and supportive devices, used appropriately, are not considered emergency behavior interventions. For information on protective and supportive devices, see Divisions 4 and 5 of Subchapter J of this chapter (relating to Child Care). Source Note: The provisions of this §748.2451 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2451 What types of emergency behavior intervention may I administer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189254 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189254 03/12/2026 Only a caregiver qualified in emergency behavior intervention may administer any form of emergency behavior intervention, except for the short personal restraint of a child. Source Note: The provisions of this §748.2453 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2453 Who may administer emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189255 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189255&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189255 03/12/2026 (a) Before using a permitted type of emergency behavior intervention, the caregiver must:(1) Attempt less restrictive behavior interventions that prove to be ineffective at defusing the situation; and(2) Determine that the basis for the emergency behavior intervention is:(A) An emergency situation; or(B) A need for a personal restraint to administer intra-muscular medication or other medical treatments prescribed by a licensed physician, such as administering insulin to a child with diabetes.(b) A child's active attempt to run away may be considered an emergency situation when the following is a factor:(1) The child is developmentally or chronologically under six years old;(2) The child is suicidal;(3) The operation is located near a high traffic area;(4) Adverse weather conditions pose a clear safety risk to the child; or(5) Other clear safety risks are present. Source Note: The provisions of this §748.2455 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2455 What actions must a caregiver take before using a permitted type of emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189256 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189256&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189256 03/12/2026 Generally, a short personal restraint is used in urgent situations, such as:(1) To protect the child from external danger that causes imminent significant risk to the child, such as preventing the child from running into the street or coming into contact with a hot stove. The restraint must end immediately after the danger is averted;(2) To intervene when a child under five years old (chronological or developmental age) demonstrates disruptive behavior, if other efforts to de-escalate the child's behavior have failed;(3) When a child over five years old demonstrates behavior disruptive to the environment or milieu, such as disrobing in public, provoking others that creates a safety risk, or to intervene to prevent a child from physically fighting; or(4) When a child is significantly damaging property, such as breaking car windows or putting holes into walls. Source Note: The provisions of this §748.2459 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2459 What is the appropriate use for a short personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189257 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189257&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189257 03/12/2026 (a) When a caregiver implements a short personal restraint, the caregiver must:(1) Minimize the risk of physical discomfort, harm, or pain to the child; and(2) Use the minimal amount of reasonable and necessary physical force.(b) A caregiver may not use any of the following techniques as a short personal restraint:(1) A prone or supine restraint;(2) Restraints that impair the child's breathing by putting pressure on the child's torso, including leaning a child forward during a seated restraint;(3) Restraints that obstruct the airways of the child or impair the breathing of the child, including procedures that place anything in, on, or over the child's mouth, nose, or neck, or impede the child's lungs from expanding;(4) Restraints that obstruct the caregiver's view of the child's face;(5) Restraints that interfere with the child's ability to communicate or vocalize distress; or(6) Restraints that twist or place the child's limb(s) behind the child's back. Source Note: The provisions of this §748.2461 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2461 What precautions must a caregiver take when implementing a short personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189258 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189258&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189258 03/12/2026 Emergency behavior intervention may never be used as:(1) Punishment;(2) Retribution or retaliation;(3) A means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation. Source Note: The provisions of this §748.2463 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2463 Are there any purposes for which emergency behavior intervention cannot be used? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189259 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189259&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189259 03/12/2026 According to the following chart, written orders by certain professionals are required to administer certain emergency behavior intervention: Attached Graphic Source Note: The provisions of this §748.2501 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2501 Are written orders required to administer emergency behavior intervention, and if so, who can write them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189260 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189260&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189260 03/12/2026 Yes, any type of written order that is required, must be in the child's record before a caregiver can use emergency behavior intervention on that child, except for seclusion when it is necessary to prevent the child from endangering himself or others. In this seclusion situation, a licensed psychiatrist, psychologist, or physician must provide a verbal order within one hour after a caregiver initiates the seclusion. The caregiver must document this order, and the professional who provides the verbal order must provide a written version of the order within 72 hours after issuing the order. The written copy must include the time, date, and the professional's signature. Source Note: The provisions of this §748.2503 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2503 Must the written order be in a child's record before a caregiver can use an emergency behavior intervention on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189261 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189261&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189261 03/12/2026 (a) All written orders must include the following:(1) A statement that the particular type of emergency behavior intervention may only be used in an emergency situation;(2) Designation of the specific intervention and procedure or technique that is authorized;(3) Any specific measures for ensuring the child's health, safety, and well being, and the privacy of the setting that safeguards the child's personal dignity;(4) A complete description of the behaviors and circumstances under which the intervention may be used;(5) Instructions for observation or heightened observation of the child during the intervention;(6) The behaviors that indicate the child is ready to be released from the intervention;(7) The maximum length of time the child may be restrained or secluded regardless of behaviors exhibited;(8) The prescribing professional's consideration of any potential medical and/or psychiatric contraindications for the specific child, such as a history of physical or sexual abuse or victimization involving the type of intervention; and(9) Clinical justification for the intervention.(b) For emergency medication, the written order must also include instructions on how to administer the medication.(c) For mechanical restraint, the written order must also include the specific device or devices authorized. Source Note: The provisions of this §748.2505 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2505 What information must a written order include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208619 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208619&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208619 03/12/2026 (a) PRN orders for certain emergency behavior interventions are permitted under the following conditions:Attached Graphic(b) If you obtain a PRN order, you must provide the parent with a copy of the PRN order within 72 hours. Source Note: The provisions of this §748.2507 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2507 Under what conditions are PRN orders permitted for a specific child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189263 03/12/2026 (a) The use of emergency behavior intervention must be an appropriate response to the behavior demonstrated, and de-escalation must have failed.(b) The caregiver must act to protect the child's safety and consider:(1) The characteristics of the immediate physical environment;(2) The permitted types of emergency behavior intervention; and(3) The potential risk of harm in using emergency behavior intervention versus the risk of not using emergency behavior intervention.(c) The caregiver must:(1) Initiate an emergency behavior intervention in a way that minimizes the risk of physical discomfort, harm, or pain to the child; and(2) Use the minimal amount of reasonable and necessary physical force to implement the intervention.(d) The caregiver must make every effort to protect the child's:(1) Privacy, including shielding the child from onlookers; and(2) Personal dignity and well-being, including ensuring that the child's body is appropriately covered.(e) As soon as possible after starting any type of emergency behavior intervention, the caregiver must:(1) Explain to the child the behaviors the child must exhibit to be released or have the intervention reduced, if applicable; and(2) Permit the child to suggest actions the caregivers can take to help the child de-escalate.(f) If the child does not appear to understand what the child must do to be released from the emergency behavior intervention, the caregiver must attempt to re-explain it every 15 minutes until the child understands or is released from the intervention. Source Note: The provisions of this §748.2551 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2551 What responsibilities does a caregiver have when implementing a type of emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208620 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208620&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208620 03/12/2026 A child must be released as follows:Attached Graphic Source Note: The provisions of this §748.2553 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TxReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2553 When must a caregiver release a child from an emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189265 03/12/2026 (a) During any personal restraint, a caregiver qualified in emergency behavior intervention must:(1) Monitor the:(A) Personal restraint to make sure it is being performed appropriately; and(B) Child's breathing and other signs of physical distress; and(2) Take appropriate action to ensure adequate respiration, circulation, and overall well-being.(b) If available, a caregiver who is not restraining the child should monitor the child. However, general residential operations with a capacity of more than 16 children must monitor prone and supine restraints as required in §748.2605(b) of this title (relating to What personal restraint techniques are prohibited?). Source Note: The provisions of this §748.2601 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2601 Who must monitor a personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189266 03/12/2026 Appropriate action includes responding prudently to a potentially life-threatening situation, for example, releasing a child when a child is unresponsive or indicates the child cannot breathe and immediately seeking medical assistance from a health-care professional. Source Note: The provisions of this §748.2603 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2603 What is the appropriate action for a caregiver to take to ensure the child's adequate respiration, circulation, and overall well-being? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189267 03/12/2026 (a) The following personal restraint techniques are prohibited:(1) Restraints that impair the child's breathing by putting pressure on the child's torso, including restraints that obstruct the child's lungs from expanding such as leaning a child forward during a seated restraint;(2) Restraints that obstruct the child's airway, including procedures that place anything in, on, or over the child's mouth, nose, or neck;(3) Restraints that obstruct a caregiver's ability to view the child's face;(4) Restraints that interfere with the child's ability to communicate or vocalize distress; or(5) Restraints that twist or place the child's limb(s) behind the child's back.(b) Prone and supine restraints are prohibited except:(1) As a transitional hold that lasts no longer than one minute;(2) As a last resort when other less restrictive interventions have proven to be ineffective; and(3) When an observer meeting the following qualifications ensures the child's breathing is not impaired:(A) Trained to identify risks associated with positional, compression, or restraint asphyxia;(B) Trained to identify risks associated with prone and supine holds; and(C) Not involved in the restraint. General residential operations and residential treatment centers with a capacity of 16 or fewer children are exempt from meeting this requirement. Source Note: The provisions of this §748.2605 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2605 What personal restraint techniques are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208621 03/12/2026 (a) Caregivers must continuously observe the child placed in seclusion. This observation can take place by a caregiver in the environment or room where the child is placed in seclusion, through a window or a one-way mirror. The use of a video camera in lieu of direct observation to continuously observe a child in seclusion is not permitted.(b) There must be a protected, private, and observable environment or room that safeguards the child's personal dignity and well-being that must:(1) Have 40 square-feet of floor space and a ceiling height of at least eight feet;(2) Be free of safety hazards;(3) Be adequately ventilated during warm weather and adequately heated during cold weather;(4) Be appropriately lighted; and(5) Have a mat and bedding, unless the prescribing professional writes orders to the contrary. Source Note: The provisions of this §748.2651 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2651 What are the additional responsibilities for implementing seclusion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189269 03/12/2026 (a) If a caregiver cannot obtain a written order to remove the mat or bedding, the caregiver must obtain and document a licensed psychiatrist's, psychologist's, or physician's verbal order with the rationale for the removal no later than one hour following the intervention.(b) The verbal order must include an evaluation by the psychiatrist, psychologist, or physician assessing whether seclusion is the most appropriate intervention for the child given the situation.(c) The professional who provides the verbal order must provide a written version of the order within 72 hours of issuing the order. The written copy must include the time, date, and the professional's signature. Source Note: The provisions of this §748.2653 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2653 What must occur for a caregiver to remove the mat or bedding without a written order? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189270 03/12/2026 (a) Only commercially available devices specifically designed for the safe and comfortable restraint of humans may be used as mechanical restraints.(b) Mechanical restraint devices must be inspected after each use to ensure that they are in good repair and are free from tears or protrusions that may cause injury. Damaged devices may not be used to restrain a child.(c) There must be a protected, private, and observable environment or room that safeguards the child's personal dignity and well-being.(d) Caregivers must continuously observe the child placed in mechanical restraint ensuring the child has adequate respiration, circulation, and overall well-being. This observation can take place through a window or a one-way mirror. The use of a video camera to continuously observe a child in mechanical restraint is not permitted. In addition to continual observation, a caregiver must check for circulation, skin color, and respiration at least every 15 minutes.(e) You must notify a child's parent that mechanical restraint was used on the child within 72 hours after the restraint is concluded. Source Note: The provisions of this §748.2701 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2701 What are the additional responsibilities for implementing a mechanical restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189271 03/12/2026 Yes; however, any alteration of commercially available mechanical restraint devices must be reviewed and approved by a licensed psychiatrist who must:(1) Base his approval on the individual child's special physical needs; and(2) Take into consideration any potential medical contraindications, including psychiatric contraindications, such as the child's history of sexual abuse or previous use of mechanical restraints. Source Note: The provisions of this §748.2703 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2703 May my residential treatment center use altered mechanical restraint devices when restraining a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189272 03/12/2026 The following must not be used as restraint devices:(1) Devices with metal wrist or ankle cuffs, such as handcuffs or shackles;(2) Devices with rubber bands, rope, or cord;(3) Devices with padlocks, key locks, or fastening devices;(4) Long ties, such as leashes;(5) Bed sheets or blankets; and(6) Veil beds. Source Note: The provisions of this §748.2705 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2705 What mechanical and other restraint devices are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189273 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189273 03/12/2026 (a) A caregiver may successively use emergency behavior interventions on a child only if:(1) Allowed by your policies;(2) Permitted by rules of this subchapter for both types of emergency behavior intervention; and(3) The following written orders are met:(A) If the successive intervention is seclusion immediately following a personal restraint or mechanical restraint: the written order for the seclusion meets the requirements in Division 3 of this subchapter (relating to Orders) and provides clinical justification for the use of the seclusion successive to a personal restraint or a mechanical restraint;(B) If the successive intervention is a mechanical restraint immediately following a personal restraint or seclusion: the written order for the mechanical restraint meets the requirements in Division 3 of this subchapter and permits and provides clinical justification for the use of the mechanical restraint successive to a personal restraint or a seclusion; and(C) If the successive intervention is a personal restraint immediately following a seclusion or a mechanical restraint: The professional ordering the seclusion or mechanical restraint must approve of and provide clinical justification for the successive use of the personal restraint in a written order.(b) If the successive intervention is personal restraint immediately following another personal restraint, the time spent in the personal restraints is cumulative and may not exceed the maximum length of time permitted.(c) A caregiver must allow the child:(1) Bathroom privileges as needed and at least once every two hours;(2) An opportunity to drink water at least once every two hours;(3) Regularly prescribed medications unless otherwise ordered by the licensed physician;(4) Regularly scheduled meals and snacks served in a safe and appropriate manner; and(5) An environment that is adequately ventilated during warm weather, adequately heated during cold weather, appropriately lighted, and free of safety hazards. Source Note: The provisions of this §748.2751 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2751 May a caregiver successively use emergency behavior interventions on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189274 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189274 03/12/2026 (a) A caregiver may simultaneously use emergency medication in combination with personal restraint or seclusion only if:(1) Allowed by your policies;(2) Permitted by the rules of this subchapter for both types of emergency behavior intervention; and(3) Written orders specifically allow the combination.(b) The written orders must include clinical justification for the combination of emergency medication with personal restraint or seclusion that goes beyond the justification for the use of a single emergency behavior intervention. Clinical justification for the combination must be provided by:(1) The licensed physician ordering the emergency medication for the combination of emergency medication and seclusion; or(2) Both the licensed physician ordering the emergency medication and the professional ordering the personal restraint, if they are different people. Source Note: The provisions of this §748.2753 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2753 May a caregiver simultaneously use emergency medication in combination with another emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189275 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189275 03/12/2026 (a) A caregiver may simultaneously implement mechanical restraint in combination with emergency medication only if:(1) Allowed by your policies;(2) Permitted by the rules of this subchapter for both types of emergency behavior intervention; and(3) Written orders specifically allow the combination.(b) The written orders must include clinical justification for the combination of mechanical restraint with emergency medication that goes beyond the justification for the use of a single emergency behavior intervention. Clinical justification for the combination of mechanical restraint and emergency medication must be coordinated and provided by the licensed psychiatrist ordering the mechanical restraint and the licensed physician ordering the emergency medication, if they are different people. Source Note: The provisions of this §748.2755 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2755 May a caregiver simultaneously implement mechanical restraint in combination with emergency medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189276 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189276 03/12/2026 No, mechanical restraint and seclusion may not be simultaneously implemented. Source Note: The provisions of this §748.2757 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2757 May a caregiver simultaneously implement mechanical restraint in combination with seclusion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208622 03/12/2026 The maximum length of time that certain emergency behavior interventions can be administered to a child is as follows:Attached Graphic Source Note: The provisions of this §748.2801 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2801 What is the maximum length of time that an emergency behavior intervention can be administered to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189278 03/12/2026 If a child is released from seclusion or a mechanical restraint and then secluded or mechanically restrained again within the same 12-hour period, the time spent in seclusion or mechanical restraint is cumulative and may not exceed the maximum length of time permitted. Source Note: The provisions of this §748.2803 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2803 How long may a caregiver seclude or mechanically restrain a child who has been released within the same 12-hour time period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189279 03/12/2026 A caregiver may exceed the maximum length of time for certain emergency behavior interventions as follows:Attached Graphic Source Note: The provisions of this §748.2805 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2805 Can a caregiver exceed the maximum length of time that an emergency behavior intervention can be administered to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189280 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189280 03/12/2026 (a) Yes, if:(1) The caregiver does a face-to-face evaluation of the child;(2) Verbal authorization is obtained before the end of the maximum length of time;(3) The caregiver documents the verbal continuation orders; and(4) The professional who provides the verbal order provides a written version of the order within 72 hours of issuing the order. The written copy must include the time, date, and the professional's signature.(b) If the seclusion and mechanical restraint continues beyond the maximum length of time, then the caregiver must allow the child:(1) Bathroom privileges as needed and at least once every two hours;(2) An opportunity to drink water at least once every two hours;(3) Regularly prescribed medications, unless otherwise ordered by the licensed physician;(4) Regularly scheduled meals and snacks served in a safe and appropriate manner; and(5) An environment that is adequately ventilated during warm weather, adequately heated during cold weather, appropriately lighted, and free of safety hazards.(c) If the mechanical restraint continues beyond the maximum length of time, then the caregiver must also allow the child an opportunity for range-of-motion exercises for at least five minutes of each hour a child is in restraint.(d) In no event may the order permit the seclusion or mechanical restraint to exceed four hours. Source Note: The provisions of this §748.2807 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2807 May continuation orders be obtained verbally to exceed the maximum length of time that seclusion or mechanical restraint can be administered to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189281 03/12/2026 (a) The caregivers must take appropriate actions to help the child return to routine activities. The follow-up actions of the caregivers must include:(1) Providing the child with an appropriate transition and offering the child an opportunity to return to regular activities;(2) Observing the child for at least 15 minutes; and(3) Providing the child with an opportunity to discuss the situation that led to the need for emergency behavior intervention and the caregiver's reaction to that situation. The discussion must be held in private as soon as possible and no later than 48 hours after the child's use of an emergency medication or release from any emergency behavior intervention.(b) Caregivers involved in the emergency behavior intervention must conduct a post-emergency behavior intervention discussion with the child. The goal of the discussion is to allow the child and caregiver to discuss:(1) The child's behavior and the circumstances that constituted the need for an emergency behavior intervention;(2) The strategies attempted before the use of the emergency behavior intervention and the child's reaction to those strategies;(3) The emergency behavior intervention itself and the child's reaction to the emergency behavior intervention;(4) How caregivers can assist the child in regaining self-control in the future to avoid the administration of an emergency behavior intervention; and(5) What the child can do to regain self-control in the future to avoid the administration of an emergency behavior intervention.(c) Caregivers involved in the emergency behavior intervention must:(1) Debrief with each other concerning the incident as soon as possible after the situation has stabilized; and(2) Make reasonable efforts to debrief with children in care who witness the incident.(d) The supervisor(s) of the caregivers involved in the emergency behavior intervention must review the use of the emergency behavior intervention within 72 hours of the intervention.(e) The caregivers do not have to return the child to previous activities or place the child in current activities that the group is participating in if the caregivers deem the child's participation is not in the best interests of the child or the other children in the group. However, caregivers must engage the child in an alternative routine activity.(f) This rule does not apply to the following types of emergency behavior intervention:(1) Short personal restraint; and(2) Seclusion, if the child is receiving emergency care services. Source Note: The provisions of this §748.2851 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2851 What follow-up actions must caregivers take after the child's behavior no longer constitutes an emergency situation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189282 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189282&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189282 03/12/2026 The caregiver must document the following after discussing with the child the use of the emergency behavior intervention:(1) The date and time the caregiver offered the discussion;(2) The child's reaction to the opportunity for discussion;(3) The date and time the discussion took place, if applicable; and(4) The content of the discussion, if applicable. Source Note: The provisions of this §748.2853 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2853 What must the caregiver document after discussing with the child the use of the emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189283 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189283&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189283 03/12/2026 (a) As soon as possible, but no later than 24 hours after the initiation of the emergency behavior intervention, the caregiver involved in the intervention must document in the child's record the following information:(1) The child's name;(2) A description and assessment of the circumstances and specific behaviors that caused the basis for the emergency behavior intervention;(3) The de-escalation attempted before and during the use of the emergency behavior intervention and the child's reaction to those strategies;(4) The specific emergency behavior intervention administered;(5) The date and time the intervention was administered;(6) The length of time the child was restrained or secluded;(7) The name of the caregiver(s) that participated in the incident that led to the intervention, and who administered the intervention;(8) The name of the person(s) who observed the child;(9) The names of any witnesses to the emergency behavior intervention, including any child in care who witnessed the intervention;(10) All attempts to explain to the child what behaviors were necessary for release from the intervention;(11) The child's condition following the use of the medication or release from the intervention, including any injury the child sustained as a result of the intervention or any adverse effects caused by the use of the intervention. If the child received medical assistance or treatment, the caregiver must document the name of the person(s) who provided medical assistance or treatment; and(12) The actions the caregiver(s) took to facilitate the child's return to normal activities following the end of the intervention.(b) Supervisors of caregivers involved in emergency behavior intervention of a child must document their review of the use of the intervention within 72 hours of the incident.(c) If personal restraint is used, documentation must also include the specific restraint techniques used, including a prone or supine restraint used as a transitional hold.(d) If emergency medication is used, documentation must also include the specific medication used and the dosage administered to the child.(e) If mechanical restraint is used, documentation must also include:(1) The specific restraint device used; and(2) Continuous observation and regular respiration and circulation checks and times the checks were conducted.(f) This rule does not apply to short personal restraints. Source Note: The provisions of this §748.2855 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2855 When must a caregiver document the use of an emergency behavior intervention, and what must the documentation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208623 03/12/2026 (a) As soon as possible, but no later than 72 hours after the initiation of the intervention, you must provide written notice to the parent that includes:(1) The child's name;(2) The specific emergency behavior intervention administered;(3) The length of time the child was restrained;(4) The child's condition following the use of the medication or release from the intervention, including:(A) Any injury the child sustained as a result of the intervention or any adverse effects caused by using the intervention; and(B) If the child received medical assistance or treatment, the name of each person who provided the medical assistance or treatment;(5) If a personal restraint was used, the specific restraint techniques used, including if a prone or supine restraint used as a transitional hold; and(6) If emergency medication was used, the specific medication used, and the dosage administered to the child.(b) A copy of the documentation provided to the parent must be maintained in the child's record.(c) This rule does not apply to short personal restraints. Source Note: The provisions of this §748.2857 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2857 What notice must I provide to the parent when I use an emergency behavior intervention with a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189284 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189284&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189284 03/12/2026 (a) The following circumstances trigger a review for certain emergency behavior interventions: Attached Graphic(b) You may exceed the number of restraints otherwise allowed in (2) Personal restraint of Figure: 40 TAC §748.2901(a) for a child if a licensed psychiatrist or psychologist issues a written order or if a service planning team makes a recommendation allowing you to do so and you ensure the following: (1) If applicable, the recommendation from the service planning team includes the same written information as an order, as specified in §748.2505 of this title (relating to What information must a written order include?); and (2) At least one triggered review is conducted in accordance with §748.2907 of this title (relating to What must the triggered review include and what must be documented in the child's record?) every 30 days that personal restraints in excess of the threshold are authorized. Source Note: The provisions of this §748.2901 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2901 What circumstances trigger a review of the use of emergency behavior intervention for a specific child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189285 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189285&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189285 03/12/2026 (a) A triggered review must occur as soon as possible, but no later than 30 days after the review is triggered.(b) The regularly scheduled review of the child's service plan can serve as the triggered review if it meets the requirements in §748.2907 of this title (relating to What must the triggered review include and what must be documented in the child's record?) and takes place no later than 30 days after the review is triggered. Source Note: The provisions of this §748.2903 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2903 When must a triggered review occur? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189286 03/12/2026 (a) A full service planning team must participate in the triggered review. You must invite the child, as appropriate, and the parents to the review, so they may have the opportunity to participate and provide input into the content of the review. However, you are not required to delay a review because a parent or child is unable to participate in the review at its scheduled time.(b) Even if the child is not receiving treatment services, the two additional professions required in §748.1339(b) of this title (relating to Who must be involved in developing an initial service plan?) must be involved in the triggered review. Source Note: The provisions of this §748.2905 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2905 Who must participate in the triggered review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189290 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189290 03/12/2026 (a) Except in cases in which the regularly scheduled review of the child's service plan also addresses the requirements of a triggered review in accordance with §748.2903(b) of this title (relating to When must a triggered review occur?), a triggered review is not a full review of the child's service plan and is focused on the requirements identified in subsection (c) of this section.(b) Other than the requirements in this section and in §748.2905 of this title (relating to Who must participate in the triggered review?), the notification, participation, implementation, and documentation requirements in Division 4 of Subchapter I (relating to Admission, Service Planning, And Discharge) do not otherwise apply to a triggered review.(c) The following must be included in a triggered review and documented in the child's record:(1) A review of the records and orders of the emergency behavior interventions;(2) A review and documentation of any potential medical or psychiatric reason for not using emergency behavior interventions on the child, including the prescribing professional's consideration of any potential medical and/or psychiatric contraindications for the specific child, such as a history of physical or sexual abuse or victimization involving the type of intervention;(3) An examination of identified behaviors and patterns, any significant events leading up to the use of emergency behavior intervention, and all attempted de-escalation methods, whether successful or unsuccessful;(4) Identification of alternatives to manage the child's behavior and more effectively prevent the use of emergency behavior intervention in the future; and(5) A written plan for reducing the need for emergency behavior intervention. Source Note: The provisions of this §748.2907 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective February 7, 2017, 42 TexReg 488; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2907 What must the triggered review include and what must be documented in the child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189287 03/12/2026 If there are four triggered reviews within a 90-day period:(1) A licensed psychiatrist, psychologist, clinical social worker, professional counselor, or marriage and family therapist must examine the child; and(2) The licensed professional must make service plan recommendations regarding the use of emergency behavior interventions. You must document these recommendations in the child's record. Source Note: The provisions of this §748.2909 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2909 What if there are four triggered reviews within a 90-day period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189288 03/12/2026 (a) The overall operation evaluation is an annual review regarding:(1) The use and effectiveness of emergency behavior interventions at your operation; and(2) Your emergency behavior intervention policies and procedures, including the training policy and curriculum.(b) The objectives of the evaluation are to:(1) Develop and maintain an environment or milieu that supports positive and constructive behaviors of children in care;(2) Use any type of emergency behavior intervention safely, appropriately, and effectively; and(3) Eliminate or reduce physical injuries and any other negative side effects on the child's behavior or emotional development resulting from the emergency behavior interventions.(c) One focus of the evaluation must be on:(1) The frequency, patterns, and effectiveness of the types of emergency behavior intervention techniques that are used for all children in your operation;(2) Strategies to reduce the need for emergency behavior interventions for all children in your operation; and(3) Specific strategies to reduce the need for use of specific types of emergency behavior intervention techniques for all children in your operation.(d) The results of each overall operation evaluation must be made available to us for review. Source Note: The provisions of this §748.2951 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2951 What is an overall operation evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208624 03/12/2026 (a) Quarterly, you must collect, document, and review aggregate numbers of emergency behavior interventions by type of intervention, with the exception of short personal restraints.(b) This information must be reported to us no later than 15 days after the end of each quarter.(c) You must maintain the data for five years. Source Note: The provisions of this §748.2953 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS N EMERGENCY BEHAVIOR INTERVENTION §748.2953 What data must be collected? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189291 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189291 03/12/2026 (a) A local sanitation official must conduct a sanitation inspection of your operation:(1) Before we issue you an initial permit; and(2) At least once every 12 months from the date of the last sanitation inspection.(b) Each inspection must meet regulations set by the local health department ordinances.(c) If an inspection is not available from a local sanitation official, you must:(1) Obtain documentation from a state or local sanitation official or a county judge stating that an inspection is not available; and(2) Maintain this documentation at the operation and make it available to us upon request. Source Note: The provisions of this §748.3001 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective June 1, 2014, 39 TexReg 3727; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3001 When must I have an annual sanitation inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189292 03/12/2026 You must keep the most recent sanitation inspection report, letter, or checklist at your operation to verify the inspection date and findings. The report must include the name and telephone number of the inspector. Source Note: The provisions of this §748.3003 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3003 How must I document that a sanitation inspection has been completed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189293 03/12/2026 You must correct deficiencies and comply with corrections, restrictions, or conditions that the inspector specifies in the sanitation report, letter, or checklist. Source Note: The provisions of this §748.3005 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3005 Must I make all corrections specified in the sanitation inspection report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189294 03/12/2026 You must sanitize any item or surface that comes into contact with bodily fluids and has the possibility for cross contamination. Source Note: The provisions of this §748.3007 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3007 What must I sanitize? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189295 03/12/2026 Items may be sanitized by:(1) Completing the four-step process outlined in the definition in §748.43(41) of this title (relating to What do certain words and terms mean in this chapter?);(2) Washing the items for five or more minutes in a dishwasher or washing machine that uses hot water of a temperature of at least 160 degrees Fahrenheit;(3) Washing in a three-compartment sink or three containers. The sinks and/or containers must be large enough to completely immerse the items for soaking, rinsing, and disinfecting; or(4) Following the requirements of any alternative methods that have been approved by the Department of State Health Services for your operation. Source Note: The provisions of this §748.3009 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3009 How should items be sanitized? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189296 03/12/2026 All sinks that you use for food service or food preparation must be supplied with hot and cold running water under pressure. Source Note: The provisions of this §748.3013 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3013 What are the parameters for sinks used for food service or food preparation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189297 03/12/2026 Caregivers must follow universal precautions outlined by the Centers for Disease Control (CDC) when handling blood, vomit, or other bodily fluids that may contain blood, including:(1) Using disposable, nonporous gloves;(2) Placing gloves contaminated with blood in a tied, sealed, or otherwise closed plastic bag and discarding them immediately;(3) Discarding all other gloves in a sanitary manner immediately after one use;(4) Washing hands with soap and running water after using and disposing of the gloves;(5) Disposing the bodily fluids in accordance with local regulations. Where local disposal regulations do not exist, the Department of State Health Services must be consulted regarding the appropriate disposal procedures and their recommendations must be followed; and(6) Disposing disposable syringes, needles, and other sharp items used by persons for injections or for medical or other procedures in a hard plastic, leak and puncture-resistant container immediately after use, and keep them inaccessible to children. Source Note: The provisions of this §748.3015 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3015 How must caregivers handle bodily fluids that require universal precautions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189301 03/12/2026 (a) Yes; if:(1) You have documentation at your operation showing dogs and cats have been vaccinated for rabies as required by Texas Health and Safety Code, Chapter 826; and(2) All animals on the premises, including pets and livestock, are treated according to a licensed veterinarian's recommendations to protect the health and safety of children. If you choose to have animals on the premises, you must ensure that the animals do not create health problems or a health risk for children.(b) For therapeutic camp services, you must house horses and other animals that you maintain at a camp at a reasonable distance from any sleeping, living, eating, or food preparation area. Source Note: The provisions of this §748.3017 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3017 Are animals allowed at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189298 03/12/2026 (a) You may treat your operation for pests only if the Structural Pest Control Board or Texas Department of Agriculture has certified you as a noncommercial applicator.(b) Otherwise, you must use a pest control operator licensed by the Texas Structural Pest Control Board or Texas Department of Agriculture to prevent, control, or eliminate pest infestations at your operation.(c) For therapeutic camp services, you must maintain a vector control program to ensure effective control of all insects and rodents in the buildings and on the premises of your permanent camp. If chemical control is needed, then you must comply with subsections (a) and (b) of this section. Source Note: The provisions of this §748.3019 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective March 1, 2008, 33 TexReg 1376; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3019 Must I use a licensed exterminator to treat my operation for insects, rodents, and other pests? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189299 03/12/2026 Dangerous tools and equipment, such as hatchets, saws, and axes must be stored, so they are inaccessible to children. Children may use these tools and equipment with caregiver supervision, as appropriate based on the child's age, maturity, and treatment issues. Source Note: The provisions of this §748.3021 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3021 How must I protect children from dangerous tools and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189300 03/12/2026 Your operation must be inspected for gas leaks:(1) Before we issue your initial permit; and(2) At least once every 24 months from the date of the last inspection for gas leaks. Source Note: The provisions of this §748.3061 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3061 When must my operation be inspected for gas leaks? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189302 03/12/2026 (a) If your operation uses natural gas, a licensed plumber or a gas company official must conduct the gas leak inspection.(b) If your operation uses liquefied propane (LP) gas, you must have your LP-gas system inspected for proper installation and leaks by:(1) A licensed LP-gas servicing company; or(2) A licensed plumber who is also licensed with the LP-gas section of the Texas Railroad Commission. Source Note: The provisions of this §748.3063 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3063 Who must conduct a gas leak inspection at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189303 03/12/2026 (a) A written gas inspection report must show your gas system is free of leaks and must indicate the date of the inspection, as well as the name and telephone number of the inspector.(b) You must keep the most recent inspection report at your operation to verify the inspection date and findings.(c) You must comply with all corrections, conditions, or restrictions specified in the gas inspection report within the timeframes specified by the inspector. Source Note: The provisions of this §748.3065 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3065 What documentation must I maintain regarding gas leak inspections? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189304 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189304&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189304 03/12/2026 You must have a fire inspection:(1) Before we issue your initial permit; and(2) At least once every 12 months from the date of the last fire inspection. Source Note: The provisions of this §748.3101 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3101 When must I have a fire inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189309 03/12/2026 (a) A state or local fire inspector must conduct the inspection.(b) If an inspector cannot conduct an inspection, you must provide documentation of this from a state or local fire inspector or county judge. Source Note: The provisions of this §748.3103 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3103 Who must conduct a fire inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189310 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189310&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189310 03/12/2026 (a) You must keep the most recent fire-inspection report, letter, or checklist at the operation to verify the inspection date and findings. The report must include the inspector's name and telephone number.(b) You must comply with the local code and all corrections, restrictions, or conditions specified by the inspector in the fire-inspection report, letter, or checklist. Source Note: The provisions of this §748.3105 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3105 What documentation must I maintain regarding a fire inspection? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189305 03/12/2026 (a) Your operation must have an operable smoke-detection system that is audible throughout the building. This may be:(1) An electronic fire alarm and smoke-detection system; or(2) Individual electric or battery-operated smoke detectors located according to the state or local fire inspector's recommendations. If no fire inspector is available or able to give recommendations, smoke detectors must be located in the following areas:(A) In hallways or open areas outside sleeping rooms; and(B) On each level of a building with multiple levels.(b) Depending on the size and layout of the operation, additional smoke detectors may be required based on manufacturer's or fire inspector's instructions.(c) New operations granted a permit by us on or after January 1, 2007, must have smoke detectors that get their power from building wiring from a commercial source. Wiring must be permanent. Smoke detectors must:(1) Be equipped with a battery back-up; and(2) Emit a signal when the batteries are low. Source Note: The provisions of this §748.3107 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3107 What type of smoke-detection system must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189306 03/12/2026 (a) Smoke detectors must be installed and maintained according to the manufacturer's instructions or in compliance with the state or local fire inspector's instructions.(b) Batteries must be changed annually or sooner, as required to maintain operable smoke detector units. Source Note: The provisions of this §748.3109 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3109 How must smoke detectors be installed at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189307 03/12/2026 (a) The administrator or designee must test all battery-operated smoke detectors monthly by pressing the test button or switch on the unit. The date of the test and the name of the employee who does the testing must be documented and kept at the operation for review.(b) A company licensed by the State Fire Marshal, or the state or local fire inspector, must test an electronic smoke alarm system at least annually. You must keep documentation of the inspection at the operation for review. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §748.3111 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3111 How often must the smoke detectors at my operation be tested? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189308 03/12/2026 (a) Your operation must have a fire-extinguishing system, which may be a sprinkler system and/or fire extinguishers.(b) The state or local fire inspector must approve the sprinkler system and/or fire extinguishers in your operation. If an inspector cannot conduct an inspection, you must have at least one fire extinguisher in the operation rated not less than 3A:40BC.(c) Any fire extinguisher that has been used or has lost operating pressure must be serviced or replaced immediately with an equivalent unit. Source Note: The provisions of this §748.3113 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3113 Must my operation have a fire-extinguishing system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189311 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189311&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189311 03/12/2026 You must inspect the fire extinguisher(s) monthly and ensure:(1) There will be no interference with access to the extinguisher in an emergency, for example, there are no objects blocking access;(2) Fire extinguishers are accessible for immediate use by employees, caregivers, and volunteers; and(3) Fire extinguishers are serviced as required by manufacturer's instructions, or as required by the state or local fire inspector. Source Note: The provisions of this §748.3115 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3115 How often must I inspect and service the fire extinguisher(s)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189312 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189312&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189312 03/12/2026 (a) A company licensed by the State Fire Marshal must inspect each fire extinguisher at least annually and conduct any required service or testing. Newly purchased fire extinguishers do not require inspection during the first 12 months of service unless indicated by the monthly inspection.(b) You must keep documentation of the inspection and/or the purchase of new fire extinguishers at the operation for review. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §748.3117 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3117 How often must the state or local fire inspector inspect fire extinguisher(s)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189313 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189313&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189313 03/12/2026 (a) If your operation has a fire sprinkler system, a company licensed by the State Fire Marshal must inspect the fire sprinkler system at least annually and conduct any required service or testing.(b) You must keep the most recent inspection report at the operation for review. The documentation must indicate the date of the inspection and the inspector's name and telephone number. Source Note: The provisions of this §748.3119 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3119 How often must a fire sprinkler system be inspected? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189314 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189314&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189314 03/12/2026 (a) Gas appliances must be safe and in good repair.(b) Space heaters must be enclosed and have a screen or guard.(c) You must ensure that children do not have access to floor and wall furnace grates, steam and hot water pipes, and electric space heaters.(d) If you use a fireplace or wood-burning stove, it must be kept clean and have a screen or guard.(e) You may not use a stove to heat any part of the operation, including portable camp stoves.(f) You may not use open flame or liquid fuel heaters. Source Note: The provisions of this §748.3161 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3161 What steps must I take to ensure that heating devices do not present hazards to children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189315 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189315&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189315 03/12/2026 You must have an operable carbon monoxide detector-system if your operation has gas appliances. This may be:(1) An electronic carbon monoxide detector-system; or(2) Individual electric or battery-operated carbon monoxide detectors. Source Note: The provisions of this §748.3191 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3191 Must I have a carbon monoxide detector-system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189316 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189316&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189316 03/12/2026 (a) You must install carbon monoxide detectors that meet Underwriters Laboratories Inc. requirements (UL-Listed).(1) You must install carbon monoxide detectors according to manufacturer's specifications for proper location and installation; and(2) Furniture, draperies, or other items must not cover up detectors.(b) If you use an electronic carbon monoxide detection-system connected to an alarm/smoke detection system, the system must be installed according to the state or local fire inspector's requirements. Source Note: The provisions of this §748.3193 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3193 How must carbon monoxide detectors be installed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189317 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189317&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189317 03/12/2026 You must maintain electric or battery-operated carbon monoxide detectors in compliance with the manufacturer's instructions. Source Note: The provisions of this §748.3195 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3195 How must I maintain carbon monoxide detectors? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189321 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189321&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189321 03/12/2026 (a) An emergency evacuation and relocation plan is a plan designed to ensure the safety of children during a fire, severe weather conditions, or another type of emergency requiring evacuation or relocation of children in care.(b) In an emergency, your first responsibility is to move all the children to a designated safe area known to all employees, caregivers, and volunteers. Your plan must also require the person in charge of your operation during the emergency to:(1) Designate an employee to call the fire department in case of fire or danger of fire, explosion, toxic fumes, or other chemical release. If the danger requires immediate evacuation of the operation, this person must first evacuate the operation and then make the necessary call from another location;(2) Designate an employee responsible for securing children's emergency numbers, emergency medical authorizations, and medications during the emergency;(3) Once the person in charge is at the designated safe area, account for all children who were in attendance at the time of the emergency; and(4) Ensure that no one uses elevators during a fire. Source Note: The provisions of this §748.3231 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3231 What is an emergency evacuation and relocation plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189322 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189322&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189322 03/12/2026 (a) You must have a written emergency evacuation and relocation diagram specifying directions for egress on file at your operation.(b) The emergency evacuation and relocation diagram must show the following:(1) A floor plan of your operation;(2) The designated location outside of the operation where all caregivers and children meet to ensure everyone has exited the operation safely;(3) The designated location inside the operation where all caregivers and children take shelter from threatening weather; and(4) At least two exit routes that:(A) Are located in distant parts of the building and lead to the outside;(B) Are not blocked in any way, including with furniture or equipment;(C) Are not through a kitchen or other hazardous area, unless specifically approved in writing by the state or local fire inspector. The written approval must be signed and dated by the state or local fire inspector and maintained at your operation for our review;(D) Are not a window, unless children and caregivers are physically able to exit through the window to the ground outside safely and quickly;(E) Are not doors or windows that are locked and require a key to open from the inside, unless specifically approved in writing by the state or local fire inspector. The written approval must be signed and dated by the state or local fire inspector and maintained at your operation for our review;(F) Do not lead into a pool area; and(G) If above the ground level, are served by standard stairs and do not require ladders, folding stairs, or trap doors to gain access to the ground floor. Source Note: The provisions of this §748.3233 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3233 Must I have an emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189318 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189318&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189318 03/12/2026 You must post the emergency evacuation and relocation diagram in a prominent and visible location in all buildings used by an employee, volunteer, or child. Source Note: The provisions of this §748.3235 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3235 Where must I post the emergency evacuation and relocation diagram? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189319 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189319&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189319 03/12/2026 (a) Closet door latches must allow children to open the door from the inside of the closet.(b) In case of electrical failure, you must have an operable source of emergency lighting that is approved by the state or local fire inspector, or operable battery-powered lighting.(c) Children must be able to open emergency exit doors easily from the inside, unless specifically approved in writing by the state or local fire inspector. The written approval must be signed and dated by the state or local fire inspector and maintained at your operation for our review. Source Note: The provisions of this §748.3237 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3237 What other safety provisions must I make? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189320 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189320&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189320 03/12/2026 (a) You must practice an unannounced fire drill at least once every six months from the date of the last fire drill. During each drill:(1) You must set off a fire alarm or smoke detector;(2) The participants must use alternate exit routes;(3) The children must be able to safely exit the building to the designated meeting place within three minutes; and(4) The participants must not use elevators.(b) You must practice a severe weather drill at least once every six months from the date of the last severe weather drill.(c) Emergency evacuation and relocation plans must be routinely practiced at different times during hours of operation.(d) You must document these drills, including the date of the drill, time of the drill, type of drill, and length of time for the evacuation or relocation to take place. Source Note: The provisions of this §748.3239 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3239 How often must I practice my emergency evacuation and relocation plans? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189324 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189324&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189324 03/12/2026 Yes. All separate living areas and buildings must have a complete first-aid kit available. A first-aid kit must also be available for all field trips. Each first-aid kit must be:(1) Clearly labeled;(2) Kept in a clean and sanitary condition;(3) In good condition and not have expired medications or supplies;(4) Easily accessible to all employees;(5) Stored in a designated location known to all employees; and(6) Kept out of the reach of children. Source Note: The provisions of this §748.3271 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3271 Must I have a first-aid kit at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208625 03/12/2026 Each first-aid kit must contain at least the following supplies:(1) A current guide to first aid and emergency care;(2) Adhesive tape;(3) Antiseptic solution or wipes;(4) Adhesive bandages;(5) Scissors;(6) Sterile gauze pads;(7) Thermometer;(8) Tweezers; and(9) Waterproof, disposable gloves. Source Note: The provisions of this §748.3273 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3273 What must each first-aid kit contain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208626 03/12/2026 A product is considered unsafe if, after it has been recalled for any reason by the United States Consumer Product Safety Commission:(1) The recall has not been rescinded; and(2) The product has not been made safe through being remanufactured or retrofitted. Source Note: The provisions of this §748.3281 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3281 When is a product considered unsafe? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208627 03/12/2026 (a) You are responsible for reviewing the United States Consumer Product Safety Commission (CPSC) recall list. You may view all current and past recalls through the CPSC's Internet website at www.cpsc.gov. You must ensure that there are no unsafe products at your operation unless one or more of the following apply:(1) The product is an antique or collectible and is not used by, or accessible, to any child; or(2) The unsafe product is being retrofitted to make it safe and the product is not used by, or accessible, to any child.(b) You are responsible for ensuring that no unsafe products are at the operation. You must post a notice for parents and employees in a prominent and publicly accessible place that includes information on how to access a listing of unsafe products through the CPSC Internet website or through the Texas Health and Human Services Internet website. Source Note: The provisions of this §748.3283 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS O SAFETY AND EMERGENCY PRACTICES §748.3283 What are my responsibilities regarding unsafe products at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208628 03/12/2026 (a) Buildings, including exterior and interior surfaces (such as walls, floors, and ceilings), must:(1) Be structurally sound and not pose a risk to the health and safety of children;(2) Be clean and in good repair; and(3) Comply with applicable building, plumbing, electrical, fire, and similar codes.(b) Paints used at the operation after January 1, 2007, must be lead-free.(c) Windows and doors must be in good repair and free of broken glass or hazards. Windows used for ventilation, including windows in doors, must be provided with properly fitted and secure screens in good repair for protection from insects when windows are open.(d) Walkways must be free of ice, snow, and obstruction.(e) Outdoor areas must be well drained.(f) The grounds of the operation must be well maintained and free of hazards.(g) The grounds of the operation must be free of accumulation of garbage and debris and maintained in a sanitary manner. All garbage must be disposed of in a sanitary manner in accordance with the Texas Commission on Environmental Quality (see 30 TAC Chapter 330, Municipal Solid Waste). Outdoor garbage cans must have lids.(h) The building must be free of rodents and insects.(i) Equipment and furniture must be safe for children and must be kept clean and in good repair. Source Note: The provisions of this §748.3301 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3301 What general physical site requirements must my operation meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189353 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189353 03/12/2026 Living quarters, recreation areas, dining areas, bathrooms, bedrooms, and kitchens must be adequately ventilated by at least one operable window or mechanical ventilation system. Source Note: The provisions of this §748.3303 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3303 What parts of my operation must be ventilated? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189354 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189354 03/12/2026 (a) Each ramp, stairway, and steps exceeding two steps must have a well-secured handrail. Stairs must have a minimum width of 36 inches.(b) Each porch or deck that has over an 18-inch drop must have a well-secured railing.(c) If a door opens directly to a stairway, the door must be a minimum of 34 inches wide. There must be a landing between the door and the stairs. The landing must be wide enough to allow the door to open and a person to safely step on to the landing while closing the door. Source Note: The provisions of this §748.3305 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3305 What are the requirements for handrails, railings, and stairway and stairwell landings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189355 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189355 03/12/2026 (a) All living quarters must be provided with electric services.(b) The following must be lighted in order to avoid accidents:(1) Habitable rooms;(2) Common use rooms, such as dining rooms, living rooms, laundry rooms, and gymnasiums;(3) Bathrooms;(4) Hallways;(5) Interior stairs;(6) Outside steps and doorways;(7) Porches;(8) Ramps; and(9) Fire escapes.(c) You may not use propane, kerosene, or other flammable fuel as a light source. Source Note: The provisions of this §748.3307 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3307 What are the requirements for lighting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189360&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189360 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189360&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189360 03/12/2026 Your operation must have:(1) An operable telephone with an outside line that is accessible to employees in emergencies. This telephone must have a listed telephone number and not be coin-operated; and(2) A communication system to allow employees to contact other employees in the operation for assistance in an emergency or as needed. Source Note: The provisions of this §748.3309 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3309 What are the requirements for a communication system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189361&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189361 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189361&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189361 03/12/2026 You must never permit a child:(1) Under 16 years old to operate a tractor; or(2) To ride as a passenger on a tractor. Source Note: The provisions of this §748.3311 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3311 What are the requirements for using a tractor? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189362&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189362 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189362&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189362 03/12/2026 You may use water from a private water system if you maintain:(1) The water supply in a safe and sanitary manner; and(2) Written records indicating the private water supply meets the requirements of the Texas Commission on Environmental Quality. Source Note: The provisions of this §748.3313 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3313 May I use water from a private water system? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189356 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189356 03/12/2026 A thermostat must control the temperature of hot water accessible to children, so the water temperature is no higher than 120 degrees Fahrenheit. Source Note: The provisions of this §748.3315 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3315 What are the requirements for running hot water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189357 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189357 03/12/2026 You may use a septic system for sewage disposal if the septic system:(1) Is sanitary; and(2) Meets the standards of the Texas Commission on Environmental Quality, including any routine inspections required by law. Source Note: The provisions of this §748.3317 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3317 May I use a septic system for sewage disposal? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211290 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211290&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211290 03/12/2026 (a) If your operation is a residential treatment center, you must post the "No Trespassing" signs required by subsections (b) and (c) of this section.(b) You may create your own "No Trespassing" signs or use the ones we provide you, but the signs must:(1) State that entry to the property is forbidden;(2) Include a description of the provisions of §30.05, Penal Code, including the penalties for violating §30.05, Penal Code;(3) Include the name and address of the person under whose authority the notice is posted, unless your operation provides trafficking victim services under Subchapter V of this chapter (relating to Additional Requirements for Operations that Provide Trafficking Victim Services);(4) Be written in English and Spanish; and(5) Be at least 8-1/2 by 11 inches in size.(c) You must post the "No Trespassing" signs in the following places:(1) Parallel to and along the exterior boundaries of the grounds;(2) For grounds not fenced, at least every 500 feet along the exterior boundaries of the grounds;(3) At each roadway or other way of access to the grounds;(4) At each entrance to the grounds; and(5) In conspicuous places reasonably likely to be viewed by intruders. Source Note: The provisions of this §748.3319 adopted to be effective December 21, 2022, 47 TexReg 8115. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3319 What "No Trespassing" signs must I post if my operation is a residential treatment center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211291 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211291&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211291 03/12/2026 Regarding the "No Trespassing" signs described in §748.3319 of this chapter (relating to What "No Trespassing" signs must I post if my operation is a residential treatment center?), you:(1) Must ensure each "No Trespassing" sign is legible and reflects under whose authority the sign is currently posted; and(2) May request new "No Trespassing" signs from us, as needed to ensure you are in compliance with the rules in this chapter. Source Note: The provisions of this §748.3321 adopted to be effective December 21, 2022, 47 TexReg 8115. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3321 What additional responsibilities do I have regarding the "No Trespassing" signs if my operation is a residential treatment center? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189358 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189358&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189358 03/12/2026 You must provide:(1) Living space, appropriate furnishings, and bathroom facilities that are safe, clean, and maintained in good repair;(2) Provisions for personal storage space in the child's bedroom for each child's clothing and belongings;(3) At least 40 square feet per child, including adult residents and children of caregivers residing at the operation, of indoor activity space, excluding bedrooms, halls, kitchens, bathrooms, and any other space not regularly available to a child;(4) Each bedroom with at least one window with outside exposure as a source of natural light, unless you were granted a permit by us prior to January 1, 2007, and your permit is still valid; and(5) Every bedroom window with curtains, blinds, shades, or other provisions for rest and privacy. Source Note: The provisions of this §748.3351 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3351 What are the requirements for general living space? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189359&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189359 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189359&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189359 03/12/2026 (a) Video cameras may be used to supervise infants and toddlers.(b) Video cameras may not be used to supervise children, other than infants and toddlers unless the:(1) Parent, or other person legally authorized to consent, consents to the use of the video camera; and(2) Child:(A) Is younger than five years old;(B) Has primary medical needs; or(C) Requires heightened supervision, such as a child who sleepwalks, experiences night terrors, engages in physically aggressive or sexual behavior problems, or resides in a bedroom with such a child. You must document the justification for the video camera in each child's service plan, and each child must have other accessible and reasonable locations where the child may change clothing in private.(c) Video cameras may not be used to tape the child, and images may not be accessible except to operation employees and caregivers. Source Note: The provisions of this §748.3353 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3353 May I use a video camera to supervise a child in the child's bedroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189363 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189363&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189363 03/12/2026 (a) Audio monitoring devices may be used to supervise infants and toddlers.(b) Audio monitoring devices may not be used to supervise other children, except infants and toddlers, unless the:(1) Parent, or other person legally authorized to consent, consents to the use of the audio monitoring device; and(2) Child:(A) Is younger than five years old;(B) Has primary medical needs; or(C) Requires heightened supervision, such as a child who sleepwalks, experiences night terrors, engages in physically aggressive or sexual behavior problems, or resides in a bedroom with such a child. You must document the justification for the audio monitoring device in each child's service plan. Source Note: The provisions of this §748.3355 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3355 May I use an audio monitoring device to supervise a child in the child's bedroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189364 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189364&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189364 03/12/2026 (a) Floor space:(1) Is space that a child can use for daily activities;(2) Does not include closets or other alcoves; and(3) May not be averaged.(b) You must provide comfortable sleeping arrangements that meet one of the following:(1) A single occupancy bedroom with at least 80 square feet of floor space; or(2) A bedroom with at least 60 square feet of space for each occupant and no more than four occupants per bedroom are permitted even if the square footage of the room would accommodate more than four occupants. The four-occupant restriction does not apply to children receiving treatment services for primary medical needs.(c) If, we granted you a permit prior to January 1, 2007, then you are exempt from the maximum bedroom occupancy requirement until:(1) You move your operation to a new building;(2) You structurally alter the current building by adding a new room; or(3) Your permit is no longer valid.(d) If we granted you a permit to provide emergency care services to a child prior to January 1, 2007, then you are also exempt from the 60 square feet of bedroom space for each occupant until:(1) You move your operation to a new building;(2) You structurally alter the current building by adding a new room; or(3) Your permit is no longer valid. Source Note: The provisions of this §748.3357 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3357 What are the requirements for floor space in a bedroom used by a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189365 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189365&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189365 03/12/2026 You may not use the following as bedrooms:(1) Rooms commonly used for other purposes, such as dining rooms, living rooms, hallways, porches or dens, except for a child temporarily requiring close supervision or a child who is admitted to your operation during sleeping hours (for the first night only). These exceptions are permitted only if the child is provided with comfortable sleeping arrangements and if supervision of the child is not compromised;(2) Rooms that are passageways to other rooms; or(3) Basements; however, if prior to January 1, 2007, we granted you a permit, then basements may be used as bedrooms as long as other relevant requirements are met, and until:(A) You move your operation to a new building;(B) You structurally alter the current building by adding a new room; or(C) Your permit is no longer valid. Source Note: The provisions of this §748.3359 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3359 What rooms may I not use as bedrooms? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208632 03/12/2026 (a) Generally, each child should have the child's own designated bedroom or share a bedroom with other children.(b) A child may share a bedroom with an adult caregiver if:(1) It is in the best interest of the child;(2) The child is under three years old and sleeps in the bedroom of the caregiver; and(3) The service planning team dates and documents the approval in the child's service plan.(c) A child must not sleep in the same bed with an adult caregiver at any time.(d) Subsections (a) and (b) of this section do not apply to travel and camping situations. Source Note: The provisions of this §748.3361 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3361 May a child in care share a bedroom with an adult caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208633 03/12/2026 (a) A child six years old or older must not share a bedroom with a child of the opposite gender, unless:(1) They are siblings;(2) The older child is the younger child's parent; or(3) Both children are non-ambulatory and receive treatment services for primary medical needs.(b) The following must occur before you may allow children of the opposite gender to share a bedroom, unless the older child is the younger child's parent:(1) The service planning team must determine that there is no known risk of harm to either of the children after assessing:(A) Their behaviors;(B) Their compatibility with each other;(C) Their respective relationships;(D) Any history of possible sexual trauma or sexually inappropriate behavior; and(E) Any other identifiable factor that may affect the appropriateness of the children sharing a bedroom.(2) The service planning team must date and document the assessment and approval in each child's service plan. Source Note: The provisions of this §748.3363 adopted to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3363 May children of opposite genders share a bedroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189368 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189368&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189368 03/12/2026 (a) You must provide each child with an individual bed or bunk bed in the child's bedroom that elevates the mattress off of the floor. For infants and toddlers, a crib is allowable. For crib requirements, see §748.1751 of this title (relating to What specific safety requirements must my cribs meet?).(b) Each bed being used by a child must have:(1) A clean and comfortable mattress; and(2) A mattress with a cover or protector if the child is not provided with a mattress that is waterproof.(c) You must also provide the child with:(1) A pillow and linens appropriate for the temperature, including a pillowcase, top sheet, and fitted or bottom sheet;(2) Extra linens as needed for the child's warmth and comfort, such as a blanket or bedspread; and(3) Clean linens that are changed or laundered if used by a different child and as often as needed for cleanliness and sanitation, but not less than once a week.(d) If laundry service is not provided, laundry facilities supplied with hot and cold water under pressure must be provided for all children in care to use. Source Note: The provisions of this §748.3365 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3365 What are the requirements for beds and bedding? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189369 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189369&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189369 03/12/2026 The following types of beds are not allowed:(1) Triple-deck beds;(2) Veil beds designed to prohibit a child from leaving the bed, not including beds that have mosquito netting to protect the child from mosquitoes or other insects;(3) Beds that have bedrails that can entrap a child; or(4) Any cribs, except for infants and toddlers. Source Note: The provisions of this §748.3367 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3367 What types of beds are not allowed for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189370 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189370&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189370 03/12/2026 (a) A bunk bed must only consist of double-deck beds.(b) A child who is under six years old, non-ambulatory, or subject to seizures or other medical or physical problems who may require greater caregiver supervision and caregiver access must not use a top bunk bed.(c) A bunk bed must allow enough space in between beds and the ceiling to allow a child to sit up in bed.(d) A bunk bed must be equipped with a securely attached ladder capable of supporting the child using the bed and an employee.(e) A bunk bed that is more than 30 inches above the floor must be equipped with securely attached safety bedrails along the lengths of the bed on each side with a means to allow a child to get in and out of bed. Bunk beds securely attached to a wall may use the wall as one of the required guardrails. The top of safety guardrails must be at least five inches above the top of the mattress. The bed rails and the mattress supports under the mattress must not be an entrapment hazard.(f) Openings in guardrails or between ladder rungs must not have openings that can entrap a child's body or body part that has penetrated the opening. Openings must measure less than 3 1/2 inches or more than nine inches to prevent a child's body or body part from being entrapped.(g) A bunk bed must be spaced to provide a walk space on at least one side and one end of each bed. Source Note: The provisions of this §748.3369 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3369 What are the requirements for bunk beds? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189371 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189371&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189371 03/12/2026 (a) All bathrooms must be maintained in good repair and kept clean at all times.(b) You must provide bathrooms located on the same floor as the child's bedroom. The child must not have to exit the building to access the bathroom.(c) To provide privacy, you must ensure a child does not have to cross an activity room, dining room, living room, or similar type room to access a bathroom from the child's bedroom. If prior to January 1, 2007, we granted you a permit, you are exempt from this requirement until:(1) You move your operation to a new location;(2) You structurally alter the current building by adding a new room; or(3) Your permit is no longer valid.(d) Each bathroom or room with a lock must be able to be unlocked from the outside during an emergency. Source Note: The provisions of this §748.3391 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3391 What are the general requirements for bathroom facilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189327 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189327&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189327 03/12/2026 (a) Your operation must dispose of wastewater into a sanitary sewage system, or an approved septic system in accordance with the Texas Commission on Environmental Quality, and submit to any routine inspections required by law.(b) You must provide:(1) At least one toilet for every eight children. All toilets must provide individual privacy, including doors to individual toilet stalls; and(2) Separate toilet facilities for males and females.(c) When toilet facilities for each gender are located in the same building, the toilet facilities must be:(1) Distinctly marked for each gender; and(2) Separated by a solid wall from floor to ceiling.(d) Toilets must be equipped with toilet paper at all times.(e) Toilet facilities must meet the handicap accessibility standards according to the American with Disabilities Act, if applicable.(f) Urinals may be substituted for the toilets for the males on a ratio of one urinal or 24 inches of trough-type urinal for one toilet, not to exceed one-third of the required toilets. Urinals must have privacy walls on three sides that must be constructed of nonabsorbent materials. Source Note: The provisions of this §748.3393 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3393 What are the requirements for a toilet that a child uses? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189325 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189325&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189325 03/12/2026 (a) You must maintain all hand-washing sinks in good repair and keep them clean at all times.(b) You must provide:(1) At least one hand-washing sink for every eight children;(2) A hand-washing sink that is adjacent to toilet facilities;(3) Hand-washing sinks with hot and cold running water under sufficient pressure to meet the demands of the children; and(4) Hand-washing sinks equipped with soap and a personal towel, single-use disposable towels, or hot air hand dryers. Source Note: The provisions of this §748.3395 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3395 What are the requirements for hand-washing sinks that a child uses? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189326 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189326&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189326 03/12/2026 (a) All bath and shower areas must provide for individual privacy. This includes doors or nonabsorbent shower curtains to individual bathtubs and showers stalls.(b) You must provide:(1) At least one bathtub or shower for every eight females and one for every eight males; and(2) Separate shower and bath facilities for each gender, where applicable.(c) When common-use shower facilities for each gender are located in the same building, the facilities must be:(1) Distinctly marked for each gender; and(2) Separated by a solid wall from the floor to ceiling.(d) Each shower and bathtub must be equipped with:(1) Hot and cold running water under sufficient pressure to meet the demands of the children; and(2) Sufficient hot water to meet the demands of the children.(e) If prior to January 1, 2007, we granted you a permit, then you do not have to comply with these requirements until:(1) You move your operation to a new location;(2) You structurally alter the current bathroom facilities; or(3) Your permit is no longer valid. Source Note: The provisions of this §748.3397 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3397 What are the requirements for bathing facilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189328 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189328&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189328 03/12/2026 No. You may not use a video camera or audio monitoring device to supervise a child while the child is in a bathroom. Source Note: The provisions of this §748.3399 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3399 May I use a video camera or audio monitoring device to supervise a child while the child is in a bathroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208631 03/12/2026 You must ensure that poisonous or flammable materials are:(1) Stored in their original, labeled containers;(2) Kept separate from medication, food, food preparation surfaces, and dining surfaces;(3) Stored in an area that is inaccessible to children, unless caregivers have evaluated a child as capable and likely to use such items responsibly; and(4) Cleaned up immediately when spilled. Source Note: The provisions of this §748.3421 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3421 What are the requirements for protecting children from poisonous or flammable material? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189332 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189332 03/12/2026 (a) All food and drinks must be of safe quality and must be stored, prepared, distributed, and served under sanitary and safe conditions.(b) You must sanitize food service equipment, dishware, and utensils after each use. All eating and cookware must be properly stored.(c) You must keep furniture, equipment, food contact surfaces, and other areas where food is prepared, eaten, or stored clean and in good repair.(d) If your operation lacks adequate facilities for sanitizing dishes and utensils, you must only use disposable, single-use items.(e) You must discard single-service napkins, bibs, dishware, containers, and utensils after each use.(f) You must wash re-useable napkins and bibs after each use.(g) You must wash re-useable tablecloths when soiled.(h) Persons who handle food and/or eating utensils for the group must:(1) Maintain personal cleanliness;(2) Keep hands clean at all times;(3) Wash his hands with soap and water thoroughly after each visit to the toilet;(4) Be free of infections commonly transmitted through the handling of food or drink and free of communicable diseases; and(5) Minimize food contamination through the use of utensils.(i) Food packages must be in good condition and protect the integrity of the contents, so food is not exposed to adulteration or potential contaminants. You must discard cans that are leaking, bulging, or rusted.(j) When you serve an infant or toddler:(1) If the child is capable of sitting up, you must serve food on plates, napkins, or other sanitary holders, such as a high chair tray; and(2) You must not serve foods that present a risk of choking.(k) When you prepare a meal at the operation, the food preparation area must be in a separate space from the eating, play, and bathroom areas.(l) Fruits and vegetables must be properly washed before use.(m) Food must be thawed in the refrigerator, in cold water in a leak-proof bag, or in the microwave.(n) Food must be protected from contamination.(o) You must keep raw meat, poultry, fish, and their juices away from other food. After cutting raw meat, you must wash your hands, the cutting board, the knife, and the countertops with hot, soapy water. You must sanitize cutting boards by using a solution of one-teaspoon chlorine bleach in one quart of water.(p) You must maintain hot food at 140 degrees Fahrenheit or above.(q) You must refrigerate perishable food at proper temperatures:(1) Within one hour after use when the temperature is above 90 degrees Fahrenheit; or(2) Otherwise, within two hours.(r) Uneaten food from a person's plate must not be served again or used in the preparation of other dishes.(s) You must not permit animals to be in the area of food storage, food preparation, and dining.(t) This rule does not apply to cottage homes. Source Note: The provisions of this §748.3441 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3441 What general requirements apply to food service and preparation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208634 03/12/2026 (a) All food items must be:(1) Covered and stored off the floor;(2) Stored on clean surfaces;(3) Protected from contamination;(4) Stored in a container that is protected from insects and rodents;(5) Stored in the refrigerator, if the food requires refrigeration; and(6) Covered when stored in the refrigerator.(b) You must have a thermometer in refrigerators and freezers and store:(1) Refrigerated food at 40 degrees Fahrenheit or below; and(2) Frozen food at 0 degrees Fahrenheit or below.(c) Subsection (b) of this section does not apply to cottage homes. Source Note: The provisions of this §748.3443 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3443 What are the requirements for storing food? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189331 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189331 03/12/2026 (a) All food and drinks must be of safe quality and must be stored, prepared, and served under sanitary and safe conditions.(b) You must keep furniture, equipment, food contact surfaces, and other areas where food is prepared, eaten, or stored clean and in good repair.(c) Persons who handle food and/or eating utensils for the group must:(1) Maintain personal cleanliness;(2) Keep hands clean at all times;(3) Be free of infections commonly transmitted through the handling of food or drink and free of communicable diseases; and(4) Minimize food contamination through the use of utensils.(d) Food must be protected from contamination.(e) When you serve an infant or toddler:(1) If the child is capable of sitting up, you must serve food on plates, napkins, or other sanitary holders, such as a high chair tray; and(2) You must not serve food that presents a risk of choking.(f) Utensils and containers intended for one-time use, such as paper and plastic dishes, must not be used more than once. Source Note: The provisions of this §748.3445 adopted to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3445 How must kitchen, dining areas, supplies, and equipment be maintained in a cottage home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189333 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189333 03/12/2026 You must ensure that outdoor equipment and supplies at the operation are safe for the children as follows:(1) The outdoor activity space must be arranged, so caregivers can adequately supervise children at all times;(2) The design, scale, and location of the equipment must be appropriate for the body size and ability of the children using the equipment;(3) Equipment must not have openings that can entrap a child's body or body part that has penetrated the opening;(4) Equipment must not have protrusions or openings that can entangle something around a child's neck or a child's clothing;(5) Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, moving, or overturning;(6) All anchoring devices must be placed below the level of the playing surface to prevent tripping or injury resulting from a fall;(7) Equipment must not have exposed pinch, crush, or shear points on or underneath it;(8) You must not install climbing equipment, swings, or slides over asphalt or concrete, unless the asphalt or concrete is covered with properly installed unitary surfacing materials as specified in this subchapter;(9) Outdoor platforms more than 20 inches in height for children five years old and younger, and more than 30 inches in height for school-age children, must be equipped with guardrails that surround the elevated surface, except for entrances and exits, and that prevent children from crawling over or through the guardrail;(10) The height of the highest play surface or platform cannot be more than eight feet; and(11) Stairs and steps on outdoor climbing equipment, regardless of height, must have well-secured handrails on both sides of stairs and steps that the children can reach. Rung ladders do not require handrails. Source Note: The provisions of this §748.3471 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3471 What are the minimum safety requirements for outdoor equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189334 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189334 03/12/2026 Guardrails and protective barriers must be at least:(1) 29 inches high for pre-kindergarten or younger children; and(2) 38 inches high for school-age children. Source Note: The provisions of this §748.3473 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3473 How high must platform guardrails be? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189335&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189335 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189335&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189335 03/12/2026 (a) Your administrator or designee must inspect the playground weekly to ensure no hazards are present. Your administrator or designee must inspect the equipment and surfacing material for:(1) Normal wear and tear;(2) Broken or missing parts;(3) Debris or foreign objects;(4) Drainage problems; or(5) Other hazards, such as tripping hazards, like exposed concrete footings, tree stumps, and rocks.(b) Your administrator or designee must:(1) Ensure that hazards or defects identified during the inspection are removed or repaired promptly; and(2) Arrange for protection of the children or prohibit use of the equipment until the hazards or defects can be removed or repaired. Source Note: The provisions of this §748.3475 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3475 What special maintenance procedures must I follow for my playground? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189336 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189336 03/12/2026 (a) All swing seats must be constructed of durable, lightweight, rubber or plastic material.(b) Edges of all swing seats must be smooth or rounded and have no protrusions.(c) Swings must not be attached to a composite play structure (a playscape or structure containing equipment for a variety of activities).(d) Only children under four years old may use a bucket swing, and only if an adult is present to lift and secure the child into the swing. The distance between the protective surfacing and the bottom of a bucket swing must be at least 24 inches to minimize the likelihood of unsupervised young children climbing into the swing.(e) Tire swings must:(1) Not be made from heavy truck tires, or tires with exposed steel-belted radials;(2) Not be suspended from a composite play structure (a playscape or structure containing equipment for a variety of activities) or with other swings in the same swing bay;(3) Have drainage holes drilled in the underside of the tire and maintained to facilitate water drainage; and(4) Have a minimum clearance between the seating surface of a tire swing and the uprights of the supporting structure of 30 inches or more when the tire is in a position closest to the support structure. Source Note: The provisions of this §748.3477 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3477 What are the specific safety requirements for swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189337 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189337 03/12/2026 You may have indoor climbing equipment if you comply with the following safety standards:(1) Floor surfaces under indoor climbing equipment and platforms over 20 inches in height must have a unitary surface that will effectively cushion the fall of a child. The surface must be installed in the use zone and maintained according to the manufacturer's directions. Carpeting alone, even if it is installed over thick padding, is not an acceptable surface under indoor climbing equipment.(2) Stairs and steps on indoor climbing equipment, regardless of height, must have well-secured handrails on both sides of stairs and steps that the children can reach. Rung ladders do not require handrails.(3) Platforms, including stairs and steps, over 20 inches in height must be equipped with protective barriers that prevent young children from crawling over or falling through the barrier, or becoming entrapped. Source Note: The provisions of this §748.3479 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3479 May I have indoor equipment such as climbing equipment or platforms? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189338 03/12/2026 (a) The use zone is the surface area under and around a piece of playground equipment and platforms onto which a child falling from or exiting from the equipment would be expected to land.(b) Other than the equipment itself, the use zone must be free of obstacles that a child could run into or fall on top of and be injured. Source Note: The provisions of this §748.3521 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3521 What does the term "use zone" mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189339 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189339&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189339 03/12/2026 (a) The use zone for stationary equipment, excluding slides, must extend a minimum of six feet in all directions from the perimeter of the equipment.(b) Use zones for stationary equipment must not overlap the use zones of any other equipment. Source Note: The provisions of this §748.3523 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3523 How do I measure the use zone for stationary equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189343 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189343&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189343 03/12/2026 (a) The use zone in front of the access and to the sides of a slide must extend a minimum of six feet from the perimeter of the equipment.(b) The use zone in front of the exit of a slide must extend a minimum of six feet.(c) The use zone in front of the slide exit must not overlap the use zone of any other equipment. Source Note: The provisions of this §748.3525 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3525 How do I measure the use zone for slides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189344 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189344&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189344 03/12/2026 (a) The use zone to the front and back of to-fro swings (single-axis swings) must extend twice the height of the suspending bar to the protective surfacing below.(b) The use zone to the front and back of the to-fro swing must not overlap the use zone of any other equipment.(c) The use zone around the sides of the to-fro swing structure (frame which supports the swings) must be at least six feet and may overlap the use zone of an adjacent swing structure. Source Note: The provisions of this §748.3527 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3527 How do I measure the use zone for to-fro swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189340 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189340&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189340 03/12/2026 (a) The use zone for tire swings or other multi-axis swings must extend in all directions for a distance equal to the height of the suspending bar to the top of the sitting surface of the tire, plus six feet.(b) The use zone on the sides of the tire swing support structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §748.3529 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3529 How do I measure the use zone for tire swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189341 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189341&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189341 03/12/2026 (a) The use zone to the front and rear of the bucket swing must extend twice the height from the swing beam to the top of the swing-sitting surface.(b) The use zone specified in subsection (a) of this section must not overlap any other use zone.(c) The use zone on the sides of the bucket swing structure must be at least six feet and may overlap the use zone on the sides of an adjacent swing support structure. Source Note: The provisions of this §748.3531 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3531 How do I measure the use zone for bucket swings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189342 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189342&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189342 03/12/2026 (a) The use zone for rotating or rocking equipment on which the child sits must be at least six feet from the perimeter when not in use.(b) The use zone for rotating or rocking equipment or track rides on which the child stands or rides must be at least seven feet from the perimeter of the equipment when not in use.(c) The use zone for rocking and rotating equipment must not overlap any other use zone. Source Note: The provisions of this §748.3533 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3533 How do I measure the use zone for rotating or rocking equipment or for track rides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189345 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189345&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189345 03/12/2026 You must install protective surfacing in use zones identified in Division 7 of this subchapter (relating to Playground Use Zones). Source Note: The provisions of this §748.3561 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3561 Where must I install protective surfacing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189346 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189346&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189346 03/12/2026 (a) There must be loose-fill surfacing material or unitary surfacing material in the use zones for all climbing, rocking, rotating, bouncing, or moving equipment, slides, and swings. Loose-fill surfacing materials include loose particles such as sand, pea gravel, shredded wood products, and shredded rubber.(b) You must not install loose-fill surfacing materials over concrete or asphalt.(c) If you use loose-fill surfacing materials, you must install nine inches or more of uncompressed loose-fill material in the use zones.(d) You must ensure nine inches of the loose-fill materials are maintained at all times.(e) You must mark all equipment support posts to indicate the depth at which the loose-fill surfacing material must be maintained.(f) If you use unitary materials, they must be installed and maintained according to manufacturer's specifications. Unitary surfacing materials are manufactured materials including rubber tiles, mats, or poured-in-place materials cured to form a unitary shock-absorbing surface.(g) Unitary materials may be installed over concrete or asphalt only if recommended by the manufacturer. Source Note: The provisions of this §748.3563 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3563 What are the requirements of protective surfacing for use zones? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189348 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189348&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189348 03/12/2026 (a) If you use unitary surfacing materials, you must have test data from the manufacturer showing:(1) The impact rating of the material (the maximum height of equipment that may be installed over the surfacing material); and(2) Installation and maintenance requirements.(b) This documentation must be at the operation and available for review by Licensing staff upon request. Source Note: The provisions of this §748.3565 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3565 What documentation must I keep at the operation if I use unitary surfacing materials? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208636 03/12/2026 If a swimming pool with more than two feet of water is used in an activity sponsored by you, then the swimming pool, either at or away from your operation, must meet the following criteria:(1) At least two life-saving devices must be available, such as a reach pole, backboard, buoy, or a safety throw bag with a brightly colored buoyant rope or throw line;(2) One additional life-saving device must be available for each 2,000 square feet of water surface, so a pool of 2,000 square feet would require three life saving devices;(3) Drain grates, vacuum outlets, and skimmer covers must be in place;(4) Pool chemicals and pumps must be inaccessible to all children;(5) Machinery rooms must be locked when any child is present;(6) All parts of the swimming pool, including the bottom of the pool, must be clearly visible during the use of the pool;(7) Pool covers must be completely removed prior to pool use and must not present an entrapment hazard; and(8) Swimming area rules and emergency procedures must be posted at the swimming area and explained to the children. Source Note: The provisions of this §748.3601 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3601 What are the requirements for swimming pools that a child uses? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208635 03/12/2026 (a) The swimming pool must be built and maintained according to the standards of the Department of State Health Services and any other applicable state or local regulations.(b) An adult must be present who is able to immediately turn off the pump and filtering system when any child is in a swimming pool.(c) If the swimming pool is aboveground, it must meet all swimming pool safety requirements specified in this subchapter and have a barrier that prevents a child's unauthorized access to the swimming pool.(d) Outdoor swimming pools must be enclosed with a six-foot fence or wall that prevents children's access to the swimming pool. It must be constructed so that the fence or wall does not obscure the swimming pool from view.(e) Doors, operable windows, or gates of living quarters must not be part of the swimming pool enclosure for outdoor swimming pools.(f) Fence gates leading to the outdoor swimming pool area must have self-closing and self-latching hardware located at least 60 inches from the ground and must be locked when the swimming pool is not in use. An indoor swimming pool must be secured at all times to prevent children's access to the swimming pool when a lifeguard is not on duty.(g) Fence gates must open outward away from the swimming pool and must not be propped open.(h) The space between the ground and the bottom of the fence must not exceed four inches.(i) When a fence is made of horizontal and vertical slats, the horizontal slats must be located on the swimming pool side of the fence.(j) Doors from the operation leading to the swimming pool area must have a lock that can only be opened by an adult, unless:(1) the state or local fire authority determines that the height of the lock violates or would violate the fire code; and(2) you have documentation of the fire authority's determination on file.(k) The doors and fence gates leading to or through the swimming pool area must not be designated as fire and emergency evacuation exits.(l) The drain grates, vacuum outlets, and skimmer covers that must be in place, must also be in good repair, and not be able to be removed without using tools.(m) All indoor/outdoor areas within 50 feet outside of the fence around the swimming pool must be free of furniture and equipment that a child could use to gain unauthorized access to the swimming pool. Source Note: The provisions of this §748.3603 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3603 What are the additional requirements for a swimming pool located at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189347&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189347 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189347&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189347 03/12/2026 (a) Wading/splashing pools (two feet of water or less) at your operation must be:(1) Stored out of children's reach, when not in use;(2) Drained at least daily and sanitized; and(3) Stored, so they do not hold water.(b) A portable wading pool must not be placed on concrete or asphalt. Source Note: The provisions of this §748.3605 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3605 What are the safety requirements for wading/splashing pools at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189351 03/12/2026 A hot tub must be:(1) Enclosed per the requirements in §748.3603 of this title (relating to What are the additional requirements for a swimming pool located at my operation?); or(2) Covered with a locking cover when not in use. Source Note: The provisions of this §748.3607 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS P PHYSICAL SITE §748.3607 What are the requirements for a hot tub? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189373 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189373&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189373 03/12/2026 (a) You must provide daily indoor and outdoor recreational and other activities appropriate to the needs, interests, and abilities of the children, so every child may participate.(b) You must have a written plan for ensuring that a range of indoor and outdoor recreational and leisure opportunities are provided for children in care.(c) Except for a child who has written medical orders to the contrary, your programs for non-ambulatory children must include:(1) Physical fitness development that prescribes a variety of body positions; and(2) Changes in environment.(d) Each child must have individual free time as appropriate to the child's age and abilities.(e) You must provide the follow types of recreational activities based on each individual child's needs:Attached Graphic Source Note: The provisions of this §748.3701 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3701 What are my responsibilities for providing opportunities for recreational activities and physical fitness? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189374 03/12/2026 You must provide indoor and outdoor recreational areas and equipment for stimulating children in appropriate recreational activities. The activities must be in sufficient variety and quantity, so every child may participate and have some choice of activities. Source Note: The provisions of this §748.3703 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3703 What are the requirements for recreational areas and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189375 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189375&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189375 03/12/2026 Higher risk recreational activities are activities that present a greater potential of injury to the child and involve special technical skill, equipment, or safety regulations for participation, including using all-terrain vehicles, swimming activities, watercraft activities, riding horses, wilderness hiking and camping excursions, trampoline use, and using weapons, firearms, explosive materials, and projectiles. Source Note: The provisions of this §748.3705 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3705 What are higher risk recreational activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189376 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189376&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189376 03/12/2026 Licensing only regulates activities that are sponsored or conducted by the operation, including higher risk recreational activities. Source Note: The provisions of this §748.3707 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3707 Does Licensing regulate higher risk recreational activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189377 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189377&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189377 03/12/2026 You must meet the following requirements when children participate in a higher risk recreational activity:(1) There must be a person that is responsible for and supervises the higher risk recreational activity;(2) When the person supervising the higher risk recreational activity is an employee of the operation, the supervising employee must:(A) Determine each participant's experience and skill level; and(B) Take this information into account in supervising and assigning equipment or animals to children;(3) Continue to meet the child/caregiver ratios and appropriately supervise the children at all times. If the person supervising the higher risk recreational activity is not a caregiver with the operation, then that person cannot be counted in the child/caregiver ratio. For additional requirements for child/adult ratios for swimming activities, see Division 2 of this subchapter (relating to Swimming Activities); and(4) You must provide children with equipment that is appropriate to the activity, properly sized and adjusted where applicable, and in good condition. Source Note: The provisions of this §748.3709 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3709 What are the requirements when children participate in a higher risk recreational activity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189378 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189378&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189378 03/12/2026 (a) The higher risk recreational activity must be supervised by a person:(1) Knowledgeable about safety precautions for the type of higher risk recreational activity being performed; and(2) Who has the appropriate experience, training, and/or certification in the activity.(b) If the person supervising a higher risk recreational activity is an employee of the operation, you must document these qualifications in the employee's personnel record. Source Note: The provisions of this §748.3711 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3711 Who must supervise a higher risk recreational activity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189379 03/12/2026 A person supervising higher risk recreational activities must:(1) Be present at the site of the activity whenever the activity is being carried out;(2) Facilitate training or experience for other persons working in the activity to prepare them for foreseeable risks;(3) Assign duties to other persons working in the activity;(4) Ensure there is a person at the site of the activity that has a current first-aid and CPR certificate when the activity is in progress;(5) Ensure that all necessary equipment is complete, in good repair, and safe to use;(6) Ensure there is a first-aid kit located at the site of the activity that contains appropriate and sufficient equipment for the type of activity and number of participants;(7) Obtain information on weather and travel conditions before a trip or activity that is outdoors;(8) Develop a plan for action in case of emergencies relevant to the terrain and activity, including lost participants, injuries, and illnesses and communicate the plan to other persons working on the activity;(9) Consider each participant's age, physical condition, and experience, as well as the season and weather trends;(10) Ensure that risk factors are explained to the child prior to the activity, and that the child has an opportunity to decline participation; and(11) Instruct children on the safety precautions and proper use of relevant items or animals. This must be done before access to the item or animal is allowed. Source Note: The provisions of this §748.3713 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3713 What duties are required for a person supervising higher risk recreational activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189380 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189380&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189380 03/12/2026 (a) A child in care may not ride on or operate a three-wheel all-terrain vehicle.(b) Only a child 16 years or older may ride on or operate a four-wheel all-terrain vehicle. Source Note: The provisions of this §748.3719 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3719 May children in care use all-terrain vehicles? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189381 03/12/2026 (a) A certified lifeguard must supervise children at all times during a swimming activity involving a body of water two feet deep or more which occurs at your operation.(b) At all times during a swimming activity sponsored by the operation involving a body of water two feet deep or more which occurs away from your operation:(1) If there are six or fewer children participating in the swimming activity, at least one adult counted in the swimming child/adult ratio must be able to swim or must be trained to carry out a water rescue; and(2) If more than six children are participating in the swimming activity, a certified lifeguard must also be on duty.(c) A child in your care who is a certified lifeguard may act as the lifeguard if he is:(1) At least 16 years old; and(2) Not counted as an adult or caregiver in the required child/adult swimming ratio. Source Note: The provisions of this §748.3751 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3751 Must a certified lifeguard be on duty during a swimming activity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189382 03/12/2026 A certified lifeguard's training must be provided through a recognized organization. Source Note: The provisions of this §748.3753 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3753 Who must provide a certified lifeguard's training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189383 03/12/2026 The lifeguard must be located in a position to observe all swimmers and to respond to emergencies. Source Note: The provisions of this §748.3755 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3755 Where must a certified lifeguard be positioned when supervising children who are swimming? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208637 03/12/2026 (a) The maximum number of children one adult can supervise during swimming activities is based on the age of the youngest child in the group and is specified in the following chart:Attached Graphic(b) When all of the children in the group are at least four years of age or older, in addition to meeting the required swimming child/adult ratio listed in subsection (a) of this section, at least two adults must supervise four or more children who are actually in the water.(c) When a child who is non-ambulatory or who is subject to seizures is engaged in swimming activities, you must assign one adult to that one child. This adult must be in addition to the lifeguard on duty in the swimming area. You do not have to meet this requirement if a licensed physician writes orders in which the physician determines that the child:(1) Is at low risk of seizures and that special precautions are not needed; or(2) Only needs to wear a Coast Guard approved life jacket while swimming and additional special precautions are not needed. (d) A child must wear a Coast Guard approved life jacket while participating in swimming activities in other bodies of water such as ponds, rivers, lakes and oceans if the child is:(1) Under the age of 12; or(2) Unable to swim, regardless of the child's age.(e) So long as you comply with the child/caregiver ratios required in §748.1003 of this title, the ratios in subsection (a) of this section:(1) Do not include children over the age of 12 years old who are competent swimmers; and(2) Are not required when children are participating in water activities such as sprinkler play or splash pad or wading pool, as long as the standing water is less than two feet deep. Source Note: The provisions of this §748.3757 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3757 What are the child/adult ratios for swimming activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189385 03/12/2026 A lifeguard who is supervising the area where the children are swimming may be counted in the child/adult ratio except as specified in §748.3751(c) of this title (relating to Must a certified lifeguard be on duty during a swimming activity?). The lifeguard must never be left alone with any of the children unless the lifeguard is also a qualified caregiver for your operation. Source Note: The provisions of this §748.3759 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3759 May I count the certified lifeguard in the swimming child/adult ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189386 03/12/2026 To meet the swimming child/adult ratio, you may include adult volunteers and employees of the operation who do not meet the minimum qualifications for caregivers, providing you:(1) Maintain enough caregivers to meet the ratios required in Subchapter G of this chapter (relating to Child/Caregiver Ratios); and(2) Ensure compliance with all other rules of this chapter, including rules relating to supervision and discipline. Source Note: The provisions of this §748.3763 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3763 May I include volunteers or employees who do not meet minimum qualifications for caregivers in the swimming child/adult ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189387 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189387 03/12/2026 (a) Prior to any activity regarding a body of water, you must explain the dangers of the body of water and the rules governing the activity to the children in a manner that each child can understand.(b) If your operation sponsors a swimming activity and you allow a child to swim in a body of water:(1) The supervising adult must clearly designate the swimming areas;(2) You must meet the swimming child/adult ratios; and(3) If more than six children are participating in the activity, you must have life-saving equipment present at all times that is sufficient to reach and rescue the child, such as a safety throw bag with a brightly colored 50-foot buoyant rope or a rescue boat equipped with a reach pole and a buoy. Source Note: The provisions of this §748.3765 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3765 What are the requirements for a child's access to a body of water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189388 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189388 03/12/2026 No. You may not use a stock tank used by livestock for a swimming activity. Source Note: The provisions of this §748.3767 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3767 May I use a stock tank as a pool for a swimming activity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189389 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189389&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189389 03/12/2026 The rules of this division apply to activities involving bodies of water:(1) In which more than six children participate; and(2) That involve boats, canoes, kayaks, sailboats, rafts, jet skis, or inflatable tubes. Source Note: The provisions of this §748.3801 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3801 What watercraft activities do the rules of this division apply to? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189390 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189390&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189390 03/12/2026 (a) A non-swimmer must wear a life vest.(b) At least two adults able to swim and carry out a water rescue must be at the shoreline and/or on the water to respond to emergencies any time children are on the water during watercraft activities. Source Note: The provisions of this §748.3803 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3803 What are the requirements for watercraft activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189391 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189391&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189391 03/12/2026 The supervisor of the watercraft activity must:(1) Assess the skill and swimming ability of each child prior to the activity;(2) Accompany children on any trip;(3) Determine if an adult must be in the boat with the child or children; and(4) Take into account hazards, such as the size of the body of water, the skill and swimming ability of the children, the air temperature, the conditions of the water, and the temperature of the water when determining:(A) Whether to permit children to participate in a watercraft activity;(B) The experience and number of adults necessary; and(C) Whether or not each child must wear a life vest. Source Note: The provisions of this §748.3805 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3805 What considerations must the watercraft activity supervisor take into account prior to the implementation of the activity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189392 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189392&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189392 03/12/2026 (a) The watercraft and all equipment must be kept in good repair at all times.(b) You must meet the watercraft requirements of Texas Parks and Wildlife, if applicable. Source Note: The provisions of this §748.3807 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3807 What are the requirements for watercraft equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189393 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189393&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189393 03/12/2026 When you participate in a hiking or camping activity in an area unfamiliar to the participating adults, and the hiking activity lasts more than two hours:(1) The person qualified to supervise the hiking or camping excursion must consider the following when selecting the area for hiking or camping:(A) Evacuation;(B) Communication; and(C) Water quality and quantity;(2) The person qualified to supervise the hiking or camping excursion must have experience leading a group in hiking or camping at the elevation, terrain, and climate where the activity is to take place;(3) Before participation, the caregivers and children must receive instruction on:(A) The fundamental safety procedures for the area where the hiking or camping will occur;(B) Procedures to follow if the participant gets lost;(C) Proper health and sanitation procedures;(D) Potential high-risk areas where the hiking or camping will occur; and(E) Fire risks;(4) The emergency medical care consent forms must be readily accessible to the caregivers accompanying them;(5) Caregivers participating in the hiking or camping activity must regularly monitor and care for the health and safety of children; and(6) If the excursion will be on private land, you must have an agreement with the person responsible for that land. Source Note: The provisions of this §748.3841 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3841 What are the requirements for hiking or camping excursions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189394 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189394&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189394 03/12/2026 Caregivers participating in the hiking or camping activity must ensure that:(1) Each child participating in the hiking or camping activity has the clothing, equipment, and provisions necessary to protect the child from the environment, including insect repellent and sunscreen;(2) A child does not carry a load of more than 30% of the child's body weight;(3) Hiking does not exceed the physical capabilities of the weakest member of the group. If a participating child cannot or will not hike, the group must not continue unless other provisions have been made to care for the child;(4) In temperatures above 80 degrees Fahrenheit:(A) Children are offered a minimum of three quarts of drinking water per day;(B) Electrolyte replacement is available to children at all times; and(C) Other techniques are available to cool a participant, such as water to coat a child's body or cold packs; and(5) Potable water is available at each campsite. Caregivers must verify water cache location information before the group leaves camp each day, if applicable. Source Note: The provisions of this §748.3843 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3843 What are the requirements for monitoring children's safety and health during hiking or camping excursions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189395 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189395&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189395 03/12/2026 (a) For hiking or camping excursions that last for over five hours, you must have an itinerary prepared prior to departure, including the:(1) Time of departure and anticipated time of return;(2) Destination; and(3) Travel route.(b) For hiking or camping excursions that last overnight, each point of the itinerary must also identify:(1) Sources of emergency care, such as hospitals, police, and forest service offices;(2) Methods of communicating with sources of emergency care; and(3) Date and time of departure and anticipated date and time of return.(c) The caregivers on the excursion must:(1) Follow the itinerary as closely as possible; and(2) Notify the operation of any change, when possible. Source Note: The provisions of this §748.3845 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3845 What type of itinerary must I have for hiking or camping excursions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189396&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189396 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189396&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189396 03/12/2026 (a) You must keep a copy of the itinerary on file at the operation.(b) If the excursion is on land governed by the national or state forest service, then you must also provide the service's office with a copy of the itinerary. Source Note: The provisions of this §748.3847 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3847 Where must the itinerary be kept? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189397&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189397 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189397&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189397 03/12/2026 (a) During an overnight excursion, you must provide each child with:(1) Adequate shelter, such as a tent, tarp, or cabin; and(2) Reasonable insulation from cold and dampness by such things as a rain fly, ground cloth, and an insulated pad under bedrolls or sleeping bags.(b) Open air sleeping is allowable if:(1) The weather permits;(2) The child consents; and(3) You provide a ground cloth and an insulated pad under bedrolls or sleeping bags. Source Note: The provisions of this §748.3849 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3849 What are the requirements for shelter during an overnight excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189398&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189398 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189398&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189398 03/12/2026 You must provide each child with:(1) An individual bed, bedroll, or sleeping bag;(2) Extra linens as needed for the child's warmth and comfort, such as a blanket;(3) Clean bed linens that are changed as often as needed for cleanliness and sanitation, but not less than once a week, if applicable; and(4) Provisions for proper laundering of bedrolls and sleeping bags between trips or between uses by different individuals. Source Note: The provisions of this §748.3851 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3851 What are the requirements for bed equipment used during an overnight excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189399&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189399 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189399&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189399 03/12/2026 (a) You may only use foods capable of being maintained in a wholesome condition with the available equipment.(b) You must refrigerate perishable food when possible.(c) If you use an ice chest to refrigerate food during the excursion, you must provide adequate ice at all times.(d) You must drain ice chests to prevent accumulation of water from melted ice.(e) You may not store meat and other highly perishable foods for more than 24 hours.(f) You must discard any contaminated foods. Source Note: The provisions of this §748.3853 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3853 What are the specific requirements for storing food during a hiking or camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189400&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189400 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189400&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189400 03/12/2026 (a) A common use drinking cup, container, or utensil must be washed with uncontaminated hot water and detergent before another person uses it.(b) You must not use a dish, container, or utensil that is chipped, cracked, broken, damaged, or constructed so as to prevent proper cleaning and sanitizing.(c) You must discard disposable or single-use dishes, containers, or utensils used in handling food after one use.(d) You must store eating utensils:(1) Separately from foods or other materials or substances; and(2) In clean, dry containers. Source Note: The provisions of this §748.3855 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3855 What requirements must I meet for food utensils and equipment when camping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189401&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189401 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189401&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189401 03/12/2026 (a) Drinking water used during a hiking or camping excursion must come from a source known to be safe or must be rendered safe.(b) An adequate supply of water, under pressure where possible, must be provided at the cooking area for hand washing, dishwashing, food preparation, and drinking. Source Note: The provisions of this §748.3857 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3857 What parameters must I follow for drinking water during a hiking or camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189402&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189402 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189402&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189402 03/12/2026 (a) If the campsite is not provided with toilet facilities, pit privies or other portable toilets, there must be separate designated areas for each gender for toilet use.(b) Toilet paper must be available at all times, as needed.(c) Privies must be located at least:(1) 20 feet from any stream, lake, well, spring, or other water supply; and(2) 75 feet from the camp, tent, sleeping, or housing arrangement.(d) Soap and water for hand washing must be located within 20 feet of the toilet areas. Source Note: The provisions of this §748.3861 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3861 What are the requirements for toilet facilities during overnight camping excursions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189403&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189403 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189403&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189403 03/12/2026 (a) You may use a trampoline if:(1) The use of the trampoline and the number of children allowed on the trampoline at one time meets the manufacturer's instructions;(2) Shock-absorbing pads cover the springs, hooks, and frame;(3) Ladders are removed from the trampoline when the trampoline is not in use; and(4) A caregiver provides supervision as follows:(A) For children under 12 years old, the caregiver must be immediately present, watching the child/ren at all times, enforcing safety rules and manufacturer's instructions, and able to respond to an emergency; and(B) For children 12 years old and older, the caregiver must be on the premises, visually check on the child/ren at frequent intervals, and able to respond in an emergency.(b) You may use a trampoline as gym equipment as provided in §748.3893 of this title (relating to What are the requirements for using a trampoline as gym equipment?). Source Note: The provisions of this §748.3891 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3891 May I use a trampoline? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189404&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189404 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189404&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189404 03/12/2026 You may use a trampoline for supervised training programs, such as gymnastics, diving, and other competitive sports if you meet the following requirements:(1) You must prohibit the use of the trampoline when there is no trampoline supervisor present;(2) The trampoline supervisor must have formal training and experience in the use of the trampoline and knowledge of trampoline safety and spotting techniques;(3) When the trampoline is in use, personal spotters must be present, ready to intervene, and posted on four sides of each trampoline;(4) You must prohibit any child younger than six years old from using the trampoline, even in supervised training programs;(5) A safety pad must cover all portions of the steel frame and springs;(6) The surface around the trampoline must have an impact absorbing surface material;(7) Only one child at a time may use a trampoline, regardless of the size of the trampoline;(8) Children must not be allowed to jump off the trampoline. If the trampoline is above ground, children must dismount the trampoline by sitting on the edge and sliding off;(9) The trampoline must be secured and inaccessible when not in use;(10) The condition of the trampoline must be checked for tears, rust, and detachments at least monthly and repaired prior to its next use; and(11) The child using a trampoline must be at the center of the mat and must not attempt to do maneuvers beyond the child's capability or training. Source Note: The provisions of this §748.3893 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3893 What are the requirements for using a trampoline as gym equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208638 03/12/2026 (a) Generally, weapons, firearms, explosive materials, and projectiles (such as darts or arrows) are permitted; however, there are some specific restrictions:(1) A handgun is a type of firearm that is never permitted at an operation or during any type of activity;(2) A child receiving treatment services or emergency care services is not permitted to use weapons, firearms, explosive materials, or projectiles;(3) If you allow weapons, firearms, explosive materials, or projectiles, you must develop and enforce a policy identifying specific precautions to ensure that a child does not have unsupervised access to them, including:(A) Weapons, firearms, the ammunition, explosive materials, and projectiles must be kept in locked storage;(B) The locked storage must be made of strong, unbreakable material, except that the storage may have a glass or another breakable front or enclosure;(C) Any gun placed in a locked storage that has a glass or another breakable front or enclosure must be secured with a locked cable or chain placed through the trigger guard; and(D) Weapons and ammunition must be separately stored and locked;(4) You must determine it is appropriate for a child receiving only child-care services to use the weapons, firearms, explosive materials, or projectiles; and(5) No child may use a weapon, firearm, explosive material, or projectile, unless the child is directly supervised by an adult knowledgeable about the use of the weapon, firearm, explosive material, or projectile that is to be used by the child.(b) A child receiving treatment services or emergency care services is not permitted to use toys that explode or shoot. For a specific child receiving only child-care services, you must determine whether it is appropriate for that child to use toys that explode or shoot. The child must be supervised when using or being around toys that explode or shoot, and the toy must be age appropriate to the child.(c) Firearms that are inoperable and solely ornamental are exempt from the storage requirements in this rule. Source Note: The provisions of this §748.3931 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3931 Are weapons, firearms, explosive materials, and projectiles permitted at my operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189406&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189406 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189406&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189406 03/12/2026 When determining if these items are stored adequately, you must consider the age, history, emotional maturity, and background of the children in your care. Source Note: The provisions of this §748.3933 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3933 What factors must I consider when determining whether weapons, firearms, explosive materials, or projectiles are stored adequately? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189372 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189372&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189372 03/12/2026 A caregiver may not transport a child in a vehicle where a handgun is present. Otherwise, a caregiver may transport a child in a vehicle where weapons, firearms, explosive materials, or projectiles are present if:(1) The child is only receiving child-care services;(2) All firearms are not loaded; and(3) The weapons, firearms, explosive materials, or projectiles are inaccessible to the child. Source Note: The provisions of this §748.3935 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS Q RECREATION ACTIVITIES §748.3935 May a caregiver transport a child in a vehicle where weapons, firearms, explosive materials, or projectiles are present? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208639 03/12/2026 We regulate any transportation that you provide for trips away from and to your operation. Source Note: The provisions of this §748.4001 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2248. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4001 What types of transportation does Licensing regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189408&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189408 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189408&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189408 03/12/2026 Anytime you transport a child away from the operation, you must comply with each of the following requirements:(1) Each driver must:(A) Be at least 21 years old. For an exception for children in care, see §748.4005 of this title (relating to May a child in care transport other children in care?);(B) Be covered by automobile insurance; and(C) Have a current driver's license allowing the driver to operate the type of vehicle that is used to transport children.(2) You must not transport more people than the capacity of the vehicle.(3) The vehicle must travel at a safe speed consistent with the speed limit, terrain, and weather conditions.(4) For requirements regarding firearms and transportation, see §748.3935 of this title (relating to May a caregiver transport a child in a vehicle where weapons, firearms, explosive materials, or projectiles are present?). Source Note: The provisions of this §748.4003 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4003 What requirements must I meet when transporting a child away from the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189409&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189409 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189409&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189409 03/12/2026 Yes, a child in care may transport other children in care if the child:(1) Has a valid drivers license;(2) Is covered by automobile insurance; and(3) Is given permission by the service planning team to drive and transport other children in care. Source Note: The provisions of this §748.4005 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4005 May a child in care transport other children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189410&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189410 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189410&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189410 03/12/2026 The following information and items must be accessible and in each vehicle you use to transport children during overnight trips:(1) A list of the children being transported, which you must check in order to account for the presence of all participating children;(2) Emergency medical transport and treatment authorization forms for each child being transported;(3) A list of medications each child is currently taking, the dosage, and the frequency;(4) Your operation's name and telephone number, and the administrator's or permit holder's name;(5) Parent's names and telephone numbers and emergency telephone numbers for each child being transported;(6) A fire extinguisher approved by the local or state fire marshal, secured in the passenger compartment and accessible to the adult occupants;(7) A first-aid kit; and(8) An operable flashlight. Source Note: The provisions of this §748.4007 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4007 What specific information and equipment must be in a vehicle I use to transport children during overnight trips away from the operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189411&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189411 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189411&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189411 03/12/2026 (a) You must ensure the driver and caregivers have clear instructions in handling emergency breakdowns and accidents, including vehicle evacuation procedures, supervision of the children, and contacting emergency help.(b) The administrator or designee in charge of the operation must know what action to take in responding to a transportation emergency call.(c) Emergency transportation must be available at all times. It may be provided by the operation or pre-arranged with community services. Source Note: The provisions of this §748.4009 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4009 What plan must I have for handling transportation emergencies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189412&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189412 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189412&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189412 03/12/2026 You must take the following precautions when loading and unloading a child from any vehicle used for transportation, including a bus with a gross vehicular weight rating (GVWR) of 10,000 pounds or more:(1) You must account for all children exiting the vehicle before leaving the vehicle unattended.(2) You must not allow a child under eight years old to cross a street to enter a vehicle or after exiting a vehicle, unless an adult accompanies the child.(3) You must never leave a child under eight years old unattended in a vehicle. Source Note: The provisions of this §748.4011 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4011 What safety precautions must I take when loading and unloading a child from the vehicle? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189413&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189413 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189413&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189413 03/12/2026 (a) If your operation takes children on out-of-state overnight trips, you must:(1) Develop a written itinerary and safety plan for each trip;(2) Provide necessary equipment and make provisions to meet participants' needs on the trip; and(3) Inform parents before the planned departure date, and document in the child's record the discussion and date when this contact occurred.(b) You must obtain the written permission from each child's parent for each out-of-state trip or must obtain a general written permission from each child's parent for any out-of-state trip in which the child will participate. Source Note: The provisions of this §748.4013 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4013 What is required when my operation takes children on out-of-state overnight trips? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189414&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189414 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189414&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189414 03/12/2026 The driver and all passengers must follow all federal, state, and local laws when driving, including laws on the use of a child passenger safety seat system, seat belts, and liability insurance. Source Note: The provisions of this §748.4041 adopted to be effective January 1, 2017, 41 Tex Reg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4041 What are the requirements for transporting children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189415&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189415 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189415&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189415 03/12/2026 (a) Children may be transported in the bed of a pick-up truck on the facility grounds if the following conditions are met:(1) If children are being transported in the bed of a pick-up truck, children must be at least 13 years old;(2) Children must be seated;(3) No children may sit on the side of the vehicle, the tire wells, or on the tailgate;(4) No children may lean against the tailgate;(5) The tailgate must be securely closed while the vehicle is in motion;(6) The vehicle must travel at a safe speed consistent with the terrain and weather conditions;(7) The driver of the vehicle must be knowledgeable about the dangers associated with issues, such as but not limited to, sudden braking and travel over uneven terrain; and(8) Open bed pick-up trucks or trailers must not be used to transport children on public roads.(b) Subsection (a) of this section does not apply to hay-rides on trailer beds for special occasions as long as there is adequate adult supervision to prevent children from falling off of the trailer.(c) At all other times transportation is provided by the operation, employees, or volunteers, each child must be in a child passenger safety seat system when the vehicle is in motion. Source Note: The provisions of this §748.4043 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4043 Do the seat belt requirements prohibit transporting children in the bed of a pick-up truck? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189416 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189416&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189416 03/12/2026 No. Only one person may use each child passenger safety seat system or seat belt. Source Note: The provisions of this §748.4045 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4045 May I place more than one person in each child passenger safety seat system or seat belt? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189417&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189417 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189417&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189417 03/12/2026 (a) We do not regulate the type of vehicle you may use to transport children.(b) You must make special provisions if you transport nonambulatory children. When necessary, this may include locks for wheel chairs and hydraulic lifts. Source Note: The provisions of this §748.4081 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4081 What type of vehicle may I use to transport children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189418&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189418 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189418&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189418 03/12/2026 (a) You must maintain a vehicle in a safe operating condition at all times.(b) Each vehicle you use must be registered and have a current inspection sticker for the state in which it is registered. Source Note: The provisions of this §748.4083 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4083 What vehicle maintenance requirements must I maintain for a vehicle used for transporting children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189419&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189419 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189419&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189419 03/12/2026 (a) You must maintain on file at your operation the name of each driver who transports children and a copy of a valid driver's license for that person.(b) You must also maintain the following:(1) Insurance verification in the vehicle; or(2) If your transportation services are provided by a private person, a firm under contract, or by another arrangement, you must maintain on file a copy of the person's or firm's insurance coverage. Source Note: The provisions of this §748.4111 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS R TRANSPORTATION §748.4111 What transportation records must I maintain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189424&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189424 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189424&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189424 03/12/2026 (a) If you admit a child for emergency care services who does not meet the requirements to consent to emergency care services, you must try to contact the child's parent(s) within 24 hours, if you know their identity and how to contact them.(b) If you cannot contact the parent(s), you must notify the appropriate public agency (Child Protective Services, Juvenile Probation, or police department) of the child's presence.(c) Your operation must document in the child's record efforts to contact the child's parent(s) and contacts with public agencies. Source Note: The provisions of this §748.4201 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4201 What must I do when I admit a child who cannot consent to emergency care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189425&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189425 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189425&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189425 03/12/2026 Each child receiving emergency care services must receive a health screening or EPSDT examination within 72 hours after admission:(1) A health-care professional must provide the screening examination. The health-care professional does not have to be your employee.(2) With the exception of EPSDT examinations, the person who does the examination must sign and date the results of the screening examination. You must document the results of the examination in the child's record.(3) If a child has been in a residential child-care operation and has had a health screening in the last 12 months, the child does not have to have another health screening unless there is reason to believe the child is ill or has been abused.(4) If the child is coming from a medical setting, you may accept a statement from a licensed health-care professional in place of the examination. Source Note: The provisions of this §748.4203 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4203 What are the additional medical requirements when I admit a child to receive emergency care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189426&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189426 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189426&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189426 03/12/2026 A child receiving emergency care services may stay in care without a placement extension for a maximum of 15 days. Source Note: The provisions of this §748.4205 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4205 What is the maximum amount of time a child receiving emergency care services may stay in care without a placement extension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189427&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189427 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189427&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189427 03/12/2026 (a) If there is an appropriate reason for continuing the care, a child:(1) Younger than five years old may continue the placement for emergency care services for up to a total of 30 days in care; and(2) Five years old or older may continue the placement for emergency care services for up to a total of 90 days in care.(b) If a child of any age has a parent under 18 years old admitted in the operation or has a sibling five years old or older admitted in the operation, the child may continue placement for emergency care services for the length of time the parent or sibling is receiving emergency care services if:(1) Deemed in the best interests of the child by the service planning team; and(2) Only for a maximum of 90 days. Source Note: The provisions of this §748.4207 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4207 What is the maximum amount of time a child receiving emergency care services may stay in care with a placement extension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189428&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189428 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189428&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189428 03/12/2026 (a) The child's service planning team must document the reason for the extension in the child's record.(b) If the parent responsible for the child has begun presenting the child's information to different operations, agencies, or foster homes based on what the parent believes the child's needs are and where the child's needs can best be met, you must document in the child's record the following verbal information that you receive from the parent:(1) The reason(s) why a placement cannot be completed timely; and(2) The date a placement is expected to be completed.(c) In other situations, you must document the following information for the placement extension, as appropriate:(1) The child has qualified for financial assistance under Chapter 31, Human Resources Code, and is on the waiting list for housing assistance; or(2) The child meets the requirements to consent to emergency care and consents to the continuation of services to the child or the child's offspring.(d) You must document your efforts to contact the parent and obtain the rationale for the continuation of care, including the dates you made those efforts. Source Note: The provisions of this §748.4209 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4209 What are the documentation requirements for a placement extension? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189431&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189431 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189431&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189431 03/12/2026 (a) You must document the reason for continuing emergency care services in the child's record by the 16th day that the child is in care.(b) You must include documentation of additional continuations in the child's record every 30 days thereafter, if applicable.(c) This documentation must be available for our review. Source Note: The provisions of this §748.4211 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4211 When must I document the appropriate reason for continuing emergency care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189432&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189432 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189432&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189432 03/12/2026 (a) If the child receives emergency care services for more than 15 days, you must have a written preliminary discharge plan for the child from the person responsible for the child.(b) You must place the preliminary discharge plan in the child's record on or before the child's 16th day in care at your operation.(c) You must obtain written documentation from the person responsible for the child that the preliminary discharge plan is reviewed and updated at least weekly.(d) The preliminary discharge plan and weekly reviews must be available for our review. Source Note: The provisions of this §748.4213 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4213 What are the requirements for a preliminary discharge plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189429&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189429 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189429&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189429 03/12/2026 (a) An admission assessment must provide an initial evaluation of the appropriate placement of the child and must include:(1) The child's immediate needs;(2) The name of the referral source;(3) The date and time of placement;(4) A description of the child's condition as observed by the intake worker; and(5) Only for emergency care services:(A) The reason for emergency placement;(B) The child's understanding of the need for emergency care services; and(C) The child's feelings about the crisis situation and operation care.(b) You must also obtain the following information as soon as possible after admission:(1) The child's identity, date of birth, and as applicable any additional information needed to determine the child's ability to consent to emergency care services for the child or the child's offspring. To consent to services, the child must be:(A) The parent of a child;(B) Pregnant; or(C) 16 years old or older; and(i) Residing separate and apart from the child's parent, regardless of whether the parent consents to the admission and duration; and(ii) Managing his own financial affairs, regardless of the source of income;(2) Name, address, and telephone number of the child's parents, if available. This information is not required if the child meets the requirements to consent to emergency care services;(3) Medications the child is taking;(4) Chronic health conditions, such as asthma or diabetes; and(5) Allergies to medication or food.(c) If you cannot obtain the required information for an assessment:(1) You must make reasonable efforts to obtain all required information.(2) If attempting to get information at the time of placement would not be in the child's best interests, you may postpone attempting to acquire the information.(3) In the child's admission assessment, you must document why a:(A) Particular piece of information is unavailable; or(B) Delay in obtaining a piece of information is necessary, including efforts made to obtain the information. Source Note: The provisions of this §748.4231 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4231 What information must an admission assessment include for a child needing emergency care services, including respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189430&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189430 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189430&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189430 03/12/2026 (a) Respite child-care services are not subject to regulation under this subchapter, if the:(1) Respite child-care services are completely separate from the emergency care services. You must provide the respite child-care services in a completely separate physical space using different caregivers from the caregivers for the emergency care services; and(2) Care meets the short-term program's criteria for exemption as specified §745.117(2) of this title (relating to Which programs of limited duration are exempt from Licensing regulation?).(b) An operation that only provides emergency care services to children may provide respite child-care services, if you:(1) Meet all applicable requirements for all services, including children admitted only for respite child-care. This includes compliance with capacity limits, child/caregiver ratios, and supervision rules; and(2) Ensure that your respite child-care services do not present a conflict of care for any child receiving emergency care services. Source Note: The provisions of this §748.4261 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4261 May I provide respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189423 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189423 03/12/2026 You must notify the child's parent before accepting the child for respite child-care. Source Note: The provisions of this §748.4263 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4263 Whom must I notify when I accept a child for respite child-care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189420 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189420&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189420 03/12/2026 To ensure continuity of care, you must obtain the following information:(1) Specific needs of a child, including:(A) All psychological, psychiatric, or medical treatment currently being provided;(B) Medication regimen and medication instructions;(C) Authorization for medical treatment;(D) Safety plans, including any special supervision precautions;(E) Sleeping information;(F) Discipline instructions;(G) Any expectations that the current caregiver may have of the operation; and(H) Any other needs of a child that should be addressed by the operation;(2) Non-routine events taking place in the life of the child, including any scheduled appointments such as family and sibling visits;(3) Emergency contact information, including the:(A) Child's physician(s);(B) Child's parent; and(C) Telephone number of the agency or operation that placed the child; and(4) The child's history that may affect the operation's ability to provide care for the child, including:(A) Background of abuse and/or neglect;(B) Physical aggression or sexual behavior problems;(C) Fire setting;(D) Maiming or killing animals;(E) Suicidal ideations and attempts; and(F) Run-away behaviors. Source Note: The provisions of this §748.4265 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4265 What information regarding a child must I receive prior to providing respite child-care services to that child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189421 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189421&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189421 03/12/2026 (a) With the exception of subsection (b) of this section, a child may be in respite child-care for 14 consecutive days or 40 days each year.(b) A respite child-care services placement that is made because a child's foster home is under investigation for abuse or neglect does not count toward nor is it limited by the time frames noted in subsection (a) of this section. However, these placements are limited to a maximum of 60 days.(c) If a child needs respite child-care for more than 14 consecutive days or more than 60 days for an abuse or neglect investigation, this is considered a new placement and will not be respite child-care.(d) When a child finishes a respite child-care placement, he may not return to respite child-care for at least 10 days.(e) Respite child-care must not be used if it could be detrimental to the child. Source Note: The provisions of this §748.4267 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4267 How long may a child be in respite child-care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189422 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189422 03/12/2026 When you admit into your respite child-care services program a child to whom you have already provided respite child-care, you may update the existing admission assessment information rather than completing a new assessment. Source Note: The provisions of this §748.4269 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS S ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE EMERGENCY CARE SERVICES §748.4269 May I update an admission assessment when I provide respite child-care services to a child to whom I have already provided respite child-care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189433&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189433 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189433&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189433 03/12/2026 (a) No. This subchapter only regulates general residential operations that also provide an assessment services program.(b) Services provided by other individuals, agencies, and organizations are not subject to regulation under this subchapter. Source Note: The provisions of this §748.4301 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4301 Does Licensing regulate all assessment services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189434&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189434 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189434&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189434 03/12/2026 (a) The person responsible for the assessment services program must review and approve in writing the determination that your program will be able to provide or obtain all assessment services the child appears to need at intake.(b) The review, determination, and approval must be:(1) In writing, signed, and dated from the person responsible for the assessment services program; and(2) Completed prior to the admission of the child into your assessment services program.(c) The determination on the appropriateness of the program to meet the child's assessment needs must be filed in the child's record if the child is admitted into your assessment services program.(d) You must document in the child's record whether you are:(1) Only providing assessment services to the child; or(2) Also providing other services, such as emergency care services.(e) You must document in the child's record the date of the child's admission into your assessment services program. Source Note: The provisions of this §748.4331 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4331 What are the requirements for approving a child's admission into my assessment services program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189435&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189435 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189435&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189435 03/12/2026 (a) You must complete the child's individual plan for the assessment within 10 days from the date of the child's admission into the program.(b) You must document the plan in the child's record. Source Note: The provisions of this §748.4361 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4361 When must I complete the child's individual plan for the assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189436&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189436 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189436&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189436 03/12/2026 Admission into the assessment services program begins when:(1) The parent makes the decision to place the child into the assessment services program; and(2) You decide to accept the child for these services. Source Note: The provisions of this §748.4363 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4363 When does admission into the assessment services program begin? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189437 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189437&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189437 03/12/2026 (a) An individual plan for the assessment must include:(1) Time frames for providing all assessment services;(2) Recommendations for the child's care during the assessment process;(3) Any treatment to be provided during the assessment period; and(4) Current data from the caregiver's evaluation of the child's behavior and level of functioning.(b) The common application is not and must not serve as the individual plan for the assessment. Source Note: The provisions of this §748.4365 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4365 What must an individual plan for the assessment include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189438 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189438&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189438 03/12/2026 (a) Your assessment services program must systematically collect information from caregivers throughout the child's participation in the assessment services program. This information includes the caregivers' observations and opinions of the child.(b) You must document this information in the child's record. Your documentation must include your consideration of the caregivers' observations and opinions. Source Note: The provisions of this §748.4369 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4369 How must my assessment services program collect information from a child's caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189439 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189439&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189439 03/12/2026 (a) The plan for the assessment is complete when it contains the necessary information and the signed approval of the person responsible for the assessment services program or a designated employee who meets the qualifications of a person responsible for the assessment program.(b) The parent must review and be provided a copy of the plan for the assessment. Source Note: The provisions of this §748.4371 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4371 When is the plan for the assessment complete? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189443&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189443 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189443&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189443 03/12/2026 (a) The assessment report that is the result of the assessment services is a narrative report that pulls together data from:(1) Professional evaluation reports on the child; and(2) The program's assessment on how the child is managing in the program.(b) The report includes:(1) Recommendations made in other professional evaluations; and(2) Recommendations based on the program's experiences with and assessment of the child.(c) The common application is not and must not serve as the assessment report. Source Note: The provisions of this §748.4391 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4391 What is an assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189440 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189440&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189440 03/12/2026 (a) The assessment report must be completed rapidly, consistent with good practice, in order to allow for a permanent placement as soon as possible.(b) You must complete the assessment report within:(1) 30 days after you admit the child, if the child is younger than five years old; or(2) 45 days after you admit the child, if the child is five years old or older.(c) With the approval of the child's parent, you may extend the time frame for completing the report for an additional 15 days. You must document the need for the extension of time in the child's record.(d) You must complete the assessment report before a planned discharge of the child from the assessment services program. However, additional assessment services may be conducted subsequent to placement if a quick placement is in the best interest of the child.(e) You must provide a copy of the assessment report to the child's parent as soon as the report is complete. Source Note: The provisions of this §748.4393 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective September 1, 2010, 35 TexReg 7497; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4393 When must I complete the assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189441 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189441&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189441 03/12/2026 In addition to the requirements set forth in §748.1217 of this title (relating to What information must an admission assessment include?), a written assessment report must include:(1) Copies and results of the determination of the child's basic health and social and developmental assessment, including:(A) The child's basic health status, as determined under the supervision of a licensed physician;(B) The child's basic social and developmental needs, as determined under the supervision of the person responsible for the assessment services program or a designated employee who meets the qualifications for a person responsible for the assessment program;(C) Recommendations for any further assessment services and testing; and(D) An assessment of the child's immediate and extended family in terms of an ongoing relationship with the child;(2) Copies and results of all evaluations and testing;(3) A summary of the primary caregivers' evaluations of the child's behavior and level of functioning;(4) An assessment of the results and summary in terms of appropriate short- and long-term planning for the child;(5) Recommendations for placement; and(6) A recommended behavior management plan based on the assessment results and the primary caregivers' evaluations of the child's behavior and level of functioning. Source Note: The provisions of this §748.4395 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4395 What must be included in the written assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189442 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189442&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189442 03/12/2026 (a) The following people must review the assessment report:(1) The person responsible for the assessment program or a designated employee who meets the qualifications of a person responsible for the assessment program;(2) The child's primary caregiver; and(3) The child's parent.(b) The person responsible for the assessment program, or the designated qualified employee, must approve and sign the report.(c) You must file the original, approved and signed assessment report, including any addendums to the report, in the child's record. Source Note: The provisions of this §748.4397 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS T ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §748.4397 Who must review and approve an assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189444 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189444 03/12/2026 These words have the following meanings in this subchapter:(1) Permanent camp--The permanent structure at which the basic needs for camp operation, such as resident housing, water supply and septic systems, and permanent toilet and/or cooking facilities, are provided.(2) Permanent structure--Man-made permanent or semi-permanent structures in which groups of people live, eat, sleep, or assemble, such as dining halls, dormitories, cabins, or other structures which are not constructed to be readily movable.(3) Primitive camp--A portion of the permanent campsite premises or another site at which the basic needs for camp operation, such as water supply systems, and permanent toilet and/or cooking facilities or other permanent structures, are not provided and in which a child stays no longer than 14 days before returning to the permanent camp. Source Note: The provisions of this §748.4401 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4401 What do certain words mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189445 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189445&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189445 03/12/2026 (a) For a child to be eligible to participate in a therapeutic camp program, the child must:(1) Be 13 years old or older;(2) Be in need of treatment services for an emotional disorder; and(3) Have difficulty functioning in his home, school, or community.(b) Individuals that are not eligible to participate in a therapeutic camp program include:(1) An adult;(2) A child under 13 years old;(3) A child who receives child-care services only, including a child in a transitional living services program;(4) A child who is pregnant. If a child becomes pregnant while in care, you must arrange for the child's immediate discharge or transfer from your therapeutic camp program;(5) An adolescent parent with his or her child;(6) A child with primary medical needs or other medical conditions that cannot be easily provided to the child at the permanent campsite or during primitive camping excursions;(7) A child diagnosed with Autism Spectrum Disorder;(8) A child diagnosed with an intellectual disability;(9) A child for an emergency admission; and(10) A child for child day care services. Source Note: The provisions of this §748.4403 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4403 What children are eligible to participate in a therapeutic camp program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189446 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189446&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189446 03/12/2026 You must ensure that:(1) An employee with at least six weeks experience in supervising a similar type of activity supervises an adventure/challenge program that requires spotting or belaying;(2) Prior to assuming duty as a spotter and belayer, a person receives instruction in the proper procedures;(3) A spotter or belayer is directly supervised until the person demonstrates competency;(4) There is a method for controlling access to the equipment and the activity area in order to prevent unauthorized or unsupervised use by a child;(5) Safety checks are performed on all equipment and ropes prior to each use;(6) Each child has a safety orientation before engaging in the activity; and(7) Each child wears appropriate personal protective equipment during an activity. Source Note: The provisions of this §748.4431 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4431 What are the requirements for an adventure/challenge program that requires spotting or belaying? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189447 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189447&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189447 03/12/2026 A primitive camping excursion lasts no more than 14 days, after which children on the camping excursion must return to the permanent camp. Source Note: The provisions of this §748.4461 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4461 What is considered a primitive camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189448 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189448&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189448 03/12/2026 (a) If your therapeutic camp program only allows children to stay at the camp for less than 90 days, then children must remain at the permanent camp at least two days between primitive camping excursions and activities.(b) If your therapeutic camp program allows children to stay at the camp for 90 days or more, then children must remain at the permanent camp at least 21 days between primitive camping excursions and activities. Source Note: The provisions of this §748.4463 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4463 How long must children remain at the operation's permanent camp between primitive camping excursions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189452 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189452&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189452 03/12/2026 (a) In addition to meeting the child/caregiver ratio requirements in Subchapter G of this chapter (relating to Child/Caregiver Ratios), you must have at least two caregivers during any primitive camping excursion.(b) In a mixed gender group, there must be a caregiver of each gender at all times. Source Note: The provisions of this §748.4465 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4465 What child/caregiver ratios apply to a primitive camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189453 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189453&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189453 03/12/2026 (a) You may use pit privies and portable toilets in remote camping areas. You must ensure that the pit privies and portable toilets are:(1) Maintained in good repair and kept clean at all times;(2) Constructed and maintained according to manufacturer designs and standards set forth by the Department of State Health Services, General Sanitation Division;(3) Maintained to prevent access by flies and animals to the contents contained within, to prevent fly breeding, and to prevent contamination of any water supply;(4) Equipped with toilet paper at all times; and(5) Serviced for the disposal of human excreta that meet regulations set forth by the Texas Commission on Environmental Quality.(b) If the camp site is not provided with pit privies or other portable toilets, you must:(1) Comply with the requirements of §748.3861 of this title (relating to What are the requirements for toilet facilities during overnight camping excursions?); and(2) Have a readily available supply of clean earth backfill or other disposal methods that meet regulations set forth by the Texas Commission on Environmental Quality for the disposal of human excreta in these areas. Source Note: The provisions of this §748.4467 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4467 What are the requirements for toilet facilities for a primitive camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189449 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189449&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189449 03/12/2026 (a) Children and employees must sanitize their hands.(b) At least one of the following methods for sanitizing hands must be available at the campsite:(1) Bathrooms equipped with running water must always have soap available for use within 20 feet of the toilet areas;(2) A hand-washing sink using a portable water supply must have a sanitary catch system approved by your local health department and must always have antibacterial liquid soup or an alcohol-based hand sanitizer available for use:(A) You must follow label directions when using alcohol-based hand sanitizers; and(B) Children must not have access to soiled water; or(3) Privies and portable toilet facilities not equipped with running water must always have at least a waterless alcohol-based hand sanitizer available for use adjacent to toilet facilities. You must follow label directions when using alcohol-based hand sanitizers. Source Note: The provisions of this §748.4469 adopted to be effective January 1, 2007, 31 TexReg 7377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4469 What are the requirements for sanitizing hands at a primitive campsite? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189450 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189450&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189450 03/12/2026 You must provide the following to a child who participates in a primitive camping excursion with:(1) Personal hygiene supplies that are biodegradable;(2) A means for a child to bathe or clean the child's body at least twice weekly; and(3) Females with body or hand sanitizing wipes or similar products for feminine hygiene purposes. Source Note: The provisions of this §748.4471 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4471 What personal hygiene provisions must I provide to a child who participates in a primitive camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189451 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189451&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189451 03/12/2026 You must provide the following to a child who participates in a primitive camping excursion:(1) A way to launder clothes at least weekly; or(2) Clean clothes at least weekly. Source Note: The provisions of this §748.4473 adopted to be effective January 1, 2007, 31 TexReg 7377; amended to be effective January 1, 2017, 41 TexReg 10393; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS U ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE THERAPEUTIC CAMP SERVICES §748.4473 What are the requirements for laundry provisions on a primitive camping excursion? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189456 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189456&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189456 03/12/2026 In this subchapter, trafficking victim services means a specialized type of child-care services designed to treat and support trafficking victims, in addition to basic child care services. Source Note: The provisions of this §748.4501 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4501 What does "trafficking victim services" mean when used in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189458&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189458 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189458&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189458 03/12/2026 You must meet the additional rules of this subchapter if you provide trafficking victim services to:(1) 25 or more children; or(2) More than 30% of the children in your care. Source Note: The provisions of this §748.4503 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4503 When am I required to meet the additional rules of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189459 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189459&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189459 03/12/2026 An operation that is required to comply with this subchapter must comply with all other rules in this chapter that apply to all operations, as well as the rules that apply to an operation that provides treatment services to children with an emotional disorder, unless any such rule is replaced by a rule in this subchapter, as noted in §748.4507 of this title (relating to What rules in this subchapter replace other rules in this chapter?). Source Note: The provisions of this §748.4505 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4505 In addition to the rules in this subchapter, what other rules in this chapter apply to an operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189454 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189454&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189454 03/12/2026 An operation that is required to comply with the rules in this subchapter is not required to comply with other rules in this chapter if the rule has been replaced, as specified in the following chart: Attached Graphic Source Note: The provisions of this §748.4507 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4507 What rules in this subchapter replace other rules in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189455 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189455&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189455 03/12/2026 You must develop written policies that address how your operation will:(1) Provide a variety of engaging activities to help trafficking victims develop their skills and independence and gain a sense of personal identity, including providing life skills training for children 14 years of age or older;(2) Tailor education to the child's needs;(3) Provide mentoring services; and(4) Prevent and discourage trafficking victims from running away from your operation. Source Note: The provisions of this §748.4551 adopted to be effective December 1, 2014, 39 TexReg 9052; amended to be effective June 1, 2016, 41 TexReg 3756; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4551 What additional child-care policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211292 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211292&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211292 03/12/2026 You must develop written policies that address:(1) The measures you will implement to ensure the safety and security of trafficking victims and employees, including measures that address both interior and exterior security while promoting a comfortable and nurturing environment on the grounds of your operation;(2) Employee protocols and procedures for ensuring a safe environment, including:(A) An internal and external communication system that addresses emergency situations; and(B) How to handle visitors not allowed on the premises of the operation; and(3) Appropriate safeguards with respect to a trafficking victim's access to forms of communication, including telephones, cell phones, computer, internet, mail, and visitors, which may pose a risk of further victimization of the child. Source Note: The provisions of this §748.4553 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 21, 2022, 47 TexReg 8115. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4553 What safety and security policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189460 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189460&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189460 03/12/2026 You must develop written policies that address confidentiality, including policies that:(1) Restrict the disclosure of information, both written and oral, that would identify a child as a trafficking victim, or describe the nature of the victim's trafficking history, other than as needed to serve the victim or comply with other laws;(2) Specify to whom and under what circumstances an employee or volunteer may disclose the location of the operation; and(3) Specify the circumstances under which a visitor may or may not be allowed on the premises of the operation. Source Note: The provisions of this §748.4555 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4555 What confidentiality policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189461 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189461&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189461 03/12/2026 A treatment director that provides or oversees treatment services for trafficking victims must:(1) Be a psychiatrist or psychologist;(2) Have a master's degree in a human services field from an accredited college or university and three years of experience providing treatment services for trafficking victims or children with an emotional disorder, including one year in a residential setting; or(3) Be a licensed master social worker, a licensed clinical social worker, a licensed professional counselor, or a licensed marriage and family therapist, and have three years of experience providing treatment services for trafficking victims or children with an emotional disorder, including one year in a residential setting. Source Note: The provisions of this §748.4601 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4601 What qualifications must a treatment director have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189462 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189462&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189462 03/12/2026 Each volunteer whose responsibilities include working with trafficking victims must have one hour of training prior to working with the children. The training must include the following components that explain:(1) The operation's confidentiality policies; and(2) How the effects of trauma impact working with trafficking victims. Source Note: The provisions of this §748.4603 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4603 Are there additional training requirements for volunteers who have contact with children receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189463 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189463&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189463 03/12/2026 (a) Before you may assign a caregiver to be the only caregiver responsible for a child in care, the caregiver must have a minimum of 40 hours of supervised child-care experience in:(1) Your operation;(2) Another general residential operation, in which treatment services for children with an emotional disorder or trafficking victim services are provided to 25 or more children or 30% or more of the operation's children; or(3) A child-placing agency, in which treatment services for children with an emotional disorder or trafficking victim services are provided to 30 or more children or 50% or more of the agency's children;(b) Until a caregiver has the minimum amount of supervised child-care experience as specified in subsection (a) of this section, the caregiver must be supervised at all times by another caregiver who has already satisfied the minimum caregiver qualifications described in subsection (a) of this section.(c) The supervised child-care experience must be documented in the appropriate personnel record. Source Note: The provisions of this §748.4651 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4651 What are the pre-service experience requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189464 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189464&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189464 03/12/2026 (a) Caregivers and certain employees must complete the following training hours before the noted time frame: Attached Graphic(b) You must document the completion of each training requirement in the appropriate personnel record. Source Note: The provisions of this §748.4653 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4653 What are the pre-service hourly training requirements for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189465 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189465&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189465 03/12/2026 (a) An operation does not have to provide additional general pre-service training or pre-service training regarding emergency behavior intervention to any caregiver or employee who is exempt from this training by §748.867 of this title (relating to Must I provide pre-service training to a caregiver or an employee who has previously worked in an operation?). In addition, a caregiver or employee (child-care administrator, treatment director, professional level service provider, or case manager) does not have to complete the five hours of pre-service training regarding complex trauma experienced by trafficking victims if the caregiver or employee:(1) During the last 12 months:(A) Worked in a general residential operation that provides trafficking victim services to 25 or more children, or 30% or more of the operation's children in care; or(B) Was a caregiver or employee for a child-placing agency that provides trafficking victim services to 30 or more children, or 50% or more of the child-placing agency's children in care; and(2) Has documentation that the caregiver or employee has previously received the five hours of pre-service training.(b) You must document the exemption factors in the appropriate personnel record. Source Note: The provisions of this §748.4655 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4655 Must I provide pre-service training to a caregiver or employee who has previously worked in another operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189469 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189469 03/12/2026 Caregivers and certain employees must complete the following training hours:Attached Graphic Source Note: The provisions of this §748.4657 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4657 What are the annual training requirements for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211293 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211293&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211293 03/12/2026 The four hours of annual training must include:(1) One hour of training in preventing compassion fatigue and secondary traumatic stress; and(2) Three hours of training in areas appropriate to the needs of children for whom the operation or caregiver will be providing care, which may include:(A) Typology of trafficking victims;(B) Manifestations of trauma and practice in trauma informed care;(C) How trafficking victims are manipulated and controlled;(D) Making informed decisions and setting boundaries for trafficking victims;(E) Understanding and avoiding the triggers of trafficking victims;(F) Creating and maintaining nurturing environments for trafficking victims; and(G) Identifying and responding to internal and external safety and security risks at the operation, including the grounds of the operation (e.g., high flight risk, potential self-harm, harm to others, internal recruitment, unapproved visitors, and intruders). Source Note: The provisions of this §748.4659 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 21, 2022, 47 TexReg 8115. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4659 What areas or topics must the four hours of training regarding trafficking victims include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189466 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189466&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189466 03/12/2026 (a) A single caregiver may care for a maximum of four children during waking hours.(b) A child does not count in the child/caregiver ratio while the child is away from the operation participating in an approved unsupervised childhood activity. Source Note: The provisions of this §748.4701 adopted to be effective December 1, 2014, 39 TexReg 9052; amended to be effective January 1, 2017, 41 TexReg 10422; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4701 For purposes of the child/caregiver ratio, how many children can a single caregiver care for during the children's waking hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189467 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189467&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189467 03/12/2026 (a) A single caregiver may care for a maximum of eight children during night-time sleeping hours.(b) Caregivers must remain awake during night-time sleeping hours. Source Note: The provisions of this §748.4703 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4703 For purposes of the child/caregiver ratio, how many children can a single caregiver care for when children are asleep at night? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189468 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189468&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189468 03/12/2026 In addition to meeting the requirements under §748.1223 of this title (relating to What are the medical requirements when I admit a child into care?):(1) You must ensure that a child receiving trafficking victim services is screened within 72 hours of admission to determine whether there is an immediate need for any of the following types of medical services:(A) A medical examination by a health-care professional; and(B) Medical tests for pregnancy and the following infectious diseases:(i) Hepatitis B;(ii) Hepatitis C;(iii) HIV;(iv) Sexually transmitted diseases (STDs); and(v) Tuberculosis.(2) Each individual screening is not required if:(A) The child was previously placed in a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department;(B) There was a previous screening completed within the last 12 months;(C) You have documentation of the outcome of the screening;(D) The child did not run away from the operation or get discharged from the program since the previous screening; and(E) There is no clear indication that the child has been injured, victimized, or re-victimized since the previous screening.(3) If the results of the required screening indicate that there is an immediate need for a medical examination or medical tests, you must obtain the medical examination and/or medical tests within five days. Source Note: The provisions of this §748.4751 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4751 Are there additional medical requirements when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189472 03/12/2026 Yes, you must ensure that a child receiving trafficking victim services is screened for alcohol and substance abuse within 72 hours of admission. The screening is not required if:(1) You have documentation of:(A) A child's alcohol and substance abuse screening that was conducted within the previous 12 months during the child's placement at a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department; or(B) A professional assessment that was conducted within the previous 12 months that determined whether alcohol and substance abuse services were needed for the child; and(2) There is no clear indication that the child has developed an alcohol or substance abuse dependency since the date of the previous screening or assessment. Source Note: The provisions of this §748.4753 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4753 Must a child I admit for trafficking victim services have an alcohol and substance abuse screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189473 03/12/2026 If an alcohol and substance abuse screening determines a child receiving trafficking victim services may need alcohol or substance abuse treatment, you must:(1) Within 14 days, coordinate and schedule the child for an alcohol and substance abuse professional assessment;(2) Ensure the professional recommendations are carried out; and(3) File documentation of the professional assessment, recommendations, and follow-up in the child's record. Source Note: The provisions of this §748.4755 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4755 What must I do if an alcohol and substance abuse screening determines that a child receiving trafficking victim services may need alcohol or substance abuse treatment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189474 03/12/2026 (a) Within 30 days of admission, you must ensure that a child receiving trafficking victim services is assessed for the following:(1) Post-Traumatic Stress Disorder (PTSD);(2) Depression; and(3) Anxiety.(b) The results of all assessments must be documented in the child's record.(c) Each individual behavioral health assessment is not required if:(1) The child was previously placed at a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department;(2) There was a previous assessment completed within the last 12 months;(3) You have documentation of the outcome of the child's assessment; and(4) There is no clear indication that the child has developed one of these disorders since the previous assessment. Source Note: The provisions of this §748.4757 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4757 What behavioral health assessments are required when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189471 03/12/2026 (a) A professional service provider must:(1) Provide individual counseling to each child receiving trafficking victim services. The counseling must address any issues noted in the behavioral health assessment and whether intervention and additional treatment is needed for sexual assault;(2) Provide family counseling, as appropriate; and(3) Assess the frequency and duration of the counseling.(b) You must document the assessment in the child's record.(c) If a child refuses counseling, you must document this refusal in the child's record.(d) For purposes of this rule, a professional service provider means:(1) A psychiatrist licensed by the Texas State Board of Medical Examiners;(2) A psychologist licensed by the Texas State Board of Examiners of Psychologists;(3) A master's level social worker or higher licensed by the Texas State Board of Social Work Examiners;(4) A professional counselor licensed by the Texas State Board of Examiners and Professional Counselors;(5) A marriage and family therapist licensed by the Texas State Board of Examiners of Marriage and Family Therapists; or(6) A master's level or higher nurse licensed as an Advanced Practice Registered Nurse by the Texas Board of Nursing and board certified in Psychiatric/Mental Health. Source Note: The provisions of this §748.4759 adopted to be effective December 1, 2014, 39 TexReg 9052; amended to be effective June 1, 2016, 41 TexReg 3756; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4759 What mental health services are required for a child receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189477 03/12/2026 In addition to the requirements listed in §748.1331 of this title (relating to What are the requirements for a preliminary service plan?), the preliminary service plan for a child receiving trafficking victim services must include a description of the child's immediate:(1) Safety needs; and(2) Behavioral health and treatment care needs. Source Note: The provisions of this §748.4761 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4761 Are there additional requirements for a preliminary service plan when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189478 03/12/2026 (a) In addition to the requirements and items noted in §748.1337 of this title (relating to What must a child's initial service plan include?), the initial service plan for a child receiving trafficking victim services must include:(1) The plans to obtain alcohol treatment, substance abuse treatment, or both, for children who require it;(2) Updated plans for behavioral health treatment, including intervention and treatment services for sexual assault, for children who require it; and(3) A description of any legal services required for the child and how you will assist the child in meeting those needs.(b) You must document all professional consultations, examinations, recommendations, and treatment in the child's record. Source Note: The provisions of this §748.4763 adopted to be effective December 1, 2014, 39 TexReg 9052; amended to be effective June 1, 2016, 41 TexReg 3756; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4763 What additional items must be included in a child's initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189475 03/12/2026 (a) You may admit a young adult into your transitional living program.(b) For other programs and services for trafficking victims, you may admit a young adult into your care if the young adult is determined to be a trafficking victim as stated in §748.61(2)(E) of this title (relating to What types of services does Licensing regulate?) and:(1) Is placed at your operation directly after being discharged from another residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department; or(2) Is placed at your operation within 12 months after being discharged from another residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department.(c) A young adult may remain in your care until the young adult's 23rd birthday. Source Note: The provisions of this §748.4765 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4765 May I admit a young adult into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189476 03/12/2026 (a) In addition to the requirements listed in §748.1937 of this title (relating to May an adult in care share a bedroom with a child in care?), a professional level service provider for operations must complete a re-assessment anytime a child or young adult:(1) Runs away from the operation and returns to care; or(2) Is discharged from your program and returns to care.(b) The re-assessment and approval by the professional level service provider must be documented and dated in the child's record. Source Note: The provisions of this §748.4767 adopted to be effective December 1, 2014, 39 TexReg 9052; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS V ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE TRAFFICKING VICTIM SERVICES §748.4767 May a young adult in care share a bedroom with a child in care receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221135 03/12/2026 In this subchapter, the following terms have the following meanings unless the context clearly indicates otherwise:(1) Individual--A person who is 21 years of age or younger.(2) Psychiatric health treatments and services--In addition to basic child-care services, a specialized type of child-care services provided by a certified psychiatric residential youth treatment facility to treat and support individuals who have a severe emotional disturbance.(3) Psychiatric Residential Youth Treatment Facility (PYRTF)--As defined at Texas Health and Safety Code §577A.001(3), a private facility that provides psychiatric health treatments and services in a residential, non-hospital setting exclusively to individuals and is licensed as a general residential operation.(4) Severe emotional disturbance--As defined at Texas Health and Safety Code §577A.001(4), a mental, behavioral, or emotional disturbance of sufficient duration to result in functional impairment that substantially interferes with or limits an individual's role or ability to function in family, school, or community activities. Source Note: The provisions of this §748.4801 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4801 What do the following terms mean when used in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221136 03/12/2026 A GRO that is a certified psychiatric residential youth treatment facility must meet the additional rules in this subchapter when providing psychiatric health treatments and services to an individual. Source Note: The provisions of this §748.4803 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4803 When is a general residential operation (GRO) required to meet the additional rules of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221137 03/12/2026 In addition to complying with the rules in this subchapter, a PRYTF must comply with all other rules in this chapter that apply to all operations, unless any such rule is replaced by a rule in this subchapter, as noted in §748.4809 of this division (relating to What rules in this subchapter replace other rules in this chapter?). Source Note: The provisions of this §748.4805 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4805 In addition to the rules in this subchapter, what other rules in this chapter apply to a psychiatric residential treatment facility (PRYTF)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221138 03/12/2026 The rules in this chapter that apply to a PRYTF as noted in §748.4805 of this division (relating to In addition to the rules in this subchapter, what other rules in this chapter apply to a psychiatric residential youth treatment facility (PRYTF)?) also apply to the care of a young adult 18 to 21 years of age whom the PRYTF has admitted for psychiatric health treatments and services. Source Note: The provisions of this §748.4807 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4807 How do the rules in this subchapter apply to the care of a young adult 18 to 21 years of age at a psychiatric residential treatment facility (PRYTF)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221134 03/12/2026 A psychiatric residential youth treatment facility (PRYTF) is not required to comply with other rules in this chapter if the rule has been replaced in this subchapter, as specified in this chart:Attached Graphic Source Note: The provisions of this §748.4809 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4809 What rules in this subchapter replace other rules in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221139 03/12/2026 A GRO must develop written policies that address:(1) How the PRYTF will provide 24-hour medical and emergency services, including 24-hour nursing services; and(2) How caregivers will supervise young adults 18 to 21 years of age receiving psychiatric health treatments and services and children in the GRO, including the PRYTF, when sharing restrooms or indoor or outdoor activity areas. The policy must:(A) Include a schedule for the young adults and children to use restrooms, for indoor activity time, including cafeteria usage, and outdoor activity time; and(B) Outline the specific staffing schedule caregivers will use and how the caregivers will maintain supervision, based on the supervision needs in the young adults' and children's service plans. Source Note: The provisions of this §748.4821 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4821 What additional policies must a general residential operation (GRO) submit as part of the application process for a psychiatric residential youth treatment facility (PRYTF) certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221140 03/12/2026 (a) A PRYTF must always meet the accreditation requirement of §745.9053 of this title (relating to What requirements must a general residential operation meet before applying for a psychiatric residential youth treatment facility (PRYTF) certificate?).(b) A PRYTF must notify CCR within two days if the accreditation organization informs the PRYTF that it has taken or will take an action that will result in the PRYTF no longer meeting the accreditation requirement of §745.9053 of this title for any period. Such an action includes revoking, suspending, or refusing to renew the PRYTF's accreditation. Source Note: The provisions of this §748.4823 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4823 When must a psychiatric residential youth treatment facility (PRYTF) notify Child Care Regulation (CCR) about accreditation changes regarding the PRYTF? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221141 03/12/2026 The PRYTF must post the PRYTF certificate in a prominent and publicly accessible place where employees, children, young adults, parents, and others will be able to view it easily. Source Note: The provisions of this §748.4825 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4825 Where must a psychiatric residential youth treatment facility (PRYTF) post the PRYTF certificate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221142 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221142&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221142 03/12/2026 A PRYTF must have a treatment director that is a full-time employee of the general residential operation. Source Note: The provisions of this §748.4831 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4831 Must a psychiatric residential youth treatment facility (PRYTF) have a treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221143 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221143&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221143 03/12/2026 A treatment director who provides or oversees psychiatric health treatments and services under this subchapter must:(1) Be a licensed psychiatrist, psychologist, or physician;(2) Have a master's degree in a human services field from an accredited college or university and three years of experience providing treatment services for children or young adults with an emotional disorder, including one year in a residential setting; or(3) Be a licensed master social worker, licensed clinical social worker, licensed professional counselor, or licensed marriage and family therapist, and have three years of experience providing treatment services for children or young adults with an emotional disorder, including one year in a residential setting. Source Note: The provisions of this §748.4833 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4833 What qualifications must a treatment director for a psychiatric residential youth treatment facility have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221144 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221144&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221144 03/12/2026 (a) A caregiver responsible for an individual receiving psychiatric health treatments and services must have a minimum of 40 hours of supervised caregiver experience in:(1) The current general residential operation providing treatment services to children with an emotional disorder;(2) Another general residential operation providing treatment services to children with an emotional disorder;(3) A psychiatric residential youth treatment facility providing psychiatric health treatments and services to children or young adults; or(4) A residential or hospital setting providing direct care, supervision, guidance, and protection of children or young adults with a severe emotional disturbance.(b) Until a caregiver has the minimum amount of supervised child-care experience as specified in subsection (a) of this section, the caregiver:(1) May not be assigned as the only caregiver responsible for a group of individuals if any individual in the group is receiving psychiatric health treatments and services;(2) Must be always supervised by another caregiver who has already satisfied the 40-hour experience requirement; and(3) Must have their supervised child-care experience documented in the appropriate personnel record. Source Note: The provisions of this §748.4841 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4841 What are the pre-service experience requirements for a caregiver providing psychiatric health treatments and services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221145 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221145&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221145 03/12/2026 (a) In addition to the types of pre-service training and hours at §748.863(a) of this chapter (relating to What are the pre-service training requirements for a caregiver?), a caregiver must complete four hours of suicide prevention training before the caregiver may be counted in the child to caregiver ratio if any individual in the group is receiving psychiatric health treatments and services.(b) In addition to the types of pre-service training and hours at §748.864(a) of this chapter (relating to What are the pre-service training requirements for an employee?), a child-care administrator, professional level service provider, treatment director, and case manager must complete four hours of suicide prevention training within 90 days of beginning job duties that include:(1) Providing services to or planning services for individuals receiving psychiatric health treatments and services; or(2) Managing or overseeing employees that provide services to or plans services for individuals receiving psychiatric health treatments and services.(c) To meet the pre-service training requirements, the suicide prevention training must meet:(1) The instructor requirements at §748.869(a) and (b) of this chapter (relating to How must pre-service training be conducted?); and(2) The curriculum requirements at §748.125(c)(1) of this chapter (relating to What is the model suicide prevention, intervention, and postvention policy?).(d) A caregiver or employee (child-care administrator, professional level service provider, treatment director, and case manager) does not have to complete the four hours of suicide prevention training if the caregiver or employee has documentation that it was completed during the last 12 months.(e) The PRYTF must document the exemption factor in the appropriate personnel record. Source Note: The provisions of this §748.4843 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4843 What additional pre-service training requirements apply to a caregiver or an employee at a psychiatric residential youth treatment facility (PRYTF)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221146 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221146&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221146 03/12/2026 (a) Caregivers providing psychiatric health treatments and services to individuals must have a current certificate of training with an expiration or renewal date in:(1) First-aid with rescue breathing and choking, which may be through instructor-led training or self-instructional training; and(2) Pediatric and adult cardiopulmonary resuscitation (CPR).(b) Each caregiver must be certified in first aid and CPR within 90 days of employment.(c) At least one person counted in the child to caregiver ratio must be certified in first aid and CPR at all times.(d) To meet the first-aid and CPR training requirements, the training must meet:(1) The CPR training requirements at §748.913 of this chapter (relating to What are the requirements for CPR training?); and(2) The documentation requirements at §748.915 of this chapter (relating to What documentation must I maintain for the first aid and CPR certifications?). Source Note: The provisions of this §748.4845 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4845 Who must have first-aid and CPR training in a psychiatric residential youth treatment facility? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221147 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221147&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221147 03/12/2026 (a) A caregiver providing psychiatric health treatments and services to an individual in a PRYTF must complete 50 annual training hours.(b) In addition to the one hour of annual suicide prevention training required in §748.125(c) of this chapter (relating to What is the model suicide prevention, intervention, and postvention policy?):(1) A caregiver must complete four additional hours of annual suicide prevention training for a total of five hours of annual suicide prevention training if the caregiver provides care to an individual receiving psychiatric health treatments and services; and(2) A child-care administrator, professional level service provider, treatment director, and case manager must complete four additional hours of annual suicide prevention training for a total of five hours of annual suicide prevention training if the employee is or will be:(A) Providing services to or planning services for individuals receiving psychiatric health treatments and services; or(B) Managing or overseeing other employees that provide services to or plans services for individuals receiving psychiatric health treatments and services.(c) In addition to the specific types of annual training and hours required in §748.930(b) of this chapter (relating to What are the annual training requirements for a caregiver?), a caregiver providing psychiatric health treatments and services to an individual must complete two hours of annual training on administering psychotropic medication.(d) In addition to the specific types of annual training and hours required in §748.931(b) and (c) of this chapter (relating to What are the annual training requirements for an employee), a child-care administrator, professional level service provider, treatment director, and case manager must complete two hours of annual training on administering psychotropic medication if the employee is or will be:(1) Providing services to or planning services for individuals receiving psychiatric health treatments and services; or(2) Managing or overseeing other employees that provide services to or plans services for individuals receiving psychiatric health treatments and services.(e) To meet the annual training requirements, the annual training must meet the requirements in:(1) §748.935 of this chapter (relating to When must an employee or caregiver complete the annual training?);(2) §748.937 of this chapter (relating to What types of hours or instruction can be used to complete the annual training requirements?);(3) §748.941 of this chapter (relating to How must annual training be conducted?);(4) §748.945 of this chapter (relating to What curriculum components must be included in the annual training for administering psychotropic medication?);(5) §748.125(c)(1) of this chapter (relating to What is the model suicide prevention, intervention, and postvention policy?), relating to the curriculum components for suicide prevention training; and(6) §748.949 of this chapter (relating to What documentation must I maintain for annual training?). Source Note: The provisions of this §748.4847 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4847 What additional annual training requirements apply to a caregiver or an employee at a psychiatric residential youth treatment facility (PRYTF)? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221148 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221148&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221148 03/12/2026 (a) If any child in the group is receiving psychiatric health treatments and services, a single caregiver may care for a maximum of six children during the night-time sleeping hours.(b) Caregivers must remain awake during night-time sleeping hours.(c) This ratio also applies to any young adults 18 to 21 years of age who are receiving psychiatric health treatments and services under this subchapter. Source Note: The provisions of this §748.4851 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4851 For purposes of the child to caregiver ratio, how many children can a single caregiver care for when a child receiving psychiatric health treatments and services is asleep at night? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221149 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221149&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221149 03/12/2026 A PRYTF may only admit an individual for psychiatric health treatments and services who:(1) Is 21 years of age or younger;(2) Has been diagnosed with a severe emotional disturbance by a licensed mental health professional;(3) Requires residential psychiatric treatment under the direction of a licensed physician to improve the individual's condition; and(4) Was referred for treatment or services in a PRYTF by a licensed mental health professional. Source Note: The provisions of this §748.4861 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4861 Whom may a psychiatric residential youth treatment facility (PRYTF) admit for psychiatric health treatments and services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221150 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221150&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221150 03/12/2026 (a) Except as provided by subsections (c) and (d) of this section, children receiving different types of service may reside in the same living quarters as long as:(1) A professional level service provider completes an evaluation of the living quarters for each child that the psychiatric residential youth treatment facility (PRYTF) places in the living quarters; and(2) In each evaluation, the professional level service provider ensures that:(A) There is no conflict of care with the best interests of any of the children placed in the living quarters;(B) Placing the child with different service or treatment needs in the living quarters will not adversely impact the other children in the living quarters;(C) The number of children in the living quarters is appropriate at all times based on the needs of all children in the living quarters;(D) Caregivers can appropriately supervise all children in the living quarters at all times; and(E) The PRYTF can meet the needs of all children in the living quarters.(b) If the treatment or service needs of any child in the living quarters changes, the professional level service provider must evaluate the needs of each child in the living quarters to ensure there is no conflict of care.(c) Children admitted for emergency care services must receive any therapeutic services (such as group therapy or art therapy) separately from children admitted for non-emergency care and must have separate living quarters, such as a separate wing of an operation, or a separate cottage. The PRYTF may combine children admitted for emergency care services with children in non-emergency care for meals, recreation, and transportation.(d) Young adults 18 to 21 years of age receiving psychiatric health treatments and services that are not in the care of the Texas Department of Family and Protective Services and did not come immediately from another residential child-care operation:(1) Must receive therapeutic services (such as group therapy or art therapy) separately from children admitted to the operation, including the PRYTF;(2) Must have separate living quarters, such as a separate wing of an operation, or a separate cottage; and(3) Must not use an area of the general residential operation's building or grounds at the same time with children admitted to the operation, including the PRYTF, except restrooms and indoor and outdoor activity areas may be shared under a policy required by §748.4821 of this subchapter (relating to What additional policies must a general residential operation (GRO) submit as part of the application process for a psychiatric residential youth treatment facility (PRYTF) certificate?). Source Note: The provisions of this §748.4863 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4863 May individuals receiving different types of service live in the same living quarters? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221151 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221151&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221151 03/12/2026 When a PRYTF admits an individual for psychiatric health treatments and services, in addition to the requirements listed in §748.1331 of this chapter (relating to What are the requirements for a preliminary service plan?), the preliminary service plan for an individual receiving psychiatric health treatments and services must include:(1) Therapeutic needs, including plans for psychiatric evaluation, the use of psychotropic medications, and one-to-one therapy;(2) Family engagement activities;(3) Plans to consult with qualified professionals, including case managers, primary care professionals, community-based mental health providers, school staff, and other support planners; and(4) Nursing care. Source Note: The provisions of this §748.4865 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4865 Are there additional requirements for a preliminary service plan when a psychiatric residential youth treatment facility (PRYTF) admits an individual for psychiatric health treatments and services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221152 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221152&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221152 03/12/2026 (a) In addition to the requirements listed in (b)(2) in Figure: 26 TAC §748.1337(b) of this chapter (relating to What must a child's initial service plan include?), the initial service plan for an individual receiving psychiatric health treatments and services must include:(1) One-to-one therapy;(2) Family engagement activities;(3) Consultation services with qualified professionals, including case managers, primary care professionals, community-based mental health providers, school staff, and other support planners;(4) 24-hour nursing services, though services do not need to be onsite; and(5) Direct care and supervision services, supportive services for daily living and safety, and positive behavior management services.(b) A PRYTF must document all professional consultations, examinations, recommendations, and treatment in the individual's record. Source Note: The provisions of this §748.4867 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4867 Are there additional requirements for an initial service plan when a psychiatric residential youth treatment facility (PRYTF) admits an individual for psychiatric health treatments and services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221153 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221153&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221153 03/12/2026 (a) A service planning team must develop the service plan. The team must consist of:(1) At least one of the individual's current caregivers;(2) For a child, a person designated to make decisions regarding a child's participation in childhood activities; and(3) At least one professional level service provider who provides direct services to the individual.(b) Except as provided by subsection (c) of this section, if a general residential operation is providing treatment services to a child, the team must also include two of the following professions:(1) A licensed professional counselor;(2) A psychologist;(3) A psychiatrist or physician;(4) A licensed registered nurse;(5) A licensed masters level social worker;(6) A licensed or registered occupational therapist; or(7) Any other person in a related discipline or profession that is licensed or regulated in accordance with state law.(c) If a psychiatric residential youth treatment facility is providing psychiatric health treatments and services to an individual, the team must also include a licensed psychiatrist or physician and one of the following professionals:(1) A licensed professional counselor;(2) A psychologist;(3) A licensed registered nurse;(4) A licensed masters level social worker; or(5) Any other person in a related discipline or profession that is licensed or regulated in accordance with state law.(d) The individual and parents or guardian must be invited to a service planning meeting, so that they may participate and provide input into the development of the service plan. Source Note: The provisions of this §748.4869 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4869 Who must be involved in developing an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221154 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=221154&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 221154 03/12/2026 A child who turns 18 years old in the care of a PRYTF may remain in care until the young adult's 22nd birthday. Source Note: The provisions of this §748.4881 adopted to be effective October 15, 2024, 49 TexReg 8164. 1 HEALTH AND HUMAN SERVICES COMMISSION 748 MINIMUM STANDARDS FOR GENERAL RESIDENTIAL OPERATIONS W ADDITIONAL REQUIREMENTS FOR OPERATIONS THAT PROVIDE PSYCHIATRIC HEALTH TREATMENTS AND SERVICES §748.4881 After a child in the care of a psychiatric residential youth treatment facility (PRYTF) turns 18 years old, may the young adult remain in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189479 03/12/2026 The purpose of this chapter is to set forth the rules that apply to child-placing agencies. Source Note: The provisions of this §749.1 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES A PURPOSE AND SCOPE §749.1 What is the purpose of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189480 03/12/2026 The permit holder must ensure compliance with all rules of this chapter at all times, with the exception of those rules identified for specific types of services that your agency does not offer. For example, if we grant you a permit to offer adoption services only, you do not have to comply with rules that apply to foster care services; however, you must comply with all other rules of this chapter. Source Note: The provisions of this §749.3 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES A PURPOSE AND SCOPE §749.3 Who is responsible for complying with the rules of this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192558 03/12/2026 The following words have the following meanings in this chapter:(1) I, my, you, and your--An applicant or permit holder, unless otherwise stated.(2) We, us, our, and Licensing--The Child Care Licensing Department of the Health and Human Services Commission (HHSC). Source Note: The provisions of this §749.41 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 19, 2018, 43 TexReg 6658. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.41 What do certain pronouns mean in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211294 03/12/2026 The words and terms used in this chapter have the meanings assigned to them under §745.21 of this title (relating to What do the following words and terms mean when used in this chapter?), unless another meaning is assigned in this section or unless the context clearly indicates otherwise. The following words and terms have the following meanings unless the context clearly indicates otherwise:(1) Accredited college or university--An institution of higher education accredited by one of the following regional accrediting entities:(A) The Southern Association of Colleges and Schools Commission on Colleges, a subdivision of the Southern Association of Colleges and Schools;(B) The Middle States Commission on Higher Education, a component of the Middle States Association of Colleges and Schools;(C) The Commission on Institutions of Higher Education, a subdivision of the New England Association of Schools and Colleges;(D) The Higher Learning Commission (formerly part of the North Central Association of Colleges and Schools);(E) The Northwest Commission on Colleges and Universities;(F) The Accrediting Commission for Senior Colleges and Universities, a subdivision of the Western Association of Schools and Colleges; or(G) The Accrediting Commission for Community and Junior Colleges, a subdivision of the Western Association of Schools and Colleges.(2) Adaptive functioning--Refers to how effectively a person copes with common life demands and how well the person meets standards of personal independence expected of someone in his particular age group, socio-cultural background, and community setting.(3) Adoption record--All information received by the child-placing agency that bears the child's name or pertains to the child, including any information about the birth parents and adoptive parents, is considered to be part of the adoption record.(4) Adoptive home screening--Also known as a pre-adoptive home screening. A written evaluation, prior to the placement of a child in an adoptive home, of the:(A) Prospective adoptive parents;(B) Family of the prospective adoptive parents; and(C) Environment of the adoptive parents and their family in relation to their ability to meet the needs of a child, and if a child has been identified for adoption, the needs of that particular child.(5) Adult--A person 18 years old or older.(6) Adverse action--See corrective or adverse action.(7) Babysitter--A person who temporarily cares for a child in foster care for no more than 12 consecutive hours. A babysitter is not required to meet the requirements for a caregiver unless the babysitter is a verified foster parent, an agency employee, a contract service provider, or a volunteer.(8) Babysitting--Care provided by a babysitter.(9) Caregiver--A caregiver:(A) Is a person counted in the child/caregiver ratio for foster care services, including employees, foster parents, contract service providers, and volunteers, whose duties include direct care, supervision, guidance, and protection of a child in care. This includes any person who is solely responsible for a child in foster care. For example, a child-placement staff that takes a foster child on an appointment or doctor's visit is considered a caregiver;(B) Does not include a babysitter, an overnight care provider, or a respite child-care provider unless the person is:(i) A verified foster parent;(ii) An agency employee;(iii) A contract service provider; or(iv) A volunteer.(C) Does not include a contract service provider who:(i) Provides a specific type of service to your agency for a limited number of hours per week or month;(ii) Works with one particular child; or(iii) Is a nurse being reimbursed by Medicaid;(D) Does not include a person left alone momentarily with a child in care while the caregiver leaves the room; and(E) Does not include an adoptive parent.(10) Certified fire inspector--Persons certified by the Texas Commission on Fire Protection to conduct fire inspections.(11) Chemical restraint--A prohibited type of emergency behavior intervention that uses chemicals or pharmaceuticals through topical application, oral administration, injection, or other means to immobilize or sedate a child as a mechanism of control. The use of a medication is not a chemical restraint under this chapter if the medication:(A) Is prescribed by a treating health-care professional;(B) Is administered solely for medical or dental reasons; and(C) Has a secondary effect of immobilizing or sedating a child.(12) Child in care--A child who has been placed by a child-placing agency in a foster or adoptive home, regardless of whether the child is temporarily away from the home. Unless a child has been discharged from the child-placing agency, the child is considered a child in care.(13) Child/caregiver ratio--The maximum number of children for whom one caregiver can be responsible.(14) Childhood activities--Activities that are generally accepted as suitable for children of the same chronological age, level of maturity, and developmental level as determined by a reasonable and prudent parent standard as specified in §749.2605 of this chapter (relating to What is the "reasonable and prudent parent standard"?). Examples of childhood activities include extracurricular activities, in-school and out-of-school activities, enrichment activities, cultural activities, and employment opportunities. Childhood activities include unsupervised childhood activities.(15) Contract service provider--A person or entity that is contracting with the operation to provide a service, whether paid or unpaid. Also referred to as "contract staff" and "contractor" in this chapter.(16) Corporation or other type of business entity--May include an association, corporation, nonprofit association, nonprofit corporation, nonprofit association with religious affiliation, nonprofit corporation with religious affiliation, limited liability company, political subdivision, or state agency. For purposes of this chapter, this definition does not include any type of "partnership," which is defined separately.(17) Corrective or adverse action--Is any action by you that places a restriction or condition on a foster home's verification, including the revocation of the verification. Note: For information regarding a corrective or adverse action which Licensing is taking against you, see Subchapter L of Chapter 745 (relating to Enforcement Actions).(18) Counseling--A procedure used by professionals from various disciplines in guiding individuals, families, groups, and communities by such activities as delineating alternatives, helping to articulate goals, processing feelings and options, and providing needed information. This definition does not include career counseling.(19) Days--Calendar days, unless otherwise stated.(20) De-escalation--Strategies used to defuse a volatile situation, to assist a child to regain behavioral control, and to avoid a physical restraint or other behavioral intervention.(21) Department--The Department of Family and Protective Services (DFPS).(22) Discipline--A form of guidance that is constructive or educational in nature and appropriate to the child's age, development, situation, and severity of the behavior.(23) Emergency Behavior Intervention (EBI)--Interventions used in an emergency situation, including personal restraints, mechanical restraints, emergency medication, and seclusion.(24) Emergency medication--A type of emergency behavior intervention that uses chemicals or pharmaceuticals through topical application, oral administration, injection, or other means to modify a child's behavior. The use of a medication is not an emergency medication under this chapter if the medication:(A) Is prescribed by a treating health-care professional;(B) Is administered solely for a medical or dental reason (e.g. Benadryl for an allergic reaction or medication to control seizures); and(C) Has a secondary effect of modifying a child's behavior.(25) Emergency situation--A situation in which attempted preventative de-escalatory or redirection techniques have not effectively reduced the potential for injury, so that intervention is immediately necessary to prevent:(A) Imminent probable death or substantial physical injury to the child because the child attempts or continually threatens to commit suicide or substantial physical injury; or(B) Imminent physical harm to another because of the child's overt acts, including attempting to harm others. These situations may include aggressive acts by the child, including serious incidents of shoving or grabbing others over their objections. These situations do not include verbal threats or verbal attacks.(26) Employee--A person an operation employs full-time or part-time to work for wages, salary, or other compensation. For the purposes of this chapter, employees include all child-placing agency staff and any owner who is present at the operation or a foster home or transports any child in care.(27) Family members--An individual related to another individual within the third degree of consanguinity or affinity. For the definitions of consanguinity and affinity, see Chapter 745 of this title (relating to Licensing). The degree of the relationship is computed as described in Government Code, §573.023 (relating to Computation of Degree of Consanguinity) and §573.025 (relating to Computation of Degree of Affinity).(28) Foster care--Care that is provided to a foster child by a foster family home.(29) Foster family home--A home that is the primary residence of the foster parent(s) and provides care for six or fewer children or young adults, under the regulation of a child-placing agency. Also referred to as a "foster home" in this chapter.(30) Foster home screening--A written evaluation, prior to the verification of the foster home, of the:(A) Prospective foster parent(s);(B) Family of the prospective foster parent(s);(C) All other part- or full-time household members; and(D) Environment of the foster parent(s) and their family in relation to their ability to meet the child's needs.(31) Foster parent--A person verified to provide child-care services in the foster home.(32) Full-time--At least 30 hours per week.(33) Governing body--A group of persons or officers of the corporation or other type of business entity having ultimate authority and responsibility for the child-placing agency.(34) Grounds--Includes any parcel of land where the foster home is located and any building, other structure, body of water, play equipment, street, sidewalk, walkway, driveway, parking garage, or parking lot on the parcel. Also referred to as "premises" in this chapter.(35) Health-care professional--A licensed physician, licensed advanced practice registered nurse (APRN), physician's assistant, licensed vocational nurse (LVN), licensed registered nurse (RN), or other licensed medical personnel providing health care to the child within the scope of the person's license. This does not include physicians, nurses, or other medical personnel not licensed to practice in the United States or in the country in which the person practices.(36) High-risk behavior--Behavior of a child that creates an immediate safety risk to the child or others. Examples of high-risk behavior include suicide attempt, self-abuse, physical aggression causing bodily injury, chronic running away, substance abuse, fire setting, and sexual aggression or perpetration.(37) Human services field--A field of study that contains coursework in the social sciences of psychology and social work including some counseling classes focusing on normal and abnormal human development and interpersonal relationship skills from an accredited college or university. Coursework in guidance counseling does not apply.(38) Immediate danger to self or others--A situation where a prudent person would conclude that bodily harm would occur if there were no immediate interventions. Immediate danger includes a serious risk of suicide, serious physical injury to self or others, or the probability of bodily harm resulting from a child running away. Immediate danger does not include:(A) Harm that might occur over time or at a later time; or(B) Verbal threats or verbal attacks.(39) Infant--A child from birth through 17 months.(40) Master record--The compilation of all required records for a specific person or home, such as a master personnel record, master case record for a child, or a master case record for a foster or adoptive home.(41) Mechanical restraint--A prohibited type of emergency behavior intervention that uses the application of a device to restrict the free movement of all or part of a child's body in order to control physical activity.(42) Mental health professional--Refers to:(A) A psychiatrist licensed by the Texas Medical Board;(B) A psychologist licensed by the Texas State Board of Examiners of Psychologists;(C) A master's level social worker or higher licensed by the Texas State Board of Social Work Examiners;(D) A professional counselor licensed by the Texas State Board of Examiners of Professional Counselors;(E) A marriage and family therapist licensed by the Texas State Board of Examiners of Marriage and Family Therapists; and(F) A master's level or higher nurse licensed as an Advanced Practice Registered Nurse by the Texas Board of Nursing and board certified in Psychiatric/Mental Health.(43) Non-ambulatory--A child that is only able to move from place to place with assistance, such as a walker, crutches, a wheelchair, or prosthetic leg.(44) Non-mobile--A child that is not able to move from place to place, even with assistance.(45) Normalcy--See §749.2601 of this chapter (relating to What is "normalcy"?).(46) Overnight care--Care provided by an overnight care provider.(47) Overnight care provider--A person who temporarily cares for a child in foster care for more than 12 consecutive hours, but no more than 72 consecutive hours.(48) Owner--The sole proprietor, partnership, or corporation or other type of business entity who owns a child-placing agency.(49) Parent--A person or entity that has legal responsibility for or legal custody of a child, including the managing conservator, or legal guardian of the child or a legally authorized representative of an entity with that status.(50) Partnership--A partnership may be a general partnership, (general) limited liability partnership, limited partnership, or limited partnership as limited liability partnership.(51) Permit holder--The owner of the child-placing agency that is granted the permit.(52) Person legally authorized to give consent--The person legally authorized to give consent by the Texas Family Code or a person authorized by the court.(53) Personal restraint--A type of emergency behavior intervention that uses the application of physical force without the use of any device to restrict the free movement of all or part of a child's body in order to control physical activity.(54) Physical force--Pressure applied to a child's body that reduces or eliminates the child's ability to move freely.(55) Post-adoption services--Services available through the child-placing agency (direct or on referral) to birth and adoptive parents and the adoptive child after the adoption is consummated. Examples include counseling, maintaining a registry if a central registry is not used, providing pertinent, new medical information to birth or adoptive parents, or providing the adult adoptee a copy of his record upon request.(56) Post-placement adoptive report--A written evaluation of the assessments and interviews, after the adoptive placement of the child, regarding the:(A) Child;(B) Prospective adoptive parent(s);(C) Family of the prospective adoptive parent(s);(D) Environment of the prospective adoptive parents and their family; and(E) Adjustment of all individuals to the placement.(57) Pre-adoptive home screening--See adoptive home screening.(58) Premises--See the term "grounds" and its definition in this section.(59) PRN--A standing order or prescription that applies "pro re nata" or "as needed according to circumstances."(60) Professional service provider--Refers to:(A) A child placement management staff or person qualified to assist in child placing activity;(B) A psychiatrist licensed by the Texas Medical Board;(C) A psychologist licensed by the Texas State Board of Examiners of Psychologists;(D) A master's level social worker or higher licensed by the Texas State Board of Social Work Examiners;(E) A professional counselor licensed by the Texas State Board of Examiners of Professional Counselors;(F) A marriage and family therapist licensed by the Texas State Board of Examiners of Marriage and Family Therapists;(G) A master's level or higher nurse licensed as an Advanced Practice Registered Nurse by the Texas Board of Nursing and board certified in Psychiatric/Mental Health; and(H) Other professional employees in fields such as drug counseling, nursing, special education, vocational counseling, pastoral counseling, and education who may be included in the professional staffing plan for your agency that provides treatment services if the professional's responsibilities are appropriate to the scope of the agency's program description. These professionals must have the minimum qualifications generally recognized in the professional's area of specialization.(61) Prone restraint--A restraint in which the child is placed in a chest-down hold.(62) Psychosocial assessment--An evaluation by a mental health professional of a child's mental health that includes a:(A) Clinical interview of the child;(B) Diagnosis from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), or statement that rules out a DSM-5 diagnosis;(C) Treatment plan for the child, including whether further evaluation of the child is needed (for example: is a psychiatric evaluation needed to determine if the child would benefit from psychotropic medication or hospitalization; or is a psychological evaluation with psychometric testing needed to determine if the child has a learning disability or an intellectual disability); and(D) Written summary of the assessment.(63) Re-evaluate--Assessing all factors required for the initial evaluation for the purpose of determining if any substantive changes have occurred. If substantive changes have occurred, these areas must be fully evaluated.(64) Regularly--On a recurring, scheduled basis. Note: For the definition for "regularly or frequently present at an operation" as it applies to background checks, see §745.601 of this title (relating to What words must I know to understand this subchapter?).(65) Residential child-care operation--A licensed or certified operation that provides residential child care. Also referred to as a "residential child-care facility."(66) Sanitize--The use of a product (usually a disinfecting solution) registered by the Environmental Protection Agency (EPA) that substantially reduces germs on inanimate objects to levels considered safe by public health requirements. Many bleach and hydrogen peroxide products are EPA-registered. You must follow the product's labelling instructions for sanitizing (paying particular attention to any instructions regarding contact time and toxicity on surfaces likely to be mouthed by children, such as toys and crib rails). For an EPA-registered sanitizing product or disinfecting solution that does not include labelling instructions for sanitizing (a bleach product, for example), you must conduct these steps in the following order:(A) Washing with water and soap;(B) Rinsing with clear water;(C) Soaking in or spraying on a disinfecting solution for at least two minutes. Rinsing with cool water only those items that a child is likely to place in his mouth; and(D) Allowing the surface or item to air-dry.(67) School-age child--A child who is five years old or older and is enrolled in or has completed kindergarten.(68) Seat belt--A lap belt and any shoulder strap included as original equipment on or added to a motor vehicle.(69) Seclusion--A type of emergency behavior intervention that involves the involuntary separation of a child from other children and the placement of the child alone in an area from which the child is prevented from leaving. Examples of such an area include where the child is prevented from leaving by a physical barrier, force, or threat of force.(70) Service plan--A plan that identifies a child's basic and specific needs and how those needs will be met.(71) Short personal restraint--A personal restraint that does not last longer than one minute before the child is released.(72) Single source continuum contractor--A child-placing agency that contracts with the Texas Department of Family and Protective Services to provide community-based care as described in Subchapter B-1, Chapter 264, Texas Family Code.(73) State or local fire authority--A fire official who is authorized to conduct fire safety inspections on behalf of the city, county, or state government, including certified fire inspectors.(74) Substantial physical injury--Physical injury serious enough that a reasonable person would conclude that the injury needs treatment by a medical professional, including dislocated, fractured, or broken bones; concussions; lacerations requiring stitches; second and third degree burns; and damages to internal organs. Evidence that physical injury is serious may include the location or severity of the bodily harm or the age of the child. Substantial physical injury does not include minor bruising, the risk of minor bruising, or similar forms of minor bodily harm that will resolve healthily without professional medical attention.(75) Supine restraint--Placing a child in a chest up restraint hold.(76) Supplement--Includes vitamins, herbs, and any supplement labeled dietary supplement.(77) Swimming activities--Activities related to the use of swimming pools, wading/splashing pools, hot tubs, or other bodies of water.(78) Toddler--A child from 18 months through 35 months old.(79) Trafficking victim--A child who has been recruited, harbored, transported, provided or obtained for the purpose of forced labor or commercial sexual activity, including any child subjected to an act or practice as specified in Penal Code §20A.02 or §20A.03.(80) Trauma informed care (TIC)--Care for children that is child-centered and considers the unique culture, experiences, and beliefs of the child. TIC takes into consideration:(A) The impact that traumatic experiences have on the lives of children;(B) The symptoms of childhood trauma;(C) An understanding of a child's personal trauma history;(D) The recognition of a child's trauma triggers; and(E) Methods of responding that improve a child's ability to trust, to feel safe, and to adapt to changes in the child's environment.(81) Treatment director--The person responsible for the overall treatment program providing treatment services. A treatment director may have other responsibilities and may designate treatment director responsibilities to other qualified persons.(82) Unsupervised childhood activities--Childhood activities that a child in care participates in away from the foster home and the foster parents. Childhood activities that the foster parents conduct or supervise or the child-placing agency sponsors are not unsupervised childhood activities. Unsupervised childhood activities may include playing sports, going on field trips, spending the night with a friend, going to the mall, or dating. Unsupervised childhood activities may last one or more days.(83) Volunteer--A person who provides:(A) Child-care services, treatment services, or programmatic services under the auspices of the agency without monetary compensation; or(B) Any type of services under the auspices of the agency without monetary compensation when the person has unsupervised access to a child in care.(84) Young adult--An adult whose chronological age is between 18 and 22 years, who is currently in a residential child-care operation, and who continues to need child-care services. Source Note: The provisions of this §749.43 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective June 1, 2008, 33 TexReg 4196; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective June 1, 2015, 40 TexReg 2790; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272; amended to be effective December 21, 2022, 47TexReg 8120. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.43 What do certain words and terms mean in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192552 03/12/2026 We regulate the following types of services:(1) Child-Care Services--Services that meet a child's basic need for shelter, nutrition, clothing, nurture, socialization and interpersonal skills, care for personal health and hygiene, supervision, education, and service planning;(2) Treatment Services--In addition to child-care services, a specialized type of child-care services designed to treat and/or support children:(A) With Emotional Disorders who have a current DSM-5 diagnosis, such as mood disorders, psychotic disorders, or dissociative disorders, and demonstrate two or more of the following:(i) Major self-injurious actions, including a suicide attempt within the last 12 months;(ii) Difficulties that present a significant risk of harm to others, including frequent or unpredictable physical aggression; or(iii) An additional DSM-5 diagnosis of substance-related and/or addictive disorder with severe impairment;(B) With a DSM-5 diagnosis of Intellectual Disability characterized by prominent, severe deficits and pervasive impairment in one or more of the following areas:(i) Conceptual, social, and practical adaptive skills to include daily living and self-care;(ii) Communication, cognition, or expressions of affect;(iii) Self-care activities or participation in social activities;(iv) Responding appropriately to an emergency; or(v) Multiple physical disabilities, including sensory impairments;(C) With a DSM-5 diagnosis of Autism Spectrum Disorder that is characterized by prominent, severe deficits and pervasive impairment in one or more of the following areas of development:(i) Conceptual, social, and practical adaptive skills to include daily living and self-care;(ii) Communication, cognition, or expressions of affect;(iii) Self-care activities or participation in social activities;(iv) Responding appropriately to an emergency; or(v) Multiple physical disabilities including sensory impairments;(D) With Primary Medical Needs, who cannot live without mechanical supports or the services of others because of life-threatening conditions, including:(i) The inability to maintain an open airway without assistance. This does not include the use of inhalers for asthma;(ii) The inability to be fed except through a feeding tube, gastric tube, or a parenteral route;(iii) The use of sterile techniques or specialized procedures to promote healing, prevent infection, prevent cross-infection or contamination, or prevent tissue breakdown; or(iv) Multiple physical disabilities including sensory impairments; and(E) Determined to be a trafficking victim, including a child:(i) Determined to be a trafficking victim as the result of a criminal prosecution or who is currently alleged to be a trafficking victim in a pending criminal investigation or prosecution;(ii) Identified by the parent or agency that placed the child with the child-placing agency as a trafficking victim; or(iii) Determined by the child-placing agency to be a trafficking victim based on reasonably reliable criteria, including one or more of the following:(I) The child's own disclosure as a trafficking victim;(II) The assessment of a counselor or other professional; or(III) Evidence that the child was recruited, harbored, transported, provided to another person, or obtained for the purpose of forced labor or commercial sexual activity; and(3) Additional Programmatic Services, which include:(A) Transitional Living Program--A residential services program designed to serve children 14 years old or older for whom the service or treatment goal is basic life skills development toward independent living. A transitional living program includes basic life skills training and the opportunity for children to practice those skills. A transitional living program is not an independent living program;(B) Assessment Services Program--Services to provide an initial evaluation of the appropriate placement for a child to ensure that appropriate information is obtained in order to facilitate service planning; and(C) Respite Child-Care Services--See §749.2621 of this title (relating to What are respite child-care services?). Source Note: The provisions of this §749.61 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9069; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.61 What types of services does Licensing regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192553 03/12/2026 You may provide each type of service that we regulate under the following conditions:(1) On your permit, we list the type of service that you have been approved to provide; and(2) Your operational policies and procedures ensure:(A) Children are admitted appropriately;(B) The needs of all children in care are met;(C) Children are appropriately supervised;(D) Children are protected from one another, if appropriate; and(E) You meet the applicable rules of this chapter. Source Note: The provisions of this §749.63 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.63 Can I provide each type of service that Licensing regulates? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192554 03/12/2026 (a) For a child to be eligible to participate in a transitional living program, the child must be 14 years old or older.(b) For a child to be eligible to receive the level of caregiver supervision described in §749.2597 of this title (relating to Where must the caregivers reside in order to supervise children who are in a transitional living program?), the child must be 16 years old or older. Source Note: The provisions of this §749.65 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.65 What children are eligible to participate in a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192555 03/12/2026 A transitional living program must have a training program for children that demonstrates competency in the following areas:(1) Health, general safety, and fire safety practices;(2) Money management;(3) Transportation skills;(4) Accessing community and other resources; and(5) Child health and safety, child development, and parenting skills, if the child is a parent of a child living with him. Source Note: The provisions of this §749.67 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.67 What are the requirements for a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192556 03/12/2026 An "independent living program" is a program that provides case management services to a child who lives independently, without supervision and child/caregiver ratio, and the constant presence of an on-site caregiver. Source Note: The provisions of this §749.69 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.69 What is an "independent living program"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=192557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 192557 03/12/2026 Your agency may not provide an independent living program for a child in care under 18 years old. Source Note: The provisions of this §749.71 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES B DEFINITIONS AND SERVICES §749.71 May I have an independent living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189489 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189489 03/12/2026 As part of the application process, you must submit the following plans to us for approval:(1) An operation plan that must include:(A) The location and telephone numbers of all of your offices, including branch offices;(B) Your hours of operation at your main office and any branch offices; and(C) A list of persons or officers and their titles who comprise the governing body, if applicable;(2) A fiscal plan that includes:(A) A detailed estimate of the operating costs of the agency for the first three months;(B) Documentation of reserve funds or available credit at least equal to operating costs for the first three months;(C) An estimated 12-month budget of income and expenses; and(D) Predictable funds sufficient for the first year of operation;(3) A plan to evaluate the effectiveness of your system for meeting the rules of this chapter, including evaluating the accuracy of foster home screenings and the comprehensiveness of the supervisory visits. This plan must describe how your evaluation process will:(A) Identify problems, including deficiencies;(B) Correct the problems identified; and(C) Document the problems identified and when and how the problems were corrected; and(4) A plan to ensure that you will:(A) Investigate reports of minimum standards violations, upon our request; and(B) Submit reports of your agency's investigative actions and finding to us within 30 days for our review, follow-up, and closure. Source Note: The provisions of this §749.101 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.101 What plans must I submit for Licensing's approval as part of the application process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210101 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210101&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210101 03/12/2026 (a) You must develop the policies and procedures identified in subsection (b) of this section. Your policies and procedures must comply with or exceed the minimum standards specified in this chapter, Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating to Licensing), and any other applicable law.(b) As part of the application process, you must submit the following policies and procedures to us for our approval:(1) Policies and procedures related to record keeping, including where the records will be located. The policies must be consistent with Subchapter D of this chapter (relating to Reports and Records Keeping);(2) Personnel policies and procedures consistent with §749.105 of this title (relating to What are the requirements for my personnel policies and procedures?);(3) Conflict of interest policies consistent with §749.107 of this title (relating to What must my conflict of interest policies include?);(4) Admission policies consistent with §749.109 of this title (relating to What must my admission policies include?);(5) Placement policies consistent with §749.111 of this title (relating to What must my placement policies include?);(6) Child-care policies consistent with §749.113 of this title (relating to What child-care policies must I develop?);(7) Emergency behavior intervention policies consistent with §749.115 of this title (relating to What emergency behavior intervention policies must I develop if my foster homes are permitted to use emergency behavior intervention?);(8) Discipline policies consistent with §749.117 of this title (relating to What are the requirements for my discipline policies for children in care?);(9) Foster care policies consistent with §749.119 of this title (relating to What foster care policies must I develop?);(10) Rights and responsibilities of the child-placing agency and the foster parents consistent with §749.121 of this title (relating to What policies must I develop concerning the rights and responsibilities of the child-placing agency and foster parents?);(11) Additional policies for foster parents that provide treatment services consistent with §749.123 of this title (relating to What policies must I develop regarding foster parents who provide treatment services to a child with primary medical needs?);(12) Additional policies for foster parents who offer a transitional living program consistent with §749.125 of this title (relating to What policies must I develop for foster parents who offer a transitional living program?);(13) Policies for babysitters, overnight care providers, and respite care providers consistent with §749.127 of this title (relating to What policies must I develop for babysitters, overnight care providers, and respite care providers?);(14) Policies for a legal risk placement program consistent with §749.129 of this title (relating to What policies must I develop for a legal risk placement program for foster-adoptive families?);(15) Adoption policies, if applicable, consistent with §749.131 of this title (relating to What policies must I develop if I offer adoption services?);(16) Volunteer policies consistent with §749.133 of this title (relating to What policies must I develop if I use volunteers?);(17) Abuse and neglect policies consistent with §749.135 of this title (relating to What abuse and neglect policies must I develop?);(18) An appeal process for adult clients consistent with Division 8 of this subchapter (relating to Clients and Appeals);(19) A weapons, firearms, explosive materials, and projectiles policy, for foster care services, consistent with Division 3 of Subchapter O (relating to Weapons, Firearms, Explosive Materials, and Projectiles);(20) A tobacco and e-cigarette policy consistent with §749.2931 of this title (relating to What policies must I enforce regarding tobacco products and e-cigarettes?); and(21) A suicide prevention, intervention, and postvention policy consistent with §749.136 of this division (relating to What suicide prevention, intervention, and postvention policy must I have?). Source Note: The provisions of this §749.103 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.103 What policies and procedures must I submit for Licensing's approval as part of the application process? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208641 03/12/2026 Your personnel policies and procedure must:(1) Include an organizational chart showing the administrative, professional, and staffing structures and lines of authority;(2) Include written job descriptions, including minimum qualifications and job responsibilities for each position;(3) Include a written professional staffing plan that:(A) Demonstrates that the number, qualifications, and responsibilities of professional positions, including the child-placing agency administrator, are appropriate for the size and scope of your services and that workloads are reasonable enough to meet the needs of the children in care;(B) Describes in detail the qualifications, duties, responsibilities, and authority of professional positions. For each position, the plan must show whether employment is on a full-time, part-time, or continuing consultative basis. For part-time and consulting positions, the plan must specify the number of hours and frequency of services, if applicable; and(C) Describes how staff or service providers support clients served through branch offices;(4) Include written training requirements for employees and caregivers;(5) Comply with background check requirements outlined in Subchapter F of Chapter 745 of this title (relating to Background Checks);(6) Require your employees to report serious incidents and suspected abuse, neglect, or exploitation. An employee who suspects abuse, neglect, or exploitation must report the employee's suspicion directly to the Texas Abuse and Neglect Hotline, as directed by Texas Family Code §261.101(b). An employee may not delegate the responsibility to make a report, and you may not require an employee to seek approval to file a report or to notify you that a report was made;(7) Require that all employees and consulting, contracting, and volunteer professionals who work with a child and others with access to information about a child be informed in writing of their responsibility to maintain child confidentiality; and(8) Either adopt the model drug testing policy or have a written drug testing policy that meets or exceeds the criteria in the model policy provided in §745.4151 of this title (relating to What drug testing policy must my residential child-care operation have?). Source Note: The provisions of this §749.105 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.105 What are the requirements for my personnel policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189492 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189492 03/12/2026 Your conflict of interest policies must include:(1) A statement that child placement staff and child placement management staff will not conduct, review, or approve foster home screenings, adoptive home screenings, or post-placement adoptive reports if there is a conflict of interest or bias with the family or the child. For example, there would be a conflict of interest if the staff is related to or has a personal relationship with the family or the child;(2) A statement that it is a conflict of interest for your agency to verify as a foster parent or approve as an adoptive parent any of the following persons or relatives of any of the following persons: any current owner, member of the governing body, executive director, or any other employee or contract service provider of your agency;(3) A code of conduct on the relationship between your agency's owners (including members of the governing body, if applicable), employees, contract service providers, children in placement, children's families, and prospective and current foster and adoptive parents, including required parameters for entering into independent financial relationships or transactions;(4) For corporations or other types of business entities, a statement that the majority of the voting members of the governing body must consist of persons who do not have a conflict of interest that would potentially interfere with objective decision making. Persons who have such a conflict of interest include the following:(A) Family members of:(i) An officer of the governing body;(ii) The administrator or executive director of the child-placing agency; or(iii) Any person with a controlling interest in the entity's stock; or(B) If the governing body is a non-profit entity, persons who benefit financially from the agency, including but not limited to persons employed by or working at the agency, paid consultants, subcontractors, or vendors; and(5) For adoptions, you may state whether the person whom you evaluated appears to be suitable for adoption, even if there are other individuals requesting adoption. If you have not evaluated parties of a disputed case, you must refrain from making an adoption or custody recommendation, unless otherwise directed by the court. Source Note: The provisions of this §749.107 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.107 What must my conflict of interest policies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189495 03/12/2026 Your admission policies must include a description of each program you offer, including:(1) The program's goals and services provided, including whether the program accepts emergency admissions; and(2) The characteristics of the population the program serves, such as gender, age range, behaviors, and diagnoses. If the program includes treatment services, your policy must describe the type of treatment services the program is designed to treat, including emotional disorders, intellectual disability, autism spectrum disorder, primary medical needs, or trafficking victim services. Source Note: The provisions of this §749.109 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.109 What must my admission policies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189493 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189493 03/12/2026 Your placement policy must include a description of how you will:(1) Ensure that your agency will not place a child before determining that foster care and/or adoption is appropriate for the child;(2) Match a child with a foster and/or adoptive home to ensure that the child's needs are met;(3) Make every effort to place siblings together and document in each child's record when it is necessary to separate siblings; and(4) Ensure contact between siblings is maintained when siblings are not placed together or document why contact is not appropriate for one or more of the siblings. Source Note: The provisions of this §749.111 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.111 What must my placement policies include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189494 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189494 03/12/2026 You must develop policies that describe:(1) Visitation rights between the child and family members and the child and friends;(2) The child's right to correspond by mail with family members and friends, including any policies regarding mail restrictions and receipt of electronic messages and mail;(3) The child's right to correspond by telephone with family members and friends;(4) The child's right to receive and give gifts to family, friends, staff or caregivers, or other children in care, including any restrictions on gifts;(5) How a child obtains clothing;(6) Personal possessions a child is or is not allowed to have, where the possessions may be stored, and search policies;(7) Emergency behavior intervention techniques if the use of emergency behavior intervention is permitted in your agency. The policy must be consistent with §749.115(5) of this title (relating to What emergency behavior intervention policies must I develop if my foster homes are permitted to use emergency behavior intervention?);(8) Any religious program or activity that you offer, including whether children must participate in the program or activity, and if so, with or without caregivers;(9) The plans for meeting the educational needs of each child;(10) When trips with caregivers away from the home are allowed and what protocols will be used;(11) Program expectations and rules that apply to all children, including an overview of your discipline policy;(12) Child grievance procedures;(13) The types and frequency of reports to parents;(14) Procedures for routine and emergency diagnosis and treatment of medical and dental problems;(15) Routine health care relating to pregnancy and childbirth, if you admit and/or care for a pregnant child;(16) Your plan for providing health-care services to a child with primary medical needs;(17) Transitional living policies, if applicable;(18) How you will determine whether it is appropriate for a child to use weapons, firearms, explosive materials, and projectiles, if applicable. This information must be consistent with §749.103(b)(19) of this title (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?). Source Note: The provisions of this §749.113 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.113 What child-care policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189496 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189496 03/12/2026 At a minimum, you must develop emergency behavior intervention policies to implement the requirements in Subchapter L of this chapter (relating to Foster Care Services: Emergency Behavior Intervention). The policies must include the following:(1) A complete description of emergency behavior interventions that you permit caregivers to use;(2) The specific techniques that caregivers can use;(3) The qualifications for caregivers who assume the responsibility for emergency behavior intervention implementation, including required experience and training, and an evaluation component for determining when a specific caregiver meets the requirements of a caregiver qualified in emergency behavior intervention. You must have an on-going program to evaluate caregivers qualified in emergency behavior intervention and the use of emergency behavior interventions;(4) Your requirements for and restrictions on the use of permitted emergency behavior interventions;(5) For the orientation required in §749.1111(b)(6) of this title (relating to What orientation must I provide a child?), how you will:(A) Explain and document to a child in a manner that the child can understand:(i) Who can use an emergency behavior intervention;(ii) The actions a caregiver must first attempt to defuse the situation and avoid the use of emergency behavior intervention;(iii) The situations in which emergency behavior intervention may be used;(iv) The types of emergency behavior intervention you permit;(v) When the use of an emergency behavior intervention must cease;(vi) What action the child must exhibit to be released from the emergency behavior intervention;(vii) The way to report an inappropriate emergency behavior intervention;(viii) The way to provide voluntary comments during or after an emergency behavior intervention; and(ix) The process for making written comments after an emergency behavior intervention, such as comments regarding the incident that led to the emergency behavior intervention, the manner in which a caregiver intervened, and the manner in which the child was the subject or to which they were a witness. You may create a standardized form that is easily accessible or give children the permission to submit comments on regular paper; and(B) Obtain each child's input on preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process;(6) Requirements that caregivers must attempt less restrictive and less intrusive emergency behavior interventions as preventive measures and de-escalating interventions to avoid the use of emergency behavior intervention;(7) Training for emergency behavior intervention. The policy must include a description of the emergency behavior intervention training curriculum that meets the requirements in the rules of this chapter, the amount and type of training required for different levels of caregivers (if applicable), training content, and how the training will be delivered; and(8) Prohibitions for discharging or otherwise retaliating against:(A) An employee, child in care, foster parent or other adult client, resident, or other person for filing a complaint, presenting a grievance, or otherwise providing in good faith information relating to the misuse of emergency behavior intervention at the agency or foster home; or(B) A child in care, foster parent or other adult client, or resident because someone on behalf of the client or resident files a complaint, presents a grievance, or otherwise provides in good faith information relating to the misuse of emergency behavior intervention at the agency or foster home. Source Note: The provisions of this §749.115 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.115 What emergency behavior intervention policies must I develop if my foster homes are permitted to use emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189497 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189497 03/12/2026 (a) You must develop discipline policies for children in foster care or in an adoptive placement prior to consummation that must:(1) Guide caregivers and employees in the methods used for the discipline of children;(2) Integrate trauma informed care into the care, treatment, and management of each child;(3) Include measures for positive responses to appropriate behavior;(4) Include the importance of nurturing behavior, stimulation, and promptly meeting the child's needs; and(5) Include a statement that discipline of any type is not allowable for infants. Source Note: The provisions of this §749.117 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.117 What are the requirements for my discipline policies for children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189498 03/12/2026 You must develop foster care policies that include the following:(1) Criteria and procedures for screening and accepting foster parent applicants or agency home caregivers who can meet the needs of the children your agency serves;(2) Criteria for making decisions about the number, ages, gender, and needs of children who may be placed in a foster home;(3) Pre-service and annual training requirements for foster parents or agency home caregivers that at a minimum meet the requirements of Subchapter F of the Chapter (relating to Training and Professional Development); and(4) Policies on how you will provide services if the home provides more than one type of care. Source Note: The provisions of this §749.119 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.119 What foster care policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189499 03/12/2026 You must develop policies clearly stating the rights and responsibilities of the child-placing agency and foster parents. The policies must specify:(1) What decisions you will make, what decisions the foster parents will make, and which ones you and the foster parents must agree upon. This policy must support normalcy consistent with Subchapter M, Division 7 of this chapter (relating to Normalcy);(2) For training requirements for foster parents:(A) What part you will provide;(B) What part the foster parents must acquire on their own; and(C) A statement about who will be responsible for training fees, travel expenses, and associated child-care costs;(3) How you and the foster parents will communicate with each other;(4) The amount of reimbursement you will provide the foster parents and when the foster parents will receive it;(5) The type of relevant information and pre-placement contact you will provide, so the foster parents can make an informed decision about a placement;(6) How much discretion the foster parents have in accepting or declining specific placements;(7) The type and amount of support and services that are available to foster parents, including what support and services you will provide for babysitting, overnight care, and respite child-care services;(8) The type of information that the foster parents must report to you and within what time frames;(9) The foster parents' role in the services to children in care, including expectations for the foster parents' participation in service planning and implementation of the service plan;(10) The foster parents' right to appeal your actions and decisions that affect them and the procedures for making an appeal;(11) The responsibilities of the child-placing agency and the foster parents for complying with the rules of this chapter; and(12) How foster parents may review their child-placing agency home record. Source Note: The provisions of this §749.121 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.121 What policies must I develop concerning the rights and responsibilities of the child-placing agency and foster parents? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189500 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189500 03/12/2026 Your support and services policies for foster parents that are required in §749.121(7) of this title (relating to What policies must I develop concerning the rights and responsibilities of the child-placing agency and foster parents?) must include the provision of overnight care and respite care for foster parents who provide treatment services to a child with primary medical needs. The policies must include:(1) Making arrangements to provide at least 72 hours of overnight care to the foster parents each year; and(2) Providing respite child care services as necessary. Source Note: The provisions of this §749.123 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.123 What policies must I develop regarding foster parents who provide treatment services to a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189501 03/12/2026 For foster parents who offer a transitional living program, you must develop policies that address the following:(1) Criteria used to select participants for the program;(2) Supervision of participants consistent with §749.2597 of this title (relating to Where must the caregivers reside in order to supervise children who are in a transitional living program?);(3) Expected behaviors of participants and consequences for failure to comply;(4) Training, education, and experiences to be achieved in the program; and(5) Roles of participants, agency employees, contract staff, and caregivers. Source Note: The provisions of this §749.125 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.125 What policies must I develop for foster parents who offer a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189502 03/12/2026 For both in-home and out-of-home care, you must develop policies specifically for babysitters, overnight care providers, and respite care providers that include:(1) Minimum age for each type of provider;(2) Minimum amount and type of prior child-care experience that each type of provider must have;(3) Amount and type of training each type of provider must have;(4) Reference and background information that foster parents or you must obtain before using each type of provider;(5) Number of children that each type of provider can care for;(6) Information that the foster parents must share with a provider, including information about the children in care and emergency contact information for the foster parent and the agency;(7) Specific care instructions that the foster parents must share with a provider for children with treatment needs;(8) A method for contact between the foster parent (and/or the child-placing agency) and provider during the time of the provider's care;(9) Procedures for agency review and approval of arrangements; and(10) Requirements for documentation of arrangements, including agency child placement staff review and approval, in the foster home record. Source Note: The provisions of this §749.127 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.127 What policies must I develop for babysitters, overnight care providers, and respite care providers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189503 03/12/2026 If you operate a legal risk placement program, you must develop policies that specify:(1) The requirements for foster-adoptive families to participate in this program; and(2) Criteria used in selecting children for appropriate legal-risk placements. Source Note: The provisions of this §749.129 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.129 What policies must I develop for a legal risk placement program for foster-adoptive families? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189504 03/12/2026 You must develop policies for adoption services that include:(1) Procedures and criteria for qualifying, screening, and selecting adoptive parents, including the:(A) Criteria you will use to evaluate potential adoptive parents;(B) Criteria you will use to make decisions about placing specific children with an adoptive family; and(C) Procedures you will use to implement the selection criteria;(2) Training and programs for the adoptive parents;(3) Statement of the rights and responsibilities of the agency and adoptive parents prior to the consummation of the adoption;(4) How you will assist the adoptive homes on how to best preserve the cultural identity of the children in their care;(5) Fees charged to adoptive parents and reimbursements to birth mothers consistent with Division 5 of this subchapter (relating to Financial Assistance to Birth Mothers);(6) Services that will be offered to birth parents;(7) Degree to which birth parents may be involved in planning for and placing their child; and(8) Post adoption services that will be offered to adoptive parents, adopted children, and birth parents. Source Note: The provisions of this §749.131 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.131 What policies must I develop if I offer adoption services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189505 03/12/2026 If you use volunteers, you must develop policies that:(1) Include job descriptions and/or responsibilities for the volunteers;(2) Address qualifications, screening, and selection procedures for the volunteers;(3) Address orientation and training programs for the volunteers;(4) Address supervision of volunteers; and(5) Address volunteer contact with children in care. Source Note: The provisions of this §749.133 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.133 What policies must I develop if I use volunteers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189506 03/12/2026 You must develop policies on preventing, recognizing, and responding to abuse and neglect of children, including:(1) Required annual training for employees;(2) Methods for increasing employee awareness of issues regarding child abuse and neglect, including warning signs that a child may be a victim of abuse or neglect;(3) Methods for increasing employee awareness of prevention techniques for child abuse and neglect;(4) Strategies for coordination between the agency and appropriate community organizations; and(5) Actions that the parent of a child who is a victim of abuse or neglect should take to obtain assistance and intervention. Source Note: The provisions of this §749.135 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.135 What abuse and neglect policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210100 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210100&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210100 03/12/2026 (a) A child-placing agency that is licensed or certified to provide only foster care services or to provide both foster care services and adoption services must adopt either:(1) The model suicide prevention, intervention, and postvention policy in §749.137 of this division (relating to What is the model suicide prevention, intervention, and postvention policy?); or(2) Another suicide prevention, intervention, and postvention policy that is approved by the Executive Commissioner of the Texas Health and Human Services Commission or designee and:(A) Addresses suicide prevention, intervention, and prevention for children in the care of your agency;(B) Is based on current and best evidence-based practices;(C) Requires employees to receive annual suicide prevention training that includes understanding of safety planning and screening for risk;(D) Requires foster parents in homes verified to care for children five years of age or older to complete at least one hour of suicide prevention training:(i) Within a year of being verified; and(ii) every two years thereafter;(E) Promotes suicide prevention training for non-employees, as appropriate; and(F) Includes plans and procedures to support children who return to your agency's care following hospitalization for a mental health condition.(b) The suicide prevention, intervention, and postvention policy adopted under subsection (a) of this section may be part of a broader mental health crisis plan if the components of the plan include suicide prevention, intervention, and postvention. Source Note: The provisions of this §749.136 adopted to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.136 What suicide prevention, intervention, and postvention policy must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210102 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210102&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210102 03/12/2026 (a) Purpose. The purpose of the model suicide prevention, intervention, and postvention policy is to:(1) Protect the health and well-being of children in an agency's care by implementing procedures to prevent suicide, including screening and assessment procedures for risk of suicide;(2) Require intervention when a child attempts or dies by suicide; and(3) Address the needs of children in an agency's care, employees, caregivers, and adoptive parents after a child attempts or dies by suicide.(b) Definitions.(1) Postvention--Activities that promote healing and reduce the risk of suicide by a person affected by the suicide of another.(2) Protective factors of suicide--Characteristics that make it less likely that a child will consider, attempt, or die by suicide, including:(A) Effective behavioral health care;(B) Connectedness to individuals, family, community, and social institutions;(C) Supportive relationships with caregivers;(D) Problem-solving skills, coping skills, and ability to adapt to change;(E) Self-esteem or sense of purpose; and(F) Cultural or personal beliefs that discourage suicide.(3) Risk factors of suicide--Characteristics or conditions that increase the chance that a child may consider, attempt, or die by suicide, including:(A) A prior suicide attempt;(B) Knowing someone who died by suicide, particularly a family member, friend, peer, or hero;(C) Access to lethal means;(D) History of childhood trauma, including neglect, physical abuse, or sexual abuse or assault;(E) A history of being bullied;(F) A mental health diagnosis, particularly depressive disorders and other mood disorders;(G) Abuse of alcohol or drugs;(H) Social isolation;(I) Severe or prolonged stress;(J) Chronic physical pain or illness;(K) Loss of a family member; or(L) The ending of a relationship.(4) Suicide contagion--Exposure to suicide or suicidal behaviors within a family, or from friends or media reports, that can result in an increase in suicide or suicidal behaviors.(5) Suicide risk assessment--A comprehensive evaluation of a child by a medical health professional to confirm suspected suicide risk, estimate the immediate danger to the child, and decide on a course of treatment and a plan for intervention to ensure the child's safety.(6) Suicide risk screening--A procedure in which a standardized instrument is used to identify children who may be at risk of suicide. The screening may be done orally (with the screener asking questions), with pencil and paper, or using a computer.(7) Warning signs of suicide--Indicators that a child may be in danger of suicide and need help, including:(A) Talking about wanting to die or to hurt or kill oneself;(B) Looking for a way to kill oneself;(C) Being preoccupied with death in conversation, writing, or drawing;(D) Talking about feeling hopeless or having no reason to live;(E) A change in personality;(F) Giving away belongings;(G) Withdrawing from friends and family;(H) Having aggressive or hostile behavior;(I) Neglecting personal appearance;(J) Running away from home or a residential placement; or(K) Risk-taking behavior, such as reckless driving or being sexually promiscuous.(c) Prevention--Training.(1) Employees and foster parents must complete at least one hour of suicide prevention training as follows:(A) Employees must complete the training annually;(B) Foster parents verified to care for children five years of age or older must complete the training:(i) Within a year of verification; and(ii) every two years thereafter; and(C) The suicide prevention training must meet the instructor and documentation requirements of Subchapter F, Division 7 of this chapter (relating to Annual Training).(2) The curriculum for the suicide prevention training in paragraph (1) of this subsection must include:(A) The risk factors, protective factors, and warning signs of suicide;(B) Understanding safety planning, including:(i) How safety plans are created;(ii) How safety plans are shared with employees and caregivers;(iii) How safety plans are expected to be implemented by employees and caregivers; and(iv) Each employee's or caregiver's role in the prevention of suicide, including never leaving a child alone if the suicide risk screening finds that the child is a high risk for suicide, until a mental health professional conducts a suicide risk assessment; and(C) Understanding suicide screening, including clarifying:(i) Each person's role in the screening process;(ii) When an employee or caregiver should initiate a suicide risk screening for a child; and(iii) What actions an employee or caregiver must take to initiate a suicide risk screening for a child.(3) The agency must promote suicide prevention training for non-employees, as appropriate.(d) Prevention--Suicide Risk Screening.(1) The policy must describe the suicide risk screening tool that you will use and the process for implementing the screenings.(2) The suicide risk screening tool must be supported by evidence-based research demonstrating the tool performs reliably regardless of who administers the tool or performs the scoring or rating.(3) Any person who meets the conditions and training requirements of the screening tool manual or instructions may administer the suicide risk screening to a child. You must document that any person conducting a screening meets the conditions and training requirements.(4) For children receiving foster care services, the screening tool must be administered:(A) At admission for each child 10 years of age or older;(B) At admission for each child younger than 10 years of age if:(i) The information provided to the operation at the time of admission indicates that the child has a history of suicide attempts or suicidal thoughts; or(ii) The parent who admits the child, a foster parent, or child-placing agency requests a screening to be administered because of the child's risk factors or warning signs of suicide;(C) Every 90 days after admission for all children 10 years of age or older; and(D) Immediately for a child of any age whenever the child exhibits warning signs of suicide that necessitate a suicide screening be conducted, including when requested by a foster parent.(5) For children receiving adoption services, the screening tool must be administered immediately for a child of any age whenever the child exhibits warning signs of suicide that necessitate a suicide screening be conducted, including when requested by an adoptive parent.(6) Any screening must be performed in a manner that protects the child's privacy.(7) Each screening must be documented in the child's record.(e) Intervention--Based on the Results of a Suicide Risk Screening.(1) If the suicide risk screening finds the child to be a high risk for suicide, the agency, caregiver, or adoptive parent must:(A) Immediately refer the child to a mental health professional for a suicide risk assessment;(B) Not leave the child alone until a mental health professional assesses the child;(C) Remove any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt;(D) Alert each person responsible for the child's care or supervision of the high risk for suicide and any new or updated safety plan; and(E) Upon conclusion of the risk assessment, follow through on recommendations by the mental health professional and update the child's safety plan and service plan accordingly.(2) If the suicide risk screening finds the child to have a potential for risk of suicide, the agency, caregiver, or adoptive parent must:(A) Refer the child to a mental health professional for a suicide risk assessment within 24 hours;(B) Closely monitor the child to ensure the child's safety until a mental health professional assesses the child;(C) Remove any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt;(D) Alert each person responsible for the child's care or supervision of the potential risk of suicide and any new or updated safety plan; and(E) Upon conclusion of the risk assessment, follow through on recommendations by the mental health professional and update the child's safety plan and service plan accordingly.(f) Intervention--Returning Post Hospitalization. To ensure a child's readiness to return to care under the same child-placing agency following a mental health crisis (for example, from a suicide attempt or psychiatric hospitalization):(1) Child placement management staff must meet with the child within 24 hours of the child's arrival to a home to discuss protocols that would help to ease the child's transition into the home post hospitalization, ensure the child's safety, and reduce any risk of suicide.(2) The protocols must include:(A) Weekly suicide risk screenings for the first 30 days or until the child is no longer reporting suicidal thoughts, whichever is longer;(B) Creating or reviewing and updating the child's safety plan; and(C) Removal of any harmful objects, chemicals, or substances that a child could use to carry out a suicide attempt or self-harm for a period to be determined by the treatment team, but not less than 30 days.(3) The agency must alert any persons responsible for the child's care or supervision of the new protocols and new or updated safety plan.(g) Postvention.(1) Addressing Suicide Deaths.(A) Create a Postvention Team and Written Action Plan and Protocols. To prevent suicide contagion and support employees, children, caregivers, and adoptive parents, you must create a postvention team. This team is responsible for developing a written action plan with protocols in the event of a death by suicide. The postvention team should consider:(i) How a death would affect employees, caregivers, adoptive parents, and other children receiving services in the home where the death occurred; and(ii) How to provide psychological first-aid, crisis intervention, and other support to the employees, caregivers, adoptive parents, and other children receiving services in the home where the death occurred.(B) While the action plan needs to be flexible for varying situations, the written action plan must include:(i) A communication strategy that:(I) Does not inadvertently glamorize or romanticize the child or the death;(II) Occurs in settings that allow the postvention team to monitor responses of individuals in the home;(III) Strives to treat all deaths in the same way (for example, having one approach for honoring a child who dies from cancer, a car accident, or suicide);(IV) Emphasizes the importance of seeking help for anyone with an underlying mental health diagnosis, such as a mood disorder;(V) Emphasizes the importance of employees, caregivers, adoptive parents, and children recognizing the signs of suicide; and(VI) Decreases the stigma associated with seeking help for mental health concerns;(ii) Mental health resources for employees, caregivers, adoptive parents, and children who have a difficult time coping, including:(I) Opportunities to debrief to process thoughts and feelings related to the suicide death; and(II) Referrals to grief counseling and suicide survivor support groups to the extent possible; and(iii) A review of lessons learned from the child's death by suicide. All communications regarding lessons learned should be approached in a way that ensures a blame-free environment.(2) Addressing Suicide Attempts. In the event of a suicide attempt according to §749.505 of this chapter (relating to What constitutes a suicide attempt by a child?):(A) The caregiver must, as needed, immediately call emergency services and render first aid until professional medical treatment can be provided;(B) The caregiver must not leave the child alone until a mental health professional assesses the child;(C) The caregiver must move all other children out of the immediate area as soon as possible;(D) The agency must report and document the suicide attempt as a serious incident as required by:(i) §749.503(a)(12) of this chapter (relating to When must I report and document a serious incident?);(ii) §749.511 of this chapter (relating to How must I document a serious incident?); and(iii) §749.513(1) of this chapter (relating to What additional documentation must I include with a written serious incident report?);(E) The agency must offer mental health resources for employees, caregivers, and children who have a difficult time coping, including:(i) Opportunities to debrief to process thoughts and feelings related to the suicide attempt; and(ii) Referrals to community services and other resources when a child has attempted suicide; and(F) The agency must conduct a review of lessons learned from the child's suicide attempt. All communications regarding lessons learned should be approached in a way that ensures a blame-free environment. Source Note: The provisions of this §749.137 adopted to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.137 What is the model suicide prevention, intervention, and postvention policy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210103 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210103&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210103 03/12/2026 (a) The requirements for policies only apply to your policies that are required or governed by this chapter.(b) All employees and caregivers must be aware of and follow your policies and procedures. Source Note: The provisions of this §749.138 adopted to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.138 What are the general requirements for an agency's policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189508 03/12/2026 (a) Your agency's plans, policies, and procedures must indicate the date on which you adopted them and their effective date.(b) You must formalize the adoption of your agency's plans, policies, and procedures as appropriate for your type of ownership:(1) If you are a sole proprietor, you must sign them;(2) If you are a partnership, each partner must sign them; or(3) If you are a corporation or other type of business entity, the governing body must take a written action to adopt (sometimes this may be an order or the adoption may be included in the minutes of the governing body). Source Note: The provisions of this §749.139 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.139 What requirements must I follow when adopting my child-placing agency's plans, policies, and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189509 03/12/2026 Yes, if you violate plans, policies, or procedures, then we may cite the relevant standard in Division 1 of this Subchapter (relating to Plans and Policies Required During the Application Process) as a deficiency. Source Note: The provisions of this §749.141 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.141 Can Licensing cite my agency for a deficiency if I fail to operate according to my approved plans, policies, and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204813 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204813&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204813 03/12/2026 While you are operating, you must:(1) Have a designated full-time child-placing agency administrator who meets the minimum qualifications of §749.631 of this title (relating to What qualifications must a child-placing agency administrator meet?);(2) Operate according to your approved plans, policies, and procedures;(3) Maintain current, true, accurate, and complete records;(4) Allow us to inspect your child-placing agency during its hours of operation;(5) Allow us to inspect or monitor any of your foster homes at any time;(6) Not offer unrelated types of services that conflict or interfere with the best interests of a child in care, a caregiver's responsibilities, or space in the homes. If you offer more than one type of service, you must determine and document that no conflict exists;(7) Comply with the liability insurance requirements in this division; and(8) Prepare the annual budget and control expenditures and ensure compliance with Division 3 of this Subchapter (relating to General Fiscal Requirements). Source Note: The provisions of this §749.151 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.151 What are my operational responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215286 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215286&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215286 03/12/2026 (a) You must provide written notification to your Licensing Representative:(1) As soon as possible, but at least 30 days before you:(A) Change the legal structure of your agency or your governing body, if applicable;(B) Move your agency to another location as required in §745.435 of this title (relating to What must I do if I relocate my operation after I receive my license or certification?);(C) Open a branch office; or(D) Change your agency's or a branch office's hours of operation;(2) As soon as possible, but at least 15 days before you:(A) Make changes to the plans required in §749.101(3) and (4) of this subchapter (relating to What plans must I submit for Licensing's approval as part of the application process?); or(B) Make changes to the policies and procedures required in §749.103(b) of this subchapter (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?);(3) As soon as possible, but no later than two days after:(A) You change your child-placing agency administrator, or your child-placing agency administrator position becomes vacant;(B) A new individual becomes a controlling person at your child-placing agency;(C) An individual ceases to be a controlling person at your child-placing agency; or(D) There is a significant change in the information we maintain about a controlling person, such as a name change or mailing address change; and(4) About a foster home's verification status as described in §749.2489 of this chapter (relating to What information must I submit to Licensing about a foster home's verification status?).(b) You must report to the Texas Abuse and Neglect Hotline as soon as you become aware of any foster or adoptive placements that appear to have been made by someone other than the child's parents or a child-placing agency. Source Note: The provisions of this §749.153 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective November 23, 2022, 47 TexReg 7728; amended to be effective October 19, 2023, 48 TexReg 5980. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.153 What changes must I notify Licensing about regarding my child-placing agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215287 03/12/2026 If you do not have a back-up child-placing agency administrator when your administrator position becomes vacant, to carry out the duties in §749.635 of this chapter (relating to What responsibilities must the child-placing agency administrator have?), you have 60 days from the date the position becomes vacant to obtain a licensed child-care administrator before we can cite you for not having an administrator. Source Note: The provisions of this §749.154 adopted to be effective October 19, 2023, 48 TexReg 5980. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.154 What is my timeframe for filling my child-placing agency administrator position if it becomes vacant while I do not have a back-up administrator to carry out the administrator duties? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204814 03/12/2026 Unless you have an acceptable reason not to have the insurance, you must:(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of negligence that covers injury to a child while the child is on your premises or in your care; and(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance of your permit. Source Note: The provisions of this §749.155 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.155 What are the liability insurance requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204815 03/12/2026 (a) You do not have to have liability insurance that meets the requirements of §749.155 of this division (relating to What are the liability insurance requirements?) if you cannot carry insurance because:(1) Of financial reasons;(2) You are unable to locate an underwriter who is willing to issue a policy to the operation; or(3) You have already exhausted the limits of a policy that met the requirements.(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason listed in subsection (a) of this section, you must send written notification to Licensing by the anniversary date of the issuance of your permit. Your notification must include the reason that you cannot carry the insurance. Source Note: The provisions of this §749.157 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.157 What are acceptable reasons not to have liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204816 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204816&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204816 03/12/2026 (a) If you do not carry liability insurance that meets the requirements of §749.155 of this division (relating to What are the liability insurance requirements?), then you must notify the parent of each child in your care in writing that you do not carry liability insurance before you admit the child into your care.(b) If you previously carried the liability insurance and subsequently stop carrying the liability insurance, then you must notify the parent of each child in your care in writing that you do not carry the insurance within 14 days after you stop carrying it.(c) You may use Form 2962, Verification of Liability Insurance, located on the Licensing provider website, to notify parents. Regardless of whether you use this form, you must be able to demonstrate that you provided written notice to the parents of each child in your care. Source Note: The provisions of this §749.159 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.159 When must I notify parents that I do not carry liability insurance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189512 03/12/2026 (a) You must establish and maintain your agency on a sound fiscal basis, including:(1) Paying your employees timely;(2) Paying foster parents per your agreement with them; and(3) Making sure the needs of children in care are being met.(b) You must maintain complete financial records that comply with Generally Accepted Accounting Principles, including:(1) Accounting for a child's money separately from the funds of your agency and the foster home. You may not use a child's personal earnings, allowances, or gifts to pay for the child's room and board, unless such use is a part of the child's service plan and the child's parent approves it in writing. You must give or send the child's money to the child, parent, or next placement within 30 days of the child's discharge; and(2) Making one of the following available for our review:(A) An annual review of your financial records conducted by an independent Certified Public Accountant in accordance with the Generally Accepted Accounting Principles; or(B) Proof of reserve funds equal to at least three months of operating expenses for your agency. Source Note: The provisions of this §749.161 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.161 What are my fiscal requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189513 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189513 03/12/2026 (a) You must submit an annual financial report to us on a form that we provide. The report must include:(1) Information on adoption-related income from all sources, including the source of the income and the amount; and(2) Adoption-related agency expenses, including the expense category and the category detail.(b) You must submit the financial report to us within 60 days of the end of your agency's fiscal year. Source Note: The provisions of this §749.191 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.191 What type of financial report must I submit to Licensing if I provide adoption services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189514 03/12/2026 No, you may not make any payments for adoption referrals. Source Note: The provisions of this §749.193 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.193 May I make payments for adoption referrals? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189515 03/12/2026 You may only accept reasonable application fees, home study fees, and fees for education and training of the prospective adoptive parents prior to the completion of the home study. Source Note: The provisions of this §749.195 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.195 What types of fees may I collect prior to the completion and approval of a home study? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189516 03/12/2026 (a) For adoption services, you must have an adoption fee or adoption fee schedule that you apply to all clients. The policy must include the type of expenditures you will meet for birth parents and whether you will do so through an overall fee, pass-through expenses, or some combination. Policies on pass-through expenses must comply with all requirements listed in §749.273 of this title (relating to What must I do if I pass through expenses to adoptive families?).(b) If you charge additional fees, your policy must explain clearly what the fees cover.(c) You must have a clear policy on refunds. Source Note: The provisions of this §749.197 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.197 For adoption services, what fee policies must I have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189517 03/12/2026 No, you are not required to charge the same fees for all adoptions. The fee or fee schedule may take into consideration relevant factors such as adoptive placement of children considered to be hard to place. You may also have a sliding scale fee schedule. The parameters of any differential fee schedules must be specified and equally applied. Source Note: The provisions of this §749.199 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.199 Must I charge the same fees for all adoptions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189518 03/12/2026 (a) You may provide financial assistance to a birth mother to meet her reasonable and necessary living expenses and legal costs.(b) Reasonable and necessary living expenses include:(1) Housing expenses;(2) Necessary utilities, such as electric, water, or telephone bills;(3) Food for the birth mother and her minor children that are living with her;(4) Travel expenses for transportation necessary to support the pregnancy, such as gasoline or bus fares to medical appointments or the grocery store;(5) Medical costs; and(6) Child-care or foster care while a birth mother is hospitalized or unable to care for her children.(c) Reasonable and necessary living expenses do not include:(1) Any expenses met by a birth mother's existing resources;(2) Any expenses supporting other family members, with the exception of the birth mother's minor children who are living with her;(3) Any expenses for recreational and leisure activities; or(4) The purchase of an automobile. Source Note: The provisions of this §749.231 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.231 What financial assistance may I provide for a birth mother? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189519 03/12/2026 Financial assistance may only be provided:(1) During the time of the pregnancy; and(2) After the pregnancy, during the time the birth mother requires inpatient or outpatient postpartum care. Source Note: The provisions of this §749.233 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.233 During what period of time may I provide financial assistance to a birth mother? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189520 03/12/2026 (a) You must review the birth mother's financial resources.(b) Your evaluation must include an evaluation of family support, medical insurance, and other resources available.(c) The evaluation must justify a payment you make for the birth mother's reasonable and necessary living expenses and legal costs related to the adoption and, if applicable, post partum care.(d) You must document the evaluation and provide a copy to the birth mother. Source Note: The provisions of this §749.235 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.235 How do I determine the birth mother's need for financial assistance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189521 03/12/2026 (a) You must document financial assistance that you provide for the birth mother through receipts.(b) A receipt must include the date, payee identification, purpose of payment, and documentation that the funds were expended for services rendered or goods provided for the birth mother.(c) You must organize and maintain this documentation in the individual record of the birth mother. Source Note: The provisions of this §749.237 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.237 How do I document financial assistance that I provide for a birth mother? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189526 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189526&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189526 03/12/2026 (a) For reasonable and necessary living expenses, you may provide cash payments to birth mothers to cover the cost of day-to-day routine purchases, such as food, household supplies, personal hygiene or grooming items, and gasoline or public transportation if your policies:(1) State when and for what purpose you can make cash payments to a birth mother;(2) Establish a maximum amount per category, per time period, based on the current rates in the community in which the care is provided; and(3) Require you to obtain documentation from a birth mother acknowledging receipt of the payments.(b) Each cash disbursement may cover a period of up to one month. Source Note: The provisions of this §749.239 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.239 May I provide cash payments to birth mothers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189522 03/12/2026 (a) No, you may not require a birth mother to repay you for expenses and/or services incurred.(b) You must inform a birth mother of this policy in writing upon establishing any formal relationship between your agency and a birth mother and post it in the agency's offices in a place routinely visible to birth mothers. The written policy provided to the birth mother must be in a language spoken and read by the birth mother. Source Note: The provisions of this §749.241 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.241 If a birth mother decides not to relinquish a child for adoption, may I require her to repay my agency or the adoptive parent for expenses and services incurred? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189523 03/12/2026 Yes, as long as the foster care services provided free of charge or at a reduced rate are not contingent upon the relinquishment of the child for adoption, you may provide the foster care services. Source Note: The provisions of this §749.243 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.243 May I provide foster care services free of charge or at a reduced rate to a birth mother that needs time to make a decision about adoptive placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189524 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189524&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189524 03/12/2026 (a) If a birth mother's needs are met through an existing resource, you must not, by action or advice, disrupt that unless your child placement management staff determines that it is in the best interest of the birth mother and her child that other arrangements be made based on documented proof that her current living situation impacts the basic health or safety of the birth parent or the child, including psychological or emotional abuse. For example, if family members are providing housing at no cost to a birth mother, your agency may not advise the birth mother to move to an apartment for which your agency would pay rent.(b) This rule applies to any kind of financial assistance.(c) You must document the impact and determination of best interest before any arrangements are made and/or expenses are paid. Source Note: The provisions of this §749.245 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.245 If a birth mother's needs are met through existing resources, can I disrupt that arrangement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189525 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189525&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189525 03/12/2026 (a) You may pass through to the adoptive parents certain expenses that:(1) You incur on behalf of the birth mother; or(2) The birth mother incurs.(b) You cannot pass through expenses for medical or other services that were met through a birth mother's insurance company or some other source or that were provided free to the birth mother. Source Note: The provisions of this §749.271 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.271 May I require adoptive families to reimburse me for expenses incurred by the birth mother? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189527 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189527&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189527 03/12/2026 You must meet the following requirements if you pass through the birth mother's expenses to adoptive families:(1) Your fee policy must include a complete description of the types of expenses that you may pass through to adoptive families.(2) The fee policy must comply with the financial assistance requirements in Division 5 of this subchapter (relating to Financial Assistance to Birth Mothers).(3) You must prepare an individual report for each case where you pass through expenses to the adoptive family. The report must be organized by expense category and include the date, amount, and a description of each expenditure. You must give the report to the adoptive family. The report must be available for our review.(4) If requested by an adoptive parent, you must provide an itemized list of how pass though money was expended and if there is a surplus.(5) With the exception of unforeseeable medical and legal expenses, you must provide to the adoptive family a written estimate of the pass-through expenses you anticipate will be associated with the adoption. You must provide this estimate before the adoptive family makes any financial commitment to the placement.(6) If you exceed the estimated expenses by more than 10%, you must obtain acknowledgement and agreement in writing from the adoptive parents that they will incur the additional expenses. If you cannot reach an agreement with the adoptive parents, you must incur the additional expenses.(7) If there is a surplus of pass through money, you must refund the surplus back to the adoptive parents.(8) You must inform the adoptive family, in writing, that:(A) A birth mother may choose not to relinquish a child for adoption; and(B) You are prohibited from seeking repayment from that birth mother for expenses incurred in providing adoption services. Source Note: The provisions of this §749.273 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.273 What must I do if I pass through expenses to adoptive families? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189528 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189528&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189528 03/12/2026 (a) A branch office is anywhere the child placement staff and child master records or foster/adoptive home master records are located.(b) You may operate a branch office if you:(1) Maintain compliance with the rules of this chapter; and(2) Are in good standing with us. Source Note: The provisions of this §749.301 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.301 What is a branch office? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189529 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189529&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189529 03/12/2026 At least 30 days prior to the opening of a branch office, you must provide us the following information with your request to amend your license:(1) The address, telephone numbers (if available), and office hours for the branch office;(2) The name, qualifications, and contact information of the administrative staff person who will be primarily responsible for the day-to-day operation of the branch office;(3) The name(s), qualifications, and contact information of the child placement management staff that will be responsible for child-placing activities of the branch office;(4) The name(s) and qualifications of other employees who will be involved in child-placing activities at the branch office; and(5) An updated written professional staffing plan that includes how child placement management staff, the Licensed Child-Placing Agency Administrator, and the treatment director, if applicable, will supervise services provided from the branch office. Source Note: The provisions of this §749.303 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.303 What must I do before opening a branch office? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189530 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189530&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189530 03/12/2026 You must have either a main or branch office:(1) In each region of the department where you verify homes; or(2) Within 150 miles of each verified foster home. Source Note: The provisions of this §749.304 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.304 Where must I have a main or branch office? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208642 03/12/2026 (a) You must comply with one of the following:(1) The main office and each branch office, must have a separate:(A) Administrator who meets §749.631 of this title (relating to What qualifications must a child-placing agency administrator meet?); and(B) Treatment director, if applicable, per §749.721 of this title (relating to Must I have a treatment director?); or(2) Offices that operate based on the following caseload limits for child placement staff may share the same administrator and treatment director:(A) A caseload of foster children only that does not exceed:(i) 35 for children receiving child-care services;(ii) 25 for children receiving treatment services; and(iii) 30 for a combination of children receiving child-care services and children receiving treatment services;(B) A caseload of foster homes only that does not exceed 15 homes; and(C) A combination caseload of both children and homes that does not exceed 30 cases. Calculate the maximum of 30 cases by counting:(i) Each child as one case; and(ii) Each foster family home as one case.(b) This rule does not apply to a child-placing agency that provides only adoption services, including foster homes verified by a private adoption agency solely for the care of infants awaiting placement in an adoptive home pending the resolution of the child's eligibility for adoption, or the readiness of an appropriate adoptive home, or both. This exception does not apply to a foster home that is also the intended adoptive home. Source Note: The provisions of this §749.305 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.305 What are the requirements for administrators and treatment directors for a main office and branch offices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189532 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189532&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189532 03/12/2026 (a) If the branch office closure is related to a corrective or adverse action which Licensing is taking or has taken against your agency, you must:(1) Close a foster home under that branch office; or(2) Transfer a foster home under that branch office to your main or another branch office, including:(A) Updating the foster home study per §749.2473 of this title (relating to What must I do to verify a foster home that another child-placing agency has previously verified?), with the exception of new criminal history and central registry background checks;(B) Ensuring that all required criminal history and central registry background checks for the foster home have been conducted within the last 24 months; and(C) Amending the verification certificate.(b) If the branch office closure is not related to a corrective or adverse action which Licensing is taking or has taken against your agency, you may transfer the foster homes to the main office or another branch office without updating the foster home screening. Source Note: The provisions of this §749.307 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.307 What happens to the foster homes supervised by a branch office when the branch office closes? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206299 03/12/2026 (a) Anyone can request information from you or attend a meeting open to all interested persons. A person becomes your client when you establish a relationship beyond that available to someone who is merely an interested person.(b) Your child clients include children in:(1) Foster care; and(2) Pre-consummated adoptive placement.(c) Your adult clients include:(1) Birth parents, managing conservators, or whoever has legal responsibility for children they are placing in your care;(2) Foster parent applicants;(3) Foster parents;(4) Adoptive applicants;(5) Adoptive parents prior to consummation of the adoption;(6) Adoptive parents and birth parents seeking post adoption services; and(7) Young adults in your care. Source Note: The provisions of this §749.421 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.421 Who are my clients? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206300 03/12/2026 When a person becomes your adult client, you must inform the person in writing:(1) That the rules of this chapter, any compliance reports, and your policies are available for review upon their request;(2) Of their right to appeal agency actions and decisions that affect them, and the procedures for making an appeal;(3) Of procedures for making a complaint to us regarding a violation of minimum standards; and(4) Of other entities and their phone numbers and addresses where it is appropriate to file complaints, such as the board or state agency that professionally licenses individuals whom you employ or contract with, and the procedures for making complaints to those entities. Source Note: The provisions of this §749.423 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.423 What rights do my adult clients have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206301 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=206301&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 206301 03/12/2026 (a) You must have a written appeal process for your adult clients in regard to your actions and decisions that affect those clients.(b) The process must describe:(1) How you will inform clients of their right to appeal;(2) The procedures and time frames for clients to make an appeal;(3) The criteria or basis that will be used to make the decision;(4) Who will hear an appeal and make the decision;(5) Time frames for making a decision and communicating the decision to the client; and(6) How the client will be informed of the decision.(c) You must provide this information to each birth parent, foster parent applicant, or adoptive applicant before you make that person your client.(d) Your appeal process does not have to involve anyone from outside your agency. An internal review procedure is sufficient. Source Note: The provisions of this §749.425 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES C ORGANIZATION AND ADMINISTRATION §749.425 What must my appeal process include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199379 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199379&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199379 03/12/2026 These terms have the following meanings in this subchapter:(1) Serious incident--A non-routine occurrence that has or may have dangerous or significant consequences for the care, supervision, or treatment of a child. The different types of serious incidents are noted in §749.503 of this division (relating to When must I report and document a serious incident?).(2) Triggered review of a child's unauthorized absences--A review of a specific child's pattern of unauthorized absences when the child has had three unauthorized absences within a 60-day timeframe.(3) Unauthorized absence--A child is absent from a foster home without permission from the foster parent, or other temporary caregiver, and cannot be located. This includes when an unauthorized person has removed the child from the foster home. Source Note: The provisions of this §749.501 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.501 What do certain terms mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222374 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=222374&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 222374 03/12/2026 (a) A CPA must report and document the following types of serious incidents involving a child in the CPA's care. The reports must be made to the following entities, and the reporting and documenting must be within the specified timeframes: Attached Graphic(b) If there is a medically pertinent incident that does not rise to the level of a serious incident, a CPA does not have to report the incident but the CPA must document the incident in the same manner as for a serious incident, as described in §749.511 of this division (relating to How must I document a serious incident?). (c) If a child returns before the required reporting timeframe outlined in (a)(8) - (10) in Figure: 26 TAC §749.503(a), the CPA is not required to report the absence as a serious incident. Instead, the CPA must document within 24 hours after the CPA becomes aware of the unauthorized absence in the same manner as for a serious incident, as described in §749.511 of this division. (d) If there is a serious incident involving an allegation of abuse, neglect, or exploitation of an elderly adult or an adult with a disability in a residential child-care operation, the CPA must document the incident in the same manner as a serious incident. The CPA must also report the incident to: (1) The Department of Family and Protective Services intake through:(A) The Texas Abuse and Neglect Hotline (1-800-252-5400); or(B) Online at https://www.txabusehotline.org;(2) Law enforcement, if there is a fatality; and(3) The parent, if the adult resident is not capable of making decisions about the resident's own care. (e) A CPA must report and document the following types of serious incidents involving the CPA, one of its foster homes, an employee, professional level service provider, contract staff, or a volunteer to the following entities within the specified timeframe: Attached Graphic Source Note: The provisions of this §749.503 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective June 1, 2014, 39 TexReg 3730; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 1, 2020, 45 TexReg 3329; amended to be effective April 25, 2021, 46 TexReg 2454; amended to be effective April 25, 2022,47 TexReg 2272; amended tobe effective November 23, 2022, 47 TexReg 7728; amended to be effective December 22, 2024, 49 TexReg 9555. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.503 When must a child-placing agency (CPA) report and document a serious incident? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189538 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189538&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189538 03/12/2026 A suicide attempt is a child's attempt to take his own life using means or methods for causing his death, including any act a child commits intending to cause his death, but excluding suicidal gestures where it is clear that the act was unlikely to cause death. Suicidal thoughts are not reportable as a suicide attempt. Source Note: The provisions of this §749.505 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.505 What constitutes a suicide attempt by a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189539 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189539&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189539 03/12/2026 (a) All serious incident reports must be made directly to the Texas Abuse and Neglect Hotline.(b) Foster parents must report any serious incidents directly to the Texas Abuse and Neglect Hotline if the incident involves a child under the care of the foster parent. Source Note: The provisions of this §749.509 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.509 How do I make a report of a serious incident or occurrence to Licensing? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208699 03/12/2026 A serious incident must be documented in a written report that includes the following information:(1) The name of the foster home or adoptive home, physical address, and telephone number;(2) The time and date of the incident;(3) The name, age, gender, and date of admission of the child or children involved;(4) The names of all adults involved and their role in relation to the child(ren);(5) The names or other means of identifying witnesses to the incident, if any;(6) The nature of the incident;(7) The circumstances surrounding the incident;(8) Interventions made during and after the incident, such as medical interventions, contacts made, and other follow-up actions;(9) The treating licensed health-care professional's name, findings, and treatment, if any;(10) The resolution of the incident; and(11) If the child returns to the operation after you complete the report for an unauthorized absence, an update regarding the unauthorized absence and the child's return. Source Note: The provisions of this §749.511 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.511 How must I document a serious incident? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199381 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199381&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199381 03/12/2026 You must include the following additional documentation with a written serious incident report, as applicable:Attached Graphic Source Note: The provisions of this §749.513 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.513 What additional documentation must I include with a written serious incident report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189542 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189542&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189542 03/12/2026 You must keep a copy of the incident reports on file for two years. The reports must be easily accessible to Licensing upon request. Source Note: The provisions of this §749.515 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.515 How long must I keep my incident reports? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204811 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204811&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204811 03/12/2026 (a) You must notify the parent of each child in the care of each foster home verified by your Child-Placing Agency of a deficiency in:(1) A safe sleeping standard noted in subsection (b) of this section; or(2) The abuse, neglect, or exploitation standard in §749.1003(b)(1)(B) of this chapter (relating to What rights does a child in care have?).(b) The following are safe sleeping standards requiring notification:(1) §749.1807(a)(1) of this chapter (relating to What specific safety requirements must my cribs meet?);(2) §749.1809(2)(A) of this chapter (relating to Are mesh cribs or port-a-cribs allowed?);(3) §749.1813(a)(5) and (b) of this chapter (relating to What types of equipment may a foster home not use with infants?);(4) §749.1815 of this chapter (relating to What are the specific sleeping requirements for infants?);(5) §749.1817 of this chapter (relating to May I allow an infant to sleep in a restrictive device?); and(6) §749.1821 of this chapter (relating to May I swaddle an infant to help the infant sleep?).(c) When meeting the notice requirements in subsection (a) of this section, your main office or a branch office must notify the parents of children in the care of each foster home that the office supervises. Source Note: The provisions of this §749.517 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.517 What are the notification requirements when Licensing finds my operation deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204812 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204812&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204812 03/12/2026 (a) Within five days after you receive notification of a deficiency described in §749.517 of this division (relating to What are the notification requirements when Licensing finds my operation deficient in a standard related to safe sleeping or the abuse, neglect, or exploitation of a child in care?), you must notify the parents of each child in the care of each foster home verified by your Child-Placing Agency at the time of notification, including a child who may not have been in care on the day of the actual incident.(b) When meeting the notice requirements in subsection (a) of this section, your main office or a branch office must notify the parents of children in the care of each foster home that the office supervises.(c) If the deficiency is for a safe sleeping standard, you must notify the parents using Form 2970, Notification of Safe Sleeping Deficiency, located on the Licensing provider website.(d) If the deficiency is for the standard related to the abuse, neglect, or exploitation of a child in care, you must notify the parents using Form 7266, Notification of Abuse/Neglect/Exploitation Deficiency, located on the Licensing provider website. (e) You must maintain and make available for our review, upon request, proof that you have notified parents in writing of deficiencies in safe sleeping and abuse, neglect, or exploitation, as required by subsection (a) of this section. Source Note: The provisions of this §749.519 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.519 How must I notify parents of a safe sleeping deficiency or an abuse, neglect, or exploitation deficiency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189543 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189543&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189543 03/12/2026 (a) You must maintain a copy of your policies and procedures at the agency. They must be available for review by employees, contract staff, caregivers, Licensing, or your clients, upon request.(b) You must maintain copies of all current and previous policies for at least two years. Source Note: The provisions of this §749.529 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.529 What are the retention requirements for my agency's policies? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189544 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189544&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189544 03/12/2026 You must have policies and procedures for:(1) Protecting paper and electronic records from destruction and loss; and(2) Clarifying the persons:(A) Within your agency who are authorized to access records; and(B) Outside of your agency who are authorized by law to have access to records. Source Note: The provisions of this §749.531 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.531 What policies and procedures must I have for protecting records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189545 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189545&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189545 03/12/2026 If you keep electronic records, you must develop policies and procedures in addition to the requirements in §749.531 of this title (relating to What policies and procedures must I have for protecting records?). These policies and procedures must address:(1) What records must be in the external paper file and what records can be stored in the electronic file;(2) Computer security systems, including confidentiality, passwords, and employee procedures to ensure the security of the system;(3) Requirements for routine back-up of data;(4) Anti-virus protection systems; and(5) Limit access to your electronic files to persons within your agency authorized to see specific information in an electronic file. Source Note: The provisions of this §749.533 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.533 What additional policies and procedures must I have for electronic records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189546 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189546&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189546 03/12/2026 Yes, you may use electronic and digital signatures, including approvals by e-mail and electronic approvals. Source Note: The provisions of this §749.534 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.534 Are electronic signatures allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189547 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189547&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189547 03/12/2026 (a) All documentation must be in the record:(1) No later than 30 days after the occurrence or event;(2) As otherwise specified in this chapter.(b) Foster parents must submit copies of any records they keep. They must submit them within 15 days from the end of the month. You must file these records in the child's record. Source Note: The provisions of this §749.535 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.535 How current must a record be? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189548 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189548&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189548 03/12/2026 (a) You must make all active records available for our immediate review and reproduction.(b) You must make all archived records available for our review and reproduction within 48 hours.(c) We must have reasonable access to your storage and file areas in order to monitor your record keeping. Source Note: The provisions of this §749.537 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.537 Must I make records available for Licensing to review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189549 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189549&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189549 03/12/2026 You must maintain a copy of each current foster home disaster and emergency plan at the main office, the relevant branch office, or in a central administratively designated location. Source Note: The provisions of this §749.539 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.539 Where must I maintain foster home disaster and emergency plans? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189550 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189550&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189550 03/12/2026 (a) You must maintain all active personnel records at the main office or keep individual personnel records at the office where each person is working.(b) You must maintain archived personnel records at the main office, the relevant branch office, and/or in a central administratively designated location.(c) You may archive entire closed personnel records electronically.(d) Your system for maintaining all personnel records must be uniform throughout the agency.(e) You must maintain in the main office of the agency a master list of active and archived personnel records with a notation of the location of those records. Source Note: The provisions of this §749.551 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9444; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.551 Where must I maintain personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189551 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189551&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189551 03/12/2026 For each employee, excluding foster parents, the personnel record must include: (1) Documentation showing the date of employment; (2) Documentation showing how the person meets the minimum age and qualifications for the position; (3) A current job description;(4) Evidence of any valid professional licensures, certifications, or registrations the person must have to meet qualifications for the position, such as a current renewal card or a letter from the credentialing entity verifying that the person has met the required renewal criteria; (5) A copy of the record of tuberculosis screening conducted prior to the person having contact with children in care showing that the employee is free of contagious tuberculosis as provided in §749.1417 of this title (relating to Who must have a tuberculosis (TB) examination?); (6) A notarized Licensing Affidavit for Applicants for Employment form as specified in Human Resources Code, §42.059;(7) A statement signed and dated by the employee documenting that the employee has read a copy of the operational policies required by §749.103 of this title (relating to What policies and procedures must I submit for Licensing's approval as part of the application process?);(8) A statement signed and dated by the employee indicating the employee must immediately report any suspected incident of child abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the agency's administrator or administrator's designee; (9) Proof of request for background checks required by Chapter 745, Subchapter F of this title (relating to Background Checks); (10) For each person who transports a child, a copy of:(A) The person's valid driver's license; or(B) A driver's license check conducted through the Texas Department of Public Safety within the last 12 months;(11) A record of training, including the date of the training, the number of training hours, and the curriculum covered; (12) Any documentation of the person's performance with the agency; and (13) The date and reason for the person's separation, if applicable. Source Note: The provisions of this §749.553 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective March 1, 2014, 39 TexReg 1193; amended to be effective January 1, 2017, 41 TexReg 9444; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.553 What information must the personnel record of an employee include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189552 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189552&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189552 03/12/2026 All background check results must be kept confidential, in accordance with Human Resources Code §40.005(d) and (e). Background check results must be protected from unauthorized access or release. Source Note: The provisions of this §749.554 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.554 What information regarding personnel must be kept confidential? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189553 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189553&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189553 03/12/2026 (a) You must maintain annual training records for current personnel for the last full training year and current training year.(b) With the exception of subsection (a) of this section, you must keep personnel records for a year after an employee's last day on the job, or until any investigation involving the employee is resolved, whichever is longer. Source Note: The provisions of this §749.555 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.555 How long must I maintain personnel records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189554 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189554&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189554 03/12/2026 You must maintain master records for all clients. The records must be individualized, current, and complete. The master record may include electronic records. Source Note: The provisions of this §749.571 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.571 What client records must I maintain? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189555 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189555&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189555 03/12/2026 (a) You must maintain the active master case record for a child at the office where the child placement staff that is managing the child's placement is located.(b) You must maintain the active master record for a foster or adoptive home at the office where the child placement staff that is managing the home is located.(c) You must maintain a master list of active client records with a notation of the location of those records in the main office of the agency. Source Note: The provisions of this §749.573 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.573 Where must I maintain active master records for clients? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189556 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189556&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189556 03/12/2026 An active child record consists of the child's record for the most recent 12 months of service. Source Note: The provisions of this §749.575 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.575 What is an active record for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189557 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189557&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189557 03/12/2026 For each child, the active record must include:(1) The child's full name and another method of identifying the child, such as a client number; and(2) Documentation of known allergies and chronic conditions on the exterior of the child's record or in another place where the information is clearly visible to persons with access to the record, including a notation of "no known allergies" when applicable. Source Note: The provisions of this §749.577 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.577 What information must an active child record include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189558 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189558&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189558 03/12/2026 On an on-going basis, you must ensure that each child's record is:(1) Kept accurate and current;(2) Locked and kept in a safe location or locations; and(3) Kept confidential as required by law. Source Note: The provisions of this §749.579 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.579 How must I maintain an active child record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189559 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189559&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189559 03/12/2026 (a) You must maintain archived client records at the main office, the branch office that served the client, and/or in a central administratively designated location.(b) You may archive entire closed client records electronically.(c) Your system for maintaining all client records must be uniform throughout the agency.(d) You must maintain a master list of archived client records with a notation of the location of those records in the main office of the agency. Source Note: The provisions of this §749.581 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.581 Where must I maintain archived master records for clients? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189560 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189560&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189560 03/12/2026 Unless you are releasing information to a parent, to us, or as required by law, you may not release any portion of a child's record to any agency, organization, or individual without the written consent of the person legally authorized to consent to the release. Source Note: The provisions of this §749.583 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.583 Who must consent to the release of a child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189561 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189561&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189561 03/12/2026 (a) For children placed in adoption, you must maintain complete child, birth parent, and adoptive family records permanently or transfer them, as appropriate, to the Bureau of Vital Statistics.(b) You must maintain a foster child's complete record from admittance to discharge for two years from the date of discharge, or until the resolution of any investigation involving the child, whichever is longer.(c) You must maintain records for verified foster homes for at least five years after the foster home is closed. This includes foster homes that did not receive placements.(d) You must maintain records for approved adoptive applicants with whom you did not place a child for at least five years after the family withdraws or you close consideration of the family for a placement.(e) You must maintain records for applicants for foster or adoptive homes whom you did not verify or approve for at least one year after denial of the application.(f) You do not have to maintain records of foster or adoptive home applicants who drop out before the completion of a home screening. Source Note: The provisions of this §749.585 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.585 How long must I maintain client records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189562 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189562&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189562 03/12/2026 (a) If you cease operating, you must transfer adoption records to:(1) The Department of State Health Services, Bureau of Vital Statistics, and provide written notification to Licensing of the transfer; or(2) Another licensed child-placing agency. If you transfer your records to another child-placing agency, you must inform the Bureau of Vital Statistics, in writing, of the closing and of the location of the adoption records. You must send a copy of the letter you send to the Bureau of Vital Statistics to the local Licensing office.(b) You must transfer the records within the time frame specified by the Bureau of Vital Statistics. Source Note: The provisions of this §749.587 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.587 How must I handle adoption records if I cease operating? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199382 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199382&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199382 03/12/2026 (a) For each unauthorized absence of a child, you must:(1) Document the unauthorized absence in an annual summary log, as required by §749.591 of this division (relating to What documentation must be included in an annual summary log for a child who has an unauthorized absence?); and(2) Debrief the child, as required by §749.592 of this division (relating to What are the requirements for debriefing a child after an unauthorized absence?).(b) If a child has three unauthorized absences within a 60-day timeframe, you must conduct a triggered review of the child's unauthorized absences that is consistent with the rules in this division; and(c) You must conduct an overall agency evaluation for unauthorized absences every six months, as required by §749.596 of this division (relating to What is an overall agency evaluation for unauthorized absences?). Source Note: The provisions of this §749.590 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.590 What additional requirements are there for unauthorized absences of children from a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199383 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199383&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199383 03/12/2026 (a) For each unauthorized absence during the relevant year, you must document the following information in an annual summary log:(1) The name, age, gender, and date of admission of the child who was absent;(2) The time and date the unauthorized absence was discovered;(3) How long the child was gone or if the child did not return;(4) The name of the caregiver responsible for the child at the time the child's absence was discovered;(5) The intake report number, if a report was made to Licensing or the Department of Family and Protective Services; and(6) Whether law enforcement was contacted, including the name of any law enforcement agency that was contacted and the number of the police report, if applicable.(b) You must maintain each annual summary log for five years.(c) You must make the annual summary logs available to Licensing for review and reproduction, upon request. Source Note: The provisions of this §749.591 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.591 What documentation must be included in an annual summary log for a child who has an unauthorized absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199384 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199384&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199384 03/12/2026 (a) After a child returns to the foster home from an unauthorized absence, the foster parent, or other appropriate person, must conduct a debriefing with the child as soon as possible, but no later than 24 hours after the child's return. The purpose of the debriefing is for the child and the foster parent, or other appropriate person, to discuss the following:(1) The circumstances that led to the child's unauthorized absence;(2) The trauma informed strategies the child can use to avoid future unauthorized absences and how the foster parent can support those strategies;(3) The child's condition; and(4) What occurred while the child was away from the foster home, including where the child went, who was with the child, the child's activities, and any other information that may be relevant to the child's health and safety.(b) The foster parent must allow the child to return to routine activities, excluding any activity that the foster parent determines would be inappropriate because of the child's condition following the unauthorized absence or something that occurred during the unauthorized absence.(c) The debriefing must be documented in the child's record, including any routine activity that would be inappropriate for the child to return to and the explanation for why the activity is inappropriate. Source Note: The provisions of this §749.592 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.592 What are the requirements for debriefing a child after an unauthorized absence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199385 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199385&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199385 03/12/2026 (a) A triggered review of a child's unauthorized absences must occur as soon as possible, but no later than 30 days after the child's third unauthorized absence within a 60-day timeframe.(b) A regularly scheduled review of the child's service plan can serve as the triggered review of a child's unauthorized absences, if the regularly scheduled review:(1) Meets the requirements in §749.595 of this division (relating to What must the triggered review of a child's unauthorized absences include?); and(2) Takes place no later than 30 days after the child's third unauthorized absence within a 60-day timeframe. Source Note: The provisions of this §749.593 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.593 When must a triggered review of a child's unauthorized absences occur? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199386 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199386&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199386 03/12/2026 (a) The triggered review of a child's unauthorized absences must include the following participants:(1) The child;(2) The foster parent; and(3) Child placement staff.(b) You must notify the child's parent at least two weeks before the triggered review of a child's unauthorized absences, so the parent will have an opportunity to participate in the review. Source Note: The provisions of this §749.594 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.594 Who must participate in a triggered review of a child's unauthorized absences? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199387 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199387&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199387 03/12/2026 A triggered review for a child's unauthorized absences must include the following:(1) A review of the child's records documenting previous unauthorized absences, including previous debriefings;(2) A review of service plan elements identified in §749.1309(b)(1)(D) and (H) and, as applicable, §749.1309(b)(2) and (3) of this chapter (relating to What must a child's initial service plan include?);(3) An examination of trauma informed alternatives to minimize the unauthorized absences of the child; and(4) A written plan to reduce the unauthorized absences of the child, which you must document in the child's record. Source Note: The provisions of this §749.595 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.595 What must a triggered review of a child's unauthorized absences include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199388 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=199388&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 199388 03/12/2026 (a) Every six months, you must conduct an overall agency evaluation for unauthorized absences that have occurred at your foster homes during that time period.(b) The objectives of the evaluation are to:(1) Develop and maintain a trauma informed environment that supports positive and constructive behaviors by children in care; and(2) Ensure the overall safety and well-being of children in care.(c) The evaluation must include:(1) The frequency and patterns of unauthorized absences of children from your foster homes; and(2) Specific trauma informed strategies to reduce the number of unauthorized absences from your foster homes.(d) You must maintain the results of each six-month overall agency evaluation for unauthorized absences for five years.(e) You must make the results of each overall agency evaluation for unauthorized absences available to Licensing for review and reproduction, upon request. Source Note: The provisions of this §749.596 adopted to be effective June 1, 2020, 45 TexReg 3329. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES D REPORTS AND RECORD KEEPING §749.596 What is an overall agency evaluation for unauthorized absences? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189568 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189568&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189568 03/12/2026 Yes, however you must provide supporting information indicating that the education is equivalent to the minimum educational qualifications for the position for which the person is applying. Documents written in a foreign language must be translated into English. Source Note: The provisions of this §749.603 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.603 Does education received outside of the United States count toward educational qualifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189563 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189563&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189563 03/12/2026 (a) An employee's behavior or health status must not present a danger to children in care. (b) Each employee who is regularly or frequently present while children are in care must: (1) Meet the requirements in Subchapter F of Chapter 745 of this title (relating to Background Checks); (2) Have a record of a tuberculosis screening, showing the employee is free of contagious TB as provided in §749.1417 of this title (relating to Who must have a tuberculosis (TB) examination?); (3) Be physically, mentally, and emotionally capable of performing assigned tasks and must have the skills necessary to perform assigned tasks; and (4) Complete a notarized Licensing Affidavit for Applicants for Employment form, as specified in Human Resources Code, §42.059. Source Note: The provisions of this §749.605 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.605 What minimum qualifications must all employees meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189564 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189564&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189564 03/12/2026 Regardless of whether the employee or caregiver is counted in the child/caregiver ratio, each employee or caregiver must:(1) In the absence of a more specific rule requirement, demonstrate competency, prudent judgment, and self-control in the presence of children and when performing assigned responsibilities;(2) Report suspected abuse, neglect, and exploitation to the Child Abuse Hotline and to the designated administrator or supervisor; and(3) Know and comply with rules of this chapter, Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating to Licensing), and any other laws which are relevant to the person's duties. Source Note: The provisions of this §749.607 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.607 What general responsibilities do all employees and caregivers have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189565 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189565&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189565 03/12/2026 Before having contact with children in care, all caregivers, employees, contract staff, volunteers, foster home household members, and employees in foster homes must be screened for tuberculosis as provided in §749.1417 of this title (relating to Who must have a tuberculosis (TB) examination?). Source Note: The provisions of this §749.609 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.609 What are the requirements for tuberculosis screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189566 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189566&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189566 03/12/2026 (a) A child-placing agency administrator must:(1) Meet the qualifications established by the agency's governing body;(2) Be a Licensed Child-Placing Agency Administrator according to Chapter 43 of the Human Resources Code and Chapter 745, Subchapter N of this title (relating to Administrator Licensing);(3) Be a full-time employee of the agency; and(4) Be present at a Texas office of the agency to provide on-site administrative oversight.(b) If acting as the administrator for two residential child-care operations under §749.633 of this title (relating to Can a child-placing agency administrator be an administrator for two residential child-care operations?), the administrator must split a full-time schedule between the two operations as described in the professional staffing plans for each operation. Source Note: The provisions of this §749.631 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.631 What qualifications must a child-placing agency administrator meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215288 03/12/2026 A child-placing agency administrator can be an administrator for two residential child-care operations, including a general residential operation or residential treatment center, if:(1) Both operations are in good standing with Licensing;(2) The size and scope of the operations are manageable by one person, which is clarified in the written professional staffing plans;(3) The person also holds a valid full Child-Care Administrator License, if the second operation is a general residential operation; and(4) At least one child-placing agency is managing 25 or fewer foster homes. Source Note: The provisions of this §749.633 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective October 19, 2023, 48 TexReg 5980. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.633 Can a child-placing agency administrator be an administrator for two residential child-care operations? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208645 03/12/2026 The child-placing agency administrator must:(1) Have daily supervision and overall administrative responsibility for all your offices, including your main office and any branch offices;(2) Ensure that the operation complies with current heightened monitoring plan(s), if applicable; and(3) Be responsible for or assign responsibility for:(A) Administering and managing the agency according to your policies;(B) Ensuring that the agency complies with applicable rules of this chapter, Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating to Licensing), and other applicable laws;(C) Personnel matters, including hiring, assigning duties, training, supervision, evaluation of employees, and terminations;(D) Ensuring persons whose behavior or health status presents a danger to children are not allowed at the agency or foster homes; and(E) Administering and managing your approved agency plans as stated in §749.101(3) and (4) of this title (relating to What plans must I submit for Licensing's approval as part of the application process?). These plans:(i) Evaluate the effectiveness or your system for meeting the rules of this chapter; and(ii) Ensure the investigation of reports of minimum standards violations, upon our request. Source Note: The provisions of this §749.635 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909l amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.635 What responsibilities must the child-placing agency administrator have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189572 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189572&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189572 03/12/2026 (a) The child-placing agency administrator must designate an employee to be responsible for the overall administration of the agency while the administrator is absent from the agency on a frequent and/or extended basis.(b) The designee must be a Licensed Child-Placing Agency Administrator as required in Chapter 43 of the Human Resources Code. Source Note: The provisions of this §749.637 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.637 Who must have overall administrative responsibility when the child-placing agency administrator is absent on a frequent and/or extended basis? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189569 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189569&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189569 03/12/2026 Your agency must have the following employees identified:(1) Child placement staff; and(2) Child placement management staff. Source Note: The provisions of this §749.661 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.661 What employees must my agency have to perform child placement activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189570 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189570&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189570 03/12/2026 (a) Child placement staff providing foster care services are responsible for:(1) Deciding whether to admit a child for placement, including completion of an admission assessment and any other evaluation of a child for placement;(2) Placing a child into a foster home or other substitute living arrangement;(3) Managing the case of a child, including:(A) Developing and updating of service plans;(B) Maintaining direct contact with the child and the foster parents or other caregivers; and(C) Performing any additional case management activities, including conducting and documenting supervisory visits for compliance with §749.2815 of this title (relating to How often must I have supervisory visits with the foster home and what must be evaluated during a supervisory visit?);(4) Orientation, assessment, and verification of foster parents; and(5) Monitoring and providing support services to foster parents, including the initiation of development plans, corrective actions, or adverse actions.(b) Child placement staff providing adoption services are responsible for:(1) Deciding whether to admit a child for placement;(2) Placing a child into a foster home, adoptive home, or other substitute living arrangement;(3) Managing the case of a child, including:(A) Developing and updating of service plans;(B) Maintaining direct contact with the child and the foster parents, adoptive parents, or other caregivers; and(C) Performing any additional case management activities;(4) Case management and service delivery to birth parents; and(5) Orientation, assessment, and approval of adoptive parents. Source Note: The provisions of this §749.663 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.663 What are the responsibilities of child placement staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189577 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189577&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189577 03/12/2026 Child placement management staff must:(1) Review and approve:(A) All child placement activities, as outlined in §749.663 of this title (relating to What are the responsibilities of child placement staff?);(B) Documentation of supervisory visits for compliance with §749.2815 of this title (relating to How often must I have supervisory visits with the foster home and what must be evaluated during a supervisory visit?);(C) Investigation findings of minimum standards deficiencies that Licensing requested you conduct; and(D) Corrective and adverse action plans involving foster families; and(2) Supervise child placement staff, if any, including planning for the staff's professional development and taking any other appropriate action in regard to their child-placing decisions.(3) Directly perform the responsibilities of the child placement staff, as appropriate (e.g. the child placement staff is absent or unavailable). Source Note: The provisions of this §749.667 adopted to be effective January 1, 2007, 31 TexReg 7469l; amended to be effective September 1, 2014, 39 TexReg 6229; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.667 What are the responsibilities of child placement management staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189573 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189573&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189573 03/12/2026 Child placement management staff must review and approve by signing and dating the following documents:(1) Assessment/admission forms;(2) Initial and subsequent placement documents;(3) Foster and adoptive home screenings;(4) Investigation reports of minimum standards deficiencies that Licensing requested you conduct;(5) Foster home development and/or corrective action plans;(6) Initial and updated service plans;(7) Discharge or transfer plans and summaries;(8) Any restrictions you impose on the child:(A) For more than 30 days that the treatment director or service planning team has not approved; and(B) That continues for more than 30 days and must be re-evaluated by the child placement management staff;(9) Any restrictions to communication and visitation with family imposed on a child;(10) Any restrictions to a particular room or building for more than 24 hours imposed on a child; and(11) Child placement staff contacts with children per §749.1291 of this title (relating to What are the requirements for contact between child placement staff and children in foster care?). Source Note: The provisions of this §749.669 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.669 How do child placement management staff document approval? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215776 03/12/2026 In addition to the requirements that all employees must meet, employees who perform child placement activities must meet the following qualifications:Attached Graphic Source Note: The provisions of this §749.673 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.673 What are the qualifications that an employee must have to perform child placement activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215777 03/12/2026 In addition to the requirements that all employees must meet, employees who perform child placement management activities must meet the following qualifications:Attached Graphic Source Note: The provisions of this §749.675 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.675 What are the qualifications an employee must have to perform child placement management activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215774 03/12/2026 (a) You must have a child placement management staff assigned for each branch office to perform the child-placement activities.(b) Your child placement management staff must have and document at least 10 monthly supervision conferences per year with a branch-office employee who performs child-placing activities.(c) Employees performing child-placing activities must have reasonable access to their supervisor(s). Source Note: The provisions of this §749.677 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.677 What are the requirements for child placement management staff at a branch office? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215775 03/12/2026 There are no caseload requirements for child placement staff; however, you must:(1) Maintain compliance with §749.305(a)(2) of this title (relating to What are the requirements for administrators and treatment directors for a main office and branch offices?), if applicable; and(2) Ensure that all caseloads allow child placement staff to meet the needs of children in care and adequately support foster and adoptive homes. Source Note: The provisions of this §749.679 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.679 What are the requirements for the caseloads of my child placement staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189579 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189579&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189579 03/12/2026 You must have a treatment director if you provide treatment services to 30 or more children at any one time, or to more than 50% of the children in your care. Your treatment director must be a full-time employee of your agency. Source Note: The provisions of this §749.721 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.721 Must I have a treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189580 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189580&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189580 03/12/2026 (a) Your treatment director:(1) Is responsible for your overall treatment program, including clinical responsibility for the management of your agency's therapeutic interventions; and(2) Provides direction and overall management of your treatment program.(b) When assigning responsibilities to your treatment director, you must ensure that the treatment director can oversee the treatment of all children receiving treatment services. Source Note: The provisions of this §749.723 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.723 What are the responsibilities of my treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189581 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189581&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189581 03/12/2026 (a) A treatment director that provides or oversees treatment services for children with intellectual disabilities or children with autism spectrum disorder must be:(1) Licensed as a psychiatrist, psychologist, professional counselor, clinical social worker, marriage and family therapist, or registered nurse; or(2) Certified by the Texas Education Agency as an education diagnostician, have a master's degree in special education or a human services field, and have three years of experience working with children with intellectual disabilities or autism spectrum disorder.(b) A treatment director that provides or oversees treatment services for children with primary medical needs must be a physician or a licensed registered nurse.(c) A treatment director that provides or oversees treatment services for children with emotional disorders must:(1) Be a psychiatrist or psychologist;(2) Have a master's degree in a human services field from an accredited college or university and three years of experience providing treatment services for children with an emotional disorder, including one year in a residential setting; or(3) Be a licensed master social worker, a licensed clinical social worker, a licensed professional counselor, or a licensed marriage and family therapist, and have three years of experience providing treatment services for children with an emotional disorder, including one year in a residential setting. Source Note: The provisions of this §749.725 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.725 What qualifications must a treatment director have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189582 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189582&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189582 03/12/2026 Yes, you can have one treatment director if he meets the required qualifications for the most prevalent treatment services your agency offers. Source Note: The provisions of this §749.727 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.727 If I provide more than one type of treatment service, can I have one treatment director? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189583 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189583&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189583 03/12/2026 A registered nurse must be on staff or on contract and must:(1) Perform a nursing assessment of the child to include documentation of the child's diagnosed medical needs and selection of placement;(2) Lead or participate in the service planning process for the child's care;(3) Review medical records, including compliance with written physician orders;(4) Contact other professionals, as needed, for the child's care;(5) Monitor the implementation of the child's service plan; and(6) Document outcomes for interventions used in the child's care. Source Note: The provisions of this §749.741 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.741 What treatment services must a registered nurse provide if I support a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208647 03/12/2026 (a) You must maintain a personnel record for each volunteer.(b) The personnel record must include a statement signed and dated by the volunteer indicating the volunteer must immediately report any suspected incident of abuse, neglect, or exploitation to the Texas Abuse and Neglect Hotline and the agency's administrator or administrator's designee. An internal reporting policy may not require or allow a volunteer to delegate the person's responsibility or require a volunteer to obtain approval to report suspected abuse, neglect, or exploitation. Source Note: The provisions of this §749.761 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.761 What are the requirements for a volunteer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189584 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189584&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189584 03/12/2026 (a) A volunteer or contractor that performs any employee or caregiver function must meet the same requirements as an employee or caregiver who performs that function.(b) You must maintain records documenting how these requirements are met. Source Note: The provisions of this §749.763 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.763 Are there additional requirements for a volunteer or contractor that performs employee or caregiver functions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189585 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189585&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189585 03/12/2026 (a) A volunteer or contractor who is part of another organization is subject to your policies and procedures unless that organization provides screening, training, and supervision to the volunteer/contractor that are adequate to protect the health and safety of children. Before the volunteer/contractor can have contact with children:(1) The volunteer/contractor must meet the relevant requirements of your policies and procedures; or(2) You must confirm that the organization provides adequate screening, training, and supervision.(b) An organization may be another licensed operation. Source Note: The provisions of this §749.767 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.767 When is a volunteer or contractor who is a part of another organization subject to my policies and procedures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189586 03/12/2026 A person may not perform community service at your agency. For the purpose of this rule, community service includes service a person must perform because the person is on probation, parole, or otherwise required to perform the service through the courts because of criminal activity. Source Note: The provisions of this §749.769 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES E AGENCY STAFF AND CAREGIVERS §749.769 May a person perform community service hours at my agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208648 03/12/2026 The words and terms used in this subchapter have the following meanings:(1) CPR--Cardiopulmonary resuscitation.(2) Hours--Clock hours.(3) Instructor-led training--Training that is characterized by the communication and interaction that takes place between the student and the instructor. Instructor-led training does not have to be in person, but it must include an opportunity for the student to interact with the instructor to obtain clarifications and information beyond the scope of the training materials. For such an opportunity to exist, the instructor must be able to answer questions, provide feedback on skills practice, provide guidance or information on additional resources, and proactively interact with students. Examples of this type of training include classroom training, online distance learning, blended learning, video-conferencing, or other group learning experiences.(4) Self-instructional training--Training designed to be used by one individual working alone and at the individual's own pace to complete lessons or modules. Lessons or modules commonly include questions with clear right and wrong answers. An example of this type of training is web-based training. Self-study training is also a type of self-instructional training.(5) Self-study training--Non-standardized training where an individual reads written materials, watches a training video, or listens to a recording to obtain certain knowledge that is required for annual training. Self-study training is limited to three hours of annual training per year, as described in §749.935(d) of this subchapter (relating to What types of hours or instruction can be used to complete the annual training requirements?). Source Note: The provisions of this §749.801 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.801 What do certain words and terms mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205233 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205233&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205233 03/12/2026 (a) A caregiver must complete the following training requirements, unless the caregiver meets the requirements of an exemption or a waiver for the training that is provided in this subchapter:Attached Graphic(b) You must ensure that a caregiver who provides care to a child receiving treatment services meets the pre-service experience requirements specified in §749.861 of this subchapter (relating to What are the pre-service experience requirements for caregivers?). Source Note: The provisions of this §749.811 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.811 What are the training and experience requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205234 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205234&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205234 03/12/2026 An employee must complete the following training requirements, unless the employee meets the requirements of an exemption for the training that is provided in this subchapter:Attached Graphic Source Note: The provisions of this §749.813 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.813 What are the training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205308 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205308&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205308 03/12/2026 (a) Prior to beginning job duties or having contact with children in care, each caregiver or employee must have orientation that includes:(1) An overview of the relevant and applicable rules of this chapter;(2) Your philosophy, organizational structure, policies, and a description of the services and programs you offer; and(3) The needs and characteristics of children that you serve.(b) You must document the completion of the orientation in the appropriate personnel record. Source Note: The provisions of this §749.831 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.831 What is the orientation requirement for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205235 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205235&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205235 03/12/2026 (a) A person who was a caregiver or employee at your agency during the past 12 months may be exempt from orientation if you meet the following requirements:(1) You discuss with the person any changes in your services or programs that have occurred since the person was previously a caregiver or employee;(2) If the person is an employee, you ensure the employee received training during the past 12 months from your agency on prevention, recognition, and reporting on child abuse, neglect, and exploitation; and(3) If the person is acting as a caregiver, you do not allow the person to be the only caregiver for a group of children before you meet the requirement in paragraph (1) of this section.(b) You must document the discussion and the previous training in the person's foster home record or personnel record. Source Note: The provisions of this §749.833 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.833 When may a caregiver or employee be exempt from orientation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205309 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205309&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205309 03/12/2026 (a) For caregivers providing care to children only receiving child-care services and/or programmatic services, there are no pre-service experience requirements.(b) Before a caregiver can provide care to a child receiving treatment services, you must ensure that the caregiver has the experience to care for the child's treatment need. If a caregiver does not have the necessary experience, your child-placement management staff must prescribe a regimen of specific child-care experience that the caregiver must complete before you place a child with treatment needs in the caregiver's home, including a minimum of eight hours of observations of interactions with children receiving similar treatment services as the prospective caregiver would be providing.(c) You must document the caregiver's experience and/or prescribed regimen in the home's record. Source Note: The provisions of this §749.861 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.861 What are the pre-service experience requirements for caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205247 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205247&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205247 03/12/2026 (a) A caregiver must complete the following applicable types of pre-service training within the noted timeframe:Attached Graphic(b) A caregiver who cares exclusively for children receiving treatment services for primary medical needs is exempt from the pre-service emergency behavior intervention training requirement.(c) To meet the pre-service training requirements, the training must comply with the applicable curriculum requirements in Division 5 of this subchapter (relating to Curriculum Components for Pre-Service Training).(d) You must document the completion of each training requirement in the appropriate foster home record or personnel record. Source Note: The provisions of this §749.863 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.863 What are the pre-service training requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205248 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205248&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205248 03/12/2026 (a) An employee must complete the following applicable training types and hours within the noted timeframes:Attached Graphic(b) To meet the pre-service training requirements, the training must comply with the applicable curriculum requirements in Division 5 of this subchapter (relating to Curriculum Components for Pre-Service Training).(c) You must document the completion of each training requirement in the appropriate personnel record. Source Note: The provisions of this §749.864 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.864 What are the pre-service training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205307 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205307&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205307 03/12/2026 No, the orientation training must be separate from the pre-service hourly training requirement. Source Note: The provisions of this §749.865 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.865 Can time spent in orientation training count towards pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205249 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205249&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205249 03/12/2026 (a) A caregiver is exempt from completing the eight hours of general pre-service training if the caregiver has been a caregiver for a residential child-care operation during the past 12 months.(b) A caregiver or employee is exempt from completing the two hours of normalcy training if the foster parent or employee has:(1) Been a caregiver for or employed by a residential child-care operation during the past 12 months;(2) Received training on normalcy during the past 12 months; and(3) Can document that the training was received.(c) A caregiver or employee is exempt from completing the pre-service training for emergency behavior intervention if the caregiver or employee:(1) Has been a caregiver for or employed by a residential child-care operation during the past 12 months;(2) Has received emergency behavior intervention training during the past 12 months that meets the required curriculum components of the following applicable rule:(A) §749.887 of this subchapter (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?); or(B) §749.889 of this subchapter (relating to If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?); and(3) Can demonstrate knowledge and competency of the training material in writing and, if the child-placing agency allows the use of emergency behavior intervention, in physical techniques.(d) You must document the exemption factors in the appropriate foster home record or personnel record. Source Note: The provisions of this §749.867 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.867 What caregivers or employees are exempt from certain pre-service training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208649 03/12/2026 (a) A child-placing agency, including a single source continuum contractor, may waive any of the following pre-service training requirements for a foster parent if the agency determines that the requirement is not directly related to the ages and number of children the foster home will care for and the types of services the home will provide:(1) General pre-service training;(2) Normalcy; or(3) Emergency behavior intervention.(b) After waiving a pre-service training requirement for a foster parent, an agency must reevaluate the waiver if, within the first year, there is a change in the foster home's verification with respect to the ages or number of children the home can care for or the types of services the home can provide. If the agency determines that the waived preservice training is directly related to the ages or number of children the home can care for, or the types of services the home can provide, the foster parent must complete the training.(c) You must document:(1) any determination that a waiver of pre-service training is appropriate for a foster parent; and(2) any re-evaluation of the foster home due to changes to the ages or number of children the home can care for or the types of services the home can provide. Source Note: The provisions of this §749.868 adopted to be effective June 27, 2021, 46 TexReg 3525; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.868 Can a child-placing agency waive pre-service training requirements for a foster parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205251 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205251&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205251 03/12/2026 (a) Instructor-led training and self-instructional training must include:(1) Specifically stated learning objectives;(2) An evaluation or assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(3) A certificate, letter, or a signed and dated statement of successful completion from the training source.(b) Pre-service training must be provided by an instructor who:(1) Holds a generally recognized credential; or(2) Possesses documented knowledge or experience relevant to the training the instructor will provide.(c) Training on administering psychotropic medication must be instructor-led, as defined in §749.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?). The instructor must be a health-care professional or pharmacist.(d) Training on emergency behavior intervention must:(1) Be instructor-led with each instructor certified in a recognized method of emergency behavior intervention or otherwise able to document knowledge of:(A) Emergency behavior intervention;(B) The course material;(C) Methods for delivering the training, including physical techniques for restraints, if applicable; and(D) Methods for evaluating and assessing a participant's knowledge and competency of the training material and physical techniques, if applicable;(2) Be competency-based; and(3) At the end of the training, require each participant to demonstrate knowledge and competency of the training material:(A) In writing; and(B) If the child-placing agency allows the use of emergency behavior intervention, by demonstrating the physical technique the participant is allowed to use. Source Note: The provisions of this §749.869 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.869 How must pre-service training be conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205294 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205294&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205294 03/12/2026 The general pre-service training must include the following curriculum components:(1) Topics appropriate to the needs of children for whom the caregiver will be providing care, such as developmental stages of children, fostering children's self-esteem, constructive guidance and discipline of children, water safety, and strategies and techniques for monitoring and working with these children;(2) Trauma informed care;(3) The different roles of caregivers;(4) Measures to prevent, recognize, and report suspected occurrences of child abuse (including sexual abuse), neglect, and exploitation;(5) Procedures to follow in emergencies, such as weather related emergencies, volatile persons, and severe injury or illness of a child or adult; and(6) Preventing the spread of communicable diseases. Source Note: The provisions of this §749.881 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.881 What curriculum components must be included in the general pre-service training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205295 03/12/2026 The pre-service training for normalcy must include the following curriculum components:(1) A discussion of the definitions of normalcy and the reasonable and prudent parent standard;(2) The developmental stages of children, including a discussion of the cognitive, social, emotional, and physical development of children;(3) Age appropriate activities for children, including unsupervised childhood activities;(4) The benefits of childhood activities to a child's well-being, mental health, and social, emotional, and developmental growth;(5) How to apply the reasonable and prudent parent standard to make decisions; and(6) The child's and the caregiver's responsibilities when participating in childhood activities. Source Note: The provisions of this §749.882 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.882 What curriculum components must be included in the pre-service training for normalcy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205297 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205297&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205297 03/12/2026 The pre-service training for safe sleeping must include the following curriculum components:(1) Recognizing and preventing shaken baby syndrome and abusive head trauma;(2) Understanding safe sleeping practices and preventing sudden infant death syndrome; and(3) Understanding early childhood brain development. Source Note: The provisions of this §749.883 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.883 What curriculum components must be included in the pre-service training for safe sleeping? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205298 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205298&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205298 03/12/2026 The pre-service training for administering psychotropic medication must include the following curriculum components:(1) Identification of psychotropic medications;(2) Basic pharmacology (the actions and side effects of, and possible adverse reactions to, various psychotropic medications);(3) Techniques and methods of administering medications;(4) Who is legally authorized to provide consent for the psychotropic medication; and(5) Any related policies and procedures. Source Note: The provisions of this §749.885 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.885 What curriculum components must be included in the pre-service training for administering psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205296 03/12/2026 If you do not allow the use of emergency behavior intervention, the pre-service training for emergency behavior intervention must focus on early identification of potential problem behaviors and strategies and techniques for less restrictive interventions, including the following curriculum components:(1) Developing and maintaining an environment that supports positive and constructive behaviors;(2) The causes of behaviors potentially harmful to a child, including aspects of the environment;(3) Early signs of behaviors that may become dangerous to a child or others;(4) Strategies and techniques a child can use to avoid harmful behaviors;(5) Teaching a child to use the strategies and techniques of your agency's de-escalation protocols to avoid harmful behavior, and supporting the children's efforts to progress into a state of self-control;(6) Less restrictive strategies caregivers can use to intervene in potentially harmful behaviors;(7) Less restrictive strategies caregivers can use to work with an oppositional child;(8) Addressing circumstances when all de-escalation strategies fail; and(9) The risks associated with the use of prone or supine restraints, including positional, compression, or restraint asphyxia. Source Note: The provisions of this §749.887 adopted to be effective amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.887 If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205299 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205299&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205299 03/12/2026 (a) If you allow the use of emergency behavior intervention, at least 75 percent of the pre-service training for emergency behavior intervention must focus on early identification of potential problem behaviors and strategies and techniques for less restrictive interventions, including the curriculum components listed in §749.887 of this division (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?).(b) The training does not have to address the use of any type of emergency behavior intervention that your policies do not allow.(c) The other 25 percent of the pre-service training curriculum for emergency behavior intervention must include the following components:(1) Different roles and responsibilities of caregivers qualified in emergency behavior intervention, versus employees or volunteers who are not qualified in emergency behavior intervention;(2) Escape and evasion techniques to prevent harm to the child and caregiver without requiring the use of an emergency behavior intervention;(3) Safe implementation of the restraint techniques and procedures that are appropriate for the age and weight of children served and permitted by the rules in this chapter and your policies and procedures;(4) The physiological impact of emergency behavior intervention;(5) The psychological impact of emergency behavior intervention, such as flashbacks from prior abuse;(6) How to adequately monitor the child during the administration of an emergency behavior intervention to prevent injury or death;(7) Monitoring physical signs of distress and obtaining medical assistance;(8) Health risks for children associated with the use of specific techniques and procedures;(9) Drawings, photographs, or videos of each personal restraint permitted by your policy; and(10) Strategies for re-integration of children into the environment after the use of emergency behavior intervention, including the debriefing of caregivers and the child. Source Note: The provisions of this §749.889 adopted to be effective amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.889 If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205252 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205252&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205252 03/12/2026 (a) Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric first aid with rescue breathing and choking. This training may be through instructor-led training or self-instructional training.(b) Each caregiver must have a current certificate of training with an expiration or renewal date in pediatric CPR. The pediatric CPR training:(1) Must adhere to the guidelines for CPR for a layperson established by the American Heart Association, and consist of a curriculum that incudes use of a CPR manikin and both written and hands-on skill-based instruction, practice, and testing; and(2) May be provided through blended learning that utilizes online technology, including self-instructional training, as long as the criteria in paragraph (1) of this subsection is met.(c) One foster parent must be certified in pediatric first aid and pediatric CPR before you place a child in the home. Other caregivers, including a second foster parent, must be certified in pediatric first aid and pediatric CPR within 90 days after you place the child in the home.(d) In lieu of either or both certifications, a caregiver may provide documentation of the following:(1) Training as a health professional that includes the knowledge covered in either pediatric first aid or pediatric CPR, or both; and(2) The caregiver's employment as a health professional requires that the relevant skills remain current. Source Note: The provisions of this §749.911 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.911 Who must have pediatric first aid and pediatric CPR training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205253 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205253&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205253 03/12/2026 (a) If a caregiver is absent from the home on an extended basis as a condition of the caregiver's employment or military service, the caregiver is exempt from obtaining current certification in pediatric first aid and pediatric CPR during this time of absence. The caregiver must obtain pediatric first aid and pediatric CPR certifications within 90 days after returning home.(b) A child-placement staff member who meets the definition of a caregiver only because the staff member provides transportation for children in foster care, must obtain pediatric first-aid certification, but is exempt from pediatric CPR certification. Source Note: The provisions of this §749.913 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.913 Are there any exemptions from pediatric first aid and pediatric CPR certification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205254 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205254&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205254 03/12/2026 (a) You must document the caregiver's completion of each training requirement in the appropriate foster home record or personnel record. The documentation may be a certificate, letter, or a signed and dated statement of successful completion from the training source. You may maintain a photocopy of the original pediatric first-aid or pediatric CPR certificate or letter in the foster home record or personnel record, as long as the caregiver can provide an original document upon request by Licensing.(b) The documentation must include:(1) The participant's name;(2) Date of the training;(3) Title or subject of the training;(4) The trainer's name and qualifications;(5) The expiration date of the certification as determined by the organization providing the certification; and(6) Length of the training in hours. Source Note: The provisions of this §749.915 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.915 What documentation must I maintain for pediatric first-aid and pediatric CPR certifications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205300 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205300&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205300 03/12/2026 (a) A caregiver must complete the number of annual training hours described in the following chart:Attached Graphic(b) For a home with two foster parents, the foster parents may combine their individual training hours to meet the total number of required annual training hours. If each foster parent is required to complete 10 hours, they must collectively complete 20 hours. If each foster parent is required to complete 25 hours, they must collectively complete 50 hours. But the foster parents do not have to split the total number of required hours equally, if:(1) Each foster parent completes each of the required annual training hours noted in subsection (c) of this section; and(2) They complete the combined total number of required hours for annual training.(c) For the annual training hours described in subsection (a) of this section, each caregiver must complete the following specific types of training and hours:Attached Graphic(d) To meet the mandated annual training requirements in subsection (c) of this section, the training must comply with the applicable curriculum requirements in Division 8 of this subchapter (relating to Topics and Curriculum Components for Annual Training).(e) After completing the type of annual training required in subsection (c) of this section, any remaining number of annual training hours must be in areas appropriate to the needs of children for whom the caregiver provides care, as required by §749.941 of this subchapter (relating to What areas or topics are appropriate for annual training?). Source Note: The provisions of this §749.930 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.930 What are the annual training requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208650 03/12/2026 (a) Each type of employee in the chart must complete the following number of annual training hours:Attached Graphic(b) For the annual training hours described in subsections (a)(1), (2), and (3) of this section, each employee must complete the following specific types of training and hours:Attached Graphic(c) The annual training hours for an employee described in subsection (a)(4) of this section:(1) Must include one hour of training on prevention, recognition, and reporting on child abuse, neglect, and exploitation; and(2) May include annual training hours that the employee completes to maintain a relevant professional license, if the hours include the necessary components of subsection (c)(1) of this section or the employee completes those components separately.(d) There are no annual training requirements for emergency behavior intervention. However, the employee must be retrained whenever there is a substantial change in techniques, types of intervention, or agency policies for emergency behavior intervention. Source Note: The provisions of this §749.931 adopted to be effective June 27, 2021, 46 TexReg 3525; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.931 What are the annual training requirements for an employee? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205302 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205302&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205302 03/12/2026 (a) If a caregiver is absent from the home on an extended basis as a condition of the caregiver's employment or military service, you must prorate the caregiver's annual training requirements based on the number of months out of the year that the caregiver will be at the home. If a caregiver is absent for an entire year, the caregiver is exempt for the annual training hours for that year.(b) A child-placing agency, including a single source continuum contractor, may waive certain annual training requirements for a foster parent or for a foster home as described in subsection (c) of this section if:(1) The foster parent or foster home has been verified by the child-placing agency the previous two years; and(2) During that timeframe, the child-placing agency was not cited for any deficiencies related to the foster parent or the foster home and there are no pending allegations related to the foster parent or the foster home.(c) For a foster parent or foster home that meets the requirements described in subsection (b) of this section, the agency may waive the following types of training upon determining that the training is not directly related to the care of any foster child in the home:(1) Emergency behavior intervention;(2) Trauma informed care; or(3) Normalcy.(d) A child-placing agency that waives certain annual training requirements for a foster home under subsection (c) of this section may waive the training for one or both foster parents and any other caregiver in the home.(e) A child-placing agency may not waive a foster parent's annual training for emergency behavior intervention, trauma informed care, or normalcy during consecutive years.(f) You must document the basis of the exemption, proration, or waiver in the appropriate foster home record or personnel record. Source Note: The provisions of this §749.932 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.932 What exemptions or waivers may apply to the annual training requirements for a caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205303 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205303&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205303 03/12/2026 (a) Each person must complete the annual training:(1) Within 12 months from when:(A) You hire the person as an employee, including employees hired or acting as a caregiver;(B) You verify the person as a foster parent; or(C) A caregiver in the home, that is not an employee or foster parent, begins providing care to a child; and(2) During each subsequent 12-month period after the anniversary date of hire, verification, or beginning the provision of care.(b) Alternatively, you have the option of prorating the person's annual training requirements from the date of hire or verification to the end of the calendar year or the end of the agency's fiscal year and then beginning a new 12-month period that coincides with the calendar or fiscal year.(c) Whether an agency uses subsection (a) or (b) of this section as your method for completing annual training requirements, you must use the method consistently throughout your agency. Source Note: The provisions of this §749.933 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.933 When must an employee or caregiver complete the annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208651 03/12/2026 (a) If the training complies with the other rules in this division (relating to Annual Training), annual training may include hours or Continuing Education Units earned through:(1) Workshops or courses offered by local school districts, colleges or universities, or Licensing;(2) Conferences or seminars;(3) Instructor-led training, as defined at §749.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?);(4) Self-instructional training, as defined at §749.801(5) of this subchapter;(5) Planned learning opportunities provided by child-care associations or Licensing;(6) Planned learning opportunities provided by a child-placing agency administrator, professional contract service provider, professional service provider, treatment director, child placement management staff, child placement staff, contractor, or caregiver who meets minimum qualifications in the rules of this chapter; or(7) Completed college courses for which a passing grade is earned, with three college credit hours being equivalent to 50 clock hours of required training. College courses do not substitute for required CPR or first aid certification or required annual training on emergency behavior intervention or psychotropic medication.(b) For annual training hours, you may count:(1) The hours of annual training that a person received at another residential child-care operation, if the person:(A) Received the training within the time period you are using to calculate the person's annual training; and(B) Provides documentation of the training;(2) Pediatric first aid and pediatric CPR;(3) Any hours of pre-service training that the person earned in addition to the required pre-service hours, although you may not carry over more than 15 hours of a person's pre-service training hours for use as annual training hours during the upcoming year;(4) Half of the hours spent developing initial training curriculum that is relevant to the population of children served, but no additional credit hours for training curriculum development are permitted for repeated training sessions; and(5) One-fourth of the hours spent updating and making revisions to training curriculum that is relevant to the population of children served.(c) For annual training hours, you may not count:(1) Orientation training;(2) Required pre-service training;(3) The hours involved in case staffings and conferences with the supervisor; or(4) The hours presenting training to others.(d) No more than 80 percent of the required annual training hours may come from self-instructional training as defined at §749.801(5) of this subchapter. No more than three of those self-instructional hours may come from self-study training as defined at §749.801(6) of this subchapter.(e) If a person earns more than the minimum number of annual training hours required during a particular year, the person can carry over to the next year a maximum of 15 annual training hours. Source Note: The provisions of this §749.935 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.935 What types of hours or instruction can be used to complete the annual training requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205305 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205305&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205305 03/12/2026 We do not approve or endorse training resources or trainers for training hours. Source Note: The provisions of this §749.937 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.937 Does Licensing approve training resources or trainers for annual training hours? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205306 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205306&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205306 03/12/2026 (a) Instructor-led training and self-instructional training, excluding self-study training, must include:(1) Specifically stated learning objectives;(2) A curriculum that includes experiential or applied activities;(3) An evaluation or assessment tool to determine whether the person has obtained the information necessary to meet the stated objectives; and(4) A certificate, letter, or a signed and dated statement of successful completion from the training source.(b) Training on emergency behavior intervention and administering psychotropic medication must be instructor-led, as defined at §749.801(3) of this subchapter (relating to What do certain words and terms mean in this subchapter?).(c) Training on emergency behavior intervention must:(1) Be led by an instructor who is certified in a recognized method of emergency behavior intervention or otherwise able to document knowledge of:(A) Emergency behavior intervention;(B) The course material;(C) Methods for delivering the training, including physical techniques for restraints, if applicable; and(D) The methods for evaluating and assessing a participant's knowledge and competency of the training material and physical techniques, if applicable;(2) Be competency-based; and(3) At the end of the training, require each participant to demonstrate knowledge and competency of the training material:(A) In writing; and(B) If the child-placing agency allows the use of emergency behavior intervention, by demonstrating the physical techniques that the participant may use.(d) A health-care professional or a pharmacist must lead the training in administering psychotropic medication. The trainer must assess each participant after the training to ensure that the participant has learned the course content. Source Note: The provisions of this §749.939 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.939 How must annual training be conducted? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205262 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205262&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205262 03/12/2026 (a) Other than the mandated topics, annual training for caregivers must be in areas appropriate to the needs of children for whom the caregiver provides care, which may include:(1) Developmental stages of children;(2) Constructive guidance and discipline of children;(3) Fostering children's self-esteem;(4) Positive interaction with children;(5) Strategies and techniques for working with the population of children served;(6) Supervision and safety practices in the care of children, including making reasonable and prudent parenting decisions for a foster child's participation in childhood activities;(7) Preventing the spread of communicable diseases;(8) Water Safety;(9) Administration of medication;(10) Medical-related training to help children receiving treatment services for primary medical needs;(11) Helping children experience grief or loss;(12) Prevention, recognition, and reporting of child abuse, neglect, and exploitation; or(13) Safe sleeping as specified in §749.883 of this subchapter (relating to What curriculum components must be included in the pre-service training for safe sleeping?).(b) Other than mandated topics, annual training for employees must be in areas appropriate to the needs of children for whom the child-placing agency provides care, which may include:(1) The areas listed in subsection (a) of this section and;(2) Emergency behavior intervention. Source Note: The provisions of this §749.941 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.941 What areas or topics are appropriate for annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205263 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205263&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205263 03/12/2026 (a) The annual training for normalcy must include the curriculum components covered in the pre-service training for normalcy, see §749.882 of this subchapter (relating to What curriculum components must be included in the pre-service training for normalcy?).(b) Subsequent annual training for normalcy should include curriculum components that further develops and refines the employee's knowledge and understanding of normalcy, including how to implement normalcy. Source Note: The provisions of this §749.943 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.943 What curriculum components must be included in the annual training for normalcy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205264 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205264&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205264 03/12/2026 The annual training for the prevention, recognition, and reporting of child abuse, neglect, and exploitation must include the following curriculum components:(1) The factors indicating a child is at risk for abuse, neglect, or exploitation;(2) The warning signs indicating a child may be a victim of abuse, neglect, or exploitation;(3) The procedures for reporting child abuse, neglect, or exploitation; and(4) A list of community organizations that have training programs available to child-placing agency staff members, children, and parents. Source Note: The provisions of this §749.944 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.944 What curriculum components must be included in the annual training for employees on the prevention, recognition, and reporting of child abuse, neglect, and exploitation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205265 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205265&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205265 03/12/2026 The annual training for administering psychotropic medication must include the curriculum components identified in §749.885 of this subchapter (relating to What curriculum components must be included in the pre-service training for administering psychotropic medication?). Source Note: The provisions of this §749.945 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.945 What curriculum components must be included in the annual training for administering psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205266 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205266&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205266 03/12/2026 (a) The annual training for emergency behavior intervention must include curriculum components that:(1) Reinforce basic principles covered in the pre-service training identified in §749.887 of this subchapter (relating to If I do not allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?) and §749.889 of this subchapter (relating to If I allow the use of emergency behavior intervention, what curriculum components must be included in the pre-service training for emergency behavior intervention?); and(2) Develop and refine the caregiver's skills.(b) You may determine the content of the training based on your evaluation of your emergency behavior intervention programs.(c) The training may repeat pre-service training components, including training in the proper use and implementation of emergency behavior intervention. Source Note: The provisions of this §749.947 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.947 What curriculum components must be included in the annual training for emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205267 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205267&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205267 03/12/2026 (a) You must keep documentation verifying completion of annual training in the appropriate foster home record or personnel record. The documentation may be a certificate, letter, or a signed and dated statement of successful completion from the training source. The documentation may also be a transcript from an accredited college or university.(b) The documentation for training other than college courses must include the following information:(1) The participant's name;(2) Date of the training;(3) Title or subject of the training;(4) The trainer's name and qualifications, or the source of the training for self-instructional training; and(5) Length of the training in hours. Source Note: The provisions of this §749.949 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES F TRAINING AND PROFESSIONAL DEVELOPMENT §749.949 What documentation must I maintain for annual training? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189621 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189621&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189621 03/12/2026 (a) You must protect the rights of children while they are in foster care or in adoptive placement prior to the consummation of the adoption.(b) You must ensure that a caregiver or an adoptive parent, prior to consummation of the adoption, does not restrict or deny a child's rights.(c) You are responsible for removing a child from a situation where abuse, neglect, or exploitation exists. Source Note: The provisions of this §749.1001 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1001 How must I protect the rights of children served by my child-placing agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189622 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189622&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189622 03/12/2026 (a) A child's rights are cumulative of any other rights granted by law or other Licensing rules.(b) The following categories include the child's rights that you must adhere to:(1) Safety and care, including:(A) The right to good care and treatment that meets the child's needs in the most family-like setting possible;(B) The right to be free from abuse, neglect, and exploitation; and(C) The right to fair treatment;(2) Family contacts, including the right to maintain regular contact with the child's parents and siblings, unless restrictions are necessary because of the child's best interest, the decision of an appropriate professional, or a court order;(3) Living a normal life, including:(A) The right to speak and be spoken to in the child's own language, including Braille if the child is blind or sign language if the child is deaf. This should also occur within a reasonable time after an emergency admission of a child, if applicable. You must make every effort to place a child with foster parent(s) who can communicate with the child. If these efforts are not successful, you must document in the preliminary service plan your plan to meet the communication needs of the child;(B) The right to receive educational services appropriate to the child's age and developmental level;(C) The right to have the child's religious needs met;(D) The right to participate in childhood activities, including foster family activities and activities away from the foster home and the foster parents, that are appropriate for the child's age, maturity, and developmental level;(E) The right to privacy, including sending and receiving unopened mail, making and receiving phone calls, keeping a personal journal, and having visitors, unless the child's best interest, appropriate professionals, or court order necessitates restrictions;(F) The right to personal care, hygiene, and grooming equipment and supplies and training in how to use them;(G) The right to have comfortable clothing, which is suitable to the child's age and size and similar to the clothing of other children in the community. Teenagers should have reasonable opportunities to select the clothing;(H) The right to clothing that protects the child against the weather;(I) The right to have personal items at the child's home and to get additional things within reasonable limits;(J) The right to personal space in the child's bedroom to store clothes and belongings;(K) The right to be informed of search policies and be free of unreasonable searches and unreasonable removal of personal items;(L) Depending on the child's age and maturity, the right to seek employment, keep the child's own money, have a bank account in the child's name, and get paid for any work done for the agency or home as part of the child's service plan or vocational training, with the exception of assigned routine duties that relate to the child's living environment, such as cleaning the child's room, or other chores, or work assigned as a disciplinary measure;(M) The right to consent in writing before taking part in any publicity or fund raising activity for the foster home or agency, including the use of the child's photograph;(N) The right to refuse to make public statements showing gratitude to the foster home or agency; and(O) The right to not be pressured to get an abortion, give up her child for adoption, or parent her child, if applicable;(4) Discipline, including:(A) The right to be free from any harsh, cruel, unusual, unnecessary, demeaning, or humiliating treatment or punishment. This means the child must not be:(i) Shaken;(ii) Subjected to or threatened with corporal punishment, including spanking or hitting the child;(iii) Forced to do unproductive work that serves no purpose except to demean the child, such as moving rocks from one pile to another or digging a hole and then filling it in;(iv) Denied food, sleep, a bathroom, mail, or family visits as punishment;(v) Subjected to remarks that belittle or ridicule the child or the child's family;(vi) Threatened with the loss of placement or shelter as punishment; and(vii) Subjected to demeaning behavior to embarrass, control, harm, intimidate, or isolate the child. "Demeaning behavior" may include using physical force, rumors, threats, or inappropriate comments;(B) The right to discipline that is appropriate to the child's age, maturity, and developmental level; and(C) The right to have restrictions or disciplinary policies explained to the child at admittance and when the measures are imposed;(5) Plans for the child while in care, including:(A) The right to have a comprehensive service plan that addresses the child's needs, including transitional and discharge planning; and(B) The right to actively participate in the development of the child's service plan within the limits of the child's comprehension and ability to manage the information. The child has the right to a copy or summary of the plan. A child 14 years of age or older has the right to review and sign the service plan;(6) Medical care and records, including:(A) The right to medical, dental, vision, and mental health care and developmental services that adequately meet the child's needs. The right to request that the care or services be separate from adults (other than young adults) who are receiving services;(B) The right to be free of unnecessary or excessive medication; and(C) The right to confidential care and treatment, including keeping medical records and agency records private and only discussing them when it is about the child's care; and(7) Complaints, including the right to make calls, reports, or complaints without interference, coercion, punishment, retaliation, or threats of punishment or retaliation. The child may make these calls, reports, or complaints anonymously. Depending upon the nature of the complaint, the child has the right to call, report, or complain to:(A) The DFPS Texas Abuse/Neglect Hotline at 1-800-252-5400;(B) The HHSC Ombusman for Children and Youth Currently in Foster Care at 1-844-286-0769;(C) The DFPS Office of Consumer Affairs at 1-800-720-7777; or(D) Disability Rights of Texas at 1-800-252-9108. Source Note: The provisions of this §749.1003 adopted to be effective January 1, 2017, 41TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1003 What rights does a child in care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189623 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189623&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189623 03/12/2026 (a) Within seven days after you admit a child into your agency, you must review the child's rights with the child and a child's parent, unless the parent's consent is not required. You must also provide the child and a child's parent with a written copy of the child's rights.(b) Child rights must be written in:(1) Simple, non-technical terms; and(2) English, unless the person does not understand English. The child's rights must be written in the person's primary language, if possible.(c) If the person you are informing has a visual or auditory impairment, you must explain the child's rights in a manner that is understandable to the person.(d) The person you are informing of the child's rights must sign a statement indicating that the person has read and understands these rights. A copy of a timely signed "CPS Rights of Children and Youth in Foster Care" will meet this standard. You must put the signed copy in the child's record. Source Note: The provisions of this §749.1005 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1005 How must I inform a child and the child's parents of their rights? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189624 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189624&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189624 03/12/2026 (a) A child must have an appropriate education through participation in an educational/vocational program in the most appropriate and least restrictive educational settings, for example: attending regular classes conducted in an accredited elementary, middle, or secondary school within the community or home schooling.(b) Foster parents and caregivers must, as applicable:(1) Attend and participate in school staffings, conferences, and education planning meetings;(2) Make reasonable efforts to allow the child to participate in extracurricular activities; and(3) Make reasonable efforts to allow the child to participate in school extracurricular activities to the extent of his interests and abilities and in accordance with his service plan. Source Note: The provisions of this §749.1007 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1007 What are a child's rights regarding education? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189628 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189628&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189628 03/12/2026 (a) You must allow contact between a child and his parent whose parental rights have not been terminated according to:(1) Your policies; and(2) The provisions of a court order or any visitation agreement.(b) You must document in the child's record:(1) Any plans for contact between the child and a parent; and(2) Any decision to limit contact with a parent.(c) Before you can temporarily restrict ongoing contacts or communication between the child and a parent, your child placement management staff must:(1) Explain the reasons for the restrictions to the child and the child's parent; and(2) Document the reasons in the child's record.(d) Restrictions imposed by you that continue more than 30 days must be re-evaluated monthly by your child placement management staff, who also must:(1) Explain the reasons for the continued restrictions to the child and the child's parents; and(2) Document the reasons in the child's record.(e) If you limit communications or visits with a parent for practical reasons, such as geographical distance or expense, you must discuss the limits with the child and the child's parents. You must document the limits in the child's record. Source Note: The provisions of this §749.1009 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1009 What right does a child have regarding contact with a parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189625 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189625&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189625 03/12/2026 (a) A child must have a reasonable opportunity for sibling visits and contacts in an effort to preserve sibling relationships.(b) You must address plans for sibling visits and contacts in the child's record.(c) When you restrict sibling contact, you must include justification in the child's record. Restrictions imposed by you that continue for more than 60 days must be re-evaluated every 60 days by your child placement management staff, who also must:(1) Explain the reasons for the continued restrictions to the child; and(2) Document the reasons in the child's record.(d) If barriers to visits exist, such as unavoidable geographic distance and expense issues, the agency must make provisions for sibling contact through letters, telephone calls, or some other means. Source Note: The provisions of this §749.1011 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1011 What right does a child have regarding contact with siblings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189626 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189626&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189626 03/12/2026 (a) Except as determined by child placement management staff or the child's parent, you may not:(1) Open or read the child's incoming or outgoing mail, including electronic mail, unless necessary to assist the child with reading or writing; or(2) Listen to or screen the child's telephone calls unless the child needs assistance with using the telephone.(b) You must document in the child's record:(1) Any reason for restrictions on the child's mail or telephone calls that you impose; and(2) A listing of the mail or telephone calls that you restrict.(c) You must inform the child and parent about restrictions that you place on the child.(d) Restrictions imposed by you that continue for more than 30 days must be re-evaluated monthly by your child placement management staff, who also must:(1) Explain the reasons for the continued restrictions to the child; and(2) Document the reasons in the child's record. Source Note: The provisions of this §749.1013 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1013 What right to privacy does a child have with respect to his contact with others? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189627 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189627&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189627 03/12/2026 (a) A child's possessions must be free of unreasonable searches and unreasonable removal of personal items.(b) You may search a child, his possessions, or his room only when you have reasonable suspicion:(1) Of the presence of a prohibited item or an item that endangers the child's safety;(2) That the child made suicidal threats or threatened to hurt himself or others; or(3) That the child or children was involved in theft.(c) Only a caregiver may conduct searches that involve the removal of clothing, other than outer clothing, such as coats, jackets, hats, gloves, shoes, or socks.(d) If a search of a child who is five years old or younger involves the removal of clothing (other than outer clothing), another adult must witness the search.(e) If a search of a child who is over the age of five involves the removal of clothing (other than outer clothing), an adult of the same gender must witness the search.(f) The caregiver must ensure that other children do not witness a search that involves the removal of clothing, other than outer clothing. Source Note: The provisions of this §749.1015 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1015 Under what circumstances may I conduct a search for prohibited items or items that endanger a child's safety? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189629 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189629&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189629 03/12/2026 With the exception of a child's mouth, a caregiver may not conduct a body cavity search of a child in care. Source Note: The provisions of this §749.1017 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1017 May a caregiver conduct a body cavity search of a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189630 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189630&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189630 03/12/2026 A caregiver must document the following in the child's record when conducting a search if it results in the removal of personal items or clothing worn by the child:(1) The date of the search;(2) The name of the child;(3) Reason for the search;(4) A description of what was searched;(5) The articles of clothing removed, if applicable;(6) The name of the person conducting the search;(7) The name of the witness, if applicable;(8) The results of the search; and(9) The resolution of the issue with the child or children involved. Source Note: The provisions of this §749.1019 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1019 What must a caregiver document regarding a search? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189631 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189631&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189631 03/12/2026 Certain techniques must not be used on a child, including:(1) Chemical restraints, mechanical restraints, and seclusion. For more information on emergency behavior intervention, see Subchapter L of this chapter (relating to Foster Care Services: Emergency Behavior Intervention);(2) Aversive conditioning, which includes, but is not limited to, any technique designed to or likely to cause a child physical pain, the application of startling stimuli, and the release of noxious stimuli or toxic sprays, mists, or substances in proximity to the child's face;(3) Pressure points;(4) Rebirthing therapy; and(5) Hug and/or holding therapy. Source Note: The provisions of this §749.1021 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES G CHILDREN'S RIGHTS §749.1021 What techniques am I prohibited from using on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189637 03/12/2026 (a) You may only admit children or young adults who meet your admission policy guidelines and whose needs you can meet. If you adopt a change in your admission policies that requires a change in the conditions of your permit, you must request an amendment to your permit with us.(b) Each placement must meet the child's physical, medical, recreational, educational, and emotional needs as identified in the child's admission assessment. Source Note: The provisions of this §749.1101 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1101 Who may I admit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189639 03/12/2026 (a) A young adult may remain in your care until his 23rd birthday in order to:(1) Transition to independence, including attending college or vocational or technical training;(2) Attend high school, a program leading to a high school diploma, or GED classes;(3) Complete your program; or(4) Stay with a minor sibling.(b) A young adult who turns 18 in your care may remain in your care indefinitely if the person:(1) Continues to need the same level of care; and(2) Is unlikely to physically and/or intellectually progress over time. Source Note: The provisions of this §749.1103 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1103 After a child in my care turns 18 years old, may the person remain in my care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189640 03/12/2026 (a) You may admit a young adult into your transitional living program.(b) For other programs or services, the young adult must:(1) Come immediately from another residential child-care operation if the reason for admittance is consistent with a condition listed in §749.1103 of this title (relating to After a child in my care turns 18 years old, may the person remain in my care?); or(2) Be in the care of the Texas Department of Family and Protective Services.(c) A young adult may remain in your care until his 23rd birthday. Source Note: The provisions of this §749.1105 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1105 May I admit a young adult into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210104 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210104&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210104 03/12/2026 (a) You must include the following in the child's record at the time of admission:(1) The child's name, gender, race, religion, and date of birth;(2) The name, address, and telephone number of the managing conservator, the primary caregivers for the child, any person with whom the child is allowed to leave the foster home, and any other individual who has the legal authority to consent to the child's medical care;(3) The names, addresses, and telephone numbers of biological or adoptive parents, unless parental rights have been terminated;(4) The names, addresses, and telephone numbers of siblings;(5) The date of admission;(6) Medication the child is taking;(7) The child's immunization record;(8) Allergies, such as food, medication, sting, and skin allergies;(9) Chronic health conditions, such as asthma or diabetes;(10) Known contraindications to the use of restraint;(11) Identification of the child's treatment needs, if applicable, and any additional treatment services or programmatic services the child is receiving;(12) Identification of the child's high-risk behaviors, if applicable, and the safety plan employees and caregivers will implement related to the behaviors;(13) If a suicide risk screening is required at admission and the child is screened as having a high or potential risk of suicide:(A) The identification of any risk factors or warning signs of suicide, if applicable and not already identified in paragraph (12) of this section; and(B) The safety plan employees and caregivers will implement related to the risk factors and warning signs;(14) The results of the suicide screening at admission, if required;(15) A copy of the placement agreement, if applicable; and(16) Documentation of the attempt to notify the parent of the child's location as required by §749.1113(c)(3) of this title (relating to What information must I share with the parent at the time of placement?), if applicable.(b) For emergency admissions, you must meet the requirements in Division 4 of this subchapter (relating to Emergency Admission). Source Note: The provisions of this §749.1107 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective March 1, 2014, 39 TexReg 1193; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1107 What information must I document in the child's record at the time of admission? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189638 03/12/2026 (a) A placement agreement is your agreement with a child's parent or the child that defines your roles and responsibilities and authorizes you to obtain or provide services for the child. The placement agreement must include:(1) Authorization permitting you to care for the child;(2) A medical consent form signed by a person authorized by the Texas Family Code to provide consent; and(3) The reason for placement and anticipated length of time in care.(b) A placement agreement must be signed by the child's parent, except as provided in subsection (c).(c) For a transitional living program, a child 16 years old or older may sign the placement agreement on the child's own behalf, as provided in the Texas Family Code §32.203, without the consent of the child's parent if the child:(1) Resides separate and apart from the child's parent and manages the child's own financial affairs;(2) Is unmarried and pregnant; or(3) Is unmarried and a parent. Source Note: The provisions of this §749.1109 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1109 What is a placement agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189643 03/12/2026 (a) Within seven days of admission, you must provide orientation to each newly admitted child who is five years old or older. You must gear orientation to the intellectual level of the child.(b) Orientation must include information about your policies on the following:(1) Visitation, including family visitation and overnight visitation;(2) Mail;(3) Telephone calls;(4) Gifts;(5) Personal possessions, including any limits placed on the possessions the child may or may not have;(6) Emergency behavior intervention, including your agency's policies and practices on the use of personal restraint and the child's input on preferred de-escalation techniques that caregivers can use to assist the child in the de-escalation process;(7) Discipline;(8) The religious program and practices;(9) The educational program;(10) Trips away from the home;(11) Program expectations and rules; and(12) Internal grievance procedures.(c) Orientation must include information on how to:(1) Make complaints to outside agencies; and(2) Contact parties to a child's case (i.e. caseworker, attorney ad litem, guardian ad litem, CASA worker, etc.).(d) You must document in the child's record when the orientation occurred, any item that the orientation did not include, and the reason that the orientation did not include that item. Source Note: The provisions of this §749.1111 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1111 What orientation must I provide a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208652 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208652 03/12/2026 (a) At admission, you must provide the following policies to the parent placing the child:(1) Fee policies;(2) Emergency behavior intervention policies;(3) Discipline policies;(4) Adoption policies, if applicable; and(5) Any other policies required by us, upon request of the parent.(b) At admission, you must provide and explain the following written information and policies to the parent placing the child:(1) Information about the policies that you would present a child during orientation;(2) Your policies regarding the:(A) Use of volunteers, if applicable;(B) Type and frequency of notifications made to parents; and(C) Involvement of the child in any publicity or fundraising activity for the agency; and(3) Information about the parent's right to refuse to or withdraw consent for a child to participate in:(A) Research programs; or(B) Publicity or fundraising activities for the agency.(c) If you sign a placement agreement for a transitional living program with a child as specified in §749.1109(c) of this title (relating to What is a placement agreement?), then you:(1) Must share the policies noted in subsection (a) of this section with the child, instead of the parent;(2) Do not have to comply with subsection (b) of this section, but you must provide and explain to the child your policies regarding the:(A) Use of volunteers;(B) Involvement of the child in any publicity or fundraising activity for the agency; and(C) Child's right to refuse to or withdraw consent to participate in:(i) Research programs; or(ii) Publicity or fundraising activities for the agency; and(3) Must attempt to notify the child's parent of the child's location, if the child was admitted without the consent of the parent. Source Note: The provisions of this §749.1113 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2014, 39 TexReg 1193; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1113 What information must I share with the parent at the time of placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189642 03/12/2026 (a) By the day you admit the child for care, you must provide the caregivers responsible for the child's care with information about the child's immediate needs, such as enrolling the child in school or obtaining needed medical care or clothing.(b) You must inform appropriate caregivers of any special needs, such as medical or dietary needs or conditions or supervision needs, and document that you shared the information with the caregiver. Source Note: The provisions of this §749.1115 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1115 What information must I provide caregivers when I admit a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189645 03/12/2026 You must complete a non-emergency admission assessment prior to admission. Source Note: The provisions of this §749.1131 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1131 When must I complete the admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208653 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208653 03/12/2026 (a) An admission assessment must provide an initial evaluation of the appropriate placement for a child and ensure that you obtain the information necessary for you to facilitate service planning.(b) Prior to a child's non-emergency admission, an admission assessment must be completed, which includes:(1) The child's legal status;(2) A description of the circumstances that led to the child's referral for substitute care;(3) A description of the child's behavior, including appropriate and maladaptive behavior, and any high-risk behavior;(4) Any history of physical, sexual, or emotional abuse or neglect;(5) Any history of trauma;(6) Current medical and dental status, including the available results of any medical and dental examinations;(7) Current mental health and substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment;(8) The child's current developmental, educational, and behavioral level of functioning;(9) The child's current educational level, and any school problems;(10) Any applicable requirements of §749.1135 of this division (relating to What are the additional admission assessment requirements when I admit a child for treatment services?);(11) Documentation indicating efforts made to obtain any of the information in paragraphs (1) - (10) of this subsection, if any information is not obtainable;(12) The services you plan to provide to the child;(13) Immediate goals of placement;(14) The parent's expectations for placement, duration of the placement, and family involvement;(15) The child's understanding of the placement; and(16) A determination of whether and how you can meet the needs of the child.(c) Prior to completing a child's initial service plan, the following information must be added to the admission assessment:(1) The child's social history, including information about past and existing relationships with the child's birth parents, siblings, extended family members, and other significant adults and children, and the quality of those relationships with the child;(2) A description of the child's home environment and family functioning;(3) The child's birth and neonatal history;(4) The child's developmental history;(5) The child's mental health and substance abuse history;(6) The child's school history, including the names of previous schools attended and the dates the schools were attended, grades earned, and special achievements;(7) The child's history of any other placements outside the child's home, including the admission and discharge dates and reasons for placement;(8) The child's criminal history, if applicable;(9) The child's skills and special interests;(10) Documentation indicating efforts made to obtain any of the information in paragraphs (1) - (9) of this subsection, if any information is not obtainable;(11) The services you plan to provide to the child, including long-range goals of placement;(12) Recommendations for any further assessments and testing;(13) A recommended behavior management plan; and(14) A determination of whether and how you can meet the needs of the child, based on an evaluation of the child's special strengths and needs.(d) You must attempt to obtain a signed authorization, so you can subsequently request in writing materials from the child's current or most recent placement, such as the admission assessment, professional assessments, and the discharge summary. You must consider information from these materials when you complete your admission assessment if they are made available to you. Source Note: The provisions of this §749.1133 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1133 What information must an admission assessment include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210105 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210105&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210105 03/12/2026 When you admit a child for treatment services, you must do the following, as applicable:Attached Graphic Source Note: The provisions of this §749.1135 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg; amended to be effective June 1, 2015, 40 TexReg 2790; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1135 What are the additional admission assessment requirements when I admit a child for treatment services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189648 03/12/2026 (a) You must make reasonable efforts to obtain all required information.(b) If you and the child's parent determine that attempting to get information at the time of placement would not be in the child's best interests, you may postpone attempting to acquire the information.(c) In the child's admission assessment, you must document why a:(1) Particular piece of information is unavailable; or(2) Delay obtaining a piece of information is necessary, including efforts made to obtain the information. Source Note: The provisions of this §749.1137 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1137 What if I cannot obtain the required information for an admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189649 03/12/2026 (a) You must ensure that the child has a medical examination by a health-care professional within 30 days after the date of admission. This exam is not required if you have documentation that the child has had a medical examination within the past year, including documentation in the child's health passport if the child is in the department's conservatorship.(b) If you admit a child with primary medical needs, you must provide the child with a medical examination by a health-care professional within seven days before or three days after admission.(c) If a child admitted shows symptoms of abuse or illness, a health-care professional must examine the child immediately.(d) The reports and findings of any medical examination must be documented in the child's record according to §749.1401(b) and (c) of this title (relating to What general medical requirements must my agency meet?). Source Note: The provisions of this §749.1151 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1151 What are the medical requirements when I admit a child into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189650 03/12/2026 (a) If the child is younger than three years old and a health-care professional recommends a dental examination, then you must ensure that a dentist examines the child.(b) A child three years old or older must have a dental appointment scheduled with a dentist within 30 days after the date of admission, and the examination must occur within 90 days after the date of admission. A dental examination is not required if you have documentation that the child has had a dental examination within the past year, including documentation in the child's health passport if the child is in the department's conservatorship.(c) The report and findings of the dental examination must be documented in the child's record according to §749.1409(b) and (c) of this title (relating to What general dental requirements must my agency meet?). Source Note: The provisions of this §749.1153 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1153 What are the dental requirements when I admit a child into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189651 03/12/2026 For re-admission, you must complete the admission documentation as if the child was never in your care; or for children that were discharged from your agency within the last 12 months, you may update the previous admission documentation. Source Note: The provisions of this §749.1155 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1155 What must I document when I re-admit a child for care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189654 03/12/2026 You may accept emergency admissions in all of your programs with the exception of a transitional living program. Source Note: The provisions of this §749.1181 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1181 For which of my programs may I accept emergency admissions? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191422 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191422&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191422 03/12/2026 It is an emergency admission if:(1) You must place the child within 72 hours;(2) The child was removed from a situation involving alleged abuse or neglect;(3) The child is an alleged perpetrator of abuse and cannot be served in the child's current placement due to the child's perpetrating behaviors;(4) The child displays behavior that is an immediate danger to self or to others and cannot function or be served in his current setting;(5) The child was abandoned and, after exercising reasonable efforts, the child's identity cannot be immediately determined. You must document the efforts made to obtain information on the child's identity in the child's record;(6) The child was removed from the child's home or placement, and there is an immediate need to find a residence for the child;(7) A law enforcement officer released the child to your child-placing agency that has been authorized to accept such admissions; or(8) The child is otherwise without adult care. Source Note: The provisions of this §749.1183 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4463. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1183 What constitutes an emergency admission to my child-placing agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191423 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191423&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191423 03/12/2026 You may take possession of a child from a law enforcement officer only if you meet the requirements of 40 TAC Chapter 745, Subchapter H, Division 2 (relating to Taking Possession of a Child Directly from a Law Enforcement Officer). Source Note: The provisions of this §749.1185 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4463. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1185 May I take possession of a child from a law enforcement officer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189652 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189652 03/12/2026 (a) For an emergency admission, you must complete all of the requirements (see Division 2 of this subchapter (relating to Admission Assessment)) for an admission assessment within 40 days from the date of the child's admission.(b) In an emergency admission of a child receiving treatment services, the child must not continue in care for more than 30 days after the date of admission unless the child has received the psychiatric evaluation, psychological evaluation, psychosocial assessment, or medical evaluation that is required by §749.1135 of this title (relating to What are the additional admission assessment requirements when I admit a child for treatment services?), and the evaluation or assessment indicates manifestations of the disorder requiring treatment services. All evaluations and assessments must be signed, dated, and documented in the child's record. Source Note: The provisions of this §749.1187 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1187 For an emergency admission, when must I complete all of the requirements for an admission assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210106 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210106&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210106 03/12/2026 At the time of the emergency admission you must document in the child's record:(1) A brief description of the circumstances necessitating the emergency admission;(2) The date of admission;(3) Allergies, such as food, medication, sting, and skin allergies;(4) Chronic health conditions, such as asthma or diabetes;(5) Known contraindications to the use of restraint;(6) Identification of the child's high-risk behaviors, if applicable, and the safety plan employees and caregivers will implement related to the behaviors;(7) If a suicide risk screening is required at admission and the child is screened as having a high or potential risk of suicide:(A) The identification of any risk factors or warning signs of suicide, if applicable and not already identified in paragraph (6) of this section; and(B) The safety plan employees and caregivers will implement related to the risk factors and warning signs;(8) The results of the suicide screening at admission, if required; and(9) For the purpose of providing treatment services:(A) A brief description of the child's history;(B) The child's current behavior; and(C) Your evaluation of how the placement will meet the child's needs and best interests. Source Note: The provisions of this §749.1189 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1189 At the time of an emergency admission, what information must I document in the child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189634 03/12/2026 (a) A child over six months of age must visit the foster home at least once before placement.(b) There must be a meaningful interval between the pre-placement visit and the placement. This interval must be at least sufficient to allow a child and foster parents to have privacy, an opportunity to discuss and consider placement, and to have their questions, opinions, and concerns addressed.(c) You must document pre-placement visits in the child's record.(d) Pre-placement visits are not required for emergency admissions. Source Note: The provisions of this §749.1251 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1251 What are the requirements for pre-placement visits for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189635 03/12/2026 (a) The child-placement staff must discuss with the child the circumstances that make the placement necessary, as appropriate to the child's age and ability to respond orally and behaviorally to such a discussion. The discussion must take place prior to or at the time of the placement of a child.(b) You must document into the child's record:(1) That the discussion occurred; and(2) The child's understanding of and response to the discussions and the placement. Source Note: The provisions of this §749.1253 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1253 What must staff do to prepare a child for a placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189632 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189632&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189632 03/12/2026 (a) In a non-emergency placement, you must share all information from the admission assessment with the foster parents or caregiver responsible for the child's care prior to placement.(b) In an emergency placement, you must share with the foster parents or caregiver responsible for the child's care:(1) At the time of placement, all available information relating to the child's needs and your plans for care and management; and(2) Within 10 days of completing the admission assessment, all information from the admission assessment.(c) You must document the following in the child's record:(1) The information you share with the caregiver;(2) Any information you do not share and the reason why you did not share the information; and(3) How the placement is capable of meeting the child's needs. Source Note: The provisions of this §749.1255 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1255 What information from an admission assessment must I share with the caregivers responsible for the child's care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189633 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189633&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189633 03/12/2026 (a) If the move is not an emergency, child placement management staff must:(1) Review and approve the move before you move the child to the new placement;(2) Document the review and approval in the child's record, including signature and date; and(3) Comply with the pre-placement requirements in §749.1251 of this title (relating to What are the requirements for pre-placement visits for a child?).(b) If the move is an emergency, child placement management staff must:(1) Give verbal approval before the move; and(2) Document the verbal approval in the child's record within 10 days of the placement. Documentation must be signed and dated and include the date verbal approval was given and circumstances of the emergency placement.(c) For all moves, child placement staff must prepare a child according to §749.1253 of this title (relating to What must staff do to prepare a child for a placement?). Source Note: The provisions of this §749.1281 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1281 What are the requirements when I move a child from one foster home to another? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189636 03/12/2026 (a) Except for children receiving treatment services for primary medical needs, child placement staff must have monthly face-to-face contact with a child in care. However, staff can miss two visits per year, provided a child does not go longer than 60 days without a visit.(b) For children receiving treatment services for primary medical needs, child placement staff or a nurse must have face-to-face contact with a child in care twice every month with no more than 20 days between visits. However, staff can miss two visits per year, provided a child does not go longer than 30 days without a visit.(c) At least half of the contacts must occur in the foster home.(d) These contacts are to ensure the:(1) Child is safe;(2) Needs of a child are being met; and(3) Placement continues to be appropriate.(e) If the child is able to communicate in a meaningful way, the contact with the child must:(1) Be for a length of time sufficient to address the child's needs and determine the appropriateness of the placement;(2) Provide an opportunity to meet in private; and(3) Provide an opportunity for the child to express his feelings about how the placement is working out.(f) If the child is non-verbal or pre-verbal, the contact with the child must be for a length of time sufficient for an appropriate observation of the child and the child's placement, including an assessment of any changes in behavior or developmental progress or delays as well as a verification that the placement is meeting the child's needs as specified in the service plan.(g) The required contacts must be significant and must be documented in the child's record. The documentation in the child's record must be sufficient to address the requirements of subsections (e) and (f) of this section.(h) Child placement management staff must review and approve documentation of contacts. Source Note: The provisions of this §749.1291 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES H FOSTER CARE SERVICES: ADMISSION AND PLACEMENT §749.1291 What are the requirements for contact between child placement staff and children in foster care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189657 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189657&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189657 03/12/2026 (a) You must complete a preliminary service plan that addresses the immediate needs of the child within 72 hours, such as supervision requirements, enrolling the child in school or obtaining needed medical care or clothing.(b) In addition, for a child receiving treatment services the preliminary service plan must include:(1) A description of the child's immediate treatment and care needs;(2) A description of the child's immediate, educational, medical, and dental needs, including possible side effects of medications or treatment prescribed to the child;(3) A description of how you will meet the child's needs, including any necessary increased supervision or follow-up actions of possible side effects of medication or treatment provided to the child;(4) The identification of any issues or concerns the child may have that could escalate a child's behavior. Identification of a child's issues or concerns must serve to avoid the use of unnecessary emergency behavior interventions with the child. Child concerns may include issues with food, eye contact, physical touch, personal property, or certain topics; and(5) A designation of who will be responsible for meeting each of the child's needs.(c) The plan must be compatible with the information included in the child's admission assessment.(d) You must document the plan in the child's record.(e) You must inform each professional service provider and caregiver working with a child about the child's preliminary service plan.(f) You must implement and follow the preliminary service plan. Source Note: The provisions of this §749.1301 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1301 What are the requirements for a preliminary service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189658 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189658 03/12/2026 The child placement staff must develop, sign, and date the preliminary service plan. Source Note: The provisions of this §749.1305 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1305 Who must be involved in developing the preliminary service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189659 03/12/2026 You must complete the initial service plan within 45 days after you admit the child. Source Note: The provisions of this §749.1307 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1307 When must I complete an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210107 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210107&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210107 03/12/2026 (a) You must base the child's initial service plan on the child's needs identified in the child's admission assessment and integrate trauma informed care in the care, treatment, and management of each child. The service planning team may prioritize the child's service planning goals and objectives based on the child's admission assessment. However, any required service plan components not initially addressed must have a justification for the delay in addressing the needs. (b) The child's initial service plan must be documented in the child's record and include those items that a preliminary plan must include (see §749.1301 of this title (relating to What are the requirements for a preliminary service plan?)), and the items noted below for each specific type of service that you provide the child:Attached Graphic Source Note: The provisions of this §749.1309 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1309 What must a child's initial service plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189660 03/12/2026 (a) A service planning team must meet (e.g. face-to-face, video conference, or teleconference) to discuss and develop the service plan. The team must consist of:(1) At least one of the child's current caregivers;(2) At least one professional service provider who provides direct services to the child; and(3) If you are providing treatment services to the child, at least two of the following professionals:(A) A licensed professional counselor;(B) A psychologist;(C) A psychiatrist or physician;(D) A licensed registered nurse;(E) A licensed master's level social worker;(F) A licensed or registered occupational therapist; or(G) Any other person in a related discipline or profession that is licensed or regulated in accordance with state law.(b) The child, if verbal and developmentally able to participate, the parents, and the foster parents must be invited to the service planning meeting and should participate and provide input into the development of the service plan, including discussions regarding the child's participation in childhood activities. Source Note: The provisions of this §749.1311 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1311 Who must be involved in developing an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189661 03/12/2026 Yes, the service planning team may meet in one meeting, two or more meetings, or in separate meetings, provided that each service planning team member is informed of the discussions and comments regarding the child's service plan that were made at each meeting. Source Note: The provisions of this §749.1312 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1312 Can the service planning team discuss and develop a child's service plan in separate meetings? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189663 03/12/2026 (a) The child's parents and foster parents must have at least two weeks advance notice of the initial service plan meeting.(b) The child's record must include documentation of the notice and any responses from the parents and foster parents. Source Note: The provisions of this §749.1313 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1313 When must I inform the child's parents and foster parents of an initial service plan meeting? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189664 03/12/2026 No. You may employ or contract with a professional service provider or any other professional who participates in a child's service plan. Source Note: The provisions of this §749.1315 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1315 Must a professional service provider or a professional who must participate in a child's service plan be an employee of my agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189665 03/12/2026 The roles of professional service providers in service planning include:Attached Graphic Source Note: The provisions of this §749.1317 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1317 What roles do professional service providers have in service planning? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189668 03/12/2026 (a) You must document the professional service provider's:(1) Name; and(2) Date of participation.(b) The professional service provider must sign and date the document. If the provider disagrees with any portion of the plan, the provider must document the issue(s) of contention before signing it. Source Note: The provisions of this §749.1319 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1319 What must I document regarding a professional service provider's participation in the development of an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189669 03/12/2026 (a) You must give a copy or summary of the initial service plan to the:(1) Child, when appropriate. At a minimum, you must give a copy or summary of the plan to a child 14 years of age or older, unless there is justification for not providing the plan;(2) Child's parents; and(3) Child's caregivers.(b) If you provide a copy or summary of the initial service plan to a child:(1) The child must review the plan;(2) The child must sign the plan, or you must document the child's refusal to sign it; and(3) You must document if the child disagrees with the plan.(c) If you do not provide a copy or summary of the initial service plan to a child, you must document your justification for not sharing the plan in the child's record.(d) You must document in the child's record that you provided a copy or summary of the initial service plan to the child's parents. Source Note: The provisions of this §749.1321 adopted to be effective January 1, 2007, 31 TexReg 746; amended to be effective January 1, 2017, 41 TexReg 99449; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1321 With whom do I share the initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189670 03/12/2026 You must implement and follow an initial service plan as soon as all of the service planning team members have reviewed and signed the plan, but no later than 15 days after the date of the scheduled service-planning meeting involving the parents, foster parents, and the child. Source Note: The provisions of this §749.1323 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1323 When must I implement a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189666 03/12/2026 Except for when the child's placement within your agency changes because of a change in the child's needs, you must review and update the service plan as follows:Attached Graphic Source Note: The provisions of this §749.1331 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1331 How often must I review and update a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189667 03/12/2026 (a) You must review a child's service plan whenever the child's placement changes because of a change in the child's needs.(b) If the child's placement changes for another reason:(1) The child' service planning team must approve the decision not to review the plan; and(2) You must document the decision not to review the plan. Source Note: The provisions of this §749.1333 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1333 How does a child's transfer affect the timing of the review of the child's service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189671 03/12/2026 To review and update a service plan, you must:(1) Evaluate the child's progress and the effectiveness of strategies and techniques used toward meeting identified needs, including educational progress reports and medical interventions;(2) Identify any new needs and strategies or techniques to meet these needs, including instructions to appropriate employees and caregivers;(3) Document any achieved or changed objectives;(4) If the review shows no progress towards meeting the identified needs of the child, document reasons for continued placement;(5) Evaluate the possible effectiveness and side effects in the use of psychotropic medications prescribed for the child, any change in psychotropic medications during the period since the last review, and the behaviors and reactions of the child observed by caregivers, professional service providers, and parents, if applicable;(6) Document visitation and contacts between the child and the child's parents, the child and the child's siblings, and the child and the child's extended family;(7) Update the estimated length-of-stay and discharge plans, if changed;(8) Evaluate the use and effectiveness of emergency behavior intervention techniques, if used, since the last service plan. If applicable, this evaluation must focus on:(A) The frequency, patterns, and effectiveness of types of emergency behavior interventions;(B) Strategies to reduce the need for emergency behavior interventions overall; and(C) Specific strategies to reduce the need for use of personal restraints or emergency medication, as applicable;(9) Document in the child's record the review and update of the plan; and(10) Document the names of the persons participating in the review and update. Source Note: The provisions of this §749.1335 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522 ; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1335 How do I review and update a service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189672 03/12/2026 Yes, a single service plan that continues throughout the time a child is in residential child care is acceptable, as long as you:(1) Complete a preliminary service plan as required by §749.1301 of this title (relating to What are the requirements for a preliminary service plan?) each time a child is admitted into your care; and(2) Continue to comply with the service plan review and update requirements in this Division of this Subchapter (relating to Service Plan Reviews and Updates). Source Note: The provisions of this §749.1336 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1336 Can the child-placing agency continue to review and update a child's previous service plan without creating a new service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189673 03/12/2026 Yes, the same requirements found in Division 1 of this subchapter (relating to Service Plans) apply to a service plan review and update. Source Note: The provisions of this §749.1337 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1337 Are the notification, participation, implementation, and documentation requirements for a service plan review and update the same as for an initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189674 03/12/2026 (a) Each child's intellectual functioning must be re-evaluated at least every three years by a psychologist qualified to provide psychological testing; or(b) A psychologist must determine the need and frequency for a specific child's intellectual functioning to be re-evaluated, such as a young child who may require more frequent testing. This determination, including justification for the time frame, must be documented in the child's record annually by the service planning team. Source Note: The provisions of this §749.1339 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1339 How often must I re-evaluate the intellectual functioning of a child receiving treatment services for intellectual disabilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189675 03/12/2026 A transfer refers to a child in care who is moved from one of your programs to another one of your programs operated under the same permit or at the same location. For example, a child may transfer from one foster home in which he was receiving treatment services to another foster home that offers a transitional living program. A child may also transfer from your child-placing agency to your general residential operation, if your child-placing agency office is located on the same property as your general residential operation. This term does not apply if the child experiences a change in programs or services but remains in the same foster home. This term also does not apply if the child moves from one foster home to another for a reason other than a need for different services/programming, such as moving to be closer to siblings. Source Note: The provisions of this §749.1361 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1361 What does a "transfer" of a child in care mean? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189680 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189680&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189680 03/12/2026 (a) You must involve at least the following persons in planning the child's non-emergency discharge or transfer:(1) At least one of the child's current caregivers; and(2) At least one professional service provider involved in the child's service planning.(b) You must invite the following persons to participate in planning the child's non-emergency discharge or transfer, if appropriate:(1) The child;(2) The child's parent(s); and(3) Any other person pertinent to the child's care.(c) If you are unable to plan the transfer or discharge with the persons required in subsections (a) and (b) of this section, you must document in the child's record the reason why.(d) If a child in your care is not receiving treatment services, you must inform the child of the non-emergency discharge or transfer at least four days prior to the date of the discharge or transfer, unless your licensed child-placing agency administrator or child placement management staff has clear justification for not giving the child such notice. The licensed child-placing agency administrator or child placement management staff who determines the justification for the child not having the advance notice of the discharge or transfer, must put the justification in writing and sign and date it. The justification must be in the child's record.(e) If a child in your care is receiving treatment services, you must inform the child of the non-emergency discharge or transfer at least four days prior to the date of the discharge or transfer, unless your treatment director, three members of the child's service planning team, or the child's psychiatrist or psychologist has a justification for not giving the child such notice. Whoever determines the justification for the child not having the advance notice of the discharge or transfer must put the justification in writing and sign and date it. The justification must be in the child's record. Source Note: The provisions of this §749.1363 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1363 Who must plan a child's non-emergency discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189676 03/12/2026 No, the foster home must not release a child to any person without your consent. Source Note: The provisions of this §749.1365 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1365 May a foster home release a child to any person without my consent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189677 03/12/2026 You must discharge a child to the child's parent or to anyone with written authorization from the parent or a person authorized by the court or by law to assume custody of the child. Source Note: The provisions of this §749.1367 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1367 To whom can I discharge a child in a non-emergency situation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189678 03/12/2026 The child's caregiver(s) or the child placement staff must accompany the child to the receiving operation, agency, or person unless the child's parent or law enforcement transports the child. Source Note: The provisions of this §749.1369 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1369 How do I discharge or transfer a child who is an immediate danger to self or others? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189679 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189679&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189679 03/12/2026 At the time of a discharge or transfer, you must document the following:(1) The date and circumstances of the discharge or transfer;(2) Date and time the child was informed of his discharge or transfer, if applicable;(3) For discharge, the name, address, telephone number and relationship of the person to whom you discharge the child, unless the child legally consents to a discharge. If the child legally consents to a discharge and does not want to involve the child's parent(s), you must document this in the child's record;(4) The child's service plans while in your care for the past 12 months;(5) A list of medications the child is taking, the dosage, frequency, and reason the medication was prescribed;(6) Any treatment for a physical condition that is in progress and requires continuing or follow-up medical care; and(7) For emergency discharge or transfer, the explanation given to the child regarding the reason for the discharge or transfer and the child's reaction to the discharge or transfer. Source Note: The provisions of this §749.1371 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1371 What must I document in the child's record at the time of a discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189682 03/12/2026 (a) On or before the child's discharge, you must attempt to obtain legal consent to release the information in subsection (b) of this section. If consent is not obtained, your attempt to obtain consent must be documented in the child's record. If consent is obtained, the information must be provided to the receiving placement or caregiver within 15 days of the date the child is discharged.(b) If not already provided at the time of discharge, copies of the following documentation must be provided to the next placement or caregiver:(1) A written discharge summary, which must include:(A) Services provided to the child while in your care;(B) Accomplishments of the child while in your care;(C) An assessment of the child's remaining needs;(D) Recommendations about the services to meet the child's remaining needs;(E) Support resources for the child, including telephone numbers and addresses; and(F) Aftercare plans and recommendations for the child, including medical, psychiatric, psychological, dental, educational, and social appointments;(2) The child's background information, including progress notes for the past 60 days if applicable;(3) Any unresolved incidents or investigations involving the child, if applicable; and(4) and/or evaluations that you have performed for the child, including the child's admission assessment, diagnostic assessment, educational assessment, neurological assessment, and psychiatric or psychological evaluation. Source Note: The provisions of this §749.1373 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1373 When I discharge a child, what information must I provide to the next placement or caregiver? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189681 03/12/2026 An emergency transfer or discharge occurs when:(1) The parent withdraws a child unexpectedly from care;(2) There is a medical emergency requiring inpatient care;(3) The child is absent from the home and cannot be located; or(4) There is an immediate danger to the child or others and you determine that you cannot serve the child. Source Note: The provisions of this §749.1377 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES I FOSTER CARE SERVICES: SERVICE PLANNING, DISCHARGE §749.1377 What constitutes an emergency discharge or transfer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189685 03/12/2026 (a) A child in your care must receive medical care:(1) Initially, according to the requirements in §749.1151 of this title (relating to What are the medical requirements when I admit a child into care?);(2) As needed for injury, illness, and pain; and(3) As needed for ongoing maintenance of medical health.(b) The child's record must include a written record of each medical examination that consists of:(1) A copy of the results of the medical examination;(2) The follow-up treatment recommended and any appointments scheduled;(3) A notation of the child's refusal to accept medical treatment, if applicable;(4) If the medical examination is a result of an injury or illness, the documentation of the date, time, and circumstances surrounding the injury or illness; and(5) Any other documentation provided by the health-care professional who performed the examination.(c) For a child in the conservatorship of the department, you must supplement any information already documented in the child's health passport in order to comply with subsection (b) of this section. In your written record for the child, you are not required to repeat information that is already in the child's health passport.(d) You must obtain follow-up medical treatment as recommended by the health-care professional. Source Note: The provisions of this §749.1401 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1401 What general medical requirements must my agency meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189686 03/12/2026 A health-care professional determines the need and frequency for ongoing maintenance of medical care and treatment for a child. Source Note: The provisions of this §749.1403 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1403 Who determines the need and frequency for ongoing maintenance of medical care and treatment for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189687 03/12/2026 A health-care professional licensed in the United States to practice in an appropriate medical or health-care discipline must perform medical care examinations and provide medical treatment for a child. Source Note: The provisions of this §749.1405 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1405 Who must perform medical care examinations and provide medical treatment for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189688 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189688 03/12/2026 (a) A child in your care must receive dental care:(1) Initially, according to the requirements in §749.1153 of this title (relating to What are the dental requirements when I admit a child into care?);(2) At as early an age as necessary;(3) As needed for relief of pain and infections; and(4) As needed for ongoing maintenance of dental health.(b) The child's record must include a written record of each dental examination that consists of:(1) A copy of the results of the dental examination;(2) Follow-up treatment recommended and any appointments scheduled; and(3) A notation of the child's refusal to accept dental treatment, if applicable.(c) For a child in the conservatorship of the department, you must supplement any information already documented in the child's health passport in order to comply with subsection (b) of this section. In your written record for the child, you are not required to repeat information that is already in the child's health passport.(d) You must obtain follow-up dental work indicated by the examination, such as treatment of cavities and cleaning. Source Note: The provisions of this §749.1409 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1409 What general dental requirements must my agency meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189689 03/12/2026 A licensed dentist must determine the frequency and need for ongoing maintenance of dental health for a child. You must comply with dentist recommendations for examinations and treatment for each child Source Note: The provisions of this §749.1411 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1411 Who must determine the frequency and need for ongoing maintenance of dental health for a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189690 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189690&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189690 03/12/2026 A health-care professional licensed in the United States to practice dentistry must provide dental care. Source Note: The provisions of this §749.1413 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1413 Who must perform dental examinations and provide dental treatment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189691 03/12/2026 (a) You must notify the Department of State Health Services (DSHS) after you become aware that a person in your care, an employee, a contract service provider, a caregiver, someone else in one of your foster homes, or a volunteer has contracted a communicable disease that the law requires you to report to the DSHS as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases).(b) If a person in your care has symptoms of a communicable disease that is reportable to the DSHS, you must:(1) Consult a health-care professional about the person's treatment;(2) Follow the treating physician's orders, which may include separating the person from others;(3) Notify the person's parent, if applicable; and(4) Sanitize all items used by the sick person before another person uses one of them.(c) If a health-care professional diagnoses a person in your care with a communicable disease that is reportable to DSHS, a health-care professional must authorize the person's participation in any routine activities at the foster home. The authorization must:(1) Be in the person's record;(2) Include a written statement that the person will not pose a serious threat to the health of others; and(3) Include any specific instructions and precautions to be taken for the protection of others, if necessary.(d) If an employee, a contract service provider, a caregiver, someone else in one of your foster homes, or a volunteer has a communicable disease that is reportable to DSHS, you must obtain written authorization from a health-care professional for the person to be present at the agency or foster home. The written authorization must include a statement that the person will not pose a serious threat to the health of others.(e) You must follow any written instructions and precautions specified by a health-care professional. Source Note: The provisions of this §749.1415 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2008, 33 TexReg 6607; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1415 What health precautions must I take if a person in care, employee, caregiver, someone else in one of my foster homes, or someone else in my agency has a communicable disease? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189692 03/12/2026 (a) All persons over the age of one year old must have a documented tuberculosis screening that was conducted as recommended by the Center for Disease Control (CDC) within 30 days before or after beginning to live, work, or volunteer at your operation unless the person:(1) Has lived, worked, or volunteered at a regulated residential child-care operation within the previous 12 months. For example, an employee beginning employment in a regulated residential child-care operation for the first time would need a baseline tuberculosis screening. Employment in a different residential child-care operation would not require a new screening, as long as documentation in paragraph (2) of this subsection is also provided. If the employee left employment in regulated residential child-care for more than 12 months and then returned, a new screening would be required; and(2) Provides documentation of a tuberculosis screening.(b) Documentation must consist of a copy of the results of the baseline tuberculosis screening or chest radiograph, which must be in the person's record at your operation within 40 days of the person beginning to live, work, or volunteer at your operation. Documentation of a copy of the results of treatment (if treatment is required) must also be maintained in the person's record. For a child in DFPS conservatorship, documentation in the child's health passport is sufficient.(c) Except on the advice of a physician, no additional screening is required for a person who continues to live, work, and/or volunteer in a regulated residential child-care setting. Source Note: The provisions of this §749.1417 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1417 Who must have a tuberculosis (TB) examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189693 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189693 03/12/2026 (a) Each child that you admit must meet and continue to meet applicable immunization requirements as specified by the Department of State Health Services.(b) You must maintain current immunizations records for each child in your care, including any immunization exemptions or exceptions.(c) Unless the child is exempt from immunization requirements, all immunizations required for the child's age must:(1) Be completed by the date of admission; or(2) Begin within 30 days after admission. Source Note: The provisions of this §749.1421 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1421 What immunizations must a child in my care have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189694 03/12/2026 (a) A child may be exempt from immunization requirements for a medical reason and reason of conscience, including a religious belief. To claim an exemption, the person applying for the child's admission must meet criteria specified by:(1) §42.043(d) and (d-1) of the Human Resources Code; or(2) The Department of State Health Services rule in 25 TAC §97.62 (relating to Exclusions from Compliance).(b) For some diseases, a child who previously had a disease and is accordingly naturally immune from it may qualify for an exception to the immunization requirements for the disease. To claim this exception, the person applying for the child's admission must meet the criteria specified by the Department of State Health Services rule in 25 TAC §97.65 (relating to Exceptions to Immunization Requirements). Source Note: The provisions of this §749.1423 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1423 What exemptions or exceptions are there concerning immunization requirements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189695 03/12/2026 Acceptable documentation includes:(1) An official immunization record generated from a state or local health authority, including a record from another state. Examples include a registry, a copy of the current immunization record that is on file at the pre-kindergarten program or school, or the health passport for a child in the conservatorship of DFPS, so long as the record includes:(A) The child's name and date of birth;(B) The type of vaccine and number of doses; and(C) The month, day, and year the child received each vaccination; or(2) An official immunization record or photocopy, such as from a doctor's office, that includes:(A) The child's name and date of birth;(B) The type of vaccine and number of doses;(C) The month, day, and year the child received each vaccination;(D) The signature (including a rubber stamp or electronic signature) of the health-care professional who administered the vaccine, or another health-care professional's documentation of the immunization as long as the name of the health-care professional that administered the vaccine is documented; and(E) Clinic contact information, if the immunization record is generated from an electronic health record system. Source Note: The provisions of this §749.1425 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1425 What documentation is acceptable for an immunization record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189696 03/12/2026 (a) You must ensure that each child you admit is screened for possible vision and hearing problems that meet the requirements of the Special Senses and Communication Disorders Act, Health and Safety Code, Chapter 36. If problems are detected, the child must have a professional vision and hearing examination.(b) For each child required to be screened, you must keep one of the following in each child's record:(1) The individual vision and hearing screening results; however, results found in the child's health passport if the child is in DFPS conservatorship are sufficient to meet this requirement;(2) A signed statement from the child's parent that the child's screening records are current and on file at the program or school the child attends away from the agency. The statement must be dated and include the name, address, and telephone number of the program or school; or(3) An affidavit from the child's parent stating that the vision or hearing screening and/or examination conflicts with the tenets or practices of a church or religious denomination of the parents. Source Note: The provisions of this §749.1427 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1427 Must children in my care have a vision and hearing screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189697 03/12/2026 You must:(1) Schedule the child for professional examination and needed health services;(2) Ensure the professional and medical recommendations are carried out; and(3) Convey the information concerning the child's visual and/or hearing difficulty to the educational and agency caregivers, so the recommended adjustments can be made in programs. Source Note: The provisions of this §749.1429 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1429 What must I do if a child in my care is identified as needing a diagnostic vision or hearing examination? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189698 03/12/2026 When recommended by a physician or other health-care professional, you must ensure that a child with a physical disability has any special equipment recommended that can be reasonably obtained. Source Note: The provisions of this §749.1431 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1431 What special equipment must I provide for a child with a physical disability? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189699 03/12/2026 (a) A licensed physician must review a child's primary medical needs:(1) At least every 90 days or on a schedule recommended by the child's physician; and(2) Whenever a medical or related problem occurs.(b) The review must address:(1) Whether the child can continue to be cared for appropriately in the foster home; and(2) Any new or changed orders regarding the items outlined in §749.1135 of this title (relating to What are the additional admission requirements when I admit a child for treatment services?).(c) Documentation of each physician review must be filed in the child's record. Source Note: The provisions of this §749.1433 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1433 How often must the physician review a child's primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189700 03/12/2026 (a) Only the following may insert a nasogastric tube:(1) A physician;(2) A licensed nurse according to a physician's written orders; or(3) A caregiver instructed by a licensed nurse according to a physician's written orders.(b) The caregiver must document each insertion in the child's record. The documentation for each insertion must include the:(1) Signature of the nurse or caregiver who inserted the tube; and(2) Date of the insertion.(c) The caregiver must follow the physician's written orders concerning the tube. Source Note: The provisions of this §749.1435 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1435 What are the requirements for using a nasogastric tube? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208655 03/12/2026 For an injury or illness that requires immediate treatment by a health-care professional, the caregiver must immediately have the child treated by a healthcare professional, contact emergency services, or take the child to the nearest emergency room after ensuring the supervision of any other children present. The caregiver must not be required to seek approval to contact emergency services or to take the child to the nearest emergency room. Source Note: The provisions of this §749.1437 adopted to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1437 How must a caregiver respond when a child is injured or ill and requires immediate treatment by a health-care professional? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189701 03/12/2026 (a) You must obtain a general written consent to administer routine, preventive, and emergency medications.(b) You must obtain a written, signed, and dated consent, specific to the psychotropic medication to be administered, from the person legally authorized to give medical consent before administering a new psychotropic medication to a child, per §749.1603 of this title (relating to If my agency employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give consent before requesting his consent for the child to be placed on psychotropic medication?) or §749.1605 of this title (relating to If my agency does not employ or contract with the health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give medical consent prior to the health-care professional prescribing psychotropic medications to a child in care?). Source Note: The provisions of this §749.1461 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1461 What consent must I obtain to administer medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189705 03/12/2026 (a) To the best of their knowledge, caregivers must inform the person legally authorized to give medical consent of the benefits, risks, and side effects of all prescription medication and treatment procedures used and the medical consequences of refusing them, and/or provide the name and telephone number of the prescribing health-care professional for more information.(b) For prescription medications, caregivers must:(1) Be informed about possible side effects of medications administered to the child;(2) Store all medication in the original container unless the caregiver has an additional container with the same label and instructions;(3) Administer all medications according to the instructions on the label or according to a prescribing health-care professional's subsequent signed orders;(4) Administer each child's medication within one hour of preparation;(5) Ensure the child has taken the medication as prescribed;(6) Ensure a person trained in and authorized to administer medication administers the medication to a child in care unless the child is on a self-medication program;(7) Maintain any documentation provided by the health-care professional on the administration of current medication;(8) Not physically force a child to take medication;(9) Ensure that a child is not given any medication or treatment except on written orders of a health-care professional;(10) Not borrow or administer medication to a child that is prescribed to another person; and(11) Not administer medication to more than one child from the same container. Only the child for whom the medication was prescribed may use the medication. Source Note: The provisions of this §749.1463 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1463 What are the requirements for administering prescription medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208656 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208656&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208656 03/12/2026 (a) For non-prescription medications and supplements, you must:(1) Follow the label instructions for dosage; and(2) Ensure that the non-prescription medication or supplement is not contraindicated with any medication prescribed for the child or medical condition that the child has.(b) You may give non-prescription medication or supplements to more than one child from one container. Source Note: The provisions of this §749.1469 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1469 What are the requirements for administering non-prescription medication and supplements? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189703 03/12/2026 For a child to be on a self-medication program:(1) The child's parent must give written authorization for the child to be on the program;(2) The child's service plan must include the self-medication program and any requirements for caregiver supervision; and(3) The health-care professional who prescribed the medication must be consulted and any concerns of the health-care professional documented in the child's record. Source Note: The provisions of this §749.1501 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1501 What are the requirements for a self-medication program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189704 03/12/2026 When a child who is on a self-medication program takes a dosage of the medication, you must ensure there is a system for reviewing the child's medication each day and that the child either:(1) Records the daily dosage; or(2) Reports the medication to a caregiver, who must then do the actual daily recording. Source Note: The provisions of this §749.1503 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1503 Who must record the medication dosage if the child is on a self-medication program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189706 03/12/2026 A foster home must:(1) Store medication in a locked container;(2) Keep medication inaccessible other than to caregivers responsible for stored medication;(3) Store medication covered by Schedule II of the Texas Controlled Substances Act under double lock in a separate container. For example, a double lock can include a lock on the cabinet or filing cabinet and the door to the closet where medications are stored;(4) Make provisions for storing medication that requires refrigeration;(5) Keep medication storage area(s) clean and orderly;(6) Remove discontinued medication immediately and store it in a separate locked area until it is destroyed within 30 days;(7) Remove medication on or before the expiration date and store it in a separate locked area until it is destroyed within 30 days;(8) Remove medication of a discharged or deceased child immediately and store it in a separate locked area until it is destroyed within 30 days; and(9) Provide prescription medication to the person to whom a child is discharged or transferred if the child is taking the medication at that time. Source Note: The provisions of this §749.1521 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1521 What medication storage and destruction requirements must a foster home meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189707 03/12/2026 (a) Caregivers must maintain a cumulative medication record of all:(1) Prescription medication dispensed to each child; and(2) Nonprescription medications and supplements that are dispensed to a child under five years old.(b) The cumulative medication record must be updated within 24 hours of administering medication.(c) Caregivers must maintain the medication record, which must include:(1) Child's full name;(2) Prescribing health-care professional's name, if applicable;(3) Reason medication was prescribed, for prescription medication;(4) Medication name, strength, and dosage;(5) Date (day, month, and year) and the time the medication was administered;(6) Name and signature of the person who administered the medication;(7) Child's refusal to accept medication, if applicable; and(8) Reasons for administering the medication, including the specific symptoms, condition, and/or injuries of the child that the caregiver is treating, only for:(A) PRN psychotropic medication; and(B) Nonprescription medications and supplements for children under five years old.(d) You must document in the medication record any non-prescription medication or supplement that is given to the child and how often the child receives the medication or supplement.(e) Caregivers must document any prohibited prescription medications (for example, medication allergies or contraindications) or prohibited nonprescription medications and supplements in the medication record.(f) You must incorporate the medication record into the child's record. Source Note: The provisions of this §749.1541 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1541 What records must caregivers maintain for each child receiving medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189708 03/12/2026 (a) The foster parents must maintain at the foster home the child's medication records for the current month.(b) Foster parents must submit copies of the child's medication records to you each month. You must file these medication records in the child's record.(c) You must maintain copies of all the child's medication records for the length of time that you provide services to the child. Source Note: The provisions of this §749.1543 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1543 Where must a child's medication records be maintained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189709 03/12/2026 You must make suitable forms available to caregivers for maintaining adequate records of all medications administered to a child. Source Note: The provisions of this §749.1545 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1545 What other requirements must I meet regarding medication records? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189710 03/12/2026 A medication error includes, but is not limited to, the following:(1) A child receives the wrong medication;(2) A child receives medication prescribed to someone else;(3) A child receives the wrong dosage of medication;(4) A child receives medication at the wrong time;(5) A medication dose is skipped or missed;(6) A child receives expired medication;(7) Not following the medication administration instructions, such as giving a child medication on an empty stomach when the medication should be given with food; and(8) A child receives medication that was not stored as required to maintain the effectiveness of the medication, such as refrigerating or not refrigerating the medication or exposing the medication to heat or sunlight. Source Note: The provisions of this §749.1561 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1561 What is a medication error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189711 03/12/2026 (a) If a caregiver finds a medication error regarding a prescribed medication, the caregiver must contact a health-care professional immediately, unless the error is the type described in paragraph (4) or (5) of §749.1561 of this title (relating to What is a medication error?), and follow the health-care professional's recommendations.(b) If a caregiver finds a medication error regarding a nonprescription medication, the caregiver must take the appropriate and necessary actions as required by the circumstances.(c) For all medication errors, a caregiver must document the following within 24 hours:(1) The time and date of the error;(2) The medication error;(3) The time and date of the call(s) to the licensed health-care professional, if applicable;(4) The name and title of the health-care professional contacted, if applicable; and(5) The health-care professional's medical recommendations for ensuring the child's safety, if applicable. Source Note: The provisions of this §749.1563 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1563 What must a caregiver do if the caregiver finds a medication error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189712 03/12/2026 If a caregiver finds a medication label error, the caregiver must:(1) Report the error to the pharmacist; and(2) Have the label on the medication container corrected as soon as possible but no later than the next business day. Source Note: The provisions of this §749.1565 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1565 What must a caregiver do if the caregiver finds a medication label error? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189713 03/12/2026 If a child has an adverse reaction (unexpected or dangerous reaction) to a medication, the caregiver must:(1) Immediately report the reaction to a health-care professional and the child's parent;(2) Follow the health-care professional's recommendations;(3) Seek further medical care for the child if the child's condition appears to worsen; and(4) Document in the child's medical record the:(A) Adverse reactions that the child had to the medication;(B) Time and date of call(s) to the health-care professional;(C) Name and title of the health-care professional contacted; and(D) Health-care professional's medical recommendations for ensuring the child's safety. Source Note: The provisions of this §749.1581 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1581 What must a caregiver do if a child has an adverse reaction to a medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189714 03/12/2026 (a) A side effect from any medication is an effect of medication in addition to the medication's intended effect, often an undesirable effect.(b) If a child experiences side effects from any medication, the caregiver must:(1) Document the observed and reported side effects;(2) Immediately report any serious side effects to the child's prescribing health-care professional and the child's parent; and(3) Report any other side effect to the prescribing health-care professional within 72 hours. Source Note: The provisions of this §749.1583 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1583 What must a caregiver do if a child experiences side effects from any medications? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189718 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189718&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189718 03/12/2026 (a) Before requesting the person's written consent to give the child psychotropic medication, the prescribing health-care professional must give the following in writing or document a discussion with the person or a combination of both:(1) The child's diagnosis;(2) The nature of the child's mental illness or condition;(3) An explanation of the purpose of the medication;(4) A description of the benefits expected;(5) A description of any accompanying discomforts and risks, including those which could result from long-term use of the medication, and possible side effects, including side effects that are known to frequently occur in persons, side effects to which the child may be predisposed, and the nature and possible occurrence of irreversible symptoms;(6) A statement of whether the medication is habituating in nature;(7) Alternative interventions to the use of psychotropic medication that have been attempted and that have been unsuccessful;(8) Other alternative treatments or procedures to the use of the psychotropic medication;(9) Risks and benefits of the alternative treatments or procedures;(10) Risks and benefits of not receiving or undergoing a treatment or procedure;(11) An explanation that the person legally authorized to give medical consent may ask questions about the child's response to the medication, and may review your daily records on request; and(12) An explanation that the person legally authorized to give medical consent may withdraw consent and request the medication be discontinued at any time.(b) The health-care professional must offer to answer any questions the person legally authorized to give consent has about the medication.(c) The person must sign a consent form that acknowledges that you have provided all of the information set forth in subsection (a) of this section. A copy of this signed consent form must be filed in the child's record. Source Note: The provisions of this §749.1603 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1603 If my agency employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give consent before requesting his consent for the child to be placed on psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189715 03/12/2026 If you are requesting consent and the person legally authorized to give consent is not privy to this information, you must:(1) Before requesting the person's written consent to give the child psychotropic medication, provide information in writing or document a discussion with the person regarding:(A) The nature of the child's mental illness or condition;(B) A general explanation of the purpose of the medication;(C) A general description of the benefits expected;(D) An explanation that the person may ask questions about the child's response to the medication; and(E) An explanation that the person may withdraw medical consent and request the medication be discontinued at any time.(2) Offer to answer any questions the person legally authorized to give medical consent has about the medication and/or provide the name and telephone number of the prescribing health-care professional for further information.(3) Obtain a signed consent form from the person legally authorized to give medical consent that acknowledges that you have provided all of the information set forth in paragraph (1) of this section. A copy of this signed consent form must be filed in the child's record. Source Note: The provisions of this §749.1605 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1605 If my agency does not employ or contract with the health-care professional who prescribes psychotropic medications to a child in care, what information must I provide the person legally authorized to give medical consent prior to the health-care professional prescribing psychotropic medications to a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189716 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189716&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189716 03/12/2026 (a) If a physician has made a determination that there is an emergency according to §266.009 of the Family Code and the emergency requires the administration of a psychotropic medication, then you must follow the physician's orders and do not have to obtain consent prior to the administration of the medication.(b) Within 72 hours after you have administered the medication, you must notify the parent and the person legally authorized to give medical consent.(c) The physician's statement regarding the emergency and the prescription must be documented in the child's record. Source Note: The provisions of this §749.1607 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1607 What are the requirements if a physician orders administration of a psychotropic medication to a child in an emergency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189717 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189717&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189717 03/12/2026 (a) You must ensure that caregivers maintain a daily record of the child's use of such medication according to the requirements in §749.1541 of this title (relating to What records must caregivers maintain for each child receiving medication?).(b) Caregivers must document in the child's record a description of any noticeable change in the child's behavior in response to the medication.(c) You must provide the information in subsection (b) of this section to the prescribing health-care professional or the child's current health-care professional to use in evaluating the appropriateness of continuing the medication. You must document the health-care professional's evaluation and review in the child's record. Source Note: The provisions of this §749.1609 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1609 What information must be documented about a child's use of psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189719 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189719&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189719 03/12/2026 (a) If a child takes psychotropic medications, the prescribing health-care professional must evaluate and document in the child's medication record a description of the child's response to the medication and an assessment of its effectiveness and the appropriateness of continuing the medication on at least a quarterly basis. The written evaluation must include any reasons for discontinuing the medication.(b) If the health-care professional decides that he can evaluate the appropriateness of continuing the medication without seeing the child, you do not have to schedule an appointment for the evaluation.(c) The health-care professional must consider the target symptoms and treatment goals in evaluating the child's use of psychotropic medications.(d) The health-care professional must document whether the child needs to continue taking the medication. You must document the health-care professional's decision in the child's record.(e) If the health-care professional does not substantiate the effectiveness of a specific psychotropic medication within 90 days, the health-care professional must provide a written rationale for continuing the medication for an additional period. The continuation of the medication may not exceed an additional 90 days (for a total of 180 days) if the health-care professional does not substantiate effectiveness. A copy of the written rationale must be documented in the child's record. Source Note: The provisions of this §749.1611 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1611 If my agency employs or contracts with a health-care professional who prescribes psychotropic medications to a child in care, what are the requirements for evaluating whether a child should continue taking a psychotropic medication? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189720 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189720&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189720 03/12/2026 (a) A protective device:(1) Protects a person from involuntary self-injurious behavior or permits wounds to heal; and(2) Does not prohibit a person's mobility.(b) Examples of a protective device are helmets, elbow guards, mittens, and wheelchair seat belts.(c) If used appropriately, devices intended to encourage mobility or minimally restrain a young child for safety purposes, such as wheelchairs, car seats, high chairs, strollers, bed rails, and child leashes manufactured and sold specifically to harness a young child for safety purposes, are not protective devices. Source Note: The provisions of this §749.1641 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1641 What is a protective device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189721 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189721&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189721 03/12/2026 Involuntary self-injurious behavior means a person's physical movements that are automatic and not subject to control of the person's will that may inflict injury to the person. Source Note: The provisions of this §749.1643 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1643 What does "involuntary self-injurious behavior" mean when used in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189722 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189722&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189722 03/12/2026 (a) You may use protective devices if a licensed physician orders their use for a specific child. The orders must indicate the circumstances under which the protective device is permitted.(b) You may not use protective devices as:(1) Punishment;(2) Retribution or retaliation;(3) A means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation.(c) You must document the use of protective devices in the child's record, service plan, and service plan reviews. The service planning team must discuss and document in the child's service plan reviews:(1) Clinical justification for continued use of protective devices; and(2) Ways to reduce the need for protective devices. Source Note: The provisions of this §749.1645 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1645 May I use protective devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189723 03/12/2026 A licensed physician ordering protective devices may use PRN orders. The physician must review PRN orders for protective devices at least every 90 days. Source Note: The provisions of this §749.1647 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1647 Who may use PRN orders with respect to protective devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189724 03/12/2026 (a) A supportive device used:(1) To support a person's posture;(2) To assist a person who cannot obtain and/or maintain normal physical functioning to improve his mobility and independent functioning; or(3) As an adjunct to proper care and treatment, for example physical therapy.(b) The purpose of a supportive device is not to restrict movement. Source Note: The provisions of this §749.1671 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1671 What is a supportive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189684 03/12/2026 (a) You may use supportive devices if a licensed physician orders their use for a specific child. The orders must indicate the circumstances under which the supportive device is permitted.(b) You may not use a supportive device as a substitute for appropriate nursing care.(c) You may not use supportive devices that include tying or depriving or limiting the use of a child's hands or feet.(d) You may not use supportive devices as:(1) Punishment;(2) Retribution or retaliation;(3) Means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation.(e) If a device is not specifically for assisting with sleep or safety during sleep, you must remove the device during rest periods.(f) You must document the use of supportive devices in the child's record, service plan, and service plan reviews. The service planning team must discuss and document in the child's service plan reviews:(1) Clinical justification for continued use of supportive devices; and(2) Ways to reduce the need for supportive devices. Source Note: The provisions of this §749.1673 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1673 May I use supportive devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189683 03/12/2026 A licensed physician ordering supportive devices may use PRN orders. The physician must review PRN orders for supportive devices at least every 90 days. Source Note: The provisions of this §749.1675 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES J FOSTER CARE SERVICES: MEDICAL AND DENTAL §749.1675 Who may use PRN orders with respect to supportive devices? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209005 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=209005&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 209005 03/12/2026 These words have the following meanings in this division:(1) Baby bungee jumper--A bucket seat that is suspended from a doorway by an elastic bungee cord that allows an infant to bounce while sitting in the seat.(2) Baby walker--A baby walker allows an infant to sit inside the walker equipped with rollers or wheels and move across the floor.(3) Bouncer seat--A stationary seat designed to provide gentle rocking or bouncing motion by an infant's movement or by battery-operated movement. This type of equipment is designed for an infant's use from birth until the child can sit up unassisted.(4) Restrictive device--Equipment that places the body of an infant in a position that may restrict airflow or cause strangulation; usually, the infant is placed in a semi-seated position. Examples of restrictive devices are car seats, swings, bouncy seats, and highchairs. Source Note: The provisions of this §749.1801 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1801 What do certain words mean in this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189768 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189768&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189768 03/12/2026 (a) Each infant must receive individual attention, including playing, talking, cuddling, and holding.(b) A caregiver must provide prompt attention to an infant's physical needs, such as feeding and diapering.(c) An infant's caregiver must ensure that the environment is safe. For example, free the area of objects that may choke or harm the infant, take measures to prevent electric shock, free the area of furniture that is in disrepair or unstable, and allow no unsupervised access to water to prevent the risk of drowning.(d) Items necessary for diaper changing must be kept out of the reach of children, but do not need to be in locked storage.(e) An infant's caregiver must never leave the infant unsupervised:(1) A sleeping infant is considered supervised if the caregiver is within eyesight or hearing range of the infant and can intervene as needed, or if the caregiver uses a video camera or audio monitoring device to monitor the infant and is close enough to the infant to intervene as needed; and(2) An awake infant is considered supervised if the caregiver is within eyesight of the infant and is close enough to the infant to intervene as needed. For short periods of time in the course of routine household activities, the infant may be out of the caregiver's eyesight, as long as the:(A) Infant is within hearing range;(B) Infant's environment is free of any safety hazards; and(C) Caregiver is able to intervene immediately, as needed. Source Note: The provisions of this §749.1803 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1803 What are the basic care requirements for an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189769 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189769&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189769 03/12/2026 An infant care area must at a minimum include the following furnishings and equipment:(1) An individual crib for each infant; and(2) A sufficient number of toys to keep each child engaged in activities. Source Note: The provisions of this §749.1805 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1805 What furnishings and equipment must I have in an infant care area? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189770 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189770&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189770 03/12/2026 (a) All cribs must have:(1) A firm, flat mattress that snugly fits the sides of the crib. The mattress must not be supplemented with additional foam material or pads;(2) Sheets that fit snugly and do not present an entanglement hazard;(3) A mattress that is waterproof or washable;(4) Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts;(5) A maximum of 2 3/8 inches between crib slats or poles;(6) No corner posts over 1/16 inch above the end panels;(7) No cutout areas in the headboard or footboard that would entrap a child's head or body; and(8) Drop rails, if present, which fasten securely and cannot be opened by a child.(b) Caregivers must sanitize each crib when soiled and before reassigning the crib to a different child.(c) Caregivers must never leave children in the crib with the side down.(d) The foster home must not have stackable cribs. Source Note: The provisions of this §749.1807 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1807 What specific safety requirements must my cribs meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189775 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189775&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189775 03/12/2026 A foster home may use a full-size, portable, or mesh-side crib if:(1) Caregivers follow the manufacturer's instructions;(2) The crib has:(A) Mesh that is securely attached to the top rail, side rail, and floor plate; and(B) Folded sides that securely latch in place when raised;(3) Caregivers never leave a child in a mesh-sided crib with a side folded down; and(4) If you become aware of a recall for the port-a-crib used, you must discontinue its use. Source Note: The provisions of this §749.1809 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1809 Are mesh cribs or port-a-cribs allowed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189771 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189771&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189771 03/12/2026 (a) A high chair, swing, stroller, infant carrier, rocker, bouncer seat, or a similar type of equipment that a foster home uses for an infant must be equipped with safety straps; and(b) The safety straps must be fastened whenever the infant is using the equipment. Source Note: The provisions of this §749.1811 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1811 What equipment must have safety straps before I can use it with an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189772 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189772&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189772 03/12/2026 (a) A foster home may not use any of the following types of equipment with infants:(1) Baby walkers;(2) Baby bungee jumpers;(3) Accordion safety gates;(4) Toys that are not large enough to prevent swallowing or choking; and(5) Bean bags, waterbeds, and foam pads for use as sleeping equipment.(b) Except for a tight fitting sheet and as provided in subsection (c), the crib must be bare for an infant younger than twelve months of age.(c) A crib mattress cover may be used to protect against wetness, but the cover must:(1) Be designed specifically for the size and type of crib and crib mattress that it is being used with;(2) Be tight fitting and thin; and(3) Not be designed to make the sleep surface softer.(d) An infant receiving treatment services for primary medical needs may have special items that assist with safe sleep at the written recommendation of a health-care professional. You must keep the recommendation in the child's record. Source Note: The provisions of this §749.1813 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective June 1, 2014, 39 TexReg 3730; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1813 What types of equipment may a foster home not use with infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189773 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189773&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189773 03/12/2026 (a) Caregivers must place an infant not yet able to turn over on his own in a face-up sleeping position unless a health-care professional orders otherwise. You must keep any orders from a health-care professional in the child's record.(b) An infant's head, face, or crib must not be covered at any time by an item such as a blanket, linen, or clothing.(c) An infant may not sleep in a prone position with a sleeping adult at any time, including in the adult's bed, on a couch, etc. Source Note: The provisions of this §749.1815 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1815 What are the specific sleeping requirements for infants? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204817 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204817&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204817 03/12/2026 You may not allow an infant to sleep in a restrictive device. If an infant falls asleep in a restrictive device, you must remove the infant from the device and place the infant in a crib as soon as possible. Source Note: The provisions of this §749.1817 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1817 May I allow an infant to sleep in a restrictive device? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189774 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189774&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189774 03/12/2026 (a) Caregivers must feed an infant based on the recommendations of the infant's health-care professional.(b) Unless recommendations from the service team are contrary, caregivers must hold the infant while feeding an infant that is:(1) Birth through six months old; or(2) Unable to sit unassisted in a high chair or other seating equipment during feeding.(c) Caregivers must never prop a bottle by supporting it with anything other than the infant's or adult's hand.(d) A caregiver who cares for more than one infant must:(1) Sterilize shared bottles or training cups between uses by different infants; and(2) Clean high chair trays before each use. Source Note: The provisions of this §749.1819 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1819 What are the specific requirements for feeding an infant? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=204818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 204818 03/12/2026 You may not lay a swaddled infant down to sleep or to rest on any surface at any time, unless you have an order signed by a health-care professional. You must keep the order in the child's record. Source Note: The provisions of this §749.1821 adopted to be effective April 25, 2021, 46 TexReg 2454. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1821 May I swaddle an infant to help the infant sleep? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189779 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189779&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189779 03/12/2026 (a) Each toddler must receive individual attention, including playing, talking, and cuddling.(b) A toddler's caregiver must ensure that the environment is safe. For example, free the area of objects that may choke or harm the toddler, take measures to prevent electric shock, free the area of furniture that is in disrepair or unstable, and allow no unsupervised access to water to prevent the risk of drowning.(c) A toddler's caregiver must never leave the toddler unsupervised. A toddler is considered supervised if the caregiver is within eyesight or hearing range of the child and can intervene as needed, or if the caregiver uses a video camera or an audio monitoring device to monitor the child and is close enough to the child to intervene as needed. Source Note: The provisions of this §749.1841 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1841 What are the basic care requirements for a toddler? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189780 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189780&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189780 03/12/2026 You must:(1) Ensure information, training, and counseling is available regarding health aspects of pregnancy, preparation for child birth, and recovery from child birth;(2) Ensure the pregnant child receives nutritional counseling and guidance that meets generally accepted standards, including nutrition during pregnancy, lactation, and foods to avoid; and(3) Inform the child, within seven days of admission or upon learning of the pregnancy, of her right to be free from pressure to get an abortion, relinquish her child for adoption, or to parent her child. Source Note: The provisions of this §749.1861 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1861 What information must I provide a pregnant child regarding her pregnancy? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189776 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189776&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189776 03/12/2026 If your policies allow for the use of personal restraints and you have a pregnant child in care:(1) The health-care professional attending to the child's pregnancy must document whether any type of emergency behavior intervention that your policies allow is inadvisable; and(2) You may not use any emergency behavior intervention that the child's health-care professional attending to her pregnancy finds inadvisable. Source Note: The provisions of this §749.1863 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1863 Is the use of emergency behavior intervention of a pregnant child permitted in a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189777 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189777&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189777 03/12/2026 If your policies permit the admission of adolescent parents with their child(ren):(1) An adolescent parent must provide most of the care for her child;(2) Caregivers must be available to the adolescent parent as a resource and support; and(3) When you care for an adolescent's child in the adolescent parent's absence, you are responsible for that child as if the child is in your care. Source Note: The provisions of this §749.1865 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1865 If my policies permit the admission of adolescent parents with their child(ren), who is responsible for the care of an adolescent's child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189778 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189778&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189778 03/12/2026 (a) You must arrange an appropriate education for each child, including:(1) Ensuring the child in care attends an educational facility or program that is approved or accredited by the Texas Education Agency, the Southern Association of Colleges and Schools, or the Texas Private School Accreditation Commission, unless the child's service planning team approves the child attending another educational facility or program with documented justification. You must keep documentation of the planning team's justification and approval in the child's record;(2) Ensuring a school-age child receives education and training in the least restrictive setting necessary to meet the child's needs and abilities;(3) For a child attending an accredited educational facility or program, ensuring the facility or program implements a special education student's individual education plan (IEP); and(4) Advocating that a school-age child receives the educational and related services to which he is entitled under provisions of federal and state law and regulations.(b) For children receiving treatment services you must designate a liaison between the agency and the child's school. Source Note: The provisions of this §749.1891 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1891 What responsibilities do I have for the education of a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208658 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208658&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208658 03/12/2026 Caregivers must:(1) Review report cards and other information received from teachers or school authorities with the child and provide necessary information to agency staff;(2) Counsel and assist the child regarding adequate classroom performance;(3) Permit, encourage, and make reasonable efforts to involve the child in extracurricular activities as determined by a reasonable and prudent parent standard to the extent of the child's interests and abilities and in accordance with the child's service plan.(4) Provide a quiet, well-lighted space for the child to study and allow regular times for homework and study;(5) Know what emergency behavior interventions are permitted and being used with the child;(6) Request ARD (admission, review, and dismissal), IEP (individual education plan), and ITP (individual transitional planning) meetings if concerned with the child's educational program or if the child does not appear to be making progress;(7) Provide notice to the parent of the child of any scheduled ARD, IEP, or ITP meetings;(8) Attend ARD, IEP, ITP meetings, other school staffings, and conferences to represent the child's educational best interests, including the child being evaluated for and provided with services needed for the child to benefit from educational services, and positive behavior supports designed to decrease the need for negative disciplinary techniques or interventions; and(9) Know what is in the child's IEP and support the school's efforts to implement the IEP, if applicable. Source Note: The provisions of this §749.1893 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1893 What responsibilities do caregivers have for the educational needs of a child in their care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189755 03/12/2026 You must ensure that the educational program for a child with an autism spectrum disorder:(1) Encourages normalization through appropriate stimulation and by encouraging self-help skills; and(2) Is appropriate to the child's intellectual and social functioning. Source Note: The provisions of this §749.1895 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1895 What are the specific requirements for the educational program of a child diagnosed with autism spectrum disorder? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189756 03/12/2026 (a) Caregivers must provide daily indoor and outdoor recreational and other activities appropriate to the needs, interests, and abilities of the children so every child may participate. (b) Except for written medical orders to the contrary, your programs for non-ambulatory children must include:(1) Physical fitness development that prescribes a variety of body positions; and(2) Changes in environment. (c) Each child must have individual free time as appropriate to the child's age and abilities.(d) Caregivers must provide the following types of recreational activities based on each individual child's needs:Attached Graphic Source Note: The provisions of this §749.1921 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1921 What responsibilities do foster parents have for providing a child with opportunities for recreational activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189758 03/12/2026 (a) A child receiving treatment services for primary medical needs or intellectual disability must have a minimum of one hour of physical stimulation each day.(b) Training programs for non-mobile children must include development of physical fitness. This must include a variety of body positions and changes in environment. Source Note: The provisions of this §749.1923 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1923 What physical fitness activities must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189759 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189759&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189759 03/12/2026 A child receiving treatment services for primary medical needs or intellectual disability must have a schedule that is based on the normalization principle. In order to help the child obtain an existence as normal as possible, the daily schedule must:(1) Demonstrate an understanding of normal child development; and(2) Enhance the child's physical, emotional, and social development. Source Note: The provisions of this §749.1925 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1925 What type of daily schedule must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189760 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189760&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189760 03/12/2026 A child receiving treatment services for primary medical needs or intellectual disabilities should experience normalcy as much as possible and as appropriate for the child's special needs. This means that the child's foster parents must be routinely and personally involved with the child. This involvement must include:(1) Daily one-on-one interaction between the child and the foster parent primarily responsible for the child's care;(2) Participation in everyday family activities to the extent the child is able, such as having meals together, participating in family time, and participating in family outings;(3) Sensory stimulation for the child, such as the child being held, being read to, being played with, and being talked to, and the foster family watching television and listening to music together;(4) Actively participating in the child's medical care, including appointments and hospitalizations; and(5) Actively participating in the child's educational needs. Source Note: The provisions of this §749.1927 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1927 To what extent must a child receiving treatment services for primary medical needs or intellectual disabilities have normal life experiences? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189761 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189761&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189761 03/12/2026 (a) Only a caregiver known to and knowledgeable of a child may discipline the child.(b) Each disciplinary measure must:(1) Be consistent with your policies and procedures;(2) Not be physically or emotionally damaging to the child;(3) Be individualized to meet each child's needs;(4) Be appropriate to the child's level of understanding, age, and developmental level; and(5) Be appropriate to the incident and severity of the behavior demonstrated.(c) The goal of each disciplinary measure must be to teach the child acceptable behavior and self-control. The caregiver must explain the reason for the disciplinary measure when the caregiver imposes the measure. Source Note: The provisions of this §749.1951 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1951 What are the requirements for disciplinary measures? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189762 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189762&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189762 03/12/2026 (a) You may not use or threaten to use corporal punishment with any child in care.(b) Corporal punishment is the infliction of physical pain on any part of a child's body as means of controlling or managing the child's behavior. It includes:(1) Hitting or spanking a child with a hand or instrument; or(2) Forcing or requiring the child to do any of the following as a method of managing or controlling behavior:(A) Perform any form of physical exercise, such as running laps or doing sit ups or push ups;(B) Hold a physical position, such as kneeling or squatting; or(C) Do any form of "unproductive work." Source Note: The provisions of this §749.1953 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1953 May I use corporal punishment for children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189763 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189763&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189763 03/12/2026 (a) "Unproductive work" is work that serves no purpose except to demean the child. Examples include moving rocks or logs from one pile to another or digging a hole and then filling it in. Unproductive work is never an appropriate behavior management tool.(b) "Unproductive work" does not include work that corrects damage that the child's behavior caused. For example, you may require a child who defaces a fence or wall to repaint it. This example includes a logical consequence and an acceptable behavior management tool. Source Note: The provisions of this §749.1955 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1955 What is "unproductive work"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208659 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208659&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208659 03/12/2026 In addition to corporal punishment, prohibited discipline techniques include, but are not limited to:(1) Any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline or punishment;(2) Denial of mail or visits with their families as discipline or punishment;(3) Threatening with the loss of placement as discipline or punishment;(4) Using sarcastic or cruel humor;(5) Maintaining an uncomfortable physical position, such as kneeling, or holding his arms out;(6) Pinching, pulling hair, biting, or shaking a child;(7) Putting anything in or on a child's mouth;(8) Humiliating, shaming, ridiculing, rejecting, or yelling at a child;(9) Subjecting a child to abusive or profane language;(10) Placing a child in a dark room, bathroom, or closet;(11) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age;(12) Confining a child to a highchair, box, or other similar furniture or equipment as discipline or punishment;(13) Denying basic child rights as a form of discipline or punishment;(14) Withholding food that meets the child's nutritional requirements; and(15) Using or threatening to use emergency behavior intervention as discipline or punishment. Source Note: The provisions of this §749.1957 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1957 What other methods of punishment are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189765 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189765&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189765 03/12/2026 (a) Within limits, a foster parent may restrict a child's activities as a behavior management tool.(b) Restrictions of activities, that will be imposed on a child for more than 14 days, must be reviewed with and approved by the child placement management staff or treatment director prior to or within 24 hours of imposing the restriction.(c) Restrictions to a particular room or building that will be imposed on a child for more than 24 hours must have approval from the service planning team, a professional service provider, or treatment director prior to or within 24 hours of imposing the restriction.(d) You must inform the child and parent about any such restrictions you place on the child.(e) Documentation of all approvals, justification for the restriction, and informing the child and parents must be in the child's record. Source Note: The provisions of this §749.1959 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1959 To what extent may a caregiver restrict a child's activities as a behavior management tool? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189766 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189766&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189766 03/12/2026 No. A person in care must not discipline or punish another person in care except when babysitting under §749.2599 of this title (relating to Can a child serve as a babysitter?). Source Note: The provisions of this §749.1961 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES K FOSTER CARE SERVICES: DAILY CARE, PROBLEM MANAGEMENT §749.1961 May a person in care discipline or punish another person in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208660 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208660&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208660 03/12/2026 These terms have the following meaning in this subchapter:(1) Transitional hold--The use of a temporary restraint technique that lasts no longer than one minute as part of the continuation of a longer personal restraint.(2) Triggered review--A review of a specific child's placement, treatment plan, and orders or recommendations for intervention, because a certain number of interventions have been made within a specified period of time. Source Note: The provisions of this §749.2001 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective June 1, 2008, 33 TexReg 4196; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2001 What do certain terms mean in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189726 03/12/2026 (a) If permitted in your policies and you meet the requirements of this subchapter, a caregiver may administer the following types of emergency behavior intervention to a child in your care:(1) Short personal restraint;(2) Personal restraint; and(3) Emergency medication.(b) You may never administer chemical restraints, mechanical restraints, or seclusion.(c) Protective and supportive devices, used appropriately, are not considered emergency behavior interventions. For information on protective and supportive devices, see Divisions 9 and 10 of Subchapter J of this chapter (relating to Foster Care Services: Medical and Dental). Source Note: The provisions of this §749.2051 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2051 What types of emergency behavior intervention may I administer? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189727 03/12/2026 Only a caregiver qualified in emergency behavior intervention may administer any form of emergency behavior intervention, except for the short personal restraint of a child. Source Note: The provisions of this §749.2053 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2053 Who may administer emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189728 03/12/2026 (a) Before using a permitted type of emergency behavior intervention, the caregiver must:(1) Attempt less restrictive behavior interventions that prove to be ineffective at defusing the situation; and(2) Determine that the basis for the emergency behavior intervention is:(A) An emergency situation; or(B) A need for a personal restraint to administer intra-muscular medication or other medical treatments prescribed by a licensed physician, such as administering insulin to a child with diabetes.(b) A child's active attempt to run away may be considered an emergency situation when the following is a factor:(1) The child is developmentally or chronologically under six years old;(2) The child is suicidal;(3) The operation is located near a high traffic area;(4) Adverse weather conditions pose a clear safety risk to the child; or(5) Other clear safety risks are present. Source Note: The provisions of this §749.2055 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2055 What actions must a caregiver take before using a permitted type of emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189729 03/12/2026 Generally, a short personal restraint is used in urgent situations, such as:(1) To protect the child from external danger that causes imminent significant risk to the child, such as preventing the child from running into the street or coming into contact with a hot stove. The restraint must end immediately after the danger is averted;(2) To intervene when a child under the age of five (chronological or developmental age) demonstrates disruptive behavior, if other efforts to de-escalate the child's behavior have failed;(3) When a child over five years old demonstrates behavior disruptive to the environment or milieu, such as disrobing in public, provoking others that creates a safety risk, or to intervene to prevent a child from physically fighting; or(4) When a child is significantly damaging property, such as breaking car windows or putting holes into walls. Source Note: The provisions of this §749.2059 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2059 What is the appropriate use for a short personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189730 03/12/2026 (a) When a caregiver implements a short personal restraint, the caregiver must:(1) Minimize the risk of physical discomfort, harm, or pain to the child; and(2) Use the minimal amount of reasonable and necessary physical force.(b) A caregiver may not use any of the following techniques as a short personal restraint:(1) A prone or supine restraint;(2) Restraints that impair the child's breathing by putting pressure on the child's torso, including leaning a child forward during a seated restraint;(3) Restraints that obstruct the airways of the child or impair the breathing of the child, including procedures that place anything in, on, or over the child's mouth, nose, or neck, or impede the child's lungs from expanding;(4) Restraints that obstruct the caregiver's view of the child's face;(5) Restraints that interfere with the child's ability to communicate or vocalize distress; or(6) Restraints that twist or place the child's limb(s) behind the child's back. Source Note: The provisions of this §749.2061 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2061 What precautions must a caregiver take when implementing a short personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189731 03/12/2026 Emergency behavior intervention may never be used as:(1) Punishment;(2) Retribution or retaliation;(3) A means to get a child to comply;(4) A convenience for caregivers or other persons; or(5) A substitute for effective treatment or habilitation. Source Note: The provisions of this §749.2063 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2063 Are there any purposes for which emergency behavior intervention cannot be used? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189732 03/12/2026 According to the following chart, written orders by certain professionals are required to administer certain emergency behavior intervention: Attached Graphic Source Note: The provisions of this §749.2101 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2101 Are written orders required to administer emergency behavior intervention, and if so, who can write them? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189733 03/12/2026 Yes, any type of written order that is required must be in the child's record before a caregiver can use emergency behavior intervention on that child. Source Note: The provisions of this §749.2103 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2103 Must the written order be in a child's record before a caregiver can use an emergency behavior intervention on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189734 03/12/2026 (a) All written orders must include the following:(1) A statement that the particular type of emergency behavior intervention may only be used in an emergency situation;(2) Designation of the specific intervention and procedure or technique that is authorized;(3) Any specific measures for ensuring the child's health, safety, and well being, and the privacy of the setting that safeguards the child's personal dignity;(4) A complete description of the behaviors and circumstances under which the intervention may be used;(5) Instructions for observation or heightened observation of the child during the intervention;(6) The behaviors that indicate the child is ready to be released from the intervention;(7) The maximum length of time the child may be restrained regardless of behaviors exhibited;(8) The prescribing professional's consideration of any potential medical and/or psychiatric contraindications for the specific child, such as a history of physical or sexual abuse or victimization involving the type of intervention; and(9) Clinical justification for the intervention.(b) For emergency medication, the written order must also include instructions on how to administer the medication. Source Note: The provisions of this §749.2105 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2105 What information must a written order include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208661 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208661&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208661 03/12/2026 (a) PRN orders for certain emergency behavior interventions are permitted under the following conditions:Attached Graphic(b) If you obtain a PRN order, you must provide the parent with a copy of the PRN order within 72 hours. Source Note: The provisions of this §749.2107 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2107 Under what conditions are PRN orders permitted for a specific child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189736 03/12/2026 (a) The use of emergency behavior intervention must be an appropriate response to the behavior demonstrated, and de-escalation must have failed.(b) The caregiver must act to protect the child's safety and consider the:(1) Characteristics of the immediate physical environment;(2) Permitted types of emergency behavior intervention; and(3) Potential risk of harm in using emergency behavior intervention versus the risk of not using emergency behavior intervention.(c) The caregiver must:(1) Initiate an emergency behavior intervention in a way that minimizes the risk of physical discomfort, harm, or pain to the child; and(2) Use the minimal amount of reasonable and necessary physical force to implement the intervention.(d) The caregiver must make every effort to protect the child's:(1) Privacy, including shielding the child from onlookers; and(2) Personal dignity and well-being, including ensuring that the child's body is appropriately covered.(e) As soon as possible after starting any type of emergency behavior intervention, the caregiver must:(1) Explain to the child the behaviors the child must exhibit to be released or have the intervention reduced, if applicable; and(2) Permit the child to suggest actions the caregivers can take to help the child de-escalate.(f) If the child does not appear to understand what the child must do to be released from the emergency behavior intervention, the caregiver must attempt to re-explain it every 15 minutes until the child understands or is released from the intervention. Source Note: The provisions of this §749.2151 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2151 What responsibilities does a caregiver have when implementing a type of emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208662 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208662&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208662 03/12/2026 A child must be released as follows:Attached Graphic Source Note: The provisions of this §749.2153 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2153 When must a caregiver release a child from an emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189738 03/12/2026 During any personal restraint, a caregiver qualified in emergency behavior intervention must:(1) Monitor the:(A) Personal restraint to make sure it is being performed appropriately; and(B) Child's breathing and other signs of physical distress; and(2) Take appropriate action to ensure adequate respiration, circulation, and overall well-being. Source Note: The provisions of this §749.2201 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2201 Who must monitor a personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189739 03/12/2026 Appropriate action includes responding prudently to a potentially life-threatening situation, for example, releasing a child when a child is unresponsive or indicates the child cannot breathe and immediately seeking medical assistance from a health-care professional. The caregiver must take into account that a child may thrash about more violently as the child struggles to breathe. Source Note: The provisions of this §749.2203 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2203 What is the appropriate action for a caregiver to take to ensure the child's adequate respiration, circulation, and overall well-being? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189740 03/12/2026 (a) The following personal restraint techniques are prohibited:(1) Restraints that impair the child's breathing by putting pressure on the child's torso, including restraints that obstruct the child's lungs from expanding such as leaning a child forward during a seated restraint;(2) Restraints that obstruct the child's airway, including procedures that place anything in, on, or over the child's mouth, nose, or neck;(3) Restraints that obstruct a caregiver's ability to view the child's face;(4) Restraints that interfere with the child's ability to communicate or vocalize distress; or(5) Restraints that twist or place the child's limb(s) behind the child's back.(b) Prone and supine restraints are also prohibited as a short personal restraint.(c) Prone and supine restraints are also prohibited as a personal restraint except:(1) As a transitional hold that lasts no longer than one minute;(2) As a last resort when other less restrictive interventions have proven to be ineffective; and(3) When an observer meeting the following qualifications ensures the child's breathing is not impaired:(A) Trained to identify risks associated with positional, compression, or restraint asphyxia; and(B) Trained to identify risks associated with prone and supine holds. Source Note: The provisions of this §749.2205 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2205 What personal restraint techniques are prohibited? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189741 03/12/2026 (a) A caregiver may successively use emergency behavior interventions on a child only if:(1) Allowed by your policies;(2) Permitted by rules of this subchapter for both types of emergency behavior intervention; and(3) Written orders specifically allow the combination.(b) The written orders must include clinical justification for the successive use of emergency behavior interventions that goes beyond the justification for the use of a single intervention. The licensed physician ordering the emergency medication must provide clinical justification for the combination of emergency medication and personal restraint.(c) A caregiver must allow the child:(1) Bathroom privileges as needed and at least once every two hours;(2) An opportunity to drink water at least once every two hours;(3) Regularly prescribed medications unless otherwise ordered by the licensed physician;(4) Regularly scheduled meals and snacks served in a safe and appropriate manner; and(5) An environment that is adequately ventilated during warm weather, adequately heated during cold weather, appropriately lighted, and free of safety hazards. Source Note: The provisions of this §749.2231 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2231 May a caregiver successively use emergency behavior interventions on a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189742 03/12/2026 (a) A caregiver may simultaneously use emergency medication in combination with personal restraint only if:(1) Allowed by your policies;(2) Permitted by the rules of this subchapter for both types of emergency behavior intervention; and(3) Written orders specifically allow the combination.(b) The written orders must include clinical justification for the combination of emergency medication with personal restraint that goes beyond the justification for the use of a single emergency behavior intervention. If they are different people, both the licensed physician ordering the emergency medication and the professional ordering the personal restraint must provide the clinical justification for the combination. Source Note: The provisions of this §749.2233 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2233 May a caregiver simultaneously use emergency medication in combination with personal restraint? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208663 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208663&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208663 03/12/2026 The maximum length of time that certain emergency behavior interventions can be administered to a child is as follows:Attached Graphic Source Note: The provisions of this §749.2281 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective February 7, 2017, 42 TexReg 491; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2281 What is the maximum length of time that an emergency behavior intervention can be administered to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189744 03/12/2026 A caregiver may exceed the maximum length of time for certain emergency behavior interventions as follows:Attached Graphic Source Note: The provisions of this §749.2283 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective February 7, 2017, 42 TexReg 491; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2283 Can a caregiver exceed the maximum length of time that an emergency behavior intervention can be administered to a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189745 03/12/2026 (a) The caregivers must take appropriate actions to help the child return to routine activities. The follow-up actions of the caregivers must include:(1) Providing the child with an appropriate transition and offering the child an opportunity to return to regular activities;(2) Observing the child for at least 15 minutes; and(3) Providing the child with an opportunity to discuss the situation that led to the need for emergency behavior intervention and the caregiver's reaction to that situation. The discussion must be held in private as soon as possible and no later than 48 hours after the child's use of an emergency medication or release from any emergency behavior intervention.(b) Caregivers involved in the emergency behavior intervention must conduct a post-emergency behavior intervention discussion. The goal of the discussion is to allow the child and caregiver to discuss:(1) The child's behavior and the circumstances that constituted the need for an emergency behavior intervention;(2) The strategies attempted before the use of the emergency behavior intervention and the child's reaction to those strategies;(3) The emergency behavior intervention itself and the child's reaction to the emergency behavior intervention;(4) How caregivers can assist the child in regaining self-control in the future to avoid the administration of an emergency behavior intervention; and(5) What the child can do to regain self-control in the future to avoid the administration of an emergency behavior intervention.(c) Caregivers involved in the emergency behavior intervention must:(1) Debrief with child placement staff concerning the incident as soon as possible after the situation has stabilized; and(2) Make reasonable efforts to debrief with children in care who witness the incident.(d) The child placement staff must review the use of the emergency behavior intervention within 72 hours of the intervention.(e) The caregivers do not have to return the child to previous activities or place the child in current activities that the group is participating in if the caregivers deem the child's participation is not in the best interests of the child or the other children in the group. However, caregivers must engage the child in an alternative routine activity.(f) This rule does not apply to short personal restraint. Source Note: The provisions of this §749.2301 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2301 What follow-up actions must caregivers take after the child's behavior no longer constitutes an emergency situation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189746 03/12/2026 The caregiver must document the following after discussing with the child the use of the emergency behavior intervention:(1) The date and time the caregiver offered the discussion;(2) The child's reaction to the opportunity for discussion;(3) The date and time the discussion took place, if applicable; and(4) The content of the discussion, if applicable. Source Note: The provisions of this §749.2303 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2303 What must the caregiver document after discussing with the child the use of the emergency behavior intervention? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189747 03/12/2026 (a) As soon as possible, but no later than 24 hours after the initiation of the intervention, the caregiver must document in the child's record the following information:(1) The child's name;(2) A description and assessment of the circumstances and specific behaviors that caused the basis for the emergency behavior intervention;(3) The de-escalation attempted before and during the use of the emergency behavior intervention and the child's reaction to those strategies;(4) The specific emergency behavior intervention administered;(5) The date and time the intervention was administered;(6) The length of time the child was restrained;(7) The name of the caregiver(s) that participated in the incident that led to the intervention, and who administered the intervention;(8) The name of the person(s) who observed the child;(9) The names of any witnesses to the emergency behavior intervention, including child witnesses in the home;(10) All attempts to explain to the child what behaviors were necessary for release from the intervention;(11) The child's condition following the use of the medication or release from the intervention, including any injury the child sustained as a result of the intervention or any adverse effects caused by the use of the intervention. If the child received medical assistance or treatment, the caregiver must document the name of the person(s) who provided medical assistance or treatment; and(12) The actions the caregiver(s) took to facilitate the child's return to normal activities following the end of the intervention.(b) The child placement staff must document their review of the use of the emergency behavior intervention within 72 hours of the incident.(c) If personal restraint is used, documentation must also include the specific restraint techniques used, including a prone or supine restraint used as a transitional hold.(d) If emergency medication is used, documentation must also include the specific medication used and the dosage administered to the child.(e) This rule does not apply to short personal restraints. Source Note: The provisions of this §749.2305 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2305 When must a caregiver document the use of an emergency behavior intervention, and what must the documentation include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208664 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208664&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208664 03/12/2026 (a) As soon as possible, but no later than 72 hours after the initiation of the intervention, you must provide written notice to the parent that includes:(1) The child's name;(2) The specific emergency behavior intervention administered;(3) The length of time the child was restrained;(4) The child's condition following the use of the medication or release from the intervention, including:(A) Any injury the child sustained as a result of the intervention or any adverse effects caused by the intervention; and(B) If the child received medical assistance or treatment, the name of each person who provided the medical assistance or treatment;(5) If a personal restraint was used, the specific restraint techniques used, including if a prone or supine restraint used as a transitional hold; and(6) If emergency medication was used, the specific medication used, and the dosage administered to the child.(b) A copy of the documentation provided to the parent must be maintained in the child's record.(c) This rule does not apply to short personal restraints. Source Note: The provisions of this §749.2307 adopted to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2307 What notice must I provide to the parent when I use an emergency behavior intervention with a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189748 03/12/2026 (a) The following circumstances trigger a review for certain emergency behavior interventions:Attached Graphic(b) You may exceed the number of restraints otherwise allowed in (2) Personal restraint of Figure: 40 TAC §749.2331(a) for a child if a licensed psychiatrist or psychologist issues a written order or if a service planning team makes a recommendation allowing you to do so and you ensure the following:(1) If applicable, the recommendation from the service planning team includes the same written information as an order, as specified in §749.2105 of this title (relating to What information must a written order include?); and(2) At least one triggered review is conducted in accordance with §749.2337 of this title (relating to What must the triggered review include and what must be documented in the child's record?) every 30 days that personal restraints in excess of the threshold are authorized. Source Note: The provisions of this §749.2331 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective February 7, 2017, 42 TexReg 491; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2331 What circumstances trigger a review of the use of emergency behavior intervention for a specific child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189749 03/12/2026 (a) A triggered review must occur as soon as possible, but no later than 30 days after the review is triggered.(b) The regularly scheduled review of the child's service plan can serve as the triggered review if it meets the requirements in §749.2337 of this title (relating to What must the triggered review include and what must be documented in the child's record?) and takes place no later than 30 days after the review is triggered. Source Note: The provisions of this §749.2333 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2333 When must a triggered review occur? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189750 03/12/2026 (a) The service planning team must participate in the triggered review.(b) You must invite the child, as appropriate, and the parents to the review, so they may have the opportunity to participate and provide input into the content of the review. However, you are not required to delay a review because a parent or child is unable to participate in the review at its scheduled time. Source Note: The provisions of this §749.2335 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective February 7, 2017, 42 TexReg 491; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2335 Who must participate in the triggered review? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189751 03/12/2026 (a) Except in cases in which the regularly scheduled review of the child's service plan also addresses the requirements of a triggered review in accordance with §749.2333(b) of this title (relating to When must a triggered review occur?), a triggered review is not a full review of the child's service plan and is focused on the requirements identified in subsection (c) of this section.(b) Other than the requirements in this section and in §749.2335 of this title (relating to Who must participate in the triggered review?), the notification, participation, implementation, and documentation requirements in Division 4 of Subchapter I (relating to Admission, Service Planning, And Discharge) do not apply to a triggered review.(c) The following must be included in a triggered review and documented in the child's record:(1) A review of the records and orders of the emergency behavior interventions;(2) A review and documentation of any potential medical or psychiatric reason for not using emergency behavior interventions on the child, including the prescribing professional's consideration of any potential medical and/or psychiatric contraindications for the specific child, such as a history of physical or sexual abuse or victimization involving the type of intervention;(3) An examination of identified behaviors and patterns, any significant events leading up to the use of emergency behavior intervention, and all attempted de-escalation methods, whether successful or unsuccessful;(4) Identification of alternatives to manage the child's behavior and more effectively prevent the use of emergency behavior intervention in the future; and(5) A written plan for reducing the need for emergency behavior intervention. Source Note: The provisions of this §749.2337 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective February 7, 2017, 42 TexReg 491; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2337 What must the triggered review include and what must be documented in the child's record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189752 03/12/2026 If there are four triggered reviews within a 90-day period:(1) A licensed psychiatrist, psychologist, clinical social worker, professional counselor, or marriage and family therapist must examine the child; and(2) The licensed professional must make service plan recommendations regarding the use of emergency behavior interventions. You must document these recommendations in the child's record. Source Note: The provisions of this §749.2339 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2339 What if there are four triggered reviews within a 90-day period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189753 03/12/2026 (a) The overall agency evaluation is an annual review regarding:(1) The use and effectiveness of emergency behavior interventions at your agency; and(2) Your emergency behavior intervention policies and procedures, including the training policy and curriculum.(b) The objectives of the evaluation are to:(1) Develop and maintain an environment that supports positive and constructive behaviors of children in care;(2) Use any type of emergency behavior intervention safely, appropriately, and effectively; and(3) Eliminate or reduce physical injuries and any other negative side effects on the child's behavior or emotional development resulting from the emergency behavior interventions.(c) One focus of the evaluation must be on:(1) The frequency, patterns, and effectiveness of the types of emergency behavior intervention techniques that are used for all children in your foster homes;(2) Strategies to reduce the need for emergency behavior interventions for all children in your foster homes; and(3) Specific strategies to reduce the need for use of specific types of emergency behavior intervention techniques for all children in your foster homes.(d) The results of each overall agency evaluation must be made available to us for review. Source Note: The provisions of this §749.2381 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2381 What is an overall agency evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208665 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208665&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208665 03/12/2026 (a) Quarterly, you must collect, document, and review aggregate numbers of emergency behavior interventions by type of intervention except for short personal restraints.(b) This information must be reported to us no later than 15 days after the end of each quarter.(c) You must maintain the data for five years. Source Note: The provisions of this §749.2383 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES L FOSTER CARE SERVICES: EMERGENCY BEHAVIOR INTERVENTION §749.2383 What data must be collected? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205268 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205268&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205268 03/12/2026 (a) You may verify only one spouse if:(1) The spouse whom you verify will be the only one involved in the care of any foster child in the home;(2) The spouses have been living apart for at least two years; and(3) After interviewing the spouse living outside of the foster home as part of the screening process, you determine that the spouse will not:(A) Have unsupervised access to foster children, as "unsupervised access" is defined in §745.601 of this title (relating to What words must I know to understand this subchapter); or(B) Regularly or frequently be present at the foster home, as defined in §745.601 of this title.(b) If the requirements in subsection (a) of this section are not met, you must verify both spouses to provide foster care.(c) If at any time the requirements in subsection (a) of this section are no longer being met, the change in circumstances:(1) Is considered a "major life change in the foster family";(2) Requires an update to the foster home screening, as required by §749.2453 of this chapter (relating to When must I update the foster home screening?); and(3) Requires closure of the foster home or adding the spouse to the verification certificate. Source Note: The provisions of this §749.2401 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2401 In what circumstances may I verify an individual spouse as a foster parent? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189807 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189807&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189807 03/12/2026 Each caregiver in a home that you verify must be at least 21 years old. Source Note: The provisions of this §749.2403 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2403 What minimum age requirement must foster parents and caregivers meet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189808 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189808&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189808 03/12/2026 Yes, you will have to re-verify that home in both spouse's names. Source Note: The provisions of this §749.2405 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2405 Will my home have to be re-verified if I am a single foster parent and I get married after my home is verified? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189809 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189809&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189809 03/12/2026 (a) A home may not be verified to provide foster care services by more than one child-placing agency at one time.(b) A home may be simultaneously verified by one child-placing agency for foster care services only and approved by another child-placing agency(ies) for adoption only. Source Note: The provisions of this §749.2407 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2407 May a home be verified or approved by more than one child-placing agency simultaneously? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189810 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189810&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189810 03/12/2026 (a) You must complete a foster home screening prior to verifying the foster home.(b) Your child placement management staff must review and approve each foster home screening.(c) The foster home screening must document:(1) Required information (see §749.2447 of this title (relating to What information must I obtain for the foster home screening?));(2) An assessment of the information obtained to determine whether the applicant meets the requirements for verification; and(3) An evaluation of the information obtained in order to make recommendations about the applicant's capacity to work with children, including but not limited to age, gender, special needs, and number of children.(d) Regarding §749.2447(7) of this title, you must report to Licensing only the information obtained about the prospective foster family's domestic violence history, as applicable. You must report this information regardless of whether you verify the home. Source Note: The provisions of this §749.2445 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2445 What is a foster home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205269 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205269&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205269 03/12/2026 You must obtain, document, and assess the following information about a prospective foster home:Attached Graphic Source Note: The provisions of this §749.2447 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective September 1, 2014, 39 TexReg 6229; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2447 What information must I obtain for the foster home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205270 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205270&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205270 03/12/2026 (a) Interviews for a foster home screening must be documented and must include at least:(1) One individual interview with each prospective foster parent;(2) One individual interview with each child three years old or older living in the home either full- or part-time;(3) One individual interview with each other person living in the home either full- or part-time;(4) One joint interview with the prospective foster parents;(5) One family group interview with all family members living in the home;(6) One interview, by telephone, in person, or by letter, with each minor child 12 years old or older or adult child of the prospective foster parents not living in the home;(7) A minimum of one interview, by telephone, in person, or by letter with a family member not living in the home and not already interviewed; and(8) A minimum of two interviews, by telephone, in person, or by letter with neighbors, school personnel if the prospective foster parents have school age children, clergy, or any other member of the prospective foster parents' community who are unrelated to the foster parents and can provide a description of the prospective foster parents' suitability to provide care for children.(b) You must visit the home at least once when all members of the household are present.(c) For subsection (a)(6) of this section, if you are unsuccessful in contacting an adult child, you may omit the interview with the adult child if you document your diligent efforts to locate the adult child in the home screening. Diligent efforts require at least three attempts to locate the adult child, multiple methods of contact (i.e. in person or virtual, by telephone, or by letter), as applicable, and discussions with the prospective foster parents and any other relevant persons about the location of the adult child. Source Note: The provisions of this §749.2449 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2014, 39 TexReg 6229; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2449 Whom must I interview when conducting a foster home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189814 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189814&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189814 03/12/2026 (a) You must document all interviews of persons you are required to interview for a foster home screening.(b) The documentation must include the date and method used to contact each required person, the date of each interview, who was present at each interview, their relationship to the prospective foster parents, and a summary of each interview.(c) This documentation must be a part of the foster home record. Source Note: The provisions of this §749.2451 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2451 What must I document regarding interviews I conduct for a foster home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189815 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189815&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189815 03/12/2026 (a) You must update a foster home screening, as follows:(1) Under the circumstances described in §749.307(a) of this title (relating to What happens to the foster homes supervised by a branch office when the branch office closes?);(2) When there is a major life change in the foster family as described in §749.2805 of this title (relating to What is a "major life change in the foster family"?); and(3) When there is a change that affects a foster home's verification as described in §749.2803 of this title (relating to What changes affect a foster home's verification?).(b) A foster home screening update may be made by using an addendum.(c) You must complete a foster home screening update that is needed under the circumstances described in §749.307(a) of this title before issuing a new verification certificate.(d) You must do the following when updating a foster home screening because of a major life change in the foster family:(1) Assess the appropriateness of any current placement of children in the foster home, immediately upon notification; and(2) Complete the update within 30 days of the notification of the major life change. Source Note: The provisions of this §749.2453 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective September 1, 2014, 39 TexReg 6229; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2453 When must I update the foster home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205272 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205272&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205272 03/12/2026 (a) You must take the following steps to verify a foster family home:(1) Complete and document the requirements for §749.2447 of this subchapter (relating to What information must I obtain for the foster home screening?);(2) Complete and document the required interviews as specified in §749.2449 of this subchapter (relating to Whom must I interview when conducting a foster home screening?);(3) Obtain the following:(A) A floor plan of the home that shows the dimensions and purposes of all rooms in the home and identifies the indoor areas for children's use; and(B) A sketch or photo of the outside areas that shows the buildings, driveways, fences, storage areas, gardens, recreation areas, and pools, ponds, or other bodies of water;(4) Inspect the home to ensure and document that the home meets the appropriate rules of this chapter, including:(A) Subchapter K of this chapter (relating to Foster Care Services: Daily Care, Problem Management); and(B) Subchapter O of this chapter (relating to Foster Homes: Health and Safety Requirements, Environment, Space and Equipment), including a:(i) Health inspection; and(ii) Fire inspection;(5) If the home will provide a transitional living program, ensure the home complies with the policies developed according to §749.125 of this chapter (relating to What policies must I develop for foster parents who offer a transitional living program?);(6) Evaluate all areas required in this subchapter and make recommendations about the home's ability to care for and work with children with respect to a child's gender and age, the number of children, and the types of services to be provided;(7) If there are any indicators of potential risk to children based on the assessment and evaluation of an area required in this subchapter, document the indicators and how you addressed them with the prospective foster family before approval and verification of the home;(8) Obtain from the child placement management staff the review and approval of the home screening, and the recommended verification of the home; and(9) Issue a verification certificate that specifies the:(A) Name of the foster family home;(B) Foster family home address and location;(C) Foster family home's total capacity, which includes the biological and adopted children of the caregivers who live in the foster family home, any children receiving foster care or respite child-care, and any children for whom the family provides day care;(D) Foster family home's foster care capacity, a subset of the total capacity, which includes only children placed for foster care or respite child-care;(E) Gender and ages of children for which the home is verified to provide foster care or respite child-care;(F) Types of services the foster family home will provide;(G) Agency's main office or branch office, which issued the verification; and(H) Expiration date of a time-limited verification, if applicable.(b) You can verify a foster home before the foster parents complete the pre-service training. However, foster parents must comply with the training requirements described in §749.863 of this subchapter (relating to What are the pre-service training requirements for a caregiver?) before you may place a child in the home. Source Note: The provisions of this §749.2470 adopted to be effective October 19, 2018, 43 TexReg 6658; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2470 What must I do to verify a foster family home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205273 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205273&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205273 03/12/2026 (a) When a home has previously been verified by another agency, you must conduct and complete an entirely new home screening and comply with all of the requirements in §749.2471 of this title (relating to What must I do to verify a foster home?).(b) If the foster home is transferring from another child-placing agency, you must submit a written request to the agency that the foster home is transferring from requesting the background information required in §749.2447(23) of this title (relating to What information must I obtain for the foster home screening?).(c) If the foster home is transferring from another child-placing agency, with a child in care, you may verify the foster home prior to completion of the background check.(d) For a provisional verification, see Division 4 of this subchapter (relating to Temporary, Time-Limited, and Provisional Verifications). Source Note: The provisions of this §749.2473 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective March 1, 2014, 39 TexReg 1195; amended to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2473 What must I do to verify a foster home that another child-placing agency has previously verified? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189818 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189818&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189818 03/12/2026 (a) If background information is requested by a child-placing agency conducting a foster home screening, pre-adoptive home screening, or post placement adoptive report, then you must release background information regarding the current or previous foster home.(b) Background information must also be released to independent contractors who are hired or required by the court to conduct a social study under Chapter 107 of the Texas Family Code.(c) For the purposes of this section, background information includes:(1) A foster home screening, pre-adoptive home screening, and post placement adoptive report and related documentation;(2) Documentation of supervisory visits and evaluations for the past year;(3) Any record of deficiencies and their resolutions for the past year, including information regarding pending investigations and unresolved deficiencies;(4) The most current fire and health inspections;(5) The transfer/closing summary for the foster home, as required by §749.2497 of this title (relating to Are transfer/closing summaries required for foster homes?);(6) Copies of any current or previous plan to achieve compliance or other type of development plan for the past two years, if applicable; and(7) Copies of any current or previous correction action or adverse action plans for the past two years, if applicable.(d) You must release the background information to the requesting agency by the 10th day after receiving the written request, including informing the requesting agency of any pending investigations and/or unresolved deficiencies. By the 10th day after the completion of any pending investigations and/or the resolution of any deficiencies, you must release to the requesting agency the:(1) Outcome of any investigations and any resulting deficiencies cited; and(2) Resolution of any deficiencies. Source Note: The provisions of this §749.2475 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2475 To whom must I release information regarding a family on which I previously conducted a foster home screening, pre-adoptive home screening, or post placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189819 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189819&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189819 03/12/2026 No. Before you can verify a foster home, child placement management staff must:(1) Review and approve the verification, including the documented foster home screening, home study, and other requirements; and(2) Sign and date the document. Source Note: The provisions of this §749.2477 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2477 May I verify a foster home prior to approval by child placement management staff? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189820 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189820&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189820 03/12/2026 No, you cannot place children in a foster home before completing the foster home screening and verification. Source Note: The provisions of this §749.2479 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2479 May I place children in a foster home before verifying the home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189821 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189821&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189821 03/12/2026 (a) You must give the home a verification certificate after:(1) Verifying the home; and(2) Making any change that affects the verification certificate.(b) The home must post the current verification certificate or have it immediately available upon request. Source Note: The provisions of this §749.2481 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2481 What type of certificate must a foster home have in order to prove verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189822 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189822&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189822 03/12/2026 No, they do not have to own or rent the home they live in for it to be considered their primary residence. Source Note: The provisions of this §749.2483 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2483 Do foster parent applicants have to own the home they live in for it to be their primary residence? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208666 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208666&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208666 03/12/2026 (a) You must verify the home in the name of one foster family for whom the home is the primary residence. You may only verify the home in the name of one foster family.(b) A home is considered a primary residence if the person lives there on a routine basis and:(1) It is the place of residence on their most recent tax return; or(2) It is the address listed on their motor vehicle registration, driver's license, voter's registration, or other document filed with a public agency. Source Note: The provisions of this §749.2485 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2485 What are the requirements for verifying a foster home at a residence that I own? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189824 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189824&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189824 03/12/2026 (a) You must sign a written agreement with each agency foster home at the time that you verify the home. You and the foster home must each have copies of the signed agreement. You must file a copy of the signed agreement in the agency home record.(b) The agreement must specify the following:(1) The foster parents' responsibility for complying with rules of this chapter;(2) The financial agreement between you and the foster home;(3) The foster home agrees not to admit a non-relative child for 24-hour care from any source other than you;(4) You have the right to remove the child from the home at your discretion;(5) You must consent to any discharge of a child from the home;(6) Visits by the child's parents or relatives must be arranged through you;(7) You are responsible for regular supervision of the foster home;(8) The foster parents' commitment to comply with your policies regarding child care, discipline, supervision of children, and children's visits or trips away from the foster home; and(9) The foster parents' commitment to comply with your policies about foster parents' reports to you regarding foster children and events or occurrences impacting the provision of foster care. Source Note: The provisions of this §749.2487 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2487 What are the requirements for an agreement that I have with a foster home that I verify? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189825 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189825&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189825 03/12/2026 (a) You must provide foster parents with a written copy of the following statement that lists the rights and responsibilities of foster parents and the child-placing agency:(1) Foster parents have the right to be treated with dignity, respect, and consideration as a member of the service planning team;(2) Foster parents have the right and responsibility to participate in service planning and implementation of the service plan;(3) Foster parents have the right and responsibility to obtain training that will assist them in meeting the needs of children placed in their home;(4) The child-placing agency has a responsibility to assist foster parents in identifying training that will enhance the foster parents ability to meet the needs of children placed in their home;(5) Foster parents and the child-placing agency have the responsibility to communicate with each other in a timely and effective manner;(6) Foster parents have the right to be reimbursed for care of the children placed in their home in a timely manner and according to the child-placing agency's policy;(7) The child-placing agency has the responsibility to provide relevant information about a child to foster parents when placing or considering placing the child;(8) Foster parents have the right and responsibility to obtain information and ask questions about children the child-placing agency would like to place in their home, including requesting a pre-placement visit;(9) Foster parents have the right to know how much discretion they have in declining specific placements without fear of negative repercussions;(10) The child-placing agency has the responsibility to provide support to all of their foster parents and inform them of any services available to foster parents;(11) Foster parents have the responsibility to report to the child-placing agency and Licensing information as required by the child-placing agency's policies and this chapter;(12) Foster parents have the right to appeal child-placing agency actions and decisions that affect them and to know the procedures for making an appeal;(13) Foster parents have the responsibility to comply with this chapter as applicable;(14) The child-placing agency has the responsibility to provide foster parents with support, training, and oversight in order to ensure the foster parents are in compliance, as applicable, with this chapter; and(15) Foster parents have the right to review their foster home record maintained by the child-placing agency.(b) You and the foster parents must sign a copy of the statement at the time you verify the home.(c) The foster home must have a copy of the signed statement.(d) You must file a copy of the signed statement in the foster home record maintained by the child-placing agency.(e) At the time you verify the home, you must also provide foster parents with a written copy of your policies relating to §749.121 of this title (relating to What policies must I develop concerning the rights and responsibilities of the child-placing agency and the foster parents?). Source Note: The provisions of this §749.2488 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2488 What statement must I provide to foster parents regarding foster parent and child-placing agency rights and responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205274 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205274&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205274 03/12/2026 You must submit information to us within two working days of:(1) Verifying a new foster home;(2) Temporarily verifying a foster home and when the verification is no longer temporary;(3) Putting a foster home on inactive status or taking a foster home off of inactive status;(4) Changing conditions of the verification for an existing home;(5) Extending a time-limited verification;(6) Changing a time-limited verification to a non-expiring verification;(7) Provisionally verifying a foster home and when the verification is no longer provisional; or(8) Closing a foster home, including:(A) The reason the foster home closed; and(B) The name and contact information of a person at your agency who may be contacted by another child-placing agency to obtain records relating to the closed foster home. Source Note: The provisions of this §749.2489 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2489 What information must I submit to Licensing about a foster home's verification status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189829 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189829&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189829 03/12/2026 (a) You may verify a foster home to provide different services as long as a child placement staff completes an assessment of the home that includes a review of the following:(1) The number, ages, and needs of children to be placed in the home;(2) The foster home's capacity to provide each different service and supervise all children appropriately;(3) The needs of any children currently in the home; and(4) The foster parents' experience and ability to provide each service.(b) The child placement staff must sign, date, and document this assessment in the foster home record. The different services permitted must be listed on the verification certificate.(c) Child placement management staff must review and approve the documentation prior to the placement of a child. You must document the review and approval in the record.(d) For each placement of a child into a home verified to provide multiple types of services, a child placement staff must ensure there will be no conflict of care. Examples of conflicts in care are placements that:(1) Place one child at serious risk for harm by another child;(2) Significantly compromise the care and supervision of any child in care;(3) Require a level of expertise by the foster parents and/or caregivers that they do not possess; or(4) Create an environment that is appropriately restrictive for one child but inappropriate for another.(e) A child needing treatment services may only be placed in a foster home that is verified to provide the treatment services needed by that child. If the treatment service needs of any of the children in a foster home changes and the home is not verified to provide that particular treatment service, the foster parent must notify the child placement staff and a new assessment of the home must be completed, signed, and dated by the child placement management staff. If the foster home is not approved to provide the services after the assessment, then the child must be moved to a placement that can provide the needed services. Source Note: The provisions of this §749.2491 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2491 May I verify a foster home to provide different services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208667 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208667&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208667 03/12/2026 A foster family home may provide day care in addition to foster care under the following conditions:(1) The number and ages of children in both types of care must meet all relevant laws and rules, including the requirements listed in §745.375 of this title (relating to May I offer child day care at my agency foster home or independent foster home?);(2) The caregivers can supervise all children appropriately, meet all children's needs, and protect all children in both foster and day care;(3) There is adequate space and there are adequate staff or caregivers to meet all applicable rules;(4) The child-placing agency completes a written assessment, signed by child placement management staff, of the:(A) Needs of the children in foster care and how the needs of the children in day care may impact the foster children; and(B) Basis for determining no conflict of care exists in providing the two types of care; and(5) Both the Residential Child-Care and Child Day-Care Divisions of Licensing approve. Source Note: The provisions of this §749.2493 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2493 May a foster home provide day care in addition to foster care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205275 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205275&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205275 03/12/2026 Only temporary, time-limited, and provisional verifications have expiration dates. All other verifications are non-expiring. Source Note: The provisions of this §749.2495 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2495 Do foster home verifications expire? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205271 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205271&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205271 03/12/2026 (a) You must have either a transfer summary or closing summary when a foster home transfers to another child-placing agency or closes. This includes when you do not issue a non-expiring verification to a foster home with a time-limited verification, temporary verification, or provisional verification.(b) A transfer summary must be completed by the 10th day after you receive a written request to transfer, and you must forward it immediately to the requesting child-placing agency.(c) A closing summary must be completed by the 20th day after the foster home is closed.(d) A transfer or closing summary must include:(1) A copy of the verification certificate;(2) The foster home addresses for the past two years and, as needed, directions for rural addresses;(3) The length of time the foster parents have been fostering with you;(4) For the children that were in care for the last two years, the:(A) Number of children fostered;(B) Type of treatment services provided to each child; and(C) Reason for each child's discharge from care;(5) A description of any limitations on verification that were in place for the foster home in caring for and working with children (such as gender, age, number of children, treatment services, special needs, or type of abuse or neglect experienced by the child), regardless of whether the limitation was requested by the foster parent or imposed by you;(6) For a closing summary, the reason the foster home is closing, including whether you required the foster home to close;(7) For a transfer summary, any pending investigations or unresolved deficiencies;(8) For a closing summary, any unresolved deficiencies that had not been corrected and what those deficiencies were;(9) Any indicators of risk to children at the time of the transfer or closing and what those indicators are;(10) Any plan to achieve compliance or other type of development plan that was in place within the previous 12 months of the date of the transfer or closing;(11) Any corrective action or adverse action plan that was in place at the time of the transfer or closing; and(12) A statement concerning whether you would recommend the foster home for verification in the future, including whether you would recommend any limitations or restrictions on the verification, and the basis of your recommendation or lack thereof. Source Note: The provisions of this §749.2497 adopted to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2497 What requirements are there for a transfer or closing summary? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205276 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205276&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205276 03/12/2026 The purpose of a temporary verification is to permit continued care of foster children in a verified foster home when a foster family moves from one residence to another and there is a short-term delay in ensuring the foster home will continue to meet all minimum standards in the new location. For example, fire and health inspections cannot be obtained prior to the move. Source Note: The provisions of this §749.2520 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2520 What is the purpose of a temporary verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189832 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189832&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189832 03/12/2026 (a) You may only issue a temporary verification after:(1) You inspect the new location;(2) You determine that the home meets the minimum standards, including all health and safety, environment, and space and equipment standards; and(3) The child placement management staff reviews and approves the temporary verification by signing and dating it.(b) You may not use a temporary verification to change the verification conditions (number of children, age, gender, or services provided) of an agency home other than residence address.(c) You may not issue a temporary verification if no children are in placement in the foster home. Source Note: The provisions of this §749.2521 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2521 What must I do prior to issuing a temporary verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189833 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189833&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189833 03/12/2026 (a) You may issue a temporary verification for up to six months.(b) A temporary verification is valid for no longer than six months from the date the verification is issued. You may not renew the temporary verification. Source Note: The provisions of this §749.2523 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2523 For what length of time can I issue a temporary verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189834 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189834&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189834 03/12/2026 Yes, children who were in the care of the foster family at the time of the move may continue to live in the foster home while the temporary verification is in effect. However, you may not make new placements of children into a home that is temporarily verified. Source Note: The provisions of this §749.2525 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2525 Can foster children remain in the foster home while a temporary verification is in effect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205277&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205277 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205277&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205277 03/12/2026 The purpose of a time-limited verification is to permit you to limit the length of time a home will be verified by assigning the verification a pre-determined end date, after which the home will no longer be verified to provide foster care. Foster homes with time-limited verifications must meet the same rules as foster homes with non-expiring verifications. Source Note: The provisions of this §749.2526 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2526 What is the purpose of a time-limited verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189835 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189835&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189835 03/12/2026 You must issue a time-limited verification according to the same rules and procedures as a non-expiring verification. Source Note: The provisions of this §749.2527 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2527 What must I do to issue a time-limited verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189836 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189836&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189836 03/12/2026 You may issue a time-limited verification for any length of time you determine to be appropriate. Source Note: The provisions of this §749.2529 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2529 For what length of time may I issue a time-limited verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189837 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189837&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189837 03/12/2026 Yes. To extend a time-limited verification or change the verification from time-limited to non-expiring, you must comply with the requirements in Subchapter N of this chapter (relating to Foster Homes: Management and Evaluation). Source Note: The provisions of this §749.2531 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2531 Can I extend a time-limited verification or change the verification from time-limited to non-expiring? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205278 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205278&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205278 03/12/2026 The purpose of a provisional verification is to permit continued care of foster children in a foster home that is transferring from one child-placing agency to another, whether in the current residence or a new residence. Source Note: The provisions of this §749.2533 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2533 What is the purpose of a provisional verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205279 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205279&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205279 03/12/2026 (a) You may only issue a provisional verification if the foster home will continue to care for foster children that the previous agency placed in the home.(b) You may only issue a provisional verification after:(1) You request and receive the background information from the foster home's former child-placing agency, which the agency is required to send according to §749.2475 of this subchapter (relating to To whom must I release information regarding a family on which I previously conducted a foster home screening, pre-adoptive home screening, or post placement adoptive report?);(2) Based on the background information you receive from the former child-placing agency, and any current screening and evaluation that your agency has conducted up to this point, you determine that the home does not present a potential risk to the health or safety of children;(3) If the foster home is moving to a new residence, you:(A) Inspect the new location; and(B) Determine that the home meets the minimum standards, including the standards in Subchapter O of this chapter (relating to Foster Homes: Health and Safety Requirements, Environment, Space and Equipment); and(4) The child placement management staff reviews and approves the provisional verification by signing and dating it.(c) A foster home with a provisional verification must meet the same rules as a foster home with a non-expiring verification, except for any screening requirements that have not been completed.(d) A provisional verification must include any condition (number of children, age, gender, services provided) or any other restriction that was in the previous child-placing agency's verification. Source Note: The provisions of this §749.2535 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2535 What must I do prior to issuing a provisional verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205280 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205280&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205280 03/12/2026 (a) A provisional verification is valid:(1) For six months from the date it is issued; or(2) Until the foster home is issued a non-expiring verification or closed.(b) You may not renew the provisional verification. Source Note: The provisions of this §749.2537 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2537 For what length of time can I issue a provisional verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205281 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=205281&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 205281 03/12/2026 Children who are in the care of a foster family that is transferring from one child-placing agency to another may continue to live in the foster home while the provisional verification is in effect. However, you may not make new placements of children into a home that is provisionally verified. Source Note: The provisions of this §749.2539 adopted to be effective June 27, 2021, 46 TexReg 3525. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2539 Can foster children remain in the foster home while a provisional verification is in effect? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189838 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189838&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189838 03/12/2026 "Children with primary medical needs requiring total care" means children receiving treatment services for primary medical needs who are completely or primarily dependent upon the foster parents for their activities of daily living, such as eating/feeding, bathing, grooming, dressing and ambulation. Source Note: The provisions of this §749.2550 adopted to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2550 What does "children with primary medical needs requiring total care" mean when used in this Division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210923 03/12/2026 (a) A one-parent foster family home with one additional full-time, live-in caregiver or a two-parent foster family home may care for up to six children, except as noted in the chart below: Attached Graphic(b) A one-parent foster family home with one additional full-time, live-in caregiver or a two-parent foster family home may care for seven or eight children if all of the following criteria are met: (1) Each foster or adoptive child that you place in the home that expands the home's capacity to more than six children is placed in the home for the purpose of allowing: (A) Siblings to remain together;(B) A child with an established meaningful relationship with the foster family (including a relative or close family friend) to remain with the family; (C) A parenting youth in care to remain with the child of the parenting youth; or(D) A family with special training or skills to provide care to a child who has a severe disability;(2) The foster family home cares for a maximum of two infants and two more children less than six years old, unless the placement is necessary to maintain a sibling group of children; (3) The foster family home cares for a maximum of three children with primary medical needs requiring total care, unless the placement is necessary to maintain a sibling group of children; (4) You complete a Foster Family Home Capacity Exception Form with the appropriate signatures and place the form in the foster family home record; and (5) After you complete the exception form, you lower the home's capacity each time a child listed on the form leaves the home until the home's capacity does not exceed six. This applies to both a foster child that leaves and a child who was placed in the home to be adopted leaves without the adoption being consummated. (c) A one-parent foster family home or two-parent foster family home with one foster parent absent for extended periods of time (such as military service or out-of-town job assignments) may care for up to six children, except as noted in the chart below: Attached Graphic(d) Notwithstanding subsections (a), (b), and (c) of this section, a child-placing agency may request an exception for a foster family home to care for seven or eight children by using the process for requesting a variance that is in 26 TAC Chapter 745, Subchapter J of this title (relating to Waivers and Variances for Minimum Standards) and meeting the requirements of that subchapter. When processing a request for a variance related to a foster home's capacity, we will consider any limitations in state or federal law.(e) The maximum number of children that a foster family home may care for includes any biological and adopted children of the caregivers who live in the foster home, any children receiving foster or respite child-care, and any children for whom the family provides day care. All adults in care must also be counted in the capacity of the home as required by §749.2651(b) of this chapter (relating to May a foster home accept adults into the home for care?). Source Note: The provisions of this §749.2551 adopted to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4464; amended to be effective November 23, 2022, 47 TexReg 7728. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2551 What is the maximum number of children a foster family home may care for? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189841 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189841&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189841 03/12/2026 Capacity of the home is based on the:(1) Number of caregivers, and the age of the children in the home and in placement;(2) Services being provided and the needs of the children in care;(3) Amount of space available for children; and(4) Bathroom accommodations in the home. Source Note: The provisions of this §749.2555 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2555 How do I determine capacity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189784 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189784&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189784 03/12/2026 (a) The number of children in a foster home, including the biological and adopted children of the caregivers who live in the foster home, any children receiving foster or respite child-care, and children for whom the family provides day care, must not exceed the total capacity stated on the home's verification.(b) Children visiting the home or in the home for infrequent babysitting are not counted in the capacity of the home. However, the caregivers in the home must ensure that the presence of additional children in the home does not prevent adequate supervision of children in foster and respite child-care. Source Note: The provisions of this §749.2557 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2557 May a foster home exceed its verified capacity? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189787 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189787&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189787 03/12/2026 (a) Your child placement management staff must ensure that supervision of children in care adequately accounts for the following:(1) Specific needs of the children in care in each home;(2) Non-routine events taking place in the lives of individual children, the foster parents, or the group of children in care; and(3) The children's history, including background of abuse or neglect by caretakers, sexual or physical abuse against others, fire-setting, maiming or killing animals, suicide attempts, and run-away behaviors.(b) Your child placement management staff must also approve a written plan for the increased supervision of a child who presents an immediate harm to himself or others. Source Note: The provisions of this §749.2591 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2591 How am I responsible for ensuring adequate supervision of children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189788 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189788&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189788 03/12/2026 (a) The caregiver is responsible for:(1) Knowing which children they are responsible for;(2) Being aware of and accountable for each child's on-going activity;(3) Providing the level of supervision necessary to ensure each child's safety and well being, including auditory and/or visual awareness of each child's on-going activity as appropriate;(4) Being able to intervene when necessary to ensure each child's safety; and(5) Not performing tasks that clearly impede the caregiver's ability to supervise and interact with the children while being responsible for the supervision of the children and meet any service-planning requirement regarding supervision of any child.(b) In deciding how closely to supervise a child, the caregiver must take into account:(1) The child's age;(2) The child's individual differences and abilities;(3) The indoor and outdoor layout of the home;(4) Surrounding circumstances, hazards, and risks; and(5) The child's physical, mental, emotional, and social needs.(c) Caregivers counted in the child/caregiver ratio must:(1) Be aware of the children's habits, interests, and any special needs, including any special supervision needs;(2) Provide a safe environment;(3) Cultivate developmentally appropriate independence in children through planned but flexible program activities;(4) Positively reinforce children's efforts and accomplishments;(5) Ensure continuity of care for children by sharing with incoming caregivers information about each child's activities during the previous shift and any verbal or written information or instructions given by the parent or other professionals; and(6) Implement and follow the children's service plans.(d) When a child participates in an unsupervised childhood activity, the caregiver must:(1) Know where the child is scheduled to be;(2) Give the child a specific time to return to the foster home or the caregiver's location;(3) Provide, arrange, or confirm an appropriate method of transportation to and from the activity;(4) Give the child a way to contact the caregiver in an emergency; and(5) Be available to respond if the child contacts the caregiver and needs immediate assistance.(e) Caregivers that supervise a child receiving treatment services must maintain progress notes for the child, at a frequency determined by the service planning team. Caregivers must sign and date each progress note at the time the progress note is completed. Progress notes must be available for Licensing staff to review. Source Note: The provisions of this §749.2593 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2593 What responsibilities does a caregiver have when supervising a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189786 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189786&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189786 03/12/2026 (a) Video cameras may be used to supervise infants and toddlers.(b) Video cameras may not be used to supervise children, other than infants and toddlers, unless the:(1) Parent, or other person legally authorized to consent, consents to the use of the video camera; and(2) Child:(A) Is younger than five years old;(B) Has primary medical needs; or(C) Has a service plan that permits the use for purposes of reducing risks of sexually offensive behavior, physical aggression, or other behaviors identified as requiring heightened supervision, such as night terrors, sleepwalks, or resides in a bedroom with such a child. You must document the justification for the video camera in the child's service plan, and the child must have other accessible and reasonable locations where he may change his clothing in private.(c) Video cameras may not be used to tape the child, and images may not be accessible except to the foster home's caregivers. Source Note: The provisions of this §749.2595 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2595 May I use a video camera to supervise a child in the child's bedroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189789 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189789&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189789 03/12/2026 Caregivers counted in the child/caregiver ratio and responsible for supervising children in a transitional living program must:(1) Reside within close physical proximity of the child's living quarters;(2) Be physically available to the children at all times;(3) Be capable of responding quickly in an emergency; and(4) Be capable of monitoring the comings and goings of the children in the program. Source Note: The provisions of this §749.2597 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2597 Where must the caregivers reside in order to supervise children who are in a transitional living program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189790 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189790&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189790 03/12/2026 A child who is 16 years old or older, including a foster child, may serve as a babysitter for children under the age of 13 as long as:(1) The child placement management staff approves the child to babysit and establishes limits with duration and frequency;(2) The child acts as a babysitter for no more than eight hours and never over night;(3) The child is certified in first aid and cardiopulmonary resuscitation (CPR); and(4) Neither the child babysitting nor any of the foster children in the babysitter's care is receiving treatment services. Source Note: The provisions of this §749.2599 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2599 Can a child serve as a babysitter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189791 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189791&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189791 03/12/2026 Normalcy is the ability of a child in care to live as normal a life as possible, including:(1) Engaging in childhood activities that are suitable for children of the same age, level of maturity, and developmental level as determined by a reasonable and prudent parent standard; and(2) Having normal interaction and experiences within a foster family and participating in foster family activities. Source Note: The provisions of this §749.2601 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2601 What is "normalcy"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189792 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189792&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189792 03/12/2026 (a) Children in care must participate in childhood activities, including unsupervised childhood activities, as much as possible.(b) Service planning meetings, and any decision making regarding the child's need for supervision, must include discussions on how normalcy for the child can be achieved, and discussions, if applicable, regarding a child's refusal to participate in childhood activities. The child's service plan must specify whether there are any restrictions on the child's participation in these activities and whether the activities may extend into sleeping hours. Source Note: The provisions of this §749.2603 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2603 Are children in care required to participate in childhood activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189793 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189793&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189793 03/12/2026 (a) The reasonable and prudent parent standard is the standard of care that a parent of reasonable judgment, skill, and caution would use to maintain the health, safety, and best interest of the child and encourage the emotional and social growth and development of the child.(b) When using the reasonable and prudent parent standard, a foster parent must take into consideration the following when deciding whether a child may participate in normal childhood activities:(1) The child's age and level of maturity;(2) The child's cognitive, social, emotional, and physical development level;(3) The child's behavioral history and ability to safely participate in a proposed activity;(4) The child's overall abilities;(5) Whether the activity is a normal childhood activity for a child of that age and level of maturity;(6) The child's desires;(7) The surrounding circumstances, hazards, and risks of the activity;(8) Outside supervision of the activity, if available and appropriate;(9) The supervision instructions in the child's service plan; and(10) The importance of providing the child with the most normal family-like living experience possible.(c) There is a presumption that a reasonable and prudent parent would include the child in normal interactions and experiences within the foster family and allow the child to participate in foster family activities, to the same extent as a similarly situated child born to the family. Source Note: The provisions of this §749.2605 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2605 What is the "reasonable and prudent parent standard"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189794 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189794&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189794 03/12/2026 (a) Except as otherwise provided in subsection (c) of this section, a foster parent makes decisions regarding a child's participation in childhood activities.(b) When making decisions regarding a foster child's participation in childhood activities, the foster parent must follow the reasonable and prudent parent standard.(c) The service plan may not require the prior approval of the parent before the foster parent may consent to a foster child's participation in childhood activities. However, if the parent provides notice in advance that the child is prohibited from participating in a specific activity, the foster parent must follow the parent's decision. Source Note: The provisions of this §749.2607 adopted to be effective January 1, 2017, 41 TexReg 9978; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2607 Who makes the decision regarding a foster child's participation in childhood activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189795 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189795&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189795 03/12/2026 (a) Respite child-care services are a planned alternative 24-hour care that has the purpose of providing relief to the child's primary caregiver.(b) For the purposes of this chapter, respite child-care placement is a placement that lasts more than 72 hours. The placement of a child in a home for less than 72 hours is not respite child-care. Source Note: The provisions of this §749.2621 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2621 What are respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189796 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189796&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189796 03/12/2026 Before placing the child in respite child-care services, you must:(1) Notify the child's parent; and(2) Inform the child of the plan for respite child-care services, including the intended time of stay. Source Note: The provisions of this §749.2623 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2623 What must occur before I place a child for respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189797 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189797&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189797 03/12/2026 Before a babysitter, overnight care provider or respite care provider may provide care to a child, you must share the following information with the provider to ensure continuity of care:(1) Specific needs of a child, including:(A) All psychological, psychiatric or medical treatment currently being provided;(B) Medication regimen and medication instructions;(C) Authorization for medical treatment;(D) Safety plans;(E) Sleeping information;(F) Discipline instructions;(G) Any expectations that the foster parent or agency may have of the provider; and(H) Any other needs of a child that should be addressed by the provider;(2) Non-routine events taking place in the life of the child, including any scheduled appointments such as family and sibling visits;(3) Emergency contact information, including the:(A) Child's physician(s);(B) Child's parent; and(C) Agency's telephone number; and(4) The child's history that may affect the provider's ability to provide care for the child, including:(A) Background of abuse and/or neglect;(B) Physical aggression or sexual behavior problems;(C) Fire setting;(D) Maiming or killing animals;(E) Suicidal ideations and attempts; and(F) Run-away behaviors. Source Note: The provisions of this §749.2625 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2625 What information regarding the child must I share with the babysitter, overnight care provider, and respite care provider? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189798 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189798&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189798 03/12/2026 (a) You must approve each occurrence of respite child-care services in your homes. Respite child-care services must not be provided if it could be detrimental to the child.(b) Your child placement management staff must determine that the respite placement will not cause a conflict in care for any child that you have already placed in the foster home. The record of the foster home providing respite child-care services must include documentation of this determination. Source Note: The provisions of this §749.2627 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2627 What must occur before one of my foster homes accepts a child for respite child-care service? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189801 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189801&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189801 03/12/2026 You and the foster home providing respite child-care must meet all requirements of the applicable rules of this chapter for all children in care, including children admitted for respite child-care services. This includes compliance with capacity and child/caregiver ratios and supervision rules. Children receiving respite care in a foster home are counted in the capacity and child/caregiver ratio for the home. Source Note: The provisions of this §749.2629 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2629 In addition to the requirements of this division, what requirements of this chapter apply to respite child-care services that a foster home provides? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189802 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189802&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189802 03/12/2026 (a) With the exception of subsection (b) of this section, a child may be in respite child-care services for 14 consecutive days or 40 days each year.(b) A respite child-care placement that is made because a child's foster home is under investigation for abuse or neglect does not count toward nor is it limited by the time frames noted in subsection (a) of this section. However, these placements are limited to a maximum of 60 days.(c) If a child needs respite child-care services for more than 14 consecutive days or more than 60 days for an abuse or neglect investigation, this is considered a new placement and will not be respite child-care.(d) When a child finishes a respite child-care placement, he may not return to respite child-care services for at least 10 days.(e) Respite child-care must not be used if it could be detrimental to the child. Source Note: The provisions of this §749.2631 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2631 How long may a child be in respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189803 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189803&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189803 03/12/2026 (a) The home may not provide respite child-care services for more than:(1) 14 consecutive days; or(2) 60 days annually.(b) A respite child-care placement that is made because a child's foster home is under investigation for abuse or neglect does not count toward nor is it limited by the time frames noted in subsection (a) of this section. However, these placements are limited to a maximum of 60 days.(c) This rule does not apply to foster homes that exclusively provide respite child-care services. Source Note: The provisions of this §749.2633 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2633 How frequently may a foster home provide respite child-care services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189799 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189799&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189799 03/12/2026 Yes, you may place a child in a home that Licensing does not regulate for babysitting, overnight care, or respite care, if the provider:(1) Is not subject to regulation by Licensing; and(2) Meets the policy requirements your agency developed according to §749.127 of this title (relating to What policies must I develop for babysitters, overnight care providers, and respite care providers?). Source Note: The provisions of this §749.2635 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective December 1, 2014, 39 TexReg 9058; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2635 May I place a child for babysitting, overnight care, or respite care services in a home that Licensing does not regulate? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189800 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189800&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189800 03/12/2026 (a) Foster homes may accept adults into the home for care if the adult:(1) Is related to the foster family;(2) Is a client in the Department of Aging and Disability Services, Community Based Services Program; or(3) Meets one of the requirements of §749.1105 of this title (relating to May I admit a young adult into your care?).(b) Adults in care must be counted in the capacity of the home. Source Note: The provisions of this §749.2651 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2651 May a foster home accept adults into the home for care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189804 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189804&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189804 03/12/2026 (a) Before a foster home may add a new member to the household:(1) The home must notify you of the potential new member of the household;(2) The home must comply with requirements specified in Subchapter F of Chapter 745 of this title (relating to Background Checks) and §749.1417 of this title (relating to Who must have a tuberculosis (TB) examination?); and(3) You must evaluate the effect that the adult will have on the foster children in the home. Your evaluation must include the following considerations:(A) The needs of the foster children in care;(B) The impact the adult will have in the foster family and for the foster children; and(C) Whether the change in household will conflict with the children's best interest.(b) You must document the following in the foster home record:(1) The results of the background check and the tuberculosis screening;(2) Your evaluation; and(3) The approval of the child placement management staff. Source Note: The provisions of this §749.2653 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2653 What are the requirements for an unrelated adult to reside in a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189805 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189805&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189805 03/12/2026 A foster home must notify you of any of the following changes as follows:Attached Graphic Source Note: The provisions of this §749.2655 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES M FOSTER HOMES: SCREENINGS AND VERIFICATIONS §749.2655 When must a foster home notify you of changes that affect the foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189846 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189846&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189846 03/12/2026 (a) You must evaluate a foster home for compliance with the relevant Licensing rules affecting the need for the evaluation, whenever:(1) You receive an allegation of deficiency;(2) There is a major life change in the foster family;(3) A change occurs that affects the conditions of the verification; or(4) You receive a family violence report from DFPS.(b) You must evaluate a foster home for compliance with all rules that apply to that home:(1) Every two years;(2) When you plan to extend a foster home's time-limited verification; and(3) When you plan to change a foster home's verification from time-limited to non-expiring. Source Note: The provisions of this §749.2801 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2010, 35 TexReg 10283; amended to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2801 When must I evaluate a foster home for compliance with Licensing rules? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189842 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189842&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189842 03/12/2026 (a) Changes that affect a foster home's verification include a:(1) Marriage, divorce, separation, death, birth, or any other change in household composition;(2) Change in the foster home's address and/or location;(3) Change in the foster home's capacity, as determined by the capacity requirements in §749.2557 of this title (relating to May a foster agency home exceed its verified capacity?);(4) Changes in the ages and gender(s) of children for which the home is authorized to provide care; or(5) Changes in the types of services the foster home will provide.(b) You must issue a new or temporary verification certificate to a foster home to:(1) Change the home's verification, including the home's address or location;(2) Extend the expiration date of the home's time-limited verification; or(3) Change a foster home's verification from time-limited to non-expiring.(c) A verification certificate becomes invalid at the point of:(1) The occurrence of any changes that affect a foster home's verification, including the home's address and/or location; or(2) The foster home's limited verification expires. Source Note: The provisions of this §749.2803 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2010, 35 TexReg 10283; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2803 What changes affect a foster home's verification? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189843 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189843&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189843 03/12/2026 A major life change in the foster family includes:(1) Marriage, divorce, separation, death, birth, or any other change in household composition;(2) A serious health problem or significant change in work schedule that affects the ability of the foster parent to care for children; or(3) Extended absences by one parent, such as military service or out-of-town job assignments. Source Note: The provisions of this §749.2805 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2805 What is a "major life change in the foster family"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189844 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189844&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189844 03/12/2026 You are responsible for the home's ongoing compliance with our rules. You must evaluate the home as follows:(1) When there is an allegation of a deficiency, you must evaluate the rule and any rules related to the deficiency;(2) When a change in the conditions of the verification or a major life change occurs, you must evaluate the rules related to the conditions or change;(3) When an unplanned change in housing or employment occurs, you must evaluate the rules related to the change;(4) You must document the rules that were evaluated and the determination of the evaluation;(5) During any contact with the foster family, including routine supervisory contacts and investigations, you must cite and address any deficiencies noted;(6) Your documentation of deficiencies must include plans for achieving compliance; and(7) You must also document a plan for follow-up to ensure compliance was achieved. Source Note: The provisions of this §749.2807 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2807 How do I evaluate a foster home's compliance with the relevant Licensing rules affecting the need for the evaluation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189845 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189845&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189845 03/12/2026 The plan for achieving compliance must include:(1) Specific actions or changes needed for the foster home to achieve compliance;(2) Time frames for corrections and consequences for failure to achieve compliance;(3) A determination of whether children can remain in the foster home before the home achieves compliance; and(4) A determination whether you will make new placements in the home before the home achieves compliance. Source Note: The provisions of this §749.2809 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2809 What must a plan for achieving compliance include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189850 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189850&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189850 03/12/2026 You must:(1) Re-inspect the foster home or receive documentation from the home showing that all deficiencies have been corrected; and(2) Document that the foster home has corrected all deficiencies in the foster home's record. Source Note: The provisions of this §749.2811 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2811 How do I follow-up to ensure compliance? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189851 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189851&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189851 03/12/2026 You may either:(1) Perform a rule-by-rule evaluation of the home once every two years; or(2) Evaluate different parts of the rules at different times during the two-year period. Source Note: The provisions of this §749.2813 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2813 How do I evaluate Licensing rules for each home every two years? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189847 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189847&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189847 03/12/2026 You must evaluate the foster home for compliance with each applicable rule of this chapter prior to extending the foster home's time-limited verification or changing the foster home's verification from time-limited to non-expiring. Source Note: The provisions of this §749.2814 adopted to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2814 How do I evaluate a foster home prior to extending its time-limited verification or changing its verification from time-limited to non-expiring? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189848 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189848&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189848 03/12/2026 (a) Child placement staff must conduct supervisory visits:(1) In the foster home at least quarterly;(2) With both foster parents, if applicable, at least once every six months; and(3) With all household members at least once every year.(b) At least two supervisory visits per year must be unannounced.(c) At least once every quarter, your supervisory visit must evaluate and document the following:(1) Any change to household members, frequent visitors, or persons who will provide support as a caregiver during an unexpected event or crisis situation;(2) Any major life change in the foster family as described in §749.2805 of this title (relating to What is a "major life change in the foster family"?);(3) Any change to the foster home disaster and emergency plans as described in §749.2907 of this title (relating to What disaster and emergency plans much each foster home have?); and(4) Any challenging behaviors of the current children in the home, the level of stress the foster family is currently experiencing (including any significant change in finances), and any methods for responding to each child's challenging behavior and/or alleviating any significant stress the foster family is experiencing.(d) You must document each visit in the home's record. The documentation must include the names of all household members present during the visit, specific issues identified and any rules evaluated, results of the evaluation, deficiencies found, plans for achieving compliance, plans for follow-up to ensure compliance was achieved, and any changes to the information in the foster home screening since the last supervisory visit, including the reasons for any change in the home's verification.(e) For each supervisory visit, documentation of the visit must be signed by each foster parent present for the visit and the child-placement staff conducting the visit. Source Note: The provisions of this §749.2815 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective September 1, 2014, 39 TexReg 622; amended to be effective January 1, 2017, 41 TexReg 99449; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2815 How often must I have supervisory visits with the foster home and what must be evaluated during a supervisory visit? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189849 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189849&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189849 03/12/2026 (a) You must maintain all monitoring and supervisory requirements if the home is available for placements.(b) If you place the home on inactive status, you do not have to monitor the home or have supervisory visits. Source Note: The provisions of this §749.2817 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2817 Must I monitor and have supervisory visits with a foster home where no children are placed? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189852 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189852&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189852 03/12/2026 (a) You may place a foster home on inactive status if:(1) There are no foster children in the home;(2) You and the foster parents agree that the home will be on inactive status;(3) You document in the home's record that the home is on inactive status and will not accept a child for placement; and(4) For a foster home with a time-limited verification, the home's verification has not expired.(b) You may not place a home that you should close on inactive status. A home that you should close includes a home:(1) Whose repeated noncompliance with rules endangers the health or safety of children;(2) That repeatedly fails to comply with agency policies or corrective action plans;(3) That refuses to comply with the rules of this chapter or agency policies; or(4) That refuses to allow you or our staff to inspect the home.(c) When you place a home on inactive status or remove a home from inactive status, you must inform us by submitting an agency home report form. Source Note: The provisions of this §749.2819 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective December 1, 2010, 35 TexReg 10283; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2819 When may I place a foster home on inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189853 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189853&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189853 03/12/2026 (a) Foster parents may prorate their annual training requirement for the period of time that the home was on inactive status.(b) If the home remains on inactive status for more than a year, the foster parents must complete at least eight hours of pre-service retraining before you may place children in the home. Source Note: The provisions of this §749.2821 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2821 How do the foster parents meet their training requirements while their home is on inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189854 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189854&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189854 03/12/2026 Background checks are not required for homes that are on inactive status. If the home is taken off of inactive status and it has been more than two years since the last background check for any person(s) at the home for whom a check is required, the background check(s) must be requested before a child or children can be placed in the home. Source Note: The provisions of this §749.2823 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2823 Are background checks required on homes that are on inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189855 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189855&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189855 03/12/2026 When the home is ready to become active and accept children, you must:(1) Make a supervisory contact in the home prior to placing a child in the home;(2) Document that the home is complying with all applicable rules of this chapter; and(3) Ensure that the home is in compliance with all background check requirements. Source Note: The provisions of this §749.2825 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES N FOSTER HOMES: MANAGEMENT AND EVALUATION §749.2825 How do I take a foster home off inactive status? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189856 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189856&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189856 03/12/2026 All agency homes must comply with all applicable fire, health, and safety laws, ordinances, and regulations. Source Note: The provisions of this §749.2901 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2901 What health and safety regulations must each foster home meet in addition to Licensing rules? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189857 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189857&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189857 03/12/2026 (a) Foster homes must have either:(1) A health inspection conducted from the local health authority; or(2) A health and safety evaluation conducted by your child placement staff using our Environmental Health Checklist form for foster homes.(b) You must document each health inspection or health and safety evaluation, including the name and telephone number of the person who conducted the inspection or evaluation.(c) The foster home must correct any deficiencies documented during any inspection or evaluation and must comply with any conditions or restrictions specified by the inspector or evaluator. Source Note: The provisions of this §749.2902 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2902 What health and safety measures are required at a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208668 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208668&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208668 03/12/2026 (a) Foster family homes not serving children receiving treatment services for primary medical needs must have either:(1) A fire inspection conducted by a state or local fire authority; or(2) A fire safety evaluation conducted by your child placement staff using the State Fire Marshal's fire prevention checklist for foster home(b) Each fire inspection or fire safety evaluation must be documented, including the name and telephone number of the person who conducted the inspection or evaluation.(c) The foster home must correct any deficiencies documented during any inspection or evaluation and must comply with any conditions or restrictions specified by the inspector or evaluator.(d) If a foster family home changes verification to become either a foster family home serving children receiving treatment services for primary medical needs, then the foster home must meet the fire safety measures for §749.2904 of this title (relating to What fire safety measures are required at a foster family home serving children receiving treatment services for primary medical needs?) before changing the verification. Source Note: The provisions of this §749.2903 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2903 What fire safety measures are required at a foster family home not serving children receiving treatment services for primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208669 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208669&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208669 03/12/2026 (a) Foster family homes serving children receiving treatment services for primary medical needs must have a fire inspection conducted by a state or local fire authority. You must document efforts to obtain a fire inspection. If, after exploring and documenting efforts to obtain a fire inspection for a home, you cannot obtain a fire inspection, then a fire safety evaluation may be conducted by your child-placement staff using the State Fire Marshal's fire prevention checklist for foster homes. Documentation of efforts to obtain a fire inspection must include each date, the name of the person contacted, and the person's response to the request to complete an inspection.(b) Each inspection or use of the State Fire Marshal's checklist must be documented, including the name and telephone number of the person who conducted the inspection or evaluation.(c) Deficiencies documented during any inspection or use of the State Fire Marshal's checklist must be corrected, and the foster home must comply with any conditions or restrictions specified by the inspector or child-placement staff.(d) Once you document that a fire inspection is not available in a particular area, you may use that documentation for any foster home verified by you in that area. A copy of the documentation must be on file in each foster home record to which the documentation applies.(e) Documentation that a fire inspection is not available in a particular area is valid for one year. Source Note: The provisions of this §749.2904 adopted to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2904 What fire safety measures are required at a foster family home serving children receiving treatment services for primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208670 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208670&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208670 03/12/2026 (a) Unless otherwise stated in the report, a fire or health inspection report obtained from a local health authority or state or local fire authority is current for two years for a foster family home.(b) A fire safety or health and safety evaluation conducted by your child placement staff using the State Fire Marshal's checklist for foster homes is current for one year. Source Note: The provisions of this §749.2905 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective June 1, 2008, 33 TexReg 4196; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2905 How often must fire and health inspections be conducted at a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189860 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189860&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189860 03/12/2026 (a) Each foster home must have written plans and procedures for handling potential disasters and emergencies, such as fire, severe weather emergencies, and transportation emergencies. Each plan must include:(1) Procedures for relocating children to a designated safe area or alternate shelter including specific procedures for evacuating children who are under 24 months of age, who have limited mobility, or who otherwise may need assistance in an emergency, such as children who have mental, visual, or hearing impairment, or a medical condition that requires assistance; and(2) How you will ensure medications and equipment will be made available to children with special needs or medical conditions.(b) Foster parents and caregivers must know the procedures for meeting disasters and emergencies, including evacuation procedures, supervision of the children, and contacting emergency help. Source Note: The provisions of this §749.2907 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective June 1, 2014, 39 TexReg 3730; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2907 What disaster and emergency plans must each foster home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189861 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189861&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189861 03/12/2026 (a) A foster home must practice disaster and emergency plans each year by:(1) Discussing the plans and procedures for handling a fire and weather emergency with the children in care;(2) Conducting a fire drill, so children are able to safely exit the foster home within three minutes; and(3) Conducting a severe weather drill.(b) The foster home must document the discussions and the drills, including the date and time of each.(c) For foster homes treating children with primary medical needs, a substitute (such as a large body pillow) should be used for each child with primary medical needs if the drill would endanger or overstimulate the child. Source Note: The provisions of this §749.2908 adopted to be effective December 1, 2014, 39 TexReg 9058; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2908 How must a foster home practice disaster and emergency plans? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189866 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189866&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189866 03/12/2026 (a) Each home must have a working smoke detector in the following areas:(1) In hallways or open areas outside sleeping rooms; and(2) On each level of a home with multiple levels.(b) Depending on the size and layout of the home, additional smoke detectors may be required based on the manufacturer's or the state or local fire authority's instructions. Source Note: The provisions of this §749.2909 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2909 How many smoke detectors must a foster home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189867 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189867&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189867 03/12/2026 Smoke detectors must be installed and maintained according to the manufacturer's instructions, or in compliance with the state or local fire authority's instructions. Source Note: The provisions of this §749.2911 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2911 How must smoke detectors be installed and maintained at a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189868 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189868&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189868 03/12/2026 (a) A foster home must have a fire extinguisher:(1) In each kitchen; and(2) On each level of the home.(b) The fire extinguisher(s) must:(1) Be serviced or replaced after each use; and(2) Have a maintenance check once a year by a person qualified to inspect fire extinguishers. Source Note: The provisions of this §749.2913 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2913 How many fire extinguishers must a foster home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189863 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189863&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189863 03/12/2026 A foster home must store dangerous tools and equipment, such as hatchets, saws, and axes, so they are inaccessible to children. Children may use these tools and equipment, with caregiver supervision as needed based on the child's age, maturity, and treatment issues. Source Note: The provisions of this §749.2915 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2915 Where must a foster home store dangerous tools and equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189864 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189864&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189864 03/12/2026 (a) Any animals on the premises of a home must be kept free of disease and must not create health problems or a health risk for children.(b) Animals must be vaccinated and treated as recommended by a licensed veterinarian.(c) The caregivers must have documentation at the home showing that dogs and cats have been vaccinated for rabies as required by Texas Health and Safety Code, Chapter 826. Source Note: The provisions of this §749.2917 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2917 What are the requirements for animals that are present at a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189865 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189865&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189865 03/12/2026 (a) A child may not use or possess tobacco products, e-cigarettes, or any type of vaporizers.(b) Caregivers and other adults may only smoke tobacco products, e-cigarettes, and vaporizers outside.(c) No one may smoke tobacco products, e-cigarettes, or vaporizers in a motor vehicle while transporting children in care. Source Note: The provisions of this §749.2931 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2931 What policies must I enforce regarding tobacco products and e-cigarettes? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208671 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208671&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208671 03/12/2026 (a) Generally, weapons, firearms, explosive materials, and projectiles (such as darts or arrows), are permitted. However, there are some specific restrictions.(1) If you allow weapons, firearms, explosive materials, or projectiles, you must develop and enforce a policy identifying specific precautions to ensure that a child does not have unsupervised access to them, including requiring a foster parent to keep them in locked storage when they are not in use.(2) You must determine that it is appropriate for a specific child to use the weapons, firearms, explosive materials, or projectiles.(3) No child may use a weapon, firearm, explosive material, or projectile, unless the child is directly supervised by an adult knowledgeable about the use of the weapon, firearm, explosive material, or projectile that is to be used by the child.(b) Your policies must require foster parents to notify you if there is a change in the type of or an addition to weapons, firearms, explosive materials, projectiles, or toys that explode or shoot that are on the property where the foster home is located.(c) You must determine whether it is appropriate for a specific child to use a toy that explodes or shoots. The child must be supervised when using or being around a toy that explodes or shoots, and the toy must be age appropriate to the child.(d) Firearms that are inoperable and solely ornamental are exempt from the storage requirements in this rule. Source Note: The provisions of this §749.2961 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective June 27, 2021, 46 TexReg 3525; amended to be effectiveApril 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2961 Are weapons, firearms, explosive materials, and projectiles permitted in a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189869 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189869&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189869 03/12/2026 When determining if these items are stored adequately, you must consider the age, history, emotional maturity, and background of the children in the home. Source Note: The provisions of this §749.2963 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2963 What factors must I consider when determining whether weapons, firearms, explosive materials, or projectiles are stored adequately? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189870 03/12/2026 (a) When you complete a foster home screening, you must ask whether weapons, firearms, explosive materials, or projectiles are present in the home. If these items are present, you must review your policies and requirements with the prospective foster parents.(b) The foster home record must include documentation on the:(1) Items present in the home; and(2) Specific precautions the caregivers must take to ensure that children do not have unsupervised access.(c) The two-year evaluation of compliance with rules of this chapter must include a discussion of whether the home has weapons, firearms, explosive materials, or projectiles, and if so, how these items are stored. Source Note: The provisions of this §749.2965 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2965 How must I determine whether weapons, firearms, explosive materials, or projectiles are present in a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208672 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208672&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208672 03/12/2026 (a) A caregiver may transport a child in a vehicle where firearms (other than handguns), other weapons, explosive materials, or projectiles are present if:(1) All firearms are not loaded;(2) The firearms, other weapons, explosive materials, or projectiles are inaccessible to the child; and(3) Possession of the firearm is legal.(b) A caregiver may transport a child in a vehicle where a handgun is present if:(1) The handgun is in the possession and control of the caregiver; and(2) The caregiver is not prohibited by law from carrying a handgun. Source Note: The provisions of this §749.2967 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective March 1, 2008, 33 TexReg 1377; amended to be effective March 1, 2012, 37 TexReg 941; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.2967 May a caregiver transport a child in a vehicle where firearms, other weapons, explosive materials, or projectiles are present? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189873 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189873&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189873 03/12/2026 (a) A bedroom must have at least 40 square feet of space for each occupant and no more than four occupants per bedroom are permitted, even if the square footage of the room would accommodate more than four occupants. The four occupants restriction does not apply to children receiving treatment services for primary medical needs.(b) Single occupant bedrooms must have at least 80 square feet of floor space.(c) The floor space requirement must not include closets or other alcoves.(d) Floor space must be space that children can use for daily activities.(e) If a foster home was verified before January 1, 2007, then a foster home is exempt from the maximum bedroom occupancy requirement until:(1) The foster family moves to a new home;(2) The foster home is structurally altered by adding a new room; or(3) The foster home's verification is no longer valid. Source Note: The provisions of this §749.3021 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3021 How much space must bedrooms used by foster children have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189874 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189874&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189874 03/12/2026 (a) Only a room that provides adequate opportunities for rest and privacy may be used as a bedroom.(b) Bedrooms used by foster children must have at least one source of natural lighting.(c) Foster children or any other household members may not use any of the following as a bedroom:(1) A room commonly used for other purposes, including dining rooms, living rooms, hallways, or porches;(2) A passageway to other rooms; or(3) A room that does not have doors for privacy.(d) A foster child may use a detached structure as a bedroom if:(1) The child is 16 years old or older;(2) The service planning team approves; and(3) The detached structure is included in required fire and health inspections for the foster home.(e) A foster child may use a basement as a bedroom if there is a second fire escape route from the basement.(f) A foster child may not use a room, including a basement or detached structure, as a bedroom if there is no natural lighting:(1) Unless you verified the home prior to January 1, 2007; and(2) Until the verification is no longer valid, or the home is structurally altered through the addition of a new room. Source Note: The provisions of this §749.3023 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3023 Which rooms in the home may not be used as bedrooms? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208673 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208673&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208673 03/12/2026 (a) An adult in care may share a bedroom with a child in care if:(1) The adult and child are siblings;(2) The adult is the child's parent;(3) Both of them are non-ambulatory and receive treatment services for primary medical needs; or(4) The child is at least 16 years old, the age difference between them does not exceed 24 months, and the adult meets the requirements of:(A) §749.1103 of this chapter (relating to After a child in my care turns 18 years old, may the person remain in my care?); or(B) §749.1105 of this chapter (relating to May I admit a young adult into care?).(b) The following must occur before you may allow an adult in care and a child in care to share a bedroom, unless the adult is the child's parent:(1) The service planning team must determine that there is no known risk of harm to the child after assessing:(A) Their behaviors;(B) Their compatibility with each other;(C) Their respective relationships;(D) Any history of possible sexual trauma or sexually inappropriate behavior; and(E) Any other identifiable factor that may affect the appropriateness of the adult and child sharing a bedroom; and(2) The service planning team must date and document the assessment and approval in the child's service plan.(c) The adult and the child must not sleep in the same bed unless the adult is the child's parent, and the child is between the ages of one year and 10 years old.(d) Subsections (a) and (b) of this section do not apply to travel and camping situations. Source Note: The provisions of this §749.3025 adopted to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3025 May an adult in care share a bedroom with a child in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208674 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208674&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208674 03/12/2026 (a) A child may share a bedroom with an adult caregiver if:(1) It is in the best interest of the child;(2) The child is under three years old and sleeps in the bedroom of a caregiver; and(3) The service planning team dates and documents the approval in the child's service plan.(b) An exception for a child to share a bedroom with an adult caregiver may be made during specific travel and camping situations if no other more reasonable provision is available to the child and other requirements are met.(c) Children may not sleep in the same bed with an adult caregiver at any time.(d) To facilitate continuous supervision of a child, the caregiver may move a child to a location where the caregiver can directly and continuously supervise a child until there is no longer an immediate danger to self or others. However, the caregiver must provide comfortable sleeping arrangements for the child. Source Note: The provisions of this §749.3027 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3027 May a child in care share a bedroom with an adult caregiver in the foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208675 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208675&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208675 03/12/2026 (a) A child six years old or older must not share a bedroom with a child of the opposite gender, unless:(1) They are siblings;(2) The older child is the younger child's parent; or(3) Both children are non-ambulatory child and receive treatment services for primary medical needs.(b) The following must occur before you may allow children of the opposite sex to share a bedroom, unless the older child is the younger child's parent:(1) The service planning team must determine that there is no known risk of harm to either of the children after assessing:(A) Their behaviors;(B) Their compatibility with each other;(C) Their respective relationships;(D) Any history of possible sexual trauma or sexually inappropriate behavior; and(E) Any other identifiable factor that may affect the appropriateness of the children sharing a bedroom.(2) The service planning team must date and document the assessment and approval in each child's service plan. Source Note: The provisions of this §749.3029 adopted to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3029 May children of opposite genders share a bedroom? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189881 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189881&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189881 03/12/2026 (a) Each foster child shall have their own bed and mattress. This does not prevent a child receiving respite care or requiring closer supervision from sleeping on a couch, sleeping bag, etc. for fewer than seven days.(b) Beds must be clean and comfortable.(c) Mattresses must be off of the floor and have covers or protectors.(d) Linens must be changed when soiled, and not less often than once a week. Source Note: The provisions of this §749.3031 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3031 What are the requirements for beds and bedding? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189882 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189882&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189882 03/12/2026 Each child must have accessible storage space for his clothing and personal possessions. Source Note: The provisions of this §749.3033 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3033 What type of personal storage space must a foster child have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189877 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189877&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189877 03/12/2026 (a) A foster home must have one lavatory, one tub or shower, and one toilet for every eight household members. A foster home verified before January 1, 2007, is exempt from this requirement until it is no longer verified by the agency under which it is currently verified, or it makes structural changes to the home by adding additional bathrooms.(b) All lavatories, tubs, and showers must have hot and cold running water.(c) For foster homes that care for primary medical needs children, the child's bedroom and the child's bathroom must be located on the same floor. A foster home verified before January 1, 2007, is exempt from this requirement until it is no longer verified by the agency.(d) Bathrooms must allow for privacy. Source Note: The provisions of this §749.3035 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3035 What bathroom accommodations must a home have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189878 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189878&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189878 03/12/2026 (a) Children must have indoor areas for their use. There must be at least 40 square feet for each child. This does not include bedrooms, kitchens, bathrooms, utility rooms, unfinished attics, or hallways.(b) A foster home must identify indoor areas that children can use.(c) You must approve the indoor space that a home designates for the children's use. Source Note: The provisions of this §749.3037 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3037 What are the requirements for indoor space that children can use? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189879 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189879&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189879 03/12/2026 (a) Equipment must not have openings, angles, or protrusions that can entangle a child's clothing or entrap a child's body or body parts.(b) Equipment must be securely anchored according to manufacturer's specifications to prevent collapsing, tipping, sliding, moving, or overturning.(c) Climbing equipment, swings, and slides must not be installed over asphalt or concrete.(d) Equipment must be appropriate, cleaned, maintained, and repaired.(e) Trampolines may only be used at the foster home if:(1) The number of children allowed on the trampoline at one time meets the manufacturer's instructions;(2) Shock-absorbing pads cover the springs, hooks, and frame;(3) Ladders are removed from the trampoline when the trampoline is not in use; and(4) A caregiver provides supervision as follows:(A) For children under 12 years old, the caregiver must be immediately present, watching the child(ren) at all times, enforcing safety rules and manufacturer's instructions, and able to respond in an emergency; and(B) For children 12 years old and older, the caregiver must be on the premises, visually check on the child(ren) at frequent intervals, and able to respond in an emergency. Source Note: The provisions of this §749.3039 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3039 What are the requirements for outdoor recreation equipment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189886 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189886&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189886 03/12/2026 The foster home must ensure that:(1) The home is safe for children, kept clean, and in good repair;(2) Equipment and furniture are safe for children, kept clean, and in good repair;(3) Exits in living areas are not blocked by furniture;(4) The outdoor areas are safe for children, kept clean, and in good repair;(5) Outdoor areas are well drained;(6) Windows and doors used for ventilation are screened;(7) Flammable or poisonous substances are stored out of the reach of children unless caregivers have evaluated a child as capable and likely to use such items responsibly; and(8) The home is free of rodents and insects. Source Note: The provisions of this §749.3041 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3041 What are the requirements for a foster home's physical environment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208676 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208676&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208676 03/12/2026 (a) A product is considered unsafe if, after it has been recalled for any reason by the United States Consumer Product Safety Commission (CPSC):(1) The recall has not been rescinded; and(2) The product has not been made safe through being remanufactured or retrofitted.(b) A caregiver is responsible for reviewing the CPSC recall list. All current and past recalls may be viewed through the CPSC's Internet website at: www.cpsc.gov. A caregiver must ensure that there are no unsafe products at the foster home unless:(1) The product is an antique or collectible and is not used by, or accessible to, any child; or(2) The unsafe product is being retrofitted to make it safe and the product is not used by, or accessible to, any child. Source Note: The provisions of this §749.3043 adopted to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3043 When is a product considered unsafe and what are a caregiver's responsibilities regarding unsafe products in a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189887 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189887&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189887 03/12/2026 (a) Caregivers must feed an infant whenever the infant is hungry.(b) Caregivers must provide a toddler or school age child with three meals and at least one snack a day.(c) No more than 14 hours may pass between the last meal or snack of the day and the availability of the first meal the following day. Source Note: The provisions of this §749.3061 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3061 What are the requirements for feeding children in care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189888 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189888&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189888 03/12/2026 (a) Caregivers must provide a child with food that is:(1) Of adequate variety, quality, and in sufficient quantity to supply the nutrients needed for proper growth and development according to the United States Department of Agriculture guidelines; and(2) Appropriate for the child's age and activity level.(b) Caregivers must not serve a child nutrient concentrates and supplements, such as protein powders, liquid protein, vitamins, minerals, and other nonfood substances in lieu of food to meet the child's daily nutritional need, except with written instructions from a licensed health-care professional.(c) Caregivers must ensure drinking water is always available to each child and is served in a safe and sanitary manner. Children must be well hydrated and must be encouraged to drink water during physical activity and in warm weather. Source Note: The provisions of this §749.3063 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3063 What types of food and water must caregivers provide children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189883 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189883&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189883 03/12/2026 (a) The caregiver must offer a child a meal or snack according to this division, but the caregiver may not force the child to eat. The caregiver does not have to offer other food to a child who:(1) Refuses a meal or snack; or(2) Chooses not to be present when a meal or snack is scheduled.(b) The caregiver must discuss recurring eating problems with child placement staff and the child's parent.(c) If a meal or snack is not appropriate to meet a child's individual needs, for example food allergies or religious reasons, then you must offer the child an appropriate nutritional substitute. Source Note: The provisions of this §749.3065 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3065 What must the caregiver do if a child refuses to or cannot eat a meal or snack that is offered? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189884 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189884&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189884 03/12/2026 A caregiver may not use food that meets a child's nutritional requirements as a reward or punishment or as part of a behavior management program. Food cannot be withheld. Source Note: The provisions of this §749.3067 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3067 May a caregiver use food as a reward or punishment or as part of any behavior management program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189885 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189885&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189885 03/12/2026 (a) A caregiver must offer a child in care the same food choices that other children in the home are offered, unless medically contraindicated for the child.(b) A caregiver must offer a child in care food choices that are at least comparable to what the adults in the home are eating, unless medically contraindicated for the child. Source Note: The provisions of this §749.3069 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3069 May caregivers offer a child in care different food choices than what the family is eating? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189891 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189891&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189891 03/12/2026 (a) For a caregiver to serve a therapeutic or special diet to a child, you must have written approval in the child's record from a licensed physician or a registered or licensed dietician. This approval must be in the child's record.(b) If a child requires a therapeutic or special diet, you must give information regarding the diet to the child's caregivers.(c) Caregivers must make dietary alternatives available to a child who has special health needs as instructed by a licensed health-care professional. Source Note: The provisions of this §749.3071 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3071 What must I do if a child requires a therapeutic or special diet? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189892 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189892&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189892 03/12/2026 (a) Caregivers must feed a child with primary medical needs according to his medical and developmental needs.(b) A licensed physician must prescribe tube feeding. A dietician or physician must plan the diet that the physician prescribes.(c) Children must eat in an upright position unless the service planning team's recommendations are to the contrary. Source Note: The provisions of this §749.3073 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3073 What are the nutrition requirements for a child with primary medical needs? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189893 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189893&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189893 03/12/2026 (a) Caregivers must encourage self-help and development when feeding children receiving treatment services for primary medical needs or intellectual disabilities, including non-mobile children.(b) A toddler or older child must eat or be fed in the dining area, unless the service planning team's recommendations are to the contrary.(c) Infants must be held during feedings, unless the service planning team's recommendations are to the contrary. Source Note: The provisions of this §749.3075 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3075 What are the feeding requirements for children receiving treatment services for primary medical needs or intellectual disabilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189894 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189894&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189894 03/12/2026 (a) A registered or licensed dietician, physician, or a registered nurse must ensure and document that the caregiver that prepares formula is adequately trained and has demonstrated competency in preparing the formula.(b) Tube-feeding formulas must supply the recommended dietary allowance for each child.(c) Caregivers must prepare and store the formula:(1) According to directions; or(2) As prescribed by a health-care professional. Source Note: The provisions of this §749.3077 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3077 What are the requirements for tube-feeding formula? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189889 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189889&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189889 03/12/2026 All food items must be:(1) Covered and stored off the floor;(2) Stored on clean surfaces;(3) Protected from contamination;(4) Stored in a container that is protected from insects and rodents;(5) Refrigerated immediately after use and after meals, if the food requires refrigeration; and(6) Covered when stored in the refrigerator. Source Note: The provisions of this §749.3079 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3079 What are the requirements for storing food? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189890 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189890&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189890 03/12/2026 (a) Caregivers must keep furniture, equipment, food contact surfaces, and other areas where food is prepared, eaten, or stored clean and well repaired.(b) Utensils and containers intended for one-time use, such as paper and plastic dishes, must not be used more than once. Source Note: The provisions of this §749.3081 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3081 How must kitchen, dining areas, supplies, and equipment be maintained? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189899 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189899&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189899 03/12/2026 Vehicles used to transport foster children must be:(1) Maintained in safe operating conditions at all times; and(2) Inspected and registered according to federal, state, and local laws. Source Note: The provisions of this §749.3101 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3101 What are the requirements for the vehicles used to transport foster children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189895 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189895&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189895 03/12/2026 The driver and all passengers must follow all federal, state, and local laws when driving, including laws on the use of a child passenger safety seat system, seat belts, and liability insurance. Source Note: The provisions of this §749.3103 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3103 What are the requirements for transporting foster children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189896 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189896&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189896 03/12/2026 Other children in the foster home may transport a foster child if the:(1) Child driving has a valid drivers license; and(2) Service planning teams for the foster children being transported and the foster child transporting, if applicable, approve of the transportation arrangements. Source Note: The provisions of this §749.3105 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3105 May children transport other foster children? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189897 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189897&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189897 03/12/2026 (a) With your approval, caregivers may teach or supervise foster children in learning to drive. You must document your approval in the child's record.(b) Only the caregiver responsible for instruction and the child(ren) learning to drive may be present in the vehicle. Source Note: The provisions of this §749.3107 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3107 May caregivers teach or supervise foster children in learning to drive? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189898 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189898&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189898 03/12/2026 (a) A sufficient number of caregivers to meet the child's needs must accompany the child.(b) Special provision(s) must be made for transporting non-ambulatory and non-mobile children. When necessary, this must include locks for wheelchairs and hydraulic lifts. Source Note: The provisions of this §749.3109 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3109 What are the special requirements for transporting a child who requires increased supervision or is non-ambulatory or non-mobile? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189900 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189900&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189900 03/12/2026 Yes. Children must be inside the vehicle when transported. The back of a pick-up truck is not considered inside the vehicle. Children must never be transported in the bed of a pick-up truck, while standing on runners, or while on the hood or trunk of any vehicle. Source Note: The provisions of this §749.3111 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3111 Do the seat belt requirements prohibit transporting children in the bed of a pick-up truck or other parts of the vehicle on the foster parents' property or public roads? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189901 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189901&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189901 03/12/2026 These requirements only apply to homes that are providing foster care services. This includes foster homes also approved as adoptive homes, but does not include adoptive homes only approved for adoption. Source Note: The provisions of this §749.3131 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3131 Who is responsible for complying with the requirements in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208677 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208677&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208677 03/12/2026 (a) The caregivers must inform children about house rules for use of the swimming pool and appropriate safety precautions. Adult supervision and monitoring of safety features must be adequate to protect children younger than 12 years of age and children of any age who are not competent swimmers from unsupervised access to the swimming pool.(b) The swimming pool must be built and maintained according to the standards of the Texas Department of State Health Services and any other applicable state or local regulations.(c) The swimming pool must have a barrier, including a fence or wall, that prevents a child's unauthorized access to the swimming pool. A swimming pool cover does not meet this requirement unless it is a power safety cover that meets the specifications of the American Society for Testing Materials, which specifies safety performance requirements for pool covers.(d) A fence or wall that is at least four feet high must enclose the pool area. The fence must be well constructed and be installed completely around the pool area. The back wall of a house may serve as one side of the fence or wall as long as the requirements in subsection (f) of this section are met.(e) Fence gates leading to the outdoor pool area must be self-closing and self-latching. Gates must be locked when the pool is not in use. Keys or locks to open the gate must not be accessible to children under the age of 12 years old, children of any age who are not competent swimmers, or any children receiving treatment services.(f) If the home serves as one side of the fence or wall, any door that leads from the home to the swimming pool area must have:(1) A door alarm; and(2) A lock that only adults or children over 12 years old can reach. The lock must be completely out of the reach of children younger than 12 years old, unless:(A) the state or local fire authority determines that the height of the lock violates or would violate the fire code; and(B) the fire authority's determination is kept in the foster home record.(g) Furniture, equipment, or large materials must not be close enough to the swimming pool area for a child to use them to gain unauthorized access to the swimming pool.(h) At least two life-saving devices must be available, such as a reach pole, backboard, buoy, or a safety throw bag with a brightly colored buoyant rope or throw line. One additional life-saving device must be available for each 2,000 square feet of water surface, so a swimming pool of 2,000 square feet would require three life saving devices.(i) Drain grates must be in place, in good repair, and capable of being removed only with tools.(j) Caregivers must be able to clearly see all parts of the swimming pool when supervising activity in the area.(k) The bottom of the swimming pool must be visible at all times.(l) Swimming pool covers must be completely removed prior to pool use.(m) An adult must be present who is able to immediately turn off the pump and filtering system when any child is in the swimming pool.(n) Swimming pool chemicals and pumps must be inaccessible to all children.(o) Machinery rooms must be locked to keep children out.(p) An aboveground swimming pool must:(1) Be inaccessible to children under the age of 12 years old, children of any age who are not competent swimmers, or any children receiving treatment services when it is not in use; and(2) Meet all other requirements in this division. Source Note: The provisions of this §749.3133 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3133 What are the requirements for a swimming pool at a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189902 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189902&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189902 03/12/2026 (a) Caregivers must use prudent judgment and ensure children in your care who are younger than 12 years old, children of any age who are not competent swimmers, and children receiving treatment services are protected from unsupervised access to water such as a swimming pool, hot tub, fountain, pond, lake, creek, or other body of water.(b) If children are allowed to swim in a body of water such as a river, creek, pond, or lake, the supervising adult must clearly designate swimming areas.(c) Rules governing the activity and the dangers of the body of water must be explained to participants in a manner that is clearly understood prior to their participation. Source Note: The provisions of this §749.3135 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3135 What general requirements must caregivers meet for children regarding a body of water? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208678 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208678&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208678 03/12/2026 (a) The maximum number of children one adult can supervise during swimming activities is based on the age of the youngest child in the group and is specified in the following chart:Attached Graphic(b) When all of the children in the group are at least four years of age or older, in addition to meeting the required swimming child/adult ratio listed in subsection (a) of this section, at least two adults must supervise four or more children who are actually in the water.(c) When a child who is non-ambulatory or who is subject to seizures is engaged in swimming activities, you must assign one adult to that one child. This adult must be in addition to any lifeguard on duty in the swimming area. You do not have to meet this requirement if a licensed physician writes orders in which the physician determines that the child:(1) Is at low risk of seizures and that special precautions are not needed; or(2) Only needs to wear a Coast Guard approved life jacket while swimming and additional special precautions are not needed. (d) A lifeguard who is supervising the area where the children are swimming may be counted in the child/adult ratio; however, one caregiver must always be present and the lifeguard may not be the only person counted in the child/adult ratio.(e) A child must wear a Coast Guard approved life jacket while participating in swimming activities in other bodies of water, such as ponds, rivers, lakes, and oceans, if the child is:(1) Under the age of 12; or(2) Unable to swim, regardless of the child's age.(f) The ratios in subsection (a) of this section:(1) do not include children over the age of 12 years old who are competent swimmers.(2) are not required when children are participating in water activities such as sprinkler play or splash pad/wading pool, as long as the standing water is less than two feet. Source Note: The provisions of this §749.3137 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3137 What are the child/adult ratios for swimming activities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189905 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189905&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189905 03/12/2026 To meet the swimming child/adult ratio, you may include adult volunteers and adult relatives who do not meet the minimum qualifications for caregivers, providing:(1) You maintain enough caregivers to meet the child/caregiver ratio required in Subchapter M, Division 5 of this chapter (relating to Capacity and Child/Caregiver Ratio);(2) Persons in your care do not supervise swimming activities; and(3) You ensure compliance with all other rules of this chapter, including, but not limited to, rules relating to supervision and discipline. Source Note: The provisions of this §749.3139 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3139 May I include volunteers or relatives who do not meet minimum qualifications for caregivers in the swimming child/adult ratio? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189906 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189906&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189906 03/12/2026 A child must wear a life jacket when:(1) Participating in boating activities;(2) The child is in more than two feet of water and does not know how to swim; or(3) Ordered by a physician for a child with a medical problem or disability. Source Note: The provisions of this §749.3141 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3141 When must a child wear a life jacket? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189907 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189907&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189907 03/12/2026 At all times during a swimming activity, at least one adult counted in the swimming child/adult ratio must be able to swim, carry out a water rescue, and be prepared to do so in an emergency. Source Note: The provisions of this §749.3143 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3143 Must persons who are counted in the swimming child/adult ratio know how to swim and carry out a water rescue? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189908 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189908&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189908 03/12/2026 Wading/splashing pools (less than two feet of water) must be:(1) Stored out of children's reach, when not in use;(2) Drained at least daily; and(3) Stored, so it does not hold water. Source Note: The provisions of this §749.3145 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3145 What are the safety requirements for wading pools? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189909 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189909&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189909 03/12/2026 A hot tub must be:(1) Enclosed per the requirements in §749.3133 of this title (relating to What are the requirements for a pool at a foster home?); or(2) Covered with a locking cover when not in use. Source Note: The provisions of this §749.3147 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3147 What are the requirements for a hot tub? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189910 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189910&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189910 03/12/2026 You must document the following regarding a body of water that is on or adjacent and accessible to the premises of a foster home:(1) Type, location, and size of the body of water; and(2) Barriers between the foster home and the body of water. Source Note: The provisions of this §749.3149 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3149 What must I document regarding a body of water that is on or adjacent and accessible to the premises of a foster home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189911 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189911&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189911 03/12/2026 Yes, a foster parent using the "reasonable and prudent parent standard" as defined in §749.2605 of this title (relating to What is the "reasonable and prudent parent standard"?) may approve a child to participate in unsupervised childhood activities (activities away from the foster home and the foster parents) involving swimming that do not comply with the rules of this Division of this subchapter (relating to Swimming Pools, Bodies of Water, Safety). However, depending upon the background of the child (for example the child's age, level of maturity and responsibility, and proficiency in swimming), such an approval may or may not require limitations like other adult supervision or the need for a life jacket when boating. Source Note: The provisions of this §749.3151 adopted to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES O FOSTER HOMES: HEALTH AND SAFETY REQUIREMENTS, ENVIRONMENT, SPACE AND EQUIPMENT §749.3151 Can foster parents approve a child to participate in swimming activities as an unsupervised childhood activity without complying with the rules of this division? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189914 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189914&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189914 03/12/2026 Yes. You may approve applicants as a foster-adoptive home. Source Note: The provisions of this §749.3201 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES P FOSTER-ADOPTIVE HOMES AND LEGAL RISK PLACEMENTS §749.3201 May I verify the same applicant as a foster family home and an adoptive placement at the same time? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189912 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189912&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189912 03/12/2026 (a) You must follow all rules for verifying a foster family home and for approving an adoptive home.(b) You may combine the foster home screening and pre-adoptive home screening into one screening report as long as requirements for each screening are covered. Source Note: The provisions of this §749.3203 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES P FOSTER-ADOPTIVE HOMES AND LEGAL RISK PLACEMENTS §749.3203 What rules must I follow to verify a foster-adoptive home? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189913 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189913&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189913 03/12/2026 (a) A "legal risk placement" exists when you:(1) Have a child that is not available for adoption because his parent(s)' rights have not been terminated;(2) Have placed a child into a home that has been jointly verified as a foster home and approved as an adoptive home; and(3) Intend for the placement to change from foster care to adoption once the child is eligible for adoption.(b) A "legal risk placement" does not exist when you merely place a child with foster parents who want to adopt the child but have not been approved as an adoptive home. Source Note: The provisions of this §749.3221 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES P FOSTER-ADOPTIVE HOMES AND LEGAL RISK PLACEMENTS §749.3221 What is a "legal risk placement"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189924 03/12/2026 To place a child in adoptive care, you must have an agreement signed by you and the person legally authorized to consent to the child's placement. Source Note: The provisions of this §749.3301 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3301 What legal authority must I have to place a child in adoptive care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189925 03/12/2026 (a) You must initiate the plan when you accept a child or enter into a written agreement with the birth parent for adoption placement services.(b) You must complete the service plan within 40 days of initiation. Source Note: The provisions of this §749.3321 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3321 When must I initiate and complete the adoption service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189926 03/12/2026 (a) The service plan must address:(1) The needs of the birth parents (unless parental rights have been relinquished or involuntarily terminated), the fetus or child, and the adoptive family; and(2) Any other issue that impacts the adoption.(b) The adoptive family becomes part of the service plan when matched with a child, or with a birth parent and fetus. You do not have to develop separate service plans for adoptive families that do not have a completed home study.(c) The plan must include specific strategies to meet the needs and issues identified, and an estimate of the time required to consummate the adoption. You must inform the birth parents (unless parental rights have been relinquished or involuntarily terminated) and adoptive parents of the services you provide. Source Note: The provisions of this §749.3323 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3323 What must an adoption service plan include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189927 03/12/2026 If you place siblings in the same adoptive home, you do not have to develop a plan for each child. If you place siblings in separate adoptive homes, you have to develop separate plans for each home. Source Note: The provisions of this §749.3325 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3325 When placing a sibling group, must I develop a plan for each child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189928 03/12/2026 No. The adoption service plan may be a continuation of the foster care service plan. Source Note: The provisions of this §749.3327 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3327 If a child had a foster care service plan prior to preparation for adoption, must I complete a new adoption service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189929 03/12/2026 (a) You must have contact at least quarterly with the child being considered for adoption. The contact must be meaningful and must include:(1) Continued preparation for adoption; and(2) Updated information concerning the adoption.(b) You must make a minimum of three face-to-face contacts with a child who is 18 months old or older to prepare the child for adoption.(c) You must make a minimum of one face-to-face contact with an infant who is age zero to 18 months old.(d) You must document each contact in the child's record.(e) You may contract with another licensed child-placing agency to make these contacts as long as:(1) The person making the contacts meets the minimum qualifications for a child placement staff in §749.673 of this title (relating to What are the qualifications that an employee must have to perform child placement activities?);(2) The agency submits the required documentation to you;(3) Your child-placement management staff reviews and approves the documentation; and(4) You maintain the documentation in the child's record. Source Note: The provisions of this §749.3341 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3341 How often must I have contact with a child being considered for adoptive placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189930 03/12/2026 (a) Preparation must include helping a child five years old or older to:(1) Know and understand his history;(2) Understand the difference between biological, foster, and adoptive parents;(3) Express hopes and fears about adoption, including fears of disruption;(4) Separate from people he is close to, and grieve their loss;(5) Form new attachments; and(6) As appropriate, make a plan for contact with siblings, other family members, and/or other significant persons.(b) Preparation for children under five years old must include as many of the items in subsection (a) of this section as appropriate based on the child's age and intellectual level.(c) Regardless of the child's age, you must document in the child's record any items in subsection (a) of this section not addressed with the child during preparation for adoption and the reason for not addressing each item.(d) You must document preparation activities in the child's record. Source Note: The provisions of this §749.3343 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3343 What does preparing a child for adoption include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189931 03/12/2026 (a) A person meeting the qualifications of child placement staff or child placement management staff must prepare a child for adoption.(b) Before you can place the child in the adoptive home, child placement management staff must review and approve the preparation and related documentation. Source Note: The provisions of this §749.3345 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3345 Who must prepare a child for adoption? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189932 03/12/2026 (a) The extent of the professional assessment required depends on the age, history, and special needs of the child being considered.(b) The professional assessment must always include a medical examination by a licensed physician.(c) If the child's age is zero to 18 months old, the professional assessment must also include an evaluation by a professional credentialed in the area appropriate to the child's needs if:(1) There is history of abuse, neglect, or failure to thrive; or(2) The child is physically or mentally disabled or developmentally delayed.(d) If the child's age is over 18 months old, the assessment must include an evaluation by a licensed psychiatrist, psychologist, or other appropriately licensed or credentialed professional.(e) Required assessments must be current within:(1) 30 days of placement if the child is less than 18 months old;(2) Three months of placement if the child is 18 months to four years old; and(3) Six months of placement if the child is five years old or older.(f) You must provide any testing that an assessment recommends for the child.(g) You must document the assessments and results in the child's record.(h) If professional assessments have been completed since the child was placed in the home, you are not required to repeat them. Source Note: The provisions of this §749.3349 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3349 What professional assessments must I obtain on a child being placed for adoption? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189936 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189936&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189936 03/12/2026 You must share the following with the adoptive family:(1) All information from the licensed physician and from the licensed psychiatrist, psychologist, or other licensed or credentialed professional about the potential impact on the child of existing conditions; and(2) All information about any further testing or assessments that these professionals recommend. Any such tests must be scheduled by the date of placement. Source Note: The provisions of this §749.3351 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3351 What information from the professional assessments must I share with the adoptive family? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189933 03/12/2026 You must make a referral to the Social Security Administration to determine the child's eligibility for Social Security Income (SSI). Source Note: The provisions of this §749.3353 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3353 What other referrals must I make regarding a child who has or may have a disability? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189934 03/12/2026 (a) Except in the case of children one month old and younger, a child must have at least one pre-placement visit with the adoptive family prior to placement. You must base the length, location, and number of visits on the age, development, and needs of the child.(b) You must schedule these visits over a period of time that ensures that both the child and the adoptive family have adequate time to prepare for the placement. The period of time should be based on the age and developmental needs of the child.(c) The planning for the pre-placement visits must include the child, if applicable, the foster parents, and the adoptive parents.(d) You must document the plan for pre-placement visits. Your child placement management staff must approve the plan before visits are initiated. Source Note: The provisions of this §749.3371 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3371 What are the requirements for a child to visit the adoptive family prior to placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189935 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189935&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189935 03/12/2026 (a) Before placing the child into the home, you must have a written agreement with the adoptive parents signed by you and the adoptive parents.(b) You must give a signed copy of this agreement to the adoptive parents and place a copy in the case record.(c) The agreement must specify the following:(1) The parties' agreement to complete the adoption at a specified time;(2) The adoptive parents agreement for you to supervise them prior to the completion of the adoption;(3) That the adoptive parents must notify you before moving their residence prior to the completion of the adoption;(4) That you and the adoptive parents each have the discretion to end the placement prior to the adoption; and(5) The fee and schedule of payment. Source Note: The provisions of this §749.3373 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3373 What must my agreement with the adoptive parents include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189937 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189937&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189937 03/12/2026 This may be done only if the prospective adoptive parent is a:(1) Member of the child's family related by the second degree of consanguinity or affinity; or(2) Foster family with whom the child has been living immediately prior to the request for an adoptive home screening. Source Note: The provisions of this §749.3375 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3375 May I place a child in the home of a prospective adoptive parent before I complete the adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210108 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210108&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210108 03/12/2026 (a) As part of the Health, Social, Educational, and Genetic History report, you must compile the following information for a child you are considering for adoption placement:Attached Graphic(b) In addition, you must document the following in the child's record:Attached Graphic(c) This section does not apply to an adoption by the child's:(1) Grandparent;(2) Aunt or uncle by birth, marriage, or prior adoption; or(3) Stepparent. Source Note: The provisions of this §749.3391 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4463; amended to be effective June 27, 2021, 46 TexReg 3525; amended to be effective April 25, 2022, 47 TexReg 2272; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3391 What information must I compile for a child I am considering for adoptive placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189939 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189939&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189939 03/12/2026 (a) You must provide:(1) Written authorization to care for the child;(2) Written information about the legal status, including if the parental rights to the child have not been terminated; and(3) Written consent for the medical care of the child at the time of the child's placement in the home, if available.(b) You must file a copy of the signed authorizations and consent forms in the child's record and in the adoptive home record. Source Note: The provisions of this §749.3393 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3393 What written authorization must I give adoptive parents at the time of placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210109 03/12/2026 (a) The agency must discuss information about the child and his birth parents with the prospective adoptive parents.(b) According to the Texas Family Code §162.0062, you must inform the prospective adoptive parents of their right to examine the records and other information relating to the history of the child, including the Health, Social, Educational, and Genetic History (HSEGH) report and the child's health history within the HSEGH, if you are required to do a HSEGH for the adoption.(c) Any records or other information examined by the prospective adoptive parents or any written information provided to the prospective adoptive parents must be edited to protect any confidential information.(d) You must also provide the prospective adoptive parents with:(1) Research, which may be suggested reading materials and/or websites, on how any known health issue that the child has and/or any trauma the child has experienced (i.e. abuse or neglect) may impact child development and the family's ability to maintain permanency;(2) Information about the Department of Family and Protective Services (DFPS) adoption assistance programs, if the family may be eligible for such assistance;(3) Information about community services and other resources available to support a parent who adopts a child, including community services and other resources for a child who has suicidal thoughts or attempts suicide; and(4) The options available to the adoptive parent if the parent is unable to care for the adopted child, including working with the parent's post adopt provider about the possibility of post adoption substitute care services or working with the child placing agency that placed the child for adoption regarding any additional services. You should also inform the adoptive parents that the Texas Family Code, §162.026 makes it illegal to informally transfer the custody of an adopted child to a person, unless the person is a relative or stepparent of the child or an adult who has a significant long-standing relationship with the child, or the transfer of custody is a formal transfer of custody of the child through a court. Source Note: The provisions of this §749.3395 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective July 29, 2018, 43 TexReg 4463; amended to be effective April 25, 2022, 47 TexReg 2272; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3395 What information must I provide the adoptive parents prior to or at the time of adoptive placement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189915 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189915&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189915 03/12/2026 During the post-placement period, you must:(1) Ensure the adoptive placement continues to meet the child's needs;(2) Maintain responsibility for the child until the court signs the adoption decree; and(3) Make every effort to see that the adoption is consummated as stipulated within the written agreement, or renegotiate another time frame for when the adoption will be consummated. Source Note: The provisions of this §749.3421 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3421 What are my responsibilities for the child during the post-placement period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210110 03/12/2026 (a) To reduce the risk of adoptive placement breakdown, you must offer counseling services to the adoptive family.(b) Counseling services may be provided by your agency or by an outside counseling resource.(c) The counseling services must provide mental health resources for the child, if applicable, the adoptive parents, and other children in the care of your agency that are placed in the adoptive home, including:(1) Opportunities to debrief to process thoughts and feelings related to a suicide attempt or suicide death;(2) Referrals to community services and other resources for a child who has suicidal thoughts or attempted suicide; and(3) Referrals to grief counseling and suicide survivor support groups.(d) You must ensure that the adoptive family is aware that counseling is available. Source Note: The provisions of this §749.3423 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective September 19, 2022, 47 TexReg 5490. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3423 What responsibility do I have to offer counseling services to the adoptive family? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189917 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189917&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189917 03/12/2026 (a) You must have face-to-face contacts with the child and adoptive parents, as follows: Attached Graphic(b) Contacts not in the home must allow you enough privacy to counsel with the adoptive family and evaluate the placement. (c) After the first six months of placement, you must have at least quarterly face-to-face contacts in the adoptive home with the entire adoptive family until the adoption decree is entered. (d) Contacts must be documented by child placement staff. (e) You may contract with another licensed child-placing agency to make these contacts as long as: (1) The person making the contacts meets the minimum qualifications for a child placement staff in §749.673 of this title (relating to What are the qualifications that an employee must have to perform child placement activities?); (2) The agency submits the required documentation to you; (3) Your child-placement management staff reviews and approves the documentation; and (4) You maintain the documentation in the child's record. Source Note: The provisions of this §749.3425 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3425 What are the requirements for post-placement contacts with the adoptive family and child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189918 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189918&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189918 03/12/2026 (a) The following individuals must assess why the adoption was not completed within the time frame stipulated in the written agreement:(1) Staff who supervise the adoption placement;(2) Any other professional staff involved with the family; and(3) The adoptive family.(b) You must establish a plan for finalizing the adoption and for supervising the placement. The plan must be based upon the assessment. The plan for supervising the placement must require at least quarterly face-to-face contacts in the adoptive home with both parents present.(c) You must document the assessment and the plan.(d) Child placement management staff must:(1) Review the documentation and plan; and(2) Determine whether the assessment and plan will meet the needs of the child for safety, care, and permanency.(e) The adoptive placement must be re-evaluated if consummation of the adoption has not been completed within one year. Source Note: The provisions of this §749.3427 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3427 What must I do if the adoption is not completed within the time frame stipulated in the written agreement? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189920 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189920&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189920 03/12/2026 (a) You must remove the child from the adoptive family if the placement and adoption is not in the best interest of the child and/or the adoptive family.(b) The decision to remove the child must be reviewed and approved by child placement management staff prior to the removal.(c) If the child comes back into your care, you must document the following in the child's record:(1) The circumstances necessitating the removal from the adoptive family; and(2) An update of the child's service plan. Source Note: The provisions of this §749.3431 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3431 What must I do if I determine that the placement cannot be completed and/or is not in the best interest of the child and/or the adoptive family? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189921 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189921&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189921 03/12/2026 (a) You must offer counseling services to the adoptive child and adoptive parents after the adoption is consummated.(b) You may offer these services through your agency or an outside counseling resource. Source Note: The provisions of this §749.3461 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3461 Must I offer counseling services after the adoption is consummated? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189923 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189923&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189923 03/12/2026 (a) You must make reasonable efforts to inform the adoptive parents and/or an adult adoptee, in writing, about supplemental medical, psychological, or psychiatric information, including developing genetic conditions, terminal illnesses, or death of a birth parent, that subsequently comes to your attention. You must document the information provided, the date and method of providing the information, and the names of the persons receiving the information.(b) When an adoptive placement is made, you must tell older adopted children and adoptive parents that you will communicate the information in subsection (a) of this section to them provided that they keep you informed of their whereabouts. You must document when you gave this information to the child and to adoptive parents.(c) When you receive information on the identified topic, you must, at a minimum:(1) Write the adoptive parents and/or adult adoptee at the last known address;(2) If the letter is returned to you as undeliverable, check the telephone directory or Internet search for the city where the adoptive parents and/or adult adoptee were last known to be living;(3) If this action does not locate the adoptive parents and/or adult adoptee, check the record for contact information on family members or others who may have knowledge of the adoptive parents and/or adult adoptee's whereabouts and attempt to contact these persons and obtain forwarding information; and(4) Document your attempts to locate the adoptive parents and/or adult adoptee. Source Note: The provisions of this §749.3463 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3463 If supplemental information concerning birth parents subsequently comes to my attention, what are my responsibilities? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189922 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189922&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189922 03/12/2026 (a) According to Texas Family Code §162.006, you must provide to the adult adoptee a copy of the adoption report that has been edited to protect any confidential information.(b) If the adoptee is younger than 18 years of age, the request for the information must come from or must include the written consent of the adoptee's adoptive parents or managing conservator. Source Note: The provisions of this §749.3465 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES Q ADOPTION SERVICES: CHILDREN §749.3465 What must I do when an adoptee requests his adoption record? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189940 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189940&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189940 03/12/2026 (a) Upon establishing a formal relationship with birth parents, you must provide the following information to them in writing:(1) Alternatives and options to adoption that your policies do not oppose;(2) The services you provide, including counseling and post-adoption services;(3) Adoption registries;(4) Legal rights and responsibilities of both birth parents in regard to:(A) Relinquishment of parental rights;(B) Waivers of Interest;(C) Affidavit of status;(D) Termination of parental rights;(E) Designating the father of a child as "unknown" based on legal requirements; and(F) Paternity registry requirements; and(5) Any assistance available through the agency to meet housing, medical, and prenatal care and other needs;(b) You must provide and discuss this information to birth parents in a language that they understand; and(c) You must document the:(1) Date the information was shared; and(2) Agency staff that shared the information. Source Note: The provisions of this §749.3501 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3501 What information must I provide to birth parents who contact me for services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208681 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208681&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208681 03/12/2026 (a) Child placement staff must have at least:(1) Two face-to-face contacts with birth parents prior to the relinquishment of parental rights over a period of two or more days. At least one interview must be held after the birth of the child. If face-to-face contact with the birth father is not feasible, you must document justification for contacts that are not face-to-face; and(2) Except in cases of relinquishment or involuntary termination of parental rights, quarterly contact with birth parents prior to placement of the child.(b) If the contacts required in subsection (a) of this section cannot be made, you must document that you have exercised reasonable efforts to locate the absent parent, and you must document why the contacts could not be made. Reasonable efforts to locate an absent parent are not required for an alleged biological father whose rights will be terminated under Texas Family Code §161.002(c-1).(c) Contacts must assist birth parents to:(1) Understand their feelings regarding relinquishing the child for adoption;(2) Understand the long-range implications of relinquishing the child for adoption;(3) Freely make a choice regarding relinquishing the child to the agency for adoption. The birth parents must not be pressured to make a decision to place their child for adoption;(4) Express their expectations for adoptive placement, if placement is chosen, and the degree and type of involvement, if any, they desire with adoptive family; and(5) Provide the required Health, Social, Educational, and Genetic History Report (HSEGH) information, if applicable.(d) The following topics must be discussed with the birth parents:(1) Preparation for childbirth, when applicable;(2) Relinquishment or waiver of parental rights;(3) Termination of parental rights; and(4) Counseling in regard to separation, loss, and grief issues.(e) Staff providing the service must document all contacts with birth parents.(f) You may contract with another licensed child-placing agency to make these contacts as long as:(1) The person making the contacts meets the minimum qualifications for a child-placement staff in §749.673 of this title (relating to What are the qualifications that an employee must have to perform child placement activities?);(2) The agency submits the required documentation to you;(3) Your child-placement management staff reviews and approves the documentation; and(4) You maintain the documentation in the child's record. Source Note: The provisions of this §749.3503 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2008, 33 TexReg 6607; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3503 What are the requirements for contacting birth parents that become my clients? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189941 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189941&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189941 03/12/2026 You must comply with all state and federal laws regarding termination of parental rights, including Chapter 161 of the Texas Family Code (relating to Termination of the Parent-child Relationship). Source Note: The provisions of this §749.3521 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3521 What requirements must I follow regarding termination of parental rights? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189942 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189942&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189942 03/12/2026 A parent who signs an affidavit of voluntary relinquishment of parental rights regarding a biological child must also prepare a medical history report form that we issue as required by §161.1031 of the Texas Family Code. If the child is:(1) In the managing conservatorship of Child Protective Services, DFPS must maintain the form and make it available to persons with whom the child is placed; and(2) Placed for private adoption through a licensed child-placing agency, that agency must maintain the form. Source Note: The provisions of this §749.3523 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3523 What specific information must I obtain from birth parents that voluntarily relinquish their parental rights? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189943 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189943&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189943 03/12/2026 (a) Yes. You must offer counseling services to birth parents after the consummation of the adoption.(b) You must ensure that birth parents are notified in writing that counseling services are available through the agency on an ongoing basis.(c) You may provide counseling services directly or through referrals to counseling resources outside your agency. Source Note: The provisions of this §749.3571 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3571 Must I offer counseling services to birth parents after the adoption of their child is consummated? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189945 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189945&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189945 03/12/2026 (a) You must make reasonable efforts to inform birth parents, in writing, about developing genetic conditions, terminal illness, or death of the biological child that comes to your attention.(b) At the time the adoption placement is made, you must tell birth parents that you will communicate the information in subsection (a) of this section to them provided that they keep you informed of their whereabouts.(c) When you receive information on the identified topics, you must document your attempts to locate the birth parents, the information provided, the date and method of providing the information, and the names of the persons receiving the information. Source Note: The provisions of this §749.3573 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES R ADOPTION SERVICES: BIRTH PARENTS §749.3573 What are the requirements to provide information about the child to birth parents after the adoption is consummated? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189971 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189971&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189971 03/12/2026 Prior to establishing any formal relationship with prospective adoptive applicants, you must provide written information regarding:(1) The services you provide, including counseling and post-adoptive services;(2) Fee policies and payment procedures;(3) Agency requirements and procedures;(4) Legal requirements for adoption, including their right to have independent legal counsel for legal consummation. You may require that the legal counsel selected by the applicants be experienced in adoptions. If the attorney selected by the applicants is not experienced in adoptions, you may require the adoptive applicants to have an additional, experienced attorney handle the adoption requirements while allowing oversight by the applicants' choice of attorney; and(5) Adoption registries. Source Note: The provisions of this §749.3601 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3601 What information must I provide to persons inquiring about agency adoption services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189972 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189972&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189972 03/12/2026 An adoptive home screening contains documentation of the following:(1) Interviews with adoption applicants, their families, and collateral contacts as necessary;(2) Information obtained through review of documents, reports, and inspections;(3) Assessment of the information obtained to determine whether applicants meet the requirements for approval as adoptive families;(4) Evaluation of the information obtained in order to make recommendations about the family's capacity for adoption, including the age, number, sex, and special needs of the children the family has the capacity to parent;(5) Assessment of basic care and safety issues, including safety of the environment of the adoptive home; and(6) Review and approval by child placement management staff, including the ages and gender(s) of the children for whom the home is approved, the special needs of the children for whom the home is approved, and the approved capacity of the home. Source Note: The provisions of this §749.3621 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3621 What is an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189951 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189951&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189951 03/12/2026 You must obtain, document, and assess the following information about a prospective adoptive home: Attached Graphic Source Note: The provisions of this §749.3623 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3623 What information must I obtain for the adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189946 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189946&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189946 03/12/2026 Section 162.0025 of the Texas Family Code prohibits any person conducting an adoptive home study from considering membership in the armed forces of the United States, Texas National Guard, National Guard in another state, or in a reserve component of the armed forces of the United States as a negative factor in determining whether the adoptive parent would be a suitable parent or whether an adoption is in the best interests of the child. Source Note: The provisions of this §749.3624 adopted to be effective March 1, 2008, 33 TexReg 1377; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3624 May I consider a prospective adoptive parent's membership in a military organization as a factor in approving an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189947 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189947&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189947 03/12/2026 Interviews for an adoptive home screening must include:(1) At least one individual interview with each prospective adoptive parent;(2) At least one individual interview with each child three years or older living in the home either full or part time;(3) At least one individual interview with any other person living full or part time with the family;(4) At least one joint interview with the adoptive applicants;(5) At least one family group interview with family members living in the home; and(6) At least one interview, by telephone, in person or by letter, with any minor child 12 years old or older or adult child of the adoptive applicants not living in the home. If you cannot reach an adult child to interview, you must document your reasonable efforts to locate the child. Source Note: The provisions of this §749.3625 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3625 Whom must I interview when conducting an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189948 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189948&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189948 03/12/2026 You must document all interviews and attempts to complete interviews. The documentation must be a part of the adoptive home record and include:(1) The date and method used to contact each required person;(2) The date of each interview;(3) Who was present at each interview and their relationship to the adoptive applicants; and(4) A summary of each interview. Source Note: The provisions of this §749.3627 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3627 What must I document regarding interviews for an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189949 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189949&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189949 03/12/2026 (a) Unless the child is already placed in the home for foster care, you must visit the home when all members of the household are present.(b) You must document in the record the date, persons present, their relationship to the prospective adoptive family, and observations made during the visit. Source Note: The provisions of this §749.3629 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3629 What are the requirements for visiting the home during an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189950 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189950&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189950 03/12/2026 (a) You must request information related to the parents' experience and performance as foster and/or adoptive parents from the previous agency and any background information regarding the foster home as described in §749.2447(22) of this title (relating to What information must I obtain for the foster home screening?).(b) If provided, you must evaluate the information as part of your screening and placement decisions regarding the home. You must use the information to evaluate the family's ability to work with specific kinds of behaviors and backgrounds. Source Note: The provisions of this §749.3631 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3631 What are the requirements if adoptive applicants previously adopted a child from another child-placing agency or were previously foster parents for another agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189952 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189952&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189952 03/12/2026 (a) You must update an adoptive home screening for a family seeking adoptive placement:(1) Every 12 months; and(2) After a major life change in the adoptive family.(b) The update must include:(1) A review and any required updating of each category of information required for an adoptive home screening; and(2) Documentation of at least one visit to the adoptive home when all household members are present within the 90-day period before the update is approved by the child placement management staff.(c) No update is required for adoptive homes that also are providing foster care as a foster home verified by your agency. Source Note: The provisions of this §749.3633 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3633 When must I update an adoptive home screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189956 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189956&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189956 03/12/2026 A major life change in the adoptive family includes:(1) Marriage, divorce, separation, death, birth, adoption, or any other change in household composition; or(2) A serious health problem that affects the ability of the adoptive parent to care for children. Source Note: The provisions of this §749.3635 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3635 What is a "major life change in the adoptive family"? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189953 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189953&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189953 03/12/2026 Yes. If prospective adoptive parents plan to adopt another child, either in addition to or instead of the child for whom the screening was done, you must complete a written adoptive home screening update. Source Note: The provisions of this §749.3637 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3637 Must I complete an adoptive home screening update if the prospective adoptive parents plan to adopt another child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189954 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189954&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189954 03/12/2026 (a) Adoptive applicants must submit a sketch of the floor plan of the home showing dimensions and purposes of all rooms in the home.(b) Adoptive applicants must submit a sketch or photo of the outside areas showing areas of the grounds to be used by the child.(c) If the home is providing foster care, you may use the foster care screening information.(d) You must review the sketches and/or photos to determine:(1) Whether there is sufficient space to accommodate the members of the household and the adoptive child(ren); and(2) Any potential safety or health issues. Source Note: The provisions of this §749.3661 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3661 What information must adoptive applicants submit on their home and grounds as a part of their application? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189955 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189955&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189955 03/12/2026 (a) The home must be clean, safe, and free of obvious fire and other hazards. The home must be equipped with smoke detectors.(b) Pets must be vaccinated and treated as recommended by a licensed veterinarian.(c) If the adoptive home has a swimming pool, wading pool, hot tub, or other bodies of water on the premises, you must discuss safety issues and plans to ensure the safety of the child with the adoptive applicants.(d) You must discuss and assess basic care and safety issues depending on the age and specific needs of the child or children being considered for placement in the home. When you select a child for placement in the home, you must discuss issues specific to the child including supervision, special health or behavior risks, and general child care needs according to the experience and training needs of the adoptive parents. Source Note: The provisions of this §749.3663 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3663 What are the basic safety requirements for the home and grounds? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189957 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189957&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189957 03/12/2026 (a) After you accept a family as a potential adoptive placement, you must maintain at least quarterly contact with them.(b) You must discuss any changes in the information that you obtain during the adoption screening.(c) In addition to the quarterly contacts, you must provide education and training in regard to the following as deemed appropriate by the child placement staff:(1) Bonding with adoptive children;(2) Parenting issues and concerns; and(3) Children with special needs, if appropriate.(d) You must document each contact and training that was provided in the family's record, indicating the date, type of contact, and content.(e) You may contract with another licensed child-placing agency to make these contacts as long as:(1) The person making the contacts meets the minimum qualifications for a child-placement staff in §749.673 of this title (relating to What are the qualifications that an employee must have to perform child placement activities?);(2) The agency submits the required documentation to you;(3) Your child-placement management staff reviews and approves the documentation; and(4) You maintain the documentation in the child's record. Source Note: The provisions of this §749.3691 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3691 What contacts must I maintain with adoptive applicants prior to the placement of a child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189958 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189958&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189958 03/12/2026 Your agency must:(1) Ensure the child's needs are met in the adoptive placement;(2) Maintain responsibility for the child until the court has entered the adoption decree; and(3) Offer counseling services to the adoptive family. These services may be provided through referrals outside the agency. Source Note: The provisions of this §749.3721 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3721 What are my agency's responsibilities during the pre-adoption supervisory period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189959 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189959&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189959 03/12/2026 (a) Your agency must make every effort to see that the adoption is consummated as stipulated within the written agreement.(b) You must make an assessment of why the adoption will not be completed according to the time frame in the written agreement in §749.3373(c)(1) of this title (relating to What must my agreement with the adoptive parents include?). The assessment must include:(1) Input from staff who have supervised the adoption placement, professionals who have provided counseling for the family, any other professional staff involved with the family, and the adoptive family; and(2) A plan for finalization of the adoption and for supervision of the placement that is based upon the assessment.(c) The assessment and plan must be documented. Child placement management staff must review the documentation and plan and must determine whether the assessment and plan will meet the needs of the child for safety, care, and permanency.(d) The adoptive placement must be re-evaluated if it has not been completed within one year. Source Note: The provisions of this §749.3725 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3725 If the adoption has not been completed within the stipulated time frame in the written agreement, what actions must my agency take? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189960 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189960&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189960 03/12/2026 Your agency must document in the adoptive home record any changes in the adoptive family that may affect the child and assess the effect of the changes on the child. This includes any major life change in the adoptive family. Source Note: The provisions of this §749.3727 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3727 What actions must my agency take if there are changes to the adoptive family during the post-placement period? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189961 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189961&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189961 03/12/2026 Your agency must remove the child from the adoptive family if the placement and adoption is not in the best interests of the child and/or the adoptive family. The decision to remove the child must be reviewed and approved by child placement management staff prior to the removal. You must document the circumstances necessitating the removal and the child's needs in the child's record. Source Note: The provisions of this §749.3729 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3729 What must my agency do if the placement cannot be completed and/or is not in the best interests of the child and/or the adoptive family? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189962 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189962&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189962 03/12/2026 A post-placement adoptive report is a written evaluation of the assessments and interviews, after the placement of the child, regarding the:(1) Child;(2) Prospective adoptive parent(s);(3) Family of the prospective adoptive parent(s);(4) Environment of the prospective adoptive parent(s) and their family; and(5) Adjustment of all individuals to the placement. Source Note: The provisions of this §749.3741 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3741 What is a post-placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189963 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189963&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189963 03/12/2026 (a) Interviews for a post-placement adoptive report may be conducted in one visit and must include:(1) Individual interviews with each adoptive parent;(2) Individual interviews with each child three years or older living in the home and any other person living full or part-time with the family;(3) A joint interview with the adoptive parents; and(4) A family group interview with all family members living in the home.(b) These interviews are not required for a post-placement adoptive report when a foster family adopts a foster child who has been placed in that home at least six months. Source Note: The provisions of this §749.3743 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3743 Whom must I interview when developing a post-placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189964 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189964&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189964 03/12/2026 You must document in the record all interviews and attempts to interview persons listed in §749.3743 of this title (relating to Whom must I interview when developing a post-placement adoptive report?). The documentation must include the date and method taken to contact each required person, the date of each interview, who was present at each interview, their relationship to the adoptive parents, and a summary of each interview. Source Note: The provisions of this §749.3745 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3745 What must I document regarding interviews for a post-placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189965 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189965 03/12/2026 Yes. You must visit the home when all members of the household are present. You must document in the record the date, persons present, their relationship to the adoptive parents, and observations made during the visit. This visit is not required for a post-placement adoptive report when a foster family adopts a foster child who has been placed in that home at least six months. Source Note: The provisions of this §749.3747 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3747 Is a visit to the home required when developing a post-placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189966 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189966&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189966 03/12/2026 You must conduct the interview for a post-placement adoptive report after the child has resided with the adoptive parent for at least five months, unless otherwise directed by the court. However, you may start developing the post-placement adoptive report (e.g. the gathering of written information) after the placement of the child. Source Note: The provisions of this §749.3749 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3749 When must I develop a post-placement adoptive report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189967 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189967&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189967 03/12/2026 Each interview should focus on the adjustment of the family and the child following the placement of the child. You must also address any items required by §749.3623 of this title (relating to What information must I obtain for the adoptive home screening?) that changed since the adoptive home screening was approved. Source Note: The provisions of this §749.3751 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3751 What issues should an interview for a post-placement adoptive report address? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189968 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189968&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189968 03/12/2026 (a) It must include the following documented information:(1) A summary of all assessments and available information about the child who is the subject of a petition for adoption, including:(A) Health history, social history, educational history, genetic and family history, and other information required by the Texas Family Code, §162.005 and §162.007;(B) History of physical, sexual, or emotional abuse experienced by the child;(C) History of any previous placements, including the date and reasons for placement;(D) The child's understanding of adoptive placement; and(E) The child's legal status;(2) A summary of all assessments, interviews, and available information about the adoptive parents including:(A) The adoptive home screening (See §749.3623 of this title (relating to What information must I obtain for the adoptive home screening?)), including the results of the criminal history and central registry background checks;(B) The birth parents' expectations for adoptive placement and further involvement and the details of agreements for future contact, if any;(C) Individual strengths and weaknesses of the adoptive parents;(D) Observations made relative to the family's interactions with each other;(E) Interviews conducted, as applicable, in accordance with §749.3743 of this title (relating to Whom must I interview when developing a post-placement adoptive report?); and(F) A visit to the home conducted in accordance with §749.3747 of this title (relating to Is a visit to the home required when developing a post-placement adoptive report?);(3) An evaluation of the child's present or prospective physical, intellectual, social, and psychological functioning and needs, and whether the environment will meet those needs;(4) A summary of the adjustment of the family and child in the home during the post-placement period, if appropriate;(5) Sources of information and verification, to the extent possible, of all statements of fact pertinent to the report;(6) The basis for your conclusions or recommendations; and(7) The names and the qualifications of all persons involved in the preparation and evaluation of the report.(b) All persons involved in the preparation and evaluation of the report must sign the report. Source Note: The provisions of this §749.3753 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3753 What information must the post-placement adoptive report include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189969 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189969&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189969 03/12/2026 Yes, you must offer counseling services post-placement and post-adoption. The services may be provided directly or through referrals outside of your agency. Source Note: The provisions of this §749.3771 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3771 Is my agency required to offer counseling services to the adoptive family? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189970 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189970&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189970 03/12/2026 (a) Before you may place another child into the home, you must update the adoptive home screening.(b) The update must include at least one:(1) Individual interview with each applicant;(2) Individual interview with each child three years or older living in the home either full or part time;(3) Individual interview with any other person living full or part time with the family; and(4) Visit to the home while all family members are present.(c) You must complete all other requirements for an adoptive placement.(d) If a subsequent adoption occurs within one year from a previous adoption, in which all of the required home visits and interviews were conducted, an individual interview with each adoptive parent and a home visit with all household members present will meet the interview and home visit requirements. Source Note: The provisions of this §749.3781 adopted to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES S ADOPTION SERVICES: ADOPTIVE PARENTS §749.3781 What are the requirements if adoptive parents apply to adopt another child? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189973 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189973&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189973 03/12/2026 (a) No. This subchapter only regulates child-placing agencies that also provide an assessment services program.(b) Services provided by other individuals, agencies, and organizations are not subject to regulation under this subchapter. Source Note: The provisions of this §749.3801 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3801 Does Licensing regulate all assessment services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189974 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189974&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189974 03/12/2026 (a) The person responsible for the assessment services program must review and approve in writing the determination that your program will be able to provide or obtain all assessment services the child appears to need at intake.(b) The review, determination, and approval must be:(1) In writing, signed, and dated from the person responsible for the assessment services program; and(2) Completed prior to the admission of the child into your assessment services program.(c) The determination on the appropriateness of the program to meet the child's assessment needs must be filed in the child's record if the child is admitted into your assessment services program.(d) You must document in the child's record whether you are:(1) Only providing assessment services to the child; or(2) Also providing other services, such as transitional living services.(e) You must document in the child's record the date of the child's admission into your assessment services program. Source Note: The provisions of this §749.3831 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3831 What are the requirements for approving a child's admission into my assessment services program? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189975 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189975&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189975 03/12/2026 (a) You must complete the child's individual plan for the assessment within 10 days from the date of the child's admission into the program.(b) You must document the plan in the child's record. Source Note: The provisions of this §749.3861 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3861 When must I complete the child's individual plan for the assessment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189976 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189976&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189976 03/12/2026 Admission into the assessment services program begins when:(1) The parent makes the decision to place the child into the assessment services program; and(2) You decide to accept the child for these services. Source Note: The provisions of this §749.3863 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3863 When does admission into the assessment services program begin? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189977 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189977&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189977 03/12/2026 (a) An individual plan for the assessment must include:(1) Time frames for providing all assessment services;(2) Recommendations for the child's care during the assessment process;(3) Any treatment to be provided during the assessment period; and(4) Current data from the caregiver's evaluation of the child's behavior and level of functioning.(b) The common application is not and must not serve as the individual plan for the assessment. Source Note: The provisions of this §749.3865 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3865 What must an individual plan for the assessment include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189978 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189978&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189978 03/12/2026 (a) Your assessment services program must systematically collect information from caregivers throughout the child's participation in the assessment services program. This information includes the caregivers' observations and opinions of the child.(b) You must document this information in the child's record. Your documentation must include your consideration of the caregivers' observations and opinions. Source Note: The provisions of this §749.3869 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3869 How must my assessment services program collect information from a child's caregivers? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189979 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189979&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189979 03/12/2026 (a) The plan for the assessment is complete when it contains the necessary information and the signed approval of the person responsible for the assessment services program or a designated employee who meets the qualifications of a person responsible for the assessment program.(b) The parent must review and be provided a copy of the plan for the assessment. Source Note: The provisions of this §749.3871 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3871 When is the plan for the assessment complete? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189980 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189980&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189980 03/12/2026 (a) The assessment report that is the result of the assessment services is a narrative report that pulls together data from:(1) Professional evaluation reports on the child; and(2) The program's assessment on how the child is managing in the program.(b) The report includes:(1) Recommendations made in other professional evaluations; and(2) Recommendations based on the program's experiences with and assessment of the child.(c) The common application is not and must not serve as the assessment report. Source Note: The provisions of this §749.3891 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3891 What is an assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189981 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189981&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189981 03/12/2026 (a) The assessment report must be completed rapidly, consistent with good practice, in order to allow for a permanent placement as soon as possible.(b) You must complete the assessment report:(1) Within 30 days after you admit the child, if the child is younger than five years old; or(2) Within 45 days after you admit the child, if the child is five years old or older.(c) With the approval of the child's parent, you may extend the time frame for completing the report for an additional 15 days. You must document the need for the extension of time in the child's record.(d) You must complete the assessment report before a planned discharge of the child from the assessment services program. However, additional assessment services may be conducted subsequent to placement if a quick placement is in the best interest of the child.(e) You must provide a copy of the assessment report to the child's parent as soon as the report is complete. Source Note: The provisions of this §749.3893 adopted to be effective January 1, 2007, 31 TexReg 7469; amended to be effective September 1, 2010, 35 TexReg 7522; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3893 When must I complete the assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189982 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189982&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189982 03/12/2026 In addition to the requirements set forth in §749.1133 of this title (relating to What information must an admission assessment include?), a written assessment report must include:(1) Copies and results of the determination of the child's basic health and social and developmental assessment, including:(A) The child's basic health status, as determined under the supervision of a licensed physician;(B) The child's basic social and developmental needs, as determined under the supervision of the person responsible for the assessment services program or a designated employee who meets the qualifications for a person responsible for the assessment program;(C) Recommendations for any further assessment services and testing; and(D) An assessment of the child's immediate and extended family in terms of an ongoing relationship with the child;(2) Copies and results of all evaluations and testing;(3) A summary of the primary caregivers' evaluations of the child's behavior and level of functioning;(4) An assessment of the results and summary in terms of appropriate short- and long-term planning for the child;(5) Recommendations for placement; and(6) A recommended behavior management plan based on the assessment results and the primary caregivers' evaluations of the child's behavior and level of functioning. Source Note: The provisions of this §749.3895 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3895 What must be included in the written assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189983 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189983&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189983 03/12/2026 (a) The following people must review the assessment report:(1) The person responsible for the assessment program or a designated employee who meets the qualifications of a person responsible for the assessment program;(2) The child's primary caregiver; and(3) The child's parent.(b) The person responsible for the assessment program, or the designated qualified employee, must approve and sign the report.(c) You must file the original, approved and signed assessment report, including any addendums to the report, in the child's record. Source Note: The provisions of this §749.3897 adopted to be effective January 1, 2007, 31 TexReg 7469; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES T ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE AN ASSESSMENT SERVICES PROGRAM §749.3897 Who must review and approve an assessment report? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189984 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189984&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189984 03/12/2026 In this subchapter, trafficking victim services means a specialized type of child-care services designed to treat and support trafficking victims, in addition to basic child care services. Source Note: The provisions of this §749.4001 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4001 What does "trafficking victim services" mean when used in this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189985 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189985&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189985 03/12/2026 You must meet the additional rules of this subchapter if you provide trafficking victim services to:(1) 30 or more children; or(2) More than 50% of the children in your care. Source Note: The provisions of this §749.4003 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4003 When am I required to meet the additional rules of this subchapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189991 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189991&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189991 03/12/2026 A child-placing agency that is required to comply with this subchapter must comply with all other rules in this chapter that apply to all child-placing agencies, as well as the rules that apply to a child-placing agency that provides treatment services to children with an emotional disorder, unless any such rule is replaced by a rule in this subchapter, as noted in §749.4007 of this title (relating to What rules in this subchapter replace other rules in this chapter?). Source Note: The provisions of this §749.4005 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4005 In addition to the rules in this subchapter, what other rules in this chapter apply to a child-placing agency? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189986 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189986&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189986 03/12/2026 A child-placing agency that is required to comply with the rules in this subchapter is not required to comply with other rules in this chapter if the rule has been replaced, as specified in the following chart: Attached Graphic Source Note: The provisions of this §749.4007 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4007 What rules in this subchapter replace other rules in this chapter? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189987 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189987&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189987 03/12/2026 You must develop written policies that address how a foster home will:(1) Provide a variety of engaging activities to help trafficking victims develop their skills and independence and gain a sense of personal identity, including providing life skills training for children 14 years of age or older;(2) Tailor education to the child's needs;(3) Provide mentoring services; and(4) Prevent and discourage trafficking victims from running away from the foster home. Source Note: The provisions of this §749.4051 adopted to be effective December 1, 2014, 39 TexReg 9069; amended to be effective June 1, 2016, 41 TexReg 3757; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4051 What additional child-care policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211295 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211295&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211295 03/12/2026 You must develop written policies that address:(1) The measures you will implement to ensure the safety and security of trafficking victims, caregivers, and employees, including measures that address both interior and exterior security while promoting a comfortable and nurturing environment on the grounds of the foster home;(2) Foster parent protocols and procedures for ensuring a safe environment, including how to handle visitors not allowed at the foster home; and(3) Appropriate safeguards with respect to a trafficking victim's access to forms of communication, including telephones, cell phones, computer, internet, mail, and visitors, which may pose a risk of further victimization of the child. Source Note: The provisions of this §749.4053 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 21, 2022, 47 TexReg 8120. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4053 What safety and security policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189989 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189989&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189989 03/12/2026 You must develop written policies that address confidentiality, including policies that:(1) Restrict the disclosure of information, both written and oral, that would identify a child as a trafficking victim, or describe the nature of the victim's trafficking history, other than as needed to serve the victim or comply with other laws;(2) Specify to whom and under what circumstances a caregiver, employee, or volunteer may disclose the location of a foster home; and(3) Specify the circumstances under which a visitor may or may not be allowed at the foster home. Source Note: The provisions of this §749.4055 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4055 What confidentiality policies must I develop? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189990 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189990&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189990 03/12/2026 A treatment director that provides or oversees treatment services for trafficking victims must:(1) Be a psychiatrist or psychologist;(2) Have a master's degree in a human services field from an accredited college or university and three years of experience providing treatment services for trafficking victims or children with an emotional disorder, including one year in a residential setting; or(3) Be a licensed master social worker, a licensed clinical social worker, a licensed professional counselor, or a licensed marriage and family therapist, and have three years of experience providing treatment services for trafficking victims or children with an emotional disorder, including one year in a residential setting. Source Note: The provisions of this §749.4101 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4101 What qualifications must a treatment director have? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189992 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189992&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189992 03/12/2026 Each volunteer whose responsibilities include working with trafficking victims must have one hour of training prior to working with the children. The training must include the following components that explain:(1) The child-placing agency's confidentiality policies; and(2) How the effects of trauma impact working with trafficking victims. Source Note: The provisions of this §749.4103 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4103 Are there additional training requirements for volunteers who have contact with children receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189993 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189993&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189993 03/12/2026 (a) Caregivers and certain employees must complete the following training hours before the noted time frame: Attached Graphic(b) You must document the completion of each training requirement in the appropriate personnel record. Source Note: The provisions of this §749.4151 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4151 What are the pre-service hourly training requirements for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189994 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189994&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189994 03/12/2026 (a) A child-placing agency does not have to provide additional general pre-service training or pre-service training regarding emergency behavior intervention to any caregiver or employee who is exempt from this training by §749.867 of this title (relating to Must I provide pre-service training to a caregiver or employee who was previously a caregiver or employee for a residential child-care operation?). In addition, a caregiver or employee (child-placing agency administrator, treatment director, child placement management staff, child placement staff, or full-time professional service provider) does not have to complete the five hours of pre-service training regarding complex trauma experienced by trafficking victims if the caregiver or employee:(1) During the last 12 months:(A) Worked in a general residential operation that provides trafficking victim services to 25 or more children, or to 30% or more of the operation's children in care; or(B) Was a caregiver or employee for or a child-placing agency that provides trafficking victim services to 30 or more children, or 50% or more of the CPA's children in care; and(2) Has documentation that the caregiver or employee has previously received the five hours of pre-service training.(b) You must document the exemption factors in the appropriate personnel record. Source Note: The provisions of this §749.4153 adopted to be effective December 1, 2014, 39 TexReg 9069; amended to be effective January 1, 2017, 41 TexReg 9944; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4153 Must I provide pre-service training to a caregiver or an employee who was previously a caregiver or employee for another operation? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208682 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208682&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208682 03/12/2026 Caregivers and certain employees must complete the following training hours:Attached Graphic Source Note: The provisions of this §749.4155 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4155 What are the annual training requirements for caregivers and employees? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211296 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211296&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211296 03/12/2026 The four hours of annual training must include:(1) One hour of training in preventing compassion fatigue and secondary traumatic stress; and(2) Three hours of training in areas appropriate to the needs of children for whom the caregiver will be providing care, which may include:(A) Typology of trafficking victims;(B) Manifestations of trauma and practice in trauma informed care;(C) How trafficking victims are manipulated and controlled;(D) Making informed decisions and setting boundaries for trafficking victims;(E) Understanding and avoiding the triggers of trafficking victims;(F) Creating and maintaining nurturing environments for trafficking victims; and(G) Identifying and responding to internal and external safety and security risks at a foster home, including the grounds of a foster home (e.g., high flight risk, potential self-harm, harm to others, internal recruitment, unapproved visitors, and intruders). Source Note: The provisions of this §749.4157 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective December 21, 2022, 47 TexReg 8120. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4157 What areas or topics must the four hours of training regarding trafficking victims include? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189997 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189997&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189997 03/12/2026 In addition to meeting the requirements under §749.1151 of this title (relating to What are the medical requirements when I admit a child into care?):(1) You must ensure that a child receiving trafficking victim services is screened within 72 hours of admission to determine whether there is an immediate need for any of the following types of medical services:(A) A medical examination by a health-care professional; and(B) Medical tests for pregnancy and the following infectious diseases:(i) Hepatitis B;(ii) Hepatitis C;(iii) HIV;(iv) Sexually transmitted diseases (STDs); and(v) Tuberculosis.(2) Each individual screening is not required if:(A) The child was previously placed in a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department;(B) There was a previous screening completed within the last 12 months;(C) You have documentation of the outcome of the screening that was completed;(D) The child did not run away from the operation or get discharged from the program since the previous screening; and(E) There is no clear indication that the child has been injured, victimized, or re-victimized since the previous screening.(3) If the results of the required screening indicate that there is an immediate need for a medical examination or medical tests, you must obtain the medical examination and/or medical tests within five days. Source Note: The provisions of this §749.4251 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4251 Are there additional medical requirements when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189998 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189998&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189998 03/12/2026 Yes, you must ensure that a child receiving trafficking victim services is screened for alcohol and substance abuse within 72 hours of admission. The screening is not required if:(1) You have documentation of:(A) A child's alcohol and substance abuse screening that was conducted within the previous 12 months during the child's placement at a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department; or(B) A professional assessment that was conducted within the previous 12 months that determined whether alcohol and substance abuse services were needed for the child; and(2) There is no clear indication that the child has developed an alcohol or substance abuse dependency since the date of the previous screening or assessment. Source Note: The provisions of this §749.4253 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4253 Must a child I admit for trafficking victim services have an alcohol and substance abuse screening? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189999 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=189999&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 189999 03/12/2026 If an alcohol and substance abuse screening determines a child receiving trafficking victim services may need alcohol or substance abuse treatment, you must:(1) Within 14 days, coordinate and schedule the child for an alcohol and substance abuse professional assessment;(2) Ensure the professional recommendations are carried out; and(3) File documentation of the professional assessment, recommendations, and follow-up in the child's record. Source Note: The provisions of this §749.4255 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4255 What must I do if an alcohol and substance abuse screening determines that a child receiving trafficking victim services may need alcohol or substance abuse treatment? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190000 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190000&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190000 03/12/2026 (a) Within 30 days of admission, you must ensure that a child receiving trafficking victim services is assessed for the following:(1) Post-Traumatic Stress Disorder (PTSD);(2) Depression; and(3) Anxiety.(b) The results of all assessments must be documented in the child's record.(c) Each individual behavioral health assessment is not required if:(1) The child was previously placed at a residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department;(2) There was a previous assessment completed within the last 12 months;(3) You have documentation of the outcome of the child's assessment; and(4) There is no clear indication that the child has developed one of these disorders since the previous assessment. Source Note: The provisions of this §749.4257 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4257 What behavioral health assessments are required when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190001 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190001&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190001 03/12/2026 (a) A specialized professional service provider must:(1) Provide individual counseling to each child receiving trafficking victim services. The counseling must address any issues noted in the behavioral health assessment and whether intervention and additional treatment is needed for sexual assault;(2) Provide family counseling, as appropriate; and(3) Assess the frequency and duration of the counseling.(b) You must document the assessment in the child's record.(c) If a child refuses counseling, you must document this refusal in the child's record.(d) For purposes of this rule, a specialized professional service provider means:(1) A psychiatrist licensed by the Texas State Board of Medical Examiners;(2) A psychologist licensed by the Texas State Board of Examiners of Psychologists;(3) A master's level social worker or higher licensed by the Texas State Board of Social Work Examiners;(4) A professional counselor licensed by the Texas State Board of Examiners and Professional Counselors;(5) A marriage and family therapist licensed by the Texas State Board of Examiners of Marriage and Family Therapists; or(6) A master's level or higher nurse licensed as an Advanced Practice Registered Nurse by the Texas Board of Nursing and board certified in Psychiatric/Mental Health. Source Note: The provisions of this §749.4259 adopted to be effective December 1, 2014, 39 TexReg 9069; amended to be effective June 1, 2016, 41 TexReg 3757; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4259 What mental health services are required for a child receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190002 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190002&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190002 03/12/2026 In addition to the requirements listed in §749.1301 of this title (relating to What are the requirements for a preliminary service plan?), the preliminary service plan for a child receiving trafficking victim services must include a description of the child's immediate:(1) Safety needs; and(2) Behavioral health and treatment care needs. Source Note: The provisions of this §749.4261 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4261 Are there additional requirements for a preliminary service plan when I admit a child for trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190003 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190003&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190003 03/12/2026 (a) In addition to the requirements and items noted in §749.1309 of this title (relating to What must a child's initial service plan include?), the initial service plan for a child receiving trafficking victim services must include:(1) The plans to obtain alcohol treatment, substance abuse treatment, or both, for children who require it;(2) Updated plans for behavioral health treatment, including intervention and treatment services for sexual assault, for children who require it; and(3) A description of any legal services required for the child and how you will assist the child in meeting those needs.(b) You must document all professional consultations, examinations, recommendations, and treatment in the child's record. Source Note: The provisions of this §749.4263 adopted to be effective December 1, 2014, 39 TexReg 9069; amended to be effective June 1, 2016, 41 TexReg 3757; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4263 What additional items must be included in a child's initial service plan? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190004 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=190004&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 190004 03/12/2026 (a) You may admit a young adult into your transitional living program;(b) For other programs and services for trafficking victims, you may admit a young adult into your care if the young adult is determined to be a trafficking victim as stated in §749.61(2)(E) of this title (relating to What types of services does Licensing regulate?) and:(1) Is placed at your child-placing agency directly after being discharged from another residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department; or(2) Is placed at your child-placing agency within 12 months after being discharged from another residential child-care operation regulated by DFPS or a facility operated by the Texas Juvenile Justice Department.(c) A young adult may remain in your care until the young adult's 23rd birthday. Source Note: The provisions of this §749.4265 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4265 May I admit a young adult into care? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208683 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=208683&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 208683 03/12/2026 (a) In addition to the requirements listed in §749.3025 of this chapter (relating to May an adult in care share a bedroom with a child in care?), you must re-assess the behaviors, maturity level, and relationships of each resident to determine whether there are risks to either the child in care or adult in care anytime a resident:(1) Runs away from the foster home and returns to care; or(2) Is discharged from your program and returns to care.(b) The re-assessment must be documented and dated in the child's record. Source Note: The provisions of this §749.4267 adopted to be effective December 1, 2014, 39 TexReg 9069; transferred effective March 9, 2018, as published in the Texas Register February 16, 2018, 43 TexReg 909; amended to be effective April 25, 2022, 47 TexReg 2272. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES V ADDITIONAL REQUIREMENTS FOR CHILD-PLACING AGENCIES THAT PROVIDE TRAFFICKING VICTIM SERVICES §749.4267 May an adult in care share a bedroom with a child in care receiving trafficking victim services? https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226469 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226469&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226469 03/12/2026 These terms have the following meanings in this subchapter.(1) Affinity--Related by marriage, as set forth in Texas Government Code §573.024.(2) Consanguinity--Two individuals are related to each other by consanguinity if one is a descendant of the other, or they share a common ancestor. An adopted child is related by consanguinity for this purpose. Consanguinity is defined in Texas Government Code §573.022. (3) Kinship caregiver--A kinship caregiver:(A) Is a person counted in the child/caregiver ratio for kinship foster care services, including employees, kinship foster parents, contract service providers, and volunteers whose duties include direct care, supervision, guidance, and protection of a kinship foster child, including any person who is solely responsible for a kinship foster child; a child placement staff taking a kinship foster child on an appointment or doctor's visit is an example of a kinship caregiver; and(B) Does not include a babysitter, an overnight care provider, or a respite child-care provider unless the person is:(i) A verified kinship foster parent;(ii) An agency employee;(iii) A contract service provider; or(iv) A volunteer.(4) Kinship foster child--A child in the care of a kinship foster home who:(A) Is related to the kinship foster parents by consanguinity or affinity; or(B) Has, or whose family has a longstanding and significant relationship with the kinship foster parent.(5) Kinship foster home--A foster family home that has a kinship foster parent or parents.(6) Kinship foster home verification--A verification for a kinship foster home. A kinship foster home must meet certain requirements for a non-expiring foster home verification, as provided in this subchapter, and may only care for kinship foster children.(7) Kinship foster parent--A foster parent who:(A) Is related to a foster child by consanguinity or affinity;(B) Has a longstanding and significant relationship with a foster child or the child's family before the child is placed; or(C) Is the spouse of a foster parent who has a longstanding and significant relationship with the foster child or the foster child's family. Source Note: The provisions of this §749.4401 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4401 Definitions for Subchapter W https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226470 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226470&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226470 03/12/2026 (a) A child-placing agency (CPA) must comply with the rules in the following subchapters of this chapter, as applicable, before issuing a kinship foster home verification and while the kinship foster home verification is in effect:(1) Subchapter A (relating to Purpose and Scope);(2) Subchapter B (relating to Definitions and Services);(3) Subchapter C (relating to Organization and Administration); (4) Subchapter D (relating to Reports and Record Keeping); (5) Subchapter E (relating to Agency Staff and Caregivers); (6) Subchapter G (relating to Children's Rights);(7) Subchapter I (relating to Foster Care Services: Service Planning, Discharge);(8) Subchapter L (relating to Foster Care Services: Emergency Behavior Intervention);(9) Subchapter N (relating to Foster Homes: Management and Evaluation); and(10) Subchapter P (relating to Foster-Adoptive Homes and Legal Risk Placements).(b) For the regulation and ongoing monitoring of a kinship foster home, the CPA must comply with the divisions of this subchapter as noted in the following chart.Attached Graphic(c) A foster family home that also provides care to a kinship foster child may follow the rules in this subchapter relating to the direct care of kinship foster children. However, the home must:(1) Be verified as a foster family home; and(2) Follow all other applicable rules in this chapter for the direct care of non-kinship foster children. Source Note: The provisions of this §749.4403 adopted to be effective November 6, 2025, 50TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4403 Scope https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226471 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226471&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226471 03/12/2026 (a) A child-placing agency (CPA) must document completion of all required training, including any training certificates and signed agreements reviewed during pre-verification training, in the appropriate kinship foster home record.(b) Certificates for pediatric first aid and pediatric cardiopulmonary resuscitation must have an expiration date, and the training documented on the certificate must be renewed prior to the expiration date.(c) If the CPA determines that a kinship foster home requires additional training to address areas of non-compliance identified during the CPA's annual evaluation of the kinship foster home, the CPA must document:(1) The additional training topics covered;(2) The curriculum used for each of the kinship caregiver's additional training; and(3) How the CPA determined which additional training topics were appropriate. Source Note: The provisions of this §749.4421 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4421 Documentation of Required Trainings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226472 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226472&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226472 03/12/2026 Prior to a child-placing agency (CPA) verifying a kinship foster home, each kinship caregiver must have pre-verification training that includes:(1) An overview of the relevant and applicable rules of this chapter;(2) The CPA's philosophy, organizational structure, and policies, as well as a description of services and programs the CPA offers;(3) A review of the reasonable and prudent parent standard, including how the kinship caregivers will use the standard to ensure safety in the kinship foster home;(4) A review of the agreements between the CPA and kinship foster parents while the verification is in effect; and(5) A review of the CCR Statement of Foster Parent and Child-Placing Agency Rights and Responsibilities, Form 2907, or a form created by the CPA with the same information. Source Note: The provisions of this §749.4423 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4423 Pre-Verification Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226473 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226473&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226473 03/12/2026 (a) One kinship foster parent must be certified in pediatric first aid and pediatric CPR before a child-placing agency (CPA) issues the kinship foster home verification. Other kinship caregivers, including a second kinship foster parent, must be certified in pediatric first aid and CPR within 90 days after the CPA verifies the home.(b) Pediatric first aid must include training related to rescue breathing and choking.(c) Pediatric CPR training must adhere to guidelines for CPR established by the American Heart Association. Source Note: The provisions of this §749.4425 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4425 Pediatric First Aid and Pediatric Cardiopulmonary Resuscitation (CPR) Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226474 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226474&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226474 03/12/2026 A kinship caregiver must complete the following applicable types of general training within the noted timeframes.Attached Graphic Source Note: The provisions of this §749.4427 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4427 General Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226475 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226475&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226475 03/12/2026 (a) From the date a child-placing agency (CPA) verifies a kinship foster home, the CPA must annually evaluate the kinship foster home to identify any areas of non-compliance with minimum standards. (b) If the CPA identifies areas of non-compliance in the kinship foster home, the CPA must provide all kinship caregivers in that kinship foster home with additional training appropriate to address the areas of non-compliance.(c) For each kinship foster home that provides care to a kinship foster child receiving treatment services for emotional disorders, intellectual disabilities, or autism spectrum disorder, the CPA must provide at least one hour of annual training to each kinship caregiver relating to the treatment services that the kinship foster child receives, regardless of whether the CPA identifies concerns in the home. Source Note: The provisions of this §749.4429 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4429 Additional Training Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226476 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226476&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226476 03/12/2026 (a) A kinship foster home may only provide foster care to kinship foster children. A kinship foster child may be admitted as a regular admission or emergency admission.(b) Each kinship placement must meet the kinship foster child's physical, medical, recreational, educational, and emotional needs as identified in the kinship foster child's admission assessment or the written assessment of the child's needs and strengths by the Texas Department of Family and Protective Services.(c) After a kinship foster child turns 18 years old, the person may remain in care until the person's 23rd birthday to:(1) Transition to independence, including attending college or vocational or technical training;(2) Attend high school, a program leading to a high school diploma, or GED classes;(3) Complete the child-placing agency's program; or(4) Stay with a minor sibling.(d) A young adult who turns 18 years old in the care of a kinship foster home may remain in care indefinitely if the person:(1) Continues to need the same level of care; and(2) Is unlikely to physically or intellectually progress over time.(e) The CPA may admit a young adult into the care of a kinship foster home if the person:(1) Comes immediately from another residential child-care operation;(2) Meets the conditions of subsection (d) of this section; and(3) Is in the care of the Texas Department of Family and Protective Services. Source Note: The provisions of this §749.4441 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4441 Admission Criteria https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226477 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226477&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226477 03/12/2026 A child-placing agency (CPA) must document the following in the kinship child's record:(1) Initial admission information;(2) The admission assessment;(3) The signed placement agreement; and(4) Post-placement contacts. Source Note: The provisions of this §749.4443 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4443 Documentation of Admission Information https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226478 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226478&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226478 03/12/2026 For each kinship foster child living in the kinship foster home at the time of verification or who is subsequently placed in the home, a child-placing agency (CPA) must obtain the following information prior to verifying the home or admitting the kinship foster child:(1) A brief description of the circumstance that led to the kinship foster child's placement in the kinship foster home;(2) Current health status, chronic or acute health conditions, such as asthma, diabetes, or allergies, and medication the kinship foster child is taking;(3) Identification of the kinship foster child's high-risk behaviors, if applicable; suicide risk screening, if required; and supervision needs;(4) Known contraindication to the use of restraint; and(5) Any safety plans kinship caregivers will implement related to the behaviors or risk factors. Source Note: The provisions of this §749.4445 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4445 Initial Requirements at the Time of Admission or Verification https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226479 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226479&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226479 03/12/2026 A placement agreement is a child-placing agency's (CPA's) agreement with the kinship foster child's parent or the kinship foster child that defines the CPA's roles and responsibilities and authorizes the CPA to obtain or provide services for the kinship foster child. The placement agreement must include:(1) Authorization permitting the CPA to care for the kinship foster child;(2) A medical consent form signed by a person authorized by the Texas Family Code to provide consent; and(3) The reason for placement and anticipated length of time in care. Source Note: The provisions of this §749.4447 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4447 Placement Agreement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226480 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226480&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226480 03/12/2026 (a) A child-placing agency (CPA) must use the information obtained during the admission assessment to facilitate service planning and evaluate whether the placement is appropriate for the kinship foster child.(b) The admission assessment must be complete within the following timeframe.Attached Graphic(c) The admission assessment must include:(1) A description of the circumstances that led to the kinship foster child's referral for substitute care;(2) A description of the kinship foster child's behavior, including appropriate and maladaptive behavior and any high-risk behavior;(3) Any history of physical, sexual, or emotional abuse or neglect;(4) Current medical status, including the available results of any medical and dental examinations;(5) Current mental health and substance abuse status, including available results of any psychiatric evaluation, psychological evaluation, or psychosocial assessment;(6) The child's current developmental, educational, and behavioral level of functioning;(7) The kinship foster child's social history, including information about the past and existing relationship with the kinship foster child's birth parents, siblings, and extended family members and the quality of those relationships with the child;(8) The kinship foster child's criminal history, if applicable;(9) A determination how the CPA can meet the needs of the kinship foster child and the services the CPA plans to provide; and(10) If the child is at least three years of age, the most recent copy of the written assessment of the child's needs and strengths by the Texas Department of Family and Protective Services (DFPS).(d) The written assessment of the child's needs and strengths by DFPS may be used in place of completing the admission assessment. If the DFPS assessment is used in place of the admission assessment, it must be requested and reviewed within the timeframe established in subsection (b) of this section.(e) The competed admission assessment or written assessment of the child's needs and strengths by DFPS must be shared with the kinship foster parents. Source Note: The provisions of this §749.4449 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4449 Admission Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226481 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226481&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226481 03/12/2026 (a) Child placement staff must have monthly face-to-face contact with a kinship foster child.(b) Monthly visits must meet the following requirements:(1) At least half of the contacts must occur in the foster home;(2) The child placement staff must ensure that the kinship foster child is safe and their basic needs are being met;(3) The visits must:(A) Be for a length of time to address the needs of a kinship foster child who is verbal, or observe the kinship foster child if they are non-verbal;(B) Provide an opportunity to meet privately; and(C) Provide an opportunity for the kinship foster child to express their feelings about how the placement is working out. Source Note: The provisions of this §749.4451 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4451 Post-Placement Contacts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226482 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226482&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226482 03/12/2026 (a) A child-placing agency (CPA) must verify that the following is documented either in the kinship foster child's health passport or in the kinship foster child's record:(1) Each emergency medical and dental visit or hospitalization, including a discharge summary; and(2) Applicable immunization requirements.(b) A kinship foster home must maintain a daily medication log for each controlled substance and psychotropic prescription medication administered to a kinship foster child on a form provided by the CPA. The daily medication log must include:(1) The name of the kinship foster child;(2) The name of the controlled substance or psychotropic medication administered; and(3) The date and time the medication was administered.(c) If a kinship caregiver fails to administer any medication to a kinship foster child according to the medication label or subsequent signed orders, the kinship caregiver must document the following on a form provided by the CPA:(1) The kinship foster child's name;(2) The medication name;(3) A description of the medication error; and(4) How the kinship caregiver ensured the kinship foster child's safety. Source Note: The provisions of this §749.4461 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4461 Documentation Requirements for Medical and Dental Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226483 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226483&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226483 03/12/2026 (a) A kinship foster child must receive timely routine and emergency medical and dental care.(b) At the time of verification, a child-placing agency (CPA) must verify whether a kinship foster child who is at least three years old has had a medical examination within the past year and a dental examination within the past year. If the CPA determines that the child has not had one of these examinations during that time frame, the CPA must develop a plan for the child to receive the examination.(c) All medications must be administered according to the instructions on the label or according to a prescribing health-care professional's subsequent signed order.(d) All medications must be stored securely and in a way that makes them inaccessible to kinship foster children.(e) Each kinship foster child that a child-placing agency admits must meet and continue to meet applicable immunization requirements as specified by the Texas Department of State Health Services. Source Note: The provisions of this §749.4463 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4463 General Medical, Dental, Immunization, and Medication Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226484 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226484&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226484 03/12/2026 A kinship foster parent must ensure a kinship foster child has the opportunity to participate in childhood activities, including unsupervised activities, as much as possible. Childhood activities, including unsupervised activities, must be appropriate in relation to the kinship foster child's age and developmental needs. Source Note: The provisions of this §749.4471 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4471 Normalcy https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226485 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226485&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226485 03/12/2026 (a) Each infant in a kinship foster home must receive individual attention, including play, talking, cuddling, and holding.(b) A kinship caregiver must provide prompt attention to an infant's physical needs, such as feeding and diapering.(c) A kinship caregiver must ensure that the environment is safe for each infant, including:(1) Keeping the area free of objects that may choke or harm the infant; and(2) Ensuring accessible electrical outlets have childproof covers or safety outlets.(d) Items necessary for diaper changing must be kept out of the reach of kinship foster children.(e) A kinship caregiver must never leave an infant unsupervised.(1) A sleeping infant is considered supervised if the kinship caregiver:(A) Is within eyesight or hearing range of the infant and can intervene as needed; or(B) Uses a video camera or audio monitoring device to monitor the infant and is close enough to the infant to intervene as needed.(2) An awake infant is considered supervised if the kinship caregiver is within eyesight of the infant and is close enough to the infant to intervene as needed. For short periods of time during routine household activities, the infant may be out of the kinship caregiver's eyesight, as long as:(A) The infant is within hearing range of the kinship caregiver;(B) The infant's environment is free of any safety hazards; and(C) The kinship caregiver can intervene immediately, as needed. Source Note: The provisions of this §749.4473 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4473 Infants: Basic Care and Supervision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226486 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226486&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226486 03/12/2026 (a) A kinship foster home that provides care to a kinship foster child who is an infant must have an individual crib for the infant. All cribs must:(1) Have a firm, flat mattress that snugly fits the sides of the crib, and the mattress must not be supplemented with additional foam material or pads and must be waterproof or washable;(2) Have sheets that fit snugly and do not present an entanglement hazard;(3) Be bare, except for a tight-fitting sheet, for an infant who is younger than twelve months of age; and(4) Be assembled per the manufacturer's instructions with no loose hardware, damaged parts, or entrapment hazards.(b) A kinship foster home may use a full-sized, portable, or mesh-side crib if:(1) The kinship caregivers follow the manufacturer's instructions; and(2) The crib has mesh that is securely attached to the top of the rails and floor plate, and the folded sides are securely latched in place when raised.(c) The kinship foster home may not use a stackable crib for an infant.(d) A kinship caregiver must never leave an infant in a crib, portable crib, or mesh-side crib with a side folded down.(e) An infant receiving treatment services for primary medical needs may have special items that assist with safe sleep at the written recommendation of a health-care professional. The child-placing agency (CPA) must keep the recommendation in the kinship foster child's record.(f) The CPA must notify the parent of each child in care of each kinship foster home verified by the CPA of any deficiencies relating to subsections (a)(1), (a)(3), or (b)(2) of this section. Source Note: The provisions of this §749.4475 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4475 Infants: Cribs https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226487 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226487&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226487 03/12/2026 (a) A kinship caregiver must place an infant who is unable to turn over without assistance in a face-up sleeping position unless a healthcare professional orders otherwise. A child-placing agency (CPA) must keep any orders from a healthcare professional in the kinship foster child's record.(b) An infant's head, face, or crib must not be covered at any time by any item, including a blanket, linen, or clothing. (c) An infant must not co-sleep with any individual in any location.(d) An infant must not sleep in a restrictive device, such as a car seat, swing, bouncy seat, or highchair. If an infant falls asleep in one of these devices, the kinship caregiver must move the infant to a crib as soon as possible.(e) An infant who can roll over without assistance must not be swaddled.(f) The CPA must notify the parent of each child in care of each kinship foster home verified by the CPA of any deficiencies cited in this section. Source Note: The provisions of this §749.4477 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4477 Infants: Safe Sleep Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226488 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226488&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226488 03/12/2026 A highchair, swing, stroller, infant carrier, rocker, bouncy seat, or similar type of equipment that a kinship foster home uses for an infant must have safety straps fastened when the equipment is in use with the infant. Source Note: The provisions of this §749.4479 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4479 Infants: Equipment Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226489 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226489&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226489 03/12/2026 (a) Kinship caregivers must feed an infant based on the recommendations of the infant's health-care professional.(b) Unless recommendations from the service planning team are contrary, kinship caregivers must hold the infant while feeding the infant if the infant is:(1) Birth through six months old; or(2) Unable to sit unassisted in a highchair or other seating equipment during feeding.(c) Kinship caregivers must never prop a bottle by supporting it with anything other than the infant's or adult's hands.(d) A kinship caregiver who cares for more than one infant must:(1) Sterilize shared bottles or training cups between uses by different infants; and(2) Clean highchair trays before each use. Source Note: The provisions of this §749.4481 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4481 Infants: Feeding Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226490 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226490&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226490 03/12/2026 (a) Each toddler must receive individual attention, including play, talking, and cuddling.(b) A kinship caregiver must ensure that the environment is safe for each toddler, including:(1) Keeping the area free of objects that may choke or harm the toddler; and(2) Ensuring each accessible electrical outlet has a childproof cover or safety outlet.(c) A kinship caregiver must never leave a toddler unsupervised. A toddler is considered supervised if the kinship caregiver: (1) Is within eyesight or hearing range of the child and can intervene as needed; or(2) Uses a video camera or an audio monitoring device to monitor the kinship foster child and is close enough to the child to intervene as needed. Source Note: The provisions of this §749.4483 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4483 Toddlers: Basic Care Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226491 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226491&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226491 03/12/2026 A child-placing agency must ensure information, training, and counseling is available regarding prenatal care, childbirth, and recovery from childbirth. Source Note: The provisions of this §749.4485 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4485 Additional Requirements for Pregnant Kinship Foster Children https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226492 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226492&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226492 03/12/2026 (a) A kinship caregiver who cares for a kinship foster child receiving treatment services for primary medical needs or an intellectual disability must follow recommendations from the kinship foster child's medical providers, including recommendations relating to physical stimulation.(b) A kinship caregiver must ensure that a kinship foster child receiving treatment services for primary medical needs or an intellectual disability has opportunities for sensory stimulation. Source Note: The provisions of this §749.4487 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4487 Additional Requirements for Kinship Foster Children Receiving Treatment Services for Primary Medical Needs or Intellectual Disabilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226493 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226493&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226493 03/12/2026 (a) A child-placing agency (CPA) must arrange appropriate education for each kinship foster child, including:(1) Ensuring the kinship foster child attends an educational facility or program that is approved or accredited;(2) Advocating for the kinship foster child to receive educational and related services to which the child is entitled under provisions of federal and state law and regulations, including the implementation of an individual education plan (IEP) for students receiving special education services; and(3) Ensuring that an education program for a kinship foster child with autism spectrum disorder:(A) Encourages normalization through appropriate stimulation and by encouraging self-help skills; and(B) Is appropriate to the kinship foster child's intellectual and social functioning.(b) For a kinship foster child receiving treatment services, the CPA must designate a liaison between the agency and the kinship foster child's school. Source Note: The provisions of this §749.4489 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4489 Educational Services: General https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226494 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226494&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226494 03/12/2026 Kinship caregivers must:(1) Request Admission, Review, and Dismissal (ARD), Individual Education Plan (IEP), and Individual Transitional Planning (ITP) meetings, if concerned with a kinship foster child's education program or if the kinship foster child does not appear to be making progress;(2) Attend ARD, IEP, ITP meetings, or other school staffings and conferences to represent the kinship foster child's educational best interests; and(3) Know what is in the kinship foster child's IEP and support the school's efforts to implement the IEP, if applicable. Source Note: The provisions of this §749.4491 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4491 Educational Services: Caregiver Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226495 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226495&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226495 03/12/2026 (a) Only a kinship caregiver known to and knowledgeable of a kinship foster child may discipline the child.(b) All disciplinary measures used with a kinship foster child must be consistent with the child's rights related to discipline and punishment. Source Note: The provisions of this §749.4493 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4493 Discipline and Punishment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226496 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226496&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226496 03/12/2026 (a) Each kinship foster parent must be at least 18 years old.(b) A child-placing agency (CPA) may verify only one spouse as a kinship foster parent if:(1) The spouse whom the CPA verifies will be the only one responsible for the day-to-day care of kinship foster children in the home; and(2) The CPA determines that the spouses maintain separate residences.(c) A kinship foster home may not be verified to provide kinship foster services by more than one CPA at a time; however, a home may be verified by one agency to provide kinship foster care services only and approved by another CPA for adoption only. Source Note: The provisions of this §749.4501 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4501 General Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226497 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226497&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226497 03/12/2026 (a) A child-placing agency (CPA) must complete a home screening before verifying a kinship foster home. The CPA may:(1) Complete the home screening as detailed in this section; or(2) Use a completed home assessment obtained from the Texas Department of Family and Protective Services (DFPS) or Single Source Continuum Contractor (SSCC). If the CPA uses the home assessment obtained from DFPS or SSCC, the CPA is responsible for ensuring it meets the requirements of this division.(b) The CPA must update a kinship foster home screening with an addendum any time there is a major life change in the kinship foster family.(c) Through interviewing each prospective kinship foster parent or completing a joint interview, a CPA must obtain, discuss, document, and assess the following information about a prospective kinship foster home.Attached Graphic(d) Regarding (c)(7) in subsection (c) of this section the CPA must report to Child Care Regulation the information obtained about the prospective kinship foster family's domestic violence history, as applicable. The CPA must report this information regardless of whether the CPA verifies the home. Source Note: The provisions of this §749.4503 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4503 Kinship Foster Home Screenings https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226498 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226498&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226498 03/12/2026 A child-placing agency (CPA) must take the following steps to verify a kinship foster home.(1) Complete and document the requirements in this division.(2) Obtain the following:(A) A sketch, photo, or other documentation of the home that shows the purposes of all rooms in the home and identifies the indoor areas for the kinship foster children's use; and(B) A sketch or photo of the outside areas that shows the buildings, driveways, fences, storage areas, gardens, recreation areas, and bodies of water.(3) Evaluate all areas required in this subchapter by:(A) Completing an inspection of the kinship foster home to ensure that the home meets applicable rules relating to Daily Care, Education, and Discipline, and Health and Safety Requirements, Environment, Space and Equipment of this subchapter; and(B) Making recommendations about the home's overall ability to keep kinship foster children safe, paying specific attention to areas of substantial safety risk to kinship foster children and how the CPA addressed areas of identified safety risks with the prospective kinship foster parent before approving and verifying the kinship foster home; and(C) Documenting in the kinship foster home file the details of the inspection of the kinship foster home and any identified safety risks.(4) Obtain from the child placement management staff the review and approval of the home screening, and the recommended verification of the home.(5) Issue a verification certificate that must be posted at the kinship foster home or immediately available for review upon request that includes:(A) The name and address of the kinship foster family;(B) The kinship foster home's total capacity and kinship foster care capacity, including ages and sex of the kinship foster children being served; and(C) The types of services the home provides. Source Note: The provisions of this §749.4505 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4505 Verifying a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226499 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226499&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226499 03/12/2026 (a) For a kinship foster home previously verified by another child-placing agency (CPA), the receiving CPA must conduct and complete a new home screening as required in this subchapter.(b) If the kinship foster home is transferring from another CPA, the receiving CPA must request information about the home by submitting a written request to the agency that transferred the kinship foster home.(c) If the kinship foster home is transferring from another CPA with a child in care, the receiving CPA may verify the kinship foster home prior to completion of the background check. Source Note: The provisions of this §749.4507 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4507 Previously Verified Kinship Foster Homes https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226500 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226500&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226500 03/12/2026 (a) A child-placing agency (CPA) must release background information regarding a current or previous kinship foster home to:(1) Another CPA conducting a foster home screening, pre-adoptive home screening, or post-placement adoptive report; or(2) An independent contractor who is hired or required by the court to conduct a social study under Chapter 107 of the Texas Family Code.(b) Background information includes:(1) The kinship foster home screening and any related documentation or addendums;(2) Documentation of supervisory visits and evaluations for the past year;(3) Any record of deficiencies and their resolutions for the past year, including information regarding pending investigations and unresolved deficiencies;(4) The most current fire and health inspections or checklists;(5) The transfer or closing summary for the kinship foster home;(6) Copies of any current or previous plans to achieve compliance or other type of development plan for the past two years, if applicable; and(7) Copies of any current or previous corrective action or adverse action plans for the past two years, if applicable.(c) A CPA must release the background information to the requesting agency by the 10th day after receiving the written request, including informing the requesting agency of any pending investigations and unresolved deficiencies. By the 10th day after the completion of any pending investigations and the resolution of any deficiencies, the CPA must release to the requesting agency the:(1) Outcome of any investigations and any resulting deficiencies cited; and(2) Resolution of any deficiencies. Source Note: The provisions of this §749.4509 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4509 Releasing Information About a Previously Verified Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226501 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226501&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226501 03/12/2026 (a) A child-placing agency (CPA) must submit information to Child Care Regulation within two business days of:(1) Verifying a new kinship foster home or issuing a temporary kinship foster home verification;(2) Placing a kinship foster home on or taking it off inactive status;(3) Changing conditions of the verification for an existing kinship foster home; and(4) Closing a kinship foster home, including the reason the CPA closed the home.(b) If a CPA changes the conditions of a kinship foster home's verification to allow the home to provide additional services, the child placement management staff must ensure there is no conflict of care with children currently in the home.(c) If the kinship foster home adds a new, unrelated household member, the CPA must:(1) Ensure the individual has the necessary background checks; and(2) Evaluate the impact the individual will have on the kinship foster family and kinship foster children prior to the individual moving into the home. Source Note: The provisions of this §749.4511 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4511 Changes to the Verification Status of a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226502 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226502&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226502 03/12/2026 (a) A child-placing agency (CPA) must complete a transfer summary or closing summary when a kinship foster home transfers to another CPA or closes.(b) A transfer summary and a closing summary must include: (1) A copy of the verification certificate;(2) The kinship foster home's addresses for the past two years and, as needed, directions for rural addresses;(3) The length of time the kinship foster parents have been verified by the CPA;(4) For the kinship foster children that were in care for the last two years, the:(A) Number of kinship children fostered;(B) Type of treatment services provided to each kinship foster child; and(C) Reason for each kinship foster child's discharge from care;(5) A description of any limitations on the verification that were in place for the kinship foster home in caring for and working with kinship foster children;(6) A description of any indicators of risk to children at the time of the transfer or closing;(7) Any plan to achieve compliance or other type of development plan that was in place within the previous 12 months of the date of transfer or closing;(8) Any corrective action or adverse action plan that was in place at the time of transfer or closing; and(9) A statement concerning whether the CPA would recommend the kinship foster home for verification in the future, including whether the CPA would recommend any limitations or restrictions on the verification, and the basis of the CPA's recommendation.(c) A transfer summary must also:(1) Include pending investigations or unresolved deficiencies; and(2) Be completed by the 10th day after a CPA receives a written request to transfer and the transferring CPA must forward it immediately to the requesting CPA.(d) A closing summary must also:(1) Include the reason the home is closing, including whether the CPA required the kinship foster home to close;(2) Include any unresolved deficiencies that have not been corrected and a description of those deficiencies; and(3) Be completed by the 20th day after a kinship foster home is closed. Source Note: The provisions of this §749.4513 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4513 Transferring or Closing a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226503 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226503&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226503 03/12/2026 (a) A child-placing agency (CPA) may issue a temporary kinship foster home verification when a kinship foster home moves from one residence to another. Within 30 days of the kinship foster home moving to the new residence, the CPA must inspect the new residence for compliance with health and safety requirements in this subchapter.(b) Before issuing the non-expiring kinship foster home verification, the CPA must ensure the kinship foster home is compliant with all requirements in this subchapter. (c) A temporary kinship foster home verification is valid for a maximum of six months. Source Note: The provisions of this §749.4515 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4515 Temporary Kinship Foster Home Verifications https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226504 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226504&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226504 03/12/2026 (a) A kinship foster home may care for up to six children regardless of the number of caregivers or ages of the children in the home. This capacity includes kinship foster children, as well as adopted and biological children living in the home, children receiving respite services, and children for whom the kinship foster home provides daycare.(b) A kinship foster home may care for seven or eight children as recommended and approved by the Texas Department of Family and Protective Services and a child-placing agency (CPA). To approve expanding the kinship foster home's capacity, the CPA must:(1) Complete Form 4003 Foster Family Home Capacity Exception; and(2) Request a variance from Child Care Regulation. Source Note: The provisions of this §749.4517 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4517 Capacity and Child/Caregiver Ratio https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226505 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226505&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226505 03/12/2026 (a) The child placement management staff must ensure that supervision of a kinship foster child adequately accounts for:(1) The specific needs of the kinship foster child, including any history of high- risk behaviors that would require additional supervision; and(2) The environment where the supervision is taking place.(b) A kinship caregiver is responsible for:(1) Knowing which kinship foster children the kinship caregiver is responsible for;(2) Providing the level of supervision necessary to ensure each kinship foster child's safety and well-being, including auditory and/or visual awareness of each kinship foster child's ongoing activity as appropriate;(3) Being able to intervene when necessary to ensure each kinship foster child's safety; and(4) Being aware of any special supervision needs based on the kinship foster child's developmental age, maturity, and service plan restrictions.(c) When a kinship foster child participates in an unsupervised childhood activity, the kinship caregiver must know:(1) Where the kinship foster child is scheduled to be, and who they will be with; and(2) How and when the kinship foster child will be returning home. Source Note: The provisions of this §749.4519 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4519 Supervision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226506 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226506&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226506 03/12/2026 (a) A kinship foster child may serve as a babysitter for another kinship foster child if the child placement management staff approves the child to babysit and establishes limits with duration and frequency.(b) A child-placing agency must consider:(1) The developmental age of the child who will provide the babysitting; and(2) Any known history of high-risk behaviors of the child providing the babysitting and the child who will be babysat. Source Note: The provisions of this §749.4521 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4521 Kinship Foster Children as Babysitters https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226507 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226507&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226507 03/12/2026 (a) A kinship foster home may only provide respite services to a kinship foster child.(b) The child placement management staff (CPMS) must approve any respite child-care and ensure that the placement will not cause a conflict of care for any child that is already placed in the home.(c) The CPMS must ensure information is shared about the kinship foster children to ensure continuity of care, including any special supervision requirements or safety plans. Source Note: The provisions of this §749.4523 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4523 Respite Child-Care Services https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226508 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226508&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226508 03/12/2026 A child-placing agency must document the following in the kinship foster home's record:(1) The results of each health inspection or health and safety evaluation;(2) The results of each fire inspection or fire safety evaluation; and(3) A copy of the home's emergency preparedness plan, including any subsequent reviews. Source Note: The provisions of this §749.4551 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4551 Documentation of Health and Safety Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226509 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226509&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226509 03/12/2026 (a) A kinship foster home must have either:(1) A health inspection conducted by the local health authority; or(2) A health and safety evaluation conducted by the child-placing agency's (CPA's) child placement staff using the Environmental Health Checklist for Kinship Foster Homes form.(b) A kinship foster home must also have either:(1) A fire inspection conducted by a state or local fire authority; or(2) A fire safety evaluation developed and conducted by the CPA's child placement staff.(c) A kinship foster home must correct any deficiencies documented during any inspection or evaluation and comply with any conditions or restrictions specified by the inspector or evaluator. Source Note: The provisions of this §749.4553 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4553 Health and Fire Inspections https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226510 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226510&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226510 03/12/2026 (a) A kinship foster home must have a written plan for handling potential disasters and emergencies, including fire and severe weather. The child-placing agency (CPA) that verified the home must annually review and evaluate the plan with all kinship caregivers and kinship foster children in the home. The review of the plan must be provided in the kinship foster child's communication method.(b) The CPA may develop the emergency plan with the kinship foster family or obtain a copy of the emergency plan the family developed with the Texas Department of Family and Protective Services or Single Source Continuum Contractor. Source Note: The provisions of this §749.4555 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4555 Emergency Plans https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226511 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226511&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226511 03/12/2026 (a) A kinship foster home must have a working smoke detector in the following areas:(1) The kitchen;(2) Hallways or open areas outside of sleeping rooms; and(3) On each level of a home with multiple levels.(b) The kinship foster home must have one non-expired, operational fire extinguisher that is accessible in the case of emergency. (c) The kinship foster home must ensure that exits to the home are not blocked. Source Note: The provisions of this §749.4557 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4557 Fire Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226512 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226512&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226512 03/12/2026 Any animal on the premises of a kinship foster home must not pose a health or safety threat to the kinship foster children. Source Note: The provisions of this §749.4559 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4559 Animals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226513 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226513&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226513 03/12/2026 (a) Each child-placing agency (CPA) must have and enforce a policy that addresses the presence of weapons, firearms, explosive materials, and projectiles in a kinship foster home. The policy must contain specific requirements to ensure that a kinship foster child does not have unsupervised access to these items, including requiring a kinship foster parent to keep such items in locked storage when they are not in use.(b) The CPA must determine whether it is appropriate for a specific kinship foster child to use weapons, firearms, explosive materials, or projectiles.(c) No kinship foster child may use a weapon, firearm, explosive material, or projectile unless the kinship foster child is directly supervised by an adult knowledgeable about the use of the weapon, firearm, explosive material, or projectile that is to be used by the kinship foster child.(d) The CPA must determine whether it is appropriate for a specific kinship foster child to use a toy that explodes or shoots. (e) No kinship foster child may use or be around a toy that explodes or shoots unless the kinship foster child is directly supervised by an adult and the toy is age-appropriate for the kinship foster child. Source Note: The provisions of this §749.4561 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4561 Weapons, Firearms, Explosive Materials, and Projectiles in a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226514 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226514&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226514 03/12/2026 (a) When determining if weapons, firearms, explosive materials, and projectiles are stored so that a kinship foster child does not have unsupervised access to such items, the child-placing agency (CPA) must consider the age, history, emotional maturity, and background of the children in the kinship foster home.(b) A CPA may not require the kinship foster home to disclose the specific types of firearms that are stored or otherwise present in the kinship foster home. (c) Firearms that are inoperable and solely ornamental are exempt from the storage requirements in this rule. Source Note: The provisions of this §749.4563 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4563 Storage of Weapons, Firearms, Explosive Materials, or Projectiles in a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226515 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226515&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226515 03/12/2026 (a) When a child-placing agency (CPA) completes a kinship foster home screening, the CPA must ask whether weapons, firearms, explosive materials, or projectiles are present in the kinship foster home. If these items are present, the CPA must review the CPA's weapons, firearms, explosive materials, and projectiles policy and requirements with the prospective kinship foster parents.(b) The kinship foster home record must include documentation on:(1) Whether weapons, firearms, explosive materials, or projectiles are present in the home; and(2) Specific precautions the kinship caregivers will take to ensure kinship foster children do not have unsupervised access.(c) The two-year evaluation of a kinship foster home's compliance with this chapter must include a discussion of whether the kinship foster home has weapons, firearms, explosive materials, or projectiles, and if so, how these items are stored.(d) In complying with this rule, a CPA may not require the kinship foster home to disclose the specific types of firearms that are stored or otherwise present in the kinship foster home.(e) In complying with this rule, a CPA may not require the kinship foster home to notify the CPA if there is any change in the types of firearms that are present in the home. Source Note: The provisions of this §749.4565 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4565 Determining if Weapons, Firearms, Explosive Materials, or Projectiles are Present in a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226516 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226516&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226516 03/12/2026 (a) A kinship caregiver may transport a kinship foster child in a vehicle where firearms (other than handguns), other weapons, explosive materials, or projectiles are present if:(1) All firearms are not loaded;(2) The firearms, other weapons, explosive materials, or projectiles are inaccessible to the kinship foster child; and(3) Possession of the firearm is legal.(b) A kinship caregiver may transport a kinship foster child in a vehicle where a handgun is present if:(1) The handgun is in the possession and control of the kinship caregiver; and(2) The kinship caregiver is not prohibited by law from carrying a handgun. Source Note: The provisions of this §749.4567 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4567 Transporting a Kinship Foster Child in a Vehicle Where Firearms, Explosive Materials, or Projectiles are Present https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226517 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226517&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226517 03/12/2026 (a) A kinship foster home must ensure that indoor and outdoor space and equipment does not pose an undue safety risk to kinship foster children.(b) Kinship caregivers must provide adequate supervision to prevent access to space or equipment that poses a safety risk to a kinship foster child as needed based on the kinship foster child's developmental age, maturity, and service plan restrictions. Source Note: The provisions of this §749.4569 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4569 Physical Environment of a Kinship Foster Home https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226518 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226518&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226518 03/12/2026 (a) Unless approved to share by the child placement management staff (CPMS), each kinship foster child must have the child's own:(1) Sleeping space; and(2) Sleep surface, which may include a bed, mattress, air mattress, futon, or couch.(b) Before approving a kinship foster child to share a sleeping space or sleeping surface, the CPMS must determine and document in the kinship foster child's service plan there is no known risk of harm to the kinship foster child by sharing a sleeping space or sleeping surface with the other individual after assessing:(1) The relationship between the kinship foster child and the individual;(2) The ages and developmental levels of the kinship foster child and the individual, noting that after the kinship foster child's 18th birthday, the kinship foster child may share a bedroom with another youth who is 16 years of age or older, provided the age difference does not exceed two years;(3) The behaviors of the kinship foster child and the individual;(4) Any history of possible sexual trauma or sexually inappropriate behaviors of the kinship foster child and the individual; and(5) Any other identifiable factors that may affect the appropriateness of the individual and the kinship foster child sharing a bedroom.(c) CPMS may not approve an infant to share a sleeping surface. Source Note: The provisions of this §749.4571 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4571 Indoor Space: Sleeping Spaces and Sleeping Surfaces https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226519 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226519&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226519 03/12/2026 A kinship foster home must have at least:(1) one bathroom that allows for privacy;(2) one toilet; and(3) one bathroom sink and one tub or shower that have hot and cold running water. Source Note: The provisions of this §749.4573 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4573 Indoor Space: Bathrooms https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226520 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226520&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226520 03/12/2026 (a) Kinship caregivers must provide a kinship foster child with drinking water and food that is served in a safe and sanitary manner.(b) A kinship home must ensure that all food items are stored in a manner that protects them from contamination, spoiling, and insects and rodents. Source Note: The provisions of this §749.4575 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4575 Nutrition and Food Safety https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226521 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226521&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226521 03/12/2026 (a) Kinship caregivers must utilize safe and reliable transportation for a kinship foster child.(b) Special provisions must be made for transporting non-ambulatory and non-mobile children. When necessary, this may include locks for wheelchairs and hydraulic lifts.(c) A kinship caregiver must secure each kinship foster child in an infant safety seat, rear-facing convertible child safety seat, forward-facing child safety seat, child booster seat, safety vest, harness, or a safety belt, as appropriate to the kinship foster child's age, height, and weight and according to the manufacturer's instructions. Source Note: The provisions of this §749.4577 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4577 Transportation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226522 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226522&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226522 03/12/2026 (a) Any door that leads from the home to an area with a swimming pool, hot tub, or body of water must have:(1) A door alarm; or(2) A lock that is only accessible and operational by an adult unless:(A) The state or local fire authority determines that the lock violates the fire code; and(B) The child-placing agency keeps the fire authority's determination in the kinship foster home record.(b) The bottom of a swimming pool must be always visible.(c) Swimming pool chemicals and machinery rooms must be inaccessible to kinship foster children. Source Note: The provisions of this §749.4579 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4579 Water Safety: Pools, Hot Tubs, and Bodies of Water https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226523 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=226523&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 226523 03/12/2026 (a) Kinship caregivers must inform each kinship foster child about house rules for the use of a swimming pool, hot tub, or other body of water and appropriate safety precautions.(b) Supervision and monitoring of safety features must be adequate to protect any kinship foster child from unsupervised access to the swimming pool, hot tub, or other body of water.(c) Kinship caregivers must ensure that a kinship foster child has access to a lifesaving device when using a swimming pool, hot tub, or body of water.(d) A personal flotation device (PFD) is a vest or suit designed to keep the wearer afloat in water and prevent drowning. A kinship foster child participating in a swimming activity who is unable to swim must wear a PFD that is U.S. Coast Guard-approved for use by a child that is the correct size for the child.(e) Kinship caregivers must be able to clearly see all parts of the swimming pool or hot tub when supervising activity in the area. Source Note: The provisions of this §749.4581 adopted to be effective November 6, 2025, 50 TexReg 7107. 1 HEALTH AND HUMAN SERVICES COMMISSION 749 MINIMUM STANDARDS FOR CHILD-PLACING AGENCIES W KINSHIP FOSTER HOMES §749.4581 Swimming Supervision https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191870 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=191870&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 191870 03/12/2026 (a) As funding allows, a state supported living center (SSLC) may provide the following services to a Medicaid recipient who is not a resident of an SSLC:(1) physical therapy;(2) occupational therapy;(3) speech and language therapy;(4) dental services;(5) primary care provider services;(6) psychiatry services;(7) behavioral health services;(8) adaptive aids; and(9) durable medical equipment.(b) Services are billed according to the appropriate Medicaid fee schedule or negotiated rate with a managed care organization. Source Note: The provisions of this §900.101 adopted to be effective September 1, 2018, 43 TexReg 5387. 1 HEALTH AND HUMAN SERVICES COMMISSION 900 HEALTH AND SPECIALTY CARE SYSTEM B STATE SUPPORTED LIVING CENTER COMMUNITY SERVICES §900.101 Clinical Services to Individuals Residing in the Community https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219747 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219747&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219747 03/12/2026 This chapter applies to an individual or group volunteering at or donating to a facility, other than an individual employed by the Texas Health and Human Services Commission. An employee who wishes to volunteer with a facility should consult HHSC policy and guidelines. Source Note: The provisions of this §901.1 adopted to be effective February 6, 2019, 44 TexReg 479. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY A VOLUNTEER AND COMMUNITY ENGAGEMENT §901.1 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219748 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219748&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219748 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) 501(c)(3) organization--An organization exempt from taxation under Section 501(c)(3) of the Internal Revenue Code.(2) Community relations director--The employee responsible for coordinating a facility's community engagement functions, volunteer programs, fund-raising, and donations.(3) Donation--A contribution of anything of value, such as funds or in-kind goods and services, freely given to a facility, a person served, or a VSC. The term does not include funding under a federal, state, private, or non-profit organization grant for which a facility has submitted a formal written application and is subject to an agreement between the recipient and the donor relating to the use of the grant.(4) Employee--An individual who is legally employed or contracted to perform work for HHSC.(5) Facility--A state supported living center or state hospital.(6) HHSC--The Texas Health and Human Services Commission.(7) Person served--A person receiving services from a facility.(8) Private donor--A person that makes a donation to a facility directly or through a VSC.(9) Volunteer and community relations unit--HHSC employees responsible for promoting individual and community awareness, volunteerism, community collaborations, and partnerships.(10) VSC--Volunteer Services Council--A 501(c)(3) organization formed to generate resources for the benefit of a facility and for a person served and has an established MOU with the designated facility. Source Note: The provisions of this §901.2 adopted to be effective February 6, 2019, 44 TexReg 479. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY A VOLUNTEER AND COMMUNITY ENGAGEMENT §901.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219749 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219749&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219749 03/12/2026 (a) A facility may not accept a donation from a person who is a party to a contested case before HHSC until the 30th day after the date the decision of the case becomes final. "Contested case" has the meaning assigned by Government Code Section 2001.003.(b) A private donor may only use HHSC property or services provided by an HHSC employee under a contract with HHSC. HHSC does not make services or property available to a private donor in exchange for a donation. Source Note: The provisions of this §901.3 adopted to be effective February 6, 2019, 44 TexReg 479. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY A VOLUNTEER AND COMMUNITY ENGAGEMENT §901.3 Limitations on Donations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219750 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219750&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219750 03/12/2026 (a) A VSC may generate resources to enhance the lives of the people served at a facility.(b) The community relations director and volunteer and community relations unit may work with a VSC to enhance fund-raising activities.(c) The state supported living center director and community relations director are nonvoting members of the VSC board associated with the state supported living center.(d) The state hospital superintendent and community relations director are nonvoting members of the VSC board associated with the state hospital.(e) No employee may sign a VSC check or use a VSC debit or credit card.(f) The volunteer and community relations unit may maintain a VSC petty cash fund of up to $300.00 to be used for the benefit of persons served by a facility.(1) The community relations director may make expenditures of up to $300.00 from the petty cash fund on behalf of the VSC for the benefit of persons served.(2) The community relations director must appoint a primary and alternate custodian for the VSC petty cash fund.(3) The primary custodian for the petty cash fund is responsible for maintaining receipts and accurate documentation of all funds disbursed and for furnishing this documentation to the VSC treasurer.(4) An officer of the VSC, or an employee outside of the volunteer and community relations unit, must reconcile the petty cash fund at least once every two months.(g) The volunteer and community relations unit may process and issue receipts for donations to the VSC.(h) A facility may provide the following items of support for the VSC:(1) office space;(2) fund-raising assistance;(3) clerical and administrative services;(4) assistance in the coordination of activities; and(5) other items or services requested by the VSC upon approval by the associate commissioner.(i) Funds generated by the VSC may be used only for:(1) the needs of a person served;(2) the enhancement of existing facility operations;(3) recognition and education projects;(4) new initiatives to improve the quality of life for persons served;(5) employee recognition events; and(6) other expenses specifically authorized by the VSC board of directors.(j) The VSC must not use funds or reference the facility's name or branding for:(1) recognition events, receptions, or gifts for a legislator;(2) political contributions, political advertisements, or lobbying efforts;(3) alcoholic beverages, unless used at an off-campus fund-raising event;(4) loans, including travel advances;(5) operating programs, or contracting for programs on behalf of a facility;(6) cash awards or salary supplementation for employees; and(7) other purposes determined by HHSC to be unethical, unlawful, or inappropriate.(k) All funds and goods donated to the VSC remain the property of the VSC until a facility accepts them.(l) The Health and Specialty Care System has the right to review and approve all VSC donations of real property and any permanent improvements to existing real property that may be donated to a facility by a VSC. Source Note: The provisions of this §901.4 adopted to be effective February 6, 2019, 44 TexReg 479. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY A VOLUNTEER AND COMMUNITY ENGAGEMENT §901.4 Volunteer Services Councils https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219751 03/12/2026 The purpose of this subchapter is to establish policies and procedures for donating and completing a permanent improvement. Source Note: The provisions of this §901.100 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.100 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219752 03/12/2026 The provisions of this subchapter apply to situations in which a donor proposes to donate a permanent improvement. Source Note: The provisions of this §901.102 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.102 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219753 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Asset Management--The Central Office division whose staff are responsible for overseeing TDMHMR's real property.(2) Board--The Texas Board of Mental Health and Mental Retardation.(3) Business entity--A sole proprietorship (including a person), partnership, firm, corporation, holding company, joint-stock company, receivership, trust, or any other entity recognized by law.(4) Community group--A volunteer services council that is affiliated with TDMHMR or a group of people associated with an organization (e.g. civic, fraternal, corporate, religious, social, service, community, or educational).(5) Construction--The implementation of a physical improvement (e.g., erecting, remodeling, renovating, or altering a building or addition thereto, gazebo, pavilion, road, sidewalk, fountain, or pond) and/or installing or extending a building system (e.g., roofing, mechanical, plumbing, or electrical system) that is integral to the durability and habitability of a building (e.g., air conditioning units, water or wastewater distribution lines, electrical wiring located in walls or underground, and subflooring or foundation work).(6) Construction documents--Construction drawings, specifications, and all addenda issued prior to, and all modifications issued after execution of the contract.(7) Dedicated construction account--A unique, restricted interest-bearing account insured by an agency of the federal government that is established for the sole purpose of ensuring that sufficient funds are in place prior to initiating construction of a permanent improvement.(8) Donor--A person, community group, or business entity who wants to donate a permanent improvement.(9) Director, facility community relations--The staff person who is responsible for coordinating the community relations functions, volunteer programs, and fundraising at a facility.(10) Endowment fund--A permanent, restricted fund established and maintained by the volunteer services council to fund, by generating interest income from the principal fund, the ongoing operating expenses for a specific permanent improvement.(11) Facility--A state school, state hospital, state center, or other real property, except Central Office, that is operated by the Texas Department of Mental Health and Mental Retardation (TDMHMR).(12) Facility chief executive officer (CEO)--The chief administrator of a facility.(13) Landscaping--An improvement involving the systematic installation of plant materials (e.g., trees, shrubs, grass, blooming plants, irrigation systems, and/or grading, clearing, or other alteration of the existing topography and composition of the land).(14) Local project manager--A facility staff person designated by the permanent improvement committee who acts on behalf of the permanent improvement committee in dealing with the design professional and contractor for the duration of the improvement's construction.(15) Permanent improvement (improvement)--A facility improvement that requires construction or an improvement consisting of landscaping.(16) Permanent improvement committee (PI committee)--The committee that is appointed by the executive committee of the facility's volunteer services council for the purpose of overseeing and/or donating a permanent improvement.(17) SMHMRFs--State Mental Health and Mental Retardation Facilities.(18) TDMHMR--The Texas Department of Mental Health and Mental Retardation.(19) Volunteer services council (VSC)--A facility's 501(c)(3) organization that is formed for generating resources on behalf of the facility and to appoint a permanent improvement committee to implement permanent improvements.(20) Volunteer services council (VSC) board--The board of directors of the facility's volunteer services council.(21) Volunteer services council (VSC) chair--The primary officer of the board of directors of the facility volunteer services council, elected according to the VSC bylaws. Source Note: The provisions of this §901.104 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.104 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219754 03/12/2026 (a) The facility CEO, with assistance from the director, facility community relations, and the VSC chair, must submit a written description of the proposed permanent improvement (improvement) by completing and submitting the Permanent Improvement Concept form referred to in §417.159 of this title.(b) If the concept is approved by the commissioner or designee as described in §417.155 of this title (relating to Permanent Improvement Approval), the facility CEO with assistance from the director, facility community relations, and the VSC chair, submit a completed Permanent Improvement Proposal form, which is referred to in §417.159 of this title (relating to References).(c) The director, facility community relations, or VSC chair may consult with the donor throughout all phases of the review and approval process, including:(1) the proposal review process;(2) the design, fundraising, and construction review process; and(3) the acceptance process.(d) If requested by the facility CEO, the donor must establish an endowment fund for ongoing maintenance and support for the improvement. Source Note: The provisions of this §901.106 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.106 Permanent Improvement Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219755 03/12/2026 The commissioner or designee must approve all phases of the Permanent Improvement Process as described in the Community Relations Program Manual , permanent improvements section. Source Note: The provisions of this §901.108 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.108 Permanent Improvement Approval https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219756 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219756&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219756 03/12/2026 (a) Following the approval of the proposal, the executive committee of the facility's volunteer services council (VSC) board of directors may act as the PI committee or may appoint a PI committee for each improvement, which comprises: (1) VSC members who are individuals from the community; and (2) facility staff who are nonvoting members of the PI committee. (b) The PI committee must: (1) provide adequate, sufficient documentation prior to initiating construction that funds sufficient to pay for the improvement have been deposited in a dedicated construction account; and (2) implement the improvement according to the phases described in §417.154(c) of this title relating to (Permanent Improvement Process) and the Community Relations Program Manual . Source Note: The provisions of this §901.110 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.110 Responsibilities of the Volunteer Services Councils (VSC) Board, VSC Chair, and Permanent Improvement Committee https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219757 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219757&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219757 03/12/2026 (a) The VSC chair and a member of the PI committee or a designee from the VSC who is not an employee must be designated as co-signers on the dedicated construction account.(b) If conditions warrant, the commissioner or designee may require that the dedicated construction account be established with a third-party escrow agent. Source Note: The provisions of this §901.112 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.112 Dedicated Construction Account Requirements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219758 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219758&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219758 03/12/2026 (a) Upon completing the improvement, the VSC chair or designee notifies the commissioner in writing that the PI committee is ready to convey the improvement to the state.(b) The commissioner acknowledges the acceptance of the improvement in writing to the facility CEO, the VSC chair, and the donor. Source Note: The provisions of this §901.114 adopted to be effective April 27, 2003, 28 TexReg 3352; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4931. 1 HEALTH AND HUMAN SERVICES COMMISSION 901 VOLUNTEER AND COMMUNITY ENGAGEMENT AT A STATE FACILITY C DONATING PERMANENT IMPROVEMENTS TO A STATE FACILITY §901.114 Accepting an Improvement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207444 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=207444&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 207444 03/12/2026 (a) Transfer of an individual committed to a state supported living center (SSLC).(1) An individual committed to an SSLC for residential services may be transferred to a state hospital for mental health care if a licensed physician of the SSLC determines after an examination that care, treatment, and rehabilitation in a state hospital is in the best interest of the individual.(2) The individual will be returned to the SSLC within 30 calendar days unless a court order transferring the individual is obtained by the state hospital as described in paragraph (3) of this subsection.(3) If the state hospital determines hospitalization of the individual is necessary for longer than 30 calendar days, the state hospital will request from the committing court an order transferring the individual to the state hospital. In support of the request, the state hospital will submit two certificates of medical examination for a mental illness to the court, as described in Texas Health and Safety Code §574.011, stating that the individual:(A) is a person with a mental illness; and(B) requires observation or treatment in the state hospital.(4) If the state hospital determines an individual who has been transferred to a state hospital under a court order no longer requires hospitalization, the state hospital will request that the committing court approve the return of the individual to the SSLC, in accordance with Texas Health and Safety Code §594.045.(b) Transfer of an Individual voluntarily admitted to an SSLC. An individual admitted to an SSLC under a regular voluntary admission for residential services may be transferred to a state hospital only if the individual consents to the transfer. Source Note: The provisions of this §902.1 adopted to be effective January 5, 2022, 46 TexReg 9400. 1 HEALTH AND HUMAN SERVICES COMMISSION 902 CONTINUITY OF SERVICES--TRANSFERRING INDIVIDUALS FROM STATE SUPPORTED LIVING CENTERS TO STATE HOSPITALS §902.1 Transfer of an Individual from a State Supported Living Center to a State Hospital https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203331 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203331&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203331 03/12/2026 This chapter implements Texas laws authorizing the transfer of a person with intellectual and developmental disabilities and mental or behavioral health disorders and co-diagnoses receiving services at a state operated facility between Texas and other states. Source Note: The provisions of this §903.1 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203332 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203332&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203332 03/12/2026 This chapter applies to the Texas Health and Human Services Commission (HHSC) state hospitals and state supported living centers (SSLCs), and local authorities. Source Note: The provisions of this §903.2 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203333 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203333&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203333 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context indicates otherwise.(1) Family member--The person's spouse, parent, sibling, adult child, or any individual the person identifies as playing a significant role in their life.(2) HHSC--Texas Health and Human Services Commission.(3) ICC--Interstate compact coordinator. The individual who facilitates the transfer of a person served in Texas state hospitals and SSLCs out-of-state to another state's facility or the transfer of a person from out-of-state psychiatric hospitals and intermediate care facilities for individuals with intellectual disabilities into Texas state hospitals and SSLCs.(4) Informed consent--The knowing agreement of the person or the person's legally authorized representative (LAR) to a proposed transfer. This consent must be given under the person's or LAR's ability to exercise free power of choice without undue pressure or any element of force, fraud, deceit, duress, or other form of constraint or coercion.(5) LAR--Legally authorized representative. An individual authorized by law to make decisions for a person about the matters described in this chapter. The LAR may include a parent, guardian, or managing conservator of a child or adolescent, or a guardian of an adult.(6) Local authority--An entity designated by HHSC in accordance with the Texas Health and Safety Code §533.035(a).(7) Person--An individual who is eligible for care, treatment, or supervision at an SSLC or state hospital, as determined by the laws of the sending state, and for whom interstate transfer is requested.(8) SSLC--State supported living center. An intermediate care facility for individuals with an intellectual disability or related condition that HHSC operates.(9) State hospital--A psychiatric hospital with an inpatient component that HHSC operates.(10) Transfer--Moving a person from a facility in one state to a facility in a different state under Texas Health and Safety Code §571.008; Texas Health and Safety Code §533A.011 and §533.014(a)(3); or the Interstate Compact on Mental Health, Texas Health and Safety Code Chapter 612. Source Note: The provisions of this §903.3 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203334 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203334&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203334 03/12/2026 (a) To transfer a person to a state operated facility in another state from a Texas state hospital or SSLC:(1) the person must be a resident or former resident of the receiving state;(2) the person's LAR must live in the receiving state; or(3) the person must have a family member living in the receiving state who will play a significant role in the person's life.(b) To transfer a person from a state operated facility in another state to a Texas state hospital or SSLC:(1) the person must be a resident of Texas;(2) the person's LAR must live in Texas; or(3) the person must have a family member living in Texas who will play a significant role in the person's life. Source Note: The provisions of this §903.4 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.4 Prerequisite for Transfer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203335&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203335 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203335&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203335 03/12/2026 (a) A person with a mental illness or an intellectual or developmental disability who is involuntarily committed by another state and who transfers to Texas may be detained for up to 96 hours. To detain a person for more than 96 hours, one of the following must apply:(1) a voluntary admission to a Texas state hospital or SSLC;(2) an order of protective custody; or(3) a commitment order of a Texas court.(b) An appropriate court in the county of a state hospital or local authority's service area may conduct commitment proceedings of a person transferred to the state hospital or local authority from another state.(c) Court commitment of a person with intellectual and developmental disabilities to an SSLC is governed by Texas Health and Safety Code §593.041 and §593.052.(d) Voluntary admission of a person with an intellectual and developmental disability to an SSLC is governed by Texas Health and Safety Code Chapter 593, Subchapters A and B and 40 TAC Chapter 2, subchapter F (relating to Continuity of Services--State Facilities).(e) Voluntary admission of a person with mental illness to a state hospital is governed by Chapter 306, subchapter D of this title (relating to Mental Health Services--Admission, Continuity, and Discharge) and Texas Health and Safety Code Chapter 572. Source Note: The provisions of this §903.5 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.5 Legal Basis for Institutionalization https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203336 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203336&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203336 03/12/2026 The Texas ICC coordinates requests for interstate transfer to or from Texas. Anyone interested in an interstate transfer may contact the Texas ICC by email at Interstate_Compact_Coordination@hhsc.state.tx.us or by mail at HHSC, Texas ICC, P.O. Box 12668, Austin, Texas 78711-2668. The Texas ICC must not discriminate on the grounds of race, color, national origin, religion, sex, age, disability, or political affiliation. Source Note: The provisions of this §903.6 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.6 Coordinating Requests for Interstate Transfer https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203337 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203337&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203337 03/12/2026 (a) A letter of request for interstate transfer of a person with mental illness or intellectual and developmental disabilities from a state hospital or SSLC must be sent to the Texas ICC by email (preferred) or mail.(b) State hospital or SSLC staff must discuss the proposed transfer and the person's preference with the person, the person's LAR, and the person's family, or, if appropriate, other available sources to ascertain whether the transfer is in the person's best interest.(c) If the transfer will not occur, the Texas ICC must provide written notification to the person or LAR and the individual who requested the transfer that the transfer will not occur and the reason for not proceeding with the transfer.(d) The Texas ICC must contact the receiving state's ICC and make a reasonable effort to obtain authorization for the transfer if HHSC determines the transfer of a person is in the person's best interest.(e) If the person is proposed to be transferred from a state hospital or SSLC to a facility in another state that is a party to the interstate compact, HHSC must not take final action without the approval of the committing Texas court.(f) If the receiving state decides to accept the person for immediate transfer, then the state hospital or SSLC must:(1) make all travel arrangements, including coordinating with the facility in the receiving state to assist with travel inside the receiving state;(2) be responsible for all transfer expenses;(3) ensure arrangements are made for an escort or escorts to accompany and assist the person to reach their destination;(4) ensure the following items accompany the person upon transfer to the receiving state:(A) all appropriate legal documents;(B) the person's Medicaid, Medicare, or third-party insurance card or cards, if available;(C) copies of all the person's laboratory reports and physical exams conducted within the past 30 days and any additional significant reports made within the past year;(D) all the person's personal belongings at the state hospital or SSLC; and(E) the supply of all prescribed medication as agreed upon by the sending and receiving facilities.(g) The Texas ICC must ensure all authorized parties are informed of the progress made on the transfer request. Source Note: The provisions of this §903.7 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.7 Requests for a person with Mental Illness or Intellectual and Developmental Disabilities to Transfer from Texas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203338 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=203338&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 203338 03/12/2026 (a) A written request for interstate transfer of a person with a mental illness or an intellectual and developmental disability to a Texas state hospital or SSLC must be sent by the requesting state's ICC, or its designee, to the Texas ICC by email to Interstate_Compact_Coordination@hhsc.state.tx.us.(b) The written request must be accompanied by the following information:(1) documentation that the prerequisites for transfer to Texas are met, in accordance with §903.4(b) of this chapter (relating to Prerequisite for Transfer);(2) a consent to the interstate transfer and release of records to the Texas ICC, signed by the person or the person's LAR;(3) the completed "Request for Interstate Transfer" form;(4) a copy of the person's immunization record;(5) a copy of the person's social security card;(6) a copy of the person's birth certificate or appropriate substitute;(7) a copy of the person's diagnosis of mental illness or intellectual and developmental disabilities;(8) a copy of the person's comprehensive medical history, including any medical evaluations, current physician's orders, and list of current medications;(9) a summary of the person's social history and history of mental illness or intellectual and developmental disabilities, including a copy of any psychiatric or psychological evaluations;(10) a copy of the person's current individual habilitation plan and annual planning conference documents for a person with intellectual and developmental disabilities;(11) a copy of the original order of commitment and any renewals and, if required, documentation of approval to transfer from the committing court;(12) a copy of guardianship or other legal documentation pertaining to the person requesting transfer, if applicable; and(13) a brief cover letter signed by the institution's chief executive officer, or designee, stating the circumstances or reasons for requesting the transfer.(c) Upon receipt, the Texas ICC must review the request packet.(1) If the request packet is complete, the Texas ICC must forward it to the appropriate local authority, which may request additional information to determine whether the person is eligible for admission to:(A) a state hospital in accordance with Texas Health and Safety Code Chapters 574 and 575; and Chapter 306, subchapter D of this title (relating to Mental Health Services--Admission, Continuity, and Discharge); or(B) an SSLC in accordance with Texas Health and Safety Code Chapter 591, and 40 TAC Chapter 2, subchapter F (relating to Continuity of Services--State Facilities).(2) If the request packet is incomplete, the Texas ICC contacts the requesting state's ICC and identifies the specific information or documentation that must be received for the transfer to proceed.(d) If the local authority determines the person is eligible for admission, the local authority authorizes admission. The local authority provides written notification to the Texas ICC and the appropriate state hospital or SSLC of the admission authorization. The Texas ICC provides written notification to the requesting state's ICC of the person's eligibility and authorization for admission and includes the name and phone number of the state hospital or SSLC contact.(e) If the local authority determines that the person is not eligible for admission, the local authority provides written notification to the Texas ICC of the person's ineligibility for admission. The Texas ICC provides written notification to the requesting state's ICC of:(1) the person's ineligibility for admission;(2) the person's or LAR's right to provide additional information for consideration in re-determining eligibility, if the person believes incomplete information was used to determine ineligibility; and(3) the person's or LAR's right to contact the Texas Health and Human Services Office of the Ombudsman by mailing Mail Code H-700, P.O. Box 13247, Austin, Texas 78711-3247, or by calling 1-800-252-8154. Source Note: The provisions of this §903.8 adopted to be effective January 18, 2021, 46 TexReg 459. 1 HEALTH AND HUMAN SERVICES COMMISSION 903 INTERSTATE COMPACT ON MENTAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL DISABILITIES §903.8 Requests for a Person with Mental Illness or Intellectual and Developmental Disabilities to Transfer to Texas https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215109 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215109&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215109 03/12/2026 The purpose of this subchapter is to:(1) establish criteria and procedures for:(A) the admission, placement, or commitment of an individual to a state mental retardation facility in accordance with:(i) the Persons with Mental Retardation Act (PMRA);(ii) the Texas Family Code, Chapter 55; and(iii) the Texas Code of Criminal Procedure, §46.02 and §46.03;(B) the transfer of an individual from:(i) one state MR facility to another;(ii) a state MR facility to a state MH facility; and(iii) a state MH facility to a state MR facility;(C) an individual's move to an alternative living arrangement from a state MR facility; and(D) the discharge of an individual from a state MR facility;(2) describe the responsibilities of the mental retardation authority (MRA) for:(A) the admission, placement, or commitment of an individual to a state MR facility;(B) an individual's move to an alternative living arrangement from a state MR facility; and(C) the review of an individual who moved from a state MR facility prior to September 1, 1997, and has an assignment of community placement in CARE; and(3) describe the responsibilities of the ombudsman in the department's Central Office. Source Note: The provisions of this §904.1 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES A GENERAL PROVISIONS §904.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215110 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215110&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215110 03/12/2026 This subchapter applies to:(1) state mental retardation facilities (state MR facilities);(2) mental retardation authorities (MRAs);(3) providers; and(4) the department's Central Office. Source Note: The provisions of this §904.3 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES A GENERAL PROVISIONS §904.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220751 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220751&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220751 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise.(1) Actively involved--Significant and ongoing involvement with the individual based on the following:(A) observed interactions of the person with the individual;(B) advocacy for the individual;(C) knowledge of and sensitivity to the individual's preferences, values and beliefs; and(D) availability to the individual for assistance or support when needed.(2) Applicant--An individual seeking residential services in a residential care facility.(3) CARE--A Texas Health and Human Services Commission (HHSC) data system with demographic and other data about an individual who is receiving services and supports or on whose behalf services and supports have been requested.(4) CLOIP--Community living options information process. The activities described in §904.99(a)(2) of this chapter (relating to Consideration of Living Options for Individuals Residing in State MR Facilities) performed by a contract local intellectual and developmental disability authority (LIDDA) to provide information and education about community living options to an individual who is 22 years of age or older residing in a residential care facility and to the individual's legally authorized representative (LAR), if the individual has an LAR.(5) Commissioner--The executive commissioner of HHSC.(6) Community-based Services--Services which include:(A) a Medicaid waiver program in Title XIX, §1915(c) of the Social Security Act, including:(i) the Community Living Assistance and Support Services Program;(ii) the Deaf Blind with Multiple Disabilities Program;(iii) the Home and Community-based Services Program; or(iv) the Texas Home Living Program;(B) an intermediate care facility licensed under the Texas Health and Safety Code (THSC) Chapter 252;(C) services from a local school district;(D) services from the local mental health authority or local behavioral health authority;(E) a home and community support services agency licensed under THSC Chapter 142;(F) local Aging and Disability Resource Center; or(G) services from the local intellectual and developmental disability authority.(7) Consensus--A negotiated agreement that all parties can and will support in implementation. The negotiation process involves the open discussion of ideas with all parties encouraged to express opinions.(8) Contract LIDDA--A LIDDA that has a contract with HHSC to conduct the CLOIP.(9) Contract mental retardation authority (MRA)-- A contract LIDDA.(10) CRCG-- Community Resource Coordination Group. A local interagency group composed of public and private agencies that develops service plans for individuals whose needs can be met only through interagency coordination and cooperation. The group's role and responsibilities are described in the Memorandum of Understanding on Coordinated Services to Persons Needing Services from More Than One Agency, available on the Texas Health and Human Services Commission website at https://crcg.hhs.texas.gov.(11) DADS--The Department of Aging and Disability Services. As a result of the reorganization of health and human services delivery in Texas, DADS was abolished, and its functions transferred to HHSC.(12) Dangerous behavior--Physically aggressive, self-injurious, sexually aggressive, or seriously disruptive behaviors that require a written behavioral intervention plan to prevent or reduce serious physical injury or psychological injury to the person engaging in these behaviors or others.(13) Department--Department of Aging and Disability Services, predecessor agency whose functions have been dissolved and transferred to HHSC.(14) Designated LIDDA--The LIDDA assigned to an individual in the HHSC data system.(15) Designated MRA-- A designated LIDDA.(16) Discharge--The release by HHSC of an individual voluntarily admitted or committed by court order for residential care services from the custody and care of a residential care facility and termination of the individual's assignment to the residential care facility in the HHSC data system.(17) Emergency admission and discharge agreement--A written agreement between the residential care facility, the individual or LAR, and the designated LIDDA that describes:(A) the purpose of the emergency admission, including the circumstances that precipitated the need for the admission and the expected outcomes from the admission;(B) the responsibilities of each party regarding the care, treatment, and discharge of the individual, including how the terms of the agreement are monitored;(C) the length of time of the emergency admission, which is that amount of time necessary to accomplish the purpose of the admission; and(D) the anticipated date of discharge.(18) Facility of record--The residential care facility that serves the local service area assigned to the individual's designated-LIDDA.(19) Family-based alternative--A family setting in which the family provider or providers are specially trained to provide support and in-home care for children with disabilities or children who are medically fragile.(20) Head of the facility--The director of a residential care facility.(21) HHSC--The Texas Health and Human Services Commission.(22) ICAP--Inventory for Client and Agency Planning. A validated, standardized assessment that measures the level of supervision an individual requires and, thus, the amount and intensity of services and supports the individual needs.(23) ICAP service level--A designation that identifies the level of services needed by an individual as determined by the ICAP.(24) IDT--Interdisciplinary team. A team comprised of intellectual disability professionals, paraprofessionals, and other concerned persons, as appropriate, who assess an individual's treatment, training, and habilitation needs and make recommendations for services, including recommendations of whether the individual is best served in a residential care facility or in a community setting.(A) The team must include:(i) the individual;(ii) the individual's LAR, if any; and(iii) persons specified by a LIDDA or a residential care facility, as appropriate, who are professionally qualified or certified or licensed with special training and experience in the diagnosis, management, needs, and treatment of individuals with an intellectual disability.(B) Other participants in IDT meetings may include:(i) other concerned persons whose inclusion is requested by the individual or the LAR;(ii) at the discretion of the LIDDA or residential care facility, persons who are directly involved in the delivery of services to individuals with an intellectual disability;(iii) if the individual is eligible for public school services, representatives of the appropriate school district;(iv) actively-involved family members or friends of the individual who has neither the ability to provide legally adequate consent nor an LAR; and(v) when an individual is a client of the Protection and Advocacy System, a representative of the Protection and Advocacy System.(25) Individual--A person who has or is believed to have an intellectual disability.(26) Intellectual disability--Consistent with THSC §591.003, significantly subaverage general intellectual functioning that is concurrent with deficits in adaptive behavior and originated during the developmental period.(27) Interstate transfer--The admission of an individual to a residential care facility directly from a similar facility in another state.(28) IQ--Intelligence quotient. A score reflecting the level of an individual's intelligence as determined by the administration of a standardized intelligence test.(29) LAR--Legally authorized representative. A person authorized by law to act on behalf of an individual regarding a matter described in this chapter, and may include a parent, guardian, or managing conservator of a minor, or the guardian of an adult.(30) Legally adequate consent--Consent given by a person when each of the following conditions have been met.(A) Legal status. The individual giving the consent:(i) is 18 years of age or older, or younger than 18 years of age and is or has been married or had his or her disabilities of minority removed for general purposes by court order, as described in the Texas Family Code Chapter 31; and(ii) has not been determined by a court to lack capacity to make decisions with regard to the matter for which consent is being sought.(B) Comprehension of information. The individual giving the consent has been informed of and comprehends the nature, purpose, consequences, risks, and benefits of and alternatives to the procedure and the fact that withholding or withdrawal of consent shall not prejudice the future provision of care and services to the individual with an intellectual disability.(C) Voluntariness. The consent has been given voluntarily and free from coercion and undue influence.(31) Less restrictive setting--A setting which allows the greatest opportunity for the individual to be integrated into the community.(32) LIDDA--Local intellectual and developmental disability authority. An entity to which HHSC's authority and responsibility described in THSC §531.002(12) has been delegated.(33) Local service area--A geographic area composed of one or more Texas counties delimiting the population which may receive services from a LIDDA.(34) Mental retardation--Terminology previously used to describe intellectual disability.(35) Minor--An individual under the age of 18.(36) MRA--Mental retardation authority. A LIDDA.(37) Natural support network--Those persons, including family members, church members, neighbors, and friends, who assist and sustain an individual with supports that occur naturally within the individual's environment and that are not reimbursed or purposely developed by a person or system.(38) Ombudsman--An employee of HHSC who is responsible for assisting an individual or a person acting on behalf of an individual with an intellectual or developmental disability (IDD) or a group of individuals with an IDD with a complaint or grievance regarding the infringement of the rights of an individual with an IDD or the delivery of intellectual disability services submitted under THSC §592.039. The ombudsman must explain and provide information on HHSC and LIDDA services, facilities, and programs, and the rules, procedures, and guidelines applicable to the individual denied services, and refer the individual to the appropriate entity to assist the individual in gaining access to an appropriate program or in placing the individual on an appropriate interest list.(39) Permanency planning--A philosophy and planning process that focuses on the outcome of family support for an individual under 22 years of age by facilitating a permanent living arrangement in which the primary feature is an enduring and nurturing parental relationship.(40) Planning team--A team convened by the LIDDA and composed of:(A) the individual;(B) the individual's LAR, if any;(C) actively-involved family members or friends of the individual who has neither the ability to provide legally adequate consent nor an LAR;(D) other concerned persons whose inclusion is requested by the individual with the ability to provide legally adequate consent or the LAR;(E) a representative from the designated LIDDA;(F) a representative from the individual's provider; and(G) when an individual is a client of the Protection and Advocacy System, a representative of the Protection and Advocacy System.(41) PIDA--Persons with an Intellectual Disability Act, Texas Health and Safety Code, Title 7, Subtitle D.(42) PMRA--PIDA.(43) Provider--A public or private entity that delivers services and supports for individuals as an alternative to a residential care facility, including an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), a nursing facility, or an entity that provides waiver services.(44) Related services--Services for school eligible individuals, as defined in Title 34 Code of Federal Regulations §300.34.(45) Residential care facility--A state supported living center or the ICF/IID component of the Rio Grande Center.(46) Respite admission and discharge agreement--A written agreement between the residential care facility, the individual or LAR, and LIDDA, that describes:(A) the purpose of the respite admission, including the circumstances that precipitated the need for the admission and the expected outcomes from the admission;(B) the length of time the individual will receive respite services from the residential care facility; and(C) the responsibilities of each party regarding the care, treatment, and discharge of the individual.(47) School eligible--A term describing those individuals between the ages of three and 22 who are eligible for public education services.(48) Service delivery system--All facility and community-based services and supports operated or contracted by HHSC.(49) Services and supports--Programs and assistance for persons with an intellectual disability that may include a determination of intellectual disability, interdisciplinary team recommendations, education, special training, supervision, care, treatment, rehabilitation, residential care, and counseling, but does not include those services or programs that have been explicitly delegated by law to other state agencies.(50) Significantly subaverage general intellectual functioning--Measured intelligence on standardized general intelligence tests of two or more standard deviations, not including standard error of measurement adjustments, below the age-group mean for the tests used consistent with THSC §591.003.(51) State MH facility--State mental health facility. A state hospital.(52) State MR facility--State mental retardation facility. A residential care facility.(53) State MR facility living options instrument--A written document used to guide the discussion of living options during a planning meeting that results in a recommendation by the IDT of whether the individual should remain in the current living arrangement at the residential care facility or move to an alternative living arrangement.(54) TGC--Texas Government Code.(55) THSC--Texas Health and Safety Code.(56) Waiver services--Home and community-based services provided through a Medicaid waiver program approved by Centers for Medicare and Medicaid Services (CMS), as described in §1915(c) of the Social Security Act. Source Note: The provisions of this §904.5 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; amended to be effective April 2, 2009, 34 TexReg 2154; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397; amended to be effective September 18, 2024, 49 TexReg 7361. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES A GENERAL PROVISIONS §904.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215112 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215112&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215112 03/12/2026 (a) The department will maintain a balanced and effective service delivery system that affords a full range of services and supports to individuals and their families.(1) The continuum of care within the department's service delivery system encompasses residential services in state mental retardation (MR) facilities and community-based ICF/MR programs, waiver services, and those services and supports provided or contracted by a mental retardation authority (MRA).(2) Residential services in a state MR facility are intended to serve individuals with severe or profound mental retardation and those individuals with mental retardation who are medically fragile or who have behavioral problems.(b) If an individual or LAR chooses services in a state MR facility, the MRA serving the local service area where the individual lives will assist the individual or LAR in accessing those services if the individual is eligible, i.e., meets the criteria described in this subchapter for admission or commitment to a state MR facility.(c) It is the policy of the State of Texas to strive to ensure that the basic needs for safety, security, and stability are met for each individual under 22 years of age with a developmental disability. A successful family is the most efficient and effective way to meet those needs. The state and local communities must work together to provide encouragement and support for well-functioning families and ensure that each individual receives the benefits of being a part of a successful permanent family as soon as possible.(d) For an individual residing in a state MR facility, the MRA designated in CARE for that individual is responsible for:(1) maintaining a link between the individual and the individual's home community;(2) ensuring that the individual, LAR, and state MR facility are provided with information concerning alternative living arrangements that may be appropriate for the individual;(3) assisting the individual or LAR who decides to seek an alternative living arrangement in accessing the alternative living arrangement, including working with other MRAs if the alternative living arrangement being sought is outside the designated MRA's local service area; and(4) providing the state MR facility with current, provider-furnished information about services and supports in the MRA's local service area.(e) The MRA and state MR facility will provide the supports and encouragement necessary to ensure that each individual or LAR is able to exercise choice and decision-making authority in all issues related to services and supports.(1) Whether an individual lives in the community or is a resident of a state MR facility, if the individual does not have an LAR and cannot communicate a preference concerning services and supports, the MRA or state MR facility will involve those persons who are actively involved with the individual in discussions regarding services and supports.(2) For the individual residing in a state MR facility, the state MR facility must have procedures in place to ensure that an individual residing in the state MR facility or the individual's LAR is supported in making decisions concerning living options.(3) The following principles support choice and decision-making by the individual or LAR. Each MRA and state MR facility must follow these principles when addressing issues of services and supports.(A) The choices, preferences, expectations, likes, and dislikes of the individual and LAR are the dominant force in discussions about service planning.(B) When considering Medicaid services, the individual with the ability to provide legally adequate consent or LAR is entitled to choose a provider from:(i) a list of ICF/MR Program providers qualified and willing to provide services and supports to that individual; or(ii) a list of waiver program providers serving the area in which the individual or LAR is interested.(C) The individual will be provided with opportunities for appropriate training, counseling, and other learning experiences that may facilitate the exercise of choice and decision-making. If the individual has an LAR, these opportunities will be provided only with the consent of the LAR.(D) Whenever possible, the individual and the LAR will be encouraged to visit a residential setting prior to the individual's admission. If the individual does not have an LAR, persons who are actively involved with the individual will be encouraged to visit a residential setting prior to the individual's admission, unless the individual objects. Source Note: The provisions of this §904.7 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES A GENERAL PROVISIONS §904.7 Department's Philosophy Concerning Continuum of Care https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220752 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220752&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220752 03/12/2026 (a) In accordance with THSC §§593.003, 593.052, and 593.041, except as provided by subsection (b) of this section, an adult may be committed to a residential care facility for residential services only if:(1) the adult is determined to have an intellectual disability in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability);(2) the adult, because of an intellectual disability:(A) represents a substantial risk of physical impairment or injury to self or others; or(B) is unable to provide for and is not providing for the adult's most basic personal physical needs;(3) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting, as demonstrated by documentation that alternative settings have been identified, evaluated, and determined to be unavailable or unable to meet the adult's identified needs;(4) the residential care facility provides habilitative services, care, training, and treatment appropriate to the adult's needs; and(5) a report by an IDT recommending the placement has been completed in accordance with §904.43 of this subchapter (relating to LIDDA IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA during the six months preceding the date of the commitment hearing; and(6) the court determines beyond a reasonable doubt that the adult meets the requirements of subsection (d) of this section and paragraphs (1), (2)(A) or (2)(B), (3), and (4) of this subsection.(b) In accordance with THSC §§593.003, 593.041, 593.0511, and 593.052, an adult may be committed to a residential care facility for residential services without an IDT recommendation only if:(1) the adult is determined to have an intellectual disability in accordance with §304.401 of this title;(2) the guardian of the adult petitions the court to issue a commitment order and shows, because of an intellectual disability, the adult:(A) represents a substantial risk of physical impairment or injury to self or others; or(B) is unable to provide for and is not providing for the adult's most basic personal physical needs;(3) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting, as demonstrated by documentation that alternative settings have been identified, evaluated, and determined to be unavailable or unable to meet the adult's identified needs;(4) the residential care facility provides habilitative services, care, training, and treatment appropriate for the adult's needs; and(5) the court determines beyond a reasonable doubt that the adult meets the requirements of subsection (d) of this section and paragraphs (1), (2)(A) or (2)(B), (3), and (4) of this subsection.(c) An adult with the capacity to give legally adequate consent may be admitted to a residential care facility under a regular voluntary admission for residential services only if:(1) in accordance with THSC §§593.003, 593.013, and 593.026:(A) the adult has been determined to have an intellectual disability in accordance with §304.401 of this title;(B) a report by a LIDDA's IDT recommending the placement has been completed in accordance with §904.43 of this subchapter during the six months preceding the request for admission;(C) HHSC determines space is available in a residential care facility; and(D) the facility director determines that the residential care facility provides services that meet the needs of the adult; and(2) the IDT report referenced in paragraph (1)(B) of this subsection includes the following findings:(A) because of an intellectual disability, the adult:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the adult's most basic personal physical needs;(B) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting, as demonstrated by documentation that alternative settings have been identified, evaluated, and determined to be unavailable or unable to meet the adult's identified needs; and(C) the residential care facility provides habilitative services, care, training, and treatment appropriate for the adult's needs.(d) An adult represents a substantial risk of physical impairment or injury to self or others or is unable to provide for and is not providing for the adult's most basic personal physical needs, as referenced in subsections (a)(2), (b)(2)(A), and (c)(2)(A) of this section, if:(1) the adult's IQ is four or more standard deviations below the mean, (i.e., in the severe or profound range of intellectual disability); or(2) the adult's ICAP service level equals:(A) 1, 2, 3, or 4; or(B) 5 or 6 and the adult:(i) has extraordinary medical needs that would require direct nursing treatment for at least 180 minutes per week if the adult's caregiver were not providing such treatment; or(ii) exhibits incidents of dangerous behavior that would require intensive staff intervention and resources to prevent serious physical injury to the adult or others if the adult's caregiver were not managing such incidents.(e) In accordance with THSC §593.056, a party to a commitment proceeding under subsections (a) or (b) of this section has the right to appeal the judgment to the appropriate court of appeals.(1) The Texas Rules of Civil Procedure apply to an appeal under this section.(2) An appeal under this section shall be given a preference setting.(3) The county court may grant a stay of commitment pending the outcome of the appeal. Source Note: The provisions of this §904.25 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397; amended to be effective September 18, 2024, 49 TexReg 7361. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.25 Criteria for Commitment, Commitment for Residential Services Without an Interdisciplinary Team Recommendation, and Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215114 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215114&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215114 03/12/2026 (a) In accordance with Texas Code of Criminal Procedure (TCCP), Article 46.02, §5, an adult must be committed to the maximum security unit of a facility designated by the department for residential services for a period not to exceed 18 months if:(1) the adult is found incompetent to stand trial for any felony or misdemeanor because of mental retardation; and(2) the court did not make a determination that there is no substantial probability that the adult will become competent in the foreseeable future.(b) In accordance with TCCP, Article 46.02, §6, an adult must be committed to a state MR facility for residential services if:(1) the following criteria are met:(A) the adult is found incompetent to stand trial and there is found no substantial probability that the adult will become competent in the foreseeable future; or(B) the adult has been previously committed to a maximum security unit of a facility under TCCP, Article 46.02, §5, in connection with the same offense; and(2) all charges pending against the adult have not been dismissed; and(3) in accordance with THSC, §§593.003, 593.052, and 593.041:(A) the adult is determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR));(B) the adult, because of mental retardation:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the adult's most basic personal physical needs;(C) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting;(D) the state MR facility provides habilitative services, care, training and treatment appropriate to the adult's needs; and(E) a report by an IDT recommending the placement has been completed in accordance with §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the date of the commitment hearing.(c) In accordance with TCCP, Article 46.02, §7, an adult must be committed to a state MR facility for residential services if:(1) the following criteria are met:(A) the adult is found incompetent to stand trial and there is found no substantial probability that the adult will become competent in the foreseeable future; or(B) the adult has been previously committed to a facility under TCCP, Article 46.02, §5, in connection with the same offense; and(2) all charges pending against the adult have been dismissed; and(3) in accordance with THSC, §§593.003, 593.052, and 593.041:(A) the adult is determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR));(B) the adult, because of mental retardation:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the adult's most basic personal physical needs;(C) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting;(D) the state MR facility provides habilitative services, care, training and treatment appropriate to the adult's needs; and(E) a report by an IDT recommending the placement has been completed in accordance with §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the date of the commitment hearing.(d) In accordance with TCCP, Article 46.02, §8, an adult committed to a state MR facility in accordance with TCCP, Article 46.02, §6, who has felony charges pending or an adult committed to a state MR facility in accordance with TCCP, Article 46.02, §7, who has had felony charges dismissed must be:(1) committed to the maximum security unit of the facility designated by the department; and(2) within 60 calendar days of arrival on the maximum security unit, be transferred to a nonsecurity unit or to a community program designated by the department, unless the adult is determined to be manifestly dangerous by a review board of the department.(e) In accordance with TCCP, Article 46.03, §4(a), an adult may be committed to a state MR facility for residential services if:(1) the adult is found not guilty of criminal conduct by reason of insanity;(2) the conduct did not involve an act, attempt, or threat of serious bodily injury to another person; and(3) in accordance with THSC, §§593.003, 593.052, and 593.041:(A) the adult is determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR));(B) the adult, because of mental retardation:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the adult's most basic personal physical needs;(C) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting;(D) the state MR facility provides habilitative services, care, training and treatment appropriate to the adult's needs; and(E) a report by an IDT recommending the placement has been completed in accordance with §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the date of the commitment hearing.(f) In accordance with TCCP, Article 46.03, §4(b) and (d), an adult must be committed to the maximum security unit of a facility designated by the department for residential services if:(1) the adult is found not guilty of criminal conduct by reason of insanity;(2) the conduct involved an act, attempt, or threat of serious bodily injury to another person; and(3) in accordance with THSC, §§593.003, 593.052, and 593.041:(A) the adult is determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR));(B) the adult, because of mental retardation:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the adult's most basic personal physical needs;(C) the adult cannot be adequately and appropriately habilitated in an available, less restrictive setting;(D) the state MR facility provides habilitative services, care, training and treatment appropriate to the adult's needs; and(E) a report by an IDT recommending the placement has been completed in accordance with §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the date of the commitment hearing.(g) In accordance with TCCP, Article 46.03, §4(b), an adult committed to the maximum security unit of a facility designated by the department as described in subsection (g) of this section, must, within 60 calendar days of arrival on the maximum security unit, be transferred to a nonsecurity unit designated by the department, unless the adult is determined to be manifestly dangerous by a review board of the department.(h) An adult represents a substantial risk of physical impairment or injury to self or others or is unable to provide for and is not providing for the adult's most basic personal physical needs, as referenced in subsections (b)(3)(B), (c)(3)(B), (e)(3)(B), and (f)(3)(B) of this section, if:(1) the adult's IQ is four or more standard deviations below the mean, (i.e., in the severe or profound range of mental retardation);(2) the adult's ICAP service level equals:(A) 1, 2, 3, or 4; or(B) 5 or 6 and the adult:(i) has extraordinary medical needs that would require direct nursing treatment for at least 180 minutes per week if the adult's caregiver were not providing such treatment; or(ii) exhibits incidents of dangerous behavior that would require intensive staff intervention and resources to prevent serious physical injury to the adult or others if the adult's caregiver were not managing such incidents; or(3) the adult meets other objective measures as determined by the department. Source Note: The provisions of this §904.27 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.27 Criteria for Commitment of an Adult under the Texas Code of Criminal Procedure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220753 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220753&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220753 03/12/2026 (a) In accordance with Texas Government Code §546.0208 and §546.0203, before a minor may be committed to a residential care facility for residential services, the CRCG or the LIDDA, if the minor resides in a county that is not served by a CRCG, must fully inform the parent or guardian of all community-based services and any other service and support options for which the minor may be eligible and complete the permanency planning process, as described in §904.171 of this chapter (relating to MRA and State MR Facility Responsibilities).(b) A minor represents a substantial risk of physical impairment or injury to self or others or is unable to provide for and is not providing for the minor's most basic personal physical needs, as referenced in subsections (d)(2) and (e)(2) of this section, if:(1) the minor's IQ is four or more standard deviations below the mean, (i.e., in the severe or profound range of intellectual disability); or(2) the minor's ICAP service level equals:(A) 1, 2, 3, or 4; or(B) 5 or 6 and the minor:(i) has extraordinary medical needs that would require direct nursing treatment for at least 180 minutes per week if the minor's caregiver were not providing such treatment; or(ii) exhibits incidents of dangerous behavior that would require intensive staff intervention and resources to prevent serious physical injury to the minor or others if the minor's caregiver were not managing such incidents.(c) A determination that a minor cannot be adequately and appropriately habilitated in an available, less restrictive setting, as referenced in subsections (d)(3) or (e)(3) of this section, may not be made unless:(1) a CRCG, or the LIDDA, if the minor resides in a county that is not served by CRCG, held a staffing concerning the minor and provided information to the minor's family about available community supports that could serve as an alternative to admission of the minor to a residential care facility;(2) available community supports that could serve as an alternative to admission of the minor to a residential care facility were attempted; and(3) if there are indications that the minor may have a serious emotional disturbance, the minor was assessed by a children's mental health professional to determine if a serious emotional disturbance exists and services to address the serious emotional disturbance were attempted.(d) In accordance with THSC §§593.003, 593.052, and 593.041, except as provided by subsection (e) of this section, a minor may be committed to a residential care facility for residential services only if:(1) the minor is determined to have an intellectual disability in accordance with §304.401 of this title (relating to Conducting a Determination of Intellectual Disability);(2) the minor, because of an intellectual disability:(A) represents a substantial risk of physical impairment or injury to self or others; or(B) is unable to provide for and is not providing for the minor's most basic personal physical needs;(3) the minor cannot be adequately and appropriately habilitated in an available, less restrictive setting;(4) the residential care facility provides habilitative services, care, training, and treatment appropriate to the minor's needs;(5) a report by a LIDDA's IDT recommending the placement has been completed in accordance with §904.43 of this subchapter (relating to LIDDA IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA) during the six months preceding the date of the commitment hearing; and(6) the court determines beyond a reasonable doubt that the minor meets the requirements of subsection (c) of this section and paragraphs (1), (2)(A) or (2)(B), (3), and (4) of this subsection.(e) In accordance with THSC §§593.003, 593.041, 593.0511 and 593.052, a minor may be committed to a residential care facility for residential services without an IDT recommendation only if:(1) the minor is determined to have an intellectual disability in accordance with §304.401 of this title;(2) the parent of a minor petitions the court to issue a commitment order and shows, because of an intellectual disability, the minor:(A) represents a substantial risk of physical impairment or injury to self or others; or(B) is unable to provide for and is not providing for the minor's most basic personal physical needs;(3) the minor cannot be adequately and appropriately habilitated in an available, less restrictive setting;(4) the residential care facility provides habilitative services, care, training, and treatment appropriate to the minor's needs; and(5) the court determines beyond a reasonable doubt that the minor meets the requirements of subsection (c) of this section and paragraphs (1), (2)(A) or (2)(B), (3), and (4) of this subsection.(f) In accordance with THSC §593.056, a party to a commitment proceeding under subsections (d) or (e) of this section has the right to appeal the judgment to the appropriate court of appeals.(1) The Texas Rules of Civil Procedure apply to an appeal under this section.(2) An appeal under this section shall be given a preference setting.(3) The county court may grant a stay of commitment pending the outcome of the appeal. Source Note: The provisions of this §904.29 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397; amended to be effective September 18, 2024, 49 TexReg 7361. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.29 Criteria for Commitment and Commitment for Residential Services Without an Interdisciplinary Team Recommendation of a Minor to a Residential Care Facility Under the PIDA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215116 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215116&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215116 03/12/2026 (a) In accordance with Texas Family Code, §55.33, a minor in the juvenile justice system may be placed in a state MR facility for not more than 90 calendar days if:(1) the minor is found to be unfit to proceed; and(2) the juvenile court determines that the minor meets the commitment criteria described in §412.257 of this title (relating to Criteria for Commitment of a Minor to a State MR Facility Under the PMRA).(b) In accordance with Texas Family Code, §55.52, a minor in the juvenile justice system may be placed in a state MR facility for not more than 90 calendar days if:(1) the minor is found to lack responsibility for the minor's actions; and(2) the juvenile court determines that the minor meets the commitment criteria described in §412.257 of this title (relating to Criteria for Commitment of a Minor to a State MR Facility Under the PMRA). Source Note: The provisions of this §904.31 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.31 Criteria for Placement of a Minor in a State MR Facility for Assessment Under the Texas Family Code https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215117 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215117&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215117 03/12/2026 (a) In accordance with Texas Family Code, §55.41 and §55.60, a minor in the juvenile justice system may be committed to a state MR facility only if:(1) the minor is found to be unfit to proceed or to lack responsibility for the minor's actions pursuant to juvenile charges;(2) the minor is determined to have mental retardation and the mental retardation is the reason that the minor is unfit to proceed or that the minor lacks responsibility for his actions;(3) because of mental retardation, the minor:(A) represents a substantial risk of physical impairment or injury to self or others; or(B) is unable to provide for and is not providing for the minor's most basic personal physical needs;(4) the minor cannot be adequately and appropriately habilitated in an available, less restrictive setting; and(5) the state MR facility provides habilitative services, care, training and treatment appropriate to the minor's needs.(b) A minor represents a substantial risk of physical impairment or injury to self or others or is unable to provide for and is not providing for the minor's most basic personal physical needs, as referenced in subsection (a)(3) of this section, if:(1) the minor's IQ is four or more standard deviations below the mean, (i.e., in the severe or profound range of mental retardation);(2) the minor's ICAP service level equals:(A) 1, 2, 3, or 4; or(B) 5 or 6 and the minor:(i) has extraordinary medical needs that would require direct nursing treatment for at least 180 minutes per week if the minor's caregiver were not providing such treatment; or(ii) exhibits incidents of dangerous behavior that would require intensive staff intervention and resources to prevent serious physical injury to the minor or others if the minor's caregiver were not managing such incidents; or(3) the minor meets other objective measures as determined by the department. Source Note: The provisions of this §904.33 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.33 Criteria for Commitment of a Minor to a State MR Facility Under the Texas Family Code https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215118 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215118&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215118 03/12/2026 A state MR facility will not permit the regular voluntary admission of a minor under the PMRA. Source Note: The provisions of this §904.35 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.35 Criteria for Regular Voluntary Admission of a Minor to a State MR Facility under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215119 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215119&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215119 03/12/2026 (a) In accordance with THSC, §593.027, an individual may be admitted under an emergency admission to a state MR facility for residential services without:(1) the individual having been determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR); or(2) a report by an IDT recommending the placement having been completed in accordance with §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the request for admission.(b) An admission under subsection (a) of this section may occur if:(1) there is persuasive evidence that the individual has mental retardation;(2) the individual has an urgent need for the services;(3) the state MR facility has appropriate space available; and(4) the state MR facility can provide relief within a year after the date of admission. Source Note: The provisions of this §904.37 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.37 Criteria for Emergency Admission of an Adult or a Minor to a State MR Facility Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215120 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215120&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215120 03/12/2026 (a) In accordance with THSC, §593.028, an individual may be admitted to a state MR facility for respite care without:(1) the individual having been determined to have mental retardation in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR); or(2) a report by an IDT recommending the placement having been completed in accordance with subsection §412.264 of this title (relating to IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA) during the six months preceding the request for admission.(b) An admission under subsection (a) of this section may occur if:(1) there is persuasive evidence that the individual has mental retardation;(2) the state MR facility has appropriate space available;(3) the state MR facility provides services that meet the needs of the individual; and(4) the individual or the individual's family urgently requires assistance or relief that can be provided within a period not to exceed 30 calendar days after the date of admission. Source Note: The provisions of this §904.39 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.39 Criteria for Admission of an Adult or a Minor to a State MR Facility for Respite Care Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215121 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215121&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215121 03/12/2026 (a) In accordance with THSC, §593.044, an individual for whom an application for commitment is filed may be taken into protective custody only if the court determines from certificates filed with the court that the individual is:(1) believed to be a person with mental retardation; and(2) likely to cause injury to self or others if not immediately restrained.(b) An individual under an order of protective custody may be detained for not more than 20 calendar days after the date on which the custody begins pending an order of the court.(c) The state MR facility in which an individual is held in protective custody must discharge the individual not later than the 20th day after the date on which custody begins if the court that issued the order of protective custody has not issued a court commitment or further detention orders. Source Note: The provisions of this §904.41 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.41 Criteria for an Order of Protective Custody https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220754 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220754&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220754 03/12/2026 The IDT at a LIDDA must do the following in making a report of its findings and recommendations, as described in §904.25(a)(5) and (c)(1)(B) of this subchapter (relating to Criteria for Commitment, Commitment for Residential Services Without an Interdisciplinary Team Recommendation, and Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA), §904.27(b)(3)(E), (c)(3)(E), (e)(3)(E), and (f)(3)(E) of this subchapter (relating to Criteria for Commitment of an Adult under the Texas Code of Criminal Procedure), and §904.29(d)(5) of this subchapter (relating to Criteria for Commitment and Commitment for Residential Services Without an Interdisciplinary Team Recommendation of a Minor to a Residential Care Facility Under the PIDA) .(1) In accordance with THSC §593.013, the IDT must:(A) interview the individual and the individual's legally authorized representative (LAR);(B) review the individual's:(i) social and medical history;(ii) medical assessment, which must include an audiological, neurological, and vision screening;(iii) psychological and social assessment, including the ICAP; and(iv) determination of adaptive behavior level;(C) determine the individual's need for additional assessments, including educational and vocational assessments;(D) obtain any additional assessments necessary to plan services;(E) identify the individual's or LAR's habilitation and service preferences and the individual's needs;(F) recommend services to address the individual's needs that consider the individual's or LAR's interests, choices, and goals and, for an individual under 22 years of age, the individual's permanency planning goal;(G) give the individual and the individual's LAR an opportunity to participate in IDT meetings;(H) if desired, use a previous assessment, social history, or other relevant record from a school district, public or private agency, or appropriate professional if the IDT determines that the assessment, social history or record is valid;(I) prepare a written report of its findings and recommendations that is signed by each IDT member and send a copy of the report within 10 working days to the individual or LAR, as appropriate; and(J) if the individual is being considered for commitment to the residential care facility, submit the IDT report promptly to the court, as ordered, and to the individual or LAR, as appropriate; and(2) determine whether:(A) the individual, because of an intellectual disability:(i) represents a substantial risk of physical impairment or injury to self or others; or(ii) is unable to provide for and is not providing for the individual's most basic personal physical needs;(B) the individual cannot be adequately and appropriately habilitated in an available, less restrictive setting, as demonstrated by documentation that alternative settings have been identified, evaluated, and determined to be unavailable or unable to meet the individual's identified needs; and(C) the residential care facility provides habilitative services, care, training and treatment appropriate to the individual's needs. Source Note: The provisions of this §904.43 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397; amended to be effective September 18, 2024,49 TexReg 7361. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.43 LIDDA IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220755 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220755&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220755 03/12/2026 (a) If an individual or legally authorized representative (LAR) requests residential services in a residential care facility, the designated LIDDA must provide an oral and written explanation of the residential services and supports for which the individual may be eligible, as described in Texas Administrative Code (TAC) Title 40 §2.307(b)(2) (relating to Access, Intake, and Enrollment Related Responsibilities).(b) If the LIDDA's IDT determines that an applicant meets the criteria for residential services in a residential care facility or if a court orders an individual committed to residential care facility, as described in §904.25 of this subchapter (relating to Criteria for Commitment, Commitment for Residential Services Without an Interdisciplinary Team Recommendation, and Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA or, as described in §904.29 of this subchapter (relating to Criteria for Commitment and Commitment for Residential Services Without an Interdisciplinary Team Recommendation of a Minor to a Residential Care Facility Under the PIDA), the LIDDA:(1) notifies the applicant or LAR in writing, if applicable;(2) contacts the residential care facility serving the area in which the applicant lives or, if the applicant is requesting an interstate transfer, the area in which the individual's LAR or family lives or intends to live;(3) contacts the interstate compact coordinator at HHSC, if the applicant is requesting an interstate transfer;(4) compiles and submits all information required to complete an application packet, as described in subsection (i) of this section; and(5) opens an assignment in the HHSC data system indicating the applicant is waiting for services in a residential care facility.(c) If the LIDDA's IDT determines that the applicant does not meet the criteria for commitment or regular voluntary admission to a residential care facility, as described in this subchapter, the LIDDA:(1) notifies the applicant or LAR in writing of the determination and explains the procedure for the applicant or LAR to request a review of the IDT's determination by the LIDDA in accordance with §301.155 of this title (relating to Notification and Appeals Process); or(2) if the applicant requests an interstate transfer, notifies the interstate compact coordinator in writing of the determination.(d) If a review by the LIDDA of the IDT's determination results in the determination being upheld, the LIDDA informs the applicant or LAR in writing that they may request a review by HHSC's Intellectual or Developmental Disability (IDD) ombudsman by calling 1-800-252-8154 or they can visit the HHSC website for additional contact information for the IDD Ombudsman.(e) If the applicant or LAR requests a review, HHSC's IDD ombudsman reviews relevant documentation provided by the applicant and LAR, the IDT, and the LIDDA, and determines if the processes described in this subchapter were followed.(1) The ombudsman issues a written decision to the applicant, the applicant's LAR, and the LIDDA within 14 calendar days of the request.(2) If the ombudsman decides that the processes in this subchapter were followed, the ombudsman provides information about other services the individual may be eligible for, including who to contact to place the applicant on interest lists.(3) If the ombudsman decides that the processes in this subchapter were not followed, the LIDDA must take action to follow the processes in this subchapter.(f) If the guardian of an adult petitions the court to issue a commitment order per THSC §§593.041, 593.0511, and 593.052, and the court issues the commitment order, the guardian must notify the LIDDA and provides a copy of the commitment order to the LIDDA.(g) If the LIDDA determines that an applicant meets the criteria described in §904.37 of this subchapter (relating to Criteria for Emergency Admission of an Adult or a Minor to a State MR Facility Under the PMRA) or §904.39 of this subchapter (relating to Criteria for Admission of an Adult or a Minor to a State MR Facility for Respite Care Under the PMRA), the LIDDA:(1) contacts the residential care facility serving the area in which the applicant lives;(2) compiles all of the information required to complete an application packet, as described in subsection (j) or (k) of this section, as appropriate; and(3) requests the applicant's enrollment in the Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions Program, as described in §261.244(e) of this title (relating to Applicant Enrollment in the ICF/MR Program), if appropriate.(h) The guardian must assist the LIDDA in compiling the information required to complete an application packet.(i) A complete application packet, as referenced in subsection (b)(4) of this section, must include:(1) the original order of commitment, if applicable;(2) a completed Form 8654, State Supported Living Center (SSLC) Admission Application, including signature of the applicant, if the applicant is able to sign, or the applicant's LAR, if applicable (Form 8654 is available on the HHSC website);(3) a Determination of Intellectual Disability (DID) report with statement that the applicant has an intellectual disability, in accordance with §304.402 of this title (relating to The Determination of Intellectual Disability Report);(4) a completed ICAP booklet and Intellectual Disability and Related Conditions (ID/RC) Assessment form;(5) an IDT report completed, as described in §904.43 of this subchapter (relating to LIDDA IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a Residential Care Facility Under the PIDA recommending the commitment or regular voluntary admission of the applicant to a residential care facility, unless the applicant is court committed, as described in §904.25(b) of this subchapter or §904.29(e);(6) copies of available psychological, medical, and social histories for the applicant;(7) a copy of any divorce decree pertaining to the applicant;(8) any legal document dealing with the custody of a minor;(9) current letters of guardianship, order appointing a guardian, and related orders, if the applicant has a guardian;(10) a copy of any will naming the applicant as a devisee;(11) a certified copy of the applicant's birth certificate;(12) a copy of the applicant's immunization record;(13) a copy of the applicant's social security card;(14) a copy of the applicant's Medicare and Medicaid card (if applicable);(15) any record regarding care and treatment of the individual in a state mental health facility or a psychiatric hospital;(16) for the applicant who is school eligible, the Admission, Review and Dismissal Committee report, Individual Education Plan, and Comprehensive Assessment;(17) for the applicant who is a minor, results of the CRCG or LIDDA staffing held, as described in §904.29(c)(1) of this subchapter;(18) for the applicant under 22 years of age, results of the LIDDA's permanency planning process, as described in §904.171(a) of this chapter (relating to MRA and State MR Facility Responsibilities); and(19) any documents concerning the applicant's immigration status.(j) A complete application packet for emergency admission of an individual, as referenced in subsection (g)(2) of this section, must include:(1) a completed Form 8654, State Supported Living Center (SSLC) Admission Application, including signature of the applicant, if the applicant is able to sign, or the applicant's LAR, if applicable (Form 8654 is available on the HHSC website);(2) a written request from the LIDDA for the emergency admission of the applicant;(3) documentation:(A) describing the persuasive evidence that the individual has an intellectual disability;(B) of the reasons supporting the individual's urgent need for the emergency admission, including the circumstances precipitating the need for the emergency admission;(C) of the expected outcomes from the emergency admission; and(D) that the requested relief can be provided by the residential care facility within a year after the individual is admitted;(4) a copy of any divorce decree pertaining to the individual;(5) any legal document dealing with the custody of a minor;(6) current letters of guardianship, order appointing a guardian and related orders, if the individual has a guardian;(7) a certified copy of the applicant's birth certificate;(8) a copy of the applicant's immunization record;(9) a copy of the applicant's social security card;(10) a copy of the applicant's Medicare and Medicaid card (if applicable);(11) for the applicant who is school eligible, the Admission, Review and Dismissal Committee report, Individual Education Plan, and Comprehensive Assessment;(12) for the applicant who is a minor, the results of the CRCG or LIDDA staffing held, as described in §904.29(c)(1) of this subchapter;(13) for the applicant under 22 years of age, results of the LIDDA's permanency planning process, as described in §904.171(a) of this chapter;(14) any record regarding care and treatment of the individual in a state mental health facility or a psychiatric hospital;(15) any documents concerning the applicant's immigration status; and(16) if requested by HHSC:(A) a DID report with a statement that the applicant has an intellectual disability, in accordance with §304.402 of this title (relating to The Determination of Intellectual Disability Report); and(B) a completed ICAP booklet and ID/RC Assessment form.(k) A complete application packet for admission of an individual for respite care, as referenced in subsection (g)(2) of this section, must include:(1) a completed Form 8654, State Supported Living Center (SSLC) Admission Application, including signature of the applicant, if the applicant is able to sign, or the applicant's LAR, if applicable (Form 8654 is available on the HHSC website);(2) a written request from the LIDDA for the admission of the applicant for respite care;(3) documentation:(A) describing the persuasive evidence that the individual has an intellectual disability;(B) of the reasons why the individual or the individual's family urgently requires respite care; and(C) that the requested assistance or relief can be provided by the residential care facility within a period not to exceed 30 calendar days after the date of admission;(4) a copy of any divorce decree pertaining to the individual;(5) any legal document dealing with the custody of a minor;(6) current letters of guardianship, order appointing a guardian and related orders, if the individual has a guardian;(7) a certified copy of the applicant's birth certificate;(8) a copy of the applicant's immunization record;(9) a copy of the applicant's social security card;(10) a copy of the applicant's Medicare and Medicaid card (if applicable);(11) for the applicant who is school eligible, the Admission, Review and Dismissal Committee report, Individual Education Plan, and Comprehensive Assessment;(12) any documents concerning the applicant's immigration status; and(13) if requested by HHSC:(A) a DID report with a statement that the applicant has an intellectual disability in accordance with §304.402 of this title; and(B) a completed ICAP booklet and ID/RC Assessment form. Source Note: The provisions of this §904.45 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397; amended to be effective September 18, 2024, 49 TexReg 7361. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.45 LIDDA Referral of an Applicant to a Residential Care Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215124 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215124&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215124 03/12/2026 (a) If a court orders an individual committed to a state MR facility, the MRA will coordinate the compilation of an application packet for submission to the state MR facility serving the individual's county of residence.(b) The MRA must retain a copy of the application packet, as described in §2.265(g) of this subchapter (relating to MRA Referral of an Applicant to a State MR Facility) and send the original application packet to the admission coordinator of the state MR facility.(c) DADS will determine when a vacancy exists in a state MR facility and which individuals are appropriate to fill the vacancy, based on the information in the application packets.(d) Upon notification from DADS that an appropriate vacancy in a state MR facility is available, the MRA will contact the LAR or family of each individual identified by DADS as appropriate to fill the vacancy and will:(1) determine whether the LAR or family of the individual is still seeking admission of the individual to a state MR facility under the commitment;(2) determine whether the individual would accept the proposed admission to the state MR facility; and(3) update the information in the individual's application packet, including ensuring that the assessments reflect the individual's current level of functioning.(e) The state MR facility will offer admission under the commitment order to one of those individuals identified by DADS as appropriate to fill the vacancy and who the MRA has determined would accept the proposed admission to the state MR facility.(f) If the applicant or the applicant's LAR accepts the proposed admission, the MRA must request enrollment of the applicant in the ICF/MR Program as described in §9.244 of this title (relating to Applicant Enrollment in the ICF/MR Program), if appropriate.(g) If the applicant or LAR has accepted the proposed admission, and the MRA has filed for commitment, but the commitment order has not been completed, the MRA may petition the court for an order of protective custody.(h) The MRA shall coordinate the following with the state MR facility's admission coordinator:(1) transportation arrangements for the individual on the day of the admission;(2) arrangements for the individual's LAR to be present at the state MR facility when the individual is admitted, or if the individual does not have an LAR, for the individual's family members or other actively involved persons to be present; and(3) the exchange of essential information training necessary to familiarize staff at the state MR facility with the needs of the individual.(i) If the LAR or family of the individual no longer wishes to pursue admission of the individual to a state MR facility under the commitment order, the MRA will notify the court in writing. Source Note: The provisions of this §904.47 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.47 Process for Admission of an Adult or a Minor Who Has Been Committed to a State MR Facility Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215125 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215125&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215125 03/12/2026 (a) In accordance with THSC, §593.021, only the adult seeking admission may apply for a regular voluntary admission to a state MR facility for residential services.(b) If the MRA IDT recommends that the applicant be admitted to a state MR facility for regular voluntary services, the MRA must retain a copy of the application packet, as described in §2.265(g) of this subchapter (relating to MRA referral of an Applicant to a State MR Facility) and send the original application packet to the admission coordinator of the state MR facility.(c) DADS will determine when a vacancy exists in a state MR facility and which individuals are appropriate to fill the vacancy, based on the information in the application packets.(d) Upon notification from DADS that an appropriate vacancy in a state MR facility is available, the MRA will contact each individual identified by DADS as appropriate to fill the vacancy and will:(1) determine whether the individual is still seeking admission to a state MR facility;(2) update the information in the individual's application packet, including ensuring that the assessments reflect the individual's current level of functioning; and(3) determine if the individual would accept the proposed admission to the state MR facility.(e) The state MR facility will offer admission to one of those individuals identified by DADS as appropriate to fill the vacancy and who the MRA has determined would accept the proposed admission to the state MR facility.(f) If the applicant or the applicant's LAR accepts the proposed admission, the MRA must request enrollment of the applicant in the ICF/MR Program as described in §9.244 of this title (relating to Applicant Enrollment in the ICF/MR Program), if appropriate.(g) The MRA will coordinate the individual's pre-admission visit, if such visit is appropriate and desired by the individual. Source Note: The provisions of this §904.49 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.49 Process for the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215126 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215126&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215126 03/12/2026 (a) If DADS is notified by a juvenile court that a placement order for a minor has been issued under Texas Family Code, §55.33 or §55.52, DADS will notify the appropriate MRA of the placement order.(b) Prior to the minor's admission under a placement order, the MRA must submit the following documents to the state MR facility:(1) the original court order;(2) an offense record;(3) a DMR, if available;(4) a current medical assessment;(5) a physician's medication orders;(6) a social history;(7) a psychological history;(8) an immunization record;(9) a copy of social security card;(10) a certified copy of birth certificate;(11) the Admission, Review and Dismissal (ARD) Committee report, Individual Education Plan (IEP), and Comprehensive Assessment;(12) a copy of the Medicaid card, if applicable;(13) any legal document dealing with custody of the minor;(14) current letters of guardianship, order appointing a guardian, and related orders, if the minor has a guardian;(15) any documents concerning the minor's immigration status;(16) a completed ICAP (Inventory for Client and Agency Planning) booklet and MR/RC assessment form, if available; and(17) other available evaluations.(c) Upon receipt of the required documents, the state MR facility will coordinate admission arrangements with the juvenile probation department or the MRA.(d) Within 30 calendar days after the minor is admitted to the state MR facility, the state MR facility will schedule an IDT meeting to develop an individual program plan (IPP) for the minor.(e) Not later than the 75th calendar day after the date the court issues a placement order under Texas Family Code, §55.33, the state MR facility will submit to the court a report that:(1) describes the treatment of the minor provided by the state MR facility;(2) states whether the state MR facility believes the minor is fit or unfit to proceed; and(3) if the state MR facility believes the minor is unfit to proceed, states whether the minor meets the commitment criteria described in §2.257 of this subchapter (relating to Criteria for Commitment of a Minor to a State MR Facility Under the PMRA).(f) If the state MR facility believes that the minor is unfit to proceed and meets the commitment criteria described in §2.257 of this subchapter, the state MR facility will submit an affidavit to the court stating the conclusions reached as a result of the diagnosis.(g) Not later than the 75th calendar day after the date the court issues a placement order under Texas Family Code, §55.52, the state MR facility will submit to the court a report that:(1) describes the treatment of the minor provided by the state MR facility;(2) states whether the state MR facility believes the minor has mental retardation; and(3) if the state MR facility believes the minor has mental retardation, states whether the minor meets the commitment criteria described in §2.257 of this subchapter.(h) If the state MR facility believes that the minor has mental retardation and meets the commitment criteria described in §2.257 of this subchapter, the state MR facility will submit an affidavit to the court stating the conclusions reached as a result of the diagnosis. Source Note: The provisions of this §904.51 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.51 Process for Placement of a Minor under the Texas Family Code in a State MR Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215127 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215127&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215127 03/12/2026 (a) In accordance with THSC, §593.021, only the following persons may apply for admission to a state MR facility for emergency services:(1) the individual seeking admission; or(2) the LAR of an individual.(b) If the MRA determines that an individual meets the criteria for emergency admission under §2.261 of this subchapter (relating to Criteria for Emergency Admission of an Adult or a Minor to a State MR Facility Under the PMRA), the MRA must retain a copy of the application packet, as described in §2.265(h) of this subchapter (relating to MRA Referral of an Applicant to a State MR Facility) and send the original application packet to the admission coordinator of the state MR facility.(c) DADS will determine when a vacancy exists in a state MR facility and which individuals are appropriate to fill the vacancy, based on the information in the application packets.(d) Upon notification from DADS that an appropriate vacancy in a state MR facility is available, the MRA will contact each individual identified by DADS as appropriate to fill the vacancy and will:(1) determine whether the individual is still seeking emergency admission to a state MR facility;(2) update the information in the individual's application packet, including ensuring that the assessments reflect the individual's current level of functioning; and(3) determine whether the individual would accept the proposed emergency admission to the state MR facility.(e) The state MR facility will offer emergency admission to one of those individuals identified by DADS as appropriate to fill the vacancy and who the MRA has determined would accept the proposed emergency admission to the state MR facility.(f) Prior to admission of the individual, the MRA must:(1) negotiate the terms of the Emergency Admission/Discharge Agreement with the parties and prepare the agreement;(2) send a copy of the completed Emergency Admission/Discharge Agreement to the individual or LAR, the state MR facility, and the Department of Aging and Disability Services, Provider Services Division, State Mental Retardation Facilities Section, P.O. Box 149030, Mail Code W-511, Austin, Texas 78714-9030; and(3) develop a service coordination plan to accomplish the expected outcomes identified in the Emergency Admission/Discharge Agreement.(g) If the individual is under 22 years of age, the Emergency Admission/Discharge Agreement must incorporate elements of the individual's permanency plan, as appropriate, and specify that the individual is to be admitted for no longer than six months to receive emergency services in the state MR facility.(h) The Emergency Admission/Discharge Agreement must be approved by the commissioner or designee prior to the admission of the individual by the state MR facility.(i) If the Emergency Admission/Discharge Agreement is approved by the commissioner or designee and the individual is admitted, the state MR facility will, at the time of admission:(1) complete a physical examination of the individual and issue orders addressing the applicant's medication, treatment, and diet needs; and(2) develop a plan of services and supports to be provided while the individual is a resident.(j) Within 30 calendar days after the individual is admitted, the state MR facility will arrange for:(1) a DMR to be conducted in accordance with §5.155 of this title (relating to Determination of Mental Retardation (DMR)); and(2) an IDT at the state MR facility to make findings and recommendations in accordance with the process described for an MRA IDT in §2.264 of this subchapter (relating to MRA IDT Recommendation Concerning the Commitment of an Adult or a Minor or the Regular Voluntary Admission of an Adult to a State MR Facility Under the PMRA).(k) The terms of the Emergency Admission/Discharge Agreement, including the date of discharge, may not be amended unless the MRA obtains approval from the commissioner or designee.(l) The individual will be discharged by the state MR facility under the terms of the Emergency Admission/Discharge Agreement.(m) If DADS determines that the terms of the Emergency Admission/Discharge Agreement cannot be met, the MRA may initiate commitment proceedings under the PMRA. Source Note: The provisions of this §904.53 adopted to be effective January 1, 2001, 25 TexReg 12746; amended to be effective March 31, 2002, 27 TexReg 2445; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.53 Process for the Emergency Admission of an Adult or a Minor to a State MR Facility Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215128 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215128&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215128 03/12/2026 (a) In accordance with THSC, §593.021, only the following persons may apply for admission to a state MR facility for respite care:(1) the individual seeking admission; or(2) the LAR of an individual.(b) If the MRA determines that an applicant meets the criteria for respite care under §412.262 of this title (relating to Criteria for Admission of an Adult or a Minor to a State MR Facility for Respite Care Under the PMRA), the MRA must retain a copy of the application packet, as described in §412.265(i) of this title (relating to MRA Referral of an Applicant to a State MR Facility) and send the original application packet to the admission coordinator of the state MR facility.(c) The department will determine when a vacancy exists in a state MR facility and which individuals for whom the state MR facility can meet their needs and are appropriate to fill the vacancy, based on the information in the application packets.(d) Upon notification from the department that an appropriate vacancy in a state MR facility is available, the MRA will contact each individual identified by the department as appropriate to fill the vacancy and will:(1) determine whether the individual is still seeking respite care in a state MR facility;(2) update the information in the individual's application packet, including ensuring that the assessments reflect the individual's current level of functioning; and(3) determine whether the individual would accept the proposed admission for respite care to the state MR facility.(e) The state MR facility will offer admission for respite care to one of those individuals identified by the department as appropriate to fill the vacancy and who the MRA has determined would accept the proposed admission to the state MR facility.(f) At the time of admission:(1) the MRA must:(A) negotiate the terms of the Respite Admission/Discharge Agreement with the parties and prepare the agreement; and(B) develop a service coordination plan to accomplish the purpose of the admission described in the Respite Admission/Discharge Agreement; and(2) the state MR facility will:(A) complete a physical examination of the individual and issue orders addressing the applicant's medication, treatment, and diet needs; and(B) develop a plan of services and supports to be provided while the individual is a resident.(g) The individual will be discharged by the state MR facility under the terms of the Respite Admission/Discharge Agreement.(h) One extension of no more than 30 calendar days to the individual's agreed length of stay may be granted by the head of the state MR facility if:(1) the relief sought by the individual or the individual's family has not been provided within 30 calendar days of the date of admission;(2) the MRA submits an amended Respite Admission/Discharge Agreement to the state MR facility at least three working days prior to the expiration of the original Respite Admission/Discharge Agreement;(3) the head of the state MR facility determines that the requested assistance or relief can be provided during the requested extension period including that space is available at the state MR facility; and(4) the parties to the original Respite Admission/Discharge Agreement consent to the extension. Source Note: The provisions of this §904.55 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES B ADMISSION AND COMMITMENT §904.55 Process for Admission of an Adult or a Minor to a State MR Facility for Respite Care Under the PMRA https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215129 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215129&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215129 03/12/2026 (a) The transfer of an individual from one state MR facility to another may be proposed by:(1) the individual who is able to provide legally adequate consent;(2) the individual's LAR; or(3) the state MR facility in which the individual resides.(b) The transfer of an individual from one state MR facility to another may be made if the state MR facility in which the individual resides determines that:(1) the state MR facility is no longer appropriate to the individual's needs;(2) the individual can be treated and habilitated better in another state MR facility; or(3) the individual can be treated and habilitated in a state MR facility located geographically closer to the individual's family.(c) If a state MR facility proposes that the individual be transferred to another state MR facility, the state MR facility will notify the individual or LAR, in writing, at least 31 calendar days before the date of the proposed transfer, of the proposed transfer and the right to request an administrative hearing to contest the proposed transfer, in accordance with §414.155 of this title (relating to Notice of Hearing).(d) If the individual or LAR, or another person as the representative of the individual or LAR, requests an administrative hearing, the individual will not be transferred pending the hearing.(e) If the state MR facility denies a request from the individual or LAR for a transfer, the state MR facility will notify the individual or LAR, in writing, of the right to request an administrative hearing to contest the denial, in accordance with §414.155 of this title (relating to Notice).(f) If a transfer proposed by the individual or LAR is approved by the state MR facility or a transfer proposed by the state MR facility is not contested by the individual or LAR, the state MR facility will send necessary documents regarding the individual to the receiving state MR facility. In addition, the state MR facility in which the individual resides will notify the individual's designated MRA of the proposed transfer.(g) The receiving state MR facility will review the documentation and initiate any necessary action, including arranging for a pre-transfer visit, to determine whether the receiving state MR facility can provide appropriate services to the individual.(h) At the conclusion of its review and necessary action, the receiving state MR facility will notify the state MR facility in which the individual resides, in writing, of its determination of whether it can provide appropriate services to the individual and, if it can provide appropriate services, the projected date of an available vacancy.(i) The state MR facility in which the individual resides will notify the individual or LAR and the individual's designated MRA of the determination made by the receiving state MR facility and the projected date of an available vacancy, if applicable.(j) Pending the vacancy becoming available, the state MR facility in which the individual resides will provide periodic updates to the individual or LAR about the status of the transfer.(k) When the vacancy at the receiving state MR facility becomes available, the state MR facility in which the individual resides will notify the individual or LAR about such availability and coordinate arrangements with the receiving state MR facility for the individual to be transferred. Source Note: The provisions of this §904.75 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES C TRANSFERS §904.75 Transfer of an Individual Between State MR Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215130 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215130&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215130 03/12/2026 (a) An individual committed to a state MR facility for residential services may be transferred to a state MH facility for mental health care if a licensed physician of the state MR facility determines after an examination that care, treatment, control and rehabilitation in a state MH facility is in the best interest of the individual.(b) The individual will be returned to the state MR facility within 30 calendar days unless a court order transferring the individual is obtained by the state MH facility as described in subsection (c) of this section.(c) If the state MH facility determines that hospitalization of the individual is necessary for longer than 30 calendar days, the state MH facility will request from the committing court an order transferring the individual to the state MH facility. In support of the request, the state MH facility will submit two certificates of medical examination for mental illness to the court, as described in THSC, §574.011, stating that the individual:(1) is a person with mental illness; and(2) requires observation or treatment in the state MH facility.(d) If the state MH facility determines that an individual who has been transferred to a state MH facility under a court order no longer requires hospitalization, the state MH facility will request that the committing court approve the return of the individual to the state MR facility, in accordance with THSC, §594.045.(e) An individual admitted to a state MR facility under a regular voluntary admission for residential services may be transferred to a state MH facility only if the individual consents to the transfer. Source Note: The provisions of this §904.77 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES C TRANSFERS §904.77 Transfer of an Individual from a State MR Facility to a State MH Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215131 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215131&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215131 03/12/2026 An individual receiving inpatient services in a state MH facility, other than an individual transferred under §412.272 of this title (relating to Transfer of an Individual from a State MR Facility to a State MH Facility), who has been determined by the MRA to require residential services in a state MR facility, may be admitted to the state MR facility only in accordance with the criteria and process set forth in Division 2 of this subchapter (relating to Admission and Commitment). Source Note: The provisions of this §904.79 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES C TRANSFERS §904.79 Transfer of an Individual from a State MH Facility to a State MR Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215132 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215132&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215132 03/12/2026 (a) Individuals 22 years of age or older.(1) A contract MRA must conduct the CLOIP for an individual 22 years of age or older residing in a state MR facility:(A) before the individual's annual planning meeting as referenced in subsection (c)(2) of this section; and(B) upon request of the individual or LAR to learn about living options other than the state MR facility.(2) In conducting the CLOIP, the contract MRA must:(A) provide standardized educational materials approved by DADS describing living options and supports in the community;(B) offer the individual or LAR the opportunity to visit examples of living options available in the community and to visit with peers utilizing these options; and(C) document the results of the CLOIP in a format approved by DADS.(3) A state MR facility must notify the contract MRA, in accordance with DADS procedures, of a request by an individual or LAR for information regarding living options other than the state MR facility.(4) After the contract MRA receives the notification required by paragraph (3) of this subsection, the contract MRA must contact the individual or LAR and conduct the CLOIP in accordance with paragraph (2) of this subsection.(5) The contract MRA must:(A) submit results of the CLOIP to the state MR facility in accordance with DADS procedures to assist the IDT in making a recommendation described in subsection (g)(4)(D) of this section; and(B) participate in person or by telephone in a planning meeting for which the contract MRA is notified in accordance with subsection (d)(3) of this section, unless the individual or LAR requests otherwise.(b) Individuals under 22 years of age. The designated MRA must discuss community living options with an individual under 22 years of age residing in a state MR facility or LAR in accordance with the permanency planning process described in §9.244(f) - (i) of this title (relating to Applicant Enrollment in the ICF/MR Program).(c) Types of planning meetings in which living options are discussed for an individual residing in a state MR facility.(1) Within 30 days after admission of an individual to a state MR facility, the state MR facility must conduct an initial planning meeting in which living options are discussed.(2) Annually, the state MR facility must conduct a planning meeting in which living options are discussed (annual planning meeting).(3) The state MR facility must conduct a planning meeting if, at any time, the individual or LAR requests a discussion about living options including a request for information about living options other than the state MR facility or requests to move to a specific setting or area of the state.(d) Notification of planning meetings. In accordance with DADS procedures, the state MR facility must notify:(1) the individual and LAR of a planning meeting described in subsection (c) of this section;(2) the designated MRA of a planning meeting described in subsection (c) of this section and, if appropriate, request from the designated MRA information about alternative living arrangements and community services and supports in the area in which the individual is interested in living that the IDT will need before making a recommendation as described in subsection (g)(4)(D) of this section; and(3) the contract MRA:(A) of an annual planning meeting described in subsection (c)(2) of this section for an individual 22 years of age or older; and(B) a planning meeting described in subsection (c)(3) of this section for which a CLOIP must be conducted by the contract MRA in accordance with subsection (a)(1)(B) of this section.(e) Additional planning meeting participants as determined by individual or LAR. The individual with the ability to provide legally adequate consent or the LAR of an individual who does not have the ability to provide legally adequate consent may choose to:(1) invite other family members, friends, or other interested persons to a planning meeting; or(2) exclude any and all family members, friends, or other interested persons from attending a planning meeting.(f) Facilitation of a planning meeting. The state MR facility must:(1) encourage the attendance and participation in a planning meeting by those persons invited by the individual or LAR;(2) make a reasonable attempt to schedule the planning meeting at a time that is convenient for the individual's LAR and those family members, friends, or other persons invited by the individual or LAR; and(3) use communication devices and techniques (including the use of sign language), as appropriate, to facilitate the involvement of the individual and LAR during a planning meeting.(g) Conducting the planning meeting.(1) At a planning meeting described in subsection (c)(1) of this section, the IDT must review the individual's or LAR's awareness of living options explained by the designated MRA during the admission process, as required by §5.159(c) of this title (relating to Assessment of Individual's Need for Services and Supports).(2) At a planning meeting described in subsection (c)(2) or (3) of this section, the IDT must review, as appropriate to the individual's age:(A) the results of the CLOIP submitted to the state MR facility in accordance with subsection (a)(5)(A) of this section; or(B) the results of the permanency planning process submitted to the state MR facility in accordance with §9.244(f)(7)(C) of this title.(3) In conducting a planning meeting described in subsection (c) of this section, the IDT must use the State MR Facility Living Options Instrument which may be obtained from the Department of Aging and Disability Services, Provider Services Division, State Mental Retardation Facilities Section, P.O. Box 149030, Mail Code W-511, Austin, Texas 78714-9030 or at www.dads.state.tx.us.(4) At the conclusion of a planning meeting described in subsection (c) of this section, the IDT must document:(A) the decision of an individual who has the ability to provide legally adequate consent or an LAR to consider potential living options;(B) the choice of living option preferred by the individual or the individual's LAR;(C) the IDT's conclusions as to whether or not the state MR facility is the most appropriate living arrangement for the individual;(D) the recommendation by the IDT of whether the individual should remain in the current living arrangement at the state MR facility or move to an alternative living arrangement; and(E) for an individual under 22 years of age, the IDT's conclusions as to whether or not the permanency planning goal has been accomplished.(h) Choice for individual to remain in state MR facility. An individual with the ability to provide legally adequate consent or the LAR may choose for the individual to remain a resident of a state MR facility if the individual has been determined to have mental retardation in accordance with §5.155 of this title (relating to Determination of Mental Retardation). Source Note: The provisions of this §904.99 adopted to be effective April 2, 2009, 34 TexReg 2154; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES D MOVING FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT §904.99 Consideration of Living Options for Individuals Residing in State MR Facilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215133 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215133&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215133 03/12/2026 (a) If an individual with the ability to provide legally adequate consent or an LAR agrees with and accepts an IDT recommendation to seek an alternative living arrangement, the IDT will inform the individual's designated MRA to schedule a planning meeting as appropriate.(b) If the individual is a minor, the IDT's goal in identifying potential alternative living arrangements is to ensure that the alternative living arrangement will provide a consistent, nurturing environment and an enduring, positive adult relationship with a specific person who will be an advocate for that minor.(1) If it is not possible for the minor to live with the natural family, the feasibility of other family living arrangements should be explored as possible support options.(2) The IDT will determine the frequency, timing, and scope of IDT meetings to ensure that a minor residing in a state MR facility is reviewed by the IDT as often as necessary based on the changing needs of the minor and the family. The IDT will designate a state MR facility contact person with whom the designated MRA must communicate at least quarterly to discuss existing and planned alternative living arrangements which may be appropriate for the minor. This information will be communicated to the minor's LAR in a manner and frequency preferred by the LAR.(c) When the individual is school eligible, at least 30 calendar days notice of IDT meetings will be given to the individual, the LAR, and the representative from the appropriate school district. The school district representative will be invited to IDT meetings at which movement by the school eligible individual to the community will be discussed.(d) During an IDT meeting, state MR facility staff and staff from the designated MRA will describe the different types of alternative living arrangements and answer any questions the individual or LAR may have. The individual or LAR will be asked to identify the desired outcomes for the alternative living arrangement, and preferences of geographic location(s) within the state where the individual wants to live or the LAR wants the individual to live.(e) Once the desired outcomes and preferences of the individual or the LAR have been identified, the designated MRA is responsible for:(1) contacting other involved MRAs and obtaining information about providers in their local service areas;(2) coordinating communication between the individual or LAR, the state MR facility, other involved MRAs and providers; and(3) inviting a representative from each involved MRA to a meeting of the state MR facility's IDT to discuss the preferences and desires of the individual or LAR regarding alternative living arrangements, as well as the service and support needs identified by the IDT, the individual, and the LAR.(f) At the meeting described in subsection (e)(3) of this section or a later meeting of the IDT, state MR facility staff will begin the process of completing the community living profile as described in §412.278(c)(1) of this title (relating to Community Living/Discharge Plan for Alternative Living Arrangements).(1) Copies of the completed profile will be sent to the individual or LAR and the designated MRA within 14 calendar days of the IDT meeting at which it was initiated.(2) If the preferred geographic location(s) of the individual or LAR is in the local service area of another MRA(s), the designated MRA will provide copies of the profile to the other involved MRA(s).(g) The designated MRA will provide the individual, the LAR, and the IDT with a list of the providers in the preferred geographic locations and current information prepared by the providers.(1) The individual or LAR will select providers to which the community living profile is to be sent.(2) The state MR facility's IDT will ensure that the individual or the LAR have been informed that the community living profile will be shared with providers in accordance with §414.7(d) of this title (relating to When Consent for Disclosure is not Required: Clients Receiving MHMR Services).(h) Within 14 calendar days of receiving the completed community living profile, the MRA will send the profile to the providers selected by the individual or the LAR. When more than one MRA is involved, the designated MRA will coordinate with the other involved MRAs to ensure that profiles are sent to all selected providers.(i) The designated MRA must coordinate with the state MR facility and other involved MRAs, as appropriate, to assist the individual or LAR in making arrangements for visits to proposed providers. If an overnight visit is planned, the state MR facility will, prior to the visit, furnish the proposed provider with the following:(1) identifying data including legal status and determined disability(ies);(2) pertinent medical/medication information;(3) behavioral data; and(4) other pertinent treatment information.(j) The state MR facility will send an adequate medication supply, clothing, personal items, and adaptive equipment with the individual at the time of the overnight visit.(k) The individual or LAR will inform a designated state MR facility staff person when a provider has been selected. The individual or LAR may choose a provider with an immediate opening or, if there is no immediate opening, may ask to be placed on a waiting list for the desired services.(l) After the individual or LAR has selected provider, the IDT will meet to complete the community living/discharge plan as described in §412.278 of this title (relating to Community Living/Discharge Plan for Alternative Living Arrangements).(m) The individual or LAR may request that the designated MRA facilitate the development of a specific community living arrangement if there is no arrangement in existence which meets the individual's service and support needs as described in the community living profile and the preferences and desired outcomes of the individual or LAR. Source Note: The provisions of this §904.101 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES D MOVING FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT §904.101 Accessing Alternative Living Arrangements for an Individual Residing in a State MR Facility Who Has the Ability to Provide Legally Adequate Consent or Has a Legally Authorized Representative (LAR) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215134 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215134&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215134 03/12/2026 (a) If the IDT recommends an alternative living arrangement for an individual who does not have the ability to give legally adequate consent and who does not have an LAR, the IDT will:(1) notify the individual's designated MRA and persons actively involved with the individual of the recommendation;(2) identify issues which could prevent the individual from successfully adapting to an alternative living arrangement including:(A) the individual's inability to provide legally adequate consent; and(B) the lack of effective community services and supports to address behavioral or medical concerns;(3) recommend possible solutions to address the issues; and(4) document the identified issues and recommended solutions in the IDT report.(b) If the IDT identifies the individual's inability to provide legally adequate consent as an issue that could prevent the individual from successfully adapting to an alternative living arrangement, the IDT will:(1) explore options for addressing the issue; and(2) document the options and the activities necessary for implementing the options in the community living/discharge plan.(c) A representative from the designated MRA will meet with the individual, any persons actively involved with the individual, and the IDT to discuss the desired outcomes for the alternative living arrangement and preferences of geographic locations.(1) During the meeting, state MR facility staff and the MRA representative will describe the different types of alternative living arrangements which are available and answer any questions asked by the individual and persons actively involved with the individual.(2) The desired outcomes and preferences of the individual and persons actively involved with the individual will be documented in the written report of the IDT meeting.(d) Once the desired outcomes and preferences of the individual and persons actively involved with the individual have been identified, the designated MRA is responsible for:(1) contacting other involved MRAs and obtaining information about providers in their local service areas;(2) coordinating communication between the individual, persons actively involved with the individual, the state MR facility, other involved MRAs and providers; and(3) inviting a representative from each involved MRA to a meeting of the state MR facility's IDT to discuss the preferences and desires of the individual and persons actively involved with the individual regarding alternative living arrangements, as well as the service and support needs identified by the IDT, the individual, and persons actively involved with the individual.(e) At the meeting described in subsection (d)(3) of this section or a later meeting of the IDT, state MR facility staff will begin the process of completing the community living profile as described in §412.278(c)(1) of this title (relating to Community Living/Discharge Plan for Alternative Living Arrangements).(1) Copies of the completed profile will be sent to the individual, any actively involved persons, and the designated MRA within 14 calendar days of the IDT meeting at which it was initiated.(2) If the preferred geographic location(s) of the individual is in the local service area of another MRA(s), the designated MRA will provide copies of the profile to the other involved MRA(s).(f) The designated MRA will provide the individual, persons actively involved with the individual and the IDT with a list of the providers in the preferred geographic locations and current information prepared by the providers.(g) The IDT will select providers to which the community living profile is to be sent. The providers selected must:(1) consider any preferences and desires which may have been expressed by the individual or any persons actively involved with the individual;(2) meet the needs of the individual, as determined by the IDT, including:(A) medical and health;(B) emotional and behavioral;(C) transportation; and(D) employment, vocational, and educational; and(3) complement the individual's existing social relationships and support network.(h) The IDT must ensure that the individual and persons actively involved with the individual have been informed that the community living profile will be shared with providers in accordance with §414.7(d) of this title (relating to When Consent for Disclosure is not Required: Clients Receiving MHMR Services).(i) Within 14 calendar days of receiving the completed community living profile, the MRA will send the profile to the providers selected by the IDT. When more than one MRA is involved, the designated MRA will coordinate with the other involved MRAs to ensure that profiles are sent to all selected providers.(j) The designated MRA must coordinate with the state MR facility and other involved MRAs, as appropriate, to assist the individual and persons actively involved with the individual, as appropriate, in making arrangements for visits to proposed providers. If an overnight visit is planned, the state MR facility will, prior to the visit, furnish the proposed provider with the following:(1) identifying data including legal status and determined disability(ies);(2) pertinent medical/medication information;(3) behavioral data; and(4) other pertinent treatment information.(k) The state MR facility will send an adequate medication supply, clothing, personal items, and adaptive equipment with the individual at the time of the overnight visit.(l) Following any visits to a proposed provider by the individual, the IDT will meet to select a provider and complete the community living/discharge plan.(m) The IDT may request that the designated MRA facilitate the development of a specific alternative living arrangement if there is no arrangement in existence which meets the individual's service and support needs as described in the community living profile and the preferences and desires of the individual.(n) If there is no consensus by the IDT concerning issues about the alternative living arrangement or other issues related to the individual's move as described in this section or in §412.277 of this title (relating to Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility), the IDT will notify the head of the state MR facility within one working day of the date the IDT determines it cannot reach a consensus. The head of the state MR facility will name a review team, consistent with the state MR facility's written policies and procedures, to evaluate the situation and make a consensus recommendation to the head of the state MR facility within 21 calendar days.(1) Within three working days of receiving the review team's recommendation, the head of the state MR facility will issue a written decision to:(A) the staff members on the IDT;(B) the individual; and(C) any person(s) actively involved with the individual.(2) The state MR facility will include with the written decision sent to the individual and each person who is actively involved with the individual a notice that the individual or actively involved person may request a review of the head of the facility's decision by the department's ombudsman in Central Office.(A) The individual or actively involved person may request the review at any time prior to the individual moving from the state MR facility into an alternative living arrangement.(B) The request for a review by the department's ombudsman may be made in writing to Consumer Services and Rights Protection, Ombudsman, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas, 78711-2668, or by calling 1-800-252-8154.(3) The ombudsman will decide whether the processes in this subchapter have been followed by reviewing relevant documentation from the IDT, the review team, the head of the facility, and the person who requested the review.(A) The ombudsman will issue a written decision within 14 calendar days of the request to the person who requested the review and to the head of the state MR facility.(B) If the ombudsman decides that the processes in this subchapter have been followed, then the head of the facility will take action to implement the decision referenced in paragraph (1) of this subsection.(C) If the ombudsman decides that the processes in this subchapter have not been followed, then the head of the facility must take action to follow the processes in this subchapter. Source Note: The provisions of this §904.103 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES D MOVING FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT §904.103 Accessing Alternative Living Arrangements for an Individual Residing in a State MR Facility Who Does Not Have the Ability to Give Legally Adequate Consent and Who Does Not Have a Legally Authorized Representative (LAR) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215135 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215135&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215135 03/12/2026 (a) Within 14 calendar days of the IDT meeting at which a provider is selected the state MR facility will forward the following to the designated MRA, any other involved MRA, the provider, and the individual with the ability to provide legally adequate consent or the LAR, as appropriate:(1) a copy of the draft community living/discharge plan;(2) the planned date for the individual's move, if available;(3) the report from the last annual planning meeting of the IDT;(4) the most recent psychological, social, medical, and vocational/educational assessments; and(5) reports from any interim meetings of the IDT which addressed living options issues not addressed at the annual planning meeting.(b) The MRA will review the material and visit the provider setting as needed, to determine whether the provider setting:(1) complies with applicable Life Safety Code requirements;(2) presents environmental concerns that impact the individual's needs;(3) effectively addresses the outcomes important to the individual or LAR and the services and supports necessary assist the individual in achieving those outcomes; and(4) ensures the individual's health, safety, and welfare.(c) Within 14 calendar days of making its determination in subsection (b) of this section, the MRA must notify the IDT in writing that:(1) the provider setting meets the criteria in subsection (b) of this section and that the MRA recommends that the IDT approve the provider setting; or(2) the provider setting does not meet the criteria in subsection (b) of this section and that the MRA recommends that the IDT not approve the provider setting.(d) If the MRA recommends that the IDT not approve the provider setting, the MRA must include in the notice described in subsection (c)(2) of this section:(1) the criteria described in subsection (b) of this section that the provider setting did not meet; and(2) the reasons why the MRA determined the criteria was not met.(e) If the IDT accepts an MRA recommendation to approve the provider setting, the community living/discharge plan will be completed for distribution to all parties, and final arrangements will be initiated for the individual's move to the community.(f) If the MRA has recommended that the provider setting not be approved, the IDT will make written recommendations for specific remedies to address the problems and send the recommendations to the provider and the individual or LAR.(1) The individual with the ability to provide legally adequate consent or the LAR has the option of:(A) continuing with the move after the IDT determines that the recommendations have been or are in the process of being implemented by the provider;(B) continuing with the move without the IDT determining that the recommendations have been or are in the process of being implemented by the provider; or(C) selecting another provider.(2) If the individual does not have the ability to provide legally adequate consent and does not have an LAR, then the individual will remain in the state MR facility until:(A) the IDT determines that the recommendations have been or are in the process of being implemented by the provider; or(B) another provider is identified by the by the IDT.(g) When the individual moves, the state MR facility shall ensure the following:(1) a 30-day supply of prescribed medications has been provided;(2) the individual's personal belongings accompany the individual;(3) all necessary financial arrangements and agreements are addressed;(4) appropriate special instructions for the individual or others are furnished in writing and orally prior to or at the time of departure;(5) the records described in subsection (i) of this section accompany the individual; and(6) the appropriate Social Security office has been notified of the individual's impending move.(h) Responsibilities for transporting the individual to the alternative living arrangement will be detailed in the community living/discharge plan. If deemed necessary by the IDT, these responsibilities could include having state MR facility and/or MRA staff accompany the individual and remaining there for a period of time deemed necessary for satisfactory transition. The MRA must assign a service coordinator who will meet with the individual and LAR before or on the day of the move.(i) The following records, as applicable, will be provided by the state MR facility to the provider before the move or will accompany the individual, with copies also offered to the individual or LAR, before or at the time of the move:(1) a copy of the birth certificate;(2) copies of any current legal documents;(3) a copy of the individual's Social Security card;(4) a current photograph;(5) a copy of the immunization record;(6) a copy of the height and weight record;(7) a copy of the seizure record;(8) a copy of the most recent physician's orders, to include treatment and diet orders;(9) a copy of the most recent medical and dental examination;(10) copies of the most recent laboratory test results to include any one of a kind laboratory test results;(11) copies of any additional significant reports including the most recent chest X-ray, electrocardiogram (EKG), or electroencephalogram (EEG);(12) a copy of the social history and the most recent psychological examination;(13) Medicaid, Medicare, or third-party insurance cards, if available;(14) a copy of current nursing care plan;(15) a summary of the individual's medical history to include all major surgeries, significant acute illnesses, and injuries requiring hospitalization or a long recovery period;(16) a summary of the individual's medication history to include start and stop dates, dose ranges and effectiveness of all long-term medications, and history of antibiotic use to include dates, effectiveness, sensitivities, and allergies;(17) a summary of dental history including all oral surgeries, extractions, restorations, appliances, and types of anesthesia required for dental work; and(18) any other data requested by the community program or by the individual or LAR.(j) Prior to or at the time of movement, the state MR facility physician shall prepare a letter summarizing the highly relevant medical information to be given to the new physician or health care entity that will be providing services to the individual in the community. The letter will be copied to the designated MRA and other involved MRA and the provider. When appropriate, the state MR facility physician shall communicate directly with the new physician or health care entity.(k) If a school eligible individual will be enrolled in public school, the state MR facility and MRA must provide the following to the school district prior to the move or within 14 working days after the move:(1) the birth certificate or other document as proof of identity;(2) the medical history and medical records, including current immunization records;(3) the social history;(4) the vision and hearing screening and/or evaluation;(5) reports of psychological, educational, related services, and vocational assessments;(6) the habilitation plan, including plan for reintegration;(7) the Admission, Review and Dismissal (ARD) Committee report, Individual Education Plan (IEP), and Comprehensive Assessment, and, for school eligible individuals over the age of 13, the most recent Individual Transition Plan; and(8) if the individual was committed to the state MR facility, a copy of the court order.(l) A provider required to comply with §411.63 of this title (relating to Interagency Coordination of Special Education Services to Students with Disabilities in Residential Care Facilities) must notify, in writing, the school district where the provider is located of the admission of a school eligible individual. The notification will occur no later than three working days after the admission. Source Note: The provisions of this §904.105 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES D MOVING FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT §904.105 Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215136 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215136&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215136 03/12/2026 (a) Designated state MR facility staff will prepare the community living/discharge plan as described in §412.277 of this title (relating to Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility) and this section. The plan incorporates information provided by the individual, LAR, MRA, other state MR facility staff, and the provider. The plan:(1) is customized based on the abilities and needs of the individual to specify the:(A) timelines and intervals for monitoring activities;(B) form those monitoring activities will take (e.g. on-site visitations, phone contacts, record reviews, and written reports);(C) responsibilities of the designated MRA and other MRAs if the proposed move is outside the designated MRA's local services area;(D) responsibilities of the provider; and(E) criteria for a recommendation for discharge from the state MR facility;(2) identifies the individual's or LAR's desired outcomes for an alternative living arrangement that serve as the basis for the person directed plan and service coordination plan to be developed by the designated MRA or the MRA for the local service area where the individual will live; and(3) is approved by the individual, LAR, MRA, state MR facility, and provider before the individual moves from the state MR facility.(b) The plan can be in any format acceptable to all parties (individual, LAR, MRA, state MR facility, and provider), but must contain the elements described in this section. A sample format provided by the department may be used as is or modified as deemed appropriate. Copies are available by contacting the Office of State Mental Retardation Facilities, Texas Department of Mental Health and Mental Retardation, P.O. Box 12268, Austin, Texas 78711-2668, 512/206-4516.(c) The community living/discharge plan will be completed as follows:(1) The community living profile (section I of the sample format), completed by the IDT when a recommendation for an alternative living arrangement has been made and accepted, describes:(A) essential information identifying the individual;(B) the preferences and desired outcomes of the individual or LAR;(C) health and safety issues;(D) the date of the determination of mental retardation conducted as described in §415.155 of this title (relating to Determination of Mental Retardation (DMR)); and(E) name and telephone number of state MR facility contact person.(2) The community living data (section II of the sample format), completed by the state MR facility upon selection of a provider, with information from the provider and MRA, describes:(A) the name, address, and telephone number(s) of the physician or health care entity that will become the individual's primary health care provider;(B) the name(s), address(es), and telephone numbers of contacts at the designated MRA, and others, as appropriate;(C) the name, address, telephone number, and type (e.g. HCS or ICF/MR) of provider, and contact person (address and telephone number, if different);(D) the name, address, telephone number for school, job, or day program and contact person (address and telephone number, if different);(E) the name, address, and telephone number of individual program coordinator; and(F) the identification of the MRA service coordinator assigned to provide continuity of services.(3) The findings and observations (section III of the sample format) are described by the state MR facility and include:(A) thorough medical and behavioral information, which will be communicated to the physician who will be providing care in the community;(B) all current physician orders and treatments, including rationale for all medications prescribed and dispensed by the state MR facility, and amount dispensed which will be continued after the move; and(C) a brief summary of findings, events, and progress during the period the individual resided in the state MR facility;(4) The community living information (section IV of the sample format) is compiled based on information supplied by the individual, LAR, state MR facility and MRA staff, and the provider and includes:(A) the individual's personal likes, dislikes, and preferences (including friends and important relationships);(B) the specific steps and activities necessary to accomplish a successful transition;(C) the outcomes important to the individual and related personal goals; and(D) the services and supports necessary to support the individual in achieving the personal outcomes important in the individual's life (e.g. residential, vocational, social, leisure, religion, health, safety, financial, and transportation);(5) The community living monitoring activities (section V of the sample format) include:(A) the responsibilities of the MRA(s), as the agent of the department, for determining whether the outcomes and criteria established for successful transition have been met with a description of how the determination is to be accomplished (e.g. on-site visitation, phone contacts, record reviews, and written reports) and specific timelines for the completion of monitoring activities;(B) the specific actions to be taken by the MRA(s) and state MR facility in the event that the outcomes and criteria are not being met;(C) the criteria by which the MRA(s) will make a recommendation to the head of the state MR facility that the individual be discharged from the state MR facility;(D) a list of the persons, which must include the individual or LAR, to be notified of the recommendation that the individual be discharged from the state MR facility and how such notice will be accomplished;(E) the timeframe for changing the county of residence in CARE if the move is outside the local service area of the designated MRA; and(F) the expected date of discharge from the state MR facility.(6) The agreements portion (section VI of the sample format) is reviewed and signed by the individual, if appropriate, LAR, and an authorized representative of the state MR facility, MRA(s), and provider, and contains the typed names and titles of the signatories, and the date the plan is approved and signed. This portion includes, at a minimum, the following terms:(A) the provider agrees that the community physician, assigned direct care staff, provider consultants, and other service providers have been informed of all the information contained in the community living/discharge plan;(B) the provider agrees that the MRA(s), as the agent of the department, shall have access to the individual, the living setting, and necessary records;(C) the provider agrees to notify the MRA(s) and the individual's LAR of any conditions which may indicate the living arrangement is in jeopardy and to give the MRA(s) and LAR written notice of intent to discharge the individual at least 30 calendar days before the planned day of discharge;(D) the MRA(s) agrees that the provider and a designated state MR facility staff person will receive accurate and timely written reports, including a list of specific findings for any significant monitoring activity described in paragraph (5) of this subsection;(E) the state MR facility and MRA(s) agree that the individual and LAR have had an opportunity to participate in the development of the community living/discharge plan; and(F) the individual, LAR, state MR facility, MRA(s), and provider agree to make a good faith effort to resolve issues that may be identified by any of these parties until the community living/discharge plan culminates in the individual's discharge from the state MR facility.(7) The discharge plans/activities (section VI of the sample format) are summarized by the state MR facility upon completion of the terms and conditions specified in the community living monitoring activities portion of the plan and will include:(A) a summary of the outcomes and status of the alternative living arrangement;(B) a resolution of any issues that occurred during the transition process; and(C) date of discharge from the state MR facility.(d) If the provider does not actively participate in the development of the community living/discharge plan before the individual is moved from the state MR facility to the alternative living arrangement, the IDT will inform the individual or LAR of the circumstances.(1) The individual with the ability to provide legally adequate consent or the LAR has the option of:(A) continuing with the move after resolution of the problems;(B) continuing with the move without resolution of the problems with the understanding that the individual will be discharged from the state MR facility 30 calendar days after the move; or(C) selecting another provider.(2) If the individual does not have the ability to provide legally adequate consent and does not have an LAR, then the individual will remain in the state MR facility until:(A) the problems are resolved (in a reasonable period of time as determined by the IDT) and community living/discharge plan is completed satisfactorily; or(B) another provider is selected by the IDT because the problems cannot be resolved.(e) In the event that issues cannot be resolved during the development or implementation of the community living/discharge plan, the issue may be forwarded to the commissioner or designee for review and recommended action.(f) If, following the individual's move to the community, the provider doesn't comply with the provisions of the community living/discharge plan and the MRA(s) has exhausted all options to resolve the conflict, the IDT at the state MR facility will be reconvened.(1) If the IDT determines that the individual with the ability to provide legally adequate consent or the LAR wants to continue with the alternative living arrangement the IDT will recommend to the head of the state MR facility that the individual be discharged from the state MR facility within 30 calendar days of the IDT meeting and that monitoring activities required by the community living/discharge plan be discontinued.(2) If the IDT determines that the individual with the ability to provide legally adequate consent or the LAR is not satisfied with the alternative living arrangement and the issues are not resolved, the individual or LAR may request that the IDT reconvene to address the issues causing the dissatisfaction and to assist the individual or LAR to find another alternative living arrangement.(3) If the individual does not have the ability to provide legally adequate consent and does not have an LAR, the IDT will research the situation and will refer the issue to the commissioner or designee for review and recommended action. If it is determined that the individual should be removed from the provider's services, the IDT and MRA(s) will work cooperatively to find alternative services.(g) If during the term of this plan representatives of the department and staff of the MRA have evidence to believe that an individual is in an unsafe environment or that the individual's needs are not being met, they will immediately notify:(1) the appropriate licensing or regulatory agency;(2) the LAR; and(3) the state MR facility from which the individual moved.(h) If the necessity for an out-of-state transfer is indicated, the state MR facility will contact the department's Interstate Compact coordinator in Central Office. Source Note: The provisions of this §904.107 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES D MOVING FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT §904.107 Community Living/Discharge Plan for Alternative Living Arrangements https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215137 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215137&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215137 03/12/2026 (a) An individual who moves from a state MR facility into an alternative living arrangement may be discharged from the state MR facility of record pursuant to THSC, Chapter 594, if the state MR facility determines and documents in the individual's Community Living/Discharge plan or other record that:(1) the individual's needs are better served in a setting other than a state MR facility; and(2) the individual is being successfully treated and habilitated in the current community living arrangement.(b) Upon receipt of a recommendation from an MRA as referenced in §412.278(c)(5)(C) of this title (relating to Community Living/Discharge Plan for Alternative Living Arrangements), the state MR facility may determine that the criteria described in subsection (a) of this section have been met and, if so, will:(1) document in the individual's record the receipt of the notification; and(2) send notice of the intent to discharge in accordance with §414.155 of this title (relating to Notice).(c) If the individual was committed under the PMRA, the committing court will be notified of the discharge from the state MR facility as required in THSC, §594.018.(d) As a courtesy, the facility sends written notice of the intent to discharge to the actively involved family member or friend of the individual who does not have an LAR, unless the individual has requested that those persons not be notified of information regarding the individual.(e) If the individual or the LAR, or another person as the representative for the individual or LAR, requests an administrative hearing before the proposed date of the discharge, the facility of record will arrange for the hearing following the procedures described in Chapter 414, Subchapter D of this title (relating to Administrative Hearings Under the PMRA).(f) If the individual or LAR does not request an administrative hearing to contest the proposed discharge within the time period allowed by §414.156 of this title (relating to Request for an Administrative Hearing), the state MR facility:(1) initiates the discharge entry into CARE;(2) notifies the individual, LAR, if any, or actively involved family member or friend in writing that discharge has been completed;(3) notifies the committing court, as required by THSC, §594.018, of the discharge if the individual was committed under THSC, Chapter 593; and(4) sends written notification to the designated MRA and provider that discharge has been completed. Source Note: The provisions of this §904.125 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES E DISCHARGE §904.125 Discharge from a State MR Facility of an Individual Who Moves to an Alternative Living Arrangement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215138 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215138&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215138 03/12/2026 (a) A state MR facility may discharge an individual who has been admitted or committed to a state MR facility if:(1) the individual is determined as a result of a DMR conducted in accordance with §415.155 of this title (relating to Determination of Mental Retardation (DMR)) to not have mental retardation;(2) the individual has been listed as an unauthorized departure for at least 30 calendar days and attempts to locate the individual have been unsuccessful; or(3) the individual with the ability to provide legally adequate consent or with an LAR moves from the state MR facility against staff advice.(b) The state MR facility will notify the individual or LAR of a proposed discharge at least 31 calendar days prior to the date of the proposed discharge.(1) If the proposed discharge is because the individual is determined not to have mental retardation, as described in subsection (a)(1) of this section, the notice will specify that the individual or LAR has the right to request an administrative hearing to contest the findings of the DMR in accordance with §414.155 of this title (relating to Notice ).(2) If the proposed discharge is because the individual has been listed as an unauthorized departure as described in subsection (a)(2) of this section or individual is leaving the state MR Facility against staff advice as described in (a)(3) of this section, the notice will specify that the individual or LAR has the right to request an administrative hearing to contest the proposed discharge in accordance with §414.155 of this title (relating to Notice). Source Note: The provisions of this §904.127 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES E DISCHARGE §904.127 Administrative Discharges Initiated by a State MR Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215139 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215139&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215139 03/12/2026 A state MR facility must discharge an individual who has been voluntarily admitted to a state MR facility no later than 96 hours after the time the individual or LAR requests discharge of the individual unless:(1) the head of the MR facility determines that the individual's condition or other circumstances are such that the individual cannot be discharged without endangering the safety of the individual or the general public;(2) the head of the facility files an application for judicial commitment under THSC, §593.041; and(3) a court issues an order of protective custody under THSC, §593.044 pending a final determination on the application for judicial commitment. Source Note: The provisions of this §904.129 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES E DISCHARGE §904.129 Administrative Discharges from a Voluntary Admission Initiated by an Individual or LAR https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215140 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215140&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215140 03/12/2026 (a) Upon written notification to MRAs from the department identifying individuals who moved from a state MR facility into an alternative living arrangement prior to September 1, 1997, a planning team organized by the designated MRA must review each identified individual's:(1) treatment and habilitation in the alternative living arrangement; and(2) need, if any, for monitoring.(b) The designated MRA must notify the individual with the ability to provide legally adequate consent or LAR, if any, in writing of the intent to conduct the review and request suggestions of convenient times and locations. If the individual does not have the ability to provide legally adequate consent and does not have an LAR, notice of the intent to conduct the review with a request for convenient times and locations must be sent to an actively involved family member or friend.(1) The notice must explain the purpose of the review and state that the review may result in the discharge of the individual from the state MR facility designated in CARE for that individual.(2) Copies of the notice must be sent to the individual's provider and the state MR facility with a request for suggestions of convenient times and locations for the review.(c) The review must be scheduled at a time and location mutually agreeable to all members of the planning team and conducted using the Guidelines for Determining Level of Monitoring by Designated MRA, copies of which are available from the Office of State Mental Retardation Facilities, TDMHMR. P.O. Box 12668, Austin, Texas 78711-2668. The review must address:(1) the level of satisfaction in the alternative living arrangement on the part of the individual, LAR, or actively involved family member or friend;(2) behavioral issues;(3) employment/vocation issues;(4) medical issues;(5) provider issues; and(6) any other issues which are of concern to any member of the planning team.(d) If a need for monitoring activities is identified by the planning team during the review, the designated MRA must send a letter to all members of the planning team that describes:(1) the type of monitoring activities recommended by the planning team;(2) the persons responsible for conducting the monitoring activities;(3) a timeline for accomplishing the monitoring activities; and(4) a tentative date for the planning team to reconvene and review whether the individual is being successfully treated and habilitated in that alternative living arrangement and the individual's need, if any, for continued monitoring.(e) If the planning team determines that monitoring activities for the individual are not needed, the designated MRA must notify the state MR facility, in writing, with copies to all members of the planning team.(f) An individual may be discharged from the state MR facility designated in CARE pursuant to THSC, Chapter 594, if the state MR facility determines that:(1) the individual's needs are better served in a setting other than a state MR facility; and(2) the individual is being successfully treated and habilitated in the current alternative living arrangement.(g) Upon receipt of a notification from an MRA as described in subsection (e) of this section, the state MR facility may conclude that the criteria described in subsection (f) of this section have been met and, if so, will:(1) document the receipt of the notification and the findings of the planning team;(2) send notice of the intent to discharge in accordance with §414.155 of this title (relating to Notice); and(3) if the individual was committed under the THSC, Chapter 593, Subchapter C, notify the committing court of the discharge from the state MR facility as required in THSC, §594.018.(h) As a courtesy, the state MR facility will send written notice of the intent to discharge to the actively involved family member or friend of the individual who does not have an LAR, unless the individual has requested that those persons not be notified of information regarding the individual.(i) If the individual or LAR, or another person as the representative for the individual or LAR, requests an administrative hearing before the proposed date of the discharge, the state MR facility will arrange for the hearing following the policies and procedures described in Chapter 414, Subchapter D of this title (relating to Administrative Hearings Under the PMRA ).(j) If the individual or LAR does not request an administrative hearing to contest the proposed discharge within the time period allowed by §414.156 of this title (relating to Request for an Administrative Hearing) the state MR facility will:(1) initiate the discharge entry into CARE;(2) notify the individual, LAR, if any, or actively involved family member or friend in writing that discharge has been completed;(3) notify the committing court, as required by THSC, §594.018, of the discharge if the individual was committed under THSC, Chapter 593; and(4) send written notification to the designated MRA and provider that discharge has been completed. Source Note: The provisions of this §904.151 adopted to be effective January 1, 2001, 25 TexReg 12746; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES F SPECIAL CONSIDERATIONS FOR INDIVIDUALS WHO MOVED FROM A STATE FACILITY TO AN ALTERNATIVE LIVING ARRANGEMENT PRIOR TO SEPTEMBER 1, 1997 §904.151 Review by Local MRA of Individual in a Community Living Arrangement https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215141 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=215141&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 215141 03/12/2026 (a) MRA responsibilities.(1) Except for a request for admission for respite care, when admission to a state MR facility is requested for an individual under 22 years of age, the designated MRA must:(A) before the individual is admitted to the facility, inform the LAR:(i) of the benefits of living in a family or community setting;(ii) that the individual's stay in the facility is considered temporary; and(iii) that an ongoing permanency planning process is required;(B) take or ensure that the actions described in §9.244(f) of this title (relating to Applicant Enrollment in the ICF/MR Program) are taken to conduct permanency planning; and(C) take the actions described in §9.244(g)-(i) of this title regarding a volunteer advocate.(2) An MRA does not have to comply with paragraph (1)(A) of this subsection if the individual has been committed to a state MR facility under Chapter 46B, Code of Criminal Procedure, or Chapter 55, Family Code.(3) For an individual under 22 years of age who resides in a state MR facility, the designated MRA must conduct a permanency planning review in accordance with §9.250 of this title (relating to Permanency Planning Reviews).(b) State MR facility responsibilities.(1) Upon the admission of an individual under 22 years of age to a state MR facility, a state MR facility:(A) requests from and encourages the LAR to provide the information described in §9.222(e) of this title (relating to Permanency Planning and LAR Participation for Individuals Under 22 Years of Age);(B) makes notifications as described in §9.222(c) and (d) of this title; and(C) incorporates permanency planning as an integral part of the individual's initial individual program plan (IPP) and identifies information in the IPP as described in §9.222(a) of this title.(2) For an individual under 22 years of age who resides in a state MR facility, a state MR facility:(A) incorporates permanency planning as an integral part of the individual's IPP and identifies information in the IPP as described in §9.222(a) of this title;(B) takes the actions described in §9.222(b) of this title to assist the individual's designated MRA in conducting permanency planning;(C) requests from and encourages the LAR to provide the information described in §9.222(e) of this title;(D) provides notice to the individual and LAR of a meeting to conduct the annual review of the individual's IPP as described in §9.222(g) of this title;(E) attempts to notify the LAR of an emergency situation as described in §9.222(h) of this title;(F) attempts to locate the LAR as described in §9.222(i) of this title, if the LAR does not respond to a notification by the state MR facility; and(G) notifies DADS as described in §9.222(j) of this title if the LAR cannot be located.(3) A state MR facility makes reasonable accommodations to promote the participation of the LAR as described in §9.222(f) of this title.(4) A state MR facility documents compliance with the requirements of this subsection in the individual's record.(c) DADS referral. If, within one year of the date DADS receives the notification described in subsection (b)(2)(G) of this section, DADS is unable to locate the LAR, DADS refers the case to:(1) the Child Protective Services Division of the Department of Family and Protective Services if the individual is under 18 years of age; or(2) the Adult Protective Services Division of the Department of Family and Protective Services if the individual is 18-22 years of age. Source Note: The provisions of this §904.171 adopted to be effective September 1, 2006, 31 TexReg 6783; transferred effective September 1, 2023, as published in the August 11, 2023, issue of the Texas Register, 48 TexReg 4397. 1 HEALTH AND HUMAN SERVICES COMMISSION 904 CONTINUITY OF SERVICES--STATE FACILITIES G PERMANENCY PLANNING AND LAR NOTIFICATION REQUIREMENTS FOR AN INDIVIDUAL UNDER 22 YEARS OF AGE §904.171 MRA and State MR Facility Responsibilities https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219729 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219729&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219729 03/12/2026 Pursuant to the Texas Health and Safety Code Chapter 552, Subchapter B, and Chapter 593, Subchapter D, the purpose of this chapter is to describe:(1) the assessment of fees for individuals' support, maintenance, and treatment at Texas Health and Human Services Commission facilities;(2) the process to appeal an assessed fee; and(3) the process to file a notice of lien. Source Note: The provisions of this §910.1 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219730 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219730&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219730 03/12/2026 This chapter applies to all facilities operated by the Texas Health and Human Services Commission that provide inpatient or residential services. Source Note: The provisions of this §910.2 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219738 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219738&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219738 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Administrative Law Judge (ALJ)--An independent hearing examiner assigned by the Texas Health and Human Services Commission (HHSC) who presides over a hearing for an appeal of a fee with the power to administer oaths, receive evidence, take testimony, and make findings of fact or law.(2) Adult--A person who is not a minor.(3) Appellant--The individual or their legally authorized representative (LAR) appealing a fee.(4) Charges--The total amount of all fees.(5) Current maximum rate--The rate, established by HHSC, that reflects the average daily cost of support, maintenance, and treatment (SMT) per individual for each facility. A copy of the current maximum rates for all facilities may be obtained at www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals; www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs; or by contacting HHSC Health and Specialty Care System, Reimbursement Management, P.O. Box 12668, Mail Code E-619, Austin, Texas 78701-2668.(6) Facility--Any state hospital, state supported living center, and the intermediate care facility for individuals with an intellectual disability (ICF/IID) component of the Rio Grande State Center operated by HHSC.(7) Fee--A specific amount of money assessed, based on at least one source of funds, that is owed monthly to a facility for an individual's SMT.(8) Full day--A 24-hour period extending from midnight to midnight.(9) HHSC--Texas Health and Human Services Commission.(10) Individual--Any person who is admitted to a facility and who is provided SMT as an inpatient or resident (i.e., a person to whom a bed is assigned by the facility).(11) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual, including a parent, guardian, or managing conservator of a minor individual, or a guardian of an adult individual.(12) Minor--A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.(13) Party--The appellant or HHSC.(14) Reimbursement office--The HHSC facility reimbursement office that manages the assessment and notification of charges and the appeal process.(15) SMT--Support, maintenance, and treatment. Source Note: The provisions of this §910.3 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219736 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219736&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219736 03/12/2026 (a) General provisions. The fee for an individual's support, maintenance, and treatment (SMT) is assessed in accordance with this section.(1) Charges to the individual or legally authorized representative (LAR), as appropriate, will not exceed the facility's current maximum rate.(2) Failure of the individual or LAR to provide financial information upon request or to assign third-party benefits may result in charges equal to the facility's current maximum rate accruing to the individual.(3) The finances and assets of an adult's guardian or the guardian of the estate of a minor, who is not also the legal guardian of the minor, are not considered in assessing fees.(4) Charges to a payor that is not an individual or LAR may exceed the facility's current maximum rate.(b) Necessary financial information. Upon an individual's admission to a facility, or shortly afterward, the reimbursement office shall provide the individual, and their personal representative, or their LAR, with a property and financial statement form, appropriate to the type of services provided to the individual.(c) Assessing fees for services provided to minor individuals.(1) The following sources of funds are property from which the state may be reimbursed for a minor individual's SMT and are considered separately in assessing a fee:(A) third-party coverage of the minor individual;(B) the minor individual's benefits from governmental and non-governmental agencies and institutions;(C) child support ordered in a divorce or attorney general proceeding or a suit affecting the parent-child relationship pursuant to Texas Health and Safety Code §552.014 and §593.077;(D) real or personal property in the minor individual's guardianship estate or owned by the minor individual;(E) the net taxable income of the minor individual's parents as authorized by the Texas Health and Safety Code §552.017, §593.075, and §593.076, in accordance with the Taxable Income of Parents formula, which may be obtained at www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals; www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs; or by contacting the Texas Health and Human Services Commission (HHSC) Health and Specialty Care, Reimbursement Management, P.O. Box 12668, Austin, Texas 78701-2668, and Internal Revenue Services' guidelines; and(F) monthly net income of the minor individual (excluding income from the source described in subparagraph (B) of this paragraph) receiving services at a state supported living center, in accordance with the Individuals in State Supported Living Centers formula, which may be obtained at www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs or by contacting the facility reimbursement office.(2) An order in a divorce proceeding that provides for child support payments (as referenced in paragraph (1)(C) of this subsection) does not limit the fee that may be assessed (except that it may not exceed the current maximum rate), nor does the order exempt either parent from liability for the charges.(d) Assessing a fee for adult individuals in inpatient mental health facilities. The following sources of funds are considered separately in assessing a fee:(1) third-party coverage of the adult individual;(2) the adult individual's benefits from governmental and non-governmental agencies and institutions;(3) real or personal property in the adult individual's guardianship estate or owned by the adult individual or spouse; and(4) monthly gross income of the adult individual (excluding income from the source described in paragraph (2) of this subsection) and income of the spouse, in accordance with the Adult Individuals in Inpatient Mental Health Facilities formula, which may be obtained at www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals or by contacting the facility reimbursement office.(e) Assessing a fee for adult individuals in state supported living centers and the ICF/IID component of the Rio Grande State Center. The following sources of funds are considered separately in assessing a fee:(1) third-party coverage of the adult individual;(2) the adult individual's benefits from governmental and non-governmental agencies and institutions;(3) real or personal property in the adult individual's guardianship estate or owned by the adult individual or spouse;(4) the adult individual's monthly net earned income in accordance with the Individuals in State Supported Living Centers formula, which may be obtained at www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs or by contacting HHSC Health and Specialty Care, Reimbursement Management, P.O. Box 12668, Austin, Texas 78701-2668; and(5) income of the adult individual (excluding income from the sources described in paragraphs (2) and (4) of this subsection) and income of the spouse.(f) Trusts. The provisions of the Texas Health and Safety Code §552.018 and §593.081, apply to the fee assessment for an individual who is a beneficiary of a trust or trusts.(g) Notification of charges. After a fee has been assessed, the reimbursement office shall provide written notification to the individual or LAR of charges that includes:(1) the date on the notification of charges;(2) the name of the individual receiving SMT from the facility;(3) the fees and the sources of funds used to assess the fees;(4) the effective dates of the fees;(5) the facility's current maximum rate;(6) a statement that the individual or LAR is responsible for notifying the facility's reimbursement office within 30 days of the change, when there is a change in any of the sources of funds HHSC uses to assess a fee or a change in family status that would affect any assessed fee;(7) information on possible payments from a third-party payor; and(8) a statement that the individual or LAR has the right to appeal under the following conditions if they disagree with the fee.(A) If the individual or LAR has submitted complete financial information, then the individual or LAR must notify the reimbursement office of their intent to appeal the fee. The individual or LAR must initiate the appeal, in accordance with §910.8(c) of this chapter (relating to Appeal Process), within 45 business days of the date on the notification of charges.(B) If the individual or LAR has not submitted complete financial information, the individual or LAR must contact the reimbursement office and provide complete financial information within 15 business days of the date on the notification of charges or the individual or LAR forfeits the right to appeal. If the individual or LAR provides complete financial information within 15 business days of the date on the notification of charges, the individual or LAR must initiate the appeal, in accordance with §910.8(c) of this chapter, within 45 business days of the date on the notification of charges.(h) Complete financial information received within 15 business days of the date on the notification of charges. If the reimbursement office receives complete financial information from the individual or LAR within 15 business days of the date on the notification of charges as required in subsection (g)(8)(B) of this section, the reimbursement office shall, within 10 business days:(1) review the financial information;(2) revise the fee, if appropriate; and(3) inform the individual or LAR in writing:(A) of the fee amount;(B) that the individual or LAR has a right to appeal if they disagree with the fee; and(C) that an appeal must be initiated, in accordance with §910.8(c) of this chapter within 45 business days of the date on the notification of charges referenced in subsection (g) of this section.(i) Fee revision. HHSC shall determine if a fee revision is warranted each time HHSC receives information indicating:(1) a change in any of the sources of funds HHSC uses to assess a fee; and(2) a change in family status that would affect any assessed fee.(j) Individuals transferring between two facilities. If an individual is transferred between two facilities, only the receiving facility may bill for the day of transfer. The transferring facility may not bill on the individual's date of admission from a transfer from another HHSC operated facility.(k) Individuals receiving Medicaid Benefits. If an individual is receiving Medicaid benefits, reimbursement will be completed pursuant to applicable federal and state Medicaid laws. Source Note: The provisions of this §910.4 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.4 Fee Assessment and Notification of Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219737 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219737&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219737 03/12/2026 (a) Except when charging is prohibited by law or contract and subject to the provisions in this section, charges continue to accrue:(1) for the entire period the individual receives support, maintenance, and treatment at the facility;(2) for the entire period of the individual's absence from the facility, if the individual remains under the care, custody, and control of facility personnel;(3) for the entire period the individual is absent from the facility for admission to an inpatient medical facility and charges for the medical services at the inpatient medical facility are not paid by a third-party payor; and(4) for the first three days of the individual's absence from the facility, other than an absence described in paragraphs (2) and (3) of this subsection, from which the individual plans to return.(b) The following are considered a full day at the facility:(1) the day of the individual's admission to the facility;(2) the day of the individual's death at the facility; and(3) the day the individual returns to the facility from an absence.(c) The day of the individual's discharge from the facility is considered a full day away from the facility.(d) If the individual or legally authorized representative (LAR) has provided complete financial information and the person disagrees with the fees assessed by the Texas Health and Human Services Commission, and the individual has not yet been admitted to a state hospital, the individual or LAR may contact the reimbursement office of the state hospital in which the individual would receive services to appeal charges to the state hospital superintendent, or designee. Source Note: The provisions of this §910.5 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.5 State Hospital Accruing Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219731 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219731&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219731 03/12/2026 (a) Except when charging is prohibited by law or contract and subject to the provisions in this section, charges continue to accrue:(1) for the entire period the individual receives support, maintenance, and treatment at the facility;(2) for the entire period of the individual's absence from the facility, if the individual remains under the care, custody, and control of facility personnel;(3) for the entire period the individual is absent from the facility for admission to an inpatient medical facility and charges for the medical services at the inpatient medical facility are not paid by a third-party payor;(4) for the first full three days of the individual's absence from the facility, other than an absence described in paragraphs (2) and (3) of this subsection, from which the individual plans to return; and(5) for 10 days per calendar year of the individual's absence from the facility for an extended leave.(b) The following are considered a full day at the facility:(1) the day of the individual's admission to the facility;(2) the day of the individual's death at the facility;(3) the day the individual leaves the facility for an absence; and(4) the day the individual returns to the facility from an absence.(c) The following are considered a full day away from the facility:(1) the day of the individual's discharge from the facility; and(2) the day of the individual's transfer from an SSLC to a state hospital. Source Note: The provisions of this §910.6 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.6 State Supported Living Center Accruing Charges https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219732 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219732&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219732 03/12/2026 (a) If the individual or legally authorized representative (LAR) has provided complete financial information and the person disagrees with the fees assessed by the Texas Health and Human Services Commission (HHSC), the individual or LAR may contact the reimbursement office of the state hospital in which the individual would receive services to request a reduction and review of charges by the state hospital superintendent, or designee. The request must be made in writing within 10 business days of the date on the notification of charges letter. The individual or LAR retains the right to formally appeal the charges without using the rate review process at a state hospital.(b) The individual or LAR will be notified of the rate review process at the time of initial rate determination and upon any subsequent rate determination.(c) A request under this section will delay the deadline under §910.8(c)(2) of this chapter (relating to Appeal Process) for an appeal request to be submitted until a determination is made regarding a review under this section.(d) If HHSC requests more information for a review, the request must be made within 7 business days of the original review request. An individual must submit additionally requested information within 15 business days. If the additional information is not received within 15 days, the request under this section will be considered withdrawn. If additional information is not received, HHSC must provide a notice to the individual that the request under this section is considered withdrawn and that the individual may proceed with an appeal under §910.8 of this chapter.(e) Once HHSC receives all necessary information, HHSC must issue a review decision within seven business days and provide notice of the decision to the individual or LAR. Source Note: The provisions of this §910.7 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.7 Rate Review Process at State Hospitals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219733 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219733&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219733 03/12/2026 (a) Right to appeal. If the individual or legally authorized representative (LAR) has provided complete financial information and the individual or LAR disagrees with any fees assessed by the Texas Health and Human Services Commission (HHSC), then the individual or LAR is entitled to appeal such fees.(b) Obtaining forms to initiate an appeal. To appeal a fee, the individual or LAR must notify the reimbursement office at the facility providing support, maintenance, and treatment to the individual of their intent to appeal the fee. Upon such notification, the reimbursement office shall ensure the individual or LAR has provided complete financial information before sending the individual or LAR a copy of this chapter and a Request for Appeal form. Upon determination that complete financial information has been provided to the reimbursement office, the reimbursement office must provide the form to the individual or LAR within five business days. Additionally, forms can be obtained at, www.hhs.texas.gov/services/mental-health-substance-use/state-hospitals and www.hhs.texas.gov/services/disability/intellectual-or-developmental-disabilities/state-supported-living-centers-sslcs.(c) Initiating the appeal.(1) The individual or LAR initiates an appeal by completing, signing, and sending the Request for Appeal form, referenced in subsection (b) of this section or §910.9(a)(4) of this chapter (relating to Filing Notice of Lien), to: OCC_Appeals_ContestedCases@hhs.texas.gov or HHSC Appeals Division, P.O. Box 149030, Mail Code W-613, Austin, Texas 78714-9030.(2) An appeal may be initiated before the 45th business day after notification of charges.(d) Representation.(1) The appellant may represent their self or use legal counsel, a relative, a friend, or other spokesperson.(2) HHSC is represented by an HHSC attorney.(e) Type of hearing. The appellant may choose to:(1) appear by telephone conference, or by virtual platform, or have their representative appear by telephone conference or by virtual platform at the hearing; or(2) have a document desk review hearing in which the administrative law judge (ALJ) makes a decision based solely upon documentation filed by the parties with neither party appearing.(f) Scheduling the hearing. The ALJ shall schedule the hearing to be held not later than the 120th business day after the date the Request for Appeal form is received by the Appeals Division. The ALJ shall consider any request for reasonable accommodations related to a disability of the appellant or the appellant's representative.(1) If the appellant chooses to appear by telephone conference, the ALJ shall schedule a date, time, and phone number for the hearing. At least 20 calendar days before the hearing, the ALJ shall notify the parties, in accordance with subsection (g) of this section, of the scheduled date, time, and phone number of the hearing.(2) If the appellant chooses to have a document desk review, at least 20 calendar days before the document hearing, the ALJ shall notify the parties, in accordance with subsection (g) of this section, of the date that all documentation must be filed with the Appeals Division and copies submitted to the other party or the other party's representative.(g) Notification of parties.(1) The appellant is notified by electronic and certified mail.(2) The designated HHSC attorney is notified by intra-agency mail, fax, or electronic mail.(h) Ex parte communication. Except for communications regarding procedural matters, the ALJ may not communicate with a party, directly or indirectly, on any issue of fact or law, unless both parties are present, or the communication is in writing and a copy is delivered to both parties.(i) Privileged communication. No party is required to disclose communications between an attorney and the attorney's clients, accountant and the accountant's client, a husband and wife, a clergy-person and a person seeking spiritual advice, or the name of an informant, or other information protected from being divulged by substantive federal or state law.(j) Withdrawing. The appellant may withdraw the appeal or HHSC may withdraw the fees being appealed at any time prior to the hearing. Upon withdrawal of either party, no hearing is held. The ALJ will issue an order of dismissal and notify the parties of such dismissal in accordance with subsection (g) of this section.(k) Settlement. At any time before the hearing, parties may enter into a settlement disposing of the contested issues. A settlement agreement must be in writing, signed by the parties or their representatives, and filed with the Appeals Division. Upon receipt of the settlement agreement, the ALJ will issue an order of dismissal and notify the parties of such dismissal in accordance with subsection (g) of this section.(l) Filing documents.(1) Hearing at which the parties will appear by telephone.(A) If a party intends to introduce documents at the hearing, the party shall send such documents to the Appeals Division and submit a copy of the documents to the other party or the other party's representative at least 10 business days before the hearing. Failure to submit copies of documents to the other party will result in a continuance if requested by the party who did not receive the documents.(B) At the hearing, the ALJ may request either or both parties to file additional documents for consideration in making a decision. The ALJ shall indicate in writing the date by which the additional documents must be received by the Appeals Division.(2) Document hearing. If a party intends for the ALJ to consider their documents at a document hearing, then the party shall send such documents to the Appeals Division and submit a copy of the documents to the other party or the other party's representative by the date identified by the ALJ as described in subsection (f)(2) of this section. Failure to submit copies of documents to the other party will result in a continuance if requested by the party who did not receive the documents.(m) Continuance. The ALJ may grant continuances on the request of either party provided the party shows good cause for requesting the continuance. A request for a continuance may be written or oral and may be made before or during a hearing. If a hearing is continued, the ALJ shall schedule the hearing to be continued on a day that is not later than the 45th day after the hearing was originally scheduled. The ALJ must notify the parties, in accordance with subsection (g) of this section, of the continued hearing date within five business days of granting a continuance.(n) Telephone conference.(1) Telephone conference equipment used for a hearing must be capable of allowing the parties and the ALJ to hear and speak to each other at all times during the hearing.(2) If a party elected to appear by telephone, on the date and time of the hearing, the ALJ shall initiate telephone contact with the party using the telephone number provided by the party.(o) Failure to appear. If the appellant fails to appear at the hearing, the ALJ shall adjourn the hearing. If the appellant notifies the ALJ within three business days after the hearing date and provides evidence of good cause for failing to appear and requests a continuance, the ALJ may grant a continuance. If the ALJ has not been notified by the fourth business day after the hearing date, the ALJ shall close the record and consider all the documents previously filed by both parties and prepare a decision based on such previously filed documents.(p) Evidence.(1) Documents. Documents provided as evidence for the hearing do not need authentication.(2) Testimony. Material and relevant testimony is admissible.(q) Procedural rights. Each party has the right to:(1) establish all pertinent facts and circumstances;(2) present an argument without undue interference;(3) question or refute any evidence; and(4) have an audio recording of the hearing proceedings. The ALJ will provide a recording on request.(r) Audio recording of hearing proceedings. If the hearing is not a document desk review, the ALJ shall make an audio recording of the hearing proceedings. The appellant may request and receive a copy of the audio recording at minimal charge.(s) Record. The record of the hearing closes when the hearing is adjourned or at the end of the business day on the date that all documents are required to be submitted. The record consists of:(1) all documents submitted to the Appeals Division, together with the ruling on admissibility made by the ALJ; and(2) the audio recording of the hearing proceedings made by the ALJ, as required in subsection (r) of this section, if the hearing was not a document desk review.(t) Decision. Not later than the 30th calendar day after the hearing record has closed, the ALJ shall issue a decision. Hearing decisions must be based exclusively on evidence in the record. Evidence admitted in the hearing is retained in accordance with the HHSC retention schedule. The decision shall be in writing, signed, and dated by the ALJ, and state:(1) the names of the parties and their representatives (if any), and that they appeared by telephone, if the hearing was not a document desk review;(2) findings of fact and conclusions of law, separately stated;(3) whether the appealed fees have been sustained, reduced, or increased; and(4) the amount of the fees.(u) Effective date. A decision issued under this section is effective on the date it is signed by the ALJ.(v) Notice of decision. After the ALJ signs the decision, the Appeals Division shall send a copy of the ALJ's decision to the parties in accordance with subsection (g) of this section.(w) Finality. The decision of the ALJ is final. For correcting a clerical error, the ALJ retains jurisdiction for 20 calendar days after the date the decision is signed.(x) Charges. HHSC will not seek reimbursement for services while an appeal decision is pending. Any adjustments made to the service charge as a result of an appeal decision will be included in the updated charge submitted to an individual or their LAR. Source Note: The provisions of this §910.8 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.8 Appeal Process https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219734 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219734&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219734 03/12/2026 (a) If the Texas Health and Human Services Commission (HHSC) intends to file a written notice of lien pursuant to Texas Health and Safety Code §533.004, 31 calendar days prior to filing the written notice of the lien with the county clerk, HHSC shall notify by certified mail the individual or legally authorized representative (LAR) of HHSC's intent to file a lien. HHSC also will send the notice by an alternative means when a patient or person legally responsible for the payment of services makes such a request and provides the necessary contact information. The notice to the individual or LAR shall include:(1) a statement of the unpaid charges;(2) a copy of the statutory procedures related to filing a lien as provided by Texas Health and Safety Code §533.004;(3) a copy of §910.8 of this chapter (relating to Appeal Process);(4) a Request Appeal form and a statement that to stay the filing of the lien, the completed Request for Appeal form must be received by the Appeals Division within 31 calendar days after the date the notification of HHSC's intent to file a lien was mailed; and(5) the name and phone number of the HHSC staff sending the notification.(b) If the person does not request an appeal within 31 calendar days after the date the notification of HHSC's intent to file a lien was mailed, HHSC may proceed to file the written notice of lien.(c) If the person requests an appeal and the ALJ's decision:(1) sustains the appealed fees, HHSC may proceed to file the written notice of lien any time after 31 calendar days of the date the notification of HHSC's intent to file a lien was mailed;(2) reduces the appealed fees to less than the assessed amount but more than zero, the person must pay the reduced amount or HHSC may proceed to file the written notice of lien any time after 31 calendar days of the date the notification of HHSC's intent to file a lien was mailed;(3) reduces the appealed fees to zero, HHSC must withdraw its notice of intent to file a lien in writing; or(4) increases the appealed fees, the person must pay the increased amount or HHSC may proceed to file the written notice of lien any time after 31 calendar days of the date the notification of HHSC's intent to file a lien was mailed.(d) HHSC shall not file a lien until the conclusion of the ALJ decision. Source Note: The provisions of this §910.9 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.9 Filing Notice of Lien https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219735 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219735&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219735 03/12/2026 If the amount shown as annual taxable income of the parents as reported on their most current financial statement, their latest federal income tax return, or other appropriate evidence of income, at the election of the parent:(1) is equal to or less than the U.S. federal poverty income level (FPIL), the monthly fee per individual, based on parental income, is $0; or(2) is greater than the FPIL, the monthly fee per individual, based on parental income, is no more than $200 for each 50 percent increase of income over the FPIL. Source Note: The provisions of this §910.10 adopted to be effective March 24, 2022, 47 TexReg 1457. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS A CHARGES FOR SERVICES IN STATE FACILITIES §910.10 Taxable Income of the Parents https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219739 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219739&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219739 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise:(1) CEO--The superintendent of a facility.(2) DADS--The Department of Aging and Disability Services.(3) Department--The Department of Aging and Disability Services.(4) Facility--A state mental retardation facility operated by DADS.(5) Individual--A person receiving services from a facility.(6) LAR (legally authorized representative)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter and may include a parent, guardian, or managing conservator of a minor individual, a guardian of an adult individual, or a personal representative of a deceased individual.(7) Mental retardation--Subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and originating during the developmental period.(8) Material safety data sheet--The document provided by a manufacturer that describes a material's or part's chemical properties along with guidelines for proper use, storage, and disposal.(9) Non-commercial group--A group of people associated with an organization (for example, a civic, fraternal, religious, social, service, community, or public employee organization).(10) Sales receipt--A written statement issued by the seller that includes the date it was created and the cost of the item or service.(11) Trust fund--An account at a financial institution in a facility's control that contains funds of an individual.(12) Unauthorized departure that may have unusual consequences--The unauthorized departure of an individual that causes a reasonably prudent staff member who has knowledge of the individual's condition to believe that harm or injury to the individual or to others may occur as a result of the unauthorized departure, for example, the unauthorized departure of an individual whom the treatment staff believes to be a danger to self or to others or the unauthorized departure of an individual who requires maintenance medication such as insulin. Source Note: The provisions of this §910.51 adopted to be effective June 1, 2006, 31 TexReg 4235; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS B STATE FACILITY FINANCIAL RESPONSIBILITIES §910.51 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219740 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219740&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219740 03/12/2026 The CEO or designee is responsible for ensuring that:(1) all funds received are deposited with the state treasurer or in an account that is insured under state or federal law.(2) the balance of such account does not exceed the insured limit of the financial institution; and(3) all funds that must be deposited in the State Treasury are deposited within three business days of receipt. Source Note: The provisions of this §910.53 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS B STATE FACILITY FINANCIAL RESPONSIBILITIES §910.53 Depositing Department Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219741 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219741&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219741 03/12/2026 (a) The CEO or designee must ensure that funds which are not required for current use are invested with Texas financial institutions or the Central Office investment plan. Earnings on invested funds other than trust funds shall be added to the funds from which earnings are derived. The interest rate and the availability for withdrawal in case of emergency must be considered in making investment selections.(1) Texas financial institutions. If the Texas financial institution is insured under state or federal law, the funds may be invested in certificates of deposit or savings accounts. If the investment amount exceeds the limits of state and federal insurance the investment source must pledge additional securities equal to the investment amount.(2) Central Office investment program. Central Office offers a short term fund, current interest rate, investment plan for the benefit of all facilities. Funds may be transferred to Central Office, Financial Services in multiples of $2,500 for immediate return upon request. Interest payments are remitted by Central Office, Financial Services at the end of each month.(b) A register of investments, including individuals' personal funds must be maintained in the office of the CEO or designee, including:(1) name of financial institution;(2) a description of each investment;(3) the amount and date of the investment;(4) interest due dates;(5) interest paid dates;(6) maturity date; and(7) reinvestment information.(c) The CEO or designee must use the register of investments to verify collection of income and principal. Source Note: The provisions of this §910.55 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS B STATE FACILITY FINANCIAL RESPONSIBILITIES §910.55 Investing Department Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219742 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219742&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219742 03/12/2026 (a) Authority. As authorized by the Texas Health and Safety Code, §551.004, the CEO must be the trustee of a special fund designated as the benefit fund. The CEO may expend the money in any such fund for the education or entertainment of individuals or for the actual expense of maintaining the fund at the financial institution. (b) Source of funds. The source of benefit funds are: (1) private donations or gifts; and (2) interest earned from investment of benefit funds. (c) Use of funds. Except for specific purpose funds, benefit funds may be used only for the purposes of education or entertainment of individuals and be of general benefit to the facility's population. However, this does not mean or imply that every individual must benefit from each expenditure from the benefit fund. Benefit funds must not be spent in a manner that shows partiality or preferential treatment of an individual or selected groups of individuals. Expenditures from the benefit fund must be supported by sales receipts to show the exact purpose and, if practical, to show the name of the individuals' benefiting from the expenditure. (d) Allowable expenditures. Expenditures from the benefit funds may include items such as: (1) supplies for behavior therapy programs, which involve a token economy or point level system; (2) outings for individuals, including admission fees and meals for those staff who are required to accompany the individuals; (3) coffee for individuals; (4) religious items; (5) educational books and supplies; (6) salaries of temporary teachers, including athletic instructors and recreation assistants; (7) playground equipment, televisions, record players, and stereos, for use by individuals as a whole in the living areas; and (8) grocery items purchased for classes in home economics. (e) Unallowable expenditures. Expenditures that cannot be made from the benefit fund include: (1) travel of state employees; (2) operating supplies; (3) supplies for volunteer center training program; (4) nursery stock; (5) clothing for individuals; (6) cash issues to individuals with no personal funds. (7) purchase of canteen coupon books for individuals with no personal funds; (8) staff salary augmentation; (9) transportation for individuals' home visits; and (10) furniture and equipment normally purchased from state appropriated funds. (f) Prohibition on use of funds. Unless prohibited by department policy or state or federal laws and regulations, funds that are donated for a specific purpose must be used for that purpose. If the purpose for the funds is prohibited, the donor is contacted and asked to specify a purpose that permits expenditure in compliance with department policy or state or federal law and regulations. (g) Depositing funds. The CEO or designee must ensure that all benefit fund receipts are deposited in a financial institution insured by state or federal and all expenditures are made by check according to the TDMHMR Fiscal Manual . (h) Administrative expenses. The actual expense of maintaining benefit funds may include expenditures to cover administrative errors which arise in the administration or disbursement of benefit funds and personal funds, provided the following restrictions are met: (1) the amount of benefit funds expended to cover any single loss does not exceed $250; (2) in each instance of loss, prior approval for the use of benefit funds to cover the administrative error must be obtained from the CEO; (3) the circumstances surrounding each administrative error must be documented and attached in the supporting records; (4) for auditing purposes, the expenditure, if approved and made, must be charged to cash shortage; (5) benefit funds must not be used to cover losses that result from the gross negligence of any employee or employees; (6) the facility in which the administrative error occurred must take the action necessary to correct the error and/or prevent its recurrence, including, but not limited to, counseling staff on the correct procedure for the administration and disbursement of benefit funds and personal funds; and (7) employees responsible for administrative errors in the administration or disbursement of benefit funds and personal funds may be subject to disciplinary action. Source Note: The provisions of this §910.57 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS B STATE FACILITY FINANCIAL RESPONSIBILITIES §910.57 Benefit Funds: Use and Control https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219743 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219743&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219743 03/12/2026 A state vehicle used primarily for transporting individuals receiving services from a facility is exempt from the requirement in Texas Transportation Code, §721.002, to have "Texas Department of Aging and Disability Services" printed on the vehicle. The purpose served by this exemption is to provide confidentiality, safety, and normalization for individuals receiving services and to reduce the stigma associated with mental retardation. Source Note: The provisions of this §910.103 adopted to be effective October 6, 2002, 27 TexReg 9152; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; amended to be effective June 1, 2006, 31 TexReg 4235; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS C STATE FACILITY PROPERTY §910.103 Inscription on State Facility Vehicles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219744 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219744&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219744 03/12/2026 (a) Policy. The facility CEO may make facility resources available to the public at large whenever it can do so without compromising the department's primary mission. (b) Requesting permission. The Facility/Premises Use Request form, which is in the TDMHMR Contracts Manual, must be completed and submitted to the facility CEO. (c) Criteria for approving requests. The facility CEO may approve or disapprove the use of facility resources based on whether: (1) the organization agrees in writing to abide by all rules and regulations established by the facility CEO regarding the use facility resources and that its meetings in no way interfere with or disrupt the delivery of services to the individuals mental illness or mental retardation; (2) the event does not conflict with any of the facility's scheduled events, programs, or priorities; (3) the event is consistent with the physical constraints of the resources to be used; (4) the facility can provide the services for the time period requested; and (5) the event does not conflict with the best interests of the facility or individuals. (d) Facility resource use fee. Any non-commercial group may be charged a facility resource use fee according to the Facility Resource Use Fee Schedule, which is in the TDMHMR Contracts Manual. (e) Revoking permission. Permission granted pursuant to such a request continues until revoked by the facility CEO. The non-commercial group must immediately notify the facility CEO of any change in the information stated in its written request for permission to use the facilities. (f) Advertising. If language clearly reflects that the facility is not sponsoring or promoting the event is included in the copy, the facility's name may be used to advertise the location of the activities. The facility CEO may require that a proof of the advertising copy be submitted for approval and may require the a disclaimer, e.g., (facility name) is not a promoter or sponsor of this event. No inference of support can be drawn because of the event's location. (g) Liability. Any non-commercial group or any member thereof using facility resources is liable for any destruction or damage to the resources. The department is not liable for any injury to any person or for the loss of or damage to the property of any person, organization, or group using facility resources. (h) Required documentation. As described in the TDMHMR Contracts Manual and this subchapter, if the request is for an athletic or sporting event, a water-related activity, overnight use, or an event that is open to the public at large or attendance is expected to exceed 25 or more people, then the requestor by no later than 72 hours prior to the event must:(1) execute a license and use agreement; (2) execute a waiver and indemnity agreement; and (3) obtain general liability insurance in an amount sufficient to cover TDMHMR's potential liability (as established on the Facility/Premises Use Request form), with the Texas Department of Mental Health and Mental Retarded and/or its successors listed as an additional insured; and (4) submit the use and indemnity agreements and proof of insurance to the facility CEO. Source Note: The provisions of this §910.105 adopted to be effective October 6, 2002, 27 TexReg 9152; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS C STATE FACILITY PROPERTY §910.105 Non-Commercial Groups at a State Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219745 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219745&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219745 03/12/2026 If a facility has on-site overnight accommodations that are made available to family members or guests of an individuals receiving services, a facility resource use fee may be charged. The facility use fee schedule is in the TDMHMR Fiscal Manual. If the family member or guest is unable to pay the entire use fee, the facility CEO may waive any portion or all of the fee based on the family member's or guest's ability to pay. Source Note: The provisions of this §910.107 adopted to be effective October 6, 2002, 27 TexReg 9152; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS C STATE FACILITY PROPERTY §910.107 Overnight Accommodations for Guests of an Individual Receiving Services at a State Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224634 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224634&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224634 03/12/2026 The following words and terms when used in this subchapter have the following meanings, unless the context clearly indicates otherwise.(1) Budgeted amount--The amount of cash that may be disbursed to an individual at regular intervals, e.g., weekly or monthly for discretionary spending without obtaining a sales receipt for the expenditure.(2) CEO--The chief executive officer of a state mental health facility or a state mental retardation facility.(3) Commercial lease--A lease of real property to a private enterprise.(4) Competitive bid--A competitive process for determining the award of a lease, more particularly described in Texas Health and Safety Code, §533.084 and §533.087.(5) Department--The Texas Department of Mental Health and Mental Retardation (TDMHMR).(6) Facility--A state mental health facility (SMHF) or a state mental retardation facility (SMRF) operated by the TDMHMR.(7) Individual--A person receiving services from the Texas Department of Mental Health and Mental Retardation.(8) LAR (legally authorized representative)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and may include a parent, guardian, or managing conservator of a minor individual, a guardian of an adult individual, or a personal representative of a deceased individual.(9) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, senility, substance abuse or dependency, mental retardation, autism or pervasive developmental disorder) that:(A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.(10) Mental retardation--Subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and originating during the developmental period.(11) Material safety data sheet--The document provided by a manufacturer that describes a material's or part's chemical properties along with guidelines for proper use, storage, and disposal.(12) Non-commercial group--A group of people associated with an organization, e.g., civic, fraternal, religious, social, service, community, or public employee organization.(13) Pooled account--A trust fund account containing the personal funds of more than one individual.(14) Prevailing market rate--A reasonable estimate of the annual rent for a real property based upon its fair market value that reflects the real property's condition, location, and other salient factors.(15) Public benefit lease--A lease of non-surplus real property between the department and a federal or state agency, a unit of local government, a not-for-profit organization, or an entity that provides services to individuals and/or employees. Such a lease is determined or defined by the board as providing a public benefit.(16) Public employee organization--An organization that represents department staff in legislative, human resource, and related issues.(17) Sales receipt--A written statement issued by the seller that includes:(A) the date it was created; and(B) the cost of the item or service.(18) SMHF--A state mental health facility (e.g., state hospital).(19) SMRF--A state mental retardation facility (e.g., state school or state center).(20) Surplus property--Real property designated by the Texas Mental Health and Mental Retardation Board (board) as having minimal value to the present delivery system as described in the department's long-range plan.(21) Trust fund account--An account at a financial institution in the facility's control that contains personal funds.(22) Unauthorized departure that may have unusual consequences--The unauthorized departure of an individual that causes a reasonably prudent staff member who has knowledge of the person's condition to believe that harm or injury to the individual or to others may occur as a result of the unauthorized departure, e.g., the unauthorized departure of an individual who the treatment staff believes to be a danger to self or to others or the unauthorized departure of an individual who requires maintenance medication such as insulin.(23) Unclaimed personal funds or property--Personal funds or property managed by the facility that has not been disbursed to the individual or LAR within 30 calendar days after the individual's discharge, e.g., if an individual dies and staff are unable to find the LAR or heir to the estate.(24) Unidentified personal funds or property--Personal funds or property managed by the facility for which the facility cannot identify ownership. Source Note: The provisions of this §910.151 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.151 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224635 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224635&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224635 03/12/2026 (a) The CEO or designee must ensure that funds which are not required for current use are invested with Texas financial institutions or the Central Office investment plan. Earnings on invested funds other than trust funds shall be added to the funds from which earnings are derived. The interest rate and the availability for withdrawal in case of emergency must be considered in making investment selections.(1) Texas financial institutions. If the Texas financial institution is insured under state or federal law, the funds may be invested in certificates of deposit or savings accounts. If the investment amount exceeds the limits of state and federal insurance the investment source must pledge additional securities equal to the investment amount.(2) Central Office investment program. Central Office offers a short term fund, current interest rate, investment plan for the benefit of all facilities. Funds may be transferred to Central Office, Financial Services in multiples of $2,500 for immediate return upon request. Interest payments are remitted by Central Office, Financial Services at the end of each month.(b) A register of investments, including individuals' personal funds must be maintained in the office of the CEO or designee, including:(1) name of financial institution;(2) a description of each investment;(3) the amount and date of the investment;(4) interest due dates;(5) interest paid dates;(6) maturity date; and(7) reinvestment information.(c) The CEO or designee must use the register of investments to verify collection of income and principal. Source Note: The provisions of this §910.153 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.153 Investing Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224636 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224636&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224636 03/12/2026 (a) Rules concerning the personal funds of individuals receiving services from a state mental retardation facility (SMRF) are in Chapter 419, Subchapter E, concerning ICF/MR Program.(b) The state mental health facility (SMHF) must implement §§417.39 - 417.46 of this title according to the generally accepted accounting principles of the American Institute of Certified Public Accountants.(c) The CEO must develop and implement local procedures regarding personal funds that protect the financial interest of individuals and, at a minimum, require the SMHF to allow individuals to hold and manage their personal funds to the extent of their abilities. Source Note: The provisions of this §910.155 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.155 Protecting an Individual's Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224637 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224637&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224637 03/12/2026 At the time of admission to the SMHF, and if changes to services or charges occur, staff must provide each individual or LAR with written notification containing the following information:(1) a written explanation of §417.41 of this title (relating to Determining Management of Personal Funds), which describes who may manage personal funds;(2) a statement that the admitting physician determines whether the individual has the ability to manage his or her personal funds and if, an individual is unable to manage such funds, the funds are deposited in the trust fund account for no longer than seven calendar days when the treating physician reevaluates the admitting physician's determination;(3) a statement that the individual, CEO, or LAR may request that the Social Security Administration appoint a representative payee to receive the individual's federal benefits in accordance with 20 CFR Part 416, Subpart F;(4) a statement that, if the facility manages the individual's personal funds, staff must make available the individual's personal funds ledger upon the individual's or LAR's request but in no case longer than 30 calendar days; and(5) a statement that at the request of the individual or LAR, or if the individual is discharged from the SMHF, the SMHF must whenever possible disburse the individual's personal funds to the individual or LAR upon discharge but in no event more than 30 calendar days after the request or discharge, if the SMHF manages the individual's personal funds.(6) a statement that the facility is not responsible for personal funds mailed directly to individuals; and(7) a statement that the SMHF maintains a trust fund to protect personal funds and such funds including cash and checks that are to be deposited in the trust fund must be mailed to the cashier's attention. Source Note: The provisions of this §910.157 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.157 Notice Regarding Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224638 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224638&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224638 03/12/2026 (a) Within seven business days after an individual is admitted to the SMHF, the treating physician must determine if the individual has the ability to manage his or her personal funds.(b) If an individual does not have an LAR and is determined by the treating physician to have the ability to decide who manages his or her personal funds or if an individual has an LAR, the facility must allow the individual or LAR to choose one of the following to manage his or her personal funds and document such choice as determined by local procedures:(1) the individual, if the individual is determined to have the ability to manage his or her personal funds;(2) the individual's LAR;(3) another person identified by the individual or LAR who has agreed in writing to manage the individual's personal funds; or(4) the facility.(c) If an individual is determined not to have the ability to decide who manages his or her personal funds and the individual has no LAR, the SMHF must manage the individual's personal funds in accordance with this subchapter.(d) The treating physician must reassess an individual's understanding of financial management at the individual's or LAR's request. Source Note: The provisions of this §910.159 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.159 Determining Management of Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224639 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224639&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224639 03/12/2026 (a) Accounting for personal funds. If the facility manages an individual's personal funds, the SMHF must comply with this section and ensure that:(1) a complete accounting of personal funds entrusted to the SMHF is maintained;(2) personal funds are not commingled with facility funds or the funds of any person other than another individual for whom the SMHF manages personal funds; and(3) an individual's personal funds are only expended for that individual's use and benefit.(b) Account requirements. The SMHF must manage personal funds in a pooled trust fund account.(1) The trust fund account must be insured under federal or state law.(2) The SMHF must retain all bank statements from financial institutions regarding trust fund accounts.(3) Within 30 calendar days after receiving the bank statement, the facility must reconcile the bank statement with the general ledger as described in subsection (c) of this section and personal funds ledger as described in subsection (h)(5) of this section.(4) Each business day, staff must reconcile:(A) each individual's transactions with the trust fund control ledger; and(B) the personal funds ledger with the trust fund control ledger.(c) General ledger. The SMHF must maintain a general ledger that separately identifies each financial transaction, including: (1) the name of the individual for whom the transaction was made;(2) the date and amount of the transaction, including interest;(3) the balance after the transaction; and(4) identify the SMHF name in the account title and the type of account, e.g., Austin State Hospital, Trust Fund Account.(d) Investment. Unless an exception is granted by the director, State Mental Health Facilities and written documentation of such is maintained at the facility, the SMHF must invest at least 75% of the average monthly balance of the total held in trust for the previous six months in an insured Texas financial institution.(e) Interest. If personal funds accrue interest, the SMHF must prorate and distribute the interest earned to each participating individual at the end of the month.(f) Depositing personal funds. The SMHF must deposit in the trust fund account all funds that it receives on behalf of an individual.(g) Access to personal funds. The treating physician must determine the individual's ability to manage his or her personal funds and:(1) if there is a need for a budgeted amount, set the amount, and document the amount in the individual's medical record; and(2) if there is a need to restrict the individual's use of personal funds the treating physician must document the need for the restriction in the individual's medical record.(h) Personal funds documentation. Staff must maintain a personal funds documentation for each individual that includes:(1) the name of the individual;(2) the name of the individual's LAR and representative payee, as applicable;(3) the date of the individual's admission to the SMHF;(4) the individual's budgeted amount;(5) a personal funds ledger that includes the date and amount of each transaction and the balance after each transaction; and(6) any contribution acknowledgment as described in §417.46 of this title (relating to Contributions).(i) Documenting expenditures and deposits.(1) Expenditures.(A) Staff must retain a sales receipt for each expenditure made on behalf of an individual.(i) If a sales receipt documents an expenditure for more than one individual, the SMHF must indicate on the sales receipt the amount allocated to each individual.(ii) If a sales receipt does not include the specific item or service purchased or the name of the seller, staff must attach such documentation.(B) Staff must explain each expenditure to the individual and request that the individual sign the receipt. If staff determine that the individual does not understand the explanation, the individual does not sign the receipt, or the individual's signature is illegible, a witness to the expenditure must sign the receipt. The witness cannot be responsible for managing personal funds or responsible for supervising persons performing such duties.(2) Deposits. Except for deposits made electronically, staff must retain a deposit slip issued by the financial institution for each deposit. Source Note: The provisions of this §910.161 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.161 State Hospital Managed Personal Funds https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224640 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224640&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224640 03/12/2026 If staff receive a request, from an individual or other person except staff to expend an individual's personal funds without written evidence supporting the disbursement, a written request specifying the amount and purpose of the expenditure is signed by the requestor, the facility may release such funds to the requestor if the funds recipient acknowledges receiving the funds in writing. Source Note: The provisions of this §910.163 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.163 Requests for Personal Funds from Trust Fund Accounts https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224641 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224641&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224641 03/12/2026 If an individual is discharged from the facility, staff must upon discharge or in no case more than 30 calendar days after the discharge:(1) reconcile the personal funds ledger to the trust fund control ledger and the trust fund control ledger to the general ledger;(2) transfer all personal funds managed by the facility:(A) to the facility receiving the individual, if the individual is discharged to another facility; or(B) to the individual or LAR, if the individual is not discharged to another SMHF;(C) the copy of a check serves as documentation for the distribution of personal funds.(3) provide to the admitting SMHF, individual, or LAR the individual's current personal funds documentation. Source Note: The provisions of this §910.165 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.165 Returning Individual's Personal Funds on Discharge https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224642 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224642&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224642 03/12/2026 (a) If a person makes a request for an individual's unclaimed personal funds or property that: (1) exceeds $500 and provides written authorization from the probate court to receive such funds or property, staff release the funds or property. (2) is $500 or less and the CEO or designee is reasonably certain that the person is the lawful heir and that there is no concern for a future dispute over the disbursed funds or property, facility staff release the funds or property. (b) If no request for the unclaimed funds or property is received, staff must make a good faith effort to locate the individual to whom the funds or property belong or the LAR. If the individual or LAR: (1) is located or a request for the personal funds or property is received, staff must transfer the funds or property to the individual or LAR; or (2) is not located, staff must maintain the personal funds in a bank account as described in §417.42(b) of this title (relating to SMHF--Managed Personal Funds) or maintain the property in a secure location. (A) The SMHF must hold the unclaimed personal funds or property for three years. (B) At the end of three years if no request for the funds or property is received, the SMHF must transfer to State Comptroller's Office the unclaimed funds or property according to the Holder Information Report instructions published by the State Comptroller's Office. Source Note: The provisions of this §910.167 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.167 Unclaimed Personal Funds and Property https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224643 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224643&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224643 03/12/2026 If the individual or LAR makes a contribution to the SMHF using personal funds, the SMHF and the contributor must sign and date an acknowledgement that the SMHF's services are not predicated on a contribution and the contribution is voluntary. The acknowledgement must be made a part of the individual's personal funds documentation. There are additional requirements for accepting contributions in Chapter 417, Subchapter G, concerning community relations. Source Note: The provisions of this §910.169 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS D PERSONAL FUNDS OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.169 Contributions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224644 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224644&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224644 03/12/2026 (a) Local procedures. The CEO or designee is responsible for developing and implementing local procedures to ensure an individual's right to reasonable protection of personal property including clothing and mail from theft or loss consistent with Chapter 404, Subchapter E, concerning Rights of Persons Receiving Mental Health Services, and Chapter 405, Subchapter Y, concerning Client Rights--Mental Retardation Services or any other department rules that concern the rights of individuals.(b) Personal property. The CEO or designee is responsible for developing and implementing written processes that protect each individual's personal property that include:(1) advising individuals and LARs that the facility is limited in its ability to protect any personal property that an individual keeps on the unit, however, if loss or theft of such property is reported staff must make every effort to find and return the missing property to the owner;(2) documenting the receipt of any personal property that is to be held under the facility's control;(3) physically inventorying personal property under the facility's control and documenting personal property received from individuals to ensure it is accounted for and if a discrepancy arises develop a process for documenting, investigating, and resolving the discrepancy;(4) documenting and honoring an individual's request for the return of any or all of his or her personal property previously under the facility's control.(c) Returning personal property. If an individual is discharged from the facility, staff must upon discharge or a soon as possible thereafter document and return to the individual or LAR all of the individual's personal property under the facility's control.(d) Individual's personal mail. Except as described in this section and department rules concerning the rights of individuals, an individual's personal mail must be delivered unopened to the addressee. If staff have reason to believe that mail addressed to an individual is an invoice and the facility is responsible for its payment, then the mail must be opened by the individual and witnessed by two staff. If the mail contains such an invoice, it is forwarded to accounts payable for processing, an explanation of the situation is given to the individual, and the situation is documented in the individual's record. Source Note: The provisions of this §910.200 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS E PERSONAL PROPERTY OF INDIVIDUALS SERVED IN STATE HOSPITALS §910.200 An Individual's Personal Property https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224645 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224645&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224645 03/12/2026 If a facility has on-site overnight accommodations that are made available to family members or guests of an individuals receiving services, a facility resource use fee may be charged. The facility use fee schedule is in the TDMHMR Fiscal Manual. If the family member or guest is unable to pay the entire use fee, the facility CEO may waive any portion or all of the fee based on the family member's or guest's ability to pay. Source Note: The provisions of this §910.251 adopted to be effective October 6, 2002, 27 TexReg 9152; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1933. 1 HEALTH AND HUMAN SERVICES COMMISSION 910 STATE FACILITY BUSINESS OPERATIONS F FEES FOR GUESTS OF INDIVIDUALS SERVED BY STATE FACILITIES §910.251 Fees for Guests of Individuals Served by State Facilities for Overnight Accommodations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210925 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210925&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210925 03/12/2026 The purpose of this chapter is to:(1) describe the components and use of an institutional review board for the review of research requests and activities pertaining to mental health, substance use, and intellectual or developmental disabilities services within the Texas Health and Human Services Commission (HHSC), as listed in §925.2 (Application); and(2) establish uniform guidelines for the review, approval, conduct, and oversight of research involving HHSC services that:(A) ensures human subjects involved in research have established rights, privacy, and welfare protections;(B) ensures human subjects' participation is voluntary;(C) ensures allegations of misconduct regarding the adherence to scientific standards in research are properly investigated; and(D) conforms with the requirements of 45 Code of Federal Regulations Part 46, Subparts A, B, C, and D. Source Note: The provisions of this §925.1 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210926 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210926&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210926 03/12/2026 This chapter applies to research involving one or more of the following:(1) Texas Health and Human Services Commission (HHSC) in-patient or community-based mental health services;(2) HHSC community-based substance use services;(3) HHSC intellectual or developmental disabilities services;(4) data owned or created regarding individuals receiving HHSC services; or(5) related HHSC resources (e.g., employees, property, and non-public information). Source Note: The provisions of this §925.2 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210927 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210927&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210927 03/12/2026 The following words and terms have the following meanings when used in this chapter.(1) Authorization--The written permission given by an individual who is participating in a research study or the individual's legally authorized representative to use or disclose certain protected health information related to the research study.(2) Children--Consistent with 45 Code of Federal Regulations §46.402(a), individuals who have not attained the legal age for consent to treatments or procedures involved in the research, under the applicable law of the jurisdiction in which the research will be conducted.(3) Code of Federal Regulations (CFR)--The codification of the general and permanent rules and regulations published in the Federal Register by the executive departments and agencies of the Federal Government.(4) Designated institutional review board--The institutional review board whose purpose is to review, approve, and monitor proposed research studies as well as oversee the conduct of approved research, which includes:(A) an external institutional review board established and operated by a non-Texas Health and Human Services Commission organization with an active Federalwide Assurance (see, 48 C.F.R. Subpart §370.3 Acquisitions Involving Human Subjects) approved by the Office for Human Research Protection (OHRP); and(B) IRB2.(5) HHSC--Texas Health and Human Services Commission.(6) HHSC services--Services provided by HHSC or an HHSC-contracted provider. For purposes of this chapter, HHSC services are:(A) services delivered in state psychiatric hospitals;(B) services delivered in state supported living centers;(C) community-based mental health services;(D) intellectual or developmental disabilities services;(E) substance use prevention, intervention, and treatment services; and (F) services delivered by other HHSC-contracted behavioral health providers required to submit data and information to HHSC.(7) HHSC services authorized person--A person with the authority to allow research at the proposed research site where HHSC services are delivered (i.e., superintendent, director, or chief executive officer).(8) Human subject--Consistent with 45 CFR §46.102(e)(1), a living individual about whom an investigator (whether professional or student) conducting research:(A) obtains information or biospecimens through intervention or interaction with the individual, and uses, studies, or analyzes the information or biospecimens; or(B) obtains, uses, studies, analyzes, or generates identifiable private information or identifiable biospecimens.(9) Individual--A person who previously received, or is currently receiving, HHSC services.(10) Informed consent--The knowing approval by an individual or an individual's legally authorized representative to participate in a research study, given under the individual's or legally authorized representative's decision without undue influence or any element of force, fraud, deceit, duress, or other form of constraint or coercion.(11) Institutional review board (IRB)--A board that reviews and approves proposed research, as well as oversees the conduct of approved research.(12) Intellectual or developmental disability (IDD)--Intellectual disability consistent with Texas Health and Safety Code §591.003 or a disability that meets the criteria described in the definition of "persons with related conditions" in 42 CFR §435.1010.(13) Investigational medication or device--Any drug, biological product, or medical device under investigation for human use that is not currently approved by the U.S. Food and Drug Administration for the indication being studied.(14) Investigator--A principal investigator, a co-investigator, or a person who has direct and ongoing contact with human subjects participating in a research study or with prospective human subjects.(15) IRB2--The Mental Health, Substance Use and Intellectual or Developmental Disabilities Institutional Review Board, which is established and operated by the Texas State Hospital Central Administration. (16) Legally authorized representative (LAR)--Consistent with 45 CFR §46.102(i), an individual or judicial or other body authorized under applicable law to consent on behalf of a prospective subject to the subject's participation in the procedure or procedures involved in the research. If there is no applicable law addressing this issue, LAR means an individual recognized by institutional policy as acceptable for providing consent in the non-research context on behalf of the prospective subject to the subject's participation in the procedure or procedures involved in the research.(17) Limited data set--Consistent with 45 CFR §164.514(e), protected health information of an individual or of relatives, employers, or household members of an individual that excludes the following direct identifiers:(A) names;(B) postal address information, other than town or city, state, and zip code;(C) telephone numbers;(D) fax numbers;(E) electronic mail addresses;(F) social security numbers;(G) medical record numbers;(H) health plan beneficiary numbers;(I) account numbers;(J) certificate or license numbers;(K) vehicle identifiers and serial numbers;(L) device identifiers and serial numbers;(M) Web universal resource locators (URLs);(N) Internet protocol (IP) address numbers;(O) biometric identifiers, including finger and voice prints; and(P) full face photographic images and comparable images.(18) Minimal risk--The probability and magnitude of harm or discomfort anticipated in the research are not greater, in and of themselves, than those ordinarily encountered in daily life or during the performance of routine physical or psychological examination or tests.(19) Misconduct in science--The fabrication, falsification, plagiarism, or other practices that seriously deviate from those that are commonly accepted within the scientific community for proposing, conducting, or reporting research. It does not include honest error or honest differences in interpretations or judgments of data.(20) Notice of privacy practices--A written notice describing:(A) the uses and disclosures of protected health information that may be made; and(B) the individual's rights and the legal duties of the HHSC service with respect to protected health information.(21) Office for Human Research Protection (OHRP)--The office that provides leadership in the protection of the rights, welfare, and wellbeing of human subjects involved in research conducted or supported by the U.S. Department of Health and Human Services.(22) Principal investigator--The investigator identified as responsible for conducting a research study.(23) Privacy coordinator--An HHSC staff member who is responsible for working with the Texas Health and Human Services Privacy Division to implement the policies and procedures relating to state and federal privacy laws.(24) Protected health information (PHI)--(A) Any information that identifies or could be used to identify an individual, whether oral or recorded in any form, that relates to:(i) the past, present, or future physical or mental health or condition of the individual;(ii) the provision of health care to the individual; or(iii) the payment for the provision of health care to the individual.(B) The term includes:(i) an individual's name, address, date of birth, or Social Security number;(ii) an individual's medical record or case number;(iii) a photograph or recording of an individual;(iv) statements made by an individual, either orally or in writing, while seeking or receiving HHSC services;(v) any acknowledgment that an individual is seeking or receiving or has sought or received HHSC services;(vi) direct identifiers of relatives, employers, or household members of the individual; and(vii) any information by which the identity of an individual can be determined either directly or by reference to other publicly available information.(C) The term does not include:(i) health information that has been de-identified in accordance with 45 CFR §164.514(b); and(ii) employment records.(25) Research--Consistent with 45 CFR §46.102(l), a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities that meet this definition constitute research for purposes of this chapter, whether or not they are conducted or supported under a program that is considered research for other purposes. For example, some demonstration and service programs may include research activities. For purposes of this chapter, the following activities are not deemed as research.(A) Scholarly and journalistic activities (e.g., oral history, journalism, biography, literary criticism, legal research, and historical scholarship), including the collection and use of information, that focus directly on the specific individuals about whom the information is collected.(B) Public health surveillance activities, including the collection and testing of information or biospecimens, conducted, supported, requested, ordered, required, or authorized by a public health authority. Such activities are limited to those necessary to allow a public health authority to identify, monitor, assess, or investigate potential public health signals, onsets of disease outbreaks, or conditions of public health importance (including trends, signals, risk factors, patterns in diseases, or increases in injuries from using consumer products). Such activities include those associated with providing timely situational awareness and priority setting during an event or crisis that threatens public health (including natural or man-made disasters).(C) Collection and analysis of information, biospecimens, or records by or for a criminal justice agency for activities authorized by law or court order solely for criminal justice or criminal investigative purposes.(D) Authorized operational activities (as determined by each agency) in support of intelligence, homeland security, defense, or other national security missions.(26) Rights officer--A person who oversees the research site to protect and advocate for the rights of individuals receiving HHSC services.(27) State Hospital Central Administration--The HHSC office that is responsible for the management and oversight of the state hospital system.(28) Texas Health and Human Services Commission Privacy Division--The HHSC workforce responsible for creating and maintaining privacy policies and procedures and investigating potential unauthorized disclosures of protected health information, personally identifiable information, and sensitive personal information. The Privacy Division is responsible for declaring whether an incident is a breach of information and notifying or recommending notification to affected individuals. The Privacy Division acts as a resource and subject matter experts to HHSC. Source Note: The provisions of this §925.3 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210928 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210928&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210928 03/12/2026 (a) Participation in research that can advance scientific knowledge of mental disorders, substance use disorders, and intellectual or developmental disability supports the mission of the Texas Health and Human Services Commission (HHSC).(b) HHSC's guiding principle for all research involving human subjects is the protection of the personal rights, safety, well-being, privacy, and dignity of the subjects to:(1) ensure the protection of human subjects involved in research, HHSC promulgates this chapter and adopts by reference 45 Code of Federal Regulation (CFR) Part 46, Subparts A, B, C, and D;(2) ensure ethical principles are maintained when research involving human subjects is conducted, HHSC adopts by reference "The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, Report of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research" (April 18, 1979);(3) ensure all research undertaken is conducted with a fundamental commitment to high ethical standards regarding the conduct of scientific research, HHSC adopts by reference 42 CFR Part 93;(4) ensure research subjects' participation is voluntary; and(5) protect the privacy of human subjects involved in research, HHSC adopts by reference the Federal Standards for Privacy of Individually Identifiable Health Information, 45 CFR Part 160 and Part 164, Subparts A and E, promulgated by the U.S. Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996.(c) HHSC is committed to research conducted in a manner that is consistent with the best interests and protection of personal rights and the welfare of human subjects involved in the research.(1) An investigator may not approach an individual to participate in a research study if the research conflicts with the individual's treatment goals.(2) No research involving human subjects may be conducted unless the risks to human subjects are minimized and are reasonable in relation to the anticipated benefits.(3) No undue influence or coercion may be used to influence an individual to participate in a research study.(4) Unless scientifically justified, an individual may not be excluded from participating in research based on personal characteristics, such as race, color, ethnicity, national origin, religion, sex, age, or ability.(5) Human subject participation in research studies must be equitable, with measures taken to ensure the research sample is representative of the population of interest. Within the population of interest, subject selection procedures must offer equitable opportunity for access to participation in research and access to potential benefits of participation.(6) An investigator may not approach an individual receiving HHSC services under an order of protective custody pursuant to the Texas Health and Safety Code Chapter 574 about participation in a research study involving an investigational medication or device prior to the entry of an order for temporary or extended mental health services.(7) Research may not be conducted with a human subject who is involuntarily committed if the research involves:(A) placebos as the primary medication therapy;(B) medication or doses of medication as the primary medication therapy which are known to be ineffective for the targeted disorder or condition; or(C) an investigational medication or device that is proposed to be undertaken when previous research on the medication or device with 100 human subjects or fewer has provided minimal or no documentation of the efficacy and safety of the medication or device for the population with the targeted disorder or condition.(8) Research may not be conducted if the protocol:(A) extends the use of a placebo or washout period beyond what has been approved by the institutional review board (IRB);(B) deprives the human subject of reasonable relief in consultation with the subject; or(C) extends a human subject's use of placebos as the primary medication therapy after the subject is discharged.(9) Unless otherwise provided for in this chapter, research involving human subjects may not be conducted unless:(A) the designated IRB reviews and approves the research in accordance with §925.7 of this chapter (relating to Review and Approval of Proposed Research);(B) the HHSC services authorized person agrees to the research being conducted; and(C) the necessary assurance and certification has been submitted to the appropriate federal agency, (e.g., Health and Human Services, Food and Drug Administration) if required, and the agency has indicated its approval.(10) Research conducted may not hinder the ability of the research site or program to accomplish its primary purpose.(d) Right to file a complaint.(1) An individual involved in research or the individual's legally authorized representative (LAR) is entitled to file a complaint about alleged mistreatment or other concerns relating to the research with an HHSC rights officer or through any other applicable complaint mechanism.(2) An individual or the individual's LAR is entitled to file a complaint about violations of the Federal Standards for Privacy of Individually Identifiable Health Information as provided by 45 CFR Part 160 and Part 164, Subparts A and E with the Office for Civil Rights at the U.S. Department of Health and Human Services or refer to the HHSC Health Insurance Portability and Accountability Act policy, which can be found at https://hhs.texas.gov/laws-regulations/legal-information/hipaa-privacy-laws, as set forth in the Notice of Privacy Practices. Source Note: The provisions of this §925.4 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.4 General Principles https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210929 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210929&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210929 03/12/2026 (a) Each research project conducted involving Texas Health and Human Services Commission (HHSC) services must have a designated institutional review board (IRB). The designated IRB is responsible for reviewing, approving, and monitoring all research conducted.(b) In accordance with 45 CFR §46.114, cooperative research, defined as projects that involve more than one institution, must rely on a single IRB to review and approve the portion of research conducted in the United States.(c) The designated IRB will be one of the following:(1) an external IRB with IRB2 approval; or(2) the IRB2.(d) The membership of the designated IRB must comply with the requirements in 45 CFR §46.107.(e) In addition to 45 CFR §46.107, the IRB2 membership must include at least three members who are familiar with the mental disorders or conditions, intellectual or developmental disability (IDD), and concerns of the populations of individuals HHSC serves, including:(1) at least one of the three members must be a professional in the field of mental health, IDD, or substance use; and(2) at least two of the three members described in this paragraph must be:(A) an individual with a serious mental illness, severe emotional disturbance, substance use disorder, or a person with IDD who is or has received HHSC services;(B) a family member of a person described in subparagraph (A) of this paragraph; or(C) an advocate for an individual described in subparagraph (A) of this paragraph.(f) Each designated IRB must have written policies and procedures that are consistent with this chapter and HHSC's rules governing the care and protection of individuals as described in Texas Administration Code Title 25, Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services) and 40 TAC Chapter 4, Subchapter C (relating to Rights of Individuals with an Intellectual Disability) and that address:(1) the review or screening process to determine whether proposed research is exempt from the requirements of federal regulations made in accordance with 45 CFR §46.104, including required documentation and any necessary approvals;(2) the process for ensuring that each IRB member and investigator involved in an approved research study receives documented training in applicable ethics, laws, and regulations governing research involving human subjects; and(3) the process for disclosing and considering potential conflicts of interest, financial or otherwise, by IRB members and investigators. Source Note: The provisions of this §925.5 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.5 Designated Institutional Review Board https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210930 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210930&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210930 03/12/2026 (a) Each designated institutional review board (IRB) shall:(1) follow its written policies and procedures as described in §925.5(f) of this chapter (relating to Designated Institutional Review Board);(2) function in accordance with 45 Code of Federal Regulations (CFR) §46.108;(3) ensure proposed research is reviewed and approved in accordance with §925.7 of this chapter (relating to Review and Approval of Proposed Research);(4) exercise appropriate oversight to ensure:(A) its policies and procedures designed for protecting the rights, privacy, and welfare of human subjects are being applied; and(B) research is being conducted in accordance with the approved protocol;(5) maintain records of its operations in accordance with 45 CFR §46.115;(6) maintain documentation of its continuing review of all approved and active research protocols; and(7) maintain documentation of any unanticipated serious problems or events involving risks to the human subjects or others.(b) Each designated IRB will suspend or terminate research that is not being conducted in accordance with the IRB's requirements or that has been associated with significant unexpected harm to human subjects. If an IRB suspends or terminates research, the IRB must promptly notify the following in writing of the suspension or termination and include a statement of the reasons for the IRB's action:(1) the principal investigator;(2) the appropriate HHSC services authorized person; and(3) the IRB2.(c) When IRB2 is not the designated IRB for a research protocol, a reliance agreement will be signed by the IRB2 chair outlining all oversight responsibilities and obligations in order to ensure the protection of human subjects. Source Note: The provisions of this §925.6 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.6 Designated Institutional Review Board Functions and Operations https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210931 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210931&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210931 03/12/2026 (a) Proposed research must be submitted to the designated institutional review board (IRB) and contain written information for the IRB to determine whether the requirements described in 45 Code of Federal Regulations (CFR) §46.111 are satisfied.(b) Each designated IRB shall review all proposed research in accordance with 45 CFR §46.109.(c) Each designated IRB has the authority to approve, require modifications to, or disapprove any proposed research. Approval of proposed research shall be based on:(1) consideration of the information described in 45 CFR §46.111;(2) the designated IRB's verification that the requirements in 45 CFR §46.111, §925.4 of this chapter (relating to General Principles), and §925.8 of this chapter (relating to Informed Consent) are met; and(3) the designated IRB's verification that procedures for obtaining and documenting authorization to use or disclose protected health information (PHI) meet the requirements in 45 CFR §164.508, unless:(A) the designated IRB approves a waiver or alteration of the authorization requirement as permitted in §925.9(b) of this chapter (relating to Using and Disclosing Protected Health Information in Research); or(B) the designated IRB determines and documents that:(i) the data needed for the research is contained in a limited data set and the investigator will comply with the requirements in 45 CFR §164.514(e), including the execution of a data use agreement; or(ii) the data needed for the research is limited to decedents' PHI and documentation submitted by the investigator meets the requirements in 45 CFR §164.512(i)(1).(d) The designated IRB may take into consideration deliberations and reviews from another IRB that has approved the protocol for a specific research proposal, but the designated IRB is ultimately responsible for approval of the proposed research.(e) Research review and documentation process.(1) External IRB as the designated IRB. The research review and documentation process for research using an external IRB is generally as follows.(A) The IRB2 screens the research proposal and, if determined appropriate for implementation, the investigator submits the research proposal to the external IRB for review.(B) The external IRB reviews the research proposal.(C) The investigator informs the IRB2 of the external IRB's approval or disapproval. The IRB2 informs the Texas Health and Human Services Commission (HHSC) services authorized person of the external IRB's approval or disapproval.(D) Any approval by an external IRB is subject to HHSC policy requirements.(2) IRB2 as the designated IRB. The research review and documentation process for research involving HHSC services using the IRB2 is generally as follows.(A) The principal investigator submits the proposal to the IRB2.(B) The IRB2 reviews the research proposal.(C) The IRB2 informs the HHSC services authorized person of the IRB2's approval or disapproval and recommendations, if any.(D) If the research proposal is approved by the IRB2, the HHSC services authorized person considers the IRB2's recommendations, if any, and either approves or disapproves the research proposal for implementation.(f) In addition to approval by the designated IRB and HHSC services authorized person, review and approval by the chief medical officer or chief medical director of the state hospitals, state supported living centers, or other entity primarily responsible for the health and safety of the research subjects, as applicable, is required for any research proposal involving:(1) a placebo as the primary medication therapy;(2) medication or doses of medication as the primary medication therapy with an unknown effectiveness for the targeted disorder or condition; or(3) an investigational medication or device.(g) The review process for proposed research may require additional steps as necessary, (e.g., in the event a proposal is initially rejected).(h) The HHSC services authorized person is responsible for ensuring that all investigators are qualified to perform any clinical duties assigned to them and are knowledgeable of HHSC's rules governing the care and protection of individuals as described in 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services) and 40 TAC Chapter 4, Subchapter C (relating to Rights of Individuals with an Intellectual Disability). Source Note: The provisions of this §925.7 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.7 Review and Approval of Proposed Research https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210932 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210932&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210932 03/12/2026 Requirements for approval of proposed research. Investigators shall ensure:(1) procedures for obtaining and documenting informed consent meet the requirements in 45 Code of Federal Regulations (CFR) §46.116 and 45 CFR §46.117 and address:(A) any extension of the subject's length of stay because of participation in the research;(B) the subject's ability to receive the medication or device after the research has concluded if the research involves an investigational medication or device;(C) whether the research involves the use of a placebo and the likelihood of assignment to the placebo condition;(D) whether the research involves medication or doses of medication which are known to be ineffective for the targeted disorder or condition and the likelihood of assignment to such medication or doses of medication; and(E) any risk of deterioration in the subject's condition and the potential consequences of such deterioration (e.g., an extension in the length of stay, or the use of interventions, such as restraint, seclusion, or emergency medications);(2) there are procedures to ensure prospective human subjects are assessed for capacity to consent for research protocols that present greater than minimal risk, and:(A) provide for a qualified professional to assess prospective human subjects for capacity to consent;(B) identify and document who will conduct the assessments; and(C) describe the nature of the assessment and justification if less formal procedures to assess capacity will be used;(3) the requirements in 45 CFR §46.408 are met if children are the proposed human subjects;(4) there are procedures that:(A) each prospective human subject or the subject's legally authorized representative (LAR) understands the information provided before obtaining consent to research participation; and(B) if consent is obtained from the subject's LAR, attempts are made, to the extent possible given the prospective subject's capacity, to obtain the human subject's assent to participation. Assent is an affirmative agreement of a prospective human subject to participate in research, which is obtained when the subject does not have the capacity or legal authority to consent;(5) there are adequate safeguards to minimize the possibility of coercion or undue influence. For example, the possible advantages of the subject's participation in the research may not be so valuable as to impair the subject's ability to weigh the risks of the research against those advantages. Possible advantages within the limited choice environment may include enhancement of general living conditions, medical care, quality of food, or amenities; opportunity for earnings; or a change in commitment status;(6) there are procedures for ensuring a prospective human subject's objection to enrollment in research or a human subject's objection to continued participation in a research protocol is heeded in all circumstances, regardless of whether the subject or the subject's LAR has given consent. Objection may be conveyed verbally, in writing, behaviorally, or by other indications or means; and(7) procedures to ensure, throughout the course of the research study, human subjects' comprehension and capacity are assessed and enhanced since informed consent is an ongoing process. The procedures must take into consideration a prospective human subject's preferred method of communication for consent or objection. Source Note: The provisions of this §925.8 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.8 Informed Consent https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210933 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210933&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210933 03/12/2026 (a) Except as provided by this section, to use or disclose protected health information (PHI), an authorization is required that:(1) conforms with the requirements of 45 Code of Federal Regulations (CFR) §164.508 and, if applicable 42 CFR Part 2; and(2) includes a statement that the subject's right to access his or her PHI created or obtained during research may be temporarily suspended while the research is in progress, and will be reinstated upon completion of the research, if the research includes treatment.(b) During the review of proposed research, the designated institutional review board (IRB) has the authority to approve a waiver or alteration of the authorization requirement in accordance with 45 CFR §164.512(i).(c) The designated IRB has the authority to approve the use or disclosure of PHI for purposes preparatory to research if the IRB obtains from the investigator adequate representations as required by 45 CFR §164.512(i)(1)(ii). Source Note: The provisions of this §925.9 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.9 Using and Disclosing Protected Health Information in Research https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210934 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210934&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210934 03/12/2026 (a) Investigation of misconduct in science is the formal examination and evaluation of all relevant facts to determine if misconduct in science has occurred.(b) All research involving Texas Health and Human Services Commission (HHSC) services shall be conducted with a fundamental commitment to high ethical standards regarding the conduct of scientific research.(c) Reports of alleged misconduct in science are made to the IRB2, which must ensure:(1) each allegation is reviewed and investigated by an appropriate entity in accordance with 42 Code of Federal Regulations (CFR) Part 93;(2) the investigating entity submits to the IRB2 information documenting the disposition of each allegation; and(3) the following are notified of confirmed incidents of misconduct in science:(A) the institutional review board (IRB) that approved the research protocol; and(B) the agency funding the research. Source Note: The provisions of this §925.10 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.10 Investigation of Allegations of Misconduct in Science https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210924 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=210924&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 210924 03/12/2026 Other responsibilities of IRB2 include:(1) reviewing and developing Texas Health and Human Services Commission (HHSC) rules and policies governing the conduct of research; and(2) providing technical assistance and interpretation of policies, procedures, HHSC rules, and regulations concerning the conduct of research involving human subjects. Source Note: The provisions of this §925.11 adopted to be effective November 27, 2022, 47 TexReg 7731. 1 HEALTH AND HUMAN SERVICES COMMISSION 925 RESEARCH INVOLVING HEALTH AND HUMAN SERVICES COMMISSION SERVICES §925.11 Responsibilities of the Institutional Review Board 2 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219684 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219684&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219684 03/12/2026 This chapter applies to state hospitals in accordance with Texas Health and Safety Code (HSC) §552.052 and state supported living centers in accordance with Texas HSC §555.024. Source Note: The provisions of this §926.1 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.1 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219685 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219685&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219685 03/12/2026 The following words and terms, when used in this chapter, have the following meaning, unless the context clearly indicates otherwise.(1) Direct care employee--A facility employee who provides direct delivery of services to an individual.(2) Facility--A state hospital or state supported living center.(3) Individual--A person who is receiving services at a facility.(4) State hospital--A hospital as defined under Texas Health and Safety Code (HSC) §552.0011 operated by the Texas Health and Human Services Commission (HHSC) primarily to provide inpatient care and treatment for individuals with mental illness.(5) State supported living center (SSLC)--An SSLC as defined by Texas HSC §531.002 and the intermediate care facility for individuals with intellectual disabilities component of the Rio Grande State Center operated by HHSC. Source Note: The provisions of this §926.2 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.2 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219686 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219686&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219686 03/12/2026 Before an employee performs employment duties without direct supervision, the employee must receive competency-based training and instruction on general duties.(1) The focus of training must be on:(A) the uniqueness of the individuals with whom the employee works;(B) techniques for improving quality of life for and promoting the health and safety of individuals; and(C) the conduct expected of employees.(2) The training must include instruction and information on:(A) the general operation and layout of the facility at which the person is employed;(B) armed intruder lockdown procedures;(C) respecting personal choices made by individuals;(D) the safe and proper use of restraints;(E) recognizing and reporting:(i) abuse, neglect, and exploitation of individuals;(ii) unusual or reportable incidents;(iii) reasonable suspicion of illegal drug use in the workplace;(iv) workplace violence; and(v) sexual harassment in the workplace;(F) preventing and treating infection;(G) responding to emergencies, including information about first aid and cardiopulmonary resuscitation procedures;(H) the Health Insurance Portability and Accountability Act of 1996 (Pub. L. No. 104-191);(I) the rights of employees;(J) additional topics for state hospital employees, which include:(i) an introduction to mental illness;(ii) an introduction to substance use;(iii) an introduction to dual diagnosis; and(iv) the rights of individuals with mental illness;(K) additional topics for state supported living center employees, which include:(i) an introduction to intellectual disabilities;(ii) an introduction to autism; and(iii) an introduction to mental illness and dual diagnosis; and(L) the rights of individuals with an intellectual or developmental disability, including the right to live in the least restrictive setting appropriate to the individual's needs and abilities. Source Note: The provisions of this §926.3 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.3 Training for New Employees https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219687 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219687&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219687 03/12/2026 (a) Before an employee who provides direct delivery of services begins to perform direct care duties without direct supervision, the facility must provide the employee relevant training essential to perform the employee's duties regarding implementation of the interdisciplinary treatment program for each individual for whom the employee will provide direct care, including the following topics:(1) prevention and management of aggressive or violent behavior;(2) observing and reporting changes in behavior, appearance, or health of an individual;(3) positive behavior support;(4) emergency response;(5) person-directed plans;(6) self-determination; and(7) trauma-informed care.(b) Facilities must provide training on the following topics relevant to the individuals the direct care employee will serve:(1) techniques for lifting, positioning, moving and increasing mobility;(2) specialized needs of geriatric individuals;(3) assisting individuals with visual, hearing, or communication impairments or who require adaptive devices and specialized equipment;(4) recognizing appropriate food textures;(5) using proper feeding techniques to assist individuals with meals;(6) specific to state supported living center direct care employees:(A) seizure safety;(B) working with aging individuals;(C) assisting individuals with personal hygiene;(D) physical and nutritional management plans;(E) home and community-based services, including the principles of community inclusion and participation and the community living options information process; and(F) procedures for securing evidence following an incident of suspected abuse, neglect, or exploitation; and(7) specific to state hospital direct care employees:(A) seizure safety;(B) assisting patients with personal hygiene; and(C) physical and nutritional management plans. Source Note: The provisions of this §926.4 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.4 Additional Training for Employees who Provide Direct Care to Individuals https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219688 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219688&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219688 03/12/2026 State hospitals must provide all employees annual training relevant to their position on the topics outlined in §926.3 of this chapter (relating to Training for New Employees) and §926.4 of this chapter (relating to Additional Training for Employees who Provide Direct Care to Individuals), as the topics pertain to state hospital employees. State hospitals must provide this training throughout an employee's employment or association with the state hospital, unless the agency determines in good faith and with good reason a particular employee's performance will not be adversely affected in the absence of such refresher training. Source Note: The provisions of this §926.5 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.5 State Hospital Refresher Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219689 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219689&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219689 03/12/2026 (a) An SSLC must provide employees annual training on:(1) abuse, neglect, and exploitation; and(2) unusual incidents.(b) An SSLC must provide training to employees who are not direct care employees on the rights of individuals every two years.(c) An SSLC must provide all direct care employees annual training relevant to their position on the topics outlined in §926.3 of this chapter (relating to Training for New Employees) and §926.4 of this chapter (relating to Additional Training for Employees who Provide Direct Care to Individuals), unless otherwise addressed in this section, as the topics pertain to SSLC employees. Source Note: The provisions of this §926.6 adopted to be effective March 20, 2024, 49 TexReg 1719. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES A TRAINING REQUIREMENTS FOR STATE FACILITY STAFF §926.6 State Supported Living Center (SSLC) Refresher Training https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224586 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224586&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224586 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise: (1) Abuse--An act or failure to act that, with regard to an individual, meets the definition of "physical abuse," "sexual abuse," or "verbal/emotional abuse" in Chapter 711, Subchapter A of this title (relating to Introduction), or the definition of "abuse," "physical abuse," "sexual abuse," "verbal abuse," "psychological abuse," or "threat" in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov. (2) Administrative death review--An administrative, quality-assurance activity related to the death of an individual to identify non-clinical problems requiring correction and opportunities to improve the quality of care at a facility. (3) Allegation--A report by a person suspecting or having knowledge that an individual has been or is in a state of abuse, neglect, or exploitation as defined in this chapter. (4) Alleged offender--An individual who was committed or transferred to a facility: (A) under Texas Code of Criminal Procedure, Chapters 46B or 46C, as a result of being charged with or convicted of a criminal offense; or (B) under Texas Family Code, Chapter 55, as a result of being alleged by petition or having been found to have engaged in delinquent conduct constituting a criminal offense. (5) Applicant--A person who has applied to be an employee, volunteer, or unpaid professional intern. (6) Attending physician--The physician who has primary responsibility for the treatment and care of an individual. (7) Bedroom--The room at a facility in which an individual usually sleeps. (8) Behavioral crisis--An imminent safety situation that places an individual or others at serious risk of violence or injury if no intervention occurs. (9) CANRS--The client abuse and neglect reporting system maintained by DADS Consumer Rights and Services. (10) Capacity--An individual's ability to: (A) understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment; and (B) make a decision whether to undergo the proposed treatment. (11) Chemical restraint--Any drug prescribed or administered to sedate an individual or to temporarily restrict an individual's freedom of movement for the purpose of managing the individual's behavior. (12) Child--An individual less than 18 years of age who is not and has not been married and who has not had the disabilities of minority removed pursuant to Texas Family Code, Chapter 31. (13) Clinical death review--A clinical, quality-assurance, peer review activity related to the death of an individual and conducted in accordance with statutes that authorize peer review in Texas to identify clinical problems requiring correction and opportunities to improve the quality of care at a facility. (14) Clinical practice--The demonstration of professional competence in nursing, dental, pharmacy, or medical practice as described in the relevant chapter of the Texas Occupations Code. (15) Confirmed--Term used to describe an allegation that DFPS determines is supported by a preponderance of the evidence. (16) Contractor--A person who contracts with a facility to provide services to an individual, including an independent school district that provides educational services at the facility. (17) Conviction--The adjudication of guilt for a criminal offense. (18) Covert electronic monitoring--Electronic monitoring that is not open and obvious, and that is conducted when the director of the facility in which the monitoring is being conducted has not been informed about the device by the individual, by a person who placed the device in the bedroom, or by a person who uses the device. (19) Crisis intervention--The use of interventions, including physical, mechanical, or chemical restraint, in a behavioral crisis, after less restrictive measures have been determined to be ineffective or not feasible. (20) Crisis intervention plan--A component of the individual support plan (ISP) action plan that provides instructions for staff on how to effectively and safely use restraint procedures, as long as they are needed to prevent imminent physical injury in a behavioral crisis when less restrictive prevention or de-escalation procedures have failed and the individual's behavior continues to present an imminent risk of physical injury. The plan is developed with input from the PCP and direct support professionals familiar with the individual and the individual and LAR and includes a description of how the individual behaves during a behavioral crisis, along with information about the types of restraints that have been most effective with the individual, staff actions to be avoided because they have been ineffective in the past in preventing or reducing the need for restraints, the restraint's maximum duration, a description of the behavioral criteria for determining when the imminent risk of physical injury abates, and reporting requirements. A crisis intervention plan is not considered a therapeutic intervention. It is implemented only to ensure that restraint procedures are carried out effectively and safely and may be adjusted depending upon the individual's progress in the ISP action plan. (21) DADS--Department of Aging and Disability Services or its successor agency. (22) DADS Commissioner--The commissioner of DADS or a position at the Health and Human Services Commission that assumes a duty of the commissioner of DADS described in this chapter. (23) Deferred adjudication--Has the meaning given to "community supervision" in Texas Code of Criminal Procedure, Article 42.12, §2. (24) Designated representative--A person designated by an individual or an individual's LAR to be a spokesperson or advocate for the individual. (25) DFPS--Department of Family and Protective Services or its successor agency. (26) Director--The director of a facility or the director's designee. (27) Direct support professional--An unlicensed employee who directly provides services to an individual. (28) Electronic monitoring--The placement of an electronic monitoring device in an individual's bedroom and making a tape or a recording with the device. (29) Electronic monitoring device (EMD)--A device that: (A) includes: (i) a video surveillance camera; and (ii) an audio device designed to acquire communications or other sounds; and (B) does not include an electronic, mechanical, or other device that is specifically used for the nonconsensual interception of wire or electronic communications. (30) Employee--A person employed by DADS whose assigned duty station is at a facility. (31) Exploitation--An act or failure to act that, with regard to an individual, meets the definition of "exploitation" in Chapter 711, Subchapter A of this title (relating to Introduction), or the definition of "mistreatment" in the CMS State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov. (32) Facility--A state supported living center or the intermediate care facility for individuals with an intellectual disability component of the Rio Grande State Center. (33) Family member--An individual's parent, spouse, children, or siblings. (34) Forensic facility--A facility designated under Texas Health and Safety Code (THSC), §555.002(a) for the care of high-risk alleged offenders. (35) Guardian--An individual appointed and qualified as a guardian of the person under Texas Estates Code, Title 3. (36) High-risk alleged offender--An alleged offender who has been determined to be at risk of inflicting substantial physical harm to another person in accordance with THSC §555.003. (37) Inconclusive--Term used to describe an allegation when there is not a preponderance of credible evidence to indicate that abuse, neglect, or exploitation did or did not occur due to lack of witnesses or other available evidence. (38) Independent mortality review organization--An independent organization designated in accordance with Texas Government Code Chapter 546, Subchapter O, to review the death of an individual. (39) Individual--A person with an intellectual disability or a condition related to an intellectual disability who is receiving services from a facility. (40) Individual support plan (ISP)--An integrated, coherent, person-directed plan that reflects an individual's preferences, strengths, needs, and personal vision, as well as the protections, supports, and services the individual will receive to accomplish identified goals and objectives. (41) Interdisciplinary team (IDT)--A team consisting of an individual, the individual's legally authorized representative (LAR) and qualified developmental disability professional, other professionals dictated by the individual's strengths, preferences, and needs, and staff who regularly and directly provide services and supports to the individual. The team is responsible for assessing the individual's treatment, training, and habilitation needs and making recommendations for services based on the personal goals and preferences of the individual using a person-directed planning process, including recommendations on whether the individual is best served in a facility or community setting. (42) Legally adequate consent--Consent from a person who: (A) is not a minor and has not been adjudicated incompetent to manage the person's personal affairs by an appropriate court of law; (B) has been informed of and understands: (i) the nature, purpose, consequences, risks, and benefits of the medication, treatment, or procedure for which the consent is given; (ii) alternatives to the medication, treatment, or procedure for which the consent is given; (iii) that withdrawing or refusing to give consent will not prejudice the future provision of care and services; and (iv) the method of administration, if the person is giving consent for an unusual or hazardous treatment procedure, experimental research, organ transplantation, or nontherapeutic surgery; and (C) consents voluntarily, free from coercion or undue influence. (43) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual, including a parent, guardian, or managing conservator of a minor individual, or a guardian of an adult individual. (44) Life-sustaining medical treatment--Treatment that, based on reasonable medical judgment, sustains the life of an individual and without which the individual will die. The term includes both life-sustaining medications and artificial life support such as mechanical breathing machines, kidney dialysis treatment, and artificial nutrition and hydration. The term does not include the administration of pain management medication or the performance of a medical procedure considered necessary to provide comfort care or any other medical care provided to alleviate an individual's pain. (45) Mechanical restraint--Any device attached or adjacent to an individual's body that he or she cannot easily remove that restricts freedom of movement or normal access to his or her body. The term does not include a protective device. (46) Medical emergency--Any illness or injury that requires immediate assessment and treatment by medical staff for conditions considered to be life threatening, including, but not limited to, respiratory or cardiac arrest, choking, extreme difficulty in breathing, status epilepticus, allergic reaction to an insect sting, snake bite, extreme pain in the chest or abdomen, poisoning, hemorrhage, loss of consciousness, sudden loss of function of a body part, injuries resulting in broken bones, possible neck or back injuries, or severe burns. (47) Medical intervention--Treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician assistant, or advanced practice registered nurse in accordance with general acceptable clinical practice. (48) Medical restraint--A health-related protection prescribed by a primary care provider (PCP) or dentist that is necessary for the conduct of a specific medical or dental procedure, or is only necessary for protection during the time that a medical or dental condition exists, for the purpose of preventing an individual from inhibiting or undoing medical or dental treatment. Medical restraint includes pre-treatment sedation. (49) Medical restraint plan--A component of the ISP action plan that provides instructions for staff on how to effectively and safely carry out medical restraint procedures. The plan is developed with input from the PCP or dentist and meaningful input from the individual and LAR and includes a description of the individual's behaviors that do not allow for a safe and effective implementation of needed medical or dental procedures, information about the types of restraints that have been most effective with the individual, a description of the criteria for releasing the restraint, and reporting requirements. A medical restraint plan is not considered a therapeutic intervention and may be adjusted depending upon the individual's progress in the ISP action plan. (50) Medication-related emergency--A situation in which it is immediately necessary to administer medication to an individual to prevent: (A) imminent probable death or substantial bodily harm to the individual because the individual: (i) overtly or continually is threatening or attempting to commit suicide or serious bodily harm; or (ii) is behaving in a manner that indicates that the individual is unable to satisfy the individual's need for nourishment, essential medical care, or self-protection; or (B) imminent physical or emotional harm to another because of threats, attempts, or other acts the individual overtly or continually makes or commits. (51) Mental health services provider--Has the meaning assigned in Texas Civil Practice and Remedies Code, Chapter 81. (52) Neglect--An act or failure to act that, with regard to an individual, meets the definition of "neglect" in Chapter 711, Subchapter A of this title (relating to Introduction), or the definition of "neglect" in the CMS State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov. (53) Peer review--A review of clinical or professional practice of a doctor, pharmacist, licensed vocational nurse, or registered nurse conducted by his or her professional peers. (54) Perpetrator--A person who has committed abuse, neglect, or exploitation. (55) Person--Includes a corporation, organization, governmental subdivision or agency, or any other legal entity. (56) Physical restraint--Any manual method that restricts freedom of movement or normal access to one's body, including hand or arm holding to escort an individual over his or her resistance to being escorted. Physical restraint does not include brief and limited use of physical guidance, positioning, or prompting techniques used to redirect an individual or assist, support, or protect the individual during a functional therapeutic or physical exercise activity; response blocking and brief redirection used to interrupt an individual's limbs or body without the use of force so that the occurrence of challenging behavior is prevented; holding an individual, without the use of force, to calm or comfort, or hand holding to escort an individual from one area to another without resistance from the individual; and response interruption used to interrupt an individual's behavior, using facility-approved techniques. (57) Physician on duty--The physician designated by the facility's medical director to provide medical care or respond to emergencies outside regular working hours. (58) Positive behavior support plan (PBSP)--A comprehensive, individualized plan that contains intervention strategies designed to modify the environment, teach or increase adaptive skills, and reduce or prevent the occurrence of target behaviors through interventions that build on an individual's strengths and preferences, without using aversive or punishment contingencies. (59) Preponderance of the evidence--Evidence that is of greater weight or more convincing than the evidence that is offered in opposition to it; that is, evidence that, as a whole, shows that the fact sought to be proved is more probable than not. (60) Primary care provider (PCP)--A physician, advanced practice registered nurse, or physician assistant who provides primary care to a defined population of patients. The PCP is involved in health promotion, disease prevention, health maintenance, and diagnosis and treatment of acute and chronic illnesses. (61) Prone restraint--Any physical or mechanical restraint that places the individual in a face-down position. Prone restraint does not include when an individual is placed in a face-down position as a necessary part of a medical intervention, or when an individual moves into a prone position during an incident of physical restraint, if staff immediately begin an adjustment to restore the individual to a standing, sitting, or side-lying position or, if that is not possible, immediately release the person. Prone restraint is prohibited. (62) Protection and advocacy organization--The protection and advocacy system for Texas designated in accordance with the Code of Federal Regulations, Title 45, §1326.20. (63) Protective mechanical restraint for self-injurious behavior--A type of mechanical restraint applied before an individual engages in self-injurious behavior, for the purpose of preventing or mitigating the danger of the self-injurious behavior because there is evidence that the targeted behavior can result in serious self-injury when it occurs and intensive, one-to-one supervision and treatment have not yet reduced the danger of self-injury. Examples include, but are not limited to, protective head gear for head banging, arm splints for eye gouging, or mittens for hand-biting. The term does not include medical restraints or protective devices. (64) Protective mechanical restraint plan for self-injurious behavior--A component of the ISP action plan that provides instructions for staff on how to effectively and safely apply the protective mechanical restraint that is used to prevent or mitigate the effects of serious self-injurious behavior. The plan is developed with input from direct support professionals familiar with the individual and meaningful input from the individual and LAR, and includes a description of the individual's self-injurious behaviors, the type of restraint to be used, the restraint's maximum duration, and the circumstances to apply and remove the restraint. The plan must identify any low-risk situations when the restraint may be safely removed, what staff should do during those situations to continue to protect the individual from harm, and adjustments in staff instructions as progress is made for gradually eliminating the use of the restraints, including details on any specialized staff training and reporting. The plan is not considered a therapeutic intervention and is adjusted depending upon the individual's progress in the ISP action plan and an evaluation by the PCP that the individual's behavior is no longer at the dangerous level that is producing serious self-injury. (65) Psychotropic medication--A medication that is prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorder and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness. Psychotropic medication, sometimes referred to as "psychoactive medication," includes the following categories of medication: (A) antipsychotics or neuroleptics; (B) antidepressants; (C) agents for control of mania or depression; (D) antianxiety agents; (E) sedatives, hypnotics, or other sleep-promoting drugs; and (F) psychomotor stimulants. (66) Registered nurse--A nurse licensed by the Texas Board of Nursing to practice professional nursing in Texas. (67) Registries-- (A) The Nurse Aide Registry maintained by DADS in accordance with §94.12 of this title (relating to Findings and Inquiries); and (B) The Employee Misconduct Registry maintained by DADS in accordance with Chapter 93 of this title (relating to Employee Misconduct Registry (EMR)). (68) Reporter--A person who reports an allegation of abuse, neglect, or exploitation. (69) Restraint monitor--A designated facility employee who has received competency-based training and demonstrated proficiency in the application and assessment of restraints, who has experience working directly with individuals with developmental disabilities, and who is trained to conduct a face-to-face assessment of the individual who was restrained and the staff involved in the restraint to review the application and results of the restraint. (70) Retaliation--An action intended to inflict emotional or physical harm or inconvenience on a person including harassment, disciplinary action, discrimination, reprimand, threat, and criticism. (71) SSLC--A state supported living center. (72) State office mortality review--A quality assurance activity to review data related to the death of an individual to identify trends, best practices, training needs, policy changes, or facility or systemic issues that need to be addressed to improve services at facilities. (73) Supine restraint--Any physical or mechanical restraint that places the individual on his or her back. Supine restraint does not include when an individual is placed in a supine position as a necessary part of a medical restraint, or when an individual moves into a supine position during an incident of physical restraint, if staff immediately begin an adjustment to restore the individual to a standing, sitting, or side-lying position or, if that is not possible, immediately release the person. Supine restraint does not include persons who have freedom of movement in a hospital bed or dental chair that is at a reclined position. Supine restraint is prohibited. (74) THSC--Texas Health and Safety Code. (75) Treating physician--A physician who has provided medical or psychiatric treatment or evaluation and has an ongoing treatment relationship with an individual. (76) Unconfirmed--Term used to describe an allegation in which a preponderance of evidence exists to prove that it did not occur. (77) Unfounded--Term used to describe an allegation that DFPS determines is spurious or patently without factual basis. (78) Unusual incident--An event or situation that seriously threatens the health, safety, or life of an individual. (79) Victim--An individual who has been or is alleged to have been abused, neglected, or exploited. (80) Volunteer--A person who is not part of a visiting group, who has active, direct contact with an individual, and who does not receive compensation from DADS other than reimbursement for actual expenses. Source Note: The provisions of this §926.51 adopted to be effective October 6, 2011, 36 TexReg 6511; amended to be effective April 10, 2012, 37 TexReg 2431; amended to be effective October 29, 2012, 37 TexReg 8595; amended to be effective May 16, 2013, 38 TexReg 2841; amended to be effective November 1, 2014, 39 TexReg 8409; amended to be effective April 7, 2015, 40 TexReg 1988; amended to be effective June 20, 2017, 42 TexReg 3161; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925; amended to be effective April 1, 2025, 50 TexReg 2212. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.51 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219691 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219691&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219691 03/12/2026 (a) Before employment or assignment, a facility must conduct a criminal history check and registry clearance of an applicant for employment or volunteer status consisting of:(1) a criminal history check obtained directly from the Texas Department of Public Safety;(2) a criminal history check obtained through the Federal Bureau of Investigation using a complete set of fingerprints; and(3) searches of the registries and CANRS.(b) A facility may not employ or assign volunteer status to an applicant who:(1) has been convicted of or has received deferred adjudication for any of the criminal offenses listed in Texas Health and Safety Code (HSC) §250.006(a);(2) has been convicted of or has received deferred adjudication for any of the criminal offenses listed in HSC §250.006(b) within five years preceding the date of employment or assignment of volunteer status;(3) has been convicted of or has received deferred adjudication for a criminal offense that DADS has determined to be a contraindication to employment or volunteer status pursuant to HSC §533.007;(4) is listed as revoked in the Nurse Aide Registry;(5) is listed as unemployable in the Employee Misconduct Registry; or(6) has a confirmation of abuse or neglect in CANRS.(c) Pursuant to HSC §533.007(b), a facility may not take an adverse personnel action based on an arrest warrant or wanted persons information. Source Note: The provisions of this §926.53 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.53 Pre-employment or Pre-assignment Checks and Clearances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219692 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219692&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219692 03/12/2026 (a) A facility may employ an applicant on a temporary basis pending the results of a criminal history check if:(1) the facility has searched the registries and CANRS and determined that the applicant:(A) is not listed as revoked in the Nurse Aide Registry;(B) is not listed as unemployable in the Employee Misconduct Registry; and(C) does not have a finding of abuse or neglect in CANRS; and(2) an emergency exists in which, as a result of unfilled positions, the health and safety of individuals is at risk or the operations of the facility are severely impaired.(b) The facility must initiate a criminal history check of a person employed on a temporary basis as described in §3.201(a)(1) - (2) of this subchapter (relating to Pre-employment or Pre-assignment Checks and Clearances) within 72 hours after the applicant is employed.(c) If a facility employs a person pending a criminal history check, the facility must ensure that the person has no direct contact with an individual until the facility obtains the person's criminal history record information and verifies the person's employability as required by §3.201 of this subchapter.(d) A facility must immediately discharge or dismiss an employee whose criminal history check reveals a conviction or deferred adjudication for any of the criminal offenses listed in §3.201(b)(1) - (3) of this subchapter. Source Note: The provisions of this §926.55 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.55 Emergency Employment Pending Criminal History Check https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219693 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219693&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219693 03/12/2026 A facility must provide the following information to applicants in writing at the time an application is made:(1) that the facility will conduct a criminal history check and registry clearance;(2) that conviction of or deferred adjudication for certain criminal offenses may constitute a bar to employment or volunteer status;(3) that being listed as revoked in the Nurse Aide Registry or being listed as unemployable in the Employee Misconduct Registry is a bar to employment or volunteer status; and(4) that a confirmation of abuse or neglect in CANRS is a bar to employment or volunteer status. Source Note: The provisions of this §926.57 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.57 Notification to Applicants https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219694 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219694&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219694 03/12/2026 (a) At any time while employed by or assigned to a facility, an employee, volunteer, or unpaid professional intern must report to the designated person within five calendar days any of the following events:(1) the employee's, volunteer's, or intern's conviction, arrest, indictment, adjudication of guilt, plea of guilty or nolo contendre, assessment of probation, pretrial diversion, or deferred adjudication for any criminal offense; or a dismissal, acquittal, or similar final outcome for any criminal offense that does not involve a plea of guilty or nolo contendre; and(2) any listing of the employee, volunteer, or intern as revoked in the Nurse Aide Registry or as unemployable in the Employee Misconduct Registry.(b) If an employee, volunteer, or unpaid professional intern fails to report information in accordance with subsection (a) of this section, DADS may take disciplinary action, including termination, against the employee, volunteer, or intern.(c) A facility must conduct subsequent criminal history checks and registry clearances for an employee or volunteer annually. A facility may conduct subsequent criminal history checks and registry clearances more frequently at the facility's discretion.(d) If DADS finds from a subsequent criminal history check or registry clearance that an employee or volunteer meets any of the criteria that constitute a bar to employment or assignment as described §3.201(b) of this subchapter (relating to Pre-employment or Pre-assignment Checks and Clearances), DADS may take disciplinary action, including termination, against the employee or volunteer. Source Note: The provisions of this §926.61 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.61 Self-Reporting and Subsequent Criminal History Checks and Registry Clearances https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219695 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219695&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219695 03/12/2026 (a) A facility may not allow an unpaid professional intern to have direct contact with an individual if that intern:(1) has been convicted of or received deferred adjudication for any of the criminal offenses listed in HSC §250.006(a);(2) has been convicted of or received deferred adjudication for any of the criminal offenses listed in HSC §250.006(b) within five years preceding the date of assignment;(3) has been convicted of or received deferred adjudication for a criminal offense that DADS has determined to be a contraindication to assignment pursuant to HSC §533.007;(4) is listed as revoked in the Nurse Aide Registry;(5) is listed as unemployable in the Employee Misconduct Registry; or(6) has a confirmation of abuse or neglect in CANRS.(b) A facility must have a written agreement with the unpaid professional intern's sponsoring university or college. The written agreement must include:(1) a statement that the facility retains responsibility for the care of the individuals; and(2) a statement that the sponsoring college or university will conduct and fund a criminal history check and registry clearance of the unpaid professional intern that complies with §3.201 of this subchapter (relating to Pre-employment or Pre-assignment Checks and Clearances). Source Note: The provisions of this §926.63 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES B CRIMINAL HISTORY CHECKS AND REGISTRY CLEARANCES AT STATE FACILITIES §926.63 Unpaid Professional Interns https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219696 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219696&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219696 03/12/2026 (a) Abuse, neglect, and exploitation of an individual are prohibited.(b) If an aggressive action by an individual, including non-consensual sexual activity between individuals, occurs as a result of possible neglect, the facility must report the action as neglect. Source Note: The provisions of this §926.103 adopted to be effective October 6, 2011, 36 TexReg 6511; amended to be effective June 20, 2017, 42 TexReg 3161; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.103 Prohibition of Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219697 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219697&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219697 03/12/2026 (a) A person who knows or suspects an individual has been abused, neglected, or exploited must immediately report the alleged abuse, neglect, or exploitation to DFPS within one hour of learning of or suspecting the incident by calling 1-800-647-7418. Abuse, neglect, or exploitation may occur before an individual is admitted to a facility, during an absence from a facility, or while in residence at the facility.(b) A facility must report incidents identified as abuse, neglect, or exploitation during the course of a facility investigation or peer review.(c) If the person with knowledge or suspicion of abuse, neglect, or exploitation is not an employee or contractor, an employee must assist the person in making a report, if necessary.(d) DADS may take disciplinary action, including termination, against an employee who is found to have:(1) failed to report as required by this section within the allotted time period without sufficient justification; or(2) made a false statement of fact, refused to cooperate, or destroyed evidence during an investigation. Source Note: The provisions of this §926.105 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.105 Reporting Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219698 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219698&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219698 03/12/2026 (a) A facility may not retaliate against a person who in good faith reports an allegation.(b) A person who believes he or she has been subjected to retaliation as a result of reporting an allegation, or who believes an allegation has been ignored, may contact the director of the facility where the alleged abuse, neglect, or exploitation occurred or DADS state office. An employee may also contact:(1) The Office of the Attorney General at (512) 463-2185 (Consumer Protection Division), if the employee believes adverse personnel action was taken against him or her in violation of Texas Government Code, Chapter 554; or(2) The Office of Inspector General at 1-800-436-6184.(c) DADS may take disciplinary action, including termination, against an employee who retaliates against a person who in good faith reports an allegation. Source Note: The provisions of this §926.107 adopted to be effective October 6, 2011, 36 TexReg 6511; amended to be effective October 29, 2012, 37 TexReg 8601\; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.107 Prohibition Against Retaliation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219699 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219699&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219699 03/12/2026 (a) Immediately after receiving notification of an allegation from a DFPS investigator, the director receiving the notification must take measures to protect the alleged victim of abuse, neglect, or exploitation in accordance with DADS operational procedures.(b) The director must arrange for immediate and on-going medical and psychological attention for an alleged victim and any other individual involved in the incident, as necessary.(c) The director must:(1) ensure that required reports are made to DFPS, DADS Regulatory Services Division, and law enforcement;(2) in accordance with the Civil Practice and Remedies Code, Chapter 81, report allegations of sexual exploitation committed by a mental health services provider to the prosecuting attorney in the county where the alleged sexual exploitation occurred and any state licensing board with responsibility for the mental health services provider's licensing; and(3) notify the following persons of the allegation immediately, but in no case more than 24 hours, after being notified of an allegation:(A) the alleged victim, unless contraindicated based on clinical evaluation; and(B) the alleged victim's guardian or primary contact, or parent if the alleged victim is a child.(d) The director must cooperate with a DFPS investigator by:(1) preserving and safeguarding evidence, if any, of the alleged abuse, neglect, or exploitation, including taking precautionary measures necessary to prevent physical evidence from loss, destruction, or tampering; and(2) ensuring the availability of employees, records, keys, private interview space, and a private telephone upon request by the investigator. Source Note: The provisions of this §926.109 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.109 During an Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219700 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219700&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219700 03/12/2026 (a) A director may not change a confirmed finding of abuse, neglect, or exploitation made by DFPS. A director may change an unconfirmed, inconclusive, or unfounded finding of abuse, neglect, or exploitation made by DFPS to a confirmed finding. If the director changes a finding to confirmed, the confirmed finding may not be appealed to DFPS.(b) A facility has the appeal opportunities described in Chapter 711, Subchapter J, of this title (relating to Appealing the Investigative Finding). If a director disagrees with the secondary appeal decision made by DFPS in accordance with §711.911(b) of this title (relating to How and When is the Appeal Conducted?), the director must notify the DADS Commissioner of the disagreement. If the DADS Commissioner also disagrees with the secondary appeal decision, the DADS Commissioner may request that the DFPS Commissioner reconsider the decision. The DADS Commissioner must submit a reconsideration request to the DFPS Commissioner within 60 days after the date of the secondary appeal decision. DADS may not contest the decision of the DFPS Commissioner.(c) A director must ensure that a victim, a victim's LAR, and the protection and advocacy organization, if the protection and advocacy organization is the victim's designated representative, are promptly notified of:(1) a final finding made by DFPS;(2) the process for appealing the final finding as described in Chapter 711, Subchapter J , of this title; and(3) the right to receive a copy of the DFPS investigative report, if requested from the director.(d) A director must ensure that a perpetrator or alleged perpetrator is notified of a final finding made by DFPS.(e) If DFPS makes a final finding that an employee has abused, neglected, or exploited an individual, the director of the facility at which the employee is employed must take disciplinary action against the employee in accordance with DADS operational procedures.(1) The director must notify the employee in writing of the disciplinary action being taken, the opportunity to access a copy of the DFPS report, and of any opportunity that the employee may have to file a complaint or request a grievance hearing.(2) If the employee makes a written request to the director for a copy of the investigative report and acknowledges in writing that the contents of the report must be kept confidential, the director must provide the employee with a copy of or access to the DFPS investigative report.(f) A facility must establish and implement a mechanism to:(1) evaluate a problematic pattern or trend identified by a DFPS investigator or the facility; and(2) take action to address the pattern or trend.(g) A director must ensure that a victim, a victim's LAR, and the protection and advocacy organization, if the protection and advocacy organization is the victim's designated representative, are promptly notified of:(1) the disciplinary action taken against the perpetrator;(2) an employee's right to request a grievance hearing to dispute disciplinary action;(3) the opportunity to be informed if an employee files a grievance; and(4) the opportunity to request a copy of the DFPS investigative report.(h) If the protection and advocacy organization informs a director in writing that it represents a victim, the director must notify the protection and advocacy organization if a perpetrator requests a grievance hearing.(i) If DFPS confirms abuse, neglect, or exploitation and the perpetrator is a licensed professional employed at a facility, the director of the facility at which the perpetrator is employed must ensure that the appropriate licensing board is notified of the confirmation.(j) If an alleged perpetrator is a licensed professional and the DFPS investigator determines that the allegation involves clinical practice rather than abuse, neglect, or exploitation, the facility at which the alleged perpetrator is employed must conduct an investigation to determine if the allegation meets the licensing board's criteria for peer review. If it meets peer review criteria, the facility must conduct the peer review and ensure that the appropriate licensing board is notified of the results.(k) Upon request, a director must provide a copy of a DFPS investigative report to a victim, a victim's LAR, and the protection and advocacy organization, if the protection and advocacy organization is the victim's designated representative. The identity of an individual, other than the victim, and any other information confidential by law, must be concealed. If the designated representative is the protection and advocacy organization, the director must provide an unredacted copy of the DFPS investigative report.(l) A facility must report a finding of abuse, neglect, or exploitation against an employee of the facility to CANRS. Source Note: The provisions of this §926.111 adopted to be effective October 6, 2011, 36 TexReg 6511; amended to be effective October 29, 2012, 37 TexReg 8601; amended to be effective June 20, 2017, 42 TexReg 3161; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.111 Completion of an Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219701 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219701&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219701 03/12/2026 (a) A director is responsible for requiring the facility's contractors to comply with this subchapter (relating to Abuse, Neglect, and Exploitation).(b) A director must ensure that a contractor is provided a copy of DFPS rules in 40 TAC Chapter 711 (relating to Investigations in DADS Mental Retardation and DSHS Mental Health Facilities and Related Programs). Source Note: The provisions of this §926.113 adopted to be effective October 6, 2011, 36 TexReg 6511; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4925. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES C ABUSE, NEGLECT, AND EXPLOITATION AT STATE SUPPORTED LIVING CENTERS §926.113 Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224646 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224646&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224646 03/12/2026 The purpose of this subchapter is to prescribe procedures:(1) for effective reporting of allegations of abuse, neglect, and exploitation;(2) for ensuring the safety and protection of persons served involved in allegations;(3) for facilitating Texas Department of Protective and Regulatory Services investigations of allegations;(4) for facilitating peer review of allegations involving clinical practice;(5) for notifying appropriate licensing authorities and other individuals regarding issues relating to an allegation;(6) for contesting the Adult Protective Services (APS) review of a finding of an investigation;(7) for ensuring proper disciplinary action is taken; and(8) for training staff in identifying, reporting, and preventing abuse, neglect, and exploitation. Source Note: The provisions of this §926.151 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.151 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224647 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224647&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224647 03/12/2026 (a) This subchapter apply to all facilities of the Texas Department of Mental Health and Mental Retardation and their agents.(b) All facilities are responsible for amending their contracts to ensure contractors' compliance as specified in §417.513 of this title (relating to Contractors).(c) This subchapter does not apply to:(1) psychiatric hospitals licensed by the Texas Department of Health (TDH) under Chapter 577 of the Texas Health and Safety Code; or(2) state-funded community hospitals, which are inpatient mental health facilities licensed by the Texas Department of Health under the Texas Health and Safety Code, Chapter 242, or operated by a university health system and exempted from licensure, that provides TDMHMR-funded inpatient mental health services pursuant to a contract between TDMHMR and a local authority. Source Note: The provisions of this §926.153 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.153 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224648 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224648&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224648 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings, unless the context clearly indicates otherwise:(1) Adult Protective Services (APS) investigator--An employee of the Texas Department of Protective and Regulatory Services (TDPRS) with expertise and demonstrated competence in conducting investigations. (2) Advanced practice nurse (APN)--A registered nurse approved by the Board of Nurse Examiners for the State of Texas to practice as an advanced practice nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with advanced nurse practitioner.(3) Agent--Any individual not employed by the facility but working under the auspices of the facility, (e.g., a volunteer, a student).(4) Allegation--A report by an individual suspecting or having knowledge that a person served has been or is in a state of abuse, neglect, or exploitation as defined in this subchapter.(5) Child--A person served under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed pursuant to the Texas Family Code, Chapter 31.(6) Clinical practice--Relates to the demonstration of professional competence in nursing, dental, pharmacy, or medical practice as described, respectively, in the Nursing Practice Act, Vocational Nurse Act, Dental Practice Act, Pharmacy Practice Act, or Medical Practice Act.(7) Confirmed--Term used to describe an allegation which is determined to be supported by the preponderance of evidence.(8) Contractor--Any organization, entity, or individual who contracts with a facility to provide mental health and mental retardation services. The term includes a local independent school district with which a facility has a memorandum of understanding (MOU) for educational services.(9) Designee--A staff member immediately available who is temporarily or permanently appointed to assume designated responsibilities of the head of the facility.(10) Facility--A state hospital, state school, state center, or other entity providing mental retardation or mental health services that is operated by the Texas Department of Mental Health and Mental Retardation.(11) Guardian--An individual appointed and qualified as a guardian of the person under the Probate Code, Chapter 13.(12) Head of the facility--The superintendent or executive director of a facility, or designee. (If the superintendent or executive director is the alleged perpetrator, then the designee assumes all responsibilities of the head of the facility described in this subchapter.) (13) Incitement--To spur to action or instigate into activity; implies responsibility for initiating another's actions.(14) Inconclusive--Term used to describe an allegation leading to no conclusion or definite result due to lack of witnesses or other relevant evidence.(15) Medical intervention--Treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or advanced practice nurse (APN). For the purposes of this subchapter, the term does not include first aid, an examination, diagnostics (e.g., x-ray, blood test), or the prescribing of oral or topical medication.(16) Non-serious physical injury--Any injury requiring minor first aid and determined not to be serious by a registered nurse, advanced practice nurse (APN), or physician.(17) Office of Consumer Services and Rights Protection - Ombudsman--The office located at the Texas Department of Mental Health and Mental Retardation's Central Office.(18) Peer review--A review of clinical and/or medical practice(s) by peer physicians; a review of clinical and/or dental practice(s) by peer dentists; a review of clinical and/or pharmacy practice(s) by peer pharmacists; or a review of clinical and/or nursing practice(s) by peer nurses.(19) Perpetrator--A person who has committed an act of abuse, neglect, or exploitation.(20) Perpetrator unknown--Term used to describe instances in which abuse, neglect, or exploitation is evident but positive identification of the responsible person(s) cannot be made, and in which self-injury has been eliminated as the cause.(21) Person served--Any person registered or assigned in the Client Assignment and Registration (CARE) system who is receiving services from a facility or contractor.(22) Preponderance of evidence--The greater weight of evidence, or evidence which is more credible and convincing to the mind.(23) PMAB or Prevention and Management of Aggressive Behavior--TDMHMR's proprietary risk management program that uses the least intrusive, most effective options to reduce the risk of injury for persons served and for staff from acts or potential acts of aggression.(24) Primary contact--In cases in which the alleged victim is an adult with mental retardation who is unable to authorize the disclosure of protected health information and who does not have a guardian, the individual designated as the alleged victim's correspondent who receives all other information about the alleged victim (e.g., spouse, parent).(25) Reporter--The individual who reports an allegation of abuse, neglect, or exploitation.(26) Retaliatory action--Any action intended to inflict emotional or physical harm or inconvenience on a person that is taken because the person has reported abuse, neglect, or exploitation. This includes, but is not limited to, harassment, disciplinary measures, discrimination, reprimand, threat, and criticism.(27) Review authority--An individual or panel of individuals who, at the discretion and request of the head of the facility, reviews selected cases of abuse, neglect, or exploitation, including those that are confirmed, unconfirmed, unfounded, or inconclusive. The review authority may include a member of the facility's public responsibility committee.(28) Serious physical injury--Any injury requiring medical intervention or hospitalization or any injury determined to be serious by a physician or advanced practice nurse (APN).(29) TDMHMR--The Texas Department of Mental Health and Mental Retardation.(30) TDPRS--The Texas Department of Protective and Regulatory Services.(31) Unconfirmed--Term used to describe an allegation in which a preponderance of evidence exists to prove that abuse, neglect, or exploitation did not occur.(32) Unfounded--Term used to describe an allegation that is spurious or patently without factual basis. Source Note: The provisions of this §926.155 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.155 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225287 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225287&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225287 03/12/2026 (a) Abuse, neglect, and exploitation of any person served is prohibited.(b) Consistent with Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs), the terms "abuse," "neglect," and "exploitation" are defined as follows when the alleged perpetrator is an employee, agent, contractor, or is unknown. (1) Abuse is:(A) physical abuse, which is:(i) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused physical injury or death to a person served;(ii) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to a person served; or(iii) the use of chemical or bodily restraints on a person served not in compliance with federal and state laws and regulations, including:(I) Chapter 405, Subchapter F of this title (concerning Voluntary and Involuntary Behavioral Interventions in Mental Health Programs); and(II) Chapter 405, Subchapter H of this title (concerning Behavior Management--Facilities Serving Persons with Mental Retardation); (B) sexual abuse, which is any sexual activity involving an employee, agent, or contractor and a person served, including but not limited to:(i) kissing a person served with sexual intent;(ii) hugging a person served with sexual intent;(iii) stroking a person served with sexual intent;(iv) fondling a person served with sexual intent;(v) engaging in with a person served:(I) sexual conduct as defined in the Texas Penal Code, §43.01; or(II) any activity that is obscene as defined in the Texas Penal Code, §43.21;(vi) requesting, soliciting, or compelling a person served to engage in:(I) sexual conduct as defined in the Texas Penal Code, §43.01; or(II) any activity that is obscene as defined in the Texas Penal Code, §43.21;(vii) in the presence of a person served:(I) engaging in or displaying any activity that is obscene, as defined in the Texas Penal Code §43.21; or(II) requesting, soliciting, or compelling another person to engage in any activity that is obscene, as defined in the Texas Penal Code §43.21;(viii) committing sexual exploitation, as defined in the Texas Civil Practice and Remedies Code, §81.001, against a person served. A copy of the Texas Civil Practice and Remedies Code, §81.001, is referenced as Exhibit A in §417.516 of this title (relating to Exhibits);(ix) committing sexual assault as defined in the Texas Penal Code §22.011, against a person served;(x) committing aggravated sexual assault as defined in the Texas Penal Code, §22.021, against a person served; and(xi) causing, permitting, encouraging, engaging in, or allowing the photographing, filming, videotaping, or depicting of a person served if the employee, agent, or contractor knew or should have known that the resulting photograph, film, videotape, or depiction of the person served is obscene as defined in the Texas Penal Code, §43.21, or is pornographic; and(C) verbal/emotional abuse, which is any act or use of verbal or other communication, including gestures, to curse, vilify, or degrade a person served or threaten a person served with physical or emotional harm, that results in observable distress or harm to the person served or be of such a serious nature that a reasonable person would consider it harmful or causing distress.(2) Neglect is a negligent act or omission by any individual responsible for providing services to a person served, which caused or may have caused physical or emotional injury or death to a person served or which placed a person served at risk of physical or emotional injury or death. Neglect includes, but is not limited to, the failure to:(A) establish or carry out an appropriate individual program plan or treatment plan for a person served if such failure results in a specific incident or allegation involving a person served;(B) provide adequate nutrition, clothing, or health care to a specific person served; or(C) provide a safe environment for a specific person served, including the failure to maintain adequate numbers of appropriately trained staff if such failure results in a specific incident or allegation involving a person served.(3) Exploitation is the illegal or improper act or process of using a person served or the resources of a person served for monetary or personal benefit, profit, or gain.(c) Abuse, neglect, or exploitation does not include:(1) the proper use of restraints and seclusion, including PMAB, and the approved application of behavior modification techniques as described in:(A) Chapter 405, Subchapter F of this title, relating to Voluntary and Involuntary Behavioral Interventions in Mental Health Programs;(B) Chapter 404, Subchapter E of this title, relating to Rights of Persons Receiving Mental Health Services; and(C) Chapter 405, Subchapter H of this title, relating to Behavior Management--Facilities Serving Persons With Mental Retardation; (2) other actions taken in accordance with TDMHMR rules;(3) such actions as an employee/agent/ contractor may reasonably believe to be immediately necessary to avoid imminent harm to self, persons served, or other individuals if such actions are limited only to those actions reasonably believed to be necessary under the existing circumstances. Such actions do not include acts of unnecessary force or the inappropriate use of restraints or seclusion, including PMAB; or(4) general complaints (e.g., regarding rights violations; theft of property; the daily administrative operations of a facility). (Within 24 hours of receipt of such a complaint, the APS investigator refers the complaint to the head of the facility using the Adult Protective Services Referral Form, who ensures the complaint is investigated administratively by the head of the facility, the facility rights officer, or other appropriate parties.) Source Note: The provisions of this §926.156 adopted to be effective April 23, 2003, 28 TexReg 3354; amended to be effective February 4, 2004, 29 TexReg 999; transferred effective June 30, 2025, as published in the June 6, 2025, issue of the Texas Register, 50 TexReg 3481. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.156 Prohibition and Definitions of Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224649 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224649&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224649 03/12/2026 (a) Reporting suspected abuse, neglect, or exploitation.(1) Each employee/agent/contractor who suspects or has knowledge that a person served is being abused, neglected, or exploited shall make a verbal report to TDPRS immediately, if possible, but in no case more than one hour after suspicion or after learning of the incident, by calling 1-800-647-7418.(2) Each employee/agent/contractor who suspects or has knowledge that a person served has been abused, neglected, or exploited, including prior to admission, during an absence, or while in residence at the facility, shall make a verbal report to TDPRS immediately, if possible, but in no case more than one hour after suspicion or after learning of the incident, by calling 1-800-647-7418.(3) If the person making the allegation is not an employee/agent/contractor (e.g., a person served, a guest), staff shall assist the person in making the report, if necessary.(b) Any pregnancy of a person served, provided there is medical verification that there is reasonable expectation that conception could have occurred while the person was a resident of the facility or contractor, or any diagnosis of a sexually transmitted disease in a person served which could have occurred while the person was a resident of the facility or contractor, shall be reported in accordance with this subchapter as possible abuse or neglect.(c) If an aggressive action by a person served, including non-consensual sexual activity between persons served, occurs as a result of possible neglect, then the action is reported as neglect in accordance with this subchapter.(d) Failure to make reports as required by this section within the allotted time period without sufficient justification is considered a violation of this section and makes the employee/agent subject to disciplinary action and possible criminal prosecution. An employee/agent found to have made a false statement of fact during an investigation is also subject to disciplinary action.(e) In addition to reporting to TDPRS, employees shall take appropriate steps to secure evidence related to an allegation, if any, consistent with "Guidelines for Securing Evidence," referenced as Exhibit B in §417.516 of this title (relating to Exhibits). Source Note: The provisions of this §926.157 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.157 Reporting Responsibilities of All TDMHMR Employees, Agents, and Contractors: Reports to Texas Department of Protective and Regulatory Services (TDPRS) https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224650 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224650&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224650 03/12/2026 (a) Retaliatory action. Any employee/agent or any individual affiliated with an employee/agent is prohibited from engaging in retaliatory action against a person served, a family member of a person served, the guardian of a person served, the primary contact of a person served, or an employee/agent who in good faith reports an allegation.(1) Any person who believes he or she is being subjected to retaliatory action upon reporting an allegation, or who believes an allegation has been ignored, should immediately contact the head of the facility. The person may also contact:(A) the Office of Consumer Services and Rights Protection - Ombudsman at the dedicated toll-free number for facilities at 1-800-252-8154; or(B) the Office of the Attorney General at 512/463-2185 (Consumer Protection Division) which, under the Whistleblower Act, Texas Civil Statutes, Article 6252-16a, may prosecute a supervisor who suspends or terminates a public employee for reporting a violation of law to law enforcement authorities.(2) Retaliatory action against a person served which might be considered abuse, neglect, or exploitation is reported to TDPRS in accordance with this subchapter.(b) Disciplinary action. Any employee/agent found to have engaged in retaliatory action is subject to disciplinary action. Source Note: The provisions of this §926.159 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.159 Prohibition Against Retaliatory Action https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224651 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224651&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224651 03/12/2026 (a) All allegations are investigated in accordance with Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs).(b) Immediately upon notification of an allegation by the APS investigator, the head of the facility takes measures to ensure the safety of the alleged victim(s), including the following actions:(1) As necessary, the head of the facility ensures immediate and on-going medical attention is provided to the alleged victim and any other person served involved in the incident (e.g., examination for and treatment of injuries, screening and treatment for sexually transmitted diseases). The examination and treatment of abuse/neglect-related injuries is documented on the client injury assessment, with a copy submitted to the APS investigator. All issues relating to clinical practice are referred to the medical/clinical director for consultation.(2) The head of the facility ensures the protection of the alleged victim. Action taken to ensure the protection of the alleged victim must be appropriate within the context of the allegation and may include:(A) reassigning the employee/agent to a non-direct care area in accordance with the Human Resources Operating Instruction 407-12;(B) allowing the employee/agent to remain in his or her current position pending investigation;(C) granting the employee emergency leave in accordance with the Human Resources Operating Instruction 407-12; or(D) suspending the agent pending investigation.(3) As necessary, the head of the facility ensures psychological attention is provided to the alleged victim and any other person served who may have witnessed or been affected by the incident. The psychological attention shall be provided in a timely manner while preserving the integrity of the investigation.(4) If the alleged perpetrator is known but is not an employee/agent (e.g., family member, friend, guest), the head of the facility imposes a restriction on the alleged perpetrator's access to the alleged victim pending investigation. The restriction should be documented in the record of the alleged victim.(5) Immediately, but in no case later than 24 hours after notification of an allegation, the head of the facility notifies the following individuals of the allegation:(A) the alleged victim (if appropriate); and(B) the alleged victim's guardian or primary contact (as defined), or parent if the alleged victim is a child.(c) The head of the facility designates a contact staff person to coordinate with the APS investigator to ensure private interview space, private telephones, and employees/agents are available to the APS investigator. The head of the facility shall require employees/agents to cooperate with APS investigators so that the investigators are afforded immediate access to all records and evidence and provided keys as are necessary to conduct an investigation in a timely manner. The head of the facility shall assist in whatever way possible to make employees/agents who are relevant to the investigation available in an expeditious manner. Employees/agents who fail to cooperate with an investigation are subject to disciplinary action.(d) Reports regarding alleged "sexual exploitation" committed by a "mental health services provider" (as defined in the Texas Civil Practice and Remedies Code, §81.001) are made by the head of the facility to the prosecuting attorney in the county in which the alleged sexual exploitation occurred and any state licensing board that has responsibility for the mental health services provider's licensing in accordance with the Texas Civil Practice and Remedies Code, §81.006. A copy of the Texas Civil Practice and Remedies Code, §81.001 and §81.006, is referenced as Exhibit A in §517.516 of this title (relating to Exhibits).(e) At facilities that operate an intermediate care facility for the mentally retarded (ICF/MR), the head of the facility must report those allegations that are considered reportable incidents to the Texas Department of Human Services (TDHS), ICF/MR/RC Department in accordance with the memorandum of understanding, referenced as Exhibit C in §417.516 of this title (relating to Exhibits), between TDMHMR, TDHS, and Texas Department of Protective and Regulatory Services. Source Note: The provisions of this §926.161 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.161 Responsibilities of the Head of the Facility https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224652 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224652&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224652 03/12/2026 (a) The APS investigator sends a copy of the investigative report to the head of the facility in accordance with Chapter 711, Subchapter G of Title 40 (concerning Release of Report and Findings). The investigative report includes: (1) a statement of the allegation(s); (2) a summary of the investigation; (3) an analysis of the evidence, including: (A) factual information related to what occurred; (B) how the evidence was weighed; and (C) what testimony was considered credible; (4) a finding that the allegation is confirmed, unconfirmed, inconclusive, or unfounded; (5) recommendations resulting from the investigation; (6) the name of the perpetrator or alleged perpetrator or the designation of "perpetrator unknown"; (7) a recommended classification for each allegation as described in §417.512(a) of this title (relating to Classifications and Disciplinary Actions); (8) the exam and treatment of abuse/neglect-related injuries documented on the client injury assessment; (9) photographs relevant to the investigation, including photographs showing the existence of injuries or the non-existence of injuries, when appropriate; (10) all witness statements and supporting documents; and (11) a signed and dated Client Abuse and Neglect Report (AN-1-A) form, referenced as Exhibit E in §417.516 of this title (relating to Exhibits), reflecting the information contained in paragraphs (4), (6), and (7) of this section. (b) Upon receiving the investigative report from the APS investigator, the head of the facility may submit the report and concerns articulated by the APS investigator to a review authority for review. (1) The review authority may interview witnesses in the course of its review. (2) If the review authority is reviewing a case determined by the APS investigator to be unfounded, it may consult with the APS investigator if appropriate. If the review authority determines that there is good cause to reopen the investigation (e.g., new evidence or information that was not previously available during the investigation), the head of the facility may contact the local APS supervisor to request that the case be re-opened. (3) The review authority submits a report of its review to the head of the facility. (c) The head of the facility: (1) reviews the APS investigator's report; (2) reviews the review authority's report, if applicable; and (3) interviews witnesses, if necessary. (d) The rights of employees who appear before the review authority or the head of the facility are outlined in "Procedures in Facility Abuse, Neglect, and Exploitation Investigations and Thurston Rebuttal Proceedings," referenced as Exhibit F in §417.516 of this title (relating to Exhibits). (e) The head of the facility may not change a confirmed finding. However, if the head of the facility disagrees with the APS investigator's finding of unconfirmed, inconclusive, or unfounded, the head of the facility may elect to change the finding to confirmed. If the head of the facility elects to change the finding to confirmed, then the confirmed finding cannot be appealed to TDPRS. (f) If the head of the facility believes that the methodology used in conducting the investigation was flawed (e.g., failure to collect or consider evidence, such as witnesses' statement, progress notes, test results), the head of the facility may request a review in accordance with Chapter 711, Subchapter K of Title 40 (concerning Requesting a Review of Finding if You Are the Administrator or Contractor CEO). (g) If the head the facility disagrees with: (1) the APS investigator's finding, the head of the facility may contest the finding by requesting a review in accordance with Chapter 711, Subchapter K of Title 40 (concerning Requesting a Review of Finding if You Are the Administrator or Contractor CEO). (2) the APS review as described in §711.1007 of Title 40 (relating to How is the Review of a Finding Conducted?), the head of the facility may contest the review by apprising the TDMHMR director of state mental health facilities or state mental retardation facilities, as appropriate. If the TDMHMR director also disagrees with the APS review, the TDMHMR director may request a decision by the TDMHMR commissioner and the TDPRS executive director. The decision of the TDMHMR commissioner and the TDPRS executive director may not be contested. (h) The final finding is the last uncontested finding, which may be: (1) the APS investigator's finding in accordance with subsection (a)(4) of this section; (2) the head of the facility's confirmed finding in accordance with subsection (e) of this section; (3) the APS finding in accordance with subsection (g)(1) of this section; or (4) the TDMHMR commissioner and the TDPRS executive director's decision in accordance with subsection (g)(2) of this section. (i) Within 30 calendar days of receipt of the investigative report or the final finding, the head of the facility is responsible for completing the Client Abuse and Neglect Report (AN-1-A) form, referenced as Exhibit E in §417.516 of this title (relating to Exhibits), and ensuring the information is entered into the Client Abuse and Neglect Reporting System (CANRS). (j) The APS investigator notifies the reporter in accordance with §711.609 of Title 40 (relating to How and When is the Reporter Notified of the Finding?). (k) The head of the facility ensures that the (alleged) victim or guardian or parent if the (alleged) victim is a child is promptly notified of: (1) the final finding and if any previous findings were contested; (2) the method of appealing the final finding as described in Chapter 711, Subchapter M of Title 40 (concerning Requesting an Appeal if You Are the Reporter, Alleged Victim, Legal Guardian, or With Advocacy, Incorporated), if the final finding was not made by the head of the facility as provided by subsection (e) of this section; and (3) the right to receive a copy of the investigative report in accordance with §417.511(b) of this title (relating to Confidentiality of Investigative Process and Report) upon request. (l) The head of the facility ensures that the primary contact is promptly notified of the final finding. (m) The head of the facility informs the perpetrator or alleged perpetrator of the final finding. (n) If the (alleged) perpetrator and (alleged) victim will again be in close proximity following an investigation, the head of the facility is responsible for ensuring appropriate reconciliation efforts are considered, offered, and provided in accordance with "Therapeutic Reconciliation," referenced as Exhibit G in §417.516 of this title (relating to Exhibits). (o) The head of the facility shall establish a mechanism for evaluating any recommendations concerning problematic patterns or trends identified during the investigation by the APS investigator and the review authority, if applicable. Source Note: The provisions of this §926.163 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.163 Completion of the Investigation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224653 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224653&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224653 03/12/2026 (a) The reports, records, and working papers used by or developed in the investigative process, and the resulting investigative report, are confidential and may be disclosed only as allowed by law or Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs).(b) Upon request, the head of the facility will provide a copy of the investigative report to the (alleged) victim or guardian with the identities of other persons served and any information determined confidential by law concealed. The head of the facility may charge a reasonable fee for providing a copy of the investigative report.(c) Advocacy, Inc. is entitled to access the records of the (alleged) victim in accordance with 42 USC §10805(a)(4) (Protection and Advocacy for Mentally Ill Individuals) or 42 USC §15043(a)(2)(I) (Protection and Advocacy of Individual Rights). Source Note: The provisions of this §926.165 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.165 Confidentiality of Investigative Process and Report https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224654 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224654&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224654 03/12/2026 (a) The APS investigator recommends a classification for each allegation as follows:(1) Class I Abuse, if the allegation involves:(A) physical abuse which caused or may have caused serious physical injury; or(B) sexual abuse.(2) Class II Abuse, if the allegation involves:(A) physical abuse which caused or may have caused non-serious physical injury; or(B) exploitation.(3) Class III Abuse, if the allegation involves verbal/emotional abuse.(4) Neglect, if the allegation involves neglect.(b) Under no circumstances may the head of the facility change a recommended classification to a lower classification (e.g., Class I to Class II). However, the head of the facility may change a recommended classification to a higher classification (e.g., Class II to Class I) in accordance with the evidence and subsection (a) of this section.(c) The head of the facility is responsible for taking prompt and proper disciplinary action when an allegation involving an employee/agent is confirmed.(1) Disciplinary action against an employee is based on criteria including, but not limited to:(A) the seriousness of the abuse, neglect, and/or exploitation; (B) the circumstances surrounding the incident;(C) the employee's work record; and(D) repeat violations and the length of time between violations.(2) When an allegation has been confirmed the head of the facility takes the following disciplinary action.(A) Class I Abuse. The employee/agent is dismissed.(B) Class II Abuse.(i) The employee is placed on suspension for up to 10 days, demoted, or dismissed. If the employee is exempt under the provisions of the Fair Labor Standards Act (FLSA), the suspension shall be in compliance with relevant provisions of the FLSA and current TDMHMR personnel policies.(ii) The agent is dismissed.(C) Class III Abuse or Neglect.(i) The employee receives a written reprimand which becomes a part of the employee's personnel file, or the employee is placed on suspension for up to 10 days, demoted, or dismissed. If the employee is exempt under the provisions of the FLSA the suspension shall be in compliance with relevant provisions of the FLSA and current TDMHMR personnel policies.(ii) The agent is dismissed.(d) When disciplinary action is taken against an employee based on confirmed abuse or neglect, the head of a facility notifies the employee in writing of the disciplinary action taken and any right to a grievance hearing the employee may have under TDMHMR's internal policies and procedures relating to employee grievances. If the employee files a grievance in response to disciplinary action resulting from confirmed abuse or neglect, the head of the facility, upon the employee's written request, provides the employee with a copy of or access to the investigative report. Before receiving or inspecting the report, the employee is required to complete a document acknowledging that the report's content must be kept confidential. Additional documentary evidence, if any, may be accessed by the employee in accordance with procedures outlined in the Human Resources Operating Instruction 407-12, §18 (relating to Employee Grievances).(e) When disciplinary action is taken against an agent as a result of confirmed abuse or neglect, the head of a facility notifies the agent in writing of the disciplinary action taken.(f) The head of the facility ensures the victim, guardian, or primary contact, or parent if the victim is a child is promptly notified of:(1) the disciplinary action taken against the employee/agent; (2) the employee's right to request a grievance hearing to dispute the disciplinary action; and(3) an offer to inform the victim, guardian, primary contact, or parent if the employee files a grievance if such information is requested.(g) If Advocacy, Inc. informs the head of the facility that it represents the victim of confirmed Class I abuse, the head of the facility will notify Advocacy, Inc. if the dismissed employee requests a grievance hearing.(h) If requested by the head of the facility, the APS investigator who conducted the investigation shall provide consultation and testimony at the grievance hearing.(i) The head of the facility provides the APS director with a copy of hearings officers' decisions of employee grievances that involve TDPRS investigations. Source Note: The provisions of this §926.167 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.167 Classifications and Disciplinary Actions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224655 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224655&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224655 03/12/2026 The head of the facility is responsible for requiring that all of the facility's contractors comply with this subchapter with the exception of §417.512 of this title (relating to Classifications and Disciplinary Actions) and §417.514 of this title (relating to TDMHMR Administrative Responsibilities). The head of the facility shall ensure that each contractor is provided a copy of TDPRS's rules governing investigations in TDMHMR facilities and related programs, 40 TAC Chapter 711. Each contract shall describe the procedural responsibilities of the facility and the contractor regarding at least the following:(1) the reporting of allegations of abuse, neglect, and exploitation;(2) the safety and protection of persons served involved in allegations;(3) the facilitation of proper investigations/peer reviews and the preservation of the integrity of investigations/peer reviews;(4) the notification of appropriate licensing authorities and other individuals regarding issues relating to allegations;(5) taking proper disciplinary action or other appropriate action; and(6) staff training in identifying, reporting, and preventing abuse, neglect, and exploitation. Source Note: The provisions of this §926.169 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective April 11, 2025, as published in the March 14, 2025, issue of the Texas Register, 50 TexReg 1934. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.169 Contractors https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225288 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=225288&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 225288 03/12/2026 (a) This subchapter shall be thoroughly and periodically explained to all employees/agents of each facility as follows:(1) All new employees/agents who will provide direct services to persons served and all new employees/agents who will routinely perform job duties in proximity to persons served shall receive training on the contents of this subchapter prior to performing their duties and annually thereafter. The training will include:(A) an explanation and examples of the acts and signs of possible abuse, neglect, and exploitation;(B) the effects of abuse, neglect, and exploitation;(C) an explanation that abuse, neglect, and exploitation of persons served is prohibited;(D) the disciplinary consequences for:(i) committing abuse, neglect, and exploitation; and(ii) failure to cooperate with an investigation;(E) the procedures for reporting allegations of abuse, neglect, and exploitation;(F) a definition of retaliatory action, an explanation that retaliatory action is prohibited, and an explanation of the consequences of retaliatory action;(G) practices and attitudes that support the prevention of abuse, neglect, and exploitation; and(H) PMAB.(2) All new employees/agents who will not provide direct services to persons served and who will not routinely perform any job duty in proximity to persons served shall receive training on the contents of this subchapter within two months of employment or placement and every two years thereafter. The training will include:(A) an explanation and examples of the acts and signs of possible abuse, neglect, and exploitation;(B) the effects of abuse, neglect, and exploitation;(C) an explanation that abuse, neglect, and exploitation of persons served is prohibited;(D) the disciplinary consequences for:(i) committing abuse, neglect, and exploitation; and(ii) failure to cooperate with an investigation;(E) the procedures for reporting allegations of abuse, neglect, and exploitation; and(F) a definition of retaliatory action, an explanation that retaliatory action is prohibited, and an explanation of the consequences of retaliatory action.(3) Physicians shall receive additional training on how to identify signs and symptoms of abuse, neglect, and exploitation.(4) All new employees who will provide direct services to persons served shall receive training on the procedures for securing evidence in accordance with "Guidelines for Securing Evidence," referenced as Exhibit B in §417.516 of this title (relating to Exhibits) prior to performing their duties and annually thereafter.(5) Within 90 days after the effective date of this subchapter, the head of the facility shall inform all current employees/agents/contractors of changes to policies and procedures as a result of this subchapter.(b) All supervisory personnel have a continuing responsibility to keep employees/agents informed of current rules and policies governing abuse, neglect, and exploitation and to ensure that employees/agents receive training in accordance with this section.(c) Instructional materials, audiovisual, and/or other training aids concerning this subchapter are developed and available through the TDMHMR System Human Resource Development, Central Office.(d) Records of all training content and activities related to course titles shall be kept by each facility. Records shall also be kept on each employee/agent receiving training in compliance with this section, which include:(1) the employee/agent's name and signature;(2) the course title;(3) the result of any assessment;(4) the date of the training; and(5) the name of the person facilitating, monitoring, or conducting the training. Source Note: The provisions of this §926.171 adopted to be effective April 23, 2003, 28 TexReg 3354; transferred effective June 30, 2025, as published in the June 6, 2025, issue of the Texas Register, 50 TexReg 3481. 1 HEALTH AND HUMAN SERVICES COMMISSION 926 STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES D ABUSE, NEGLECT, AND EXPLOITATION AT STATE HOSPITALS §926.171 State Hospital Staff Training in Identifying, Reporting, and Preventing Abuse, Neglect, and Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220186 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220186&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220186 03/12/2026 The purpose of this subchapter is to provide guidance and information on the right of state hospital patients, or the patient's legally authorized representative or representatives, to designate an essential caregiver and essential caregiver visitation policies in state hospitals in accordance with Texas Health and Safety Code Chapter 552, Subchapter F. Source Note: The provisions of this §930.1 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220187 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220187&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220187 03/12/2026 (a) This subchapter applies to the Texas state hospitals listed under Texas Health and Safety Code Section 552.002, any facilities that the Texas Health and Human Services Commission (HHSC) operates as a state hospital, and any contracted state hospital beds funded by HHSC.(b) The entities listed under subsection (a) of this section must adhere to the procedures outlined in this subchapter and monitor compliance with the implementation of the essential caregiver designation. Source Note: The provisions of this §930.3 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.3 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220188 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220188&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220188 03/12/2026 The following words and terms, when used in this subchapter, have the following meanings.(1) Adult--An individual who is 18 years of age or older or who is emancipated under the Texas Family Code.(2) Community Health Risk--Any action or event that places the individuals served by the facility, staff, visitors, or the general public at the chance for or exposure to injury, sickness, or loss. This includes a public safety risk or disaster declaration by government officials.(3) Day--A calendar day.(4) Essential Caregiver--A family member, friend, guardian, or other individual a patient or patient's legally authorized representative selects for in-person visits.(5) HHSC--Texas Health and Human Services Commission, or its designee.(6) In person--Within the physical presence of another person. In person does not include audiovisual or audio-only communication.(7) LAR--Legally authorized representative. A person authorized by state law to act on behalf of an individual or patient regarding a matter described by this subchapter, including the parent of a minor child.(8) Manifestly Dangerous--An individual who, despite receiving appropriate treatment, including treatment targeted to the individual's dangerousness, remains likely to endanger others and requires a maximum-security environment to continue treatment and protect public safety.(9) Minor--An individual younger than 18 years of age and who has not been emancipated under Chapter 31 of the Texas Family Code.(10) Ombudsman--The Ombudsman for Behavioral Health Access to Care established by HHSC in accordance with Texas Government Code §547.0002.(11) Parent--The biological or adoptive parent, managing conservator, or guardian of a minor.(12) Patient--An individual receiving services in a state hospital under this subchapter.(13) Revocation--Action taken to terminate an essential caregiver designation.(14) State hospital--Texas state hospitals listed under Texas Health and Safety Code Section 552.002, any facilities that HHSC operates as a state hospital, and any contracted state hospital beds funded by HHSC.(15) Suspension--Temporary prevention of in-person essential caregiver visitation. Source Note: The provisions of this §930.5 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.5 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220189 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220189&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220189 03/12/2026 Guidelines for state hospital policies and procedures.(1) Each patient or the patient's legally authorized representative (LAR) has the right to designate an essential caregiver with whom in-person state hospital visitation may not be prohibited except as prescribed in §930.9 of this subchapter (relating to Revocation) and §930.11 of this subchapter (relating to Temporary Suspension of Essential Caregiver Visits).(2) If a patient is a minor, the patient's LAR may designate up to two parents as essential caregivers.(3) An essential caregiver may visit the patient for at least two hours each day except when HHSC identifies a serious community health risk under §930.9 or §930.11 of this subchapter.(4) Physical contact between the patient and the essential caregiver during in-person visitation may occur except in circumstances where physical contact is, as a matter of safety and in the exercise of reasonable medical judgment of a member of the medical staff, determined to present a significant risk of harm to the patient, essential caregiver, or others in light of the patient's current medical or psychiatric condition; including if a patient has been determined to be manifestly dangerous pursuant to 25 TAC Chapter 415, Subchapter G (relating to Determination of Manifest Dangerousness). The determination must be documented in the patient's medical record.(5) The state hospital must provide a copy of visitation policies to the designated essential caregiver within 48 hours after the designated essential caregiver's agreement to become the essential caregiver and obtain a signed agreement form certifying that the essential caregiver agrees to follow the state hospital safety protocols for essential caregiver visits. This signed agreement must be placed in the patient's medical record.(6) The state hospital may not establish safety protocols more restrictive for essential caregivers than those established for state hospital staff. Source Note: The provisions of this §930.7 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.7 Essential Caregiver In-Person Visitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220190 03/12/2026 (a) Each patient or the patient's LAR has the right to revoke an essential caregiver designation. The patient, the patient's guardian, or the patient's LAR may then designate another person as the essential caregiver.(b) The state hospital may revoke an essential caregiver designation if the essential caregiver violates state hospital policies, procedures, or safety protocols. At the time of revocation, the essential caregiver and the patient or the patient's LAR will be provided a copy of the violated policy, procedure, or safety protocol.(c) If a state hospital revokes an essential caregiver designation under this section:(1) the patient, or the patient's LAR, has the right to designate another essential caregiver immediately;(A) within 24 hours, the state hospital must notify the patient or the patient's LAR of the revocation in person or by phone and the notification must be documented in the patient's record; and(B) within two business days, the state hospital must send a revocation notification letter to the patient or the patient's LAR via certified mail to include the state hospital appeal process;(2) the patient or the patient's LAR may petition the state hospital associate commissioner to appeal the revocation of an essential caregiver's designation;(A) not later than the 14th calendar day after the date of revocation, the patient or the patient's LAR, may request an appeal by submitting a written request to the state hospital associate commissioner's office;(B) the state hospital associate commissioner or designee will make a determination on the essential caregiver appeal not later than the 14th calendar day after receiving the request; and(C) the outcome will be documented in the patient's record and a decision letter will be sent to the requestor within two business days after the determination, if the patient or the patient's LAR files an appeal; and(3) if the revocation is upheld, within two business days, the state hospital will send a revocation letter to the essential caregiver and the patient or the patient's LAR via certified mail, including how to contact the Ombudsman in a language the essential caregiver and the patient or their LAR understands for information or assistance at 1-800-252-8154 or the HHSC website. Source Note: The provisions of this §930.9 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.9 Revocation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220191 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=220191&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 220191 03/12/2026 (a) Each state hospital may petition the state hospital associate commissioner or the state hospital associate commissioner's designee to suspend in-person essential caregiver visitation if in-person visitation poses a serious community health risk.(1) The state hospital associate commissioner or designee may only approve a suspension for up to seven calendar days.(2) State hospitals must request each suspension separately.(3) The state hospital associate commissioner may deny the state hospital request if HHSC determines that in-person visitation does not pose a serious community health risk.(b) Each state hospital may petition the state hospital associate commissioner or the state hospital associate commissioner's designee to extend a suspension of in-person essential caregiver visitation for more than seven calendar days if in-person visitation continues to pose a serious community health risk.(1) The state hospital associate commissioner or designee may only approve an extension for up to seven calendar days.(2) State hospitals must request each extension separately.(3) The state hospital associate commissioner may deny the state hospital request if HHSC determines that in-person visitation does not pose a serious community health risk.(c) A state hospital may not suspend in-person essential caregiver visitation in the 12 months from the date of the initial suspension for a period that:(1) is more than 14 consecutive calendar days; or(2) is more than a total of 45 calendar days. Source Note: The provisions of this §930.11 adopted to be effective August 13, 2024, 49 TexReg 5998. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES A STATE HOSPITAL ESSENTIAL CAREGIVER §930.11 Temporary Suspension of Essential Caregiver Visits https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219746 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219746&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219746 03/12/2026 (a) Local procedures. The CEO or designee is responsible for developing and implementing local procedures to ensure an individual's right to reasonable protection of personal property including clothing and mail from theft or loss consistent with Chapter 404, Subchapter E, concerning Rights of Persons Receiving Mental Health Services, and Chapter 405, Subchapter Y, concerning Client Rights--Mental Retardation Services or any other department rules that concern the rights of individuals.(b) Personal property. The CEO or designee is responsible for developing and implementing written processes that protect each individual's personal property that include:(1) advising individuals and LARs that the facility is limited in its ability to protect any personal property that an individual keeps on the unit, however, if loss or theft of such property is reported staff must make every effort to find and return the missing property to the owner;(2) documenting the receipt of any personal property that is to be held under the facility's control;(3) physically inventorying personal property under the facility's control and documenting personal property received from individuals to ensure it is accounted for and if a discrepancy arises develop a process for documenting, investigating, and resolving the discrepancy;(4) documenting and honoring an individual's request for the return of any or all of his or her personal property previously under the facility's control.(c) Returning personal property. If an individual is discharged from the facility, staff must upon discharge or a soon as possible thereafter document and return to the individual or LAR all of the individual's personal property under the facility's control.(d) Individual's personal mail. Except as described in this section and department rules concerning the rights of individuals, an individual's personal mail must be delivered unopened to the addressee. If staff have reason to believe that mail addressed to an individual is an invoice and the facility is responsible for its payment, then the mail must be opened by the individual and witnessed by two staff. If the mail contains such an invoice, it is forwarded to accounts payable for processing, an explanation of the situation is given to the individual, and the situation is documented in the individual's record. Source Note: The provisions of this §930.53 adopted to be effective April 27, 2003, 28 TexReg 3347; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4929. 1 HEALTH AND HUMAN SERVICES COMMISSION 930 ADDITIONAL RIGHTS OF INDIVIDUALS RECEIVING SERVICES AT STATE FACILITIES B PERSONAL PROPERTY OF AN INDIVIDUAL RECEIVING SERVICES AT A STATE FACILITY §930.53 Individual's Personal Property https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211350 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211350&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211350 03/12/2026 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise.(1) Abuse--An act or failure to act that, with regard to an individual, meets the definition of "physical abuse," "sexual abuse," or "verbal/emotional abuse" in Chapter 711, Subchapter A of this title (relating to Introduction), or the definition of "abuse," "physical abuse," "sexual abuse," "verbal abuse," "psychological abuse," or "threat" in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov.(2) Bedroom--The room at a facility in which an individual usually sleeps.(3) Capacity--An individual's ability to:(A) understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment; and(B) make a decision whether to undergo the proposed treatment.(4) Covert electronic monitoring--Electronic monitoring that is not open and obvious, and that is conducted when the director of the facility in which the monitoring is being conducted has not been informed about the device by the individual, by a person who placed the device in the bedroom, or by a person who uses the device.(5) Director--The director of a facility or the director's designee.(6) Electronic monitoring--The placement of an electronic monitoring device in an individual's bedroom and making a tape or a recording with the device.(7) Electronic monitoring device (EMD)--A device that:(A) includes:(i) a video surveillance camera; and(ii) an audio device designed to acquire communications or other sounds; and(B) does not include an electronic, mechanical, or other device that is specifically used for the nonconsensual interception of wire or electronic communications.(8) Exploitation--An act or failure to act that, with regard to an individual, meets the definition of "exploitation" in Chapter 711, Subchapter A of this title (relating to Introduction), or the definition of "mistreatment" in the CMS State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov.(9) Facility--A state supported living center or the intermediate care facility for individuals with an intellectual disability component of the Rio Grande State Center.(10) Guardian--An individual appointed and qualified as a guardian of the person under Texas Estates Code Title 3.(11) HHSC--Texas Health and Human Services Commission.(12) Interdisciplinary team (IDT)--A team consisting of an individual, the individual's legally authorized representative and qualified developmental disability professional, other professionals dictated by the individual's strengths, preferences, and needs, and staff who regularly and directly provide services and supports to the individual. The team is responsible for assessing the individual's treatment, training, and habilitation needs and making recommendations for services based on the personal goals and preferences of the individual using a person-directed planning process, including recommendations on whether the individual is best served in a facility or community setting.(13) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual, including a parent, guardian, or managing conservator of a minor individual, or a guardian of an adult individual.(14) Neglect--An act or failure to act that, with regard to an individual, meets the definition of "neglect" in Chapter 711, Subchapter A of this title, or the definition of "neglect" in the CMS State Operations Manual, Appendix J, Guidance to Surveyors: Intermediate Care Facilities for Individuals with Intellectual Disabilities, available at www.cms.gov.(15) SSLC--A state supported living center. Source Note: The provisions of this §965.1 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.1 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211351 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211351&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211351 03/12/2026 (a) A facility must permit an individual or an individual's legally authorized representative (LAR) to conduct electronic monitoring if the individual or LAR complies with the requirements for conducting electronic monitoring in this chapter. A facility must not discharge an individual because the individual or the individual's LAR conducts electronic monitoring in accordance with this chapter.(b) A facility must not refuse to admit an individual and must not discharge an individual from the facility because the individual or individual's LAR:(1) requests authorization to conduct electronic monitoring;(2) refuses to give consent or gives consent to conduct electronic monitoring requested by another individual or the other individual's LAR; or(3) withdraws consent for another individual or the individual's LAR to conduct electronic monitoring.(c) A facility must not discharge an individual because covert electronic monitoring is conducted by or on behalf of an individual. Source Note: The provisions of this §965.2 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.2 Electronic Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211352 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211352&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211352 03/12/2026 (a) An individual or an individual's legally authorized representative must complete and sign the required Texas Health and Human Services Commission form pertaining to placing an electronic monitoring device in an individual's bedroom upon admission to a state supported living center.(b) A facility must maintain a copy of the completed and signed form in the individual's active record. Source Note: The provisions of this §965.3 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.3 Information Regarding Electronic Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211353 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211353&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211353 03/12/2026 (a) To conduct electronic monitoring, an individual or an individual's legally authorized representative (LAR) must request authorization to do so by using the Texas Health and Human Services Commission (HHSC) form. The form must be signed and dated by the person described in subsection (b) of this section and given to the director of the facility in which the individual resides.(b) A request to conduct electronic monitoring in an individual's bedroom may be made:(1) only by an individual, if the individual's interdisciplinary team (IDT) determines that the individual has the capacity to request electronic monitoring in accordance with §965.6 of this chapter (relating to Capacity to Request or Consent to Electronic Monitoring) and the individual has not been judicially declared to lack the required capacity;(2) only by the guardian of an individual, if the individual has been judicially declared to lack the capacity required for taking an action such, as requesting electronic monitoring; or(3) only by an LAR, other than the guardian, of an individual if the individual's IDT determines that the individual does not have the capacity to request electronic monitoring in accordance with §965.6 of this chapter, but the individual has not been judicially declared to lack the required capacity.(c) A facility may move an individual to a different bedroom to accommodate a request for electronic monitoring.(d) A facility must maintain a completed and signed copy of the HHSC form in the individual's active record of the individual requesting authorization to conduct electronic monitoring. Source Note: The provisions of this §965.4 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.4 Request to Conduct Electronic Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211354 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211354&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211354 03/12/2026 (a) An individual or an individual's legally authorized representative (LAR) who requests to conduct electronic monitoring in the individual's bedroom must obtain consent annually on behalf of any individual who shares a bedroom with the requesting individual, using the required Texas Health and Human Services (HHSC) form. To provide consent, the form must be signed and dated by a person described in subsection (b) of this section and given to the director of the facility in which the individual resides. If the person's consent is conditioned on a limitation, the limitation must be stated on the form.(b) Consent to conduct electronic monitoring may be given:(1) only by an individual who shares a bedroom with the requesting individual, if the individual's interdisciplinary team (IDT) determines that the individual has the capacity to consent to electronic monitoring in accordance with §965.6 of this chapter (relating to Capacity to Request or Consent to Electronic Monitoring) and the individual has not been judicially declared to lack the required capacity; or(2) only by the guardian of an individual who shares a bedroom with the requesting individual, if the individual has been judicially declared to lack the required capacity; or(3) only by an LAR, other than the guardian, of an individual who shares a bedroom with the requesting individual, if the individual's IDT determines that the individual does not have the capacity to consent to electronic monitoring in accordance with §965.6 of this chapter, but the individual has not been judicially declared to lack the required capacity.(c) Except as provided in subsection (g) of this section, consent given in accordance with this section may be conditioned on:(1) pointing the camera away from the roommate, when the proposed electronic monitoring device (EMD) is a video surveillance camera;(2) limiting or prohibiting the use of an audio EMD;(3) limiting or prohibiting the use of a recording made by an EMD; or(4) limiting or prohibiting the use of an EMD in any other way.(d) If an individual who has not yet consented to electronic monitoring moves into a bedroom in which electronic monitoring is being conducted, the electronic monitoring must cease until consent is obtained from or on behalf of the individual in accordance with this section.(e) If more than a year has elapsed since consent was given by or on behalf of an individual who shares a bedroom with an individual conducting electronic monitoring, the electronic monitoring must cease until consent is obtained in accordance with this section.(f) A facility must maintain a copy of the required HHSC form in the individual's active record of the individual consenting to electronic monitoring.(g) Consent that is subject to a condition, as described in subsection (c) of this section, must not prevent a person from complying with this chapter or other law, including §965.9(a) of this chapter (relating to Reporting Abuse, Neglect, and Exploitation). If a condition on consent would require a person to violate this chapter or other law, the consent is not valid. Source Note: The provisions of this §965.5 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.5 Annual Consent by a Roommate https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211355 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211355&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211355 03/12/2026 The interdisciplinary team of an individual who has not been judicially declared to lack the capacity to request or consent to electronic monitoring determines if the individual has the capacity to request or consent to electronic monitoring. The facility must document the determination made in the individual's active record. Source Note: The provisions of this §965.6 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.6 Capacity to Request or Consent to Electronic Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211356 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211356&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211356 03/12/2026 (a) Once a director receives a completed Texas Health and Human Services Commission (HHSC) form requesting electronic monitoring, the director authorizes electronic monitoring to be conducted in accordance with this chapter.(b) A person conducting electronic monitoring must post and maintain a conspicuous notice at the entrance to the bedroom in which the monitoring is being conducted. The notice must state that the bedroom is being monitored by an electronic monitoring device (EMD).(c) A person conducting electronic monitoring must ensure that:(1) the electronic monitoring is conducted in plain view;(2) an EMD is installed and maintained in a manner that is safe for individuals, employees, and visitors, and that meets the requirements of applicable safety codes and laws;(3) electronic monitoring complies with any condition placed on it by a person giving consent in accordance with §965.5 of this chapter (relating to Annual Consent by a Roommate);(4) a video tape or recording made by the EMD shows the time and date that the recorded events occurred;(5) a tape or recording made by the EMD is not edited or artificially enhanced; and(6) if the contents of a recording are transferred from the original format to another technological format, a qualified professional performs the transfer and the content of the tape or recording is not altered.(d) A person conducting electronic monitoring must pay for all costs associated with conducting the monitoring, including the cost to install, maintain, repair, and remove the EMD, and to post and remove the notice required by subsection (b) of this section, other than the cost of electricity. Source Note: The provisions of this §965.7 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.7 Conducting Electronic Monitoring https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211357 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211357&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211357 03/12/2026 (a) A facility must post a notice at the main facility entrance titled "Electronic Monitoring." The notice must state, in large, easy-to-read type, "The bedrooms of some individuals may be monitored electronically by or on behalf of those individuals. Monitoring may not be open and obvious."(b) A facility must make reasonable physical accommodation for electronic monitoring, which includes providing:(1) a reasonably secure place to mount an electronic monitoring device (EMD); and(2) access to power sources for an EMD. Source Note: The provisions of this §965.8 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.8 Required Facility Notice and Accommodation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211349&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211349 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211349&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211349 03/12/2026 (a) If, based on a person's viewing of or listening to a recording obtained through electronic monitoring, the person has cause to believe that an individual is in a state of abuse, neglect, or exploitation or has been abused, neglected, or exploited, the person must:(1) report the suspected or known abuse, neglect, or exploitation to the Texas Health and Human Services Commission Provider Investigations (HHSC-PI) and the director of the facility in which the alleged abuse, neglect, or exploitation occurred immediately, if possible, but in no case more than one hour after the person knows or suspects that abuse, neglect, or exploitation has occurred; and(2) provide the original tape or recording to HHSC-PI.(b) A person who sends more than one tape or recording to HHSC-PI must identify each tape or recording on which the person believes an incident of abuse or exploitation or evidence of neglect may be found. A person is encouraged to identify the place on the tape or recording where an incident of abuse or exploitation or evidence of neglect may be found. Source Note: The provisions of this §965.9 adopted to be effective December 21, 2022, 47 TexReg 8275. 1 HEALTH AND HUMAN SERVICES COMMISSION 965 ELECTRONIC MONITORING IN AN INDIVIDUAL'S BEDROOM IN A STATE SUPPORTED LIVING CENTER §965.9 Reporting Abuse, Neglect, or Exploitation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224587 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=224587&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 224587 03/12/2026 The Texas Health and Human Services Commission contracts with an independent mortality review organization pursuant to Texas Government Code Chapter 546, Subchapter O. A state supported living center (SSLC) must report the death of a person with an intellectual or developmental disability who, at the time of the person's death or at any time during the 24-hour period before the person's death, resided in or received services from the SSLC. The death must be reported to the independent mortality review organization within 72 hours after the pronouncement of death. Source Note: The provisions of this §967.1 adopted to be effective December 18, 2022, 47 TexReg 8126; amended to be effective April 1, 2025, 50 TexReg 2212. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS A STATE SUPPORTED LIVING CENTER INDEPENDENT MORTALITY REVIEW §967.1 Independent Mortality Review https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219703 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219703&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219703 03/12/2026 (a) Expectations.(1) A facility must implement and operationalize statewide policy addressing the use of restraint.(2) At least one person trained as a restraint monitor must be on duty at all times to respond to the initiation of restraint procedures in a behavioral crisis, immediately if possible but in no case in more than 15 minutes. If data suggests a high number of incidents of restraint, additional restraint monitors may be required.(3) If an individual is in restraint at the time of shift change, staff must communicate and coordinate between shifts to provide continuity of care.(4) A licensed nurse must assess, for injuries and other negative health effects, an individual who has been restrained; determine if the individual's vital signs are stable; and document the individual's mental status as soon as possible but within 30 minutes after the initiation of restraint. Staff must continuously monitor the individual until the licensed nurse arrives.(5) A mechanical or physical restraint administered to an individual must:(A) be the least restrictive restraint effective to prevent imminent physical harm in a behavioral crisis, or to safely and effectively implement a medical or dental procedure, or to prevent or mitigate the documented danger of self-injurious behavior;(B) be used for the shortest period of time necessary to prevent imminent physical injury, to safely and effectively implement a medical or dental procedure, or to prevent or mitigate the documented danger of self-injurious behavior;(C) end immediately once the imminent risk of physical injury abates;(D) be applied with the minimum amount of force or pressure necessary to prevent harm to the individual and others; and(E) be used in the safest, least restrictive, most humane, and most respectful manner possible.(6) Staff must attempt to provide an environment that safeguards the individual's personal dignity, privacy, and well-being while ensuring safety.(7) Staff must provide continuous one-to-one supervision to individuals while in restraint. Individuals receiving medical restraints must receive supervision as ordered by the PCP or dentist in accordance with facility procedures. The director may approve an alternate level of supervision based on the IDT's clinical justification and recommendation.(8) Staff must respond appropriately to signs or symptoms of restraint-related injuries or distress, including an immediate release from restraint and checks by medical staff.(9) If an emergency evacuation or an evacuation drill occurs while an individual is in restraint, staff must respond as described in the facility's policies and procedures to ensure the individual's safety.(10) Staff must allow an individual who has been released from restraint time to recover and return to regular activities, including the opportunity to relax and exercise restrained limbs, to drink fluids, to toilet, to complete a snack or meal, and to receive prescribed medications.(11) Staff must take all necessary steps to avoid causing undue physical discomfort, harm, or pain to the individual while initiating and implementing restraint.(12) A facility must obtain legally adequate consent for a crisis intervention plan, medical restraint plan, or protective mechanical restraint plan for self-injurious behavior. A plan must be reviewed by the Behavior Support Committee and the facility director and approved by the Human Rights Committee before implementation.(13) An authorization to use or extend physical restraints in response to a behavioral crisis may be in effect no longer than 12 consecutive hours.(b) Allowed uses. Restraints may only be used to protect an individual or others from imminent physical injury resulting from:(1) a behavioral crisis;(2) a medical or dental procedure; or(3) documented self-injurious behavior for which intensive, one-to-one supervision and treatment have not sufficiently reduced the risk of self-injury.(c) Prohibitions.(1) A restraint may not be used on an individual unless the restraint is necessary to prevent imminent physical injury to the individual or another person.(2) A restraint may not be used for punishment, disciplinary purposes, retaliation, retribution, or convenience or as a substitute for treatment or habilitation.(3) A restraint may not be used on an individual as part of a positive behavior support plan.(4) Prone or supine restraint may not be used.(5) A restraint may not be used if it:(A) secures the individual to a stationary object while he or she is in a standing position;(B) obstructs the individual's airway, including the placement of anything in, on, or over his or her mouth or nose;(C) impairs the individual's breathing by putting pressure on his or her torso;(D) interferes with the individual's ability to communicate;(E) extends muscle groups away from each other;(F) uses hyperextension of joints;(G) uses pressure points or pain; or(H) is prohibited by the individual's medical orders or ISP or is medically contraindicated.(6) A standing order for restraint may not be used. Source Note: The provisions of this §967.27 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.27 General Provisions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219704 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219704&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219704 03/12/2026 (a) Safety and maintenance.(1) Only commercially available mechanical restraint devices designed specifically for the safe and relatively comfortable use of restraint may be used. The director must approve any modifications to a mechanical restraint to accommodate an individual's specific physical needs.(2) Staff must inspect a mechanical device before and after each use to ensure that the device is in good repair and without tears or protrusions that may cause injury. Staff must have a damaged mechanical device repaired before it can be used to restrain an individual.(3) Staff must ensure that a mechanical device is applied correctly.(b) Prohibited devices. The following mechanical devices may not be used:(1) metal wrist or ankle cuffs;(2) rubber bands, ropes, and cords, unless part of an approved device;(3) long ties and leashes, including halter leashes;(4) restraining sheets attached to any stationary object other than a bed;(5) padlocks;(6) papoose or restraint boards;(7) restraint chairs;(8) camisoles;(9) transport jackets;(10) strait jackets; and(11) barred enclosures with tops, including crib-style beds with mesh tops. Source Note: The provisions of this §967.29 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.29 Mechanical Devices https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219705 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219705&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219705 03/12/2026 (a) The IDT must develop and implement person-centered proactive supports, training, and treatment with the goal of making the use of restraints unnecessary.(b) When evidence indicates that the individual's behaviors result in a behavioral crisis or sustained self-injury or make it difficult to provide needed medical or dental care, the IDT, including the individual and LAR, with the involvement of a PCP and other relevant professional staff, must assess and identify any issues or contraindications for the use of restraint, including:(1) any physical, behavioral, psychiatric, or medical conditions that constitute a risk; and(2) any considerations in the use of restraint due to the individual's communication level, cognitive functioning level, height, weight, emotional condition (including whether the individual has a history of having been physically or sexually abused), and age.(c) The IDT must ensure that a PCP reviews and updates, as necessary in response to changes in condition and at IDT meetings, but at least annually, any conditions, factors, or limitations on specific physical techniques, drugs, or mechanical devices used for restraint.(d) For individuals participating in a program outside the facility, the IDT must coordinate with staff from the outside program to assess and develop interventions consistent with the ISP and any action plans and invite staff from the outside program to participate in IDT meetings at which interventions are discussed.(e) An ISP action plan must:(1) be developed to decrease and ultimately eliminate the use of restraint for the individual, with consideration of protection from harm and safety issues;(2) include an interdisciplinary analysis that identifies the circumstances that contribute to causing the dangerous behaviors that result in the use of restraint;(3) identify actions, data collection, and the responsible persons for implementing the actions;(4) address a broad range of changes, which may include changing living arrangements, implementing calming procedures, and incorporating preferences in programs;(5) include a PBSP and other therapeutic plans, as applicable; and(6) contain individualized instructions to direct support professionals in the safe and effective use of restraint procedures.(f) A facility must develop or revise an interdisciplinary ISP action plan in response to significant events, including but not limited to, the following:(1) more than three behavioral crises in a 30-day rolling period have required the use of restraints;(2) restraint use has not decreased over time and may be likely to continue at a stable rate unless an action plan is developed;(3) the individual's characteristics require that standard restraint procedures be adapted to meet his or her needs;(4) a pattern of injuries to the individual or others is observed as restraint procedures are carried out;(5) an individual has sustained, self-injurious behavior, and supervision and treatment have not been successful in reducing harm; or(6) an individual's behavior is presenting a risk to medical or dental treatment or to healing.(g) A facility must develop and implement an ISP action plan by:(1) reviewing the individual's relevant adaptive skills and biological, medical, and psychosocial factors;(2) reviewing possible contributing environmental conditions;(3) completing or revising structural and functional assessments of the behavior leading to use of restraint;(4) developing or revising a PBSP based on the structural and functional assessments of the behavior leading to the use of restraint that identifies the individual's particular strengths, specifies the behavior to be addressed, prescribes alternative, positive adaptive behaviors to be taught or strengthened to replace the dangerous behavior that requires the use of restraint, and describes prevention procedures to be followed as the individual's behavior indicates an escalation of behaviors that are dangerous and likely to result in restraint;(5) as applicable, developing or revising other programs to reduce or eliminate the use of restraint that are not part of the PBSP, such as treatment or strategies to minimize or eliminate the need for medical restraints;(6) as applicable, developing or revising a crisis intervention plan or medical restraint plan, including staff instructions on how to safely and appropriately use a recommended restraint procedure with a specific individual, any changes in the type of restraint used, the maximum duration of the restraint, and the criteria for terminating the restraint;(7) as applicable, developing or revising a protective mechanical restraint plan for self-injurious behavior, including procedures for gradually increasing the time the individual is able to stay safe but not be in restraints and any changes in the type of restraint used; and(8) specifying the persons responsible for activities, including obtaining legally adequate consent from the individual or LAR before implementing the plan, providing required staff training, monitoring activities, evaluating effectiveness, and ensuring any necessary reviews by the Human Rights Committee.(h) The IDT must review, assess, and revise an ISP action plan at least annually and more frequently as necessary. The IDT must review, at least quarterly and more frequently as necessary, an individual who was restrained for a behavioral crisis or for whom medical restraint was used. The IDT must review a protective mechanical restraint plan for self-injurious behavior at least monthly and more frequently as necessary.(i) The IDT may consult with a facility discipline director, state office discipline coordinator, or outside consultant to explore alternative treatment strategies. Source Note: The provisions of this §967.31 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.31 Evaluation and Assessment https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219706 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219706&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219706 03/12/2026 (a) Only staff who have successfully completed competency-based training on the use of restraints may implement restraint procedures. Staff who implement restraint procedures must also complete training on person-specific instructions and other measures regarding restraints contained in an individual's crisis intervention plan or other plan.(b) The following conditions must be met before a PCP may order a restraint in response to a behavioral crisis:(1) the individual's behavior constitutes a behavioral crisis;(2) if no PBSP, desensitization plan, or other preventive measures are in place, staff have considered the level of imminent risk of violence or injury and have applied a graduated range of less-restrictive approved procedures as safety permits and the measures have not reduced the risk of imminent physical harm to the individual or others;(3) if a PBSP, desensitization plan, or other preventive measures are in place, the individualized procedures for prevention, de-escalation and a graduated range of less restrictive measures have been followed, as safety permits, but have not reduced the risk of imminent physical harm to the individual or others; and(4) if a helmet, mittens with ties, wristlets, or other mechanical restraints will be used to prevent self-injury in a behavioral crisis:(A) an approved crisis intervention plan allowing the use of the mechanical restraint must be in place; or(B) the use of the mechanical restraint must be approved by the individual's psychologist or board certified behavior analyst (BCBA) or the psychologist or BCBA on call, the administrator on duty, and the director of psychology or behavioral services.(c) If a mechanical restraint is used in accordance with subsection (b)(4)(B) of this section, its use must be reviewed by the chairperson of the facility's human rights committee as soon as possible but within 24 hours after initiation of the restraint.(d) A psychotropic medication may be ordered as a chemical restraint in response to a behavioral crisis, but only if immediate use of the medication is essential to prevent or mitigate the danger of the individual's harmful behavior and the following conditions have been met:(1) the individual is experiencing a behavioral crisis;(2) a graduated range of less restrictive alternatives to stop the behavior and protect the individual and others has been attempted, as safety permits, but has not reduced the risk of imminent physical harm to the individual or others;(3) the requirements of any component of the ISP have been followed but have not reduced the risk of imminent harm to the individual or others;(4) a psychiatrist or PCP has determined that early administration of a regularly prescribed psychotropic medication instead of chemical restraint is not a reasonable option; and(5) a psychiatrist or PCP approves and orders the use of the chemical restraint. Source Note: The provisions of this §967.33 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.33 Imminent Harm Resulting from a Behavioral Crisis https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219707 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219707&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219707 03/12/2026 (a) Only a PCP, dentist, or psychiatrist may order a medical restraint. Medical restraint orders must include a specific start and stop date or time. If the time limit on the original order is exceeded, the PCP must write a new order.(b) Only staff who have successfully completed competency-based training on the use of restraints may implement restraint procedures. Staff who implement restraint procedures must also complete training on person-specific instructions and other measures regarding restraints contained in an individual's medical restraint plan or other plan.(c) If restraint is used before or during intervention for routine medical or dental care, a medical restraint plan must be developed to describe the rationale for use of the restraint and to provide specific individualized instructions on how to safely implement the restraint. Source Note: The provisions of this §967.35 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.35 Imminent Harm Resulting from a Medical or Dental Procedure https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219708 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219708&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219708 03/12/2026 (a) Only staff who have successfully completed competency-based training on the use of restraints may implement restraint procedures. Staff who implement restraint procedures must also complete training on person-specific instructions and other measures regarding restraints contained in an individual's protective mechanical restraint plan for self-injurious behavior or other plan.(b) Staff may implement restraint to protect an individual from imminent harm resulting from documented self-injurious behavior if the following conditions have been met:(1) the IDT has developed an ISP action plan for the individual that describes the need for protective mechanical restraint for self-injurious behavior; includes the procedures that will be employed to reduce the need for restraint, including a PBSP; and provides specific individualized instructions for staff on how to apply the restraints safely and the periods of time and the conditions under which the restraints can be safely removed;(2) a structural and functional assessment has been completed or revised that identifies possible functions of the self-injurious behavior;(3) the IDT has developed other clinical plans, as applicable, such as habilitation plans supported by an assessment or evaluation, to reduce the need for protective mechanical restraint;(4) a PBSP has been completed or revised, based on a structural and functional assessment, that includes procedures, as appropriate, for teaching and strengthening alternative behaviors to self-injurious behaviors and teaching procedures that will help prevent self-injurious behavior as the time without the use of protective mechanical restraints increases;(5) the instructions for applying the protective mechanical restraint for self-injurious behavior have been developed, including a schedule for removing and replacing the mechanical restraint that safely increases the time out of protective mechanical restraint;(6) a PCP has assessed the individual and determined that the self-injurious behavior is at an intensity and frequency that causes imminent risk of serious physical injury and there is a need for protective mechanical restraints for self-injurious behavior; and(7) a system for monthly reviews of data by the IDT has been established, including the PCP's continued reevaluation as to whether the intensity and frequency of the self-injurious behavior warrants continuing the restraint plan. Source Note: The provisions of this §967.37 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.37 Imminent Harm Resulting from Documented Self-Injurious Behavior https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219709 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219709&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219709 03/12/2026 (a) An individual who is restrained as a result of a behavioral crisis must be released from restraint as soon as he or she no longer poses an imminent risk of physical harm to self or others.(b) The PCP or appropriate provider must determine the release criteria for an individual restrained in response to imminent harm resulting from a medical or dental procedure.(c) For mechanical restraints used for protection from self-injurious behavior, removal of restraints must follow the individual's protective mechanical restraint plan for self-injurious behavior. A fading schedule, designed to phase out the use of a restraint device, must be reviewed by the IDT, including the PCP and appropriate therapists, each month and adjusted to permit the maximum safe time out of restraints.(d) If an individual experiences a medical emergency while in restraint, staff must release the individual from the restraint immediately and ensure that the medical emergency is promptly addressed according to statewide and facility policies and procedures. Source Note: The provisions of this §967.39 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.39 Release https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219710 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219710&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219710 03/12/2026 (a) Staff must report and investigate a serious injury or death occurring during restraint or within 24 hours after the release from a restraint in accordance with statewide policy on incident management.(b) The facility must review the use of each restraint in a timely manner to determine whether the application of restraint was justified, the restraint was applied correctly, injuries occurred, or factors exist that, if modified, may prevent the future use of restraint.(c) A pharmacist and psychiatrist must conduct a clinical review of each chemical restraint in a timely manner to determine whether the restraint was clinically justified, to identify any potential medication-related risks, and to make any applicable recommendations to the IDT.(d) The IDT, with a determination of risk of physical harm made by the PCP, must review the continued application of restraint in response to risk from documented self-injurious behavior monthly to determine whether current risk warrants continuing the restraint, to analyze the effectiveness of the fading plan, and to adjust the time without restraint, if possible to safely do so.(e) The IDT must review an individual restrained in response to a behavioral crisis or medical or dental intervention at least quarterly to assess progress in changing the circumstances that lead to the use of restraint.(f) A facility must track, trend, and analyze data regarding the application of restraints in accordance with statewide policy on the use of restraints to identify issues or emerging trends and to develop appropriate responses.(g) DADS must report the restraint of an individual to the executive commissioner. Source Note: The provisions of this §967.41 adopted to be effective May 16, 2013, 38 TexReg 2841; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS B USE OF RESTRAINTS IN STATE SUPPORTED LIVING CENTERS §967.41 Reporting, Tracking, and Documentation https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219711 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219711&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219711 03/12/2026 (a) A facility must obtain legally adequate consent or authorization for non-emergency administration of psychotropic medication in accordance with subsection (b) or (c) of this section, unless the administration of the medication is authorized by an order issued under THSC §592.156:(1) before the initial administration of each class of psychotropic medication and annually thereafter; and(2) before the administration of a dosage of psychotropic medication that is not within the dosage range for which consent or authorization has been given.(b) Legally adequate consent for the administration of psychotropic medication to an individual may be provided in accordance with subsection (a) of this section by the following:(1) the individual, if the individual has capacity to provide consent; or(2) the individual's LAR, if the individual has an LAR.(c) The director of the facility in which the individual resides may authorize the administration of psychotropic medication to an individual if the individual:(1) has been:(A) committed to a facility involuntarily under:(i) THSC, Chapter 593, Subchapter C;(ii) Texas Code of Criminal Procedure, Chapter 46B or 46C; or(iii) Texas Family Code, Chapter 55; or(B) transferred to a facility under the Texas Mental Health Code, THSC, Title 7, Subtitle C;(2) does not have capacity to provide legally adequate consent for the administration of psychotropic medication;(3) does not have an LAR; and(4) has not refused to take the medication, as described in §3.803(b) of this subchapter (relating to Refusal of Psychotropic Medication).(d) Before obtaining legally adequate consent or authorization to administer psychotropic medication to an individual in accordance with subsection (b) or (c) of this section, the individual's treating physician, or the treating physician's designee, must provide the following information in simple, non-technical terms in the primary language or mode of communication of the individual, the individual's LAR, or the director:(1) the name of the psychotropic medication;(2) the class of psychotropic medication, the dosage range, the route of administration, and proposed course of the medication;(3) the indication for the medication's use, including the rationale for using the psychotropic medication if the medication is being used for a purpose or in a manner that has not been approved by the FDA;(4) the diagnosis that is the specific condition to be treated by the psychotropic medication;(5) the symptoms of the condition being treated and the target symptoms that the facility will monitor;(6) the beneficial effects expected from the psychotropic medication;(7) the probable, clinically significant side effects and risks associated with the psychotropic medication;(8) the generally accepted alternative treatments to the psychotropic medication, if any, and an explanation of why the treating physician recommends that the alternatives be rejected;(9) an explanation of the probable health care consequences of not consenting to the psychotropic medication;(10) an explanation that the individual, LAR, or director has the right to refuse or revoke consent to or authorization for the administration of the psychotropic medication at any time;(11) an explanation that refusal or revocation of consent or authorization will not prevent the individual from receiving care and services in the future; and(12) an offer to answer any questions from the individual, LAR, or director concerning treatment with the psychotropic medication.(e) The consent of an individual or LAR or the authorization of the director must be evidenced in the individual's active record by a completed and signed consent form, in a format approved by DADS.(f) If the treating physician designates another person to provide the information specified in subsection (d) of this section, then no later than two days, excluding Saturday, Sunday, and a national or state holiday listed in Texas Government Code §662.003(a) or (b), after the designee provides the information, the treating physician must meet with the individual and, if appropriate, with the individual's LAR who provided the consent or the director who provided the authorization, to review the information and answer any questions.(g) A facility must review a consent to or authorization for psychotropic medication given in accordance with subsection (b) or (c) of this section with an individual, an individual's LAR, or the director at least annually. The review must include a discussion of the information specified in subsection (d) of this section, as well as a discussion of the individual's, LAR's, or director's decision regarding continuation of the psychotropic medication. Source Note: The provisions of this §967.77 adopted to be effective April 7, 2015, 40 TexReg 1988; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS C CONSENT OR AUTHORIZATION FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION AT STATE SUPPORTED LIVING CENTERS §967.77 Legally Adequate Consent or Authorization for Non-Emergency Administration of Psychotropic Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219712 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219712&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219712 03/12/2026 (a) A facility may administer psychotropic medication to an individual who is having a medication-related emergency without consent, authorization, or a court order.(b) If psychotropic medication is administered in accordance with subsection (a) of this section, a physician must:(1) issue an order to administer the psychotropic medication in a manner that is consistent with clinically appropriate medical care and that is the least restrictive of the individual's personal liberty; and(2) document in the individual's active record, in specific medical or behavioral terms, the necessity of the order and that the physician has evaluated but rejected other generally accepted, less intrusive forms of treatment, if any. Source Note: The provisions of this §967.79 adopted to be effective April 7, 2015, 40 TexReg 1988; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS C CONSENT OR AUTHORIZATION FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION AT STATE SUPPORTED LIVING CENTERS §967.79 Administration of Psychotropic Medication during a Medication-Related Emergency https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219713 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219713&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219713 03/12/2026 (a) An individual has the right to refuse to take psychotropic medication.(b) An individual's refusal to take psychotropic medication may be demonstrated through written or oral communication or behavior that indicates an objection to the medication, including refusing or pretending to swallow medication, or refusing to submit to hypodermic injection of medication.(c) An individual's LAR may refuse to consent to the administration of psychotropic medication on the individual's behalf.(d) The director may refuse to authorize the administration of psychotropic medication for an individual.(e) A facility must document in the active record of an individual who refuses to take psychotropic medication, whose LAR refuses to consent to the administration of psychotropic medication, or for whom the director refuses to authorize the administration of psychotropic medication:(1) the individual's refusal to take psychotropic medication and the manner in which the individual demonstrated his refusal to take the psychotropic medication;(2) the LAR's refusal to consent to the administration of psychotropic medication on the individual's behalf; or(3) the director's refusal to authorize the administration of psychotropic medication to the individual.(f) A facility must not administer psychotropic medication to an individual whose LAR refuses to consent to the administration of psychotropic medication on the individual's behalf unless the individual is having a medication-related emergency.(g) A facility must not administer psychotropic medication to an individual who refuses to take the medication unless:(1) the individual is having a medication-related emergency;(2) the refusing individual's LAR has consented to the administration; or(3) the administration of the psychotropic medication is authorized by:(A) an order issued under THSC §592.156 (relating to Hearing and Order Authorizing Psychotropic Medication); or(B) an order issued under Texas Code of Criminal Procedure, Article 46B.086 (relating to Court-Ordered Medications). Source Note: The provisions of this §967.81 adopted to be effective April 7, 2015, 40 TexReg 1988; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS C CONSENT OR AUTHORIZATION FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION AT STATE SUPPORTED LIVING CENTERS §967.81 Refusal of Psychotropic Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219714 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219714&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219714 03/12/2026 In accordance with THSC §592.154, a treating physician may file an application in a probate court or a court with probate jurisdiction on behalf of the State of Texas for an order authorizing the administration of a psychotropic medication to an individual if:(1) the individual refuses to take the psychotropic medication;(2) the treating physician believes that the individual lacks the capacity to make a decision regarding the administration of the psychotropic medication;(3) the treating physician determines that the psychotropic medication is the proper course of treatment for the individual;(4) the individual does not have an LAR; and(5) the individual:(A) has been committed to a facility involuntarily under:(i) THSC, Chapter 593, Subchapter C;(ii) Texas Code of Criminal Procedure, Chapter 46B or 46C; or(iii) Texas Family Code, Chapter 55;(B) has been transferred to a facility under the Texas Mental Health Code, THSC, Title 7, Subtitle C; or(C) has had an application for the individual's commitment to a facility filed in accordance with THSC Chapter 593, Subchapter C. Source Note: The provisions of this §967.83 adopted to be effective April 7, 2015, 40 TexReg 1988; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS C CONSENT OR AUTHORIZATION FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION AT STATE SUPPORTED LIVING CENTERS §967.83 Order Authorizing Administration of Psychotropic Medication https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219715 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=219715&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 219715 03/12/2026 (a) An individual's consent to take a psychotropic medication is not valid and may not be relied on if the individual is subject to an order issued under THSC §592.156.(b) The issuance of an order under THSC §592.156 is not a determination or an adjudication of mental incompetency and does not limit in any other respect the individual's rights as a citizen or the individual's property rights or legal capacity. Source Note: The provisions of this §967.85 adopted to be effective April 7, 2015, 40 TexReg 1988; transferred effective July 31, 2024, as published in the July 5, 2024, issue of the Texas Register, 49 TexReg 4927. 1 HEALTH AND HUMAN SERVICES COMMISSION 967 CLIENT CARE OF INDIVIDUALS RECEIVING SERVICES AT STATE SUPPORTED LIVING CENTERS C CONSENT OR AUTHORIZATION FOR ADMINISTRATION OF PSYCHOTROPIC MEDICATION AT STATE SUPPORTED LIVING CENTERS §967.85 Effect of Order https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211723 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211723&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211723 03/12/2026 The purpose of this chapter is to describe efforts to prevent and treat the human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) for people receiving services from state supported living centers (SSLCs) operated by the Texas Health and Human Services Commission. This chapter also describes workplace guidelines for HHSC contractors providing services to individuals served by the SSLCs. Source Note: The provisions of this §985.1 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.1 Purpose https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211724 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211724&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211724 03/12/2026 This chapter applies to all SSLCs. Source Note: The provisions of this §985.2 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.2 Application https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211725 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211725&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211725 03/12/2026 The following words and terms, when used in this chapter, shall have the following meanings, unless the context indicates otherwise.(1) Acquired immune deficiency syndrome (AIDS)--As defined by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services.(2) Individual--A person who is receiving services at an SSLC.(3) State Supported Living Center (SSLC)--A state supported living center as defined by Texas Health and Safety Code §531.002 and the intermediate care facility for individuals with intellectual disabilities component of the Rio Grande State Center operated by the Texas Health and Human Services Commission.(4) Test results--Any statement that indicates that an identifiable individual has or has not been tested for the acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection, antibodies to HIV, or infection with any other probable causative agent of AIDS, including a statement or assertion that the person is positive, negative, at risk, or has or does not have a certain level of antigen or antibody. Source Note: The provisions of this §985.3 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.3 Definitions https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211726 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211726&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211726 03/12/2026 (a) Texas Health and Safety Code §85.113 requires an entity that contracts with the Texas Health and Human Services Commission (HHSC) to operate a program involving direct client contact to adopt and implement human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) workplace guidelines similar to the guidelines adopted by the agency. A contractor operating a program involving direct client contact with an individual must follow the HIV/AIDS Model Workplace Guidelines for Businesses, State Agencies, and State Contractors listed on the Department of State Health Services website.(b) Texas Health and Safety Code §85.114 requires HIV and AIDS education for individuals served at SSLCs. HIV/AIDS education, including risk reduction, must be tailored to each individual and routinely made available to all individuals or their legally authorized representative. If education cannot be provided, the reasons must be documented in the individual's medical record. Source Note: The provisions of this §985.4 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.4 Education https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211727 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211727&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211727 03/12/2026 Each individual to be screened shall be offered pre- and post- HIV/AIDS test counseling from trained counselors. For individuals who are likely to be discharged from the state supported living center prior to receipt of test results, consent should be obtained from the individual or their legally authorized representative (LAR) to refer the individual to the local public health department for further HIV/AIDS treatment services. Prior to referral, consent should also be obtained from the individual or their LAR to send the individual's test results to the local public health department. Source Note: The provisions of this §985.5 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.5 Counseling https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211728 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=211728&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 211728 03/12/2026 The behavioral and medical considerations of each individual will be evaluated by the attending physician with appropriate consultation, and only those restrictions recognized to be necessary relative to the containment of infection in each case will be imposed. Source Note: The provisions of this §985.6 adopted to be effective January 1, 2023, 47 TexReg 8732. 1 HEALTH AND HUMAN SERVICES COMMISSION 985 HUMAN IMMUNODEFICIENCY VIRUS PREVENTION AND TREATMENT IN STATE SUPPORTED LIVING CENTERS §985.6 Limitation of an Individual's Activity https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=197190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 197190 03/12/2026 https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=197190&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 197190 03/12/2026 (a) A state supported living center (SSLC) resident's guardian may notify the SSLC of an anatomical gift by signing a form indicating the resident's guardian elects to make an anatomical gift on behalf of the resident in accordance with Health and Safety Code, Chapter 692A.(b) An SSLC resident's guardian may elect to make an anatomical gift on behalf of the resident in accordance with Health and Safety Code, Chapter 692A, without signing the form prescribed by this section. Source Note: The provisions of this §990.1 adopted to be effective December 5, 2019, 44 TexReg 7397. 1 HEALTH AND HUMAN SERVICES COMMISSION 990 ANATOMICAL GIFT §990.1 Anatomical Gift Form https://texas-sos.appianportalsgov.com/rules-and-meetings?recordId=15965&queryAsDate=03%2F12%2F2026&interface=VIEW_TAC_SUMMARY&$locale=en_US 15965 03/12/2026